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

Francisco Zarra; Adnan Hussain Shahid; Dhruv Nihal Gandhi; Luis Rafael Moscote Salazar; Bipin Chaurasia

doi:10.1007/s00381-024-06405-9

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 Apr 16. doi: 10.1007/s00381-024-06405-9. Online ahead of print.

Authors

Francisco Zarra¹, Adnan Hussain Shahid², Dhruv Nihal Gandhi³, Luis Rafael Moscote Salazar⁴, Bipin Chaurasia⁵

Affiliations

¹ Department of Neurosurgery, University of Buenos Aires School of Medicine, Buenos Aires, Argentina. franciscozarra@hotmail.com.
² Department of Neurosurgery, MGM Medical College Indore, Indore, India.
³ Kj Somaiya Medical College and Research Center, Mumbai, India.
⁴ Department of Research, Colombian Clinical Research Group in Neurocritical Care, Bogota, Colombia.
⁵ Department of Neurosurgery, Neurosurgery Clinic, Birgunj, Nepal.

PMID: 38625589
DOI: 10.1007/s00381-024-06405-9

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.

Keywords: Distal anal catheter migration; Hydrocephalus; Tuberculous meningitis; VPS.