Acute infections of the nervous system are among the most important and common conditions in pediatrics. These distinct clinical syndromes include acute pyogenic meningitis, viral meningitis-encephalitis, focal infections such as brain abscess and subdural empyema, and infectious thrombophlebitis. Early recognition & diagnosis with the rapid institution of therapy can be life-saving[1].Meningitis is a significant cause of morbidity and mortality in children worldwide. Without treatment, the case-fatality rate can be as high as 70 percent, and one in five survivors of bacterial meningitis may be left with permanent sequelae including hearing loss, neurologic disability [2].

Case fatality rates for bacterial meningitis range from 4.5% in developed countries to 15–50% in developing countries [3,4]. Bacterial meningitis, still one of the most life-threatening problems worldwide, is more prevalent in children and its timely and early differentiation from non-bacterial meningitis has a huge impact on the treatment of affected patients. Quick diagnosis and effective management is key to success [5].

The evolution of clinical signs and symptoms caused by meningitis or encephalitis varies greatly. Thus, the clinician must sort out the form of clinical presentation, assess the rapidity of its evolution, and make a specific etiological diagnosis. The examination of cerebrospinal fluid is an essential and often critical tool in the evaluation and management of patients with meningitis. Although CSF examination is often useful for definitive diagnosis. But this is not always the case scenario. Cultures have the drawback of the time required, 24 to 48 hours or more to become positive, an unacceptable delay in initiating the treatment [6].Culture and sensitivity, Gram stain, cytology and biochemistry of cerebrospinal fluid (CSF) samples are traditionally being done to diagnose and to differentiate pyogenic from aseptic meningitis. CSF cytology and culture sensitivity reports may be affected by prior antibiotic therapy. Gram’s stain lacks specificity and has interpretative errors. Possible causes of the false-positive result of Gram’s stain include contamination of tubes from lumber puncture trays, glass slides and or Gram’s reagents. The overall sensitivity of Gram’s stain to detect bacterial meningitis was 67% with a positive predictive value of 60%.

• Feeding problems.
• Vomiting.
• Irritability
• Seizures or sluggishness.
• High pitched crying

Exclusion criteria

• Patients in whom lumbar puncture is contraindicated i.e.
• Sepsis at the local site
• Papilloedema or other signs of raised intracranial pressure
• Marked spinal deformity
• Bleeding diathesis or on anticoagulant therapy
• Patients on steroid
• Traumatic lumbar puncture
• Refusal to consent
• Patients having congenital CNS abnormality and who is known case of neurodegenerative disorder of the brain.

Statistical Method: ANOVA, unpaired t-test.

Sample Size: 102 patients were included after the protocol was approved by an ethical review committee of Government Medical College, Kota. Informed written consent was taken.A detailed history has been taken. A general physical and systemic examination was done. Investigations including Complete Blood Count with CSF analysis (appearance, cell count & differential, sugar, protein, gram’s stain, culture), quantitative CSF-CRP, blood sugar, Mantoux Test (MT) in tubercular suspected, cranial CT scan and MRI brain if indicated was done.

Patients investigated as above were divided into three groups as mentioned below:

Group-I: Pyogenic meningitis

Group-II: Non-Pyogenic meningitis (Tubercular meningitis, Aseptic meningitis, etc.)

Group-III:- No Meningitis (Normal CSF: cerebral malaria, febrile convulsion, dyselectrolytemia etc.)

We assessed the role of CSF C-reactive protein quantitatively in acute meningitis by using compute based program statistical package for social science (SPSS) version 20.0 programs.

Cytological examination shows 41 (77.1%) cases of pyogenic meningitis had WBC count in the range of 100 to 2000 cell/mm3. In Non-Pyogenicmeningitis, where 26 (96.2%) were in the range of 6 to 500 cell/mm3. The mean value of the total count of WBC/mm3 in CSF, in pyogenic meningitis was 910.15+ 808.76, in Non-Pyogenic meningitis was 154.37+139.22 and in the case of normal CSF was 1.86+1.58.All 53 cases (100%) of pyogenic meningitis had more than 50%Polymorphs in CSF. In Non-Pyogenicmeningitis where 27 cases (100%) were cell type is Lymphocytes was > 50%. The mean value of Polymorphs in CSF, in pyogenic meningitis was 74.09+10.47, in Non-Pyogenic meningitis was 75.29+9.01 and in the case of normal CSF was 68.18+47.67.

In 52 cases (98.1%) of Pyogenic meningitis had elevated CSF-CRP level >1.1µg/ml and 1 case (1.8%) were in the range of 0.05-0.10 µg/ml. In the case of Non-Pyogenic meningitis 27 (96.2%) were found to have in the range of 0.05-0.10 µg/ml.

* The mean difference is significant at the 0.05 level.

Table 8 shows that in the pyogenic meningitis group, CSF culture was positive only in 15% of patients and common bacteria were grown in CSF culture were Streptococcus pneumoniae (7.5%), Staphylococcus aureus (3.7%) and H. influenza (1.8%) and E.Coli (1.8). Among the 4 cases of Streptococcus pneumoniae meningitis, 2 cases were below 12 months and 2 cases were more than 12 months (48 months& 6year).

(98.11%), and good negative predictive value (96.3%) and good Diagnostic Accuracy (97.5%) for Pyogenic meningitis.

Table 9: CSF-CRP Test Estimation

C-reactive protein (CRP), an acute-phase inflammatory response reactantwas discovered in 1930 by Tillett et al [12].CRP is the acute phase protein that is synthesized by hepatocytes in response to infection or inflammation. In healthy the median concentration of serum C - reactive protein is 0.8mg/l. CRP concentrations in the CSF is much lower than those of serum. Meningeal irritation stimulates C-reactive protein production. Its production is controlled by Interleukin-6 and it binds to polysaccharides present in many bacteria, fungi and protozoal, parasites [13].Almost any inflammatory disease will cause detectable quantities of CRP to be present in serum or fluids closely associated with affected tissues [14,5,16].

Increased CRP production is an early and sensitive response to most forms of microbial infections and the value of its measurement in the diagnosis and management of various infective conditions has been established [17,18].In western countries, attention was recently drawn to the value of serum CRP measurement in differentiating bacterial and non-bacterial infections [19].However, routine diagnostic use of CSF- CRP in differentiating bacterial and non-bacterial meningitis has been evaluated by very few workers. Since meningitis is a potentially hazardous disease of childhood, diagnostic test which is readily available, easy to interpret and simple to perform is of paramount importance.

This report demonstrates the usefulness of a latex agglutination test for the detection of CSF-CRP as a rapid and simple, method in diagnosing and differentiating cases of bacterial and non-bacterial meningitis in children [20]. The concentration of CSF CRP is raised in patients with meningitis.