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Yatomi M, Akasaka K, Sato S, Chida M, Kanbe M, Sawada H, Yokota I, Wakamatsu I, Muto S, Sato M, Yamaguchi K, Miura Y, Tsurumaki H, Sakurai R, Hara K, Koga Y, Sunaga N, Yamakawa H, Matsushima H, Yamazaki S, Endo Y, Motegi SI, Hisada T, Maeno T. A case of autoimmune pulmonary alveolar proteinosis during the course of treatment of rapidly progressive interstitial pneumonia associated with anti-MDA5 antibody-positive dermatomyositis. BMC Pulm Med 2024; 24:170. [PMID: 38589870 PMCID: PMC11003183 DOI: 10.1186/s12890-024-02989-9] [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: 12/17/2023] [Accepted: 04/01/2024] [Indexed: 04/10/2024] Open
Abstract
BACKGROUND Autoimmune pulmonary alveolar proteinosis (APAP) is a diffuse lung disease that causes abnormal accumulation of lipoproteins in the alveoli; however, its pathogenesis remains unclear. Recently, APAP cases have been reported during the course of dermatomyositis. The combination of these two diseases may be coincidental; however, it may have been overlooked because differentiating APAP from a flare-up of interstitial pneumonia associated with dermatomyositis is challenging. This didactic case demonstrates the need for early APAP scrutiny. CASE PRESENTATION A 50-year-old woman was diagnosed with anti-melanoma differentiation-associated gene 5 (anti-MDA5) antibody-positive dermatitis and interstitial pneumonia in April 2021. The patient was treated with corticosteroids, tacrolimus, and cyclophosphamide pulse therapy for interstitial pneumonia complicated by MDA5 antibody-positive dermatitis, which improved the symptoms and interstitial pneumonia. Eight months after the start of treatment, a new interstitial shadow appeared that worsened. Therefore, three additional courses of cyclophosphamide pulse therapy were administered; however, the respiratory symptoms and interstitial shadows did not improve. Respiratory failure progressed, and 14 months after treatment initiation, bronchoscopy revealed turbid alveolar lavage fluid, numerous foamy macrophages, and numerous periodic acid-Schiff-positive unstructured materials. Blood test results revealed high anti-granulocyte-macrophage colony-stimulating factor (GM-CSF) antibody levels, leading to a diagnosis of APAP. The patient underwent whole-lung lavage, and the respiratory disturbance promptly improved. Anti-GM-CSF antibodies were measured from the cryopreserved serum samples collected at the time of diagnosis of anti-MDA5 antibody-positive dermatitis, and 10 months later, both values were significantly higher than normal. CONCLUSIONS This is the first report of anti-MDA5 antibody-positive dermatomyositis complicated by interstitial pneumonia with APAP, which may develop during immunosuppressive therapy and be misdiagnosed as a re-exacerbation of interstitial pneumonia. In anti-MDA5 antibody-positive dermatomyositis, APAP comorbidity may have been overlooked, and early evaluation with bronchoalveolar lavage fluid and anti-GM-CSF antibody measurements should be considered, keeping the development of APAP in mind.
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Affiliation(s)
- Masakiyo Yatomi
- Division of Allergy and Respiratory Medicine, Integrative Center of Internal Medicine, Gunma University Hospital, 3-39-15 Showa-Machi, Maebashi, Gunma, 371- 8511, Japan.
| | - Keiichi Akasaka
- Department of Respiratory Medicine, Saitama Red Cross Hospital, 1-5, Shintoshin, Chuo-Ku, Saitama, 330-8553, Japan
| | - Shintaro Sato
- Department of Respiratory Medicine, Saitama Red Cross Hospital, 1-5, Shintoshin, Chuo-Ku, Saitama, 330-8553, Japan
| | - Mizuki Chida
- Department of Dermatology, Gunma University Graduate School of Medicine, Gunma University Hospital, 3-39-15 Showa-Machi, Maebashi, Gunma, 371- 8511, Japan
| | - Mio Kanbe
- Division of Allergy and Respiratory Medicine, Integrative Center of Internal Medicine, Gunma University Hospital, 3-39-15 Showa-Machi, Maebashi, Gunma, 371- 8511, Japan
| | - Hiru Sawada
- Division of Allergy and Respiratory Medicine, Integrative Center of Internal Medicine, Gunma University Hospital, 3-39-15 Showa-Machi, Maebashi, Gunma, 371- 8511, Japan
| | - Itaru Yokota
- Division of Allergy and Respiratory Medicine, Integrative Center of Internal Medicine, Gunma University Hospital, 3-39-15 Showa-Machi, Maebashi, Gunma, 371- 8511, Japan
| | - Ikuo Wakamatsu
- Division of Allergy and Respiratory Medicine, Integrative Center of Internal Medicine, Gunma University Hospital, 3-39-15 Showa-Machi, Maebashi, Gunma, 371- 8511, Japan
| | - Sohei Muto
- Division of Allergy and Respiratory Medicine, Integrative Center of Internal Medicine, Gunma University Hospital, 3-39-15 Showa-Machi, Maebashi, Gunma, 371- 8511, Japan
| | - Mari Sato
- Division of Allergy and Respiratory Medicine, Integrative Center of Internal Medicine, Gunma University Hospital, 3-39-15 Showa-Machi, Maebashi, Gunma, 371- 8511, Japan
| | - Kochi Yamaguchi
- Division of Allergy and Respiratory Medicine, Integrative Center of Internal Medicine, Gunma University Hospital, 3-39-15 Showa-Machi, Maebashi, Gunma, 371- 8511, Japan
| | - Yosuke Miura
- Division of Allergy and Respiratory Medicine, Integrative Center of Internal Medicine, Gunma University Hospital, 3-39-15 Showa-Machi, Maebashi, Gunma, 371- 8511, Japan
| | - Hiroaki Tsurumaki
- Division of Allergy and Respiratory Medicine, Integrative Center of Internal Medicine, Gunma University Hospital, 3-39-15 Showa-Machi, Maebashi, Gunma, 371- 8511, Japan
| | - Reiko Sakurai
- Oncology Center, Gunma University Hospital, 3-39-15 Showa-Machi, Maebashi, Gunma, 371-, 8511, Japan
| | - Kenichiro Hara
- Division of Allergy and Respiratory Medicine, Integrative Center of Internal Medicine, Gunma University Hospital, 3-39-15 Showa-Machi, Maebashi, Gunma, 371- 8511, Japan
| | - Yasuhiko Koga
- Division of Allergy and Respiratory Medicine, Integrative Center of Internal Medicine, Gunma University Hospital, 3-39-15 Showa-Machi, Maebashi, Gunma, 371- 8511, Japan
| | - Noriaki Sunaga
- Division of Allergy and Respiratory Medicine, Integrative Center of Internal Medicine, Gunma University Hospital, 3-39-15 Showa-Machi, Maebashi, Gunma, 371- 8511, Japan
| | - Hideaki Yamakawa
- Department of Respiratory Medicine, Saitama Red Cross Hospital, 1-5, Shintoshin, Chuo-Ku, Saitama, 330-8553, Japan
| | - Hidekazu Matsushima
- Department of Respiratory Medicine, Saitama Red Cross Hospital, 1-5, Shintoshin, Chuo-Ku, Saitama, 330-8553, Japan
| | - Sahori Yamazaki
- Department of Dermatology, Gunma University Graduate School of Medicine, Gunma University Hospital, 3-39-15 Showa-Machi, Maebashi, Gunma, 371- 8511, Japan
| | - Yukie Endo
- Department of Dermatology, Gunma University Graduate School of Medicine, Gunma University Hospital, 3-39-15 Showa-Machi, Maebashi, Gunma, 371- 8511, Japan
| | - Sei-Ichiro Motegi
- Department of Dermatology, Gunma University Graduate School of Medicine, Gunma University Hospital, 3-39-15 Showa-Machi, Maebashi, Gunma, 371- 8511, Japan
| | - Takeshi Hisada
- Gunma University Graduate School of Health Sciences, 3-39-22 Showa-Machi, Maebashi, Gunma, 371-8514, Japan
| | - Toshitaka Maeno
- Division of Allergy and Respiratory Medicine, Integrative Center of Internal Medicine, Gunma University Hospital, 3-39-15 Showa-Machi, Maebashi, Gunma, 371- 8511, Japan
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Muto Y, Hagiwara E, Baba T, Sato Y, Sakayori M, Tabata E, Sekine A, Komatsu S, Okudela K, Sayama K, Ogura T. Unilateral Autoimmune Pulmonary Alveolar Proteinosis with Polymyositis-related Interstitial Lung Disease. Intern Med 2022; 61:3095-3100. [PMID: 35370233 PMCID: PMC9646339 DOI: 10.2169/internalmedicine.9015-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
A 61-year-old patient with cystic bronchiectasis and bronchial artery hyperplasia in the left lung was diagnosed with polymyositis-related interstitial lung disease. After nine months of immunosuppressive therapy, he developed unilateral autoimmune pulmonary alveolar proteinosis (APAP) in the right lung with respiratory failure. After bronchial artery embolization to prevent massive hemoptysis, whole-lung lavage was performed using veno-venous extracorporeal membrane oxygenation. His respiratory condition improved, and he was discharged from the hospital with supplemental oxygen. Three reported cases of APAP with polymyositis-related interstitial lung disease, including the present case, were all positive for anti-glycyl tRNA synthetase antibody and were under immunosuppressive treatment.
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Affiliation(s)
- Yutaka Muto
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Japan
| | - Eri Hagiwara
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Japan
| | - Tomohisa Baba
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Japan
| | - Yozo Sato
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Japan
| | - Masashi Sakayori
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Japan
| | - Erina Tabata
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Japan
| | - Akimasa Sekine
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Japan
| | - Shigeru Komatsu
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Japan
| | - Koji Okudela
- Department of Pathology, Yokohama City University School of Medicine, Japan
| | - Koichi Sayama
- Department of Respiratory Medicine, Kawasaki Municipal Hospital, Japan
| | - Takashi Ogura
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Japan
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3
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Ishimoto H, Sakamoto N, Yura H, Hara A, Kido T, Yamaguchi H, Yamamoto K, Obase Y, Ishimatsu Y, Satoh M, Mukae H. Autoimmune pulmonary alveolar proteinosis exacerbated by steroid therapy due to misdiagnosis as anti-aminoacyl-tRNA synthetase (ARS) antibody positive- interstitial pneumonia: a case report. BMC Pulm Med 2022; 22:120. [PMID: 35361191 PMCID: PMC8973538 DOI: 10.1186/s12890-022-01909-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 03/22/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Anti-aminoacyl-tRNA synthetase (anti-ARS) antibodies are myositis-specific autoantibodies that have been identified in a subset of patients with interstitial pneumonia who do not present with dermatomyositis or polymyositis. Anti-ARS antibody-positive interstitial pneumonia is commonly treated with steroids or immunosuppressive agents and is usually responsive to these therapies. Here, we present in detail a case in which respiratory failure of a patient diagnosed with anti-ARS antibody-positive interstitial pneumonia was exacerbated by treatment with steroids and immunosuppressive agents. Further examination revealed misdiagnosis of this patient and a subsequent diagnosis of autoimmune pulmonary alveolar proteinosis. CASE PRESENTATION A 66-year-old man presented to the hospital with dyspnea on exertion, which resulted in the detection of interstitial pneumonia. Serum anti-ARS antibodies were detected; however, there were no other findings suggestive of myositis. Pulmonary alveolar proteinosis (PAP) was suspected based on the marked increase in serum KL-6 and chest computed tomography findings. The bronchoalveolar lavage revealed no milky changes in the lavage fluid. After treatment with steroids and initiation of immunosuppressive agents for anti-ARS antibody-positive interstitial pneumonia, respiratory failure and chest imaging findings showed worsening of the condition. Bronchoscopy was repeated, and milk-like alveolar lavage fluid was collected; serum anti-granulocyte macrophage colony-stimulating factor antibody was identified. Steroids and immunosuppressive agents were gradually tapered and discontinued, and the patient's condition stabilized after repeated alveolar lavage under general anesthesia. CONCLUSION Due to similar presentation, PAP can be misdiagnosed as interstitial pneumonia. If pulmonary lesions due to interstitial pneumonia are exacerbated by immunosuppressive treatment, physicians should reconsider the diagnosis and include PAP in the differential diagnosis.
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Affiliation(s)
- Hiroshi Ishimoto
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Noriho Sakamoto
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan.
| | - Hirokazu Yura
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan.,Department of Respiratory Medicine, National Hospital Organization Nagasaki Medical Center, 2-1001-1 Kubara, Ohmura, Nagasaki, 856-8562, Japan
| | - Atsuko Hara
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Takashi Kido
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Hiroyuki Yamaguchi
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Kazuko Yamamoto
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Yasushi Obase
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Yuji Ishimatsu
- Department of Nursing, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8520, Japan
| | - Minoru Satoh
- Department of Clinical Nursing, School of Health Sciences, University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, Fukuoka, 807-0804, Japan
| | - Hiroshi Mukae
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
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4
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Arai T, Kasai T, Shimizu K, Kawahara K, Katayama K, Sugimoto C, Hirose M, Okamoto H, Tachibana K, Akira M, Inoue Y. Autoimmune Pulmonary Alveolar Proteinosis Complicated with Sarcoidosis: the Clinical Course and Serum Levels of Anti-granulocyte-macrophage colony-stimulating Factor Autoantibody. Intern Med 2020; 59:2539-2546. [PMID: 32611952 PMCID: PMC7662056 DOI: 10.2169/internalmedicine.3853-19] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Autoimmune pulmonary alveolar proteinosis (APAP) is caused by macrophage dysfunction due to anti-granulocyte-macrophage colony-stimulating factor (GM-CSF) autoantibody. We experienced 2 cases of APAP complicated with sarcoidosis in a 42-year-old woman and a 51-year-old man (age at the sarcoidosis diagnosis). APAP preceded sarcoidosis in the woman, and both diseases were diagnosed simultaneously in the man. Sarcoidosis lesions were observed in the lung, skin, and eyes, and the pathological findings of APAP were not marked at the diagnosis of sarcoidosis in either case. Low-grade positive serum anti-GM-CSF autoantibody was suspected to be correlated with the occurrence of sarcoidosis and resolution of APAP.
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Affiliation(s)
- Toru Arai
- Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Japan
| | - Takahiko Kasai
- Department of Pathology, National Hospital Organization Kinki-Chuo Chest Medical Center, Japan
| | - Kazunori Shimizu
- Department of Pulmonary Critical Care Medicine, Osaka Prefectural Hospital Organization Osaka Habikino Medical Center, Japan
| | - Kunimitsu Kawahara
- Department of Pathology, Osaka Prefectural Hospital Organization Osaka Habikino Medical Center, Japan
| | - Kanako Katayama
- Department of Internal Medicine, National Hospital Organization Kinki-Chuo Chest Medical Center, Japan
| | - Chikatoshi Sugimoto
- Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Japan
| | - Masaki Hirose
- Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Japan
| | | | - Kazunobu Tachibana
- Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Japan
- Department of Internal Medicine, National Hospital Organization Kinki-Chuo Chest Medical Center, Japan
| | - Masanori Akira
- Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Japan
- Department of Radiology, National Hospital Organization Kinki-Chuo Chest Medical Center, Japan
| | - Yoshikazu Inoue
- Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Japan
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5
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Sato S, Akasaka K, Ohta H, Tsukahara Y, Kida G, Tsumiyama E, Kusano K, Oba T, Nishizawa T, Kawabe R, Yamakawa H, Amano M, Matsushima H, Takada T. Autoimmune pulmonary alveolar proteinosis developed during immunosuppressive treatment in polymyositis with interstitial lung disease: a case report. BMC Pulm Med 2020; 20:84. [PMID: 32252718 PMCID: PMC7132862 DOI: 10.1186/s12890-020-1110-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Accepted: 03/10/2020] [Indexed: 11/15/2022] Open
Abstract
Background Pulmonary alveolar proteinosis (PAP) is characterized by the accumulation of surfactant proteins within the alveolar spaces. Autoimmune PAP (APAP) caused by elevated levels of GM-CSF autoantibodies (GM-Ab) is very rarely associated with systemic autoimmune disease. Here we report a case of APAP manifested during immunosuppressive treatment for polymyositis with interstitial lung disease. Case presentation A 52-year-old woman treated at our hospital because of polymyositis with interstitial pneumonia had maintained remission by immunosuppressive treatment for 15 years. She had progressive dyspnea subsequently over several months with her chest CT showing ground-glass opacities (GGO) in bilateral geographic distribution. Her bronchoalveolar lavage fluid with cloudy appearance revealed medium-sized foamy macrophages and PAS-positive amorphous eosinophilic materials by cytological examination. We diagnosed her as APAP due to an increased serum GM-CSF autoantibody level. Attenuating immunosuppression failed to lead GGO improvement, but whole lung lavage (WLL) was effective in her condition. Conclusions PAP should be considered as one of the differential diseases when the newly interstitial shadow was observed during immunosuppressive treatment. WLL should be regarded as the treatment option for APAP concurred in connective tissue disease (CTD).
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Affiliation(s)
- S Sato
- Department of Respiratory Medicine, Saitama Red Cross Hospital, 1-5, Shintoshin, Chuo-ku, Saitama, 330-8553, Japan.
| | - K Akasaka
- Department of Respiratory Medicine, Saitama Red Cross Hospital, 1-5, Shintoshin, Chuo-ku, Saitama, 330-8553, Japan
| | - H Ohta
- Department of Respiratory Medicine, Saitama Red Cross Hospital, 1-5, Shintoshin, Chuo-ku, Saitama, 330-8553, Japan
| | - Y Tsukahara
- Department of Respiratory Medicine, Saitama Red Cross Hospital, 1-5, Shintoshin, Chuo-ku, Saitama, 330-8553, Japan
| | - G Kida
- Department of Respiratory Medicine, Saitama Red Cross Hospital, 1-5, Shintoshin, Chuo-ku, Saitama, 330-8553, Japan
| | - E Tsumiyama
- Department of Respiratory Medicine, Saitama Red Cross Hospital, 1-5, Shintoshin, Chuo-ku, Saitama, 330-8553, Japan
| | - K Kusano
- Department of Respiratory Medicine, Saitama Red Cross Hospital, 1-5, Shintoshin, Chuo-ku, Saitama, 330-8553, Japan
| | - T Oba
- Department of Respiratory Medicine, Saitama Red Cross Hospital, 1-5, Shintoshin, Chuo-ku, Saitama, 330-8553, Japan
| | - T Nishizawa
- Department of Respiratory Medicine, Saitama Red Cross Hospital, 1-5, Shintoshin, Chuo-ku, Saitama, 330-8553, Japan
| | - R Kawabe
- Department of Respiratory Medicine, Saitama Red Cross Hospital, 1-5, Shintoshin, Chuo-ku, Saitama, 330-8553, Japan
| | - H Yamakawa
- Department of Respiratory Medicine, Saitama Red Cross Hospital, 1-5, Shintoshin, Chuo-ku, Saitama, 330-8553, Japan
| | - M Amano
- Department of Respiratory Medicine, Saitama Red Cross Hospital, 1-5, Shintoshin, Chuo-ku, Saitama, 330-8553, Japan
| | - H Matsushima
- Department of Respiratory Medicine, Saitama Red Cross Hospital, 1-5, Shintoshin, Chuo-ku, Saitama, 330-8553, Japan
| | - T Takada
- Uonuma Institute of Community Medicine, Niigata University Medical and Dental Hospital, Minami-Uonuma, Japan
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Yamasue M, Nureki SI, Usagawa Y, Ono T, Matsumoto H, Kan T, Kadota JI. Elevated Serum Anti-GM-CSF Antibodies before the Onset of Autoimmune Pulmonary Alveolar Proteinosis in a Patient with Sarcoidosis and Systemic Sclerosis. TOHOKU J EXP MED 2018; 243:77-83. [PMID: 28966213 DOI: 10.1620/tjem.243.77] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Pulmonary alveolar proteinosis (PAP) is characterized by the accumulation of periodic acid-schiff stain-positive lipoproteinaceous materials in the alveolar space due to impaired surfactant clearance by alveolar macrophage. Autoimmune PAP is the most common form of PAP, but rarely accompanies collagen disease or sarcoidosis. We report here a rare case of autoimmune PAP preceded by systemic sclerosis and sarcoidosis. A 64-year-old woman was admitted to our hospital for blurred vision, muscle weakness of extremities, Raynaud's phenomenon, and exertional dyspnea. We diagnosed her as having systemic sclerosis complicated with sarcoidosis. Chest computed tomography (CT) and transbronchial lung biopsy showed the findings of pulmonary fibrosis without PAP. We treated her with corticosteroid and intravenous cyclophosphamide therapy, followed by tacrolimus therapy. Thereafter, her symptoms improved except for exertional dyspnea, and she began to complain of productive cough thirteen months after corticosteroid and immunosuppressant therapy. On the second admission, a chest CT scan detected the emergence of crazy-paving pattern in bilateral upper lobes. Bronchoalveolar lavage (BAL) fluid with milky appearance and a lung biopsy specimen revealed acellular periodic acid-schiff stain-positive bodies. The serum titer of anti-granulocyte macrophage colony stimulating factor (GM-CSF) antibodies was elevated on first admission and remained high on second admission. We thus diagnosed her as having autoimmune PAP. Reducing the dose of immunosuppressive agents and repeating the segmental BAL resulted in the improvement of her symptoms and radiological findings. Immunosuppressant therapy may trigger the onset of autoimmune PAP in a subset of patients with systemic sclerosis and/or sarcoidosis.
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Affiliation(s)
- Mari Yamasue
- Department of Respiratory Medicine and Infectious Diseases, Oita University Faculty of Medicine
| | - Shin-Ichi Nureki
- Department of Respiratory Medicine and Infectious Diseases, Oita University Faculty of Medicine
| | - Yuko Usagawa
- Department of Respiratory Medicine and Infectious Diseases, Oita University Faculty of Medicine
| | - Tomoko Ono
- Department of Respiratory Medicine and Infectious Diseases, Oita University Faculty of Medicine
| | - Hiroyuki Matsumoto
- Department of Respiratory Medicine and Infectious Diseases, Oita University Faculty of Medicine
| | - Takamasa Kan
- Department of Respiratory Medicine and Infectious Diseases, Oita University Faculty of Medicine
| | - Jun-Ichi Kadota
- Department of Respiratory Medicine and Infectious Diseases, Oita University Faculty of Medicine
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Ito S, Wakahara K, Kojima T, Takahashi N, Nishiwaki K, Yamaguchi E, Hasegawa Y. Two cases of autoimmune pulmonary alveolar proteinosis with rheumatoid arthritis. Allergol Int 2017; 66:507-509. [PMID: 28242199 DOI: 10.1016/j.alit.2017.02.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Revised: 12/19/2016] [Accepted: 12/22/2016] [Indexed: 11/27/2022] Open
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