Visceral leishmaniasis (VL) has increased as a complicating infection in subjects with human immunodeficiency virus (HIV) in developing countries. Both infections tend to lower the cell-mediated immunity resulting in poor drug response. In HIV-positive subjects the clinical course as well as organ involvement of VL simulates tuberculosis, another very common tropical infection. We present a case of VL/HIV co-infection where the individual failed to respond to first and second line antiretroviral therapy with persistently low CD4 counts. This patient was also subjected empirically to antitubercular therapy with no clinical improvement; he was finally diagnosed as a case of VL in HIV upon revelation of amastigotes in bone marrow despite the initial negative serology on two occasions. He showed dramatic improvement in CD4 counts and clinical status on Amphotericin B therapy. In endemic areas and in HIV positive subjects a systemic and careful parasitology follow-up is necessary to ensure that no clinical form of leishmaniasis is overlooked.