Sterile shunt malfunction. A scanning electron microscopic perspective.

Recently, a delayed hypersensitivity reaction to silicone plastics has been demonstrated in some patients with breast and joint implants and subcutaneously injected silicone. In this study, the authors examined the internal surface of shunting systems to evaluate the cellular response to implanted silicone plastic. The distal peritoneal tubing from 20 patients with ventriculoperitoneal shunts was examined with a scanning electron microscope. Twelve tubes were removed because of documented distal shunt malfunction and eight for an elective lengthening procedure. Cultures of all tubing were negative. The catheters removed for malfunction contained a variety of cells: sometimes in clumps, sometimes associated with platelets and densely adherent to the silicone tubing wall. In several shunts, giant cells were seen with multiple foot processes adherent to the internal silicone surface. The internal surface of the tubing of two malfunctioning shunts was embedded in electron microscopy plastic and studied with transmission electron microscopy. The cells proved to be neutrophils with no evidence of silicone granules inside the cell bodies. The shunts removed for elective revision showed only a few cells, and those were never associated with platelets. There was proteinaceous material scattered on the internal surface of the tubing, but the cellular response was markedly different from that in malfunctioning shunts. The authors postulate that the findings in malfunctioning shunt tubing represent a delayed hypersensitivity to silicone similar to that seen with other types of silicone implants.