Drug treatment of tuberculosis meningitis in children. A practical guide
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 pyrazinamide cannot be used for the first 2 months of treatment. Hydrocephalus and raised intracranial pressure frequently complicate stage II and stage m tuberculosis meningitis. In the presence of communicating hydrocephalus, confirmed on air encephalogram by the appearance of air in 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. Ventriculo-peritoneal shunting should be brain but not in the ventricles, in those children with non-communicating hydrocephalus, demonstrated on air encephalogram by the presence of air at the base of the brain but not in the ventricles, and in those children who do not respond satisfac torily 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. Tuberculosis meningitis is the most serious extrapulmonary complication of tuberculosis and the commonest cause of death in childhood as a result of tuberculosis. Appropriate treatment must be started as soon as a diagnosis of tuberculosis meningitis is suspected. The main aims of the drug treatment of tuberculosis meningitis are the eradication of the causative organism Mycobacterium tuberculosis, the control of raised intracranial pressure, and modulation of the immune processes causing 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 geographical area, but a reduction in the dose of rifampicin may compromise its sterilising capacity. If it is possible that the disease is caused by drug-resistant organisms, the above regimen should be augmented by ethionamide 20 mg/kg/day or streptomycin 20 to 40 mg/kg/day.