Introduction: Tuberculosis (TB) remains underdiagnosed in Sri Lanka. We describe the clinical spectrum and outcomes of children admitted to a tertiary referral unit with pulmonology services over four years. Methods: This retrospective, record-based cross-sectional sudy included children admitted or transferred between 2019–2021 and 2023–2026. Clinical and outcome data were analysed. Results: Thirty children were included (mean age 7 .6 ± 3.2 years; M:F 17:15). Fever >1 week occurred in all prior to presentation; however, 40% (12/30) were afebrile at diagnosis. Growth faltering was present in 73%(22/30), while loss of appetite was reported in 23%(7/30). Pulmonary TB(PTB) accounted for 33%(10/30). Extrapulmonary TB(EPTB) comprised 63% (19/30): pleural 30% (9/30), lymph node 13% (4/30), bone 7%(2/30), pericardial 3%(1/30), and CNS 3%(1/30). Disseminated TB was seen in 7%(2/30). PTB frequently presented as poorly resolving pneumonia. All pleural TB cases presented as complicated pneumonia. A contact history was identified in 47%(14/30). ESR exceeded 75 mm/hr in all children and was >100 mm/hr in 69%(20/29). TST was positive in 77% of PTB and 63% of EPTB. All diagnoses of pleural TB were based on histology others were based on the positive gene Xpert of relevant samples. Three bone TB cases were initially evaluated for malignancy or osteomyelitis. All children were fully recovered. Conclusion: EPTB is predominant and the presentations are atypical in paediatric TB. Low contact identification, negative molecular tests in pleural TB, and initial misdiagnoses underscore diagnostic challenges. Clinical suspicion and early referral are crucial to prevent delays and improve outcomes in pediatric TB.