CEREBROSPINAL FLUID

DR.P.G.KONAPUR
VMKV MEDICAL COLLEGE
SALEM

 Introduction
Specimen collection: LP Technique
Complications of LP
Routine examination of CSF.
Physical examination
Chemical examination
Cytological examination
Microbiological examination

 found in the subarachnoid space

surrounding the brain and spinal

cord..
an ultrafiltrate of plasma
protects the central nervous system
from injury

 Spinal needle - 22 gauge:

AGE& Length of needle:
Less than 1 year--3.75 cm (1.5 inch)
1 year to middle childhood--6.25cm (2.5
inch)
Older children to adolescents--8.75 cm (3.5
inch)
Povidone-iodine solution.
1% Lidocaine and 25 gauge needle for local
anesthesia.
Sterile 4 x 4 gauze.
3-4 sterile specimen tubes.
For viral cultures: an additional tube
CSF manometers and 3 way stopcock.

Use Sitting Position:

Patients with pulmonary
disorders.
Young infants

INDICATIONS

Meningitis and encephilitis--viral,

bacterial, fungal, or parasitic infections.

metastatic tumors (e.g., leukemia) and
central nervous system tumors that
shed cells into the CSF
Syphilis
bleeding (hemorrhaging) in the brain
and spinal cord
Guillain-Barr-- a demyelinating disease

COMPLICATIONS

Post-tap headaches.
Vomiting.
Paralysis (low risk)
Subarachnoid epidermal cyst.
Epidural hematomas.
Subdural or subarachnoid hemorrhage.
Spinal cord bleeding.
Acute neurologic or respiratory deterioration.
Hypoxemia or apnea
Cerebral herniation.
Introduction of infection with resultant bacterial
meningitis, epidural abscess, diskitis or
osteomyelitis. (low risk)
Ocular muscle palsy. (transient)

ROUTINE EXAMINATION
Physical examination:

Normal CSF is clear and colourless,

specific gravity is 1.0032.
Colour Red colour is seen due to trauma occurring during
L.P
yellow colour called xanthochromia
is due to previous hemorrhage with lysis of RBCS in the
CSF and due to tumour.
Turbidity or cloudiness is seen when

500/ul)

increase in number of cells in CSF ( ie 400

or
numerous bacteria
or
both.

 Coagulum: protein content is

increased.

tuberculous meningitis (cobweb

coagulum is seen)

 Chemical examination:

Glucose
two-thirds of the fasting plasma glucose.
A glucose level below 40 mg/dL is significant
bacterial and fungal meningitis and in malignancy..
Protein
High levels ------bacterial

fungal meningitis,

tumors,

subarachnoid hemorrhage,

traumatic tap.

Lactate

bacterial and fungal meningitis V/S viral meningitis

bacterial and fungal meningitis------ increased lactate,

viral meningitis------------------------NORMAL
Lactate Dehydrogenase
elevated in

bacterial and fungal meningitis,

malignancy,

subarachnoid hemorrhage.

Cytological Examination
Centrifuge
smears from deposit
stain -romanowasky
Cell Count
immediately
(pus cells stick to each other)
Method
count all 9 squares
Normal--- 0 5 lymphocytes per cubic mm.

Neutrophils increased
acute pyogenic
meningitis.
Lymphocytes-----increased
viral meningitis.,
syphilitic meningitis.,
tubercular meningitis.
fungal meningitis.
RBCs : subarachnoid hemorrhage,
stroke,
traumatic tap
Malignant cells:
50 percent of--- metastatic cancers
10 percent of------CNS tumors( shed
cells into the CSF).

Micobiological Examination:
Gram stain :on a sediment
Positive in--60 percent of cases of
bacterial
meningitis.
Culture: aerobic and anaerobic
bacteria. Other stains:
The Z-N for Mycobacterium
tuberculosis,
Fungal culture:

feature

normal

Ac.pyo.me
ningitis

Ac.viral
meningiti

Chr.tb.menin
gitis

Naked eye

Clear
&colorless

Cloudy,fra
nkly
purulent

Clear/slight Clear/slighttu
turbid
rbid,cobweb

pressure

60-150

>180

>250

>300

Cell count,type 0-4lympho 1010,000neu

tro

10100100lympho 1000lympho

protein

1545mg/dl

raised

raised

raised

glucose

50-80

reduced

normal

reduced

bacteria

sterile

sterile

Tb bacilli+

Serological examination:
Syphilis serology --neurosyphilis.
The fluorescent treponemal antibodyabsorption (FTA-ABS) test: positive
!.with active and treated
syphilis.
!.used in conjunction with the
VDRL

PLEURAL FLUID
ANALYSIS
Specimen collection Procedures

Diagnostic thoracentesis
Therapeutic thoracentesis
Tube thoracostomy
Causes of pleural effusion
Difference between transudate and exudate
Routine examination of Pleural fluid.
Physical examination

Chemical examination

Immunological examination

Cytological examination

Algorythym for pleural effusion.

 Diagnostic thoracentesis:

@if the etiology of the effusion is unclear

@if the presumed cause of the effusion
does not
respond to therapy as
expected.
@Pleural effusions do not require
thoracentesis
underlying congestive heart
failure(bilateral effusions)
@by recent thoracic or abdominal surgery.
@Relative contraindications:
bleeding diathesis
systemic anticoagulation,
mechanical ventilation,
cutaneous disease over site.

Complications:

pain at the puncture site,

cutaneous or internal bleeding,
pneumothorax,
empyema,
spleen/liver puncture
Pneumothorax -12-30% of

thoracenteses( requires treatment with

a chest tube in less than 5% of cases)
Use of needles larger than 20 gauge
increases the risk of a pneumothorax

Therapeutic
thoracentesis
to remove larger amounts of pleural
fluid

 DIFFERENCES BETWEEN A

TRANSUDATE AND A EXUDATE

CHARACTERISTICS TRANSUDATE
TRANSUDATE CLEAR,
STRAW YELLOW
Sp gr:< 1.018
PROTEIN :< 2G/DL

INFLAMMATORY CELLS :LOW COUNT

 EXUDATE
Appearance:CLOUDY MAY BE

CLOTTED
Colour: YELLOW TO RED
Sp gr:> 1.018
Protein:> 2G/DL
INFLAMMATORY CELLS: HIGH COUNT

 Physical examination:
1. Volume: Measure and record the

volume of fluid received.

Appearance, colour, clot formation:
Note colour whether clear or cloudy,
whether clot is formed on standing

 Chemical examination:
Protein estimation:
Glucose estimation:

 Immunological studies:
ANA titres are useful in diagnosing

effusion due to SLE,and rheumatoid

factor is commonly present in
pleureal effusion associated with sero
positive rheumatoid arthritis

 Immunological studies:
ANA titres are useful in diagnosing
effusion due to SLE,
rheumatoid factor is commonly
present in pleureal effusion
associated with sero positive
rheumatoid arthritis

NEUBAUER COUNTING
CHAMBER

Count in the four corners

Count in the four corners

Cells in one corner

square

MESOTHELIAL CELLS

BENIGN MESOTHELIAL
CELLS

FOAMY MACROPHAGES

INFLAMMATORY PLEURAL FLUID

ACID FAST BACILLI

CANDIDA IN PLEURAL FLUID

Abnormal mitosis

SMALL CELL CA

METASTIC CA FROM BREAST

ATYPICAL PLASMA CELLS

ASCITIC FLUID ANALYSIS

Specimen collection: Procedure

Abdominal paracentesis fluid.

Causes of Ascitis
Routine examination of Ascitic fluid.
Physical examination
Chemical examination
Cytological examination
Microbiological examination

SPECIMEN COLLECTION
Abdominal paracentesis:
The removal of 5 L of fluid is considered

large-volume paracentesis.
Total paracentesis, ie, removal of all ascites
(even >20 L),
Recent studies demonstrate that
supplementing 5 g of albumin per each liter
over 5 L decreases complications of
paracentesis, such as electrolyte imbalances,
and increases in serum creatinine secondary
to large shifts of intravascular volume

CAUSES FOR ASCITIS

alcoholic liver disease.

Obesity,
hypercholesterolemia
type 2 diabetes mellitus

steatosis
steatosis
steatosis

cancer, (especially gastrointestinal cancer)

malignant ascites.

cirrhosis
cirrhosis
cirrhosis

Portal hypertension (serum-ascites albumin

gradient [SAAG] >1.1 g/dL)
Hepatic congestion,
congestive heart failure,
constrictive pericarditis,
tricuspid insufficiency,
Budd-Chiari syndrome
Liver disease,
cirrhosis,
alcoholic hepatitis,
fulminant hepatic failure,
massive hepatic metastases
Hypoalbuminemia (SAAG <1.1 g/dL)
Nephrotic syndrome
Protein-losing enteropathy
Severe malnutrition with anasarca

Miscellaneous conditions (SAAG <1.1 g/dL)

Chylous ascites
Pancreatic ascites
Bile ascites
Nephrogenic ascites
Urine ascites
Ovarian disease
Diseased peritoneum (SAAG <1.1 g/dL)

Infections
Bacterial peritonitis
Tuberculous peritonitis
Fungal peritonitis
HIV-associated peritonitis

Malignant conditions :
Peritoneal carcinomatosis
Primary mesothelioma
Pseudomyxoma peritonei
Hepatocellular carcinoma
Other rare conditions:
Familial Mediterranean fever
Vasculitis
Granulomatous peritonitis
Eosinophilic peritonitis.

Routine examination
PHYSICAL EXAMINATION:
transparent and tinged yellow.

A minimum of 10,000 red blood cells/L is required for

ascitic fluid to appear pink,

more than 20,000 red blood cells/L is considered
distinctly blood tinged.
a traumatic tap or malignancy.

Bloody fluid from a traumatic tap is heterogeneously

bloody, and the fluid will clot.

Nontraumatic bloody fluid is homogeneously red and

does not clot because it has already clotted and lysed.

Neutrophil counts of more than 50,000 cells/L have

a purulent cloudy consistency and indicate infection.

Chemical examination:
SERUM-ASCITES ALBUMIN GRADIENT (SAAG):
The SAAG ascites into portal hypertensive (SAAG
>1.1 g/dL) and nonportal hypertensive
(SAAG <1.1 g/dL) causes.
Calculated by subtracting the ascitic fluid
albumin value from the serum albumin value,
it correlates directly with portal pressure.
TOTAL PROTEIN:
In the past, ascitic fluid ---an exudate (if the
protein level is greater than or equal to 2.5
g/dL). However, the accuracy is only
approximately 56% for detecting exudative
causes.
The total protein level +SAAG.
An elevated SAAG and a high protein
ascites
due to hepatic congestion.
Those patients with malignant ascites
have a low SAAG and a high protein level.

Cytological examination:
Cytology:
58-75% sensitive
Mal cells
sediment is smeared on slides.
Papanicolaou stain and Leishman stains
A cytospin preparation can be used for
clear fluid.
A cell block may also be prepared if
adequate sediment is available.

 Cell count:
Normal <500 leukocytes/L
< 250 polymorphonuclear
leukocytes/L.
A neutrophil count > 250 cells/L - highly
suggestive of bacterial peritonitis.
In tuberculous peritonitis
&
peritoneal carcinomatosis ______ a
predominance of lymphocytes usually
occurs.

Microbiological examination:
CULTURE/GRAM STAIN:
The sensitivity with bedside
inoculation of blood culture bottles
with ascites results in 92% detection
of bacterial growth in neutrocytic
ascites.
AFB stain may be done if required.

MESOTHELIAL CELLS

MALIGNANCY IN ASCITIC FLUID

PERICARDIAL FLUID
EXAMINATION
Causes of pericardial fluid

accumulation.
Routine examination of pericardial fluid.
Physical examination
Chemical examination
Cytological examination
Microbiological examination

Pathophysiology of pericardial
effusion:

The pericardial space normally contains 15-50 mL of fluid,

Lubrication------ for the visceral and parietal layers
originate from the visceral pericardium
an ultrafiltrate of plasma.
Total protein levels are generally low
The cause of abnormal fluid production ---------underlying
etiology
secondary to------ pericarditis.
1.Transudative ------obstruction of drainage(lymphatics)
2. Exudative --------- inflammatory
infectious
malignant
autoimmune processes within the
pericardium.

 CAUSES OF PERICARDIAL FLUID

ACCUMULATION
Infectious

Viral (coxsackievirus A and B, hepatitis, HIV)

Pyogenic (pneumococci, streptococci,
staphylococci, Neisseria, Legionella species)
Tuberculous
Fungal (histoplasmosis, coccidioidomycosis,
Candida)
Other infections (syphilitic, protozoal, parasitic)

Noninfectious

Acute idiopathic
Uremia
Neoplasia
Primary tumors (benign or malignant, mesothelioma)
Tumors metastatic to pericardium (lung and breast
cancer, lymphoma, leukemia)

Myxedema

Acute myocardial infarction

Postirradiation
Aortic dissection (with leakage into pericardial sac)
Trauma
Cholesterol
Chylopericardium
Familial Mediterranean fever
Whipple disease
Sarcoidosis

Hypersensitivity or autoimmunity
related :

Rheumatic fever
Collagen vascular disease (systemic lupus
erythematosus, rheumatoid arthritis, ankylosing
spondylitis, scleroderma, acute rheumatic fever,
Wegener granulomatosis)
Drug-induced (eg, procainamide, hydralazine,
isoniazid, minoxidil, phenytoin, anticoagulants,
methysergide)
Postcardiac injury.

ROUTINE EXAMINATION
Physical examination:
Colour. Clot formation. Specific

gravity: Altered colour is seen in

Bacterial pericarditis,Tuberculosis,
SLE, Rheumatoid pleuritis,
Lymphoma, carcinoma.

Chemical examination:
Includes test for glucose and
proteins

Cytological examination:
Includes WBC count
RBC count,
Differential count
malignant cells.

Microbiological
examination
Grams stain
AFB stains
Pericardial fluid culture

SUMMARY
Normally -10-50 ml
excess fluid -----pericardial effusion.
Fluid is obtained by using a sterile
needle under aseptic precaution
called as pericardiocantisis.
Physical examination
chemical examination
Microbiological examination

SYNOVIAL FLUID
ANALYSIS
Specimen collection: Procedure
Causes of Synovial fluid
accumulation

Routine examination of Synovial

fluid

SIGNIFICANCE

Synovial fluid is found around the joint.

Chemical composition: is similar to that of
other body fluids except it has

hyaluronic acid.
Hyaluronic acid ----mucodysacchride

that acts as a binding and protective agent

for connective tissue.
CLINICAL SIGNIFICANCE:
Diagnosis of Arthritis
Gout
Infection (septic arthritis)

SPECIMEN COLLECTION
Obtained by aspiration of a joint
Anticoagulant (EDTA) :-----cell counting
Fluoride:---------------------- glucose
analysis

ROUTINE EXAMINATION
PHYSICAL EXAMINATION:
APPEARANCE Normal synovial fluid
straw coloured celar and viscous
TURBIDITY Increase in case of
inflammatory and infected conditions.
Grossly Purulent fluid with an increased
leucocyte count is typical of acute
Septic arthritis.
XANTHOCHROMIA Supernatent
synovial fluid indicates Tumours,
Trauma

 VISCOSITY Synovial fluid is

viscous ----hyaluronic acid.

INFLAMMATORY DISORDERS of
the joint rendor an enzymatic
(hyaluronidase)

Breakdown of hyaluronic acid

Loss of viscosity of synovial fluid

TESTS
STRING TEST
Hold a drop of specimen between
thumb and index finger.
A drop of normal synovial fluid will
form a string.
4 6cm in length_______normal
<3cm__________viscosity is lower
than normal

 MUCIN CLOT TESTClots in the presence of acetic acid.

If there is breakdown of hyaluronic
acid does not allow the formation of
firm clot.
PROCEDURE Synovial fluid is
added drop by drop in a dilute
solution of acetic acid.
firm clot---------- Normal and non
inflammatory conditions
poor clot------ inflammatory
conditions (Hyaluronic acid content
decreases)

CHEMICAL EXAMINATION:
GLUCOSE Synovial fluid for glucose

ANALYSIS - Must be taken from a fasting patient

(6 12 hrs) and treated with fluoride
Samples of the patient synovial fluid and blood
specimen must be obtained at the same time for a
comparison of two values.
In case of non inflammatory arthritis, the difference
of blood glucose and synovial fluid glucose is only
10mg/dl
Increase to 25 50mg/dl in case of infectious septic
arthritis
In mild inflammatory conditions (gout pseudogout
Rheumatoid arthritis)
Glucose content of synovial fluid is close to normal.

MICROSCOPIC
EXAMINATION

Total leucocyte count

Differential count is important for

diagnosis of joint related disorders.

Leucocyte count of normal synovial
fluid is very low (50 cells/cu mm). If
specimen turbid saline containing
methylene blue are diluent
If specimen bloody, haemolyse the
erythrocytes by diluting with O 1N Hcl
or 1% saporin in saline. Smear the
slide.

NORMAL SYNOVIAL
FLUID
NORMAL SYNOVIAL FLUID Has a
few mononuclear white cells
Increased neutrophil count (>70 %)
is suggestive of bacterial arthritis
In inflammatory disorders white cell
count is moderately high
(>10m000/cu mm)

MICROSCOPIC
EXAMINATION OF CRYSTALS
Clear a slide and a coverslip with alcohol and acetone.
Place a few drops of synovial fluid on the slide just

sufficient enough to reach the periphery of the cover

slip.
Needle shaped intracellular urate crystals (sodium and
urate) - Gouty arthritis
Rhomboid calcium pyrophosphate crystals in
pseudogiant
Rheumatoid arthritis Cholesterol crystals

Recognized by their flat, clear rhombic appearance

with one corner punched out

 MICROBIOLOGY EXAMINATION:

Gram staining and acid fast staining.

Lab
Test

Non
Inflammatory
inflam
mator
y

Infectio
n

APEARAN
CE

Clear
Yellow

Clear
Yellow

Mild

Severe

Turbid to
purulent

VISCOSI
TY
LEUCOC
YTE /cu
mm

High

High

TurbidDecrea
sed

turbid
Decreased

Decrease
d

0 200

0- 5,000 0- 10,000

500 50,000

50020,000

NEUTRO
PHILS %
GLUCOS
E
(mg/dl)

0 25

0- 25

0- 50

0 90

40-100

0 10

0- 10

0- 20

0 40

20-100