CASE PRESENTATION: A 46 year old female with HIV diagnosed in 2000 was admitted to a neighboring hospital for intractable left thigh pain, skin lesions, and significant weight loss. Physical examination found limited left thigh movement and multiple papulosquamous eruptions overlying the right glabella. Laboratory studies were significant for CD4 count of 116 mm3, CD8 count of 173 mm3, undetectable viral load, and CD4/CD8 ratio of 0.7. CT imaging showed lytic destruction involving the left ischium, femoral head, lumbar vertebrae of L4-L5 and marked mediastinal adenopathy. Biopsy of the lumbar vertebral lesions showed histocytic inflammation. The patient was discharged with outpatient follow-up. She presented to our hospital with persistent left thigh pain. Given her lytic lesions and immunosuppression, she was admitted for further evaluation and treatment. Blastomycosis was the presumptive diagnosis due to clinical presentation and region of residence. She was empirically started on amphotericin B. Comprehensive testing for infectious etiologies, including Blastomyces, were negative. Biopsy of the left ischium and right glabella showed non-caseating granulomas with special stains negative for acid-fast bacilli, malignancy, spirochetes, fungi, or viral inclusions. She was diagnosed with sarcoidosis based on histopathologic findings and prescribed oral corticosteroids. Amphotericin B was discontinued. Within several weeks, her symptoms abated.