Cerebrospinal Fluid Cellularity Research Articles

Chronic brain changes caused by severe systemic inflammatory episode

AbstractBackgroundSepsis‐associated encephalopathy (SAS) is a neurological complication of a severe systemic inflammatory episode that compromises brain function. This neurological impairment can lead to cognitive dysfunction that appears to precede neurodegenerative disorders such as Alzheimer’s disease. However, the events by which systemic inflammation causes such significant damage to the brain are not yet fully established. With that in mind, this study sought to investigate persistent brain changes after a severe systemic inflammatory episode.MethodMale Wistar rats (90 days old) were divided into two experimental groups: sham (n = 33) and sepsis (n = 37). For the induction of severe systemic inflammation, the animals underwent cecal ligation and perforation (CLP). Animals were followed for 30, 60 and 120 days. In all time‐points, we performed the object recognition task to evaluate declarative memory and Western Blotting to assess astrocyte‐related proteins (GFAP, GLT‐1 and Mao‐B). At 30 and 120 days, we evaluated the ΒBB integrity [cerebrospinal fluid (CSF) albumin levels and cellularity by HCLP] and brain glucose metabolism (FDG‐PET imaging).ResultOur results show that CLP model compromised long‐term memory at 60 and 120 days. Furthermore, we found higher levels of albumin in the CSF in CLP animals compared to sham at 30 (p = 0.023) and 120 days post‐sepsis (p = 0.002). In addition, we also observed an increase in CSF cellularity in CLP animals after 30 days after sepsis induction. We also found persistent glucose whole brain hypometabolism at 30 (local maxima, t(12) = ‐3.7) and 120 days (local maxima, t(9) = ‐8.45), suggesting persistent metabolic abnormalities. Finally, we observed changes in astrocyte‐related proteins. At 30 days, hippocampal GLT‐1 (p<0.001) and cortical GFAP (p < 0.0001) immunocontents were reduced in CLP rats compared to sham. At 60 days, we observed decreased hippocampal GFAP (p < 0,05) and MAO‐B (p < 0.01) immunocontents. At 120 days, we found decreased MAO‐B in the hippocampus (p<0.05).ConclusionWe found that a severe systemic inflammation episode causes persistent changes in brain glucose metabolism and BBB integrity, which seems associated with long‐term memory impairment. In addition, astrocytes seem to be reacting by changing their protein expression, a typical feature of reactive astrocytes.

Diagnostic Accuracy of Urinary Reagent Strip to Determine CSF Chemistry and Cellularity

Background: Cerebrospinal Fluid (CSF) examination is a common investigation to diagnose and evaluate different neurological diseases. The gold standard method of CSF examination is microscopy, biochemistry and culture in a standard laboratory, which require an experienced microscopist and laboratory support. Urinary reagent strip can be a point of care test in such condition. The study aimed to document the diagnostic accuracy of urinary reagent strip for the semi-quantitative analysis of CSF chemistry and cellularity.
 Materials and methods: One hundred hospitalized patients from the Department of Neurology, Chittagong Medical College Hospital were included in this study. CSF samples of the patients were subjected for the de nitive test (CSF microscopy and laboratory biochemical values) and the index test [Combur-10 urinary reagent strip was used as the index test for protein, glucose, leukocytes and erythrocytes. The diagnostic accuracy of each index test was calculated using different cut-off levels (Glucose 1+ vs. CSF glucose >50 mg/dL, protein 1+ vs. CSF protein >30 mg/dL, leukocyte esterase 1+ positivity vs. >10 granulocytes/mm3 and erythrocyte 1+ positivity versus >5 RBC/mm3 in CSF sample).
 Results: The diagnostic accuracy of protein estimation by reagent strip shows 100% sensitivity, 84.21% specificity for detection of CSF protein at level 30mg/dl. Glucose reagent strip positivity had 98.8% sensitivity and 75% specificity for detection of CSF glucose at level 50 mg/dl. Leukocyte esterase positivity by test strip had sensitivity of 60% and specificity of 100% for the detection of CSF granulocyte of >10 granulocytes/mm3. The diagnostic accuracy of erythrocyte estimation by reagent strip show 92% sensitivity, 92% specificity for detection of CSF RBC >5 cells/mm3.
 Conclusion: Urinary reagent strip can be used routinely for rapid analysis of CSF.A resource-limited hospital might find it useful as a point-of-care laboratory workup of CSF.
 Chatt Maa Shi Hosp Med Coll J; Vol.21 (2); July 2022; Page 9-13

Assessment of a Multiplex LAMP Assay (Eazyplex® CSF Direct M) for Rapid Molecular Diagnosis of Bacterial Meningitis: Accuracy and Pitfalls.

Background: Automated molecular panels are attractive tools for improving early meningitis diagnosis. This study assessed the Eazyplex® CSF direct M panel (EP), a multiplex real-time Loop-Mediated Isothermal Amplification assay. Methods: From December 2016 to December 2019, cerebrospinal fluid (CSF) samples were routinely tested with the EP V1.0. CSF parameters and microbiological and clinical data were retrospectively collected. Results: Out of 230 CSF samples, the EP yielded positive, negative, and invalid results for 32 (13.9%) (16 N. meningitidis, nine S. pneumoniae, two S. agalactiae, two E. coli, two H. influenzae, one L. monocytogenes), 182 (79.1%), and 16 (7%) samples, respectively. Among the positive samples, 14 (44%) remained negative in culture (antibiotic therapy before lumbar puncture (n = 11), meningococcal meningitis (n = 3)). High CSF protein concentrations and cellularity were associated with LAMP inhibition, counteracted by centrifugation. The automated software yielded 13 false positive and five false negative results. Amplification curve analysis was necessary and enabled the attainment of positive (PPA) and negative percentage agreement and positive and negative predictive values of 91.4%, 100%, 100%, and 98.3%. Three false negative results remained (two E. coli and one N. meningitidis). E. coli presented the poorest PPA (50%). Conclusion: This work confirms the strong performance of the EP, of particular interest in cases of antibiotic therapy before lumbar puncture.

Cerebrospinal fluid cell count variability is a major confounding factor in external ventricular drain-associated infection surveillance diagnostics: a prospective observational study

BackgroundExternal ventricular drain (EVD)-related infections (EVDIs) are feared complications that are difficult to rapidly and correctly diagnose, which can lead to unnecessary treatment with broad-spectrum antibiotics. No readily available diagnostic parameters have been identified to reliably predict or identify EVDIs. Moreover, intraventricular hemorrhage is common and affect cerebrospinal fluid (CSF) cellularity. The relationship between leukocytes and erythrocytes is often used to identify suspected infection and triggers the use of antibiotics pending results of cultures, which may take days. Cell count based surveillance diagnostics assumes a homogeneous distribution of cells in the CSF. Given the intraventricular sedimentation of erythrocytes on computed tomography scans this assumption may be erroneous and could affect diagnostics.AimsTo evaluate the consistency of cell counts in serially sampled CSF from EVDs, with and without patient repositioning, to assess the effect on infection diagnostics.MethodsWe performed a prospective single-center study where routine CSF sampling was followed by a second sample after 10 min, allocated around a standard patient repositioning, or not. Changes in absolute and pairwise cell counts and ratios were analyzed, including mixed regression models.ResultsData from 51 patients and 162 paired samples were analyzed. We observed substantial changes in CSF cellularity as the result of both resampling and repositioning, with repositioning found to be an independent predictor of bidirectional cellular change. Glucose and lactate levels were affected, however clinically non-significant. No positive CSF cultures were seen during the study. Thirty percent (30%) of patients changed suspected EVDI status, as defined by the cell component of local and national guidelines, when resampling after repositioning.ConclusionsCSF cell counts are not consistent and are affected by patient movement suggesting a heterogeneity in the intraventricular space. The relationship between leukocytes and erythrocytes was less affected than absolute changes. Importantly, cell changes are found to increase with increased cellularity, often leading to changes in suspected EVDI status. Faster and more precise diagnostics are needed, and methods such as emerging next generation sequencing techniques my provide tools to more timely and accurately guide antibiotic treatment.Trial Registration NCT04736407, Clinicaltrials.gov, retrospectively registered 2nd February 2021.

PB1686 USE OF FLOW CYTOMETRY AND IMMUNOHISTOCHEMISTRY TO RULE OUT CNS RELAPSE OF ACUTE LYMPHOBLASTIC LEUKEMIA

Background: Increased cerebrospinal fluid (CSF) cellularity in an otherwise asymptomatic patient with acute lymphoblastic leukemia (ALL) may indicate CNS disease. Aims: To describe how flow cytometry and immunohistochemistry helped in ruling out suspicion of CNS relapse because of unexpected CSF findings in a child with acute lymphoblastic leukemia in CR during maintenance phase of chemotherapy. Methods: Examination of cytospin CSF samples with flow cytometry, fluorescent in vitro hybridization (FISH) for centromeres of chromosomes 7 and 8 on 200 cells and immunohistochemistry for CD10 and terminal deoxynucleotidyl transferase (TdT). Results: A 15-year old girl was diagnosed in 2005 with B common ALL with hyperdiploidy including trisomy 8, and no CNS involvement. She was treated according to a modified New York II protocol with good prednisone response and negative flow cytomerty minimal residual disease (MRD) on day 33, and prophylactic cranial radiation of 1200 cGy. She went on with maintenance treatment consisting of 6-mercaptopurine 300 mg/m2/d d0-3, cyclophosphamide 1200 mg/m2 d4, vincristine 1.5 mg/m2 d11, 18, 25, prednisonse 180 mg/m2/d d18-25, methotrexate 200 mg/m2 over 4 h d25, daunorubicin 20 mg/m2 d40, 41, cytosine arabinoside 100 mg/m2, thioguanine 40 mg/m2/dose 6 doses d42-44, methotrexate IT d60/0. Days 0 and 60 CSF findings were normal. However, on day 0 of the subsequent cycle, increased ceullarity was found incidentally. CSF cell number was 45/μL and increased up to 130/μL despite additional methotrexate IT injections. Examination of cytospin preparations showed 75% lymphocytes and 25% monocytes/macrophages. Morphological discrimination between lymphoblasts and mature lymphocytes was difficult. Protein level in CSF was mildly increased up to 71 mg/dL and glucose level in CSF was normal. The patient was free of symptoms and the neuroimaging was normal. Immunohistochemistry on cytospin preparation showed no TdT expression on lymphocytes. Flow cytometry of CSF using the initial immunophenotype showed normal lymphocytes and monocytes and no leukemic blasts. FISH on a cytospin preparation to detect trisomy 8, which was present at diagnosis, and using as an internal negative control chromosome 7 ploidy, was normal with two signals for chromosomes 8 and 7, respectively. Those results in addition to increasing cellularity despite intrathecal chemotherapy and progressive enrichment of CSF in monocytes and uneventful clinical course and undetactable MRD in bone marrow, led to the conclusion that high CSF high cellularity was of reactive nature. CSF cellularity returned to normal within 2 weeks. The patient completed maintenance treatment and remains in persistent complete first remission for 10 years. Summary/Conclusion: Incidental high CSF cellularity arousing suspicion of CNS relapse may be misleading. Sensitive methods of immunophenotyping and genotyping at the cellular level provide confidence in diagnosing reactive CSF pleocytosis secondary to previous intrathecal chemotherapy and avoid unnecessary treatment plan modifications.

Predictors of mortality in outborns with neonatal sepsis: A prospective observational study.

Neonatal sepsis-related mortalities are the outcome of a complex interaction of maternal-foetal colonisation, transplacental immunity and physical and cellular defence mechanisms of neonates. The objective of this study was to evaluate the risk factors of mortality in outborn neonatal sepsis. A 1-year prospective observational study was undertaken at a tertiary care centre. All referred neonates with maternal and neonatal risk factors of sepsis were enrolled. Blood culture, sepsis screen and other relevant investigations were performed. The mortality rate of neonatal sepsis among outborns was 38.24%. The common presentations of these neonates were respiratory distress, lethargy and hypothermia. On univariate analysis, significant risk factors for mortality included male sex (P = 0.05), weight on admission <1500 g (P < 0.001), hypothermia (P = 0.003), respiratory distress (P = 0.04), cyanosis (P = 0.001), convulsions (P = 0.02), prolonged capillary refill time (P < 0.001), thrombocytopenia (P < 0.001), abnormal radiological finding (P = 0.01), cerebrospinal fluid cellularity (P = 0.002) and positive C-reactive protein (P < 0.001). Maternal factors such as hypertension in pregnancy (P = 0.001) and antepartum haemorrhage (P = 0.03) were associated with statistically significant mortality. Gestational age (odds ratio [OR]: 0.49, confidence interval [CI]: 0.26-0.90, P = 0.02), weight on admission (OR: 1.57, CI: 1.08-2.27, P = 0.01), age at admission (OR: 0.89, CI: 0.78-0.99, P = 0.04), distance travelled with neonate (OR: 1.01, CI: 1.00-1.01, P = 0.003), duration of hospital stay (OR: 0.69, CI: 0.63-0.74, P < 0.001), hypothermia (OR: 1.87, CI: 1.01-3.42, P = 0.04), convulsion (OR: 2.88, CI: 1.33-6.20, P = 0.007), cyanosis (OR: 2.39, CI: 1.07-5.35, P = 0.03) and prolonged capillary refill time (OR: 3.34, CI: 1.78-6.24, P < 0.001) were the independent predictors of mortality in neonatal sepsis. Gestational age; birth weight; long distance travelled with neonate and presentation with hypothermia, cyanosis, convulsions and prolonged capillary refill time were the independent risk factors for mortality in neonatal sepsis among outborns.

Extraparenchymal neurocysticercosis: Demographic, clinicoradiological, and inflammatory features.

BackgroundExtraparenchymal neurocysticercosis (ExPNCC), an infection caused by Taenia solium cysticerci that mainly occurs in the ventricular compartment (Ve) or the basal subarachnoid space (SAb), is more severe but less frequent and much less studied than parenchymal neurocysticercosis (ParNCC). Demographic, clinical, radiological, and lumbar cerebrospinal fluid features of patients affected by ExPNCC are herein described and compared with those of ParNCC patients.Methodology and principal findings429 patients with a confirmed diagnosis of neurocysticercosis, attending the Instituto Nacional de Neurología y Neurocirugía, a tertiary reference center in Mexico City, from 2000 through 2014, were included. Demographic information, signs and symptoms, radiological patterns, and lumbar cerebrospinal fluid (CSF) laboratory values were retrieved from medical records for all patients. Data were statistically analyzed to assess potential differences depending on cyst location and to determine the effects of age and sex on the disease presentation. In total, 238 ExPNCC and 191 ParNCC patients were included. With respect to parenchymal cysts, extraparenchymal parasites were diagnosed at an older age (P = 0.002), chiefly caused intracranial hypertension (P < 0.0001), were more frequently multiple and vesicular (P < 0.0001), and CSF from these patients showed higher protein concentration and cell count (P < 0.0001). SAb patients were diagnosed at an older age than Ve patients, and showed more frequently seizures, vesicular cysticerci, and higher CSF cellularity. Gender and age modulated some traits of the disease.ConclusionsThis study evidenced clear clinical, radiological, and inflammatory differences between ExPNCC and ParNCC, and between SAb and Ve patients, and demonstrated that parasite location determines different pathological entities.

Expression of microRNAs miR-21 and miR-181c in cerebrospinal fluid and serum in canine meningoencephalomyelitis of unknown origin

The potential of microRNAs (miRNAs) as biomarkers for canine meningoencephalomyelitis of unknown origin (MUO) was investigated by using quantitative real-time (qRT)-PCR to determine the expression of microRNA-21 (miR-21) and microRNA-181c (miR-181c) in the cerebrospinal fluid (CSF) of dogs. Dogs with MUO (n = 10) had higher levels of expression of miR-21 and miR-181c in the CSF than dogs with non-inflammatory neurological diseases (n = 8). There was a positive correlation between CSF cellularity and expression of miRNAs in the CSF, particularly for miR-21 in the MUO group.

Semi-quantitative analysis of cerebrospinal fluid chemistry and cellularity using urinary reagent strip: An aid to rapid diagnosis of meningitis.

The examination of the cerebrospinal fluid (CSF) for proteins, glucose, and leukocytes still remains the basic gold standard investigation for the initial diagnosis of meningitis. Early diagnosis and initiation of antibiotics within 3 h can reduce the mortality and morbidity associated with meningitis. Hence, we conducted this study to document the usefulness of urinary reagent strip for the semi-quantitative analysis of CSF chemistry and cellularity. All clear CSF samples were subjected for two types of tests, the definitive test and the index test. CSF microscopy and biochemical values are considered as definitive. Combur-10 urinary reagent strip was used as the index test for proteins, glucose, and leukocytes. The diagnostic accuracy of each index test was calculated using different cut-off levels (leukocyte esterase positivity 1+ vs. CSF granulocytes ≥10/cumm, proteins 1+ and 2+ vs. CSF protein ≥30 mg/dl and ≥100 mg/dl, respectively, and glucose 0 vs. ≤40 mg/dl and ≤50 mg/dl). Statistical analysis was performed to derive the specificity, sensitivity, positive predictive value, negative predictive value, likelihood ratio (LR)+, LR-, and area under curve (AUC). The study subjects comprised 103 cases. The strip showed a high sensitivity and specificity for leukocytes ≥10 cells/cumm. The strip showed a sensitivity of 96% and a specificity of 87.1% for proteins at a cut-off ≥100 mg/dl while the strip was less specific at a cut-off of ≥30 mg/dl. With respect to glucose, the strip was highly specific (100%) and less sensitive at both the cut-off levels. The AUC for leukocytes ≥10 cells/cumm was 99.05%; for proteins ≥30 mg/dl and ≥100 mg/dl, it was 84.86% and 95.69%, respectively; and, for glucose ≤40 mg/dl and ≤50 mg/dl, it was 86.51% and 76.99%, respectively. The routinely used urinary reagent strip can be utilized for the rapid analysis of CSF. If implemented, this technique will be useful in rural areas. It would also decrease the turnaround time in centers where the facility is available.

Flow cytometric analysis of T cell/monocyte ratio in clinically isolated syndrome identifies patients at risk of rapid disease progression

Background: Multiple sclerosis is a chronic inflammatory central nervous system disease diagnosed by clinical presentation and characteristic magnetic resonance imaging findings. The role of cerebrospinal fluid (CSF) analysis has been emphasized in particular in the context of differential diagnosis in patients with a first episode suggestive of multiple sclerosis. Objective: We investigated here the potential additional value of analysis of CSF cellularity by fluorescence activated cell sorting (FACS) in the setting of a routine diagnostic work-up in our inpatient clinic. Methods: CSF cells from back-up samples from patients with suspected chronic inflammatory central nervous system disorder were analyzed by FACS and correlated with clinical data, magnetic resonance imaging findings and oligoclonal band status. Results: We found distinct changes of T cell/monocyte (CD4/CD14) and B cell/monocyte (CD20/CD14) ratios between clinically isolated syndrome (CIS)/multiple sclerosis and other neurologic diseases or other inflammatory neurologic diseases. In particular, patients with a rapid transition from CIS to multiple sclerosis had an elevated CD4/CD14 ratio. A subgroup analysis showed diagnostic value of CD4/CD8 ratio in the differential diagnosis of CIS/multiple sclerosis to neurosarcoidosis. Conclusion: The diagnostic and prognostic accuracy of autoimmune neuroinflammatory diseases can be improved by FACS analysis of CSF cells.

Características del líquido cefalorraquídeo en niños con infecciones del sistema de derivación ventrículo-peritoneal

A common (5%) complication of cerebrospinal fluid (CSF) shunt systems is infection. CSF cytochemical findings have been used to choose the initial empirical antimicrobial treatment. The objective was to evaluate the results of cytochemical and microbiological analyses of CSF samples obtained from children with pyogenic ventriculitis associated to ventriculoperitoneal shunt systems. This was a retrospective, descriptive and analytical study. Thirty-two cases of pyogenic ventriculitis were included; Gram-positive bacteria were predominant in 26 cases (81.25%); the rest corresponded to Gram-negative bacteria. There were no statistically significant differences for the studied outcome variables (CSF cellularity, glucose and protein levels). Gram-positive bacteria were widely predominant as a cause of pyogenic ventriculitis associated to the surgical procedure. CSF characteristics show a high heterogeneity and were not associated to the type of microorganism in this studied sample.

Epstein-Barr virus in the cerebrospinal fluid of HIV-positive patients. Observational cross-sectional study

Different viruses are detected in the cerebrospinal fluid (CSF) of HIV-positive patients, with controversial implications in central nervous system (CNS) impairment. Objectives: to evaluate the presence, frequency and associations of Epstein-Barr virus (EB) in the CSF in HIV-positive patients. We retrospectively analyzed CSF samples from HIV-positive adult patients (≥18 years old), with or without CNS impairment, collected between Oct 2011 and Oct 2012 in a Romanian tertiary infectious diseases hospital. We performed a multiplex PCR coupled with electrospray ionization – time-of-flight mass spectrometry (Abbott Molecular) which can simultaneously detect: herpesviruses (1-5 and 8), polyomaviruses, enteroviruses, adenoviruses and parvoviruses. The patients were characterized based on the immunological and virological HIV status, neurological findings (including neuroimagery and CSF exam) and comorbidities. A number of 55 patients were analyzed, with a mean age of 33.4 years (31.5 median) and a male:female ratio of 1.9:1. The CD4 count had a mean of 32 (75 median and IQR=225). The most frequently detected virus was EB in 20/55 cases. The EB-positive subgroup had a similar mean age of 33.5 years (median of 31.0) but a different male:female ratio, of 1.2:1. The CD4 count had a mean of 105.7 (59.5 median and IQR=156). The following analyses refer to the EB-positive group: 17/20 patients had neurologic impairment. Imagery was performed in 15 cases and was normal in 5. CSF cellularity had a median of 2/cmm, IQR=10, CSF-glucose a median of 48.0 mg/dL, IQR=34 and CSF-protein a median of 55.5mg/dL, IQR=49.5. In 8/20 cases EB was found as singular agent in the CSF and in 12/20 it was associated with other microorganisms: other herpesviruses (3 cases), JC virus (4 cases), Mycobacterium tuberculosis (2 cases), Cryptococcus neoformans (2 cases) and Toxoplasma gondii (one case). The CSF-HIV viral load was available in 12/20 cases, being detectable in 10 cases. Regarding the neurological events (totalizing the neurological signs/symptoms, CSF exam and imagery), EB was probably causal in 4/20 cases, possibly causal in another 4/20 cases and was a bystander in 12/20 (3 cases with no impairment and 9 cases in which the impairments were strongly attributable to another germ). EB is the most frequent agent found in the CSF (40% of HIV-positive cases), mainly in women. It can be mono-detected but it especially appears in multiple associations. In more than half of the cases EB acts as an innocent bystander.

Factors influencing shunt malfunction in patients with tuberculous meningitis

Abstract Hydrocephalus secondary to tuberculous meningitis (TBM) is a challenging condition to treat. Though ventriculo-peritoneal (VP) shunt is an accepted modality of treatment for hydrocephalus in TBM, there is a high rate of complications associated with the same. The study was planned to evaluate various factors associated with shunt malfunction in patients undergoing VP shunt surgery for hydrocephalus due to TBM. A retrospective review of all the patients undergoing VP shunt and shunt revision for TBM between 2004 and 2008 was performed. 449 VP shunt surgeries were performed in 432 patients for hydrocephalus due to TBM. Among these 70 shunt revisions were performed in 53 patients. Shunt malfunction rate in our series was 16.2%. High cerebrospinal fluid (CSF) protein concentration (&gt;200 mg/dL) was associated with 5 times increased incidence of shunt malfunction. Patients with hyponatremia (Na+ &lt;130 mEq/dL) prior to surgery had a 3 times increased incidence of shunt malfunction (P &lt; 0.05). Other factors such as duration of symptoms, presence of neurological deficits, Evan’s index, third ventricular diameter, thickness of exudates, presence of infarcts, anemia, CSF cellularity and CSF glucose concentration were not associated with increased incidence of shunt malfunction. Analysis showed that shunt viability was longest in patients with normal serum sodium levels and CSF protein concentration less than 200 mg/dL and shortest in patients with low serum sodium and CSF protein concentration more than 200 mg/dL. Patients with pre-operative hyponatremia and high CSF protein concentration have a higher incidence of shunt malfunction and need to be followed-up closely.

Reversible mental status change and renal dysfunction associated with the use of high-dose oral valaciclovir therapy for acute retinal necrosis.

The purpose of this study was to report the case of a patient with acute retinal necrosis who developed neurotoxicity while being treated with oral valaciclovir antiviral therapy. Testing used was clinical examination including fundus photographs, renal biochemistry, cerebrospinal fluid analysis, and renal ultrasound. A 63-year-old, healthy, white woman was being treated with oral valaciclovir for acute retinal necrosis. Several days later, she developed visual hallucinations and confusion. Renal biochemistry was abnormal, and renal ultrasound was normal. Cerebrospinal fluid cellularity was normal, but cerebrospinal fluid 9-carboxymethoxymethylguanine, an aciclovir metabolite, level was elevated. Treatment was changed to intravenous aciclovir titrated based on serum aciclovir levels with intravenous fluid supplementation to good effect. Regular monitoring of renal function and ample fluid intake are important when high doses of aciclovir/valaciclovir are used, even in patients with no previous history of renal failure. Monitoring of serum aciclovir level is useful in those with renal impairment to titrate doses, and high-dose oral valaciclovir should be used with caution.

Neurocysticercosis: local and systemic immune-inflammatory features related to severity

Neurocysticercosis (NC) is caused by the establishment of Taenia solium cysticerci in the central nervous system. Previous studies have established that neuroinflammation plays a key role in the severity of the disease. However, the relationship between peripheral and local immune response remains inconclusive. This work studies the peripheral and local immune-inflammatory features and their relationships, toward the identification of potential peripheral immunologic features related to severity. A panel of cytokines was measured in paired cerebrospinal fluid (CSF) and in the supernatant of antigen-specific stimulated peripheral blood mononuclear cells samples (SN) in a total of 31 untreated inflammatory and non-inflammatory NC patients. Increased clinical and radiologic severity was associated with an increased cerebrospinal fluid cell count. A peripheral proliferative depression that negatively correlates with CSF cellularity and TNFα and that positively correlates with SN IL5 was observed in severe NC patients. These results provide evidences to support the systemic proliferative response as a biomarker to monitor the level of neuroinflammation, of possible value in the patients' follow-up during treatment.

Human Neurocysticercosis: Comparison of Different Diagnostic Tests Using Cerebrospinal Fluid

Neurocysticercosis (NC), caused by the larval stage of Taenia solium, is one of the most common parasitic diseases of the central nervous system. The diagnosis of NC is mostly based on costly brain neuroimaging (computed tomography and/or nuclear magnetic resonance), which is rarely accessible in most affected areas. The most sensitive and specific tools for NC diagnosis are imagery techniques. The identification of specific antibodies and antigens is currently used only to support NC diagnosis due to their limited specificity and sensitivity. This study was performed to compare immunodiagnostic assays (antibody detection by enzyme-linked immunosorbent assay [ELISA] and enzyme-linked immunoelectrotransfer blotting [EITB] and HP10 antigen detection by ELISA) with the detection of parasite DNA by PCR amplification of a repetitive element of the parasite genome in the cerebrospinal fluid (CSF) of 121 radiologically and clinically characterized NC patients. Patients were divided into six groups according to the stage of the parasites and their localization. The CSF cellularity of each patient was also recorded. When all patients were considered, PCR exhibited the highest sensitivity (95.9%) and variable specificity (80% or 100%) depending on the controls used. The sensitivities of antibody detection by ELISA and EITB were not significantly different, and ELISA identified HP10 antigen mostly when vesicular cysticerci were located in the subarachnoideal basal cisterns. These results can help in the selection of different individual assays or combinations of assays to be used in NC diagnosis according to different requirements.

Changes in B- and T-Lymphocyte and Chemokine Levels With Rituximab Treatment in Multiple Sclerosis

B cells are implicated in the pathogenesis of multiple sclerosis. A beneficial effect of B-cell depletion using rituximab has been shown, but the complete mechanism of action for this drug is unclear. To determine the relationship between T and B cells and changes in cerebrospinal fluid (CSF) chemokine levels with rituximab, a monoclonal antibody that targets CD20. Phase 2 trial of rituximab as an add-on therapy. The John L. Trotter Multiple Sclerosis Center, Washington University. Participants and Intervention Thirty subjects who had relapsing-remitting multiple sclerosis with clinical and magnetic resonance imaging activity despite treatment with an immunomodulatory drug received 4 weekly doses of rituximab (375 mg/m(2)). Lumbar puncture was performed before and after rituximab infusions in 26 subjects. Levels of B and T lymphocytes in the CSF were enumerated by flow cytometry, and chemoattractant levels were measured by enzyme-linked immunosorbent assay. After rituximab administration, CSF B-cell levels were decreased or undetectable in all subjects, and CSF T-cell levels were reduced in 21 subjects (81%). The mean reduction in CSF cellularity was 95% for B cells and 50% for T cells. After rituximab infusion, CSF CXCL13 and CCL19 levels decreased (P = .002 and P = .03, respectively). The proportional decline in CSF T-cell levels correlated with the proportional decrease in CXCL13 levels (r = 0.45; P = .03), suggesting a possible relationship. The CSF IgG index, IgG concentration, and oligoclonal band number were unchanged following treatment. In subjects with multiple sclerosis, B cells are critical for T-cell trafficking into the central nervous system and may alter the process by influencing chemokine production within the central nervous system.

Influence of neurotoxoplasmosis characteristics on real-time PCR sensitivity among AIDS patients in Brazil

Cerebral toxoplasmosis among individuals with AIDS may be difficult to diagnose and needs to be differentiated from other neurological diseases. A validation study was performed on real-time PCR for detecting the B1 gene of Toxoplasma gondii in the blood and cerebrospinal fluid (CSF) of AIDS patients with cerebral toxoplasmosis. The study included 135 AIDS patients divided into two groups: Group I comprised 85 patients with neurotoxoplasmosis; and Group II comprised 50 patients with non-toxoplasmic neurological diseases. Real-time PCR on blood showed a sensitivity of 1.5%, specificity of 100.0%, positive predictive value (PPV) of 100.0% and negative predictive value (NPV) of 36.5%. CSF testing produced better results, with a sensitivity of 35.3%, specificity of 100.0%, PPV of 100.0% and NPV of 44.7%. The group presenting with pleocytosis and four or more encephalic lesions was associated with greater CSF positivity on PCR. In conclusion, real-time PCR on blood was not useful for diagnosis. CSF testing showed low sensitivity but high specificity. Greater numbers of lesions and greater CSF cellularity may improve the sensitivity of the method.

Infectious inflammation of the CNS involves activation of mitogen-activated protein kinase and AKT proteins in CSF in humans

The mitogen-activated protein kinases (MAPKs) and the AKT are interacting proteins that serve as transmitters of numerous extracellular signals to their intracellular targets, thereby regulating many cellular processes, such as proliferation, differentiation, development or stress responses. Whereas a large amount of information about the MAPKs/AKT participation in biological processes is available, less is known about their role in human diseases. We postulated that the MAPKs/AKT could be involved in inflammatory processes of the central nervous system (CNS) in humans and we investigated the CSF of 12 patients with viral infection of the CNS for the presence of the distinct components of these cascades. The cerebrospinal fluid (CSF) of 18 individuals who underwent a lumbar puncture for diagnostic purposes served as controls. Six patients with inflammatory disease of the CNS revealed the presence of activated ERK. In five patients p38MAPK was detected, in three in its activated form. The activity of AKT could be demonstrated in four patients. JNK was not found. None of the control patients showed the presence of MAPK enzymes. The mean CSF cellularity was higher in MAPK-positive than in MAPKnegative patients. There was no difference in mean age or gender between the patients and controls, or between the MAPK- and AKT-positive or -negative patients. Our work demonstrates that the MAPK and AKT cascades might participate in inflammatory processes of the CNS. As selective inhibitors of the MAPKs are available, their application in the future might reduce an inappropriate inflammatory response and thus limit brain damage in severe cases of meningoencephalitis.

Expression of neurotrophic factors in cerebrospinal fluid and plasma of children with viral and bacterial meningoencephalitis.

To evaluate the expression of neurotrophic factors (nerve growth factor (NGF), brain-derived neurotrophic factor (BDNF), glial-derived neurotrophic factor (GDNF)) and their association with the clinical-radiological characteristics and outcome of children with viral and bacterial meningoencephalitis (ME). Prospective observational clinical study performed on 13 children with ME and 12 controls with non-inflammatory obstructive hydrocephalus. Neurotrophic factor levels in the cerebro-spinal fluid (CSF) and plasma were measured using an immunoenzymatic assay. High levels of NGF and BDNF were demonstrated in all patients, while GDNF levels did not undergo significant variations. NGF expression in the CSF was higher in viral ME than in bacterial ME and was correlated with CSF cellularity (particularly mononuclear cells). BDNF expression in the CSF was higher in bacterial ME than in viral ME and was correlated with CSF cellularity and blood platelet count. No relationships were noted between CSF protein or serum C-reactive protein levels and the expression of neurotrophic factors. Regarding clinical and radiological features, elevated NGF/BDNF levels in the CSF correlated with higher incidence of seizures and prolonged comatose state and with specific radiological lesions. No correlation was found between NGF/BDNF levels and final outcome. The variations in neurotrophic factor levels may reflect an endogenous attempt at neuroprotection against biochemical and molecular changes during both viral and bacterial ME. The expression of these factors is likely to play a neuro-immunomodulatory or neurosurvival role in ME infections.