Eosinophilia of the cerebrospinal fluid in a case of shunt infection: case report

Eosinophilic meningoencephalitis successfully treated with glucocorticoids and intravenous immunoglobulin: a case report

Eosinophilic meningoencephalitis is a rare inflammatory condition of the central nervous system. As a limited number of cases has been reported, debate remains on the optimal treatment. We present a case of idiopathic eosinophilic meningoencephalitis successfully treated with glucocorticoids and intravenous immunoglobulin (IVIG). After extensive evaluation to rule out other possible causes, the patient was treated with intravenous (IV) dexamethasone and showed significant improvement within a few days. However, neurologic impairment persisted, and follow-up lumbar puncture results showed only a mild decrease in pleocytosis. Even after an additional 5 days of IV methylprednisolone, cerebrospinal fluid (CSF) pleocytosis persisted, and brain magnetic resonance imaging (MRI) showed an increase in enhanced lesions, implying persistent neuroinflammation. The patient was maintained on high-dose oral prednisolone for 2 months, and additional immune-modulatory effects were treated with IVIG. Follow-up MRI at 2 months showed a significant decrease in the extent of multiple enhanced lesions and a normalized CSF profile. The patient was maintained on regular maintenance doses of IVIG for an additional 6 months without any neurologic signs or symptoms. Inflammation is the key pathophysiology underlying neurological damage in eosinophilic meningoencephalitis. A literature review revealed that corticosteroid treatment is the only anti-inflammatory treatment used in cases of idiopathic meningoencephalitis, resulting in sufficient response in most patients but only partial response or death in a few cases. This is the first case report of IVIG use in idiopathic eosinophilic meningoencephalitis, suggesting the possibility of a new treatment modality for refractory cases.

Eosinophilic Meningitis Secondary to Intravenous Vancomycin

Eosinophilic meningitis may be due to infectious or noninfectious etiologies. Parasitic infections cause this entity most frequently and of the noninfectious causes, medications play an important role. We describe a 32-year-old male who developed eosinophilic meningitis while receiving intravenous vancomycin. No other apparent cause of the eosinophilic meningitis was appreciated. This case represents the first description of eosinophilic meningitis due to systemic vancomycin.

Cerebrospinal fluid eosinophilia associated with intraventricular shunts

CSF eosinophilia (CSF-eo) is uncommon and is usually caused by helminthic infections. However, it has also been found in ∼30% of patients experiencing intraventricular shunt malfunctions. We present a case report and review the conditions associated with CSF-eo and their prophylaxis. An 8 year-old boy with tetraventricular hydrocephalus has had several shunt malfunctions over the last three years. During hospitalization in January 2009 for shunt revision, a transient 30% eosinophilia was detected in his cerebral spinal fluid (CSF) concomitant with Staphylococcus epidermidis infection and long term vancomycin administration. After several shunt replacements and antibiotic treatment, CSF-eo eventually disappeared with good overall clinical response. CSF-eo is a transient and focal event mainly associated with infection, reactions to foreign substances, particles or blood, or obstruction of tubing by normal or fibro-granulomatous tissues. Infection associated with CSF-eo is usually caused by S. epidermidis and Propioniumbacterium acnes. In addition to infection, allergy to silicone and other foreign materials may also be a cause of CSF-eo. We review the diversity of conditions and proposed mechanisms associated with CSF-eo, as well as recommendations for the care of patients with shunts. Detection of CSF-eo has been shown to be a useful indicator of shunt malfunction. As such, it provides physicians with an indicator of a hypersensitivity reaction that is underway or the need to identify bacterial infection. We also highlight the need for improved biocompatibility of shunt hardware and describe strategies to avoid conditions leading to shunt malfunction.

Update on eosinophilic meningoencephalitis and its clinical relevance

Eosinophilic meningoencephalitis is caused by a variety of helminthic infections. These worm-specific infections are named after the causative worm genera, the most common being angiostrongyliasis, gnathostomiasis, toxocariasis, cysticercosis, schistosomiasis, baylisascariasis, and paragonimiasis. Worm parasites enter an organism through ingestion of contaminated water or an intermediate host and can eventually affect the central nervous system (CNS). These infections are potentially serious events leading to sequelae or death, and diagnosis depends on currently limited molecular methods. Identification of parasites in fluids and tissues is rarely possible, while images and clinical examinations do not lead to a definitive diagnosis. Treatment usually requires the concomitant administration of corticoids and anthelminthic drugs, yet new compounds and their extensive and detailed clinical evaluation are much needed. Eosinophilia in fluids may be detected in other infectious and noninfectious conditions, such as neoplastic disease, drug use, and prosthesis reactions. Thus, distinctive identification of eosinophils in fluids is a necessary component in the etiologic diagnosis of CNS infections.

Cerebrospinal fluid eosinophilia in children with ventricular shunts

OBJECT

Eosinophils have been reported in children with cerebrospinal fluid (CSF) shunts. The goal of this study was to describe the risk factors, relationship to infection, and clinical significance of CSF eosinophilia in a large group of shunt-treated patients.

METHODS

The authors performed a retrospective review of data obtained in all patients who underwent ventricular shunt placement or revision at the James Whitcomb Riley Hospital for Children between 2000 and 2004.

RESULTS

Eosinophils were identified during a follow-up shunt evaluation in 93 (31%) of 300 patients after initial shunt placement. Eosinophilia was statistically related to CSF extravasation (p < 0.0001), shunt infection (p = 0.031), blood in CSF (p < 0.0001), younger age at shunt insertion (p = 0.030), and the diagnosis of posthemorrhagic hydrocephalus (p < 0.0001). Patients with CSF eosinophilia had a higher risk of subsequent shunt failure (p < 0.0001). Analysis was performed using data obtained in a cohort of patients with a total of 130 shunt infections. Cerebrospinal fluid eosinophils were identified in 118 infections (90.8%). The leukocytic and eosinophilic reactions were dependent on the infecting organism. Propionibacterium acnes had a statistically lower CSF leukocyte count but higher differential percentage of eosinophils than the other common pathogens.

CONCLUSIONS

Cerebrospinal fluid eosinophilia is a relatively common finding in children with shunts. Patients with CSF eosinophilia had an increased risk of shunt malfunction in the present series. Eosinophilia is associated with infection, CSF extravasation, and blood in the CSF. Patients with P. acnes-induced shunt infections have higher eosinophil percentages than are found in infections associated with other common organisms. Therefore, in patients with eosinophilia, extended anaerobic culture studies should be performed with particular attention paid to searching for this pathogen.

A case of abdominal CSF pseudocyst associated with silicone allergy

CASE REPORT

The authors present a case of a patient with an abdominal CSF pseudocyst that resulted from an allergic reaction to silicone. The patient underwent repair surgery of the meningomyelocele associated with the Chiari II malformation, and the V-P shunt was instituted at 6 months of age. A formation of the abdominal CSF pseudocyst and the consequent shunt malfunction were observed 40 days after the V-P shunt. An increase in the number of the peripheral eosinophils and serum immunoglobulin E (IgE), and an infiltration of eosinophils in the specimen harvested from the pseudocyst wall suggested an allergic reaction as the cause of the pseudocyst. A sixth operation to revise the V-P shunt was performed using the shunt system made of "extracted silicone", which was produced extracting the allergic substances.

OUTCOME

The serum IgE was normalized after surgery and the abdominal CSF pseudocyst has not recurred for 22 months.

Eosinophilic meningitis

Eosinophilic meningitis is a rare clinical entity that can be useful in narrowing the differential diagnosis of central nervous system disease. It is defined by the presence of 10 or more eosinophils/microL in the cerebrospinal fluid (CSF) or a CSF eosinophilia of at least 10%. The most common cause is invasion of the central nervous system by helminthic parasites, particularly Angiostrongylus cantonensis, but other infections as well as noninfectious conditions may also be associated. This review describes the etiologies of eosinophilic meningitis, focusing primarily on the helminths that cause CSF eosinophilia.

Predictors of ventriculoperitoneal shunt pathology

BACKGROUND

Diagnosis of ventriculoperitoneal (VP) shunt pathology remains a dilemma in patients with nonspecific constitutional signs and symptoms. Eosinophilia has been described in association with shunt infection and malfunction. Our purpose was to further define the relationship of eosinophilia and shunt pathology and to determine other predictors of VP shunt infection and malfunction.

METHODS

Records of all patients admitted with a suspected VP shunt infection or malfunction were reviewed. The following data were abstracted: age; reason for and age at initial shunt placement; number of revisions; date of last revision; history of fever or vomiting; ventricular fluid cell count; differential and culture; complete blood count and differential; need for shunt revision or replacement; and use of antibiotics. After exclusion of patients admitted for initial shunt placement, the remainder were divided into three groups: those with shunt infection; those with shunt malfunction; and those without documented infection or malfunction.

RESULTS

Of 12 patients with shunt infection and 69 with shunt malfunction, 2 and 11, respectively, had eosinophilia defined as > or =5%. The presence of eosinophilia had a 96% positive predictive value for shunt pathology and raised the pretest probability of pathology from 84% to a post test probability of 96%. The combination of fever history and ventricular fluid neutrophils >10% had a 99% specificity for shunt infection, had a 93 and 95% positive and negative predictive value, respectively, and raised the pretest probability of infection from 12% to a posttest probability of 92%.

CONCLUSIONS

In patients suspected of having a VP shunt malfunction, the presence of > or =5% eosinophils in the ventricular fluid indicates shunt pathology. The combination of fever and ventricular fluid neutrophils > 10% is predictive of shunt infection.

Ventricular cerebrospinal fluid eosinophilia in children with ventriculoperitoneal shunts

To determine the significance of cerebrospinal fluid (CSF) eosinophilia, the charts of 106 patients treated with shunt-related procedures during the calendar year 1985 were reviewed. Sixty-nine patients presented for a shunt revision; their charts were retrospectively reviewed from the time of shunt insertion until January, 1988. The remaining 37 patients had a ventriculoperitoneal shunt inserted during the study period and were subsequently followed to January, 1988. A total of 558 shunt-related procedures were performed on these patients during the study period, with a mean follow-up period of 6.9 years. The infection rate was 3.8%. Eosinophilia was diagnosed when eosinophils accounted for 8% or more of the total CSF white blood cell count. Ventricular CSF eosinophilia occurred in 36 patients sometime during their clinical course. These 36 patients required a mean of 8.5 shunt revisions, while the remaining patients required a mean of 2.5 revisions (p less than 0.001). Shunt infections were also more frequent in patients with eosinophilia (p less than 0.01). In no case was peripheral eosinophilia or a parasitic infection present. This study demonstrates that CSF eosinophilia is common in children with shunts. Children with this laboratory finding will experience more shunt failures. In addition, the new appearance of eosinophilia in the CSF of a patient with a shunt in place suggests the possibility of a shunt infection.

Cerebrospinal fluid analysis and clinical outcome of eight dogs with eosinophilic meningoencephalomyelitis

Eight dogs, 14 weeks to 5.5 years of age, had signs of diffuse or multifocal meningoencephalomyelitis. The total white cell counts of the cerebrospinal fluid (CSF) ranged from 11 to 5,550 cells/microliters; the percentage of eosinophils ranged from 21% to 98%. The total CSF protein content range was 19 to 1,430 mg/dl. On necropsy, two dogs had granulomatous encephalomyelitis due to protozoan infection. The other six dogs, of which three were Golden Retriever dogs, appeared to have an idiopathic eosinophilic meningoencephalitis; four of these dogs recovered. The significance of eosinophils in CSF and the possible emergence of a new encephalitic syndrome of dogs involving a hypersensitivity to an unknown agent is also discussed.