A patient with a steroid-resistant conjunctival nodule developed severe necrotizing granulomatous conjunctivitis during aggressive treatment with topical, subconjunctival, and systemic steroids. Culture of the tissue yielded Coccidioides immitis. A cavitary lesion was noted on a chest radiograph, and the same organism was recovered from a lung biopsy specimen. The granulomatous conjunctivitis was controlled only after aggressive debridement of the affected area and months of treatment with topical amphotericin B and oral fluconazole. A review of the literature suggests that subclinical ocular involvement from pulmonary coccidioidomycosis may be more common than generally believed. Conditions that blunt the host immune response may lead to a higher incidence of clinically significant ocular involvement.