Question

Meningitis Case Study #3

Patient A: A 73-year-old Guatemalan man named Francisco Salazar was brought into the ER by his daughter with a chief complaint of a 5-day history of fever, back and neck pain, headache, and confusion. Francisco’s daughter notes that they live on a dairy farm and he has a history of cirrhosis and non-insulin dependent diabetes. A lumbar puncture was performed for cerebrospinal fluid (CSF) analysis.

	Normal CSF ranges	Patient #A	Patient #B
Leukocytes (per mm3)		1145	115
% Neutrophils		70	30
Glucose (mg/dL)		20	54
Protein (mg/dL)		410	53

Question 1: What type of meningitis do the patients have? What could be the pathogens?

Questions 2: What specific staining and cultures of your patients' CSF samples would help identify the pathogen, and why?

Question 3: What specific Serological or Biochemical Tests would be ordered to help identify the viral pathogens, and why?

Question 4: Final Report: Final Diagnosis, Treatment, and Prognisos for each patient.

Answer 1

What if CSF test?

CSF or Cerebro Spinal Fluid test is done for analysing any infection in brain or spine with a sample of cerebrospinal fluid taken from a lumbar puncture which is commoly known as spinal tap. This test analyses the concentration of cells and particles in cerebro spinal fluid whose fluctuation indicates serious pathogenic infection.

What is CSF?

Cerebro spinal fluid is a colourless fluid found in brain and spinal cord. It is produced in ependymal cells in brain.

Answer
1) Patient A is affected with BACTERIAL MENINGITIS and patient B is affected with VIRAL MENINGITIS.

Eventhough patient A has diabetes, the bacterial infection caused his decreased glucose level.

WHAT IS MENINGITIS?

Meningitis is simply inflammation in meninges. The three layer membrane covering the brain is called meninges. This inflammation occurs due to pathogenic attack. Thus body reacts with immune system. Thus the excited immune responce can be mainly seen in cerebro spinal fluid. Thats why CSF test is done to diagnose meningitis. Severe meningitis can cause paralysis, stroke and even death. Viral meningitis is the common one. Bacterial is the lethal one.

Pathogens causing the infection;
Bacterial: Streptococcus pneumoniae- Pneumococcus.
Neressaria meningitidis- meningococcus
Haemophillus influenzae
Listeria monocytogenesis

Symptoms include;
• Fever
• Neck pain
• Severe headache.

Viral pathogen: Herpes simplex, HIV, mumps, west nile virus etc..

Symptoms include;
• Fever
• Confusion
• Sensitivity to light.
• Sleepiness

2) Staining and culturing of species can helps to identify the pathogen.

Bacterial: Latex agglutination test- Identify streptococcus strains, Detection of bacterial antigen by antigen antibody agglutination.

Direct microscopy- Bacteria can be observed and identified.

Gram staining- Pathogen show 60 percentage of gram staining. Mainly meningitis is caused by gram negative bacteria.

Bacterial culture- CSF sample is cultured in 5 percentage sheep blood agar, chocolate agar and enriched broth. Incubated at 37 degree celcius for 72 hours.

Viral : culturing and staining diagnosis cannot be done in virus.

3) A procalcitonin blood test can be done to identify whether the meningotis is bacterial or viral. Csf test can also reveals the viral meningitis. The increased neutrophil, increased leukocyte etc.. cangive an ideas for viral infection.

PCR assays are effective for testing viral meningitis.
CRP( C-Reactive proteins) test is used to differentiate between bacterial and viral meningitis. It is mainly used to diagnosis inflammations in central nervous system. CRP level is very low in viral meningitis.

4) Final report

Final diagnosis- Both patients are infected by pathogens which causes meningitis affecting central nervous system. Patient A is affected by bacterial meningitis and B by viral meningitis. Patient A has low glucose level, high neutrophil level and elevated protein level. Main symptom is highly elevated lymphocyte level.

Treatment
For patient A
Bacterial meningitis- By intravenous antibiotics (cephalosporin, rocephin), corticosteroids, penicillin, Aminoglycoside drugs such as gentamycin etc..
It is a serious disease and can be fatal if treatment is not taken. It can cause hearing impairment, brain damage and even death.

For patient B
Viral meningitis- Doesn't require specific medication. It is not much serious condition. It will be cured by its own. Sometimes, antiviral medications are taken.

Prognisos

For patient A- If left untreated, it may be fatal, as the age is not much healthier also. As the symptoms were shown 5 days back. It can be treated and cired as the condition is not worsened.

For patient B- As it is viral meningitis, it need no treatment. It will be cured self by our own immune system.