A 9-year-old female primary 3 pupil presented at Federal Medical Centre, Umuahia, Abia State, South Eastern Nigeria, with a year history of recurrent cough (initially productive of bloody sputum but later became dry), 3 months history of recurrent fever, and generalized weight loss. There was no history of contact with a patient with pulmonary tuberculosis. The mother tested positive to HIV, while the blind father was HIV negative. On examination she was chronically ill looking and pale with generalized muscle wasting and hypopigmented spots.
Investigations carried out included retroviral test, CD4, sputum acid-fast bacilli and chest X-Ray. The retroviral test was positive, and the CD4 count was 543 cells/uL. The chest X-ray was suggestive of pulmonary TB. The sputum acid-fast bacilli (AFB) result at presentation was 0, +. The diagnosis of retroviral disease was made first and pulmonary tuberculosis a month later. The patient was started on antituberculosis drug with category one regimen which includes rifampicin, isoniazid and pyrazinamide for 2 months and rifampicin and isoniazid for 4 months (2RHZ/4RH). After five months, the patient's sputum AFB was still positive and was declared a failure case. The category two regimen was then started with two months of streptomycin, rifampicin, isoniazid and pyrazinamide, one month of rifampicin, isoniazid, and pyrazinamide and 5 months of rifampicin and isoniazid (2SRHZ/RHZ/5RH) concurrently with antiretroviral drugs (zidovudine, lamivudine and efavirenz). However, at five months, the patient was still sputum AFB positive with results as follows: 6/100 and + and CD4 count of 268 cells/uL, and the patient was declared as failure case after retreatment. The patient was suspected as a case of multidrug-resistant TB and the sputum was collected and sent to a centre in Ebonyi State, South Eastern Nigeria, where there is instrument for investigation (Gene Xpert). The Gene Xpert was done and the result of multidrug resistant tuberculosis was positive. Since multi drug resistant cases are not managed in this particular centre the patient was referred to University College Hospital (UCH), Ibadan, South Western Nigeria, where facilities for management of MDR-TB cases are available and culture and DST were done to confirm the diagnosis. The patient is presently receiving treatment in UCH and responding very well. At the time this patient was referred to this centre, it was confirmed as the first paediatric multidrug-resistant case seen and needed to get the regimen for the management.