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Abstract Background Tuberculous abdominal cocoon is an uncommon manifestation of abdominal tuberculosis. As a rare clinical entity, it is often encountered unexpectedly in patients with small intestinal obstruction. Here we presented a rare case of tuberculous abdominal cocoon which was suspected to be peritoneal carcinomatosis and was finally diagnosed by laparoscopy. Case presentation A 47-year-old man developed small intestinal obstruction and massive ascites that did not resolve with conservative management. Surgical exploration revealed a fibrous sheath covering the small-bowel, and pathologic assessment of biopsies confirmed intra-abdominal tuberculous infection. After antituberculosis therapy, the ascites has greatly diminished and the patient was functioning normally. Conclusion Preoperative diagnosis of tuberculous abdominal cocoon is a true challenge. Early diagnostic peritoneal biopsy should be recommended and surgery is usually unnecessary if definitive diagnosis can be made.