Renal and urogenital disease is a prevalent finding of extrapulmonary Mycobacterium tuberculosis. Patients can present with unusual complaints not immediately suspicious for tuberculosis. We describe a 38-year-old man who presented with vomiting and an acute kidney injury. Imaging studies showed nodules throughout the lungs, retroperitoneum, abdominal viscera, and kidneys. Asymmetrical hydronephrosis was found on renal imaging. A classic beaded ureteral appearance (ureteritis cystica) was found during retrograde pyelography. The patient was screened and found to have a negative purified protein derivative skin test, negative acid-fast bacilli of sputum in three samples, and an indeterminate QuantiFERON Gold test. Evaluation of the urine for acid-fast bacilli was negative in four separate samples. A fifth urine sample for acid-fast bacilli was positive. A renal biopsy showed granulomatous interstitial nephritis with multiple areas of caseous necrosis. The patient was diagnosed with active tuberculosis and started on traditional four-drug antituberculous medical therapy. Kidney function remained marginal but did mildly improve with volume expansion and urinary drainage.