- Email: [email protected]
CSF cells in tuberculous meningitis
Journal 6/the Neurological Sciences, 1981,49:223-228 © Elsevier/North-Holland Biomedical Press
223
CSF CELLS IN TUBERCULOUS MENINGITIS Humoral and Cellular Immune Response
S. PELC and E. DE MAERTELAERE
Neurology (Department of Pediatrics) and Cytology (Department of Haematology), University of Brussels, H6pital Saint-Pierre, rue Haute, 1000 Brussels (Belgium) (Received 12 June, 1980) (Revised, received 10 september, 1980) (Accepted 18 September, 1980)
SUMMARY
In 10 patients with tuberculous meningitis both T and B lymphocyte activation was observed in the CSF from clinical onset of disease. During the course of the illness, the humoral response remained most marked, disappearing by 2 months, while the cellular immune response continued for about another 3 months. This contrasts with acute viral meningitis, in which both responses cease within 1-2 weeks of disease.
INTRODUCTION
It is generally acknowledged that in viral and tuberculous meningitis the CSF contains a majority of lymphocytes and that unusual plasma cells may be recognized (Sayk 1960; Olischer and Sayk 1967; P6ter 1967; Mazalton and Lebeau 1970; Guseo 1976; Oehmichen 1976; Schoenen et al. 1976; Glasser et al. 1977). In recent years, however, other abnormal cells have been reported occasionally in the conditions, such as cells in mitosis (Olischer and Sayk 1967; Oehmichen 1976) and "transformed" lymphocytes (also named atypical or reactive lymphocytes or immunocytes) (Mazalton and Lebeau 1970; Gupta 1973; Oehmichen 1976; Schoenen et al. 1976; Glasser et al. 1977) that are now regarded, together with plasmacytes, as part of the process of lymphoid-cell line proliferation and differentiation induced in vivo by antigen stimulation. In a previous light-microscopical study of CSF in viral meningitis and meningoencephalitis (Pelc and De Maertelaere, in press) we have been able to identify such distinctive cells and observe major immune reactivity in plasma cells. The findings were all prominent within the first days of the disease.
224 We have recently had the opportunity to investigate similarly CSF of tuberculous meningitis in 10 proven cases and to disclose qualitatively identical findings But, in contrast to viral infections, they were seen to persist for several months. The CSF findings in tuberculous meningitis are reported and are compared to those in viral disease. So far as we are aware, no detailed morphologic account exists of the immune phenomena in CSF in the course of tuberculous meningitis. MATERIALS AND METHODS
Ten patients, 3 adults and 7 children, with positive Tb bacillus in CSF culture (and with Tb antibiotic therapy) were investigated. In 8 of them, several fluids were examined during the course of disease and in 2 more, both infants, only one sample taken on hospital admission was available. The conventional CSF findings in the 10 cases are summarized in Table 1, with respect to the day of clinical onset of meningitis (day zero). The cell numbers were established by the standard counting chamber method and type percentages, including those of transformed lymphocytes and plasmacytes, were determined on a CSF sediment stained with May-Grfinwald-Giemsa, as previously described (Pelc and De Maertelaere, in press). Other cytomorphological findings relevant to immune reactivity are listed separately in Table 2, also according to clinical disease onset. The data from Table 1 and 2 pertaining to the cell responsiveness in the 10 patients during the course of their disease are grouped and represented in Fig. 1, thus providing an overview of the ranges of immunocompetent lymphocyte manifestations in the CSF cells during the course of Tb meningitis. RESULTS
As seen in Table 1 and Fig. 1, transformed lymphocytes and plasma cells, though each in variable amount, could be observed already on day 2 and were prone to persist up to day 128 and 40, respectively. During this 128-day period, most likely as another sign of both T and B lymphocyte activation, many transformed lymphocytes and some small lymphocytes or plasma cells could be found with evidence of nuclear polylobulation (Table 2 and Fig. 1). Lymphoid cell division (metaphasis or binucleation), as expected in early antigen stimulation, happened to be seen from the very onset of disease and to last for about 1 to 2 months (Table 2 and Fig. 1). In addition to the plain fully mature antibody-secreting cells, seen during the first 40 days, other plasmacytes, in small numbers, with morphologically gammaglobulin increased secretion (+'flaming"), storage (Russell bodies, morular cells) or release (clasmatosis) tended to be found for about the first 2 months of disease (Table 2 and Fig. 1).
225 TABLE 1 L A B O R A T O R Y F I N D I N G S IN T H E CSF
Patients age
Day after onset
Cells/#l
Granulo- L y m p h o - TransPlasmaMonocytes (~o) cytes (~o) formed cytes (I~;) cytes ( ~ ) lymphocytes (/o) o,
1. 6 years
XIV XX XXXVII LXXX XC
376 153 40 30 4
50 38 8 3
36 56 85 90 90
2. 9 years
XIII XVIII XXXVI
157 208 62
3 47
85 30 99
3. 6 months
IIl
300
4. 16 years
XIII XXII XXXVII XXXlX LXVIII
217 280 280 115 310
5. 31 years
XIV XXII XXIX
155 179 106
6. VII 8 m o n t h s XVIII XXVI LIIII XC
6 4 6 7 10 2 12
20
78
3 9 15 4 96
67 54 71 90 2
18 8
5 10 3
84 80 83
40 12 2
38 46 68 93 88
I00 85 150 41 12 76 8
12 3 17
79 90 70 100 96 90 99
70 2 7 5 0.7
7. 52 years
1I XXXXVI XXXXIX LVIII LXXVIII C CXXVIII
8. 3 years
XXIV XXXX LV CIIII
60 47 27 17
20 1
70 80 83 90
9. 8 months
XX
59
4
90
10. 7 months
X XXVII XXXXVI LXXXVI
105 110 85 15
8
87 91 80 69
4
5 23 4 3
18 40 21 7 12
5 16 12 10
3 6 14 31
Protein (mg/dl) (N = 50 mg)
Sugar (mg/dl) CSF/Serum
186 70 58 26 32
25/69 30/62 36/73
144 90 32
32/112 44/95
224
23/85
218 160 218 292 1800
49/179
333 280 230
15/119 20/87 18/72
40 37 10 21 26
47/109
128 245 288 200 138 129 85
48/128 20/95
93 64 52 48
44/81 48/75
112
38/123
144 106 58 43
21/115 33/106
226 TABLE 2 CSF C Y T O M O R P H O L O G I C A L
FINDINGS OF IMMUNE
Patients
Day
Poly-
age
after onset
lobulated nucleus a
Binucleated cells
Cellmitosis
REACTIVITY
" F l a m i n g " Russell plasmabodies in cytes plasmacytes
Morular cells .
_
I. 6 years
XIV XX XXXVII LXXX XC
+ + +
XIII XVIll XXXV1
+
III
+
+
+
Xlll XXII XXXVII XXXIX LXVIII
+ + + + +
+ + + + +
+ + +
XIV XXII XXIX
+ + +
+
+
VII XVIll XXVI LIIII XC
+
+ +
+ + +
+
+
+
+
2. 9 years
3. 6 months
+
4. 16 years
+ +
+ + + + +
+ +
5. 31 y e a r s
+ + +
+ +
+
+
+
6. 8 months
+ +
7. 52 y e a r s
ii XXXXVI XXXXIX LVIII LXXVIII C CXXVIII
+ + + +
-t-
XXIV XXXX LV CIIII
+ + + +
XX
+
+
X XXVI I XXXXVI LXXXVI
+ +
+
+
+ +
8. 3 years
9, 8 months 10. 7 months
+
+
+
+
+
a Was seen more often in transformed lymphocytes than in lymphocytes and plasma cells.
Clasmatosis
227 68
Plasmacyte clasmatosis Morulor -cells
;~
2~2
Plasmacytes with Russell bodies 3
78
i
i
13
"Flaming" plasmacytes
i
Plasmacytes
,2
Binucleated cells
2,
41 i
49
3,9
Mitosis Polylobulated nuclei ~
2
128
128 J
Reactive lymphocytes
6o ~see table 2
15o
150 cloys from onset of diseose
Fig. 1. Ranges of CSF immunocompetent cell responsiveness in the course of tuberculous meningitis.
DISCUSSION
The occurrence in CSF close to the onset of Tb meningitis of plain and highly activated plasma cells was similar in time and quality to that observed in acute viral meningitis (Pelc and De Maertelaere, in press). It may account, in both circumstances, for the marked humoral immune response to antigenic stimulation. However, in contradistinction to viral illness, in which this phenomenon disappeared within less than 2 weeks, in Tb meningitis, it appeared to continue and remain equally intense for as long as 2 months. The second phenomenon in CSF that was found to be common to viral and tuberculous meningitis was that of partition and differentiation of the lymphoid cells from the very onset of disease. But, again, whereas in viral infection the process was seen to come to an end by the first week of disease, in Tb bacillus infection, cell mitosis and plasma cell maturation tended to persist for 6-8 weeks while mainly transformed lymphocytes with either normal or abnormal appearing nuclei could still be observed beyond that period, namely for about 3 further months. Since, admittedly, regular plasma cells are short-lived B lymphocytes and hyperactive ones are end cells, it may reasonably be assumed that most of the cells that continued to develop over the remaining 3 months were actually T lymphocytes. The present cell findings therefore suggest that in the CSF of Tb meningitis
228 the cellular immune response, T-cell mediated, tends to be much more protracted than the humoral, B-cell dependent, response. This differs strikingly from acute viral menigitis in which both responses appear to be of equal and short duration. Perhaps this difference may account t~r the usual course of Tb meningitis. ACKNOWLEDGEMENTS
We are grateful to Dr. R. Denolin-Reubens and Dr. P. Fondu (Department of Haematology) for their support and encouragement and to M.J. Hupin for his skilful technical assistance. REFERENCES Glasser, L., C. Payn e and J.J. Corrigan (1977) The in vivo development of plasma cells, Neurology ( Minneap. ), 27:448-459. Gupta, P. K. (1973) Cytodiagnosis of viral encephalitis, Lancet, i: 609. Guseo, A. (1976) Morpphological signs as indications of function of cells in the cerebrospinal fluid, J. Neurol., 212: 159-170. Mazalton, A. and J. LeBeau (1970) Diagnostic cytologique des m6ningites ~ liquide clair par la technique de Suta. Ann. Mkd. int., 121 : 341 346. Oehmichen, M. (1976) Cerebrospinal Fluid Cytology--An Introduction and Atlas, Thieme, Stuttgart. Olischer, R. M. and J. Sayk (1967) Der Liquor - - Insbesondere Zellbefunde bei Meningitiden, Fortsehr. Neurol. Psychiat., 35: 453-478. Pelc, S. and E. De Maertelaere, CSF of acute viral meningitis and meningoencephalitis - Cytomorphological features of early marked immune stimulation, Europ. Neurol., In press. P6ter, A. (1967) The plasma cells of the cerebrospinal fluid, J. neurol. Sci., 4:227 239. Sayk, J. (1960) Cytologic der Cerebrospinalfliissigkeit, Fischer, Jena. Schoenen, J., N. Einaudi and J. J. Delwaide (1976) Analyse cytologique qualitative du liquide c6phalorachidien, Rev. rn~d. Liege, 31 : 471484.
223
CSF CELLS IN TUBERCULOUS MENINGITIS Humoral and Cellular Immune Response
S. PELC and E. DE MAERTELAERE
Neurology (Department of Pediatrics) and Cytology (Department of Haematology), University of Brussels, H6pital Saint-Pierre, rue Haute, 1000 Brussels (Belgium) (Received 12 June, 1980) (Revised, received 10 september, 1980) (Accepted 18 September, 1980)
SUMMARY
In 10 patients with tuberculous meningitis both T and B lymphocyte activation was observed in the CSF from clinical onset of disease. During the course of the illness, the humoral response remained most marked, disappearing by 2 months, while the cellular immune response continued for about another 3 months. This contrasts with acute viral meningitis, in which both responses cease within 1-2 weeks of disease.
INTRODUCTION
It is generally acknowledged that in viral and tuberculous meningitis the CSF contains a majority of lymphocytes and that unusual plasma cells may be recognized (Sayk 1960; Olischer and Sayk 1967; P6ter 1967; Mazalton and Lebeau 1970; Guseo 1976; Oehmichen 1976; Schoenen et al. 1976; Glasser et al. 1977). In recent years, however, other abnormal cells have been reported occasionally in the conditions, such as cells in mitosis (Olischer and Sayk 1967; Oehmichen 1976) and "transformed" lymphocytes (also named atypical or reactive lymphocytes or immunocytes) (Mazalton and Lebeau 1970; Gupta 1973; Oehmichen 1976; Schoenen et al. 1976; Glasser et al. 1977) that are now regarded, together with plasmacytes, as part of the process of lymphoid-cell line proliferation and differentiation induced in vivo by antigen stimulation. In a previous light-microscopical study of CSF in viral meningitis and meningoencephalitis (Pelc and De Maertelaere, in press) we have been able to identify such distinctive cells and observe major immune reactivity in plasma cells. The findings were all prominent within the first days of the disease.
224 We have recently had the opportunity to investigate similarly CSF of tuberculous meningitis in 10 proven cases and to disclose qualitatively identical findings But, in contrast to viral infections, they were seen to persist for several months. The CSF findings in tuberculous meningitis are reported and are compared to those in viral disease. So far as we are aware, no detailed morphologic account exists of the immune phenomena in CSF in the course of tuberculous meningitis. MATERIALS AND METHODS
Ten patients, 3 adults and 7 children, with positive Tb bacillus in CSF culture (and with Tb antibiotic therapy) were investigated. In 8 of them, several fluids were examined during the course of disease and in 2 more, both infants, only one sample taken on hospital admission was available. The conventional CSF findings in the 10 cases are summarized in Table 1, with respect to the day of clinical onset of meningitis (day zero). The cell numbers were established by the standard counting chamber method and type percentages, including those of transformed lymphocytes and plasmacytes, were determined on a CSF sediment stained with May-Grfinwald-Giemsa, as previously described (Pelc and De Maertelaere, in press). Other cytomorphological findings relevant to immune reactivity are listed separately in Table 2, also according to clinical disease onset. The data from Table 1 and 2 pertaining to the cell responsiveness in the 10 patients during the course of their disease are grouped and represented in Fig. 1, thus providing an overview of the ranges of immunocompetent lymphocyte manifestations in the CSF cells during the course of Tb meningitis. RESULTS
As seen in Table 1 and Fig. 1, transformed lymphocytes and plasma cells, though each in variable amount, could be observed already on day 2 and were prone to persist up to day 128 and 40, respectively. During this 128-day period, most likely as another sign of both T and B lymphocyte activation, many transformed lymphocytes and some small lymphocytes or plasma cells could be found with evidence of nuclear polylobulation (Table 2 and Fig. 1). Lymphoid cell division (metaphasis or binucleation), as expected in early antigen stimulation, happened to be seen from the very onset of disease and to last for about 1 to 2 months (Table 2 and Fig. 1). In addition to the plain fully mature antibody-secreting cells, seen during the first 40 days, other plasmacytes, in small numbers, with morphologically gammaglobulin increased secretion (+'flaming"), storage (Russell bodies, morular cells) or release (clasmatosis) tended to be found for about the first 2 months of disease (Table 2 and Fig. 1).
225 TABLE 1 L A B O R A T O R Y F I N D I N G S IN T H E CSF
Patients age
Day after onset
Cells/#l
Granulo- L y m p h o - TransPlasmaMonocytes (~o) cytes (~o) formed cytes (I~;) cytes ( ~ ) lymphocytes (/o) o,
1. 6 years
XIV XX XXXVII LXXX XC
376 153 40 30 4
50 38 8 3
36 56 85 90 90
2. 9 years
XIII XVIII XXXVI
157 208 62
3 47
85 30 99
3. 6 months
IIl
300
4. 16 years
XIII XXII XXXVII XXXlX LXVIII
217 280 280 115 310
5. 31 years
XIV XXII XXIX
155 179 106
6. VII 8 m o n t h s XVIII XXVI LIIII XC
6 4 6 7 10 2 12
20
78
3 9 15 4 96
67 54 71 90 2
18 8
5 10 3
84 80 83
40 12 2
38 46 68 93 88
I00 85 150 41 12 76 8
12 3 17
79 90 70 100 96 90 99
70 2 7 5 0.7
7. 52 years
1I XXXXVI XXXXIX LVIII LXXVIII C CXXVIII
8. 3 years
XXIV XXXX LV CIIII
60 47 27 17
20 1
70 80 83 90
9. 8 months
XX
59
4
90
10. 7 months
X XXVII XXXXVI LXXXVI
105 110 85 15
8
87 91 80 69
4
5 23 4 3
18 40 21 7 12
5 16 12 10
3 6 14 31
Protein (mg/dl) (N = 50 mg)
Sugar (mg/dl) CSF/Serum
186 70 58 26 32
25/69 30/62 36/73
144 90 32
32/112 44/95
224
23/85
218 160 218 292 1800
49/179
333 280 230
15/119 20/87 18/72
40 37 10 21 26
47/109
128 245 288 200 138 129 85
48/128 20/95
93 64 52 48
44/81 48/75
112
38/123
144 106 58 43
21/115 33/106
226 TABLE 2 CSF C Y T O M O R P H O L O G I C A L
FINDINGS OF IMMUNE
Patients
Day
Poly-
age
after onset
lobulated nucleus a
Binucleated cells
Cellmitosis
REACTIVITY
" F l a m i n g " Russell plasmabodies in cytes plasmacytes
Morular cells .
_
I. 6 years
XIV XX XXXVII LXXX XC
+ + +
XIII XVIll XXXV1
+
III
+
+
+
Xlll XXII XXXVII XXXIX LXVIII
+ + + + +
+ + + + +
+ + +
XIV XXII XXIX
+ + +
+
+
VII XVIll XXVI LIIII XC
+
+ +
+ + +
+
+
+
+
2. 9 years
3. 6 months
+
4. 16 years
+ +
+ + + + +
+ +
5. 31 y e a r s
+ + +
+ +
+
+
+
6. 8 months
+ +
7. 52 y e a r s
ii XXXXVI XXXXIX LVIII LXXVIII C CXXVIII
+ + + +
-t-
XXIV XXXX LV CIIII
+ + + +
XX
+
+
X XXVI I XXXXVI LXXXVI
+ +
+
+
+ +
8. 3 years
9, 8 months 10. 7 months
+
+
+
+
+
a Was seen more often in transformed lymphocytes than in lymphocytes and plasma cells.
Clasmatosis
227 68
Plasmacyte clasmatosis Morulor -cells
;~
2~2
Plasmacytes with Russell bodies 3
78
i
i
13
"Flaming" plasmacytes
i
Plasmacytes
,2
Binucleated cells
2,
41 i
49
3,9
Mitosis Polylobulated nuclei ~
2
128
128 J
Reactive lymphocytes
6o ~see table 2
15o
150 cloys from onset of diseose
Fig. 1. Ranges of CSF immunocompetent cell responsiveness in the course of tuberculous meningitis.
DISCUSSION
The occurrence in CSF close to the onset of Tb meningitis of plain and highly activated plasma cells was similar in time and quality to that observed in acute viral meningitis (Pelc and De Maertelaere, in press). It may account, in both circumstances, for the marked humoral immune response to antigenic stimulation. However, in contradistinction to viral illness, in which this phenomenon disappeared within less than 2 weeks, in Tb meningitis, it appeared to continue and remain equally intense for as long as 2 months. The second phenomenon in CSF that was found to be common to viral and tuberculous meningitis was that of partition and differentiation of the lymphoid cells from the very onset of disease. But, again, whereas in viral infection the process was seen to come to an end by the first week of disease, in Tb bacillus infection, cell mitosis and plasma cell maturation tended to persist for 6-8 weeks while mainly transformed lymphocytes with either normal or abnormal appearing nuclei could still be observed beyond that period, namely for about 3 further months. Since, admittedly, regular plasma cells are short-lived B lymphocytes and hyperactive ones are end cells, it may reasonably be assumed that most of the cells that continued to develop over the remaining 3 months were actually T lymphocytes. The present cell findings therefore suggest that in the CSF of Tb meningitis
228 the cellular immune response, T-cell mediated, tends to be much more protracted than the humoral, B-cell dependent, response. This differs strikingly from acute viral menigitis in which both responses appear to be of equal and short duration. Perhaps this difference may account t~r the usual course of Tb meningitis. ACKNOWLEDGEMENTS
We are grateful to Dr. R. Denolin-Reubens and Dr. P. Fondu (Department of Haematology) for their support and encouragement and to M.J. Hupin for his skilful technical assistance. REFERENCES Glasser, L., C. Payn e and J.J. Corrigan (1977) The in vivo development of plasma cells, Neurology ( Minneap. ), 27:448-459. Gupta, P. K. (1973) Cytodiagnosis of viral encephalitis, Lancet, i: 609. Guseo, A. (1976) Morpphological signs as indications of function of cells in the cerebrospinal fluid, J. Neurol., 212: 159-170. Mazalton, A. and J. LeBeau (1970) Diagnostic cytologique des m6ningites ~ liquide clair par la technique de Suta. Ann. Mkd. int., 121 : 341 346. Oehmichen, M. (1976) Cerebrospinal Fluid Cytology--An Introduction and Atlas, Thieme, Stuttgart. Olischer, R. M. and J. Sayk (1967) Der Liquor - - Insbesondere Zellbefunde bei Meningitiden, Fortsehr. Neurol. Psychiat., 35: 453-478. Pelc, S. and E. De Maertelaere, CSF of acute viral meningitis and meningoencephalitis - Cytomorphological features of early marked immune stimulation, Europ. Neurol., In press. P6ter, A. (1967) The plasma cells of the cerebrospinal fluid, J. neurol. Sci., 4:227 239. Sayk, J. (1960) Cytologic der Cerebrospinalfliissigkeit, Fischer, Jena. Schoenen, J., N. Einaudi and J. J. Delwaide (1976) Analyse cytologique qualitative du liquide c6phalorachidien, Rev. rn~d. Liege, 31 : 471484.