Efficacy and Safety of Corticosteroids in Tuberculous Meningitis: Systematic Review, Meta-Analysis, and Meta-Regression.

BACKGROUND

Tuberculous meningitis (TBM) carries a case fatality rate of up to 50% in resource-limited settings despite standard anti-tuberculosis therapy. Adjunctive corticosteroids are widely recommended, yet their effect on mortality and safety across diverse populations remains imprecisely defined.

METHODS

We conducted a systematic review and meta-analysis of randomized and quasi-randomized controlled trials identified through PubMed, Cochrane Library, ClinicalTrials.gov, Scopus, and Google Scholar up to May 2025. The outcomes were all-cause mortality, gastrointestinal bleeding, visual and auditory impairment, hydrocephalus, and joint disorders. Statistical heterogeneity was assessed using the I2 statistic. Certainty of evidence was assessed with the GRADE framework.

RESULTS

Eleven studies enrolling 1917 patients were included. Corticosteroids significantly reduced all-cause mortality (RR = 0.84, 95% CI: 0.76-0.94, p = 0.002) with low heterogeneity (I2 = 0%). Subgroup analysis revealed pronounced benefits in low-income countries (RR = 0.82, CI: 0.72-0.95) and dexamethasone use (RR = 0.87, CI: 0.77-0.97). In HIV-positive patients, corticosteroids did not significantly impact mortality (RR = 0.90, CI: 0.77-1.05, p = 0.18). No statistically significant increase in adverse outcomes was detected, including gastrointestinal bleeding (RR  =  0.87), visual impairment (RR  =  1.62), auditory impairment (RR  =  0.79), hydrocephalus (RR  =  0.47), or joint disorders (RR  =  0.63).

CONCLUSION

Adjunctive corticosteroids, particularly dexamethasone, significantly reduce mortality in TBM without increasing major adverse effects. The absence of benefit in HIV-positive patients highlights the need for targeted trials in this subgroup and in pediatric populations.