Lab Specimen and MicroscopyUnit 3 Exam Study guide

The best study guide for your exam is the Learning Objective section and the Key Terms locate at the beginning of each chapter.

Chapter 10- CSF

Learning Objective: 1, 2, 4, 5 6, 14, 17, 18, 20, 221 State the three major functions of cerebrospinalfluid (CSF).cerebrospinal fluid (CSF) is a major fluid of the body.1 CSF provides a physiologic system to supply nutrients to the nervous tissue, remove metabolic wastes, and produce a mechanical barrier to cushionthe brain and spinal cord against trauma

2 Distribute CSF specimen tubes numbered 1, 2,and 3 to their appropriate laboratory sections andcorrectly preserve them.TUBE 1 - Chemistry and serology tubes are frozen.TUBE2 - Microbiology tubes remain at room temperature.TUBE 3 - Hematology tubes are refrigerated.

4 Define xanthochromia and state its significance.

Xanthochromia is a term used to describe CSF supernatant that is pink, orange, or yellow. The cause of xanthochromia, with the most common being the presence of RBC degradation products.

the color will vary from pink (very slight amount of oxyhemoglobin) to orange (heavy hemolysis) to yellow (conversion of oxyhemoglobin to unconjugated bilirubin). Other causes of xanthochromia include elevated serum bilirubin, presence of the pigment carotene, markedly increased protein concentrations, and melanoma pigment. Xanthochromia that is caused by bilirubin due to immature liver function is also commonly seen in infants, particularly in those who are premature.

SEE Table 10-1

5 Differentiate between CSF specimens caused byintracranial hemorrhage and a traumatic tap.

Three visual examinations of the collected specimens can usually determine whether the blood is the result of hemorrhage or a traumatic tap.

Uneven Distribution of BloodBlood from a cerebral hemorrhage will be evenly distributed throughout the three CSF specimen tubes, whereas a traumatic tap will have the heaviest concentration of blood in tube 1, with gradually diminishing amounts in tubes 2 and 3.

Clot FormationFluid collected from a traumatic tap may form clots owing to the introduction of plasma fibrinogen into the specimen. Bloody CSF caused by intracranial hemorrhage does not contain enough fibrinogen to clot.

Xanthochromic SupernatantRBCs must usually remain in the CSF for approximately 2 hours before noticeable hemolysis begins; therefore, a xanthochromic supernatant would be the result of blood that has been present longer than that introduced by the traumatic tap

6 Calculate CSF total, white blood cell (WBC), and red blood cell (RBC) counts when given thenumber of cells seen, amount of specimen dilution,and the squares counted in the Neubauerchamber.

14 Discuss the significance of CSF electrophoresisfindings in multiple sclerosis and the identificationof CSF.ElectrophoresisThe primary purpose for performing CSF protein electrophoresis is for the detection of oligoclonal bands representing inflammation within the CNS. The bands are located in the gamma region of the protein electrophoresis, indicating immunoglobulin production.

The presence of two or more oligoclonal bands in theCSF that are not present in the serum can be a valuable tool in the diagnosis of multiple sclerosis, particularly with increase IgG.

17 Briefly discuss the diagnostic value of CSF lactate and glutamine determinations.

lactate levels can be a valuable aid in the diagnosis and management of meningitis cases. In bacterial,tubercular, and fungal meningitis, the elevation of CSF lactate to levels greater than 25 mg/dL occurs much more consistently than does the depression of glucose and provides more reliable information when the initial diagnosis is difficult.Levels greater than 35 mg/dL are frequently seen with bacterial meningitis, whereas in viral meningitis, lactate levels remain lower than 25 mg/dL. CSF lactate levels remain elevated during initial treatment but fall rapidly when treatment is successful, thus offering a sensitive method for evaluating the effectiveness of antibiotic therapy.Destruction of tissue within the CNS owing to oxygen deprivation (hypoxia) causes the production of increased CSF lactic acid levels. Therefore, elevated CSF lactate is not limited to meningitis and can result from any condition that decreases the flow of oxygen to the

tissues. CSF lactate levels are frequently used to monitor head trama.

Glutamine is produced from ammonia and _-ketoglutarate by the brain cells. This process serves to remove the toxic metabolic waste product ammonia from the CNS. The normal concentration of glutamine in the CSF is 8 to 18 mg/dL.20

Elevated levels are found in association with liver disorders that result in increased blood and CSF ammonia. Increased synthesis of glutamine is caused by the excess ammonia disturbance of consciousness is almost always seen when glutamine levels are more than 35 mg/dL.13 Therefore, the CSF glutamine test is a frequently requested procedure for patients with coma of unknown origin. Approximately 75% of children with Reye syndrome have elevated CSF glutamine levels.21

18 Name the microorganism associated with a positive India ink preparation.fungal meningitis are Gram stained and often have an India ink preparation performed on them to detect the presence of thickly encapsulated Cryptococcus neoformans

20 Determine whether a suspected case of meningitis is most probably of bacterial, viral, fungal, or tubercular origin, when presented with pertinent laboratory data.…. ? this question is stupid and super vague I refuse to do it.

22 Describe quality control procedures and safetyprecautions related to CSF procedures.commercial controls for spinal fluid RBC and WBCcounts are available from several manufacturers. They can be purchased at two levels of concentration. In-house controls can also be prepared. On a biweekly basis, all diluents should be checked for contamination by examination in a counting chamber under 4 _ magnification. Contaminated

diluents should be discarded and new solutions prepared.On a monthly basis, the speed of the cytocentrifuge should be checked with a tachometer, and the timing should be checked with a stopwatch.If nondisposable counting chambers are used, they must be soaked in a

bactericidal solution for at least 15 minutes and then thoroughly rinsed with water and cleaned with isopropyl alcohol.

Figure 10-2, 10-3, 10-4, 10-35

Scan thru the pictures of cells.

All Tables, all summary boxes

Cell count---what type of diluent used to dilute csf to count all cells, to count just the WBCs?

Calculation of CSF cell counts:[#cells counted x dilution factor] / [#of squares counted x volume of 1 square] = cells/ul

Volume of 1 square = 0.1ul

Protein Fraction: the purpose of testing for protein fraction???Routine CSF protein procedures are designed to measure total protein concentration. However, diagnosis of neurologic disorders associated with abnormal CSF protein often requires measurement of the individual protein fractions. Protein that appears in the CSF as a result of damage to the integrity of the blood-brain barrier contains fractions proportional to those in plasma, with albumin present in the highest concentration. Diseases, including multiple sclerosis, that stimulate the immunocompetent cells in the CNS show a higher proportion of IgG.

CSF / Serum albumin index = CSF albumin (mg/dl) / Serum albumin (g/dl)CSF / Serum IgG index = CSF IgG / Serum IgG

IgG index = [CSF IgG (mg/dl) / Serum IgG (g/dl)] / CSF albumin (mg/dl) / Serum albumin (g/dl)

STUDY QUESTIONS1. The functions of the CSF include all of the followingexcept:A. Removal of metabolic wastesB. Producing an ultrafiltrate of plasmaC. Supplying nutrients to the CNSD. Protection of the brain and spinal cord

2. The CSF flows through the:A. Choroid plexusB. Pia materC. Arachnoid spaceD. Dura mater

3. Substances present in the CSF are contolled by the:A. Arachnoid granulationsB. Blood-brain barrierC. Presence of one-way valvesD. Blood-CSF barrier

4. The CSF tube labeled 3 is sent to:A. The hematology departmentB. The chemistry departmentC. The microbiology departmentD. The serology department

5. The CSF tube that should be refrigerated is:A. Tube 1B. Tube 2C. Tube 3D. Tube 4

6. Place the appropriate letter in front of the statementthat best describes CSF specimens in these two conditions:A. Traumatic tapB. Intracranial hemorrhage_____Even distribution of blood in all tubes_____Xanthochromic supernatant_____Concentration of blood in tube 1 is greaterthan in tube 3_____Specimen contains clots

7. The presence of xanthochromia can be caused by allof the following except:A. Immature liver functionB. RBC degradationC. A recent hemorrhageD. Elevated CSF protein

8. A web-like pellicle in a refrigerated CSF specimen isindicative of:A. Tubercular meningitisB. Multiple sclerosisC. Primary CNS malignancyD. Viral meningitis

9. Given the following information, calculate the CSFWBC count: cells counted, 80; dilution, 1:10; largeNeubauer squares counted, 10.A. 8B. 80C. 800D. 8000

10. A CSF WBC count is diluted with:A. Distilled waterB. Normal salineC. Acetic acidD. Methylene blue

11. A total CSF cell count on a clear fluid should be:A. Reported as normalB. Not reportedC. Diluted with normal salineD. Counted undiluted

12. The purpose of adding albumin to CSF beforecytocentrifugation is to:A. Increase the cell yieldB. Decrease the cellular distortionC. Improve the cellular stainingD. Both A and B

13. The primary concern when pleocytosis of neutrophilsand lymphocytes is found in the CSF is:A. MeningitisB. CNS malignancyC. Multiple sclerosisD. Hemorrhage

14. Neutrophils with pyknotic nuclei may be mistakenfor:A. LymphocytesB. Nucleated RBCsC. Malignant cellsD. Spindle-shaped cells

15. The presence of which of the following cells isincreased when a CNS shunt malfunctions?A. NeutrophilsB. MacrophagesC. EosinophilsD. Lymphocytes

16. Macrophages appear in the CSF following:A. HemorrhageB. Repeated spinal tapsC. Diagnostic proceduresD. All of the above

17. Nucleated RBCs are seen in the CSF as a result of:A. Elevated blood RBCsB. Treatment of anemiaC. Severe hemorrhageD. Bone marrow contamination

18. Following a CNS diagnostic procedure, which of thefollowing might be seen in the CSF?A. Choroidal cellsB. Ependymal cellsC. Spindle-shaped cellsD. All of the above

19. Hemosiderin granules and hematoidin crystals areseen in:A. LymphocytesB. MacrophagesC. Ependymal cellsD. Neutrophils

20. Myeloblasts are seen in the CSF:A. In bacterial infectionsB. In conjunction with CNS malignancyC. Following cerebral hemorrhageD. As a complication of acute leukemia

21. Cells resembling large and small lymphocytes withcleaved nuclei represent:A. Lymphoma cellsB. Choroid cellsC. Melanoma cellsD. Medulloblastoma cells

22. The normal value of CSF protein is:A. 6–8 g/dLB. 15–45 g/dLC. 6–8 mg/dLD. 15–45 mg/dL

23. CSF can be differentiated from plasma by the presenceof:A. AlbuminB. GlobulinC. PrealbuminD. Tau transferring

24. In plasma, the second most prevalent protein is IgG;in CSF, the second most prevalent protein is:A. TransferrinB. PrealbuminC. IgAD. Ceruloplasmin

25. Elevated CSF protein values can be caused by all ofthe following except:A. MeningitisB. Multiple sclerosisC. Fluid leakageD. CNS malignancy

26. The integrity of the blood-brain barrier is measuredusing the:A. CSF/serum albumin indexB. CSF/serum globulin ratioC. CSF albumin indexD. CSF IgG index

27. Given the following results, calculate the IgG index:CSF IgG, 50 mg/dL; serum IgG, 2 gm/dL; CSF albumin,70 mg/dL; serum albumin, 5 gm/dL.A. 0.6B. 6.0C. 1.8D. 2.8

28. The CSF IgG index calculated in Study Question 27is indicative of:A. Synthesis of IgG in the CNSB. Damage to the blood-brain barrierC. Cerebral hemorrhageD. Lymphoma infiltration

29. The finding of oligoclonal bands in the CSF and notin the serum is seen with:A. Multiple myelomaB. CNS malignancyC. Multiple sclerosis

D. Viral infections

30. A CSF glucose of 15 mg/dL, WBC count of 5000, 90%neutrophils, and protein of 80 mg/dL is suggestive of:A. Fungal meningitisB. Viral meningitisC. Tubercular meningitisD. Bacterial meningitis

31. A patient with a blood glucose of 120 mg/dL wouldhave a normal CSF glucose of:A. 20 mg/dLB. 60 mg/dLC. 80 mg/dLD. 120 mg/dL

32. CSF lactate will be more consistantly decreased in:A. Bacterial meningitisB. Viral meningitisC. Fungal meningitisD. Tubercular meningitis

33. Measurement of which of the following can bereplaced by CSF glutamine analysis in children withReye syndrome?A. AmmoniaB. LactateC. GlucoseD. _-ketoglutarate

34. Prior to performing a Gram stain on CSF, the specimenmust be:A. FilteredB. Warmed to 37_CC. CentrifugedD. Mixed

35. All of the following statements are true about cryptoccocalmeningitis except:A. An India Ink preparation is positiveB. A starburst pattern is seen on Gram stainC. The WBC count is over 2000D. A confirmatory immunology test is available

36. The test of choice to detect neurosyphilis is the:A. RPRB. VDRLC. FTA

D. FTA-ABS

Case Studies and Clinical Situations1. Three tubes of CSF containing evenly distributed visibleblood are drawn from a 75-year-old disorientedpatient and delivered to the laboratory. Initial testresults are as follows:WBC COUNT: 250 _L PROTEIN: 150 mg/dLGLUCOSE: 70 mg/dL GRAM STAIN: No organisms seenDIFFERENTIAL: Neutrophils, 68%; monocytes, 3%; lymphocytes,28%; eosinophils, 1%Many macrophages containing ingested RBCsa. What is the most probable condition indicatedby these results? State two reasons for youranswer.b. Are the elevated WBC count and protein of significance?Explain your answer.c. Are the percentages of the cells in the differentialof any significance? Explain your answer.d. What two other structures besides RBCs might becontained in the macrophages?e. If the blood was unevenly distributed and nucleatedRBCs and capillary structures were seeninstead of macrophages, what would thisindicate?

2. A patient with AIDS is hospitalized with symptoms ofhigh fever and rigidity of the neck. Routine laboratorytests on the CSF show a WBC count of 100/_L with apredominance of lymphocytes and monocytes, glucoseof 55 mg/dL (plasma: 85 mg/dL), and a protein of70 mg/dL. The Gram stain shows a questionable starburstpattern.a. What additional microscopic examination shouldbe performed?b. If the test is positive, what is the patient’s diagnosis?

c. If the results of the test are questionable, whatadditional testing can be performed?d. What could cause a false-positive reaction in thistest?e. If the tests named in a and c are negative, the glucoselevel is 35 mg/dL, and a pellicle is observedin the fluid, what additional testing should be performed?f. If CSF and serum IFE was performed on thispatient, what unusual findings might be present?

3. A 35-year-old woman is admitted to the hospital withsymptoms of intermittent blurred vision, weakness,and loss of sensation in her legs. A lumbar puncture isperformed with the following results:APPEARANCE: Colorless, clearWBC COUNT: 35 cells/_L (90% lymphocytes)GLUCOSE: 60 mg/dL (plasma: 100 mg/dL)PROTEIN: 60 mg/dL (serum: 8 g/dL)ALBUMIN: 40 mg/dL (serum: 6 g/dL)IGG globulin: 20 mg/dL (serum: 2 g/dL)a. Name and perform the calculation to determinethe integrity of the patient’s blood-brain barrier.b. Does the patient have an intact barrier?c. Name and perform the calculation used to determineif IgG is being synthesized within the CNS.d. What does this result indicate?e. Considering the patient’s clinical symptoms andthe calculation results, what diagnosis is suggested?f. If immunofixation electrophoresis is performed onthe patient’s serum and CSF, what findings wouldbe expected?g. What substance in the CSF can be measured tomonitor this patient?

4. Mary Howard, age 5, is admitted to the pediatricsward with a temperature of 105_F, lethargy, and cervicalrigidity. A lumbar spinal tap is performed, and

three tubes of cloudy CSF are delivered to the laboratory.Preliminary test results are as follows:APPEARANCE: HazyWBC COUNT: 800 cells/_LDIFFERENTIAL: 80% lymphocytes, 15% monocytes,5% neutrophilsPROTEIN: 65 mg/dLGLUCOSE: 70 mg/dLGRAM STAIN: No organisms seena. From these results, what preliminary diagnosiscould the physician consider?b. Is the Gram stain result of particular significance?Why or why not?c. Are the lymphocytes of significance? Why or whynot?d. Would a CSF lactate test be of any value for thediagnosis? Why or why not?5. State possible technical errors that could result in thefollowing discrepancies:a. An unusual number of Gram stains reported asgram-positive cocci fail to be confirmed by positivecultures.b. A physician complains that CSF differentials arebeing reported only as polynuclear and mononuclearcells.c. Bacteria observed on the cytospin differential cannotbe confirmed by Gram stain or culture.d. The majority of CSF specimens sent to thelaboratory from the neurology clinic haveglucose readings less than 50% of the correspondingblood glucose results performedin the clinic.

Chapter 12 Synovial Fluid

Learning Objectives: 1, 2, 4, 5, 6, 7, 8

1 Describe the formation and function of synovialfluid.Synovial fluid, often referred to as “joint fluid,” is a viscous liquid found in the cavities of the movable joints (diarthroses) or synovial joints. As shown in Figure 12-1, the bones in the synovial joints are lined with smooth articular cartilage and separated by a cavity containing the synovial fluid. The joint is enclosed in a fibrous joint capsule lined by the synovial membrane. The synovial membrane contains specialized cells called synoviocytes. The smooth articular cartilage and synovial fluid reduce friction between the bones during joint movement. In addition to providing lubrication in the joints, synovial fluid provides nutrients to the articular cartilage and lessens the shock of joint compression that occurs during activities such as walking and jogging. Synovial fluid is formed as an ultrafiltrate of plasma across the synovial membrane. however, provide nutrients for the vascular- deficient cartilage. The synoviocytes secrete a mucopolysaccharide containing hyaluronic acid and a small amount of protein (approximately one fourth of the plasma concentration) into the fluid

2 Relate laboratory test results to the four commonclassifications of joint disorders.

3 State the five most diagnostic tests performed onsynovial fluid.

4 Determine the appropriate collection tubes forrequested laboratory tests on synovial fluid.

5 Describe the appearance of synovial fluid in normaland abnormal states.

6 Discuss the normal and abnormal cellular composition of synovial fluid.

7 List and describe six crystals found in synovialfluid.

8 Explain the differentiation of monosodium urateand calcium pyrophosphate crystals using polarizedand compensated polarized light.

Tables 12-1, 12-2, 12-3, 12-4, 12-5

Diluent used for total cell count?

traditional WBC diluting fluid cannot be used because it contains acetic acid that causes the formation of mucin clots. Normal saline can be used as a diluent. If it is necessary to lyse the RBCs, hypotonic saline (0.3%) or saline that contains saponin is a suitable diluent. Methylene blue added to the normal saline stains theWBC nuclei, permitting separation of the RBCs and WBCs during counts performed on mixed specimens

Diluent used for WBC count?saline

How Hyaluronidase is used in aiding cell count? Red blood cell (RBC) counts are seldom requested. To prevent cellular disintegration, counts should be performed as soon as possible or the specimenshould be refrigerated. Very viscous fluid may need to be pretreated by adding a pinch of hyaluronidase to 0.5 mL of fluid or one drop of 0.05% hyaluronidase in phosphate buffer per milliliter of fluid and incubating at 37_C for 5 minutes.3

QUESTIONS1. The functions of synovial fluid include all of the followingexcept:A. Lubrication for the jointsB. Removal of cartilage debrisC. Cushioning joints during joggingD. Providing nutrients for cartilage

2. The primary function of synoviocytes is to:A. Provide nutrients for the jointsB. Secrete hyaluronic acidC. Regulate glucose filtrationD. Prevent crystal formation

3. Which of the following is not a frequently performedtest on synovial fluid?A. Uric acidB. WBC countC. Crystal examinationD. Gram stain

4. The procedure for collection of synovial fluid is called:A. SynovialcentesisB. ArthrocentesisC. Joint punctureD. Arteriocentesis

5. Match the following disorders with their appropriategroup:A. NoninflammatoryB. InflammatoryC. SepticD. Hemorrhagic____Gout____N. gonorrhoeae infection____Lupus erythematosus____Osteoarthritis____Hemophilia____Rheumatoid arthritis____Heparin overdose

6. Normal synovial fluid resembles:A. Egg whiteB. Normal serumC. Dilute urineD. Lipemic serum

7. Powdered anticoagulants should not be used in tubesfor synovial fluid testing because it interferes with:A. Cell countsB. Glucose testsC. Crystal examinationD. Differentials

8Addition of a cloudy, yellow synovial fluid to aceticacid produces a/an:A. Yellow-white precipitateB. Easily dispersed clotC. Solid clotD. Opalescent appearance

9. To determine if a fluid is synovial fluid, it shouldbe mixed with:A. Sodium hydroxideB. Hypotonic salineC. HyaluronidaseD. Acetic acid

10. The highest WBC count can be expected to be seen

with:A. Noninflammatory arthritisB. Inflammatory arthritisC. Septic arthritisD. Hemorrhagic arthritis

11. When diluting a synovial fluid WBC count, all of thefollowing are acceptable except:A. Acetic acidB. Isotonic salineC. Hypotonic salineD. Saline with saponin

12. The lowest percentage of neutophils would be seenin:A. Noninflammatory arthritisB. Inflammatory arthritisC. Septic arthritisD. Hemorrhagic arthritis

13. All of the following are abnormal when seen in synovialfluid except:A. RA cellsB. Reiter cellsC. Synovial lining cellsD. Lipid droplets

14. Synovial fluid crystals that occur as a result of purinemetabolism or chemotherapy for leukemia are:A. Monosodium urateB. CholesterolC. Calcium pyrophosphateD. Apatite

15. Synovial fluid crystals associated with inflammationin dialysis patients are:A. Calcium pyrophosphateB. Calcium oxalateC. CorticosteroidD. Monosodium urate

16. Crystals associated with pseudogout are:A. Monosodium urateB. Calcium pyrophosphateC. ApatiteD. Corticosteroid

17. Synovial fluid for crystal examination should beexamined as a/an:A. Wet preparation

B. Wright stainC. Gram stainD. Acid-fast stain

18. Crystals that have the ability to polarize light are:A. CorticosteroidB. Monosodium urateC. Calcium oxalateD. All of the above

19. In an examination of synovial fluid under compensatedpolarized light, rhombic-shaped crystals areobserved. What color would these crystals be whenaligned parallel to the slow vibration?A. WhiteB. YellowC. BlueD. Red

20. If crystals shaped like needles are aligned perpendicularto the slow vibration of compensated polarizedlight, what color are they?A. WhiteB. YellowC. BlueD. Red

21. Negative birefringence occurs under compensatedpolarized light when:A. Slow light is impeded more than fast lightB. Slow light is less impeded than fast lightC. Fast light runs against the molecular grain of thecrystalD. Both B and C

22. Synovial fluid cultures are often plated on chocolateagar to detect the presence of:A. Neisseria gonorrhoeaeB. Staphylococcus agalactiaeC. Streptococcus viridansD. Enterococcus faecalis

23. The most frequently performed chemical test onsynovial fluid is:A. Total proteinB. Uric acidC. CalciumD. Glucose

24. Serologic tests on patients’ serum may be performedto detect antibodies causing arthritis for all of the followingdisorders except:A. PseudogoutB. Rheumatoid arthritisC. Lupus erythematosusD. Lyme arthritis

25. Serologic testing of synovial fluid for fibrinogen andC-reactive protein is performed to:A. Determine clot formationB. Determine the amount of inflammationC. Detect osteoarthritisD. Diagnose rheumatoid arthritis

Case Studies and Clinical Situations1. A 50-year-old man presents in the emergency roomwith severe pain and swelling in the right knee.Arthrocentesis is performed and 20 mL of milky synovialfluid is collected. The physician orders a Gramstain, culture, and crystal examination of the fluid, aswell as a serum uric acid. He requests that the synovialfluid be saved for possible additional tests.a.Describe the tubes into which the fluid would beroutinely placed.b.If the patient’s serum uric acid level is elevated,what type of crystals and disorder are probable?c. Describe the appearance of these crystals underdirect and compensated polarized light.d. Why were the Gram stain and culture ordered?

2. A medical technology student dilutes a synovial fluidprior to performing a WBC count. The fluid forms aclot.a.Why did the clot form?b.How can the student perform a correct dilution ofthe fluid?

c.After the correct dilution is made, the WBC countis 100,000/_L. State two arthritis classifications thatcould be considered.d.State two additional tests that could be run todetermine the classification.

3. Fluid obtained from the knee of an obese 65-year-oldwoman being evaluated for a possible knee replacementhas the following results:APPEARANCE: Pale yellow and hazyWBC COUNT: 500 cells/mLGRAM STAIN: NegativeGLUCOSE: 110 mg/dL (serum glucose: 115 mg/dL)a. What classification of joint disorder do theseresults suggest?b. Under electron microscopy, what crystals mightbe detected?c. How does the glucose result aid in the disorderclassification?

4. A synovial fluid delivered to the laboratory for a cellcount is clotted.a. What abnormal constituent is present in the fluid?b. What type of tube should be sent to the laboratoryfor a cell count?c. Could the original tube be used for a Gram stainand culture? Why or why not?

Chapter 13 Serous Fluid

Learning Objectives: 1, 2 , 3, 4, 5, 7, 8, 10, 14,

1 Describe the normal formation of serous fluid.FormationSerous fluids are formed as ultrafiltrates of plasma, with no additional material contributed by the mesothelial cells that line the membranes. Production and reabsorption are subject to hydrostatic and colloidal (oncotic) pressures from the capillaries that serve the cavities and the capillary permeability. Under normal conditions, colloidal pressure from serum proteins is the same in the capillaries on both sides of the membrane.Therefore, the hydrostatic pressure in the parietal andvisceral capillaries causes fluid to enter between the membranes. The filtration of the plasma ultrafiltrate results in increased oncotic pressure in the capillaries that favors reabsorption of fluid back into the capillaries. This produces a continuous exchange of serous fluid and maintains the normal volume of fluid beween the membranes. The slightly different amount of positive pressure in the parietal and visceral capillaries creates a small excess of fluid that is reabsorbed by the lymphatic capillaries located in the membranes.

2 Describe four primary causes of serous effusions. Elevated lymphocyte counts are seen in effusions resulting from tuberculosis, viral infections, malignancy, and autoimmune disorders such as rheumatoid arthritis and systemic lupus erythematosus

3 Differentiate between a transudate and an exudate,including etiology, appearance, and laboratorytests. See tables 3-2

Transudates are effusions that form because of a systemic disorder that disrupts the balance in the regulation of fluid filtration and reabsorption—such as the changes in hydrostatic pressure created by congestive heart failure or the hypoproteinemia associated with the nephrotic syndrome

Exudates are produced by conditions that directly involve the membranes of the particular cavity,including infections and malignancies.

4 Differentiate between a hemothorax and a hemorrhagic exudate.To differentiate between a hemothorax and hemorrhagicexudate, a hematocrit can be run on the fluid. If the bloo is from a hemothorax, the fluid hematocrit is more than50% of the whole blood hematocrit, because the effusion is actually occurring from the inpouring of blood from the injury.5 A chronic membrane disease effusion contains both blood and increased pleural fluid, resulting in a much lower hematocrit.

a hemothorax (traumatic injury) - The presence of blood in the pleural fluid, membrane damage such as occurs in malignancy, or a traumatic aspiration.

Hemothorax is defined as pleural fluid with a hematocrit >50% of the blood hematocrit hence the hematocrit level will distinguish between hemothorax and haemorrhagic effusion

5 Differentiate between a chylous and a pseudochylous exudate. See table 3-4

Chylous material from thoracic duct leakageSudan III staining is strongly positive with chylous material, Milky/white, Predominantly lymphocytes, Triglycerides more than 110 mg/dL

Pseudochylous material from chronic inflammation, contain cholesterol crystals, Milky/green tinge, Mixed cells, triglycerides less than 50 mg/dL,

7 Describe the morphologic characteristics ofmesothelial cells and malignant cells.

mesothelial cells - membranes lining the serous cavities contain a single layer of mesothelial cells; therefore, it is not unusual to find these cells in the serous fluids. Mesothelial cells are pleomorphic; they resemble lymphocytes, plasma cells, and malignant cells, frequently making identification difficultnormal/ reactive cells“Reactive” mesothelial cells mesothelial cells may appear in clusters; have varying amounts of cytoplasm, eccentric nuclei, and prominent nucleoli; and be multinucleated, and thus more closely resemble malignant cells

Distinguishing characteristics of malignant cells may include nuclear and cytoplasmic irregularities, hyperchromatic nucleoli, cellular clumps with cytoplasmic molding (community borders), and abnormal nuclear-to-cytoplasmic ratiosTABLE 13-6

8 List three common chemistry tests performed onpleural fluid, and state their significance.

performed to differentiate between a pleural transudate and exudate, the most common chemical tests performed on pleural fluid are glucose, pH, adenosine deaminase (ADA), and amylase. Triglyceride levels may also be measured to confirm the presence of a chylous effusion.

Decreased glucose levels are seen with tuberculosis,rheumatoid inflammation, and purulent infections. pleural fluid glucose levels parallel plasma levels with values less than 60 mg/dL considered decreased.

Pleural fluid pH lower than 7.0 may indicate the needfor chest-tube drainage, in addition to administration antibiotics in cases of pneumonia. In cases of acidosis, the pleural fluid pH should be compared to the blood pH. Pleural fluid pH at least 0.30 degrees lower than the blood pH is considered significant.6

The finding of a pH as low as 6.0 indicates an esophageal rupture that is allowing the influx of gastric fluid.

ADA levels over 40 U/L are highly indicative of tuberculosis. They are also frequently elevated with malignancy. As with serum, elevated amylase levels are associated with pancreatitis, and amylase is often elevated first in the pleural fluid. Pleural fluid amylase, including salivary amylase, may also be elevated in esophageal rupture and malignancy.

10 Discuss the diagnostic significance of peritoneallavage.Peritoneal lavage is a sensitive test for the detection of intra-abdominal bleeding in blunt trauma cases, and results of the RBC count can be used along with radiographic procedures to aid in determining the need for surgery. RBC counts greater than 100,000/_L are blunt trama.

14 List four chemical tests performed on asciticfluid, and state their significance.ascites - Accumulation of fluid between the peritoneal membranes, and the fluid is commonly referred to as ascetic fluid rather than peritoneal fluid.

Chemical examination of ascitic fluid consists primarily of glucose, amylase, and alkaline phosphatase determinations.

Glucose is decreased below serum levels in bacterial, tubercular peritonitis and malignancy

Amylase is determined on ascitic fluid to ascertain cases of pancreatitis, and it may be

elevated in patients with gastrointestinal perforations

Elevated alkaline phosphatase level is also highly diagnostic of intestinal perforation.

Tables 13-1, 13-2, 13-3 (sudan III stain), 13-4, 13-5, 13-6, 13-7, 13-8, 13-9

SASG = Serum albumin – Fluid albumin

QUESTIONS1. The primary purpose of serous fluid is:A. Removal of waste productsB. Lowering of capillary pressureC. Lubrication of serous membranesD. Nourishing serous membranes

2. The membrane that lines the wall of a cavity is the:A. VisceralB. PeritonealC. PleuralD. Parietal

3. During normal production of serous fluid, the slightexcess of fluid is:A. Absorbed by the lymphatic systemB. Absorbed through the visceral capillariesC. Stored in the mesothelial cellsD. Metabolized by the mesothelial cells

4. Production of serous fluid is controlled by:A. Capillary oncotic pressureB. Capillary hydrostatic pressureC. Capillary permeabilityD. All of the above

5. An increase in the amount of serous fluid is calleda/an:A. ExudateB. TransudateC. EffusionD. Malignancy

6. Pleural fluid is collected by:A. PleurocentesisB. ParacentesisC. PericentesisD. Thoracentesis

7. Place the appropriate letter in front of the followingstatements describing transudates and exudates.A. TransudateB. Exudate____Caused by increased capillary permeability____Caused by increased hydrostatic pressure____Caused by decreased oncotic pressure

____Caused by congestive heart failure____Malignancy related____Tuberculosis related____Nephrotic syndrome related____Cloudy appearance

8. Fluid-to–serum protein and lactic dehydrogenaseratios are performed on serous fluids:A. When malignancy is suspectedB. To classify transudates and exudatesC. To determine the type of serous fluidD. When a traumatic tap has occurred

9. Which of the following requires the most additionaltesting?A. TransudateB. Exudate

10. An additional test performed on pleural fluid to classifythe fluid as a transudate or exudate is the:A. WBC countB. RBC countC. Fluid-to-cholesterol ratioD. Fluid-to–serum protein gradient

11. A milky-appearing pleural fluid is indicative of:A. Thoracic duct leakageB. Chronic inflammationC. Microbial infectionD. Both A and B

12. Which of the following best represents a hemothorax?A. Blood HCT: 42 Fluid HCT: 15B. Blood HCT: 42 Fluid HCT: 10C. Blood HCT: 30 Fluid HCT: 10D. Blood HCT: 30 Fluid HCT: 20

13. All of the following are normal cells seen in pleuralfluid except:A. Mesothelial cellsB. NeutrophilsC. LymphocytesD. Mesothelioma cells

14. A differential observation of pleural fluid associatedwith tuberculosis is:A. Increased neutrophilsB. Decreased lymphocytesC. Decreased mesothelial cellsD. Increased mesothelial cells

15. All of the following are characteristics of malignantcells except:A. Cytoplasmic moldingB. Absence of nucleoliC. Mucin-containing vacuolesD. Increased N:C ratio

16. A pleural fluid pH of 6.0 is indicative of:A. Esophageal ruptureB. MesotheliomaC. MalignancyD. Rheumatoid effusion

17. A mesothelioma cell seen in pleural fluid indicates:A. Bacterial endocarditisB. Primary malignancyC. Metastatic lung malignancyD. Tuberculosis infection

18. Another name for a peritoneal effusion is:A. PeritonitisB. LavageC. AscitesD. Cirrhosis

19. The test performed on peritoneal lavage fluid is:A. WBC countB. RBC countC. Absolute neutrophil countD. Amylase

20. The recommended test for determining if peritonealfluid is a transudate or an exudate is the:A. Fluid-to–serum albumin ratioB. Serum ascites albumin gradientC. Fluid-to–serum lactic dehydrogenase ratioD. Absolute neutrophil count

21. Given the following results, classify this peritonealfluid: serum albumin, 2.2 g/dL; serum protein, 6.0g/dL; fluid albumin, 1.6 g/dL.A. TransudateB. Exudate

22. Differentiation between bacterial peritonitis and cirrhosis

is done by performing a/an:A. WBC countB. DifferentialC. Absolute neutrophil countD. Absolute lymphocyte count

23. Detection of the CA 125 tumor marker in peritonealfluid is indicative of:A. Colon cancerB. Ovarian cancerC. Gastric malignancyD. Prostate cancer

24. Chemical tests primarily performed on peritonealfluid include all of the following except:A. Lactose dehydrogenaseB. GlucoseC. Alkaline phosphataseD. Amylase

25. Cultures of peritoneal fluid are incubated:A. AerobicallyB. AnaerobicallyC. At 37_C and 42_CD. Both A and B

Case Studies and Clinical Situations

1. Fluid from a patient with congestive heart failure iscollected by thoracentesis and sent to the laboratoryfor testing. It appears clear and pale yellow and has aWBC count of 450/mL, fluid:serum protein ratio of0.35, and fluid:serum LD ratio of 0.46.a. What type of fluid was collected?b. Based on the laboratory results, would this fluid beconsidered a transudate or an exudate? Why?c. List two other tests that could be performed to aidin classifying this fluid.

2. A cloudy pleural fluid has a glucose level of 30 mg/dL

(serum glucose level is 100 mg/dL) and a pH of 6.8.a. What condition do these results indicate?b. What additional treatment might the patientreceive based on these results?

3. The following results were obtained on a peritonealfluid: serum albumin, 2.8 g/dL; fluid albumin, 1.2 g/dL.a. Calculate the SAAG.b. Is this a transudate or an exudate? Why?c. What is the most probable cause of the effusion?

4. Paracentesis is performed on a patient with ascites.The fluid appears turbid and has an elevated WBCcount. Additional tests ordered include an absolutegranulocyte count, amylase, creatinine, CEA, andCA 125.a. What is the purpose for the absolute granulocytecount? If it is less than 250 cells/mL, what conditionis indicated?b. If the amylase level is elevated, what is its significance?State an additional test that might beordered.c. Explain the significance of an elevated creatininelevel.d. What is the purpose of the CEA and CA 125 tests?

5. Describe a situation in which paracentesis might beperformed on a patient who does not have ascites. Ifthe RBC count is 300,000/mL, what does this indicate?

6. Microscopic examination of an ascitic fluid shows

many cells with nuclear and cytoplasmic irregularitiescontaining Psammoma bodies. The CEA test result isnormal. What additional test would be helpful?