CASE REPORT

Ventriculoperitoneal shunt infection after an insect sting

Mehmet Yaman & Kaya Suer & Asli Kaptanoglu &

Ferhat Harman & Erkan Kaptanoglu

Received: 3 January 2012 /Accepted: 11 January 2012 /Published online: 10 February 2012# Springer-Verlag 2012

Introduction

Ventriculoperitoneal (VP) shunt transfers cerebrospinal flu-id from the lateral ventricles of the brain to the peritoneumvia subcutaneous tubing. VP shunt implantation is the mostwidely used treatment for the management of hydrocepha-lus [2]. Although VP shunting reduces the mortality andmorbidity of hydrocephalus, there are potential shunt com-plications such as infection, obstruction, mechanical dis-connection, and breakage. These complications may causeshunt failure and reoperations [22]. The long-term studiesshow that 45% to 59% of all patients require surgicalrevisions [5].

VP shunt infections are serious complications. Infectionsof the catheter may spread into the abdomen by ascendingdirection or into the brain ventricles by descending directionand may threaten life. The incidence of shunt infection rangesfrom 1% to 29% [3, 20]. Therapeutic modalities for thetreatment of shunt infections vary from only antibiotic treat-ment to IV antibiotics with removal of the infected shunt.

We herein report a case of shunt infection after an insectsting. Although an insect sting can cause local and inflam-matory reactions, to the best our knowledge, this is the firstreport of a shunt infection after a single insect sting in Englishliterature.

Case report

An 8-year-old girl had VP shunt placement when she was50 days of age because of post-traumatic hydrocephaly due toa traffic accident. On admission, she was stung by an insect ather left hip and her right chest skin just over the VP shunttunnel. The patient was admitted to our clinic 1 day after theinsect sting which was declared to be a mosquito by herfamily. Her physical examination revealed an erythemato-edematous, inflamed, 14 cm in diameter, annular plaque witha central picur sign on her left femoral area in addition to alinear erythema with local swelling on her right thoracal areasuperposing with her VP shunt (Fig. 1). Computerized to-mography (CT) of the brain revealed a ventricular catheter inthe right lateral ventricle. There was neither hydrocephalusnor periventricular edema on brain CT. Abdominal ultra-sound was obtained to exclude an intraabdominal abscess,and there was no pathological finding except the distal cath-eter end. There were elevated CRP and ESR on her bloodtests. She had mild fever.

The patient was diagnosed with a shunt infection due toan insect sting and given an oral antihistamine and sulta-micillin (ampicillin + sulbactam) 2×375 mg for 2 weeks.Skin lesions disappeared in 2 days. Her blood tests werenormal in the first week. Six weeks later, she was brought toour department with a hyperemic lesion on trase of thedistal catheter on her right chest. She was given oral sulta-micillin 2×375 mg for 2 weeks. In 2 days, the hyperemia

M. Yaman : F. Harman : E. Kaptanoglu (*)Department of Neurosurgery, Faculty of Medicine,Near East University,Lefkosa, Mersin-10, Turkeye-mail: erkankaptanoglu@gmail.com

K. SuerDepartment of Infectious Diseases and Clinical Microbiology,Faculty of Medicine, Near East University,Lefkosa, Mersin-10, Turkey

A. KaptanogluDepartment of Dermatology, Faculty of Medicine,Near East University,Lefkosa, Mersin-10, Turkey

Childs Nerv Syst (2012) 28:955–957DOI 10.1007/s00381-012-1700-5

disappeared. Four weeks later, she was brought to ourdepartment again with a similar but larger hyperemic lesionon the trase of the distal catheter on her right chest. Sheresponded to the same antibiotic treatment clinically. Twoweeks later, she was admitted again with a larger hyperemiaon her right chest and elevated CRP while she was onantibiotic treatment.

She was operated on, in order to remove the VP shunt.On operation, the distal shunt catheter was calcified andattached to surrounding tissue on her right chest wall(Fig. 2). Specimens were obtained from the catheter andsurrounding tissue for pathological and microbiologicalexaminations. The histopathological findings were consis-tent with macrocalcifications. Microbiological culturerevealed Corynebacterium matruchotii which was sensitiveto sultamicillin. Thus, she was given sultamicillin 2×375 mg for 4 weeks on the postoperative period. Her neu-rological exam was normal on her follow-ups, and therewere no signs of hydrocephalus. Postoperative ventriclediameters have not increased on brain CTs. The patientbecame asymptomatic 3 months postoperatively, and herCRP was in normal limits.

Discussion

Implantation of the ventriculoperitoneal shunt is the mostwidely used treatment for hydrocephalus. VP shunt infec-tion is one of the most important and common complica-tions [4, 10, 12, 14–16, 19, 20]. The main concern in suchcases is spreading of infection into brain ventricles or intothe abdomen. Although the skin lesion was enlarging ineach of her admissions to the hospital, fortunately, she didnot develop intracerebral or intraperitoneal infection.

The most common pathogens for shunt infections arecoagulase-negative staphylococci (50–90%), followed byStaphylococcus aureus (13–27%) and other organisms includ-ing aerobic gram-negative bacilli, streptococci, and others [4,10, 20]. In our case, microbiological culture revealed C.matruchotiiwhich grew as a pure colony in the culture media.Gram-positive coryneform rods are often considered non-pathogenic components of normal skin flora and mucosalmembranes. These are frequently encountered in culturesbut are often regarded as contaminants or as non-pathogenic.In recent years, there have been increasing reports of theirpathogenic potential in numerous clinical pictures [1, 8, 11,13]. Thus, we demonstrated that C. matruchotii may havepathogenic potential and cause shunt infection.

In children, as in adults, insect stings can cause local orgeneralized allergic reactions [6, 7, 9, 21]. Unusual reactionsmay also occur following insect stings [9, 17]. These reac-tions give symptoms related by cardiac, renal, neurologic,pulmonary, or hematological systems. These reactions arequite diverse and often have no known underlying patho-genesis. In the same way, acute compartment syndrome ofthe hand has been reported after an insect sting due to atriggered inflammatory reaction [18].

In the present case, the sting most likely destroyed the skinbarrier and permitted bacilli to enter the subcutaneous tissueand reach the distal shunt catheter. With the antibiotic treat-ment, the microorganism was shown to be sensitive to sulta-micillin, and the infection was limited to the catheter and did

Fig. 1 The insect sting is seen as erythemato-edematous, inflamed,annular plaque with central picur sign on her left femoral area and alinear erythema with local swelling on her right thoracal area super-posing with VP shunt

Fig. 2 The distal catheter of the VP shunt is seen with its calcifiedsurrounding tissues

956 Childs Nerv Syst (2012) 28:955–957

not spread into the brain or peritoneum which could havebeen disastrous. In shunt-related infections, there is no singleconsensus at present concerning the best method of treatment.In these conditions, the frequently used method includesantibiotic treatment and removal of the shunt. In cases wherethe treatment of hydrocephalus is still necessary, externalventriculostomy drainage may be needed until the infectionis controlled. Because of the recurrent nature of infection, wehave to remove the device as it behaves like a foreign bodyand as a surface for colonization.

We here present a case of an insect sting causing VP shuntinfection. After diagnosis is made, treatment is a standard forshunt infection.

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