1. Cytology of body fluids involves examining fluids from various body cavities including cerebrospinal fluid, pleural fluid, peritoneal fluid, pericardial fluid, and synovial fluid. Specimen collection and laboratory analysis includes gross examination, cell counts, biochemical analysis, and microscopic examination. 2. Transudates and exudates are distinguished based on characteristics like protein content and cell differentials. Infection, inflammation, and malignancy can be identified by analyzing changes in fluid characteristics. 3. Cytology of body fluids provides diagnostic information for conditions affecting various organ systems. Proper collection and analysis of physical and chemical properties aids in differential diagnosis.

1. CYTOLOGY OF
BODY FLUID
DR SHABNEEZ HUSSAIN
HAEMATOLOGY RESIDENT

3. CAVITY FLUIDS
 Abdominal 􀂄 Pleural 􀂄 Pericardial 􀂄
Synovial 􀂄 CSF

4. Schematic representation of the three body cavities

5. CAVITY FLUIDS
 Sampling techiques
 appearance during collection EDTA to
prevent clotting
 direct smear -
 delayed processing
 Cell concentration
 Protein concentration

6.  TRANSUDATE
 EXUDATE
 MODIFIED TRANSUDATE

7. 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

8. 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

9. 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

10. 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

11.  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

12. 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

13. SAMPLE COLLECTION
 FNA of effusion fluids
 Tapping

14. Collection and preparation of specimen

15. 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

16. 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.

17. 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)

18.  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

33. 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

34. 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.

35.  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

36.  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.

37. 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

38. 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)

39. 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)

40. 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

41. WBC’S
 Infection!
 PMN predominance: likely bacterial meningitis
 Lymphocytic predominance: viral vs. fungal vs.
TB vs. malignancy

42. 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)

43. GLUCOSE
Normal
 Viral infection
Low glucose
 Bacterial meningitis, TB, fungal
Really low
 <18 is strongly suggestive of bacterial meningitis

44. TYPICAL VIRAL MENINGITIS
 CSF WBC elevated, but <250 (first PMNs, then
lymphocytes)
 CSF protein elevated, but <150
 Glucose > 50% of serum concentration

45. TYPICAL BACTERIAL MENINGITIS
 CSF WBC >1000, PMN predominance
 CSF protein >500mg/dl
 CSF glucose <45 mg/dl

46. • Effusion:
• Transudate
• Exudates
• Lab analysis: Gross exam, cell count, etc.
• Differential: PMN, Lymph, Mono, etc.
2- Pleural Fluid: Lung fluid

47. • 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.

48. 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

49. 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

50. 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

51. EXUDATE
Caused by local, not systemic, factors
 Infection
 Neoplasm
 Pancreatitis
 Esoph perf
 RA
 SLE
 Sarcoid, Wegeners, PE, Meig’s,
Chylothorax

52. LYMPHOCYTOSIS
 Malignancy (50-70% lymphs)
 Also TB, sarcoid, RA, chylothorax (>90% lymphs)

53. PLEURAL EOSINOPHILIA
 Pneumothorax
 Hemothorax
 Pulm infarct
 Parasitic disease
 Fungal infection
 Drugs
 Malignancy
 Asbestos

54. WHY IS GLUCOSE LOW?
(<60)
 RA
 TB
 Empyema
 SLE
 Malignancy
 Esophageal rupture

55. 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.

56. 
Removal procedure- paracentesis
 Lab analysis: distinguish between transudate and exudates,
gross exam, cell count, sedimentation, chemical analysis

57. 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.

58.  Lymphocytes: CHF, liver cirrhosis, nephrotic syndrome
 Mesothelial Cells: Associated with TB effusions
 Malignant cells: seen with malignancy

59. WHAT TO SEND FLUID FOR
 Cell count with diff
 Albumin
 LDH
 Total protein
 glucose
 Gram stain/cx
 cytology

60. 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

61. 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

62. 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

63.  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

64.  Measure pH: pH less than 7.0 associated with infection or
rheumatoid disorder.
 Cell count: see limited RBCs and WBCs
Evaluate sedimentation

65. • 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

66. • 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:

67. • 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

68. THANK YOU