Adjunctive infliximab for paradoxical reactions and immune reconstitution inflammatory syndrome in central nervous system tuberculosis: a scoping review

INTRODUCTION: Tuberculous meningitis and other forms of central nervous system tuberculosis (CNS-TB) kill or disable nearly half of affected adults. Much of the damage comes from a TNF-α-driven inflammatory response. Some patients worsen paradoxically despite effective antitubercular therapy (ATT) and corticosteroids. Infliximab, an anti-TNF-α monoclonal antibody, is increasingly used off-label in this setting. AREAS COVERED: Following PRISMA-ScR, we searched five databases and Google Scholar up to 15 July 2026. We mapped 22 studies: two retrospective cohorts, three case series, 13 case reports and four comparator studies. No randomized trial exists. In the only controlled cohort, infliximab was linked to higher six-month disability-free survival (63.3% vs 31.7%; relative risk 2.3, 95% CI 1.28-4.36). Mortality was lower (6.7% vs 21.7%), but not significantly. A low-dose (5 mg/kg) cohort reported 60% disability-free survival at three months. Response to the first dose predicted overall outcome. Serious drug-related harm was rare. EXPERT OPINION: The evidence is observational and of low certainty, but it points one way. Infliximab is a reasonable add-on for severe, steroid-refractory paradoxical reactions. It does not replace corticosteroids. A 5 mg/kg induction appears adequate. Earlier use, better patient selection and a randomized trial are the next steps.