Transbronchial lung biopsy (TBLB) in diagnosing pulmonary alveolar proteinosis (PAP): forgotten role in Australia?

Transbronchial lung biopsy (TBLB) is uncommonly performed in non-malignant conditions because of its low sensitivity and small tissue samples. It is not routinely performed in Australia to investigate idiopathic pulmonary fibrosis, although it can be a useful adjunct in obtaining tissue diagnosis in selected conditions in interstitial lung disease (ILD). A 52-year-old non-smoker received a living unrelated renal transplant in January 2014 but developed insidious onset of dyspnea on exertion 1 year later. Computed tomography of the thorax showed bilateral persistent ground glass opacifications with a characteristic crazy paving pattern, although P neumocystis jirovecii pneumonia was more concerning. He was treated as P neumocystis jirovecii pneumonia but his initial bronchoscopy failed to confirm either diagnoses. He then went on to TBLB that showed the presence of periodic acid-Schiff staining material. We conclude that TBLB is a useful adjunct to obtain histological diagnosis of ILD in carefully selected patients with appropriate radiological indications.