Recently,
granulocyte-macrophage colony-stimulating factor (
GM-CSF) auto-
antibodies have been found in many patients with
pulmonary alveolar proteinosis (PAP). The present study reports a retrospective case series of patients who used aerosolised
GM-CSF in the treatment of idiopathic PAP. Between 1999 and 2003, 12 patients elected to receive aerosolised
GM-CSF (250 microg b.i.d. every other week) in lieu of whole-lung lavage or observation. Patient characteristics, pulmonary function tests, arterial blood gas analysis, laboratory values and chest radiographs were extracted from the patient's medical records. Of the six patients tested, all had
GM-CSF neutralising
antibodies. Additionally, abnormalities in
GM-CSF gene expression (one patient), receptor expression (two patients) and ability to upregulate adhesion molecules (one patient) were found. All patients except one had a positive response (mean improvements in arterial
oxygen tension, alveolar-arterial
oxygen gradient,
carbon monoxide diffusing capacity of the lung and forced vital capacity were 17.1 mmHg, 18.4 mmHg, 16.6%
pred and 13.5%
pred, respectively). Two patients made a complete recovery and were disease free 1 and 2 yrs after discontinuing treatment. Four patients showed complete response to both the initial course or when treated again for recurrence after discontinuation of treatment. One patient required dose escalation (500 microg b.i.d.) with complete response.
GM-CSF was well tolerated without late toxicity after median (range) follow-up of 30.5 (3-68) months. In conclusion, aerosolised
granulocyte-macrophage colony-stimulating factor is safe and effective in treating
pulmonary alveolar proteinosis providing an alternative to whole-lung lavage or subcutaneous
granulocyte-macrophage colony-stimulating factor.