SESSION TITLE: Disorders of the Pleura 2 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 pm - 02:15 pm INTRODUCTION: Ventriculopleural shunt (VPLS) is an alternative to the commonly used ventriculoperitoneal shunt (VPS). The pleural space has an excellent absorptive capacity. Pleural effusion is one of the most common complications following VPLS, likely due to inflammation causing an imbalance between cerebrospinal fluid (CSF) production and pleural space resorption. CASE PRESENTATION: A 55-year-old male with a PMH of VPS after surgical removal of a giant bi-frontal meningioma in 2015, complicated with enterococcus and Propionibacterium CSF infection requiring multiple shunt revision, modification of shunt valve and external drainage. He underwent placement of right VPLS in April of 2017. 10 months after placement of VPLS, he presented to ED with one week of flu-like symptoms and right-sided pleuritic chest pain. Physical examination revealed absent breath sounds over the right lung base and hypoxia needing 6 L of Oxygen via NC. Pleural ultrasound revealed moderate right-sided pleural effusion with fibrinous septations. Thoracentesis revealed un-complicated LDH discordant exudative pleural effusion. CSF culture was again positive for Propionibacterium acne, blood and pleural fluid culture were negative. He underwent chest tube placement with TPA/Dornase instillation. Neurosurgery proceeded with VPLS removal and placement of an external ventricular drain for a week followed by placement of a new antibiotic-impregnated VPS. DISCUSSION: The most common indication for using pleural cavity for drainage in a patient with a pre-existent ventriculoperitoneal shunt is due to the infection, adhesion or thrombosis of the shunt causing obliteration. Most of the complications including pleural effusion following VPLS occur within the first year of placement. Pleural fluid analysis showing clear transudative effusion resembling CSF, but exudative effusion can occur secondary to chronic inflammation. Most of the cases of mild effusion resolve spontaneously without any specific treatment but symptomatic cases with moderate effusion may require a thoracentesis, chest tube insertion and in recurrent cases even a shunt replacement. P. acnes is a part of the skin flora and most isolates in culture are considered as contaminant. On the contrary, P. acnes is frequently isolated in patients with shunt infections and evidence suggests that a P. acnes positive CSF culture should not be neglected and treated with appropriate antibiotics. The use of anti-siphon pressure control devices and acetazolamide have been proven to somewhat reduce the likelihood of developing the pleural effusion. CONCLUSIONS: The pleural cavity is the most common alternative to peritoneal cavity for drainage of CSF in a patient presenting with refractory hydrocephalus. He was also found positive for P. acnes on CSF culture. We suggest drainage of pleural cavity and revision/replacement of shunt as well as antibiotic therapy for P. acnes infection. Reference #1: Sahn SA. Pleural effusions of extravascular origin. Clin Chest Med. 2006;27:285–308. Reference #2: Nisbet M, Briggs S, Ellis-Pegler R, Thomas M, Holland D. 2007. Propionibacterium acnes: an under-appreciated cause of post-neurosurgical infection. J. Antimicrob. Chemother. 60:1097–1103. 10.1093/jac/dkm351 Reference #3: Martínez-Lage JF, Torres J, Campillo H, Sanchez-del-Rincón I, Bueno F, Zambudio G, et al. Ventriculopleural shunting with new technology valves. Childs Nerv Syst. 2000;16:867–71. DISCLOSURES: No relevant relationships by James Dean, source=Web Response No relevant relationships by Shuhong Guo, source=Web Response No relevant relationships by Brandon Murguia, source=Web Response No relevant relationships by Ali Saeed, source=Web Response No relevant relationships by Samarthkumar Thakkar, source=Web Response