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A 5-year-old female presents with swollen lesions on abdomen, chest
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A 5-year-old female with a ventriculoperitoneal shunt was referred to the pediatric surgery clinic for evaluation of two discrete, swollen lesions on the upper abdomen and lower chest.
James H. Brien
The first lesion, along with some cephalad streaking, was first noted by the mother about 2 months earlier, which was diagnosed by their primary care physician as cellulitis and treated with cefdinir (Omnicef, Abbott Laboratories) with a good initial result.
However, she soon developed some intermittent, vague abdominal pain with some periodic erythema over the area along the ventriculoperitoneal (VP) shunt tubing, prompting two more visits to the ED without any findings at the time of the visits, including a normal CT scan of the head and a normal shunt series. A CT scan of the abdomen at that time did note that there was a soft tissue swelling about the shunt tubing in the abdominal wall (Figure 1) that was of unclear significance, but she was sent home since she seemed to be clinically well. She was briefly admitted to the hospital with the second visit to the ED for further evaluation of possible VP shunt infection. After 2 days of treatment with vancomycin and ceftriaxone and observation, including evaluation by neurosurgery, no signs or symptoms of infection were seen, and she was discharged. This was the first time I saw her, and I supported that she go home with no further treatment.
Figure 1. A CT scan of the abdomen at that time did note that there was a soft tissue swelling about the shunt tubing in the abdominal wall.
Source: Brien JH
Her past medical history was that of a 25-week premature baby, resulting in a grade 4 intraventricular bleed causing hydrocephalus requiring the shunt placement by 8 months of age with no revision since. Otherwise, she has done very well with no significant developmental delay. Her immunizations are up-to-date. There’s no history of trauma or sick contacts.
Figures 2 and 3. Two large swollen areas that were erythematous with overlying shinny skin that seemed to be in the area defined by the VP shunt tubing.
Examination on this admission revealed a normal-appearing 5-year-old female in no acute distress, whose vital signs were normal and whose VP shunt appeared intact with two large swollen areas that were erythematous with overlying shinny skin (Figures 2 and 3) that seemed to be in the area defined by the VP shunt tubing. There was very little pain on palpation, which revealed fluctuance.
What's Your Diagnosis?
A. VP shunt cerebrospinal fluid (CSF) infection
B. VP shunt tunnel infection
C. VP shunt erosion into abdominal wall
D. CSF pseudocysts
The answer turned out to be an infection of the VP shunt tunnel (B). When the lesions were drained and the shunt was removed, methicillin-sensitive Staphylococcus aureus (MSSA) was recovered. This may help explain the rather circuitous route that the patient took to arrive at the diagnosis, as the previous antimicrobial therapy probably had some delaying effect on the natural progression of the infection. At the previous admission, the parents felt that there was an infection; however, there was no evidence to support their fears until the lesions reappeared. The unusual course may also have had something to do with the virulence of the responsible organism, or rather the lack of virulence. In any case, the only acceptable way to manage a tunnel infection like this is to remove the shunt and treat with antibiotics based on the organism recovered. In the meantime, a ventricular drain can be used to drain the CSF till a new shunt is placed, which should be tunneled through a different area. A reasonable time frame is usually about a week after the shunt is removed, with negative cultures, then about another week or so, depending on the cause and clinical course.
I did not give any information about the status of the CSF, but if the CSF is infected, sterilization of the CSF for about a week is usually long enough for shunt replacement. Whether it’s a tunnel infection or an infection of the devise in the ventricle, the shunt must come out to optimize the outcome. A great, concise review of the management of infected shunts can be found in the July 2002 edition of The Pediatric Infectious Diseases Journal (Schreffler RT. Pediatr Infect Dis J. 2002;21:632-636).
Figure 4. Shunt erosion can occur anywhere along the route of the tubing — the intestine, bladder pleura and abdomen.
Shunt erosion can occur anywhere along the route of the tubing — the intestine, bladder pleura and abdomen (Figures 4 and 5). The erosion is often discovered by becoming infected. Treatment is the same: antimicrobials to cover S. aureus and Gram-negative rods pending culture results, and shunt removal.
CSF pseudocysts usually occur in the abdomen at the tip end of the shunt. The underlying cause is not completely clear, but is thought to be related to inflammation, adhesions, elevated CSF protein or some combination of these factors. The fibrinous wall of the pseudocyst can continue to expand until it exerts enough pressure to cause a bowel obstruction (Figure 6, showing the large cystic lesion compressing the bowel and the shunt shown in the box), which may be the presenting complaint. Treatment is surgical drainage of the cyst and revision of the distal shunt.
Shunt erosion can occur anywhere along the route of the tubing — the intestine, bladder pleura and abdomen (Figure 5). Figure 6 shows the large cystic lesion compressing the bowel and the shunt shown in the box..
The above case reminds us that sometimes the parents can know something is wrong even though we can’t see it at first.
Columnist Comments
In May 1994, retired Army Colonel John Pierce (then Deputy Commander of Walter Reed Army Medical Center) and I attended the funeral of Lewis B. Puller Jr., at Arlington National Cemetery at Fort Myer, Va.. First Lieutenant. Puller, a severely wounded Vietnam War veteran who had been medically retired from the military, was an attorney and author of his autobiographical account of his life as the son of the legendary World War II Marine Corps Maj. Gen. Lewis (Chesty) Puller. His 1991 Pulitzer Prize-winning book, Fortunate Son: The Healing of a Vietnam Vet, also detailed his personal journey through rehabilitation for both his injuries, as well as drug and alcohol dependence.
In May 2011, I attended the funeral of another severely wounded Vietnam War vet named David Towns, at a small, very remote cemetery in Robertson County, Texas; about 1,400 miles from Arlington.
Puller died of a self-inflicted gunshot wound. David died of complications of chronic pain medications. I did not know Lewis Puller, but I grew up with David in the very small town of Calvert, Texas. They both had families, including children, and were both tormented by the chronic pain of their physical and psychological injuries. I think many people consider these former soldiers to be casualties of war, albeit delayed.
Now that the US military involvement in Iraq is essentially over, and that in Afghanistan will soon follow, these conflicts will fade from the public consciousness. However, the casualties will continue for decades to come. Almost exactly 10 years ago, I made my first commentary on these wars and our military personnel and medical colleagues in uniform. And with that, I will make this the last.
I regret to inform you that the 47th Annual Uniformed Services Pediatric Seminar has been canceled due to Department of Defense budget cutbacks. As a retired Army physician, I witnessed the budget battles every year for over 20 years, and when cuts are discussed, the Medical Corps is always in jeopardy, especially Pediatrics because of having no combat mission. However, there would always be a last minute rescue to continue with just enough to continue the mission of taking care of military dependents, which was done with a standard of care that is unparalleled. This is a very disappointing development that hopefully will be temporary and not cause much lasting damage to the morale or capability of military pediatricians; not to mention the potential deleterious effect on military dependents. Every survey done on the subject of soldier morale has shown that the vast majority do a better job on the battlefield when they are not worried about the care of their spouses and children back home. My message to the Department of Defense: “Wise up. The money saved by cutting the medical educational funding of those who take care of soldiers’ dependents, could end up costing much more than money can buy on the battlefield in the form of poor morale.”
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James H. Brien, DO, is a member of the Infectious Diseases in Children Editorial Board, as well as Vice Chair for Education at The Children’s Hospital at Scott and White, and is the Associate Professor of Pediatrics at Texas A&M University, College of Medicine, Temple, Texas, can be reached at jhbrien@aol.com.
Disclosure: Brien reports no relevant financial disclosures.