A 26-month-old male child was admitted to the Pediatric Intensive Care Unit of the Fondazione IRRCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy, because of the sudden onset of rapidly increasing swelling of the neck, face and upper trunk a few hours before. The child’s medical history had been uneventful except for the onset of a non-productive cough two months previously and nightly intermittent mild fever for the previous 15 days. The administration of oral amoxicillin 50 mg/kg/day for 10 days had had no effect on the cough or fever. Furthermore, two days before admission, the child had ingested several peanuts before being noticed by his parents. Upon admission, the patient was conscious and oriented: his weight was 13 kg, body temperature 36.5°C, pulse rate 120/min, respiratory rate 36/min, blood pressure 98/62 mm/Hg, and O2 saturation 97% in air. Palpation revealed SE over the swollen skin areas, and an examination of the respiratory system revealed crepitations in the left part of the chest without any significant suggestion of mediastinal shift. The results of cardiovascular and central nervous system examinations were normal. Blood tests revealed normal hemoglobin with moderate leukocytosis (total leukocytes 15,300 mm3; differential count: neutrophils 61%, lymphocytes 30%). His C-reactive protein level was 7 mg/L. Arterial blood gas analysis showed pH 7.41, pCO2 42 mm Hg and pO2 90 mmHg. Chest radiography revealed significant enlargement of the left lung hilum with pneumomediastinum and SE. Flexible optical fibre bronchoscopy was carried out because of the suspicion the child may have inhaled a peanut. This excluded the presence of a foreign body, but showed that the left main bronchus was partially obstructed with caseous material and that there were significant signs of granulomatous inflammation on the wall. This material was extracted and sent to the laboratory for histological and microbiological examination. Contrast- enhanced computed tomography (CECT) of the lung confirmed SE and pneumomediastinum, and revealed bilateral hilum lymph node disease with infiltration of the adjacent anatomical structure, and a substantial breach in the left primary bronchus wall conditioning the passage of air in the mediastinum and subcutaneous tissue. As a tuberculin skin test and polymerase chain reaction (PCR) for M. tuberculosis on bronchial material and gastric aspirate were positive, a diagnosis of TB was made and it was discovered that the child’s mother had a cavitary pulmonary TB. An oral therapy with isoniazid (15 mg/kg/day), rifampin (16 mg/kg/day), pyrazinamide (40 mg/kg/day) and ethambutol (23 mg/kg/day) was started. The SE disappeared about one week after admission, and a control examination after 10 days of treatment revealed a significant increase in alanine aminotransferase serum levels (478 IU/L). This led to the discontinuation of rifampin after 2 weeks from the beginning of therapy and the dose of isoniazid was reduced to 10 mg/kg/day. Moreover, due to concerns about drug resistance (although when the culture became available M. tuberculosis resulted fully sensitive), amikacin (15 mg/kg/day) was added. Corticosteroids were not added to the treatment. A gastric aspirate evaluation four weeks after the beginning of therapy revealed that the treatment had eliminated M. tuberculosis. Amikacin was discontinued, the child was discharged and it was suggested to continue a 3-drug regimen for a total of two months followed by a 2-drug regimen for seven months, while returning periodically for further controls.