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Spinal intradural empyema: The mystery behind a difficult lumbar puncture

Chan KJ, Nawawi O, Fong CY

Pediatr Int, 2023;65(1):e15649.
PMID: 37804048 DOI: 10.1111/ped.15649
Matched MeSH terms: Spinal Puncture*
Fulltext Epidural blood patch for post dural puncture headache

Vijayan R, Chan L

Med J Malaysia, 1995 Jun;50(2):196-7.
PMID: 7565198
Matched MeSH terms: Spinal Puncture/adverse effects*
Fulltext Lumbar puncture refusal in febrile convulsion

Ling SG, Boey CC

Singapore Med J, 2000 Oct;41(10):485-8.
PMID: 11281439

A descriptive study was carried out on patients admitted for febrile convulsion over a two-year period to determine rate of lumbar puncture (LP) refusal, factors associated with LP refusal and outcome of such patients. From 77 patients indicated and requested for LP, 19 (25%) patients refused the procedure. Refusal of LP was significantly more common among the Malay ethnic group (p = 0.01) but not significantly associated with age,gender or whether the patient was admitted for a first or recurrent febrile convulsion. Half of the patients who refused LP had to be started empirically on antibiotics for meningitis. Patients who refused LP were also 8.5 times more likely to discharge themselves "at own risk" (AOR), compared to other patients with febrile convulsion (p = 0.004). In conclusion, LP refusal is a common problem in the local setting and is a hindrance to the proper management of patients with fever and seizure. Appropriate measures must be carried out to educate the public, particularly those from the Malay ethnic group on the safety and usefulness of the procedure. Reasons for patients discharging AOR following LP refusal also need to be addressed and problems rectified.

Matched MeSH terms: Spinal Puncture*
Comments on "The Value of the Optic Nerve Sheath Diameter (ONSD) in Predicting Postdural Puncture Headache (PDPH): A Prospective Observational Study"

Suresh V, Magoon R, Sethuraman RM

Pain Physician, 2023 May;26(3):E243-E244.
PMID: 37192253
Matched MeSH terms: Spinal Puncture
A case of spinal meningioma

Monteiro ES

Journal of the Malaya Branch of the British Medical Association, 1940;3:410-4.

Matched MeSH terms: Spinal Puncture
Accurate prediction of the needle depth required for successful lumbar puncture

Chong SY, Chong LA, Ariffin H

Am J Emerg Med, 2010 Jun;28(5):603-6.
PMID: 20579557 DOI: 10.1016/j.ajem.2009.02.006

The aim of this study is to formulate an accurate estimate of the spinal needle depth for a successful lumbar puncture in pediatric patients.

Matched MeSH terms: Spinal Puncture/methods*
Fulltext Incidence of postdural puncture headache. A prospective study of 101 spinal anaesthetics in orthopaedic patients

Chan L, Delilkan AE

Med J Malaysia, 1992 Mar;47(1):20-6.
PMID: 1387444

Spinal anaesthesia was performed on 101 patients with a 25-Gauge (0.52 mm) needle. We found a 13.9% overall incidence of postdural puncture headache (PDPH) in an orthopaedic population whose mean age was 33.6 years. This incidence is too high and an alternative technique may be needed.

Matched MeSH terms: Spinal Puncture/adverse effects*
Fulltext Parents' views of lumbar puncture in children with febrile seizures

Deng CT, Zulkifli HI, Azizi BH

Med J Malaysia, 1994 Sep;49(3):263-8.
PMID: 7845277

A study was carried out to ascertain the views of parents regarding the performance of lumbar punctures on their children admitted for febrile seizures. One hundred and seventeen (117) children with febrile seizures were recruited over nine months. Either one of the parents was interviewed a day after admission. In most cases, this was usually the mother. The ethnic groups of the patients were Malays (62.4%), Indians (26.5%), Chinese (8.5%) and others (2.6%). Lumbar punctures were requested by the doctor in attendance in only 28 (23.9%) patients This showed that the rate of request for lumbar punctures in febrile seizures was low. Parents of eight of them refused. The main reasons for the refusal were: fears that the child might be paralysed, advice from relatives and fear that the child might die from the procedure, or might find it too painful. All the parents who refused were Malays. A lumbar puncture was also more likely to be refused in a girl. Those who consented to lumbar puncture did so because they wanted the doctor to get to the diagnosis. Another reason given was that it might be therapeutic. Parents whose children did not require a lumbar puncture also thought that lumbar puncture may cause paralysis. The main sources of information on lumbar punctures for the parents were their relatives and/or friends. In only 85% of the cases were the reasons for the lumbar puncture explained to the parent. In 71.4% of the time the explanation was done by the medical officer, and in only 4.8% of the time was the consultant involved.(ABSTRACT TRUNCATED AT 250 WORDS)

Matched MeSH terms: Spinal Puncture/psychology*
Fulltext A rare case of idiopathic intracranial hypertension in prepubertal age

Nurul Najieha Amir, Nor Fadhilah Mohamad, Mimiwati Zahari, Choo May May

Malaysian Journal of Medicine and Health Sciences, 2020;16(3):331-333.
MyJurnal

A 2-year-old girl who was under genetic follow up for developmental delay and dysmorphism was accidentally found to have bilateral optic disc swelling during screening examination. She showed response to optokinetic drum examination and the anterior segment examination was unremarkable. Optic disc swellings were seen in both eyes. Lumbar puncture shows high opening pressure of 50 cm H2O with unremarkable CSF analysis. MRI of brain was done and showed features in keeping with mild cerebral atrophy, with no evidence of hydrocephalus or space oc- cupying lesion. She was diagnosed with idiopathic intracranial hypertension and oral acetazolamide 125mg bd was commenced. However, papilloedema persist despite medical therapy. Ventriculoperitonel shunt was inserted to re- duce the csf pressure. This case report highlights the importance of considering idiopathic intracranial hypertension as a cause of optic disc swelling in pre-pubertal children because delay in diagnosis and treatment may permanently affect visual function especially in children.

Matched MeSH terms: Spinal Puncture
Fulltext Parkinsonism and brain MRI findings in a relapsed culture-proven salmonella typhi infection: a case report in Malaysia

Ng, Y.M., Cheng, J.T.

JUMMEC, 2016;19(1):1-2.
MyJurnal

Typhoid fever is a systemic infection caused by Salmonella typhi, which may be associated with extra-intestinal
complications. Neurological manifestations, particularly Parkinsonism, are rarely reported. We report a
17-year-old patient with relapsed culture-proven Salmonella typhi infection who developed septic shock and
subsequently Parkinsonism. Lumbar puncture revealed acellular cerebrospinal fluid with raised protein level.
Magnetic resonance imaging revealed cerebral petechial haemorrhages resulted from small vessels vasculitis.
His symptoms resolved spontaneously after 3 months.

Matched MeSH terms: Spinal Puncture
Consent for lumbar puncture -factors that influence the decision

Malik, A.S.

Malaysian Journal of Paediatrics and Child Health, 2000;12(1):35-41.
MyJurnal

Lumbar puncture (LP) is an important procedure both for diagnostic and therapeutic purposes. In Kelantan, Malaysia, on many occasions consent for this procedure is not granted by patients or guardians. The aim of this study was to find out the factors that influence the decision to grant or refuse the consent for LP. This was a cross-sectional study in which 86 parents (who agreed or refused to give consent for LP on their child) were interviewed by using a standard questionnaire. A scoring system was used to assess their knowledge about the purpose and technique of the procedure. Consent for LP was granted in 23 and refused in 27 children. The refusal rate was significantly higher when family members other than parents made the decision. The factors which did not play a statistically significant role in decision-making included: age of the child and parents; gender of the patient; number of children in the family; patient's birth order among the siblings; place of residence; monthly income of the family; parents' level of education; and number of days after admission when LP was requested. The factors that positively influenced the decision to give consent included knowledge about the purpose of LP and underlying disease. In order to receive positive consent for LP it is concluded that the parents/guardians and other family members who may influence the decision-making should be explained the role of LP in (1) making diagnosis and (2) choosing right antibiotics for treatment. They should also be informed about the side-effects of antibiotics, which may be used unnecessarily in unconfirmed cases of central nervous system infections.

Matched MeSH terms: Spinal Puncture
Which and what headache were we treating? Epidural blood patch for atypical headache following obstetric epidural anaesthesia

Chiu CL, Chan YK

Int J Obstet Anesth, 2000 Oct;9(4):273-5.
PMID: 15321079 DOI: 10.1054/ijoa.2000.0397

We present a case of headache following epidural anaesthesia for caesarean section. The patient did not exhibit the classical features of post dural puncture headache and the cause was uncertain. The headache was complicated by post partum seizure and a history of pregnancy-induced hypertension. A diagnostic lumbar puncture had to be done to exclude meningitis as she had a raised white blood count. An epidural blood patch performed 12 days post partum resolved the headache immediately.

Matched MeSH terms: Spinal Puncture
Fulltext A Retrospective Study on the First Cerebrospinal Fluid Taken from External Ventricular Drainage Insertion in Meningitis Patients with Hydrocephalus

Afifi AM, Abdullah JM, Siregar JA, Idris Z

Malays J Med Sci, 2019 Sep;26(5):64-73.
PMID: 31728119 MyJurnal DOI: 10.21315/mjms2019.26.5.6

Background: Ventriculoperitoneal (VP) shunting is a permanent form of cerebrospinal fluid (CSF) diversion that can be performed for hydrocephalus. Sterility of the CSF is an important prerequisite for permanent shunt placement. It has been hypothesised that in early stage of meningitis, ventricular CSF remains sterile. A study is conducted on the first CSF sample taken from patients suspected to have meningitic hydrocephalus.
Method: A retrospective review case records of patients who had undergone external ventricular drainage (EVD) for suspected meningitic hydropcephalus in Hospital Sultanah Aminah Johor Bahru (HSAJB), Johor, Malaysia.
Results: Fifty-one cases were analysed. Mean age of patients was 37.27 years old, with 64.7% of them was male. Univariate analysis revealed that the main parameters to determine CSF sterility were CSF glucose (95% CI, 0.852, 10.290, P = 0.001), CSF protein (CI 95%, 0.722, 14.898, P < 0.001), CSF gram stain (95% CI, 16.437, 0.877, P < 0.001 ) and CSF appearance ( 0.611, 6.362, P = 0.012). Multivariate analysis had proven that gram stain was the main parameter in the CSF analysis (CI 95%, 16.437, 0.029, P = 0.016). No significant differences in CSF results were observed from EVD and lumbar puncture.
Conclusion: The most significant parameter in CSF to determine infection was gram stain.

Matched MeSH terms: Spinal Puncture
Fulltext Meningococcal diseases: post men c vaccination era

Bazlin Ramly

Malaysian Journal of Paediatrics and Child Health, 2019;23(2):36-44.
MyJurnal

Meningococcal Diseases: Post Men C Vaccination EraMalaysian Journal of Paediatrics and Child Health, Vol. 23 (2), December 2017: 36-44© 2017 MJPCH. All Rights Reserved.36ORIGINAL ARTICLEMENINGOCOCCAL DISEASES: POST MEN C VACCINATION ERABazlin RamlyPaediatric Department, Letterkenny University Hospital, Co Donegal, Ireland.AbstractIntroduction: Meningococcal infections are caused by Neisseria Meningitidis and they are manifested in a spectrum of disease in particular meningitis. There are different strains of this bacteria which are A, C, B, W and Y. Mortality rates are from 5-15% with 10-15% suffering permanent disability. After the introduction of Men C vaccination in the year 2000, the incidences of meningitis caused by both Neisseria Meningitidis Serotype C and Serotype B have significantly reduced. Methods: A retrospective study of children whomlumbar puncture was performed with the preliminary diagnosis of meningococcal disease/ meningitis. Total numbers of children were 30 after excluding neonates, those with non-infectious diagnosis and failed lumbar puncture. Symptoms, signs and investigations results were collected in a data collection sheet using the documented data from the patients’ chart. Results: Five children had positive results in either the cultures or the PCR samples sent. None of these children had Serotype C. Three children had Serotype B and 2 others were Serotype W135. Conclusions: There were presence of Nisseria Meningitidis Serotype B and Serotype W135 when blood and cerebrospinal fluid samples were sent. It shows how significant is the value of lumbar puncture to be done to secure a definite diagnosis of meningitis. The preventive strategy to include Men B vaccination in the national vaccination schedule is definite so that death and morbidity can be reduced.

Matched MeSH terms: Spinal Puncture
Fulltext Paddy, piggy and Japanese encephalitis in Kerian – a case series

Rosilawati A. R., Mohd Zamri M. A.

Malaysian Journal of Medicine and Health Sciences, 2019;15(106):40-40.
MyJurnal

Introduction: Japanese encephalitis (JE) is a vector-borne zoonotic disease caused by the Japanese encephalitis virus (JEV). Paddy fields are high risk area for JEV transmission due the presence of Culex tritaeniorhynchus as vector and wild boar as an amplifier host. Methods: We presented case reports for three patients infected with JEV residing in paddy field area from 2015 to 2018 in Kerian, Perak; illustrating the symptoms and epidemiology trend of the dis-ease. Results: All three cases live next to paddy field and were exposed during peak biting hours. They presented with fever and altered consciousness. IV Acylovir was started as one of the treatments and all had lumbar puncture for CSF testing. Two cases (adult) were confirmed JE after they had passed away. Two cases occurred during fasting month where food wastes were abundance. The source of infection was probably from wild boars that came out at night to hunt for food. Presence of C. tritaeniorhynchus was demonstrated as the main vector in these areas. Conclusion: JE has no cure and human vaccination is the main prevention method. At the moment, vector control, environmental management, chemical control and personal protection are the main mitigation strategies for this area. Further study on JEV and wild board in Kerian will be most beneficial.

Matched MeSH terms: Spinal Puncture
Tuberculous meningitis: diagnostic and management pitfalls

Khairul Azman Mohd. Khalid, Hussain Imam Mohd Ismail, Mohd Sham Kasim

Malaysian Journal of Child Health, 1992;4(1):16-19.
MyJurnal

The diagnosis of tuberculous meningitis (TBM) demands a high index of suspicion. The prognosis depends on the stage of the disease the diagnosis is made and how early the treatment is instituted. The outcome of the disease is very poor when the diagnosis and treatment are late. This is what happened to this child, a 7-year-old Malay girl who presented at stage III TBM. The diagnosis was confirmed by a positive culture of M. tuberculosis from the cerebrospinal fluid (CSF). The delay in the diagnosis in this child had catastrophic consequences. She had hydrocephalus at presentation; however ventricular drainage was not done because parental consent was not obtained. She was started on acetazolamide and frusemide, and daily lumbar puncture in an attempt to reduce the raised intracranial pressure (ICP) in addition to anti-tuberculous chemotherapy. However when she showed no improvement, an external lumbar drain was inserted. The CSF was checked daily and the level of protein and glucose became normal after 6 weeks. The CT scan showed improvement of the hydrocephalus. However, the girl remained severely disabled after treatment and had to be fed via nasogastric tube and needed constant nursing care.

Matched MeSH terms: Spinal Puncture
Coma and consciousness

Black W, Arumugasamy N

Med J Malaya, 1971 Jun;25(4):241-9.
PMID: 4261293
Matched MeSH terms: Spinal Puncture
Talaromyces (Penicillium) species infection in the central nervous system

Chuah CH, Ong YC, Kong BH, Woo YY, Wong PS, Leong KN, et al.

J R Coll Physicians Edinb, 2020 Jun;50(2):138-140.
PMID: 32568283 DOI: 10.4997/JRCPE.2020.211

Talaromycosis typically occurs as an opportunistic infection among immunocompromised individuals. Infection caused by species other than T. marneffei is uncommon. While most reported cases describe infection in the lungs, we report an extremely rare intracranial Talaromyces species infection. This 61-year-old with end-stage renal disease who was unwell for the previous two months, presented with fever and worsening confusion lasting for three days. Lumbar puncture was suggestive of meningitis. Cerebrospinal fluid (CSF) culture was later confirmed to be Penicillium chrysogenum. The patient was co-infected with Group B Streptococcus sepsis. He improved with amphotericin B and ceftriaxone and was discharged with oral itraconazole for four weeks. However, he died of unknown causes two weeks later at home. Talaromyces species infection in the central nervous system is uncommon. This case highlighted a rare but life-threatening fungal meningitis. Among the four reported cases worldwide, none of the patients survived.

Matched MeSH terms: Spinal Puncture
Fulltext Leptomeningeal Carcinomatosis With Optic Nerve Metastasis Secondary to Breast Cancer

Chew C, Wan Hitam WH, Ahmad Tajudin LS

Cureus, 2021 Mar 31;13(3):e14200.
PMID: 33936906 DOI: 10.7759/cureus.14200

Leptomeningeal carcinomatosis (LC) and optic nerve metastasis are uncommon occurrences in breast cancer. We report a rare case of LC with optic nerve infiltration secondary to breast cancer. A 45-year-old lady who was a known case of treated right breast carcinoma six years ago presented with a blurring of vision in both eyes, floaters, and diplopia for one month. She also had recurrent attacks of seizure-like episodes, headache, and vomiting. Examination revealed high blood pressure with tachycardia. Her right eye visual acuity was counting fingers at two feet and 6/36 in the left eye. She had right abducens nerve palsy. Fundoscopy showed bilateral optic disc swelling with pre-retinal, flame-shaped haemorrhages and macular oedema. CT scan of brain and orbit was normal. She was admitted for further investigations. While in the ward, her vision deteriorated further. Her visual acuity in both eyes was at the level of no perception to light. She also developed bilateral abducens nerve palsy and right facial nerve palsy. Subsequently, she started having bilateral hearing loss. There were few episodes of fluctuations in conscious awareness. MRI brain showed mild hydrocephalus. Both optic nerves were thickened and enhanced on T1-weighted and post-gadolinium. Lumbar puncture was performed. There was high opening pressure. Cerebrospinal fluid cytology showed the presence of malignant cells. Family members opted for palliative care in view of poor prognosis. Unfortunately, she succumbed after a month's stay in hospital. Diagnosis of LC and optic nerve infiltration presents a formidable challenge to clinicians especially in the early stages where neuroimaging appears normal and lumbar puncture has high false negatives. Multiple high-volume taps are advised if clinical suspicion of LC is high.

Matched MeSH terms: Spinal Puncture
Current trends in morbidity and mortality of children in Malaysia

Lin, Hai Peng, Mohd Sham Kasim

Malaysian Journal of Child Health, 1997;9(2):104-132.
MyJurnal

Malaysia is a rapidly developing country with a very young population, about 36% of which are below the age of 15 years. The standard of child health has improved greatly. However, there are great changes in the morbidity and mortality patterns of childhood diseases relating mainly to an improved standard of living; availability of safe water supply and adequate sanitary latrines; a higher literacy rate; rapid industrialisation and urban migration. The infant mortality rate has droppedfrom 50.1 per 1,000 livebirths in 1986 to 10.4 in 1995, and similar trends apply also to neonatal, perinatal and toddler mortality rates. Nevertheless, current major child health problems are those relating to events in the perinatal period and to infections. Despite improvements in the standard of neonatal care with the use ofhigh technology, the commonest cause of certified deaths still occur in the neonatal period. A rapid and inexpensive screening test for G6PD deficiency, a disease present in 2-3% of the population, is now widely available and, together with the use of phototherapy is largely responsible for the declining incidence of kernicterus in the country. Infections remain an important cause of morbidity and mortality although their patterns have changed. The very high (>95%) WHO-EPI-vaccines coverage rate is linked to the great reduction in the incidence of diphtheria, pertussis, tetanus, poliomyelitis and measles. Childhood tuberculosis is less common now, with about 250 - 300 reported cases per year and TB meningitis is rare with about 30-40 reported cases/year. The hepatitis B carrier rate is high (5%) and the introduction of routine newborn hepatitis B vaccination in 1989 is expected to have a positive impact as is the immunisation of young girls against rubella introduced in 1985 in reducing the incidence of congenital rubella syndrome. The incidence of malaria has declined but remains prevalent in the interiors of PeninsularMalaysia and in Sabah and Sarawak. Filariasis is largely under control. Unfortunately, despite great efforts at mosquito control, dengue virus infection remains a major problem with thousands of cases reported every year. Children are most susceptible to dengue haemorrhagic fever with many dying from the shock syndrome. The incidence of acute gastroenteritis has also dropped with most cases being due to a viral aetiology. Acute respiratory infections, mostly viral in origin, account for most attendances at paediatric outpatient services. Although staphylococcal and streptococcal impetigo and pneumonia are common, the incidence of streptococcal related diseases like rheumatic fever and acute glomendonephritis is rapidly declining. The nutritional status of children has improved in tandem with the rise in the standard of living, but subclinical malnutrition is prevalent, particularly among urban squatters and the rural poor. There is a disturbing decline in breastfeeding among urban working mothers. Poor weaning practices and food habits are responsible for the common occurrence of nutritional anaemia (5%) among infants and young children. Greater prosperity, rapid industrialisation and urbanisation have resulted in changes in the childhood disease pattern where non-communicable diseases assume greater importance as the problems of malnutrition and infection are gradually overcome. Road traffic accidents are a major killer and home accidents, largely preventable, are an important cause of morbidity and mortality. Childhood cancer, with about 550 new cases a year, is an important cause of death beyond infancy. Major congenital malformations, with a 1% prevalence rate, cause much ill-health. Thalassaemia is a particularly common genetic disease with fl thalassaemia gene frequency of about 5%. The prevalence of asthma is increasing, with a rate of 13.9% in the Kiang Valley but the prevalence of asthma-related symptoms is much higher. Physical, sexual child abuse and neglect, abandoned babies, substance abuse are but signs of stress of modern city living and peoples inability to cope with it. Although the general standard of child health has greatly improved, there are several states where it is still not satisfactory. In Sabah where there is a large illegal immigrant population, the infant mortality and infection rates are relatively high. In Kelantan and Trengganu, it is common for parents to refuse permission for a lumbar puncture required to treat meningitis. Other still deeply entrenched, culturally-related adverse health practices include : a fatalistic attitude to illness; a preference for traditional practitioners of medicine resulting in late treatment; and 'doctor-hopping' with unrealistic expectations of 'instant cure'. Childhood illnesses that are uncommon in Malaysia include: cystic fibrosis, coeliac disease, ulcerative colitis, Crohns disease, Sudden Infant Death Syndrome, Encopresis, enuresis and epiglottitis due to Haemophilus Influen:ae.

Matched MeSH terms: Spinal Puncture

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