A 34-year-old woman who had been considered cured of Hodgkin's lymphoma underwent bilateral lung transplantation for bleomycin-associated pulmonary fibrosis. She had a benign clinical course for the next 7 years despite persistent poor graft function, but was then diagnosed with a left breast ductal carcinoma and underwent mastectomy and was started on tamoxifen. Three months later she noted persistent mild symptoms of cough and dyspnoea on exertion, associated with new persistent infiltrates on imaging (Figure 1, E and F), accompanied by a significant decline in FEV1 and oxyhaemoglobin desaturation with activity. TBB revealed AFOP, and high-dose corticosteroids and broad-spectrum antibiotics were given. BAL detected multi-drug resistant S. maltophilia, for which antibacterial coverage was adjusted. She gradually improved and was discharged to home, but after a stable period of 6 months, she developed increased shortness of breath, and a thoracic HRCT showed multiple new lung nodules. Lung biopsy revealed metastatic breast cancer, to which she succumbed 3 months later.
Case 3: Transverse high-resolution computed tomography (HRCT) image (D) demonstrates patchy peribronchial ground-glass opacity with superimposed reticulation and mild traction bronchiectasis (arrows).