We report a 65-year-old man who presented with Coccidioides meningitis complicated by hydrocephalus and vasculitis. He initially presented with a brief pneumonia followed by escalating headaches after recent travel to Arizona. After three months of persistent headaches, two lumbar punctures revealed cerebrospinal fluid with pleocytosis, extremely low glucose, and increased protein. Cytology, infectious and rheumatologic workup were unrevealing. Cultures and serological studies were normal. On axillary lymph node biopsy, non-caseating granuloma was identified and the patient was started on steroids for presumed neurosarcoidosis. After two weeks of steroids, the patient developed worsening headaches, diplopia and ataxia. CT head revealed severe hydrocephalus, and CT chest showed new reticulonodular opacities with mediastinal and hilar lymphadenopathy concerning for worsening sarcoid versus infection. He was transferred to a tertiary care facility for VP shunt placement and was started on empiric antimicrobials. A trans-bronchial biopsy revealed fungal elements. CSF and serum Coccidioides antibody returned positive, and re-evaluation of initial lymph node biopsy suggested necrotic granuloma. The patient was started on amphotericin B and fluconazole shortly after transfer, however he rapidly deteriorated due to ongoing vasculitis evident on diffusion-weighted imaging of the brain. He was terminally extubated per family’s wishes. CSF and lung tissue cultures subsequently grew Coccidioides species.