In the ED her BP was 220/130 mm Hg, her heart rate was 140 beats/min, and her respiratory rate was 35 breaths/min. Oxygen saturation was 80% on room air, and noninvasive positive pressure ventilation (NIPPV) was initiated for respiratory support. The ECG showed sinus tachycardia with T-wave inversions in the lateral leads. Chest radiograph demonstrated diffuse lung haziness with increased density at the right lung base (Fig 1). Before NIPPV was initiated, her pH was 7.15, Pco2 was 56 mm Hg, O2 was 64 mm Hg with a lactic acid level of 6 mmol/L on 100% Fio2. Her WBC count was 22.4 K/μL, and her pro-brain natriuretic peptide level was 1,880 pg/mL (normal < 450 pg/mL). Broad-spectrum antibiotics and diuretics were administered.