A 52-year-old female of African American origin, with past medical history significant for asthma, seasonal allergies, recurrent sinusitis, and recently diagnosed peripheral neuropathy presented to our tertiary care centre with chief complaint of intermittent substernal chest pain and acute vision loss. The chest pain began during an argument, lasted for only a few minutes, and was noted to be centrally located with right shoulder radiation. The visual deficit was described as a ‘burnt foil’ covering the patient’s left eye. Of note, the patient had recently received a diagnosis of peripheral neuropathy at an outside hospital for which she was started on gabapentin therapy. Our patient’s family history was significant for hypertension in her mother and alcohol dependence and cardiovascular disease in her father. She denied any history of tobacco, alcohol, or illicit drug use. Upon presentation to the emergency department, she was noted to have the following vitals: afebrile, heart rate: 87–106 beats per minute (b.p.m.), blood pressure: 116–155/80–96, and oxygen saturation: 93–96% on room air. Cardiovascular exam revealed a regular rate and rhythm, normal S1 and S2 heart sounds, no jugular venous distention, and no murmurs. Pulmonary exam revealed lungs, which were clear to auscultation bilaterally. No gross deficits were noted on neurological exam and extremities did not reveal any peripheral oedema. On ophthalmological exam, the right eye revealed a large area of whitening of the retina with a cherry red macula and left eye was largely unremarkable. Laboratory results were significant for white blood cell (WBC): 18.85 bil/L (ref: 3.4–10.8 ×10E3/µL), haemoglobin (Hgb): 13.5 g/dL (ref: 11.1–15.9 g/dL), platelets: 345 10E3/µL (ref: 150–450 ×10E3/µL), K: 3.3 mm/L (ref: 3.5—5.2 mmol/L), Troponin: 0.33 ng/mL (ref: ≤0.03 ng/mL), and Creatine kinase myocardial band (CKMB): 8.9 ng/mL (ref: 0.0–7.5 ng/mL). Electrocardiogram (ECG) demonstrated sinus rhythm without ischaemic changes (). She was started on a heparin infusion and admitted for evaluation of non-ST-elevation myocardial infarction (NSTEMI), with a peak troponin I level of 0.45 ng/mL. A transthoracic echocardiogram (TTE) was obtained, demonstrating a left ventricular ejection fraction (EF) of 25%, with global hypokinesis with more predominant septal involvement and preserved wall thickness. A moderate decrease in right ventricular systolic function was also noted, without any signs of valvular disease ( and ). Given these findings, the patient was referred for coronary angiography which noted normal coronary arteries ( and ). From an ophthalmology perspective, she was diagnosed with central retinal artery occlusion of her right eye and was outside the window to undergo hyperbaric oxygen protocol. With slight improvement in her vision, additional workup including carotid ultrasound and rheumatological work up was initiated and she was advised to follow-up as outpatient. Regarding the newly diagnosed systolic heart failure, the patient’s chest pain had improved, and she was medically optimized with guideline-directed medical therapy including angiotensin-converting enzyme inhibitor (ACE-i), beta blockade (BB), and statin therapy. Further diagnostic workup including multimodality imaging and laboratory work up was to be completed on an outpatient basis. The patient was readmitted to our facility 11 days later, with recurrent complaints of shortness of breath, bilateral upper extremity rash, and generalized fatigue. Labs were again notable for a persistent leucocytosis with WBC 18.44 bil/L (ref: 3.4–10.8 ×10E3/µL), Hgb 12.3 g/dL (ref: 11.1–15.9 g/dL), an unremarkable chemistry panel, a Troponin upon presentation at 1.8 ng/mL (ref: ≤0.03 ng/mL) with peak at 2.27 ng/mL, CKMB: 22.8 ng/mL (peak) (ref: 0.0–7.5 ng/mL), and peripheral eosinophil percentage of 67.2 (ref: 0.0–6.5%). ECG during this admission showed sinus tachycardia (heart rate: 105) without ischaemic changes. In the setting of NSTEMI, unremarkable ECG, normal coronary arteries on recent angiogram, and recent diagnosis of MINOCA just 11 days prior, the patient was referred for cardiac magnetic resonance (CMR) imaging which showed an EF of 45% with global hypokinesis with regional involvement. There was predominant focal anteroseptal and inferoseptal akinesis with focal sub-endocardial delayed enhancement, indicative of myocardial infarction involving the septal branches of the left anterior descending artery ( and ). Due to the focal findings on CMR, peripheral eosinophilia, rash, and acute vision loss, the patient was evaluated for EGPA. A multidisciplinary approach was pursued, including dermatology for biopsy of the rash and rheumatology for evaluation of possible vasculitis. Rheumatological workup was significant for elevated inflammatory markers including erythrocyte sedimentation rate 44 mm/h (ref: 0–30 mm/h) and C-reactive protein 5.5 mg/dL (ref: 0–0.8 mg/dL). Serum IgE was also elevated at 772 IU/mL (ref: 0.0–100.0 IU/mL), along with rheumatoid factor 46.8 IU/mL (ref: 0–20 IU/mL). Skin biopsy of the peripheral rash demonstrated leucocytoclasis, which was indicative of small vessel vasculitis. An enhanced diagnosis of EGPA involving multiple systems including coronary vasculature leading to MINOCA was made. Patient was initially treated with methylprednisolone 16 mg intravenous every 8 h for 2 days and then transitioned to Prednisone 60 mg per oral for 1 month with directions to decrease by 10 mg every 2 weeks until on 30 mg daily. The patient was also started on Rituximab 375 mg/m2, which she continues to receive on a weekly basis. During follow-up at approximately 6 months, the patient reported improvement in exercise tolerance and orthopnoea but continued to report intermittent chest pain. Two years later, the patient underwent a subsequent CMR to evaluate the progression of coronary artery disease and assess the EF. The CMR at follow-up demonstrated a focal aneurysm in the distal inferoseptum and mid anteroseptum, precisely at the location of the previously noted delayed enhancement and an EF of 48% ( and ). Currently, she reports compliance with her heart failure regimen (i.e. ACE-I and BB) remains with minimal functional limitations particularly with exertion, and without subsequent readmissions or symptom recurrence.