This document provides guidance on interpreting cerebrospinal fluid (CSF) results and summarizes typical CSF findings for various diseases. Normal CSF ranges are provided for appearance, white blood cells, red blood cells, protein, glucose, and opening pressure. Example cases are then presented showing how to interpret abnormal CSF results and arrive at a diagnosis of conditions like bacterial meningitis, viral meningitis, fungal meningitis, tuberculosis meningitis, subarachnoid hemorrhage, and Guillain-Barré syndrome.
This document provides guidance on interpreting cerebrospinal fluid (CSF) results and summarizes typical CSF findings for various diseases. Normal CSF ranges are provided for appearance, white blood cells, red blood cells, protein, glucose, and opening pressure. Example cases are then presented showing how to interpret abnormal CSF results and arrive at a diagnosis of conditions like bacterial meningitis, viral meningitis, fungal meningitis, tuberculosis meningitis, subarachnoid hemorrhage, and Guillain-Barré syndrome.
This document provides guidance on interpreting cerebrospinal fluid (CSF) results and summarizes typical CSF findings for various diseases. Normal CSF ranges are provided for appearance, white blood cells, red blood cells, protein, glucose, and opening pressure. Example cases are then presented showing how to interpret abnormal CSF results and arrive at a diagnosis of conditions like bacterial meningitis, viral meningitis, fungal meningitis, tuberculosis meningitis, subarachnoid hemorrhage, and Guillain-Barré syndrome.
This document provides guidance on interpreting cerebrospinal fluid (CSF) results and summarizes typical CSF findings for various diseases. Normal CSF ranges are provided for appearance, white blood cells, red blood cells, protein, glucose, and opening pressure. Example cases are then presented showing how to interpret abnormal CSF results and arrive at a diagnosis of conditions like bacterial meningitis, viral meningitis, fungal meningitis, tuberculosis meningitis, subarachnoid hemorrhage, and Guillain-Barré syndrome.
This guide provides a structured approach to cerebrospinal fluid interpretation (CSF
interpretation), including typical CSF results for specific disease processes. Reference ranges vary between labs, so always consult your local medical school or hospital guidelines.
Normal CSF ranges (adults)
Appearance: Clear and colourless
White blood cells (WBC): 0 – 5 cells/µL
No neutrophils present, primarily lymphocytes
Normal cell counts do not rule out meningitis or any other pathology
Red blood cells (RBC): 0 – 10/mm³
Protein: 0.15 – 0.45 g/L (or <1% of the serum protein concentration)
Causes Newborns: Listeria monocytogenes, E. Coli, Group B Streptococci Older children: Neisseria meningitidis, Haemophilus influenzae Type B, Streptococcus pneumoniae Adults: Neisseria meningitidis, Streptococcus pneumoniae, Listeria monocytogenes
Symptoms Headache Fever Neck stiffness Photophobia Meningococcal meningitis presents with a characteristic petechial rash
Further investigations CSF gram stain and cultures CSF bacterial antigens CSF PCR Blood cultures Imaging to rule out other intracranial pathology – CT / MRI head
Viral (aseptic) meningitis
Appearance: Clear
Opening pressure: Normal or elevated
WBC: Elevated (50 – 1000 cells/µL, primarily lymphocytes, can be PMN early on)
Glucose level: Normal (>60% serum glucose however may be low in HSV infection)
Protein level: Elevated (>50 mg/dL)
Causes Herpes simplex virus (HSV 2 is more common than HSV 1) Enteroviruses Varicella zoster virus (VZV) Mumps 2/8 HIV Adenovirus
Further investigations CSF PCR for viruses (e.g. Herpes simplex virus (HSV) / Varicella-zoster virus (VZV)) Blood cultures Imaging to rule out other intracranial pathology – CT / MRI head
Fungal meningitis Appearance: Clear or cloudy
Opening pressure: Elevated
WBC: Elevated (10 – 500 cells/µL)
Glucose level: Low
Protein level: Elevated
Causes Cryptococcus neoformans Candida
Symptoms Patients are often immunocompromised Headache Confusion Nausea Vomiting Fever and neck stiffness are less common
Further investigations CSF cultures CSF PCR CSF staining HIV test (with consent) 3/8 Blood cultures Imaging to rule out other intracranial pathology – CT / MRI head
Tuberculosis meningitis Appearance: Opaque, if left to settle it forms a fibrin web
Opening pressure: Elevated
WBC: Elevated (10 – 1000 cells/µL, Early PMNs then mononuclears)
Further investigations CSF cultures CSF bacterial antigens CSF PCR HIV test (with consent) Blood cultures Imaging to rule out other intracranial pathology – CT / MRI head Chest X-ray
Subarachnoid haemorrhage Appearance: Blood stained initially, then xanthochromia (yellowish) >12 hours later
Further investigations MRI head Oligoclonal bands of IgG on electrophoresis (CSF and Serum) Evoked potential tests (visual/somatosensory)
Worked examples
Case 1 A 55-year-old woman has been getting more confused over the last 2 months. Over the last 3 days, she has been vomiting and suffering from lack of energy. She has no neck stiffness and a CD4 count of 100/mm³
CSF results Appearance: Cloudy
Opening pressure: 25 cm H₂O
WBC: 400 cells/µL
6/8 Glucose level: < 40% of serum glucose concentration
Protein level: 1g/L
This is fungal meningitis, in this particular case this lady is found to have cryptococcal meningitis on CSF culture. The patient is also found to have HIV, likely the cause of her impaired immune function (CD4 count 100/mm³), leaving her vulnerable to cryptococcal infection.
Case 2 A 28-year-old male presents with a 12-hour history of high fever, severe headache, confusion, photophobia and neck stiffness. He has no significant past medical history and takes no regular medication.
CSF results Appearance: Cloudy
Opening pressure: 30 cm H₂O
WBC: 936 cells/µL (>95% PMN cells)
Glucose level: < 40% of serum glucose
Protein level: 3 g/L
This is bacterial meningitis. This young gentleman has presented with meningeal symptoms, fever, confusion which have progressed rapidly over the last 12 hours. The CSF is cloudy on inspection, the white cell count is significantly raised and glucose levels are low. The history and CSF results are strongly suggestive of bacterial meningitis and therefore he should be treated empirically whilst culture results are awaited.
Case 3 A 38-year-old female presents with 24 hours of headache, photophobia, mild neck stiffness, in addition to coryzal symptoms. She is fully orientated and her observations are stable.
CSF results Appearance: Clear
Opening pressure: 23 cm H₂O
WBC: 150 cells /µL (primarily lymphocytes)
Glucose level: Normal
7/8 Protein level: 90 mg/dL
This is viral meningitis. This lady has presented with a history of meningitic symptoms alongside coryzal symptoms which suggests the presence of a viral type illness. The CSF findings are more suggestive of viral meningitis given the clear appearance of the CSF, the mildly raised WCC (consisting mainly of lymphocytes), raised protein level and normal glucose. Further investigations including CSF PCR can be useful in identifying the specific virus.
Case 4 A 52 year old male presents to A&E with history of a sudden onset severe headache which occurred whilst he was at his desk yesterday. Since the headache he has been feeling nauseated, but he is otherwise well and fully orientated. Examination is largely unremarkable, but he does appear to have some mild neck stiffness.
CSF results Appearance: Yellowish
Opening pressure: 23 cm H₂O
WBC: Normal
Red cell count: Raised
Glucose level: Normal
Protein level: 80 mg/dL
Xanthochromia: positive
This is subarachnoid haemorrhage (SAH). The typical history of a sudden severe
headache (often described as thunderclap) and meningitic symptoms (neck stiffness) is strongly suggestive of SAH. CT head is often the first line investigation, but it has a sensitivity of 98% in the first 12 hours and becomes less sensitive after that. As a result lumbar puncture is used to rule out SAH. The CSF typically shows a persistently raised red cell count (due to blood present in the CSF from the initial bleed). Within several hours, the red blood cells in the cerebrospinal fluid are destroyed, releasing their oxygen- carrying molecule heme, which is metabolized by enzymes to bilirubin, a yellow pigment. This yellow pigment can be detected and its presence is referred to as xanthochromia
