PERCUTANEOUS ENDOSCOPIC GASTROSTOMY AND VENTRICULOPERITONEAL SHUNTS: A DANGEROUS COMBINATION?

Background: We report the largest European series of patients in whom both ventriculoperitoneal shunts (VPS) and percutaneous endoscopic gastrostomies (PEG) have been inserted with the aim of determining if this combination is safe or if there is an increased risk of VPS infection. Patients and Methods: The paper and electronic records of 302 patients who had a ventriculoperitoneal (VP) shunt inserted in the regional Neurosciences unit at Salford Royal NHS Foundation Trust between 2002 and 2007 were reviewed. Results: A total of 24 patients with VP shunts had 26 PEG inserted. Thirteen PEG were inserted in 11 patients with a pre‐existing VP shunt. The median age was 58 years (21–77 Yrs) with seven male and 17 female patients. In total, five patients developed a shunt infection (20.8%) compared to the overall rate of VP shunt infection for Salford Royal NHS Foundation Trust of 7% (P = 0.017). The increase in number of VP shunt infections when the procedures were done more than 10 days apart (2/14) was not significant (P = 0.25). Conclusion: In patients who need long‐term enteral feeding following a VP shunt insertion it may be prudent to delay insertion of a PEG for at least 10 days to reduce VPS infection. In stable patients who have had a VP shunt inserted on previous hospital admissions PEG insertion need not be avoided because of concern regarding cerebrospinal fluid or shunt infection.     

Microbiology and Treatment of Cerebrospinal Fluid Shunt Infections in Children

Infections of cerebrospinal fluid (CSF) shunts remain a common surgical complication causing significant morbidity in children with hydrocephalus. As most of the literature regarding these infections includes only small cohorts from a single institution’s experience, there remain large knowledge gaps and little support for the prevailing management strategies. Regarding the microbiology of shunt infections, little has changed in the past 10 years, other than the emergence of methicillin-resistant strains of coagulase-negative staphylococcus (CoNS) and Staphylococcus aureus, which remain the two predominant etiologic agents. Molecular diagnostics such as multiplex PCR have been used to identify the complex microflora of shunt infections and in the future could prove a useful adjunct for early diagnosis and targeting of antimicrobial therapy. Antibiotic-impregnated catheters for use in external ventricular drains and CSF shunts have been adopted into clinical practice and appear to reduce the risk of shunt infection by susceptible organisms.     

Ventriculoatrial shunt infection caused by Staphylococcus warneri: case report and review.

Staphylococcus warneri, a coagulase-negative species, is a rare cause of infection of cerebrospinal fluid (CSF) shunts. In one recently studied case of ventriculoatrial shunt infection, the repeated isolation of S. warneri (i.e., from all of six blood cultures and from a CSF sample obtained directly from the valve of the shunt) suggested that this organism can be clinically significant. Review of the literature clearly indicates that S. warneri is a rare but potentially dangerous pathogen in both immunocompetent and immunocompromised hosts with prosthetic devices. The removal of the infected shunt in association with systemic and local antibiotic administration probably constitutes the treatment of choice in such infections. Further experience is needed to determine the prevalence and the pathogenic significance of S. warneri and of the related organisms Staphylococcus epidermidis and Staphylococcus saprophyticus in patients with prosthetic devices.     

Meningitis caused by Oerskovia xanthineolytica

In summary, we describe a case of central nervous system infection with O. xanthineolytica in which the infecting microbe probably was engrafted on a ventricular shunt. The bacteria caused a smoldering meningitis that did not respond to penicillin and rifampin despite in vitro sensitivity, presumably because of inadequate cerebrospinal fluid penetration of the penicillin and the recognized difficulty of eradicating bacteria from contaminated shunts. Removal of the shunt and continued treatment with penicillin and rifampin resulted in cure.     

Cure of ventriculitis and central nervous system shunt infection by Staphylococcus epidermidis with vancomycin by intraventricular injection in a liver transplant recipient

A 19-year-old female underwent orthotopic liver transplantation for acute hepatic failure because of fulminant Wilson's disease. Three months post transplantation she developed systemic fungal meningoencephalitis and obstructive hydrocephalus that required cerebrospinal fluid (CSF) shunting by a ventriculo-atrial shunt. Subsequently, she contracted Staphylococcus epidermidis bacteremia, ventriculitis, and shunt infection. Treatment with vancomycin either by conventional intravenous (i.v.) or continuous i.v. injection proved ineffective because of insufficient drug concentrations in the CSF. Eradication of S. epidermidis from CSF and cure of chronic ventriculitis and shunt infection was readily achieved by delivering vancomycin by intraventricular injection (5 mg/24 h) via an extraventricular drain together with continuous i.v. infusion (4 g/24 h) over a period of 18 days. This treatment was well tolerated and free of untoward side effects despite the patient's chronic immunosuppression subsequent to liver transplantation. Intraventricular injection of vancomycin is an effective and safe procedure to eradicate S. epidermidis from the central nervous system when i.v. vancomycin treatment fails.     

Treatment of infections of cerebrospinal fluid shunts

There is no unanimity at present concerning the best method of treatment of cerebrospinal fluid shunt-related infections. The most frequently used method includes removal of the shunt followed by antibiotic therapy and later replacement of the shunt. The experience at the University of Cincinnati during the past 15 years indicates that many shunt infections can be effectively treated without shunt removal. This report summarizes experiences with 11 consecutive ventriculoperitoneal shunt infections. These were treated by externalization of the peritoneal catheter followed by intraventricular and systemic antimicrobial therapy and by later replacement of the peritoneal catheter. The advantages of this method include the avoidance of two major operative procedures and the elimination of a period in which the intracranial pressure is not controlled. The need for externalization of the peritoneal catheter relates to the occurrence of localized peritoneal infection and pseudocyst formation, which prevents cure of the infection in many instances if the catheter is left in place. After follow-up periods of four months to five years, 10 of the 11 patients have apparently been cured of their infection.     

Fièvre prolongée intermittente survenant à l’effort

Introduction

Fever of unknown origin is a common reason for care in internal medicine. The wide variety of possible etiologies makes it difficult to standardize the diagnostic work-up that has to be primarily guided by the interview and physical examination.

Case report

We report a case of prolonged fever having as main characteristics to be intermittent and triggered by efforts. The diagnosis of cerebrospinal fluid shunt infection with Propionibacterium acnes was finally made. In reaching this conclusion, many tests were needed, including renal explorations with biopsy showing an aspect of shunt nephritis.

Conclusion

Prolonged fever of unknown origin in a patient having prosthetic material should raise the suspicion of prosthesis infection (especially if the fever is associated with efforts).     

Bacterial meningitis in the elderly with neurosurgical procedures]

Bacterial meningitis is one of complications in the elderly with neurosurgical procedures. In an attempt to find the clinical features of this complication we analyzed 10 cases, which were found in 30 cases of the bacterial meningitis in Tokyo Metropolitan Geriatric Hospital from 1972 to 1989. The patients were 4 males and 6 females, 52-86 years old (the mean, 69). While 2 Enterococcus species were isolated after craniotomy, Staphylococci were common pathogens (4 S. aureus, 4 S. epidermidis and 1 P. aeruginosa) in patients with shunt infection. Most of these patients lacked typical manifestations of meningitis except the fever. Symptoms occurred long after surgery with little abnormality in the data of serum and cerebrospinal fluid. However, blood cultures were positive in 75% of the cases. Removal of the infected catheter was effective in the cases of shunt infection.     

Hydrocephalus. Abesia--dementia--incontinence. Drain or not?

The syndrome of abasia (gait disorder) and incontinence in old age is aetiologically ambiguous. If it is combined with an internal communicating hydrocephalus, it is necessary to think of the syndrome of malabsorption hydrocephalus and consequently of a drainage of the cerebro-spinal fluid. The indication for a shunt is defined with a diagnostic lumbar puncture, a cerebrospinal fluid scan, and if it is still uncertain, by continuous cerebro-spinal fluid pressure records. In a well-defined indication with the shunt, more than half of the patients would improve and about one third of them would have a very good recovery. However, a shunt operation on a patient with hydrocephalus ex vacuo (from cerebral atrophy) should be avoided since it could worsen the patient's condition. Therefore it is essential to discriminate clearly between these two very different types of hydrocephalus.     

False-negative cerebrospinal fluid cryptococcal antigen test due to small-colony variants of Cryptococcus neoformans meningitis in a patient with cystopleural shunt

This is the first report of a small-colony variant Cryptococcus neoformans isolated from the cerebrospinal fluid of a patient with cystopleural shunt associated chronic meningitis. Cryptococcal antigen testing of the cerebrospinal fluid and the serum were both negative. The atypical morphology and the false-negative test may lead to delay of diagnosis and treatment.     

Delayed Intracerebral Hemorrhage Secondary to Ventriculoperitoneal Shunt: A Case Report and Literature Review

The ventriculoperitoneal (VP) shunt is a routine procedure for cerebrospinal fluid (CSF) diversion, and is associated with many complications. A delayed hemorrhage after the VP shunt surgery, however, is quite rare. In this study, we report a case involving late-onset hemorrhage. The 67-year-old male patient with a history of head trauma and brain surgery underwent a VP shunt placement for hydrocephalus. The surgery course was uneventful and no bleeding was revealed in the first computed tomographic (CT) scan after the procedure. However, a massive intraparenchymal and intraventricular hemorrhage occurred 8 h following adjustment of the valve system on the 8th day after surgery.Erosion of the vasculature by catheter cannulation and a sudden reduction of CSF pressure after downregulation of the valve could be one of the possible causes of the intracerebral hemorrhage (ICH).     

Adequately Treated Remote Syphilis<br />Does Not Augment<br />CNS HIV-1 Expression

Objective: The co-occurence of human immunodeficiency virus (HIV) infection and syphilis may accelerate the course of both infections. We investigated whether remote syphilis infection augmented the activation of central nervous system (CNS) HIV infection and increased the frequency of cerebrospinal fluid (CSF) abnormalities. Methods: The subjects consist of HIV seropositive men who had CSF as part of prospective neurological studies performed at the Johns Hopkins University. Prior syphilis infection was determined by measuring serum FTA-ABS. All subjects had received adequate treatment for syphilis with negative RPR's or RPR's ≤ 1:8 and completed a full neurological examination and underwent lumbar punctures for analysis of cerebrospinal fluid. A range of CSF tests were performed including HIV culture, p24 antigen, β₂ microglobulin (β2M) and CSF/albumin ratios. Results: The FTA positive group was significantly older (p = .005), more advanced in HIV clinical staging (p = .04), had more minor neurological symptoms (p = .03), and was more likely to be on antiretroviral therapy (p = .03). No differences between FTA positive and FTA negative groups were observed either in the frequency of CFS anbormalities or the mean CSF values. Conclusions: Based on these findings, it appears that adequately treated remote syphilis does not augment HIV-1 expression within the CNS.     

A retrospective study of central nervous system shunt infections diagnosed in a university hospital during a 4-year period

Background  

Ventriculoperitoneal (VP) shunts are used for intracranial pressure management and temporary cerebrospinal fluid (CSF) drainage. Infection of the central nervous system (CNS) is a major cause of morbidity and mortality in patients with CSF shunts. The aim of the present study was to evaluate the clinical features, pathogens, and outcomes of 22 patients with CSF shunt infections collected over 4 years.     

Ventriculoperitoneal shunt malfunction diagnosis based on substance dilution

Objective:Current methods for the diagnosis of ventriculoperitoneal (VP) shunt malfunction lack specific standards; therefore, it may be missed or misdiagnosed. Hence, providing a reliable diagnostic method will help improve the accuracy of preoperative decision-making. Therefore, the aim of the study was to provide a new method for the diagnosis of VP shunt malfunction.Methods:After in vitro testing, we enrolled a total of 12 patients with VP shunt malfunction. Before revision surgery, 0.1 mL of a 5% sodium valproate (SV) solution was injected into the reservoir; 0.1 mL of the cerebrospinal fluid (CSF) was withdrawn 20 minutes later from the reservoir to measure the SV concentration. The process was repeated on the seventh day after surgery and compared with the preoperative results.Results:The mean ± standard deviation preoperative SV concentration in the cerebrospinal fluid was greater than the postoperative concentration (5967.8 ± 1281.3 vs 391.1 ± 184.6 μg/mL, P = .001).Conclusion:The proposed method is a reliable, safe, and relatively simple alternative for the diagnosis of VP shunt malfunction and further provides a reference for treatment.     

Isolated central nervous system histoplasmosis in immunocompetent hosts: a series of 11 cases

Histoplasmosis of the central nervous system occurs in a significant percentage of patients with Histoplasma capsulatum infection, but has usually been described in association with immunosuppression and/or disseminated histoplasmosis. We aim to review the clinical and laboratory features of isolated histoplasmosis of the central nervous system in the immunocompetent host by presenting a series of 11 cases with this condition. Most of these patients presented with headache, meningeal irritation signs and mental status changes, comprising a somewhat different picture from that described in immunosuppressed patients. Moreover, almost all patients had signs of ventricular dilatation in neuroimaging studies, and 8 of the 11 patients had a ventriculoperitoneal shunt at the time of diagnosis, suggesting hydrocephalus to be an important feature of this condition and/or the possibility of shunt infection by the fungus. Immunodiffusion analysis of the cerebrospinal fluid appeared to be the most efficient way to reach the diagnosis and should be considered in immunocompetent patients with chronic lymphocytic meningitis, especially in those who have ventricular shunt or live in endemic areas of Histoplasma capsulatum.     

Normal pressure hydrocephalus

Normal pressure hydrocephalus (NPH) is a reversible disorder characterized by gait impairment, subcortical dementia, and urinary urgency and incontinence associated with impaired cerebrospinal fluid circulation and ventriculomegaly. Treatment with shunt surgery is most likely to increase mobility, and may also improve dementia and urinary symptoms. An international, independent study group recently published guidelines for the diagnosis and management of idiopathic NPH. This article helps geriatricians identify patients who might have NPH, and care for these patients after shunt placement.     

双途径替加环素治疗广泛耐药鲍曼不动杆菌颅内感染的疗效观察

目的探讨双途径应用替加环素治疗广泛耐药鲍曼不动杆菌（XDRAB）颅内感染的作用。 方法选取解放军陆军第八十一集团军医院神经外科自2016年10月至2021年10月收治的30例XDRAB颅内感染患者为研究对象,按照随机数字表法将患者分为试验组和对照组,每组15例。试验组给予替加环素100 mg静脉注射,1次/12 h,行腰穿或腰大池引流释放脑脊液同时鞘内注射4 mg替加环素治疗（浓度为1 mg/mL）,每日1次。对照组给予美罗培南（2 g,1次/8 h）+头孢哌酮钠舒巴坦钠治疗（3 g,1次/8 h）,并行腰穿或腰大池引流释放脑脊液治疗。比较2组患者治疗前后脑脊液各项指标变化情况及治疗效果。 结果治疗4周后,试验组脑脊液白细胞计数及蛋白质含量均低于对照组,葡萄糖含量高于对照组,差异有统计学意义（P<0.05）;试验组治愈率（73.3%）高于对照组(40.0%),差异有统计学意义（P<0.05）。2组患者均未发现有明确严重相关不良反应发生。 结论双途径替加环素治疗XDRAB颅内感染,可显著改善脑脊液各项指标及提高患者治愈率,取得良好的临床疗效,值得临床推广应用。     

Infection of cerebrospinal fluid shunts: causative pathogens, clinical features, and outcomes

This retrospective chart review describes the clinical features, pathogens, and outcomes of 46 patients with cerebrospinal fluid (CSF) shunt infections collected over 16 years. The overall CSF shunt infection rate was 2.1%, broken down into 1.7 and 9.3% in adult and pediatric groups, respectively. Fever and progressive consciousness disturbance were the most clinical features in the adult patient group, whereas disturbance of consciousness and abdominal symptoms and signs were the two most common clinical features in the pediatric patient group. The most frequently isolated microorganisms were of the Staphylococcus spp., including Staphylococcus aureus and coagulase negative Staphylococcus, which accounted for 47% of the episodes. Furthermore, increases in polymicrobial and Gram-negative bacilli infections were observed in our study. Due to the high proportion of oxacillin-resistant Staphylococcus spp. and polymicrobial infections, we recommend initial empirical antibiotics with both vancomycin and a third-generation cephalosporin for cases in which the causative bacteria has not been identified or for which the results of antimicrobial susceptibility tests are not available. For patients who develop smoldering fevers, progressive disturbed consciousness, seizures, or abdominal fullness after ventriculoperitoneal shunt procedures, CSF shunt infections should be suspected. Although some infections have been managed successfully with antimicrobial therapy alone, the timely use of appropriate antibiotics according to antimicrobial susceptibility testing and the removal of the shunt apparatus are essential for successful treatment.     

Correlation of herpes simplex virus types 1 and 2 with clinical features of infection.

Strains (338) of herpes simplex virus (HSV) were isolated in Stockholm during 1965-1974. By immunoelectroosmophoresis it was possible to identify all strains as either HSV type 1 (HSV-1) or 2 (HSV-2). No strains of intermediate antigenic type or with untypable characteristics were found. The antigenic type of HSV was correlated with body site and clinical features of infection. A case of severe, recurrent, abdominal pain in association with HSV-2 infection is described. In one patient with acute aseptic meningitis, both coxsackievirus A9 and HSV-2 were isolated from the same specimen of cerebrospinal fluid. Serology suggested a primary infection with coxsackievirus A9 and a recurrent HSV-2 infection. HSV-1 was isolated from specimens of cerebrospinal fluid. Serology suggested a primary infection with coxsackievirus A9 and a recurrent HSV-2 infection. HSV-1 was isolated from specimens of cerebrospinal fluid from two of four adults with HSV encephalitis.     

Cerebrospinal fluid and human immunodeficiency virus. Findings in healthy, asymptomatic, seropositive men

Involvement of the central nervous system by human immunodeficiency virus is an important cause of morbidity and mortality. We have undertaken a longitudinal study of asymptomatic individuals found to be human immunodeficiency virus seropositive to identify and characterize cerebrospinal fluid abnormalities early in the disease process. Our findings in 25 individuals have been notable for a frequent incidence of cerebrospinal fluid abnormalities. Pleocytosis or elevated cerebrospinal fluid protein was found in 12 (48%) of 15 patients studied. Oligoclonal banding was present in 6 (26%) of 23 patients. Human immunodeficiency virus was isolated by culture in 4 asymptomatic patients. The cerebrospinal fluid abnormalities we observed indicate an active process occurring in the central nervous system, even in early human immunodeficiency virus infection in asymptomatic patients. Serial observation of these patients for development of neuropsychiatric findings may provide answers to the significance of cerebrospinal fluid abnormalities identified in these patients.