An Intra-Abdominal Pseudocyst around a Ventriculoperitoneal Shunt due to Streptococcus Infection 7 Years after Shunt Surgery

In 1999, a 50-year-old woman underwent ventriculoperitoneal (VP) shunt surgery for hydrocephalus after subarachnoid hemorrhage. She was hospitalized for fever and recurrent systemic seizures in November 2006. Head computed tomography (CT) showed only old changes. The seizures and fever were controlled by medicinal therapy. However, in December, her consciousness level suddenly decreased, and she showed progressive lower abdominal distension. Head CT showed marked ventriculomegaly, and abdominal CT showed a giant cystic mass at the shunt-tube tip in the lower abdominal cavity. Because thick pus was aspirated from the intra-abdominal mass, we diagnosed the patient with acute obstructive hydrocephalus due to an infected abdominal pseudocyst. Laparotomy and direct cyst drainage were performed, and antibiotic therapy against Streptococcus, the causative pathogen, was administered. The VP shunt tube was replaced. The postoperative course was uneventful, and postoperative CT showed hydrocephalus improvement and no pseudocyst recurrence. Abdominal pseudocysts, which are rare after VP shunt surgeries, usually occur after the subacute postoperative course in younger cerebral hemorrhagic cases. Our case was quite rare because the cyst developed in the chronic phase in an older patient and was caused by streptococcal infection. The cyst components should be examined before cyst drainage when choosing surgical strategies. 1. Introduction Complications after ventriculoperitoneal (VP) shunt operations are observed relatively often. However, among these complications, intraperitoneal pseudocysts (IPP) are rare. We describe a case of an IPP that occurred 7 years after a VP shunt operation in a patient who was infected with pseudomonas and who presented with acute hydrocephalus due to shunt malfunction. 2. Case Presentation A 50-year-old female was transferred to our hospital in November 2006 because of recurrent attacks of epilepsy and fever. In 1999, she had undergone an aneurysm clipping surgery after subarachnoid hemorrhage (SAH) in our institute and had also had a VP shunt operation against SAH-induced hydrocephalus after a month from initial clipping. After that, she received long-term rehabilitation after being transferred to another hospital. Upon admission to our hospital, the patient’s consciousness level was impaired (Glasgow Coma Scale, E4V2？M5), and hemiplegia of the right side due to a cerebral infarction that was triggered by vasospasms after the prior SAH was observed. Frequent clonic epilepsy attacks occurred daily on the left side of the body, including