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TEACHING QUESTIONS

CSF FINDINGS IN NEUROLOGICAL DISEASE

LUMBAR PUNCTURE AND SPINAL FLUID

John E. Greenlee, M.D.

Case 1

Patient presenting with rapidly progressive headache and obtundation. Your examination shows neck stiffness

Pressure 350 mm CSF

Fluid Turbid, colorless

Glucose 18

Protein 475 mg/dl

Cells 850 cells, 97% PMNs

What do you suspect? What else to you want to order or to do?

Case 2

5 year old child seen in the E.R. last night for irritability and fever, thought to be otitis media. Today she is brought back in coma.

Pressure 200 mm CSF

Fluid clear, colorless

Glucose 5 mg/dl

Protein 40

Cells 10; all lymphs

What are your concerns? What else to you want to order or to do?

Case 3

57 year old man with the sudden onset of “the worst headache I ever had in my life.” Your exam shows mild left-sided weakness and mild neck stiffness

Pressure 500 mm CSF

Fluid xanthochromic

Glucose 50

Protein 175

Cells 1,000 RBC/cu mm. 15 WBCs, all lymphs

What are your concerns? What else to you want to order or to do?

Case 4

37 year old Native American presents with a 4 day history of steadily worsening headache and neck stiffness

Pressure 210 mm CSF

Fluid v. sl turbid

Glucose 20 mg/dl

Protein 270 mg/dl

Cells 510 cells/cu mm; 78% lymphs, 22% poly's

What do you suspect? What else to you want to order or to do?

Case 5

Patient presenting with tingling in both legs and progressive lower extremity weakness

Pressure 100 mm CSF

Fluid: Clear, colorless

Glucose 80 mg/dl

Protein 120 mg/dl

Cells 2 WBC’s, 100% lymphs

What do you suspect? What else to you want to order or to do?

Case 6

23 year old woman with a prior history of severe dizziness. Now presents with loss of vision in her right eye and bilateral leg weakness.

Pressure 100 mm CSF

Fluid: Clear, colorless

Glucose 80 mg/dl

Protein 50 mg/dl

Cells 10 cells, all lymphs

Oligoclonal bands: present

What do you suspect?

Case 7

10 year old boy visiting Utah on summer vacation presents with headache, mild fever, nausea, vomiting, and photophobia. Your examination is normal except for neck stiffness.

Pressure 100 mm CSF

Fluid: Clear, colorless

Glucose 80 mg/dl

Protein 60 mg/dl

Cells 100 cells; 70% lymphs, 30% PMNs

What do you suspect? What else to you want to order or to do?

ANSWERS

1. The combination of elevated protein, low glucose, and high cell count consisting almost exclusively of polymorphonuclear leukocytes is typical for bacterial meningitis. In terms of diagnostic studies, you will already have submitted the fluid for Gram’s stain and culture. You will need check to place the patient on provisional antibiotic coverage and modify your choice of agents as results of Gram’s stain and then culture become available.

2. This case is more difficult, since the only abnormalities are a slightly elevated cell count and a very low glucose. This CSF is, however, typical of very early tuberculous meningitis, and you will likely begin anti-tuberculous therapy while awaiting results of CSF PCR.

3. There are several things to note about this spinal fluid. The red cells could conceivably be either traumatic or due to subarachnoid blood. However, the presence of xanthochromia, means that blood has been present in the CSF long enough to break down and suggests subarachnoid hemorrhage. The elevated protein supports this: the number of red blood cells present could raise CSF protein (remember CSF protein rises 1 mg/dl per 1000 RBCs) only slightly, but protein is much more elevated, suggesting that some process has altered blood-brain barrier permeability. The white blood cell count might or might not be elevated, depending on the white count present in blood.

4. These findings are highly typical for tuberculous meningitis. Here, again, you will likely begin anti-tuberculous therapy while awaiting results of CSF PCR.

5. Findings here, in this setting, are typical for Guillain-Barre syndrome. The patient will need rapid evaluation and very likely treatment with IV IgG or plasma exchange.

6. Findings here, together with this clinical picture, are very suggestive of multiple sclerosis

7. These findings are typical of viral meningitis. You might want, given the time of year, to check CSF for enteroviruses by PCR, but this will probably not alter your treatment, which involves no treatment and probably no admission but close follow-up over the next few days.

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