A 34-year-old male with no previous known co-morbidities initially reported to a peripheral hospital with history of cough with mucoid expectoration, dyspnoea and weight loss of 14 kilograms in 1 month. On examination, he was cachectic (weight: 34 kilograms) and had pallor. The chest examination showed decreased expansion on right side with bronchial breath sounds on auscultation over right infra- and interscapular areas. On evaluation, he has anaemia (haemoglobin 9 mg/dl) and thrombocytosis, while rest of the biochemical parameters were within normal limits [Table 1]. He was also found to have positive hepatitis B antigen. His sputum ZN staining showed presence of AFB (2+), and sputum CBNAAT (gene Xpert) confirmed the presence of AFB but showed high-level rifampicin resistance. The chest radiograph showed non-homogenous opacity with extensive cavitary involvement of right upper and mid-zone [Figure 2a]. He was diagnosed as a case of sputum smear positive rifampicin-resistant pulmonary tuberculosis and was transferred to our centre for further management. At our centre, he underwent sputum LPA-1 which confirmed rifampicin and isoniazid resistance, and LPA-2 showed resistance to fluoroquinolone but sensitive to aminoglycoside. He was managed as case of pre-XDR tuberculosis and was started on bedaquiline-based ATT. He showed suboptimal response to the therapy and continued to be symptomatic with radiological worsening. He also developed secondary spontaneous pneumothorax on right side which was managed with chest tube drainage, and later pleurodesis was also done with 2.5% povidone iodine. In view of clinical and radiological deterioration, delamanid was added to the therapy. The patient showed significant response to the ATT and attained smear conversion after two months and culture conversion after five months [Figure 2b]. Due to his extensive disease, the patient had developed post-tuberculosis sequelae which was confirmed by computed tomography of chest. His CT chest showed marked tubular, varicose and cylindrical bronchiectasis with bronchial wall thickening in segmental and subsegmental bronchi of all the lobes of both lungs with more conspicuous involvement of right upper and middle lobes. There were areas of consolidation on both sides. The spirometry showed mixed defect-moderate restriction (FVC-3.76 L (53.8%) and obstruction (FEV1/FVC-50.2%), FEV1-3.23L (46.6%). His DLCO was reduced suggestive of mild diffusion defect. The patient was given 06 months of bedaquiline and delamanid and was later continued continuation phase of ATT with total duration of ATT for 18 months.