The patient is a 4-year-old boy from southern Africa who was hospitalized seven months ago after presenting with four months of cough, fever and generalized anasarca. His mother had a remote history of TB. He was hypoalbuminemic and anemic. Chest x-ray revealed a left upper lobe infiltrate along with bilateral hilar opacities. Hospital staff, however, could not obtain a sputum sample for microbiologic testing. The patient was diagnosed with presumed pulmonary TB based on his symptoms and abnormal chest imaging. He was discharged on a six-month course of isoniazid, rifampin and pyrazinamide and nutritional supplementation.

The patient did poorly over the next few months with worsening cough and failure to thrive. He was re-evaluated one month ago upon completing six months of Category I. Gastric lavage was AFB 3+ and culture grew M. tuberculosis. The DST showed resistance to isoniazid, rifampin ethambutol and streptomycin.

The patient was subsequently referred to your clinic for further management. He continues to have cough with associated shortness of breath. Fever has resolved.

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