This document provides information on the examination of cerebrospinal fluid (CSF). CSF is produced by the choroid plexus and circulates in the subarachnoid space, providing mechanical protection and transport functions. Diagnosis of various central nervous system conditions can be made through CSF analysis, including meningitis, encephalitis, and malignancy. Proper specimen collection and examination of opening pressure, cell count, glucose, protein and microscopic analysis can help diagnose these conditions.
2. SPUTUM EXAMINATION
Specimen Collection â
â˘Ideal â should contain lower respiratory tract secretions
1st
morning sample is ideal ,contaminant may be prt.
â˘Needs patient co-operation and understanding.
â˘May be spontaneous/induced.
â˘In children â 3 methods â
Nasopharyngeal swab, Cough plate, Cough swab
â˘Collection in sterile,disposable container with a screw cap
â˘Delivered to the lab immediately
3. SPUTUM âGROSS EXAMINATION
Consistency and appearance â normal â viscoelastic
Opaqueness â due to pus,epithelial cells, Curshmannâs spirals,
caseous material,bronchial casts,food subs.
Colour â Yellow â pus,epithelial cells
Green â pseudomonas
Rust coloured â infarct,pneumonia
Bright red â acute LVF, TB,malignancy.
Odour â normal â no odour
putrid â lung abscess,cavities.
Others â foreign bodies,parasites,broncholiths
4. SPUTUM âMICROSCOPIC EXAMINATION
â˘All suspicious particles â transferred with sterile instrument
â˘Smears can be dried ,heat fixed to kill organisms
â˘Special stains to be applied â Grams,ZN,pap,Giemsa,H&E
â˘Presence of alveolar macrophage â sample is representative
â˘Other cells â bronchial epithelial cells
â˘Abnormal cells â Intact neutrophils â pyogenic infections
Eosinophils â in large nosâ bronchial asthma
RBCâs in large nos. exudate, haemorrhage
6. SPUTUM CULTURE
â˘Microscopic examination should preceede culture
â˘2 methods â
Classic technique â streaking on agar plate
should be corelated with Grams stained smears.
Quantitive analysis of the organisms
7. SPUTUM IN DISEASE
â˘Tuberculosis â 24 hr specimen,early morning,bronchial
⢠washings,transtracheal aspiration & gastric
â˘Pretreatment by digestion procedures facilitates demonstration
â˘Liquefying sputum, lowering specific gravity,
Decontamination of other organisms
â˘Staining with ZN stain
â˘Flourescent microscopy.
19. SPECIMEN COLLECTION
â˘Done by attending physician/nurse
â˘Delivered to the lab immediately
â˘Should be examined fresh â as cells disintegrate
bacteria grow fast
altered chemical composition
â˘Need for another collection to be avoided
â˘Avoid traumatic tap
â˘Anticoagulant may be needed
â˘Collection in 3 bulbs â microbiology,cells & proteins,
biochemistry.
26. Whole fluid without centrifugation-
⢠Appearance â clear,cloudy,chylous
⢠Colour â milky,red,yellow etc.
Normal = clear/straw-coloured
Red = trauma/rupture/tumour/ bleeding disorder
Milky = chylous - filariasis
Mucinous = adenocarcinoma
Purulent = empyema/peritonitis
FLUID â PHYSICAL EXAMINATION
27. FLUID â PHYSICAL EXAMINATION
â˘Turbid fluids can be centrifuged-
If supernatent clear â turbidity due to cells
If supernatent turbid â chylous/pseudochylous
â˘Specific Gravity â to decide whether transudate/exudate
32. Plasma ultrafiltrate with added hyaluronic acid.
⢠Indications
a. synovitis - acute suppurative
- gout / pseudogout
b. DD of arthritis
⢠Collection - sterile, disposable plastic heparinized
syringe (1 ml in each large joint)
- Despatch similar to the other fluids
SYNOVIAL FLUID
36. SYNOVIAL FLUID
Tests for viscosity â
Principle â based on presence of hyaluronic acid
â˘String test -hold a drop of fluid between thumb &index finger
-pull them apart to form a string
-normal -a string can be formed â 4-6 cm long
-abnormal - < 3 cm long and breaks
â˘Mucin clot test â clot formation on addition of acetic acid
-grading of clots
-normal â firm clot
-abnormal â poor clot.
37. SYNOVIAL FLUID - BIOCHEMISTRY
â˘Glucose Examination-
-Must be taken from fasting patient and treated with flouride
-Reported as difference between blood-synovial fluid glucose
-Normal and Non inflammatory arthritis â diff =10mg/dl
-Infectious arthritis âdiff=25-50 mg/dl
-Severe inflammatory â diff=increased.
â˘Protein Content â
increased in severe inflammatory conditions
â˘Lactate â more values â septic arthritis
40. SYNOVIAL FLUID- MICROBIOLOGY
â˘Smear Preparation â Gram stain
ZN stain
â˘Culture Examination â first tube to be used
centrifuged specimen â use sediment.
41. â˘Rh factor - +ve in 60% of RA patients
â˘ANA - +ve in SLE
â˘C4 - âed in RA, SLE, arthritis, gout, etc.
SYNOVIAL FLUID - IMMUNOLOGY
42. ⢠Water(99%),hydrocloric acid,organic acids,various
enzymes, mucin and intrinsic factor.saliva and
regurgitated duodenal contents are also present.
⢠Psycological factors,systemic diseases,GITract ds,
hence co related with clinical and other findings.
⢠No defined normal values.
⢠Unpleasant for the pt, time consuming and
cumbersome procedure
GASTRIC AND DUODENAL CONTENTS`
43. ⢠To determine gastric acid secretion. Macrocytic
anaemia, pernicious anaemia, peptic ulcerand other
ulcerative lesions
⢠To measure amount of acid production in peptic ulcer
and post operative stomach ulcer
⢠Diagnosis of Zollinger-Ellison syndrome
⢠To determine completeness of vagotomy by insulin
tests
⢠M. tuberculosis isolation in children
⢠Detection of malignancy by cytology
INDICATIONS
44. GASTRIC INTUBATION
⢠Overnight fasting
⢠55cms mark- antrum
⢠Contraindicated in esophageal varices, diverticula,
stenosis,aortic aneurysms,recent gastric haemorrhage,CCF
and pregnancy.
⢠Volume in ml, titrable acidity(0.1 N NaOH and phenol red
as indicator), pH measured electrometrically.
45. GASTRIC JUICE - Physical examination
⢠Pale grey,transluscent,slightly viscid and pungent
⢠Fasting volume varies upto 50ml
⢠Food particles indicate delayed gastric emptying
⢠Bile is seen in regurgitation, excess seen in intestinal
obstruction beyond the ampulla of Vater
⢠Blood may be due to trauma. Coffee ground may be
due to gastritis,ulcer, carcinoma or blood swallowed
from mouth, nasopharynx or pulmonary sources
46. GASTRIC JUICE - MICROSCOPY
â˘Normal - RBCâs,WBCâs,epithelial cells,yeasts,bacteria,mucus
â˘Neutrophils â increased nos. - gastric mucosal inflammation
â˘Epithelial cells â increased in gastritis
â˘Parasites rarely found â giardia,ascaris,strongyloides etc.
â˘Not really useful
47. AMNIOTIC FLUID
Indications â
â˘Cytogenetic â increased maternal age,chromosomal abn,
previous history,exposure to irradiation,single gene
disorders
â˘AFP â neural tube defects
â˘Erythroblastosis fetalis â based on presence of products of
hemolysis
â˘Surfactant analysis â lung maturation
â˘Intrauterine infections â
TORCH,syphilis,TB,Salmonella,candida,HIV
49. CONTENT
⢠Anatomy and Physiology
⢠Specimen Collection
⢠Opening Pressure
⢠Total cell count
⢠Differential cell count
⢠Glucose
⢠Protein
50. Anatomy and Physiology
ďClear & Colourless fluid
ďProduced by choroid
plexus & ultrafiltration
ď leaves ventricular system by
lateral & medial foramina
ď flows within subarachnoid
space
ď CSF resorption occurs at
arachnoid villi.
Volume: 120 â 180 ml in adultsVolume: 120 â 180 ml in adults
60 â 80 ml in babies60 â 80 ml in babies
51. Functions of CSF
⢠Mechanical protection
⢠Transport of biomolecules
⢠Clearance of catabolites
⢠Maintenance of constant ICT
52. Diagnosis by CSF
⢠High sensitivity, high specificity
â Bacterial, TB, and fungal meningitis
⢠High sensitivity, moderate specificity
â Viral meningitis, SAH, MS, CNS syphilis, abcess
⢠Moderate sensitivity, high specificity
â Meningeal malignancy
⢠Moderate sensitivity, moderate specificity
â Intracranial hemorrhage, viral encephalitis,
subdural hematoma
54. Specimen Collection
⢠Lumbar puncture (LP) is the insertion of a needle
into the subarachnoid space (the area under the
membrane that surrounds the brain and spinal cord)
of the lumbar (lower back) region for diagnostic or
therapeutic purposes. This allows access to the
cerebrospinal fluid (CSF) in which the brain and
spinal cord float.
⢠Although the subarachnoid space can be accessed
from other levels, the lumbar region is most often
used as it allows the needle to be inserted below the
end of the spinal cord.
55.
56. Routine Lab Tests
⢠Required
⢠Opening CSF pressure
⢠Total cell count and differential (stained)
⢠Glucose (CSF/plasma ratio)
⢠Protein
⢠Optional
⢠Cultures, gram stain, antigens, cytology
⢠Protein electrophoresis, VDRL, D-dimers
60. CSF specimen is usually devided into 3 serially collected sterile tubes
Tube-1 For chemistry & immunological studies
Tube-2 For microbiological examination
Tube-3 For cell counts
Specimen should be delivered to the lab & processesd within 1 hr.
Refrigeration is contraindicated for culture examination
Gross Examination:
Normal CSF is clear & colourless
Abnormal CSF may appear cloudy, frankly purulent or pigment tinged
Viscous CSF may be seen in metastatic mucin producing
adenocarcinoma, cryptococcal meningitis.
61. Xanthochromia
⢠Pink, orange, or yellow discoloration
⢠RBC lysis or hemoglobin breakdown
⢠May be seen within hours of LP
⢠Peak intensity at 24 - 36 hours
⢠RBC > 6000/uL (SAH, ICH, infarct,
traumatic)
⢠Oxyhemoglobin, bilirubin, increased
protein
⢠Carotinoids, melanin, rifampin
therapy
CSF supernatantCSF supernatant
colourcolour
Disease/DisordersDisease/Disorders
PinkPink RBC lysisRBC lysis
YellowYellow HyperbilirubenemiaHyperbilirubenemia
OrangeOrange Hypervitaminosis AHypervitaminosis A
Yellow-GreenYellow-Green HyperbilirubenemiaHyperbilirubenemia
BrownBrown Metastatic melanomaMetastatic melanoma
62.
63.
64.
65.
66.
67. Differential Dx of Bloody CSF
⢠Traumatic tap - blood clears between tubes
⢠Xanthochromia - pink tinge, RBCs
⢠SAH - blood does not clear or clot
68. Microscopic examination
Done on undiluted CSF in a manual Neubauerâs counting chamber.
No RBCs should be present in normal CSF
If numerous (except a traumatic trap) indicates trauma or pathologic
processes like malignancy, infarct, hemorrhage
69.
70. Increased Neutrophils in CSF
⢠Meningitis (bacterial, early TB, viral, fungal)
⢠Other infections
⢠Following seizures
⢠Following CNS hemorrhage
⢠Following CNS infarct
⢠Reaction to repeated LP
⢠Foreign materials
⢠Metastatic tumor
71. Increased Lymphocytes in CSF
⢠Meningitis (aseptic, L
monocytogenes,Viral,tuberculous,fun
gal,syphilitic)
⢠Parasitic infections
⢠Degenerative disorders
â SSPE, MS, encephalopathy due to
drugs, GBS
⢠Other inflammatory conditions
â Sarcoidosis, polyneuritis,
periarteritis involving the CNS
72. Eosinophilic pleocytosis in CSF
⢠Commonly associated with
⢠Parasitic infections
⢠Fungal infections
⢠Reaction to foreign material
⢠Infrequently associated with
⢠Bacterial or tuberculous
meningitis
⢠Viral, rickettsial infection,
lymphoma, sarcoidosis
74. Bacterial Meningitis
⢠0 - 1m: Group B strept & E. coli (GNR)
⢠1m - 5y: H. influenzae
⢠5 - 29y: N. meningitidis
⢠>29y: S. pneumoniae
⢠Listeria monocytogenes common in newborns,
elderly, and other immunocompromised hosts
75. Bacterial Meningitis
CSF Gram stain showingCSF Gram stain showing Gram-negativeGram-negative
diplococcidiplococci characteristic of N.meningitidis.characteristic of N.meningitidis.
76. Granulocytic type of reaction:
1) Purulen meningitis
2) Initial phase of
serous inflammation
Purulent Meningitis â Prevalence of Granulocytes
77. Typical CSF Findings in Meningitis
TestTest BacterialBacterial ViralViral FungalFungal TuberculouTuberculou
ss
OpeningOpening
pressurepressure
ElevatedElevated Usually normalUsually normal VariableVariable VariableVariable
LeukocyteLeukocyte
countcount
>1000/microL>1000/microL <100/microL<100/microL VariableVariable VariableVariable
Cell differentialCell differential MainlyMainly
neutrophilsneutrophils
MainlyMainly
lymphocyteslymphocytes
MainlyMainly
lymphocyteslymphocytes
MainlyMainly
lymphocyteslymphocytes
ProteinProtein MarkedlyMarkedly
increasedincreased
Normal to mildNormal to mild
increaseincrease
IncreasedIncreased IncreasedIncreased
GlucoseGlucose <40 mg/dl<40 mg/dl NormalNormal DecreasedDecreased DecreasedDecreased
CSF to serumCSF to serum
glucose ratioglucose ratio
MarkedlyMarkedly
decreasedecrease
Usually normalUsually normal LowLow LowLow
Lactic acidLactic acid MarkedlyMarkedly
increaseincrease
Normal to mildNormal to mild
increaseincrease
Mild to modMild to mod
increaseincrease
Mild to modMild to mod
increaseincrease
78. ⢠Gradual onset of headache and decreased
consciousness
â Low grade evening fevers
â Night sweats
â Weight loss
â Neck stiffness and positive Kernigâs sign
â Cranial nerve palsies result from exudate
around base of the brain
Mycobacterial Infection: M. tuberculosis
(TB Meningitis)
Presenting Signs and Symptoms