Indonesia has been known as an endemic country of tuberculosis (TB). Most of the cases are pulmonary TB, and pleural effusion is one of the common cases. Untreated pleural effusion can become massive pleural effusion, a true emergency case in the emergency room. In this report we present a 21-years-old female patient with new onset massive pleural effusion due to TB infection. A 21-year-old female patient with no previous medical illness came to ER with shortness of breaths since a week ago. Cough and unmeasured fever have been reported since a month ago. Tachypnea, extreme tachycardia, asymmetric chest movement, decreased vocal fremitus, dullness of percussion, and decreased left pulmonary sound were found. Chest x-ray showed a massive left pleural effusion with tracheal deviation. High flow nasal cannula was given due to blood gas analysis interpreting moderate respiratory distress. Thoracentesis was immediately performed with estimated 1200 CC yellow coloured fluid production. Other laboratory findings include hyponatremia and hypoalbuminemia. This patient was diagnosed with pleural effusion type pulmonary TB, treated with anti-TB drugs, mucolytic, corticosteroid, and analgesics. Serial chest x-rays showed improvement of pleural effusion. In developing countries like Indonesia, the most common causes of pleural effusion was TB infection besides malignancy. A massive pleural effusion diagnosis can be established with history taking, physical examination, chest sonography, chest x-ray, and/or CT-scan. Thoracentesis must be performed within minutes after massive pleural effusion was established.