Cerebrospinal Cerebrospinal FluidFluid

CSFCSF

Third major fluid in the bodyThird major fluid in the body

Functions:Functions:

1.1. Supply nutrients to the CNSSupply nutrients to the CNS

2.2. Remove metabolic wastesRemove metabolic wastes

3.3. Produce a mechanical barrier to Produce a mechanical barrier to cushion brain and spinal cord cushion brain and spinal cord against traumaagainst trauma

Volume:Volume: 20 ml/hr in the choroid plexuses and 20 ml/hr in the choroid plexuses and

reabsorbed by the arachnoid villireabsorbed by the arachnoid villi 140-170 ml in adults140-170 ml in adults 10-60 ml in neonates10-60 ml in neonates

Collection:Collection: Lumbar puncture between 3Lumbar puncture between 3rdrd and 4 and 4th th

or 4 or 4thth and 5 and 5thth lumbar vertebrae lumbar vertebrae Note intracranial pressure and Note intracranial pressure and

prevent introduction of infection and prevent introduction of infection and damage to neural tissues damage to neural tissues

Collected in 3 containers:Collected in 3 containers:

1.1. Chemical and serologic tests Chemical and serologic tests

2.2. MicrobiologicalMicrobiological

3.3. Cell countCell count

4.4. Additional testsAdditional tests

Characteristics:Characteristics:1.1. AppearanceAppearance

- crystal clear, hemolyzed/bloody- crystal clear, hemolyzed/bloody- cloudy – presence of WBC- cloudy – presence of WBC- xanthocromic - pink, orange and yellow- xanthocromic - pink, orange and yellow

- presence of RBC degradation - presence of RBC degradation products, products,

elevated bilirubin, carotene, increased elevated bilirubin, carotene, increased protein protein

concentrations, melanin pigmentsconcentrations, melanin pigments- bloody - indication of intracranial - bloody - indication of intracranial hemorrhage or hemorrhage or

traumatic taptraumatic tap

HemorrhageHemorrhage Traumatic tapTraumatic tap

1.1. Blood evenly Blood evenly distributed in all distributed in all 3 CSF specimen 3 CSF specimen tubestubes

2.2. No clot No clot

3.3. Xanthocromic Xanthocromic supernatantsupernatant

1.1. Heaviest Heaviest concentration of concentration of blood in tube 1blood in tube 1

2.2. Clot formation due Clot formation due to introduction of to introduction of plasma fibrinogen plasma fibrinogen into the CSFinto the CSF

3.3. Clear supernatantClear supernatant

2.2. Cell Count:Cell Count:

- adult - 0-5 WBC/ml - adult - 0-5 WBC/ml

(lymphocytes:monocytes 70:30)(lymphocytes:monocytes 70:30)

- neonates - 0-30 WBC/ml - neonates - 0-30 WBC/ml

(more monocytes)(more monocytes)

- specimens with 200 WBC/ml or 400 - specimens with 200 WBC/ml or 400

RBC/ml → clearRBC/ml → clear

3.3. Protein: 15-45 mg/dl, mostly albuminProtein: 15-45 mg/dl, mostly albumin4.4. Glucose: 60-70% of plasma glucose drawn 2 hrs prior to Glucose: 60-70% of plasma glucose drawn 2 hrs prior to

LPLP5.5. Lactate: Lactate:

- 25 mg/dl- 25 mg/dl- elevations can result from any condition that - elevations can result from any condition that

decreases decreases

the flow of Othe flow of O2 2 to the tissuesto the tissues- used to monitor severe head injuries- used to monitor severe head injuries

6.6. Glutamine Glutamine - 8 to 18 mg/dl- 8 to 18 mg/dl- 35 mg/dl : show disturbance in consciousness → - 35 mg/dl : show disturbance in consciousness →

comacoma- ↑ ammonia in CSF ↓ - ↑ ammonia in CSF ↓ αα ketoglutarate ketoglutarate

8.8. Enzymes:Enzymes:A. Lactate dehydrogenase (LD)A. Lactate dehydrogenase (LD)

LD1 LD2LD1 LD2 brain tissuebrain tissueLD2 LD3LD2 LD3 lymphocyteslymphocytesLD4 LD5LD4 LD5 neutrophilsneutrophils

B. Creatine kinase isoenzymes CKBBB. Creatine kinase isoenzymes CKBB < 17 mg/ml< 17 mg/ml predict predict

recovery after recovery after cardiac arrestcardiac arrest

> 17 mg/ml> 17 mg/ml poor prognosispoor prognosis

Differential Diagnosis of Differential Diagnosis of MeningitisMeningitis

BacterialBacterial ViralViral TBTB FungalFungal

↑ ↑ WBC, WBC, neutrophilsneutrophils

↑ ↑ WBC, WBC, lymphocytelymphocytess

↑ ↑ WBC, WBC, lymphocytelymphocytes and s and monocytesmonocytes

↑ ↑ WBC, WBC, lymphocytelymphocytes and s and monocytesmonocytes

↑ ↑ CHONCHON ↑ ↑ CHONCHON ↑ ↑ CHONCHON ↑ ↑ CHONCHON

↓ ↓ CHOCHO Normal Normal CHOCHO

↓ ↓ CHOCHO Normal - ↓ Normal - ↓ CHOCHO

↑ ↑ LactateLactate Normal Normal LactateLactate

↑ ↑ LactateLactate ↑ ↑ LactateLactate

↑ ↑ LD4 & LD4 & LD5LD5

↑ ↑ LD2 & LD2 & LD3LD3

↑ ↑ LD2 & LD2 & LD3LD3

↑ ↑ LD2 & LD2 & LD3LD3

Seminal Fluid Seminal Fluid AnalysisAnalysis

Seminal Fluid AnalysisSeminal Fluid Analysis

1.1. Evaluation of fertility casesEvaluation of fertility cases

2.2. Post vasectomy casesPost vasectomy cases

Composition:Composition: Spermatozoa produced in the testis Spermatozoa produced in the testis

and mature in the epididymisand mature in the epididymis Seminal vesicles form viscous liquid Seminal vesicles form viscous liquid

that furnishes fructose and other that furnishes fructose and other nutrients to maintain the spermatozoanutrients to maintain the spermatozoa

Prostate produce milky liquid Prostate produce milky liquid containing acid phosphatase and containing acid phosphatase and proteolytic enzymes that act on the proteolytic enzymes that act on the fluid from the seminal vesicles fluid from the seminal vesicles resulting in coagulation and resulting in coagulation and liquefaction of the semenliquefaction of the semen

Collection:Collection: Specimen should be collected in Specimen should be collected in

sterile containers following a 3 day sterile containers following a 3 day period of sexual abstinenceperiod of sexual abstinence

A fresh specimen is collected and A fresh specimen is collected and should liquefy within 30 minutes of should liquefy within 30 minutes of collectioncollection

Volume: 2-5 mlVolume: 2-5 ml

Viscosity: pours in dropletsViscosity: pours in droplets

pH: 7.3 – 8.3 (alkaline)pH: 7.3 – 8.3 (alkaline)

Sperm count: 20-160 million/mlSperm count: 20-160 million/ml

: 10-20 million/ml borderline: 10-20 million/ml borderline

Motility: 50-60% with fair quality within 3 Motility: 50-60% with fair quality within 3 hourshours

Morphology: oval head 3x5 um with long Morphology: oval head 3x5 um with long tapered tapered

tailtail

: < 30% abnormal forms: < 30% abnormal forms

Synovial FluidSynovial Fluid

Synovial FluidSynovial Fluid

Joint fluidJoint fluid Viscous fluid found in joint cavitiesViscous fluid found in joint cavities Ultrafiltrate of plasma across the Ultrafiltrate of plasma across the

synovial membranesynovial membrane Composed of mucopolysaccharide Composed of mucopolysaccharide

containing hyaluronic acid and proteincontaining hyaluronic acid and protein Supplies nutrients to the cartilage and Supplies nutrients to the cartilage and

acts as lubricant to surfaces of moving acts as lubricant to surfaces of moving jointsjoints

Collection: fine needle aspiration or Collection: fine needle aspiration or arthrocentesisarthrocentesis

Volume: 3.5 mlVolume: 3.5 ml

Characteristics: clear to pale yellowCharacteristics: clear to pale yellow

: does not clot: does not clot

Viscosity: polymerization of the Viscosity: polymerization of the hyaluronic acid hyaluronic acid

string test 4-6 cmstring test 4-6 cm

Cell count: WBC>200 cells/mlCell count: WBC>200 cells/ml

Classification of Joint Classification of Joint DisordersDisorders

Group ClassificationGroup Classification Pathologic Pathologic SignificanceSignificance

Lab FindingsLab Findings

I. Non-inflammatoryI. Non-inflammatory Degenerative joint Degenerative joint disordersdisorders

Clear yellow fluidClear yellow fluid

Good viscosityGood viscosity

WBC < 2,000WBC < 2,000

Neutro < 30%Neutro < 30%

Glucose normalGlucose normal

II. InflammatoryII. Inflammatory Immunologic Immunologic disorders including disorders including RA & SLERA & SLE

Cloudy yellow fluidCloudy yellow fluid

Poor viscosityPoor viscosity

WBC 2,000-5,000WBC 2,000-5,000

Neutro > 50%Neutro > 50%

Decreased glucoseDecreased glucose

Possible Possible autoantibodies autoantibodies present present

III. SepticIII. Septic Microbial infectionMicrobial infection Cloudy, yellow Cloudy, yellow green fluidgreen fluid

Poor viscosityPoor viscosity

WBC 10,000-WBC 10,000-200,000200,000

Neutro > 90%Neutro > 90%

Decreased glucoseDecreased glucose

Positive culture Positive culture and gram stainand gram stain

IV. Crystal-IV. Crystal-inducedinduced

GoutGout

PseudogoutPseudogoutCloudy or milky Cloudy or milky fluidfluid

Poor viscosityPoor viscosity

WBC <50,000WBC <50,000

Neutro < 90%Neutro < 90%

Decreased glucoseDecreased glucose

Elevated uric acidElevated uric acid

Crystals presentCrystals present

V. HemorrhagicV. Hemorrhagic TraumaTrauma

Coagulation Coagulation deficienciesdeficiencies

Cloudy, red fluidCloudy, red fluid

Poor viscosityPoor viscosity

WBC >5,000WBC >5,000

Neutro < 50,000Neutro < 50,000

Normal glucoseNormal glucose

RBC present RBC present

CrystalsCrystals ShapeShape PathologyPathology

Monosodium Monosodium urateurate

NeedlesNeedles GoutGout

Calcium Calcium pyrophosphatpyrophosphatee

RodsRods

NeedlesNeedles

RhombusRhombus

PseudogoutPseudogout

CholesterolCholesterol Notched Notched rhombic rhombic platesplates

CholesterolosCholesterolosisis

ApatiteApatite Small needlesSmall needles Minerals from Minerals from cartilagecartilage

CorticosteroiCorticosteroidsds

Flat platesFlat plates Drug Drug infectionsinfections

Serous fluids:Serous fluids:1.1. Pleural - thoracentesisPleural - thoracentesis2.2. Pericardial - pericardiocentesisPericardial - pericardiocentesis3.3. Peritoneal - paracentesisPeritoneal - paracentesis

Collection:Collection:1.1. EDTA tube: cell countEDTA tube: cell count2.2. Sterile tube: cultureSterile tube: culture3.3. Heparinized tube: chemistryHeparinized tube: chemistry

Effusions - systemic disorder that Effusions - systemic disorder that disrupts the balance in the disrupts the balance in the regulation of fluid filtration and regulation of fluid filtration and reabsorptionreabsorption

1.1. Transudates results from changes in Transudates results from changes in hydrostatic pressurehydrostatic pressure

2.2. Exudates results from an Exudates results from an inflammatory processinflammatory process

TransudateTransudate ExudateExudate

AppearanceAppearance ClearClear CloudyCloudy

Specific gravitySpecific gravity < 1.015< 1.015 > 1.015> 1.015

Total CHONTotal CHON < 3.0 g/dl< 3.0 g/dl > 3.0 g/dl> 3.0 g/dl

LDLD < 200 IU< 200 IU > 200 IU> 200 IU

Fluid : serum Fluid : serum protein ratioprotein ratio

< 0.6< 0.6 >0.6>0.6

Cell countCell count < 1,000/uL< 1,000/uL >1,000/uL>1,000/uL

Spontaneous clotSpontaneous clot No No PossiblePossible

Pleural fluid Pleural fluid cholesterolcholesterol

< 55 mg/dl< 55 mg/dl > 55 mg/dl> 55 mg/dl