Tuberculosis (TB) remains a leading cause of death from infectious disease worldwide with 80,000 pediatric deaths annually. Disease caused by Mycobacterium tuberculosis (Mtb) is usually asymptomatic in pediatric patients and resolves after completion of standard therapy with isoniazid (INH). Rare reports document children greater than 10 years of age in endemic regions developing adult type cavitary disease, an infectious pulmonary tuberculosis lesion. This is a notable case of post-infectious pulmonary TB disease with adult type cavitation in an immigrant adolescent, which developed even after completing standard therapy with INH. With increasing immigration of refugees from endemic regions into the United States, the Center for Disease Control implemented standardized testing and treatment of TB. However even with identification of disease, many immigrants may not seek treatment or complete therapy given lack of health insurance, and poor access to health care. This case of a 14 year old adolescent with post primary cavitary TB highlights the importance of directly observed therapy (DOT) and medication compliance. Perhaps as noteworthy, this case also emphasizes the need for pediatricians to recognize the impact on public health and the potential for spread of active TB within schools and the community especially in pulmonary cavitary lesion.