A 48-year-old man presented for evaluation of general weakness. Because he had a history of excessive alcohol use, an abdominal computed tomography scan was obtained, which revealed a left adrenal mass. Hormonal evaluation showed elevated levels of urinary catecholamines. Bilateral hilar lymphadenopathy was detected on a chest radiograph. The suspected diagnosis was asymptomatic pheochromocytoma with sarcoidosis. We performed a mediastinoscopic lymph node biopsy, which was followed by endoscopic adrenalectomy. Histologic tissue analysis confirmed an adrenal pheochromocytoma and sarcoid granulomas in the mediastinal lymph nodes. This case highlights the difficulty in determining the appropriate work up of patients presenting with an adrenal incidentaloma and concomitant systemic disease.