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  2. 2. 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.
  3. 3. CLINICAL CONDITION1.TRANSUDATES Hypoproteinemia Congestive heart failure (weakness of heart) Liver cirrhosis2.EXUDATES Fluid in lungs
  4. 4. 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
  5. 5. 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)
  6. 6. 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
  7. 7. 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.
  8. 8. 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.
  9. 9. 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)
  10. 10. 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.
  11. 11. 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.
  12. 12. 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
  13. 13. 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.
  14. 14. 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)
  15. 15. 2. Bloody (hemorrhage , lyses RBC’s , traumatic tap)3. Xanthochromic (pale pink to orange yellow) Hemoglobin – old hemorrhage , lyses RBC in CSF. Bilirubin in CSF – RBC breakdown , increase serum level Protein (150 mg/dl) - RBC breakdown , increase serum level - disorder affect blood brain barrier Melanin (Brownish color) - meningeal melanosarcoma
  16. 16. 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)
  17. 17. * 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
  18. 18. 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
  19. 19. 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
  20. 20. 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
  21. 21. 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
  22. 22. 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.
  23. 23. 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
  24. 24. 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.
  25. 25. 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.
  26. 26. 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)
  27. 27. # 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
  28. 28. 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.