Postgraduate Medicine
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
Bacterial or viral meningitis? Elizabeth M. Bailey MD, Philip Domenico PhD & Burke A. Cunha MD To cite this article: Elizabeth M. Bailey MD, Philip Domenico PhD & Burke A. Cunha MD (1990) Bacterial or viral meningitis?, Postgraduate Medicine, 88:5, 217-223, DOI: 10.1080/00325481.1990.11716403 To link to this article: http://dx.doi.org/10.1080/00325481.1990.11716403
Published online: 07 Jul 2016.
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Citing articles: 3 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20 Download by: [FU Berlin]
Date: 27 November 2016, At: 20:45
~' CME credit article
Bacterial or viral meningitis? Measuring lactate in CSF can help you know quickly
Elizabeth M. Bailey, MD
Philip Domenico, PhD
Burke A. Cunha, MD
Preview
Differential diagnosis
Measurement of lactate levels in cerebrospinal fluid can aid in the prompt differentiation of viral (aseptic) and bacterial (purulent) meningitis. Drs Bailey, Domenico, and Cunha discuss the application of this test in difficult diagnostic situations.
Measurement of lactate in CSF can simplcy differential diagnosis of various types and stages of disease. For example, in a severely ill patient who has an aseptic CSF profile and a negative Gram stain, the presence of lactate in CSF may indicate a very early bacterial (purulent) meningitis or a particularly severe viral (aseptic) meningitis. More commonly, in a patient with mild symptoms, a negative Gram stain, and a few unexplained polymorphonuclear leukocytes in CSF, the presence of CSF lactate may differentiate a relatively mild bacterial meningitis from a very early viral meningitis. MENINGITIDFS--We suggest three working diagnostic criteria based on the CSF lactate concentration, which can be determined in minutes: • If the concentration is more than 6 mmoVL, the patient most likely has bacterial meningitis. • If the concentration is less than 3 mmoVL (the normal range), the diagnosis of viral meningitis can be made, thus eliminating the need for empirical antibiotic coverage. • If the concentration is 3 to 6 mmoVL and the patient has an equivocal CSF profile and a negative Gram stain and has been treated with antibiotics before presentation, the most likely diagnosis is partially treated bacterial meningitis. It is precisely the wide variety of diseases in which increases in CSF lactate occur that has led some investigators to state that increased CSF continued
Knowing whether a patient has bacterial or viral meningitis is very important and sometimes very difficult, especially when antibiotics have already been given. If the cerebrospinal fluid (CSF) lactate level is low, the meningitis is probably viral, and if CSF lactate is elevated, the meningitis is likely bacterial. This practical method of differentiation can be used in several different ways, including detection of partially treated meningitis.
Origin of the idea In 1917, Levinson 1 observed a decrease in the pH of CSF in patients with bacterial meningitis. His posrulation that this might be due to the presence oflactate was confirmed by Killian in 1925.2 Several subsequent reports suggested that the measurement of CSF lactate concentration is useful in the diagnosis of meningitis..l-7 Other studies concluded that such measurement does not add to the clinical picture and that more traditional methods are best used to differentiate the meningitides. 8'9 In 1967, Posner and Plum 10 suggested that since lactate is completely ionized at physiologic pH, it cannot permeate the blood-brain barrier. Indeed, these investigators and others
found that lactate levels in CSF are independent oflactate levels in peripheral blood. 11 ' 12 The lactate in CSF appears to be a product of anaerobic metabolism in the central nervous system. 13- 15 Other studies have concentrated on determining whether the presence of white blood cells in CSF may cause an increase in lactate. 16 However, when incubated in CSF, white blood cells produce little lactate.4 In addition, the increase in CSF lactate observed in patients with tuberculous meningitis, in whom a paucity of white blood cells is the usual finding, is not explained by the hypothesis. 6 Moreover, the presence of red blood cells in CSF, as occurs in subarachnoid hemorrhage, greatly increases lactate levels in CSF.
Elizabeth M. Bailey, MD Philip Domenico, PhD Burke A. Cunha, MD Dr Bailey is a pathology resident, infectious disease division, Massachusetts General Hospital, Boston. Dr Domenico is director, infectious disease research laboratory, WinthropUniversity Hospital, Mineola, New York. Dr Cunha is chief, infectious disease division, Winthrop-University Hospital, and associate professor of medicine, School of Medicine, State University of New York at Stony Brook.
VOL 88/NO 5/0CTOBER 1990IPOSTGRADUATE MEDICINE • . .NINOITIS
217
Measurement of lactate in CSF can simplify differential diagnosis of various types and stages of disease.
Table 1. Cerebrospinal fluid lactate values in selected conditions
Infectious disease Meningitis (viral) Meningitis (bacterial) Partially treated meningitis (bacterial) Tuberculous meningitis Torular meningitis (Cryptococcus neoformans) Cerebral malaria {Plasmodium falciparum) Mild Severe Noninfectious disease Hepatic encephalopathy Stages 1 and 2 Stages 3 and 4 Systemic lupus erythematosus Inactive in CNS Active in CNS Polyarteritis nodosa with CNS involvement Diabetes mellitus Controlled Hypoglycemic coma Ketoacidosis Non-Hodgkin's lymphoma with meningeal dissemination Perinatal hypoxia Mild Severe Other conditions After open heart surgery Without neurologic complications With neurologic complications After severe head injury
Mean value
Control value
(mmoVL)
(mmoVL)
2.2-3.0 6.0-9.7 3.0-6.0 7.0 1.5
1.6-3.3 1.6-3.3 1.6-3.3 1.3 1.4
3.4 9.0
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
Bacterial or viral meningitis? Elizabeth M. Bailey MD, Philip Domenico PhD & Burke A. Cunha MD To cite this article: Elizabeth M. Bailey MD, Philip Domenico PhD & Burke A. Cunha MD (1990) Bacterial or viral meningitis?, Postgraduate Medicine, 88:5, 217-223, DOI: 10.1080/00325481.1990.11716403 To link to this article: http://dx.doi.org/10.1080/00325481.1990.11716403
Published online: 07 Jul 2016.
Submit your article to this journal
View related articles
Citing articles: 3 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20 Download by: [FU Berlin]
Date: 27 November 2016, At: 20:45
~' CME credit article
Bacterial or viral meningitis? Measuring lactate in CSF can help you know quickly
Elizabeth M. Bailey, MD
Philip Domenico, PhD
Burke A. Cunha, MD
Preview
Differential diagnosis
Measurement of lactate levels in cerebrospinal fluid can aid in the prompt differentiation of viral (aseptic) and bacterial (purulent) meningitis. Drs Bailey, Domenico, and Cunha discuss the application of this test in difficult diagnostic situations.
Measurement of lactate in CSF can simplcy differential diagnosis of various types and stages of disease. For example, in a severely ill patient who has an aseptic CSF profile and a negative Gram stain, the presence of lactate in CSF may indicate a very early bacterial (purulent) meningitis or a particularly severe viral (aseptic) meningitis. More commonly, in a patient with mild symptoms, a negative Gram stain, and a few unexplained polymorphonuclear leukocytes in CSF, the presence of CSF lactate may differentiate a relatively mild bacterial meningitis from a very early viral meningitis. MENINGITIDFS--We suggest three working diagnostic criteria based on the CSF lactate concentration, which can be determined in minutes: • If the concentration is more than 6 mmoVL, the patient most likely has bacterial meningitis. • If the concentration is less than 3 mmoVL (the normal range), the diagnosis of viral meningitis can be made, thus eliminating the need for empirical antibiotic coverage. • If the concentration is 3 to 6 mmoVL and the patient has an equivocal CSF profile and a negative Gram stain and has been treated with antibiotics before presentation, the most likely diagnosis is partially treated bacterial meningitis. It is precisely the wide variety of diseases in which increases in CSF lactate occur that has led some investigators to state that increased CSF continued
Knowing whether a patient has bacterial or viral meningitis is very important and sometimes very difficult, especially when antibiotics have already been given. If the cerebrospinal fluid (CSF) lactate level is low, the meningitis is probably viral, and if CSF lactate is elevated, the meningitis is likely bacterial. This practical method of differentiation can be used in several different ways, including detection of partially treated meningitis.
Origin of the idea In 1917, Levinson 1 observed a decrease in the pH of CSF in patients with bacterial meningitis. His posrulation that this might be due to the presence oflactate was confirmed by Killian in 1925.2 Several subsequent reports suggested that the measurement of CSF lactate concentration is useful in the diagnosis of meningitis..l-7 Other studies concluded that such measurement does not add to the clinical picture and that more traditional methods are best used to differentiate the meningitides. 8'9 In 1967, Posner and Plum 10 suggested that since lactate is completely ionized at physiologic pH, it cannot permeate the blood-brain barrier. Indeed, these investigators and others
found that lactate levels in CSF are independent oflactate levels in peripheral blood. 11 ' 12 The lactate in CSF appears to be a product of anaerobic metabolism in the central nervous system. 13- 15 Other studies have concentrated on determining whether the presence of white blood cells in CSF may cause an increase in lactate. 16 However, when incubated in CSF, white blood cells produce little lactate.4 In addition, the increase in CSF lactate observed in patients with tuberculous meningitis, in whom a paucity of white blood cells is the usual finding, is not explained by the hypothesis. 6 Moreover, the presence of red blood cells in CSF, as occurs in subarachnoid hemorrhage, greatly increases lactate levels in CSF.
Elizabeth M. Bailey, MD Philip Domenico, PhD Burke A. Cunha, MD Dr Bailey is a pathology resident, infectious disease division, Massachusetts General Hospital, Boston. Dr Domenico is director, infectious disease research laboratory, WinthropUniversity Hospital, Mineola, New York. Dr Cunha is chief, infectious disease division, Winthrop-University Hospital, and associate professor of medicine, School of Medicine, State University of New York at Stony Brook.
VOL 88/NO 5/0CTOBER 1990IPOSTGRADUATE MEDICINE • . .NINOITIS
217
Measurement of lactate in CSF can simplify differential diagnosis of various types and stages of disease.
Table 1. Cerebrospinal fluid lactate values in selected conditions
Infectious disease Meningitis (viral) Meningitis (bacterial) Partially treated meningitis (bacterial) Tuberculous meningitis Torular meningitis (Cryptococcus neoformans) Cerebral malaria {Plasmodium falciparum) Mild Severe Noninfectious disease Hepatic encephalopathy Stages 1 and 2 Stages 3 and 4 Systemic lupus erythematosus Inactive in CNS Active in CNS Polyarteritis nodosa with CNS involvement Diabetes mellitus Controlled Hypoglycemic coma Ketoacidosis Non-Hodgkin's lymphoma with meningeal dissemination Perinatal hypoxia Mild Severe Other conditions After open heart surgery Without neurologic complications With neurologic complications After severe head injury
Mean value
Control value
(mmoVL)
(mmoVL)
2.2-3.0 6.0-9.7 3.0-6.0 7.0 1.5
1.6-3.3 1.6-3.3 1.6-3.3 1.3 1.4
3.4 9.0
