Review Question - QID 110037

A 33-year-old immigrant from Bangladesh is evaluated by a primary care physician as a new patient. He immigrated from Bangladesh to the United States 1 month ago and lives with his extended family. He worked in a clothing factory in Bangladesh and has not been seen by a doctor in over 10 years. He reports that he has had a chronic cough for the past year that he attributes to smoking. He says that he feels well and has no complaints. He denies any past medical history and takes no medications. He smokes 2 packs of cigarettes per day. His temperature is 98.6°F (37°C), blood pressure is 120/75 mmHg, pulse is 105/min, and respirations are 20/min. On examination, he appears mildly cachectic with cervical lymphadenopathy. A purified protein derivative test leads to 12 mm of induration. A chest radiograph demonstrates an apical cavitary lesion. The patient is started on the standard medication regimen for his condition, including a medication that inhibits mycobacterial cell wall carbohydrate polymerization. Resistance to this medication is most likely to stem from which of the following processes?