1 - OTHER BODY FLUIDS

CSF

is routinely collected by lumbar puncture between the third, fourth, or fifth lumbar vertebrae

three

CSF

Specimens are collected in _ sterile tubes, which are labeled 1, 2, and 3 in the order in which they are withdrawn

Tube 1

CSF

used for chemical and serologic tests

Tube 2

CSF

usually designated for the microbiology laboratory

Tube 3

CSF

used for the cell count

fourth tube

CSF

A _ _ may be drawn for the microbiology laboratory to provide better exclusion of skin contamination or for additional serologic tests

Supernatant fluid

CSF

_ _ that is left over after each section has performed its tests may also be used for additional chemical or serologic tests

Excess fluid

CSF

_ _ should not be discarded and should be frozen until there is no further use for it

crystal clear, cloudy or turbid, milky, xanthochromic, and hemolyzed/bloody

CSF

appearance includes (5)

Xanthochromia

CSF

_ is a term used to describe CSF supernatant that is pink, orange, or yellow

oxyhemoglobin

hemolysis

unconjugated bilirubin

CSF

Due to the presence of RBC degradation products, the color will vary from pink (very slight amount of _) to orange (heavy _) to yellow (conversion of oxyhemoglobin to _ _).

CSF

leukocyte (WBC) count

CSF

Cell Count

The cell count that is routinely performed on CSF specimens is the _ _

RBC counts

CSF

Cell Count

_ _ are usually determined only when a traumatic tap has occurred and a correction for leukocytes or protein is desired

total cell count

WBC count

CSF

Cell Count

The RBC count can be calculated by performing a _ _ _ and a _ _ and subtracting the WBC count from the total count, if necessary

0 to 5

30

CSF

Cell Count

Normal adult CSF contains _-_ WBCs/L. The number is higher in children, and as many as _ mononuclear cells/L can be considered normal in newborns

200

400

CSF

Cell Count

Specimens that contain up to _ WBCs or _ RBCs/l may appear clear, so it is necessary to examine all specimens microscopically

Clear

CSF

Total Cell Count

_ specimens may be counted undiluted, provided no overlapping of cells is seen during the microscopic examination

normal saline

CSF

Total Cell Count

Dilutions for total cell counts are made with _ _, mixed by inversion, and loaded into the hemocytometer with a Pasteur pipette

four corner

center

CSF

Total Cell Count

Cells are counted in the _ _ squares and the _ square on both sides of the hemocytometer

CSF

Total Cell Count

Formula

Undiluted

CSF

CSF Dilution

Clear

1:10

CSF

CSF Dilution

Slightly hazy

1:20

CSF

CSF Dilution

Hazy

1:100

CSF

CSF Dilution

Slightly cloudy

1:200

CSF

CSF Dilution

Cloudy/Slightly bloody

1:10,000

CSF

CSF Dilution

Bloody/Turbid

Lysis

CSF

WBC Count

_ of RBCs must be obtained prior to performing the WBC count on either diluted or undiluted specimens

methylene blue

CSF

WBC Count

Addition of _ _ to the diluting fluid stains the WBCs, providing better differentiation between neutrophils and mononuclear cells

four

3% glacial acetic acid

1

CSF

WBC Count

To prepare a clear specimen that does not require dilution for counting, place _ drops of mixed specimen in a clean tube. Rinse a Pasteur pipette with _% _ _ _, draining thoroughly, and draw the four drops of CSF into the rinsed pipette. Allow the pipette to sit for _ minute, mix the solution in the pipette, discard the first drop, and load the hemocytometer

dilution factor

CSF

WBC Count

As in the total cell count, WBCs are counted in the four corner squares, and the center square on both sides of the hemocytometer and the number is multiplied by the _ _ to obtain the number of WBCs per microliter

Lymphocytes

CSF

Predominant Cells Seen in Cerebrospinal Fluid

Major Clinical Significance: Normal, viral, tubercular, and fungal meningitis, multiple sclerosis

Microscopic Findings: All stages of development may be found

Neutrophils

CSF

Predominant Cells Seen in Cerebrospinal Fluid

Major Clinical Significance: Bacterial meningitis, early cases of viral, tubercular, and fungal meningitis, cerebral hemorrhage

Microscopic Findings: Granules may be less prominent than in blood, cells disintegrate rapidly

15 to 45

CSF

Cerebrospinal Protein

Normal CSF contains a very small amount of protein. Normal values for total CSF protein are usually listed as _-_ mg/dL, but are somewhat method dependent

elevated

CSF

Cerebrospinal Protein

The causes of _ CSF protein include damage to the blood-brain barrier, production of immunoglobulins within the CNS, decreased clearance of normal protein from the fluid, and degeneration of neural tissue

Meningitis

hemorrhage

CSF

Cerebrospinal Protein

_ and _ conditions that damage the blood-brain barrier are the most common causes of elevated CSF protein

CSF

Cerebrospinal Protein

CSF serum albumin index formula

CSF

Cerebrospinal Protein

IgG index formula

60, 70

65

CSF

Cerebrospinal Fluid Glucose

Glucose enters the CSF by selective transport across the bloodbrain barrier, which results in a normal value that is approximately _% to _% that of the plasma glucose. If the plasma glucose is 100 mg/dL, then a normal CSF glucose would be approximately _ mg/dL

2

CSF

Cerebrospinal Fluid Glucose

The blood glucose should be drawn about _ hours prior to the spinal tap to allow time for equilibration between the blood and fluid. CSF glucose is analyzed using the same procedures employed for blood glucose

plasma

CSF

Cerebrospinal Fluid Glucose

Elevated CSF glucose values are always a result of _ elevations

bacterial meningitis

CSF

Cerebrospinal Fluid Glucose

The finding of a markedly decreased CSF glucose accompanied by an increased WBC count and a large percentage of neutrophils is indicative of _ _

tubercular meningitis

CSF

Cerebrospinal Fluid Glucose

If the WBCs are lymphocytes instead of neutrophils, _ _ is suspected

viral meningitis

CSF

Cerebrospinal Fluid Glucose

Likewise, if a normal CSF glucose value is found with an increased number of lymphocytes, the diagnosis would favor _ _

meningitis

CSF

Cerebrospinal Fluid Lactate

The determination of CSF lactate levels can be a valuable aid in the diagnosis and management of _ cases

25

CSF

Cerebrospinal Fluid Lactate

In bacterial, tubercular, and fungal meningitis, the elevation of CSF lactate to levels greater than _ mg/dL occurs much more consistently than does the depression of glucose and provides more reliable information when the initial diagnosis is difficult

bacterial meningitis

viral meningitis

CSF

Cerebrospinal Fluid Lactate

Levels greater than 35 mg/dL are frequently seen with _ _, whereas in _ _, lactate levels remain lower than 25 mg/dL

hypoxia

CSF

Cerebrospinal Fluid Lactate

Destruction of tissue within the CNS owing to oxygen deprivation (_) causes the production of increased CSF lactic acid levels

8 to 18

CSF

Cerebrospinal Fluid Glutamine

The normal concentration of glutamine in the CSF is _-_ mg/dL.

liver disorders

CSF

Cerebrospinal Fluid Glutamine

Elevated levels are found in association with _ _ that result in increased blood and CSF ammonia

Gram Stain

AFB

India Ink

Culture

CSF

Microbiology Tests

(4)

VDRL

FTA-ABS

Latex agglutination and enzyme-linked immunosorbent assay (ELISA) methods

Test kits are available to detect Streptococcus group B, H. influenzae type b, S. pneumoniae, N. meningitidis A, B, C, Y, W135, and E. coli K1 antigens.

BACTIGEN Test

CSF

Serologic Testing

(5)

Synovium

Synovial Fluid

refers to the tissue lining synovial tendon sheaths, bursae, and diarthrodial joints except for the articular surface

1-3

Synovial Fluid

Synovium

Compose of _-_ cell layers that form a discontinuous surface overlying fatty, fibrous, or periosteal joint tissue

Synovial Fluid

Synovial Fluid

Synovium

an imperfect ultrafiltrate of plasma combined with hyaluronic acid produced by the synovial cells

plasma

Synovial Fluid

Synovium

Small ions and molecules like glucose and urea cross easily into the joint space and are therefore similar in concentration to _, but large molecules are absent or present only in trace amounts

Synovial fluid

Synovial Fluid

Synovium

_ _ acts as a lubricant and adhesive and provides nutrients for the avascular articular cartilage

Arthrocentesis

Synovial Fluid

Specimen Collection

indicated in a patient with an undiagnosed effusion or a clinical change related to a known effusion

Effusion

Synovial Fluid

Specimen Collection

escape of fluid into a part; exudation, transudation

bacteremia

Synovial Fluid

Specimen Collection

caution is necessary to avoid aspirating a sterile joint in someone with _ or aspirating through a cutaneous or peroarticular soft tissue infection into a sterile joint

4

Synovial Fluid

Specimen Collection

Even large joints like the knee normally contain no more than _ mL of synovia, so a small sample size is common unless an effusion is present

plastic syringes

Synovial Fluid

Specimen Collection

Sterile, disposable needles are used; _ _ are used to avoid contamination by birefringent particulates

25

Synovial Fluid

Specimen Collection

Syringe may be heparinized by _ units of sodium heparin per millilitre of SF in routine arthrocentesis

Oxalate, powdered EDTA, and lithium heparin

Synovial Fluid

Specimen Collection

(3) should be avoided because they form crystal artifacts that may be misleading during examination

5-10

Synovial Fluid

Specimen Collection

_-_ ML placed in a sterile heparinized tube or syringe for microbiologic studies

2-5

Synovial Fluid

Specimen Collection

_-_ ML is placed in an anticoagulant tube (sodium heparin of liquid EDTA) for microscopic examination

5

Synovial Fluid

Specimen Collection

_ ML is put into a plain, “red top” tube and allowed to clot (normal SF does not clot)

125

1 or 2

Synovial Fluid

Specimen Collection

Concentrations of heparin greater than _ U/mL have an inhibitory effect on some pathogenic bacteria; specimens for culture should therefore be at least _ or _ mL in volume if they are submitted in “green top” heparin tubes

infectious arthritis

synovial fluid crystals

Synovial Fluid

Recommended Tests

Diagnosis of _ _ and _ _ _ is the most compelling reason for SF analysis

Diagnosis

Synovial Fluid

Recommended Tests

It is vital that they be performed well because they can provide highly specific diagnostic information

bedside

Synovial Fluid

Recommended Tests

Total volume should be recorded at the _, especially if the sample is to be divided for submission to different laboratory sections

Color

Synovial Fluid

Recommended Tests

_ is evaluated in a clear glass tube against a white background

colorless

pale yellow

Synovial Fluid

Recommended Tests

Normal SF is _ to _ _ owing to diapedesis of a few RBCs associated with even mild trauma

Diapedesis

Synovial Fluid

Recommended Tests

_ - the passage of blood cells through capillary walls into the tissues—called also emigration

xanthochromia

Synovial Fluid

Gross Examination

Non-inflammatory and inflammatory disorders are usually straw to yellow in color (_)

Septic fluid

Synovial Fluid

Gross Examination

_ _ may be yellow, brown, or green depending on the chromogen produced by the offending organism and the host response, including the WBCs and RBCs

Traumatic Tap

Synovial Fluid

Gross Examination

produces an uneven distribution of blood during arthrocentesis or streaking in the syringe

Red-Brown

Synovial Fluid

Gross Examination

color following centrifugation is good evidence of pathologic hemarthrosis

Clarity

Synovial Fluid

Gross Examination

relates to the number and type of particles within the synovia

transparent

Synovial Fluid

Gross Examination

Normal SF is _; newsprint is easily read through tube

leukocytes

Synovial Fluid

Gross Examination

_ are most commonly responsible for changes in clarity, but massive numbers of crystals may produce an opaque, milky-opalescent fluid without white cells

cholesterol crystals

Synovial Fluid

Gross Examination

A shimmering, oily-appearing specimen suggests an abundance of _ _ which may look like pus

fibrin

Synovial Fluid

Gross Examination

Increased turbidity is less often due to concentrations of _, free-floating “rice bodies” (fragments of degenerating proliferative synovial cells)

ground pepper

Synovial Fluid

Gross Examination

A “_ _” appearance resulting from pigmented cartilage is a sign of ochronosis; hardening of tendons & ligaments can predispose them to rupture. Colour changes in the joints can be observed clinically

Total Cell Count

Synovial Fluid

Microscopic Examination

should be promptly performed to avoid degenerative cell loss, which begins as soon as one hour following arthrocentesis

inverted

haemocytometer

Synovial Fluid

Microscopic Examination

Total Cell Count

Tubes must be _ before sampling to ensure uniform mixing; Counts are performed in standard _

0-2

1300

Synovial Fluid

Microscopic Examination

Total Cell Count

A wet-prep slide count of _-_ leukocytes/hpf (average 10 fields/hpf) predicts less than _ WBCs by cell count

50,000

Synovial Fluid

Microscopic Examination

Total Cell Count

Leukocytes counts over _/uL require dilution which should be done with saline not acetic acid, to avoid mucin clot formation and cell clumping

hyaluronidase

Synovial Fluid

Microscopic Examination

Total Cell Count

Highly viscous should be incubated with _ before it is counted

hyaluronan

Synovial Fluid

Microscopic Examination

Total Cell Count

hyaluronidase lowers the viscosity of _, thereby increasing tissue permeability

0.3 N saline

0.1 N HCl

1% saponin in saline

Synovial Fluid

Microscopic Examination

Total Cell Count

RBCs should be counted unless it is obvious traumatic tap; if in large number, lyse first with the use of _ _, _ _, or _ _ in _

150-200/uL

Synovial Fluid

Microscopic Examination

Total Cell Count

upper limit of normal SF for leukocytes in clinical specimens

Cytospin preparations

Synovial Fluid

Microscopic Examination

Differential Count

_ _ are preferred over smears of centrifuged SF because they have better cell morphology; treatment with hyaluronidase may be necessary to produce thin smears in viscous specimens

Neutrophils

Synovial Fluid

Microscopic Examination

Differential Count

normally account for about 20% of SF leukocytes. SF from patients with urate gout or RA may also have high percentages

pyknosis

karyorrhexis

Synovial Fluid

Microscopic Examination

Differential Count

Neutrophils frequently exhibits _ and _ and may contain bacteria, crystals, lipid droplets, vacuoles or dark blue inclusions (ragocytes, RA cells)

Lymphocytes

Synovial Fluid

Microscopic Examination

Differential Count

15% of the differential, prominent in early RA, chronic infections and collagen disorders. Reactive forms, including immunoblasts may be seen

Monocytes and macrophages

Synovial Fluid

Microscopic Examination

Differential Count

accounts for approximately 65% of the normal cell count. Monocytosis may be self-limited in patients with viral arthritis or serum sickness or more chronic in those with SLE

Eosinophilia

Synovial Fluid

Microscopic Examination

Differential Count

defined over 2% of the leukocyte count; reported in RA, RF, metastatic carcinoma. Lyme disease, parasitic infections, chronic urticarial, angioedema, and following arthrography and irradiation