A 24 year-old man with a history of Crohn's disease of the ileum and colon and previous perianal fistula presented with a non-productive cough of 2 months duration. He had been on no maintenance therapy for his Crohn's disease, and simultaneous to the development of the cough, he developed active inflammatory symptoms of diarrhea, and perianal fistula drainage. Initial referral by his primary care physician to a pulmonary specialist resulted in a work-up including chest radiograph, pulmonary function testing, chest computed tomography, and empiric therapies including bronchodilators, cough expectorants and suppressants, and even proton pump inhibitors for possible extra-esophageal reflux disease. He did not have relief of symptoms despite these efforts. He was then referred to gastroenterology for evaluation of his active Crohn's disease. Upper endoscopy revealed no evidence of gastric or esophageal Crohn's disease, and colonoscopy confirmed the presence of active inflammatory bowel disease of the terminal ileum and perianal area. He was initiated with azathioprine 2 mg/kg and infliximab 5 mg/kg at weeks 0, 2 and 6. Several days after the first infusion of infliximab, his inflammatory bowel symptoms resolved, but surprisingly, his persistent cough disappeared as well. In the ensuing 2 years, he has required maintenance infusions of inflixmab approximately every 8 weeks, and occasionally has had breakthrough bowel symptoms accompanied by respiratory symptoms, both of which rapidly respond to repeat infusions. A variety of pulmonary manifestations of inflammatory bowel disease have been described, usually with pleural or bronchial abnormalities which can be demonstrated by CT scan. However, also described is an idiopathic phenomenon without obvious laboratory or imaging findings. In this case, the respiratory symptoms paralleled the activity of the Crohn's disease. Whether the infliximab was treating the bowel which in turn improved the lungs, or whether infliximab addressed a separate parallel TNF-mediated condition in the lungs remains unclear.