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A 43-year-old man with a past medical history of HIV/AIDS presented with a cough, fever and night sweats. He was febrile, with normal heart rate and blood pressure. Initial laboratory testing included a mild leukocytosis. Chest X-ray demonstrated a right perihilar opacity and bilateral pleural effusions. He was admitted for treatment of pneumocystis pneumonia vs tuberculosis. He developed respiratory failure and was transferred to the ICU. He subsequently developed abdominal pain and severe lactic acidosis. CT scan demonstrated pneumatosis. Considering the clinical concern for mesenteric ischemia he was taken to the operating room, where it was noted that he had hepatomegaly and viable bowel. The mesentery demonstrated diffuse lymphadenopathy. Mesenteric lymph nodes were biopsied. He failed to improve clinically and his leukocytosis continued to increase to as high as 102,000, with a blood smear revealing atypical appearing lymphocytes. The patient continued to decline and ultimately died. Autopsy results demonstrated diffuse non-Hodgkin's lymphoma. Only 30 cases of non-Hodgkin's lymphoma have been reported in the literature as causing liver failure. This is the only case that included pneumatosis and lactic acidosis that mimicked mesenteric ischemia. How to cite this article Letourneau PA, Shah SK, Tchakarov A, Tanner AH, Hetz RA, Jani PP, Walker PA, Martinez EJ, Khan SA. Lactic Acidosis, Multiorgan Failure and Pneumatosis: A Rare Presentation of Lymphoma. Panam J Trauma Critical Care Emerg Surg 2013;2(2):94-96.