SHORT REPORT Massive ascites as unique sign of shunt infection by Propionibacterium acnes NICOLA MONTANO M. D., CARMELO STURIALE M. D., GIOVANNA PATERNOSTER M. D., LIVERANA LAURETTI M. D., EDUARDO FERNANDEZ M. D. & ROBERTO PALLINI M. D. Institute of Neurosurgery, Catholic University, Rome Abstract Propionibacterium acnes (P. acnes) has been associated with shunt infection. The signs of infection are mild. We report on a case of P. acnes shunt infection presenting with massive ascites as the unique sign of CSF infection. Shunt removal, antibiotic therapy and drenaige of ascites were performed with a rapid clinical recovery. Key words: Shunt infection, Propionibacterium acnes, ascites. Case report P. acnes is a ubiquitous skin bacterium that has been associated to shunt infection in children and adults. 1,2,3 In a large retrospective analysis of adult patients, P. acnes shunt infection was detected in 9% of cases 2 . Usually, the signs of infection are mild: fever, leukocytosis, low CSF leukocyte count, high glucose ratio and abdominal pain have been re- ported 1 . Abdominal pseudocyst formation has pre- viously been described 1,3 . P. acnes shunt infection may be underdiagnosed. Therefore a prolonged observation of CSF cultures is recommended 3 . To our knowledge we report on the first case of P. acnes shunt infection presenting with massive ascites as the unique sign of CSF infection. A 51-year-old woman was admitted with a 6-month history of progressive ascites. Two years before, she had undergone surgical removal of a large left vestibular schwannoma with ventriculo-peritoneal shunt posi- tioning because of obstructive hydrocephalus. On admission, a massive ascites without physical and hematochemical sign of infection was evident. Neurological examination revealed left hearing loss and slight facial palsy. Head CT scan did not show hydrocephalus (Fig. 1A). Abdominal CT scan revealed a huge intraperitonal fluid collection with- out associated abdominal diseases (Figs. 1B,C,D,E). The shunt was removed and a ventricular catheter was placed for external drainage. On chemical examination of CSF, only slight low protein level was evident, whereas microbiological cultures re- vealed a P. acnes infection. Ascitic fluid analysis evidenced a protein level of 2.7 gr/dl and a white blood cell (WBC) count of 300/ml. Intravenous Teicoplanin was administered for 15 days and 1 liter per day of ascitic fluid was drained with complete clinical recovery. Since prolonged ICP monitoring did not show patological values, the ventricular catheter was removed. The patient is in good clinical conditions at 12 months follow-up. Discussion Ascites, as a complication of ventriculoperitoneal shunt placement, has been reported in the litera- ture 4,5,6 and its formation has been related to several factors. Impaired absorption of fluid within the peritoneum due to multiple shunt reconstructions and tube extensions resulting in chronic inflamma- tion 5 and elevated level of CSF protein, as in shunt placement for hydrocephalus due to recurrent craniopharyngioma 7 , have been hypothesized to have a role in the pathogenesis of ascites. Yount et al. reported on 4 cases of ascites complicating ventricu- loperitoneal shunting: two patients had active infec- tion. In this work the authors focused attention on the ascitic fluid analysis: patients with infection had a protein level greater than 3 gr/dl and a WBC count Correspondence: Nicola Montano, Institute of Neurosurgery, Catholic University, Largo Agostino Gemelli, 8, 00168 Rome, Italy. Tel.: þ39 0630154120, þ39 0630154358. Fax: þ39 063051343. E-mail: nicolamontanomd@yahoo.it Received for publication 16 May 2009. Accepted 3 December 2009. British Journal of Neurosurgery, April 2010; 24(2): 221–223 ISSN 0268-8697 print/ISSN 1360-046X online Ó The Neurosurgical Foundation DOI: 10.3109/02688690903531067 Br J Neurosurg Downloaded from informahealthcare.com by ZHAW Zurich University of Applied Sciences on 07/22/10 For personal use only.