Breaking symmetry: unilateral sarcoidosis presenting as a diagnostic challenge

<i>Unilateral sarcoidosis can mimic malignancy.</i> Even in the absence of bilateral lymphadenopathy, sarcoidosis should remain in the differential for unilateral, positron emission tomography (PET) fluorodeoxyglucose (FDG)-avid pulmonary nodules to avoid unnecessary surgical interventions.<i>Calcified pleural-based nodules represent an uncommon sarcoid phenotype.</i> The presence of coarse calcification does not exclude active disease, and interval progression with evolving FDG avidity highlights the need for longitudinal imaging surveillance.<i>Targeted biopsy and measured therapy are key</i>. In atypical presentations without accessible lymphadenopathy or extrapulmonary disease, percutaneous parenchymal biopsy is essential for diagnosis. Steroid therapy can be highly effective, and a surveillance-first approach can spare patients from invasive procedures.