A 55-year old gentleman with moderately controlled diabetes mellitus presented with exertional breathlessness, cough, right-sided shoulder pain and weight loss of one month's duration. There was no anorexia or expectoration. He was a farmer by occupation and did not have exposure to poultry or occupational dusts and chemicals. Physical examination showed fine bilateral crepitations without clubbing. Renal function tests, serum calcium, urine microscopy, ACE levels and hemogram were normal. Chest radiographs showed miliary nodules (Figure 5, left). Human Immunodeficiency virus was negative by enzyme-linked sorbent assay. Tuberculin skin testing was strongly positive (18 mm, 1 TU). CT-Chest showed random micronodules without lymphadenopathy (Figure 6, left). FOB was done with BAL and TBLB; BAL was negative for acid-fast bacilli and Xpert MTB/RIF. TBLB showed well-formed perivascular granulomas with Langhans' giant cells, occasional fibrinoid necrosis and lymphocytes rimming (Figure 6, right). A diagnosis of miliary tuberculosis was made and four-drug weight-based ATT was started. However, his symptoms continued to worsen with worsening nodules and development of hypoxemia needing oxygen at four weeks (Figure 5, right). BAL mycobacterial cultures were negative in the meantime. Steroids were added with a presumptive diagnosis of immune reconstitution syndrome, with resolution of hypoxemia and symptoms. Symptoms recurred after stopping steroids at four weeks; right-sided vision loss due to uveitis occurred. After a clinico-pathological review, a possibility of concurrent miliary tuberculosis with sarcoidosis was considered. ATT was continued and low-dose tapering steroids and methotrexate (in view of poorly controlled diabetes) were added, with complete resolution of symptoms by eight weeks. He remains asymptomatic after two years of cessation of ATT and methotrexate.