A 27-year-old male with a history of HIV on antiretroviral therapy, asthma, alcohol use disorder, and epilepsy, presented to the ED with concern for a breakthrough seizure. He was at home with his mother when his legs became rigid, and he was unable to move them. He reported good recollection of the entire event, no loss of consciousness, and spontaneous resolution after several minutes. His mother witnessed the event and called for an ambulance. The patient reported that his typical seizures are generalized, tonic-clonic in nature, with loss of consciousness. His last typical seizure occurred 1.5 months prior to presentation. On further review of systems, the patient revealed he had been having nausea, non-bloody, non-bilious emesis, and diarrhea for 3 days. He had not been tolerating oral intake and had poor compliance with his antiepileptic medication due to nausea and vomiting. He reported multiple episodes of loose stool but denied frank blood or melena. He complained of generalized, constant abdominal pain without specific character or location. He also described tactile fever, headache, and night sweats over the preceding 3 days. The patient reported drinking a pint of liquor daily, but due to nausea and vomiting had not had any alcohol in 3 days. Examination in the ED revealed a well appearing male in no distress. Vital signs were reassuring; the patient was afebrile (97 oF) with a heart rate of 79 beats per minute and a blood pressure of 147/91 mm of mercury. Abdominal examination was notable for normal bowel sounds, and diffuse tenderness with voluntary guarding but no rebound. Neurologic examination was normal, and the patient had a normal mental status. Initial finger stick glucose in the ED was 54 mg/dL (reference range 70–99 mg/dL), corrected to 124 mg/dL after an ampule of dextrose 50% intravenous (IV) push. Additional laboratory evaluation was notable for white blood cell count (WBC) 3.9 times 109 cells per liter (109/L) (reference range 3.5–11 × 109/L), hemoglobin 10.6 g/dL (reference range 13.5–17.5 g/dL), neutrophils 80% (reference range 39–75%), and absolute neutrophil count (ANC) 3.14 times 109 cells per liter (109/L) (reference range 1.12–6.72 × 109/L). Initial CD4 count was 290 cells in a cubic millimeter (cells/mm3) (reference range 500–1200 cells/mm3), and viral load was undetectable. Chemistry was notable for a metabolic acidosis with bicarbonate of 12 mEq/L (reference range 23–30 mEq/L) and anion gap 40 mmol/L (reference range 6–15 mmol/L) with a lactic acid of 5.0 mmol/L (reference range 0.5–2.2 mmol/L). Hepatic function panel was notable for elevated liver enzymes, with aspartate aminotransferase (AST) 2363 U/L (reference range 6–37 U/L) and alanine transaminase (ALT) 583 U/L (reference range 5–35 U/L). Acute hepatitis A, B, and C panel was not reactive, acetaminophen assay was negative, blood cultures were negative for growth after 5 days, and a stool panel testing for more than 20 common diarrheal pathogens, including C. difficile, was negative. A right upper quadrant ultrasound showed hepatomegaly and echogenic liver, favored to represent fatty infiltration in this clinical picture. No evidence of cholelithiasis or cholecystitis was seen. A CT scan of the abdomen and pelvis with contrast revealed wall thickening of the cecum and proximal ascending colon, suggestive of NE. The patient was initiated on cefepime (2 g IV every 8 h (Q8H)) and metronidazole (500 mg IV Q8H) and admitted for further management. During his admission, he became increasingly leukopenic and neutropenic, with a nadir of a total WBC of 1.6 × 109/uL and ANC of 0.72 × 109/uL 4 days after presentation to the ED. As a result, antibiotics were switched to piperacillin/tazobactam (4.5 g Q8H) until discharge. During his hospitalization he had several episodes of blood in his stool, a characteristic symptom of NE. Colonoscopy with histologic examination of the bowel mucosa for definitive diagnosis was deferred due to neutropenia and risk of perforation. His symptoms continued to improve, and he was successfully managed with bowel rest and antibiotics, with no operative intervention required. He was ultimately discharged on amoxicillin/clavulanic acid and trimethoprim/sulfamethoxazole for a total of 10 days of antibiotic coverage. His elevated liver enzymes were attributed to alcohol ingestion and improved during hospitalization, with an AST 450 U/L and ALT 309 U/L on discharge. Last known absolute CD4 count during admission was 141 cells/mm3 and his HIV-1 viral load was not detectable. While follow up is limited to presentations within our medical system, the patient did return to the ED 8 months after the initial presentation with mild rectal bleeding due to hemorrhoids and no mention was made of further episodes or complications of his NE.