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As already indicated, the lumbar puncture is an indispensable part of the examination of patients with the symptoms and signs of meningitis or of any patient in whom this diagnosis is suspected Bacteremia is not a contraindication to lumbar puncture If there is clinical evidence of a focal lesion with increased intracranial pressure, then CT scanning of the head or MRI, looking for a mass lesion, is a prudent rst step, but in most cases this is not necessary and should not delay the administration of antibiotics In an attempt to determine the utility of the CT scan performed prior to a lumbar puncture, Hasbun and colleagues were able to identify several clinical characteristics that were likely to be associated with an abnormality on the scan in patients with suspected meningitis; these included a recent seizure, coma or confusion, gaze palsy, and others The more salient nding in our opinion was that only
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INFECTIONS OF THE NERVOUS SYSTEM AND SARCOIDOSIS
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2 percent of 235 patients had a focal mass lesion that was judged a risk for lumbar puncture; many others had CT ndings of interest, including some with diffuse mass effect This study does not totally clarify the issue of the safety of lumbar puncture but it emphasizes that patients who lack major neurologic ndings are unlikely to have ndings on the scan that will preclude lumbar puncture Any coagulopathy that is deemed a risk for hemorrhagic complication of lumbar puncture should be rapidly reversed if possible The dilemma concerning the risk of promoting transtentorial or cerebellar herniation by lumbar puncture, even without a cerebral mass, as indicated in Chaps 2 and 17, has been settled in favor of performing the tap if there is a reasonable suspicion of meningitis The highest estimates of risk come from studies such as those of Rennick, who reported a 4 percent incidence of clinical worsening among 445 children undergoing lumbar puncture for the diagnosis of acute meningitis; most series give a lower number It must be pointed out that a cerebellar pressure cone (tonsillar herniation) may occur in fulminant meningitis independent of lumbar puncture; therefore the risk of the procedure is probably even less than usually stated The spinal uid pressure is so consistently elevated (above 180 mmH2O) that a normal pressure on the initial lumbar puncture in a patient with suspected bacterial meningitis raises the possibility that the needle is partially occluded or the spinal subarachnoid space is blocked Pressures over 400 mmH2O suggest the presence of brain swelling and the potential for cerebellar herniation Many neurologists favor the administration of intravenous mannitol if the pressure is this high, but this practice does not provide assurance that herniation will be avoided A pleocytosis in the spinal uid is diagnostic The number of leukocytes ranges from 250 to 100,000 per cubic millimeter, but the usual number is from 1000 to 10,000 Occasionally, in pneumococcal and in uenzal meningitis, the CSF may contain a large number of bacteria but few if any neutrophils for the rst few hours Cell counts of more than 50,000 per cubic millimeter raise the possibility of a brain abscess having ruptured into a ventricle Neutrophils predominate (85 to 95 percent of the total), but an increasing proportion of mononuclear cells is found as the infection continues for days, especially in partially treated meningitis In the early stages, careful cytologic examination may disclose that some of the mononuclear cells are myelocytes or young neutrophils Later, as treatment takes effect, the proportions of lymphocytes, plasma cells, and histiocytes steadily increase Substantial hemorrhage or substantial numbers of red cells in the CSF are uncommon in meningitis, the exceptions being anthrax meningitis (see Lanska) as well as certain rare viral infections (Hantavirus, Dengue fever, Ebola virus, etc) and some cases of amebic meningoencephalitis The protein content is higher than 45 mg/dL in more than 90 percent of the cases; in most it falls in the range of 100 to 500 mg/dL The glucose content is diminished, usually to a concentration below 40 mg/dL, or less than 40 percent of the blood glucose concentration (measured concomitantly or within the previous hour) provided that the latter is less than 250 mg/dL However, in atypical or culture-negative cases, other conditions associated with a reduced CSF glucose should be considered These include hypoglycemia from any cause; sarcoidosis of the CNS; fungal or tuberculous meningitis; and some cases of subarachnoid hemorrhage, meningeal carcinomatosis, chemically induced in ammation from craniopharyngioma or teratoma, or meningeal gliomatosis Gram s stain of the spinal uid sediment permits identi cation
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of the causative agent in most cases of bacterial meningitis; pneumococci and H in uenzae are identi ed more readily than meningococci Small numbers of gram-negative diplococci in leukocytes may be indistinguishable from fragmented nuclear material, which may also be gram-negative and of the same shape as bacteria In such cases, a thin lm of uncentrifuged CSF may lend itself more readily to morphologic interpretation than a smear of the sediment The most common error in reading Gram-stained smears of CSF is the misinterpretation of precipitated dye or debris as gram-positive cocci or the confusion of pneumococci with H in uenzae The latter organisms may stain heavily at the poles, so that they resemble gram-positive diplococci, and older pneumococci often lose their capacity to take a gram-positive stain Cultures of the spinal uid, which prove to be positive in 70 to 90 percent of cases of bacterial meningitis, are best obtained by collecting the uid in a sterile tube and immediately inoculating plates of blood, chocolate, and MacConkey agar; tubes of thioglycolate (for anaerobes); and at least one other broth The advantage of using broth media is that large amounts of CSF can be cultured The importance of obtaining blood cultures is mentioned below The problem of identifying causative organisms that cannot be cultured, particularly in patients who have received antibiotics, may be overcome by the application of several special laboratory techniques One of these is counterimmunoelectrophoresis (CIE), a sensitive test that permits the detection of bacterial antigens in the CSF in a matter of 30 to 60 min It is particularly useful in patients with partially treated meningitis, in whom the CSF still contains bacterial antigens but no organisms on a smear or grown in culture Several more recently developed serologic methods, radioimmunoassay (RIA) and latex-particle agglutination (LPA), as well as an enzyme-linked immunosorbent assay (ELISA), may be even more sensitive than CIE An argument has been made that these procedures are not cost-effective, since in virtually all instances in which the bacterial antigen can be detected Gram s stain also shows the organism Our sense is that the more expensive tests are of some assistance if Gram s stain is dif cult to interpret and one or more doses of antibiotics render the cultures negative Gene ampli cation by the polymerase chain reaction (PCR) is the most recently developed and most sensitive technique As it becomes more widely available in clinical laboratories, rapid diagnosis may be facilitated (Desforges; Naber), but the use of careful Gram-stained preparations still needs to be encouraged Measurements of chloride concentrations in the CSF are not very useful, but they are usually found to be low, re ecting dehydration and low serum chloride levels In contrast, CSF lactate dehydrogenase (LDH), although infrequently measured, can be of diagnostic and prognostic value A rise in total LDH activity is consistently observed in patients with bacterial meningitis; most of this is due to fractions 4 and 5, which are derived from granulocytes Fractions 1 and 2 of LDH, which are presumably derived from brain tissue, are only slightly elevated in bacterial meningitis but rise sharply in patients who develop neurologic sequelae or later die Lysozymal enzymes in the CSF derived from leukocytes, meningeal cells, or plasma may also be increased in meningitis, but the clinical signi cance of this observation is unknown Levels of lactic acid in the CSF (determined by either gas chromatography or enzymatic analysis) are also elevated in both bacterial and fungal meningitides (above 35 mg/dL) and may be helpful in distinguishing these disorders from viral meningitides, in which lactic acid levels remain normal
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