A novel immunodeficiency syndrome as a rare cause of secondary pulmonary alveolar proteinosis: A diagnosis after 5 decades

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Please cite this article in press as: Ferreira PG, et al. A novel immunodeﬁciency syndrome as a rare www.revportpneumol.org

CASE

REPORT

A

novel

immunodeﬁciency

syndrome

as

a

rare

cause

of

secondary

pulmonary

alveolar

proteinosis:

A

diagnosis

after

5 decades

Pedro

G. Ferreira

a,∗

_,

_Lina

_Carvalho

b

_,

_Fernanda

_Gamboa

a a_Pulmonology_Department,_Coimbra_Hospital_and_University_Centre,_Coimbra,_Portugal b_{Anatomopathology}_Department,_Coimbra_Hospital_and_University_Centre,_Coimbra,_Portugal

Received11July2013;accepted22August2013

KEYWORDS AlveolarPulmonary Proteinosis; Immunodeﬁciency; Parenchymallung disease;

Systemicdiseasewith lunginvolvement

Abstract Casereportofamalepatientwithafive-decadefollow-uphistoryinatertiarycare hospitaldistinguishedformalabsorptionsyndrome,failure-to-thrive,meningitisandrecurrent bacterial,fungalandmycobacterialpulmonaryinfections.Additionally,hedeveloped epider-modysplasia verruciformis, several in situspinocellular carcinomas andan uncharacteristic parenchymallungdisease.Surgicallungbiopsysuggestedpulmonaryalveolarproteinosiswith fibrotic change.Retrospectively,severemonocytopeniahadbeenoverlookedinthepast,as wellaslowBandNKcellbloodcounts.Flowcytometryconfirmedtheabsenceoftheprevious cellsubsetsalongwithanundetectablepopulationofdendriticbloodcells.

Dendriticcell,monocyte,BandNKlymphoidHumanDeficiencySyndrome(DCMLS)isanovel rareimmunodeficiencydescribedin2010,linkedtoGATA-2mutation.Thissyndromeshouldbe highlightedasararecauseofacquiredPAP,witharadiologicalpatternencompassingpotential fibroticchange.Failuretorecognizemonocytopeniamayimpedethechancetodiagnose. © 2013SociedadePortuguesa dePneumologia. Publishedby Elsevier España,S.L. Allrights reserved.

PALAVRAS-CHAVE

ProteinoseAlveolar Pulmonar;

Imunodeficiência; Doençapulmonar parenquimatosa; Doençasistémica comenvolvimento pulmonar

Umanovasíndromedaimunodeﬁciênciacomocausararadeproteinosealveolar pulmonar:umdiagnósticoapós5décadas

Resumo Relatodeumcasoclínicodeumdoentedosexomasculinocomumhistorialde acom-panhamentodecincodécadas,numhospitaldecuidadosterciários,caracterizadoporum sín-dromedemalabsorção,insuficiênciadecrescimento,meningiteeinfecçõespulmonares bacte-rianas,fúngicasemicobacterianasrecorrentes.Alémdisso,desenvolveuepidermodisplasia ver-ruciforme,diversoscarcinomasespinocelularesinsitueumadoençapulmonarparenquimatosa nãodefinida.UmabiópsiapulmonarcirúrgicasugeriuumaProteinoseAlveolarPulmonarcom alteraçõesfibróticas.Emretrospectiva,umamonocitopeniagravenegligenciadanopassado,

∗_{Corresponding}_author.

E-mailaddress:pgoncalof@hotmail.com(P.G.Ferreira).

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2 P.G.Ferreiraetal. bemcomoumabaixacontagemdecélulasB(linfócitosB)eNK(células‘naturalkiller’).Uma citometriadefluxoconfirmouaausênciadossubconjuntosdecélulasanteriores,juntamente comumapopulaçãoindetectáveldecélulasdendríticassanguíneas.

ASíndromedeDeficiênciaHumanadecélulasdendríticas,monócitos,linfóidesBeNKéuma raraimunodeficiênciadescritarecentementeem2010erelacionadacomamutaçãodogene GATA-2.EstasíndromedeveráserreferidacomoumacausararadePAP(proteinosealveolar pul-monar)adquirida,comumpadrãoradiológicoquepoderáapresentarumapotencialalteração fibriótica.Aausênciadereconhecimentodamonocitopeniapodeimpediraoportunidadede chegaraestediagnóstico.

Wepresentthecasereportofa61-year-oldmalepatient witha ﬁve-decade history of medicalfollow-up in a ter-tiarycareUniversityHospitalwhoisanon-smokerwithout relevantfamilyhistoryoroccupationalexposures.The his-toryof thepresent illness started atthe ageof 9,witha diagnosisofpulmonarytuberculosis(PT)forwhichstandard antibacillarytreatmentwascompleted.Hepresented fail-uretothriveinhisearlychildhood,andattheageof18,he wasadmittedtwiceintheInternalMedicineDepartmentfor diarrhea,malabsorptionsyndromeandacute tracheobron-chitis.By the ageof 20 hehadpneumococcal meningitis, buthadrecoveredwithoutneurologicalsequelae.Duringthe followingdecadehehadfurtheradmissionsfor community-acquiredpneumonias,‘‘middle lobesyndrome’’andotitis media.

Attheageof37hewasagaindiagnosedwithPTand com-pletedstandardtreatment,supervisedbytheTuberculosis DistrictCenter. In hisforties hestarted presenting recur-rentprocessesofbronchitiswithisolationofHaemophilus inﬂuenzaeandStreptococcuspneumoniae.Healsostarted dermatologicalconsultationsforepidermodysplasia verruci-formisthatgraduallydevelopedonhishands,upperlimbs, torso,andneck,andsevereperinealcondylomasthatwere repeatedly treated withelectrodessication and curettage (Fig.1).Sincethen,hehasbeendiagnosedsix timeswith insitucutaneousspinocellularcarcinoma.Hisskinbiopsies typicallyrevealeddyskeratoticspinocellularcarcinomasand ‘‘bowenoidpapulosis’’ofaverruciformnature,with abnor-malitiesinthegranulosacelllayersuggestinginfectionby humanpapillomavirus(HPV).

Attheageof47,oneofhisadmissionstothePulmonology Department was for Aspergillus fumigatus lung infection (the patient did not fulﬁll the criteria for allergic bron-chopulmonarymycosis).Acompleteinvestigationforcystic ﬁbrosiswasperformedand,afteraborderline sweattest, heshowednormalspermogram andnegativeCystic Fibro-sisTransmembraneConductanceRegulator(CFTR)genotype mutationstudy.

Gradually, he started developing parenchymal lung disease, initially with reticulomicronodular pattern with upperlobepredominanceonchestradiograph.Inhisﬁfties, computed tomography (CT) scan showed a septal thick-ening pattern with reticulation, traction bronchiectasis and micronodulation. Pulmonary function tests presented

moderately severe restriction by spirometry (Tiffeneau index of 0.74, Forced Vital Capacity 57.2%, forced expi-ratory volumein one second 52.8%), corrected to normal by plethysmographic lung volumes (total lung capacity 80.8%,residualvolume109.2%),withamoderatelyaffected diffusion capacity(DLCO 54%),while maintaining satisfac-tory blood gas analysis at room air (pO2 80mmHg, pCO2

41mmHg,SaO296%).

At his last admission, at the age of 61 years, he presented a more pronounced diffuse interstitial reticulomicronodular pattern and progressive emaciation. He complained of productive cough with high vol-ume purulent sputum and worsened dyspnea (grade III mMRC). High-resolution chest CT showed a more pro-fuse septal thickening, micronodular pattern of random distribution, ‘‘tree-in-bud’’ images, along with apical subpleural blebs, linear fibrotic lines and distortion of the normal bronchovascular architecture (Fig. 2). Flex-ible bronchoscopy presented inflammatory changes of the mucosa and mucopurulent sputum. BAL, in the context of infection, showed a concordant neutrophilic cellular profile (860,000total cells/mL, with 84% neu-trophils). The cytopathological study was negative and microbiological workup allowed for the identification of Corynebacterium species and Acinetobacter baumannii. Serum immunoglobulins were normal, as were comple-ment levels and serum angiotensin-converting enzyme titers. There were positive anti-nuclear antibodies with positiveanti-cytoskeletonfibersandanti-vimentin antibod-ies, and negative anti-neutrophil cytoplasmic antibodies (ANCAs).Hisserologicalpanel wasnegativefor syphilis,B and Chepatitis andHuman Immunodeficiencyvirus (HIV)-1/2 infection, but presented high IgM and IgG titers for cytomegalovirus, Epstein---Barr and herpes simplex virus-1.

Heunderwentamultiple-lobesurgicallungbiopsy,which was suggestive of alveolar proteinosis with some ﬁbrotic trace. It revealed aspects of diffuse alveolar occupation byeosinophilic,Periodic-Acid-Schiffpositiveproteinaceous material,withalightmacrophagicreaction,togetherwith abnormal lobular architecture, diffuse septal ﬁbrosis withfocalcollagendepositionandsomemultinucleate for-eignbodygiantcellswithcholesterolcrystalclefts(Fig.2). Therewerenogranulomas.

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Please cite this article in press as: Ferreira PG, et al. A novel immunodeﬁciency syndrome as a rare

Anovelimmunodeﬁciencysyndrome 3

Figure1 Epidermodysplasiaverruciformisonpatient’shands,trunkandhead.

By this time absent serum monocytes and low B and NK cell counts had been acknowledged. Indeed, severe monocytopenia had been ignored for years, as had low B and NK cell blood counts on previous blood workup. At this moment, suspicion about a possible immunode-ﬁciency syndrome associated with diffuse parenchymal lung disease was assessed. A peripheral blood sample was studied by a detailed ﬂow cytometry at a His-tocompatibility Center Laboratory (Fig. 3). It revealed an almost complete absence of monocytes (CD14+, CD300E+), B cells (CD19+CD20+) and NK cells (CD56+, CD3−). Additionally, there was no detectable myeloid or plasmacytoid population of dendritic cells --- DCs ---(CD16+).

Bone marrow biopsy disclosed hypocellularity with megakaryocytic dysplasia and maturative abnormalities. Marrow immunophenotyping revealed very scarce mono-cytes(0.4%),mainlyconsistingofimmatureforms (promono-cytes), absence of CD34+ B cell precursors, and scarce myeloid DCs and absent plasmacytoid DCs or CD34+ cells compromisedwiththislineage.

The patient fulﬁlled the diagnostic criteria for Den-driticcell,Monocyte,BandNKLymphoidHumanDeﬁciency (DCML)Syndrome,assuggestedbyBigleyandCollin.1,2_He

presentedcutaneousepidermodysplasiawithseveralinsitu carcinomas;mycobacterialinfection---twoepisodesofPT; severebloodmonocytopenia,BcellandNKcelldeﬁciencies; absolute blood DCs deﬁciency; hypocelullar bone marrow withmegakaryocytic dysplasia; and normal immunoglobu-lins.

DCML,alsoknownas‘‘autosomicdominantandsporadic monocytopenia’’3 _or _{‘‘MonoMAC’’}4_, _is _a _novel

immu-nodeﬁciency syndrome, primarily described in 2010 by Vinh and colleagues.3 _It _results _from _one _of _several

known GATA-2 mutations5 _determining _a _progressive _and

selective loss of bone-marrow multi-lymphoid progeni-tors--- pluripotent cells that originateDC, monocytes and lymphoid cells --- and partial depletion of granulocyte-macrophage progenitors (although sufﬁcient to sustain granulopoiesis).2

The associateddeﬁcit ofDCs andtheunderstanding of theimmunoregulatorymechanismswerehighlightedin2011 byBigley.1_DC_depletion_is_associated_with_a_marked_increase

in fms-like tyrosine-kinase ligand (FLT3L) and concomi-tant loss of regulatory T cells, which can contribute to auto-immunephenomena.2,6,7_Remarkably,_despite_the_near

absenceofmonocytes,tecidualmacrophages---likealveolar macrophages---arepreservedbutareprobablyfunctionally

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4 P.G.Ferreiraetal.

Figure2 Patient’sparenchymallungdisease---imagingandlungbiopsy.(A)ChestCTimageswithinterlobularthickeningpattern withreticulation,micronodulationandsmallscatteredareasofground-glassandlobularopacities.Alveolarproteinosisdepicted bydiffusealveolarfloodingbyeosinophilicproteinaceousmaterial,chroniclymphocyticinfiltrateandseptalfibrosiswithcollagen deposition.

defective, explaining the possible feature of PAP.2 _It _has

been suggested that tecidual macrophages may originate fromlocalproliferation.

This progressive form of bone marrow lymphoid fail-ure, at a given point in time, assumes features of a distinct form of myelodysplasia4 _with _composed

deﬁ-ciency of monocytes, B, NK and DCs subsets, along with

proneness to mycobacterial, fungal and viral infections, epidermodysplasia verruciformis and in situ carcinomas related tochronic HPV infection,and the possible devel-opment of PAP in a signiﬁcant number of patients. Cases may be sporadic or of autosomal dominant heredity, and tend to present in the third or fourth decades of life --- although previous unnoticed monocytopenia might

CD3:APC-A logical

A

B

C

D

E

F

CD56:PE-A logical

IREM-2:APC-A logical CD19:PE Cy7-A logical

Tcells (15%)

NK cells (0,3%)

Monocytes (0,06%)

Plasmacytoid dendritic cells (0,0%) Myeloid dendritic cells (0,0%)

B cells (0,1%) SSC-A e xp-SSC lo w SSC-A e xp-SSC lo w SSC-A e xp-SSC lo w

CD14:perCP Cy5-5-A logical

HLADR:APC-H7-A logical HLADR:APC-H7-A logical

CD33:PE Cy7-A logical CD123:PE-A logical

Figure3 Flowcytometryanalysisofperipheralblood.NormalTcells;(B)severemonocytopenia;(C)Bcelldeﬁciency;(D)NK celldeﬁciency;(E)absentmyeloiddendriticcells;(F)absentplasmacytoiddendriticcells.

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Please cite this article in press as: Ferreira PG, et al. A novel immunodeﬁciency syndrome as a rare

Anovelimmunodeﬁciencysyndrome 5

have been present several decades earlier along with an ill-deﬁnedhistoryofunusualinfectionsstartingatanearly age.3

Unlikemonocytopenia,NKandBcelldeﬁcienciesare gen-erallynoteasilydetectedinregularbloodcountsduetothe preservationofperipheralTcells.Patientstendtopresent normocellularor hypocellular (89%) marrows,always with megakaryocytedysplasia.4

Severe perineal HPV infection from adolescence is a common feature, progressing with variously diffuse epi-dermodysplasia verruciformis, apparently as a result of thecombinedmonocyte andNK celldeﬁciencies.8 _Weight

lossandconstitutionalsymptomsarefrequentlyreported,3

but the natural history is marked by prominent recurrent infections by mycobacteria, aerobic bacteria and fungus. Althoughnotanuniversalﬁnding,mycobacterialinfectionis seeninthemajorityofpatients1_and_possibly_derives_from

defectivephagocytosisresultingfromGATA2mutation,9_as

wellasfromimpairmentoftheIL-12/INF-␥axisinducedby thecellulardeﬁciencies.2

In advanceddisease, progressiontoacute myeloblastic leukemiaisfrequentandautoimmunephenomena--- lupus-like syndrome, multiple sclerosis --- may also occur in a fractionofpatients.3

Regarding the emergence of parenchymal lung disease in DCML, PAP occurs in 33% of patients (36% in spo-radic and 29% in autosomal-dominant patients), with a medianonsetageof42years,andwithoutdetectableanti granulocyte-macrophage colony-stimulating factor (GM-CSF)antibodies.3_The_{impossibility}_to_perform_anti-GM-CSF

antibody testing at our Centeris a limitation inthis case report.However,asthepatientfulﬁlledallthe diagnostic criteriaproposedbyBigleyandCollin,wecanspeculatethat anti-GM-CSFantibodieswouldprobablynotbepresentinthis caseeither,accordingtowhatisreportedonpatientswith DCML.

It apparently results from monocyte/macrophage dysfunction3 _with _metabolism _and _phagocytic _impairment

(induced by GATA-2 mutations),9 _although _some _believe

that mycobacterial infection may play a pathogenetic role.TherapeuticadministrationofGM-CSFdoes notseem to have a signiﬁcant effect, but whole-lung lavage may presentmoderatesuccess.3

A remarkableaspect of this case is that the patient’s diffuseparenchymallungdiseasewashistologically consis-tent withchronic PAP that evolvedto ﬁbrosis. As already suggested by some authors, established ﬁbrotic burden probablyresultsfromthetecidualreactiontolong-lasting subclinicalproteinosis,althoughitispossiblethatthe his-toryofrecurrentbacterialandmycobacterialinfectionsmay have also contributed.10 _Generally, _PAP _CT _pattern _is _not

strictlyalveolarasmanypatientspresenta‘‘mosaic atten-uationpattern’’withgroundglassopaciﬁcation,orairspace consolidation,overabackgroundofthickenedinterlobular septae.11,12_Moreover,_there_are_various_reports_of_pulmonary

ﬁbrosis ofvariousdegreesassociated withPAP,sometimes diagnosed several years after disease onset.10---17 _In _some

cases the onset of PAP was clearly established prior to ﬁbrosis,usingseriallung biopsies.15,17_A_review_by_Holbert

regardingCTﬁndingsinasmallgroupofpatientswithPAP foundsubstantialﬁbrosisin2cases.10_{Interestingly,}_a_recent

paperfromIshiialsofoundthatamarkedcysticand

intersti-tialappearancemightbeparticularlyrelatedtohereditary or secondary forms of PAP.18 _Thus, _a _lung _ﬁbrotic_pattern

maybe encountered in the context of chronic secondary PAP(sometimessubclinical),namelyinthecontextofDMCL syndrome.

Regarding treatment options, hematopoietic stem cell transplantation is seen as potentially curative for DMCL patients, even for subjects with established respiratory failure.1,3

This entity should be considered as a possible eti-ology of unexplained persistent monocytopenia, high susceptibilitytoopportunisticinfectionsandsimultaneous epidermodysplasia verruciformis, with possible develop-ment of secondary PAP potentially progressing to ﬁbrotic change.FurthercharacterizationofDMCLsyndrome, stud-iesaddressing thepathogeneticmechanismsofinterstitial ﬁbrosisinpatientswithPAPandthedifferentreactionsof lungparenchymainthisdiseasewillbeimportantinthenear future.

Atthetimeofthispublication,arrangementsarebeing madetoinvestigatethespeciﬁcGATA-2mutationinvolvedin thispatient.Ideally,genetictestingshouldalwaysbe accom-plishedinordertoexpandtheknowledgeoforphandiseases suchasDCML.

Ethical

disclosures

Protection of human and animal subjects.The authors declarethatnoexperimentswereperformedonhumansor animalsforthisstudy.

Conﬁdentialityofdata.Theauthorsdeclarethattheyhave followedtheprotocolsoftheirworkcenteronthe publica-tionofpatientdataandthatallthepatientsincludedinthe studyreceivedsufﬁcientinformationandgavetheirwritten informedconsenttoparticipateinthestudy.

Righttoprivacyandinformedconsent.Theauthorshave obtainedthe written informed consentof the patients or subjectsmentionedinthearticle.Thecorrespondingauthor isinpossessionofthisdocument.

Conﬂicts

of

interest

Theauthorshavenoconﬂictsofinteresttodeclare.

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