Novel Insights from Clinical Practice Pediatr Neurosurg 2013;49:374–376 DOI: 10.1159/000369172
Received: August 1, 2014 Accepted after revision: October 19, 2014 Published online: November 26, 2014
Ventriculoperitoneal Shunt Infection with Non-Typhoidal Salmonella Species in an Infant Alexa Bodman Walter Hall Department of Neurosurgery, SUNY Upstate Medical University, Syracuse, N.Y., USA
Established Facts • Shunt Infections are common in pediatric neurosurgery.
Novel Insights • Salmonella spp. is a rare cause of shunt infection and coverage for this organism should be included when treating shunt infections in infants.
Key Words Meningitis · Salmonella · Shunt infection · Ventriculoperitoneal shunt
Abstract Shunt infections are common in pediatric neurosurgery. We present a case of a 3-month-old male with a history of a ventriculoperitoneal shunt for posthemorrhagic hydrocephalus after premature birth who presented to the emergency department with irritability and decreased oral intake. His presentation was concerning for shunt infection and evaluation for this was undertaken. He was found to have a shunt infection due to non-Salmonella typhi species, a rare cause of
© 2014 S. Karger AG, Basel 1016–2291/14/0496–0374$39.50/0 E-Mail [email protected] www.karger.com/pne
meningitis in children in the United States and rarer cause of shunt infection. With effective treatment for this organism, the patient did well and was discharged home in good condition. © 2014 S. Karger AG, Basel
Introduction
Cerebrospinal fluid (CSF) shunt infections in the pediatric population are a difficult and well-known complication. In patients under 1 year of age, an infection rate of 8.1% has been reported for the 1st year after shunt placement [1]. The most common pathogens for Alexa Bodman, MD 750 East Adams Street Syracuse, NY 13210 (USA) E-Mail bodmana @ upstate.edu
shunt infection are Staphylococcus epidermidis, Staphylococcus aureus, Propionibacterium acnes, and Gramnegative bacilli such as Klebsiella pneumoniae and Escherichia coli [2–4]. Shunt infections are associated with significant neurological morbidity and are difficult to treat. An awareness of the unusual pathogens that cause shunt infections is necessary for prompt and effective treatment. In this case, a 3-month-old male presented with ventriculoperitoneal shunt (VPS) infection where the CSF cultures demonstrated growth of non-Salmonella typhi spp.
drain was weaned and removed, which the patient tolerated. The Pediatric Infectious Disease service was consulted and they recommended a 4-week treatment with intravenous cefotaxime. The child remained hospitalized throughout the treatment due to an unstable home life. The patient was discharged home in good condition. Magnetic resonance imaging of the brain performed 6 weeks after discontinuing the antibiotics showed an increase in the ventricular size. The child was admitted for an uneventful VPS placement. Cultures sent during the replacement of the VPS were negative.
Discussion Case Report A 3-month-old male presented to the emergency department with irritability and decreased appetite. According to his caretakers, the child was in his usual state of health until 10 h earlier. His twin brother had a recent episode of gastroenteritis. The caretakers also noted the presence of fever and because of his past medical history brought him to the emergency department. The infant was born at 29 weeks from twin gestation and was found to have germinal matrix hemorrhage with intraventricular extension. During the patient’s stay at the neonatal intensive care unit, a ventricular access device was placed for the treatment of posthemorrhagic hydrocephalus. Phenobarbital was also started to prevent seizures. After reaching an appropriate weight for surgery, a VPS was placed and the patient was discharged home. After discharge from the neonatal intensive care unit, the patient had an unstable family state and was moved from the home of his biological mother to that of his biological father. Examination of the patient showed a head circumference of 37 cm with a soft flat anterior fontanel. The child was irritable, particularly when examining the abdomen. A cranial ultrasound was performed; compared to previous studies, the ventricular size had decreased and there was complete resolution of the previous hemorrhage. X-rays of the shunt showed an intact shunt system. The white blood cell count was 2,600 cells/μl, hemoglobin was 10.7 g/dl, hematocrit was 33.1%, and the platelet count was 230,000/μl. Erythrocyte sedimentation rate was 4 mm/h and the C-reactive protein level was 21.1 mg/l. Urinalysis was unremarkable. Blood cultures were drawn. CSF was sampled from the VPS and demonstrated a white blood cell count of 2,900/μl with 90% polymorphonuclear cells and 10% mononuclear cells with a red blood cell count of 328/μl. The CSF protein level was 801 mg/dl and glucose was
Received: August 1, 2014 Accepted after revision: October 19, 2014 Published online: November 26, 2014
Ventriculoperitoneal Shunt Infection with Non-Typhoidal Salmonella Species in an Infant Alexa Bodman Walter Hall Department of Neurosurgery, SUNY Upstate Medical University, Syracuse, N.Y., USA
Established Facts • Shunt Infections are common in pediatric neurosurgery.
Novel Insights • Salmonella spp. is a rare cause of shunt infection and coverage for this organism should be included when treating shunt infections in infants.
Key Words Meningitis · Salmonella · Shunt infection · Ventriculoperitoneal shunt
Abstract Shunt infections are common in pediatric neurosurgery. We present a case of a 3-month-old male with a history of a ventriculoperitoneal shunt for posthemorrhagic hydrocephalus after premature birth who presented to the emergency department with irritability and decreased oral intake. His presentation was concerning for shunt infection and evaluation for this was undertaken. He was found to have a shunt infection due to non-Salmonella typhi species, a rare cause of
© 2014 S. Karger AG, Basel 1016–2291/14/0496–0374$39.50/0 E-Mail [email protected] www.karger.com/pne
meningitis in children in the United States and rarer cause of shunt infection. With effective treatment for this organism, the patient did well and was discharged home in good condition. © 2014 S. Karger AG, Basel
Introduction
Cerebrospinal fluid (CSF) shunt infections in the pediatric population are a difficult and well-known complication. In patients under 1 year of age, an infection rate of 8.1% has been reported for the 1st year after shunt placement [1]. The most common pathogens for Alexa Bodman, MD 750 East Adams Street Syracuse, NY 13210 (USA) E-Mail bodmana @ upstate.edu
shunt infection are Staphylococcus epidermidis, Staphylococcus aureus, Propionibacterium acnes, and Gramnegative bacilli such as Klebsiella pneumoniae and Escherichia coli [2–4]. Shunt infections are associated with significant neurological morbidity and are difficult to treat. An awareness of the unusual pathogens that cause shunt infections is necessary for prompt and effective treatment. In this case, a 3-month-old male presented with ventriculoperitoneal shunt (VPS) infection where the CSF cultures demonstrated growth of non-Salmonella typhi spp.
drain was weaned and removed, which the patient tolerated. The Pediatric Infectious Disease service was consulted and they recommended a 4-week treatment with intravenous cefotaxime. The child remained hospitalized throughout the treatment due to an unstable home life. The patient was discharged home in good condition. Magnetic resonance imaging of the brain performed 6 weeks after discontinuing the antibiotics showed an increase in the ventricular size. The child was admitted for an uneventful VPS placement. Cultures sent during the replacement of the VPS were negative.
Discussion Case Report A 3-month-old male presented to the emergency department with irritability and decreased appetite. According to his caretakers, the child was in his usual state of health until 10 h earlier. His twin brother had a recent episode of gastroenteritis. The caretakers also noted the presence of fever and because of his past medical history brought him to the emergency department. The infant was born at 29 weeks from twin gestation and was found to have germinal matrix hemorrhage with intraventricular extension. During the patient’s stay at the neonatal intensive care unit, a ventricular access device was placed for the treatment of posthemorrhagic hydrocephalus. Phenobarbital was also started to prevent seizures. After reaching an appropriate weight for surgery, a VPS was placed and the patient was discharged home. After discharge from the neonatal intensive care unit, the patient had an unstable family state and was moved from the home of his biological mother to that of his biological father. Examination of the patient showed a head circumference of 37 cm with a soft flat anterior fontanel. The child was irritable, particularly when examining the abdomen. A cranial ultrasound was performed; compared to previous studies, the ventricular size had decreased and there was complete resolution of the previous hemorrhage. X-rays of the shunt showed an intact shunt system. The white blood cell count was 2,600 cells/μl, hemoglobin was 10.7 g/dl, hematocrit was 33.1%, and the platelet count was 230,000/μl. Erythrocyte sedimentation rate was 4 mm/h and the C-reactive protein level was 21.1 mg/l. Urinalysis was unremarkable. Blood cultures were drawn. CSF was sampled from the VPS and demonstrated a white blood cell count of 2,900/μl with 90% polymorphonuclear cells and 10% mononuclear cells with a red blood cell count of 328/μl. The CSF protein level was 801 mg/dl and glucose was
