Congenital multidrug-resistant tuberculosis (MDR-TB) in an extremely low birth weight neonate: diagnostic challenges, management and a narrative review.

BACKGROUND: Congenital tuberculosis(TB) is rare and often fatal, particularly with multidrug-resistant strains. Neonatal diagnosis is challenging due to nonspecific features and low-yield microbiology. Management in extremely preterm infants is further complicated by limited evidence on second-line drug dosing, safety, and monitoring. METHODS: We describe a single patient case alongside a narrative review of the relevant literature. Literature search was conducted in major databases using predefined keywords. Reports describing congenital/presumed congenital drug-resistant tuberculosis in neonates or young infants were selected, and data concerning maternal disease, neonatal presentation, diagnosis, treatment, and outcome were extracted. RESULTS: We report a rare case of congenital disseminated multidrug-resistant tuberculosis (MDR-TB) in a preterm neonate born to a mother later confirmed to have katG-mediated isoniazid, and rifampicin resistance.Accompanying narrative review idenntified eight neonatal drug‑resistant cases worldwide, demonstrating consistent themes of:maternal disseminated/extrapulmonary TB as the predominant risk factor, symptom onset typically between 2-4 weeks of life, frequent initial false-negative/partially informative resistance results on early CBNAAT, and improved outcomes with early repeat molecular testing and tailored MDR-regimens.Mortality remains high, particularly when diagnosis is delayed.In contrast, our infant showed steady clinical recovery without any major drug-related toxicities.At 12 months corrected age, neurodevelopment was normal.. On telephone follow-up at 2 years of age, the caregivers reported that the child was developmentally well and thriving. CONCLUSION: This case highlights the diagnostic and therapeutic challenges of congenital disseminated MDR-TB in extremely preterm infants, where evidence is limited. To our knowledge, this is only the second preterm infant with MDR-TB to survive without neurological deficits and the first reported case of disseminated congenital MDR-TB with TB meningitis. Narrative review consolidates current evidence to guide clinicians facing similar high-risk scenarios.