CASE PRESENTATION: 30 year old construction worker presented with 3 weeks of dry cough and low grade fever. He coughed a small amount of blood 2 days prior to the clinic visit. Clinical exam was unremarkable. 1 month ago he returned from a trip to Queretaro, Mexico. Patient was a life time non-smoker, no history of illicit drug use, inhalational exposure and sick contacts. Patient was admitted to air borne isolation, 3 serial sputum specimens were negative for acid fast bacilli. CT scan of chest showed diffuse pulmonary nodules in random distribution.HIV was negative. Considering the recent trip to a highly endemic area of tuberculosis patient was started on a four drug regimen anti-tubercular therapy. Flexible fibre-optic bronchoscopy showed multiple fleshy pale yellow nodules in the right tracheobronchial tree. Endobronchial biopsies were obtained from involved areas and trans-bronchial biopsies from the right lower lobe. Bronchial alveolar lavage was lymphocyte and eosinophil predominant. Bacterial, fungal and mycobacterial cultures were negative. Histopathology of bronchial biopsies showed abundant chronic inflammatory cells and scattered coccidioidomycosis spherules with endospores. Serum coccidioidomycosis antibodies were elevated at 1:8. Anti-tubercular therapy was stopped and patient was treated with flucanozole.