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Background: Pulmonary tuberculosis (TB) and diffuse alveolar hemorrhage (DAH) have some commonalities in several parts of the world. However, acute hemoptysis with diffuse alveolar shadows while a patient is on anticoagulant and antiplatelet therapy for a specific reason suggests DAH over TB. Case Presentation: In this case, a patient was presented with acute respiratory symptoms with hypoxia and bilateral alveolar shadows. He was treated for DAH at the initial encounter. However, on follow-up, he was confirmed having active pulmonary TB based on sputum acid-fast-bacilli culture. Conclusion: He was successfully treated with standard first-line anti-tubercular therapy and was subsequently declared cured. Pulmonary DAH with TB, in the absence of an underlying autoimmune disorder, is rare.