Hepatic cerebrospinal fluid pseudocyst: A rare complication of ventriculoperitoneal shunt
A 40-year-old male patient presented to the hospital with a 7-day fever, abdominal distention, and pain. His medical and surgical history includes VP shunt placement following a head injury from a motor vehicle crash one year earlier. The patient had no history of malignancy and pancreatic or liver disease. An initial physical examination revealed low-grade fever with mild right-upper-quadrant discomfort and a slightly distended abdomen. Bowel sounds were normal, and there were no peritoneal signs. A central nervous system (CNS) examination was within normal limits. Blood test on admission showed mild leukocytosis (WBC, 13,200/mm3), anemia (hemoglobin, 9.0 g/dL; hematocrit, 26.9%), elevation of C-reactive protein levels (15.70 mg/dl) and erythrocyte sedimentation rate (110 mm/h), as well as glutamic oxaloacetic transaminase levels (255 U/L), glutamic pyruvic transaminase levels, (186 U/L) gamma-glutamyl transferase levels (275 U/L), and alkaline phosphatase levels (162 U/L). Bilirubin was normal. Examination of the CSF indicates VP shunt infection, and a microbiological analysis showed Staphylococcus epidermidis. The ultrasonographical and abdominal computed tomography (CT) evaluation of the abdomen showed a cystic lesion in the hepatic segment V measuring 81 × 74 × 62 mm, with the shunt catheter placed inside [Figures and ]. The cystic mass did not show contrast enhancement. After this, we took out the proximal and distal VP shunt catheter from the previous cranial and abdominal incision (right lower abdominal quadrant), and an adequate antibiotic treatment was administrated for 14 days. A follow-up brain CT scan revealed no enlargement of the ventricular size, and a CT of the abdomen showed a regression of the cystic form [] with a marked decrease in abdominal symptoms within 3 days and normalization of the abdominal condition within 10 days after the removal of the VP shunt.\nTwo weeks after the surgical procedure, a subsequent cranial CT scan showed bilateral ventricular dilatation, and after three consecutive negative CSF cultures, we performed a shunt reinsertion on the opposite side of the peritoneum. On his 20th day in the hospital, the patient was discharged with complete resolution of previous symptoms. Liver enzymes returned to normal levels, and no clinical recurrence of the hepatic CSF pseudocyst was evident during the 9-month follow-up period.