What is the initial management for a patient with new onset seizures and cerebrospinal fluid (CSF) findings of elevated neutrophils, normal glucose, and normal protein?

From the Guidelines

The initial management for a patient with new onset seizures and CSF findings of elevated neutrophils, normal glucose, and normal protein should focus on empiric treatment for bacterial meningitis, with immediate initiation of broad-spectrum antibiotics and seizure control measures. The patient's presentation with elevated neutrophils in the CSF is highly suggestive of an acute bacterial infection, despite the normal glucose and protein levels, which can sometimes be seen early in the disease course 1. Key considerations in the management include:

• Starting broad-spectrum antibiotics, such as a combination of vancomycin and a third-generation cephalosporin, to cover a wide range of potential pathogens
• Administering dexamethasone to reduce inflammation and potential neurological complications
• Using benzodiazepines for acute seizure management, followed by levetiracetam or phenytoin for ongoing seizure prophylaxis It is crucial to prioritize prompt treatment, as bacterial meningitis is life-threatening and can rapidly progress to increased intracranial pressure, cerebral edema, and permanent neurological damage. In terms of diagnostic workup, an MRI of the head is an important tool for identifying and characterizing focal causative lesions, assessing progression, and determining prognosis, as well as guiding treatment strategy 1. However, in the emergent setting, a CT scan may be quicker and more appropriate, with MRI to follow once the patient is stabilized. The use of intravenous contrast and specific MRI sequences, such as coronal T1-weighted and fluid-attenuated inversion recovery sequences, can help assess for hippocampal signal abnormality, atrophy, and loss of internal structure, as well as malformations of cortical development.

From the Research

Initial Management of New Onset Seizures with CSF Findings

The initial management of a patient with new onset seizures and cerebrospinal fluid (CSF) findings of elevated neutrophils, normal glucose, and normal protein involves a comprehensive approach to determine the underlying cause of the seizures.

• The presence of elevated neutrophils in the CSF may indicate an infectious or inflammatory process 2, 3.
• Normal glucose and protein levels in the CSF can help rule out certain conditions such as bacterial meningitis or subarachnoid hemorrhage 4.
• A thorough medical history, physical examination, and diagnostic tests such as electroencephalography (EEG), magnetic resonance imaging (MRI), and laboratory tests are essential to determine the etiology of the seizures 2, 3, 5.
• The management of new onset seizures with abnormal CSF findings should include a careful evaluation of the patient's clinical presentation, laboratory results, and imaging studies to guide further treatment and management 2, 3, 5.

Differential Diagnosis

The differential diagnosis for new onset seizures with elevated neutrophils in the CSF includes:

• Infectious causes such as meningitis or encephalitis 2, 3, 4
• Inflammatory causes such as autoimmune encephalitis 2, 3
• Other conditions such as cerebral vasculitis or neoplastic disorders 5
• It is essential to consider the patient's clinical presentation, medical history, and laboratory results when determining the underlying cause of the seizures 2, 3, 5.

Further Evaluation and Management

Further evaluation and management of the patient may involve:

• Additional laboratory tests such as CSF cultures, PCR, or serology to identify infectious or inflammatory causes 2, 3, 4
• Imaging studies such as MRI or CT scans to evaluate for structural abnormalities or inflammation 2, 3, 5
• Electroencephalography (EEG) to evaluate for seizure activity or encephalopathy 2, 3, 5
• Consultation with specialists such as neurologists, infectious disease specialists, or rheumatologists to guide further management and treatment 2, 3, 5.