A patient with ascites received a peritoneal-venous shunt for presumed cirrhosis, however surgical specimens grew Mycobacterium tuberculosis (MTb) sensitive to all anti-tuberculous drugs. Directly-Observed-Therapy (DOT) led to improvement followed by relapse with multidrug resistant MTb (MDRTB). We discuss pathways for selection of MDRTB within mycobacterial biofilm. This case illustrates the potential for development of MDRTB in patients with long-term indwelling catheters. We emphasize catheter removal and if not possible continuing follow-up for symptoms and signs of relapse.