Bacterial meningitis presenting with normal cerebrospinal fluid

At a large children's hospital cases of bacterial meningitis with normal initial cerebrospinal fluid determinations other than culture or antigen detection assays were reviewed in an attempt to determine clinical or other laboratory findings accompanying this presentation. During a 5-year period from January, 1980, through December, 1985, 7 of 261 pediatric meningitis patients (2.7%) fulfilled these criteria. Ages ranged from 3 weeks to 18 months. All 7 patients were hospitalized for observation with all but 1 begun on empiric antibiotic therapy. Laboratory parameters such as a complete blood count, sedimentation rate or C-reactive protein did not influence decisions for management. Cerebrospinal fluid antigen detection assays were negative in all but one patient with pneumococcal meningitis. Review of these cases did not reveal unique indicators for bacterial meningitis. The results emphasize that the physician must rely on clinical judgment in initiating empiric antimicrobial therapy once apparently normal cerebrospinal fluid parameters are observed.