Background: Leptospirosis is a zoonotic disease with high prevalence in Sri Lanka predominantly in paddy cultivat­ing areas. Severe leptospirosis is rarely described in pregnancy and there is a scarcity of data regarding its effect on pregnant patients. Acute lung injury has been recognized as the commonest fatal complication of leptospirosis. We report a case of delayed presentation of fulminant leptospirosis in a pregnant patient complicated with acute respi­ratory distress syndrome (ARDS) and severe coagulopathy resulting in death despite the optimum medical care.Case Presentation: A-31-year-old woman in the twelfth-week of pregnancy admitted with a subacute history of frequent vomiting, dry cough, watery stools, vaginal spotting, hemoptysis, and progressive shortness of breath. She had tachycardia, hypotension, and acute severe respiratory distress with high-grade fever on admission. Her inflammatory markers were high with evidence of severe coagulopathy. With worsening clinical and biochemical parameters despite intensive medical intervention, patient had a fatal outcome. The autopsy revealed shock lung with multiple intra-alveolar hemorrhages. The serum Leptospira microscopic agglutination test (MAT) was positive confirming the fulminant leptospirosis.Conclusion: Prolongrespiratory symptoms; positive lung signs with acute respiratory distress can mimic the clinical picture of atypical pneumonia. Delayed presentation of ARDS limits the management options whilst increasing the risk of fatality. A high degree of suspicion is needed to diagnose leptospirosis in pregnancy.