Abstract Introduction Healthcare workers (HCWs) in high TB-burden settings remain at elevated occupational risk for drug-resistant tuberculosis. We describe a case of MDR pulmonary and extrapulmonary TB involving mediastinal lymph nodes in a junior resident in India, treated with the WHO-endorsed all-oral BPaLM regimen. Case Presentation A 26-year-old previously healthy male resident presented with one month of persistent cough and mediastinal lymphadenopathy. CT chest showed perihilar patchy consolidation. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) of mediastinal lymph nodes yielded a wash culture positive for Mycobacterium tuberculosis, while bronchial wash was negative. MGIT culture confirmed M. tuberculosis resistant to isoniazid, rifampicin, ethambutol, and streptomycin, and susceptible to bedaquiline, linezolid, moxifloxacin, and kanamycin. Diagnosis: MDR mediastinal tuberculous lymphadenitis with radiographic pulmonary changes but no microbiologic pulmonary involvement. Intervention:The patient was initiated on 6-month BPaLM: bedaquiline (400 mg daily for 2 weeks, then 200mg three times weekly), pretomanid 200 mg daily, linezolid 600 mg daily, moxifloxacin 400 mg nightly, and pyridoxine supplementation. Toxicity surveillance included serial QTc, CBC, and neuropathy/visual assessments. Occupational restrictions maintained until non-infectious was achieved. Outcome He demonstrated symptom resolution by week 4 with stable hematologic parameters, 1kg weight gain and no severe neuropathy or QT prolongation. Adherence was supported through India’s NTEP digital and nutritional programs. Discussion This case highlights the importance of safe delivery of a shorter BPaLM regimen consistent with findings from Nix-TB, ZeNix, and TB-PRACTECAL trials. The discordance between the negative bronchial wash and positive EBUS-TBNA findings supports a diagnosis of nodal-predominant disease with minimal airway involvement and underscores the role of EBUS-TBNA in diagnosing extrapulmonary tuberculosis. As frontline HCW’s in India face high TB incidence, improved ventilation, N95 fit-testing, and occupational health surveillance are critical safeguards. Post-TB lung disease screening and airway evaluation should be incorporated into follow-up given common residual impairment. Conclusion BPaLM shows early clinical improvement with manageable toxicity in MDR extrapulmonary TB in a health care worker. Toxicity monitoring, strengthening adherence support, and occupational TB infection control programs is important to protect healthcare workers in places like India with high-burden countries. This abstract is funded by: None
Atoma et al. (Fri,) studied this question.