The case describes the presumed diagnosis of miliary tuberculosis (TB) in an 11-year-old, immunocompetent boy based on chest X-ray changes and clinical symptoms. The high incidence of TB in Namibia and hence high pretest probability made the diagnosis likely, despite consistently negative cultures. Failure of clinical response should have made the treating doctors question the diagnosis much earlier. Only upon referral to a specialist service with scrutinizing of the history followed by diagnostic opportunities of high resolution computed tomography (HR-CT), bronchoscopy and trans-bronchial biopsy made the alternative diagnosis of idiopathic pulmonary hemosiderosis (IPH) possible.