Blastomyces dermatidis, a dimorphic fungus endemic in the central and southeast United States, causes acute, subacute, and chronic lung infections. A limited number of cases present with blastomycosis-associated ARDS and fulminant diffuse pneumonia.30 More commonly, the manifestations are less severe, such as lobar pneumonia, mass-like consolidative lesions, pulmonary nodules, and chronic fibrocavitary disease. Dissemination does occur with spread to the skin being most common. Dissemination to bone, and rarely to the CNS, can also occur. For mild to moderately ill immunocompetent patients, oral itraconazole, 200 bid for 6 months, will generally suffice.26 However, in patients with bone involvement, prolonging the treatment course with itraconazole to a total of 12 months is needed. In severe pulmonary blastomycosis, such as with diffuse lung injury or severe systemic disease, initial therapy should be based on daily IV liposomal amphotericin B until clinical improvement is established.1 Subsequently, oral itraconazole, 200 mg bid for an additional 6 months, should be administered. Voriconazole, 200 mg bid, may be used as an alternative, based on in vitro and limited clinical data.31 Adjunctive corticosteroids, such as for histoplasmosis, can be beneficial in selected cases of severe blastomycosis-related ARDS.