CASE PRESENTATION: A 58 year old male African American man with past medical history of suspected Lupus well controlled on Hydroxychloroquine, Chronic Hepatitis B was seen in pulmonary clinic for recurrent left sided pleural effusion. He was never on any other immunomodulatory therapy or steroids. Thoracentesis was done with fluid LDH of 1221 IU/dl, Protein of 6.6 gm/dl indicating an exudative collection. Bacterial, fungal, AFB smear and other studies were negative. He felt better after the procedure and the pleural effusion was attributed to Lupus serositis. Subsequent follow up in clinic revealed re-accumulation and worsening symptoms. He underwent Pleuroscopy with pleural biopsy. Pleural biopsy was positive for necrotizing pleuritis with Cryptococcus visible on GMS stain. HIV testing was negative and CSF was negative for meningitis. He was started on Oral Ketoconazole for 9 months and has done well since treatment initiation.