CASE PRESENTATION: A 53 year old white female with a past medical history of Crohn’s colitis controlled with adalimumab for 5 years and asthma controlled with omalizumab for 8 months presented to the hospital with 8 days of fever, headache, neck pain, and chills. She also noted recent weight loss of 9 kilograms. Vitals signs were normal except a temperature of 38.3 C. She was ill-appearing, and lungs were clear to auscultation. Spinal fluid was consistent with aseptic, lymphocytic meningitis. Extensive infectious and rheumatologic workup was unrevealing. Chest CT revealed enlarged subcarinal lymph nodes (image 1). Biopsy of this lymph node demonstrated non-caseating granulomatous inflammation, with negative AFB stain. The lymphadenopathy and constitutional symptoms gradually resolved after cessation of both adalimumab and omalizumab (image 2). Given her presentation and negative workup, she was diagnosed with a sarcoid-like reaction, likely due to anti-TNF therapy with possible anti-IgE therapy contribution.