A 28-year-old male patient known to have bronchial asthma and allergic rhinitis presented in February 2014 with complains of fever, productive cough, and shortness of breath for 2 weeks.
He was febrile, and his chest radiograph was showing lower, mid zone consolidation.
He was initially treated as a community-acquired pneumonia with antibiotics. His fever however did not subside, so he had further investigations including sputum culture and acid-fast bacilli smear were negative, and then bronchoscopy with bronchoalveolar lavage was done, turned to be positive acid-fast bacilli smear, and confirm rifampicin resistance, and later culture confirms the MDR-TB as the resistance including rifampicin, isoniazid, ethambutol, and streptomycin.
So, he was started on MDR-TB regimen which include six drugs: amikacin, moxifloxacin, pyrazinamide (PZA), cycloserine (cyclo), linezolid (Lzd), ethionamide (Eto).
However, he was able to continue this regimen for only 3 months, and then he developed severe lower limb sensory motor polyneuropathy. Unfortunately, he took only Eth, cyclo, and para-aminosalycilic acid (PAS) for another 10 months and then ethionamide and cycloserine (due to PAS-induced GI upset) for another 4 months, and after that, the patient chose to stop the treatment after total treatment period of 17 months.
Two months later, he started to complain of right shoulder pain, tenderness with right shoulder pain, and with limitation of movement for 4 months. MRI shoulder showed abscess-like lesion in the proximal humerus (Fig. 1). At this stage, he denied any respiratory symptoms, while his chest X-ray showed resolution of right lower lobe consolidation.
He got admitted for incision and drainage. The bone was found to express frank pus which was sent for TB-PCR which came also positive from the pus.
Biopsy specimen of the bone revealed necrotizing granulomatous inflammation and abscess formation (Fig. 2). After a discussion between the Infectious & respiratory teams which decided to resume second line anti TB and due to the high possibility being even of XDR-TB especially that quinolone sensitivity was not available.
Moreover, a decision was made to treat the patient with the initiation phase of treatment was given for 4 months (6 drugs: Mfx, Lzd, capreomycin, cyclo, PZA, Clr); he was instructed for good compliance.
He was able to be on this regimen only for 4 months as he developed again severe peripheral neuropathy in his lower limbs and hands despite using high dose of vitamin B6, i.e., pyridoxine (200 mg daily) plus symptomatic treatment with gabapentin and carbamazepine. So Capreomycin, Moxifloxacin & Linezolid were suspended then he was continued on {PZA, PAS,, Cyclo,Co-amoxiclav (Clav) & Bedaquiline (Bdq)} was started then continued for 1 year only because of shortage in cycloserine supply it was discontinued so he remain on {PZA, PAS, Bdq, Clav & Clarithromycin (Clr)} which is considered relatively weak regimen although the patient was advised to resume either linezolid or fluoroquinolone but he was reluctant because of neurotoxicity as well as no other options of second line anti TB regimen was available.
The last second-line regimen mainly depends on three drugs including PZA, PAS, and Bdq according to the recent WHO guidelines 2020 in addition to old two drugs which is Clr and Clav which is considered no longer recommended in prolong MDR-TB treatment, so he was continued on this regimen, but for longer duration guided by radiological imaging, he completed another 4 years with serial follow up of MRI humorous which showed dramatic response of the size of the osteomyelitis infection (Fig. 3).
In view of suboptimum continuation phase, so total treatment was extended to almost 5 years, and it was discontinued with follow-up MRI showing dramatic improvement after 14 months from stopping the treatment without any signs of recurrence.