A 36-year-old woman who emigrated from the Ecuador in 2002 presented to the emergency department with a one-year history of intermittent abdominal pain, diarrhea, and a 70-pound weight loss. She had no reported medical history, recent travel outside of the US, or known sick contacts. She appeared cachectic with diffuse muscle wasting and had a body mass index (BMI) of 14. Initial labs were notable for a white blood cell count 4.5 k/mm3, hemoglobin 8.8 g/dL, iron 17 mcg/dL, TIBC 47 mcg/dL, ferritin 123  mug/L, C-reactive protein 9.4 mg/dL, HIV negative, anti-nuclear antibody screen negative, anti-myeloperoxidase antibody negative, anti-perinuclear-3-antibody negative, and albumin 1.8 g/dL. Computed tomography (CT) of the chest and abdomen showed several right-sided pulmonary nodules, a large left-sided pleural effusion, and diffuse small and large bowel wall thickening with enlarged mesenteric lymph nodes. EGD revealed atrophic mucosa throughout the stomach and proximal duodenum. Esophageal, gastric, and duodenal biopsies were unrevealing. Colonoscopy showed circumferential friable ulcerated mucosa in the descending colon (Figure 3). The colonoscope was not advanced beyond this area. Biopsies showed necrotic tissue that was negative for acid-fast bacilli (AFB). Extensive autoimmune and infectious workup was unrevealing. Mycobacterium tuberculosis (MTB) polymerase chain reaction from an induced sputum sample was positive. Stool culture was positive for acid-fast bacilli. Soon after antituberculin therapy was initiated she developed a large bowel obstruction with segmental colitis and strictures at multiple areas including the splenic and hepatic flexures as seen on CT scan (Figures 1 and 2), and she required a subtotal colectomy with end-ileostomy. Pathology of the resected colon showed confluent necrotizing granulomatous inflammation with transmural colonic wall involvement and stricture at the splenic flexure, as well as necrotizing granulomas of the surrounding lymph nodes, consistent with tuberculosis (Figures 4 and 5). There was no inflammation or pathology in the terminal ileum. She was continued on antituberculin therapy and was discharged to a rehabilitation facility with improvement in her symptoms and malnutrition.