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Glucose 40 mg/dL
0%
0/0
WBC count 500 cells/mm^3
Protein 20 mg/dL
Opening CSF pressure 160 mm H2O
20% polymorphonuclear leukocytes
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This patient has pneumococcal meningitis. Typical CSF findings of bacterial meningitis include: elevated CSF opening pressure above 200 mmHg, WBC count > 1000 cells/mm^3, polymorphonuclear leukocyte predominance > 80%, glucose < 45 mg/dL, and protein > 250 mg/dL. Meningitis may be bacterial, viral, fungal, or TB. Fever, altered mental status, and positive Brudzinski's sign are typical signs and symptoms. An lumbar puncture should be obtained rapidly, as assessment of CSF WBC count, protein, glucose, and lactic acid can differentiate these different causative organisms and thereby guide pharmacologic therapy. Normal CSF glucose levels are based on serum glucose and are expected to be 2/3 of the serum glucose level. Bamberger discusses the evaluation and management of meningitis. Empiric antibiotic therapy for bacterial meningitis should not be delayed to obtain head imaging or multiple attempts at a lumbar puncture. Initiating dexamethasone with antibiotics has been shown to improve morbidity and mortality in patients suffering from S. pneumoniae meningitis. Cunha reviews laboratory values that can be useful in diagnosing acute bacterial meningitis. CSF Gram stain and elevated lactic acid levels are the most rapid and reliable ways to confirm the diagnosis of acute bacterial meningitis. Normal CSF lactic acid levels can rule out bacterial meningitis and may re-direct diagnosis towards encephalitis or viral meningitis. Figure A shows a Gram stain of CSF containing Gram-positive diplococci that is suggestive of S. pneumoniae bacterial meningitis. Illustration A summarizes the CSF findings of several different types of meningitis and contrasts them with normal CSF findings in patients without meningitis. Note that there is substantial variability in the numerical cut-offs for each of these categories; however, the general trends of increased versus decreased versus no-change in these values compared to normal CSF are consistent. Incorrect Answers: Answer 2: Bacterial meningitis is characterized by increased WBC count, typically greater than 1000 cells/mm^3 Answer 3: Protein is usually elevated to greater than 250 mg/dL in bacterial meningitis. Answer 4: 160 mm H2O is a normal CSF opening pressure; bacterial meningitis is often associated with an elevated CSF pressure (greater than 200 mmHg) Answer 5: Bacterial meningitis is characterized by a PMN predominance, typically greater than 80%.
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