What are the treatment options for reducing pleocytosis in cerebrospinal fluid (CSF)?

Treatment Options for Reducing Pleocytosis in Cerebrospinal Fluid

Corticosteroids are the primary treatment for reducing cerebrospinal fluid (CSF) pleocytosis, with intrathecal dexamethasone (4 mg) being particularly effective for aseptic meningitis and chemotherapy-induced pleocytosis. 1

Causes of CSF Pleocytosis

CSF pleocytosis (elevated white blood cell count in cerebrospinal fluid) can result from various conditions:

• Infectious causes (61.4% of cases) - including bacterial, viral, fungal, and parasitic infections 2
• Non-infectious causes (38.6%) including:
  • Autoimmune/inflammatory conditions (21%) 3
  • Neoplastic diseases (16%) 3
  • Vascular conditions (9.7%) 2
  • Neurodegenerative disorders (7%) 2
  • Post-seizure states (up to 34% of patients with seizures) 4
  • Medication-induced (particularly chemotherapeutic agents) 1

Treatment Approaches Based on Etiology

1. Chemotherapy-Induced Pleocytosis

• Intrathecal corticosteroids: 4 mg intrathecal dexamethasone is recommended for prevention and treatment of aseptic meningitis caused by chemotherapeutic agents 1
• For methotrexate-induced myelopathy with pleocytosis:
  • High-dose folate metabolites may be beneficial 1
  • Steroids administered via lumbar route should be considered 1

2. Infectious Causes

Bacterial Meningitis

• Appropriate antibiotics based on suspected pathogen 1
• For Lyme disease with CSF pleocytosis:
  • Adults: Ceftriaxone 2g IV daily for 14-21 days 1
  • Children: Ceftriaxone 50-75 mg/kg/day (max 2g) IV daily 1
  • Alternatives: Cefotaxime or penicillin G 1

Viral Encephalitis/Meningitis

• Antiviral treatment (e.g., acyclovir for HSV) 1
• Supportive care 1
• CSF pleocytosis typically resolves with treatment of the underlying infection 1

Parasitic Causes (Eosinophilic Meningitis)

• Angiostrongylus cantonensis:

  • Corticosteroids (reduces severity and duration of headache) 1
  • Albendazole (15 mg/kg/day for 14 days) 1
  • Therapeutic lumbar punctures may be necessary 1

• Neuroschistosomiasis:

  • Dexamethasone 4 mg four times daily, reducing after 7 days, over 2-6 weeks 1
  • Followed by praziquantel 40 mg/kg twice daily for 5 days 1

• Toxocariasis (eosinophilic meningoencephalitis):

  • Corticosteroids plus albendazole 1

3. Autoimmune/Inflammatory Causes

• Systemic corticosteroids (prednisone or equivalent) 5
• Dose depends on severity but typically starts at 0.5-1 mg/kg/day 5
• Gradual taper to minimize risk of adrenal insufficiency 5
• Disease-modifying therapies based on specific autoimmune condition

4. Post-Seizure Pleocytosis

• Usually self-limiting and resolves spontaneously 4
• No specific treatment required for the pleocytosis itself 4
• Treatment of underlying seizure disorder is primary approach 4

5. Idiopathic CSF Pleocytosis

• In conditions like relapsing polychondritis, CSF pleocytosis may occur without infection 6
• Empiric antimicrobial therapy is not recommended in the absence of demonstrated infection 6
• Observation and monitoring may be sufficient 6

Special Considerations

• CSF pleocytosis during treatment for tuberculous meningitis may represent a paradoxical reaction rather than treatment failure 7

  • These changes typically resolve within a week without additional treatment 7
  • Continued anti-tuberculous therapy is recommended 7

• For chemotherapy-induced pleocytosis:

  • Consider temporary discontinuation of the offending agent if clinically feasible 1
  • Symptoms typically resolve spontaneously with supportive treatment 1

• For severe pleocytosis with neurological symptoms:

  • Control of blood pressure is crucial, especially with posterior reversible encephalopathy syndrome (PRES) 1
  • Antiepileptic treatment for seizures 1

Monitoring and Follow-up

• Serial lumbar punctures may be necessary to monitor response to treatment in severe cases 1
• CSF normalization typically correlates with clinical improvement 4
• The degree of pleocytosis can help distinguish between causes - infections typically present with higher cell counts (median 82 cells/μL) compared to autoimmune (11 cells/μL) or neoplastic diseases (19 cells/μL) 3