Can high dose corticosteroids cause WBC with polyseg predominance in the CSF?

[ieatpizza]

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How does administering high dose corticosteroids alter a patient's CSF cell count? Let's say you have a patient without any meningism being treated with high dose corticosteroids for another condition. You find that the CSF shows about 15 WBCs with 90% polysegs. Can this be explained by corticosteroids?

 

[Strokeguy]

Short answer is 'NO'. In this situation you must rule out a pathology (infection, ..) or blood contamination during spinal tap.
Steroids cause increased leucocytes in peripheral blood. These PMNs were initially adherent to the arterial wall and then join the blood stream with systemic steroid administration. The normal CSF under any given situation never has more than 5 lymphocytes (no PMNs).

 

[ieatpizza]

Let's say you've ruled out traumatic tap because there are only 2 RBCs and no significant peripheral leukocytosis. Let's say it's not clinically bacterial because the patient has had meningismal symptoms for 2 weeks and you don't think it's viral because you wouldn't expect a neutrophil predominance 2 weeks out. What's on your differential for an aseptic meningitis with a neutrophil predominance?

 

[typhoonegator]

Check the meds, you'd be surprised how many medications can cause an aseptic meningitis (metronidazole being one of the most famous culprits).

However, as Strokeguy points out, you must exonerate infectious sources first before you settle on anything more convenient. This is particularly important given that the patient is on high-dose steroids.

Think about HIV, think about opportunistic infections, fungal pathology, etc. Crypto can cause an indolent meningitis which then becomes angio-invasive and quite nasty. CMV can be quite indolent in the beginning before it starts picking off nerve roots. The opening pressure can be helpful with some of these things. AFB and india-ink stains sometimes can give you the diagnosis. PPD/quantiferon gold for TB? West Nile? EEE/WEE (depending on where you are)? HIV can cause an acute encephalo-radiculomyelitis that starts off with headache and meningism, although this is typically in people on ineffective HAART or who have acutely stopped their HAART.

We can't give advice on this forum, but a patient with meningeal symptoms and inflammatory cells in the CSF needs to be fully worked up.

Thank god for a clinical thread on this forum! I really hope the OP's next question isn't about how to integrate this experience into his personal statement.

 

[bluntdissector]

Check the meds, you'd be surprised how many medications can cause an aseptic meningitis (metronidazole being one of the most famous culprits).

However, as Strokeguy points out, you must exonerate infectious sources first before you settle on anything more convenient. This is particularly important given that the patient is on high-dose steroids.

Think about HIV, think about opportunistic infections, fungal pathology, etc. Crypto can cause an indolent meningitis which then becomes angio-invasive and quite nasty. CMV can be quite indolent in the beginning before it starts picking off nerve roots. The opening pressure can be helpful with some of these things. AFB and india-ink stains sometimes can give you the diagnosis. PPD/quantiferon gold for TB? West Nile? EEE/WEE (depending on where you are)? HIV can cause an acute encephalo-radiculomyelitis that starts off with headache and meningism, although this is typically in people on ineffective HAART or who have acutely stopped their HAART.

We can't give advice on this forum, but a patient with meningeal symptoms and inflammatory cells in the CSF needs to be fully worked up.

Thank god for a clinical thread on this forum! I really hope the OP's next question isn't about how to integrate this experience into his personal statement.

Regarding India Ink - I'd have thought you mostly use CLAT in the US?
Similarly, I'd have thought Auramine staining on centrifuged CSF rather than ZN for AFB?

Just wondering...