For the last three decades miliary tuberculosis (MT) has been observed in adolescent and elderly patients with an increasing prevalence. The development of acute respiratory distress syndrome (ARDS) on the background of MT is a complication that may be difficult to recognize as it may not be thought of, even though its frequency is not negligible. The mortality of the syndrome in this situation is very high and negative prognostic factors are hyponatraemia, hypoalbuminaemia, elevated blood levels of transaminases and older age. This report describes the case of an immunocompetent 78 year-old woman who presented with MT and later meningitis. Despite the administration of appropriate antituberculosis treatment the patient’s condition deteriorated rapidly, with significant hypoxaemia and development of new opacities on the chest X ray that were consistent with ARDS. Mycobacterium tuberculosis was detected in the bronchoalveolar lavage (BAL), gastric contents and cerebrospinal fluid (CSF), which was reported sensitive to all primary antituberculous drugs. The patient’s clinical condition worsened and she succumbed two days later from progressive ARDS. The development of ARDS in the setting of MT may have an adverse outcome despite administration of the appropriate treatment.