Hypereosinophilic syndrome (HES) is a disease with diverse clinical presentations including cardiac, neurologic, cutaneous, or pulmonary manifestations.1 We present a case of a 64-year-old man, active smoker, with history of occasional cocaine use who visited the emergency department because of progressive darkening of fingertips for 2 weeks, accompanied by intense pain and aggravated by cold temperature. Physical examination showed ischemia of all fingertips bilaterally, with necrosis of left index, middle, and annular fingers and right middle finger (Figure 1, A), associated with decreased temperature and tenderness to palpation.