Abstract
ObjectivesWe describe clinical characteristics and outcome of adults with bacterial meningitis presenting with a normal CSF leukocyte count. MethodsWe studied community-acquired bacterial meningitis with a normal CSF leukocyte count (≤ 5 per mm3) in adults from a prospective nationwide cohort study. ResultsFrom 2006 through 2020, 39 of 2,357 (2%) episodes presented with a normal CSF leukocyte count. Immunocompromising conditions were present in 19 of 39 patients (49%), compared to 690 of 2303 (30%) in patients with elevated leukocytes (P = 0.02). The triad of fever, neck stiffness, and altered consciousness was present in 6 of 34 patients (18%). CSF protein was abnormal in 25 of 37 patients (68%). We identified 3 clinical subgroups: those with severe pneumococcal meningitis (20 patients [51%]), with mainly sepsis (8 [21%]), and a miscellaneous group (11 [28%]). All patients with severe pneumococcal meningitis presented with high CSF protein levels and 18 of 19 (95%) had bacteria in the CSF Gram stain. Outcome was unfavorable in 23 of 39 (59%) patients and 12 (31%) died. ConclusionPatients with bacterial meningitis may present with normal CSF leukocyte counts. In these patients, CSF protein levels and Gram staining are important diagnostic parameters.
Highlights
Community-acquired bacterial meningitis is associated with high mortality and morbidity rates despite effective vaccination strategies. [1-3] Early diagnosis and initiation of treatment with antibiotics and dexamethasone is crucial and European guidelines recommend initiation of treatment within one hour after arrival in the hospital. [4, 5] Cerebrospinal fluid (CSF) findings play an important role in the diagnosis of bacterial meningitis
Rare, patients with bacterial meningitis may present with normal CSF leukocyte counts
The proportion of patients with normal CSF leukocyte counts at diagnostic lumbar puncture was 1.7%, comparable to that reported by a Danish study
Summary
Community-acquired bacterial meningitis is associated with high mortality and morbidity rates despite effective vaccination strategies. [1-3] Early diagnosis and initiation of treatment with antibiotics and dexamethasone is crucial and European guidelines recommend initiation of treatment within one hour after arrival in the hospital. [4, 5] Cerebrospinal fluid (CSF) findings play an important role in the diagnosis of bacterial meningitis. Community-acquired bacterial meningitis is associated with high mortality and morbidity rates despite effective vaccination strategies. [4, 5] Cerebrospinal fluid (CSF) findings play an important role in the diagnosis of bacterial meningitis. CSF leukocyte counts have the highest diagnostic accuracy in discriminating between bacterial meningitis and other diagnoses. [6, 7] some patients with community-acquired bacterial meningitis present with normal CSF leukocyte counts. [6, 8-10] Prior antibiotic treatment, very early diagnosis, and co-existing septic shock have been associated with low cerebrospinal fluid leukocyte counts. (6, 9, 11) Lower CSF leukocyte counts have been associated with an adverse outcome. [12] We describe characteristics and outcome of patients with community-acquired bacterial meningitis from a prospective nationwide cohort study presenting with a CSF leukocyte count at the diagnostic lumbar puncture CSF leukocyte counts have the highest diagnostic accuracy in discriminating between bacterial meningitis and other diagnoses. [6, 7] some patients with community-acquired bacterial meningitis present with normal CSF leukocyte counts. [6, 8-10] Prior antibiotic treatment, very early diagnosis, and co-existing septic shock have been associated with low cerebrospinal fluid leukocyte counts.
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