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BODY FLUIDS
BOND KING (SUNIL)
TRANSUDATES
 Decrease plasma albumin
 Increase venous pressure
 Increase venous obstruction
 Cardiac failure
 Disturbance of circulation with passive
EXUDATES
 Damage of mesothelial linings
 Cause malignancy and infection.
CLINICAL CONDITION
1.TRANSUDATES
 Hypoproteinemia
 Congestive heart failure (weakness of heart)
 Liver cirrhosis


2.EXUDATES
 Fluid in lungs
DIFFERENT PARAMETERS       TRANSUDATES                EXUDATES

Origin                 Non- inflammatory            Inflammatory

PH                     Alkaline                     Acidic

Sp. gravity            < 1.018                      > 1.018

Coagulation            No clot formation            clot formation( due to the
                                                    presence of fibrinogen)
Protein                < 3 gm                       > 3 gm

Glucose                Same with blood glucose      Lower than blood glucose

LDH                    200 IU/L                     > 200 IU/L

Chloride               Lower than blood chloride    Higher than blood chloride

Cells                  Less ( usually lymphocyte)   Many ( neutrophils /
                                                    polymorphonuclear cells
                                                    (PMN))
Crystals               Absent                       Present
Types of Exudates
1.   Serous – pale yellow and contains few cells
2.   Fibrinous – Dark yellow and contain fibrinogen
3.   Serofibrinous – pale to dark yellow ; contains few
     cells and fibrinogen.
4.   Purulent – many pus cells (WBC) ; yellow green/
     light brown.
5.   Hemorrhagic – blood
6.   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 malayi
8.   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 COLLECTION
1. 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 meningitis


Symptoms 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)
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
Grayish / Greenish color of CSF
  Causes are acute meningitis, increase pus
   cells.
 Differentiate sub-arachnoid block from
   traumatic Taps
     Sub- Arachnoid               Traumatic Tap
1. Even distribution of blood   1.Uneven distribution of blood
tubes 1-4
2. Clot formation(presence of   2. No clot
fibrinogen)
3.Presence of siderophage       3. Absence of siderophage
4.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 TEST
1. 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 test
4.   Noguchi’s test
 10% of butyric acid
 Presence of ppt is positive test
QUANTITAIVE TEST
1.   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 test
4. 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   Tubercular
Glucose   Decrease               Normal             Decrease
Cells     PMN                    lymphocyte         lymphocyte


Note:- 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 ENZYME
LACTATE DEHYDROGENASE(LDH)
 Adult – 40 U/L
 Child – 70 U/L
Isoenzyme
 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)
# culture
Immunologic tests
1. 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 Tests
1. Latex Agglutination Test
 For bacterial antigen test (BATs) for
    C. neoformans
2. ELISA
 * Litmus lysate assay
 For the detection of presence of endotoxin.
 Sp.test for bacterial meningitis.

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Z Score,T Score, Percential Rank and Box Plot GraphZ Score,T Score, Percential Rank and Box Plot Graph
Z Score,T Score, Percential Rank and Box Plot Graph
 

BODY FLUIDS

  • 2. TRANSUDATES  Decrease plasma albumin  Increase venous pressure  Increase venous obstruction  Cardiac failure  Disturbance of circulation with passive EXUDATES  Damage of mesothelial linings  Cause malignancy and infection.
  • 3. CLINICAL CONDITION 1.TRANSUDATES  Hypoproteinemia  Congestive heart failure (weakness of heart)  Liver cirrhosis 2.EXUDATES  Fluid in lungs
  • 4. DIFFERENT PARAMETERS TRANSUDATES EXUDATES Origin Non- inflammatory Inflammatory PH Alkaline Acidic Sp. gravity < 1.018 > 1.018 Coagulation No clot formation clot formation( due to the presence of fibrinogen) Protein < 3 gm > 3 gm Glucose Same with blood glucose Lower than blood glucose LDH 200 IU/L > 200 IU/L Chloride Lower than blood chloride Higher than blood chloride Cells Less ( usually lymphocyte) Many ( neutrophils / polymorphonuclear cells (PMN)) Crystals Absent Present
  • 5. Types of Exudates 1. Serous – pale yellow and contains few cells 2. Fibrinous – Dark yellow and contain fibrinogen 3. Serofibrinous – pale to dark yellow ; contains few cells and fibrinogen. 4. Purulent – many pus cells (WBC) ; yellow green/ light brown. 5. Hemorrhagic – blood 6. 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 malayi 8. Serosanguinopurulent – combination of serous to chylous ( bacterial infection , pus and blood hemorrhage)
  • 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. 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. 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. 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 COLLECTION 1. 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. 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. 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. 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. Clinical condition of fibrinogen in CSF  Traumatic tap  Froin’s syndrome  Tubular meningitis/ sub acute meningitis Symptoms of Meningitis  Cob- web like clot  Pellicle like clot (12- 24 hours after refrigeration)  Pine tree like clot.
  • 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. 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. Grayish / Greenish color of CSF  Causes are acute meningitis, increase pus cells. Differentiate sub-arachnoid block from traumatic Taps Sub- Arachnoid Traumatic Tap 1. Even distribution of blood 1.Uneven distribution of blood tubes 1-4 2. Clot formation(presence of 2. No clot fibrinogen) 3.Presence of siderophage 3. Absence of siderophage 4.Quekensted test (+Ve) 4. D-dimer (-ve)
  • 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. QUALITATIVE TEST 1. 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 test 4. Noguchi’s test  10% of butyric acid  Presence of ppt is positive test
  • 19. QUANTITAIVE TEST 1. 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 test 4. Biuret Method  spectrophotometer
  • 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. Comparison Bacterial meningitis Viral meningitis Tubercular Glucose Decrease Normal Decrease Cells PMN lymphocyte lymphocyte Note:- 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. 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. 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. CSF ENZYME LACTATE DEHYDROGENASE(LDH)  Adult – 40 U/L  Child – 70 U/L Isoenzyme  LD1 and LD2 – produced by brain cells.  LD2 and LD3 – produced by lymphocyte.  LD4 and LD5 – produced by neutrophils.
  • 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. 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. # culture Immunologic tests 1. 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. Agglutination Tests 1. Latex Agglutination Test  For bacterial antigen test (BATs) for C. neoformans 2. ELISA * Litmus lysate assay  For the detection of presence of endotoxin.  Sp.test for bacterial meningitis.