A 25-year-old male, non-smoker with no other co-morbidities initially reported at a peripheral hospital with history of cough and weight loss of 1 month duration. The cough was insidious in onset with mucoid expectoration and history of weight loss of 05 kilograms with reduced appetite and generalized malaise. On examination, he had bronchial breath sounds in left infraclavicular and interscapular area, and crackles were heard in right mammary area. On evaluation, there was thrombocytosis and raised erythrocyte sedimentation rate, with normal haemoglobin, liver and renal function tests. His chest radiograph showed dense acinar radiopacities in the left upper zone and superior part of Left middle zone, suggestive of active pulmonary tuberculosis [Figure 1a]. On sputum smear, Ziehl-Neelsen (ZN) stain 2+ acid-fast bacilli (AFB) were seen (RNCTP grading). He was diagnosed as sputum smear positive pulmonary tuberculosis and was initially started on first-line antitubercular drugs. He showed features of clinical deterioration with no weight gain, worsening of his chest radiograph and continued to be sputum smear positive even after one month of ATT. He was further evaluated at our centre, his sputum CBNAAT (gene Xpert) showed presence of Mycobacterium (MTB detected high), and rifampicin resistance was also present [Table 1]. His sputum MTB LJ medium culture showed positive growth for MTB with resistance to isoniazid, rifampicin, pyrazinamide, levofloxacin and ethambutol. The first-line probe assay (LPA-1) confirmed the rifampicin resistance (presence of rpoB mutation) and resistance to isoniazid (presence of katG mutation), while the second-line probe assay (LPA-2) showed fluoroquinolone resistance but sensitive to aminoglycosides. The patient was diagnosed as a case of pre-extensively drug-resistant tuberculosis and was started on bedaquiline-based therapy consisting of bedaquiline, linezolid, clofazimine, cycloserine and levofloxacin. However, he had suboptimal response and continued to have productive cough and radiological progression of disease even after 04 months of the above regime. In view of his worsening of disease, he was started on delamanid-based therapy. He showed significant clinical response in form amelioration of his cough and weight gain of 13 kilograms. He became sputum and culture negative after one month of delamanid therapy. His repeat chest radiograph showed significant improvement [Figure 1b]. His delamanid was stopped after 06 months, and he was discharged on continuation phase of ATT.