The American Journal of Forensic Medicine and Pathology 22(2):207–210, 2001. ©2001 Lippincott Williams & Wilkins, Inc., Philadelphia 207 A 10-year-old boy with Arnold-Chiari malformation, spina bifida, and a ventriculoperitoneal shunt for hydro- cephalus died unexpectedly, having appeared to be only mildly unwell with fever on the night before death. At autopsy, the shunt was partially obstructed with an as- sociated enterococcal meningitis. The tip of the shunt was located within the transverse colon, which was em- bedded in a mass of fibrous adhesions resulting from previous abdominal surgery. Blood cultures were sterile. Intestinal perforation is a rare complication of ventricu- loperitoneal shunting that may be associated with the de- velopment of meningitis and unexpected death. The au- topsy assessment of children with such indwelling devices requires examination of the functional state of the shunt, full septic workup, and determination of the precise location of the tip of the catheter within the peri- toneal cavity. Key Words: Sepsis—Unexpected death—Ventriculo- peritoneal shunt. Ventriculoperitoneal shunt insertion is a well-es- tablished treatment for obstructive hydrocephalus involving drainage of cerebrospinal fluid through a subcutaneous catheter into the peritoneal cavity. Very rarely, the tip of the catheter may perforate the intestine, resulting in ascending intracerebral sepsis (1–3). A case of unexpected death in a 10-year-old boy is reported, with review of steps to be taken at autopsy in such cases. CASE REPORT A 10-year-old boy had a history of spina bifida and Arnold-Chiari malformation with ventriculo- peritoneal shunting for obstructive hydrocephalus. He was severely developmentally delayed, with an intellectual capacity below that of a 2-year-old child. He presented with a history of appearing to be only mildly unwell with fever on the night be- fore death. This was followed by sudden collapse and cardiac arrest the following morning. Resusci- tation was unsuccessful. His history included shunt insertion at the age of 1 week, with myelomeningocele closure at 1 month of age. A diversion vesicostomy was performed at 10 months because of recurrent urinary tract infections. This was subsequently revised and then closed with construction of an augmentation enterocys- toplasty. Ventriculoperitoneal shunt revision oc- curred on one occasion. Other procedures included bilateral ureteric reimplantation, open reduction of a dislocated left hip, and bilateral lower limb tenot- omies. Small intestinal obstruction caused by post- surgical fibrous adhesions necessitated hospitaliza- tion with nonsurgical treatment several months before death. At autopsy, the body was that of a small boy (height and weight 3rd percentile) with marked kyphoscoliosis and a relatively large head. The proximal portion of the shunt was partially blocked, Unexpected Childhood Death Due to a Rare Complication of Ventriculoperitoneal Shunting Roger W. Byard, M.D., Barbara Koszyca, Ph.D., and Ming Qiao, M.B.B.S., Ph.D. Manuscript received May 3, 2000; accepted August 21, 2000. From the Forensic Science Centre, Adelaide, (R.W.B.); De- partment of Pathology, University of Adelaide, Adelaide, (B.K.); and Infectious Disease Laboratories Institute of Med- ical and Veterinary Science, Adelaide (M.Q.), Australia. Address correspondence to Roger W. Byard, M.D., Forensic Science Centre, 21 Divett Place, Adelaide 5000, Australia; email: byardr01@forensic.sa.gov.au.