A-3 months-old-boy presented with severe malnutrition, known cholestatic jaundice diagnosed as congenital cytomegalovirus infection and contact of his father who was diagnosed with MDR-TB but was not compliant with his treatment. His tuberculin skin test was positive, chest radiograph revealed right perihilar infiltrate and X-pert MTB/RIF on gastric aspirate was positive for M. tuberculosis complex with resistance to rifampicin. Other baseline investigations revealed a small atrial septal defect on echocardiography, mild to moderate hearing loss on audiology, normal vision and retinas on ophthalmological evaluation, raised bilirubin and liver enzymes (alanine and aspartate transaminases) and positive cytomegalovirus (CMV) IgM with a negative CMV PCR. He was HIV-unexposed and his HIV ELISA was negative, but CD4% was low (19%). Culture of the gastric aspirate eventually was positive, confirming M. tuberculosis resistant to isoniazid and rifampicin on line-probe assay as well as resistant to second-line injectable agents with second-line LPA, but susceptible to the fluoroquinolones. He was therefore confirmed as pre-XDR-TB. The mother's sputum was X-pert MTB/RIF negative. The chest x-ray showed active tuberculosis with infiltrates at the right upper-middle lung field with an increased of bronchovascular marking (Fig. 1). We treated him with five kind of less hepatotoxic anti tuberculosis drugs by individualized treatment based on the updated WHO 2018 guidelines. He commenced the treatment with moxifloxacin (10 mg/kg/day divided in tow dose), linezolid (10 mg/kg/day once daily), cycloserin (10 mg/kg/day once daily), ethambutol (20 mg/kg/day once daily) and para-aminosalysilic acid (200 mg/kg/day divided in two dose). After seven days receiving the pre- XDR-TB treatment, the liver enzymes improved, no adverse reaction such as vomiting, dhiarrea was reported. He also recieved gancyclovir for the CMV infection. He was followed every one month, he shows weight increment to 5.8 kg from 3.6 kg in 3 months and increased gradually every month. His nutritional status improved to normal from severe malnutrition after 20 months of treatment. No adverse reaction such as vomiting nor dhiarrea was reported. The growth and milestones development were appropriate. Laboratory evaluation showed improvement of liver function. Hematologic and neurologic (peripheral and toxic optic neuropathy) adverse effects were monitored during linezolid treatment. No anemia nor thrombocytopenia was found. For the optic toxic neuropathy evaluation, normal vision was concluded through examination of response to light, pupil response, ability to follow a target and ophthalmoscopy examination of the retina was also done to exclude CMV retinitis symptom and the result was normal. The M.tuberculosis culture evaluation result was negative on the first and third month of treatment.