Cavagnaro Body Fluid Analysis2008 4 16 2 to 3pm Ho

7/22/2019 Cavagnaro Body Fluid Analysis2008 4 16 2 to 3pm Ho

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Body Fluid Analysis

Marian J. Cavagnaro, MS, MT(ASCP)DLMMarian J. Cavagnaro, MS, MT(ASCP)DLM

Director, Laboratory ServicesDirector, Laboratory Services

Memorial Hospital WestMemorial Hospital West

Pembroke Pines, FloridaPembroke Pines, Florida

PARTICIPANTS (LEARNERS)

OBJECTIVES

The participant will learn about methods and techniquesThe participant will learn about methods and techniquesfor preparing body fluid cytospin smears.for preparing body fluid cytospin smears.

The participant will recognize normal and abnormal cellsThe participant will recognize normal and abnormal cellsin CSF, synovial, and serous fluids on cytospin preparedin CSF, synovial, and serous fluids on cytospin preparedWrightWright--Giemsa and WrightGiemsa and Wrights stained smears.s stained smears.

The participant will be able to recognize differentials thatThe participant will be able to recognize differentials thatare abnormal in CSF, synovial, and serous fluids and thatare abnormal in CSF, synovial, and serous fluids and thatcorrelate to different clinical conditionscorrelate to different clinical conditions

BODY FLUID ANALYSIS

Physical (volume, color, clarity, viscosityPhysical (volume, color, clarity, viscosity))

Microscopic (total cell count and differential)Microscopic (total cell count and differential)

Chemical (protein, glucose, enzymes, etc.)Chemical (protein, glucose, enzymes, etc.)

Microbiologic (bacteria, parasites, yeast/fungi)Microbiologic (bacteria, parasites, yeast/fungi)

Immunologic examination (not routine)Immunologic examination (not routine)

Cytologic examination (not routine)Cytologic examination (not routine)


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BODY FLUID DIFFERENTIALS

(CYTOSPIN)

Ratio of cells counted on the hemacytometerRatio of cells counted on the hemacytometerchamber to cells seen on cytospin preparation ischamber to cells seen on cytospin preparation isapproximately 1:5 to 1:10approximately 1:5 to 1:10

For any differential that does not reach 100 cells,For any differential that does not reach 100 cells,indicate number of WBCindicate number of WBCs counteds counted

Differentials should still be reported on fluids thatDifferentials should still be reported on fluids thatpresent with clotspresent with clots

Cytocentrifuge artifacts (nucleus & cytoplasm)Cytocentrifuge artifacts (nucleus & cytoplasm)

Albumin enhances morphologyAlbumin enhances morphology

Cytocentrifuge

ManufacturersManufacturers--(examples)(examples)-- Wescor, ShandonWescor, Shandon

LipshawLipshaw

Fluid vs. Drops/SlideFluid vs. Drops/Slide-- (saline diluent)(saline diluent)

Clear and colorlessClear and colorless-- 10 drops10 drops

Slt. CloudySlt. Cloudy-- 66--9 drops9 drops

CloudyCloudy--44--5 drops5 drops

Grossly Bloody/CloudyGrossly Bloody/Cloudy-- 11--2 drops2 drops

Synovial fluidSynovial fluid--push smearspush smears

Cytocentrifuge


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Cytocentrifuge

Speed/TimeSpeed/Time--

(examples)(examples)-- 600 RPM600 RPM

for 10 minutes; 800for 10 minutes; 800

RPM for 10 minutes;RPM for 10 minutes;

1200 RPM for 51200 RPM for 5

minutesminutes

CYTOCENTRIFUGE ARTIFACTS

NUCLEUSNUCLEUS

Accentuation of nucleoliAccentuation of nucleoli

Blebs and accentuation of lobulationBlebs and accentuation of lobulation

Denser chromatin in cells in center of slideDenser chromatin in cells in center of slide

Peripheral localization of nuclear lobesPeripheral localization of nuclear lobes

VacuolizationVacuolization

CYTOPLASMCYTOPLASM

Clear or granular paranuclear area in mononuclearClear or granular paranuclear area in mononuclearcellscells

Localization of cytoplasmic granulesLocalization of cytoplasmic granules

Irregular blebs and processesIrregular blebs and processes Peripheral vacuolizationPeripheral vacuolization

Cells in Body Fluids

Red CellsRed Cells

GranulocytesGranulocytes

LymohocytesLymohocytes MonocytesMonocytes


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CSF-Anatomy &Physiology

The cerebrospinalThe cerebrospinalfluid (CSF) bathesfluid (CSF) bathesthe brain and spinalthe brain and spinalcord. Most of thecord. Most of theCSF is in theCSF is in theventricles of theventricles of thebrain, which arebrain, which arelarge cavities withinlarge cavities withinthe brain whichthe brain whichproduce andproduce andreabsorb the CSF.reabsorb the CSF.

CSF- Anatomy and Physiology

CSF- Specimen Collection


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CSF-Specimen Collection

CollectionCollection-- lumbar puncture between 3lumbar puncture between 3rdrdand 4and 4thth lumbarlumbarvertebraevertebrae

SpecimenSpecimen --divided into 3(or sometimes 4) samples anddivided into 3(or sometimes 4) samples andplaced into 3 sterile sequentially labeled tubes (1placed into 3 sterile sequentially labeled tubes (1--4 mL4 mLin each)in each)

Tube #1Tube #1-- chemical and immunologic testschemical and immunologic tests

Tube #2Tube #2-- microbiologic examinationmicrobiologic examination

Tube#3Tube#3-- hematologic/cytologichematologic/cytologicexaminationexamination

cells counts and differentialcells counts and differential

ABNORMAL FINDINGS IN CSF XANTHOCHROMIA (see notes **)XANTHOCHROMIA (see notes **)

HemorrhageHemorrhage

Severe and chronic jaundiceSevere and chronic jaundice

CLOTSCLOTS

ParesisParesismany small clotsmany small clots

Tuberculosis meningitisTuberculosis meningitisweblike clotweblike clot

Blockage of spinal fluid circulationBlockage of spinal fluid circulationlarge clotlarge clot

**NOTES:**NOTES:

1.1. Fluid from a subarachnoid hemorrhage has a paleFluid from a subarachnoid hemorrhage has a paleorange color supernatantorange color supernatantif RBCif RBCs present within 2s present within 2--4 hours; within 24 hours, hemoglobin is converted to4 hours; within 24 hours, hemoglobin is converted tobilirubin and supernatant is yellowish colorbilirubin and supernatant is yellowish color

2.2. In a bloody tap, lysis of RBCIn a bloody tap, lysis of RBCs occurs within 4 hrss occurs within 4 hrs--process quickly to prevent a false +. xanthochromiaprocess quickly to prevent a false +. xanthochromia

CSF TRAUMATIC TAP VS. SUBARACHNOID

HEMORRHAGE

Presence of blood in the tubes (varied vs.Presence of blood in the tubes (varied vs.no variationno variation))

Supernatant (clear vs.Supernatant (clear vs. xanthochromicxanthochromic))

Siderophage/erythrophages (absent vs.Siderophage/erythrophages (absent vs.presentpresent))

Clot Formation (clot vs.Clot Formation (clot vs. no clotno clot))

Repeat puncture (clear vs.Repeat puncture (clear vs. not clearnot clear))


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CSF

Gross AppearanceGross Appearance

Color of SupernatantColor of Supernatant

APPROACH TO CEREBROSPINAL FLUID

LABORATORY STUDIES

ROUTINE INITIAL STUDIESROUTINE INITIAL STUDIES

Cell count/differentialCell count/differential, Glucose, Total, Glucose, TotalProtein, Gram stain, Aerobic culture)Protein, Gram stain, Aerobic culture)

INITIAL SUTDIES (When indicated)INITIAL SUTDIES (When indicated)

Cytology, Fungal culture, India inkCytology, Fungal culture, India inkpreparation, Cryptococcal Ag. (Latexpreparation, Cryptococcal Ag. (Latexagglut.), AFB Culture, AFB Smear, Bacterialagglut.), AFB Culture, AFB Smear, BacterialAg. (Latex agglut.), Viral culturesAg. (Latex agglut.), Viral cultures

RETROSPECTIVE STUDIESRETROSPECTIVE STUDIES

VDRL, Oligoclonal band analysis,VDRL, Oligoclonal band analysis,

Immunoglobulin studies, Viral antibodyImmunoglobulin studies, Viral antibodytiters, Tumor markerstiters, Tumor markers

CELL TYPES IN CSFSNORMAL AND ABNORMAL

Ventricular Lining Cells (ependymalVentricular Lining Cells (ependymal

or choroid plexus)or choroid plexus)

Chondrocyte (cartillage cell)Chondrocyte (cartillage cell)

BacteriaBacteria--cocci or rodscocci or rods

Yeast/fungiYeast/fungi

MacrophageMacrophage

Neutrophil macrophage withNeutrophil macrophage withphagocytized fungi/bacteriaphagocytized fungi/bacteria

Erythrophage(containing RBCErythrophage(containing RBCs)s)

Siderophage(containing hemosiderin)Siderophage(containing hemosiderin)

Hematin CrystalsHematin Crystals

Signet ring macrophageSignet ring macrophage

Lipophage(containing lipid)Lipophage(containing lipid)

Multinucleated histiocytic giant cellMultinucleated histiocytic giant cell

LymphocyteLymphocyte

MonocyteMonocyte

Segmented NeutrophilSegmented Neutrophil

Band/MetamyelocyteBand/Metamyelocyte

EosinophilEosinophil

BasophilBasophil

PromyelocytePromyelocyte

BlastBlast

NRBCNRBC

Lymphocyte (reactive/atypical)Lymphocyte (reactive/atypical)

Transformed Lymph (immunoblast)Transformed Lymph (immunoblast)

Plasma cellPlasma cell

Lymphoma cellLymphoma cell

Malignant CellMalignant Cell

Bone marrow cellsBone marrow cells


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CSF- Bone marrow

contamination Occurs because needle was inadvertently pushed to far anteriorlyOccurs because needle was inadvertently pushed to far anteriorly, into, into

the marrow cavity of a vertebral body forcing bonethe marrow cavity of a vertebral body forcing bone--marrow cells intomarrow cells into

the needle. After needle was pulled out and repositioned in thethe needle. After needle was pulled out and repositioned in the

subarachnoid space, adherent marrow cells were flushed out by thsubarachnoid space, adherent marrow cells were flushed out by thee

flow of CSF into the specimenflow of CSF into the specimen

WBC may be falsely increased and differential may be uninterpretWBC may be falsely increased and differential may be uninterpretableable

because some or all of the cells (including mature cells) are ofbecause some or all of the cells (including mature cells) are ofmarrowmarrow

origin, making recognition of endogenous fluid cells difficult.origin, making recognition of endogenous fluid cells difficult.

Finding of CSF pleocytosis in an infant ; or in an elderly womanFinding of CSF pleocytosis in an infant ; or in an elderly womanwhowho

has vertebralhas vertebral--bone abnormalities including osteoporosis, andbone abnormalities including osteoporosis, and

metastatic involvement by cancer should warn the physician tometastatic involvement by cancer should warn the physician to

consider bone marrow contamination.consider bone marrow contamination.

A new specimen of CSF may be necessaryA new specimen of CSF may be necessary

Blood Cell Maturation

Predominant Cells in CSF


Adult NormalAdult Normal-- 4040--80%80%

Children and InfantsChildren and Infants-- 55--35%35%

MonocyteMonocyte

Adult NormalAdult Normal-- 15%15%--45%45%

Children and InfantsChildren and Infants --50%50%--90%90%

NeutrophilNeutrophil

Adult Normal less than 6%Adult Normal less than 6%

Children and Infants less than 8%Children and Infants less than 8%

Terry, 2004Terry, 2004


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CSF- ventricular lining cells

Low ratio of nuclear to cytoplasmic cellLow ratio of nuclear to cytoplasmic cell

materialmaterial

Round to oval nuclei with smooth nuclearRound to oval nuclei with smooth nuclear

contours, evenly distributed nuclearcontours, evenly distributed nuclear

chromatin and inconspicuous nucleichromatin and inconspicuous nuclei

Sheets or clusters with minimal nuclearSheets or clusters with minimal nuclear

moldingmolding

MONONUCLEAR PHAGOCYTIC SERIES

Monocyte/MacrophageMonocyte/Macrophage

Erythrophage (macrophage containingErythrophage (macrophage containingerythrocyte(s)erythrocyte(s)

Lipophage (macrophage containing abundantLipophage (macrophage containing abundantsmall lipid vacuoles)small lipid vacuoles)

Neutrophage (macrophage containingNeutrophage (macrophage containingneutrophil(s)neutrophil(s)

Siderophage (macrophage containingSiderophage (macrophage containinghemosiderin)hemosiderin)

With or without hematin (enzymaticWith or without hematin (enzymatic

degredation of hemoglobin)degredation of hemoglobin)

Monocyte/Macrophage


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DIFFERENTIALS IN ABNORMAL CSF

Inc. PMNInc. PMNSS Bacterial meningitis, early viral tuberculosis andBacterial meningitis, early viral tuberculosis andmycotic meningitis, cerebral abscess, CNS hemorrhage,mycotic meningitis, cerebral abscess, CNS hemorrhage,cerebral infarct, malignancies, CML in CNScerebral infarct, malignancies, CML in CNS

Inc. LYMPHS Viral meningitis, tuberculous meningitis, multipleInc. LYMPHS Viral meningitis, tuberculous meningitis, multiplesclerosis, Guillainsclerosis, Guillain--Barre Syndrome, lymphoma andBarre Syndrome, lymphoma andleukemialeukemia

Inc. MONOS Chronic bacterial meningitis, partially treated bactInc. MONOS Chronic bacterial meningitis, partially treated bacterialerialmeningitis, syphilitic meningitis, CNS malignanciesmeningitis, syphilitic meningitis, CNS malignancies

Inc. EOSInc. EOS Parasitic infections, fungal infections, reaction to foreignParasitic infections, fungal infections, reaction to foreignmaterialmaterialCNS (shunts, dyes), drug reactionsCNS (shunts, dyes), drug reactions

Neutrophils- PMN & Band

Lymphocytes


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Monocytes

Neutrophil, Eosinophil,Basophil

Cell Types seen in Meningitis

BacterialBacterial

Neutrophilic pleocytosisNeutrophilic pleocytosis --IncreasedIncreasedneutrophils(acute)neutrophils(acute)

ViralViral Lymphocytic pleocytosisLymphocytic pleocytosis--Predominance ofPredominance of

reactive lymphocytesreactive lymphocytes

Small to medium to large lymphs withSmall to medium to large lymphs withplasmacytoid appearanceplasmacytoid appearance

Neutrophilic pleocytosis (early)Neutrophilic pleocytosis (early)

FungalFungal

Neutrophilic pleocytosisNeutrophilic pleocytosis


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Causes of Neutrophilic Pleocytosis

Bacterial MeningitisBacterial Meningitis

Early Viral Meningitis (first 6Early Viral Meningitis (first 6--8 hrs)8 hrs)

Cerebral abscessCerebral abscess

CNS HemorrhageCNS Hemorrhage

TraumaTrauma

PostPost--myelogrammyelogram

Primary brain tumor or Metastatic tumorPrimary brain tumor or Metastatic tumor

Intrathecal injection of drugsIntrathecal injection of drugs

Previous lumbar puncture (8Previous lumbar puncture (8--12 hrs before)12 hrs before)

CSF- Bacterial Infection

Gram stain ofGram stain of

cerebrospinalcerebrospinal

fluid showingfluid showing

B. anthracisB. anthracis

CSF- Bacterial Meningitis


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Causes of Lymphocytic Pleocytosis

Viral MeningitisViral Meningitis

TB MeningitisTB Meningitis

Resolving Bacterial Meningitis (mature plasmaResolving Bacterial Meningitis (mature plasma

cells frequent)cells frequent)

CNS SyphilisCNS Syphilis

Multiple Sclerosis (plasmacytoid reactive forms)Multiple Sclerosis (plasmacytoid reactive forms)

CLL, LymphomaCLL, Lymphoma

Disseminated CarcinomaDisseminated Carcinoma

CSF-Viral Meningitis

CSF- Fungal Meningitis


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Cell types - in subarachnoid

hemorrhage 22-- 24 hours:24 hours:

Erythrocytes; Neutrophilic granulocytesErythrocytes; Neutrophilic granulocytes(30%(30%--60%); Lymphocytes;60%); Lymphocytes;Monocytes/MacrophagesMonocytes/Macrophages

1212--48 hours:48 hours:

Monocytes/Macrophages;Monocytes/Macrophages;Lymphocytes;ErythrophagocytosisLymphocytes;Erythrophagocytosis

48 hours:48 hours:

Monocytes/Macrophages;Monocytes/Macrophages;Erythrophagocytosis; Siderophages and orErythrophagocytosis; Siderophages and orHematin crystalsHematin crystals

K eldsbur and Kni ht, 1993Kjeldsburg and Knight, 1993

CSF lymphoid cells,leukemic

lymphoblasts, lymphoma cells Lymphoid cellsLymphoid cells

Mixture of small, large and transformedMixture of small, large and transformedlymphocyteslymphocytes

Leukemic lymphoblastsLeukemic lymphoblasts

Delicate dispersed chromatin nucleus;Delicate dispersed chromatin nucleus;nucleoli presentnucleoli present

Lymphoma cellsLymphoma cells

Distinct nuclear clefts or irregularitiesDistinct nuclear clefts or irregularities

CSF- Leukemic Cells


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CSF- Leukemia/Lymphoma

CSF-Malignant Lymphoma

CSF- carcinoma (malignant) cells

High ratio of nuclear to cytoplasmic cellHigh ratio of nuclear to cytoplasmic cell

materialmaterial

Pleomorphic nuclei with irregularlyPleomorphic nuclei with irregularly

distributed chromatin and prominentdistributed chromatin and prominentnucleolinucleoli

Clusters of cell with nuclear moldingClusters of cell with nuclear molding


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CSF- Malignant Cells

CSF- Malignant Cells

Pleural Effusion


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Paracentesis

INDICATIONS:INDICATIONS:

Differential diagnosis ofDifferential diagnosis of ascitesascites

Intraabdominal pressure causingIntraabdominal pressure causing

respiratory distressrespiratory distress

Differential diagnosis ofDifferential diagnosis of acute peritonitisacute peritonitis

Paracentesis

The procedure toThe procedure to

remove abnormalremove abnormal

collection of fluidcollection of fluid

from thefrom the

peritoneal cavity.peritoneal cavity.

Peritoneal Dialysis


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Pericardial Fluid

APPROACH TO SEROUS FLUIDLABORATORY STUDIES

ROUTINE INITIAL STUDIESROUTINE INITIAL STUDIES

Cell count/differentialCell count/differential, Aerobic culture, Gram stain,, Aerobic culture, Gram stain,Albumin & Serum albumin (Ascites only), Protein &Albumin & Serum albumin (Ascites only), Protein &Serum protein (Pleural effusion only), LDH & SerumSerum protein (Pleural effusion only), LDH & SerumLDHLDH

INITIAL STUDIES (When indicated)INITIAL STUDIES (When indicated)

CytologyCytology , Anaerobic cultures, Fungal cultures, India, Anaerobic cultures, Fungal cultures, Indiaink smear, AFB culture, AFB smear, pHink smear, AFB culture, AFB smear, pH

RETROSPECTIVE STUDIESRETROSPECTIVE STUDIES

Glucose, Total protein (Ascites only), Amylase,Glucose, Total protein (Ascites only), Amylase,Lipid studies, Tumor markers, Immunologic stainsLipid studies, Tumor markers, Immunologic stains

Pleural Fluids: Color/Turbidity


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CELL TYPES IN SEROUS FLUIDS

NORMAL AND ABNORMAL

Malignant cellMalignant cell

Mesothelial cellMesothelial cell

Reactive mesothelial cellReactive mesothelial cell


Lipid laden macrophage (Lipophage)Lipid laden macrophage (Lipophage)

Neutrophil laden macrophageNeutrophil laden macrophage

(Neutrophage)(Neutrophage)

Erythrocyte laden macrophageErythrocyte laden macrophage

(Erythrophage)(Erythrophage)

Hemosiderin granulesHemosiderin granules

Bacteria or FungiBacteria or Fungi

Cholesterol crystalsCholesterol crystals

Uric acid crystalsUric acid crystals


MonocyteMonocyte

Segmented neutrophilSegmented neutrophil

Band/MetamyelocyteBand/Metamyelocyte


Basophil & Mast cellsBasophil & Mast cells

Myelocyte/PromyelocyteMyelocyte/Promyelocyte

BlastBlast


Transformed lymph (immunoblast)Transformed lymph (immunoblast)


LE CellLE Cell

Degenerating cell, NOSDegenerating cell, NOS

ParasitesParasites

DIFFERENTIALS IN ABNORMAL

PLEURAL FLUID

Inc.Inc. PMNSPMNS -- Pneumonia, pancreatitis,Pneumonia, pancreatitis,

pulmonary infarction,pulmonary infarction,

malignancy,CMLmalignancy,CML

Inc. LYMPHSInc. LYMPHS -- Viral pneumonia, tuberculosis,Viral pneumonia, tuberculosis,

lymphoproliferative disorderslymphoproliferative disorders

Inc. EOSInc. EOS -- Pneumothorax, parasites, pulmonaryPneumothorax, parasites, pulmonary

infarction, Hodgkininfarction, Hodgkins disease,s disease,

eosinohilic leukemia, dermatologiceosinohilic leukemia, dermatologic

conditions.conditions.

Peritoneal Fluid-Transudate

CytocentrifugedCytocentrifugedsmear contains 54%smear contains 54%macrophages, 43%macrophages, 43%neutrophils, 3%neutrophils, 3%lymphocytes,lymphocytes,

occasional reactiveoccasional reactivemesothelial cells, andmesothelial cells, andmoderate numbers ofmoderate numbers ofred blood cells.red blood cells.Infectious agents andInfectious agents andatypical cells are notatypical cells are notdetected.detected.


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Pleural Fluid- Pleomorphic

Lymphocytes

Pleural Fluid-Mesothelial Cell

( Multi-Nucleated)

Pleural Fluid-Mesothelial Cells


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Pleomorphic Mesothelial Cells

Mesothelial cell hyperplasia

Plasma Cells


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Macrophage

Pleural Fluid- Macrophage

Macrophages engulfMacrophages engulf

invaders and destroyinvaders and destroy

them with powerfulthem with powerful

enzymesenzymes

Macrophage attackingMacrophage attacking

streptococcus bacteriastreptococcus bacteria

that cause pneumoniathat cause pneumonia


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Pleural effusion- Adult T-cell

Leukemia/Lymphoma

MORPHOLOGIC CHARACTERISTICSBENIGN MESOTHELIAL VS. MALIGNANT CELLS

MALIGNANTMALIGNANT

Large, pleomorphicLarge, pleomorphic

IrregularIrregular

UnevenUneven

Yes, dissimilar sizeYes, dissimilar size

LargeLarge

HighHigh

In some carcinomasIn some carcinomas

NonNon--uniformuniform

Single or multipleSingle or multiple

Cohesive clustersCohesive clusters

BENIGNBENIGN

MESOTHELIALMESOTHELIAL

Round, oval, uniformRound, oval, uniform

EvenEven

EvenEven

Yes, uniform sizeYes, uniform size

SmallSmall

LowLow

AbsentAbsent

UniformUniform

Large, multipleLarge, multiple

Single or mixed clustersSingle or mixed clusters

MORPHOLOGICMORPHOLOGIC

CHARACTERISTICSCHARACTERISTICS

NUCLEUSNUCLEUS

ShapeShape

Nuclear membraneNuclear membrane

ChromatinChromatin

MultinucleatedMultinucleated

NucleoliNucleoli

NN--C ratioC ratio

Nuclear moldingNuclear molding

CYTOPLASMCYTOPLASM

StainingStaining

VacuolesVacuoles

Signet ring cellsSignet ring cells

Pleural Fluid

Malignant cellsMalignant cells

Reactive MesothelialReactive Mesothelial

cellscells


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Pleural Fluid- Malignant Cells

Pleural Fluid- Adenocarcinoma

Metastatic Pleural Effusion

(Primary in Breast)


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Synovial Fluid

Synovial Fluid-Rheumatoid Arthritis

APPROACH TO SYNOVIAL FLUID -

LABORATORY STUDIES

ROUTINE INITIAL STUDIESROUTINE INITIAL STUDIES Cell count/differentialCell count/differential, Glucose, Enzymes, Total protein, Gram, Glucose, Enzymes, Total protein, Gram

stain, Aerobic culturestain, Aerobic culture

INITIAL STUDIES (When indicated)INITIAL STUDIES (When indicated) Mucin clot*, Cytology, Fungal culture, AFB culture, AFBMucin clot*, Cytology, Fungal culture, AFB culture, AFB

smear, Viral culture,smear, Viral culture, Crystal identificationCrystal identification

RETROSPECTIVE STUDIESRETROSPECTIVE STUDIES Countercurrent immunoelectrophoresis for microbial antigens,Countercurrent immunoelectrophoresis for microbial antigens,

Hemolytic complement titration, complement componentsHemolytic complement titration, complement components

* measures hyaluronic acid* measures hyaluronic acid--poor clot that fragments resultspoor clot that fragments resultsfrom inflammatory effusionsfrom inflammatory effusions


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CELL TYPES IN SYNOVIAL FLUIDS

NORMAL AND ABNORMAL

Synovial lining cellSynovial lining cell

Mutinucleated s ynovial cellMutinucleated synovial cell

BacteriaBacteria -- cocci or rodscocci or rods

Acid fast bacilliAcid fast bacilli

Yeast/fungiYeast/fungi


Neutrophil macrophage with orNeutrophil macrophage with or

without crystalswithout crystals

LipophageLipophage

Cholesterol crystalsCholesterol crystals

Monosodium urate crystalsMonosodium urate crystals

Calcium Purophosphate crystalsCalcium Purophosphate crystals


MonocyteMonocyte

Segmented NeutrophilSegmented Neutrophil

Band/MetamayelocyteBand/Metamayelocyte


BasophilBasophil

Myelocyte/PromyelocyteMyelocyte/Promyelocyte


Transformed Lumph (immunoblast)Transformed Lumph (immunoblast)


Malignant cellMalignant cell

Degenerating neutrophilsDegenerating neutrophils

Reiter cellReiter cell

DIFFERENTIALS IN ABNORMAL PERITONEAL

AND PERICARDIAL FLUIDS

Inc. PMNInc. PMNSS -- Peritonitis, malignancyPeritonitis, malignancy

Inc. LYMPHSInc. LYMPHS -- Tuberculosis, chylous ascitis,Tuberculosis, chylous ascitis,lymphoproliferative disorderslymphoproliferative disorders

Inc. EOSInc. EOSSS -- Eosinophilic gastroenteritis, chronicEosinophilic gastroenteritis, chronicperitoneal dialysis, abdominalperitoneal dialysis, abdominallymphomalymphoma

********************************** Inc. PMNInc. PMNSS -- Bacterial pericarditisBacterial pericarditis

Inc. LYMPHSInc. LYMPHS -- Viral pericarditis, tuberculosis,Viral pericarditis, tuberculosis,lymphoproliferative disorderslymphoproliferative disorders

CLINICAL CORRELATIONS

IN ABNORMAL SYNOVIAL FLUIDS

(CASE STUDIES)

GROUP I (NONGROUP I (NON--INFLAMMATORY)INFLAMMATORY)

Degenerative joint disease, Traumatic arthritis, OsteochondritisDegenerative joint disease, Traumatic arthritis, Osteochondritisdissecansdissecans

GROUP II (INFLAMMATORY)GROUP II (INFLAMMATORY)

Rheumatoid arthritis, ReiterRheumatoid arthritis, Reiters syndrome, Ankylosing spondylitiss syndrome, Ankylosing spondylitis GROUP III (INFECTIONS)GROUP III (INFECTIONS)

Rheumatoid arthritis, ReiterRheumatoid arthritis, Reiters syndrome, Ankylosing spondylitiss syndrome, Ankylosing spondylitis

GROUP IV (CRYSTALGROUP IV (CRYSTAL--INDUCED)INDUCED)

Gout, PseudogoutGout, Pseudogout

GROUP V (HEMORRHAGIC)GROUP V (HEMORRHAGIC)

Hemorrhagic, Traumatic arthritis, SynoviomasHemorrhagic, Traumatic arthritis, Synoviomas

Classification of ArthritideClassification of Arthritide


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DIFFERENTIALS IN ABNORMAL

SYNOVIAL FLUID

GROUP IGROUP I --NonNon--InflammatoryInflammatory -- PMNPMNs = < 25%s = < 25%

GROUP IIGROUP II -- InflammatoryInflammatory -- PMNPMNs = 25s = 25 -- 50%50%

GROUP IIIGROUP III -- Septic ReactionsSeptic Reactions -- PMNPMNs = >75%s = >75%

GROUP IVGROUP IVCrystalCrystal --InducedInduced -- PMNPMNS = > 50%S = > 50%

GROUP VGROUP V -- Hemorrhagic ReactionsHemorrhagic Reactions -- PMNPMNS = > 25%S = > 25%

**************************************************************************************************

Increased neutrophils indicates a septic condition; whereas, anIncreased neutrophils indicates a septic condition; whereas, an elevatedelevated

cell count with a predominance of lymphocytes suggests nonsepticcell count with a predominance of lymphocytes suggests nonseptic

inflammation.inflammation.

Other abnormal cells: LE cells, Reiter cells, and RA cells or rOther abnormal cells: LE cells, Reiter cells, and RA cells or ragocytes.agocytes.

Synovial Fluid

MonocyteMonocyte


Synovial Lining CellSynovial Lining Cell

Synovial Lining Cell


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Synovial Fluid- Neutrophils

Synovial Fluid- Neutrophils

SYNOVIAL FLUID CRYSTALS

Monosodium Urate (MSU) /TophiMonosodium Urate (MSU) /Tophi--large crystal deposits inlarge crystal deposits injoints, tendons, and soft tissuejoints, tendons, and soft tissue

GoutGout

Calcium Pyrophosphate Dihydrate (CPPD)Calcium Pyrophosphate Dihydrate (CPPD)

Pseudogout,degenerative or metabolic arthritisPseudogout,degenerative or metabolic arthritis

CholesterolCholesterol

Chronic synovial effusions, rheumatoid arthritisChronic synovial effusions, rheumatoid arthritis

Calcium oxalateCalcium oxalate

Renal dialysis patientsRenal dialysis patients

Corticosteroid crystals/steroidsCorticosteroid crystals/steroids

Drug injection for joint inflammationDrug injection for joint inflammation


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Synovial Fluid Crystal

Identification BirefringenceBirefringence-- certain structures have the abilitycertain structures have the ability

to rotate or polarize lightto rotate or polarize light--known as birefringenceknown as birefringence

(weakly/calcium pyrophosphate or(weakly/calcium pyrophosphate or

strongly/monosodium urate)strongly/monosodium urate)

Polarizing filterPolarizing filter-- insert a polarizing filter betweeninsert a polarizing filter between

light source and object; and then anotherlight source and object; and then another

polarizing filter(this is analyzer) betweenpolarizing filter(this is analyzer) between

eyepiece and specimeneyepiece and specimen

Synovial Fluid Crystal

Identification (cont.) Polarizing filter with compensationPolarizing filter with compensation-- using a polarizerusing a polarizer

and and analyzer with a first order red compensator. Theand and analyzer with a first order red compensator. Thered compensator is a retardation plate that alters thered compensator is a retardation plate that alters thepassage of light into slow and first components when thepassage of light into slow and first components when thecompensator is inserted between the polarizer andcompensator is inserted between the polarizer andanalyzer, it retards the lights so that the field backgroundanalyzer, it retards the lights so that the field backgroundbecomes red instead of black.becomes red instead of black.

Monosodium urate crystalsMonosodium urate crystals-- appearappear yellowyellow whenwhenlongitudinal axis islongitudinal axis is parallelparallel to the slow component ofto the slow component ofthe compensator and they appearthe compensator and they appear blueblue when the axiswhen the axisisis perpendicularperpendicular

Calcium pyrophosphate crystalsCalcium pyrophosphate crystals --appearappear blueblue whenwhen

parallelparallel to compensator andto compensator and yellowyellow whenwhenperpendicularperpendicular

Synovial Crystals

NeedleNeedle--shapedshaped

monosodiummonosodium

crystals seen bycrystals seen by

light microscopy oflight microscopy of

synovial fluid in asynovial fluid in a

patient with gout.patient with gout.


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Synovial Fluid Crystals-

Monosodium Urate

Synovial fluidSynovial fluid

with sodium uratewith sodium urate

crystals, polarizedcrystals, polarized

light with redlight with red

compensatorcompensator

microscopic.microscopic.

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Cavagnaro Body Fluid Analysis2008 4 16 2 to 3pm Ho