Chest
Volume 98, Issue 4, October 1990, Pages 801-805
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Pulmonary Alveolar Proteinosis Associated with Pneumocystis carinii: Ultrastructural Identification in Bronchoalveolar Lavage in AIDS and Immunocompromised Non-AIDS Patients

https://doi.org/10.1378/chest.98.4.801Get rights and content

Pneumocystis carinii (PC) has been recognized as frequently responsible for most opportunistic pulmonary infections occurring in immunocompromised AIDS and non-AIDS patients. Moreover, these patients can be considered at risk for secondary pulmonary alveolar proteinosis. Therefore, we have investigated the occurrence of associated secondary alveolar proteinosis and PC pneumonitis in AIDS and non-AIDS immunocompromised patients. In a series of 26 bronchoalveolar lavages (BAL) in patients with PC pneumonitis (19 AIDS and seven non-AIDS patients), we observed on light microscopy, in addition to the honeycombed material, areas of an extracellular material that had a different pattern which was suggestive of that described in alveolar proteinosis. A systematic ultrastructural study of these 26 BAL fluid samples demonstrated in each of them an accumulation of phospholipid surfactantlike extracellular material mixed or not with the PC cysts. In nine cases, the observation of lipoproteinaceous material on light microscopy and abundant phospholipid material with myelinlike and myelin tubular laminated structures on electron microscopy was highly suggestive of an associated pulmonary alveolar proteinosis (PAP). Such an accumulation of extracellular material was not observed in the 11 BAL fluid samples collected in immunocompromised patients (seven AIDS and four non-AIDS patients) without PC pneumonitis. These findings demonstrated a particular frequency of associated PAP with PC pneumonitis. These results raise important questions concerning (1) the consequence of such an alveolar accumulation of lipoproteinaceous material on the clinical status and prognosis of the pneumonitis, and (2) the mechanisms responsible for this accumulation.

BAL = bronchoalveolar lavage; PC = Pneumocystis carinii; PAP = pulmonary alveolar proteinosis; MGG = May Grünwald Giemsa; TEM = transmission electron microscopy; PII = type II pneumonocyte

Section snippets

Patients

An ultrastructural study of the BAL fluid was performed in 37 patients. In these patients, BAL was undertaken to investigate episodes of pneumonitis. Pneumonitis was suspected because of pulmonary symptoms and/or fever and/or abnormal chest roentgenogram.

Twenty-six patients had a PC pneumonitis, 19 with AIDS and seven with an immunodeficiency related to heart (n = 3) or kidney (n = 4) transplantation fiable 1). The chest roentgenogram revealed a diffuse reticulonodular pattern in 21 patients, a

Light Microscopy

In each of the 26 cases, the identification in the BAL fluid of PC cysts by Gomori-Grocott staining confirmed the diagnosis of PC pneumonitis.

On MGG- or Papanicolaou-stained slides from BAL with PC, foamy honeycombed material containing PC cysts and trophozoites was observed in 23 of these 26 BAL fluid samples. In nine cases, an extracellular material with a different pattern was observed associated with the honeycombed material (Fig la). This extracellular material was pale, homogeneous, and

DISCUSSION

The present systematic ultrastructural investigation of a series of BAL fluid samples collected in patients with PC pneumonitis demonstrated in all of them, in addition to the aggregates of PC cysts and trophozoites, the presence of an extracellular material composed of an accumulation of phospholipids and lipoproteinaceous substance with the characteristic pattern of surfactant. This material was detected by light microscopic examination in nine cases due to the amount of the extracellular

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    This investigation was supported by Crédits Universitaires, Université Paris XII, France.

    Manuscript received October 20; revision accepted March 29.

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