now we will talk about the normal composition of CSF and we will also discuss that what are
the changes in CSF due to different types of infections of the meninges is that right
uh we say that inflammation of meninges is called meningitis and usually in the meningitis there is
inflammation mainly of parameter and arachnid matter and fear matter with arachnid matter
together are called leptomenanges so meningitis is meningitis is defined as inflammation of
laptop meninges is that right and we will see in this lecture that when someone has
leptomaning meningeal inflammation what are the changes in CSF first we'll talk
about normal that first of all color of CSF in a normal person the color of CSF is
clear crystal clear is that right it's Crystal Clear number one about the color number two the
cells in CSF do you think normally CSF has any type of cells yes please CSF as what type of only
few lymphocytes you know lymphocytes are the cells of the connective tissue and extracellular fluid
and you are allowed to have less than five lymphocytes in CSF per cubic millimeter
and there should be no neutrophil and no RBC in the normal CSF there should be no red blood cell
there should be no neutrophil and few lymphocyte means that lymphocytes are less than yes less than
5 per cubic millimeter is the milliliter per cubic milliliter so in the cells we say these are the
neutrophils neutral filters you know having multi-lobated nucleus
neutrophils normally they should be
no neutrophil they should be no neutrophils and there may be lymphocytes how many lymphocytes
lymphocytes have a big nucleus with very little cytoplasm right they should be less than
five lymphocytes per cubic milliliter is that right then we come to glucose glucose and
glucose level and CSF you know that glucose is transported from the correct plexus not
freely and usually CSF level of glucose is about two thirds of the level in the plasma is that
right so you can say normally glucose level in CSF is 66 percent of the plasma glucose level or blood
glucose plasma glucose concentration it means whenever you do lumbar puncture it's wise to take
the venous blood glucose level as well is that right for example if when when the moment when
you do the lumbar puncture at that very time if blood glucose level is 100 milligram per DL then
glucose level in the CSF should be around 65 but if glucose level in the blood is 70 then of course
lower value will be acceptable in CSF is that right so usually we say that glucose level in
the CSF is about two-thirds of the glucose level in the blood am I clear then proteins
plasma proteins are not freely allowed to move into CSF right and CSF is very poor in
proteins I mean the normally the upper level of proteins and CSF is 0.4 grams per liter
it is very low level the plasma protein level is how much yes please
plasma protein level is how much seven to eight grams per DL seven to eight grams per
Dr or 70 to 80 grams per liter
plasma proteins level you should know as you know the name of your friends every doctor must know
all the time it's a very common value and one liter of blood one liter of plasma
there are 70 to 80 grams of plasma proteins but in one liter of CSF plasma protein will
be just point four gram just very very low is that right these are some basic values
now We compare the changes in CSF and three types of infections right a specially
yes pyogenic meningitis pyogenic bacterial meningitis what is meant by pyogenic
yes performance like pyogenic meningitis may be due to meningococcus or it may
be due to E coli or it may be due to streptococcus staphylococcus is that right
pyogenic meningitis the bacteria which produce pus second meningitis I can talk
about tuberculous meningitis tuberculus meningitis and third is viral meningitis right now pyogenic
meningitis first of all what will happen to the color yes what will happen to the color
color will become yellow or turbid or turbid it will not be crystal clear
CSF because this person that is that right but when you compare the tuberculous meningitis with
pyogenic meningitis and tuberculous meningitis because fibrin leaks into CSF so there's a web
their turbid color with some web formation in the CSF so in case of tuberculosis we say
that there is turbid color and with that there is yes fibrin web or fibrant web
and viral meningitis virus does not produce pus viral inflammation is not so severe that
fibrinogen from the blood should leak right so usually it is clear CSF right so here CSF is
clear in viral case right so this is gross appearance of CSF it may be yellow and turbid
pyogenic meningitis in case of turbid with fibrin cobweb that is meningitis and if you know there
is meningitis but CSF is clear you must think of viral meningitis is that right then we come
to the South now in the past there are always lot of neutrophils so in pyogenic meningitis uh
neutrophils level will be very very hi right so there's a very high levels of neutrophils
in case of pyogenic meningitis which cells we are talking about we are talking about neutrals
but in tuberculous meningitis because tuberculosis is a chronic inflammation and tuberculosis is a
chronic inflammation and neutrophils are the cells of acute inflammation so neutrophils
are not abundant in tuberculus meningitis they are very less and in viral Alto neutrals are very less
so if in the CSF you find lot of neutrophil which infection is
indicated pyogenic bacteria then we come to the lymphocytes then we come to the lymphocytes
in acute infection lymphocytes are less because lymphocytes take long time to accumulate at the
site of inflammation acute inflammation most of the pyogenic bacteria produce chemotactic agent
which attract the neutrophil moral lymphocyte class so in acute inflammation write acute
meningitis due to pyogenic inflammation right acute meningitis due to pyogenic
bacteria will show a lot of neutrals but very little lymphos is that right but if you look at
CSF from a patient with tuberculos meningitis tuberculosis meningitis is acute or chronic
it's a chronic and when this is a classical saying that lymphocyte accumulate and viral infection and
chronic infection lymphocyte normally accumulated viral infection and chronic infections and acute
polygenic mainly collect neutrophils so what you will find here lot of lymphocytes Lord of
lymphocytes right and in viral also you will find lot of lymphocytes
it means that when you have a lot of neutral Health it is pyogenic
when there are a lot of lymphocytes then it may be tuberculosis it may be viral
but the other way is how to differentiate these two from each other
is that clear up to now now we talk about glucose remember bacteria love
to eat of glucose virus are not bothered about glucose is that right so it's very clear that
CSF level of glucose will be low in pyogenic meningitis and CSF level of glucose will be low
in tuberculosis meningitis low mean that it will be less than 50 percent of plasma glucose level
of blood glucose level CSF level of glucose will be less than 50 percent of the plasma
glucose level because pyogenic bacteria every type of bacteria love to take the glucose
bacteria are usually glycophilic they love the glucose biogenic as well as tuberculosis so in
this case also the glucose level is less than 50 percent of plasma or blood glucose level here yeah
blood glucose level is more than 50 so CSF glucose level is more than 50 percent of blood or plasma
glucose level so what really happens that we can say that in viral in viral meningitis
glucose level and CSF is normal is it right so normal glucose level with a lot of lymphos 0.2
viral but lot of lymphos with normal glucose is viral but a lot of lymphosis with low glucose is
bacterial and chronic material at the top must be tabi and lot of neutrons with low glucose 0.2
pyogenic is that right then we talk about the proteins now the CSF protein levels
what happened to it of course Whenever there is inflammation there is increased mic permeability
in the micro circulation so proteins level will go up in every meningitis protein
levels go up but viral viral inflammation disturb the micro circulation very little
it does disturb but slightly so here is glue here plasma so CSF protein level goes only mildly up
is that right but in case of tuberculosis
CSO protein level goes severely up and even in pyogenic it is moderate to severe lay up
you can understand why because when bacterial infection is there right it disrupts the micro
circulation and there's increased permeabilities a lot of proteins leak from vascular system to the
CSF am I clear right but viral information does not disrupt the micro circulation so much does not
increase uh micro permeability so much that lot of proteins do not shift so normal protein level
is what 0.4 grams per letter so here it may be up to 1 gram from point four it may go up to one gram
but U leads always less than one gram and viral infections CSF proteins are really less than one
gram but in these cases it is usually more than one gram right or we can say very simply that
in viral infection and viral infection plasma CSF protein slightly increase and pyogenic infection
it moderately increase in tuberculous infection rate severely increase now look rather than
making memorization of this chart remember the very basic thing without looking at that
a person who comes with suppose meningococcal infection meningococcal meningitis or pneumococcal
meningitis so staphylococcal meningitis or streptococcus meningitis or E coli meningitis
or any these organisms are pyogenic so what will happen CSI will become turbid color due to pass
because they have made pass and there will be lot of neutrophils which is the future of acute
inflammation where if there will be lymphocytes but not as much as neutrophil and lot of proteins
are there and glucose is down is it difficult to remember then you compare it with tuberculus
everything is similar except few in pyogenic bacteria and tuberculous bacteria both eat of
the glucose in both cases glucose will be low both will damage the micro circulation and both will
take the proteins up is that right both will make the ah that color turbid especially there will be
cobweb formation and tuberculus what is the real difference the real difference is in the cells
that if there's neutrals it is pyogenic acute if their lymphosis it is
tuberculosis and the how about viral viral is color is clear most of the time secondly enviral
meningitis neutrons are not there it is lymphos meningitis if it is lymphos you can differentiate
it from TB which is also imposed that in TB glucose goes downward viral glucose does not go
down and and TB proteins go too high tuberculosis is very very disruptive but viral is usually not
that much disruptive so proteins are not that high now I will ask you a question we have a
CSF here turbid color lot of neutrophils what is this what will happen to glucose if you check
and what will happen to proteins if you check hi I bring another you can say bottle
CSF is clear what do you think it may be normal it may be normal my friend oh my God
what happened
vision is not necessarily sometimes you do lumbar punctures and due to some other reason so
CSF is clear if I say CSF is clear lymphos are three neutrals are absent now listen carefully
neutral neutrals are absent proteins are high I'm making really Trek with you again listen CSF color
is clear right lymphos are not normal is that right neutrals are not there rbcs are not there
glucose is normal some proteins are high and those proteins are immunoglobulin this is some immune
mediated disease to central nervous system some immune mediated disease immunological disorder not
infection is that right okay but this is not that important at this level but at your level it is
now uh you tell me I bring another bottle a bottle fall down but anyway hypothetically in
this bottle CSF is clear lymphother high glucose is normal proteins are slightly high it is viral
is that right so again in the bottle you find lot of neutrophils with high protein high low glucose
pyogenic lot of lymphos with low glucose and high proteins tuberculosis a lot of lymphos with normal
glucose and little increase in proteins viral it's difficult now I'll tell you another thing
you find the CSF in lot of rbcs and if you let the CSF bottle stand for some time at the top of
the bottle there's some yellow coloration we call it xanthochromia we call that thing zento chromia
I'll be impress you if you tell me you do the lumbar puncture and there are a lot of rbcs in CSF
and there is some yellow color at the top of the CSF what do you think
yeah Hammer is very good which hemorrhoid subarachnid hybrid
because in subregnite Hemorrhage blood will mix with the CSF and it will spread all over
rbcs and some rbcs will rupture and release the contents which give yellow color is that
right so in sub arachnid Hemorrhage what is the main change in CSF of course lot of services and
at the top of that bottle you will find xantho chromium or yellow coloration right am I clear