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Year : 2022  |  Volume : 5  |  Issue : 1  |  Page : 41-43

Abnormal chest skiagram in a normal individual a case report on orphan lung disease – Pulmonary alveolar microlithiasis

Department of Chest Medicine, Meenakshi Medical College, Kanchipuram, Tamil Nadu, India

Date of Submission07-Mar-2022
Date of Decision05-Apr-2022
Date of Acceptance02-Jun-2022
Date of Web Publication12-Aug-2022

Correspondence Address:
K Gokul
Room No: 5, Sai Apartments, Balagi Nagar, Enathur, Kanchipuram 631552, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/japt.japt_3_22

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Pulmonary alveolar microlithiasis (PAM) is a rare inherited disorder of sodium phosphate cotransporter which causes accumulation of microliths in alveoli. This is a case report of a 46-year-old female, came for surgical fitness for laparoscopic cholecystectomy with abnormal chest skiagram. Chest skiagram showed typical sand storm appearance. Since the patient had no respiratory complaints, high-resolution computed tomography chest was taken which showed diffuse micronodular calcifications suggestive of PAM.

Keywords: Calcification, chest skiagram, pulmonary alveolar microlithiasis

How to cite this article:
Kumar D S, Gokul K. Abnormal chest skiagram in a normal individual a case report on orphan lung disease – Pulmonary alveolar microlithiasis. J Assoc Pulmonologist Tamilnadu 2022;5:41-3

How to cite this URL:
Kumar D S, Gokul K. Abnormal chest skiagram in a normal individual a case report on orphan lung disease – Pulmonary alveolar microlithiasis. J Assoc Pulmonologist Tamilnadu [serial online] 2022 [cited 2023 Jan 27];5:41-3. Available from: http://www.japt.com/text.asp?2022/5/1/41/353743

  Introduction Top

Pulmonary alveolar microlithiasis (PAM) is a rare inherited disorder of sodium phosphate co transporter (Npt2b) in type 2 alveolar epithelial cells which causes accumulation of calcified microliths in the alveoli.[1],[2] Majority of reported cases of PAM in literature are from Asia and Europe. The incidence of PAM in India is 0.06 per million persons.[1],[3] Type 2 alveolar cells normally synthesize surfactants and maintain fluid balance. Pulmonary surfactant is normally made of phospholipids where they are broken down by alveolar macrophages. These breakdown releases phosphates which are removed by the Npt2b which is situated in the distal type 2 alveolar cells.

  Case Report Top

A 46-year-old male never smoker, alcoholic admitted to the surgical ward for elective laparoscopic cholecystectomy. The patient was referred from the surgical ward for pulmonary fitness. Chest skiagram showed bilateral widespread diffuse symmetrical micronodular opacities suggestive of sand storm appearance [Figure 1]. Currently, the patient has no respiratory complaints and no significant history of tuberculosis, and no significant occupational and other exposure history. Routine investigations were normal. High-resolution computed tomography (HRCT) chest was taken which showed diffuse hyperdense ground-glass opacifications with linear calcifications are seen [Figure 2]. Spirometry shows a mild restrictive ventilatory defect. Sputum examination was inconclusive.
Figure 1: Chest skiagram shows bilateral widespread diffuse symmetrical micronodular opacities predominantly involving basal regions, a typical sandstorm appearance

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Figure 2: (a) HRCT chest shows diffuse hyperdense ground-glass opacifications with linear calcifications. (b) HRCT chest shows typical black pleura sign. HRCT: High-resolution computed tomography

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Since chest imaging is suggestive of PAM, we planned for fiberoptic bronchoscopic-guided biopsy, but the patient was not willing and she told that she will come to our outpatient department in case of any respiratory issues in near future. After that, patient underwent surgery and she was discharged successfully without any postoperative complications.

  Discussion Top

PAM is a chronic lung disorder of Npt2b of type 2 alveolar epithelial cells. Genetic studies have revealed an SLC34A2 gene defect in few populations and which is an autosomal recessive pattern. Patients usually remain asymptomatic for a long time. Patients usually present as an incidental finding in their third to fourth decades of life. Patients will have mild dyspnea in the late stage and pneumothorax in rare cases. If patients are asymptomatic, then they can be left undisturbed as effective treatment is not available.

Radiological manifestation in pulmonary alveolar microlithiasis

Castellana et al.[4] classified PAM into four stages.

  • Stage 1: Precalcified stage
  • Stage 2: Typical sand storm appearance
  • Stage 3: Progressive opacification with obscuring cardiac and diaphragm borders – vanishing heart phenomenon
  • Stage 4: Intense calcification – typical white-out lung.

The patient may have emphysematous changes, lung cyst, and pulmonary fibrosis.

Apart from lung, extrapulmonary microliths deposition can also occur in male external genitalia which may lead to male infertility.[1]

In a large review from ERS journal, diseases reported to be associated with PAM included rheumatoid arthritis, Sjögren syndrome, lymphocytic interstitial pneumonitis, psoriasis, antiphospholipid syndrome, and discoid lupus after varicella-zoster infection, diaphyseal aclasia, autosomal recessive Waardenburg-anophthalmia, milk-alkali syndrome, pericardial cyst, osteopetrosis, pectus excavatum, and non-Hodgkin lymphoma.[1]

HRCT chest should always be performed since it can reveal typical characteristic patterns of PAM, reserving lung biopsy for atypical cases.[5]

Fiberoptic bronchoscopic-bronchoalveolar lavage may reveal microliths and bronchoscopy-guided transbronchial biopsy usually reveals microliths within the alveolar lumen.

Since PAM is a genetically transmissible disease by autosomal recessive pattern, familial screening mainly for siblings should be done by chest skiagram.[6]

Currently, there is no effective treatment available for PAM. Low-phosphate diet and bisphosphate binders like etidronate can be tried in few patients who are symptomatic. Lung transplantation is the last resort and can be considered in symptomatic patients with the severe ventilatory defect.[1],[7]

Differential diagnosis of PAM includes miliary tuberculosis, pneumoconiosis, fungal infection, sarcoidosis, tropical pulmonary eosinophilia, and metastasis.[3]

Complication of pulmonary alveolar microlithiasis

  • Respiratory failure
  • Infections like tuberculosis
  • Pulmonary hypertension
  • Cor pulmonale
  • Pneumothorax
  • Male infertility.

  Conclusion Top

PAM is an orphan lung disease that can affect middle-aged women, with chronic and deteriorating evolutionary course. Clinicians should be aware of its existence and its characteristic radiological feature.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Kosciuk P, Meyer C, Wikenheiser-Brokamp KA, McCormack FX. Pulmonary alveolar microlithiasis. Eur Respir Rev 2020;29:200024.  Back to cited text no. 1
Puhr L. Mikrolithiasis alveolaris pulmonum. [Pulmonary alveolar microlithiasis]. Virchows Arch (Pathol Anat) 1933;290:156.  Back to cited text no. 2
Castellana G, Castellana R, Fanelli C, Lamorgese V, Florio C. Pulmonary alveolar microlithiasis: Clinical and radiological course of three cases according to conventional radiology and HRCT. A hypothesis for radiological classification. Radiol Med 2003;106:160-8.  Back to cited text no. 3
Edelman JD, Bavaria J, Kaiser LR, Litzky LA, Palevsky HI, Kotloff RM. Bilateral sequential lung transplantation for pulmonary alveolar microlithiasis. Chest 1997;112:1140-4.  Back to cited text no. 4
Chan ED, Morales DV, Welsh CH, McDermott MT, Schwarz MI. Calcium deposition with or without bone formation in the lung. Am J Respir Crit Care Med 2002;165:1654-69.  Back to cited text no. 5
Castellana G, Castellana G, Gentile M, Castellana R, Resta O. Pulmonary alveolar microlithiasis: Review of the 1022 cases reported worldwide. Eur Respir Rev 2015;24:607-20.  Back to cited text no. 6
Sabbagh Y, O'Brien SP, Song W, Boulanger JH, Stockmann A, Arbeeny C, et al. Intestinal npt2b plays a major role in phosphate absorption and homeostasis. J Am Soc Nephrol 2009;20:2348-58.  Back to cited text no. 7


  [Figure 1], [Figure 2]


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