Cryptococcal Infection of the Ventriculoperitoneal Shunt in an Immunocompetent Patient

Abstract

Patient: Male, 52Final Diagnosis: Cryptococcal ventriculoperitoneal shunt infectionSymptoms: Confusion • fever • LethargyMedication: Amphotericin B • FlucytosineClinical Procedure: Ventriculoperitoneal shunt removalSpecialty: Infectious diseaseObjective:Rare diseaseBackground:Ventriculoperitoneal shunting is an effective treatment for hydrocephalus. Ventriculoperitoneal shunt (VPS) infection is a common complication. Cryptococcus neoformans as an implicated organism is rare. In this report, we describe a patient with cryptococcal VPS infection.Case Report:A 52-year-old male with normal pressure hydrocephalus, status post implantation of VPS one year prior to the presentation; who was admitted with a fever, lethargy and confusion for three days. He was treated empirically with intravenous cefepime and vancomycin for VPS infection. The CSF analysis from both the lumbar puncture and the VPS was significant for a low white blood count, low glucose and high protein. Other work-up including India ink and cryptococcal antigen was unrevealing. He remained febrile despite antibiotic treatment for 5 days. The CSF from the shunt was sent for analysis again and it demonstrated similar results from the prior study, but the culture was now positive for Cryptococcus neoformans. The patient was started on oral flucytosine and intravenous liposomal amphotericin B. The VPS was removed and an externalized ventricular catheter was placed. The patient showed rapid resolution of the symptoms.Conclusions:To date, there was a total of nine reported cases of cryptococcal VPS infection upon review of the literature. Our presenting case and the literature review highlight the difficulties in making an accurate diagnosis of cryptococcal shunt infection. There were case reports of false negative cryptococcal antigen tests with culture proven cryptococcal meningitis. The CSF culture from the shunt remains a mainstay for identifying cryptococcal shunt infection. Cryptococcal shunt infections are rare and early diagnosis and treatment is essential for patient management which involves shunt replacement with concomitant administration of intravenous antifungal medication. High clinical suspicion is crucial and shunt culture preferably from the valve is recommended.

Delineating the Biofilm Inhibition Mechanisms of Phenolic and Aldehydic Terpenes against Cryptococcus neoformans

“…3 Moreover, the increased use of ventricular shunts for intracranial hypertension management has been associated with adherence of C. neoformans on these medical devices. 4,5 This highlights the significance of C. neoformans biofilm as a critical pathogenic condition. The biofilm is a wellstructured phenotype of sessile cryptococcal cells embedded within a self-produced polysaccharide-rich extracellular polymeric matrix (EPM) attached to the surface.…”

“…Moreover, the increased use of ventricular shunts for intracranial hypertension management has been associated with adherence of C. neoformans on these medical devices. , This highlights the significance of C. neoformans biofilm as a critical pathogenic condition.…”

Intravitreal Voriconazole for the Treatment of Cryptococcus neoformans Endogenous Endophthalmitis

“…3 Additionally, according to 2 recent (2018 and 2016) reports, our patient's VPS may have also predisposed him to cryptococcal infection. 7,13 Of these 2 reported cases of VPS-associated Cryptococcus, 1 patient did not have ocular involvement, and the symptoms rapidly resolved with the removal of VPS and administration of oral flucytosine and IV amphotericin B. 13 The patient in the case reporting fungal endophthalmitis associated with a VPS had a poor response to amphotericin B, but the lesion was stabilized with systemic fluconazole.…”

“…7,13 Of these 2 reported cases of VPS-associated Cryptococcus, 1 patient did not have ocular involvement, and the symptoms rapidly resolved with the removal of VPS and administration of oral flucytosine and IV amphotericin B. 13 The patient in the case reporting fungal endophthalmitis associated with a VPS had a poor response to amphotericin B, but the lesion was stabilized with systemic fluconazole. 7 These cases highlight the potential link between cryptococcal infection and VPS.…”

The treatment of patients with posthemorrhagic hydrocephalus

“…Пациенты детского возраста в среднем переносят до 2 ревизий шунтирующих систем в течение 10 лет. Так, к наиболее частым осложнениям шунтирующих операций, кроме инфекционно-воспалительных, относят атипичное расположение катетеров, вторичное смещение компонентов дренажных систем, обструкцию как вентрикулярного, так и дистального отделов шунта, и последствия неадекватного подбора параметров клапанной системы [8,[14][15][16][17].…”