A 44-year-old artisanal digger of coltan (Niobium + Tantalum) was transferred to hospital for multi-drug-resistant tuberculosis or rifampicin-resistant tuberculosis (MDR/RR-TB) treatment. As per the national guidelines, he has completed the first-line drug regimen, including 2 months of rifampicin (R), isoniazid (H), pyrazinamide (Z), and ethambutol (E), followed by 4 months of R and H (2RHZE/4RH). Due to persistence of symptomatology, he was retreated for failure by an 8-month regimen, including streptomycin (S) for the first 2 months (2SRHZE/1RHZE/5RHE). MDR/RR-TB was suspected as the patient persisted having fever, cough with bloodstained mucopurulent sputum a month after his second rifampicin-susceptible TB (RS-TB) treatment. The patient's history noted that, for four months since the first occurrence of respiratory manifestations to the first RS-TB, the patient self-medicated with cotrimoxazole and sought traditional/religious leaders help without success. On clinical examination, he presented with pyrexia, was dyspneic with reduced chest compliance, dullness on percussion with absence of tactile fremitus and majorly diminished breath sounds on the left side of the chest.
Laboratory investigations showed a leukocytosis (21 7 x 109 per L) with marked eosinophilia. Sputum culture showed gram-negative bacteria (non-identified). Ziehl-Neelsen test for acid-fast bacilli on different sputum samples and HIV-infection serology were negative. Xpert-MTB/RIF on sputum sample was positive. Chest x-ray showed a mosaic of lesions suggestive of a complicated PTB (Fig. 1). CT-Scan was not available in the province. Audiometry confirmed a bilateral sensorineural hearing loss (103 and 105 dB on the right and left respectively) post streptomycin ototoxicity.
In addition to MDR-TB and respiratory failure, we treated possible colonization (bacterial subsequently developed into an abscess and chronic pulmonary aspergillosis). We combined moxifloxacin (Mfx), clofazimine (Cfz), E, and Z throughout, supplemented by kanamycin (Km), prothionamide (Pto), and high dose isoniazid (Hh) during a 4-month intensive phase (4KmMfxPtoCfzZHhE/5MfxCfzZE) for MDR-TB short regimen. Cochlear implant, line probe assays to detect isoniazid resistance as well as mycobacterial culture were unfortunately not available for logistical reasons. Evolution was characterized by onset of severe septic status requiring "hygienic thoracic surgery" that could have not been performed in our setting. The patient passed away at the third month of hospitalization.