CEREBROSPINAL FLUID

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CEREBROSPINAL FLUID

• DR.P.G.KONAPUR
• VMKV MEDICAL COLLEGE
• SALEM

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• Introduction
• Specimen collection LP Technique
• Complications of LP
• Routine examination of CSF.
• Physical examination
• Chemical examination
• Cytological examination
• Microbiological examination

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• found in the subarachnoid space surrounding the
  brain and spinal cord..
• an ultrafiltrate of plasma
• protects the central nervous system from injury

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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.
• 3-4 sterile specimen tubes.
• For viral cultures an additional tube
• CSF manometers and 3 way stopcock.

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Use Sitting PositionPatients with pulmonary
disorders. Young infants
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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-- a demyelinating disease

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COMPLICATIONS

• Post-tap headaches.
• Vomiting.
• Paralysis (low risk)
• Subarachnoid epidermal cyst.
• Epidural hematomas.
• Subdural or subarachnoid hemorrhage.
• Spinal cord bleeding.
• Acute neurologic or respiratory deterioration.
• Hypoxemia or apnea
• Cerebral herniation.
• Introduction of infection with resultant
  bacterial meningitis, epidural abscess, diskitis
  or osteomyelitis. (low risk)
• Ocular muscle palsy. (transient)

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ROUTINE EXAMINATION

• Physical examination
• Normal CSF is clear and colourless,
• specific gravity is 1.0032.
• Colour Red colour is seen due to trauma
  occurring during L.P
• yellow colour called xanthochromia
• is due to previous hemorrhage with lysis of
  RBCS in the CSF and due to tumour.
• Turbidity or cloudiness is seen when
• increase in number of cells in
  CSF ( ie 400 500/ul)
• or
• numerous bacteria
• or
• both.

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• Coagulum protein content is increased.
• tuberculous meningitis (cobweb coagulum is seen)

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• Chemical examination Glucose
• two-thirds of the fasting plasma
  glucose.
• A glucose level below 40 mg/dL is
  significant
• bacterial and fungal
  meningitis and in malignancy..Protein
• High levels -------
• bacterial
• fungal meningitis,
• tumors,
• subarachnoid hemorrhage,
  
• traumatic tap.Lactate
• bacterial and fungal meningitis
  V/S viral meningitis
• bacterial and fungal
  meningitis------ increased lactate,
• viral meningitis----------------
  --------NORMAL
• Lactate Dehydrogenase
• elevated in
• bacterial and
  fungal meningitis,
• malignancy,
• subarachnoid
  hemorrhage.

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Cytological Examination
Centrifuge
smears from deposit stain -romanowaskyCell
Count immediately (pus cells stick to each
other) Method count all 9 squaresNormal---
0 5 lymphocytes per cubic mm.
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• Neutrophils increased
• acute pyogenic
  meningitis. Lymphocytes-----increased
• viral
  meningitis.,
• syphilitic
  meningitis.,
• tubercular
  meningitis.
• fungal
  meningitis.
• RBCs subarachnoid hemorrhage,
• stroke,
• traumatic tap
• Malignant cells
• 50 percent of--- metastatic cancers
• 10 percent of------CNS tumors( shed
  cells into the CSF).

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Micobiological ExaminationGram stain on a
sediment Positive in--- 60
percent of cases of bacterial
meningitis. Culture aerobic and anaerobic
bacteria. Other stains The Z-N for
Mycobacterium tuberculosis, Fungal culture
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Serological examinationSyphilis serology
--neurosyphilis. The fluorescent treponemal
antibody-absorption (FTA-ABS) test positive
!.with active and treated
syphilis. !.used in
conjunction with the VDRL
(for nontreponemal antibodies)
is positive-- in active syphilis,
negative in treated cases.
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PLEURAL FLUID ANALYSIS

• Specimen collection Procedures
• Diagnostic thoracentesis
• Therapeutic thoracentesis
• Tube thoracostomy  
• Causes of pleural effusion
• Difference between transudate and exudate
• Routine examination of Pleural fluid.
• Physical examination
• Chemical examination
• Immunological examination
• Cytological examination
• Algorythym for pleural effusion.

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• Diagnostic thoracentesis _at_if the etiology of
  the effusion is unclear _at_if the presumed cause
  of the effusion does not respond to therapy
  as expected. _at_Pleural effusions do not require
  thoracentesis underlying congestive heart
  failure(bilateral effusions) _at_by recent
  thoracic or abdominal surgery._at_Relative
  contraindications bleeding
  diathesis systemic
  anticoagulation, mechanical
  ventilation, cutaneous disease
  over site. Mechanical ventilation

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Complications

• pain at the puncture site,
• cutaneous or internal bleeding,
• pneumothorax,
• empyema,
• spleen/liver puncture
• Pneumothorax -12-30 of thoracenteses( requires
  treatment with a chest tube in less than 5 of
  cases)
• Use of needles larger than 20 gauge increases the
  risk of a pneumothorax

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Therapeutic thoracentesis

• to remove larger amounts of pleural fluid

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• DIFFERENCES BETWEEN A TRANSUDATE AND A EXUDATE
• CHARACTERISTICS TRANSUDATE
• TRANSUDATE CLEAR,
• STRAW YELLOW
• Sp grlt 1.018
  
• PROTEIN lt 2G/DL
  
• INFLAMMATORY CELLS LOW COUNT

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• EXUDATE
• AppearanceCLOUDY MAY BE CLOTTED
• Colour YELLOW TO RED
• Sp grgt 1.018
• Proteingt 2G/DL
• INFLAMMATORY CELLS HIGH COUNT

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• Physical examination
• 1. Volume Measure and record the volume of fluid
  received.
• Appearance, colour, clot formation Note colour
  whether clear or cloudy, whether clot is formed
  on standing

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• Chemical examination
• Protein estimation
• Glucose estimation

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• Immunological studies
• ANA titres are useful in diagnosing effusion due
  to SLE,and rheumatoid factor is commonly present
  in pleureal effusion associated with sero
  positive rheumatoid arthritis

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• Immunological studies
• ANA titres are useful in diagnosing effusion due
  to SLE,
• rheumatoid factor is commonly present in
  pleureal effusion associated with sero positive
  rheumatoid arthritis

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NEUBAUER COUNTING CHAMBER
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Count in the four corners
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Count in the four corners
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Cells in one corner square
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MESOTHELIAL CELLS
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BENIGN MESOTHELIAL CELLS
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FOAMY MACROPHAGES
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INFLAMMATORY PLEURAL FLUID
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ACID FAST BACILLI
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CANDIDA IN PLEURAL FLUID
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Abnormal mitosis
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SMALL CELL CA
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METASTIC CA FROM BREAST
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ATYPICAL PLASMA CELLS
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ASCITIC FLUID ANALYSIS

• Specimen collection Procedure Abdominal
  paracentesis fluid.
• Causes of Ascitis
• Routine examination of Ascitic fluid.
• Physical examination
• Chemical examination
• Cytological examination
• Microbiological examination

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SPECIMEN COLLECTION

• Abdominal paracentesis
• The removal of 5 L of fluid is considered
  large-volume paracentesis.
• Total paracentesis, ie, removal of all ascites
  (even gt20 L),
• Recent studies demonstrate that supplementing 5 g
  of albumin per each liter over 5 L decreases
  complications of paracentesis, such as
  electrolyte imbalances, and increases in serum
  creatinine secondary to large shifts of
  intravascular volume

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CAUSES FOR ASCITIS

• alcoholic liver disease.
• Obesity, steatosis
  cirrhosis
• hypercholesterolemia steatosis
  cirrhosis
• type 2 diabetes mellitus steatosis
  cirrhosis
• cancer, (especially gastrointestinal cancer)
  malignant ascites.

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• Portal hypertension (serum-ascites albumin
  gradient SAAG gt1.1 g/dL)
• Hepatic congestion,
• congestive heart failure,
• constrictive pericarditis,
• tricuspid insufficiency,
• Budd-Chiari syndrome
• Liver disease,
• cirrhosis,
• alcoholic hepatitis,
• fulminant hepatic failure,
• massive hepatic metastases
• Hypoalbuminemia (SAAG lt1.1 g/dL)
• Nephrotic syndrome
• Protein-losing enteropathy
• Severe malnutrition with anasarca

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• Miscellaneous conditions (SAAG lt1.1 g/dL)
• Chylous ascites
• Pancreatic ascites
• Bile ascites
• Nephrogenic ascites
• Urine ascites
• Ovarian disease
• Diseased peritoneum (SAAG lt1.1 g/dL)
• Infections
• Bacterial peritonitis
• Tuberculous peritonitis
• Fungal peritonitis
• HIV-associated peritonitis

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• Malignant conditions
• Peritoneal carcinomatosis
• Primary mesothelioma
• Pseudomyxoma peritonei
• Hepatocellular carcinoma
• Other rare conditions
• Familial Mediterranean fever
• Vasculitis
• Granulomatous peritonitis
• Eosinophilic peritonitis.

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Routine examination

• PHYSICAL EXAMINATION
• transparent and tinged yellow.
• A minimum of 10,000 red blood cells/µL is
  required for ascitic fluid to appear pink,
• more than 20,000 red blood cells/µL is
  considered distinctly blood tinged.
• a traumatic tap or malignancy.
• Bloody fluid from a traumatic tap is
  heterogeneously bloody, and the fluid will clot.
• Nontraumatic bloody fluid is
  homogeneously red and does not clot because it
  has already clotted and lysed.
• Neutrophil counts of more than 50,000
  cells/µL have a purulent cloudy consistency and
  indicate infection.

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Chemical examination

• SERUM-ASCITES ALBUMIN GRADIENT (SAAG)
• The SAAG ascites into portal hypertensive (SAAG
  gt1.1 g/dL) and nonportal hypertensive (SAAG lt1.1
  g/dL) causes.
• Calculated by subtracting the ascitic fluid
  albumin value from the serum albumin value, it
  correlates directly with portal pressure.
• TOTAL PROTEIN
• In the past, ascitic fluid ---an exudate (if the
  protein level is greater than or equal to 2.5
  g/dL). However, the accuracy is only
  approximately 56 for detecting exudative causes.
  
• The total protein level SAAG.
• An elevated SAAG and a high protein ascites
  due to hepatic congestion.
• Those patients with malignant ascites
  have a low SAAG and a high protein level.

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Cytological examination

• Cytology
• 58-75 sensitive Mal cells
• sediment is smeared on slides.
• Papanicolaou stain and Leishman stains
• A cytospin preparation can be used for clear
  fluid.
• A cell block may also be prepared if adequate
  sediment is available.

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• Cell count
• Normal lt500 leukocytes/µL
• lt 250 polymorphonuclear
  leukocytes/µL.
• A neutrophil count gt 250 cells/µL - highly
  suggestive of bacterial peritonitis.
• In tuberculous peritonitis
• peritoneal carcinomatosis ______ a
  predominance of lymphocytes usually occurs.

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Microbiological examination

• CULTURE/GRAM STAIN
• The sensitivity with bedside inoculation of
  blood culture bottles with ascites results in 92
  detection of bacterial growth in neutrocytic
  ascites.
• AFB stain may be done if required.

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MESOTHELIAL CELLS
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MALIGNANCY IN ASCITIC FLUID
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PERICARDIAL FLUID EXAMINATION

• Causes of pericardial fluid accumulation.
  
• Routine examination of pericardial fluid.
• Physical examination
• Chemical examination
• Cytological examination
• Microbiological examination

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Pathophysiology of pericardial effusion

• The pericardial space normally contains 15-50 mL
  of fluid,
• Lubrication------ for the visceral and parietal
  layers
• originate from the visceral pericardium
• an ultrafiltrate of plasma.
• Total protein levels are generally low
• The cause of abnormal fluid production
  ---------underlying etiology
• secondary to------ pericarditis.
• 1.Transudative ------obstruction of
  drainage(lymphatics)
• 2. Exudative --------- inflammatory
• infectious
• malignant
• autoimmune
  processes within the pericardium.

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• CAUSES OF PERICARDIAL FLUID ACCUMULATION
• Infectious
• Viral (coxsackievirus A and B, hepatitis, HIV)
• Pyogenic (pneumococci, streptococci,
  staphylococci, Neisseria, Legionella species)
• Tuberculous
• Fungal (histoplasmosis, coccidioidomycosis,
  Candida)
• Other infections (syphilitic, protozoal,
  parasitic)
• Noninfectious
• Acute idiopathic
• Uremia
• Neoplasia
• Primary tumors (benign or malignant,
  mesothelioma)
• Tumors metastatic to pericardium (lung and breast
  cancer, lymphoma, leukemia)
• Myxedema

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• Acute myocardial infarction
• Postirradiation
• Aortic dissection (with leakage into pericardial
  sac)
• Trauma
• Cholesterol
• Chylopericardium
• Familial Mediterranean fever
• Whipple disease
• Sarcoidosis
• Hypersensitivity or autoimmunity related
• Rheumatic fever
• Collagen vascular disease (systemic lupus
  erythematosus, rheumatoid arthritis, ankylosing
  spondylitis, scleroderma, acute rheumatic fever,
  Wegener granulomatosis)
• Drug-induced (eg, procainamide, hydralazine,
  isoniazid, minoxidil, phenytoin, anticoagulants,
  methysergide)
• Postcardiac injury.

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ROUTINE EXAMINATION

• Physical examination
• Colour. Clot formation. Specific gravity Altered
  colour is seen in Bacterial pericarditis,Tuberculo
  sis, SLE, Rheumatoid pleuritis, Lymphoma,
  carcinoma.

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Chemical examination

• Includes test for glucose and proteins

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Cytological examination

• Includes WBC count
• RBC count,
• Differential count
• malignant cells.

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Microbiological examination

• Grams stain
• AFB stains
• Pericardial fluid culture

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SUMMARY

• Normally -10-50 ml
• excess fluid -----pericardial effusion.
• Fluid is obtained by using a sterile needle under
  aseptic precaution called as pericardiocantisis.
• Physical examination
• chemical examination
• Microbiological examination

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SYNOVIAL FLUID ANALYSIS

• Specimen collection Procedure
• Causes of Synovial fluid accumulation
• Routine examination of Synovial fluid

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SIGNIFICANCE

• Synovial fluid is found around the joint.
• Chemical composition is similar to that of other
  body fluids except it has hyaluronic acid.
• Hyaluronic acid ----mucodysacchride that acts as
  a binding and protective agent for connective
  tissue.
• CLINICAL SIGNIFICANCE
• Diagnosis of Arthritis
• Gout
• Infection (septic
  arthritis)

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SPECIMEN COLLECTION

• Obtained by aspiration of a joint
• Anticoagulant (EDTA) -----cell counting
• Fluoride---------------------- glucose analysis

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ROUTINE EXAMINATION

• PHYSICAL EXAMINATION
• APPEARANCE Normal synovial fluid straw
  coloured celar and viscous
• TURBIDITY Increase in case of
  inflammatory and infected conditions.
• Grossly Purulent fluid with an increased
  leucocyte count is typical of acute Septic
  arthritis.
• XANTHOCHROMIA Supernatent synovial fluid
  indicates Tumours, Trauma

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• VISCOSITY Synovial fluid is viscous
  ----hyaluronic acid.
• INFLAMMATORY DISORDERS of the joint rendor an
  enzymatic (hyaluronidase)
• Breakdown of hyaluronic acid
• Loss of viscosity of synovial fluid

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TESTS

• STRING TEST
• Hold a drop of specimen between thumb and
  index finger.
• A drop of normal synovial fluid will form a
  string.
• 4 6cm in length_______normal
• lt3cm__________viscosity is lower than normal

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• MUCIN CLOT TEST-
• Clots in the presence of acetic acid. If
  there is breakdown of hyaluronic acid does not
  allow the formation of firm clot.
• PROCEDURE Synovial fluid is added drop by
  drop in a dilute solution of acetic acid.
• firm clot---------- Normal and non
  inflammatory conditions
• poor clot------ inflammatory conditions
  (Hyaluronic acid content decreases)

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CHEMICAL EXAMINATION

• GLUCOSE Synovial fluid for glucose
• ANALYSIS - Must be taken from a fasting
  patient (6 12 hrs) and treated with fluoride
• Samples of the patient synovial fluid and
  blood specimen must be obtained at the same time
  for a comparison of two values.
• In case of non inflammatory arthritis, the
  difference of blood glucose and synovial fluid
  glucose is only 10mg/dl
• Increase to 25 50mg/dl in case of infectious
  septic arthritis
• In mild inflammatory conditions (gout
  pseudogout Rheumatoid arthritis)
• Glucose content of synovial fluid is close to
  normal.

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MICROSCOPIC EXAMINATION

• Total leucocyte count
• Differential count is important for diagnosis of
  joint related disorders.
• Leucocyte count of normal synovial fluid is very
  low (50 cells/cu mm). If specimen turbid saline
  containing methylene blue are diluent
• If specimen bloody, haemolyse the erythrocytes by
  diluting with O 1N Hcl or 1 saporin in saline.
  Smear the slide.

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NORMAL SYNOVIAL FLUID

• NORMAL SYNOVIAL FLUID Has a few mononuclear
  white cells
• Increased neutrophil count (gt70 ) is suggestive
  of bacterial arthritis
• In inflammatory disorders white cell count is
  moderately high (gt10m000/cu mm)

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MICROSCOPIC EXAMINATION OF CRYSTALS

• Clear a slide and a coverslip with alcohol and
  acetone.
• Place a few drops of synovial fluid on the slide
  just sufficient enough to reach the periphery of
  the cover slip.
• Needle shaped intracellular urate crystals
  (sodium and urate) - Gouty arthritis
• Rhomboid calcium pyrophosphate crystals in
  pseudogiant
• Rheumatoid arthritis Cholesterol crystals
  
• Recognized by their flat, clear rhombic
  appearance with one corner punched out

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• MICROBIOLOGY EXAMINATION Gram staining and acid
  fast staining.

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