CM Synovial Fluid

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SYNOVIAL

FLUID()

hua yue

Presented by:

Nathaniel Sim

Myca Pua


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PHYSIOLOGY & COMPOSITION


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Movable joints (diarthroses) composed of:

Bones lined with articular cartilage

Separated by a cavity containing synovial fluid

enclosed in a synovial membrane

Synovial membrane

synoviocytes:

PhagocyticSynthesizes hyaluronate

Connective tissue

Blood vessels, lymphatics & nerves



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Fluid formation

Ultrafiltrate of plasma across synovial

membraneNon selectiveExcludes proteins of high molecular weight

Synoviocytes

Secrete mucopolysaccharides whichcontains:

Hyaluronic acid

protein



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Volume


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JOINT DISORDER CLASSIFICATION


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Group Classification SignificanceI. Noninflammatory Degenerative joint disorders

II . Inflammatory Immunologic problems (RA, LE)

Gout & pseudogout (crystal

induced)III. Septic Microbial infection

IV. Hemorrhagic Traumatic injury

Coagulation deficiency

Note:

* categories overlap

* multiple conditions can occur

simultaneously

* disease stage can vary laboratory results

JOINT DISORDER CLASSIFICATION


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Arthrocentesis

joint aspiration

Arthos joint +

Kentesis puncture

Aspiration of synovial

fluid using a syringein a joint capsule

SPECIMEN COLLECTION


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Volume:

Normal= 3.5 mL

Diseased / inflamed = up to 25 mL

Collect in the following tubes

Sterile Heparin tube : microbiology

Plain top: chemistry and immunology

EDTA (liquid) : hematology

Sodium fluoride tube: glucose analysis

*Avoid all powdered anticoagulants interfere

with crystal analysis

SPECIMEN COLLECTION


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Fluid verification

Mucin clot test-

Add fluid to dilute acetic acid

turbidity (clotformation) due to hyaluronate

Metachromatic staining

Place fluid on filter paper + few drops of toluidine

blue metachromatic staining

SPECIMEN COLLECTION


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Color:

Normal clear, pale yellow

Red to brown: indicates trauma of procedure or

disorder

Turbidity: associated with presence of WBCs

Milky: may indicate presence of crystals

Viscosity:Measured at bedside by ability to form a string

from tip of syringe

Normal: 4-6 cm

PHYSICAL EXAMINATION


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Ropes test (mucin clot test)measurement of hyaluronatepolymerization

Fluid forms a clot surrounded by clear fluidwhen added to acetic acid

Clot quality is reported:Good = solid clot

Fair = soft clotPoor = friable clot

Very poor = no clot

Test is of questionable precision andseldom used



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Cell Count WBCs

Method

Use Neubauer counting chamberMay pretreat viscous fluids with hyaluronidase

& incubate at 37oC for 5 min.

Dilution with hypotonic saline is used to lyse

any RBCs OR

Dilute with normal saline/methylene blue

mixture to differentiate WBCs from RBCs

Normal =


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Differential Count

Cytocentrifuge specimen and prepare typicalblood smear

Normal: 60% monocytes, macrophages

neutrophils:


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MICROSCOPIC EXAMINATION

Cell/inclusion

Significance Cell/inclusion

Significance

Neutrophil Bacterial sepsisCrystal inducedinflammation

Synoviallining cell

Normal

Lymphocyte Nonspeticinflammation

LE cell Lupuserythematosus

Macrophage NormalViral infection

Reiter cell Reiter syndromeNonspecific

inflammation


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MICROSCOPIC EXAMINATION

Cell/inclusion

Significance Cell/inclusion

Significance

RA cell(Ragocyte)

Rheumatoidarthritis

Immunologic

inflammation

Fat droplets Traumatic injuryChronicinflammation

Cartilage

cells

Osteoarthritis Hemosiderin Pigmented

villonodularsynovitis

Rice bodies TuberculosisSeptic and

rheumatoid

arthritis


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Neutrophils in synovial fluid


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Lymphs in synovial fluid


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Synovial lining cell


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LE cell in synovial fluid


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CRYSTAL IDENTIFICATION

Important diagnostic test in the

evaluation of arthritis.

Crystal formation in a joint is frequentlyacute, painful inflammation

Crystal formation may be due to:

1. Metabolic disorders2. Decreased renal excretion

3. Cartilage and bone degeneration

4. Medicinal injection (ex: corticosteroids)


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CRYSTAL POLARIZATION

Under Polarizing Light (Direct Polarization)

Birefringent substances appear asbright objects on a black background


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CRYSTAL POLARIZATION

Under Compensated Polarizing Light

A red compensator plate is placed

between the crystal and slide Crystals aligned parallel to the

compensator appear yellow (negative

birefringence) Crystals aligned perpendicular to the

compensator appear blue (positive

birefringence)


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SLIDE PREPARATION

Fluid is Examined Using the WetPreparation Technique unstained)

1. ASAP examination as pH and temperatureaffect observation

2. Ideally examined prior to WBC disintegration

3. Examine under both direct and compensated

polarizing light

4. May also be observed in Wright stain

preparations


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TYPES OF CRYSTALS

Monosodium Urate Crystals MSU)1. Indicate gouty arthritis due to:

Increased serum uric acid

Decreased renal excretion of uric acid

Impaired metabolism of nucleic acid

2. Exhibit negative birefringence (yellow

color)3. Extracellular or located within the

cytoplasm of the neutrophils

4. Needle shaped


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Calcium pyrophosphate CCPD)1. Indicates pseudogout due to:

Degenerative arthritis

Endocrine disorders with increasedserum calcium

Calcification of cartilage2. Exhibit positive birefringence (blue

color)3. Located within the vacuoles of the

neutrophil

4. Rhombic or square but may appear as

short rods

TYPES OF CRYSTALS


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Hydroxyapatite HA) CalciumPhosphate) Crystals1. Associated with calcified cartilagedeposition

2. No birefringence

3. Small particles require an electronmicroscope to examine

4. Usually seen in osteoarthritis

TYPES OF CRYSTALS


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Cholesterol Crystal1. Associated with chronic

inflammation2. Exhibit negative birefringence

3. Notched, Rhombic plates

TYPES OF CRYSTALS


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Corticosteroid Crystals1. Associated with intra-articular

injections2. Exhibit positive and negative

birefringence

3. Flat, variable shaped plates

TYPES OF CRYSTALS


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Calcium Oxalate Crystals Associated with renal dialysis patient

Envelope Negative birefringes

Birefringence Artifacts Precipitated anticoagulant Talc and Starch (gloves)

Scratches on slides and coverslips

Dust particles

TYPES OF CRYSTALS


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Acute gout (uric acid crystals)


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Uric acid crystals


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Corticosteroid in Synovial Fluid


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Glucose determination

-Most frequently requested

-Markedly decrease values indicates

Inflammatory (group 2) and Septic (group 3)

disorders

-Fasting: 8hours

-Normal synovial glucose = not more than 10mg/dL lower than blood value

-Analyzed within 1 hour or preserved with

sodium fluoride

CHEMISTRY TEST


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1. Total Protein Determination

-Normal synovial fluid protein = less than 3

g/dL

-Elevated in Inflammatory and Hemorrhagic

disorders

2. Uric Acid Determination-Performed as first evaluation of gout

-Confirm gout when crystals cannot be

demonstrated in fluid

OTHER CHEMISTRY TEST


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3. Lactate

May differentiate between inflammatoryand septic arthritis

Septic arthritis = >250 mg/dL

Gonococcal arthritis = normal to lowlevels

Production results from :

Increased demand for energy

Tissue hypoxia

Severe inflammatory conditions

OTHER CHEMISTRY TEST


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Most important test: Grams Stain and

Culture

Bacterial (most frequently seen),fungal, tubercular, viral infections

Routine bacterial culture should include

enrichment medium like chocolate agarStaphylococcus, streptococcus,

haemophilus, N.gonorrhoeae

MICROBIOLOGY TESTS


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Diagnosis of joint disorders

Autoimmune disease is

demonstrated by autoantibodies on

serum

1. Rheumatoid arthritis (RA)

2. Lupus erythematosus (LE)

SEROLOGY TESTS


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Antibody detection in patients

serum

1. Borrelia burgdorferi Causative agent of Lyme disease

Confirm the cause of arthritis

Extent of inflammation is

determined by concentration of

acute phase reactants (like

SEROLOGY TESTS

CM Synovial Fluid

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