A Mexican woman, aged 71 years, with life-long exposure to soot from a wood cook stove in a closed environment, who was treated for tuberculosis 4-years prior, presented with prominent mediastinal lymphadenopathy with anthracosis. Mediastinal lymphadenopathy is a common presentation of diverse granulomatous, malignant and infectious conditions like tuberculosis. Anthracotic pigment is found in different conditions such as tuberculosis or domestically acquired particulate lung disease. Accurate assessment of chronology and causative factors presents a challenge. Recognizing that pneumoconiosis can mimic or coexist with other granulomatous, infectious and malignant conditions presenting as mediastinal lymphadenopathy is important. Misdiagnosis may result in under- or over-treatment of potentially curable conditions such as tuberculosis, under-treatment of a lethal condition such as melanoma, or exposure of patients to inappropriate administration of costly therapy with potential untoward effects.