CASE PRESENTATION: A 24-year-old hispanic male male is transferred to our hospital with a three month history of multiple evaluations by different physicians for his concerns of hemoptysis and night sweats. After multiple normal CT angiograms and multiple rounds of steroids and levofloxacin, his symptoms had progressed. He was admitted for new onset dyspnea and chest pain upon exertion and incidentally reported an “intentional” 200 pound weight-loss over the past two years. Examination revealed a rapid heart beat and jugular venous distension with normal lung auscultation. Chest radiography showed hilar lymphadenopathy and mild focal interstitial opacities (see image 1). Electrocardiogram revealed sinus tachycardia with right-axis deviation and poor R-wave progression (see image 2). Laboratory results were significant for a normocytic, normochromic anemia, thrombocytopenia and elevation of indirect bilirubin. Peripheral smear demonstrated several schistocytes. Concerns for thrombotic thrombocytopenic purpura prompted the initiation of emergent plasma exchange. Evaluation of symptomatic hypotension with bedside echocardiography revealed a “D-shaped” septum, concerning for severe pulmonary hypertension. Before right-heart catheterization could be performed, patient had a witnessed cardiac arrest and died despite resuscitative efforts. Post-mortem examination revealed pulmonary tumor thrombotic microangiopathy secondary to metastatic poorly differentiated gastric adenocarcinoma with pulmonary lymphangitic carcinomatosis.