Cerebrospinal Fluid in CNS Infections

Transcription

1 Cerebrospinal Fluid in CNS Infections Osvaldo M. Takayanagui Departamento de Neurologia Faculdade de Medicina de Ribeirão Preto Universidade de São Paulo

2 Diagnosis of CNS Infections Heinrich Quincke

3 Acute Bacterial Meningitis

4 CSF Puncture - Lumbar - Cisternal - Ventricular - High cervical

5 Examination of CSF Gross appearance Cytology Biochemistry Culture Detection of antibodies Detection of antigens

6 Gross appearance Clear, colorless Xantochromia subarachnoid bleeding protein hyperbilirubinemia Turbid subarachnoid bleeding meningitis (>100 cells) Purulent acute bacterial meningitis

7 Fuchs Rosenthal counting chamber Cryptococcus neoformans

8 Cytology CSF in CNS Infections

9 Cytology CSF in CNS Infections

10 S. pneumoniae CSF in CNS Infections Haemophilus influenzae N. meningitidis Gram stain

11 India ink Cryptococcus neoformans

12 Ziehl-Neelsen stain M. tuberculosis

13 Strongyloides stercoralis in the CSF Takayanagui et al Neurology, 1995

14 Trypanosoma cruzi trypomastigote in the CSF Yoo et al. - Clin Infect Dis, 2004

15 Hypoglycorrhachia Acute purulent meningitis Tuberculous meningitis Fungal meningitis Meningeal cysticercosis Viral meningoencephalitis mumps (25%) herpes simplex herpes zoster Occasionally reduced enterovirus

16 Culture: CSF and blood C. neoformans H. influenzae Candida albicans

17 Lowenstein-Jensen culture M. tuberculosis

18 Viral culture CSF in CNS Infections

19 HIV-1 RNA viral load 1- NASBA, NucliSens 2- RT-PCR, Amplicor 3- branched DNA, Quantiplex

20 HIV-1 - RNA viral load Method Principle Gene Branched DNA Quantiplex Hibridization pol Amplicor HIV-1 Monitor RT-PCR gag Lower limit (copies/ml) Volume Time ml 1,5 d µl 6 h NASBA NucliSens Amplification gag µl-1 ml 5 h

21 HIV-1 - RNA viral load Plasma CSF Carga Viral 7 Plas ma cópias/ml em log ,14 2, ,67 4, ,9 3 5,79 4 4,92 4 5,27 4 Líquor Pacientes (transtorno cognitivo associado ao HIV-1)

22 Detection of Antibodies - Indirect Imunofluorescence - Passive Hemoagglutination - ELISA - Particle Agglutination - Contraimmunoelectrophoresis - Western blot

23 ELISA CSF in CNS Infections

24 Particle Agglutination CSF in CNS Infections

25 Western Blot controls I I I I P P N P I I P P P I P Intern Control rgp46-i rgp46-ii p53 gp46 p36 p32 p28 p26 p24 gp21 p19 GD21

26 Intrathecal IgG synthesis IgG index = CSF IgG Serum IgG CSF Albumin Serum Albumin Reiber s Diagram

27 Intrathecal IgG synthesis Oligoclonal IgG bands

28 Polymerase Chain Reaction P1 P2 P3 P4 P5 P6 P7 P8 C+ C - Bl P1 P2 P3 P4 P5 P6 P7 P8

29 Vírus HSV-1 HSV-2 Enterovirus CMV Epstein-Barr JC virus HIV HTLV-I HTLV-II PCR Bacteria M. tuberculosis T. pallidum B. burgdorferi Protozoa Toxoplasma gondii P. falciparum

30 PCR Advantages - high sensitivity and specificity - fast - requires only small CSF volumes Disadvantages - expensive - low sensitivity for M. tuberculosis

31 PCR Virus HSV-1 CMV Varicella zoster Epstein-Barr JC virus Enterovirus Sensitivity (%) > Specificity (%)

32 Tuberculous meningitis Test Initial CSF Sensitivity (%) 2 weeks later Ziehl-Neelsen Culture PCR* * Specificity 96% Muniz

33 CSF in Meningitis Bacteria Virus Crypto TB Pressure nl or nl or Leucocytes > < 500 < 500 < 500 Cytology PMN LM LM LM Glucose nl Stained smear (%) Culture (%) Other tests Agglutination PCR Agglutination PCR CIE CIE

34 Contraindication to lumbar punction

35 Contraindication to lumbar punction

36 Contraindication to lumbar punction

37 CT before CSF in suspected meningitis 301 patients with suspected meningitis 235 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 Hasbun et al. N Engl J Med 345: 1727, 2001

38 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