Cerebrospinal Fluid Gram Stain Research Articles

HSV-2 Associated Meningitis Case: A Challenging Diagnosis in An Immunocompetent Woman

Herpes simplex virus type-2 (HSV-2) associated aseptic meningitis is rarely seen in healthy individuals. Herein, we report a rare case of meningitis, associated with HSV-2, without the presence of genital lesions. A healthy, 40-year-old female was presented to the emergency service with unremitting headache, vomiting and nausea. Her cerebrospinal fluid (CSF) revealed elevated protein level of 308,2 mg/dL, high leukocyte cell count of 1,118,000 cells/µL with 98% lymphocytes and 2% polymorphonuclear neutrophils (PMNs). The bacterial culture and gram staining of CSF were negative. Real-time quantitative polymerase chain reaction (RT-qPCR) CSF analysis indicated the presence of HSV-2. The cranial MRI revealed meningeal contrast enhancement. The patient was administered acyclovir for 10 days during her hospital stay and she was discharged without any neurological sequela. The patient has a history of herpes infection. This case report shows that HSV-2 meningitis can occur in immunocompetent individuals via re-activation and should always be considered by the clinicians even in the absence of genital lesions.

Nosocomial outbreaks of aseptic meningitis: A public health concern

Nosocomial outbreaks of aseptic meningitis: A public health concern

Leptomeningeal carcinomatosis in a patient with recurrent unresectable squamous cell carcinoma of the retromolar trigone—a brief report

BackgroundThe reported incidence of leptomeningeal carcinomatosis is 3–8% in patients with solid tumours. More commonly, it has been described in the setting of advanced cancers of the lung, breast and malignant melanoma.Case presentationA 50-year-old diabetic patient with recurrent unresectable squamous cell carcinoma (SCC) of the right retromolar trigone (rT4bN0M0) presented with severe low backache and weakness in bilateral lower limbs 20 days after the completion of concurrent chemoradiotherapy. Contrast-enhanced MRI of the spine showed multiple nodular enhancing leptomeningeal lesions at the lumbar level and an intramedullary T2/FLAIR-hyperintense longitudinal lesion involving the central cord from C2 to C7 vertebral levels, suggestive of leptomeningeal metastases. Cerebrospinal fluid (CSF) analysis revealed pleocytosis, elevated protein and markedly decreased glucose. The CSF cytology revealed scattered large atypical cells, suspicious for metastasis. Non-contrast MRI of the brain showed a T2/FLAIR-hyperintense lesion involving the right caudate nucleus suggestive of either an acute infarct with haemorrhagic transformation or a haemorrhagic brain metastasis. During assessment, he had high-grade fever and was started on empirical intravenous antibiotics (ceftriaxone, vancomycin and subsequently meropenem) in line with the management for acute bacterial meningitis. Gram staining of CSF did not demonstrate the presence of any bacteria and the specimen was sterile on culture. He did not respond to empirical antibiotics, had a progressive downhill course and eventually died due to aspiration pneumonia.ConclusionThis brief report highlights the importance of awareness of leptomeningeal carcinomatosis as a possible cause of backache with sensorimotor deficit and autonomic dysfunction in a previously treated case of head and neck SCC.

A Daily Operational Huddle and a Real-Time Communication Application Improve Efficiency of Laboratory Processes.

Clinical laboratory processes that require cooperation among geographically distinct sections often face challenges. We describe these challenges as related to the Gram staining of cerebrospinal fluid, a key test in the management of patients with suspected central nervous system infections, and our attempts to improve quality outcomes. To evaluate multiple tools and strategies for their effectiveness in optimizing the turnaround time of tests sharing a specimen or workflow. Over the course of 5 years, the turnaround time of cerebrospinal fluid Gram stain was studied at one of the largest children's health systems in the United States. Baseline data showed suboptimal compliance to targeted turnaround times. A conventional approach to process standardization and 2 innovative tools that facilitate horizontal integration were applied to the main campus laboratory as follows: a daily operational huddle and a novel electronic communication application that was interfaced with the laboratory information system. Turnaround time and its variation were assessed. Two other hospital laboratories within the health system that did not undergo these quality interventions served as controls. Standardization of processes reduced the variability of turnaround time but only minimally shortened it. In contrast, an interteam daily huddle that monitored key quality metrics together with the communication application improved turnaround time significantly and sustainably. Communication strategies involving a physical or virtual gathering of laboratory representatives encourage horizontal communication and improve turnaround times. These tools are generally applicable and could be used to improve other processes in healthcare, especially those where a workflow is shared between 2 geographically distinct areas of a health system.

Performance of the Modified Boston and Philadelphia Criteria for Invasive Bacterial Infections.

The ability of the decades-old Boston and Philadelphia criteria to accurately identify infants at low risk for serious bacterial infections has not been recently reevaluated. We assembled a multicenter cohort of infants 29 to 60 days of age who had cerebrospinal fluid (CSF) and blood cultures obtained. We report the performance of the modified Boston criteria (peripheral white blood cell count [WBC] ≥20 000 cells per mm3, CSF WBC ≥10 cells per mm3, and urinalysis with >10 WBC per high-power field or positive urine dip result) and modified Philadelphia criteria (peripheral WBC ≥15 000 cells per mm3, CSF WBC ≥8 cells per mm3, positive CSF Gram-stain result, and urinalysis with >10 WBC per high-power field or positive urine dip result) for the identification of invasive bacterial infections (IBIs). We defined IBI as bacterial meningitis (growth of pathogenic bacteria from CSF culture) or bacteremia (growth from blood culture). We applied the modified Boston criteria to 8344 infants and the modified Philadelphia criteria to 8131 infants. The modified Boston criteria identified 133 of the 212 infants with IBI (sensitivity 62.7% [95% confidence interval (CI) 55.9% to 69.3%] and specificity 59.2% [95% CI 58.1% to 60.2%]), and the modified Philadelphia criteria identified 157 of the 219 infants with IBI (sensitivity 71.7% [95% CI 65.2% to 77.6%] and specificity 46.1% [95% CI 45.0% to 47.2%]). The modified Boston and Philadelphia criteria misclassified 17 of 53 (32.1%) and 13 of 56 (23.3%) infants with bacterial meningitis, respectively. The modified Boston and Philadelphia criteria misclassified a substantial number of infants 29 to 60 days old with IBI, including those with bacterial meningitis.

Cerebrospinal Fluid Profiles of Infants ≤60 Days of Age With Bacterial Meningitis.

We aimed to describe the cerebrospinal fluid (CSF) profiles of infants ≤60 days old with bacterial meningitis and the characteristics of infants with bacterial meningitis who did not have CSF abnormalities. We included infants ≤60 days old with culture-positive bacterial meningitis who were evaluated in the emergency departments of 11 children's hospitals between July 1, 2011, and June 30, 2016. From medical records, we abstracted clinical and laboratory data. For infants with traumatic lumbar punctures (CSF red blood cell count of ≥10 000 cells per mm3), we used a red blood cell count/white blood cell (WBC) count correction factor of 1000:1 to determine the corrected CSF WBC count. We calculated the sensitivity for bacterial meningitis of a CSF Gram-stain and corrected CSF pleocytosis (≥16 WBCs per mm3 for infants ≤28 days old and ≥10 WBCs per mm3 for infants 29-60 days old). Among 66 infants with bacterial meningitis, the sensitivity of a CSF Gram-stain was 71.9% (95% confidence interval [CI]: 59.2-82.4), and the sensitivity of corrected CSF pleocytosis was 80.3% (95% CI: 68.7-89.1). The sensitivity of combining positive Gram-stain results with corrected CSF pleocytosis was 86.4% (95% CI: 75.7-93.6). Of 9 infants with meningitis who had a negative Gram-stain result and no corrected CSF pleocytosis, 8 (88.9%) had either an abnormal peripheral WBC count (>15 000 or <5000 cells per μL) or bandemia >10%. Most infants ≤60 days old with bacterial meningitis have CSF pleocytosis or a positive Gram-stain result. Infants with no CSF pleocytosis and a negative Gram-stain result are unlikely to have bacterial meningitis in the absence of other laboratory abnormalities.

Listeria

Listeria

Epidemiological surveillance of herpes viral encephalitis in Cordoba, Colombia.

Objective To establish an epidemiological surveillance of viral herpes encephalitis in major hospitals of Monteria, Cordoba. Methods From September 2009 to December 2011, a descriptive study of cases of viral encephalitis was made in three hospitals in the city of Monteria. Cerebrospinal fluid (CSF) samples from 118 patients were included in the study. Clinical aspects, as well as cytochemical and microbiological analysis (Gram stain and culture) of CSF, were used for selecting the patients. Virus detection was performed by using multiplex nested PCR for Herpes simplex virus 1 and 2, Epstein Barr virus, Cytomegalovirus and Varicella zoster virus. Results Viral DNA of herpesvirus was detected in the CSFs of 30 (25.4 %) participants, as follows: 22 (18.6 %) Herpes simplex 1 and 2 viruses, 4 (3.3 %) Cytomegalovirus and 1 (0.8 %) Varicella zoster virus. Co-infections were observed in 3 patients (2.5 %), 1 case by HSV-VZV and 2 cases by CMV/HSV. The clinical manifestations of the patients included: headache (18.6 %), fever (14.4 %), asthenia (10.1 %), seizures (9.3 %), vomiting (8.4 %), and stiff neck (5.9 %). Thirty percent of the patients also had HIV-AIDS. A case fatality rate of 20 % was observed for the patients. Conclusions This paper shows that herpesvirus is a cause of infection of the CNS in patients from Cordoba. This study contributes to the epidemiology of encephalitis, as well as to patient management.

Incidence of acute pyogenic meningitis in infants and children

118 cases of acute pyogenic meningitis were admitted in the department of Paediatrics Liaquat Medical College, Hospitals Jamshoro/ Hyderabad in one year period with prevalence of 1.57% of the total admissions. After selecting the cases on clinical ground we proceeded further to confirm the diagnosis by cerebrospinal fluid cytochemical analysis, gram staining, culture and sensitivity and detection of the antigen of micro-organism by latex agglutination test.

Epidemiology of meningitis with a negative CSF Gram stain: under-utilization of available diagnostic tests.

Meningitis with a negative cerebrospinal fluid Gram stain (CSF-GS) poses a diagnostic challenge as more than 50% of patients remain without an aetiology. The introduction of polymerase chain reaction (PCR) and arboviral serologies have increased diagnostic capabilities, yet large scale epidemiological studies evaluating their use in clinical practice are lacking. We conducted a prospective observational study in New Orleans between November 1999 and September 2008 (early era) when PCR was not widely available, and in Houston between November 2008 and June 2013 (modern era), when PCR was commonly used. Patients presenting with meningitis and negative CSF-GS were followed for 4 weeks. All investigations, PCR used, and results were recorded as they became available. In 323 patients enrolled, PCR provided the highest diagnostic yield (24·2%) but was ordered for 128 (39·6%) patients; followed by serology for arboviruses (15%) that was ordered for 100 (31%) of all patients. The yield of blood cultures was (10·3%) and that of CSF cultures was 4%; the yield for all other tests was <10%. Overall, 65% of the patients remained without a diagnosis at 4 weeks: 72·1% in early era vs. 53·4% (P < 0·01) in modern era; this change was attributed to diagnosing more viral pathogens, 8·3% and 26·3% (P < 0·01), respectively. The introduction of PCR and arboviral serologies has improved the yield of diagnosing patients with meningitis and a negative CSF-GS, but both tests are being under-utilized.

Chemical Meningitis after Spinal or Epidural Anesthesia

Background: Chemical meningitis results from foreign materials causing inflammation to the meninges covering the brain and spinal cord. Cerebrospinal fluid (CSF) study of chemical meningitis mimics bacterial meningitis. Case Report: We report three cases of chemical meningitis after spinal or epidural anesthesia with mepivacaine or bupivacaine. They experienced mental change or seizure. The results of CSF study revealed increased polymorphonuclear cell count and protein level and decreased glucose concentration. Gram staining and bacterial culture of CSF were all negative. We started empirical antibiotics and corticosteroids immediately and the patients were rapidly improved. Concclusion: The chemical meningitis should be differentiated in bacterial meningitis because bacterial meningitis is life-threatening and requires immediate antibiotic therapy. Chemical meningitis dramatically responds to steroid. The results of CSF study improved shortly after steroid administration. Key Words: Chemical meningitis; Epidural anesthesia; Spinal

Chemical Meningitis after Spinal or Epidural Anesthesia

Background: Chemical meningitis results from foreign materials causing inflammation to the meninges covering the brain and spinal cord. Cerebrospinal fluid (CSF) study of chemical meningitis mimics bacterial meningitis. Case Report: We report three cases of chemical meningitis after spinal or epidural anesthesia with mepivacaine or bupivacaine. They experienced mental change or seizure. The results of CSF study revealed increased polymorphonuclear cell count and protein level and decreased glucose concentration. Gram staining and bacterial culture of CSF were all negative. We started empirical antibiotics and corticosteroids immediately and the patients were rapidly improved. Conclusion: The chemical meningitis should be differentiated in bacterial meningitis because bacterial meningitis is life-threatening and requires immediate antibiotic therapy. Chemical meningitis dramatically responds to steroid. The results of CSF study improved shortly after steroid administration. J Neurocrit Care 2014;7(1):40-43

Adult pneumococcal meningitis presenting with normocellular cerebrospinal fluid: two case reports

IntroductionNormocellular bacterial meningitis is rarely observed in adult patients. We here report two cases of adult patients with pneumococcal meningitis with a normal cerebrospinal fluid leukocyte count and review eight other cases in the literature.Case presentationCase 1 was a 34-year-old Japanese woman with a history of splenectomy who presented with pyrexia, nausea, headache, and loss of hearing in her right ear. She was in a hypotensive state with no neck stiffness and had a normal mental status at the initial presentation. She became progressively disoriented during out-patient management. A cerebrospinal fluid examination showed a normal leukocyte count despite the presence of Streptococcus pneumoniae, which was detectable with Gram staining. She survived after prompt treatment, but her hearing loss remained. Case 2 was a 62-year-old Japanese man with a history of laryngeal cancer who was transferred to our emergency department after an acute onset of delirium and rapid progression to septic shock. As in Case 1, cerebrospinal fluid examination showed a normal leukocyte count despite the presence of S. pneumoniae, which was detectable with Gram staining. Within 1 hour of arrival, he developed hypotension and subsequent cardiopulmonary arrest, and resuscitation was unsuccessful.ConclusionsThese cases imply that a normal leukocyte count in the cerebrospinal fluid does not exclude the possibility of bacterial meningitis. Gram staining of cerebrospinal fluid and immediate administration of antibiotics should be performed in all patients with suspected bacterial meningitis.

Serum Procalcitonin level and other biological markers in children with bacterial or non-bacterial meningitis

Acute meningitis in children is predominantly aseptic and does not require specific treatment. However, meningitis has a bacterial origin in about 5% of patients and carries a risk of fatal outcome or severe neurological sequelae, especially when diagnosis and antibiotic administration are delayed. The objective of the present study was to evaluate the value of determining procalcitonin levels to discriminate between bacterial and non-bacterial meningitis in young children or infants and describe the variation in serum PCT levels over time during the treatment of meningitis. A total of 50 children with meningitis admitted to a University Hospital were followed in this prospective study. Cerebrospinal fluid (CSF) and serum levels of procalcitonin were measured. The diagnosis of meningitis was based on clinical findings, gram staining, culture, and chemical analysis of CSF. Twenty-five children were diagnosed as bacterial meningitis and the other 25 children as non-bacterial Meningitis.The mean procalcitonin level on admission in patients with acute bacterial meningitis was 18.3 ng/mL, and the lower level was 4.6 ng/mL, while the higher level in patients with non-bacterial meningitis was 0.62 ng/mL (mean level, 0.38 ng/mL). It is clear from the range of serum procalcitonin level that, there are no overlapping values seen for serum procalcitonin in both groups.serum PCT levels can be used in the early diagnosis of acute bacterial meningitis and is more valuable than the other predictive marker. Similarly, they may be useful adjuncts in differential diagnosis of bacterial and non-bacterial meningitis and diminishing the value of 2 nd lumbar puncture performed 48-72 hours after admission to assess treatment efficacy.

Treatment and Microbiology of Repeated Cerebrospinal Fluid Shunt Infections in Children

A small group of children have second and even more cerebrospinal fluid (CSF) shunt infections (SIs). We sought to describe the treatment approaches used for, and the microbiology of, repeated SIs. The study population included 31 children with second shunt infection (SI-2) among those undergoing initial CSF shunt placement and treatment for initial infection at Primary Children's Medical Center. CSF SI was defined as follows: (1) presence of bacteria in Gram stain and/or culture of CSF, wound, and/or pseudocyst; (2) visible hardware; (3) abdominal pseudocyst; or (4) presence of bacteria in a blood culture in children with a ventriculoatrial shunt. Infection rates were generated using per-patient denominators, and the concordance of organisms across infections was summarized. Of the 31 children with SI-2, most were less than 6 months of age at initial shunt placement (81%), male (77%), and with ventriculoperitoneal shunts (71%). Of total, 18 developed SI-3 and 8 developed SI-4. Infection rates were 60% (95% confidence interval [CI]: 42%-75%, n = 18/30) for SI-3 and 47% (95% CI: 26%-69%, n = 8/17) for SI-4. The median time to SI-3 was 477 days (range, 5-828) and to SI-4 it was 2137 days (range, 9-2137). Gram-positive organisms predominated (93% of SI-2, 94% of SI-3). The majority of SI-2 demonstrated Gram-stain concordance with both the initial (first) SI (58%, 95% CI: 41%-74%) and with the following (third) SI (78%, 95% CI: 55%-91%). Children with SI-2 experience high subsequent reinfection rates with a long time to reinfection.

Streptococcus suisMeningitis without History of Animal Contact, Italy

<i>Streptococcus suis</i>Meningitis without History of Animal Contact, Italy

Streptococcus suisMeningitis, United States

<i>Streptococcus suis</i>Meningitis, United States

Meningitis due toRhodotorula glutinisin an HIV infected patient

Rhodotorula spp, though considered a common saprophyte, recently has been reported as causative agent of opportunistic mycoses. We present a case of meningitis in an immunocompromised human immunodeficiency virus infected patient who presented with longstanding fever. He was diagnosed as a case of chronic meningitis. Diagnosis was confirmed by cell cytology, India ink preparation, Gram staining and culture of cerebrospinal fluid (CSF) sample. CSF culture grew Rhodotorula glutinis. Therapy with amphotericin B was successful in eliminating the yeast from CSF and the patient was discharged after recovery.

Evaluation of a real-time polymerase chain reaction assay for the diagnosis of pneumococcal and meningococcal meningitis in a tertiary care hospital

This study evaluated the performance of a real-time polymerase chain reaction (PCR) assay in comparison with Gram staining and culture of cerebrospinal fluid for the diagnosis of meningococcal and pneumococcal meningitis in patients with suspected bacterial meningitis. The sensitivity for detection of Neisseria meningitidis in cerebrospinal fluid was 87% (20/23) for the PCR assay, 27% (6/22) for Gram staining, and 17% (4/23) for culture. The sensitivity for detection of Streptococcus pneumoniae in cerebrospinal fluid was 100% (14/14) for the PCR assay, 62% (8/13) for Gram staining, and 36% (5/14) for culture. Therefore, we recommend that real-time PCR of cerebrospinal fluid for detection of N. meningitidis and S. pneumoniae become a part of the routine diagnostic procedure for patients with suspected bacterial meningitis.

Diagnosis of Streptococcus pneumoniae meningitis by polymerase chain reaction amplification of the gene for pneumolysin

Diagnosis of bacterial meningitis has long been based on classical methods of Gram stain, serological tests, and culture of cerebrospinal fluid (CSF). The performance of these methods, especially culture and direct smear is thwarted by failure to detect bacteria following administration of antimicrobial agents and reluctance to performance lumbar punctures at admission. Indeed, patients with meningitis frequently receive antibiotics orally or by injection before the diagnosis is suspected or established Thus an alternative method has become necessary to help clinicians and epidemiologists to management and control of bacterial meningitis. We evaluate the application of a polymerase chain reaction-based (PCR) assay for amplification of pneumolysin gene (ply) to diagnosis of Streptococcus pneumoniae meningitis. The PCR assay sensitivity for CSF was 96% (95% confidence interval, CI, 90-99%) compared to a sensitivity of 59% for culture (95% CI 49-69%), 66% for Gram stain (95% CI 56-74%), and 78% for latex agglutination test (95% CI 69-86%); PCR specificity was 100% (95% CI 83-100%). PCR results were available within 4 h of the start of the assay. This molecular approach proved to be reliable and useful to identify this bacterium compared with other classical laboratory methods for identification of bacterial meningitis pathogens.