Examination of hematocylin-eosin–stained sections of the biopsy specimen obtained from the plaque on the left hand revealed irregular epidermal acanthosis with an overlying crust (Figure 2). The dermis showed a mixed-cell infiltrate of neutrophils, plasma cells, lymphocytes, and foreign body giant cells. There were numerous thick-walled yeast structures containing endospores within the dermis that were visually identified as Coccidioides immitis (Figure 3). Fungal cultures from the facial plaque and the soft tissue mass involving the lower thoracic spine also yielded filamentous fungus consistent with C immitis. Amphotericin B therapy was initiated, and the patient underwent surgery for spinal cord decompression. With treatment, her skin lesions resolved completely. She initially regained functional movement of her lower extremities, but a postoperative hematoma at the surgery site caused further cord compression that led to permanent paralysis.