Silicosis is an occupational lung disease caused by exposure to crystalline quartz particles, leading to lung inflammation and scarring. Pulmonary tuberculosis is an infectious disease caused byMycobacterium tuberculosis , primarily affecting the lungs. Silicosis increases the risk of developing tuberculosis in high-burden settings. We present the case of a 40-year-old smoker male, with a history of stone crushing for 10 years, who presented to the emergency department with dyspnea and cough which increased progressively for the past nine months with sputum production. All pulmonary TB patients should have their sputum examined by microscopy to determine if they are infectious or not but in this case the sputum examination is negative, posing a diagnostic challenge and previously diagnosed as active TB based on X-ray abnormalities and clinical findings and had a full course of TB treatment. This case emphasizes the difficulty in differentiating silicosis from tuberculosis, as tuberculosis can mask the symptoms and radiological features of silicosis. Thus, a comprehensive occupational history, clinical features, and radiological evaluation are crucial for an accurate diagnosis.