Tuberculous meningitis
ICD-10 A17.0 · ICD-11 1B11.0

Treatment of Tuberculous Meningitis in Adults (Age 18+) Without HIV Co-infection

This protocol covers the management of tuberculous meningitis in hospitalised adults aged 18 years or older who do not have HIV co-infection — a population for which high-certainty evidence supports a strong treatment recommendation.

Clinical Scenario

Adults (18 years or older) admitted to hospital with tuberculous meningitis, with confirmed absence of HIV co-infection. High certainty of evidence supports a strong recommendation for this population, distinct from the case-by-case approach required when HIV is present.

Treatment Overview (Partial)

When initial treatment does not adequately control symptoms in refractory cases, the protocol calls for the addition of an immunomodulating agent — involving a class of biological therapy targeted at specific inflammatory mediators. Agent selection, dosing, sequencing, and the full decision algorithm are detailed in the complete protocol.

Partial overview only — the full structured regimen is available below.

Instant Access to Structured Evidence-Based Regimens

References

DOI: 10.1016/S1473-3099(25)00364-0

Population: adults in hospital requiring treatment for tuberculous meningitis.

Is there HIV co-infection? — High certainty of evidence, strong recommendation for use in individuals without HIV; high certainty of evidence, weak recommendation for use in people living with HIV so the decision to use should be made on a case-by-case basis.

If corticosteroids do not control symptoms, then small case-series and case reports have described the use of anti-TNF biologicals (eg, infliximab), thalidomide, or anakinra.

A retrospective cohort study in India reported adjunctive infliximab (10 mg/kg for one to three doses, 4 weeks apart) was safe and effective in treating severe inflammatory complications of tuberculous meningitis.

Observational studies in South African children have suggested that adjunctive thalidomide (2–5 mg/kg per day) was safe and effective in treating tuberculous mass lesions and optochiasmatic arachnoiditis.

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