This single case report describes reactivation of previous pulmonary tuberculosis (TBC) after 23 months of treatment with the IL-1 receptor antagonist anakinra. This patient had severe acute rheumatoid arthritis (Disease Activity Score >6). Initially, he received treatment with 10 mg prednisolone daily along with oral methotrexate 15 mg weekly. Methotrexate was discontinued after 3 months because of repeated liver enzyme elevation. After the disease became more active, he was treated with the IL-1 receptor antagonist along with 10 mg prednisolone daily. One month later, the patient improved significantly, and prednisolone was decreased to 5 mg on alternate days and discontinued after another 3 months. After 23 months of anakinra monotherapy, the patient developed pulmonary TBC and was put on quadruple anti-TBC treatment, which resulted in excellent recovery. Six years before, the patient had pulmonary TBC and received triple anti-TBC treatment for 9 months with complete clinical and radiologic remission. We believe this is the first reported case of TBC reactivation during anakinra treatment.