Introduction: Disseminated tuberculosis (TB) is rare, affects any organ system, and presents mainly in immunocompromised populations. Typical presentation is non-specific, posing a challenge for diagnosis.

Case Report: This case presents an immunocompetent male presenting with severe headaches with meningeal signs. Lab and lumbar puncture results suggested bacterial meningitis, yet initial cerebral spinal fluid cultures and meningitis/encephalitis polymerase chain reaction were negative. A chest radiograph (CXR) provided the only evidence suggesting TB, leading to further tests showing dissemination to the brain, spinal cord, meninges, muscle, joint, and bone.

Discussion: This case stands to acknowledge the difficulty of diagnosis in the emergency department (ED), and the need for emergency physicians to maintain a broad differential including disseminated TB as a possibility from the beginning of assessment. In this case, emergency physicians should be aware of predisposing factors of disseminated TB in patients presenting with non-specific symptoms. They should also acknowledge that TB may present atypically in patients with minimal predisposing factors, rendering the need to further investigate abnormal CXR images despite lab results inconsistent with TB.

Conclusion: While this diagnosis is easily missed, early identification in the ED can lead to optimal treatment.