A 41-year-old man with rheumatoid arthritis (RA) presented with worsening dyspnea and deconditioning. He had recently been treated with adalimumab for rheumatoid pleural effusions but developed non-tuberculous mycobacterial pleurisy due to Mycobacterium heckeshornense. Despite therapy with appropriate anti-mycobacterial agents, he ultimately required video assisted thoracoscopy for decortication. While Mycobacterium heckeshornense has been reported to cause infection in multiple sites including the lung, this is the first case to our knowledge of infection confined to the pleural space. Rheumatoid pleural effusions can be complex and difficult to treat, especially when complicated by mycobacterial infection.