SELECTION OF LAB INVESTIGATION IN VARIOUS DISEASES AND THEIR INTERPRETATION FOR PROPER DIAGNOSIS

(SERUM, URINE,SEMEN & CSF)

PRESENTED BY DR. JAYAKRISHNAN. V

HEAMATOLOGICAL INVESTIGATION AND THEIR INTERPRETATION

INTRODUCTION; Hematology is the branch of internal medicine, physiology, pathology, clinical

laboratory work, and pediatrics that is concerned with the study of blood, the blood-forming organs, and blood diseases. Hematology includes the study of etiology, diagnosis, treatment, prognosis, and prevention of blood diseases. The laboratory work that goes into the study of blood is frequently performed by a medical technologist.

Normal values
Sodium 31- 33 mg\dl Potassium 14- 20 mg\dl Chloride 340-370 mg\dl Total calcium8.4-10.2 mg\dl Inorganic phosphorus--- 1.0- 1.5 mmol\L Magnesium ---1.5-2.0 MG\DL PHArterial 7.34- 7.45mmol\L VENOUS-7.31-7.41mmol\L Total Protein;3.5-4.8 g\L

Albumin;3.5-4.8 u\L Total Bilirubin0.2-1.3mg\dL Direct/Conjugated Bilirubin;0.4mg\dl Alanine transaminase ;female;6-34iu\L male;8-40iu\L Aspartate transaminase;female;42-98u\L male;53-128u\L Alkaline phosphatase ; 5-40u\L

 Uric acid;

female;2.0-7.0mg\dl male;2.1- 8.5mg\dl Creatinine; male;..8-1.3 mg\dl female;.8-1.1 mg\dl Full blood glucose (fasting) 60-100mg\dl Triglycerides;age b\w 10-39 yrs- 54-110 mg\dl 40-59 yrs70-150 mg\dl more than 60; 80-150 mg Total cholesterol;120- 200 mg\dl HDL cholesterol female- >40

 HDL cholesterol male; 35-80 mg\dl LDL cholesterol;

80-120 mg\dl. WBC; 4.1-11 million X 109 Neutrophyil; 45-62% WBC Lymphocytes; 16-33 % WBC Monocytes; 3-7 %WBC Eosinophil ; 1-3 % WBC Basophil; 0- .75% WBC Bleeding time; 2-9 minutes ESR; Age\ 2 + 10 mm\hr in male

RED BLOOD CELLS Total red blood cells- The number of red cells is

given as an absolute number per litre. Hemoglobin - The amount of hemoglobin in the blood, expressed in grams per decilitre. (Low hemoglobin is called anemia.) Hematocritor packed cell volume (PCV) - This is the fraction of whole blood volume that consists of red blood cells

Red blood cell indices

1. Mean corpuscular volume (MCV) - the average volume of

the red cells, measured in femtolitres. Anemia is classified as microcytic or macrocytic based on whether this value is above or below the expected normal range. Other conditions that can affect MCV include thalassemia and reticulocytosis. 2. Mean corpuscular hemoglobin (MCH) - the average amount of hemoglobin per red blood cell, in picograms. 3. Mean corpuscular hemoglobin concentration (MCHC) - the average concentration of hemoglobin in the cells. 4. Red blood cell distribution width (RDW) - a measure of the variation of the RBC population

White cells
Total white blood cells - All the white cell types

are given as a percentage and as an absolute number per litre. Neutrophil granulocytes - May indicate bacterial infection. May also be raised in acute viral infections.Because of the segmented appearance of the nucleus, neutrophils are sometimes referred to as "segs." The nucleus of less mature neutrophils is not segmented, but has a band or rod-like shape. Less mature neutrophils - those that have recently been released from the bone marrow into the bloodstream - are known as "bands" or "stabs". Stab is a German term for rod.

 Lymphocytes - Higher with some viral infections

such as glandular fever and Also raised in lymphocytic leukemimia.Can be decreased by HIV infection. In adults, lymphocytes are the second most common WBC type after neutrophils. In young children under age 8, lymphocytes are more common than neutrophils. Monocytes - May be raised in bacterial infection, tuberculosis, malaria, Rocky Mountain spotted fever, monocytic leukemia, chronic ulcerative colitis and regional enteritis.

 Eosinophil granulocytes - Increased in parasitic

infections, asthma, or allergic reaction. Basophil granulocytes- May be increased in bone marrow related conditions such as leukemia or lymphoma. A manual count will also give information about other cells that are not normally present in peripheral blood, but may be released in certain disease processes.

Interpretation

Certain disease states are defined by an absolute increase or decrease in the number of a particular type of cell in the bloodstream. For example:
Type of Cell Increase Decrease

Red Blood Cells White Blood Cells(WBC): lymphocytes granulocytes neutrophils eosinophils basophils Platelets

erythrocytosis or polycythemia anemiaor erythroblastopenia leukocytosis -- lymphocytosis -- granulocytosis -- --neutrophilia -- --eosinophilia -- --basophilia thrombocytosis leukopenia lymphocytopenia granulocytopeniaor agranulocytosis neutropenia eosinopenia basopenia thrombocytopenia pancytopenia

ALL CELLS LINE leukocytosis can be a sign of infection. thrombocytopenia can result from drug toxicity. pancytopenia is generally as the result of decreased production from the bone marrow, and is a common complication of cancer chemotherapy.

The Analytes
Sodium; Increase in serum sodium is seen in conditions with water loss in excess of salt loss, as in profuse sweating, severe diarrhea or vomiting, polyuria, hypergluco or mineralocorticoidism, and inadequate water intake. Drugs causing elevated sodium include steroids with mineralocorticoid activity, carbenoxolone, diazoxide,, licorice, methyldopa, oxyphenbutazone, sodium bicarbonate, methoxyflurane, and reserpine.

 Decrease in sodium is seen in states characterized by intake of free water or hypotonic solutions, as may occur in fluid replacement following sweating, diarrhea, vomiting, and diuretic abuse. Dilatational hyponatremia may occur in cardiac failure, liver failure, nephrotic syndrome, malnutrition. There are many other causes of hyponatremia, mostly related to corticosteroid metabolic defects or renal tubular abnormalities. Drugs other than diuretics may cause hyponatremia, including ammonium chloride, chlorpropamide, heparin, vasopressin, cyclophosphamide.

Potassium
Increase in serum potassium is seen in states characterized by excess destruction of cells, with redistribution of K+ from the intra to the extracellular compartment, as in massive hemolysis, crush injuries, hyperkinetic activity, and malignant hyperpyrexia. Decreased renal K+ excretion is seen in acute renal failure, some cases of chronic renal failure, Addison's disease, and other sodiumdepleted states. Hyperkalemia due to pure excess of K+ intake is usually iatrogenic.

 Decrease in serum potassium is seen usually in states characterized by excess K+ loss, such as in

vomiting, diarrhea, villous adenoma of the colo rectum, certain renal tubular defects, hypercorticoidism, etc. Redistribution hypokalemia is seen in glucose/insulin therapy, alkalosis (where serum K+ is lost into cells and into urine), and familial periodic paralysis. Drugs causing hypokalemia include amphotericin, carbenicillin, corticosteroids, diuretics, licorice, salicylates, and ticarcillin.

 Increase in serum chloride is seen in dehydration,

Chloride

renal tubular acidosis, acute renal failure, diabetes insipidus, prolonged diarrhea, salicylate toxicity, respiratory alkalosis, hypothalamic lesions, and adrenocortical hyperfunction. Drugs causing increased chloride include acetazolamide, androgens, corticosteroids, diazoxide, estrogens, gua, methyldopa, oxyphenbutazone, thiazides, and triamterene. Bromides in serum will not be distinguished from chloride in routine testing, so intoxication may show spuriously increased chloride .

 Decrease in serum chloride is seen in excessive sweating, prolonged vomiting, salt-losing

nephropathy, adrenocortical deficiency, various acid base disturbances, conditions characterized by expansion of extracellular fluid volume, SIADH, etc. Drugs causing decreased chloride include bicarbonate, carbenoxolone, corticosteroids, diuretics, laxatives, and theophylline.

CO2 content
Increase in serum CO2 content for the most part reflects increase in serum bicarbonate concentration rather than dissolved CO2 gas (which accounts for only a small fraction of the total). Increased serum bicarbonate is seen in compensated respiratory acidosis and in metabolic

alkalosis. Diuretics, corticosteroids (in long term use), and laxatives (when abused) may cause increased bicarbonate

 Decrease in blood CO2 is seen in metabolic acidosis

and compensated respiratory alkalosis. Substances causing metabolic acidosis include ammonium chloride, acetazolamide, ethylene glycol, methanol, paraldehyde, and phenformin. Salicylate poisoning is characterized by early respiratory alkalosis followed by metabolic acidosis with attendant decreased bicarbonate.

Anion gap
Increased serum anion gap reflects the presence of unmeasured anions, as in uremia (phosphate, sulfate), diabetic ketoacidosis (acetoacetate, betahydroxybutyrate), shock, exercise-induced physiologic anaerobic glycolysis, fructose and

phenformin administration (lactate), and poisoning by methanol (formate), ethylene glycol (oxalate), paraldehyde, and salicylates. Therapy with diuretics, penicillin, and carbenicillin may also elevate the anion gap.

 Decreased serum anion gap is seen in dilatational states and hyperviscosity syndromes associated with paraproteinemias. Because bromide is not

distinguished from chloride in some methodologies, bromide intoxication may appear to produce a decreased anion gap.

Glucose
Hyperglycemia can be diagnosed only in

relation to time elapsed after meals and after ruling out spurious influences (especially drugs, including caffeine, corticosteroids, estrogens, indomethacin, oral contraceptives, lithium, phenytoin, thiazides, thyroxine, and many more). Previously, the diagnosis of diabetes mellitus was made by demonstrating a fasting blood glucose >140 mg/dL and or 2-hour postprandial glucose >200 mg/dL on more than one occasion.

 In adults, hypoglycemia can be observed in certain neoplasms (islet cell tumor, adrenal and gastric carcinoma, fibrosarcoma, hepatoma), severe liver disease, poisonings (arsenic, CCl4, chloroform,

phosphorous, alcohol, salicylates, and antihistamines), adrenocortical insufficiency, hypothroidism, and functional disorders (postgastrectomy, gastroenterostomy, autonomic nervous system disorders). Failure to promptly separate serum from cells in a blood collection tube causes falsely depressed glucose levels.

Urea nitrogen (BUN)

Serum urea nitrogen (BUN) is increased in acute

and chronic intrinsic renal disease, in states characterized by decreased effective circulating blood volume with decreased renal perfusion, in post renal obstruction of urine flow, and in high protein intake states Decreased serum urea nitrogen (BUN) is seen in high carbohydrate/low protein diets, states characterized by increased anabolic demand (late pregnancy, infancy, acromegaly), malabsorption states, and severe liver damage. In Europe, the test is called simply "urea."

Creatinine
Increase in serum creatinine is seen any renal functional impairment. Because of its insensitivity in detecting early renal failure, the creatinine clearance is significantly reduced before any rise in

serum creatinine occurs. The renal impairment may be due to intrinsic renal lesions, decreased perfusion of the kidney, or obstruction of the lower urinary tract. Decrease in serum creatinine is seen in pregnancy and in conditions characterized by muscle wasting.

Uric acid
Increase in serum uric acid is seen idiopathically and in renal failure, disseminated neoplasms, toxemia of

pregnancy, psoriasis, liver disease, sarcoidosis, ethanol consumption, etc. Many drugs elevate uric acid, including most diuretics, catecholamines, ethambutol, pyrazinamide, salicylates, and large doses of nicotinic acid. Decreased serum uric acid level may not be of clinical significance. It has been reported in Wilson's disease, Fanconi's syndrome, in some neoplasms, including Hodgkin's disease, myeloma, and bronchogenic carcinoma.

Inorganic phosphorus
Hyperphosphatemia may occur in myeloma, Paget's disease of bone, osseous metastases, Addison's disease, leukemia, sarcoidosis, milk-alkali syndrome, vitamin D excess, healing fractures, renal failure, hypoparathyroidism, diabetic ketoacidosis, acromegaly, and malignant hyperpyrexia. Drugs causing serum phosphorous elevation include androgens, furosemide, growth hormone, hydrochlorthiazide, oral contraceptives, parathormone, and phosphates.

 Hypophosphatemia can be seen in a variety of biochemical derangements, incl. acute alcohol intoxication, sepsis, hypokalemia, malabsorption

syndromes, hyperinsulinism, hyperparathyroidism, and as result of drugs, e.g., acetazolamide, aluminum-containing antacids, anesthetic agents, anticonvulsants, and estrogens (incl. oral contraceptives). Citrates, mannitol, oxalate, tartrate, and phenothiazines may produce spuriously low phosphorus by interference with the assay.

Calcium
Hypercalcemia is seen in malignant neoplasms , primary and tertiary hyperparathyroidism, sarcoidosis, vitamin D intoxication, milk-alkali

syndrome, Paget's disease of bone (with immobilization), thyrotoxicosis, acromegaly, and diuretic phase of renal acute tubular necrosis. Prolonged tourniquet pressure during venipuncture may spuriously increase total calcium. Drugs producing hypercalcemia include alkaline antacids, diuretics (chronic administration), estrogens (incl. oral contraceptives), and progesterone.

 Hypocalcemia must be interpreted in relation to serum albumin concentration.True decrease in the physiologically active ionized form of Ca++ occurs in

many situations, including hypoparathyroidism, vitamin D deficiency, chronic renal failure, magnesium deficiency, prolonged anticonvulsant therapy, acute pancreatitis, massive transfusion, alcoholism, etc. Drugs producing hypocalcemia include most diuretics, estrogens, fluorides, glucose, insulin, excessive laxatives, magnesium salts, and phosphates.

Iron
Serum iron may be increased in hemolytic,

megaloblastic, and aplastic anemias, and in hemochromatosis, acute leukemia, lead poisoning, pyridoxine deficiency, thalassemia, excessive iron therapy, and after repeated transfusions. Drugs causing increased serum iron include chloramphenicol, cisplatin, estrogens (including oral contraceptives), ethanol, iron dextran, and methotrexate.

 Iron can be decreased in iron-deficiency

anemia, acute and chronic infections, carcinoma, nephrotic syndrome, hypothyroidism, in protein- calorie malnutrition, and after surgery.

Alkaline phosphatase (ALP)

Increased serum alkaline phosphatase is seen

in states of increased osteoblastic activity (hyperparathyroidism, osteomalacia, primary and metastatic neoplasms), hepatobiliary diseases characterized by some degree of intra- or extrahepatic cholestasis, and in sepsis, chronic inflammatory bowel disease, and thyrotoxicosis. Isoenzyme determination may help determine the organ/tissue responsible for an alkaline phosphatase elevation.

 Decreased serum alkaline phosphatase may

not be clinically significant. However, decreased serum levels have been observed in hypothyroidism, scurvy, kwashiokor, deposition of radioactive materials in bone, and in the rare genetic condition hypophosphatasia.

Lactate dehydrogenase (LD or "LDH")

Increase of LD activity in serum may occur in

any injury that causes loss of cell cytoplasm. More specific information can be obtained by LD isoenzyme studies. Also, elevation of serum LD is observed due to in vivo effects of anesthetic agents, clofibrate, dicumarol, ethanol, fluorides, methotrexate, narcotic analgesics, quinidine, and sulfonamides. Decrease of serum LD is probably not clinically significant.

ALT (SGPT)
Increase of serum alanine aminotransferase

(ALT, formerly called "SGPT") is seen in any condition involving necrosis of hepatocytes, myocardial cells, erythrocytes, or skeletal muscle cells.

AST (SGOT)
Increase of aspartate aminotransferase (AST,

formerly called "SGOT") is seen in any condition involving necrosis of hepatocytes, myocardial cells, or skeletal muscle cells. Decreased serum AST is of no known clinical significance.

GGTP (GAMMA-GT)
Gamma-glutamyltransferase is markedly increased in lesions which cause intrahepatic or extrahepatic obstruction of bile ducts, including parenchymatous liver diseases with a major cholestatic component (e.g., cholestatic hepatitis). Lesser elevations of gamma-GT are seen in other liver diseases,

and in infectious mononucleosis, hyperthyroidism, myotonic dystrophy, Drugs causing hepatocellular damage and cholestasis may also cause gamma-GT elevation .

 Gamma-GT is a very sensitive test for liver

damage, and unexpected, unexplained mild elevations are common. Alcohol consumption is a common culprit. Decreased gamma-GT is not clinically significant.

Bilirubin
Serum total bilirubin is increased in hepatocellular damage (infectious hepatitis, alcoholic and other toxic hepatopathy,

neoplasms), intra- and extrahepatic biliary tract obstruction, intravascular and extravascular hemolysis, physiologic neonatal jaundice, Crigler-Najjar syndrome, Gilbert's disease, Dubin-Johnson syndrome, and fructose intolerance.

 Disproportionate elevation of direct

(conjugated) bilirubin is seen in cholestasis and late in the course of chronic liver disease. Indirect (unconjugated) bilirubin tends to predominate in hemolysis and Gilbert's disease. Decreased serum total bilirubin is probably not of clinical significance but has been observed in iron deficiency anemia.

Total protein
Increase in serum total protein reflects

increases in albumin, globulin, or both. Generally significantly increased total protein is seen in volume contraction, venous stasis, or in hypergammaglobulinemia. Decrease in serum total protein reflects decreases in albumin, globulin or both .

Albumin
Increased absolute serum albumin content is not seen as a natural condition. Relative increase may occur in hemoconcentration. Absolute increase may occur artificially by infusion of hyperoncotic albumin suspensions. Decreased serum albumin is seen in states of decreased synthesis (malnutrition,

malabsorption, liver disease, and other chronic diseases), increased loss (nephrotic syndrome, many GI conditions, thermal burns, etc.), and increased catabolism (thyrotoxicosis, cancer chemotherapy, Cushing's disease, familial hypoproteinemia).

 Decreased T3 uptake (increased TBG) may

occur due to the effects of exogenous estrogens (including oral contraceptives), pregnancy, acute hepatitis, and in geneticallydetermined elevations of TBG. Drugs producing increased TBG include clofibrate, lithium, methimazole, phenothiazines, and Decreased T3 uptake may occur in hypothyroidism.

Thyroxine (T4)
It is increased in hyperthyroidism and in thyroid states characterized by increased TBG. Occasionally, hyperthyroidism will not be

manifested by elevation of T4 but only by elevation of T3 . Therefore, if thyrotoxicosis is clinically suspect, and T4 and FTI are normal, the test "T3-RIA" is recommended .

T3 uptake
Increased T3 uptake (decreased TBG) in

patients is seen in chronic liver disease, protein-losing states, and with use of the following drugs: androgens, barbiturates, chlorpropamide, corticosteroids, danazol, dthyroxine, penicillin, phenylbutazone, valproic acid, and androgens. It is also seen in hyperthyroidism.

 T4 is decreased in hypothyroidism and in

thyroid states characterized by decreased TBG. A separate test for "T4" is available, but it is not usually necessary for the diagnosis of functional thyroid disorders.

FTI (T7)
Increased FTI is seen in hyperthyroidism, and

decreased FTI is seen in hypothyroidism. Early cases of hyperthyroidism may be expressed only by decreased thyroid stimulation hormone (TSH) with normal FTI. Early cases of hypothyroidism may be expressed only by increased TSH with normal FTI.

Triglycerides
Markedly increased triglycerides (>500 mg/dL) usually indicate a nonfasting patient (i.e., one

having consumed any calories within 12-14 hour period prior to specimen collection). If patient is fasting, hypertriglyceridemia is seen in hyperlipoproteinemia types I, IIb, III, IV, and V. Exact classification theoretically requires lipoprotein electrophoresis, Cholestyramine, corticosteroids, estrogens, ethanol, oral contraceptives, stress, and high carbohydrate intake are known to increase triglycerides. Decreased serum triglycerides are seen in chronic obstructive pulmonary disease, hyperthyroidism, malnutrition, and malabsorption states.

RBC (Red Blood Cell) count

The RBC count is most useful as raw data for

calculation of the erythrocyte indices MCV and MCH . Decreased RBC is usually seen in anemia of any cause with the possible exception of thalassemia minor, where a mild or borderline anemia is seen with a high or borderline-high RBC. Increased RBC is seen in erythrocytotic states, whether absolute or relative (dehydration, stress polycthemia), and in thalassemia minor .

URINE TEST AND THEIR INTERPRETATION

A urine test checks different components of

urine, a waste product made by the kidneys. A regular urine test may be done to help find the cause of symptoms. The test can give information about your health and problems you may have. The kidneys take out waste material, minerals, fluids, and other substances from the blood to be passed in the urine. Urine has hundreds of different body wastes.

Regular urinalysis
Color. Many things affect urine color, including

fluid balance, diet, medicines, and diseases. How dark or light the color is tells you how much water is in it. Vitamin B supplements can turn urine bright yellow. Some medicines, blackberries, beets, rhubarb, or blood in the urine can turn urine red-brown

 Clarity; Urine is normally clear. Bacteria,

blood, sperm, crystals, or mucus can make urine look cloudy. Odor; Urine does not smell very strong, but has a slightly "nutty" odor. Some diseases cause a change in the odor of urine. For example, an infection with E. coli bacteria can cause a bad odor, while diabetes or starvation can cause a sweet, fruity odour

 Specific gravity; This checks the amount of

substances in the urine. It also shows how well the kidneys balance the amount of water in urine. The higher the specific gravity, the more solid material is in the urine. When you drink a lot of fluid, your kidneys make urine with a high amount of water in it which has a low specific gravity. When you do not drink fluids, your kidneys make urine with a small amount of water in it which has a high specific gravity.

 PH; The pH is a measure of how acidic or

alkaline (basic) the urine is.A urine pH of 4 is strongly acidic, 7 is neutral (neither acidic nor alkaline), and 9 is strongly alkaline. Sometimes the pH of urine is affected by certain treatments. For example, your doctor may instruct you how to keep your urine either acidic or alkaline to prevent some types of kidney stones from forming.

 Protein; Protein is normally not found in the

urine. Fever, hard exercise, pregnancy, and some diseases, especially kidney disease, may cause protein to be in the urine. Glucose; Glucose is the type of sugar found in blood. Normally there is very little or no glucose in urine. When the blood sugar level is very high, as in uncontrolled diabetes, the sugar spills over into the urine. Glucose can also be found in urine when the kidneys are damaged or diseased.

 Nitrites; Bacteria that cause a urinary tract

infection (UTI) make an enzyme that changes urinary nitrates to nitrites. Nitrites in urine show a UTI is present. Leukocyte esterase (WBC esterase). Leukocyte esterase shows leukocytes (white blood cells in the urine. WBCs in the urine may mean a UTI is present

 Ketones; When fat is broken down for energy,

the body makes substances called ketones (or ketone bodies). These are passed in the urine. Large amounts of ketones in the urine may mean a very serious condition, diabetic ketoacidosis, is present. A diet low in sugars and starches (carbohydrates), starvation, or severe vomiting may also cause ketones to be in the urine.

 Microscopic analysis; In this test, urine is spun

in a special machine (centrifuge) so the solid materials (sediment) settle at the bottom. The sediment is spread on a slide and looked at under a microscope. Red or white blood cells; Blood cells are not found in urine normally. Inflammation, disease, or injury to the kidneys, ureters, bladder, or urethra can cause blood in urine. Strenuous exercise, such as running a marathon, can also cause blood in the urine. White blood cells may be a sign of infection or kidney disease.

 Casts; Some types of kidney disease can cause

plugs of material (called casts) to form in tiny tubes in the kidneys. The casts then get flushed out in the urine. Casts can be made of red or white blood cells, waxy or fatty substances, or protein. The type of cast in the urine can help show what type of kidney disease may be present. Crystals; Healthy people often have only a few crystals in their urine. A large number of crystals, or certain types of crystals, may mean kidney stones are present or there is a problem with how the body is using food (metabolism).

 Bacteria, yeast cells, or parasites. There are no

bacteria, yeast cells, or parasites in urine normally. If these are present, it can mean you have an infection. Squamous cells. The presence of squamous cells may mean that the sample is not as pure as it needs to be. These cells do not mean there is a medical problem, but your doctor may ask that you give another urine sample.

CSF AND THEIR INTERPRETATION

Purpose of CSF
The purpose of a CSF analysis is to diagnose medical disorders that affect the central nervous system, Some of these conditions are: meningitis and encephalitis, which may be viral, bacterial, fungal, or parasitic infections
metastatic tumors (e.g., leukemia) and central

nervous system tumors that shed cells into the CSF

 syphilis, a sexually transmitted bacterial disease bleeding (hemorrhaging) in the brain and spinal

cord multiple sclerosis, a degenerative nerve disease that results in the loss of the myelin coating of the nerve fibers of the brain and spinal cord Guillain-Barr syndrome, a demyelinating disease involving peripheral sensory and motor nerves

Routine examination of CSF

GROSS EXAMINATION. Color and clarity are

important diagnostic characteristics of CSF. Straw, pink, yellow, or amber pigments are abnormal and indicate the presence of bilirubin, hemoglobin, red blood cells, or increased protein. Turbidity (suspended particles) indicates an increased number of cells.

 GLUCOSE. CSF glucose is normally

approximately two-thirds of the fasting plasma glucose. A glucose level below 40 mg/dL is significant and occurs in bacterial and fungal meningitis and in malignancy. PROTEIN. Total protein levels in CSF are normally very low, and albumin makes up approximately twothirds of the total. High levels are seen in many conditions including bacterial and fungal meningitis, multiple sclerosis, tumors, subarachnoid hemorrhage, and traumatic tap.

 LACTATE. The CSF lactate is used mainly to help

differentiate bacterial and fungal meningitis, which cause increased lactate, from viral meningitis, which does not. LACTATE DEHYDROGENASE. This enzyme is elevated in bacterial and fungal meningitis, malignancy, and subarachnoid hemorrhage.

 WHITE BLOOD CELL (WBC) COUNT. The number of white blood cells in CSF is very low, usually necessitating a manual WBC count. An increase in WBCs may occur in many conditions including

infection (viral, bacterial, fungal, and parasitic), allergy, leukemia, multiple sclerosis, hemorrhage, traumatic tap, encephalitis, and Guillain-Barr syndrome. The WBC differential helps to distinguish many of these causes. For example, viral infection is usually associated with an increase in lymphocytes, while bacterial and fungal infections are associated with an increase in polymorphonuclear leukocytes (neutrophils).

 RED BLOOD CELL (RBC) COUNT. While not

normally found in CSF, RBCs will appear whenever bleeding has occurred. Red cells in CSF signal subarachnoid hemorrhage, stroke, or traumatic tap. Since white cells may enter the CSF in response to local infection, inflammation, or bleeding, GRAM STAIN. The Gram stain is performed on a sediment of the CSF and is positive in at least 60% of cases of bacterial meningitis. Culture is performed for both aerobic and anaerobic bacteria.

 SYPHILIS SEROLOGY. This involves testing for

antibodies that indicate neurosyphilis. The fluorescent treponemal antibody-absorption test is often used and is positive in persons with active and treated syphilis. The test is used in conjunction with the VDRL test for nontreponemal antibodies, which is positive in most persons with active syphilis, but negative in treated cases.

SEMEN TEST AND THEIR INTERPRETATION

Macroscopic evaluation OF SEMEN

Appearance; The semen sample is first

evaluated by simple inspection. A normal sample has a grey-opalescent appearance, is homogenous and liquefies within 60min at room temperature under the influence of enzymes of prostatic origin. In some cases, liquefaction does not occur within the normal time period and this fact should be recorded, as it may suggest functional disturbance of the prostate. Normal semen samples may contain jelly-like grains which do not liquefy.

 The sample may appear clear if the sperm

concentration is too low. It may also appear brown when red blood cells are present in the ejaculate (haematospermia). The presence of mucous streaks may interfere with the counting procedure and suggests inflammation or abnormal liquefaction.

 Consistency; The consistency, also called

viscosity, of the liquefied sample can be estimated by gentle aspiration into a 5-ml pipette and then allowing the semen to drop by gravity and observing the length of the thread formed. A normal sample leaves the needle as small discrete drops, while in cases of abnormal consistency the drop will form a thread of >2 cm .

 Volume; A low ejaculate volume can reflect

abnormalities in accessory sex gland fluid synthesis or secretion . It can also be indicative of a physical obstruction somewhere in the reproductive tract or may occur in cases of incomplete or retrograde ejaculation . Large volumes are sometimes found in association with varicocele or after relatively long periods of sexual abstinence .

PH; The pH is determined by acidic secretions of the prostate and alkaline secretions of the seminal vesicles. It should normally be in the range of 7.2-8.0 .

Initial microscopic investigation

Motility; The microscopic field is scanned systematically

and the motility of each spermatozoon encountered is graded a, b ,c or d ,according to whether it shows: (a) rapid progressive motility. (b) slow or sluggish progressive motility (c) non-progressive motility. (d) immotility.

Agglutination
Agglutination of spermatozoa means that motile spermatozoa stick to each other, head to head, midpiece to midpiece, tail to tail, or

mixed, e.g. midpiece to tail. The presence of agglutination is suggestive of, but not sufficient evidence to prove the existence of an immunological factor of fertility.

Analysis of the morphological characteristics of spermatozoa The following categories of defects should be scored. Head shape/size defects, including large, small, tapering, pyriform, amorphous, vacuolated (>20% of the head area occupied by unstained vacuolar areas), or double heads, or any combination of these. Neck and midpiece defects, including absent tail, non inserted or bent tail (the tail forms an angle of about 90 to the long axis of the head),distended/irregular/bent midpiece, abnormally thin midpiece or any combination of these. Tail defects, including short, multiple, hairpin, broken, irregular width, or coiled tails, tails with terminal droplets, or any combination of these. Cytoplasmic droplets greater than one-third of the area of a normal sperm head.

CONCLUSION
It is important to note that values listed for

various lab test should be viewed as reference values rather than absolute normal values. Values may vary due to age, gender, body build, diet and environment of the subject or the equipment, methods and standards of the lab performing the measurement.