ML S MTA P1

L E S SO N 7 : CER EBRO SP I NAL F L UI D

• Choriod plexuses are capillary networks that form

SUMMARY the CSF (ultrafiltrate) from plasma by
I Formation and Physiology mechanisms of selective filtration under
II Specimen Collection and Handling hydrostatic pressure and active transport
A Normal Opening Pressure in the Subarachnoid secretion
Space
III Appearance
A Xanthochromia SPECIMEN COLLECTION AND HANDLING
B Cloudy or Turbid
C Grossly Bloody
i Traumatic Tap
ii Uneven Distribution of Blood
iii Clot Formation
iv Xanthochromic Supernatant
IV Cell Count
A WBC Count
V Chemistry Tests
A Protein
i Artificially Induced Proteins
ii Methods
iii other Tests
iv Myelin Basic Protein
B CSF Glucose Figure 1. Lumbar puncture
i Tests for Glucose
C CSF Lactate • Collected by lumbar puncture between the third,
D CSF Glutamine fourth, or fifth lumbar vertebrae
E CSF Chloride • Volume that can be removed is based on volume
F Lactate Dehydrogenase available in patient (adult vs. neonate) and the
VI CSF Culture opening pressure of the CSF taken when the
A Gram Stain needle first enters the subarachnoid space
B Acid-Fast Stain
C India Ink
• Elevated pressure requires fluid to be withdrawn
D Latex Agglutination slowly, with careful monitoring of the pressure,
E Serologic Testing and may prevent the collection of a large volume
F VDRL • Lying position – preferred as the flow of CSF is
VII Laboratory Diagnosis normal
A Bacterial Meningitis • Lateral/sitting position – higher opening pressure
B Viral meningitis
C Tubercular Meningitis
• other methods of collection
D Fungal Meningitis o Cysternal Technique – method of puncturing
E Primary Amoebic Meningoencephalitis (PAM) the suboccipital area
o Ventricular Technique – performed among
neonates, FONTANEL (bununan) is the site of
FORMATION AND PHYSIOLOGY collection

• A major fluid of the body from the CNS

• Provides a physiologic system:
o To supply nutrients to the nervous tissues
o To remove metabolic wastes
o To produce a mechanical barrier to cushion
the brain and spinal cord against trauma
• Produced in the choroid plexuses of the two
lumbar ventricles and the third and fourth
ventricles
• Approximately 20 mL is produced every hour in
adults
• To maintain a volume of 90-150 mL in adults and Figure 2. Drawing a CDF sample: lumbar puncture. After the
10-60 mL in neonates, the circulating fluid is area is completely numbed with local anesthetic, a small
reabsorbed back into the blood capillaries in the needle is slipped between—not into—the bones of the spine
below where the spinal cord itself ends. There is no risk of
arachnoid granulations/villae at a rate equal to its
paralysis.
production

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NORMAL OPENING PRESSURE IN THE

SUBARACHNOID SPACE
• Adults:
o 90 - 180 mmHg (lateral position)
o Slightly higher if the patient is sitting or is
markedly obese and varies up to 10 mmHg
depending on respiration
• Infants and Young Children:
o 10 to 100 mmHg
o Attaining the adult range by the age of six (6)
to eight (8) years

Figure 3. Spinal needle is inserted, usually between NOTE: If the opening pressure is greater than 200
the 3rd and 4th lumbar vertebrae mmHg for a relaxed patient, NO more than 2 mL should
be collected
• Specimens are collected in three sterile tubes,
which are labeled 1, 2, and 3 in the order in which
Table 1. CSF Pressure
they are withdrawn: Elevated CSF Pressure Decreased CSF Pressure
o Tube 1 - for Chemistry and Serology tests • Spinal-subarachnoid
▪ These tests are least affected by blood or • Tensed / Strained block
bacteria introduced as a result of the tap • Congestive Heart • Dehydration
Failure • Circulatory collapse
procedure
• Meningitis • CSF leakage
▪ CSF • Superior Vena Cava
o Tube 2 – for Microbiology tests Syndrome After removal of 1-2 mL CSF
▪ Possible contaminants are flushed • Thrombosis (venous then the pressure drops
already in Tube 1 sinuses) dramatically, it suggests
▪ MRT • Cerebral Edema herniation of spinal block
o Tube 3 – for Hematology tests (cell count) • Mass lesions above the puncture site.
• Hypo-osmolality REMEDY: Stop collection –
▪ It is least likely to contain cells
• Conditions that No further fluid can be
introduced by the spinal tap procedure inhibit CSF absorption drawn
▪ HR
• A fourth tube may be drawn for the microbiology
laboratory to provide better exclusion of skin NOTES TO REMEMBER
contamination or for additional serologic tests
• Avoid glass tubes because cell adhesion to the
• Supernatant fluid that is left over after each
section (micro & hema) has performed its tests glass affects cell count and differentiation
o Use plastic or polyester tube
may also be used for additional chemical or
serologic tests (NOTE: Borrowing of samples could • Processing time should be quick – cellular
be done in reverse order) degradation begins one (1) hour after collection
• Excess fluid should not be discarded and should • Refrigeration is contraindicated for culture
be frozen until there is no further use for it specimens (Tube #2) because fastidious
o Discard only after release of results organisms such as Hemophilus influenza and
• Storage: Neisseria meningitides will not survive
(meningitis)
o Hematology tubes are refrigerated (HR)
o Microbiology tubes remain at room
temperature (MRT) APPEARANCE
o Chemistry and serology tubes are frozen (CSF)
• Normally crystal clear
• The major terminology used to describe CSF
appearance includes crystal clear, cloudy or
turbid, milky, xanthochromic, and
hemolyzed/bloody
• Cloudy or turbid CSF
o Presence of microorganisms
o Increased protein
o Increased WBC, RBC
• Xanthochromic CSF
o Increased carotene
o Intake of rifampin
o Increased protein (>150mg/dL)
• Grossly Bloody CSF
Figure 4. CSF collection tubes o 6,000 RBC/uL
o Traumatic tap

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o Intracranial hemorrhage GROSSLY BLOODY

XANTHOCHROMIA • Clots may interfere with cell counts accuracy by

entrapping inflammatory cells
• Term used to describe CSF supernatant that is • Reasons For Clotting
pink, orange, or yellow 1. Traumatic tap
• Presence of RBC degradation products ▪ fresh blood has clotting factor fibrinogen
• Color will vary: ▪ bloody
o Pink – very slight amount of oxyhemoglobin 2. Subarachnoid blocking
o Orange – heavy hemolysis 3. Suppurative meningitis (pus cells, bacterial
o Yellow – conversion of oxyhemoglobin to meningitis)
unconjugated bilirubin 4. Tubercular meningitis
• other causes of Xanthochromia: 5. Froin Syndrome – when CSF clots without the
o Elevated serum bilirubin presence of blood, there is damage to blood-
o Presence of the pigment carotene brain barrier
o Markedly increased protein concentrations
o Melanoma pigment NOTE: Bloody CSF indicates the presence of clotting
• Xanthochromia that is caused by bilirubin due to factor fibrinogen. Milky white/turbid CSF indicates the
immature liver function is also commonly seen in increased of proteins.
infants, particularly in those who are premature
TRAUMATIC COLLECTION (TAP)

• Grossly bloody CSF can be an indication of

intracranial hemorrhage, but it may also be due to
the puncture of a blood vessel during the spinal
tap procedure
• Three visual examinations of the collected
specimens can usually determine whether the
blood is the result of hemorrhage or a traumatic
tap

Figure 5. Xanthochromia vs water

CLOUDY OR TURBID
• Turbidity and cloudiness begin to appear with:
o CSF WBC counts >200 cells/uL or
o CSF RBC counts >400 cells/uL
o CSF with cell counts of <50 cells/uL when
direct sunlight is directed to the tube at 90- Figure 6. (Left) Traumatic Tap (Right) Intracranial hemorrhage
degree angle from the observer appears
“sparkling” or “snowy” → TYNDALL Effect

Table 2. Different Appearances of CSF

Appearance Cause Major Significance
Crystal clear Normal
WBC Meningitis
Microorganisms Meningitis
Hazy, turbid, milky, cloudy
Protein Disorders that affect blood-brain barrier,
production of IgG within CNS
Oily Radiographic contrast media
RBC Hemorrhage (Pathologic)
Bloody
Traumatic tap (Nonpathologic)
Hemoglobin Old hemorrhage (Yellow)
Lysed cells (Pink or Orange)
Bilirubin RBC degradation
Xanthochromic Elevated bilirubin
Carotene Increased serum level
Protein Disorders affecting blood-brain barrier
Melanin Meningeal melanosarcoma
Protein (milky white) Disorders affecting blood-brain barrier
Clotted
Clotting factor (red/brown) Traumatic tap
Protein Disorders affecting blood-brain barrier
Pellicle
Clotting factor Tubular meningitis

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UNEVEN DISTRIBUTION OF BLOOD • Protein

• Culture
• Blood from a cerebral (intracranial) hemorrhage • GS / AFB Stain
• Fungal and Bacterial
will be evenly distributed throughout the three Special
Antigen
CSF specimen tubes, whereas a traumatic tap will (useful in certain
• Cytology
circumstances)
have the heaviest concentration of blood in tube 1, • Protein electrophoresis
with gradually diminishing amounts in tubes 2 • VDRL (Syphilis)
and 3 • Fibrin derivative D-dimer
• Performing RBC counts on all three tubes to
measure decreasing or constant blood is not
always reliable CELL COUNT
• RBC counts are usually determined only when a
CLOT FORMATION
traumatic tap has occurred and a correction for
leukocytes or protein is desired
• Introduction of plasma fibrinogen into the
o subtract 1 WBC for every 700 RBC
specimen (traumatic tap)
o subtract 8 mg/dL protein for every 10,000
• Bloody CSF caused by intracranial hemorrhage RBC/uL
DOES NOT contain enough fibrinogen to clot
• The RBC count can be calculated by performing a
• Diseases in which damage to the blood-brain total cell count and a WBC count and subtracting
barrier allows increased filtration of protein and the WBC count from the total count, if necessary
coagulation factors also cause clot formation but o Any cell count should be performed
do not usually produce a bloody fluid immediately
o Meningitis
• Specimens that cannot be analyzed immediately
o Froin syndrome
should be refrigerated
o blockage of CSF circulation through the
• The microscopic finding of macrophages
subarachnoid space
containing ingested RBCs or hemosiderin
• A classic web-like pellicle is associated with
granules is indicative of intracranial hemorrhage
tubercular meningitis and can be seen after
• Detection of the fibrin degradation product, D-
overnight refrigeration of the fluid
dimer, by latex agglutination immunoassay
indicates the formation of fibrin at a hemorrhage
XANTHOCHROMIC SUPERNATANT site

• RBCs must usually remain in the CSF for

approximately 2 hours before noticeable
hemolysis begins
o Therefore, a xanthochromic supernatant
would be the result of blood that has been
present longer than that introduced by the
traumatic tap
• To examine a bloody fluid for the presence of
xanthochromia:
o The fluid should be centrifuged in a
microhematocrit tube
o The supernatant examined against a white
background Figure 7. Counting chamber

Table 3. Traumatic Tap Vs Intracranial Hemorrhage

Traumatic Intracranial
Hemorrhage
Distribution of
1>2>3 1=2=3
Blood
Positive Negative
Clot Formation (plasma (fibrinogen
fibrinogen) absent)
Color of
Clear Xanthochromic
Supernatant
Erythrophages
(macrophages Negative Positive
w/ ingested RBC)

Table 4. Recommended Lab Test

• Opening CSF pressure
• Total cell count
Routine Figure 8. Cell count. Square 1, 3, 7, 9 (single line
• Diff. count (smear)
with 16 smaller squares) → WBC count. Corners
• Glucose (CSF: Plasma)
and middle of square 5 → RBC count

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WBC COUNT NOTE: For CSF specimens that are slightly hazy to
turbid, dilution is necessary.

Table 5. Dilution Factors for CSF Specimens

Amount of Amount of
• Routinely done Clarity Dilution
sample diluent
• Normal Adult = 0 to 5 WBCs/uL
• Neonates = 0 to 30 WBC/uL Slightly hazy 1:10 30 uL 270 uL
• Specimens that contain up to 200 WBCs or 400 Hazy 1:20 30 uL 570 uL
RBCs/uL may appear clear, so it is necessary to
examine all specimens microscopically Slightly cloudy 1:100 30 uL 2,970 uL
• An improved Neubauer counting chamber is Slightly bloody 1:200 30 uL 5,970 uL
routinely used for performing CSF cell counts
0.1 mL of a
• Diluent: 3% acetic acid + Methylene blue Cloudy/Bloody
1:10,000 1:100 9.9 mL
• 70% lymphocytes (adult) /Turbid
dilution
• 80% monocytes (neonate)
• Pleocytosis – increased number of normal cells in • Lymphocyte
CSF o Normal in CSF
• Primarily mononuclear cells o If increased – seen in viral, fungal and
• Lympho-to-mono = 70:30 (adults; reversed in tubercular meningitis
children) • Monocyte
• Pleocytosis – increased mononuclear count; o Normal in CSF
abnormal o If increased – seen in fungal and tubercular
• Other abnormal constituents meningitis
o Immature WBCs • Neutrophil
o Eosinophils o Not normal
o Plasma cells o Indicative of bacterial meningitis
o Macrophages o Found in early cases of viral, fungal, and
o Increased tissue cells tubercular meningitis
o Malignant cells • Erythrophages
• CSF differential is useful when pleocytosis is o Macrophages with ingested RBC
present o Seen in intracranial hemorrhage
• Pleocytosis w/ ↑neutrophils = bacterial meningitis • Plasma Cells
• Moderate pleocytosis w/ ↑mononuclears = viral, o Seen in multiple sclerosis – can lead to
tubercular, fungal, or parasitic paralysis
• Blast Cells
o Seen in leukemia

Table 6. WBCs
Type of Cell Major Clinical Significance Microscopic Findings
Normal
Viral, tubercular and fungal All stages of development may be
Lymphocytes
meningitis found
Multiple sclerosis
Granules may be less prominent
Bacterial meningitis
than in blood
Early cases of viral, tubercular and
Neutrophils
fungal meningitis
Cells disintegrate rapidly
Cerebral hemorrhage
Normal
Viral, tubercular and fungal
Monocytes Found mixed with lymphocytes
meningitis
Multiple sclerosis
May contain phagocytized RBCs
RBC in spinal fluid appearing as empty vacuoles or
Macrophages
Contrast media ghost cells, hemosiderin granules
and hematoidin crystals
Lymphoblasts, myeloblasts, or
Blast Acute leukemia
monoblasts
Lymphoma cells Disseminated lymphoma Resemble lymphocytes with cleft nuclei
Multiple sclerosis
Plasma cells Traditional and classic forms seen
Lymphocyte reaction
Ependymal, choroidal, spindle-shaped Seen in clusters with distinct nuclei and
Diagnostic procedures
cells distinct cell walls
Metastatic carcinomas Seen in clusters with fusing of cell
Malignant cells
Primary CNS carcinoma borders and nuclei

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NEUTROPHILS • Introduction of foreign material (i.e., medications

and shunts)
• Increased in bacterial meningitis
• Also seen in early stages of viral, fungal, MACROPHAGES
tubercular, and parasitic meningitis
• Also increased in CNS bleeding, repeated lumbar • Indicates previous hemorrhages
punctures, injection of medications or • Hemosiderin granules – degraded phagocytosed
radiographic dyes RBCs; dark-blue or black granules
• May become vacuolated after cytocentrifugation • Hematoidin crystals – further degradation
products; iron-free, consisting of hemoglobin and
unconjugated bilirubin

Figure 9. Neutrophils

Figure 7. Macrophages
MONONUCLEAR CELLS

• Increased in viral, tubercular, fungal, and parasitic NON-PATHOLOGIC SIGNIFICANT CELLS

meningitis
• Increased HIV/AIDS
• Moderate pleocytosis (<WBC/μL) with increased
normal and reactive lymphocytes and plasma
cells indicates MS or other neurodegenerative
disorders
• Frequently seen after diagnostic procedures
• Choroidal cells – epithelial lining of choroid
plexus; no nucleoli; uniform appearance
• Ependymal cells – lining of ventricles and neural
canal; less-defined membranes; in clusters; with
nucleoli
• Spindle-shaped cells – lining cells of arachnoid; in
clusters; seen with systemic malignancies

Figure 10. Mononuclear cells

EOSINOPHILS

• Associated with parasitic (i.e., A. strongyloides) Figure 8. Choroidal cells

and fungal infections (i.e., Coccidoides immitis)

Figure 6. Eosinophil Figure 9. Ependymal cells

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Figure 10. Spindle-shaped cells Figure 14. Lymphoma cells with nucleoli

MALIGNANT CELLS 0F HEMATOLOGIC ORIGIN MALIGNANT CELLS OF NON-HEMATOLOGIC ORIGIN

• Lymphoblasts, monoblasts, myeloblasts • Metastatic carcinoma of the lung, breast, renal,

• Complications of acute leukemia
• Nucleoli are more prominent than in blood smears
• Lymphoma cells – indicates dissemination
• Lymphoma cells – indicates dissemination from
lymphoid tissues
• Resemble large and small lymphocytes
• Nucleoli may appear cleaved; prominent nucleoli
are present
and GIT
• Astrocytomas, retinoblastomas,
medulloblastomas – primary CNS tumors
• Appear in clusters and must be differentiated
from clusters of normal cells

Figure 15. Medulloblastomas

Figure 11. Monoblast and two lymphocytes

CHEMISTRY TESTS

CSF PROTEIN
• The most frequently performed chemical test on
CSF
• Reference Range:
o Adults – 15-45 mg/dL
o Infants – 150 mg/dL
▪ Premature – 500 mg/dL
• Albumin
o Primary protein fraction (same as serum)
• Prealbumin
Figure 12. Myeloblasts from acute myelocytic
leukemia o Second most prevalent (distinctive to CSF)
• Alpha globulins
o Haptoglobin
o Ceruloplasmin
• Beta Globulin
o Transferrin (Major)
o Tau – carbohydrate deficient variant of
transferrin (unique to CSF)
• Gamma globulin
o IgG (primarily)
o IgA (small amount)

NOTE: IgM, Fibrinogen, and Beta lipoprotein are NOT

Figure 13. Lymphoblasts from acute
normally found in CSF.
lymphocytic leukemia

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• Elevated Results in: o IgG Index - used for diagnosis of disease with
o Meningitis increase CNS IgG production (e.g., multiple
o Hemorrhage sclerosis)
o Primary CNS tumors ▪ Normal = <0.77
o Multiple sclerosis
o Guillain-Barré syndrome (CSF IgG mg/dL) / (serum IgG g/dL)
IgG Index =
o Neurosyphilis (CSF Albumin mg/dL)/(Serum Albumin)
o Polyneuritis
o Myxedema OTHER TESTS
o Cushing disease
o Polyneuritis 1. Rose Jones – for Globulin
o Diabetes o Rgt: Ammonium sulfate
o Uremia o (+) turbidity or grayish white ring
o Connective tissue disease 2. Nonne Apelt – for Globulin
• Decreased Results in: o Rgt: Ammonium sulfate
o CSF leakage/trauma o (+) turbidity
o Recent puncture 3. Pandy’s – for Globulin
o Rapid CSF production o Rgt: Saturated phenol solution
o Water intoxication o (+) turbidity or bluish white cloudiness
4. Lange’s Colloidal Gold Test
ARTIFICALLY INDUCED PROTEINS o Albumin-Globulin ratio (increased Globulin =
infection)

MYELIN BASIC PROTEIN

• Presence in the CSF is indicative of recent
destruction of the myelin sheath that protects the
axons of the neurons (demyelination)
• Used to monitor the course of Multiple sclerosis -
• Decreased Results in: provides valuable measure of the effectiveness of
• CSF leakage/trauma current and future treatments
• Recent puncture • Immunoassay techniques are used for
• Rapid CSF production measurement
• Water intoxication
CSF GLUCOSE
METHODS
• Glucose enters the CSF by selective transport
across the blood-brain barrier, which results in a
1. Turbidimetry
normal value that is approximately 60% to 70%
o TCA (Trichloroacetic acid) – more preferred, it
that of the plasma glucose
can precipitate both albumin and globulin
o SSA (Sulfosalicylic acid) – precipitates only • If plasma glucose is 100 mg/dL, then CSF glucose
albumin would be 50 to 80 mg/dL
2. Dye Binding • The blood glucose should be drawn about 2 hours
o CBB (Coomasie Brilliant Blue) prior to the spinal tap to allow time for
Red + Protein = Blue (read photometrically) equilibration between the blood and fluid
3. Immunologic • CSF glucose is analyzed using the same
o Advantage: small amount of CSF is needed procedures employed for blood glucose.
(25-50 uL) Specimens should be tested immediately
o Protein fractions because glycolysis occurs rapidly in the CSF
▪ R – Radial immunodiffusion • High CSF Glucose
▪ E – Electrophoresis o ALWAYS due to plasma elevations
▪ N – Nephelometry • Normal to Low CSF Glucose
o Albumin Index – assess blood brain barrier o Suggestive to the causative agent of
permeability meningitis
▪ Normal = <9 • Normal Glucose with High Lymphocytes – Viral
▪ Damage = >9 (value of 100 – completely Meningitis
damaged) • Low Glucose with High Neutrophils – indicative of
Bacterial Meningitis
mg • Low Glucose with High Lymphocytes – suggestive
CSF Albumin ( )
Albumin Index = dL to Tubercular Meningitis
g
Serum Albumin ( )
dL

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TESTS FOR GLUCOSE • However, there are certain procedures that may
serve as a preliminary diagnosis:
• Copper reduction test o Gram Stain → bacterial
o Fehling’s o Acid-Fast Stain → tubercular
o Benedicts o India Ink → fungal
o Follin-Wu o Latex agglutination → fungal
• Orthotoluidine / Aromatic technique
• Enzymatic technique GRAM STAIN
• Heavy metal determination
• Routinely performed on CSF from ALL SUSPECTED
o Nelson-Somogyi
cases of meningitis
• Performed on concentrated specimens ONLY
CSF LACTATE
• Recommended for the detection of
• Valuable aid in the diagnosis and management of microorganisms
meningitis cases o Centrifugation at 1500rpm for 15 minutes is
• Inversely proportional to glucose standard
• Normal = 10-22 mg/Dl o Cytocentrifuge offers a greater yield
• Moderately elevated = 23-35 percentage
• Highly Elevated = > 35
ACID-FAST STAIN
Table 7. Lactate Levels and Their Probable Cause
• Not routinely performed
Lactate Level Probable Cause
Bacterial, Tubercular and • A positive report is extremely valuable
Greater than 25 mg/dL
Fungal Meningitis
Greater than 35 mg/dL Bacterial Meningitis INDIA INK
Lower than 25 mg/dL Viral Meningitis
• Performed with possible cases of FUNGAL
CSF GLUTAMINE Meningitis.
• Detects Cryptococcus neoformans (thickly
• Produced from ammonia and alpha-ketoglutarate encapsulated) – starburst pattern in Gram stain
by the brain cells o A frequent complication of AIDS –
• Production of Glutamine serves to remove the Cryptococcal meningitis
toxic metabolic waste product ammonia from the
CNS
LATEX AGGLUTINATION
• The normal concentration is 8 to 18 mg/dL
• 75% of children with Reye’s syndrome have • Used to detect the presence of Cryptococcus
elevated glutamine levels neoformans antigen in serum and CSF
• More sensitive than India Ink
CSF CHLORIDE
SEROLOGIC TESTING
• Normal value: 125 – 135 mg/dl
• Decreased chloride = meningitis • Primarily used in addition to detecting
o Acute meningitis caused by bacteria microorganisms as a tool in diagnosing
o TB meningitis NEUROSYPHILIS
• Tests:
o Fantus Test NOTE: Positive serologic tests SHOULD be confirmed by
o Titration Technique culture and demonstration of the organism in India
Ink preparation. This is due to the occurrence of false-
LACTATE DEHYDROGENASE positives interference by rheumatoid factor (most
common).
• Serum LD = 2 > 1 > 3 > 4 > 5
o If 1 > 2 = MI (myocardial infarction)
• CSF LD = 1 > 2 > 3 > 4 > 5
o If 2 > 1 = neurologic disorder VDRL (VENERAL DISEASE RESEARCH
o 5 > 4 > 3 > 2 > 1 = bacterial meningitis LABORATORIES)
• Sources of LD in CSF:
o LD 2 and LD 3 – lymphocytes • RECOMMENDED TEST by the CDC in diagnosing
o LD 1 and LD 2 – brain tissue Neurosyphilis.
o LD 4 and LD 5 – neutrophil • Less sensitive than Fluorescent treponemal
antibody-absorption (FTA-ABS)
CSF CULTURE
• Employed as a confirmatory rather than a
diagnostic procedure

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LABORATORY DIAGNOSIS o (+) India Ink – demonstration of capsule

BACTERIAL MENINGITIS PRIMARY AMOEBIC MENINGOENCEPHALITIS

(PAM)
• Group B Strep and GNB – birth to 1 month old
• H. influenzae – 1month to 5 years old • Caused by free-living amoeba
• N. meningitidis – 5 years to 29 years old • Used of Acridine orange stain (amoeba stains
• S. pneumoniae – >29 years old brick-red)
• L. monocytogenes – newborn, elderly
o immunocompromised and
REFERENCES
immunosuppressed
• Features: Urinalysis and Body Fluids ,6th Edition. Susan King
o Increased WBC count (neutrophil) Strasinger and Marjorie Schaub Di Lorenzo
o Increased Protein
o Decreased Glucose Fundamental of Urine and Body Fluid Analysis, 3rd
o >35 mg/dl lactate Edition. Nancy A. Brunzel
o (+) bacteria in gram stain
Notes from synchronous session by Mr. Edison D. Ramos,
o (+) Limulus Lysate test RMT, MPH, MSMT

VIRAL MENINGITIS

• Enteroviruses
o Poliovirus
o Coxsackie virus
o Echovirus
• Features:
o Increased WBC count (Lymphocyte)
o Increased Protein
o Normal Glucose
o Normal Lactate

TUBERCULAR MENINGITIS
• Mycobacterium tuberculosis
• Features:
o Increased WBC count (Monocyte,
Lymphocyte)
o Increased Protein
o Decreased Glucose
o >25 mg/dL Lactate
o (+) Pellicle Formation/ Clot Formation (in
specimen placed in refrigerator for 12-24
hours)

FUNGAL MENINGITIS
• Cryptococcus neoformans
• Features:
o Increased WBC count (Monocyte,
Lymphocyte)
o Increased Protein
o Decreased Glucose
o >25 mg/dl Lactate

Table 8. Meningitis Summary

Meningitis WBC Count Protein Glucose Lactate
↑
Bacterial ↑ ↓ ↑↑ (+) Gram Stain
Neutro
↑
Viral ↑ Normal Normal
Lympho
↑ (+) Pellicle
Tubercular ↑ ↓ ↑
Mono, Lympho Formation
↑
Fungal ↑ ↓ ↑ (+) India Ink
Mono, Lympho

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