Fazal-e-Rabi Subhani
The Rotunda Hospital, Ireland
Title: Role of adjunctive glucocorticoid therapy in central nervous system tuberculosis
Biography
Biography: Fazal-e-Rabi Subhani
Abstract
Introduction: Central nervous system (CNS) tuberculosis (TB) is a frequently encountered infection in the regions of the world where the prevalence of post-primary dissemination is common among children & adults. It includes three clinical categories: tuberculous meningitis, intracranial tuberculoma, & spinal tuberculous arachnoiditis. In CNS TB intense hypersensitivity reaction with consequent significant inflammatory changes are known to develop in the subarachnoid space due to the spillage of tubercular protein explaining the potential need for adjunctive glucocorticoid therapy to help reduce the case-fatality ratio, which over years have remained relatively high (15-40%) despite effective antimicrobial regimens.
Method: A comprehensive search of PubMed & EMBASE from their inceptions to October 2019 was made using 3 search items: glucocorticoid therapy, tuberculous meningitis, & intracranial pressure. The search items were combined using the Boolean operator. A further search was made of the United States Centres for Disease Control & Prevention (CDC), Cochrane Database Syst Rev, World Health Organization guidelines, & ClinicalTrials.gov with no language restriction.
Results: Randomized control trials (RCTs) have demonstrated a mortality benefit when adjunctive glucocorticoid therapy is used in HIV-uninfected CNS TB patients. Since data in HIV-infected patients is sparse, the same mortality benefit has not been reproduced thus far in such cases. In a systemic review including nine trials (1337 patients with CNS TB), adjunctive glucocorticoid therapy was associated with a lower mortality rate (risk ratio 0.75, 95% CI 0.65-0.87). In a RCT from Vietnam (545 patients with CNS TB), lower mortality rate was observed in patients who received dexamethasone (32 versus 41 percent; relative risk 0.69, 95% CI, 0.52-0.92). In a RCT from South Africa (141 children with CNS TB), lower mortality rate was observed in patients who received prednisolone (4 versus 17 percent). Additionally, children who received steroid therapy were more likely to have subsequent IQ >75 (52 versus 33 percent).
Conclusion: There is good quality evidence now available supporting the use of adjunctive glucocorticoid therapy in patients with CNS TB (confirmed or suspected). Reducing doses of first intravenous (IV) Dexamethasone for one month & then oral for one month remains the regimen of choice: 0.3-0.4 mg/kg/day IV x 2 weeks, then 0.2 mg/kg/day x 1 week, then 0.1 mg/kg/day x 1 week, then 4 mg/day orally x 1 week tapering 1 mg off the daily dose each week thereafter (total duration approximately two months).