Aims: To describe articular histoplasmosis as the presenting feature of disseminated infection in an immunocompetent host, and to review the musculoskeletal manifestations of histoplasmosis. Methods: Case report and narrative review of the literature. Results: A 73-year-old immunocompetent man, whose only exposure was military service in Africa fifty years earlier, presented with a bleeding gingival lesion and left wrist monoarthritis. Acute phase reactants, autoantibodies and HIV serology were negative. Ultrasound-guided synovial biopsy yielded Histoplasma capsulatum on both mycological culture and histopathology. Computed tomography, magnetic resonance imaging and echocardiography disclosed adrenal infiltration and pericardial effusion, establishing disseminated disease. Itraconazole was complicated by rhabdomyolysis arising from interaction with simvastatin; after amphotericin B for fourteen days and twelve months of itraconazole, the arthritis resolved within six weeks. Conclusions: Infection should be considered in unexplained monoarthritis irrespective of immune status. Ultrasound-guided synovial biopsy was decisive here, and articular disease may be the only clue to disseminated histoplasmosis, warranting a systemic search.