Multidrug resistant tuberculosis (MDR) and Covid-19 infection in a 4-year-old boy

Background: MDR tuberculosis in young children is a rare infection and difficult to treat. Experience with co-infections by SARS-Cov-2 is limited and not covered by guidelines, although this can lead to life-threatening conditions. Case report: In 2022 a 2-year-old boy was diagnosed with latent tuberculosis (TB). A Mycobacterium (M.) tuberculosis strain resistant to isoniazid and rifampicin was isolated from the index patient. Due to an unappealing taste, he refused the intake of medication (levofloxacine and clofamizimine). Attempts to increase compliance (switching from levofloxacine to moxifloxacine or ameliorating the taste with aromas) were not successful. A chest x-ray 5/24 showed a space occupying lesion in the right upper lung in the 4-year-old without any physical complaints. The CT guided needle aspiration of a thoracal lymph node revealed M. tuberculosis (PCR) resistant to rifampicin. To ensure compliance to therapy (levofloxacin, linezolid, bedaquiline, clofamizimine) a PEG (percutanous enterogastric tube) was established. In 10/24 he presented with a sore throat, vomiting and a SARS-CoV-2 positive swab. Laboratory tests revealed sings of severe bacterial infection (WBC 31,33 x 10 3 /µl (neutrophils 73%), CRP 206,3 mg/l, Procalcitonin 4,95 ng/ml. Piperacillin/Tazobactam and remdesivir (for 5 days) was started. On day 2, clinical deterioration (differential diagnosis: capillary leak syndrome vs. miliary TB): antibiotics were switched to meropenem. Tuberculostatics were escalated to a doubled dose of levofloxacin and additionally amikacin iv. Moreover, prednisolone was started. On day 3 referral to ICU with respiratory decompensation: pleural effusion (transudate) additionally myocardial effusion. There was no evidence of involvement of the CNS (lumbar puncture, CT scan), abdomen or urogenital tract of TB. The course of the illness was interpreted as Paediatric Inflammatoric Multisystem Disorder. He received iv immunoglobulines on day 6 and was discharged on day 11. After 1 year of treatment with levofloxacin, linezolid, bedaquiline, clofazimine MRT chest revealed substantially regredient consolidation and therapy was stopped. Control chest x-ray 6 months after termination of therapy showed no progression of disease. Conclusion: Co-infection with SARS-CoV-2 in active TB may lead to an unbalanced immune response with life-threatening consequences. In children with active TB, vaccination against seasonal diseases such as COVID-19 should be considered. Publication History Article published online: 26 February 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany