Behind the Mask of HIV—Unmasking Bone Marrow Tuberculosis in a Child

We report a rare case of disseminated tuberculosis with bone marrow involvement in an 11-year-old girl living with HIV. She presented with prolonged fever, abdominal pain, severe malnutrition, and hepatosplenomegaly despite initiation of antiretroviral therapy. Initial investigations, including microbiological tests for tuberculosis, were negative; however, imaging revealed necrotic mesenteric lymphadenopathy suggestive of abdominal tuberculosis, and empirical antitubercular therapy was initiated. The clinical course was complicated by persistent symptoms, evolving intra-abdominal lesions, and progressive cytopenias. Bone marrow biopsy showed granulomatous inflammation. Based on regional tuberculosis prevalence, clinical features, imaging, and bone marrow biopsy findings, drug-resistant tuberculosis was suspected despite negative molecular assays. The patient was subsequently treated with an individualized multidrug-resistant antitubercular regimen, resulting in clinical and radiological improvement. This case highlights the diagnostic challenges of extrapulmonary tuberculosis in immunocompromised children, especially in endemic regions. It underscores the importance of maintaining a high index of suspicion, recognizing atypical presentations, and relying on histopathology when microbiological confirmation is lacking to guide timely and appropriate management.