Updates in the clinical management of tuberculous meningitis.

INTRODUCTION: Tuberculous meningitis is frequently associated with significant mortality and persistent neurological sequelae. Diagnosis is often delayed due to nonspecific symptoms and the low sensitivity of cerebrospinal fluid (CSF) tests. Standard pulmonary tuberculosis regimens are suboptimal for central nervous system involvement due to poor drug penetration and prolonged treatment. Emerging resistance, particularly to rifampicin and isoniazid, further complicates the management.

AREAS COVERED: This review synthesizes recent data particularly on diagnostic tools, drug treatment, host-directed treatments, and supportive care in tuberculous meningitis. We summarize updated WHO recommendations and explore the pharmacokinetics and CSF penetration of antituberculosis drugs. Emphasis is placed on high-dose rifampicin, linezolid, and novel oxazolidinones such as sutezolid and delpazolid. Special populations, including children, pregnant women, those with human immunodeficiency virus, and drug-resistant disease are reviewed separately. The latest information of a variety of host-directed therapies is discussed. The utility of artificial intelligence for diagnosis and prognostication is also discussed.

EXPERT COMMENTARY: Despite advances, tuberculous meningitis remains a clinical challenge. Early diagnosis, optimized dosing, and host-directed therapy are key priorities. Individualized regimens based on pharmacokinetics, drug resistance, and host factors are urgently needed. Precision diagnostics, new therapeutic agents, and artificial intelligence - driven tools may reduce mortality and improve outcomes.