CASE PRESENTATION: A 51-year-old non-smoker African-American male was referred to clinic for evaluation of chronic dry cough and worsening dyspnea. He denied fever, night sweats, chest pain or weight loss. He was hemodynamically stable on presentation. Physical examination revealed decreased left-sided air entry with dullness to percussion and decreased tactile vocal fremitus on the left. Imaging studies showed massive left-sided pleural effusion with mediastinal shift (Fig. 1a and b), splenomegaly and hilar as well as mediastinal lymphadenopathy, highly suspicious for malignancy. Thoracentesis revealed lymphocyte-predominant exudative fluid using protein criteria with a negative cytology for malignant cells. Histopathological examination of the hilar and mediastinal lymph nodes revealed non-caseating granulomas (Fig. 1c) with a negative fungal and AFB stain, suggestive of sarcoidosis. Subsequent ACE level was 90 micrograms/L (normal < 40 micrograms/L). Once infectious etiology was ruled out, the patient was started on oral steroids with rapid resolution of his symptoms as well as radiologic findings.