CASE PRESENTATION: A 45 year-old African-American male with significant history of quadriplegia and neurogenic bladder attributed to multiple sclerosis (MS) was admitted with a urinary tract infection and hypothermia. A brain MRI showed new hypothalamic lesions, suggestive of sarcoidosis. A subsequent computed tomography (CT) of chest revealed mediastinal lymphadenopathy. Eight years prior to presentation, the patient was ambulatory and presented for progressive lower extremity weakness, which eventually led to a clinical diagnosis of MS. He was treated with cyclophosphamide and subsequently methotrexate, with no improvement in his functional status and progression to quadriplegia. CSF studies were not consistent with MS. Of note, review of a CT chest 6 years prior showed significant hilar lymphadenopathy, but no referral was made to pulmonary at that time. During the present admission, a bronchoscopy with endobronchial ultrasound with trans-bronchial needle aspiration revealed focal granulomas without evidence of infection. Given the clinical constellation, a diagnosis of NS was made. Our patient was initiated on steroids with mild improvement in his left upper extremity function.