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Letters to the Editor

Indian Pediatrics 2002; 39:602-603

An Indigenous Leucocyte Esterase Test along with Pandy’s Test for the Diagnosis of Bacterial Meningitis

 

We read with interest the recent article on the subject(1) and have the following comments to offer:

1. The predictive value of both the positive leukocyte esterase test and Pandy’s test in combination has been shown as 100%. The simultaneous rise in CSF proteins and cells may not be seen in all the cases of meningitis, though rise either in proteins or cells alone has been seen more frequently. Even CSF can be normal in early meningitis.

2. Authors have admitted their limitations in diagnosis of tubercular meningitis alone, though the same holds true for fungal meningitis, where polymorphs are seen early and there is rise in CSF proteins(2).

3. It has not been mentioned for how many hours leukocyte esterase test, remains positive in CSF samples after cell lysis, i.e. half life of leukocyte esterase.

4. Age group in the study is from 1 month - 12 years. The neonatal CSF protein values achieve childhood levels after 2 months of age(3). So from 1 month to 2 completed months of age, Pandy’s test will be false positive.

5. In the results, it has been mentioned that two traumatic CSF samples with polymorphs were leukocyte esterase positive whereas in Table 1, in cases with traumatic CSF, the percentage of polymorphs is 0. In two samples of viral meningitis, it has been mentioned in the text that there were 33 and 100 lymphocytes respectively, where in second sample, there were only 6 lymphocytes/mm3 as shown in Table I.

Table I- Cerebrospinal Fluid Findings in Various Central Nervous 
System Infections
Infection
Pressure
(mmH2O)
Leukocytes
Total(mm3)
PMN
(%)
Protein
(mg/dl)
Glucose
(mg/dl)
No infection (normal)
50-80
<5
<25
20-45
>50
Viral meningo-encephalitis
100-150
10-1000
<25
50-200
>50
Bacterial meningitis
100-300
100-10,000
>75
100-500
<40
Brain abscess
100-300
10-200
<25
75-500
>50
*May be predominance of PMNs in the first several hours of infection.

6. In the study, polymorph >1 mm3 has been taken as a criteria for the diagnosis of bacterial meningitis, whereas authors themselves have mentioned in the text that presence of even one polymorph denotes meningitis.

7. The criteria used for the diagnosis of bacterial meningitis do not match with those mentioned in the original reference(4) (Table I).

8. The 31 cases shown in Table I have been categorized in 4 categories, namely, bacterial meningitis, partially treated bacterial meningitis, normal CSF and traumatic CSF.

(i) Cases at serial nos. 9, 29 and 30 have protein levels of 124, 86 and 60 mg/dl, respectively. These cases have been mentioned as normal though yardstick of protein > 40 mg/dl has been used for the diagnosis of meningitis (bacterial/viral).

(ii) As per criteria in original references, polymorphs >75% is used for diagnosis of bacterial meningitis, whereas cases at serial nos. 3, 4, 14, 16, 18-21 and 25 with lymphocytic predominance have been labelled as bacterial meningitis.

9. Reference 2 quoted by the authors is not available in JAMA 1989; 262: 1121-1124, instead some advertisement has been published on same pages.

K.K. Locham,

Manpreet Sodhi,

Geetanjali Jindal,

Department of Pediatrics,

Government Medical College,

Rajindra Hospital,

Patiala 147 001,

India.

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 References


1. Srivastava RK, Gupta S, Bhargava M, Kumar N, Upadhyaya P, Puliyel JM. An indigenous leukocyte esterase test along with Pandy’s test for the diagnosis of bacterial meningitis. Indian Pediatr 2001; 38: 1281-1286.

2. Prober CG. Central nervous system infections. In: Nelson Textbook of Pediatrics, 16th edn. Eds. Behrman RE, Kleigman RM, Jenson HB. Philadelphia, W.B. Saunders Company, 2000; pp 751-761.

3. Aneja S, Aggarwal A. Acute bacterial meningitis. Indian Pediatr 1997; 34: 1097-1109.

4. Prober CG. Infections of the central nervous system. In: Nelson Textbook of Pediatrics, 15th edn. Eds. Behrman RE, Kleigman RM, Arvin AM. Philadelphia, W.B. Saunders Company, 1996; pp 707-716.

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