2020

Case Reports / Journal of Clinical Neuroscience 21 (2014) 2020–2021

Cryptococcal ventriculoperitoneal shunt infection Matthew J. Viereck a, Nohra Chalouhi a, David I. Krieger a, Kevin D. Judy a,b,⇑ a b

Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, USA Thomas Jefferson University, Sidney Kimmel Medical College, 909 Walnut Street, Philadelphia, PA 19107, USA

a r t i c l e

i n f o

Article history: Received 30 July 2014 Accepted 1 August 2014

Keywords: CNS shunt infection Cryptococcus Ventriculoperitoneal shunt

a b s t r a c t The standard treatment of hydrocephalus is placement of a ventriculoperitoneal (VP) shunt. While infection is a common complication, rarely are fungal organisms implicated. Cryptococcus neoformans has been reported in only nine cases of shunt infection to our knowledge. The timing from shunt placement to symptom onset varies widely from 10 days to 15 months. We present a patient who developed a cryptococcal infection of his VP shunt more than two decades following shunt placement. Ó 2014 Elsevier Ltd. All rights reserved.

1. Introduction Shunting of cerebrospinal fluid (CSF) using a ventriculoperitoneal (VP) shunt is the standard treatment of hydrocephalus [1]. While VP shunting is effective at reducing the morbidity and mortality associated with hydrocephalus, high rates of complications lead to about 32% of adult patients needing revision surgery [2] Infections are among the most common complications, with bacteria the most often implicated organism [3–6]. Fungal organisms rarely cause VP shunt associated infections. Only 58 cases of shunt-related fungal infections have been reported in the literature to our knowledge. While the timing from shunt placement to infection varies, we present a patient with a cryptococcal infection of a VP shunt, originally placed more than 20 years ago. 2. Case presentation The patient is a 65-year-old man who was admitted to an outside hospital with a complaint of difficulty ambulating and confusion. The patient had a VP shunt placed more than 20 years ago for treatment of normal pressure hydrocephalus. He was transferred to Jefferson Hospital for Neuroscience for further treatment and was noted to have lower extremity weakness (2/5). A shunt tap indicated proper shunt function, but CSF cultures revealed the presence of Cryptococcus neoformans. The patient was diagnosed with an infected right occipital VP shunt. He was treated with flucytosine and amphotericin B and underwent externalization of the peritoneal catheter. The patient was taken to the operating room where the shunt was removed and a right frontal ventriculostomy was placed. Daily CSF cultures were followed until they remained negative for more than a week. A new VP shunt was placed 15 days after the removal of the previous shunt. The patient was discharged 1 month after admission neurologically intact and was continued on amphotericin B and flucytosine. At 3 month follow-up, the patient remained neurologically intact and symptom free. 3. Discussion Cryptococcal infection is a rare complication associated with VP shunts. Only nine cases of shunt related cryptococcal infections have been reported to our knowledge [7,8]. The majority of patients with cryptococcal infection not associated with VP shunts ⇑ Corresponding author. Tel.: +1 215 503 7005; fax: +1 215 503 9357. E-mail address: [email protected] (K.D. Judy).

are immuno-comprised [9,10]. Interestingly, five out of the nine previously reported cases of cryptococcal shunt infection had no underlying medical conditions [8]. The present patient had multiple underlying medical conditions, but was believed to be immuno-competent at the time of presentation. In previous cases of cryptococcal shunt infection, the time from shunt placement to symptom onset ranged from 10 days to 15 months [8,11]. The present case is exceptionally unusual, with a shunt placement to symptom onset time of more than 20 years. The most commonly reported symptoms from the previous patients were headache (44.4%, n = 4), emesis (44.4%, n = 4), and fever (33.3% n = 3). Three patients were treated with amphotericin B, flucytosine, and fluconazole, five patients with amphotericin B and flucytosine, and one patient with only amphotericin B [7,12]. Treatment included removal of the shunt in eight out of the nine reported cases. One patient was successfully treated with systemic therapy alone [12]. Four (44%) patients died as a result of the infection or related complications. Several sources of cryptococcal shunt infection exist. Six of the nine previous cases resulted from shunt placement in previously infected individuals [8,13]. One patient developed infection following shunt placement [12]. The duration from shunt placement to infection suggests our patient was not likely to have been infected pre-operatively, nor is it likely that the infection was acquired during shunt placement. Rather, the cryptococcal infection was likely acquired after shunt placement. VP shunt fungal infection is a rare but serious complication of CSF shunting. Many patients who develop shunt fungal infections were infected prior to shunt placement. Consequently, a diagnosis of fungal meningitis should be ruled out for patients prior to shunt placement. The present case report demonstrates that cryptococcal shunt infections may also occur more than two decades following shunt placement. Treatment involves shunt removal, anti-fungal therapy, and shunt replacement. Conflicts of Interest/Disclosures The authors declare that they have no financial or other conflicts of interest in relation to this research and its publication. References [1] Finney GR. Normal pressure hydrocephalus. Int Rev Neurobiol 2009;84: 263–81. [2] Reddy GK, Bollam P, Caldito G. Ventriculoperitoneal shunt surgery and the risk of shunt infection in patients with hydrocephalus: long-term single institution experience. World Neurosurg 2012;78:155–63.

Case Reports / Journal of Clinical Neuroscience 21 (2014) 2021–2023 [3] Reddy GK, Bollam P, Shi R, et al. Management of adult hydrocephalus with ventriculoperitoneal shunts: long-term single-institution experience. Neurosurgery 2011;69:774–80 [discussion 780–1]. [4] Wong JM, Ziewacz JE, Ho AL, et al. Patterns in neurosurgical adverse events: cerebrospinal fluid shunt surgery. Neurosurg Focus 2012;33:E13. [5] Rehman AU, Rehman TU, Bashir HH, et al. A simple method to reduce infection of ventriculoperitoneal shunts. J Neurosurg Pediatr 2010;5:569–72. [6] Vacca V. Diagnosis and treatment of idiopathic normal pressure hydrocephalus. J Neurosci Nurs 2007;39:107–11. [7] Veeravagu A, Ludwig C, Camara-Quintana JQ, et al. Fungal infection of a ventriculoperitoneal shunt: histoplasmosis diagnosis and treatment. World Neurosurg 2013;80:222.e5–13. [8] Ingram CW, Haywood HB, Morris VM, et al. Cryptococcal ventricularperitoneal shunt infection: clinical and epidemiological evaluation of two closely associated cases. Infect Control Hosp Epidemiol 1993;14:719–22.

2021

[9] Mirza SA, Phelan M, Rimland D, et al. The changing epidemiology of cryptococcosis: an update from population-based active surveillance in 2 large metropolitan areas, 1992–2000. Clin Infect Dis 2003;36:789–94. [10] Zarrin M, Zarei Mahmoudabadi A. Central nervous system fungal infections; a review article. Jundishapur J Microbiol 2010;3:41–7. [11] To KK, Cheng VC, Tang BS, et al. False-negative cerebrospinal fluid cryptococcal antigen test due to small-colony variants of Cryptococcus neoformans meningitis in a patient with cystopleural shunt. Scand J Infect Dis 2006;38: 1110–4. [12] Yadav SS, Perfect J, Friedman AH. Successful treatment of cryptococcal ventriculoatrial shunt infection with systemic therapy alone. Neurosurgery 1988;23:372–3. [13] Mangham D, Gerding DN, Peterson LR, et al. Fungal meningitis manifesting as hydrocephalus. Arch Intern Med 1983;143:728–31.

http://dx.doi.org/10.1016/j.jocn.2014.08.001

Endovascular thrombectomy and stenting in the management of carotid fibromuscular dysplasia presenting with major ischemic stroke José E. Cohen a,b,⇑, Eyal Itshayek a, Galina Keigler c, Roni Eichel c, Ronen R. Leker c a b c

Department of Neurosurgery, Hadassah-Hebrew University Medical Center, POB 12000, Jerusalem 91120, Israel Department of Endovascular Neurosurgery and Interventional Neuroradiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel

a r t i c l e

i n f o

Article history: Received 24 July 2014 Accepted 28 July 2014

Keywords: Carotid artery Fibromuscular dysplasia Ischemic stroke Stent Thrombectomy

a b s t r a c t Fibromuscular dysplasia (FMD) affecting the internal carotid artery (ICA) is considered a benign condition; however, retinal and cerebral ischemic events may occur. We present a patient with carotid FMD presenting with a major ischemic stroke due to major embolic occlusion of the ICA in conjunction with a hemodynamic component caused by narrowing and beading of the lumen associated with FMD. The patient was successfully treated with intracranial stent-assisted thrombectomy followed by cervical ICA stenting that aimed to reconstruct and angioplasty the FMD-affected arterial segment. Recently, stent-based thrombectomy has emerged as the most effective endovascular option for the rapid revascularization of major intracranial occlusions; however, to our knowledge, its use in a rare case of FMD-associated major stroke has not yet been reported. Ó 2014 Elsevier Ltd. All rights reserved.

1. Introduction Fibromuscular dysplasia (FMD) affecting the internal carotid artery (ICA) is considered a benign condition, and is usually detected incidentally [1,2]. However, it is an infrequent cause of retinal and cerebral ischemic events and, in rare cases, of major ischemic stroke. It most commonly occurs in middle-aged women [1–4]. We present a patient with carotid FMD presenting with a major ischemic stroke, successfully treated by intracranial stent-assisted thrombectomy followed by cervical ICA stenting. 2. Case presentation A 47-year-old woman with an unremarkable medical history except for hypertension and chronic headaches was admitted through the emergency room 3 hours after presenting with an episode of sudden onset speech alterations and right-side hemiparesis. Upon admission, gaze deviation, global aphasia and dense right hemiparesis were evident (National Institutes of Health Stroke Scale 24). Urgent noncontrast head CT scan ruled out intracranial hemorrhage but showed incipient signs of insular cortex

⇑ Corresponding author. Tel.: +972 2 677 7092; fax: +972 2 641 6281. E-mail address: [email protected] (J.E. Cohen).

grey-white matter effacement. CT angiogram confirmed occlusion of the distal left ICA. The patient was urgently brought to the neurointerventional suite and general anesthesia was induced. Diagnostic angiogram confirmed complete ‘‘T’’ occlusion of the left ICA and showed the ‘‘string of beads’’ pattern preceded by a tapered luminal stenosis that is characteristic of FMD, but there were no signs of dissection (Fig. 1). The distal ICA was rapidly recanalized by way of stent-based thrombectomy, as described in a previous technical note [5]. Briefly, an 8 French balloon-tipped guiding catheter was placed at the proximal ICA. Coaxially, a 0.02 inch microcatheter was navigated across the occluded arterial segment and a self-expandable microstent (Solitaire, Covidien/eV3, Plymouth, MN, USA) was deployed across the embolus and retrieved under proximal occlusion and aspiration. After complete ICA recanalization was confirmed (Fig. 2), 300 mg of aspirin and 600 mg of clopidogrel were administered per nasogastric tube and the ICA segment affected by FMD was covered by a single carotid stent to achieve angiographic reconstruction of the artery (Fig. 3). Coagulation tests performed at admission and cardiovascular studies at admission and on follow-up were unremarkable. No cardioembolic sources were detected on prolonged Holter, echocardiographic and tomographic cardiovascular studies. The renal arteries were not found to be affected by FMD. The patient was

Cryptococcal ventriculoperitoneal shunt infection.

The standard treatment of hydrocephalus is placement of a ventriculoperitoneal (VP) shunt. While infection is a common complication, rarely are fungal...
126KB Sizes 1 Downloads 7 Views