Question

The opening CSF pressure when you performed the lumbar puncture was 101 mmH₂O. The CSF analysis revealed a white blood cell (WBC) count of 5X10⁶ /L, clear appearance, a protein level of 0.62 g/L, and a glucose level of 70% of serum levels. A CSF EIA for pathogens was ordered, the result of which would be available 12 hours after the lumbar puncture had been performed. But Jose had already slipped into a coma. Describe these results and if/how they change your preliminary diagnosis.

Answer 1

Answer with discussion and explanation :

Cerebrospinal fluid is drawn through lumbar puncture for diagnosis of infectious, autoimmune and malignant conditions involving meninges and central nervous system.

Normal CSF values are :

1) Opening pressure - 50 - 180 mm of water

2) Appearence - Clear

3) Protein content - 15 - 45 mg /dL

4) Glucose level - 40 - 80 mg /dL (60 - 80 % of blood glucose level)

5) Cell count - 0 - 5 cells /cubic mm (all lymphocytes).

As given in this case :

1) Opening pressure - 101 mm of water

2) Appearence - Clear

3) Protein content - 0.62 g/L = 62 mg /dL

4) Sugar level - 70 % of serum level

5) Cell count - 5 × 10 (6)/L = 5 cells/ cubic mm.

Hence, all parameters are within normal range, except slightly raised protein level. These findings rule out pyogenic (bacterial) and tubercular meningitis.

Even in viral meningitis cell count is marginally raised (20 - 50 cells/cubic mm). Here cell count is normal.

But patient went into coma, so differential diagnosis should include and should be ruled out:

1) Cerebral malaria - Taking travel history to malaria prone area and testing for malaria

2) Heat stroke - Taking history of working place and home environment and any exposure to hot and humid condition

3) Metabolic causes - Examining blood glucose, lactate, pH level. Urine examination. Looking for signs of any toxicity or any illicit substance abuse.

4) Leptospirosis  

The above picture represents albumino cytological dissociation because protein is raised without cellular pleocytosis. Albumino cytological dissociation is seen in Gullian Barre syndrome and Multiple sclerosis. But in these conditions, it is less likely that patient will go into coma.

So, all above differentials should be considered according to the information provided. By history and proper clinical examination, many differentials can be ruled out. Further testing should be done to confirm the more likely diagnosis.