This man with severe chronic fibrosing alveolitis underwent a single left lung transplant at the end of November 2004. Postoperatively he developed reperfusion pulmonary oedema and was difficult to ventilate. He also developed acute renal failure requiring haemodialysis/haemofiltration which corrected his fluid overload and rising creatinine.Rejection was prevented with cyclosporin, mycophenolate and a decreasing dose of methylprednisolone. Cardiovascular problems identified mild pulmonary anastomostic stenosis with a 5% pressure gradient. He had a tracheostomy about 12 days post transplant. He then developed episodes of hypoxia and increased ventilatory pressures. Several bronchoscopies showed mucus plugging in the trachea and major bronchi. These were aspirated, with improvement of oxygenation. Cultures of one of these plugs grew A. fumigatus. These images show a bronchoscopy view of the trachea and anastomosis. Major obstruction of the airway is visible (70%) distal to the anastomosis which looks healthy. Some evidence of tracheal inflammation is visible.