A 37-year-old Portuguese man, heavy smoker, with a history of alcohol and drug abuse, and concomitant HIV infection (CD4+T cell count 360 cells/muL) under highly active antiretroviral therapy since 1998, was currently medicated with efavirenz, emtricitabine, and tenofovir. One year before presentation, he had a TB contact and was not screened for active or latent TB infection. He was admitted due to a two-month history of severe back pain, with no constitutional or respiratory symptoms and no neurological signs. Magnetic resonance imaging (MRI) of the spine revealed peripheral lesions located at T9-T10 vertebral bodies, associated with discreet compression of spinal cord, small paravertebral abscess, and empyema. A percutaneous biopsy was performed. The microscopy smear of the acid-fast bacilli (AFB), the nucleic acid amplification test (NAAT), and the culture of Mycobacterium tuberculosis (MT) were positive, with no drugs resistance. The patient was started on isoniazid (H), rifampin (R), pyrazinamide (Z), and ethambutol (E) (HRZE) for 4 months, due to slow radiological resolution of the vertebral lesions, and remained in therapy with HR for 2 years. He currently has no symptoms or significant vertebral sequelae.