Two cases of pathologically confirmed miliary pulmonary tuberculosis complicated with ARDS were presented. Both had systemic lupus erythematous and used maintenance dose of corticosteroid. Case one developed respiratory distress and severe hypoxemia one day postpartum and chest radiograph revealed nodular and miliary infiltrations and pleural effusion. The patient was intubated and placed on a volume-cycled ventilator. A FIO2 of 70% and a PEEP of 0.98 kPa were required to maintain the oxygen tension at 6.95 kPa. The effective compliance of the lung decreased progressively and the patient died 5 days later. Autopsy revealed disseminated tuberculosis extensively involving the lungs, the liver and kidney. The alveoli were filled with edematous fluid with formation of hyaline membranes and micro-atelectasis. Case two developed respiratory distress and pulmonary edema at the third month of pregnancy. Cardiopulmonary arrest occurred when trying to intubate the patient. Postmortem needle puncture of the lungs and liver revealed charges comparable with tuberculosis and ARDS. In considering the relatively high incidence of pulmonary tuberculosis in China, the percentage of miliary tuberculosis as a potential cause of ARDS might not be very low. It is important to maintain a high index of suspicion for this treatable precipitating disorder and initial appropriate therapy early enough in patients with ARDS.