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Pulmonary Alveolar Proteinosis

By

Joyce Lee

, MD, MAS, University of Colorado School of Medicine

Last full review/revision Jun 2021| Content last modified Jun 2021
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Pulmonary alveolar proteinosis is a rare disorder in which the air sacs of the lungs (alveoli) become plugged with a protein- and fat-rich fluid.

  • Pulmonary alveolar proteinosis typically affects people who are aged 20 to 50 and who have not had lung disease.

  • People have difficulty breathing and cough.

  • Diagnosis is by computed tomography and testing a sample of lung fluid obtained using a bronchoscope.

  • If symptoms are severe, the lungs are washed out, one at a time.

The cause of pulmonary alveolar proteinosis is almost always unknown, but recent studies have linked it to production of an antibody directed against a protein that seems to be involved with the production or the breakdown of surfactant (a substance normally produced in the lungs). Occasionally, development of pulmonary alveolar proteinosis is related to exposure to toxic substances, such as inorganic dusts, infection with Pneumocystis jirovecii Causes Pneumonia is infection of the lungs. Pneumonia in people whose immune system is weakened or impaired (for example, by acquired immunodeficiency syndrome [AIDS], cancer, organ transplantation... read more , certain cancers, and immunosuppressants. Rarely, it occurs in newborns.

The protein in the lungs plugs up the alveoli and small airways (bronchioles). In rare instances, lung tissue becomes scarred. The disease may progress, remain stable, or disappear spontaneously.

Symptoms of Pulmonary Alveolar Proteinosis

When the alveoli are plugged, the transfer of oxygen to the blood from the lungs is severely impaired. Consequently, most people with pulmonary alveolar proteinosis experience shortness of breath when they exert themselves. Some people have severe difficulty breathing, even at rest. People often have severe disability due to inadequate lung function. Most people also have a cough that often does not produce sputum, but occasionally people expectorate chunky gelatinous material.

Other symptoms may include fatigue, weight loss, and low-grade fever. Lung infections may occur, and infection can quickly worsen symptoms of shortness of breath and cause fever.

Diagnosis of Pulmonary Alveolar Proteinosis

  • Chest computed tomography

  • Bronchoalveolar lavage

Doctors do several tests, including a chest x-ray and computed tomography (CT) of the chest, and other tests to determine how well the lungs are functioning. A chest x-ray shows evidence of plugging of the alveoli. Computed tomography (CT) shows this plugging and other changes that suggest pulmonary alveolar proteinosis.

Pulmonary function testing Pulmonary Function Testing (PFT) Pulmonary function tests measure the lungs' capacity to hold air, to move air in and out, and to absorb oxygen. Pulmonary function tests are better at detecting the general type and severity... read more Pulmonary Function Testing (PFT) reveals that the volume of air that the lungs can hold is abnormally small. Tests show low levels of oxygen in the blood, at first only during exercise but later also when the person is at rest. The elimination of carbon dioxide from the lungs may be impaired.

Blood test results may show abnormalities that occur in pulmonary alveolar proteinosis as well as in other disorders. For example, levels of some substances (for example, lactic dehydrogenase, red blood cells, serum surfactant proteins, and gamma globulin) are often elevated.

To make a definitive diagnosis of pulmonary alveolar proteinosis, doctors examine a sample of the fluid from the alveoli. To obtain a sample, doctors use a bronchoscope Bronchoscopy Bronchoscopy is a direct visual examination of the voice box (larynx) and airways through a viewing tube (a bronchoscope). A bronchoscope has a camera at the end that allows a doctor to look... read more Bronchoscopy to wash segments of the lung with a salt-water solution and then collect the washings (bronchoalveolar lavage). The washings are often opaque or milky because the fluid is rich in protein and fats. Sometimes doctors obtain a lung tissue sample for microscopic examination (lung biopsy) during bronchoscopy. Occasionally, a larger sample is needed, which must be removed surgically.

Treatment of Pulmonary Alveolar Proteinosis

  • Lung washing

People who have few or no symptoms do not require treatment.

For people with disabling symptoms, the protein- and fat-rich fluid in the alveoli can be washed out with a salt solution during bronchoscopy or through a special tube inserted through the mouth or through the windpipe (trachea) and into one lung. This procedure is called a lung lavage. Sometimes only a small section of the lung must be washed, but if symptoms are severe and the levels of oxygen in the blood are very low, the person is given general anesthesia, so that one entire lung can be washed. About 3 to 5 days later, the other lung is washed, again after the person has been given general anesthesia. One washing is enough for some people, but others need washings every 6 to 12 months for many years.

Recombinant granulocyte-macrophage colony stimulating factor, a substance that stimulates the body's production of white blood cells, may be given by inhalation or subcutaneous injection.

Corticosteroids, such as prednisone, are often not effective and may actually increase the chance of infection. Bacterial infections are treated with antibiotics, usually taken by mouth.

Some people with pulmonary alveolar proteinosis are short of breath indefinitely, but the disease is rarely fatal as long as they have regular lung washings.

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Coughing Up Blood
Coughing up blood from the respiratory tract is called hemoptysis. Which of the following is the most likely cause of hemoptysis in adults?
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