(1217) Acute Fibrinous and Organizing Pneumonia (AFOP) in Lung Transplant Recipient: A Case Report of Successful Treatment with Infliximab® and Tocilizumab®

IntroductionAcute fibrinous and organizing pneumonia (AFOP) is an uncommon yet severe complication after lung transplantation (LT). We discuss the case of an 18-year-old LT recipient at 5-years post-transplantation with suboptimal therapeutic adherence to immunosuppressive therapy who developed AFOP following a viral infection.Case ReportFollowing a positive naso-pharyngeal PCR for Adenovirus and Rhinovirus, the patient rapidly developed dyspnea at rest. Pulmonary functions showed rapid harmonious loss of both forced expiratory volume in 1 second (FEV1) and forced vital capacity. Thoracic CT-scan revealed multifocal ground glass opacities associated with lower lobes peribronchial condensations (Figure 1C and E). Despite high dose corticosteroids (CS) (Methylprednisolone 500 mg IV daily for 3 days), no clinical improvement was achieved. Cryobiopsies showed intra-alveolar fibrin balls (arrows in Figure 1A and B) and both bronchial aspiration and bronchoalveolar lavage PCR were positive for Aspergillus spp (286000 and 41000 copies/ml, respectively) with no hyphae at histopathology. Her condition rapidly deteriorated with severe hypoxemic respiratory failure necessitating orotracheal intubation (OTI). IV Infliximab® 250 mg (based on cases report), Tocilizumab® 8mg/kg (based on IL-6 elevation on serum cytokinic panel) and CS (prednisone 1 mg/kg) were administered. Aspergillus spp was treated with IV Voriconazole. The patient was extubated after 11 days. A second dose of Infliximab® 150 mg was administered 3 weeks later. Repeat CT-scan showed resolution of ground glass opacities (Figure 1D and F). The patient was discharged at home 42 days post-OTI with 1L/min O2.SummaryAn 18-year-old LTx recipient developed AFOP with severe respiratory failure necessitating OTI. Infliximab®, Tocilizumab® and high dose CS allowed weaning of mechanical ventilation on day 11 and home discharge on day 42 after OTI.