csf fluid analysis[1]

7/30/2019 CSF Fluid Analysis[1]

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CSF fluid analysis


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Type of CSF findings

1. Purulent profiles:2. Lymphocytic - normal glucose

3. Lymphocytic - low glucose

4. Eosinophilic


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Pt: cloudy, pressure 220 mmH2O, cell 1100/mm3, PMN

predominantly, protein 125 mg%, sugar 20 mg%


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Purulent CSF: PMN, low sugar, high prot,slightly ICP1.Bacterial meningitis*** :Streptococcus pneumoniae

Haemophilus influenzae

Neisseria meningitidis.2. Amoebic meningoencephalitis

(Naegleria fowleri)

3.Chemical meningitis: contrast media, ruptured

dermoid/epidermoid cyst4. Drug induced meningitis: NSAID, penicillin,

co-trimoxazole, IVIG

Streptococcus suis


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2. Lymphocytic - normal glucose CSF: normal ICP,normal or slightly increased protein

1. Viral meningitis/encephalitis*** :Adenovirus, echovirus, herpes virus, etc.

2. Post-viral/post-vaccinal meningoencephalitis

3. Spirochete/rickettsial

4. Bacterial meningitis: partially treated,

Listeria monocytogenes

5. Parameningeal infection6. Vasculitic disease


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3. Lymphocytic low glucose CSF: high prot,high ICP

1. TB meningitis***

2. Fungal meningitis***:

Cryptococcus neoformans, etc.

3. Carcinomatous meningitis:

CA, lymphoma, leukemia

4. Viral: mumps, Herpes simplex,

Lymp choriomeningitis


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4. Eosinophilic CSF: high ICP, N/slightly high prot,sometime low sugar1. Angiostrongylus cantonensis &

Gnathostoma spinigerum**

usually Eo more than 20%

2. Other parasitic infection: usually no more than20%

3. Tumor

4. CSF eosinophilia: present Eo in the CSF (trauma,blood, gas)


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http://jcm.asm.org/content/38/5/1965/F1.large.jpg


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1. Clinical syndrome of meningitis

Clinical: fever + headache + neck stiffness

Acute vs chronic

2. Source of infection

Clinical: history, physical exam

3. Laboratory

CSF exam, CT/MRI head, other fluid stain/culture,

other lab chem: hemoculture, CBC, antibody titer, etc.

Diagnosis of meningitis


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How to approach patient with CNS infection

Does the patient have CNS infection?

What is the location of infection?

What is the nature (organism)?

How to manage patient with CNS infection?


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2. Subacute/chronic meningitis syndrome+ + -

+/- photophobia, CN palsy, other focal S&S,

consciousness, papilledema

Systemic exam. May reveal clues: PPE, Hairy

leukoplakia, umbilicated papule, cachexia

Diagnosis: Hx + PE +/- CT + CSF exam

Causes1. TB meningitis*** 2. Cryptococcal meningitis***

3. Carcinomatous meningitis: CA, hematologic

malignancy

4. Neurosyphilis 5.Vasculitic diseases 6. Sarcoidosis


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http://www-sequence.stanford.edu/group/C.neoformans/images/index.html


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3. Acute encephalitis syndrome+ // +/- +/-

Diagnosis: Hx + PE + CSF exam +/- CT scan

Causes:1. Viral encephalitis***2. Post viral/post vaccinal encephalitis3. Spirochete, rickettsia4. Mycoplasma pneumoniae

5. Amoeba6. Cerebral malaria7. Rabies


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Treatment

1. Symptomatic : analgesic, anticonvulsant, etc.

2. In case ofHerpes simplex encephalitis:

positive temporal lobe lesion in imaging and/or

suggestive CSF ( slightly low sugar, lymphocyte, red

blood cell) acyclovir 10 mg/kg IV q 8 hr 7-10 d

Acute encephalitis syndrome


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MRI, herpes simplex encephalitis.area of increased signal in the right temporal lobe confined predominantly to

the gray matter.


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3. Cerebral malaria:

Artesunate/Quinine IVplasma exchange in case of hyerparasitemia +impaired consciousness (parasitemia > 10%)


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Approach to peritoneal fluid

analysis


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Pathophysiology of Cirrhotic Ascites

Khayyat ,Approach to peritoneal fluidanalysis

22


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Historyin Ascites

Onset,progression,severity (breathing),precipitating and

relieving factors

Associated :fever, abdominal pain

,nausea,vomiting,jaundice

Liver disease history:viral,alcoholic,etc,or established

cirrhosis

Previous Investigations or treatment

Sacral, Scrotal and lower limbs edema

Rule out other abdominal distension causes: Intestinalobstruction-Dilated bowel-Internal bleeding.

Identify PPT factors of Ascites: compliance,diet,other

23Khayyat ,Approach to peritoneal fluidanalysis


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Vital signs:fever,tachycardia,tachpnea

General: Encephalopathy,Jaundice,resp distress JVP: distension due to RHF

CVS:

RESP: pleural effusion

ABDOMEN:

Inspection: everted umbilicus, flank fullness,striae

Palpation:

Percussion: [Flank dullness( if absent this means that there is < 10%

chance of having Ascites) there is at least 1.5 liters of Ascites if

dullness is present], shifting dullness, fluid thrill.

Lower Limbs: pitting edema

Physical Examination in Ascites



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Paracentesis Procedure Indication: new onset Ascites in inpatient or

outpatient .

Ascitic Tapping ( movie demonstration)

Prophylactic use of IV FFP or platelets is not

needed before paracentesis.

15 gauge needle 3.25 inch is better than 14

gauge is more successful in obtaining

paracentesis.

http://youtu.be/TTFNgIzgKTwhttp://youtu.be/TTFNgIzgKTw


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Ascitic fluid analysis panel Cell count: differential ,PMN,% neutrophils on

differential.

Chemistry: Albumin, total

protein,LDH,glucose,amylase SAAG : SerumAlbumin-AscitesAlbumin

Microbiology: gram stain, cultures ( aerobic

and anaerobic),TB stain ( AFB) Cytology:senstivity of 3 samples is better

96.7%



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Interpretation of Ascitic fluid infection findingsAbsolute PMN /mm3Ascitic fluids culture

250PositiveSBP

250

No growthCulture negative

neutrocytic

Ascites

< 250

PositiveMonomicrobial

non neutrocyticAscites


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Underlying cause of Ascites: The DDHigh gradient

Ascites

>1.1 g/dl ( > 11g/l)

Low gradient Ascites


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Treatment of Ascitic fluids Infection

SBP

Culturenegativeneutrocytic

Ascites

Monomicrobial non

neutrocyticAscites

Polymicrobial

bacteriascites

5 days of IV

antibiotics

5 days of

IV

antibiotics

5 days of IV

antibiotics

5 days ofIV

antibiotic

s +

anaerobic29Khayyat ,Approach to peritoneal fluid

analysis


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HospitalizationPrecipitati

ng causes

DiureticsRestriction

Guidelines of Ascites treatment

30Khayyat ,Approach to peritoneal fluidl i

csf fluid analysis[1]

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