The occurrence of tuberculosis (TB) is exceedingly rare in the United States (US), and incidence has steadily declined since 1993, but the pace of decline has slowed in recent years. The US TB rate during 2019 declined to 2.7 cases per 100,000 persons, the lowest level on record. The abdominal form is the sixth leading cause of extrapulmonary TB, after lymphatic, genitourinary, osteoarticular, miliary, and meningeal. Abdominal TB can infect any part of the gastrointestinal tract, including the peritoneum and the pancreaticobiliary system. We present a case of persistently elevated adenosine deaminase in peritoneal ascites of a young, healthy female with new-onset ascites. An extended diagnostic evaluation was performed to reach the diagnosis.