TRANSUDATES Decrease plasma albumin Increase venous pressure Increase venous obstruction Cardiac failure Disturbance of circulation with passiveEXUDATES Damage of mesothelial linings Cause malignancy and infection.
CLINICAL CONDITION1.TRANSUDATES Hypoproteinemia Congestive heart failure (weakness of heart) Liver cirrhosis2.EXUDATES Fluid in lungs
DIFFERENT PARAMETERS TRANSUDATES EXUDATESOrigin Non- inflammatory InflammatoryPH Alkaline AcidicSp. gravity < 1.018 > 1.018Coagulation No clot formation clot formation( due to the presence of fibrinogen)Protein < 3 gm > 3 gmGlucose Same with blood glucose Lower than blood glucoseLDH 200 IU/L > 200 IU/LChloride Lower than blood chloride Higher than blood chlorideCells Less ( usually lymphocyte) Many ( neutrophils / polymorphonuclear cells (PMN))Crystals Absent Present
Types of Exudates1. Serous – pale yellow and contains few cells2. Fibrinous – Dark yellow and contain fibrinogen3. Serofibrinous – pale to dark yellow ; contains few cells and fibrinogen.4. Purulent – many pus cells (WBC) ; yellow green/ light brown.5. Hemorrhagic – blood6. Putrid – many pus cells; seen in Gangrene (death of tissue)7. Chylous – milky appearance ; contains fat globules, pseudo globulin and lecithin ; associated with thoracic duct destruction and brugia malayi8. Serosanguinopurulent – combination of serous to chylous ( bacterial infection , pus and blood hemorrhage)
CEREBROSPINAL FLUID (CSF) • Third major body fluid in the body • Clear colorless fluid produced by highly vascular chloride plexus of ventricles of the brain. • 500 ml/day or 20 ml/hour
HISTORY Cotungo in 1764 3rd major body fluid .THE FLOW OF CSF 70% CSF is derived by ultrafiltration and secretions through choroid plexus. 30% from ependymal lining of ventricle and cerebral subarachnoid spaces.
Importance Act as a mechanical receptor (which prevents the brain and skull from coming into contact). Serves as excretory channel(collect waste and excrete out in the form of sweat , urine and feces). Serves as nutrient to brain. Cushions to brain and lubricate the central nervous system.
Importance of CSF Analysis To detect infection and to differentiate meningitis( particularly bacterial meningitis). To detect CNS disorder To detect sub-arachnoid block. (Froin’s syndrome) flow of CSF is abnormal.METHOD OF COLLECTION1. Lumbar puncture (to measure intercranial pressure) Safe and simplest method for puncture Puncture in shrimp position. Lumbar 3 & 4 (adults) Lumbar 4 & 5 (children)
2. Cisternal (occipital) Recommended in cases of paralysis and meningitis.3. Ventricular puncture (lateral cervical) Neck For infants Ventricular cannula.* The length of syringe used for CSF collection is 18 cm.
TUBES ( DISPOSABLE) 1st tube – chemistry and serology (Red / yellow top ; frozen) 2nd tube – Microbiology section (black top ; refrigerated not allowed) 3rd tube – Hematology section (purple, EDTA, Light blue, Green) 4th tube – additional test (blue top; cytology)Note:-• If malignancy is suspect then only 4 th tube is used.• Avoid glass tube becoz cell adhere to glass affecting cell count.• Perform immediately becoz of cell degradation.
Macroscopic Examination Volume – (90 - 170 ml) pH – (7.3 – 7.45) 7.31 Specific gravity – 1.006 to 1.008 Pressure – 50 – 200 mm H2O (90 to 180 mm H2O) (adult) 10 – 100 mm H20 (children) Clear; colorless Coagulation – normal CSF doesn’t clot (transudate) Viscous as water
Clinical condition of fibrinogen in CSF Traumatic tap Froin’s syndrome Tubular meningitis/ sub acute meningitisSymptoms of Meningitis Cob- web like clot Pellicle like clot (12- 24 hours after refrigeration) Pine tree like clot.
Variation in color (clinical significance of CSF Appearance)1. Turbid (Tyndall effect) WBC ‘s - 200 cell/UL (associated with meningitis) RBC ‘s – over 400/UL ( associated with hemorrhage, traumatic tap) Microorganism – meningitis (viral, bacterial etc.) Protein – Disorder of production of IgG in CSF (blood brain barrier)
Grayish / Greenish color of CSF Causes are acute meningitis, increase pus cells. Differentiate sub-arachnoid block from traumatic Taps Sub- Arachnoid Traumatic Tap1. Even distribution of blood 1.Uneven distribution of bloodtubes 1-42. Clot formation(presence of 2. No clotfibrinogen)3.Presence of siderophage 3. Absence of siderophage4.Quekensted test (+Ve) 4. D-dimer (-ve)
* Siderophage – macrophage with phagocyte erythrocyte# Quekensted Test Most useful method to detect sub-arachnoid block. Done by comprising external jugular vein.# Chemical examination of CSF Protein – over 80% from plasma Normal value – (15 – 45) mg/dl Increase CSF may found in Infection , meningitis , multiple sclerosis and hemorrhage
QUALITATIVE TEST1. Ross Jones ( excess of globulin in CSF)2. Nonne apelt Reagent :- ammonium sulfate Presence of white ring of ppt give positive test (both 1 & 2 )3. Pandy’s test Reagent :- phenol Presence of bluish white cloud give positive test4. Noguchi’s test 10% of butyric acid Presence of ppt is positive test
QUANTITAIVE TEST1. Turbidimetric Test (ppt is positive test) Reagent :- SSA (Sulfosalicylic Acid) and TCA (Tricarboxylic Acid)2. Nephelometric Test Reagent:-Benzyl chromium chloride (ppt is positive test)3. Dye binding technique Reagent :- Coomassie brilliant blue G250 Blue ppt give positive test4. Biuret Method spectrophotometer
Glucose in CSF Normal value – 50 to 85 mg/dl(approx.65 mg/dl) Increased - Diabetes mellitus - Infectious encephalitis Decreased - hypoglycemia - pyogenic meningitis - Fungal meningitis - Toxoplasmosis - Subarachnoid hemorrhage - primary tumor of brain
Comparison Bacterial meningitis Viral meningitis TubercularGlucose Decrease Normal DecreaseCells PMN lymphocyte lymphocyteNote:- In case of glucose only Exudates decrease but Transudates remains Normal.Chlorides Normal value :- 113 – 127 MEQ/L Test :- schales and schales ; cotlove chloridometer
Lactate Normal value : 10 -22 mg/dl (Newborn) - (9 – 26)mg/dl (adult) As to detect viral from bacterial mycoplasma, TB and fungal meningitis. Method:- Automated Analysers. Lactate > 35 – bacterial meningitis Lactate < 25 – viral meningitis Antibiotic therapy fall lactate level rapidly.
GLUTAMINE Normal value :- 8 – 18mg/dl Over 35 mg/dl – hepatic encephalopathy Reflects brain ammonia(ammonia + a- ketoglutarate) In case of coma of unknown origin Reye’s syndrome – acute brain damage and liver function
CSF ENZYMELACTATE DEHYDROGENASE(LDH) Adult – 40 U/L Child – 70 U/LIsoenzyme LD1 and LD2 – produced by brain cells. LD2 and LD3 – produced by lymphocyte. LD4 and LD5 – produced by neutrophils.
CREATINE KINASE Normal value - < 5 U/L (adult) < 17 U/L (infants) CK-BB – brain is the isoform. CK-MM – muscle is the isoform. CK-MB – brain and muscle both is isoform.Serologic Examination CEA – metastatic carcinoma hCG – choriacarcinoma and germ cell tumors. CSF ferritin – CNS malignancy ; patient with inflammatory disease.
Microbiological Exam# Staining Gram stain – most important to differentiate bacterial pathogens. India Ink – Cryptococcus neformans Acid fast stain – TB agent Auramine - Rhodamine – TB agent Acridine agent – Differential amoeba (brick red) from leukocytes (bright green)
# cultureImmunologic tests1. Counter immunoelectrophoresis Limited for the detection and identification of H. influenza – 1month to 5 years S. pneumoniae – 29 yrs old and above N. meningitidis – 5 to 29 yrs old E. coli - all age group Group B streptococci – all age group
Agglutination Tests1. Latex Agglutination Test For bacterial antigen test (BATs) for C. neoformans2. ELISA * Litmus lysate assay For the detection of presence of endotoxin. Sp.test for bacterial meningitis.