Bronchiolitis obliterans organizing pneumonia (BOOP) is a syndrome with distinct clinical, radiological, and histological features. The radiographic changes of BOOP vary from multiple patchy, alveolar, or ground‐glass infiltrates to diffuse reticulonodular opacities. The most frequently observed CT features are areas of lung consolidation and ground‐glass opacity often with a subpleural distribution and small nodules; in addition, bronchial wall thickening and bronchodilatation can be seen. The exact pathogenesis of BOOP after organ transplantation remains to be clarified. Some researchers have suggested that BOOP is a non‐specific reaction to injury; rejection is the most common injury in lung and kidney transplant recipients.

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Benign metastatic leiomyoma (BML) of the lungs is a rare disorder that affects women with a history of uterine leiomyoma [1,2]. Although BML is a benign tumor, it can behave aggressively and lead to severe morbidity and mortality. Only-few cases of death secondary to extensive pulmonary metastases were reported in literature [3]. We present a rare case of benign metastasizing leiomyoma to the lungs that led to death from related complications 4 years after the initial diagnosis.CASE PRESENTATION: 50 years old African American female with history of uterine leiomyomas, post remote hysterectomy, and BML to the lungs proven on pathology in 2016 by wedge excision which was treated with Lupron for 6 months, presented to the hospital complaining of shortness of breath with oxygen saturation of 70% on room air. Computed tomography (CT) of chest was obtained and showed enlarging multiple bilateral lung masses compared to previous CT of the chest back in 2017, measuring 1-14 centimeters in diameter; some were complex, and located mainly around the bases. CT guided biopsy of a large right lower lobe mass was obtained and showed acellular debris and scant stroma. Patient was treated with antibiotics and discharged with a plan to follow up with tertiary center. Patient was readmitted 8 days later with severe respiratory distress, was intubated, and admitted to the intensive care unit. Bronchoscopy was performed and showed extrinsic compression of the right middle and lower lobes airway segments and cultures grew pseudomonas which was appropriately treated. One of the larger masses was found to compress the right side of the heart causing shock. With no further treatments offered by the tertiary facility, patient continued to decline and expired.DISCUSSION: We present a rare case of BML to the lungs secondary to uterine leiomyomas that progressed even after hysterectomy. Mean age of diagnosis of BML is 47-54 years. In our case, the diagnosis was confirmed by a wedge excision of the left medial upper lobe in 2016 many years after reported hysterectomy. It is not uncommon for BML to progress even with treatments [4,5]. During the 4 years after diagnosis, the lung masses did not regress with estrogen reducing medications like Lupron, and surgery was not an option due to the multiple masses in the lungs. Even though patient's respiratory cultures grew pseudomonas, it was believed that the main cause of the respiratory and hemodynamic failures was the extensive lung masses causing extrinsic compression to the airways and right heart.CONCLUSIONS: BML can progress many years after hysterectomy and after initial diagnosis despite estrogen reducing medications. BML most common organ of metastases is the lungs, and despite the benign histology, it can lead to significant morbidity and mortality due to compression of vital organs including the airways and heart.