cm synovial fluid
TRANSCRIPT
-
7/22/2019 CM Synovial Fluid
1/42
SYNOVIAL
FLUID()
hua yue
Presented by:
Nathaniel Sim
Myca Pua
-
7/22/2019 CM Synovial Fluid
2/42
PHYSIOLOGY & COMPOSITION
-
7/22/2019 CM Synovial Fluid
3/42
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
PHYSIOLOGY & COMPOSITION
-
7/22/2019 CM Synovial Fluid
4/42
Fluid formation
Ultrafiltrate of plasma across synovial
membraneNon selectiveExcludes proteins of high molecular weight
Synoviocytes
Secrete mucopolysaccharides whichcontains:
Hyaluronic acid
protein
PHYSIOLOGY & COMPOSITION
-
7/22/2019 CM Synovial Fluid
5/42
Volume
-
7/22/2019 CM Synovial Fluid
6/42
JOINT DISORDER CLASSIFICATION
-
7/22/2019 CM Synovial Fluid
7/42
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
-
7/22/2019 CM Synovial Fluid
8/42
Arthrocentesis
joint aspiration
Arthos joint +
Kentesis puncture
Aspiration of synovial
fluid using a syringein a joint capsule
SPECIMEN COLLECTION
-
7/22/2019 CM Synovial Fluid
9/42
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
-
7/22/2019 CM Synovial Fluid
10/42
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
-
7/22/2019 CM Synovial Fluid
11/42
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
-
7/22/2019 CM Synovial Fluid
12/42
PHYSICAL EXAMINATION
-
7/22/2019 CM Synovial Fluid
13/42
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
PHYSICAL EXAMINATION
-
7/22/2019 CM Synovial Fluid
14/42
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 =
-
7/22/2019 CM Synovial Fluid
15/42
Differential Count
Cytocentrifuge specimen and prepare typicalblood smear
Normal: 60% monocytes, macrophages
neutrophils:
-
7/22/2019 CM Synovial Fluid
16/42
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
-
7/22/2019 CM Synovial Fluid
17/42
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
-
7/22/2019 CM Synovial Fluid
18/42
-
7/22/2019 CM Synovial Fluid
19/42
Neutrophils in synovial fluid
-
7/22/2019 CM Synovial Fluid
20/42
Lymphs in synovial fluid
-
7/22/2019 CM Synovial Fluid
21/42
Synovial lining cell
-
7/22/2019 CM Synovial Fluid
22/42
LE cell in synovial fluid
-
7/22/2019 CM Synovial Fluid
23/42
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)
-
7/22/2019 CM Synovial Fluid
24/42
CRYSTAL POLARIZATION
Under Polarizing Light (Direct Polarization)
Birefringent substances appear asbright objects on a black background
-
7/22/2019 CM Synovial Fluid
25/42
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)
-
7/22/2019 CM Synovial Fluid
26/42
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
-
7/22/2019 CM Synovial Fluid
27/42
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
-
7/22/2019 CM Synovial Fluid
28/42
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
-
7/22/2019 CM Synovial Fluid
29/42
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
-
7/22/2019 CM Synovial Fluid
30/42
Cholesterol Crystal1. Associated with chronic
inflammation2. Exhibit negative birefringence
3. Notched, Rhombic plates
TYPES OF CRYSTALS
-
7/22/2019 CM Synovial Fluid
31/42
Corticosteroid Crystals1. Associated with intra-articular
injections2. Exhibit positive and negative
birefringence
3. Flat, variable shaped plates
TYPES OF CRYSTALS
-
7/22/2019 CM Synovial Fluid
32/42
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
-
7/22/2019 CM Synovial Fluid
33/42
Acute gout (uric acid crystals)
-
7/22/2019 CM Synovial Fluid
34/42
Uric acid crystals
-
7/22/2019 CM Synovial Fluid
35/42
Corticosteroid in Synovial Fluid
-
7/22/2019 CM Synovial Fluid
36/42
-
7/22/2019 CM Synovial Fluid
37/42
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
-
7/22/2019 CM Synovial Fluid
38/42
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
-
7/22/2019 CM Synovial Fluid
39/42
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
-
7/22/2019 CM Synovial Fluid
40/42
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
-
7/22/2019 CM Synovial Fluid
41/42
Diagnosis of joint disorders
Autoimmune disease is
demonstrated by autoantibodies on
serum
1. Rheumatoid arthritis (RA)
2. Lupus erythematosus (LE)
SEROLOGY TESTS
-
7/22/2019 CM Synovial Fluid
42/42
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