A 42-year-old woman with an 8-year history of unexplained macrocytosis (MCV 114) and mild thrombocytopaenia (105) presented with dry cough and dyspnea. She was noted to have fine inspiratory crepitations on auscultation of the chest and gray eyebrows and hair roots (Figure 1). The patient admitted to coloring her hair since she went completely gray at the age of 17. A thin section computed tomography scan of the chest demonstrated subpleural and basal predominant reticular changes and early honeycombing (Figure 2, arrowheads), and open lung biopsy confirmed usual interstitial pneumonia (Figure 3, hematoxylin and eosin, ×20) with fibroblastic foci (arrow, inset ×100) and early honeycomb change. Her peripheral blood mononuclear cell telomere length was well below the 1st percentile for her age, and Sanger sequencing confirmed a novel mutation resulting in a change from alanine to aspartic acid at position 678 in the TERT gene (Figure 4). There was no family history of lung disease; however, details were limited because the patient was adopted. Telomerase deficiency leads to progressive shortening of telomere length and premature cellular senescence, and is a recently identified cause of familial and sporadic pulmonary fibrosis, with which premature graying and hematologic abnormalities are often associated (1–4).