Clinical Neurology and Neurosurgery 103 (2001) 245– 246 www.elsevier.com/locate/clineuro
A case of shunt nephritis diagnosed 17 years after ventriculoatrial shunt implantation Motoo Kubota a,*, Yoshinori Sakata a, Naokatsu Saeki a, Akira Yamaura a, Makoto Ogawa b a
Department of Neurosurgery, Chiba Uni6ersity School of Medicine, Inohana, 1 -8 -1, Chuo-ku, Chiba-shi, Chiba 260 -8670, Japan b The First Department of Internal Medicine, Chiba Uni6ersity School of Medicine, Chiba, Japan Received 21 May 2001; received in revised form 17 July 2001; accepted 8 August 2001
Keywords: Shunt nephritis; Immune-complex; Enzyme immunoassay
2.1. The first admission
Shunt nephritis is an immune-complex-mediated nephritis associated with chronically infected ventricular shunts [1–5]. This infrequent complication tends to occur within several years after shunt operation . We describe a case of shunt nephritis confirmed using enzyme immunoassay 17 years after ventriculoatrial (VA) shunt implantation. We should consider that VA shunts always carry the risk for nephritis, and the possibility of this uncommon complication even more than 10 years after surgery.
He was somnolent and mildly disorientated. A CT scan revealed hydrocephalus. An emergency procedure with X-ray visualization of the CSF flow through the shunt showed no obstruction. The next day he became alert, and the enlarged ventricles were normalized without specific treatment. He left our hospital on the 3rd day.
2. Case presentation A 52-year-old male with mild consciousness impairment was admitted to our hospital on September 6, 1996. He had undergone an episode of neck clipping surgery for a ruptured cerebral aneurysm followed by VA shunt implantation for treatment of hydrocephalus on November 27, 1979, 17 years before admission. The postoperative course seemed to have been uneventful and satisfactory.
* Corresponding author. Tel.: + 81-43-226-2158; fax: +81-43-2262159. E-mail address: [email protected]
2.2. The second admission He was readmitted for recurrent consciousness disturbance on September 15, 1996. A CT scan showed re-enlargement of the ventricular system, indicating shunt malfunction. We placed a new ventricloperitoneal (VP) shunt without removing the old shunt system to avoid additional complications. He became alert again immediately after the operation. He began to show intermittent fever of unknown origin from the 3rd postoperative day. Blood culture yielded a few colonies of Staphylococcus epidermidis. Laboratory data showed mild anemia (haematocrit 31.3%), hypoalbuminemia (2.1 g/dl), mildly increased CRP (1.7 mg/dl) and decreased compliments levels (C3: 33 mg/dl, C4: 22 mg/ dl). His cerebrospinal fluid contained 32/3 mm3 mononuclear and 4/3 mm3 polymorphonuclear cells. Repeated urine analysis showed continuous proteinuria (8.3 g/day). Shunt nephritis was highly suspected. Renal biopsy revealed endothelial proliferation with mesangial
0303-8467/01/$ - see front matter © 2001 Elsevier Science B.V. All rights reserved. PII: S 0 3 0 3 - 8 4 6 7 ( 0 1 ) 0 0 1 5 5 - X
M. Kubota et al. / Clinical Neurology and Neurosurgery 103 (2001) 245–246
expansion. Enzyme immunoassay demonstrated deposition of immune-complexes including IgM on the glomerular basement membrane. The pathological diagnosis was membranoproliferative glomerulo-nephritis. We removed the VA shunt system on October 27. Culture of the shunt tube also revealed S. epidermidis. He became afebrile after removal of the old shunt system. Signs of renal impairment disappeared 6 months after surgery.
3. Discussion Shunt nephritis is an infrequent complication associated with a chronically infected shunt system [2– 5] first described in 1965 . The overall incidence of ventricular shunt infection varies between 3 and 11%. Shunt nephritis is known to occur in 0.7– 2.25% of patients with an infected shunt . Low virulent bacteria are the responsible pathogens because prolonged infection is essential to immune-complex mediated nephritis [2–4]. Patients suffer from chronic renal impairment with infectious signs and cerebral symptoms [2– 5]. The prognosis for impaired renal function is good only with early diagnosis and treatment including adequate an-
tibiotic therapy following removal of the infected shunt system [2–5]. This complication tends to occur within several years after the last shunt implantation . Our case was diagnosed 17 years after shunt insertion. From our experience, the possibility of this uncommon complication in patients with ventricular shunts even more than 10 years after surgery should be considered. A VP shunt system is favorable in avoiding this complication.
References  Black JA, Challacombe DN, Ockenden BG. Nephrotic syndrome associated with bacteremia after shunt operations for hydrocephalus. Lancet 1965;2:921 – 4.  Bogdanovic R, Nikolic V, Ognjanovic M, Marjanovic B, Sindjic M, Djordjevic M, Markovic M, Sarjanovic L. Shunt nephritis. 2 case reports and a review of the literature. Srp Arh Celok Lek 1996;124:29 – 36.  Haffner D, Schindera F, Aschoff A, Matthias S, Waldhere R, Scharer K. The clinical spectrum of shunt nephritis. Nephrol Dial Transplant 1997;12:1143 – 8.  Samtleben W, Bosch T, Bauriedel G, Gotz C, Klare B, Henselmann L, Banthien FC, Gurland HJ. Internal medicine complications of ventriculoatrial shunt. Med Klin 1995;90:67 – 71.  Rifkinson-Mann S, Rifkinson N, Leong T. Shunt nephritis: case report. J Neurosurg 1991;74:656 –9.