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CSF fluid analysis

Type of CSF findings

1. Purulent profiles:
2. Lymphocytic - normal glucose

3. Lymphocytic - low glucose

4. Eosinophilic

Pt: cloudy, pressure 220 mmH2O, cell 1100/mm3, PMN predominantly, protein 125 mg%, sugar 20 mg%

Purulent CSF: PMN, low sugar, high prot, slightly ICP

1.Bacterial meningitis*** : Streptococcus pneumoniae Streptococcus suis Haemophilus influenzae Neisseria meningitidis.
2. Amoebic meningoencephalitis (Naegleria fowleri) 3.Chemical meningitis: contrast media, ruptured dermoid/epidermoid cyst 4. Drug induced meningitis: NSAID, penicillin, co-trimoxazole, IVIG

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 infection 6. Vasculitic disease

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

4. Eosinophilic CSF: high ICP, N/slightly high prot, sometime low sugar

1. Angiostrongylus cantonensis & Gnathostoma spinigerum**

usually Eo more than 20% 2. Other parasitic infection: usually no more than 20% 3. Tumor 4. CSF eosinophilia: present Eo in the CSF (trauma, blood, gas)

Diagnosis of meningitis
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.

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?

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
Causes 1. TB meningitis*** 2. Cryptococcal meningitis*** 3. Carcinomatous meningitis: CA, hematologic malignancy 4. Neurosyphilis 5.Vasculitic diseases 6. Sarcoidosis

3. Acute encephalitis syndrome

+/- +/- + //

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

Causes: 1. Viral encephalitis*** 2. Post viral/post vaccinal encephalitis 3. Spirochete, rickettsia 4. Mycoplasma pneumoniae 5. Amoeba 6. Cerebral malaria 7. Rabies

Acute encephalitis syndrome

1. Symptomatic : analgesic, anticonvulsant, etc. 2. In case of Herpes 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

area of increased signal in the right temporal lobe confined predominantly to the gray matter.

MRI, herpes simplex encephalitis.

3. Cerebral malaria: Artesunate/Quinine IV plasma exchange in case of hyerparasitemia + impaired consciousness (parasitemia > 10%)

Approach to peritoneal fluid analysis

Pathophysiology of Cirrhotic Ascites

Khayyat ,Approach to peritoneal fluid analysis


History in 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: Intestinal obstruction-Dilated bowel-Internal bleeding. Identify PPT factors of Ascites: compliance,diet,other
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Physical Examination in Ascites

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
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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.
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Ascitic fluid analysis panel

Cell count: differential ,PMN,% neutrophils on differential. Chemistry: Albumin, total protein,LDH,glucose,amylase SAAG : Serum Albumin- Ascites Albumin 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 findings

Ascitic fluids culture Absolute PMN /mm3

SBP Culture negative neutrocytic Ascites Monomicrobial non neutrocytic Ascites Polymicrobial bacteriascites


250 250 < 250

No growth

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Underlying cause of Ascites: The DD

High gradient Ascites >1.1 g/dl ( > 11g/l) Low gradient Ascites <1.1 g/dl ( <11g/l)

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Treatment of Ascitic fluids Infection

5 days of IV antibiotics
Culture negative neutrocytic Ascites

5 days of IV antibiotics


5 days of IV antibiotics

Monomicrobi al non neutrocytic Ascites

Polymicrobial bacteriascites

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5 days of IV antibiotic s+ 29 anaerobic


Precipitati ng causes

Guidelines of Ascites treatment

Restriction Diuretics

Khayyat ,Approach to peritoneal fluid analysis