The patient is a 29 year old sandblaster from Tehran with history of acute silicosis, pulmonary tuberculosis and secondary alveolar proteinosis on anti TB medications for a month and lung transplant candidate who presents with acute respiratory distress to our hospital. His respiratory symptoms have worsened in 10 days and in the past two days later was bed-bound. He denied fevers, chills or night sweats but produced small amounts of sputum. He also denied hemoptysis, and lost weight of 8 Kg in the two months with decreased appetite in few days. Two months prior to this admission, he was hospitalized in the TB ward with complaint of weakness, shortness of breath, cough and fever and chills. He also complained of headaches. He denied contact with a tuberculosis patient or any other medical conditions. Sputum smear was once positive for Acid Fast bacilli. He had undergone bronchoscopy and transbronchial biopsy and was diagnosed with silicosis and secondary alveolar proteinosis with an inflammatory necrotic lesion consistent with tuberculosis. Bronchoalveolar fluid lavage smear and biopsy showed numerous dust laden macrophages, squamous and columnar epithelial cells and was negative for malignancy. At this time, he was diagnosed with acutely exacerbated silicosis and secondary alveolar proteinosis. After evaluation, he was placed in lung transplant list. He received anti TB medications and intravenous hydrocortisone. At presentation, his medications were isoniazid, ethambutol, rifampin, pyrazinamide and prednisolone. He was prevented from medication allergies. He was married, worked as a sandblaster and denied smoking or substance abuse. He did not have family history of any diseases. 
 On physical examination, the patient was in respiratory distress. Blood oxygen saturation on arrival was 55-60% and oxygenation with a reserve bag mask eventually improved oxygen measurement upto 90 to 95%. The patient had a temperature of 38.3 oC, pulse rate 160, respiratory rate 22 and blood pressure 120/80. He was cyanotic due to respiratory distress. No lymphadenopathy was found. Cardiac exam showed present heart sounds S1 and S2 with no murmurs. Rales in both lungs were found. Abdominal exam was soft, nontender with no organomegally. Clubbing and edema was not present. Cardiac, neurologic and abdominal exam were all normal. 
 High resolution computed tomography (HRCT) of the lungs showed bilateral alveolar ground glass opacities and consolidations prominently in mid upper zones with inter lobular septal thickening. The patterns were noted to be characteristic but not diagnostic for pulmonary alveolar proteinosis with silicoproteinosis. In comparison with previous CT scan (two months prior) disease progression was noted (Fig. 1). 
 Laboratory values are shown in Table 1  and the report for radiology and pathology shown at the end of the report. 
 Sputum cultures, from previous hospitalization was negative for mycobacteria, BAL smear and polymerase chain reaction (PCR). He had negative TB cultures from this hospitalization as well. 
 The patient had spiked fevers up to 38.5oC and sweats during his hospital stay. Multiple arterial blood gases (ABG's) showed hypoxemia so oxygenation with reserve bag mask was administered. He was continued with TB medications and started on broad spectrum antibiotics clindamycin, Ceftazidime. Parenteral hydrocortisone was administered for diagnosis of acute silicosis. Furthermore, the aggressive nature of the disease caused concern about pneumocystis carinii (PCP) and cotrimoxazole was administered. Medications were continued during hospital stay of 16 days. Sputum for bacteriology was collected and bronchoalveolar lavage done with BAL. 
 Bronchoalveolar lavage (BAL) microscopic study showed many dust laden alveolar macrophages and was negative for malignancy and diagnosis of accelerated (cellular) phase of silicosis associated with secondary alveolar proteinosis was made. 
 Upon negative sputum and BAL smear and cultures on discharge and according to previous positive pathology, the overriding diagnosis of tuberculosis was settled and medications switched to TB coverage. He was a candidate for therapeutic lung lavage but too ill to undergo it. He was discharged from hospital with an oxygen mask, TB medications and prednisolone 40mg/day. 
 Resistant tuberculosis and acute silicosis was in the differential diagnosis for this patient with sudden progression of disease. 
 Shortly in a few days, the patient returned to the hospital emergency department with respiratory failure and hypoxemia. SPO2 on arrival was 55-60% with reserve bag mask. In attempt to intubate the patient, he suffered from cardiopulmonary arrest and died despite continued effort.