CASE PRESENTATION: 65 year old female with no significant pmhx and on no medications presenting with shortness of breath, fevers, nausea and vomiting, cough with yellowish sputum to the emergency department for three weeks. She was hypoxemic, tachypneic, had respiratory and metabolic acidosis. On peripheral blood smear she had severe hemolytic anemia with Hb=2 and was positive for cold agglutin. Chest x-ray was clear and CT scan of thorax showed mild bilateral opacities at the bases. She had leukocytosis, anuric renal failure. On admission to ICU, she had septic shock and was started on vasopressors and CRRT. A new RBBB developed (Image 1). Her chest xray remained unchanged (Image 2), rheumatological and infectious serologies were sent but she continued to more hypotensive and went into PEA arrest on hospital day 2. She was unable to be resuscitated. Her autopsy showed massive saddle PE.