Bacterial meningitis lumbar puncture: Difference between revisions
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==Overview== | ==Overview== | ||
Lumbar puncture is the single most specific test to confirm the diagnosis of bacterial meningitis. It is indicated in all patients with suspicion of bacterial meningitis unless there is a contraindication. The CSF findings in patients with bacterial meningitis include low glucose concentration, high protein content, increased no of granulocytes and lactate levels >2.1mmol/l.<ref name="pmid12432041">{{cite journal| author=de Gans J, van de Beek D, European Dexamethasone in Adulthood Bacterial Meningitis Study Investigators| title=Dexamethasone in adults with bacterial meningitis. | journal=N Engl J Med | year= 2002 | volume= 347 | issue= 20 | pages= 1549-56 | pmid=12432041 | doi=10.1056/NEJMoa021334 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12432041 }} [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12725615 Review in: ACP J Club. 2003 May-Jun;138(3):60] </ref><ref name="pmid8416268">{{cite journal| author=Durand ML, Calderwood SB, Weber DJ, Miller SI, Southwick FS, Caviness VS et al.| title=Acute bacterial meningitis in adults. A review of 493 episodes. | journal=N Engl J Med | year= 1993 | volume= 328 | issue= 1 | pages= 21-8 | pmid=8416268 | doi=10.1056/NEJM199301073280104 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8416268 }} </ref> | |||
==Lumbar puncture== | ==Lumbar puncture== | ||
===Indications of lumbar puncture=== | ===Indications of lumbar puncture=== | ||
Lumbar puncture is indicated in all pateints with strong suspicion of meningitis for the following reasons:<ref name="pmid25075138">{{cite journal| author=Doherty CM, Forbes RB| title=Diagnostic Lumbar Puncture. | journal=Ulster Med J | year= 2014 | volume= 83 | issue= 2 | pages= 93-102 | pmid=25075138 | doi= | pmc=4113153 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25075138 }} </ref> | |||
*To confirm the diagnosis | |||
*To differentiate the different causes of meningitis | |||
*To diagnose the specific causative agent for bacterial meningitis | |||
*To start the appropriate treatment as early as possible to prevent complications | |||
===Findings of lumbar puncture in bacterial meningitis=== | ===Findings of lumbar puncture in bacterial meningitis=== | ||
Following CSF findings may suggest bacterial meningitis:<ref name="pmid12432041">{{cite journal| author=de Gans J, van de Beek D, European Dexamethasone in Adulthood Bacterial Meningitis Study Investigators| title=Dexamethasone in adults with bacterial meningitis. | journal=N Engl J Med | year= 2002 | volume= 347 | issue= 20 | pages= 1549-56 | pmid=12432041 | doi=10.1056/NEJMoa021334 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12432041 }} [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12725615 Review in: ACP J Club. 2003 May-Jun;138(3):60] </ref><ref name="pmid8416268">{{cite journal| author=Durand ML, Calderwood SB, Weber DJ, Miller SI, Southwick FS, Caviness VS et al.| title=Acute bacterial meningitis in adults. A review of 493 episodes. | journal=N Engl J Med | year= 1993 | volume= 328 | issue= 1 | pages= 21-8 | pmid=8416268 | doi=10.1056/NEJM199301073280104 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8416268 }} </ref> | Following CSF findings may suggest bacterial meningitis:<ref name="pmid12432041">{{cite journal| author=de Gans J, van de Beek D, European Dexamethasone in Adulthood Bacterial Meningitis Study Investigators| title=Dexamethasone in adults with bacterial meningitis. | journal=N Engl J Med | year= 2002 | volume= 347 | issue= 20 | pages= 1549-56 | pmid=12432041 | doi=10.1056/NEJMoa021334 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12432041 }} [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12725615 Review in: ACP J Club. 2003 May-Jun;138(3):60] </ref><ref name="pmid8416268">{{cite journal| author=Durand ML, Calderwood SB, Weber DJ, Miller SI, Southwick FS, Caviness VS et al.| title=Acute bacterial meningitis in adults. A review of 493 episodes. | journal=N Engl J Med | year= 1993 | volume= 328 | issue= 1 | pages= 21-8 | pmid=8416268 | doi=10.1056/NEJM199301073280104 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8416268 }} </ref> | ||
*A pressure of over 180 mmH2O <ref name="pmid12432041">{{cite journal| author=de Gans J, van de Beek D, European Dexamethasone in Adulthood Bacterial Meningitis Study Investigators| title=Dexamethasone in adults with bacterial meningitis. | journal=N Engl J Med | year= 2002 | volume= 347 | issue= 20 | pages= 1549-56 | pmid=12432041 | doi=10.1056/NEJMoa021334 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12432041 }} [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12725615 Review in: ACP J Club. 2003 May-Jun;138(3):60] </ref><ref name="pmid8416268">{{cite journal| author=Durand ML, Calderwood SB, Weber DJ, Miller SI, Southwick FS, Caviness VS et al.| title=Acute bacterial meningitis in adults. A review of 493 episodes. | journal=N Engl J Med | year= 1993 | volume= 328 | issue= 1 | pages= 21-8 | pmid=8416268 | doi=10.1056/NEJM199301073280104 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8416268 }} </ref> | *A pressure of over 180 mmH2O <ref name="pmid12432041">{{cite journal| author=de Gans J, van de Beek D, European Dexamethasone in Adulthood Bacterial Meningitis Study Investigators| title=Dexamethasone in adults with bacterial meningitis. | journal=N Engl J Med | year= 2002 | volume= 347 | issue= 20 | pages= 1549-56 | pmid=12432041 | doi=10.1056/NEJMoa021334 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12432041 }} [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12725615 Review in: ACP J Club. 2003 May-Jun;138(3):60] </ref><ref name="pmid8416268">{{cite journal| author=Durand ML, Calderwood SB, Weber DJ, Miller SI, Southwick FS, Caviness VS et al.| title=Acute bacterial meningitis in adults. A review of 493 episodes. | journal=N Engl J Med | year= 1993 | volume= 328 | issue= 1 | pages= 21-8 | pmid=8416268 | doi=10.1056/NEJM199301073280104 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8416268 }} </ref><ref name="pmid21194480">{{cite journal| author=Huy NT, Thao NT, Diep DT, Kikuchi M, Zamora J, Hirayama K| title=Cerebrospinal fluid lactate concentration to distinguish bacterial from aseptic meningitis: a systemic review and meta-analysis. | journal=Crit Care | year= 2010 | volume= 14 | issue= 6 | pages= R240 | pmid=21194480 | doi=10.1186/cc9395 | pmc=3220013 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21194480 }} </ref><ref name="pmid21382412">{{cite journal| author=Sakushima K, Hayashino Y, Kawaguchi T, Jackson JL, Fukuhara S| title=Diagnostic accuracy of cerebrospinal fluid lactate for differentiating bacterial meningitis from aseptic meningitis: a meta-analysis. | journal=J Infect | year= 2011 | volume= 62 | issue= 4 | pages= 255-62 | pmid=21382412 | doi=10.1016/j.jinf.2011.02.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21382412 }} </ref> | ||
*CSF cell count in 1000s. | *CSF cell count in 1000s<ref name="pmid8416268">{{cite journal| author=Durand ML, Calderwood SB, Weber DJ, Miller SI, Southwick FS, Caviness VS et al.| title=Acute bacterial meningitis in adults. A review of 493 episodes. | journal=N Engl J Med | year= 1993 | volume= 328 | issue= 1 | pages= 21-8 | pmid=8416268 | doi=10.1056/NEJM199301073280104 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8416268 }} </ref> | ||
*Granulocytes > | *[[Granulocytes]] > lymphocytes | ||
*Elevated protein may range between 100-500mg/dl | *Elevated protein may range between 100-500mg/dl | ||
*Glucose ratio(CSF/plasma)<0.3 | *Glucose ratio (CSF/plasma) <0.3 | ||
*CSF lactate >2.1mmol/l | *CSF lactate >2.1mmol/l<ref name="pmid21194480">{{cite journal| author=Huy NT, Thao NT, Diep DT, Kikuchi M, Zamora J, Hirayama K| title=Cerebrospinal fluid lactate concentration to distinguish bacterial from aseptic meningitis: a systemic review and meta-analysis. | journal=Crit Care | year= 2010 | volume= 14 | issue= 6 | pages= R240 | pmid=21194480 | doi=10.1186/cc9395 | pmc=3220013 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21194480 }} </ref><ref name="pmid21382412">{{cite journal| author=Sakushima K, Hayashino Y, Kawaguchi T, Jackson JL, Fukuhara S| title=Diagnostic accuracy of cerebrospinal fluid lactate for differentiating bacterial meningitis from aseptic meningitis: a meta-analysis. | journal=J Infect | year= 2011 | volume= 62 | issue= 4 | pages= 255-62 | pmid=21382412 | doi=10.1016/j.jinf.2011.02.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21382412 }} </ref> | ||
*CSF gram stain findings | |||
:*Gram positive diplococcus - [[Streptococcus Group A|Streptococcus Pneumonia]] | |||
:*Gram negative [[diplococcus]] - [[Neisseria Meningitidis|Neisseria Meningitides]] | |||
:*Gram positive [[coccobacillus]] - [[Listeria monocytogenes|Listeria Monocytogenes]] | |||
:*Small [[pleomorphic]] gram - negative coccobacilli - [[Haemophilus Influenzae B|Haemophilus Influenzae]] | |||
===Contraindications of lumbar puncture=== | ===Contraindications of lumbar puncture=== | ||
Contraindications of lumbar puncture may include the following:<ref name="pmid17918111">{{cite journal| author=Sempere AP, Berenguer-Ruiz L, Lezcano-Rodas M, Mira-Berenguer F, Waez M| title=[Lumbar puncture: its indications, contraindications, complications and technique]. | journal=Rev Neurol | year= 2007 | volume= 45 | issue= 7 | pages= 433-6 | pmid=17918111 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17918111 }} </ref><ref name="pmid25075138">{{cite journal| author=Doherty CM, Forbes RB| title=Diagnostic Lumbar Puncture. | journal=Ulster Med J | year= 2014 | volume= 83 | issue= 2 | pages= 93-102 | pmid=25075138 | doi= | pmc=4113153 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25075138 }} </ref> | |||
*Increased intracranial pressure | |||
*Mass lesion such as tumour | |||
*Thrombocytopenia | |||
*Bleeding diathesis | |||
==References== | ==References== | ||
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Latest revision as of 20:34, 29 July 2020
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Bacterial meningitis Microchapters |
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Diagnosis |
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Treatment |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aysha Anwar, M.B.B.S[2]
Overview
Lumbar puncture is the single most specific test to confirm the diagnosis of bacterial meningitis. It is indicated in all patients with suspicion of bacterial meningitis unless there is a contraindication. The CSF findings in patients with bacterial meningitis include low glucose concentration, high protein content, increased no of granulocytes and lactate levels >2.1mmol/l.[1][2]
Lumbar puncture
Indications of lumbar puncture
Lumbar puncture is indicated in all pateints with strong suspicion of meningitis for the following reasons:[3]
- To confirm the diagnosis
- To differentiate the different causes of meningitis
- To diagnose the specific causative agent for bacterial meningitis
- To start the appropriate treatment as early as possible to prevent complications
Findings of lumbar puncture in bacterial meningitis
Following CSF findings may suggest bacterial meningitis:[1][2]
- A pressure of over 180 mmH2O [1][2][4][5]
- CSF cell count in 1000s[2]
- Granulocytes > lymphocytes
- Elevated protein may range between 100-500mg/dl
- Glucose ratio (CSF/plasma) <0.3
- CSF lactate >2.1mmol/l[4][5]
- CSF gram stain findings
- Gram positive diplococcus - Streptococcus Pneumonia
- Gram negative diplococcus - Neisseria Meningitides
- Gram positive coccobacillus - Listeria Monocytogenes
- Small pleomorphic gram - negative coccobacilli - Haemophilus Influenzae
Contraindications of lumbar puncture
Contraindications of lumbar puncture may include the following:[6][3]
- Increased intracranial pressure
- Mass lesion such as tumour
- Thrombocytopenia
- Bleeding diathesis
References
- ↑ 1.0 1.1 1.2 de Gans J, van de Beek D, European Dexamethasone in Adulthood Bacterial Meningitis Study Investigators (2002). "Dexamethasone in adults with bacterial meningitis". N Engl J Med. 347 (20): 1549–56. doi:10.1056/NEJMoa021334. PMID 12432041. Review in: ACP J Club. 2003 May-Jun;138(3):60
- ↑ 2.0 2.1 2.2 2.3 Durand ML, Calderwood SB, Weber DJ, Miller SI, Southwick FS, Caviness VS; et al. (1993). "Acute bacterial meningitis in adults. A review of 493 episodes". N Engl J Med. 328 (1): 21–8. doi:10.1056/NEJM199301073280104. PMID 8416268.
- ↑ 3.0 3.1 Doherty CM, Forbes RB (2014). "Diagnostic Lumbar Puncture". Ulster Med J. 83 (2): 93–102. PMC 4113153. PMID 25075138.
- ↑ 4.0 4.1 Huy NT, Thao NT, Diep DT, Kikuchi M, Zamora J, Hirayama K (2010). "Cerebrospinal fluid lactate concentration to distinguish bacterial from aseptic meningitis: a systemic review and meta-analysis". Crit Care. 14 (6): R240. doi:10.1186/cc9395. PMC 3220013. PMID 21194480.
- ↑ 5.0 5.1 Sakushima K, Hayashino Y, Kawaguchi T, Jackson JL, Fukuhara S (2011). "Diagnostic accuracy of cerebrospinal fluid lactate for differentiating bacterial meningitis from aseptic meningitis: a meta-analysis". J Infect. 62 (4): 255–62. doi:10.1016/j.jinf.2011.02.010. PMID 21382412.
- ↑ Sempere AP, Berenguer-Ruiz L, Lezcano-Rodas M, Mira-Berenguer F, Waez M (2007). "[Lumbar puncture: its indications, contraindications, complications and technique]". Rev Neurol. 45 (7): 433–6. PMID 17918111.