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Introduction <p>Spinal tuberculosis (Pott’s spine) is the most severe form of musculoskeletal TB and, if inadequately treated, can result in permanent deformity and/or paraparesis. While most patients respond well to standard first-line anti-tubercular therapy (ATT), a subset may show early clinical or radiological worsening. Potential causes include paradoxical reactions, drug resistance, poor adherence, malabsorption, or pharmacokinetic variability leading to subtherapeutic drug levels. Furthermore, male patients are especially at risk of poorer treatment outcomes, underscoring the importance of individualized management. Lack of improvement in the first two months of ATT warrants careful evaluation for these possibilities.</p> Case Description <p>A 45-year-old male with L1–L2 tuberculous spondylodiscitis, confirmed on cartridge-based nucleic acid amplification test (CBNAAT), was started on weight based first-line ATT. He initially improved but experienced worsening back pain at two months, with MRI showing disease progression. Adherence was confirmed, and rifampicin resistance was excluded. Therapeutic drug monitoring (TDM) revealed subtherapeutic serum concentrations of isoniazid and rifampicin, likely related to pharmacokinetic variability. Dose escalation tailored to achieve therapeutic drug levels led to significant clinical improvement and MRI-documented resolution of lesions.</p> Conclusion <p>This case illustrates how therapeutic drug monitoring can identify subtherapeutic drug levels in tuberculosis, enabling timely dose optimization and preventing unwarranted second-line therapy.</p>

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Therapeutic Drug Monitoring in the Management of Clinical Worsening in Spinal Tuberculosis- A Case Report

  • 期刊论文

  • 发表日期：

    2025年9月17日

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  • Neeraj Sharma,
  • Sanjay Kumar Panda,
  • Robin Chaudhary,
  • Debasheesh S. R. Das,
  • Puneet Saxena,
  • Prateek Chiyyarath Muralidharan

摘要

Introduction

Spinal tuberculosis (Pott’s spine) is the most severe form of musculoskeletal TB and, if inadequately treated, can result in permanent deformity and/or paraparesis. While most patients respond well to standard first-line anti-tubercular therapy (ATT), a subset may show early clinical or radiological worsening. Potential causes include paradoxical reactions, drug resistance, poor adherence, malabsorption, or pharmacokinetic variability leading to subtherapeutic drug levels. Furthermore, male patients are especially at risk of poorer treatment outcomes, underscoring the importance of individualized management. Lack of improvement in the first two months of ATT warrants careful evaluation for these possibilities.

Case Description

A 45-year-old male with L1–L2 tuberculous spondylodiscitis, confirmed on cartridge-based nucleic acid amplification test (CBNAAT), was started on weight based first-line ATT. He initially improved but experienced worsening back pain at two months, with MRI showing disease progression. Adherence was confirmed, and rifampicin resistance was excluded. Therapeutic drug monitoring (TDM) revealed subtherapeutic serum concentrations of isoniazid and rifampicin, likely related to pharmacokinetic variability. Dose escalation tailored to achieve therapeutic drug levels led to significant clinical improvement and MRI-documented resolution of lesions.

Conclusion

This case illustrates how therapeutic drug monitoring can identify subtherapeutic drug levels in tuberculosis, enabling timely dose optimization and preventing unwarranted second-line therapy.