Polymorphonuclear Predominance Research Articles

Laboratory-Based Cytological and Biochemical Profile of Cerebrospinal Fluid for Children With Acute Bacterial Meningitis in Bangladesh

An attempt was made to analyze the cerebrospinal fluid (CSF) for a cytological and biochemical profile to identify etiological agents from children with suspected acute bacterial meningitis. The cerebrospinal fluid (CSF) samples from 371 suspected meningitis cases were examined, and the highest bacterial meningitis was found in 52(14.0%) cases in this study. Among a total of 371 samples of CSF, 272(73.3%) were crystal clear, 52(14.0%) were moderately turbid, 47(12.7%) highly turbid. The total leukocyte cell count of the CSF was proportionate to the turbidity. In the case of crystal clear CSF’s, total leukocyte counts (TLC) were normally ranging from <5 to 45 per mm3 with predominant lymphocytes. Moderately turbid fluid showed 46 to 500 cells per mm3 and highly turbid fluid showed from 501 to more than 10,00 cells/mm3. In the latter cases, differential counts demonstrated polymorphonuclear predominance. In addition, about 100% (52 cases) of positive and 12.5% (40/319) of negative cases had CSF protein concentration >100 mg/dL. CSF protein concentration greater than 100 mg/dl and sugar level below 40 mg/dl were considered as suspected bacterial meningitis in this study. Surprisingly, the C-Reactive Protein (CRP) values were found to be >40 mg/dL in both culturally positive and negative cases. Most of meningitis positive cases showed increased total cell counts as well as protein concentration, and decreased serum sugar concentrations. J. Asiat. Soc. Bangladesh, Sci. 47(2): 137-147, December 2021

Mycobacteria avium-related peritonitis in a patient undergoing peritoneal dialysis: case report and review of the literature

BackgroundMycobacteria avium (M. avium) is a species of ubiquitous slowly growing nontuberculous mycobacteria. It causes opportunistic infections. However, M. avium-related peritonitis in peritoneal dialysis (PD) patients is rare.Case presentationA 51-year-old female end-stage kidney disease patient undergoing PD was admitted for a noninfectious complication. She presented catheter exit site drainage and slightly increased PD effluent white cell count (WCC) with polymorphonuclear predominance on admission. Exit site infection and PD-related peritonitis were diagnosed. Repeated cultures of effluent and drainage were negative. Initial empirical antibiotics and further adjustment were not rewarding. PD was terminated 2 weeks later, however, shortly the patient developed stupor, high fever, peritoneal irritation, and spontaneous chylous ascites, and showed elevated ascitic adenosine deaminase (ADA). The manifestations persisted and the patient’s general condition deteriorated despite intensified antibiotic therapy. Massive parallel sequencing identified M. avium in ascites on hospital day 25, and 4-drug treatment with azithromycin, amikacin, rifampin, and ethambutol was initiated. Nevertheless, the patient died from sepsis on hospital day 30.ConclusionsWe report a case of PD-related M. avium peritonitis. Prolonged culture-negative peritonitis, chylous ascites, and elevated ascitic ADA may hint the possibility of mycobacterial infections. Diagnostic method allowing prompt identification of the pathogen is warranted. The prognosis can be extremely poor, and the prophylaxis and treatment should be better defined.

Enterovirus Meningitis in Adults: A Prospective Nationwide Population-Based Cohort Study.

To test the hypothesis that enterovirus meningitis (EM) is a frequent and self-limiting condition, the epidemiology of EM in adults was examined. Using a prospective, nationwide, population-based database, all adults with EM confirmed by PCR of the CSF from 2015 to 2019 were included. Unfavorable outcome was defined as Glasgow Outcome Scale scores of 1-4 at discharge. Modified Poisson regression was used to compute adjusted relative risks (RRs). A total of 419 cases of EM in 418 adults (46% female, median age 31 years [interquartile range (IQR) 27-35]) yielded an incidence of 1.80/100,000/year. Admission diagnoses included CNS infection 247/397 (62%), other neurologic conditions 89/397 (22%), and cerebrovascular diseases 33/397 (8%). Genotype was available for 271 cases, of which echovirus 30 accounted for 155 (57%). Patients presented with headache 412/415 (99%), history of fever 303/372 (81%), photophobia 292/379 (77%), and neck stiffness 159/407 (39%). Fever (≥38.0°C) was observed in 192/399 (48%) at admission. The median CSF leukocyte count was 130 106/L (range 0-2,100) with polymorphonuclear predominance (>50%) in 110/396 (28%). Cranial imaging preceded lumbar puncture in 127/417 (30%) and was associated with non-CNS infection admission diagnoses and delayed lumbar puncture (median 4.8 hours [IQR 3.4-7.9] vs 1.5 [IQR 0.8-2.8], p < 0.001). Unfavorable outcome occurred in 99/419 (24%) at discharge; more often in female patients (RR 2.30 [1.58-3.33]) and less frequent in echovirus 30 (RR 0.67 [0.46-1.00]) in adjusted analyses. Outcome remained unfavorable in 22/379 (6%) after 6 months. EM is common among young, healthy adults. Although the long-term prognosis remains reassuring, a substantial proportion have moderate disability at discharge, especially female patients.

Serial Polymorphonuclear Predominance of Cerebrospinal Fluid in a Child with Advanced Tuberculous Meningitis: A Case Report

Introduction: Tuberculous meningitis (TBM) is the most fatal form of tuberculosis. Despite adequate treatment, its mortality and morbidity is high. Clinical, laboratory, and radiologic findings help in diagnosis of TBM, although analysis of cerebrospinal fluid (CFS) might sometimes delay and mislead the rapid diagnosis. Case Presentation: We present a 14- year- old Afghan immigrant male, with uncommon laboratory results of advanced TBM, who referred to Baharloo hospial in Tehran, Iran, in September 2016. He experienced headache and anxiety one month prior to referring to the hospital; he had fever, severe headache, vomiting and showed bizarre behavior 7 days before admission. Suspecting meningoencephalitis, the physician advised empirical treatment. The first CSF revealed polymorphonuclear (PMN) predominance with low glucose, which was repeated in the second and third CSF analysis. This pattern indicates early phase of TB meningitis. In day 4, antituberculous treatment with corticosteroid was administered empirically. Unfortunately, he succumbed to disease in day 36. Polymerase chain reaction (PCR) for mycobacterium tuberculosis (MTB) in CSF was positive. The patient’s presentation (lethargic to coma) and brain computed tomography (CT) scan indicated advanced stage of disease. Conclusions: All physicians should consider TB meningitis in any patient with low glucose even with serial PMN predominance in CSF.

Spontaneous Bacterial Empyema (SBEM) Treated With Antibiotic Therapy Followed by TIPS

Introduction: Hepatic hydrothorax is a complication of liver failure occurring in 5-12% of cirrhotic patients. Infection of the pleural fluid of a hepatic hydrothorax is referred to as spontaneous bacterial empyema (SBEM). We describe a case of spontaneous bacterial empyema in a patient with recurrent hepatic hydrothorax in which transjugular intrahepatic portopulmonary shunt (TIPS) was utilized in addition to antibiotic therapy to assist with symptom control. Case Report: A 64 year old female with a history of alcoholic cirrhosis complicated by esophageal varices, mild hepatic encephalopathy, and recurrent hepatic hydrothorax presented for abrupt worsening dyspnea and cough. She had three previous admissions over the last two months for hepatic hydrothorax requiring thoracentesis. On physical exam she was afebrile, hypotensive, hypoxic, with decreased breath sounds on the right hemithorax. Computed tomography of the chest, demonstrated large right pleural effusion with collapse of the right, middle, and lower lobes. There was no evidence of pneumonic process. A repeat thoracentesis was performed which was consistent with SBEM (Table 1). Pleural fluid gram stain and culture were negative. She was treated with levofloxacin for a total of 4 weeks. She required repeated thoracentesis every 2-3 days secondary to dyspnea and after eight days of antibiotics she underwent TIPS procedure. She required two further thoracenteses prior to discharge. She completed her antibiotic therapy, and did not require further thoracentesis for the last six months.Table 1: Laboratory Work UpDiscussion: SBEM is diagnosed when a patient with known hepatic hydrothorax develops pleural fluid with polymorphonuclear predominance (PMN > 500 cells/mm3 or > 250 cells/mm3 with positive fluid culture) without evidence of pneumonia at the time of diagnosis. Light's criteria is not useful for diagnosis, as pleural fluid can remain transudative. Treatment of SBEM parallels that of spontaneous bacterial peritonitis and relies on antibiotic therapy. Unlike a parapneumonic empyema chest tube drainage is contraindicated. The use of TIPS in patients recovering from SBEM has not been specifically studied, but can be considered in patients with refractory hepatic hydrothorax.

Study of H1N1 cases admitted at tertiary care hospital with special reference to neutrophil-lymphocyte ratio and lymphocyte-monocyte ratio as a screening tool for suspected H1N1

Background: Influenza A (H1N1) infection has been causing significant morbidity and mortality since 2009 epidemic all over the world. There needs to be rapid isolation of suspected patient to prevent further spread. Real-time polymerase chain reaction is a time consuming and costly test to confirm the diagnosis. There is a need of rapid and simple diagnostic test for H1N1. Objective: The study was done to evaluate the utility of neutrophil–lymphocyte ratio and lymphocyte–monocyte ratio as screening tool for suspected H1N1 cases. Material and Methods: This was a retrospective study in which confirmed H1N1 cases from isolation ward for influenza were identified. Data were recorded in validated case record form. All the data regarding clinical history, examination findings, X-ray, and blood count were collected from case records of patients. Negative H1N1 cases were excluded from the study. Result: Mean age of patients was 27.7 year. Mean duration of stay was 5.85 days with range of 3–8 days. The most common symptoms were cough and sore throat (79.41%), fever (76.47%), and breathlessness (47.05%). Low WBC count was observed only in two patients (5.88%) Polymorphonuclear predominance was observed in 21 patients (61.76%). Polymorphonuclear to lymphocyte ratio was >2 in 21 patients and lymphocyte-to-monocyte ratio was observed >2 in 33 patients. Conclusion: P–L ratio and L–M ratio cannot be used as criteria of exclusion of H1N1 infection because of higher prevalence of secondary bacterial infection. This needs to be further evaluated in larger patient population.

English

Perforation of a Meckel's diverticulum is a rare complication. This case report is about a 9yr old child who presented to our emergency department with diffuse abdominal pain, vomiting and fever. He had leucocytosis and free fluid in the peritoneal cavity on USG. Erect x-ray abdomen shows gas under the diaphragm. A perforated appendix or a bowel perforation was suspected and a diagnosis of a ruptured MD was finally made by laparotomy. INTRODUCTION: MD is a true intestinal diverticulum that results from the failure of the vitelline duct (omphalomesenteric duct) to obliterate during the 5 th week of fetal development 1 . MD is the most common congenital abnormality occurring in about 2% of the population. Meckel diverticulum is typically lined by ileal mucosa, but other tissue types are also found with varying frequency. The heterotopic mucosa is most commonly gastric (present in 50% of all MD's) and pancreatic mucosa is encountered in about 5% of diverticula; less commonly, these diverticula may harbour colonic mucosa 2 . This is important because peptic ulceration of this or adjacent mucosa can lead to painless bleeding, perforation, or both. CASE PRESENTATION: A 9 year old, previously healthy child, presented at the emergency room of Dept. of Surgery, AIMS, Bellur, with abdominal pain, that started in the left iliac fossa 24 hrs ago and progressed to be diffuse, accompanied with vomiting and high grade fever. Physical examination showed the patient to be pale and febrile (body temperature of 102 F) with diffuse tenderness along with rebound tenderness in the right iliac fossa. Guarding was noted in all the quadrants. Laboratory tests showed anemia (10.0g %) with leukocytosis (13000cells/cu mm) accompanied with polymorphonuclear predominance (89%) and normal blood biochemistry analysis. Erect X-ray abdomen showed gas under the diaphragm. USG abdomen revealed echogenic free fluid in the peritoneal cavity with few septations in the RIF-? Pyoperitoneum. These findings led to the diagnosis of a bowel perforation. A laparotomy incision made and pyoperitoneum confirmed. Appendix was inflamed and the bowel inspected. A perforated MD found and resection anastomosis of ileum along with appendectomy done. The patient recovered uneventfully and 7 days later was discharged in a fine condition. Histopathological examination showed Meckel's diverticulitis with ectopic gastric tissue forming an adenoma.

Neuro-Behçet: differential diagnosis of recurrent meningitis

Behçet disease is a systemic inflammatory perivasculitis characterized by recurrent episodes of oral and genital ulcers associated with skin and ocular lesions. Neurological involvement occurs in 5 to 10% of the cases, and isolated meningeal involvement is very uncommon. We report a 21 years old man with a Behçet disease and a history of acute meningeal syndrome in two previous crises and meningoencephalitis in three others. He reported a history of conjunctivitis and oral and genital ulcers. On examination, he presented oral aphthoid lesions, macular edema, involvement of cranial nerves, pyramidal signs and meningeal irritation. The cell count in cerebrospinal fluid was 1800 cells/mm³, with polymorphonuclear predominance. Magnetic resonance imaging showed lesions in basal ganglia and the brainstem. The patient improved dramatically after intravenous steroid therapy.

Atypical manifestations and poor outcome of herpes simplex encephalitis in the immunocompromised

To characterize clinical features, neuroimaging, and outcomes of herpes simplex encephalitis (HSE) in immunocompromised individuals. We performed a retrospective case control review of patients diagnosed with HSE. Adult patients were dichotomized into immunocompromised (n = 14) and immunocompetent groups (n = 15). Fewer immunocompromised patients presented with prodromal symptoms and focal deficits. While the majority of CSF profiles in the immunocompromised patients were mononuclear cells predominant, 3 had polymorphonuclear predominance and another 3 had normal profiles. MRI showed widespread cortical involvement, with brainstem or cerebellar involvement in some. Two immunocompromised patients had recurrent HSE. The immunosuppressed state was associated with a decrease in Karnofsky Performance Status Scale (KPSS) score of 23.1 (p = 0.018). Every 1-day delay in initiation of acyclovir was associated with a decrease in KPSS of 10.2 (p = 0.002), and every 10 cell/mm(3) increase of CSF leukocytosis was associated with an increase in KPSS of 0.7 (p = 0.009). Mortality rate was 6 times higher in the immunocompromised patients. Immunocompromised states may predispose to HSE with atypical clinical and neuroradiologic features. Immunocompromised individuals with HSE have significantly worse outcomes and mortality. Early diagnosis and treatment is associated with improved outcome. The findings are particularly important in light of the increasing use of potent immunosuppressive and immunomodulatory therapies.

Importancia de las imágenes y el diagnóstico etiológico en el paciente inmunocomprometido con afección del sistema nervioso central: Tercera parte

A twenty four year-old male patient with a history of morbid obesity and acute lymphocytic leukemia diagnosed in 2003, underwent an autologous bone marrow transplantation the same year. He had two relapses of leukemia on 2003 and 2007. On January 2009, he underwent a double cord bone marrow transplantation with myeloablative conditioning and craneospinal radiotherapy. The patient received prophylaxis with aciclovir, cotrimoxazole and fluconazole. The latter was changed afterwards to posaconazole. On day 16 post-transplantation, fever and meningeal signs appeared. The cerebrospinal fluid exam revealed pleocytosis with polymorphonuclear predominance. Empirical therapy was started with meropenem. Due to neurological impairment, at day 33, a brain magnetic resonance imaging (MRI) was performed, showing multiple hypodense supra and infratentorial nodules with peripheral edema. Biopsy, universal PCR for fungi and a new cerebrospinal fluid analysis were performed and amphotericin B was added showing a favorable response. He was discharged with itraconazole, as the universal PCR of brain tissue revealed Penicillium spp. This is the third report presented in this journal that stresses the importance of early neuroimaging, especially MRI to certify the involvement of the central nervous system in immunocompromised patients.

Aseptic Meningitis in Children: Analysis of 506 Cases

BackgroundNon-polio human enteroviruses are the leading cause of aseptic meningitis in children. The role of enterovirus PCR for diagnosis and management of aseptic meningitis has not been fully explored.Methodology/Principal FindingsA retrospective study was conducted to determine the epidemiological, clinical, and laboratory characteristics of aseptic meningitis and to evaluate the role of enterovirus PCR for the diagnosis and management of this clinical entity. The medical records of children who had as discharge diagnosis aseptic or viral meningitis were reviewed. A total of 506 children, median age 5 years, were identified. The annual incidence rate was estimated to be 17/100,000 children less than 14 years of age. Most of the cases occurred during summer (38%) and autumn (24%). The dominant clinical symptoms were fever (98%), headache (94%) and vomiting (67%). Neck stiffness was noted in 60%, and irritation in 46% of the patients. The median number of CSF cell count was 201/mm3 with polymorphonuclear predominance (>50%) in 58.3% of the cases. Enterovirus RNA was detected in CSF in 47 of 96 (48.9%) children tested. Children with positive enterovirus PCR had shorter hospitalization stay as compared to children who had negative PCR or to children who were not tested (P = 0.01). There were no serious complications or deaths.ConclusionsEnteroviruses accounted for approximately one half of cases of aseptic meningitis. PCR may reduce the length of hospitalization and plays important role in the diagnosis and management of children with aseptic meningitis.

Acute Appendicitis: The Reliability of Diagnosis by Clinical Assessment Alone

This prospective study aimed to review the trustworthiness of the initial clinical assessment in acute appendicitis without employment of imaging modalities, laparoscopy or any other adjunct diagnostic test. 717 patients were operated on for appendicitis by six different surgeons. Initial clinical and laboratory examination were evaluated in relation to the intraoperative and the pathological appreciation of the appendiceal inflammation. 598 patients were found to have appendicitis, 34 a different condition, 41 had both appendicitis and an additional condition and 44 no pathology. 6% of the laparotomies and 11% of the appendectomies were unnecessary. The severity of the inflammation correlated significantly with periumbilical pain, pain migrating to right lower quadrant, loss of appetite, fever, rebound tenderness, local rigidity, polymorphonuclear predominance on deferential, polymorhonucleosis and leukocytosis. Leukocytosis was less frequent in aged patients. All the six surgeons were found to be equally reliable, although they all underestimated the setting compared to the pathologists. Patients with a long duration of symptoms had milder forms of inflammation and increased percentage of unanticipated abdominal conditions. Appendicitis can be reliably diagnosed clinically without employment of adjunct tests. These can be reserved for equivocal cases.

ENCEPHALITIS IN A BOY FROM SOUTH CAROLINA

ENCEPHALITIS IN A BOY FROM SOUTH CAROLINA

Cerebrospinal fluid investigations in tuberculous meningitis

The results of conventional cerebrospinal fluid (CSF) investigations (CSF cell count, protein and glucose concentrations and Pandy's test for CSF globulin) obtained on admission and sequentially from weekly follow-up lumbar punctures for 4 weeks were evaluated in 99 children (median age 28 months) with stage II (50 children) and stage III (49 children) tuberculous meningitis. On admission, six children (6%) had a CSF cell count greater than 500 x 10(6)/l and nine (9%) a polymorphonuclear predominance. A CSF protein less than 0.8 g/l was found in 17 children (18%) of 97 in whom CSF protein was evaluated. Globulin was either absent or present as a trace only in 26 children (27%). CSF glucose was less than 2.2 mmol/l in 58 cases (60%) and less than 2.5 mmol/l in 67 (69%). In 63 children weekly CSF specimens obtained for the 1st 4 weeks of therapy showed an uninterrupted decline in cell count in 23 (37%), a fluctuating downward trend in 27 (43%) and a fluctuating upward trend in 13 (21%). Sequential CSF protein values in 57 children showed an uninterrupted rise in three (5%), a fluctuating upward course in 19 (33%), an uninterrupted downward trend in seven (12%), and a fluctuating downward course in 28 (49%). Of the 61 children in whom sequential CSF glucose concentrations were available, 11 (18%) experienced fluctuating concentrations, values falling to less than 2.2 mmol/l after being greater than 2.2 mmol/l on admission or after having risen to greater than 2.2 mmol/l.(ABSTRACT TRUNCATED AT 250 WORDS)

Characteristics of Pleural Effusions Associated With Pulmonary Embolism

Pleural fluid characteristics were analyzed in 26 patients with pulmonary embolism. All determinations were highly variable. A bloody effusion occurred in 65%, while clear fluid was found in 35%. White blood cell counts had a wide distribution of values; polymorphonuclear leukocytes predominated in 61% and lymphocytes in 39%. Less than two thirds of tested specimens were exudates by standard criteria. Only 27% of effusions had the "typical" pattern of bloody appearance, polymorphonuclear predominance, and characteristics of an exudate. Roentgenographically evident infiltrates occurred in 62% and were correlated with bloody pleural fluid (P less than .01), which suggests that infarction is not necessary for effusion to occur, but may account for a bloody appearance. The variability of these results indicates that there are no typical or diagnostic pleural fluid findings in pulmonary embolism.