P-434. Role of Thalidomide in Children with Central Nervous System Tuberculosis

TL;DR

This study explores the use of thalidomide in children with central nervous system tuberculosis, showing it can reduce tuberculoma size and number when steroids are ineffective.

Contribution

The study provides evidence that thalidomide may be an effective alternative for pediatric CNS-TB patients unresponsive to steroids.

Findings

Thalidomide reduced the mean number of tuberculomas from 5.6 to 3.53.

The mean size of the largest tuberculoma decreased from 21mm to 12.13mm.

Radiological improvement was observed in 93.33% of patients after thalidomide treatment.

Abstract

Corticosteroids have long been used in the treatment of central nervous system tuberculosis (CNS-TB) to reduce local inflammation and the spread of the disease. However, in cases of non-response or paradoxical response to steroids or steroid-induced adverse effects, an alternative anti-inflammatory agent must be sought for. Thalidomide, an inhibitor of tumour necrosis factor-alpha, may play a role in reducing the disease severity in such patients. The aim of this study is to determine the role of thalidomide in the treatment of paediatric CNS-TB in a cohort of Indian children.Table 1:Clinical manifestations of the patients at presentationNote: TBM- tuberculous meningitis, PTB- Pulmonary tuberculosis, EPTB- extrapulmonary tuberculosis, IQR- interquartile range, ICP- intracranial pressure.Table 2:Radiological features of the patients before and after thalidomide exposure

Clinical manifestations of the patients at presentation

Note: TBM- tuberculous meningitis, PTB- Pulmonary tuberculosis, EPTB- extrapulmonary tuberculosis, IQR- interquartile range, ICP- intracranial pressure.

Radiological features of the patients before and after thalidomide exposure

A retrospective single centre study was conducted from December 2018 to July 2024 and included 16 children less than 18 years of age, diagnosed with CNS-TB, having persistent tuberculomas in spite of steroid and anti-tubercular therapy (ATT), and having received thalidomide at 3 mg/kg/day. Radiological assessment for the number and size of tuberculomas pre- and post-thalidomide was done to determine the therapeutic response. Adverse reactions to steroids and thalidomide were also determined.Table 3:Adverse effects of anti-tubercular therapy, thalidomide and steroidsNote: ATT- anti-tubercular therapy.Table 4:Individual patient characteristics including radiological, treatment and outcome details.Note: Lt- left, Rt- right, CPA- cerebellopontine angle, MCP- middle cerebellar peduncle, SE- subependymal, MCA- middle cerebral artery, NA- not available

Adverse effects of anti-tubercular therapy, thalidomide and steroids

Note: ATT- anti-tubercular therapy.

Individual patient characteristics including radiological, treatment and outcome details.

Note: Lt- left, Rt- right, CPA- cerebellopontine angle, MCP- middle cerebellar peduncle, SE- subependymal, MCA- middle cerebral artery, NA- not available

The mean age at presentation was 10.38±3.37 years with a male-to-female ratio of 1:3. Thirteen (81.25%) patients had TB meningitis, and 14 (87.5%) had tuberculomas at presentation. The mean number of tuberculomas pre- and post-thalidomide was 5.6±1.68 and 3.53±1.36, respectively (p=0.001). The mean size of the largest tuberculoma pre- and post-thalidomide was 21±10.62mm and 12.13±6.55mm, respectively (p=0.044). Radiological improvement post-thalidomide was seen in 14 (93.33%) out of 15 patients. The mean duration of thalidomide received was 10.25±4.9 months, and the mean duration of ATT received was 29.06±14.91 months. Anemia was seen in 10 (62.5%) patients, hepatotoxicity in 4 (25%) patients, thrombocytopenia in 2 (12.5%) patients, and a skin rash in 1 (6.25%) patient.

Thalidomide can significantly reduce the size and number of tuberculomas in pediatric CNS-TB patients, particularly in those who are steroid unresponsive or develop a paradoxical reaction to steroid and ATT.

All Authors: No reported disclosures

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