A 77-year-old gentleman, a holidaymaker in the area, presented with a 2-month history of cough productive of rust-coloured sputum and exertional dyspnoea. His initial chest x-ray showed bibasal interstitial shadowing. He then deteriorated rapidly to type 1 respiratory failure with acute renal failure. A CT chest showed bilateral alveolar haemorrhage. Testing for p-anti-neutrophil cytoplasmic antibody was strongly positive, with an anti-myeloperoxidase antibody titre of 198 units/ml (normal range 0–6 units/ml). A diagnosis of microscopic polyangitis was made. Following treatment with plasma exchange, cyclophosphamide and steroids, he made a good recovery.