This is the case of a 76 year-old, non-smoking Honduran female with history of diabetes who was referred to our pulmonary clinic for years of persistent dry cough and non-exertional chest discomfort. Prior cardiac evaluation was unremarkable. She was treated with antibiotics by her primary care physician, which did not improve her symptoms. She did not use an angiotensin-converting enzyme inhibitor and denied symptoms of gastroesophageal reflux, allergic rhinitis, and there was no personal or family history of asthma. Her lung exam demonstrated wheezing heard over the right mid-posterior chest. Pulmonary function testing was inconclusive on multiple occasions, as she was unable to perform the required maneuvers due to excessive cough. Posterior-anterior and lateral chest radiographs demonstrated reticular thickening at the right major fissure and are shown in Fig. 1, Fig. 2. A non-contrast computed tomography (CT) scan (Fig. 3) demonstrated multiple sub-centimeter nodules, right middle lobe and lingular segmental bronchial narrowing with bibasilar atelectasis and mild interlobular septal thickening. A contrast-enhanced chest CT (Fig. 4) followed which further demonstrated distinct, enlarged mediastinal adenopathy. The differential diagnosis was broad, but it included systemic inflammatory conditions such as sarcoidosis, infections such as endobronchial tuberculosis, endemic mycosis infection and malignancy such as lymphoma and bronchogenic carcinoma. She underwent elective bronchoscopy, which showed diffuse airway mucosal hyperpigmentation and right upper lobe multi-segmental narrowing, right middle lobe medial segmental narrowing and lingular multi-segmental narrowing (Fig. 5). Endobronchial ultrasound (EBUS) demonstrated enlarged mediastinal lymph nodes, and transbronchial needle aspirates were taken at multiple stations. Sampling revealed necrotic tissue with black anthracotic pigment both grossly and microscopically (Fig. 6). Acid-fast-staining and cultures of samples were negative, though serum interferon gamma release assay was positive. Post-procedurally, the patient revealed her regular use of a wood stove in an enclosed, poorly-ventilated kitchen while a resident of Honduras for more than 40 years. She declined treatment for latent tuberculosis.