|Year : 2007 | Volume
| Issue : 1 | Page : 31-32
Unusual manifestations of infection following shunt: An interesting case summary
Raj Kumar, AK Mahapatra
Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow - 226 014, UP
Source of Support: None, Conflict of Interest: None
| Abstract|| |
One 3 years male child was operated for a large vermian pilocytic astrocytoma. He developed fever and features of raised intracranial pressure after 2 weeks to require external ventricular drainage and ventriculoperitoneal shunt subsequently. The cause of fever could not be established even after thorough repeated investigations in this child and he did not respond to changing antibiotics during next 2 weeks. He responded dramatically to empirical antituberculous chemotherapy, which was started on the basis of history of contact with tuberculosis. The role of uncommon shunt infection is discurred to explain the clinical scenario in this case.
Keywords: Shunt Infection, uncommon shunt infection, infection in hydrocephalus
|How to cite this article:|
Kumar R, Mahapatra A K. Unusual manifestations of infection following shunt: An interesting case summary. J Pediatr Neurosci 2007;2:31-2
| Case Report|| |
A 3-year-old male child presented to us with history of holocranial headache for 3 months, intermittent vomiting for 2 months and swaying on either side while walking for 1 month. On examination he had bilateral papilledema, midline cerebellar signs and impaired tandem gait. Contrast cranial magnetic resonance imaging (MRI) revealed an extensive heterointense lesion with heterointense enhancement having solid and cystic component [Figure - 1] occupying the entire vermis. It was extending superiorly up to tentorium and even compressing quadrigerminal cistern. A gross obstructive hydrocephalus was noted. Considering the diagnosis of pilocytic astrocytoma, a midline suboccipital craniectomy and excision of solid and cystic component were achieved. Cystic component of the tumor contained a dark brown fluid, and the solid part was soft, tenacious and rubbery. The tumor was occupying mainly superior vermis and was found attached to the floor of the fourth ventricle also. It was a defined and vascular but extensive mass. Total excision could be achieved with difficulty, and cerebrospinal fluid (CSF) pathway could be reestablished; a dilated aqueduct was noted [Figure - 2]. He received a single dose of cefotoxim and amikacin perioperatively. Histopathology of specimen was reported to be pilocytic astrocytoma. The child had an uneventful course up to 13 days. Then, he developed one spike of fever, which resolved without antipyretic treatment. On the 16 th postoperative day, he deteriorated in sensorium and had an abnormal tonic posturing. An immediate ventricular tap and external ventricular drainage were done. The CSF showed only 15 lymphocytes with normal sugar and protein. The child was put on ventilatory support for the next 24 h in view of evidence of mild hypoxia on blood gas analysis. Since MRI following deterioration revealed ventriculomegaly and CSF pressure was very high during ventricular tap, a ventriculoperitoneal shunt was installed under cover of single dose of cefotoxim and amikacin as per the department's policy. One day later, the child developed fever of 102°F. He was thoroughly investigated for fever, which included total and differential blood counts, malaria parasite screening and culture of central venous pressure line, external ventricular drainage tube, CSF, blood and urine. Blood culture and malaria parasitic films were made at the peak of fever. When no evidence of infection could be demonstrated on investigation and fever continued for 4 days, he was put on empirical antimeningitic treatment on the 5 th day in combination with cefoperazone sulbactam, metrogyl and amikacin. On the 7 th day again, the screening of fever was repeated, which remained inconclusive. On the 16 th day when there was no response to antimeningitic treatment, a diagnostic lumbar puncture was performed, which showed elevation in cell count (cells 16, mainly lymphocytes) and borderline elevation of proteins (45 mg %) with sterile culture. The antibiotic regimen was changed, but fever did not respond. Antimalarial treatment was tried and drug fever was also ruled out by stopping antibiotics for 2 days. An ultrasound abdomen was done to rule out an occult source of infection like subphrenic abscess. By the 22 nd day when no cause of fever could be established and fever persisted, an empirical antitubercular treatment was started on the 28 th day. It was started following review of his history, as one of his close family members had just completed antitubercular chemotherapy 2 weeks back, given for pulmonary tuberculosis. The child was given three-drug regimen (rifampicin, isoniazid and pyrazinamide) of chemotherapy according to his weight along with pyridoxine. Fever subsided within 6 days and the child was discharged. A repeat MRI at 6-month follow-up remained normal [Figure - 3]. The child is attending his school normally and still continuing on antitubercular chemotherapy.
Most probably, the child had developed tuberculous infection following surgical trauma. It is difficult to know whether this child developed shunt infection or other systemic tubercular infection. But atypical systemic infections and atypical shunt infections are known to occur.  The shunt apparatus has physical properties that may promote and perpetuate bacterial growth by protecting bacteria, making them inaccessible to either host defenses or bactericidal drugs. The use of prophylactic antibiotics has also not shown any significant difference in the rate of shunt infection. Many times, the investigations to pick up the shunt infections also remain inconclusive. The gold standard to diagnose the shunt infection is exteriorization of shunt and culture of shunt tube.  This was not required in this case as shunt was functioning very well. Infection is a big problem in India. It is difficult to prove the cause of, and confirm the site of, infection in this case; however, the child was treated on the basis of past experience based on the management of a small premature child of age 2 months who was referred to us with refractory ventriculitis and had received 21 antibiotics following his birth, without response. We could control ventriculitis and install ventriculoperitoneal shunt following commencement of antituberculous chemotherapy within 3 weeks on him, and he was found to be well at follow-up of 2 years.
| Acknowledgement|| |
The authors are extremely grateful to Mr. A. P. Dhar Dwivedi, Department of Neurosurgery, SGPGIMS, Lucknow, for secretarial assistance.
| References|| |
|1.||Raj Kumar, Vinita Singh, Marakani VK Kumar. Shunt revision and outcome following VP shunt in hydrocephalic children of North India. Indian J Pediatr 2005;72:843-7. |
|2.||Walters BC. Cerebrospinal fluid shunt infection in Neurosurgery clinics of North America. Haines SJ, Hall WA, editors. WB Saunders Company: Philadelphia, USA; 1992. p. 387-401. |
[Figure - 1], [Figure - 2], [Figure - 3]