Tension hydrothorax from intrapleural migration of a ventriculoperitoneal shunt

A male newborn underwent a myelomeningocele repair, with subsequent placement of a ventriculoperitoneal shunt for treatment of hydrocephalus. Five days after shunt surgery, the infant acutely developed a deeply sunken fontanel, pallor, tachypnea, bradycardia, and irritability. Chest radiographs revealed intrathoracic migration of the distal shunt tubing and a tension hydrothorax. Treatment consisted of tube thoracostomy and temporary externalization of the distal shunt tubing. The patient fully recovered. The acute onset of shock in association with a sunken fontanel in a neonate with a shunt should raise the suspicion of tension hydrothorax. For critically ill infants immediate needle aspiration or thoracostomy is suggested. In less severely ill children, exposure of the shunt tubing in the neck and withdrawal of the pleural effusion by the distal shunt tubing may be performed as an emergency measure. The early recognition and urgent management of this problem are emphasized.