Comparative study of high-resolution CT findings between autoimmune and secondary pulmonary alveolar proteinosis

Chest. 2009 Nov;136(5):1348-1355. doi: 10.1378/chest.09-0097.


Background: Acquired pulmonary alveolar proteinosis (PAP) has been reclassified into autoimmune or secondary PAP according to the occurrence of serum granulocyte macrophage colony-stimulating factor autoantibody. Most patients undergo high-resolution CT (HRCT) scanning in order for physicians to make a differential diagnosis of diffuse lung diseases, but no information is available to distinguish the HRCT scan features of secondary PAP from those of autoimmune PAP. The objective of this study was to characterize the HRCT scan features of autoimmune and secondary PAP.

Methods: HRCT scans of 42 patients (21 patients each in the autoimmune PAP and secondary PAP groups) were centrally collected and evaluated in a blinded manner.

Results: Ground-glass opacities (GGO) were a major finding in both the autoimmune PAP and secondary PAP groups. In the secondary PAP group, GGOs typically showed a diffuse pattern (62%), whereas GGOs showed a patchy geographic pattern in the autoimmune PAP group (71%; p < 0.005). The so-called "crazy-paving" appearance and subpleural sparing were frequently seen in the autoimmune PAP group (both 71%), whereas they were less frequently seen in the secondary PAP group (14% and 33%, respectively). The involved area of GGO was even in craniocaudal distribution for the secondary PAP group, whereas it was predominant in the lower lung field compared with the upper lung field in the autoimmune PAP group (p < 0.05).

Conclusions: Typical HRCT scan findings for autoimmune PAP patients were GGO with a patchy geographic pattern, subpleural sparing, crazy-paving appearance, and predominance in the lower lung field. These findings were rather infrequent for secondary PAP patients.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Aged
  • Autoimmune Diseases / diagnostic imaging
  • Carcinoembryonic Antigen / blood
  • Cough
  • Female
  • Fever
  • Humans
  • Male
  • Middle Aged
  • Pulmonary Alveolar Proteinosis / diagnostic imaging*
  • Pulmonary Alveolar Proteinosis / etiology
  • Pulmonary Alveolar Proteinosis / immunology*
  • Pulmonary Alveolar Proteinosis / physiopathology
  • Pulmonary Surfactant-Associated Protein A / blood
  • Pulmonary Surfactant-Associated Protein D / blood
  • Tomography, X-Ray Computed
  • Young Adult


  • Carcinoembryonic Antigen
  • Pulmonary Surfactant-Associated Protein A
  • Pulmonary Surfactant-Associated Protein D