Clinical presentation, investigations and management by organ specific site are reviewed in the following sections. Evidence for treatment duration and other adjunct measures for each organ site is summarized in Table 3. Examples of published corticosteroid regimens for relevant organ sites are described in Table 2.
Table 2. Examples of published corticosteroid regimens for extra-pulmonary TB.a
|TBM Children(329,330) (≤14 years) Adults/Adolescents(196) (>14 years)||Pericardial TB Adults(301) (≥18 years)|
|Clinical Status||All||Alert (GCS 15)||Altered LOC (GCS <15)
+/- focal neurologic deficits
(8 wk course)
|Alert (GCS 15), no focal neurologic deficits
(6 wk course)
|Week 1||DEXA 0.6 mg/kg/d IV||Prednisolonea
4 mg/kg/d PO (max 60 mg/d)
|DEXA 0.4 mg/kg/d IV||DEXA 0.3 mg/kg/d IV||Prednisolone PO
120 mg PO
|Week 2||“||“||0.3 mg/kg/d IV||0.2 mg/kg/d IV||90 mg PO|
|Week 3||“||“||0.2 mg/kg/d IV||0.1 mg/d PO b||60 mg PO|
|Week 4||“||“||0.1 mg/kg/d IV||3 mg/d PO b||30 mg PO|
|Week 5+||Tapered through Week 8||Tapered through
|4 mg/d PO b decrease by 1 mg/wk||2 mg/d PO b decrease by 1 mg/wk||Week 5 = 15 mg PO
Week 6 = 5 mg PO
Abbreviations: TB, tuberculosis; TBM, tuberculosis meningitis; LOC, level of consciousness; GCS, Glascow Coma Scale; DEXA, dexamethasone; IV, intravenous; PO, by mouth; BMRC, modified British Medical Research Council TBM severity grading; GI, gastrointestinal.199
aAll corticosteroid doses assume concurrent use of rifampin. If rifampin is not part of TB regimen, then dose adjustment advised.
bcontinue as IV if significant GI intolerance or compromise, early switch to PO may be considered in those with prompt improvement and GI tolerance.
Table 3. Summary of evidence for duration of treatment in extra-pulmonary TB with adjunct measures.
|Site||Duration TB treatment||Level of guidance||Evidencea||Adjunct measures|
|Type of Studies||Number||Consistency||Corticosteroids
|Other Measures (ref)|
|Pleural||6 months||Conditional||OBS||4(122–125)||454||Good||Do not use( 126 )||Drainage not necessary( 123 , 127 )|
|Lymph Node||6 months||Conditional||RCT||2( 105 , 106 )||290||Good||–b||Surgery not necessary( 98 )|
|6 months||Conditional||SRMA||3( 151 )||328||Good|
|Bone and Joint||6 months, consider 9-12 months with markers of severe disease||Conditional||RCT/OBS/Review
|Review 77 studies( 183 )
2 RCTs( 184 , 186 )
|Good, two studies with higher relapse rates Dutt et al. 331 twice weekly self-administered therapy for 9 months and Ramachandran et al. 332 primarily based on lack of radiograph response||Surgical intervention is not routinely recommended as part of treatment in spinal tuberculosis. Surgical treatment of spinal TB should be considered in those with neurologic deterioration and in those less than 15 years of age with significant kyphosis( 161 , 185 , 189 )|
|Central Nervous System||TBM
|Conditional||OBS/SR||18 c ( 236 )||2,098||Good||Use for all individuals, dosing guided by age group and disease severity.( 239 ) See Table 2 for dosing guidance||Higher dose rifampin (IV or oral up to maximum dose 35 mg/kg/day) advised during intensive phase of therapy( 223–225 , 229 , 333 , 334 )
Routine use fluoroquinolone not advised unless concern about drug resistant TBM( 228 , 231 )
|Conditional||OBS||20( 246 )||742||Poor||Do not use unless clinical significant mass effect( 28 , 246 )|
|Disseminated||6 months||Conditional||Expert opinion|
|2( 289 , 335 )
1( 291 )
N/A – one study
|Pericardial||6 months||OBS||4( 82 ,299–301)||660||Good||Use for HIV negative populations.
People with HIV not on ARV-do not use.( 296 )
Limited data for People with HIV on ARV
|Ocular||6 months||Conditional||OBS||4( 303 , 314 , 316 , 317 )||426||Poor|
|Cutaneous||6 months||Conditional||OBS||Case reports and reviews|
Abbreviations: ARV, anti-retrovirals; TB, tuberculosis; OBS, observational study; RCT, randomized clinical trial; SR, systematic review; SRMA, systematic review meta-analysis.
a(-) Insufficient data.
bOne cohort in SR was unpublished.
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