A 48-year-old female received a heart-lung transplant for congenital heart disease. Early sputum cultures demonstrated Gram-negative rods for which piperacillin-tazobactam was given, and she was extubated on the second day, post-transplant, and commenced ambulation. However, small bowel complications developed and required surgical resection, and she developed dialysis-dependent acute renal insufficiency. Intubation and mechanical ventilation were required on day 30, and chest imaging showed persistent diffuse infiltrates (Figure 1, A and B). TBB showed minimal acute rejection (Grade A1B0). She was extubated 9 days later but required reintubation (post-transplant day 58) for progressive respiratory failure. TBB biopsy showed AFOP but did not show acute rejection (Figure 2, A and B), and an endomyocardial biopsy was negative for cardiac rejection. A laparotomy and right hemicolectomy were performed for persistent volvulus (post-transplant day 100). Lung function worsened, and Citrobacter freundii was isolated from blood cultures, BAL, and urine cultures. Respiratory status progressively worsened, and life support was withdrawn.