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Chloride levels in meningitis

Article in South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde · June 1988
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 522 SAMT VOL 73 7 MEI1988

• • • •
Chloride levels In menIngItIs
A. RAMKISSOON, H. M. COOVADIA

Summary
The blood/cerebrospinal fluid bromide ratio is sensi-
tive and specific in the diagnosis of tuberculous
meningitis (TBM). Blood/CSF chloride (CII ratios
were not found to be useful in differentiating between
TBM and viral and acute bacterial meningitis in 59
. black children. In a study of 148 children with
bacterial or viral meningitis or TBM, the majority
(112) had CSF CI- levels below the lower limit of
normal. Accordingly, CSF and blood CI- leVels and
the blood/CSF cr
ratio were not found to be useful
in, differentiating between TBM, acute bacterial
meningitis and viral meningitis.
Patients
A total of 148 black children (88 boys and 60 girls) with bacterial
or viral meningitis or TBM admitted to King Edward VIII
Hospital, Durban during the 6-month penod February - August
1985 were studied. The diagnoses were made on the baSIS of
clinical examination, routine cytological and biochemical tests on
the CSF, and culture studies. These have been reponed previously.
There were 10 children with TBM (age range 3 months - 10
years), 34 with viral meningitis (age range 2 days - 9 years), and
104 patients with bacterial meningitis (age range 1 day - II years).
CSF chloride (Cr) measurements were not done III all cases. The
blood/CSF cr nitio was computed in 59 patients for whom both
blood and CSF cr values were available. Only those patients in
whom blood and CSF were obtained at about the same time
(within 12 hours) were considered.

S Air Med J 1988; 73: 522-523.

Chloride and bromide share physical and chemical properties
and are hence grouped together as 'halides'. Studies by Mandal
el al., 'Mann el al. 2 and others have shown that after a loading
dose, the relative concentrations of bromide in the blood and
cerebrospinal fluid are normally in a ratio of about 3: 1. When
the bloodlbrain barrier is damaged, as in tuberculous meningitis
(TBM) but not viral meningitis, the bromide ratio in blood
and CSF tends to equalise. Conflicting reports exist about the
importance of CSF cr levels in the diagnosis of TBM,3,4
although a low level is thought to be suggestive of the disease. 5
We have recently shown 6 that the bromide partition test has a
specificity of 92% and a sensitivity of 92% in the diagnosis of
TBM. Its usefulness is, however, limited by the requirements
for facilities to measure radio-isotope activity. We therefore
explored the possibility that chloride estimations in blood and
CSF would be helpful in the diagnosis ofTBM.
Department of Paediatrics and Child Health, University of
Natal, Durban
A. RAMKISSOON, B.Se., M.Se. (MED.Se.)
H. M. COOVADIA, M.D., F.e.P. (S.A.l, M.Se. (IMMU~OL.l
Accepted: 25 May 198i.
Methods
cr levels in blood and CSF were measured with a fully automated
instrument, the Beckman Astra-8 Automated Stat/Routine
Analyser. The method of measurement was colorimetric titration.
Both the anode and the cathode consisted of silver chloride.
Measurements were made in mmol/1.
Results (Table I)
The blood/CSF cr ratio was 0,943 ± 0,032 in 6 patients with
TBM, 0,940 ± 0,003 in 16 with viral meningitis, 0,899 ± 0,217 in
18 with Haemophilus influenzae meningitis, 0,922 ± 0,059 in 13
with Slreprococcus pneumoniae meningitis and 0,914 ± 0,038 in 6
with Neisseria meningilidis meningitis. The normal blood/CSF cr
ratio is generally accepted as falling in the range 0,75 - 0,85; hence
the ratios in patients with bacterial arid viral meningitis and TBM
were elevated compared with those of healthy individuals.
The CSF cr level was the lower limit of normal in 9 out of 10
children with TBM, 84 out of 104 with acute bacterial meningitis
and 19 out of 34 with viral meningitis. The blood cr level was
found to be either raised, normal or reduced in 7 patients with
TBM and 41 with bacterial meningitis. Of 17 patients with viral
meningitis, 4 had a normal and 13 an elevated blood cr level.
Hence patients could not be differentiated into viral meningitis,
bacterial meningitis or TBM groups on the basis of either blood or
CSF cr values.

TABLE I. BLOOD AND CSF cr LEVELS (mmol/I) AND BLOOD/CSF cr RATIOS IN PATIENTS WITH BACTERIAL MENINGITIS,
VIRAL MENINGITIS OR TBM
Blood cr CSF CI- Blood/CSF CI- ratio
Mean±SD Range Mean±SD Range Mean ± SD Range
Normal 100 95 - 105 125 120 - 130 0,8 0,731 - 0,875
Meningitis
TBM 98,O±13,2 82 -120 107,O±9,7 94 -125 0,943 ± 0,032 0,896 - 0,979
Viral 115,O±8,7 105-136 122,0±1,4 112 -135 0,940 ± 0,003 0,781 - 1,088
S. pneumoniae 106,0±8,5 92 -120 113,0 ± 6,1 99 -122 0,922 ± 0,059 0,818 - 1,034
H. influenzae 104,1 ±4,9 92 -110 116,4 ± 9,4 90 -139 0,899 ± 0,217 0,794 - 1,020
N. meningitidis 104,3±4,9 96 -109 114±5,8 105 -122 0,914 ± 0,038 0,880 - 0,965
Klebsiella ND ND 117±7,7 108-127 ND ND
NO - not done.

Disussion
The value of eSF er levels as a diagnostic pointer in cases of
TBM is questionable. Parsons 3 states that the eSF chloride
level is 'no longer thought to be important'. Jaffe,4 however,
states that a very low eSF er value « 100 mmol/I) is
strongly suggestive of TBM provided that the blood er level
is not also very low. Our findings are different from those of
Jaffe. 4 Only 2 out of 10 patients with TBM had eSF er levels
below 100 mmol/I; their blood er levels were equally low. In
practice, once the diagnosis of bacterial meningitis has been
excluded, uncommonly low eSF er values « 110 mmol/I)
may be associated with TBM but not with viral meningitis.
The blood er value, eSF er value and blood/eSF er
ratio do not provide a'basis for distinguishing between bacterial
meningitis, viral meningitis and TBM. It is evident that the
• •
.Prevention of death from head Injury
•
In Natal
M. R. R. BULLOCK, M. D. DU TREVOU,
C. P. McKEOWN
Summary
A detailed review of 100 consecutive head injury
deaths in the Natal area was undertaken after forensic
autopsies had been performed; neurohistological
examination was carried out in 69 cases. It was
found that one-third of deaths could have been
prevented by medical treatment. Hypoxic and
ischaemic brain damage was judged to be a contri-
buting cause of death in 88% of all victims. Factors
isolated as major causes of preventable death
included: failure to prevent hypoxic brain damage by
timeous endotracheal intubation and rapid resuscita-
tion; major delays in referral from feeder hospitals;
and failure to detect intracerebral haematomas and
contusions which subsequently caused raised intra-
cranial pressure. Recommendations for improving
this situation are discussed, with particular reference
to the situation in N·atal.
S Afr Med J 1988; 73: 523-527.
Departments of Neurosurgery and Forensic Medicine,
University of Natal and Wentworth Hospital, Durban
M. R. R. BULLOCK, M.B. CH.B. (BIRM.), F.R.CS. (GLASG.), F.R.CS.
(EDIN.)
M. D. DU TREVOU, M.B. CH.B., F.CS. (S.A.)
J. R. VAN DELLEN, M.B. B.CH., F.R.CS., PH.D.
J. P. NEL, M.B. CH.B., M.MED. (MED. FORENS.)
C. P. McKEOWN, DIP. PHARM.
Accepted 10 Dee 1987.
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SAMJ VOL. 73 7 MAY 1988 523
dynamics of halide tra..'lsfer across the blood/brain barrier in
TBM is not uniform and differs between bromide and chloride.
REFERENCES
1. Mandal BK, Evans DIK, lronside AG, Pullan BR. Radioactive bromide
partirion resr in differential diagnosis of tuberculous meningitis. Br Med J
1972; 4: 413-415.
2. Mann MD, MacFarlane CM, Verburg CJ, Wiggelinkhuizen J. The bromide
partirion test and CSF adenosine deaminase activity in the diagnosis of
tuberculous meningitis in children. S Afr Med J 1982; 62: 431-433.
3. Parsons M. Tuberculous Meningitis: A Handbook for Clinicians. New York:
Oxford University Press, 1979: 1-18.
4. Jaffe IP. Tuberculous meningitis in childhood. Lancer 1982; i: 738.
5. Smythe PM. Tul;>erculosis. In: Coovadia HM, Loening WEK, eds. Paedi-
atrics and Child HeaiIh: A Handbook for HeaiIh Professionals in the Third
World. Cape Town: Oxford University Press, 1984: 131.
6. Coovadia YM, Dawood A, Ellis ME, Coovadia HM, Daniel TM. Evaluation
of adenosine deaminase activity and antibody to Mycobacterium tuberculosis
antigen 5 in cerebrospinal fluid and rhe radioactive bromide partition test for
the early diagnosis of tuberculous meningitis. Arch Dis Child 1986; 61:
428-435..
J. R. VAN DELLEN, J. P. NEL
Many South Africans continue to die needlessly from prevent-
able complications after head injury. In common with most
countries, other than parts of the USA, acute head injury care
in the RSA is provided by a wide spectrum of doctors, many
of whom are not experienced in the management of these
patients; the consequences of mismanagement may be death or
survival in a severely disabled state. l The cost of death or
. permanent disability in terms of loss of earning capacity, state
support, and family suffering in a predominantly young popu-
lation, requires little emphasis.
Three significant advances have improved head injury care
over the last decade.
I. Increased availability of computed tomography (eT) and
its liberal use in as wide a spectrum of head injured patients as
possible has led to earlier detection of haematomas and contu-
sions and tht;ir evacuation before clinical deterioration occurs. 2
2. Recognition of the freq1!ency and importance of hypoxic
brain damage in head injured people has led to a greater
awareness of the need to ciptimise oxygenation and brain
perfusion as early as possible after injuryY Speed is important.
Efficient accident-site resuscitation, airway care, and speedy
and accurate diagnosis and surgery have always been a yardstick
by which emergency services have been judged. Head injury
mortality rates have fallen where standards of pre-hospital care
for these patients have improved. 5
3. The emergence of neurological intensive care directed at
optimising brain perfusion and minimising ischaemic brain
damage has improved survival statistics after head injury
without an increase in the number of severely disabled and
vegetative patients. 6
The mortality details of a series of fatally head injured
patients referred to the neurosurgical unit of Wentworth
Hospital, Durban, are reviewed in order to isolate preventable
factors and then discuss their implications for improved