The initial assessment was that of a 5-month-old female  infant, retroviral disease-exposed with a negative HIV-PCR at  birth, recurrent chest infection, failure to thrive and pulmonary  tuberculosis. The infant was admitted to the paediatric medical ward  to exclude primary immune deficiency, cystic fibrosis, Pneumocystis jirovecii pneumonia and cytomegalovirus (CMV) infection. She was  started on piperacillin/tazobactam, amikacin, nebulisation with  fenoterol, oral prednisone and tuberculosis treatment. 
 The following investigations were performed: sputum microscopy,  culture and sensitivity (MC&S) (no growth); GeneXpert test for  tuberculosis (negative); respiratory syncytial virus and adenovirus  (negative); P. jirovecii (negative); CMV DNA viral load (<1 000 copies);  SARS-COVID-19 (negative). A full blood count, C-reactive protein  and blood culture were normal. A stool sample for faecal elastase  as well as a primary immune deficiency screen were normal. Chest  X-rays showed bilateral infiltrates and a chest scan report showed  bilateral multiple consolidation with no bronchiectasis. A small patent  ductus arteriosus (negligible) was observed on echocardiogram. 
 On observation in the ward, the infant coughed excessively during  feeds, a barium swallow contrast study was performed (Fig. 1) and a  fistula was identified between the trachea and oesophagus. The patient  was referred to paediatric surgery. Figs 2 and 3 are intraoperative  images. Postoperatively, she recovered well and was discharged home  after 2 weeks. At the time of publication of this report, the infant was  clinically well, gaining weight and no further cough had been observed.