Cerebrospinal fluid immunoglobulins in children

Cerebrospinal fluid (CSF) immunoglobulins were measured in 62 normal children, in 9 children with purulent meningitis, and in 10 children with presumptive viral meningitis. The mean values in normal children were IgA 0, IgM 0, and IgG 0.84 +/- 1.4 mg/100 ml (+/- SD). The mean levels of all CSF immunoglobulins were raised in acute bacterial meningitis and were significantly greater than the levels found in viral meningitis. CSF IgM was 0.16 +/- 0.5 mg/100 ml in viral meningitis compared with 2.64 +/- 2.06 mg/100 ml in bacterial meningitis (P less than 0.01). However, these values overlapped to a considerable extent and, generally, measurement of CSF immunoglobulins did not enhance diagnostic accuracy in this group of children.     

Cerebrospinal fluid shunt infections in children

Forty-six episodes of cerebrospinal fluid shunt infections developed in 32 patients undergoing cerebrospinal fluid shunt operations during a 13-year period (1972 to 1984). The infection rate was 21%/operative procedure and 33%/patient. The shunt infection rate in revisions of infected shunts was 52%, a rate significantly larger than that in revisions of noninfected shunts (11%). Eight patients (25%) of the initially infected patients had more than one infectious episode. Predominating pathogens in patients who had shunt revisions included coagulase-negative staphylococci in 8 of 15 episodes (4 patients). Coagulase-negative staphylococci accounted for 28% and coagulase-positive staphylococci for 14% of the initial infectious episodes. Risk factors for development of shunt infection included age younger than 3 years, a previously infected shunt and surgery to revise the infected shunt. Therapy of infected shunts with antibiotics alone or with antibiotics plus an operative shunt revision resulted in similar success rates.     

Cerebrospinal fluid shunt infections in children

Infections of cerebrospinal fluid shunts continue to be a substantial source of mortality and morbidity in children with hydrocephalus. Although several therapeutic modalities are currently used for the treatment of shunt infections, there are no clear guidelines for treatment. The purpose of this study was to determine the common pathogens of cerebrospinal fluid shunt infections and evaluate the success of our management. Thirty-five children treated for ventriculoperitoneal shunt infections over the past 9 years were reviewed. The management protocol consisted of the removal of the infected shunt, the application of ventricular taps or reservoir placement, intraventricular antibiotic treatment, and the placement of a new shunt when cerebrospinal fluid sterility was achieved. Four patients were treated with antibiotics alone. Most episodes occurred within 4 months of shunt placement. The most common causative microorganism identified was Staphylococcus epidermidis, followed by S. aureus, and S. warneri. Three patients died from complications of shunt infections, 2 patients had a recurrent shunt infection, while the remaining 29 patients remained free from shunt-related complications. In agreement with the evidence published in the literature, our findings suggest that the above management protocol is effective for the treatment of cerebrospinal fluid shunt infections.     

Cerebrospinal fluid pyrazinamide concentrations in children with tuberculous meningitis

Cerebrospinal fluid pyrazinamide concentrations were determined by high pressure liquid chromatography in 53 samples from 13 children who had tuberculous meningitis complicated by increased intracranial pressure. Peak concentrations of up to 50 micrograms/ml were achieved between 1 1/2 and 2 1/2 hours after pyrazinamide administration and in most cases a concentration of 20 micrograms/ml or more was achieved. We conclude that pyrazinamide easily gains entry into the cerebrospinal fluid of children with tuberculous meningitis and should be included in treatment regimens for that disease.     

Cerebrospinal fluid concentrations of atrial natriuretic peptide in children

Concentrations of atrial natriuretic peptide (ANP) in plasma and in cerebrospinal fluid (CSF) were measured in preterm neonates, in infants and in children with hydrocephalus. Plasma ANP in preterm neonates were elevated compared to infants and children with hydrocephalus. CSF-ANP in all groups were lower than plasma levels. ANP concentrations in the liquor exhibited higher values in children with hydrocephalus. No correlation was found between plasma and CSF-ANP levels while CSF-pressure and ANP concentration in the liquor correlated positively. Our data provide evidence for the existence of a cerebral ANP system in humans. The CSF-ANP system seems to be independent from the systemic, atrial ANP. CSF-ANP may be of great importance in the regulation of water and ion content of central nervous system and probably liquor formation.     

Cerebrospinal fluid biomarkers in neurological diseases in children

Analysis of cerebrospinal fluid (CSF) biomarkers is an integral part of neurology. Basic CSF biomarkers, such as CSF/serum albumin ratio and CSF cell counts, have been used to diagnose inflammatory and infectious CNS disorders in adults and children for decades. During recent years, however, numerous biomarkers for neuronal and astroglial injury, as well as disease-specific protein inclusions, have been developed for neurodegenerative disorders in adults. The overall aim of this paper is to give an updated overview of some of these biomarkers with special focus on their possible relevance to neurological disorders in children and adolescents.     

Cerebrospinal fluid shunting in children on renal dialysis. Report of two cases

The concurrent need for both cerebrospinal fluid shunting for hydrocephalus and dialysis for end-stage renal disease is rare. No large case series are found in the literature. Because dialysis involves frequent access to either the peritoneal cavity or the venous system, concern over potential cerebrospinal shunt infection represents a point of concern. We present 2 cases in which patients underwent both dialysis and cerebrospinal fluid shunting. In one case, a child underwent ventriculoperitoneal shunting, while in the second case ventriculoatrial shunting was performed as the initial procedure. Management strategies and potential complications are discussed.     

Cerebrospinal fluid lysozyme in meningitis in children. Value in establishing the etiologic diagnosis

Cerebrospinal fluid lysozyme (CSF-LZM) concentrations were determined in 62 controls, 28 viral meningitis and 22 bacterial meningitis, as compared to CSF lactic acid routinely used. CSF-LZM measurement was performed by a rapid turbidimetric assay which required 50 microliters CSF only. The mean CSF-LZM concentration of the control group was 0.23 mg/l, the highest value being 0.65 mg/l. The mean LZM levels in viral meningitis were 1.10 mg/l, never exceeding 3 mg/l. The range of pretreatment LZM levels in bacterial meningitis was 7.2 to 65 mg/l and above 3 mg/l in all cases 48 h after treatment. On the 6th day after admission, 12 of 16 samples showed abnormal values. The CSF-LZM assay seems to be of more value than that of lactic acid. Thus, before treatment, LZM concentrations were 10 to 100 fold higher than that of the normal values, with persistent high levels on the 2nd and even on the 6th day of treatment (whereas lactic acid values were all normal on day 6).     

Cerebrospinal fluid neurotransmitter metabolites in neurologically normal infants and children

Significant inverse correlations with age were observed for free 3-methoxy-4-hydroxyphenylglycol (MHPG), 5-hydroxyindoleacetic acid (5-HIAA), and homovanillic acid (HVA) concentrations in CSF from 75 neurologically normal newborns, infants, and children aged 1 day to 10 years. The concentration of free MHPG decreased rapidly in early neonatal life and was reduced to near adult levels by 8 to 9 months of age. Adult levels of 5-HIAA were observed at about 4 years of age whereas HVA concentrations were still above adult levels at 10 years of age. Data from 0- to 1-month-old premature (28 to 32 weeks of gestation) and full-term (37 weeks of gestation) infants revealed marked changes in HVA and 5-HIAA concentrations which were related to postconceptional rather than postnatal age. This study demonstrates a previously undetected age effect on CSF MHPG concentration during the neonatal period and provides valuable normal data that are necessary for the interpretation of CSF monoamine metabolites in infants and children with hyperphenylalaninemia and other neurologic disease involving monoamine neurotransmitters.     

Cerebrospinal fluid and plasma levels of vitamin C in children

Vitamin C (ascorbic acid) levels in cerebrospinal fluid (CSF) and plasma from 67 children, in whom lumbar puncture had to be performed for medical reasons, are reported in this preliminary paper. 14 children of this group show normal CSF laboratory values and serve as controls. Vitamin C concentrations in CSF of controls are on average 2.5-3-times higher (30.1 +/- 6.3 mg/l) than the pertaining values in their plasma (12.2 +/- 4.9 mg/l). Significant differences are exhibited by premature and term babies, which have up to 16-times higher values of vitamin C in CSF than in plasma. Furthermore CSF vitamin C is 4-5 times higher in premature babies than in schoolchildren of our group (118.2 +/- 65.9 versus 28.3 +/- 3.0 mg/l). Another interesting finding in this study is a significant decrease of CSF vitamin C in cases of acute purulent meningitis (12.3 +/- 4.8 versus 30.1 +/- 6.3 mg/l, p less than 0.05). These results, in connection with reports about high vitamin C concentrations in brain tissue, particularly in prematures, make one suspect important functions of this vitamin in physiological and pathological mechanisms in the central nervous system.     

Cerebrospinal fluid concentrations of ethionamide in children with tuberculous meningitis

Cerebrospinal fluid ethionamide concentrations were determined in 18 children (median age 26.5 months) with tuberculous meningitis complicated by raised intracranial pressure. Lumbar spinal fluid specimens were obtained before and after weekly hour-long monitoring of intracranial pressure. Thirty-five paired and four single specimens were evaluated. A dosage schedule of 15 mg/kg was used on 26 occasions, and a spinal fluid ethionamide concentration of 2.5 micrograms/ml, the in vitro minimal inhibitory concentration for Mycobacterium tuberculosis, was exceeded on only seven occasions (27%). A dosage of 20 mg/kg was administered on 13 occasions, and in only two instances (15%) was a concentration of 2.5 micrograms/ml not achieved. Ethionamide in a single daily dosage of 20 mg/kg should be considered for the initial treatment of tuberculous meningitis when the presence of isoniazid-resistant M. tuberculosis cannot be excluded.     

Cerebrospinal fluid investigations in tuberculous meningitis.

The results of conventional cerebrospinal fluid (CSF) investigations (CSF cell count, protein and glucose concentrations and Pandy's test for CSF globulin) obtained on admission and sequentially from weekly follow-up lumbar punctures for 4 weeks were evaluated in 99 children (median age 28 months) with stage II (50 children) and stage III (49 children) tuberculous meningitis. On admission, six children (6%) had a CSF cell count greater than 500 x 10(6)/l and nine (9%) a polymorphonuclear predominance. A CSF protein less than 0.8 g/l was found in 17 children (18%) of 97 in whom CSF protein was evaluated. Globulin was either absent or present as a trace only in 26 children (27%). CSF glucose was less than 2.2 mmol/l in 58 cases (60%) and less than 2.5 mmol/l in 67 (69%). In 63 children weekly CSF specimens obtained for the 1st 4 weeks of therapy showed an uninterrupted decline in cell count in 23 (37%), a fluctuating downward trend in 27 (43%) and a fluctuating upward trend in 13 (21%). Sequential CSF protein values in 57 children showed an uninterrupted rise in three (5%), a fluctuating upward course in 19 (33%), an uninterrupted downward trend in seven (12%), and a fluctuating downward course in 28 (49%). Of the 61 children in whom sequential CSF glucose concentrations were available, 11 (18%) experienced fluctuating concentrations, values falling to less than 2.2 mmol/l after being greater than 2.2 mmol/l on admission or after having risen to greater than 2.2 mmol/l.(ABSTRACT TRUNCATED AT 250 WORDS)     

Cerebrospinal fluid pressure in pyogenic meningitis.

The pressure of cerebrospinal fluid taken at lumbar puncture was recorded objectively by strain gauge pressure measurement in 35 infants and children with pyogenic meningitis. Raised pressures were found in 33 children. The median pressure was 15 mm Hg (range 4-70 mm Hg) in all age groups. The pressure level varied throughout the infection, but a higher median pressure (19 mm Hg) was found when this was measured on the day of admission. The clinical features of the meningitis in these patients suggest that many of the presenting symptoms and signs are those of pressure. These results show that high pressure is frequently present in childhood meningitis, not just in those who die from cones or who have radiological evidence of hydrocephalus. We conclude that raised cerebrospinal fluid pressure is a frequent accompaniment of childhood meningitis and may need treatment in its own right and is therefore one further important factor influencing the course and outcome of childhood meningitis.