UNIVERSITY OF SANTO TOMASFACULTY OF PHARMACY

DEPARTMENT OF MEDICAL TECHNOLOGY

CSF AND OTHER BODY FLUIDS

AQUINO, CHRISTIALANE JOYPASCUAL, BOB DYLANQUERO, MARC DELVIN

ROSARIO, KRISELLE DIANNEVILLANUEVA, JOSE LORENZO

4E-Medical Technology

MR. ALVIN REY FLORES, RMT, MT (ASCPi)Seminar II Instructor

SEROUS FLUIDS

A. Composition and Formation

Serous fluid is the small amount of fluid that lies between the membranes lining the body cavities (parietal) and those covering the organs within the cavities (visceral).

1. It is considered an “ultrafiltrate” of the plasma and closely resembles it.

2. Production and reabsorption are normally at a constant rate. They are influenced by:

a. Changes in osmotic and hydrostatic pressure in the bloodb. Concentration of the chemical constituents in the plasmac. Permeability of blood vessels and the membranes

3. There are three types of serous fluids

a. Peritoneal fluid (ascetic fluid) – from the abdominal cavity – paracentesisb. Pleural fluid (thoracic fluid) – lung – thoracentesisc. Pericardial fluid – heart – pericardiocentesis

B. Indications – infections, hemorrhages, malignancies, other disorders

C. Collection

1. Needle aspiration – parecentesis, thoracentesis, pericardiocentesis; 3 sterile tubes, often in EDTA to prevent clotting

2. Lavage – peritoneal

D. Transudates vs. Exudates

A build up of serous fluid is called an effusion.

1. Transudatea. Due to a systemic disorder, ex. CHFb. Disruption in the balanced regulation of fluid filtration (formation) and its

reabsorptionc. Thought of as a mechanical process

2. Exudatea. Produced by conditions that directly involve the membranes of the particular

cavity, ex. Infections, inflammation, and malignancies

b. Thought of as an inflammatory process

Transudate ExudateAppearance Clear CloudySpecific Gravity <1.015 >1.015Total Protein <3.0 g/dl >3.0 g/dlFluid Protein : Serum Protein Ratio <0.5 >0.5Lactic Dehydrogenase (LDH) <200 IU >200 IUFluid LD : Serum LD Ratio <0.6 >0.6WBC Count <1000/ul >1000/ulRBC Count O-low high

I. PLEURAL FLUID

Pleural fluid – from pleural cavity, located between the parietal pleural membrane lining the chest wall and the visceral pleural membrane covering the lungs.

Transudate ExudatePleural fluid cholesterol < 60 mg/dl >60 mg/dlPleural fluid : Serum cholesterol ratio <0.3 >0.3Pleural fluid : Serum TB ratio <0.6 >0.6

1. Appearance

Appearance SignificanceClear, pale yellow Normal

Turbid, white Microbial infection (tuberculosis)Bloody Hemothorax, Hemmorhagic effusion, pulmonary embolis,

tuberculosis, malignancyMilky Chylous material from thoracic duct leakage

Brown Rupture of amoebic liver abcessBlack Aspergillous

Viscous Malignant mesothelioma (↑ hyaluronic acid)

2. Hematology TestsPrimary cells associated: neutrophils, lymphocytes, eosinophils, mesothelial cells, plasma cells, and malignant cells

Cell SignificanceNeutrophils Pneumonia; Pancreatitis; Pulmonary infarction

Lymphocytes Tuberculosis; Viral infection; Autoimmune disorders; Malignancy

Mesothelial cells Normal and reactive forms have no clinical significance; ↓ mesothelial cells are associated

with tuberculosisPlasma cells Tuberculosis

Malignant cells Primary adenocarcinoma and small cell carcinoma; Metastatic carcinoma

3. Chemistry Tests

a. Glucose - ↓ in tuberculosis, rheumatoid inflammation, purulent infectionsb. pH - <7.2 may indicate pneumonia; <6.0 indicates esophageal rupturec. Adenosine Deaminase (ADA) - >40 U/L is indicative of TBd. Amylase - ↑ in pancreatitise. Lactate - ↑ in bacterial infection

4. Microbiologic and Serologic Tests

Bacteria primary associated with pleural effusions:Staphylococcus aureusEnterobacteriaceaeAnaerobesMycobaterium tuberculosis

Serologic Tests:Antinuclear antibody (ANA)Rheumatoid factor (RF)CEA - metastatic uterine cancerCA 15-3 – breast cancerCA 549 – breast cancerCYFRA 21-1 – lung cancer

II. PERICARDIAL FLUID

Pericardial fluid – found between the pericardial serous membranes; 10-50mL

Pericardial effusion due to:a. Infection (pericarditis)b. Metabolic disorders e.g. uremia, hypothyroidism c. Cardiac compression (tamponade)

1. Appearance

2. Hematologic Testsa. Neutrophils - ↑ in bacterial endocarditis

Apperance SignificanceClear, pale yellow Normal, transudate

Blood-streaked Infection, malignancyGrossly bloody Cardiac puncture, anticoagulant medications

Milky Chylous and pseudochylous material

b. Malignant cells – metastatic carcinoma

3. Chemistrya. Adenosine deaminase – tubercular effusion

4. Microbiologic and Serologic Tests

Bacteria/ viruses primary associated with pericardial effusions:HaemophilusStreptococcusStaphylococcusAdenovirusCoxsackievirus

GS/CS – bacterial endocarditis Acid Fast stain – tubercular effusion

III. PERITONEAL FLUID

Accumulated fluids between the peritoneal membranes

Peritoneal lavage - a sensitive test for the detection of intra-abdominal bleeding in blunt trauma cases, and results of the RBC count can be used along with radiographic procedures to aid in determining the need for surgery

Normal saline - use as a lavage

Cirrhosis -frequent causes of ascitic transudates.

Bacterial infections (peritonitis)—often as a result of intestinal perforation or a ruptured appendix—and malignancy are the most frequent causes of exudative fluids

Transudates vs. Exudates

The serum-ascites albumin gradient (SAAG) is recommended over the fluid:serum total protein and LD ratios for the detection of transudates of hepatic origin.

1. AppearanceAppearance Significance

Clear, pale yellow NormalTurbid Microbial infectionGreen Gallbladder, pancreatic disorders

Blood-streaked Trauma, infection or malignancyMilky Lymphatic trauma and blockage

2. Hematologic Tests

Normal WBC counts are less than 350 cells/uL, and the count increases with bacterial peritonitis and cirrhosis.

RBC counts greater than 100,000/uL are indicative of blunt trauma injuries.< 500 cells/uL – normal> 500 cells/uL – bacterial peritonitis, cirrhosis

3. Chemistrya. Glucose - ↓ in tubercular peritonitis, malignancyb. Amylase - ↑ in pancreatitis, gastrointestinal perforationc. Alkaline Phosphatase - ↑ in gastrointestinal perforationd. BUN/Creatinine – ruptured or punctured bladdere. Adenosine deaminase – tubular peritonitis

4. Microbiologic and Serologic Tests

GS/CS for both aerobes and anaerobes when bacterial peritonitis is suspected.

AMNIOTIC FLUID

A. Composition and Formation1. Found in membranous sac (amnion) surrounding fetus2. Formed by

a. Metabolism of fetal cellsb. Transfer of water across placental membranec. Fetal urine (later stages of development)

3. Serves as a protective cushion for the fetus4. Allow fetal movement5. Stabilize temperature to protect the fetus from extreme temperature changes6. Permit proper lung development7. Water and molecule exchange between mother and child8. Composition is similar to the maternal plasma with a small number of cells from the

skin, urinary tract, digestive tract9. Volume: increases throughout the pregnancy up to 1100-1500mL at 36 weeks10.Increased: creatinine (1.5-2.0 mg/dL at 36 weeks) (>2.0 mg/dL after 36 weeks)11.Regulation of the amniotic fluid is facilitated by the swallowing of the developing fetus12. Polyhydraminos – failure of the fetus to begin swallowing results in excessive

accumulation of amniotic fluid 13. Oligohydraminos- decreased amniotic fluid production

14.The fetus secretes lung fluid and pulmonary substances

B. Indications – suspected chromosomal abnormalities, metabolic disorders, neural tube defects HDN, gestational age, infections, fetal maturity

C. Collection and HandlingUse ultrasound (sonography) to locate placenta and fetal position

1. Amniocentesis – 15 weeks to 18 weeks gestation thru needle aspiration2. Specimen – collection of no more than 30 mL or may cause premature labor or rupture

membranes3. Special precautions – protect from light, process immediately

D. Amniotic Fluid Color

Color SignificanceColorless Normal

Blood-streaked Traumatic tap; abdominal trauma; intra-amniotic hemorrhage

Yellow HDN (bilirubin)Dark Green Meconium

Dark Red-Brown Fetal Death

E. Differentiation of Amniotic Fluid from Maternal Urine

Amniotic Maternal urineCreatinine Higher

Urea Higher Glucose Higher protein Higher

Fern test Fernlike crystals

F. Tests for Fetal Status

1. Genetic and Congenital disordersa. Alpha-fetoprotein and Acetylcholinesterase – neural tube defects

2. Fetal Distressa. HDN (Erythroblastosis fetalis) – when mother develops Ab against the childb. Amniotic fluid bilirubin – uncojugated bilirubin, may determine anemiac. Infection – Bacterial vaginosis and trichomoniasisd. Respiratory distress syndrome – most common cause of fetal death

3. Fetal Lung Maturity Testa. Lecithin : Sphingomyelin ratio (L/S Ratio)

L/S ratio routinely used to determine fetal lung maturity and to determine if it is safe to deliver a premature baby.

Hyalin membrane disease – most common cause of death of a newborn

Lecithin – produces at constant rate, equal to sphingomyelin until 33-35th week of gestation. Then there is a sharp increase in lecithin production

Sphingomyelin – produced at a constant rate throughout pregnancy

Ration of 2:1 (L/S) or greater indicates that the lungs are mature enough for delivery

b. Phosphatidyl glycerol – surface lipid that increases greatly after 35th week gestation. More sensitive method than L/S

4. Foam Test or Shake Testa. Screening test for FLS(fetal lung surfactant) in amniotic fluidb. The highest conc of 95% etOH able to support a ring of foamc. More surfactant is needed to maintain foam in greater conc of etOHd. ≥0.47 is considered maturee. Interferences: blood and meconium

5. Amniostat-FLMa. Uses anti-sera specific for phosphatidylglycerolb. Not affected by blood and meconiumc. Good correlation with TLCd. Slightly higher incidence of false-negative results

6. Micro Viscosity Fluorescence Polarization Assaya. To evaluate the amniotic fluid content of pulmonary surfactant relative to

albuminb. < 40mg/g indicates immature lungsc. >70 mg/g indicates mature lungsd. Fluorophore is mixed with amniotic fluid

7. Lamellar Bodiesa. Storage forms of lung phospholipids b. Secreted into the alveolar lumen at approximately 20 to 24 weeks of

gestation.

c. Not affected by bilirubin or lysed whole blood

SWEAT

A. Indication – sweat test is used to confirm the diagnosis of cystic fibrosis (most common fatal inherited disease of Americans)

B. Source: Sweat glands (of skin)

C. Appearance: clear and colorless

D. Laboratory Procedure : Policarpine iontophoresis

1. Sweat glands on the cleansed forearm are subject to the sweat inducing alkaloid pilocarpine in the presence of a mild electrical current for 5-10 min.

2. Sweat is then collected for 25-30 minutes onto filter paper or a tubing apparatus3. Chloride content is measured4. Sodium levels are measured in conjunction with chloride5. Results: Na and Cl values over 50 mEq/L = CF; 40-70 mEq/L = borderline

Sources:

Strasinger, S., & Di Lorenzo, M. (2008). Urinalysis and Body Fluids. 5th Edition. Bangkok, Thailand: iGroup Press Co., Ltd

Jarreau, P. (2012). Clinical Laboratory Science Review. New Orleans, USA: LSU Medical Center

Henry, J., McPherson, R., & Pincus, M. (2011). Henry’s Clinical Diagnosis and Management by Laboratory Methods. 21st Edition. Philadelpia, USA: Elsevier/Saunders.