CASE PRESENTATION: A 74-year-old woman first presented to our institution in 2010 with dyspnea and hemoptysis. Chest CT showed diffuse infiltrates (Image 1), and video assisted thoracoscopic lung biopsy revealed pulmonary hemorrhage with focal neutrophilic capillaritis. Extensive work-up (including ANCA panel, ANA, rheumatoid factor, anti-dsDNA, celiac serologies, anti-GBM, anti-cardiolipin, cryoglobulins, vWF) was unrevealing for an underlying cause, suggesting the diagnosis of IPPC. Prednisone and cyclophosphamide were initiated, resulting in symptom improvement, but development of atypical bladder cytology necessitated discontinuation of cyclophosphamide. She was tried on azathioprine then later mycophenolate, but had recurrent DAH after attempts at dose reduction. Her case was further complicated by out of hospital thrombotic events. In 2011, she represented with bilateral PE (Image 2), and an IVC filter was placed as an alternative to anticoagulation which posed a life-threatening bleeding risk. Aspirin 81mg daily was initiated which was changed to every-other-day dosing when she had another DAH flare. Four years later, she had a second out of hospital PE. She was treated with heparin drip and discharged on rivaroxaban, but unfortunately experienced recurrence of DAH. Rivaroxaban was discontinued, high dose prednisone was initiated, and her IVC filter was replaced. She also completed a four-week course of weekly rituximab, and restarted Aspirin 81mg daily. On this therapy she has remained free of both alveolar hemorrhage and pulmonary thrombosis.