Case Report and Review of Alveolar Proteinosis

Abstract

A 47-year-old Mexican-American man was referred to our hospital for persistent coughing that had lasted 7 months. He also had mild whitish sputum production and dyspnea on exertion. He had no history of fever, chills, wheezing, chest pain, or sudden or excess weight loss. He had longstanding, intermittent nasal congestion with a clear discharge. He had been treated for pneumonia in 1991, 1995, 2008, and 2010 with numerous antibiotics but his nasal congestion had not improved. His medical history included chronic sinusitis and 2 surgical procedures to correct septal deviation. He was not currently on any medications, was a lifelong nonsmoker, and worked at a mail-sorting company in a position that involved using a forklift and carrying boxes. He reported drinking 3 to 4 beers each weekend and had no known allergies, pets, exposure to chemicals or fumes, or history of recent travel.On physical examination, the patient was not in respiratory distress. His arterial O 2 saturation on room air was 96%. Auscultation of the chest revealed few rhonchi. No wheezing was heard and no rales were observed. Pulmonary function tests revealed minimal obstructive airway disease and mild restriction. His first heart sound (A2) was regular; his second heart sound (P2), which reflects the anatomical closing of the pulmonic valve, was unremarkable. Results of his abdominal examination were unremarkable; peripheral cyanosis and edema were not observed.Laboratory findings included a normal complete blood count and a normal five part leukocyte count; however, his lactate dehydrogenase (LDH) 6 months earlier had been 292 (91-232 U/L). Arterial blood gas analysis showed a pH of 7.45, CO 2 partial pressure of 36.5 mm Hg, and PO 2 of 75 mm Hg. Microbiologic and serologic tests for fungal infections, tuberculosis, and autoimmune diseases were all negative. Chest radiographic imaging demonstrated bilateral perihilar infiltrates and diffuse reticulonodular lesions in both lung fields; these entities were centrally located and revealed a density in the right lower lobe pleural base. A computed tomographic scan of the chest showed bilateral interstitial confluent pulmonary infiltrates.The patient underwent bronchoscopy with bronchoalveolar lavage and brushings from the right lower lobe. Endobronchial and transbronchial biopsies performed with the help of computed radiographic C-arm fluoroscopic imaging was also performed on the right lower lobe. All cytologic and tissue specimens were sent to the Department of Pathology for routine cytologic and histologic evaluation. Results for the cytologic specimensWe describe the case of a 47-year-old Mexican-American man who had had a persistent cough for the previous 7 months. He had undergone multiple treatments with antibiotics which yielded no improvement in his condition. During his most recent coughing episode, he underwent a bronchoscopic procedure that revealed alveolar proteinosis. In this case report we discuss the unusual presentation and review the treatment and clinical course of alveolar pro...