Miliary tuberculosis (MTB) of the liver can present non-specifically, which often leads to a diagnostic delay. The objective of this clinical case report is to highlight an unusual presentation of miliary TB in a young female patient, who was admitted to hospital with right upper quadrant tenderness and constitutional symptoms. Most of her investigations yielded little to support the diagnosis until a subsequent positive TB Elispot test and CT chest, abdomen and pelvis with contrast were done. Features of this case are discussed, together with anti-tubercular treatment (ATT) strategy utilized for miliary TB with hepatic involvement.