Pulmonary Alveolar Microlithiasis and Rheumatoid Arthritis with Pulmonary Tuberculosis

Pulmonary alveolar microlithiasis (PAM) is a rare autosomal recessive disease, characterised by widespread intra-alveolar accumulation of microliths. A 30-year-old male patient, known case of rheumatioid arthritis on treatment, presented with occasional complaints of cough with expectoration, since 1 year. He was found to be sputum AFB positive for which AKT was started, and a chest xray was advised, which showed diffuse bilateral micronodular calcific opacities having sand-like appearance distributed throughout the lungs, with a evident black pleural sign, which made us suspect PAM. An HRCT chest showed, multiple dense micronodular opacities in bilateral lung parenchyma prominently in the middle and lower lung zones giving a classical sandstorm appearance with sparing of a thin peripheral subpleural rim of parenchyma, giving a black pleura sign. The patient was symptomatically treated and was counselled for lung transplant and presents for regular follow up