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Csf sugarwia 15 cell count 160 neutrophils 60% lymphocytes 40%

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"meningitis"[MeSH Terms] AND "cerebrospinal fluid"[MeSH Terms]

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CSF glucose 15 mg/dL (I'm assuming mg/dL), 160 cells/µL, 60% neutrophils, 40% lymphocytes
This is a mixed pleocytosis with a very low glucose. It is not a typical viral picture. Treat it as bacterial, tuberculous or fungal meningitis until proven otherwise.
Interpretation
  • Glucose 15 is markedly low. Normal is 50-75 mg/dL, or more than 60% of paired blood glucose. A ratio below 0.4 favours bacterial, TB or fungal infection. Please get a simultaneous blood glucose.
  • 160 cells is raised. Normal is 0-5/µL.
  • The differential is mixed. Neutrophils (60%) lean towards bacterial, but 40% lymphocytes is too many for a classic untreated pyogenic picture.
  • Viral meningitis is unlikely. It usually has a normal glucose. Neutrophils can predominate early, but the glucose would still be normal. As the Washington Manual puts it, "CSF lymphocytosis with profoundly decreased glucose level should prompt a workup for tuberculous or fungal meningitis" (The Washington Manual of Medical Therapeutics, p. 520).
Differential, in order of concern
  1. Partially treated or early bacterial meningitis. Typical findings are 100-5000 neutrophils, glucose below 40 and protein 100-500 (Washington Manual, Table 14-3). Prior oral antibiotics can lower the count and shift the differential.
  2. Tuberculous meningitis. Typical findings are 50-300 cells, mainly lymphocytes, glucose below 45 and protein 50-300. Neutrophils can predominate early. Your cell count falls in this range.
  3. Cryptococcal or other fungal meningitis. Typical findings are 20-500 lymphocytes, glucose below 40 and raised opening pressure. This is more likely if the patient is immunocompromised or has HIV.
  4. Listeria. It can give a mixed picture, especially in older, pregnant or immunosuppressed patients.
  5. Less likely causes. Consider carcinomatous or lymphomatous meningitis, which can lower glucose. Also consider neurosarcoidosis, neurocysticercosis, and an amoebic or parasitic cause where relevant.
Next steps
  • Add to the CSF work-up: protein, Gram stain and culture, AFB smear, TB PCR (GeneXpert) and culture, ADA, cryptococcal antigen and India ink, fungal culture, and a meningitis/encephalitis PCR panel. Add VDRL and cytology if indicated.
  • Also send: paired blood glucose, blood cultures, CBC, CRP or procalcitonin, and HIV status.
  • Get imaging: CT or MRI of the brain with contrast. Look for basal meningeal enhancement, hydrocephalus, tuberculomas or infarcts.
  • Check opening pressure: it is raised in TB, fungal and bacterial meningitis.
  • Treatment: do not wait for the results if the patient is unwell. Start empiric therapy right after the LP. For age 2-50 this is ceftriaxone 2 g IV q12h plus vancomycin 15-20 mg/kg IV q8-12h. Add ampicillin 2 g IV q4h if the patient is over 50 or immunocompromised (Washington Manual). Add dexamethasone per bacterial meningitis protocols. If clinical or CSF features point to TB, start empiric anti-TB therapy early, because delay worsens outcome.
I need a few details to narrow this down: the patient's age, how long the illness has lasted, any antibiotics already taken, HIV or immune status, the CSF protein, and the blood glucose.
A search of the last 2 years of meta-analyses and systematic reviews found nothing that changes this approach.
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