Background: Besides surfactant protein B (SP-B), respiratory distress syndrome in term neonates is associated to mutations of ABCA3, a gene encoding a type II pneumocyte protein essential for intracellular surfactant metabolism.Study goal: To correlate mutations in surfactant-related genes with specific tissue/cell structural anomalies and alterations of surfactant-related protein expression.Methods: 4 neonates with primary, progressive respiratory failure unresponsive to exogenous surfactant. Optical microscopy (OM) on formalin-fixed lung biopsy: HE, PAS, Masson trichrome; immunohistochemestry with CD45, CD68, SP-B and SP-C antibodies; immunofluorescence with ABCA3 antibody. Electron microscopy (EM) on Karnowsky-fixed ultrathin sections. Direct sequencing of SP-B, SP-C and ABCA3 genes on PCR-amplified genomic DNA.Results: Case 1, 2 and 3 were term-born infants dead at 68, 48 and 55d; case 4 was a 32-week preterm alive with severe respiratory failure at 4 months. OM: All cases showed marked interstitial thickening with monocyte infiltrate, type II pneumocyte hyperplasia, intra-alveolar proteinaceous material and macrophage accumulation. SP-B and SP-C protein expression was normal. ABCA3, abundantly expressed with a cytoplasmic granular pattern in normal subjects, was either absent (1), low with a diffuse cytoplasmic pattern (2,4), or apparently normal (3). EM: In all cases, type II pneumocyte lamellar bodies appeared much smaller than normal and filled with homogenous material with an eccentric, denser inclusion. Pseudomyelin structures, corresponding to intracellular surfactant, were virtually absent. Molecular genetics: SP-B and SP-C gene sequences were normal. In the ABCA3 gene, homozygous frameshift (1) or double heterozygote missense mutations (2,3,4) were found.Conclusions: ABCA3 deficiency is a rare but relevant cause of progressive respiratory failure in newborns. Various recessive mutations are associated with this phenotype, leading in most cases to absent or aberrant ABCA3 protein expression and/or function. Whereas OM may be nonspecific, EM shows typical anomalies of the lamellar bodies that may contribute to early diagnosis.