BODY FLUIDS BOND KING (SUNIL)

TRANSUDATES Decrease plasma albumin Increase venous pressure Increase venous obstruction Cardiac failure Disturbance of circulation with passive EXUDATES Damage of mesothelial linings Cause malignancy and infection.

CLINICAL CONDITION 1. TRANSUDATES Hypoproteinemia Congestive heart failure (weakness of heart) Liver cirrhosis 2. EXUDATES Fluid in lungs

DIFFERENT PARAMETERS TRANSUDATES EXUDATES

Origin Non- inflammatory Inflammatory

PH Alkaline Acidic

Sp. gravity < 1.018 > 1.018

Coagulation No clot formation clot formation( due to the presence of fibrinogen)

Protein < 3 gm > 3 gm

Glucose Same with blood glucose Lower than blood glucose

LDH 200 IU/L > 200 IU/L

Chloride Lower than blood chloride Higher than blood chloride

Cells Less ( usually lymphocyte) Many ( neutrophils / polymorphonuclear cells (PMN))

Crystals Absent Present

Types of Exudates 1. Serous – pale yellow and contains few cells 2. Fibrinous – Dark yellow and contain fibrinogen 3. Serofibrinous – pale to dark yellow ; contains few

cells and fibrinogen. 4. Purulent – many pus cells (WBC) ; yellow green/

light brown. 5. Hemorrhagic – blood 6. Putrid – many pus cells; seen in Gangrene (death

of tissue) 7. Chylous – milky appearance ; contains fat

globules, pseudo globulin and lecithin ; associated with thoracic duct destruction and brugia malayi

8. Serosanguinopurulent – combination of serous to chylous ( bacterial infection , pus and blood hemorrhage)

CEREBROSPINAL FLUID (CSF) • Third major body fluid in the body • Clear colorless fluid produced by highly vascular chloride plexus of ventricles of the brain. • 500 ml/day or 20 ml/hour

HISTORY Cotungo in 1764 3rd major body fluid . THE FLOW OF CSF 70% CSF is derived by ultrafiltration and

secretions through choroid plexus. 30% from ependymal lining of ventricle and

cerebral subarachnoid spaces.

Importance Act as a mechanical receptor (which prevents

the brain and skull from coming into contact). Serves as excretory channel(collect waste and

excrete out in the form of sweat , urine and feces).

Serves as nutrient to brain. Cushions to brain and lubricate the central

nervous system.

Importance of CSF Analysis To detect infection and to differentiate

meningitis( particularly bacterial meningitis). To detect CNS disorder To detect sub-arachnoid block. (Froin’s

syndrome) flow of CSF is abnormal. METHOD OF COLLECTION

1. Lumbar puncture (to measure intercranial pressure)

Safe and simplest method for puncture Puncture in shrimp position. Lumbar 3 & 4 (adults) Lumbar 4 & 5 (children)

2. Cisternal (occipital) Recommended in cases of paralysis and

meningitis. 3. Ventricular puncture (lateral cervical) Neck For infants Ventricular cannula. * The length of syringe used for CSF collection

is 18 cm.

TUBES ( DISPOSABLE) 1st tube – chemistry and serology (Red / yellow

top ; frozen) 2nd tube – Microbiology section (black top ;

refrigerated not allowed) 3rd tube – Hematology section (purple, EDTA,

Light blue, Green) 4th tube – additional test (blue top; cytology) Note:- • If malignancy is suspect then only 4th tube is used. • Avoid glass tube becoz cell adhere to glass affecting

cell count. • Perform immediately becoz of cell degradation.

Macroscopic Examination Volume – (90 - 170 ml) pH – (7.3 – 7.45) 7.31 Specific gravity – 1.006 to 1.008 Pressure – 50 – 200 mm H2O (90 to 180 mm

H2O) (adult) 10 – 100 mm H20 (children) Clear; colorless Coagulation – normal CSF doesn’t clot

(transudate) Viscous as water

Clinical condition of fibrinogen in CSF Traumatic tap Froin’s syndrome Tubular meningitis/ sub acute meningitis Symptoms of Meningitis Cob- web like clot Pellicle like clot (12- 24 hours after

refrigeration) Pine tree like clot.

Variation in color (clinical significance of CSF Appearance)

1. Turbid (Tyndall effect) WBC ‘s - 200 cell/UL (associated with

meningitis) RBC ‘s – over 400/UL ( associated with

hemorrhage, traumatic tap) Microorganism – meningitis (viral, bacterial

etc.) Protein – Disorder of production of IgG in CSF (blood brain barrier)

2. Bloody (hemorrhage , lyses RBC’s , traumatic tap) 3. Xanthochromic (pale pink to orange yellow) Hemoglobin – old hemorrhage , lyses RBC in CSF. Bilirubin in CSF – RBC breakdown , increase serum

level Protein (150 mg/dl) - RBC breakdown , increase serum level - disorder affect blood brain barrier Melanin (Brownish color) - meningeal melanosarcoma

Grayish / Greenish color of CSF Causes are acute meningitis, increase pus

cells. Differentiate sub-arachnoid block from

traumatic Taps Sub- Arachnoid Traumatic Tap

1. Even distribution of blood tubes 1-4

1.Uneven distribution of blood

2. Clot formation(presence of fibrinogen)

2. No clot

3.Presence of siderophage 3. Absence of siderophage 4.Quekensted test (+Ve) 4. D-dimer (-ve)

* Siderophage – macrophage with phagocyte erythrocyte

# Quekensted Test Most useful method to detect sub-arachnoid

block. Done by comprising external jugular vein. # Chemical examination of CSF Protein – over 80% from plasma Normal value – (15 – 45) mg/dl Increase CSF may found in Infection , meningitis

, multiple sclerosis and hemorrhage

QUALITATIVE TEST 1. Ross Jones ( excess of globulin in CSF) 2. Nonne apelt Reagent :- ammonium sulfate Presence of white ring of ppt give positive test

(both 1 & 2 ) 3. Pandy’s test Reagent :- phenol Presence of bluish white cloud give positive test 4. Noguchi’s test 10% of butyric acid Presence of ppt is positive test

QUANTITAIVE TEST 1. Turbidimetric Test (ppt is positive test) Reagent :- SSA (Sulfosalicylic Acid) and TCA

(Tricarboxylic Acid) 2. Nephelometric Test Reagent:-Benzyl chromium chloride (ppt is

positive test) 3. Dye binding technique Reagent :- Coomassie brilliant blue G250 Blue ppt give positive test 4. Biuret Method spectrophotometer

Glucose in CSF Normal value – 50 to 85 mg/dl(approx.65 mg/dl) Increased - Diabetes mellitus - Infectious encephalitis Decreased - hypoglycemia - pyogenic meningitis - Fungal meningitis - Toxoplasmosis - Subarachnoid hemorrhage - primary tumor of brain

Comparison Note:- In case of glucose only Exudates decrease

but Transudates remains Normal. Chlorides Normal value :- 113 – 127 MEQ/L Test :- schales and schales ; cotlove

chloridometer

Bacterial meningitis Viral meningitis Tubercular Glucose Decrease Normal Decrease Cells PMN lymphocyte lymphocyte

Lactate Normal value : 10 -22 mg/dl (Newborn) - (9 – 26)mg/dl (adult) As to detect viral from bacterial mycoplasma, TB

and fungal meningitis. Method:- Automated Analysers. Lactate > 35 – bacterial meningitis Lactate < 25 – viral meningitis Antibiotic therapy fall lactate level rapidly.

GLUTAMINE Normal value :- 8 – 18mg/dl Over 35 mg/dl – hepatic encephalopathy Reflects brain ammonia(ammonia + a-

ketoglutarate) In case of coma of unknown origin Reye’s syndrome – acute brain damage and liver

function

CSF ENZYME LACTATE DEHYDROGENASE(LDH) Adult – 40 U/L Child – 70 U/L Isoenzyme LD1 and LD2 – produced by brain cells. LD2 and LD3 – produced by lymphocyte. LD4 and LD5 – produced by neutrophils.

CREATINE KINASE Normal value - < 5 U/L (adult) < 17 U/L (infants) CK-BB – brain is the isoform. CK-MM – muscle is the isoform. CK-MB – brain and muscle both is isoform. Serologic Examination CEA – metastatic carcinoma hCG – choriacarcinoma and germ cell tumors. CSF ferritin – CNS malignancy ; patient with

inflammatory disease.

Microbiological Exam # Staining Gram stain – most important to differentiate

bacterial pathogens. India Ink – Cryptococcus neformans Acid fast stain – TB agent Auramine - Rhodamine – TB agent Acridine agent – Differential amoeba (brick

red) from leukocytes (bright green)

# culture Immunologic tests

1. Counter immunoelectrophoresis Limited for the detection and identification of H. influenza – 1month to 5 years S. pneumoniae – 29 yrs old and above N. meningitidis – 5 to 29 yrs old E. coli - all age group Group B streptococci – all age group

Agglutination Tests 1. Latex Agglutination Test For bacterial antigen test (BATs) for

C. neoformans 2. ELISA * Litmus lysate assay For the detection of presence of endotoxin. Sp.test for bacterial meningitis.