CASE PRESENTATION: A 65-year-old woman with history of smoking had a spine MRI with gadolinium contrast for new-onset severe back pain. She had no other complaints and her physical examination was unremarkable. The MRI showed hypointense lesions in T1, T2, T5, T6, L3 and L4, concerning for metastatic malignancy. This prompted the acquisition of a CT of the chest, abdomen and pelvis which revealed extensive bilateral mediastinal and pulmonary lymphadenopathies, found to be FDG-avid (all with SUV >6) on a subsequent PET scan. The bone lesions did not have increased metabolic activity except for a new right scapular lesion (SUV 6.3). The patient underwent a bronchoscopy with EBUS-guided fine needle aspiration of lymph nodes (LN) 4R, 7 and 12R. Cytology specimens returned with non-necrotizing granulomas (NNGs) and no malignant cells. There was concern for a neoplasia-related granulomatous reaction and the patient was referred to thoracic surgery for an excisional biopsy. She had a mediastinoscopy with excision of anthracotic LNs 3 and 4R. Final pathology showed NNGs with negative bacterial and fungal cultures. In light of this evidence, the patient was diagnosed with sarcoidosis with spinal lytic lesions. Therapy with glucocorticoids is planned to begin soon.