CASE PRESENTATION: A 75 year old Jamaican male presented with 8 months of worsening dyspnea, productive cough and weight loss. He was transferred to our tertiary care facility in hypoxic respiratory failure requiring non-invasive ventilatory support. Eight months prior to admission, he was diagnosed with chronic sinusitis requiring surgical drainage. His chronic cough persisted which prompted CT imaging, which revealed left-sided hilar lymphadenopathy and bronchiectasis. Transbronchial needle aspiration revealed necrotizing lymphadenitis and culture from an alveolar lavage revealed numerous organisms including: pseudomonas, streptococcus viridans, aspergillus flavus, and Pencillium species. Despite 2 courses of antimicrobial therapy, his symptoms progressed, and he was transferred to our hospital for further diagnosis and treatment. He denied recent travel, alcohol, or illicit drug use or high risk sexual behaviors. A repeat CT of the chest is shown in figure 1. Bronchoscopic evaluation showed purulent material in all bronchial segments of the left lung and a large mass eroding through and obstructing the left lower lobe bronchi, revealing a bronchoesophageal fistula. Transbronchial needle biopsy of a sub-carinal lymph node revealed: large atypical lymphocytes, with flow cytometry consistent with peripheral T cell lymphoma. Serum samples confirmed HTLV-1 positive serology.