E. coli meningitis as an indicator of intestinal perforation by V-P shunt tube

Detection of Malpositioned VP Shunt Catheter by Radionuclide CSF Cisternography

ABSTRACT

A 37-year-old man presented with a 2-week history of abdominal pain, headaches, nausea, vomiting, and leukocytosis. Medical history includes congenital hydrocephalus, with a ventriculoperitoneal shunt placed several years ago. Radionuclide cerebrospinal fluid cisternography shows curvilinear activity in the abdomen, in the pattern of small and large bowel loops, suggesting that the tip of the catheter is inside a small bowel loop. No activity is seen in the intraperitoneal compartment. CT of the abdomen and pelvis followed by laparoscopic surgery confirmed the findings.

Bowel perforation of ventriculoperitoneal shunt catheter: endoscopically treated two cases

PURPOSE

Many techniques were used for the treatment of hydrocephalus, and ventriculoperitoneal shunt surgery is a widely used procedure. Ventriculoperitoneal shunt surgery has been associated with several complications like obstruction of the tube, infection, cerebrospinal fluid loculation, intestinal obstruction, migration of the shunt, and perforation of the intestinal organs. Perforation of the bowel owing to protrusion of ventriculoperitoneal shunt catheter from the anus is an extremely rare complication. Mini or exploratory laparotomy and revision of peritoneal part of shunt and repair of bowel perforation, or pulling out the ventriculoperitoneal shunt catheter and using external ventricular drainage and antibiotics, or colonoscopic removal of ventriculoperitoneal shunt catheter and repair of the bowel can be performed. Retrograde contamination of cerebrospinal fluid and meningitis is a very important part of the treatment in these cases. We aimed to present two cases with bowel perforation who treated with endoscopically.

METHODS

We report the cases of 2 patients with transanal protrusion of VPS catheter and the management via endoscopic therapeutic options.

RESULTS

Successful treatment of the patients was achieved by endoscopic removal of the catheter and endoscopic repair of the bowel perforation.

CONCLUSION

If peritonitis, bowel obstruction, or abscess does not occur, endoscopic removal of shunt and bowel repairing with endoclips may be enough.

A ventriculoperitoneal shunt incidentally found in the stomach

We report a case of a ventriculoperitoneal shunt incidentally found within the stomach while the patient was undergoing a percutaneous endoscopic gastrostomy (PEG) tube placement. Among the complications of ventriculoperitoneal shunt placement, bowel perforation is rare a complication found in 0.01%-0.07% of cases, and typically occurs in premature infants and neonates [1]. To date, less than 100 such cases have been recorded of which only a few have appeared in the radiological literature. Here we discuss the current literature, the radiological features, clinical presentations and the management.

Silent Migration of Ventriculoperitoneal Shunt per Anus in a Child: Management and Review of Literature

The aim of this paper is to report a case of ventriculoperitoneal (VP) shunt tube coming out through the anus in a 6-year-old boy, who had undergone shunt revision surgery for the malfunctioning of the peritoneal end 6 months back. Among the complications of VP shunt surgery, such unusual migration of peritoneal end of the VP shunt is very rare. The possible factors responsible for this complication, in our case, were abdominal adhesions and thin bowel wall in the children. Although this complication has been previously reported, it remains an exceedingly rare case. Risk factors and possible mechanisms of migration are discussed.

Migration of a ventriculo-peritoneal shunt catheter into a back incision of a patient with previous spinal fusion

INTRODUCTION

This case examines a unique, longitudinal presentation of an abandoned, migrating VP shunt which presents as multiple complications, including a weeping abscess in the patients back. We believe that the latter complication was potentially caused by the wound from the patient's previous history of spinal fusion surgery.

CASE PRESENTATION

The patient presents with an associated type 2 Chiari malformation, hydrocephalus, and a previous history of posterior spinal fusion (T4-L5 anterior fusion and T2-L5 posterior fusion) at age 11. The patient had undergone shunt revisions in early adolescence as well. At 22, the patient is admitted into emergency care due to recurrent infections caused by a migrating VP shunt. Due to complications in corrective surgery at the time, the shunt was forced to be abandoned. This resulted in the most recent presentation of a weeping abscess at the patient's spinal fusion surgery wound; the culprit was the abandoned, migrating VP shunt..

MANAGEMENT/OUTCOME

An initial course of broad-spectrum antibiotics was started. However, the abscess continued to recur. Eventually, the catheter was surgically removed, a tailored antibiotic regiment was started, and a 6-month patient follow-up was performed. The patient is no longer symptomatic and off of antibiotics.

DISCUSSION

In abandoned VP shunts, migration into a non-sterile cavity dictates prompt removal, especially after symptoms of infection present. Additionally, careful monitoring for signs of peritonitis or other symptoms for a dedicated period of time is necessary. To the authors' best knowledge, this is the first case of an occult shunt migration through the patient's back that presented with a weeping abscess.

Our initial experience with ventriculo-epiplooic shunt in treatment of hydrocephalus in two centers

INTRODUCTION

Hydrocephalus represents impairment in cerebrospinal fluid (CSF) dynamics. If the treatment of hydrocephalus is considered difficult, the repeated revisions of ventriculo-peritoneal (VP) shunts are even more challenging.

OBJECTIVE

The aim of this article is to evaluate the efficiency of ventriculo-epiplooic (VEp) shunt as a feasible alternative in hydrocephalic patients.

MATERIAL AND METHODS

A technical modification regarding the insertion of peritoneal catheter was imagined: midline laparotomy 8-10cm long was performed in order to open the peritoneal cavity; the great omentum was dissected between its two layers; we placed the distal end of the catheter between the two epiplooic layers; a fenestration of 4cm in diameter into the visceral layer was also performed. A retrospective study of medical records of 15 consecutive patients with hydrocephalus treated with VEp shunt is also presented.

RESULTS

Between 2008 and 2014 we performed VEp shunt in 15 patients: 5 with congenital hydrocephalus, 8 with secondary hydrocephalus and 2 with normal pressure hydrocephalus. There were 7 men and 8 women. VEp shunt was performed in 13 patients with multiple distal shunt failures and in 2 patients, with history of abdominal surgery, as de novo extracranial drainage procedure. The outcome was favorable in all cases, with no significant postoperative complications.

CONCLUSIONS

VEp shunt is a new, safe and efficient surgical technique for the treatment of hydrocephalus. VEp shunt is indicated in patients with history of recurrent distal shunt failures, and in patients with history of open abdominal surgery and high risk for developing abdominal complications.

Transanal presentation of a distal ventriculoperitoneal shunt catheter: Management of bowel perforation without laparotomy

Background:

Bowel perforation is a serious but rare complication after a ventriculoperitoneal shunt (VPS) procedure. Prior studies have reported spontaneous bowel perforation after VPS placement in adults of up to 0.07%. Transanal catheter protrusion is a potential presentation of VPS bowel perforation and places a patient at risk for both peritonitis and ventriculitis/meningitis via retrograde migration of bacteria. This delayed complication can be fatal if unrecognized, with a 15% risk of mortality secondary to ventriculitis, peritonitis, or sepsis.

Case Description:

We describe a unique case of a patient with distal VPS catheter protrusion from the anus whose bowel perforation did not cause clinical sequelae of infection. We were able to manage the patient without laparotomy.

Conclusions:

A subset of patients can be managed without laparotomy and only with externalization of the ventricular shunt with antibiotics until the cerebrospinal fluid cultures finalize without growth.

Anal extrusion of migrated ventriculo-peritoneal shunt catheter: An unusual complication and review of literature

Authors present an unusual case of anal extrusion of peritoneal end of ventriculo-peritoneal shunt in a 2-year-old male child. Pertinent literature is reviewed regarding this rare complication of a very commonly performed neurosurgical procedure.

Small bowel perforation: a rare complication of ventriculoperitoneal shunt placement

Small bowel perforation is a rare complication of ventriculoperitoneal (VP) shunt placement. When seen, it most commonly affects the stomach or colon. We describe a case and image findings of an 8-year-old female who presented with sepsis and erosion of the VP shunt into the small bowel. The imaging findings were confirmed surgically. We also provide an overview of the current literature discussing previously reported cases, clinical features, and treatment.

Asymptomatic bowel perforation by abandoned ventriculoperitoneal shunt

We report a case of an abandoned abdominal ventriculoperitoneal shunt that migrated into the gastric antrum, colonic hepatic flexure, and liver parenchyma, which was discovered incidentally on an abdominal CT obtained for renal stones. In regards to the migrated abandoned VP shunt, the patient was asymptomatic. Upon review of prior CT scans, these findings had progressed over approximately 7 years. We describe the case and discuss the clinical and radiologic findings, complications resulting from ventriculoperitoneal shunts, and possible approaches to their management.

Protrusion of a peritoneal catheter via abdominal wall and operated myelomeningocele area: a rare complication of ventriculoperitoneal shunt

BACKGROUND

Ventriculoperitoneal shunting is mostly used in the treatment of hydrocephalus, and many complications have been reported with this method. These complications include obstruction, mechanical shunt failure, infection, and abdominal complications. Abdominal complications include intestinal obstruction, volvulus, peritonitis, peritoneal cyst, cerebrospinal fluid ascites, as well as migration of the distal catheter via the intestinal tract, umbilicus, scrotum, and vagina. Various mechanisms have been suggested with regards to the catheter migration.

CASE REPORT

We present a case of a 21-month-old female patient who had myelomeningocele at birth. She underwent repair of the myelomeningocele at the age of 10 days. After 4 months, cranial computed tomography revealed hydrocephalus, and ventriculoperitoneal shunt was placed. Because of shunt dysfunction, a new ventriculoperitoneal shunt system was installed at the age of 12 months. Eight months later, her mother noticed the protrusion of peritoneal catheter via abdominal wall and repaired myelomeningocele area. Revision of the lower end of the shunt was done, and myelomeningocele area was repaired again.

CONCLUSION

We report a unique patient with the protrusion of the distal catheter through repaired myelomeningocele area and abdominal wall in the lumbar region.

Conservative management of ventriculoperitoneal shunts in the setting of abdominal and pelvic infections

OBJECT

The optimal management of a ventriculoperitoneal shunt in the setting of acute, non-shunt related abdominal and pelvic infections is unknown. In the literature, distal shunt catheter reimplantation with or without a variable period of externalization has been recommended to prevent ascending ventriculitis. While this strategy is effective, there is little to almost no published data suggesting that it is necessary in all cases. Furthermore, it is not clear that shunt externalization to an external drainage bag during the treatment of non-shunt related peritonitis is any less likely to lead to ventriculitis than leaving the catheter in place. In the authors' experience, shunt externalization or revision during an episode of acute, non-shunt related peritonitis is unnecessary to prevent ventriculitis or chronic peritonitis.

METHODS

In the present case series, the authors report on 7 patients whose shunts were left in the abdomen while they were treated for acute peritonitis. The patients were followed clinically for up to 21 months after the diagnosis to assess for evidence of recurrent abdominal infections, shunt infections, or shunt failure.

RESULTS

In a follow-up period ranging from 13 to 22 months, no patient developed ventriculitis, required a shunt revision, or was unable to clear the peritoneal infection.

CONCLUSIONS

The results of this small series suggest that leaving the distal end of a shunt catheter in place in a patient with acute peritonitis is a reasonably safe choice in specific patients, provided the source of infection is aggressively treated with systemic antibiotics and local debridement when necessary.

Perforation into gut by ventriculoperitoneal shunts: A report of two cases and review of the literature

We report two cases of gastrointestinal perforation by ventriculoperitoneal (VP) shunts and review the literature on the topic. The time interval between shunt surgery and detection of bowel perforation is minimum in infants and increases with age. Sigmoid and transverse colon followed by stomach are the most frequent sites of gastrointestinal perforations by VP shunts.

Erosive bladder perforation as a complication of ventriculoperitoneal shunt with extrusion from the urethral meatus: case report and literature review

Ventriculoperitoneal (VP) shunt surgery is the most common technique used in the treatment of hydrocephalus. Erosive bladder perforation is an extremely rare complication of VP shunt surgery. Only 2 cases of erosive bladder perforation by a peritoneal catheter have been reported in the English literature. The authors present the case of a 14-year-old male with a history of cerebral palsy, severe developmental delay and hydrocephalus who presented with VP shunt tubing protruding from his urethral meatus. The patient had no evidence of neurological change. The VP shunt had been last revised over 11 years prior to admission. Imaging demonstrated the VP shunt to be intact, but displaced inferiorly, with the ventricular catheter in the extracranial soft tissue of the neck and the peritoneal catheter passing into the abdomen, bladder, and out through the urethra. Shunt removal was achieved through a multidisciplinary approach, involving both neurosurgery and urology teams. The authors discuss other reported cases of perforation by a VP shunt, potential mechanisms, and considerations for management of this rare complication.

Bowel perforation secondary to ventriculoperitoneal shunt: case report and clinical analysis

Bowel perforation is an unusual complication of ventriculoperitoneal shunting. This article describes a case of bowel perforation associated with a ventriculoperitoneal shunt inserted in an 8-month-old male infant for meningocoele and hydrocephalus. Ten months after insertion of the shunt the infant presented with the shunting tube protruding through the anus. There were no signs of meningitis or peritonitis. At laparotomy the tube was seen to enter the transverse colon and was encapsulated by the greater omentum. The tube was cut and the distal end removed via the anus. The transverse colon was repaired. The catheter continued to function effectively and the patient remained asymptomatic. The literature on this rare complication is reviewed and the therapeutic options are discussed.

Transoral protrusion of a peritoneal catheter: a rare complication of ventriculoperitoneal shunt

Ventriculoperitoneal (VP) shunt surgery is the most used technique for the treatment of hydrocephalus. This procedure is associated with a large amount of complications. Bowel perforation caused by a peritoneal shunt catheter is one of these complications, sometimes fatal, and is usually difficult to recognize, except when protrusion of the peritoneal catheter through a natural orifice occurs. This report presents the case of a 2-year-old boy who had undergone a VP shunt and later presented with protrusion of the peritoneal catheter through his mouth. The shunt device was removed and an external shunt procedure was achieved, using the original ventricular catheter kept in place. The diagnosis of bacterial meningitis was retained and an antibiotic therapy was started. The evolution was fatal in 15 days secondary to a bacterial ventriculitis. Through the reported cases of bowel perforation, many risk factors were individualized, such as age, congenital etiology of the hydrocephalus, silicon allergy or the length of the peritoneal catheter. Bowel perforation is a serious complication of VP shunt surgery, leading sometimes to a fatal outcome.

Ventriculoperitoneal shunt catheter masquerading as ascariasis

We describe extrusion of a ventriculoperitoneal shunt catheter through the anus occurring in an eight month child with hydrocephalus. This is a rare complication of ventriculoperitoneal shunt. Perforation of the bowel by the peritoneal catheter of the shunt occurred without peritonitis or retrograde infection of the shunt system. Pathogenesis and the literature is reviewed.

Méningites au cours des bactériémies à Escherichia coli à la clinique des maladies infectieuses Ibrahima-Diop-Mar du Centre hospitalier national de Fann à Dakar (Sénégal)

OBJECTIVES

The aim of this study was to describe epidemiological, clinical, and bacteriological aspects of Escherichia coli bacteremia and meningitis in the Ibrahima-Diop-Mar infectious diseases clinic, Dakar Fann National Hospital Center (Senegal).

MATERIALS AND METHODS

Data was collected from the bacteriology laboratory and hospitalization files.

RESULTS

57 cases of E. coli bacteremia were reported. Among them, 10 were associated with meningitis. AIDS was diagnosed in 74% of the cases. The global lethality rate was 47% but this rate was higher in cases of associated meningitis (80 vs 37%) and in AIDS patients (50 vs 27%). Ceftriaxone, aztreonam, gentamicin, and ciprofloxacin were active on more than 95% of strains but cotrimoxazole was active on only 49% of the strains. Resistance to cotrimoxazole was higher among E. coli strains isolated from AIDS patients (62 vs 13%).

CONCLUSION

The low susceptibility to cotrimoxazole might increase the incidence of E. coli infections among patients with AIDS. It is therefore important to find an alternative to cotrimoxazole chemoprophylaxis.

Meningitis caused by Enterococcus gallinarum in patients with ventriculoperitoneal shunts

Vancomycin-resistant enterococci have recently emerged as significant nosocomial pathogens. Here we describe two Japanese patients, a 57-year-old man and a 12-year-old boy, with ventriculoperitoneal shunts for hydrocephalus who developed meningitis caused by vancomycin-resistant Enterococcus gallinarum. The infection of the central nervous system in these two patients may have been associated with E. gallinarum derived from the gut. Removal of the shunts and antimicrobial treatment promoted apparent improvement in these patients. The risk factors and management of vancomycin-resistant enterococcal infections in the central nervous system are discussed.

Total extrusion of a cranial peritoneal shunt per rectum

This case report demonstrates an unusual complication of a cranial peritoneal shunt. The shunt perforated the bowel and was extruded per rectum. This caused significant anxiety for the individual but did not cause any serious morbidity.

Unexpected childhood death due to a rare complication of ventriculoperitoneal shunting

A 10-year-old boy with Arnold-Chiari malformation, spina bifida, and a ventriculoperitoneal shunt for hydrocephalus died unexpectedly, having appeared to be only mildly unwell with fever on the night before death. At autopsy, the shunt was partially obstructed with an associated enterococcal meningitis. The tip of the shunt was located within the transverse colon, which was embedded in a mass of fibrous adhesions resulting from previous abdominal surgery. Blood cultures were sterile. Intestinal perforation is a rare complication of ventriculoperitoneal shunting that may be associated with the development of meningitis and unexpected death. The autopsy assessment of children with such indwelling devices requires examination of the functional state of the shunt, full septic workup, and determination of the precise location of the tip of the catheter within the peritoneal cavity.

Infection of central nervous system by motile Enterococcus: first case report

A 66-year-old man with four indwelling ventriculoperitoneal shunts for multiloculated hydrocephalus from a complicated case of meningitis a year before developed shunt infection based on a syndrome of fever, drowsiness, and cerebrospinal fluid neutrophil pleocytosis in the background of repeated surgical manipulation to relieve successive shunt blockages. The cerebrospinal fluid culture, which yielded a motile Enterococcus species, was believed to originate from the gut. This isolate was lost in storage and could not be characterized further. The patient improved with vancomycin and high-dose ampicillin therapy. He relapsed a month later with Enterococcus gallinarum shunt infection, which responded to high-dose ampicillin and gentamicin therapy. This is probably the first case report of motile Enterococcus infection of the central nervous system.

Feculent meningitis: polymicrobial meningitis in colorectal surgery

Polymicrobial anaerobic meningitis is a rare event secondary to a contiguous infection in the head or neck. Anaerobic meningitis due to a meningo-intestinal fistula is a rare event with only two cases reported in the literature. We describe a new case of adult polymicrobial anaerobic meningitis after colorectal surgery and radiotherapy and review the previous two cases.

Spontaneous bowel perforation after ventriculoperitoneal shunt surgery: case report and a review of 45 cases

BACKGROUND

Ventriculoperitoneal shunt surgery is the most widely used procedure in the treatment of hydrocephalus. However, this invasive procedure has been associated with several delayed abdominal complications. Perforation of the bowel is a very rare complication occurring in less than 0.1% of cases. Although infrequent, this delayed complication can be fatal if it goes unrecognized.

CASE DESCRIPTION

This report presents an adult patient who had undergone ventriculoperitoneal shunt surgery and later presented with rectal protrusion of the shunt tube after asymptomatic perforation of the bowel wall. The shunt was removed without complication and the patient remained asymptomatic.

CONCLUSIONS

Forty-five similar cases have been reported in the literature. The information provided within this report examines the case at hand, as well as provides an analysis of the literature as it relates to bowel perforation through symptomatic presentation, diagnosis, cultures, management with or without laparotomy, and outcome.