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ZEESHAN YOUSUF
Indications
Meningeal infection* Subarachnoid hemorrhage (SAH) CNS malignancy Demyelinating diseases
Diagnosis by CSF
High sensitivity, high specificity
Bacterial, TB, and fungal meningitis
Gross Examination
Normal CSF is clear, colorless Viscosity equal to water Clot seen in traumatic tap, not SAH Viscous CSF with increased protein exudate Turbidity:
WBC > 200 cells/uL RBC > 400 cells/uL Microorganisms, increased protein
Xanthochromia
Pink, orange, or yellow discoloration RBC lysis or hemoglobin breakdown May be seen within hours of LP Peak intensity at 24 - 36 hours RBC > 6000/uL (SAH, ICH, infarct, traumatic) Oxyhemoglobin, bilirubin, increased protein Carotinoids, melanin, rifampin therapy
20 72 3 5 Rare Rare
Plasmacytosis in CSF
TB meningitis Syphilitic meningitis MS Parasitic infections SSPE GBS Sarcoidosis Acute viral infections
Chemical Analysis
Total protein non-specific marker of disease Turbidimetric methods based on TCA or SSA & sodium sulfate for precipitation Simple, rapid, no special instrumentation 300 different proteins have been isolated from CSF using two-dimensional electrophoresis and silver staining
Electrophoresis
Identification of oligoclonal bands 2 or more discrete bands in the gamma region absent or of lesser intensity in concurrently run patients serum Silver stain more sensitive than paragon violet IFE better resolution and more specific Sensitivity = 83 - 94%
Bacterial Meningitis
0 - 1m: Group B strept & E. coli (GNR) 1m - 5y: H. influenzae 5 - 29y: N. meningitidis >29y: S. pneumoniae Listeria monocytogenes common in newborns, elderly, and other immunocompromised hosts
Bacterial Meningitis
Grams stain sensitivity = 60 - 90% Depends on organism, experience, # Culture sensitivity = 80 - 90% Latex agglutination becoming more widely used due to simplicity and accuracy
Bacterial Meningitis
Neurosyphilis
Darkfield microscopy for spirochetes CSF FTA-ABS 100% sensitive Negative test rules out diagnosis VDRL nearly 100% specific Positive test rules in neurosyphilis RPR unsuitable for CSF (higher FP than VDRL)
Neurosyphilis
Viral Meningitis
Enteroviruses (echoviruses, coxsachie, polio viruses) account for 80% cases Diagnosis of exclusion, rarely use cultures Viral inclusions for CMV, HSV PCR for HSV available Usually requires brain biopsy
HIV
Wide variety of abnormalities with or without neurological disease Lymphocytic pleocytosis, elevated IgG, and oligoclonal bands ID of opportunistic (fungal) infections main reason for examining CSF
Fungal Meningitis
India ink for cryptococcal capsular halos 50% sensitivity LA and CF antibodies now available Sensitivity as high as 96%
Tuberculous Meningitis
Early diagnosis extremely difficult Sensitivity for acid-fast stains 10% Large volumes of CSF recommended Higher levels of adenosine deaminase ELISA and PCR now available Sensitivity = 50 - 82% Specificity = 90 - 100%