CASE PRESENTATION: A 46 year old female with past history of PG, endometriosis, and breast adenoma was referred for necrotic lung nodules. She was diagnosed with PG of the right upper extremity 5 years before and treated for years with prednisone and mycophenolate mofetil and on narcotics for pain from PG skin ulcers. Because of an abnormal chest radiograph, a right sided video assisted thorascopic surgery was done. It showed only inflammation and dense adhesions. At the current admission she was febrile, had night sweats and pleuritic chest pain. She recently completed an unsuccessful course of levofloxacin. On exam, she had a 5cm x 5cm right calf hyperpigmented denuded area which did not have fluctuance, erythema, purulence or tenderness. It was consistent with PG. CT chest (below) showed mediastinal and hilar lymphadenopathy with large cavitary lesions bilaterally. Labs revealed a normocytic anemia, mildly positive C-ANCA (1:20) with negative PR-3/MPO antibodies.