cytology of body fluid

1. CYTOLOGY OF
BODY FLUID
DR SHABNEEZ HUSSAIN
HAEMATOLOGY RESIDENT

3. CAVITY FLUIDS
Abdominal ?????? Pleural ?????? Pericardial ??????
Synovial ?????? CSF

4. Schematic representation of the three body cavities

5. CAVITY FLUIDS
Sampling techiques
appearance during collection EDTA to
prevent clotting
direct smear -
delayed processing
Cell concentration
Protein concentration

6. TRANSUDATE
EXUDATE
MODIFIED TRANSUDATE

7. Accumulation of fluids in body cavities
Transudates
• Increased hydrostatic pressure: Congestive heart
failure
• Decreased oncotic pressure (decreased albumin) :
liver cirrhosis, nephrosis, and malnutrition
Exudate
• Inflammation: Infection, infarction, hemorrhage
• Tumor

8. DIFFERENCES BETWEEN TRANSUDATE AND
EXUDATE
Feature Transudate Exudate
Gross appearanceWatery, clearTurbid or cloudy
Specific gravityLess than 1015More than 1015
Protein Less than 3mg/dlMore than 3mg/dl
Clots No Yes
cells Usually benign:
Few mesothelial
cells, few histocytes
and lymphocytes
More mesothelial cells,
acute or chronic
inflammatory cells,
RBCs, malignant cells

9. MODIFIED TRANSUDATE
Moderate protein concentration: 2,52,5-
7,5g/dl
Moderate cellularity 1000-7000 cells/ μg
Cardiovascular disease
Neoplastic disease
Rupture of urinary bladder
Hepatic disease

10. DIAGNOSTIC ROLE OF EFFUSION
CYTOLOGY
It is very useful for diagnosis of premalignant and
malignant tumors, especially metastatic tumors.
It is very useful for diagnosis of inflammatory
conditions (septic effusion, or chronic specific
inflammation e.g. TB

11. Respiratory Tract
Urinary Tract
Oral Cavity
Gastrointestinal Tract
Effusions (pleural, pericardial, joint)
Cerebral Spinal Fluid
Amniotic fluid
 Many other body sites
Non-Gynecological Specimen Collection

12. EXAMINATION OF BODY FLUID
Gross exam
Total cell count
Microscopic exam
Any other special test (Chemistry, Microbiology,
cytology (
Test are performed in various areas of lab based on what
the physician orders.
Body fluids sterile vs. non-sterile

13. SAMPLE COLLECTION
FNA of effusion fluids
Tapping

14. Collection and preparation of specimen

15. FIXATION
1ml of heparin + 100ml of effusion fluid to prevent
clotting
N.B.: do not use alcohol in fixation of fluid before
spread cytological smear on glass slides

16. TYPES OF STAINING SMEARS
PAP
Gram Stain
Hx & E
Cell block for remnant sediment and histopathological
examination.
Other special stains for the most suspected diseases, to
confirm diagnosis.

17. Heparinized
bottles (3 units
heparin/ml)
Unfixed
Alcohol-fixed
Papanicolaou-stained
Cytocentrifuge preparation
Cell block
Adding plasma and thrombin
solution
Wrapped in filter paper
Placed in a cassette
Embedded in paraffin
Cut and H&E stain
Air-dried cytocentrifuge preparation
(Hematologic malignancy is
suspected)

18. Adequacy: on site
Background: necrotic, mucinous
Cell concentration: high, low
Cell preservation: lysis
Inflammatory cells: which? dominant?
Lining cells: mesothelial, epithelial
Cells of interest: tumor cells

33. 1- CEREBROSPINAL FLUID
Fluid surrounding brain and spinal cord
Sterile
Specimen collection: by Lumbar puncture
Collect 3-5 vials, each tube has a designated department.
Gross exam: Turbidity, Color, microscopic exam, cell
count

34. CSF CELL DIFFERENTIAL
Numerate and differentiate cells seen
Lymphocytes: usually are few; increased with viral,
fungal, bacterial meningitis, or nervous system disease
Monocytes: Less than 2% of normal CSF, increased
with TB meningitis, viral encephalitis, subarachnoid
hemorrhage.

35. PMN: are few, associated with Viral and acute bacterial
inflammation.
Macrophages: are few in number associated with malignancy,
hemorrhage, inflammation
Eosinophils/Basophils: not normally seen in CSF

36. Plasma cells: not normally present; associated with viral disorders,
and Hodgkin's diseases.
Red Blood Cells: Few to none present
Mesothelial cells: not present
Malignant cells: will see with malignant disease and infiltrate.

37. CSF EVALUATION
Tube 1-cell count and differential
Tube 2-glucose, protein
Tube 3-cultures, gram stain, cytology, (HSV PCR,
West Nile, India ink, Crypto Antigen, VDRL,
Lyme Ab, AFB...)
Tube 4-cell count and differential

38. NORMAL CSF COMPOSITION
Clear color
<5 RBC’s
<5 WBC’s
Protein 23-38mg/dl (can use 14-45)
Glucose—60% of serum level (75-100)

39. OPENING PRESSURE
Normal = 80-180 mmHg
Obese pts: up to 250mmHg can be normal
Pathologically elevated: >250mmHg
If elevated, likely due to cerebral edema from
intracranial pathology
Infection (cryptococcal meningitis), tumor, benign
ICH (pseudotumor)

40. RBCS
Always send tube #1 and #4 for cell count
and compare RBCs
Traumatic tap: Elev RBC in tube 1, nl in
tube 4
1000 RBC : 1 WBC to adjust WBC count in
bloody tap
SAH or HSV: Elev RBC in tube 1 AND
tube 4
“Crenated RBCs” and xanthochromia
(yellow supernatant after centrifuge)
Seen in hyperbilirubinemia (ESLD), old SAH,
old blood from prior traumatic LP or bleed

41. WBC’S
Infection!
PMN predominance: likely bacterial meningitis
Lymphocytic predominance: viral vs. fungal vs.
TB vs. malignancy

42. PROTEIN
Normal: protein is excluded from CSF by blood-
CSF barrier
Increased: nonspecific
Elevated in all infectious meningitis
May remain elevated for months post-meningitis
(viral or bacterial)
Increased in malignancy and inflammatory
conditions (ie Guillain-Barre)

43. GLUCOSE
Normal
Viral infection
Low glucose
Bacterial meningitis, TB, fungal
Really low
<18 is strongly suggestive of bacterial meningitis

44. TYPICAL VIRAL MENINGITIS
CSF WBC elevated, but <250 (first PMNs, then
lymphocytes)
CSF protein elevated, but <150
Glucose > 50% of serum concentration

45. TYPICAL BACTERIAL MENINGITIS
CSF WBC >1000, PMN predominance
CSF protein >500mg/dl
CSF glucose <45 mg/dl

46. •Effusion:
•Transudate
•Exudates
•Lab analysis: Gross exam, cell count, etc.
•Differential: PMN, Lymph, Mono, etc.
2- Pleural Fluid: Lung fluid

47. •Cells unique to the lungs: Mesothelial cells
•RBCs and WBCs: are limited, if increased without
traumatic tap ----- indicates infarction
•Cytology exam: useful in identifying malignancy or
abnormal morphological cells.

48. WHAT TO ORDER?
Serum LDH, total protein (Add on to am
labs)
Pleural fluid:
Total Protein, LDH
Glucose, cell count and diff, pH (on ice)
Gram stain, culture, fungal stain and
culture, AFB
Cytology
Other: triglyceride level to r/o
chylothorax; amylase to r/o pancreatitis,
esoph perf; Adenosine deaminase to eval
TB

49. LIGHT’S CRITERIA FOR EXUDATES
Fluid is exudate if it meets 1 of 3 criteria:
1. Pleural fluid LDH/serum LDH > 0.6
2. Pleural fluid protein/serum protein > 0.5
3. Pleural fluid LDH > upper limit of normal
serum LDH
If all 3 negative, fluid is Transudate

50. TRANSUDATE
Result from imbalances in oncotic and
hydrostatic pressure
Usually low oncotic +/- high hydrostatic
pressure
Pulm Edema/CHF
Cirrhosis with ascites
Hypoalbuminemia/Nephrotic syndrome,
ESLD
Fluid overload s/p aggressive IVF
Peritoneal dialysis

51. EXUDATE
Caused by local, not systemic, factors
Infection
Neoplasm
Pancreatitis
Esoph perf
RA
SLE
Sarcoid, Wegeners, PE, Meig’s,
Chylothorax

52. LYMPHOCYTOSIS
Malignancy (50-70% lymphs)
Also TB, sarcoid, RA, chylothorax (>90% lymphs)

53. PLEURAL EOSINOPHILIA
Pneumothorax
Hemothorax
Pulm infarct
Parasitic disease
Fungal infection
Drugs
Malignancy
Asbestos

54. WHY IS GLUCOSE LOW?
(<60)
RA
TB
Empyema
SLE
Malignancy
Esophageal rupture

55. 3- PERITONEAL FLUID
Abnormal accumulation of fluid (effusion) in peritoneal
cavity: Ascites
Ascites: a condition in which fluid accumulates within
the peritoneal space.
Must have an accumulation of > 100ml (several 100) before effusion
can be detected on physical exam.

56. 
Removal procedure- paracentesis
Lab analysis: distinguish between transudate and exudates,
gross exam, cell count, sedimentation, chemical analysis

57. PHYSICAL CHARACTERISTICS
Peritoneal Fluid Appearance: Color and clarity.
Color and clarity can indicate certain infections and diseases.
Total Cell Count: Assist in diagnosis of certain
diseases by determining total RBC and WBC number.

58. Lymphocytes: CHF, liver cirrhosis, nephrotic syndrome
Mesothelial Cells: Associated with TB effusions
Malignant cells: seen with malignancy

59. WHAT TO SEND FLUID FOR
Cell count with diff
Albumin
LDH
Total protein
glucose
Gram stain/cx
cytology

60. APPEARANCE OF FLUID
Clear—usually indicates uncomplicated ascites,
ie liver failure/cirrhosis
Turbid/cloudy—infected
Pink/bloody—traumatic, punctured collateral
vessel, malignancy
Correct for bloody tap: 1 WBC: 750 RBC
1 PMN: 250 RBC

61. SERUM-TO-ASCITES ALBUMIN
GRADIENT (SAAG)
=Serum albumin – ascitic fluid albumin
If the gradient is >1.1:
Portal HTN (drives fluids into
peritoneum)
SBP, cirrhosis, Alcoholic hepatitis, CHF
If the gradient is < 1.1:
(protein leaks into peritoneum and fluid
follows)
Peritoneal carcinomatosis, peritoneal TB,
pancreatitis, nephrotic syndrome

62. SBP
SAAG > 1.1
Suspect if >250 PMNs (>100 PMNs in pt on
peritoneal dialysis)
70% GNR (E.coli, Klebsiella)
30% GPC (S. pneumo, Enterococcus)
Treat with ceftriaxone, cefotaxime
“Culture negative SBP” if >250 PMNs but cx neg;
treat the same

63. Pericardial Fluid: accumulation of fluid of the lining of
the heart (effusion)
Cause: neoplasm, infections, collagen disease, renal
disease, Cardiovascular disease.
Gross Exam: Report appearance (bloody, clear, cloudy)
4- Pericardial Fluid

64. Measure pH: pH less than 7.0 associated with infection or
rheumatoid disorder.
Cell count: see limited RBCs and WBCs
Evaluate sedimentation

65. •Examine physical, chemical and microscopic detail
•Count number of sperm, report morphology and
motility
•Specimen must be a fresh collection-clean, sterile
container.
•Gross Exam: Color, pH, Volume, and viscosity.
•Agglutination study
5- Seminal Fluid

66. •Joint Fluid: normally clear, viscous
•Functions as a lubricate and transports nutrient
•Arthrocentesis: aspirate of the joint fluid, aseptic
technique
•Lab Assay: Gross exam, microscopic exam, Gram
stain, cultures,...
6- Synovial Fluid:

67. •Appearance: clear, transparent, viscous
•Viscosity test
•Mucin Clot test
•Note crystals (intracellular vs. extra cellular)
•Slide exam: usually performed on concentration of the fluid
using Giemsa or Papnicolaou

68. THANK YOU