An 8-year-old female child was referred to Inkosi Albert Luthuli Central Hospital (IALCH) from a provincial hospital with a 4-month history of chronic purulent sputum, severe weight loss and constitutional symptoms. There was no tuberculosis (TB) contact but her 6-year-old brother had similar symptoms. They lived on a farm at Nkonjeni in rural KwaZulu-Natal, South Africa. She was assessed as having pulmonary tuberculosis and commenced on 4-drug anti-tuberculosis therapy (rifampicin/isoniazid/pyrazinamide and ethambutol) at the provincial hospital. The diagnosis of TB was based on the clinical presentation and chest radiology (Fig. 1). 
 GeneXpert and TB cultures were negative. The erythrocyte sedimentation rate (ESR) was greater than 140 mm/hr, monocytes 2.56 x109 /L and the globulin fraction was 37 g/L. Her HIV test was negative. 
 After 2 months of TB treatment, the patient deteriorated and presented to the provincial hospital with severe respiratory distress. A chest X-ray showed a right pleural effusion, a thoracentesis yielded pus and an inter-costal chest drain was inserted. She developed respiratory failure, and she was referred to the paediatric intensive care unit (PICU) at IALCH for mechanical ventilation. On examination, she was clinically wasted, weighed 24 kg (z-score between -2 and -3), was in respiratory distress, displaying pallor, clubbing and axillary lymphadenopathy. She had absent breath sounds on the right hemithorax with left-sided crackles. Abdominal examination revealed a 7 cm firm hepatomegaly with 3 cm splenomegaly. She was encephalopathic with meningism. An initial assessment of disseminated TB was made. She was intubated and ventilated. TB treatment was continued, and ethambutol was changed to ethionamide. Meropenem was added to the treatment. An urgent computed tomography (CT) brain scan showed age incongruent cerebral and cerebellar involutional  changes with no basal enhancement or hydrocephalus or features of raised intracranial pressure (Fig. 2). Lumbar puncture showed lymphocytes of 28, neutrophils of 12, no erythrocytes, glucose 1.1 mmol/L, protein 2.5 g/L and chloride 122 mmol/L. Admission blood results: white blood cells were 45.3 x109 /L, with predominant neutrophilia of 35 x109 /L and monocytes of 4.99 x109 /L, Platelets were 1169 x109 /L, ESR >140 mm/hr and procalcitonin 52 ng/dL. 
 Gene Xpert and TB culture were negative. A CT chest scan showed destruction of the right lung with bronchiectasis and cavities (Fig. 3). Endotracheal aspirates and pleural fluid cultured Nocardia spp. sensitive to meropenem and co-trimoxazole. An assessment  of disseminated nocardiosis was made. The patient was treated with meropenem and high-dose co-trimoxazole and after 7 days of therapy she showed signs of improvement, was successfully extubated and transferred to the infectious diseases unit to continue with both antibiotics and TB treatment. A month later, she developed generalised tonic-clinic seizures and decreased level of consciousness (Glasgow Coma Scale (GCS) score 7/15) and localising sign of dilated left pupil. She was then re-ventilated and transferred back to PICU. An urgent CT brain showed active tetra-ventricular hydrocephalus with transependymal seepage. An external ventricular drain was inserted by the neurosurgeons; however, the patient continued to deteriorate and demised on the ventilator.
Computed tomography chest scan showing destruction of the
entire right lung with bronchiectasis with cavitatory disease.