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Case Reports
. 2010 Mar 1;181(5):458-64.
doi: 10.1164/rccm.200907-1022CR. Epub 2009 Dec 17.

Pulmonary alveolar proteinosis in workers at an indium processing facility

Kristin J Cummings  1 , Walter E Donat, David B Ettensohn, Victor L Roggli, Peter Ingram, Kathleen Kreiss
Affiliations
Case Reports

Pulmonary alveolar proteinosis in workers at an indium processing facility

Kristin J Cummings et al. Am J Respir Crit Care Med. .

Abstract

Two cases of pulmonary alveolar proteinosis, including one death, occurred in workers at a facility producing indium-tin oxide (ITO), a compound used in recent years to make flat panel displays. Both workers were exposed to airborne ITO dust and had indium in lung tissue specimens. One worker was tested for autoantibodies to granulocytemacrophage-colonystimulating factor (GM-CSF) and found to have an elevated level. These cases suggest that inhalational exposure to ITO causes pulmonary alveolar proteinosis, which may occur via an autoimmune mechanism.

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Figures

Figure 1.
Figure 1.
High resolution computed tomography scan of the (A) left and (B) right chest showing bilateral ground glass opacities, centrilobular nodules, and intralobular and interlobular septal thickening. The changes were most prominent in the lower lobes.
Figure 1.
Figure 1.
High resolution computed tomography scan of the (A) left and (B) right chest showing bilateral ground glass opacities, centrilobular nodules, and intralobular and interlobular septal thickening. The changes were most prominent in the lower lobes.
Figure 2.
Figure 2.
Histopathological sections of lung biopsy, hematoxylin and eosin stain. (A) Low-power overview showing filling of alveolar spaces by eosinophilic material (magnification ×10). (B) High-power view showing granular eosinophilic material and cholesterol clefts. Note the particulate material within the intraalveolar exudate (magnification ×200). Birefrigent particles were identified with polarizing microscopy, consistent with the presence of crystalline indium-tin oxide. (C) Periodic acid-Schiff (PAS) stain after diastase digestion, showing granular, PAS-positive intraalveolar material, and cholesterol clefts (magnification ×100).
Figure 2.
Figure 2.
Histopathological sections of lung biopsy, hematoxylin and eosin stain. (A) Low-power overview showing filling of alveolar spaces by eosinophilic material (magnification ×10). (B) High-power view showing granular eosinophilic material and cholesterol clefts. Note the particulate material within the intraalveolar exudate (magnification ×200). Birefrigent particles were identified with polarizing microscopy, consistent with the presence of crystalline indium-tin oxide. (C) Periodic acid-Schiff (PAS) stain after diastase digestion, showing granular, PAS-positive intraalveolar material, and cholesterol clefts (magnification ×100).
Figure 2.
Figure 2.
Histopathological sections of lung biopsy, hematoxylin and eosin stain. (A) Low-power overview showing filling of alveolar spaces by eosinophilic material (magnification ×10). (B) High-power view showing granular eosinophilic material and cholesterol clefts. Note the particulate material within the intraalveolar exudate (magnification ×200). Birefrigent particles were identified with polarizing microscopy, consistent with the presence of crystalline indium-tin oxide. (C) Periodic acid-Schiff (PAS) stain after diastase digestion, showing granular, PAS-positive intraalveolar material, and cholesterol clefts (magnification ×100).
Figure 3.
Figure 3.
(A) Negative backscattered electron image obtained with the scanning electron microscope in an area of proteinosis shows numerous (dark) angulated particles within the respiratory size range (magnification ×2300). (B) Energy dispersive x-ray analyses of dozens of these particles identified only indium (In) and tin (Sn). A representative energy dispersive spectrum from one of these particles shows multiple peaks for In (including the small peak at 2.920 keV). There is overlap of the peaks between In and Sn, but the small right-most peak almost certainly represents Sn.
Figure 3.
Figure 3.
(A) Negative backscattered electron image obtained with the scanning electron microscope in an area of proteinosis shows numerous (dark) angulated particles within the respiratory size range (magnification ×2300). (B) Energy dispersive x-ray analyses of dozens of these particles identified only indium (In) and tin (Sn). A representative energy dispersive spectrum from one of these particles shows multiple peaks for In (including the small peak at 2.920 keV). There is overlap of the peaks between In and Sn, but the small right-most peak almost certainly represents Sn.
Figure 4.
Figure 4.
High resolution computed tomography scan of the chest showing bilateral alveolar ground-glass opacities and interstitial thickening in a mosaic pattern. These findings, commonly referred to as “crazy paving,” are consistent with, but not specific for, pulmonary alveolar proteinosis (10).
Figure 5.
Figure 5.
Histopathological sections of lung biopsy. (A) Hematoxylin and eosin stain showing filling of alveolar spaces with eosinophilic material (magnification ×40). (B) Periodic acid-Schiff (PAS) stain after diastase digestion, showing granular, PAS-positive intraalveolar material and cholesterol clefts (magnification ×400).
Figure 5.
Figure 5.
Histopathological sections of lung biopsy. (A) Hematoxylin and eosin stain showing filling of alveolar spaces with eosinophilic material (magnification ×40). (B) Periodic acid-Schiff (PAS) stain after diastase digestion, showing granular, PAS-positive intraalveolar material and cholesterol clefts (magnification ×400).
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Comment in

References

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    1. Homma S, Miyamoto A, Sakamoto S, Kishi K, Motoi N, Yoshimura K. Pulmonary fibrosis in an individual occupationally exposed to inhaled indium-tin oxide. Eur Respir J 2005;25:200–204. - PubMed
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    1. National Institute for Occupational Safety and Health (NIOSH). NIOSH pocket guide to chemical hazards. U.S. Department of Health and Human Services; 2005. DHHS Publication No. (NIOSH) 2005-149.

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