Acta Clinica Belgica International Journal of Clinical and Laboratory Medicine
ISSN: 1784-3286 (Print) 2295-3337 (Online) Journal homepage: http://www.tandfonline.com/loi/yacb20
A NEONATE WITH A MENINGOMYELOCELE COMPLICATED BY AEROMONAS CAVIAE VENTRICULOPERITONEAL SHUNT INFECTION CP den Butter & LM Mahieu To cite this article: CP den Butter & LM Mahieu (2013) A NEONATE WITH A MENINGOMYELOCELE COMPLICATED BY AEROMONAS CAVIAE VENTRICULOPERITONEAL SHUNT INFECTION, Acta Clinica Belgica, 68:5, 380-381 To link to this article: http://dx.doi.org/10.2143/ACB.3385
Published online: 06 May 2014.
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Article views: 14
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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=yacb20 Download by: [Cornell University Library]
Date: 09 October 2016, At: 12:35
380
FIRST REPORT OF AN AEROMONAS SPP. VENTRICULOPERITONEAL SHUNT INFECTION
Case Report
A NEONATE WITH A MENINGOMYELOCELE COMPLICATED BY AEROMONAS CAVIAE VENTRICULOPERITONEAL SHUNT INFECTION den Butter CP1, 2, Mahieu LM2 1
GZA St. Augustinus Hospital, Edegem, Belgium 2Neonatal Intensive Care Unit, University Hospital Antwerp, Edegem, Belgium Correspondence and offprint requests to: Paul den Butter, E-mail: [email protected]
ABSTRACT We report on a newborn girl with a Aeromonas caviae shunt infection and meningitis after insertion of a ventriculoperitoneal shunt and surgical repair of a meningomyelocele in one procedure. This pathogen has never been reported, related to ventriculoperitoneal shunt infections. Beside the need for surgical revision of the shunt because of shunt obstruction and septa formation in the ventricles, the clinical outcome was good with intravenous cefotaxime therapy. Key words: Ventriculoperitoneal shunt infection, Aeromonas caviae, meningomyelocele, newborn
INTRODUCTION There is a lot of discussion about the timing of insertion of ventriculoperitoneal shunt (VPS) in infants with a meningomyelocele (MMC).(1, 2) We want to report an uncommon microbial cause of VPS-infection, very probably related to a MMC-repair combined with the insertion of the VPS.
CASE REPORT A girl was born by a caesarian section at term after a spontaneous pregnancy, complicated by premature contractions at AD 34 weeks. A sacral spina bifida and a Arnold Chiari II malformation with a hydrocephalus was diagnosed by prenatal ultrasound. This was confirmed by magnetic resonance imaging immediately after birth. Within 36 hours after birth the meningomyelocele was surgically repaired and in the same procedure a VPS was inserted. After surgery she was
Acta Clinica Belgica, 2013; 68-5
admitted for 8 days, mainly for teaching the parents the bladder catheterization. On the day of discharge the wound was healing. Although not fully closed the wound was but not leaking cerebrospinal fluid (CSF). Sixteen days after the first procedure the infant was readmitted with subfebrility (37.8°C), vomiting and leakage of CSF from the spinal wound. Physical examination showed a lethargic infant with a bulging fontanel and clinical signs of a sepsis (pale, capillary refill of 3 seconds, cold acra). Spinal wound showed some redness and leakage of fluid. The insertion wound of the shunt was closed. Laboratory tests were as follows: C-reactive protein was increased up to 619 nmol/l (65 mg/L), WBC-count 7.8.10E9/L, neutrophils 0.78.10E9/L. In the CSF the WBC-count was rising until 400.10E9/L, the protein concentration was 6.74 g/L. Cultures of the spinal wound and of CSF taken via the VPS showed growth of Aeromonas caviae. Because of shunt malfunction and presumed infection the VPS was immediately removed and an external ventricular drain was placed. Intravenous antimicrobial treatment for presumed sepsis and meningitis was initiated with cefotaxime monotherapy. Culture of CSF was sterile after 2 days of therapy. The external drain got obstructed by high protein levels in CSF twice. After 25 days of antibiotic treatment a new VPS could be inserted. At the age of 4 months there was an increase in head circumference. On magnetic resonance imaging a septation of the ventricle was seen. Revision of the VPS showed an obstruction of the proximal part of the VPS which was displaced. Cultures of CSF and shunt were sterile. After this no neurologic complications were seen during follow up of 8 months
DISCUSSION The closure of a MMC and insertion of a VPS in one procedure is complicated in our patient by an infection with
doi: 10.2143/ACB.3385
FIRST REPORT OF AN AEROMONAS SPP. VENTRICULOPERITONEAL SHUNT INFECTION
Aeromonas caviae. This infection was complicated with an acute shunt obstruction, but probably also with a late obstruction after 2 months and formation of ventricular septa as a result of ventriculitis. Aeromonas are oxidase-positive, facultatively anaerobic, gram-negative rods (3). A. caviae is one of the species that can be present in meat and water (3). Aeromonas colonization happens mainly outside the hospital via surfaces, not by contact with family members (4). A. caviae is in general susceptible for carbapenems, cephalosporins and aminoglycosides (3). To our knownledge, A. caviae has never been described as a cause of a ventriculoperitoneal shunt infection (5) and also not for meningitis (3). In neonates few bacteraemias with have been reported, most of them were lethal. More common are skin infections after trauma, gastroenteritis and urinary tract infections (3). Usually shunt infections develop during insertion of the shunt but can occur from two weeks until 6 months after surgery (5). Most common pathogens are Staphylococcus aureus (SA) and Coagulase negative staphylococci. (5) Insertion of a VPS in children with a MMC is mostly done in one procedure for several reasons. It shorthens hospital stay, reduces need of anaesthetics, decreases risk of infection because of lowering the CSF-pressure and drops the risk of CSF-leakage at the spinal wound (1, 2). When there has already been CSFleakage some will argue that first infection needs to be excluded and or treated. Opposers of this strategy argue that lowering intraventricular pressure by a VPS can cause a flow of infected CSF from the spinal wound to the shunt (1, 2).
The shunt infection in our case is probably caused by a spinal wound infection, that was not visible at the day of discharge. This probably started after hospital discharge as can be estimated from the epidemiologic studies (3, 4). This case shows that as long as the spinal wound is not fully closed sterile care is needed to prevent infections from apparent clean surfaces and even drinking water. Also giving antibiotics until the wounds are closed in children who had an insertion of a VPS in the same session should be considered. With a wound in the diaper region uncommon pathogens causing a shunt infection can be expected and antibiotic regimen should eventually be adapted.
REFERENCES 1. Clemmensen D, Rasmussen MM, Mosdal C. A retrospective study of infections after primary VP shunt placement in the newborn with myelomeningocele without prophylactic antibiotics. Childs Nerv Syst 2010; 26: 1517-1521. 2. Yilmaz A, Müslüman AM, Dalgıc N et al. Shunt insertion in newborns with myeloschisis/myelomenigocele and hydrocephalus. J Clin Neurosci 2010; 17: 14931496. 3. Janda JM, Abbott SL. The Genus Aeromonas: Taxonomy, Pathogenicity, and Infection. Clin Microbiol Rev 2010; 23: 35-73. 4. Demarta A, Tonolla M, Carninada AP, Beretta M, Peduzzi R. Epidemiological Relationships between Aeromonas Strains Isolated from Symptomatic Children and Household Environments as Determined by Ribotyping. Eur J Epidemiol 2000; 16: 447-453. 5. Prusseit J, Simon M, Von der Brelie, C et al. Epidemiology, Prevention and Management of Ventriculoperitoneal Shunt Infections in Children. Pediatr Neurosurg 2009; 45: 325-336.
Acta Clinica Belgica, 2013; 68-5
381
ISSN: 1784-3286 (Print) 2295-3337 (Online) Journal homepage: http://www.tandfonline.com/loi/yacb20
A NEONATE WITH A MENINGOMYELOCELE COMPLICATED BY AEROMONAS CAVIAE VENTRICULOPERITONEAL SHUNT INFECTION CP den Butter & LM Mahieu To cite this article: CP den Butter & LM Mahieu (2013) A NEONATE WITH A MENINGOMYELOCELE COMPLICATED BY AEROMONAS CAVIAE VENTRICULOPERITONEAL SHUNT INFECTION, Acta Clinica Belgica, 68:5, 380-381 To link to this article: http://dx.doi.org/10.2143/ACB.3385
Published online: 06 May 2014.
Submit your article to this journal
Article views: 14
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=yacb20 Download by: [Cornell University Library]
Date: 09 October 2016, At: 12:35
380
FIRST REPORT OF AN AEROMONAS SPP. VENTRICULOPERITONEAL SHUNT INFECTION
Case Report
A NEONATE WITH A MENINGOMYELOCELE COMPLICATED BY AEROMONAS CAVIAE VENTRICULOPERITONEAL SHUNT INFECTION den Butter CP1, 2, Mahieu LM2 1
GZA St. Augustinus Hospital, Edegem, Belgium 2Neonatal Intensive Care Unit, University Hospital Antwerp, Edegem, Belgium Correspondence and offprint requests to: Paul den Butter, E-mail: [email protected]
ABSTRACT We report on a newborn girl with a Aeromonas caviae shunt infection and meningitis after insertion of a ventriculoperitoneal shunt and surgical repair of a meningomyelocele in one procedure. This pathogen has never been reported, related to ventriculoperitoneal shunt infections. Beside the need for surgical revision of the shunt because of shunt obstruction and septa formation in the ventricles, the clinical outcome was good with intravenous cefotaxime therapy. Key words: Ventriculoperitoneal shunt infection, Aeromonas caviae, meningomyelocele, newborn
INTRODUCTION There is a lot of discussion about the timing of insertion of ventriculoperitoneal shunt (VPS) in infants with a meningomyelocele (MMC).(1, 2) We want to report an uncommon microbial cause of VPS-infection, very probably related to a MMC-repair combined with the insertion of the VPS.
CASE REPORT A girl was born by a caesarian section at term after a spontaneous pregnancy, complicated by premature contractions at AD 34 weeks. A sacral spina bifida and a Arnold Chiari II malformation with a hydrocephalus was diagnosed by prenatal ultrasound. This was confirmed by magnetic resonance imaging immediately after birth. Within 36 hours after birth the meningomyelocele was surgically repaired and in the same procedure a VPS was inserted. After surgery she was
Acta Clinica Belgica, 2013; 68-5
admitted for 8 days, mainly for teaching the parents the bladder catheterization. On the day of discharge the wound was healing. Although not fully closed the wound was but not leaking cerebrospinal fluid (CSF). Sixteen days after the first procedure the infant was readmitted with subfebrility (37.8°C), vomiting and leakage of CSF from the spinal wound. Physical examination showed a lethargic infant with a bulging fontanel and clinical signs of a sepsis (pale, capillary refill of 3 seconds, cold acra). Spinal wound showed some redness and leakage of fluid. The insertion wound of the shunt was closed. Laboratory tests were as follows: C-reactive protein was increased up to 619 nmol/l (65 mg/L), WBC-count 7.8.10E9/L, neutrophils 0.78.10E9/L. In the CSF the WBC-count was rising until 400.10E9/L, the protein concentration was 6.74 g/L. Cultures of the spinal wound and of CSF taken via the VPS showed growth of Aeromonas caviae. Because of shunt malfunction and presumed infection the VPS was immediately removed and an external ventricular drain was placed. Intravenous antimicrobial treatment for presumed sepsis and meningitis was initiated with cefotaxime monotherapy. Culture of CSF was sterile after 2 days of therapy. The external drain got obstructed by high protein levels in CSF twice. After 25 days of antibiotic treatment a new VPS could be inserted. At the age of 4 months there was an increase in head circumference. On magnetic resonance imaging a septation of the ventricle was seen. Revision of the VPS showed an obstruction of the proximal part of the VPS which was displaced. Cultures of CSF and shunt were sterile. After this no neurologic complications were seen during follow up of 8 months
DISCUSSION The closure of a MMC and insertion of a VPS in one procedure is complicated in our patient by an infection with
doi: 10.2143/ACB.3385
FIRST REPORT OF AN AEROMONAS SPP. VENTRICULOPERITONEAL SHUNT INFECTION
Aeromonas caviae. This infection was complicated with an acute shunt obstruction, but probably also with a late obstruction after 2 months and formation of ventricular septa as a result of ventriculitis. Aeromonas are oxidase-positive, facultatively anaerobic, gram-negative rods (3). A. caviae is one of the species that can be present in meat and water (3). Aeromonas colonization happens mainly outside the hospital via surfaces, not by contact with family members (4). A. caviae is in general susceptible for carbapenems, cephalosporins and aminoglycosides (3). To our knownledge, A. caviae has never been described as a cause of a ventriculoperitoneal shunt infection (5) and also not for meningitis (3). In neonates few bacteraemias with have been reported, most of them were lethal. More common are skin infections after trauma, gastroenteritis and urinary tract infections (3). Usually shunt infections develop during insertion of the shunt but can occur from two weeks until 6 months after surgery (5). Most common pathogens are Staphylococcus aureus (SA) and Coagulase negative staphylococci. (5) Insertion of a VPS in children with a MMC is mostly done in one procedure for several reasons. It shorthens hospital stay, reduces need of anaesthetics, decreases risk of infection because of lowering the CSF-pressure and drops the risk of CSF-leakage at the spinal wound (1, 2). When there has already been CSFleakage some will argue that first infection needs to be excluded and or treated. Opposers of this strategy argue that lowering intraventricular pressure by a VPS can cause a flow of infected CSF from the spinal wound to the shunt (1, 2).
The shunt infection in our case is probably caused by a spinal wound infection, that was not visible at the day of discharge. This probably started after hospital discharge as can be estimated from the epidemiologic studies (3, 4). This case shows that as long as the spinal wound is not fully closed sterile care is needed to prevent infections from apparent clean surfaces and even drinking water. Also giving antibiotics until the wounds are closed in children who had an insertion of a VPS in the same session should be considered. With a wound in the diaper region uncommon pathogens causing a shunt infection can be expected and antibiotic regimen should eventually be adapted.
REFERENCES 1. Clemmensen D, Rasmussen MM, Mosdal C. A retrospective study of infections after primary VP shunt placement in the newborn with myelomeningocele without prophylactic antibiotics. Childs Nerv Syst 2010; 26: 1517-1521. 2. Yilmaz A, Müslüman AM, Dalgıc N et al. Shunt insertion in newborns with myeloschisis/myelomenigocele and hydrocephalus. J Clin Neurosci 2010; 17: 14931496. 3. Janda JM, Abbott SL. The Genus Aeromonas: Taxonomy, Pathogenicity, and Infection. Clin Microbiol Rev 2010; 23: 35-73. 4. Demarta A, Tonolla M, Carninada AP, Beretta M, Peduzzi R. Epidemiological Relationships between Aeromonas Strains Isolated from Symptomatic Children and Household Environments as Determined by Ribotyping. Eur J Epidemiol 2000; 16: 447-453. 5. Prusseit J, Simon M, Von der Brelie, C et al. Epidemiology, Prevention and Management of Ventriculoperitoneal Shunt Infections in Children. Pediatr Neurosurg 2009; 45: 325-336.
Acta Clinica Belgica, 2013; 68-5
381
