806: OPIOID-INDUCED TOXIC LEUKOENCEPHALOPATHY AND MULTIORGAN DYSFUNCTION IN A PEDIATRIC PATIENT

Abstract

Learning Objectives: Cerebrospinal fluid (CSF) ascites is a rare complication of ventriculoperitoneal shunt (VPS) surgery that commonly results from infection and peritonitis. We report an unusual case of persistent CSF ascites and respiratory distress in a VPS patient secondary to CSF overproduction. Methods: A 2-year-old female with multiple congenital anomalies presented in acute respiratory failure requiring mechanical ventilation. She was treated with VPS early in infancy for communicating hydrocephalus secondary to choroid plexus hyperplasia. Previously, at 16 months of age, she had presented with mild respiratory distress and abdominal distention with no enlargement of ventricles on MRI and moderate ascites on abdominal ultrasound. She stabilized then, without any surgical intervention and was discharged home. This admission, she presented with acute respiratory failure secondary to Influenza B infection associated with an enlarged abdomen. Her head CT scan revealed stable ventricular size, her shunt series study was normal, shunt tap of the reservoir demonstrated a functioning shunt, and her abdominal ultrasound demonstrated massive simple ascites. A peritoneal drain was placed for persistent abdominal distention and lack of respiratory improvement. 1.5 liters of transudate fluid was drained in 24 hours. She demonstrated significant improvement in her respiratory status that worsened again when the peritoneal drain was clamped. In order to reduce this burden, the patient’s VPS was converted to a ventriculo-atrial shunt (VAS). She was weaned off mechanical ventilation with no further ascites development. Results: VPS placement is a standard mode of therapy for communicating hydrocephalus, including choroid plexus hyperplasia. Over time, CSF overproduction in choroid plexus hyperplasia can exceed the absorptive capacity of the peritoneal surface resulting in sterile ascites and can be associated with fatal complications if unrecognized. Our case demonstrates the need for evaluation and intervention for a pediatric patient with VPS who presents with persistent abdominal distention and/or respiratory distress as it can be secondary to sterile CSF ascites.