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Journal of Postgraduate Medicine
Medknow Publications and Staff Society of Seth GS Medical College and KEM Hospital, Mumbai, India
ISSN: 0022-3859 EISSN: 0972-2823
Vol. 46, Num. 1, 2000, pp. 37-38

Journal of Postgraduate Medicine, Vol. 46, No. 1, January-March, 2000, pp. 37-38

Case Report

Round Worm Migration Along Ventriculoperitoneal Shunt Tract: A Rare Complication

Agarwal P, Malapure SM, Gupta R, Mane P, Parelkar S, Oak SN

Department of Paediatric Surgery, T. N. Medical College and B. Y. L. Nair Ch. Hospital, Mumbai - 400 008, India.
Address for correspondence: Dr. S. N. Oak, A-111404, Neelam Nagar, Mulund (East), Mumbai 400 081.E-Mail: sanjayoak@yahoo.com

Code Number: jp00012

Abstract:

Though a ventriculoperitoneal shunt has been associated with myriads of unusual complications, so has been that with roundworms. A case of a three-year-old boy is presented who had an unusual complication of roundworm migration along the shunt tract that presented as shunt tract infection. (J Postgrad Med 2000; 46:37-38)

Key Words: Ventriculoperitoneal shunt, Complication, Ascariasis.

The common complications associated with ventriculo-peritoneal (VP) shunts are obstruction, shunt infection ventriculitis and shunt migration, etc 1 . Unusual complications include complete migration of the VP shunt into the ventricle or even passage through the rectum 1,2 . On similar lines, symptomatology commonly encountered by a paediatric surgeon related to roundworm infestation are obstruction (due to bolus formation or intussusception), perforation (due to penetration of ulcers) or retrograde migration to stomach and upper aero-digestive tracts. Infrequent complications include appendicitis, obstructive jaundice, pancreatitis, liver abscesses and obstructions at anastomotic sites 3,4,5 . The above features are due to the tendency of the roundworms to negotiate small orifices, which serves as an impetus for further migration 6 .

Case Report

A three-year-old boy presented with high-grade fever and redness of right mastoid region of five days duration. He was mentally retarded with delayed milestones. The patient was treated for tubercular meningitis with hydrocephalus, for which a VP shunt was introduced when the patient was a year old. He made uneventful recovery after the surgery till the present illness. There was no history of abdominal discomfort or any respiratory problems in the past. There was history of passage of roundworms in the stools on three occasions and he had vomited a roundworm once.

On local examination, there was redness over the mastoid area and mastoid tenderness was present. Shunt was functioning and skin over the tract was inflamed. Abdominal wound was unhealthy and on milking the shunt tract, pus could be expressed through the abdominal wound. Pus was sent for culture and sensitivity. The patient was started on vancomycin and amikacin. Despite five day antibiotic therapy, there were no signs of resolution Therefore; it was decided to remove the shunt.

Under local anaesthesia, a small incision was given over the previous cranial incision and the shunt was removed. While removing the shunt a membranous soft tissue was pulled along the tube, which was thought to be a necrotic fascia around the shunt. On full withdrawal of shunt, the soft tissue was found to be a dead roundworm. The wound was stitched and shunt tip was sent for culture and sensitivity. The patient was on antibiotics for 15 days after which a fresh shunt was introduced on the opposite side when all infective foci had disappeared.

Discussion

Infection remains the foremost complication associated with shunt procedures for hydrocephalus. Many studies emphasize the frequency of shunt infections in either ventriculo-atrial or VP shunts. The factors responsible for shunt infections are poor preoperative skin conditions, intercurrent seats of infection, patient's age, type of operation (whether primary insertion, revision, or reinsertion after infection), which end of the shunt was revised and the presence of post operative wound dehiscence or scalp necrosis 7 .

Figure 1

Though Staphylococcal epidermidis was the most common pathogen along with other gram negative and gram positive pathogens we could not find a similar case report as ours where a roundworm had migrated along the shunt track and was the cause of shunt tract infection.

It was unusual regarding the migration of roundworm from the bowel lumen without demonstrable signs of perforative peritonitis. In some instances, several roundworms may be found lying free in the peritoneal cavity in absence of a demonstrable perforation in the intestinal wall 8 . Roundworm migration has been reported through the umbilicus and the drainage tube of an empyema 9,10 . Roundworms are also seen coming out of infected inguinal wound following strangulated hernia repair and from drainage site of a subphrenic abscess 11,12 . Roundworms on rare occasion migrate far out from the gastro intestinal tract and are located in place like pleural cavity, lacrymal duct, middle ear and even in femoral artery. Round worm have been reported to have caused fatal invasion of the pelvis of the left kidney through a uretero colic fistula 13,14 .

We present this unique case report for its rarity and claim it to be the first of its kind as there is no mention of a similar case report in the literature.

References

  1. Scott R Michael. Neurosurgery; Shunt complications Vol. 3. 2 nd  Ed. Mc Graw Hill. 1996; pp3655-3664.
  2. Yamamura K, Kodarna O, Kajikawa H, Kawanishi M, Sugie A, Kajikawa M, et al. Rare intra- abdominal complication of a ventriculoperitoneal shunt: report of three cases. No Shinkei Geka 1998; 26:1007-1011.
  3. Chatterjee KD. Parasitology; Phylum Nemathelminthes: Class Nematoda, Ascariodea. 12 th  Edn. Calcutta: Chatterjee Medical Publisher; 1981. pp158-206.
  4. Khuroo MS, Zangar SA, Mahajan R. Hepato biliary and pancreatic ascariasis in India. Lancet 1990; 335:1503-1506.
  5. Kasat LS, Naregal A, Jain M, Bajaj R, Borwankar SS, Tamwekar V, et al. Roundworm obstruction of the hepatic limb of a Roux-en-Y anastomosis. Ped Surg Int 1998; 13:553-554.
  6. Milroy P. The movement of adult Ascaris lumbricoides. Br J Surg 1972; 59:437-442.
  7. Renier D, Lacombe J, Khan AP, Rose CS, Hirsch JF. Factors causing acute shunt infection: Computer analysis of 1174 operations. J Neurosurgery 1984; 61:1072-1078.
  8. Parashar SK, Nadkarni SV, Varma RA. Primary roundworm peritonitis. Indian J Surg 1974; 36:200-201.
  9. Mulchandani HJ. Roundworm infestation of Meckel's diverticulum. J Indian Med Assoc 1966; 46:262.
  10. Chand ST, Bhargava KP. 'Extrusion of ascaris lumbricoides worm through an empyema tube (A case report)'. Indian J Surg 1964; 26:5, 474-475.
  11. Laha NK. Case of strangulated hernia (right side) with a peculiar complication-escape of roundworms through wound. Indian Med Gaz 1952; 87:203.
  12. Iswariah JD. Ascaris lumbricoides-some surgical aspects. Indian J Surg 1965; 27:8, 529-532.
  13. Roche PJL. 'Ascaris in the Lachrymal duct', Trans R Soc Trop Med Hyg 1971; 65:540.
  14. Busta mante-Sarabia J, Martuscelli QA, Tay J. Ectopic ascaniasis: Report of a case with adult worms in the kidney. Am J Trop Med & Hyg 1977; 26:568-569.

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Copyright 2000 - Journal of Postgradate Medicine


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