CASE PRESENTATION: A 24-year-old Caucasian female with a history of systemic lupus erythematous complicated by lupus nephritis (on azathioprine, hydroxychloroquine and low dose prednisone) and recent parturition presented with one month of dyspnea, productive cough, and fever. Initial exam revealed an afebrile, tachycardic and tachypneic woman with a systolic murmur. Work up revealed acute on chronic renal failure, metabolic acidosis, and a right lower lobe infiltrate on chest radiograph. She was admitted to the intensive care unit and started on broad spectrum antibiotics for presumed health care associated pneumonia, and started on hemodialysis for renal failure. Chest computed tomography showed groundglass and nodular consolidative opacities in a bronchovascular distribution in the right middle lobe and lung bases, as well as scattered subcentimeter nodules particularly in the right lung base. On the fourth day of hospitalization her blood cultures returned positive for yeast, which speciated to Cryptococcus neoformans. Cryptococcus blood antigen was also positive. She was started on liposomal amphotericin B and flucytosine and immunosuppression was discontinued. Lumbar puncture results were normal. Transesophageal echocardiogram showed an echodensity on the mitral valve, which was felt to represent early sclerosis, rather than fungal endocarditis. She was ultimately discharged on a two-week course of liposomal amphotericin B plus flucytosine, followed by a prolonged course of fluconazole and minimization of immunosuppression.