title: Self-injection of household cleaning detergents into a ventriculoperitoneal shunt reservoir during a suicide attempt: a case report and literature review.
abstract: Self-injection of household cleaning detergents (more specifically, commercial toilet bowl cleaner) into the reservoir of a ventriculoperitoneal shunt (VPS) has never been reported in the neurosurgical literature. A right-handed 41-year-old female with a past medical history significant for bipolar depression (with multiple prior hospital admissions for suicide attempts) and pseudotumor cerebri (status-post VPS placement from a right frontal approach) successfully injected ∼5 ml of toilet bowl cleaner into her ventricular shunt reservoir during a suicide attempt. She was found unresponsive by a family member 48 h after this event and presented to our hospital in moribund neurological condition (bilaterally fixed and dilated pupils with decerebrate posturing). Head computed tomography (CT) demonstrated marked ventriculomegaly. She was taken emergently to the operating room for placement of a left frontal ventriculostomy. Cerebrospinal fluid (CSF) sampled intraoperatively showed numerous Gram-positive cocci (later determined to be Staphylococcus epidermidis). For this reason, her right-sided shunt system was also removed in its entirety. She was treated with broad-spectrum intravenous and intraventricular antibiotics for her bacterial ventriculitis and her CSF was aggressively drained to treat her hydrocephalus. Once her infection had resolved, the shunt was replaced (using a right parietal approach) and she went on to make an excellent neurological recovery. Here, the authors present the case of a patient who self-injected household cleaning detergents into her VPS reservoir-and, likely, the ventricular system-during a suicide attempt and subsequently developed hydrocephalus and ventriculitis. Following this infrequent clinical scenario, consideration should be given to temporary ventriculostomy placement and shunt removal. Moreover, in patients with a known history of psychiatric co-morbidities-and particularly those patients with prior suicide attempts-the neurosurgeon should give serious consideration to placing the shunt system in an anatomical region which is difficult for the patient to self-access based upon their handedness.
authors.affiliation: Department of Neurological Surgery, Emory University School of Medicine, Atlanta, GA, USA.
authors.forename: Jason W
authors.initials: JW
authors.lastname: Signorelli
authors.affiliation: Department of Neurological Surgery, Emory University School of Medicine, Atlanta, GA, USA.
authors.forename: Joshua W
authors.initials: JW
authors.lastname: Osbun
authors.affiliation: Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA.
authors.forename: Eric J
authors.initials: EJ
authors.lastname: Arias
authors.affiliation: Department of Occupational Therapy, Washington University School of Medicine, St. Louis, MO, USA.
authors.forename: Lauren C
authors.initials: LC
authors.lastname: Reynolds
authors.affiliation: Department of Neurological Surgery, Medical College of Wisconsin, St. Vincent Hospital, Green Bay, WI, USA.
authors.forename: Douglas
authors.initials: D
authors.lastname: Chyatte
authors.affiliation: Department of Neurological Surgery, Emory University School of Medicine, Atlanta, GA, USA. matthew.reynolds@emory.edu.|Department of Neurological Surgery, Medical College of Wisconsin, St. Vincent Hospital, Green Bay, WI, USA. matthew.reynolds@emory.edu.
authors.forename: Matthew R
authors.initials: MR
authors.lastname: Reynolds
mesh_terms: D000328:Adult; D002552:Cerebral Ventricles / Q000187:drug effects* / Q000601:surgery; D003902:Detergents / Q000008:administration & dosage / Q000506:poisoning*; D005260:Female; D006801:Humans; D006849:Hydrocephalus / Q000601:surgery; D007267:Injections; D013406:Suicide, Attempted; D017287:Ventriculoperitoneal Shunt
chemical_list: D003902:Detergents
keywords: Bleach; Household cleaning detergent; Hydrocephalus; Injection; Intraventricular; Sodium hypochlorite; Toilet bowel cleaner; Ventriculitis; Ventriculoperitoneal shunt