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Tuberculosis (TB) remains a significant global health challenge, particularly within pediatric populations. This article reports the case of a 7-year-old female patient admitted with massive fibrinous pleural effusion secondary to TB, highlighting the key role of ultrasound in disease monitoring and therapeutic guidance. The patient presented with fever, cough, and abdominal pain. Imaging confirmed the presence of pleural effusion and lymphadenopathy. Serial ultrasound assessments demonstrated superior sensitivity compared to CT in characterizing the pleural effusion, leading to the initiation of intrapleural urokinase therapy under ultrasound guidance. The treatment resulted in the successful dissolution of fibrin septations and marked clinical improvement. The discussion explores the diagnostic advantages of ultrasound in pediatric TB, its effectiveness in monitoring therapeutic response, and the utility of localized fibrinolytic therapy. This case highlights the value of ultrasound as a cost-effective, noninvasive, radiation-free tool in the management of pediatric TB, advocating for its increased integration into routine pediatric care.