CRA24 MULTIDRUG-RESISTANT ABDOMINAL TUBERCULOSIS: MALAYSIA’S FIRST SUCCESSFUL CASE TREATED WITH BPALM REGIMEN

Wan Yi Leong, Umadevi A. Muthukumaru, Irfhan Hyder Ali, Jaya Muneswarao
Penang General Hospital, Malaysia

Introduction
The WHO 2022 guidelines and the updated 2025 consolidated guidelines recommend a 6-month oral BPaLM regimen for the treatment of MDR/RR-TB, including most extrapulmonary forms, with the exception of central nervous system, osteoarticular, and disseminated TB. However, the South African Clinical Management of Rifampicin-Resistant Tuberculosis (2023) excludes abdominal TB from BPaLM use due to insufficient supporting evidence. Here, we report Malaysia’s first successful case of primary abdominal MDR-TB treated with the BPaLM regimen.

Case Presentation
A 53-year-old Malay man, a habitual smoker and marijuana user with no known comorbidities, presented with three days of abdominal pain, constipation, and fever. Classical TB symptoms were absent. A contrast-enhanced CT of the abdomen and pelvis showed a rim-enhancing hypodense lesion in the right mesorectum. Colonoscopy and biopsy of the terminal ileum and rectum revealed Peyer’s patches and solitary rectal ulcer syndrome. Histopathology was negative for TB. A pigtail catheter drained the collection. Though acid-fast bacilli staining was negative, culture confirmed Mycobacterium tuberculosis resistant to isoniazid and rifampicin but sensitive to fluoroquinolones, ruling out pre-XDR TB. He was diagnosed with primary abdominal MDR-TB and treated with BPaLM: bedaquiline 400 mg daily for 2 weeks, then 200 mg three times weekly (Monday/Wednesday/Friday); pretomanid 200 mg daily; linezolid 600 mg daily; and moxifloxacin 400 mg daily. He completed six months of therapy without adverse events and had good clinical progression. Follow-up imaging confirmed resolution.

Discussion
The present case illustrates that with appropriate clinical oversight, BPaLM can be effective for abdominal MDR-TB, despite limited trial data and restrictive national guidelines. A shorter, all-oral regimen likely improved treatment adherence and minimized toxicity. This case underscores the importance of real-world evidence and supports expanding BPaLM use in extrapulmonary TB through future studies.