A 41-year-old man developed widespread skin rash involving his knees, elbows, and gluteal region. He received methotrexate for approximately 1 month and later developed dyspnea and a left-sided eosinophilic pleural effusion. He was transiently placed on oral steroids. Subsequent skin biopsy showed psoriatric arthritis. Methotrexate was restarted and 8 weeks into the treatment, he developed dyspnea, a hemorrhagic pericardial effusion, and a right-sided eosinophilic pleural effusion. Methotrexate was discontinued, but patient developed dyspnea with a recurrent right eosinophilic pleural effusion, 2 weeks later. Pleural biopsies were obtained through medical pleuroscopy that revealed mild chronic inflammation with prominent eosinophils and no evidence for malignancy. Oral steroids were restarted with significant improvement in his symptoms.