CASE PRESENTATION: 25 year old female with history of bipolar disorder, anxiety disorder presented to our ED with c/o fever, SOB & generalized weakness of 1 week duration & in the ED was found to be tachycardic, febrile (100.5 F), tachypneic in moderate to severe respiratory distress. Chest examination revealed bibasilar rhonchi .Patient was saturating 93 % on 5 liters of O2 via NC. Patient ended up getting intubated. CXR showed bilateral lower lobe dense consolidation concerning for pneumonia. CT chest showed severe bilateral consolidative change, most prominent in the lower lobes. Patient was initially managed for pneumonia. But upon more detailed physical examination, she was found to have multiple tattoos & granulomatous patches in her buttocks. IV antibiotics were changed to IV steroids & patient responded dramatically with successful extubation.