Nayyar Yaqoob, Shahid Mumtaz Abbasi, Liaqat Hussain.
Cerebrospinal Fluid Ascites.
J Coll Physicians Surg Pak Jan ;13(5):289-90.

Cerebrospinal fluid (CSF) ascites can be a refractory problem in the management of patients with hydrocephalus developing as a result of tuberculous meningitis. A young 17-year-old patient developed CSF ascites due to the drainage of CSF into the peritoneal cavity via a ventriculoperitoneal shunt. The ascites failed to resolve despite repeated courses of antituberculous chemotherapy. Eventually diversion of CSF away from the peritoneal cavity through a ventriculoatrial shunt relieved the ascites.

Case Report: A 17-year-old boy developed tuberculous meningitis, complicated by obstructive hydrocephalus and tuberculoma of left cerebrum, presented to the department of medicine, Fauji Foundation hospital, Rawalpindi in March 1998. He subsequently underwent ventriculoperitoneal shunting to relieve hydrocephalus and antituberculous chemotherapy was started. After three months he presented with progressive uniform abdominal distention owing to accumulation of ascitic fluid. Diagnostic paracentesis revealed a transudate with a protein content of 2.6 gm/dl with a cell content of <50 mm2 and mostly lymphocytes. A peritoneal biopsy specimen showed a chronic caseating granulomatous inflammation consistent with peritoneal tuberculosis. He was later discharged home on antituberculous chemotherapy. His abdominal distention kept worsening with the appearance of a paraumbilical hernia. During the next three months the patient received continuous antituberculous chemotherapy in addition to a course of clarithromycin and ciprofloxacin for six months with poor response. He also received antidiuretics with repeated sessions of therapeutic paracentesis. The ascitic fluid kept re-accumulating. Peritoneal biopsy was repeated in March 2001, which showed chronic non-specific inflammation. The repeat ascitic fluid was again reported as transudate with no malignant cells or acid fast bacilli. The cultures of the ascitic fluid were unremarkable. Liver function tests were normal. Eventually the patient underwent conversion of ventriculoperitoneal into ventriculoatrial shunting in September 2001. After this procedure, 12 liters of ascitic fluid was drained during a single session with complete disappearance of CSF ascites.

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