cytology of body fluid

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cytology of body fluid

  1. 1. CYTOLOGY OF BODY FLUID DR SHABNEEZ HUSSAIN HAEMATOLOGY RESIDENT
  2. 2. CAVITY FLUIDS  Abdominal 􀂄 Pleural 􀂄 Pericardial 􀂄 Synovial 􀂄 CSF
  3. 3. Schematic representation of the three body cavities
  4. 4. CAVITY FLUIDS  Sampling techiques  appearance during collection EDTA to prevent clotting  direct smear -  delayed processing  Cell concentration  Protein concentration
  5. 5.  TRANSUDATE  EXUDATE  MODIFIED TRANSUDATE
  6. 6. Accumulation of fluids in body cavities Transudates • Increased hydrostatic pressure: Congestive heart failure • Decreased oncotic pressure (decreased albumin) : liver cirrhosis, nephrosis, and malnutrition Exudate • Inflammation: Infection, infarction, hemorrhage • Tumor
  7. 7. DIFFERENCES BETWEEN TRANSUDATE AND EXUDATE Feature Transudate Exudate Gross appearance Watery, clear Turbid or cloudy Specific gravity Less than 1015 More than 1015 Protein Less than 3mg/dl More than 3mg/dl Clots No Yes cells Usually benign: Few mesothelial cells, few histocytes and lymphocytes More mesothelial cells, acute or chronic inflammatory cells, RBCs, malignant cells
  8. 8. MODIFIED TRANSUDATE  Moderate protein concentration: 2,52,5- 7,5g/dl  Moderate cellularity 1000-7000 cells/ μg  Cardiovascular disease  Neoplastic disease  Rupture of urinary bladder  Hepatic disease
  9. 9. DIAGNOSTIC ROLE OF EFFUSION CYTOLOGY  It is very useful for diagnosis of premalignant and malignant tumors, especially metastatic tumors.  It is very useful for diagnosis of inflammatory conditions (septic effusion, or chronic specific inflammation e.g. TB
  10. 10.  Respiratory Tract  Urinary Tract  Oral Cavity  Gastrointestinal Tract  Effusions (pleural, pericardial, joint)  Cerebral Spinal Fluid  Amniotic fluid  Many other body sites Non-Gynecological Specimen Collection
  11. 11. EXAMINATION OF BODY FLUID  Gross exam  Total cell count  Microscopic exam  Any other special test (Chemistry, Microbiology, cytology (  Test are performed in various areas of lab based on what the physician orders.  Body fluids sterile vs. non-sterile
  12. 12. SAMPLE COLLECTION  FNA of effusion fluids  Tapping
  13. 13. Collection and preparation of specimen
  14. 14. FIXATION  1ml of heparin + 100ml of effusion fluid to prevent clotting  N.B.: do not use alcohol in fixation of fluid before spread cytological smear on glass slides
  15. 15. TYPES OF STAINING SMEARS  PAP  Gram Stain  Hx & E  Cell block for remnant sediment and histopathological examination.  Other special stains for the most suspected diseases, to confirm diagnosis.
  16. 16. Heparinized bottles (3 units heparin/ml) Unfixed Alcohol-fixed Papanicolaou-stained Cytocentrifuge preparationCell block Adding plasma and thrombin solution Wrapped in filter paper Placed in a cassette Embedded in paraffin Cut and H&E stain Air-dried cytocentrifuge preparation (Hematologic malignancy is suspected)
  17. 17.  Adequacy: on site  Background: necrotic, mucinous  Cell concentration: high, low  Cell preservation: lysis  Inflammatory cells: which? dominant?  Lining cells: mesothelial, epithelial  Cells of interest: tumor cells
  18. 18. 1- CEREBROSPINAL FLUID  Fluid surrounding brain and spinal cord  Sterile  Specimen collection: by Lumbar puncture  Collect 3-5 vials, each tube has a designated department.  Gross exam: Turbidity, Color, microscopic exam, cell count
  19. 19. CSF CELL DIFFERENTIAL  Numerate and differentiate cells seen  Lymphocytes: usually are few; increased with viral, fungal, bacterial meningitis, or nervous system disease  Monocytes: Less than 2% of normal CSF, increased with TB meningitis, viral encephalitis, subarachnoid hemorrhage.
  20. 20.  PMN: are few, associated with Viral and acute bacterial inflammation.  Macrophages: are few in number associated with malignancy, hemorrhage, inflammation  Eosinophils/Basophils: not normally seen in CSF
  21. 21.  Plasma cells: not normally present; associated with viral disorders, and Hodgkin's diseases.  Red Blood Cells: Few to none present  Mesothelial cells: not present  Malignant cells: will see with malignant disease and infiltrate.
  22. 22. CSF EVALUATION  Tube 1-cell count and differential  Tube 2-glucose, protein  Tube 3-cultures, gram stain, cytology, (HSV PCR, West Nile, India ink, Crypto Antigen, VDRL, Lyme Ab, AFB...)  Tube 4-cell count and differential
  23. 23. NORMAL CSF COMPOSITION  Clear color  <5 RBC’s  <5 WBC’s  Protein 23-38mg/dl (can use 14-45)  Glucose—60% of serum level (75-100)
  24. 24. OPENING PRESSURE  Normal = 80-180 mmHg  Obese pts: up to 250mmHg can be normal  Pathologically elevated: >250mmHg  If elevated, likely due to cerebral edema from intracranial pathology  Infection (cryptococcal meningitis), tumor, benign ICH (pseudotumor)
  25. 25. RBCS Always send tube #1 and #4 for cell count and compare RBCs Traumatic tap: Elev RBC in tube 1, nl in tube 4 1000 RBC : 1 WBC to adjust WBC count in bloody tap SAH or HSV: Elev RBC in tube 1 AND tube 4  “Crenated RBCs” and xanthochromia (yellow supernatant after centrifuge) Seen in hyperbilirubinemia (ESLD), old SAH, old blood from prior traumatic LP or bleed
  26. 26. WBC’S  Infection!  PMN predominance: likely bacterial meningitis  Lymphocytic predominance: viral vs. fungal vs. TB vs. malignancy
  27. 27. PROTEIN  Normal: protein is excluded from CSF by blood- CSF barrier  Increased: nonspecific  Elevated in all infectious meningitis  May remain elevated for months post-meningitis (viral or bacterial)  Increased in malignancy and inflammatory conditions (ie Guillain-Barre)
  28. 28. GLUCOSE Normal  Viral infection Low glucose  Bacterial meningitis, TB, fungal Really low  <18 is strongly suggestive of bacterial meningitis
  29. 29. TYPICAL VIRAL MENINGITIS  CSF WBC elevated, but <250 (first PMNs, then lymphocytes)  CSF protein elevated, but <150  Glucose > 50% of serum concentration
  30. 30. TYPICAL BACTERIAL MENINGITIS  CSF WBC >1000, PMN predominance  CSF protein >500mg/dl  CSF glucose <45 mg/dl
  31. 31. • Effusion: • Transudate • Exudates • Lab analysis: Gross exam, cell count, etc. • Differential: PMN, Lymph, Mono, etc. 2- Pleural Fluid: Lung fluid
  32. 32. • Cells unique to the lungs: Mesothelial cells • RBCs and WBCs: are limited, if increased without traumatic tap ----- indicates infarction • Cytology exam: useful in identifying malignancy or abnormal morphological cells.
  33. 33. WHAT TO ORDER? Serum LDH, total protein (Add on to am labs) Pleural fluid:  Total Protein, LDH  Glucose, cell count and diff, pH (on ice)  Gram stain, culture, fungal stain and culture, AFB  Cytology  Other: triglyceride level to r/o chylothorax; amylase to r/o pancreatitis, esoph perf; Adenosine deaminase to eval TB
  34. 34. LIGHT’S CRITERIA FOR EXUDATES Fluid is exudate if it meets 1 of 3 criteria: 1. Pleural fluid LDH/serum LDH > 0.6 2. Pleural fluid protein/serum protein > 0.5 3. Pleural fluid LDH > upper limit of normal serum LDH  If all 3 negative, fluid is Transudate
  35. 35. TRANSUDATE  Result from imbalances in oncotic and hydrostatic pressure  Usually low oncotic +/- high hydrostatic pressure  Pulm Edema/CHF  Cirrhosis with ascites  Hypoalbuminemia/Nephrotic syndrome, ESLD  Fluid overload s/p aggressive IVF  Peritoneal dialysis
  36. 36. EXUDATE Caused by local, not systemic, factors  Infection  Neoplasm  Pancreatitis  Esoph perf  RA  SLE  Sarcoid, Wegeners, PE, Meig’s, Chylothorax
  37. 37. LYMPHOCYTOSIS  Malignancy (50-70% lymphs)  Also TB, sarcoid, RA, chylothorax (>90% lymphs)
  38. 38. PLEURAL EOSINOPHILIA  Pneumothorax  Hemothorax  Pulm infarct  Parasitic disease  Fungal infection  Drugs  Malignancy  Asbestos
  39. 39. WHY IS GLUCOSE LOW? (<60)  RA  TB  Empyema  SLE  Malignancy  Esophageal rupture
  40. 40. 3- PERITONEAL FLUID  Abnormal accumulation of fluid (effusion) in peritoneal cavity: Ascites  Ascites: a condition in which fluid accumulates within the peritoneal space.  Must have an accumulation of > 100ml (several 100) before effusion can be detected on physical exam.
  41. 41.  Removal procedure- paracentesis  Lab analysis: distinguish between transudate and exudates, gross exam, cell count, sedimentation, chemical analysis
  42. 42. PHYSICAL CHARACTERISTICS  Peritoneal Fluid Appearance: Color and clarity.  Color and clarity can indicate certain infections and diseases.  Total Cell Count: Assist in diagnosis of certain diseases by determining total RBC and WBC number.
  43. 43.  Lymphocytes: CHF, liver cirrhosis, nephrotic syndrome  Mesothelial Cells: Associated with TB effusions  Malignant cells: seen with malignancy
  44. 44. WHAT TO SEND FLUID FOR  Cell count with diff  Albumin  LDH  Total protein  glucose  Gram stain/cx  cytology
  45. 45. APPEARANCE OF FLUID  Clear—usually indicates uncomplicated ascites, ie liver failure/cirrhosis  Turbid/cloudy—infected  Pink/bloody—traumatic, punctured collateral vessel, malignancy  Correct for bloody tap: 1 WBC: 750 RBC 1 PMN: 250 RBC
  46. 46. SERUM-TO-ASCITES ALBUMIN GRADIENT (SAAG) =Serum albumin – ascitic fluid albumin If the gradient is >1.1:  Portal HTN (drives fluids into peritoneum)  SBP, cirrhosis, Alcoholic hepatitis, CHF If the gradient is < 1.1: (protein leaks into peritoneum and fluid follows)  Peritoneal carcinomatosis, peritoneal TB, pancreatitis, nephrotic syndrome
  47. 47. SBP  SAAG > 1.1  Suspect if >250 PMNs (>100 PMNs in pt on peritoneal dialysis)  70% GNR (E.coli, Klebsiella) 30% GPC (S. pneumo, Enterococcus)  Treat with ceftriaxone, cefotaxime  “Culture negative SBP” if >250 PMNs but cx neg; treat the same
  48. 48.  Pericardial Fluid: accumulation of fluid of the lining of the heart (effusion)  Cause: neoplasm, infections, collagen disease, renal disease, Cardiovascular disease.  Gross Exam: Report appearance (bloody, clear, cloudy) 4- Pericardial Fluid
  49. 49.  Measure pH: pH less than 7.0 associated with infection or rheumatoid disorder.  Cell count: see limited RBCs and WBCs Evaluate sedimentation
  50. 50. • Examine physical, chemical and microscopic detail • Count number of sperm, report morphology and motility • Specimen must be a fresh collection-clean, sterile container. • Gross Exam: Color, pH, Volume, and viscosity. • Agglutination study 5- Seminal Fluid
  51. 51. • Joint Fluid: normally clear, viscous • Functions as a lubricate and transports nutrient • Arthrocentesis: aspirate of the joint fluid, aseptic technique • Lab Assay: Gross exam, microscopic exam, Gram stain, cultures,... 6- Synovial Fluid:
  52. 52. • Appearance: clear, transparent, viscous • Viscosity test • Mucin Clot test • Note crystals (intracellular vs. extra cellular) • Slide exam: usually performed on concentration of the fluid using Giemsa or Papnicolaou
  53. 53. THANK YOU

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