A 40-year old gentleman presented with polyuria, fatigue and nausea of 20 days duration. There was also history of unquantified weight loss and exertional dyspnea. He did not smoke and did not raise pets, abuse drugs or have exposure to occupational dusts. Physical examination showed raised papulonodular skin lesions over hands and legs. Renal function tests showed serum creatinine of 2.65 mg/dL (normal <0.8 mg/dL); Urine microscopy showed 2+ albumin with bland sediments. Hemoglobin was 10.9 g/dL with normal leukocyte and platelet counts. Ultrasound showed normal kidney size with preserved corticomedullary distinction. Chest radiographs showed miliary nodules. Serum ionized calcium was 1.8 mg/dL (normal 1.1-1.3 mg/dL) with suppressed parathyroid hormone (1.9 pg/mL, normal 15-65) and normal vitamin D levels (23.6 ng/mL). ACE levels were elevated (98 U/mL, normal 8-53). Tuberculin skin testing was negative. CT-Chest showed random micronodules without zonal preponderance and bilateral hilar lymphadenopathy (Figure 3, left). FOB was done with BAL and TBLB; BAL was negative for acid-fast bacilli and Xpert MTB/RIF. TBLB showed perivascular non-caseating granulomas with Schaumann and asteroid bodies (Figure 4). Punch biopsy of the skin also showed non-caseating granulomas in the dermis. He was started on steroids with resolution of hypercalcemia and normalization of renal function. His subsequent course was complicated by steroid-aggravated diabetes presenting with hyperosmolar coma; methotrexate was added and steroids were tapered. He remained asymptomatic with near-complete radiologic clearing (Figure 3, right) after one year of stopping methotrexate but relapsed by 18 months and remains on methotrexate.