The First Extensively Drug-Resistant (XDR) Tuberculosis Patient Diagnosed in Malawi – a Case Report

George C. Talama¹, Bright Kadyeremwana¹, Charles Kwenje², Sosten Mtalika³, Billy Banda⁴, Tisungane Mwenyenkulu³, Kuzani Mbendera³, Sam Phiri^1,5, Joep J van Oosterhout^1,6

1. Partners in Hope, Malawi.
2. Chikwawa District Council, Malawi.
3. National TB and Leprosy Elimination Program, Ministry of Health and Sanitation, Malawi.
4. Public Health Institute of Malawi, Ministry of Health and Sanitation, Malawi.
5. School of Global and Public Health, Kamuzu University of Health Sciences, Lilongwe, Malawi.
6. University of California Los Angeles, Department of Medicine, David Geffen School of Medicine, United States.

• Corresponding Author: George Complex Talama; E-mail: gtalama@pihmalawi.com/gctalama@gmail.com

Abstract
We report the first case of extensively drug-resistant (XDR) TB diagnosed in Malawi. A 43-year-old female living with HIV, on tenofovir-lamivudine-dolutegravir antiretroviral therapy, with long-term viral suppression, accumulated resistance to rifampicin, levofloxacin, and linezolid on successive TB treatment regimens between 2018 and 2024, qualifying as XDR-TB. Throughout treatment as an outpatient, she regularly missed TB visits and reported poor TB drug adherence, mainly related to alcohol abuse and inconsistent availability of funds for transport. After XDR-TB diagnosis, the patient, guardians, treatment providers, and health facility leadership agreed to management as an inpatient in August 2024, when she started an 18-month regimen of bedaquiline-delamanid-cycloserine-clofazimine-pyrazinamide, with good treatment outcome. The emergence of XDR-TB in Malawi calls for further scale-up of TB resistance testing and structured approaches to improving drug adherence among drug-resistant TB patients.

Keywords: Tuberculosis, Drug-resistance, XDR-TB, Adherence, Malawi