Coccidioidomycosis is a fungal infection caused by Coccidioides immitis and Coccidioides posadasii. While infections are usually mild, severe disease occurs in immunocompromised patients. Dissemination is associated with severe morbidity and mortality. Because of the tendency of this disease to imitate many diseases, diagnosis may be difficult on presentation. We present a case of disseminated coccidioidomycosis in a patient who was initially managed as miliary tuberculosis. In endemic areas, coccidioidomycosis is one of the two top differentials for miliary micronodular distribution on chest imaging. The patient was a recently diagnosed HIV positive patient and presented to the hospital with multiorgan failure, septic shock, and acute respiratory distress syndrome. He rapidly deteriorated and died within three days of presentation at the emergency department.