CASE PRESENTATION: A 72 year old male presented with fever, cough and altered mental status in the setting of metastatic prostate cancer with bony and liver metastasis diagnosed nine years ago. He underwent palliative radiation five weeks prior to admission and was being treated with Abiraterone and Prednisone 10mg daily. The patient was febrile, tachypnic and tachycardic. Physical exam revealed a lethargic male with diffuse crackles on lung auscultation. Chest X-ray revealed bibasilar interstitial opacifications. Rapid flu nasal swab returned influenza A positive and Oseltamivir was started in addition to empiric antibiotics. CT chest (figure 1) showed diffuse bilateral airspace disease. The patient subsequently developed increased oxygen requirements with PaO2/FiO2 of 59 and hemolytic anemia requiring transfusion. Repeat chest x-ray (figure 1) showed worsening diffuse interstitial infiltrates and nodular densities. He was electively intubated and transferred to the ICU. Low tidal volume ventilation was initiated and bedside bronchoscopy was performed revealing diffuse airway petechiae. Lingular bronchoalveolar lavage returned blood without clearance after multiple sequential aliquots (figure 2). Cell count showed 700 WBC (50% neutrophils, 16% lymphocytes and 34% monocytes) and 150,000 RBC. Pathology returned with pigment-laden macrophages. Bronchial cultures were negative for bacteria, fungi and viruses. Rheumatologic serology was negative. Patient suffered a prolong ICU stay but was ultimately successfully extubated.