Tuberculosis (TB) is a deadly disease that infects millions of people annually. TB has a global distribution and remains a significant cause of mortality, despite decades of eradication campaigns and antibiotic development. TB is caused by genetically similar pathogens in the Mycobacterium tuberculosis complex (MTBC), and human infections are generally caused by human-associated strains, although humans can contract animal-associated strains. Skeletal evidence of TB on archaeological human skeletal remains and evolutionary dating of MTBC genomes reveal that TB has afflicted humans for approximately 6,000 years. Previous research has shown that MTBC pathogens were introduced into the Americas through a zoonotic transmission from seals and sea lions along the coasts of South America by at least 1000 CE. Characterizing the introduction and enigmatic intercontinental spread of a successful zoonotic transmission over hundreds of years provides valuable insight into the potential of zoonotic MTBC infections. Through the recovery and phylogenomic analysis of the first ancient MTBC genomes (n = 2) from pre-contact North America, I establish that there were multiple contemporaneous MTBC lineages circulating in human populations in the Americas. The high genomic diversity and deep divergence of strains from Mesoamerica suggest that TB was endemic in the region. To reveal the impact of TB within a Mesoamerican city, I examined human skeletons (n = 137) for evidence of disease from sacrificial and natural mortality burial contexts within Tlatelolco, a ceremonial precinct and interregional marketplace at the heart of the Aztec Empire (1300-1521 CE). I found that TB disproportionately affected sacrificial victims, who also exhibited evidence of food insecurity and resource inequality. These results mirror the socioeconomic patterns of TB distribution today. Further, I sampled broadly from sacrificial victims with skeletal evidence of TB not only for biomolecular confirmation of MTBC but also to uncover associations between skeletal TB manifestation and ability to recover ancient MTBC DNA. I identify 10 additional cases of MTBC at Tlatelolco and link ancient MTBC DNA recovery to TB skeletal lesion characteristics and age-at-death of the infected individual. Overall, this body of work combines paleogenomic and paleopathological data to highlight the impact of ancient TB zoonoses.