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Mycobacterium tilburgii is an opportunistic pathogen that has only been described 11 times in the literature. Hyperammonemia as a resulting symptom of a mycobacterial infection has only been reported once. We describe a patient with a disseminated M. tilburgii infection, leading to hyperammonemia.A 57-year-old man was referred with stupor, rapidly declining to coma. Hyperammonemia was found as the underlying cause. Ammonia-lowering interventions had an overall disappointing effect. Frequent causes of hyperammonemia were excluded. Finally, a disseminated opportunistic M. tilburgii infection was diagnosed by using 16sRNA sequencing. A combination of antimicrobial drugs was started, after which ammonia level declined and consciousness improved. Unfortunately, it failed to eradicate the infection. The patient died od pneumonia and multiorgan failure.Hyperammonemia requires an urgent response to prevent cerebral damage. M. tilburgii is not cultivable and diagnosis is performed using 16S RNA sequencing. Long-term antimicrobial drugs are required for eradication.