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High TLC, CSF high counts with normal biochemistry



Preterm 32 wks born by NVD. No H/O leaking PV or fever in mother. TLC on day1 was 48000, on day 2 was 62000, on day 5 was 35000. Had about 75% neutrophils, normal platelets, 5% metamyelocytes. Started on Cefotaxime and Amikacin on day 1. LP done on day 4 of life showed cell count of 600, all lymphocytes, protein of 187, sugat of 63mg% ( Pre LP RBS 92 mg%). Would you think of starting Acyclovir or treat as bacterial meningitis. CSF HSV PCR later came out to be negative. LP repeated on day 7 of life showed no cells with protein of 127 and sugar of 96mg%.


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Interesting and a little challenging case!

High TLC is difficult to ignore but studies have shown that high TLC is not very sensitive/specific marker of neonatal sepsis (not as useful as leukopenia is). It would be useful to know serial inflammatory markers (CRP etc). Also, I wonder why CSF was done (symptomatic baby or part of routine sepsis work-up etc). What is CSF red cell count as that can change the CSF picture. Obviously herpes is ruled out as -ve PCR. It is interesting to see CSF white cells count (0) on day-7 in a preterm and I wonder if first CSF was blood stained.

To conclude, if we have other supportive evidence, then will treat as possible bacterial meningitis with 14 days of appropriate antibiotics - this is obviously a pragmatic approach.

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Whoever reads this blog (actually not a blog), kindly shift this discussion to forums. Lumbar puncture was done as part of sepsis work up. CSF had only 20,000 RBC. It cannot account for 600 cells in CSF. Never seen a CSF picture like this with increased cells and normal biochemistry in CSF and then all cells just vanishing (0 cell count) within one week of treatment.

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