Medical Management of Tuberculosis of the Central Nervous System in Children

  • Antibiotics: Anti-TB therapy helps to reduce the inflammatory response, thereby leading to opening of the CSF pathways.
  • Recommended treatment regimen for CNS TB caused by fully susceptible M. tuberculosis: Since the 1980s the 6- to 8-month regimen using a four-drug combination (HRZE) in the initial phase followed by a two-drug combination (HR or HE) in the continuation phase has been widely accepted (47). In 2004 the results of a multicenter randomized clinical trial showed higher efficacy for the 6-month regimen (2 months of HRZE plus 4 months of HR) compared with the 8-month therapy (2 months of HRZE plus 6 months of HE) (48).The recommended first-line treatment agents for all forms of CNS TB are isoniazid, rifampicin, pyrazinamide, and ethambutol, taken daily either individually or in combination form (26) as given below.
Drug Daily Dose (Children) Daily Dose (Adults) Duration
Isoniazid 10-20 mg/kg 300 mg 10-12 months
Rifampicin 10-20 mg/kg

450 mg (<50 kg);

600 mg (> 50 kg)

10-12 months
Pyrazinamide 15-30 mg/kg

1.5 g (<50 kg);

2 g (> 50 kg)

2 months
Ethambutol 15-20 mg/kg 15 mg/kg 2 months

 

  • Steroids: See Adjuvant Therapies.
  • Diuretics: For individuals with communicating hydrocephalus, the addition of acetazolamide and furosemide to standard anti-TB therapy is superior to the use of antibiotics alone. Mannitol can be used only for acute decompensation and is not recommended for more than 72 hours due to the occurrence of rebound intracranial hypertension. Acetazolamide (100 mg/kg) and furosemide (1 mg/kg) can be given for longer periods of up to 1 month. The addition of acetazolamide and furosemide was significantly more effective in achieving normal ICP than anti-TB therapy alone (49).
  • Lumbar puncture: For those with hydrocephalus and in poor grade, serial LPs may be done to manage elevated ICPs and also to document clinical improvement. Only those who improve may be subject to shunt surgery. Follow-up serial LPs are also done on patients with TB meningitis to document changes occurring in the CSF during the course of treatment. Normalization of the CSF then serves as confirmation of a positive response to therapy.