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A 49-year-old woman with acute lymphocytic leukemia (ALL) who had been intermittently treated with chemotherapy during a 3-year period developed cough and expectoration of increasing severity. Chest X-ray film revealed miliary shadows and bilateral hilar enlargement. Milky fluid was obtained by bronchoalveolar lavage. The intensity of these shadows showed temporary decrease, but thereafter progressively increased until the time of the patient's death. Autopsy findings were consistent with pulmonary alveolar proteinosis and systemic aspergillosis. Secondary alveolar proteinosis is rare, and in most reported cases is associated with hematological malignancy. To our knowledge, only 45 cases in which it was associated with hematological disorders have been reported. The examination of a patient with any hematological disorder, however, should include differential diagnosis of chest X-ray abnormalities to exclude secondary alveolar proteinosis, which can be lethal if left untreated.
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