Thalidomide in the treatment of human immunodeficiency virus-negative tuberculous meningitis: A case report

Abstract

Introduction: Tuberculous meningitis (TBM) is the most fatal type of tuberculosis in which corticosteroids are added with antitubercular therapy to prevent permanent brain damage. However, this treatment may produce paradoxical reactions. In such cases, thalidomide use might reduce central nervous system inflammation and improve the outcome. We present the case of a human immunodeficiency virus-negative patient with TBM who developed paradoxical reactions manifesting as multiple intracranial tuberculomas that were resistant to standard care (antitubercular drugs and corticosteroids) but responded well to thalidomide.

Patient's main concern and clinical findings: The patient was a 40-year-old Chinese female, who was admitted with a 10-day history of headaches, night sweats, and cough. She was healthy before contracting the infection and had no history of contact with tuberculosis patients.

Diagnoses, intervention, and outcome: We diagnosed the patient with TBM complicated by the occurrence of pulmonary tuberculosis. Positive results were obtained from Gram and Ziehl-Neelsen staining of the sputum and acid-fast bacilli sputum culture. Standard treatment was initiated with antitubercular drugs (daily isoniazid, rifampicin, ethionamide, and pyrazinamide) and corticosteroids (dexamethasone). However, 3 months later the magnetic resonance imaging of the head revealed some new tuberculoma lesion. Thus, a specific therapy of antitubercular drugs and thalidomide was introduced. On completion of a 12-month course of antitubercular drugs with 2 months of thalidomide, the patient showed favorable outcomes without neurologic sequelae. Moreover, thalidomide appeared safe and well tolerated in the patient.

Conclusion: In addition to the specific anti-tubercular and adjuvant corticosteroid therapies for TBM, thalidomide can be used as a "salvage" antitubercular drug in cases that are unresponsive to corticosteroids.

Figure 1

(A and B) Cerebrospinal fluid magnetic resonance imaging (MRI) of the brain showed in both sides of the cerebral cortex, the left basal ganglia, the left thalamus, the middle brain, the pontine, the right cerebellar hemisphere, there were many abnormal signals. T1WI showed low signal, T2WI, T2-FLAIR showed high signal, DWI showed high signal, the enhanced scan was ring strengthening, and no obvious abnormal enhancement was found in the meninges.

Figure 2

(A and B) The head MRI revealed some new lesion compatible with tuberculoma after a standard 3 mo care with anti-tuberculosis drugs and corticosteroids. MRI = magnetic resonance imaging.

Figure 3

(A and B) Thalidomide treatment significantly improved the intracranial lesions after 2 mo.