Corresponding author:
Dr. Alauldeen Alqasim
Email: aladdinalqasim@yahoo.com
Abstract: Lumbar puncture is a common medical procedure
especially in neurology and hematology patients. It is done mainly for
the diagnosis of meningitis, SAH, CNS leukemia and other neurological
disorders. Analysis usually includes biochemistry, Gram stain, culture,
cell count and morphology.
Key words: Hemophagocytosis, meningitis, CSF
Key Clinical Message: Hemophagocytosis is usually observed in
bone marrow. However, it can be an incidental finding in other body
fluids in severe infections like cerebrospinal fluid in case of
meningitis. This should alert the clinicians to rule out primary type of
hemophagocytic syndrome.
Case: A 39 year old patient had endoscopic trans-sphenoidal
drainage of a supra-sellar benign cystic lesion. Five weeks later, she
was presented with bacterial meningitis complicated by cavernous sinus
thrombosis. CSF analysis revealed negative viral screen, Gram positive
cocci and bacterial antigen test was positive for strptococcus
pnumoniae. Leukocytes=810/cumm(NR=0-10) and RBC=2000/cumm(NR=0). CSF
cytology showed a very large number of neutrophils in addition to many
monocytes and few plasma cells. What was striking is the prominent
hemophagocytic activity (Figures 1-4). This is usually observed in BM
aspirate of patients with primary or secondary HLH but a very unusual
phenomenon in CSF. This finding should alert the physicians to exclude
an underlying primary HLH. Her CBC results showed Hb=11g/l,
leukocytes=22.6*109/l (neutrophils=20.1
*109/l), plt=342*109/l. Fibrinogen =
5.4 g/l (NR= 1.7 - 3.6 g/l).
Meningococcal sepsis secondary to an underlying primary HLH has been
reported.1 Another study of 96 cases of primary HLH
found that CSF examinations showed abnormalities in 23 patients
(39.0%), of which 10 patients had elevated white blood cell counts and
13 patients had elevated protein contents. 2 The
patient did not fulfil the criteria of primary HLH.
Informed consent: The patient’s next of kin signed written
informed consent.
Conflict of interests: None declared.
Authors’ contribution: AMZ Alqasim wrote the draft and provided
images, R Kariyattil provided clinical care for the patient.