A 66-year-old female patient without medical history or professional exposures was diagnosed with ankylosing spondylitis 12 years ago. She had formerly responded to nonsteroidal inflammatory drugs. In 2006, she started treatment with infliximab, due to poor therapeutic response to various NSAIDs. After eight years of remission, the patient had repeated flares of ankylosing spondylitis symptoms with increased inflammatory back pain. In August 2015, due to persistent clinical activity with increased acute-phase reactant levels (C-reactive protein level of 16 mg/l), the treatment with etanercept at 25 mg twice weekly was started. Following national guidelines to exclude latent tuberculosis, mycobacterium tuberculosis research in sputum and interferon-gamma test were negative and a chest radiograph was normal. Two months after etanercept therapy onset, the patient developed persistent dry cough and dyspnea without fever or night sweating. Physical examination was unremarkable apart from tachypnea and severe spinal stiffness. High-resolution computed tomography (HRCT) scanning showed mediastinal lymphadenopathy and multiple nodules in both lung fields (Figure 1). Echocardiography was normal. The blood analysis demonstrated ESR 35 mm/h, CRP 14 mg/l, and normal renal and hepatic function tests. Sputum culture and polymerase chain reaction and interferon-gamma release assays were negative. Viral serology (human immunodeficiency virus, hepatitis B virus, and hepatitis C virus) and syphilis serology were negative. Serum angiotensin-converting enzyme was very elevated at 147 UI/ml (reference range 8-52 UI/ml). Calcemia and calciuria tests were normal. The pulmonary function test showed restrictive ventilatory alteration. It was not possible to perform neither bronchoscopy nor thoracoscopy because of respiratory failure and severe ankylosis of the cervical spine. Histopathological examination of minor salivary gland biopsy revealed a chronic granulomatous sialadenitis without caseous necrosis (Figure 2). Diseases showing similar histologic changes were excluded, and a diagnosis of sarcoidosis was made. Etanercept was discontinued plus a course of corticosteroids with 40 mg/day of prednisone for two months. An evident improvement of cough and dyspnea was seen. Follow-up HRCT 4 months later showed regression of mediastinal lymph nodes and pulmonary nodules (Figure 3).