Part 2

1,2

Cell Count

• Any cell count should be performed immediately

  • WBCs & RBCs begin to lyse within an ____ hour

  • 40% of WBCs disintegrate within ___ hours

WBC count

Cell count

• Routinely performed on CSF

0-5, 0-30

Cell count

• Normal values for WBC count for

• Adults:______ WBCs/uL

• Neonates:______ WBCs/uL

3% acetic acid with methylene blue

Cell count

• Diluting fluid for WBC count

RBC count

Cell count

• Done only in cases of traumatic tap and correction for WBCs or proteins is needed

total cell count

Cell count

• Cells are counted in the 4 corner squares and the center square of the hemocytometer

NSS

Cell count

• Diluent of Total cell count

WBC correction

Cell count

• A calculation is used to correct CSF WBC counts which are falsely increased due to a traumatic tap

1, 750

Cell count : WBC Correction

• If the patient’s peripheral WBC and RBC counts are within normal limits, some laboratories use the following formula:

  • Subtract ____white cell from the CSF WBC count for each_____ RBC counted in the spinal fluid

sedimentation, filtration, cytocentrifugation, centrifugation

Differential Count

• Performed on stained smear

• Specimen should be concentrated before smearing by using what methods (4)

  • ___________

  • ___________

  • ___________- 0.1 mL of CSF combined with 1 gtt of 30% albumin produces adequate cell yield

  • ___________- 5- 10 min

lymphocytes, monocytes, neutrophils

Differential count

• What normal cells that are found?

  • __________- predominant in ADULTS (L:M ratio - 70:30)

  • __________- predominant in CHILDREN

  • __________- rarely found (If present causes; bacterial meningitis)

pleocytosis

Differential count

• Increased numbers of normal cells are considered as ABNORMAL finding

• LYMPHOTIC PLEOCYTOSIS: 90% lymphocytes, 10% monocytes

• MONOCYTIC PLEOCYTOSIS: 90% monocytes, 10% lymphocytes

lymphocytes and monocytes

Predominant Cells in CSF

• normal, all stages of development may be found

• monocytes mixed with lymphocytes

• increased in viral, tubercular, & fungal meningitis

• Multiple Sclerosis

neutrophils

Predominant Cells in CSF

• increased in bacterial meningitis & in early cases of viral, tubercular, & fungal meningitis

  also found in cerebral hemorrhage

• cell disintegrate rapidly

eosinophils

Predominant Cells in CSF

• associated with parasitic infections, fungal infection (C. immitis), introduction of foreign material

macrophages

Predominant Cells in CSF

• found with RBCs in spinal fluid

• may contain phagocytized RBCs (erythrophages) appearing as empty vacuoles, hemosiderin granule, etc.

• increased number indicates previous hemorrhage

blasts

Predominant Cells in CSF

• found in acute leukemia

• either in lymphoblast, myeloblast, or monoblast form

lymphoma cells

Predominant Cells in CSF

• found in disseminated lymphoma

• resemble lymphocytes with cleft nuclei

plasma cells

Predominant Cells in CSF

• found in multiple sclerosis

• due to lymphocyte reactions

ependymal, choroidal and spindle shaped cells

Predominant Cells in CSF

• for diagnostic procedures

• seen in clusters with distinct nuclei & distinct cell walls

malignant cells

Predominant Cells in CSF

• found in metastatic carcinomas & primary CNS carcinomas

• seen in clusters with fusing of cell borders & nuclei

CSF protein

• Most frequently performed chemical test on CSF

15-45 mg/dL

CSF protein

• NV?

  • Values are higher in infants and older persons

  • CSF proteins are < 1% compared to serum

hemorrhage and meningitis

CSF protein

Is increased in;

• ______________ - most common, due to damage to the blood brain barrier

multiple sclerosis

CSF protein

Is increased in;

• ____________- due to production of immunoglobulins within the CNS

CSF leakage

CSF protein

Is decreased in; ?

albumin, pre albumin

CSF protein

• Major CSF Protein?

• Second most prevalent?

haptoglobin & ceruloplasmin

CSF protein

• Alpha-globulins?

b2 transferrin

CSF protein

• Beta-globulins?

  • Carbohydrate deficient transferrin, also known as “tau”

Note: This is the identifying protein for CSF, meaning this indicates that the specimen is really CSF

Not found in blood, only in CSF

IgG and some IgA

CSF protein

• Gamma-globulins?

IgM, fibrinogen and lipids

CSF protein

• Not found in normal CSF

3 % TCA

CSF protein : TURBIDIMETRIC

• preferred method, precipitates both albumin & globulin

3 % SSA

CSF protein : TURBIDIMETRIC

• precipitates albumin only

• to precipitate globulin, add SODIUM SULPHATE

coomassie brilliant blue

CSF protein : DYE BINDING

• protein binds to dye which turns RED to BLUE

csf serum albumin index

CSF protein : PROTEIN FRACTIONS

• Evaluates the integrity of the BBB

< 9

CSF protein : PROTEIN FRACTIONS

• Normal CSF/serum albumin index?

• Abnormal: ≥ 9

  • indicates destruction of the BBB

csf serum igG index

CSF protein : PROTEIN FRACTIONS

• Measure IgG synthesis within the CNS

< 0.77

CSF protein : PROTEIN FRACTIONS

• Normal CSF/serum IgG index?

• Abnormal: ≥ 0.77

  • indicates increased IgG production within the CNS (ex. Multiple Sclerosis)

electrophoresis

CSF protein : PROTEIN FRACTIONS

• Agarose gel electrophoresis followed by CBB (Commasie) staining – most frequently performed

• Methods of choice when it is necessary to determine if the fluid is CSF (“tau” identification)

• Done in conjunction with serum electrophoresis

• For detection of OLIGOCLONAL BAND

  • Indicates immunoglobulin production

multiple sclerosis

CSF protein : PROTEIN FRACTIONS

• In Electrophoresis, the presence of 2 or more oligoclonal bands in CSF but NOT in serum is valuable for the diagnosis of?

• Other conditions:

  • neurosyphilis,

  • encephalitis,

  • neoplastic disorders,

  • Guillain-Barre syndrome

csf glucose

• Done in conjunction with blood glucose

• Specimen for blood glucose should be drawn 2 hours PRIOR to spinal tap

2 hours prior

CSF Glucose

• Specimen for blood glucose should be drawn _________to spinal tap

60 – 70%

CSF Glucose

• Normal Value?

csf lactate

• Aids in diagnosis and management of meningitis case

Inversely proportional

CSF Lactate

• ___________to glucose

  • Glucose is utilized by bacterial or fungi converting it to energy and producing lactate as a by-product

10-22mg/dL

CSF Lactate

• Normal Value:

CSF glutamaine

• Chemical test frequently performed in CSF but not in blood

• INDIRECT measure of CSF Ammonia

decreases

CSF glutamaine

• INDIRECT measure of CSF Ammonia

• As CSF ammonia increases, alpha-ketoglutarate ________ due to conversion into glutamine, resulting in coma

Brain tissue destruction

CSF Enzymes

• Increased LD1 & LD2–

Viral Meningitis

CSF Enzymes

• Increased LD2 & LD3

Bacterial Meningitis

CSF Enzymes

• Increased LD4 & LD5

creatine kinase

CSF Enzymes

• Elevated in stroke, MS, brain tumors, viral & bacterial meningitis, & epileptic seizure

AST

CSF Enzymes

• Elevated in intracerebral & subarachnoid hemorrhage

gram stain

CSF Microbiological Exam

blood culture

CSF Microbiological Exam

• Done because the causative agent will be in both blood and CSF

acid fast / fluorescent antibody stains

CSF Microbiological Exam

• For suspected cases of tubercular meningitis

india ink

CSF Microbiological Exam

• Detects the presence of Cryptococcus neoformans

  • produce a star-burst pattern in gram stain

limulus lysate test

CSF Microbiological Exam

• Detects gram negative bacterial endotoxins in body fluids

• Principle:

  • In the presence of endotoxins, the amoebocytes (WBCs) will release lysate (protein)

  • (+) clumping/clot formation

horseshoe cram blood

CSF Microbiological Exam

• Limulus lysate test reagent? It contains hemocyanin

VDRL

CSF Serologic exam

• Recommended by CDC due to its ability to detect active cases of syphilis

FTA-ABS

CSF Serologic exam

• Used with care to avoid contamination with blood because it remains positive in the serum of treated cases of syphilis

RPR

CSF Serologic exam

• Not recommended because it is less sensitive than VDRL