A 37-year-old female with no significant past medical history presented with hearing loss in her left ear for 5 months, cough, low-grade fever, hemoptysis, and night sweats for 1 month. Initially, she was diagnosed to have pulmonary tuberculosis (PTB) on a radiological basis and was started on anti-tubercular therapy (ATT) (HRZE). She continued to worsen even after being on ATT for 4 months and was referred to us for further evaluation. On physical examination, PR was 82 beats/min, BP was 110/68 mmHg, respiratory rate was 20 breaths/min without any use of accessory muscles of respiration, and no lymphadenopathy. On respiratory system examination, there were no abnormal findings. The rest of the systemic examination was normal. Routine hematologic investigations showed an ESR-40 mm/h and other routine investigations were normal. Chest radiographs demonstrated a cavity in the right upper and lower zone [Figure 1a]. Differentials considered were rheumatoid vasculitis, tuberculosis, GPA, and fungal infection. Urine microscopic examination showed microscopic hematuria (7-10 RBC/HPF). Urine and blood cultures were sterile. Sputum smear examination for acid-fast bacilli (AFB) and sputum cultures (pyogenic, mycobacterial, and fungal) were negative, and a tuberculin test was nonreactive (5 x 6 mm). Ultrasonography (USG) of the whole abdomen was normal. CT scan of the thorax [Figure 1c] revealed a cavity measuring 4 x 3 cm with a few nodules in the right upper lobe and a cavity measuring 5 x 2 cm in the right lower lobe with normal surrounding lung parenchyma. Bronchoalveolar lavage (BAL) fluid cytology revealed mononuclear cell preponderance and was negative for Mycobacterium tuberculosis, fungus, and malignant cells. A pure tone audiogram (PTA) was done which revealed mild sensorineural hearing loss (SNHL) in the right ear and severe mixed hearing loss with profound loss at high frequency in the left ear [Figure 1d]. The serum perinuclear antineutrophil cytoplasmic antibodies (p-ANCA) were negative, while the serum cytoplasmic antineutrophil antibodies (c-ANCA) were positive (76.0 IU/ml). Diagnosis of granulomatosis with polyangiitis was made based on the American College of Rheumatology- European Alliance of Associations for Rheumatology (ACR-EULAR) criteria. A combination of oral prednisone, cyclophosphamide, and sulfamethoxazole-trimethoprim was initiated after which the patient showed significant improvement in pulmonary symptoms. Follow-up chest X-ray showed significant improvement after 2 months [Figure 1b]. Unfortunately, repeat PTA confirmed persistent unilateral hearing loss in the left ear with no significant improvement even after treatment.