organizing pneumonia ( op ) is characterized by an indolent clinical course and a favorable prognosis although a fulminant variant has been documented . pulmonary air leak comprising pneumothorax , pneumomediastinum , and subcutaneous emphysema is rarely a presenting feature of an op . the exact pathogenesis and an appropriate management guideline have not yet been established for this dreaded complication . review of medical literature reveals only a few case reports of air leak in op . here , we report a case of op secondary to bleomycin chemotherapy , where pulmonary air leak was the major presenting symptom , which has never been reported previously . a 43-year - old female presented to our emergency department with severe shortness of breath , diffuse neck swelling , and neck pain , of 1 day duration . she had a stage iii ovarian immature teratoma diagnosed 6 months back and was treated with bilateral salpingo oophorectomy followed by 6 cycles of chemotherapy with bleomycin , etoposide , and cisplatin . one week prior to the admission , she had fever and severe cough which was treated from a local hospital . on examination , she had respiratory distress with a respiratory rate of 32/min . her spo2 was 82% in room air , blood pressure 110/70 mmhg , and heart rate 110/min . examination of the respiratory system showed equal breath sounds on both sides with bilateral fine basal crepitations and muffled heart sounds . the values for the blood gas analysis were a ph of 7.42 , pco2 of 34 mmhg , and po2 of 65 mmhg . chest x - ray showed [ figure 1 ] features suggestive of subcutaneous emphysema and mediastinal emphysema with bilateral haziness and alveolar opacities in lower zones . a computed tomography ( ct ) thorax [ figure 2 ] with findings of ground - glass opacities and peripheral consolidation , confirmed the diagnosis of pneumonia and mediastinal emphysema . mediastinal emphysema and diffuse haziness in chest x - ray ( a - c ) serial computed tomography images showing bilateral diffuse ground - glass opacities , mediastinal emphysema , and peripheral consolidation with this clinical presentation of a pulmonary air leak syndrome and radiologic picture of bilateral predominant ground glass opacities with patchy consolidations , we considered the possibility of pneumocystis jiroveci pneumonia or a drug - induced lung disease like diffuse alveolar damage / op . since the patient had severe respiratory distress and hypoxemia , she was immediately taken up for surgical management . a video - assisted thoracoscopy was done [ figure 3 ] , and the mediastinum dissected revealing multiple paracardiac blebs . these blebs were ablated ; the pneumomediastinum drained into left hemithorax , and an intercostal drainage tube was inserted in left hemithorax . video - assisted thoracoscopy showing paracardiac blebs patient 's condition improved dramatically with rising oxygen saturation . she was shifted to the intensive care unit and was treated with antibiotics , steroids , and supportive treatment . biopsy of the lung specimen [ figure 4 ] revealed bronchiolitis obliterans organizing pneumonia ( boop ) . soon the air - leak disappeared , and she was discharged from the hospital with a long - term course of steroids and macrolide . ( a ) histology showed plugs of fibrous tissue in terminal bronchioles , ( b ) trichrome stain showing fibrous proliferation op is a clinicopathologic syndrome first described by davison and epler et al . in the 1980s . causes of secondary op include infections , drugs , connective tissue diseases , organ transplantation , and inflammatory bowel diseases . the manifestations of op are nonspecific ; hence , the diagnosis is delayed in many . high index of suspicion should be kept to diagnose secondary op , especially in patients with chemotherapy , organ transplantation , etc . a unique manifestation of bleomycin toxicity is multiple pulmonary nodules in ct mimicking metastasis and having histologic characteristic of op / boop . a study conducted by mokhtari et al . found that of the 43 patients with isolated boop in cancer patients , 3 were found to be due to bleomycin . kofteridis et al . , iwanaga et al . , and yang et al . have published case reports of air leak syndrome in boop . the hallmark of op is the presence of intraalveolar buds of granulation tissue consisting of fibroblasts - myofibroblasts embedded in connective tissue . these buds may extend from one alveolus to the next through the interalveolar pores and into the bronchioles obstructing the lumen ( bronchiolitis obliterans ) . the pathogenesis proposed for air leak is that , localized plugs of fibrous tissue in the bronchiole lumen in op , produce a ball valve mechanism and alveolar over - distension , eventually leading to rupture . the air dissects through the bronchovascular sheath and ascends toward the hilum to produce a pneumomediastinum and also along the subcutaneous connective tissue to cause subcutaneous emphysema . air leakage in the mediastinum may also occur due to the rupture of paracardiac bleb . in severe interstitial lung disease ( ild ) , we also considered the possibility of pneumocystis jiroveci pneumonia and metastasis as a differential in this immunocompromised patient with fever , cough , radiologically bilateral ground glassing , and air leak , but investigation profile proved against this . in our patient , the treatment of op is long - term steroid , and the treatment for massive pneumomediastinum is limited mediastinotomy and drainage . op should be included in our differential diagnosis list , whenever a patient presents with air leak . lung biopsy should be done to confirm the diagnosis and would prove to be lifesaving as this disease responds well to steroids . limited mediastinotomy and drainage of pneumomediastinum in massive air leak is lifesaving and gives rapid improvement .
organizing pneumonia ( op ) is a less common interstitial lung disease with varying clinical picture . 
 the development of pulmonary air leak in a case of op is an extremely rare complication . here 
 , we report the case of a 46-year - old female with carcinoma ovary , postchemotherapy who developed respiratory distress with pneumomediastinum , and subcutaneous emphysema . lung biopsy showed evidence of op . 
 this turned out to be a rare case of op , secondary to bleomycin chemotherapy , presenting with pulmonary air leak .