Background: Pulmonary hypoplasia presenting for the first time in adulthood is rare and can pose a diagnostic challenge without a high index of suspicion and proper investigations. Materials and Method: We present a 42 year old man with an initial diagnosis of lung fibrosis from pulmonary tuberculosis but who on further evaluation was found to have left pulmonary hypoplasia. The history and clinical examination findings and are presented and management discussed. The patient was treated with empirical antibiotics, bronchodilators and referred for surgical evaluation. Pulmonary hypoplasia should be suspected in adults with homogenous opacification of the hemithorax.