As inflammatory changes play an important role in the neuropathogenesis of the disease, adjunctive
corticosteroid treatment may be of benefit in
tuberculous meningitis. In an open-label study in India, 97 patients with such
meningitis were randomized into a control group, a
dexamethasone group (with the drug given intravenously once a day for 4 weeks, and then orally, once daily, for another 4 weeks) and a
methylprednisolone group (with the drug given intravenously once a day for 5 days). All the patients also received standard
anti-tuberculosis drugs. The primary outcome measure was death or severe disability 6 months after the randomization, with a modified Rankin scale used to assess each patient's level of disability. The other outcome measures investigated were deterioration in vision, focal neurological deficits and new-onset
seizures. Six patients (one of those given
dexamethasone, three of those given
methylprednisolone and two of those in the control group) were lost to follow-up. Although each
corticosteroid was associated with a reduction in death or disability, this reduction did not reach statistical significance in either the
dexamethasone group (relative risk of death=0.6, with a 95% confidence interval of 0.29-1.2; P>0.05) or the
methylprednisolone group (relative risk of death=0.7, with a 95% confidence interval of 0.4-1.4; P>0.05), probably because of the small sample sizes. Among the patients who died within 10 months of randomization, the mean time to death (post-randomization) was 8.8 months in the
dexamethasone group, 8.2 months in the
methylprednisolone group, and 7.1 months in the control group (P>0.05). The prevalence of impaired vision, among all the patients evaluated, decreased from 41.8% at baseline to 29.9% (among the survivors) 6 months later. Adverse events were similar and equally reported in the two
corticosteroid groups. Larger trials are still needed to determine if
dexamethasone and/or
methylprednisolone are useful in the treatment of
tuberculous meningitis, at least in India.