A 71-year-old African American man presented with a 3-week history of fever, productive cough and progressively worsening shortness of breath to the emergency department. An RT-PCR COVID-19 test (Xpert Xpress SARS-CoV-2, Cepheid, Sunnyvale, CA, USA) was performed via nasopharyngeal swab on arrival to the emergency department, and the patient was found to be positive. The patient had a rapidly deteriorating course with increased work of breathing and oxygen requirement and, therefore, was transferred to the intensive care unit. On presentation to the intensive care unit, his physical exam showed: temperature 102.6°F; heart rate 92 b.p.m.; respiratory rate of 30 breaths per minute; blood pressure 157/95 mmHg; and SpO2 of 95% on 2 l nasal cannula. He was in mild respiratory distress. Chest examination showed decreased breath sounds and dullness to percussion on the posterior aspect of the left chest. Chest X-ray showed a left-sided, alveolar consolidation with air bronchograms consistent with pneumonia and a large left-sided pleural fluid collection concerning for a parapneumonic effusion. The pertinent laboratory tests were as follows: (i) white blood cell count of 10.3 × 103/µl (4.0–10.5 × 103/µl); (ii) lactate dehydrogenase 363 U/l (94–200 U/l); (iii) ferritin 343.2 ng/ml (22.9–336.2 ng/ml); (iv) fibrinogen 798 mg/dl (200–393 mg/dl); (v) D-dimer 1144 ng/ml (≤500 ng/ml); and (vi) procalcitonin 0.16 ng/ml (0.00–0.50 ng/ml). Chest computed tomography demonstrated a large left pleural effusion and mediastinal lymphadenopathy.