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Intractable Intracranial Tuberculous Infection Responsive to Thalidomide: Report of Four Cases

Departments of Paediatrics and Child Health and Neurosurgery, Tygerberg Children's Hospital and Faculty of Health Sciences, Stellenbosch University, Tygerberg, South Africa, jfs{at}sun.ac.za.

Graham Fieggen, FCS SA

Department of Neurosurgery, Red Cross Children's Hospital, Cape Town, South Africa

Neil Seller, FCPaed SA

Departments of Paediatrics and Child Health and Neurosurgery, Tygerberg Children's Hospital and Faculty of Health Sciences, Stellenbosch University, Tygerberg, South Africa

Marc Mendelson, PhD

Department of Infectious Diseases, Groote Schuur Hospital, Cape Town, South Africa

Bennie Hartzenberg, MMed

Departments of Paediatrics and Child Health and Neurosurgery, Tygerberg Children's Hospital and Faculty of Health Sciences, Stellenbosch University, Tygerberg, South Africa

Paradoxical enlargement and development of new intracranial tuberculomas and tuberculous brain abscesses on adequate antituberculosis treatment are well recognized and supposedly cytokine mediated. These lesions are often unresponsive to conventional antituberculosis treatment, corticosteroids, and surgery. We therefore assessed the effect of adjunctive thalidomide, a tumor necrosis factor —modulating drug, in intractable intracranial tuberculosis that did not respond to standard medical and surgical therapy. Four consecutive children (three children with bacteriologic proof and one child with clinical evidence of intracranial tuberculosis) were studied. Three patients each had a giant tuberculous abscess, and the fourth had chronic basal arachnoiditis with progressive loss of vision. Three of the four patients had relentless neurologic deterioration, and all showed disease progression on neuroimaging despite full medical and appropriate surgical treatment. Marked clinical and neuroradiologic improvement occurred after thalidomide was added to the antituberculosis treatment regimen of these four patients. Adjunctive thalidomide might have a role in the management of intractable intracranial tuberculosis and needs further investigation in this regard. (J Child Neurol 2 0 0 6; 2 1: 3 0 1 — 3 0 8; DOI 10.2310/7010.2006.00071).

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