Cerebrospinal Fluid Analysis

This short reference guide provides generic information that may guide
initial interpretation of cerebrospinal fluid (CSF) studies but should not be
used alone for determination of normal or abnormal results. For further
information, see Lumbar Puncture.
The patient’s specific factors (which are beyond the scope of this brief
guide), as well as the reference range variability among different
laboratories, must be considered by the treating provider when obtaining
and interpreting tests. [1]
Caution is warranted in the routine clinical use of existing clinical predictive
rules for bacterial meningitis until high diagnostic performance is
prospectively validated. [2]
Approximately 90% of immunocompetent patients with culture-proven
meningitis have CSF findings characteristic of acute community-acquired
bacterial meningitis. Immunocompromised patients and patients with
tuberculosis meningitis may present with acellular / low – white blood cell
(WBC) – CSF meningitis. [3, 4]
Normal results in adults
See the list below:
 Appearance: Clear
 Opening pressure: 10-20 cm H 2 O
 WBC count: 0-5 cells/µL (< 2 polymorphonucleocytes [PMN]); normal
cell counts do not rule out meningitis or any other pathology
 Glucose level: >60% of serum glucose
 Protein level: < 45 mg/dL
Consider additional tests: CSF culture, others depending on clinical
findings
Bacterial meningitis
See the list below:
 Appearance: Clear, cloudy, or purulent
 Opening pressure: Elevated (>25 cm H 2 O)
 WBC count: >100 cells/µL (>90% PMN); partially treated cases may
have as low as 1 WBC/µL
 Glucose level: Low (< 40% of serum glucose)
 Protein level: Elevated (>50 mg/dL)
Consider additional tests: CSF Gram stain and cultures, blood cultures,
CSF bacterial antigens, CSF polymerase chain reaction (PCR), others
depending on clinical findings
Aseptic (viral) meningitis
See the list below:
 Appearance: Clear
  Opening pressure: Normal or elevated
 WBC count: 10-1000 cells/µL (lymph but PMN early)
 Glucose level: >60% serum glucose (may be low in HSV infection)
 Protein level: Elevated (>50 mg/dL)
Consider additional tests: CSF Gram stain and cultures, blood cultures,
CSF bacterial antigens, CSF PCR (eg, herpes simplex virus [HSV],
varicella-zoster virus [VZV]), others depending on clinical findings
Fungal meningitis
See the list below:
 Appearance: Clear or cloudy
 Opening pressure: Elevated
 WBC count: 10-500 cells/µL
 Glucose level: Low
 Protein level: Elevated
Consider additional tests: CSF Gram stain and cultures, blood cultures,
CSF bacterial antigens, CSF PCR, CSF India ink, others depending on
clinical findings
Tuberculosis
See the list below:
 Appearance: Clear or opaque
 Opening pressure: Elevated
 WBC count: 50-500 cells/µL (early PMN then lymph)
 Glucose level: Low
 Protein level: Elevated
Consider additional tests: CSF Gram stain and cultures, blood cultures,
CSF bacterial antigens, CSF PCR, CSF tuberculosis culture/stain, others
depending on clinical findings
Subarachnoid hemorrhage
See the list below:
 Appearance: Xanthochromia, bloody, or clear
 Opening pressure: Elevated
 WBC count: (1 additional WBC per 1000 RBCs is considered normal
correction)
 Glucose level: Normal
 Protein level: Elevated
Consider additional tests: CSF Gram stain and cultures, others depending
on clinical findings
Multiple sclerosis
See the list below:
 Appearance: Clear
 Opening pressure: Normal
  WBC count: 0-20 cells/µL (lymph)
 Glucose level: Normal
 Protein level: Mildly elevated (45-75 mg/dL)
Consider additional tests: Oligoclonal band analysis (serum and CSF),
others depending on clinical findings
Guillain Barré syndrome
See the list below:
 Appearance: Clear or xanthochromia
 Opening pressure: Normal or elevated
 WBC count: Normal or elevated
 Glucose level: Normal
 Protein level: Elevated