Authors Spoorthi Davala1, Elizabeth Gibb1, Fatima Neemuchwala1, Kelly Tuveson1, Kensho Iwanaga1, Gywnne Church1, Ngoc Ly1 UCSF Benioff Children's Hospital Oakland, Oakland, CA, United States
Case
A 12-year-old female presented to the ED with four days of acute
worsening of chronic cough and dyspnea. Upon presentation, saturations
were 80% on RA and she was placed on 5LPM nasal cannula. Exam was
notable for diminished breath sounds bilaterally, otherwise no crackles
or wheezes. Chest x-ray showed bilateral diffuse opacification.
Respiratory viral panel was positive for non-novel coronavirus 229E. She
was initially admitted to the general wards, but overnight required
escalation of respiratory support to 25L heated high-flow nasal canula
and was transferred to ICU.
Infectious disease and Pulmonary were consulted. Further history
revealed that the family lived in the Central Valley in California until
she was 8 years old and she had an intermittent dry cough, improving
with short acting beta agonist (SABA) as needed. Her cough resolved
after moving to the Bay Area. Four months prior to presentation, she
visited the Central Valley when her cough returned and did not improve
with inhaled SABA and steroids.
Figure 1. Chest CT was obtained.Figure 2. Bronchoalveolar lavage was performed and showed
On the physical exam, the chest wall was symmetric, without
deformity. No tenderness was appreciated upon palpation of the chest
wall. The patient did not exhibit signs of respiratory distress; and
normal heartbeat and breath sounds were heard upon auscultation. The
patient denied chest pain, and shortness of breath.
Laboratory evaluation was unremarkable, but serology revealed that the patient was positive for Influenza type A.
Question
What is the most likely etiology of these findings?
A. Coccidioides B. Mycobacterial Infection C. Bronchiolitis Obliterans D. Pulmonary Alveolar Proteinosis E. Hypersensitivity Pneumonitis
Answer
Answer D. Pulmonary Alveolar Proteinosis
Discussion
The bronchoalveolar lavage (BAL) was highly concerning for Pulmonary
Alveolar Proteinosis (PAP). PAP is defined as accumulation of PAS
positive lipoproteinaceous material in alveolar spaces and is caused by
overproduction or inadequate clearance of surfactant. 1 The
etiologies of PAP can be divided into three larger categories including
autoimmune, congenital and secondary causes. Autoimmune is the most
common cause and is characterized by the presence of auto-antibodies
directed against GM-CSF signaling. This leads to decreased clearance of
surfactant by alveolar macrophages and thus accumulation in alveolar
spaces. Congenital causes present in the neonatal period and are
secondary to genetic abnormalities affecting surfactant production.
Secondary PAP often presents in adulthood and is caused by
immunodeficiency disorders, malignancies, hematopoietic disorders and
exposures to high levels of dust or toxic fumes. 1, 2
Clinically, patients can present with progressive dyspnea on
exertion, cough, sputum production and fatigue. Less commonly patients
may experience fever, chest pain or hemoptysis, usually in the presence
of secondary infection. Physical exam findings are nonspecific, however
50% may present with crackles. Less than 25% may present with clubbing
or cyanosis. 3 Routine laboratory testing are usually normal except for elevated serum lactate dehydrogenase. 1-3
Chest X-rays typically show ill-defined bilateral, symmetric air-space
disease in the mid and lower lung fields. High-resolution CT scan shows
ground glass opacification with intralobular and interlobular septal
thickening lung tissue, often referred to as “crazy paving”. Pulmonary
function testing (PFT) reveals a restrictive ventilatory defect with
decreased forced vital capacity and disproportionate reduction in carbon
monoxide diffusing capacity. 2
In approximately 75% of cases, BAL can be used to establish diagnosis
of PAP. Lavage fluid is often described as having an opaque and milky
appearance due to large, foamy alveolar macrophages filled with large
amounts of periodic acid Schiff (PAS) stain-positive lipoproteinaceous
material. In autoimmune PAP, serum and BAL anti-GM-CSF antibodies are
elevated. To exclude other infectious etiologies, BAL fluid should be
sent for cultures. If BAL findings are non-diagnostic the next step is
often transbronchial or surgical lung biopsy. 1
Treatment for PAP depends on the severity and etiology of disease. In
asymptomatic or mild disease, supportive care with serial monitoring of
PFTs and imaging is recommended. In moderate to severe disease, whole
lung lavage (WLL) continues to be the standard of care. In autoimmune
PAP, several trials have shown improvement in lung function with the use
of nebulized recombinant GM-CSF. 2, 3 There are also ongoing studies evaluating the role of rituximab, an anti-CD20 monoclonal antibody. 4
Other trials are evaluating the use of statins in lowering
intracellular cholesterol accumulation and thus improving surfactant
uptake and clearance by alveolar macrophages. 5 Therapy for
congenital PAP includes supportive care and eventual lung transplant.
Therapy for secondary PAP generally involves treatment of the underlying
condition.
Figure 3
Multiliter bags of normal saline solution, run through a blood
warmer, are used to lavage the lungs. IV tubing with a stopcock creates
the lavage and drainage limbs, both of which are connected to a dual
lumen endotracheal tube. Multiple drainages are performed and fluid is
noted to become progressively less opaque.
Our patient’s BAL pathology report showed granular eosinophilic
proteinaceous fluid, staining positive for PAS. Anti-GM CSF antibodies
returned positive. Bacterial, viral and fungal cultures from BAL were
negative. Autoimmune work-up was normal. She underwent a total of six
WLL via rapid infuser system (see figure above) and required nocturnal
positive pressure support. She was started on nebulized GM-CSF treatment
(Sargramostim). Due to her inadequate response, she was then started on
atorvastatin. She has subsequently improved and now remains only on
statin therapy with improving PFTs. She has not required WLL since
initiating atorvastatin.
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