CASE PRESENTATION: A 43 year-old female with no significant past medical history presented with sudden onset of submassive hemoptysis and dyspnea. Exam revealed a room air oxygen saturation of 85% and diffuse inspiratory crackles. Chest radiograph showed bilateral lower lobe infiltrates (Figure 1). Her condition rapidly deteriorated and she required intubation for severe hypoxemia. Lung protective ventilation was initiated and the PaO2 was 167 despite an FiO2 of 1.0 and PEEP of 18 cmH2O. Sequential lavage during bronchoscopy confirmed DAH. Serological studies, anti-DNA, anti-Smith, SSA, RNP, SMRNP complex, Anti-chromatin, and SCL-70 returned positive for a pattern suggesting SLE. She was treated with pulse methylprednisolone 1 gram daily for 2 days and tapered down to prednisone 60mg daily, cyclophosphamide 1580 mg for one dose, and five sessions of plasmapharesis. Her clinical condition and chest radiograph rapidly improved (Figure 2) and the patient was extubated after six days and discharged home on hospital day sixteen.