Laboratory Diagnosis Of Meningitis-Books Pdf

Laboratory Diagnosis of Meningitis
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186 Meningitis, early phases of viral meningitis and bacterial meningitis the symptoms are almost similar. Carbonnelle 2009, Fungal meningitis is rare but can be life threatening Although anyone can get fungal. meningitis people at higher risk are those who have AIDS leukemia or other forms of. immunodeficiency The most common cause of fungal meningitis in HIV is Cryptococcus. spp In the last two decades more elaborative use of intensive care units for serious medical. disorders advancements in transplant procedures and concomitant use of. immunosuppressive therapies as well as the pandemic spread of HIV etc have increased. the incidence of Central Nervous System CNS fungal infections which present with. various clinical syndromes meningitis commonly The clinical picture may mimic TBM and. therefore needs careful evaluation The CNS mycoses carry higher risks of morbidity and. mortality as compared to other infective processes and therefore promptly require precise. diagnosis and appropriate medical and or surgical management strategies to optimize the. outcome Raman Sharma 2010, Chemical meningitis can develop after neurosurgical procedures and can be differentiated. from bacterial meningitis by Cerebrospinal fluid CSF glucose levels and CSF White Blood. Cell WBC values, The causes of non infectious meningitis include cancers systemic lupus erythematosus. drug induced head trauma brain surgery etc, 2 Collection transportation receipt and storage of CSF.
Direct testing of CSF is the most accurate way to confirm the diagnosis of bacterial. meningitis CSF should be collected from all the cases with suspected meningitis before. commencement of antimicrobial therapy unless lumbar puncture LP is contraindicated. Petechial fluid can be another specimen in cases with meningococcal meningitis Petechial. lesions if present may be gently irrigated by injecting 0 2 ml of sterile saline solution using. a small syringe with a fine needle and the fluid collected for smear and culture. Early diagnosis is essential and is best established by laboratory examination of CSF. However therapy should not be dependent or delayed pending lumbar puncture or. laboratory results WHO, To initiate the definitive identification of a bacterium responsible for meningitis CSF. specimens should be obtained from patients with clinical signs and symptoms of meningitis. and should be transported to the laboratory without delay N meningitidis S pneumoniae. and H influenzae are fastidious organisms that may not survive long transit times. The processing of a CSF specimen is one of the few clinical microbiology procedures that must. be done immediately Laboratorians should always record the date and time a specimen was. received Usually three or more tubes of CSF are collected during a LP procedure. The tubes should be numbered in sequential order with tube number one containing the. first sample of CSF obtained The CSF in tubes 1 2 and 3 most often are examined for. chemistry microbiology and cytology respectively Gray Fedorko 1992 However the. particular tests performed on tubes 2 and 3 are subjective and probably best determined by. the laboratarians, www intechopen com, Laboratory Diagnosis of Meningitis 187. Contamination with skin flora and disinfectant will be ruled out after the first tube of CSF is. collected The probabilities of detecting microorganisms by staining and by culturing are. related to the volume of specimen that is concentrated and examined Tenney et al 1982 as. cited in Gray Fedorko 1992, CSF volumes of 2 to 3 ml are usually sufficient to detect bacteria but for mycological and. mycobacterial investigations a minimum of 5 ml preferably 10 to 15 ml of CSF is required. If only a small amount of CSF is received with requests for multiple assays the order of. priority of the tests is determined after discussion with the physician. The specimen should not be refrigerated before subjecting to microbiological tests as it may. prevent the recovery of the organisms fastidious organisms may not survive variations in. temperature Kasten 1990 cited in Gray Fedorko 1992. CSF specimens should be stored at room temperature or at 37oC if they cannot be processed. immediately or till microscopy and bacterial cultures are performed after which it can be. refrigerated for further use WHO, 3 Laboratory diagnosis of bacterial meningitis. Bacterial meningitis is a significant cause of mortality and morbidity worldwide. Neurological outcome and survival depend largely on damage to CNS prior to effective. antibacterial treatment Quick diagnosis and effective treatment is the key to success The. diagnostic dilemma in acute pyogenic meningitis is due to large spectrum of signs and. 3 1 Examination of CSF, The CSF should arrive still warm and either be examined immediately or placed in an.
incubator for examination within an hour If delay is anticipated either in transportation to. the laboratory or for examination CSF should be divided into two containers one in a plain. bottle and the other in a bottle having a few drops of glucose broth In the laboratory CSF. from the plain bottle can be used for making smears for staining whereas cultures are done. from containers having CSF in glucose broth The residual CSF should be preserved frozen. in the CSF bank for further assessment and evaluation with evolving additional. contributory findings, An examination of CSF involves the following. 3 1 1 Macroscopic examination, 3 1 2 Cytological examination. 3 1 3 Examination of Gram stained smear, 3 1 4 Culture and antimicrobial susceptibility testing. 3 1 5 Latex agglutination test for antigen detection. 3 1 6 Other diagnostic methods, 3 1 1 Macroscopic examination. By appearance the CSF is normally clear like water cloudy purulent bloody or pigmented. CSF as per the disease states, www intechopen com, 188 Meningitis.
Hazy cloudy turbid CSF indicates either metastatic spread of tumors into the CNS or. pleocytosis or severe meningeal infection Opalescent CSF may be suggestive of. cryptococcal meningitis The turbid nature of the CSF is attributable to both the bacteria and. leukocytes present, Hemorrhagic CSF may be indicative of Anthrax meningitis with supportive clinical. Frank clots or pellicles in CSF occur only if protein concentration exceeds 15g L. Xanthochromia of CSF is seen within 4 weeks of a cerebral hemorrhage. In evaluating patients with suspected meningitis or encephalitis a careful history along with. biochemical and cellular analysis of CSF is required. 3 1 1 1 CSF glucose, CSF glucose concentrations 45 mg dL are indicative of bacterial meningitis Bonadio. 1992 CSF glucose concentrations depend on serum concentrations and should always be. tested on paired samples A CSF serum ratio cut off of 0 4 is helpful in distinguishing. between bacterial and aseptic meningitis with a sensitivity and specificity of 91 and 96. respectively Genton Berger 1990, The individual predictors of bacterial meningitis consists of a glucose concentration of less. than 40 mg dl and a ratio of CSF to blood glucose of 23 mg dl Brouwer et al 2010 Gray. Fedorko 1992, Chemical meningitis can be differentiated from bacterial meningitis by CSF glucose levels. 10 mg dL and CSF WBC values 7500 cells L Forgacs et al 2001. 3 1 1 2 CSF protein, Despite typical CSF findings the spectrum of CSF values in bacterial meningitis is so wide.
that the absence of one of more of the typical findings may not affect the diagnosis In. community acquired bacterial meningitis CABM only 50 percent may have a CSF glucose. above 40 mg dL 2 2 mmol L less than half cases may have a CSF protein below 200. mg dL CSF protein measurements of 55 mg dL are diagnostic of bacterial fungal and. tubercular meningitis Bonadio 1992, 3 1 2 Cytological examination. In untreated bacterial meningitis the WBC count is elevated usually in the range of 1000. 5000 cells mm3 although this range can be quite broad 100 to 10 000 cells mm3. Bacterial meningitis usually leads to a neutrophil predominance in CSF typically between 80. and 95 10 of patients with acute bacterial meningitis present with a lymphocyte. predominance defined as 50 lymphocytes or monocytes in CSF Tunkel et al 2004. Preponderance of CSF polymorphonuclear cells may be used to distinguish bacterial. meningitis from other causes It is important to note that a false positive elevation of the CSF. WBC can be found after traumatic lumbar puncture or in patients with intracerebral or. subarachnoid hemorrhage in which both red blood cells and white blood cells are introduced. into the subarachnoid space In these instances the following formula can be used as a. correction factor for the true WBC count in the presence of CSF red blood cells RBC. www intechopen com, Laboratory Diagnosis of Meningitis 189. True WBC in CSF Actual WBC in CSF, WBC in blood x RBC in CSF. RBC in blood, Generalized seizures may also induce a transient CSF pleocytosis primarily neutrophilic. although the CSF WBC count should not exceed 80 microL in this setting However CSF. pleocytosis should not be ascribed to seizure activity alone unless the fluid is clear and. colorless the opening pressure and CSF glucose are normal the CSF Gram stain is negative. and the patient has no clinical evidence of bacterial meningitis. Since the CSF is hypotonic neutrophils may lyse and counts may decrease by 32 after 1. hour and by 50 after 2 hours in CSF specimens held at room temperature Steele et al. 1986 as cited in Gray Fedorko 1992 hence a delay may produce a cell count that does. not reflect the clinical situation of the patient, Characteristic CSF findings for bacterial meningitis consist of polymorphonuclear.
pleocytosis hypoglycorrhachia and raised CSF protein levels Van De Beek et al 2006 as. cited in Brouwer et al 2010 However low CSF WBC do occur especially in patients with. septic shock and systemic complications Heckenberg et al 2008 and Weisfelt et al 2006 as. cited in Brouwer et al 2010 A relationship between a large bacterial CSF load lack of. leukocytes response Tauber et al 1992 as cited in Brouwer et al 2010 probably indicating. excessive bacterial growth and poor cell response is well known especially in cases of. pneumococcal meningitis Brouwer et al 2010, In CABM 10 15 percent have a CSF WBC below 100 microL Durand et al 1993 In some. proportion of the patients of CABM around 15 percent may not exhibit characteristic CSF. findings Van de Beek et al 2004, Some patients have milder CSF abnormalities which cannot usually be identified Potential. causes include early presentation recent prior antibiotic therapy etc. WBC differential may be misleading early in the course of meningitis as in small proportion. there may be an initial lymphocytic predominance and viral meningitis may initially be. dominated by neutrophils Arevalo 1989 as cited in Seehusen 2003. In our study the cell counts of the CSF samples ranged from acellular to sheets of cells not. countable on the hemocytometer A predominance of polymorphonuclear cells was the. common feature in all cases with high cell counts, In some facilities clinical and management decisions are made on the cell type and the. number Thus patients with cerebrospinal fluid pleocytosis on further assessment may. have a preponderance of polymorphonuclear cells that would prompt a diagnosis of. bacterial meningitis 14 cases in our study had a CSF cell count of 100 cells cumm 2 of. which had a cell count of 10 cells cmm and one had no cells All these cases yielded. S pneumoniae on culture Normal or marginally elevated CSF white cell counts are known. to occur in 5 10 patients and are associated with an adverse outcome Van De Beek et al. 2004 as cited in Mani et al 2007, 3 1 3 Examination of Gram stained smear. It is preferable to make a smear from CSF at the time of collection itself for direct. demonstration of organisms, www intechopen com, 190 Meningitis.
The Gram stained smear made either directly from the CSF or from the centrifuged deposit. can reveal not only the Gram character of the causative organism but can also clinch the. diagnosis in some cases Gram stain may not be interpretable in grossly blood stained. Although Gram staining of CSF sediment is a very useful cheap and fairly rapid method of. identification of organism the sensitivity in developing countries is only 25 40 Singh. 1988 as cited in Sanya 2007 when compared to 80 85 in developed countries Gray. Fedorko 1992, CSF Gram staining may swiftly identify the causative microorganism for patients with. suspected bacterial meningitis The additional value of Gram staining for CSF culture. negative patients is elucidative Brouwer et al 2010 In 1 3rd of the cases with bacterial. meningitis defined by CSF parameters may have negative CSF cultures around 50 of the. CSF culture negative patients have a positive Gram stain with equal percent of patients. being pretreated with antibiotics Bryan 1990 as cited in Brouwer et al 2010. The Gram stain is positive in 10 to 15 percent of patients who have bacterial meningitis but. with negative CSF cultures Durand 1993, In developing countries among suspected meningitis cases CSF Gram staining can identify. the causative organisms in 2 3rd and CSF culture is positive in 1 10th of the pretreated. patients Shameem et al 2008 as cited in Brouwer et al 2010. Gram staining correctly identifies the pathogen in 69 to 93 of patient. chemistry microbiology and cytology respectively Gray amp Fedorko 1992 Howev er the particular tests performed on tubes 2 and 3 are subjective and probably best determined by the laboratarians www intechopen com Laboratory Diagnosis of Meningitis 187 Contamination with skin flora and disinfectant w ill be ruled out after the first tube of CSF is collected The probabilities of

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