Neither Cytomegalovirus (CMV) or Mycobacteria tuberculosis (MTb) is commonly associated with massive intestinal bleeding. We present a patient with newly diagnosed HIV infection and MTb who had massive hematochezia from ileocolonic ulcerations found to be positive for CMV and MTb. A 31 year old male with newly diagnosed HIV and pulmonary MTb presents with 2 months of intermittent hematochezia. Initial exam showed no active bleeding. Abdominal CT suggested tuberculous peritonitis. Paracentesis and sputum examination showed acid fast bacteria. Four drug MTb treatment was initiated. Five days later, massive hematochezia occurs with hemodynamic instability requiring 9 units of blood transfusion. Pan-endoscopy showed multiple right colonic and ileocecal ulcers with bleeding proximal to the examined ileum. A right hemicolectomy with ileal resection showed skipped pebble appearing granulomatous lesions in the affected intestine and ulcers with associated omental adhesions. Histologic examination demonstrated cells containing cytoplasmic inclusions consistent with CMV along with AFB positive caseating granulomas. Patient did well post-operatively and he was discharged after 12 days on pharmacologic treatment for MTb and CMV. Massive hematochezia from MTb has traditionally been reported rarely, but recent case series show an incidence of 4–9%. Endoscopic evaluation and histologic demonstration of MTb is the gold standard of diagnosis. Anti-tuberculous medical therapy combined with endoscopic therapy have been reported as successful treatment modalities for tuberculous enteritis or colitis. Surgical therapies are reserved for uncontrollable bleeding, perforation, or obstruction. Common symptoms of intestinal CMV include pain and diarrhea, bleeding is reported to occur in 10% of cases. Severe bleeding is rare. Diagnosis of CMV colitis can be obtained by viral culture, detection of CMV antigen or genome in the tissue, or demonstration of typical cytopathology. Standard medical treatment includes intravenous Gancyclovir or Foscarnet individually or in combination. Octreotide has been reported to halt massive bleeding in case reports. CMV colitis has traditionally been more likely than luminal MTb to be a cause of significant bleeding in patients with advanced HIV, but the incidence of MTb causing massive hematochezia may be rising.