Jon-Emile S. Kenny [@heart_lung] A 66 year old man presents to the emergency department with sudden-onset fevers, chills, and scant hemoptysis. He is hypoxemic, tachypneic and noted to have egophony with focal crackles and wheezing across his right, anterior chest. Further, he is found to be in acute kidney injury and his chest x-ray reveals a bulging fissure sign with dense right middle lobe infiltrate. The emergency department resident contacts the patient’s pulmonologist who confirms that 6 weeks ago the patient had a chest CT for malignancy screening which demonstrated only bi-apical emphysema. Ceftriaxone, azithromycin and methylprednisolone are administered.