Infection with human immunodeficiency virus (HIV) is the strongest known risk factor for active tuberculosis (TB), and the risk of developing active TB in people living with HIV (PLWH) is 15–22 times higher than in people without HIV [1]. Active TB may develop at any stage of HIV infection, but the risk correlates negatively with CD4+ cells count. TB is the leading cause of morbidity, hospitalisations, and mortality in PLWH [1]. There were 214,000 deaths due to TB among HIV-positive people in 2020 worldwide, which accounted for 31.5% of all HIV-related deaths [1,2]. Therefore, it is recommended to screen for TB in HIV-positive patients, and for HIV infection in newly diagnosed TB patients [3,4,5]. Around 16% of all PLWH do not know that they are infected with HIV [1], and about 25% of incident HIV patients present to care with advanced disease [3]. Immunosuppression caused by HIV infection affects clinical and radiologic presentation of TB. Atypical TB presentation is often observed in the late stages of HIV infection [6,7,8,9]. Such atypical TB presentation in a person with HIV infection not yet diagnosed, may be challenging, as described below. A 42-year-old woman of Indian origin was referred to a respiratory medicine department after her chest X-ray (Figure 1) revealed nodular opacifications in the lungs and bilateral pleural effusion (arrows). The patient had a 4-month history of unspecific chest and feet pains, mild dry cough, fatigue, reduced appetite, and body weight loss of 6 kg. She denied dyspnoea, sputum expectoration, haemoptysis, night sweats, or fever. On admission to the hospital, she was in good condition, her vital signs were normal, BMI was 19.2. There was no palpable peripheral lymphadenopathy or oedema; the vesicular breathing sound was reduced bibasiliary on chest auscultation. Blood tests showed elevated CRP—109.4 (N:<5) mg/L and ERS—120 (N: < 12), normal procalcitonin, normal leukocyte and neutrophil counts, decreased lymphocyte count—0.84 × 103 (N:1.18 × 103–3.74 × 103) cells/mm3.