Infection (2016) 44:251–253 DOI 10.1007/s15010-015-0817-3
CASE REPORT
Mycobacterium abscessus ventriculoperitoneal shunt infection and review of the literature Jose A. Montero1 · Sally F. Alrabaa1 · Todd S. Wills1
Received: 31 March 2015 / Accepted: 26 June 2015 / Published online: 7 July 2015 © Springer-Verlag Berlin Heidelberg 2015
Abstract A 30-year-old man with history of neonatal hydrocephalus requiring ventriculoperitoneal shunt placement presented with Mycobacterium abscessus shunt infection despite no shunt manipulation over 10 years prior to presentation. Cure was not achieved until complete removal of all CNS shunt foreign body was performed despite initial adequate antimicrobial therapy. Keywords Nontuberculous mycobacteria · Ventriculoperitoneal shunt · Meningitis
Introduction Infections of the CNS caused by nontuberculous mycobacteria are rare. A variety of mechanisms for these infections have been proposed in prior reported cases including endocarditis, neurosurgical procedures with and without foreign bodies, otomastoiditis, and disseminated infections [1–3]. Disseminated disease is almost exclusively seen in immunocompromised patients; however, many other patients have no significant underlying immunosuppression. Postneurosurgical cases have mostly been reported with Mycobacterium fortuitum, with fewer cases involving Mycobacterium abscessus [2]. In this report, we describe a case of M. abscessus meningoencephalitis involving a ventriculoperitoneal shunt and our difficulty in eradication of this infection requiring both surgical and medical challenges.
* Jose A. Montero [email protected] 1
University of South Florida Morsani College of Medicine, 1 Tampa General Circle, Tampa, FL 33606, USA
Case A 30-year-old man with cerebral palsy and severe developmental delay initially underwent a ventriculoperitoneal (VP) shunt placement at 3 months of age due to hydrocephalus. He required shunt revisions 12 years thereafter. He presented in December 2010 with nausea, vomiting, and lethargy. He had a history of esophageal dysmotility and also a possible diagnosis of Crohn’s disease. A CT of head revealed increase in size of his lateral and 3rd ventricles. Of note was the presence of the current VP shunt and as well as multiple fragments of prior VP shunt left behind during past revisions. On admission, he was afebrile and laboratory results revealed a WBC of 10.4 K/μl, sedimentation rate of 37 mm/h, and C-reactive protein of 16.7 mg/ dl. On examination, he was found to have a normal chest and abdomen. Due to his cerebral palsy, he had generalized increased spasticity in all extremities but was able to ambulate with assistance. However, he displayed more lethargy than his baseline and was unable to ambulate at all during his initial presentation. Due to VP shunt malfunction, our patient underwent a removal of the active VP shunt and placement of an external ventricular drain (EVD). CSF analysis at that time revealed 350 nucleated cells/ mm3 (80 % PMNs, 10 % lymphs, 10 % monos), 0 RBCs/ mm3, protein 10 mg/dl, glucose 53 mg/dl (serum glucose ~119 mg/dl). The patient was empirically given intravenous vancomycin and cefepime and then a new VP shunt was placed 1 week later after bacterial cultures from initial CSF were found to be negative. While the EVD was in place, CSF cultures were obtained at least every 48 h until the VP shunt was replaced. Two days after VP shunt replacement; our microbiology lab began reporting multiple CSF cultures with AFB growth, eventually identifying the organism
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as M. abscessus. Mycobacterial PCR for M. tuberculosis complex, M. intracellulare avium complex, and mycobacterial species DNA were negative on cerebral spinal fluid. No pathology was available as only the shunt was removed and no tissue obtained for pathology. Our patient was then promptly initiated on systemic antimicrobial therapy consisting of intravenous azithromycin, imipenem, and amikacin. At this time patient’s lethargy improved and he became more responsive and was able to sit up and communicate. After 2 weeks in hospital, he was discharged home with therapy consisting of oral azithromycin, intravenous imipenem, and oral SMX/TMP while awaiting antimicrobial susceptibilities. No CT scan of thorax, echocardiogram or further investigation was obtained during his first admission due to improvement of his mental status and resolution of vomiting after shunt replacement. Our patient returned to the hospital on this same therapy 5 weeks thereafter with nausea, ileus formation, abdominal discomfort, and intermittent lethargy. On examination, patient was again more lethargic and less communicative than his baseline. Chest was normal and he exhibited mild generalized abdominal tenderness. The VP shunt that was recently placed was removed and an EVD again placed while the patient continued receiving therapy with intravenous azithromycin, imipenem, and amikacin. Susceptibilities of M. abscessus at this point became known and were found to be sensitive to amikacin (MIC 16 mcg/ml), cefoxitin (MIC
CASE REPORT
Mycobacterium abscessus ventriculoperitoneal shunt infection and review of the literature Jose A. Montero1 · Sally F. Alrabaa1 · Todd S. Wills1
Received: 31 March 2015 / Accepted: 26 June 2015 / Published online: 7 July 2015 © Springer-Verlag Berlin Heidelberg 2015
Abstract A 30-year-old man with history of neonatal hydrocephalus requiring ventriculoperitoneal shunt placement presented with Mycobacterium abscessus shunt infection despite no shunt manipulation over 10 years prior to presentation. Cure was not achieved until complete removal of all CNS shunt foreign body was performed despite initial adequate antimicrobial therapy. Keywords Nontuberculous mycobacteria · Ventriculoperitoneal shunt · Meningitis
Introduction Infections of the CNS caused by nontuberculous mycobacteria are rare. A variety of mechanisms for these infections have been proposed in prior reported cases including endocarditis, neurosurgical procedures with and without foreign bodies, otomastoiditis, and disseminated infections [1–3]. Disseminated disease is almost exclusively seen in immunocompromised patients; however, many other patients have no significant underlying immunosuppression. Postneurosurgical cases have mostly been reported with Mycobacterium fortuitum, with fewer cases involving Mycobacterium abscessus [2]. In this report, we describe a case of M. abscessus meningoencephalitis involving a ventriculoperitoneal shunt and our difficulty in eradication of this infection requiring both surgical and medical challenges.
* Jose A. Montero [email protected] 1
University of South Florida Morsani College of Medicine, 1 Tampa General Circle, Tampa, FL 33606, USA
Case A 30-year-old man with cerebral palsy and severe developmental delay initially underwent a ventriculoperitoneal (VP) shunt placement at 3 months of age due to hydrocephalus. He required shunt revisions 12 years thereafter. He presented in December 2010 with nausea, vomiting, and lethargy. He had a history of esophageal dysmotility and also a possible diagnosis of Crohn’s disease. A CT of head revealed increase in size of his lateral and 3rd ventricles. Of note was the presence of the current VP shunt and as well as multiple fragments of prior VP shunt left behind during past revisions. On admission, he was afebrile and laboratory results revealed a WBC of 10.4 K/μl, sedimentation rate of 37 mm/h, and C-reactive protein of 16.7 mg/ dl. On examination, he was found to have a normal chest and abdomen. Due to his cerebral palsy, he had generalized increased spasticity in all extremities but was able to ambulate with assistance. However, he displayed more lethargy than his baseline and was unable to ambulate at all during his initial presentation. Due to VP shunt malfunction, our patient underwent a removal of the active VP shunt and placement of an external ventricular drain (EVD). CSF analysis at that time revealed 350 nucleated cells/ mm3 (80 % PMNs, 10 % lymphs, 10 % monos), 0 RBCs/ mm3, protein 10 mg/dl, glucose 53 mg/dl (serum glucose ~119 mg/dl). The patient was empirically given intravenous vancomycin and cefepime and then a new VP shunt was placed 1 week later after bacterial cultures from initial CSF were found to be negative. While the EVD was in place, CSF cultures were obtained at least every 48 h until the VP shunt was replaced. Two days after VP shunt replacement; our microbiology lab began reporting multiple CSF cultures with AFB growth, eventually identifying the organism
13
252
as M. abscessus. Mycobacterial PCR for M. tuberculosis complex, M. intracellulare avium complex, and mycobacterial species DNA were negative on cerebral spinal fluid. No pathology was available as only the shunt was removed and no tissue obtained for pathology. Our patient was then promptly initiated on systemic antimicrobial therapy consisting of intravenous azithromycin, imipenem, and amikacin. At this time patient’s lethargy improved and he became more responsive and was able to sit up and communicate. After 2 weeks in hospital, he was discharged home with therapy consisting of oral azithromycin, intravenous imipenem, and oral SMX/TMP while awaiting antimicrobial susceptibilities. No CT scan of thorax, echocardiogram or further investigation was obtained during his first admission due to improvement of his mental status and resolution of vomiting after shunt replacement. Our patient returned to the hospital on this same therapy 5 weeks thereafter with nausea, ileus formation, abdominal discomfort, and intermittent lethargy. On examination, patient was again more lethargic and less communicative than his baseline. Chest was normal and he exhibited mild generalized abdominal tenderness. The VP shunt that was recently placed was removed and an EVD again placed while the patient continued receiving therapy with intravenous azithromycin, imipenem, and amikacin. Susceptibilities of M. abscessus at this point became known and were found to be sensitive to amikacin (MIC 16 mcg/ml), cefoxitin (MIC
