Correspondence

Sterile Cerebrospinal Fluid Ascites and Chronic Peritonitis

N Engl J Med 2001; 345:297-298July 26, 2001

Article

To the Editor:

Sterile ascites after ventriculoperitoneal shunting is rare and usually of unknown cause.1 We describe a patient in whom an inflammatory reaction to silicone tubing used in the creation of a shunt was a possible cause of sterile ascites.

A 28-year-old woman presented with abdominal distention of three months' duration. She had undergone ventriculoperitoneal shunting at six months of age for hydrocephalus and subsequently required multiple revisions and replacements of silicone–elastomer shunts. She had no history of shunt infection or of abdominal or pelvic infection or surgery. She took valproic acid and carbamazepine for seizures. The results of routine blood and urine tests were normal. Computed tomography of the abdomen and pelvis showed extensive ascites. Paracentesis revealed clear fluid with 150 leukocytes per cubic millimeter (95 percent mononuclear cells) and a protein level of 2.8 g per deciliter; cytologic examination showed no malignant cells. The serum–ascites albumin gradient was 2.5 g per deciliter. No organisms grew in cultures of ascitic fluid. The results of abdominal ultrasonography, echocardiography, and a liver biopsy were normal.

Despite diuretic therapy, the patient required multiple therapeutic paracenteses, with a total of 18 liters drained over a period of six months. Laparoscopy revealed extensive abdominopelvic adhesions, numerous tiny nodules on the visceral and parietal peritoneum and inferior surface of the liver, and a fragment of a shunt tube. The laparoscopist extracted the fragment and removed 5 liters of ascitic fluid. Biopsy specimens of the peritoneum revealed lymphohistiocytic nodules and fibrosis (Figure 1Figure 1Biopsy Specimen of the Parietal Peritoneum, Showing a Lymphohistiocytic Nodule (N) and Fibrosis (F) (Hematoxylin and Eosin, ×100).), but no polarizing material was found and no microorganisms were identified by auramine and Gomori's methenamine silver staining. Despite therapy with prednisone (60 mg daily for four weeks), the patient's ascites recurred. After she stopped taking the drug, the peritoneal catheter was removed and a ventriculoatrial shunt was placed. Within two weeks, her abdominal distention disappeared. No ascites was evident on ultrasonography one and a half years later.

Impaired absorption of cerebrospinal fluid across an inflamed peritoneum has been proposed as the cause of cerebrospinal fluid ascites. Diversion of cerebrospinal fluid from the abdomen is an effective treatment.1 A patient from Spain with pathological features similar to those in our patient has been reported.2 Silicone and its constituents do not cause specific immune responses,3 but silicone shunts can degrade over time and elicit nonspecific tissue inflammation.4

George F. Longstreth, M.D.
Naomi R. Buckwalter, M.D.
Kaiser Permanente Medical Care Program, San Diego, CA 92120
george.f.longstreth@kp.org

4 References

1. 1

   Yukinaka M, Nomura M, Mitani T, et al. Cerebrospinal ascites developed 3 years after ventriculoperitoneal shunting in a hydrocephalic patient. Intern Med 1998;37:638-641
   CrossRef | Web of Science | Medline

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   Perez Pena F, Aparicio Campillo G, Lopez Asenjo JA, et al. Ascitis por acúmulo de líquido cefalorraquídeo. Rev Clin Esp 1990;187:128-130
   Medline

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   Saxon A. The antigen that wasn't -- silicone. Clin Immunol 2000;95:171-172
   CrossRef | Web of Science | Medline

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   Del Bigio MR. Biological reactions to cerebrospinal fluid shunt devices: a review of the cellular pathology. Neurosurgery 1998;42:319-326
   CrossRef | Web of Science | Medline

Citing Articles (3)

Citing Articles

1. 1

   Hamilton Matushita, Daniel Cardeal, Fernando Campos Pinto, Jose Pindaro Pereira Plese, Jocielle Santos Miranda. (2008) The ventriculoomental bursa shunt. Child's Nervous System 24:8, 949-953
   CrossRef

2. 2

   Rajeev Kariyattil, Paul Steinbok, Ashutosh Singhal, D. Douglas Cochrane. (2007) Ascites and abdominal pseudocysts following ventriculoperitoneal shunt surgery: variations of the same theme. Journal of Neurosurgery: Pediatrics 106:5, 350-353
   CrossRef

3. 3

   Michael L. DiLuna, Michele H. Johnson, Wenya Linda Bi, Veronica L. Chiang, Charles C. Duncan. (2006) Sterile ascites from a ventriculoperitoneal shunt: a case report and review of the literature. Child's Nervous System 22:9, 1187-1193
   CrossRef