Comparison of cerebrospinal fluid lactate with physical, cytological, and other biochemical characteristics as prognostic factors in acute bacterial meningitis / Comparação do lactato no líquido cefalorraquidiano com as características físicas, citológicas e outros marcadores bioquímicos, como fator prognostico nas meningites bacterianas agudas

ABSTRACT Bacterial meningitis (BM) is associated with a high morbidity and mortality. Cerebrospinal fluid (CSF) lactate may be used as a prognostic marker of this condition. We hypothesized that CSF lactate levels would remain elevated in participants who died of acute BM compared with those who recovered from this disease. Objective: To evaluate the potential use of lactate and other CSF biomarkers as prognostic markers of acute BM outcome. Methods: This retrospective, longitudinal study evaluated dynamic CSF biomarkers in 223 CSF samples from 49 patients who fulfilled the inclusion criteria of acute BM, with bacteria identified by CSF culturing. The participants were grouped according to outcome: death (n = 9; 18.37%) and survival (n = 40; 81.63%). All participants received appropriate antibiotic treatment. Results: In the logistic regression model, lactate concentration in the final CSF sample, xanthochromia, and CSF glucose variation between the first and last CSF samples were predictors of a poor outcome (death). In contrast, decrease in CSF white blood cell count and CSF percentage of neutrophils, increase in the percentage of lymphocytes, and normalization of the CSF lactate concentration in the last CSF sample were predictors of a good prognosis. Conclusion: The study confirmed the initial hypothesis. The longitudinal analysis of CSF lactate is an important predictor of prognosis in acute BM.

RESUMO As meningites bacterianas (MB) estão associadas à alta morbidade e mortalidade. O lactato no líquido cefalorraquidiano (LCR) pode ser usado como biomarcador de prognóstico nas MB. A hipótese desse estudo é que os níveis de lactato no LCR se mantém elevados entre pacientes com MB aguda que evoluem para óbito, ao contrário do que ocorre em pacientes com bom prognóstico. Objetivo: Avaliar o uso potencial do lactato e outros marcadores no LCR como indicador de prognóstico na MB aguda. Métodos: Foi realizado um estudo retrospectivo longitudinal da dinâmica dos biomarcadores bioquímicos, celulares e físicos no LCR. Foram analisadas 223 amostras de 49 pacientes com MB aguda com bactérias identificadas por cultura do LCR. Os participantes foram divididos em dois grupos de acordo com o desfecho: óbito (n = 9; 18,37%) e não óbito (n = 40; 81,63%). Todos os participantes receberam antibioticoterapia adequada. Resultados: No modelo de regressão logística, as variáveis que diferiram significativamente entre os dois grupos foram concentração de lactato na amostra final de LCR, xantocromia e variação da concentração de glicose entre a primeira e a última amostra de LCR. A alteração desses fatores indicou desfechos negativos (óbito), enquanto a diminuição do número de leucócitos e da porcentagem de neutrófilos, assim como a normalização da concentração de lactato no LCR foram preditores de bom prognóstico. Conclusão: O estudo confirmou a hipótese inicial. A análise longitudinal do lactato no LCR é um importante preditor de prognóstico na MB aguda.

Valores del análisis citoquímico de líquido cefalorraquídeo en pacientes con derivación ventrículo-peritoneal / Values of cerebrospinal fluid cytochemistry in pediatric patients with ventriculoperitoneal shunt

Resumen Introducción: La derivación ventrículo-peritoneal (DVP) es el tratamiento para la hidrocefalia. El líquido cefalorraquídeo (LCR) se evalúa para el manejo de sus complicaciones; sin embargo, la información de los valores del citoquímico en esta población es insuficiente. Objetivo: Describir las características del citoquímico del LCR de niños en manejo con DVP. Materiales y Métodos: Estudio de tipo observacional descriptivo, desarrollado en Bogotá (Colombia), entre el año 2008 y 2016. Se revisaron los registros de procedimientos de DVP y relacionados. Se incluyeron pacientes entre 6 meses y 18 años de edad. Resultados: Se revisaron 285 registros e ingresaron 31 muestras. Los valores de LCR fueron, respectivamente, para la mediana y al percentil 90%: leucocitos totales: 0 y 7 céls/mm3, neutrófilos: 0 y 6,8 céls/mm3, linfocitos: 0 y 2 céls/mm3, proteínas: 13,4 y 67,2 mg/dL, glucosa: 59 y 27,4 mg/dL. Discusión: Los valores de glucosa presentan un rango normal hacia el extremo inferior más amplio, con valores de proteínas mayores a los valores esperados. El rango de celularidad es la variable que presenta menor variación. Conclusiones: Los valores del citoquímico de LCR en paciente con DVP no son equiparables a los de la población sana y deben interpretarse según las características propias de esta población.

Background: The ventriculo-peritoneal shunt (VPS) is the treatment for hydrocephalus, the cerebrospinal fluid (CSF) is evaluated for the management of its complications; however, information on the values of the cytochemistry in this population is insufficient. Aim: To describe the characteristics of the CSF cytochemistry of children in VPS management. Methods: Descriptive observational study, developed in Bogotá (Colombia), from 2008 to 2016. VPS and related procedures records were reviewed. Patients between 6 months and 18 years were included. Results: A total of 285 records were reviewed, 31 samples were entered. The CSF values were, respectively, for the median and 90% percentile: total leukocytes: 0 and 7 cells/mm3, neutrophils: 0 and 6.8 cells/mm3, lymphocytes: 0 and 2 cells/mm3, proteins: 13.4 and 67.2 mg/dL, glucose: 59 and 27.4 mg/dL. Discussion: Glucose values evinced a normal rank towards the widest inferior limit with protein values exceeding the values expected. Cellularity is the variable with the lowest variation. Conclusions: The values of the CSF cytochemistry in patients with VPS are not comparable to those of the healthy population and should be interpreted according to the characteristics of this population.

Usefulness of Flow Cytometric Analysis for Detecting Leptomeningeal Diseases in Non-Hodgkin Lymphoma

BACKGROUND: The clinical usefulness of flow cytometry (FCM) for the diagnosis of leptomeningeal diseases (LMD) in non-Hodgkin lymphomas has been suggested in previous studies but needs to be further validated. With this regards, we evaluated the use of FCM for LMD in a series of Korean patients with non-Hodgkin lymphoma. METHODS: FCM and cytomorphology were conducted using samples obtained from clinically suspected LMD patients, follow-up LMD patients, and those with high risk of developing tumorigenic diseases. We then compared results of FCM and cytomorphology. In total, 55 and 47 CSF samples were analyzed by FCM and cytomorphology, respectively. RESULTS: Of the samples analyzed, 25.5% (14/55) and 12.8% (6/47) were positive by FCM and cytomorphology, respectively. No samples were determined as negative by FCM but positive by cytomorphology. Seven patients were positive only by FCM and negative by cytomorphology, and six among them were clinically confirmed to have LMD either by follow-up cytomorphology or imaging study. CONCLUSIONS: We observed a high detection rate of tumor cells by FCM compared with cytomorphology. FCM study can be useful in early sensitive detection of LMD.

Analysis of cerebrospinal fluid in racemose form of neurocysticercosis / Análise do líquido cefalorraquidiano na forma racemosa da neurocisticercose

The present work aimed to evaluate the pattern of CSF alterations in patients diagnosed with neurocysticercosis (NCC) in racemose form.Method This is a retrospective cohort study of patients with diagnosis of NCC in racemose form. CSF samples from 26 patients were analyzed. After patient-chart analysis was performed descriptive analysis of case studies and comparison between sexes in relation to variables were obtained with CSF by Mann-Whitney and Student’s t-tests.Results The sexes did not differ statistically when compared to pleocytosis in CSF. Eosinophils were present in 31% in samples while the ELISA test presented 80% sensitivity in this case series. Of the patient total, 24 presented a meningitis pattern with lymphocytic predominance.Conclusion There was no difference in inflammatory pattern between the sexes, with predominance of lymphocytic meningitis and 80% sensitivity by ELISA test of CSF patients with racemose form of NCC.

O objetivo deste trabalho foi avaliar o padrão de alterações do LCR de pacientes com diagnóstico de neurocisticercose (NCC) na forma racemosa.Método Trata-se de estudo de coorte retrospectiva, de pacientes com diagnóstico de forma racemosa da NCC. Foram analisadas amostras de LCR de 26 pacientes. Após análise de prontuário foi realizada análise descritiva da casuística e comparação entre sexos em relação às variáveis obtidas com o LCR por meio dos testes de Mann-Whitney e t-Student.Resultados Não houve diferença estatisticamente significante quando comparado à pleocitose no LCR entre os sexos. Houve presença de eosinofilorraquia em 31% das amostras e o teste ELISA apresentou sensibilidade de 80% nesta casuística. Do total de paciente, 24 apresentaram padrão de meningite com predomínio linfocítico.Conclusão Não houve diferença no padrão inflamatório entre os sexos, com predomínio de meningite linfocítica e sensibilidade de 80% ao teste ELISA do LCR de pacientes da forma racemosa de NCC.

Meningite bacteriana aguda na infância: fatores de risco para complicações agudas e sequelas / Childhood acute bacterial meningitis: risk factors for acute neurological complications and neurological sequelae

OBJETIVO: Estudo retrospectivo que visa avaliar as complicações neurológicas agudas e sequelas neurológicas das meningites bacterianas agudas na infância, a fim de determinar possíveis sinais de alerta. MÉTODOS: Foram avaliadas crianças (entre 1 mês e 14 anos) internadas entre 2003 e 2006, com meningite bacteriana aguda. RESULTADOS: Dos 44 pacientes incluídos, 17 (38,6%) apresentaram complicações neurológicas agudas, sendo crise convulsiva a mais frequente (31,8%). Os pacientes com complicações neurológicas agudas apresentaram com mais frequência: menor contagem de neutrófilos (p = 0,03), crise convulsiva na admissão (p < 0,01) e S. pneumoniae como agente etiológico (p = 0,01). Os fatores de risco para o desenvolvimento de complicações neurológicas agudas foram: S. pneumoniae [razão de chances (odds ratio, OR) = 6,4; intervalo de confiança (IC) 1,7-24,7] e contagem de neutrófilos < 60% (p < 0,01). De 35 pacientes seguidos ambulatorialmente, 14 apresentaram sequelas neurológicas (40%), sendo alteração comportamental a mais frequente. A ocorrência de crise convulsiva na internação (OR = 5,6; IC 1.2-25,9), proteinorraquia > 200 mg/dL (p < 0,01) e menor relação glicorraquia/glicemia (p < 0,01) foram identificadas como variáveis de risco para sequelas. CONCLUSÃO: Contagem de neutrófilos < 60%, crise convulsiva na admissão e S. pneumoniae como agente etiológico foram identificados como sinais de alerta para a ocorrência de complicação neurológica aguda, enquanto que proteinorraquia, menor relação glicorraquia/glicemia e crise convulsiva na internação foram observados como fatores de risco para a ocorrência de sequelas neurológicas.

OBJECTIVE: To assess acute neurological complications and neurological sequelae of childhood acute bacterial meningitis in order to determine possible warning signs. METHODS: This retrospective study evaluated children with acute bacterial meningitis (between 1 month and 14 years of age) admitted between 2003 and 2006. RESULTS: Of the 44 patients studied, 17 (38.6%) had acute neurological complications. Seizure was the most frequent (31.8%) complication. Patients with acute neurological complications showed a higher frequency of lower neutrophil count (p = 0.03), seizure at admission (p < 0.01), and S. pneumoniae as the etiologic agent (p = 0.01). Risk factors for the development of acute neurological complications were S. pneumoniae (odds ratio [OR] = 6.4, confidence interval [CI] 1.7-24.7) and neutrophil count < 60% (p < 0.01). Of the 35 patients who were followed up, 14 had neurological sequelae (40%). Behavioral change (22.9%) was the most frequent sequela. Seizures at admission (OR = 5.6, CI 1.2-25.9), cerebrospinal fluid protein concentration > 200 mg/dL (p < 0.01), and cerebrospinal fluid glucose concentration/glycemia ratio (p < 0.01) were identified as risk variables for sequelae. CONCLUSION: Neutrophil count < 60%, seizure at admission, and S. pneumoniae as the etiologic agent were identified as warning signs for acute neurological complications, while protein levels, cerebrospinal fluid glucose concentration/glycemia ratio, and seizure at admission were seen as risk factors for neurological sequelae.

Pattern of sepsis and meningitis in a university hospital

To define the clinical and cerebrospinal fluid [CSF] criteria that establishes a diagnosis of sepsis and meningitis immediately on admission. One thousand children, aged one day to 13 years, presenting with acute onset of vomiting, fever, convulsion, and diarrhea to the Pediatrics Department, King Abdul-Aziz University Hospital, Jeddah, Kingdom of Saudi Arabia from January 1997 to December 2000 were evaluated. Cases were subjected to history, clinical examination, and lumbar puncture [LP]. On admission, chemical, cytological, and bacteriological examinations of blood and CSF were carried out. Patients were divided into sepsis [n=94] and meningitis [n=26] groups. The most common age liable for LP was in the neonatal period [35.8%]. Septic cases were more than meningitis [78.3% versus 21.7%]. Neonates were the most commonly affected age in sepsis and meningitis; and the predominant symptom in all groups was vomiting. In meningitis, hemoglobin was less [p<0.05] while, blood white blood cell counts [WBCs] [p<0.05], blood neutrophils [p<0.05], CSF-chloride [p<0.000] and CSF-WBCs [p<0.001] were more than sepsis. In meningitis, a positive correlation was found between CSF-glucose with WBCs [r=0.52, p<0.05], neutrophils [r=0.49, p<0.05], and blood-glucose [r=0.56, p<0.01]; and between CSF-WBCs and CSF-protein [r=0.55, p<0.01]. In sepsis, a positive correlation was found between CSF-lymphocyte and CSF-red blood cell count [r=0.37, p<0.001]. More septic cases were admitted to the Pediatric Department through Emergency than meningitis cases. The most common pediatric patients liable to LP were neonates, and the most common presenting symptom was vomiting. Children with vomiting and convulsion and no organism in CSF must be carefully examined, and urine and blood culture must be collected. These children must be closely observed in hospital and re-evaluated by a pediatrician

C-reactive protien and lactate dehydrogenase in serum and cerebrospinal fluid in rapid and early diagnosis of childhood meningitis

Bacterial meningitis is still a life threatening epidemiological problem especially in many developing countries; considering its dire consequences, its prompt and accurate diagnosis has become a priority for clinicians. Because of the various limitations of conventionally used laboratory techniques, we evaluated and compared the diagnostic utility of C-reactive protein and lactate dehydrogenase in serum and cerebrospinal fluid in the diagnosis of bacterial meningitis and its effectivity in distinguishing it from aseptic meningitis. A total of 125 pediatric cases, aged between 1 month and 12 years, including patients with bacterial meningitis [n=45], aseptic meningitis [n=42] and a control group [n=38], were retrospectively analyzed on the basis of data from the initial clinical examinations. Cultures, smears and other common serum and CSF indices were compared with serum and CSF CRP levels and LDH activity. Compared with each of the other variables, there were significant differences in the mean values of serum-CRP, CSF-glucose, CSF-LDH and CSF/serum LDH ratio between the bacterial and aseptic meningitis groups [p<0.001]. Of all the tests applied, the highest sensitivity [95%] and negative predictive value [95%] belonged to CSF-LDH activity and the most specific [100%] test with the highest positive predictive value [100%] was CSF-CRP titration as well as smear and culture. Combination of CSF-CRP serum-CRP, and CSF-LDH yielded the highest sensitivity [100%] and negative predictive value but the combined application of CSF-LDH and CSF-CRP proved to be the most specific and efficient. In the presence of a normal CRP titration and low glucose level in CSF, bacterial meningitis is excluded, whereas elevated level of CSF-LDH activity is a valid confirmatory predictor of BM. In addition, combination of these three tests with serum CRP is far more effective than the separate determination of any of these parameters

Clinical and laboratory findings in neurobrucellosis: a study of 43 cases

Brucellosis is a common zoonotic infection that is endemic in many parts of the world. Neurological involvement is a rare entity, occurs in 2-5% of cases. Neurobrucellosis comprises a variety of complications, including meningitis, meningoencephalitis, myelitis and myelopaties, peripheral and cranial neuropathies, and psychiatric manifestations. The aim of the present study was to evaluate neurological manifestations and cerebrospinal fluid [CSF] findings in a group of Iranian patients with neurobrucellosis. During a 10-year period [1996-2005], medical records of 43 hospitalized patients with definite diagnosis of neurobrucellosis were studied. Inclusion criteria were a minimum titer of 1/160 for Wright and abnormal CSF findings. Age, gender, neurological manifestations, CSF analysis and its changes were investigated. Neurological manifestations include meningitis [64.9%], meningoencephalitis [11.6%], cranial nerve palsy [11.6%], brain abscess [2.4%], myelitis [2.4%] and psychiatric disorders [6.9%]. Pleocytosis [100%], high protein [40%] and low glucose levels [40%] were noted in CSF analysis clinical manifestations and CSF abnormality of nearobrucellosis is similar to tuberculosis an nearobrucellosis must be kept in mind in approach of patients with acute or chronic lymphocytic meningitis with increased protein and low glucose level in CSF and risk factors of brucellosis

Biochemical changes in cerebrospinal fluid after death

Biochemical changes in various body fluids after death have been investigated before in various countries. They were found to be useful in a variety of situations. They may aid in finding the cause of death when autopsy is negative or not available and in estimation of the time since death. To asses the biochemical changes in cerebrospinal fluid after death as well as to asses these changes in relation to different postmortem intervals in order to estimate the time since death. A total of forty autopsy cases were selected randomly for the study at the medicolegal institute in Baghdad. Time of death was obtained from police reports, close relatives and case sheets for those admitted to hospitals. CSF was aspirated from the brain and centrifugation was done immediately. The supernatant was collected; determinations of glucose, protein, sodium, potassium and urea were done at Kadhmiya Teaching Hospital. There was an increase in potassium level in CSF with increasing postmortem interval and a significant correlation was found between them [p<0.001]. A slight to moderate reduction in sodium level in CSF and no correlation was found with postmortem interval. Glucose was decreasing with increasing postmortem interval and a significant correlation was found between the two parameters [p < 0.001]. Proteins levels were higher than their normal ante mortem value in CSF and no correlation was found with postmortem interval. Urea was a relatively stable parameter. The study revealed a significant correlation between potassium and glucose concentrations in CSF with postmortem interval aiding in estimation of time since death with other means, while there were no correlation between sodium, urea and protein with postmortem interval. Urea was a stable biochemical marker reflecting its ante mortem level

Effects of decreased cerebral perfusion pressure on cerebral hemodynamics, brain cell membrane function and energy metabolism during the early phase of experimental Escherichia coli meningitis in the newborn piglet

In this study, we tested the hypothesis that decreased cerebral perfusion pressure (CPP) induces cerebral ischemia and worsen brain damage in neonatal bacterial meningitis. Meningitis was induced by intracisternal injection of 10(9) colony forming units of Escherichia coli in 21 newborn piglets. Although CPP decreased significantly at 8 hr after bacterial inoculation, deduced hemoglobin (HbD), measured as an index of changes in cerebral blood flow by near infrared spectroscopy, did not decrease significantly. In correlation analyses, CPP showed significant positive correlation with brain ATP and inverse correlation with brain lactate levels. CPP also correlated positively with HbD and oxidized cytochrome aa3 (Cyt aa3) by near infrared spectroscopy. However, CPP did not show significant correlation with cerebral cortical cell membrane Na+,K+-ATPase activity, nor with levels of lipid peroxidation products. In summary, decreased CPP observed in this study failed to induce cerebral ischemia and further brain injury, indicating that cerebrovascular autoregulation is intact during the early phase of experimental neonatal bacterial meningitis.

Utilidad de la tira reactiva de orina en el diagnóstico de meningitis bacteriana aguda / Utility of urine strip in the diagnosis of acute bacterial meningitis

La meningitis bacteriana aguda (MBA) es un cuadro grave de alto porcentaje de secuelas y alta letalidad, por lo que el laboratorio clínico tiene un papel fundamental en el diagnóstico precoz. Dado que es de gran utilidad disponer de métodos sencillos se evaluó la utilidad de la tira reactiva de orina Combur 10R (para los parámetros de glucosa, proteínas y leucocitos) y del resto de los exámenes de laboratorio en muestras de LCR en la obtención de un diagnóstico rápido de MBA. Para esto se estudiaron 87 muestras de LCR que ingresaron al Laboratorio de Urgencia del Hospital Clínico de la Pontificia Universidad Católica de Chile proveniente de pacientes con sospecha clínica de MBA. A estos se les realizó estudio citoquímico, recuento celular, tinción de Gram, test de aglutinación por látex y la tira reactiva de orina Combur 10MR, evaluando visualmente los parámetros de glucosa, proteínas y leucocitos. De los 87 LCR analizados, en 13 el diagnóstico definitivo fue MBA, en 2 meningitis viral y en 72 otros. La sensibilidad y especificadad diagnóstica de la tira reactiva para dos parámetros (cualquier combinación) fueron de 100 por ciento y 87,8 por ciento respectivamente. Para tres parámetros positivos la sensibilidad fue de 76,9 por ciento, que aumentó al 84,6 por ciento si se complementa con la información de la tinción de Gram y aun 92,3 por ciento si se agrega a lo anterior el test de aglutinación por látex. Se concluye que la tira reactiva de orina Combur 10MR es un método diagnóstico suficientemente sensible, rápido y simple que puede ser utilizado como método de aproximación diagnóstica en MBA. Dado el rendimiento y alto costo del test de aglutinación por látex, se recomienda reservarlo para aquellos casos en que los otros métodos diagnóticos orienten fuertemente al diagnóstico de MBA

Potenciales evocados auditivos de tronco cerebral en la hipoacusia postmeningítica / Auditory brainstem evoked potentials after bacterial meningitis

Catorce niños con meningitis bacteriana fueron examinados con potenciales evocados auditivos de tronco cerebral (PEAT) durante su hospitalización. En 8 (57,14%) se detectó hipoacusia neurosensorial de grado variable, que fue detectada precozmente. Los niños menores de un año parecen tener mayor susceptibilidad al déficit auditivo. En ninguno de los 6 pacientes en que se repitió el PEAT había desaparecido totalmente la hipoacusia. La evolución a corto plazo sugiere que el proceso agudo puede prolongarse más de un mes después del ingreso al hospital y que, a mediano plazo, la alteración de la función auditiva tiende a persistir. A pesar de las limitaciones metodológicas de esta investigación, ella confirma la utilidad de los PEAT en el diagnóstico precoz de la hipoacusia neurosensorial postmeningítica y su seguimiento

Correlaçäo entre os valores do pH e concentraçäo de glicose no líquido cefalorraquídeo e sangue arterial em pacientes pediátricos / Correlation between pH values and glicose concentration in cerebrospinal fluid and arterial blood in pediatric patients

Em 30 pacientes, submetidos à anestesia raquídica, para cirurgias eletivas, foi colhida, previamente, amostra de líquor, para a verificaçäo do pH e valor da glicose, além da amostra de sangue arterial, com idêntica finalidade. Também foi colhida amostra de suco gástrico, em todos os pacientes, a fim de se verificar o valor do pH. Os valores obtidos, para o pH e glicose do líquor e sangue arterial, foram agrupados em tabelas e submetidos à análise estatística, com base no teste "t" de Student, adotando-se, como nível de significância, p < 0,05. As médias globais foram para o líquor: pH = 7,38 (7,13 a 8,50) e glicose = 62,60 (42 a 89) mg%; para o sangue arterial: pH = 7,34 (7,20 a 7,42) e glicose = 86 (68) a 130) mg% e para o suco gástrico: pH = 2,03 (1 a 5). O valor médio da relaçäo glicorraquia/glicemia foi 0,73 (0,46 a 0,92). Considerando que, em pacientes pediátricos, os valores médios dos parâmetros estudados säo escassos na literatura médica, achamos importante um trabalho desta natureza

Glucosa en líquido cefalorraquídeo / Glucose in the cerebrospinal fluid

Se revisan las fuentes de glucosa del líquido cefalorraquídeo (LCR), así como los mecanismos de entrada, utilización y relación LCR/sangre. También se analizan los niveles de glucosa en el LCR de acuerdo al sitio anatómico de obtención del mismo y las variaciones de acuerdo a la edad. Se considera que la glucosa en el LCR se halla en proporción de 60% a 80% de esta misma substancia en sangre. En condiciones normales, los valores más altos han sido informados en recién nacidos, lo cual puede estar en relación con um proceso de maduración de la barrera hematoencefálica y/o a diferencias del flujo cerebral con la edad