Body fluids

P. SUNIL KUMAR
Dept.of Haematology & Transfusion Medicine
St.John’s Medical College & Hospital
Bangalore
10/13/2018 1
SUNIL KUMAR.P ST.JOHN'S MEDICAL
COLLEGE

BODY FLUIDS
Cerebrospinal fluid
Peritoneal fluid(Ascitic fluid)
Synovial fluid
Pleural fluid
Pericardial fluid
Sputum
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CEREBROSPINAL FLUID
• Cerebrospinal fluid (CSF) is formed in the
choroid plexuses (70%) by combined process of
active transport and ultra filtration
• CSF flows through the subarachnoid space
between the arachanoid and piamater surrounds
the brain and spinal cord
• CSF protects the brain and spinal cord, and
collects waste, circulates nutrients, cushions and
lubricates the central nervous system (CNS).
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Composition of Normal Lumbar CSF
Pressure 80-150 mm CSF
Appearance Clear, colorless, no coagulum or deposit
Cells & pH 0-4 x 106/L; Lymphocytes (L) or Mononuclears (M). pH- 7.3
Specific Gravity 1.006 – 1.007
Protein Content 0.15 – 0.45 g/L
Globulin Pandy test Negative
Lange Curve None given
IgG/TP < 0.13
Glucose 45- 100 mg/dL
Chloride 120 – 130 mmol/L
Calcium 1.38 – 1.50 mmol/L
Phosphate 0.5 – 0.7 mmol/L
Urea 20 – 40 mg/dL
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COMPOSITION
Protein Content 0.15 – 0.45 g/L
Glucose 40- 80 mg/dL
Sodium 136-150 meq/L
potassium 2-3.5 meq/L
chloride 118-130 meq/L
creatinine 0.5-1.5 mg/dl
pH 7.3
Specific gravity 1.006-1.007
cells 0-5 lymphocytes/cu mm
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COLLECTION
• CSF is collected by a sterile lumbar puncture
between
third, fourth, fifth lumbar vertebrae from the
subarachnoid space of meningeal covering
• Indications are mainly :
– possible cases of CNS infections, malignancies,
hemorrhage in the brain and spinal cord
• Contra indications are
– Increased intracranial pressure
– Infection in the area of puncture
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LP NEEDLE
• The needle measures 10-12 cm in length.
• In children , a shorter needle is used.
• It has needle and a stilette.
• The stilette has a pin which fits into the slot of the
head of the needle & helps to keep the needle
patent.
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Requirements
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• Spinal needle - 22 gauge:
• AGE& Length of needle:
• Less than 1 year--3.75 cm (1.5 inch)
• 1 year to middle childhood--6.25cm (2.5 inch)
• Older children to adolescents--8.75 cm (3.5 inch)
• Povidone-iodine solution.
• 1% Lidocaine and 25 gauge needle for local
anesthesia.
• Sterile 4 x 4 gauze.
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INDICATIONS:
• Meningitis and encephilitis--viral, bacterial,
fungal, or parasitic infections.
• metastatic tumors (e.g., leukemia) and central
nervous system tumors that shed cells into the
CSF
• Syphilis
• bleeding (hemorrhaging) in the brain and spinal
cord
• Guillain-Barré, Multiple sclerosis---------a
demyelinating disease
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• Normal volume 90 -150 ml
• CSF usually collected in three sterile tubes
- Label 1 / Tube 1 – used for chemical and
serologic test
( tubes are frozen)
- Label 2 / Tube 2 – used for microbiology lab (
room temp.)
- Label 3 / Tube 3 – used for hematology (cell
count)
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PROCESSING
• PHYSICAL EXAMINATION
1 ) pH – measured by pH paper
2) Color - crystal clear and colorless
causes of change in color
 Xanthochromatia : supernatant is pink, orange, or yellow-
due to
- high protein content (>150 mg/dl)
- bilirubinemia(yellow)
- hemolysis(pink)
- carotenaemia(orange)
- melanin (brown)
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3) Appearance : normally clear
 Turbidity/cloudiness due to;
- increase number of cells (>400-500) or numerous bacteria
or both
 smoky/opalescence – smaller number of cell (RBC and/or
leukocytes)
 Clot formation due to
- protein in CSF (subarachanoid block, pyogenic meningitis)
- traumatic tap (presence of fibrinogen)
- tuberculosis (cobweb like)
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MICROSCOPICAL EXAMINATION
– Total leukocyte count
- By using improved neubaur counting chamber
- if csf is clear charge directly
- if it is turbid make 1/20 dilution using WBC pipette
- all area of chamber should be counted
calculation
WBC in csf/cumm (undiluted) = NO of cell counted x 10(depth factor)
9 (area counted|)
diluted(1/20) = Number of cell counted x 10 x 20(dilution factor)
9 (area counted)
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 Reference range = 0 – 5 cells/cumm
 RBC count also should perform if it is present
 RBC will be absent unless if it is traumatic tap(fresh RBCs)
 If RBC is crenated, should be reported, it indicates
pathological hemorrhage
 RBC due to pathological hemorrhage and traumatic tap can
be differentiated by
- Gross appearance of csf
- clot formation (traumatic trap specimen will clot)
- by centrifugation (clear supernatant in traumatic trap )
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• DEFFERENTIAL COUNT
– prepare a smear directly(if count >500 ) or after
centrifugation (if count <200) on a clean slide
– Fix in alcohol and stain with Leishman stain
– Observe under oil immersion objective and count the
cells
REPORTING
 Cells reported in percentage after counted 100 cell
Increased polymorphs seen in
- bacterial meningitis
- amoebic encephalomyelytes
- cerebral abscess
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 Increased number of lymphocytes in
- viral meningoencephalitis
- tuberculous meningitis
- fungal meningitis
 Increased number of eosinophils
- parasitic , fungal infection etc..
 Basophil may observed in CML Involving the meningitis
Mixed reaction with nuetrophil ,lymphocyte ,plasmacell
and monocytes ,is feature of tuberculous ,fungal, chronic
bacterial meningitis and rapture of brain abscess etc…
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Presence of bacteria, budding yeast cell also
should see
Ependymal (unique to CSF)normal lining cells of
CNS . may be seen occasionally . Increased
number can be observed after neurosurgery
,brain infarcts
Reactive lymphocyte may occur in viral infection
Presence of siderophages indicate previous
hemorrhage
Ependymal cell
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CHEMICAL EXAMINATION
 Estimation of glucose by enzymatic methods
Reduced in bacterial/tuberculous/fungal
meningitis
No change in viral meningitis
Hypoglycemia & malignancies – low level
 Estimation of protein
Elevated in tuberculous/fungal / bacterial
meningitis ,tumors, subarachnoid hemorrhage
etc…
 chloride , LDH ,are also estimating
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Contraindications
• Raised intracranial pressure
• Local infective lesions
• Disseminated sclerosis
• Brain tumor.
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Complications of LP
• Herniation of cerebellum
• Hematoma,
• Introduction of infection by the LP needle
through the infected skin or subcutaneous
tissue.
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SYNOVIAL FLUID
• Fluid found around joints such as knee, ankle, hip,
elbow, wrist and shoulder
• Secreted by the cells of the synovial membrane in the
joint
• Functions: Supplies nutrients to the cartilage also acts
as a lubricant for the free movement
• Clinical significance – infections, hemorrhage,
degenerative disorders (arthritis), inflammatory
disease ,gout etc…
• The composition resembles other fluid in addition it
contain mucopolysaccaride and hyaluronic acid
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• Collection (Arthrocentesis) — needle
aspiration of joint fluid
1. Tube with EDTA –Used for cell counts and
microscopical examination
2. Tube with fluoride-oxalate mixture used for
glucose estimation
3. Plain tube – used for physical, chemical,
microbiological and serological examinations
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• Color and appearance
- Normally clear and straw colored and viscous
- Cloudiness- inflammation, crystals, fibrin, cartilage
fragments
- Turbid yellow- septic/non-septic inflammation
- bloody- hemorrharage in joints ,traumatic tap etc..
• volume – normally 1 ml, increases during
inflammation
• pH- 7.4
• specific gravity- <1.016
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• Viscosity test
- Evaluated using “String test”
- Normal = 5cm long before breaking
- Low viscosity indicates inflammation
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• Mucin clot test
- 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.
- Good = tight ropey mass with clear surrounding
- Fair = soft clot in a turbid solution
- poor= a friable clot with cloudy surrounding
- very poor = no clot formation
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• MICROSCOPIC EXAMINATION
– Cell counts
Reference range of SF leukocyte is 0-200/cumm.
Performing by using hemocytometer manually.
 highly viscose fluid may need to stand for 30 mts.
Bloody sample should be differentiated whether
traumatic tap or hemorrharage
 A very high count (>100,000/cumm) strongly
suggests bacterial infection.
Automated method also used (sysmax XT-4000)
unless it is highly viscous.
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• Differential count
 Method is same as csf
 The mean distribution : neutrophils- <25% lymphocytes -
24%, monocytes- 48%, macrophages- 10%, and synovial
lining cells 4%
 The routine differential count usually is reported only as
percentage of neutrophil
 The accepted upper limit is 25% neutrophils
 A very high percentage (>90%) neutrphils indicate bacterial
arthritis even if the TLC is in normal range
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• Crystals
• can be observe by wet preparation or after staining
the smear
• Mono sodium urates crystal – Gout
• Calcium pyrophosphate crystal – pseudogout
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• LE cell can be seen in SLE
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PLEURAL FLUID
• A transudate seen inside pleural cavity of lung
• Analysis is important to know the etiology of
pleural effusion
• PF is collected under aseptic precaution by
percutaneous puncture (thoracentesis)
• it is important to differentiate transude
effusion and exudate effusion
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 Normal PF is clear, pale yellow, scanty in
amount(20ml)
 increased volume seen in CCF , CLD etc…
 turbidity is usually due to increased leukocyte in
inflammation
Milky fluid in chylous or pseudo chylous effusion
It is important to distinguish hemorrhagic fluid
from blood-tinged fluid due to traumatic tap
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cont…
• Specific gravity: <1.018 indicate fluid is
transudate and >1.018 indicate exudate.
• clot formation indicates inflammatory cause
for effusion
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• MICROSCOPICAL EXAMINATION
– RBC count
– WBC count
– differential count
 WBC count of <1000 /cumm indicate it is a transudate
 WBC count of >1000 /cumm with >50% of neutrophils
suggest bacterial infection
 RBC count of >100,000 /cumm is highly suggestive of
malignancy, trauma or pulmonary infarction
 high percentage of lymphocytes suggests tuberculosis,
viral infection etc..
 presence of mesothelial cells should be report.
 Eosinophilic effusion(>10%) seen in pneumothorax,
parasitic infection, asthma , etc…
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• CHEMICAL EXAMINATION
– Estimation of protein
– Estimation of glucose
– Estimation of LDH
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PERITONEAL FLUID
Peritoneal cavity normally contain upto 50ml of
clear straw colored fluid
Patient with peritoneal effusion is said to have
ascitis and it is called ascitic fluid
The procedure of collecting the ascitic fluid is
called abdominal paracentesis
Indications: ascitis of unknown etiology, acute
abdominal pain, post operative hypotension,
intra abdominal hemorrhage etc…
Specimen collected into tubes same as for other
fluid
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 Color and appearance: normally clear and pale
yellow
 Turbid: appendicitis, pancreatitis etc..
 Green: intestinal perforation, cholecystitis
 Milky: nephrotic syndrome, carcinoma, parasitic
infection
 Bloody: hemorrhagic pacreatitis, reptured spleen
or liver
 Examine for clot formation
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• MICROSCPIC EXAMINATION
Total leukocyte useful in spontaneous bacterial
peritonitis (SBP)
Approximately 90% of (SBP) have leukocyte count
> >500/cumm and over 50% neutrophiles
Eosinophilia > 10% most commonly associates
with CHF, vasculitis, lymphoma and ruptured
hydatid cyst
 Mesothelial Cells: Associated with TB effusions
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• CHEMICAL EXAMINATION
Estimation of glucose-
decreased in peritonitis ,malignancy
Estimation of amylase
Increased in acute pancreatitis
Estimation of ALP
Elevated in intestinal perforation
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PERICARDIAL FLUID
• About 10-50 ml of fluid is normally present in the
pericardial space
• Accumulation of excess fluid- pericardial effusion
• Fluid is obtained by aspiration using a sterile
needle under aseptic condition called
pericardiocentesis
Color: straw colored clear normally
Cloudy/turbid: septic condition, chronic effusion
Blood tinged: traumatic tap
Milky effusion : TB ,leakage from thoracic duct.
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• MICROSCPIC EXAMINATION
Increased leukocyte (>1000/cumm) with a
predominant of polymorphs suggests bacterial
pericarditis
Predominance of lymphocytes indicate
tuberculous or viral pericarditis
Eosinophilia of pericardial fluid is rare.
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SPUTUM
Sputum is a colorless, watery , and odorless
tracheobronchial secretion.
This mucus-like secretion may become
infected, bloodstained, or contain abnormal
cells that may lead to a diagnosis
Normal sputum is a mixture of plasma, mucin,
electrolytes and water(95%).
The consistency of sputum determined by the
glycoprotein content and degree of hydration
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COLLECTION
Instruct the patient to rinse the mouth thoroughly
The sputum must be coughed up from the lungs
or the bronchi and should be collected in wide
mouth sterile container
Early morning sample : for routine examination
24 hr sputum sample : for demonstration of
tubercle bacilli by concentrating the sputum
sample
Induced sputum- by inhaling aerosol containing
NaCl and glycerin
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PHYSICAL EXAMINATION
Color – normally clear and colorless
Greenish – psuedomonas infection
Rust color- pneumonia and pulmonary infarction
Bright red- fresh blood due to TB ,tumors
Black – heavy smokers
Yellow- pulmonary infections (presence of pus)
Consistency and appearance- opalescent with slighty
uneven consistency normally
Serous -frothy colorless- pulmonary oedema
Purulent – ruptured empyma and bronchiectasis
Blood tinged – carcinoma , TB, pulmonary infarction
Mucoid ,tenacious- bronchitis, asthma , lobar pneumonia
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 Odor : odorless normally , suppurative condition makes putrid
odor
 Miscellaneous findings
Cheesy masses (fragments of necrotic tissue) –in TB
Bronchial casts – bronchitis, bronchiolitis or pneumonia
Broncholiths(lung stones)- cavitary TB, chronic fungal
infection
Dittrich’s Plug- putrid bronchitis and bronchiectasis
Forign bodies also can observe in certain situation
Parasites are rarely seen
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MICROSCOPICAL EXAMINATION
3-4 smear are made on a clean , dry glass slides
and allow to dry at room temperature
One for Gram’s stain
One for AFB
One stain with Leishman’s for differential count
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Unstained /stained preparation
Pus cells- numerous number indicate pyogenic
infection
RBC-many, indicate inflammation or hemorrhage
Heart failure cells-pulmonary congestion, hemorrhage
curschmann’s spirals- bronchial asthma
Carbon laden cells- anthrocosis.
Elastic fibers- breaking down of lung parenchyma
Charcot laden crystals- bronchial asthma
Cholesterol crystals- empyma ,chronic TB
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Cruschmann’s spirals
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Charcot laden crystal
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BRONCHO ALVEOLAR LAVAGE (BAL)
 Bronchoalveolar lavage (BAL) is a medical procedure in
which a bronchoscope is passed through the mouth or
nose into the lungs and fluid(Saline) is squirted into a
small part of the lung and then recollected for
examination
 BAL is typically performed to diagnose infections in
people with immune system problems, pneumonia in
people on ventilators, lung cancer, scarring of the lung
(interstitial lung disease)
 It provides important information about immunologic,
lnfectious processes taking place at the alveolar level
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Processing
• PHYSICAL FINDINGS
– Volume
– Appearance
• MICOSCOPICAL EXAMINATION
– Total count
– Differential count
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• BAL in healthy non-smokers
Macrophages > 80 %
 Lymphocytes < 10 %
 Neutrophils < 1 %
 Clean background
 Epithelial cells < 5 %
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 Increased lymphocytes seen in sarcoidosis and hypersensitivity
pneumonia
 Neutrophilia seen in acute respiratory distress Syndrome, bacterial
infection, lung fibrosis
 Macrophages may show nuclear abnormality (multi -nucleation) in
inflamation , granulomatous reaction
 Macrophages also show inclusions inside the cytoplasm due to
-Smoking
-Asbestosis
-Histoplasma capsulatum
- hemosiderin
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• Reference
1) Text book of clinical diagnosis & management, John Bernard Henry
2) Text book of Medical Laboratory Technology, Praful B, Godkar
3 ) Text book of Medical Laboratory Technology, Ramnik Sood
4) Graff’s Textbook of Routine Urinalysis and Body Fluids
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