FEAR. DEPENDS ON WHAT YOU DREAD THE MOST

Transcription

1 FEARLESS FLUIDS

2 FEAR. DEPENDS ON WHAT YOU DREAD THE MOST YUCKY CELL COUNTS SCARY CELLS

3 WHAT WE LL COVER. CSF, SEROUS, SYNOVIAL MANUAL CELL COUNTS A LITTLE, VERY LITTLE AUTOMATED CELL COUNTS AMR, CRR, METHOD VALIDATION, ETC BENIGN VS MALIGNANT CELLS COOL CASE STUDIES

4 BODY FLUID STUFF

5 CSF STUFF FACTS & FIGURES volume ml total production ml/day

6 CSF STUFF DIAGNOSTIC ANALYSIS meningitis subarachnoid hemorrhage cns malignancy demyelinating disease

7 SEROUS MEMBRANE LINED CAVITIES EFFUSION FLUIDS PLEURAL PERITONEAL

8 SEROUS STUFF effusion thorocentesis, paracentesis, Minimal volume Pleural < 15 ml Peritoneal < 50 ml

9 SYNOVIAL STUFF arthrocentesis lubricates provide nutrients removes debris NO TRANSUDATES OR EXUDATES GROUPS

10 DO YOU NEED TO KNOW ANY OF THAT STUFF? NOT REALLY.. SOMETIMES IT HELPS

11 CELL COUNTING

12 CELL COUNTING- MANUAL (very brief) FORMULA - MANUAL cells/µl = cells counted area x depth x dilution

13 CELL COUNTING -AUTOMATED

14 WHY YOU WANT TO DO THIS - better precision - more efficient - safer BEFORE YOU START.THERE ARE SOME RULES

15 FIRST. SYNOVIAL FLUIDS SHOULD BE TREATED WITH HYALURONIDASE

16 ORIGINAL REFERENCE ADD 5 MG TO A 0.5 TO 1 ML ALIQUOT IN REALITY SIGMA #H-3757 TYPE VIII BOVINE STERILE FILTERED

17 IT S A SECOND. TOTAL NUCLEATED CELL COUNT (MACROPHAGES, MESOTHELIAL CELLS etc) NOT JUST A WBC

18 AND THIRD.. IF THERE ARE CLOTS OR FIBRIN GOOBERS TAKE THEM OUT AND REPORT THE CELL COUNT AS APPROXIMATE

19 AUTOMATED CELL COUNTS WHAT S IMPORTANT? - BACKGROUNDS - PICTURES - AMR (Analytic measurement range) - CRR (Clinical reportable range)

20 SYSMEX XE2100 PICTURES

21 SYSMEX XE2100 PICTURES

22 SYSMEX XE5000

23 KNOW WHEN IT S GOOD..

24 AND WHEN IT S NOT

25 WHAT YOU HAVE TO DO ESTABLISH THE AMR, CRR METHOD COMPARISON OLD TO NEW csf, effusions, synovial aim for 10 of each low to high counts

26 AMR, CRR, Huh? AMR ANALYTIC MEASUREMENT RANGE CRR CLINICAL REPORTABLE RANGE

27 AMR, CRR, Huh? AMR = LINEARITY How low and how high can the instrument measure CRR = CLINICAL REPORTABLE RANGE How low and how high can you report results And why would these be different???

28 XE5000 LINEARITY - SYNOVIAL FLUID AMR = LINEARITY XE5000 EXPECTED XE5000 EXPECTED DILUTION nucleated cells RBC CORR SLOPE

29 EXPECTED WBC XE5000 LINEARITY - WBC R 2 = XE WBC

30 AMR, CRR, Huh? AMR = LINEARITY CRR = CLINICAL REPORTABLE RANGE WHY WOULD THESE BE DIFFERENT???

31 WHAT IF WBC LINEARITY (AMR) IS 10 CELLS 100,000 CELLS / mcl CRR could be ,000 / mcl BUT WHAT ABOUT COUNTS <10 CELLS OR > 100,000 CELLS

32 WHAT ABOUT COUNTS 0 CELLS Manual count or CRR could be <10 100,000 / mcl COUNTS > 100,000 CELLS Dilute sample or CRR could be <10 - > 100,000

33 WHAT ELSE DO YOU HAVE TO DO? METHOD COMPARISONS NUCLEATED CELL COUNT MANUAL RED CELL COUNT MANUAL SAMPLE ID FLUID TYPE XE2100 XE5000TC WBC XE2100 XE5000 RBC T CSF X CSF T PER DIALYS 12 5 W CSF W CSF W CSF H CSF H PERITONEAL 2 1 W PERITONEAL 3 4 C CSF H CSF T PLEURAL H PERITONEAL T CSF W PLEURAL 96 65

34 NUCLEATED CELL COUNT RED CELL COUNT SAMPLE ID FLUID TYPE XE2100 XE5000 XE2100 XE5000 H PLEURAL C SYNOVIAL T PLEURAL W CSF S PLEURAL T PERITONEAL F PERITONEAL A SYNOVIAL W PERITONEAL W PLEURAL C SYNOVIAL H PLEURAL H PLEURAL C SYNOVIAL F PLEURAL

35 RBC counts are of little clinical use except in CSF

36 HOW CLOSE SHOULD THE METHODS MATCH? Depends on the methods manual to automated automated to automated

37 NOT GOOD ENOUGH? y = x R 2 =

38 LOOK AT THE NUMBERS. NUCLEATED CELL COUNT MANUAL RED CELL COUNT MANUAL SAMPLE ID FLUID TYPE XE2100 XE5000TC WBC XE2100 XE5000 RBC T CSF X CSF T PER DIALYS 12 5 W CSF W CSF W CSF H CSF H W PERITONEA L 2 1 PERITONEA L 3 4 C CSF H CSF T PLEURAL H PERITONEA L T CSF W PLEURAL 96 68

39 y = x R 2 =

40 A DOSE OF REALITY

41 NUCLEATED CELL COUNTS RESULTS ARE RARELY HELPFUL FREQUENTLY NOT HELPFUL LACK SPECIFICITY NEED CLINICAL JUDGEMENT

42 THE TYPE OF CELL PRESENT IS MORE IMPORTANT THAN THE CELL COUNT.

43 MORE REALITY

44 CSF

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47 Hmmmmm.. should I dilute this? Or do I want to do a manual count?

48 CELLS BEFORE YOU START.THERE ARE SOME MORE RULES

49 FIRST YOU NEED ONE OF THESE or something like it

50 SECOND.. EVEN IF IT S CLOTTED YOU CAN DO SOMETHING WITH IT!

51 THE PROBLEM CELLS MESOTHELIAL CELLS MALIGNANT CELLS

52 MESOTHELIAL CELLS

53 WHERE THEY COME FROM The pleural and peritoneal membrane

54 MESOTHELIAL individual uniform flat clusters n/c ratio low MALIGNANT cannibalism bizarre ball-like clusters n/c ratio high

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63 MESOTHELIAL MALIGNANT smooth chromatin smooth nuclear membrane round/oval nuclei if multinucleateduniform minimal vacuolization uneven chromatin irregular nuclear membrane nuclear clefting/molding multinucleated - nonuniform dramatic vacuolization

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73 SYNOVIAL CELLS LOOK LIKE MESOTHELIAL CELLS.BUT THEY RE NOT!

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76 CSF CELLS OTHER CELLS THAT LOOK LIKE MESOTHELIAL CELLS BUT THEY RE NOT

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78 EPENDYMAL, CHOROID PLEXUS, GERMINAL MATRIX?? = NEUROECTODERMAL CELLS

79 COOL CASE STUDIES.AND ONE, NOT SO COOL

80 67 YEAR OLD FEMALE MEDICAL HISTORY UNREMARKABLE SEEN IN ER WITH COMPLAINTS OF HEADACHE AND DIZZINESS CSF RBC NONE SEEN WBC 135 / mcl

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83 UGLY AREN T THEY? A clue is their size Another clue is the irregular nuclear chromatin and large vacuoles. These are malignant cells from metastasized breast cancer. The breast cancer was not previously diagnosed. THIS IS WHY MAMMOGRAMS ARE IMPORTANT

84 Very big cells or clusters of cells will appear here because they have a lot of fluorescence.

85 24 YEAR OLD FEMALE SEEN IN ER FOR HEADACHE AND NAUSEA PREVIOUS HISTORY OF MENINGITIS CSF RBC 17 / mcl WBC 754 /mcl

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88 The patient has viral meningitis more specifically a recurrence of herpes meningitis. She is positive for HSV- Type 2. Recurrent meningitis is known as Mollaret s Meningitis. Herpes meningitis occurs in 10% of cases of primary genital HSV-2. Women are at higher risk for herpes meningitis than men. Surprisingly, herpes meningitis resolves without complications in 7 10 days but can recur in some patients.

89 lymphocytes

90 67 YEAR OLD MALE 5.5 YRS POST HEART TRANSPLANT PLEURAL FLUID NUCLEATED CELLS 5,998 /mcl

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93 Monomorphic post transplant lymphoproliferative disorder Burkitt s lymphoma

94 60 YEAR OLD MALE NO HISTORY AVAILABLE CSF RBC 37 /mcl WBC 85 / mcl (manual count)

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97 Cryptococcus meningitis Cryptococcus neoformans is commonly found in soil and bird droppings. It can also be found on fruits and vegetables. Most people are exposed to cryptococcus but a normal immune system prevents disease 50% of AIDS patients with a low T4 count (< 50) develop cryptococcus meningitis

98 debris

99 A REALLY ODD WBC/BASO SCATTER This is what it s supposed to look like

100 44 YEAR OLD MALE SYNOVIAL FLUID RIGHT KNEE NUCLEATED CELLS 365,000 / mcl - sort of

101 XE dilution

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103 GRAM + COCCI STAPH AUREUS

104 IF YOU RE WONDERING SYNOVIAL FLUID

105 URIC ACID CRYSTALS POLARIZED LIGHT

106 RED COMPENSATOR FILTER

107 The diff channel on the XE showed interference from the uric acid crystals as did the WBC/BASO channel. A manual count would need to be performed but..

108 HOW ARE YOU GOING TO FIND THE CELLS? AND DOES IT MATTER?

109 If you worry about what this may do to your instrument don t. It s just fine. This is the background after running the fluid

110 47 YEAR OLD FEMALE ER PATIENT ALTERED VISION?? CSF NUCLEATED CELLS 4 / mcl RBC 3 / mcl

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114 SOMETHING TO REMEMBER. CYTOCENTRIFUGE CONCENTRATION ~ 20 FOLD IF YOU DO IT RIGHT!

115 47 YEAR OLD FEMALE CSF NUCLEATED CELLS 4 / mcl RBC 3 / mcl REPEAT COUNT NUCLEATED CELLS 29 / mcl

116 THANK YOU The best body fluid references: Body Fluids, 3 rd edition (Kjeldsberg) ASCP Press Color Atlas of Body Fluids CAP