Intracerebral sepsis due to intestinal perforation by ventriculo-peritoneal shunts: two cases

Central Nervous System Infections in Patients With Ventriculoperitoneal Shunts Admitted for Primary Abdominal Infections: A US Nationwide Cohort Analysis

BACKGROUND AND OBJECTIVES

Although ventriculoperitoneal (VP) shunts are a common treatment for hydrocephalus, there are complication risks including infections. Late complications such as ventriculitis from ascending abdominal infections can have severe consequences. However, the incidence of central nervous system (CNS) infections in VP shunt patients with abdominal infections is not well understood. We aimed to determine the incidence of CNS infections in VP shunt patients admitted with abdominal infections.

METHODS

Using the National Inpatient Sample, we studied patients from 2016 to 2019 to determine the incidence of CNS infections in VP shunt patients admitted with abdominal infections. Results were compared with VP shunt patients admitted for primary pneumonia.

RESULTS

Among 725 VP shunt patients presenting with abdominal infections, 20 (2.8%) had CNS infections. Chronic obstructive pulmonary disease, hypertension, older age, and a smoking history were more common in patients with CNS infections and primary abdominal infection (P < .05). Patients who developed CNS infection had a significantly higher likelihood of both blood transfusion and coma but a lower likelihood of seizures. VP shunt patients with CNS infections were more likely to undergo shunt removal (odds ratio [OR] = 23.167, P < .001). 4.1% of VP shunt patients with primary abdominal infections died during admission. In a population of primary abdominal infection and pneumonia patients with VP shunts, a multivariate logistic regression analysis controlling for age, sex, and comorbidities identified abdominal infection as an independent risk factor for both CNS infection (OR = 51.208, P < .001) and inpatient death (OR = 3.417, P < .001). Among 6620 VP shunt patients admitted with primary pneumonia, only 5 (0.1%) had CNS infection compared with 20 (2.8%) in those with a primary abdominal infection (OR = 37.532, P < .001), and mortality was 1.6% vs 4.1% for those with a primary abdominal infection (P < .05).

CONCLUSION

CNS infections in VP-shunted patients with abdominal infections are relatively rare but may lead to increased risks of death and other serious adverse outcomes.

Spontaneous Anal Extrusion of Ventriculoperitoneal Shunt Catheter: Case Report

Background Ventriculoperitoneal shunt (VPS) has become the standard treatment for congenital hydrocephalus. In the neurosurgical practice, it is a common procedure which usually results in low rates of complication. However, some serious complications can occur, including infections, intestinal perforation, and even death.

Case Description A 19-year-old, female, asymptomatic patient, with a history of appendectomy and revision of the VPS 6 years before, presented spontaneous transanal extrusion of the catheter. Abdominal radiographs and tomography scans showed perforation of the descending colon without peritonitis, with expulsion of the distal tip of the catheter through the anus. The patient underwent removal of the proximal part of the VPS and installation of an external ventricular drain (EVD). On the second postoperative day, there was spontaneous elimination of the distal portion of the catheter, dispensing any additional surgical procedures. With antimicrobial prophylaxis and the contralateral VPS performed, the patient evolved without further complications until discharge. Diverging from cases reported in the literature, the patient in question did not present any abdominal manifestations.

Conclusion Intestinal perforation by VPS may be asymptomatic until anal extrusion occurs. However, the early approach should avoid infections, which are associated with increased mortality. Removing only the proximal catheter, together with antimicrobial prophylaxis, can be an effective, safe and less invasive alternative to manage this complication of VPS.

Spontaneous trans-anal extrusion of caudally migrated ventriculo-peritoneal shunt tip in a child: a case report

Background

Bowel perforation caused by the ventriculo-peritoneal shunt is a rare occurrence with an estimated incidence rate of 0.1% to 1.0% among all cases of VP shunt displacement. This is an unusual report of spontaneous trans-anal extrusion of caudally migrated ventriculo-peritoneal shunt tip in a child. Literature was reviewed to find out therapeutic strategies.

Case presentation

An asymptomatic 8 months old boy presented with spontaneous trans-anal extrusion of caudally migrated left-sided Chhabra type of ventriculo-peritoneal (VP) shunt for last 1 day, following surgery for hydrocephalus initially done 3 months ago. He had no features of peritonitis or encephalitis. Digital X-ray of the whole abdomen in postero-anterior view in erect posture was only evident of the expulsion of radio-opaque distal catheter tip through the anus into the exterior. Noncontrast-enhanced computed tomography scan (NCCT) of brain showed proximal catheter in the lateral ventricle of the brain. Under sedation, the distal part of the VP shunt catheter was resected out, aseptically, over the abdomen and pulled out gently through the anus. The proximal catheter part along with the reservoir was removed through a separate incision in the neck and sent for bacteriological study, which came out later to be negative. Postoperatively, the child was put on a prophylactic antibiotic and 3 weeks later another VP shunt was placed in the contralateral side.

Conclusions

Spontaneous trans-anal extrusion of VP shunt tip is a surgical emergency. The whole catheter must be removed aseptically in such a way that both contamination of the cerebral cavity and spillage into the peritoneum can be avoided. Awareness of this unusual complication among surgeons is needed for early recognition, management, and timely intervention to minimize morbidity.

Bowel perforation after ventriculoperitoneal-shunt placement: case report and review of the literature

Bowel perforation by a peritoneal catheter (BPPC) is a serious complication after ventriculoperitoneal shunting, with high mortality and morbidity rates. This patient presented with scalp ulceration over the shunt valve at the retromastoid region 26 years after shunt placement. During revision, the catheter distal to the valve was divided in the clavicular region. As there was no cerebrospinal fluid drainage, we decided to remove the ventricular catheter and valve. The ulceration was debrided and primarily closed. Distal to the clavicle, the disconnected peritoneal catheter was encased in a fibrous, calcified tunnel. To avoid piecemeal resection with multiple incisions, the catheter was not retrieved. Two years later, the patient presented with an abscess and pus draining from the clavicular wound. Cultures were positive for enteric bacteria. BPPC with retrograde spread of infection was suspected, and abdominal computed tomography confirmed perforation. We removed the disconnected catheter, but the perforation site could not be detected during laparotomy. The patient was treated with intravenous antibiotics and recovered without complications. To minimize complications, abandoned catheters should be avoided. Otherwise, patients unnecessarily have a life-long risk of developing abdominal complications. In patients with abandoned catheters and severe abdominal symptoms, BPPC is an important differential diagnosis.

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.

Late small intestine perforation after cementless total hip arthroplasty

We report a case of late small intestine perforation by an acetabular cup fixation screw after total hip arthroplasty (THA). A 79-year-old-woman underwent THA for hip osteoarthritis 13 years previously at another hospital. Although the acetabular cup fixation screw protruded into the pelvis, she had no symptoms. She later presented with peritonitis and was admitted to the hospital and prescribed antibiotic therapy. Computed tomography showed that the screw was adjacent to the intestine and was the likely cause of her peritonitis. After the peritonitis healed, she was referred to our hospital for surgical treatment of the screw. During laparotomy, we performed a resection of the intra-pelvic portion of the screw. The screw perforated the small intestine, so a small intestinal resection was also performed. The patient had an uneventful recovery.

Brain abscess formation as a CSF shunt complication: a case report

The formation of a brain abscess as a result of a cerebrospinal fluid shunt complication is extremely rare in the literature with only 7 cases reported in the last 20 years. We report a patient that developed a brain abscess adjacent to a functioning ventricular catheter in the presence of shunt infection by another pathogen. Clinicians should consider this complication in any shunted patient with clinical features of infection and suggestive changes on imaging however subtle. Expedited standard management for the abscess and the CSF shunt infection, if present, should be employed. Removal of all non-functioning catheters should be encouraged.

Management of brain abscesses in children

Brain abscesses occur infrequently but continue to be problematic for the pediatric neurosurgical community. The incidence of brain abscesses in children has not changed much, although individual reports may show an increase or decrease in the number of reported cases depending on the patient population studied. An increase could be attributed to earlier detection due to advancements in imaging modalities and/or to an increase in the number of children with immunodeficient states caused by AIDS, chemotherapy for malignant lesions, and immunosuppressive therapy for organ transplantation. A decrease in the incidence of brain abscesses could be attributed to practices such as antibiotic treatment for otitis media, sinusitis, and/or prophylactic antimicrobial treatment for congenital heart disease in children. The morbidity and mortality rates associated with brain abscesses have not changed dramatically in the antibiotic and imaging era, and their preferred management can vary among healthcare providers. These lesions have been successfully treated by neurosurgeons. The causes of brain abscesses are highly variable in children, which is also the case in adults, but the predisposing factors in the pediatric population differ in prevalence. Cyanotic congenital heart disease, hematogenous dissemination, contiguous infection, and penetrating traumatic injuries are the most common causes of brain abscesses in children. In this review, the authors discuss the causes and medical and surgical management of brain abscesses in children.

Subgaleal migration of a ventriculoperitoneal shunt

Blockage of a ventriculoperitoneal (VP) shunt is very common. Here, we describe an unusual case of shunt blockage in an infant. He was shunted for hydrocephalus associated with a Dandy-Walker malformation diagnosed at birth. At surgery, the entire VP shunt was found to have migrated into the subgaleal space, which clinically presented as shunt obstruction. We suggest techniques to avoid this rare, but preventable, complication of shunt surgery.

Biofilm-related infections of cerebrospinal fluid shunts

Cerebrospinal fluid (CSF) shunts carry a high risk of complications. Infections represent a major cause of shunt failure. Diagnosis and therapy of such infections are complicated by the formation of bacterial biofilms attached to shunt surfaces. This study correlated the pathophysiology and clinical course of biofilm infections with microscopical findings on the respective shunts. Surface irregularities, an important risk-factor for shunt colonisation with bacteria, were found to increase over time because of silicone degradation. Scanning electron-microscopy (SEM) documented residual biological material (dead biofilm), which can further promote extant bacterial adhesion, on newly manufactured shunts. Clinical course and SEM both documented bacterial dissemination against CSF flow and the monodirectional valve. In all cases, biofilms grew on both the inner and outer surfaces of the shunts. Microscopy and conventional culture detected all bacterial shunt infections. Analyses of 16S rDNA sequences using conserved primers identified bacteria in only one of three cases, probably because of previous formalin fixation of the samples.

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.

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.

Pneumocephalus secondary to colonic perforation by ventriculoperitoneal shunt catheter

We present a case of colonic perforation as a complication arising from ventriculoperitoneal shunt catheter. A 58-year-old woman with a ventriculoperitoneal shunt catheter inserted for obstructive hydrocephalus was admitted to hospital with signs and symptoms of meningitis. CT showed an air-fluid level within both lateral ventricles, raising the possibility of colonic perforation since no other aetiology for the pneumocephalus could be found. The CT demonstration of the colonic perforation played a crucial role in patient management.