She was transferred to the ICU for acute hypoxic respiratory failure and treated with antibiotics for suspected community-acquired pneumonia and infective endocarditis. Her arterial blood gas analysis showed a pH of 7.46, Paco2 of 25 mm Hg, and Pao2 of 66 mm Hg on room air. On day 2 of hospitalization, her respiratory status worsened, requiring higher Fio2. IV steroids were initiated to promote fetal maturity. On day 3 of hospitalization, she developed worsening pulmonary infiltrates (Fig 2) and was electively intubated. Following intubation, she developed moderate hemoptysis, for which she underwent emergency fiberoptic bronchoscopy, which revealed diffuse oozing of blood from all lung segments. Elective cesarean section with delivery of viable fetus was performed. The BAL fluid cleared with lavage. Gram stain and cultures results were negative, and cytology did not reveal malignant cells. Her hospital course was complicated by ARDS, septic shock (a blood culture grew Acinetobacter baumannii), and multiple organ failure. A work-up for vasculitis was negative. Her levels of β human chorionic gonadotropin (β-HCG) declined from 71,139 IU/L to 40,331 IU/L post delivery. A second fiberoptic bronchoscopy for hemoptysis revealed hemosiderin-laden macrophages in the BAL fluid; again, cytology and microbiology of the BAL specimens were negative. A transesophageal echocardiogram showed normal heart function with no vegetations. The patient remained in critical condition with refractory ARDS, requiring high oxygen concentration (Fio2 80%) and positive end expiratory pressure (16 cmH2O). A surgical lung biopsy was not possible because of critical status. The patient expired on hospital day 13. An autopsy was performed, and histopathology slides are shown in Figures 3 and 4.