Complications of Therapies for Tuberculosis of the Central Nervous System in Children

Medical

• Paradoxical worsening: New or worsening neurological signs in patients being treated for CNS TB should prompt immediate imaging and neurosurgical review. Intracranial tuberculomas appear or paradoxically increase in size during treatment for TB meningitis. Concomitant steroid therapy probably has a preventive role against these focal lesions (57-59).
• Hyponatremia as a cause of coma and seizures: SIADH or reduced plasma volume with persistent natriuresis should be considered. Sodium level should be corrected, either by sodium and water replacement if the patient is hypovolemic or by fluid restriction if they are euvolemic (60).
• Drug-induced hepatitis: The serious complication of drug-induced hepatitis is the commonest drug-related event and is usually reported in extremes of age, malnutrition, alcoholism, HIV infection, and chronic hepatitis B and C infections (6, 61). If the serum transaminase levels continue to rise and albumin level falls, chemotherapy needs to be stopped. Streptomycin and ethambutol should be given, and the addition of moxifloxacin or levofloxacin should be considered for those patients with severe disease. Rifampicin and isoniazid can be restarted immediately after the liver function tests normalize. The guidelines recommend gradually increasing the dose of both drugs over 5–7 days, with regular liver function tests. The gradual reintroduction of pyrazinamide is optional as it may increase the likelihood of recurrent hepatitis. If pyrazinamide is not given, ethambutol should be given throughout therapy, which should be extended to 18 months. Streptomycin can be stopped once the full dose of rifampicin and isoniazid are tolerated (26).

Surgical

• Shunt surgery: Complications of shunt surgery are more frequent in patients with TB meningitis than in patients with other conditions. Reasons include the poor general condition of these patients and also the presence of higher protein levels and cellular content in the CSF, leading to more frequent shunt obstructions that require multiple shunt revisions. Shunt infection and erosion of skin over the shunt components are the other major complications of shunt surgery in patients with advanced stages of TB meningitis and hydrocephalus due to their suboptimal nutritional status (25).
• ETV: Bleeding during surgery and CSF leakage from the wound due to failure of the ETV are the most commonly reported complications of ETV. Risk of injury to the basilar artery and its branches is theoretically higher in patients with TB meningitis due to thickening and opacification of the floor of the third ventricle.