Infected Ventriculoperitoneal Shunt Due to Cryptococcus neoformans: the Case Report

Background: Cryptococcal infection usually occurs in HIV-infected patients with low CD4 count. The clinical manifestations typically involve central nervous and pulmonary systems. We reported a case of a 49-year-old HIV-infected man with infected ventriculoperitoneal (VP) shunt due to Cryptococcus neoformans. Methods: A retrospective review of medical record of the patient, who was hospitalized at King Chulalongkorn Memorial Hospital (KCMH), Bangkok, Thailand, was analyzed. Results: A 49-year-old Thai man was hospitalized at KCMH on April 27, 2013 due to the alteration of consciousness and a few months old abdominal mass. He was diagnosed with HIV infection in 1995, and his last CD4 count and HIV viral load were 730 (25%) cell/mm3 and less than 20 copies per milliliter, respectively. Six months prior to admission, a diagnosis of tuberculous meningitis with obstructive hydrocephalus due to basal arachnoiditis was made, and the patient was treated with standard short-course anti-tuberculous therapy and emergent VP shunt. Physical examination revealed a man with drowsiness but without focal neurological deficits. Abdomen examination revealed a non-tender cystic mass with rubbery consistency, 10 cm in size, at suprapubic area. There was no instant refill of the reservoir of the VP shunt at right temporal area. Abdominal computed tomogram showed a huge cystic mass measure, 20 cm in size, located at mid to lower abdomen around the tip of VP shunt. Ultrasound-guided drainage of the cyst yielded 800 mL of yellow clear fluid which had white blood cells of 19 cells/mm3 (neutrophil 60%), sugar of 80 mg/dL, protein of 1,400 mg/dL, and positive India ink stain and cryptococcal antigen. The shunt was then removed. The fluid and tip of VP shunt finally grew C. neoformans. He gradually improved 1 week after treatment with intravenous fluconazole of 400 mg daily, but unfortunately died 18 days after hospitalization due to superimposed bacterial pneumonia. Conclusions: Cryptococcal infection typically occurs in HIV-infected patients with low CD4 cell counts (<100 cells/mm3) and usually positive cryptococcal antigen assays. The clinical manifestations mostly present in central nervous system and pulmonary system. In our patient with high CD4 count, this was an unusual presentation, with slow development of neurological sign and negative for serum and cryptococcal antigen test in CSF. Only a large volume of abdominal fluid and tip culture from VP shunt were detected organism loculated infection. A large-volume tap may have increased the yield of detected organism. (J Infect Dis Antimicrob Agents 2014;31:181-5.) CASE REPORT