Adjunctive Corticosteroids May Reduce Mortality in Tuberculous Meningitis; Dexamethasone Shows Favorable Benefit: Study
Pakistan: Adjunctive corticosteroid therapy may reduce the risk of death in patients with tuberculous meningitis (TBM), a study published in Brain and Behavior has revealed. The findings suggest that dexamethasone may offer a particularly favorable survival benefit. Given the high mortality associated with this severe neurological complication of Mycobacterium tuberculosis infection, corticosteroids may play an important role alongside anti-tuberculosis therapy by controlling excessive inflammation and improving clinical outcomes.
TBM remains a serious and potentially fatal form of tuberculosis, with case fatality rates reaching 50% in resource-limited settings despite standard anti-tuberculosis treatment. Although corticosteroids are commonly recommended as an adjunctive therapy, uncertainty remains regarding their effectiveness across different patient populations and their potential adverse effects.
Researchers led by Ayesha Younas from the Department of Medicine, Allama Iqbal Medical College, Lahore, Pakistan, and colleagues conducted a systematic review and meta-analysis to assess the efficacy and safety of corticosteroids in TBM.
The investigators searched PubMed, the Cochrane Library, ClinicalTrials.gov, Scopus, and Google Scholar for randomized and quasi-randomized controlled trials available through May 2025. The analysis examined all-cause mortality as well as adverse outcomes, including gastrointestinal bleeding, visual and auditory impairment, hydrocephalus, and joint disorders. The certainty of evidence was assessed using the GRADE framework.
The following were the key findings:
- 11 studies involving 1,917 patients were included in the meta-analysis.
- Adjunctive corticosteroids significantly reduced all-cause mortality compared with control treatment (RR, 0.84), with no statistical heterogeneity (I²=0%).
- The mortality benefit was particularly evident in patients from low-income countries (RR, 0.82).
- Dexamethasone was associated with lower mortality (RR, 0.87).
- Corticosteroids did not significantly reduce mortality among HIV-positive patients (RR, 0.90).
- No significant increase in major adverse outcomes was observed, 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).
The researchers noted several limitations, including differences across studies in corticosteroid type, dosage, and treatment duration. Incomplete reporting of HIV status and baseline disease severity also limited interpretation of subgroup findings. Additionally, children and HIV-positive patients were underrepresented, while differences in outcome definitions and imaging practices may have affected the assessment of neurological complications. Restricting eligible studies to English-language publications may also have introduced language bias.
The authors concluded that adjunctive corticosteroids, particularly dexamethasone, may provide a significant survival benefit in TBM without increasing major adverse effects. They emphasized the need for larger, high-quality trials to clarify treatment strategies for HIV-positive and pediatric patients, optimize corticosteroid regimens, and determine their long-term neurological effects.
Reference:
Younas, A., Noor, R., Shaukat, M. T., Ijlal, A., Tariq, I., Satea, M., Almas, M. S., Jamil, R., Khan Sherwani, M. R., Gamarra Valverde, N. N., Qadri, M., Siddiqi, M., Qureshi, K., Yangi, K., & Chaurasia, B. (2026). Efficacy and Safety of Corticosteroids in Tuberculous Meningitis: Systematic Review, Meta-Analysis, and Meta-Regression. Brain and Behavior, 16(8), e71639. https://doi.org/10.1002/brb3.71639
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