A 21-year-old man was brought to our Emergency Room presenting with a one-month history of abdominal pain, which had increased during the last 48 h. The pain was originally localized in the epigastrium and had migrated to the right lower abdominal quadrant. The patient complained of nausea, diarrhea and weight loss during the last couple of months. Physical examinations revealed abdominal distension with tenderness at the McBurney point, increased peristalsis and fever. The rest of the physical examination was normal. The patient denied any drug or alcohol abuse. The patient had recently been diagnosed with Crohn's disease and treatment had previously been initiated with azathioprine, mesalazine and corticosteroids. Laboratory blood test were in normal range, except for C-reactive protein (209 mg/L) and albumin (2,8 g/dL). An abdominal CT-scan was performed (Fig. 1), displaying moderate ascites, mesenteric lymphadenopathy, diffuse small bowel, and colonic wall thickening, concentrating in the cecum. The chest X-ray was normal. The patient underwent a colonoscopy, which could not be completed due to the patient's incompliance. The patient was then admitted to the Gastroenterological Unit with the diagnosis of Crohn's disease exacerbation. Medical treatment was started with corticosteroids, azathioprine, mesalazine, therapeutic monoclonal antibody (adalimumab), and antibiotic therapy. Due to the worsening of symptoms, a sudden increase in the white cell blood count and C-reactive protein and the display of acute abdomen on physical examination, an emergency explorative laparotomy was performed a week after admission. During surgery a distal ileum and right colon wall thickening, signs of perforation and purulent four-quadrant peritonitis were observed. Hence, we decided to perform a right colectomy, with an 80 cm terminal ileum resection (Fig. 2), an ileostomy on the right side of the abdominal wall and a colonic mucous fistula on the left side. During the postoperative course, the patient was admitted to the ICU with severe sepsis and acute respiratory distress syndrome caused by an Extended Spectrum Beta-Lactamase (ESBL) Escherichia coli infection. Total parenteral nutrition, and antibiotic therapy with meropenem and metronidazole were started. The histopathological findings of the surgical specimen (Fig. 3) revealed a severe distortion of glandular pattern, decreased goblet cell number, crypt abscesses and necrotic areas. This result was consistent with the biopsy obtained during the initial colonoscopy. The presence of necrotic areas in the surgical specimen led the pathologist to consider TB as a differential diagnosis. The key to diagnosis was performing a PCR to identify M. tuberculosis DNA on the tissue in paraffin. M. tubercolosis DNA was detected in a high concentration. After the histological diagnosis of abdominal tuberculosis, the patient was started on tuberculosis RIPE therapy (rifampin, isoniazid, pyrazinamid, and ethambutol). A postoperative chest CT scan was performed, showing bilateral pleural effusion (treated with bilateral chest tube placement) but without signs of active TB. Bacterial cultures from the pleural fluid, and from the bronchial lavage were performed and the diagnosis of TB was confirmed. The patient was finally discharged after one hundred days of hospitalization.