A girl aged 12 years was hospitalized after eight months of unsuccessful treatment for disseminated pulmonary rifampin resistant tuberculosis (RR-TB) to determine further treatment tactics. A household contact with the father, who was ill with TB since 2016, was established; drug susceptibility data were absent. The girl was diagnosed with TB in December 2018 at the referral to a health facility with complaints of high temperature (39  S), expectoration, and weakness. Plain chest X-ray revealed infiltrative changes with cavities in the upper lobe of the left lung with multiple dissemination foci into both lungs. Ziehl-Neelsen sputum smear microscopy result was positive. The Xpert  MTB/RIF assay determined resistance to rifampin. Chemotherapy was administered as follows: AmZELfx - three months; ZELfxEto - five months. The treatment outcome: a positive sputum smear result by microscopy, lack of positive X-ray dynamics. The BACTEC MGIT-960 detected growth of mycobacteria in culture.
Multidrug resistance (MDR) of M. tuberculosis was established with the following spectrum: isoniazid, rifampin, ethambutol, pyrazinamide, ethionamide, levofloxacin, moxifloxacin, para-aminosalicylic acid (HREZEtoLfxMfxPAS). Susceptibility to amikacin, capreomycin, cycloserine, linezolid, bedaquiline (AmCmCsLzdBdq) was preserved. Chest computed tomography (CT) showed the presentations of disseminated pulmonary TB (Fig. 1). Considering the prior treatment failure due to drug resistance and severity of the disease, we used a personalized chemotherapy regimen (AmCsLzdBdq) adapted to the specific case. The chemotherapy regimen contained bedaquiline, which was a new drug with age restrictions for that moment: age 18 years or above. We obtained an informed consent for bedaquiline use from the patient's father. Amikacin was withdrawn after three months due to the toxic reaction (sensorineural hearing loss), and the treatment was continued with CsLzdBdq. We used three courses of bedaquiline due to life-saving considerations. Sputum conversion was observed after one month. Chest CT after 18 months of treatment showed significant resolution of infiltrates and dissemination foci in S 1, 2 of the left lung, cavity closure (Fig. 2). We did not observe cardiotoxic effects of the prolonged use of bedaquiline (the QTs interval did not change during the whole treatment course).
A fragment of the chest CT image after 18-month bedaquiline-containing chemotherapy: residual changes after disseminated pulmonary TB in the form of single small solid foci in both lungs.