Synovial fliud analysis

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Synovial fliud analysis

  1. 1. Dr. Ravichandra Yadav
  2. 2. Chapter outline Physiology and Composition of Synovial Fluid Specimen Collection Laboratory Testing  Macroscopic Evaluation  Chemical Examination  Microscopic Examination Classification of Joint Disorders
  3. 3. Synovial Fluid Synovial = syn (like) + ovia (egg). Synovial fluid is a thick, stringy fluid found in the cavities of synovial jointsWith its egg like consistency . The inner membrane of synovial joints is called the synovial membrane and secretes synovial fluid into the joint cavity This fluid forms a thin layer [roughly 50 milli microns] at the surface of cartilage.
  4. 4. composition Synovial tissue is composed of connective tissue that lacks a basement membrane. Two cell types [typeA and typeB ]are present. Type B produces synovial fluid & type A produces hyaluronic acid. Synovial fluid is made of hyaluronic acid and lubricin , proteinases and collagenases. Normal synovial fluid contains 3-4 mg/ml hyaluronan [hyaluronic acid ], a polymer of disaccharides .composed of D-glucronic acid and D-N –acetyl glucosamine joined by alternating beta-1,4 and beta-1,3glycosidic bonds.
  5. 5. composition Hyaluronan is synthesized by the synovial membrane and secreted into the joint cavity to increase the viscosity and elasticity of articular cartilages and lubricate the surface between synovium and cartilage. Synovial fluid also contains lubricin secreted by synovial cells. It is chiefly responsible for so called boundary layer lubrication, which reduces friction between opposing surfaces of cartilage. There is also some evidence that it helps regulate synovial cell growth.
  6. 6. functions Reducing friction by lubricating the joint . Absorbing shocks. Supplying oxygen and nutrients to removing carbon dioxide and metabolic wastes from the chondrocytes with in articular cartilage . It also contains phagocytic cells that remove microbes and the debris that results from normal wear and tear in the joint.
  7. 7. Synovial joint
  8. 8. Synovial Fluid Synovial membrane from a normal knee joint showsjoint space, synovial membrane composed of synovial cells embedded in a loose connective tissue stroma overlying dense collagen (hematoxylin and eosin).
  9. 9. Synovial Fluid: Physiology andComposition Clear viscous ultra filtrate of plasma Glucose and uric acid equivalent to plasma Protein lower than plasma Hyaluronate protein complex containing mucin  Moistens and lubricates joints
  10. 10. Bulge testThe Bulge test is used to determine if there is an abnormalamount of fluid surrounding a joint Bulge test of joint for the detection of synovial effusion
  11. 11. Synovial Fluid: Specimen Collection(cont.) Needle insertion Placement of needle in arthrocentesis of (A) elbow and (B) knee joints.
  12. 12. Laboratory Testing: Macroscopic Volume Color and Clarity Inclusions Viscosity Clotting Mucin Clot
  13. 13. Laboratory Testing: Macroscopic Volume  Normal up to 4 mL of fluid  Result usually recorded at bedside  Some laboratories may include volume in reports
  14. 14. Macroscopic Analysis: Color and Clarity Colorless and clear  normal Red, brown, or xanthochromic  hemorrhage into the joint Yellow/clear  noninflammatory effusions Yellow/cloudy  inflammation White/cloudy  crystals
  15. 15. Macroscopic Analysis: Inclusions Rice bodies. Free-floating aggregates of tissue appear as rice bodies.  rheumatoid arthritis (RA)  Degenarated synovium enriched with fibrin  Ochronotic shards  debris from joint prosthesis  look like ground pepper A =ochronotic shards B= rice bodies
  16. 16. Macroscopic Analysis: Viscosity Evaluated using “String test” Normal = 5cm long before breaking Low viscosity indicates inflammation
  17. 17. Macroscopic Analysis: Clotting Clotting of synovial fluid = fibrinogen Damaged synovial membrane Traumatic tap Clots interfere with performance of cell counts
  18. 18. Macroscopic Analysis: Mucin Clot Estimation of hyaluronic acid–protein complex integrity the adding of acetic acid to normal synovial fluid, which causes clot formation. The compactness of the clot and the clarity of the supernatant fluid are the criteria on which the result is based. Evaluated using “Rope’s test” Good = tight ropey mass  normal Poor = beaks easily  haluronate destruction  haluronate dilution
  19. 19. Laboratory Testing: Chemical Protein Glucose Uric Acid Lactic Acid Lactate Dehydrogenase Rheumatoid Factor
  20. 20. Chemical Analysis: Protein All proteins found in plasma Exception: various high–molecular weight proteins which may be present in very small amount  Fibrinogen  beta 2 macroglobulin  alpha 2 macroglobulin Use common serum protein procedures
  21. 21. Chemical Analysis: Protein (cont.) Normal range 1-3 g/dl Increased protein  ankylosing spondylitis  arthritis  Crohn disease  Gout  Psoriasis  Reiter syndrome  ulcerative colitis.
  22. 22. Chemical Analysis: Glucose Compare to serum glucose levels Normal synovial glucose is no lower than 10mg/dl less than serum glucose levels. Decreased – joint disorders Greater than 20mg/dl decrease may indicate infection
  23. 23. Chemical Analysis: Uric Acid Normal - 6 to 8 mg/dL Increased – gout May form crystals
  24. 24. Chemical Analysis: Lactic Acid Rarely measured in synovial fluid Can be helpful in diagnosing septic arthritis. Normal = less than 25 mg/dL Septic arthritis can show levels up to 1000 mg/dL
  25. 25. Laboratory Testing: LactateDehydrogenase May be elevated in synovial fluid, while serum levels remain normal. Increased in  Rheumatoid arthritis (RA)  infectious arthritis,  gout. Neutrophils increased during the acute phase of these disorders contribute to this increased LD.
  26. 26. Laboratory Testing: Rheumatoid Factor RF is an antibody to immunoglobulins. Present in rheumatoid arthritis:  Serum – most cases  Synovial fluid - 50%  Rarely elevated only in synovial fluid and not serum False positives in other chronic inflammatory diseases.
  27. 27. Laboratory Testing: Microscopic Cell Counts Differential Crystals
  28. 28. Microscopic Analysis: Cell Counts Perform within 1 hour of specimen collection Usually counted manually Normal values:  RBCs = none  WBCs = 0 – 150/cumm
  29. 29. Microscopic Analysis: Differential Cytocentrifuge prepared smears Normal values:  Neutrophils 7%  Lymphocytes 24%  Monocytes (Histocytes) 48%  Macrophages 10%  Synovial lining cells 4%
  30. 30. Microscopic Analysis: Differential Normal cellular elements found in synovial fluid
  31. 31. Microscopic Analysis: Differential(cont.) Elevated neutrophils:  Septic arthritis  Later stages of RA  ragocytes [a polymorphonuclear phagocyte,]
  32. 32. Microscopic Analysis: Differential(cont.) Elevated Monocytes  Serum sickness associated arthritis  Viral infections  Crystal-induced arthritis
  33. 33. Microscopic Analysis: Differential(cont.) Elevated lymphocytes: tuberculosis Early stages of RA
  34. 34. Microscopic Analysis: Differential LE cells LE cells are neutrophils that have engulfed a nucleus of a lymphocyte that has been altered by antinuclear antibody Tart cells Tart cells, monocytes that have engulfed nuclearMaterial
  35. 35. Microscopic Analysis: Differential Reiter cellsReiter cells are neutrophil-laded macrophages
  36. 36. Microscopic Analysis: Differential Differential-Lipophage Lipid-laden macrophage
  37. 37. Microscopic Analysis: Crystals-Uric Acid Synovial fluid with acute inflammation and monosodium Synovial fluid with acute urate crystals. The needle-shaped inflammation and monosodium crystals demonstrate negative urate crystals. (Wright–Giemsa birefringence, because they are stain and polarized light). yellow when aligned with the compensator filter and blue when perpendicular to the filter (Wright– Giemsa stain and polarized/compensated light).
  38. 38. Microscopic Analysis: Crystals-other Synovial fluid with acute Synovial fluid with acute inflammation and calcium inflammation and calcium pyrophosphate dihydrate crystals. The pyrophosphate dihydrate crystals rhomboidal intracellular crystal (Wright–Giemsa stain and (center) demonstrates positive polarized light). birefringence, because it is blue when aligned with the compensator filter (Wright–Giemsa stain and polarized/compensated light).
  39. 39. Microscopic Analysis: Crystals-other Corticosteroid crystals :crystals are needle-shaped  intra-articular injections Cholesterol crystals :  chronic effusions from patients with osteoarthritis or RA Apatite crystals :(small chunky rods)  calcific periarthritis  osteoarthritis  inflammatory arthritis
  40. 40. Laboratory Testing: Microbiology Infectious organisms  Bacteria  Fungi  Mycobacteria  Viruses Route of entry  Bloodstream  Penetrating wounds  Osteomyelitis rupture  Arthroscopy  intra-articular steroidm injections  prosthetic joint surgery
  41. 41. Laboratory Testing: Microbiology (cont.) Staining  Smears prepared by centrifugation or cytocentrifugation  Saline dilution reduces clustering of cells  Gram’s stain most common  Positive in only 50% of cases Culture  Set up with positive or negative stain results  Aerobic  anaerobic
  42. 42. Classification of Joint Disorders
  43. 43.  Pathology Many synovial fluid types are associated with specific diagnoses Noninflammatory (Group I)  Osteoarthritis,degenerative joint disease  Trauma  Rheumatic fever  Chronic gout or pseudogout  scleroderma  Polymyositis  Systemic lupus erythematosus  Erythema nodosum  Neuropathic arthropathy (with possible hemorrhage)  Sickle-cell disease  Hemochromatosis  Acromegaly  Amyloidosis
  44. 44.  Inflammatory (Group II)  Rheumatoid arthritis  Reactive arthritis  Psoriatic arthritis  Acute rheumatic fever  Acute gout or pseuodgout  Scleroderma  Polymyositis  Systemic lupus erythematosus  Ankylosing spondylitis  Inflammatory bowel disease arthritis  Infection(viral, fungal, bacterial) including Lyme disease  Acute crystal synovitis
  45. 45.  Septic (Group III)  Pyogenic bacterial infection  Septic arthritis Hemorrhagic  Trauma  Tumors  Hemophilia/coagulopathy  Scurvy  Ehlers-Danlos syndrome  Neuropathic arthropathy
  46. 46. Review of Key Points Synovial fluid analysis  Is a well-established procedure for evaluation of joint disease.  Determines the presence of arthritis  Assists in the classification of joint disorders  Helps guides appropriate treatments
  47. 47. Thank you

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