Cerebrospinal, Synovial, and Serous Body Fluids - PowerPoint Presentation

Slide1

Cerebrospinal, Synovial, and Serous Body Fluids

2Slide2

Gram stain and culture

Antigen tests

Urine reagent strips Slide3

Large volumes of CSF, often from multiple lumbar punctures, are recommended to improve the sensitivity

antigens and antibodies

PCR nucleic acid amplification for detecting

Mycobacterium tuberculosis

DNA-specific sequencesSlide4

Gram stain, culture, and crystal examination

,

Clinical context

Gross & microscopic examination

Other tests

are not of practical value for routine use, they

may provide important

diagnostic

information

under

certain circumstances.Slide5

Noninflammatory

effusions (Group I)

leukocyte counts less than 3000/

μ

L, with a minority of neutrophils.

Inflammatory effusions (Group II)

Purulent (infectious) effusions (Group III)

Typically have leukocyte counts greater than 50 000, of which 90% or more are neutrophils. Bacterial, fungal, &

tuberculous

joint infections constitute this group.Slide6

Examination of

the synovial fluid are imperative

differential

diagnosis of joint

disease

Crystal-induced & infectious

arthritis

.

Staphylococcus

aureus

Joint irreversibly

damaged within a couple of daysSlide7

Polarized microscopy

DiffQuik

staining

method

repeat

examination following 24

hours of

refrigeration at 4°C may result in a significant increase in the number

of crystal-positive fluids

X-ray crystallography

and Fourier transform infrared

spectroscopy

more sophisticated and reliable methodsSlide8

A control slide of

MSU

crystals should

always be used for comparison.Slide9

Pleural Fluid

the

pleural cavity normally contains a small amount

of fluid

a plasma

filtrate

It

is produced

continuously at a rate

dependent

on capillary hydrostatic

pressure, plasma

oncotic pressure, and

capillary permeability.

reabsorbed through the

lymphatics

&

venules

of the visceral pleura.Slide10

An

accumulation

of fluid is called an

effusion

serous

effusion

fluid accumulation

in the

pleural,

pericardial,

and peritoneal

cavities

Thoracentesis

is indicated

for

any

undiagnosed pleural effusion

or for therapeutic

purposesSlide11

The specimen

should be collected in heparinized

tubes

EDTA tube for total and differential cells

counts

Aliquots for aerobic and anaerobic bacterial cultures are best

inoculated into

blood culture media at the bedside. Slide12

If malignancy, fungal infection,

or mycobacterial

infection is suspected, all remaining fluid (100 m L or

more) should

be submitted to maximize yield of stains and culture

.

Serous effusions

are more forgiving than CSF in maintaining cellular

integrity

Specimens

for cytology may be stored up to 48 hours in

the refrigerator

with satisfactory results.Slide13

For pH measurements, the

fluid should

be collected anaerobically in a heparinized syringe and

submitted to

the laboratory on ice

.

Grossly purulent specimens do not require

pH measurement

and may clog the analyzerSlide14

Classification of Pleural EffusionsSlide15

Laboratory Criteria for Pleural Fluid ExudateSlide16

The evaluation of serous body fluids (pleural. pericardial, peritoneal)

is directed

first toward differentiating

transudative

from exudative effusions

.

Transudates generally require no further

work-upSlide17
Slide18

Total leukocyte, differential

, and

red cell counts are of limited use in the evaluation of serous effusions.Slide19

Gross Examination

Transudates are typically clear, pale yellow to straw-colored, odorless,

and do

not clot

.

Turbid

, milky

, and/or

bloody specimens should be centrifuged and the

supernatant examinedSlide20

Characteristic Features of

Chylous

and

pseudochylous

EffusionsSlide21

pseudochylous

fluids

due to

Increased leukocytes

and necrotic debris

,

Presence of

increased lecithin-globulin complexes

.

A true

chylous

effusion

Lipoprotein electrophoresis

Lipid measurementsSlide22

Microscopic Examination

Cell

Counts

Differential

Leukocyte Count

The relative proportions of T cells, B cells

,…

Filtration

or automated

concentration

methods

with

Papanicolaou

stain may

also be used, especially if there is concern for cell loss

.

Or by

cytocentrifugation

Cytologic

analysis will establish the diagnosis

for

malignancySlide23

Cellular

Differenlial

of Pleural EffusionsSlide24

Correct diagnosis

Immunophenotyping

by flow

cytometry

or

immunocytochemistly

,

in conjunction

with cellular

morphology.Slide25

Chemical Analysis

Protein

total protein or albumin

has little

clinical

value

except when combined with other

parameters

differentiate exudates from

transudates

Protein

electrophoresis

pattern similar to

serum

Glucose

normal pleural fluid, transudates, and

most exudates

is similar to serum levels

.

Decreased

<60

mgldL

,

rheumatoid

pleuritis

Malignancy,

tuberculosisSlide26

Chemical Analysis

Lactate

infectious

pleuritis

Bacterial &

tuberculous

pleural

infections

Enzymes

Lactate dehydrogenase

(LD)

Rise

,

in proportion to

the degree

of inflammation

.

Declining

LD, inflammatory

process is

resolving.

Adenosine

deaminase

(ADA

)

Tuberculous

pleuritisSlide27

pH

.

the

highest diagnostic accuracy

in assessing

the prognosis of

parapneumonic

(pneumonia-related)

effusions.

pH greater than

7.30,

resolves with medical therapy

alone

pH less than

7.20,

indicates a complicated

parapneumonic

effusion

requiring surgical drainage.Slide28

Tumor

Markers

Carcinoembryonic

antigen

(CEA

),

the most useful single marker for adenocarcinomas

,

A combination of tumor markers increases the accuracy of diagnosisSlide29

Immunologic Studies

elevated RF

titers

Antinuclear

antibody (ANA)

titers

Decreased Complement levels Slide30

Microbiological Examination

Bacteria most commonly associated with

parapneumonic

effusions

Staphylococcus

aureus

, Streptococcus

pneumoniae

, beta-hemolytic group

A streptococci

, gamma-streptococci, and some Gram-negative

bacilli

Anaerobic

bacteria

anaerobic

&

aerobic

cultures

Gram staining

, acid-fast staining Slide31

Microbiological Examination

Pleural

biopsy

Demonstration of

granulomas or acid-fast bacteria

.

Combining culture and acid-fast

stains with

pleural biopsy increases the

sensitivity

Adenosine

deaminase

(ADA

)

rapid chemical evidence

for

tuberculous

interferon-gamma is also significantly increased

in

tuberculousSlide32

Pericardial Fluid

10-50

mL of fluid is

normally present

Produced by

a

transudative

process

Pericardial effusionsSlide33

Etiology of Pericardial EffusionsSlide34

Pericardial Fluid

Recommended laboratory tests

Many, as described

for pleural

fluid

Indication

effusions of unknown

etiology

Large effusions

Specimen Collection

Pericardiocentesis

(sterile needle aspiration

).

Nonmal

pericardial

fluid

pale

yellow and

clear

Turbid effusions

Infection or

malignancy

Hemorrhagic effusionsSlide35

Pericardial Fluid

Milky appearance

Chylous

or

pseudochylous

Routine

testing of pericardial

effusions

Cell count

, glucose, total protein, LD, bacterial culture, and

cytology

Other more

specific

tests

diseases

of high

clinical suspicionSlide36

Pericardial Fluid

Microscopic Examination

Hemorrhagic effusion

The hematocrit &

red cell

count

Total leukocyte

counts

> 10 000/

μ

L, bacterial,

tuberculous

,

or malignant

pericarditis

.

a stained smear should always be

examined

Cytologic

analysis

Metastatic carcinoma of the lung and

breast

The most

frequently

observed in

malignant pericardial effusionsSlide37

Pericardial Fluid

Chemical Analysis

Protein

>

3.0

g/

dL

has a sensitivity of 97%

for exudative

effusions

, low specificity

total protein has no discriminating power

in pericardial diagnosis

Glucose

<60 mg/

dL

, in identifying pericardial

exudates

< 40

mg/

dL

bacterial,

tuberculous

, rheumatic, or malignant effusions

. Slide38

Pericardial Fluid

Chemical Analysis

pH

<7.10

Rheumatic or

purulent pericarditis

.

Lipids

Triglyceride &

cholesterol measurements

,

Lipoprotein electrophoresis

for

chylomicrons

Enzymes

LD , >200U/

LPericardial

exudates

Acute myocardial injury Slide39

Pericardial Fluid

Chemical Analysis

Adenosine

deaminase

(ADA

)

tuberculous

pericarditis

cases with negative acid-fast

stains

Interferon-gamma

(INF-gamma)

& ADA are

Significantly higher

in

tuberculous

pericarditis

than

in other pathologic

effusions

Polymerase Chain Reaction (PCR

)

more specific than adenosine

deaminase

cases with negative

M

. tuberculosisSlide40

Pericardial Fluid

Immunologic Studies

high antinuclear

antibodies (ANA

)

Lupus

serositis

Malignancy Slide41

Pericardial

Fluid

Microbiological

Examination

Gram Stain

and

culture

for bacterial

pericarditis

Aerobic &

anaerobic

baaeria

Important aerobic bacteria

include

S

.

au

reus

,

S.

pneumoniae

,

S

.

pyogenes

,

beta-hemolytic group A streptococcus, and

Gram-negative bacilli.

The

major anaerobic organisms

the

Bacteroides

fragilis

group, anaerobic

streptococci,clostridium

species,

Fusobacterium

species, and

Bifidobacrerium

species.Slide42

Pericardial

Fluid

Microbiological

Examination

Diagnosis of a specific etiologic agent in viral pericarditis is

difficult

rarely

isolated

Sera for

antibody response

support the diagnosis

acid-fast stains and culture for

tuberculous

PCR is a sensitive

technique

a negative test does

not exclude

the diagnosis of

tuberculous

pericarditis.Slide43

Peritoneal Fluid

Ascites

Pathologic accumulation

of excess fluid in the

peritoneal cavity.

Normal

Up

to 50 mL

Production

An

ultrafiltrate

of

plasma

Vascular permeability

,

& hydrostatic and oncotic

Starling forces.Slide44

Peritoneal Fluid

Ascitic

fluid is

classifed

as

Transudate

or

Exudate

Common

causes of peritoneal effusionsSlide45

Etiology of Peritoneal EffusionsSlide46

Peritoneal Fluid

Criteria for Exudate

The

serum-ascites

albumin gradient

,

Serum albumin-

ascitic

fluid albumin

The most

reliable method to differentiate

peritoneal transudates

from

exudates

< 1. 1 g/

dL

, exudate

An

ascitic

fluid to serum bilirubin ratio of 0.6 or

greater

ascitic

fluid LDH

is > 130 U/L and the

ascitic

fluid

to

serum total

protein ratio is >

0.4.Slide47

Peritoneal Fluid

Specimen Collection

(

Paracentesis

)

Indication

Patients with new ascites

Change in

the clinical picture of a patient

with ascites

Rapid fluid

accumulation or fever development

.

A minimum of 30

mL is

needed

100 mL,

if ,

cytologic

examinationSlide48

Samples for

cell counts

should be placed in an EDTA-

anticoagulated

venipuncture

tube

Culture

specimens

Should include

blood culture bottles that have

been inoculated

at the bedside with

ascitic

fluid

(10 mL per culture

bottle)Slide49

Rapid screening for significant

abdominal

hemorrhage

evaluation of hollow

viscus

injuries

.Slide50

Recommended Tests in Peritoneal EffusionSlide51

Relative importance varies depending on the type of

sample and

clinical findings

.

For

example,

RBCand

WBCcounts

are more

imponant

than

cytology or the serum-ascites albumin gradient in the evaluation

of the

abdominal effects of trauma.Slide52

Peritoneal Fluid

Gross Examination

Transudates

pale

yellow and dear

,

Exudates

Cloudy or turbid,

due to the presence of leukocytes, tumor cells, or increased

protein

bloody

fluid

Traumatic tap,

malignancy and tuberculosis,

Trauma.

Milky fluid

that

does

not

clear with centrifugation suggests a

chylous

or

pseudochylous

effusion.Slide53

Peritoneal Fluid

Gross Examination

Food particles

, foreign material, or green-yellow

bile staining

Perforation of

the gastrointestinal

or biliary

tract.Slide54

Peritoneal Fluid

Microscopic

Examination