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Highlights • Esophageal perforation due to tuberculosis should be considered in countries with high prevalence of Tuberculosis. • Antibiosis for tuberculosis coverage should be initiated in appropriate group of patients with esophageal perforation with no response to conventional antibiotics and adequate surgical source control. • In patient with perforation and sepsis due to acute mediastinitis, surgical intervention should be considered., Introduction Tuberculosis is a multisystematic disease and is the most common cause of infectious disease–related mortality worldwide. Gastrointestinal tract is an uncommon site for extrapulmonary tuberculosis (TB). Esophageal TB is exceedingly rare. Presentation of case We report a 22-years-old male with esophageal TB that presented in septic shock from esophageal perforation. Despite all measures including surgical intervention and aggressive support in the intensive care unit, patient passed away. Discussion The most common mechanism for esophageal involvement is secondary to direct spread from mediastinal structures and/or spreading the inoculation of swallowed sputum, or hematogenous or lymphatic spread. Once the diagnosis of TB is established, antibiosis is the cornerstone of treatment. Surgery is reserved only for complications of TB such as fistula, abscess, strictures or perforation. Less than 50% of cases are diagnosed within 24 h, and delay in diagnosis lead to significant increases in the mortality. Conclusion In countries with high prevalence of TB, this diagnosis should be considered in those with esophageal perforation with no underlying etiology and medical treatment for TB should be initiated in addition to conventional treatment in appropriate group of patients.