An 85-year-old Caucasian man with no significant past medical history presented to an outside dermatology clinic with a 6-month history of rash on his hands and feet. The patient worked as a farmer for 30 years in rural Mississippi and retired 30 years prior. He denied any known trauma or penetrating injury, exotic exposures, or significant travel except to South Korea 60 years ago. Skin biopsy was performed on the right dorsal hand and revealed granulomatous inflammation on hematoxylin and eosin stain (HE stain). Acid-fast bacillus (AFB) stain was positive for numerous bacilli on both histopathology and on tissue submitted to the clinical microbiology laboratory. However, mycobacterial cultures demonstrated no growth after 8 weeks of incubation. The skin lesions continued to progress despite 6 weeks of clarithromycin, which was stopped due to diarrhea, followed by 4 weeks of ciprofloxacin and minocycline. The lesions were associated with significant pain and swelling, prompting him to present to our medical center for further evaluation.