DRUG-TREATMENT OF TUBERCULOSIS MENINGITIS IN CHILDREN - A PRACTICAL GUIDE

Tuberculosis meningitis is the most serious extrapulmonary complicatio n of tuberculosis and the commonest cause of death in childhood as a r esult of tuberculosis. Appropriate treatment must be started as soon a s a diagnosis of tuberculosis meningitis is suspected. The main aims o f the drug treatment of tuberculosis meningitis are the eradication of the causative organism Mycobacterium tuberculosis, the control of rai sed intracranial pressure, and modulation of the immune processes caus ing cerebral vasculitis and the associated exudate at the base of the brain, Isoniazid, rifampicin (rifampin) and pyrazinamide are essential drugs in the treatment of tuberculosis meningitis in dosages of 20 mg /kg/day, 20 mg/kg/day and 40 mg/kg/day, respectively. Lower dosages of isoniazid (10 mg/kg/day) and rifampicin (10 mg/kg/day) can be used if infectious hepatitis is a recognised problem in a particular geograph ical area, but a reduction in the dose of rifampicin may compromise it s sterilising capacity, If it is possible that the disease is caused b y drug-resistant organisms, the above regimen should br augmented by e thionamide 20 mg/kg/day or streptomycin 20 to 40 mg/kg/day. Treatment must be continued for a minimum of 6 months, but should be extended to 9 or 12 months if rifampicin cannot be used throughout and if pyrazin amide cannot be used for the first 2 months of treatment. Hydrocephalu s and raised intracranial pressure frequently complicate stage II and stage III tuberculosis meningitis. In the presence of communicating hy drocephalus, confirmed on air encephalogram by the appearance of air i n the ventricles, furosemide (frusemide) 1 mg/kg/day and acetazolamide 100 mg/kg/day given in 6- or 8-hourly divided doses will expedite the normalisation of intracranial pressure in the majority of cases. Vent riculo-peritoneal shunting should be undertaken immediately in those c hildren with non-communicating hydrocephalus, demonstrated on air ence phalogram by the presence of air at the base of the brain but not in t he ventricles, and in those children who do not respond satisfactorily to medical management. Corticosteroids, in the form of prednisone or dexamethasone, have been shown to improve both morbidity and mortality in tuberculosis meningitis. These drugs should be given for the first month of treatment.