Tuberculosis (TB) has usual pattern but challenging diagnosis in pediatric patients. A ten year old girl with chronic dry cough, anorexia and weight loss since 6 month ago was referred to our hospital emergency department with respiratory distress. In physical exam, she was ill with no fever, but had respiratory distress. Patient was intubated and transferred to Intensive care unit (ICU). Her uncle was deceased from unknown pulmonary disease. Patient had respiratory symptoms from 5 years ago and has been misdiagnosed with interstitial lung disease (ILD). Treatment was started by systemic corticosteroids from 6 month ago. Her symptoms were aggravated afterwards. Acid fast staining (AFB) from gastric aspirate was reported to be positive for Mycobacterium tuberculosis (MTB). Combined anti-TB therapy with 4 drugs was started immediately. Unfortunately patient expired after 36 hours. In conclusion, in pediatric patients, the gastric aspirate is the choice samples for diagnosis of TB. Additionally, molecular or other rapid diagnostic test should take into consideration. Reviewing the family history or close contact cases among pediatric patients it looks mandatory.