2010classroomreviewcsfserous_2

7/30/2019 2010classroomreviewCSFSerous_2

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Urinalysis and Body FluidsCRg

Unit 4

Cerebrospinal Fluid


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Cerebrospinal Fluid (CSF) Produced at the Choroid plexus of the 4 ventricles

by modified Ependymal cells At rate @20 ml / hr (adults)

Med training says @ 150 ml/day is produced

CSF flows through theSubarachnoid space Where a volume of 90 150 ml

is maintained (adults)

Reabsorbed at theArachnoid villus /granulation to be eventually reabsorbed

into the blood


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Cerebrospinal Fluid (CSF)

Blood Brain Barrier Occurs due to tight fitting endothelial cells that

prevent filtration of larger molecules.

Controls / restricts / filters blood components

Restricts entry of large molecules, cells, etc.

Therefore CSF composition is unlike bloods

** CSF is NOT an ultrafiltrate


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Blood Brain Barrier Essential to protect the brain

Blocks chemicals, harmful substances Antibodies and medications also blocked

Tests for those substances normally blocked can

indicate level of disruption by diseases: iemeningitis and multiple sclerosis.


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CSF functions

Supplies nutrients to nervous tissues Removes metabolic wastes

Protects / cushions against trauma


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Four major categories of disease

Meningeal infections Subarachnoid hemorrhage

CNS malignancy

Demyelinating disease


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Indications for analysis

To confirm diagnosis of meningitis Evaluate for intracranial hemorrhage

Diagnose malignancies, leukemia

Investigate central nervous systemdisorders


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Specimen collection and handling

Routinely collected via lumbar puncturebetween 3rd & 4th, or 4th & 5th lumbarvertebrae under sterile conditions

Intracranial measurement taken beforefluid is withdrawn.


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Specimen collection and handlingTube 1 chemistries and serology

Tube 2 microbiology cultures

Tube 3 hematology

Testing considered STAT

Specimen potentially infectious


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Specimen collection and handling If immediate processing not possible

Tube 1 (chem-sero) frozen

Tube 2 (micro) room temp

Tube 3 (hemo) refrigerated


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Cerebrospinal Fluid (CSF)Appearance

Normal - Crystal clear, colorless

Descriptive Terms hazy, cloudy,turbid, milky, bloody,

xanthrochromicOften are quantitated slight,moderate, marked, or grossly.

Unclear specimens may contain

increased lipids, proteins, cells orbacteria. Use precautions.


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Cerebrospinal Fluid (CSF) ASCP 17, CSF tubes over newsprint


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Appearance Xanthrochromic Yellowing discoloration

of supernatent (may be pinkish, or orange).

Most commonly due to presence of old blood. Other causes include increased bilirubin,

carotene, proteins, melanoma


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Appearance Clots indicates increased fibrinogen & usually due to traumatic tap, but may indicate

damage to blood-brain barrier. (see below)

Pellicle formation in refrigerated specimen associated with tubercular meningitis.

Pellicle formation - picture at right (pellicle in L. tube, R is normal)

Milky increased lipids Oily contaminated with x-ray media


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Cerebrospinal Fluid (CSF) - procedures

All specimens should be examined microscopically hematology

Stat priority, RBC lyse in 1 hour, WBC in 2 hrs. Refrigerate ifnot able to process immediately.

Electronic counters generally unusable. Manual count

No dilution usually required (use saline if needed)

ave. # cells counted x dilution

# squares counted x volume of each square


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Cerebrospinal Fluid (CSF) Count and differentiate 100 nucleated cells.

Any cell found in peripheral blood may be seen in CSF,other nucleated cells and malignant cells can also be found.

Entire smear should be evaluated for

abnormal cells, inclusions within cells, Clusters, Presence ofintracellular organisms

Normal differential values Adults: 70% lymps, 30% monos.

Children / newborns: monocyte

Types of cells Neutrophils occasionally (with normal count)

Macrophages increase following CVA

Ependymal cells, and normal lining cells can also be seen.


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Lymphocytes & monocytes / macrophages Mono / macro, segs and lymph

L lymphocytes & macrophages


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Cerebrospinal Fluid (CSF) CSF cells

L neutrophiles & @6 macrophages

R neutrophiles and intracellular bacteria


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Eosinophils Often associated with parasitic / fungal

infections, allergic reactions including reaction toshunts and other foreign objects.


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Cerebrospinal Fluid (CSF) Ependymal cells

Normal cell, unique to CSF

Line the ventricles, produce CSFfluid

Large cell with distinctround/oval nucleus, sometimesfound in sheets


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Suspicious / unclassified or malignant cells are reported as other orunclassified AND are sent to pathology. (as seen below)

1986 CAP CM10 CSF blasts (appearance similar to peripheral blood, alwaysconsult with hematology specialist / pathologist) ( see below right)


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Cerebrospinal Fluid (CSF) Cellular inclusions

Erythrophage

Siderophage

Hematoidin crystals (see below)


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CSF Quality Control Commercial quality control samples available

>>>>>>>>>>>>>>>>>>>>>>>>>>> Chemistry

Blood brain barrier causes selective filtration

Abnormal values from altered permeability

Increased production

Increased metabolism


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Cerebrospinal Fluid (CSF) - protein

Normal 15 45 mg/dL .

Albumin fraction. If IgG from damaged B-B, or CNSproduced? Can electrophoresis to evaluate oligoclonal /malignant bands.

Decreased levels not significant Increases levels

Damaged B-B (as in meningitis or hemorrhage)

Production of immunoglobulins within CNS (MS)

Degeneration of neural tissue

Dye-binding methods preferred

Alkaline biuret

Coomassie brilliant blue - a blue color produced isproportional to the amount of protein present (Beers Law)


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Cerebrospinal Fluid (CSF) - glucose

Selectively transported across blood-brain barrier

Normal values: 60-70% of blood glucose

STAT procedure, glycolysis reduces level quickly.

Procedure performed as for blood specimen Decreased levels seen in bacterial & fungal meningitis

Hypoglycemia

Brain tumors

Leukemias

Damage to CNS


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Differential Diagnosis of Meningitisby Laboratory Results

Bacterial Viral Tubercular Fungal

Increased WBC count Increased WBC count Increased WBC count Increased WBC count

Neutrophils Lymphs Lymps & Monos Lymphs & Monos

Marked protein Mod. protein Mod-Marked protein Mod-Marked protein

Marked glucose normal glucose glucose Normal to glucose

Lactate > 35mg/dL

Lactate normal Lactate > 25 mg/dL Lactate > 25mg/dL

+ gram stains Pellicle formation + India ink withCryptococcusneoformans

+ bacterialantigen tests

+ immunologicaltest for C. neo.


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Cerebrospinal Fluid (CSF) CSF Lactate

Normal values = 11-22 mg/dL

Increase as result of hypoxia

Bacterial meningitis. Head injury

CSF Glutamine Normal 8-18 mg/dL Increased levels associated with increases in ammonia (toxin)

CSF Enzymes Lactate dehydrogenase (LDH or LD)

5 isoenzyme types; LD1&LD2 are in brain tissue Creatine kinase (CPK or CK)

Isoenzyme CK3/ CK-BB from brain tissue

Following cardiac arrest, patients with CSF levels


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Cerebrospinal Fluid (CSF)- microbiology

Gram stain Extremely important for early diagnosis of bacterial meningitis Even when well performed, 10% false negatives occur

Use of Cytospin to concentrate specimen increases sensitivity Cultures- Aerobic & Anaerobic. Culture blood at same time Organisms

Newborns

E. coli & group B Strep. Children

Streptococcus pneumoniae Hemophilus influenzae

Neisseria meningitidis

Adults -

Neisseria meningitidis Streptococcus pneumoniae

Staph. aureus (if a shunt is present)

Immunocompromised

Cryptococcus neoformans,

Candida albicans, Coccidioides, or

any opportunistic organism


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India-ink / nigrosin preparation Negative stain to view the encapsulated

Cryptococcus neoformans (often AIDs /immunocompromisedcomplication)

Instead of stain, can also use dark fieldmicroscopy for same effect.

These direct procedures have @ 25-50%sensitivity Prefer latex agglutination tests, better results


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Serology VDRL (Veneral Disease Research

Laboratory) For detection of neurosyphilis

On CSF test low sensitivitiy, but greatspecificity

FTA-Abs also used on CSF, more sensitive, butmust prevent blood contamination.


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Urinalysis and Body FluidsCRg

Unit 4

Serous Body Fluids


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Serous Fluids

Serous fluids small amount of fluid that lies between the

membranes lining the body cavities (parietal)

and those covering the organs within thecavities (visceral).

acts as lubricant,

provide nutrients,

remove wastes


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Serous Fluids

Body cavities Pericardial - heart

Pleural - lungs

Peritoneal abdominal

Membranes

Parietal lines cavity wall Visceral covers organs contained within


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Serous Fluids

Serous fluid an ultra filtrate of the plasma

closely resembles the plasma - as opposed to CSF

Production ( parietal membrane)

Re-absorption ( visceral membrane)

normally at a constant rate.


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Serous Fluids

Production and re-absorption areinfluenced by: Changes in osmotic and hydrostatic pressure in

the blood

Concentration of chemical constituents in theplasma

Permeability of blood vessels and themembranes


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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.


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Serous Fluids- effusions

Effusion an increase in the serous fluid due to some disruption in production

&/ re-absorption processes.

Transudate - an effusion that is a result of a systemic disorderthat disrupts the balance of fluid production / fluid re-absorption. (Think that the problem has been transferred.Examples: Pleural transudate congestive heart failure; Pericardialtransudate nephrotic syndrome, metastatic cancer

Exudates term to classify the effusion that is a result of aproblem with the membranes themselves.

Thought of as an inflammatory process Produced by conditions that directly involve the membranes of the particular

cavity, ex. infections, inflammation, and malignancies

o Pleural exudate carcinoma, pneumonia, trauma

o Pericardial exudate infection, cardiovascular disease (CV) trauma,cancer


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Serous Fluids

Specimen Collection and Handling Needle aspiration

Paracentesis

Thoracentesis

Pericardiocentesis

Lavage ( ie. peritoneal lavage) Ringers lactate / saline is infused into abdomen

then retrieved for analysis.

Specimen sometimes called ascites fluid.


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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 andcomparisons of test results made.


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Serous Fluids

Variety of tests used to aid in determining thecause of the effusion: appearance, protein level,LDH level, cell counts, whether or not it will form aclot, etc.

Authors recommend fluid to blood ratios of proteinand LDH.

Protein in fluid / protein in serum LDH in fluid / LDH in serum


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General lab procedures for serous fluids

Hematology Color & clarity NV = yellow & clear (other terms as

for CSF are sometimes used, EXCEPTxanthrochromic

Cell count same as for CSF Differential

any cell in peripheral blood,

mesothelial cells, (cells lining these cavities more info

soon) malignant cells


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General lab procedures for serous fluids

Chemistry (varies depending on which fluid) Total protein & enzymes (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


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Serous Fluids

Microbiology Gram stain & acid fast

Cultures aerobic & anaerobic


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Serous Fluids

Serology rarely done.

Serum results better. Cytology

if malignancy suspected

Quality control no commercialcontrols, must use serum controls.


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Serous Fluids

Mesothelial cells Unique to serous fluids, originate from lining of

peritoneal, pleural, and pericardial cavities.

Large round cell with abundant blue cytoplasmand purple nucleus which may be eccentric

Cell sometimes described as having a "friedegg" appearance. - usually are single or maybe in sheets

Nucleus round to oval & has a smooth outline,takes up @ 1/3 - of the space.

Smooth spherical nuceoi may be seen.


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Serous Fluids

Mesothelial cells Pleomorphic

If reactive may appear in clusters, have prominentnucleoli and be multinucleated

Nucleus still distinct and round with uniform stainingcharacteristics.

A cluster of reactive mesos may resemble malignant cellclusters, but the mesos display "cell windows."


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Serous fluid - Mesothelial cell

Mesothelial cell


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Serous Fluids

lymphocyte, macrophage/mono, basophil

Mesothelial cells


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Serous Fluids

Macrophage engulfed Candidia species in a pleural fluid, mesothelialcells.


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Serous Fluids 1987CAP CM-16 Pleural fluid mesothelial cell


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Serous Fluids 1992 cap CM-20 Pleural fluid, seg, lymph, macrophage,


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Serous Fluids

Pleural fluid mesothelial cells


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Serous Fluids ASCP 3 reactive mesothelial cells


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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 onelocation to another.

Cells have irregular size, shape, and staining characteristicsof nucleus and cytoplasm. Usually deeply basophilic, moldedor balled up clusters of cells with little distinction from onecell to the next. May be vacuolated.


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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


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Serous FluidsMalignant cells ACSP 7 Case 1 cont.

peritoneal fluid,malignancy


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Serous FluidsMalignant cells ASCP 9 Case 2 pleural fluid 42

year old, breast cancer


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Serous FluidsMalignant cells ASCP 10 Case 3, ascitic fluid, 62

year old admitted for GI bleeding


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Serous Fluids

Malignant cells ASCP 11 Case 3, ascitic fluid, 62 year

old admitted for GI bleeding. Liverbiopsy, H&E stain. Nest of malignantcells.


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Serous Fluids

Malignant cells ASCP 12 Case 4, 30 year old with

back pain and inability to work.Pleural effusion fluid malignanttumor on spinal cord


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Serous Fluids

Malignant cells ASCP 12 Case 4, 30 year old with

back pain and inability to work.Pleural effusion fluid malignanttumor on spinal cord


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Serous Fluids

Malignant cells 1992 CAP CM-31 peritoneal

fluid malignant cell


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Serous Fluids

Malignant cells sheets of atypical cells

with irregular nuclearcontours, nuclearhyperchromasia, basophiliccytoplasm, and jaggedoutline of cell borders.

Squamous cell carcinoma(x400 , Diff-Quik staining)


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Serous Fluids-LE cells

Seen in patients with Systemic Lupus Erythmatosis(SLE) a systemic disease in which an autoantibodyattacks the patients organs and body systems

LE cell is a neutrophilthat has engulfed ahomogeneous mass of purple staining nuclearmaterial


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Serous Fluids pericardial fluid 1987 CAP CM21 Pericardial

fluid, intracellular bacteria


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Serous Fluids peritoneal fluid 1992 CAP CM41 Peritoneal fluid.

Seg, macro, yeast


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Serous Fluids peritoneal fluid 1992 CAP CM40 Peritoneal fluid.

Seg, macro, yeast

Abdominal fluid


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Abdominal fluid plasma cells / multiple myeloma


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Serous Fluids 1991 CAP CM 20

2010classroomreviewcsfserous_2

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