A 50-year-old man presents with fever, headache, and altered sensorium for 3 days. He has neck stiffness and right-sided weakness. CSF shows lymphocytic pleocytosis (180 cells/μL, 90% lymphocytes), protein 1.8 g/L, glucose 1.8 mmol/L (simultaneous blood glucose 5.5 mmol/L), and a positive Xpert MTB/RIF assay. MRI shows basal exudates and hydrocephalus. Which regimen is the most appropriate initial antitubercular therapy?

• A Isoniazid, rifampicin, pyrazinamide, and ethambutol for 2 months followed by isoniazid and rifampicin for 7-10 months (total 9-12 months) ✓
• B Isoniazid, rifampicin, pyrazinamide, ethambutol, and streptomycin for 2 months followed by HR for 7-10 months
• C Isoniazid, rifampicin, pyrazinamide, and ethambutol (HRZE) for 2 months followed by HR for 4 months
• D Isoniazid and rifampicin alone for 12 months

Explanation

Tuberculous meningitis requires prolonged therapy. The standard regimen is 2 months of intensive phase with HRZE followed by 7-10 months of continuation phase with isoniazid and rifampicin, giving a total duration of 9-12 months. Short-course regimens (6 months) used for pulmonary TB are inadequate for TBM. Streptomycin is no longer preferred as a first-line drug and has poor CNS penetration. National and WHO guidelines for TBM recommend the 9-12 month regimen.

Reference: Park's Textbook of Preventive and Social Medicine and RNTCP/WHO guidelines, 25th (Park); WHO 2010 TB meningitis guidelines ed.

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Written and medically reviewed by the StethoPrep medical team.