A 60-year-old female with a history of ventriculoperitoneal shunt (VPS) placement three years prior presented with a painful abdominal wall mass. The patient denied fevers, nausea, vomiting, headaches, or dizziness. Physical exam revealed an afebrile, well-appearing female with a raised, erythematous, fluctuant mass on the right lower abdominal wall. She had no abdominal tenderness otherwise. Labs were unremarkable. A bedside ultrasound revealed a complex fluid collection over the area of fluctuance that tracked along the course of the VPS tubing into the abdomen. Plan for incision and drainage was deferred. Neurosurgery was consulted. The neurosurgeon attempted to tap the shunt but encountered very high resistance. The patient was admitted for intravenous antibiotics for VPS infection and malfunction.

VPSs are neurosurgically implanted devices used to treat hydrocephalus by shunting cerebral spinal fluid from the lateral ventricles of the brain into the peritoneum. Shunt infections, including meningitis, ventriculitis, and peritonitis, occur in 2–17% of VPS cases.^1-3 Clinicians should maintain a high index of suspicion for VP shunt complications in patients who present with typical symptoms suggestive of increased intracranial pressure. In this case, a less obvious complication such as an abscess in an atypical location lowered the practitioner’s threshold for bedside imaging and further investigation.

Footnotes

Section Editor: Sean O. Henderson, MD

Full text available through open access at http://escholarship.org/uc/uciem_westjem

Address for Correspondence: Erik A. Berg, MD, LAC+USC Medical Center, 1200 N. State Street Room 1011, Los Angeles, CA 90033. Email: eberg19@gmail.com. 12 / 2015; 16:1180 – 1180

Submission history: Revision received August 5, 2015; Accepted August 24, 2015

Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. The authors disclosed none.

REFERENCES

1. Choksey MS, Malik IA. Zero tolerance to shunt infections: can it be achieved?. J Neurol Neurosurg Psychiatry. 2004;75(1):87-91.

2. Lee JH, Kim DS, Choi JU. Complications after ventriculoperitoneal shunt according to the time course. J Korean Neurosurg Soc. 2007;41:391-6.

3. Park IS, Lee CM, Kim YT, et al. Post-shunt infection in hydrocephalus. J Korean Neurosurg Soc. 1998;27:476-80.