Treatment of Tuberculous Meningitis with HIV Co-infection in Adults
This protocol is for hospitalised adults aged 18 years or older with tuberculous meningitis who have HIV co-infection. The presence of HIV co-infection is a key clinical modifier that directly affects the strength of evidence-based treatment recommendations in this setting.
HIV co-infection — clinical significance
In adults hospitalised for tuberculous meningitis, HIV co-infection requires case-by-case treatment decision-making. Current evidence supports a strong recommendation for adjunctive therapy in HIV-negative patients, but only a weak recommendation for people living with HIV — meaning the decision must be individualised.
Treatment approach — refractory cases
When initial treatment does not adequately control symptoms, the protocol provides a structured approach to escalation involving an immunomodulating agent. The specific agent selection, criteria for use, and sequencing are defined in the complete protocol.
References
- 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.
DOI: 10.1016/S1473-3099(25)00364-0
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