Pulmonary Alveolar Proteinosis After Exposure to Cleaning Fluids

Abstract

SESSION TITLE: Critical Care 1 SESSION TYPE: Affiliate Case Report Slide PRESENTED ON: Sunday, October 29, 2017 at 10:45 AM - 12:00 PM INTRODUCTION: Pulmonary Alveolar Proteinosis (PAP) is a rare disorder characterized by the accumulation of amorphous, periodic acid-Schiff positive material composed of surfactant phospholipids and apoproteins. This can be congenital, primary or secondary. We present a case of secondary PAP in a housecleaner after exposure to cleaning fluids. CASE PRESENTATION: 64 year old woman, with 30 pack smoking years, presented with worsening shortness of breath and dry cough over 6 months. She was initially diagnosed with pneumonia and had partial response to treatment with antibiotics and steroids. Subsequent high resolution computed tomography scan (CT) of the chest revealed bilateral diffuse ground glass infiltrates with intralobular septal thickening with crazy pavement pattern. Further history brought to light her house cleaning occupation using commercial cleaning products. Bronchoscopy revealed the presence of opaque lavage and transbronchial biopsies confirmed alveolated parenchyma with eosinophilic granular material, periodic acid Schiff stain positive foamy exudates. Blood testing for antibodies against Granulocyte Macrophage-Colony Stimulating Factor was negative. The patient was interested in whole lung lavage, however, given her clinical picture and high suspicion for secondary PAP, we recommended a conservative approach with a focus on pulmonary rehabilitation, quitting smoking and avoidance of exposure to cleaning chemicals. At 3 months follow up, her symptoms dramatically improved and a repeat CT chest showed marked resolution of previous findings. DISCUSSION: Secondary PAP develops in association with conditions involving functional impairment or reduced numbers of alveolar macrophages. Such conditions include some hematologic cancers, pharmacologic immunosuppression, inhalation of inorganic dust or toxic fumes1 including silica, paint, wood powder, titanium and welding smoke. Cleaning fluids are commonplace in certain occupations and in domestic life, hence unanswered questions regarding variation in susceptibility after exposure, patient phenotype, level of exposure and constituent chemicals persist and warrant further investigation. Temporal improvement after avoidance of the exposure lends credence to the etiological role played by these agents. CONCLUSIONS: 1Exposure history is paramount when investigating secondary PAP, even outside of the realm of traditional occupational exposures. Reference #1: Trapenll B. et.al, Pulmonary Alveolar Proteinosis N Engl J Med 2003; 349:2527-2539 DISCLOSURE: The following authors have nothing to disclose: Karthika Linga, Minkyung Kwon, Brendon Colaco, Vichaya Arunthari, Neal Patel No Product/Research Disclosure Information