Successful treatment of pre-extensively drug-resistant tuberculous meningoencephalomyelitis in pregnancy with a bedaquiline and delamanid-based regimen: a case report

BACKGROUND: Management of pre-extensively drug-resistant tuberculosis (pre-XDR-TB) during pregnancy poses a formidable clinical challenge, particularly when complicated by tuberculous meningoencephalomyelitis (TBMEM), While the WHO operational handbook provides a general framework for drug-resistant TB, robust evidence and specific guidelines for managing severe CNS involvement in pregnancy remain limited. CASE PRESENTATION: We report the successful outcome for a mother and infant in an extremely high-risk case. The patient, at 17 + 6 weeks of gestation following in vitro fertilization (IVF), was diagnosed with pre-XDR-TB. Hematogenous dissemination was confirmed by chest CT showing diffuse miliary nodules, and spinal MRI confirmed meningoencephalomyelitis. Her clinical course was complicated by life-threatening conditions, including TB-associated sepsis (TB-Sepsis) and severe neurological immune reconstitution inflammatory syndrome (Neuro-IRIS) presenting as an intracranial hypertensive crisis. An individualized, multidisciplinary approach centered on a bedaquiline (Bdq) and delamanid (Dlm)-based regimen was implemented. The patient’s condition was effectively controlled, and she delivered a healthy female infant at 35 + 1 weeks of gestation. Both mother and infant recovered well. CONCLUSIONS: This case demonstrates that a carefully monitored Bdq/Dlm-based regimen can be a life-saving option for severe DR-TB in pregnancy. It also underscores the critical need for systematic TB screening prior to assisted reproductive technology (ART) in high-burden regions.