Tuberculosis Meningitis with Brainstem Mass Lesion—Adjunctive Treatment with Thalidomide: A Case Report

Background: We report on a 12-month-old child with recurrence of intracranial tuberculosis after de-escalation of the initial therapy with levofloxacin, rifampicin, ethambutol, and pyrazinamide in an outpatient clinic. After initial improvement of atactic movement disorder with ongoing motoric and mental development the child deteriorated with progressive impairment of vigilance. Magnetic resonance imaging (MRI) of the brain showed meningitis together with a cerebellar abscess and brainstem mass lesion resulting in increased intracranial pressure. Surgical decompression was incomplete due to massive granuloma formation in the basal meninges. Postinterventional the child remained comatose and showed extension spasm. Besides reinitiation of the tuberculostatic therapy (adjusted after blood and CSF concentrations) with rifampicin, pyrazinamide, prothionamide and levofloxacin we started high dose steroid therapy to reduce intracranial edema. Tuberculosis abscess and mass lesions tend to induce an inadequate tumor necrosis factor (TNF)-α–dependent cytokine response. Therefore additional treatment with the TNF-α inhibitor thalidomide was started to control the intracranial tuberculosis granuloma formation and to reduce steroid therapy. After five months of treatment the MRI showed regression of the tuberculous mass lesion and the patient caught up on motoric and mental development.

Results: Thalidomide inhibits TNF-α secretion. Excessive TNF-α secretion evident in tuberculosis abscesses leads to extensive granuloma and necrosis formation in the setting of intracranial tuberculosis disease. The immunomodulatory effect of thalidomide resulted in a remarkable clinically improvement in our patient without any side effects.

Conclusion: We suggest considering thalidomide as an adjunctive treatment of intracranial tuberculosis disease to reduce granuloma formation and intracranial lesions.