Background: Drug-resistant tuberculosis (DR-TB) remains a major challenge in tuberculosis control, particularly among patients with recurrent disease and structural lung damage.

Objective: To describe the clinical presentation, resistance patterns, and management of recurrent rifampicin-resistant pulmonary tuberculosis in three patients treated at a tertiary TB center.

Methods: A retrospective case series of three adult male patients with microbiologically confirmed rifampicin-resistant tuberculosis admitted at a tertiary tuberculosis hospital in Mumbai. Clinical, radiological, and molecular diagnostic findings were analyzed along with treatment strategies under the National TB Elimination Programme.

Results: All three patients presented with chronic respiratory symptoms and prior tuberculosis history. Molecular testing confirmed rifampicin resistance in all cases, with two patients demonstrating additional fluoroquinolone resistance suggestive of Pre-XDR tuberculosis. Radiological findings showed fibrocavitatory lung disease and extensive structural damage. Individualized all-oral regimens including Bedaquiline, Linezolid, Delamanid, Cycloserine, and Clofazimine were initiated according to resistance profiles.