A Case of Acute Fibrinous and Organizing Pneumonia During Early Postoperative Period After Lung Transplantation I.O. Alici a, *, E. Yekeler a , A. Yazicioglu a , S. Turan a , Y. Tezer-Tekce a , F. Demirag b , and N. Karaoglanoglu a a Thoracic Surgery and Lung Transplantation Center, Turkiye Yuksek Ihtisas Education and Research Hospital, Ankara, Turkey; and b Department of Pathology, Ataturk Chest Diseases and Thoracic Surgery Education and Research Hospital, Ankara, Turkey ABSTRACT Acute fibrinous and organizing pneumonia (AFOP) is a distinct histologic pattern usually classified under the term chronic lung allograft dysfunction. We present a 48-year-old female patient who experienced AFOP during the 2nd week of double lung transplantation for pul- monary Langerhans cell histiocytosis and secondary pulmonary hypertension. During the 8th day after transplantation, fever and neutrophilia developed together with bilateral consolida- tion. Infection markers were elevated. Despite coverage of a full antimicrobial spectrum, the situation progressed. The patient was diagnosed with AFOP with transbronchial biopsy. The infiltration resolved and the patient improved dramatically with the initiation of pulse corti- costeroid treatment. AFOP should be suspected when there is a pulmonary consolidation after lung transplantation, even in the very early post-transplantation period. Several causes, such as alveolar damage and drug reactions, should be considered in the differential diagnosis. A CUTE FIBRINOUS AND ORGANIZING PNEU- MONIA (AFOP) is a distinct histologic pattern with intra-alveolar deposition of fibrin and is often related to orga- nizing pneumonia [1]. Although it has been shown to be related to various conditions, there are few cases after lung trans- plantation. We present a case of AFOP which interestingly occurred during the very early postoperative period after lung transplantation. CASE PRESENTATION The patient was a 48-year-old woman who had undergone double lung transplantation surgery indicated for pulmonary Langerhans cell his- tiocytosis and secondary pulmonary arterial hypertension. The patient was discharged from the operation room to the intensive care unit with venoarterial extracorporeal membrane oxygenator (ECMO) which was constituted peripherally through the femoral vein and artery. T- and B-cell crossmatch was negative. She received alemtuzumab in- duction followed by initiation of intravenous tacrolimus and predniso- lone. After a grade III primary graft dysfunction that was cleared on the 5th day, the ECMO was weaned on the 7th day after the operation. The day after (8th day), a fever (>39  C) developed together with neutro- philia and high C-reactive protein (CRP) and procalcitonin levels. The time line of the events is shown in Fig 1. Bilateral infiltrations on the chest roentgenogram grew in time. Computerized tomography of the thorax revealed an area of consolidation on the lower lobes bilaterally (Fig 2). Vascular and bronchial anastomoses and distal bronchial structures were patent. We immediately broadened the antibacterial spectrum and added systemic antifungal treatment because of the history of ECMO and vaginal candidiasis. Bronchoalveolar lavage fluid (BALF) revealed marked neutrophilia without any remarkable micro- organism. Oseltamivir was started but discontinued after 2 days because polymerase chain reaction (PCR) for community-acquired respiratory viruses in the BALF was found to be negative. Mycobacterial PCR and direct fluorescent antibody for Pneumocystis jirovecii were also negative. Despite full coverage of antiinfective therapy, the infiltration grew, the fever remained, and CRP and procalcitonin increased up to 38.8 mg/ dL and 76.7 ng/mL, respectively. The transbronchial biopsy from the right lower lobe revealed AFOP with a degree of interstitial thickening, intra-alveolar fibrin deposits, and organizing pneumonia. Eosinophilic infiltration and hyaline membranes were absent. There was no sign of acute rejection; ISLHT classification was A0Bx (Fig 3). Because of the severity of the clinical condition and the nature of the histologic diagnosis, we started a pulse corticosteroid therapy of 1 g/d intravenous methylprednisolone for 3 days followed by 1 mg/kg/d prednisolone. The infiltration resolved, fever declined, and other biomarkers decreased to normal levels within a week. Surveillance biopsy confirmed the healing process. DISCUSSION The early postoperative period after lung transplantation is usually a great challenge for a transplant team, with several *Address correspondence to Alici Io, Turkiye Yuksek Ihtisas Training and Research Hospital, Lung Transplantation Center, Kizilay Sok 06100 Sihhiye Ankara, Turkey. E-mail: ioalici@ hotmail.com 0041-1345/15 http://dx.doi.org/10.1016/j.transproceed.2015.02.002 ª 2015 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710 836 Transplantation Proceedings, 47, 836e840 (2015)