Renal tuberculosis poses diagnostic challenges due to diverse clinical presentations and varied radiographic findings. We present a 68-year-old male with chronic tuberculous infection evident on contrast-enhanced CT. Imaging revealed a contracted left kidney with perinephric fat stranding, hypodense areas, and retroperitoneal lymphadenopathy. Fistulous tracts between the upper pole of the left kidney and adjacent structures indicated tuberculous kidney with reno-colic and reno-psoas fistulous changes, complicated by Pott’s spine. This underscores the need to consider renal tuberculosis in patients with nonspecific symptoms and suggestive imaging, highlighting prompt multidisciplinary management for optimal outcomes.