A 15-YEAR-OLD male had a 4-month history of cough productive of blood-tinged sputum, low-grade fevers, night sweats, progressive left wrist pain, and a 40-lb weight loss.1 Symptoms and radiographic findings of a right middle lobe pneumonia persisted despite multiple courses of antibiotics, including erythromycin, bactrim, and ciprofloxacin over the next 4 months. He was thought to have an asthmatic component to his respiratory symptoms and was prescribed a course of prednisone and albuterol without improvement. He developed worsening left wrist pain, stiffness, swelling, and dysfunction. Social and travel history was notable only for a brief visit to central Wisconsin 14 months prior to the development of symptoms. Findings from physical examination revealed a cooperative male in no distress. His temperature was 39°C with a respiratory rate of 24, heart rate of 96, and blood pressure of 139/96 mm Hg. He had multiple verrucous and ulcerating lesions on his face, scalp, arms, and back (Figure 1). He had a 16-cm symmetric goiter that was not nodular, tender, or warm (Figure 2). His lungs had decreased aeration in the right middle lung field. His left wrist was contracted, and he had a 4 × 5-cm friable purulent wound on the volar aspect (Figure 3). A chest radiograph revealed a right middle lobe consolidation (Figure 4) and a radiograph of his left wrist revealed an extensive destructive lesion involving the distal radius (Figure 5). He underwent a diagnostic procedure. Skin and bone specimens were collected for biopsy (Figure 6).