Modulation of alloimmunity to major histocompatibility complex class I by cotransfer of cytokine genes in vivo

Major histocompatibility complex (MHC) class I antigen is a potent stimulus for alloimmune responses and is the principal immunologic target mediating acute cellular rejection of allografts. Using a method of direct in vivo gene transfer of cDNA encoding donor type MHC class I, we showed in a rat model that recipient muscle could express the transferred MHC class I cDNA, resulting in alloimmunization of the recipient. This was most graphically demonstrated by accelerated rejection of cardiac allografts expressing the same MHC class I as encoded by the immunizing cDNA. We now report the use of the particle-mediated gene transfer via a gene gun (Geneva, Middleton, WI, USA) to transfer MHC class I, as well as cytokine gene expression vectors, into rat skin. Compared to intramuscular injection, gene gun transfer to skin resulted in more efficient immunization. Donor-specific cytotoxic T lymphocyte (CTL) responsiveness and antibody levels increased. Furthermore, coexpression of certain cytokine genes with the MHC class I cDNA modulated the immune response. Specifically, coimmunization with IL-10 cDNA abrogated immunity to allo-MHC class I, while coimmunization with GM-CSF cDNA enhanced it. The influence of expression of these genes in skin was demonstrated by alteration of donor cardiac allograft survival. This model is useful for induction and modulation of alloimmune responses and may be used to develop gene therapy strategies to modify them.

Regulation of human luteal steroidogenesis in vitro by nitric oxide

To evaluate the effect of nitric oxide (NO.) in human corpus luteum (CL) function, we investigated the expression and the presence of NO. synthase (NOS) in the human CL and the action of NO. on the in vitro luteal steroid production. The expression of endothelial NOS (eNOS) in early, mid-, and late CL was assessed by reverse transcriptase polymerase chain reaction (RT-PCR) and the immunohistochemical study was performed in human CL histological sections by using monoclonal antibodies (MAbs) against the distinct NOS isoforms. In addition, seven human mid-CLs were enzymatically dispersed, and the cells were cultured with NO. donor compounds. Steroid production was measured in the culture media by specific radioimmunoassay. The results show that the expression of eNOS was highly detected in mid- and early CL, and to a lesser extent, in late CL. Meanwhile, the immunohistochemical study indicated that both isoenzymes of NOS were expressed in mid-human CL, eNOS being the more abundant isoform present. On the other hand, functional studies showed that NO. donors (L-arginine [L-Arg] and sodium nitroprusside) elicited an inhibitory action on steroid synthesis, preferentially on estradiol production by the luteal cell cultures (p < 0.05). In conclusion, the NO-NOS system is present in the human CL, and it may serve as a modulator of the in vitro human luteal steroidogenesis.

Rapidly progressive extensive subcutaneous emphysema associated with an implantable intratracheal oxygen catheter

Localized subcutaneous emphysema is a recognized complication of transtracheal oxygen catheters. It usually occurs in the immediate postoperative period or in association with catheter tip migration. This is a case of rapidly progressive, extensive subcutaneous emphysema apparently resulting from paroxysms of coughing in a patient with a normally functioning implanted intratracheal oxygen catheter several weeks after placement.

Regulatory role of angiotensin II on progesterone production by cultured human granulosa cells. Expression of angiotensin II type-2 receptor

The role of angiotensin II (AngII) in ovarian steroidogenesis is not clearly understood. In order to study its action on progesterone synthesis and to determine which receptor subtype is involve, granulosa cells obtained from women undergoing in-vitro fertilization were cultured for 2 or 4 days and then incubated in the presence of AngII (10(-7) M) with or without human chorionic gonadotrophin (HCG, 10 IU/ml) for 3 or 18 h. In cells cultured for 2 days, incubation with AngII decreased progesterone secretion by 36%, and inhibited activity of 3 beta-hydroxysteroid dehydrogenase (3 beta-HSD) by 87% (P < 0.05), although its expression was not significantly reduced. However, in cells cultured for 4 days, progesterone production was enhanced by incubation with AngII (38%), and no change was observed in 3 beta-HSD expression. Both inhibitory and stimulatory effects were dose-dependent. Progesterone secretion was increased (93%) by incubation with HCG of cells cultured for 4, but not for 2 days, and no potentiation was observed with AngII. Treatment with PD123177 completely blocked the action of AngII and decreased the HCG-stimulated secretion of progesterone by 27%. Angiotensin type-2 (AT2) receptor mRNA was expressed in cells cultured for 4 days. In conclusion, AngII showed a regulatory role in in-vitro progesterone production by human granulosa luteinized cells, modulating the activity of 3 beta-HSD. It is likely that these actions may be mediated via membrane receptors, possibly of the AT2 receptor family.

A sensitive immunoassay to detect the alpha-chemokine GRO in rabbit blood and lung fluids

GRO-alpha, GRO-beta and GRO-gamma are closely related peptides that stimulate growth of tumor cells and activate leukocytes in acute inflammatory reactions. In order to study the biology of GRO peptides in the lungs of experimental animals, we have developed and characterized a sensitive and specific immunoassay for rabbit GRO, and used this assay to measure GRO in rabbit lung fluids and plasma. GRO was cloned from a rabbit cDNA library and expressed in Escherichia coli. Specific goat polyclonal antibodies were used to create an antigen-capture immunoassay. The assay is sensitive to approximately 30 pg/ml GRO and does not crossreact with rabbit IL-8 or MCP-1, or human GRO. The assay accurately measures GRO in rabbit bronchoalveolar lavage fluid, plasma and serum. Rabbit erythrocytes bind little GRO and do not interfere with the detection of GRO in lung fluids. Circulating GRO was detected in the plasma of 4 of 6 pathogen-free rabbits, but the function of circulating GRO in normal animals is uncertain. This immunoassay will facilitate the study of the biology of GRO in rabbits with acute and chronic inflammation in the lungs and other tissues.

The Cooperative Cardiovascular Project in Oklahoma

BACKGROUND AND OBJECTIVES

Acute myocardial infarction is the leading cause of death in the United States and a common cause for admission of Oklahoma Medicare beneficiaries. Based on guidelines for the management of acute myocardial infarction published by a joint committee of the American College of Cardiology and the American Heart Association, the Cooperative Cardiovascular Project was developed by the Health Care Financing Administration to measure performance on quality indicators that describe care provided to Medicare beneficiaries. The objective of the project is to use those performance measures to assist hospitals in the development of quality improvement efforts for acute myocardial infarction care.

METHODS

Retrospective review was performed on the inpatient medical records of 3,436 patients from 102 hospitals in Oklahoma and a random national sample of 2,441 patients discharged with a principal diagnosis of acute myocardial infarction.

RESULTS

The diagnosis of acute myocardial infarction was confirmed in 3,055 (89%) of the cases reviewed. For patients considered to be ideal candidates for an intervention, 62% received reperfusion therapy (thrombolytic or PTCA), 84% received aspirin during the hospitalization, 76% received aspirin at discharge, and 40% received beta-blockers at discharge. There were significant variations in performance between hospital peer groups in the use of reperfusion therapy, aspirin, beta-blockers, and smoking cessation counseling.

CONCLUSIONS

Potentially life-saving treatments for Medicare patients hospitalized with an acute myocardial infarction are often underutilized. Improving quality of care for Medicare beneficiaries with acute myocardial infarction has been identified as a national priority.

Chromosome abnormalities in congenital heart disease

Refinements in cytogenetic techniques have promoted progress in understanding the role that chromosome abnormalities play in the cause of congenital heart disease. To determine if mutations at specific loci cause congenital heart disease, irrespective of the presence of other defects, and to estimate the prevalence of chromosome abnormalities in selected conotruncal cardiac defects, we reviewed retrospectively cytogenetic and clinical databases at St. Louis Children's Hospital. Patients with known 7q11.23 deletion (Williams syndrome), Ullrich-Turner syndrome (UTS), and most autosomal trisomies were excluded from this analysis. Two groups of patients were studied. Over a 6.5-year period, 57 patients with chromosomal abnormalities and congenital heart disease were identified. Of these, 37 had 22q11 deletions; 5 had abnormalities of 8p; and 15 had several other chromosome abnormalities. The prevalence of chromosome abnormalities in selected conotruncal or aortic arch defects was estimated by analysis of a subgroup of patients from a recent 22-month period. Chromosome abnormalities were present in 12% of patients with tetralogy of Fallot, 26% in tetralogy of Fallot/pulmonary atresia, 44% in interrupted aortic arch, 12% in truncus arteriosus, 5% in double outlet right ventricle, and 60% in absent pulmonary valve. We conclude that chromosome analysis should be considered in patients with certain cardiac defects. Specifically, fluorescent in situ hybridization (FISH) analysis of 22q11 is indicated in patients with conotruncal defects or interrupted aortic arch. High resolution analysis should include careful evaluation of the 8p region in patients with either conotruncal or endocardial cushion defects.

Pulmonary and systemic inflammatory responses in rabbits with gram-negative pneumonia

The major goals of this study were to define the relationships between intrapulmonary and systemic inflammatory responses in animals with gram-negative pneumonia. We treated rabbits with intrapulmonary Escherichia coli (1 x 10(7) to 1 x 10(10) cfu/ml), and then measured physiologic, cellular, and molecular events in the lungs and systemic circulation for 24 h. The treatment protocols resulted in groups of animals that mimicked the stages of the septic inflammatory response in humans. Animals treated with low inocula had systemic changes consistent with systemic inflammatory response syndrome and cleared the bacteria and inflammatory products from the lungs. Animals treated with high inocula failed to clear bacteria from the lungs, had severe intrapulmonary inflammatory responses, and developed septic shock. Intrapulmonary leukocyte recruitment was directly related to the size of the bacterial inoculum, but lung protein accumulation was not. Tumor neurosis factor-alpha (TNF-alpha), interleukin-8 (IL-8), and GRO were detectable in lung lavage fluid at 4 h and declined by 24 h in animals that cleared intrapulmonary E. coli. In contrast, lavage TNF-alpha, IL-8, and GRO increased over 24 h in animals that failed to clear intrapulmonary bacteria. MCP-1 increased between 4 h and 24 h in the lungs of all of the animals as the histologic response evolved from neutrophilic to mononuclear cell predominance. Thus, the intensity of systemic inflammatory and physiologic responses to intrapulmonary gram-negative infection depends on the inoculum size and whether the bacteria are cleared from or proliferate in the lungs. The results provide experimental support for the recently proposed classification of septic responses in humans.

Endothelial cell injury in cardiovascular surgery: the systemic inflammatory response

Many of the components currently used to perform cardiovascular operations lead to systemic insults that result from cardiopulmonary bypass circuit-induced contact activation, circulatory shock, and resuscitation, and a syndrome similar to endotoxemia. Experimental observations have demonstrated that these events have profound effects on activating endothelial cells to recruit neutrophils from the circulation. Once adherent to the endothelium, neutrophils release cytotoxic proteases and oxygen-derived free radicals, which are responsible for much of the end-organ damage seen after cardiovascular operations. Recently the cellular and molecular mechanisms of endothelial cell activation have become increasingly understood. It is conceivable that once the molecular mechanisms of endothelial cell activation are better defined, therapies will be developed allowing the selective or collective inhibition of vascular endothelial activation during the perioperative period.

The genetic basis of pediatric cardiovascular disease

Congenital heart disease (CHD), cardiomyopathy, and vasculopathies are common causes of mortality and morbidity in pediatrics, including the perinatal period. This article reviews evidence that single gene defects cause many of the pediatric heart diseases. Vasculopathies discussed include Marfan's syndrome, supravalvar aortic stenosis and Williams' syndrome, Alagille's syndrome, and hereditary telangiectasia, the Osler-Weber-Rendu syndrome. Genetic causes of hypertrophic cardiomyopathy caused by sarcomeric protein mutations (beta-cardiac myosin heavy chain) and of dilated cardiomyopathy secondary to structural protein deficiencies (dystrophin) are presented. Defects in proteins essential for myocardial energy production such as oxidative phosphorylation proteins and fatty acid oxidation genes that cause cardiomyopathy or sudden death are described. Gene ablation models in mice, such as RXR alpha and homeobox gene knockouts, which result in cardiac phenotypes resembling human congenital heart disease, are described. Familial types of human CHD which are being investigated for genetic causes by positional cloning methods and known cytogenetic causes of CHD, including the CATCH-22 syndrome and monosomy at 22q11, are presented. General lessons and principles derived from these new and exciting discoveries in human cardiovascular development are surmised.

Sensitive and specific immunoassays to detect rabbit IL-8 and MCP-1: cytokines that mediate leukocyte recruitment to the lungs

The alpha- and beta-chemokines such as IL-8 and MCP-1 direct the recruitment of neutrophils and monocytes into the lungs and other tissues. In order to study the roles of IL-8 and MCP-1 in animals models, specific reagents are required that provide accurate measurements of these cytokines in biological fluids. Here we describe the development of sensitive and specific immunoassays for rabbit IL-8 and rabbit MCP-1, and the validation of these assays in rabbit plasma and bronchoalveolar lavage fluid. The sensitivity of each assay in 0.25 ng/ml for IL-8 and 0.1 ng/ml for MCP-1. The rabbit IL-8 assay does not crossreact with rabbit GRO, another alpha-chemokine, and crossreacts only weakly with human IL-8. The rabbit MCP-1 assay does not crossreact with human MCP-1. Anticoagulants interfere with the detection of IL-8 and MCP-1 in plasma, although. EDTA has the least inhibitory effect. Heat-sensitive inhibitors in normal rabbit serum interfere with the detection of IL-8 and MCP-1, although autoantibodies to IL-8 and MCP-1 were not detected. Rabbit erythrocytes bind IL-8 and MCP-1, but erythrocyte contamination of bronchoalveolar lavage fluid causes only a small error in the detection of IL-8 and MCP-1, unless the number of erythrocytes approaches the number found in blood. These assays provide sensitive and specific means to detect IL-8 and MCP-1 in rabbit plasma and bronchoalveolar lavage fluid, and demonstrate the importance of using species-specific reagents in animal studies.

Differential expression of vasoactive intestinal peptide receptors 1 and 2 (VIP-R1 and VIP-R2) mRNA in murine lymphocytes

Vasoactive intestinal peptide (VIP), a neuropeptide present in the lymphoid microenvironment, modulates cytokine expression and affects T cell proliferation. Recent molecular studies identified two VIP receptors. VIP-R1 and VIP-R2, primarily in nonlymphoid cells. In this study, we investigate the expression of VIP-R1 and VIP-R2 mRNA in unstimulated and stimulated lymphocytes and thymocytes, and in various lymphocyte subpopulations. In contrast to VIP-R1 which is constitutively expressed, the expression of VIP-R2 is induced only following stimulation through the TCR-associated CD3 complex. Both CD4+ and CD8+ T cells express VIP-R1 and VIP-R2. Two T cell lines, EL-4.IL-2 and D10.G4.1 express exclusively VIP-R2. VIP induces the expression of the VIP-R2 gene in the absence of additional stimuli. Differential expression and regulation of the two VIP receptors in T lymphocytes suggests different physiological roles in mediating the immunomodulatory activities of VIP and related neuropeptides.

Murine T-lymphocytes express vasoactive intestinal peptide receptor 1 (VIP-R1) mRNA

Vasoactive intestinal peptide (VIP), a neuropeptide present in primary and secondary lymphoid organs has been previously reported to inhibit IL-2 and IL-4 production as well as the proliferation of mitogen- or antigen-stimulated T-cells. Binding studies suggested that the immunoregulatory effects of VIP are mediated through specific VIP-binding sites present on lymphocyte subpopulations. Here we report on the expression of VIP-R1 mRNA in various murine lymphocyte subpopulations. By using RT-PCR. RNase protection assay, cDNA cloning, and sequence analysis, we show that stimulated and unstimulated murine spleen cells, thymocytes. CD4+ and CD8+ T-cells express VIP-R1. The VIP-R1 fragment amplified from murine brain, thymocytes, spleen cells and CD4+ T-cells share identical nucleotide sequences, and a high degree of homology with the corresponding nonlymphoid rat and human VIP-R1 sequences. The expression of VIP-R1 in thymocytes and peripheral lymphocytes, and especially in the CD4+ T-cell subset supports the idea that VIP produced or released locally in the lymphoid microenvironment could directly affect cytokine production and proliferation of T-lymphocytes.

Synthesis and activity of a novel series of 3-biarylquinuclidine squalene synthase inhibitors

Quinuclidines with a 3-biaryl substituent are a new class of potent, orally active squalene synthase (SQS) inhibitors. Variants around these rigid structures indicate key structural requirements for cationic SQS inhibitors. Thus the lower in vitro potency found for quinuclidines bearing 3-substituents, which did not overlay the biphenyl group of 3-(biphenyl-4-yl)-3-hydroxyquinuclidine (2) (IC50 = 16 nM, rat microsomal SQS), implied a directional requirement for the 3-substituent. Similarly, the lower potency of the 3-terphenyl analogue 6 (IC50 = 370 nM) indicated size constraints for this substituent. In compounds with a linking group between the quinuclidine and biphenyl ring, linking groups of lower lipophilicity were less well tolerated (e.g., 17, CH2CH2, IC50 = 5 nM vs 19, NHCO, IC50 = 1.2 microM). Replacement of the distal phenyl ring of 2 with a more polar pyridine heterocycle caused a reduction in in vitro potency. In general, good in vivo activity in the rat was restricted to 3-hydroxy analogues, with the 3-[4-(pyrid-4-yl)phenyl] derivative 39 (IC50 = 161 nM) showing the best inhibition (following oral dosing) of cholesterol biosynthesis from mevalonate (ED50 = 2.7 mg/kg).

Molecular expression of the alpha-chemokine rabbit GRO in Escherichia coli and characterization of its production by lung cells in vitro and in vivo

GRO proteins are alpha-chemokine cytokines that attract neutrophils and stimulate the growth of a variety of cells. Previously, we observed that rabbit alveolar macrophages transcribe the genes for at least two GRO homologues. In order to study the role of GRO cytokines in lung inflammation, we cloned the predominant rabbit GRO cDNA (RabGRO) from alveolar macrophages, expressed bioactive recombinant protein (rRabGRO) in Escherichia coli, and developed a sensitive and specific enzyme-linked immunosorbent assay for RabGRO protein. We found that rabbit AM express and secrete GRO in vitro in response to both exogenous (e.g. lipopolysaccharide, heat-killed Staphylococcus aureus, and crystalline silica) and endogenous inflammatory stimuli (e.g. tumor necrosis factor-alpha) as determined by both radioimmunoprecipitation and enzyme-linked immunosorbent assay. Biologically significant amounts of GRO are present in vivo in the bronchoalveolar lavage fluid of rabbits with E. coli pneumonia; by in situ hybridization, GRO mRNA is detectable in infiltrating pulmonary leukocytes and bronchial epithelial cells. These results indicate that GRO chemokines are likely to be important mediators of the inflammatory response that accompanies acute infectious processes in the lungs.

Localization of insulin-like growth factor (IGF-I) and IGF-I receptor expression in human corpora lutea: role on estradiol secretion

OBJECTIVE

To determine whether insulin-like growth factor (IGF-I) and its receptors are expressed by human corpus luteum (CL) and to establish the effect of IGF-I on E2 biosynthesis in human luteal cell cultures.

DESIGN

Middle corpora lutea were obtained from women undergoing surgical sterilization. The tissue was frozen for binding and in situ studies or dispersed for cell cultures.

SETTING

Procedures were performed at the San Borja-Arriarán Hospital, National Health Service, and Institute of Maternal and Child Research, Faculty of Medicine, University of Chile.

PATIENTS

Twelve patients aged 30 to 40 years requesting surgical sterilization in our institution. The laparotomy was scheduled 6 to 8 days after ovulation.

MAIN OUTCOME MEASURES

Expression of IGF-I and IGF-I receptor messenger RNAs (mRNAs) by in situ hybridization. Concentration of IGF-I receptor and binding characteristics. Production of E2 by luteal cells.

RESULTS

The binding of IGF-I was detected in middle human CL membranes. In addition, this tissue expressed the mRNAs of IGF-I and its receptor. In culture, IGF-I caused a progressive increase on E2 production.

CONCLUSION

These data suggest that the IGF-I system is present in middle human CL. The topographic distribution of IGF-I and its receptors and the ability of IGF-I to stimulate E2 secretion strongly suggest that IGF-I has a role as a paracrine or autocrine regulator of the human luteal function.

Activation of human endothelial cells by viable or heat-killed gram-negative bacteria requires soluble CD14

In response to bacterial lipopolysaccharides (LPS; endotoxin), endothelial cells are converted to an activation phenotype expressing both proinflammatory and procoagulant properties that include the induction of leukocyte adhesion molecules and tissue factor expression. LPS-induced endothelial cell activation requires a soluble form of the monocyte LPS receptor, sCD14. We evaluated the capacity of multiple strains of gram-negative and gram-positive bacteria to induce endothelial E-selectin and tissue factor expression through sCD14-dependent pathways with cultured human umbilical vein endothelial cells (HUVE). Both viable and heat-killed gram-negative bacteria (Bacteroides fragilis, Enterobacter cloacae, Haemophilus influenzae, and Klebsiella pneumoniae) but not viable or heat-killed gram-positive bacteria (Staphylococcus aureus, Enterococcus faecalis, and Streptococcus pneumoniae) induced prominent E-selectin surface expression detected by enzyme-linked immunosorbent assay. Tissue factor activity on HUVE, indicated by factor X activation, was induced in response to gram-negative bacteria but not in response to gram-positive bacteria. Gram-negative bacteria induced transcriptional activation in HUVE, indicated by the appearance of E-selectin-specific mRNA and by the demonstration of activation of NF-kappa B, a trans-activating factor necessary for E-selectin and tissue factor gene transcription. In contrast, neither E-selectin mRNA nor activation of NF-kappa B was detected in HUVE treated with gram-positive bacteria. Endothelial cell activation by gram-negative bacteria in each of these assays was inhibited with a monoclonal antibody (60bd) against CD14. Furthermore, CHO-K1 cells, transfected with human recombinant CD14, responded to all strains of gram-negative bacteria (viable or heat killed), indicated by CHO-K1 NF-kappa B activation. We conclude that gram-negative bacteria induce endothelial cell activation through a common sCD14-dependent pathway.

Anomalous origin of the right pulmonary artery from the aorta and CATCH 22 syndrome

We report repair of anomalous origin of the right pulmonary artery from the ascending aorta in a premature neonate with a deletion in the CATCH 22 region of chromosome 22. This case suggests that the pathogenesis of anomalous origin of the right pulmonary artery involves genetically determined abnormalities of the neural crest. Repair of this defect in a premature infant can prevent the development of severe pulmonary vascular disease.

Deletion within chromosome 22 is common in patients with absent pulmonary valve syndrome

Interstitial deletions in chromosome 22 and features associated with CATCH-22 syndrome have been reported in patients with conotruncal congenital heart anomalies. Absent pulmonary valve syndrome is characterized by absent or rudimentary pulmonary valve cusps, absent ductus arteriosus, conoventricular septal defect, and massive dilation of the pulmonary arteries. Because absence of the ductus arteriosus is a key element in the pathogenesis of this syndrome and aortic arch malformations are frequently seen in patients with CATCH-22 syndrome, we hypothesized that patients with absent pulmonary valve syndrome would have a high incidence of deletions in the critical region of chromosome 22. Eight patients with absent pulmonary valve syndrome were studied. Metaphase preparations were examined with fluorescent in situ hybridization of the N25 (D22S75) probe to the critical region of chromosome 22q11.2. Deletions were detected in 6 of 8 patients. The presence of deletions in chromosome 22 in most of the patients we have examined with a diagnosis of absent pulmonary valve syndrome supports a specific genetic and embryologic mechanism involving the interaction of the neural crest and the primitive aortic arches as one cause of congenital absence of the pulmonary valve.

The genetic basis of paediatric heart disease

This review focuses on recent advances in understanding the pathogenesis of paediatric heart disease and on the known single gene defects responsible for these diseases. Many paediatric cardiovascular diseases are heritable, have clinical manifestations in adult ages, are frequent in occurrence, and can have significant social and economic impact. Specific gene defects have been identified for hypertrophic and dilated cardiomyopathies, mitochondrial cardiomyopathies, Marfan's syndrome, Williams syndrome, familial supravalvar aortic stenosis, CATCH-22 syndrome and atrioventricular canal. Limited phenotypic response of the developing heart accounts for similar cardiovascular defects from differing gene defects. Although environmental factors affect expression of many of these genes, it is clear that single gene defects can be identified which cause paediatric cardiovascular disease. Interactions among cardiologists, cardiovascular surgeons, geneticists and basic scientists are vitally important in understanding the genetic basis of paediatric heart disease, its diagnosis and its therapy.

Delayed intrapleural migration of a ventriculoperitoneal shunt

We report a case of delayed intrapleural migration of the peritoneal catheter of a ventriculoperitoneal shunt. This is an unusual but life-threatening complication of peritoneal shunting for the treatment of hydrocephalus. A method of treatment and abbreviated review of shunt complications is included.