Cerebrospinal, pleural, abdominal and synovial fluid

Adisorn bunnag, M.D Clinical pathology unit Uttaradit hospital

Cerebrospinal Fluid(CSF) examination

Open pressure Gross examination Cell count and differential count Microbiological examination Immunological examination Chemical analysis Lumbar puncture

Cerebrospinal fluid open pressure

Normal adult: 9- 18 cmH2O children < 8 years: 1-10 cmH2O

Gross examination
Normal CSF: crystal clear, colorless, viscosity

similar to water
Abnormal CSF: cloudy, purulent or pigment

tinged

CSF: cell count and differential count

Total Cell Count
Manual counting chamber Should be perform within 1 hr ( avoid cell lysis )

Normal WBC
Adult: 0-5 cells/L Neonate: 0-30 cells/L

Normal RBC: 0 cells/L

CSF with Hemorrhagic fluid

Traumatic tap Subarachnoid hemorrhage

Clot

Yes

No

Normal peripheral blood = 1 WBC : 700 RBCs

CSF Reference Values for Differential Count Celltype Adults(%)

Lymphocytes Monocytes Neutrophils Histiocytes Ependymal cells Eosinophils 60-70 30-50 none Rare Rare Rare

CSF examination for tumor cells

Leukemia Metastatic carcinoma CNS malignancy

Acutelymphoblastic leukemiainCSF

Acutemyeloblastic leukemia inCSF

Microbiological Examination
Grams stain

Acid fast stain

India ink preparation

Cryptococcus neoformans

CSF culture and antimicrobial susceptibility test

CSF PCR (polymerase chain reaction)

Mycobacterium tuberculosis,Viruses (Herpes simplex virus, Enterovirus, Arbovirus)

Immunological examination
CSF antigen detection for microorganisms
Haemophilus influenzae, Streptococcus pneumoniae, Neisseria meningitidis, Cryptococcus neoformans

Negative

Positive

CSF VDRL for neurosyphilis

Chemical analysis
Total protein Glucose Lactate (not commonly used) Enzymes (not commonly used)

Meningitis ()
Bacteria, virus, fungus, parasite

(neck stiffness)

Typical Lumbar CSF Findings in Meningitis

Test
Opening pressure

Bacterial
Elevated

Viral
Usually normal <100/L

Fungal
Variable Variable

Tuberculous
Variable Variable

Leukocytecount 1000/L

Celldifferential Protein Glucose

Mainly Mainlyneutrophils lymphocytes Mildmarked increase Usually 40 mg/dL Normalmarked decrease Normalmild increase Normal

Mainly lymphocytes Increased Decreased

Mainly lymphocytes Increased Decreased:may be<45mg/dL Low

CSFtoserum glucoseratio

Usually normal

Low

Primary Amebic Meningoencephalitis (PAM)

Rarediseasecausedbythefreelivingameba

Naegleria fowleri

Acanthamoeba sp.

CSF fresh smear: positive

Pleural fluid examination Pleuraleffusion Thoracentesis

Pleural effusion Transudates:

hydrostaticpressure plasmaoncotic pressure

Exudates:
capillarypermeability lymphaticresorption

Laboratory Criteria for Pleural Fluid Exudate

Pleuralfluid/serumproteinratio Pleuralfluid/serumLDratio PleuralfluidLD

0.50 0.60 upperlimitof

normalserumLD

Exudate : 1criteria LD=Lactatedehydrogenase

Cytological examination Mesothelial cells

inflammatoryprocesses Tuberculous pleurisy,empyema,rheumatoidpleuritis, patientswhohavehadpleurodesis

Malignancycells

Chemical Analysis
Protein,Glucose,Lactate
Enzymes Amylase Lactatedehydrogenase (LD) Adenosinedeaminase (ADA)

pH
pH<7.20requiringsurgicaldrainage pH<6.0:characteristicofesophagealrupture pHinsevereempyema may 6.0

Microbiological Examination
Gramstain(sensitivity50%) Anaerobic/aerobiccultures

M.tuberculosis
Acidfaststainsensitivity:2030% Pleuralbiopsyculturesensitivity:5075% Combiningcultureandacidfaststainswith pleuralbiopsysensitivity:95%

Peritoneal Fluid
Ascites:pathologicaccumulationofexcessfluidin peritonealcavity Peritoneal Fluid Examiation Grossexamination Microscopicexamination Chemicalanalysis Microbiologicalexamination
Paracentesis

Gross examination

Bloody:malignancy,tuberculosis,pancreatic ascites,nephrosis Strawcolor:cirrhosis,congestiveheartfailure, malignancy Milky:lymphaticobstruction,chylous Turbid :infection

Microscopic Examination
cellcountanddifferentialcount
Wbc PMN:pyogenic peritonitis lymphocyte:tuberculous peritonitis variablecelltypes:pancreaticascites Rbc Malignancycells

Microbiological Examination
Gramsstain AFBstain Culture PCR

The serumascites albumin gradient (SAG) transudateexudate

SAG=serumalbuminconcentration ascitic fluid albuminconcentration
Transudate SAG Exudate

1.1g/dL

<1.1g/dL
increasedcapillary permeabilityordecreased lymphaticresorption

Cause increasedhydrostatic pressureordecreased plasmaoncotic pressure

Transudates:increasedhydrostaticpressureordecreasedplasmaoncotic pressure (SAG1.1g/dl)

Congestiveheartfailure Hepaticcirrhosis Hypoproteinemia (e.g.,nephrotic syndrome)

Exudates: increasedcapillarypermeabilityordecreasedlymphaticresorption (SAG<1.1g/dl)

Infections Primarybacterialperitonitis Secondarybacterialperitonitis(e.g.,appendicitis,bowelrupture) Tuberculosis Neoplasms(Hepatoma/Lymphoma/Mesothelioma/Metastatic carcinoma/Ovarian carcinoma/Prostatecancer) Trauma/Pancreatitis/Bileperitonitis(e.g.,rupturedgallbladder)

Chylous effusion

Damagetoorobstructionofthoracicduct(e.g.,trauma,lymphoma,carcinoma, tuberculosisandothergranulomas [e.g.,sarcoidosis,histoplasmosis,etc.],parasitic infestation)

Condition Cirrhosis

Grossappearance SAG Strawcolor

Cells/l

>1.1 <250;mesothelial
predominate

Congestive heart failure Tuberculous peritonitis Pyogenic peritonitis

Strawcolor

>1.1 <1000;usually
mesothelial, Mononuclear predominate

Clear,turbid, hemorrhagic, chylous Turbidorpurulent

<1.1 >1000;usually
Lymphocytes predominate

<1.1 polymorphonuclear
Leukocytes Predominantly

Synovial Fluid examination

1. 2. 3. 4.
Arthrocentesis

Synovial Fluid
Grossexamination Microscopicexamination
Totalcellcount Differentialleukocytecount Crystalexamination

Microbiologicalexamination

Chemicalandimmunologicalexamination

Synovial fluid categories

1. Noninflammatory effusions(GroupI) 2.Inflammatoryeffusions(GroupII)
3.Purulent(infectious)effusions(GroupIII)

4.Hemorrhagiceffusions(GroupIV)

Gross examination
Color Normal=colorlessorpalestrawcolor Clarity normal=transparent

Viscosity
normal=stringeffect, longtailbehindeach synovialdrop

normalviscosity:Noninflammatory/trauma reducedviscosity :Inflammatory,septicfluid

Microscopic Examination
Total cell count

NormalWBC<150/L
WBC>10000/L,(often>50000/L) Crystalinducedarthritis chronicinflammatoryarthritis septicarthritis WBC<10000/L Osteoarthritis,trauma

NormalRBC= none

Differential Leukocyte Count Cells

Neutrophils Lymphocytes Monocytes

conditions
Septicarthritis,acutecrystal inducedarthritis,RA Viralarthritis,TB arthritis,early RA, SLE Viralarthritis,OA,chrionic crystal inducedarthritis Parasiticarthritis,TB arthritis,Post radiationarthritis

Eosinophils

Crystal Examination Crystalsacuteinflammation

Commontypesofendogenouscrystals
Monosodiumurate monohydrate(urate gout) Calciumpyrophosphatedihydrate (pseudogout)

Gout

Monosodium urate (MSU) crystals

Needleshapedrods5-20 m Polarizedmicroscope: negativebirefringence yellow :paralleltocompensator blue :perpendiculartocompensator

(CPPD)

Calcium pyrophosphate dihydrate

CPPDcrystaldepositiondisease Rhomboids,rodsorrectangles1-20 m Weaklybirefringent :positiveelongation (bluewhenalignedwithcompensatoraxis)

Microbiological Examination

Septicarthritis
Gramsstain Acidfaststain KOH Culture PCR

Normal synovial Fluid profile

Finding
Clarity Color viscosity WBCs/L PMNs (%) RBCs

Normal Transparent Cleartopaleyellow Veryhigh

0 -150 < 25
No

Synovial fluid findings

Category

Finding Clarity Color WBCs/mL PMNs (%) RBCs Culture

GroupINon inflammatory

GroupII Inflammatory

GroupIII Infectious

GroupIV Hemorrhagic

Transparent
Yellow

Transparent Opaque /opaque

Yellowto white/bloody Yellowto green

Opaque
Redbrownor xanthochromic

< 3000

300075 000

50 000200 000

5010 000

< 30
No negative

> 50
No negative

> 90
Yes positive

< 50
Yes negative