Diagnosing Meningitis: CSF Lactate, procalcitonin & Fungiell
Rhonda Cadena explains the process of diagnosing and managing meningitis. It is a skill that involves rapid identification, workup, and treatment. In most cases, the diagnosis of meningitis is not a diagnostic dilemma, but the workup and treatment are not as straightforward.
Meningitis is inflammation of the lining of the brain and spinal cord. This can be caused by bacteria, autoimmune process, drug reactions, viruses, and fungi. Rhonda delves deeper into bacterial meningitis. Worldwide there are over 1 million cases per year of bacterial meningitis. This equates to 135 000 deaths. Of the survivors, half will be left with neurological deficits.
So, the swift identification and treatment of this disease process is crucial. Symptoms include fever, headache, nuchal rigidity and altered mental status with almost all patients having at least two. A lumbar puncture is absolutely necessary. Only insist on a CT first if you suspect a mass lesion or increased intracranial pressure.
Otherwise, the delay in antibiotics can lead to an increased morbidity and mortality. Labs are next in the workup. All the common labs should be ordered along with a procalcitonin which can be diagnostic for a bacterial infection (although it will be positive with any bacterial infection so make sure it fits the clinical picture!)
Likewise, fungitell can be useful in looking for some of the more common fungal infections. Blood cultures will guide antibiotic coverage. Steroids can be beneficial for prevention of neurological sequalae in patients who are infected with pneumococcal meningitis. They should be started in anyone with suspected meningitis. You can then cease if cultures come back negative for pneumococcus. Importantly steroids must be started before or during antibiotics.
Finally Rhonda discusses prophylactic treatment. This is necessary for contacts of patients with Neisseria infections. Think household member, day care contacts, and anyone exposed to secretions. This scintillating talk addresses the challenges during the workup, which labs to send during the initial workup, and how specialized labs such as CSF lactate, procalcitonin, and fungitell may help in the workup along with helpful advice for management.
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Rhonda Cadena, MD
Rhonda Cadena M.D., is a board certified Neurointensivist and Emergency Physician at the University of North Carolina Hospital in Chapel Hill. She is an Associate Professor in the Departments of Neurology, Neurosurgery, and Emergency Medicine and is the fellowship director of the Neurocritical Care fellowship at UNC. Clinical Interests include: Neurocritical care, stroke, neurological emergencies, and education.Education/Training: MD, Southern Illinois University School of Medicine; Residency, Emergency Medicine University of Cincinnati; Fellowship, Neurocritical Care and Stroke, University of Cincinnati.