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Migration of the anal distal end due to ventriculoperitoneal shunt placement: an atypical case report of a 9-month-old infant with tuberculous meningitis and review of the literature

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Abstract

Background

Ventriculoperitoneal shunt (VPS) represents one of the most classic and widely used treatments for hydrocephalus in pediatric patients. Migration and externalization of the distal end of the catheter through the rectum are extremely rare complications of intestinal perforation with devastating consequences such as meningitis or peritonitis due to enteric bacteria that are significantly life-threatening. Besides, one of the biggest topics with that is that it can happen without producing symptoms, like the patient we present in this case report, which further masks the condition and puts the patient's life more at risk.

Case presentation

We present a case of a 9-month-old infant patient, with a history of prematurity, tuberculous meningitis (TBM), and hydrocephalus, who came to ED with a functional VPS and the distal end of the catheter protruding outside the rectum for 7 days, without presenting neurological or intestinal symptoms accompanying. One of the parameters that guided the diagnosis and made us suspicious of asymptomatic intestinal perforation (IP) was the background of TMB. The patient was immediately transferred to the OR where both ends of the shunt were removed: in the first instance, the shunt tube was disconnected through the abdomen, thus withdrawing through the anus, and subsequently, the proximal end of the catheter was exteriorized. In turn, the intestinal fistula was successfully repaired laparoscopically, and prophylactic antibiotic treatment was early administered. On the 6th postop day, a shunt was internalized, and a child was discharged on postop day 15 without complications with alarm guidelines.

Conclusions

The authors of this article strongly suggest that (1) anal extrusion of catheters is an uncommon complication but real: for this reason, its development should be considered in all patients with VPS, especially in infants. (2) The patients are often asymptomatic since false tracts can form around the catheter protecting it from spillage, and thus can be removed without complications. (3) Special care should be taken in patients with conditions that increase the risk of developing IP, such as TMB.

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Availability of data and materials

No datasets were generated or analysed during the current study.

Abbreviations

VPS:

Ventriculoperitoneal shunt

CSF:

Cerebrospinal fluid

ICP:

Intracranial pressure

IP:

Intestinal perforation

TBM:

Tuberculous meningitis

ATT:

Anti-tubercular therapy

Cong Hydroc:

Congenital hydrocephalus

Communic.Hydroc:

Communicating hydrocephalus

PTH:

Post-traumatic hydrocephalus

Postop Hydroc:

Postoperative hydrocephalus

EVD:

External ventricular drainage

CoNS:

Coagulase-negative Staphylococci

P. stuartii :

Providencia stuartii

SPM:

Streptococcus pneumoniae Meningoencephalitis

EC:

Escherichia coli

GBS:

Group B Strep

BM:

Bacterial meningitis

BP:

Bacterial peritonitis

USG:

Ultrasonography

Sigmoidesc:

Sigmoidoscopy

MMC:

Myelomeningocele

VM:

Ventriculomegaly

IVH:

Intraventricular hemorrhage

DWM:

Dandy-Walker malformation

SAH:

Subarachnoid hemorrhage

TBI:

Traumatic brain injury

TBM:

Tubercular meningitis

OM:

Occipital meningocele

SMR:

Severe mental retardation

Oligod.:

Oligodendroglioma

References

  1. Zhang X, Li P, Wen J, Chang J, Chen Y, Yin R, Xu H, Liu X, Yang L, Wei J (2023) Ventriculoperitoneal shunt for tuberculous meningitis-associated hydrocephalus: long-term outcomes and complications. BMC Infect Dis 23(1):742. https://doi.org/10.1186/s12879-023-08661-7

    Article  PubMed  PubMed Central  Google Scholar 

  2. Bryant MS, Bremer AM, Tepas JJ III, Mollitt DL, Nquyen TQ, Talbert JL (1988) Abdominal complications of ventriculoperitoneal shunts. Case reports and review of the literature. Am Surg 54(1):50–55

    CAS  PubMed  Google Scholar 

  3. Sharma RM, Pruthi N, Arimappamagan A, Somanna S, Devi BI, Pandey P (2015) Tubercular meningitis with hydrocephalus with HIV co-infection: role of cerebrospinal fluid diversion procedures. J Neurosurg 122(5):1087–1095

    Article  PubMed  Google Scholar 

  4. Sekhon MS, Griesdale DE (2015) Neurocritical care essentials: a practical guide. Cambridge University Press

    Book  Google Scholar 

  5. Lutz BR, Venkataraman P, Browd SR (2013) New and improved ways to treat hydrocephalus: pursuit of a smart shunt. Surg Neurol Int 4(Suppl 1):S38

    Article  PubMed  PubMed Central  Google Scholar 

  6. Sarkiss CA, Sarkar R, Yong WH, Lazareff JA (2014) Time dependent pattern of cellular characteristics causing ventriculoperitoneal shunt failure in children. Clin Neurol Neurosurg 127:30–32. https://doi.org/10.1016/j.clineuro.2014.09.029

    Article  PubMed  Google Scholar 

  7. Sharifian A, Abdollahi A, Maddah G, Anaraki F, Alvandipour M, Abbasi Sahebi M, Bigdeli N, Hasanzadeh AM (2013) Spontaneous transanal protrusion of ventriculoperitoneal catheter: a case report. Acta Med Iran 51(2):135–138

    PubMed  Google Scholar 

  8. Reddy GK, Bollam P, Caldito G (2014) Long-term outcomes of ventriculoperitoneal shunt surgery in patients with hydrocephalus. World Neurosurg 81(2):404–410

    Article  PubMed  Google Scholar 

  9. Browd SR, Ragel BT, Gottfried ON, Kestle JR (2006) Failure of cerebrospinal fluid shunts: part I: obstruction and mechanical failure. Pediatr Neurol 34(2):83–92

    Article  PubMed  Google Scholar 

  10. Mohta A, Jagdish S (2009) Spontaneous anal extrusion of ventriculoperitoneal shunt. Afr J Paediatr Surg 6(1):71–72

    Article  PubMed  Google Scholar 

  11. Sarkari A, Borkar S, Mahapatra A (2016) Anal extrusion of migrated ventriculo-peritoneal shunt catheter: an unusual complication and review of literature. Asian J Neurosurg 11(04):459–459

    Article  PubMed  PubMed Central  Google Scholar 

  12. Sathyanarayana S, Wylen EL, Baskaya MK, Nanda A (2000) Spontaneous bowel perforation after ventriculoperitoneal shunt surgery: case report and a review of 45 cases. Surg Neurol 54(5):388–396

    Article  CAS  PubMed  Google Scholar 

  13. Bakshi S (2020) Spontaneous trans-anal extrusion of caudally migrated ventriculo-peritoneal shunt tip in a child: a case report. Surg Case Rep 6(1):50. https://doi.org/10.1186/s40792-020-00813-0

    Article  PubMed  PubMed Central  Google Scholar 

  14. Martinez Hernández-Magro P, Barrera Román C, Villanueva Sáenz E, Zavala MJ (2006) Colonic perforation as a complication of ventriculoperitoneal shunt: a case report. Tech Coloproctol 10:353–355

    Article  PubMed  Google Scholar 

  15. Miserocchi G, Sironi VA, Ravagnati L (1984) Anal protrusion as a complication of ventriculo-peritoneal shunt. Case report and review of the literature. J Neurosurg Sci 28(1):43–46

    CAS  PubMed  Google Scholar 

  16. Ghritlaharey RK, Budhwani KS, Shrivastava DK, Gupta G, Kushwaha AS, Chanchlani R, Nanda M (2007) Trans-anal protrusion of ventriculo-peritoneal shunt catheter with silent bowel perforation: report of ten cases in children. Pediatr Surg Int 23:575–580

    Article  PubMed  Google Scholar 

  17. Nataprawira HM, Gafar F, Risan NA, Wulandari DA, Sudarwati S, Marais BJ et al (2022) Treatment outcomes of childhood tuberculous meningitis in a real-world retrospective cohort, Bandung, Indonesia. Emerg Infect Dis 28(3):660

    Article  PubMed  PubMed Central  Google Scholar 

  18. Chiang SS, Khan FA, Milstein MB, Tolman AW, Benedetti A, Starke JR, Becerra MC (2014) Treatment outcomes of childhood tuberculous meningitis: a systematic review and meta-analysis. Lancet Infect Dis 14(10):947–957

    Article  PubMed  Google Scholar 

  19. Enicker B, Aldous C (2023) Factors associated with in-hospital mortality in HIV-infected children treated for tuberculous meningitis hydrocephalus. Childs Nerv Syst. https://doi.org/10.1007/s00381-023-06205-7

    Article  PubMed  PubMed Central  Google Scholar 

  20. Hai A, Rab AZ, Ghani I, Huda MF, Quadir AQ (2011) Perforation into gut by ventriculoperitoneal shunts: a report of two cases and review of the literature. J Indian Assoc Pediatr Surg 16(1):31

    Article  PubMed  PubMed Central  Google Scholar 

  21. Chugh A, Gotecha S, Amle G, Patil A, Punia P, Kotecha M (2018) Abnormal migration and extrusion of abdominal end of ventriculoperitoneal shunt: an experience of eight cases. J Pediatr Neurosci 13(3):317–321. https://doi.org/10.4103/JPN.JPN_18_18

    Article  PubMed  PubMed Central  Google Scholar 

  22. Hasan A, Sharma S, Chopra S, Purohit DK (2018) Anal extrusion of ventriculoperitoneal shunt: a report of two cases and review of literature. J Pediatr Neurosci 13(1):8

    Article  PubMed  PubMed Central  Google Scholar 

  23. Akyüz M, UÇar, T. A. N. J. U., & Göksu, E. (2004) A thoracic complication of ventriculoperitoneal shunt: symptomatic hydrothorax from intrathoracic migration of a ventriculoperitoneal shunt catheter. Br J Neurosurg 18(2):171–173

    Article  PubMed  Google Scholar 

  24. Brownlee JD, Brodkey JS, Schaefer IK (1998) Colonic perforation by ventriculoperitoneal shunt tubing: a case of suspected silicone allergy. Surg Neurol 49(1):21–24

    Article  CAS  PubMed  Google Scholar 

  25. Vinchon M, Baroncini M, Laurent T, Patrick D (2006) Bowel perforation caused by peritoneal shunt catheters: diagnosis and treatment. Oper Neurosurg 58(1):ONS-76

    Article  Google Scholar 

  26. Allouh MZ, Al Barbarawi MM, Asfour HA, Said RS (2017) Migration of the distal catheter of the ventriculoperitoneal shunt in hydrocephalus: a comprehensive analytical review from an anatomical perspective. Clin Anat 30(6):821–830

    Article  PubMed  Google Scholar 

  27. Ghritlaharey RK (2015) Extrusion of ventriculoperitoneal shunt catheter through mouth in a two-year-old girl: A case report. Int J Clin Pediatr Surg 1:1–4

    Google Scholar 

  28. İştemen İ, Arslan A, Olguner SK, Açık V (2021) Bowel perforation of ventriculoperitoneal shunt catheter: endoscopically treated two cases. Childs Nerv Syst 37:315–318

    Article  PubMed  Google Scholar 

  29. Digray NC, Thappa DR, Arora M, Mengi Y, Goswamy HL (2000) Silent bowel perforation and transanal prolapse of a ventriculoperitoneal shunt. Pediatr Surg Int 16:94–95

    Article  CAS  PubMed  Google Scholar 

  30. Karshe NA, Osman FAO, Elmi AM, Mohamed Dirie A (2024) Anal extrusion of silent migrated ventriculoperitoneal shunt: case report and literature review. Radiol Case Rep 19(4):1524–1527. https://doi.org/10.1016/j.radcr.2023.11.067

    Article  PubMed  PubMed Central  Google Scholar 

  31. Basehi A, Al-Saleh AM, Almoffarreh H, Alkarawi S, Alharbi M (2023) A n causing meningitis in a child. Cureus 15(9):e45857. https://doi.org/10.7759/cureus.45857

    Article  PubMed  PubMed Central  Google Scholar 

  32. Khizar A, Zahid S (2022) Anal protrusion of peritoneal end of ventriculoperitoneal shunt and multiple brain abscesses: a case report with review of literature. Iran J Neurosurg 8(1):E5. https://doi.org/10.32598/irjns.8.5

    Article  Google Scholar 

  33. Heng YW, Yap KB (2021) Trans-anal protrusion of the distal end of ventriculo-peritoneal (VP) shunt-the role of ommaya shunt. J Pediatr Surg Case Rep 72:101965. https://doi.org/10.1016/j.epsc.2021.101965

    Article  Google Scholar 

  34. Indra Gunawan P, Gunadi Ranuh IR, Fardah Atthiyah A (2017) Anal extrusion of the ventriculoperitoneal shunt catheter. Acta medica academica 46(1):65–66. https://doi.org/10.5644/ama2006-124.190

    Article  PubMed  Google Scholar 

  35. Sahoo SK, Srivastava C, Tomar A (2017) Shunt tip perforating large bowel through vermiform appendix. Med J DY Patil Univ 10(2):216. https://doi.org/10.4103/0975-2870.202106

    Article  CAS  Google Scholar 

  36. Bodeliwala S, Agrawal A, Mittal A, Singh D, Vageesh BG, Singh H (2016) Transanal protrusion of ventriculoperitoneal shunt via appendicular perforation: a rare case report. J Pediatr Neurosci 11(3):274–276. https://doi.org/10.4103/1817-1745.193383

    Article  PubMed  PubMed Central  Google Scholar 

  37. Bansal H, Gupta G, Gupta M, Kaushal R (2015) Unusual ventriculoperitoneal (VP) shunt tube extrusion through anus in a child with Dandy Walker malformation: a rare case report. J Clin Diagnos Res 9(1):PD25–PD26. https://doi.org/10.7860/JCDR/2015/11354.5488

    Article  Google Scholar 

  38. Lee C, Tseng S, Chen Y (2015) Ileal perforation and transanal protrusion of the peritoneal tube in a boy with a ventriculoperitoneal shunt and literature review. Formos J Surg 48(6):209–213. https://doi.org/10.1016/j.fjs.2015.08.002

    Article  CAS  Google Scholar 

  39. Singh A, Mathur V, Goyal R, Pardeshi R, Jangid MK (2014) A rare case of bowel perforation secondary to ventriculo peritoneal shunt. J Evol Med Dent Sci 3(53):12362–12365. https://doi.org/10.14260/jemds/2014/3633

    Article  Google Scholar 

  40. Grewal SS, Jhawar SS, Gupta B, y Bedi NK (2014) Perforación intestinal silenciosa con protrusión anal de la derivación ventriculoperitoneal. CHRISMED Revista de Salud e Investigación 1(2):113–115

    Google Scholar 

  41. Lawther S, Patel RV, Gabra H (2013) Laparoscopic management of silent colonic perforation with trans-anal protrusion of ventriculo-peritoneal shunt catheter. J Pediatr Surg Case Rep 1(5):106–107. https://doi.org/10.1016/j.epsc.2013.03.015

    Article  Google Scholar 

  42. Chiang LL, Kuo MF, Fan BJ, Hsu WM (2010) Transanal repair of colonic perforation due to ventriculoperitoneal shunt—case report and review of the literature. J Formos Med Assoc 109(6):472–475

    Article  PubMed  Google Scholar 

  43. Vuyyuru S, Ravuri SR, Tandra VR, Panigrahi MK (2009) Anal extrusion of a ventriculo peritoneal shunt tube: endoscopic removal. J Pediatr Neurosci 4(2):124–126. https://doi.org/10.4103/1817-1745.57342

    Article  PubMed  PubMed Central  Google Scholar 

  44. Jang HD, Kim MS, Lee NH, Kim SH (2007) Anal extrusion of distal VP shunt catheter after double perforation of large intestine. J Korean Neurosurg Soc 42(3):232–234

    Google Scholar 

  45. Zhou F, Chen G, Zhang J (2007) Bowel perforation secondary to ventriculoperitoneal shunt: case report and clinical analysis. J Int Med Res 35(6):926–929

    Article  CAS  PubMed  Google Scholar 

  46. Handa R, Kale R, Harjai MM (2007) Unusual complication of ventriculoperitoneal shunt: anal extrusion. Med J Armed Forces India 63(1):82–84

    Article  CAS  PubMed  PubMed Central  Google Scholar 

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Authors and Affiliations

  1. Department of Neurosurgery, University of Buenos Aires School of Medicine, Buenos Aires, Argentina

    Francisco Zarra

  2. Department of Neurosurgery, MGM Medical College Indore, Indore, India

    Adnan Hussain Shahid

  3. Kj Somaiya Medical College and Research Center, Mumbai, India

    Dhruv Nihal Gandhi

  4. Department of Research, Colombian Clinical Research Group in Neurocritical Care, Bogota, Colombia

    Luis Rafael Moscote Salazar

  5. Department of Neurosurgery, Neurosurgery Clinic, Birgunj, Nepal

    Bipin Chaurasia

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  2. Adnan Hussain Shahid
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  3. Dhruv Nihal Gandhi
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  4. Luis Rafael Moscote Salazar
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  5. Bipin Chaurasia
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Contributions

FZ: conceptualization, investigation, methodology, and wrote the main manuscript text, AHS: writing—review editing and prepared Figs. 1 and 2, DNG: investigation and editing Table  1 , LRMS, BC: formal validation. All the authors reviewed the final manuscript.

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Correspondence to Francisco Zarra.

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The authors confirm that there was no use of artificial intelligence (AI)–assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.

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The authors of this article express a rare case report with the purpose of enriching the little published literature on Trans-Anal Migration of the distal end of the Catheter. The authors have Intellectual Property Rights (IPR) over said article in writing, and it can be cited by other authors after its publication in the Journal.

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Zarra, F., Shahid, A.H., Gandhi, D.N. et al. Migration of the anal distal end due to ventriculoperitoneal shunt placement: an atypical case report of a 9-month-old infant with tuberculous meningitis and review of the literature. Childs Nerv Syst (2024). https://doi.org/10.1007/s00381-024-06405-9

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