Lesson of urgent bilateral lobar lung transplantation for acute fibrinous and organizing pneumonia: a case report

BACKGROUND: Acute fibrinous and organizing pneumonia (AFOP) is one of acute expiratory diseases, which occurs rarely with a difficult diagnosis. AFOP is related to an idiopathic cause or autoimmune disease, drug use, infection, cancer, or transplantation. Variation of treatment depends on different institutions. To date, no evidence shows that lobar lung transplantation is applied in an urgent situation such as AFOP. CASE DESCRIPTION: A 33-year-old female patient experienced fever, cough, and dyspnea four days prior to admission. She had no underlying health conditions. Initially, she received oxygen therapy and empiric antimicrobial treatment, but later developed pulmonary consolidation. Pathological examination confirmed the diagnosis of AFOP. Despite receiving standardized treatment involving extracorporeal membrane oxygenation (ECMO) and mechanical ventilation, the patient’s respiratory function remained compromised. Consequently, an urgent lobar lung transplantation was performed. However, the patient encountered several challenges including carbapenem-resistant Pseudomonas aeruginosa pneumonia, exophytic granulation tissue, anastomotic stenosis, bronchopleural fistulae, anastomotic infections, septic shock, bacteremia, reperfusion syndrome, primary graft dysfunction, severe renal failure, and critical illness myopathy. Although the patient ultimately recovered and had a favorable survival outcome over 1-year post-discharge through multidisciplinary care, there are several key points to consider. Based on the findings from a systematic review, urgent transplantation may be a potential alternative treatment for AFOP. However, peri-transplantation programs should be enhanced, particularly regarding criteria selection, ECMO management, and the role of enhanced recovery after transplantation. CONCLUSIONS: The case demonstrates the feasibility of bilateral lobar lung transplantation in patients with AFOP, especially in an urgent situation.