Peripheral blood smear images showing numerous schistocytes per high-power field (black arrows), anisocytosis, enucleated red blood cells (blue arrow) and eosinophils (red arrow). This sample was collected from a 65-year-old female diagnosed with hemolytic uremic syndrome (HUS) following initial presentation to the emergency department for one week of nausea, vomiting and diarrhea with two episodes of hematochezia during evaluation. Two days later, she developed acute kidney injury and thrombocytopenia with platelets decreasing from 450 10*3/ul on presentation to 106 10*3/ul. A change in mental status followed with active hallucinations and episodic delirium. Lactate dehydrogenase was 1800 U/L and haptoglobin level was below 10 mg/dL. With concern for thrombotic thrombocytopenic purpura (TTP), an ADAMTS13 level was collected, she was initiated on plasma exchange (PLEX) and, after two days of treatment, was transferred to a tertiary care facility. The peripheral smears presented were collected immediately after transfer. Initial gastrointestinal PCR testing was negative, and the patient's lab work improved while receiving PLEX and intravenous steroids. Shiga toxin 2 screening was positive and the ADAMTS13 level from initial hospital resulted at 83.5%. She was diagnosed with HUS. Additional history obtained from family revealed that the patient routinely consumes dishes prepared with raw beef. The patient's kidney function and platelets normalized after 4 days and her mental status returned to baseline.