CASE PRESENTATION: A 21-year-old African American male with a history of Hashimoto’s thyroiditis presented with a one-week history of malaise, non-productive cough, shortness of breath, chest pain; on review of systems he admitted to months of polyarthralgia, rash, and endorsed foamy urine for weeks. His mother had a nonspecific rheumatologic disorder. His exam was significant for fever, hypoxic respiratory distress, sinus tachycardia, rales worse in the lung bases, and a purpuric rash of the left hand dorsum. CT chest revealed multilobar consolidations and bilateral ground-glass opacities (Fig. 1). Lab results revealed anemia, nephrotic range proteinuria, RBC’s and WBC’s in the urine, but no casts; ESR was 106; C3 and C4 were low. ANA, anti-DS DNA, ENA RNP, ENA Smith, Anti-chromatin IgG were all elevated. An infectious work-up was negative. With these findings, the patient was started on high dose methylprednisolone. A renal biopsy revealed interstitial fibrosis (Fig. 2a), segmental endocapillary proliferation, closure of capillary loops and thickened arterioles (Fig. 2b), most consistent with lupus nephritis. Steroids were tapered and he was started on mycophenolate and hydroxychloroquine. The patient improved with this treatment.