TB ventriculitis

   May 11, 2020  Posted in Central Nervous System, Infection

Clinical:

  • An 18 years old girl
  • Underlying beta thalassemia major on frequent blood transfusion
  • Presented with headache, fever and meningism.
  • CT brain shows ventriculitis
  • EVD inserted-pus drained.
MRI in axial plane; T2 weighted image and T1 post gadolinium
MRI brain in sagittal and coronal plane T1 post contrast

MRI findings:

  • There is a cystic lesion seen within the atrium of the left lateral ventricle with barely perceptible thin enhancing walls. It measures 2.9 x 2.8 x 2.9cm (APxWxCC).
  • Layering signal intensity seen within suggestive of sediments. Sediments are also seen within the right lateral ventricle.
  • The ventricles are dilated. The ependymal linings show marked enhancement post contrast.
  • Generalised leptomeningeal enhancement noted in both cerebral sulci extending into the visualized upper cervical region.
  • No abnormal signal intensity seen within the brain parenchyma.

Progress of patients:

  • Patient was treated as intraventricular abscess.
  • Condition worsened after one month of treatment
  • EVD inserted twice, hydrocephalus increased in severity.
  • First and second CSF sample shows no significant finding.
  • Third CSF sample positive for TB
  • Patient shows good response after antiTB treatment.

Repeat  MRI prior to anti-TB treatment:

  • Previously seen multiseptated collections involving entire right lateral ventricle are more enhancing with thickened wall.
  • Presence of debries within the right temporal horn, pocket of air seen within as noted previously.
  • The perilesional oedema more conspicious in this study compared to previous images.
  • Enhancement along the EVD are more prominent .
  • The leptomeningeal enhancement is more pronounced in this study.

Discussion:

  • Ventriculitis refers to inflammation of the ependymal lining of the cerebral ventricles.
  • Many causes can lead to ventriculitis, such as meningitis, cerebral abscess, trauma, post
    brain procedure and secondary to brain neoplasms.
  • Tuberculous ventriculitis is a rare complication of the central nervous system tuberculosis.
  • The imaging findings are abnormal meningeal enhancement predominant
    in the basal cisterns, hydrocephalus, and enhancement of the ependymal
    surface (granulomatous ependymitis) with intraventricular pus or debris.
  • Parenchymal abnormalities may be seen including masses of granulomatous
    tissue (low signal on T2WI), granulomatous abscesses (hypo- or iso or
    central hyperintensity with a hypointense rim on T2WI).
  • Vasculitis and ischaemic events can also occur.
Author: radhianahassan