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CSF Lactate

Bacterial/ Viral
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nofastingrequire

No Fasting Required

Details

Measures lactate in CSF.

₹1,110₹1,586

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CSF Lactate - Comprehensive Diagnostic Guide

  • Why is it done?
    • Measures lactate concentration in cerebrospinal fluid (CSF) to assess metabolic and neurological conditions affecting the central nervous system
    • Diagnose bacterial meningitis - elevated CSF lactate suggests bacterial infection rather than viral or aseptic meningitis
    • Evaluate suspected fungal or tuberculous meningitis and other CNS infections
    • Assess mitochondrial disorders and metabolic encephalopathies characterized by impaired aerobic metabolism
    • Evaluate hypoxic-ischemic encephalopathy and brain injury with compromised oxygen delivery
    • Investigate seizure disorders and status epilepticus with cellular energy depletion
    • Performed during lumbar puncture when meningitis or CNS infection is suspected, or when metabolic brain disorders are being investigated
  • Normal Range
    • Reference Range: 1.5 - 2.2 mmol/L (or 10-15 mg/dL)
    • Units of Measurement: mmol/L (millimoles per liter) or mg/dL (milligrams per deciliter)
    • Normal Result: Values within the reference range indicate adequate cerebral oxygenation, normal aerobic metabolism, and absence of significant CNS infection or metabolic compromise
    • Elevated (High) Result: Values >2.2 mmol/L suggest shift to anaerobic metabolism, CNS infection (particularly bacterial meningitis), or tissue hypoxia. Generally, lactate >4 mmol/L is considered significantly elevated
    • Interpretation Cutoffs: >4 mmol/L strongly suggests bacterial infection; 2.2-4 mmol/L may indicate viral, fungal infection or metabolic abnormality; borderline values (2.0-2.5 mmol/L) require correlation with clinical presentation and other CSF parameters
  • Interpretation
    • Markedly Elevated Lactate (>4 mmol/L): Indicates bacterial meningitis with high sensitivity (80-90%) and specificity. Anaerobic bacteria produce lactate causing CSF accumulation. Suggests urgent need for antibiotic therapy and aggressive treatment
    • Mildly to Moderately Elevated (2.2-4 mmol/L): May indicate viral meningitis, early bacterial infection, tuberculous meningitis, fungal meningitis, or metabolic disturbance. Requires correlation with glucose levels, protein levels, cell counts, and Gram stain to differentiate etiologies
    • Normal Range (1.5-2.2 mmol/L): Suggests absence of significant CNS infection or metabolic compromise. Renders bacterial meningitis less likely. If clinical suspicion remains high, repeat LP or advanced imaging may be warranted
    • Factors Affecting Results: Timing of sample (best within first 48 hours of symptoms); antibiotic therapy before LP may lower lactate; hemolysis from traumatic tap; delayed processing; seizures or cerebral hypoxia causing increased lactate; prematurity in neonates; underlying metabolic disorders
    • Complementary CSF Analysis: Compare with CSF glucose (low <40 mg/dL suggests bacterial/fungal), protein (elevated), WBC differential, Gram stain, and culture. CSF lactate/plasma lactate ratio >0.4 indicates CNS pathology. CSF glucose/plasma glucose ratio <0.4 supports bacterial infection
    • Clinical Significance Patterns: Bacterial meningitis typically shows: high lactate (>4), low glucose, high protein, elevated PMN count. Viral meningitis: normal or mildly elevated lactate, normal glucose, normal to mildly elevated protein, lymphocytic pleocytosis. Tuberculous: moderately elevated lactate, low glucose, very high protein
  • Associated Organs
    • Primary Organ Systems: Central nervous system (brain, spinal cord), meninges, cerebrospinal fluid compartment
    • Diseases Associated with Abnormal Results:
      • Bacterial meningitis (caused by Streptococcus pneumoniae, Neisseria meningitidis, Haemophilus influenzae, Listeria monocytogenes)
      • Tuberculous meningitis (Mycobacterium tuberculosis)
      • Fungal meningitis (Cryptococcus, Candida, Aspergillus species)
      • Viral meningitis and encephalitis (HSV, VZV, enterovirus, EBV, CMV)
      • Mitochondrial disorders (MELAS, MERRF) with impaired cerebral energy metabolism
      • Hypoxic-ischemic encephalopathy and perinatal brain injury
      • Status epilepticus and severe seizure disorders
      • Metabolic acidosis affecting CNS
      • CNS lymphoma and malignant infiltration
      • Hypoglycorrhachia conditions (low CSF glucose) with increased lactate
      • Cerebral vasculitis and inflammatory CNS disorders
    • Potential Complications/Risks of Abnormal Results:
      • Elevated lactate with bacterial meningitis can progress to bacteremia, sepsis, shock, and death if untreated or undertreated
      • Neurological sequelae including permanent hearing loss, cognitive impairment, and motor deficits from CNS infection
      • Cerebral edema and increased intracranial pressure from inflammatory response
      • Hydrocephalus and subdural empyema as complications of meningitis
      • Progression to severe metabolic derangement in mitochondrial or metabolic disorders
      • Long-term neurological sequelae from recurrent hypoxic episodes or persistent seizures
  • Follow-up Tests
    • Immediate Concurrent Tests:
      • CSF glucose and plasma glucose (calculate CSF/plasma ratio; ratio <0.4 suggests bacterial/fungal infection)
      • CSF protein level (elevated in meningitis; very high in TB meningitis)
      • CSF cell count and differential (PMN pleocytosis in bacterial, lymphocytic in viral/TB)
      • CSF Gram stain and culture (identifies causative organism)
      • Blood cultures and blood lactate levels
      • Procalcitonin (elevated in bacterial infection)
    • Follow-up Tests If Elevated Lactate:
      • Repeat lumbar puncture (24-48 hours) to assess response to treatment in bacterial meningitis
      • CSF PCR for viral pathogens (HSV, VZV, enterovirus, CMV) if viral meningitis suspected
      • CSF fungal cultures and cryptococcal antigen if fungal meningitis suspected
      • CSF TB culture and TB PCR for tuberculous meningitis evaluation
      • Brain MRI with contrast to assess for complications (subdural empyema, ventriculitis, brain abscess)
      • CT head to evaluate for increased intracranial pressure, hemorrhage, or mass effect
      • Metabolic panel, arterial blood gas, plasma lactate, and ammonia if metabolic disorder suspected
    • Advanced/Specialized Tests:
      • Metabolic testing (pyruvate, alanine, carnitine) if mitochondrial disorder suspected
      • Genetic testing for mitochondrial DNA mutations (MELAS, MERRF, other mitochondriopathies)
      • EEG (electroencephalography) for seizure evaluation or status epilepticus
      • Brain PET imaging for metabolic assessment in complex cases
      • Neuropsychological testing for assessment of cognitive sequelae
    • Monitoring Frequency:
      • Bacterial meningitis: Repeat LP at 24-48 hours if inadequate clinical response or complications suspected
      • Tuberculous meningitis: Follow-up LP at 4-8 weeks to assess treatment response
      • Metabolic disorders: Long-term monitoring with repeat CSF and plasma lactate measurements as clinically indicated
      • Post-acute phase: Neurological follow-up at 2-4 weeks and 8-12 weeks post-meningitis to assess for sequelae
  • Fasting Required?
    • Fasting Requirement: NO - Fasting is not required for CSF lactate measurement
    • Rationale: CSF is obtained via lumbar puncture and is not affected by oral intake. CSF lactate reflects CNS metabolism independent of peripheral glucose status, though plasma glucose should be measured simultaneously for interpretation
    • Patient Preparation Requirements:
      • Empty bladder before procedure to reduce discomfort during lumbar puncture
      • Obtain signed informed consent explaining risks (headache, infection, bleeding) and benefits of the procedure
      • Position patient in sitting position leaning forward or left lateral decubitus position with knees drawn to chest
      • Local anesthetic (typically 1% lidocaine) applied to puncture site
      • Simultaneous blood draw for plasma glucose and lactate for comparison ratios
      • Ensure patient remains supine for 30-60 minutes post-procedure to minimize postdural puncture headache risk
      • Increase fluid intake post-procedure to promote CSF reaccumulation
    • Medications to Avoid:
      • No specific medications need to be discontinued for CSF lactate measurement; however, anticoagulants (warfarin, direct oral anticoagulants) may increase bleeding risk and should be discussed with provider
      • Antiplatelet agents (aspirin, clopidogrel) should be evaluated for bleeding risk on case-by-case basis
      • Antibiotics do not need to be withheld; early antibiotic therapy is critical for meningitis and results interpretation accounts for this
      • Sedatives or analgesics may be used to reduce anxiety and discomfort during lumbar puncture as appropriate
    • Contraindications to Lumbar Puncture:
      • Suspected increased intracranial pressure (unless imaging rules out mass/herniation risk)
      • Coagulopathy or thrombocytopenia (platelet count <50,000)
      • Spinal cord compression or suspected epidural abscess
      • Local skin infection or cellulitis at lumbar puncture site
      • Patient unable to cooperate or remain still (though sedation may be used)

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