Tuberculous meningitis: Special features of treatment

Abstract

Summary The management of tuberculous, meningitis is controversial mainly because its treatment is prolonged and difficult. As a result continued attempts are being made to simplify the regime, and the results are often good. This is the reason for the exclusion or curtailment of intrathecal therapy, for the general use of corticosteroids with systemic chemotherapy alone, and for failure to use the alternative adjuvant, intrathecal PPD. The cases presented in this paper have been collected as examples of failure of these simplified forms of treatment. It is admitted that they are highly selected. But on first admission they were not unusual, and in none could an unfavourable course have been predicted. On present day standards all should have had an uneventful illness, and recovered without disability. The majority ultimately recovered when treatment was altered to include prolonged daily intrathecal chemotherapy, and intrathecal PPD. When the course of an illness is thus repeatedly reversed when treatment is changed, then it is reasonable to suppose that the change in treatment is responsible. And one must therefore conclude that in the cases presented here the simplified regimes of treatment given before transfer were not the optimum form of therapy. Were it not for the risks of delaying the institution of an intensive and difficult form of treatment there would be much to be said in favour of trying a simple regime first. The inevitable hazards of prolonged intrathecal medication, and the difficulties of PPD treatment, would thus be avoided in many cases. The change from an early to an advanced stage of the disease may be rapid and unheralded, and, although most of the patients considered here survived ultimately, in some the quality of recovery was poor, e.g. one patient, an early grade I case when treatment was first begun became blind. In this patient and in some of the others irreparable harm had already been done by the time treatment was altered. In such a potentially grave illness it is not justifiable to withhold any measure of treatment which might be beneficial. One must conclude that while the many hundreds of cases reported in the literature provide evidence that intrathecal medication is not essential in every patient, the group of patients presented here equally provides evidence that it is essential in some. Accordingly every patient with tuberculous meningitis should be given intra-thecal therapy from the outset, for the sake of those in whom it will later be necessary.