A 4-year-old malnourished girl (11 kg, < 3 rd percentile) was admitted to the Hospital Infantil Menino Jesus, Sao Paulo State, Brazil, with a history of intermittent fever for 20 days, diarrhea without blood, night sweats, weight loss and dry cough. The patient had no comorbidities, no history of contact with a patient with pulmonary tuberculosis and received BCG vaccination. Laboratory exams revealed anemia (hemoglobin 8.8 g/dL), leukocytosis 21,600/mm 3 (1% band, 79% segmented neutrophils, 15% lymphocytes and 10% monocyte), platelets 269,000/mm 3 , INR 1,25, urea 18 mg/dL (normal range 7-18), creatinine 0.2 mg/dL (normal range 0.66-1.25), alanine transaminase 22 U/L (normal range < 35) and aspartate transaminase 29 U/L (normal range 15-50). Chest radiography presented a miliary pattern ( Figure 1 ). Ceftriaxone and first-line oral anti-tuberculosis agents (RHZ: rifampicin, isoniazid and pyrazinamide) were introduced after the diagnosis of disseminated tuberculosis confirmed by gastric washing that identified a rifampicin-sensitive Mycobacterium tuberculosis (X-pert MTB/RIF assay). The patient evolved with respiratory distress, septic shock, melena and hematochezia with massive bleeding requiring red blood cell transfusion of about 80 mL/kg six days after starting the enteral anti-tuberculous therapy. Upper digestive endoscopy, colonoscopy and angiography failed to identify the bleeding source. The macroscopic findings of endoscopy revealed no abnormalities in the esophagus and stomach. In the duodenum, there was a shallow ulceration in the second portion with no sign of active bleeding. A duodenal biopsy showed chronic duodenitis and a positive acid-fast bacilli test ( Figure 2 ), confirming the diagnosis of disseminated tuberculosis. The abdominal tomography revealed lymphadenopathy, jejunal loops clusters with difficult identification of their contours, distal ileal and sigmoid wall thickening ( Figure 3 ). The patient did not receive any medications that could increase the risk of bleeding, except for hydrocortisone due to the refractory septic shock. The severity of the case and the intestinal involvement cast doubt on the expected response of the enteral absorption of oral drugs. Thereafter, an intravenous second line drug therapy was associated: linezolid (10 mg/kg/day), amikacin (15 mg/kg/day), meropenem (120 mg/kg/day) and ciprofloxacin (20 mg/kg/day). After seven days of combined therapy there was no more bleeding. Linezolid was suspended after 14 days of treatment, amikacin after 7 days, meropenem after 12 days and ciprofloxacin after 14 days. She was discharged after 35 days of hospitalization with RHZ regimen. The patient's parents had neither respiratory symptoms nor abnormalities on their chest radiographs.