FEARLESS FLUIDS

DEPENDS ON WHAT YOU DREAD THE MOST

YUCKY CELL COUNTS SCARY CELLS

Disclosure

• I am receiving an honorarium from Sysmex for today’s presentation

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

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

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

SEROUS “STUFF”• thorocentesis, paracentesis, 

• Minimal volume

Pleural < 15 ml

Peritoneal < 50 ml

TRANSUDATE or EXUDATE

??

PLEURAL SPACE – NORMAL

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

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

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”

AUTOMATEDCELL COUNTS

WHAT’S IMPORTANT ?

- BACKGROUNDS- PICTURES

PICTURES

SYSMEX XE2100

PICTURES

SYSMEX XE2100

SYSMEX XE5000    

KNOW WHEN IT’S GOOD..

AND WHEN IT’S NOT…

REALITY

THE TYPE OF CELL PRESENT

IS MORE IMPORTANT THAN

THE CELL COUNT.

CELLS

BEFORE YOU START….THERE IS ANOTHER RULE

EVEN IF IT’S CLOTTED…

YOU CAN DO SOMETHING WITH IT !

THE PROBLEM CELLS

MESOTHELIAL CELLS

MALIGNANT CELLS

MESOTHELIAL CELLS

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

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

CELLS THAT LOOK LIKE MESOTHELIAL CELLS

….BUT THEY’RE NOT !

SYNOVIAL LINING CELLS

CSF …NEURAL LINING CELLS

EPENDYMAL, CHOROID PLEXUS, GERMINAL MATRIX ?? 

BRONCHIAL LINING CELLS

BRONCHIAL LINING CELLS

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

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

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

Monomorphic post transplant lymphoproliferative disorder

Burkitt’s lymphoma

IF YOU’RE WONDERING………………

SYNOVIAL FLUID

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……..

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

SOMETHING TO REMEMBER….

CYTOCENTRIFUGE CONCENTRATION

~ 20 FOLD

…IF YOU DO IT RIGHT !

REPEAT COUNT… NUCLEATED CELLS 29 / mcL

WHAT WENT WRONG ?

NEW RULE

ALL FLUIDS – CLEAR, COLORLESS, WHATEVER –

ANALYZED ON THE XE

SYNOVIAL FLUID …failure in the opposite direction

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

WHAT WENT WRONG ?

AND THIS…….

WAS FEARLESS FLUIDS !

THANK YOU

QUESTIONS ?