Mycobacterial disease has been characterized to cause human illness since the 1950’s but practitioners whom address pulmonary disease can overlook its insidious presentation. This case report documents the presentation of a mycobacterial illness treated as a severe pneumonia. This is the case of a critically ill 43-year-old male, with poorly treated diabetes who presented with severe, long-standing respiratory distress in DKA. He had a history of weight loss, night sweats, decreased oral intake, and weakness for about a month. He was treated for euglycemia and his pulmonary disease was characterized as a bacterial pneumonia. Common pathogens were ruled out in an RIDP and he was treated with broad-spectrum antibiotics and discharged. On hospital follow up, careful examination of imaging report and history taking consisted with a timely screening for TB. A quantiferon gold test was positive and our patient was admitted to isolation on our inpatient service for evaluation. His AFB smear being positive, he was started on RIPE therapy. He was discharged with three negative sputum smears on the same therapy with cultures pending final characterization. This report documents a common treatment algorithm, based on a differential focused on typical culprits for pulmonary infection. Latent mycobacterial infections in our community are on the rise, especially in individuals whom are immunocompromised such as HIV+ or diabetics. First, these individuals must be identified using a screening tool such as a questionnaire. Second, obtaining screening labwork, even in non-compliant individuals are easily obtainable. Quantiferon gold assays could be administered to those identified as high risk even with no previous testing or prior negative test results. As these tests result, evaluation with a chest X-ray will stratify our groups to either further evaluation for latent mycobacterial infections or for treatment based on a positive chest X-ray. There needs to be a focus on identifying patients at risk for exposure to TB and providing diagnosis and treatment for latent infection or active disease. This will decrease the spread of tuberculosis.