CASE PRESENTATION: A 69-year-old man presents with 6 months of progressive unilateral hearing loss, recurrent fever, chills, sweats and unilateral facial paralysis. Laboratory testing showed mild leukocytosis. Urinalysis had large blood and elevated BUN of 29 mg/dL and Creatinine of 2.3 mg/dL. An initial AFB of the sputum was positive. CT Chest showed multiple scattered pulmonary nodular opacities with central cavitations and mediastinal lymphadenopathy. The patient had no personal history of TB but a positive history in many immediate family members. The patient was placed on respiratory precautions for suspected TB. Further specimens were obtained via bronchoscopy including AFBs, TB-PCR and cytology specimens. He was prophylactically started on rifampin, isoniazid, pyrazinamide and ethambutol. Inflammatory markers, CRP and ESR, were mildly elevated and anti-MPO Ab were increased without anti-PR-3, nor anti-GBM Ab. The involvement of renal pulmonary systems prompted further investigation via renal biopsy. It showed diffuse, necrotizing and crescentic glomerulonephritis with MPO-ANCA. A diagnosis of GPA was made. Bronchoscopic TB tests were negative. The patient was promptly started on methylprednisolone and cyclophosphamide. His creatinine improved dramatically and the facial paralysis resolved.