A previously well two-year-old child presented to the emergency department with a two-week history of fever and lethargy. Seven days before presentation, she was prescribed amoxicillin for otitis media. On examination, she appeared lethargic but conscious, responding to questions. There were no obvious focal neurological signs, although a possible neck stiffness was present. A lumbar puncture yielded clear cerebrospinal fluid (CSF) with a white blood cell count of 230 cells/μL (35% lymphocytes, 55% neutrophils and 20% monocytes), protein level of 1.4 g/L and glucose level of 2.1 mmol/L. Ceftriaxone and vancomycin were initiated for presumed partially treated bacterial meningitis. On the following day, she appeared drowsier. A computed tomography scan of the head revealed enlargement of the lateral ventricles and basal meningeal enhancement, highly suspicious for tuberculosis (TB). A small amount of CSF was retrieved from the laboratory and sent for tuberculosis culture. Isoniazid (INH), rifampin, pyrazinamide and ethambutol were commenced, together with dexamethasone. A tuberculin skin test (TST) was negative (0 mm) at 48 h. The child’s subsequent course included a ventriculoperitoneal shunt insertion for hydrocephalus. The original small CSF volume did not grow any organisms; however, the larger volume obtained at the time of shunt placement grew Mycobacterium tuberculosis, resistant to INH but sensitive to other first-line agents. INH was discontinued, and levofloxacin and cycloserine were added to the regimen. The child developed seizures on the 25th day of therapy, with magnetic resonance imaging evidence of a right-sided stroke with subsequent left hemiparesis and global delay. On contact tracing by the public health department, a family member born in a TB-endemic country was identified with smear and culture-positive pulmonary TB. The patient’s four-year-old asymptomatic brother was TST positive (11 mm induration) and found to have hilar lymphadenopathy on chest x-ray. His gastric aspirates did not grow M tuberculosis and he underwent nine months of treatment with rifampin, ethambutol and pyrazinamide, with significant radiological improvement.