Patients with HIV can often present a diagnostic challenge and may have atypical presentations of more common diseases. This case demonstrates such a scenario; we describe a 35-year-old man with a recent diagnosis of HIV infection complaining of backache, anorexia and weight loss. On investigation he was found to have bilateral tuberculous psoas abscesses. A review of the literature shows that this is a rare presentation of an already unusual problem, with subtle signs requiring a high index of clinical suspicion. However, with HIV-positive patients more likely to present with extrapulmonary tuberculosis, there is need for increased awareness of this diagnosis.