Clinical Vignettes CSF

Case 1:
A 28-year old man is playing in a rural pub as a drummer with his part-time band. During
the gig he experiences a sudden severe occipital headache and falls to the ground with a
20 second loss of consciousness. An ambulance is called and on his way to hospital he
vomits twice.

What is the most likely diagnosis?

Subarachnoid haemorrhage

List two possible differentials

Infectious meningo-encephalitis
Seizure disorder
Space-occupying lesion

Outline your immediate management

ABCs
Monitor vital signs
Cardiac/respiratory monitoring
Investigations

List appropriate investigations

Urgent CT, CT angio/ MRI
LP once rule out cerebral oedema
- wcc, rcc, protein, glucose, m, c+s, gram stain

CBC
Blood glucose
Toxicology screen
Septic screen

How should this patient be treated for this disorder?

Emergency neurosurgical intervention with clipping of aneurysm

Radiological coiling of aneurysm
HDU/ICU transfer
Haemodynamics monitoring

Familial screening
The morning after admission a lumbar puncture is performed which reveals the
following:

Bottle


1


2

3
RCC (per CMM) 21,800 22,500 20,900
WCC (per CMM) 18 19 17

CSF protein (mg/dL) 72 (15 - 45)

CSF glucose (mmol/L) 3.5
Serum glucose (mmol/L) 5.1

Gram Stain - Organisms not seen

1. Discuss the results above - outline the abnormalities.

2. What is the most likely diagnosis?
3. Why?
4. What else would you look for in the CSF which is a sensitive
marker for this disorder?
Case 2:
A 22-year old engineering student misses her Monday morning lectures because she has
been at home all weekend trying to shake off a cold. Her symptoms are a worsening
headache, dislike for light and general malaise. She has vomited twice. By Tuesday
morning, her headache is quite severe and she feels bad enough to present herself to the
Emergency Department.

What is the most likely diagnosis?

Meningitis

Give a differential diagnosis

Viral illness
Encephalitis
Migraine

Give three other points of information which you would like to obtain from the
history/exam

Symptoms of infection fever, sweats, cough, rash, sinusitis, etc.

Neck stiffness
Head injury/trauma
Previous episodes
Kernigs/Brudsinskis sign
Petechial rash
Signs of infection/shock

List three appropriate investigations

LP - LP once rule out cerebral oedema
- wcc, rcc, protein, glucose, m, c+s, gram stain

CBC
Blood glucose
Toxicology screen
Septic screen
CT/MRI

List management aspects

ABCs
IV ceftriaxone/cefotaxime and vancomycin
IV dexamethasone if suspect strep pneumoniae/ cerebral oedema
IVF
Respiratory support- NIPPV/intubation
Change antibiotics according to sensitivities when cultures back
Contact tracing/Notification
Her lumbar puncture shows:

Bottle



1

2

3
RCC (per CMM) 326 112 38
WCC (per CMM) 228 225 230 [predominantly

neutrophils]

CSF protein (mg/dL) 96 (15 - 45)

CSF glucose (mmol/L) 5.2
Serum glucose (mmol/L) 12.0
Serum leucocyte count (/L) 17 x 109 (93% neutrophils)

CSF microscopy:

1. Outline the abnormalities

 2. What is the diagnosis ?

Case 3
A32yearoldbanktellerleavesworkearlybecauseofgradualonsetofpainfulblurring
affecting visioninherrighteyesinceearlier thatmorning.That evening sheattends
A&E.Shehasneverbeenunwellbefore.Shetakesnomedicationsotherthantheoral
contraceptive pill. She has never had surgery. Review of systems reveals occasional
constipationandpinsandneedles.

Listtwolikelycausesofthispresentation
Opticneuritis
Temporalarteritis
Migraine
Clusterheadache
Cornealulceration
Trauma/FB
Cerebralvasculitis

Listappropriateinvestigations

MRI
LP
Serumglucose
Serumelectrophoresis
ESR,CRP
Autoantibodyscreen

Listsomeaspectsofmanagement

Steroids
Interferon
Specialistnurseandregularneurologyfollowup
Radiologyfollowup
Glatirimir
Azathioprine
Bottle


1

2

3
RCC (per CMM) 23 8 3
WCC (per CMM) 7 8 6

CSF protein (mg/dL) 43 [15 45]

CSF glucose (mmol/L) 2.4
CSF IgG index elevated
CSF IgG pattern oligoclonal
Serum glucose (mmol/L) 4.1

1. What is the diagnosis?

2. What is the clinical definition of this disorder?
3. List some classifications of this disorder.