Cytology of Body Fluid
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Transcript of Cytology of Body Fluid
CYTOLOGY OF BODY FLUID
DR SHABNEEZ HUSSAINHAEMATOLOGY RESIDENT
CAVITY FLUIDS
Abdominal 1048708 Pleural 1048708 Pericardial 1048708 Synovial 1048708 CSF
Schematic representation of the three body cavities
CAVITY FLUIDS
Sampling techiques appearance during collection EDTA to
prevent clotting direct smear - delayed processing Cell concentration Protein concentration
TRANSUDATE EXUDATE MODIFIED TRANSUDATE
Accumulation of fluids in body cavities
Transudates
bull Increased hydrostatic pressure Congestive heart failure
bull Decreased oncotic pressure (decreased albumin) liver cirrhosis nephrosis and malnutrition
Exudate
bull Inflammation Infection infarction hemorrhage
bull Tumor
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 3mgdl More than 3mgdl
Clots No Yes
cells Usually benign
Few mesothelial
cells few histocytes
and lymphocytes
More mesothelial cells
acute or chronic
inflammatory cells
RBCs malignant cells
MODIFIED TRANSUDATE
Moderate protein concentration 2525- 75gdl
Moderate cellularity 1000-7000 cells μg Cardiovascular disease Neoplastic disease Rupture of urinary bladder Hepatic disease
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 eg TB
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
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
SAMPLE COLLECTION
FNA of effusion fluids
Tapping
Collection and preparation of specimen
FIXATION
1ml of heparin + 100ml of effusion fluid to prevent
clotting
NB do not use alcohol in fixation of fluid before
spread cytological smear on glass slides
TYPES OF STAINING SMEARS
PAP
Gram Stain
Hx amp E
Cell block for remnant sediment and histopathological
examination
Other special stains for the most suspected diseases to
confirm diagnosis
Heparinized bottles (3 units heparinml) 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 HampE stain
Air-dried cytocentrifuge preparation
(Hematologic malignancy is suspected)
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
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
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
PMN are few associated with Viral and acute bacterial
inflammation
Macrophages are few in number associated with malignancy
hemorrhage inflammation
EosinophilsBasophils not normally seen in CSF
Plasma cells not normally present associated with viral disorders
and Hodgkins diseases
Red Blood Cells Few to none present
Mesothelial cells not present
Malignant cells will see with malignant disease and infiltrate
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
NORMAL CSF COMPOSITION
Clear color lt5 RBCrsquos lt5 WBCrsquos Protein 23-38mgdl (can use 14-45) Glucosemdash60 of serum level (75-100)
OPENING PRESSURE
Normal = 80-180 mmHg Obese pts up to 250mmHg can be normal Pathologically elevated gt250mmHg If elevated likely due to cerebral edema from
intracranial pathology Infection (cryptococcal meningitis) tumor
benign ICH (pseudotumor)
RBCS
Always send tube 1 and 4 for cell count and compare RBCs
Traumatic tap Elev RBC in tube 1 nl in tube 41000 RBC 1 WBC to adjust WBC count in
bloody tap
SAH or HSV Elev RBC in tube 1 AND tube 4
ldquoCrenated RBCsrdquo and xanthochromia (yellow supernatant after centrifuge)Seen in hyperbilirubinemia (ESLD) old SAH
old blood from prior traumatic LP or bleed
WBCrsquoS
Infection PMN predominance likely bacterial
meningitis Lymphocytic predominance viral vs fungal
vs TB vs malignancy
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)
GLUCOSE
Normal Viral infectionLow glucose Bacterial meningitis TB fungalReally low lt18 is strongly suggestive of bacterial
meningitis
TYPICAL VIRAL MENINGITIS
CSF WBC elevated but lt250 (first PMNs then lymphocytes)
CSF protein elevated but lt150 Glucose gt 50 of serum concentration
TYPICAL BACTERIAL MENINGITIS
CSF WBC gt1000 PMN predominance CSF protein gt500mgdl CSF glucose lt45 mgdl
bull Effusion
bull Transudate
bull Exudates
bull Lab analysis Gross exam cell count etc
bull Differential PMN Lymph Mono etc
2- Pleural Fluid Lung fluid
bull Cells unique to the lungs Mesothelial cells
bull RBCs and WBCs are limited if increased without
traumatic tap ----- indicates infarction
bull Cytology exam useful in identifying malignancy or
abnormal morphological cells
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 ro
chylothorax amylase to ro pancreatitis esoph perf Adenosine deaminase to eval TB
LIGHTrsquoS CRITERIA FOR EXUDATES
Fluid is exudate if it meets 1 of 3 criteria 1 Pleural fluid LDHserum LDH gt 062 Pleural fluid proteinserum protein gt 053 Pleural fluid LDH gt upper limit of normal
serum LDH If all 3 negative fluid is Transudate
TRANSUDATE
Result from imbalances in oncotic and hydrostatic pressure
Usually low oncotic +- high hydrostatic pressure
Pulm EdemaCHF Cirrhosis with ascites HypoalbuminemiaNephrotic
syndrome ESLD Fluid overload sp aggressive IVF Peritoneal dialysis
EXUDATE
Caused by local not systemic factors Infection Neoplasm Pancreatitis Esoph perf RA SLE Sarcoid Wegeners PE Meigrsquos
Chylothorax
LYMPHOCYTOSIS
Malignancy (50-70 lymphs) Also TB sarcoid RA chylothorax (gt90
lymphs)
PLEURAL EOSINOPHILIA
Pneumothorax Hemothorax Pulm infarct Parasitic disease
Fungal infection Drugs Malignancy Asbestos
WHY IS GLUCOSE LOW(lt60)
RA TB Empyema SLE Malignancy Esophageal rupture
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 gt 100ml (several 100) before effusion
can be detected on physical exam
Removal procedure- paracentesis
Lab analysis distinguish between transudate and exudates
gross exam cell count sedimentation chemical analysis
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
Lymphocytes CHF liver cirrhosis nephrotic syndrome
Mesothelial Cells Associated with TB effusions
Malignant cells seen with malignancy
WHAT TO SEND FLUID FOR
Cell count with diff Albumin LDH Total protein
glucose Gram staincx cytology
APPEARANCE OF FLUID
Clearmdashusually indicates uncomplicated ascites ie liver failurecirrhosis
Turbidcloudymdashinfected Pinkbloodymdashtraumatic punctured collateral
vessel malignancy Correct for bloody tap 1 WBC 750 RBC
1 PMN 250 RBC
SERUM-TO-ASCITES ALBUMIN GRADIENT (SAAG)
=Serum albumin ndash ascitic fluid albuminIf the gradient is gt11 Portal HTN (drives fluids into
peritoneum) SBP cirrhosis Alcoholic hepatitis CHFIf the gradient is lt 11(protein leaks into peritoneum and fluid
follows) Peritoneal carcinomatosis peritoneal
TB pancreatitis nephrotic syndrome
SBP SAAG gt 11 Suspect if gt250 PMNs (gt100 PMNs in pt on
peritoneal dialysis) 70 GNR (Ecoli Klebsiella)
30 GPC (S pneumo Enterococcus) Treat with ceftriaxone cefotaxime ldquoCulture negative SBPrdquo if gt250 PMNs but cx
neg treat the same
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
Measure pH pH less than 70 associated with infection or
rheumatoid disorder
Cell count see limited RBCs and WBCs
Evaluate sedimentation
bull Examine physical chemical and microscopic detail
bull Count number of sperm report morphology and
motility
bull Specimen must be a fresh collection-clean sterile
container
bull Gross Exam Color pH Volume and viscosity
bull Agglutination study
5- Seminal Fluid
bull Joint Fluid normally clear viscous
bull Functions as a lubricate and transports nutrient
bull Arthrocentesis aspirate of the joint fluid aseptic
technique
bull Lab Assay Gross exam microscopic exam Gram
stain cultures
6- Synovial Fluid
bull Appearance clear transparent viscous
bull Viscosity test
bull Mucin Clot test
bull Note crystals (intracellular vs extra cellular)
bull Slide exam usually performed on concentration of the fluid
using Giemsa or Papnicolaou
THANK YOU
CAVITY FLUIDS
Abdominal 1048708 Pleural 1048708 Pericardial 1048708 Synovial 1048708 CSF
Schematic representation of the three body cavities
CAVITY FLUIDS
Sampling techiques appearance during collection EDTA to
prevent clotting direct smear - delayed processing Cell concentration Protein concentration
TRANSUDATE EXUDATE MODIFIED TRANSUDATE
Accumulation of fluids in body cavities
Transudates
bull Increased hydrostatic pressure Congestive heart failure
bull Decreased oncotic pressure (decreased albumin) liver cirrhosis nephrosis and malnutrition
Exudate
bull Inflammation Infection infarction hemorrhage
bull Tumor
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 3mgdl More than 3mgdl
Clots No Yes
cells Usually benign
Few mesothelial
cells few histocytes
and lymphocytes
More mesothelial cells
acute or chronic
inflammatory cells
RBCs malignant cells
MODIFIED TRANSUDATE
Moderate protein concentration 2525- 75gdl
Moderate cellularity 1000-7000 cells μg Cardiovascular disease Neoplastic disease Rupture of urinary bladder Hepatic disease
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 eg TB
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
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
SAMPLE COLLECTION
FNA of effusion fluids
Tapping
Collection and preparation of specimen
FIXATION
1ml of heparin + 100ml of effusion fluid to prevent
clotting
NB do not use alcohol in fixation of fluid before
spread cytological smear on glass slides
TYPES OF STAINING SMEARS
PAP
Gram Stain
Hx amp E
Cell block for remnant sediment and histopathological
examination
Other special stains for the most suspected diseases to
confirm diagnosis
Heparinized bottles (3 units heparinml) 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 HampE stain
Air-dried cytocentrifuge preparation
(Hematologic malignancy is suspected)
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
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
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
PMN are few associated with Viral and acute bacterial
inflammation
Macrophages are few in number associated with malignancy
hemorrhage inflammation
EosinophilsBasophils not normally seen in CSF
Plasma cells not normally present associated with viral disorders
and Hodgkins diseases
Red Blood Cells Few to none present
Mesothelial cells not present
Malignant cells will see with malignant disease and infiltrate
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
NORMAL CSF COMPOSITION
Clear color lt5 RBCrsquos lt5 WBCrsquos Protein 23-38mgdl (can use 14-45) Glucosemdash60 of serum level (75-100)
OPENING PRESSURE
Normal = 80-180 mmHg Obese pts up to 250mmHg can be normal Pathologically elevated gt250mmHg If elevated likely due to cerebral edema from
intracranial pathology Infection (cryptococcal meningitis) tumor
benign ICH (pseudotumor)
RBCS
Always send tube 1 and 4 for cell count and compare RBCs
Traumatic tap Elev RBC in tube 1 nl in tube 41000 RBC 1 WBC to adjust WBC count in
bloody tap
SAH or HSV Elev RBC in tube 1 AND tube 4
ldquoCrenated RBCsrdquo and xanthochromia (yellow supernatant after centrifuge)Seen in hyperbilirubinemia (ESLD) old SAH
old blood from prior traumatic LP or bleed
WBCrsquoS
Infection PMN predominance likely bacterial
meningitis Lymphocytic predominance viral vs fungal
vs TB vs malignancy
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)
GLUCOSE
Normal Viral infectionLow glucose Bacterial meningitis TB fungalReally low lt18 is strongly suggestive of bacterial
meningitis
TYPICAL VIRAL MENINGITIS
CSF WBC elevated but lt250 (first PMNs then lymphocytes)
CSF protein elevated but lt150 Glucose gt 50 of serum concentration
TYPICAL BACTERIAL MENINGITIS
CSF WBC gt1000 PMN predominance CSF protein gt500mgdl CSF glucose lt45 mgdl
bull Effusion
bull Transudate
bull Exudates
bull Lab analysis Gross exam cell count etc
bull Differential PMN Lymph Mono etc
2- Pleural Fluid Lung fluid
bull Cells unique to the lungs Mesothelial cells
bull RBCs and WBCs are limited if increased without
traumatic tap ----- indicates infarction
bull Cytology exam useful in identifying malignancy or
abnormal morphological cells
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 ro
chylothorax amylase to ro pancreatitis esoph perf Adenosine deaminase to eval TB
LIGHTrsquoS CRITERIA FOR EXUDATES
Fluid is exudate if it meets 1 of 3 criteria 1 Pleural fluid LDHserum LDH gt 062 Pleural fluid proteinserum protein gt 053 Pleural fluid LDH gt upper limit of normal
serum LDH If all 3 negative fluid is Transudate
TRANSUDATE
Result from imbalances in oncotic and hydrostatic pressure
Usually low oncotic +- high hydrostatic pressure
Pulm EdemaCHF Cirrhosis with ascites HypoalbuminemiaNephrotic
syndrome ESLD Fluid overload sp aggressive IVF Peritoneal dialysis
EXUDATE
Caused by local not systemic factors Infection Neoplasm Pancreatitis Esoph perf RA SLE Sarcoid Wegeners PE Meigrsquos
Chylothorax
LYMPHOCYTOSIS
Malignancy (50-70 lymphs) Also TB sarcoid RA chylothorax (gt90
lymphs)
PLEURAL EOSINOPHILIA
Pneumothorax Hemothorax Pulm infarct Parasitic disease
Fungal infection Drugs Malignancy Asbestos
WHY IS GLUCOSE LOW(lt60)
RA TB Empyema SLE Malignancy Esophageal rupture
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 gt 100ml (several 100) before effusion
can be detected on physical exam
Removal procedure- paracentesis
Lab analysis distinguish between transudate and exudates
gross exam cell count sedimentation chemical analysis
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
Lymphocytes CHF liver cirrhosis nephrotic syndrome
Mesothelial Cells Associated with TB effusions
Malignant cells seen with malignancy
WHAT TO SEND FLUID FOR
Cell count with diff Albumin LDH Total protein
glucose Gram staincx cytology
APPEARANCE OF FLUID
Clearmdashusually indicates uncomplicated ascites ie liver failurecirrhosis
Turbidcloudymdashinfected Pinkbloodymdashtraumatic punctured collateral
vessel malignancy Correct for bloody tap 1 WBC 750 RBC
1 PMN 250 RBC
SERUM-TO-ASCITES ALBUMIN GRADIENT (SAAG)
=Serum albumin ndash ascitic fluid albuminIf the gradient is gt11 Portal HTN (drives fluids into
peritoneum) SBP cirrhosis Alcoholic hepatitis CHFIf the gradient is lt 11(protein leaks into peritoneum and fluid
follows) Peritoneal carcinomatosis peritoneal
TB pancreatitis nephrotic syndrome
SBP SAAG gt 11 Suspect if gt250 PMNs (gt100 PMNs in pt on
peritoneal dialysis) 70 GNR (Ecoli Klebsiella)
30 GPC (S pneumo Enterococcus) Treat with ceftriaxone cefotaxime ldquoCulture negative SBPrdquo if gt250 PMNs but cx
neg treat the same
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
Measure pH pH less than 70 associated with infection or
rheumatoid disorder
Cell count see limited RBCs and WBCs
Evaluate sedimentation
bull Examine physical chemical and microscopic detail
bull Count number of sperm report morphology and
motility
bull Specimen must be a fresh collection-clean sterile
container
bull Gross Exam Color pH Volume and viscosity
bull Agglutination study
5- Seminal Fluid
bull Joint Fluid normally clear viscous
bull Functions as a lubricate and transports nutrient
bull Arthrocentesis aspirate of the joint fluid aseptic
technique
bull Lab Assay Gross exam microscopic exam Gram
stain cultures
6- Synovial Fluid
bull Appearance clear transparent viscous
bull Viscosity test
bull Mucin Clot test
bull Note crystals (intracellular vs extra cellular)
bull Slide exam usually performed on concentration of the fluid
using Giemsa or Papnicolaou
THANK YOU
Schematic representation of the three body cavities
CAVITY FLUIDS
Sampling techiques appearance during collection EDTA to
prevent clotting direct smear - delayed processing Cell concentration Protein concentration
TRANSUDATE EXUDATE MODIFIED TRANSUDATE
Accumulation of fluids in body cavities
Transudates
bull Increased hydrostatic pressure Congestive heart failure
bull Decreased oncotic pressure (decreased albumin) liver cirrhosis nephrosis and malnutrition
Exudate
bull Inflammation Infection infarction hemorrhage
bull Tumor
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 3mgdl More than 3mgdl
Clots No Yes
cells Usually benign
Few mesothelial
cells few histocytes
and lymphocytes
More mesothelial cells
acute or chronic
inflammatory cells
RBCs malignant cells
MODIFIED TRANSUDATE
Moderate protein concentration 2525- 75gdl
Moderate cellularity 1000-7000 cells μg Cardiovascular disease Neoplastic disease Rupture of urinary bladder Hepatic disease
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 eg TB
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
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
SAMPLE COLLECTION
FNA of effusion fluids
Tapping
Collection and preparation of specimen
FIXATION
1ml of heparin + 100ml of effusion fluid to prevent
clotting
NB do not use alcohol in fixation of fluid before
spread cytological smear on glass slides
TYPES OF STAINING SMEARS
PAP
Gram Stain
Hx amp E
Cell block for remnant sediment and histopathological
examination
Other special stains for the most suspected diseases to
confirm diagnosis
Heparinized bottles (3 units heparinml) 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 HampE stain
Air-dried cytocentrifuge preparation
(Hematologic malignancy is suspected)
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
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
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
PMN are few associated with Viral and acute bacterial
inflammation
Macrophages are few in number associated with malignancy
hemorrhage inflammation
EosinophilsBasophils not normally seen in CSF
Plasma cells not normally present associated with viral disorders
and Hodgkins diseases
Red Blood Cells Few to none present
Mesothelial cells not present
Malignant cells will see with malignant disease and infiltrate
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
NORMAL CSF COMPOSITION
Clear color lt5 RBCrsquos lt5 WBCrsquos Protein 23-38mgdl (can use 14-45) Glucosemdash60 of serum level (75-100)
OPENING PRESSURE
Normal = 80-180 mmHg Obese pts up to 250mmHg can be normal Pathologically elevated gt250mmHg If elevated likely due to cerebral edema from
intracranial pathology Infection (cryptococcal meningitis) tumor
benign ICH (pseudotumor)
RBCS
Always send tube 1 and 4 for cell count and compare RBCs
Traumatic tap Elev RBC in tube 1 nl in tube 41000 RBC 1 WBC to adjust WBC count in
bloody tap
SAH or HSV Elev RBC in tube 1 AND tube 4
ldquoCrenated RBCsrdquo and xanthochromia (yellow supernatant after centrifuge)Seen in hyperbilirubinemia (ESLD) old SAH
old blood from prior traumatic LP or bleed
WBCrsquoS
Infection PMN predominance likely bacterial
meningitis Lymphocytic predominance viral vs fungal
vs TB vs malignancy
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)
GLUCOSE
Normal Viral infectionLow glucose Bacterial meningitis TB fungalReally low lt18 is strongly suggestive of bacterial
meningitis
TYPICAL VIRAL MENINGITIS
CSF WBC elevated but lt250 (first PMNs then lymphocytes)
CSF protein elevated but lt150 Glucose gt 50 of serum concentration
TYPICAL BACTERIAL MENINGITIS
CSF WBC gt1000 PMN predominance CSF protein gt500mgdl CSF glucose lt45 mgdl
bull Effusion
bull Transudate
bull Exudates
bull Lab analysis Gross exam cell count etc
bull Differential PMN Lymph Mono etc
2- Pleural Fluid Lung fluid
bull Cells unique to the lungs Mesothelial cells
bull RBCs and WBCs are limited if increased without
traumatic tap ----- indicates infarction
bull Cytology exam useful in identifying malignancy or
abnormal morphological cells
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 ro
chylothorax amylase to ro pancreatitis esoph perf Adenosine deaminase to eval TB
LIGHTrsquoS CRITERIA FOR EXUDATES
Fluid is exudate if it meets 1 of 3 criteria 1 Pleural fluid LDHserum LDH gt 062 Pleural fluid proteinserum protein gt 053 Pleural fluid LDH gt upper limit of normal
serum LDH If all 3 negative fluid is Transudate
TRANSUDATE
Result from imbalances in oncotic and hydrostatic pressure
Usually low oncotic +- high hydrostatic pressure
Pulm EdemaCHF Cirrhosis with ascites HypoalbuminemiaNephrotic
syndrome ESLD Fluid overload sp aggressive IVF Peritoneal dialysis
EXUDATE
Caused by local not systemic factors Infection Neoplasm Pancreatitis Esoph perf RA SLE Sarcoid Wegeners PE Meigrsquos
Chylothorax
LYMPHOCYTOSIS
Malignancy (50-70 lymphs) Also TB sarcoid RA chylothorax (gt90
lymphs)
PLEURAL EOSINOPHILIA
Pneumothorax Hemothorax Pulm infarct Parasitic disease
Fungal infection Drugs Malignancy Asbestos
WHY IS GLUCOSE LOW(lt60)
RA TB Empyema SLE Malignancy Esophageal rupture
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 gt 100ml (several 100) before effusion
can be detected on physical exam
Removal procedure- paracentesis
Lab analysis distinguish between transudate and exudates
gross exam cell count sedimentation chemical analysis
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
Lymphocytes CHF liver cirrhosis nephrotic syndrome
Mesothelial Cells Associated with TB effusions
Malignant cells seen with malignancy
WHAT TO SEND FLUID FOR
Cell count with diff Albumin LDH Total protein
glucose Gram staincx cytology
APPEARANCE OF FLUID
Clearmdashusually indicates uncomplicated ascites ie liver failurecirrhosis
Turbidcloudymdashinfected Pinkbloodymdashtraumatic punctured collateral
vessel malignancy Correct for bloody tap 1 WBC 750 RBC
1 PMN 250 RBC
SERUM-TO-ASCITES ALBUMIN GRADIENT (SAAG)
=Serum albumin ndash ascitic fluid albuminIf the gradient is gt11 Portal HTN (drives fluids into
peritoneum) SBP cirrhosis Alcoholic hepatitis CHFIf the gradient is lt 11(protein leaks into peritoneum and fluid
follows) Peritoneal carcinomatosis peritoneal
TB pancreatitis nephrotic syndrome
SBP SAAG gt 11 Suspect if gt250 PMNs (gt100 PMNs in pt on
peritoneal dialysis) 70 GNR (Ecoli Klebsiella)
30 GPC (S pneumo Enterococcus) Treat with ceftriaxone cefotaxime ldquoCulture negative SBPrdquo if gt250 PMNs but cx
neg treat the same
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
Measure pH pH less than 70 associated with infection or
rheumatoid disorder
Cell count see limited RBCs and WBCs
Evaluate sedimentation
bull Examine physical chemical and microscopic detail
bull Count number of sperm report morphology and
motility
bull Specimen must be a fresh collection-clean sterile
container
bull Gross Exam Color pH Volume and viscosity
bull Agglutination study
5- Seminal Fluid
bull Joint Fluid normally clear viscous
bull Functions as a lubricate and transports nutrient
bull Arthrocentesis aspirate of the joint fluid aseptic
technique
bull Lab Assay Gross exam microscopic exam Gram
stain cultures
6- Synovial Fluid
bull Appearance clear transparent viscous
bull Viscosity test
bull Mucin Clot test
bull Note crystals (intracellular vs extra cellular)
bull Slide exam usually performed on concentration of the fluid
using Giemsa or Papnicolaou
THANK YOU
CAVITY FLUIDS
Sampling techiques appearance during collection EDTA to
prevent clotting direct smear - delayed processing Cell concentration Protein concentration
TRANSUDATE EXUDATE MODIFIED TRANSUDATE
Accumulation of fluids in body cavities
Transudates
bull Increased hydrostatic pressure Congestive heart failure
bull Decreased oncotic pressure (decreased albumin) liver cirrhosis nephrosis and malnutrition
Exudate
bull Inflammation Infection infarction hemorrhage
bull Tumor
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 3mgdl More than 3mgdl
Clots No Yes
cells Usually benign
Few mesothelial
cells few histocytes
and lymphocytes
More mesothelial cells
acute or chronic
inflammatory cells
RBCs malignant cells
MODIFIED TRANSUDATE
Moderate protein concentration 2525- 75gdl
Moderate cellularity 1000-7000 cells μg Cardiovascular disease Neoplastic disease Rupture of urinary bladder Hepatic disease
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 eg TB
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
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
SAMPLE COLLECTION
FNA of effusion fluids
Tapping
Collection and preparation of specimen
FIXATION
1ml of heparin + 100ml of effusion fluid to prevent
clotting
NB do not use alcohol in fixation of fluid before
spread cytological smear on glass slides
TYPES OF STAINING SMEARS
PAP
Gram Stain
Hx amp E
Cell block for remnant sediment and histopathological
examination
Other special stains for the most suspected diseases to
confirm diagnosis
Heparinized bottles (3 units heparinml) 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 HampE stain
Air-dried cytocentrifuge preparation
(Hematologic malignancy is suspected)
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
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
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
PMN are few associated with Viral and acute bacterial
inflammation
Macrophages are few in number associated with malignancy
hemorrhage inflammation
EosinophilsBasophils not normally seen in CSF
Plasma cells not normally present associated with viral disorders
and Hodgkins diseases
Red Blood Cells Few to none present
Mesothelial cells not present
Malignant cells will see with malignant disease and infiltrate
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
NORMAL CSF COMPOSITION
Clear color lt5 RBCrsquos lt5 WBCrsquos Protein 23-38mgdl (can use 14-45) Glucosemdash60 of serum level (75-100)
OPENING PRESSURE
Normal = 80-180 mmHg Obese pts up to 250mmHg can be normal Pathologically elevated gt250mmHg If elevated likely due to cerebral edema from
intracranial pathology Infection (cryptococcal meningitis) tumor
benign ICH (pseudotumor)
RBCS
Always send tube 1 and 4 for cell count and compare RBCs
Traumatic tap Elev RBC in tube 1 nl in tube 41000 RBC 1 WBC to adjust WBC count in
bloody tap
SAH or HSV Elev RBC in tube 1 AND tube 4
ldquoCrenated RBCsrdquo and xanthochromia (yellow supernatant after centrifuge)Seen in hyperbilirubinemia (ESLD) old SAH
old blood from prior traumatic LP or bleed
WBCrsquoS
Infection PMN predominance likely bacterial
meningitis Lymphocytic predominance viral vs fungal
vs TB vs malignancy
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)
GLUCOSE
Normal Viral infectionLow glucose Bacterial meningitis TB fungalReally low lt18 is strongly suggestive of bacterial
meningitis
TYPICAL VIRAL MENINGITIS
CSF WBC elevated but lt250 (first PMNs then lymphocytes)
CSF protein elevated but lt150 Glucose gt 50 of serum concentration
TYPICAL BACTERIAL MENINGITIS
CSF WBC gt1000 PMN predominance CSF protein gt500mgdl CSF glucose lt45 mgdl
bull Effusion
bull Transudate
bull Exudates
bull Lab analysis Gross exam cell count etc
bull Differential PMN Lymph Mono etc
2- Pleural Fluid Lung fluid
bull Cells unique to the lungs Mesothelial cells
bull RBCs and WBCs are limited if increased without
traumatic tap ----- indicates infarction
bull Cytology exam useful in identifying malignancy or
abnormal morphological cells
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 ro
chylothorax amylase to ro pancreatitis esoph perf Adenosine deaminase to eval TB
LIGHTrsquoS CRITERIA FOR EXUDATES
Fluid is exudate if it meets 1 of 3 criteria 1 Pleural fluid LDHserum LDH gt 062 Pleural fluid proteinserum protein gt 053 Pleural fluid LDH gt upper limit of normal
serum LDH If all 3 negative fluid is Transudate
TRANSUDATE
Result from imbalances in oncotic and hydrostatic pressure
Usually low oncotic +- high hydrostatic pressure
Pulm EdemaCHF Cirrhosis with ascites HypoalbuminemiaNephrotic
syndrome ESLD Fluid overload sp aggressive IVF Peritoneal dialysis
EXUDATE
Caused by local not systemic factors Infection Neoplasm Pancreatitis Esoph perf RA SLE Sarcoid Wegeners PE Meigrsquos
Chylothorax
LYMPHOCYTOSIS
Malignancy (50-70 lymphs) Also TB sarcoid RA chylothorax (gt90
lymphs)
PLEURAL EOSINOPHILIA
Pneumothorax Hemothorax Pulm infarct Parasitic disease
Fungal infection Drugs Malignancy Asbestos
WHY IS GLUCOSE LOW(lt60)
RA TB Empyema SLE Malignancy Esophageal rupture
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 gt 100ml (several 100) before effusion
can be detected on physical exam
Removal procedure- paracentesis
Lab analysis distinguish between transudate and exudates
gross exam cell count sedimentation chemical analysis
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
Lymphocytes CHF liver cirrhosis nephrotic syndrome
Mesothelial Cells Associated with TB effusions
Malignant cells seen with malignancy
WHAT TO SEND FLUID FOR
Cell count with diff Albumin LDH Total protein
glucose Gram staincx cytology
APPEARANCE OF FLUID
Clearmdashusually indicates uncomplicated ascites ie liver failurecirrhosis
Turbidcloudymdashinfected Pinkbloodymdashtraumatic punctured collateral
vessel malignancy Correct for bloody tap 1 WBC 750 RBC
1 PMN 250 RBC
SERUM-TO-ASCITES ALBUMIN GRADIENT (SAAG)
=Serum albumin ndash ascitic fluid albuminIf the gradient is gt11 Portal HTN (drives fluids into
peritoneum) SBP cirrhosis Alcoholic hepatitis CHFIf the gradient is lt 11(protein leaks into peritoneum and fluid
follows) Peritoneal carcinomatosis peritoneal
TB pancreatitis nephrotic syndrome
SBP SAAG gt 11 Suspect if gt250 PMNs (gt100 PMNs in pt on
peritoneal dialysis) 70 GNR (Ecoli Klebsiella)
30 GPC (S pneumo Enterococcus) Treat with ceftriaxone cefotaxime ldquoCulture negative SBPrdquo if gt250 PMNs but cx
neg treat the same
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
Measure pH pH less than 70 associated with infection or
rheumatoid disorder
Cell count see limited RBCs and WBCs
Evaluate sedimentation
bull Examine physical chemical and microscopic detail
bull Count number of sperm report morphology and
motility
bull Specimen must be a fresh collection-clean sterile
container
bull Gross Exam Color pH Volume and viscosity
bull Agglutination study
5- Seminal Fluid
bull Joint Fluid normally clear viscous
bull Functions as a lubricate and transports nutrient
bull Arthrocentesis aspirate of the joint fluid aseptic
technique
bull Lab Assay Gross exam microscopic exam Gram
stain cultures
6- Synovial Fluid
bull Appearance clear transparent viscous
bull Viscosity test
bull Mucin Clot test
bull Note crystals (intracellular vs extra cellular)
bull Slide exam usually performed on concentration of the fluid
using Giemsa or Papnicolaou
THANK YOU
TRANSUDATE EXUDATE MODIFIED TRANSUDATE
Accumulation of fluids in body cavities
Transudates
bull Increased hydrostatic pressure Congestive heart failure
bull Decreased oncotic pressure (decreased albumin) liver cirrhosis nephrosis and malnutrition
Exudate
bull Inflammation Infection infarction hemorrhage
bull Tumor
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 3mgdl More than 3mgdl
Clots No Yes
cells Usually benign
Few mesothelial
cells few histocytes
and lymphocytes
More mesothelial cells
acute or chronic
inflammatory cells
RBCs malignant cells
MODIFIED TRANSUDATE
Moderate protein concentration 2525- 75gdl
Moderate cellularity 1000-7000 cells μg Cardiovascular disease Neoplastic disease Rupture of urinary bladder Hepatic disease
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 eg TB
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
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
SAMPLE COLLECTION
FNA of effusion fluids
Tapping
Collection and preparation of specimen
FIXATION
1ml of heparin + 100ml of effusion fluid to prevent
clotting
NB do not use alcohol in fixation of fluid before
spread cytological smear on glass slides
TYPES OF STAINING SMEARS
PAP
Gram Stain
Hx amp E
Cell block for remnant sediment and histopathological
examination
Other special stains for the most suspected diseases to
confirm diagnosis
Heparinized bottles (3 units heparinml) 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 HampE stain
Air-dried cytocentrifuge preparation
(Hematologic malignancy is suspected)
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
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
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
PMN are few associated with Viral and acute bacterial
inflammation
Macrophages are few in number associated with malignancy
hemorrhage inflammation
EosinophilsBasophils not normally seen in CSF
Plasma cells not normally present associated with viral disorders
and Hodgkins diseases
Red Blood Cells Few to none present
Mesothelial cells not present
Malignant cells will see with malignant disease and infiltrate
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
NORMAL CSF COMPOSITION
Clear color lt5 RBCrsquos lt5 WBCrsquos Protein 23-38mgdl (can use 14-45) Glucosemdash60 of serum level (75-100)
OPENING PRESSURE
Normal = 80-180 mmHg Obese pts up to 250mmHg can be normal Pathologically elevated gt250mmHg If elevated likely due to cerebral edema from
intracranial pathology Infection (cryptococcal meningitis) tumor
benign ICH (pseudotumor)
RBCS
Always send tube 1 and 4 for cell count and compare RBCs
Traumatic tap Elev RBC in tube 1 nl in tube 41000 RBC 1 WBC to adjust WBC count in
bloody tap
SAH or HSV Elev RBC in tube 1 AND tube 4
ldquoCrenated RBCsrdquo and xanthochromia (yellow supernatant after centrifuge)Seen in hyperbilirubinemia (ESLD) old SAH
old blood from prior traumatic LP or bleed
WBCrsquoS
Infection PMN predominance likely bacterial
meningitis Lymphocytic predominance viral vs fungal
vs TB vs malignancy
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)
GLUCOSE
Normal Viral infectionLow glucose Bacterial meningitis TB fungalReally low lt18 is strongly suggestive of bacterial
meningitis
TYPICAL VIRAL MENINGITIS
CSF WBC elevated but lt250 (first PMNs then lymphocytes)
CSF protein elevated but lt150 Glucose gt 50 of serum concentration
TYPICAL BACTERIAL MENINGITIS
CSF WBC gt1000 PMN predominance CSF protein gt500mgdl CSF glucose lt45 mgdl
bull Effusion
bull Transudate
bull Exudates
bull Lab analysis Gross exam cell count etc
bull Differential PMN Lymph Mono etc
2- Pleural Fluid Lung fluid
bull Cells unique to the lungs Mesothelial cells
bull RBCs and WBCs are limited if increased without
traumatic tap ----- indicates infarction
bull Cytology exam useful in identifying malignancy or
abnormal morphological cells
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 ro
chylothorax amylase to ro pancreatitis esoph perf Adenosine deaminase to eval TB
LIGHTrsquoS CRITERIA FOR EXUDATES
Fluid is exudate if it meets 1 of 3 criteria 1 Pleural fluid LDHserum LDH gt 062 Pleural fluid proteinserum protein gt 053 Pleural fluid LDH gt upper limit of normal
serum LDH If all 3 negative fluid is Transudate
TRANSUDATE
Result from imbalances in oncotic and hydrostatic pressure
Usually low oncotic +- high hydrostatic pressure
Pulm EdemaCHF Cirrhosis with ascites HypoalbuminemiaNephrotic
syndrome ESLD Fluid overload sp aggressive IVF Peritoneal dialysis
EXUDATE
Caused by local not systemic factors Infection Neoplasm Pancreatitis Esoph perf RA SLE Sarcoid Wegeners PE Meigrsquos
Chylothorax
LYMPHOCYTOSIS
Malignancy (50-70 lymphs) Also TB sarcoid RA chylothorax (gt90
lymphs)
PLEURAL EOSINOPHILIA
Pneumothorax Hemothorax Pulm infarct Parasitic disease
Fungal infection Drugs Malignancy Asbestos
WHY IS GLUCOSE LOW(lt60)
RA TB Empyema SLE Malignancy Esophageal rupture
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 gt 100ml (several 100) before effusion
can be detected on physical exam
Removal procedure- paracentesis
Lab analysis distinguish between transudate and exudates
gross exam cell count sedimentation chemical analysis
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
Lymphocytes CHF liver cirrhosis nephrotic syndrome
Mesothelial Cells Associated with TB effusions
Malignant cells seen with malignancy
WHAT TO SEND FLUID FOR
Cell count with diff Albumin LDH Total protein
glucose Gram staincx cytology
APPEARANCE OF FLUID
Clearmdashusually indicates uncomplicated ascites ie liver failurecirrhosis
Turbidcloudymdashinfected Pinkbloodymdashtraumatic punctured collateral
vessel malignancy Correct for bloody tap 1 WBC 750 RBC
1 PMN 250 RBC
SERUM-TO-ASCITES ALBUMIN GRADIENT (SAAG)
=Serum albumin ndash ascitic fluid albuminIf the gradient is gt11 Portal HTN (drives fluids into
peritoneum) SBP cirrhosis Alcoholic hepatitis CHFIf the gradient is lt 11(protein leaks into peritoneum and fluid
follows) Peritoneal carcinomatosis peritoneal
TB pancreatitis nephrotic syndrome
SBP SAAG gt 11 Suspect if gt250 PMNs (gt100 PMNs in pt on
peritoneal dialysis) 70 GNR (Ecoli Klebsiella)
30 GPC (S pneumo Enterococcus) Treat with ceftriaxone cefotaxime ldquoCulture negative SBPrdquo if gt250 PMNs but cx
neg treat the same
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
Measure pH pH less than 70 associated with infection or
rheumatoid disorder
Cell count see limited RBCs and WBCs
Evaluate sedimentation
bull Examine physical chemical and microscopic detail
bull Count number of sperm report morphology and
motility
bull Specimen must be a fresh collection-clean sterile
container
bull Gross Exam Color pH Volume and viscosity
bull Agglutination study
5- Seminal Fluid
bull Joint Fluid normally clear viscous
bull Functions as a lubricate and transports nutrient
bull Arthrocentesis aspirate of the joint fluid aseptic
technique
bull Lab Assay Gross exam microscopic exam Gram
stain cultures
6- Synovial Fluid
bull Appearance clear transparent viscous
bull Viscosity test
bull Mucin Clot test
bull Note crystals (intracellular vs extra cellular)
bull Slide exam usually performed on concentration of the fluid
using Giemsa or Papnicolaou
THANK YOU
Accumulation of fluids in body cavities
Transudates
bull Increased hydrostatic pressure Congestive heart failure
bull Decreased oncotic pressure (decreased albumin) liver cirrhosis nephrosis and malnutrition
Exudate
bull Inflammation Infection infarction hemorrhage
bull Tumor
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 3mgdl More than 3mgdl
Clots No Yes
cells Usually benign
Few mesothelial
cells few histocytes
and lymphocytes
More mesothelial cells
acute or chronic
inflammatory cells
RBCs malignant cells
MODIFIED TRANSUDATE
Moderate protein concentration 2525- 75gdl
Moderate cellularity 1000-7000 cells μg Cardiovascular disease Neoplastic disease Rupture of urinary bladder Hepatic disease
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 eg TB
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
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
SAMPLE COLLECTION
FNA of effusion fluids
Tapping
Collection and preparation of specimen
FIXATION
1ml of heparin + 100ml of effusion fluid to prevent
clotting
NB do not use alcohol in fixation of fluid before
spread cytological smear on glass slides
TYPES OF STAINING SMEARS
PAP
Gram Stain
Hx amp E
Cell block for remnant sediment and histopathological
examination
Other special stains for the most suspected diseases to
confirm diagnosis
Heparinized bottles (3 units heparinml) 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 HampE stain
Air-dried cytocentrifuge preparation
(Hematologic malignancy is suspected)
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
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
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
PMN are few associated with Viral and acute bacterial
inflammation
Macrophages are few in number associated with malignancy
hemorrhage inflammation
EosinophilsBasophils not normally seen in CSF
Plasma cells not normally present associated with viral disorders
and Hodgkins diseases
Red Blood Cells Few to none present
Mesothelial cells not present
Malignant cells will see with malignant disease and infiltrate
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
NORMAL CSF COMPOSITION
Clear color lt5 RBCrsquos lt5 WBCrsquos Protein 23-38mgdl (can use 14-45) Glucosemdash60 of serum level (75-100)
OPENING PRESSURE
Normal = 80-180 mmHg Obese pts up to 250mmHg can be normal Pathologically elevated gt250mmHg If elevated likely due to cerebral edema from
intracranial pathology Infection (cryptococcal meningitis) tumor
benign ICH (pseudotumor)
RBCS
Always send tube 1 and 4 for cell count and compare RBCs
Traumatic tap Elev RBC in tube 1 nl in tube 41000 RBC 1 WBC to adjust WBC count in
bloody tap
SAH or HSV Elev RBC in tube 1 AND tube 4
ldquoCrenated RBCsrdquo and xanthochromia (yellow supernatant after centrifuge)Seen in hyperbilirubinemia (ESLD) old SAH
old blood from prior traumatic LP or bleed
WBCrsquoS
Infection PMN predominance likely bacterial
meningitis Lymphocytic predominance viral vs fungal
vs TB vs malignancy
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)
GLUCOSE
Normal Viral infectionLow glucose Bacterial meningitis TB fungalReally low lt18 is strongly suggestive of bacterial
meningitis
TYPICAL VIRAL MENINGITIS
CSF WBC elevated but lt250 (first PMNs then lymphocytes)
CSF protein elevated but lt150 Glucose gt 50 of serum concentration
TYPICAL BACTERIAL MENINGITIS
CSF WBC gt1000 PMN predominance CSF protein gt500mgdl CSF glucose lt45 mgdl
bull Effusion
bull Transudate
bull Exudates
bull Lab analysis Gross exam cell count etc
bull Differential PMN Lymph Mono etc
2- Pleural Fluid Lung fluid
bull Cells unique to the lungs Mesothelial cells
bull RBCs and WBCs are limited if increased without
traumatic tap ----- indicates infarction
bull Cytology exam useful in identifying malignancy or
abnormal morphological cells
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 ro
chylothorax amylase to ro pancreatitis esoph perf Adenosine deaminase to eval TB
LIGHTrsquoS CRITERIA FOR EXUDATES
Fluid is exudate if it meets 1 of 3 criteria 1 Pleural fluid LDHserum LDH gt 062 Pleural fluid proteinserum protein gt 053 Pleural fluid LDH gt upper limit of normal
serum LDH If all 3 negative fluid is Transudate
TRANSUDATE
Result from imbalances in oncotic and hydrostatic pressure
Usually low oncotic +- high hydrostatic pressure
Pulm EdemaCHF Cirrhosis with ascites HypoalbuminemiaNephrotic
syndrome ESLD Fluid overload sp aggressive IVF Peritoneal dialysis
EXUDATE
Caused by local not systemic factors Infection Neoplasm Pancreatitis Esoph perf RA SLE Sarcoid Wegeners PE Meigrsquos
Chylothorax
LYMPHOCYTOSIS
Malignancy (50-70 lymphs) Also TB sarcoid RA chylothorax (gt90
lymphs)
PLEURAL EOSINOPHILIA
Pneumothorax Hemothorax Pulm infarct Parasitic disease
Fungal infection Drugs Malignancy Asbestos
WHY IS GLUCOSE LOW(lt60)
RA TB Empyema SLE Malignancy Esophageal rupture
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 gt 100ml (several 100) before effusion
can be detected on physical exam
Removal procedure- paracentesis
Lab analysis distinguish between transudate and exudates
gross exam cell count sedimentation chemical analysis
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
Lymphocytes CHF liver cirrhosis nephrotic syndrome
Mesothelial Cells Associated with TB effusions
Malignant cells seen with malignancy
WHAT TO SEND FLUID FOR
Cell count with diff Albumin LDH Total protein
glucose Gram staincx cytology
APPEARANCE OF FLUID
Clearmdashusually indicates uncomplicated ascites ie liver failurecirrhosis
Turbidcloudymdashinfected Pinkbloodymdashtraumatic punctured collateral
vessel malignancy Correct for bloody tap 1 WBC 750 RBC
1 PMN 250 RBC
SERUM-TO-ASCITES ALBUMIN GRADIENT (SAAG)
=Serum albumin ndash ascitic fluid albuminIf the gradient is gt11 Portal HTN (drives fluids into
peritoneum) SBP cirrhosis Alcoholic hepatitis CHFIf the gradient is lt 11(protein leaks into peritoneum and fluid
follows) Peritoneal carcinomatosis peritoneal
TB pancreatitis nephrotic syndrome
SBP SAAG gt 11 Suspect if gt250 PMNs (gt100 PMNs in pt on
peritoneal dialysis) 70 GNR (Ecoli Klebsiella)
30 GPC (S pneumo Enterococcus) Treat with ceftriaxone cefotaxime ldquoCulture negative SBPrdquo if gt250 PMNs but cx
neg treat the same
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
Measure pH pH less than 70 associated with infection or
rheumatoid disorder
Cell count see limited RBCs and WBCs
Evaluate sedimentation
bull Examine physical chemical and microscopic detail
bull Count number of sperm report morphology and
motility
bull Specimen must be a fresh collection-clean sterile
container
bull Gross Exam Color pH Volume and viscosity
bull Agglutination study
5- Seminal Fluid
bull Joint Fluid normally clear viscous
bull Functions as a lubricate and transports nutrient
bull Arthrocentesis aspirate of the joint fluid aseptic
technique
bull Lab Assay Gross exam microscopic exam Gram
stain cultures
6- Synovial Fluid
bull Appearance clear transparent viscous
bull Viscosity test
bull Mucin Clot test
bull Note crystals (intracellular vs extra cellular)
bull Slide exam usually performed on concentration of the fluid
using Giemsa or Papnicolaou
THANK YOU
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 3mgdl More than 3mgdl
Clots No Yes
cells Usually benign
Few mesothelial
cells few histocytes
and lymphocytes
More mesothelial cells
acute or chronic
inflammatory cells
RBCs malignant cells
MODIFIED TRANSUDATE
Moderate protein concentration 2525- 75gdl
Moderate cellularity 1000-7000 cells μg Cardiovascular disease Neoplastic disease Rupture of urinary bladder Hepatic disease
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 eg TB
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
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
SAMPLE COLLECTION
FNA of effusion fluids
Tapping
Collection and preparation of specimen
FIXATION
1ml of heparin + 100ml of effusion fluid to prevent
clotting
NB do not use alcohol in fixation of fluid before
spread cytological smear on glass slides
TYPES OF STAINING SMEARS
PAP
Gram Stain
Hx amp E
Cell block for remnant sediment and histopathological
examination
Other special stains for the most suspected diseases to
confirm diagnosis
Heparinized bottles (3 units heparinml) 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 HampE stain
Air-dried cytocentrifuge preparation
(Hematologic malignancy is suspected)
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
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
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
PMN are few associated with Viral and acute bacterial
inflammation
Macrophages are few in number associated with malignancy
hemorrhage inflammation
EosinophilsBasophils not normally seen in CSF
Plasma cells not normally present associated with viral disorders
and Hodgkins diseases
Red Blood Cells Few to none present
Mesothelial cells not present
Malignant cells will see with malignant disease and infiltrate
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
NORMAL CSF COMPOSITION
Clear color lt5 RBCrsquos lt5 WBCrsquos Protein 23-38mgdl (can use 14-45) Glucosemdash60 of serum level (75-100)
OPENING PRESSURE
Normal = 80-180 mmHg Obese pts up to 250mmHg can be normal Pathologically elevated gt250mmHg If elevated likely due to cerebral edema from
intracranial pathology Infection (cryptococcal meningitis) tumor
benign ICH (pseudotumor)
RBCS
Always send tube 1 and 4 for cell count and compare RBCs
Traumatic tap Elev RBC in tube 1 nl in tube 41000 RBC 1 WBC to adjust WBC count in
bloody tap
SAH or HSV Elev RBC in tube 1 AND tube 4
ldquoCrenated RBCsrdquo and xanthochromia (yellow supernatant after centrifuge)Seen in hyperbilirubinemia (ESLD) old SAH
old blood from prior traumatic LP or bleed
WBCrsquoS
Infection PMN predominance likely bacterial
meningitis Lymphocytic predominance viral vs fungal
vs TB vs malignancy
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)
GLUCOSE
Normal Viral infectionLow glucose Bacterial meningitis TB fungalReally low lt18 is strongly suggestive of bacterial
meningitis
TYPICAL VIRAL MENINGITIS
CSF WBC elevated but lt250 (first PMNs then lymphocytes)
CSF protein elevated but lt150 Glucose gt 50 of serum concentration
TYPICAL BACTERIAL MENINGITIS
CSF WBC gt1000 PMN predominance CSF protein gt500mgdl CSF glucose lt45 mgdl
bull Effusion
bull Transudate
bull Exudates
bull Lab analysis Gross exam cell count etc
bull Differential PMN Lymph Mono etc
2- Pleural Fluid Lung fluid
bull Cells unique to the lungs Mesothelial cells
bull RBCs and WBCs are limited if increased without
traumatic tap ----- indicates infarction
bull Cytology exam useful in identifying malignancy or
abnormal morphological cells
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 ro
chylothorax amylase to ro pancreatitis esoph perf Adenosine deaminase to eval TB
LIGHTrsquoS CRITERIA FOR EXUDATES
Fluid is exudate if it meets 1 of 3 criteria 1 Pleural fluid LDHserum LDH gt 062 Pleural fluid proteinserum protein gt 053 Pleural fluid LDH gt upper limit of normal
serum LDH If all 3 negative fluid is Transudate
TRANSUDATE
Result from imbalances in oncotic and hydrostatic pressure
Usually low oncotic +- high hydrostatic pressure
Pulm EdemaCHF Cirrhosis with ascites HypoalbuminemiaNephrotic
syndrome ESLD Fluid overload sp aggressive IVF Peritoneal dialysis
EXUDATE
Caused by local not systemic factors Infection Neoplasm Pancreatitis Esoph perf RA SLE Sarcoid Wegeners PE Meigrsquos
Chylothorax
LYMPHOCYTOSIS
Malignancy (50-70 lymphs) Also TB sarcoid RA chylothorax (gt90
lymphs)
PLEURAL EOSINOPHILIA
Pneumothorax Hemothorax Pulm infarct Parasitic disease
Fungal infection Drugs Malignancy Asbestos
WHY IS GLUCOSE LOW(lt60)
RA TB Empyema SLE Malignancy Esophageal rupture
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 gt 100ml (several 100) before effusion
can be detected on physical exam
Removal procedure- paracentesis
Lab analysis distinguish between transudate and exudates
gross exam cell count sedimentation chemical analysis
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
Lymphocytes CHF liver cirrhosis nephrotic syndrome
Mesothelial Cells Associated with TB effusions
Malignant cells seen with malignancy
WHAT TO SEND FLUID FOR
Cell count with diff Albumin LDH Total protein
glucose Gram staincx cytology
APPEARANCE OF FLUID
Clearmdashusually indicates uncomplicated ascites ie liver failurecirrhosis
Turbidcloudymdashinfected Pinkbloodymdashtraumatic punctured collateral
vessel malignancy Correct for bloody tap 1 WBC 750 RBC
1 PMN 250 RBC
SERUM-TO-ASCITES ALBUMIN GRADIENT (SAAG)
=Serum albumin ndash ascitic fluid albuminIf the gradient is gt11 Portal HTN (drives fluids into
peritoneum) SBP cirrhosis Alcoholic hepatitis CHFIf the gradient is lt 11(protein leaks into peritoneum and fluid
follows) Peritoneal carcinomatosis peritoneal
TB pancreatitis nephrotic syndrome
SBP SAAG gt 11 Suspect if gt250 PMNs (gt100 PMNs in pt on
peritoneal dialysis) 70 GNR (Ecoli Klebsiella)
30 GPC (S pneumo Enterococcus) Treat with ceftriaxone cefotaxime ldquoCulture negative SBPrdquo if gt250 PMNs but cx
neg treat the same
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
Measure pH pH less than 70 associated with infection or
rheumatoid disorder
Cell count see limited RBCs and WBCs
Evaluate sedimentation
bull Examine physical chemical and microscopic detail
bull Count number of sperm report morphology and
motility
bull Specimen must be a fresh collection-clean sterile
container
bull Gross Exam Color pH Volume and viscosity
bull Agglutination study
5- Seminal Fluid
bull Joint Fluid normally clear viscous
bull Functions as a lubricate and transports nutrient
bull Arthrocentesis aspirate of the joint fluid aseptic
technique
bull Lab Assay Gross exam microscopic exam Gram
stain cultures
6- Synovial Fluid
bull Appearance clear transparent viscous
bull Viscosity test
bull Mucin Clot test
bull Note crystals (intracellular vs extra cellular)
bull Slide exam usually performed on concentration of the fluid
using Giemsa or Papnicolaou
THANK YOU
MODIFIED TRANSUDATE
Moderate protein concentration 2525- 75gdl
Moderate cellularity 1000-7000 cells μg Cardiovascular disease Neoplastic disease Rupture of urinary bladder Hepatic disease
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 eg TB
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
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
SAMPLE COLLECTION
FNA of effusion fluids
Tapping
Collection and preparation of specimen
FIXATION
1ml of heparin + 100ml of effusion fluid to prevent
clotting
NB do not use alcohol in fixation of fluid before
spread cytological smear on glass slides
TYPES OF STAINING SMEARS
PAP
Gram Stain
Hx amp E
Cell block for remnant sediment and histopathological
examination
Other special stains for the most suspected diseases to
confirm diagnosis
Heparinized bottles (3 units heparinml) 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 HampE stain
Air-dried cytocentrifuge preparation
(Hematologic malignancy is suspected)
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
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
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
PMN are few associated with Viral and acute bacterial
inflammation
Macrophages are few in number associated with malignancy
hemorrhage inflammation
EosinophilsBasophils not normally seen in CSF
Plasma cells not normally present associated with viral disorders
and Hodgkins diseases
Red Blood Cells Few to none present
Mesothelial cells not present
Malignant cells will see with malignant disease and infiltrate
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
NORMAL CSF COMPOSITION
Clear color lt5 RBCrsquos lt5 WBCrsquos Protein 23-38mgdl (can use 14-45) Glucosemdash60 of serum level (75-100)
OPENING PRESSURE
Normal = 80-180 mmHg Obese pts up to 250mmHg can be normal Pathologically elevated gt250mmHg If elevated likely due to cerebral edema from
intracranial pathology Infection (cryptococcal meningitis) tumor
benign ICH (pseudotumor)
RBCS
Always send tube 1 and 4 for cell count and compare RBCs
Traumatic tap Elev RBC in tube 1 nl in tube 41000 RBC 1 WBC to adjust WBC count in
bloody tap
SAH or HSV Elev RBC in tube 1 AND tube 4
ldquoCrenated RBCsrdquo and xanthochromia (yellow supernatant after centrifuge)Seen in hyperbilirubinemia (ESLD) old SAH
old blood from prior traumatic LP or bleed
WBCrsquoS
Infection PMN predominance likely bacterial
meningitis Lymphocytic predominance viral vs fungal
vs TB vs malignancy
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)
GLUCOSE
Normal Viral infectionLow glucose Bacterial meningitis TB fungalReally low lt18 is strongly suggestive of bacterial
meningitis
TYPICAL VIRAL MENINGITIS
CSF WBC elevated but lt250 (first PMNs then lymphocytes)
CSF protein elevated but lt150 Glucose gt 50 of serum concentration
TYPICAL BACTERIAL MENINGITIS
CSF WBC gt1000 PMN predominance CSF protein gt500mgdl CSF glucose lt45 mgdl
bull Effusion
bull Transudate
bull Exudates
bull Lab analysis Gross exam cell count etc
bull Differential PMN Lymph Mono etc
2- Pleural Fluid Lung fluid
bull Cells unique to the lungs Mesothelial cells
bull RBCs and WBCs are limited if increased without
traumatic tap ----- indicates infarction
bull Cytology exam useful in identifying malignancy or
abnormal morphological cells
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 ro
chylothorax amylase to ro pancreatitis esoph perf Adenosine deaminase to eval TB
LIGHTrsquoS CRITERIA FOR EXUDATES
Fluid is exudate if it meets 1 of 3 criteria 1 Pleural fluid LDHserum LDH gt 062 Pleural fluid proteinserum protein gt 053 Pleural fluid LDH gt upper limit of normal
serum LDH If all 3 negative fluid is Transudate
TRANSUDATE
Result from imbalances in oncotic and hydrostatic pressure
Usually low oncotic +- high hydrostatic pressure
Pulm EdemaCHF Cirrhosis with ascites HypoalbuminemiaNephrotic
syndrome ESLD Fluid overload sp aggressive IVF Peritoneal dialysis
EXUDATE
Caused by local not systemic factors Infection Neoplasm Pancreatitis Esoph perf RA SLE Sarcoid Wegeners PE Meigrsquos
Chylothorax
LYMPHOCYTOSIS
Malignancy (50-70 lymphs) Also TB sarcoid RA chylothorax (gt90
lymphs)
PLEURAL EOSINOPHILIA
Pneumothorax Hemothorax Pulm infarct Parasitic disease
Fungal infection Drugs Malignancy Asbestos
WHY IS GLUCOSE LOW(lt60)
RA TB Empyema SLE Malignancy Esophageal rupture
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 gt 100ml (several 100) before effusion
can be detected on physical exam
Removal procedure- paracentesis
Lab analysis distinguish between transudate and exudates
gross exam cell count sedimentation chemical analysis
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
Lymphocytes CHF liver cirrhosis nephrotic syndrome
Mesothelial Cells Associated with TB effusions
Malignant cells seen with malignancy
WHAT TO SEND FLUID FOR
Cell count with diff Albumin LDH Total protein
glucose Gram staincx cytology
APPEARANCE OF FLUID
Clearmdashusually indicates uncomplicated ascites ie liver failurecirrhosis
Turbidcloudymdashinfected Pinkbloodymdashtraumatic punctured collateral
vessel malignancy Correct for bloody tap 1 WBC 750 RBC
1 PMN 250 RBC
SERUM-TO-ASCITES ALBUMIN GRADIENT (SAAG)
=Serum albumin ndash ascitic fluid albuminIf the gradient is gt11 Portal HTN (drives fluids into
peritoneum) SBP cirrhosis Alcoholic hepatitis CHFIf the gradient is lt 11(protein leaks into peritoneum and fluid
follows) Peritoneal carcinomatosis peritoneal
TB pancreatitis nephrotic syndrome
SBP SAAG gt 11 Suspect if gt250 PMNs (gt100 PMNs in pt on
peritoneal dialysis) 70 GNR (Ecoli Klebsiella)
30 GPC (S pneumo Enterococcus) Treat with ceftriaxone cefotaxime ldquoCulture negative SBPrdquo if gt250 PMNs but cx
neg treat the same
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
Measure pH pH less than 70 associated with infection or
rheumatoid disorder
Cell count see limited RBCs and WBCs
Evaluate sedimentation
bull Examine physical chemical and microscopic detail
bull Count number of sperm report morphology and
motility
bull Specimen must be a fresh collection-clean sterile
container
bull Gross Exam Color pH Volume and viscosity
bull Agglutination study
5- Seminal Fluid
bull Joint Fluid normally clear viscous
bull Functions as a lubricate and transports nutrient
bull Arthrocentesis aspirate of the joint fluid aseptic
technique
bull Lab Assay Gross exam microscopic exam Gram
stain cultures
6- Synovial Fluid
bull Appearance clear transparent viscous
bull Viscosity test
bull Mucin Clot test
bull Note crystals (intracellular vs extra cellular)
bull Slide exam usually performed on concentration of the fluid
using Giemsa or Papnicolaou
THANK YOU
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 eg TB
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
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
SAMPLE COLLECTION
FNA of effusion fluids
Tapping
Collection and preparation of specimen
FIXATION
1ml of heparin + 100ml of effusion fluid to prevent
clotting
NB do not use alcohol in fixation of fluid before
spread cytological smear on glass slides
TYPES OF STAINING SMEARS
PAP
Gram Stain
Hx amp E
Cell block for remnant sediment and histopathological
examination
Other special stains for the most suspected diseases to
confirm diagnosis
Heparinized bottles (3 units heparinml) 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 HampE stain
Air-dried cytocentrifuge preparation
(Hematologic malignancy is suspected)
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
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
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
PMN are few associated with Viral and acute bacterial
inflammation
Macrophages are few in number associated with malignancy
hemorrhage inflammation
EosinophilsBasophils not normally seen in CSF
Plasma cells not normally present associated with viral disorders
and Hodgkins diseases
Red Blood Cells Few to none present
Mesothelial cells not present
Malignant cells will see with malignant disease and infiltrate
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
NORMAL CSF COMPOSITION
Clear color lt5 RBCrsquos lt5 WBCrsquos Protein 23-38mgdl (can use 14-45) Glucosemdash60 of serum level (75-100)
OPENING PRESSURE
Normal = 80-180 mmHg Obese pts up to 250mmHg can be normal Pathologically elevated gt250mmHg If elevated likely due to cerebral edema from
intracranial pathology Infection (cryptococcal meningitis) tumor
benign ICH (pseudotumor)
RBCS
Always send tube 1 and 4 for cell count and compare RBCs
Traumatic tap Elev RBC in tube 1 nl in tube 41000 RBC 1 WBC to adjust WBC count in
bloody tap
SAH or HSV Elev RBC in tube 1 AND tube 4
ldquoCrenated RBCsrdquo and xanthochromia (yellow supernatant after centrifuge)Seen in hyperbilirubinemia (ESLD) old SAH
old blood from prior traumatic LP or bleed
WBCrsquoS
Infection PMN predominance likely bacterial
meningitis Lymphocytic predominance viral vs fungal
vs TB vs malignancy
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)
GLUCOSE
Normal Viral infectionLow glucose Bacterial meningitis TB fungalReally low lt18 is strongly suggestive of bacterial
meningitis
TYPICAL VIRAL MENINGITIS
CSF WBC elevated but lt250 (first PMNs then lymphocytes)
CSF protein elevated but lt150 Glucose gt 50 of serum concentration
TYPICAL BACTERIAL MENINGITIS
CSF WBC gt1000 PMN predominance CSF protein gt500mgdl CSF glucose lt45 mgdl
bull Effusion
bull Transudate
bull Exudates
bull Lab analysis Gross exam cell count etc
bull Differential PMN Lymph Mono etc
2- Pleural Fluid Lung fluid
bull Cells unique to the lungs Mesothelial cells
bull RBCs and WBCs are limited if increased without
traumatic tap ----- indicates infarction
bull Cytology exam useful in identifying malignancy or
abnormal morphological cells
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 ro
chylothorax amylase to ro pancreatitis esoph perf Adenosine deaminase to eval TB
LIGHTrsquoS CRITERIA FOR EXUDATES
Fluid is exudate if it meets 1 of 3 criteria 1 Pleural fluid LDHserum LDH gt 062 Pleural fluid proteinserum protein gt 053 Pleural fluid LDH gt upper limit of normal
serum LDH If all 3 negative fluid is Transudate
TRANSUDATE
Result from imbalances in oncotic and hydrostatic pressure
Usually low oncotic +- high hydrostatic pressure
Pulm EdemaCHF Cirrhosis with ascites HypoalbuminemiaNephrotic
syndrome ESLD Fluid overload sp aggressive IVF Peritoneal dialysis
EXUDATE
Caused by local not systemic factors Infection Neoplasm Pancreatitis Esoph perf RA SLE Sarcoid Wegeners PE Meigrsquos
Chylothorax
LYMPHOCYTOSIS
Malignancy (50-70 lymphs) Also TB sarcoid RA chylothorax (gt90
lymphs)
PLEURAL EOSINOPHILIA
Pneumothorax Hemothorax Pulm infarct Parasitic disease
Fungal infection Drugs Malignancy Asbestos
WHY IS GLUCOSE LOW(lt60)
RA TB Empyema SLE Malignancy Esophageal rupture
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 gt 100ml (several 100) before effusion
can be detected on physical exam
Removal procedure- paracentesis
Lab analysis distinguish between transudate and exudates
gross exam cell count sedimentation chemical analysis
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
Lymphocytes CHF liver cirrhosis nephrotic syndrome
Mesothelial Cells Associated with TB effusions
Malignant cells seen with malignancy
WHAT TO SEND FLUID FOR
Cell count with diff Albumin LDH Total protein
glucose Gram staincx cytology
APPEARANCE OF FLUID
Clearmdashusually indicates uncomplicated ascites ie liver failurecirrhosis
Turbidcloudymdashinfected Pinkbloodymdashtraumatic punctured collateral
vessel malignancy Correct for bloody tap 1 WBC 750 RBC
1 PMN 250 RBC
SERUM-TO-ASCITES ALBUMIN GRADIENT (SAAG)
=Serum albumin ndash ascitic fluid albuminIf the gradient is gt11 Portal HTN (drives fluids into
peritoneum) SBP cirrhosis Alcoholic hepatitis CHFIf the gradient is lt 11(protein leaks into peritoneum and fluid
follows) Peritoneal carcinomatosis peritoneal
TB pancreatitis nephrotic syndrome
SBP SAAG gt 11 Suspect if gt250 PMNs (gt100 PMNs in pt on
peritoneal dialysis) 70 GNR (Ecoli Klebsiella)
30 GPC (S pneumo Enterococcus) Treat with ceftriaxone cefotaxime ldquoCulture negative SBPrdquo if gt250 PMNs but cx
neg treat the same
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
Measure pH pH less than 70 associated with infection or
rheumatoid disorder
Cell count see limited RBCs and WBCs
Evaluate sedimentation
bull Examine physical chemical and microscopic detail
bull Count number of sperm report morphology and
motility
bull Specimen must be a fresh collection-clean sterile
container
bull Gross Exam Color pH Volume and viscosity
bull Agglutination study
5- Seminal Fluid
bull Joint Fluid normally clear viscous
bull Functions as a lubricate and transports nutrient
bull Arthrocentesis aspirate of the joint fluid aseptic
technique
bull Lab Assay Gross exam microscopic exam Gram
stain cultures
6- Synovial Fluid
bull Appearance clear transparent viscous
bull Viscosity test
bull Mucin Clot test
bull Note crystals (intracellular vs extra cellular)
bull Slide exam usually performed on concentration of the fluid
using Giemsa or Papnicolaou
THANK YOU
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
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
SAMPLE COLLECTION
FNA of effusion fluids
Tapping
Collection and preparation of specimen
FIXATION
1ml of heparin + 100ml of effusion fluid to prevent
clotting
NB do not use alcohol in fixation of fluid before
spread cytological smear on glass slides
TYPES OF STAINING SMEARS
PAP
Gram Stain
Hx amp E
Cell block for remnant sediment and histopathological
examination
Other special stains for the most suspected diseases to
confirm diagnosis
Heparinized bottles (3 units heparinml) 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 HampE stain
Air-dried cytocentrifuge preparation
(Hematologic malignancy is suspected)
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
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
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
PMN are few associated with Viral and acute bacterial
inflammation
Macrophages are few in number associated with malignancy
hemorrhage inflammation
EosinophilsBasophils not normally seen in CSF
Plasma cells not normally present associated with viral disorders
and Hodgkins diseases
Red Blood Cells Few to none present
Mesothelial cells not present
Malignant cells will see with malignant disease and infiltrate
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
NORMAL CSF COMPOSITION
Clear color lt5 RBCrsquos lt5 WBCrsquos Protein 23-38mgdl (can use 14-45) Glucosemdash60 of serum level (75-100)
OPENING PRESSURE
Normal = 80-180 mmHg Obese pts up to 250mmHg can be normal Pathologically elevated gt250mmHg If elevated likely due to cerebral edema from
intracranial pathology Infection (cryptococcal meningitis) tumor
benign ICH (pseudotumor)
RBCS
Always send tube 1 and 4 for cell count and compare RBCs
Traumatic tap Elev RBC in tube 1 nl in tube 41000 RBC 1 WBC to adjust WBC count in
bloody tap
SAH or HSV Elev RBC in tube 1 AND tube 4
ldquoCrenated RBCsrdquo and xanthochromia (yellow supernatant after centrifuge)Seen in hyperbilirubinemia (ESLD) old SAH
old blood from prior traumatic LP or bleed
WBCrsquoS
Infection PMN predominance likely bacterial
meningitis Lymphocytic predominance viral vs fungal
vs TB vs malignancy
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)
GLUCOSE
Normal Viral infectionLow glucose Bacterial meningitis TB fungalReally low lt18 is strongly suggestive of bacterial
meningitis
TYPICAL VIRAL MENINGITIS
CSF WBC elevated but lt250 (first PMNs then lymphocytes)
CSF protein elevated but lt150 Glucose gt 50 of serum concentration
TYPICAL BACTERIAL MENINGITIS
CSF WBC gt1000 PMN predominance CSF protein gt500mgdl CSF glucose lt45 mgdl
bull Effusion
bull Transudate
bull Exudates
bull Lab analysis Gross exam cell count etc
bull Differential PMN Lymph Mono etc
2- Pleural Fluid Lung fluid
bull Cells unique to the lungs Mesothelial cells
bull RBCs and WBCs are limited if increased without
traumatic tap ----- indicates infarction
bull Cytology exam useful in identifying malignancy or
abnormal morphological cells
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 ro
chylothorax amylase to ro pancreatitis esoph perf Adenosine deaminase to eval TB
LIGHTrsquoS CRITERIA FOR EXUDATES
Fluid is exudate if it meets 1 of 3 criteria 1 Pleural fluid LDHserum LDH gt 062 Pleural fluid proteinserum protein gt 053 Pleural fluid LDH gt upper limit of normal
serum LDH If all 3 negative fluid is Transudate
TRANSUDATE
Result from imbalances in oncotic and hydrostatic pressure
Usually low oncotic +- high hydrostatic pressure
Pulm EdemaCHF Cirrhosis with ascites HypoalbuminemiaNephrotic
syndrome ESLD Fluid overload sp aggressive IVF Peritoneal dialysis
EXUDATE
Caused by local not systemic factors Infection Neoplasm Pancreatitis Esoph perf RA SLE Sarcoid Wegeners PE Meigrsquos
Chylothorax
LYMPHOCYTOSIS
Malignancy (50-70 lymphs) Also TB sarcoid RA chylothorax (gt90
lymphs)
PLEURAL EOSINOPHILIA
Pneumothorax Hemothorax Pulm infarct Parasitic disease
Fungal infection Drugs Malignancy Asbestos
WHY IS GLUCOSE LOW(lt60)
RA TB Empyema SLE Malignancy Esophageal rupture
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 gt 100ml (several 100) before effusion
can be detected on physical exam
Removal procedure- paracentesis
Lab analysis distinguish between transudate and exudates
gross exam cell count sedimentation chemical analysis
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
Lymphocytes CHF liver cirrhosis nephrotic syndrome
Mesothelial Cells Associated with TB effusions
Malignant cells seen with malignancy
WHAT TO SEND FLUID FOR
Cell count with diff Albumin LDH Total protein
glucose Gram staincx cytology
APPEARANCE OF FLUID
Clearmdashusually indicates uncomplicated ascites ie liver failurecirrhosis
Turbidcloudymdashinfected Pinkbloodymdashtraumatic punctured collateral
vessel malignancy Correct for bloody tap 1 WBC 750 RBC
1 PMN 250 RBC
SERUM-TO-ASCITES ALBUMIN GRADIENT (SAAG)
=Serum albumin ndash ascitic fluid albuminIf the gradient is gt11 Portal HTN (drives fluids into
peritoneum) SBP cirrhosis Alcoholic hepatitis CHFIf the gradient is lt 11(protein leaks into peritoneum and fluid
follows) Peritoneal carcinomatosis peritoneal
TB pancreatitis nephrotic syndrome
SBP SAAG gt 11 Suspect if gt250 PMNs (gt100 PMNs in pt on
peritoneal dialysis) 70 GNR (Ecoli Klebsiella)
30 GPC (S pneumo Enterococcus) Treat with ceftriaxone cefotaxime ldquoCulture negative SBPrdquo if gt250 PMNs but cx
neg treat the same
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
Measure pH pH less than 70 associated with infection or
rheumatoid disorder
Cell count see limited RBCs and WBCs
Evaluate sedimentation
bull Examine physical chemical and microscopic detail
bull Count number of sperm report morphology and
motility
bull Specimen must be a fresh collection-clean sterile
container
bull Gross Exam Color pH Volume and viscosity
bull Agglutination study
5- Seminal Fluid
bull Joint Fluid normally clear viscous
bull Functions as a lubricate and transports nutrient
bull Arthrocentesis aspirate of the joint fluid aseptic
technique
bull Lab Assay Gross exam microscopic exam Gram
stain cultures
6- Synovial Fluid
bull Appearance clear transparent viscous
bull Viscosity test
bull Mucin Clot test
bull Note crystals (intracellular vs extra cellular)
bull Slide exam usually performed on concentration of the fluid
using Giemsa or Papnicolaou
THANK YOU
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
SAMPLE COLLECTION
FNA of effusion fluids
Tapping
Collection and preparation of specimen
FIXATION
1ml of heparin + 100ml of effusion fluid to prevent
clotting
NB do not use alcohol in fixation of fluid before
spread cytological smear on glass slides
TYPES OF STAINING SMEARS
PAP
Gram Stain
Hx amp E
Cell block for remnant sediment and histopathological
examination
Other special stains for the most suspected diseases to
confirm diagnosis
Heparinized bottles (3 units heparinml) 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 HampE stain
Air-dried cytocentrifuge preparation
(Hematologic malignancy is suspected)
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
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
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
PMN are few associated with Viral and acute bacterial
inflammation
Macrophages are few in number associated with malignancy
hemorrhage inflammation
EosinophilsBasophils not normally seen in CSF
Plasma cells not normally present associated with viral disorders
and Hodgkins diseases
Red Blood Cells Few to none present
Mesothelial cells not present
Malignant cells will see with malignant disease and infiltrate
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
NORMAL CSF COMPOSITION
Clear color lt5 RBCrsquos lt5 WBCrsquos Protein 23-38mgdl (can use 14-45) Glucosemdash60 of serum level (75-100)
OPENING PRESSURE
Normal = 80-180 mmHg Obese pts up to 250mmHg can be normal Pathologically elevated gt250mmHg If elevated likely due to cerebral edema from
intracranial pathology Infection (cryptococcal meningitis) tumor
benign ICH (pseudotumor)
RBCS
Always send tube 1 and 4 for cell count and compare RBCs
Traumatic tap Elev RBC in tube 1 nl in tube 41000 RBC 1 WBC to adjust WBC count in
bloody tap
SAH or HSV Elev RBC in tube 1 AND tube 4
ldquoCrenated RBCsrdquo and xanthochromia (yellow supernatant after centrifuge)Seen in hyperbilirubinemia (ESLD) old SAH
old blood from prior traumatic LP or bleed
WBCrsquoS
Infection PMN predominance likely bacterial
meningitis Lymphocytic predominance viral vs fungal
vs TB vs malignancy
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)
GLUCOSE
Normal Viral infectionLow glucose Bacterial meningitis TB fungalReally low lt18 is strongly suggestive of bacterial
meningitis
TYPICAL VIRAL MENINGITIS
CSF WBC elevated but lt250 (first PMNs then lymphocytes)
CSF protein elevated but lt150 Glucose gt 50 of serum concentration
TYPICAL BACTERIAL MENINGITIS
CSF WBC gt1000 PMN predominance CSF protein gt500mgdl CSF glucose lt45 mgdl
bull Effusion
bull Transudate
bull Exudates
bull Lab analysis Gross exam cell count etc
bull Differential PMN Lymph Mono etc
2- Pleural Fluid Lung fluid
bull Cells unique to the lungs Mesothelial cells
bull RBCs and WBCs are limited if increased without
traumatic tap ----- indicates infarction
bull Cytology exam useful in identifying malignancy or
abnormal morphological cells
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 ro
chylothorax amylase to ro pancreatitis esoph perf Adenosine deaminase to eval TB
LIGHTrsquoS CRITERIA FOR EXUDATES
Fluid is exudate if it meets 1 of 3 criteria 1 Pleural fluid LDHserum LDH gt 062 Pleural fluid proteinserum protein gt 053 Pleural fluid LDH gt upper limit of normal
serum LDH If all 3 negative fluid is Transudate
TRANSUDATE
Result from imbalances in oncotic and hydrostatic pressure
Usually low oncotic +- high hydrostatic pressure
Pulm EdemaCHF Cirrhosis with ascites HypoalbuminemiaNephrotic
syndrome ESLD Fluid overload sp aggressive IVF Peritoneal dialysis
EXUDATE
Caused by local not systemic factors Infection Neoplasm Pancreatitis Esoph perf RA SLE Sarcoid Wegeners PE Meigrsquos
Chylothorax
LYMPHOCYTOSIS
Malignancy (50-70 lymphs) Also TB sarcoid RA chylothorax (gt90
lymphs)
PLEURAL EOSINOPHILIA
Pneumothorax Hemothorax Pulm infarct Parasitic disease
Fungal infection Drugs Malignancy Asbestos
WHY IS GLUCOSE LOW(lt60)
RA TB Empyema SLE Malignancy Esophageal rupture
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 gt 100ml (several 100) before effusion
can be detected on physical exam
Removal procedure- paracentesis
Lab analysis distinguish between transudate and exudates
gross exam cell count sedimentation chemical analysis
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
Lymphocytes CHF liver cirrhosis nephrotic syndrome
Mesothelial Cells Associated with TB effusions
Malignant cells seen with malignancy
WHAT TO SEND FLUID FOR
Cell count with diff Albumin LDH Total protein
glucose Gram staincx cytology
APPEARANCE OF FLUID
Clearmdashusually indicates uncomplicated ascites ie liver failurecirrhosis
Turbidcloudymdashinfected Pinkbloodymdashtraumatic punctured collateral
vessel malignancy Correct for bloody tap 1 WBC 750 RBC
1 PMN 250 RBC
SERUM-TO-ASCITES ALBUMIN GRADIENT (SAAG)
=Serum albumin ndash ascitic fluid albuminIf the gradient is gt11 Portal HTN (drives fluids into
peritoneum) SBP cirrhosis Alcoholic hepatitis CHFIf the gradient is lt 11(protein leaks into peritoneum and fluid
follows) Peritoneal carcinomatosis peritoneal
TB pancreatitis nephrotic syndrome
SBP SAAG gt 11 Suspect if gt250 PMNs (gt100 PMNs in pt on
peritoneal dialysis) 70 GNR (Ecoli Klebsiella)
30 GPC (S pneumo Enterococcus) Treat with ceftriaxone cefotaxime ldquoCulture negative SBPrdquo if gt250 PMNs but cx
neg treat the same
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
Measure pH pH less than 70 associated with infection or
rheumatoid disorder
Cell count see limited RBCs and WBCs
Evaluate sedimentation
bull Examine physical chemical and microscopic detail
bull Count number of sperm report morphology and
motility
bull Specimen must be a fresh collection-clean sterile
container
bull Gross Exam Color pH Volume and viscosity
bull Agglutination study
5- Seminal Fluid
bull Joint Fluid normally clear viscous
bull Functions as a lubricate and transports nutrient
bull Arthrocentesis aspirate of the joint fluid aseptic
technique
bull Lab Assay Gross exam microscopic exam Gram
stain cultures
6- Synovial Fluid
bull Appearance clear transparent viscous
bull Viscosity test
bull Mucin Clot test
bull Note crystals (intracellular vs extra cellular)
bull Slide exam usually performed on concentration of the fluid
using Giemsa or Papnicolaou
THANK YOU
SAMPLE COLLECTION
FNA of effusion fluids
Tapping
Collection and preparation of specimen
FIXATION
1ml of heparin + 100ml of effusion fluid to prevent
clotting
NB do not use alcohol in fixation of fluid before
spread cytological smear on glass slides
TYPES OF STAINING SMEARS
PAP
Gram Stain
Hx amp E
Cell block for remnant sediment and histopathological
examination
Other special stains for the most suspected diseases to
confirm diagnosis
Heparinized bottles (3 units heparinml) 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 HampE stain
Air-dried cytocentrifuge preparation
(Hematologic malignancy is suspected)
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
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
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
PMN are few associated with Viral and acute bacterial
inflammation
Macrophages are few in number associated with malignancy
hemorrhage inflammation
EosinophilsBasophils not normally seen in CSF
Plasma cells not normally present associated with viral disorders
and Hodgkins diseases
Red Blood Cells Few to none present
Mesothelial cells not present
Malignant cells will see with malignant disease and infiltrate
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
NORMAL CSF COMPOSITION
Clear color lt5 RBCrsquos lt5 WBCrsquos Protein 23-38mgdl (can use 14-45) Glucosemdash60 of serum level (75-100)
OPENING PRESSURE
Normal = 80-180 mmHg Obese pts up to 250mmHg can be normal Pathologically elevated gt250mmHg If elevated likely due to cerebral edema from
intracranial pathology Infection (cryptococcal meningitis) tumor
benign ICH (pseudotumor)
RBCS
Always send tube 1 and 4 for cell count and compare RBCs
Traumatic tap Elev RBC in tube 1 nl in tube 41000 RBC 1 WBC to adjust WBC count in
bloody tap
SAH or HSV Elev RBC in tube 1 AND tube 4
ldquoCrenated RBCsrdquo and xanthochromia (yellow supernatant after centrifuge)Seen in hyperbilirubinemia (ESLD) old SAH
old blood from prior traumatic LP or bleed
WBCrsquoS
Infection PMN predominance likely bacterial
meningitis Lymphocytic predominance viral vs fungal
vs TB vs malignancy
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)
GLUCOSE
Normal Viral infectionLow glucose Bacterial meningitis TB fungalReally low lt18 is strongly suggestive of bacterial
meningitis
TYPICAL VIRAL MENINGITIS
CSF WBC elevated but lt250 (first PMNs then lymphocytes)
CSF protein elevated but lt150 Glucose gt 50 of serum concentration
TYPICAL BACTERIAL MENINGITIS
CSF WBC gt1000 PMN predominance CSF protein gt500mgdl CSF glucose lt45 mgdl
bull Effusion
bull Transudate
bull Exudates
bull Lab analysis Gross exam cell count etc
bull Differential PMN Lymph Mono etc
2- Pleural Fluid Lung fluid
bull Cells unique to the lungs Mesothelial cells
bull RBCs and WBCs are limited if increased without
traumatic tap ----- indicates infarction
bull Cytology exam useful in identifying malignancy or
abnormal morphological cells
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 ro
chylothorax amylase to ro pancreatitis esoph perf Adenosine deaminase to eval TB
LIGHTrsquoS CRITERIA FOR EXUDATES
Fluid is exudate if it meets 1 of 3 criteria 1 Pleural fluid LDHserum LDH gt 062 Pleural fluid proteinserum protein gt 053 Pleural fluid LDH gt upper limit of normal
serum LDH If all 3 negative fluid is Transudate
TRANSUDATE
Result from imbalances in oncotic and hydrostatic pressure
Usually low oncotic +- high hydrostatic pressure
Pulm EdemaCHF Cirrhosis with ascites HypoalbuminemiaNephrotic
syndrome ESLD Fluid overload sp aggressive IVF Peritoneal dialysis
EXUDATE
Caused by local not systemic factors Infection Neoplasm Pancreatitis Esoph perf RA SLE Sarcoid Wegeners PE Meigrsquos
Chylothorax
LYMPHOCYTOSIS
Malignancy (50-70 lymphs) Also TB sarcoid RA chylothorax (gt90
lymphs)
PLEURAL EOSINOPHILIA
Pneumothorax Hemothorax Pulm infarct Parasitic disease
Fungal infection Drugs Malignancy Asbestos
WHY IS GLUCOSE LOW(lt60)
RA TB Empyema SLE Malignancy Esophageal rupture
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 gt 100ml (several 100) before effusion
can be detected on physical exam
Removal procedure- paracentesis
Lab analysis distinguish between transudate and exudates
gross exam cell count sedimentation chemical analysis
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
Lymphocytes CHF liver cirrhosis nephrotic syndrome
Mesothelial Cells Associated with TB effusions
Malignant cells seen with malignancy
WHAT TO SEND FLUID FOR
Cell count with diff Albumin LDH Total protein
glucose Gram staincx cytology
APPEARANCE OF FLUID
Clearmdashusually indicates uncomplicated ascites ie liver failurecirrhosis
Turbidcloudymdashinfected Pinkbloodymdashtraumatic punctured collateral
vessel malignancy Correct for bloody tap 1 WBC 750 RBC
1 PMN 250 RBC
SERUM-TO-ASCITES ALBUMIN GRADIENT (SAAG)
=Serum albumin ndash ascitic fluid albuminIf the gradient is gt11 Portal HTN (drives fluids into
peritoneum) SBP cirrhosis Alcoholic hepatitis CHFIf the gradient is lt 11(protein leaks into peritoneum and fluid
follows) Peritoneal carcinomatosis peritoneal
TB pancreatitis nephrotic syndrome
SBP SAAG gt 11 Suspect if gt250 PMNs (gt100 PMNs in pt on
peritoneal dialysis) 70 GNR (Ecoli Klebsiella)
30 GPC (S pneumo Enterococcus) Treat with ceftriaxone cefotaxime ldquoCulture negative SBPrdquo if gt250 PMNs but cx
neg treat the same
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
Measure pH pH less than 70 associated with infection or
rheumatoid disorder
Cell count see limited RBCs and WBCs
Evaluate sedimentation
bull Examine physical chemical and microscopic detail
bull Count number of sperm report morphology and
motility
bull Specimen must be a fresh collection-clean sterile
container
bull Gross Exam Color pH Volume and viscosity
bull Agglutination study
5- Seminal Fluid
bull Joint Fluid normally clear viscous
bull Functions as a lubricate and transports nutrient
bull Arthrocentesis aspirate of the joint fluid aseptic
technique
bull Lab Assay Gross exam microscopic exam Gram
stain cultures
6- Synovial Fluid
bull Appearance clear transparent viscous
bull Viscosity test
bull Mucin Clot test
bull Note crystals (intracellular vs extra cellular)
bull Slide exam usually performed on concentration of the fluid
using Giemsa or Papnicolaou
THANK YOU
Collection and preparation of specimen
FIXATION
1ml of heparin + 100ml of effusion fluid to prevent
clotting
NB do not use alcohol in fixation of fluid before
spread cytological smear on glass slides
TYPES OF STAINING SMEARS
PAP
Gram Stain
Hx amp E
Cell block for remnant sediment and histopathological
examination
Other special stains for the most suspected diseases to
confirm diagnosis
Heparinized bottles (3 units heparinml) 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 HampE stain
Air-dried cytocentrifuge preparation
(Hematologic malignancy is suspected)
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
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
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
PMN are few associated with Viral and acute bacterial
inflammation
Macrophages are few in number associated with malignancy
hemorrhage inflammation
EosinophilsBasophils not normally seen in CSF
Plasma cells not normally present associated with viral disorders
and Hodgkins diseases
Red Blood Cells Few to none present
Mesothelial cells not present
Malignant cells will see with malignant disease and infiltrate
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
NORMAL CSF COMPOSITION
Clear color lt5 RBCrsquos lt5 WBCrsquos Protein 23-38mgdl (can use 14-45) Glucosemdash60 of serum level (75-100)
OPENING PRESSURE
Normal = 80-180 mmHg Obese pts up to 250mmHg can be normal Pathologically elevated gt250mmHg If elevated likely due to cerebral edema from
intracranial pathology Infection (cryptococcal meningitis) tumor
benign ICH (pseudotumor)
RBCS
Always send tube 1 and 4 for cell count and compare RBCs
Traumatic tap Elev RBC in tube 1 nl in tube 41000 RBC 1 WBC to adjust WBC count in
bloody tap
SAH or HSV Elev RBC in tube 1 AND tube 4
ldquoCrenated RBCsrdquo and xanthochromia (yellow supernatant after centrifuge)Seen in hyperbilirubinemia (ESLD) old SAH
old blood from prior traumatic LP or bleed
WBCrsquoS
Infection PMN predominance likely bacterial
meningitis Lymphocytic predominance viral vs fungal
vs TB vs malignancy
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)
GLUCOSE
Normal Viral infectionLow glucose Bacterial meningitis TB fungalReally low lt18 is strongly suggestive of bacterial
meningitis
TYPICAL VIRAL MENINGITIS
CSF WBC elevated but lt250 (first PMNs then lymphocytes)
CSF protein elevated but lt150 Glucose gt 50 of serum concentration
TYPICAL BACTERIAL MENINGITIS
CSF WBC gt1000 PMN predominance CSF protein gt500mgdl CSF glucose lt45 mgdl
bull Effusion
bull Transudate
bull Exudates
bull Lab analysis Gross exam cell count etc
bull Differential PMN Lymph Mono etc
2- Pleural Fluid Lung fluid
bull Cells unique to the lungs Mesothelial cells
bull RBCs and WBCs are limited if increased without
traumatic tap ----- indicates infarction
bull Cytology exam useful in identifying malignancy or
abnormal morphological cells
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 ro
chylothorax amylase to ro pancreatitis esoph perf Adenosine deaminase to eval TB
LIGHTrsquoS CRITERIA FOR EXUDATES
Fluid is exudate if it meets 1 of 3 criteria 1 Pleural fluid LDHserum LDH gt 062 Pleural fluid proteinserum protein gt 053 Pleural fluid LDH gt upper limit of normal
serum LDH If all 3 negative fluid is Transudate
TRANSUDATE
Result from imbalances in oncotic and hydrostatic pressure
Usually low oncotic +- high hydrostatic pressure
Pulm EdemaCHF Cirrhosis with ascites HypoalbuminemiaNephrotic
syndrome ESLD Fluid overload sp aggressive IVF Peritoneal dialysis
EXUDATE
Caused by local not systemic factors Infection Neoplasm Pancreatitis Esoph perf RA SLE Sarcoid Wegeners PE Meigrsquos
Chylothorax
LYMPHOCYTOSIS
Malignancy (50-70 lymphs) Also TB sarcoid RA chylothorax (gt90
lymphs)
PLEURAL EOSINOPHILIA
Pneumothorax Hemothorax Pulm infarct Parasitic disease
Fungal infection Drugs Malignancy Asbestos
WHY IS GLUCOSE LOW(lt60)
RA TB Empyema SLE Malignancy Esophageal rupture
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 gt 100ml (several 100) before effusion
can be detected on physical exam
Removal procedure- paracentesis
Lab analysis distinguish between transudate and exudates
gross exam cell count sedimentation chemical analysis
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
Lymphocytes CHF liver cirrhosis nephrotic syndrome
Mesothelial Cells Associated with TB effusions
Malignant cells seen with malignancy
WHAT TO SEND FLUID FOR
Cell count with diff Albumin LDH Total protein
glucose Gram staincx cytology
APPEARANCE OF FLUID
Clearmdashusually indicates uncomplicated ascites ie liver failurecirrhosis
Turbidcloudymdashinfected Pinkbloodymdashtraumatic punctured collateral
vessel malignancy Correct for bloody tap 1 WBC 750 RBC
1 PMN 250 RBC
SERUM-TO-ASCITES ALBUMIN GRADIENT (SAAG)
=Serum albumin ndash ascitic fluid albuminIf the gradient is gt11 Portal HTN (drives fluids into
peritoneum) SBP cirrhosis Alcoholic hepatitis CHFIf the gradient is lt 11(protein leaks into peritoneum and fluid
follows) Peritoneal carcinomatosis peritoneal
TB pancreatitis nephrotic syndrome
SBP SAAG gt 11 Suspect if gt250 PMNs (gt100 PMNs in pt on
peritoneal dialysis) 70 GNR (Ecoli Klebsiella)
30 GPC (S pneumo Enterococcus) Treat with ceftriaxone cefotaxime ldquoCulture negative SBPrdquo if gt250 PMNs but cx
neg treat the same
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
Measure pH pH less than 70 associated with infection or
rheumatoid disorder
Cell count see limited RBCs and WBCs
Evaluate sedimentation
bull Examine physical chemical and microscopic detail
bull Count number of sperm report morphology and
motility
bull Specimen must be a fresh collection-clean sterile
container
bull Gross Exam Color pH Volume and viscosity
bull Agglutination study
5- Seminal Fluid
bull Joint Fluid normally clear viscous
bull Functions as a lubricate and transports nutrient
bull Arthrocentesis aspirate of the joint fluid aseptic
technique
bull Lab Assay Gross exam microscopic exam Gram
stain cultures
6- Synovial Fluid
bull Appearance clear transparent viscous
bull Viscosity test
bull Mucin Clot test
bull Note crystals (intracellular vs extra cellular)
bull Slide exam usually performed on concentration of the fluid
using Giemsa or Papnicolaou
THANK YOU
FIXATION
1ml of heparin + 100ml of effusion fluid to prevent
clotting
NB do not use alcohol in fixation of fluid before
spread cytological smear on glass slides
TYPES OF STAINING SMEARS
PAP
Gram Stain
Hx amp E
Cell block for remnant sediment and histopathological
examination
Other special stains for the most suspected diseases to
confirm diagnosis
Heparinized bottles (3 units heparinml) 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 HampE stain
Air-dried cytocentrifuge preparation
(Hematologic malignancy is suspected)
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
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
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
PMN are few associated with Viral and acute bacterial
inflammation
Macrophages are few in number associated with malignancy
hemorrhage inflammation
EosinophilsBasophils not normally seen in CSF
Plasma cells not normally present associated with viral disorders
and Hodgkins diseases
Red Blood Cells Few to none present
Mesothelial cells not present
Malignant cells will see with malignant disease and infiltrate
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
NORMAL CSF COMPOSITION
Clear color lt5 RBCrsquos lt5 WBCrsquos Protein 23-38mgdl (can use 14-45) Glucosemdash60 of serum level (75-100)
OPENING PRESSURE
Normal = 80-180 mmHg Obese pts up to 250mmHg can be normal Pathologically elevated gt250mmHg If elevated likely due to cerebral edema from
intracranial pathology Infection (cryptococcal meningitis) tumor
benign ICH (pseudotumor)
RBCS
Always send tube 1 and 4 for cell count and compare RBCs
Traumatic tap Elev RBC in tube 1 nl in tube 41000 RBC 1 WBC to adjust WBC count in
bloody tap
SAH or HSV Elev RBC in tube 1 AND tube 4
ldquoCrenated RBCsrdquo and xanthochromia (yellow supernatant after centrifuge)Seen in hyperbilirubinemia (ESLD) old SAH
old blood from prior traumatic LP or bleed
WBCrsquoS
Infection PMN predominance likely bacterial
meningitis Lymphocytic predominance viral vs fungal
vs TB vs malignancy
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)
GLUCOSE
Normal Viral infectionLow glucose Bacterial meningitis TB fungalReally low lt18 is strongly suggestive of bacterial
meningitis
TYPICAL VIRAL MENINGITIS
CSF WBC elevated but lt250 (first PMNs then lymphocytes)
CSF protein elevated but lt150 Glucose gt 50 of serum concentration
TYPICAL BACTERIAL MENINGITIS
CSF WBC gt1000 PMN predominance CSF protein gt500mgdl CSF glucose lt45 mgdl
bull Effusion
bull Transudate
bull Exudates
bull Lab analysis Gross exam cell count etc
bull Differential PMN Lymph Mono etc
2- Pleural Fluid Lung fluid
bull Cells unique to the lungs Mesothelial cells
bull RBCs and WBCs are limited if increased without
traumatic tap ----- indicates infarction
bull Cytology exam useful in identifying malignancy or
abnormal morphological cells
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 ro
chylothorax amylase to ro pancreatitis esoph perf Adenosine deaminase to eval TB
LIGHTrsquoS CRITERIA FOR EXUDATES
Fluid is exudate if it meets 1 of 3 criteria 1 Pleural fluid LDHserum LDH gt 062 Pleural fluid proteinserum protein gt 053 Pleural fluid LDH gt upper limit of normal
serum LDH If all 3 negative fluid is Transudate
TRANSUDATE
Result from imbalances in oncotic and hydrostatic pressure
Usually low oncotic +- high hydrostatic pressure
Pulm EdemaCHF Cirrhosis with ascites HypoalbuminemiaNephrotic
syndrome ESLD Fluid overload sp aggressive IVF Peritoneal dialysis
EXUDATE
Caused by local not systemic factors Infection Neoplasm Pancreatitis Esoph perf RA SLE Sarcoid Wegeners PE Meigrsquos
Chylothorax
LYMPHOCYTOSIS
Malignancy (50-70 lymphs) Also TB sarcoid RA chylothorax (gt90
lymphs)
PLEURAL EOSINOPHILIA
Pneumothorax Hemothorax Pulm infarct Parasitic disease
Fungal infection Drugs Malignancy Asbestos
WHY IS GLUCOSE LOW(lt60)
RA TB Empyema SLE Malignancy Esophageal rupture
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 gt 100ml (several 100) before effusion
can be detected on physical exam
Removal procedure- paracentesis
Lab analysis distinguish between transudate and exudates
gross exam cell count sedimentation chemical analysis
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
Lymphocytes CHF liver cirrhosis nephrotic syndrome
Mesothelial Cells Associated with TB effusions
Malignant cells seen with malignancy
WHAT TO SEND FLUID FOR
Cell count with diff Albumin LDH Total protein
glucose Gram staincx cytology
APPEARANCE OF FLUID
Clearmdashusually indicates uncomplicated ascites ie liver failurecirrhosis
Turbidcloudymdashinfected Pinkbloodymdashtraumatic punctured collateral
vessel malignancy Correct for bloody tap 1 WBC 750 RBC
1 PMN 250 RBC
SERUM-TO-ASCITES ALBUMIN GRADIENT (SAAG)
=Serum albumin ndash ascitic fluid albuminIf the gradient is gt11 Portal HTN (drives fluids into
peritoneum) SBP cirrhosis Alcoholic hepatitis CHFIf the gradient is lt 11(protein leaks into peritoneum and fluid
follows) Peritoneal carcinomatosis peritoneal
TB pancreatitis nephrotic syndrome
SBP SAAG gt 11 Suspect if gt250 PMNs (gt100 PMNs in pt on
peritoneal dialysis) 70 GNR (Ecoli Klebsiella)
30 GPC (S pneumo Enterococcus) Treat with ceftriaxone cefotaxime ldquoCulture negative SBPrdquo if gt250 PMNs but cx
neg treat the same
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
Measure pH pH less than 70 associated with infection or
rheumatoid disorder
Cell count see limited RBCs and WBCs
Evaluate sedimentation
bull Examine physical chemical and microscopic detail
bull Count number of sperm report morphology and
motility
bull Specimen must be a fresh collection-clean sterile
container
bull Gross Exam Color pH Volume and viscosity
bull Agglutination study
5- Seminal Fluid
bull Joint Fluid normally clear viscous
bull Functions as a lubricate and transports nutrient
bull Arthrocentesis aspirate of the joint fluid aseptic
technique
bull Lab Assay Gross exam microscopic exam Gram
stain cultures
6- Synovial Fluid
bull Appearance clear transparent viscous
bull Viscosity test
bull Mucin Clot test
bull Note crystals (intracellular vs extra cellular)
bull Slide exam usually performed on concentration of the fluid
using Giemsa or Papnicolaou
THANK YOU
TYPES OF STAINING SMEARS
PAP
Gram Stain
Hx amp E
Cell block for remnant sediment and histopathological
examination
Other special stains for the most suspected diseases to
confirm diagnosis
Heparinized bottles (3 units heparinml) 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 HampE stain
Air-dried cytocentrifuge preparation
(Hematologic malignancy is suspected)
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
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
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
PMN are few associated with Viral and acute bacterial
inflammation
Macrophages are few in number associated with malignancy
hemorrhage inflammation
EosinophilsBasophils not normally seen in CSF
Plasma cells not normally present associated with viral disorders
and Hodgkins diseases
Red Blood Cells Few to none present
Mesothelial cells not present
Malignant cells will see with malignant disease and infiltrate
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
NORMAL CSF COMPOSITION
Clear color lt5 RBCrsquos lt5 WBCrsquos Protein 23-38mgdl (can use 14-45) Glucosemdash60 of serum level (75-100)
OPENING PRESSURE
Normal = 80-180 mmHg Obese pts up to 250mmHg can be normal Pathologically elevated gt250mmHg If elevated likely due to cerebral edema from
intracranial pathology Infection (cryptococcal meningitis) tumor
benign ICH (pseudotumor)
RBCS
Always send tube 1 and 4 for cell count and compare RBCs
Traumatic tap Elev RBC in tube 1 nl in tube 41000 RBC 1 WBC to adjust WBC count in
bloody tap
SAH or HSV Elev RBC in tube 1 AND tube 4
ldquoCrenated RBCsrdquo and xanthochromia (yellow supernatant after centrifuge)Seen in hyperbilirubinemia (ESLD) old SAH
old blood from prior traumatic LP or bleed
WBCrsquoS
Infection PMN predominance likely bacterial
meningitis Lymphocytic predominance viral vs fungal
vs TB vs malignancy
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)
GLUCOSE
Normal Viral infectionLow glucose Bacterial meningitis TB fungalReally low lt18 is strongly suggestive of bacterial
meningitis
TYPICAL VIRAL MENINGITIS
CSF WBC elevated but lt250 (first PMNs then lymphocytes)
CSF protein elevated but lt150 Glucose gt 50 of serum concentration
TYPICAL BACTERIAL MENINGITIS
CSF WBC gt1000 PMN predominance CSF protein gt500mgdl CSF glucose lt45 mgdl
bull Effusion
bull Transudate
bull Exudates
bull Lab analysis Gross exam cell count etc
bull Differential PMN Lymph Mono etc
2- Pleural Fluid Lung fluid
bull Cells unique to the lungs Mesothelial cells
bull RBCs and WBCs are limited if increased without
traumatic tap ----- indicates infarction
bull Cytology exam useful in identifying malignancy or
abnormal morphological cells
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 ro
chylothorax amylase to ro pancreatitis esoph perf Adenosine deaminase to eval TB
LIGHTrsquoS CRITERIA FOR EXUDATES
Fluid is exudate if it meets 1 of 3 criteria 1 Pleural fluid LDHserum LDH gt 062 Pleural fluid proteinserum protein gt 053 Pleural fluid LDH gt upper limit of normal
serum LDH If all 3 negative fluid is Transudate
TRANSUDATE
Result from imbalances in oncotic and hydrostatic pressure
Usually low oncotic +- high hydrostatic pressure
Pulm EdemaCHF Cirrhosis with ascites HypoalbuminemiaNephrotic
syndrome ESLD Fluid overload sp aggressive IVF Peritoneal dialysis
EXUDATE
Caused by local not systemic factors Infection Neoplasm Pancreatitis Esoph perf RA SLE Sarcoid Wegeners PE Meigrsquos
Chylothorax
LYMPHOCYTOSIS
Malignancy (50-70 lymphs) Also TB sarcoid RA chylothorax (gt90
lymphs)
PLEURAL EOSINOPHILIA
Pneumothorax Hemothorax Pulm infarct Parasitic disease
Fungal infection Drugs Malignancy Asbestos
WHY IS GLUCOSE LOW(lt60)
RA TB Empyema SLE Malignancy Esophageal rupture
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 gt 100ml (several 100) before effusion
can be detected on physical exam
Removal procedure- paracentesis
Lab analysis distinguish between transudate and exudates
gross exam cell count sedimentation chemical analysis
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
Lymphocytes CHF liver cirrhosis nephrotic syndrome
Mesothelial Cells Associated with TB effusions
Malignant cells seen with malignancy
WHAT TO SEND FLUID FOR
Cell count with diff Albumin LDH Total protein
glucose Gram staincx cytology
APPEARANCE OF FLUID
Clearmdashusually indicates uncomplicated ascites ie liver failurecirrhosis
Turbidcloudymdashinfected Pinkbloodymdashtraumatic punctured collateral
vessel malignancy Correct for bloody tap 1 WBC 750 RBC
1 PMN 250 RBC
SERUM-TO-ASCITES ALBUMIN GRADIENT (SAAG)
=Serum albumin ndash ascitic fluid albuminIf the gradient is gt11 Portal HTN (drives fluids into
peritoneum) SBP cirrhosis Alcoholic hepatitis CHFIf the gradient is lt 11(protein leaks into peritoneum and fluid
follows) Peritoneal carcinomatosis peritoneal
TB pancreatitis nephrotic syndrome
SBP SAAG gt 11 Suspect if gt250 PMNs (gt100 PMNs in pt on
peritoneal dialysis) 70 GNR (Ecoli Klebsiella)
30 GPC (S pneumo Enterococcus) Treat with ceftriaxone cefotaxime ldquoCulture negative SBPrdquo if gt250 PMNs but cx
neg treat the same
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
Measure pH pH less than 70 associated with infection or
rheumatoid disorder
Cell count see limited RBCs and WBCs
Evaluate sedimentation
bull Examine physical chemical and microscopic detail
bull Count number of sperm report morphology and
motility
bull Specimen must be a fresh collection-clean sterile
container
bull Gross Exam Color pH Volume and viscosity
bull Agglutination study
5- Seminal Fluid
bull Joint Fluid normally clear viscous
bull Functions as a lubricate and transports nutrient
bull Arthrocentesis aspirate of the joint fluid aseptic
technique
bull Lab Assay Gross exam microscopic exam Gram
stain cultures
6- Synovial Fluid
bull Appearance clear transparent viscous
bull Viscosity test
bull Mucin Clot test
bull Note crystals (intracellular vs extra cellular)
bull Slide exam usually performed on concentration of the fluid
using Giemsa or Papnicolaou
THANK YOU
Heparinized bottles (3 units heparinml) 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 HampE stain
Air-dried cytocentrifuge preparation
(Hematologic malignancy is suspected)
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
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
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
PMN are few associated with Viral and acute bacterial
inflammation
Macrophages are few in number associated with malignancy
hemorrhage inflammation
EosinophilsBasophils not normally seen in CSF
Plasma cells not normally present associated with viral disorders
and Hodgkins diseases
Red Blood Cells Few to none present
Mesothelial cells not present
Malignant cells will see with malignant disease and infiltrate
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
NORMAL CSF COMPOSITION
Clear color lt5 RBCrsquos lt5 WBCrsquos Protein 23-38mgdl (can use 14-45) Glucosemdash60 of serum level (75-100)
OPENING PRESSURE
Normal = 80-180 mmHg Obese pts up to 250mmHg can be normal Pathologically elevated gt250mmHg If elevated likely due to cerebral edema from
intracranial pathology Infection (cryptococcal meningitis) tumor
benign ICH (pseudotumor)
RBCS
Always send tube 1 and 4 for cell count and compare RBCs
Traumatic tap Elev RBC in tube 1 nl in tube 41000 RBC 1 WBC to adjust WBC count in
bloody tap
SAH or HSV Elev RBC in tube 1 AND tube 4
ldquoCrenated RBCsrdquo and xanthochromia (yellow supernatant after centrifuge)Seen in hyperbilirubinemia (ESLD) old SAH
old blood from prior traumatic LP or bleed
WBCrsquoS
Infection PMN predominance likely bacterial
meningitis Lymphocytic predominance viral vs fungal
vs TB vs malignancy
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)
GLUCOSE
Normal Viral infectionLow glucose Bacterial meningitis TB fungalReally low lt18 is strongly suggestive of bacterial
meningitis
TYPICAL VIRAL MENINGITIS
CSF WBC elevated but lt250 (first PMNs then lymphocytes)
CSF protein elevated but lt150 Glucose gt 50 of serum concentration
TYPICAL BACTERIAL MENINGITIS
CSF WBC gt1000 PMN predominance CSF protein gt500mgdl CSF glucose lt45 mgdl
bull Effusion
bull Transudate
bull Exudates
bull Lab analysis Gross exam cell count etc
bull Differential PMN Lymph Mono etc
2- Pleural Fluid Lung fluid
bull Cells unique to the lungs Mesothelial cells
bull RBCs and WBCs are limited if increased without
traumatic tap ----- indicates infarction
bull Cytology exam useful in identifying malignancy or
abnormal morphological cells
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 ro
chylothorax amylase to ro pancreatitis esoph perf Adenosine deaminase to eval TB
LIGHTrsquoS CRITERIA FOR EXUDATES
Fluid is exudate if it meets 1 of 3 criteria 1 Pleural fluid LDHserum LDH gt 062 Pleural fluid proteinserum protein gt 053 Pleural fluid LDH gt upper limit of normal
serum LDH If all 3 negative fluid is Transudate
TRANSUDATE
Result from imbalances in oncotic and hydrostatic pressure
Usually low oncotic +- high hydrostatic pressure
Pulm EdemaCHF Cirrhosis with ascites HypoalbuminemiaNephrotic
syndrome ESLD Fluid overload sp aggressive IVF Peritoneal dialysis
EXUDATE
Caused by local not systemic factors Infection Neoplasm Pancreatitis Esoph perf RA SLE Sarcoid Wegeners PE Meigrsquos
Chylothorax
LYMPHOCYTOSIS
Malignancy (50-70 lymphs) Also TB sarcoid RA chylothorax (gt90
lymphs)
PLEURAL EOSINOPHILIA
Pneumothorax Hemothorax Pulm infarct Parasitic disease
Fungal infection Drugs Malignancy Asbestos
WHY IS GLUCOSE LOW(lt60)
RA TB Empyema SLE Malignancy Esophageal rupture
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 gt 100ml (several 100) before effusion
can be detected on physical exam
Removal procedure- paracentesis
Lab analysis distinguish between transudate and exudates
gross exam cell count sedimentation chemical analysis
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
Lymphocytes CHF liver cirrhosis nephrotic syndrome
Mesothelial Cells Associated with TB effusions
Malignant cells seen with malignancy
WHAT TO SEND FLUID FOR
Cell count with diff Albumin LDH Total protein
glucose Gram staincx cytology
APPEARANCE OF FLUID
Clearmdashusually indicates uncomplicated ascites ie liver failurecirrhosis
Turbidcloudymdashinfected Pinkbloodymdashtraumatic punctured collateral
vessel malignancy Correct for bloody tap 1 WBC 750 RBC
1 PMN 250 RBC
SERUM-TO-ASCITES ALBUMIN GRADIENT (SAAG)
=Serum albumin ndash ascitic fluid albuminIf the gradient is gt11 Portal HTN (drives fluids into
peritoneum) SBP cirrhosis Alcoholic hepatitis CHFIf the gradient is lt 11(protein leaks into peritoneum and fluid
follows) Peritoneal carcinomatosis peritoneal
TB pancreatitis nephrotic syndrome
SBP SAAG gt 11 Suspect if gt250 PMNs (gt100 PMNs in pt on
peritoneal dialysis) 70 GNR (Ecoli Klebsiella)
30 GPC (S pneumo Enterococcus) Treat with ceftriaxone cefotaxime ldquoCulture negative SBPrdquo if gt250 PMNs but cx
neg treat the same
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
Measure pH pH less than 70 associated with infection or
rheumatoid disorder
Cell count see limited RBCs and WBCs
Evaluate sedimentation
bull Examine physical chemical and microscopic detail
bull Count number of sperm report morphology and
motility
bull Specimen must be a fresh collection-clean sterile
container
bull Gross Exam Color pH Volume and viscosity
bull Agglutination study
5- Seminal Fluid
bull Joint Fluid normally clear viscous
bull Functions as a lubricate and transports nutrient
bull Arthrocentesis aspirate of the joint fluid aseptic
technique
bull Lab Assay Gross exam microscopic exam Gram
stain cultures
6- Synovial Fluid
bull Appearance clear transparent viscous
bull Viscosity test
bull Mucin Clot test
bull Note crystals (intracellular vs extra cellular)
bull Slide exam usually performed on concentration of the fluid
using Giemsa or Papnicolaou
THANK YOU
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
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
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
PMN are few associated with Viral and acute bacterial
inflammation
Macrophages are few in number associated with malignancy
hemorrhage inflammation
EosinophilsBasophils not normally seen in CSF
Plasma cells not normally present associated with viral disorders
and Hodgkins diseases
Red Blood Cells Few to none present
Mesothelial cells not present
Malignant cells will see with malignant disease and infiltrate
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
NORMAL CSF COMPOSITION
Clear color lt5 RBCrsquos lt5 WBCrsquos Protein 23-38mgdl (can use 14-45) Glucosemdash60 of serum level (75-100)
OPENING PRESSURE
Normal = 80-180 mmHg Obese pts up to 250mmHg can be normal Pathologically elevated gt250mmHg If elevated likely due to cerebral edema from
intracranial pathology Infection (cryptococcal meningitis) tumor
benign ICH (pseudotumor)
RBCS
Always send tube 1 and 4 for cell count and compare RBCs
Traumatic tap Elev RBC in tube 1 nl in tube 41000 RBC 1 WBC to adjust WBC count in
bloody tap
SAH or HSV Elev RBC in tube 1 AND tube 4
ldquoCrenated RBCsrdquo and xanthochromia (yellow supernatant after centrifuge)Seen in hyperbilirubinemia (ESLD) old SAH
old blood from prior traumatic LP or bleed
WBCrsquoS
Infection PMN predominance likely bacterial
meningitis Lymphocytic predominance viral vs fungal
vs TB vs malignancy
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)
GLUCOSE
Normal Viral infectionLow glucose Bacterial meningitis TB fungalReally low lt18 is strongly suggestive of bacterial
meningitis
TYPICAL VIRAL MENINGITIS
CSF WBC elevated but lt250 (first PMNs then lymphocytes)
CSF protein elevated but lt150 Glucose gt 50 of serum concentration
TYPICAL BACTERIAL MENINGITIS
CSF WBC gt1000 PMN predominance CSF protein gt500mgdl CSF glucose lt45 mgdl
bull Effusion
bull Transudate
bull Exudates
bull Lab analysis Gross exam cell count etc
bull Differential PMN Lymph Mono etc
2- Pleural Fluid Lung fluid
bull Cells unique to the lungs Mesothelial cells
bull RBCs and WBCs are limited if increased without
traumatic tap ----- indicates infarction
bull Cytology exam useful in identifying malignancy or
abnormal morphological cells
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 ro
chylothorax amylase to ro pancreatitis esoph perf Adenosine deaminase to eval TB
LIGHTrsquoS CRITERIA FOR EXUDATES
Fluid is exudate if it meets 1 of 3 criteria 1 Pleural fluid LDHserum LDH gt 062 Pleural fluid proteinserum protein gt 053 Pleural fluid LDH gt upper limit of normal
serum LDH If all 3 negative fluid is Transudate
TRANSUDATE
Result from imbalances in oncotic and hydrostatic pressure
Usually low oncotic +- high hydrostatic pressure
Pulm EdemaCHF Cirrhosis with ascites HypoalbuminemiaNephrotic
syndrome ESLD Fluid overload sp aggressive IVF Peritoneal dialysis
EXUDATE
Caused by local not systemic factors Infection Neoplasm Pancreatitis Esoph perf RA SLE Sarcoid Wegeners PE Meigrsquos
Chylothorax
LYMPHOCYTOSIS
Malignancy (50-70 lymphs) Also TB sarcoid RA chylothorax (gt90
lymphs)
PLEURAL EOSINOPHILIA
Pneumothorax Hemothorax Pulm infarct Parasitic disease
Fungal infection Drugs Malignancy Asbestos
WHY IS GLUCOSE LOW(lt60)
RA TB Empyema SLE Malignancy Esophageal rupture
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 gt 100ml (several 100) before effusion
can be detected on physical exam
Removal procedure- paracentesis
Lab analysis distinguish between transudate and exudates
gross exam cell count sedimentation chemical analysis
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
Lymphocytes CHF liver cirrhosis nephrotic syndrome
Mesothelial Cells Associated with TB effusions
Malignant cells seen with malignancy
WHAT TO SEND FLUID FOR
Cell count with diff Albumin LDH Total protein
glucose Gram staincx cytology
APPEARANCE OF FLUID
Clearmdashusually indicates uncomplicated ascites ie liver failurecirrhosis
Turbidcloudymdashinfected Pinkbloodymdashtraumatic punctured collateral
vessel malignancy Correct for bloody tap 1 WBC 750 RBC
1 PMN 250 RBC
SERUM-TO-ASCITES ALBUMIN GRADIENT (SAAG)
=Serum albumin ndash ascitic fluid albuminIf the gradient is gt11 Portal HTN (drives fluids into
peritoneum) SBP cirrhosis Alcoholic hepatitis CHFIf the gradient is lt 11(protein leaks into peritoneum and fluid
follows) Peritoneal carcinomatosis peritoneal
TB pancreatitis nephrotic syndrome
SBP SAAG gt 11 Suspect if gt250 PMNs (gt100 PMNs in pt on
peritoneal dialysis) 70 GNR (Ecoli Klebsiella)
30 GPC (S pneumo Enterococcus) Treat with ceftriaxone cefotaxime ldquoCulture negative SBPrdquo if gt250 PMNs but cx
neg treat the same
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
Measure pH pH less than 70 associated with infection or
rheumatoid disorder
Cell count see limited RBCs and WBCs
Evaluate sedimentation
bull Examine physical chemical and microscopic detail
bull Count number of sperm report morphology and
motility
bull Specimen must be a fresh collection-clean sterile
container
bull Gross Exam Color pH Volume and viscosity
bull Agglutination study
5- Seminal Fluid
bull Joint Fluid normally clear viscous
bull Functions as a lubricate and transports nutrient
bull Arthrocentesis aspirate of the joint fluid aseptic
technique
bull Lab Assay Gross exam microscopic exam Gram
stain cultures
6- Synovial Fluid
bull Appearance clear transparent viscous
bull Viscosity test
bull Mucin Clot test
bull Note crystals (intracellular vs extra cellular)
bull Slide exam usually performed on concentration of the fluid
using Giemsa or Papnicolaou
THANK YOU
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
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
PMN are few associated with Viral and acute bacterial
inflammation
Macrophages are few in number associated with malignancy
hemorrhage inflammation
EosinophilsBasophils not normally seen in CSF
Plasma cells not normally present associated with viral disorders
and Hodgkins diseases
Red Blood Cells Few to none present
Mesothelial cells not present
Malignant cells will see with malignant disease and infiltrate
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
NORMAL CSF COMPOSITION
Clear color lt5 RBCrsquos lt5 WBCrsquos Protein 23-38mgdl (can use 14-45) Glucosemdash60 of serum level (75-100)
OPENING PRESSURE
Normal = 80-180 mmHg Obese pts up to 250mmHg can be normal Pathologically elevated gt250mmHg If elevated likely due to cerebral edema from
intracranial pathology Infection (cryptococcal meningitis) tumor
benign ICH (pseudotumor)
RBCS
Always send tube 1 and 4 for cell count and compare RBCs
Traumatic tap Elev RBC in tube 1 nl in tube 41000 RBC 1 WBC to adjust WBC count in
bloody tap
SAH or HSV Elev RBC in tube 1 AND tube 4
ldquoCrenated RBCsrdquo and xanthochromia (yellow supernatant after centrifuge)Seen in hyperbilirubinemia (ESLD) old SAH
old blood from prior traumatic LP or bleed
WBCrsquoS
Infection PMN predominance likely bacterial
meningitis Lymphocytic predominance viral vs fungal
vs TB vs malignancy
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)
GLUCOSE
Normal Viral infectionLow glucose Bacterial meningitis TB fungalReally low lt18 is strongly suggestive of bacterial
meningitis
TYPICAL VIRAL MENINGITIS
CSF WBC elevated but lt250 (first PMNs then lymphocytes)
CSF protein elevated but lt150 Glucose gt 50 of serum concentration
TYPICAL BACTERIAL MENINGITIS
CSF WBC gt1000 PMN predominance CSF protein gt500mgdl CSF glucose lt45 mgdl
bull Effusion
bull Transudate
bull Exudates
bull Lab analysis Gross exam cell count etc
bull Differential PMN Lymph Mono etc
2- Pleural Fluid Lung fluid
bull Cells unique to the lungs Mesothelial cells
bull RBCs and WBCs are limited if increased without
traumatic tap ----- indicates infarction
bull Cytology exam useful in identifying malignancy or
abnormal morphological cells
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 ro
chylothorax amylase to ro pancreatitis esoph perf Adenosine deaminase to eval TB
LIGHTrsquoS CRITERIA FOR EXUDATES
Fluid is exudate if it meets 1 of 3 criteria 1 Pleural fluid LDHserum LDH gt 062 Pleural fluid proteinserum protein gt 053 Pleural fluid LDH gt upper limit of normal
serum LDH If all 3 negative fluid is Transudate
TRANSUDATE
Result from imbalances in oncotic and hydrostatic pressure
Usually low oncotic +- high hydrostatic pressure
Pulm EdemaCHF Cirrhosis with ascites HypoalbuminemiaNephrotic
syndrome ESLD Fluid overload sp aggressive IVF Peritoneal dialysis
EXUDATE
Caused by local not systemic factors Infection Neoplasm Pancreatitis Esoph perf RA SLE Sarcoid Wegeners PE Meigrsquos
Chylothorax
LYMPHOCYTOSIS
Malignancy (50-70 lymphs) Also TB sarcoid RA chylothorax (gt90
lymphs)
PLEURAL EOSINOPHILIA
Pneumothorax Hemothorax Pulm infarct Parasitic disease
Fungal infection Drugs Malignancy Asbestos
WHY IS GLUCOSE LOW(lt60)
RA TB Empyema SLE Malignancy Esophageal rupture
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 gt 100ml (several 100) before effusion
can be detected on physical exam
Removal procedure- paracentesis
Lab analysis distinguish between transudate and exudates
gross exam cell count sedimentation chemical analysis
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
Lymphocytes CHF liver cirrhosis nephrotic syndrome
Mesothelial Cells Associated with TB effusions
Malignant cells seen with malignancy
WHAT TO SEND FLUID FOR
Cell count with diff Albumin LDH Total protein
glucose Gram staincx cytology
APPEARANCE OF FLUID
Clearmdashusually indicates uncomplicated ascites ie liver failurecirrhosis
Turbidcloudymdashinfected Pinkbloodymdashtraumatic punctured collateral
vessel malignancy Correct for bloody tap 1 WBC 750 RBC
1 PMN 250 RBC
SERUM-TO-ASCITES ALBUMIN GRADIENT (SAAG)
=Serum albumin ndash ascitic fluid albuminIf the gradient is gt11 Portal HTN (drives fluids into
peritoneum) SBP cirrhosis Alcoholic hepatitis CHFIf the gradient is lt 11(protein leaks into peritoneum and fluid
follows) Peritoneal carcinomatosis peritoneal
TB pancreatitis nephrotic syndrome
SBP SAAG gt 11 Suspect if gt250 PMNs (gt100 PMNs in pt on
peritoneal dialysis) 70 GNR (Ecoli Klebsiella)
30 GPC (S pneumo Enterococcus) Treat with ceftriaxone cefotaxime ldquoCulture negative SBPrdquo if gt250 PMNs but cx
neg treat the same
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
Measure pH pH less than 70 associated with infection or
rheumatoid disorder
Cell count see limited RBCs and WBCs
Evaluate sedimentation
bull Examine physical chemical and microscopic detail
bull Count number of sperm report morphology and
motility
bull Specimen must be a fresh collection-clean sterile
container
bull Gross Exam Color pH Volume and viscosity
bull Agglutination study
5- Seminal Fluid
bull Joint Fluid normally clear viscous
bull Functions as a lubricate and transports nutrient
bull Arthrocentesis aspirate of the joint fluid aseptic
technique
bull Lab Assay Gross exam microscopic exam Gram
stain cultures
6- Synovial Fluid
bull Appearance clear transparent viscous
bull Viscosity test
bull Mucin Clot test
bull Note crystals (intracellular vs extra cellular)
bull Slide exam usually performed on concentration of the fluid
using Giemsa or Papnicolaou
THANK YOU
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
PMN are few associated with Viral and acute bacterial
inflammation
Macrophages are few in number associated with malignancy
hemorrhage inflammation
EosinophilsBasophils not normally seen in CSF
Plasma cells not normally present associated with viral disorders
and Hodgkins diseases
Red Blood Cells Few to none present
Mesothelial cells not present
Malignant cells will see with malignant disease and infiltrate
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
NORMAL CSF COMPOSITION
Clear color lt5 RBCrsquos lt5 WBCrsquos Protein 23-38mgdl (can use 14-45) Glucosemdash60 of serum level (75-100)
OPENING PRESSURE
Normal = 80-180 mmHg Obese pts up to 250mmHg can be normal Pathologically elevated gt250mmHg If elevated likely due to cerebral edema from
intracranial pathology Infection (cryptococcal meningitis) tumor
benign ICH (pseudotumor)
RBCS
Always send tube 1 and 4 for cell count and compare RBCs
Traumatic tap Elev RBC in tube 1 nl in tube 41000 RBC 1 WBC to adjust WBC count in
bloody tap
SAH or HSV Elev RBC in tube 1 AND tube 4
ldquoCrenated RBCsrdquo and xanthochromia (yellow supernatant after centrifuge)Seen in hyperbilirubinemia (ESLD) old SAH
old blood from prior traumatic LP or bleed
WBCrsquoS
Infection PMN predominance likely bacterial
meningitis Lymphocytic predominance viral vs fungal
vs TB vs malignancy
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)
GLUCOSE
Normal Viral infectionLow glucose Bacterial meningitis TB fungalReally low lt18 is strongly suggestive of bacterial
meningitis
TYPICAL VIRAL MENINGITIS
CSF WBC elevated but lt250 (first PMNs then lymphocytes)
CSF protein elevated but lt150 Glucose gt 50 of serum concentration
TYPICAL BACTERIAL MENINGITIS
CSF WBC gt1000 PMN predominance CSF protein gt500mgdl CSF glucose lt45 mgdl
bull Effusion
bull Transudate
bull Exudates
bull Lab analysis Gross exam cell count etc
bull Differential PMN Lymph Mono etc
2- Pleural Fluid Lung fluid
bull Cells unique to the lungs Mesothelial cells
bull RBCs and WBCs are limited if increased without
traumatic tap ----- indicates infarction
bull Cytology exam useful in identifying malignancy or
abnormal morphological cells
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 ro
chylothorax amylase to ro pancreatitis esoph perf Adenosine deaminase to eval TB
LIGHTrsquoS CRITERIA FOR EXUDATES
Fluid is exudate if it meets 1 of 3 criteria 1 Pleural fluid LDHserum LDH gt 062 Pleural fluid proteinserum protein gt 053 Pleural fluid LDH gt upper limit of normal
serum LDH If all 3 negative fluid is Transudate
TRANSUDATE
Result from imbalances in oncotic and hydrostatic pressure
Usually low oncotic +- high hydrostatic pressure
Pulm EdemaCHF Cirrhosis with ascites HypoalbuminemiaNephrotic
syndrome ESLD Fluid overload sp aggressive IVF Peritoneal dialysis
EXUDATE
Caused by local not systemic factors Infection Neoplasm Pancreatitis Esoph perf RA SLE Sarcoid Wegeners PE Meigrsquos
Chylothorax
LYMPHOCYTOSIS
Malignancy (50-70 lymphs) Also TB sarcoid RA chylothorax (gt90
lymphs)
PLEURAL EOSINOPHILIA
Pneumothorax Hemothorax Pulm infarct Parasitic disease
Fungal infection Drugs Malignancy Asbestos
WHY IS GLUCOSE LOW(lt60)
RA TB Empyema SLE Malignancy Esophageal rupture
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 gt 100ml (several 100) before effusion
can be detected on physical exam
Removal procedure- paracentesis
Lab analysis distinguish between transudate and exudates
gross exam cell count sedimentation chemical analysis
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
Lymphocytes CHF liver cirrhosis nephrotic syndrome
Mesothelial Cells Associated with TB effusions
Malignant cells seen with malignancy
WHAT TO SEND FLUID FOR
Cell count with diff Albumin LDH Total protein
glucose Gram staincx cytology
APPEARANCE OF FLUID
Clearmdashusually indicates uncomplicated ascites ie liver failurecirrhosis
Turbidcloudymdashinfected Pinkbloodymdashtraumatic punctured collateral
vessel malignancy Correct for bloody tap 1 WBC 750 RBC
1 PMN 250 RBC
SERUM-TO-ASCITES ALBUMIN GRADIENT (SAAG)
=Serum albumin ndash ascitic fluid albuminIf the gradient is gt11 Portal HTN (drives fluids into
peritoneum) SBP cirrhosis Alcoholic hepatitis CHFIf the gradient is lt 11(protein leaks into peritoneum and fluid
follows) Peritoneal carcinomatosis peritoneal
TB pancreatitis nephrotic syndrome
SBP SAAG gt 11 Suspect if gt250 PMNs (gt100 PMNs in pt on
peritoneal dialysis) 70 GNR (Ecoli Klebsiella)
30 GPC (S pneumo Enterococcus) Treat with ceftriaxone cefotaxime ldquoCulture negative SBPrdquo if gt250 PMNs but cx
neg treat the same
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
Measure pH pH less than 70 associated with infection or
rheumatoid disorder
Cell count see limited RBCs and WBCs
Evaluate sedimentation
bull Examine physical chemical and microscopic detail
bull Count number of sperm report morphology and
motility
bull Specimen must be a fresh collection-clean sterile
container
bull Gross Exam Color pH Volume and viscosity
bull Agglutination study
5- Seminal Fluid
bull Joint Fluid normally clear viscous
bull Functions as a lubricate and transports nutrient
bull Arthrocentesis aspirate of the joint fluid aseptic
technique
bull Lab Assay Gross exam microscopic exam Gram
stain cultures
6- Synovial Fluid
bull Appearance clear transparent viscous
bull Viscosity test
bull Mucin Clot test
bull Note crystals (intracellular vs extra cellular)
bull Slide exam usually performed on concentration of the fluid
using Giemsa or Papnicolaou
THANK YOU
PMN are few associated with Viral and acute bacterial
inflammation
Macrophages are few in number associated with malignancy
hemorrhage inflammation
EosinophilsBasophils not normally seen in CSF
Plasma cells not normally present associated with viral disorders
and Hodgkins diseases
Red Blood Cells Few to none present
Mesothelial cells not present
Malignant cells will see with malignant disease and infiltrate
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
NORMAL CSF COMPOSITION
Clear color lt5 RBCrsquos lt5 WBCrsquos Protein 23-38mgdl (can use 14-45) Glucosemdash60 of serum level (75-100)
OPENING PRESSURE
Normal = 80-180 mmHg Obese pts up to 250mmHg can be normal Pathologically elevated gt250mmHg If elevated likely due to cerebral edema from
intracranial pathology Infection (cryptococcal meningitis) tumor
benign ICH (pseudotumor)
RBCS
Always send tube 1 and 4 for cell count and compare RBCs
Traumatic tap Elev RBC in tube 1 nl in tube 41000 RBC 1 WBC to adjust WBC count in
bloody tap
SAH or HSV Elev RBC in tube 1 AND tube 4
ldquoCrenated RBCsrdquo and xanthochromia (yellow supernatant after centrifuge)Seen in hyperbilirubinemia (ESLD) old SAH
old blood from prior traumatic LP or bleed
WBCrsquoS
Infection PMN predominance likely bacterial
meningitis Lymphocytic predominance viral vs fungal
vs TB vs malignancy
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)
GLUCOSE
Normal Viral infectionLow glucose Bacterial meningitis TB fungalReally low lt18 is strongly suggestive of bacterial
meningitis
TYPICAL VIRAL MENINGITIS
CSF WBC elevated but lt250 (first PMNs then lymphocytes)
CSF protein elevated but lt150 Glucose gt 50 of serum concentration
TYPICAL BACTERIAL MENINGITIS
CSF WBC gt1000 PMN predominance CSF protein gt500mgdl CSF glucose lt45 mgdl
bull Effusion
bull Transudate
bull Exudates
bull Lab analysis Gross exam cell count etc
bull Differential PMN Lymph Mono etc
2- Pleural Fluid Lung fluid
bull Cells unique to the lungs Mesothelial cells
bull RBCs and WBCs are limited if increased without
traumatic tap ----- indicates infarction
bull Cytology exam useful in identifying malignancy or
abnormal morphological cells
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 ro
chylothorax amylase to ro pancreatitis esoph perf Adenosine deaminase to eval TB
LIGHTrsquoS CRITERIA FOR EXUDATES
Fluid is exudate if it meets 1 of 3 criteria 1 Pleural fluid LDHserum LDH gt 062 Pleural fluid proteinserum protein gt 053 Pleural fluid LDH gt upper limit of normal
serum LDH If all 3 negative fluid is Transudate
TRANSUDATE
Result from imbalances in oncotic and hydrostatic pressure
Usually low oncotic +- high hydrostatic pressure
Pulm EdemaCHF Cirrhosis with ascites HypoalbuminemiaNephrotic
syndrome ESLD Fluid overload sp aggressive IVF Peritoneal dialysis
EXUDATE
Caused by local not systemic factors Infection Neoplasm Pancreatitis Esoph perf RA SLE Sarcoid Wegeners PE Meigrsquos
Chylothorax
LYMPHOCYTOSIS
Malignancy (50-70 lymphs) Also TB sarcoid RA chylothorax (gt90
lymphs)
PLEURAL EOSINOPHILIA
Pneumothorax Hemothorax Pulm infarct Parasitic disease
Fungal infection Drugs Malignancy Asbestos
WHY IS GLUCOSE LOW(lt60)
RA TB Empyema SLE Malignancy Esophageal rupture
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 gt 100ml (several 100) before effusion
can be detected on physical exam
Removal procedure- paracentesis
Lab analysis distinguish between transudate and exudates
gross exam cell count sedimentation chemical analysis
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
Lymphocytes CHF liver cirrhosis nephrotic syndrome
Mesothelial Cells Associated with TB effusions
Malignant cells seen with malignancy
WHAT TO SEND FLUID FOR
Cell count with diff Albumin LDH Total protein
glucose Gram staincx cytology
APPEARANCE OF FLUID
Clearmdashusually indicates uncomplicated ascites ie liver failurecirrhosis
Turbidcloudymdashinfected Pinkbloodymdashtraumatic punctured collateral
vessel malignancy Correct for bloody tap 1 WBC 750 RBC
1 PMN 250 RBC
SERUM-TO-ASCITES ALBUMIN GRADIENT (SAAG)
=Serum albumin ndash ascitic fluid albuminIf the gradient is gt11 Portal HTN (drives fluids into
peritoneum) SBP cirrhosis Alcoholic hepatitis CHFIf the gradient is lt 11(protein leaks into peritoneum and fluid
follows) Peritoneal carcinomatosis peritoneal
TB pancreatitis nephrotic syndrome
SBP SAAG gt 11 Suspect if gt250 PMNs (gt100 PMNs in pt on
peritoneal dialysis) 70 GNR (Ecoli Klebsiella)
30 GPC (S pneumo Enterococcus) Treat with ceftriaxone cefotaxime ldquoCulture negative SBPrdquo if gt250 PMNs but cx
neg treat the same
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
Measure pH pH less than 70 associated with infection or
rheumatoid disorder
Cell count see limited RBCs and WBCs
Evaluate sedimentation
bull Examine physical chemical and microscopic detail
bull Count number of sperm report morphology and
motility
bull Specimen must be a fresh collection-clean sterile
container
bull Gross Exam Color pH Volume and viscosity
bull Agglutination study
5- Seminal Fluid
bull Joint Fluid normally clear viscous
bull Functions as a lubricate and transports nutrient
bull Arthrocentesis aspirate of the joint fluid aseptic
technique
bull Lab Assay Gross exam microscopic exam Gram
stain cultures
6- Synovial Fluid
bull Appearance clear transparent viscous
bull Viscosity test
bull Mucin Clot test
bull Note crystals (intracellular vs extra cellular)
bull Slide exam usually performed on concentration of the fluid
using Giemsa or Papnicolaou
THANK YOU
Plasma cells not normally present associated with viral disorders
and Hodgkins diseases
Red Blood Cells Few to none present
Mesothelial cells not present
Malignant cells will see with malignant disease and infiltrate
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
NORMAL CSF COMPOSITION
Clear color lt5 RBCrsquos lt5 WBCrsquos Protein 23-38mgdl (can use 14-45) Glucosemdash60 of serum level (75-100)
OPENING PRESSURE
Normal = 80-180 mmHg Obese pts up to 250mmHg can be normal Pathologically elevated gt250mmHg If elevated likely due to cerebral edema from
intracranial pathology Infection (cryptococcal meningitis) tumor
benign ICH (pseudotumor)
RBCS
Always send tube 1 and 4 for cell count and compare RBCs
Traumatic tap Elev RBC in tube 1 nl in tube 41000 RBC 1 WBC to adjust WBC count in
bloody tap
SAH or HSV Elev RBC in tube 1 AND tube 4
ldquoCrenated RBCsrdquo and xanthochromia (yellow supernatant after centrifuge)Seen in hyperbilirubinemia (ESLD) old SAH
old blood from prior traumatic LP or bleed
WBCrsquoS
Infection PMN predominance likely bacterial
meningitis Lymphocytic predominance viral vs fungal
vs TB vs malignancy
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)
GLUCOSE
Normal Viral infectionLow glucose Bacterial meningitis TB fungalReally low lt18 is strongly suggestive of bacterial
meningitis
TYPICAL VIRAL MENINGITIS
CSF WBC elevated but lt250 (first PMNs then lymphocytes)
CSF protein elevated but lt150 Glucose gt 50 of serum concentration
TYPICAL BACTERIAL MENINGITIS
CSF WBC gt1000 PMN predominance CSF protein gt500mgdl CSF glucose lt45 mgdl
bull Effusion
bull Transudate
bull Exudates
bull Lab analysis Gross exam cell count etc
bull Differential PMN Lymph Mono etc
2- Pleural Fluid Lung fluid
bull Cells unique to the lungs Mesothelial cells
bull RBCs and WBCs are limited if increased without
traumatic tap ----- indicates infarction
bull Cytology exam useful in identifying malignancy or
abnormal morphological cells
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 ro
chylothorax amylase to ro pancreatitis esoph perf Adenosine deaminase to eval TB
LIGHTrsquoS CRITERIA FOR EXUDATES
Fluid is exudate if it meets 1 of 3 criteria 1 Pleural fluid LDHserum LDH gt 062 Pleural fluid proteinserum protein gt 053 Pleural fluid LDH gt upper limit of normal
serum LDH If all 3 negative fluid is Transudate
TRANSUDATE
Result from imbalances in oncotic and hydrostatic pressure
Usually low oncotic +- high hydrostatic pressure
Pulm EdemaCHF Cirrhosis with ascites HypoalbuminemiaNephrotic
syndrome ESLD Fluid overload sp aggressive IVF Peritoneal dialysis
EXUDATE
Caused by local not systemic factors Infection Neoplasm Pancreatitis Esoph perf RA SLE Sarcoid Wegeners PE Meigrsquos
Chylothorax
LYMPHOCYTOSIS
Malignancy (50-70 lymphs) Also TB sarcoid RA chylothorax (gt90
lymphs)
PLEURAL EOSINOPHILIA
Pneumothorax Hemothorax Pulm infarct Parasitic disease
Fungal infection Drugs Malignancy Asbestos
WHY IS GLUCOSE LOW(lt60)
RA TB Empyema SLE Malignancy Esophageal rupture
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 gt 100ml (several 100) before effusion
can be detected on physical exam
Removal procedure- paracentesis
Lab analysis distinguish between transudate and exudates
gross exam cell count sedimentation chemical analysis
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
Lymphocytes CHF liver cirrhosis nephrotic syndrome
Mesothelial Cells Associated with TB effusions
Malignant cells seen with malignancy
WHAT TO SEND FLUID FOR
Cell count with diff Albumin LDH Total protein
glucose Gram staincx cytology
APPEARANCE OF FLUID
Clearmdashusually indicates uncomplicated ascites ie liver failurecirrhosis
Turbidcloudymdashinfected Pinkbloodymdashtraumatic punctured collateral
vessel malignancy Correct for bloody tap 1 WBC 750 RBC
1 PMN 250 RBC
SERUM-TO-ASCITES ALBUMIN GRADIENT (SAAG)
=Serum albumin ndash ascitic fluid albuminIf the gradient is gt11 Portal HTN (drives fluids into
peritoneum) SBP cirrhosis Alcoholic hepatitis CHFIf the gradient is lt 11(protein leaks into peritoneum and fluid
follows) Peritoneal carcinomatosis peritoneal
TB pancreatitis nephrotic syndrome
SBP SAAG gt 11 Suspect if gt250 PMNs (gt100 PMNs in pt on
peritoneal dialysis) 70 GNR (Ecoli Klebsiella)
30 GPC (S pneumo Enterococcus) Treat with ceftriaxone cefotaxime ldquoCulture negative SBPrdquo if gt250 PMNs but cx
neg treat the same
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
Measure pH pH less than 70 associated with infection or
rheumatoid disorder
Cell count see limited RBCs and WBCs
Evaluate sedimentation
bull Examine physical chemical and microscopic detail
bull Count number of sperm report morphology and
motility
bull Specimen must be a fresh collection-clean sterile
container
bull Gross Exam Color pH Volume and viscosity
bull Agglutination study
5- Seminal Fluid
bull Joint Fluid normally clear viscous
bull Functions as a lubricate and transports nutrient
bull Arthrocentesis aspirate of the joint fluid aseptic
technique
bull Lab Assay Gross exam microscopic exam Gram
stain cultures
6- Synovial Fluid
bull Appearance clear transparent viscous
bull Viscosity test
bull Mucin Clot test
bull Note crystals (intracellular vs extra cellular)
bull Slide exam usually performed on concentration of the fluid
using Giemsa or Papnicolaou
THANK YOU
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
NORMAL CSF COMPOSITION
Clear color lt5 RBCrsquos lt5 WBCrsquos Protein 23-38mgdl (can use 14-45) Glucosemdash60 of serum level (75-100)
OPENING PRESSURE
Normal = 80-180 mmHg Obese pts up to 250mmHg can be normal Pathologically elevated gt250mmHg If elevated likely due to cerebral edema from
intracranial pathology Infection (cryptococcal meningitis) tumor
benign ICH (pseudotumor)
RBCS
Always send tube 1 and 4 for cell count and compare RBCs
Traumatic tap Elev RBC in tube 1 nl in tube 41000 RBC 1 WBC to adjust WBC count in
bloody tap
SAH or HSV Elev RBC in tube 1 AND tube 4
ldquoCrenated RBCsrdquo and xanthochromia (yellow supernatant after centrifuge)Seen in hyperbilirubinemia (ESLD) old SAH
old blood from prior traumatic LP or bleed
WBCrsquoS
Infection PMN predominance likely bacterial
meningitis Lymphocytic predominance viral vs fungal
vs TB vs malignancy
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)
GLUCOSE
Normal Viral infectionLow glucose Bacterial meningitis TB fungalReally low lt18 is strongly suggestive of bacterial
meningitis
TYPICAL VIRAL MENINGITIS
CSF WBC elevated but lt250 (first PMNs then lymphocytes)
CSF protein elevated but lt150 Glucose gt 50 of serum concentration
TYPICAL BACTERIAL MENINGITIS
CSF WBC gt1000 PMN predominance CSF protein gt500mgdl CSF glucose lt45 mgdl
bull Effusion
bull Transudate
bull Exudates
bull Lab analysis Gross exam cell count etc
bull Differential PMN Lymph Mono etc
2- Pleural Fluid Lung fluid
bull Cells unique to the lungs Mesothelial cells
bull RBCs and WBCs are limited if increased without
traumatic tap ----- indicates infarction
bull Cytology exam useful in identifying malignancy or
abnormal morphological cells
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 ro
chylothorax amylase to ro pancreatitis esoph perf Adenosine deaminase to eval TB
LIGHTrsquoS CRITERIA FOR EXUDATES
Fluid is exudate if it meets 1 of 3 criteria 1 Pleural fluid LDHserum LDH gt 062 Pleural fluid proteinserum protein gt 053 Pleural fluid LDH gt upper limit of normal
serum LDH If all 3 negative fluid is Transudate
TRANSUDATE
Result from imbalances in oncotic and hydrostatic pressure
Usually low oncotic +- high hydrostatic pressure
Pulm EdemaCHF Cirrhosis with ascites HypoalbuminemiaNephrotic
syndrome ESLD Fluid overload sp aggressive IVF Peritoneal dialysis
EXUDATE
Caused by local not systemic factors Infection Neoplasm Pancreatitis Esoph perf RA SLE Sarcoid Wegeners PE Meigrsquos
Chylothorax
LYMPHOCYTOSIS
Malignancy (50-70 lymphs) Also TB sarcoid RA chylothorax (gt90
lymphs)
PLEURAL EOSINOPHILIA
Pneumothorax Hemothorax Pulm infarct Parasitic disease
Fungal infection Drugs Malignancy Asbestos
WHY IS GLUCOSE LOW(lt60)
RA TB Empyema SLE Malignancy Esophageal rupture
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 gt 100ml (several 100) before effusion
can be detected on physical exam
Removal procedure- paracentesis
Lab analysis distinguish between transudate and exudates
gross exam cell count sedimentation chemical analysis
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
Lymphocytes CHF liver cirrhosis nephrotic syndrome
Mesothelial Cells Associated with TB effusions
Malignant cells seen with malignancy
WHAT TO SEND FLUID FOR
Cell count with diff Albumin LDH Total protein
glucose Gram staincx cytology
APPEARANCE OF FLUID
Clearmdashusually indicates uncomplicated ascites ie liver failurecirrhosis
Turbidcloudymdashinfected Pinkbloodymdashtraumatic punctured collateral
vessel malignancy Correct for bloody tap 1 WBC 750 RBC
1 PMN 250 RBC
SERUM-TO-ASCITES ALBUMIN GRADIENT (SAAG)
=Serum albumin ndash ascitic fluid albuminIf the gradient is gt11 Portal HTN (drives fluids into
peritoneum) SBP cirrhosis Alcoholic hepatitis CHFIf the gradient is lt 11(protein leaks into peritoneum and fluid
follows) Peritoneal carcinomatosis peritoneal
TB pancreatitis nephrotic syndrome
SBP SAAG gt 11 Suspect if gt250 PMNs (gt100 PMNs in pt on
peritoneal dialysis) 70 GNR (Ecoli Klebsiella)
30 GPC (S pneumo Enterococcus) Treat with ceftriaxone cefotaxime ldquoCulture negative SBPrdquo if gt250 PMNs but cx
neg treat the same
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
Measure pH pH less than 70 associated with infection or
rheumatoid disorder
Cell count see limited RBCs and WBCs
Evaluate sedimentation
bull Examine physical chemical and microscopic detail
bull Count number of sperm report morphology and
motility
bull Specimen must be a fresh collection-clean sterile
container
bull Gross Exam Color pH Volume and viscosity
bull Agglutination study
5- Seminal Fluid
bull Joint Fluid normally clear viscous
bull Functions as a lubricate and transports nutrient
bull Arthrocentesis aspirate of the joint fluid aseptic
technique
bull Lab Assay Gross exam microscopic exam Gram
stain cultures
6- Synovial Fluid
bull Appearance clear transparent viscous
bull Viscosity test
bull Mucin Clot test
bull Note crystals (intracellular vs extra cellular)
bull Slide exam usually performed on concentration of the fluid
using Giemsa or Papnicolaou
THANK YOU
NORMAL CSF COMPOSITION
Clear color lt5 RBCrsquos lt5 WBCrsquos Protein 23-38mgdl (can use 14-45) Glucosemdash60 of serum level (75-100)
OPENING PRESSURE
Normal = 80-180 mmHg Obese pts up to 250mmHg can be normal Pathologically elevated gt250mmHg If elevated likely due to cerebral edema from
intracranial pathology Infection (cryptococcal meningitis) tumor
benign ICH (pseudotumor)
RBCS
Always send tube 1 and 4 for cell count and compare RBCs
Traumatic tap Elev RBC in tube 1 nl in tube 41000 RBC 1 WBC to adjust WBC count in
bloody tap
SAH or HSV Elev RBC in tube 1 AND tube 4
ldquoCrenated RBCsrdquo and xanthochromia (yellow supernatant after centrifuge)Seen in hyperbilirubinemia (ESLD) old SAH
old blood from prior traumatic LP or bleed
WBCrsquoS
Infection PMN predominance likely bacterial
meningitis Lymphocytic predominance viral vs fungal
vs TB vs malignancy
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)
GLUCOSE
Normal Viral infectionLow glucose Bacterial meningitis TB fungalReally low lt18 is strongly suggestive of bacterial
meningitis
TYPICAL VIRAL MENINGITIS
CSF WBC elevated but lt250 (first PMNs then lymphocytes)
CSF protein elevated but lt150 Glucose gt 50 of serum concentration
TYPICAL BACTERIAL MENINGITIS
CSF WBC gt1000 PMN predominance CSF protein gt500mgdl CSF glucose lt45 mgdl
bull Effusion
bull Transudate
bull Exudates
bull Lab analysis Gross exam cell count etc
bull Differential PMN Lymph Mono etc
2- Pleural Fluid Lung fluid
bull Cells unique to the lungs Mesothelial cells
bull RBCs and WBCs are limited if increased without
traumatic tap ----- indicates infarction
bull Cytology exam useful in identifying malignancy or
abnormal morphological cells
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 ro
chylothorax amylase to ro pancreatitis esoph perf Adenosine deaminase to eval TB
LIGHTrsquoS CRITERIA FOR EXUDATES
Fluid is exudate if it meets 1 of 3 criteria 1 Pleural fluid LDHserum LDH gt 062 Pleural fluid proteinserum protein gt 053 Pleural fluid LDH gt upper limit of normal
serum LDH If all 3 negative fluid is Transudate
TRANSUDATE
Result from imbalances in oncotic and hydrostatic pressure
Usually low oncotic +- high hydrostatic pressure
Pulm EdemaCHF Cirrhosis with ascites HypoalbuminemiaNephrotic
syndrome ESLD Fluid overload sp aggressive IVF Peritoneal dialysis
EXUDATE
Caused by local not systemic factors Infection Neoplasm Pancreatitis Esoph perf RA SLE Sarcoid Wegeners PE Meigrsquos
Chylothorax
LYMPHOCYTOSIS
Malignancy (50-70 lymphs) Also TB sarcoid RA chylothorax (gt90
lymphs)
PLEURAL EOSINOPHILIA
Pneumothorax Hemothorax Pulm infarct Parasitic disease
Fungal infection Drugs Malignancy Asbestos
WHY IS GLUCOSE LOW(lt60)
RA TB Empyema SLE Malignancy Esophageal rupture
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 gt 100ml (several 100) before effusion
can be detected on physical exam
Removal procedure- paracentesis
Lab analysis distinguish between transudate and exudates
gross exam cell count sedimentation chemical analysis
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
Lymphocytes CHF liver cirrhosis nephrotic syndrome
Mesothelial Cells Associated with TB effusions
Malignant cells seen with malignancy
WHAT TO SEND FLUID FOR
Cell count with diff Albumin LDH Total protein
glucose Gram staincx cytology
APPEARANCE OF FLUID
Clearmdashusually indicates uncomplicated ascites ie liver failurecirrhosis
Turbidcloudymdashinfected Pinkbloodymdashtraumatic punctured collateral
vessel malignancy Correct for bloody tap 1 WBC 750 RBC
1 PMN 250 RBC
SERUM-TO-ASCITES ALBUMIN GRADIENT (SAAG)
=Serum albumin ndash ascitic fluid albuminIf the gradient is gt11 Portal HTN (drives fluids into
peritoneum) SBP cirrhosis Alcoholic hepatitis CHFIf the gradient is lt 11(protein leaks into peritoneum and fluid
follows) Peritoneal carcinomatosis peritoneal
TB pancreatitis nephrotic syndrome
SBP SAAG gt 11 Suspect if gt250 PMNs (gt100 PMNs in pt on
peritoneal dialysis) 70 GNR (Ecoli Klebsiella)
30 GPC (S pneumo Enterococcus) Treat with ceftriaxone cefotaxime ldquoCulture negative SBPrdquo if gt250 PMNs but cx
neg treat the same
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
Measure pH pH less than 70 associated with infection or
rheumatoid disorder
Cell count see limited RBCs and WBCs
Evaluate sedimentation
bull Examine physical chemical and microscopic detail
bull Count number of sperm report morphology and
motility
bull Specimen must be a fresh collection-clean sterile
container
bull Gross Exam Color pH Volume and viscosity
bull Agglutination study
5- Seminal Fluid
bull Joint Fluid normally clear viscous
bull Functions as a lubricate and transports nutrient
bull Arthrocentesis aspirate of the joint fluid aseptic
technique
bull Lab Assay Gross exam microscopic exam Gram
stain cultures
6- Synovial Fluid
bull Appearance clear transparent viscous
bull Viscosity test
bull Mucin Clot test
bull Note crystals (intracellular vs extra cellular)
bull Slide exam usually performed on concentration of the fluid
using Giemsa or Papnicolaou
THANK YOU
OPENING PRESSURE
Normal = 80-180 mmHg Obese pts up to 250mmHg can be normal Pathologically elevated gt250mmHg If elevated likely due to cerebral edema from
intracranial pathology Infection (cryptococcal meningitis) tumor
benign ICH (pseudotumor)
RBCS
Always send tube 1 and 4 for cell count and compare RBCs
Traumatic tap Elev RBC in tube 1 nl in tube 41000 RBC 1 WBC to adjust WBC count in
bloody tap
SAH or HSV Elev RBC in tube 1 AND tube 4
ldquoCrenated RBCsrdquo and xanthochromia (yellow supernatant after centrifuge)Seen in hyperbilirubinemia (ESLD) old SAH
old blood from prior traumatic LP or bleed
WBCrsquoS
Infection PMN predominance likely bacterial
meningitis Lymphocytic predominance viral vs fungal
vs TB vs malignancy
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)
GLUCOSE
Normal Viral infectionLow glucose Bacterial meningitis TB fungalReally low lt18 is strongly suggestive of bacterial
meningitis
TYPICAL VIRAL MENINGITIS
CSF WBC elevated but lt250 (first PMNs then lymphocytes)
CSF protein elevated but lt150 Glucose gt 50 of serum concentration
TYPICAL BACTERIAL MENINGITIS
CSF WBC gt1000 PMN predominance CSF protein gt500mgdl CSF glucose lt45 mgdl
bull Effusion
bull Transudate
bull Exudates
bull Lab analysis Gross exam cell count etc
bull Differential PMN Lymph Mono etc
2- Pleural Fluid Lung fluid
bull Cells unique to the lungs Mesothelial cells
bull RBCs and WBCs are limited if increased without
traumatic tap ----- indicates infarction
bull Cytology exam useful in identifying malignancy or
abnormal morphological cells
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 ro
chylothorax amylase to ro pancreatitis esoph perf Adenosine deaminase to eval TB
LIGHTrsquoS CRITERIA FOR EXUDATES
Fluid is exudate if it meets 1 of 3 criteria 1 Pleural fluid LDHserum LDH gt 062 Pleural fluid proteinserum protein gt 053 Pleural fluid LDH gt upper limit of normal
serum LDH If all 3 negative fluid is Transudate
TRANSUDATE
Result from imbalances in oncotic and hydrostatic pressure
Usually low oncotic +- high hydrostatic pressure
Pulm EdemaCHF Cirrhosis with ascites HypoalbuminemiaNephrotic
syndrome ESLD Fluid overload sp aggressive IVF Peritoneal dialysis
EXUDATE
Caused by local not systemic factors Infection Neoplasm Pancreatitis Esoph perf RA SLE Sarcoid Wegeners PE Meigrsquos
Chylothorax
LYMPHOCYTOSIS
Malignancy (50-70 lymphs) Also TB sarcoid RA chylothorax (gt90
lymphs)
PLEURAL EOSINOPHILIA
Pneumothorax Hemothorax Pulm infarct Parasitic disease
Fungal infection Drugs Malignancy Asbestos
WHY IS GLUCOSE LOW(lt60)
RA TB Empyema SLE Malignancy Esophageal rupture
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 gt 100ml (several 100) before effusion
can be detected on physical exam
Removal procedure- paracentesis
Lab analysis distinguish between transudate and exudates
gross exam cell count sedimentation chemical analysis
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
Lymphocytes CHF liver cirrhosis nephrotic syndrome
Mesothelial Cells Associated with TB effusions
Malignant cells seen with malignancy
WHAT TO SEND FLUID FOR
Cell count with diff Albumin LDH Total protein
glucose Gram staincx cytology
APPEARANCE OF FLUID
Clearmdashusually indicates uncomplicated ascites ie liver failurecirrhosis
Turbidcloudymdashinfected Pinkbloodymdashtraumatic punctured collateral
vessel malignancy Correct for bloody tap 1 WBC 750 RBC
1 PMN 250 RBC
SERUM-TO-ASCITES ALBUMIN GRADIENT (SAAG)
=Serum albumin ndash ascitic fluid albuminIf the gradient is gt11 Portal HTN (drives fluids into
peritoneum) SBP cirrhosis Alcoholic hepatitis CHFIf the gradient is lt 11(protein leaks into peritoneum and fluid
follows) Peritoneal carcinomatosis peritoneal
TB pancreatitis nephrotic syndrome
SBP SAAG gt 11 Suspect if gt250 PMNs (gt100 PMNs in pt on
peritoneal dialysis) 70 GNR (Ecoli Klebsiella)
30 GPC (S pneumo Enterococcus) Treat with ceftriaxone cefotaxime ldquoCulture negative SBPrdquo if gt250 PMNs but cx
neg treat the same
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
Measure pH pH less than 70 associated with infection or
rheumatoid disorder
Cell count see limited RBCs and WBCs
Evaluate sedimentation
bull Examine physical chemical and microscopic detail
bull Count number of sperm report morphology and
motility
bull Specimen must be a fresh collection-clean sterile
container
bull Gross Exam Color pH Volume and viscosity
bull Agglutination study
5- Seminal Fluid
bull Joint Fluid normally clear viscous
bull Functions as a lubricate and transports nutrient
bull Arthrocentesis aspirate of the joint fluid aseptic
technique
bull Lab Assay Gross exam microscopic exam Gram
stain cultures
6- Synovial Fluid
bull Appearance clear transparent viscous
bull Viscosity test
bull Mucin Clot test
bull Note crystals (intracellular vs extra cellular)
bull Slide exam usually performed on concentration of the fluid
using Giemsa or Papnicolaou
THANK YOU
RBCS
Always send tube 1 and 4 for cell count and compare RBCs
Traumatic tap Elev RBC in tube 1 nl in tube 41000 RBC 1 WBC to adjust WBC count in
bloody tap
SAH or HSV Elev RBC in tube 1 AND tube 4
ldquoCrenated RBCsrdquo and xanthochromia (yellow supernatant after centrifuge)Seen in hyperbilirubinemia (ESLD) old SAH
old blood from prior traumatic LP or bleed
WBCrsquoS
Infection PMN predominance likely bacterial
meningitis Lymphocytic predominance viral vs fungal
vs TB vs malignancy
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)
GLUCOSE
Normal Viral infectionLow glucose Bacterial meningitis TB fungalReally low lt18 is strongly suggestive of bacterial
meningitis
TYPICAL VIRAL MENINGITIS
CSF WBC elevated but lt250 (first PMNs then lymphocytes)
CSF protein elevated but lt150 Glucose gt 50 of serum concentration
TYPICAL BACTERIAL MENINGITIS
CSF WBC gt1000 PMN predominance CSF protein gt500mgdl CSF glucose lt45 mgdl
bull Effusion
bull Transudate
bull Exudates
bull Lab analysis Gross exam cell count etc
bull Differential PMN Lymph Mono etc
2- Pleural Fluid Lung fluid
bull Cells unique to the lungs Mesothelial cells
bull RBCs and WBCs are limited if increased without
traumatic tap ----- indicates infarction
bull Cytology exam useful in identifying malignancy or
abnormal morphological cells
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 ro
chylothorax amylase to ro pancreatitis esoph perf Adenosine deaminase to eval TB
LIGHTrsquoS CRITERIA FOR EXUDATES
Fluid is exudate if it meets 1 of 3 criteria 1 Pleural fluid LDHserum LDH gt 062 Pleural fluid proteinserum protein gt 053 Pleural fluid LDH gt upper limit of normal
serum LDH If all 3 negative fluid is Transudate
TRANSUDATE
Result from imbalances in oncotic and hydrostatic pressure
Usually low oncotic +- high hydrostatic pressure
Pulm EdemaCHF Cirrhosis with ascites HypoalbuminemiaNephrotic
syndrome ESLD Fluid overload sp aggressive IVF Peritoneal dialysis
EXUDATE
Caused by local not systemic factors Infection Neoplasm Pancreatitis Esoph perf RA SLE Sarcoid Wegeners PE Meigrsquos
Chylothorax
LYMPHOCYTOSIS
Malignancy (50-70 lymphs) Also TB sarcoid RA chylothorax (gt90
lymphs)
PLEURAL EOSINOPHILIA
Pneumothorax Hemothorax Pulm infarct Parasitic disease
Fungal infection Drugs Malignancy Asbestos
WHY IS GLUCOSE LOW(lt60)
RA TB Empyema SLE Malignancy Esophageal rupture
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 gt 100ml (several 100) before effusion
can be detected on physical exam
Removal procedure- paracentesis
Lab analysis distinguish between transudate and exudates
gross exam cell count sedimentation chemical analysis
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
Lymphocytes CHF liver cirrhosis nephrotic syndrome
Mesothelial Cells Associated with TB effusions
Malignant cells seen with malignancy
WHAT TO SEND FLUID FOR
Cell count with diff Albumin LDH Total protein
glucose Gram staincx cytology
APPEARANCE OF FLUID
Clearmdashusually indicates uncomplicated ascites ie liver failurecirrhosis
Turbidcloudymdashinfected Pinkbloodymdashtraumatic punctured collateral
vessel malignancy Correct for bloody tap 1 WBC 750 RBC
1 PMN 250 RBC
SERUM-TO-ASCITES ALBUMIN GRADIENT (SAAG)
=Serum albumin ndash ascitic fluid albuminIf the gradient is gt11 Portal HTN (drives fluids into
peritoneum) SBP cirrhosis Alcoholic hepatitis CHFIf the gradient is lt 11(protein leaks into peritoneum and fluid
follows) Peritoneal carcinomatosis peritoneal
TB pancreatitis nephrotic syndrome
SBP SAAG gt 11 Suspect if gt250 PMNs (gt100 PMNs in pt on
peritoneal dialysis) 70 GNR (Ecoli Klebsiella)
30 GPC (S pneumo Enterococcus) Treat with ceftriaxone cefotaxime ldquoCulture negative SBPrdquo if gt250 PMNs but cx
neg treat the same
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
Measure pH pH less than 70 associated with infection or
rheumatoid disorder
Cell count see limited RBCs and WBCs
Evaluate sedimentation
bull Examine physical chemical and microscopic detail
bull Count number of sperm report morphology and
motility
bull Specimen must be a fresh collection-clean sterile
container
bull Gross Exam Color pH Volume and viscosity
bull Agglutination study
5- Seminal Fluid
bull Joint Fluid normally clear viscous
bull Functions as a lubricate and transports nutrient
bull Arthrocentesis aspirate of the joint fluid aseptic
technique
bull Lab Assay Gross exam microscopic exam Gram
stain cultures
6- Synovial Fluid
bull Appearance clear transparent viscous
bull Viscosity test
bull Mucin Clot test
bull Note crystals (intracellular vs extra cellular)
bull Slide exam usually performed on concentration of the fluid
using Giemsa or Papnicolaou
THANK YOU
WBCrsquoS
Infection PMN predominance likely bacterial
meningitis Lymphocytic predominance viral vs fungal
vs TB vs malignancy
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)
GLUCOSE
Normal Viral infectionLow glucose Bacterial meningitis TB fungalReally low lt18 is strongly suggestive of bacterial
meningitis
TYPICAL VIRAL MENINGITIS
CSF WBC elevated but lt250 (first PMNs then lymphocytes)
CSF protein elevated but lt150 Glucose gt 50 of serum concentration
TYPICAL BACTERIAL MENINGITIS
CSF WBC gt1000 PMN predominance CSF protein gt500mgdl CSF glucose lt45 mgdl
bull Effusion
bull Transudate
bull Exudates
bull Lab analysis Gross exam cell count etc
bull Differential PMN Lymph Mono etc
2- Pleural Fluid Lung fluid
bull Cells unique to the lungs Mesothelial cells
bull RBCs and WBCs are limited if increased without
traumatic tap ----- indicates infarction
bull Cytology exam useful in identifying malignancy or
abnormal morphological cells
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 ro
chylothorax amylase to ro pancreatitis esoph perf Adenosine deaminase to eval TB
LIGHTrsquoS CRITERIA FOR EXUDATES
Fluid is exudate if it meets 1 of 3 criteria 1 Pleural fluid LDHserum LDH gt 062 Pleural fluid proteinserum protein gt 053 Pleural fluid LDH gt upper limit of normal
serum LDH If all 3 negative fluid is Transudate
TRANSUDATE
Result from imbalances in oncotic and hydrostatic pressure
Usually low oncotic +- high hydrostatic pressure
Pulm EdemaCHF Cirrhosis with ascites HypoalbuminemiaNephrotic
syndrome ESLD Fluid overload sp aggressive IVF Peritoneal dialysis
EXUDATE
Caused by local not systemic factors Infection Neoplasm Pancreatitis Esoph perf RA SLE Sarcoid Wegeners PE Meigrsquos
Chylothorax
LYMPHOCYTOSIS
Malignancy (50-70 lymphs) Also TB sarcoid RA chylothorax (gt90
lymphs)
PLEURAL EOSINOPHILIA
Pneumothorax Hemothorax Pulm infarct Parasitic disease
Fungal infection Drugs Malignancy Asbestos
WHY IS GLUCOSE LOW(lt60)
RA TB Empyema SLE Malignancy Esophageal rupture
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 gt 100ml (several 100) before effusion
can be detected on physical exam
Removal procedure- paracentesis
Lab analysis distinguish between transudate and exudates
gross exam cell count sedimentation chemical analysis
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
Lymphocytes CHF liver cirrhosis nephrotic syndrome
Mesothelial Cells Associated with TB effusions
Malignant cells seen with malignancy
WHAT TO SEND FLUID FOR
Cell count with diff Albumin LDH Total protein
glucose Gram staincx cytology
APPEARANCE OF FLUID
Clearmdashusually indicates uncomplicated ascites ie liver failurecirrhosis
Turbidcloudymdashinfected Pinkbloodymdashtraumatic punctured collateral
vessel malignancy Correct for bloody tap 1 WBC 750 RBC
1 PMN 250 RBC
SERUM-TO-ASCITES ALBUMIN GRADIENT (SAAG)
=Serum albumin ndash ascitic fluid albuminIf the gradient is gt11 Portal HTN (drives fluids into
peritoneum) SBP cirrhosis Alcoholic hepatitis CHFIf the gradient is lt 11(protein leaks into peritoneum and fluid
follows) Peritoneal carcinomatosis peritoneal
TB pancreatitis nephrotic syndrome
SBP SAAG gt 11 Suspect if gt250 PMNs (gt100 PMNs in pt on
peritoneal dialysis) 70 GNR (Ecoli Klebsiella)
30 GPC (S pneumo Enterococcus) Treat with ceftriaxone cefotaxime ldquoCulture negative SBPrdquo if gt250 PMNs but cx
neg treat the same
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
Measure pH pH less than 70 associated with infection or
rheumatoid disorder
Cell count see limited RBCs and WBCs
Evaluate sedimentation
bull Examine physical chemical and microscopic detail
bull Count number of sperm report morphology and
motility
bull Specimen must be a fresh collection-clean sterile
container
bull Gross Exam Color pH Volume and viscosity
bull Agglutination study
5- Seminal Fluid
bull Joint Fluid normally clear viscous
bull Functions as a lubricate and transports nutrient
bull Arthrocentesis aspirate of the joint fluid aseptic
technique
bull Lab Assay Gross exam microscopic exam Gram
stain cultures
6- Synovial Fluid
bull Appearance clear transparent viscous
bull Viscosity test
bull Mucin Clot test
bull Note crystals (intracellular vs extra cellular)
bull Slide exam usually performed on concentration of the fluid
using Giemsa or Papnicolaou
THANK YOU
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)
GLUCOSE
Normal Viral infectionLow glucose Bacterial meningitis TB fungalReally low lt18 is strongly suggestive of bacterial
meningitis
TYPICAL VIRAL MENINGITIS
CSF WBC elevated but lt250 (first PMNs then lymphocytes)
CSF protein elevated but lt150 Glucose gt 50 of serum concentration
TYPICAL BACTERIAL MENINGITIS
CSF WBC gt1000 PMN predominance CSF protein gt500mgdl CSF glucose lt45 mgdl
bull Effusion
bull Transudate
bull Exudates
bull Lab analysis Gross exam cell count etc
bull Differential PMN Lymph Mono etc
2- Pleural Fluid Lung fluid
bull Cells unique to the lungs Mesothelial cells
bull RBCs and WBCs are limited if increased without
traumatic tap ----- indicates infarction
bull Cytology exam useful in identifying malignancy or
abnormal morphological cells
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 ro
chylothorax amylase to ro pancreatitis esoph perf Adenosine deaminase to eval TB
LIGHTrsquoS CRITERIA FOR EXUDATES
Fluid is exudate if it meets 1 of 3 criteria 1 Pleural fluid LDHserum LDH gt 062 Pleural fluid proteinserum protein gt 053 Pleural fluid LDH gt upper limit of normal
serum LDH If all 3 negative fluid is Transudate
TRANSUDATE
Result from imbalances in oncotic and hydrostatic pressure
Usually low oncotic +- high hydrostatic pressure
Pulm EdemaCHF Cirrhosis with ascites HypoalbuminemiaNephrotic
syndrome ESLD Fluid overload sp aggressive IVF Peritoneal dialysis
EXUDATE
Caused by local not systemic factors Infection Neoplasm Pancreatitis Esoph perf RA SLE Sarcoid Wegeners PE Meigrsquos
Chylothorax
LYMPHOCYTOSIS
Malignancy (50-70 lymphs) Also TB sarcoid RA chylothorax (gt90
lymphs)
PLEURAL EOSINOPHILIA
Pneumothorax Hemothorax Pulm infarct Parasitic disease
Fungal infection Drugs Malignancy Asbestos
WHY IS GLUCOSE LOW(lt60)
RA TB Empyema SLE Malignancy Esophageal rupture
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 gt 100ml (several 100) before effusion
can be detected on physical exam
Removal procedure- paracentesis
Lab analysis distinguish between transudate and exudates
gross exam cell count sedimentation chemical analysis
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
Lymphocytes CHF liver cirrhosis nephrotic syndrome
Mesothelial Cells Associated with TB effusions
Malignant cells seen with malignancy
WHAT TO SEND FLUID FOR
Cell count with diff Albumin LDH Total protein
glucose Gram staincx cytology
APPEARANCE OF FLUID
Clearmdashusually indicates uncomplicated ascites ie liver failurecirrhosis
Turbidcloudymdashinfected Pinkbloodymdashtraumatic punctured collateral
vessel malignancy Correct for bloody tap 1 WBC 750 RBC
1 PMN 250 RBC
SERUM-TO-ASCITES ALBUMIN GRADIENT (SAAG)
=Serum albumin ndash ascitic fluid albuminIf the gradient is gt11 Portal HTN (drives fluids into
peritoneum) SBP cirrhosis Alcoholic hepatitis CHFIf the gradient is lt 11(protein leaks into peritoneum and fluid
follows) Peritoneal carcinomatosis peritoneal
TB pancreatitis nephrotic syndrome
SBP SAAG gt 11 Suspect if gt250 PMNs (gt100 PMNs in pt on
peritoneal dialysis) 70 GNR (Ecoli Klebsiella)
30 GPC (S pneumo Enterococcus) Treat with ceftriaxone cefotaxime ldquoCulture negative SBPrdquo if gt250 PMNs but cx
neg treat the same
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
Measure pH pH less than 70 associated with infection or
rheumatoid disorder
Cell count see limited RBCs and WBCs
Evaluate sedimentation
bull Examine physical chemical and microscopic detail
bull Count number of sperm report morphology and
motility
bull Specimen must be a fresh collection-clean sterile
container
bull Gross Exam Color pH Volume and viscosity
bull Agglutination study
5- Seminal Fluid
bull Joint Fluid normally clear viscous
bull Functions as a lubricate and transports nutrient
bull Arthrocentesis aspirate of the joint fluid aseptic
technique
bull Lab Assay Gross exam microscopic exam Gram
stain cultures
6- Synovial Fluid
bull Appearance clear transparent viscous
bull Viscosity test
bull Mucin Clot test
bull Note crystals (intracellular vs extra cellular)
bull Slide exam usually performed on concentration of the fluid
using Giemsa or Papnicolaou
THANK YOU
GLUCOSE
Normal Viral infectionLow glucose Bacterial meningitis TB fungalReally low lt18 is strongly suggestive of bacterial
meningitis
TYPICAL VIRAL MENINGITIS
CSF WBC elevated but lt250 (first PMNs then lymphocytes)
CSF protein elevated but lt150 Glucose gt 50 of serum concentration
TYPICAL BACTERIAL MENINGITIS
CSF WBC gt1000 PMN predominance CSF protein gt500mgdl CSF glucose lt45 mgdl
bull Effusion
bull Transudate
bull Exudates
bull Lab analysis Gross exam cell count etc
bull Differential PMN Lymph Mono etc
2- Pleural Fluid Lung fluid
bull Cells unique to the lungs Mesothelial cells
bull RBCs and WBCs are limited if increased without
traumatic tap ----- indicates infarction
bull Cytology exam useful in identifying malignancy or
abnormal morphological cells
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 ro
chylothorax amylase to ro pancreatitis esoph perf Adenosine deaminase to eval TB
LIGHTrsquoS CRITERIA FOR EXUDATES
Fluid is exudate if it meets 1 of 3 criteria 1 Pleural fluid LDHserum LDH gt 062 Pleural fluid proteinserum protein gt 053 Pleural fluid LDH gt upper limit of normal
serum LDH If all 3 negative fluid is Transudate
TRANSUDATE
Result from imbalances in oncotic and hydrostatic pressure
Usually low oncotic +- high hydrostatic pressure
Pulm EdemaCHF Cirrhosis with ascites HypoalbuminemiaNephrotic
syndrome ESLD Fluid overload sp aggressive IVF Peritoneal dialysis
EXUDATE
Caused by local not systemic factors Infection Neoplasm Pancreatitis Esoph perf RA SLE Sarcoid Wegeners PE Meigrsquos
Chylothorax
LYMPHOCYTOSIS
Malignancy (50-70 lymphs) Also TB sarcoid RA chylothorax (gt90
lymphs)
PLEURAL EOSINOPHILIA
Pneumothorax Hemothorax Pulm infarct Parasitic disease
Fungal infection Drugs Malignancy Asbestos
WHY IS GLUCOSE LOW(lt60)
RA TB Empyema SLE Malignancy Esophageal rupture
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 gt 100ml (several 100) before effusion
can be detected on physical exam
Removal procedure- paracentesis
Lab analysis distinguish between transudate and exudates
gross exam cell count sedimentation chemical analysis
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
Lymphocytes CHF liver cirrhosis nephrotic syndrome
Mesothelial Cells Associated with TB effusions
Malignant cells seen with malignancy
WHAT TO SEND FLUID FOR
Cell count with diff Albumin LDH Total protein
glucose Gram staincx cytology
APPEARANCE OF FLUID
Clearmdashusually indicates uncomplicated ascites ie liver failurecirrhosis
Turbidcloudymdashinfected Pinkbloodymdashtraumatic punctured collateral
vessel malignancy Correct for bloody tap 1 WBC 750 RBC
1 PMN 250 RBC
SERUM-TO-ASCITES ALBUMIN GRADIENT (SAAG)
=Serum albumin ndash ascitic fluid albuminIf the gradient is gt11 Portal HTN (drives fluids into
peritoneum) SBP cirrhosis Alcoholic hepatitis CHFIf the gradient is lt 11(protein leaks into peritoneum and fluid
follows) Peritoneal carcinomatosis peritoneal
TB pancreatitis nephrotic syndrome
SBP SAAG gt 11 Suspect if gt250 PMNs (gt100 PMNs in pt on
peritoneal dialysis) 70 GNR (Ecoli Klebsiella)
30 GPC (S pneumo Enterococcus) Treat with ceftriaxone cefotaxime ldquoCulture negative SBPrdquo if gt250 PMNs but cx
neg treat the same
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
Measure pH pH less than 70 associated with infection or
rheumatoid disorder
Cell count see limited RBCs and WBCs
Evaluate sedimentation
bull Examine physical chemical and microscopic detail
bull Count number of sperm report morphology and
motility
bull Specimen must be a fresh collection-clean sterile
container
bull Gross Exam Color pH Volume and viscosity
bull Agglutination study
5- Seminal Fluid
bull Joint Fluid normally clear viscous
bull Functions as a lubricate and transports nutrient
bull Arthrocentesis aspirate of the joint fluid aseptic
technique
bull Lab Assay Gross exam microscopic exam Gram
stain cultures
6- Synovial Fluid
bull Appearance clear transparent viscous
bull Viscosity test
bull Mucin Clot test
bull Note crystals (intracellular vs extra cellular)
bull Slide exam usually performed on concentration of the fluid
using Giemsa or Papnicolaou
THANK YOU
TYPICAL VIRAL MENINGITIS
CSF WBC elevated but lt250 (first PMNs then lymphocytes)
CSF protein elevated but lt150 Glucose gt 50 of serum concentration
TYPICAL BACTERIAL MENINGITIS
CSF WBC gt1000 PMN predominance CSF protein gt500mgdl CSF glucose lt45 mgdl
bull Effusion
bull Transudate
bull Exudates
bull Lab analysis Gross exam cell count etc
bull Differential PMN Lymph Mono etc
2- Pleural Fluid Lung fluid
bull Cells unique to the lungs Mesothelial cells
bull RBCs and WBCs are limited if increased without
traumatic tap ----- indicates infarction
bull Cytology exam useful in identifying malignancy or
abnormal morphological cells
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 ro
chylothorax amylase to ro pancreatitis esoph perf Adenosine deaminase to eval TB
LIGHTrsquoS CRITERIA FOR EXUDATES
Fluid is exudate if it meets 1 of 3 criteria 1 Pleural fluid LDHserum LDH gt 062 Pleural fluid proteinserum protein gt 053 Pleural fluid LDH gt upper limit of normal
serum LDH If all 3 negative fluid is Transudate
TRANSUDATE
Result from imbalances in oncotic and hydrostatic pressure
Usually low oncotic +- high hydrostatic pressure
Pulm EdemaCHF Cirrhosis with ascites HypoalbuminemiaNephrotic
syndrome ESLD Fluid overload sp aggressive IVF Peritoneal dialysis
EXUDATE
Caused by local not systemic factors Infection Neoplasm Pancreatitis Esoph perf RA SLE Sarcoid Wegeners PE Meigrsquos
Chylothorax
LYMPHOCYTOSIS
Malignancy (50-70 lymphs) Also TB sarcoid RA chylothorax (gt90
lymphs)
PLEURAL EOSINOPHILIA
Pneumothorax Hemothorax Pulm infarct Parasitic disease
Fungal infection Drugs Malignancy Asbestos
WHY IS GLUCOSE LOW(lt60)
RA TB Empyema SLE Malignancy Esophageal rupture
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 gt 100ml (several 100) before effusion
can be detected on physical exam
Removal procedure- paracentesis
Lab analysis distinguish between transudate and exudates
gross exam cell count sedimentation chemical analysis
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
Lymphocytes CHF liver cirrhosis nephrotic syndrome
Mesothelial Cells Associated with TB effusions
Malignant cells seen with malignancy
WHAT TO SEND FLUID FOR
Cell count with diff Albumin LDH Total protein
glucose Gram staincx cytology
APPEARANCE OF FLUID
Clearmdashusually indicates uncomplicated ascites ie liver failurecirrhosis
Turbidcloudymdashinfected Pinkbloodymdashtraumatic punctured collateral
vessel malignancy Correct for bloody tap 1 WBC 750 RBC
1 PMN 250 RBC
SERUM-TO-ASCITES ALBUMIN GRADIENT (SAAG)
=Serum albumin ndash ascitic fluid albuminIf the gradient is gt11 Portal HTN (drives fluids into
peritoneum) SBP cirrhosis Alcoholic hepatitis CHFIf the gradient is lt 11(protein leaks into peritoneum and fluid
follows) Peritoneal carcinomatosis peritoneal
TB pancreatitis nephrotic syndrome
SBP SAAG gt 11 Suspect if gt250 PMNs (gt100 PMNs in pt on
peritoneal dialysis) 70 GNR (Ecoli Klebsiella)
30 GPC (S pneumo Enterococcus) Treat with ceftriaxone cefotaxime ldquoCulture negative SBPrdquo if gt250 PMNs but cx
neg treat the same
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
Measure pH pH less than 70 associated with infection or
rheumatoid disorder
Cell count see limited RBCs and WBCs
Evaluate sedimentation
bull Examine physical chemical and microscopic detail
bull Count number of sperm report morphology and
motility
bull Specimen must be a fresh collection-clean sterile
container
bull Gross Exam Color pH Volume and viscosity
bull Agglutination study
5- Seminal Fluid
bull Joint Fluid normally clear viscous
bull Functions as a lubricate and transports nutrient
bull Arthrocentesis aspirate of the joint fluid aseptic
technique
bull Lab Assay Gross exam microscopic exam Gram
stain cultures
6- Synovial Fluid
bull Appearance clear transparent viscous
bull Viscosity test
bull Mucin Clot test
bull Note crystals (intracellular vs extra cellular)
bull Slide exam usually performed on concentration of the fluid
using Giemsa or Papnicolaou
THANK YOU
TYPICAL BACTERIAL MENINGITIS
CSF WBC gt1000 PMN predominance CSF protein gt500mgdl CSF glucose lt45 mgdl
bull Effusion
bull Transudate
bull Exudates
bull Lab analysis Gross exam cell count etc
bull Differential PMN Lymph Mono etc
2- Pleural Fluid Lung fluid
bull Cells unique to the lungs Mesothelial cells
bull RBCs and WBCs are limited if increased without
traumatic tap ----- indicates infarction
bull Cytology exam useful in identifying malignancy or
abnormal morphological cells
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 ro
chylothorax amylase to ro pancreatitis esoph perf Adenosine deaminase to eval TB
LIGHTrsquoS CRITERIA FOR EXUDATES
Fluid is exudate if it meets 1 of 3 criteria 1 Pleural fluid LDHserum LDH gt 062 Pleural fluid proteinserum protein gt 053 Pleural fluid LDH gt upper limit of normal
serum LDH If all 3 negative fluid is Transudate
TRANSUDATE
Result from imbalances in oncotic and hydrostatic pressure
Usually low oncotic +- high hydrostatic pressure
Pulm EdemaCHF Cirrhosis with ascites HypoalbuminemiaNephrotic
syndrome ESLD Fluid overload sp aggressive IVF Peritoneal dialysis
EXUDATE
Caused by local not systemic factors Infection Neoplasm Pancreatitis Esoph perf RA SLE Sarcoid Wegeners PE Meigrsquos
Chylothorax
LYMPHOCYTOSIS
Malignancy (50-70 lymphs) Also TB sarcoid RA chylothorax (gt90
lymphs)
PLEURAL EOSINOPHILIA
Pneumothorax Hemothorax Pulm infarct Parasitic disease
Fungal infection Drugs Malignancy Asbestos
WHY IS GLUCOSE LOW(lt60)
RA TB Empyema SLE Malignancy Esophageal rupture
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 gt 100ml (several 100) before effusion
can be detected on physical exam
Removal procedure- paracentesis
Lab analysis distinguish between transudate and exudates
gross exam cell count sedimentation chemical analysis
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
Lymphocytes CHF liver cirrhosis nephrotic syndrome
Mesothelial Cells Associated with TB effusions
Malignant cells seen with malignancy
WHAT TO SEND FLUID FOR
Cell count with diff Albumin LDH Total protein
glucose Gram staincx cytology
APPEARANCE OF FLUID
Clearmdashusually indicates uncomplicated ascites ie liver failurecirrhosis
Turbidcloudymdashinfected Pinkbloodymdashtraumatic punctured collateral
vessel malignancy Correct for bloody tap 1 WBC 750 RBC
1 PMN 250 RBC
SERUM-TO-ASCITES ALBUMIN GRADIENT (SAAG)
=Serum albumin ndash ascitic fluid albuminIf the gradient is gt11 Portal HTN (drives fluids into
peritoneum) SBP cirrhosis Alcoholic hepatitis CHFIf the gradient is lt 11(protein leaks into peritoneum and fluid
follows) Peritoneal carcinomatosis peritoneal
TB pancreatitis nephrotic syndrome
SBP SAAG gt 11 Suspect if gt250 PMNs (gt100 PMNs in pt on
peritoneal dialysis) 70 GNR (Ecoli Klebsiella)
30 GPC (S pneumo Enterococcus) Treat with ceftriaxone cefotaxime ldquoCulture negative SBPrdquo if gt250 PMNs but cx
neg treat the same
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
Measure pH pH less than 70 associated with infection or
rheumatoid disorder
Cell count see limited RBCs and WBCs
Evaluate sedimentation
bull Examine physical chemical and microscopic detail
bull Count number of sperm report morphology and
motility
bull Specimen must be a fresh collection-clean sterile
container
bull Gross Exam Color pH Volume and viscosity
bull Agglutination study
5- Seminal Fluid
bull Joint Fluid normally clear viscous
bull Functions as a lubricate and transports nutrient
bull Arthrocentesis aspirate of the joint fluid aseptic
technique
bull Lab Assay Gross exam microscopic exam Gram
stain cultures
6- Synovial Fluid
bull Appearance clear transparent viscous
bull Viscosity test
bull Mucin Clot test
bull Note crystals (intracellular vs extra cellular)
bull Slide exam usually performed on concentration of the fluid
using Giemsa or Papnicolaou
THANK YOU
bull Effusion
bull Transudate
bull Exudates
bull Lab analysis Gross exam cell count etc
bull Differential PMN Lymph Mono etc
2- Pleural Fluid Lung fluid
bull Cells unique to the lungs Mesothelial cells
bull RBCs and WBCs are limited if increased without
traumatic tap ----- indicates infarction
bull Cytology exam useful in identifying malignancy or
abnormal morphological cells
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 ro
chylothorax amylase to ro pancreatitis esoph perf Adenosine deaminase to eval TB
LIGHTrsquoS CRITERIA FOR EXUDATES
Fluid is exudate if it meets 1 of 3 criteria 1 Pleural fluid LDHserum LDH gt 062 Pleural fluid proteinserum protein gt 053 Pleural fluid LDH gt upper limit of normal
serum LDH If all 3 negative fluid is Transudate
TRANSUDATE
Result from imbalances in oncotic and hydrostatic pressure
Usually low oncotic +- high hydrostatic pressure
Pulm EdemaCHF Cirrhosis with ascites HypoalbuminemiaNephrotic
syndrome ESLD Fluid overload sp aggressive IVF Peritoneal dialysis
EXUDATE
Caused by local not systemic factors Infection Neoplasm Pancreatitis Esoph perf RA SLE Sarcoid Wegeners PE Meigrsquos
Chylothorax
LYMPHOCYTOSIS
Malignancy (50-70 lymphs) Also TB sarcoid RA chylothorax (gt90
lymphs)
PLEURAL EOSINOPHILIA
Pneumothorax Hemothorax Pulm infarct Parasitic disease
Fungal infection Drugs Malignancy Asbestos
WHY IS GLUCOSE LOW(lt60)
RA TB Empyema SLE Malignancy Esophageal rupture
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 gt 100ml (several 100) before effusion
can be detected on physical exam
Removal procedure- paracentesis
Lab analysis distinguish between transudate and exudates
gross exam cell count sedimentation chemical analysis
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
Lymphocytes CHF liver cirrhosis nephrotic syndrome
Mesothelial Cells Associated with TB effusions
Malignant cells seen with malignancy
WHAT TO SEND FLUID FOR
Cell count with diff Albumin LDH Total protein
glucose Gram staincx cytology
APPEARANCE OF FLUID
Clearmdashusually indicates uncomplicated ascites ie liver failurecirrhosis
Turbidcloudymdashinfected Pinkbloodymdashtraumatic punctured collateral
vessel malignancy Correct for bloody tap 1 WBC 750 RBC
1 PMN 250 RBC
SERUM-TO-ASCITES ALBUMIN GRADIENT (SAAG)
=Serum albumin ndash ascitic fluid albuminIf the gradient is gt11 Portal HTN (drives fluids into
peritoneum) SBP cirrhosis Alcoholic hepatitis CHFIf the gradient is lt 11(protein leaks into peritoneum and fluid
follows) Peritoneal carcinomatosis peritoneal
TB pancreatitis nephrotic syndrome
SBP SAAG gt 11 Suspect if gt250 PMNs (gt100 PMNs in pt on
peritoneal dialysis) 70 GNR (Ecoli Klebsiella)
30 GPC (S pneumo Enterococcus) Treat with ceftriaxone cefotaxime ldquoCulture negative SBPrdquo if gt250 PMNs but cx
neg treat the same
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
Measure pH pH less than 70 associated with infection or
rheumatoid disorder
Cell count see limited RBCs and WBCs
Evaluate sedimentation
bull Examine physical chemical and microscopic detail
bull Count number of sperm report morphology and
motility
bull Specimen must be a fresh collection-clean sterile
container
bull Gross Exam Color pH Volume and viscosity
bull Agglutination study
5- Seminal Fluid
bull Joint Fluid normally clear viscous
bull Functions as a lubricate and transports nutrient
bull Arthrocentesis aspirate of the joint fluid aseptic
technique
bull Lab Assay Gross exam microscopic exam Gram
stain cultures
6- Synovial Fluid
bull Appearance clear transparent viscous
bull Viscosity test
bull Mucin Clot test
bull Note crystals (intracellular vs extra cellular)
bull Slide exam usually performed on concentration of the fluid
using Giemsa or Papnicolaou
THANK YOU
bull Cells unique to the lungs Mesothelial cells
bull RBCs and WBCs are limited if increased without
traumatic tap ----- indicates infarction
bull Cytology exam useful in identifying malignancy or
abnormal morphological cells
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 ro
chylothorax amylase to ro pancreatitis esoph perf Adenosine deaminase to eval TB
LIGHTrsquoS CRITERIA FOR EXUDATES
Fluid is exudate if it meets 1 of 3 criteria 1 Pleural fluid LDHserum LDH gt 062 Pleural fluid proteinserum protein gt 053 Pleural fluid LDH gt upper limit of normal
serum LDH If all 3 negative fluid is Transudate
TRANSUDATE
Result from imbalances in oncotic and hydrostatic pressure
Usually low oncotic +- high hydrostatic pressure
Pulm EdemaCHF Cirrhosis with ascites HypoalbuminemiaNephrotic
syndrome ESLD Fluid overload sp aggressive IVF Peritoneal dialysis
EXUDATE
Caused by local not systemic factors Infection Neoplasm Pancreatitis Esoph perf RA SLE Sarcoid Wegeners PE Meigrsquos
Chylothorax
LYMPHOCYTOSIS
Malignancy (50-70 lymphs) Also TB sarcoid RA chylothorax (gt90
lymphs)
PLEURAL EOSINOPHILIA
Pneumothorax Hemothorax Pulm infarct Parasitic disease
Fungal infection Drugs Malignancy Asbestos
WHY IS GLUCOSE LOW(lt60)
RA TB Empyema SLE Malignancy Esophageal rupture
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 gt 100ml (several 100) before effusion
can be detected on physical exam
Removal procedure- paracentesis
Lab analysis distinguish between transudate and exudates
gross exam cell count sedimentation chemical analysis
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
Lymphocytes CHF liver cirrhosis nephrotic syndrome
Mesothelial Cells Associated with TB effusions
Malignant cells seen with malignancy
WHAT TO SEND FLUID FOR
Cell count with diff Albumin LDH Total protein
glucose Gram staincx cytology
APPEARANCE OF FLUID
Clearmdashusually indicates uncomplicated ascites ie liver failurecirrhosis
Turbidcloudymdashinfected Pinkbloodymdashtraumatic punctured collateral
vessel malignancy Correct for bloody tap 1 WBC 750 RBC
1 PMN 250 RBC
SERUM-TO-ASCITES ALBUMIN GRADIENT (SAAG)
=Serum albumin ndash ascitic fluid albuminIf the gradient is gt11 Portal HTN (drives fluids into
peritoneum) SBP cirrhosis Alcoholic hepatitis CHFIf the gradient is lt 11(protein leaks into peritoneum and fluid
follows) Peritoneal carcinomatosis peritoneal
TB pancreatitis nephrotic syndrome
SBP SAAG gt 11 Suspect if gt250 PMNs (gt100 PMNs in pt on
peritoneal dialysis) 70 GNR (Ecoli Klebsiella)
30 GPC (S pneumo Enterococcus) Treat with ceftriaxone cefotaxime ldquoCulture negative SBPrdquo if gt250 PMNs but cx
neg treat the same
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
Measure pH pH less than 70 associated with infection or
rheumatoid disorder
Cell count see limited RBCs and WBCs
Evaluate sedimentation
bull Examine physical chemical and microscopic detail
bull Count number of sperm report morphology and
motility
bull Specimen must be a fresh collection-clean sterile
container
bull Gross Exam Color pH Volume and viscosity
bull Agglutination study
5- Seminal Fluid
bull Joint Fluid normally clear viscous
bull Functions as a lubricate and transports nutrient
bull Arthrocentesis aspirate of the joint fluid aseptic
technique
bull Lab Assay Gross exam microscopic exam Gram
stain cultures
6- Synovial Fluid
bull Appearance clear transparent viscous
bull Viscosity test
bull Mucin Clot test
bull Note crystals (intracellular vs extra cellular)
bull Slide exam usually performed on concentration of the fluid
using Giemsa or Papnicolaou
THANK YOU
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 ro
chylothorax amylase to ro pancreatitis esoph perf Adenosine deaminase to eval TB
LIGHTrsquoS CRITERIA FOR EXUDATES
Fluid is exudate if it meets 1 of 3 criteria 1 Pleural fluid LDHserum LDH gt 062 Pleural fluid proteinserum protein gt 053 Pleural fluid LDH gt upper limit of normal
serum LDH If all 3 negative fluid is Transudate
TRANSUDATE
Result from imbalances in oncotic and hydrostatic pressure
Usually low oncotic +- high hydrostatic pressure
Pulm EdemaCHF Cirrhosis with ascites HypoalbuminemiaNephrotic
syndrome ESLD Fluid overload sp aggressive IVF Peritoneal dialysis
EXUDATE
Caused by local not systemic factors Infection Neoplasm Pancreatitis Esoph perf RA SLE Sarcoid Wegeners PE Meigrsquos
Chylothorax
LYMPHOCYTOSIS
Malignancy (50-70 lymphs) Also TB sarcoid RA chylothorax (gt90
lymphs)
PLEURAL EOSINOPHILIA
Pneumothorax Hemothorax Pulm infarct Parasitic disease
Fungal infection Drugs Malignancy Asbestos
WHY IS GLUCOSE LOW(lt60)
RA TB Empyema SLE Malignancy Esophageal rupture
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 gt 100ml (several 100) before effusion
can be detected on physical exam
Removal procedure- paracentesis
Lab analysis distinguish between transudate and exudates
gross exam cell count sedimentation chemical analysis
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
Lymphocytes CHF liver cirrhosis nephrotic syndrome
Mesothelial Cells Associated with TB effusions
Malignant cells seen with malignancy
WHAT TO SEND FLUID FOR
Cell count with diff Albumin LDH Total protein
glucose Gram staincx cytology
APPEARANCE OF FLUID
Clearmdashusually indicates uncomplicated ascites ie liver failurecirrhosis
Turbidcloudymdashinfected Pinkbloodymdashtraumatic punctured collateral
vessel malignancy Correct for bloody tap 1 WBC 750 RBC
1 PMN 250 RBC
SERUM-TO-ASCITES ALBUMIN GRADIENT (SAAG)
=Serum albumin ndash ascitic fluid albuminIf the gradient is gt11 Portal HTN (drives fluids into
peritoneum) SBP cirrhosis Alcoholic hepatitis CHFIf the gradient is lt 11(protein leaks into peritoneum and fluid
follows) Peritoneal carcinomatosis peritoneal
TB pancreatitis nephrotic syndrome
SBP SAAG gt 11 Suspect if gt250 PMNs (gt100 PMNs in pt on
peritoneal dialysis) 70 GNR (Ecoli Klebsiella)
30 GPC (S pneumo Enterococcus) Treat with ceftriaxone cefotaxime ldquoCulture negative SBPrdquo if gt250 PMNs but cx
neg treat the same
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
Measure pH pH less than 70 associated with infection or
rheumatoid disorder
Cell count see limited RBCs and WBCs
Evaluate sedimentation
bull Examine physical chemical and microscopic detail
bull Count number of sperm report morphology and
motility
bull Specimen must be a fresh collection-clean sterile
container
bull Gross Exam Color pH Volume and viscosity
bull Agglutination study
5- Seminal Fluid
bull Joint Fluid normally clear viscous
bull Functions as a lubricate and transports nutrient
bull Arthrocentesis aspirate of the joint fluid aseptic
technique
bull Lab Assay Gross exam microscopic exam Gram
stain cultures
6- Synovial Fluid
bull Appearance clear transparent viscous
bull Viscosity test
bull Mucin Clot test
bull Note crystals (intracellular vs extra cellular)
bull Slide exam usually performed on concentration of the fluid
using Giemsa or Papnicolaou
THANK YOU
LIGHTrsquoS CRITERIA FOR EXUDATES
Fluid is exudate if it meets 1 of 3 criteria 1 Pleural fluid LDHserum LDH gt 062 Pleural fluid proteinserum protein gt 053 Pleural fluid LDH gt upper limit of normal
serum LDH If all 3 negative fluid is Transudate
TRANSUDATE
Result from imbalances in oncotic and hydrostatic pressure
Usually low oncotic +- high hydrostatic pressure
Pulm EdemaCHF Cirrhosis with ascites HypoalbuminemiaNephrotic
syndrome ESLD Fluid overload sp aggressive IVF Peritoneal dialysis
EXUDATE
Caused by local not systemic factors Infection Neoplasm Pancreatitis Esoph perf RA SLE Sarcoid Wegeners PE Meigrsquos
Chylothorax
LYMPHOCYTOSIS
Malignancy (50-70 lymphs) Also TB sarcoid RA chylothorax (gt90
lymphs)
PLEURAL EOSINOPHILIA
Pneumothorax Hemothorax Pulm infarct Parasitic disease
Fungal infection Drugs Malignancy Asbestos
WHY IS GLUCOSE LOW(lt60)
RA TB Empyema SLE Malignancy Esophageal rupture
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 gt 100ml (several 100) before effusion
can be detected on physical exam
Removal procedure- paracentesis
Lab analysis distinguish between transudate and exudates
gross exam cell count sedimentation chemical analysis
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
Lymphocytes CHF liver cirrhosis nephrotic syndrome
Mesothelial Cells Associated with TB effusions
Malignant cells seen with malignancy
WHAT TO SEND FLUID FOR
Cell count with diff Albumin LDH Total protein
glucose Gram staincx cytology
APPEARANCE OF FLUID
Clearmdashusually indicates uncomplicated ascites ie liver failurecirrhosis
Turbidcloudymdashinfected Pinkbloodymdashtraumatic punctured collateral
vessel malignancy Correct for bloody tap 1 WBC 750 RBC
1 PMN 250 RBC
SERUM-TO-ASCITES ALBUMIN GRADIENT (SAAG)
=Serum albumin ndash ascitic fluid albuminIf the gradient is gt11 Portal HTN (drives fluids into
peritoneum) SBP cirrhosis Alcoholic hepatitis CHFIf the gradient is lt 11(protein leaks into peritoneum and fluid
follows) Peritoneal carcinomatosis peritoneal
TB pancreatitis nephrotic syndrome
SBP SAAG gt 11 Suspect if gt250 PMNs (gt100 PMNs in pt on
peritoneal dialysis) 70 GNR (Ecoli Klebsiella)
30 GPC (S pneumo Enterococcus) Treat with ceftriaxone cefotaxime ldquoCulture negative SBPrdquo if gt250 PMNs but cx
neg treat the same
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
Measure pH pH less than 70 associated with infection or
rheumatoid disorder
Cell count see limited RBCs and WBCs
Evaluate sedimentation
bull Examine physical chemical and microscopic detail
bull Count number of sperm report morphology and
motility
bull Specimen must be a fresh collection-clean sterile
container
bull Gross Exam Color pH Volume and viscosity
bull Agglutination study
5- Seminal Fluid
bull Joint Fluid normally clear viscous
bull Functions as a lubricate and transports nutrient
bull Arthrocentesis aspirate of the joint fluid aseptic
technique
bull Lab Assay Gross exam microscopic exam Gram
stain cultures
6- Synovial Fluid
bull Appearance clear transparent viscous
bull Viscosity test
bull Mucin Clot test
bull Note crystals (intracellular vs extra cellular)
bull Slide exam usually performed on concentration of the fluid
using Giemsa or Papnicolaou
THANK YOU
TRANSUDATE
Result from imbalances in oncotic and hydrostatic pressure
Usually low oncotic +- high hydrostatic pressure
Pulm EdemaCHF Cirrhosis with ascites HypoalbuminemiaNephrotic
syndrome ESLD Fluid overload sp aggressive IVF Peritoneal dialysis
EXUDATE
Caused by local not systemic factors Infection Neoplasm Pancreatitis Esoph perf RA SLE Sarcoid Wegeners PE Meigrsquos
Chylothorax
LYMPHOCYTOSIS
Malignancy (50-70 lymphs) Also TB sarcoid RA chylothorax (gt90
lymphs)
PLEURAL EOSINOPHILIA
Pneumothorax Hemothorax Pulm infarct Parasitic disease
Fungal infection Drugs Malignancy Asbestos
WHY IS GLUCOSE LOW(lt60)
RA TB Empyema SLE Malignancy Esophageal rupture
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 gt 100ml (several 100) before effusion
can be detected on physical exam
Removal procedure- paracentesis
Lab analysis distinguish between transudate and exudates
gross exam cell count sedimentation chemical analysis
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
Lymphocytes CHF liver cirrhosis nephrotic syndrome
Mesothelial Cells Associated with TB effusions
Malignant cells seen with malignancy
WHAT TO SEND FLUID FOR
Cell count with diff Albumin LDH Total protein
glucose Gram staincx cytology
APPEARANCE OF FLUID
Clearmdashusually indicates uncomplicated ascites ie liver failurecirrhosis
Turbidcloudymdashinfected Pinkbloodymdashtraumatic punctured collateral
vessel malignancy Correct for bloody tap 1 WBC 750 RBC
1 PMN 250 RBC
SERUM-TO-ASCITES ALBUMIN GRADIENT (SAAG)
=Serum albumin ndash ascitic fluid albuminIf the gradient is gt11 Portal HTN (drives fluids into
peritoneum) SBP cirrhosis Alcoholic hepatitis CHFIf the gradient is lt 11(protein leaks into peritoneum and fluid
follows) Peritoneal carcinomatosis peritoneal
TB pancreatitis nephrotic syndrome
SBP SAAG gt 11 Suspect if gt250 PMNs (gt100 PMNs in pt on
peritoneal dialysis) 70 GNR (Ecoli Klebsiella)
30 GPC (S pneumo Enterococcus) Treat with ceftriaxone cefotaxime ldquoCulture negative SBPrdquo if gt250 PMNs but cx
neg treat the same
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
Measure pH pH less than 70 associated with infection or
rheumatoid disorder
Cell count see limited RBCs and WBCs
Evaluate sedimentation
bull Examine physical chemical and microscopic detail
bull Count number of sperm report morphology and
motility
bull Specimen must be a fresh collection-clean sterile
container
bull Gross Exam Color pH Volume and viscosity
bull Agglutination study
5- Seminal Fluid
bull Joint Fluid normally clear viscous
bull Functions as a lubricate and transports nutrient
bull Arthrocentesis aspirate of the joint fluid aseptic
technique
bull Lab Assay Gross exam microscopic exam Gram
stain cultures
6- Synovial Fluid
bull Appearance clear transparent viscous
bull Viscosity test
bull Mucin Clot test
bull Note crystals (intracellular vs extra cellular)
bull Slide exam usually performed on concentration of the fluid
using Giemsa or Papnicolaou
THANK YOU
EXUDATE
Caused by local not systemic factors Infection Neoplasm Pancreatitis Esoph perf RA SLE Sarcoid Wegeners PE Meigrsquos
Chylothorax
LYMPHOCYTOSIS
Malignancy (50-70 lymphs) Also TB sarcoid RA chylothorax (gt90
lymphs)
PLEURAL EOSINOPHILIA
Pneumothorax Hemothorax Pulm infarct Parasitic disease
Fungal infection Drugs Malignancy Asbestos
WHY IS GLUCOSE LOW(lt60)
RA TB Empyema SLE Malignancy Esophageal rupture
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 gt 100ml (several 100) before effusion
can be detected on physical exam
Removal procedure- paracentesis
Lab analysis distinguish between transudate and exudates
gross exam cell count sedimentation chemical analysis
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
Lymphocytes CHF liver cirrhosis nephrotic syndrome
Mesothelial Cells Associated with TB effusions
Malignant cells seen with malignancy
WHAT TO SEND FLUID FOR
Cell count with diff Albumin LDH Total protein
glucose Gram staincx cytology
APPEARANCE OF FLUID
Clearmdashusually indicates uncomplicated ascites ie liver failurecirrhosis
Turbidcloudymdashinfected Pinkbloodymdashtraumatic punctured collateral
vessel malignancy Correct for bloody tap 1 WBC 750 RBC
1 PMN 250 RBC
SERUM-TO-ASCITES ALBUMIN GRADIENT (SAAG)
=Serum albumin ndash ascitic fluid albuminIf the gradient is gt11 Portal HTN (drives fluids into
peritoneum) SBP cirrhosis Alcoholic hepatitis CHFIf the gradient is lt 11(protein leaks into peritoneum and fluid
follows) Peritoneal carcinomatosis peritoneal
TB pancreatitis nephrotic syndrome
SBP SAAG gt 11 Suspect if gt250 PMNs (gt100 PMNs in pt on
peritoneal dialysis) 70 GNR (Ecoli Klebsiella)
30 GPC (S pneumo Enterococcus) Treat with ceftriaxone cefotaxime ldquoCulture negative SBPrdquo if gt250 PMNs but cx
neg treat the same
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
Measure pH pH less than 70 associated with infection or
rheumatoid disorder
Cell count see limited RBCs and WBCs
Evaluate sedimentation
bull Examine physical chemical and microscopic detail
bull Count number of sperm report morphology and
motility
bull Specimen must be a fresh collection-clean sterile
container
bull Gross Exam Color pH Volume and viscosity
bull Agglutination study
5- Seminal Fluid
bull Joint Fluid normally clear viscous
bull Functions as a lubricate and transports nutrient
bull Arthrocentesis aspirate of the joint fluid aseptic
technique
bull Lab Assay Gross exam microscopic exam Gram
stain cultures
6- Synovial Fluid
bull Appearance clear transparent viscous
bull Viscosity test
bull Mucin Clot test
bull Note crystals (intracellular vs extra cellular)
bull Slide exam usually performed on concentration of the fluid
using Giemsa or Papnicolaou
THANK YOU
LYMPHOCYTOSIS
Malignancy (50-70 lymphs) Also TB sarcoid RA chylothorax (gt90
lymphs)
PLEURAL EOSINOPHILIA
Pneumothorax Hemothorax Pulm infarct Parasitic disease
Fungal infection Drugs Malignancy Asbestos
WHY IS GLUCOSE LOW(lt60)
RA TB Empyema SLE Malignancy Esophageal rupture
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 gt 100ml (several 100) before effusion
can be detected on physical exam
Removal procedure- paracentesis
Lab analysis distinguish between transudate and exudates
gross exam cell count sedimentation chemical analysis
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
Lymphocytes CHF liver cirrhosis nephrotic syndrome
Mesothelial Cells Associated with TB effusions
Malignant cells seen with malignancy
WHAT TO SEND FLUID FOR
Cell count with diff Albumin LDH Total protein
glucose Gram staincx cytology
APPEARANCE OF FLUID
Clearmdashusually indicates uncomplicated ascites ie liver failurecirrhosis
Turbidcloudymdashinfected Pinkbloodymdashtraumatic punctured collateral
vessel malignancy Correct for bloody tap 1 WBC 750 RBC
1 PMN 250 RBC
SERUM-TO-ASCITES ALBUMIN GRADIENT (SAAG)
=Serum albumin ndash ascitic fluid albuminIf the gradient is gt11 Portal HTN (drives fluids into
peritoneum) SBP cirrhosis Alcoholic hepatitis CHFIf the gradient is lt 11(protein leaks into peritoneum and fluid
follows) Peritoneal carcinomatosis peritoneal
TB pancreatitis nephrotic syndrome
SBP SAAG gt 11 Suspect if gt250 PMNs (gt100 PMNs in pt on
peritoneal dialysis) 70 GNR (Ecoli Klebsiella)
30 GPC (S pneumo Enterococcus) Treat with ceftriaxone cefotaxime ldquoCulture negative SBPrdquo if gt250 PMNs but cx
neg treat the same
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
Measure pH pH less than 70 associated with infection or
rheumatoid disorder
Cell count see limited RBCs and WBCs
Evaluate sedimentation
bull Examine physical chemical and microscopic detail
bull Count number of sperm report morphology and
motility
bull Specimen must be a fresh collection-clean sterile
container
bull Gross Exam Color pH Volume and viscosity
bull Agglutination study
5- Seminal Fluid
bull Joint Fluid normally clear viscous
bull Functions as a lubricate and transports nutrient
bull Arthrocentesis aspirate of the joint fluid aseptic
technique
bull Lab Assay Gross exam microscopic exam Gram
stain cultures
6- Synovial Fluid
bull Appearance clear transparent viscous
bull Viscosity test
bull Mucin Clot test
bull Note crystals (intracellular vs extra cellular)
bull Slide exam usually performed on concentration of the fluid
using Giemsa or Papnicolaou
THANK YOU
PLEURAL EOSINOPHILIA
Pneumothorax Hemothorax Pulm infarct Parasitic disease
Fungal infection Drugs Malignancy Asbestos
WHY IS GLUCOSE LOW(lt60)
RA TB Empyema SLE Malignancy Esophageal rupture
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 gt 100ml (several 100) before effusion
can be detected on physical exam
Removal procedure- paracentesis
Lab analysis distinguish between transudate and exudates
gross exam cell count sedimentation chemical analysis
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
Lymphocytes CHF liver cirrhosis nephrotic syndrome
Mesothelial Cells Associated with TB effusions
Malignant cells seen with malignancy
WHAT TO SEND FLUID FOR
Cell count with diff Albumin LDH Total protein
glucose Gram staincx cytology
APPEARANCE OF FLUID
Clearmdashusually indicates uncomplicated ascites ie liver failurecirrhosis
Turbidcloudymdashinfected Pinkbloodymdashtraumatic punctured collateral
vessel malignancy Correct for bloody tap 1 WBC 750 RBC
1 PMN 250 RBC
SERUM-TO-ASCITES ALBUMIN GRADIENT (SAAG)
=Serum albumin ndash ascitic fluid albuminIf the gradient is gt11 Portal HTN (drives fluids into
peritoneum) SBP cirrhosis Alcoholic hepatitis CHFIf the gradient is lt 11(protein leaks into peritoneum and fluid
follows) Peritoneal carcinomatosis peritoneal
TB pancreatitis nephrotic syndrome
SBP SAAG gt 11 Suspect if gt250 PMNs (gt100 PMNs in pt on
peritoneal dialysis) 70 GNR (Ecoli Klebsiella)
30 GPC (S pneumo Enterococcus) Treat with ceftriaxone cefotaxime ldquoCulture negative SBPrdquo if gt250 PMNs but cx
neg treat the same
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
Measure pH pH less than 70 associated with infection or
rheumatoid disorder
Cell count see limited RBCs and WBCs
Evaluate sedimentation
bull Examine physical chemical and microscopic detail
bull Count number of sperm report morphology and
motility
bull Specimen must be a fresh collection-clean sterile
container
bull Gross Exam Color pH Volume and viscosity
bull Agglutination study
5- Seminal Fluid
bull Joint Fluid normally clear viscous
bull Functions as a lubricate and transports nutrient
bull Arthrocentesis aspirate of the joint fluid aseptic
technique
bull Lab Assay Gross exam microscopic exam Gram
stain cultures
6- Synovial Fluid
bull Appearance clear transparent viscous
bull Viscosity test
bull Mucin Clot test
bull Note crystals (intracellular vs extra cellular)
bull Slide exam usually performed on concentration of the fluid
using Giemsa or Papnicolaou
THANK YOU
WHY IS GLUCOSE LOW(lt60)
RA TB Empyema SLE Malignancy Esophageal rupture
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 gt 100ml (several 100) before effusion
can be detected on physical exam
Removal procedure- paracentesis
Lab analysis distinguish between transudate and exudates
gross exam cell count sedimentation chemical analysis
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
Lymphocytes CHF liver cirrhosis nephrotic syndrome
Mesothelial Cells Associated with TB effusions
Malignant cells seen with malignancy
WHAT TO SEND FLUID FOR
Cell count with diff Albumin LDH Total protein
glucose Gram staincx cytology
APPEARANCE OF FLUID
Clearmdashusually indicates uncomplicated ascites ie liver failurecirrhosis
Turbidcloudymdashinfected Pinkbloodymdashtraumatic punctured collateral
vessel malignancy Correct for bloody tap 1 WBC 750 RBC
1 PMN 250 RBC
SERUM-TO-ASCITES ALBUMIN GRADIENT (SAAG)
=Serum albumin ndash ascitic fluid albuminIf the gradient is gt11 Portal HTN (drives fluids into
peritoneum) SBP cirrhosis Alcoholic hepatitis CHFIf the gradient is lt 11(protein leaks into peritoneum and fluid
follows) Peritoneal carcinomatosis peritoneal
TB pancreatitis nephrotic syndrome
SBP SAAG gt 11 Suspect if gt250 PMNs (gt100 PMNs in pt on
peritoneal dialysis) 70 GNR (Ecoli Klebsiella)
30 GPC (S pneumo Enterococcus) Treat with ceftriaxone cefotaxime ldquoCulture negative SBPrdquo if gt250 PMNs but cx
neg treat the same
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
Measure pH pH less than 70 associated with infection or
rheumatoid disorder
Cell count see limited RBCs and WBCs
Evaluate sedimentation
bull Examine physical chemical and microscopic detail
bull Count number of sperm report morphology and
motility
bull Specimen must be a fresh collection-clean sterile
container
bull Gross Exam Color pH Volume and viscosity
bull Agglutination study
5- Seminal Fluid
bull Joint Fluid normally clear viscous
bull Functions as a lubricate and transports nutrient
bull Arthrocentesis aspirate of the joint fluid aseptic
technique
bull Lab Assay Gross exam microscopic exam Gram
stain cultures
6- Synovial Fluid
bull Appearance clear transparent viscous
bull Viscosity test
bull Mucin Clot test
bull Note crystals (intracellular vs extra cellular)
bull Slide exam usually performed on concentration of the fluid
using Giemsa or Papnicolaou
THANK YOU
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 gt 100ml (several 100) before effusion
can be detected on physical exam
Removal procedure- paracentesis
Lab analysis distinguish between transudate and exudates
gross exam cell count sedimentation chemical analysis
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
Lymphocytes CHF liver cirrhosis nephrotic syndrome
Mesothelial Cells Associated with TB effusions
Malignant cells seen with malignancy
WHAT TO SEND FLUID FOR
Cell count with diff Albumin LDH Total protein
glucose Gram staincx cytology
APPEARANCE OF FLUID
Clearmdashusually indicates uncomplicated ascites ie liver failurecirrhosis
Turbidcloudymdashinfected Pinkbloodymdashtraumatic punctured collateral
vessel malignancy Correct for bloody tap 1 WBC 750 RBC
1 PMN 250 RBC
SERUM-TO-ASCITES ALBUMIN GRADIENT (SAAG)
=Serum albumin ndash ascitic fluid albuminIf the gradient is gt11 Portal HTN (drives fluids into
peritoneum) SBP cirrhosis Alcoholic hepatitis CHFIf the gradient is lt 11(protein leaks into peritoneum and fluid
follows) Peritoneal carcinomatosis peritoneal
TB pancreatitis nephrotic syndrome
SBP SAAG gt 11 Suspect if gt250 PMNs (gt100 PMNs in pt on
peritoneal dialysis) 70 GNR (Ecoli Klebsiella)
30 GPC (S pneumo Enterococcus) Treat with ceftriaxone cefotaxime ldquoCulture negative SBPrdquo if gt250 PMNs but cx
neg treat the same
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
Measure pH pH less than 70 associated with infection or
rheumatoid disorder
Cell count see limited RBCs and WBCs
Evaluate sedimentation
bull Examine physical chemical and microscopic detail
bull Count number of sperm report morphology and
motility
bull Specimen must be a fresh collection-clean sterile
container
bull Gross Exam Color pH Volume and viscosity
bull Agglutination study
5- Seminal Fluid
bull Joint Fluid normally clear viscous
bull Functions as a lubricate and transports nutrient
bull Arthrocentesis aspirate of the joint fluid aseptic
technique
bull Lab Assay Gross exam microscopic exam Gram
stain cultures
6- Synovial Fluid
bull Appearance clear transparent viscous
bull Viscosity test
bull Mucin Clot test
bull Note crystals (intracellular vs extra cellular)
bull Slide exam usually performed on concentration of the fluid
using Giemsa or Papnicolaou
THANK YOU
Removal procedure- paracentesis
Lab analysis distinguish between transudate and exudates
gross exam cell count sedimentation chemical analysis
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
Lymphocytes CHF liver cirrhosis nephrotic syndrome
Mesothelial Cells Associated with TB effusions
Malignant cells seen with malignancy
WHAT TO SEND FLUID FOR
Cell count with diff Albumin LDH Total protein
glucose Gram staincx cytology
APPEARANCE OF FLUID
Clearmdashusually indicates uncomplicated ascites ie liver failurecirrhosis
Turbidcloudymdashinfected Pinkbloodymdashtraumatic punctured collateral
vessel malignancy Correct for bloody tap 1 WBC 750 RBC
1 PMN 250 RBC
SERUM-TO-ASCITES ALBUMIN GRADIENT (SAAG)
=Serum albumin ndash ascitic fluid albuminIf the gradient is gt11 Portal HTN (drives fluids into
peritoneum) SBP cirrhosis Alcoholic hepatitis CHFIf the gradient is lt 11(protein leaks into peritoneum and fluid
follows) Peritoneal carcinomatosis peritoneal
TB pancreatitis nephrotic syndrome
SBP SAAG gt 11 Suspect if gt250 PMNs (gt100 PMNs in pt on
peritoneal dialysis) 70 GNR (Ecoli Klebsiella)
30 GPC (S pneumo Enterococcus) Treat with ceftriaxone cefotaxime ldquoCulture negative SBPrdquo if gt250 PMNs but cx
neg treat the same
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
Measure pH pH less than 70 associated with infection or
rheumatoid disorder
Cell count see limited RBCs and WBCs
Evaluate sedimentation
bull Examine physical chemical and microscopic detail
bull Count number of sperm report morphology and
motility
bull Specimen must be a fresh collection-clean sterile
container
bull Gross Exam Color pH Volume and viscosity
bull Agglutination study
5- Seminal Fluid
bull Joint Fluid normally clear viscous
bull Functions as a lubricate and transports nutrient
bull Arthrocentesis aspirate of the joint fluid aseptic
technique
bull Lab Assay Gross exam microscopic exam Gram
stain cultures
6- Synovial Fluid
bull Appearance clear transparent viscous
bull Viscosity test
bull Mucin Clot test
bull Note crystals (intracellular vs extra cellular)
bull Slide exam usually performed on concentration of the fluid
using Giemsa or Papnicolaou
THANK YOU
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
Lymphocytes CHF liver cirrhosis nephrotic syndrome
Mesothelial Cells Associated with TB effusions
Malignant cells seen with malignancy
WHAT TO SEND FLUID FOR
Cell count with diff Albumin LDH Total protein
glucose Gram staincx cytology
APPEARANCE OF FLUID
Clearmdashusually indicates uncomplicated ascites ie liver failurecirrhosis
Turbidcloudymdashinfected Pinkbloodymdashtraumatic punctured collateral
vessel malignancy Correct for bloody tap 1 WBC 750 RBC
1 PMN 250 RBC
SERUM-TO-ASCITES ALBUMIN GRADIENT (SAAG)
=Serum albumin ndash ascitic fluid albuminIf the gradient is gt11 Portal HTN (drives fluids into
peritoneum) SBP cirrhosis Alcoholic hepatitis CHFIf the gradient is lt 11(protein leaks into peritoneum and fluid
follows) Peritoneal carcinomatosis peritoneal
TB pancreatitis nephrotic syndrome
SBP SAAG gt 11 Suspect if gt250 PMNs (gt100 PMNs in pt on
peritoneal dialysis) 70 GNR (Ecoli Klebsiella)
30 GPC (S pneumo Enterococcus) Treat with ceftriaxone cefotaxime ldquoCulture negative SBPrdquo if gt250 PMNs but cx
neg treat the same
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
Measure pH pH less than 70 associated with infection or
rheumatoid disorder
Cell count see limited RBCs and WBCs
Evaluate sedimentation
bull Examine physical chemical and microscopic detail
bull Count number of sperm report morphology and
motility
bull Specimen must be a fresh collection-clean sterile
container
bull Gross Exam Color pH Volume and viscosity
bull Agglutination study
5- Seminal Fluid
bull Joint Fluid normally clear viscous
bull Functions as a lubricate and transports nutrient
bull Arthrocentesis aspirate of the joint fluid aseptic
technique
bull Lab Assay Gross exam microscopic exam Gram
stain cultures
6- Synovial Fluid
bull Appearance clear transparent viscous
bull Viscosity test
bull Mucin Clot test
bull Note crystals (intracellular vs extra cellular)
bull Slide exam usually performed on concentration of the fluid
using Giemsa or Papnicolaou
THANK YOU
Lymphocytes CHF liver cirrhosis nephrotic syndrome
Mesothelial Cells Associated with TB effusions
Malignant cells seen with malignancy
WHAT TO SEND FLUID FOR
Cell count with diff Albumin LDH Total protein
glucose Gram staincx cytology
APPEARANCE OF FLUID
Clearmdashusually indicates uncomplicated ascites ie liver failurecirrhosis
Turbidcloudymdashinfected Pinkbloodymdashtraumatic punctured collateral
vessel malignancy Correct for bloody tap 1 WBC 750 RBC
1 PMN 250 RBC
SERUM-TO-ASCITES ALBUMIN GRADIENT (SAAG)
=Serum albumin ndash ascitic fluid albuminIf the gradient is gt11 Portal HTN (drives fluids into
peritoneum) SBP cirrhosis Alcoholic hepatitis CHFIf the gradient is lt 11(protein leaks into peritoneum and fluid
follows) Peritoneal carcinomatosis peritoneal
TB pancreatitis nephrotic syndrome
SBP SAAG gt 11 Suspect if gt250 PMNs (gt100 PMNs in pt on
peritoneal dialysis) 70 GNR (Ecoli Klebsiella)
30 GPC (S pneumo Enterococcus) Treat with ceftriaxone cefotaxime ldquoCulture negative SBPrdquo if gt250 PMNs but cx
neg treat the same
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
Measure pH pH less than 70 associated with infection or
rheumatoid disorder
Cell count see limited RBCs and WBCs
Evaluate sedimentation
bull Examine physical chemical and microscopic detail
bull Count number of sperm report morphology and
motility
bull Specimen must be a fresh collection-clean sterile
container
bull Gross Exam Color pH Volume and viscosity
bull Agglutination study
5- Seminal Fluid
bull Joint Fluid normally clear viscous
bull Functions as a lubricate and transports nutrient
bull Arthrocentesis aspirate of the joint fluid aseptic
technique
bull Lab Assay Gross exam microscopic exam Gram
stain cultures
6- Synovial Fluid
bull Appearance clear transparent viscous
bull Viscosity test
bull Mucin Clot test
bull Note crystals (intracellular vs extra cellular)
bull Slide exam usually performed on concentration of the fluid
using Giemsa or Papnicolaou
THANK YOU
WHAT TO SEND FLUID FOR
Cell count with diff Albumin LDH Total protein
glucose Gram staincx cytology
APPEARANCE OF FLUID
Clearmdashusually indicates uncomplicated ascites ie liver failurecirrhosis
Turbidcloudymdashinfected Pinkbloodymdashtraumatic punctured collateral
vessel malignancy Correct for bloody tap 1 WBC 750 RBC
1 PMN 250 RBC
SERUM-TO-ASCITES ALBUMIN GRADIENT (SAAG)
=Serum albumin ndash ascitic fluid albuminIf the gradient is gt11 Portal HTN (drives fluids into
peritoneum) SBP cirrhosis Alcoholic hepatitis CHFIf the gradient is lt 11(protein leaks into peritoneum and fluid
follows) Peritoneal carcinomatosis peritoneal
TB pancreatitis nephrotic syndrome
SBP SAAG gt 11 Suspect if gt250 PMNs (gt100 PMNs in pt on
peritoneal dialysis) 70 GNR (Ecoli Klebsiella)
30 GPC (S pneumo Enterococcus) Treat with ceftriaxone cefotaxime ldquoCulture negative SBPrdquo if gt250 PMNs but cx
neg treat the same
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
Measure pH pH less than 70 associated with infection or
rheumatoid disorder
Cell count see limited RBCs and WBCs
Evaluate sedimentation
bull Examine physical chemical and microscopic detail
bull Count number of sperm report morphology and
motility
bull Specimen must be a fresh collection-clean sterile
container
bull Gross Exam Color pH Volume and viscosity
bull Agglutination study
5- Seminal Fluid
bull Joint Fluid normally clear viscous
bull Functions as a lubricate and transports nutrient
bull Arthrocentesis aspirate of the joint fluid aseptic
technique
bull Lab Assay Gross exam microscopic exam Gram
stain cultures
6- Synovial Fluid
bull Appearance clear transparent viscous
bull Viscosity test
bull Mucin Clot test
bull Note crystals (intracellular vs extra cellular)
bull Slide exam usually performed on concentration of the fluid
using Giemsa or Papnicolaou
THANK YOU
APPEARANCE OF FLUID
Clearmdashusually indicates uncomplicated ascites ie liver failurecirrhosis
Turbidcloudymdashinfected Pinkbloodymdashtraumatic punctured collateral
vessel malignancy Correct for bloody tap 1 WBC 750 RBC
1 PMN 250 RBC
SERUM-TO-ASCITES ALBUMIN GRADIENT (SAAG)
=Serum albumin ndash ascitic fluid albuminIf the gradient is gt11 Portal HTN (drives fluids into
peritoneum) SBP cirrhosis Alcoholic hepatitis CHFIf the gradient is lt 11(protein leaks into peritoneum and fluid
follows) Peritoneal carcinomatosis peritoneal
TB pancreatitis nephrotic syndrome
SBP SAAG gt 11 Suspect if gt250 PMNs (gt100 PMNs in pt on
peritoneal dialysis) 70 GNR (Ecoli Klebsiella)
30 GPC (S pneumo Enterococcus) Treat with ceftriaxone cefotaxime ldquoCulture negative SBPrdquo if gt250 PMNs but cx
neg treat the same
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
Measure pH pH less than 70 associated with infection or
rheumatoid disorder
Cell count see limited RBCs and WBCs
Evaluate sedimentation
bull Examine physical chemical and microscopic detail
bull Count number of sperm report morphology and
motility
bull Specimen must be a fresh collection-clean sterile
container
bull Gross Exam Color pH Volume and viscosity
bull Agglutination study
5- Seminal Fluid
bull Joint Fluid normally clear viscous
bull Functions as a lubricate and transports nutrient
bull Arthrocentesis aspirate of the joint fluid aseptic
technique
bull Lab Assay Gross exam microscopic exam Gram
stain cultures
6- Synovial Fluid
bull Appearance clear transparent viscous
bull Viscosity test
bull Mucin Clot test
bull Note crystals (intracellular vs extra cellular)
bull Slide exam usually performed on concentration of the fluid
using Giemsa or Papnicolaou
THANK YOU
SERUM-TO-ASCITES ALBUMIN GRADIENT (SAAG)
=Serum albumin ndash ascitic fluid albuminIf the gradient is gt11 Portal HTN (drives fluids into
peritoneum) SBP cirrhosis Alcoholic hepatitis CHFIf the gradient is lt 11(protein leaks into peritoneum and fluid
follows) Peritoneal carcinomatosis peritoneal
TB pancreatitis nephrotic syndrome
SBP SAAG gt 11 Suspect if gt250 PMNs (gt100 PMNs in pt on
peritoneal dialysis) 70 GNR (Ecoli Klebsiella)
30 GPC (S pneumo Enterococcus) Treat with ceftriaxone cefotaxime ldquoCulture negative SBPrdquo if gt250 PMNs but cx
neg treat the same
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
Measure pH pH less than 70 associated with infection or
rheumatoid disorder
Cell count see limited RBCs and WBCs
Evaluate sedimentation
bull Examine physical chemical and microscopic detail
bull Count number of sperm report morphology and
motility
bull Specimen must be a fresh collection-clean sterile
container
bull Gross Exam Color pH Volume and viscosity
bull Agglutination study
5- Seminal Fluid
bull Joint Fluid normally clear viscous
bull Functions as a lubricate and transports nutrient
bull Arthrocentesis aspirate of the joint fluid aseptic
technique
bull Lab Assay Gross exam microscopic exam Gram
stain cultures
6- Synovial Fluid
bull Appearance clear transparent viscous
bull Viscosity test
bull Mucin Clot test
bull Note crystals (intracellular vs extra cellular)
bull Slide exam usually performed on concentration of the fluid
using Giemsa or Papnicolaou
THANK YOU
SBP SAAG gt 11 Suspect if gt250 PMNs (gt100 PMNs in pt on
peritoneal dialysis) 70 GNR (Ecoli Klebsiella)
30 GPC (S pneumo Enterococcus) Treat with ceftriaxone cefotaxime ldquoCulture negative SBPrdquo if gt250 PMNs but cx
neg treat the same
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
Measure pH pH less than 70 associated with infection or
rheumatoid disorder
Cell count see limited RBCs and WBCs
Evaluate sedimentation
bull Examine physical chemical and microscopic detail
bull Count number of sperm report morphology and
motility
bull Specimen must be a fresh collection-clean sterile
container
bull Gross Exam Color pH Volume and viscosity
bull Agglutination study
5- Seminal Fluid
bull Joint Fluid normally clear viscous
bull Functions as a lubricate and transports nutrient
bull Arthrocentesis aspirate of the joint fluid aseptic
technique
bull Lab Assay Gross exam microscopic exam Gram
stain cultures
6- Synovial Fluid
bull Appearance clear transparent viscous
bull Viscosity test
bull Mucin Clot test
bull Note crystals (intracellular vs extra cellular)
bull Slide exam usually performed on concentration of the fluid
using Giemsa or Papnicolaou
THANK YOU
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
Measure pH pH less than 70 associated with infection or
rheumatoid disorder
Cell count see limited RBCs and WBCs
Evaluate sedimentation
bull Examine physical chemical and microscopic detail
bull Count number of sperm report morphology and
motility
bull Specimen must be a fresh collection-clean sterile
container
bull Gross Exam Color pH Volume and viscosity
bull Agglutination study
5- Seminal Fluid
bull Joint Fluid normally clear viscous
bull Functions as a lubricate and transports nutrient
bull Arthrocentesis aspirate of the joint fluid aseptic
technique
bull Lab Assay Gross exam microscopic exam Gram
stain cultures
6- Synovial Fluid
bull Appearance clear transparent viscous
bull Viscosity test
bull Mucin Clot test
bull Note crystals (intracellular vs extra cellular)
bull Slide exam usually performed on concentration of the fluid
using Giemsa or Papnicolaou
THANK YOU
Measure pH pH less than 70 associated with infection or
rheumatoid disorder
Cell count see limited RBCs and WBCs
Evaluate sedimentation
bull Examine physical chemical and microscopic detail
bull Count number of sperm report morphology and
motility
bull Specimen must be a fresh collection-clean sterile
container
bull Gross Exam Color pH Volume and viscosity
bull Agglutination study
5- Seminal Fluid
bull Joint Fluid normally clear viscous
bull Functions as a lubricate and transports nutrient
bull Arthrocentesis aspirate of the joint fluid aseptic
technique
bull Lab Assay Gross exam microscopic exam Gram
stain cultures
6- Synovial Fluid
bull Appearance clear transparent viscous
bull Viscosity test
bull Mucin Clot test
bull Note crystals (intracellular vs extra cellular)
bull Slide exam usually performed on concentration of the fluid
using Giemsa or Papnicolaou
THANK YOU
bull Examine physical chemical and microscopic detail
bull Count number of sperm report morphology and
motility
bull Specimen must be a fresh collection-clean sterile
container
bull Gross Exam Color pH Volume and viscosity
bull Agglutination study
5- Seminal Fluid
bull Joint Fluid normally clear viscous
bull Functions as a lubricate and transports nutrient
bull Arthrocentesis aspirate of the joint fluid aseptic
technique
bull Lab Assay Gross exam microscopic exam Gram
stain cultures
6- Synovial Fluid
bull Appearance clear transparent viscous
bull Viscosity test
bull Mucin Clot test
bull Note crystals (intracellular vs extra cellular)
bull Slide exam usually performed on concentration of the fluid
using Giemsa or Papnicolaou
THANK YOU
bull Joint Fluid normally clear viscous
bull Functions as a lubricate and transports nutrient
bull Arthrocentesis aspirate of the joint fluid aseptic
technique
bull Lab Assay Gross exam microscopic exam Gram
stain cultures
6- Synovial Fluid
bull Appearance clear transparent viscous
bull Viscosity test
bull Mucin Clot test
bull Note crystals (intracellular vs extra cellular)
bull Slide exam usually performed on concentration of the fluid
using Giemsa or Papnicolaou
THANK YOU
bull Appearance clear transparent viscous
bull Viscosity test
bull Mucin Clot test
bull Note crystals (intracellular vs extra cellular)
bull Slide exam usually performed on concentration of the fluid
using Giemsa or Papnicolaou
THANK YOU
THANK YOU