Clinical implications of acute cerebrospinal fluid changes following iophendylate myelography.
HJ Mehta, R Ramakantan, DH Piparia, AM Hande, A Goel, AR Satoskar, FD Dastur
Department of Nephrology, K.E.M. Hospital, Parel, Bombay.
H J Mehta
Department of Nephrology, K.E.M. Hospital, Parel, Bombay.
Clinical features and serial cerebrospinal fluid (CSF) samples of 50 patients who underwent myelography with iophendylate were studied. Forty two patients (84%) developed one or more features suggestive of meningism lasting for 2-4 days. There was significant rise in the average (mean) CSF counts from 9.81 in the premyelogram sample to 532.6 at the end of 24 hours (p less than 0.001). Both neutrophil and lymphocyte (p less than 000) count increased. At the end of one week, there was significant decrease of total cells in the CSF to 204 (p less than 0.001). Both, neutrophils and lymphocytes decreased. There was significant rise in total proteins in the 24 hours sample, but the fall at one week was not significant statistically. The sugar and chloride values did not change significantly. All CSF samples were negative for bacterial cultures. In conclusion, a significant proportion of the patients undergoing iophendylate myelography develop clinical features suggestive of meningeal irritation and change in the CSF fractions suggestive of meningitis: however these changes are transient and do not warrant institution of chemotherapy or steroids.
|How to cite this article:|
Mehta H J, Ramakantan R, Piparia D H, Hande A M, Goel A, Satoskar A R, Dastur F D. Clinical implications of acute cerebrospinal fluid changes following iophendylate myelography. J Postgrad Med 1992;38:10-2
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Mehta H J, Ramakantan R, Piparia D H, Hande A M, Goel A, Satoskar A R, Dastur F D. Clinical implications of acute cerebrospinal fluid changes following iophendylate myelography. J Postgrad Med [serial online] 1992 [cited 2019 Dec 12 ];38:10-2
Available from: http://www.jpgmonline.com/text.asp?1992/38/1/10/741
Myelography, since its introduction by Sicard and Forestier in 1921, has assumed universal acceptance as a diagnostic technique to delineate compressive lesions of the spinal cord. Various contrast media like air, lipidol, thorotrast and tyrogel have been used in the past, and have been found unsatisfactory for various reasons. Ethyl lophendylate undecyclate (iophendylate) was first used successfully in 1950. Lophendylate was till recently the most widely used contrast medium for myelography. It has largely replaced the newer non-ionic contrast media in the west. However, iophendylate is still used for a large number of myelograms in India due to higher cost of the new non-ionic contrast media.
Transient mild meningeal reactions have been described following iophendylate myelography,. Signs and symptoms appearing immediately after or within a short interval of iophendylate injection may be attributed to chemical or non-specific inflammatory meningeal reacton to the dye, and it may be difficult to distinguish it from true septic meningitis. The present study was undertaken with an aim to distinguish such reaction following iophendylate myelography from the instances of septic meningitis.
Fifty consecutive hospitalised patients (40 male and 10 female) undergoing iophendylate myelography were studied. The clinical diagnosis in these 50 patients were as follows: various types of cord compression (28 cases), tuberculous arachnoiditis (3 cases), craniovertebral anomaly (1 case), syringomyelia (1 case), spina bifida (1 case), and lumber canal stenosis (2 cases). Besides these myelography was performed in 7 cases of acute transverse myelitis (to rule out acute cord compression) and 7 cases of motor neurone disease (to rule out associated cord compression). Details of symptoms were noted in all patients and a physical and neurological examination performed prior to myelography and every four hours after the procedure for a week. Meningitis was ruled out clinically in all cases prior to myelography. Lumbar puncture was performed under aseptic precautions and 6-9 ml. of iophendylate was injected in the subarachnoid space. The dye was not removed after the myelography. Cerebrospinal fluid (CSF) was collected just prior to, at 24 hours and seven days after the myelography. The CSF was examined using standard procedures. None of the patients received chemotherapeutic agents or steroids for a week after the myelography. Statistical analysis was carried out using Student's paired ‘t’ test.
Clinical features: The average period of onset of fresh symptoms and signs after myelography was 24 hours. Forty-two patients (84%) developed fever which ranged from 38?C to 40?C and lasted for upto 3 days. Thirty (60%) complained of severe headaches, 3 (6%) developed headaches and neck stiffness and 1 (2%) developed headache, vomiting and neck stiffness. Forty (80%) complained of severe local pain for 2-4 days after myelography. No worsening of neurological signs was observed in any patients.
The CSF was clear in 49 cases before myelography. The fluid was turbid in 36 patients (72%) at 24 hours and, remained turbid in 3 patients (6%) at the end of one week.
The CSF findings are shown in [Table:1] and [Table:2]. At 24 hours after the myelography, there was a sharp rise in cell count, mostly neutrophilic, a mild rise in protein contents and no change in sugar and chloride contents. At one week cell count had returned to normal in many cases, and in those it was still elevated, the predominant cells were lymphocytes; the protein contents returning to normal. By contrast, sugar and chloride showed no change either at 24 hours or one week. Thus the CCF showed a short lived pleocytosis, changing from neutrophilic to lymphocytic, and returning to normal in most cases by one week. Thus the CCF showed a short lived pleocytosis, changing from neutorphilic to lymphocytic and returning to normal in most cases by one week. Postmyelography, the CSF showed no organisms either on smear or culture in any case.
The study shows that the symptoms mimicking meningitis occur frequently but transiently after iophendylate myelography. The appearance of these symptoms is accompanied by significant increase in total cell count (predominantly neutrophilic) and proteins in 24 hours CSF samples. These symptoms occur transiently and disappear along with significant decrease in cell count in a week. No patient experienced symptoms after four days. The cell count in CSF normalised by orie week in about half the patients. It was less than 50 cells/cmm in the majority of the other half in whom it remained elevated, and was predominantly lymphocytic. Thus total cell count decreased significantly from the 24 hours to the one week CSF samples with significant decrease in both neutrophilic and lymphocytic counts, but the neutrophils decreasing more. Thus, the predominant cellular response shifted from neutrophilic in the 24 hour samples to lymphocytic in the one week samples. There was no significant change in sugar or chloride levels in the serial CSF samples. Similar studies in the past, followed removal of iophendylate at the end of myelography. This is the only study where the dye was not removed. Peacher and Robertson had concluded that there appears to be no direct relationship between the amount of iophendylate retained and the CSF findings.
In the present study with the use of iophendylate the development of headaches, neck stiffness, vomiting, fever, pain in the spine and bodyache were similar to that noted by Davies who had studied acute symptoms following injection of iophendylate in 125 patients. They had also included cases in whom cervical route of iopheddylate was used, and had noticed in addition to meningism, cranial nerve palsy (3rd and 6th), nystagmus, diarrhoea, shock, retention of urine, worsening of original symptoms and/or increase in sensory symptoms. These features were not observed in our patients.
Peacher and Robertson found a slight rise of neutrophils and/or lymphocytes, and occasional elevation of total proteins in the CSF after iophendylate myelography. These changes occurred most often in first week, with the height of variation from normal occuring during first few days. Our study also shows neutrophilic response to iophendylate myelography within the first 24 hours, which tends to shift towards lymphocytic within one week. The exact time during which this transition from neutrophils to lymphocytes occurs is difficult to say from our study. Schnitkar and Booth reported elevated CSF proteins and cells 3 to 10 patients studied within 24 hours of myelography. Ferry et al found increase in the number of lymphocytes 1 to 10 days after myelography, persisting for upto 80 days. As compared to these studies, we observed an early neutrophilic response in the majority of our patients, the reason for which is not known.
There was no significant change in sugar and chloride values in serial samples. Even when the total cell count was increased upto 2500/cumm in one of the patients, the sugar levels were not markedly reduced a point, which may indicate the absence of bacterial infection. The absence of growth on bacterial cultures in these patients suggests that the neutrophiis in CSF were probably due to non-specific inflammatory response. In conclusion, occurence of fever, and nuchal rigidity, and the CSF picture of neutrophilic cell count, slightly elevated proteins and near normal sugar values for few days, following iophendylate myelography should be considered a non-specific inflammatory reaction, and should not be treated as pyogenic meningitis. They should be carefully observed and treated symptomatically, while awaiting microbiology results.
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