A term male infant (37week) presented in ER at 11 months of age with weight 8.5kg, Height 80cm, FOC 53cm, came with complaints of vomiting, abdominal pain, constipation and decreased oral intake. The infant was born to 2nd gravida mother with uneventful antenatal and postnatal course via Elective cesarean section. Also had history of umbilical hernia repair at birth. Patient was alright up to 7 months of age then developed fever and increase in head circumference which was diagnosed as hydrocephalus secondary to aqueductal stenosis, right sided VPS placed but got blocked in about 2 months so left VPS placed which got blocked as well so underwent revision of lower end of shunt. CSF sample sent for culture that reported Providencia rettgeri and Enterococcus that was sensitive meropenem, vancomycin and resistant to trimethoprim-sulfamethoxazole, gentamycin, ceftriaxone and piperacillin-tazobactam. On clinical examination patient was sick pale looking lying on bed with sunset eyes. Abdomen was distended and shinning with prominent veins. On palpation abdomen was soft non tender, tympanic on percussion shifting dullness was positive, gut sounds were not audible. Rest of systemic examination unremarkable.

Patient was suspected to have intestinal obstruction, kept Nil per oral on IV fluid, laboratory markers were suggestive of infection. Patient started on IV Meropenem and Vancomycin. Nasogastric tube passed. X-rays and CT scan abdomen with contrast reported small bowel obstruction, secondary to underlying adhesion/bands and bilateral VPS. CT head showed bilateral VPS with bilateral gross hydrocephalus involving lateral and third ventricle.

Patient had Exploratory laparotomy + Resection of distal ileum + end ileostomy + primary + lambert's repair of jejunum under general anesthesia. Intraoperative findings showed Clear ascitic fluid filled bowel loop, dense adhesions between small bowel loops. Right VPS lying within distal segment of ileum. Left VPS tip adherent between jejuno-ileum adhesions. Postoperatively, the patient was initially kept nil per oral. Intravenous hydration was continued. Oxygen support was added. Nasogastric tube was passed, stoma output was measured and replaced with Ringer Lactate. Chest physiotherapy was done. Stoma care was explained to the family. Nasogastric tube was eventually removed as patient improved, and oxygen was tapered off. Orally allowed. Later on repeat CSF culture reported few colonies of Streptococcus Group D sensitive to ceftriaxone, chloramphenicol and vancomycin and few colonies of Citrobactor Diversus sensitive to amikacin, ciprofloxacin, imipenem and meropenem so antibiotic was switched to ceftriaxone and amikacin.

Repeat CSF culture after 72 hours of antibiotics reported heavy growth of pseudomonas aeruginosa that was sensitive to aztreonam and ceftazidime, with intermediate sensitivity to Meropenem and Colistin. Had issues of fever so antibiotics escalated to Meropenem, vancomycin and colistin, fluconazole added as antifungal coverage. Patient underwent bilateral VP shunt removal and Left Side EVD Placement under General anesthesia. Workup showed plasmodium vivax so Artemether/lumefantrine was given for 3 days followed by Primaquine. Antibiotic changed to ceftazidime and intrathecal amikacin.

Patient had hyponatremia for which endocrinology team was taken on board. Sodium was optimized by per oral hypertonic saline and Fludrocortisone. Repeated Malarial parasite report was negative and CSF cultures finally showed no growth, intrathecal amikacin stopped after 7 days. EVD was removed and patient now underwent VA Shunt placement under General Anesthesia. CBC showed raised WBC predominantly neutrophil so vancomycin added which also stopped once labs improved. Biopsy specimen of small bowel reported negative for granuloma and malignancy. Patient then discharged off antibiotics.