Can central nervous system (CNS) tuberculosis (TB) cause pyogenic ventriculitis?

Can CNS Tuberculosis Cause Pyogenic Ventriculitis?

Yes, CNS tuberculosis can cause ventriculitis, though it is technically tuberculous ventriculitis rather than pyogenic ventriculitis—these are distinct entities with different causative organisms, clinical presentations, and management approaches.

Understanding the Distinction

Tuberculous Ventriculitis

• Tuberculous ventriculitis is a rare but recognized complication of tuberculous meningitis, caused by Mycobacterium tuberculosis infection of the ventricular ependymal lining 1, 2.
• This represents an inflammatory infection of the ventricular system that can develop during treatment of CNS tuberculosis 1.
• The condition manifests with characteristic MRI findings including contrast enhancement of the ependymal wall, restricted diffusion, hydrocephalus, and potentially intraventricular septations with sequestered ventricles 2.

Pyogenic Ventriculitis

• Pyogenic ventriculitis is caused by bacterial pathogens (predominantly gram-negative organisms like Acinetobacter baumannii, Klebsiella pneumoniae, and Pseudomonas species), not by M. tuberculosis 3, 4.
• This is a suppurative infection with purulent CSF and carries a mortality rate of approximately 26% even with aggressive treatment 3.

Clinical Presentation of Tuberculous Ventriculitis

When CNS tuberculosis causes ventriculitis, patients typically present with:

• Papilledema (present in all reported cases) 2
• Seizures (occurring in approximately 80% of cases) 2
• Hemiparesis and vision loss (each in about 40% of cases) 2
• Signs of increased intracranial pressure and hydrocephalus 2

The condition may develop in patients with preceding pulmonary/pleural tuberculosis or in those already receiving treatment for tuberculous meningitis 2.

Diagnostic Imaging Features

MRI Characteristics Specific to Tuberculous Ventriculitis

• Contrast enhancement of the ependymal wall of lateral and/or fourth ventricles with restricted diffusion 2
• Hydrocephalus (universal finding) 2
• Intraventricular septations with sequestered ventricles (60% of cases) 2
• Ventricular sludge (40% of cases) 2
• Hyperintense ependymal wall on magnetization transfer (MT) images, which may suggest tuberculous etiology 2

These imaging features differ from pyogenic ventriculitis, which shows irregular debris in dependent portions of ventricles, periventricular hypodensities, and different enhancement patterns 5.

Management Approach

For Tuberculous Ventriculitis

Treatment requires prolonged antituberculous therapy (18 months or longer) combined with high-dose corticosteroids and aggressive supportive care 1, 2:

• Initial intensive phase: INH, RIF, PZA, and EMB for 2 months 6
• Continuation phase: INH and RIF for an additional 7-10 months minimum 6
• Total duration may extend to 18 months for ventriculitis complications 2
• Adjunctive corticosteroid therapy with dexamethasone or prednisolone tapered over 6-8 weeks is strongly recommended for CNS tuberculosis 6

Surgical Interventions

• Approximately 80% of patients with tuberculous ventriculitis require ventriculoperitoneal shunt placement for symptomatic hydrocephalus 2
• Patients with sequestered temporal lobe ventricles may require urgent surgical intervention (temporal lobectomy) if they develop acute deterioration with impending herniation 2

Key Clinical Pitfalls

Common Diagnostic Errors

• Failing to recognize tuberculous ventriculitis as a distinct entity from pyogenic ventriculitis leads to inappropriate antibiotic selection 1, 2
• Tuberculous ventriculitis can develop paradoxically during treatment of tuberculous meningitis, mimicking treatment failure 6, 1
• The condition is significantly under-recognized despite the high incidence of tuberculous meningitis in developing countries 2

Management Considerations

• Brainstem encephalitis patterns with autonomic dysfunction, myoclonus, and cranial neuropathies can indicate tuberculosis as the underlying CNS infection 6
• In immunocompromised patients with CNS tuberculosis, IRIS (immune reconstitution inflammatory syndrome) can cause expanding CNS lesions that may be mistaken for ventriculitis progression 6
• For patients with CNS tuberculosis and HIV co-infection, antiretroviral therapy should be delayed until 8 weeks after starting antituberculous treatment to avoid severe neurological IRIS complications 6

Prognosis

With appropriate treatment, approximately 80% of patients with tuberculous ventriculitis recover, though most require CSF diversion procedures 2. However, some patients may remain in a persistent vegetative state if severe neurological damage occurred before infection control 3.