Progressive massive fibrosis (PMF) secondary to pneumoconiosis involves the formation of fibrotic masses that eventually cause death from multiple complications. We present a rare but potentially serious complication in a patient with coal pneumoconiosis with PMF, in whom the appearance of paroxysmal melanoptysis was attributed to the cavitation of one of the pneumoconiotic masses. We emphasize the need for differential diagnosis to exclude other more common causes, as well as the use of bronchoscopy for diagnosis and confirmation. Strict control is needed to prevent possible respiratory failure when melanoptysis is massive.