Body Fluids.ppt for healthy students ppt

Body Fluids
By:- Abinet T.(BSc, MSc)
2/28/2024 Body Fluids 1

Chapter outline
 Introduction to body fluids
 Types of body fluids
 Cerebrospinal fluid analysis
 Synovial fluid analysis
 Serous (pleural, pericardial and peritoneal) fluid analysis
 Semen analysis
 Amniotic fluid analysis
 Routine laboratory assays
 RBC and WBC counts
 Chemical analysis
 Morphological, Microbiological and Serological Examination
 Quality control in body fluid analysis

Cerebral Spinal Fluids

Learning Objectives
 Upon completion of this chapter the student will be
able to:
 Describe the formation of CSF from blood.
 Describe cellular neurochemistry and the function of
the choroids plexus.
 Discuss diffusion mechanism across the blood brain
barrier: simple diffusion, carrier mediated diffusion,
and active transport.
 Explain the mechanism of glucose uptake into the
brain.
 List the function of amino acids in CSF formation.

Learning Objectives (continued)
 Compare the difference of pathological conditions
associated with the types of cells observed in a CSF.
 List the normal range of glucose, protein, and cell
count for a CSF.
 Evaluate abnormal laboratory results with a
pathological condition related to CSF.
 Discuss appropriate collection requirements for CSF
following a lumbar puncture.

Cerebrospinal fluid analysis
 Collection of CSF sample
 Routine Laboratory assays of CSF
 RBC &WBC counts
 Morphological Examination
 Microbiological Examination
 Serological Examination

Cerebrospinal fluid (CSF)
 Fluid in the space called sub-arachnoid space between
the arachnoid mater and pia mater
 Protects the underlying tissues of the central nervous
system (CNS)
 Serve as mechanical buffer to
 prevent trauma,
 regulate the volume of intracranial pressure
 circulate nutrients
 remove metabolic waste products from the CNS
 Act as lubricant
 Has composition similar to plasma except that it has
less protein, less glucose and more chloride ion

CSF cont’d
 Maximum volume of CSF
 Adults 150 mL
 Neonates 60 mL
 Rate of formation in adult is 450-750 mL per day or 20 ml
per hour
 reabsorbed at the same rate to maintain constant
volume
 Collection by lumbar puncture done by experienced
medical personnel
 About 1-2ml of CSF is collected for examination
 lumbar puncture is made from the space between the 4th
and 5th lumbar vertebrae under sterile conditions.

Fig. Collecting a CSF specimen
Location of CSF
 Collected in three
sequentially labeled tubes
 Tube 1 Chemical and
immunologic tests
 Tube 2 Microbiology
 Tube 3 Hematology
(gross examination,
total WBC & Diff)
 This is the list likely
to contain cells
introduced by the
puncture procedure

Lab analysis
Clinical Significance
 Diagnosis of meningitis of bacterial, fungal, mycobacterial
and amoebic origin or differential diagnosis of other
infectious diseases
 subarachnoid hemorrhage or intracerebral hemorrhage
Principle of the test
 CSF specimen examined visually and microscopically and
total number of cells can be counted and identified
Specimen: the third tube in the sequentially collected tubes*
 must be counted within 1 hour of collection (cells
disintegrate rapidly). If delay is unavoidable store 2-8oC.
 All specimens should be handled as biologically
hazardous

Uptake and Utilization of Glucose
 Glucose is major energy substrate for brain as
well as a major carbon source for many
molecules.
 Brain uses 20-25% of total oxygen and 15% of
cardiac output is directed to CNS.

Glucose Utilization
 When body glucose supply is decreased, other
organs decrease glucose utilization to maintain
adequate supply of glucose to brain.
 Other organs can readily switch to oxidation of
another substrate for energy production.
 Under certain conditions, such as chronic
starvation, the brain can oxidize other
substances but maintains a minimal obligatory
requirement for glucose.

Brain Utilization of Glucose
 Glycolysis--conversion to lactic acid
 Hexokinase has high activity in brain
 Serves to trap glucose and maintain concentration
gradient for diffusion

Microscopic
Observations of Cerebral
Spinal Fluid

Ependymal Cells
 Cells lining the ventricles (ependymal) or choroid plexus
may be shed into the CSF
 Single or in clumps
 Nuclei are round to oval with a definitive smooth nuclear
membrane
 Chromatin is distributed evenly and is finely granular or
hyperchromatic
 Nucleoli are not present
 The cytoplasm can be basophilic or pink. Microvilli may
be present.

Neutrophils and Bands
 Morphologically identical to neutrophils and
bands in blood
 Occasionally granulation disappears and
pseudo-hypersegmentation is observed.

Lymphocytes
 Almost identical morphology to lymphocytes in
the blood
 Due to "flattening-out" of the lymphs during
cytocentrifugation, nucleoli may be visible.
 Found in all fluid

Macrophages
 Leukophages:Macrophagescontaining
phagocytized WBC. WBCs are often pyknotic
and easily confused with NRBC's. Found in all
fluids.
 Erythrophages: Macrophages containing
phagocytized RBC or RBC fragments. May
contain several RBC. Found in all fluids.
 Siderophages: Macrophages containing
phagocytized particles of hemosiderin, which
stain a blue-black color.

Immature Granulocytes
 Metamyelocytes, myelocytes, and
promyelocytes may be found in fluids, though
they are rarely seen.
 They are morphologically identical to those in
the blood
 May be due to bone marrow contamination in
CSF

Blasts
 Morphologically similar to blasts found in the
blood
 There may be some clover-leaf shaped nuclei
due to cytocentrifugal distortion.
 May be found in all fluids
 Seen in association with leukemias, lymphomas
 Bone marrow contamination of CSF

Nucleated Red Blood Cells
 NRBC are rarely seen body fluids. If observed,
they should be reported as the number of NRBC
per number of WBC counted
 They must be differentiated from pyknotic WBCs
 NRBC’s are commonly due to peripheral blood
or bone marrow contamination of CSF

Abnormal Lymphocytes
 Plasmacytoid lymphs: Identical in morphology to
plasmacytoid lymphs in blood
 Found in all fluids.
 Mott cells: Plasma cells with numerous clear
cytoplasmic vacuoles containing
immunoglobulins

Reactive Macrophages
 These are most common in CSF from small
children with subarachnoid hemorrhage but may
be found in all body fluids
 May be very difficult to distinguish
morphologically from large atypical lymphocytes

Malignant Cells
 Malignant cells may be shed from solid tissue
(non-hematopoietic) neoplasms into CSF or
body cavity fluid submitted for cell counts
 Fluid will be turbid or bloody
 Malignant cells are usually seen in clusters of 3-
5 or more, but may occur singly

Microorganisms
 Intracellular bacteria or yeast can be observed in
acute bacterial or fungal infections
 It is important to coordinate your findings with
those of the Microbiology Section of the
laboratory

Bloody CSF
 When the CSF is pinkish red, this usually
indicates the presence of blood, which may have
resulted from:
 Sub arachnoid hemorrhage
 Intra cerebral hemorrhage
 Infarct
 traumatic tap

Order of Draw of Lumbar Puncture
 1st - Chemistry
 2nd - Microbiology
 3rd - Hematology

Physical Examination
 Color – Xanthochromia
 Hyperbilirubinemia
 Increased Protein
 Turbidity
 Increased White Blood Cells (Pleocytosis)

CSF Supernatant
 A traumatic tap shows progressively decreasing
RBC in serial samples
 Generally, in subarachnoid hemorrhage, the
RBC would be consistent from one tube to the
next

CSF Supernatant
 After the CSF is centrifuged, the supernatant
fluid is clear in a traumatic tap, but it is
xanthochromic in a subarachnoid hemorrhage
 Xanthochromia of the CSF refers to a pink,
orange, or yellow color of the supernatant after
the CSF has been centrifuged

Cell Count
 The white cell count is increased when there is
inflammation of the central nervous system,
particularly the meninges
 Bacterial infections are usually associated with
the presence of neutrophils in the CSF

Cell Count
 Viral infections are associated with an increase
in mononuclear cells
 An increase in mononuclear cells may also be
seen with:
 cerebral abscess
 acute leukemia
 Lymphoma
 intracranial vein thrombosis
 cerebral tumor
 multiple sclerosis

CSF Normal Adult Lab Ranges
 Normal CSF Levels:
Protein (10 - 45 mg/dL)
Glucose (40 - 70 mg/dL)
 Physical Appearance
Clear/colorless
RBC <5/mL
WBC <5/mL

Increased CSF Protein >80mg/dL
 Diabetes Mellitus
 Brain tumor
 Meningioma
 Acoustic neuroma
 Ependymoma
 Encapsulated brain abscess
 Spinal cord tumor
 Acute purulent Meningitis

Increased CSF Protein >80mg/dL
 Granulomatous Meningitis
 Carcinomatous Meningitis
 Syphilis (protein may be normal if longstanding)
 Guillain-Barre Syndrome (Infectious polyneuritis)
 Cushing's Disease
 Connective tissue disease
 Uremia
 Myxedema
 Cerebral hemorrhage

Glucose
 Low glucose levels, as compared to plasma
levels, are seen in:
 bacterial meningitis
 cryptococcal meningitis
 malignant involvement of the meninges and
sarcoidosis
 Glucose levels are usually normal in viral
infections of the CNS

Glucose
Increased CSF Glucose
 Reflects serum hyperglycemia
 CSF glucose lags Serum Glucose by 1 hour
 CSF glucose is two thirds of Serum Glucose

Lactate
 In bacterial and cryptococcal infection, an
increased CSF lactate is found earlier than a
reduced glucose
 In viral meningitis, lactate levels remain normal,
even when neutrophils are present in the CSF
 Raised levels may also occur with severe
cerebral hypoxia or genetic lactic acidosis

Semen analysis

Semen analysis
 Used in the evaluation of reproductive dysfunction
(infertility) in the male
 Used to select donors for therapeutic insemination
 Is a cost-effective and relatively simple procedure.
 Consists of microscopic and macroscopic components

Collection and transport of semen
1. Give the person a clean, dry, leak-proof container,
and request him to collect a specimen of semen at
home following 3 days of sexual abstinence
 condom is used to collect the fluid, this must be well-
washed to remove the powder which coats the rubber.
 It must be dried completely before being used.

Collection and transport, cont’d…
2. Lable the container (name ,date and time of
collection, period of abstinence
 Deliver the specimen to the laboratory within 1 hour
 Fluid should be kept as near as possible to body
temperature.
 This is best achieved by placing the container inside a
plastic bag and transporting it in the person's armpit . .

Tests for semen
 Macroscopic
-Physical (volume, viscosity, liquefaction)
-chemical (eg. ph)
 Microscopic
-stained preparation
- wet-mount

Semen analysis
 When investigating infertility, the basic analysis of
semen (seminal fluid) usually includes:
 Measurement of volume
 Measurement of pH
 Examination of a wet preparation to estimate the
percentage of motile spermatozoa and viable forms and
to look for cells and bacteria.
 Sperm count
 Examination of a stained preparation to estimate the
percentage of spermatozoa with normal morphology.

EXAMINATION OF SEMEN
Caution: Handle semen with care because it may
contain infectious pathogens, e.g. HIV, hepatitis
viruses, herpes viruses.

Macroscopic Examination
Measure the volume
 Normal semen is thick and viscous when ejaculated.
 It becomes liquefied usually within 60 minutes due to a
fibrinolysin in the fluid.
 Failure to liquefy may indicate inadequate prostate
secretion.
 When liquefied, measure the volume of fluid in millilitres
using a small graduated cylinder.
 Normal specimens: Usually 2 ml or more

Macroscopic Examination, cont….
Measure the pH
 Using a narrow range pH paper, e.g. pH 6.4–8.0, spread
a drop of liquefied semen on the paper.
 After 30 seconds, record the pH.
 pH of normal semen: Should be pH 7.2 – 7.8
 When the pH is over 7.8 this may be due to infection.
 When the pH is below 7.0 and the semen is found to
contain no sperm, this may indicate dysgenesis (failure
to develop) of the vas deferens, seminal vesicles or
epididymis.

Synovial Fluid

Synovial Fluid
Definition:
 Synovium refers to the tissue lining synovial
tendon sheaths, bursae, and diarthrodial joints
except for the articular surface.
 Synovial fluid (synovia, SF) is an imperfect
ultrafiltrate of blood plasma combined with
hyaluronic acid produced by the synovial cells.

Synovial Fluid cont’d
 Small ions and molecules (e.g., Na+, K+, glucose,
urea, etc.) readily pass into the joint space and are,
therefore, similar in concentration to plasma, while
large molecules are absent or present in trace
amounts

Classification of Synovial Fluid
Non inflammatory effusions (Group I)
 Typically have leukocyte counts less than
3000/μL, with a minority of neutrophils..
 Non inflammatory response*
 Non inflammatory effusions**
*Examination of the synovial fluid is essential to
distinguish infectious from noninfectious arthritis

Inflammatory effusions (Group II)
 have leukocyte counts 3000 - 75 000, with neutrophils
accounting for over 50% .
 Examples of this reaction group:
 Rheumatoid arthritis
 systemic lupus erythematosus (SLE)
 Reiter's syndrome
 rheumatic fever
 acute crystal-induced arthritis
 arthritis associated with inflammatory bowel disease
 psoriatic arthritis
 fat droplet synovitis

Purulent (infectious) effusions (Group III)
 typically have leukocyte counts greater than 50,000, of
which 90% or more are neutrophils.
 Bacterial, fungal, and tuberculous joint infections
constitute this group.

Hemorrhagic effusions (Group IV)
 WBC count between 50–10,000WBC/ mL, with < 50%
neutrophils
 RBCs may be present
 may be seen in association with:
 traumatic arthritis
 pigmented villonodular synovitis
 synovial hemangioma
 neuropathic osteoarthropathy
 joint prostheses
 hematologic disorders (hemophilia,
thrombocytopenia, anticoagulant therapy, sickle cell
disease or trait, myeloproliferative syndrome).

Synovial Fluid Findings by Disease Category
Category
Finding Normal Group I Non-
inflammatory
Group II Inflammatory Group III
Infectious
Group IV
Hemorrhagic
Clarity Transparent Transparent Transparent/
opaque
Opaque Opaque
Color Clear to pale
yellow
Xanthochromic Xanthochromic to
white/bloody
White Red-brown or
xanthochromic
WBCs/mL 0–150 < 3000 3000–75 000 50 000–200
000
50–10 000
PMNs (%) < 25 < 30 > 50 > 90 < 50
RBCs No No No Yes Yes
Glucose
(blood/SF
difference
mg/dL)
0–10 (0–0.56
mmol/L)
0–10 (0–0.56 mmol/L) 0–40 (0–2.2 mmol/L) 20–100 (1.11–
5.5 mmol/L)
0–20 (0–1.11
mmol/L)

Recommended Tests
 Major importance to differentiate crystal-induced joint
disease from infectious arthritis.
 When either disease is suspected perform:
 Arthrocentesis
 systematic examination of the synovial fluid
 Examination diagnostic if performed correctly
 In other joint diseases a specific diagnosis may not be
possible
Note: Fluid examination is important if only to rule out
infectious arthritis, which is a critical diagnosis to make
as a joint may be irreversibly damaged within 48 hours if
not properly treated

Microscopic Examination
 Total Cell Count
 Should be done within 1 hour following
arthrocentesis to avoid degenerative cell loss.
 Cell counts are usually performed in a standard
hemocytometer and Automated cell counters**

Microscopic Examination, cont’d…
 A wet-prep slide count of 0-2 WBCs /HPF (averaged
over 10 fields) predicts less than 1300 WBCs by cell
count
 Leukocyte counts > 10 000/μL, and often > 50 000/μL,
are characteristic of:
o crystal-induced arthritis(e.g., gout, pseudogout)
o chronic inflammatory arthritis (e.g., rheumatoid arthritis
o systemic lupus erythematosus
o ankylosing spondylitis, and others)
o septic arthritis

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