INTRODUCTION: Mesothelioma is a rare and aggressive cancer that affects the linings of the pleura, peritoneum and pericardium. Pleural involvement is however most common. Malignant Peritoneal mesothelioma (MPM) is a cancer developing in the lining of the peritoneum, which is extremely rare. Most MPM cases are caused by asbestos exposure. Common symptoms of MPM include abdominal distension, abdominal pain, swelling or tenderness and constipation or diarrhea, with most common being abdominal swelling. MPM is difficult to diagnose due to its vague, nonspecific symptoms. CASE DESCRIPTION/METHODS: 67-yo-Male presented to the ER with complaint of Shortness of Breath for 6 weeks and dry cough. He was treated as an outpatient with bronchodilator, steroid and 2 rounds of antibiotics with no relief. He also had poor appetite, unexpected 10 lb weight loss and generalized weakness. CT Chest was pertinent for abdominal findings with bilateral anterolateral mesenteric nodularity along with ascites. CT abdomen & pelvis subsequently asserted it with likely malignant diagnosis. Surgical biopsy confirmed mesothelioma of the peritoneum. Patient denied any exposure to asbestos, but had worked in construction his entire adult life. Oncology offered palliative chemotherapy, which he refused. Follow-up CT Abdomen 1 month later showed progressive MPM. With rapidly worsening disease, no chemotherapy and overall poor prognosis, patient accepted comfort care. Unfortunately, he succumbed to his fatal diagnosis within 2 months on hospice care. DISCUSSION: Ours is a rare case of MPM where patient presented with atypical respiratory symptoms. Generally, abdominal symptoms are common to present. Early on, he was treated as cough variant asthma. But without improvement, further evaluation was carried out leading to incidental unexpected abdominal findings on CT Chest. Further workup with concluding biopsy confirmed MPM. Due to rarity and short life expectancy, MPM does not have set staging system. Early and timely diagnosis aids rearranging goals of care in such instances. In terminal illnesses, quality of life with timely discussion of comfort care is crucial. With red flag symptoms, like rapid weight loss in our case despite atypical presentation, should warrant careful evaluation as it could change goals and treatment plans substantially. However, it can offset the balance for high value care at times. We hope that future medical advances will bridge this disparity positively for rare cases also.