Landouzy sepsis in a young adult with multiorgan failure: successful ECMO-assisted management using an individualized antituberculous regimen

BACKGROUND: Fulminant disseminated tuberculosis (TB) presenting as Landouzy sepsis is rare but carries high mortality. When complicated by acute respiratory distress syndrome (ARDS) and multiorgan failure, evidence for optimal management, including extracorporeal membrane oxygenation (ECMO) and modified antituberculous regimens, remains limited. CASE PRESENTATION: We describe a 23-year-old man with miliary tuberculosis who developed Landouzy sepsis, ARDS, hepatic dysfunction, and refractory hypoxemia requiring veno-venous (VV) and subsequent veno-veno-venous (VVV) ECMO for six weeks. Standard anti-TB treatment for susceptible mycobacteria was withheld due to liver injury most likely related to antituberculous drug toxicity. Despite initial treatment with isoniazid, rifampicin, and ethambutol, rising bilirubin prompted rifampicin discontinuation and transition to an individualized regimen including ethambutol, isoniazid, levofloxacin, bedaquiline, and amikacin. Corticosteroid therapy was started for suspected secondary organizing pneumonia during persistent hypercapnic respiratory failure, followed by clinical improvement. The course was complicated by thrombocytopenia, pneumothorax, arrhythmia, plasma exchange-dependent hyperbilirubinemia, and amikacin-associated sensorineural hearing loss. Microbiological clearance was achieved, organ dysfunction progressively recovered, and first-line therapy was successfully reintroduced after stabilization. The patient was ultimately discharged without oxygen requirement and started a rehabilitation program. CONCLUSIONS: This case highlights that even life-threatening tuberculosis with multiorgan failure can be survivable. Early diagnosis, flexible adaptation of anti-TB therapy, and prolonged ECMO support within multidisciplinary care were key to clinical recovery.