Case description: The patient initially presented with ear pain and was noted to have developed hematemesis from a duodenal ulcer treated with PPIs. Months after resolution of ear pain, new symptoms arose including diplopia, numbness, and shortness of breath. Autoimmune workup was positive for anti-GAD-65 and ANNA-1 antibodies. During an IVIG session, the patient had respiratory distress requiring BiPaP. A PET scan showed increased uptake in the duodenal region. Due to impaired respiratory function EGD was delayed. After a tracheostomy, EGD showed persisting duodenal ulcer. Biopsy results revealed poorly differentiated neuroendocrine carcinoma with positive synaptophysin and strong positivity of Ki-67, consistent with ESCC. Subsequent plasmapheresis and rituximab treatment had minimal effect. A Whipple procedure was recommended, though timing the procedure was complicated by tenuous respiratory function and rituxan dosing. The patient was discussed at the tumor board where platinum-based chemotherapy was recommended. The patient decided on comfort care after no symptomatic relief with chemotherapy.