DEPENDS ON WHAT YOU DREAD THE MOST - · PDF file1 fearless fluids depends on what you dread...
Transcript of DEPENDS ON WHAT YOU DREAD THE MOST - · PDF file1 fearless fluids depends on what you dread...
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FEARLESS FLUIDS
DEPENDS ON WHAT YOU DREAD THE MOST
YUCKY CELL COUNTS SCARY CELLS
WHAT WE’LL COVER….
• CSF, SEROUS, SYNOVIAL
• MANUAL CELL COUNTS – A LITTLE, VERY LITTLE
• AUTOMATED CELL COUNTS– WHAT’S IMPORTANT
• BENIGN VS MALIGNANT CELLS
• COOL CASE STUDIES
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BODY FLUID “STUFF”
CSF “STUFF”
• FACTS & FIGURES–volume
90‐150 mL total
–production500‐600 mL/day
CSF “STUFF”
• DIAGNOSTIC ANALYSIS
–meningitis
–subarachnoid hemorrhage
–cns malignancy
–demyelinating disease
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CSF “STUFF”
• TRAUMATIC TAP
–blood ‐ decreasing amounts
–clot formation
–colorless supernatant
–negative D‐dimer test
CSF “STUFF”• SUBARACHNOID HEMORRHAGE
–blood ‐ equal amounts
–no clot formation
–xanthrochromic supernatant
–positive D‐dimer test
–hemosiderin/hematoidin
SEROUS MEMBRANE LINED CAVITIES
‘EFFUSION’ FLUIDS
• PLEURAL
• PERITONEAL
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SEROUS “STUFF”• thorocentesis, paracentesis,
• Minimal volume
Pleural < 15 ml
Peritoneal < 50 ml
TRANSUDATE or EXUDATE
??
PLEURAL SPACE – NORMAL
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SYNOVIAL “STUFF”
–arthrocentesis
–lubricates
–provide nutrients
–removes debris
NO TRANSUDATES OR EXUDATES ‘GROUPS’
DO YOU NEED TO KNOW ANY OF THAT STUFF ?
NOT REALLY…..
SOMETIMES IT HELPS
CELL COUNTING
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CELL COUNTING- MANUAL(very brief)
FORMULA - MANUAL
cells/µL = cells counted
area x depth x dilution
CELL COUNTING -AUTOMATED
WHY YOU WANT TO DO THIS
- better precision- more efficient- safer
BEFORE YOU START ANY TYPE OF CELL COUNTING ….THERE ARE SOME RULES
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FIRST….
SYNOVIAL FLUIDS SHOULD BE TREATED WITH HYALURONIDASE
SECOND….
IT’S A…
TOTAL NUCLEATED CELL COUNT
(MACROPHAGES, MESOTHELIAL CELLS etc)
NOT JUST A WBC
AND THIRD…..
IF THERE ARE CLOTS OR FIBRIN GOOBERS…
TAKE THEM OUT
AND
REPORT THE CELL COUNT AS
“APPROXIMATE”
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AUTOMATEDCELL COUNTS
WHAT’S IMPORTANT ?
- BACKGROUNDS- PICTURES
PICTURES
SYSMEX XE2100
PICTURES
SYSMEX XE2100
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REALITY
THE TYPE OF CELL PRESENT
IS MORE IMPORTANT THAN
THE CELL COUNT.
CELLS
BEFORE YOU START….THERE IS ANOTHER RULE
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EVEN IF IT’S CLOTTED…
YOU CAN DO SOMETHING WITH IT !
THE PROBLEM CELLS
MESOTHELIAL CELLS
MALIGNANT CELLS
MESOTHELIAL CELLS
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WHERE THEY COME FROM
The pleural and peritoneal membrane
MESOTHELIAL MALIGNANT
• individual
• uniform
• flat clusters
• n/c ratio low
• cannibalism
• bizarre
• ball‐like clusters
• n/c ratio high
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MESOTHELIAL MALIGNANT
• smooth chromatin
• smooth nuclear membrane
• round/oval nuclei
• if multinucleated‐uniform
• minimal vacuolization
• uneven chromatin
• irregular nuclear membrane
• nuclear clefting/molding
• multinucleated ‐ non‐uniform
• dramatic vacuolization
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CSF …NEURAL LINING CELLS
EPENDYMAL, CHOROID PLEXUS, GERMINAL MATRIX ??
BRONCHIAL LINING CELLS
BRONCHIAL LINING CELLS
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MESOTHELIAL CELLS ARE FOUND
ONLY IN SEROUS FLUIDS
(PLEURAL, PERITONEAL, PEROCARDIAL)
COOL
CASE STUDIES
….AND SOME, NOT SO COOL
• 67 YEAR OLD FEMALE – MEDICAL HISTORY UNREMARKABLE– SEEN IN ER WITH COMPLAINTS OF HEADACHE AND
DIZZINESS
• CSF – RBC NONE SEEN– Nucleated cells 135 / mcL
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Very big cells or clusters of cells will appear here because they have a lot of fluorescence.
UGLY AREN’T THEY ?
A clue is their size
Another clue is the irregular nuclear chromatin and large vacuoles.
These are malignant cells from metastasized breast cancer. The breast cancer was not previously diagnosed.
• 24 YEAR OLD FEMALE– SEEN IN ER FOR HEADACHE AND
NAUSEA– PREVIOUS HISTORY OF MENINGITIS
• CSF –RBC 17 / mcL–Nucleated cells 754 /mcL
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The patient has viral meningitis – more specifically a recurrence of herpes meningitis.
She is positive for HSV- Type 2. Recurrent meningitis is known as ‘Mollaret’s Meningitis’.
Herpes meningitis occurs in 10% of cases of primary
genital HSV-2. Women are at higher risk for herpes
meningitis than men.
Surprisingly, herpes meningitis resolves without complications in 7 – 10 days but can recur in some patients.
• 67 YEAR OLD MALE
– 5.5 YRS POST HEART TRANSPLANT
• PLEURAL FLUID
– NUCLEATED CELLS 5,998 /mcL
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Monomorphic post transplant lymphoproliferative disorder
Burkitt’s lymphoma
IF YOU’RE WONDERING………………
SYNOVIAL FLUID
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URIC ACID CRYSTALS – POLARIZED LIGHT
RED COMPENSATOR FILTER
The diff channel on the XE showed interference from the uric acid crystals as did the WBC/BASO channel.
A manual count would need to be performed but……..
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HOW ARE YOU GOING TO FIND THE CELLS ?
AND DOES IT MATTER ?
• 47 YEAR OLD FEMALE– ER PATIENT– ALTERED VISION ??
• CSF– NUCLEATED CELLS 4 / mcL– RBC 3 / mcL
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SOMETHING TO REMEMBER….
CYTOCENTRIFUGE CONCENTRATION
~ 20 FOLD
…IF YOU DO IT RIGHT !
REPEAT COUNT… NUCLEATED CELLS 29 / mcL
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WHAT WENT WRONG ?
NEW RULE
ALL FLUIDS – CLEAR, COLORLESS, WHATEVER –
ANALYZED ON THE XE
SYNOVIAL FLUID …failure in the opposite direction
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REPORTED
SYNOVIAL FLUID EXAM
FLUID APPEARANCE CLEAR COLORLESS
FLUID VOLUME 3 mL
NUCLEATED CELL COUNT 147 /mcL
TOO FEW CELLS TO PERFORM DIFFERENTIAL. PREDOMINATING CELL TYPE IS NEUTROPHIL
JOINT FLUID CRYSTALS NONE SEEN
WAIT….
WHAT ?????
REPORTED
SYNOVIAL FLUID EXAM
FLUID APPEARANCE CLEAR COLORLESS
FLUID VOLUME 3 mL
NUCLEATED CELL COUNT 147 /mcL
TOO FEW CELLS TO PERFORM DIFFERENTIAL. PREDOMINATING CELL TYPE IS NEUTROPHIL
JOINT FLUID CRYSTALS NONE SEEN
ALWAYS CORRELATE THE SLIDE AND THE COUNT