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Wołoszczak J, Wrześniewska M, Hrapkowicz A, Janowska K, Szydziak J, Gomułka K. A Comprehensive Outlook on Pulmonary Alveolar Proteinosis-A Review. Int J Mol Sci 2024; 25:7092. [PMID: 39000201 PMCID: PMC11241585 DOI: 10.3390/ijms25137092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 06/13/2024] [Accepted: 06/24/2024] [Indexed: 07/16/2024] Open
Abstract
Pulmonary alveolar proteinosis (PAP) is an ultra-rare disease caused by impaired pulmonary surfactant clearance due to the dysfunction of alveolar macrophages or their signaling pathways. PAP is categorized into autoimmune, congenital, and secondary PAP, with autoimmune PAP being the most prevalent. This article aims to present a comprehensive review of PAP classification, pathogenesis, clinical presentation, diagnostics, and treatment. The literature search was conducted using the PubMed database and a total of 67 articles were selected. The PAP diagnosis is usually based on clinical symptoms, radiological imaging, and bronchoalveolar lavage, with additional GM-CSF antibody tests. The gold standard for PAP treatment is whole-lung lavage. This review presents a summary of the most recent findings concerning pulmonary alveolar proteinosis, pointing out specific features that require further investigation.
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Affiliation(s)
- Julia Wołoszczak
- Student Scientific Group of Internal Medicine and Allergology, Faculty of Medicine, Wroclaw Medical University, 50-368 Wroclaw, Poland
| | - Martyna Wrześniewska
- Student Scientific Group of Internal Medicine and Allergology, Faculty of Medicine, Wroclaw Medical University, 50-368 Wroclaw, Poland
| | - Aleksandra Hrapkowicz
- Student Scientific Group of Internal Medicine and Allergology, Faculty of Medicine, Wroclaw Medical University, 50-368 Wroclaw, Poland
| | - Kinga Janowska
- Student Scientific Group of Internal Medicine and Allergology, Faculty of Medicine, Wroclaw Medical University, 50-368 Wroclaw, Poland
| | - Joanna Szydziak
- Student Scientific Group of Internal Medicine and Allergology, Faculty of Medicine, Wroclaw Medical University, 50-368 Wroclaw, Poland
| | - Krzysztof Gomułka
- Clinical Department of Internal Medicine, Pneumology and Allergology, Faculty of Medicine, Wroclaw Medical University, 50-368 Wroclaw, Poland
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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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Li M, Liu Q, Wang W, Jiang L. HLA-DRB1*14:54 Is Associated with Pulmonary Alveolar Proteinosis: A Retrospective Real-World Audit. Biomedicines 2023; 11:2909. [PMID: 38001910 PMCID: PMC10669482 DOI: 10.3390/biomedicines11112909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 10/14/2023] [Accepted: 10/23/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND Pulmonary alveolar proteinosis (PAP) is a rare pulmonary disease characterized by abnormal accumulation of pulmonary surfactant lipids in alveoli or terminal bronchioles, leading to increased infection risk and progressive respiratory failure. Approximately more than 90% of all cases are autoimmune PAP (aPAP). Since one of the predisposing factors has been identified as genes located within the major-histocompatibility-complex region, an investigation of human leukocyte antigen (HLA) alleles associated with the risk of aPAP is warranted. METHODS We retrospectively studied 60 patients pathologically diagnosed with PAP from 2019 to 2022. Patients were divided into the aPAP group or secondary PAP (sPAP) group according to their clinical information. Qualified DNA was extracted from the paraffin-embedded tissue of 28 patients, and the PCR-sequence-based typing method was used for HLA-DRB1 genotyping. RESULTS A similar HLA-DRB1 allele profile (including the HLA-DRB1*08:03) between the aPAP group and sPAP group was revealed, except that HLA-DRB1*14:54, which has never been reported in aPAP patients, was only detected in the aPAP group rather than the sPAP group (19.4% vs. 0.0%, p = 0.030). Under inhaled granulocyte-macrophage colony-stimulating factor therapy, more clinical remission was observed in HLA-DRB1*14:54 carriers rather than in HLA-DRB1*08:03 carriers (80.0% vs. 57.1%). CONCLUSIONS Our real-world study revealed for the first time that a population with HLA-DRB1*14:54 was subject to aPAP, and HLA-DRB1*14:54 might imply a response in aPAP patients to inhaled granulocyte-macrophage colony-stimulating factor in aPAP patients.
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Affiliation(s)
| | | | | | - Lili Jiang
- Department of Pathology, West China Hospital, Sichuan University, Chengdu 610041, China; (M.L.); (Q.L.); (W.W.)
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Chandrashekar DS, Athar M, Manne U, Varambally S. Comparative transcriptome analyses reveal genes associated with SARS-CoV-2 infection of human lung epithelial cells. Sci Rep 2021; 11:16212. [PMID: 34376762 PMCID: PMC8355180 DOI: 10.1038/s41598-021-95733-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 07/01/2021] [Indexed: 12/13/2022] Open
Abstract
During 2020, understanding the molecular mechanism of SARS-CoV-2 infection (the cause of COVID-19) became a scientific priority due to the devastating effects of the COVID-19. Many researchers have studied the effect of this viral infection on lung epithelial transcriptomes and deposited data in public repositories. Comprehensive analysis of such data could pave the way for development of efficient vaccines and effective drugs. In the current study, we obtained high-throughput gene expression data associated with human lung epithelial cells infected with respiratory viruses such as SARS-CoV-2, SARS, H1N1, avian influenza, rhinovirus and Dhori, then performed comparative transcriptome analysis to identify SARS-CoV-2 exclusive genes. The analysis yielded seven SARS-CoV-2 specific genes including CSF2 [GM-CSF] (colony-stimulating factor 2) and calcium-binding proteins (such as S100A8 and S100A9), which are known to be involved in respiratory diseases. The analyses showed that genes involved in inflammation are commonly altered by infection of SARS-CoV-2 and influenza viruses. Furthermore, results of protein–protein interaction analyses were consistent with a functional role of CSF2 and S100A9 in COVID-19 disease. In conclusion, our analysis revealed cellular genes associated with SARS-CoV-2 infection of the human lung epithelium; these are potential therapeutic targets.
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Affiliation(s)
- Darshan S Chandrashekar
- Molecular and Cellular Pathology, Department of Pathology, Wallace Tumor Institute, University of Alabama at Birmingham, 4th Floor, 20B, Birmingham, AL, 35233, USA.
| | - Mohammad Athar
- Department of Dermatology, University of Alabama at Birmingham, Birmingham, AL, USA.,O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Upender Manne
- Molecular and Cellular Pathology, Department of Pathology, Wallace Tumor Institute, University of Alabama at Birmingham, 4th Floor, 20B, Birmingham, AL, 35233, USA.,O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Sooryanarayana Varambally
- Molecular and Cellular Pathology, Department of Pathology, Wallace Tumor Institute, University of Alabama at Birmingham, 4th Floor, 20B, Birmingham, AL, 35233, USA. .,O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, USA. .,Informatics Institute, University of Alabama at Birmingham, Birmingham, AL, USA.
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Uchida Y, Nakagome K, Tazawa R, Akasaka K, Ito M, Haga Y, Komiyama KI, Soma T, Nakata K, Nagata M. Modified eosinophil adhesion in pulmonary alveolar proteinosis caused by CSF2RA deletion. Allergol Int 2019; 68S:S14-S16. [PMID: 31303308 DOI: 10.1016/j.alit.2019.05.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 04/16/2019] [Accepted: 05/05/2019] [Indexed: 11/29/2022] Open
Affiliation(s)
- Yoshitaka Uchida
- Department of Respiratory Medicine, Saitama Medical University, Saitama, Japan; Allergy Center, Saitama Medical University, Saitama, Japan
| | - Kazuyuki Nakagome
- Department of Respiratory Medicine, Saitama Medical University, Saitama, Japan; Allergy Center, Saitama Medical University, Saitama, Japan.
| | - Ryushi Tazawa
- Bioscience Medical Research Center, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Keiichi Akasaka
- Bioscience Medical Research Center, Niigata University Medical and Dental Hospital, Niigata, Japan; Department of Respiratory Medicine, Saitama Red Cross Hospital, Saitama, Japan
| | - Masayuki Ito
- Bioscience Medical Research Center, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Yoshiyuki Haga
- Emergency Medical Center, Saitama Medical University, Saitama, Japan
| | - Ken-Ichiro Komiyama
- Department of Respiratory Medicine, Saitama Medical University, Saitama, Japan; Allergy Center, Saitama Medical University, Saitama, Japan
| | - Tomoyuki Soma
- Department of Respiratory Medicine, Saitama Medical University, Saitama, Japan; Allergy Center, Saitama Medical University, Saitama, Japan
| | - Koh Nakata
- Bioscience Medical Research Center, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Makoto Nagata
- Department of Respiratory Medicine, Saitama Medical University, Saitama, Japan; Allergy Center, Saitama Medical University, Saitama, Japan
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McCarthy C, Kokosi M, Bonella F. Shaping the future of an ultra-rare disease: unmet needs in the diagnosis and treatment of pulmonary alveolar proteinosis. Curr Opin Pulm Med 2019; 25:450-458. [PMID: 31365379 DOI: 10.1097/mcp.0000000000000601] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW Pulmonary alveolar proteinosis (PAP) can be considered the archetype of ultra-rare diseases with a prevalence of under 10 cases per million. We discuss the classification of PAP, the current diagnostic practice and the supplementary role of genetic testing and granulocyte-macrophage colony-stimulating factor (GM-CSF) signalling in the diagnosis of congenital and hereditary PAP. We report on novel therapeutic approaches such as GM-CSF substitution, stem cell transplantation, pioglitazone, statins and immunomodulation. RECENT FINDINGS The discovery of new genetic mutations underlying this syndrome raises the question whether the classification should be radically revised in the future. Serum GM-CSF autoantibody is the best diagnostic marker for autoimmune PAP, the most common form, but does not correlate with disease severity. Several circulating biomarkers have been investigated to assess disease activity and predict outcome. Imaging techniques have also enormously evolved and offer new tools to quantify disease burden and possibly drive therapeutic decisions. Promising clinical trials are ongoing and will generate new treatment strategies besides or in addition to whole lung lavage in the next future. SUMMARY Despite impressive advances in understanding pathogenesis, PAP remains a rare syndrome with several unanswered questions impacting diagnosis, management and treatment, and, as a result, patients' quality of life.
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Affiliation(s)
- Cormac McCarthy
- Department of Respiratory Medicine, Rare Lung Disease Centre, St. Vincent's University Hospital, University College Dublin, Dublin, Ireland
| | - Maria Kokosi
- Interstitial Lung Disease Unit, Royal Brompton Hospital and National Heart and Lung Institute, Imperial College London, London, UK
| | - Francesco Bonella
- Department of Pneumology, Centre for Interstitial and Rare Lung Disease, Ruhrlandklinik, University Hospital Essen, Essen, Germany
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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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Pulmonary Alveolar Proteinosis in Setting of Inhaled Toxin Exposure and Chronic Substance Abuse. Case Rep Pulmonol 2018; 2018:5202173. [PMID: 29607238 PMCID: PMC5828087 DOI: 10.1155/2018/5202173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 08/15/2017] [Accepted: 09/20/2017] [Indexed: 11/17/2022] Open
Abstract
Pulmonary alveolar proteinosis (PAP) is a rare lung disorder in which defects in alveolar macrophage maturation or function lead to the accumulation of proteinaceous surfactant in alveolar space, resulting in impaired gas exchange and hypoxemia. PAP is categorized into three types: hereditary, autoimmune, and secondary. We report a case of secondary PAP in a 47-year-old man, whose risk factors include occupational exposure to inhaled toxins, especially aluminum dust, the use of anabolic steroids, and alcohol abuse, which in mice leads to alveolar macrophage dysfunction through a zinc-dependent mechanism that inhibits granulocyte macrophage-colony stimulating factor (GM-CSF) receptor signalling. Although the rarity and vague clinical presentation of PAP can pose diagnostic challenges, clinician awareness of PAP risk factors may facilitate the diagnostic process and lead to more prompt treatment.
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