Clinical approach to drug-resistant tuberculosis of the brain and spine in a low-income setting: A case series

➢ Drug-resistant tuberculosis of the brain and spine are not easily accessible for sampling and culture ➢ Detection yield of mycobacterium in the cerebrospinal fluid is low ➢ Delayed detections can have serious consequences ➢ Physicians in low- and middle-income countries have limited resources and have insufficient training ➢ We present our strategy of management with three cases in resource constrained settings ➢ Detection of drug-resistance was delayed in each case, but all survived ➢ Drug-resistant brain tuberculosis causes serious complications ➢ Better outcomes need early suspicion, high clinical vigilance, and timely initiation of second line therapy Drug-resistant tuberculosis (TB) of the brain and spine is difficult to sample for culture. It poses a significant challenge to physicians in low- and middle-income countries. Lack of experience and inaccessibility to advanced diagnostics leads to devastating clinical outcomes. Here, we present three patients of drug-resistant tuberculosis and demonstrate how we manage them in limited resources. MDR1, a young female patient had cerebellar tuberculomas at presentation. While being on conventional antituberculous therapy (ATT), she developed meningitis, and deteriorated with gross hydrocephalus and impaired conscious-level. Later, patient sustained ischemic strokes resulting in bilateral spastic contractures. Second-line ATT improved her condition. Treatment course was complicated by peripheral neuropathy, and psychotic behavior. MDR2, a middle-aged woman having type-II diabetes was diagnosed with lumbar spondylitis. She was on conventional ATT for 1 year. However, symptoms of severe backache relapsed within 1 month of discontinuation of treatment. She refused from computed tomography biopsy of the affected vertebra and we had to start her on empirical second-line treatment. She had a dramatic response in pain within a month and completely recovered at 1 year. MDR3, a middle-aged woman had spondylitic changes at D10-D11 vertebral bodies on magnetic resonance imaging. Pain at the dorsal spine showed sub-optimum response to conventional ATT. The hyperintense signal changes resolved at 1 year of treatment with levofloxacin and linezolid. These outcomes will raise physicians’ awareness of the need for early suspicion, high clinical vigilance, and timely initiation of second-line therapy to avoid complications of drug-resistant TB.