Corticosteroids (dexamethasone versus intravenous methylprednisolone) in patients with tuberculous meningitis

As inflammatory changes play an important role in the neuropathogenesis of the disease, adjunctive corticosteroid treatment may be of benefit in tuberculous meningitis. In an open-label study in India, 97 patients with such meningitis were randomized into a control group, a dexamethasone group (with the drug given intravenously once a day for 4 weeks, and then orally, once daily, for another 4 weeks) and a methylprednisolone group (with the drug given intravenously once a day for 5 days). All the patients also received standard anti-tuberculosis drugs. The primary outcome measure was death or severe disability 6 months after the randomization, with a modified Rankin scale used to assess each patient's level of disability. The other outcome measures investigated were deterioration in vision, focal neurological deficits and new-onset seizures. Six patients (one of those given dexamethasone, three of those given methylprednisolone and two of those in the control group) were lost to follow-up. Although each corticosteroid was associated with a reduction in death or disability, this reduction did not reach statistical significance in either the dexamethasone group (relative risk of death=0.6, with a 95% confidence interval of 0.29-1.2; P>0.05) or the methylprednisolone group (relative risk of death=0.7, with a 95% confidence interval of 0.4-1.4; P>0.05), probably because of the small sample sizes. Among the patients who died within 10 months of randomization, the mean time to death (post-randomization) was 8.8 months in the dexamethasone group, 8.2 months in the methylprednisolone group, and 7.1 months in the control group (P>0.05). The prevalence of impaired vision, among all the patients evaluated, decreased from 41.8% at baseline to 29.9% (among the survivors) 6 months later. Adverse events were similar and equally reported in the two corticosteroid groups. Larger trials are still needed to determine if dexamethasone and/or methylprednisolone are useful in the treatment of tuberculous meningitis, at least in India.