An interesting case of rifampicin-dependent/-enhanced multidrug-resistant tuberculosis

We report a case of rifampicin (RMP) dependent/enhanced multidrug-resistant (MDR-TB) from a patient who had been treated with the World Health Organization optional thrice-weekly treatment and document the clinical and bacteriological features. RMP-enhanced tubercle bacilli that grew poorly without RMP but grew better in its presence were isolated from the patient with treatment failure. The bacteria grown without RMP consisted of mixed morphologies of short rod-shaped acid-fast bacteria and poorly stained coccoid bacteria, but stained normally as acid-fast rods when grown in the presence of RMP. The isolated RMP-enhanced bacteria harbored the common S531L mutation and a novel mutation F584S in the rpoB gene. Treatment containing RMP or replacement of RMP with more powerful rifapentine paradoxically aggravated the disease, but its removal led to successful cure of the patient. This study highlights the potential dangers of continued treatment of MDR-TB with rifamycins that can occur due to delayed or absent drug susceptibility results and calls for timely detection of RMP-dependent/-enhanced bacteria in treatment failure patients by including RMP in culture media and removal of RMP from treatment regimen upon detection.