An Uncommon Case of Recurring Pulmonary, Lymphatic, and Skeletal Tuberculosis Accompanied by Myositis: Is It Associated with Particular Resistance?

Abstract: Tuberculosis (TB) remains one of the primary causes of illness and death worldwide. Indonesia ranks second globally in TB incidence. Recurrent or relapsed TB, especially with multifocal involvement, presents significant diagnostic and therapeutic challenges, often complicated by incomplete treatment and limited molecular diagnostic capacity in developing countries. We present the case of a 26-year-old woman with a history of pulmonary, lymphatic, and skeletal tuberculosis who developed recurrence shortly after completing a 12-month anti-tuberculosis regimen (August 2024–July 2025) that excluded pyrazinamide due to gastrointestinal intolerance. She presented again in September 2025 with right-sided chest pain, productive cough, and cervical lymphadenopathy. Chest radiography revealed bilateral infiltrates, and abdominal ultrasonography suggested tuberculous myositis. The pulmonary findings, positive GeneXpert MTB/RIF Ultra result, and cervical lymph node biopsy confirming caseating granulomatous lymphadenitis were identified during the initial emergency department admission, while pus culture from the osteomyelitis lesion grew Staphylococcus aureus . The abdominal findings, including a left iliopsoas abscess with involvement of the iliacus muscle suggestive of tuberculous myositis, were detected later during outpatient follow-up evaluation, after the patient continued to experience persistent abdominal pain. The patient subsequently underwent a second course of treatment with a complete first-line anti-tuberculosis regimen combined with additional antibiotic therapy, which resulted in significant clinical improvement. In a follow-up, it was surprising that the sequence analysis of a 561 bp fragment of rpoB showed a single nucleotide deletion in comparison to the reference sequence. A six-month treatment regimen (BPaLM) has been planned as the selected regimen. This case illustrates the complexity of managing recurrent multifocal TB and underscores the need for rapid and comprehensive molecular diagnostic tools. Keywords: tuberculosis recurrence, multifocal, anti-TB regimen, GeneXpert MTB/RIF, sequencing