CSF, transudates, exudates.pptx

Cerebrospinal Fluid

1. CSF Transudates & Exudates Body Fluid 1

2. Cerebrospinal Fluid Physiologic system to supply nutrients to nervous tissue, move metabolic waste & mechanical barrier to cushion the brain & spinal cord against trauma Produce 500 ml/day Ultrafiltration and secretion through the choroid plexus Obtained by lumbar puncture, cisternal puncture, lateral cervical puncture or ventricular cannulas 2

3. Formation of Cerebrospinal Fluid 3

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5. Specimen Collection Routinely by lumbar puncture between 3 rd , 4 th or 5 th vertebrae Up to 20 mL CSF may normally be moved Collected in 3 sterile tubes: Tube 1: chemical & serologic tests Tube 2: microbiology Tube 3: cell count & differential Examination should be performed immediately (<1 hr ) 5

6. Indications Indications : Meningeal infection Subarachnoid hemorrhage CNS malignancy Demyelinating disease Opening Pressure: 90-180 mmH2O >200 mmH2O →20mL <90 mmH2O →no withdrawn 6

7. Disease detected by CSF Examination High sensitivity, high specificity bacterial, TB, fungal meningitis High sensitivity, moderate specificity viral menin gitis, subarachnoid hemorrhage Moderate sensitivity, high specificity meningeal malign ancy Moderate sensitivity, moderate specificity intracranial hemorrhage, viral encephalitis , subdural hematoma 7

8. Gross Examination Normal CSF: clear and colorless viscosity similar to water Turbidity leukocyte >200cells/ µL erithrocyte > 400 cells/ µL Clot formation traumatic tap, complete spinal block, suppurative and tuberculous meningitis 8

9. Gross Examination Viscous metastatic mucin-producing adenomacarcinomas cryptococcal adenocarcinomas Xantho chromia pink, orange or yellow due to RBC lysis or Hb breakdown bilirubin, protein >150mg/dL, carotinoids, melanin, rifampicin therapi , contamination of detergen t or methiolate disinfectan 9

10. Microscopic Examination Total Cell Count Leukocyte: normal 0-5 cells/ µL, neonates <30 cells/ µL Use Fuch Rosenthal or Neubauer counting chamber Differential Count Performed on a Wright’s-stained smear Normal: primarily lymphocytes & monocytes adult: lymphocytes : monocytes = 70:30 children: monocytes more prevalent (up to 80%)  Neutrophil: e.g bacterial meningitis Lymphocytes: e.g viral & Tb meningitis Eosinophil: e.g parasitic & fungal infections 10

11. Chemical Analysis Total Protein Derived from plasma, concentration<1% blood level (15-45 mg/dL) elevated CSF protein: Increased permeability of BBB (meningitis, hemorrhage) Decreased resorption at arachnoid villi Mechanical obstruction (tumor) Increase intrathecal immunoglobulin synthesis ( Guillain-Barre synd , multiple sclerosis) Method: Turbidimetric, colorimetric 11

12. Chemical Analysis Glucose derived from blood glucose fasting CSF glucose 50-80mg/dL 60% plasma values, normal ratio 0.3-0.9 Hypoglycorrhacia: bacterial, tuberculous and fungal meningitis 12

13. Chemical Analysis Lactate Reference: 9.0-26.0 mg/dL differentiating viral meningitis from bacterial, mycoplasma, fungal & TB meningitis Viral meningitis <35 mg/dL Bacterial meningitis >35 mg/dL Sensitivity & specificity 80-90% 13

14. Chemical Analysis Enzymes Lactate Dehydrogenase (LDH) Normal < 40U/L traumatic tap vs intracranial hemorrhage elevated in bacterial meningitis sensitivity & specificity 86% & 93% Creatine Kinase (CK) Normal < 5 U/L elevated in demyelinating disease , seizures, stroke, malignant tumors, meningitis & head injury 14

15. Microbiological Examination Gram stain, bacterial antigen test, Limulus Lysate assay Bacterial Meningitis group B Streptococcus and Gram negative rods Hemophilus influenza Neisseria meningitidis & Streptococcus pneumonia Viral meningitis Enteroviruses (polioviruses) Fungal meningitis Cryptococcus (in AIDS patients) Tuberculous meningitis 15

16. Differential Diagnosis of Meningitis Bacterial Viral Tubercular Fungal WBC count Elevated 1000-100,000 Elevated 5-300 Elevated 100-600 Elevated 40-400 Cell present neutrophil Lympho-cytes Lympho-cytes & monocytes Lympho-cytes & monocytes Protein elevated Marked 80-500 Moderate 30-100 Moderate to marked 50-300 Moderate to marked 50-300 Glucosa Decreased <40mg/dL normal Decreased<45 mg/dL Normal to decrease 16

17. 17 Transudates & Exudates Transudates: case3 increased capillary hydrostatic pressure or decreased plasma oncotic pressure Congestive heart faillure Hepatic cirrhosis Hypoproteinemia Exudates: case4 Increase capillary permeability or decreased lymphatic resorption Infections: Tb, bacterial, viral pneumonia Neoplasms: metastatic Ca Extrapleural sources: pancreatitis, ruptured esophagus

18. 18 Light’s Criteria Exudate: 1/more of following criteria PF/S protein >0.5 PF/S LD > 0.6 PF LD >2/3 serum upper limit of normal Sensitivity 98%, specificity 80%

19. 19 Gross Examination Transudates Exudates Color Pale yellow to straw Turbidity Clear Turbid/milky/ bloody Odor - Fecalent: anaerobic inf Clot - +

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21. 21 Microscopic Examination Transudates Exudates Cell counting < 1000/ µL > 1000/ µL Differential count : Mesothelial cell Neutrophilia (>50%) Lymphocytosis (>50%) Eosinophilic (>10%) negative 10% case 30% case Cong heart failure, trauma Tb, empiema, rheumatoid Bacterial pneu, pancreatitis Tb, viral inf, malignancy, SLE parasitic/fungal inf, drug rx, rheumato

22. 22 Chemical Analysis Transudates Exudates Protein <3.0 g/dL >3.0 g/dL Glucose = serum < 60mg/dL : purulent LDH PF/S <0.6 <200 IU/L PF/S >0.6 >200 IU/L Amylase ≤ serum ≤ serum pH >7.4 >/<7.3

23. 23 Immunologic & Microbiological Examination Immunologic: Rheumatoid Factor ANA titers Complement levels Microbiological: Gram’s stain Acid-fast stain culture

24. 24 Synovial Fluid Viscous liquid found in the joint cavities Ultrafiltrate of plasma combined with hyaluronic acid produced by the synovial cell Normal: < 3.5mL Functions: Acts as lubricant and adhesive Provides nutrients for the avascular articular cartilage

25. 25 Synovial Fluid

26. 26 Specimen Collection Arthrocentesis Steril, disposable needles and plastic syringe Specimen: EDTA: cell count & diff count Na-Hepar inized : chemical & immunologic test Plain : microbiologic test & crystal examination Oxalate, Li-heparin and EDTA powder avoided

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28. 28 Gross Examination Color evaluated in a clear glass tube against a white background Normal: colorless to pale yellow noninflammatory/ inflammatory dis: straw to yellow ( xantho chromia) Septic : yellow, brown, green

29. 29 Clarity Related to the number and type of particles within synovia Normal: transparent Translucent: leukocytes Opaque : massive crystals Milky opalescent : abundance of cholestero l crystal Gross Examination

30. 30 This is the colorless, clear synovial fluid from a patient with osteoarthritis accompanied by a low synovial-fluid white cell count.

31. 31 Cloudy but translucent inflammatory synovial fluid were taken from a patient with rheumatoid arthritis (left) and Gout (right).

32. 32 This bloody fluid with a thicker layer of lipid material separated after centrifugation was aspirated from a patient with a tibial fracture into the joint space.

33. 33 Synovial fluid taken from a patient with an inflammation process

34. 34 Microscopic Examination Total Cell Count 1 hour after arthrocentesis Hemacytometer or automated cell counter Incubated with hyaluronidase Normal: <150-200/ µL

35. 35 Differential Count Normal: Neutrophils 20% Lymphocytes 15% Monocytes & macrophages 65% Eosinophilia 2% Elevated: Neutrophils: inflammatory, Gout & RA Lymphocytes: early RA, chronic infection Monocytes: viral arthritis Eosinophilia: RA, metastatic carcinoma, parasitic inf Microscopic Examination

36. 36 Crystal Examination Gout: crystal deposition in articular tissue 1. monosodium urate monohydrate (MSU) 2. calcium pyrophosphate dihydrate (CPPD) 3. apatite 4. basic calcium phosphate (BCP) Polarized light microscope 1. MSU: Gout, septic arthritis 2. CPPD: degenerative arthritis, hypo-Mg, hemochromatosis Microscopic Examination

37. 37 Synovial Fluid Crystal Crystal Shape Monosodium urate Needles Ca pyrophosphate Rods cholesterol Notched rhombic plates apatite Small needles corticosteroid Flat, variable shape plates

38. 38 Monosodium urate crystals Ca pyrophosphate crystals

39. 39 Chemical Analysis Mucin clot test : add acetic acid Glucose: Normal <10 mg/dL Protein: Normal 1.38 g/dL Lipids: 1. cholesterol-rich psedochylous: chronic RA 2. lipid droplets: trauma 3. chylous effusion : RA, SLE, filariasis, pancreatitis, trauma

40. 40 Immunologic & Microbiological Examination Immunologic studies Rheumatoid Factor (RF) Complement Microbiological Examination Gram’s stain Ziehl-Neelson Culture

41. 41 Pleural Fluid Pleural cavity: between mesothelium of visceral and parietal pleura Normal: small amount of fluid Plasma filtrate derived from capillaries of the parietal pleura, reabsorbed through the lympatics and venules of the visceral pleura Effusion: accumulation of fluid Specimen collection: Thoracentesis In EDTA tube: cell counts & differential

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44. 44 Pericardial Fluid Normal: 10-50 mL Produced by transudative process Effusion: I nflammatory , malignant, hemorrhagic processes Obtained: pericardi otomy , pericardio centesis

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46. 46 Gross Examination Normal: pale yellow and clear Infection: turbid effusion Uremia: clear & straw colored effusion Chylous effusion: milky appearance Microscopic Examination Leukocyte count : >10 000/ µL: bacterial, TB, malignant Pericardial Fluid

47. 47 Chemical Analysis Protein >3.0g/dL: exudates Glucose <40mg/dL: bacterial, TB, malignant pH <7.10: rheumatic & purulent condition 7.20-7.40: malignant, uremia, TB Enzymes LD >300U/dL & fluid/serum LD ratio>0.6: exudates Pericardial Fluid

48. 48 Peritoneal Fluid Ultrafiltrate of plasma Peritoneal effusion: ascites Normal: <50mL Paracentesis , Diagnostic Peritoneal Lavage (DPL), peritoneal dialysis, peritoneal washing Specimen collection:EDTA

49. 49 Abdomen symetrically distended secondary to fluid build up in peritoneal cavity. Skin is also yellowed due to hyperbilirubinemia .

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51. 51 Gross Examination Transudates : pale yellow & clear Exudates : cloudy/ turbid Acute pancreatitis & cholecystitis: green Malignancy & TB: bloody Chylous & pseudochylous: milky fluid Peritoneal Fluid Microscopic Examination Bacterial peritonitis: leukocyte >500/ µL, >50% neutrophil Eosinophilia (>10%): chronic inflammatory process

52. 52 Chemical Analysis Protein: little value Low glucose: TB peritonitis & malignancy Elevated amylase: pancreatitis, gastrointestinal perforation Elevated alkaline phosphatase: intestinal perforation Elevated urea/ creatinine: ruptured bladder Peritoneal Fluid

53. 53 References Clinical Diagnosis and Management by Laboratory Methods.Henry JB. 20 th ed. 2001. WB Saunders co: Philadelphia London Urinalysis and Body Fluid. Strasinger SK. 2 nd ed.1989. F.A. Davis Co: Philadelphia Basic Medical Laboratory Techniques. Estridge BH, Reynolds AP, Walters NJ. 4 th ed. 2000. Delmar: Africa Australia

54. 54 Thank you very much