The optimal management of TBM complications like opto-chiasmatic arachnoiditis, spinal arachnoiditis, vasculitic infarcts, tuberculomas (esp. paradoxical as well as persisting lesions), and hydrocephalus remains to be defined. These patients are managed by the continuation of ATT and administration of high-dose systemic corticosteroids. Some authors suggest more aggressive immunomodulation.

The present study included 59 patients of Opto-chiasmatic arachnoiditis, 33 patients of spinal arachnoiditis with myelitis, and 27 patients with a paradoxical increase in the size of tuberculomas on follow-up despite being on full dose anti-tubercular drugs (ATT) and steroids. Imaging (Baseline MRI and follow-up MRI at 3 months and 1 year of treatment) was done in all patients.

The mean duration of appearance of vision loss despite being on treatment varied from 4 weeks to 9 months. The patients with spinal arachnoiditis with myelitis showed worsening from 2 weeks to 6 months, and a paradoxical response was observed as late as 8 months in a few patients.

All these patients were treated with Thalidomide at the dose of 2-3 mg/ kg body weight (Range of 50-150 mg/ day), which was continued for an average of 6 months duration.

Of 59 patients with vision loss, 39 patients showed clinical improvement in visual acuity, while 21 out of 33 patients with spinal arachnoiditis showed clinical improvement, and 18 out of 27 patients showed either reduction or healing of tuberculomas after starting this immunomodulation. Baseline MRI in most patients (>95%) showed abnormalities in the form of arachnoiditis, tuberculomas, etc., which on 2-3-month follow-up Imaging showed worsening of radiological features and responded well after starting Thalidomide.

Thalidomide is a promising immunomodulator, especially in complicated TBM cases due to worsening arachnoiditis and tuberculomas.