Abstract. We present a case of a neonate born in the United States who developed hypoxemic respiratory failure, signiﬁcant hepatomegaly, pancytopenia, and conjugated hyperbilirubinemia. It was suspected that she had hemophagocytic lymphohistiocytosis (HLH). However, she had disseminated tuberculosis. It is imperative that tuberculosis is considered in the differential diagnosis of neonatal respiratory failure, abnormal blood cell counts, elevated bilirubin, and/or hepatomegaly of unknown etiology.