Efficacy and Safety of Corticosteroids in Tuberculous Meningitis: Systematic Review, Meta-Analysis, and...

Tuberculous meningitis (TBM) carries a case fatality rate of up to 50% in resource-limited settings despite standard anti-tuberculosis therapy. Adjunctive corticosteroids are widely recommended, yet their effect on mortality and safety across diverse populations remains imprecisely defined.

We conducted a systematic review and meta-analysis of randomized and quasi-randomized controlled trials identified through PubMed, Cochrane Library, ClinicalTrials.gov, Scopus, and Google Scholar up to May 2025. The outcomes were all-cause mortality, gastrointestinal bleeding, visual and auditory impairment, hydrocephalus, and joint disorders. Statistical heterogeneity was assessed using the I² statistic. Certainty of evidence was assessed with the GRADE framework.

Eleven studies enrolling 1917 patients were included. Corticosteroids significantly reduced all-cause mortality (RR = 0.84, 95% CI: 0.76-0.94, p = 0.002) with low heterogeneity (I² = 0%). Subgroup analysis revealed pronounced benefits in low-income countries (RR = 0.82, CI: 0.72-0.95) and dexamethasone use (RR = 0.87, CI: 0.77-0.97). In HIV-positive patients, corticosteroids did not significantly impact mortality (RR = 0.90, CI: 0.77-1.05, p = 0.18). No statistically significant increase in adverse outcomes was detected, including gastrointestinal bleeding (RR  =  0.87), visual impairment (RR  =  1.62), auditory impairment (RR  =  0.79), hydrocephalus (RR  =  0.47), or joint disorders (RR  =  0.63).

Adjunctive corticosteroids, particularly dexamethasone, significantly reduce mortality in TBM without increasing major adverse effects. The absence of benefit in HIV-positive patients highlights the need for targeted trials in this subgroup and in pediatric populations.