Confusion and fever in the elderly: the necessity of lumbar puncture for CSF examination

To determine the necessity of lumbar puncture for the cerebrospinal fluid examination in the evaluation of hospitalized elderly patients with confusion and fever. It is a descriptive study conducted in Ahwaz a city southwest Iran, from July 2006 to June 2007. Sixty elderly patients with confusion and fever admitted to a teaching hospital, who had a lumbar puncture and cerebrospinal fluid evaluation to evaluate fever and confusion, were studied. After final diagnosis patients were placed in two groups [meningitis group and bacteremic group] and compared in SPSS using chi square test. Of the total sixty patients, six [10%] were diagnosed as bacterial meningitis. The remaining fifty four [90%] were diagnosed as bacteremia. The primary origins for fever and confusion in bacteremic patients included urinary tract infections [20%], pneumonia [45%], gastroenteritis [17%] and soft tissus infection [8%]. Most hospitalized, elderly patients with fever and confusion have primary causes of the confusion outside the central nervous system and may not require a routine evaluation of their cerebrospinal fluid

Bacterial meningitis: a diagnostic approach

Over a thirteen months period, 456 patients clinically suspected of having bacterial meningitis were investigated. Cerebrospinal fluid [CSF] specimens were examined by Gram's stain, white cell [WBC] counts and culture techniques. Gram's stain and cultures of CSF [232] with a cell count of less than 10 cells/mm[3] were consistently negative. However, of the CSF specimens [88] with cell counts greater than l00/mm[3], 28 [6.7%] and 23 [5.2%] of the specimens were positive by cultures and Gram's stain respectively. A total of 31 isolates were identified by culture. Streptococcus pneumoniae [22.4%], Escherichia coli [16%], and Coagulase negative Staphylococci [16%] were the predominant organisms, followed by Haemophilus influenzae [6.4%] and Neisseria men ingitidis [2.6%]. Thus it was concluded that Gram's stain and perhaps culture of CSF with cell counts of less than l0/mm[3] are of no practical diagnostic significance and may be eliminated as routine procedures. The gold standard for the diagnosis of bacterial meningitis is raised WBC cell count [>100/mm[3]], positive Gram's smear and/ or culture of CSF specimen

Molecular methods [16s-rRNA] compared to bacteriological diagnosis of meningitis

For treatment of patients with meningitis, rapid diagnosis of the agent is very important. Nowadays all of researches have approved qualification and efficiency of molecular tests. Detection of bacteria from CSF and blood is the major problem as a result of usage of antibiotics by patients. So we researched on CSF samples by PCR test and used DG74 and RDR80 primers for 16s rRNA sequence. Our cases were 51 children with meningitis symptoms that had referred to Mofid Hospital in Tehran. Theses samples were different from culture, cell counter and protein glucose amounts. After researching we reached to these results that 23.5% of cases were positive for bacterial culture and 41.1% of them were positive for PCR test. So sensitivity of PCR was 95.23%, specificity of PCR was 96.66% and efficiency of PCR was 96%. In first group 8 specimen were PCR positive [88.8%]. In second group, all of 12 specimens were PCR positive [100%]. In third, 8 specimens were suspected for viral meningitis, only one case was PCR positive, so it had bacterial agent. In fourth group, all of 22 specimens were PCR negative. Therefore sensitivity and specificity of PCR test with 16s rRNA gene sequence in identification of bacterial agent in CSF was 95.23% and 96.66% respectively

Levels of 5-hydroxyindoleacetic acid, Gamma-aminobutyric acid and Nitric oxide metabolites in cerebrospinal fluid of Egyptian women suffering of Fibromyalgia

Fibromyalgia [FM] is a complex chronic disorder predominately affects women. The lack of objective analytical image for diagnosis and prognosis of FM attract many investigators to evaluate the neuroendocrine changes in body fluids that may be related to the pathophysiology of FM. To compare the levels of 5-hydroxyindoleacetic acid [5-HIAA, serotonin metabolite], gamma-aminobutyric acid [GABA] and nitric oxide [NO] metabolites in cerebrospinal fluid [CSF] of normoglycemic women suffering of FM with those of control group. In addition, levels of insulin, insulin like growth factor-1 [IGF-1], cortisol, 5-hydroxytryptamine [5-HT, serotonin], GABA, and NO metabolites were determined in serum of FM patients compared to control group. Moreover, the correlations between all the studied parameters were performed. The present study showed altered serum levels of insulin and cortisol in normoglycemic women suffering of FM [n=15] compared to those of control group [n=15]. However, the data did not find significant differences between serum levels of IGF-1 in women suffering of FM and those in healthy women. Cortisol levels in FM sera were inversely correlated with the number of tender points [r=-0.76, p<0.001]. Also, negative correlation was observed between serum IGF-1 levels and age of FM patients [r=-0.63, p< 0.05]. Low levels of serum 5-HT and CSF 5-HIAA were also noticed among women suffering of FM. A decrement of both serum and CSF levels of GABA in those patients compared to controls was detected. Furthermore, there was a positive correlation between serum GABA levels and serum cortisol levels [r=0.61, p< 0.05], and between CSF GABA and 5-HT [r=0.56, p< 0.05]. However, CSF GABA levels were negatively correlated with age of women suffering of FM. These findings may clarify the significant role of GABA in the pathogenesis of FM. A higher serum and CSF levels of NO metabolites were detected in FM patients than in control group. In addition, serum levels of NO metabolites were correlated with those levels in CSF [r=0.63, p< 0.05]. The involvement of NO in pain process was revealed by a strong correlation between serum and CSF levels of NO metabolites with the number of tender points [r=0.91, p< 0.001; r=0.73, p< 0.01 respectively]. Also, by a negative correlation between serum levels of NO metabolites and serum cortisol levels [r=0.70, p< 0.01] in FM patients. The changes in the levels of studied hormones and neurotransmitters in women suffering of FM support the hypothesis of neuroendocrine involvement in FM pathogenesis. The current study suggested that GABA and NO may play a role in modulating FM. Alterations of their levels in serum and CSF of women suffering of FM and their correlations with age, number of tender points and/ or cortisol may confirm this suggestion. Accordingly, this investigation recommended the examination of GABAergic agents, NO synthase [NOS] inhibitors, or antioxidants for therapy of various symptoms in women suffering of FM. Furthermore, our study may find utility of these neurotransmitters as possible markers of FM, but this study warrant more investigations to confirm these findings

Herpes simplex acute encephalitis in children

to determine the incidence of HSV as a cause of acute sporadic viral encephalitis in Syria, and to describe any significant clinical, laboratory, and radiological findings that may help to indicate the causative agent of encephalitis. Materials and this was a prospective study which included 95 patients [69.5% male, 30.5% female] aged between 2 months and 12 years [average 3.4 years] who were admitted to Children University from September 1, 1998 to August 30, 2000 with a possible diagnosis of encephalitis. Laboratory, biological, and radiological investigations were done. the percentage of herpetic encephalitis was 35.7% [34 children]. The important clinical findings were: fever [97%], altered mental state [97%], seizures [88%], and focal neurological signs [47%]. Cerebrospinal fluid pleocytosis was present in 97% [lymphocytes= 90%] with mild elevation in CSF protein [47%], and normal CSF glucose. Electroencephalogram showed abnormal findings in 79%. CT scan showed abnormal findings in 87%. the study demonstrated that HSV is a significant causative agent of acute sporadic encephalitis in Syria. There was no statistical difference between the two groups of Herpes [HSE] and non-Herpes [Non-HSE] except that localized convulsions, severe deterioration in level of consciousness, localized neurological signs, morbidity, and mortality were higher in the HSE group

Intracranial tuberculoma: diagnosis treatment and outcome

Intracranial tuberculomas are conglomerate caseous foci within the substance of the brain that develop from deep-seated tubercles acquired during recent or remote hematogenous dissemination. In this study twenty four patients 10 male and 14 female with intracranial tuberculomas were treated and followed up in the neurosurgery and neurology departments in Al-Azhar University Hospitals and Nasr City Health Insurance Hospital in the period between January 1994 and July 2000. The age of the patients ranged between 6 and 48 year with a mean age of 30.1 year. The data were analyzed for presenting symptoms, its duration, physical findings, investigations and treatment. Half of the patients had past history of pulmonary tuberculosis. Fourteen patients had surgical excision. Four patients had stereotactic biopsy. Six patients had medical antituberculous treatment without excision or biopsy but one of these patients had ventriculo-peritoneal, shunt to treat the associated hydrocephalus all the patients were followed up every 6 months for a period ranged between 6-30 months with a mean period of 23.5 months. Thirteen out of the 24 patients showed improvement of their disability score on the 1st follow up after 6 months while the other 11 has the same disability score. Five out of these 11 patients showed improvement on the next follow up after 12 months while the other 6 had the same disability level. Three out of the non improved cases did not show improvement of their disability level till the end of the study, while the other 3 had improved disability level after 18 months for the 1st 2 cases and after 24 months for the 3rd patient. Ten out of the 14 patients who had craniotomy or craniectomy and tuberculoma excisions reached to disability level 0 while 2 had partial improvement and the last 2 had the same disability level as before management. Four of our patients had stereotactic biopsy and medical treatment. Three out of them reached to disability level 0 on follow up while 1 patient had partial improvement. patients who had only medical treatment were 6. Three out of them reached to disability level 0 on follow up while 2 patients had partial improvement and the 6th case had the same disability level as before management. The clinical picture of intracranial tuberculoma simulates an intracranial neoplasm, so it becomes necessary for physicians in countries where tuberculosis is common to search for any concomitant evidence of tuberculosis in every case of suspected intracranial tumor. Intracranial tuberculoma could be treated medically unless we are not sure of the diagnosis or if the tuberculoma is associated with mass effect which threatens the life of the patient

acyclovir responsive herpes simplex encephalitis definition of its radiological features; correlation with the clinical picture and CSF analysis

In the present study 13 patient with the clinico- radiological diagnosis of herpes simplex encephalitis [HSE] are included. All patients were subjected to [1] full clinical examination [2] CSF analysis that included CSF chemistry [protein, glucose and chloride], cells, latex test for bacterial antigens, CSF culture of pyogenic bacteria and TB and PCR [polymerase chain reaction] for detection of both type I and type II herpes simplex virus [HSV] DNA [3] Both MRI and CT scan of the brain with and without contrast were done to all patients. CSF analysis showed moderate rise of proteins [average 860 mg/dl, normal values up to 450 mg/dl] with normal sugar and glucose and with a predominately lymphocytic pleocytosis in all patients. Latex test was negative for all patients. Both CSF bacterial and TB cultures were eventually negative. HSV type I DNA was detected in the CSF by the PCR test in all patients, type II HSV DNA was not detected in the CSF of any of the patients examined. Involvement of the temporal lobes unilaterally or bilaterally were the cardinal radiological feature demonstrated in all patients. Other areas of the brain, such as the orbital frontal region, the paraventricular region, the basal ganglia or the brain stem, are involved but less frequently. The significance of these findings for the early diagnosis of herpes encephalitis are discussed. Also the clinical course of the patients and their response to treatment will be presented and discussed

Granulocyte macrophage - colony stimulating factor [GM- CSF] in bronchial asthma

This study included 41 subjects classified into 3 groups. Group 1: Twenty-one asthmatic patients [6 with mild and 15 with moderate asthma]; Group 2: Ten patients with other inflammatory lung diseases [bronchiectasis, COPD, IDF] and Group 3: Ten normal controls. FOB and BAL were done for groups 1 and 2; and blood sample was collected from all groups. GM-CSF levels in serum and BAL were measured. The results showed a significantly higher GM-CSF level in serum and BAL of the asthmatics compared to the other inflammatory diseases. A highly significant level was also found in the serum of asthmatic patients compared to the normal subjects. There was a significant negative correlation between the mean FEV 1% and mean levels of GM-CSF in both serum and BAL of the asthmatic patients. In light of these findings, we would recommend measurement of this important cytokine, GM-CSF in the serum and airways secretions in different asthmatic patients and this should contribute to monitoring the status of asthma and selecting the most appropriate anti-inflammatory therapy

Ruptura de la barrera hematoencefálica y sintésis intratecal de inmunoglobulinas I: indices y velocidad de sintésis de IgG / Rupture of the blood-brain barrier and intrathecal syndome of immunoglobulins: indices and velocity of IgG synthesis

En un grupo de 17 pacientes con infecciones del sistema nervioso central y con convulsiones con fiebre, se estudió la integridad de la barrera hematoencefalica basada en cálculo de la razón albúmina y la síntesis de inmunoglobulinas intratecal a partir de la utilización de los índices y la fórmula de Tourtellote. No hubo ruptura de la barrera hematoencefélica a excepción de 3 pacientes. Todos los pacientes fueron sintetizadores de IgG e IgA según el índice respecivo, y la velocidad de síntesis de IgG fue significativamente superior en las meningoencefalitis bacterianas

Esclerosis múltiple: niveles diferenciales intrarraquídeos de desmielinización / Multiple sclerosis: differential intraspinal levels of demyelination

El espectro de modificaciones bioquímicas e inmunológicas potencialmente presentes en la Esclerosis Múltiple permite definir niveles diferenciales de desmielinización intratecal. 70 pacientes con diagnóstico de esclerosis múltiple clínicamente definitivas fueron estudiados longitudinalmente y evaluados en un empuje de la enfermedad y antes de todo tratamiento. La correlación entre los hallazgos humorales del LCR con escala de incapacidad de Hyllested y sistematización funcional neurológica de Kurtzke diferenció cinco perfiles intrarraquídeos desmielinizantes de severidad progresiva: Tipo I - aumento de velocidad diaria de síntesis (mg/24 h) o magnitud de síntesis de IgG, corregida en función del grado de admisión proteica y de la permeabilidad de la barrera hematoencefálica. Tipo II - se agrega distribución oligoclonal de IgG, en número de 2 a 5 bandas catódicas, número variable de acuerdo a la topografía lesional predominante. Tipo III - se agrega alteración del arco de precipitación de la IgG en la inmunoelectroforesis independientemente del tipo de cadena liviana Kappa o Lambda presente. Tipo VI - se añade el disbalance de cadenas livianas Kappa y Lambda a predominio de la última. Tipo V - se añade a los anteriores la presencia de inmunocomplejos antígenoanticuerpo. La existencia de estos perfiles, además de caracterizar la respuesta inmunoproteica de cada paciente, deberá contribuir a definir pautas pronósticas de la afección, considerando la eventual transformación de uno a otro perfil inmunobiológico y consecuente agravación lesional. Finalmente, la confirmación de un perfil intratecal de intensa desmielinización plantea la posibilidad de una terapéutica inmunomoduladora inmediata más agresiva desde el inicio de la enfermedad

Esclerosis múltiple: parámetros clínicos y humorales intrarraquídeos de valor pronóstico / Multiple sclerosis: clinical and humoral intrarhachidian parameters of prognostic value

El diagnóstico de la Esclerosis Múltiple es eminentemente clínico, en base a la anamnesis y examen físico. El análisis del líquido cefalorraquídeo (LCR) pone en evidencia una reacción inflamatoria del Sistema Nervioso Central. Los potenciales evocados pueden mostrar lesiones multifocales latentes. La RMN revela lesiones diseminadas de la sustancia blanca y excluye otras patologías. La evolución de la enfermedad es notablemente variable de un paciente a otro, especialmente en formas de empujes y remisiones. No obstante, el estudio epidemiológico de estos enfermos, junto a los sistemas funcionales afectados y el grado de perfil desmielinizante intratecal permiten definir pautas pronósticas, favorables y desfavorables

Citoquimica do liquido cefalorraquidiano / Cytochemical of cerebrospinal fluid

O objetivo deste trabalho foi avaliar o valor diagnostico de tecnicas citoquimicas e imunocitoquimicas no estudo da citologia do liquido cefalorraquidiano (LCR). Para tanto, estudamos o comportamento citoquimico das celulas do LCR de pacientes com doencas malignas, atraves da reacao do acido periodico de Schiff (PAS) e da coloracao pelo sudam black B e/ou peroxidase, e pesquisamos a presenca da enzima deoxinucleotidil transferase terminal (TdT), atraves de reacao imunocitoquimica

Migraña asociada a pleocitosis recurrente de líquido cefalorraquídeo / Migraine associated to recurrent cerebrospinal fluid pleocytosis

Se presenta un paciente de 15 años de sexo femenino con migraña, asociada en tres episodios a pleocitosis del LCR. Se revisaron las publicaciones sobre el tema y las posibles etiologías del cuadro. El conocimiento de este síndrome es importante en orden a evitar exámenes y tratamientos innecesarios

Evaluation of co-agglutination (COA), counter immunoelectrophoresis (CIE), culture and direct microscopic (Dm) examination of cere-brospinal fluid (CSF) for detection of meningitis caused by common bacterial pathogens.

Cerebrospinal fluid from 260 children clinically diagnosed as meningitis were examined by Dm, culture, COA and CIE test. Dm revealed the presence of bacteria in 41 (15.8%) whereas culture showed growth of organism in 52 (20%) cases. COA and CIE test were done for the detection of antigen of H. influenzae, S. pneumoniae and N. meningitidis. Among the 3 methods viz. culture, COA and CIE test which were used for the detection of the above three organisms COA detected the maximum numbers (23.5%). COA test could detect antigen in both culture positive and culture negative CSF samples. COA test detected 100% of pneumococcal, 88.5% of H. influenzae and 66.7% of N. meningitidis antigens from CSF. Diagnosis by CIE in detecting H. influenzae and N. meningitidis antigens is inferior to culture and COA, whereas in detecting pneumococcal antigens CIE is superior to culture. So COA is a valuable, cheap, rapid and sensitive method for the diagnosis of meningitis caused by the above three organisms and when used along with culture 100% of cases can be diagnosed.

La rubéola y complicaciones neurológicas agudas en el pre-escolar y escolar. / Rubella and acute neurologic complications in preschoolers and schoolboys.

A raíz de una epidemia de rubéola, se estudia en el Servicio de Neuropediatría del Instituto Nacional de Salud del Niño de Lima, una casuística de 36 pacientes pre-escolares y escolares con manifestaciones neurológicas severas. Las formas clínicas más frecuentes fueron meningoenecefalitis y encefalitis con transtornos de conciencia y crisis convulsivas generalizadas. En forma poco frecuente o aislada se presentaron casos de cerebelitis, de meningitis, de meningo-panencefalitis sub-aguda y de poliradiculoneuritis. En el 94% de los casos las manifestaciones neurológicas se instalaron en forma rápida, el curso de la enfermedad fue agudo, la evolución corta y el pronóstico inmediato bueno.En un paciente con manengoencefalitis subaguda, la afección inicialmente aguda progresó durante 6 semanas para luego remitir en el lapso de 3 meses y medio, y en un niño con poliradiculoneuritis la mejoría fue discreta en el curso de un mes de observación. Los examenes auxiliares mostraron en el 78% de los pacientes una elevación de 4 veces el título basal de anticuerpos; en los líquidos cefalo-raquídeos de las meningoencefalitis y meningitis un aumento de proteínas y de células generalmente a predominio de linfocitos; en los hemogramas en la etapa aguda, leucocitos con neutrofilia y desviación izquierda y los electroencefalogramas de 8 pacientes registros anormales que no guardaron correlación con la evolución clínica. El diagnóstico se basó en el antecedente epidemiológico de rubéola, en el cuadro clínico y/o en la determinación de anticuerpos específicos por el método de inhibición de la hemaglutinación.