II. Indications
- CNS Infection
- Thunderclap Headache (evaluation for Subarachnoid Hemorrhage)
- Increased Intracranial Pressure (e.g. Pseudotumor Cerebri, Hydrocephalus)
- Neurologic Disorders (e.g. Guillain Barre Syndrome, Multiple Sclerosis)
III. Findings: Normal
- CSF Color: Clear
-
CSF Glucose
- Children and Adults: 50-80 mg/dl
- CSF to Serum Glucose Ratio
- Children and Adults: 0.44 to 0.9
- Normal newborn: >60% of simultaneous Serum Glucose
- Some guidelines define normal range 0.42 to 1.10
- Normal infant: >50% of simultaneous Serum Glucose
-
CSF Protein
- Children and Adults: 20-45 mg/dl
- Some guidelines use CSF Protein <50 mg/dl
- Normal term newborn: <70 mg/dl
- Some guidelines use CSF Protein <150 mg/dl
- Children and Adults: 20-45 mg/dl
- CSF Chloride 116-122
-
CSF Opening Pressure
- Children >8 years old and Adults: 60 to 250 mmH2O (typically <200 mmH2O)
- Newborns and Children <8 years old: 10 to 100 mmH2O
-
CSF Leukocytes
- No Neutrophils and under 6 Lymphocytes
- Normal term newborn: <10 WBCs/mm3 (<10% Neutrophils)
- Some guidelines use <20/mm3
-
CSF Leukocyte Differential
- Lymphocytes 70%
- Monocytes 30%
- PMNs rare (PMNs may be normal in newborn)
- Eosinophils rare
- CSF Lactic Acid
- Children and Adults: 11.7 to 21.6 mg/dl
- Newborns: 8.1 to 22.5 mg/dl
-
Gram Stain
- Negative for organisms
IV. Findings: Bacterial Meningitis
- See Bacterial Meningitis
- See Nigrovic Clinical Decision Rule
- See Meningitest
-
CSF Color
- Cloudy CSF (may also be green or purulent)
-
CSF Glucose
- CSF Glucose <40% of Serum Glucose has Test Sensitivity of 80%, Test Specificity 98%
- CSF Glucose <40 mg/dl (but normal in half of Bacterial Meningitis)
- CSF Glucose < 34 mg/dl is highly suggestive of Bacterial Meningitis
-
CSF Protein >100 mg/dl
- Elevated in nearly all cases of Bacterial Meningitis
- CSF Protein >220 mg/dl is highly suggestive of Bacterial Meningitis
-
CSF Leukocytes: Markedly increased Neutrophils
- WBC >100/mm3 in 99% of cases and >1000/mm3 in most cases
- CSF WBCs >2000/mm3 is highly suggestive of Bacterial Meningitis
- WBC may be normal despite culture positive Bacterial Meningitis (6% of cases in some series)
- WBC >100/mm3 in 99% of cases and >1000/mm3 in most cases
-
CSF Leukocyte Differential
- Neutrophils (PMNs) represent 80-90% of Leukocytes in most cases of Bacterial Meningitis
- CSF PMNs >1180/mm3 is highly suggestive of Bacterial Meningitis
- Lymphocytes may be predominant (>50%) in up to 10% of Bacterial Meningitis cases
-
CSF Opening Pressure: increased >200 mmH2O
- Opening Pressure >300 mmH2O in 39% with Bacterial Meningitis
- CSF lactate >35.1 mg/dl
- Not in IDSA guidelines as of 2021
- May be useful in differentiating from Viral Meningitis (esp. after neurosurgery)
- Sakushima (2011) J Infect 62(4): 255-62 +PMID: 21382412 [PubMed]
-
Gram Stain
- Organisms on Gram Stain has a Test Specificity 97% for Bacterial Meningitis
-
CSF Culture positive in 70% of cases
- CSF Culture detection rates decrease 10-20% if obtained after Antibiotics are started
- Other Tests
- CSF PCR
- Consider Latex Agglutination (if Gram Stain Negative or cultures followed Antibiotics)
- Variable efficacy, and may add little value to other testing (e.g. Gram Stain)
- References
V. Findings: Viral Meningitis
- CSF Color: Clear to Cloudy Fluid
-
CSF Glucose: Normal
- May be decreased in mumps or HIV Infection
- CSF Protein > 45 (typically near normal)
-
CSF Leukocyte Count
- Typically 100 to 1000/mm3 (higher with Enterovirus Meningitis)
-
CSF Leukocyte Differential
- Increased CSF Lymphocytes
- PMNs may be increased in early infection
- CSF RBCs may be increased in HSV Encephalitis
- CSF Opening Pressure: Normal in most cases (may be increased)
- Other Tests
- CSF Viral PCR (preferred)
- CSF or Serum Arbovirus IgM (e.g. West Nile Virus Encephalitis)
- MRI Brain (Encephalitis)
VI. Findings: Fungal Meningitis
- CSF Color: Clear to Cloudy Fluid
- CSF Glucose < 50 mg/dl
- CSF Protein > 45 mg/dl (typically 50 to 250 mg/dl)
-
CSF Leukocytes
- Increased (often >100-200/mm3)
-
CSF Leukocyte Differential
- PMNs may be present early, with later Lymphocyte predominance
- Monocytes increased
- Eosinophils may be present
- CSF Opening Pressure: Increased or variable
- CSF Gram Stain: Hyphae may be seen
- Other tests
- CSF Beta-D-Glucan (Test Sensitivity 95-100%, Test Specificity >83%)
- CSF Fungal Culture
- CSF Fungal PCR has poor Test Sensitivity (<30%)
VII. Findings: Cryptococcal Meningitis
- See Cryptococcal Meningitis
- CSF Leukocyte Count: Mildly increased (may be normal in HIV)
-
CSF Leukocyte Differential
- Lymphocytes predominant
- CSF Glucose >40 mg/dl
-
CSF Opening Pressure
- Opening Pressure >250 mmH2O in severe Cryptococcal Meningitis (requires VP Shunt, or serial LP if persists)
- CSF Protein <40 mg/dl
- Other tests
- CSF Culture
- CSF Cryptococcal Antigen
- India Ink Capsule Stain
- Latex Agglutination, ELISA or lateral flow assay
- HIV Test
VIII. Findings: Parasitic Meningitis
- CSF Leukocyte Count: 150 to 2000/mm3
-
CSF Leukocyte Differential
- Eosinophils >10%
- CSF Glucose: Normal
- CSF Opening Pressure: May be increased
- CSF Protein: Increased
- Other tests
- PCR or ELISA tests for specific organisms
IX. Findings: TuberculosisMeningitis
- See Tuberculous Meningitis
- CSF Color: Cloudy Fluid
- CSF Glucose <40-50 mg/dl (decreased with advanced disease)
- CSF Protein 100-200 mg/dl
- CSF Leukocytes: 5 to 300/mm3 (500 to 1000/mm3 in up to 20% of cases)
-
CSF Leukocyte Differential
- Early: Neutrophils increased
- Later: Lymphocytes increased
- Other tests
- Repeated acid fast stain and cultures
- TuberculosisCSF PCR (56% Test Sensitivity, 98% Test Specificity)
- CSF Adenosine Deaminase >10 U/L
X. Findings: Subarachnoid Hemorrhage (SAH)
- See Subarachnoid Hemorrhage
-
CSF Color: Bloody CSF with Xanthochromia
- Xanthochromia at 6 hours: 20% of Subarachnoid Hemorrhage
- Xanthochromia at 12 hours: 90% of Subarachnoid Hemorrhage
- Sentinel bleeds in prior 2 weeks in half of SAH patients may also persist as Xanthochromia
- CSF Glucose: Normal or decreased
- CSF Protein: >45 mg/dl
-
CSF Red Blood Cells: Increased >2000/mm3
- Decreased RBCs in tube 4 compared with tube 1 suggests Traumatic Lumbar Puncture
- However, Xanthochromia is not due to Traumatic Lumbar Puncture unless CSF RBCs >100,000/mm3
- CSF Opening Pressure: Increased >200 mmH2O
- Other tests
- CT Head (most accurate in first 6-12 hours)
XI. Findings: Neoplasm (esp. Leptomeningeal Carcinomatosis)
- See Intracranial Mass
- Metastatic Leptomeningeal Carcinomatosis may cause Meningitis signs (Headache, Nuchal Rigidity, confusion)
- CSF Color: Clear or xanthochromic
- CSF Glucose: Normal or decreased
- CSF Protein: Normal or increased
- CSF Leukocytes: Normal or increased Lymphocytes
- CSF Opening Pressure: Increased >200 mmH2O
- Other tests
- Repeated high volume Lumbar Punctures (>10 ml) and analyzed with flow cytometry, biomarkers
- Lesions may not be visible on MRI
XII. Findings: Neurosyphilis
- See Neurosyphilis
- CSF Color: Clear to cloudy fluid
- CSF Glucose: Normal
- CSF Protein: >45 mg/dl
-
CSF Leukocytes
- Early: 10 to 400/mm3
- Later: 5 to 100/mm3 (decreases with chronic disease, decades)
-
CSF Leukocyte Differential
- Monocytes increased
-
CSF Opening Pressure: Normal or increased
- Often normal in Immunocompromised patients
- Other Tests
- HIV Test
- VDRL (Test Sensitivity <75%, Test Specificity 100%)
- CSF Fluorescent Treponemal Antibody or FTA (Test Sensitivity 100%, Test Specificity <70%)
XIII. Findings: Demyelinating Disease (Guillain-Barre Syndrome, Multiple Sclerosis)
- See Guillain Barre Syndrome
- See Multiple Sclerosis
- CSF Color: Clear to cloudy fluid
- CSF Glucose: Normal
- CSF Protein much greater than 45
- CSF Leukocytes: Lymphocytes normal or increased
- CSF Opening Pressure: Normal
- Other tests
- CSF Restricted Oligoclonal Bands (Multiple Sclerosis)
XIV. References
- Kooiker in Roberts (1998) Procedures in ER, p. 1067-75
- Ravel (1995) Lab Medicine, Mosby, p. 294-9
- Tunkel in Mandell (2000) Infectious Disease, p. 974-8
- Griffith (1994) Neurol Clin 12:541-64 [PubMed]
- Mount (2017) Am Fam Physician 96(5): 314-22 [PubMed]
- Seehusen (2003) Am Fam Physician 68:1103-8 [PubMed]
- Shahan (2021) Am Fam Physician 103(7): 422-8 [PubMed]
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Related Studies
Concepts | Finding (T033) |
ICD9 | 792.0 |
ICD10 | R83 , R83.9 |
SnomedCT | 207335007, 158579002 |
English | Nonspecific abnormal findings in cerebrospinal fluid, CSF ABNORMAL, Abnormal findings in cerebrospinal fluid, unspecified abnormal finding, Cerebrospinal fluid abnorm., Cerebrospinal fluid abnormality, [D]Cerebrospinal fluid abnormality (context-dependent category), [D]Cerebrospinal fluid abnorm., [D]Cerebrospinal fluid abnormality, Spinal fluid abnorm, Cerebrospinal fluid abnormal, CSF abnormal, CSF abnormal NOS, CSF abnormality NOS, Abn fnd-cerebrospinal fl, Abnormal findings in cerebrospinal fluid, abnormalities csf, cerebrospinal fluid abnormality, abnormal csf, [D]Cerebrospinal fluid abnormality (situation), cerebrospinal; abnormal fluid, cerebrospinal; fluid abnormal, fluid; abnormal, cerebrospinal, abnormal; fluid, cerebrospinal, abnormality; fluid, cerebrospinal, Cerebrospinal fluid abnormal NOS, Cerebrospinal fluid abnormality NOS |
Dutch | CSV abnormaal, niet-specifieke abnormale bevindingen in cerebrospinaal vocht, CSV abnormaliteit NAO, cerebrospinaal vocht abnormaal, cerebrospinaal vocht abnormaal NAO, ruggenmerg vocht abnormaal, abnormaal; vloeistof, cerebrospinaal, afwijking; vloeistof, cerebrospinaal, cerebrospinaal; afwijking vloeistof, cerebrospinaal; vloeistof afwijkend, vloeistof; afwijkend, cerebrospinaal, Afwijkende bevindingen in cerebrospinale vloeistof; Niet gespecificeerde afwijkende bevinding, Afwijkende bevindingen in cerebrospinale vloeistof |
French | LCR anormal SAI, Résultats anormaux non spécifiques de l'examen du liquide céphalo-rachidien, Anomalie du LCR SAI, Liquide céphalo-rachidien anormal, LCR anormal, Liquide rachidien anormal, ANOMALIE DU LCR |
German | Liquoranomalie NNB, unspezifische anomale Befunde im Liquor, Liquor anomal, Liquor anomal NNB, Abnorme Liquorbefunde: Nicht naeher bezeichneter abnormer Befund, Abnorme Liquorbefunde, LIQUOR PATHOLOGISCH VERAENDERT |
Italian | Liquido cerebrospinale anormale non specificato, Liquido cerebrospinale anormale, Alterazione del liquido cerebrospinale NAS, Reperti anormali non specifici nel liquido cerebrospinale, Liquido spinale anormale |
Portuguese | LCR anormal, LCR anormal NE, Anomalia do LSR NE, Líquido cefalorraquidiano anormal, Dados anormais inespecíficos do LCR, ALTERACOES DO LIQUOR |
Spanish | Líquido cefalorraquídeo anormal, LCR anormal, LCR anormal NEOM, Anormalidad del LCR NEOM, Hallazgos anormales no específicos en el líquido cefalorraquídeo, [D]anomalía del líquido cefalorraquídeo (categoría dependiente del contexto), Líquido raquídeo anormal, LCR ALTERADO, [D]anomalía del líquido cefalorraquídeo (situación), [D]anomalía del líquido cefalorraquídeo |
Japanese | 髄液異常, 髄液の非特異的異常所見, CSF異常NOS, CSF異常, ズイエキノヒトクイテキイジョウショケン, 脊髄液異常, CSFイジョウNOS, CSFイジョウ, ズイエキイジョウ, セキズイエキイジョウ |
Czech | Nespecifické abnormální nálezy v mozkomíšním moku, Mozkomíšní mok abnormální, Abnormalita CSF NOS, Abnormální míšní mok, CSF abnormální, CSF abnormální NOS |
Korean | 뇌척수액의 이상 소견 |
Hungarian | Liquor kóros, Liquor kóros k.m.n., Gerincfolyadék kóros, Liquor-rendellenesség k.m.n., Nem specifikus kóros liquor leletek |