Multidrug-resistant tuberculous meningitis: Clinical problems and concentrations of second-line antituberculous medications

OBJECTIVE: TO describe a case of culture-proven multidrug-resistant tubercu lous (MDR-TB) meningitis, in which the patient survived long enough for cli nicians to adjust antituberculous therapy to second-line therapeutic agents . DESIGN: Case report. SETTING: Tertiary care hospital. PATIENT: Twenty-one-month-old girl with MDR-TB meningitis. INTERVENTIONS: Initial standard treatment failed. Subsequent treatment with second-line therapeutic agents including ciprofloxacin, cycloserine, etham butol, ethionamide, and rifabutin were given for approximately two years. C oncentrations of these drugs were measured in serum and cerebrospinal fluid in the presence and absence of meningeal inflammation. MAIN OUTCOME MEASURES/RESULTS: The patient survived for approximately two y ears after initiation of second-line anti-TB therapy. During this treatment , she developed a ventriculo-peritoneal shunt tunnel tract infection second ary to MDR-TB. CONCLUSIONS: All TB meningitis isolates for which the source case antibioti c susceptibility pattern is not known should be cultured and susceptibility tested using rapid broth techniques. Measurement and subsequent adjustment of therapeutic drug concentrations may optimize therapy with second-line a nti-TB drugs in TB meningitis. Better pediatric formulations and pharmacoki netic data for second-line and anti-TB therapeutic agents are needed.