Bone marrow necrosis (BMN) is a rare clinicopathologic entity caused by hypoxemia after failure of the microcirculation, which frequently manifests with bone pain, fever, and peripheral cytopenia. In most reported cases of BMN resulting from miliary tuberculosis (TB), the presence of marrow granulomas, pulmonary infiltrates and/or extrapulmonary involvement is common. We report a female patient with extensive BMN from miliary TB, whose initial presentation was only severe peripheral cytopenia with extensive marrow necrosis, with neither evident pulmonary manifestations nor granulomas in the marrow biopsy. Serial Ziehl-Neelsen stains and Mycobacterium tuberculosis cultures were negative. The diagnosis of suspected miliary TB was made by consecutive positive results from polymerase chain reaction analysis for TB of marrow samples at 2 separate examination time points and a good treatment response to anti-TB therapy. Magnetic resonance imaging showed a geographic pattern of multiple signal abnormalities, indicating bone infarcts over the bilateral iliac bones and T-L-spine vertebral bodies, compatible with extensive BMN. The unusual presentation of extensive BMN with severe peripheral cytopenia in the absence of granulomas or pulmonary presentations should alert clinical physicians in epidemic areas. We discuss the use of polymerase chain reaction analysis for TB and magnetic resonance imaging for diagnosis of these patients.