A 76 years old female presented to our emergency on 20th March, 2020 with a 1.5 month history of low grade intermittent fever, non-productive cough and decreased appetite with an eventual weight loss of 4 kg. She had worsening of symptoms five days prior to presentation with high grade fever followed by breathlessness 3 days prior to her presentation. There was no prior history of pulmonary TB, any recent hospital admission and no known contact with patients or family members having active TB. Her background history revealed that she was hypertensive taking tablet amlodipine 10 mg once daily. On physical examination at the time of admission, the patient was febrile (102°F) and had an arterial blood pressure of 140/80 mmHg, a heart rate of 110 beats/min, respiratory rate of 32 breaths/min and oxygen saturation of 86% on room air. Chest auscultation revealed bilateral crepitation with bronchial breathing on left side. Findings of the remainder of the systemic examination were unremarkable. The arterial blood gas on room air showed a PaO2 of 52 mmHg (Normal range: 80-100), PaCO2 of 30 mmHg (Normal range: 35-45), HCO3 of 18 mmol (Normal range: 22-26), pH of 7.46 (Normal range: 7.35-7.45) and wide alveolar‑arterial gradient of 36 mm Hg (Expected normal value- 23) suggestive of acute hypoxemic respiratory failure. Routine blood tests revealed the following: hemoglobin level of 11.5 g/dL (Normal range: 12-15 g/dl), leucocyte count of 7600 cells/mm3 (Normal range: 4000-11000 cells/mm3) with 90% neutrophils (Normal range: 40%-80%), 7.0% lymphocytes (Normal range: 20%-40%), and 3.0% monocytes (Normal range: 2%-10%), platelet count 220,000/mm3 (Normal range: 150,000/mm3-410,000/mm3), serum sodium level 133 mmol/L (Normal range: 135-145 mmol/l), urea 62.7 mg/dL (Normal range: 16-48 mg/dl) and creatinine 2.72 mg/dL (Normal range: 0.7-1.2 mg/dl). The erythrocyte sedimentation rate was elevated with 65 mm (Normal range: 0-30 in 1st hour). Other remarkable blood test findings included serum lactate dehydrogenase 550 U/L (Normal range: 135-225 U/L), High sensitive C-reactive protein- 55 mg/l (Normal value: < 5 mg/l), procalcitonin 0.5 ng/ml (Normal range: 0.0-0.5 ng/ml), NT-pro Brain Natriuretic Peptide level 600 pg/ml (Normal range: 0-249 pg/ml), ferritin level 426.2 ng/ml (Normal range: 13-150 ng/ml), troponin-I negative, creatine phosphokinase (CPK) 430 U/L (Normal range: 0-200 U/L) and CPK-MB 30.7 U/L (Normal range: 0-25 U/L). Chest radiograph revealed left lower zone alveolar opacity likely lobar consolidation as shown in Figure 1A. Computed tomography (CT) thorax revealed left lower lobe dense consolidation having air bronchogram with underlying effusion and bilateral ground glassing as shown in Figure 1 (B-F). Provisional diagnosis of community acquired pneumonia was established initially. A therapeutic trial of intravenous antibiotics (Ceftriaxone 1gm twice daily and Azithromycin 500 mg once daily) was initiated after collection of cultures along with other supportive measures. Ziehl Neelsen staining of two consecutive sputum smear samples were negative for acid fast bacilli (AFB). Her oxygenation was maintained with SpO2 around 95% with simple face mask with flow rate 8 litre/minute on admission. A short trial of intermittent non-invasive ventilation was also provided to reduce work of breathing even after achieving oxygenation. Aerobic culture of sputum, blood and urine collected at admission, were sterile. A 2D echocardiogram revealed mild concentric left ventricular hypertrophy with preserved ejection fraction, grade 1 diastolic dysfunction and no vegetations. Throat swab was negative for respiratory viruses including influenza. Serology was negative for HIV, hepatitis B and C. In view of the height of novel SARS CoV-2 pandemic worldwide, throat swab for SARS CoV-2 was also sent and found to be positive as detected by validated real-time reverse-transcriptase–polymerase-chain-reaction (RT-PCR) assay for both E-Sarbeco and RdRP genes. GeneXpert Ultra of sputum revealed rifampicin indeterminate Mycobacterium tuberculosis complex (MTBC). It was advised in view of high clinical suspicion for TB with chronicity of symptoms and radiological findings. Based on these reports, history of patient was again reviewed after enquiring all family members staying along with her. She was confirmed to have had direct contact with her grandson who travelled from France 12 days prior to the onset of acute symptoms and returned back after five days. Thereafter, her grandson also turned out to be COVID-19 positive. The treatment was modified on lines of COVID-19 that included injectable azithromycin 500 mg IV once daily, injectable methylprednisolone 40 mg IV twice daily, tablet hydroxychloroquine 400 mg twice daily for first day followed by 400 mg once daily for 4 days, tablet vitamin C 500 mg twice daily and tablet N-acetyl cysteine 600 mg twice daily. Anti-tuberculous regimen (Rifampicin-R, Isoniazid-Z, Ethambutol-E and Pyrazinamide-Z) was also started for TB component. No adverse events were reported. Patient was shifted to COVID-19 designated hospital on 24th March 2020 for further management as per national policy guidelines. Written informed consent was obtained from the patient for using clinical records in this study.