1

Body Fluid Analysis

Marian J . Cavagnaro, MS, MT(ASCP)DLM Marian J . Cavagnaro, MS, MT(ASCP)DLM
Director, Laboratory Services Director, Laboratory Services
Memorial Hospital West Memorial Hospital West
Pembroke Pines, Florida Pembroke Pines, Florida
PARTICIPANTS (LEARNERS)
OBJ ECTIVES
The participant will learn about methods and techniques The participant will learn about methods and techniques
for preparing body fluid cytospin smears. for preparing body fluid cytospin smears.
The participant will recognize normal and abnormal cells The participant will recognize normal and abnormal cells
in CSF, synovial, and serous fluids on cytospin prepared in CSF, synovial, and serous fluids on cytospin prepared
Wright Wright- -Giemsa and Wright Giemsa and Wright s stained smears. s stained smears.
The participant will be able to recognize differentials that The participant will be able to recognize differentials that
are abnormal in CSF, synovial, and serous fluids and that are abnormal in CSF, synovial, and serous fluids and that
correlate to different clinical conditions correlate to different clinical conditions
BODY FLUID ANALYSIS
Physical (volume, color, clarity, viscosity Physical (volume, color, clarity, viscosity) )
Microscopic (total cell count and differential) Microscopic (total cell count and differential)
Chemical (protein, glucose, enzymes, etc.) Chemical (protein, glucose, enzymes, etc.)
Microbiologic (bacteria, parasites, yeast/fungi) Microbiologic (bacteria, parasites, yeast/fungi)
Immunologic examination (not routine) Immunologic examination (not routine)
Cytologic examination (not routine) Cytologic examination (not routine)
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BODY FLUID DIFFERENTIALS
(CYTOSPIN)
Ratio of cells counted on the hemacytometer Ratio of cells counted on the hemacytometer
chamber to cells seen on cytospin preparation is chamber to cells seen on cytospin preparation is
approximately 1:5 to 1:10 approximately 1:5 to 1:10
For any differential that does not reach 100 cells, For any differential that does not reach 100 cells,
indicate number of WBC indicate number of WBC s counted s counted
Differentials should still be reported on fluids that Differentials should still be reported on fluids that
present with clots present with clots
Cytocentrifuge artifacts (nucleus & cytoplasm) Cytocentrifuge artifacts (nucleus & cytoplasm)
Albumin enhances morphology Albumin enhances morphology
Cytocentrifuge
Manufacturers Manufacturers- -(examples) (examples)- - Wescor, Shandon Wescor, Shandon
Lipshaw Lipshaw
Fluid vs. Drops/Slide Fluid vs. Drops/Slide- - (saline diluent) (saline diluent)
Clear and colorless Clear and colorless- - 10 drops 10 drops
Slt. Cloudy Slt. Cloudy- - 6 6- -9 drops 9 drops
Cloudy Cloudy- -4 4- -5 drops 5 drops
Grossly Bloody/Cloudy Grossly Bloody/Cloudy- - 1 1- -2 drops 2 drops
Synovial fluid Synovial fluid- -push smears push smears
Cytocentrifuge
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Cytocentrifuge
Speed/Time Speed/Time- -
(examples) (examples)- - 600 RPM 600 RPM
for 10 minutes; 800 for 10 minutes; 800
RPM for 10 minutes; RPM for 10 minutes;
1200 RPM for 5 1200 RPM for 5
minutes minutes
CYTOCENTRIFUGE ARTIFACTS
NUCLEUS NUCLEUS
Accentuation of nucleoli Accentuation of nucleoli
Blebs and accentuation of lobulation Blebs and accentuation of lobulation
Denser chromatin in cells in center of slide Denser chromatin in cells in center of slide
Peripheral localization of nuclear lobes Peripheral localization of nuclear lobes
Vacuolization Vacuolization
CYTOPLASM CYTOPLASM
Clear or granular paranuclear area in mononuclear Clear or granular paranuclear area in mononuclear
cells cells
Localization of cytoplasmic granules Localization of cytoplasmic granules
Irregular blebs and processes Irregular blebs and processes
Peripheral vacuolization Peripheral vacuolization
Cells in Body Fluids
Red Cells Red Cells
Granulocytes Granulocytes
Lymohocytes Lymohocytes
Monocytes Monocytes
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CSF-Anatomy &Physiology
The cerebrospinal The cerebrospinal
fluid (CSF) bathes fluid (CSF) bathes
the brain and spinal the brain and spinal
cord. Most of the cord. Most of the
CSF is in the CSF is in the
ventricles of the ventricles of the
brain, which are brain, which are
large cavities within large cavities within
the brain which the brain which
produce and produce and
reabsorb the CSF. reabsorb the CSF.
CSF- Anatomy and Physiology
CSF- Specimen Collection
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CSF-Specimen Collection
Collection Collection- - lumbar puncture between 3 lumbar puncture between 3
rd rd
and 4 and 4
th th
lumbar lumbar
vertebrae vertebrae
Specimen Specimen - -divided into 3(or sometimes 4) samples and divided into 3(or sometimes 4) samples and
placed into 3 sterile sequentially labeled tubes (1 placed into 3 sterile sequentially labeled tubes (1- -4 mL 4 mL
in each) in each)
Tube #1 Tube #1- - chemical and immunologic tests chemical and immunologic tests
Tube #2 Tube #2- - microbiologic examination microbiologic examination
Tube#3 Tube#3- - hematologic/cytologic hematologic/cytologic
examination examination
cells counts and differential cells counts and differential
ABNORMAL FINDINGS IN CSF
XANTHOCHROMIA (see notes **) XANTHOCHROMIA (see notes **)
Hemorrhage Hemorrhage
Severe and chronic jaundice Severe and chronic jaundice
CLOTS CLOTS
Paresis Paresis many small clots many small clots
Tuberculosis meningitis Tuberculosis meningitis weblike clot weblike clot
Blockage of spinal fluid circulation Blockage of spinal fluid circulation large clot large clot
**NOTES: **NOTES:
1. 1. Fluid froma subarachnoid hemorrhage has a pale Fluid froma subarachnoid hemorrhage has a pale
orange color supernatant orange color supernatant if RBC if RBC s present within 2 s present within 2- -
4 hours; within 24 hours, hemoglobin is converted to 4 hours; within 24 hours, hemoglobin is converted to
bilirubin and supernatant is yellowish color bilirubin and supernatant is yellowish color
2. 2. In a bloody tap, lysis of RBC In a bloody tap, lysis of RBC s occurs within 4 hrs s occurs within 4 hrs
- - process quickly to prevent a false +. xanthochromia process quickly to prevent a false +. xanthochromia
CSF TRAUMATIC TAP VS. SUBARACHNOID
HEMORRHAGE
Presence of blood in the tubes (varied vs. Presence of blood in the tubes (varied vs.
no variation no variation) )
Supernatant (clear vs. Supernatant (clear vs. xanthochromic xanthochromic) )
Siderophage/erythrophages (absent vs. Siderophage/erythrophages (absent vs.
present present) )
Clot Formation (clot vs. Clot Formation (clot vs. no clot no clot) )
Repeat puncture (clear vs. Repeat puncture (clear vs. not clear not clear) )
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CSF
Gross Appearance Gross Appearance
Color of Supernatant Color of Supernatant
APPROACH TO CEREBROSPINAL FLUID
LABORATORY STUDIES
ROUTINE INITIAL STUDIES ROUTINE INITIAL STUDIES
Cell count/differential Cell count/differential, Glucose, Total , Glucose, Total
Protein, Gramstain, Aerobic culture) Protein, Gramstain, Aerobic culture)
INITIAL SUTDIES (When indicated) INITIAL SUTDIES (When indicated)
Cytology, Fungal culture, India ink Cytology, Fungal culture, India ink
preparation, Cryptococcal Ag. (Latex preparation, Cryptococcal Ag. (Latex
agglut.), AFB Culture, AFB Smear, Bacterial agglut.), AFB Culture, AFB Smear, Bacterial
Ag. (Latex agglut.), Viral cultures Ag. (Latex agglut.), Viral cultures
RETROSPECTIVE STUDIES RETROSPECTIVE STUDIES
VDRL, Oligoclonal band analysis, VDRL, Oligoclonal band analysis,
Immunoglobulin studies, Viral antibody Immunoglobulin studies, Viral antibody
titers, Tumor markers titers, Tumor markers
CELL TYPES IN CSFS
NORMAL AND ABNORMAL
Ventricular LiningCells(ependymal Ventricular LiningCells(ependymal
or choroidplexus) or choroidplexus)
Chondrocyte(cartillagecell) Chondrocyte(cartillagecell)
Bacteria Bacteria- -cocci or rods cocci or rods
Yeast/fungi Yeast/fungi
Macrophage Macrophage
Neutrophil macrophagewith Neutrophil macrophagewith
phagocytizedfungi/bacteria phagocytizedfungi/bacteria
Erythrophage(containingRBC Erythrophage(containingRBC s) s)
Siderophage(containinghemosiderin) Siderophage(containinghemosiderin)
HematinCrystals HematinCrystals
Signet ringmacrophage Signet ringmacrophage
Lipophage(containinglipid) Lipophage(containinglipid)
Multinucleatedhistiocytic giant cell Multinucleatedhistiocytic giant cell
Lymphocyte Lymphocyte
Monocyte Monocyte
SegmentedNeutrophil SegmentedNeutrophil
Band/Metamyelocyte Band/Metamyelocyte
Eosinophil Eosinophil
Basophil Basophil
Promyelocyte Promyelocyte
Blast Blast
NRBC NRBC
Lymphocyte(reactive/atypical) Lymphocyte(reactive/atypical)
TransformedLymph(immunoblast) TransformedLymph(immunoblast)
Plasmacell Plasmacell
Lymphomacell Lymphomacell
Malignant Cell Malignant Cell
Bonemarrow cells Bonemarrow cells
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CSF- Bone marrow
contamination
Occurs becauseneedlewas inadvertently pushed to far anteriorly Occurs becauseneedlewas inadvertently pushed to far anteriorly, into , into
themarrow cavity of avertebral body forcing bone themarrow cavity of avertebral body forcing bone- -marrow cells into marrow cells into
theneedle. After needlewas pulled out and repositioned in the theneedle. After needlewas pulled out and repositioned in the
subarachnoid space, adherent marrow cells wereflushed out by th subarachnoid space, adherent marrow cells wereflushed out by the e
flow of CSF into thespecimen flow of CSF into thespecimen
WBC may befalsely increased and differential may beuninterpret WBC may befalsely increased and differential may beuninterpretable able
becausesomeor all of thecells (including maturecells) areof becausesomeor all of thecells (including maturecells) areof marrow marrow
origin, making recognition of endogenous fluid cells difficult. origin, making recognition of endogenous fluid cells difficult.
Finding of CSF pleocytosis in an infant ; or in an elderly woman Finding of CSF pleocytosis in an infant ; or in an elderly womanwho who
has vertebral has vertebral- - boneabnormalities including osteoporosis, and boneabnormalities including osteoporosis, and
metastatic involvement by cancer should warn the physician to metastatic involvement by cancer should warn the physician to
consider bonemarrow contamination. consider bonemarrow contamination.
A new specimen of CSF may benecessary A new specimen of CSF may benecessary
Blood Cell Maturation
Predominant Cells in CSF
Lymphocyte Lymphocyte
Adult Normal Adult Normal- - 40 40- -80% 80%
Children and Infants Children and Infants- - 5 5- -35% 35%
Monocyte Monocyte
Adult Normal Adult Normal- - 15% 15%- -45% 45%
Children and Infants Children and Infants - -50% 50%- -90% 90%
Neutrophil Neutrophil
Adult Normal less than 6% Adult Normal less than 6%
Children and Infants less than 8% Children and Infants less than 8%
Terry, 2004 Terry, 2004
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CSF- ventricular lining cells
Low ratio of nuclear to cytoplasmic cell Low ratio of nuclear to cytoplasmic cell
material material
Round to oval nuclei with smooth nuclear Round to oval nuclei with smooth nuclear
contours, evenly distributed nuclear contours, evenly distributed nuclear
chromatin and inconspicuous nuclei chromatin and inconspicuous nuclei
Sheets or clusters with minimal nuclear Sheets or clusters with minimal nuclear
molding molding
MONONUCLEAR PHAGOCYTIC SERIES
Monocyte/Macrophage Monocyte/Macrophage
Erythrophage (macrophage containing Erythrophage (macrophage containing
erythrocyte(s) erythrocyte(s)
Lipophage (macrophage containing abundant Lipophage (macrophage containing abundant
small lipid vacuoles) small lipid vacuoles)
Neutrophage (macrophage containing Neutrophage (macrophage containing
neutrophil(s) neutrophil(s)
Siderophage (macrophage containing Siderophage (macrophage containing
hemosiderin) hemosiderin)
With or without hematin (enzymatic With or without hematin (enzymatic
degredation of hemoglobin) degredation of hemoglobin)
Monocyte/Macrophage
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DIFFERENTIALS IN ABNORMAL CSF
Inc. PMN Inc. PMN S S Bacterial meningitis, early viral tuberculosis and Bacterial meningitis, early viral tuberculosis and
mycotic meningitis, cerebral abscess, CNS hemorrhage, mycotic meningitis, cerebral abscess, CNS hemorrhage,
cerebral infarct, malignancies, CML in CNS cerebral infarct, malignancies, CML in CNS
Inc. LYMPHS Viral meningitis, tuberculous meningitis, multiple Inc. LYMPHS Viral meningitis, tuberculous meningitis, multiple
sclerosis, Guillain sclerosis, Guillain- -BarreSyndrome, lymphomaand BarreSyndrome, lymphomaand
leukemia leukemia
Inc. MONOS Chronic bacterial meningitis, partially treated bact Inc. MONOS Chronic bacterial meningitis, partially treated bacterial erial
meningitis, syphilitic meningitis, CNS malignancies meningitis, syphilitic meningitis, CNS malignancies
Inc. EOS Inc. EOS Parasitic infections, fungal infections, reaction to foreign Parasitic infections, fungal infections, reaction to foreign
material material CNS (shunts, dyes), drug reactions CNS (shunts, dyes), drug reactions
Neutrophils- PMN & Band
Lymphocytes

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Monocytes
Neutrophil, Eosinophil,Basophil
Cell Types seen in Meningitis
Bacterial Bacterial
Neutrophilic pleocytosis Neutrophilic pleocytosis - -Increased Increased
neutrophils(acute) neutrophils(acute)
Viral Viral
Lymphocytic pleocytosis Lymphocytic pleocytosis- -Predominance of Predominance of
reactive lymphocytes reactive lymphocytes
Small to mediumto large lymphs with Small to mediumto large lymphs with
plasmacytoid appearance plasmacytoid appearance
Neutrophilic pleocytosis (early) Neutrophilic pleocytosis (early)
Fungal Fungal
Neutrophilic pleocytosis Neutrophilic pleocytosis
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Causes of Neutrophilic Pleocytosis
Bacterial Meningitis Bacterial Meningitis
Early Viral Meningitis (first 6 Early Viral Meningitis (first 6- -8 hrs) 8 hrs)
Cerebral abscess Cerebral abscess
CNS Hemorrhage CNS Hemorrhage
Trauma Trauma
Post Post- -myelogram myelogram
Primary brain tumor or Metastatic tumor Primary brain tumor or Metastatic tumor
Intrathecal injection of drugs Intrathecal injection of drugs
Previous lumbar puncture (8 Previous lumbar puncture (8- -12 hrs before) 12 hrs before)
CSF- Bacterial Infection
Gram stain of Gram stain of
cerebrospinal cerebrospinal
fluid showing fluid showing
B. anthracis B. anthracis
CSF- Bacterial Meningitis
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Causes of Lymphocytic Pleocytosis
Viral Meningitis Viral Meningitis
TB Meningitis TB Meningitis
Resolving Bacterial Meningitis (mature plasma Resolving Bacterial Meningitis (mature plasma
cells frequent) cells frequent)
CNS Syphilis CNS Syphilis
Multiple Sclerosis (plasmacytoid reactive forms) Multiple Sclerosis (plasmacytoid reactive forms)
CLL, Lymphoma CLL, Lymphoma
Disseminated Carcinoma Disseminated Carcinoma
CSF-Viral Meningitis
CSF- Fungal Meningitis
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Cell types - in subarachnoid
hemorrhage
2 2- - 24 hours: 24 hours:
Erythrocytes; Neutrophilic granulocytes Erythrocytes; Neutrophilic granulocytes
(30% (30%- -60%); Lymphocytes; 60%); Lymphocytes;
Monocytes/Macrophages Monocytes/Macrophages
12 12- -48 hours: 48 hours:
Monocytes/Macrophages; Monocytes/Macrophages;
Lymphocytes;Erythrophagocytosis Lymphocytes;Erythrophagocytosis
48 hours: 48 hours:
Monocytes/Macrophages; Monocytes/Macrophages;
Erythrophagocytosis; Siderophages and or Erythrophagocytosis; Siderophages and or
Hematin crystals Hematin crystals
Kjeldsburg and Knight, 1993 Kjeldsburg and Knight, 1993
CSF lymphoid cells,leukemic
lymphoblasts, lymphoma cells
Lymphoid cells Lymphoid cells
Mixture of small, large and transformed Mixture of small, large and transformed
lymphocytes lymphocytes
Leukemic lymphoblasts Leukemic lymphoblasts
Delicate dispersed chromatin nucleus; Delicate dispersed chromatin nucleus;
nucleoli present nucleoli present
Lymphoma cells Lymphoma cells
Distinct nuclear clefts or irregularities Distinct nuclear clefts or irregularities
CSF- Leukemic Cells
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CSF- Leukemia/Lymphoma
CSF-Malignant Lymphoma
CSF- carcinoma (malignant) cells
High ratio of nuclear to cytoplasmic cell High ratio of nuclear to cytoplasmic cell
material material
Pleomorphic nuclei with irregularly Pleomorphic nuclei with irregularly
distributed chromatin and prominent distributed chromatin and prominent
nucleoli nucleoli
Clusters of cell with nuclear molding Clusters of cell with nuclear molding
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CSF- Malignant Cells

CSF- Malignant Cells
Pleural Effusion
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Paracentesis
INDICATIONS: INDICATIONS:
Differential diagnosis of Differential diagnosis of ascites ascites
Intraabdominal pressure causing Intraabdominal pressure causing
respiratory distress respiratory distress
Differential diagnosis of Differential diagnosis of acute peritonitis acute peritonitis
Paracentesis
The procedure to The procedure to
remove abnormal remove abnormal
collection of fluid collection of fluid
from the from the
peritoneal cavity. peritoneal cavity.
Peritoneal Dialysis
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Pericardial Fluid
APPROACH TO SEROUS FLUID
LABORATORY STUDIES
ROUTINE INITIAL STUDIES ROUTINE INITIAL STUDIES
Cell count/differential Cell count/differential, Aerobic culture, Gramstain, , Aerobic culture, Gramstain,
Albumin & Serumalbumin (Ascites only), Protein & Albumin & Serumalbumin (Ascites only), Protein &
Serumprotein (Pleural effusion only), LDH & Serum Serumprotein (Pleural effusion only), LDH & Serum
LDH LDH
INITIAL STUDIES (When indicated) INITIAL STUDIES (When indicated)
Cytology Cytology, Anaerobic cultures, Fungal cultures, India , Anaerobic cultures, Fungal cultures, India
ink smear, AFB culture, AFB smear, pH ink smear, AFB culture, AFB smear, pH
RETROSPECTIVE STUDIES RETROSPECTIVE STUDIES
Glucose, Total protein (Ascites only), Amylase, Glucose, Total protein (Ascites only), Amylase,
Lipid studies, Tumor markers, Immunologic stains Lipid studies, Tumor markers, Immunologic stains
Pleural Fluids: Color/Turbidity
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CELL TYPES IN SEROUS FLUIDS
NORMAL AND ABNORMAL
Malignant cell Malignant cell
Mesothelial cell Mesothelial cell
Reactivemesothelial cell Reactivemesothelial cell
Macrophage Macrophage
Lipidladenmacrophage(Lipophage) Lipidladenmacrophage(Lipophage)
Neutrophil ladenmacrophage Neutrophil ladenmacrophage
(Neutrophage) (Neutrophage)
Erythrocyteladenmacrophage Erythrocyteladenmacrophage
(Erythrophage) (Erythrophage)
Hemosideringranules Hemosideringranules
Bacteriaor Fungi Bacteriaor Fungi
Cholesterol crystals Cholesterol crystals
Uric acidcrystals Uric acidcrystals
Lymphocyte Lymphocyte
Monocyte Monocyte
Segmentedneutrophil Segmentedneutrophil
Band/Metamyelocyte Band/Metamyelocyte
Eosinophil Eosinophil
Basophil & Mast cells Basophil & Mast cells
Myelocyte/Promyelocyte Myelocyte/Promyelocyte
Blast Blast
Lymphocyte(reactive/atypical) Lymphocyte(reactive/atypical)
Transformedlymph(immunoblast) Transformedlymph(immunoblast)
Plasmacell Plasmacell
LE Cell LE Cell
Degeneratingcell, NOS Degeneratingcell, NOS
Parasites Parasites
DIFFERENTIALS IN ABNORMAL
PLEURAL FLUID
Inc. Inc. PMNS PMNS - - Pneumonia, pancreatitis, Pneumonia, pancreatitis,
pulmonary infarction, pulmonary infarction,
malignancy,CML malignancy,CML
Inc. LYMPHS Inc. LYMPHS - - Viral pneumonia, tuberculosis, Viral pneumonia, tuberculosis,
lymphoproliferative disorders lymphoproliferative disorders
Inc. EOS Inc. EOS - - Pneumothorax, parasites, pulmonary Pneumothorax, parasites, pulmonary
infarction, Hodgkin infarction, Hodgkin s disease, s disease,
eosinohilic leukemia, dermatologic eosinohilic leukemia, dermatologic
conditions. conditions.
Peritoneal Fluid-Transudate
Cytocentrifuged Cytocentrifuged
smear contains 54% smear contains 54%
macrophages, 43% macrophages, 43%
neutrophils, 3% neutrophils, 3%
l ymphocytes, l ymphocytes,
occasional reacti ve occasional reacti ve
mesothelial cells, and mesothelial cells, and
moderate numbers of moderate numbers of
red blood cells. red blood cells.
Infectious agents and Infectious agents and
atypical cells are not atypical cells are not
detected. detected.
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Pleural Fluid- Pleomorphic
Lymphocytes

Pleural Fluid-Mesothelial Cell
( Multi-Nucleated)
Pleural Fluid-Mesothelial Cells
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Pleomorphic Mesothelial Cells
Mesothelial cell hyperplasia
Plasma Cells

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Macrophage
Pleural Fluid- Macrophage
Macrophages engulf Macrophages engulf
invaders and destroy invaders and destroy
themwith powerful themwith powerful
enzymes enzymes
Macrophage attacking Macrophage attacking
streptococcus bacteria streptococcus bacteria
that cause pneumonia that cause pneumonia
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Pleural effusion- Adult T-cell
Leukemia/Lymphoma
MORPHOLOGIC CHARACTERISTICS
BENIGN MESOTHELIAL VS. MALIGNANT CELLS
MALIGNANT MALIGNANT
Large, pleomorphic Large, pleomorphic
Irregular Irregular
Uneven Uneven
Yes, dissimilar size Yes, dissimilar size
Large Large
High High
Insomecarcinomas Insomecarcinomas
Non Non- -uniform uniform
Singleor multiple Singleor multiple
Cohesiveclusters Cohesiveclusters
BENIGN BENIGN
MESOTHELIAL MESOTHELIAL
Round, oval, uniform Round, oval, uniform
Even Even
Even Even
Yes, uniformsize Yes, uniformsize
Small Small
Low Low
Absent Absent
Uniform Uniform
Large, multiple Large, multiple
Singleor mixedclusters Singleor mixedclusters
MORPHOLOGIC MORPHOLOGIC
CHARACTERISTICS CHARACTERISTICS
NUCLEUS NUCLEUS
Shape Shape
Nuclear membrane Nuclear membrane
Chromatin Chromatin
Multinucleated Multinucleated
Nucleoli Nucleoli
N N- -C ratio C ratio
Nuclear molding Nuclear molding
CYTOPLASM CYTOPLASM
Staining Staining
Vacuoles Vacuoles
Signet ring cells Signet ring cells
Pleural Fluid
Malignant cells Malignant cells
Reactive Mesothelial Reactive Mesothelial
cells cells
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Pleural Fluid- Malignant Cells
Pleural Fluid- Adenocarcinoma
Metastatic Pleural Effusion
(Primary in Breast)
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Synovial Fluid

Synovial Fluid-Rheumatoid Arthritis
APPROACH TO SYNOVIAL FLUID -
LABORATORY STUDIES
ROUTINE INITIAL STUDIES ROUTINE INITIAL STUDIES
Cell count/differential Cell count/differential, Glucose, Enzymes, Total protein, Gram , Glucose, Enzymes, Total protein, Gram
stain, Aerobic culture stain, Aerobic culture
INITIAL STUDIES (When indicated) INITIAL STUDIES (When indicated)
Mucin clot*, Cytology, Fungal culture, AFB culture, AFB Mucin clot*, Cytology, Fungal culture, AFB culture, AFB
smear, Viral culture, smear, Viral culture, Crystal identification Crystal identification
RETROSPECTIVE STUDIES RETROSPECTIVE STUDIES
Countercurrent immunoelectrophoresis for microbial antigens, Countercurrent immunoelectrophoresis for microbial antigens,
Hemolytic complement titration, complement components Hemolytic complement titration, complement components
* measures hyaluronic acid * measures hyaluronic acid- - poor clot that fragments results poor clot that fragments results
frominflammatory effusions frominflammatory effusions
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CELL TYPES IN SYNOVIAL FLUIDS
NORMAL AND ABNORMAL
Synovial liningcell Synovial liningcell
Mutinucleatedsynovial cell Mutinucleatedsynovial cell
Bacteria Bacteria- - cocci or rods cocci or rods
Acidfast bacilli Acidfast bacilli
Yeast/fungi Yeast/fungi
Macrophage Macrophage
Neutrophil macrophagewith or Neutrophil macrophagewith or
without crystals without crystals
Lipophage Lipophage
Cholesterol crystals Cholesterol crystals
Monosodiumuratecrystals Monosodiumuratecrystals
CalciumPurophosphatecrystals CalciumPurophosphatecrystals
Lymphocyte Lymphocyte
Monocyte Monocyte
SegmentedNeutrophil SegmentedNeutrophil
Band/Metamayelocyte Band/Metamayelocyte
Eosinophil Eosinophil
Basophil Basophil
Myelocyte/Promyelocyte Myelocyte/Promyelocyte
Lymphocyte(reactive/atypical) Lymphocyte(reactive/atypical)
TransformedLumph(immunoblast) TransformedLumph(immunoblast)
Plasmacell Plasmacell
Malignant cell Malignant cell
Degeneratingneutrophils Degeneratingneutrophils
Reiter cell Reiter cell
DIFFERENTIALS IN ABNORMAL PERITONEAL
AND PERICARDIAL FLUIDS
Inc. PMN Inc. PMN S S - - Peritonitis, malignancy Peritonitis, malignancy
Inc. LYMPHS Inc. LYMPHS - - Tuberculosis, chylous ascitis, Tuberculosis, chylous ascitis,
lymphoproliferative disorders lymphoproliferative disorders
Inc. EOS Inc. EOS S S - - Eosinophilic gastroenteritis, chronic Eosinophilic gastroenteritis, chronic
peritoneal dialysis, abdominal peritoneal dialysis, abdominal
lymphoma lymphoma
***************** *****************
Inc. PMN Inc. PMN S S - - Bacterial pericarditis Bacterial pericarditis
Inc. LYMPHS Inc. LYMPHS - - Viral pericarditis, tuberculosis, Viral pericarditis, tuberculosis,
lymphoproliferative disorders lymphoproliferative disorders
CLINICAL CORRELATIONS
IN ABNORMAL SYNOVIAL FLUIDS
(CASE STUDIES)
GROUP I (NON GROUP I (NON- -INFLAMMATORY) INFLAMMATORY)
Degenerativejoint disease, Traumatic arthritis, Osteochondritis Degenerativejoint disease, Traumatic arthritis, Osteochondritis
dissecans dissecans
GROUP II (INFLAMMATORY) GROUP II (INFLAMMATORY)
Rheumatoid arthritis, Reiter Rheumatoid arthritis, Reiter s syndrome, Ankylosing spondylitis s syndrome, Ankylosing spondylitis
GROUP III (INFECTIONS) GROUP III (INFECTIONS)
Rheumatoid arthritis, Reiter Rheumatoid arthritis, Reiter s syndrome, Ankylosing spondylitis s syndrome, Ankylosing spondylitis
GROUP IV (CRYSTAL GROUP IV (CRYSTAL- -INDUCED) INDUCED)
Gout, Pseudogout Gout, Pseudogout
GROUP V (HEMORRHAGIC) GROUP V (HEMORRHAGIC)
Hemorrhagic, Traumatic arthritis, Synoviomas Hemorrhagic, Traumatic arthritis, Synoviomas
Classificationof Arthritide Classificationof Arthritide
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DIFFERENTIALS IN ABNORMAL
SYNOVIAL FLUID
GROUP I GROUP I - - Non Non- -Inflammatory Inflammatory - - PMN PMN s =<25% s =<25%
GROUP II GROUP II - - Inflammatory Inflammatory - - PMN PMN s =25 s =25 - - 50% 50%
GROUP III GROUP III - - Septic Reactions Septic Reactions - - PMN PMN s = >75% s = >75%
GROUP IV GROUP IV Crystal Crystal - -Induced Induced - - PMN PMN S =>50% S =>50%
GROUP V GROUP V - - Hemorrhagic Reactions Hemorrhagic Reactions - - PMN PMN S =>25% S =>25%
************************************************* *************************************************
Increasedneutrophilsindicatesaseptic condition; whereas, an Increasedneutrophilsindicatesaseptic condition; whereas, anelevated elevated
cell count withapredominanceof lymphocytessuggests nonseptic cell count withapredominanceof lymphocytessuggests nonseptic
inflammation. inflammation.
Other abnormal cells: LE cells, Reiter cells, andRA cellsor r Other abnormal cells: LE cells, Reiter cells, andRA cellsor ragocytes. agocytes.
Synovial Fluid
Monocyte Monocyte
Lymphocyte Lymphocyte
Synovial Lining Cell Synovial Lining Cell
Synovial Lining Cell
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Synovial Fluid- Neutrophils
Synovial Fluid- Neutrophils
SYNOVIAL FLUID CRYSTALS
MonosodiumUrate(MSU) /Tophi MonosodiumUrate(MSU) /Tophi- -largecrystal deposits in largecrystal deposits in
joints, tendons, and soft tissue joints, tendons, and soft tissue
Gout Gout
CalciumPyrophosphateDihydrate(CPPD) CalciumPyrophosphateDihydrate(CPPD)
Pseudogout,degenerative or metabolic arthritis Pseudogout,degenerative or metabolic arthritis
Cholesterol Cholesterol
Chronic synovial effusions, rheumatoid arthritis Chronic synovial effusions, rheumatoid arthritis
Calciumoxalate Calciumoxalate
Renal dialysis patients Renal dialysis patients
Corticosteroid crystals/steroids Corticosteroid crystals/steroids
Drug injection for joint inflammation Drug injection for joint inflammation
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Synovial Fluid Crystal
Identification
Birefringence Birefringence- - certain structures have the ability certain structures have the ability
to rotate or polarize light to rotate or polarize light- -known as birefringence known as birefringence
(weakly/calciumpyrophosphate or (weakly/calciumpyrophosphate or
strongly/monosodiumurate) strongly/monosodiumurate)
Polarizing filter Polarizing filter- - insert a polarizing filter between insert a polarizing filter between
light source and object; and then another light source and object; and then another
polarizing filter(this is analyzer) between polarizing filter(this is analyzer) between
eyepiece and specimen eyepiece and specimen
Synovial Fluid Crystal
Identification (cont.)
Polarizing filter with compensation Polarizing filter with compensation- - using a polarizer using a polarizer
and and analyzer with a first order red compensator. The and and analyzer with a first order red compensator. The
red compensator is a retardation plate that alters the red compensator is a retardation plate that alters the
passage of light into slow and first components when the passage of light into slow and first components when the
compensator is inserted between the polarizer and compensator is inserted between the polarizer and
analyzer, it retards the lights so that the field background analyzer, it retards the lights so that the field background
becomes red instead of black. becomes red instead of black.
Monosodium urate crystals Monosodium urate crystals- - appear appear yellow yellow when when
longitudinal axis is longitudinal axis is parallel parallel to the slow component of to the slow component of
the compensator and they appear the compensator and they appear blue blue when the axis when the axis
is is perpendicular perpendicular
Calcium pyrophosphate crystals Calcium pyrophosphate crystals - -appear appear blue blue when when
parallel parallel to compensator and to compensator and yellow yellow when when
perpendicular perpendicular
Synovial Crystals
Needle Needle- -shaped shaped
monosodium monosodium
crystals seen by crystals seen by
light microscopy of light microscopy of
synovial fluid in a synovial fluid in a
patient with gout. patient with gout.
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Synovial Fluid Crystals-
Monosodium Urate
Synovial fluid Synovial fluid
with sodium urate with sodium urate
crystals, polarized crystals, polarized
light with red light with red
compensator compensator
microscopic. microscopic.
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