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Alveolar proteinosis or the importance of identifying concurrent infections
Proteinosis alveolar o la importancia de identificar infecciones sobreañadidas
S. Mayoralasa, L. Gómeza, S. Díaza
a Servicio de Neumología. Hospital Universitario La Paz. Madrid. Spain.
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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold"> To the Editor&#58;</span> Alveolar proteinosis &#40;AP&#41; is a rare disease which affects the lungs diffusely and is characterized by the deposition of protein-like material rich in phospholipids&#46; This material is characteristically PAS positive and does not cause interstitial alveolar inflammation&#59; thus the degree of fibrosis minimal<span class="elsevierStyleSup">1</span>&#46; Signs and symptoms are nonspecific and patients are generally asymptomatic before complications occur&#46; The main complication in AP is concurrent infection with unusual germs like <span class="elsevierStyleItalic">Aspergillus</span> sp&#46;<span class="elsevierStyleItalic">&#44; Nocardia</span> sp&#46;<span class="elsevierStyleItalic">&#44; Mycobacterium</span> sp&#46;<span class="elsevierStyleItalic">&#44; Cryptococcus neoformans&#44; Histoplasma capsulatum&#44; Pneumocystis carinii</span> and certain viruses<span class="elsevierStyleSup">2</span>&#46; We report the case of a woman diagnosed with AP after being infected with <span class="elsevierStyleItalic">Mycobacterium tuberculosis</span>&#46;</p><p class="elsevierStylePara">The patient was a 41-year-old female who smoked 500 cigarettes per year and was a moderate drinker with no relevant medical or occupational history&#46; The patient complained of night sweats&#44; dyspnea upon moderate effort&#44; cough with abundant whitish sputum and wasting syndrome with loss of 6 to 7 kg in weight starting three months earlier&#46; She had presented bloody sputum on one occasion one week before admission&#46; Perihilar ground-glass opacities were observed in the chest radiograph&#46; Physical exploration showed no significant findings&#46; Relevant analytical findings were leukocytes&#44; 6550&#47;&#181;l &#40;neutrophiles 57&#37;&#44; lymphocytes 34&#37;&#41;&#59; hemoglobin&#44; 14 g&#47;dL&#59; hematocrit&#44; 38&#46;6&#37;&#59; platelets&#44; 212 000&#59; and erythrocyte sedimentation rate&#44; 10 mm&#47;h&#46; Biochemistry&#44; proteinogram&#44; coagulation and urine analyses were normal&#46; Nuclear antibodies&#44; anti-smooth muscle and rheumatoid factors were normal&#46; The angiotensin-converting enzyme level was 51 &#40;30-50&#41;&#46; The pneumonia panel was negative and no <span class="elsevierStyleItalic">Legionella</span> antigen was found in urine&#46; Lung function testing gave normal findings&#44; including a carbon monoxide diffusion capacity of 82&#46;3&#37;&#46; Resting arterial gases were measured&#44; pH being 7&#46;39&#44; PaO<span class="elsevierStyleInf">2</span> 68 mmHg and PaCO<span class="elsevierStyleInf">2</span> 41 mmHg&#46; A computed tomography scan of the thorax showed bilateral ground-glass opacities&#44; mainly in high and mid fields&#46; Bronchoscopy revealed no endobronchial lesions&#44; but PAS-positive material was detected in bronchial aspirate and bronchoalveolar lavage samples&#46; The L&#246;wenstein&#173;Jensen culture was positive for <span class="elsevierStyleItalic">M&#46; tuberculosis</span>&#46; A transbronchial biopsy gave no remarkable findings&#46; There was good response to treatment with isoniazid and rifampicin for six months and with pyrazinamide for the first two months&#46; The patient remained asymptomatic one year later&#46; A chest radiograph showed no changes&#44; pulmonary function tests were normal and the biopsy was still PAS positive&#46; L&#246;wenstein-Jensen cultures were negative&#46;</p><p class="elsevierStylePara">The clinical presentation of AP is variable and nonspecific&#46; The most frequent symptoms are dry cough and dyspnea&#46; Some patients present no symptoms before developing concurrent infections&#44; as in the case we report&#46; Although favorable results have been described after treatment with granulocytic-monocytic series colony stimulating factor<span class="elsevierStyleSup">3</span>&#44; the only treatment of proven efficacy is whole-lung lavage<span class="elsevierStyleSup">4</span>&#46; This treatment is only prescribed for patients with dyspnea or respiratory insufficency<span class="elsevierStyleSup">5&#44;6</span>&#46; Nevertheless&#44; before considering whole-lung lavage&#44; it is necessary to rule out specifically treatable concurrent infections&#46; Our patient experienced symptoms while the <span class="elsevierStyleItalic">M&#46; tuberculosis</span> infection persisted and remained asymptomatic after being treated&#59; therefore&#44; whole-lung lavage was not considered&#46; With the exception of patients with severe respiratory insufficiency&#44; identifying and treating concurrent infections is the best way to improve quality of life and prognosis for AP patients&#46; While these infections were the main cause of death in the past&#44; the prognosis has currently improved considerably with their appropriate treatment&#46;</p>"
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