A 30 yr old person has fever & headache from 20 days.CSF values is following: glucose 38 mg/dl, protein 60 mg/dl, lymphocytes pleocytosis with 20cells/ mm3. Initial lx should include:
Ans: D (HSV...)-Most probable answer In Q pt is presented with feature of meningitis with normal glucose (N value=40-70 mg/dl), normal /slightly?ed protein (N value= 20-50mg/dl) & lymphocytic pleocytosis" So, most probably it is a case of viral meningitisIn Viral meninigitis, glucose remains normal, protein- slightly increased (20-80 mg/dl) & lymphocytic pleocytosis (25-500/ pi) cellsHarrison 17th/2621-27"Patients with viral meningitis usually present with headache, fever, and signs of meningeal irritation coupled with an inflammatory CSF profile""Viral meningitis: The typical profile is a lymphocytic pleocytosis (25-500 cells/uL), a normal or slightly elevated pro tein concentration , a normal glucose concentration, and a normal or mildly elevated opening pressure (100-350 mmH2O). Organismsare not seen on Gram's or acid-fast stained smears or India ink preparations of CSF""The typical CSF profile with viral CNS infections is a lymphocytic pleocytosis with a normal glucose concentration, in contrast to PMN pleocytosis and hypoglycorrhachia characteristic of bacterial meningitis""Using a variety of diagnostic techniques, inciuding CSF PCR, culture, and serology, a specific viral cause can be found in 75-90% of cases of viral meningitis. The most important agents are enteroviruses, HSVtype 2 (HSV-2), and arboviruses""A CSF/serum glucose ratio <0.4 is highly suggestive of bacterial meningitis but may also be seen in other conditions, inciuding fungal, tuberculous, and carcinomatous meningitis" "In cryptococeal meningitis, CSF examination usually reveals evidence of chronic meningitis with mononuclear ceil pleocytosis and increased protein levels. A particularly useful test is cryptococeal antigen (CRAg) detection in CSF and blood"Differential Diagnosis of Viral Meningitis"The most important issue in the differential diagnosis of viral meningitis is to consider diseases that can mimic viral meningitis, including (1) untreated or partially treated bacterial meningitis; (2) early stages of meningitis caused by fungi, mycobacteria, or Treponema pallidum (neurosyphilis), in which a lymphocytic pleocytosis is common, cultures may be slow growing or negative, and hypoglycorrhachia may not be present early; (3) meningitis caused by agents such as Mycoplasma, Listeria spp.. Brucella spp., Coxiella spp., Leptospira spp., and Rickettsia spp.; (4) parameningeal infections; (5) neoplastic meningitis; and (6) meningitis secondary to noninfectious inflammatory diseases, including hypersensitivity' meningitis, SLE and other rheumatologic diseases, sarcoidosis, Behcet's syndrome, and the uveomeningitic syndromes'"Table (Harskmohan 6th/876): CSF changes in Infection of CSSParameter (Normal valuesBacterial MeningitisTubercu lous MeningitisViral MeningitisPressureRaisedRaisedRaisedGross appearanceTurbidClear [may clot)ClearProtein (Normal: 20-50 mg/dL)HighVery HighSlightly highGlucose (40-70 mg/ dL)Very lowLowNormalChloride (116-122 pg/dL)LowVery LowNormalCells <5/microlitNeutrophilsPlecoytosisLympho cytosisTUBERCULAR MENINGITISLu mho r pa flebu re is the cornerstone of diagno sis.In general, examination of the cerebrospinal fluid (CSF) reveals a high leukocyte count (up to 1000/pL), usually with a predominance of lymphocytes but sometimes with a predominance of neutrophils in the early stage; a protein content of 1-8 g/L (100-800 mg/dL); and a low glucose concentration. However, any of these three parameters can be within the normal range.AFB are seen on direct smear of CSF sediment in up to one- third of cases, but repeated lumbar punctures increase the yield. Culture of CSF is diagnostic in up to 80% of cases and remains the gold standard. Polymerase chain reaction (PCR) has a sensitivity' of up to 80%, but rates of false-positivity reach 10%.The ADA concentration may be a sensitive test but has low specificity'. Imaging studies (CT and MRI) may show hydrocephalus and abnormal enhancement of basal cisterns or ependy'ma.
Indian ink smear of CSF
AFB
Toxoplasmosis
HSV detection
C.N.S.