Diagnosis and Therapeutic Challenges of Drug-Resistant Tuberculosis Infection After Kidney Transplantation: A Rare Case Report.

Background: Kidney transplant recipients are at high risk for tuberculosis (TB), particularly drug-resistant forms, due to prolonged immunosuppressive therapy. The diagnosis and treatment of TB in this population pose unique challenges, including infection control, graft protection, and drug interactions. Case Presentation: We report the case of a 28-year-old male kidney transplant recipient was diagnosed with pulmonary TB four months post-transplantation. The patient self-discontinued initial anti-TB therapy after one month, leading to relapse nine months later, with confirmed rifampicin resistant. Following three months of treatment with a second-line regimen including linezolid, he developed disseminated skeletal TB, with drug susceptibility testing indicating linezolid resistance. The treatment was adjusted to an all-oral regimen including isoniazid, moxifloxacin, clofazimine, cycloserine, and bedaquiline, resulting in significant clinical and radiological improvement. Discussion: In the present case, the patient's non-adherence to the medication regimen resulted in initial treatment failure. Against the backdrop of immunosuppression, rifampicin resistance emerged rapidly. Although the subsequent linezolid-containing regimen was administered for a short duration, it likely triggered ribosomal target mutations-leading to linezolid resistance and hematogenous dissemination to the bone-driven by both drug selection pressure and the history of irregular treatment. Confronted with dual resistance and disseminated disease, the therapeutic strategy pivoted to a bedaquiline-based regimen. This shift highlights the clinical management art of finely balancing treatment efficacy with the risk of rejection through the optimized adjustment of immunosuppressants guided by therapeutic drug monitoring. Conclusion: The management of drug-resistant tuberculosis in kidney transplant recipients necessitates a flexible and comprehensive strategy. This encompasses early clinical suspicion, the prompt performance of molecular and phenotypic drug susceptibility testing to guide therapeutic decisions, rigorous management of treatment adherence, and the real-time adjustment of therapeutic regimens based on evolving resistance profiles and clinical responses. Multidisciplinary collaboration is essential for balancing anti-tuberculosis efficacy with graft survival. Although novel agents such as bedaquiline offer promising options for salvage therapy, their administration in transplant recipients requires intensified monitoring for drug-drug interactions and adverse events.