Disseminated tuberculosis (TB) results from the lymphohematogenous spread of Mycobacterium tuberculosis. Despite the availability of effective therapy, diagnosis is usually late and mortality remains high. We report a case of a 29-year-old male with a history of alcohol abuse that presented with altered mental status and was found to have a 'tree-in-bud' sign on chest radiography. Chest computed tomography revealed innumerable pulmonary nodules in a miliary pattern. Examination of sputum and cerebrospinal fluid was positive for M. tuberculosis on nucleic acid amplification testing. The case emphasizes the importance of considering disseminated TB in patients with risk factors and typical radiographic patterns even in geographic areas with low disease prevalence.