Initial experience with BPaL-based regimens to treat multidrug-resistant TB

Initial experience with BPaL-based regimens to treat multidrug-resistant TB Dear Editor, We read with interest the recent article on the latest WHO guidelines on drug-resistant TB. 1 The recommendation to implement all-oral regimens containing bedaquiline, pretomanid and linezolid (BPaL) is based on studies conducted in high-incidence settings, as data from low-incidence settings is scarce.Here, we report the first four HIV-negative patients with genotypically proven multidrug-resistant TB (MDR-TB), treated with BPaL-based regimens.The study was conducted at the Boston Medical Center (BMC)/ Boston Public Health Commission (BPHC) TB clinic in Boston, MA, USA (Table ).Patient 1 was a 23 year-old female, Xpert V R MTB/Rif (Cepheid, Sunnyvale, CA, USA) positive for TB, with evidence of rifampin resistance.Bedaquiline (BDQ) 400 mg was administered daily for 8 weeks, followed by 200 mg 3x weekly for another 18 weeks, linezolid (LZD) 600 mg daily and pretomanid (Pa) 200 mg daily.Near complete resolution of upper lobe infiltrates was noted at 26 weeks of therapy without any complications.Patient 2 was a 29 year-old male, whose screening revealed an abnormal chest radiograph.Xpert MTB/Rif was positive for TB with evidence of rifampin resistance.BDQ, LZD (600 mg daily) and Pa were started.The patient completed 26 weeks of treatment without any complications.Patient 3 was a 38 year-old male from India with subacute left axillary lymphadenopathy.Computed tomography (CT) showed 4 4 cm necrotic mass, but no pulmonary infiltrates.CT guided biopsy showed necrotizing granulomas and Mycobacterium tuberculosis was detected using real-time polymerase chain reaction.BDQ, LZD (600 mg daily), Pa and moxifloxacin (MFX) 400 mg were started.Repeated CT scan at 16 weeks showed improved left axillary mass to 1 1 cm.Treatment was complicated by development of bilateral lower extremity neuropathy at Week 20.LZD trough level was elevated at 7 ug/mL; thus, dosage was decreased to 300 mg and discontinued at Week 24 due to the persistence of neuropathic symptoms.The patient completed 26 weeks of therapy with resolution of left axillary mass.Symptoms of neuropathy improved but persisted 3 months after therapy completion.Patient 4 was a 29 year-old female, whose screening revealed a positive interferon-gamma release assay result.The patient reported previous pulmonary TB, treated with a 6-month course 3 months prior to evaluation.Xpert MTB/Rif was positive with evidence of rifampin resistance.