MEDL350L Urinalysis Exam #2

Cerebrospinal fluid (CSF): Production by, absorbed by

• Produced by ependymal cells of the brain in choroid plexus

• Absorbed into circulation by cells in the arachnoid villi of CNS

Serous intermembrane fluids: Definition (secreted & absorbed by) & Types (5)

• Small amount of fluid secreted & absorbed from mesothelial cells lining a double membrane system surrounding the lungs, heart & peritoneal cavity

• fluids accumulate under following processes:

  • Transudative (transudate), Exudative (exudate), Pleural (thoracentesis), Pericardial, Peritoneal

Transudative (transudate): Definition/pathology & Total protein level

• clear, acellular fluid accumulates due to cardiac/vascular conditions that cause heart failure & inefficient venous return to the heart → disabling absorption of fluid back into circulation

  • Total protein < 3.0 g/dL

Exudative (exudate): Definition/pathology & Total protein level

• cloudy, hemorrhagic, cellular fluid accumulates because of infection, inflammation (SLE for example) or metastatic malignancy

  • Total protein level >3.0 g/dL

Pleural vs Pericardial vs Peritoneal (Anatomy of each)

• thoracentesis: double membrane system surrounding lungs

• Pericardial: surrounding the heart

• Peritoneal: surrounding the visceral organs

Synovial fluid: Anatomy & Produced/reabsorbed by

• from joint space; elbow & knee

• Produced and reabsorbed by synovial lining cells

Handling & Appearance of Body fluid analysis: Volume documented & Appearance

• Volume in mL should be documented

• Appearance: clear, colorless, turbid, xanthochromic (bilirubin color tinge), bloody, etc. noted

CSF: Indications of lumbar puncture (8)

Meningitis, Encephalitis, Leukemia with or without CNS involvement, Metastatic tumors especially breast and lung, CNS abscess, hemorrhage, syphilis, and Multiple sclerosis

CSF Formation & Reabsorption: Plasma ultrafiltrate (protein concentration, types of proteins, glucose concentration)

• 1% of plasma protein concentration

• at least 500 different proteins

• 60-70% of plasma glucose concentration

CSF Formation & Reabsorption: Produced & secreted by

• Produced and secreted by the choroid plexus

• Ependymal lining of the ventricles and subarachnoid spaces (anatomical blood-brain barrier)

CSF Formation & Reabsorption: Functions (2) & Absorbed by

• Bathes, lubricates & cushions the brain & spinal cord

• Circulates nutrients and removes wastes

• Absorbed by the arachnoid villi

Normal CSF Values: Appearance & Total Volume

• appearance: clear & colorless (occasionally is xanthochromic in jaundiced neonates)

• vol: 90-150 mL in adults; 10-60 mL in neonates

Normal CSF Values: Turnover, Total protein (& albumin), & Glucose

• 50-500 mL/day

• protein: 15-45 mg/dL

  • albumin 10-30 mg/dL

• glucose: 50-80 mg/dL

Normal CSF Cell counts in Adults: Mononuclear, RBCs, lymphs, monocytes, neutrophils

• 0-5 mononuclear cells/microL

• Few RBCs noted especially after a “traumatic tap”

• 60±20% lymphs

• 30±15% monocytes

• 2±4% neutrophils in adults

Normal CSF Cell count in Neonates: Monocytes, lymphs, neutrophils

• 70±20% monocytes

• 20±15% lymphocytes

• 4±% neutrophils

Ependymal Cells: Other name, anatomy, morphology, associated with

• Also called choroid plexus cells line the ventricles & stain as uniform, lymphocyte-like cells with abundant gray-blue cytoplasm (found in clusters)

• are associated with trauma, surgery, encephalography & ischemic infarct in CNS

CSF pathology of Hemorrhage (CVA): Appearance, Presence of

• Appearance: bloody, pink, brown, xanthochromic

• Presence of RBCs & phagocytic WBCs (including signet-ring macrophages & Hemosiderinophages)

Hemosiderinophage vs Signet-Ring Macrophage

• Hemo: macrophages that have ingested hemosiderin; have iron deposits in cytoplasm

• Signet: macrophages that contain large, clear cytoplasmic vacuoles that push the nucleus to the periphery → “signet-ring” appearance

CSF pathology of Hemorrhage (CVA): Hemorrhage vs Traumatic Trap (Appearance of CSF)

• hemorrhage: xanthochromic or brown supernatant after centrifugation

• trap: clear supernatant after centrifugation, decreasing amount of RBCs in tubes 2 & 3 (if obtained)

CSF Pathology of CNS Infection/Inflammation: Diseases, Appearance, Presence of

• Meningitis, encephalitis, syphilis, TB, MS, etc.

• Appearance: turbid (cloudy)

• Presence of WBCs

CSF Pathology of CNS Bacterial Meningitis: WBC count, WBCs as disease progresses vs after treatment, CSF glucose & total protein levels

• WBCs often > 50,000/microL

• as disease progresses: neutrophils can make up >90% of WBCs

• after treatment/resolution: monocytes & lymphs make up majority

• CSF glucose decreased (microorganism interfere with glucose transport)

• total protein = markedly increased

CSF Pathology of Viral Meningitis: WBC count, acute response, conditions associated with

• Mild to severe leukocytosis present in CSF

• Acute response: increase of neutrophils then increase predominantly in monocytes & lymphocytes including plasma cells

• Fungal, parasitic infections, syphilis, TB, MS, & inflammatory conditions: associated with the presence of variant lymphs, eosinophils & basophils

CSF Malignancy of Malignancy: Leukemia (ALL & AML), WBC in CSF & Tumor cells

• 80% of ALL has CNS involvement

• 60% of AML has CNS involvment

• leukemic cells including basophils may be present in CSF

• Breast, lung, and other metastatic tumor cells

Serous intermembrane fluids: Type of system, type of cell that lines, covers/protects 3 organs

• Double membrane system, lined with mesothelial cells

• Covers and protects heart (pericardium), viscera (peritoneum) & lungs (pleural membranes)

Transudates: Appearance, total protein level, WBC count, LDH activity, pathology

• clear & colorless

• < 3 g/dL of total protein

• < 1000 WBC/microL

• LDH activity < 200 U/L

• Accumulation due to alteration of normal hydrostatic pressure in circulatory failure

  • Increased capillary permeability or decreased reabsorption of fluids

Exudates: Appearance, total protein level, LDH activity, WBC count, accumulation in/pathology

• turbid & purulent

• > 3 g/dL of total protein

• LDH activity > 200 U/L often >1000

• WBC/μL > 100,000 RBC/μL

• Accumulation in infection, inflammation, abscess, SLE, malignancy, hemothorax

Pleural Pathology: Presence of & Diseases

• Presence of WBCs including PMNs, lymphocytes, monocytes, eosinophils, variant lymphocytes

• bacterial infections, pneumonia, infarct, pancreatitis, tuberculosis, RA, pulmonary embolus, pneumothorax, malignancy

Pericardial Pathology: Presence of & Disease

• Presence of WBCs including PMNs, lymphocytes, monocytes, eosinophils, variant lymphocytes

• infection, malignancy, CHF, hypoproteinemia

Peritoneal Pathology: Presence of & Diseases

• Presence of WBCs including PMNs, lymphocytes, monocytes, eosinophils, variant lymphocytes

• trauma, malignancy, infection, ruptured spleen, cirrhosis, nephrotic syndrome, MS, TB, SLE, pancreatitis

Mesothelial cells: Anatomy & Infectious/Inflammatory effusions

• Cells forming lining of pleural, pericardial & peritoneal membranes

• Infectious and inflammatory effusions: proliferation and desquamation

Mesothelial cells: Morphology

• Appear as sheets or clusters of cells

• 12-30 μm with “fried egg” appearance

• May be bi- or multinucleate (>20 nuclei/cell) with small vacuoles

Synovial Fluid: Synovium & Plasma ultrafiltrate

• Synovium: cells lining space between joints

• Production and secretion of plasma ultrafiltrate enriched in hyaluronate (proteoglycan)

Synovial Fluid: Appearance, should not have, total protein value, WBC count, cell differential (mono & neutrophils)

• Appearance: light yellow, clear, viscous

• Should not clot upon standing nor contain crystals

• 1-3 g/dL total protein

• 0-200 WBC/μL; 65% monocytes; < 25% neutrophils

Synovial fluid pathology of Gout: Appearance & WBC count

• Milky, greenish with intracellular (neutrophils) & extracellular uric acid crystals present

• WBCs 65-100,000/μL with > 90% neutrophils are common

Uric Acid Crystals: Morphology & Polarized Light

• 1-20μm, needle-like

• Yellow when parallel to the slow component of the compensator (negative birefringence)

Calcium pyrophosphate: Morphology & Polarized light

• pale rod, rhomboid, plate-like crystals

• that are weakly and positively birefringent (blue when long axis is parallel to the slow component of the compensator)

Synovial fluid pathology of RA (Morphology)

Lymphocytes may predominate & ragocytes or RA cells (neutrophils containing immune complexes)

RBC morphology: Freshly Voided vs Crenated

• freshly: normal biconcave shape

• crenated: spiky/scalloped shape

Mast cell Morphology

Plasma cell morphology

Blasts (morphology & indication)

indicates malignancy & hematologic