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Table of Contents
LETTER TO THE EDITOR
Year : 2016  |  Volume : 19  |  Issue : 2  |  Page : 281-282
 

Utility of cerebrospinal fluid cortisol level in acute bacterial meningitis


1 Department of Neurology, MS Ramaiah Medical College and Hospital, Bangalore, Karnataka, India
2 Department of Medicine, MS Ramaiah Medical College and Hospital, Bangalore, Karnataka, India

Date of Submission25-Sep-2015
Date of Decision26-Sep-2015
Date of Acceptance27-Sep-2015
Date of Web Publication12-May-2016

Correspondence Address:
Rohan R Mahale
Department of Neurology, MS Ramaiah Medical College and Hospital, Bangalore - 560 054, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-2327.173412

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How to cite this article:
Mehta A, Mahale RR, Sudhir U, Javali M, Srinivasa R. Utility of cerebrospinal fluid cortisol level in acute bacterial meningitis. Ann Indian Acad Neurol 2016;19:281-2

How to cite this URL:
Mehta A, Mahale RR, Sudhir U, Javali M, Srinivasa R. Utility of cerebrospinal fluid cortisol level in acute bacterial meningitis. Ann Indian Acad Neurol [serial online] 2016 [cited 2019 Oct 19];19:281-2. Available from: http://www.annalsofian.org/text.asp?2016/19/2/281/173412


Sir,

Thank you very much for your comments and subsequent discussion regarding the article.[1]

  1. The cutoff values of cerebrospinal fluid (CSF) cortisol could not be established as the sample size was small; however, initially normative data were obtained on 25 patients (15 males and 10 females) without any preexisting neurological disorders, and those who underwent spinal anesthesia were included as controls. The average mean CSF cortisol level for controls was 1.05 µg/dL, following which, the same was studied in patients with bacterial meningitis (BM) and viral meningitis (VM) whose mean CSF cortisol levels were 13.85 µg/dL and 3.47 µg/dL, respectively, and which were statistically significant. Thus, CSF cortisol is practically easy to use and apply in the clinical setting.
  2. There is no evidence that the lumber puncture (LP) procedure is harmful in most patients with suspected central nervous system (CNS) infection. There is belief that in the majority of these patients LP is safe, and potentially beneficial. In contrast, the avoidance of LP would appear to be potentially detrimental to patient care. LPs contributed directly to patient management in 72% of cases, either by identifying an organism, allowing unnecessary antibiotics/antivirals to be stopped after 24 h, or by permitting an earlier discharge from the hospital.[2] Hence, as a rule of thumb, one does CSF analysis for every suspected case of BM on the day of admission and a repeat analysis 72 h later and thereafter depending on the therapeutic response. Thus, in the same setting one can monitor CSF cortisol levels along with CSF pleocytosis in meningitis.
  3. Yes, serum procalcitonin (PCT) could be considered as an alternative tool along with CSF cortisol level. Serum PCT decreases with antibiotic treatment and is related to the severity of the disease. However, we have also demonstrated the following:

    1. CSF cortisol levels had significant correlation with serum PCT as depicted in [Figure 3] in our article. Similar observation was made by Viallon et al. (1999) and Schwartz et al. (2000).[3],[4]
    2. There was significant reduction in the mean CSF cortisol levels with treatment (13.85 vs 1.55 µg/dL, P< 0.0001). Similar observation was also made by Holub et al. (2007).[5]


Serum PCT level estimation has its own limitation as follows:{Figure 3}

  1. Use of PCT to differentiate between BM and other causes of febrile encephalopathy, such as brain abscess is limited, as it is also elevated in patients with bacterial pneumonia, sepsis, and other bacterial infections.[6],[7],[8]
  2. Diagnostic use of PCT in patients with acute meningitis in the presence of other bacterial infections is also potentially limited when compared to CSF analysis.


Thus, serum PCT may not be specific for BM (if associated with systemic bacterial infections). In such cases, CSF cortisol may prove to be a beneficial alternative as amply demonstrated in our study and Holub et al. (2007).[5]

No single CSF test has yet been proved to be fully reliable in distinguishing BM from aseptic meningitis. For rapid etiological diagnosis in meningitis, various CSF parameters along with a new parameter in the form of CSF cortisol assay and serum PCT must be combined.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Mehta A, Mahale RR, Sudhir U, Javali M, Srinivasa R. Utility of cerebrospinal fluid cortisol level in acute bacterial meningitis. Ann Indian Acad Neurol 2015;18:210-4.  Back to cited text no. 1
[PUBMED]  Medknow Journal  
2.
Kneen R, Solomon T, Appleton R. The role of lumbar puncture in suspected CNS infection: A disappearing skill? Arch Dis Child 2001;87:181-3.  Back to cited text no. 2
    
3.
Viallon A, Zeni F, Lambert C, Pozzetto B, Tardy B, Venet C, et al. High sensitivity and specificity of serum procalcitonin levels in adults with bacterial meningitis. Clin Infect Dis 1999; 28:1313-6.   Back to cited text no. 3
    
4.
Schwarz S, Bertram M, Schwab S, Andrassy K, Hacke W. Serum procalcitonin levels in bacterial and a bacterial meningitis. Crit Care Med 2000;28:1828-32.   Back to cited text no. 4
    
5.
Holub M, Beran O, Dzupová O, Hnyková J, Lacinová Z, Prihodová J, et al. Cortisol levels in cerebrospinal fluid correlate with severity and bacterial origin of meningitis. Crit Care 2007;11:R41.  Back to cited text no. 5
    
6.
Pfister R, Kochanek M, Leygeber T, Brun-Buisson C, Cuquemelle E, Machado MB, et al. Procalcitonin for diagnosis of bacterial pneumonia in critically ill patients during 2009 H1N1 influenza pandemic: A prospective cohort study, systematic review and individual patient data meta-analysis. Crit Care 2014;18:R44.  Back to cited text no. 6
    
7.
Hoeboer SH, van der Geest PJ, Nieboer D, Groeneveld AB. The diagnostic accuracy of procalcitonin for bacteraemia: A systematic review and meta-analysis. Clin Microbiol Infect 2015;21:474-81.  Back to cited text no. 7
    
8.
Ren H, Li Y, Han C, Hu H. Serum procalcitonin as a diagnostic biomarker for sepsis in burned patients: A meta-analysis. Burns 2015;41:502-9.  Back to cited text no. 8
    




 

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