We report a case of 55-year-old Guyanese female with the history of seropositive rheumatoid arthritis (RA) for 10 years and history of latent tuberculosis. Isoniazid treatment was not completed due to abnormal liver function tests and rifampin was completed at 4 months. Her RA was poorly responsive to methotrexate 20 mg weekly, hydroxychloroquine 400 mg daily, and chronic prednisone therapy between 10 and 20 mg daily. She had been tried on leflunomide to control her symptoms but experienced severe hair loss. She was started on adalimumab (Humira), but with no clinical improvement, and also she developed rash 7 years ago. Weekly subcutaneous etanercept 50 mg was started after adalimumab with good disease control for 3 years in the absence of pulmonary or mediastinal abnormality on chest computed tomography; however it was stopped due to insurance issue 3 years ago. She started to develop cough and dyspnea. The blood analysis demonstrated ESR 40 mm/h, CRP 1.35 mg/dL, negative antinuclear antibody, hemoglobin 12.5 g/dL, white blood cell 10.3 K/mcl, platelet 296 K/mcl, and normal renal and hepatic functions. High resolution computed tomography (HRCT) showed ground glass opacities on bilateral lower lungs. Echocardiography was normal. Methotrexate was stopped. Her cough and shortness of breath improved. Bronchoscopy revealed no endobronchial lesion. The microbiological analysis of bronchial lavage, bacterial, fungal, and mycobacterial cultures, and pneumocystis smear was negative. Cytologic analysis was negative for malignant, reactive bronchial epithelial, pneumocytes, and lymphocytes cell. Transbronchial biopsy showed focal emphysematous changes, mild interstitial pneumonitis. Due to active RA, prednisone was increased to 10 mg twice daily and weekly subcutaneous etanercept 50 mg was started again. Her RA symptoms including synovitis subsequently improved and prednisone was able to slowly taper down to 5 mg every other day. After taking etanercept for 12 months, follow-up HRCT showed decreasing bilateral ground glass opacities. However mediastinal lymph nodes were increasing in size to 2.3 x 3.1 centimeters (Figure 1). Mediastinoscopy was done and showed enlarged right anterior lymph nodes. Tissue biopsy showed nonnecrotizing epithelioid granulomata (Figures 3 and 4). All infectious studies of lymph node tissues were negative. Etanercept was discontinued. Follow-up chest CT 12 months later showed resolution of mediastinal lymph nodes (Figure 2). The diagnosis of etanercept induced pulmonary sarcoidosis was made.