Introduction: Tuberculosis (TB) remains an important cause of morbidity and mortality in Madagascar. According to the World Health Organization (WHO), in 2015, the estimated incidence of TB was 57,000 and 11,000 of those cases were of patients less than 14 years old. Of the reported cases, 89% were bacteriologically confirmed. However, it is well established that bacteriologic confirmation of TB in children is especially difficult. Therefore, the incidence of TB in the pediatric population in Madagascar, and likely worldwide, is under estimated. We report a case of a 4 year old male that illustrates the challenges in diagnosis and management of TB in Madagascar. Case Report: A 4 year old male presented to a hospital in northern Madagascar with five months of chronic, non-productive cough and cachexia. Past medical and family history was unremarkable, with no sick contacts. On exam, the patient was cachectic, in severe respiratory distress and had diffuse rhonchi bilaterally. Initial laboratory data revealed a hemoglobin of 7.0. Chest radiograph demonstrated diffuse infiltrates. Due to concern for TB, an acid-fast bacilli (AFB) culture was attempted via early morning nasogastric aspirate and induced sputum. Due to concern for Pneumocystis pneumonia, trimethoprim/sulfamethoxazole was ordered, but administration was delayed for 36 hours due to resource constraints. AFB of the nasogastric aspirate and sputum were negative. Treatment of TB was not initiated due to local guidelines recommending a positive AFB prior to treatment. The patient’s respiratory status declined and the patient expired before a positive AFB culture was obtained. Discussion: The pediatric population with suspected pulmonary TB is challenging to manage in Madagascar. A positive AFB culture is required to initiate treatment for TB; however obtaining a positive AFB in children is unlikely. Unreasonable expectations of diagnostic accuracy are hindering initiation of treatment. Like many countries, Madagascar has minimal resources for TB treatment. Although treatment is government funded, a documented positive AFB is required first. Otherwise, parents are asked to cover the expense of the medications, which is rarely a feasible option. Finally, there is little public health effort to trace TB transmission in rural communities. The WHO cites that roughly 14% of the cases of TB in Madagascar are in patients less than 14; however, given the current means of diagnosis and reporting, this is a gross underestimate. This case is one of many that demonstrates the obstacles in diagnosing and treating TB in the pediatric population in Madagascar.