An ethnic predisposition to coccidioidal infection causes Filipino and African American patients to have a disproportionate burden of disseminated disease with a 10- to 175-fold higher relative risk. Extrapulmonary disease most commonly manifests in the skin, joints, or central nervous system. Peritoneal coccidioidomycosis is an unusual extrapulmonary manifestation of infection affecting less than 1% of all patients with coccidioidomycosis. Most present with abdominal pain, swelling, or the new onset of an inguinal hernia.7 Rare cases have presented with abdominal or pelvic mass lesions, including 1 case presenting with vaginal prolapse.7- 8 Despite peritoneal disease representing disseminated infection, fever is uncommon, found at presentation in only 5 of 26 prior cases.7 Diagnosis was established in 4 of 26 cases by nonsurgical means using culture of the ascitic fluid. Interestingly, 8 of 26 cases had the diagnosis incidentally discovered during herniorrhaphy after thick edematous tissue or granulomas were noted within the hernia sac. All patients demonstrated Coccidioides -specific antibody titers 1:16 or more, a value consistent with disseminated disease.9 Three patients ultimately died of disseminated coccidioidomycosis despite only 14 of 26 receiving antifungal therapy. Of these 3 mortalities, only 1 had been treated with amphotericin B (an HIV-positive patient with a CD4 cell count of 10); the other 2 did not receive treatment for unclear reasons. One other patient was HIV positive (CD4 cell count <200) and was treated with amphotericin B, eventually clearing the infection. Ultimately, 19 of 26 exhibited a complete response with no evidence of ongoing infection at follow-up. Of these 19, 5 cleared their infection without any antifungal treatment. These observations suggest the role of host immunogenetics in the ultimate control of invasive fungal infection.