CASE PRESENTATION: 51 male with history of epidermolysis bullosa acquista with SOB, sharp substernal CP and DOE for 1 month. He was febrile at 38oC, HR=40, BP=11/89. O2 sat=96% on 100% NRB. His CXR showed dense R consolidation and cardiomegaly. ECHO showed EF<10% with an LV thrombus. Pt was started on heparin drip, aspirin, plavix, Lasix, ceftriaxone, azithromycin and vancomycin. Pt was intubated and a PA catheter was inserted to distinguish between cardiogenic vs septic shock. CO=5.83, CI=3.29, PAPm=30, PAWP=18, SVR=850, PVR=165 which are numbers supporting septic shock. CT scan showed dense consolidation of bilateral lower lobes with a left sided pleural effusion. Pt continued to spike temperatures, his antibiotics was changed to cefepime and flagyl. On day 5, thoracentesis was done showing clear yellow transudative fluid. On day 6, he got a ET tube mucus plug and had a tube exchange and bronchoscopy with BAL which grew out aspergillus. He was started on voriconazole. On day 13, ID recommended sending Q fever serologies, bartonella, hensilae, toxocoara, leptospira, paracocci, cocci, Chagas, Brucella given exposure to farm animals. On day 16, pt started on doxycycline and levaquin for positive Q fever titers, he had titers rechecked and Q fever PCR checked prior to starting doxycycline. On day 21, TEE done for constant fevers which showed a possible AV vegetation vs infected LV thrombus (Image 1). On day 16, his Q fever titers increased four fold and PCR was positive and he was diagnosed with Q fever endocarditis (Table 1).