A previously healthy 17-year-old Sri Lankan man first presented to the dermatology clinic of our hospital five years ago with a three-month history of a painful induration over his left buttock and hip area. Gradually, it extended onto his upper thigh with hyperpigmentation of the overlying skin, which became dry and scaly. Apart from an intermittent fever, there were no other systemic symptoms. His cardiovascular, respiratory, abdominal and nervous systems were normal on examination. Movements of his left hip were restricted in all directions. He also complained of pain and restriction of movements in the ipsilateral knee joint, which continued for two to three months before resolving spontaneously. He was extensively investigated regarding the lump and his fever. Tuberculosis was one of the differential diagnoses considered at that time. His erythrocyte sedimentation rate (ESR) was 45 mm/hour and the results of a tuberculin skin test were negative. A blood film examination for malaria parasites, serology for typhoid/paratyphoid antigens, HIV screening and anti-nuclear antibody testing results were all negative. Results of an ultrasound of the abdomen and an echocardiogram were also normal. Skin biopsy results from the induration were negative for tuberculosis culture and detection of genomic material (TB) by polymerase chain reaction (PCR). Histology of the specimen showed a dense perivascular lymphocytic infiltrate extending into the vessel walls. There was no fibrinoid necrosis. A biopsy from the lump wall showed necrotic material. The diagnosis was hence inconclusive. Over the next two months, his pain and fever settled spontaneously. He was managed symptomatically with antipyretics, analgesics and short courses of various antibiotic combinations. The lesion did not expand further and our patient accepted his disfigurement. Three years later, he developed chronic pain in his right knee that was slowly progressive over four months. A diagnosis of monoarthritis was made and he was again referred to our clinic. He had a mild loss of appetite with weight loss, but no other systemic symptoms such as fever. On examination, his right knee was swollen and tender. His movements were restricted in all directions and an effusion was palpable. The rest of the physical examination was normal. His basic biochemical investigations and the hematological parameters were within reference ranges apart from the ESR, which was was 55 mm in the first hour. A chest roentgenogram showed bilateral lower zone pulmonary fibrosis. There was honeycombing of the right middle lobe with traction broncheictasis plus a few calcified lymph nodes suggestive of tuberculosis sequelae. A roentgenogram of the left hip and thigh showed multiple calcifications, which it was hypothesized could be the remnants of a tuberculous abscess. The effusion of the knee joint was aspirated but it kept recurring. The appearance of the aspirate was yellow and cloudy. Biochemical analysis of the aspirate showed a protein level of 50 mg/dL, glucose level of 83.5 mg/dL and lactate dehydrogenase concentration of 2893 IU/L. Acid-fast bacilli (AFB) were not seen on direct smear. Cytological analysis revealed a leukocyte count of 6.1 × 109 cells/L (lymphocytes 70%, neutrophils 30%). Histology of the synovial biopsy showed several granuloma composed of epithelioid histiocytes located below the synovial membrane. Additionally, there were several lymphoid follicles and scattered collections of lymphocytes, plus plasma cells below the synovial membrane. This was suggestive of TB. Anti-TB therapy was started immediately and continued for six months (isoniazid, rifampicin, pyrazinamide and ethambutol combination for two months plus isoniazid, rifampicin combination for the remainder). He was treated as an out-patient for the whole duration of his treatment. His knee pain and effusion settled with treatment and full range of movement was regained at the end of the treatment. The skin induration remained, but the underlying area hardened with anti-TB therapy. Subsequently, he was discharged from our clinic. Our patient remained symptom-free on follow-up two months after completion of treatment with no subsequent flare-ups.