A 69-years-old male patient was referred to physician with complains of cough for 3 months, tiredness and weight loss during September 2002 in north east of Iran. The patient indicated no history of fever at night and chills and also no family history of pulmonary tuberculosis. In examination no underlying disease and HIV was detected but he was heavy smoker. Three sputum samples were obtained over a 3-day period for acid-fast bacilli (AFB) smears and culture. The direct smears were positive for AFB, and his disease was diagnosed as pulmonary tuberculosis. He received standard anti-TB treatment recommended by WHO, consisting of rifampin (RIF), isoniazid (INH), ethambutol (EMB) and pyrazinamide (PZA) for two months, followed by four months of RIF and INH while his compliance was low. In March 2003, his weight increased and major health improvement was noticed. The smear was negative and consequently the treatment was stopped. In April 2003, because of symptoms recurrence, treatment was begun according to cat II as follow: two months treatment with RIF, INH, EMB, PZA and streptomycin (STR), followed by one month of RIF, INH, EMB and PZA, followed by five months RIF, INH and EMB. In January 2004 patient was admitted with hemoptysis. At this time direct smear was positive and therefore culture of sputum and drug sensitivity test was performed. The exams resulted in positive culture which was resistance against RIF, INH, EMB and STR. The patient was hospitalized for 124 days in the National Research Institute of Tuberculosis and Lung Diseases (NRITLD) (Tehran, Iran) and treatment was started with second-line anti-tubercular regimen consisting ciprofloxacin (Cip), amikacin (AMK), prothionamide (PTH), cycloserine (CYC), clarithromycin (CLR), amoxicillin-clavulanate and vitamin B6. The patient poorly followed his treatment for several years in spite of symptoms. In May 2008, because of no response to treatment, drug sensitivity test was performed for second-line anti-tubercular regimen using two critical proportions of 1% and 10%. The result (after 42 days incubation at 37  C) showed resistance against Amikacin, Ciprofloxacin, Cycloserine, Ofloxacin (OFX), Capreomycin (CAP), p-aminosalicylic acid (PAS), ethionamide (ETH), Kanamycin (KAN). In August 2012, due to unusual persistence and resistance of infection, more investigation was recommended using biochemical molecular methods and therefore sputum culture and drug sensitivity test was performed in Regional Tuberculosis Reference Laboratory in Mashhad. It showed that direct smear and sputum culture was still positive for AFB. In September 2012, direct smear and culture was repeatedly positive and during this time due to digestive side effects, the patient refused to use regular drugs consumption. Mycobacterium isolated was niacin negative and had smooth colony and was resistance against RIF, INH, EMB and STR. PCR was performed on isolated mycobacterium that revealed NTM (unknown species). For more confirmation, another sputum sample was sent to NRITLD on January 2013. Using molecular methods particularly Spoligotyping, the isolated strain was identified as M. tuberculosis. In March 2013, chest radiography revealed a bilateral infiltration in upper lobes (Fig. 1).
At that time his laboratory values were as follow: white blood cell (70.6% neutrophils) and red blood cell count were normal, Hemoglobin: 18.8 g/dL, Hematocrit: 58.5 mL/dL, urea: 47 mL/dL, Cr: 1.4 mL/dL, Aspartate aminotransferase (AST): 23 IU/L, Alanine aminotransferase (ALT): 19 IU/L. On physical examination, his blood pressure was 90/60 mmHg, his weight was 55 kg. The patient still complained of cough and shortness of breath.