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Cryptococcal ventricular-peritoneal shunt infection: clinical and epidemiological evaluation of two closely
C W Ingram1, H B Haywood, V M Morris
1Raleigh Infectious Diseases Associates, North Carolina 27607.
Objective:
To determine the cause of meningitis associated with Cryptococcus neoformans in two patients with recent ventricular-peritoneal (VP) shunt placement.
Design:
A retrospective review of materials, records, and concurrent cases of VP shunt procedures. Isolates of C neoformans from each patient were submitted for analysis by colony morphology, biochemical testing, and karyotyping by pulsed-field electrophoresis.
Setting:
Two 400-bed community hospitals.
Patients:
Two immunocompetent patients presented with symptoms of progressive hydrocephalus in August 1991. Each received a VP shunt on the same day by the same surgeon using materials from a common vendor and hospital.
Results:
Both patients presented within six to eight weeks with symptoms of fever, headache, rash, and cultures of cerebrospinal fluid (CSF) that yielded C neoformans. Each patient recovered after therapy with amphotericin B and flucytosine followed by several months of fluconazole, although one required replacement of the VP shunt for cure. Review of each patient's history and CSF characteristics at the time of shunt placement suggested reactivation of a preexisting infection. Isolates of C neoformans from each patient were submitted for analysis by colony morphology, biochemical testing, and karyotyping by pulsed-field electrophoresis. Each isolate was found to be unique by chromosomal karyotyping.
Conclusions:
Our data and previous reports suggest that cryptococcal VP shunt infections appear to be a complication of shunts placed in previously infected persons rather than nosocomial transmission of cryptococcus during placement.
Insights
Cryptococcal meningitis after ventricular-peritoneal shunt placement in immunocompetent patients is likely due to reactivation of prior infection, not hospital transmission. Genetic analysis confirmed unique strains in each case.
Area of Science:
- Infectious Diseases
- Neurosurgery
- Medical Microbiology
Background:
- Ventricular-peritoneal (VP) shunts are used to treat hydrocephalus.
- Cryptococcus neoformans can cause meningitis, particularly in immunocompromised individuals.
Observation:
- Two immunocompetent patients developed Cryptococcus neoformans meningitis within weeks of VP shunt placement.
- Both patients had received shunts on the same day from a common source.
- Cerebrospinal fluid cultures confirmed C neoformans infection.
Findings:
- Genetic analysis (karyotyping) revealed unique C neoformans isolates in each patient.
- Patient histories suggested reactivation of a pre-existing infection.
- Treatment involved antifungal therapy and, in one case, shunt replacement.
Implications:
- VP shunt-associated cryptococcal meningitis in immunocompetent hosts may stem from endogenous reactivation.
- This challenges the assumption of nosocomial transmission as the primary cause.
- Further investigation into pre-shunt screening for latent infections may be warranted.