DISCUSSION: Miliary TB, roughly accounts for 3% of TB cases, is a clinical disease from hematogenous dissemination, either as a result of progressive primary infection or reactivation of a latent focus. Even though the absence of necrosis on histopathology points to a non-infectious etiology, this is not pathognomonic and does not rule out tuberculosis. The diagnostic evaluation needs to be aggressively tailored to the signs and symptoms, including bronchoscopy with BAL and transbronchial biopsies. TNF-alpha inhibitors greatly increase the risk of reactivation of latent mycobacterial infection. Adalimumab is associated with a much higher rate and presents more frequently in the disseminated form of the mycobacteria compared to the other TNF alpha agents1. The patient tested negative prior to starting Adalimumab, which means that she either had a new infection or more likely, an initial false negative Quantiferon Gold in the setting of chronic immunosuppression and developed reactivation TB. The sensitivities of the Quantiferon Gold can be significantly decreased in immunosuppressed patients to as low as 63%.