BODY FLUID ANALYSIS. Synovial Fluid. Synovial Fluid Classification. CLS 426 Urinalysis and Body Fluid Analysis Body Fluid Lecture Session 1

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1 BODY FLUID ANALYSIS Synovial Fluid Serous fluids the 3 P s Peritoneal Pleural Pericardial Cerebrospinal Fluid Karen Keller, MT(ASCP), SH Synovial Fluid Lubricant and sole nutrient source of joint. Normal volume ml. Synovial Fluid Classification non-inflammatory inflammatory septic hemorrhagic Why order a synovial fluid analysis? Aspirate to distinguish inflammatory/group II (crystalinduced) from septic/group III Malignancy is not usually suspected TEST NORMAL TEST NORMAL Color Pale % PMNs <30 Turbidity Clear Culture Neg Viscosity Leukocyte Ct #/µl High <200 Glucose Plasma-fluid difference Crystals <10 No Body Fluid Lecture Session 1

2 Disorders Group I degenerative joint disorders Group II gout, pseudo-gout, SLE, Rheumatoid Arthritis Group III bacterial infection Group IV trauma, hemophilias The slow ray of the red compensator (the axis) is at the red arrow in each picture. Monosodium urate (MSU) Calcium Pyrophosphate dihydrate (CPPD) Parallel Yellow Blue Perpendicular Blue Yellow Dark field, crystals exhibit birefringence. Must polarize with red compensator to determine if crystals are positively or negatively birefringent. Birefringence Negative Positive Direction of axis Direction of axis Perpendicular yellow Parallel blue Parallel yellow Perpendicular blue Monosodium Urate (MSU) negative birefringence Calcium Pyrophosphate Dihydrate (CPPD) Positive birefringence Body Fluid Lecture Session 2

3 Other Crystals Cholesterol Talc Corticosteroid [Hydroxyapatite] Synovial Fluid Warm-up 16 year old football player seen in emergency room post-friday night game. Patient has a swollen knee. 0.5 cc fluid aspirated from left knee Synovial Fluid Warm-up Synovial Fluid Warm-up Physical Exam Color: pale Turbidity: clear Viscosity: high Microscopic Exam Leukocyte count: 100 cells/μl Differential count: Monocytes 84% Lymphocytes 12% PMNs 4% Crystals: absent Identify any abnormal results. What is the most probable cause of the football player s swollen knee? All results are in the normal range. Tissue inflammation due to a game injury. No further work-up is indicated. Body Fluid Lecture Session 3

4 Case #1 Synovial Fluid Case #1 Synovial Fluid Physical Exam Color: yellow Turbidity: cloudy Viscosity: decreased Microscopic Exam Leukocyte count: 43,000 cells/μl Differential count: Monocytes 24% Lymphocytes 13% PMNs 63% Crystals: many intracellular needleshaped crystals; negatively birefringent Case #1 Synovial Fluid Case #1 Synovial Fluid Gram stain: no bacteria seen; many leukocytes present Blood Chemistry Glucose, fasting 85 mg/dl Uric Acid:12.7 mg/dl Fluid Chemistry Glucose: 55 mg/dl Uric Acid: 12.4 mg/dl Identify the abnormal results. Calculate the plasma-synovial fluid glucose difference. Color, turbidity, viscosity, uric acid in blood and fluid, glucose in fluid, leukocyte count and PMN % on diff, presence of crystals, leukocytes on gram stain = 30 Body Fluid Lecture Session 4

5 Based on the results obtained, this synovial fluid specimen should be classified as: Test Color Normal Pale Group II Inflammatory Yellow-white a. noninflammatory (Group I) b. inflammatory (Group II) c. septic (Group III) Turbidity Clear Cloudy Viscosity High Low Leukocyte Ct #/µl d. hemorrhagic (Group IV) <200 3,000-50,000 Test % PMNs Normal <30 Group II Inflammatory >50 What is the most likely identify of the crystals observed in this patient s synovial fluid? Culture Neg Neg a. Cholesterol Glucose Plasma-fluid difference Crystals <10 No >25 Maybe b. Corticosteroid c. Calcium pyrophosphate dihydrate d. Monosodium urate These results are most consistent with a diagnosis of: a. gouty arthritis b. pseudogout c. rheumatoid arthritis d. bacterial infection e. Traumatic arthritis, with previous corticosteroid injection If no crystals were observed in the microscopic examination, would the diagnosis change? Explain. Not necessarily. MD must rely on other things. May be in area with no/low # of crystals. Crystal exam is not 100% sensitive. Body Fluid Lecture Session 5

6 Pleural, Peritoneal, Pericardial Fluids 4 factors control fluid formation: 1. Capillary permeability 2. Fluid absorption 3. Hydrostatic pressure 4. Oncotic pressure If these four factors are normal, serous fluid will not accumulate. If an abnormality exists in any one or more of these four factors, serous fluid will accumulate. Transudates: Exudates Caused by increased hydrostatic pressure or decreased plasma oncotic pressure Non-inflammatory Protein-poor fluid CHF, cirrhosis, nephrotic syndrome Caused by increased capillary permeability or decreased absorption by lymphatic system Inflammatory Protein-rich fluid Infections, neoplasms, RA, trauma Comparison of laboratory values in transudates vs. exudates Case #2 Peritoneal Fluid turbidity fluid-to-serum protein ratio fluid-to-serum LD ratio WBC cell count Transudates clear <0.5 <0.6 <1000/μl Exudates cloudy >0.5 >0.6 >1000/μl Physical Exam Color: yellow Turbidity: clear Clots Present: no Body Fluid Lecture Session 6

7 Case #2 Peritoneal Fluid Case #2 Peritoneal Fluid Microscopic Exam Leukocyte count: 8 cells/μl PMNs 100% Blood Chemistry Total Protein: 6.5 g/dl LD: 300 U/L Glucose, fasting: 82 mg/dl Liver function tests: normal (ALT, AST, GGT, ALP) Fluid Chemistry Total Protein: 2.9 g/dl LD: 125 U/L Glucose: 67 mg/dl Case #2 Peritoneal Fluid Gram stain: no organisms seen Cytology exam: no malignant cells seen Calculate the fluid-to-serum total protein ratio. 2.9 / 6.5 = 0.45 Calculate the fluid-to-serum lactate dehydrogenase ratio. Classify this peritoneal fluid specimen as a transudate or exudate. 125 / 300 = 0.42 Transudate Body Fluid Lecture Session 7

8 Identify two conditions known to cause this type of effusion. Congestive heart failure, cirrhosis (Nephrotic Syndrome) True or False Formation of the effusion in this patient could be caused by an increase in hydrostatic pressure or a decrease in oncotic pressure. TRUE A A B Case #3 Pleural Fluid C A. 1000x, mesothelial cell and lymphocyte B. 1000x, many intracellular bacteria in polymorphonuclear cells and macrophages C. 500x, malignant (tumor) cell. Notice size in comparison to RBCs. Physical Exam Color: yellow Turbidity: cloudy Clots Present: yes Case #3 Pleural Fluid Case #3 Pleural Fluid Microscopic Exam Leukocyte count: 1100 cells/μl Differential count: Monocytes: 57% Lymphocytes: 40% PMNs: 3% Gram stain: no organisms seen, leukocytes present Body Fluid Lecture Session 8

9 Case #3 Pleural Fluid Blood Chemistry Total Protein: 7.0 g/dl LD: 520 U/L Glucose, fasting: 75 mg/dl Fluid Chemistry Total Protein: 4.2 g/dl LD: 345 U/L Glucose: 55 mg/dl Calculate the fluid-to-serum total protein ratio. 4.2 / 7.0 = 0.60 Calculate the fluid-to-serum lactate dehydrogenase ratio. Classify this pleural fluid specimen as a transudate or exudate. 345 / 520 = 0.66 Exudate Identify two conditions known to cause this type of effusion. Infection Malignancy (RA, trauma) Of what significance is the differential count and gram stain in this particular case? Rules out a bacterial infection Body Fluid Lecture Session 9

10 Of what significance is the presence of clots in this specimen? A B Clots are associated with exudates. C A. 1000x, hemosiderin-laden macrophage (siderophage) B. 1000x, mesothelial cells C. 400x, malignant (tumor) cell. Notice size in comparison to RBCs and WBCs. CEREBROSPINAL FLUID Cerebrospinal Fluid Purpose: To bathe and protect central nervous system. Total volume: Adult Neonate ml ml Cerebrospinal Fluid Blood-brain barrier Glucose can cross, protein can not Cerebrospinal Fluid #1 Chemistry and Immunology #2 Microbiology - Gram stain, Culture #3 Hematology - Cell count and differential Body Fluid Lecture Session 10

11 Cerebrospinal Fluid Exam Normal Cloudy Traumatic tap Intracranial Hemorrhage Reference range for CSF WBC: 0-5/uL adults 0-30/uL newborns (Critical CSF WBC for an adult at many institutions is >10/uL) Reference range for CSF differential: ~70% lymphocytes ~30% monocytes Xanthochromia Correlation of cell type seen with disease states Correlation of cell type seen with disease states If CSF WBC is elevated and: PMNS bacterial meningitis Lymphs/monos viral, tubercular, fungal, syphilitic meningitis or parasitic infestations Eosinophils fungal infections, parasitic infestations Abnormal regardless of CSF WBC count Plasma cells Multiple Sclerosis Blasts ALL (less likely AML) Lymphoma cells - lymphoma Tumor cells metastatic carcinoma Warm-up Cerebrospinal Fluid Warm-up Cerebrospinal Fluid 3-year old child, history of Acute Lymphocytic Leukemia in remission Physical Exam Color: colorless Turbidity: clear Body Fluid Lecture Session 11

12 Warm-up Cerebrospinal Fluid Microscopic Exam Leukocyte count: 2 cells/μl Differential count: Monocytes 35% (15-45) Lymphocytes 65% (40-80) Identify any abnormal results. All results are in the normal range. Patient appears to still be in remission. Path review if institution policy requires it. Case #4 Cerebrospinal Fluid Color: Turbidity: Physical Exam colorless clear Case #4 Cerebrospinal Fluid Microscopic Exam Leukocyte count: 8 cells/μl Differential count: Monocytes 24% (15-45) Lymphocytes 75% (40-80) PMNs 1% (0-6) Case #4 Cerebrospinal Fluid Gram stain: no organisms seen Case #4 Cerebrospinal Fluid Blood Chemistry Glucose, fasting: 82 mg/dl Albumin: 4.6 g/dl IgG: 1.4 g/dl Fluid Chemistry Total Protein: 45 mg/dl Glucose: 72 mg/dl Albumin: 28 mg/dl IgG: 12.4 mg/dl Lactate: 18 mg/dl Body Fluid Lecture Session 12

13 Identify any abnormal results. Calculate the CSF/serum albumin index. Leukocyte count, IgG in CSF. 28 / 4.6 = 6.1 Why is the CSF/serum albumin index a good indicator of the integrity of the blood-brain barrier? Albumin is not synthesized in CSF. An elevated index indicates damage to the blood-brain barrier (meningitis, hemorrhage, trauma, toxin). Calculate the CSF IgG index x 4.6 = State a diagnosis that is consistent with the results obtained. List an additional test, with the expected results, that could be used to confirm this diagnosis. 90% of patients with Multiple Sclerosis have an elevated CSF IgG index. MS is a demyelinating disease that causes neurological symptoms. CSF Protein electrophoresis Body Fluid Lecture Session 13

14 90% of patients with MS demonstate CSF oligoclonal banding in the gamma region on electrophoresis. These bands are not present in serum of MS patients. Gamma zone Control Patient CSF Patient serum Oligoclonal banding in the gamma zone is present in CSF but absent in serum of this patient with Multiple Sclerosis. If oligoclonal bands are present in both CSF and serum, a lymphoproliferative disorder (not MS) is indicated. 2 lymphocytes, 2 macrophages and 2 polymorphonuclear cells in CSF. Erythrophage Hemosiderin (left) and Hematoidin (hematin) crystals (right) are indicative of an intracranial hemorrhage. It takes approximately 18 hours for histiocytes to mobilize and phagocytize erythrocytes after a hemorrhage. Hemosiderin - bleed within last 3-4 days Hematoidin (hematin)- bleed within the last week Body Fluid Lecture Session 14

15 A A B B A. 2 plasma cells, 1 lymphocyte B. Blasts, two with Auer rods, 1 lymphocyte C. Lymphoma cell, lymphocyte, macrophage THE END C Body Fluid Lecture Session 15