Late infection complications after ventriculoperitoneal shunt in adults (4 cases report and literature review)

< br / > < br / > < br / > ventriculoperitoneal shunt (VP shunt) is the main operation method for the treatment of communicating hydrocephalus at present; its operation steps are mature and the treatment effect is accurateHowever, a large-scale epidemiological survey found that the incidence of postoperative infectious complications was as high as 6.5% - 23.5%Infectious complications often lead to the removal of drainage tube and secondary operation, which has a negative impact on the long-term survival of patients; and the risk of repeated infection after treatment can not be ignored< br / > at present, most of the reports about infection after ventriculoperitoneal shunt at home and abroad are in the acute stage after operation, and few of the reports about the complications of late abdominal infection or systemic multiple infectionOnce the patients have such complications, they often need to be treated together with intracranial infection and celiac infection for a long time, so they still need to be alert and concernedIn this study, the clinical data of 4 patients with late postoperative infection of hydrocephalus in neurosurgery of Peking Union Medical College Hospital were summarized and analyzed, including 2 patients with adhesive intestinal obstruction secondary to intracranial infection, 1 patient with intraperitoneal multiple abscess secondary to intracranial infection, 1 patient with intracranial infection combined with pulmonary infection and urinary tract infectionThe report is as followsClinical data < br / > 1.1 case 1 < br / > male, 31 years oldIn April 2014, the patient underwent resection of dermoid cyst on the surface of cavernous sinus in an external hospital12 days after the operation, intracranial infection was caused by cerebrospinal fluid rhinorrheaAfter the infection was cured, communicating hydrocephalus occurredOn May 15, 2015, the patient was admitted to the hospitalOn May 25, the right ventriculocentesis ventriculoperitoneal shunt was performedThe rectus abdominis incision was taken, and the depth of the catheter was 20 cmOn June 20, 2015, the patient had dizziness, headache, intermittent left abdominal pain and difficulty in defecation; on July 8, 2015, the patient had high fever (the highest temperature was 39.3 ℃), accompanied by repeated vomiting, exhaust and defecation< br / > physical examination: clear consciousness, Glasgow Coma Scale (GCS) score of 15 points, slightly distended abdomen, diffuse tenderness in left abdomen, rebound pain (+), hyperactivity of bowel sounds; 3mm right pupil, 5mm left pupil, disappearance of light reflex; neck resistance (+)Blood routine examination: the number of leukocytes was 14.75 × 109 / L, and the proportion of neutrophils was 67.2% Cerebrospinal fluid examination: pressure: 310mmh2o, yellowish and slightly muddy, leukocyte count: 430 × 106 / L, polynuclear: 56.1%, protein: 0.53g/l, chloride: 125mmol / L, glucose: 3.6mmol/l; no positive result was found in cerebrospinal fluid culture for 72h < br / > on plain CT scan, the ventricles were enlarged, and there was no obvious abnormality in the position and shape of the shunt tube; on plain X-ray film of the standing abdomen, there was air accumulation and expansion in the abdominal cavity (Fig 1); on color ultrasound of the abdomen, there was no echo area in the left upper abdomen, and there was echo in the catheter Considering that the intracranial infection was clear and intestinal obstruction could not be eliminated, the emergency operation of ventriculoperitoneal shunt was performed After the operation, vancomycin 1g twice a day and meropenem 2G three times a day were given intravenously After 6 months follow-up, the infection did not recur; CT showed that the expansion of ventricles was basically the same as before, and hydrocephalus did not further aggravate < br / > < br / > in Figure 1, case 1, case 2, case 2 was 49 years old On September 12, 2012, he was admitted to the hospital because of the right thalamus hemorrhage breaking into the brain room He underwent the external drainage of the right ventricle puncture intraventricular hemorrhage in emergency On October 17, 2012, left lateral ventriculoperitoneal shunt was performed for communicating hydrocephalus Before operation, the CSF was examined by lumbar puncture: pressure 65 mmh2o, light yellow and transparent, leukocyte count 20 × 106 / L, monocyte 20%, polynuclear 0%, protein 0.60 g / L, chloride 119 mmol / L, sugar 3.9 mmol / L During the operation, a 4 cm incision was made at the left side of the rectus abdominis, and the depth of the tube was 20 cm One and a half months after the operation (December 1, 2012), the patient had lethargy and intermittent abdominal pain, and on December 11, the patient had fever (the highest temperature was 39.6 ℃), stopped defecation, and vomited stomach contents < br / > physical examination: drowsy state, GCS score of 10 points, abdominal distention, right lower abdominal tenderness, rebound pain, mild muscle tension, active bowel sounds; pupil left 2.0mm, right 5.0mm, slow light reflex, limb muscle strength grade IV, abdominal wall reflex weakened, left Babinski sign (+), neck rigidity (+) Blood routine examination: WBC count 19 × 109 / L, neutrophils 92.3%; CSF examination: pressure 280mmh2o, light yellow and turbid, WBC count 2512 × 106 / L, polynuclear 90%, protein 5.7g/l, cl123mmol / L, sugar 4.9mmol/l; CSF culture showed methicillin sensitive Staphylococcus aureus (MSSA), Staphylococcus goat and Candida albicans CT scan of the head showed further enlargement of the ventricles of the brain, CT scan of the abdomen showed diffuse dilatation of the intestinal tract with air accumulation in the right lower abdomen (Fig 2) < br / > During the operation, there was a little pus on the surface of the appendix, the blind part of the right lower abdominal gyrus and the lower drainage mouth At the same time, vancomycin 1g twice a day and cefepime 1g three times a day were given intravenously for 4 weeks On January 9, 2013, CSF culture was negative for three times in a row, so the right lateral ventriculoperitoneal shunt was performed again The catheter end was placed on the diaphragmatic surface of the liver and fixed on the diaphragm and falciform ligament After 1 year follow-up, there was no infection and hydrocephalus improved Case 3: male, 18 years old The patient was admitted to hospital on February 15, 2015 due to germinoma and hydrocephalus in sellar region On February 20, the right ventriculocentesis ventriculoperitoneal shunt was performed On March 28, 37 days after operation, the patient had fever (39.8 ℃), headache, abdominal pain and vomiting Physical examination: the skin of the upper abdomen is broken, reaching to the subcutaneous level, and pus liquid overflows A white latex tube can be seen in the abdominal cavity; the whole abdomen has tenderness, rebound pain, muscle tension, and the bowel sounds are very weak; the neck is stiff (+) < br / > blood routine examination: leukocyte count 40.65 × 109 / L, neutrophil 91.4% The swab culture showed that methicillin sensitive Staphylococcus aureus (MRSA) had no lumbar puncture Abdominal CT showed that there were multiple cystic low-density shadows in the middle and upper abdominal cavity on both sides, with enhanced posterior capsule wall, with a maximum cross-section of 7.5cm × 3.8cm (Fig 3) < br / > During the operation, it was found that the abdominal adhesions were very serious, the abscesses of omentum, subhepatis and paracolonial abscess, and each pus was drained about 100ml After the operation, cefoperazone sulbactam sodium 3G twice a day and metronidazole 0.915g twice a day were infused intravenously for 2 weeks, and the ventriculoperitoneal drainage tube was removed; the infection symptoms of the patient were relieved and the rupture healed; then the right lateral ventriculoperitoneal shunt was performed again The patients were followed up for 8 months Case 4 < br / > female, 50 years old He was admitted to the hospital on March 21, 2018 due to "fever, epileptiform attack, frequency of urination and urgency of urination for 3 months" In December 2013, the patient underwent "right craniotomy hematoma removal + left lateral ventriculoperitoneal shunt" due to brain injury After 4 years (December 2017), there was no obvious inducement for intermittent fever (maximum temperature 38.9 ℃) and epileptiform attack, accompanied by frequent urination, urgency of urination and increased nocturia (4-8 times / night) On February 22, 2018, the sputum culture showed Pseudomonas aeruginosa (PA) (+), the urine culture showed Enterococcus faecium ＞ 105CFU / ml; the anti infection treatment of "vancomycin + meropenem" was ineffective < br / > physical examination: the abduction and inclination of the left eye are limited, and the radiation reflex is poor; the muscle tension of the four limbs is slightly strong, the muscle strength is normal, the acupuncture sensation of the left body is decreased, the left abdominal wall reflex disappears, the neck is strong, the left Babinski sign (+), the right Babinski sign (±) Lumbar puncture CSF examination: pressure 290mmh2o (after dehydration), cell number 316 × 106 / L, leukocyte number 116 × 106 / L, polynuclear 48.3% In consideration of intracranial infection combined with pulmonary and urinary tract infection, 2 g meropenem 3 times a day, 1 g vancomycin 2 times a day anti infective treatment, mannitol + glycerol fructose dehydration to reduce intracranial pressure, 500 mg debarkin 2 times a day anti epileptic treatment were given < br / > on April 4, 2018, the patient had high fever, jet vomiting and neck rigidity CT of the head showed that the posterior and temporal angles of the right lateral ventricles were significantly widened, hydrocephalus and brain edema were significantly worse than those before (Figure 4a); CT of the abdomen showed no significant abnormality (Figure 4b) The drainage of lumbar cistern was performed beside the bed, and the removal of ventriculoperitoneal shunt was performed under general anesthesia on April 9 The bacteria culture of the drainage tube of ventriculus and abdominal cavity showed that Staphylococcus epidermidis (+) After operation, anti infection and intracranial pressure reduction were maintained for 6 weeks On April 18, the left ventriculoperitoneal shunt was implanted under general anesthesia The left side of the shunt was cut 5 cm beside the navel of rectus abdominis muscle, and the depth of the shunt was 30 cm After operation, cerebrospinal fluid reexamination: the pressure decreased from 175mmh2o to 140mmh2o and 85mmh2o, the routine and biochemical conditions were normal, and the symptoms were significantly improved and discharged The patients were followed up for 4 months < br / > A: Skull CT and occipital bone are absent, and large irregular low density shadow can be seen around; B: abdominal CT, tube shadow can be seen, and no obvious abnormality can be found < br / > < br / > 2 Discuss < br / > 2.1 etiology and aetiology < br / > in this group, 2 cases of CSF culture positive, MRSA and MSSA respectively, occurred 1-2 months after ventriculoperitoneal shunt In one patient, Staphylococcus epidermidis, Enterococcus faecium and PA were positive in the culture of bacteria, which occurred 4 years after operation According to the research of etiology, the pathogenic bacteria of infection after ventriculoperitoneal shunt are closely related to the time of infection Among the patients with postoperative infection, 60% occurred within 1 month, 70% within 2 months, and only about 10% within 1 year < br / > scholars at home and abroad have proposed that one month or nine months after operation as the time limit of early infection and late infection In the early stage of infection, the skin is usually considered as the main source of infection, and the pathogens are mostly implanted by the operation during the operation; the pathogenic bacteria are mainly gram-positive cocci, and the common Staphylococcus epidermidis, Staphylococcus aureus, Staphylococcus walleriae, etc are cultured in the peripheral blood and cerebrospinal fluid The positive rate of bacteria culture in the late stage of infection is relatively low, which is often related to the spread of secondary bacteria Patients often have exposure or infection near the shunt path, such as skin ulceration, otitis media, urinary tract infection, peritonitis, appendicitis, etc.; besides Staphylococcus epidermidis, pathogenic bacteria can also see Streptococcus, Enterococcus and Gram-negative bacteria, Such as Escherichia coli, Haemophilus influenzae, Klebsiella pneumoniae, Pseudomonas aeruginosa, diphtheria, yeast, etc In addition, there are rare cases of Brucella ovis infection abroad < br / > 2.2 clinical characteristics and diagnosis < br / > the risk factors of postoperative infectious complications include low age, hydrocephalus after hemorrhage, long operation time, lack of experience of the operator, cerebrospinal fluid leakage after operation, other intraperitoneal operations, etc In high-risk patients, we need to pay special attention to the occurrence of infectious complications The clinical manifestations of infection after ventriculoperitoneal shunt are not specific The common complaints of intracranial infection reported in the literature include: low fever, vomiting, neck rigidity, mental depression, irritability, headache, epilepsy, syndrome of inappropriate antidiuretic hormone secretion, etc Other possible local infection manifestations were related to the site of infection The manifestations of 3 patients with abdominal infection included abdominal distension, abdominal pain, vomiting, cessation of exhaust and defecation; 1 patient with urinary tract infection had frequent urination, urgent urination and increased nocturia It should be noted that fever is not a necessary condition for the diagnosis of infection Previous studies have shown that fever occurs only in 70% - 90% of patients, and its clinical manifestations are