We report a case of otitis media associated with pneumonia due to Rhodococcus equi. A 31-year-old patient with AIDS presented with cough and right facial palsy. Imaging revealed right otitis media and severe temporal bone destruction, associated with pneumonia. R. equi was isolated from ear secretions, blood, and sputum. The radiologic findings are described. This unusual pathogen should be included in the differential diagnosis of the immunocompromised patient with aggressive otitis.