SPINAL FLUID EXAMINATION IN BACTERIAL MENINGITIS

-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.

-If there is clinical evidence of a focal lesion with increased intracranial pressure, then CT or MRI
scanning of the head, looking for a mass lesion, is a prudent first step, but in most cases this is not
necessary and should not delay the administration of antibiotics.

Spinal fluid pressure

consistently elevated (above 180 mmH2O) that a normal pressure on the initial lumbar puncture
in a patient with suspected bacterial meningitis

Pressures over approximately 350 mm Hp suggest the presence of brain swelling and the
potential for cerebellar herniation.

Pleocytosis
diagnostic.
ranges from 250 to 100,000/mm3, but the usual number is from 1,000 to 10,000
in pneumococcal and influenzal meningitis, neutrophils for the first few hours.
> 50,000 I mm3 raise the possibility of a brain abscess having ruptured into a ventricle.
EARLY- Neutrophils predominate (85 to 95 percent of the total),
LATE - mononuclear cells

Substantial hemorrhage
substantial numbers of red cells in the CSF
uncommon in meningitis,
present in Anthrax meningitis ,Hantavirus, dengue fever, Ebola virus, amebic eningoencephalitis.

Protein
higher than 45 mg/ dL (range of 100 to 500 mg/ dL.)

Glucose
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.

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
inflammation fromcraniopharyngioma or teratoma, and meningeal gliomatosis.
Clinical prediction rule that classifies patients at very low risk for bacterial meningitis if they lack
all of the following criteria:
positive CSF Gram stain,
CSF absolute neutrophil count of at least 1,000 cells /mL,
CSF protein of at least 80 mg/ dL,
peripheral absolute neutrophil count of at least 10,000 cells /mL,
history of a seizure at or after the time of presentation.

THE GRAM STAIN OF THE SPINAL FLUID

- sediment permits identification of the causative agent in most cases of bacterial meningitis;
pneumococci and H. influenzae are identified 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 film 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. influenzae. The latter organism may stain heavily at the poles, so that they
resemble gram-positive diplococci, and older or rapidly growing pneumococc

CULTURES OF THE SPINAL FLUID

- 70 to 90 percent of cases of bacterial meningitis, are best obtained by collecting the fluid 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.

It takes from 30 min to several hours for the concentration of CSF GLUCOSE to reach equilibrium with
blood glucose levels therefore, administration of 50 mL of 50% glucose (D50) prior to LP, as commonly
occurs in emergency room settings, is unlikely to alter CSF glucose concentration significantly unless
more than a few hours have elapsed between glucose administration and LP.