Cerebrospinal fluid shunt infections in children over a 13-year period: anaerobic cultures and comparison of clinical signs of infection with Propionibacterium acnes and with other bacteria

Activity of an antimicrobial hydrocephalus shunt catheter against Propionibacterium acnes

Shunt infection is a major complication affecting approximately 10% of procedures. Propionibacterium acnes, an anaerobic skin bacterium, is increasingly recognized as a shunt pathogen, causing up to 14% of infections. Though susceptible to penicillin and cephalosporins, P. acnes shunt infections are not preventable by means of perioperative prophylaxis, due to poor cerebrospinal fluid penetration. Antimicrobial shunts with activity against staphylococci are available, but their activity against P. acnes is unknown, and the study was designed to determine this. Three methods of evaluation were used in order to determine the emergence of resistance when exposure is to high inocula for long periods, the time taken to kill 100% of the bacteria attached to the shunt, and the duration of activity under constant flow conditions with repeated bacterial challenge. Despite repeated exposure to high bacterial inocula over 70 days, no resistance was seen. The time taken to kill all attached bacteria, 96 h, was twice that taken to kill attached staphylococci. Nevertheless, under constant flow conditions with repeated challenges, the antimicrobial catheters resisted colonization by P. acnes for 56 days. Using tests that were designed to be clinically predictive when done together, the results suggest that the antimicrobial catheters will be able to prevent colonization of hydrocephalus shunts by P. acnes.

Abdominal cerebrospinal fluid (CSF) pseudocyst presented with inferior vena caval obstruction and hydronephrosis

PURPOSE

Abdominal cerebrospinal fluid (CSF) pseudocyst is an uncommon complication of ventriculo-peritoneal shunt placement. A large pseudocyst may exert a significant pressure effect, but vascular or urological symptoms are extremely rare. We report an unusual case of a CSF pseudocyst causing inferior vena caval and ureteric obstruction.

CASE

A 14-year-old girl had previously undergone ventriculo-peritoneal shunting for congenital hydrocephalus. She developed bilateral ankle edema as the only presenting symptom of a large non-infected cerebrospinal CSF pseudocyst. The associated abdominal distension was initially attributed to obesity, and the patient was unable to communicate due to developmental delay. Imaging studies showed that the pseudocyst was causing inferior vena caval obstruction and bilateral hydronephrosis. The ankle edema and hydronephrosis resolved after aspiration of the pseudocyst and shunt revision.

CONCLUSION

Children who require CSF shunting may suffer from associated developmental delay and are frequently unable to communicate their symptomatic complaints. This case illustrated the importance of a heightened clinical suspicion in managing these patients in whom shunt failure may present with subtle and obscure signs of lower body venous congestion.

Massive ascites as unique sign of shunt infection by Propionibacterium acnes

Propionibacterium acnes (P. acnes) has been associated with shunt infection. The signs of infection are mild. We report on a case of P. acnes shunt infection presenting with massive ascites as the unique sign of CSF infection. Shunt removal, antibiotic therapy and drenaige of ascites were performed with a rapid clinical recovery.

Characteristics of individuals with hydrocephalus and their dental care needs

Hydrocephalus is considered a congenital disease affecting the central nervous system, and is characterized by accumulation of cerebrospinal fluid in the lateral ventricles of the brain causing progressive ventricular dilatation. This review paper reports on the oral characteristics of persons with hydrocephalus and discusses their dental care needs. It has been reported that patients with hydrocephalus can present chronological changes in the eruption of their teeth, changes in the occlusion, greater accumulation of plaque, and have a higher caries prevalence. Regular dental visits are needed to control caries as well as to educate the caretakers about oral hygiene for children with hydrocephalus. In addition, the dental practitioner should be careful not to put pressure on the ventricular-peritoneal drainage tube during dental treatment. Special devices are available to support the patient's head if they have macrocephally.

Rapid identification of Propionibacterium acnes from blood cultures by fluorescence in situ hybridization

A newly designed probe for rapid identification of Propionibacterium acnes by fluorescence in situ hybridization was evaluated using 111 isolates from subculture and showed 100% sensitivity and specificity. A sensitivity of 95% and a specificity of 100% were achieved with direct application on 55 blood cultures containing Gram-positive rods.

Distal revision of ventriculoperitoneal shunts using a peel-away sheath

The authors describe a new technique for revision of an occluded distal ventriculoperitoneal shunt catheter that obviates the need for laparotomy or trocar insertion into the peritoneal cavity. The authors review their early experience with 34 patients suffering from a distal ventriculoperitoneal shunt failure and treated with this technique. There were no incidents of intraabdominal injury or wound complications. In 2 patients conversion to a minilaparotomy was required for safe placement of the shunt. Proper peritoneal placement was confirmed with abdominal radiographs in all cases. This technique has been safe and effective and may be considered an alternative to traditional laparotomy or laparoscopic methods.