A 51-year-old male with a past medical history of HIV, COPD, and hypertension presented with a four-day history of fever, shortness of breath, and nonproductive cough associated with headache and reduced appetite. He had a 30-pack-year history of smoking cigarettes and had not been compliant with his HIV medications as well as trimethoprim-sulfamethoxazole. He had no history of nonsteroidal anti-inflammatory drug (NSAID), herbal drug, or cocaine use. He denied recent ill contacts, recent travel, or camping. On examination, he was in respiratory distress with blood pressure 143/95 mmHg, pulse 135 beats per minute, respiratory rate 24 breaths per minute, temperature 39.5 degrees Celsius, and sPO2 92% on room air and 98% on 2 litres nasal cannula. He had bronchial breath sounds in the left mid and lower lung fields with crackles, but no wheezing. His heart sounds were normal. Abdomen was soft and nontender, with normal bowel sounds. Other aspects of his examination were unremarkable. His white cell count was 4.6 (4.5–11 × 103/uL); haemoglobin was 10.7 (12–16 g/dL); platelet was 246 (140–440 thou/cu mm); mean corpuscular volume was 94 (82–101 fl); Prothrombin Time (PT) was 12.9 (11–13.5 seconds); international normalised ratio (INR) was 1.0 (0.8–1.2); partial thromboplastin time (PTT) was 34 (25–35 seconds); HbA1c was 5.7% (4–5.6%); procalcitonin was 31.2 ng/mL (<0.15 ng/mL); thyroid stimulating hormone (TSH) was 0.705 (0.27–4.2 uIU·ml); sodium was 137 (135–145 mmol/L); potassium was 4.5 (3.3–4.6 mmol/L); chloride was 95 (101–110 mmol/L); BUN was 56 (6–22 mg/dL); creatine was 6.98 (0.6–1.17 mg/dL); calcium was 7.8 (8.6–10 mg/dL); albumin was 2.6 (3.8–4.9 g/dL); phosphorus was 5.5 (2.5–4.5 mg/dL); aspartate aminotransferase was 789 (14–33 IU/L); ALT was 235 (10–42 IU/L); anion gap was 22 (4–16); direct bilirubin was 3.3 (0–0.2 mg/dL); indirect bilirubin was 0.4 mg/dL (0.2–1.2 mg/dL); total bilirubin was 3.7 (0.2–1.0 mg/dL); alkaline phosphatase was 66 (40–129 IU/L); total creatine kinase was 51092 U/L (22–195 U/L), and urine was positive for myoglobin. His CD 4 count was 41 cells/ul, and HIV viral load was 34900 copies/mL. Urine analysis with Alere BinaxNOW lateral flow immunochromatographic assay for Legionella antigen serogroup 1 was positive; urine pneumococcal antigen was negative; blood culture, respiratory culture, and urine culture were without bacterial growth; respiratory viral panel was reported negative for influenza, parainfluenza, rhinovirus, respiratory syncytial virus (RSV) virus, human metapneumovirus, H1, and H3. His electrocardiogram showed sinus tachycardia. Chest X-ray (CXR) showed a homogenous consolidation in the left lower lung field (). CT chest showed consolidation in the left lingual with air bronchograms consistent with lobar pneumonia, without pleural effusion. Echocardiograph showed a left ventricular ejection fraction of 65%. Renal ultrasound showed normal sized kidneys with normal echogenicity without hydronephrosis. He was diagnosed with Legionella pneumonia, rhabdomyolysis, and acute renal failure and started on levofloxacin and atovaquone. He became further oliguric, with rising creatine and BUN, with worsening respiratory status requiring intubation and ventilation in addition to dialysis which were commenced on the second day of admission. Azithromycin was added to his antibiotic regimen in the ICU. His maximum creatine was 13.04 mg/dL, and BUN was 153 mg/dL during his hospital course. His respiratory and renal function improved during his ICU stay. He was extubated after six days. With improvement in his urine output and renal indices; he no longer required dialysis. On discharge, after 28 days of hospital stay and seven days of ICU stay, his creatine was 2.6 md/dL, BUN 36 md/dL, total creatine kinase (CK) 69 U/L, aspartate aminotransferase (AST) 16 IU/L, alanine aminotransferase (ALT) 30 IU/L, direct bilirubin 0.1 mg/dL, indirect bilirubin 0.1 mg/dL, and total bilirubin 0.2 mg/dL. After three-weeks follow-up in the outpatient setting, his creatine was back to normal at 1.06 (0.6–1.17 mg/dL), with resolution of the chest X-ray consolidation (). Renal biopsy was not pursued in light of recovery of normal renal function.