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Background Miliary tuberculosis (TB) can cause diagnostic confusion for clinicians because its radiological appearance can resemble that of metastatic cancer. Case Report Here, we describe the case of a 72-yearold woman with miliary TB mimicking brain metastasis from renal cell carcinoma. The patient visited our clinic because of dysarthria and sluggish speech. A metastatic cancer such as renal cell carcinoma or brain tumor was suspected. However, the patient was diagnosed with miliary TB associated with multiple intracranial tuberculomas and a subsequent paradoxical response to anti-TB therapy. Conclusion Clinicians should be aware that miliary TB can mimic metastatic cancer even in older people, especially in TB-endemic regions.