High dose versus low dose steroids in children with tuberculous meningitis

Guidelines for the best steroid dose in children with tuberculous meningitis (TBM) have not been established. We enrolled 63 children with TBM and divided them into three steroid dose groups: Group 1 (prednisolone 2mg/kg/day over 4 weeks), Group 2 (prednisolone 4 mg/kg/day over 1 week and 2mg/kg/day for the next 3 weeks) and Group 3 (prednisolone 4 mg/kg/day over 4 weeks). All patients received standard antituberculous therapy. Optic atrophy, tuberculoma, hydrocephalus, mental retardation, spasticity, hearing impairment, vasculitis and mortality outcomes were compared. Optic atrophy was higher in Group 3 compared to Group 1 (odds ratio [OR]=2.8) and Group 2 (OR=2.8), although Group 3 had a high incidence of optic atrophy at diagnosis. Tuberculomas were more frequent in Group 1 (OR=2.4) and Group 3 (OR=3.0) as compared to Group 2. Infarcts were more common in Group 3 than in Group 1 (OR=1.9) and in Group 2 (OR=3.5). Hearing loss was higher in Group 2 as compared to Group 1 (OR=2.88) and Group 3 (OR=4.8). Evolving hydrocephalus was higher in Group 3 as compared to Group 2 (OR=2.8) and Group 1 (OR=3.1). Mental retardation was higher in children in Group 3 (OR=1.6) and in Group 2 (OR=1.9) as compared to Group 1. Spasticity was higher in Group 3 (OR=2.0) and in Group 2 (OR=1.4) as compared to Group 1. There was no difference in mortality between the groups. We conclude that prednisolone at a dose of 4 mg/kg/day for 1 week followed by 2mg/kg/day for 3 weeks is associated with fewer tuberculomas and infarcts but a higher incidence of hearing loss. A prolonged period of high dose steroids increases the risk of optic atrophy and hydrocephalus. Prednisolone at a dose of 2mg/kg/day is associated with lower risk of mental retardation and spasticity.