A 47-year-old woman had asthma since childhood and a history of nasal polyps, aspirin sensitivity, and gastroesophageal reflux. She was a lifetime nonsmoker with no reported occupational exposures. Her asthma was well controlled with budesonide, 200 μg three for four puffs bid, and formoterol, 12 μg two puffs bid, until 2 years ago. Over the last 2 years, she had three episodes of cough and yellow sputum. A high-resolution CT scan of the thorax did not show any abnormalities. Most recently, the patient presented with a 10-day history of nocturnal wheezing and mucopurulent sputum. She had started herself on prednisone, 30 mg/d, as had been the previous practice. This did not relieve her symptoms. Sputum induction with a hypertonic saline solution aerosol as described previously3 revealed a total cell count of 98.4 × 106 cells/g, of which 93% were neutrophils and there were no eosinophils (healthy adults: < 9.7 × 106 cells/g, < 64.4%, and < 2% respectively).4 Sputum routine culture findings were negative for seven common respiratory viruses and bacteria. The CBC count showed mildly low total lymphocytes and a low CD4+ component. Microimmunofluorescence assay for Chlamydia and Mycoplasma species were negative. A quantitative polymerase chain reaction (PCR) analysis5 of blood and sputum was positive for C pneumoniae and negative for Chlamydophila trachomatis. The patient was prescribed azithromycin, 500 mg qd for 3 days, and 500 mg 1 day per week for the following 5 weeks. She was advised to discontinue prednisone. Over the following 4 years, monitoring of sputum cells and prophylactic macrolide therapy with increasing C pneumoniae titers prevented exacerbations without the need for systemic corticosteroids and enabled the reduction of budesonide dose to 1,200 to 1,600 μg/d. A summary of the course of the symptoms, lung function tests, and treatment is provided in Table 1.