CASE PRESENTATION: A 62-year-old man with stage IV Non-IgM LPL presented to the oncology clinic for follow up. He endorsed dyspnea, headaches, visual disturbances, and ataxia. Due to concerns of hyperviscosity syndrome, he was admitted to the hospital for treatment. A computed tomography (CT) chest was performed which showed a large right pleural effusion with pleural thickening and small pneumothorax (Image 1). Cytology of the pleural fluid was consistent with LPL. These image findings were worse as compared to a staging positron emission tomography (PET)/CT scan three months prior which showed a small right pleural effusion with pleural thickening (Image 2). On admission, he was started on plasmapheresis with subsequent chest tube placement. A follow up chest X-ray revealed improvement of the right pleural effusion as well as the pneumothorax. Overall, his symptoms resolved and the chest tube was removed. He was discharged and is currently undergoing chemotherapy with rituximab, cyclophosphamide, and steroids.