Unsuspected pulmonary alveolar proteinosis in a patient with acquired immunodeficiency syndrome: a case report

A 42-year-old African American man infected with human immunodeficiency virus was admitted with chronic respiratory symptoms and diffuse pulmonary infiltrates. Chest computed tomography revealed bilateral spontaneous pneumothoraces, for which he required bilateral chest tubes. Initial laboratory investigations did not reveal any contributory conditions. Histological examination of a lung biopsy taken during video-assisted thoracoscopy showed pulmonary alveolar proteinosis concurrent with cytomegalovirus pneumonitis. After ganciclovir treatment, our patient showed radiologic and clinical improvement.The differential diagnosis for patients with immunosuppression and lung infiltrates requires extensive investigations. As pulmonary alveolar proteinosis is rare, the diagnosis can be easily missed. Our case highlights the importance of invasive investigations and histology in the management of patients infected with human immunodeficiency virus and pulmonary disease who do not respond to empiric therapy.Pulmonary alveolar proteinosis (PAP) was first described in 1958 by Rosen et al.[1]. It is a rare pulmonary disorder characterized by an abnormal accumulation of surfactant-derived material in the alveoli, leading to disease that ranges from mild symptoms with complete spontaneous resolution to progressive disease with ensuing respiratory failure [1,2].Associated infections have been reported in 5 to 20% of PAP cases. This wide range may be due to reporting bias or difficulties detecting infectious processes [3]. The infectious agents include Nocardia asteroides, Mycobacterium tuberculosis, Mycobacterium avium-intracellulare, Pneumocystis jirovecii (formerly carinii) and cytomegalovirus (CMV). Most of these infectious agents have been reported in immunocompromised patients uninfected with human immunodeficiency virus (HIV); however, PAP is a rare finding in patients with HIV [4].We present a unusual case of a patient with HIV infection admitted with chronic respiratory sym