CASE PRESENTATION: A 58-year-old male, who was agricultural field farmer developed high fever, cough and expectoration on July 20th in 2015. Initially, he was treated with antibiotic moxifloxacin by local practitioners as an outpatient basis. Meanwhile, he gradually developed steaky hemoptysis and given bronchial artery embolism because of massive hemoptysis on August 8th 2015, but he had still a haemoptysis. When he got admitted to Respiratory Intensive Care Unit of Xiangya Hospital, Initial arterial blood gas revealed type I respiratory failure with high flow oxygen of 15L/min (pH7.46, PCO2 28mmHg, HCO3-19.9mmol/l, PO2 68mmHg, SaO 294%). Routine blood picture showed leukocyte 21900/cu mm, neutrophilic leucocytosis 20000/cu mm. Other laboratory examinations appear normal. Bronchoscopy caught sight of bleeding of left upper lower lobe and right upper lobe (Figure 1). Chest X-ray revealed bilateral non-homogenous opacities in both middle and upper lung zones (Figure 2). Review CT thorax with clinical manifestations found that pulmonary hemorrhage progressed fast (Figure 3-4). Our experienced old professors suspected severe rare leptospirosis with alveolar hemorrhage and the serum IgM leptospira was done immediately, result of antibody titer was 1:1600 (cut-off: 1:400). Intravenous piperacillin-tazobactam started immediately. Within 72 h, the patient became afebrile and remarkablely reduced hemoptysis and rechecked CT thorax found that both lung lesions were improved markedly after 1 week (Figure 5). The patient recovered smoothly and discharged soon.