Pediatric Neurology 48 (2013) 477e478
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Spontaneous Bowel Perforation From Distal Catheter Leading to Meningitis: A Rare but Frequently Overlooked Complication of Ventriculoperitoneal Shunts Tobias A. Mattei MD *, Asem Salma MD, Julian J. Lin MD Department of Neurosurgery, University of Illinois at Peoria, Peoria, Illinois
Introduction
Discussion
A 13-year-old girl with severe cognitive impairment and chronic seizures was brought to the emergency department with a history of constipation as well as episodes of vomiting and low-grade fever for the past few days. At the neurologic examination, the patient presented with elevated temperature, nuchal rigidity, and photophobia, suggesting the diagnosis of meningitis. At the general examination, it was possible to visualize a filiform structure protruding from the patient’s anal region. The family reported that the patient had placement of a ventriculoperitoneal (VP) shunt at 3 weeks old owing to neonatal hydrocephalus. Plain x-rays confirmed the penetration of the distal (peritoneal) catheter of the VP shunt into the bowels as well as its trajectory from the abdominal toward the perineal region (Fig 1). After the neurosurgery team was consulted, the patient had the proximal (ventricular) catheter externalized. In the sequence, the peritoneal catheter was removed from this distal portion without resistance after being disconnected from the proximal portion in the neck during the shunt externalization. The cerebrospinal fluid analysis revealed a pattern suggestive of bacterial meningitis (leukocytes 5956, glucose 24, protein 117). Broad-spectrum antibiotic therapy was instituted for 14 days. The cultures of both the initial cerebrospinal fluid sample and the cranial tip of the VP shunt revealed Enterococcus faecalis betalactamase negative. After the end of the antibiotic treatment and three negative cultures, the patient was subjected to implant of a new VP shunt and was discharged home without long-term sequelae from the infectious event.
Spontaneous bowel perforation from peritoneal catheters from VP shunts is a rare (estimated incidence of 0.1% to 0.7% of shunted patients) but dangerous event that can lead to devastating complications such as meningitis and ventriculitis, especially if unrecognized for a significant period of time [1]. The likelihood of these complications has been reported to be higher in nonambulatory patients. Anal extrusion of the catheter was estimated to occur in only 15% of the cases and, although presenting an awkward situation for the family, it does help in the diagnosis of such a neurosurgical emergency, which, otherwise, may be significantly delayed. Plain x-rays may confirm the diagnosis of spontaneous bowel perforation as they demonstrate the trajectory of the peritoneal VP-shunt catheter toward the perineal region. Computed tomography scan of the abdomen is helpful to rule out the presence of any abdominal abscess. Once the diagnosis of spontaneous bowel perforation has been established, the treatment consists of total shunt removal, externalization of the ventricular drainage, and institution of broad-based antibiotic therapy for at least 14 days. The exact pathophysiology of spontaneous bowel perforation is still unclear, although it has been suggested that the bowel wall erosion may be related to inflammation caused by pre-existing shunt infection [2,3]. As the bowel perforation caused by the catheter is usually very small, in the vast majority of the cases it seals by itself and laparotomy is rarely necessary, being indicated only in those patients presenting with acute abdomen [4].
* Communications should be addressed to: Dr. Mattei; Department of Neurosurgery; University of Illinois College of Medicine; Peoria; 828 NE Glen Oak Avenue, #302; Peoria, IL 61603. E-mail address:
[email protected] 0887-8994/$ - see front matter Ó 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.pediatrneurol.2013.02.011
Conclusions
In summary, it is extremely important for pediatric neurologists to suspect and properly diagnosis spontaneous bowel perforation, especially in the setting of bacterial meningitis in a patient with previous history of VP shunt
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Figure 1. Left: Picture of the distal peritoneal catheter of the ventriculoperitoneal shunt protruding through the patient’s anal region. Right: Plain abdominal x-ray confirming bowel perforation by the distal peritoneal catheter as well as its trajectory from the abdominal cavity toward the perineal region.
and presenting with the presence of any suspicious structures extruding from the perineal region.
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[2] Brownlee JD, Brodkey JS, Schaefer IK. Colonic perforation by ventriculoperitoneal shunt tubing: A case of suspected silicone allergy. Surg Neurol 1998;49(1):21e4. [3] Glatstein M, Constantini S, Scolnik D, Shimoni N, Roth J. Ventriculoperitoneal shunt catheter protrusion through the anus: Case report of an uncommon complication and literature review. Childs Nerv Syst 2011;27(11):2011e4. [4] Park CK, Wang KC, Seo JK, Cho BK. Transoral protrusion of a peritoneal catheter: A case report and literature review. Childs Nerv Syst 2000;16(3):184e9.
