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CSF (Cerebrospinal Fluid)
Ms. Brown, a 28 year old pre-school teacher experienced numbness in her left leg and difficulty
walking last Christmas vacation. Since then, the numbness has seemed to come and go along
with episodes of dizziness. A week before her hospital confinement, she noticed numbness on
the ride side of her face and a ͞blurred͟ vision in the right eye that comes and goes. She
complains that she gets tired easily. During her classes, she suddenly lost balance, was
unconscious until she was brought to the hospital to be examined. Blood and CSF samples
were tested and gave the following results:

BLOOD CHEMISTRY RESULTS

FBS: 85 mg/dL
Albumin: 4.6 g/dL
IgG: 1.4 g/dL

CSF RESULTS
A. `hysical exam
a. Color: colorless
b. Clarity: clear
B. Microscopic exam
a. Leukocyte: 3 cells/uL
b. Differential count:
i. Monocytes 24%
ii. Lymphocytes 75%
iii. Neutrophils 1%
C. Chemical exam
a. Total protein 45 mg/dL
b. Glucose 72 mg/dL
c. IgG 12.4 mg/dL
d. Lactate: 18 mg/dL
D. Gram stain results: no organisms seen

1. Enumerate any abnormal results.

2. Calculate the CSF/serum albumin index.
3. Why is the CSF/serum albumin index a good indicator of Blood-brain barrier
integrity?
4. Calculate the CSF IgG index.
5. State a diagnosis that is consistent with the results obtained.
6. List two additional chemical tests, with the results expected that could be used to
confirm his diagnosis.
Answers to guide questions:

1. Enumerate any abnormal results.

a. Glucose(abnormally high) normal value- CSF glucose= 60-70% blood/serum
glucose.(51-59.5 mg/dl); favors viral meningitis(due to lymphocytes)
b. lactate( depends greatly on the glucose level) in this case its low. Normal
value= not >25mg/dL; Indicative of viral meningitis
c. CSF serum albumin index( abnormally high normal value <9); considers
blood-brain barrier damage and production of immunoglobilins in the CNS.
d. IgG 12.4 mg/dL; indicative of immunoglobulin production in th CNS
e. Monocytes 24%; frequently present in viral infections
f. Lymphocytes 75%; frequently present in viral infections

2. Calculate the CSF/serum albumin index.

CSF/serum albumin index= CSF albumin (mg/dL) / serum albumin (g/dL)

= 45mg/dl / 4.6 g/dl = 9.78

3. Why is the CSF/serum albumin index a good indicator of Blood-brain barrier
integrity?

Elevated total protein/albumin values are frequently seen in pathologic conditions.

Abnormally low values are present when there is fluid leaking in the CNS that
cause͛s elevated CSF protein which includes damage to the blood brain barrier.
Meningitis and hemorrhage are conditions that damage the blood brain barrier and
causes elevated protein values.

4. Calculate the CSF IgG index.

IgG index =( CSF IgG / serum IgG ) / ( CSF albumin / serum albumin)
= 8.86 / 9.78 = 0.90

5. State a diagnosis that is consistent with the results obtained.

It is consistent of viral meningitis due to the presence of lymphocytes and increased

CSF protein levels and destruction of the blood brain barrier due to trauma of the
CNS. Also, multiple sclerosis may be considered due to the signs and symptoms of
manifested by the patient. Continuous monitoring is advised.

6. List two additional chemical tests, with the results expected that could be used to
confirm his diagnosis.
 1. Electrophoresis - primary purpose for performing this is for detection of
oligoclonal bands representing inflammation within the CNS. The bands are located
in the gamma region of the protein electrophoresis, indicating Ig production.
>Viral infections may produce serum banding.
>Banding representing both systemic and neurologic involvement is seen in the
serum and CSF with HIV infection.

2. Cerebrospinal fluid lactate - is a vital test for ruling out and management
meningitis cases. The values of the CSF fluid lactate determine the
classification of meningitis present in the patient. The determination of CSF
lactate levels can be valuable aid in the diagnosis and management of meningitis
cases. In viral meningitis, lactate levels remain lower than 25 mg/dL.

`ertinent information

CSF- Cerebrospinal fluid (CSF), Liquor cerebrospinalis, is a clear bodily fluid that occupies the
subarachnoid space and the ventricular system around and inside the brain. In essence, the
brain "floats" in it. The CSF occupies the space between the arachnoid mater (the middle layer
of the brain cover, meninges), and the pia mater (the layer of the meninges closest to the
brain). It constitutes the content of all intra-cerebral (inside the brain, cerebrum) ventricles,
cisterns, and sulci (singular sulcus), as well as the central canal of the spinal cord.
It acts as a "cushion" or buffer for the cortex, providing a basic mechanical and immunological
protection to the brain inside the skull.

Specimen collection

There are different ways to get a sample of CSF. Lumbar puncture, commonly called a spinal
tap, is the most common method. The test is usually done like this:

› The patient lies on his or her side, with knees pulled up toward the chest, and chin
tucked downward. Sometimes the test is done with the person sitting up, but bent
forward.
› After the back is cleaned, the health care provider will inject a local numbing medicine
(anesthetic) into the lower spine.
› A spinal needle is inserted, usually into the lower back area.
› Once the needle is properly positioned, CSF pressure is measured and a sample is
collected.
› The needle is removed, the area is cleaned, and a bandage is placed over the needle
site. The person is often asked to lie down for a short time after the test.
 › Occasionally, special x-rays are used to help guide the needle into the proper position.
This is called fluoroscopy.

Lumbar puncture with fluid collection may also be part of other procedures, particularly a
myelogram (x-ray or CT scan after dye has been inserted into the CSF).

Alternative methods of CSF collection are rarely used, but may be necessary if the person has a
back deformity or an infection.

Cisternal puncture uses a needle placed below the occipital bone (back of the skull). It can be
dangerous because it is so close to the brain stem. It is always done with fluoroscopy.

Ventricular puncture is even rarer, but may be recommended in people with possible brain
herniation. This test is usually done in the operating room. A hole is drilled in the skull, and a
needle is inserted directly into one of brain's ventricles.

CSF may also be collected from a tube that's already placed in the fluid, such as a shunt or a
venitricular drain. These sorts of tubes are usually placed in the intensive care unit.

Oultiple Scelrosis

Multiple sclerosis (MS) is a nervous system disease that affects your brain and spinal cord. It
damages the myelin sheath, the material that surrounds and protects your nerve cells. This
damage slows down or blocks messages between your brain and your body, leading to the
symptoms of MS. They can include

› Visual disturbances
› Muscle weakness
› Trouble with coordination and balance
› Sensations such as numbness, prickling, or "pins and needles"
› Thinking and memory problems

No one knows what causes MS. It may be an autoimmune disease, which happens when your
body attacks itself. Multiple sclerosis affects women more than men. It often begins between
the ages of 20 and 40. Usually, the disease is mild, but some people lose the ability to write,
speak or walk. There is no cure for MS, but medicines may slow it down and help control
symptoms. `hysical and occupational therapy may also help.
Synovial Fluid
Carla, a 37 year old woman met a vehicular accident. The surgeon performed an arthroscopic
repair of the torn ligament. After a week, she comes back to the doctor complaining of a
persistent and painful swelling in her left knee. Arthrocentesis is performed and synovial fluid
analysis reveals the following:

BLOOD CHEMISTRY RESULTS

FBS: 79 mg/dL (Reference range: 60 to 105 mg/dL)
Uric acid: 6.2 mg/dL (Reference range; 2.6 to 8.0 mg/dL)

SYNOVIAL FLUID RESULTS

c  `hysical exam
a. Color: yellow
b. Clarity: cloudy
c. Viscosity: decreased
h  Microscopic exam
a. Crystals: none present
b. Leukocyte: 97,000 cells/uL
c. Differential count:
i. Monocytes 13%
ii. Lymphocytes 5%
iii. Neutrophils 82%
  Chemical exam
a. Total protein 5.3 g/dL
b. Glucose 35 mg/dL
c. Lactate 35 mg/dL
d. Uric acid 5.9 mg/dL
@  Gram stain results: G`C present; many leukocytes present

1. Enumerate any abnormal results.

2. Calculate the plasma-synovial fluid glucose difference.
3. How may the Synovial fluid be classified based on the results obtained?
4. What is the most likely diagnosis?

Answers to guide questions

1. Enumerate any abnormal results

a. Color- normal color is colorless to pale yellow, yellow color of the synovial
fluid indicate presence of inflammatory effusions
b. Clarity - should be clear, turbidity is associated with the presence of WBC
 c. viscosity- should be viscous because of hyaluronic acid, normal viscosity can
be measured using string test and normal synovial fluid have a result of 4-6
cm. in this case it is decreased.
d. `resence of large number of WBC. Normal WBC count should be less than
200 cells/uL, and neutrophils having the highest percentage of leukocytes
present indicate bacterial infection.
e. `rotein- abnormally high, normal value= <3g/dL, increased levels indicate
inflammatory and hemorrhagic disorders.
f. Glucose- decreased, normal value= the difference between synovial and
serum glucose should not exceed 10mg/dl; decreased glucose in the synovial
fluid due to bacterial consumption
g. The presence of bacteria indicates sepsis in the synovial fluid.

2. Calculate the plasma-synovial fluid glucose difference.

`lasma-synovial glucose difference = serum glucose-synovial glucose

= 79mg/dL ʹ 35mg/dL = 44mg/dL (abnormally high normal value not greater than 10mg/dL)

3. How may the Synovial fluid be classified based on the results obtained?

The synovial fluid can be classified as septic and inflammatory type. It is due to the
infection and proliferation of microbes.

4. What is the most likely diagnosis?

The diagnosis would probably be secondary septic infection. Also inflammation and
trauma of the joints and ligaments of the patient may be possible.

`ertinent information

Arthrocentesis- Joint aspiration, a procedure whereby a sterile needle and syringe are used to
drain fluid from a joint. This is usually done as an office procedure or at the bedside in the
hospital.

For an arthrocentesis, the skin over the joint is sterilized with a liquid. Local anesthetic is
applied to the area of the joint either by injection or topical liquid freezing, or both. A needle
with a syringe attached is inserted within the joint and fluid is sucked back (aspirated). For
certain conditions medication is put into the joint after fluid removal. The needle is then
removed and a bandaid or dressing is applied over the entry point.
Joint fluid is typically sent for examination to the lab to determine the cause of the joint
swelling, such as infection, gout, and rheumatoid arthritis.

Arthrocentesis can be helpful in relieving joint swelling and pain. Occasionally, cortisone
medications are injected into the joint during the arthrocentesis in order to rapidly relieve joint
inflammation and further reduce symptoms.

Septic arthritis should be considered whenever one is assessing a patient with joint pain.
Usually only one joint is affected (monoarthritis) however in seeding arthritis, several joints can
be affected simultaneously; this is especially the case when the infection is caused by
staphylococcus or gonococcus bacteria.

The diagnosis of septic arthritic can be difficult as no test is able to completely rule out the
possibility.

A number of factors should increase one's suspicion of the presence of an infection. In children
these are: fever > 38.5 C, non-weight-bearing, serum WBCs > 12 x 10^9, ESR > 40 mm/hr, CR` >
20 mg/dL, a previous visit for the same.

Diagnosis is by aspiration (giving a turbid, non-viscous fluid), Gram stain and culture of fluid
from the joint, as well as tell-tale signs in laboratory testing (such as a highly elevated
neutrophils (approx. 90%), ESR or CR`). A proportion of patients with septic arthritis have little
in the way of fever or raised ESR, although the CR` is usually raised

The Gram stain can rule in the diagnosis of septic arthritis however cannot exclude.

Treatment

Therapy is usually with intravenous antibiotics, analgesia and washout/aspiration of the joint to
dryness.

In infection of a prosthetic joint, a biofilm is often created on the surface of the prosthesis
which is resistant to antibiotics. Surgical debridement or arthrotomy is usually indicated in
these cases. A replacement prosthesis is usually not inserted at the time of removal to allow
antibiotics to clear infection of the region.

`atients in whom surgery is contraindicated may trial long-term antibiotic therapy.

References:

http://www.nlm.nih.gov/medlineplus/multiplesclerosis.html
http://www.medterms.com/script/main/art.asp?articlekey=7090
http://en.wikipedia.org/wiki/Septic_arthritis

http://www.nlm.nih.gov/medlineplus/ency/article/003428.htm

Strasinger, Susan King; Urinalysis and Other Body Fluids