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Ann Saudi Med 28(4) July-August 2008 www.saudiannals.net Pulmonary alveolar microlithiasis (PAM) is a rare disease of unknown etiology and pathog genesis.2,3 This disorder is characterized by ing tragalveolar development and deposition of microliths or calcispherytes containing calcium phosphate.2,3 The age range of patients is from newborn to 80 years. The mean age at presentation is in the third to fourth deg cade with no sexual predominance, but in approximateg ly half the reported cases a familial pattern has been found. Most of the patients have few or no symptoms despite the gross radiographic changes. The dissociag tion between the definite xgray pattern of the lungs and the relatively poor clinical symptoms is the most comg mon characteristic of this disease. However, a certain degree of dyspnea with productive cough may occur together with a sporadic hemoptysis, thoracic pain and sometimes spontaneous pneumothorax.4,5 The lungs are hardened with associated deterioration of pulmog nary hypertension and thus cor pulmonale occurs.6 Pulmonary fibrosis is also observed in association with PAM.7,8 In such cases, as in our patient, a posteroanteg rior chest xgray shows a dissemination of radiogopaque nodules of almost equal sizes and the lungs appear to be sprinkled with sand. Very fine sandglike micronodulag tions with calcified densities were observed throughout both lungs fields (Figure 1). Histological examination demonstrated oniongskinglike microliths occupying the alveoli. Amorphous eosinophilic material filled the alg veoli (Figure 2). Some authors suggested that PAM may be a peg culiar exudative response to a variety of insults, which include pneumonia and rheumatic fever.9g11 Our report describes PAM after exposure to mustard gas. In other cases of microlithiasis sandstormgassociated, the exact cause has not been proved; only in 50% of cases has a genetic or familial factor been reported, but other causes have not been confirmed. In all cases, either acquired or genetic, it can be assumed that there is a disorder in the bronchial cilia or alveolar endothelium. Therefore, it can Diagnosis: Pulmonary alveolar microlithiasis after exposure to mustard gas