A multitude of risk factors have been associated with the presentation of acute respiratory distress syndrome (ARDS). We describe a case of ARDS in which the etiology was unusual and unexpected. A 65-year-old Hispanic female with a past medical history of asthma presented with severe respiratory distress to the emergency room. Her other symptoms included shortness of breath, wheezing, nonproductive cough, and weight loss for the past 2 months. She was treated on two separate occasions for suspected pneumonia and asthma exacerbation with antibiotics and bronchodilators. However, her symptoms did not resolve, and she was in acute hypoxemic respiratory failure on presentation (PaO2/FiO2 ratio < 200), requiring intubation and initiation of mechanical ventilation. Chest radiography revealed bilateral diffuse alveolar infiltrates. A diagnosis of ARDS secondary to multilobar pneumonia was initially made and diagnostic bronchoscopy with bronchoalveolar lavage was performed. Her hospital course was characterized by initial improvement in oxygenation with nonresolving radiographic pulmonary infiltrates. Cytology revealed a diagnosis of non-small cell lung cancer. CT imaging studies showed a left upper lobe lung mass, with brain and spinal metastases confirming metastatic lung cancer. Hospice care was initiated, culminating in the patient's demise. In this patient, lung cancer evolved as a surprise diagnosis. ARDS is usually thought to be associated with acute or subacute diffuse lung injury due a variety of causes, including pneumonia, shock, sepsis, trauma, etc. An “ARDS-like” presentation of lung cancer is highly uncommon, with very few cases described in the literature. Although rare, lung cancer may need to be considered as a differential diagnosis in a patient with bilateral pulmonary infiltrates.
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