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BR - CSF Station - Tutor Notes

The document presents several clinical cases involving lumbar puncture (LP) results and their interpretations. It discusses findings indicative of viral and bacterial meningitis, normal CSF results, subarachnoid hemorrhage, traumatic lumbar puncture, and bacterial infection caused by Streptococcus pneumoniae. Each case highlights the importance of CSF analysis in diagnosing various neurological conditions.

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KasraSr
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28 views5 pages

BR - CSF Station - Tutor Notes

The document presents several clinical cases involving lumbar puncture (LP) results and their interpretations. It discusses findings indicative of viral and bacterial meningitis, normal CSF results, subarachnoid hemorrhage, traumatic lumbar puncture, and bacterial infection caused by Streptococcus pneumoniae. Each case highlights the importance of CSF analysis in diagnosing various neurological conditions.

Uploaded by

KasraSr
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Bell Ringer: CSF

Station Prepared by Dr.


Chloë Bogaty
CM37
0

1) 32 day old baby is brought to the emergency room for new onset fever and irritability. Septic work-up
is done,
including an lumbar puncture. Results are as
follows: Total nucleated cell count 35
cells/microL
• 72% lymphocytes, 12%
polymorphonuclear cells Protein 1.2 g/L Glucose 3.5
mmol/L

Please interpret the CSF


findings.

The LP is not normal due to the fact that the TNCC and total protein (normal 0.2 to 0.45 g/L) are elevated.
Seeing that the TNCC remains <100 cells/microL with lymphocyte predominance, the most likely etiology is
a viral process. The glucose being completely normal further supports this.

Due to the patient’s age, infection with either HSV or enterovirus must be
suspected.

2) 19 year-old male university athlete presents to the emergency room with complaints of
headache and
photophobia for the last 12 hours. He is febrile on presentation, and has nuchal rigidity. A lumbar
puncture is done, with the following results:

Total nucleated cell count 560


cells/microL
• 92% polymorphonuclear
cells Protein 1.3 g/L Glucose 0.6
mmol/L

Please interpret the CSF


findings.
The LP shows a highly elevated TNCC with PMN predominance, therefore bacterial meningitis must be
suspected. The elevated protein and low glucose also support a bacterial process. Prompt initiation of
antibiotics and dexamethasone is required.

CM37
0

3) A 89 year-old woman was found unconscious in her apartment by her neighbour. In the emergency
department,
the patient is found to be febrile and confused. A septic work-up is sent, including a lumbar
puncture. Red blood cells 4 cells/microL Total nucleated cell count 2 cells/microL Protein 0.5
g/L Glucose 2.9 mmol/L

Please interpret the CSF


findings.

The CFS is entirely normal in this case. If the patient has an infection as a cause of her fever and confusion,
the source is elsewhere than the CNS. A pulmonary or urinary infection is highly likely in an elderly patient.

4) A 47 year-old male is brought to the emergency room after sudden onset of severe headache.
He has no
previous history of headaches. An initial CT scan is negative. A lumbar puncture is
performed.

Xanthochromia Red blood cells 120


000 cells/microL Total nucleated cell
count 550 cells/microL Protein 1.2 g/L
Glucose 3.5 mmol/L

Please interpret the CSF


findings.

The history and CSF findings are highly suggestive of a subarachnoid hemorrhage. Neurosurgery should be
consulted for further management, as this patient may need clipping of an aneurysm.

CM37
0

5) A 56 year-old woman is being assessed for a new finding of a brain mass. Underlying cancer is
suspected. A
lumbar puncture is done as part of her work-up, and tube 1 and tube 4 are both sent for
cell count.

Tube
1
• Bloody
• Red blood cells 35 000
cells/microL
• Total nucleated cell count 300
cells/microL
• Protein 0.9 g/L
• Glucose 3.8 mmol/L

Tube
4
• Clear
• Red blood cells 120
cells/microL
• Total nucleated cell count 6
cells/microL

What
happened?

This is indicative of a traumatic lumbar puncture. A small blood vessel/capillary was likely traumatized during
needle insertion, resulting in the initial high cell count (both RBC and WBC). Tube 4 has nearly normal results,
and drastically different from tube 1. The nicked capillary has had time to vasoconstrict, and the initial bleeding
captured in tube 1 is no longer appreciated in tube 4. Had the findings been consistent with a subarachnoid
bleed, the findings seen in tube 1 would have persisted into tube 4.

6) A 24 year-old female presents to the emergency department with headache and


fever.
Total nucleated cell count 1200
cells/microL
90% polymorphonuclear
cells Protein 1.8 g/L Glucose 0.2
mmol/L

Please interpret the CSF


findings.

The LP shows a highly elevated TNCC with PMN predominance, therefore bacterial meningitis must be
suspected. The elevated protein and low glucose also support a bacterial process. The CSF gram stain
reveals Gram-positive diplococci, which suggests infection with Streptococcus pneumoniae (pneumococcus).
3

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