A 40-year-old ethnic Kashmiri man presented in January 2009 with symptoms of burning paresthesias and motor weakness of the distal parts of his limbs, associated with feverish feel, over the past ten days. Symptoms first started with the left foot and progressively involved the hands, making it difficult to hold even a glass of water. Preceding the onset of neurological symptoms, he complained of nasal stuffiness, cough, wheezing, and breathlessness for three to four months. He had no history of urinary incontinence, toxin exposure, or substance abuse. He had bilateral wheeze on chest auscultation and spirometry showed a pattern consistent with bronchial asthma (FEV1: 2.87 L, FEV1/FVC: 68% predicted normal, and postbronchodilator FEV1: 3.24 L, 13% increment). Neurological examination revealed bilateral foot drop, symmetrical weakness of knee flexors, and asymmetrical weakness of the hand muscles (lower limbs > upper limbs). Ankle jerks were absent bilaterally. Touch and pain sensation was also diminished over right foot and palmar aspect of right hand. The rest of his general and systemic examination was unremarkable. He had hemoglobin level of 10 gm/dL and TLC of 16500/mm3 with differential count showing 50% eosinophils and absolute eosinophil count of 7000/mm3. Serum levels of urea, creatinine, bilirubin, and electrolytes were within normal limits. Urine examination revealed mild (2+) albuminuria. X-ray chest and tests for ANA, p-ANCA, and rheumatoid factor were normal. Electrodiagnostic studies revealed severe bilateral common peroneal, posterior tibial, right ulnar, and median neuropathies. In view of his asthma, eosinophilia, and peripheral neuropathy, Churg-Strauss syndrome was suspected and oral steroids were started. At follow-up, four weeks later he reported improvement in motor power and sensory symptoms and albuminuria resolved. His steroids were tapered off to an alternate day maintenance regimen and azathioprine 100 mg was started. He would get infrequent exacerbations of varying severity of his respiratory symptoms in 2010 and 2011 along with eosinophilia (>20%), which improved with short escalated courses of steroids. In October 2012, he again presented to the emergency department with three-weeks history of fever (101 F), recurrent vomiting, and body pains. He had a TLC of 21,800 cells/mm3 with differential count showing 46% eosinophils and absolute eosinophil count of 10,028/mm3 and ESR of 65 mm at the 1st hour. Urine examination revealed 3+ albuminuria. His urine and blood cultures were sterile. Although his general condition improved after hydration and intravenous antibiotics, his fever and vomiting improved dramatically only after administration of intravenous steroids. He tested positive for p-ANCA with bone marrow aspirate showing 40% eosinophils (Figure 2). When last seen in December 2012 he was doing well on low dose oral steroids and azathioprine daily.