india has the world 's highest burden of tuberculosis ( tb ) . in india ,
the multidrug - resistant tb ( mdr - tb ) prevalence among all patients with tb combined is estimated to be 4.1% . a crude estimate derived from these data is that 4500  6000 hiv - infected persons develop mdr - tb annually in india .
diagnosis of any form of tb , including drug - resistant ( dr ) tb , is more challenging in the presence of hiv disease and together they result in higher case fatality rates .
poly - drug resistant tb indicates resistance to two or more anti - tb drugs but not to both isoniazid ( inh ) and rifampicin ( r ) simultaneously .
treatment of dr - tb in patients on antiretroviral therapy ( art ) is complex due to the drug interactions .
dr - tb in hiv - infected children is difficult to diagnose and rarely reported .
a 3-year - old hiv - infected boy was referred for further management in january 2005 .
mother was diagnosed as tuberculous pleural effusion with hiv infection with acid fast bacillus ( afb ) seen on sputum examination and was on ofloxacin ( o ) , inh ( h ) , and rifampicin ( r ) for the same .
he had cervical adenopathy ( non - tender , non - matted ) and other systems were normal .
investigations showed positive mantoux test ( 20  22 mm ) and chest x - ray was suggestive of primary complex .
his venereal disease research laboratory ( vdrl ) test , hbsag , and anti - hepatitis c were negative . he was started on anti - tuberculous therapy ( att ) consisting of 2 hrze + 10 hr ( z = pyrazinamide , e = ethambutol ) .
he was asymptomatic till june 2007 , when we had mild molluscum contagiosum . in february 2009 , at the age of 7 years ,
he was hospitalized with right lower zone pneumonia and his sputum was positive for afb .
his sputum culture grew mycobacterium tuberculous ( mtb ) complex after 6 weeks and sensitivity after another 2 weeks showed resistance to streptomycin ( s ) and h. he was then shifted to rezo in may 2009 and art was started in the same period in view of decreasing cd4 count , consisting of zidovudine ( azt ) , lamivudine ( 3tc ) , and nevirapine ( nvp at 400 mg / m / day ) .
ofloxacin was stopped in august 2009 and he was advised rez for another 6 months .
in india , mdr - tb is estimated to account for 2.3% [ 95% confidence intervals ( ci ) : 1.8  2.8 ] of new cases and 17.2% ( 95% ci : 14.9  19.5 ) of previously treated tb cases
. those at highest risk of dr - tb are in whom prior treatment had failed , cases of relapse , defaulters , and contacts of mdr - tb .
drug resistance is rarely acquired in the pediatric population due to the paucibacillary nature of the disease and originates mainly in the adults who are treatment failures or defaulters .
thus , the main method of resistance in children is primary transmission of the resistant bacilli .
our patient had been treated for pulmonary tb in 2005 for 1 year but again developed tb in 2009 , which is suggestive of a relapse .
hiv co - infection is considered important in the development of dr - tb by increasing the rates of malabsorption of anti - tb drugs , thus causing treatment failures .
the diagnosis of dr - tb is established by laboratory methods ( drug susceptibility tests or dst ) which , however , are not available in most resource - limited settings and are difficult to do in children .
treatment of poly - resistant tb varies as per drug resistance pattern and consists of three to four sensitive drugs for six to eighteen months duration . for h and s resistance , as in our patient ,
the suggested regimen is rze for 69 months , and fluoroquinolone can be added in patients with extensive disease to strengthen the regimen .
thus , children who had been treated for tb in the past should be screened for drug resistance by dst .
this has also been reiterated in our series of children with mdr - tb and partial over extensively drug - resistant ( xdr ) tb in whom we found that over 50% of patients had been treated for tb in the past .
dr - tb in hiv - infected children should be considered if the child has been treated with att in the past or there is contact with adults on second - line att therapy .
poly - resistant tb is rare in children , especially in hiv - infected children .
 drug - resistant tuberculosis ( dr - tb ) has been reported in india , but has been rarely documented in children . 
 hiv co - infection has led to resurgence of tuberculosis ( tb ) , making treatment even more difficult due to complex drug interactions . 
 poly - resistant tb is rare in children , especially in hiv - infected children . 
 we report an hiv - infected child who developed poly - resistant tb ( resistance to streptomycin and isoniazid ) after 3 years of completion of anti - tuberculosis treatment ( att ) . 
 his mother had also received att 3 years back . 
 we conclude that dr - tb in hiv - infected children should be considered if the child had been treated with att in the past or there is contact with adults on second - line att therapy . 
Introduction
Case Report
Discussion
Conclusion