Treatment of TB of the brain: drugs, antibiotics

Current World Health Organization (WHO) guidelines recommend treatment with four antibiotics:

• isoniazid 10-15 mg/kg/day.
• rifampicin 10-20 mg/kg/day
• pyrazinamide 30-40 mg/kg/day
• ethambutol 15-25 mg/kg/day

All are taken in combination for 2 months, followed by a regimen of two more drugs, isoniazid and rifampicin. This two-combination regimen is given for 10 months.

The total duration of treatment is therefore 12 months.

Liver function should be monitored during this period, especially at the beginning of treatment.

In developing countries, the lack of effective antibiotics can be a problem. But even in modern countries, effective treatment of tuberculous meningitis is compromised.

Mycobacterial resistance to certain drugs is a problem. It is also called multidrug resistance (MDR).

When multidrug resistance (MDR) is suspected, the drug of choice is quinolone and cycloserine or terizadone.

Great effort must be made to obtain a sample of bacteria directly from the liquor to test the pathogen's susceptibility to the antibiotic in question.

Corticosteroids are especially recommended for the treatment of children with tuberculous meningitis because of the marked symptoms from increased intracranial pressure, which glucocorticoids reduce.

They are given at a daily dose of 2 mg/kg. For example, prednisone (max 60 mg/day) is used for the first month of treatment and the dose is then gradually reduced.

Corticosteroids, among other things, improve the integrity of the blood-brain barrier, which is damaged by inflammation and penetrating bacteria.

Hydrocephalus is a relatively common complication of tuberculous meningitis. Hydrocephalus is treated surgically. Surgery is appropriate for patients with non-communicating hydrocephalus who are in immediate danger of death due to cerebellar herniation (protrusion of the cerebellum through the lower cerebral opening).

Even with proper antituberculous treatment, repeated CT and MRI scans can often show progressive inflammatory changes in the brain. New granulomas and infarcts are likely to form, which are probably immune-mediated.

They respond well to corticosteroids and the chemotherapeutic drug thalidomide. Thalidomide is also effective in preventing blindness due to progressive optochymatous arachnoiditis, a complication of tuberculous meningitis.