Meningitis with normal CSF
                        ==========================

There have been case reports of meningitis with normal CSF cell count,
glucose, protien etc. that subsequently grew out organisms on culture.  This
has been described far more often in the pediatric literature but, every now
and then, an adult with this picture is identified (1,2,3). Although more
common in patients who are immunosuppresed or who have low peripheral WBC
counts (4) it has been described in the absence of these findings.

Were the CSF cultures from the original tap (assuming they were sent)
positive?


H. Louzon MD


"I did not like that fat ole doctor, he was mean and rude to me and I tried
to track him down for an hour to find out what was exactly wrong with me. I
think he works the 3d shift, he was very judgemental and impolite. I think
he need to take his fat, prejudice ass and enroll in a kindness course."


(1)

Coll MT, Uriz MS, Pineda V, Fontanals D, Bella F, Nava JM, Deulofeu F,
Morera MA, Mart¡ C, Lite J, et al
Meningococcal meningitis with 'normal' cerebrospinal fluid.
J Infect, 29: 3, 1994 Nov, 289-94

A prospective study was made of all patients with normal CSF counts and
positive cultures for Neisseria meningitidis diagnosed in "El Vall‚s"
County, Barcelona between January 1987 and December 1990. Meningococcal
meningitis was documented in 82 patients, eight of whom (seven children,
five boys and two girls with a mean age of 5.6 +/- 3.3 years, and a
69-year-old male patient) had no apparent CSF abnormalities in the initial
lumbar puncture. At the time of admission all patients had fever (mean 39.1
degrees C) of 10.8 +/- 5.6 hour duration and petechial rash which had been
present for a mean of 3.6 +/- 3.3 hours. Signs of meningeal irritation were
not found. A 4-month-old infant with symptoms of circulatory collapse,
intracranial hypertension and impairment of consciousness subsequently died
of septicemia in 48 hours. Group B N. meningitidis was isolated in six cases
(reduced penicillin-susceptibility in two cases) and group C N. meningitidis
in the remaining two (reduced penicillin-susceptibility in one case).
Patients without pleocytosis did not differ in a statistically significant
fashion from the patients with high pleocytosis in the duration of
temperature, and petechial rash, leukopenia, positive blood culture and
fatal outcome.


(2)

Domingo P, Mancebo J, Blanch L, Coll P, Net A, Nolla J
Bacterial meningitis with "normal" cerebrospinal fluid in adults: a report
on five cases.
Scand J Infect Dis, 22: 1, 1990, 115-6

Five adult patients with bacterial meningitis and normal cerebrospinal fluid
(CSF) findings are described. All were patients in whom the lumbar puncture
was performed very early in the course of the disease, or who had a low
white blood cell count in peripheral blood. In such cases the diagnosis of
bacterial meningitis may be overlooked.

(3)

Onorato IM, Wormser GP, Nicholas P
'Normal' CSF in bacterial meningitis.
JAMA, 244: 13, 1980 Sep 26, 1469-71

Cerebrospinal fluid with a normal cell count, glucose and protein values,
and a negative Gram's stain smear is usually assumed to exclude the
possibility of meningitis. We describe four patients and review from
literature 19 patients with pyogenic meningitis in whom the CSF initially
appeared normal. Thus, finding minimal or no initial CSF abnormality is
consistent with early or developing bacterial meningitis. Repeated lumbar
puncture and CSF examination within 24 hours should be considered in all
febrile patients in whom the clinical features remain compatible with
meningitis.

(4)

Fishbein DB, Palmer DL, Porter KM, Reed WP
Bacterial meningitis in the absence of CSF pleocytosis.
Arch Intern Med, 141: 10, 1981 Sep, 1369-72

Two cases of acute bacterial meningitis occurred with an absent CSF WBC
response. To determine the incidence and clinical characteristics of such
patients, 50 consecutive cases of meningitis were reviewed retrospectively.
In addition to the two initially noted cases, five additional cases were
found. In the seven
cases, there were six or fewer cells, but bacteria were detected in the CSF.
A distinctive clinical and laboratory syndrome emerged. All seven patients
were either old or had Hodgkin's disease or severe alcoholism. All patients
had evidence of an overwhelming infection with confusion or nuchal rigidity.
As compared with the remaining 45 patients with meningitis and CSF
pleocytosis, no fever (less than 38 degrees C), a lower peripheral WBC
count, and near-normal CSF glucose and protein concentrations were common.
Organisms involved were EScherichia coli in three patients, Pneumococcus in
three patients, and mixed anaerobes in patient. A fatal outcome ensued in
six of seven patients. Despite the correct choice of an antibacterial agent,
doses were late and suboptimal for meningitis. This syndrome is surprisingly
common in host-defective cases, has an ominous prognosis, and must be
treated expectantly with antimicrobial agents that enter the CSF.