American Journal of Respiratory and Critical Care Medicine

The anti–granulocyte-macrophage colony–stimulating factor (GM-CSF) autoantibody is inferred to cause idiopathic pulmonary alveolar proteinosis (iPAP): the antibody neutralizes GM-CSF and thereby impairs differentiation of alveolar macrophages. Administration of GM-CSF improves respiratory function of patients with iPAP, as confirmed in this study using aerosolized GM-CSF. To elucidate its mechanism, we characterized bronchoalveolar lavage fluid and alveolar macrophages obtained from three patients with iPAP who were treated successfully with aerosolized GM-CSF. Cell number, expressions of surface mannose receptor and the transcription factor PU.1, and phagocytic ability of alveolar macrophages were all restored to control levels. With treatment, the neutralizing capacity of GM-CSF activity was reduced markedly, concomitant with the decreasing autoantibody levels. Interestingly, the amount of GM-CSF autoantibody complex also decreased. In one case in which the complex was analyzed, the majority of GM-CSF binding the complex was endogenous protein, suggesting that the complex is removed immediately from the lung after treatment. Our study shows that GM-CSF administration engenders a decrease in the neutralizing capacity against the protein in the lungs. Thereby, it facilitates restoration of the normal function of alveolar macrophages.

Pulmonary alveolar proteinosis (PAP) is an uncommon lung disease characterized by an accumulation of surfactant that fills terminal airways and alveoli, thereby impairing gas exchange and engendering respiratory insufficiency (13). Three clinically and etiologically distinct forms of PAP are acknowledged (congenital, secondary, and idiopathic), but more than 90% of cases are idiopathic (iPAP). In iPAP, respiratory symptoms initiate insidiously, with no precipitating event or illness. Alveolar macrophages from patients with iPAP show impaired chemotactic activity, reduced adhesion to glass, and poor phagocytosis (4). Dysfunction that impairs surfactant clearance of alveolar macrophages is considered responsible for iPAP (24).

A serendipitous observation first suggested that abnormalities of GM-CSF signaling may be involved pathogenically in iPAP: mice lacking the hematopoietic growth factor granulocyte-macrophage colony–stimulating factor (GM-CSF) or its receptor develop histologic changes similar to those seen in PAP (57). In mice, GM-CSF regulates the terminal differentiation of alveolar macrophages. It is necessary for normal catabolism of surfactant lipids and proteins (8). Genetic abnormalities of GM-CSF or its receptor were reported in a small number of patients with congenital PAP (9), but were not found in iPAP (2). Instead, all patients with iPAP evaluated so far have high titers of neutralizing anti–GM-CSF autoantibody. No more than trace amounts of the antibody were detected in patients with congenital or secondary PAP, other lung diseases, or healthy volunteers (10, 11). Taken together, loss of GM-CSF activity caused by the autoantibody cripples normal functions of alveolar macrophages, thereby reducing surfactant clearance.

Recombinant human GM-CSF is used clinically to stimulate bone marrow recovery in neutropenic patients and after bone marrow transplantation. Several investigators have administered GM-CSF subcutaneously to patients with PAP and have observed varied responses (1215). A single case report describes a patient who was treated successfully using aerosolized GM-CSF (16). A recent study demonstrated that extrinsic GM-CSF administration restored expression of a transcriptional factor, PU.1, in alveolar macrophages, and thereby improved the maturation of alveolar macrophages in patients with PAP (17, 18). Considering the preexisting autoantibody, which binds GM-CSF with high avidity and specificity (19), it is unlikely that administered GM-CSF can directly stimulate immature alveolar macrophages by binding their GM-CSF receptors.

To investigate mechanisms of action of administered GM-CSF, we observed changes in the function of alveolar macrophages, together with changes in the neutralizing activity against GM-CSF and the amount of autoantibody in bronchoalveolar lavage fluid (BALF) of three patients treated with aerosolized GM-CSF. Results suggested that inhaled GM-CSF reduced the neutralizing capacity of BALF against GM-CSF with decreased concentration of both free autoantibody and the immune complex. Consequently, inhaled extrinsic GM-CSF might condition the alveolar microenvironment in the lung, allowing alveolar macrophages' functional recovery and clearance of proteinaceous materials. Some of the results of this study have been reported previously in the form of an abstract (20).

See the online supplement for further details on the methods.

Patients and GM-CSF Administration

The institutional review board approved this study. It was conducted after obtaining written, informed consent from each participant between December 2000 and October 2002. We treated a series of three individuals with iPAP (one man and two women; age range, 51–57 years) with aerosolized GM-CSF (Table 1)

TABLE 1. Patient profile

Case 1

Case 2

Case 3
Age and sex51-yr female56-yr male57-yr female
Diagnostic procedureBALF, TBLB, AbBALF, TBLB, AbBALF, TBLB, Ab
Prior treatmentLeft lung lavageOxygen treatment
   immunosuppressants*Oxygen treatment
A-aDO2 decrease after GM-CSF inhalation (torr)

*Case 2 had received prednisone and cyclosporine as the treatment for Wegener's granulomatosis, which was diagnosed 17 months earlier to the onset of idiopathic pulmonary alveolar proteinosis (see the online supplement for further details).

Brief profile and the effects of GM-CSF inhalation on a mucinlike glycoprotein, KL-6, and serum anti–GM-CSF antibody of Case 3 was reported previously (24).

Case 3 had just stopped smoking when pulmonary aveolar proteinosis was diagnosed.

Definition of abbreviations: A-aDO2 = alveolar–arterial oxygen gradient; Ab = serum titer of anti–GM-CSF antibody; BALF = bronchoalveolar lavage fluid; GM-CSF = granulocyte-macrophage colony–stimulating factor; TBLB = transbronchial lung biopsy.

. BAL, transbronchial lung biopsy, and anti–GM-CSF antibody in the serum confirmed the iPAP diagnosis. The patients were administered recombinant GM-CSF (125 μg in 2 ml normal saline; Leucomax; Novartis AG, Basel, Switzerland) by aerosol (LC Plus jet nebulizer; PARI Respiratory Equipment, Inc., Starnberg, Germany) twice daily, during alternate weeks for 24 weeks. This schedule of treatment was based on a report by Anderson and coworkers (21). They administered aerosol GM-CSF to seven patients with metastatic lung tumors and found low toxicity. Improvement was defined as 10 mm Hg or greater decrease in the alveolar–arterial oxygen gradient (A-aDO2).

BAL Procedures

Three 50-ml aliquots of normal saline were instilled and suctioned sequentially from the right middle lobe under bronchoscopy and processed immediately. Cells were stained by modified Giemsa; 400 nucleated cells were counted differentially in cytocentrifuge preparations. Then 200 alveolar macrophages were measured for lengthwise diameter and classified into the following two morphologic groups based on Iyonaga and colleagues (22): (1) nonfoamy, monocyte-like cells and (2) foamy cells.

Electron Micrograph of Alveolar Macrophages

BALF was incubated in a plastic culture dish at 37°C for 1 hour. After removing nonadherent cells by gentle washing, adherent cells (alveolar macrophages) were fixed and processed for Epon-embedded sections to be observed with a transmission electron microscope.

Phagocytic Activity of Alveolar Macrophages

Alveolar macrophages, isolated as previously described, were suspended in Roswell Park Memorial Institute (RPMI)/10% fetal calf serum and plated in a four-well chamber slide (LabTek Chamber; Nunc, Rosklide, Denmark). After placing at 37°C for 2 hours, cells were incubated with 0.5% phycoerythrin (PE)-labeled latex beads (Sigma-Aldrich Corp., St. Louis, MO) for 30 minutes and fixed in 4% paraformaldehyde at 4°C for 15 minutes. Cells were then stained with a 1:3,000 dilution of Syber green (Dojindo Laboratories, Kumamoto, Japan). The alveolar macrophages that had phagocytosed beads were counted using a confocal laser microscope.

Immunohistochemical Staining

Alveolar macrophages were fixed with 4% paraformaldehyde and stained with antimannose receptor antibody (Beckman Coulter, Inc., Fullerton, CA) and horseradish peroxidase-labeled antimouse IgG antibody (Nichirei Corp., Tokyo, Japan) to examine expression of the mannose binding protein, a maturation marker for macrophages. We examined PU.1 expression by double immunostaining using a rabbit polyclonal anti-PU.1 antibody (Santa Cruz Biotechnology, Inc., Santa Cruz, CA), which was detected using an alkaline phosphatase-labeled antirabbit IgG (Promega Corp., Madison, WI) and a mouse anti-CD68 monoclonal antibody labeled with horseradish peroxidase. Two pathologists independently determined quantification of a ratio of macrophages expressing PU.1. They counted the number of cells stained through a binary decision. Mean values are presented (Figure 6C).

To observe localization of PU.1, alveolar macrophages were immunostained with a rabbit anti-PU.1 polyclonal antibody and PE-labeled antirabbit polyclonal antibody (DakoCytomation, Glostrup, Denmark), counterstained with 1:3,000 dilution of Syber green; they were then examined using confocal laser microscopy.

Quantification of Anti–GM-CSF Autoantibody

Autoantibody concentrations in BALF or in serum were measured using purified autoantibody as a standard (15, 23).

Neutralizing Capacities against GM-CSF in BALF

The GM-CSF bioactivity was quantified using TF-1, a GM-CSF–dependent cell line, as described elsewhere (19).

Detection of GM-CSF in GM-CSF–Autoantibody Immune Complexes

Protein samples obtained from BALF of patients with iPAP and normal control subjects using protein-A sepharose were subjected to ELISA and Western blotting to detect GM-CSF, as described previously (19).

Statistical Analyses

Statistical analyses were performed using StatView version 4 software (SAS Institute, Inc., Cary, NC), using the Mann-Whitney's U test or Kruskal-Wallis rank sum procedures for nonparametric data. Correlation of variables was assessed using the Spearman rank correlation coefficient. We considered p < 0.05 to be significant.

Population, Morphology, and Function of Alveolar Macrophages during GM-CSF Treatment

The 24-week course of inhaled GM-CSF therapy showed improved oxygenation of arterial blood with no side effects. All three patients showed a 10 mm Hg decrease or more in A-aDO2 after treatment (Table 1). Serum levels of surfactant protein-D, lactate dehydrogenase, and carcinoembryonic antigen were also improved (Figure 1

; Figures E1 and E2 in the online supplement) (24). Case 1 recurred 20 months after the GM-CSF therapy (see Figure 1 and the online supplement for further details). Table 2

TABLE 2. Bronchoalveolar lavage fluid analyses before and after aerosolized granulocyte-macrophage colony–stimulating factor therapy

Case 1

Case 2

Case 3

Recovery, % of 150 ml696053484070
Cell counts, × 104/ml 2.915.9 4.016.2 7.527.1
Macrophages, %627666954724
Lymphocytes, %292132 44076
Neutrophils, % 9 3 2 112 0
Eosinophils, % 0 0 0 0 0 0
CD4/8 ratio
summarizes general characteristics of the cells in BALF. Alveolar macrophages increased after a 24-week GM-CSF inhalation (p < 0.05), whereas extracellular proteinaceous material and cell debris markedly decreased (Figures 2A–2C and 3A). Although the percentage of macrophages decreased in Case 3 after treatment, the absolute number of macrophages in 1 ml of BALF increased, for the substantial increase of total BAL cells (Table 1 and Figure 3A). Foamy macrophages decreased after treatment (Figure 3B). Nonfoamy alveolar macrophages, smaller than normal control (p < 0.01) before the treatment, were of normal size after GM-CSF treatment (Figure 3C). Alveolar macrophages after the treatment showed mature ultrastructural features with the development of microvilli and clear organelles, compared with those before treatment (Figure 2D).

We examined alveolar macrophages before and after treatment for changes in phagocytic activity and in the expression of two molecules. Phagocytic activity, as measured using the number of the cells harboring beads, was increased after the treatment (Figure 4)

. Expression of the mannose receptor, a crucial molecule for macrophages to phagocytose microorganisms, and expression of PU.1, a critical transcription factor regulating differentiation and maturation, were both increased after treatment (Figures 5 and 6). These results suggest that GM-CSF treatment promoted differentiation and restored the normal functions of alveolar macrophages.

Neutralizing Capacity against GM-CSF in BALF Was Reduced after Treatment with a Decreased Level of the Autoantibody

Anti–GM-CSF antibodies in patients with iPAP have a wide range of target epitopes. In addition, the crude amount of the autoantibody may not be correlated with the biological effect or a state of the disease (20). Consequently, to investigate the effect of GM-CSF inhalation on autoantibody levels in the lung, we examined BALF after treatment for the following: (1) neutralization capacity, which suppresses biological activities of GM-CSF using a GM-CSF–dependent cell line, and (2) the amount of IgG binding to GM-CSF by enzyme immunoassay (EIA) (Table 3)

TABLE 3. Effects of gm-csf inhalation on the antibody against gm-csf and its neutralizing capacity

Anti–GM-CSF Ab (μg/ml)

Neutralizing Capacity

(IC50 GM-CSF ng/BALF ml)
Case 1
 Pre1.3830.54 4.13
 Post0.1021.85 0.47
Case 2
 Pre0.5857.40 1.33
 Post0.0333.70 0.32
Case 3

Definition of abbreviations: Ab = serum titer of anti–GM-CSF antibody; BALF = bronchoalveolar lavage fluid; GM-CSF = granulocyte-macrophage colony–stimulating factor; NA = not available.

. In the three cases of that study, the neutralizing capacity against GM-CSF declined remarkably to normal levels after GM-CSF treatment (p < 0.05). Consistently, the amount of the anti–GM-CSF antibody was also markedly decreased after GM-CSF inhalation (p < 0.05). The serum titer of the antibody after treatment was approximately 60 to 70% of the titer before the treatment. The neutralizing capacity of GM-CSF in BALF exhibited significant correlation with serum carcinoembryonic antigen (r = 0.886, n = 6, p = 0.0476), serum surfactant protein-D (r = 0.943, n = 6, p = 0.035), and a mucin-like glycoprotein, KL-6 (r = 0.943, n = 6, p = 0.035). It also showed marked correlation with the titer of anti–GM-CSF antibody in BALF (r = 0.829, n = 6, p = 0.0639) and Po2 (r = −0.829, n = 6, p = 0.0639), but not with the serum titer of anti–GM-CSF antibody (r = 0.143, n = 6, p = 0.7494). Our results suggest that inhalation of GM-CSF restored bioactivity in the lung of patients with iPAP by reduction of neutralizing capacity against GM-CSF with a proportionate reduction in the amount of the autoantibody in BALF.

GM-CSF–Autoantibody Immune Complex Was Reduced after the Treatment

The effects of inhaled exogenous GM-CSF on reduction of both the neutralizing capacity and titer of the autoantibody suggested that exogenous GM-CSF bound to the free autoantibody and thereby reduced the free autoantibody detected by both ELISA and bioassay. If that occurs, GM-CSF bound to the autoantibody in BALF may increase after treatment. To elucidate this, the concentration of GM-CSF bound or unbound to the autoantibody in BALF was measured and compared before and after treatment. Unexpectedly, concentrations of GM-CSF bound to the autoantibody were reduced consistently to a level below the range of detection after treatment (Table 4)

TABLE 4. Concentration (pg/ml) of granulocyte-macrophage colony–stimulating factor bound or unbound to the autoantibody in bronchoalveolar lavage fluid

Before Treatment

After Treatment

Case 171.3ND54.1ND
Case 224.0NDNDND
Case 3

Definition of abbreviation: ND = not detected.

The lower detection range of the granulocyte-macrophage colony–stimulating factor enzyme immunoassay kit we used is 2.8 pg/ml.

. On the other hand, concentrations of GM-CSF that was unbound to the autoantibody in BALF were at levels below the range of detection in any cases before or after treatment, suggesting that GM-CSF in BALF was trapped completely by the autoantibody in the lung of patients with iPAP. To investigate GM-CSF bound to the autoantibody, we performed immunoblotting assay of GM-CSF stripped from the immune complexes in the BALF of Case 1. The assay demonstrated a band of 23 kD corresponding to intrinsic GM-CSF, which was larger than extrinsic GM-CSF of 14.5 kD. Furthermore, the band of extrinsic GM-CSF was not detected in BALF.

Alveolar macrophages in the BALF of patients with iPAP in severe cases show defective mature alveolar macrophage functions (25, 26). Surfactant catabolism and host defense immunity regulated by transcription factor PU.1 are typical of such functions (27). Our previous studies suggested that maturation arrest of alveolar macrophages is caused by abundant autoantibody against GM-CSF in the lung (19). Because the therapeutic efficacy of extrinsic GM-CSF on iPAP has been established in clinical trials over the last decade (1316), it is plausible to hypothesize that administered GM-CSF alters the unclear balance between GM-CSF and the autoantibody in the pulmonary microenvironment.

Several investigators have addressed the mechanism of extrinsic GM-CSF action on the pathologic status of iPAP. Seymour and colleagues (28) reported that patients with iPAP who were treated with 5 μg/kg/day of GM-CSF showed an impaired hematopoietic response to GM-CSF. Schoch and coworkers (15) demonstrated that GM-CSF treatment restored morphology and adhesive function of alveolar macrophages in patients with iPAP. The serum anti–GM-CSF titer has been reported to decrease with improvement of iPAP in patients treated with GM-CSF or plasmapheresis (24, 29). Bonfield and colleagues (18) showed that suppressed expression of PU.1 and macrophage colony–stimulating factor receptor in alveolar macrophages of patients with PAP was changed to upregulation by GM-CSF treatment in both in vitro experiments and in vivo after subcutaneous injection.

These studies demonstrated that treatment accelerated maturation of alveolar macrophages, but they did not explore alterations of the pulmonary microenvironment in which alveolar macrophages reside. Consequently, we have conducted analyses that specifically address the following two points: (1) estimation of the neutralizing capacity of the BALF against GM-CSF during the treatment and (2) determination of the GM-CSF–autoantibody immune complex. We found the following: (1) the neutralizing capacities and the levels of autoantibody against GM-CSF were decreased in BALF of patients with iPAP after aerosolized GM-CSF treatment (Table 3), (2) the amounts of GM-CSF–autoantibody immune complexes were also decreased in BALF after the treatment (Table 4), and (3) GM-CSF bound to the immune complex in BALF was not extrinsic recombinant protein but rather natural glycosylated human protein in Case 1.

Aerosolized recombinant human GM-CSF given to cynomolgus monkeys increased the total number of BAL cells more effectively than intravenous infusion of GM-CSF (30). Aerosolized GM-CSF also improved lung histology, alveolar macrophage differentiation, and surfactant protein B (SP-B) immunostaining to normal levels in GM-CSF–deficient mice (8). These results suggest that inhalation of GM-CSF might be an effective approach to affect alveolar macrophages' proliferation and functional maturation. It is notable that Case 3 demonstrated the increase of lymphocytes in BALF after GM-CSF treatment. The increase of lymphocytes was greater than in other two cases, and it might be associated with smoking cessation (Table 1). BAL lymphocytosis was also observed in a patient with PAP throughout the treatment course of subcutaneous GM-CSF injection, despite clinical improvement (15). The pulmonary infiltrates of lymphocytes in GM-CSF–deficient mice decreased but remained under successful treatment with aerosolized GM-CSF (8). Aerosolized GM-CSF itself increased lymphocytes in BALF of healthy cynomolgus macaques (30). The mechanism of the persistent BAL lymphocytosis during PAP treatment with GM-CSF remains to be elucidated.

The lungs of patients with iPAP contain abundant anti–GM-CSF antibody, and they produce GM-CSF to the comparable extent of normal lung (19). Decreased levels of the anti–GM-CSF antibody and the immune complex in BALF of the post-treatment patients suggested that aerosolized GM-CSF might affect the regulatory mechanism of production/disposition of anti–GM-CSF antibody locally or systemically. We infer that the reduced antibody restores bioactivity of intrinsic GM-CSF, engendering an increase of alveolar macrophages. To test the assumption, we attempted to demonstrate the presence of biologically active endogenous GM-CSF in BALF using TF-1, a GM-CSF–dependent cell line. However, neither BALF from normal control subjects nor BALF from the post-treatment patients sustained cell survival; their GM-CSF activities were below the detectable range (data not shown).

It remains unclear why treatment with extrinsic GM-CSF can decrease both the amount and the neutralizing capacity of autoantibody against GM-CSF in BALF of patients with iPAP (14, 15). It is a remarkable finding that the aerosolized GM-CSF therapy decreased the titer and neutralizing capacity of the anti–GM-CSF antibody in BALF during administration of immunosuppressants in Case 2. Further study should address the following: (1) the immune complex might modify a profile of T-cell population that regulates the autoantibody production and (2) apoptosis of the B cells that produce anti–GM-CSF antibody might be triggered by the immune complex of extrinsic GM-CSF and the autoantibody through Fc receptors, such as inhibitory FcγRIIB, as in the process of negative selection of B cells (31).

The clinical implication of the present study is that quantification of anti–GM-CSF antibody in BALF is useful to predict the response to GM-CSF treatment in each patient. The neutralizing capacity of GM-CSF in BALF is correlated significantly with serum markers including carcinoembryonic antigen, KL-6, and surfactant protein-D. It is also strongly correlated with the titer of anti–GM-CSF antibody in BALF and Po2. Clinical trials of GM-CSF treatment revealed the existence of patients who showed no improvement in clinical parameters such as Po2, computed tomographic, and pulmonary function tests (13, 14). Furthermore, these clinical markers often showed delayed response to GM-CSF therapy in some cases. Techniques to evaluate the amount and the neutralizing capacity of anti–GM-CSF antibody in BALF during GM-CSF treatment would be useful tools to enable prediction of the response to GM-CSF treatment.

In conclusion, the present study demonstrated the importance of evaluating microenvironments surrounding macrophages in lungs as well as functions of alveolar macrophages in patients with iPAP. Techniques for detecting the neutralizing capacity and amount of anti–GM-CSF autoantibody in BALF could contribute to optimization of treatment for patients with iPAP.

The authors thank Dr. John F. Seymour and Dr. Bruce C. Trapnell for their critical reading of the manuscript.

1. Rosen SH, Castleman B, Liebow AA. Pulmonary alveolar proteinosis. N Engl J Med 1958;258:1123–1142.
2. Seymour JF, Presneill JJ. Pulmonary alveolar proteinosis: progress in the first 44 years. Am J Respir Crit Care Med 2002;166:215–235.
3. Trapnell BC, Whitsett JA, Nakata K. Pulmonary alveolar proteinosis. N Engl J Med 2003;349:2527–2539.
4. Trapnell BC, Whitsett JA. GM-CSF regulates pulmonary surfactant homeostasis and alveolar macrophage-mediated innate host defense. Annu Rev Physiol 2002;64:775–802.
5. Dranoff G, Crawford AD, Sadelain M, Ream B, Rashid A, Bronson RT, Dickersin GR, Bachurski CJ, Mark EL, Whitsett JA, et al. Involvement of granulocyte-macrophage colony-stimulating factor in pulmonary homeostasis. Science 1994;264:713–716.
6. Stanley E, Lieschke GJ, Grail D, Metcalf D, Hodgson G, Gall JA, Maher DW, Cebon J, Sinickas V, Dunn AR. Granulocyte/macrophage colony-stimulating factor-deficient mice show no major perturbation of hematopoiesis but develop a characteristic pulmonary pathology. Proc Natl Acad Sci USA 1994;91:5592–5596.
7. Nishinakamura R, Nakayama N, Hirabayashi Y, Inoue T, Aud D, McNeil T, Azuma S, Yoshida S, Toyoda Y, Arai K. Mice deficient for the IL-3/GM-CSF/IL-5 beta c receptor exhibit lung pathology and impaired immune response, while beta IL3 receptor-deficient mice are normal. Immunity 1995;2:211–222.
8. Reed JA, Ikegami M, Cianciolo ER, Lu W, Cho PS, Hull W, Jobe AH, Whitsett JA. Aerosolized GM-CSF ameliorates pulmonary alveolar proteinosis in GM-CSF deficient mice. Am J Physiol 1999;262:L556–L563.
9. Dirksen U, Nishinakamura R, Groneck P, Hattenhorst U, Nogee L, Murray R, Burdach S. Human pulmonary alveolar proteinosis associated with a defect in GM-CSF/IL-3/IL-5 receptor common b chain expression. J Clin Invest 1997;100:2211–2217.
10. Kitamura T, Tanaka N, Watanabe J, Uchida K, Kanegasaki S, Yamada Y, Nakata K. Idiopathic pulmonary alveolar proteinosis as an autoimmune disease with neutralizing antibody against granulocyte/macrophage colony-stimulating factor. J Exp Med 1999;190:875–880.
11. Kitamura T, Uchida K, Tanaka N, Tsuchiya T, Watanabe J, Yamada Y, Hanaoka K, Seymour JF, Schoch OD, Doyle I, et al. Serological diagnosis of idiopathic pulmonary alveolar proteinosis. Am J Respir Crit Care Med 2000;162:658–662.
12. Seymour JF, Dunn AR, Vincent JM, Presneill JJ, Pain MC. Efficacy of granulocyte-macrophage colony stimulating factor in acquired alveolar proteinosis. N Engl J Med 1996;335:1924–1925.
13. Seymour JF, Presneill JJ, Schoch OD, Downie GH, Moore PE, Doyle IR, Vincent JM, Nakata K, Kitamura T, Langton D, et al. Therapeutic efficacy of granulocyte-macrophage colony-stimulating factor in patients with idiopathic acquired alveolar proteinosis. Am J Respir Crit Care Med 2001;163:524–531.
14. Kavuru MS, Sullivan EJ, Piccin R, Thomassen MJ, Stoller JK. Exogenous granulocyte-macrophage colony-stimulating factor administration for pulmonary alveolar proteinosis. Am J Respir Crit Care Med 2000;161:1143–1148.
15. Schoch OD, Schanz U, Koller M, Nakata K, Seymour JF, Russi EW, Boehler A. BAL findings in a patient with pulmonary alveolar proteinosis successfully treated with GM-CSF. Thorax 2002;57:277–280.
16. Wylam ME, Ten RM, Katzmann JA, Clawson M, Prakash UBS, Anderson PM. Aerosolized GM-CSF improves pulmonary function in idiopathic pulmonary alveolar proteinosis [abstract]. Am J Respir Crit Care Med 2000;161:A889.
17. Shibata Y, Berclaz PY, Chroneos ZC, Yoshida M, Whitsett JA, Trapnell BC. GM-CSF regulates alveolar macrophage differentiation and innate immunity in the lung through PU.1. Immunity 2001;15:557–567.
18. Bonfield TL, Raychaudhuri B, Malur A, Abraham S, Trapnell BC, Kavuru MS, Thomassen MJPU. 1 Regulation of human alveolar macrophage differentiation requires granulocyte macrophage colony stimulating factor (GM-CSF). Am J Physiol Lung Cell Mol Physiol 2003;285:L1132–L1136.
19. Uchida K, Nakata K, Trapnell BC, Terakawa T, Hamano E, Mikami A, Matsushita I, Seymour JF, Oh-Eda M, Ishige I, et al. High affinity autoantibodies specifically eliminate granulocyte-macrophage colony-stimulating factor activity in the lungs of patients with idiopathic pulmonary alveolar proteinosis. Blood 2004;103:1089–1098.
20. Tazawa R, Hamano E, Ohta H, Ishimoto T, Arai T, Uchida K, Watanabe M, Ebina M, Inoue Y, Nakata K, et al. Effects of aerosolized GM-CSF therapy on alveolar macrophages in patients with pulmonary alveolar proteinosis [abstract]. Am J Respir Crit Care Med 2004;169:A227.
21. Anderson PM, Markovic SN, Sloan JA, Clawson M, Prakash UBS, Arndt CAS, Smithson WA, Burch P, Gornet M, Rahman E. Aerosol granulocyte-macrophage colony-stimulating factor: a low toxicity, lung specific biologic therapy in patients with lung metastases. Clin Cancer Res 1999;5:2316–2323.
22. Iyonaga K, Suga M, Yamamoto T, Ichiyasu H, Miyakawa H, Ando M. Elevated bronchoalveolar concentrations of MCP-1 in patients with pulmonary alveolar proteinosis. Eur Respir J 1999;14:383–389.
23. Seymour JF, Doyle IR, Nakata K, Presneill JJ, Schoch OD, Hamano E, Uchida K, Fisher R, Dunn AR. Relationship of anti-GM-CSF antibody concentration, surfactant protein A and B levels, and serum LDH to pulmonary parameters and response to GM-CSF therapy in patients with idiopathic alveolar proteinosis. Thorax 2003;58:252–257.
24. Arai T, Hamano E, Inoue Y, Tazawa R, Nukiwa T, Sakatani M, Nakata K. Serum neutralizing capacity of GM-CSF reflects disease severity in a patient with pulmonary alveolar proteinosis successfully treated with inhaled GM-CSF. Respir Med 2004;98:1227–1230.
25. Gonzalez-Rothi RJ, Harris JO. Pulmonary alveolar proteinosis: further evaluation of abnormal alveolar macrophages. Chest 1986;90:656–661.
26. Milleron BJ, Costabel U, Teschler H, Ziesche R, Cadranel JL, Matthys H, Akoun GM. Bronchoalveolar lavage cell data in alveolar proteinosis. Am Rev Respir Dis 1991;144:1330–1332.
27. Berclaz PY, Shibata Y, Whitsett JA, Trapnell BC. GM-CSF, via PU.1, regulates alveolar macrophage Fcgamma R-mediated phagocytosis and the IL-18/IFN-gamma -mediated molecular connection between innate and adaptive immunity in the lung. Blood 2002;100:4193–4200.
28. Seymour JF, Begley CG, Dirksen U, Presneill JJ, Nicola NA, Moore PE, Schoch OD, van Asperen P, Roth B, Burdach S, et al. Attenuated hematopoietic response to granulocyte-macrophage colony-stimulating factor in patients with acquired pulmonary alveolar proteinosis. Blood 1998;92:2657–2667.
29. Bonfield TL, Kavuru MS, Thomassen MJ. Anti-GM-CSF titer predicts response to GM-CSF therapy in pulmonary alveolar proteinosis. Clin Immunol 2002;105:342–350.
30. Rose RM, Kobzik L, Dushay K, Wolfthal S, Hondalus M, Metzger M, Stoudemire J, Brain JD, Garnick M, O'Donnell C, et al. The effect of aerosolized recombinant human granulocyte macrophage colony-stimulating factor on lung leukocytes in nonhuman primates. Am Rev Respir Dis 1992;146:1279–1286.
31. Pearse RN, Kawabe T, Bolland S, Guinamard R, Kurosaki T, Ravetch JV. SHIP recruitment attenuates Fc gamma RIIB-induced B cell apoptosis. Immunity 1999;10:753–760.
Correspondence and requests for reprints should be addressed to Koh Nakata, M.D., Ph.D., Bioscience Medical Research Center, Niigata University Medical and Dental Hospital, Asahimachi-dori 1, Niigata, 951-8520, Japan. E-mail:


No related items
American Journal of Respiratory and Critical Care Medicine

Click to see any corrections or updates and to confirm this is the authentic version of record