Delayed Onset of Linezolid-induced Peripheral Neuropathy: A Case Report and Review with Symptom of Atypical Timeframes

Linezolid, a key drug in Multidrug-resistant Tuberculosis (MDR-TB) treatment, is known for its efficacy but is frequently associated with peripheral neuropathy, particularly with prolonged use. The authors hereby present a case of a 17-year-old young female diagnosed with extra-pulmonary MDR-TB, who developed delayed-onset peripheral neuropathy after five months of Linezolid therapy. She initially tolerated an all-oral longer regimen, including Bedaquiline, Linezolid, Cycloserine, Clofazimine, Levofloxacin and Pyridoxine. However, she later reported tingling and numbness in both lower limbs, with hyperesthesia. A neurological examination confirmed sensory axonal neuropathy. Linezolid was discontinued, leading to symptomatic improvement. To confirm, a rechallenge was performed, starting with 300 mg once daily and increasing to 600 mg once daily. Within a week, symptoms recurred, reinforcing the diagnosis of Linezolid-induced Peripheral Neuropathy (LIPN). The drug was permanently discontinued and replaced with Pyrazinamide as per Programmatic Management of Drug-resistant Tuberculosis (PMDT) guidelines. Despite its importance in MDR-TB management, there is a lack of standardised protocols for monitoring and mitigating LIPN. Future research should focus on dose-response relationships, adjunctive therapies and biochemical markers such as folate, homocysteine and oxidative stress indicators to refine treatment strategies. A balanced approach is crucial to ensuring efficacy while minimising neurotoxicity. The present case highlights the need for stringent neurological monitoring and individualised treatment adjustments in patients receiving prolonged linezolid therapy.