A 64-year-old woman received a left single-lung transplant 3 years earlier (January 1997) for end-stage idiopathic pulmonary fibrosis. Her postoperative course was relatively uncomplicated until the 7 months preceding her acute presentation, when deteriorating pulmonary function consistent with clinical bronchiolitis obliterans syndrome gradually developed, which progressed from grade 0 to grade 2. Her baseline immunosuppression after transplantation had been tacrolimus and mycophenolate mofetil. The patient however had four to five episodes per year of histologically proven rejection that always responded to treatment with augmented steroids. In the year prior to her terminal event, she had three episodes of biopsy-proven rejection—the last being grade 2–3 treated with an antilymphocyte globulin (9 months prior to presentation). The patient was enrolled in a cyclosporine-based double-blind trial comparing 40-O-[2hydroxyethyl]-rapamycin vs azathioprine for the prevention of bronchiolitis obliterans 8 months prior to her hospital admission. Her cyclosporine dose was 25 mg q12h (trough level, 115 ng/mL), and her prednisone dose was 15 mg qd po; WBC count on hospital admission was 13,200/μL (95% polymorphs). Renal function on hospital admission showed BUN of 34 mg/dL and creatinine of 1.5 mg/dL (this was her posttransplant baseline). Nine days prior to admission at the transplant center, the patient presented to a peripheral hospital with fever, cough, sputum production, and malaise, and underwent an emergency bronchoscopy for a diagnosis of pneumonia. She was started on broad-spectrum antibiotics and amphotericin based on the identification of a fungus on the locally done bronchoscopy. She was transferred to the transplant center for further management. Physical and radiologic examination on transplant center admission was found to be consistent with left lower lobe pneumonia. Treatment with broad-spectrum antibiotics and amantadine was initiated for possible community-acquired viral infection; treatment with amphotericin and long-term oral ganciclovir were continued. Bronchoscopies with BAL/bronchial wash were done on days 1, 5, and 9 of hospitalization, and open-lung biopsy was done on day 6, which showed organizing pneumonia with no organism identified histologically or with Gomori methenamine silver (GMS) stain. The patient deteriorated on day 5 and required intubation and mechanical ventilation. Treatment with itraconazole was started on day 8. Worsening oxygenation, multiorgan failure, and sepsis resulted in death on day 18. Multiple cultures of the blood, BAL, and sputum from the terminal admission grew abundant S apiospermum reported 24 h prior to the patient’s death and in the 2 days following her death, approximately 14 days after they were obtained. An autopsy limited to the thoracic cavity showed numerous and variably sized abscesses with focal aggregates of neutrophils, lymphocytes, and broad, septate, and branching hyphae that stained positive for GMS and periodic acid-Schiff but negative for mucicarmine, invading the lung and myocardium (Fig 1
). Cultures of all the lung and heart tissue postmortem grew S apiospermum.