CBME-CSF CHARTS 2nd yearb pathology.pptx

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1. CSF CHARTS

2. INTRODUCTION: The cerebrospinal fluid is a clear, colorless, transparent tissue fluid present in the cerebral ventricles, spinal canal and subarachanoid space.

3. CSF CIRCULATION:

4. INDICATIONS of csf study: Diagnostic- CNS INFECTIONS- Meningitis, encephalitis and CNS syphillis . SUBARACHANOID HEMORRHAGE. DEMYELINATING DISEASES- Multiple Sclerosis, Guilllain Barre Syndrome . MALIGNANCY - Leukemia, lymphoma. Radiographic contrast material - myelography Therapeutic- Medication- Anaesthetics , ALL(Methotrexate) , Antifungal (Amphotericin B) Reduce CSF pressure in Benign intracranial tension

5. CONTRAINDICATION: 1. Increase of intracranial pressure:-Cerebral herniation; Impending herniation 2. Coagulopathy. 3. H/o arachanoiditis . 4. Prior lumbar surgery. 5. Osteoarthiritis or degenerative disc. 6. Significant cardiorespiratory compromise. 7. Infection near the puncture site. 8. Space occupying lesion .

6. MODE OF COLLECTION CSF is obtained by:- 1)Lumbar Puncture. 2) Cisternal puncture. 3)Ventricular puncture(lateral cervical)

7. IN CHILDREN: Done in 4 th lumbar space i.e between 4 th and 5 th lumbar vertebra. IN ADULTS: L3- L4

8. Normally upto 2 ml of CSF is collected . Specimen should be transported to the laboratory immediately and processed within one hour otherwise cellular deGENERATION occurs giving false negative results.

9. Complications of lumbar puncture: Worsening of brain herniation. Subdural hematoma Headache Diplopia Hearing loss/tinnitus Backache Bloody tap, subarachanoid bleeding Infection Hazards of thrOmbocytopenia and anticoagulation.

10. It is usually collected in four sterile test tubes:- TUBE1 - BIOCHEMISTRY AND SEROLOGICAL STUDIES TUBE2 - MICROBIOLOGICAL EXAMINATION TUBE 3 - CELL COUNT, DIFFERENTIAL COUNT Tube 4 - CYTOLOGICAl , IMMUNOLOGICAL, ADDITIONAL STUDIES

11. NORMAL CSF PHYSICAL PROPERTIES COLOR : clear and colorless. VOLUME - In adults-90 to 150 ml In children-10 to 60 ml. Specific gravity- 1.006 to 1.008 NORMAL PRESSURE- 90 to 180 mm of water

12. Appearance - 1. TURBID CSF- LEUKOCYTOSIS, INCREASED RED CELLS, MICROORGANiSMS , RAISED PROTEINS 2. BLOOD MIXED CSF- Traumatic tap/SAH 3. XANTHOCHROMIA 4. CLOT FORMATION- increased proteins, spinal block 5. THICK VISCOUS CSF- cryptococcal meningitis, metASTASES , severe meningitis, release of nucleus pulposes

13. COBWEB COAGULUM: Delicate clot, formed if the sample contains fibrinogen due to mark increase in CSF proteins. characteristically seen in TUBERCULAR MENINGITIS . The clot may have entrapped tubercular bacilli, which could be demonstrated microscopically by AFB stain. METHOD:- Allow the specimen of CSF to stand over night and examine the sample for fibrin clot, which is formed if the sample contains fibrinogen.

14. Xanthochromia : Pale – pink to yellow colour to the supernatent of the centrifuged CSF. After centrifugation ,compare with a tube of distilled water. Due to lysis and RBC breakdown. Orange - oxyhemoglobin Yellow - bilirubin Yellow green - biliverdin

15. Other causes of xanthochromia : Oxyhemoglobin resulting from artifactual red cell lysis caused by detergent contamination of needle or collecting tubes or delay in refrigeration more than 1 hr. Bilirubin in jaundiced patients. Csf proteins more than 150mg/dl. Merthiolate disinfectant contamination

16. Biochemical: SUGAR: 50-80 mg/dl PROTEINS: 15-45 mg/dl CHLORIDE: 720-760 mg% Microbiological: BACTERIA: Nil Tests- gram stain, afb stains, ziehl neisson smear, culture, serological tests, pcr

17. CSF cell count It involves total leukocyte count and differential cell count. CELLS: 0-4 lymphocytes/ml Two methods:- 1) automated method 2) manual method:

18. Diluting fluid ; A)1% toluidine blue or 1% crystal violet:- stains the WBC, but does not lyse the RBC b)Dilute acetic acid; 0.1gm crystal violet, 1.0 ml glacial acetic acid , 50 ml distilled water. This fluid will lyse the rbc .This must be used if fluid is bloody .

19. CSF CELL COUNT Draw diluting fluid upto 1 mark in a WBC pipette and then draw CSF upto mark 11. Charge the Neubauers chamber and count the cells in all the 9 squares. Cells/ ul = nx1x10/9= 1.11xn

20. MENINGITIS: Meningitis is an inflammatory process involving the leptomeninges within the subarachnoid space; Meningoencephalitis - if the infection spreads into the underlying brain, Infectious meningitis can be broadly divided into acute pyogenic (usually bacterial), aseptic (usually viral), chronic (usually tuberculous, spirochetal, or fungal) subtypes

21. BACTERIAL MENINGITIS: In neonates - Escherichia coli and group B streptococci. In adolescents and young adults - Neisseria meningitidis In older adults - Streptococcus pneumoniae and Listeria monocytogenes contains acute inflammatory cells(>1000 per mm), majority being neutrophil polymorph

22. The diagnostic alterations in the CSF : 1. Naked eye appearance : cloudy or frankly purulent CSF. 2. Elevate d CSF pressure (above 180 mm water). 3. Polymorphonuclear neutrophilic leucocytosis in CSF (between 10-10,000/µl). 4 . Raised CSF protein level (higher than 50 mg/dl). 5. Decreased CSF sugar concentration (lower than 40 mg/dl). Chloride reduced 6. Bacteriologic examination by gram’s stain or by CSF culture reveals causative organism.

23. in acute meningitis, an exudate is evident within the leptomeninges on the surface of the brain The meningeal vessels are engorged and prominent, and tracts of pus may extend along blood vessels. On microscopic examination,: neutrophils may fill the entire subarachnoid space or, in less severe cases, may be confined to regions adjacent to leptomeningeal blood vessels. In untreated meningitis, gram stain reveals varying numbers of the causative organism .

24. 1. Acute BACTERIAL(pyogenic) MENINGITIS 2. In neonates - Escherichia coli and group B streptococci. In adolescents and young adults - Neisseria meningitidis In older adults - Streptococcus pneumoniae and Listeria monocytogenes 3. GRAM STAIN, Culture, AFB STAIN

25. VIRAL MENINGITIS: Viral meningitis most commonly known as aseptic meningitis. Most commonly caused by enterovirus (RNA virus) Predominant cells seen in viral meningitis are lymphocytes. The protein elevation shows mild to moderate increase and sugar content is always normal.

26. The CSF findings in viral meningitis are as under: 1. Naked eye appearance : clear o r slightly turbid CSF. 2. CSF pressure increased (above 250 mm water). 3 . Lymphocytosis in CSF (10-100 cells/ml). 4. CSF protein usually normal or mildly raised . 5. CSF sugar concentration usually normal. Chloride- reduced 6. CSF bacteriologically sterile.

27. 1.ASEPTIC (VIRAL MENINGITIS) 2. IN CHILDREN: Done in 4 th lumbar space i.e between 4 th and 5 th lumbar vertebra. IN ADULTS: L3- L4 3.ENTERO VIRUS & INFLUENZA, MEASLES

28. TUBERCULAR MENINGITIS: The CSF of patients with TB meningitis is characterised predominantly by lymophocytic pleocytosis , usually in hundreds followed by neutrophilic leukocytes, plasma cells and macrophages. Multinucleated giant cells in reaction to a foreign material also seen. Demonstration of acid fast bacilli in csf is difficult and usually require a larger volume of CSF .

29. 1. Naked eye appearance : a clear/cob web. 2. Raised CSF pressure (above 300 mm water). 3. Mononuclear leucocytosis consisting mostly of lymphocytes and some macrophages (100-1000 cells/µl). 4. Raised protein content. 5. Lowered glucose concentration. 6. Tubercle bacilli may be found on microscopy of centrifuged deposits by ZN staining in tuberculous meningitis

30. 1.TUBERCULAR MENINGITIS 2. Subdural hematoma Headache Diplopia 3. Pale –pink to yellow colour to the supernatent of the centrifuged CSF.

31. FUNGAL MENINGITIS Cryptococcus neoformans is the most common fungal isolated in CSF. Most commonly seen in i mmunocompromised patient. Round to oval yeast organisims with thick mucid capsule can be seen in microscope. Sometimes cryptococcus is perfectly round, but indented. These indentation trap air under the coverslip, resulting in crystal like artifact. Confirmed by mucin stain