Milky fluid from the lungs: pulmonary alveolar proteinosis
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CE - MEDICAL ILLUSTRATION
Milky fluid from the lungs: pulmonary alveolar proteinosis Divya P. Nimmatoori1 · Saurabh Bansal2 · Namrata Singhania3 · Anil K. Singh4 · Vijay Mohan Sudigali5 Received: 16 July 2020 / Accepted: 20 August 2020 © Società Italiana di Medicina Interna (SIMI) 2020
Keywords Ground glass opacities · Periodic acid schiff stain · Pulmonary alveolar proteinosis A 32-year old male presented with gradually progressive dry cough and breathlessness for 6 months. He denied hemoptysis, chest pain, orthopnea, and weight loss. He was recently diagnosed with mediastinal lymph node tuberculosis and was on antitubercular therapy. He denied smoking or alcohol use. His blood pressure was 140/80 mmHg, heart rate 140 beats/min, respiratory rate 28/min, temperature 37.2 °C, and oxygen saturation 85% on room air. Lung examination showed bilateral basal fine crepitations. White blood cell count was 11,700 per m m3. Renal and liver function tests were normal. Pro-calcitonin, D-dimer, pro-brain natriuretic peptide and respiratory viral testing was within normal limits or negative. Chest radiograph showed bilateral hazy opacities involving both upper and lower lung zones (Fig. 1a). Computed tomography (CT) of chest showed bilateral ground-glass opacities (GGO) with interlobular thickening suggestive of a crazy paving appearance, and mediastinal lymphadenopathy (Fig. 1b). Bronchoscopy showed a normal endobronchial tree without any lesions. Broncho-alveolar lavage returned an opaque milky-white fluid due to the abundant lipoproteinaceous material (Fig. 1c). Gram stain, culture, silver stain and acid-fast bacilli stain was negative. Cytology revealed large acellular eosinophilic aggregates, macrophages filled with * Namrata Singhania [email protected] 1
Department of Internal Medicine, GreenField Health, Portland, OR 97225, USA
2
Department of Internal Medicine, University of Illinois At Peoria, Peoria, IL 61637, USA
3
Department of Hospital Medicine, Mount Carmel East Hospital, 6001 E Broad Street, Columbus, OH 43213, USA
4
Department of Internal Medicine, Geisinger Community Medical Center, Scranton, PA, USA
5
Department of Internal Medicine, Care Hospitals, Hyderabad, Telangana 500001, India
periodic acid schiff (PAS) positive proteinaceous material, sparse lymphocytes with no malignant cells. Trans-bronchial lung biopsy revealed eosinophilic PAS positive material. He was diagnosed with pulmonary alveolar proteinosis (PAP). He was intubated with a double lumen tube and whole lung lavage (WLL) was initiated. Due to persistent hypoxemia, segmental right lung lavage was preferred. Follow-up chest radiograph revealed new right sided pneumothorax (Fig. 1d). Chest tube was placed. Patient recovered well afterwards. This was followed by left lung segmental lavage. After lavage of both lungs, the patient improved significantly and so did the chest radiograph (Fig. 1e). PAP is characterized by accumulation of PAS positive lipoproteinacious material in the alveoli and terminal bronchioles which decreas
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