This case is relevant for describing a rare presentation of intestinal tuberculosis with perianal manifestations, complicated by abscesses and recurrent fistulas. The clinical manifestations mimicked Crohn's disease and other inflammatory conditions, making the diagnosis challenging and requiring a differentiated and meticulous diagnostic process. A 45-year-old male patient presented with a chronic abscess in the left buttock lasting for two years, characterized by spontaneous purulent drainage and multiple recurrences despite surgical and clinical treatments. Imaging findings revealed associated fistulous lesions, initially interpreted as possible inflammatory complications. The definitive diagnosis was confirmed as intestinal tuberculosis with perianal involvement through colonoscopy and biopsy, which revealed caseating granulomas. Treatment included a standard antituberculous regimen (rifampin, isoniazid, pyrazinamide, and ethambutol), along with antibiotics and antifungal agents for secondary infections. Adherence to treatment was satisfactory, with progressive improvement in the fistulas. This case highlights the importance of a comprehensive differential diagnosis in extrapulmonary tuberculosis, especially with unusual manifestations. Multidisciplinary management was essential for therapeutic success and the prevention of recurrences.