Cerebrospinal fluid findings in aseptic versus bacterial meningitis
Cerebrospinal fluid findings in aseptic versus bacterial meningitis
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DOI：
10.1542/peds.105.2.316
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发表时间：
2000-02-01
期刊：
影响因子：
8
通讯作者：
Wald, ER
中科院分区：
文献类型：
--
作者：
Negrini, B;Kelleher, KJ;Wald, ER
背景无菌性脑膜炎的特点是脑脊液（CSF）中单核细胞占优势，而细菌性脑膜炎的特点是多形核白细胞（PMN）占优势。相反，其他研究表明，PMNs可能是早期无菌性脑膜炎中最常见的细胞，然后在24小时内转变为单核细胞。这些相互矛盾的报道可能导致脑膜炎诊断和治疗的不确定性。评估1）无菌性脑膜炎与细菌性脑膜炎的CSF鉴别特征，2）病程对CSF鉴别的影响，3）CSF鉴别在区分无菌性脑膜炎与细菌性脑膜炎中的作用。对1992年至1997年期间在肠道病毒性脑膜炎高峰月份（4月至10月）住院的年龄>30天的所有脑膜炎儿童病例进行了回顾性图表审查。无菌性脑膜炎病例定义为至少有20个白色血细胞/mm（3），且培养上无细菌生长。如果患者在过去5天内接受过抗生素治疗，则将其排除。细菌性脑膜炎病例定义为CSF培养阳性或CSF细胞增多伴血液培养阳性。分析CSF变量，包括白色血细胞分类和从症状发作到进行腰椎穿刺的时间。当中性粒细胞占幼稚型细胞的百分比>50%时，认为中性粒细胞占优势。回顾了158例脑膜炎病例：138例为无菌性，20例为细菌性。患者年龄范围为30天至18岁; 61%为男性。57%的无菌性脑膜炎病例以中性粒细胞为主。无菌性脑膜炎患者脑脊液中中性粒细胞的百分比与症状发作后24小时内或24小时后进行腰椎穿刺的患者无统计学差异。53例无菌性脑膜炎且病程>24小时的患者中，51%的患者PMN占优势。中性粒细胞优势区分无菌性和细菌性脑膜炎的能力进行了评估。中性粒细胞优势对无菌性脑膜炎的敏感性为57%，而特异性为10%。中性粒细胞优势对无菌性疾病的阳性预测值为81%，但阴性预测值为3%。中性粒细胞占优势的替代定义从60%到90%作为细菌性疾病的临床指标是没有用的。大多数无菌性脑膜炎患儿脑脊液中PMN占优势。PMN的优势并不局限于疾病的最初24小时。因为大多数在肠道病毒季节中性粒细胞占优势的儿童将有无菌性疾病，中性粒细胞占优势作为唯一的标准不能区分无菌性和细菌性脑膜炎。
Background. Aseptic meningitis is often reported to be characterized by a mononuclear cell predominance in the cerebrospinal fluid (CSF), whereas bacterial meningitis is characterized by a polymorphonuclear (PMN) cell predominance. In contrast, other studies suggest that PMNs can be the most prevalent cell in early aseptic meningitis followed by a shift to mononuclear cells within 24 hours. These contradictory reports may lead to uncertainty in the diagnosis and treatment of meningitis.Objectives. To assess 1) the characteristics of the CSF differential in aseptic versus bacterial meningitis, 2) the influence of duration of illness on the CSF differential, and 3) the role of the CSF differential in discriminating between aseptic versus bacterial meningitis.Methods. A retrospective chart review was conducted of all cases of meningitis in children >30 days of age hospitalized during the peak months for enteroviral meningitis (April to October) between 1992 to 1997. Cases of aseptic meningitis were defined as having at least 20 white blood cells/mm(3) and the absence of bacterial growth on culture. Patients were excluded if they received antibiotic therapy within the previous 5 days. Cases of bacterial meningitis were defined as having a positive culture of the CSF or the presence of a CSF pleocytosis with positive cultures of the blood. CSF variables including white blood cell differential and time from the onset of symptoms to the performance of a lumbar puncture were analyzed. PMNs were considered to be predominant when the percentage of neutrophils added to juvenile forms was >50% of cells.Results. One hundred fifty-eight cases of meningitis were reviewed: 138 were aseptic and 20 were bacterial. The patients ranged in age from 30 days to 18 years; 61% were male. Fifty-seven percent of cases of aseptic meningitis had a PMN predominance. The percentage of PMNs in the CSF in patients with aseptic meningitis was not statistically different for patients who had a lumbar puncture performed either within or beyond 24 hours of the onset of symptoms. Fifty-one percent of the 53 patients with aseptic meningitis and duration of illness >24 hours had a PMN predominance. The ability of a PMN predominance to differentiate between aseptic and bacterial meningitis was assessed. The sensitivity of a PMN predominance for aseptic meningitis is 57% whereas the specificity is 10%. The positive predictive value of a PMN predominance for aseptic disease is 81% but the negative predictive value is 3%. Alternative definitions of PMN predominance from 60% to 90% were not useful as a clinical indicator of bacterial disease.Conclusions. The majority of children with aseptic meningitis have a PMN predominance in the CSF. The PMN predominance is not limited to the first 24 hours of illness. Because the majority of children with a PMN predominance during enteroviral season will have aseptic disease, a PMN predominance as a sole criterion does not discriminate between aseptic and bacterial meningitis.