CASE REPORT OF EXTENSIVELY DRUG-RESISTANT TUBERCULOSIS IN A PREGNANT PATIENT: THE COMPLEXITY OF CHOOSING ANTIMICROBIALS THAT CAN BE USED IN PREGNANCY IN A RESISTANCE SCENARIO

Extensively drug-resistant pulmonary tuberculosis (TB XDR) imposes a significant restriction on antimicrobial selection due to its resistance profile, and pregnancy makes this situation even more challenging due to additional restrictions related to the risk of fetal toxicity. Female patient, 31 years old, with a past history of pleural TB in 2018, diagnosed with pulmonary TB after presenting cough, dyspnea, chest pain, fever, and sweating for 6 months. Initial sputum sample showed resistance to rifampicin and isoniazid on first-line LPA, with no mutations on second-line LPA. Chest CT showed extensive cavitary lesions in the right lung and bilateral centrilobular micronodules. On 06/01/22, treatment for TB MDR was started with linezolid, terizidone, bedaquiline, and levofloxacin. Between 12/29/22 and 02/01/23, treatment was expanded with the addition of amikacin, pyrazinamide, and ethambutol to the regimen, and a right upper lobe lobectomy on 01/10/23 due to worsening cough and return of fever. Culture dated 01/10/23 showed resistance to quinolones and bedaquiline, and on 03/15/23 an XDR-TB regimen was started containing ethionamide, meropenem, amoxicillin-clavulanate, clofazimine, linezolid, amikacin, and delamanid. The patient returned on 07/12/23 with discovery of pregnancy at 6 weeks’ gestation, which led to a change in the therapeutic regimen with suspension of ethionamide and amikacin. Treatment with meropenem, amoxicillin-clavulanate, clofazimine, and delamanid was maintained until 03/13/2024, when it was modified to clofazimine, linezolid, and delamanid (after elective cesarean delivery). Treatment was completed on 08/26/2024, and the patient maintains good clinical and radiological response on follow-up 6 months after the end of treatment. Her child evolved without intercurrences in the first year of life. The described case illustrates the complexity of the clinical management of TB-XDR, especially in pregnant patients in whom multiple antimicrobials are considered category C or D and there are few studies on the safety of delamanid use. Favorable evolution was achieved through an individualized approach, combining second-line medications and a surgical approach. The report reinforces the importance of flexible protocols and integration among the multiprofessional team for therapeutic success in TB-XDR cases.