Treatment of Cerebral Tuberculosis
For cerebral tuberculoma without meningitis, a 12-month regimen of rifampicin and isoniazid, supplemented by pyrazinamide and a fourth drug for at least the first two months is recommended. 1
Treatment Regimen
Initial Phase (First 2 Months)
- Rifampicin (10 mg/kg, up to 600 mg daily) 1
- Isoniazid (5 mg/kg, up to 300 mg daily) 1
- Pyrazinamide (35 mg/kg, up to 2 g daily) 1
- Ethambutol (15 mg/kg daily) or streptomycin as the fourth drug 1
Continuation Phase (10 Additional Months)
- Rifampicin and isoniazid for a total treatment duration of 12 months 1
Drug Selection Considerations
- Isoniazid, pyrazinamide, and prothionamide/ethionamide penetrate well into the cerebrospinal fluid 1
- Rifampicin penetrates less well into the cerebrospinal fluid but is a critical component of the regimen 1, 2
- Streptomycin and ethambutol only penetrate in adequate concentrations when the meninges are inflamed in the early stage of treatment 1
- Intrathecal administration of streptomycin is unnecessary 1
Corticosteroid Therapy
- Corticosteroids are recommended for more severe disease (stages II and III) 1
- High-dose corticosteroid treatment (prednisolone 60 mg/day initially, tapered over several weeks) has shown clear benefit 1
Special Considerations
Drug Resistance
- If pyrazinamide is omitted or cannot be tolerated, treatment should be prolonged to 18 months 1
- For suspected drug resistance, treatment must be individualized based on susceptibility studies 3
- In cases of MDR-TB, consultation with a tuberculosis expert is recommended 3
Ethambutol Use
- Although the risk of ocular toxicity at a dosage of 15 mg/kg is very small, ethambutol should be used with caution in unconscious patients as visual acuity cannot be tested 1
- The fourth drug in the initial phase can be streptomycin, ethambutol, or ethionamide 1
Monitoring
- Response to therapy should be monitored clinically and with neuroimaging 1
- Careful attention should be paid to measures designed to foster compliance and to ensure that patients take the drugs as prescribed 4
Emerging Evidence
- Recent research suggests that intensified treatment with higher doses of rifampicin (13 mg/kg intravenously) during the first two weeks may improve survival in severe cases 5
- The addition of moxifloxacin has also shown promise in improving outcomes in tuberculous meningitis 5
Pediatric Considerations
- Children with tuberculous meningitis should be treated for a minimum of 12 months with rifampicin and isoniazid, with an initial two months of pyrazinamide and a fourth drug (streptomycin or ethambutol) 1
- Dosages should be adjusted according to weight and may need to be recalculated with weight gain 1
- Supplemental pyridoxine is not necessary except for breast-fed infants and malnourished children 1