Body Fluids

CLBT 2200: CLT CERTIFICATION REVIEW

UNIT 2: BODY FLUIDS REVIEW

BODY FLUIDS - COLLECTION

  • Body Fluid Specimens

    • Specimen Collection

      • Difficult to obtain.

      • Collected by needle aspirate from site.

      • Volume varies depending upon site; typically 1 – 3 tubes collected.

      • Store unused specimens in refrigerator.

      • Immediate (STAT) testing is required due to cell degradation and glycolysis.

      • Simultaneous blood samples may be drawn for non-hematology testing (glucose, protein).

BODY FLUIDS - HEMATOLOGY

  • Basic Fluid Analysis – Hematology Lab

    • Physical Characteristics

      • Color

      • Clarity

      • Volume

      • Viscosity (notably for synovial fluid).

    • Total Cell Count (using Hemacytometer)

      • Counts total red blood cells (RBCs) and total white blood cells (WBCs).

      • Clear fluids are counted undiluted.

      • Cloudy or bloody fluids are diluted with saline and then counted.

      • Correct for dilution in calculations.

BODY FLUIDS - CEREBROSPINAL FLUID (CSF)

  • CSF Collection

    • Collected by physician.

    • 1 – 3 tubes with 1 ml in each.

    • Spinal aspirate performed between 3rd – 4th lumbar vertebrae.

    • Transported at room temperature.

    • Priority (STAT) lab testing.

CSF - SIGNIFICANCE

  • Cerebrospinal Fluid (CSF) Disease States

    • Bacterial Meningitis

      • Increased WBC count (segmented neutrophils), increased protein, decreased glucose, positive gram stain.

    • Viral Meningitis

      • Increased WBC count (lymphocytes), increased protein, normal glucose and lactate levels.

    • Tubercular Meningitis

      • Increased WBC count (mixed reaction), increased protein, decreased glucose, increased lactate, possibly pellicle formation.

CSF – PHYSICAL EXAM

  • Cerebrospinal Fluid (CSF)

    • Color: Normally colorless.

      • Hazy, cloudy, or milky appearance could indicate presence of WBCs, RBCs, bacteria, or protein.

      • Bloody appearance suggests trauma (fatty or oily indicates X-ray media).

      • Xanthochromic: pink, orange, yellow, brown color of supernatant post-centrifugation (oxyhemoglobin produces pink).

      • Caused by RBC degradation; could indicate either traumatic tap (with delayed centrifugation > 1 hour) or subarachnoid hemorrhage.

    • Normal appearance: Clear and colorless.

CSF – CELL COUNTS

  • Cerebrospinal Fluid (CSF)

    • Color: Colorless.

    • Clarity: Clear.

    • Cell Count:

      • RBCs: None (a few may appear due to peripheral blood contamination during puncture).

      • Many RBCs indicate a traumatic tap or true hemorrhage.

      • WBCs: Normal count between 0-5/ µL (primarily lymphocytes and monocytes).

        • Abnormal: Bloody appearance indicates possible issues.

CSF – TRAUMATIC TAP

  • Cerebrospinal Fluid (CSF)

    • Indicator of Traumatic Tap:

      • Gross appearance of tube #1 to #3 will show decreased red color, or a decrease in RBC count in tube #1 and #3 of greater than 10%.

      • Clotting will occur on standing due to fibrinogen presence.

      • No xanthochromia after centrifugation provided done within 1 hour post-collection.

      • Should not contain many macrophages or any macrophages with ingested intact RBC, hemosiderin, or hematoidin crystals.

NORMAL CELLS IN CSF

  • Types of Normal Cells Found:

    • Choroid plexus cells (above)

    • Ependymal cells (below)

    • Reactive lymphocytes can be seen in viral meningitis.

ABNORMAL CELLS IN CSF

  • Types of Abnormal Cells Found:

    • Blast cells (above)

    • Plasma cells (below)

    • Erythrophagocytosis observable in PMN (polymorphonuclear) cells.

    • Lymphoma cells are indicative of malignancy.

CSF CELLULAR INCLUSIONS

  • Cellular Inclusions:

    • Erythrophages, macrophages, lymphocytes, siderophages.

    • Siderophage: Contains hemosiderin.

    • Hematoidin Crystals: Result from degraded hemoglobin.

    • Examples:

      • CSF erythrophage with few iron granules present.

      • CSF hematoidin crystal/bilirubin crystal as noted in 1991 CAP study.

CSF CELLS - SIGNIFICANCE

  • Significance of CSF Cell Types:

    • Choroid Plexus Cells: Normal, seen only in CSF.

    • Ependymal Cells: Normal, seen only in CSF.

    • Blast Cells: Associated with leukemias.

    • Plasma Cells: Seen in multiple myeloma cases.

    • Lymphoma Cells: Indicative of lymphomas – Hodgkin’s and Non-Hodgkin’s types.

    • Reactive Lymphocytes: Indicative of viral meningitis.

    • Segmented Neutrophils (Increase): Indicates bacterial meningitis.

    • Erythrophages: Suggests intracranial hemorrhage.

    • Siderophages: Indicating subarachnoid hemorrhage (1 – 2 days).

    • Hematoidin Crystals: Indicating subarachnoid hemorrhage (1 – 2 weeks).

    • Parasites: Naegleria fowleri or Acanthamoeba suggest amoebic meningitis.

BODY FLUIDS - SYNOVIAL FLUIDS

  • Synovial Fluid Description:

    • A viscous liquid from joint cavities (due to hyaluronic acid) obtained through arthrocentesis.

    • Function:

      • Reduces friction (lubrication).

      • Provides essential nutrients.

      • Lessens shock to joints.

SYNOVIAL FLUID EXAMINATION

  • Synovial Fluid Characteristics:

    • Color/Clarity: Ranges from pale yellow to colorless and should be clear.

    • Cell Count:

      • WBCs: < 200/µL

      • RBCs: 0/µL — few may appear due to collection, but high numbers indicate hemorrhage into joints.

      • Dilute with saline; acetic acid cannot be used as it will clot the fluid.

    • Mucin Clot Test:

      • Add 2% acetic acid.

      • Appropriate appearance shows normal fluid, while abnormal fluids show less effective clot formation.

SYNOVIAL FLUID - INCLUSIONS

  • Inclusions Notable in Synovial Fluid:

    • “Ground pepper” inclusions (Ochronotic shards) associated with joint prosthetics.

    • “Rice bodies” inclusions which are fragments of fibrin-rich synovial tissue associated with rheumatoid arthritis or degenerated synovium.

SYNOVIAL FLUID – MACRO EXAM

  • Macroscopic Examination of Synovial Fluid

    • Analyte Normal vs. Abnormal

      • Color: Pale yellow (vs. darker yellow, red, green, white for abnormal).

      • Appearance: Clear (vs. turbid, milky for abnormal).

      • Volume: Should be < 3.5 ml.

      • Viscosity: Should form strings but should not clot.

      • pH: Normal between 7.2 – 7.4 (abnormal < 7.2 or > 7.4).

      • Inclusions: Normal shows none, while abnormalities include Ochronotic shards and rice body inclusions.

REITER CELLS vs RAGOCYTES

  • Reiter Cells:

    • Note: Dark purple cytoplasmic inclusions.

  • Ragocytes:

    • Note: Dark cytoplasmic granules often signaling presence of rheumatoid factor (RF).

LE CELLS VS TART CELLS

  • LE Cells:

    • Neutrophils that engulf a degenerated nucleus of another cell, typically a lymphocyte.

  • Tart Cells:

    • Monocytes that have engulfed nuclear materials.

SYNOVIOCYTES & OSTEOCLASTS

  • Cells Originating from Synovial Lining:

    • Synoviocytes

  • Osteoclast Cell:

    • Key role in bone resorption.

SYNOVIAL FLUID CRYSTALS

  • Types of Crystals Present in Synovial Fluid:

    • Monosodium Urates (MSU): Yellow colored needles, negative birefringence.

    • Calcium Pyrophosphate (CPPD): Rhombic-shaped intracellular crystals, positive birefringence (blue).

    • Cholesterol Crystals: Notched rhomboid plate with negative birefringence (yellow).

SYNOVIAL FLUID – MICRO EXAM

  • Normal vs. Abnormal Findings in Microscopic Exam

    • Crystals:

      • Normal: None found.

      • Abnormal: MSU indicates gout, CPPD indicates pseudogout, cholesterol indicates chylous effusions, fractures, or fat necrosis.

    • RBCs:

      • Normal: < 2000/µL.

      • Abnormal: > 2000/µL indicates bleeding.

    • WBCs:

      • Normal: < 200/µL.

      • Abnormal: > 200/µL indicates infection or inflammation.

        • Differential count: 65% monocytes, < 20% segments, < 15% lymphocytes; > 20% segments suggests sepsis and > 15% lymphocytes indicates inflammation.

    • Other Cells:

      • Includes Reiter cells, eosinophils, LE cells, ragocytes, lipids, etc.

SYNOVIAL FLUID – CHEM EXAM

  • Chemical Examination of Synovial Fluid:

    • Analyte Normal vs. Abnormal

      • Glucose: Normal < 10 mg/dL while values lower than blood sugar concentration are abnormal.

      • Lactate: Levels > 250 mg/dL indicate septic arthritis.

      • Total Protein: Normal < 3 g/dL; values > 3 g/dL indicate inflammation and/or bleeding.

      • Uric Acid: Same levels as serum; increase associated with gout.

SYNOVIAL FLUID – MUCIN CLOT TEST

  • Mucin Clot Test:

    • Evaluation based on appearance and viscosity of findings.

      • Normal solid clot should be surrounded by clear fluid.

SYNOVIAL FLUID CLASSIFICATION

  • Classification of Synovial Fluids:

    • I. Non-inflammatory: Associated with degenerative joint disorders.

      • Clear fluid, yellow, < 2000 WBCs with < 30% segments, and normal glucose.

    • II. Inflammatory:

      • Immunologic: This includes conditions like Lupus and RA.

        • Appearance: Cloudy, yellow; WBCs between 2000 – 5000 with > 50% segments and decreased glucose, possible autoantibodies present.

      • Crystal Induced: Conditions such as Gout or Pseudogout.

        • Cloudy to milky appearance; WBCs < 50,000 with < 90% segments, and decreased glucose; elevated uric acid; crystals may be identified.

    • III. Septic:

      • Cloudy, yellow-green appearance; WBCs exceed 10,000 with > 90% segments, decreased glucose.

    • IV. Hemorrhagic:

      • Acidic; traumatic injury or malignant conditions.

        • Cloudy, red appearance; WBCs < 5000 with < 50% segments; RBCs present; normal glucose; potential xanthochromia in hemorrhage with uniform distribution of blood across tubes.

SYNOVIAL FLUID DISORDERS

  • Categories of Synovial Joint Disorders:

    • Non-inflammatory: Features clear, yellow fluid.

    • Inflammatory: Varies in presentation based on type (immunological, crystal-induced, septic).

    • Traumatic/Hemorrhagic: Cloudy, red fluid associated with traumatic injuries, deficiencies, or malignancies.

BODY FLUIDS - SEROUS

  • What is Serous Fluid?

    • Also termed effusions.

    • Excess fluid forms between two layers of serous membranes due to imbalance of secretion (parietal layer) and reabsorption (visceral layer).

    • Types of Effusions:

      • Transudates.

      • Exudates.

SEROUS FLUIDS – TRANSUDATE EFFUSIONS

  • Transudates:

    • Extravascular fluid that is essentially an ultrafiltrate of plasma (seepage) containing little protein and few or no cells.

    • Results from systemic disorders disrupting fluid filtration and reabsorption (e.g., congestive heart failure, nephrotic syndrome).

    • Typically clear fluid.

SEROUS FLUIDS – EXUDATE EFFUSIONS

  • Exudates:

    • Result from direct membrane degeneration due to infections or malignancies.

    • Rich in protein and/or cells, typically cloudy (indicative of infections).

    • Appears as “ooze” (cloudy, pus).

Transudates Versus Exudates

  • Comparison of Fluid Characteristics

    • Transudate vs Exudate

      • Appearance: Clear vs Cloudy.

      • Fluid:Serum Protein Ratio: <0.5 vs >0.5.

      • Fluid:Serum LD Ratio: <0.6 vs >0.6.

      • WBC Count: >1000/µL vs <1000/µL.

      • Spontaneous Clotting: No vs Possible.

      • Pleural Fluid Cholesterol: <60 mg/dL vs >60 mg/dL.

      • Fluid:Serum Cholesterol Ratio: <0.3 vs >0.3.

      • Fluid:Serum Bilirubin Ratio: <0.6 vs >0.6.

      • Total Protein: <3.0 g/dL vs >3.0 g/dL.

      • Specific Gravity: <1.015 vs >1.015.

      • Neutrophils (Segs): <25% vs >25%.

BODY FLUIDS - PLEURAL FLUIDS

  • Pleural Fluids:

    • Collection Method: Thoracentesis.

    • Normal Characteristics:

      • Color: Pale yellow to colorless.

      • Clarity: Clear.

      • Cell Count:

        • RBCs: None, but few RBCs may occur during collection; many RBCs signal a bloody tap or true hemorrhage.

        • WBCs: < 300/µL, predominately lymphocytes, monocytes, mesothelial cells (< 25% segments).

    • Abnormal Findings: Chylous pleural fluids.

PLEURAL FLUID – MESOTHELIAL CELLS HEMATOLOGY

  • Mesothelial Cells:

    • Present as single, small or large, rounded cells with abundant blue cytoplasm and round nuclei showing uniform dark purple cytoplasm, indicating benign mesothelial cells.

PLEURAL FLUIDS – MALIGNANT CELLS

  • Reactive Mesothelial Cells:

    • Can appear in clusters with variable amounts of cytoplasm and eccentrically situated nuclei.

    • Malignant Cells:

      • May have nuclear or cytoplasmic irregularities and distinct hyperchromatic nucleoli.

      • Presence indicates malignancy (e.g., malignant mesothelioma).

MALIGNANT VS REACTIVE MESOTHELIAL CELLS

  • Comparison

    • Identifying features between malignant mesothelioma cells and reactive mesothelial cells, focusing on cytological changes that highlight differences.

PERICARDIAL/PERITONEAL FLUID

  • Linear Definitions:

    • Also termed “Ascitic Fluid.”

    • Collection methods:

      • Pericardiocentesis and paracentesis used for fluid extraction.

    • Normal Observations: Should match normal pleural fluid appearance and differential count.

    • Abnormal Cases:

      • Purulent pericardial fluid indicative of endocarditis.

PERITONEAL FLUID CELLS

  • Cell Types:

    • Reactive mesothelial cells, lymphoblasts, and lymphocytes observed.

BODY FLUID - SEMINAL FLUID

  • Characteristics of Seminal Fluid:

    • Gross examination includes appearance, volume, viscosity, pH, and time of liquefaction.

    • Microscopic examination includes motility (% motile vs nonmotile), morphology, and counts of normal versus abnormal forms/200.

    • Conditions: Hyperspermia vs Hypospermia visual differences noted.

SEMINAL FLUID VIABILITY

  • Sperm Viability Testing:

    • Procedure requires samples less than one hour old.

    • Mix samples with viability stain (eosin-nigrosine); smear made and dried.

    • Count live v. dead sperm in sample.

      • Viable sperm: Do not stain and appear white.

      • Non-viable sperm: Absorb stain and appear pink.

    • Normal threshold for viability: > 50% living sperm.

SPERMATOZOA MORPHOLOGY

  • Description:

    • Smooth, oval shaped to tapered head with well-defined acrosome covering about 50% of the head.

    • Single tail extends from a slightly wider midpiece.

    • Normal morphology includes tapered heads.

    • Abnormal morphology indicates potential fertility concerns.

SEMINAL FLUID COUNTS

  • Sperm Count Technique:

    • Count both sides of hemacytometer in the large center square and average the count; report in millions/ml.

      • Calculation Method:

        • Add 5 zeros if counted 2 squares (results in count per µL).

        • Add 6 zeros if counted 5 squares (results in count per µL).

      • Multiply by 1,000 to convert to total number per ml.

SEMINAL FLUID CHEMISTRY

  • Chemistry Testing in Seminal Fluid:

    • Measures:

      • Acid phosphatase, fructose concentration, serological tests (anti-sperm antibodies, agglutination tests).

      • Additional experiments: Enzyme-linked immunosorbent assays (ELISA) and mixed antiglobulin reaction tests.

ANTI-SPERM ANTIBODY TESTS

  • Analysis of Anti-Sperm Antibodies:

    • Types include:

      • Anti-sperm head, anti-sperm tail, all parts of sperm.

    • Assay Techniques: Hamagglutination test, anti-sperm ELISA — results analyzed to detect infertility issues.

BODY FLUID - SEMINAL FLUID NORMAL RANGES

  • Range for Normal Seminal Fluid Components:

    • Color: Milky, off-white.

    • Volume: 2 – 6 mL.

    • Odor: Musty.

    • pH: 7 – 8.

    • Appearance: Sticky, clumped; liquefies within 30 minutes.

    • Sperm Count: 50 – 150 million/mL.

    • Motility: 80% motile (50 – 60% motility in 3 hours).

    • Morphology: < 30% abnormal forms.

BODY FLUID - AMNIOTIC FLUID

  • Definition and Collection of Amniotic Fluid:

    • Watery fluid present in the membranous amniotic sac surrounding the fetus.

    • Collected by needle aspiration through the abdominal wall by a physician.

    • Transported with priority (STAT).

AMNIOTIC FLUID TESTS

  • Significance of Amniotic Fluid Testing:

    • Cytogenetics: Evaluation of alpha-fetoprotein levels for conditions like spinal bifida.

    • Fetal Distress: Bilirubin concentration assessment for hemolytic disease of the newborn (HDN).

    • Fetal Lung Maturity: Evaluating L/S ratio (> 2.0 is optimal); phosphatidylglycerol testing, particularly in diabetic pregnancies.

    • Fetal Age Estimation: Creatinine levels > 2.0 indicate fetus potentially older than 36 weeks.

AMNIOTIC FLUID - SUMMARY

  • Normal vs Abnormal Amniotic Fluid Characteristics:

    • Normal:

      • Color: Colorless to pale yellow.

      • Appearance: Slightly cloudy.

    • Abnormal:

      • Color: Dark yellow to amber (associated with increased bilirubin), green (associated with meconium), pink to red (indicates bleeding), dark red-brown (fetal death).

      • Creatinine: > 2 mg/dL indicates urine production at 36 weeks; < 2 mg/dL indicates risks.

      • L/S Ratio: > 2 indicates fetal lung maturity; < 2 indicates risk for respiratory distress syndrome (RDS).

      • Shake Test: Positive when L/S ratio > 2, negative when L/S ratio < 2.