Resolution of secondary pulmonary alveolar proteinosis following treatment of rhinocerebral aspergillosis

Artificial stone-associated silicosis with concurrent Cryptococcus infection

Acute silicoproteinosis is a disease that develops in weeks, and lasting for years, after massive exposure to silica dust in relatively closed spaces. It was rare, but the cases have recently increased worldwide due to the development of artificial stone industry. Compared with traditional silicosis, artificial stone-associated silicosis is more rapidly progressive and lethal. Hence, a correct diagnosis and optimal treatment are crucial. Here, we present the clinical course of a 33-year-old artificial stonemason who suffered from acute silicoproteinosis with concurrent Cryptococcus infection resulting in profound respiratory failure. This patient was treated by bronchoscope-assisted therapeutic segmental lung lavage and antifungal agent, under mechanical ventilator and ECMO support and recovered well. A brief review of acute silicoproteinosis and artificial stone-associated silicosis is also presented and highlights the new form of industry exposure to silica.

Viral pneumonia and pulmonary alveolar proteinosis: the cause and the effect, case report

Pulmonary alveolar proteinosis (PAP) is a rare lung disease characterized by the accumulation of amorphous lipoproteinaceous material in the distal air spaces due to defective surfactant clearance by alveolar macrophages. This leads to impaired gas exchange and arterial hypoxemia of varying degrees. Although autoimmune type of PAP is thought to be idiopathic, this focused report highlights the possible relationship between viral pneumonia and autoimmune PAP (APAP) in terms of causation, superinfection and effect of treatments. We report a newly diagnosed case of APAP with a possible viral causation "trigger" for the confirmed serum anti-granulocyte macrophage-colony stimulating factor (GM-CSF) antibody. To the best of our knowledge, this is the first report that describe and discuss this issue. The patient is a 38-year-old, ex-smoker woman who had had a progressively worsening dyspnea and a persistent, productive cough for more than 4 months. It was thought to be a community acquired pneumonia (CAP) case and was treated with multiple antibiotics which yielded no improvement in her condition. Physical examination revealed mild hypoxemia and minimal bilateral fine crepitations despite marked alveolar filling on chest X-ray (CXR). She underwent a bronchoscopic procedure that revealed PAP. The case also describes an acute flare up of the condition during the course of the disease caused by a confirmed H1N1 influenza infection. APAP should be considered in the differential diagnosis of recurrent pneumonia not responding to treatment. In this case report we suggest the possible role of viral causation "trigger" or cross-reactivity of GM-CSF antibodies that lead to APAP. We also describe the provided management, the response to the antiviral therapy and the diagnostic and management challenges that was encountered during the follow up.

Temporary remission of autoimmune pulmonary alveolar proteinosis after infectious episodes

Pulmonary alveolar proteinosis (PAP) is a rare disease of unknown aetiology. Although resolution occurs in about 30% of autoimmune PAP (APAP) cases, its pathogenesis is not yet sufficiently understood. Two APAP cases at our institute showed remission following infectious episodes. Case 1: a 40-year-old female APAP patient suffered from herpes encephalitis and was treated with an antiviral drug. Her symptoms and radiological results resolved within two months of her recovery from the encephalitis. Case 2: A 53-year-old male current-smoker APAP patient was admitted for pneumonia. After treatment with antibiotics, his radiological results and symptoms improved. He experienced a similar resolution of APAP after another infectious episode two years later. Remission of APAP may occur following viral or bacterial infection. We hypothesise that remission of APAP is triggered by the induction of granulocyte-macrophage colony-stimulating factor (GM-CSF) following viral or bacterial infection. Further studies of APAP remission, and especially of the effects of GM-CSF induction, are needed. (Sarcoidosis Vasc Diffuse Lung Dis 2017; 34: 85-90).

Autoimmune Pulmonary Alveolar Proteinosis Following Pulmonary Aspergillosis

A 59-year-old man, ex-smoker, was diagnosed with pulmonary aspergillosis according to chest radiography findings of a fungus ball and Aspergillus fumigatus detection in the bronchial lavage fluid. Two years after anti-fungal therapy, he was diagnosed with autoimmune pulmonary alveolar proteinosis (APAP) according to a crazy paving pattern in computed tomography scans of the chest, milky bronchoalveolar lavage effluent, and positive anti-granulocyte-macrophage colony-stimulating factor (GM-CSF) autoantibody in the serum. The patient ultimately died of respiratory failure caused by APAP four months after GM-CSF therapy commenced. Aspergillus infection may thus be associated with the onset and progression of APAP and tolerance to GM-CSF therapy.

Systemic lupus erythematosus complicating autoimmune pulmonary alveolar proteinosis that was worsened by immunosuppressive therapy

A 26-year-old Japanese woman developed autoimmune pulmonary alveolar proteinosis (PAP) during glucocorticoid therapy for systemic lupus erythematosus (SLE). Intensive immunosuppressive therapy worsened the PAP. De-escalation of immunosuppressive therapy improved the PAP. Autoimmune PAP is rarely associated with systemic autoimmune diseases, and the present case is the first case of autoimmune PAP associated with SLE. Moreover, the present case suggests that immunosuppressive therapy should be avoided or used carefully for the treatment of patients with anti-GM-CSF antibody, such as those with autoimmune PAP.