Hot Seat #158: Denouement

Posted on: October 12, 2020, by :

Case Review: 6-week-old female with VP shunt (placed at another institution at birth) presents with reported persistent fever despite recent inpatient hospitalization during which no source of fever was identified.

Here’s how you answered:

Denouement: After an extensive discussion with neurosurgery, during which our concerns were emphasized (bandemia, elevated inflammatory markers in a recently placed shunt), the neurosurgery team agreed that tapping shunt was indicated. Unfortunately, CSF fluid showed very high WBC count with +gram stain. Patient was admitted for operative management and IV antibiotics, had an uncomplicated inpatient stay, and was ultimately discharged home.

Discussion: Fever in children with VP shunts is challenging, to put it lightly. The discussion on the board, as well as in person, emphasized the need to rule out all sources of infection, which should include attaining CSF. To put this case in another light, even if this child had no shunt, LP would be indicated as evidenced by her CRP. (As an example, the Step-by-Step algorithm would estimate the risk of invasive bacterial infection to be 3.4-8.1%).

Shunt failures and shunt infections specifically are common. Authors have quoted a wide range of failure rates, but failure rates could be as high as 30-40% in the first year of placement. For infection specifically, the rate appears to be between 7.413%. Other authors have looked at risk factors for infection and have found that placement at <6 months of age and prior revisions significantly increase risk of infection. Finally, for that patient in front of you, the presence of fever, leukocytosis, and placement or revision within the last 90 days were all associated with increased odds on a shunt infection.

Summary: For patients with a VP shunt who appear unwell and/or have fevers, recent shunt placement, or leukocytosis, strongly consider obtaining CSF (either by LP or shunt aspiration) to rule out shunt infection.

The information in these cases has been changed to protect patient identity and confidentiality. The images are only provided for educational purposes and members agree not to download them, share them, or otherwise use them for any other purpose.

Brian Lee
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