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Short answer question case series: a complex case of fever and headache
  1. Paul Rohdenberg,
  2. Moses Graubard,
  3. Timothy Jang
  1. Department of Emergency Medicine, Harbour-UCLA Medical Center, David Geffen School of Medicine at UCLA, Torrance, California, USA
  1. Correspondence to Dr Timothy B Jang, Department of Emergency Medicine, Harbor-UCLA Medical Center, David Geffen School of Medicine at UCLA, 1000 W. Carson St, Torrance, CA 90509, USA; tbj{at}ucla.edu

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Case vignette

A 21-year-old man with a ventriculoperitoneal (VP) shunt, status post resection of a childhood ‘brain tumor’ complains of headache, photophobia, neck stiffness, fatigue and nausea. He is febrile to 38.2°C, but has several family members with fever, rhinorrhoea, vomiting and diarrhoea who were diagnosed yesterday with the ‘flu.’

Key questions

  1. What must you consider in this patient?

  2. How should this patient be evaluated?

  3. What should the disposition be?

Discussion

  • 1. In this patient, VP shunt malfunction and infection must be considered since severe morbidity or mortality can occur if either goes undetected or untreated. Symptoms of acute shunt obstruction include headache, vomiting, papilloedema, cranial nerve VI palsy, change in personality and the ‘setting sun’ sign (lack of upward gaze) in infants. Shunt malfunction may be caused by obstruction, fracture, migration or kinking of the tubing, or damage to the shunt apparatus itself. Most shunt obstructions occur in the ventricular catheter by invasion of glioependymal tissue. The most common locations for distal tube fracture include the occipito-cervical junction, the base of the neck and the junction between the inferior border of the ribs and the abdominal wall.

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