Urinalysis and Body Fluids
CRg
Unit 4
Serous Body Fluids
Serous Fluids
• Serous fluids
• small amount of fluid that lies between the
membranes lining the body cavities (parietal)
and those covering the organs within the
cavities (visceral).
• acts as lubricant,
• provide nutrients,
• remove wastes
Serous Fluids
•
Body cavities
• Pericardial - heart
• Pleural - lungs
• Peritoneal – abdominal
•
Membranes
•
•
•
•
Lined with mesothelial cells
Parietal – lines cavity wall
Visceral – covers organs contained within
Serous fluids fill the space between
Serous Fluids
• “ultra filtrate” of the plasma
• closely resembles the plasma
(as opposed to CSF)
Appearance
Possible reason / condition
Pale yellow & clear
Normal
White, turbid
WBCs / infection
Bloody
RBCs/ hemorrhage
Milky
Chyle – lymph & emulsified fats
Viscous
Increased hyaluronic acid / malignant mesothelialoma
Serous Fluids
•
Produced by hydrostatic and oncotic
(protein) pressure in the capillaries lining
the membranes
• Normally produced at a constant rate.
• Production (☛ parietal membrane)
• Re-absorption (☛ visceral membrane)
Serous Fluids
•
Production and re-absorption are influenced
by:
• Changes in osmotic and hydrostatic pressure in the
blood
• Concentration of chemical constituents in the
plasma
• Permeability of blood vessels and the membranes
Serous Fluids
•
Types of serous fluids
• Pericardial fluid – around heart
• Pleural fluid (thoracic fluid) – lung cavity
• Peritoneal (ascitic fluid) – abdominal cavity
•
Reasons for analysis
• Infections
• Hemorrhages
• malignancies,
• and other disorders.
Serous Fluids
• Specimen Collection and Handling
• Needle aspiration
• Paracentesis
• Thoracentesis
• Pericardiocentesis
• Lavage ( ie. peritoneal lavage)
• Ringer’s lactate / saline is infused into abdomen
then retrieved for analysis.
• Specimen sometimes called ascites fluid.
Serous Fluids
- Composition & Formation
•
Effusion
• an increase in the serous fluid due to some
disruption in production &/ re-absorption
processes.
• Classification of cause of an effusion is aided by
determining if the fluid is a “transudate” or an
“exudate”.
Serous Fluids
- Effusion
•
Transudate
• an effusion that is a result of a systemic disorder
that disrupts the balance of fluid production /
fluid re-absorption.
• Examples:
• Pleural transudate – congestive heart failure;
• Pericardial transudate – nephrotic syndrome,
metastatic cancer
Serous Fluids
•
Exudates
• term to classify the effusion that is a result of a
problem with the membranes themselves.
• Produced by conditions that directly involve the
membranes of the particular cavity, ex. infections,
inflammation, and malignancies
• Thought of as an inflammatory process
• Exudate examples:
• Pleural exudate – carcinoma, pneumonia, trauma
• Pericardial exudate – infection, cardiovascular disease
(CV) trauma, cancer
Differentiation Between Transudates and Exudates
CHARACTERISTIC / TEST
TRANSUDATE
EXUDATE
Color
Pale yellow
Any abnormal color
Clarity
Clear
Bloody cloudy, purulent, turbid
Specific gravity
< 1.015
>1.015
Glucose
Equal to serum
Over 30 mg less than serum level
Protein
<3.0 g/dL
>3.0 g/dL
Fluid / serum protein ratio
<0.5
>0.5
Fibrinogen / Spontaneous clotting
No
Possible
Fluid / serum amylase
<2.0
>2.0
Fluid / serum bilirubin ratio
<0.6
>0.6
Lactate dehydrogenase
< 60% of serum
> 60% of serum
Fluid/ serum LD ratio
<0.6
>0.6
Cell counts (total)
<300/L
>1000/L
Serous Fluids
•
Specimen Collection and Handling
• EDTA tube for cell count & differential
• Heparin tube for chemistries, serology,
microbiology and cytology.
• Since procedure not performed unless an effusion
exists, large amount of fluid often collected.
• Blood specimens usually collected at same time and
comparisons of test results made.
Serous Fluids - Testing overview
• Variety of tests used to aid in determining the
cause of the effusion
• Appearance
• Evaluation of clotting ability whether or not it will form a
clot, etc.
• Cell counts
• Protein level
• Both fluid and current serum level to make comparison:
fluid protein / serum protein
• LDH enzymes
• Both fluid and current serum level to make comparison:
fluid LDH/ serum LDH
• Cultures
• Serology – rarely done on serous fluids as blood testing is
adequate
• Cytology / Pathology – if malignancy is suspected.
Serous Fluids
•
Hematology / Gross examination
• Color & clarity
• NV = yellow & clear (other terms as for CSF are
sometimes used, EXCEPT ‘xanthrochromic’
• Cell count
• same as for CSF
• Differential
• any cell in peripheral blood,
• mesothelial cells,
• malignant cells
Serous Fluids
z
1991 CAP CM 20
Abdominal fluid
– plasma cells / multiple myeloma
Mesothelial cells
•
•
•
•
•
Unique to serous fluids, originate from lining of peritoneal,
pleural, and pericardial cavities.
Large round cell with abundant blue cytoplasm and purple
nucleus which may be eccentric
Cell sometimes described as having a "fried egg" appearance. usually are single or may be in sheets
Nucleus round to oval & has a smooth outline, takes up @ 1/3 ½ of the space.
Smooth spherical nuceoi may be seen.
Mesothelial cells
•
•
•
•
Pleomorphic
If ‘reactive’ may appear in clusters, have prominent nucleoli
and be multinucleated
Nucleus still distinct and round with uniform staining
characteristics.
A cluster of reactive mesos may resemble malignant cell
clusters, but the mesos display "cell windows."
Reactive mesothelial cells
Serous Fluids
•
Macrophage engulfed Candidia species in a pleural fluid, mesothelial
cells.
Serous Fluids
• Malignant cells
• A frequent concern in any serous fluid due to possibility of
cancer of any organ and/or metastasis of CA from one
location to another.
• Cells have irregular size, shape, and staining characteristics
of nucleus and cytoplasm. Usually deeply basophilic, molded
or balled up clusters of cells with little distinction from one
cell to the next. May be vacuolated.
Serous Fluids
• Malignant cells
• Characteristics
•
•
•
•
•
Irregular shape
Uneven chromatin distribution
Prominent large irregular nucleoli,
Community borders
Increased nuclei / cytoplasm ratio.
• Always send suspicious cells to cytology /
pathology
Serous Fluid Malignant cells
• ACSP 7, Case 1 peritoneal fluid, malignancy
Serous Fluid Malignant cells
• ASCP 9 Case 2 pleural fluid 42 year old, breast cancer
Serous Fluid Malignant cells
•
ASCP 10 Case 3, ascitic fluid, 62 year old admitted for GI bleeding
Serous Fluid Malignant cells
•
ASCP 12 Case 4, 30 year old with back pain and inability to work. Pleural
effusion fluid – malignant tumor on spinal cord
Serous Fluid Malignant cells
•
•
sheets of atypical cells with irregular nuclear contours, nuclear
hyperchromasia, basophilic cytoplasm, and jagged outline of cell borders.
Squamous cell carcinoma (x400 , Diff-Quik staining)
Serous Fluids-LE cells
•
•
Seen in patients with Systemic Lupus Erythmatosis (SLE) a
systemic disease in which an autoantibody attacks the patients
organs and body systems
LE cell is a neutrophil that has engulfed a homogeneous mass
of purple staining nuclear material
Serous Fluids
•
Chemistry
•
•
•
•
•
Total protein, and ratio to serum protein
LDH and ratio to serum LDH
Glucose
Amylase & Lipase – pancreatic disorders
Bilirubin - peritoneal fluid
• suspicion of perforated GI or gall bladder
• Alkaline phosphatase - peritoneal fluid
• suspicion of perforated intestine
• pH & ammonia
Serous Fluids
• Microbiology
• Gram stain & acid fast
• Cultures – aerobic & anaerobic
Serous Fluids – pericardial fluid
z 1987 CAP CM21 Pericardial fluid, intracellular bacteria
Serous Fluids – peritoneal fluid
z
1992 CAP CM41 Peritoneal fluid. Seg, macro, yeast
Serous Fluids
• Quality control
• no commercial controls
• use serum controls.
Summary
• Serous fluids are serum-like ultrafiltrates of plasma
• Volumes are maintained by tissue and capillary pressures
• Effusions are excessive accumulations of fluids – and can occur in
the pericardium, pleural and abdominal cavities.
• Laboratory testing is required to differentiate exudates from
transudates.
• Various causes contribute to the accumulation of fluids in the
serous body cavities.
• Laboratory testing
• Hematology (physical properties, cell counts and differential)
• Chemistry (serum &fluid values are compared. QC is same as for serum)
• Serology – rarely
• Cytology – if suspicious cells are seen during differential
Urinalysis and Body Fluids
Unit 4
Synovial Fluid
CRg
Synovial Fluid
• Composition and formation
• Secreted by cells of synovial membrane
• Very viscous, clear ultrafiltrate of plasma
• Contains
•
•
•
•
Hyaluronic acid
Mucopolysaccharides
Limited amount of plasma protein
Glucose & uric acid levels equivalent to plasma
Synovial Fluid
• Functions
• – supplies nutrients
• - lubrication of joint
• Reasons for analysis
•
•
•
•
Infection
Hemorrhage
Degenerative disorders (arthritis)
Inflammatory disease (SLE)
Synovial Fluid
• Collection
• Arthrocentesis
Synovial Fluid
• Collection
• Tubes
• Heparin – chemistries, immunological tests
• Sterile tube – culturing and crystal evaluation
• EDTA – hematology
Laboratory Testing
Macroscopic
Microscopic
Chemical
Other
Volume
Cell counts
Protein
Aerobic
culture
Color & Clarity
Differential
Glucose
Anaerobic
culture
Inclusions
Crystals
Uric Acid
Viscosity
Cytology
Lactic Acid
Clotting
LDH
Mucin Clot
Rheumatoid Factor
Classification of Synovial Fluid
• Normal
• Non-Inflammatory
• Degenerative joint diseases
• Inflammatory
• Immunologic disorders
( ie lupus, RA, gout crystals, ETC)
• Septic
• Microbial infections
• Hemorrhagic
• Traumatic injury, tumors, hemophilia,
anticoagulant overdose, etc.
Synovial Fluid - Laboratory procedures
• Hematology
• Physical properties
• Color & clarity = light yellow / straw & clear
• Abnormal colors/ clarity as for other fluids *
• Bloody
o Hemarthrosis
o Traumatic tap
• White / opaque with turbidity
o Indicate pus cells or debris
• Xanthrochromia term not used!
Synovial Fluid - Laboratory procedures
•
Physical properties
• Viscosity
• Screening – ‘String Test’ drop from pipette
• Evaluates viscosity
• Normal = @ 5+ cm long before breaking
• Rope’s test for mucin clot
• measures degree of hyaluronate polymerization
• Good / normal = tight ropey mass
• Poor = appears friable or fails to form
Synovial Fluid - Laboratory procedures
• Hematology
• Cell counts
• 0 RBCs / uL
• <200 WBC / uL
• Must let hemacytometer sit longer to allow cells to
settle before counting.
• If dilution needed must use saline
If you use diluent with an acid, such as Unopettes, the sample will clot.
Synovial Fluid - Laboratory procedures
• Cell differential - Wright’s stain
• Cells of peripheral circulation
•
•
•
•
neutrophils 7%,
lymphocytes 24%,
Monocytes 48%, macrophages 10%,
and synovial lining cells 4%.
Synovial Fluid - Laboratory procedures
•
Synovial lining cells
• (look somewhat similar to mesothelial cells)
Synovial Fluid - Laboratory procedures
• LE cells
• Tart cells
Synovial Fluid - Laboratory procedures
• Other cells
• Reiter cells
•
• Malignant cells
• Organisms
Synovial Fluid - Laboratory procedures
•
Microscopic exam for crystals
• Use regular and polarized light
• Crystals may be intra-cellular or extra-cellular
•
•
•
•
•
Monosodium urate – gout artheritis
Calcium pyrophosphate – pseudo gout
Cholesterol – non specific; chronic inflammatory
Apatite – calcific artheritis (mineral change in cartilage)
Corticosteroid – drug injections
Synovial Fluid - Laboratory procedures
• Chemistries
• Total protein NV =
1.07 – 2.13 g/dL
• Increases seen in inflammatory conditions and following
joint hemorrhage .
• Glucose - similar to current blood level
• Decreased in inflammation or sepsis
• Lactate – assist in differentiation of septic
and inflammatory arthritis
• Uric acid – increased in gouty arthritis.
• if gout is suspected, but no crystals, may need
uric acid level.
Synovial Fluid - Laboratory procedures
• Microbiology
• Gram stain, acid fast stain & cultures
• Certain organisms associated with age
groups
• Children - H. influenzae
• Adults 16-50 – Staph., Strep. Pneumoniae,
Strep pyogenes, Neisseria gonorrhea
• Adults > 50 – Staph. aureus
Synovial Fluid - Laboratory procedures
• Serology
• Serum results more reliable, so not often
done for diagnosis of RA or LE
• Autoantibodies
• Complement levels
• QC – no commercial controls available, use
serum controls if appropriate
Synovial fluid classification
Classification of Synovial Fluid by Test Results
Normal
Noninflammatory
Inflammatory
Septic
Hemorrhagic
Volume
< 3.5 (mL)
> 3.5 (mL)
> 3.5 (mL)
> 3.5 (mL)
> 3.5 (mL)
Color
Straw
Straw / yellow
Yellow
Variable
Red
Clarity
Clear
Clear
Cloudy
Cloudy
Variable
Viscosity
High
High
Low
Variable
Low
Cell count/uL
< 200
200-2,000
2,000-75,000
> 100,000
Same as bld.
% PMNs
< 25 %
< 25 %
> 50 %
> 75%
Same as bld.
Gram stain /
culture
Negative
Negative
Negative
> 50% Pos
Negative
Crystals
Negative
Negative
Frequently
Negative
Negative
Degenerative
joint disease
Immunologic
disorders- LE,
RA, Gout,
pseudo gout
Nongonococcal
or gonoccal
septic
arthritis
Trauma,
hemophilia,
Anticoagulant
overdose,
etc.
Associated
condition
Review of Key Points
•
Synovial fluid analysis
-
-
Plasma ultrafiltrate secreted by synovial membrane
Hyalurinic acid and mucopolysaccharides make it viscous
Lubricates and nourishes joints
Infection, hemorrhage, degenerative & inflammatory diseases are
reasons for analysis
Collection is by arthrocentesis
EDTA (hematology), heparinized (chemistries and serology) and
sterile (cultures and crystals) are collected
Straw yellow , clear and viscous are normal characteristics
0 RBC and < 200 WBC/uL are normal
Cell counts requiring dilution must be made with saline.
Any peripheral circulating cell can be seen as well as synovial lining
cells in normal patients.
Abnormals are classified as non-inflammatory, inflammatory, septic
or hemorrhagic
Synovial Fluid - Laboratory procedures
•
1989 CAP CM 23 Synovial fluid, segs, & macrophages
Synovial Fluid - Laboratory procedures
• Lupus erythematosus (LE) cells
• Just below center of field
• Neutrophil has engulfed a homogenous nuclear mass.
• ASCP 130 synovial fluid with LE cell
Synovial Fluid - Laboratory procedures
• Lupus erythematosus cell –
far right side @ 3 o’clock
Synovial Fluid - Laboratory procedures
• 1993 CAP CM 21 synovial fluid. Segs and leukophage
Synovial Fluid - Laboratory procedures
• 1993 CAP CM 20 synovial fluid. Monosodium urate crystals
Microscopic Analysis: Crystals-Uric Acid
Synovial fluid with acute
inflammation and monosodium urate
crystals. (Wright–Giemsa stain and
polarized light).
Synovial fluid with acute inflammation
and monosodium urate crystals. The
needle-shaped crystals demonstrate
negative birefringence, because they
are yellow when aligned with the
compensator filter and blue when
perpendicular to the filter (Wright–
Giemsa stain and
polarized/compensated light).
Synovial Fluid - Laboratory procedures
• Left – needle shaped monosodium urate crystals seen in a patient
with gouty arthritis
• Right 1987 CAP CM 18B synovial fluid. Monosodium urate crystals
Synovial Fluid - Laboratory procedures
• 1989 CAP CM 24 synovial fluid. Calcium pyrophosphate - polarized
Microscopic Analysis: Crystals-other
Synovial fluid with acute inflammation
and calcium pyrophosphate dihydrate
crystals (Wright–Giemsa stain and
polarized light).
Synovial fluid with acute inflammation
and calcium pyrophosphate dihydrate
crystals. The rhomboidal intracellular
crystal (center) demonstrates positive
birefringence, because it is blue when
aligned with the compensator filter
(Wright–Giemsa stain and
polarized/compensated light).