INTRODUCTION: Miliary Tuberculosis (MTB) is rare accounting for fewer than 2% of TB cases [1]. Most common extrapulmonary sites include CNS, bones, and liver [1]. We present a case of MTB in an immunocompetent man. CASE PRESENTATION: A 42 year-old man with no known medical history who recently immigrated from Guatemala presented with generalized weakness and altered mental status. Family reported two weeks of worsening fevers, chills, and nausea/ vomiting; no hemoptysis or night sweats. Initial CT head was normal and chest x-ray showed right lower lobe infiltrate. Patient appeared cachectic with oral thrush. Patient received ceftriaxone, vancomycin, azithromycin, and acyclovir for presumed community-acquired pneumonia and meningoencephalitis. Lumbar puncture revealed 6498 RBCs and 702 mg/dl of protein. Gram stain, culture and acid fast bacilli (AFB) culture of CSF and blood were negative; HSV, West Nile, coccidioides were also negative. His CD4 count was low but HIV RNA was negative. CT chest showed ground glass opacities worse in apices with small nodules throughout, which prompted airborne isolation and transition to Rifampin, isoniazid, pyrazinamide, and ethambutol for presumed MTB. Quantiferon Gold was positive. AFB sputum samples unattainable due to lack of cough. Patient underwent bronchoscopy for bronchoalveolar lavage (BAL), which revealed mycobacterium TB detected on PCR. His mental status deteriorated and repeat CT head showed new hydrocephalus. Patient initiated on dexamethasone and transferred for higher level of care. He underwent ventriculostomy, but remained unresponsive and eventually transitioned to comfort care expiring shortly thereafter.