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1.  Lumbar puncture and subarachnoid haemorrhage. 
Postgraduate Medical Journal  1986;62(733):1021-1024.
Medical notes of 123 patients with subarachnoid haemorrhage were examined. No patient deteriorated at the time of lumbar puncture. All but 2 patients with associated intracerebral haematomas had markedly impaired consciousness or focal signs. Two of 30 patients with meningitis were initially diagnosed as subarachnoid haemorrhage, and one died without lumbar puncture. If consciousness is not markedly impaired and focal signs are absent, lumbar puncture is safe in patients with subarachnoid haemorrhage.
PMCID: PMC2418952  PMID: 3628146
2.  Randomised controlled trial of atraumatic versus standard needles for diagnostic lumbar puncture 
BMJ : British Medical Journal  2000;321(7267):986-990.
Objective
To compare the ease of use of atraumatic needles with standard needles for diagnostic lumbar puncture and the incidence of headache after their use.
Design
Double blind, randomised controlled trial.
Setting
Investigation ward of a neurology unit in a university hospital.
Participants
116 patients requiring elective diagnostic lumbar puncture.
Interventions
Standardised protocol for lumbar puncture with 20 gauge atraumatic or standard needles.
Outcome measures
The primary end point was intention to treat analysis of incidence of moderate to severe headache, assessed at one week by telephone interview. Secondary end points were incidence of headache at one week analysed by needle type, ease of use by operator according to a visual analogue scale, incidence of backache, and failure rate of puncture.
Results
Valid outcome data were available for 97 of 101 patients randomised. Baseline characteristics were matched except for higher body mass index in the standard needle group. By an intention to treat analysis the absolute risk of moderate to severe headache with atraumatic needles was reduced by 26% (95% confidence interval 6% to 45%) compared with standard needles, but there was a non-significantly greater absolute risk of multiple attempts at lumbar puncture (14%, −4% to 32%). Higher body mass index was associated with an increased failure rate with atraumatic needles, but the reduced incidence of headache was maintained. The need for medical interventions was reduced by 20% (1% to 40%).
Conclusions
Atraumatic needles significantly reduced the incidence of moderate to severe headache and the need for medical interventions after diagnostic lumbar punctures, but they were associated with a higher failure rate than standard needles.
PMCID: PMC27505  PMID: 11039963
3.  Diagnostic lumbar puncture. Comparative study between 22–gauge pencil point and sharp bevel needle 
The Journal of Headache and Pain  2005;6(5):400-404.
Post–lumbar puncture headache is a frequent clinical problem. Needle design is expected to reduce post–puncture headache. In this study, we compared two different lumbar puncture needle designs in diagnostic lumbar puncture and analysed post–dural puncture headache (PDPH) and social and economical harm associated with the diagnostic lumbar puncture procedure. This prospective, controlled study consisted of 80 consecutive adult patients requiring elective diagnostic lumbar puncture due to various neurological symptoms. Lumbar puncture was completed either with Spinocan® 22 G sharp bevel needle or Whitacre® 22G pencil point needle. Patients were asked about previous headache symptoms and pain provoked by puncture. One week after the lumbar puncture all patients were interviewed by telephone and occurrence and type of headache, headache intensity, medication and frequency of impairment in activities of daily living were asked. Need for epidural blood patch was also recorded. Thirty–three of 78 (42%) patients experienced headache after diagnostic lumbar puncture and in 26 (33%) the headache could be classified as PDPH. There were no statistically significant differences between needle types in the frequency of common headache, PDPH, puncture pain intensity, need for epidural blood patch or sick leave. Also, there were no other complications except local back pain or headache. In this study, the needle design did not affect the frequency of PDPH. Also, PDPH was common, occurring in 33% cases and caused a considerable amount of disturbance in daily activities. Seeking help for this condition was insufficient and only part of these PDPH patients were treated with epidural blood patch.
doi:10.1007/s10194-005-0235-5
PMCID: PMC3452066  PMID: 16362713
Post–lumbar puncture headache; Diagnostic lumbar puncture; Puncture needle
4.  Cryptococcal meningitis in an HIV negative patient with systemic sarcoidosis. 
Journal of Clinical Pathology  1999;52(12):928-930.
A case of Cryptococcus neoformans meningitis is described in an HIV negative patient with undiagnosed systemic sarcoidosis. The patient presented with signs of meningitis together with generalised lymphadenopathy and hepatosplenomegaly. Cryptococcal meningitis was diagnosed on lumbar puncture. She was treated with intravenous amphotericin B but died within two weeks of admission. Necropsy revealed lesions in the lungs, liver, spleen, lymph nodes, small intestine, and bone marrow consistent with sarcoidosis. Microscopically the lesions contained non-caseating epithelioid cell granulomas typical of sarcoidosis. No Schaumann or Hamazaki-Wesenberg bodies were identified. Cryptococcus neoformans meningitis is generally associated with immunosuppressive disorders. As T cell abnormalities have been described in sarcoidosis, this could have been a case of opportunistic infection. Although rare, sarcoidosis merits consideration in patients with cryptococcal disease in the absence of HIV infection.
Images
PMCID: PMC501665  PMID: 10711260
5.  The role of lumbar puncture in children with suspected central nervous system infection 
BMC Pediatrics  2002;2:8.
Background
The use of the lumbar puncture in the diagnosis of central nervous system infection in acutely ill children is controversial. Recommendations have been published but it is unclear whether they are being followed.
Methods
The medical case notes of 415 acute medical admissions in a children's hospital were examined to identify children with suspected central nervous system infection and suspected meningococcal septicaemia. We determined whether lumbar punctures were indicated or contraindicated, whether they had been performed, and whether the results contributed to the patients' management.
Results
Fifty-two children with suspected central nervous system infections, and 43 with suspected meningococcal septicaemia were identified. No lumbar punctures were performed in patients with contraindications, but only 25 (53%) of 47 children with suspected central nervous system infection and no contraindications received a lumbar puncture. Lumbar puncture findings contributed to the management in 18 (72%) of these patients, by identifying a causative organism or excluding bacterial meningitis.
Conclusion
The recommendations for undertaking lumbar punctures in children with suspected central nervous system infection are not being followed because many children that should receive lumbar punctures are not getting them. When they are performed, lumbar puncture findings make a useful contribution to the patients' management.
doi:10.1186/1471-2431-2-8
PMCID: PMC126268  PMID: 12350236
6.  Emergency Lumbar Puncture in Adults 
Canadian Family Physician  1989;35:1183-1186.
Three patients who had lumbar punctures performed in the presence of undiagnosed intracranial space-occupying lesions are described. Neurologic deterioration was precipitated in one and continued in another; neurologic status was unchanged in the third patient. The use of lumbar puncture in adults in the emergency setting is discussed in light of the accepted indications and contra-indications, available data on complication rates, and regional availability of cranial computed tomography. We recommend that all patients undergo computed tomography or other brain imaging, such as magnetic resonance, prior to lumbar puncture in order to detect unsuspected intracranial mass lesions or other abnormalities (such as subarachnoid hemorrhage and hydrocephalus) that would preclude lumbar puncture.
Images
PMCID: PMC2280348  PMID: 21248954
cerebellar tonsillar herniation; lumbar puncture; neurology; spinal puncture; transtentorial herniation
7.  Computed tomography before lumbar puncture in acute meningitis: a review of the risks and benefits. 
OBJECTIVE: To determine the indications, if any, for routine computed tomography (CT) of the brain before lumbar puncture in the management of acute meningitis. DATA SOURCES: Original research papers, reviews and editorials published in English from 1965 to 1991 were retrieved from MEDLINE. The bibliographies of these articles and of numerous standard texts were examined for pertinent references. A survey of local neurologists was conducted, and legal opinion was sought from the Canadian Medical Protective Association. DATA EXTRACTION: There were no studies directly assessing the risks of lumbar puncture in meningitis; however, all sources were culled for other pertinent information. RESULTS: No cases could be found of patients with acute meningitis deteriorating as a result of lumbar puncture. The neurologic consensus refuted the need for CT in typical acute meningitis. All sources stressed speedy lumbar puncture and the early institution of appropriate antibiotic therapy to minimize the severity of the illness and the risk of death. CONCLUSIONS: (a) There is no evidence to recommend CT of the brain before lumbar puncture in acute meningitis unless the patient shows atypical features, (b) for patients with papilledema the risks associated with lumbar puncture are 10 to 20 times lower than the risks associated with acute bacterial meningitis alone, (c) CT may be necessary if there is no prompt response to therapy for meningitis or if complications are suspected, (d) the inability to visualize the optic fundi because of cataracts or senile miosis is not an indication for CT and (e) there are no Canadian legal precedents suggesting liability if physicians fail to perform CT in cases of meningitis.
PMCID: PMC1490723  PMID: 8448711
8.  Role of computed tomography before lumbar puncture: a survey of clinical practice 
Postgraduate Medical Journal  2006;82(965):162-165.
Introduction
It is becoming increasingly common to request computed tomography (CT) to rule out space occupying lesions before lumbar puncture (LP), even in patients with no clinical signs. Imaging trends within a busy district general hospital in Oxfordshire, UK were analysed with results used to clarify when imaging should be considered mandatory.
Method
A retrospective six month sample was obtained comprising all adults considered for LP. Observed frequencies of abnormal examination findings compared with abnormal investigations were used to determine sensitivity, specificity, positive predictive, and negative predictive values to assess the validity of using a normal clinical examination as a basis for excluding CT.
Results
64 patients were considered for LP. In total, 58 patients underwent LP, with a single patient receiving two. After an abnormal CT scan, six patients did not undergo a planned LP. In all six of these cases subarachnoid haemorrhage was detected, and in all cases this was considered a probable diagnosis. In no case was an LP precluded by an unsuspected space occupying lesion. Neurological examination showed a sensitivity of 0.72 (0.52 to 0.93), specificity 0.78 (0.64 to 0.91), positive predictive value 0.61 (0.41 to 0.83), and negative predictive value 0.85 (0.73 to 0.97).
Discussion
The high sensitivity and negative predictive values support normal neurological examination as an effective predictor of normal CT scan. This permits the recommendation in cases where subarachnoid haemorrhage is not suspected, a CT scan can be avoided provided there are no abnormal findings on physical or fundoscopic examination.
doi:10.1136/pgmj.2005.041046
PMCID: PMC2563700  PMID: 16517796
computed tomography; lumbar puncture; meningitis; subarachnoid haemorrhage
9.  Lumbar Puncture in the Presence of Raised Intracranial Pressure 
British Medical Journal  1969;1(5641):407-409.
Study of 30 patients with raised intracranial pressure whose condition worsened after lumbar puncture emphasizes the danger of carrying this out in the presence of raised intracranial pressure. In half the cases deterioration was immediate and dramatic, and in the other half it occurred within 12 hours. Probably a tentorial or cerebellar pressure cone, or both, had formed before lumbar puncture, and the procedure made this worse and caused the clinical deterioration.
A history of progressive headache associated with mental changes, and the development and progression of localizing neurological signs were the two features suggestive of varied intracranial pressure found most constantly in this series. A good quality plain x-ray film is important in the diagnosis of this condition.
PMCID: PMC1981862  PMID: 5763958
10.  Lumbar Puncture in HIV-Infected Patients with Syphilis and No Neurologic Symptoms 
Background
The decision to perform lumbar puncture in patients with asymptomatic human immunodeficiency virus (HIV) infection and syphilis is controversial. The Centers for Disease Control and Prevention recommend certain criteria that warrant lumbar puncture. Here, we assess the performance of these criteria for detecting asymptomatic neurosyphilis (ANS).
Methods
Eligible subjects consisted of all patients with concurrent HIV infection and syphilis in a prospective clinical cohort who had no neurologic symptoms at the time of lumbar puncture. We retrospectively applied different stratification criteria to calculate the performance of lumbar puncture in detecting ANS: (1) lumbar puncture in patients with late latent syphilis or syphilis of an unknown duration, regardless of the CD4 cell count or rapid plasma reagin titer; (2) lumbar puncture if the CD4 cell count was ≤350 cells/mL and/or the rapid plasma reagin titer was ≥1:32, regardless of the syphilis stage; and (3) lumbar puncture in the context of serologic nonresponse to syphilis therapy.
Results
Two hundred two of 231 patients with syphilis did not have neurologic symptoms. Immediate lumbar puncture was performed for 46 patients, and 10 cases (22%) of ANS were detected. With use of the first criterion, 2 (14%) of 10 cases of ANS in patients with early-stage syphilis would have been missed (sensitivity, 80% [95% confidence interval {CI}, 44%–97%]; specificity, 76% [95% CI, 60%–89%]). Criterion 2 would not have missed any cases of ANS (sensitivity, 100% [95% CI, 70%–100%]; specificity, 87% [95% CI, 72%–96%]) but would have required that a lumbar puncture be performed for 88% of patients. Performance of lumbar puncture performed in 13 cases based on serologic nonresponse to syphilis therapy yielded 4 cases (31%) of ANS.
Conclusions
In patients with concurrent HIV infection and syphilis, the use of criteria based on rapid plasma reagin titer and CD4 cell count, instead of stage-based criteria, improved the ability to identify ANS.
doi:10.1086/597096
PMCID: PMC2716000  PMID: 19187028
11.  Paradoxical Transtentorial Herniation Caused by Lumbar Puncture after Decompressive Craniectomy 
Although decompressive craniectomy is an effective treatment for various situations of increased intracranial pressure, it may be accompanied by several complications. Paradoxical herniation is known as a rare complication of lumbar puncture in patients with decompressive craniectomy. A 38-year-old man underwent decompressive craniectomy for severe brain swelling. He remained neurologically stable for five weeks, but then showed mental deterioration right after a lumbar puncture which was performed to rule out meningitis. A brain computed tomographic scan revealed a marked midline shift. The patient responded to the Trendelenburg position and intravenous fluids, and he achieved full neurologic recovery after successive cranioplasty. The authors discuss the possible mechanism of this rare case with a review of the literature.
doi:10.3340/jkns.2012.51.2.102
PMCID: PMC3322205  PMID: 22500203
Paradoxical herniation; Decompressive craniectomy; Lumbar puncture; Cranioplasty
12.  CSF Proteins as Discreminatory Markers of Tubercular and Pyogenic Meningitis 
Introduction: Meningitis is still a major cause of illness in many parts of the world. Though substantial improvement has been occurred in the diagnosis of meningitis, conclusive differentiation between tubercular and pyogenic meningitis remains to be an unsolved problem. Patients with meningitis often have severe neurological deficit or die inspite of antibiotic therapy. Thus, improvement in diagnostic test and therapy is required. The objective of the present study was to find a simple biochemical marker for diagnosis of meningitis and differentiation of tubercular and pyogenic meningitis.
Materials and Methods: CSF samples were collected from 90 paediatric patients from Nilofer Hospital, Hyderabad, India, from age group of 4 months to 12 years. CSF samples were collected by performing Lumbar Puncture under aseptic conditions and with required precaution. CSF samples were divided into 3 groups where Group 1 included Control that was without CSF inflammation, Group 2 with Tuberculous Meningitis & Group 3 consisting of Pyogenic Meningitis with 30 samples in each group. Electrophoretic analysis of CSF proteins was performed which separated as bands of pre-albumin, albumin, alpha, beta and gamma globulins.
Result: Protein content in CSF was 259 ± 409 mg/dl in tuberculous meningitis, whereas in pyogenic meningitis it was 111 ± 83.94 mg/dl and in control group was 19 ± 13.3 mg/dl. Electrophoretic analysis revealed pre-albumin band to be 2.8 ± 1.2 % in tuberculous meningitis, which was significantly decreased when compared with control and pyogenic meningitis. Albumin band in tuberculous meningitis was 34.8 ± 9.9 %, which was also significantly decreased when compared to control and pyogenic meningitis. Alpha band was 19.7 ± 6.9 % in pyogenic meningitis, but in control and tubeculous meningitis it was 10.4 ± 2.9% and 10.3 ± 5.2% respectively. Beta band was found similar in all the three groups. Gamma band was 33.2 ± 8.08% in tuberculous meningitis, 13.8 ± 4.55% in control and 16.7 ± 13.18% in pyogenic meningitis.
Conclusion: Pre-albumin band was found to be decreased and gamma band was shown to be increased in tuberculous meningitis. Alpha band was increased in pyogenic meningitis. Thus, CSF protein fraction separated and quantitated by native Polyacrylamide slab gel electrophoresis, could be used as markers in differentiation of tubercular and pyogenic meningitis.
doi:10.7860/JCDR/2013/6361.3226
PMCID: PMC3782903  PMID: 24086846
Cerebrospinal fluid (CSF); Tubercular meningitis; Pyogenic meningitis; Polyacrylamide slab gel electrophoresis
13.  Predictors of Acute Bacterial Meningitis in Children from a Malaria-Endemic Area of Papua New Guinea 
Predictors of acute bacterial meningitis (ABM) were assessed in 554 children in Papua New Guinea 0.2–10 years of age who were hospitalized with culture-proven meningitis, probable meningitis, or non-meningitic illness investigated by lumbar puncture. Forty-seven (8.5%) had proven meningitis and 36 (6.5%) had probable meningitis. Neck stiffness, Kernig’s and Brudzinski’s signs and, in children < 18 months of age, a bulging fontanel had positive likelihood ratios (LRs) ≥ 4.3 for proven/probable ABM. Multiple seizures and deep coma were less predictive (LR = 1.5–2.1). Single seizures and malaria parasitemia had low LRs (≤ 0.5). In logistic regression including clinical variables, Kernig’s sign and deep coma were positively associated with ABM, and a single seizure was negatively associated (P ≤ 0.01). In models including microscopy, neck stiffness and deep coma were positively associated with ABM and parasitemia was negatively associated with ABM (P ≤ 0.04). In young children, a bulging fontanel added to the model (P < 0.001). Simple clinical features predict ABM in children in Papua New Guinea but malaria microscopy augments diagnostic precision.
doi:10.4269/ajtmh.2012.11-0312
PMCID: PMC3269274  PMID: 22302856
14.  Accidental intrathecal mercury application 
European Spine Journal  2003;13(3):241-243.
The authors present a case of accidental intrathecal mercury application. A 69-year-old white woman was admitted to our department with suspected meningitis following surgery for spinal stenosis at another hospital. Postoperatively, she had developed a cerebro-spinal fluid (CSF) fistula with a subcutaneous cavity. Local wound irritation had been suspected and, unfortunately, mercury-containing disinfectant was injected into the cavity. Within 24 h the patient demonstrated acute neurological deterioration due to meningitis and encephalitis and was admitted to our clinic with suspected meningitis due to postoperative CSF fistula. Lumbar puncture revealed desinfectant-stained, non-bloody CSF, while lumbar MRI demonstrated the large lumbar subcutaneous cavity. Additionally, CSF fistula was visualized on MRI. Laboratory examination revealed extremely high mercury levels in CSF, blood and urine. Treatment consisted in insertion of a lumbar drainage to wash out the mercury. The patient underwent medical detoxication using chelating agents (DMPS: RS-2,3-dimercapto-1-propansulfonacid, DMSA: meso-2,3-dimercaptosuccinatacid). Surgery was performed in order to close the cavity and the fistula. Postoperatively, the patient was admitted to the intensive care unit and remained intubated for 3 days. Within 4 weeks after surgery, she demonstrated good recovery. Eighteen months after intoxication, polyneuropathy and slight neuropsychological deficiencies were detectable.
doi:10.1007/s00586-002-0504-9
PMCID: PMC3468141  PMID: 14586664
Mercury; CSF fistula; Arachnoiditis; Meningitis
15.  An unusual case of chronic meningitis 
BMC Family Practice  2004;5:21.
Background
Chronic meningitis is defined as symptoms and signs of meningeal inflammation and persisting cerebrospinal fluid abnormalities such as elevated protein level and pleocytosis for at least one month.
Case presentation
A 62-year-old woman, of unremarkable past medical history, was admitted to hospital for investigation of a four-week history of vomiting, malaise an associated hyponatraemia. She had a low-grade pyrexia with normal inflammatory markers. A CT brain was unremarkable and a contrast MRI brain revealed sub-acute infarction of the right frontal cortex but with no evidence of meningeal enhancement. Due to increasing confusion and patient clinical deterioration a lumbar puncture was performed at 17 days post admission. This revealed gram-negative coccobacilli in the CSF, which was identified as Neisseria meningitidis group B. The patient made a dramatic recovery with high-dose intravenous ceftriaxone antibiotic therapy for meningococcal meningitis.
Conclusions
1) Chronic bacterial meningitis may present highly atypically, particularly in the older adult. 2) There may be an absent or reduced febrile response, without a rise in inflammatory markers, despite a very unwell patient. 3) Early lumbar puncture is to be encouraged as it is essential to confirm the diagnosis.4) Despite a delayed diagnosis appropriate antibiotic therapy can still lead to a good outcome.
doi:10.1186/1471-2296-5-21
PMCID: PMC524513  PMID: 15469610
16.  Age-Specific Reference Values for Cerebrospinal Fluid Protein Concentration in Neonates and Young Infants 
Background
Cerebrospinal fluid (CSF) protein values decline over the first few months of life as the infant's blood-CSF barrier matures. However, published studies differ in the reported rate, timing, and magnitude of this decline.
Objective
To quantify the age-related changes in CSF protein concentration and to determine accurate, age-specific reference values for neonates and young infants.
Design, Setting and Patients
This cross-sectional study included infants age 56 days or younger who had a lumbar puncture performed in the emergency department of an urban tertiary care children's hospital between January 1, 2005 and June 30, 2007. Infants with conditions associated with elevated CSF protein concentrations, including traumatic lumbar puncture and bacterial or viral meningitis, were excluded.
Results
Of 1,064 infants undergoing lumbar puncture, 375 (35%) met inclusion criteria. The median CSF protein value was 58 mg/dL (interquartile range: 48–72 mg/dL). In linear regression, the CSF protein concentration decreased 6.8% (95% confidence interval: 5.4%–8.1%; p<0.001) with each 1 week increase in age. The 95th percentile values were 115 mg/dL for infants ≤28 days and 89 mg/dL for infants 29–56 days. The 95th percentile values by age category were as follows: ages 0–14 days, 132 mg/dL; ages 15–28 days, 100 mg/dL; ages 29–42 days, 89 mg/dL; and ages 43–56 days, 83 mg/dL.
Conclusions
We quantify the age-related decline in CSF protein concentration among infants 56 days of age and younger and provide age-specific reference values. The values reported here represent the largest series to-date for this age group.
doi:10.1002/jhm.711
PMCID: PMC2978786  PMID: 20629018
cerebrospinal fluid; infant, newborn; reference values; lumbar puncture
17.  Scrub Typhus Meningitis in South India — A Retrospective Study 
PLoS ONE  2013;8(6):e66595.
Background
Scrub typhus is prevalent in India although definite statistics are not available. There has been only one study on scrub typhus meningitis 20 years ago. Most reports of meningitis/meningoencephalitis in scrub typhus are case reports
Methods
A retrospective study done in Pondicherry to extract cases of scrub typhus admitted to hospital between February 2011 and January 2012. Diagnosis was by a combination of any one of the following in a patient with an acute febrile illness- a positive scrub IgM ELISA, Weil-Felix test, and an eschar. Lumbar puncture was performed in patients with headache, nuchal rigidity, altered sensorium or cranial nerve deficits.
Results
Sixty five cases of scrub typhus were found, and 17 (17/65) had meningitis. There were 33 males and 32 females. Thirteen had an eschar. Median cerebrospinal fluid (CSF) cell count, lymphocyte percentage, CSF protein, CSF glucose/blood glucose, CSF ADA were 54 cells/µL, 98%, 88 mg/dL, 0.622 and 3.5 U/mL respectively. Computed tomography was normal in patients with altered sensorium and cranial nerve deficits. Patients with meningitis had lesser respiratory symptoms and signs and higher urea levels. All patients had received doxycycline except one who additionally received chloramphenicol.
Conclusion
Meningitis in scrub typhus is mild with quick and complete recovery. Clinical features and CSF findings can mimic tuberculous meningitis, except for ADA levels. In the Indian context where both scrub typhus and tuberculosis are endemic, ADA and scrub IgM may be helpful in identifying patients with scrub meningitis and in avoiding prolonged empirical antituberculous therapy in cases of lymphocytic meningitis.
doi:10.1371/journal.pone.0066595
PMCID: PMC3682970  PMID: 23799119
18.  Frequency of Severe Malaria and Invasive Bacterial Infections among Children Admitted to a Rural Hospital in Burkina Faso 
PLoS ONE  2014;9(2):e89103.
Background
Although severe malaria is an important cause of mortality among children in Burkina Faso, data on community-acquired invasive bacterial infections (IBI, bacteremia and meningitis) are lacking, as well as data on the involved pathogens and their antibiotic resistance rates.
Methods
The present study was conducted in a rural hospital and health center in Burkina Faso, in a seasonal malaria transmission area. Hospitalized children (<15 years) presenting with T≥38.0°C and/or signs of severe illness were enrolled upon admission. Malaria diagnosis and blood culture were performed for all participants, lumbar puncture when clinically indicated. We assessed the frequency of severe malaria (microscopically confirmed, according to World Health Organization definitions) and IBI, and the species distribution and antibiotic resistance of the bacterial pathogens causing IBI.
Results
From July 2012 to July 2013, a total of 711 patients were included. Severe malaria was diagnosed in 292 (41.1%) children, including 8 (2.7%) with IBI co-infection. IBI was demonstrated in 67 (9.7%) children (bacteremia, n = 63; meningitis, n = 6), 8 (11.8%) were co-infected with malaria. Non-Typhoid Salmonella spp. (NTS) was the predominant isolate from blood culture (32.8%), followed by Salmonella Typhi (18.8%), Streptococcus pneumoniae (18.8%) and Escherichia coli (12.5%). High antibiotic resistance rates to first line antibiotics were observed, particularly among Gram-negative pathogens. In addition, decreased ciprofloxacin susceptibility and extended-spectrum beta lactamase (ESBL) production was reported for one NTS isolate each. ESBL production was observed in 3/8 E. coli isolates. In-hospital mortality was 8.2% and case-fatality rates for IBI (23.4%) were significantly higher compared to severe malaria (6.8%, p<0.001).
Conclusions
Although severe malaria was the main cause of illness, IBI were not uncommon and had higher case-fatality rates. The high frequency, antibiotic resistance rates and mortality rates of community acquired IBI require improvement in hygiene, better diagnostic methods and revision of current treatment guidelines.
doi:10.1371/journal.pone.0089103
PMCID: PMC3925230  PMID: 24551225
19.  Effect of the introduction of a lumbar‐puncture sticker and teaching manikin on junior staff documentation and performance of paediatric lumbar punctures 
Quality & Safety in Health Care  2006;15(5):325-328.
Background
Performing a lumbar puncture in an unwell child can cause anxiety in both the parent and the junior doctor. There is increasing evidence of post‐lumbar‐puncture complications in this age group.
Aims
To improve the documentation, consent for and technical performance of paediatric lumbar punctures to 100% of the required standard within 3 months.
Setting
The paediatric emergency department of a the Royal North Shore Hospital (University of Sydney, Sydney, Australia).
Participants
Paediatric emergency staff, including residents, registrars and consultants.
Methods
Medical records of 40 consecutive children who had undergone a lumbar puncture in the 6 months before the introduction of the lumbar‐puncture proforma were reviewed. After introduction of the proforma, the records of 25 consecutive patients were reviewed to assess changes in the outcome measures. Before introduction of the proforma, junior medical staff were instructed in the procedure using specialised lumbar puncture manikins (Baby Stap; Laerdel, USA).
Results
Before introduction of the proforma, the median number of documented indicators was 4, out of a maximum of 12. There was almost no documentation of parental consent, patient complications and analgesia. Introduction of the proforma resulted in a highly marked increase to a median of 12 documented indicators per patient (p<0.01, 95% confidence interval 6 to 8).
Conclusions
The introduction of a lumbar‐puncture proforma and formal teaching sessions using a paediatric manikin led to a marked improvement in the documentation of paediatric lumbar‐punctures. Lumbar‐punctures can be performed only by accredited medical officers who have achieved competency on the lumbar‐puncture teaching manikin.
doi:10.1136/qshc.2005.013995
PMCID: PMC2565814  PMID: 17074867
20.  Investigation of subarachnoid haemorrhage: Does the buck stop with CT?  
Journal of Medicine and Life  2010;3(3):338-342.
Background and Aim: In patients suspected of having a subarachnoid haemorrhage (SAH), a normal CT should be followed by lumbar puncture (LP) to detect xanthochromia. We studied the practice of performing a LP following a normal CT in patients with a clinical suspicion of SAH in a District General Hospital. We aimed to assess whether patients were being fully investigated for SAH and whether standards were being met.
Methods: This was a prospective study aiming to improve the patient's care by implementing the best practice. We initially recorded CT and LP results of patients with suspected SAH (phase 1) and presented the results to the referring clinicians. After a period of time, data was re–collected to study any change in practice (phase 2).
Results: In phase 1, 36 of 61 patients (59.0%) with a normal CT had a subsequent LP compared to 67/104 (64.4%) in the second phase (p=0.51). In the first phase, xanthochromia was detected in 1 of 36 patients (2.8%) who had a LP following a normal CT, compared to 1 of 67 patients (1.5%) in the second phase (p=1.0).
Conclusion: Approximately a third of patients with symptoms of SAH in both study periods did not undergo LP following a normal CT scan. This is an important finding, as it is known that a normal CT does not exclude the diagnosis of SAH and by not proceeding to LP, patients have not been fully investigated for a SAH.
PMCID: PMC3019004  PMID: 20945826
Computed tomography; Lumbar puncture
21.  Ictal asystole secondary to suspected herpes simplex encephalitis: a case report 
Cases Journal  2009;2:9378.
Herpes simplex virus is a leading cause of sporadic encephalitis. While seizures are a common feature of Herpes simplex virus encephalitis, and periods of asystole have been reported in Herpes simplex virus patients, there have been no prior reports of ictal asystole secondary to such an infection.
This case report describes a 33 year old, previously healthy, gentleman of Malaysian descent, with new onset seizures resulting in a twenty-one second period of ictal asystole. In hospital the patient developed focal neurological symptoms. A diagnosis of Herpes simplex virus encephalitis was made, although this diagnosis was not confirmed by lumbar puncture, magnetic resonance imaging or biopsy.
Literature is reviewed regarding ictal asystole as well as clinical features and cardiac complications of Herpes simplex virus encephalitis. Given the link between ictal asystole and Herpes simplex virus encephalitis, cardiac monitoring would be recommended for Herpes simplex virus encephalitis patients having seizures. The use of anticonvulsants with cardiac side effects should be carefully considered.
doi:10.1186/1757-1626-2-9378
PMCID: PMC2805652  PMID: 20069069
22.  Evaluation of pre lumbar puncture position on post lumbar puncture headache 
BACKGROUND:
The most common complication of lumbar puncture (LP) occurring in over thirty percent of patients is headache. The position after lumbar puncture, needle type and size, and volume of the extracted cerebrospinal fluid (CSF) have been evaluated as contributory factors in occurrence of post lumbar puncture headache (PLPH), but the position before lumbar puncture has not been evaluated.
METHODS:
The occurrence of post lumbar puncture headache was evaluated in 125 patients undergoing lumbar puncture, divided randomly into sitting and lateral decubitus groups in the following five days. Chi-square test was used for statistical analysis.
RESULTS:
Thirty eight patients (30.4%) reported headache after lumbar puncture in the two groups, and post lumbar puncture headache was significantly lower in the lateral decubitus position (p = 0.001). There was no significant difference between genders in the post lumbar puncture headache occurrence (p = 0.767).
CONCLUSIONS:
Lumbar puncture in sitting position could produce more post lumbar puncture headache in comparison with lateral decubitus position.
PMCID: PMC3214334  PMID: 22091245
Post-Dural Puncture Headache; Spinal Puncture; Postoperative Complications
23.  Substance P concentration and history of headache in relation to postlumbar puncture headache: towards prevention. 
Medical treatment of postlumbar puncture headache (post-LP HA) is often difficult and ineffective. Prevention would be preferable to more invasive procedures, including blood patch. The aim was to determine the incidence of post-LP HA in two suspected high risk groups compared with the general outpatient population. Based on previous research, it was hypothesised that a low substance P concentration, or a history of chronic headache, or both would be associated with a higher risk of post-LP HA. A total of 310 randomly selected patients undergoing diagnostic lumbar puncture in the outpatient neurology clinic over 30 consecutive months were studied. Follow up was by headache questionnaire or phone survey after diagnostic lumbar puncture. Substance P was measured by radioimmunoassay on a subset of 102 samples of CSF. The overall incidence of post-LP HA was 38%. Patients with a measured substance P value < 1.3 pg/ml were three times as likely to have post-LP HA than those with a higher value. A history of chronic or recurrent headache was reported by 57% of those who developed post-LP HA. This group was also three times as likely to experience post-LP HA as those who did not have chronic headaches.
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PMCID: PMC1073955  PMID: 8648338
24.  Meningococcal meningitis: an atypical case 
A case of meningococcal meningitis is described in a patient who had not received antibiotics before admission. Three lumbar punctures were performed over a seven-day period, but only the cerebrospinal fluid from the third yielded a positive culture. The importance of repeated lumbar punctures in patients with undiagnosed meningitis is emphasized.
PMCID: PMC1947812  PMID: 4213244
25.  Intracranial tumours during the first two years of life: presenting features. 
Archives of Disease in Childhood  1995;73(4):345-347.
Between 1979 and 1994, 21 children (nine females, 12 males) with intracranial tumours diagnosed before the age of 2 years (range 2-23 months) were treated at the University Hospital of Wales. The commonest presenting symptoms were vomiting (n = 9) and unsteadiness (n = 8); the commonest presenting sign was enlarged occipitofrontal circumference (> 97th centile in 16 and > 90th centile in a further two). In five cases with signs of raised intracranial pressure, meningitis was the clinical diagnosis, and a lumbar puncture was performed. For cases with long delays in diagnosis, multiple other disorders had been considered and the significance of head enlargement had not been recognised. In very early childhood, intracranial tumours are uncommon and can mimic other disorders, especially meningitis. Early neuroimaging is advised when a child presents with recent onset of neurological symptoms and a disproportionately large head.
PMCID: PMC1511347  PMID: 7492201

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