A 26-year-old man received a successful bilateral lung transplant for end-stage cystic fibrosis but required stent placement for a right main bronchial stenosis at the anastomosis site. He developed cough, dyspnoea, and fever 5 months post-transplantation; sputum cultures demonstrated mucoid Pseudomonas aeruginosa for which piperacillin-tazobactam was administered. TBB showed minimal acute rejection (Grade A1B0). Cough and dyspnoea persisted and the patient resumed use of supplemental home oxygen. He acutely decompensated 2 weeks later with diffuse infiltrates on thoracic imaging (Figure 1, C) and developed shock and respiratory insufficiency, requiring intensive care unit admission and administration of pressors, tracheal intubation, and mechanical ventilation. Group A Streptococcus pyogenes was present in multiple blood cultures, and diabetic ketoacidosis was also present. He was successfully treated, extubated, and discharged to home 12 days after admission. After a 3-month period of clinical stability, he developed sustained decline in forced expiratory volume in 1 second (FEV1). BAL showed methicillin-sensitive Staphylococcus aureus (MSSA) and mucoid P. aeruginosa. TBB did not show acute rejection or other specific parenchymal abnormality. Antibiotics were administered, and blood cultures grew Candida albicans and Stenotrophomonas maltophilia. Intubation and mechanical ventilatory support were required. Due to lack of improvement with appropriate antibacterial and anti-fungal therapies, a surgical lung biopsy was performed that showed AFOP (Figure 2, C and D). Chest imaging showed persistent infiltrates, and care was withdrawn after 1 month of mechanical ventilation.