Intestinal tuberculosis (ITB) is an underrecognized disease that shares many clinical, radiologic, endoscopic, and pathologic features with Crohn's disease, making differentiation difficult. This poses a significant problem as initiation of immunosuppressives for an assumed diagnosis of CD in a patient with ITB can lead to exacerbation of infection and life-threatening consequences. A 30-year-old Nepali man with a medical history only significant for Raynaud disease presented with a febrile illness, right lower quadrant abdominal pain, and productive cough over the course of a month. He immigrated from Nepal 3 years prior to presentation, denying other risk factors or specific symptoms of tuberculosis including night sweats or weight loss. Scant rectal bleeding attributed to external hemorrhoids was reported, otherwise, no GI bleed was noted. He had recently been found to have ileitis with worsening symptoms despite conservative therapy. On presentation to our facility, computerized tomography (CT) imaging showed scattered mediastinal, axillary, and right iliac lymphadenopathy, a left upper lobe pulmonary infiltrate, and amorphous nodular densities in the right lower lobe. Abdominal CT showed ileocolic thickening. No additional findings were revealed on subsequent magnetic resonance imaging enterography. His labs were unremarkable and inflammatory markers were normal. Infectious serology and stool studies were negative. Gastroenterology was consulted for ileitis findings on imaging. Esophagogastroduodenoscopy (EGD) results were unremarkable. Colonoscopy showed two cratered transverse colon ulcers and 20 cm of inflamed, ulcerated terminal ileal mucosa. Biopsies of the colon were benign while the terminal ileum demonstrated caseating and non-caseating granulomas with negative acid-fast bacilli staining. These results were strongly suggestive of Crohn's disease. Tuberculosis testing was performed in preparation for biologic therapy initiation. Mycobacterium tuberculosis polymerase chain reaction and complex testing were negative. However, interferon-gamma release assay was found to be positive. To follow up on this result, a regional lymph node was biopsied and PCR testing of this specimen confirmed tuberculosis. RIPE therapy was promptly initiated. The case presented demonstrates the importance of maintaining a high degree of suspicion for ITB when evaluating cases of suspected CD. Particular efforts to rule out the disease should be made if a high pretest probability exists. This is especially relevant amongst patients from endemic regions. Misdiagnosis risk is increased due to similar presentations between the two disease states and relatively low sensitivity of current ITB testing. Lastly, due to the need for relative immunosuppression in CD treatment, misdiagnosis may directly cause adverse outcomes in ITB.