Management of tuberculous meningitis in children.

Tuberculous meningitis (TBM) remains the most devastating form of tuberculosis (TB). A systematic review of TBM in children reported an overall mortality risk of almost 20% [1], yet mortality has been found to be <5% in some large paediatric studies [2,3]. In several studies, severe neurological morbidity is reported in more than 50% of survivors, but this depends largely on the stage of TBM at presentation [1,4]. Because many cases go undiagnosed, little is known about the true incidence of TBM in children, and, even if diagnosed, cases may not be reported [5,6]. In Germany, a low TB-burden country, the prevalence of TBM among TB cases from 2002 to 2009 was estimated to be approximately 1% overall, but was 3.9% in children <5 years, 2.2% in children aged 5–9 years and 1.3% in children aged 10–14 years [7]. In a high TB-burden setting in the Western Cape, South Africa, 5.6% of children (<13 years) with bacteriologically confirmed TB diagnosed at hospital level between 2013 and 2017 had TBM [8]. The World Health Organization (WHO) estimated that in 2019 there were 1.19 million new cases of TB in children (0–<15 years); if 2% of these children had TBM, it would account for ~25,000 cases per year globally. This editorial briefly describes the pathogenesis of TBM in children as well as advances in diagnostics, recent developments in antimicrobial therapy and the role of therapeutic drug monitoring.