Dexametasona en Meningitis TBC

The new england journal of medicine
original article
Dexamethasone for the Treatment

of Tuberculous Meningitis
in Adolescents and Adults
Guy E. Thwaites, M.R.C.P., Nguyen Duc Bang, M.D., Nguyen Huy Dung, M.D.,
Hoang Thi Quy, M.D., Do Thi Tuong Oanh, M.D., Nguyen Thi Cam Thoa, M.D.,
Nguyen Quang Hien, M.D., Nguyen Tri Thuc, M.D., Nguyen Ngoc Hai, M.D.,
Nguyen Thi Ngoc Lan, Ph.D., Nguyen Ngoc Lan, M.D., Nguyen Hong Duc, M.D.,
Vu Ngoc Tuan, M.D., Cao Huu Hiep, M.D., Tran Thi Hong Chau, M.D.,
Pham Phuong Mai, M.D., Nguyen Thi Dung, M.D., Kasia Stepniewska, Ph.D.,
Nicholas J. White, F.R.C.P., Tran Tinh Hien, M.D., and Jeremy J. Farrar, F.R.C.P.
abstract
background
Tuberculous meningitis kills or disables more than half of those affected with the dis- From the Oxford University Clinical Re-
ease. Previous studies have been too small to determine whether adjunctive treatment search Unit at the Hospital for Tropical Dis-
eases, Ho Chi Minh City, Vietnam, and the
with corticosteroids can reduce the risk of disability or death among adults with tuber- Centre for Tropical Medicine, Nuffield De-
culous meningitis, and the effect of coinfection with the human immunodeficiency vi- partment of Clinical Medicine, John Rad-
rus (HIV) is unclear. cliffe Hospital, Oxford, United Kingdom
(G.E.T., K.S., N.J.W., J.J.F.); Pham Ngoc
methods Thach Hospital for Tuberculosis and Lung
Disease, Ho Chi Minh City, Vietnam (N.D.B.,
We performed a randomized, double-blind, placebo-controlled trial in Vietnam in pa- Nguyen H. Dung, H.T.Q., D.T.T.O., N.T.C.T.,
tients over 14 years of age who had tuberculous meningitis, with or without HIV infec- N.Q.H., N.T.T., N.N.H., N.T.N.L., N.N.L.,
tion, to determine whether adjunctive treatment with dexamethasone reduced the risk Nguyen H. Duc, V.N.T., C.H.H.); and Hos-
pital for Tropical Diseases, Ho Chi Minh City,
of death or severe disability after nine months of follow-up. We conducted prespecified Vietnam (T.T.H.C., P.P.M., N.T.D., T.T.H.).
subgroup analyses and intention-to-treat analyses. Address reprint requests to Dr. Thwaites
at the Oxford University Clinical Research
results
Unit, the Hospital for Tropical Diseases,
A total of 545 patients were randomly assigned to groups that received either dexa- 190 Ben Ham Tu, Quan 5, Ho Chi Minh City,
methasone (274 patients) or placebo (271 patients). Only 10 patients (1.8 percent) had Vietnam, or at guy.thwaites@btinternet.
com.
been lost to follow-up at nine months of treatment. Treatment with dexamethasone
was associated with a reduced risk of death (relative risk, 0.69; 95 percent confidence N Engl J Med 2004;351:1741-51.
interval, 0.52 to 0.92; P=0.01). It was not associated with a significant reduction in the Copyright © 2004 Massachusetts Medical Society.
proportion of severely disabled patients (34 of 187 patients [18.2 percent] among sur-
vivors in the dexamethasone group vs. 22 of 159 patients [13.8 percent] in the placebo
group, P=0.27) or in the proportion of patients who had either died or were severely
disabled after nine months (odds ratio, 0.81; 95 percent confidence interval, 0.58 to
1.13; P=0.22). The treatment effect was consistent across subgroups that were defined
by disease-severity grade (stratified relative risk of death, 0.68; 95 percent confidence
interval, 0.52 to 0.91; P=0.007) and by HIV status (stratified relative risk of death, 0.78;
95 percent confidence interval, 0.59 to 1.04; P=0.08). Significantly fewer serious ad-
verse events occurred in the dexamethasone group than in the placebo group (26 of 274
patients vs. 45 of 271 patients, P=0.02).
conclusions
Adjunctive treatment with dexamethasone improves survival in patients over 14 years
of age with tuberculous meningitis but probably does not prevent severe disability.
n engl j med 351;17 www.nejm.org october 21, 2004 1741
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Copyright © 2004 Massachusetts Medical Society. All rights reserved.
diseases (Hospital for Tropical Diseases) in south-
t uberculous meningitis is the se-

verest form of infection with Mycobacteri-
rologic deficits in more than half of those affected

in spite of antituberculosis chemotherapy.1,2 Atten-
ern Vietnam.
um tuberculosis, causing death or severe neu- Only patients over 14 years of age with clinical
evidence of meningitis (defined as the combination
of nuchal rigidity and cerebrospinal fluid abnor-
uation of the inflammatory response in bacterial malities) were eligible to enter the study. Tubercu-
and mycobacterial meningitis may improve out- lous meningitis was defined as “definite” if acid-fast
come by reducing the likelihood or severity of neu- bacilli were seen in the cerebrospinal fluid. It was
rologic complications. Early studies suggested that defined as “probable” in patients with one or more
corticosteroids reduced cerebrospinal fluid inflam- of the following: suspected active pulmonary tu-
mation and time to recovery in patients with tuber- berculosis on chest radiography, acid-fast bacilli
culous meningitis, but the studies were too small found in any specimen other than the cerebrospi-
to confirm any effect on survival.3-7 Concern re- nal fluid, and clinical evidence of other extrapul-
mained that corticosteroids might reduce the case monary tuberculosis. Tuberculous meningitis was
fatality rate but increase the number of disabled pa- defined as “possible” in patients with at least four
tients.8 Randomized trials performed in Egypt9 and of the following: a history of tuberculosis, predom-
South Africa10 provided evidence that corticoste- inance of lymphocytes in the cerebrospinal fluid,
roids improved survival in children with severe dis- a duration of illness of more than five days, a ratio
ease and probably reduced neurologic sequelae. of cerebrospinal fluid glucose to plasma glucose of
A meta-analysis of all randomized controlled less than 0.5, altered consciousness, yellow cere-
trials of corticosteroids for tuberculous meningitis brospinal fluid, or focal neurologic signs.
suggested that corticosteroids were effective in re- Patients were reclassified on discharge as hav-
ducing the risk of death in children (relative risk, ing definite tuberculous meningitis if acid-fast ba-
0.77; 95 percent confidence interval, 0.62 to 0.96) cilli were seen or M. tuberculosis was cultured from
the cerebrospinal fluid, or as not having tubercu-
but not in patients over 14 years of age (relative risk,
0.96; 95 percent confidence interval, 0.50 to 1.84), lous meningitis if another diagnosis was con-
although only six trials involving a total of 595 pa- firmed by microbiologic or histopathological eval-
tients (158 adults) met the inclusion criteria,11 and uation.
there were no data on patients coinfected with the Patients were not eligible to enter the trial if the
human immunodeficiency virus (HIV). The authors enrolling physician believed that corticosteroids
concluded that small numbers of patients, poor were contraindicated, if the patient had received
concealment of the treatment-group assignments, more than one dose of any corticosteroid or more
and publication bias could account for the positive than 30 days of antituberculosis chemotherapy im-
results, and that studies in patients with HIV infec- mediately before study entry, or if the consent of ei-
tion and studies of a size large enough to assess ther the patient or the patient’s relatives was not
morbidity and the case fatality rate were required.11 obtained.
Therefore, we conducted a double-blind, placebo- The ethics and scientific committees of both
controlled trial to determine whether adjunctive dex- hospitals, the Health Services of Ho Chi Minh City,
amethasone therapy improves the outcome in pa- and the Oxfordshire Clinical Research Ethics Com-
tients over 14 years of age who have tuberculous mittee approved the study protocol. The funding
meningitis, with or without HIV infection. body played no part in the design, implementation,
or analysis of the study or in the decision to publish
methods the results. Written informed consent to partici-
pate in the study was obtained from all patients or
study participants from their relatives if the patient could not provide
We recruited study participants from two centers consent.
in Ho Chi Minh City, Vietnam: Pham Ngoc Thach
Hospital for Tuberculosis and Lung Disease and laboratory investigations
the Hospital for Tropical Diseases. These 500-bed Cerebrospinal fluid specimens were stained and
hospitals serve the local community and act as ter- cultured by standard methods for pyogenic bacte-
tiary referral centers for patients with severe tuber- ria, fungi, and mycobacteria. Isolates of M. tuber-
culosis (Pham Ngoc Thach Hospital) or infectious culosis were tested for susceptibility to isoniazid,
1742 n engl j med 351;17 www.nejm.org october 21 , 2004
dexamethasone for patients with tuberculous meningitis
rifampin, pyrazinamide, ethambutol, and strep- for week 3, then a total of 3 mg per day, decreasing
tomycin. by 1 mg each week). The concentration of dexa-
All patients were tested for antibodies to HIV and methasone, and the absence of dexamethasone
hepatitis B surface antigen. CD4 lymphocyte counts from placebo, were confirmed by liquid chromatog-
were performed by flow cytometry (FACSCalibur, raphy and mass spectroscopy performed on 10 ran-
Becton Dickinson) for all HIV-infected adults as domly selected vials of the study drug and placebo.
soon as possible after randomization. A computer-generated sequence of random
numbers was used to allocate treatment in blocks
treatment of 30. Numbered individual treatment packs con-
Adults previously untreated for tuberculosis re- taining the study drug were prepared for the dura-
ceived three months of daily oral isoniazid (5 mg tion of treatment and were distributed for sequen-
per kilogram of body weight), rifampin (10 mg per tial use once a patient fulfilled the entry criteria.
kilogram), pyrazinamide (25 mg per kilogram; max- Parenteral placebo and dexamethasone were iden-
imum, 2 g per day), and intramuscular streptomy- tical in appearance, as were oral placebo and dexa-
cin (20 mg per kilogram; maximum, 1 g per day), methasone.
followed by six months of isoniazid, rifampin, and The attending physicians were responsible for
pyrazinamide at the same daily doses. Ethambutol enrolling the participants and ensuring that the
(20 mg per kilogram; maximum, 1.2 g per day) was study drug was given from the correct treatment
substituted for streptomycin in the cases of HIV- pack. Daily monitoring of all inpatients by one of
infected patients and was added to the regimen for the authors ensured uniform management between
three months for patients who had been treated sites and accurate recording of clinical data in indi-
previously for tuberculosis. Drugs were adminis- vidual study notes. All participants, enrolling phy-
tered by nasogastric tube to patients who were un- sicians, and investigators remained blinded to the
able to swallow. None of the patients received anti- treatment allocation until the last patient complet-
retroviral drugs. ed follow-up.
Patients were stratified on entry according to
the British Medical Research Council criteria, mod- assessment of outcome
ified as follows12: patients with grade I disease had The primary outcome was death or severe dis-
a score on the Glasgow Coma Scale of 15 (possi- ability nine months after randomization. Two ex-
ble range, 3 to 15, with higher scores indicating perienced Vietnamese physicians at each site were
better status) with no focal neurologic signs; pa- trained to assess disability with the Rankin scale
tients with grade II had a score of either 11 to 14, and the “simple questions” score, two well-vali-
or of 15 with focal neurologic signs; and patients dated measures of outcome from stroke that have
with grade III had a score of 10 or less. Patients good interobserver agreement.13,14 The simple
within each grade were randomly assigned to re- questions categorized outcome in survivors by de-
ceive dexamethasone sodium phosphate or place- termining whether they required help with every-
bo (VIDIPHA, Vietnam) as soon as possible after day activities such as eating, washing, and going
the start of antituberculosis treatment. Patients with to the toilet. If the patients answered yes, they were
grade II or III disease received intravenous treat- regarded as severely disabled. If they answered
ment for four weeks (0.4 mg per kilogram per day no, they were asked whether the illness had left
for week 1, 0.3 mg per kilogram per day for week 2, them with any other problems. If so, the outcome
0.2 mg per kilogram per day for week 3, and 0.1 mg was designated “intermediate”; if not, the outcome
per kilogram per day for week 4) and then oral treat- was “good.”
ment for four weeks, starting at a total of 4 mg per The Rankin scale also assessed dependence. A
day and decreasing by 1 mg each week. score of 0 indicated no symptoms; 1 indicated mi-
Prolonged intravenous dexamethasone treat- nor symptoms not interfering with lifestyle; 2 indi-
ment of patients with mild disease was not con- cated symptoms that might restrict lifestyle, but
sidered acceptable. Therefore, patients with grade patients could look after themselves; 3 indicated
I disease received two weeks of intravenous therapy symptoms that restricted lifestyle and prevented in-
(0.3 mg per kilogram per day for week 1 and 0.2 dependent living; 4 indicated symptoms that pre-
mg per kilogram per day for week 2) and then four vented independent living, although constant care
weeks of oral therapy (0.1 mg per kilogram per day and attention were not required; and 5 indicated to-
tal dependence on others, requiring help day and odds ratio for the outcome was calculated with the
night. The classification of outcomes as “good” (a use of logistic regression. The last recorded dis-
score of 0), “intermediate” (scores of 1 or 2), or ability score was considered to be the score at nine
“severe disability” (scores of 3, 4, or 5) was defined months for patients who did not complete follow-
before the start of the trial. Patients were assessed up. The prespecified subgroup analysis compared
at one, two, six, and nine months after randomiza- the primary outcome among subgroups of patients
tion, and at each point the worst score from either defined according to HIV-infection status, the Brit-
questionnaire was taken as the outcome. ish Medical Research Council grade, and diagnos-
Secondary outcome measures were coma-clear- tic group (definite, probable, or possible tubercu-
ance time (days from randomization until obser- lous meningitis). Tests of interaction between
vation of a Glasgow coma score of 15 for more subgroups and the assigned treatment were per-
than two consecutive days), fever-clearance time formed by a Cox regression model for survival data
(days from randomization until observation of a and by logistic-regression analysis (with the use
maximal daily temperature of less than 37.5°C for of the likelihood-ratio test) for the combined out-
more than five consecutive days), time to discharge come data.
from the hospital, time to relapse (defined by the The times to fever clearance, coma clearance,
onset of new focal neurologic signs or a fall in the relapse, and discharge were summarized in each
Glasgow coma score of 2 points or more for two treatment group with the use of Kaplan–Meier es-
or more days after more than seven days of clinical timates and were compared with the use of the
stability or improvement at any time after random- log-rank test. The proportion of patients with focal
ization), and the presence of focal neurologic def- neurologic deficit by nine months and the frequen-
icit nine months after randomization. These out- cy of adverse events were compared with the use of
come measures were assessed daily by means of the chi-square test. Multivariable analysis of base-
clinical examination by the principal investigator line variables identified independent risk factors
or by the physicians trained to assess disability. for death. The analysis was performed with the use
All data were recorded prospectively into individ- of SPSS and Stata software. All reported P values
ual study notes, entered into an electronic data- are two-sided.
base (Microsoft FoxPro, Version 6.0), and double- The independent data and safety monitoring
checked before analysis. committee reviewed the results of the study after
20 deaths, after one year of recruitment, and after
statistical analysis the enrollment of 520 patients. The predefined cri-
The case fatality rate for tuberculous meningitis in terion for stopping the trial early was a difference
adult patients in the two hospitals before the study of more than 3 SD in the proportion who died in
(when corticosteroids were not routinely admin- each group; the trial was not stopped early.
istered) was 35 percent. We calculated that 270
patients would be required in each group to pro- results
vide at least 80 percent power to detect a 31 per-
cent reduction in the case fatality rate, from 35 per- A total of 545 patients over 14 years of age were ran-
cent to 24 percent, with a two-sided significance domly assigned to receive either dexamethasone
level of 5 percent. (274 patients) or placebo (271 patients) from April 4,
The outcomes were evaluated by intention- 2001, to March 29, 2003 (Fig. 1). Median follow-up
to-treat analyses and prespecified subgroup analy- was 274 days (range, 28 to 442). Ten patients did
ses. We used Kaplan–Meier estimates to display the not complete the nine-month follow-up (five in each
survival experiences of the two treatment groups group): five were lost to follow-up after one month
and the log-rank test to evaluate the equality of the (one in the dexamethasone group), three after two
survival distributions. Data on patients who were months (two in the dexamethasone group), and
lost to follow-up were censored at the time of the one after three months and one after four months
last recorded outcome. The relative risk of death (both in the dexamethasone group). Severe disabil-
between the treatment groups was calculated by ity was recorded in 4 of the 10 patients (3 in the dex-
Cox regression. The combined outcome of death amethasone group), an intermediate outcome in
or severe disability by nine months was compared 2 of 10 (1 in the dexamethasone group), and a good
between the groups by the chi-square test, and the outcome in 4 of 10 (1 in the dexamethasone group).
618 Patients assessed for eligibility
73 Patients excluded
Insufficient clinical criteria
(13)
>30 Days of antituberculosis
chemotherapy (15)
Prior corticosteroid treatment
(8)
Dexamethasone contraindi-
cated (8)
Died before entry (10)
Refused consent (19)
545 Patients enrolled
271 Patients received 274 Patients received

placebo as assigned dexamethasone as assigned
5 Patients lost to follow-up

5 Patients lost to follow-up
10 Patients withdrawn early
14 Patients withdrawn early
from treatment
from treatment
Consent withdrawn (2)
Consent withdrawn (4)
Corticosteroids contra-
Corticosteroids contra-
indicated (5)
indicated (5)
Not tuberculous meningitis
Not tuberculous meningitis
(1)
(5)
Recruitment error (2)
2 Patients became unblinded
2 Patients became unblinded
271 Patients included 274 Patients included

in analysis at 9 mo in analysis at 9 mo
(last observation carried forward) (last observation carried forward)
Figure 1. Study Design.

The observations of patients who were lost to follow-up, who stopped treatment early, or whose allocation became un-
blinded were carried forward to nine months, and all 545 patients enrolled were included in the analysis.
These observations were carried forward to nine cerebrospinal fluid or another site in 170 patients
months, and 545 patients were included in the (31.2 percent), 85 from each group. Of 170 isolates,
analysis. 99 (58.2 percent) were susceptible to all first-line
drugs (51 in the placebo group and 48 in the dex-
baseline characteristics of the patients amethasone group), 60 (35.3 percent) were resis-
The baseline characteristics at randomization were tant to streptomycin, isoniazid, or both (29 in the
similar in the dexamethasone and placebo groups placebo group and 31 in the dexamethasone group),
(Table 1), although a higher proportion of the pla- 1 was monoresistant to rifampin (in the dexameth-
cebo group was infected with HIV (19.9 percent vs. asone group), and 10 (5.9 percent) were resistant
16.1 percent). M. tuberculosis was cultured from the to at least isoniazid and rifampin (3 in the placebo
group and 7 in the dexamethasone group). (See the

Table 1. Baseline Characteristics of the Study Population.
Supplementary Appendix, available with the com-
Dexamethasone Placebo plete text of this article at www.nejm.org.)
Variable (N=274) (N=271)
Age — yr analysis of the primary outcome
Median 36.0 35.0 The proportion of patients with the combined out-
Range 15–88 15–84 come of death or severe disability nine months after
Male sex — no. (%) 168 (61.3) 163 (60.1) randomization did not differ significantly between
Diagnosis at discharge — no. (%) the groups, although treatment with dexametha-
Definite 98 (35.8) 89 (32.8) sone was strongly associated with improved sur-
Probable 130 (47.4) 131 (48.3) vival (Table 2). There was no significant difference
Possible 44 (16.1) 47 (17.3)
between the proportions of survivors in each treat-
Not tuberculous meningitis* 2 (0.7) 4 (1.5)
ment group with severe disability (P=0.27), with
an intermediate outcome (P=0.96), or with a good
Duration of symptoms — days†
outcome (P=0.44) (Table 3). Outcomes based on
Median 15 15
the two types of disability scores agreed in all but
Range 4–90 2–90
one survivor, who was defined as severely disabled
Weight — kg
according to the score based on the simple ques-
Median 45.0 45.0 tions and as intermediate according to the Rankin
Range 25–75 30–70 score. (See the Supplementary Appendix.)
Score on Glasgow coma scale‡
Median 14 14 analysis of secondary outcomes
Range 3–15 3–15 The time to fever clearance was significantly short-
Cranial nerve palsy — no. (%) 82 (29.9) 74 (27.3) er in the dexamethasone group than in the place-
Hemiparesis — no. (%) 48 (17.5) 37 (13.7) bo group (median, 9 vs. 11 days; P=0.03), but there
Paraparesis — no. (%) 28 (10.2) 11 (4.1) was no significant difference between the dexa-
MRC grade — no. (%)§ methasone and placebo groups in the time to coma
I 90 (32.8) 86 (31.7) clearance (median, 9 vs. 11 days, respectively;
II 122 (44.5) 125 (46.1) P=0.23) or the time to hospital discharge (median,
III 62 (22.6) 60 (22.1) 44 vs. 54 days; P=0.57).
HIV status — no. (%)
Relapse occurred in 89 patients (16.3 percent),
Positive 44 (16.1) 54 (19.9)
41 (15.0 percent) in the dexamethasone group and
48 (17.7 percent) in the placebo group (P=0.42),
Negative 227 (82.8) 209 (77.1)
with no significant difference in the time to relapse
Not tested 3 (1.1) 8 (3.0)
between the groups (median, 41 days in the dexa-
Lymphocyte count — per mm3¶
methasone group vs. 38 days in the placebo group;
CD4 cells
P=0.12).
Median 64 66
In patients who had hemiparesis or paraparesis
Range 14–694 7–359 at baseline, hemiparesis resolved by nine months
CD8 cells in 36 of 48 patients (75.0 percent) who were given
Median 606 386 dexamethasone and in 30 of 37 patients (81.1 per-
Range 134–998 28–1001 cent) given placebo (P=0.51). Paraparesis resolved
in 19 of 28 patients (67.9 percent) given dexameth-
* Alternative diagnoses were made only with histologic or microbiologic evi- asone and in 9 of 11 (81.8 percent) given placebo
dence.
† Data were missing for one patient in each group. (P=0.46). In patients without hemiparesis at base-
‡ Scores on the Glasgow Coma Scale range from 3 (worst) to 15 (best), line, hemiparesis was present by nine months in
with 13 or higher indicating only mild brain injury. 14 of 226 patients (6.2 percent) in the dexametha-
§ MRC denotes British Medical Research Council criteria. Grade I indicates
a Glasgow coma score of 15 with no neurologic signs, grade II a score of 11 sone group and 11 of 234 (4.7 percent) in the pla-
to 14 (or 15 with focal neurologic signs), and grade III a score of 10 or less. cebo group (P=0.48). Paraparesis was present in
¶ CD4 and CD8 cell counts were performed only for HIV-infected patients. The 11 of 246 patients who did not have paraparesis at
counts were not performed in 12 of 54 HIV-infected patients in the placebo
group and 6 of 44 in the dexamethasone group. baseline (4.5 percent) in the dexamethasone group
and 11 of 260 (4.2 percent) in the placebo group
Table 2. Outcome Nine Months after Randomization, According to Disease-Severity Grade and HIV Status.*
Relative Risk
Outcome and Group Dexamethasone Placebo (95% CI) P Value
no./total no. (%)
Death
All patients 87/274 (31.8) 112/271 (41.3) 0.69 (0.52–0.92) 0.01
Grade
I 15/90 (16.7) 26/86 (30.2) 0.47 (0.25–0.90) 0.02
II 38/122 (31.1) 50/125 (40.0) 0.71 (0.46–1.1) 0.11
III 34/62 (54.8) 36/60 (60.0) 0.81 (0.51–1.29) 0.38
Relative risk of death stratified ac- 0.68 (0.52–0.91) 0.007
cording to grade†
HIV status
Negative 57/227 (25.1) 67/209 (32.1) 0.72 (0.51–1.02) 0.07
Positive 27/44 (61.4) 37/54 (68.5) 0.86 (0.52–1.41) 0.55
Undetermined 3/3 (100) 8/8 (100) 1.16 (0.71–1.91) 0.71
Relative risk of death stratified ac- 0.78 (0.59–1.04) 0.08
cording to HIV status‡
Dexamethasone Placebo Odds Ratio P Value
no./total no. (%)
Death or severe disability
All patients 121/274 (44.2) 134/271 (49.4) 0.81 (0.58–1.13) 0.22
Grade
I 19/90 (21.1) 30/86 (34.9) 0.50 (0.25–0.98) 0.04
II 57/122 (46.7) 61/125 (48.8) 0.92 (0.56–1.52) 0.74
III 45/62 (72.6) 43/60 (71.7) 1.05 (0.47–2.31) 0.91
Odds ratio stratified according to 0.79 (0.56–1.13) 0.20
grade§
HIV status
Negative 93/230 (40.4) 96/217 (44.2) 0.86 (0.59–1.25) 0.42
Positive 28/44 (63.6) 38/54 (70.4) 0.74 (0.32–1.72) 0.48
Undetermined 3/3 (100) 8/8 (100) — —
Odds ratio stratified according to 0.87 (0.62–1.24) 0.44
HIV status¶
* Grade I indicates a Glasgow coma score of 15 with no neurologic signs, grade II a score of 11 to 14 (or 15 with focal neu-
rologic signs), and grade III a score of 10 or less. Scores on the Glasgow Coma Scale range from 3 (worst) to 15 (best).
CI denotes confidence interval.
† For this test of heterogeneity, P=0.62.
‡For this test of heterogeneity, P=0.55.
§ For this test of heterogeneity, P=0.27.
¶ For this test of heterogeneity, P=1.00.
(P=0.89). There were no significant differences of death or severe disability nine months after ran-
between the groups in the proportions of survivors
domization when we analyzed subgroups defined
with clinically defined hearing loss or with reduced
by disease-severity grade at baseline (Table 2). How-
visual acuity. ever, dexamethasone was associated with a signifi-
cantly reduced risk of death after stratification ac-
prespecified subgroup analyses cording to the grade of disease.
Dexamethasone treatment was not associated with The case fatality rate was higher among HIV-
a significant reduction in the combined outcome infected patients than among uninfected patients
Table 3. Outcomes of 545 Patients Nine Months after Randomization. A All Patients
9-mo
No. of
follow-up
Group Patients Outcome 1.0
Inter- Severe Dexamethasone

0.8
Proportion Surviving
Good mediate Disability Death
number (percent) 0.6
Dexamethasone* 274 104 (38.0) 49 (17.9) 34 (12.4) 87 (31.8) Placebo
Placebo 271 95 (35.1) 42 (15.5) 22 (8.1) 112 (41.3) 0.4
* Because of rounding, the percentages for the dexamethasone group do not 0.2
total 100. P=0.01
0.0
0 100 200 300
Days
(65.3 percent vs. 28.4 percent overall, P<0.001) re- No. at Risk
gardless of treatment assignment. Although the Dexamethasone 271 206 192 165 44
Placebo 274 179 163 146 37
number of HIV-infected patients was small, deaths
in this group occurred at a constant rate through- B Patients Not Infected with HIV
out the 9 months of treatment, whereas deaths be- 9-mo
came infrequent after 50 days among patients not follow-up
1.0
infected with HIV (Fig. 2). The effect of dexameth- Dexamethasone
asone on the combined end point of death or dis- 0.8
ability and on death alone was homogeneous across
0.6 Placebo
the HIV subgroups, although the stratified sub-
group analyses failed to confirm a significant asso- 0.4
ciation between dexamethasone and improvement
in either outcome (Table 2). 0.2
The effect of dexamethasone treatment was ho- P=0.06
0.0
mogeneous across the subgroups defined accord- 0 100 200 300
ing to whether the patients had definite, probable, Days
or possible tuberculous meningitis (tests of het-
No. at Risk
erogeneity, P=0.11 for death or severe disability; Dexamethasone 227 182 172 132 44
P=0.53 for death) and was associated with a re- Placebo 209 147 139 131 37
duced risk of death (stratified relative risk, 0.68; 95

C Patients Infected with HIV
percent confidence interval, 0.52 to 0.91; P=0.007). 9-mo
Multivariable analysis of baseline characteris- 1.0
follow-up
tics revealed that death was independently associ-
ated with a Glasgow coma score of 10 or less, hemi- 0.8
paresis, previous treatment for tuberculosis, the Dexamethasone

presence of extraneural or pulmonary tuberculo- 0.6
sis, HIV infection, a low hematocrit, a low cerebro-
0.4
Placebo
0.2
Figure 2. Kaplan–Meier Survival Estimates According to P=0.55
Treatment Group. 0.0
0 100 200 300
Panel A shows all 545 patients. Panel B shows the 436
patients who were not infected with HIV, and Panel C Days
shows the 98 HIV-infected patients. The HIV status of 11 No. at Risk
patients was not determined and was excluded from this Dexamethasone 44 24 20 16 4
analysis. P values were determined with the log-rank test. Placebo 54 29 21 17 5
spinal fluid leukocyte count, a low ratio of cerebro- steroids reduced disability.11 We assessed disability
spinal fluid glucose to plasma glucose, an adverse by means of two scores that have been well vali-
event requiring alteration to the antituberculosis- dated for the assessment of outcomes after stroke
drug dose or regimen, and treatment with placebo. in the developed world13 but not for other diseases
in different settings. We sought to reduce intraob-
exploratory subgroup analysis server and interobserver variability by training four
Heterogeneity of treatment effect was examined experienced Vietnamese physicians to assess all sur-
among subgroups defined by age (≤18 years vs. >18 vivors, and there was excellent agreement in the
years) and by duration of symptoms at presenta- scores they assigned. However, the scores may have
tion (≤15 days vs. >15 days). Heterogeneity was lacked discriminative power in this setting, and we
found to be absent with respect to death (P=0.87 for may have failed to detect a true effect. Data concern-
age, P=0.61 for duration of symptoms) and death ing focal neurologic sequelae suggest this failure
or severe disability (P=0.39 for age, P=0.49 for is unlikely — dexamethasone did not affect the inci-
duration of symptoms). A significant reduction in dence or resolution of hemiparesis, paraparesis, or
the risk of death was observed after stratification quadriparesis, which are the most common causes
according to age (relative risk, 0.69; 95 percent of severe disability due to tuberculous meningitis.
confidence interval, 0.52 to 0.93; P=0.01) and du- Previous smaller studies have reported similar find-
ration of symptoms (relative risk, 0.69; 95 percent ings; the authors hypothesized that corticosteroids
confidence interval, 0.52 to 0.92; P=0.01). exert an effect by reducing basal meningeal inflam-
mation and brain-stem encephalopathy but do not
adverse events modify infarct-causing periarteritis.10
Significantly more adverse events were reported Dexamethasone may improve outcomes by re-
in the placebo group than in the dexamethasone ducing the frequency of adverse events that ne-
group (214 of 271 vs. 186 of 274, P=0.005); signif- cessitate a change in the antituberculosis-drug
icantly more were severe in the placebo group than dose or regimen (such change was an indepen-
in the dexamethasone group (45 of 271 vs. 26 of dent risk factor for death in our study) — severe
274, P=0.02) (Table 4). In particular, eight severe clinical hepatitis, in particular. Studies of pulmo-
cases of hepatitis (one fatal) occurred in the place- nary tuberculosis showed that corticosteroids re-
bo group, and none occurred in the dexamethasone duced the incidence of severe drug-hypersensitivity
group (P=0.004). The following adverse events led reactions,15,16 but this effect has not been docu-
us to stop the study drug in 12 patients (5 in the dex- mented for other forms of tuberculosis and is not
amethasone group and 7 in the placebo group): widely recognized. No increase in corticosteroid-
gastrointestinal bleeding in 6 (3 in each group), bac- related adverse events was observed in our study.
terial sepsis in 4 (3 in the placebo group), and hyper- There are no previous data from controlled trials
tension in 2 (1 in each group). The antituberculosis- of corticosteroids for HIV-associated tuberculous
drug dose or regimen was altered because of an meningitis. The 98 HIV-infected patients recruit-
adverse event on 62 occasions in the dexametha- ed to our trial were severely immunocompro-
sone group and on 81 occasions in the placebo mised (median CD4 lymphocyte count, 66 per cubic
group, and changes in drug therapy were indepen- millimeter), and none were treated with antiretro-
dently associated with death. viral drugs. These patients had a higher case fatal-
ity rate than the patients who were not infected with
discussion HIV, and although it was not possible to determine
the cause of death, undiagnosed opportunistic in-
The results of this study show that adjunctive treat- fections may have been a factor. The treatment effect
ment with dexamethasone improved survival in of dexamethasone was homogeneous across HIV
patients over 14 years of age with tuberculous men- subsets, and stratified subgroup analysis showed
ingitis, but when the outcome measure was broad- that dexamethasone was associated with a reduc-
ened to death or severe disability, there was no sig- tion in the risk of death that was not significant
nificant benefit. Meta-analysis of previous data is (P=0.08). The numbers of HIV-infected patients
difficult, given variable methods of outcome assess- were too small for us to confirm or reject confident-
ment, loss to follow-up, and small numbers of sur- ly a treatment effect, and the results may not be
vivors, but earlier studies suggested that cortico- generalizable to populations with access to antiret-
Table 4. Adverse Events According to Severity and Treatment Group.*
Dexamethasone Placebo P Dexamethasone Placebo P

Event (N=274) (N=271) Value (N=274) (N=271) Value
no. with nonsevere event no. with severe event
Subclinical hepatitis† 42 50 0.39 0 0
Clinical hepatitis‡ 3 6 0.34 0 8 0.004
Gastrointestinal bleeding§ 4 6 0.76 2 3 0.68
Bacterial sepsis¶ 5 7 3 4 0.72
Septic shock 0 0 3 0 0.25
Brain herniation syndrome 0 0 1 4 0.21
Decrease in visual acuity 7 9 0.78 6 8 0.77
Hyponatremia (plasma sodium 4 7 0.53 1 6 0.07
<130 mmol/liter)
Hyperglycemia (fasting plasma 3 2 1.00 0 0
glucose >7.8 mmol/liter)
Hypertension (>160/95 mm Hg 1 4 0.21 0 0
for >2 days)
Vertigo 18 21 0.71 0 0
Deafness (on clinical examina- 4 4 1.00 3 3 1.00
tion)
Cushing’s features 10 2 0.04 0 0
Pruritus 4 8 0.37 0 0
Polyarthralgia 1 4 0.21 0 0
Streptomycin reaction¿ 1 3 0.37 0 0
Rifampin flu** 3 4 0.72 0 0
Rash 9 4 0.27 1 0 1.00
Other†† 44 32 0.19 6 9 0.59
Total 160 169 0.39 26 45 0.02
* A severe event was defined as any event causing or threatening to cause prolonged hospital stay, disability, or death.
† Subclinical hepatitis was defined as an increase in the aspartate aminotransferase or alanine aminotransferase level to
more than twice the upper limit of normal that was not accompanied by clinical signs of hepatitis (e.g., jaundice, liver
enlargement or tenderness, or vomiting).
‡ Clinical hepatitis was defined as an increase in the aspartate aminotransferase or alanine aminotransferase level to
more than twice the upper limit of normal that was accompanied by clinical signs of hepatitis (e.g., jaundice, liver en-
largement or tenderness, or vomiting).
§ Gastrointestinal bleeding was defined as oral or rectal gastrointestinal bleeding on visual inspection.
¶ Bacterial sepsis was confirmed microbiologically in blood or another sterile site of secondary pyogenic bacterial
infection.
¿ Streptomycin reaction was defined as local or systemic reaction to the intramuscular injection of streptomycin.
** Rifampin flu was defined as persistent fever and influenza-like symptoms temporally related to the ingestion of rifam-
pin (the symptoms stopped when the drug was stopped and recurred when the drug was restarted) with the exclusion
of other possible infective diagnoses.
†† “Other” denotes events that were reported fewer than four times.
roviral drugs. These data suggest, however, that tients over 14 years of age with tuberculous men-
dexamethasone is safe and may be of benefit in this ingitis, regardless of disease severity. However,
group of patients. Future studies should include dexamethasone probably does not prevent severe
patients who are taking antiretroviral drugs, and disability in the survivors.
such patients should be monitored carefully for Supported by the Wellcome Trust. Dr. Thwaites is a Wellcome
opportunistic infections. Trust Clinical Research Fellow, Dr. Farrar is a Wellcome Trust Senior
In summary, this study provides clinical evidence Fellow, and Professor White is a Wellcome Trust Principal Fellow.
We are indebted to the doctors and nurses at Pham Ngoc Thach
that early treatment with dexamethasone and anti- Hospital and the Hospital for Tropical Diseases who cared for the
tuberculosis drugs improves survival among pa- patients; to the administrative and laboratory staff of Pham Ngoc
Thach Hospital — in particular, Miss Dai Viet Hoa, Dr. Mai Nguyet [Oxford University, United Kingdom]); to Professor Peto for advice
Thu Huyen, Mr. Tran Huu Loc, and Miss Pham Hoang Anh; to the regarding the design and execution of the trial; to Professor Steve
data and safety monitoring committee (Dr. Julie Simpson [Cancer Ward (Liverpool University, United Kingdom) for measuring dexa-
Epidemiology Center, Victoria, Australia], Professor Charles Warlow methasone concentrations in vials of placebo and active drug; and to
[Edinburgh University, United Kingdom], and Professor Tim Peto all the patients who participated in the trial.
references
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The new england journal of medicine

Dexamethasone for the Treatment

n engl j med 351;17 www.nejm.org october 21, 2004 1741

diseases (Hospital for Tropical Diseases) in south-

t uberculous meningitis is the se-

rologic deficits in more than half of those affected

1742 n engl j med 351;17 www.nejm.org october 21 , 2004

n engl j med 351;17 www.nejm.org october 21, 2004 1743

1744 n engl j med 351;17 www.nejm.org october 21 , 2004

618 Patients assessed for eligibility

545 Patients enrolled

271 Patients received 274 Patients received

5 Patients lost to follow-up

271 Patients included 274 Patients included

Figure 1. Study Design.

n engl j med 351;17 www.nejm.org october 21, 2004 1745

group and 7 in the dexamethasone group). (See the

1746 n engl j med 351;17 www.nejm.org october 21 , 2004

n engl j med 351;17 www.nejm.org october 21, 2004 1747

Inter- Severe Dexamethasone

Placebo 271 95 (35.1) 42 (15.5) 22 (8.1) 112 (41.3) 0.4

duced risk of death (stratified relative risk, 0.68; 95

paresis, previous treatment for tuberculosis, the Dexamethasone

1748 n engl j med 351;17 www.nejm.org october 21 , 2004

n engl j med 351;17 www.nejm.org october 21, 2004 1749

Table 4. Adverse Events According to Severity and Treatment Group.*

Dexamethasone Placebo P Dexamethasone Placebo P

1750 n engl j med 351;17 www.nejm.org october 21 , 2004

full text of all journal articles on the world wide web

n engl j med 351;17 www.nejm.org october 21, 2004 1751

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