CASE PRESENTATION: The patient is a 62 year old man with history of tobacco dependence who presented with complaints of right and left sided chest pain and severe frontal headaches. The headaches were present for one month and not relieved with ibuprofen. His physical exam was normal except for splinting. CT head was negative. CT chest revealed a 2.7 x 2.5cm right upper lobe (RUL) mass, a 5.3 x 5.6cm left lower lobe (LLL) mass, and multiple pleural based nodules. Both masses were PET/CT positive. BAL was negative for infection. Transthoracic needle biopsy showed chronic granulomatous inflammation. The creatinine increased from 0.8 to 3.3 mg/dl. Auto-immune testing demonstrated ESR 115 mm/hr, CRP 38 mg/L, ANA negative, RF negative, HIV test negative, P-ANCA negative, and C-ANCA positive at 1:320 dilution. Renal biopsy demonstrated c-ANCA related necrotizing crescentic glomerulonephritis and 22/27 glomeruli with crescents. A diagnosis of granulomatosis with polyangiitis was made and treatment with rituximab followed by maintenance corticosteroids resulted in symptomatic improvement as well as radiologic improvement in lung masses.