A 36-year-old woman presented to the emergency department with a 1-day history of severe abdominal pain and a 2-week history of fever and cough. She had no known medical history and worked as a physician. On physical examination, diffuse, severe abdominal tenderness with rebound and guarding was observed. Computed tomography of the chest showed a miliary pattern of pulmonary nodules and subdiaphragmatic free air, which prompted urgent transfer to the operating room. On gross pathological examination, six perforations were seen in the terminal ileum (Panel A). Intestinal resection of the distal ileum with an ileostomy was performed. Histopathological examination showed submucosal necrotizing granulomatous inflammation (Panel B; the asterisk indicates a granuloma). Cultures and real-time polymerase-chain-reaction testing of peritoneal fluid and intestinal tissue revealed Mycobacterium tuberculosis. A diagnosis of disseminated tuberculosis with tuberculous ileitis was made. Testing for human immunodeficiency virus was negative. In intestinal tuberculosis, the ileocecal area is the most commonly involved region, and infection there may initially be misdiagnosed as appendicitis or inflammatory bowel disease. This patient completed 9 months of antituberculous therapy and underwent ileostomy closure 6 months after her initial operation. At a follow-up visit 12 months after her initial presentation, she had completely recovered.