The role of fever on cerebrospinal fluid glucose concentration of children with and without convulsions

In febrile convulsions glucose concentrations are known to increase both in the blood and cerebrospinal fluid (CSF). The reason behind this increase is, however, incompletely understood. We have studied the effects of convulsion and fever on the CSF and blood glucose concentrations in four different groups of children: febrile and non-febrile children, with and without convulsions. The concentration of glucose in the CSF was significantly higher in febrile children with (4.4 ± 0.1 mmol/1, mean ± SEM n = 35, p < 0.01, ANOVA, Duncan's test) and without convulsions (3.9 ± 0.2mmol/1, n = 22, p < 0.05) than in non-febrile, non-convulsive children (3.3 ±0.1 mmol/1, n = 21). In non-febrile convulsive children, the CSF glucose concentration was 3.7 ± 0.2mmol/l (n = 10). Both fever and seizures increased the CSF glucose levels (p < 0.0001 and p = 0.028, respectively, analysis of covariance). There was a linear correlation between the body temperature and concentration of glucose in the CSF (r = 0.454, p < 0.0001, n = 88, Pearson's correlation analysis). The changes in blood glucose concentrations between the groups parallelled those found in the CSF. Our results show that hyperglycaemia and an increase in the CSF glucose concentration in febrile convulsions is not explained just by a stress reaction, evoked by the seizure, as has been hypothesized earlier, but by the influence of increased body temperature as well.     

Bacillus species isolates from cerebrospinal fluid in patients without shunts

Of 849 CSF cultures done at Hartford Hospital, nine were positive for nonanthrax Bacillus species. Differentiation of true nonanthrax Bacillus species infection from contamination requires careful consideration of the clinical findings, the clinical course, and the laboratory data. In seven patients the nonanthrax Bacillus species represented contamination. In two patients the nonanthrax Bacillus species represented true infection. In one of these infected patients, nonanthrax Bacillus species complicated a cranial gun shot wound. Bacillus cereus meningitis developed in the second patient, a premature infant, following sepsis from a contaminated IV catheter. Nonanthrax Bacillus species, especially B cereus, can be resistant to penicillins and cephalosporins when nonanthrax Bacillus species infections are being treated, susceptibility testing should always be performed.     

Q fever encephalitis with cytokine profiles in serum and cerebrospinal fluid

A 7-year-old boy with acute encephalitis was proved to have Coxiella burnetii infection. Cerebrospinal fluid but not serum had elevated values of interleukins 1-beta and 6, but not of tumor necrosis factor.     

Plasma arginine vasopressin and the syndrome of inappropriate antidiuretic hormone secretion in tuberculous meningitis.

Biochemical evidence of the syndrome of inappropriate antidiuretic hormone secretion (SIADH) was documented in 17 of 24 (71%) children with tuberculous meningitis. Plasma arginine vasopressin concentrations in patients with signs of SIADH were significantly higher (median, 15.44 (range, 1.62 to greater than 24.52) pg/ml; n = 14) than those without (median, 1.91 (range, 0.44 to 4.91) pg/ml; n = 6) (P less than 0.002). Patients who developed evidence of SIADH were older than those who did not (median, 34 (range, 6 to 101) months vs. 10 (range, 6 to 38) months; P less than 0.007). Five patients with and none without died. In 9 patients evidence of SIADH developed only after hospitalization. These patients received a median of 58 (range, 28 to 109) ml/kg/day fluids (n = 7) before developing evidence of SIADH compared with 107 (range, 58 to 146) ml/kg/day received by patients who did not develop SIADH (n = 6) (P = 0.035). SIADH occurs commonly and its presence appears to influence the outcome of tuberculous meningitis in children.     

Plasma arginine vasopressin, diuresis, and neonatal respiratory distress syndrome

The pathogenesis of the diuresis that precedes the recovery from respiratory distress syndrome (RDS) in preterm infants has not been clearly delineated. To define the role of Arginine Vasopressin (AVP) or Antidiuretic Hormone in the diuretic phase of RDS, we obtained plasma AVP levels (radioimmunoassay) and sequential time-urine-plasma collections during the first, the third and the fifth days of life in twelve premature ventilated newborns. AVP levels were persistently elevated (12.7 +/- 7.6; 9 +/- 4.7 and 10.4 +/- 6.6 pg/ml, respectively) despite normal plasma sodium and osmolality. Maximum diuresis (output/intake greater than 0.72) occurred at 72 hours and preceded the improvement in FiO2/PaO2, significant on 5th day (p less than 0.01), and associated with a 10.6% decrease in body weight. These results suggest a nonosmotic release of AVP in ventilated newborns, and show a hypervasopressinemia unrelated to the diuresis associated with the recovery phase of RDS.     

Ferritin in cerebrospinal fluid of patients with lymphoproliferative disorders

The ferritin concentration in cerebrospinal fluid (CSF) from children and three adults with lymphoproliferative disorders was determined. While these levels were normal in children without CNS involvement before treatment, they rose during induction therapy and remained high also during consolidation therapy. As the intensity of treatment decreased during the consolidation phase, CSF ferritin declined but did not reach pretreatment concentrations. After three years of maintenance therapy (without intrathecal injections) CSF ferritin was normal. CSF ferritin concentration does not reflect the stage of the disease but seems to correlate to the treatment, especially if this is administered intrathecally. In adults with CNS involvement, CSF ferritin showed no correlation to the CSF cell count, the degree of CNS involvement or to the treatment. It is of little use in demonstrating the spread of the malignant process to the CNS.     

Cost analysis of enteroviral polymerase chain reaction in infants with fever and cerebrospinal fluid pleocytosis

BACKGROUND: Infants with fever and cerebrospinal fluid (CSF) pleocytosis are routinely admitted to the hospital for parenteral antibiotic therapy for potential bacterial meningitis pending results of CSF culture. Published estimates suggest that 90% of all episodes of meningitis are caused by enterovirus. Enteroviral polymerase chain reaction (ePCR) has a sensitivity of 92% to 100% and a specificity of 97% to 100% in CSF. OBJECTIVE: To compare a management strategy using ePCR with current practice to determine potential savings by allowing earlier discharge. METHODS: Decision analysis comparing 2 strategies for the care of a retrospective cohort of infants with fever and CSF pleocytosis: standard practice vs ePCR testing of all CSF samples. Model assumptions include the following: (1) standard practice patients continue parenteral antibiotic therapy until CSF cultures are negative at 48 hours, (2) patients with positive ePCR results would be discharged after 24 hours, (3) patients with positive ePCR results have a negative CSF culture, and (4) costs are calculated from actual patient charges with a cost-to-charge ratio of 0.65. SUBJECTS: All infants aged 28 days to 12 months admitted to an urban teaching hospital with fever, CSF pleocytosis, and a negative CSF Gram stain from January 1996 through December 1997. OUTCOME MEASURE: Total cost of hospitalization. RESULTS: A total of 126 infants were identified. One hundred twelve (89%) were discharged with a diagnosis of aseptic meningitis; 72% of these cases occurred during the peak enterovirus season (June to October). Three of 3 patients with positive CSF cultures had bacterial growth within 24 hours of admission. Mean length of stay for patients with aseptic meningitis was 2.3 days (SD, +/-1.4 days). Total cost of hospital care for all 126 infants was $381,145. In our patient population, total patient costs would be reduced by the ePCR strategy if enterovirus accounts for more than 5. 9% of all meningitis cases. Varying the sensitivity of the ePCR assay from 100% to 90% changes the "break-even" prevalence from 5.8% to 6.5%. Total cost savings of 10%, 20%, and 30% would occur at an enteroviral meningitis prevalence of 36.3%, 66.7%, and 97.1%, respectively. CONCLUSIONS: Enteroviral PCR analysis of CSF for infants admitted to the hospital with meningitis can result in cost savings when the prevalence of enteroviral meningitis exceeds 5.9%. Limiting use of ePCR to the enterovirus season would increase cost savings. A prospective study is needed to validate these results. Arch Pediatr Adolesc Med. 2000;154:817-821     

Renal response to arginine vasopressin in premature infants with late hyponatraemia.

To assess the influence of late hyponatraemia on the renal responsiveness to endogenous arginine vasopressin (AVP), urinary excretion and plasma concentration of sodium, plasma and urine osmolality, free water clearance, and urinary AVP concentration and excretion were measured in 11 healthy premature infants with a mean birth weight of 1360 g and mean gestational age of 31 weeks. Studies were performed on days 1, 5, and 19. The development of late hyponatraemia was associated with a pronounced decline in urine osmolality, whereas urine flow rate and free water clearance increased significantly. Mean (SEM) urine AVP concentration and excretion also rose significantly from 2.15 (0.31) pg/ml and 0.36 (0.55) pg/min/m2 on the first day to 6.5 (0.96) pg/ml and 3.85 (0.63) pg/min/m2 on the 19th day, respectively. When renal response to AVP was compared at different ages the highest urine osmolality and steepest response curve was observed on the first day. With development of hyponatraemia the renal response became blunted. It is concluded that the limited tubular sodium transport and hyponatraemia hinders the establishment of intrarenal osmotic gradient, impairs renal response to AVP, and prevents excessive water retention and further fall of plasma sodium.     

Osmolality and electrolytes in cerebrospinal fluid and serum of febrile children with and without seizures

Abstract During acute febrile diseases mild disturbances of water and electrolyte balance occur frequently. It has been suggested that changes in electrolyte balance, in particular hyponatraemia, might predispose a child to convulsions during febrile illness; however, the changes of electrolytes in the CSF are not known.We have studied the effects of fever and convulsions on water and electrolyte balance in CSF and serum by measuring osmolality and electrolyte concentrations in children. The febrile population consisted of 60 children, 36 of whom had seizures during fever. Twenty-one children without convulsions and nine children with epileptic symptoms were nonfebrile controls. We noticed that CSF is subject to changes in osmolality and electrolyte concentration during fever, while convulsions do not exhibit such changes. CSF osmolality and sodium concentrations were lower in febrile children than in nonfebrile controls. The osmolality in febrile children with convulsions was 3.8% (P<0.01) and without seizures 3.5% (P<0.01) lower than in nonfebrile nonconvulsive children. The changes in CSF sodium concentration, and to a lesser extent potasium and chloride concentrations, paralleled those of CSF osmolality. A positive correlation was observed between the CSF and serum osmolatities (r=0.73,P<0.0001), and sodium concentrations (r=0.63,P<0.0001). A negative correlation between the body temperature and both CSF osmolality (r=–0.66,P<0.0001) and sodium concentration (r=–0.59,P<0.0001) exhibits also the important regulative role of increased body tmeperature.Conclusion Fever is an important factor for disturbances in fluid and electrolyte balance. The alterations in CSF osmolality and sodium concentration do not, however, give an unambiguous explanation for the susceptibility to simple febrile seizures.     

Isolation of measles virus from cerebrospinal fluid of children with acute encephalopathy without rash.

OBJECTIVE: To determine the viral agent involved in cases of acute encephalopathy in children during an outbreak in Northern India. DESIGN: Virological and serological studies using serum and cerebrospinal fluid specimens from patients. METHODS: Serum and CSF specimens were tested by IgM ELISA for IgM antibodies to variety of viruses like Japanese encephalitis, West Nile, Dengue and Measles. The specimens were inoculated into Vero cell monolayer for virus isolation. The viral strains isolated were identified by indirect immunofluorescence test and qualitative in-vitro neutralization test using polyclonal and monoclonal antibodies to measles. Identity of the isolates was reconfirmed using RT-PCR method. RESULTS: Of the 28 specimens tested, 17 had IgM antibodies to measles. Commercial IgM ELISA kits confirmed the serological findings. Vero cell cultures yielded 4 isolates from CSF and 2 from serum specimens of six different patients. Cytopathic effect was typical of measles. Indirect imunofluorescence using polyclonal and monoclonal antibodies to measles HA protein, confirmed the measles etiology. Neutralization tests reconfirmed the measles strain isolation. RT-PCR amplified product was confirmed as measles. CONCLUSION: The isolation of measles virus from CSF and serum of children with acute encephalopathy without rash proved the etiological role of measles virus in this outbreak.     

The distribution of ampicillin between blood and cerebrospinal fluid in patients with and without serous meningitis (author's transl)]

1. With a constant plasma concentration of Ampicillin the ratio of concentration in the cerebrospinal fluid to concentration in the plasma reaches a constant value after 2 hrs in patients with and without serous meningitis. 2. Patients without serous meningitis have a value of 0.025, patients with serous meningitis a value of 0.061. 3. From this it can be calculated that Ampicillin passes two and a half times faster through inflamed meningeal membranes than unaffected membranes.     

Magnesium level in serum and cerebrospinal fluid in patients with protein malnutrition

Summary Fifty-eight cases of oedematous malnourished children were studied by the estimation of serum and C.S.F. magnesium. The C.S.F. magnesium level correlated well with the sensorium of the patients. Serum magnesium level does not have much diagnostic or prognostic value in malnutrition. From Kilpauk Medical College, Madras-10.     

Immunoreactive arginine vasopressin in human fetal and neonatal skeletal muscle.

We provide evidence for the presence of arginine vasopressin (AVP) in human fetal and neonatal skeletal muscle using a combination of specific RIA, tangential flow ultrafiltration and reverse-phase HPLC separation. The IR-AVP concentrations are negatively correlated with gestational age (r = -0.75, P less than 0.0001) and range from 1 to 10 pmol/g wet wt at 15 weeks gestation to 0.04 pmol/g wet wt at term. This IR-AVP substance is of low molecular weight (less than 3000 mol. wt), elutes in the same position as standard AVP after HPLC separation and is detected by four different anti-AVP antisera.     

Serial measurement of plasma arginine vasopressin in the newborn.

Plasma arginine vasopressin was measured serially in 11 preterm infants and one asphyxiated, term infant. The samples were taken through umbilical arterial catheters placed at birth for blood gas measurements because ventilatory support was required. Plasma samples of 200 to 300 microliter were taken 4 to 12 hourly for up to 100 hours after birth. Plasma arginine vasopressin was measured by a cytochemical bioassay. A significant correlation between plasma arginine vasopressin and plasma osmolality was found in only two out of six infants. The normal ''resting'' concentration was between 0.5 and 2 pg/ml. In five infants, apparent bursts of arginine vasopressin secretion were seen, and in one spontaneously breathing infant with respiratory distress, continuously high concentrations (12 to 25 pg/ml) were recorded over the first 100 hours.     

Anti-rotavirus antibody in cerebrospinal fluid.

Ten infants with benign convulsions associated with rotavirus gastroenteritis had no specific antibodies in cerebrospinal fluid by enzyme linked immunosorbent assay (ELISA). On the other hand, eight of 173 patients with other neurological diseases had specific IgG, IgA, or IgM antibodies. The reason for positive ELISA results is discussed.