Ameilia is a 45yo female with a long history of arthritis and persistent anemia, who was admitted to an outside hospital with complaints of diffuse skin rash, SOB and a recent 15# unintentional weight loss. She was started on steroids and told that she had “non-neoplastic lung nodules” and transferred to the regional cancer center for evaluation. After ruling out any neoplastic process as a cause of her symptoms, she was transferred to your MICU. She symptoms continue to progress eventually requiring intubation. She was seen by rheumatology, infections disease, and dermatology without finding a definitive etiology, though it was suspected that she had some form of autoimmune disorder or collagen vascular disease. She was started on high dose steroids as additional work-up continued. A CT of the chest showed some diffuse interstitial lung disease and some adenopathy. A transbronchial biopsy or a paratracheal node was indeterminate. Eventually her gas exchange worsened despite attempting all possible ventilator strategies, modes, and prone positioning, and the team requested an ECMO consult.