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Response

Michael J Griffiths, Fiona McGill and Tom Solomon
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DOI: https://doi.org/10.7861/clinmedicine.18-4-352
Clin Med August 2018
Michael J Griffiths
Alder Hey Children's NHS Foundation Trust, Liverpool, UK
Institute of Infection and Global Health, University of Liverpool, UK
Roles: Honorary consultant in paediatric neurology, Senior clinical lecturer
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Fiona McGill
SpR in microbiology and infectious diseases, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
Institute of Infection and Global Health, University of Liverpool, UK
Roles: Clinical lecturer
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Tom Solomon
The Walton Centre NHS Foundation Trust, Liverpool, UK
Institute of Infection and Global Health, University of Liverpool, UK
Roles: Honorary consultant neurologist, Professor of neurological sciences
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We whole-heartedly agree that CSF parameters, including CSF lactate, can be useful adjunctive markers in helping distinguish bacterial from viral (or aseptic) meningitis.

As mentioned in our article, using a combination of routine clinical and CSF laboratory parameters (eg CSF glucose, protein and leucocyte count), has shown high accuracy in distinguishing bacterial from viral meningitis in adults and children.1,2

We agree that using CSF lactate, on its own (as the correspondents suggest), or in combination with other routine clinical parameters, can further assist clinicians in distinguishing bacterial from viral meningitis.

Reliance on single biomarkers can lead to inaccurate diagnosis. For example, CSF lactate has poor sensitivity (0.49) in identifying bacterial from viral meningitis among patients exposed to antibiotics, as shown in the article by Sakushima et al which you have referenced.3 Similarly, CSF lactate can be raised in patients with malignancy, severe hypoxia, or other brain abnormalities, including raised intracranial pressure, hydrocephalus or mitochondrial disorders.4–6

To our knowledge, there are limited studies on using CSF lactate in combination with other markers, but recent results suggest inclusion of CSF lactate can improve accuracy of the Bacterial Meningitis Score.7

In summary, we support the measurement and judicious interpretation of CSF lactate. We also encourage further studies examining the diagnostic accuracy of CSF lactate in combination with other parameters to help distinguish bacterial from viral meningitis.

  • © Royal College of Physicians 2018. All rights reserved.

References

  1. ↵
    1. Spanos A
    , Jr Harrell FE, Durack DT. Differential diagnosis of acute meningitis. An analysis of the predictive value of initial observations. JAMA 1989;262:2700–7.
    OpenUrlCrossRefPubMed
  2. ↵
    1. Nigrovic LE
    , Kuppermann N, Macias CG, et al. Clinical prediction rule for identifying children with cerebrospinal fluid pleocytosis at very low risk of bacterial meningitis. JAMA 2007;297:52–60.
    OpenUrlCrossRefPubMed
  3. ↵
    1. Sakushima K
    , Hayashino Y, Kawaguchi T, Jackson JL, Fukuhara S. Diagnostic accuracy of cerebrospinal fluid lactate for differentiating bacterial meningitis from aseptic meningitis: a meta-analysis. J Infect 2011;62:255–62.
    OpenUrlCrossRefPubMed
  4. ↵
    1. Djukic M
    , Trimmel R, Nagel I, et al. Cerebrospinal fluid abnormalities in meningeosis neoplastica: a retrospective 12-year analysis. Fluids Barriers CNS 2017;14:7–8.
    OpenUrl
  5. ↵
    1. Rutledge J
    , Benjamin D, Hood L, Smith A. Is the CSF lactate ­measurement useful in the management of children with suspected bacterial meningitis? J Pediatr 1981;98:20–4.
    OpenUrlCrossRefPubMed
  6. ↵
    1. Magner M
    , Szentiványi K, Svandová I, et al. Elevated CSF-lactate is a reliable marker of mitochondrial disorders in children even after brief seizures. Eur J Paediatr Neurol 2011;15:1011.
    OpenUrl
  7. ↵
    1. Pires FR
    , Franco ACBF, Gilio AE, Troster EJ. Use of score and cerebrospinal final fluid lactate dosage in differential diagnosis of bacterial and aseptic meningitis. Rev Paul Pediatr 2017;35:369–74.
    OpenUrl
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Response
Michael J Griffiths, Fiona McGill, Tom Solomon
Clinical Medicine Aug 2018, 18 (4) 352; DOI: 10.7861/clinmedicine.18-4-352

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Response
Michael J Griffiths, Fiona McGill, Tom Solomon
Clinical Medicine Aug 2018, 18 (4) 352; DOI: 10.7861/clinmedicine.18-4-352
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