Week 8: Body Fluids

components of routine BF analysis

• gross exam

• total cell count

• differential count

• micro

• chem

• cytology

CSF function

• brain & spinal cord

• cushion for nerves

• waste collection

• nutrient circulation

• lubrication

• intracranial pressure

• chemical environment maintenance

CSF circulates between which layers?

pia and arachnoid

meninges

• dura mater = outer

• arachnoid = middle

• pia = inner

CSF volume in adults

90-150 mL

CSF volume in neonates

10-60 mL

the CSF turns over how much each day?

500-600 mL (20 mL per hour)

hydrocephalus

• increased volume of CSF

• caused by blocked circulation or impaired reabsorption

where is lumbar puncture performed?

• L3-L4 = adults

• L4-L5 = neonates

how much CSF can be safely removed during lumbar puncture?

10-20 mL

the total ___________ must be recorded of the tap in all tubes of CSF

volume

CSF collection tubes

1. chemistry

2. microbiology

3. hematology

4. storage

CSF stability

• within 1 hour, no clots

• hematology → 4 hours refrigerated

• chemistry → freeze

• microbiology → RT

CSF cell count is usually performed how?

hemocytometer or automation

what can be indicated with abnormal results from CSF?

• meningeal infection

• subarachnoid hemorrhage

• CNS malignancies

• demyelinating disorders

what is observed during gross examination of CSF?

• 3 Cs

  • color

  • clarity

  • clotting

what is evaluated during microscopic examination of CSF?

• RBC count

• WBC count

• differential

what is analyzed during chemical analysis of CSF?

• glucose

• protein

when determining a traumatic tap vs. an intracranial hemorrhage, observe CSF for _____________ from tube to tube

clearing

what is indicated from the following?

• first CSF tube contains blood but the remaining are clear

• supernatant clear

traumatic tap

what is indicated from the following?

• all CSF tubes are uniformly bloody

• supernatant yellow/pink

subarachnoid hemorrhage

after CSF centrifugation, observe for ______________

xanthochromia

a cloudy CSF supernatant indicates what?

bacteria

a milky CSF supernatant indicates what?

lipids

an oily CSF supernatant indicates what?

X ray media

what is indicated if CSF supernatant is pale pink?

• subarachnoid hemorrhage within 1-4 hours

• oxyhemoglobin

• erythrocytes, neutrophils, lymphocytes

what is indicated if CSF supernatant is yellow?

• subarachnoid hemorrhage within 12 hours

• bilirubin

• peaks 2-4 weeks

• macrophages engulf RBCs or stored iron (hemosiderin)

• siderophages 1-8 weeks

there should be no _____________ in normal CSF, since it lacks fibrinogen

clotting

is this a traumatic tap or subarachnoid hemorrhage?

• blood decreasing amounts

• clot formation

• colorless supernatant

• negative D-dimer

traumatic tap

is this a traumatic tap or subarachnoid hemorrhage?

• blood equal amounts

• does not clot

• xanthochromia

• positive D-dimer

• hemosiderin

subarachnoid hemorrhage

normal cell count in CSF

• adult = 0-5 uL

• neonate = 0-30 uL

normal cells in CSF

lymphocytes (60%) and monocytes (30%)

normal range of glucose in CSF

50-80 mg/dL

normal range of protein in CSF

15-45 mg/dL

cell count formula for CSF using hemocytometer

(number of cells x DF) / (number of squares x volume of 1 square)

most serum proteins are ___________ in CSF

present

_________ is the most abundant protein in CSF, followed by ___________

albumin, prealbumin (transthyrein)

fibrinogen should NOT be found in _______

CSF

_________ have higher protein CSF levels, and after the age of ______ protein increases

neonates, 40

what can increased protein in CSF indicate?

• traumatic tap

• increased BBB permeability

• infections

• subarachnoid hemorrhage

• increased IgG production

• neurosyphilis

• MS

what does decreased glucose in CSF indicate?

• impaired glucose transport

• increased glycolysis

• infection (utilization by bacteria)

CSF lactate indications

• bacterial meningitis > 35 mg/dL

• viral meningitis < 25 mg/dL

• monitors head injuries

• tissue destruction

pleocytosis

increased WBCs in body fluid

what are neutrophils in body fluid associated with?

bacterial infections

what are lymphocytes in body fluid associated with?

• viral infections

• Guillain-Barre

what are plasmacytes in body fluid associated with?

multiple sclerosis

what are eosinophils in body fluid associated with?

allergic reactions (rare finding)

what are monocytes and macrophages in body fluid associated with?

phagocytosis

what type of cells can be found in CSF potentially?

• WBCs

• RBCs

• ependymal

• choroid plexus

• germinal matrix cells

• macrophages

• malignant cells

which type of meningitis is indicated?

• > 50,000 WBC/uL

• 90% neutrophils

• increased protein

• decreased glucose

bacterial meningitis

what species are associated with bacterial meningitis?

• H. influenzae

• S. pneumoniae

• N. meningitidis

• group B strep

which type of meningitis is indicated?

• mild to severe leukocytosis (mainly lymphocytes)

• large and reactive lymphocytes

viral meningitis

main cause of viral meningitis

enteroviruses

what is associated with fungal meningitis?

• Cryptococcus neoformans

  • india ink prep

• low-normal glucose

• elevated protein

intracranial shunts for _______________ increase monocytes, macrophages, and eosinophils

hydrocephalus

where is synovial fluid located?

joint cavities

function of synovial fluid

• supplies nutrients to cartilage

• lubricant

• debris removal

normal synovial fluid has the same chemical composition as __________

plasma

normal color and texture of synovial fluid

straw and viscous

what is the principle mucin for lubrication in synovial fluid?

hyaluronic acid

normal volume of synovial fluid

1-4 mL in knee, hip, elbow

normal WBC count in synovial fluid

< 200 uL

most WBCs in synovial fluid are normally what?

lymphocytes (< 25% neutrophils)

should there be RBCs and crystals in synovial fluid

no

how is synovial fluid collected?

• arthrocentesis with a heparinized needle

• patient should fast for 6 hours

synovial fluid collection tubes

1. sterile for microbiology

2. heparin (Na heparin preferred) or EDTA for microscopy

3. plain for clot formation, gross exam, chemical exam

_______ tube is recommended for cell counting in synovial fluid

EDTA

routine examination components for synovial fluid

• physical appearance

• cell count — blood cells

• differential

• crystal examination

• chemical analysis — glucose and protein

synovial fluid is examined for what physical properties?

• color

• viscosity

• clarity

what does cloudy synovial fluid indicate?

inflammation

viscosity string test for synovial fluid

• 4-6 cm = normal

• small discrete droplets → inflammation

  • decreased viscosity

clotting in synovial fluid indicates excess ______________ is present

fibrinogen

mucin clot or rope’s test

• synovial fluid is treated with acetic acid to polymerize the hyaluronic acid and forms a clot

• normal = tight ropy clot

neutrophils in synovial fluid indicate what?

bacteria or crystals

lymphocytes in synovial fluid indicate what?

non septic inflammation

macrophages in synovial fluid indicate what?

normal or viral infection

what is indicated with a synovial lining cell resembling a mesothelial cell in synovial fluid?

normal

LE cell

• lupus erythematosus cell

• found in synovial fluid

• neutrophil with a round body ingested

reiter cell

• macrophage found in synovial fluid

• contains ingested neutrophil

• associated with RA

RA cell

neutrophil with dark granules (immune complexes)

rice bodies

• pieces of cartilage surrounded by fibrin

• found in synovial fluid

• most common with RA

fat droplets in synovial fluid

• refractile globular

• stains with sudan black

• associated with chronic inflammation

hemosiderin

inclusion of iron

which crystal is described?

• most common

• needle shaped uric acid crystal

• gout

• arthritis

monosodium urate

which crystal is described?

• rhomboid shape

• pseudogout

• calcification

calcium pyrophosphate dehydrate (CPPD)

which crystal is described?

• flat with one corner punched out

• RA

• osteoarthritis

cholesterol crystal

what crystal is this?

monosodium urate

what crystal is this?

calcium pyrophosphate (CPPD)

what crystal is this?

cholesterol crystal

lipid crystals showing a ______________ formation with polarized light can cause acute arthritis

Maltese cross

corticosteroid crystals are ____________ shaped

needle

monosodium appears __________ with a red compensator

yellow

pyrophosphate appears ________ with a red compensator

blue

non inflammatory joint disorders

• osteoarthritis

• sickle cell disease

inflammatory joint disorders

• RA

• LE

• reiter’s

• rheumatic fever

what can the synovial fluid described be classified as?

• clear

• yellow

• good viscosity

• WBC < 5000

• neutrophil < 30%

• normal glucose

• no crystals

non inflammatory

what can the synovial fluid described be classified as?

• cloudy

• poor viscosity

• WBC 2000-25,000

• neutrophils > 50%

• decreased glucose

inflammatory

what can the synovial fluid described be classified as?

• cloudy

• green

• poor viscosity

• WBC 10,000-50,000

• neutrophils >90%

• decreased glucose

• positive culture

septic

what can the synovial fluid described be classified as?

• cloudy

• poor viscosity

• WBC 500-50,000

• neutrophils >90%

• decreased glucose

• crystals

crystal-induced

what can the synovial fluid described be classified as?

• cloudy

• red

• poor viscosity

• WBC <5,000

• neutrophil <50%

• normal glucose

• RBCs present

hemorrhage