TUBERCULOUS MENINGITIS IN ADULTS: A REVIEW OF THE ROLE OF ADJUNCTIVE CORTICOSTEROIDS, EMERGING DRUG RESISTANCE PATTERNS, AND KEY PREDICTORS OF MORTALITY AND MORBIDITY

Abstract

Background: Tuberculous meningitis (TBM) is the most severe form of extrapulmonary tuberculosis, and despite breakthroughs in antibiotic therapy and supportive care, it remains associated with high mortality and long-term neurological impairment. Delayed diagnosis, rising multidrug-resistant tuberculosis (MDR-TB), and diversity in host immunological responses all complicate therapeutic therapy and negatively impact patient outcomes. Objectives: This review objectively assesses the existing information on the role of supplementary corticosteroid therapy, growing anti-tuberculous medication resistance patterns, and the primary determinants of death and neurological morbidity in adults with tuberculous meningitis. Methods: A comprehensive narrative review was carried out using PubMed/MEDLINE, Scopus, Web of Science, Google Scholar, and the Cochrane Library. English-language research published between January 2015 and June 2026, as well as important previous articles, were reviewed using preset eligibility criteria. The study includes 78 high-quality papers, such as randomized controlled trials, cohort studies, systematic reviews, meta-analyses, and international clinical guidelines. Due to methodological heterogeneity, findings were synthesized through a thematic narrative approach. Results: Current research confirms that additive dexamethasone is still the best corticosteroid for adult TBM, with a 22-30% decrease in mortality and reduced incidences of cerebral oedema and hydrocephalus. However, its efficacy in preventing long-term neurological impairment is limited. Drug-resistant TBM, particularly multidrug-resistant and rifampicin-resistant illness, remains a significant therapeutic challenge due to delayed diagnosis, limited treatment options, protracted therapy, and poor clinical results. Delays in starting treatment, advanced disease severity, HIV coinfection, altered consciousness, low Glasgow Coma Scale score, hydrocephalus, cerebral infarction, and significant cerebrospinal fluid abnormalities are all reliable predictors of a poor prognosis. Emerging molecular diagnostic tools, particularly next-generation sequencing and Xpert MTB/RIF Ultra, have significantly higher diagnostic sensitivity than traditional cerebrospinal fluid microscopy and culture, allowing for earlier diagnosis and more immediate therapeutic intervention. Conclusion: Adult tuberculous meningitis continues to be a deadly brain infection with significant mortality and disability rates. Earlier diagnosis using improved molecular techniques, rapid beginning of optimized anti-tuberculosis medication, routine use of adjunctive corticosteroids when appropriate, and early identification of prognostic risk factors are critical for improving clinical outcomes. To further lower the worldwide burden of TBM, more research into quick diagnostics, personalized therapy techniques, host-directed medicines, and optimized treatment regimens for drug-resistant illness will be needed.