CASE PRESENTATION: 60 year old Filipino male with history of hypertension, alcohol abuse, 20pack-year smoker, presented with sudden onset of substernal chest pain, fevers, productive cough and shortness of breath. Denied nausea, vomiting, constipation, diarrhea, recent travel, weight loss, leg swelling/pain, orthopnea, and hemoptysis. Chest X-Ray showed diffusely patchy infiltrates throughout the left lung, right lower lobe and interstitial alveolar infiltrates in the right upper lung field. Patient’s condition worsened and was intubated in the setting of ARDS. Mechanical ventilation with protective ventilation was started. Community appropriate broad spectrum antibiotics were given along with oseltamivir for influenza. Despite broadening of antibiotics the patient had no significant improvement, frequent fevers with max temperatures reaching greater than 103 Fahrenheit. At Day 10 due to no significant improvement, sputum was sent for acid fast bacili, which returned positive, RIPE therapy was initiated at this time. The cultures eventually grew mono-resistant mycobacterium tuberculosis. On day 17 steroids were started to reduce the inflammation that potentially hindered weaning, he was successfully extubated on day 20.