A 41-year-old female received a left single lung transplant for fibrotic non-specific interstitial pneumonia (NSIP). At 2 weeks post-transplant surveillance, TBB specimens showed Grade A1B1 acute rejection, and TBB performed 2 weeks later showed Grade A2B0 acute rejection. Intravenous methylprednisolone burst and taper was given, and she remained asymptomatic and continued to improve clinically until 6 weeks post-transplant when she presented with increasing dyspnoea on exertion, cough, and low-grade fever that progressed to intubation and mechanical ventilation. She was treated with broad-spectrum antibacterial agents and pulse corticosteroids. TBB demonstrated organising pneumonia (OP) but no acute rejection, and BAL did not reveal any pathogens. She was successfully extubated after 4 days, weaned to room air, and discharged to home. However, subsequent surveillance TBBs showed persistent OP as well as acute rejection (Grade A2-A3), and total lymphoid irradiation was initiated. The patient was readmitted 6 weeks later for shortness of breath and hypoxaemia that progressed to respiratory failure, requiring mechanical ventilation. Despite broad-spectrum antibiotics and pulse corticosteroids, diffuse parenchymal opacities (Figure 1, D) progressively worsened, and supportive care was eventually withdrawn. AFOP was observed in lung specimens examined at autopsy (Figure 2, E and F).