Introduction: Idiopathic Intracranial Hypertension (IIH) is a rare diagnosis affecting approximately 0.9–3/100,000 adults, mostly females of childbearing age with obesity. Surgical intervention is usually indicated in cases that prove refractory to conservative measures (such as weight loss and acetazolamide) or in cases of progressive papilledema and visual deficit. Ventriculoperitoneal shunt (VPS) is the preferred internalized cerebrospinal fluid diversion method. Here, we present a case of VPS causing ascites in a woman with IIH.
Case Description/Methods: A 33-year-old female smoker with obesity, hypertension, and IIH with VPS (Medtronic strata valve, set to 1.0., placed six years ago for headache and visual problems) presents to the ED with increased abdominal distention and discomfort along with shortness of breath. She underwent a paracentesis two weeks prior for new ascites. Paracentesis showed no malignant cells. She had no family history of gastrointestinal pathology, no risk factors for viral hepatitis, and negative hepatitis serologies. She started noticing re-accumulation of fluid that did not improve with prescribed furosemide. She had no other symptoms including fevers, chills, or neurological symptoms.
Physical exam showed ascites with a normal neurologic exam. Liver function tests were normal. CT abdomen and pelvis showed an unremarkable liver and VPS catheter without kinking. Pelvic ultrasound was unrevealing except for an ovarian cyst.
Repeat paracentesis showed SAAG (Serum Ascites Albumin Gradient) 0.8, WBC 650 cells/ul, and only 10% polymorphonuclear cells (PMN). Culture of peritoneal fluid was positive for Cutibacterium acnes. Thepatient completed an antibiotics course and underwent a removal of the distal (peritoneal) catheter of the VPS that led to resolution of her ascites.
Discussion: We present a case of recurrent ascites resolution following VPS removal. Cerebrospinal fluid (CSF) ascites is one of the rarest intra-abdominal complications of VPS. Only 29 cases have been described in the literature and only six of them were in adults. In such cases, VPS are removed and Ventriculo-pleural or Ventriculo-atrial shunts are placed.
While pathophysiology behind IIH is hypothesized to be due to inability of CSF to be reabsorbed by arachnoid granulations and extracranial lymphatics, there is no satisfactory explanation in the literature regarding the pathophysiology of CSF ascites due to VPS. It is suspected that our patient’s infected VPS caused device malfunction leading to ascites.
