Neck lymph node involvement is common in infections caused by various microorganisms, but determining the causative agent can be challenging. The case study details a 58-year-old male with left-sided cervical lymphadenopathy, fever, and weight loss persisting for two years. Despite extensive testing and empirical treatments, the cause remained unidentified. A CT scan revealed numerous enlarged lymph nodes with central necrosis. Histopathological examination suggested granulomatous lymphadenitis, although no bacteria were initially detected. Eventually, acid-fast bacilli were found via Ziehl-Neelsen staining, and Mycobacterium tuberculosis was confirmed through molecular tests. The patient was diagnosed with tuberculosis (TB) and successfully treated with anti-tuberculous therapy. The case highlights the diagnostic challenges of extrapulmonary TB, and underscores the importance of considering TB in atypical presentations, especially given the rise in multidrug-resistant strains.