Differential Diagnosis for High Protein, Low Glucose, Lymphocytic Predominance CSF with Normal Opening Pressure

• Single Most Likely Diagnosis
  • Multiple Sclerosis (MS): Although MS typically presents with normal glucose levels in the CSF, the combination of high protein, lymphocytic predominance, and normal opening pressure could be seen in some cases, especially during an acute relapse. However, oligoclonal bands, which are more specific for MS, are not mentioned here.
• Other Likely Diagnoses
  • Neurosyphilis: This condition can present with high protein and low glucose in the CSF, along with a lymphocytic predominance. The normal opening pressure does not rule out this diagnosis.
  • Lymphomatous Meningitis: Although more commonly associated with elevated opening pressure, lymphomatous meningitis can present with high protein, low glucose, and lymphocytic predominance in the CSF.
  • Cryptococcal Meningitis (in its early stages or in immunocompetent patients): While typically associated with low glucose and high protein, the lymphocytic predominance might not be as pronounced as in other conditions. However, it's a consideration, especially if the patient is immunocompromised.
• Do Not Miss Diagnoses
  • Tuberculous Meningitis: This is a critical diagnosis not to miss due to its high morbidity and mortality if untreated. It can present with high protein, low glucose, and lymphocytic predominance in the CSF, even with normal opening pressure in early stages.
  • Subarachnoid Hemorrhage (SAH) with Vasospasm: Although SAH typically presents with blood in the CSF and elevated pressure, in some cases, especially if the hemorrhage is small or the patient is seen late after the event, the CSF might show high protein and low glucose with a lymphocytic response to the blood.
• Rare Diagnoses
  • Sarcoidosis: Neurosarcoidosis can involve the meninges and present with lymphocytic predominance, high protein, and low glucose in the CSF. However, it's less common than other diagnoses listed here.
  • Behçet's Disease: This condition can rarely involve the central nervous system and present with meningitis characterized by lymphocytic predominance, high protein, and low glucose in the CSF.
  • CNS Histoplasmosis: In immunocompromised patients, histoplasmosis can disseminate to the CNS and cause meningitis with similar CSF findings.