Disseminated skeletal tuberculosis (TB) is an uncommon manifestation of extrapulmonary TB and often presents with non-specific musculoskeletal symptoms, contributing to diagnostic delay and an increased risk of irreversible structural damage. We report a 35-year-old male with diabetes mellitus who presented with two months of progressive nocturnal low back pain with functional limitation, followed by progressive painful swelling and restricted movement of the left elbow, and subsequently developed high-grade fever, weight loss, and constitutional symptoms. The coexistence of axial and peripheral skeletal involvement is uncommon and contributed to the diagnostic challenge in this case. Magnetic resonance imaging demonstrated vertebral destruction centred at the L4 level with pre- and paravertebral soft tissue involvement consistent with spinal TB, sacroiliitis with an associated psoas collection suggestive of abscess formation, and erosive changes of the left elbow with extensive periarticular soft tissue involvement mimicking septic arthritis. CT-guided tissue sampling revealed granulomatous inflammation supporting a diagnosis of disseminated skeletal TB in the appropriate clinical and radiological context. The patient was treated with prolonged first-line anti-tuberculous therapy with early clinical and biochemical improvement. This case highlights the diagnostic challenge posed by multifocal skeletal TB involving both axial and peripheral joints and underscores the importance of early consideration of TB, comprehensive imaging evaluation, and timely tissue diagnosis to enable appropriate treatment and prevent long-term morbidity.