Tuberculous meningitis is a serious form of tuberculosis affecting the meninges covering the brain and spinal cord. The clinical outcome is poor even when treated with conventional antituberculous drugs. Corticosteroids are commonly used in addition to antituberculous drugs for treating the condition. They help reduce swelling and congestion of the meninges, and thus decrease pressure inside the brain and the attendant risk of death or disabling residual neurological deficit among survivors. This review identified seven trials involving 1140 people that evaluated either dexamethasone or prednisolone given in addition to antituberculous drugs; only one trial was of high quality. Overall, the trials showed that corticosteroids help reduce the risk of death or a risk of death or disabling residual neurological deficit. Only one trial evaluated the effects of corticosteroids in HIV-positive people, but the effects were unclear. Given the results of the review, all HIV-negative people with tuberculous meningitis should receive corticosteroids, but more trials are needed in HIV-positive people.

This is a Cochrane review abstract and plain language summary, prepared and maintained by The Cochrane Collaboration, currently published in The Cochrane Database of Systematic Reviews 2010 Issue 7, Copyright © 2010 The Cochrane Collaboration. Published by John Wiley and Sons, Ltd.. The full text of the review is available in The Cochrane Library (ISSN 1464-780X).
This record should be cited as: Prasad K, Singh MB. Corticosteroids for managing tuberculous meningitis. Cochrane Database of Systematic Reviews 2008, Issue 1. Art. No.: CD002244. DOI: 10.1002/14651858.CD002244.pub3

Editorial Group: Infectious Diseases Group

This version first published online: July 24. 2000
Last assessed as up-to-date: November 14. 2007

Abstract

Background

Tuberculous meningitis, a serious form of tuberculosis that affects the meninges covering the brain and spinal cord, is associated with high mortality and disability among survivors. Corticosteroids have been used as an adjunct to antituberculous drugs to improve the outcome, but their role is controversial.

Objectives

To evaluate the effects of corticosteroids as an adjunct to antituberculous treatment on death and severe disability in people with tuberculous meningitis.

Search strategy

In September 2007, we searched the Cochrane Infectious Diseases Group Specialized Register; CENTRAL (The Cochrane Library 2007, Issue 3); MEDLINE; EMBASE; LILACS and Current Controlled Trials. We also contacted researchers and organizations working in the field, and checked reference lists.

Selection criteria

Randomized controlled trials comparing a corticosteroid plus antituberculous treatment with antituberculous treatment alone in people with clinically diagnosed tuberculosis meningitis and which include death and/or disability as outcome measures.

Data collection and analysis

We independently assessed search results and methodological quality, and independently extracted data. We analysed the data using risk ratios (RR) with 95% confidence intervals (CI) and the fixed-effect model. We also conducted complete-case and best-worst case analyses.

Main results

Seven trials involving 1140 participants (with 411 deaths) met the inclusion criteria. All used dexamethasone or prednisolone. Overall, corticosteroids reduced the risk of death (RR 0.78, 95% CI 0.67 to 0.91; 1140 participants, 7 trials). Data on disabling residual neurological deficit from three trials showed that corticosteroids reduce the risk of death or disabling residual neurological deficit (RR 0.82, 95% CI 0.70 to 0.97; 720 participants, 3 trials). Adverse events included gastrointestinal bleeding, bacterial and fungal infections and hyperglycaemia, but they were mild and treatable.

Authors' conclusions

Corticosteroids should be routinely used in HIV-negative people with tuberculous meningitis to reduce death and disabling residual neurological deficit amongst survivors. However, there is not enough evidence to support or refute a similar conclusion for those who are HIV positive.

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