Steroid Regimen for TB Meningitis in MRC Grade 1
Adjunctive corticosteroid therapy with dexamethasone is strongly recommended for all patients with tuberculous meningitis, including those with MRC grade 1 (alert patients), with dexamethasone 12 mg/day for adults given for 3 weeks and then tapered over the following 3 weeks. 1, 2
Recommended Steroid Regimen
Adult Dosing
- Initial dose of dexamethasone: 12 mg/day for adults 1, 2
- Administration: Preferably intravenous for the first 3 weeks 2, 3
- Duration: Initial dose for 3 weeks, then gradually decreased over the following 3 weeks (total 6 weeks of therapy) 1, 2
- Alternative option: Prednisolone 60 mg/day, gradually tapered over 6-8 weeks 1, 2, 4
Pediatric Dosing
- For children weighing less than 25 kg: Dexamethasone 8 mg/day 1, 2
- For children weighing 25 kg or more: Dexamethasone 12 mg/day (same as adult dose) 1, 2
- Same duration and tapering schedule as adults 1
Evidence Supporting Steroid Use in MRC Grade 1
While the evidence specifically for MRC grade 1 patients is limited, the American Thoracic Society, CDC, and Infectious Diseases Society of America strongly recommend adjunctive corticosteroid therapy for all patients with tuberculous meningitis based on moderate certainty evidence 1, 2.
- In the study by Girgis et al., there were too few patients with Stage I disease (alert) to determine the effectiveness of dexamethasone specifically for this less severely ill group 1
- However, guidelines recommend corticosteroids for all patients with TB meningitis regardless of severity grade 1, 2
- A systematic review found a mortality benefit from the use of adjuvant corticosteroids in TB meningitis 1
Concurrent Anti-TB Treatment
- Initial phase: Isoniazid (INH), rifampin (RIF), pyrazinamide (PZA), and ethambutol (EMB) for 2 months 1
- Continuation phase: INH and RIF for an additional 7-10 months (total 9-12 months) 1, 2
- Parenteral forms of INH, RIF, aminoglycosides, capreomycin, and fluoroquinolones are available for patients with altered mental status 1
Monitoring Recommendations
- Regular monitoring of cerebrospinal fluid parameters through repeated lumbar punctures, especially early in the course of therapy 1, 2
- Monitor for changes in CSF cell count, glucose, and protein 1
- Watch for development of tuberculomas during therapy, which may represent a paradoxical reaction rather than treatment failure 1
- Be alert for potential complications requiring neurosurgical referral (hydrocephalus, tuberculous cerebral abscess) 1
Important Considerations and Pitfalls
- Corticosteroids should be initiated before or concurrently with the first dose of anti-tuberculosis medication for maximum benefit 2, 5
- Symptoms of CNS inflammation may recur if the corticosteroid taper is implemented too soon or too fast 4
- For patients who worsen after shifting to oral steroids, reinitiate IV steroids until sustained improvement, then overlap with oral steroids for 7-10 days during taper 3
- Recent research suggests that patients with basal exudates and tuberculoma may be candidates for earlier transition from IV to oral steroids 3
- While some studies have explored intrathecal dexamethasone with isoniazid as an adjunctive therapy with promising results, this approach is not yet included in major guidelines 6