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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
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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
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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
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SEROUS MEMBRANE LINED CAVITIES
‘EFFUSION’ FLUIDS
• PLEURAL
• PERITONEAL
SEROUS “STUFF”• thorocentesis, paracentesis,
• Minimal volume
Pleural < 15 ml
Peritoneal < 50 ml
TRANSUDATE or EXUDATE
??
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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
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CELL COUNTING
CELL COUNTING- MANUAL(very brief)
FORMULA - MANUAL
cells/µL = cells counted
area x depth x dilution
CELL COUNTING -AUTOMATED
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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
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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
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PICTURES
SYSMEX XE2100
SYSMEX XE5000
KNOW WHEN IT’S GOOD..
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AND WHEN IT’S NOT…
REALITY
THE TYPE OF CELL PRESENT
IS MORE IMPORTANT THAN
THE CELL COUNT.
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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
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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
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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
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CELLS THAT LOOK LIKE MESOTHELIAL CELLS
….BUT THEY’RE NOT !
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SYNOVIAL LINING CELLS
CSF …NEURAL LINING CELLS
EPENDYMAL, CHOROID PLEXUS, GERMINAL MATRIX ??
BRONCHIAL LINING CELLS
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BRONCHIAL LINING CELLS
MESOTHELIAL CELLS ARE FOUND
ONLY IN SEROUS FLUIDS
(PLEURAL, PERITONEAL, PEROCARDIAL)
COOL
CASE STUDIES
….AND SOME, NOT SO COOL
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• 67 YEAR OLD FEMALE – MEDICAL HISTORY UNREMARKABLE– SEEN IN ER WITH COMPLAINTS OF HEADACHE AND
DIZZINESS
• CSF – RBC NONE SEEN– Nucleated cells 135 / mcL
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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.
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• 24 YEAR OLD FEMALE– SEEN IN ER FOR HEADACHE AND
NAUSEA– PREVIOUS HISTORY OF MENINGITIS
• CSF –RBC 17 / mcL–Nucleated cells 754 /mcL
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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
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Monomorphic post transplant lymphoproliferative disorder
Burkitt’s lymphoma
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IF YOU’RE WONDERING………………
SYNOVIAL FLUID
URIC ACID CRYSTALS – POLARIZED LIGHT
RED COMPENSATOR FILTER
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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
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SOMETHING TO REMEMBER….
CYTOCENTRIFUGE CONCENTRATION
~ 20 FOLD
…IF YOU DO IT RIGHT !
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REPEAT COUNT… NUCLEATED CELLS 29 / mcL
WHAT WENT WRONG ?
NEW RULE
ALL FLUIDS – CLEAR, COLORLESS, WHATEVER –
ANALYZED ON THE XE
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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 ?????
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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 ?
Not enough time allowed for slide to dry ???
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AND THIS…….
WAS FEARLESS FLUIDS !
THANK YOU
QUESTIONS ?