Cerebrospinal Fluid inCNS Infections

Osvaldo M. Takayanagui

Departamento de NeurologiaFaculdade de Medicina de Ribeirão Preto

Universidade de São Paulo

CSF in CNS Infections

1891- Heinrich Quincke

Diagnosis of CNS Infections

CSF in CNS Infections

Acute Bacterial Meningitis

CSF in CNS Infections

- Lumbar

- Cisternal

- Ventricular

- High cervical

CSF Puncture

CSF in CNS Infections

Gross appearance

Cytology

Biochemistry

Culture

Detection of antibodies

Detection of antigens

Examination of CSF

CSF in CNS Infections

Clear, colorlessXantochromia

subarachnoid bleeding↑ proteinhyperbilirubinemia

Turbidsubarachnoid bleedingmeningitis (>100 cells)

Purulentacute bacterial meningitis

Gross appearance

CSF in CNS Infections

Fuchs Rosenthal counting chamber

Cryptococcus neoformans

CSF in CNS Infections

Cytology

CSF in CNS Infections

Cytology

CSF in CNS Infections

S. pneumoniae

N. meningitidis

Haemophilus influenzae

Gram stainGram stain

CSF in CNS Infections

India ink

Cryptococcus neoformans

CSF in CNS Infections

M. tuberculosis

Ziehl-Neelsen stain

CSF in CNS Infections

Takayanagui et al – Neurology, 1995

Strongyloides stercoralis in the CSF

CSF in CNS Infections

Trypanosoma cruzi – trypomastigote in the CSF

Yoo et al. - Clin Infect Dis, 2004

CSF in CNS Infections

Acute purulent meningitis

Tuberculous meningitis

Fungal meningitisMeningeal cysticercosis

Viral meningoencephalitis

mumps (25%)

herpes simplex

herpes zoster

enterovirus

Hypoglycorrhachia

Occasionally reduced

CSF in CNS Infections

H. influenzae

Candida albicans

C. neoformans

Culture: CSF and blood

CSF in CNS Infections

M. tuberculosis

Lowenstein-Jensen culture

CSF in CNS Infections

Viral culture

CSF in CNS Infections

1- NASBA, NucliSens

2- RT-PCR, Amplicor

3- branched DNA, Quantiplex

HIV-1 RNA viral load

CSF in CNS Infections

Method

Principle

Gene

Lower limit (copies/ml)

Volume

Time

Branched DNA

Quantiplex

Hibridization

pol

500

1-2 ml

1,5 d

Amplicor

HIV-1 Monitor

RT-PCR

gag

200-400

200 µl

6 h

NASBA

NucliSens

Amplification

gag

80

10 µl-1 ml

5 h

HIV-1 - RNA viral load

CSF in CNS Infections

Carga Viral

2,14

5

6

3,67

4 ,84

1 ,9

5 ,79

4 ,925 ,27

2 ,6

3

3

4 4

3

44

4

0

1

2

3

4

5

6

7

1 2 3 4 5 6 7 8 9

Pacientes (transtorno cognitivo associado ao HIV-1)

cóp

ias/

ml e

m lo

g

PlasmaLíquor

HIV-1 - RNA viral loadPlasmaCSF

CSF in CNS Infections

Detection of Antibodies

- Indirect Imunofluorescence

- Passive Hemoagglutination

- ELISA

- Particle Agglutination

- Contraimmunoelectrophoresis

- Western blot

CSF in CNS Infections

ELISA

CSF in CNS Infections

Particle Agglutination

CSF in CNS Infections

Intern Controlrgp46-Irgp46-II

N P PPP P P PIIIIIIIcontrols

p53gp46

p32

GD21

gp21p19

p24p26p28

p36

WesternWestern BlotBlot

CSF in CNS Infections

Intrathecal IgG synthesis

IgG index =

CSF IgGSerum IgG

CSF AlbuminSerum Albumin

Reiber’s Diagram

CSF in CNS Infections

Oligoclonal IgG bands

Intrathecal IgG synthesis

CSF in CNS Infections

P1 P2 P3 P4 P5 P6 P7 P8

Polymerase Chain Reaction

C+ C - Bl P1 P2 P3 P4 P5 P6 P7 P8

CSF in CNS Infections

VírusHSV-1 HSV-2 Enterovirus CMVEpstein-BarrJC virusHIVHTLV-IHTLV-II

PCR

BacteriaM. tuberculosisT. pallidumB. burgdorferi

ProtozoaToxoplasma gondiiP. falciparum

CSF in CNS Infections

PCR

Advantages- high sensitivity and specificity- fast- requires only small CSF volumes

Disadvantages- expensive- low sensitivity for M. tuberculosis

CSF in CNS Infections

Virus

HSV-1

CMV

Varicella zoster

Epstein-Barr

JC virus

Enterovirus

Sensitivity (%)

>95

80-100

-

97

74-92

97

Specificity (%)

100

75-100

100

100

92-96

100

PCR

CSF in CNS Infections

Initial CSF

35

40

55

Test

Ziehl-Neelsen

Culture

PCR*

2 weeks later

6

6

54

Sensitivity (%)

Muniz - 1998* Specificity – 96%

Tuberculous meningitis

CSF in CNS Infections

Pressure

Leucocytes

Cytology

Glucose

Stained smear (%)

Culture (%)

Other tests

Bacteria

↑

> 1.000

PMN

60-90

85

Agglutination

CIE

Virus

nl or ↑

< 500

LM

nl

-

-

PCR

Crypto

nl or ↑

< 500

LM

70

50

Agglutination

CIE

TB

↑

< 500

LM

35

40

PCR

CSF in Meningitis

↑ ↑ ↑ ↑↑

CSF in CNS Infections

Contraindication to lumbar punction

CSF in CNS Infections

Contraindication to lumbar punction

CSF in CNS Infections

Contraindication to lumbar punction

CSF in CNS Infections

CT before CSF in suspected meningitis

Hasbun et al. N Engl J Med 345: 1727, 2001

301 patients with suspected meningitis235 who had brain CT - 11 (5%) mass effect

Clinical features associated with abnormal CT- Dilated pupils- Hemiparesis- Focal seizures - Rapid decrease in the level of consciousness- Decerebrate or decorticate posture

CSF in CNS Infections

“I have seen diagnostic errors and

serious harm come to patients

more frequently because of failure to

carry out an LP than from the LP itself”

Fishman, 1992