Neurology India Medknow Publications on behalf of the Neurological Society of India ISSN: 0028-3886 EISSN: 1998-4022 Vol. 52, Num. 3, 2004, pp. 393-394

Neurology India, Vol. 52, No. 3, July-September, 2004, pp. 393-394

Letter To Editor

Ventriculo-peritoneal shunt infection by mycobacterium fortuitum in an adult

Viswanathan Roopa, Bhagwati SN, Iyer Viswanathan, Newalkar Prashant

Departments of Microbiology, Bombay Hospital and Medical Research Centre

Correspondence Address:Departments of Microbiology, Bombay Hospital and Medical Research Centre
ruvishy@rediffmail.com

Code Number: ni04132

Sir,
A 60-year-old male patient with unconsciousness after an assault was operated for decompression of fracture, and right-sided ventriculo-peritoneal (VP) shunt was placed for hydrocephalus. He developed fever after a few days. The above procedures were done at another institution. The patient came to us after one-and-a-half months with fever and pneumonia. The pneumonia was treated with intravenous Amoxycillin and Clavulinic acid combination. But the fever persisted in spite of clearing the consolidation in the lungs as evidenced by the X-ray reports. On exploration, there was an abscess in the neck, which was drained. Pus was sent for culture and sensitivity and VP shunt was removed. The patient developed Cerebrospinal fluid (CSF) rhinorrhea 3 days following shunt removal for which bi-frontal craniotomy and fascia lata duraplasty was done. After 17 days of shunt removal, the abdominal wound was found to be tender, indurated and hence it was debrided. This was followed by left-sided VP shunt insertion another 10 days later.

Provisional diagnosis was pneumonia and infected VP shunt.

Investigations done showed: Hemoglobin-12.2 gm%, CBC-9820 (Neutrophils-76%, lymphocytes-24%). Cerebrospinal fluid (CSF) showed proteins-56 gm% and White blood cells (WBC) count of 20 (30% polymorphs, 65% lymphocytes).

Pus sent for culture and sensitivity yielded no growth. But Ziehl Neelsen′s stain for pus samples showed acid fast bacilli following which, culture on Lowenstein Jensen′s medium yielded a growth of M. fortuitum in a period of 7 days and anti-tuberculosis drug susceptibility testing showed sensitivity to Kanamycin and Ciprofloxacin but resistance to standard drugs namely Isoniazid, Rifampicin, Streptomycin, Ethambutol, Pyrazinamide, Ofloxacin, Amikacin, Sparfloxacin. The patient was treated with 1 gram of intramuscular Kanamycin once a day for two months and 200ml of intravenous Ciprofloxacin twice a day for three weeks followed by oral 500 mg twice daily for six months.

On discharge, the patient was afebrile, conscious, obeying, moving all four limbs. After six months, there was resolution of lesions and no systemic symptoms.

Mycobacterium fortuitum is an environmental, rapidly growing organism that is found in soil, dust and water. It can colonize without causing invasive disease. It has been implicated in soft tissue infections, osteomyelitis and postoperative infections and injection abscesses.[1] M. fortuitum infections have been reported in various surgical procedures.[2],[3],[4]

M. fortuitum very rarely causes Central Nervous System (CNS) infection. VP shunt infection by M. fortuitum was unheard of till Midani et al[5] reported it in a 13-year-old Spina bifida patient. CNS infection by M. fortuitum occurs due to trauma, contamination during surgery or communication with an infected focus. Contamination during surgery is what we speculate for the VP shunt infection in our patient. Amikacin seems to have been successfully used for the treatment of M. fortuitum infection. But in vitro drug susceptibility using Lowenstein Jensen′s medium by resistance ratio method in our case showed resistance to Amikacin and standard anti-tuberculosis drugs. Kanamycin and Ciprofloxacin were the drugs found to be effective in vitro, that were used for the treatment in our patient after the removal of the shunt and after surgical debridement which is the mainstay of treatment in skin and soft tissue infections.

Thus the possibility of contamination with M. fortuitum must be kept in mind while placing ventriculo-peritoneal shunt. So utmost care with regards to aseptic precautions is necessary.

REFERENCES

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