CASE PRESENTATION: 52-year-old male with history of psoriatic arthritis and recent sinus infection presented with sweats, fatigue, weight loss, dyspnea, productive cough, and hemoptysis for one week. Patient had significant social history including 30-pack-years of smoking, recent travel to 40 states, and exposure to tuberculosis. Shortly prior to admission, he was tapered off Prednisone and Methotrexate for psoriatic arthritis due to hepatotoxicity, and was started on Adalimumab monotherapy. On presentation, patient was febrile, tachycardic, with leukocytosis, and acute kidney injury. He had multiple purpuric lesions and bronchial breath sounds in the right lung. Imaging revealed a hilar mass, cavitary lesions, calcified nodules, and post-obstructive consolidation. Patient was treated empirically for pneumonia and disseminated fungal infection. He underwent bronchoscopy with biopsy of hilar mass and washings. Serologies including cANCA and antiproteinase-3 were positive. As concern for infection persisted, immunosuppressive therapy could not be initiated for suspected vasculitis. Kidney function rapidly worsened and transient dialysis was required. Lung, kidney, and skin biopsy revealed necrotizing granulomas with negative stain for mycobacteria and fungi. GPA was confirmed given the constellation of clinical and serological findings. Anti-infective agents were discontinued. Patient was started on treatment and his pulmonary and renal manifestations stabilized with Prednisone and Cyclophosphamide.