Initial Lumbar Puncture Research Articles

Contribution de l'analyse du LCR au diagnostic et au suivi évolutif d'une méningite tuberculeuse

We report the case of a patient who was admitted to the hospital because of language and mental confusion. His initial lumbar puncture revealed 193 leukocytes per mm3 mostly lymphocytes (95%), no red blood cells, high protein content (1.20 g/L) and normal glucose level. The antibiotic therapy by amoxicilline and aciclovir during 6 days led to complete clinical recovery in a week. A CT scan of the cerebrum showed no abnormalities, nor did chest radiography. Twelve days after discharge, the patient was rehospitalized because of a meningitis syndrome. On lumbar puncture, the CSF analysis revealed 280 leukocytes/mm3, 56% lymphocytes, 10% monocytes and 34% polymorphonuclear cells. CSF chemistry showed a protein level of 3.54 g/L, and a glucose level depressed at 0.9 mmol/L. Because of the clinical symptoms and CSF abnormalities, the patient received aciclovir, amoxicilline vancomycine, isoniazide, rifampicine, pyrazinamide and ethambutol. Screening for infections gave negative results until the 37th day, when the diagnosis of tuberculous meningitis was confirmed by the isolation of Mycobacterium tuberculosis in the repetitive CSF. Antituberculous therapy was expanded. According the Reiber diagrams, intrathecal IgG synthesis was negative at day 25, day 37, month 4, month 9, month 17. Intrathecal IgM synthesis was elevated at day 12 and day 25 and intrathecal IgA synthesis at day 25. Improvement of the patient's conditions by tuberculosis treatment was obtained in 17 months. Cerebrospinal fluid analysis has been the basis for the diagnosis and follow-up of tuberculous meningitidis.

Significance of Initial Lumbar Puncture on Day8 of Remission Induction Therapy in Childhood Acute Lymphoblastic Leukemia: The Results from the Tokyo Children's Cancer Study Group L99-15 Protocol.

Traumatic lumbar puncture with the presence of leukemic blasts (TLP+) in the cerebrospinal fluid (CSF) has been shown to adversely affect the outcome of children with acute lymphoblastic leukemia (ALL). In the Tokyo Children's Cancer Study Group (TCCSG), we adopted a strategy to defer the initial lumbar puncture (LP) and intrathecal (IT) chemotherapy until 1 week after prednisolone (PSL) monotherapy so that circulating blasts were substantially reduced when the initial LP/IT was performed. The result of L89-12 study was previously reported, in which the incidence of TLP+ was significantly diminished but the impact on the rate of central nervous system (CNS) relapse was not determined because over 80% of patients received cranial irradiation (CRT). We analyzed the result of L99-15 study in which CRT was employed in only 16% of patients. Seven hundred and fifty-five children with newly diagnosed ALL were enrolled onto the TCCSG L99-15 study between April 1999 and June 2003. Patients received the initial IT administration of methotrexate, hydrocortisone, and cytarabine on day 8 following PSL monotherapy. Patients with CNS2 (<5 leukocytes/microL of CSF with leukemic blasts) received additional IT therapy. Patients with CNS3 (>5 leukocytes/microL of CSF with leukemic blasts) or CNS1s (negative CSF finding, with cranial nerve palsy) received additional IT therapy and CRT. Patients with TLP+ did not require any reinforcement of CNS-directed therapy. The frequency of CNS1s, CNS2, CNS3, or TLP+ was 0.5%, 1.1%, 0.5% and 0.8%, respectively. These figures were almost equal to the results from L89-12 study and much lower than those reported by other study groups such as BFM. Of 22 patients (2.9% of all) classified as CNS positive group (CNS-1s, -2, -3 and TLP+), only one patient had a CNS relapse concurrently with bone marrow (BM) relapse, whereas 22 of 723 patients classified as CNS negative had CNS relapse (isolated 12, combined with BM 10). Overall, 4-year event-free survival rate was 78.2 +/− 1.6%, and 4-year cumulative incidence of overall CNS relapse was 3.3 +/− 0.7%. Our strategy may underestimate the frequency of CNS leukemia at diagnosis, however, unnecessary intensification of CNS treatment may be avoided while overall CNS relapse rate is quite low in spite of restricted indication for cranial irradiation.

Positive Cerebrospinal Fluid Cultures After Normal Cell Counts Are Contaminants

Previous literature on meningitis reports that cerebrospinal fluid (CSF) culture contaminants are threefold more common than true pathogens. Clinical follow-up of patients with CSF contaminants is costly, time-consuming, and potentially unnecessary. In this study, we hypothesized that, in immunocompetent Emergency Department (ED) patients with normal CSF cell counts and negative Gram stains, all positive bacterial cultures are contaminants and patient follow-up is unnecessary. We retrospectively reviewed 191 ED charts of patients with positive CSF cultures over 5 years. We abstracted lumbar puncture results, disposition, and follow-up activities, and determined monetary charges. There were 137 patients (72%) who met inclusion criteria with CSF white blood cells ≤7 μL, negative Gram stain, and immunocompetence. Ninety-eight were discharged from the ED and 39 were admitted to the hospital for reasons other than meningitis. All 137 positive cultures were found to be contaminants, with coagulase-negative staphylococci found most commonly. Follow-up activities included telephone calls (49%), repeat ED visits (13%), repeat lumbar punctures (9%), unnecessary antibiotic treatment (6%), and hospitalizations (6%), generating $55,000 in charges. Follow-up may be unnecessary in ED patients with positive bacterial CSF cultures who were discharged from the ED, if their initial lumbar punctures were normal.

Neurosyphilis in a clinical cohort of HIV-1-infected patients

To describe the risk factors, clinical presentation, and long-term follow up of patients enrolled in a clinical cohort of HIV-infected patients who were diagnosed and treated for neurosyphilis. Comprehensive demographic, clinical, and therapeutic data were collected prospectively on all patients between 1990 and 2006. Patients were diagnosed with neurosyphilis if they had positive syphilis serologies and any of the following: (a) one or more cerebrospinal fluid abnormalities on lumbar puncture [white blood cells >10/microl; protein >50 mg/dl; reactive venereal diseases research laboratory], (b) an otherwise unexplained neurological finding. Of 231 newly diagnosed syphilis cases, 41 neurosyphilis cases met entry criteria (median age 38.6 years, 79.1% male). Risk factors for neurosyphilis included a CD4 cell count of less than 350 cells/ml at the time of syphilis diagnosis (odds ratio: 2.87; 95% confidence interval: 1.18-7.02), a rapid plasma regain titer >1: 128 (2.83; 1.11-7.26), and male sex (2.46; 1.06-5.70). Use of any highly active antiretroviral therapy before syphilis infection reduced the odds of neurosyphilis by 65% (0.35; 0.14-0.91). Sixty-three percent of cases presented with early neurosyphilis and the median time to neurosyphilis diagnosis was 9 months. Symptomatic patients had more cerebrospinal fluid abnormalities on initial lumbar puncture than asymptomatic patients (P = 0.01). Follow-up lumbar puncture within 12 months revealed that only 38% had resolution of all cerebrospinal fluid abnormalities. At 1 year, 38% had persistence of their major symptom despite adequate treatment for neurosyphilis. Twelve of 41 (29%) patients were retreated for syphilis. Early neurosyphilis was common in this cohort. Highly active antiretroviral therapy to reverse immunosuppression may help mitigate neurological complications of syphilis.

Is the Combination of Negative Computed Tomography Result and Negative Lumbar Puncture Result Sufficient to Rule Out Subarachnoid Hemorrhage?

Current clinical practice assumes a negative computed tomography (CT) head scan result and a negative lumbar puncture result together are adequate to rule out subarachnoid hemorrhage in patients with acute headache. Our objective is to determine the sensitivity of a negative CT result combined with a negative lumbar puncture result to exclude subarachnoid hemorrhage. This prospective cohort study was conducted at 2 tertiary care emergency departments (EDs) during 3 years. We enrolled all patients who were older than 15 years, had a nontraumatic acute headache and normal neurologic examination result, and who had a CT head scan and a lumbar puncture if the CT result was negative (ie, no blood in the subarachnoid space). Patients were followed up with a structured telephone questionnaire 6 to 36 months after their ED visit and electronic hospital records review to ensure no missed subarachnoid hemorrhage. We calculated sensitivity, specificity, and likelihood ratios of the strategy of CT and then lumbar puncture for subarachnoid hemorrhage. Five hundred ninety-two patients were enrolled, including 61 with subarachnoid hemorrhage. The mean patient age was 43.6 years, with 59.1% female patients. All cases of subarachnoid hemorrhage were identified on initial CT or lumbar puncture. One patient without subarachnoid hemorrhage was subsequently diagnosed with cerebral aneurysm, requiring surgery. The strategy classified patients with subarachnoid hemorrhage with sensitivity, specificity, and positive and negative likelihood ratios (with 95% confidence intervals [CIs]) of 100% (95% CI 94% to 100%), 67% (95% CI 63% to 71%), 3.03 (95% CI 2.69 to 3.53), and 0. For diagnosis of subarachnoid hemorrhage or aneurysm, these were 98% (95% CI 91% to 100%), 67% (95% CI 63% to 71%), 2.98 (95% CI 2.63 to 3.38), and 0.02 (95% CI 0.00 to 0.17), respectively. To our knowledge, this is the largest prospective study evaluating the accuracy of a strategy of CT and lumbar puncture to rule out subarachnoid hemorrhage in alert ED patients with an acute headache. This study validates clinical practice that a negative CT with a negative lumbar puncture is sufficient to rule out subarachnoid hemorrhage.

Intermediate Dose Intravenous Methotrexate (MTX) Dramatically Reduces the Risk of Secondary Central Nervous System (CNS) Lymphoma.

Secondary CNS lymphoma (SCNSL) is a rare complication of diffuse large B cell non-Hodgkins lymphoma (DLBCL) which is almost universally fatal. Several groups have analyzed risk factors for the development of SCNSL and published risk estimates for both individual anatomic sites of DLBCL as well as combinations of clinical risk factors. Although the rates of SCNSL for all DLBCL patients range from 2.5% to 5% subgroups can be identified with risks as high as 33%. High risk scenarios where CNS prophylaxis is most commonly offered include either a combination of an elevated LDH and more than one extranodal site of disease, or disease involving the bone marrow, testicle, sinus, orbit, or a para-spinal location. The type of prophylaxis used varies widely from intrathecal to high-dose intravenous methotrexate as well as intrathecal use of cytarabine. Despite the advances made in the systemic therapy of DLBCL there is very limited data on the efficacy of these chemopreventive regimens in SCNSL. We undertook a retrospective review at our institution of all patients with DLBCL treated with inpatient intermediate dose methotrexate (3.5 grams per meter squared) followed by leucovorin rescue between 2002 and 2006 for CNS prophylaxis. We found 37 patients. Of 15 patients initially evaluated with diagnostic lumbar punctures (LP), no patient had a positive CSF cytology. The median age of the patients was 59 (26–79). The average IPI was 3. All patients were tested for HIV and 3 were found to be positive. The indications for CNS prophylaxis were primarily an elevated LDH and more than 1 extranodal site of disease (20) but also included patients with bone marrow (9), testicular (3), orbital (5), para-spinal (2) and sinus (6) involvement, with 6 patients having more than one site of involvement. All patients received an anthracycline containing chemotherapy regimen with curative intent. Thirty-six patients received rituximab. Patients received a median of 6 cycles of systemic chemotherapy and 3 courses of MTX given on day 15 of alternating cycles (usually 2, 4 and 6). In addition 2 patients received a single dose of 12 mg of intrathecal methotrexate at the time of their initial LP and 5 patients received intrathecal liposomal cytarabine. We calculated the expected number of cases of SCNSL using the estimates from van Besien et al. Blood ‘98, Hollender et al. Ann Onc ‘02, and Boehme et al. Ann Onc ‘06 as appropriate depending on the sites of disease for each patient. For this population the expected number of cases of SCNSL was 7.98 and the observed number of cases was 1 (p=.002 two-sided binomial probability). In this population of 37 patients with an elevated risk of SCNSL, the use of intravenous intermediate dose methotrexate substantially reduced their risk of this fatal complication.

Meningococcal meningitis and a negative cerebrospinal fluid: Case report and its medicolegal implications

A normal result on the initial cerebrospinal fluid (CSF) study has been traditionally used to exclude the potential diagnosis of bacterial meningitis. However, there have been a number of case studies of bacterial meningitis confirmed by CSF culture, in which an initial lumbar puncture yielded completely normal parameters. A review of the literature reports the frequency of this scenario to arise in 0.5% to 12% of cases. This might result in the delay of appropriate treatment for this potentially fatal condition. We report a 21-year-old female patient who presented with a clinical picture compatible with bacterial meningitis but with a normal initial CSF result. Neisseria meningitidis was later cultured from her CSF. The medicolegal aspects surrounding such a scenario, and its implications towards clinical practice are discussed. We conclude that an abnormal initial CSF study might indicate a diagnosis of bacterial meningitis but a normal result does not exclude it and should not delay early institution of appropriate antimicrobial therapy.

Post-transplant acute limbic encephalitis

Acute limbic encephalitis has been reported in the setting of treatment-related immunosuppression and attributed to human herpesvirus-6 (HHV6) infection. Clinical and laboratory features of the syndrome, however, have not been well characterized. We describe the clinical, EEG, MRI, and laboratory features of nine patients with acute limbic encephalitis after allogeneic hematopoietic stem cell transplantation (HSCT). To explore the relationship between HHV6 and this syndrome, we reviewed available CSF HHV6 PCR results from all HSCT patients seen at our center from March 17, 2003, through March 31, 2005. Patients displayed a consistent and distinctive clinical syndrome featuring anterograde amnesia, the syndrome of inappropriate antidiuretic hormone secretion, mild CSF pleocytosis, and temporal EEG abnormalities, often reflecting clinical or subclinical seizures. MRI showed hyperintensities within the uncus, amygdala, entorhinal area, and hippocampus on T2, fluid-attenuated inversion recovery (FLAIR), and diffusion-weighted imaging (DWI) sequences. CSF PCR assays for HHV6 were positive in six of nine patients on initial lumbar puncture. All patients were treated with foscarnet or ganciclovir. Cognitive recovery varied among long-term survivors. The one brain autopsy showed limbic gliosis and profound neuronal loss in amygdala and hippocampus. Among 27 HSCT patients with CSF tested for HHV6 over a 2-year period, positive results occurred only in patients with clinical limbic encephalitis. Patients undergoing allogeneic hematopoietic stem cell transplantation are at risk for post-transplant acute limbic encephalitis (PALE), a distinct neurologic syndrome. Treatment considerations should include aggressive seizure control and, possibly, antiviral therapy. PALE can be associated with the CSF presence of human herpesvirus-6, but the pathogenic role of the virus requires further exploration.

NEUROCUTANEOUS MELANOSIS ASSOCIATED WITH AUTOIMMUNE DIABETES MELLITUS

### Case report. A 12-year-old boy with multiple nevi presented with 6 months of polydipsia (>4 L/day), polyuria, and a 40-pound weight loss that progressed over weeks to intractable headache and vomiting. The patient subsequently developed ataxia, complex partial seizures, and encephalopathy. Medical history was significant for numerous (40 to 50) benign congenital nevi ranging in diameter from 1 to 10 cm. He did not have a previous diagnosis of neurocutaneous melanosis (NCM) or a history of CNS disease. The initial workup revealed hyperglycemia (random blood glucose of 400) and hemoglobin (Hgb) A1c 11.9%. Anti–glutamic acid decarboxylase (GAD) antibody was 2.1 U/mL (normal <0.1). There was diffuse leptomeningeal enhancement on MRI. Initial lumbar puncture revealed an opening pressure of 40 cm H2O, white blood cell count of 23, glucose 40, and protein 193. Cytology from the CSF demonstrated atypical melanocytes consistent …

Fulminant idiopathic intracranial hypertension

To describe the incidence and characteristics of acute and rapidly progressive visual loss in idiopathic intracranial hypertension (IIH). We reviewed the medical records of all patients with IIH seen at two institutions. "Fulminant IIH" was defined as the acute onset of symptoms and signs of intracranial hypertension (less than 4 weeks between onset of initial symptoms and severe visual loss), rapid worsening of visual loss over a few days, and normal brain MRI and MR venography (or CT venogram). Sixteen cases with "fulminant IIH" were included (16 women, mean age 23.8 years [range 14 to 39 years]). All were obese. One patient had iron-deficiency anemia, four had systemic hypertension, and none had known sleep apnea syndrome. Acute or subacute headache, nausea and vomiting, and visual loss were present in all patients. The first lumbar puncture performed for the diagnosis showed a mean CSF opening pressure of 54.1 cm H(2)O (range 29 to 60 cm H(2)O). In addition to the initial lumbar puncture, medical treatment included acetazolamide (1 to 2 g/day) in all patients, and IV methylprednisolone in four patients. Repeat lumbar punctures were performed in 11 of the 16 patients. Surgical treatment (optic nerve sheath fenestration in five cases, lumboperitoneal CSF shunting procedure in nine cases, and ventriculoperitoneal shunting procedure in two cases) was performed because of ongoing visual loss in all cases. The median delay between evaluation in neuro-ophthalmology and surgery was 3 days (range a few hours to 37 days). All patients reported dramatic improvement of headaches and vomiting following surgery. Visual function improved in 14 cases, although 8 patients (50%) remained legally blind. Visual fields remained severely altered in all cases. Severe and rapidly progressive visual loss suggests "fulminant idiopathic intracranial hypertension" and should prompt aggressive management. Urgent surgery may be required in these patients, and temporizing measures such as repeat lumbar punctures, lumbar drainage, and IV steroids considered.

Neonatal Candida meningitis: significance of cerebrospinal fluid parameters and blood cultures

The purpose of this study was to examine the frequency of normal cerebrospinal fluid (CSF) parameters in Candida meningitis and the proportion of candidemia associated with Candida meningitis. We evaluated the initial lumbar puncture results from infants discharged from 150 Neonatal Intensive Care Units between 1997 and 2004. Candida meningitis was diagnosed by a positive CSF culture or positive Gram stain for yeast. We calculated two-tailed P-values using non-parametric testing, Mann-Whitney, Kruskal-Wallis or Fisher's exact tests where appropriate. Twenty infants had culture-positive Candida meningitis. Normal CSF parameters were found in 43% (3/7) of the infants with Candida meningitis and only 37% (7/19) of them had positive blood cultures for Candida. Normal CSF parameters do not exclude the diagnosis of neonatal Candida meningitis. The majority of infants in this cohort with Candida meningitis did not have evidence of candidemia at the time of diagnosis.

CSF characteristics in early-onset multiple sclerosis

The authors studied CSF characteristics in 136 patients with multiple sclerosis (MS) with a disease onset before age 16. In the initial diagnostic lumbar puncture, CSF-pleocytosis was observed in 66%, blood-CSF barrier dysfunction in 13%, and oligoclonal IgG in 92% of the early-onset MS (EOMS) patients. CSF oligoclonal IgG supports the early diagnosis of MS in childhood with a sensitivity similar to adult-onset MS.

Meningitis in a newborn infant with urosepsis, negative blood cultures and initially normal cerebrospinal fluid findings

This case presentation supports the observation that initial cerebrospinal fluid findings can be normal in newborn infants with sepsis syndrome who then develop evidence for meningeal involvement. Therefore, if initial lumbar puncture results are negative, a repeat lumbar puncture is recommended to look for meningitis in newborns that are critically ill with sepsis syndrome.

Paediatric idiopathic intracranial hypertension

Aim: Idiopathic intracranial hypertension usually occurs in adults. The purpose of this study was to review paediatric idiopathic intracranial hypertension and determine the specific characteristics and outcome of the paediatric condition compared with adult idiopathic intracranial hypertension. Methods: Thirteen case notes were retrospectively reviewed (11 females, 2 males). The average presenting age was 13.5 years (range 10-17 years). Diagnosis of idiopathic intracranial hypertension followed exclusion of other neurological causes. Each patient underwent lull ophthalmic, orthoptic and neurological evaluation. Results: Three patients were asymptomatic whereas the remainder presented with symptoms including headaches, visual disturbances, lethargy, vomiting and nausea. Each patient had papilloedema. Initial lumbar puncture opening pressures ranged from 160 to 790 mmH2O. Orthoptic findings included concomitant esotropia, sixth, third and fourth nerve palsies. Visual fields were impaired in 9 cases. Treatment included prednisolone, acetazolumide, lumbar peritoneal shunting and optic nerve sheath fenestration. Conclusions: Visual fields were impaired in 9 patients despite absence of visual symptoms in 3. Medical treatment was usual although 3 patients required lumbar peritoneal shunting and I required optic nerve sheath fenestration to arrest visual deterioration. The paediatric visual outcome of idiopathic intracranial hypertension reflects the adult condition. Paediatric patients require the same evaluation, follow-up and treatment regimes to optimise outcome.

Iatrogenic spinal epidermoid tumor. A complication of spinal puncture in an adult

A case of an intraspinal epidermoid tumor following a lumbar puncture (LP) is described. This tumor developed 5 years after a LP in a man aged 31 years. The majority of epidermoid tumors reported are late complications of spinal puncture during the early neonatal period. To the best of our knowledge, this case is the third oldest patient, whose symptoms presented relatively early after the initial LP. He was successfully treated by surgery. Pathologic diagnosis revealed an epidermoid cyst. The relation between LP and epidermoid tumor and the possible risk factors involved are discussed.

Tunneled lumbar drain. Technical note.

The authors report a simple and rapid procedure for tunneling a lumbar drain subcutaneously to facilitate chronic cerebrospinal fluid (CSF) drainage. A standard lumbar puncture (LP) is performed with a large-bore Tuohy needle (14- to 16-gauge), the drainage catheter is advanced into the subarachnoid space, and the needle is removed. The free Tuohy needle is then passed from a lateral position and brought out through the initial LP site. The free catheter is fed through the needle, and the needle is removed. The drain is attached to an external drainage bag in the usual manner. The authors have found this method particularly useful in some skull base and spinal surgical applications in which longer term continuous CSF drainage is desired.

Delay of the diagnostic lumbar puncture and intrathecal chemotherapy in children with acute lymphoblastic leukemia who undergo routine corticosteroid testing: Tokyo Children's Cancer Study Group study L89-12.

To determine the effects of eliminating initial lumbar punctures in 418 consecutively treated children with acute lymphoblastic leukemia (ALL). Patients were enrolled onto a trial conducted in central Japan between 1989 and 1992. Treatment consisted of standard four-drug induction therapy followed by a risk-based intensification phase, reinduction therapy, late intensification, and remission maintenance therapy (total of 104 weeks). The initial lumbar puncture, with an intrathecal injection of chemotherapy, was performed after 1 week of prednisolone sensitivity testing (day 8). End points included response to prednisolone, CNS status at the time of the day 8 lumbar puncture, subsequent adverse events in CNS and bone marrow, and event-free survival (EFS). The remission induction rate was 93.1% with a 6-year EFS rate (+/- SE) of 68.7% +/- 2.4%, which is similar to historical results for patients who received their diagnostic lumbar puncture and first instillation of intrathecal chemotherapy on day 0. Overall, 84.5% of the patients had good responses to prednisolone, whereas 15.5% had poor responses. Clinical outcome was strikingly better for the good responders (6-year EFS, 74.1% +/- 2.5% compared with 40.1% +/- 6.4% for patients with poor responses), suggesting that omission of intrathecal chemotherapy did not alter the predictive value of drug sensitivity testing. Eighteen patients experienced CNS relapse as their first adverse event (cumulative risk, 5.1%; 95% confidence interval, 2.7% to 7.4%), coincident with reports from groups using conventional strategies of CNS clinical management. Bleeding into the CSF at the time of the day 8 lumbar puncture was apparent in 29 cases (8.1%), but leukemic blasts were identified in only two. Delay of the initial lumbar puncture and intrathecal injection of chemotherapy seems to be feasible in children with ALL. Further controlled evaluations are needed to establish the validity of this conclusion.

Initial Traumatic LP Adversely Affects Outcome in ALL

Hematology-Oncology| March 01 2001 Initial Traumatic LP Adversely Affects Outcome in ALL AAP Grand Rounds (2001) 5 (3): 24. https://doi.org/10.1542/gr.5-3-24 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Twitter LinkedIn Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation Initial Traumatic LP Adversely Affects Outcome in ALL. AAP Grand Rounds March 2001; 5 (3): 24. https://doi.org/10.1542/gr.5-3-24 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search toolbar search search input Search input auto suggest filter your search All PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP NewsAll AAP Sites Search Advanced Search Topics: blast cells, cerebrospinal fluid, leukemia, lipopolysaccharides, traumatic lumbar puncture, treatment outcome, van der woude syndrome, acute lymphocytic leukemia, atypical, central nervous system dysfunction Source: Gajjar A, Harrison PL, Sandlund JT, et al. Traumatic lumbar puncture at diagnosis adversely affects outcome in childhood acute lymphoblastic leukemia. Blood. 2000;96: 3381–3384 This retrospective study was conducted to answer an important, controversial question: does a traumatic lumbar puncture (TLP) at the time of the initial diagnostic work-up and/or induction treatment have any effect on the treatment outcome in children with acute lymphoblastic leukemia (ALL)? The authors reviewed the cerebrospinal fluid (CSF) findings of lumbar punctures (LP) performed in 546 patients enrolled on two consecutive therapeutic trials at St. Jude Children’s Research Hospital, Memphis, Tennessee between 1984 to 1991. All patients underwent 2 LPs, usually within 24–48 hrs of each other at the time of initial diagnostic evaluation and at the beginning of the induction chemotherapy. A complete blood count and examination of a centrifuged and stained CSF cell pellet were performed in all patients. The patients were divided into 5 groups depending on their central nervous system (CNS) status: LP not traumatic with <10 red blood cells (RBCs) per μL in the CNS and no leukemic blast cells (n=336), LP not traumatic with <5 white blood cells (WBCs) per μL and containing leukemic blast cells (n=80), LP not traumatic with ≥5 WBCs per μL and containing leukemic blast cells (n=16), LP traumatic with ≥10 RBCs per μL and no leukemic blast cells (TLP−, n=54), and LP traumatic with leukemic blast cells (TLP+, n=60). There were 26 patients who had 2 consecutive TLPs with blast cells (TLP++). The 5-year event-free survival (EFS± 1 SE) for the 5 groups is shown in the tableT1: The EFS was similar between patients with an atraumatic LP and no blast cells and those who were TLP− (P=.85). The EFS of patients who were TLP+ was worse than that for those who had an atraumatic LP with no blast cells (P=.026) and comparable to those who had an atraumatic LP with <5 WBCs and leukemic blast cells (P=.59). The authors conclude that a TLP during initial diagnostic evaluation and treatment of ALL leads to contamination of the CSF with circulating leukemic blast cells and will adversely affect the treatment outcome of children with ALL. Furthermore, the EFS of patients with 2 TLPs with blast cells (TLP++) was comparable to that of patients with overt CNS disease (≥5 WBCs with blast cells). The definition of CNS leukemia is controversial when the CSF contains a small number of WBCs and blasts are seen on a stained cytospin preparation. Most physicians follow the recommendation of the Rome Leukemia Workshop,1 which characterizes patients who have >5 WBCs μL with identifiable blasts as having CNS involvement. The problem is positively identifying the few “atypical” looking cells as true blasts, thus justifying more intensive CNS directed therapy. This is true even if more specific tests such as determination of surface markers by staining or flow cytometry... You do not currently have access to this content.

Chronic myeloid leukemia mimicking idiopathic intracranial hypertension

A 27-year-old woman presented with headache and bilateral optic disc edema. Neuroimaging was negative for an intracranial mass. An initial lumbar puncture showed elevated intracranial pressure, but normal cerebrospinal fluid contents.A diagnosis of ‘idiopathic intracranial hypertension’ was made. Ophthalmoscopy subsequently disclosed bilateral optic disc edema and multifocal retinal hemorrhages with white centers (Roth spots). Complete blood count and bone marrow examination confirmed the diagnosis of chronic myeloid leukemia. The diagnosis of idiopathic intracranial hypertension in patients should be suspect in patients who do not fit the typical profile (e.g., thin, elderly, or male patients or patients with unusual fundus findings).

COMA AND CONFUSIONAL STATES: EMERGENCY DIAGNOSIS AND MANAGEMENT

Coma and confusion signal a failure of brain function with many possible causes. Since many of the potential causes may quickly lead to death or severe disability, it is important to develop a focused and ordered approach to facilitate the rapid diagnosis and early institution of proper therapies. This requires an understanding of the localizing features of the neurologic examination and of the syndromes likely to cause coma and confusion, a predetermined plan for empiric therapies in certain cases of doubt when diagnostic confirmation will be delayed, and a careful consideration of cases when the diagnosis is not revealed by the initial neuroimaging, lumbar puncture, or EEG.