Case Report: Pre-Extensively Drug-Resistant Tuberculosis of the Spine in a Young Adult

Overview

This case report details a 32-year-old Indian male diagnosed with pre-extensively drug-resistant tuberculosis (pre-XDR-TB) of the spine, presenting with neurological symptoms and extensive vertebral involvement. Diagnosis was confirmed through microbiological and molecular testing, guiding a complex multidrug treatment regimen resulting in neurological recovery.

Background

Spinal tuberculosis (Pott’s disease) is an extrapulmonary form of TB caused by Mycobacterium tuberculosis, often resulting from hematogenous spread and characterized by slow progression leading to diagnostic delays. Pre-XDR-TB involves resistance to isoniazid, rifampicin, and any fluoroquinolone, complicating treatment. Diagnosis is challenging due to paucibacillary lesions and limited resistance testing availability. This report highlights the importance of microbiological confirmation and expert-guided therapy in managing pre-XDR spinal TB.

Data Highlights

Key Findings

• Patient presented with progressive gait instability, sensory loss, and back pain with constitutional symptoms but no pulmonary TB signs.
• Imaging revealed osteolytic collapse at T3 with multiple vertebral lesions and spinal cord compression.
• Histology showed necrotizing granulomatous inflammation; acid-fast bacilli detected on smear microscopy.
• Rapid molecular tests confirmed M. tuberculosis complex with rifampicin, isoniazid, and fluoroquinolone resistance, consistent with pre-XDR-TB.
• Whole genome sequencing identified multiple resistance-conferring mutations, guiding tailored multidrug therapy including amikacin, bedaquiline, linezolid, cycloserine, ethionamide, and later delamanid and pyrazinamide.
• Patient tolerated treatment well, achieved full neurological recovery, and remains on prolonged therapy with close clinical and laboratory monitoring.

Clinical Implications

This case underscores the necessity of early microbiological diagnosis and comprehensive drug susceptibility testing in spinal TB to guide effective treatment, especially in drug-resistant cases. Multidisciplinary management including surgical intervention and expert consultation is critical. Prolonged, individualized multidrug regimens with vigilant monitoring can lead to favorable outcomes despite complex resistance patterns.

Conclusion

Pre-extensively drug-resistant spinal tuberculosis presents significant diagnostic and therapeutic challenges requiring prompt microbiological confirmation and expert-guided individualized treatment. Successful management hinges on integrating surgical, pharmacological, and monitoring strategies to achieve neurological recovery and disease control.

References

1. WHO 2023 -- Global Tuberculosis Report
2. Yadav et al. 2023 -- Primary Drug Resistance in Spinal Tuberculosis
3. Cepheid -- GeneXpert MTB/RIF Ultra and MTB/XDR Assays