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The Green Cerebrospinal Fluid

greenfluidA sample of cerebrospinal fluid from a 52-year-old-woman told an interesting tale. The patient reported a 1-week history of worsening headache, shortness of breath, and fatigue but denied any fever, chest pain, orthopnea, paroxysmal nocturnal dyspnea, nausea, vomiting, abdominal pain, or diarrhea. She had experienced a subarachnoid hemorrhage 7 months earlier, and at that time, she had required several ventricular shunts for persistent hydrocephalus. When she was admitted to the Rush University Medical Center, she had a functioning ventriculopleural shunt. The original device was inserted 4 months before her current illness but replaced 2 months later at the same site after it malfunctioned.

Assessment
On admission, the patient was afebrile and had normal vital signs. Her conjunctivae were not pale, and her cardiac examination results were unremarkable. Breath sounds were decreased in the left lung field, but the patient’s extremities were free of edema. A neurologic examination indicated she was alert and oriented without any signs of meningitis.

A chest radiograph showed a left-sided pleural effusion; this was the same side where the current shunt had been placed. Because of concern for a malfunctioning shunt and possible central nervous system infection, the patient underwent shunt externalization with external ventricular drain attachment. Cerebrospinal fluid collected directly from the shunt catheter was sent for examination on a daily basis throughout her hospital course. Of note, the sample color was consistently green (Figure). Initially, the cerebrospinal fluid showed 10,000 red blood cells/μL and 40 white blood cells/μL (corrected, 38 white blood cells/μL) with 58% monocytes and 14% neutrophils. Cerebrospinal fluid glucose and total protein were normal at 87 mg/dL (simultaneous peripheral blood glucose, 117 mg/dL) and 10.1 mg/dL, respectively. Gram stain showed gram-negative rods.

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— Gerome Escota, MD, James Como, MD, Harold Kessler, MD

This article originally appeared in the May 2011 issue of The American Journal of Medicine.

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