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DR.RITTU CHANDEL
MD BIOCHEMISTRY (SECOND YR)
GRANT GOVT MEDICAL COLLEGE, BYCULLA, MUMBAI –
400008
29 – 10 -2013
Cerebrospinal fluid

Total volumes:
– Adults: 140 - 170 ml
– Children:
29-Oct-13

cerebral ventricles – 30ml
subarachnoid ...
hydrocephalus

29-Oct-13

Dr.Rittu Chandel

3
Functions of CSF
Buoyancy
2. Protective effect
3. Metabolic
4. homeostasis
1.

29-Oct-13

Dr.Rittu Chandel

4
Specimen collection

Cisternal (occipital)
In paralysis
Ventricular puncture
(lateral occipital)
For infants
29-Oct-13

Dr...
CSF analysis
CSF

Gross

microbiology
29-Oct-13

pathology

Dr.Rittu Chandel

biochemistry
6
Polypropylene tubes

29-Oct-13

Dr.Rittu Chandel

7
composition
•
•
•
•
•
•
•
•

Colour
- Colourless
PH
- 7.28 – 7.32
Appearance
- Clear
Sp. Gravity
- 1.003 – 1.004
No clot f...








Urea
Uric acid
Creatinine
Cholesterol
Ammonia
A:G ratio
Serum:CSF protein

29-Oct-13

Dr.Rittu Chandel

- 6...
Gross examination
 Appearance

Normal – crystal clear, colourless and no coagulum
1.Colour
Any change in colour is always...
xanthochromia
 Pale pink to yellow colour in supernatant of CSF

Froin’s syndrome
29-Oct-13

Dr.Rittu Chandel

11
D/D of bloody CSF
 Traumatic tap - hemorrhagic fluid clears between

first and third tubes; remains uniform in SAH
 Path...
Gross examination(contd)
 2. Turbidity
o WBC >200 cell/μl
o RBC >400 cell/μl
o Microorganisms, radiographic contrasts, as...
Pressure of CSF
Normal
Adults – 90 – 180 mm water
Infants and children – 10 – 100 mm water

>250 mm water
Intracranial hyp...
Biochemical analysis of
CSF
 1. Glucose

Normal – 45 – 100 mg/100 ml
decreased – coccal meningitis
TB meningitis
intrathe...
 2.Proteins

Normal – 15 – 45 mg/dl
Term infants – 90 – 150 mg/dl
Pre term - 115 – 170 mg/dl
 Increased CSF protein
I. I...
29-Oct-13

Dr.Rittu Chandel

17
electrophoresis

29-Oct-13

Dr.Rittu Chandel

18
Permeability of blood brain
barrier
CSF/serum albumin index
index

permeability

<9

intact barrier

9 – 14

slight impair...
CSF serum immunoglobulin
ratio

 Increases in multiple sclerosis

 Increased CSF IgM and kappa light chains – marker of
...
CSF proteins and CNS
diseases
proteins

Diseases or disorders

Α2 - macroglobulin

Subdural hemorrhage, bacterial meningit...
CSF leak (rhinorrhea)

29-Oct-13

Dr.Rittu Chandel

22
CSF lactate
 CSF and blood lactate are largely independent
 Normal

newborn – 10 – 60 mg/dl
Child and adult – 9 – 26 mg/...
CSF phenylalanine
CSF copper

 Total cell count –

Normal - 0 – 5 cells/ μl
Neonate – 0 -30 cells/ μl
No RBC
 Differenti...
Lumbar puncture findings
test

bacterial

viral

fungal

tuberculous

Opening
pressure

elevated

Usually normal

variable...
CSF enzymes
CSF enzymes

disease

Adenosine deaminase

Tubercular meningitis

Creatine kinase ( CK – BB )

Hydrocephalus, ...
CSF tumor markers
Carcinoembryonic antigen

Metastatic carcinoma of leptomeninges

Human chorionic gonadotropin

Choriocar...
Synovial fluid

29-Oct-13

Dr.Rittu Chandel

28
resilience
Surrounded by shell of water
molecules
A slippery consistency
Compressed – occupy smaller
volume
Relaxed – occu...
functions
 Reduce friction between bones
 Lubricates joints
 Fluid provides nutrients to cartilage
 Lessens shock of w...
Composition
Volume
Color
Clarity

<3.5 mL
pale yellow
clear

Neutrophils
<20% of diff.
Lymphocytes
<15 % of diff.
Monocyte...
collection
*Avoid all powdered anticoagulants – interfere
with crystal analysis
 Fluid verification


29-Oct-13

Mucin c...
examination
Synovial
fluid

Gross

microbiology
29-Oct-13

pathology

Dr.Rittu Chandel

biochemistry
33
Gross examination
 Total volume – recorded at bedside
 Normal= 3.5 mL
 Diseased / inflamed = up to 25

mL

 Colour – c...
Biochemical analysis
 Mucin clot test

Non specific finding
 Glucose
Serum synovial difference < 10 mg/dl
Septic arthrit...
Cell count
 Total count

Normal – 150 – 200 / μl
abnormal >10,000/ μl
 DLC
Normal - Neutrophils – 20%
Gout >50%
Acute ba...
Differential count






Normal
Neutrophils – 20%
Lymphocytes – 15%
Monocytes and macrophages – 65%
Abnormal
Reiters ...
Uric acid crystals

29-Oct-13

Dr.Rittu Chandel

38
crystals

29-Oct-13

Dr.Rittu Chandel

39
lymph
 The lymphatic system is an extensive vascular network
 responsible for the transport of fluid , immune cells ,

p...
 slightly basic fluid
 Resembles plasma in its content
 Protein content varies widely from 2% to 8%

29-Oct-13

Dr.Ritt...
bibliography
Harrisons internal medicine
Ranna shinde
Vasudevan
Henrys clinical diagnosis

THANK YOU
29-Oct-13

Dr.Rittu C...
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Fluids

  1. 1. DR.RITTU CHANDEL MD BIOCHEMISTRY (SECOND YR) GRANT GOVT MEDICAL COLLEGE, BYCULLA, MUMBAI – 400008 29 – 10 -2013
  2. 2. Cerebrospinal fluid Total volumes: – Adults: 140 - 170 ml – Children: 29-Oct-13 cerebral ventricles – 30ml subarachnoid space - 120 ml 10 - 60 ml Dr.Rittu Chandel 2
  3. 3. hydrocephalus 29-Oct-13 Dr.Rittu Chandel 3
  4. 4. Functions of CSF Buoyancy 2. Protective effect 3. Metabolic 4. homeostasis 1. 29-Oct-13 Dr.Rittu Chandel 4
  5. 5. Specimen collection Cisternal (occipital) In paralysis Ventricular puncture (lateral occipital) For infants 29-Oct-13 Dr.Rittu Chandel 5
  6. 6. CSF analysis CSF Gross microbiology 29-Oct-13 pathology Dr.Rittu Chandel biochemistry 6
  7. 7. Polypropylene tubes 29-Oct-13 Dr.Rittu Chandel 7
  8. 8. composition • • • • • • • • Colour - Colourless PH - 7.28 – 7.32 Appearance - Clear Sp. Gravity - 1.003 – 1.004 No clot formation on standing Proteins - 10 – 45 mg/dl Glucose - 45 – 100 mg/dl Chlorides - 120 -130 mEq/l 29-Oct-13 Dr.Rittu Chandel 8
  9. 9.        Urea Uric acid Creatinine Cholesterol Ammonia A:G ratio Serum:CSF protein 29-Oct-13 Dr.Rittu Chandel - 6.0 - 16 mg/dL - 0.5 - 3.0 mg/dL - 0.6 - 1.2 mg/dL - 0.2 - 0.6 mg/dL - 10 – 35 μg/dL - 3:1 – 200:1 9
  10. 10. Gross examination  Appearance Normal – crystal clear, colourless and no coagulum 1.Colour Any change in colour is always pathological Red Yellow 29-Oct-13 Dr.Rittu Chandel 10
  11. 11. xanthochromia  Pale pink to yellow colour in supernatant of CSF Froin’s syndrome 29-Oct-13 Dr.Rittu Chandel 11
  12. 12. D/D of bloody CSF  Traumatic tap - hemorrhagic fluid clears between first and third tubes; remains uniform in SAH  Pathological - RBC have crenated appearance  Xanthochromia, erythrophagocytosis and hemosedrin laden macrophages indicate a subarachnoid bleed in absence of prior trauma 29-Oct-13 Dr.Rittu Chandel 12
  13. 13. Gross examination(contd)  2. Turbidity o WBC >200 cell/μl o RBC >400 cell/μl o Microorganisms, radiographic contrasts, aspirated epidural fat o Protein > 150 mg/dl  Clot formation  Viscous CSF 29-Oct-13 Dr.Rittu Chandel 13
  14. 14. Pressure of CSF Normal Adults – 90 – 180 mm water Infants and children – 10 – 100 mm water >250 mm water Intracranial hypertension Tumors Decreased pressure Dehydration Circulatory collapse CSF leakage 29-Oct-13 Dr.Rittu Chandel 14
  15. 15. Biochemical analysis of CSF  1. Glucose Normal – 45 – 100 mg/100 ml decreased – coccal meningitis TB meningitis intrathecal streptomycin Increased – diabetic hyperglycemia In assessing response to treatment 29-Oct-13 Dr.Rittu Chandel 15
  16. 16.  2.Proteins Normal – 15 – 45 mg/dl Term infants – 90 – 150 mg/dl Pre term - 115 – 170 mg/dl  Increased CSF protein I. Increased permeability of blood brain barrier II. Increased intrathecal IgG secretion 29-Oct-13 Dr.Rittu Chandel 16
  17. 17. 29-Oct-13 Dr.Rittu Chandel 17
  18. 18. electrophoresis 29-Oct-13 Dr.Rittu Chandel 18
  19. 19. Permeability of blood brain barrier CSF/serum albumin index index permeability <9 intact barrier 9 – 14 slight impairment 14 – 30 moderate impairment >30 severe impairment Index slightly elevated in infants up to 6 months of age 29-Oct-13 Dr.Rittu Chandel 19
  20. 20. CSF serum immunoglobulin ratio  Increases in multiple sclerosis  Increased CSF IgM and kappa light chains – marker of multiple sclerosis 29-Oct-13 Dr.Rittu Chandel 20
  21. 21. CSF proteins and CNS diseases proteins Diseases or disorders Α2 - macroglobulin Subdural hemorrhage, bacterial meningitis Β – amyloid protein 42 and ζ protein Alzheimer’s disease Β 2 - microglobulin Leukemia/lymphoma, bechets syndrome C- reactive protein Bacterial and viral meningitis fibronectin Lymphoblastic leukemia, AIDS, meningitis methemoglobin Mild subarachnoid/subdural hemorrhage Mylein basic protein Multiple sclerosis, tumors Protein 14- 3 -3 29-Oct-13 Dr.Rittu Chandel Creutzfeldt – jacob disease 21
  22. 22. CSF leak (rhinorrhea) 29-Oct-13 Dr.Rittu Chandel 22
  23. 23. CSF lactate  CSF and blood lactate are largely independent  Normal newborn – 10 – 60 mg/dl Child and adult – 9 – 26 mg/dl Differentiating meningitis CSF lactate (mg/dl) meningitis < 25 mg/dl Almost always less than 35 mg/dl viral >35 mg/dl bacterial Persistently elevated - poor prognosis in patients with severe head injury 29-Oct-13 Dr.Rittu Chandel 23
  24. 24. CSF phenylalanine CSF copper  Total cell count – Normal - 0 – 5 cells/ μl Neonate – 0 -30 cells/ μl No RBC  Differential count Lymphocytes: monocytes = 70:30 Neutrophils – 7% 29-Oct-13 Dr.Rittu Chandel 24
  25. 25. Lumbar puncture findings test bacterial viral fungal tuberculous Opening pressure elevated Usually normal variable variable Leukocyte count > Or =1000/μl <100/μl variable variable Differential count Mainly neutrophils Mainly lymphocytes Mainly lymphocytes Mainly lymphocytes protein Mid – marked increase Normal – mild increase increased increased glucose < or = 40 mg/dl normal decreased Decreased ;<45 mg/dl CSF/serum glucose ratio Normal – marked decrease Usually normal low low 29-Oct-13 Dr.Rittu Chandel 25
  26. 26. CSF enzymes CSF enzymes disease Adenosine deaminase Tubercular meningitis Creatine kinase ( CK – BB ) Hydrocephalus, cerebral infarction, primary brain tumors, subarachnoid hemorrhage LDH CNS leukaemia, lymphoma, metastatic carcinoma, bacterial meningitis, SAH lysozyme Bacterial and tuberculous meningitis Aspartate transaminase Cerebral abscess, cerebral hemorrhage, primary or metastatic malignancy Placental alkaline phosphatase Germ cell tumor 29-Oct-13 Dr.Rittu Chandel 26
  27. 27. CSF tumor markers Carcinoembryonic antigen Metastatic carcinoma of leptomeninges Human chorionic gonadotropin Choriocarcinoma, malignant germ cell tumors Alpha feto protein Germ cell tumors CSF ferritin CNS malignancy 29-Oct-13 Dr.Rittu Chandel 27
  28. 28. Synovial fluid 29-Oct-13 Dr.Rittu Chandel 28
  29. 29. resilience Surrounded by shell of water molecules A slippery consistency Compressed – occupy smaller volume Relaxed – occupy 29-Oct-13 Dr.Rittu Chandel 29
  30. 30. functions  Reduce friction between bones  Lubricates joints  Fluid provides nutrients to cartilage  Lessens shock of walking and jogging impact 29-Oct-13 Dr.Rittu Chandel 30
  31. 31. Composition Volume Color Clarity <3.5 mL pale yellow clear Neutrophils <20% of diff. Lymphocytes <15 % of diff. Monocytes & macrophages 65% of diff. Crystals NONE Glucose <10 mg/dL (serum synovial difference) Lactate <250 mg/dL Total protein <3 g/dL Uric acid = blood value 29-Oct-13 Dr.Rittu Chandel 31
  32. 32. collection *Avoid all powdered anticoagulants – interfere with crystal analysis  Fluid verification  29-Oct-13 Mucin clot test Add fluid to dilute acetic acid  turbidity (clot formation) due to hyaluronate Dr.Rittu Chandel 32
  33. 33. examination Synovial fluid Gross microbiology 29-Oct-13 pathology Dr.Rittu Chandel biochemistry 33
  34. 34. Gross examination  Total volume – recorded at bedside  Normal= 3.5 mL  Diseased / inflamed = up to 25 mL  Colour – colourless xanthochromia red brown  Clarity –transparent opaque oily floating rice bodies ground pepper appearance 29-Oct-13 Dr.Rittu Chandel 34
  35. 35. Biochemical analysis  Mucin clot test Non specific finding  Glucose Serum synovial difference < 10 mg/dl Septic arthritis – difference 20 – 60 mg/dl  Protein Normal – 1-3 g/dl Increased in inflammation  Uric acid  RF  ANA 29-Oct-13 Dr.Rittu Chandel 35
  36. 36. Cell count  Total count Normal – 150 – 200 / μl abnormal >10,000/ μl  DLC Normal - Neutrophils – 20% Gout >50% Acute bacterial arthritis – 75% 29-Oct-13 Dr.Rittu Chandel 36
  37. 37. Differential count      Normal Neutrophils – 20% Lymphocytes – 15% Monocytes and macrophages – 65% Abnormal Reiters cell Eosinophilia >2%  Microscopic examination 29-Oct-13 Dr.Rittu Chandel 37
  38. 38. Uric acid crystals 29-Oct-13 Dr.Rittu Chandel 38
  39. 39. crystals 29-Oct-13 Dr.Rittu Chandel 39
  40. 40. lymph  The lymphatic system is an extensive vascular network  responsible for the transport of fluid , immune cells , proteins and lipids .  The failure to transport lymph fluid results in a number of disorders and diseases .  Lymphedema , for example , is a pathology characterized by the retention of fluid in limbs creating extreme discomfort , reduced mobility. 29-Oct-13 Dr.Rittu Chandel 40
  41. 41.  slightly basic fluid  Resembles plasma in its content  Protein content varies widely from 2% to 8% 29-Oct-13 Dr.Rittu Chandel 41
  42. 42. bibliography Harrisons internal medicine Ranna shinde Vasudevan Henrys clinical diagnosis THANK YOU 29-Oct-13 Dr.Rittu Chandel 42

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