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Shimamura S, Morikawa H, Shinohara K, Ohkoshi H, Omori C, Hoshino Y, Uchida Y, Masafumi S, Ikemura S, Ohishi N, Kondo T, Soejima K. A case of autoimmune pulmonary alveolar proteinosis responding to oral statin therapy. Respir Med Case Rep 2024; 50:102042. [PMID: 38845787 PMCID: PMC11154001 DOI: 10.1016/j.rmcr.2024.102042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 05/14/2024] [Accepted: 05/23/2024] [Indexed: 06/09/2024] Open
Abstract
There is no approved drug treatment for autoimmune pulmonary alveolar proteinosis (APAP), although traditionally requires complex treatments such as whole lung lavage (WLL). We herein report on a 67-year-old man diagnosed with APAP. Treatment with atorvastatin (5 mg daily) resulted in significant improvement in symptoms, lung function, and computed tomography findings, with enhanced oxygenation, although serum anti-GM-CSF antibody levels remained elevated. This case suggests that the remission observed in this case could potentially be attributed to a direct effect of atorvastatin within the pulmonary alveoli. Statins may be considered as one of the treatment options for APAP.
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Affiliation(s)
- So Shimamura
- Department of Respiratory Medicine, Graduate School of Medicine University of Yamanashi, 1110 Shimokato, Chuo, Yamanashi, 409-3892, Japan
| | - Honami Morikawa
- Department of Respiratory Medicine, Graduate School of Medicine University of Yamanashi, 1110 Shimokato, Chuo, Yamanashi, 409-3892, Japan
| | - Ken Shinohara
- Department of Respiratory Medicine, Graduate School of Medicine University of Yamanashi, 1110 Shimokato, Chuo, Yamanashi, 409-3892, Japan
| | - Hiroki Ohkoshi
- Department of Respiratory Medicine, Graduate School of Medicine University of Yamanashi, 1110 Shimokato, Chuo, Yamanashi, 409-3892, Japan
| | - Chisa Omori
- Department of Respiratory Medicine, Graduate School of Medicine University of Yamanashi, 1110 Shimokato, Chuo, Yamanashi, 409-3892, Japan
| | - Yuuki Hoshino
- Department of Respiratory Medicine, Graduate School of Medicine University of Yamanashi, 1110 Shimokato, Chuo, Yamanashi, 409-3892, Japan
| | - Yoshinori Uchida
- Department of Respiratory Medicine, Graduate School of Medicine University of Yamanashi, 1110 Shimokato, Chuo, Yamanashi, 409-3892, Japan
| | - Saiki Masafumi
- Department of Respiratory Medicine, Graduate School of Medicine University of Yamanashi, 1110 Shimokato, Chuo, Yamanashi, 409-3892, Japan
| | - Shinnosuke Ikemura
- Department of Respiratory Medicine, Graduate School of Medicine University of Yamanashi, 1110 Shimokato, Chuo, Yamanashi, 409-3892, Japan
| | - Naoki Ohishi
- Department of Pathology, Graduate School of Medicine University of Yamanashi, 1110 Shimokato, Chuo, Yamanashi, 409-3892, Japan
| | - Tetsuo Kondo
- Department of Pathology, Graduate School of Medicine University of Yamanashi, 1110 Shimokato, Chuo, Yamanashi, 409-3892, Japan
| | - Kenzo Soejima
- Department of Respiratory Medicine, Graduate School of Medicine University of Yamanashi, 1110 Shimokato, Chuo, Yamanashi, 409-3892, Japan
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Rodriguez Gonzalez C, Schevel H, Hansen G, Schwerk N, Lachmann N. Pulmonary Alveolar Proteinosis and new therapeutic concepts. KLINISCHE PADIATRIE 2024; 236:73-79. [PMID: 38286410 PMCID: PMC10883756 DOI: 10.1055/a-2233-1243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 12/15/2023] [Indexed: 01/31/2024]
Abstract
Pulmonary alveolar proteinosis (PAP) is an umbrella term used to refer to a pulmonary syndrome which is characterized by excessive accumulation of surfactant in the lungs of affected individuals. In general, PAP is a rare lung disease affecting children and adults, although its prevalence and incidence is variable among different countries. Even though PAP is a rare disease, it is a prime example on how modern medicine can lead to new therapeutic concepts, changing ways and techniques of (genetic) diagnosis which ultimately led into personalized treatments, all dedicated to improve the function of the impaired lung and thus life expectancy and quality of life in PAP patients. In fact, new technologies, such as new sequencing technologies, gene therapy approaches, new kind and sources of stem cells and completely new insights into the ontogeny of immune cells such as macrophages have increased our understanding in the onset and progression of PAP, which have paved the way for novel therapeutic concepts for PAP and beyond. As of today, classical monocyte-derived macrophages are known as important immune mediator and immune sentinels within the innate immunity. Furthermore, macrophages (known as tissue resident macrophages (TRMs)) can also be found in various tissues, introducing e. g. alveolar macrophages in the broncho-alveolar space as crucial cellular determinants in the onset of PAP and other lung disorders. Given recent insights into the onset of alveolar macrophages and knowledge about factors which impede their function, has led to the development of new therapies, which are applied in the context of PAP, with promising implications also for other diseases in which macrophages play an important role. Thus, we here summarize the latest insights into the various forms of PAP and introduce new pre-clinical work which is currently conducted in the framework of PAP, introducing new therapies for children and adults who still suffer from this severe, potentially life-threatening disease.
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Affiliation(s)
- Claudio Rodriguez Gonzalez
- Department for Pediatric Pneumology, Allergology and Neonatology,
Hannover Medical School, Hannover, Germany
| | - Hannah Schevel
- Department for Pediatric Pneumology, Allergology and Neonatology,
Hannover Medical School, Hannover, Germany
| | - Gesine Hansen
- Department for Pediatric Pneumology, Allergology and Neonatology,
Hannover Medical School, Hannover, Germany
- German Center for Lung Research (DZL), Biomedical Research in Endstage
and Obstructive Lung Disease Hannover (BREATH), Hannover, Germany
- Cluster of Excellence RESIST (EXC 2155), Hannover Medical School, 30625
Hannover, Germany.
| | - Nicolaus Schwerk
- Department for Pediatric Pneumology, Allergology and Neonatology,
Hannover Medical School, Hannover, Germany
- German Center for Lung Research (DZL), Biomedical Research in Endstage
and Obstructive Lung Disease Hannover (BREATH), Hannover, Germany
| | - Nico Lachmann
- Department for Pediatric Pneumology, Allergology and Neonatology,
Hannover Medical School, Hannover, Germany
- German Center for Lung Research (DZL), Biomedical Research in Endstage
and Obstructive Lung Disease Hannover (BREATH), Hannover, Germany
- Cluster of Excellence RESIST (EXC 2155), Hannover Medical School, 30625
Hannover, Germany.
- Fraunhofer Institute for Toxicology and Experimental Medicine,
Hannover, Germany
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Campo I, Carey BC, Paracchini E, Kadija Z, De Silvestri A, Rodi G, De Amici M, Torre C, Zorzetto M, Griese M, Meloni F, Corsico AG, Trapnell BC, Mariani F. Inhaled recombinant GM-CSF reduces the need for whole lung lavage and improves gas exchange in autoimmune pulmonary alveolar proteinosis patients. Eur Respir J 2024; 63:2301233. [PMID: 37973175 PMCID: PMC10764982 DOI: 10.1183/13993003.01233-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 10/17/2023] [Indexed: 11/19/2023]
Abstract
RATIONALE Whole lung lavage (WLL) is a widely accepted palliative treatment for autoimmune pulmonary alveolar proteinosis (aPAP) but does not correct myeloid cell dysfunction or reverse the pathological accumulation of surfactant. In contrast, inhaled recombinant granulocyte-macrophage colony-stimulating factor (rGM-CSF) is a promising pharmacological approach that restores alveolar macrophage functions including surfactant clearance. Here, we evaluate WLL followed by inhaled rGM-CSF (sargramostim) as therapy of aPAP. METHODS 18 patients with moderate-to-severe aPAP were enrolled, received baseline WLL, were randomised into either the rGM-CSF group (receiving inhaled sargramostim) or control group (no scheduled therapy) and followed for 30 months after the baseline WLL. Outcome measures included additional unscheduled "rescue" WLL for disease progression, assessment of arterial blood gases, pulmonary function, computed tomography, health status, biomarkers and adverse events. Patients requiring rescue WLL were considered to have failed their assigned intervention group. RESULTS The primary end-point of time to first rescue WLL was longer in rGM-CSF-treated patients than controls (30 versus 18 months, n=9 per group, p=0.0078). Seven control patients (78%) and only one rGM-CSF-treated patient (11%) required rescue WLL, demonstrating a 7-fold increase in relative risk (p=0.015). Compared to controls, rGM-CSF-treated patients also had greater improvement in peripheral arterial oxygen tension, alveolar-arterial oxygen tension difference, diffusing capacity of the lungs for carbon monoxide and aPAP biomarkers. One patient from each group withdrew for personal reasons. No serious adverse events were reported. CONCLUSIONS This long-term, prospective, randomised trial demonstrated inhaled sargramostim following WLL reduced the requirement for WLL, improved lung function and was safe in aPAP patients. WLL plus inhaled sargramostim may be useful as combined therapy for aPAP.
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Affiliation(s)
- Ilaria Campo
- Pneumology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo, Pavia, Italy
| | - Brenna C Carey
- Translational Pulmonary Science Center, Cincinnati Children's Hospital, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, OH, USA
| | - Elena Paracchini
- Pneumology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo, Pavia, Italy
| | - Zamir Kadija
- Pneumology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo, Pavia, Italy
| | - Annalisa De Silvestri
- Clinical Epidemiology and Biometric Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Giuseppe Rodi
- Anesthesiology and Intensive Care Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Mara De Amici
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Cristina Torre
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Michele Zorzetto
- Pneumology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo, Pavia, Italy
| | - Matthias Griese
- Dr. von Hauner Children's Hospital, University of Munich, German Center for Lung Research, Munich, Germany
| | - Federica Meloni
- Pneumology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo, Pavia, Italy
- Department of Internal Medicine, University of Pavia, Pavia, Italy
| | - Angelo Guido Corsico
- Pneumology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo, Pavia, Italy
- Department of Internal Medicine, University of Pavia, Pavia, Italy
| | - Bruce C Trapnell
- Translational Pulmonary Science Center, Cincinnati Children's Hospital, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, OH, USA
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Francesca Mariani
- Pneumology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo, Pavia, Italy
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Chuang CH, Cheng CH, Tsai YC, Tsai MJ, Sheu CC, Chong IW. Pulmonary alveolar proteinosis in Taiwan. J Formos Med Assoc 2023; 122:1061-1068. [PMID: 37105870 DOI: 10.1016/j.jfma.2023.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 03/13/2023] [Accepted: 04/07/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND/PURPOSE Pulmonary alveolar proteinosis (PAP) is rare disease manifested as alveolar macrophage dysfunction and abnormal accumulation of surfactant protein in the alveoli. In this nationwide, population-based study, we investigated the epidemiology of PAP in Taiwan, and discovered the comorbidities and prognostic factors of PAP. METHODS From the National Health Insurance Research Database (NHIRD), we obtained comprehensive information about all patients of PAP in Taiwan between 1995 and 2013. The incidence, baseline characteristics comorbidities, and prognostic factors of PAP were investigated. RESULTS The annual incidence rate of PAP was around 0.79 (range: 0.49-1.17) patients per million people after 2000, and the prevalence rate was 7.96 patients per million people by the end of 2013. In total, 276 patients of PAP were identified, including 177 (64%) and 99 (36%) patients with primary and secondary PAP, respectively. The median age of diagnosis was 53.8 years. The median survival was 9.6 years after the initial PAP diagnosis, and the 5-year survival rate was 65.96%. Twenty (7%) patients received whole lung lavage (WLL) within three months after the diagnosis had significantly better survival compared to the others. Multivariable Cox regression analyses showed that elder age, secondary PAP, and malignancy were associated with poorer survival, while WLL within 3 months of diagnosis might greatly improve the survival. CONCLUSION We demonstrated the epidemiology of PAP in Taiwan, showing several poor prognostic factors and the potential effectiveness of WLL. Further prospective studies based on registry are warranted to improve the diagnosis and treatment of PAP.
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Affiliation(s)
- Cheng-Hao Chuang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chih-Hung Cheng
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital, Kaohsiung, Taiwan
| | - Yu-Chen Tsai
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan
| | - Ming-Ju Tsai
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Respiratory Care, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.
| | - Chau-Chyun Sheu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Respiratory Care, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Inn-Wen Chong
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Respiratory Care, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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5
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Miyashita K, Hozumi H, Inoue Y, Suzuki T, Suda T. Nationwide survey of adult patients with pulmonary alveolar proteinosis using the National Database of designated intractable diseases of Japan. Respir Investig 2023; 61:364-370. [PMID: 37043919 DOI: 10.1016/j.resinv.2023.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 02/22/2023] [Accepted: 02/27/2023] [Indexed: 04/14/2023]
Abstract
BACKGROUND Autoimmune pulmonary alveolar proteinosis (APAP) and congenital/hereditary PAP were labeled intractable diseases in Japan in 2015. Since then, patients registered in the National Database of Designated Incurable Diseases (NDDID) who met certain requirements became eligible for medical subsidies. Epidemiological studies using recent data are needed for the development of management protocols for patients with PAP. METHODS We conducted the first nationwide study describing the epidemiology and characteristics of PAP using data for patients registered in the Japanese NDDID between 2015 and 2020. We focused on patient demographics, diagnosis, disease severity score (DSS), symptoms, test results, and treatment. RESULTS We identified 110 patients with PAP, among whom 96.4% had APAP/idiopathic PAP (IPAP). The median age was 58 years, with a slight male predominance. Most patients had a DSS ≥3 (64.5%) and reported symptoms (e.g., dyspnea on exertion). High-resolution computed tomography typically revealed ground glass opacity and crazy paving appearances. Pulmonary function was relatively preserved, except for carbon monoxide diffusing capacity. Only 27.4% of patients underwent therapeutic whole-lung lavage and/or bronchoalveolar lavage, while 25% required long-term oxygen therapy. Serum Krebs von den Lungen-6, surfactant protein D, and lactate dehydrogenase levels significantly and positively correlated with the DSS. CONCLUSIONS Most patients registered in the NDDID have APAP/IPAP with a DSS ≥3, and about one-quarter require long-term oxygen therapy and infrequent lavages. Our results provide important details of the current prevalence and clinical practice related to APAP/IPAP with a DSS ≥3 in Japan.
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Affiliation(s)
- Koichi Miyashita
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu 431-3192, Japan
| | - Hironao Hozumi
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu 431-3192, Japan.
| | - Yoshikazu Inoue
- Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, 1180 Nagasone-cho, Kita-ku, Sakai 591-8555, Japan
| | - Takuji Suzuki
- Department of Respirology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan
| | - Takafumi Suda
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu 431-3192, Japan
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Bai JW, Huang JN, Shi SY, Ge A, Lu HW, Sun XL, Gu SY, Liang S, Cheng KB, Tian XL, Xiao YL, Xu KF, Xu JF. Updated severity and prognosis score of pulmonary alveolar proteinosis: A multi-center cohort study in China. Front Med (Lausanne) 2023; 10:1058001. [PMID: 36824611 PMCID: PMC9941621 DOI: 10.3389/fmed.2023.1058001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 01/19/2023] [Indexed: 02/10/2023] Open
Abstract
Background The high-resolution computed tomography (HRCT) score is an important component of the severity and prognosis score of pulmonary alveolar proteinosis (SPSP). However, the HRCT score in SPSP only considers the extent of opacity, which is insufficient. Methods We retrospectively evaluated HRCT scores for 231 patients with autoimmune pulmonary alveolar proteinosis (APAP) from three centers of the China Alliance for Rare Diseases. The SPSPII was created based on the overall density and extent, incorporating the SPSP. The severity of APAP patients was assessed using disease severity scores (DSS), SPSP, and SPSPII to determine the strengths and weaknesses of the different assessment methods. We then prospectively applied the SPSPII to patients before treatment, and the curative effect was assessed after 3 months. Results The HRCT overall density and extent scores in our retrospective analysis were higher than the extent scores in all patients and every original extent score severity group, as well as higher related to arterial partial oxygen pressure (PaO2) than extent scores. The mild patients accounted for 61.9% based on DSS 1-2, 20.3% based on SPSP 1-3, and 20.8% based on SPSPII 1-3. Based on SPSP or SPSPII, the number of severe patients deteriorating was higher in the mild and moderate groups. When applied prospectively, arterial PaO2 differed between any two SPSPII severity groups. The alveolar-arterial gradient in PaO2 (P[A-a]O2), % predicted carbon monoxide diffusing capacity of the lung (DLCO), and HRCT score were higher in the severe group than in the mild and moderate groups. After diagnosis, mild patients received symptomatic treatment, moderate patients received pure whole lung lavage (WLL) or granulocyte-macrophage colony-stimulating factor (GM-CSF) therapy, and severe patients received WLL and GM-CSF therapy. Importantly, the SPSPII in mild and severe groups were lower than baseline after 3 months. Conclusion The HRCT density and extent scores of patients with APAP were better than the extent score. The SPSPII score system based on smoking status, symptoms, PaO2, predicted DLCO, and overall HRCT score was better than DSS and SPSP for assessing the severity and efficacy and predicting the prognosis. Trial registration ClinicalTrial.gov, identifier: NCT04516577.
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Affiliation(s)
- Jiu-Wu Bai
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Jian-nan Huang
- Department of Respiratory and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Shen-yun Shi
- Department of Respiratory and Critical Care Medicine, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Jiangsu, China
| | - Ai Ge
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Hai-wen Lu
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Xiao-li Sun
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Shu-yi Gu
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Shuo Liang
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Ke-bin Cheng
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Xin-lun Tian
- Department of Respiratory and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yong-long Xiao
- Department of Respiratory and Critical Care Medicine, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Jiangsu, China,*Correspondence: Yong-long Xiao,
| | - Kai-feng Xu
- Department of Respiratory and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China,Kai-feng Xu,
| | - Jin-Fu Xu
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China,Jin-Fu Xu,
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Kim C, Garcia-Tome R, Hurtado C, Ding L, Wang T, Chang CF. Characteristics of hospital admissions for pulmonary alveolar proteinosis: analysis of the nationwide inpatient sample (2012-2014). BMC Pulm Med 2022; 22:365. [PMID: 36153570 PMCID: PMC9509629 DOI: 10.1186/s12890-022-02082-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 07/20/2022] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Pulmonary alveolar proteinosis (PAP) is a rare clinical syndrome involving the accumulation of lipid-rich proteinaceous material in the alveoli. There is a paucity of published studies on this condition. To better characterize the demographics, complication rates, mortality, and healthcare costs of patients hospitalized for PAP in the United States, a secondary analysis on the Hospital Cost and Utilization Project's Nationwide Inpatient Sample (NIS) was performed on patients admitted from 2012 to 2014 with a diagnosis of pulmonary alveolar proteinosis. METHODS Using the NIS database, a secondary analysis was performed on 500 admissions with the diagnosis "pulmonary alveolar proteinosis." The clinical variables and outcome measures extracted were: patient demographics, hospital costs, length of stay, frequency of admissions, and inpatient mortality rate. RESULTS Among a weighted estimate of 500 hospital admissions from 2012 to 2014, the number of PAP admissions averaged 4.7 per million. The population was predominantly male (55%) with a mean age of 41.45 (CI 38.3-44.5) from all socioeconomic levels. Inpatient mortality was calculated to be 5%, which may result from the fact that the majority of admitted patients had few or no comorbid conditions (CCI 0.72). The most common procedure performed during admission was a bronchoalveolar lavage. Mean length of stay was 6.2 days (CI 3.9-8.5) and average cost of admission was $29,932.20 (CI 13,739-46,124). Of note, 50% of these admissions were considered "elective." CONCLUSIONS Demographics of patients with PAP who have been hospitalized in the United States are similar to previously reported demographics from prior patient cohorts, specifically a male predominance and a mean age in the 40 s. The inpatient mortality rate of 5% we found is consistent with prior studies demonstrating good disease-specific survival rates. Notably, the cost per admission and overall annual cost associated with PAP hospitalization was calculated to be $29932.20 and $5 million respectively. This reflects the high economic cost associated with hospitalization of PAP patients, and provokes thought about ways to make treatment more cost-effective.
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Affiliation(s)
- Chongiin Kim
- grid.42505.360000 0001 2156 6853Department of Internal Medicine, University of Southern California, Los Angeles, CA USA
| | - Rodrigo Garcia-Tome
- grid.42505.360000 0001 2156 6853Department of Pulmonary, Critical Care and Sleep Medicine, University of Southern California, Los Angeles, CA USA
| | - Carolina Hurtado
- grid.19006.3e0000 0000 9632 6718Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, University of California Los Angeles, Los Angeles, CA USA
| | - Li Ding
- grid.42505.360000 0001 2156 6853Department of Population and Public Health Sciences, Keck School of Medicine, Los Angeles, CA USA
| | - Tisha Wang
- grid.19006.3e0000 0000 9632 6718Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, CA USA
| | - Ching-Fei Chang
- grid.42505.360000 0001 2156 6853Department of Pulmonary, Critical Care and Sleep Medicine, University of Southern California, Los Angeles, CA USA
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McCarthy C, Carey BC, Trapnell BC. Autoimmune Pulmonary Alveolar Proteinosis. Am J Respir Crit Care Med 2022; 205:1016-1035. [PMID: 35227171 PMCID: PMC9851473 DOI: 10.1164/rccm.202112-2742so] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 02/24/2022] [Indexed: 01/23/2023] Open
Abstract
Autoimmune pulmonary alveolar proteinosis (PAP) is a rare disease characterized by myeloid cell dysfunction, abnormal pulmonary surfactant accumulation, and innate immune deficiency. It has a prevalence of 7-10 per million; occurs in individuals of all races, geographic regions, sex, and socioeconomic status; and accounts for 90% of all patients with PAP syndrome. The most common presentation is dyspnea of insidious onset with or without cough, production of scant white and frothy sputum, and diffuse radiographic infiltrates in a previously healthy adult, but it can also occur in children as young as 3 years. Digital clubbing, fever, and hemoptysis are not typical, and the latter two indicate that intercurrent infection may be present. Low prevalence and nonspecific clinical, radiological, and laboratory findings commonly lead to misdiagnosis as pneumonia and substantially delay an accurate diagnosis. The clinical course, although variable, usually includes progressive hypoxemic respiratory insufficiency and, in some patients, secondary infections, pulmonary fibrosis, respiratory failure, and death. Two decades of research have raised autoimmune PAP from obscurity to a paradigm of molecular pathogenesis-based diagnostic and therapeutic development. Pathogenesis is driven by GM-CSF (granulocyte/macrophage colony-stimulating factor) autoantibodies, which are present at high concentrations in blood and tissues and form the basis of an accurate, commercially available diagnostic blood test with sensitivity and specificity of 100%. Although whole-lung lavage remains the first-line therapy, inhaled GM-CSF is a promising pharmacotherapeutic approach demonstrated in well-controlled trials to be safe, well tolerated, and efficacious. Research has established GM-CSF as a pulmonary regulatory molecule critical to surfactant homeostasis, alveolar stability, lung function, and host defense.
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Affiliation(s)
- Cormac McCarthy
- Department of Respiratory Medicine, St. Vincent’s University Hospital, Dublin, Ireland
- University College Dublin, Dublin, Ireland
| | - Brenna C. Carey
- Translational Pulmonary Science Center, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio; and
- University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Bruce C. Trapnell
- Translational Pulmonary Science Center, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio; and
- University of Cincinnati College of Medicine, Cincinnati, Ohio
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A mini-whole lung lavage to treat autoimmune pulmonary alveolar proteinosis (PAP). Respir Res 2022; 23:60. [PMID: 35300687 PMCID: PMC8932062 DOI: 10.1186/s12931-022-01982-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 03/09/2022] [Indexed: 11/12/2022] Open
Abstract
Background PAP is an ultra-rare respiratory syndrome characterized by the accumulation of surfactant within the alveoli. Whole lung lavage (WLL) is the current standard of care of PAP, however it is not a standardized procedure and the total amount of fluid used to wash each lung is still debated. Considering ICU hospitalization associated risks, a “mini-WLL” with anticipated manual clapping and reduced total infusion volume and has been proposed in our center. The aim of the study is to retrospectively analyze the efficacy of mini-WLL compared to standard WLL at the Pavia center. Methods 13 autoimmune PAP patients eligible for WLL were included: 7 patients were admitted to mini-WLL (9 L total infusion volume for each lung) and 6 patients underwent standard WLL (14 L of infusion volume). Functional data (VC%, FVC%, TLC%, DLCO%) and alveolar-arterial gradient values (A-aO2) were collected at the baseline and 1, 3, 6, 12, 18 months after the procedure. Results A statistically significant improvement of VC% (p = 0.013, 95%CI 3.49–30.19), FVC% (p = 0.016, 95%CI 3.37–32.09), TLC% (p = 0.001, 95%CI 7.38–30.34) was observed in the mini-WLL group in comparison with the standard WLL group, while no significant difference in DLCO% and A-aO2 mean values were reported. Conclusion Mini-WLL has demonstrated higher efficacy in ameliorating lung volumes, suggesting that a lower infusion volume is sufficient to remove the surfactant accumulation and possibly allows a reduced mechanical insult of the bronchi walls and the alveoli. However, no statistically significant differences were found in terms of DLCO% and Aa-O2.
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Bai JW, Gu SY, Sun XL, Lu HW, Liang S, Xu JF. CYFRA21-1 is a more sensitive biomarker to assess the severity of pulmonary alveolar proteinosis. BMC Pulm Med 2022; 22:2. [PMID: 34980056 PMCID: PMC8725332 DOI: 10.1186/s12890-021-01795-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 12/14/2021] [Indexed: 12/01/2022] Open
Abstract
Background Serum lactate dehydrogenase (LDH), carcinoembryonic antigen (CEA) and CYFRA21-1 are the commonly used biomarkers to identify patients with autoimmune pulmonary alveolar proteinosis (APAP). However, it is not clear which of the biomarkers is more sensitive to the severity of the patient’s condition. Methods APAP patients numbering 151 were enrolled in this study. All patients’ severity was assessed through the severity and prognosis score of PAP (SPSP). According to the respective laboratory upper limits of serum levels of LDH, CEA and CYFRA21-1, APAP patients were divided into higher and lower-level groups. Patients were divided into five groups based on SPSP. 88 patients had completed six months of follow-up. We calculated sensitivity, specificity, and critical point of LDH, CEA and CYFRA21-1 between APAP patients and normal control group, and between grade 1–2 and 3–5 through receiving operating characteristics (ROC) curve. Results Serum LDH, CEA and CYFRA21-1 levels of patients with PAP were higher and distinctly related to PaO2, FVC, FEV1, DLCO, HRCT scores and SPSP. The SPSP of patients in higher-level LDH, CEA and CYFRA21-1 groups were higher than those of corresponding lower-level groups. Based on SPSP results, the patients were divided into five groups (grade I, 20; grade II, 37; grade III, 40; grade IV, 38; grade V, 16). The serum level of CYFRA21-1 of patients with APAP in grade II was higher than that of patients in grade I and lower than that of patients in grade III. Serum CYFRA21-1 of patients with APAP after six months were higher than the baseline among the aggravated group. Serum LDH, CEA and CYFRA21-1 levels after six months among patients in the relieved group of patients with APAP were lower than the baseline. ROC correlating LDH, CEA and CYFRA21-1 values with APAP severity (between grade 1–2 and 3–5) showed an optimal cutoff of LDH of over 203 U/L (< 246 U/L), CEA of over 2.56 ug/L (< 10 ug/L), and CYFRA21-1 of over 5.57 ng/ml (> 3.3 ng/ml) (AUC: 0.815, 95% CI [0.748–0.882], sensitivity: 0.606, specificity: 0.877). Conclusion Serum CYFRA21-1 level was more sensitive in revealing the severity of APAP than LDH and CEA levels among mild to moderate forms of disease.
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Affiliation(s)
- Jiu-Wu Bai
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, No. 507 Zhengmin Road, Shanghai, 200433, China
| | - Shui-Yi Gu
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, No. 507 Zhengmin Road, Shanghai, 200433, China
| | - Xiao-Li Sun
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, No. 507 Zhengmin Road, Shanghai, 200433, China
| | - Hai-Wen Lu
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, No. 507 Zhengmin Road, Shanghai, 200433, China
| | - Shuo Liang
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, No. 507 Zhengmin Road, Shanghai, 200433, China
| | - Jin-Fu Xu
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, No. 507 Zhengmin Road, Shanghai, 200433, China.
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11
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Chiş AF, Man MA, Chiş BA, Pop CM. Alveolar proteinosis - an underdiagnosed condition in young people. Med Pharm Rep 2021; 94:S40-S42. [PMID: 34527908 DOI: 10.15386/mpr-2227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Pulmonary alveolar proteinosis (PAP) is a rare lung disease characterized by an abnormal intra-alveolar accumulation of surfactant derived lipoproteinaceous compounds, leading to dyspnea and, in severe cases, to respiratory failure. The most common form of PAP is the auto-immune one. Secondary PAP has been recognized in myeloid leukemia, non-hematological neoplasms, lung infections or environmental exposure to noxious particles. Mutations in several genes (such as MARS, SFTPB, TTF1) are responsible for the alteration of surfactant production. Diagnosis tools include high-resolution computed tomography, bronchoalveolar lavage. Although over the past 20 years the pathophysiology of PAP has become more clear, the therapeutic strategies still need improvement. A national programme for patients with PAP might be useful in Romania.
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Affiliation(s)
- Ana Florica Chiş
- Department of Pneumology, Iuliu Hatieganu University of Medicine and Pharmacy Cluj-Napoca, Romania.,"Leon Daniello" Clinical Hospital of Pneumology, Cluj-Napoca, Romania
| | - Milena Adina Man
- Department of Pneumology, Iuliu Hatieganu University of Medicine and Pharmacy Cluj-Napoca, Romania.,"Leon Daniello" Clinical Hospital of Pneumology, Cluj-Napoca, Romania
| | - Bogdan Augustin Chiş
- 2 Dept of Internal medicine, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Carmen Monica Pop
- Department of Pneumology, Iuliu Hatieganu University of Medicine and Pharmacy Cluj-Napoca, Romania.,"Leon Daniello" Clinical Hospital of Pneumology, Cluj-Napoca, Romania
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12
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Kaenmuang P, Navasakulpong A. Efficacy of whole lung lavage in pulmonary alveolar proteinosis: a 20-year experience at a reference center in Thailand. J Thorac Dis 2021; 13:3539-3548. [PMID: 34277049 PMCID: PMC8264701 DOI: 10.21037/jtd-20-3308] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 05/14/2021] [Indexed: 11/21/2022]
Abstract
Background Pulmonary alveolar proteinosis (PAP) is a rare lung syndrome. The current standard treatment is whole lung lavage (WLL). We reviewed PAP cases treated with WLL during a 243-month period. The primary objective was to describe the efficacy of WLL. We compared chest imaging resolution and pulmonary function tests (PaO2 and DLCO) before the first and after the last WLL. The secondary objectives were to compare mMRC dyspnea scores, other lung function parameters, and complications of WLL. Methods We retrospectively reviewed PAP patients from 1 January 2000 to 31 March 2020. Demographic data, pulmonary function tests, and the efficacy of WLL were collected from the electronic medical database and analyzed by descriptive analysis. Differences in data used the student t-test to compare parameters pre- and post-WLL. Results A total of 19 PAP patients and 50 WLL procedures were included. Eleven patients (57.9%) were females and the mean age was 51.5±11.7 years. Dyspnea (100%) and cough (94.7%) were the two leading symptoms. The most common indication for WLL was progressive dyspnea. There were significant improvements in SpO2 from 86% to 94% (P<0.001), PaO2 from 49.3 to 66.1 (P<0.001), DLCO from 31.8% to 52.5% predicted (P=0.013), and the mMRC dyspnea score from 3 to 2 (P<0.001) without major complications. Conclusions WLL is an effective standard treatment for PAP cases. It is safe and can be used as a primary treatment in case of inhaled anti GM-CSF is not available.
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Affiliation(s)
- Punchalee Kaenmuang
- Division of Respiratory and Respiratory Critical Care Medicine, Department of Internal Medicine, Faculty of Medicine, Prince of Songkhla University, Hat Yai, Thailand
| | - Asma Navasakulpong
- Division of Respiratory and Respiratory Critical Care Medicine, Department of Internal Medicine, Faculty of Medicine, Prince of Songkhla University, Hat Yai, Thailand
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14
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Mata-Suarez SM, Castro-Lalín A, Mc Loughlin S, De Domini J, Bianco JC. Whole-Lung Lavage-a Narrative Review of Anesthetic Management. J Cardiothorac Vasc Anesth 2020; 36:587-593. [PMID: 33386193 DOI: 10.1053/j.jvca.2020.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 11/28/2020] [Accepted: 12/02/2020] [Indexed: 01/15/2023]
Abstract
Pulmonary alveolar proteinosis is a rare disease characterized by progressive accumulation of lipoprotein material in the alveoli as a result of a dysfunction in surfactant clearance. The whole-lung lavage procedure is considered the current standard of care and consists of the sequential lavage of both lungs for mechanical removal of residual material in the alveoli. However, a lack of standardization has resulted in different procedural techniques among institutions. Even though whole-lung lavage is considered to be a safe procedure, unforeseen complications might occur, and proper knowledge of physiologic implications may allow clinicians to establish the appropriate therapy. This review provides an insight into the underlying physiology of the disease, the technical details of the procedure from an anesthesiologist's perspective, and discussion of potential intraoperative complications.
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Affiliation(s)
- Santiago M Mata-Suarez
- Department of Anesthesiology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
| | - Agustina Castro-Lalín
- Department of Anesthesiology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Santiago Mc Loughlin
- Department of Anesthesiology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Juan De Domini
- Department of Anesthesiology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Juan C Bianco
- Department of Anesthesiology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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15
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Wälscher J, Wessendorf TE, Rocha M, Darwiche K, Taube C, Bonella F. Ganzlungenlavage bei pulmonaler Alveolarproteinose – Schritt für Schritt. Pneumologie 2020; 74:660-664. [DOI: 10.1055/a-0978-9137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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16
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Santos GF, Portela J, Argyropoulou D, Varudo R, Pimenta I, Oliveira A, Lança S, Fernandes A. Alveolar proteinosis due to toxic inhalation at workplace. Respir Med Case Rep 2020; 31:101199. [PMID: 32868988 PMCID: PMC7449138 DOI: 10.1016/j.rmcr.2020.101199] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 08/17/2020] [Accepted: 08/20/2020] [Indexed: 01/15/2023] Open
Abstract
We report a clinical case of a 39-year old male, without any known previous medical condition but with occupational exposure to paints and dust cement, who presented an autoimmune pulmonary alveolar proteinosis (PAP) triggered by exposure to toxic inhalation at his workplace. PAP is a rare lung disease characterized by intra-alveolar abnormal accumulation of surfactant. The presence of a crazy-paving pattern in high-resolution computed tomography scan brings the suspicion of PAP although histopathology results of bronchoalveolar lavage are always required for its final diagnosis. The autoimmune form of PAP due to toxic inhalation, such as the one here described, is rare and it is usually difficult to establish a causal relationship.
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Affiliation(s)
- Gabriela F Santos
- Pneumonology Department, Hospital Garcia de Orta, Av. Torrado da Silva, 2805-267, Almada, Portugal
| | - João Portela
- Pneumonology Department, Hospital Garcia de Orta, Av. Torrado da Silva, 2805-267, Almada, Portugal
| | - Despoina Argyropoulou
- Pathology Department, Hospital Garcia de Orta, Av. Torrado da Silva, 2805-267, Almada, Portugal
| | - Rita Varudo
- Intensive Care Department, Hospital Garcia de Orta, Av. Torrado da Silva, 2805-267, Almada, Portugal
| | - Inês Pimenta
- Intensive Care Department, Hospital Garcia de Orta, Av. Torrado da Silva, 2805-267, Almada, Portugal
| | - Ana Oliveira
- Pathology Department, Hospital Garcia de Orta, Av. Torrado da Silva, 2805-267, Almada, Portugal
| | - Sara Lança
- Intensive Care Department, Hospital Garcia de Orta, Av. Torrado da Silva, 2805-267, Almada, Portugal
| | - Antero Fernandes
- Intensive Care Department, Hospital Garcia de Orta, Av. Torrado da Silva, 2805-267, Almada, Portugal
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Zhang N, Jiang Z, Shao C. Pulmonary alveolar proteinosis: A single center retrospective analysis of 14 cases. Med Clin (Barc) 2020; 156:555-557. [PMID: 32854951 DOI: 10.1016/j.medcli.2020.05.066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 05/15/2020] [Accepted: 05/19/2020] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Pulmonary alveolar proteinosis (PAP) is a rare lung disease, characterized by abnormal alveolar accumulation of enlarged foamy macrophages and periodic acid-Schiff (PAS)-positive materials. Knowledge of the disease characteristics is still lacking. OBJECTIVE To help clinicians gain a better understanding of this rare disease. METHODS We undertook a retrospective analysis of 14 adult patients with PAP, treated in Zhongshan Hospital, Fudan University. RESULTS Serum lactate dehydrogenase (LDH) was correlated with the arterial partial pressure of oxygen (PaO2) and diffusion capacity for carbon monoxide (DLCO). Transbronchial lung biopsy (TBLB) established a definitive diagnosis for a positive rate of 100%. The patients underwent whole lung lavage (WLL) and exhibited varying degrees of remission. The patients with mild symptoms received only supportive care and observation, and remained stable during follow-up. CONCLUSION LDH may correlate with disease severity. Bronchoscopy is sufficiently sensitive for a definite diagnosis. Conventional bilateral whole lung lavage proved a reliable treatment for indicated patients, but selective unilateral lung lavage or observation may be a rational choice in certain patients.
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Affiliation(s)
- Ning Zhang
- Department of Pulmonary Medicine, Xiamen Branch, Zhongshan Hospital, Fudan University, Xiamen 361000, China; Shanghai Institute of Respiratory Diseases, Department of Pulmonary Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Zhilong Jiang
- Shanghai Institute of Respiratory Diseases, Department of Pulmonary Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Changzhou Shao
- Shanghai Institute of Respiratory Diseases, Department of Pulmonary Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China.
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Blanc PD, Annesi-Maesano I, Balmes JR, Cummings KJ, Fishwick D, Miedinger D, Murgia N, Naidoo RN, Reynolds CJ, Sigsgaard T, Torén K, Vinnikov D, Redlich CA. The Occupational Burden of Nonmalignant Respiratory Diseases. An Official American Thoracic Society and European Respiratory Society Statement. Am J Respir Crit Care Med 2020; 199:1312-1334. [PMID: 31149852 PMCID: PMC6543721 DOI: 10.1164/rccm.201904-0717st] [Citation(s) in RCA: 236] [Impact Index Per Article: 59.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Rationale: Workplace inhalational hazards remain common worldwide, even though they are ameliorable. Previous American Thoracic Society documents have assessed the contribution of workplace exposures to asthma and chronic obstructive pulmonary disease on a population level, but not to other chronic respiratory diseases. The goal of this document is to report an in-depth literature review and data synthesis of the occupational contribution to the burden of the major nonmalignant respiratory diseases, including airway diseases; interstitial fibrosis; hypersensitivity pneumonitis; other noninfectious granulomatous lung diseases, including sarcoidosis; and selected respiratory infections. Methods: Relevant literature was identified for each respiratory condition. The occupational population attributable fraction (PAF) was estimated for those conditions for which there were sufficient population-based studies to allow pooled estimates. For the other conditions, the occupational burden of disease was estimated on the basis of attribution in case series, incidence rate ratios, or attributable fraction within an exposed group. Results: Workplace exposures contribute substantially to the burden of multiple chronic respiratory diseases, including asthma (PAF, 16%); chronic obstructive pulmonary disease (PAF, 14%); chronic bronchitis (PAF, 13%); idiopathic pulmonary fibrosis (PAF, 26%); hypersensitivity pneumonitis (occupational burden, 19%); other granulomatous diseases, including sarcoidosis (occupational burden, 30%); pulmonary alveolar proteinosis (occupational burden, 29%); tuberculosis (occupational burden, 2.3% in silica-exposed workers and 1% in healthcare workers); and community-acquired pneumonia in working-age adults (PAF, 10%). Conclusions: Workplace exposures contribute to the burden of disease across a range of nonmalignant lung conditions in adults (in addition to the 100% burden for the classic occupational pneumoconioses). This burden has important clinical, research, and policy implications. There is a pressing need to improve clinical recognition and public health awareness of the contribution of occupational factors across a range of nonmalignant respiratory diseases.
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Valuable Serum Markers in Pulmonary Alveolar Proteinosis. DISEASE MARKERS 2019; 2019:9709531. [PMID: 31827650 PMCID: PMC6885220 DOI: 10.1155/2019/9709531] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 07/23/2019] [Accepted: 08/19/2019] [Indexed: 11/18/2022]
Abstract
Objective Several serum markers were reported to reflect the severity of pulmonary alveolar proteinosis (PAP). The aim of this study is to investigate a reliable and facile marker to access and monitor the clinical course of PAP in a large cohort. Methods PAP patients from January 2010 to June 2018 were enrolled. Hospital records were used as data sources. The levels of various serum indicators were detected. We evaluated the correlation between pulmonary function test results and clinical variables. Results Diffusion capacity for carbon monoxide (DLCO) level was positively correlated with the level of high-density lipoprotein cholesterol (HDL-C) (P < 0.05) in 122 patients of PAP at baseline. The levels of HDL-C and DLCO significantly increased while carcinoembryonic antigen (CEA), CYFRA21-1, neuron-specific enolase (NSE), and lactic dehydrogenase (LDH) levels decreased six months after granulocyte-macrophage colony-stimulating factor (GM-CSF) inhalation therapy between 14 patients with PAP. Nevertheless, the increased DLCO was significantly correlated with decreased CEA (r = ‐0.579, P = 0.031) and CYFRA 21-1 (r = ‐0.632, P = 0.015). In 10 PAP patients without GM-CSF inhalation therapy, HDL-C and DLCO significantly decreased while NSE and LDH levels increased after six months of follow-up. The decreased DLCO was significantly correlated with increased LDH (r = ‐0.694, P = 0.026). Conclusions Serum CEA, CYFRA21-1, and LDH are valuable serum markers for the evaluation of disease activity of PAP and may predict the response to treatment of PAP.
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20
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Er H, Lee C, Huang T. Pulmonary alveolar proteinosis with upper-lobe predominance in a non-smoking female. Respirol Case Rep 2019; 7:e00445. [PMID: 31161040 PMCID: PMC6541565 DOI: 10.1002/rcr2.445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 04/03/2019] [Accepted: 05/07/2019] [Indexed: 11/11/2022] Open
Abstract
In this report, we describe an unusual manifestation of pulmonary alveolar proteinosis (PAP). The patient is a 43-year-old non-smoking female without underlying hematologic or auto-immune disorder. Her initial presentation included non-specific respiratory symptoms (exertional dyspnoea and cough), an unremarkable physical examination, a mild elevation in her serum level of lactate dehydrogenase, a mild impairment in the diffusion capacity for carbon monoxide but a normal spirometry, and multiple ground-glass opacities with a "crazy-paving" pattern predominantly in upper lung zones on her chest radiographic images. PAP was diagnosed histologically. PAP commonly occurs in males with smoking history, and tends to affect the lung parenchyma diffusely or, as in auto-immune PAP, lower lobes predominantly. Upper-lobe predominant PAP, particularly in a non-smoking female, is rare. This report would add PAP to the list of differential diagnosis for upper-lung ground-glass opacities. A review on the relevant literature is also included in the discussion.
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Affiliation(s)
- Hong‐Ping Er
- Division of Chest Medicine, Department of Internal Medicine, National Cheng Kung University Hospital, College of MedicineNational Cheng Kung UniversityTainanTaiwan
| | - Chung‐Ta Lee
- Department of Pathology, National Cheng Kung University Hospital, College of MedicineNational Cheng Kung UniversityTainanTaiwan
| | - Tang‐Hsiu Huang
- Division of Chest Medicine, Department of Internal Medicine, National Cheng Kung University Hospital, College of MedicineNational Cheng Kung UniversityTainanTaiwan
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Piloni D, Campo I. Current management strategies and the potential of inhaled GM-CSF for the treatment of autoimmune pulmonary alveolar proteinosis. Expert Opin Orphan Drugs 2019. [DOI: 10.1080/21678707.2019.1589450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Davide Piloni
- Pneumology Unit, IRCCS Policlinico San Matteo Hospital Foundation, Pavia, Italy
| | - Ilaria Campo
- Pneumology Unit, IRCCS Policlinico San Matteo Hospital Foundation, Pavia, Italy
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22
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Trapnell BC, Nakata K, Bonella F, Campo I, Griese M, Hamilton J, Wang T, Morgan C, Cottin V, McCarthy C. Pulmonary alveolar proteinosis. Nat Rev Dis Primers 2019; 5:16. [PMID: 30846703 DOI: 10.1038/s41572-019-0066-3] [Citation(s) in RCA: 189] [Impact Index Per Article: 37.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Pulmonary alveolar proteinosis (PAP) is a syndrome characterized by the accumulation of alveolar surfactant and dysfunction of alveolar macrophages. PAP results in progressive dyspnoea of insidious onset, hypoxaemic respiratory failure, secondary infections and pulmonary fibrosis. PAP can be classified into different types on the basis of the pathogenetic mechanism: primary PAP is characterized by the disruption of granulocyte-macrophage colony-stimulating factor (GM-CSF) signalling and can be autoimmune (caused by elevated levels of GM-CSF autoantibodies) or hereditary (due to mutations in CSF2RA or CSF2RB, encoding GM-CSF receptor subunits); secondary PAP results from various underlying conditions; and congenital PAP is caused by mutations in genes involved in surfactant production. In most patients, pathogenesis is driven by reduced GM-CSF-dependent cholesterol clearance in alveolar macrophages, which impairs alveolar surfactant clearance. PAP has a prevalence of at least 7 cases per million individuals in large population studies and affects men, women and children of all ages, ethnicities and geographical locations irrespective of socioeconomic status, although it is more-prevalent in smokers. Autoimmune PAP accounts for >90% of all cases. Management aims at improving symptoms and quality of life; whole-lung lavage effectively removes excessive surfactant. Novel pathogenesis-based therapies are in development, targeting GM-CSF signalling, immune modulation and cholesterol homeostasis.
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Affiliation(s)
- Bruce C Trapnell
- Translational Pulmonary Science Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
| | - Koh Nakata
- Bioscience Medical Research Center, Niigata University, Niigata, Japan
| | - Francesco Bonella
- Interstitial and Rare Lung Disease Unit, Pneumology Department, Ruhrlandklinik University Hospital, University of Essen, Essen, Germany
| | - Ilaria Campo
- Pneumology Unit, IRCCS San Matteo Hospital Foundation, Pavia, Italy
| | - Matthias Griese
- Pediatric Pneumology, University of Munich, German Center for Lung Research (DZL), Munich, Germany
| | - John Hamilton
- University of Melbourne, Parkville, Victoria, Australia
| | - Tisha Wang
- Department of Medicine, University of California, Los Angeles, CA, USA
| | - Cliff Morgan
- Department of Critical Care and Anaesthesia, Royal Brompton Hospital, London, UK
| | - Vincent Cottin
- National Reference Center for Rare Pulmonary Diseases, University of Lyon, Lyon, France
| | - Cormac McCarthy
- Department of Medicine, St. Vincent's University Hospital and University College Dublin, Dublin, Ireland
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McCarthy C, Lara Gallego B, Trapnell BC, McCormack FX. Epidemiology of Rare Lung Diseases: The Challenges and Opportunities to Improve Research and Knowledge. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1031:419-442. [PMID: 29214586 DOI: 10.1007/978-3-319-67144-4_24] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Rare lung diseases encompass a broad spectrum of conditions and affect an estimated 1.2-2.5 million people in North America and 1.5-3 million people in Europe. While individual rare lung diseases affect less than 1 in 2000 individuals, collectively they have a significant impact upon the population at large. Hence it is vital to understand firstly the epidemiology and subsequently the pathogenesis and clinical course of these disorders. Through a greater understanding of these aspects of disease, progress can be made in reducing symptoms, containing healthcare costs and utilizing resources efficiently. Furthermore, a greater understanding of the pathobiology of rare lung diseases can inform both the pathogenesis and management of more common pulmonary disorders.In this chapter we review how epidemiological approaches and the utilization of patient registries has improved the knowledge and management of rare lung diseases. We further focus on the epidemiology of several of the more widely known rare pulmonary disorders, including idiopathic pulmonary fibrosis (IPF), cystic fibrosis (CF) and alpha-1 antitrypsin deficiency (AATD). To conclude we describe how patient advocacy groups and foundations have driven advances in research and management of ultra-rare lung diseases, namely, the major strides made in the management and understanding of lymphangioleiomyomatosis (LAM) and pulmonary alveolar proteinosis (PAP).We conclude that the models used to study some of the rarest of diseases may be successfully adopted by other rare and common disease communities, leading to improved care and the possibility of novel therapeutic options.
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Affiliation(s)
- Cormac McCarthy
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Cincinnati, Cincinnati, OH, 45267-0564, USA. .,Translational Pulmonary Science Center Cincinnati Children's Hospital, 3333 Burnet Avenue, CCRF S4621, 45229-3039, Cincinnati, OH, USA. .,Rare Lung Diseases Clinical (RLDC), Cincinnati, OH, USA.
| | - Beatriz Lara Gallego
- Respiratory Medicine Department, Coventry University Hospital, Third Floor, East wing. Clifford Bridge Road, Coventry, CV2 2DX, Warwickshire, UK
| | - Bruce C Trapnell
- Translational Pulmonary Science Center Cincinnati Children's Hospital, 3333 Burnet Avenue, CCRF S4621, 45229-3039, Cincinnati, OH, USA.,Rare Lung Diseases Clinical (RLDC), Cincinnati, OH, USA.,Medicine and Pediatrics, University of Cincinnati College of Medicine, 3333 Burnet Avenue, CCRF R4029, 45229-3039, Cincinnati, OH, USA
| | - Francis X McCormack
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Cincinnati, Cincinnati, OH, 45267-0564, USA
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Bonella F, Long X, He X, Ohshimo S, Griese M, Guzman J, Costabel U. Serum YKL-40 is a reliable biomarker for pulmonary alveolar proteinosis. Respirology 2017; 22:1371-1378. [DOI: 10.1111/resp.13082] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 02/01/2017] [Accepted: 03/08/2017] [Indexed: 12/20/2022]
Affiliation(s)
- Francesco Bonella
- Interstitial and Rare Lung Disease Unit; Ruhrlandklinik, University of Duisburg-Essen; Essen Germany
| | - Xiaoping Long
- Interstitial and Rare Lung Disease Unit; Ruhrlandklinik, University of Duisburg-Essen; Essen Germany
- Department of Respiratory Medicine; The First Affiliated Hospital of University of South China; Hunan China
| | - Xuan He
- Interstitial and Rare Lung Disease Unit; Ruhrlandklinik, University of Duisburg-Essen; Essen Germany
| | - Shinichiro Ohshimo
- Department of Molecular and Internal Medicine, Graduate School of Biomedical Sciences; Hiroshima University; Hiroshima Japan
| | - Matthias Griese
- Dr. von Haunersches Kinderspital; University of Munich; Munich Germany
| | - Josune Guzman
- General and Experimental Pathology; Ruhr University; Bochum Germany
| | - Ulrich Costabel
- Interstitial and Rare Lung Disease Unit; Ruhrlandklinik, University of Duisburg-Essen; Essen Germany
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25
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Zhao YY, Huang H, Liu YZ, Song XY, Li S, Xu ZJ. Whole Lung Lavage Treatment of Chinese Patients with Autoimmune Pulmonary Alveolar Proteinosis: A Retrospective Long-term Follow-up Study. Chin Med J (Engl) 2016; 128:2714-9. [PMID: 26481735 PMCID: PMC4736873 DOI: 10.4103/0366-6999.167295] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Pulmonary alveolar proteinosis (PAP) is a rare lung disease, the most common type of which is autoimmune PAP. The gold standard therapy for PAP is whole lung lavage (WLL). Few studies have reported the optimal technique with which to evaluate the response to WLL. In this study, we aimed to identify parameters with which to assess the need for repeat WLL during a long-term 8-year follow-up. METHODS We conducted a retrospective analysis of 120 patients with autoimmune PAP with 80 of whom underwent WLL. Physiologic, serologic, and radiologic features of the patients were analyzed during an 8-year follow-up after the first WLL treatment. RESULTS Of the 40 patients without any intervention, 39 patients either achieved remission or remained stable and only one died of pulmonary infection. Of the 56 patients who underwent WLL for 1 time, 55 remained free from a second WLL and 1 patient died of cancer. Twenty-four required additional treatments after their first WLL. The baseline PaO 2 (P = 0.000), PA-aO 2 (P = 0.000), shunt fraction rate (P = 0.001), percent of predicted normal diffusing capacity of the lung for carbon monoxide (DLCO%Pred) (P = 0.016), 6-min walk test (P = 0.013), carcinoembryonic antigen (CEA) (P = 0.007), and neuron-specific enolase (NSE) (P = 0.003) showed significant differences among the three groups. The need for a second WLL was significantly associated with PaO 2 (P = 0.000), CEA (P = 0.050) , the 6-minute walk test (P = 0.026), and DLCO%Pred (P = 0.041). The DLCO%Pred on admission with a cut-off value of 42.1% (P = 0.001) may help to distinguish whether patients with PAP require a second WLL. CONCLUSIONS WLL is the optimal treatment method for PAP and provides remarkable improvements for affected patients. The DLCO%Pred on admission with a cut-off value of 42.1% may distinguish whether patients with PAP require a second WLL.
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Affiliation(s)
| | | | | | | | | | - Zuo-Jun Xu
- Department of Respiratory Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
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Campo I, Luisetti M, Griese M, Trapnell BC, Bonella F, Grutters J, Nakata K, Van Moorsel CHM, Costabel U, Cottin V, Ichiwata T, Inoue Y, Braschi A, Bonizzoni G, Iotti GA, Tinelli C, Rodi G. Whole lung lavage therapy for pulmonary alveolar proteinosis: a global survey of current practices and procedures. Orphanet J Rare Dis 2016; 11:115. [PMID: 27577926 PMCID: PMC5006612 DOI: 10.1186/s13023-016-0497-9] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2016] [Accepted: 08/03/2016] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Whole lung lavage (WLL) is the current standard of care treatment for patients affected by pulmonary alveolar proteinosis (PAP). However, WLL is not standardized and international consensus documents are lacking. Our aim was to obtain a factual portrayal of WLL as currently practiced with respect to the procedure, indications for its use, evaluation of therapeutic benefit and complication rate. METHODS A clinical practice survey was conducted globally by means of a questionnaire and included 27 centers performing WLL in pediatric and/or adult PAP patients. RESULTS We collected completed questionnaires from 20 centres in 14 countries, practicing WLL in adults and 10 centers in 6 countries, practicing WLL in pediatric patients. WLL is almost universally performed under general anesthesia, with a double-lumen endobronchial tube in two consecutive sessions, with an interval of 1-2 weeks between sessions in approximately 50 % of centres. The use of saline warmed to 37 °C, drainage of lung lavage fluid by gravity and indications for WLL therapy in PAP were homogenous across centres. There was great variation in the choice of the first lung to be lavaged: 50 % of centres based the choice on imaging, whereas 50 % always started with the left lung. The choice of position was also widely discordant; the supine position was chosen by 50 % of centres. Other aspects varied significantly among centres including contraindications, methods and timing of follow up, use of chest percussion, timing of extubation following WLL and lung isolation and lavage methods for small children. The amount of fluid used to perform the WLL is a critical aspect. Whilst a general consensus exists on the single aliquot of fluid for lavage (around 800 ml of warm saline, in adults) great variability exists in the total volume instilled per lung, ranging from 5 to 40 liters, with an average of 15.4 liters/lung. CONCLUSIONS This international survey found that WLL is safe and effective as therapy for PAP. However these results also indicate that standardization of the procedure is required; the present survey represents the a first step toward building such a document.
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Affiliation(s)
- Ilaria Campo
- Pneumology Unit, Fondazione IRCCS Policlinico San Matteo and University of Pavia, Pavia, Italy. .,Laboratorio di Biochimica e Genetica, S.C. Pneumologia, Fondazione IRCCS Policlinico San Matteo, via Taramelli 5, 27100, Pavia, Italy.
| | - Maurizio Luisetti
- Pneumology Unit, Fondazione IRCCS Policlinico San Matteo and University of Pavia, Pavia, Italy
| | - Matthias Griese
- Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, University of Munich, Munich, Germany
| | - Bruce C Trapnell
- Translational Pulmonary Science Centre, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Francesco Bonella
- Interstitial and Rare Lung Disease Unit, Ruhrlandklinik University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Jan Grutters
- Centre of Interstitial Lung Diseases, St. Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands
| | - Koh Nakata
- Niigata University Medical and Dental School, Niigata, Japan
| | - Coline H M Van Moorsel
- Centre of Interstitial Lung Diseases, St. Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands
| | - Ulrich Costabel
- Interstitial and Rare Lung Disease Unit, Ruhrlandklinik University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Vincent Cottin
- National Reference Centre for Rare Pulmonary Disease, Hopital Louis Pradel, Lyon, France
| | - Toshio Ichiwata
- Tokyo Medical University Hachioji Medical Center, Tokyo, Japan
| | - Yoshikazu Inoue
- Department of Diffuse Lung Diseases and Respiratory Failure, Clinical Research Centre, National Hospital Organization Kinki-Chuo Chest Medical Centre, Osaka, Japan
| | - Antonio Braschi
- Department of Anesthesiology and Intensive Care, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Giacomo Bonizzoni
- Pneumology Unit, Fondazione IRCCS Policlinico San Matteo and University of Pavia, Pavia, Italy
| | - Giorgio A Iotti
- Department of Anesthesiology and Intensive Care, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Carmine Tinelli
- Clinical Epidemiology and Biometric Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Giuseppe Rodi
- Department of Anesthesiology and Intensive Care, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
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A New Scale to Assess the Severity and Prognosis of Pulmonary Alveolar Proteinosis. Can Respir J 2016; 2016:3412836. [PMID: 27635117 PMCID: PMC5007332 DOI: 10.1155/2016/3412836] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2016] [Revised: 07/20/2016] [Accepted: 07/28/2016] [Indexed: 11/17/2022] Open
Abstract
Background. Pulmonary Alveolar Proteinosis (PAP) is a syndrome characterized by pulmonary surfactant accumulation. Small proportion of PAP patients experienced spontaneous remission. Objective. The aim of this study was to assess the severity and prognosis of PAP using various indexes. Methods. Characteristics, PaO2, lung function parameters, and HRCT score of 101 patients with PAP were retrospectively analyzed. Many indexes were explored and integrated into a scale. Results. PaO2 was lower among smokers than among never-smokers. PaO2 differed between each pair of patient groups stratified according to HRCT score or DLCO, % predicted, which differed between any two groups stratified according to PaO2. The PAP patients who died presented with more symptoms, a higher HRCT score, and lower DLCO, % predicted, than survivors. Smoking status, symptoms, PaO2, HRCT score, and DLCO, % predicted, were integrated into a scale (severity and prognosis score of PAP (SPSP)). SPSP correlated positively with PaO2, FVC, % predicted, FEV1, % predicted, and DLCO, % predicted, and negatively with HRCT score. The patients who died displayed a higher SPSP than survivors. Conclusion. Smoking status, symptoms, PaO2, HRCT score, and DLCO, % predicted, were integrated into a scale (SPSP) that can be used to assess the severity and prognosis of PAP to some degree.
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Abstract
Pulmonary alveolar proteinosis (PAP) is a rare syndrome characterized by the accumulation of surfactant in alveoli and terminal airways resulting in respiratory failure. PAP comprises part of a spectrum of disorders of surfactant homeostasis (clearance and production). The surfactant production disorders are caused by mutations in genes required for normal surfactant production. The PAP syndrome is identified based on history, radiologic, and bronchoalveolar lavage and/or histopathologic findings. The diagnosis of PAP-causing diseases in secondary PAP requires further studies. Whole-lung lavage is the current standard therapy and promising new pharmacologic therapies are in development.
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Affiliation(s)
- Takuji Suzuki
- Division of Pulmonary Biology, Cincinnati Children's Hospital Medical Center, MLC7029, 3333 Burnet Avenue, Cincinnati, OH 45229, USA.
| | - Bruce C Trapnell
- Division of Pulmonary Biology, Cincinnati Children's Hospital Medical Center, MLC7029, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
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The Clinical Clues of Pulmonary Alveolar Proteinosis: A Report of 11 Cases and Literature Review. Can Respir J 2016; 2016:4021928. [PMID: 27445535 PMCID: PMC4904541 DOI: 10.1155/2016/4021928] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 03/16/2016] [Accepted: 04/06/2016] [Indexed: 01/15/2023] Open
Abstract
Pulmonary alveolar proteinosis (PAP) is a rare interstitial lung disease characterized by the abnormal alveolar accumulation of surfactant components. The diagnosis of PAP can be easily missed since it is rare and lacks specific clinical symptoms. It is of great importance to have a better understanding of the crucial clue to clinically diagnose PAP and take PAP into consideration in the differential diagnosis of interstitial pulmonary diseases or other diseases with similar manifestations. Here, we analyze the clinical characteristics of 11 cases of PAP patients in local hospital and review the relevant literature in order to provide more information in diagnosis and management of PAP. In our observation, cyfra21-1 and neuron-specific enolase (NSE) known as tumor markers probably can be useful serum markers for diagnosis of PAP. As for the method of pathologic diagnosis, open-lung biopsy was the gold standard but now it is less required because findings on examination of bronchoalveolar lavage fluid (BALF) can help to make the diagnosis. We also have deep experience about when and how to carry out lung lavage.
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Papiris SA, Tsirigotis P, Kolilekas L, Papadaki G, Papaioannou AI, Triantafillidou C, Papaporfyriou A, Karakatsani A, Kagouridis K, Griese M, Manali ED. Pulmonary alveolar proteinosis: time to shift? Expert Rev Respir Med 2015; 9:337-49. [DOI: 10.1586/17476348.2015.1035259] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Zhou X, Lu G, Yu Z, Gao F, Bian T. Long-term follow-up of whole lung lavage in patients with pulmonary alveolar proteinosis. Exp Ther Med 2014; 8:763-768. [PMID: 25120596 PMCID: PMC4113632 DOI: 10.3892/etm.2014.1788] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Accepted: 05/01/2014] [Indexed: 11/06/2022] Open
Abstract
Pulmonary alveolar proteinosis (PAP) is a rare disorder characterized by intra-alveolar accumulation of lipid and proteinaceous material. While a small subset of patients with PAP spontaneously improve or even undergo disease remission, the majority of patients develop persistent or progressive disease. Numerous therapies have been used to treat PAP over the years; however, at present, whole lung lavage (WLL) remains the gold standard treatment for PAP. In the present study, data were accumulated from a cohort of patients with PAP (n=11) between 2003 and 2011 at the Wuxi People’s Hospital Affiliated to Nanjing Medical University. The disease affected males and females with a ratio of 2.7:1 and all the males were current or previous smokers. The disease severity score (DSS) of the patients was mainly distributed in DSS 4 or DSS 5. All the patients underwent WLL at least once, with one patient undergoing WLLs twice and another patient three times. The clinical features, arterial blood gas and pulmonary function of the patients, were assessed prior to and following the lavage. WLL resulted in a significant improvement in symptoms, radiographic features, PaO2, D(A-a)O2 and DLCO in patients with PAP, while pulmonary ventilation function did not significantly improve. WLL appears to be an effective approach for the treatment of PAP and leads to an improvement in survival rate.
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Affiliation(s)
- Xiaoyan Zhou
- Department of Respiratory Medicine, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, Jiangsu 214023, P.R. China
| | - Guochu Lu
- Department of Respiratory Medicine, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, Jiangsu 214023, P.R. China
| | - Zhen Yu
- Department of Respiratory Medicine, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, Jiangsu 214023, P.R. China
| | - Fei Gao
- Department of Respiratory Medicine, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, Jiangsu 214023, P.R. China
| | - Tao Bian
- Department of Respiratory Medicine, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, Jiangsu 214023, P.R. China
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Whole lung lavage combined with Granulocyte-macrophage colony stimulating factor inhalation for an adult case of refractory pulmonary alveolar proteinosis. BMC Pulm Med 2014; 14:87. [PMID: 24886114 PMCID: PMC4030463 DOI: 10.1186/1471-2466-14-87] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2014] [Accepted: 05/06/2014] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Whole-lung lavage (WLL) is classically the first-line treatment for symptomatic pulmonary alveolar proteinosis (PAP). However, some patients require multiple WLLs because of refractory nature of their PAP. In this instance, these patients may benefit from new treatment regimens, and new therapies should be tried for these patients. CASE PRESENTATION We describe a 47-year-old Chinese woman who was confidently diagnosed with pulmonary alveolar proteinosis (PAP) after bronchoalveolar lavage and transbronchial lung biopsy. The patient received four sessions of bilateral whole lung lavage (WLL) and one session of WLL in combination with plasmapheresis, each only producing short-term symptomatic relief. The patient was given a trial of combination therapy, which consisted of WLL and Granulocyte-macrophage colony-stimulating factor (GM-CSF) inhalation. The patient showed a gradual improvement in oxygenation and her daily activity, as well as a dramatic improvement in her pulmonary CT examination. CONCLUSION Bilateral WLL, in combination with GM-CSF inhalation, may be an effective treatment option for severe refractory PAP.
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Tazawa R, Inoue Y, Arai T, Takada T, Kasahara Y, Hojo M, Ohkouchi S, Tsuchihashi Y, Yokoba M, Eda R, Nakayama H, Ishii H, Nei T, Morimoto K, Nasuhara Y, Ebina M, Akira M, Ichiwata T, Tatsumi K, Yamaguchi E, Nakata K. Duration of Benefit in Patients With Autoimmune Pulmonary Alveolar Proteinosis After Inhaled Granulocyte-Macrophage Colony-Stimulating Factor Therapy. Chest 2014; 145:729-737. [DOI: 10.1378/chest.13-0603] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Trapnell BC, Luisetti M. The parallel lives of alpha1-antitrypsin deficiency and pulmonary alveolar proteinosis. Orphanet J Rare Dis 2013; 8:153. [PMID: 24079310 PMCID: PMC3849781 DOI: 10.1186/1750-1172-8-153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Accepted: 09/12/2013] [Indexed: 11/10/2022] Open
Abstract
In 1963, five cases of alpha1-antitrypsin deficiency were reported in the scientific literature, as well as an attempt to treat pulmonary alveolar proteinosis by a massive washing of the lung (whole lung lavage). Now, fifty years later, it seems the ideal moment not only to commemorate these publications, but also to point out the influence both papers had in the following decades and how knowledge on these two fascinating rare respiratory disorders progressed over the years. This paper is therefore not aimed at being a comprehensive review for both disorders, but rather at comparing the evolution of alpha1-antitrypsin, a rare disorder, with that of pulmonary alveolar proteinosis, an ultra-rare disease. We wanted to emphasize how all stakeholders might contribute to the dissemination of the awareness of rare diseases, that need to be chaperoned from the ghetto of neglected disorders to the dignity of recognizable and treatable disorders.
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Affiliation(s)
| | - Maurizio Luisetti
- Department of Molecular Medicine, Pneumology Unit, San Matteo Hospital Foundation, University of Pavia, Piazza Golgi 1, Pavia 27100, Italy
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