Non-traumatic Lumbar Puncture Research Articles

Oligoclonal Bands in CSF May be Associated with Chronic Graft Versus Host Disease after Haploidentical Hematopoietic Stem Cell Transplantation

Introduction Haploidentical hematopoietic stem cell transplantation (haplo-HSCT) is a straightforward and effective therapy for hematology patients, and chronic graft-versus-host disease (cGVHD) is recognized as a major and important complication of haplo-HSCT. cGVHD can affect a number of organs, such as the skin, eyes, oral mucosa, liver, and lung.In addition to classical manifestations, cGVHD can imitate almost any autoimmune disease, and its central nervous system (CNS) involvement is exceedingly rare. In our studies, IgG synthesis and anti-myelin oligodendrocyte glycoprotein antibody were risk factors for CNS demyelination ( Annals of Hematology, 2018), aGVHD and hypertension were associated with posterior reversible encephalopathy syndrome ( Bone Marrow Transplantation, 2020), and aGVHD and cGVHD were identified as factors for idiopathic inflammatory demyelinating disease ( Am J Hematol, 2021). However, there are limited data available on cGVHD in the CNS. Therefore, we performed a thorough assessment of cGVHD, including examining the CSF of patients with cGVHD. Methods We performed a retrospective nested case‒control study in patients receiving haplo-HSCT between January 2013 and June 2022 in our center. In total, 86 patients suffering from cGVHD who also received CSF examinations were analyzed, of whom 42 patients showed evidence of CNS-cGVHD. Written informed consent was, and ethical approval was obtained before sample collection by the Ethics Committee of Peking University People's Hospital. The CSF samples were collected by lumbar puncture (LP). At least 1 ml of CSF was obtained from all patients by nontraumatic LP. All CSF samples were routinely screened for infection with bacterial, fungal, and virological pathogens, examined by histopathology and analyzed by fluorescence-activated cell sorting to identify tumor cells. Immune biomarkers were also evaluated. Results The median time from transplantation to cGVHD was 236 days. In the 86 cGVHD patients, aGVHD (HR 0.431, 95% CI 0.229-0.812, P=0.009), CSF protein (HR 0.634, 95% CI 0.484-0.784, P=0.)and oligoclonal bands (OCB) (HR 0.527, 95% CI 0.312-0.890, P=0.017) were identified as risk factors for the onset of cGVHD after haplo-HSCT. Moreover, we combined the variables to establish a nomogram for the cumulative incidence of cGVHD. The test showed that the fitness of the multivariate logistic regression model was suitable (P = 0.9516). The area under the ROC curve was 0.741. There were no differences in overall survival (OS), disease-free survival (DFS), or the cumulative incidence of relapse (CIR) between the cGVHD group and the control group without cGVHD. Nonetheless, there was a significant difference in nonrelapse mortality (NRM) (P=0.009). The 2-year cumulative NRM was 48.2% (95% CI 45.8%-50.6%) versus 12.6% (95% CI 12.2%-13.0%) between the cGVHD and without cGVHD groups, respectively. Then, we performed multivariate analysis for data from 42 patients who were diagnosed with CNS-cGVHD. The underlying diseases (HR 1.334, 95% CI 1.027-1.733, P=0.030) and CSF proteins (HR 0.313, 95% CI 0.126-0.776, P=0.012) were independently associated with the occurrence of CNS-cGVHD. Conclusions In conclusion, CSF immunity may be associated with the onset of cGVHD after haplo-HSCT, especially OCB, and the identification of cGVHD increases NRM after haplo-HSCT. Further multicenter prospective studies are needed to confirm the results and establish the standard diagnostic criteria and therapy for CNS-cGVHD.

Clinical characteristics and outcomes in febrile infants aged 29-90 days with urinary tract infections and cerebrospinal fluid pleocytosis.

Fever without a focus is a common reason for medical evaluations, hospitalizations, and the antimicrobial treatment of infants younger than 90 days. The presence of cerebrospinal fluid (CSF) pleocytosis could be challenge for clinicians who treat febrile young infants with urinary tract infection (UTI). We evaluated the factors associated with sterile CSF pleocytosis and the clinical outcomes of the patients. A retrospective review of patients aged 29-90 days with febrile UTIs who underwent a non-traumatic lumbar puncture (LP) at Pusan National University Hospital from January 2010 to December 2020 was conducted. CSF pleocytosis was defined as white blood cell (WBC) counts ≥9/mm3. A total of 156 patients with UTI were eligible for this study. Four (2.6%) had concomitant bacteremia. However, no patients had culture-proven bacterial meningitis. In correlation analysis, although weak strength, CSF WBC counts were positively correlated with C-reactive protein (CRP) level (Spearman r = 0.234; P = 0.003). Thirty-three patients had CSF pleocytosis [21.2%; 95% confidential interval (CI), 15.5-28.2]. The time from fever onset to the hospital visit, peripheral blood platelet counts, and CRP level at admission were statistically significant in patients with sterile CSF pleocytosis compared to those without CSF pleocytosis. In the multiple logistic regression, only CRP was independently associated with sterile CSF pleocytosis (cutoff, 3.425 mg/dl; adjusted odds ratio, 2.77; 95% CI, 1.19-6.88). The proportion of fever defervescence by hospital day 2 was 87.9% in patients with CSF pleocytosis and 89.4% in those without CSF pleocytosis (P = 0.759). There was no statistical difference in the fever defervescence curves between the two patient groups (P = 0.567). No patients had neurological manifestations or complications. Coexisting sterile CSF pleocytosis among febrile infants with UTIs suggest a systemic inflammatory response. However, the clinical outcomes between the two groups were similar. A selective LP should be considered in young infants with evidence of UTI, and inappropriate antibiotic therapy for sterile CSF pleocytosis should be avoided.

Comparison of Chloral Hydrate Solution, Hydroxyzine Syrup, and Lidocaine/Prilocaine Cream as Premedication for Lumbar Puncture in Children: A Double-Blind Study.

Objectives This study aimed to compare the clinical effectiveness of oral hydroxyzine and chloral hydrate to topical lidocaine/prilocaine 2.5% cream as premedication in pediatric leukemia patients.Materials & MethodsThis double-blind clinical trial study was conducted on 70 leukemic and nonleukemic patients aged 3-11 years. The patients were divided into four groups. In group A, chloral hydrate solution was given to 18 patients. In group B, hydroxyzine syrup was used for 18 patients. In group C, chloral hydrate solution and lidocaine/prilocaine cream were used for 17 patients. In group D, hydroxyzine syrup and lidocaine/prilocaine cream were used for 17 patients. These groups were assessed and judged based on the visual analog scale (VAS). The side effects of the drugs were also recorded. Results In this study, 54.3% (n=38) and 45.7% (n=32) of the cases were female and male, respectively. Furthermore, 77%, 7.2%, and 15.8% of the cases were reported with acute lymphocytic leukemia, acute myeloid leukemia, and infectious disease, respectively. The VAS results showed no difference in these four groups. Nontraumatic lumbar puncture (LP) (red blood cell<50) was observed in 97.1% of the cases.Conclusion Although premedications for LP with hydroxyzine syrup and chloral hydrate solution were not statistically effective in pain relief, they increased patient and parent satisfaction. Moreover, adding lidocaine/prilocaine cream does not improve the effectiveness of the drugs.

C-reactive protein as a predictor of meningitis in early onset neonatal sepsis: a single unit experience.

Objectives To determine whether there is a cut off value of serum C-reactive protein (CRP) associated with a higher risk of meningitis in suspected early onset sepsis (EOS) (onset birth to 7 days of life). Methods A retrospective cohort study on neonates admitted in neonatal intensive care unit at McMaster Children's Hospital from January 2010 to 2017 and had lumbar puncture (LP) and CRP for workup of EOS. Included subjects had either (a) non-traumatic LP or (b)traumatic LP with cerebral spinal fluid (CSF) polymerase chain reaction or gram stain or culture-positive or had received antimicrobials for 21days. Excluded were CSF done for metabolic errors, before cytomegalovirus (CMV) treatment; from ventriculo-peritoneal (VP) shunts; missing data and contamination. Neonates were classified into definite and probable meningitis and on the range of CRP. We calculated sensitivity, specificity, and likelihood ratios for CRP values; and area under the receiver operating characteristic (AUROC) curve. Results Out of 609 CSF samples, 184 were eligible (28 cases of definite or probable meningitis and 156 controls). Sensitivity, specificity, predictive values, likelihood ratios, and AUROC were too low to be of clinical significance to predict meningitis in EOS. Conclusions Serum CRP values have poor discriminatory power to distinguish between subjects with and without meningitis, in symptomatic EOS.

A Child Develops Drop Foot after Spinal Anaesthesia.

To the Editor, Spinal anesthesia has been used with children since 1909 (1). In 1950, a study reported that a cooperative child is likely to be a good subject for spinal anesthesia in cases where premedication may be inadequate (2). A nine-year-old girl weighing 20 kgs and with a height of 126 cm was diagnosed with acute appendicitis. An emergency operation was planned. Her medical history was normal except for a productive cough and runny nose over the previous three days. In the preoperative physical examination, rales in the lungs, extensive tenderness and distension in the abdomen were found. Thirty minutes before the operation, midazolam 0.05 mg/kg was given for premedication. A non-traumatic lumbar puncture was performed using a 26 G (Atraucan, 50 mm Braun Melsungen AG, Germany) pediatric spinal needle in the sitting position. At first at-tempt a clear cerebrospinal fluid flowed out, then 0.2 mg/kg of heavy bupivacaine was applied into the subarachnoid space between the third and fourth lumbar vertebrae. Sensorial block dermatome was checked using a pinprick test. When the level reached T8, the operation was started. The patient was hemodynamically stable during the operation and was in the recovery room for 30 minutes. In the sixth postoperative hour, she developed weakness in her left ankle, with muscle strength loss in the dorsiflexion (1/5), eversion (1/5), plantar flexion (3/5), toe dorsiflexion (1/5), and plantar flexion (3/5). Accompanying sensory deficit in the dorsum and anterolateral tibial part of the left leg (L5 and S1 dermatomes) was observed. Lumbar magnetic resonance imaging and computed tomography revealed normal findings. Postoperative 1st and 20th day electromyography showed no pathologic findings. A course of 25 mg/kg ga bapentin three times a day and vitamin B complex twice a day were prescribed. Physical therapy, including passive stretching, range of motion, balance, and strengthening exercises were performed. For the left anterior tibialmuscle, electrical stimulation was applied daily for 15 minutes. In neurological examination, improvement in muscle deficit was observed. Muscle strength was 4/5 in all of the muscles involved. Discharged with a home-based treatment program, she was able to walk without support on the 70th day. Although publications about complications of spinal anesthesia in children exist (3), there are few reports indicating safe and effective usage of spinal anesthesia (4,5). Transient neurological damage usually develops without pain or paresthesia during the lumbar puncture, as in our case. In differential diagnosis of neurological damage after spinal anesthesia, possible diagnosis of epidural hematoma, epidural abscess, anterior spinal artery syndrome, adhesivear-achnoiditis, caudaequina syndrome should be excluded. We excluded all these diagnoses with the help of a physical examination and MRI. Since the patient was in a supine position and had no history of any intramuscular injection, neurologic damage due to malpositioning or intramuscular injection were also excluded. In case of complications, a multidisciplinary approach is necessary for prompt and correct diagnosis, as well as to initiate the most appropriate mode of therapy for optimal results in the shortest time.

Comparison of CSF parameters between traumatic and nontraumatic puncture in term versus preterm neonates

Introduction: Evaluation of the cerebrospinal fluid (CSF) white blood cell (WBC) count and glucose and protein concentrations is used to assess the probability of the presence of central nervous system (CNS) infection. Although normal values are well established for CSF cell counts and protein and glucose contents in children and adults, this is not the case for neonates. The purpose of this study was to evaluate the composition of noninfected CSF obtained by nontraumatic lumbar puncture in neonates (age < 28 days), specifically distinguishing CSF profiles of those term babies compared with those premature infants. Materials& Methods: The CSF samples obtained by lumbar puncture from 120 neonates were examined by routine procedures.Results: By comparing CSF parameters between term gestation neonate group with premature neonate one, nontraumatic puncture, there was no statistically significant difference(p<0.05) in the mean WBC (p=0.6 )The mean protein concentration was significantly greater in those premature neonates ( p <0.04). The mean glucose concentration was also analogous in both groups (p=0.5) Conclusion: a prospective study using mortality under developmental follow up will better define the utility of CSF parameters in the premature neonate

Spinal dural arteriovenous fistula presenting with paraplegia following lumbar puncture

Spinal dural arteriovenous fistulas are rare lesions with an annual incidence of 1 per 100,000 population. In patients with this disease, an abnormal vascular dural shunt exists between a dural branch of a segmental artery and a subdural radicular vein that drains the perimedullary venous system, leading to venous hypertension and secondary congestive myelopathy. Generally, patients present with progressive paraparesis, urinary disturbances, and gait ataxia. In this report the authors describe a 61-year-old woman with a spinal dural arteriovenous fistula who developed an acute paraplegia after a nontraumatic lumbar puncture. The possible underlying mechanisms and treatment options are discussed.

Importance of normal values of CSF parameters in term versus preterm neonates

Background:Evaluation of the cerebrospinal fluid (CSF) white blood cell (WBC) count and glucose and protein concentrations is used to assess the probability of the presence of central nervous system (CNS) infection. Although normal values are well established for CSF cell counts and protein and glucose contents in children and adults, this is not the case for neonates.Aims:The purpose of this study was to evaluate the composition of noninfected CSF obtained by nontraumatic lumbar puncture in neonates (age<28 days), specifically distinguishing CSF profiles of those term babies compared with those premature infants.Materials and Methods:The CSF samples obtained by lumbar puncture from 120 neonates were examined by routine procedures.Results:By comparing CSF parameters between term gestation neonate group with premature neonate one, nontraumatic puncture, there was no statistically significant difference (P<0.05) in the mean WBC (P=0.6). The mean protein concentration was significantly greater in those premature neonates (P<0.04). The mean glucose concentration was also analogous in both groups (P=0.5).Conclusion:The CSF profile, like any other laboratory determination, should be evaluated within the clinical context of the individual case.

Cerebrospinal Fluid Findings in Children with Fever-Associated Status Epilepticus: Results of the Consequences of Prolonged Febrile Seizures (FEBSTAT) Study

This prospective multicenter study of 200 patients with fever-associated status epilepticus (FSE), of whom 136 underwent a nontraumatic lumbar puncture, confirms that FSE rarely causes cerebrospinal fluid (CSF) pleocytosis. CSF glucose and protein levels were unremarkable. Temperature, age, seizure focality, and seizure duration did not affect results. CSF pleocytosis should not be attributed to FSE.

Sterile Cerebrospinal Fluid Pleocytosis in Young Febrile Infants With Urinary Tract Infections

To determine the prevalence of and to identify risk factors for sterile cerebrospinal fluid (CSF) pleocytosis in a large sample of febrile young infants with urinary tract infections (UTIs) and to describe the clinical courses of those patients. Secondary analysis of a multicenter retrospective review. Emergency departments of 20 North American hospitals. Patients Infants aged 29 to 60 days with temperatures of 38.0°C or higher and culture-proven UTIs who underwent a nontraumatic lumbar puncture from January 1, 1995, through May 31, 2006. Febrile UTI. Presence of sterile CSF pleocytosis defined as CSF white blood cell count of 10/μL or higher in the absence of bacterial meningitis and clinical course and treatment (ie, presence of adverse events, time to defervescence, duration of parenteral antibiotic treatment, and length of hospitalization). A total of 214 of 1190 infants had sterile CSF pleocytosis (18.0%; 95% confidence interval, 15.9%-20.3%). Only the peripheral white blood cell count was independently associated with sterile CSF pleocytosis, and patients with a peripheral white blood cell count of 15/μL or higher had twice the odds of having sterile CSF pleocytosis (odds ratio, 1.97; 95% confidence interval, 1.32-2.94; P = .001). In the subset of patients at very low risk for adverse events (ie, not clinically ill in the emergency department and without a high-risk medical history), patients with and without sterile CSF pleocytosis had similar clinical courses; however, patients with CSF pleocytosis had longer parenteral antibiotics courses (median length, 4 days [interquartile range, 3-6 days] vs 3 days [interquartile range, 3-5 days]) (P = .04). Sterile CSF pleocytosis occurs in 18% of young infants with UTIs. Patients with CSF pleocytosis at very low risk for adverse events may not require longer treatment with antibiotics.

Subacute Spinal Subarachnoid Hematoma after Spinal Anesthesia That Causes Mild Neurologic Deterioration

SPINAL subarachnoid hematoma after lumbar puncture has been reported to occur in the presence of preexisting coagulopathy or anticoagulant therapy. 1-4 Although occult spinal subarachnoid hematoma may be possible, symptom onset generally is acute and dramatic, and it also represents serious complications for hemostatically compromised patients.5"7 We report a patient who developed spinal subarachnoid hematoma after lumbar puncture. However, she had normal blood coagulation profiles and no spinal disorders such as spinal stenosis or spinal fractures. The onset of her symptoms was gradual, and neurologic deterioration was mild. To our knowledge, this is the first report about spinal subarachnoid hematoma with mild and vague symptoms in a hemostatically normal patient.

What represents pleocytosis in blood-contaminated (“traumatic tap”) cerebrospinal fluid in children?

THE NUMBER of white blood cells normally present in cerebrospinal fluid after a nontraumatic lumbar puncture has been clearly established? ~2 Although the number of WBCs in CSF contaminated with blood has not been studied systematically, suggested definitions for normal values include a comparable WBC/RBC ratio in CSF and in peripheral blood ~ or the use of an arbitrary WBC/RBC ratio of 1:300. 4 Both of these definitions imply that when CSF is contaminated with blood there exists a fixed relationship between the number of RBCs and WBCs in CSF and peripheral blood, in the absence of preexisting CSF pleocytosis. Two recent analyses of blood-stained CSF specimens obtained from a small number of patients without meningitis demonstrated fewer WBCs than expected from calculation of the peripheral blood WBC/RBC ratio. ~,6 This observation suggests that current definitions might well obscure the detection of true CSF pleocytosis in such specimens, The purpose of our study was to analyze a larger number of blood-contaminated CSF samples in order to define better the relationship between the number of WBCs present and the expected number calculated from peripheral blood RBC and WBC counts. METHODS We performed a retrospective analysis of the CSF data of all patients at The Children's Memorial Hospital during 1983 whose CSF samples contained > 1000 RBC/mm 3 and in whom a complete blood count was performed simultaneously with or within 2 hours of lumbar puncture. CSF cell counts were done routinely using the standard counting chamber and acetic acid lysis technique described by Hepler. 7 CSF samples obtained by a neurosurgical procedure or with positive bacteriologic culture not judged to be a contaminant were excluded. Because it had been suggest