Low Cerebrospinal Fluid Glucose Level Research Articles

Prominent cerebral veins on susceptibility-weighted angiography in acute meningoencephalitis.

We have commonly observed prominent cerebral veins on susceptibility-weighted angiography (SWAN) in acute meningoencephalitis. This study aimed to investigate the clinical significance of these findings. Cerebral veins on SWAN of 98 patients with acute meningoencephalitis diagnosed from February 2016 through October 2020 were classified into three groups according to the degree of venous prominence (mild, 23; moderate, 53; and prominent, 22). Clinical variables and laboratory findings were compared between these groups. The influence of variables on the prediction of prominent cerebral veins was measured by random forest (RF) and gradient boosting machine (GBM). As cerebral veins became more prominent, cerebrospinal fluid (CSF) glucose level decreased (69.61±29.05vs. 59.72±22.57vs. 48.36±20.29mg/dL, p=.01) and CSF protein level increased (100.73±82.98vs. 104.73±70.99vs. 159.12±118.15mg/dL, p=.03). The etiology of meningoencephalitis, neurological symptoms, and increased intracranial pressure (ICP) signs differed between groups (p<.05). RF and GBM demonstrated that CSF protein level was the variable with the highest power to predict the prominent cerebral vein (mean decrease in node impurity: 4.19, relative influence: 50.66). The presence of prominent cerebral veins on SWAN in acute meningoencephalitis was significantly associated with a low CSF glucose level and a high CSF protein level, as well as ICP. Thus, the visual grade of the cerebral veins on SWAN may be utilized for the management of patients with acute meningoencephalitis.

Lack of Association between YEASTONE Antifungal Susceptibility Tests and Clinical Outcomes of Cryptococcus Meningitis.

The relation between antifungal susceptibility and treatment outcomes is not well-characterized. There is paucity of surveillance data for cerebrospinal fluid (CSF) isolates of cryptococcus investigated with YEASTONE colorimetric broth microdilution susceptibility testing. A retrospective study of laboratory-confirmed cryptococcus meningitis (CM) patients was conducted. The antifungal susceptibility of CSF isolates was determined using YEASTONE colorimetric broth microdilution. Clinical parameters, CSF laboratory indices, and antifungal susceptibility results were analyzed to identify risk factors for mortality. High rates of resistance to fluconazole and flucytosine were observed in this cohort. Voriconazole had the lowest MIC (0.06 µg/mL) and lowest rate of resistance (3.8%). In a univariate analysis, hematological malignancy, concurrent cryptococcemia, high Sequential Organ Failure Assessment (SOFA) score, low Glasgow coma scale (GCS) score, low CSF glucose level, high CSF cryptococcal antigen titer, and high serum cryptococcal antigen burden were associated with mortality. In a multivariate analysis, meningitis with concurrent cryptococcemia, GCS score, and high CSF cryptococcus burden, were independent predictors of poor prognosis. Both early and late mortality rates were not significantly different between CM wild type and non-wild type species.

&amp;lt;i&amp;gt;Kocuria Kristinae&amp;lt;/i&amp;gt; Meningitis and Cranial Nerve Palsies Secondary to Sphenoid Sinusitis: About a Case

Kocuria spp, previously classified as the members of Micrococcacae family, was rarely reported as a human pathogen. <i>Kocuria Kristinae</i> could cause invasive infections of large variety of tissues in patients of any age. We report the first case of meningitis with sixth and third nerve palsies secondary to sphenoid sinusitis caused by <i>Kocuria Kristinae</i> in a previously healthy 13 year-old boy. In effect, his cerebrospinal fluid (CSF) showed a cloudy appearance of the CSF, white blood cells count was 600 cells/µl (polymorphs 90% and 10% lymphocytes), red blood cells count was 200 cells/µl, protein level was elevated at 5.3 g/l and glucose level was low at 0.1 mmol/l. The direct examination showed positive-gram diplococci. The patient was initially treated with intravenous cefotaxim and vancomycin. The CSF culture was positive for gram-positive diplococci, which was identified as <i>Kocuria kristinae</i>. The meningitis was characterized by insidious evolution and persistent very low CSF glucose level. It was difficult to diagnose the sphenoid sinusitis because it is not accessible to direct clinical examination. It was diagnosed after the occurrence of a complication due to its anatomical location and proximity to the intracranial and orbital content. At day 5, the patient had remarkable resolution of symptoms. Complete recovery of cranial nerve palsy was noted at day 8. The aim of this case report is to present the first isolation of <i>Kocuria Kristinae</i> from cerebrospinal fluid sample and describe the clinical presentation and management outcomes.

The role of molecular analysis of SLC2A1 in the diagnostic workup of glucose transporter 1 deficiency syndrome

The study aimed to investigate the role of molecular analysis of SLC2A1 in the diagnostic workup of glucose transporter 1 deficiency syndrome (Glut1DS). During 2006–2020, we received 100 requests for SLC2A1 variant analysis of patients clinically suspected for Glut1DS. Pathogenic variants were detected in 37 patients, among whom 11 were familial cases. Most patients presented with epilepsy (n = 31; 84%), movement disorders (MD) (n = 28; 76%), and intellectual disabilities (ID) (n = 29; 78%). Moreover, paroxysmal dyskinesias (PD) (n = 10; 27%) were more frequently seen in familial cases (55%) than in sporadic cases (15%) (p < .05). The Glut1DS patients with ID typically had either epilepsy or MD. The presence of MD, particularly when associated with epilepsy or ID, indicated Glut1DS (p < .05). The cerebrospinal fluid (CSF) glucose levels were at or below the 10th percentile in all 32 SLC2A1-positive patients but only in 16 of 52 (31%) SLC2A1-negative patients (p < .05). Thus, CSF analysis is an essential tool in the diagnostic workup of Glut1DS. SLC2A1 molecular analysis should be performed in patients with a family history of Glut1DS or with at least one of the following clinical features, such as epilepsy, MD, and PD with or without ID, and low CSF glucose level. This would help in precise molecular diagnosis of the disease and facilitate effective treatment and appropriate genetic counseling.

Unique clinical features of cryptococcal meningitis among Chinese patients without predisposing diseases against patients with predisposing diseases.

The clinical features of cryptococcal meningitis (CM) in patients without predisposing diseases (PD) remain unclear. In sum, 162 of the 167 patients without PD and 162 of the 309 patients with PD were enrolled after propensity score matching. Demographic characteristics, symptoms, blood, and cerebrospinal fluid (CSF) characteristics were compared between the two groups. Kaplan-Meier curves and a Cox proportional hazards model were used to assess the factors associated with 10-week mortality. In total, approximately 35.1% of CM patients were without PD. CM patients without PD had blood profiles of higher white blood cells (WBC) [8.9(6.7-11.0) × 109/l], hemoglobin (128.4 ± 20.9g/l), platelets [(226.2 ± 64.1) × 109/l], and serum albumin (41.2 ± 5.8g/l) (all P ≤ .001) and CSF profiles of lower glucose (2.0 ± 1.2mmol/l), pleocytosis [65.0 (18.0-160.0) × 106/l] and higher total protein [0.9 (0.7-1.4)g/l] (all P < .05). CM patients without PD had lower Cryptococcus culture positivity in CSF (62.5%vs. 74.1%, P = .039) but higher 2-week of CSF culture sterilization rates (69.4%vs. 51.3%, P = .031). The overall 10-week survival rate was 84.7% in patients without PD and 81.1% in patients with PD (Log-rank P = .439). CSF glucose <1.5mmol/l, CSF fungal burden >20 cells/high power field and treatment lacking amphotericin B had a 3-4 times higher risk of death in patients without PD, whereas serum albumin <35g/l, CSF glucose < 1.5mmol/l, and CSF WBC <55 × 106 cell/l were risk factors for patients with PD. CM patients without PD had unique blood and CSF profiles, especially, had lower Cryptococcus culture positivity in CSF, and higher 2-week CSF culture sterilization. Low CSF glucose levels, higher fungal burden, and treatment without amphotericin B were risk factors for 10-week mortality.

Risk Factors in Predicting Prognosis of Neonatal Bacterial Meningitis-A Systematic Review.

Background: Neonatal bacterial meningitis is a severe infection with high mortality and morbidity. It is necessary to identify factors associated with a high risk of a poor prognosis so that we can prevent them with more appropriate treatments. This study was performed to summarize the prognostic factors known to predict adverse outcomes in neonatal bacterial meningitis.Methods: The Medline/PubMed, Cochrane Library and Embase databases were searched for studies of prognostic risk factors in neonates with bacterial meningitis. Studies published from the initiation of the database to April 30th, 2017 were included. The quality of cohort studies was assessed by the Newcastle-Ottawa Scale (NOS). The quality of cross-section studies was assessed by the Agency for Healthcare Research and Quality (AHRQ) scale. Each prognostic factor known to cause adverse outcomes is summarized.Results: Sixteen studies were identified, including 7 cohort studies and 9 cross section studies. Seizure and high protein levels in the cerebrospinal fluid (CSF) predict a poor prognosis in this disease. Coma, the need for ventilation support, and leukopenia also had some value for predicting poor prognoses. A bulging anterior fontanelle was valuable for predicting mortality. Low CSF glucose levels, thrombocytopenia, gestational age (GA) < 37 weeks and an altered sensorium were correlated with a poor prognosis. A birth weight < 2500 g, early onset meningitis and positive CSF cultures were correlated with mortality.Conclusions: This study provides a preliminary exploration of prognostic factors in neonatal bacterial meningitis and thereby fills some of the gaps in the study of prognoses in this disease. These prognostic factors can be used to predict and estimate outcomes in neonatal bacterial meningitis. Without a meta-analysis, the reliability of these factors cannot be assured. In addition, these results emphasize that there is an urgent need for a standardized protocol for follow-up and well-designed prognostic studies in neonatal bacterial meningitis.

Adenosine Deaminase (ADA) in Tuberculous Meningitis

Abstract not availableBangladesh J Medicine Jul 2014; 25 (2) : 61-71

Factors Associated with the Occurrence of Hearing Loss after Pneumococcal Meningitis

On the basis of a nationwide registration during a 5-year period (1999-2003), the frequency and severity of hearing loss was investigated retrospectively in 343 consecutive Danish patients who survived pneumococcal meningitis, to identify important risk factors (including the pneumococcal serotype) for development of hearing loss. Results of blood and cerebrospinal fluid (CSF) biochemistry, bacterial serotyping, follow-up audiological examinations, and medical records were collected, and disease-related risk factors for hearing loss were identified. The mean pure-tone hearing threshold levels were compared with normative data. Of 240 patients examined by use of audiometry, 129 (54%) had a hearing deficit, and 50 (39%) of these 129 patients were not suspected of hearing loss at discharge from hospital. Of the 240 patients, 16 (7%) had profound unilateral hearing loss, and another 16 (7%) had bilateral profound hearing loss. Significant risk factors for hearing loss were advanced age, the presence of comorbidity, severity of meningitis, a low CSF glucose level, a high CSF protein level, and a certain pneumococcal serotype (P < .05). By applying multivariate logistic regression analysis, we found that advanced age, female sex, and a certain serotype were significant risk factors, because fewer patients with serotype 6B had hearing loss than did patients with serotype 12F (P = .03), which was the most commonly occurring serotype. Hearing loss is common after pneumococcal meningitis, and audiometry should be performed on all those who survive pneumococcal meningitis. Important risk factors for hearing loss are advanced age, female sex, severity of meningitis, and bacterial serotype.

GLUT1 Deficiency Without Epilepsy: Yet Another Case

Glucose transporter type 1 (GLUT1) deficiency syndrome is a metabolic disorder characterized by a low cerebrospinal fluid glucose level caused by decreased activity of the glucose transporter protein. Of approximately 100 patients described with this syndrome in the published literature to date, only 3 patients have had intermittent ataxia as the initial manifestation. This case report describes a 13-year-old boy with a longstanding history of intermittent ataxia who was diagnosed as having GLUT1 deficiency syndrome after the onset of seizures at age 11 years. This case highlights the importance of a carefully organized lumbar puncture in the investigation and management of any child with neurodevelopmental delay and intermittent ataxia with or without seizures.

Clinical features, laboratory data, management and the risk factors that affect the mortality in patients with postoperative meningitis

Nosocomial meningitis is a rare complication following neurosurgical procedures and is associated with high morbidity and mortality. The aim of this study was to describe the clinical characteristics and the risk factors associated with mortality in patients who developed nosocomial meningitis following neurosurgical operations. Tertiary care hospital and an observational study. The study subjects included 2265 patients who underwent various neurosurgical operations during 2003-05. The diagnosis of nosocomial meningitis was based on the Center for Disease Control criteria. It was performed by using Statistical Package for Social Sciences for Windows 10.0 program. The incidence of postoperative nosocomial meningitis was 2.7% (62 episodes in 49 patients among 2265 patients operated). Staphylococcus aureus and Acinetobacter spp. were the most frequently isolated pathogens. Of the 49 with meningitis 20 (40.8%) patients died. In the logistic regression analysis model, Glascow coma scale score less than 10 (Odds Ratio (OR): 19.419, 95% Confidence Interval (CI); 1.637-230.41, P = 0.001), and low cerebrospinal fluid glucose level (< or = 30 mg/ dL) (OR: 10.272, 95% CI; 1.273-82.854, P = 0.002), and presence of concurrent nosocomial infection (OR: 28.744, 95% CI;1.647-501.73, P =0.001) were the independent risk factors associated with mortality. The mortality in patients who developed meningitis was high. The high percentage of concurrent nosocomial infections was associated with a high mortality rate which was a serious problem.

Thwaites’ Diagnostic Scoring and the Prediction of Tuberculous Meningitis

Objective: This study was conducted to investigate the applicability of Thwaites’ diagnostic criteria in order to differentiate tuberculous from bacterial meningitis. Material and Methods: The study was done retrospectively in HIV-negative patients (n = 126) with meningitis. Of the 126 patients, 103 had bacterial meningitis and 23 patients had tuberculous meningitis. The diagnosis was confirmed microbiologically in 59 and 12 patients with bacterial and tuberculous meningitis, respectively. The prediction of tuberculous meningitis was determined by Thwaites’ diagnostic scoring using parameters such as age, history of illness, white blood cell count, total cerebrospinal fluid (CSF) white cell count and the percent of neutrophils in CSF. The diagnostic value of the model was assessed by calculating the area under the receiver operating characteristic (ROC) curves. Results: The sensitivity and the specificity of Thwaites’ diagnostic scoring were 95.6% (22/23) and 70.8% (73/103), respectively. In microbiologically proven cases the sensitivity and the specificity were 91.7% (11/12), 79.7% (57/59), respectively. The area under the ROC curve value for the diagnostic scoring was 0.92. Conclusions: Thwaites’ diagnostic score was found to be helpful in differential diagnosis of tuberculous meningitis, however, the usefulness of diagnostic scoring should be validated in large series especially in patients with viral meningitis and low CSF glucose levels.

Pathophysiology and prognosis in vietnamese adults with tuberculous meningitis.

The pathogenesis of tuberculous meningitis remains unclear, and there are few data describing the kinetics of the immune response during the course of its treatment. We measured concentrations of pro- and anti-inflammatory cytokines in serial blood and cerebrospinal fluid (CSF) samples from 21 adults who were being treated for tuberculous meningitis. CSF concentrations of soluble tumor necrosis factor-alpha receptors and of matrix metalloprotein-9 and its tissue inhibitor were also measured, and blood-brain barrier permeability was assessed by the albumin and IgG partition indices. CSF concentrations of lactate, interleukin-8, and interferon-gamma were high before treatment and then decreased rapidly with antituberculosis chemotherapy. However, significant immune activation and blood-brain barrier dysfunction were still apparent after 60 days of treatment. Death was associated with high initial CSF concentrations of lactate, low numbers of white blood cells, in particular neutrophils, and low CSF glucose levels.

Neurologic complications of anthrax: a review of the literature.

A review of the literature suggests that the major neurologic symptom complex of infection by Bacillus anthracis is a fulminant and rapidly fatal hemorrhagic meningoencephalitis and that the reported initial mode of entry can be via the cutaneous or inhalation route. For febrile patients with acute neurologic deterioration with associated findings of dark necrotic pustules on the extremities, gram-positive rods in the cerebrospinal fluid, and multifocal areas of unexplained intracerebral hemorrhage on computed tomographic scans, anthrax should be considered within the differential diagnosis. A low cerebrospinal fluid glucose level has been reported, with gram-positive rods often noted on the gram stain of the cerebrospinal fluid in severely affected patients. Reports indicate that death usually occurs within a week.

Ventriculoperitoneal shunt infections with gram-negative bacteria.

Infection causes major morbidity and mortality in patients with cerebrospinal fluid (CSF) shunts. The prognosis of CSF shunt infections caused by Gram-negative bacteria (GNB) has been thought to be particularly poor. The authors reviewed all GNB shunt infections treated at Children's Memorial Hospital from January 1986 to January 1990 (n = 23). Of these infections 20 (87%) occurred within 4 weeks after shunt revision (median, 10 days). The most frequent symptoms were fever, lethargy, and irritability; the illness was not severe in the majority of these patients. Escherichia coli was isolated from 12 of 23 patients (52%), Klebsiella pneumoniae from 5 (22%), and mixed GNB from 3 (13%) patients. Initial treatment always included immediate shunt removal, externalized ventricular drainage, and intravenous antibiotics. Extraventricular drainage revision and/or intraventricular antibiotics were required in four patients whose CSF cultures were persistently positive for GNB. At admission, these patients had CSF glucose levels of < 10 mg/dl and CSF positive for GNB by Gram's stain. The overall cure rate was 100%, and no recurrence was observed; however, a subsequent infection with a different organism developed in four patients. Only 2 of 19 patients (11%) who were followed up suffered apparent CNS damage. One patient died of unrelated causes shortly after treatment. Our findings indicate that 1) patients with GNB CSF shunt infections often appear relatively well at presentation; 2) CSF positive for GNB by Gram's stain and very low CSF glucose levels predict continued positive CSF cultures, despite appropriate antibiotic therapy; and 3) GNB CSF shunt infections can be successfully treated by prompt shunt removal, extraventricular drainage, and intravenous antibiotics.(ABSTRACT TRUNCATED AT 250 WORDS)

Omentum graft for intractable subdural empyema

A subdural empyema developed in a young man after craniotomy for evacuation of a hematoma in a sylvian fissure arachnoid cyst and the subdural space. Despite prolonged systemic and subdural antibiotic administration and a debridement of the subdural space, infection persisted, as evidenced by persistent fever, an elevated white blood cell count, and an extremely low cerebrospinal fluid glucose level. The infection was cured after a second debridement operation where microsurgically revascularized free omentum was used to obliterate the cyst and to cover the cerebral hemisphere in the craniotomy defect. The use of vascularized free omentum may prove useful in cases of refractory cranial wound infection and cerebrospinal fluid fistulas.

REYE'S SYNDROME-Reply

<i>To the Editor</i>.—We do not share Dr. Winograd's belief that an abnormal blood or cerebrospinal fluid (CSF) glucose level is necessary to the diagnosis of Reye's syndrome. In accepting Reye's cases as a syndrome, Dr. Winograd must accept Reye's original data; a low blood or CSF glucose level was not uniformly present (CSF, 13/19; blood, 6/9). In Bradford and Latham's recent review article, a low blood glucose level was found in 27 out of 63 cases in which this determination was performed. A low CSF glucose level was found in 31 out of 59 cases. It is our view, as emphasized in the title of our report, that hepatocellular dysfunction is primary and encephalopathy is a consequence of this. Presumably, the hypoglycemia encountered in many cases is also a consequence of hepatic dysfunction. A laboratory hallmark of this syndrome, which to date has always been present when sought, is