Much of the morbidity and mortality caused by tuberculous meningitis (TBM) is mediated by a dysregulated immune response. Effective host-directed therapy is therefore critical to improve survival and clinical outcomes. Currently only one host-directed therapy (HDT), corticosteroids, is proven to improve mortality. However, there is no evidence that corticosteroids reduce morbidity and the mechanism of action for mortality reduction is uncertain. Further, it has no proven benefit in HIV co-infected individuals. One promising host-directed therapy approach is to restrict the immunopathology arising from tumour necrosis factor (TNF)-α excess is via TNF-α inhibitors. There are accumulating data on the role of thalidomide, anti-TNF-α monoclonal antibodies (infliximab, adalimumab) and the soluble TNF-α receptor (etanercept) in TBM treatment. Thalidomide was developed nearly seventy years ago and has been a highly controversial drug. Birth defects and toxic adverse effects have limited its use but an improved understanding of its immunological mechanism of action suggest that it may have a crucial role in regulating the destructive host response seen in inflammatory conditions such as TBM. Observational studies at our institution found low dosage adjunctive thalidomide safe in treating tuberculous mass lesions and blindness related to optochiasmatic arachnoiditis, with good clinical and radiological response. In this review, we discuss possible mechanisms of action for thalidomide, based on our clinico-radiologic experience and post-mortem histopathological work. We also propose a rationale for its use in the treatment of certain TBM-related complications.

结核性脑膜炎 (TBM) 引起的大部分发病率和死亡率是由失调的免疫反应介导的。因此，有效的宿主导向治疗对于提高生存率和临床结果至关重要。目前只有一种宿主导向疗法 (HDT)，即皮质类固醇，被证明可以提高死亡率。然而，没有证据表明皮质类固醇可以降低发病率，降低死亡率的作用机制尚不确定。此外，它在 HIV 合并感染者中没有被证实的益处。一种有前途的宿主导向治疗方法是通过 TNF-α 抑制剂来限制由肿瘤坏死因子 (TNF)-α 过量引起的免疫病理学。关于沙利度胺、抗- TBM 治疗中的 TNF-α 单克隆抗体（英夫利昔单抗、阿达木单抗）和可溶性 TNF-α 受体（依那西普）。沙利度胺是近七十年前开发的，一直是一种备受争议的药物。出生缺陷和毒性副作用限制了它的使用，但对其免疫学作用机制的进一步了解表明，它可能在调节炎症性疾病（如 TBM）中的破坏性宿主反应中发挥关键作用。我们机构的观察性研究发现，低剂量沙利度胺辅助治疗与视交叉性蛛网膜炎相关的结核性肿块病变​​和失明是安全的，具有良好的临床和放射学反应。在这篇综述中，我们根据我们的临床放射学经验和尸检组织病理学工作，讨论了沙利度胺的可能作用机制。