CASE PRESENTATION: A 61 year old female with history of alcohol abuse was brought to the emergency department after family found her unresponsive. On arrival to the emergency department, blood pressure was 73/42 mmHg, pulse 108 bpm, temperature 102.6 F, and respiratory rate 38/min. Physical exam was notable for coarse bilateral rhonchi on lung exam and a new, harsh pansystolic murmur. Laboratory studies showed a leukocyte count of 21,000 mm3, lactate 7 mmol/L, and creatinine 2.7 mg/dL. Troponin was 0.1 ng/dL and ECG showed sinus tachycardia with no ST-T changes. An arterial blood gas showed pH 6.75, pCO2 31 mmHg, pO2 60 mmHg, and bicarbonate 4 mEq/L. Chest x-ray showed bibasilar atelectasis and probable right lower lobe consolidation. Lumbar puncture released purulent cerebrospinal fluid. HIV and hepatitis screens were negative. The patient had a cardiac arrest due to severe metabolic acidosis with return of spontaneous circulation after cardiopulmonary resuscitation. She was intubated for respiratory failure and started on therapeutic hypothermia. Due to high suspicion for bacterial meningitis, patient was started on Ceftriaxone, Ampicillin, and Vancomycin. Blood, respiratory, and cerebrospinal fluid cultures grew S. pneumoniae. Trans-thoracic echocardiogram revealed severe mitral regurgitation and aneurysmal basal and inferolateral segments of the left ventricle - new findings compared to prior echocardiogram. The patient remained in refractory shock and developed multiorgan failure. Her family elected to withdraw care. She was extubated compassionately and passed away shortly thereafter.