Successful treatment of cryptococcal ventriculoatrial shunt infection with systemic therapy alone

Ventriculoperitoneal shunt infection by Cryptococcus neoformans sensu stricto: Case report and literature review

BACKGROUND

Cryptococcal ventriculoperitoneal shunt infection is known to occur due to an underlying infection in the patient rather than by nosocomial transmission of Cryptococcus during shunt placement. A case of chronic hydrocephalus due to cryptococcal meningitis that was misdiagnosed as tuberculous meningitis is described.

CASE REPORT

Patient details were extracted from charts and laboratory records. The identification of the isolate was confirmed by PCR-restriction fragment length polymorphism of the orotodine monophosphate pyrophosphorylase (URA5) gene. Antifungal susceptibility was determined using the CLSI M27-A3 broth microdilution method. Besides, a Medline search was performed to review all cases of Cryptococcus ventriculoperitoneal shunt infection. Cryptococcus neoformans sensu stricto (formerly Cryptococcus neoformans var. grubii), mating-type MATα was isolated from the cerebrospinal fluid and external ventricular drain tip. The isolate showed low minimum inhibitory concentrations for voriconazole (0.06mg/l), fluconazole (8mg/l), isavuconazole (<0.015mg/l), posaconazole (<0.03mg/l), amphotericin B (<0.06mg/l) and 5-fluorocytosine (1mg/l). The patient was treated with intravenous amphotericin B deoxycholate, but died of cardiopulmonary arrest on the fifteenth postoperative day.

CONCLUSIONS

This report underlines the need to rule out a Cryptococcus infection in those cases of chronic meningitis with hydrocephalus.

Cryptococcal Infection of the Ventriculoperitoneal Shunt in an HIV-Infected Patient with an Excellent Immunovirologic Status

BACKGROUND

Cryptococcus spp. is a rare cause of ventriculoperitoneal shunt (VPS) infection, with a variable clinical presentation. Diagnosis and treatment of this entity are challenging.

CASE DESCRIPTION

A cryptococcal VPS infection occurred in a human immunodeficiency virus-infected patient with an excellent immunovirologic status, with an abdominal mass as the only clinical sign at presentation. Microbiologic diagnosis was confirmed when Cryptococcus neoformans was isolated in 4 cerebrospinal fluid samples on different days. The patient was treated with dual antifungal therapy (liposomal amphotericin B plus flucytosine). The VPS was initially externalized and then removed. At 12-month follow-up, the patient remained asymptomatic, and no replacement VPS was required.

CONCLUSIONS

This is the first reported case of cryptococcal VPS infection in a patient with human immunodeficiency virus infection. Clinical outcome was excellent after dual antifungal therapy plus device withdrawal. Diagnosis and treatment of this entity remain a challenge for clinicians.

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 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.

Candida cerebrospinal fluid shunt infection. Report of two new cases and review of the literature

In this case report, we describe two patients with Candida shunt infection and review 22 cases from the previous literature. All of them had ventriculoperitoneal shunts, except one who had an external ventricular drain. The more outstanding predisposing factors were recent bacterial meningitis and/or neurosurgery (different from the shunt placement) and abdominal complications (intestinal perforation in three cases, and gastrostomy and lengthening of the distal catheter in one each). The clinical manifestations were hydrocephalus in 36%, fever in 31%, meningoencephalitis in 21%, and abdominal symptoms in 10%. The mean cerebrospinal fluid count was 78 cells/mm3 (with 77% lymphocytic predominance). Two patients died (9%); one of them was the only case in which the catheter was not removed. The recommended treatment is the replacement of the shunt and antifungal therapy with intravenous amphotericin B; in cases of poor clinical condition, the latter should also be given intraventricularly.

Ventriculitis and hydrocephalus caused by Candida albicans successfully treated by antimycotic therapy and cerebrospinal fluid shunting

A unique case of Candida albicans ventriculitis and hydrocephalus in the absence of any evidence of systemic candidiasis or immunosuppression is reported. Initial treatment with CSF shunting and intravenous antimycotic therapy appeared to have eradicated the infection. Recurrence occurred 5 months after discharge and this was treated by intravenous and intrathecal antimycotic therapy in addition to removal of the shunt system, external ventricular drainage and then replacement of the shunt. A concomitant pyogenic brain abscess responded to burrhole aspiration and antibiotics. The role of mannan antigen monitoring is discussed.

Cysto-peritoneal shunt infection with Trichosporon beigelii

Infection is a frequent problem affecting cysto-peritoneal shunts, the usual causative organisms being Staphylococcus epidermidis and Staphylococcus aureus. Fungi are rarely isolated from such infections. We present the first report, as far as the authors are aware, of a case of Trichosporon beigelii shunt infection that responded to shunt removal and antifungal therapy.