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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="p0005" class="elsevierStylePara elsevierViewall">Pulmonary alveolar proteinosis &#40;PAP&#41; is a rare disease&#46; The true prevalence is probably unknown with a recent Japanese study suggesting 6&#8211;7 per million in the general population&#46;<a class="elsevierStyleCrossRef" href="#bb0005"><span class="elsevierStyleSup">1</span></a></p><p id="p0010" class="elsevierStylePara elsevierViewall">Different forms of alveolar proteinosis exist&#58; <span class="elsevierStyleItalic">a&#41;</span> PAP due to impaired GM-CSF signaling -comprising the autoimmune&#47;common PAP and the diseases associated with GM-CSF receptor and -chain deficiency&#59; <span class="elsevierStyleItalic">b&#41;</span> PAP due to another underlying clinical disorder -secondary PAP&#59; <span class="elsevierStyleItalic">c&#41;</span> genetic disorders of surfactant production -surfactant protein B deficiency&#44; surfactant protein C dysfunction and ABCA3 dysfunction&#46;</p><p id="p0015" class="elsevierStylePara elsevierViewall">Autoimmune pulmonary alveolar proteinosis is the commonest form of PAP accounting for 90 &#37; of the cases&#46;</p><p id="p0020" class="elsevierStylePara elsevierViewall">Pulmonary alveolar proteinosis is now considered an autoimmune disorder because high levels of polyclonal&#44; neutralizing GM-CSF auto antibodies are specifically associated with this form of disease&#46; GM-CSF is critical for alveolar macrophage terminal differentiation and immune functions&#44; pulmonary surfactant homeostasis&#44; and lung host defense&#46; Autoantibody levels do not correlate with disease severity&#46;</p><p id="p0025" class="elsevierStylePara elsevierViewall">The disease occurs predominantly in males with a male&#58; female ratio of -3&#58;1&#46; The peak age of onset is 30&#8211;50 years and it occurs predominantly in smokers and individuals with ill-defined pulmonary exposures&#46;</p><p id="p0030" class="elsevierStylePara elsevierViewall">Diagnosis is often delayed&#44; 1&#47;3 of the patients in the Japanese study were diagnosed on routine chest radiographs&#44; so asymptomatic&#46; The natural history may be of spontaneous improvement&#44; persistent&#44; unremitting symptoms&#44; or progressive deterioration with respiratory failure&#46; Spontaneous remission is believed to occur in 1&#47;3 of patients&#46; Until recently whole lung lavage &#40;WLL&#41; was the sole existing treatment&#46; It is safe&#44; well tolerated and provides long-lasting benefits when performed by trained personnel&#46;<a class="elsevierStyleCrossRefs" href="#bb0010"><span class="elsevierStyleSup">2&#44;8</span></a> WLL seems to have changed the natural history of this disease&#46; In the experience of the Royal Brompton Hospital of London all patients obtained full remission of PAP&#46; In the series of Beccaria 70 &#37; of patients were free from recurrent manifestations of PAP 3 years after WLL&#46; More recently treatment with recombinant GM-CSF either aerosolized or subcutaneous has been used and the results have been presented in small clinical trials&#46; <a class="elsevierStyleCrossRef" href="#bb0005"><span class="elsevierStyleSup">1</span></a> 50&#8211;30 &#37; of patients respond to this form of treatment&#46; The optimal dose&#44; timing and route of administration or duration of therapy is not standardized nor defined&#46; It is an expensive treatment but it might be of value in a setting where WLL is not easily available or when there is a contraindication to general anesthesia&#46;</p><p id="p0035" class="elsevierStylePara elsevierViewall">When it comes to rare diseases it is often very difficult to decide practical matters like advising for or against a planned pregnancy&#46; The literature data are scarce especially if we note that besides being a rare disease there is a preponderance of males with PAP&#46; This is why the paper by Belchior at al<a class="elsevierStyleCrossRef" href="#bb0015"><span class="elsevierStyleSup">3</span></a> is so very much welcome&#46; When it comes to decision regarding rare diseases&#44; published clinical cases are usually the only available source of help&#46;</p><p id="p0040" class="elsevierStylePara elsevierViewall">The 44 y&#46;o patient addressed in their paper was diagnosed as having PAP two years before this pregnancy and had had WLL once&#46; She had seven previous pregnancies with no history of pulmonary disease and I wonder if PAP might have already been there at some time&#46; Due to symptomatic disease and a PaO<span class="elsevierStyleInf">2</span> of 53<span class="elsevierStyleHsp" style=""></span>mmHg a sequential WLL was performed at week 8 of gestation&#44; with an increase of PaO<span class="elsevierStyleInf">2</span> to 83<span class="elsevierStyleHsp" style=""></span>mmHg&#46; This permitted a near normal pregnancy and delivery at 37 weeks by cesarean section&#46; There was no danger either to mother or child&#46;</p><p id="p0045" class="elsevierStylePara elsevierViewall">Matuschack et al <a class="elsevierStyleCrossRef" href="#bb0035"><span class="elsevierStyleSup">7</span></a> presented a case of a 23 y&#46;o&#46; female with known PAP who had also had a previous twin gestation complicated with hypoxemia &#40;53<span class="elsevierStyleHsp" style=""></span>mmHg&#41;&#59; there was no intervention at that time and she had a vaginal delivery of two low birth-weight infants&#59; at 32 weeks of this second gestation a sequential WLL was done with amelioration of PaO<span class="elsevierStyleInf">2</span> from 52<span class="elsevierStyleHsp" style=""></span>mmHg to 64<span class="elsevierStyleHsp" style=""></span>mmHg allowing a full-term vaginal delivery and a healthy infant&#46; There were no complications from WLL&#46;</p><p id="p0050" class="elsevierStylePara elsevierViewall">Canto et al<a class="elsevierStyleCrossRef" href="#bb0030"><span class="elsevierStyleSup">6</span></a> published the case of 19 y&#46;o&#46; women with familial PAP with mild restrictive disease that delivered a healthy baby at 32 weeks and 6 days by vaginal delivery&#46; Pulmonary function remained unchanged throughout pregnancy and no intervention was needed&#46;</p><p id="p0055" class="elsevierStylePara elsevierViewall">Crocker et al<a class="elsevierStyleCrossRef" href="#bb0025"><span class="elsevierStyleSup">5</span></a> described a 29 y&#46;o&#46; female diagnosed as having PAP in the course of a 33 week pregnancy&#44; presenting with acute respiratory distress and a resting PaO<span class="elsevierStyleInf">2</span> of 45<span class="elsevierStyleHsp" style=""></span>mmHg&#46; A cesarean section was performed&#44; the diagnosis established by bronchoalveolar lavage and 14 WLL were needed before a normal lung function was attained&#46; The baby was transferred to a neonatal intensive care unit with a diagnosis of hyaline membrane disease&#46;</p><p id="p0060" class="elsevierStylePara elsevierViewall">Huisman et al<a class="elsevierStyleCrossRef" href="#bb0020"><span class="elsevierStyleSup">4</span></a> in a Dutch paper refer to a PAP patient treated with recombinant Gm-CSF which was suspended and resumed after parturition&#46; A cesarean section was performed&#46;</p><p id="p0065" class="elsevierStylePara elsevierViewall">At a National Congress we presented a 38 y&#46;o&#46; female &#40;unpublished data&#41; who had had an ongoing history of PAP for 19 years&#44; treated with 15 WLL and mild restrictive lung disease&#46; When she decided to attempt pregnancy two elective sequential WLL were done in order to get her in the very best condition&#46; At week 25 a slight dessaturation on effort was noted &#40;88&#8211;89 &#37; saturation&#41; and she was put under oxygen therapy&#46; At that time WLL was considered but we felt that it would do more harm than good&#46; From 28 week on her exercise O<span class="elsevierStyleInf">2</span> saturation increased to 90 &#37; and remained as so until delivery&#46; She continued on oxygen therapy&#46; A cesarean section was performed at 38 weeks and 6 days&#44; a healthy baby was born&#46; PaO<span class="elsevierStyleInf">2</span> during delivery was 52<span class="elsevierStyleHsp" style=""></span>mmHg and 12 hours after delivery went up to 79&#46;8<span class="elsevierStyleHsp" style=""></span>mmHg&#46; After this first pregnancy she did not need any additional WLL&#44; lung CT features got better&#46; Two years later she decided to become pregnant again&#46; As the disease was stable with no need of WLL or hypoxemia on effort we decided not to perform prophylactic WLL&#46; A healthy full term baby was born by cesarean section&#46; Pregnancy was uneventful with no need of oxygen supplementation&#46;</p><p id="p0070" class="elsevierStylePara elsevierViewall">From the cases presented above one may conclude that it is possible that a successful outcome can be achieved for both mother and child in pregnant patients with PAP&#46; Also&#44; WLL was performed at 8 weeks and 33 weeks gestation with no apparent harm either to the mother or the fetus&#46; Despite restrictive lung disease and hypoxemia some patients do not need any intervention&#46; Ideally in a known PAP patient pregnancy should be planned to optimize the best functional context&#44; if needed an elective WLL &#40;or recombinant GM-CSF therapy&#41; could be advised before pregnancy is attempted&#46; Some obstetricians experienced in pregnancy in a context of hypoxemic diseases would not consider intervening unless O<span class="elsevierStyleInf">2</span> saturation could not be kept above 80 &#37;&#46; Also&#44; at this point we don&#39;t have much information about the effect of therapeutic GM-CSF on maternal and fetal well-being -though the evidence suggests that it may be GMCSF deficiency that we have to worry about as there is some evidence of significantly reduced blood concentrations in unexplained recurrent abortion&#46; <a class="elsevierStyleCrossRef" href="#bb0045"><span class="elsevierStyleSup">9</span></a> It might be an appealing resource to use in a pregnant patient too ill to undergo WLL&#46;</p><p id="p0075" class="elsevierStylePara elsevierViewall">So&#44; many questions remain unanswered in this fascinating disease&#46; It is from my point of view very useful for us&#44; clinicians&#44; that Medline searchable journals accept this type of clinical case&#46; Although the results of prospective clinical studies are doubtless the stars of medical research&#44; for rare diseases the study of published clinical cases is still invaluable&#46;</p></span>"
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CASE DISCUSSION
Comment to the case: Successful pregnancy in a severely hypoxemic patient with alveolar proteinosis
Discussão de caso clínico: Gravidez de termo em doente com proteinose alveolar e insuficiência respiratória grave
A.C. Mendes
Serviço de Pneumologia, Hospital Santa Maria, Lisboa, Portugal
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="p0005" class="elsevierStylePara elsevierViewall">Pulmonary alveolar proteinosis &#40;PAP&#41; is a rare disease&#46; The true prevalence is probably unknown with a recent Japanese study suggesting 6&#8211;7 per million in the general population&#46;<a class="elsevierStyleCrossRef" href="#bb0005"><span class="elsevierStyleSup">1</span></a></p><p id="p0010" class="elsevierStylePara elsevierViewall">Different forms of alveolar proteinosis exist&#58; <span class="elsevierStyleItalic">a&#41;</span> PAP due to impaired GM-CSF signaling -comprising the autoimmune&#47;common PAP and the diseases associated with GM-CSF receptor and -chain deficiency&#59; <span class="elsevierStyleItalic">b&#41;</span> PAP due to another underlying clinical disorder -secondary PAP&#59; <span class="elsevierStyleItalic">c&#41;</span> genetic disorders of surfactant production -surfactant protein B deficiency&#44; surfactant protein C dysfunction and ABCA3 dysfunction&#46;</p><p id="p0015" class="elsevierStylePara elsevierViewall">Autoimmune pulmonary alveolar proteinosis is the commonest form of PAP accounting for 90 &#37; of the cases&#46;</p><p id="p0020" class="elsevierStylePara elsevierViewall">Pulmonary alveolar proteinosis is now considered an autoimmune disorder because high levels of polyclonal&#44; neutralizing GM-CSF auto antibodies are specifically associated with this form of disease&#46; GM-CSF is critical for alveolar macrophage terminal differentiation and immune functions&#44; pulmonary surfactant homeostasis&#44; and lung host defense&#46; Autoantibody levels do not correlate with disease severity&#46;</p><p id="p0025" class="elsevierStylePara elsevierViewall">The disease occurs predominantly in males with a male&#58; female ratio of -3&#58;1&#46; The peak age of onset is 30&#8211;50 years and it occurs predominantly in smokers and individuals with ill-defined pulmonary exposures&#46;</p><p id="p0030" class="elsevierStylePara elsevierViewall">Diagnosis is often delayed&#44; 1&#47;3 of the patients in the Japanese study were diagnosed on routine chest radiographs&#44; so asymptomatic&#46; The natural history may be of spontaneous improvement&#44; persistent&#44; unremitting symptoms&#44; or progressive deterioration with respiratory failure&#46; Spontaneous remission is believed to occur in 1&#47;3 of patients&#46; Until recently whole lung lavage &#40;WLL&#41; was the sole existing treatment&#46; It is safe&#44; well tolerated and provides long-lasting benefits when performed by trained personnel&#46;<a class="elsevierStyleCrossRefs" href="#bb0010"><span class="elsevierStyleSup">2&#44;8</span></a> WLL seems to have changed the natural history of this disease&#46; In the experience of the Royal Brompton Hospital of London all patients obtained full remission of PAP&#46; In the series of Beccaria 70 &#37; of patients were free from recurrent manifestations of PAP 3 years after WLL&#46; More recently treatment with recombinant GM-CSF either aerosolized or subcutaneous has been used and the results have been presented in small clinical trials&#46; <a class="elsevierStyleCrossRef" href="#bb0005"><span class="elsevierStyleSup">1</span></a> 50&#8211;30 &#37; of patients respond to this form of treatment&#46; The optimal dose&#44; timing and route of administration or duration of therapy is not standardized nor defined&#46; It is an expensive treatment but it might be of value in a setting where WLL is not easily available or when there is a contraindication to general anesthesia&#46;</p><p id="p0035" class="elsevierStylePara elsevierViewall">When it comes to rare diseases it is often very difficult to decide practical matters like advising for or against a planned pregnancy&#46; The literature data are scarce especially if we note that besides being a rare disease there is a preponderance of males with PAP&#46; This is why the paper by Belchior at al<a class="elsevierStyleCrossRef" href="#bb0015"><span class="elsevierStyleSup">3</span></a> is so very much welcome&#46; When it comes to decision regarding rare diseases&#44; published clinical cases are usually the only available source of help&#46;</p><p id="p0040" class="elsevierStylePara elsevierViewall">The 44 y&#46;o patient addressed in their paper was diagnosed as having PAP two years before this pregnancy and had had WLL once&#46; She had seven previous pregnancies with no history of pulmonary disease and I wonder if PAP might have already been there at some time&#46; Due to symptomatic disease and a PaO<span class="elsevierStyleInf">2</span> of 53<span class="elsevierStyleHsp" style=""></span>mmHg a sequential WLL was performed at week 8 of gestation&#44; with an increase of PaO<span class="elsevierStyleInf">2</span> to 83<span class="elsevierStyleHsp" style=""></span>mmHg&#46; This permitted a near normal pregnancy and delivery at 37 weeks by cesarean section&#46; There was no danger either to mother or child&#46;</p><p id="p0045" class="elsevierStylePara elsevierViewall">Matuschack et al <a class="elsevierStyleCrossRef" href="#bb0035"><span class="elsevierStyleSup">7</span></a> presented a case of a 23 y&#46;o&#46; female with known PAP who had also had a previous twin gestation complicated with hypoxemia &#40;53<span class="elsevierStyleHsp" style=""></span>mmHg&#41;&#59; there was no intervention at that time and she had a vaginal delivery of two low birth-weight infants&#59; at 32 weeks of this second gestation a sequential WLL was done with amelioration of PaO<span class="elsevierStyleInf">2</span> from 52<span class="elsevierStyleHsp" style=""></span>mmHg to 64<span class="elsevierStyleHsp" style=""></span>mmHg allowing a full-term vaginal delivery and a healthy infant&#46; There were no complications from WLL&#46;</p><p id="p0050" class="elsevierStylePara elsevierViewall">Canto et al<a class="elsevierStyleCrossRef" href="#bb0030"><span class="elsevierStyleSup">6</span></a> published the case of 19 y&#46;o&#46; women with familial PAP with mild restrictive disease that delivered a healthy baby at 32 weeks and 6 days by vaginal delivery&#46; Pulmonary function remained unchanged throughout pregnancy and no intervention was needed&#46;</p><p id="p0055" class="elsevierStylePara elsevierViewall">Crocker et al<a class="elsevierStyleCrossRef" href="#bb0025"><span class="elsevierStyleSup">5</span></a> described a 29 y&#46;o&#46; female diagnosed as having PAP in the course of a 33 week pregnancy&#44; presenting with acute respiratory distress and a resting PaO<span class="elsevierStyleInf">2</span> of 45<span class="elsevierStyleHsp" style=""></span>mmHg&#46; A cesarean section was performed&#44; the diagnosis established by bronchoalveolar lavage and 14 WLL were needed before a normal lung function was attained&#46; The baby was transferred to a neonatal intensive care unit with a diagnosis of hyaline membrane disease&#46;</p><p id="p0060" class="elsevierStylePara elsevierViewall">Huisman et al<a class="elsevierStyleCrossRef" href="#bb0020"><span class="elsevierStyleSup">4</span></a> in a Dutch paper refer to a PAP patient treated with recombinant Gm-CSF which was suspended and resumed after parturition&#46; A cesarean section was performed&#46;</p><p id="p0065" class="elsevierStylePara elsevierViewall">At a National Congress we presented a 38 y&#46;o&#46; female &#40;unpublished data&#41; who had had an ongoing history of PAP for 19 years&#44; treated with 15 WLL and mild restrictive lung disease&#46; When she decided to attempt pregnancy two elective sequential WLL were done in order to get her in the very best condition&#46; At week 25 a slight dessaturation on effort was noted &#40;88&#8211;89 &#37; saturation&#41; and she was put under oxygen therapy&#46; At that time WLL was considered but we felt that it would do more harm than good&#46; From 28 week on her exercise O<span class="elsevierStyleInf">2</span> saturation increased to 90 &#37; and remained as so until delivery&#46; She continued on oxygen therapy&#46; A cesarean section was performed at 38 weeks and 6 days&#44; a healthy baby was born&#46; PaO<span class="elsevierStyleInf">2</span> during delivery was 52<span class="elsevierStyleHsp" style=""></span>mmHg and 12 hours after delivery went up to 79&#46;8<span class="elsevierStyleHsp" style=""></span>mmHg&#46; After this first pregnancy she did not need any additional WLL&#44; lung CT features got better&#46; Two years later she decided to become pregnant again&#46; As the disease was stable with no need of WLL or hypoxemia on effort we decided not to perform prophylactic WLL&#46; A healthy full term baby was born by cesarean section&#46; Pregnancy was uneventful with no need of oxygen supplementation&#46;</p><p id="p0070" class="elsevierStylePara elsevierViewall">From the cases presented above one may conclude that it is possible that a successful outcome can be achieved for both mother and child in pregnant patients with PAP&#46; Also&#44; WLL was performed at 8 weeks and 33 weeks gestation with no apparent harm either to the mother or the fetus&#46; Despite restrictive lung disease and hypoxemia some patients do not need any intervention&#46; Ideally in a known PAP patient pregnancy should be planned to optimize the best functional context&#44; if needed an elective WLL &#40;or recombinant GM-CSF therapy&#41; could be advised before pregnancy is attempted&#46; Some obstetricians experienced in pregnancy in a context of hypoxemic diseases would not consider intervening unless O<span class="elsevierStyleInf">2</span> saturation could not be kept above 80 &#37;&#46; Also&#44; at this point we don&#39;t have much information about the effect of therapeutic GM-CSF on maternal and fetal well-being -though the evidence suggests that it may be GMCSF deficiency that we have to worry about as there is some evidence of significantly reduced blood concentrations in unexplained recurrent abortion&#46; <a class="elsevierStyleCrossRef" href="#bb0045"><span class="elsevierStyleSup">9</span></a> It might be an appealing resource to use in a pregnant patient too ill to undergo WLL&#46;</p><p id="p0075" class="elsevierStylePara elsevierViewall">So&#44; many questions remain unanswered in this fascinating disease&#46; It is from my point of view very useful for us&#44; clinicians&#44; that Medline searchable journals accept this type of clinical case&#46; Although the results of prospective clinical studies are doubtless the stars of medical research&#44; for rare diseases the study of published clinical cases is still invaluable&#46;</p></span>"
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ISSN: 21735115
Original language: Spanish
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