Body Fluids Serous, Synovial, CSF

Types of Fluids Serous Fluids Other Fluids Synovial Fluid Joints Pleural Fluid (Thoracic) Chest Peritoneal Fluid (Ascitic) Abdomen Pericardial Fluid Heart   Other Fluids Synovial Fluid Joints Cerebral Spinal Fluid (CSF) Brain and Spinal chord Amniotic Fluid Uterus Semen

Types of Fluids Serous Fluids Pleural Fluid - thoracic or chest Thorocentesis - procedure used to obtain Pleural Fluid Empyema - pus in pleural fluid Peritoneal Fluid - (Ascitic) Fluid in Abdomen Paracentesis is procedure used to obtain fluid from body cavity Chylous Effusion - Chyle or Lymph fluid Pericardial Fluid Fluid around the heart   Other Fluids Synovial Fluid from joints Cerebral Spinal Fluid Brain and Spinal chord Amniotic Fluid Semen

Formation of Serous Fluids Serous fluid is an ultrafiltrate of plasma An Increase in the following causes Fluid to form Hydrostatic Pressure drives fluid out of capillaries into body cavity Capillary Permeability A Decrease in the following causes a fluid to form Colloid Osmotic Pressure(COP) Protein in capillaries is impermeable Protein in capillaries absorbs fluid from cavity. Albumin contributes more than globulins. The greater the amount of albumin the greater the COP. Lymphatic Drainage Absorb fluid, protein and particulate matter from extravascular space.

Effusion Abnormal increase in fluid Transudate vs Exudate

Transudate Increased Capillary Hydrostatic Pressure Congestive Heart Failure Retention of Salt and Fluid Decreased Oncotic Pressure (Low serum protein) Nephrotic Syndrome Hepatic cirrhosis Malnutrition Protein losing enteropathy

Exudate Increased Capillary Permeability Microbial infections Membrane Inflammations Malignancy Decreased Lymphatic Drainage Tumors Infection and inflammation Thoracic Duct Injury

fluid protein/ serum protein Transudate vs Exudate Transudate Exudate Main causes Increased hydrostatic pressure, Decreased colloid osmotic pressure Inflammation Appearance Clear[1] Cloudy[1] WBC count < 1000uL >1000uL Spontaneous Clotting No Yes Specific gravity < 1.012 > 1.020 Protein content < 2.5 g/dL > 2.9 g/dL[2] fluid protein/ serum protein < 0.5 > 0.5[3] Difference of (SAAG) (S Alb minus F Alb) albumin content with blood albumin > 1.2 g/dL < 1.2 g/dL[4] fluid LDH upper limit for serum < 0.6 or < 2⁄3 > 0.6[2] or > 2⁄3[3] Cholesterol content < 45 mg/dL > 45 mg/dL[2] References[edit] ^ Jump up to: a b The University

Transudate or Exudate John Smith Billy Rubin Serum Protein 7.0 gm/dL Fluid Protein 2.5 gm/dL 2.0 gm/dL Fluid/Serum Ratio Transudate or Exudate Cause of Effusion Diagnosis

Transudate or Exudate John Smith Billy Rubin Serum Protein (6.0 – 8.0 gm/dL) 7.0 gm/dL 5.0 gm/dL Fluid Protein 2.5 gm/dL 2.0 gm/dL Fluid/Serum Ratio 2.5/7.0 = 0.35 2.0/5.0 = 0.4 Transudate or Exudate Transudate Cause of Effusion Increased Capillary Hydrostatic Pressure Decreased COP Diagnosis Congestive Heart Failure Nephrotic Syndrome, Malnutrition, Hepatic Cirrhosis

Transudate or Exudate Bobby Biuret Billy Rubin Serum Protein 7.0 gm/dL Fluid Protein 5.0 gm/dL 2.0 gm/dL Fluid/Serum Ratio Transudate or Exudate WBC count 12,000 500 Cause of Effusion Diagnosis

Transudate or Exudate Bobby Biuret Billy Rubin Serum Protein 7.0 gm/dL Fluid Protein 5.0 gm/dL 2.0 gm/dL Fluid/Serum Ratio 5.0/7.0 = 0.7 > 0.5 2.0/7.0 = 0.3 < 0.5 Transudate or Exudate Exudate Transudate Fluid WBC 12,000 > 1000 500 < 1000 Cause of Effusion Increased Capillary Permeability or Lymphatic Obstruction Decrease in COP Diagnosis Infection, Malignancy, Inflammation Nephrotic Syndrome, Malnutrition

Pleural Fluid Hematology Normal Disease Macrophage 64 – 80 % Lymphocytes 18 - 30% Increased TB Viral Infections Autoimmune disorders (Rheumatoid Arthritis) Malignancy Neutrophils 1- 2% Increased Bacterial Infection Pancreatitis Pulmonary Infarction Mesothelial cells Decreased in TB Eosinophils >10% Trauma air (pneumothorax)or blood (hemothorax) Allergic reactions Parasitic infections

Transudate vs Exudate https://www.youtube.com/watch?v=qCdNab2WLiw

Synovial Fluid

Synovial Fluid Crystals Viscosity Hyaluronic acid Fluid should be viscous Test WBC, Dif, Gram stain, culture, and crystal ID

Synovial Fluid Crystals Monosodium Urate (MSU) Gout Calcium Pyrophosphate (CPPD) Pseudogout Cholesterol

IV. Microscopic Examination Cell Count – WBCs Method Use Neubauer counting chamber May pretreat viscous fluids with hyaluronidase & incubate at 37oC for 5 min. Dilution with hypotonic saline is used to lyse any RBCs OR Dilute with normal saline/methylene blue mixture to differentiate WBCs from RBCs Normal = <200 / uL Differential Count Cytocentrifuge specimen and prepare typical blood smear Normal: 60% monocytes, macrophages neutrophils: <20% lymphocytes: <15% (* values vary between texts) Increased neutrophils – possible septic condition Increased lymphocytes – indicate nonseptic inflammation

Other cell abnormalities: Increased eosinophils – rheumatic fever, parasitic infections, metastatic carcinoma, post radiation therapy or arthrography LE cells – patients with lupus erythematosus Reiter cells – macrophages with ingested neutrophils RA cells (ragocytes) – precipitated rheumatoid factor appearing as cytoplasmic granules in neutrophils Hemosiderin granules – due to hemorrhagic process or cases of pigmented villonodular synovitis Cartilaginous cells – observed in cases of osteoarthritis Rice bodies – found in septic and rheumatoid arthritis and Tuberculosis Fat droplets – indicate traumatic injury

Synovial lining cell

Neutrophils in synovial fluid

Lymphs in synovial fluid

Uric acid crystals GOUT

Calcium Pyrophosphate Crystals http://emedicine.medscape.com/article/330936-workup#aw2aab6b5b2 Pseudogout

Hydroxyapatite (HA) (Calcium phosphate) Cholesterol Nonspecific indications Associated with chronic inflammation Exhibit negative birefringence (compensated polarized light) Usually seen extracellularly Polarized light – strongly birefringence Rhombic plates Hydroxyapatite (HA) (Calcium phosphate) Associated with calcific deposition conditions May produce an acute inflammatory reaction Intracellular Not birefringent Require an electron microscope to examine Small, needle shaped Corticosteroid Associated with intra-articular injections; NO clinical significance Primarily intracellular Exhibit positive and negative birefringence Can closely resemble MSU and CCPD Flat, variable shaped plates

Birefringent Artifacts: Calcium Oxalate Following renal dialysis Birefringent Artifacts: Anticoagulant crystals (calcium oxalate, lithium heparin) Starch granules Prosthesis fragments Collagen fibers Fibrin Dust particles

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Cerebral Spinal Fluid (CSF)

CSF Protein

CSF is a clear colorless fluid which is an ultrafiltrate of plasma. It maintains a constancy of intracranial pressure and provides mechanical protection for the brain and spinal chord.   Volume 150 ml

Collection Lumbar Puncture 5 - 10 ml in 1 to 4 tubes A certain amount of risk and trauma to the patient is involved. Specimen should always to handled with extreme care!! CSF is a precious Fluid Risks to patient include - Coning, paresis or paralysis, infection, dermoid tumor, and headache. Lumbar Puncture - Patient is placed in the fetal position on their side. A stylet with a 3 -way stopcock is inserted into the spinal chord usually in the lumbar region.. After checking for increased pressure using a manometer, fluid is allowed to drip into four different test tubes Tubes #1 and #4 Hematology Tubes #2 or #3 Chemistry or Microbiology

Tests Ordered on CSF Color and turbidity Culture, VDRL Cell Counts Tubes 1 and 4 Total Protein and Glucose, sometimes LDH, Bilirubin, and Protein Electrophoresis, are also performed

Blood in Specimen  May be the result of a Traumatic Tap or Brain Hemorrhage May be able to determine which by counting cells in both tubes #1 and #4. If blood in tube `#1 is much more prevalent than in tube #4 it is likely that there was a traumatic tap. Total Protein will also be elevated. Serum contains 200 - 400 times more protein than CSF Brain Hemorrahge  Xanthochromia - yellow pigmentation due to the presence of bilirubin

CSF Total Protein Normal Value Lumbar (15 -45 mg/dl) adults (up to 400 mg/dl) premature infants (30 - 150 mg/dl) mature infants

Clinical Significance CSF tap is indicated in suspected Meningitis Subarachanoid hemorrhage Encephalitis, CNS syphilis Spinal chord tumor Multiple Schlerosis (MS) Cerebral infarction Intracerebral hemorrhage