Response is gradual—there may be no clinical improvement
in the first two weeks—and even after one year of
treatment, relapses may be seen. At that stage, it may be
difficult to decide whether relapse is caused by ongoing
infection or a paradoxical treatment reaction. Late expansion
of a tuberculoma is a well recognised, albeit incompletely
understood, immunological phenomenon. In such circumstances,
continuing treatment with a combination of antituberculous
drugs and high dose corticosteroids is empirical
but unavoidable, until stabilisation and the beginning of
resolution are seen. The use of adjunctive corticosteroids at
the beginning of a course of anti-TBM treatment remains
controversial.9 There is more convincing evidence of benefit
in children. In adults, coma at presentation is an indication.
The dose is typically dexamethasone 16 mg/day (or an
equivalent high dose of prednisolone) for the first 2–4 weeks
of anti-TBM treatment, then tapering to zero over a similar
period.