CASE PRESENTATION: 36-year-old female is admitted due to acute-onset chest pain and found to have bilateral segmental pulmonary embolism. Her medical history was pertinent for juvenile idiopathic arthritis with symmetric joint deformations. Despite being on chronic steroids and rituximab for maintenance therapy, she had been having intermittent fevers for two weeks. Blood cultures obtained from the access port were positive for coagulase-negative Staphylococcus. Heparin and antibiotics were initiated. Anticoagulation was held due to INR of 5 on the second day of warfarin initiation. The next day, patient acutely developed excruciating right hand pain. Physical examination was pertinent for her right hand being erythematous with distinct border, swollen, and cool-to-touch (Figure 1). There were no palpable radial pulses and blood flow could not be detected by continuous wave Doppler. One hour later, similar presentation was seen in her left foot. Laboratory results were pertinent for INR >10, PT >100 seconds, PTT 97.9 seconds, fibrinogen <15 mg/dL, platelet 51 k/uL, pH of 7.13, and lactic acid of 6 mmol/L. Duplex Doppler of the extremities showed no detectable flow in the left dorsalis pedis and posterior tibial artery (PTA) (Figure 2). Reversal of flow was seen within the right subclavian and axillary arteries, with inverted diastolic flow in the remainder of the right upper extremity vessels. She was transferred to the MICU for severe DIC and metabolic acidosis. Patient was transfused with cryoprecipitate, fresh frozen plasma, platelets, and vitamin K. Low-dose continuous argatroban was initiated due to concerns for heparin-induced thrombocytopenia (HIT) and antibiotics were broadened. Dilute Russell's viper venom time was grossly abnormal but beta-2-gycoprotein was negative; ADAMTS13 activity was also normal. Peripheral smears showed 6-8 schistocytes/high power field. HIT panel was negative. Return of pulses were detected on day 4 of MICU stay.