Upon encountering yeast cells of Blastomyces in the alveoli, the host’s immune response is believed to neutralize the organism in the majority of exposed individuals, thus rendering the infection asymptomatic.4 When symptomatic infection does occur, the lung is the most commonly involved organ, where blastomycosis is one of the “great imitators.” The acute form of the disease is often mistaken for bacterial pneumonia, due to its presentation with rapid onset of fever, productive cough, dyspnea, and pleuritic pain. Miliary spread has been described, as have cases of ARDS.5,6 Chronic pulmonary blastomycosis, the more common form, evolves indolently and can mimic TB, reactivation of other endemic mycoses, and malignancy. In the majority of cases, the organism is able to evade lung immunity, resulting in extrapulmonary dissemination. Inclusion of blastomycosis on the list of so-called pulmonary-cutaneous syndromes reflects the fact that skin is, by far, the most common distant site of involvement, observed in at least 20% of cases, followed by the osteoarticular and genitourinary systems.7,8 Verrucous lesions of cutaneous blastomycosis develop at sites of subcutaneous abscesses and can be mistaken for a variety of skin neoplasms.2 Ulcers of the skin and mucosal surfaces, including those of the tongue, are sequelae of external drainage of such abscesses.4 The various skin lesions of blastomycosis, including tongue ulcers, are particularly attractive targets for sampling, due to their accessibility and the potential for an immediate clue to the diagnosis. It is likely that the diagnostic delay in the case we present could have been shortened by the prompt collection of an ulcer specimen. Table 1 lists various infectious, neoplastic, and inflammatory conditions that are capable of causing synchronous pulmonary and tongue lesions. Disease of the CNS takes the form of meningitis or mass lesions and likewise resembles other conditions.