Can tuberculous meningitis cause psychosis as a complication?

Can Tuberculous Meningitis Cause Psychosis?

Yes, tuberculous meningitis can lead to psychosis, though this occurs indirectly through structural complications—most notably hydrocephalus—rather than as a direct manifestation of the infection itself.

Mechanism of Psychosis in TB Meningitis

The pathway from tuberculous meningitis to psychotic symptoms operates through several well-documented complications:

Hydrocephalus as the Primary Culprit

• Hydrocephalus develops in 42–80% of TB meningitis patients and represents the single most surgically treatable complication 1
• Normal-pressure hydrocephalus (NPH) secondary to tuberculous meningitis can produce psychotic symptoms that completely resolve after ventriculoperitoneal shunt placement 2
• One documented case showed a patient with periodic psychosis following tuberculous meningitis who had received over 120 electroconvulsive therapy treatments; her psychotic symptoms ceased entirely after ventriculo-atrial shunting, with 5-year follow-up confirming sustained remission 2

Other Neurological Complications Contributing to Psychiatric Symptoms

• Cognitive impairment occurs in 12% of long-term survivors and represents one of the most common persistent deficits 3
• Stroke occurs in 33% of patients due to vasculitis affecting the basal ganglia, which is a major determinant of morbidity and mortality 3, 4
• Tuberculomas develop in 3% of cases and can cause focal neurological effects depending on location 3

Clinical Recognition and Imaging

When to Suspect Hydrocephalus-Related Psychosis

• Look for the triad of gait disturbance, dementia, and urinary incontinence alongside psychiatric symptoms 2
• MRI is strongly preferred over CT for superior resolution when intracranial complications are suspected 1
• The combination of meningeal enhancement plus any degree of hydrocephalus on imaging is strongly suggestive of TB meningitis 4

Critical Pitfall to Avoid

• Do not attribute psychotic symptoms solely to primary psychiatric illness in patients with a history of tuberculous meningitis—always obtain neuroimaging to exclude hydrocephalus 2
• Delaying neurosurgical consultation when hydrocephalus is identified increases mortality 1

Management Algorithm

Immediate Actions for Suspected TB Meningitis with Psychiatric Symptoms

1. Obtain MRI brain immediately to identify hydrocephalus, tuberculomas, or infarcts 1
2. Initiate four-drug anti-TB therapy (isoniazid, rifampicin, pyrazinamide, ethambutol) for 2 months, followed by isoniazid + rifampicin for 7–10 additional months (total 9–12 months) 5, 6
3. Start adjunctive dexamethasone 12 mg IV daily (or prednisolone 60 mg oral daily) tapered over 6–8 weeks, which reduces mortality by approximately 25% 5, 6

Neurosurgical Referral Criteria

• Immediate neurosurgical consultation is mandatory for:
  • Hydrocephalus requiring shunt placement 1
  • Tuberculous cerebral abscess 1
  • Paraparesis or spinal cord compression 1
• For obstructive hydrocephalus specifically, placement of an external ventricular drain is indicated 1

Prognosis and Long-Term Sequelae

• Approximately 50% of tuberculous meningitis patients die or suffer severe neurologic disability 7
• Among 81 long-term survivors in one cohort, cognitive impairment (12%) and epilepsy (11%) were the most common persistent complications 3
• Psychotic symptoms related to hydrocephalus can completely resolve with appropriate surgical intervention 2

Key Takeaway for Clinical Practice

Screen any patient with psychiatric symptoms and a history of tuberculous meningitis—or current suspected TB meningitis—with brain MRI to identify hydrocephalus, which is both common (42–80% of cases) and potentially reversible with neurosurgical intervention 1, 2. The psychosis is not a direct effect of the infection but rather a consequence of structural complications that require specific treatment beyond anti-tuberculosis therapy alone.