Although the objective of the authors in a recent CHEST article (August 2009)1 was to ascertain which method most efficiently provided tissue confirmation of sarcoidosis in persons with bilateral hilar adenopathy, the investigation tacitly assumed its necessity, or at least its desirability. Following the seminal analysis of Winterbauer et al,2 we estimated a positive predictive value of ≥99.95% for a clinical-radiographic presentation of stage I sarcoidosis (S1S).3 A back-of-the-envelope computation shows this estimate to be conservative: assuming a sarcoidosis incidence of 3 × 10−5, half with S1S, and a combined 1.3-billion population of regions—Europe, United States, Canada, Japan, and the United Kingdom—likely to report its simulation by alternative diagnoses (ADs), the annual number of S1S cases in these regions would be 20,000, or 720,000 in the 36 years since publication of Winterbauer’s dictum. If five cases in 10,000 were due to an AD, there would have been an opportunity to report on 360; none has appeared. Thus, AD simulating S1S is, quite literally, unheard of. The (British) National Health Service adopted a clinical diagnosis guideline; the combined American Thoracic Society, European Respiratory Society, and World Association of Sarcoidosis and Other Granulomatous Disorders Statement on Sarcoidosis4 cites a clinical reliability of 98%. The section authors in current editions of standard references—Baum, Fishman, Fraser and Páre, Murray and Nadel—found a clinical diagnosis acceptable. Hillerdal et al5 found a clinical diagnosis of stage II sarcoidosis acceptable as well.