Cerebrospinal Fluid Sugar Research Articles

Epidemiology of Lumbar Puncture and the Validity of Meningeal Signs in Predicting Meningitis in Children: A Cross-sectional Study

Introduction: Predictive models have been developed to estimate the likelihood of bacterial meningitis in patients with clinical features suggestive of Central Nervous System (CNS) involvement. Early diagnosis and prompt treatment of bacterial meningitis in children are crucial due to the severity and rapid progression of the disease. However, making a definitive diagnosis in the early stages can be challenging, as clinical symptoms are often non specific and may overlap with other conditions. Lumbar Puncture (LP) is a crucial diagnostic and therapeutic procedure in paediatric medicine to diagnose various neurological diseases, particularly meningitis, by analysing Cerebrospinal Fluid (CSF). Aim: To analyse the epidemiological trends of LP performed in children and to evaluate the accuracy of meningeal signs in predicting the presence of meningitis in paediatric patients. Materials and Methods: This was a cross-sectional study conducted in the Department of Paediatrics at Amala Institute of Medical Sciences, Thrissur, Kerala, South India, from August 2018 to July 2019. The records of paediatric patients (aged 1 month to 12 years) who underwent LP during the one year from August 2018 to July 2019 at the centre were collected. A checklist was prepared for all the patients, where demographic data, clinical presentations, findings of CSF, and blood analysis were recorded. The data obtained were analysed using Statistical Package for Social Sciences (SPSS) version 23.0. Results: Out of 3,125 paediatric admissions during the study period, LP was performed in 125 (4%). The most common indication for LP was fever with seizure in 53 (42.4%), followed by fever and vomiting in 44 (35.2%). There was a statistically significant association between both CSF protein and CSF sugar and a diagnosis of meningitis. Among children presenting with fever and seizure in the age group of one month to two years, 19 (52.8%) had meningitis. The incidence of pyogenic meningitis was 26 (20.8%). Organisms were isolated in 2 (1.6%) of cases. Among the meningeal signs, the Johny Vincent sign and neck stiffness showed better sensitivity, while Kernig’s sign was the most specific. Conclusion: The present study concludes that, in paediatrics, LP remains an essential procedure for differentiating patients with meningitis from those without meningitis when they present with the same symptoms, especially in children less than two years of age. In older children, clinical variables such as meningeal signs and seizures at admission had lower sensitivity and Positive Predictive Value (PPV), which again highlights the need for performing an LP.

Primary Leptomeningeal Lymphoma in HIV-infected Patients Presented with Subacute Meningitis

Primary leptomeningeal lymphoma (PLML) is extremely rare, accounting for only 7% of all primary central nervous system lymphomas. We present a case of PLML in a person living with HIV with controlled disease, presented with low cerebrospinal fluid sugar meningitis and leptomeningeal nodular enhancement, posing a diagnostic difficulty because the presentation resembled infectious diseases.

Clinical profile and mortality predictors in hospitalised patients of tuberculous meningitis

Background& Objective: Tuberculous meningitis (TBM) is a serious public health problem in developing countries like India as it leads to significant mortality and neurological sequelae. Aim of study was to describe clinico-radiological profile of TBM and determine predictors of mortality. Methods: This was a prospective study and data collected including demographic details, clinical, laboratory parameters and neuroimaging finding. Diagnosis of TBM was based according to a standard case definition proposed by Marais et al.(2010). Results: One hundred and forty two TBM patients were recruited with 54.93% males and 45.07% females. Fever was most common symptom followed by headache, vomiting, altered sensorium and seizure. Most common cranial nerve palsy was of 6th cranial nerve followed by 2nd cranial nerve. Cerebrospinal fluid (CSF)study in 77.46% of patients showed protein >100 mg/dL, 61.27% patients had CSF sugar <40 mg/dL while 87.32% of patients had total cell count >10 cells/cumm. Most common Neuroimaging finding was meningeal enhancement followed by hydrocephalus, infarcts, basal exudates and tuberculoma. In-hospital mortality was 17.61%. Higher age, low Glasgow Coma Scale (GCS) score, absence of headache, seizure, altered sensorium, anemia, low CSF glucose, infarct, hydrocephalus, and British medical research council (BMRC) Stage III at presentation were predictors of in-hospital mortality. Conclusions:. Age, GCS score, absence of headache, seizure, altered sensorium, anemia, low CSF glucose, infarct, hydrocephalus, and BMRC Stage III at presentation were predictors of in-hospital mortality based on this study from Bihar, India.

Efficacy of intensive antibiotic regimens on postcraniotomy fever and cerebrospinal fluid examination results in patients with infratentorial surgeries

Postcraniotomy fever is a common complication in patients undergoing infratentorial surgeries. There are few studies about it and the efficacy of intensive antibiotic regimens, which remain to be studied. We carried out a retrospective study in patients undergoing infratentorial surgeries to analyze the factors associated with postcraniotomy fever and further investigated the efficacy of different antibiotic regimens on fever and abnormal cerebrospinal fluid (CSF) results. Among the 115 patients, 74 (64.3%) had fever after craniotomy. Univariate analysis results showed that disease type, drainage tube placement, duration of drainage tube, and intraoperative bleeding volume were associated with postcraniotomy fever in patients undergoing infratentorial surgeries (P < .05). The multivariate analysis results showed that the duration of drainage tube (odds ratio = 1.010, 95% confidence interval: 1.232-6.178, P = .014) and duration of surgery (odds ratio = 1.010, 95% confidence interval: 1.002-1.017, P = .013) were associated with postcraniotomy fever in these patients. After treatment with different antibiotic regimens, the changes of white blood cells, sugar, chlorine and protein in CSF in patients with intensive antibiotic regimens were -638.48 × 106/L, 0.25 mmol/L, -0.76 mmol/L and -0.16 g/L respectively, which did not show significant differences when compared with ordinary antibiotic regimens (P > .05). Most cases of fever at the early stage after craniotomy in patients with infratentorial surgeries were nonintracranial infectious. Intensive antibiotic regimens did not show obvious advantages in improving the body temperature and CSF examination results. It is not necessary to use intensive antibiotic regimens too early, such as carbapenems or linezolids.

Stroke in Tuberculous Meningitis and Its correlation with Magnetic Resonance Angiography Manifestations.

Objective The primary objective of the study was to assess the location of cerebral infarction and look for corresponding magnetic resonance angiography (MRA) changes in patients with tuberculous meningitis (TBM). We also evaluated the predictors of ischemic stroke in TBM and the impact of these infarctions on patient's outcome. Methods This was a single-center prospective study between September 2018 and September 2020. Demographic and laboratory parameters were noted. Cranial magnetic resonance imaging and MRA were performed at the time of admission to the hospital. Results Among 120 patients with TBM, 46 had stroke. Nineteen (15.8%) patients died, of which 12 (10%) suffered from stroke. The most common site of infarction was the basal ganglia (54.3%). The commonest site of MRA abnormalities was the middle cerebral artery (39.1%). British Medical Research Council (BMRC) stage 3, cerebrospinal fluid (CSF) sugar, CSF adenosine deaminase (ADA) level, basal exudates, hydrocephalus, and hyponatremia were found to be predictors of stroke in TBM, while BMRC stage 3, CSF cell count, CSF ADA level, and anemia were found to be significantly associated with mortality in TBM patients with stroke. Conclusion The basal ganglia were the most common site of ischemic stroke in TBM, and middle cerebral artery was the most often involved intracranial blood vessel. BMRC stage 3 was significantly associated with both stroke and mortality in TBM patients with stroke.

Cerebrospinal Fluid Procalcitonin-A Potential Biomarker for Post-Craniotomy Bacterial Meningitis.

The literature regarding the utility of cerebrospinal fluid (CSF) procalcitonin (PCT) in the diagnosis of post-craniotomy bacterial meningitis and differentiating it from aseptic meningitis is sparse. CSF total WBC count, sugar, protein, and PCT were measured in febrile patients with suspected post-craniotomy meningitis during the first 30 days following an intradural cranial procedure for non-trauma indications. Patients were diagnosed as postoperative bacterial meningitis if CSF culture was positive (PBM, n = 28) or postoperative aseptic meningitis if CSF culture was sterile and there was no evidence of systemic infection (PAM, n = 31). CSF cytochemical parameters and PCT values were compared between the groups. Normal values of CSF PCT were obtained from 14 patients with noninfectious indications with hydrocephalus. There was no significant difference in CSF total WBC count, sugar, and protein levels between PAM and PBM groups. The median PCT level in CSF in the normal group was 0.03 ng/mL (interquartile range [IQR] 0.02-0.07 ng/mL). CSF PCT in the PBM group (median 0.37 ng/mL, IQR 0.2-1.4 ng/mL) was significantly higher than normal values as well as PAM group (median 0.12 ng/mL, IQR 0.07-0.26 ng/mL (P = 0.0004). The area under the receiver operating characteristic (ROC) curve for CSF PCT was 0.767. A cutoff value of 0.12 ng/mL yielded a sensitivity of 85.7% (95% CI: 67.3% to 96%), specificity of 51.6% (95% CI: 33% to 69.9%), positive predictive value of 61.5% (95% CI: 51.9% to 70.3%), and negative predictive value of 80% (95% CI: 60.3.8% to 91.3%). CSF PCT assay in patients who are febrile during the first 30 days post-non-trauma neurosurgical procedures has a role in the early diagnosis of bacterial meningitis.

Epidemiological evaluation of meningitis in hospitalized patients in shahid Madani Hospital in Khorramabad

Background: Bacterial meningitis is an acute infection of the meninges requiring immediate diagnosis and treatment. Clinical, laboratory, and epidemiological findings of meningitis are of utmost importance for rapid diagnosis and treatment. The present study aimed to evaluate patients with meningitis based on their epidemiological, clinical, and laboratory findings and compare these variables between patients with septic and aseptic meningitis. Materials and Methods: In this retrospective cross-sectional descriptive study, all children with suspected meningitis in Shahid Madani Hospital in Khorramabad in 2014-2015 were examined for spinal fluid culture, age, gender, seasonal distribution, and antibiogram results. Results: Among 63 patients with meningitis, 30 (47.6%) cases had septic meningitis, and 33 (52.4%) subjects had aseptic meningitis. Out of 30 patients with septic meningitis, 4 (13.3%) patients had positive microbial culture. Among patients with septic meningitis, only four bacterial isolates were isolated by the microbial culture method, out of which Streptococcus pneumoniae was the most common bacterium and the prevalence was higher in autumn and winter. The most effective antibiotics were cotrimoxazole and vancomycin with a sensitivity of 100%; nonetheless, there was relatively high resistance to cloxacillin, erythromycin, and clindamycin. The number of white blood cells (WBCs), sugar, and protein in cerebrospinal fluid (CSF) in septic meningitis were compared with aseptic meningitis, and a significant difference was observed between the two groups. There was also a significant difference between gender and septic meningitis, and male patients were more likely to suffer from septic meningitis. Conclusion: The prevalence of aseptic meningitis was higher than that of septic meningitis. Microbial tests are very effective in the correct diagnosis and treatment; however, the level of WBC, glucose, and protein in CSF can also be of great help in diagnosing different types of meningitis, especially septic meningitis.

To Study the Electroencephalogram Changes in Children with Acute Encephalitis

Aim: To study the electroencephalogram changes in children with acute encephalitis. Study design: Cross-sectional study. Place and duration of study: The cases were admitted from OPD and emergency over duration of 10 months from May2009 to March 2010 in Children Hospital PIMS, Islamabad. Method: Patients with Cerebral Palsy, Degenerative Brain disease, Cerebral Malaria and Meningitis were excluded. Written informed consent was taken from parents /guardians. All patients, from both genders, age varying from 4 months to 12 years, fitting the criteria of Acute Encephalitis according to ICD 9 &amp; 10 were included in the study, which were 56 in total. All cases had Lumbar puncture and Cerebro Spinal Fluid examination. The findings of pleocytosis (WBC count more than5 u/l), protein and sugar were recorded. EEG (Electroencecephlogram) was done in 52 patients, frequencies and percentages were calculated of the findings. Results: The mean age was 4. 6 years, (varying from 4 months to 12 years) with a standard deviation of 3. 2. From a total of fifty six patients, 38(68%) were males and 18(32%) females. All cases presented with fever (100%). Cerebro Spinal Fluid examination, showed Pleocytosis in 30(54%) while 46(46%) had normal cell count. Cerebro Spinal Fluid protein content was normal in 45(80%) and increased in 11(20%). Cerebro Spinal Fluid sugar was normal in 50(89%) and 6(11%) had low. Electroencephalogram was done in fifty-two patients out of which 30(58%) were normal, 22(42%) were abnormal. Intermittent slowing was found in 17(77%) and 5(23%) cases had focal discharges along with intermittent slowing, out of which three were unilateral temporo-frontal discharges, two cases had other focal discharges on EEG. Conclusion: In patients with Acute Encephalitis, slowing of the rhythm was the most frequent abnormal Electroencephalogram finding, followed by focal discharges in children admitted in Children’s Hospital PIMS, Islamabad. Keywords: Acute Encephalitis, Electroencephalogram (electro encephalogram), Cerebro Spinal Fluid Pleocytosis, Fever

Antimicrobial Resistance and Predictors of Adverse Outcomes in Neonates with Bacterial Meningitis: A Retrospective Study from a Tertiary Care Hospital of Northern India

AbstractThis study aimed to determine antimicrobial resistance pattern and predictors of adverse outcome in neonatal meningitis. A retrospective study by analyzing case files of 134 cases of neonatal meningitis. We noted an alarming degree of multidrug resistance (MDR) among both gram-negative (Klebsiella spp., 50%; Escherichia coli, 100%; and and Acinetobacter spp., 50%), as well as positive (Enterococcus, 100%) isolates in cerebrospinal fluid (CSF) culture. The incidence rate of adverse outcome (i.e., mortality and abnormal neurological examination at discharge) was 8.2 and 17.2%, respectively. On univariate analysis, delayed seeking of medical care, bulging anterior fontanelle, vomiting, positive sepsis screen, shock during hospital course, ventriculitis, diversion procedures for raised intracranial pressure, central line placement, low CSF sugar, and failed hearing screening test at discharge were associated with increased risk of adverse outcome. Further, delayed seeking of medical care, shock during hospital course, positive sepsis screen, thrombocytopenia, and MDR infections were independently found to be associated with adverse outcomes. An alarming degree of antimicrobial resistance among the CSF isolates necessitates the need to understand the pathogenesis of resistance and curtail the irrational prescription of antibiotics in neonatal meningitis. Further, delayed seeking of medical care, shock during hospital course, positive sepsis screen, thrombocytopenia, and MRD infection may have prognostic value in neonatal meningitis

Improved Diagnosis of Tuberculous Meningitis Using a Combination of Multiplex Antigens and Antibodies Testing Methods

Introduction: Various serological assays exists, including Antigen and Antibody detection (IgM and IgG) for diagnosis of Tuberculous Meningitis (TBM) cases. To the best of our knowledge, most of the laboratories either do Antigen detection or IgM or IgG, at a time. As different antigens get expressed in a different stage of infection it may be possible that many cases remain undiagnosed due to one test at a time approach. Aim: To evaluate the combination of Mycobacterium Tuberculosis (MTB) antigen (Ag85 Complex and Rv2623) and antibody (Anti-Ag85, Anti-45kD, Anti-HSP-16, Anti-CFP-10 Anti-GroES and Anti-ESAT-6) immunoassay panels in the Cerebrospinal Fluid (CSF) samples for diagnosis of TBM patient. Materials and Methods: In the present prospective study conducted at Central India Institute of Medical Sciences (CIIMS) from October 2013 to April 2015, a total of 200 CSF samples of different groups {confirmed TBM (n=100) and noninfectious neurological diseases as control (n=100)} were analysed by Enzyme-Linked Immunosorbent Assay (ELISA). A panel of MTB antigens consisting of Ag85B, 45kDa, HSP-16, CFP-10, GroES and ESAT-6 were used for detection of antibodies response, whereas polyclonal antibodies were used for antigen detection of Ag85 complex and Rv2623 in the CSF samples. The comparison of the CSF parameter between TBM and non-TBM patients was performed using a student t-test. A p-value &lt;0.05 was considered statistically significant for all the analyses. Results: The study population has similar age and sex distribution (p&gt;0.05). Symptoms of headache, fever, neck stiffness, vomiting, abnormal behaviour, unconsciousness were more common among the TBM patients as compared to non-TBM patients (p&lt;0.05) (TBM Vs non-TBM). Similarly TBM patients had an increase (p&lt;0.05) Vs non-TBM total cell count, protein, parallel blood sugar and decline in CSF sugar and Parallel blood sugar ratio (p&lt;0.05) (TBM Vs non-TBM). We found diagnostic accuracy of 67% to 76% with either antigen or antibody assay, however, combinations of antigen and antibody immunoassay together increase the diagnostic accuracy of up to 96%. Conclusion: Our study recommends that a combination of antigen and antibody assay should be considered for early and accurate diagnosis of TBM cases.

Analysis of Clinical Related Factors of Neonatal Hand-Foot-Mouth Disease Complicated With Encephalitis.

Objective: To explore the clinical related factors of neonatal hand-foot-mouth disease (HFMD) complicated with encephalitis.Method: The neonatal HFMD complicated with encephalitis treated in our hospital from July 2015 to July 2020 was taken as the object of study. According to the NBNA score at discharge, the patients were divided into normal group and abnormal group. The clinical symptoms, auxiliary examination and prognosis of the two groups were compared.Result: (1) General condition: there was no significant difference in sex, age, duration of fever, treatment time and etiological test between the two groups (P > 0.05). (2) Clinical symptoms and signs: there was significant difference in abnormal consciousness between the two groups (P < 0.05). However, there was no significant difference in skin rash, respiratory system symptoms, digestive system symptoms, signs of high intracranial pressure, increased muscle tone and weakening of primitive reflex (P > 0.05). (3) Auxiliary examination: the number of white blood cells and the level of cytokines (CK-BB, UCH-L1) in cerebrospinal fluid (CSF) in the group with abnormal NBNA score were significantly higher than those in the group with normal NBNA score (P < 0.05). The serum IgM level in the abnormal NBNA score group was higher than that in the normal NBNA score group, and the serum IgG level in the abnormal NBNA score group was lower than that in the normal NBNA score group, and the difference was statistically significant (P < 0.05). The abnormal rate of Craniocerebral MRI in abnormal NBNA score group was higher than that in normal NBNA score group, and there was significant difference between the two groups (P < 0.05). There was no significant difference in the levels of protein, sugar, chloride, lactate dehydrogenase, and MMP-9 in CSF and the abnormal rate of amplitude integrated EEG (aEEG) between the two groups (P > 0.05). (4) The prognoses of patients with normal and abnormal NBNA score are good, and there are not significantly differences in the prognosis between the two groups (P > 0.05).Conclusion: (1) Neonatal HFMD complicated with encephalitis occurs more than 10 days after birth, there is no obvious abnormality in male and female, the vast majority of newborns have febrile symptoms, rash is not its specific manifestation, and most of them are atypical. (2) The positive rate of HFMD-related virus detected in CSF of neonatal HFMD is high. For newborns with abnormal consciousness, CSF examination should be accomplished in time, which has certain clinical significance for early diagnosis and treatment of severe newborns. (3) The increase of white blood cell count and cytokines (CK-BB, UCH-L1) in CSF of neonatal HFMD complicated with encephalitis has a certain clinical reference value for early diagnosis and identification of severe newborns. (4) There is a certain humoral immune disorder in newborns with HFMD complicated with encephalitis, but the overall prognosis is better due to the protective effect of maternal IgG.

Surgical treatment and operation time in human immunodeficiency virus-negative cryptococcal meningitis.

There are still no unified guidelines of surgical treatment and timing for human immunodeficiency virus (HIV)-negative patients with cryptococcal meningitis (CM).The clinical data and follow-up data were collected from HIV-negative CM patients in Xiangya Hospital of Central South University from January 2009 to November 2018, and 42 patients who were treated with surgical intervention were enrolled in the present study. These 42 patients were divided into ventriculoatrial (VA) group, ventriculoperitoneal group, external ventricle drainage (EVD) group, hydrocephalus (HYC) group, non-HYC group, EVD group, and non-EVD group (VA/ ventriculoperitoneal) according to different surgical procedures. Statistical analyses were conducted using SPSS (version 19.0, Chicago, IL).Signs of headache, fever, and loss of consciousness in the VA group were significantly improved compared with the EVD group at 1 week after operation (P < .05). The mortality rate of the VA group was significantly lower than that of the EVD group (P < .05). Moreover, male patients were more prone to have HYC (P < .05). Younger patients tended to develop HYC (P < .05). Cerebrospinal fluid sugar in the non-HYC group was significantly lower compared with the HYC group (P < .05). Time of CM-to-operation in the non-HYC group was markedly shorter compared with the HYC group (P < .01).VA procedure could be one of the first choices for the treatment of uncontrollable intracranial hypertension caused by CM. Severe uncontrollable headache, loss of consciousness, and cerebral hernia were indications of emergency surgery. Repeated headache, hearing impairment, and especially progressive loss of vision were indications of early surgery to avoid permanent damage to nerve functions of HIV-negative CM patients.

Use of Urinary Reagent Strips in Testing Cerebrospinal Fluid For Meningitis - A Review

Analysis of cerebrospinal fluid (CSF) is needed to make a meningitis diagnosis to assist in the propermanagement of patients. There is a good correlation between the results of reagent strip test and laboratorymethods of CSF protein, sugar, and leukocyte estimation. CSF supplies nutrients to tissue in the nervoussystem. CSF eliminates waste products from cerebral metabolism. Cerebrospinal fluid has three mainfunctions: CSF protects against trauma on the brain and spinal cord. Meningitis is a rare infection thataffects the delicate membranes called meninges, which cover the brain and spinal cord. Index test wasdone for testing meningitis using urinary reagent strips. An intrusive outpatient procedure used to removea sample of cerebrospinal fluid (CSF) from the spine’s subarachnoid area is a lumbar puncture (LP), alsocalled a spinal tap. A urinary test strip or dipstick is a simple medical tool used in normal urinalysis to assessabnormal differences in a patient’s urine. There is a good correlation between the results of reagent strip testand laboratory methods of CSF protein, sugar, and leukocyte estimation. The review gives a clear view andknowledge about the usage of urinary reagent strips in measuring CSF for meningitis.

Study on biochemical and radiological profile in children clinically diagnosed as tubercular meningoencephalitis: a prospective study from a tertiary care centre in Rajasthan

Background: Objective of the current study was to assess biochemical profile and neuroimaging findings in children diagnosed with neurotuberculosis in a tertiary care centre in Southern Rajasthan, India.Methods: A prospective randomized controlled trial was conducted in Department of Pediatrics, tertiary care centre in Southern Rajasthan, India from July 2017 to June 2018. Total 110 children of age group of 6 months to 18 years with the diagnosis of tubercular meningoencephalitis (TBME) on the basis of clinical evaluation, cerebrospinal fluid (CSF) examination and neuroimaging were included in the study.Results: Among 110 children included in the study, CSF lymphocytic pleocytosis was seen in all. Majority of children (56.36%) cell counts were in the range of 101-500 cells/µl and mean CSF cell count was 198.09±177.86 per µl. CSF protein ranges from 100 to 400 mg/dl in 68.2% children and 19 children had CSF protein &gt;400 mg/dl with mean of 230.98±167.73 mg/dl. In majority of patients (40%) CSF glucose level was in range of 20-40 mg/dl and in 31.82% children CSF glucose was &lt;20 mg/dl. Mean CSF sugar level was 33.86±18.22 mg/dl. None of them demonstrated acid fast bacillus (AFB) on Ziehl-Neelsen staining of CSF sample. Chest radiographic abnormality was found in 41.82% cases. Mantoux test was positive in 16.36% (18) children admitted with TBME. Common abnormalities noted on neuroimaging were: Communicating hydrocephalus (77.27%), meningeal enhancement (40%), infarction (27.27%), cerebral oedema (11.82%) and 9.09% has tuberculoma on neuroimaging. CSF and gastric aspirate were examined by cartridge based nuleic acid amplification test (CBNAAT) for Mycobacterium Tuberculosis (MTB), among them 5 (4.55%) children had positive in CSF and 16 (14.55%) had gastric aspirate positive for MTB by CBNAAT.Conclusions: Clinical, biochemical and radiological parameters is sufficient enough to diagnose TBME in children.

SHUNT MALFUNCTION IN TUBERCULOUS MENINGITIS- WHETHER GRADE AND CSF PICTURE AFFECT OUTCOME

BACKGROUND Tuberculosis remains a major global problem and a public health issue of considerable magnitude. The World Health Organisation (WHO) estimates that one third of the world’s population is infected with mycobacterium tuberculosis, with the highest prevalence of tuberculosis in Asia. Shunt surgery for hydrocephalus associated with tuberculous meningitis has proven to be highly efficacious. Few studies have addressed the issue of outcome of shunt surgery and impact of CSF (Cerebrospinal fluid) picture in post tuberculous meningitis hydrocephalus shunt surgery. MATERIAL AND METHODS The study was a prospective study conducted in Department of Neurosurgery, PGIMER, Dr. RML Hospital, New Delhi. The duration of follow up was of 6 months. 70 patients were enrolled in the study. All patients who underwent ventriculo-peritoneal shunt surgery for hydrocephalus with tuberculous meningitis in Neurosurgery department at PGIMER &amp; Dr.RML hospital were included in the study. All the patients who had hydrocephalus following tuberculous meningitis were evaluated using Modified Vellore grading of TBM and hydrocephalus. All the patients who underwent ventriculo-peritoneal shunt surgery had have their CSF analysis (cytology, protein, sugar, Gram stain, ZN stain, India ink and aerobic culture) done. Outcome of the surgery were evaluated based on Glasgow outcome score (GOS), radiological parameters and complications. Statistical analysis was performed by the SPSS program for Windows, version 17.0. RESULTS The age of patients enrolled into the study varied from 2 months to 87 years with 44.3% of patients in 1-5 years age group. Patients were divided into 4 grades according to Modified Vellore Grading. Grades at the time of admission were compared with the final Glasgow outcome scale. At the time of admission 6 patients were in Grade I, 13 patients in Grade II, 45 patients in Grade III and 6 patients in Grade IV. GOS was 5 in Grade I, 4.69 +/- in Grade II, 4.50 +/- IN Grade III and 2.17+/- in Grade IV. Outcome was compared according to Cerebrospinal fluid (CSF) cell count, sugar and protein levels but none was found to be significant. Number of shunt revisions were compared to CSF cell count and sugar level but none was found to be significant. Mean FH/ID ratio before surgery was 60.89% which was reduced to 43.70% after 6 months follow up. CONCLUSION Ventriculo-peritoneal shunt surgery is a safe and effective treatment modality to treat tuberculous meningitis with hydrocephalus in all grades of patients except in Grade IV. CSF protein, sugar levels and cell count neither affect the outcome nor increase the risk of shunt malfunction

Ameliorative effects of ceftriaxone sodium combined with dexamethasone on infantile purulent meningitis and associated effects on brain-derived neurotrophic factor levels.

The aim of the present study was to evaluate the role of ceftriaxone sodium combined with dexamethasone on the treatment of infant purulent meningitis (PM) and to measure brain-derived neurotrophic factor (BDNF) levels in children with PM. Of the 177 patients enrolled into the present study, 92 patients received ceftriaxone sodium+dexamethasone (combination group) and 85 patients received ceftriaxone sodium alone (monotherapy group). The time taken for the body temperature, peripheral blood (PB) and cerebrospinal fluid (CSF) white blood cell (WBC) counts to recover back to normal levels were compared between the two groups. In addition, changes in the CSF WBC counts, CSF protein and sugar concentrations, BDNF levels, effective treatment rates and incidence of adverse reactions three days before treatment (T1), after one week of treatment (T2) and after two weeks of treatment (T3) were compared between the two groups. In the combination group, the recovery time of body temperature, WBC counts in both PB and CSF were significantly lower compared with those in the monotherapy group. The combination group also exhibited lower CSF protein concentrations and higher CSF sugar concentrations at T2 and T3 compared with those in the monotherapy group (P<0.05). The effective treatment rate of the combination group was significantly higher compared with that of the monotherapy group (P=0.006). CSF protein at T1, T2 T3, and CSF sugar concentrations and BDNF levels at T1 were significantly lower in the combination group than in the monotherapy group (P<0.05) while the CSF sugar concentrations at T2, T3 were higher in the combination group than in the monotherapy group (P<0.05). Taken together, these observations suggest that ceftriaxone combined with dexamethasone was superior compared with that of ceftriaxone alone for the treatment of infantile PM, and that this combination therapy may improve the effective treatment rate and accelerate patient rehabilitation.

Differential diagnosis of scrub typhus meningitis from tuberculous meningitis using clinical and laboratory features

ObjectivesThe involvement of the central nervous system in the form of meningitis or meningoencephalitis is common in scrub typhus and is an important differential diagnosis of other lymphocytic meningitis like tuberculous meningitis (TBM). The aim of this study was to identify the clinical and laboratory parameters that may be helpful in differentiating scrub typhus meningitis from TBM. Patients and methodsWe compared of the clinical and laboratory features of 57 patients admitted with scrub typhus meningitis or TBM during a 3-year period. Patients who had abnormal cerebrospinal fluid (CSF) and positive scrub typhus enzyme-linked immunosorbent assay serology (n=28) were included in the scrub typhus meningitis group, while the TBM group included those who satisfied the consensus diagnostic criteria of TBM (n=29). ResultsCompared with the TBM group, the mean duration of symptoms was less in patients with scrub typhus meningitis, who also had a lower magnitude of neurological deficits, such as altered mental status and cranial nerve and motor deficits. Patients with scrub typhus meningitis had a lower CSF white blood-cell count (WBC) than the TBM group (130.8±213 195±175 cells/mm3, P=0.002), lower CSF protein elevation (125±120 vs. 195.2±108.2mg/dl, P=0.002), and higher CSF sugar (70.1±32.4 vs. 48.7±23.4mg/dl, P=0.006). Features predictive of the diagnosis of scrub typhus meningitis included the absence of neurological impairment at presentation, blood serum glutamic-oxaloacetic transaminase>40 international units (IU)/L, serum glutamic-pyruvic transaminase>60 IU/L, total blood leukocyte count>10,000/mm3, CSF protein<100mg/dl, CSF sugar>50mg/dl, CSF WBC<100 cells/mm3. All patients with scrub typhus meningitis recovered completely following doxycycline therapy ConclusionsThis study suggests that, clinical features, including duration of fever, neurological deficits at presentation and laboratory parameters such as CSF pleocytosis,CSF protein elevation, CSF sugar levels and liver enzyme values are helpful in differentiating scrub typhus meningitis from tuberculous meningits. These features with scrub IgM serology may be helpful in identifying patients with scrub meningitis and in avoiding prolonged empirical antituberculous therapy in cases of lymphocytic meningitis.

"No rent is small for migration of epidural catheter into sub-arachnoid space".

Sir, Read with interest the article ‘No rent is small for migration of epidural catheter into sub-arachnoid space’.[1] I have few observations regarding this article and need further clarifications before believing that catheter could migrate through such a small opening in the sub-arachnoid space. First, 26-gauge 1½ inch (3.81 cm) long needle was used for infiltration of local anaesthesia and understandably, the needle must have been introduced up to the junction of the shaft with the hub as cerebrospinal fluid (CSF) was aspirated due to puncture of the dura. However, when epidural space was located, it was found at the depth of 4 cm, marginally more than the sub-arachnoid depth. How it can be explained? Considering some thickness for dura (0.5 mm) and a few mm of epidural space, the distance to be covered by the needle to meet the sub-arachnoid space should have been a little more than 4 cm. Second, if authors could confirm the returning fluid to be CSF (temperature and sugar analysis) from the epidural catheter, they could as well have done the same for the returning fluid from the needle used for infiltrating local anaesthetic. The injected saline returning into the catheter or needle might easily mislead us to believe it to be CSF. Often, the local anaesthetic that is injected into soft tissues flows back into the needle under pressure. I believe, this was the case in this episode also. Authors have not mentioned what medium was used to ascertain loss of resistance technique, whether air or saline. Further, since the epidural needle was inserted up to 4.0 cm, it seems more probable that the epidural needle created a large rent in the dura, leaving the arachnoid membrane intact and catheter must have penetrated arachnoid membrane with ease before entering into sub-arachnoid space.[2,3,4,5] Dura mater is thin posteriorly and relatively thicker on its anterior aspect; this fact predisposes to dural puncture by epidural catheters with a pointed tip. In this report, CSF flow was seen when the catheter was inserted up to 14 cm and, therefore, another possibility is that catheter tip might have perforated the dura and catheter entered in the sub-arachnoid space.[6] I believe entry of epidural catheter through opening made by the 26-gauge needle is solely based on a presumption as it is not confirmed by any investigation. I hope authors may be able to answer the raised queries to justify their claim.

No rent is small for migration of epidural catheter into sub-arachnoid space.

Sir, Epidural analgesia forms the mainstay of pain relief in abdominal surgeries.[1,2] Epidural needle placement and catheter insertion are preferably performed under local anaesthesia, before induction of general anaesthesia.[3] Dural puncture by the epidural needle is a known complication, and the reported incidence of accidental dural puncture varies from 0.4% to as high as 6%.[4] Dural puncture precludes the catheter placement in the same inter-vertebral space because rent created in the dura mater may allow intra-thecal migration of the epidural catheter. We report a case of inadvertent intra-thecal migration of the epidural catheter through a dural puncture by a 26 gauge needle. A 38-year-old male patient, height 167 cm and weight 63 kg. was posted for hepato-jejunostomy for the benign stricture of the common bile duct. After a written informed consent, patient was taken up for the surgery. As part of perioperative anaesthesia care, epidural catheter placement was planned in the sitting position. With all sterile precautions, inter-vertebral space between 8th and 9th thoracic vertebra was marked and was punctured with a 26 gauge 1½ inch long needle, for infiltration of local anaesthesia. An aspiration check before injecting the local anaesthetic revealed that probably dura mater had been punctured, and fluid, possibly cerebro-spinal fluid (CSF) was getting aspirated. A note of the depth at which dura mater was punctured was made. Because the dura mater was punctured with a 26 gauge needle, too small to be of concern, it was decided to use the same inter-vertebral space for epidural catheter placement. Epidural space was identified by the loss of resistance technique with a 16 Gauge 12 cm long Tuohy epidural needle (with catheter stabiliser). Skin to epidural space distance was 4 cm. There was no CSF leakage at the hub of the epidural needle. The epidural catheter was easily inserted through the needle but just as the catheter had crossed the mark of 14 cm at needle hub, fluid was seen flowing into the catheter. Fluid was aspirated into a syringe, and it was confirmed as CSF (temperature and sugar content of the aspirated fluid). Epidural catheter was then withdrawn and was placed in an inter-vertebral space higher up. Rest of the course of the hospital stay of the patient was uneventful. Dural puncture by epidural catheter on its own is not possible, though arachnoid puncture by the epidural catheter has been shown in an experimental study.[5] In our patient since dura mater and the arachnoid mater were punctured with a 26 G needle, it would have created a weak point through which subsequently the epidural catheter would have travelled into the intra-thecal space. Robbins et al. had also reported a similar case where accidental intra-thecal insertion of an extradural catheter happened during combined spinal-extradural anaesthesia.[6] They used a 26 gauge Whitacre spinal needle through 16 gauge Tuohy extradural needle. Physical characteristics like height and weight can be used to predict the depth of the epidural space to guide epidural needle placement. Ravi et al. in their study had concluded that the mean depth of epidural space in patients of body mass index (BMI) <30 is 41.60 ± 5.80 mm on the basis of a formula (Depth [mm] = a + b [BMI]. where a = 17.7966 and b = 0.9777).[7] Our patient with a calculated BMI of 22.6, the predicted depth of the epidural space was 39.89 mm. Whereas skin to sub-arachnoid space depth (SSD) in Indian males is reported to be 4.81 ± 0.68 cm,[8] the formula derived for determining SSD in the Indian population, 2.71 + 0.09 × BMI, predicts SSD of 4.74 cm for our patient.[8] We located the epidural space at 4 cm depth from the skin that was well within the predicted depth for epidural space, and was short of the predicted SSD. This also supports our observation that the epidural needle was indeed in the extradural space. In our case, that the epidural catheter migrated into the sub-arachnoid space in the absence of any undue force warrants caution. We suggest that caution should be exercised even while puncturing inter-vertebral space for infiltration for local anaesthesia and in case dural puncture happens, epidural puncture should not be attempted in the same inter-vertebral space.

Scrub typhus meningitis: An under-recognized cause of aseptic meningitis in India.

Central nervous system (CNS) involvement in scrub typhus is seen in up to a quarter of patients. However, the literature on cerebrospinal fluid (CSF) analysis and outcome in meningitis/meningo-encephalitis due to scrub typhus is scant. This retrospective study included patients who were admitted to a medical college hospital with scrub typhus meningitis/meningo-encephalitis between 2005 and 2011. The clinical and laboratory profile, details of CSF analysis and outcome were documented. The study included 189 patients with meningitis/meningo-encephalitis due to scrub typhus. The mean age of the patients was 41 ± 4 years. The mean duration of fever before presentation was 9.4 ± 3 days. The common presenting complaints were headache (64.2%), nausea/vomiting (60%), altered sensorium (53.7%) and seizures (22.1%). The presence of an eschar was documented in 27.5% of the patients. The mean CSF white blood count was 80 cells/cu mm (range: 5-740). There was a clear lymphocyte predominance (mean 87.6%). The mean CSF protein level was 105 mg% (range: 13-640). The mean CSF sugar level was 63.9 mg% (range 25-350), and was less than 40 mg% in 11.1% of the cases. The case fatality rate was 5.8% (11/189). Univariate analysis showed the presence of an eschar (15.4% vs 2.2%; Odds Ratio [OR]: 8.1) and altered sensorium (9.8% vs 1.1%; OR: 9.2) to be significant predictors of mortality. In endemic regions, scrub typhus should be considered in the differential diagnosis of aseptic meningitis. Modest elevation of cells in the CSF with lymphocytic pleocytosis and multi-organ involvement may indicate scrub typhus meningitis/meningo-encephalitis.