Pulmonary alveolar proteinosis (PAP) is an uncommon pulmonary disease characterised by abnormal excessive accumulation of surfactant. We present a case of PAP complicated by fungal aspergillosis and multidrug resistant tuberculosis.

A forty eight year old female patient came to our hospital with complaints of shortness of breath (NYHA grade I ) which gradually increased to grade IV. She did not have any other complaints of orthopnoea, paroxysomalnocturanal dyspnea, chest pain or fever. On general examination she was cachectic ,very pale, no lymphadenopathy. On auscultation she had coarse crepitations right side more than left . Chest roentogram showed an irregular opacity in right middle zone suggesting pneumonia/ fungal ball and bilateral diffuse opacities in lower lung fields. HRCT revealed crazy pavement pattern bilaterally. Fine needle aspiration biopsy proved that lesion from right side as aspergillosis , and other areas as alveolar proteinosis . She was treated with antifungals and antibiotics. In view of alveolar proteinosis we posted the case for broncho alveolar lavage (BAL) which is the standard treatment for the condition. Standard 32 french double lumen tube was used to isolate the healthy left lung from fungal infection present in right side.After 2 liters of warm saline lavage,milky white fluid came later.Patient ventilated after exchanging double lumen tube with single lumen tube.Culture from BAL showed multidrug resistant tuberculosis. Subsequently patient had sepsis and succumbed after two episodes of cardiac arrest.

Pulmonary alveolar proteinosis poses a unique challenges to the anesthesiologists. so a proper anesthetic plan has to be formulated prior to the managament and a proper co ordiantion between the anesthesiologist,pulmonolgist and surgeon is necessary for better outcome.