FEARLESS FLUIDS WHAT WE LL COVER. DEPENDS ON WHAT YOU DREAD THE MOST CSF, SEROUS, SYNOVIAL MANUAL CELL COUNTS A LITTLE, VERY LITTLE

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1 FEARLESS FLUIDS DEPENDS ON WHAT YOU DREAD THE MOST YUCKY CELL COUNTS SCARY CELLS WHAT WE LL COVER. CSF, SEROUS, SYNOVIAL MANUAL CELL COUNTS A LITTLE, VERY LITTLE AUTOMATED CELL COUNTS WHAT S IMPORTANT BENIGN VS MALIGNANT CELLS COOL CASE STUDIES 1

2 BODY FLUID STUFF CSF STUFF FACTS & FIGURES volume ml total production ml/day CSF STUFF DIAGNOSTIC ANALYSIS meningitis subarachnoid hemorrhage cns malignancy demyelinating disease 2

3 CSF STUFF TRAUMATIC TAP blood decreasing amounts clot formation colorless supernatant negative D dimer test CSF STUFF SUBARACHNOID HEMORRHAGE blood equal amounts no clot formation xanthrochromic supernatant positive D dimer test hemosiderin/hematoidin SEROUS MEMBRANE LINED CAVITIES EFFUSION FLUIDS PLEURAL PERITONEAL 3

4 SEROUS STUFF thorocentesis, paracentesis, Minimal volume Pleural < 15 ml Peritoneal < 50 ml TRANSUDATE or EXUDATE?? PLEURAL SPACE NORMAL 4

5 SYNOVIAL STUFF arthrocentesis lubricates provide nutrients removes debris NO TRANSUDATES OR EXUDATES GROUPS DO YOU NEED TO KNOW ANY OF THAT STUFF? NOT REALLY.. SOMETIMES IT HELPS CELL COUNTING 5

6 CELL COUNTING- MANUAL (very brief) FORMULA - MANUAL cells/µl = cells counted area x depth x dilution CELL COUNTING -AUTOMATED WHY YOU WANT TO DO THIS - better precision - more efficient -safer BEFORE YOU START ANY TYPE OF CELL COUNTING.THERE ARE SOME RULES 6

7 FIRST. SYNOVIAL FLUIDS SHOULD BE TREATED WITH HYALURONIDASE SECOND. IT S A TOTAL NUCLEATED CELL COUNT (MACROPHAGES, MESOTHELIAL CELLS etc) NOT JUST A WBC AND THIRD.. IF THERE ARE CLOTS OR FIBRIN GOOBERS TAKE THEM OUT AND REPORT THE CELL COUNT AS APPROXIMATE 7

8 AUTOMATED CELL COUNTS WHAT S IMPORTANT? -BACKGROUNDS - PICTURES PICTURES SYSMEX XE2100 PICTURES SYSMEX XE2100 8

9 SYSMEX XE5000 KNOW WHEN IT S GOOD.. AND WHEN IT S NOT 9

10 REALITY THE TYPE OF CELL PRESENT IS MORE IMPORTANT THAN THE CELL COUNT. CELLS BEFORE YOU START.THERE IS ANOTHER RULE 10

11 EVEN IF IT S CLOTTED YOU CAN DO SOMETHING WITH IT! THE PROBLEM CELLS MESOTHELIAL CELLS MALIGNANT CELLS MESOTHELIAL CELLS 11

12 WHERE THEY COME FROM The pleural and peritoneal membrane MESOTHELIAL individual uniform flat clusters n/c ratio low MALIGNANT cannibalism bizarre ball like clusters n/c ratio high 12

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15 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 15

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18 CELLS THAT LOOK LIKE MESOTHELIAL CELLS.BUT THEY RE NOT! SYNOVIAL LINING CELLS 18

19 CSF NEURAL LINING CELLS EPENDYMAL, CHOROID PLEXUS, GERMINAL MATRIX?? BRONCHIAL LINING CELLS BRONCHIAL LINING CELLS 19

20 MESOTHELIAL CELLS ARE FOUND ONLY IN SEROUS FLUIDS (PLEURAL, PERITONEAL, PEROCARDIAL) COOL CASE STUDIES.AND SOME, NOT SO COOL 67 YEAR OLD FEMALE MEDICAL HISTORY UNREMARKABLE SEEN IN ER WITH COMPLAINTS OF HEADACHE AND DIZZINESS CSF RBC NONE SEEN Nucleated cells 135 / mcl 20

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22 Very big cells or clusters of cells will appear here because they have a lot of fluorescence. 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. 24 YEAR OLD FEMALE SEEN IN ER FOR HEADACHE AND NAUSEA PREVIOUS HISTORY OF MENINGITIS CSF RBC 17 / mcl Nucleated cells 754 /mcl 22

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24 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. 67 YEAR OLD MALE 5.5 YRS POST HEART TRANSPLANT PLEURAL FLUID NUCLEATED CELLS 5,998 /mcl 24

25 Monomorphic post transplant lymphoproliferative disorder Burkitt s lymphoma IF YOU RE WONDERING SYNOVIAL FLUID 25

26 URIC ACID CRYSTALS POLARIZED LIGHT RED COMPENSATOR FILTER 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.. 26

27 HOW ARE YOU GOING TO FIND THE CELLS? AND DOES IT MATTER? 47 YEAR OLD FEMALE ER PATIENT ALTERED VISION?? CSF NUCLEATED CELLS 4 / mcl RBC 3 / mcl 27

28 SOMETHING TO REMEMBER. CYTOCENTRIFUGE CONCENTRATION ~ 20 FOLD IF YOU DO IT RIGHT! REPEAT COUNT NUCLEATED CELLS 29 / mcl 28

29 WHAT WENT WRONG? NEW RULE ALL FLUIDS CLEAR, COLORLESS, WHATEVER ANALYZED ON THE XE SYNOVIAL FLUID failure in the opposite direction 29

30 REPORTED SYNOVIAL FLUID EXAM FLUID APPEARANCE CLEAR COLORLESS FLUID VOLUME 3 ml NUCLEATED CELL COUNT 147 /mcl TOO FEW CELLS TO PERFORM DIFFERENTIAL. PREDOMINATING CELL TYPE IS NEUTROPHIL JOINT FLUID CRYSTALS NONE SEEN WAIT. WHAT????? REPORTED SYNOVIAL FLUID EXAM FLUID APPEARANCE CLEAR COLORLESS FLUID VOLUME 3 ml NUCLEATED CELL COUNT 147 /mcl TOO FEW CELLS TO PERFORM DIFFERENTIAL. PREDOMINATING CELL TYPE IS NEUTROPHIL JOINT FLUID CRYSTALS NONE SEEN ALWAYS CORRELATE THE SLIDE AND THE COUNT 30

31 WHAT WENT WRONG? AND THIS. WAS FEARLESS FLUIDS! 31

32 THANK YOU QUESTIONS? 32