LONG-TERM ANTICONVULSANT THERAPY IN TUBERCULOUS MENINGITIS - A 4-YEARFOLLOW-UP

A treatment protocol for long-term anticonvulsant therapy (ACT) in chi ldren with tuberculous meningitis (TBM) has been followed depending up on clinical characteristics and EEG/CT scan findings suggestive of the underlying cause of convulsions. Sixty-three children which included all patients with focal seizures (FS), and those with generalized toni c and clonic seizures (GTCS), and tonic spasms CTS) manifesting more t han once during hospitalization and/or associated with abnormal CT/EEG findings were given long-term ACT (Group A). Thirty-eight cases with GTCS before hospitalization, and/or not more than one seizure during f irst week of hospitalization and without any specific CT/EEG abnormali ties (Group B) and 35 cases without any seizures (Group C) did not rec eive any ACT. Forty-four patients who were finally discharged on long- term ACT, were given phenobarbitone (57 per cent), phenytoin (23 per c ent), and a combination of phenobarbitone + phenytoin (14 per cent), a nd phenobarbitone + sodium valproate (7 per cent). Follow-up was conti nued for 4 years with 93, 84 and 81 per cent attendance, respectively, in groups A, B and C. Some of the side-effects observed with anti-con vulsant drugs included gingival hypertrophy in 11 out of 16 cases (69 per cent) on phenytoin, hyperkinetic behaviour in 3 out of 34 (9 per c ent) cases on phenobarbitone, hypocalcaemia in 3 out of 44 cases (7 pe r cent), hypophosphataemia in 10 out of 44 cases (23 per cent) and inc rease in alkaline phosphatase in 14 out of 44 cases (32 per cent). CT scan of brain repeated in six cases with multiple tuberculomas showed marked improvement. While 4 out of 41 (10 per cent) cases in group A h ad recurrence of seizures in the follow-up, only 2 out of 28 cases (7 per cent) in group B presented with GTCS during first 3 months after d ischarge which was successfully controlled by long-term ACT in later p art of the follow-up. Two out of 21 cases (10 per cent) in group C als o presented with myoclonic seizures 3 and 5 months after discharge. Th ere was no statistically significant difference in the recurrence/appe arance of seizures in the three groups (P = > 0.05). Our results sugge st that long-term ACT is not indicated in all cases of TBM with seizur es. In view of the known side-effects of anticonvulsant drugs and dang er of interaction with antitubercular drugs, it is mandatory to clinic ally evaluate the patients, identify the cause and restrict long-term ACT only to those cases who are likely to have some abnormal focus res ulting in secondary epilepsy. All the cases with FS and some of the pa tients with GTCS and TS may need to be started on ACT. However, a clos e follow-up is necessary in all particularly in those for whom ACT has been withheld.