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Intraventricular vancomycin-induced cerebrospinal fluid eosinophilia: report of two patients
1Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pennsylvania.
Abstract:
Pediatric neurosurgeons commonly instill vancomycin into the ventricles to treat shunt infections. This use for vancomycin, however, has not been studied in the laboratory to evaluate possible toxicities and side effects. We report two cases of cerebrospinal fluid eosinophilia (CSFE) secondary to the intraventricular administration of vancomycin. Two other cases of shunt infection during the same time period were treated for only 2 days with intraventricular vancomycin and did not manifest CSFE. We address the clinical problems and possible detrimental effects of CSFE in the setting of shunt infection. We propose a mechanism of vancomycin-induced mast cell degranulation and subsequent release of eosinophil chemotactic factor as a cause of CSFE. An initial dose of intraventricular vancomycin should take into account volume of distribution (ventricular size) to obtain a peak cerebrospinal fluid concentration of 20 to 30 micrograms/mL. We recommend following daily cell counts and vancomycin peak and trough levels to calculate the amount and frequency of intraventricular vancomycin required to maintain safe and effective concentrations and to monitor for CSFE.
Insights
Intraventricular vancomycin for shunt infections can cause cerebrospinal fluid eosinophilia (CSFE). Shorter treatment durations may prevent this adverse effect, highlighting the need for careful dosing and monitoring.
Area of Science:
- Neuroscience
- Pharmacology
- Pediatric Neurosurgery
Background:
- Intraventricular vancomycin is frequently used by pediatric neurosurgeons to treat shunt infections.
- The potential toxicities and side effects of this specific administration route have not been extensively studied.
Observation:
- Two cases of cerebrospinal fluid eosinophilia (CSFE) were observed following intraventricular vancomycin administration for shunt infections.
- Two other patients with shunt infections treated with intraventricular vancomycin for only two days did not develop CSFE.
Findings:
- The study proposes vancomycin-induced mast cell degranulation and release of eosinophil chemotactic factor as the mechanism causing CSFE.
- CSFE can present significant clinical challenges and detrimental effects in the context of shunt infections.
Implications:
- Determining optimal intraventricular vancomycin dosing based on ventricular size is crucial to achieve target cerebrospinal fluid concentrations (20-30 µg/mL).
- Daily monitoring of cell counts and vancomycin levels (peak and trough) is recommended to ensure safe and effective treatment and to detect CSFE early.