Management of intracranial tuberculous mass lesions: How long should we treat for? [version 2; peer review: 1 approved, 2 approved with reservations]

Tuberculous Meningitis International Research Consortium

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Abstract

Tuberculous intracranial mass lesions are common in settings with high tuberculosis (TB) incidence and HIV prevalence. The diagnosis of such lesions, which include tuberculoma and tuberculous abscesses, is often presumptive and based on radiological features, supportive evidence of TB elsewhere and response to TB treatment. However, the treatment response is unpredictable, with lesions frequently enlarging paradoxically or persisting for many years despite appropriate TB treatment and corticosteroid therapy. Most international guidelines recommend a 9-12 month course of TB treatment for central nervous system TB when the infecting Mycobacterium tuberculosis (M.tb) strain is sensitive to first-line drugs. However, there is variation in opinion and practice with respect to the duration of TB treatment in patients with tuberculomas or tuberculous abscesses. A major reason for this is the lack of prospective clinical trial evidence. Some experts suggest continuing treatment until radiological resolution of enhancing lesions has been achieved, but this may unnecessarily expose patients to prolonged periods of potentially toxic drugs. It is currently unknown whether persistent radiological enhancement of intracranial tuberculomas after 9-12 months of treatment represents active disease, inflammatory response in a sterilized lesion or merely revascularization. The consequences of stopping TB treatment prior to resolution of lesional enhancement have rarely been explored. These important issues were discussed at the 3 International Tuberculous Meningitis Consortium meeting. Most clinicians were of the opinion that continued enhancement does not necessarily represent treatment failure and that prolonged TB therapy was not warranted in patients presumably infected with M.tb strains susceptible to first-line drugs. In this manuscript we highlight current medical treatment practices, benefits and disadvantages of different TB treatment durations and the need for evidence-based guidelines regarding the treatment duration of patients with intracranial tuberculous mass lesions.

Original languageEnglish (US)
Article number158
JournalWellcome Open Research
Volume4
DOIs
StatePublished - 2019

Bibliographical note

Funding Information:
Grant information: This work was supported by the Wellcome Trust [098316 and 203135 to GM]. FCC was supported by National Institutes of

Funding Information:
Health/Fogarty International Center [R21TW011035]. OKS was supported by the National Institutes of Health [K23 NS084054-01]. AF was supported by the National Research Foundation SARChI Chair in Clinical Neurosciences. GM is also supported by the South African Research Chairs Initiative of the Department of Science and Technology and National Research Foundation (NRF) of South Africa [64787], NRF incentive funding [UID: 85858] and the South African Medical Research Council through its TB and HIV Collaborating Centres Programme with funds received from the National Department of Health [RFA# SAMRC-RFA-CC: TB/HIV/AIDS-01-2014]. The funders had no role in the study design, data collection, data analysis, data interpretation, or writing of this report. The opinions, findings and conclusions expressed in this manuscript reflect those of the authors alone.

Keywords

  • Central nervous system
  • Imaging
  • Management
  • Treatment duration
  • Tuberculoma
  • Tuberculosis
  • Tuberculous abscess
  • Tuberculous meningitis

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