1030 Unit 5 Flashcards
What are the functions of CSF?
① supply nutrients to the nervous tissue
② removes metabolic waste
③ maintains intracranial pressure
④ cushions the brain and spinal cord
Describe the lining of the brain and spinal cord
-made up of 3 meninges
①dura mater→ hard layer that lines skull and spine column
② arachnoid filamentous inner membrane (spiderweb)
③ pia mater →gentle thin lining membrane on the brain and spinal cord
What produces CSF?
The choroid plexuses capillary network of filtration between the blood plasma and theCSF blood-brain barrier
Describe structure of the choroid Plexuses
- 2 lumen ventricles and 3rd and 4th ventricles
Describe CSF volume characteristics
- 20 ml produced every hour
-Fluid goes to the subarachnoid space - normal value → 90-150 ml
-neonates normal value → 10-60 ml
Describe blood brain Barrier
-tight fitting endothelial cells
-protects brain
- The values acts in a one-way response
What could disrupt the blood brain barrier?
-meningitis →
→infection
→ multiple sclerosis
-allows protein, guecose and leukocytes ( WBC) into the CSF
What is the location of the CSF collection?
Lumbar puncture between 3rd and 4th vertebra OR 5th and 6th vertebra
What should occur after the needle is in place in CSF collection?
-opening pressure is recorded in patient chart by the trained physician performing the lumber puncture
- elevated pressure requires the fluid to be removed slowly
Explain collection tubes for CSF collection
Specimens are collected sterilely in 4 tubes ‘
① chemistry and serology test - may be frozen
② microbiology - room temperature
③ cell count- hematology - may refrigerate up to 4 hours
④ might be used for microbiology or for extra test
When should CSF be tested?
STAT- drop what your doing and test immediately
Explain possible appearances of CSF that should be reported?
- Colorless/clear
- cloudy
- turbid
- milky
- xanthochromic → pink, orange, yellow
- bloody → red
What causes oily CSF?
_ Radiographic contrast media
What causes clotted CSF?
- clotting factor
- protein
What causes pellicle CSF?
-protein
- clotting factors
What is the normal appearance of CSF?
Clear/ colorless
What is xanthochromic?
An indication of Old blood, longer than traumatic tap
-caused by-
→hemoglobin
→ bilirubin
→ carotene
→ protein
→ melanin
How much fibrinogen is normally fInd in CSF?
None
What does red CSF indicate?
Traumatic tap
What does orange/yellow CSF indicate?
Old blood
What cells are Included in a call count?
-leukocytes (WBC)
-nucleated cells
What is the normal value for CSF for WBC?
-0-5 WBCs/ul
- children can be higher
- neonates → 30 mononuclear cells
What is the normal value for RBC in CSF?
-0
- most are due to traumatic tap
What is the traditional way to do a RBC count?
- Neubauer chamber and equation
What is the equation for find the RBC cell count?
(# of cells counted x dilution)/(#of squares counted X volume of 1 square)
What should occur if a few number of cells are present?
- Count all 9 squares
What would you do if you need WBCs to be more visible?
- Add glacial acetic acid, it will lysis RBC
Describe bacterial meningitis
-↑ WBC count
-neutrophils present
-marked protein elevation
↓ glucose level
- lactate level >35 mg/dl
- positive gram stain and bacterial antigen tests
-PCR
What causes the PCR to be positive in bacterial meningitis?
- Streptococcus pneumonia
- streptococcus agalactiae
- Neisseria meningitidis
- haemophilus influenza
- listeria monocytogenes
- escherichia coil K1
Describe viral meningitis
↑ WBC count
-Lymphocytes present
-moderate protein elevation
- normal glucose
- normal lactate level
What causes the PCR to be positive in viral meningitis?
-Enterovirus
-herpes
- simplex virus
- parechovirus
Describe tubercular meningitis
↑ WBC count
Lymphocytes present
Monocytes present
↑moderate to marked protein
↓ glucose level
> 25 mg/dl lactate level
- pellicle formation
What causes the PCR to be positive in tubercular meningitis?
- Mycobacterium tuberculosis
Describe fungal meningitis
↑ WBC count
-Lymphocytes present
-Monocytes present
↑ moderate to marked protein
-Normal OR ↓ glucose level
>25 mg/dl lactate level
Explain positive test for fungal meningitis occur?
- Positive for India ink
→ cryptococcus neoforman - positive immunological test
→ eryptococcus neoforman
-PCR positive for
→ cryptococous neoformans
What are the clinical significances of lymphocytes in CSF? What are the microscopic findings?
-normal
-Viral, tubercular, and fungal meningitis
- HIV /AIDS
- sclerosis
- degenerative disorders
- parasitic infections
MICRO → all stages of development can be found
What are the clinical significances of neutrophil sin CSF? What are the microscopic findings?
- Bacterial meningitis
- early cases of viral, fungal, and tubercular meningitis
- cerebral hemorrhage
- cerebral abscess
-CNS infarction - injection of medications or radiographIC dye into the subarachnoid space
- metastatic tumors
- repeated lumbar punctures
MICRO for bacterial meningitis→ granules may be seen less prominent than in blood
MICRO for an others → cells disintergrate rapid
What are the clinical significances of monocytes in CSF? What are the microscopic findings?
- Normal
-rival, tubercular and fungal meningitis - multiple sclerosis
MICRO → found mixed w/ lymphocytes
What are the clinical significances of eosinophils in CSF? What are the microscopic findings?
-parasitic infections
-fungal infections
- coccidioïdal meningitis
- introducing medications and shunts in CNS
What are the clinical significances of macrophages in CSF? What are the microscopic findings?
- RBCs in spinal fluid
- contrast media
MICRO→ may contain phagocytized RBCs appearing as empty vacuoles or ghost calls, hemosiderin granules and hematoidin crystals
What are the clinical significances of blast cells in CSF? What are the microscopic findings?
- Acute leukemia
MICRO → lymphoblasts, myeloblasts, or monoblasts
What are the clinical significances of lymphoma cells in CSF? What are the microscopic findings?
Disseminated lymphomas
MICRO →resemble lymphocytes with cleft nuclei
What are the clinical significances of plasma cells in CSF? What are the microscopic findings?
- Multiple sclerosis
- guillain-barre syndrome
-sarcoidosis
-parasitic infection - syphilistic meningitis
-tuburculous meningitis - lymphocytes reactions
MICRO for multiple sclerosis→ traditional and classic forms seen
MICRO for lymphocytes→ reactive lymphocytes
What are the clinical significances of ependymal,chloroidal, and spindle-shaped cells in CSF? What are the microscopic findings?
- diagnostic procedures
MICRO → seen in clusters with fusing of cell walls
What are the clinical significances of malignant cells in CSF? What are the microscopic findings?
-metastatic procedures
- primary central nervous system carcinoma
MICRO→ seen in clusters with fusing of cell borders and nuclei
What is pleocytosis?
Increase of normal cells→ abnormal
What leukocytes are classified as polynuclear?
Eosinophil
Basophil
Neutrophil
What leukocytes are classified as mononuclear?
- Monocytes
-lymphocytes
What should you do if a few number of cells are present in a cell count?
- Count all 9 squares
-sometimes, WBC may be less than RBC and you may count in different areas
What is a cytocentrifuge?
-Forces cells onto a slide in a monolayer
-filter paper absorbs moisture
- 0.1 ml CSF to 1 drop 30% albumin
0 number of WBCs counted in chamber, what would be the number of cells after cytocentrifuge?
0-40
1-5 number of WBCs counted in chamber, what would be the number of cells after cytocentrifuge?
20-100
6-10 number of WBCs counted in chamber, what would be the number of cells after cytocentrifuge?
60 - 150
11-20 number of WBCs counted in chamber, what would be the number of cells after cytocentrifuge?
150-250
21 number of WBCs counted in chamber, what would be the number of cells after cytocentrifuge?
251
What is normal to be seen in a differential count?
Lymphocytes
Monocytes
What is an easy way to differentiate between meningitis types:
↑ neutrophils= bacterial
↑ lymphocytes and monocytes= viral, tubercular, parasitic, and fungal
Explain what to expect when neutrophils are present?
- Early onset of viral, fungal, tubercular, and parasitic
- appearance
→ cytoplasm vacuolated
→ granules could be lost
→ may see phagocytized bacterial pyknotic = degenerated cells
Explain what to expect when eosinophils are present?
- Parasitic infection
- fungal infection
- introduction of forgien material = allergic reaction
Explain what to expect when lymphocytes are present?
- Normal to see in low numbers
-viral, tubercular, fungal meningitis
-reactive lymphocytes
→ dark blue cytoplasm
→ clumped chromatin
→ plasma cells
-HIV infection (AIDS), multiple sclerosis and degenerative neurological disorders
Explain what to expect when monocytes/ macrophages are present?
-usually counted together
- monoytes=blood
- macrophages/histocytes= tissue
-viral, tubercular, or fungal meningitis
What is nonpathological significant in CSF?
Appearance of lining cells
-choroidal cells
-ependymal cells
What are pathological significance in CSF?
-any form of blasts ( 1st stage of a hemopoietic cell)
- lymphoma cells can also be seen
- malignant cells
→astrocytoma
→retinoblastoma
→medulloblastomas
(usually dark, ugly, and inclusters
What is the normal value of protein in CSF?
15 - 45 mg/dl
What proteins are present in CSF?
- Albumin → predominant
-transthyretin (prealbumin)→ second predominance - alpha globulin
-beta globulin
-separate carbohydrate-deficient transfersin fraction (“tau” → not in serum) - gamma globulin
What are the types alpha globulins present in CSF?
- Haptoglobin
-ceruloplasmin
What is the beta globulin present in CSF?
Transferrin
What are the gamma globulins present in CSF?
-IgG → predominant
-IgA
What proteins are not considered normal for CSF?
-IgM
-fibrinogen
-lipoprotein
What are causes for elevated protein found in CSF?
- Damaged to blood-brain-barrier(most common)
→ meningitis
→ hemorrhage conditions
→ multiple sclerosis - immunoglobulin production within the CNS
-decreased normal protein clearance from the fluid
-neural tissue degeneration
What are principles for the two methods used for measuring protein in CSF?
-Turbidity production
→automated instrumentation in form ot nephelometry
-dye-binding ability
What does diagnosis of neurological disorders associated with abnormal CSF require?
Measurements of individual protein fractions
How do you determine if elevated IgG levels are due to blood brain barrier defect or being produced within the CNS?
-Comparisons must be made between serum and CSF levels of albumin
- methods include
→CSF/serum albumin index to evaluate the integrity of blood brain barrier
→ CSF IgG index to measure IgG synthesis within the CNS
How ao you determine the CSF/ serum albumin index?
- calculated after determining concentration of CSF albumin in mg/dl AND serum concentration in g/dl
-equation:
(CSF albumin mg/dl)/( serum albumin g/dl) - an index value less than 9 represents an intact blood- brain barrier
How do you determine the IgG index
- Comparison of CSF/serum albumin index with the CSF/serum IgG index
-equation
[CSF IgG (mg/dl)/serum IgG (g/dl)]/[CSF albumin (mg/dl)/ serum albumin (g/dl)]
What is myelin basic protein?
-Major component of the myelin nerve sheath surrounding axons of nerves in the nervous system
-presence in CSF indicates recent destruction of the myelin sheath that protects axons
- can be used to monitor the course of multiple sclerosis
-↑ in trauma, encephalitis, guillain-barre.
Describe dye binding ability
- Oligoclonal bands (immunoglobins in CSF)
. Electrophoresis
What is the normal value for glucose in CSF?
60-70% of the plasma glucose
When should CSF glucose be tested?
Should be compared to a serum glucose within 2 hours of the tap
What is elevated glucose in CSF related to?
A high serum glucose
Describe what decreased glucose in CSF is
- Significant
↓ glucose +↑ WBC (neutrophils) =?
Bacterial meningitis
↓glucose + ↑ WBC (lymphocytes)=?
Tubercular meningitis
Normal glucose + WBC (lymphocytes)=?
Viral meningitis
What are the normal values for lactate in CSF:
10 - 24 mg/dl
What is the significance of increased concentration of lactate in CSF?
> 25 mg/dl → bacterial meningitis
-test used to monitor bad head injury
What is the significance of increased glucose in CSF?
None
What is the significance of decreased levels of lactate and glutamine in the CSF?
None
What is the significance of increased glutamine in CSF?
> 35 mg/dl → some disturbance of consciousness
What is the normal value of glutamine in CSF?
8-18 mg/dl
How does glucose “move”?
Selectively transported
What is elevated in liver disease?
Glutamine
What produces glutamine in CSF?
-Ammonia
- alpha- ketoglutarate
Describe the microbiology test of CSF
- Aide in analyzing the CSF for organisms
- can take 24 hours to 6 weeks depending on organisms
-CSF culture confirms results. - preliminary test
Describe manual methods of microbiology test of CSF
- Grams stain
- acid fast stain
-India ink → cryptococcal neoform (yeast)
Describe automated microbiology tests of CSF
- Latex testing (on the way out)
- molecular testing → (nucleic acid amplification) PCR
Describe latex agglutination test/ lateral flow assay of CSF
- replaced India ink
- antigen panel-
→ strep B, H. Flu, strep phuemonia, N. Meningitis A, B, C, Y & W135, E. Coli K1
Describe naegleria Fowleri
- Parasite in water source
-enters through the nose and migrates to the brain
What serology test for syphilis I
VDRL
Describe gram stain (in CSF)
- Performed routinely when suspected meningitis
- detects bacterial and fungal organisms
What speed and time is CSF centrifuged?
1500 g for 15 minutes
What could cause a false negative in a gram stain?
Hardest stain slide to read, causing errors in diagnosing
What could cause a false positive in gram stains?
If precipitated stain or debris is mistaken for micro-organisms
What test is performed it someone is suspected of having meningitis tubercular
Acid fast or fluorescents antibody stains
What is the most common reason for false positives in immunologic assays (of CSF)?
Rheumatoid factor
Describe lateral flow assay (IFA) of CSF testing
- Rapid
- detects cryptococcal neoforms
- high sensitivity and specificity
-utilizes a reagent strip coated with monoclonal antibodies that react with the cryptococcal polysaccharide capsule
Where is CSF is produced mainly in?
Choroid plexuses
What is the primary purpose for performing CSF protein electrophoresis?
To detect oligoclonal bands-represents inflammation within the CNS
Describe oligoclonal bands
-Located in gamma region of the protein electrophoresis
-indicates immunoglobulin production
What is done to ensure the oligoclonal bands are present as a results of neurological inflammation?
Simultaneously serum electrophoresis must be performed
What disorders may produce banding in serum of electrophoresis of CSF
-leukemia
-lymphoma
-viral infection
What is a valuable tool for diagnosing multiple sclerosis?
2 or more oligoclonal bands in CSF that are not present in serum, particularly accompanied by increased IgG index
What are neurological disorders that have banding in CSF but not the Serum
-Multiple Sclerosis
-encephalitis
-neurosyphilis
-Guillian-Barre syndrome
-neoplastic disorders
What happens to oligoclonal banding when Multiple sclerosis is in remission
Remains but may disappear with other disorders
What is the confirmatory test for diagnosing Meningitis?
CSF culture
What does CSF flow through?
Subarachoidnoid space
What are the substances in CSF controlled by?
Blood brain barrier
What department is the CSF tube labeled 3 routinely sent to?
Hematology
What CSF tube should be kept at room temperature?
Tube 2
What are characteristics for a traumatic tap?
-even distribution of blood in all tubes
-xanthochromic supernatant
What are characteristics of intercranial hemorrhage?
-concentration of blood in tube 1 is greater than in tube 3
-specimen contains clots
What causes xanthrochtomia
-immature liver function
-RBC degradation
-elevated CSF
What does a web like pellicle in refrigerated CSF specimen indicate?
Tubercular meningitis
What is the CSF WBC count diluted with?
Acetic acid
A total CSF cell count on a clear fluid should be what?
Count undiluted
What is the purpose of adding albumin to CSF before cytocentrafugation?
-increase the cell yield
-decrease cellular distortion
What is the primary concern when pleocytosis of neutrophils and lymphocytes is present in the CSF fluid
Meningitis
Neutrophils with pyknotic nuclei may be mistaken for what?
Nucleated RBC
The presence of what is increased in a parasitic infection ?
Eosinophils
When do macrophages appear in the CSF?
- After hemorrhage
-after repeated spinal taps - after diagnostic procedures
When are nucleated RBCs seen in CSF?
Bone marrow contamination
What could be seen after a CNS diagnostic procedure?
- Chorodial calls
-ependymal cells - spindle. Shaped cells
What are hemosiderin granules and hematoidin crystals are seen in?
Macrophages
What are myeloblasts in the CSF considered?
As a complication of acute leukemia
What are cells that resemble large and small lymphocytes with cleaved nuclei?
Lymphoma cells
How can CSF be differentiated from serum?
-tau transferrinz
How is the integrity of the blood brain barrier is measured using what?
CSF/semm albumin index
What condition is suggested by the following results:CSF glucose of 15 mg/dl, WBC count of 5000, 90% neutrophils and protein of 80 mg/dl?
Tubercular meningitis
If a patient had a normal glucose of 120 mg/dl, what would a normal CSF glucose be?
80 mg/dl
What will CSF lactate be more consistently decreased in?
Viral meningitis
Measurement of what can be replaced by CSF glutamine analysis in children with reye syndrome?
- Ammonia
What is the most sensitive and specific method to detect the causative organism in meningitis?
PCR assay
What is the test of choice to detect neurosyphilies?
-RPR
What are the 4 components of semen?
①testes and epididymis
②seminal vessels
③prostate
④bulbourethral gland
-normal semen specimen must have all types
Describe testes and epididymis pertaining to semen
- Spermatozoa produce in seminferous tubules and mature in epididymis
- 5% of semen volume
Describe seminal vesicles
-majority of fluid of semen, 60%
- contain fructose - causes sperm motility
Describe prostate characteristics
-acidic fluid (acid phosphates, citric acid)
-20 -3090 of volume of semen
- responsible of coagulation and liquefaction
Describe bulbourethral glands
- 5% of volume of semen
-alkaline fluid
What are reasons for testing sperm
① fertility
② post vasectomy monitoring
What occurs when first portion of ejaculate is missing?
- Sperm count will be decreased
- sperm count pH is falsely increased
-specimen will not liquefy
What occurs when the last portion of ejaculate is missing?
- Semen volume is decreased
- sperm count is falsely increased
-pH is falsely decreased - specimen will not clot
What are requirements for sperm collection?
-abstinence for atleast 2 days but not more than 7 days
-WHO → 3 specimens between 7 days and 3 weeks
- give clear instructions should be given
- delivery within 1 hour of collection at room temperature
- positive indication
- collection should not have any nonspermicidal, condoms or lubrication
Explain appearance in macroscopic semen analysis
- test within 1 hour of collection
- appearance
→ normal is gray-white, translucent
→ white is ↑ WBC
→red is RBC
→yellow is urine (toxic to sperm)
Explain liquefaction in macroscopic semen analysis
- Fresh → clotted
- liquefy in 30 to 60 minutes
- if clotting continues after 60 minutes, there is decreased prostatic enzymes
What is the normal volume of semen?
- 2-5 ml
How is the viscosity reported when testing sperm?
-0 → watery
-4 → gel like
What is the pH of semen?
-7.2 - 8.0
-increased → infection
- decreased → obstruction
What factors can affect the sperm?
- Quantity (normal →20 - 250 M/mL, border line→ 10-20 M/mL)
- morphology of the head and tail
- speed- motility
Explain counting on neubauer chamber
- 1-20 dilution
-dilution fluid → bicarbonate and formalin - countin 4 corners plus the center
- side must match within 10%
What are the microscopic automated instruments for sperm?
- Sperm class analyzer
-CEROS CASA system
-automated sperm quality analyzer
Explain motility of sperm
-sperm with forward, progressive movements
-evaluate undiluted on glass slide with Cover slip
-estimate percentage with progressive forward motion in 20 HP fields or 200 sperm per slide and count percentages of different categories
- 4 indicating rapid, straight line movement
-0 indicating no movement
-normal → minimum motility with a rating of 2,0 after 1 hour is considered normal
Describe sperm viability test
-Mix with eosin-nigrosine stain
- stain dead sperm
- count number of dead per 100 sperm
Explain seminal fluidfructuse test
- Energy for sperm
-normal→ equal or greater than 13 umole/ejaculate
Explain anti-sperm antibodies test
- Antibodies can be produced by male and female
Explain post-vasectomy semen analysis
- Monthly testing beginning at 2 months
- continues until no viable sperm are seen on a wet preparation
Explain microbial testing of semen
- Detects…
- Chlamydia
- mycoplasma
-ureaplasma
What does chemical testing determine levels of (in sperm)?
- Alpha- glucosidase
-free L-carnitine - glycerophophocholine
-zinc
-citric and
-Glutamyl transpeptidase - prostatic acid phosphates
Where does the maturation of spermatozoa take place?
Epididymis
What are the enzymes for coagulation and liquefaction of semen produced by?
Prostate gland
What is the major component of seminal fluid?
Fructose
Failure of laboratory personnel to document the time a semen specimen is collected primarily affects the interpretation of what?
Viscosity
A semen specimen delivered to laboratory in a condom has a normal sperm count and markedly decreased sperm motility. What does this indicate?
-Antispermacide in the condom
What could an increased semen pH be caused by?
Prostatic infection
Why would proteolytic enzymes be added to semen specimens?
Decrease viscosity
What is the normal sperm Concentration?
More than 20 million/mL
What is the primary reason to dilute a semen speciemen before performing a sperm count?
Immobilize sperm
What is the purpose of the acromsomal cap?
To penetrate the ovum
What part of the sperm contains a mitochondrial sheath?
Midpiece
What part of the sperm does not assist in motility?
Head
What is the normal sperm morphology when using the WHO criteria?
> 30% normal forms
What round cells are need for concern and may be included in sperm counts and morphology analysis?
- Leukocytes
- spermatids
After an abnormal sperm motility test with a normal sperm count, what additional test might be ordered?
Eosino-nigrosin stain
What is the follow up testing for a low sperm concentration?
- Seminal fluid fructose
Describe the immunobead test for antisperm antibodies
- Detects presence of male antibodies
- determines presence of IgG, IgM, and IgA antibodies
-determines location of antisperm antibodies
What disorder is detected by measurement of alpha-glucosidase?
Disorder of the epididymis
Describe synovial fluid
- Joint fluid of movable joint
- knee, elbow, hip, and shoulder
- ultrafiltrate of plasma(non selective filtration)
- smooth articulate cartilage and cavity with fluid
What is the normal volume of synovial fluid?
<3.5 mL
Describe appearance of synovial fluid
- Colorless to pale yellow
- clear
-viscosity → high, able to form string
What is a normal leukocytes count in synovial fluid?
< 200 cells/micro-L
What is a normal neutrophil concentration in synovial fluid?
< 25% of the differential
What is normal glucose:plasma difference in synonial fluid?
< 10 mg/dL lower than the blood glucose level
Describe normal total protein of synovial fluid
<3 g/dL
What is the normal lactate in synovial fluid?
< 25.0 mg/dL
Describe the 2 types of synoviocytes in the membrane lining
-type A→ macrophages-phagocytosis ( similar to monocytes)
-type B→ fibroblasts- produce hyaleronic acid, fibronectin, and collagen
What are the functions of synovial fluid?
①reduce friction
②lubricate the joint
③nutrients to cartilage
④reduces shock during injury/activities
What is arthritis?
Damage to membrane creates pain and stiffness
What are the 4 classification of arthritis?
①noninflammatory
②inflammatory
③ septic
④ hemorrhagic
What health concerns are associated with the noninflammatory category of arthritis?
Degenerative, osteoarthistis
What health concerns are associated with the inflammatory category of arthritis?
- Immunologic
- lupus erythematosus (LE)
- rheumatoid arthritis (RA)
-Lyme disease crystal induced - gout
-pseudogout
What health concerns are associated with the septic category of arthritis?
Microbial infection
What health concerns are associated with the hemorrhage category of arthritis?
-trauma
-tumors
- coagulation deficiencies
Describe appearance of synovial fluid in the non inflammatory category
-clear yellow fluid
-good viscosity
Describe the WBCs count, neutrophil concentration and glucose of synovial fluid in the noninflammatory category?
WBCs = < 1000 microliters
Neutrophils <30%
Similar to blood glucose
Describe the appearance of synovial fluid in the inflammatory category
Immunologic origin
-cloudy yellow
-poor viscosity
Crystal induced origin
-cloudy or milky
-low viscosity
Describe WBC count, neutrophils and glucose in synovial fluid of the inflammatory cAtegory
Immunologic origin
-WBCs 2,000-75,000 microliters
-neutrophils >50%
-decreased blood glucose
-possibly autoantibodies present
Crystal induced origin
-WBCs up to 100,000 microliters
-neutrophils <70%
-decreased glucose levels
-crystals present
What is the appearance of synovial fluid in the septic category
-Cloudy yellow-green fluid
-variable viscosity
Describe the WBCs count, neutrophil concentration and glucose found in synovial fluid that is in the septic category
-WBCs = 50,000-100,000 microliter
-Neutrophils > 75%
-Decreased glucose level
-positive culture and gran stain
Describe the appearance of synovial fluid in the hemorrhagic category
-Cloudy, red fluid
-low viscosity
Describe the WBC count, neutrophil concentration and glucose in synovial fluid in the hemorrhagic category
-WBC equal to blood
-neutrophils equal to blood
-normal glucose
What type of tube would be used to collect synovial fluid when a gram stain and culture is being performed?
Sterile sodium heparin or sodium polyanehtol sulfonate
What type of tube would be used to collect synovial fluid when a cell count is being performed?
Sodium heparin or liquid ethylenediametetraacetic acid (EDTA)
What type of tube would be used to collect synovial fluid when glucose analysis is being performed?
Sodium fluoride or no anticoagulanted
What type of tube would be used to collect synovial fluid when all other tests are being performed?
Nonanticoagulanted
What cell count is performed most frequently on synovial fluid?
Total leukocyte count
Describe manual cell counts for synovial fluid?
- Specimen thoroughly mixed
-use neubauer counting chamber
-clear fluids can be counted undiluted
-turbid and bloody need to be diluted
What should differential counts should be performed on (synovial fluid)?
Centrifuged preparations or thinly smeared slides.
What are the primary cells seen in normal synovial fluid?
-monocytes
-macrophages
- synovial tissue cells
-<25% neutrophils
-< 15% lymphocytes
What does elevated neutrophils indicate?
Septic condition
What does an elevated cell count w/ a predominance of lymphocytes indicate?
Nonspecific inflammation
What are abnormal cells in synovial fluid?
-eosinophils
- LE
- Reiter cells
- RA cells (ragocytes)
When is lipid droplets present in synovial fluid?
Crush injuries
When are hemosiderin granules seen in synovial fluid?
- seen in cases of pigmented villonodular synovitis
What is the most frequently ordered chemistry test for synonal fluid?
Glucose determination because markedly ↓ glucose indicates inflammatory or septic disorders
What is synovial fluid an ultrafiltrate of?
Plasma
What are the types of chemistry tests for synovial fluid?
- Glucose
- total protein
- lactate
-uric acid - enzymes
What disorder has elevated uric acid levels?
Gout
What does elevated lactate levels in synovial fluid indicate?
Septic arthritis caused by gram-positive cocci and gram-negative bacilli
Why are enzymes tested in synovial fluid?
Monitor severity and prognosis of RA
What are the 2 most important tests performed on synovial fluid? And why?
- Cultures
- gram stains
- infection may occur as secondary complication of inflammation caused by trauma or through dissemination of systemic infection
- both must be performed
What are the most common organisms that infect the synovial fluid?
-staphylococcus
-streptococcus
-haemophilus species
-N. Gonorrhoere
What is the molecular method for detection of microorganisms of synovial fluid?
PCR
Why are serological tests for synovial fluid important?
- Because of immune systems association with inflammation process
- important in diagnosing joint disorders
How is synovial fluid collected?
Need aspiration → arthrocentesis
What is the normal volume of synovial fluid in a knee joint? Volume in an inflamed thee?
-normal → < 3.5 mL
-inflamed→ up to 25 mL
Describe General tube collection for synovial fluid
-EDTA→ hematology
-green (heparin) → crystal exam, chemistry test
-SPS (yellow)for culture in microbiology or a still tube
What is added to synovial fluid to reduce viscosity when conducting a cell count?
- hyaluronidase
What should be the dilution solution for a cell count on synovial fluid?
Saline
What should not be used to dilute synovial fluid? Why?
-Water or acetic acid
- can cause mucin clot formation and cell clumping
What are the guidelines for a cell count test?
- <200 nucleated cells → count all 9
- > 200 → count 4 corners
- > 400 - count 5 center boxes
- normal WBC =< 200 cells/microliter
What are the causes of crystal formation?
-metabolic disorders
-decreased renal excretion
What are primary crystals of synovial fluid?
- Monosodium urate (MSU)
- calcium pyrophosphate dihydrate CPPD
Describe monosodium urate (MSU)
- AKA uric acid
- gout
What are the causes of gout?
-↑Uric acid from impaired metabolism of purines
-↑ consumption of high-purine foods, alcohol, and fructose
- chemotherapy
- decrease of renal excretion of uric acid
Describe pyrophosphate dihydrate CPPD
-indicates pseudogout
- associated w/ degenerative arthritis, disorders causing elevated calcium levels
What are other crystals that are not considered primary in synovial fluid?
-Hydroxyapatite
- cholesterol
- corticosteroids
- calcium oxalate
- apatite (calcium phosphate)
Describe hydroxyapatite in synovial fluid
Cartilage degeneration, only seen with election microscopy
Describe cholesterol in synovial fluid
- Systemic autoimmune diseases (LE, RA) appear similar to urine cholesterol arsenals
-notched corners
Describe corticoidsteroids in synovial fluid
-injections
- flat, variable plates
Describe calcium oxalate in synovial fluid
Seen in Renal analysis patients
Describe apatite in synovial slid
-AKA calcium phosphate
- small particles
- requires election microscope
-indicates osteoarthritis
What is the primary function of synoviocytes?
Provide nutrients for the joints
What test in not frequently done on synovial fluid?
Uric acid
What is the procedure name for collection of synovial fluid?
Arthrocentesis
Before testing, what should very viscous synovial fluid be treated with?
Hyalurónidase
What color would synovial fluid be with a bacterial infection?
Green tinged
Which would be affected most if synovial fluid
was refrigerated before testing?
Crystal examination
What category of arthritis has the highest WBC count?
Septic arthritis
What category of arthritis has the lowest percentage of neutrophils?
Noninflammatory arthritis
How should synovial fluid crystal examination should be examined?
Wet preparation
It crystals shaped like needles are aligned perpendicular to the slow vibration of compensated polarized light, what color are they?
Blue
What is always need for a culture of synovial grid?
Chocolate agar
(to detect neisseira gonorrhoeae)
Describe serous membranes cavity
- Closed cavity
→ pleural-thoracic area-lung
→ pericardial - heart
→ peritoneal - peritoneal cavity liver, stomach intestine bladder, and ovaries
Describe the 2 membranes of the serous membrane
- Parietal membrane → line the cavity
-visceral membrane →membrane around the organs
What is serous fluid?
- fluid in between the membranes
- lubricate - prevent friction
-small amounts are present - production = reabsorption are constant rate
What is serous fluid an ultrafiltrate of?
Plasma
Describe hydrostatic pressure in reference to serous fluid
- Parietal and visceral capillaries enter through the membrane
-↑ oncotic pressure allowing fluid back into the capillaries
Describe oncotic pressure
-AKA colloidal pressure
- normal conditions serum protein are the same in the capillaries
What is effusion?
Build up or accumulation of serous fluid
What are causes of effusion?
-increased capillary hydrostatic pressure
- decreased oncotic pressure
- increased capillary permeability
- lymphatic obstruction
What are examples of increased capillary hydrostatic pressure?
- Congestive heart failure
- salt and fluid retention
What are examples of decreased oncotic pressure?
- Nephrotic syndrome
- hepatic cirrhosis
-malnutrition
-protein-losing enteropathy
What are examples of increased capillary permanently?
- Microbial infections
- membrane inflammation
-malignancy
What are examples of lymphatic obstruction?
-malignant tumor, lymphomas
- infection and inflammation
-thoracic duct injury
What are 2 forms of effusion?
- Translate
-exudate
Describe transudate effusion
Systemic disorder disrupting the balance of fluid filtration and reabsorption
→ change in hydrostatic pressure
Describe exudate effusion
-Conditions that involve the membranes,
-infections and malignancies
What tests are performed to differentiate between effusion fluid?
-total protein
- lactic dehydrogenase (LDH)
- cell count
- differentiate from blood ratio for total protea
And LDH
What is the appearance of translate and exudate?
Transudate → clear, pale yellow
Exudate → cloudy, color varies
What is the WBC count for transudate and exudate?
Transudate → <1000 microliters (pleural, pericardial)
→ <500 microliters (peritoneal)
Exudate→ >1000 microliter
Does transudate and exudate spontaneously clot?
Transudate→ no
Exudate → possible
What is the fluid total protein of transudate and exudate?
Transudate→ 30g/L or less
Exudate → >30 g/L
What is the fluid:semi total protein ratio of Transudate and exudate?
Transudate → <0.5
Exudates→ >0.5
What is the fluid: serum LD ratio of Transudate and exudate?
Transudate→ <0.6
Exudate → >0.6
What is the fluid LD of Transudate and exudate?
Transudate→<0.67 x ULN serum
Exudate→ > 0.67 x ULN serum
What is the pleural fluid cholesterol of Transudate and exudate?
Transudate→ < 45-60 mg/dL
Exudates→ > 45-60 mg/dL
What is the pleural fluid: serum cholesterol ratio of Transudate and exudate?
Transudate → <0.3
Exudate→ >0.3
What is the pleural fluid: bilirubin ratio of Transudate and exudate?
Transudate→ <0.6
Exudate→ >0.6
What is the serum-ascites albumin gradient of Transudate and exudate?
Transudate→ >1.1
Exudate → <1.1
What is the glucose of Transudate and exudate?
Transudate→ equal to serum
Exudate → less than or equal to serum
What is the specific gravity of Transudate and exudate?
Transudate → <1.015
Exudate → >1.015
What is the procedure called when collecting pleural fluid?
Thoracentesis
What is the procedure called when collecting pericardial and peritoneal fluid?
Paracentesis
Cell count for serous fluid is collected in what tube?
EDTA
What is the normal appearance of pleural fluid?
-pale yellow/clear
What are abnormal appearances of pleural fluid?
-turbid→ WBCs - inflammation infection
-blood → hemothorax -traumatic injury, malignancy
-milky → chylous material
How is hemothorax and hemorrhage determined?
- Run a hematocrit
- > 50%- due to injury.
-a membrane disease would have a low hemato at
Describe chemistry test of pleural fluid
- Cholesterol serum to pleural
→ >60 mg/dL
→ serum/pleural ratio >0.3
-bilirubin serum to pleural
→serum/ pleural ratio > 0.6
- glucose
→ helpful in RA
Describe hematology test of serous fluid
- Primary cells
→ macrophages
→ neutrophils
→ lymphocytes
→ eosinophil
→ mesothelial
→ plasma
→ malignant
-64 -80% macrophages
-18-30% lymphocytes
-1-2 % neutrophils
What does ↑ neutrophils in pleura’s fluid indicate?
-infection
-pancreatitis
-pulmonary infarct. (b)
What kind of monocytes are in pleural fluid
Macrophages and histocytes
What does lymphocytes indicate if present in the pleural fluid?
- Tuberculosis
- viral infection
- malignancy
- autoimmune disease
What does the presence of eosinophils in the pleural fluid indicate?
- > 10% trauma to pleural cavity
- allergic reactions
-parasites
What does the presents of lining cells in pleural third mean?
- Mesothelial
-reactive → clusters, varying amounts of cytoplasm
-eccentric nuclei and multinucleated
-may look like malignant cells
What are the most common chemistry tests for pleural fluid
-glucose
- pH
-total protein
-Adenosine deaminase
-Triglycerides
-amylase
What does↓ glucose indicate in pleural fluid?
-tuberculosis
- rheumatoid inflammation
- malignant effusion
-esophageal rupture
What does abnormal pH for pleural fluid?
- <7.3 → need of chest tube = pneumonia
- <6.0 → esophageal rupture
What are abnormal adenosine deaminase (ADA) levels and what does this indicate?
- > 40 U/L
-tuberculosis
-malignancy
What does abnormal levels of amylase indicate In pleural fluid?
- Pancreatitis
- esophageal rapture
What organisms are the primary cause of pleural effusion infection?
_Staphylococcus aureus
- enterobacterales
- anaerobics
- M. Tuberculosis
What are microbiology tests performed on pleural fluid?
- Culture with gram stain
-AFB culture with stain - new→ PCR
What are serological tests of pleural fluid?
-CEA → carcinoembryonic antigen
-CA-125→ metastatic uterine cancer
-breast cancer markers
→ CA-15.3
→CA-549
- lung. Cancer
→CYFRA 21-1
What is pericardial fluid a result of?
- Change in membrane due to infection (pericarditis), malignancy, and trauma
What does translate in pericardial cause?
- Uremia
-hypothyroidism - autoimmune diseases
What is the normal appearance of pericardial fluid?
Pale yellow/clear
What are abnormal appearances of pericardial fluid?
-red → puncture, anticoagulants
- milky → chylous
- WBC > 1000 = bacterial endocarditis
What lab tests are performed on pericardial fluid?
- Cell counts
- chemistry → lactic dehydrogenase ,(LD)
- markers levels for tumor
- cultures → routine bacterial, fungal, acid fast bacteria
What is the accumulation of fluid in peritoneal membrane?
Ascites
What causes build up of peritoneal fluid?
-hepatic disorder (cirrhosis)
-bacterial infection in intestine (peritonitis)
What is a peritoneal lavage?
- Diagnostic procedure to determineintra-abdominal bleed
-normal saline injected into cavity und with drawn and perform cell count
What is test is preferred over total protein and LD ratio when testing peritoneal fluid?
Serum- ascites albumin gradient (SAAG)
Describe Serum- ascites albumin gradient (SAAG)
- Serum and fluid albumin levels are measured ‘
- fluid level is subtracted from serum level
- difference > than 1.1 is a transudate (hepatic origin)
Serum albumin - fluid albumin= hepatic transudate
3.8- 1.2 = 2.6
What is the normal appearance of peritoneal fluid?
Pale yellow/clear
What are abnormal appearances of peritoneal fluid?-
_Tubid → bacterial infection
- green/dark brown→ bile
Describe chemistry testing of peritoneal fluid
- Glucose
→ below plasma levels = peritonitis and malignany - ↑ amylase → pancreatitis and gastrointestinal perforation
-↑ alkaline phosphatase: intestinal perforation
-↑BUN, creatinine→ ruptured bladder and accidental perforation
Describe microbiology and serology testing of peritoneal
- Gram stains and aerobic and anaerobic cultures
-anaerobic cultures → inoculate blood culture bottle a bed side - acid fast smear
- adenosine deaminase and culture for TB
-tumor markers
→CEA
→CA 125
Presence of CA 125 antigen with a negative CEA suggests what?
- The source is from ovaries, fallopian tubes, and endometrium
What does the presence of CEA antigen suggests?
Source is gastrointestinal
What is the primary purpose of serous fluid?
Lubricate serous membrane
The membrane that lines the wall of a cavity is called what?
Parietal
During normal production of serous fluid, what happens to slight excess?
Absorbed by lymphatic system
What is the production of serous fluid is controlled by?
- Capillary oncotic pressure
- capillary hydrostatic pressure
- capillary permeability
What is an Increase in the amount of serous fluid is called?
Effusion
What is caused by increased hydrostatic pressure?
Exudate
What is caused by increased capillary permeability?
Transudate
What is caused by decreased oncotic pressure?
Transudate
What is caused by congestive heart failure?
Transudate
What is malignancy related in serous fluid?
Exudate
What is TB related in serous fluid?
Exudate
What is endocarditis related in serous fluid?
Exudate
What has a clear appearance: Transudate and exudate?
Transudate
Why are fluid:serum protein and lactic dehydrogenase ratios are performed in serous fluid?
To classify Transudate and exudate
What requires additional testing: Transudate or exudate?
Exudate
What is an additional test performed on pleural fluid to classify if a fluid is Transudate or exudate?
Fluid: cholesterol ratio
What is a differential observation of pleural fluid associated with tuberculosis?
Decreased mesothelial cells
What are characteristics of malignant cells?
-Cytoplasmic molding
-mucin-containing vacuoles
-increased nucleus: cytoplasm ratio
Plasma cells seen in pleural fluid indicates what?
TB
What is a significant cell found in pericardial or pleural fluid that should be referred to cytology?
Mesothelioma cells
What is a test performed primarily on peritoneal lavage fluid?
RBC count
What is the recommended test for determining whether peritoneal fluid is Transudate or exudate?
Serum ascites albumin gradient
What test is performed to differentiate between bacterial peritonitis and cirrhosis?
Absolute neutrophil count
Describe bronchoalveola R lavage (BAL)
- method for examining cellular, immunologic and microbiological information from the lower respiratory tract
-helpful for immunocompromised patients and patients with airway/breathing problems
Describe BAL collection procedure
-bronchoscopy
-fiber optic into middle of lobe(upper or lower)
-documentation of what are examined
-sterile saline is slowly administered into scope and mixed then aspirated the contents for examination and culture
Describe saline amount for broncoscopy?
- amount instilled is 100-300 ml in 20-50 ml aliquots
Explain samples for the broncoscopy?
-first sample should be discarded
-an optimum sample is >30% of recovery (50-70%)
- <25% = chronic obstructive lung disease
Describe specimen handling of broncoscopy
-must be transports in within 39 minutes of collection
-should stay at room temperature
-cell count should be performed with in 1 hour of collection but stable for 3
-will look for WBC count
-can filter specimen to remove mucus, phlegm and dust
What are the diagnostic test for broncho specimen
- Cell count
- Microbiology
- Cytopathology
What colors can be reported for broncho specimens
-colorless
-milky white
-light brown beige
-gray-beige
-red
Describe abnormal colors of broncho specimen
Red—> diffuse hemorrhage or difficulty in collection
Orange-red —> old hemorrhage (may want to do iron stain)
Milky-light beige —> accumulation of phospholipids-protein due to surfactants
If a bronco wash has a creamy layer in top, what is that?
Lipids—> centrifuge
Describe cell counts of broncho wash
-count WBC and RBC on hemocytometer
-may need dilution
-gold standard is the chamber
What is a BMP LeukoCheck system?
-ammonium oxalate
-lysis RBC which allows for dilution and a clear solution to count WBC
Explain how to count WBC using a chamber
Count both side all 9 squares-a total of 18
Explain cell distribution over the hemocytometer for cell counts in a broncho wash
-WBC difference should not be >15 cells
-RBC differences should not be >30
-the cells should agree within 10% on each side
What should be notated if there is clumping?
Cell count may be inaccurate due to clumps of cells
What are the cell that are present in BAL?
-macrophages
-lymphocytes (CD4/CD8 ratio)
-neutrophils
-eosinophils
-ciliated columnar bronchial epithelial cells
-squamous, epithelial cells
Describe the macrophages found in BAL
-phagocytize (hemosiderin)
-normal range 56-80%
Describe lymphocytes found in BAL
-normal range —> 1-5%
- increased in lung disease, drug reactions, pulmonary lymphoma, and non bacterial infection
- >25% lymphocytes-granulomatous lung disease
- >50% lymphocytes - hypersensitivity pneomonitis
Describe neutrophils present in BAL
-Primary cell seen
-normal is <3%
-elevated in smokers, toxin exposure, bronchopneumonia and diffuse alveolar damage
- >50% acute lung injury, aspiration pneumonia or infection
Describe eosinophils present in BAL
-usually <1-2% of total cells
-seen in asthma, drug induced lung, infection (parasite, mycobacteria or fungal)
- >25% -eosinophilic lung disease
Describe erythrocytes present in BAL
-Indicates acute alveolar hemorrhage or from procedure
-phagocytized RBC - suggest a alveolar hemorrhage in last 48 hours
Hemosiderin macrophages indicate older than 48 hours
Describe epithelial cells present in BAL
-Ciliated columnar cells are prominent
-normal range —> 4-17%
What conditions are present with a low CD4/CD8 ratio?
-hypersensitivity pneumonia
-silicosis
-drug-induced disease
-HIV infection
What are conditions of normal CD4/CD8 ratio?
-TB
-malignancies
What are conditions that have a high CD4/CD8?
-sarcoidosis
-connective tissue disorder
What is a quick test that can identify pathogens of a BAL?
PCR
Explain what is being looked for in cytology of a BAL
-sulfur granules (actinomyces)
-hemosiderin-laden macrophages
-langerhans cells
-cytomegalic cells
-fat droplets (red O)
-periodic -acid Schiff (PAS) for fungus
-dust particles in pneumoconiosis or asbestos exposure
What stain is used in cytology for the diagnosis of lipid-laden alveolar macrophages?
-Sudan III stain
Describe amniotic fluid
- cytogenetic
-is the product of fetal metabolism-waste
-tells about the metabolism process and fetal maturation - in on the amnion or the amniotic sac
What are the functions of amniotic fluid?
-exchange of water and chemical between the fetus and the maternal circulation
-cushions for the fetus
-fetal movement
-regulates temperature around fetus
-permits proper lung development
Explain the volume of amniotic fluid
-regulates balance between production of fetal urine, lung fluid, absorption of fetal swallowing and intramembranous flow
-fluid increases through the fetus development
- 12 weeks = 60 ml
- 3rd trimester = 800-1200 ml —> secretes lung liquid in lung growth
What is indicated with >1200 ml of amniotic fluid?
Polyhydramnios
What is indicated when Amniotic fluid is < 800 ml?
Oligohydramnios
Describe polyhydramnios
-failure to swallow will results in increase fluid (fetal distress)
-secondary —> fetal anomalies, cardiac issues, congenital infection or chromosome abnormalities
Describe oligohydramnios
-increased fetal swallowing, urinary tract deformities, membrane leakage
-associated with congenital malformations, premature rapture of amniotic membrane and umbilical cord compression
Explain amniotic fluid composition
-placenta is the source
- made of water and solutes
-composition is of maternal plasma + small amounts of slough fetal cells
What is the biochemical composition of amniotic fluid?
-bilirubin
-lipids
-enzymes
- electrolytes
- urea
-creatinine
-uric acid
-proteins and hormones
What are the abnormal proteins in amniotic fluid due to Neural tube defect ?
-alpha-fetoprotein
-acetylcholinesterase
How does creatinine help in amniotic fluid?
- determine fetal age
—> before 36 weeks = 1.5-2.0 mg/dL
—> over 36 = >2.0 mg/dL
What should be done to determine premature membrane rupture or accidental puncture of maternal bladder from amniocentesis?
-measure creatinine and urea will be lower in amniotic fluid than urine
-creatinine and urea will be lower in amniotic fluid than urine
- amniotic fluid has <3.5 mg/dL creatinine and < 30 mg/dL urea
- urine could have up to 10 mg/dL for creatinine and 300 mg/dL for urea
Describe fern test
-Amniotic fluid specimen air dries on glass slide
-examine microscopically for fern like amniotic fluid crystals
Describe bilirubin scan in amniotic fluid
- delta A450>0.025
-hemolytic disease of the fetus and newborn
Describe Lecithin-sphingomyelin ratio of amniotic fluid
- > /=2.0
- fetal lung maturity
Describe foam stability index of amniotic fluid
> /= 47
- fetal lung maturity
When should a amniocentesis be performed?
-if serum AFP is abnormal or positive
-after observation of ultrasound, fetal body measurements may not agree with gestational age
-genetics
What are tests performed for genetics of amniotic fluid?
-karyotyping
-fluorescence in situ hybridization (FISH)
-fluorescent mapping special karyotyping (SKY)
-DNA testing
Describe collection of amniotic fluid
-transabdominal
-amniocentesis
-maximum of 30 mL collected in sterile syringes
-discard first 2-3 mL for contamination
Describe handling and processing of amniotic fluid
-perform immediately
-may need ice or be refrigerated
-always protect specimen from light due to possible bilirubin
What is the normal appearance of amniotic fluid?
Colorless with slight to moderate turbidity due to cells
What are abnormal appearances of amniotic fluid
Blood streaked —> traumatic tap, abdominal trauma, intra-amniotic hemorrhage
Bilirubin: bright yellow
Meconium (first bowel movement)—> dark green
Fetal death —> dark red brown
Development of what has decreased HDFN?
Anti-Rh
Explain fetal distress hemolytic disease of the fetus (newborn) (HDFN)
-Fetal cells with antigen enter maternal circulation and cause production of maternal antibodies
-maternal antibodies cross the placenta and destroy fetal cells with the corresponding antigen
Explain steps of antibodies crossing the placenta
- Exposed in 1st pregnancy
- Mother makes antibodies
- 2nd pregnancy the antibodies cross the placenta and bind to fetal RBC = result destroys the cells
- Cause unconjugated bilirubin in amniotic fluid
- Bilirubin is measurable using a spectrophotometer
What does the amount of unconjugated bilirubin present correlate with?
Amount of RBC destruction
Describe tests for fetal distress
-spectrophotometric analysis of fluid optical density (OD) measured in intervals between 365 and 550 nm is plotted on graph paper
-bilirubin causes OD rise at max absorbance level of 450
-difference is plotted on an Liley graph. Queenan curve
What is DeltaA450
Difference between baseline and 450 nm peak of bilirubin
What test is performed to differentiate between fetal and maternal blood?
Kleihauer-Berle
Describe Liley graph
-plots DeltaA450 against gestational age
-consists of 3 zones based on severity
Describe zone I of the Liley graph
Mildly affected fetus
Describe zone II of the Liley graph
Requires careful monitoring
Describe zone III of the Liley graph.
Severity affected fetus, may require induction of labor or intrauterine exchange transfusion
What is the most common birth defect
Neural tube defect
What are tests that are done for neural tube defect?
-maternal serum alpha- fetoprotien (MSAFP)
-ultrasound
-amniocentesis
What does elevated AFP in maternal serum and amniotic fluid indicate what?
Possible anencephaly or spina bifida
When are Increaesed levels of AFP found?
When skin fails to close over neural tissue
Explain what MoM for Neural tube defect testing?
- multiple of medians
-median is laboratory reference level for a given week of gestation
-more than two times the MoM is abnormal
What test is more specific for neural disorders?
Fluid amniotic acetylcholinesterase
What are surfactants of fetal lung maturity?
-mature lungs and allows the aveoli to remain open during inhalation and exhalation
-keeps the aveoli from collapsing, decreasing the surface tension
-allows the lungs to inflate easily
-lab tests determine fetal lung maturity
What is a primary component of lung surfactants?
Lecithin
What does sphingomyelin do
Serves as a control for the rise of lecithin
When is preterm deliveries considered safe?
L/S ratio 2.0 or higher
What is considered the reference method for testing for fetal Lung maturity
What are fetal lung maturity tests?
-lecithin-sphingomyelin ratio
-phosphatidyl glycerol
-foam stability index
-lamellar bodies
-LBC
Explain lamellar bodies
-storage form of surfactant
-90% phospholipid
-10% protein
What are lamellar bodies secreted by?
Type II Pneumocytes of fetal lung
Explain the lamellar body count
_same size as platelets (1.7-7.3 fl.)
-can be counted on a hematology analyzer (optic or independence
->50,000 microliters = Mature
-<15,000 microliters = immature
What are advantages of lamellar body count on hem analyzer
-rapid TAT
-low cost
-wide availability
-simple
-small amount of specimen needed
-great clinical performance
Give characteristics of fecal specimen
-100-200 g of feces is excreted in 24 hours
-intestine is primary site for final breakdown and reabsorption of protein, carbohydrates and fats
What aids the small intestine in break down and reabsorption of feces
Pancreatic enzymes
—> trypsin
—>chymotrypsin
—> amino peptidase
—> lioases
Liver produces bile salts that help breakdown fats
Describe what happens to the fluids in the digestion
. They are reabsorbed
- only 500–1500 ml wil make it to large intestine
-150 g mL will be excreted
Explain diarrhea
> 200 g stool weight per day with increased liquid and more than 3 movements
What are 4 classification factors for feces
- Illness duration
- Mechanism
3.severity - Stool characteristics
What are 2 types of water diarrhea
1-Secretory
2-osmotic types (fecal electrolytes)
What are test performed for diarrhea?
-fecal electrolytes
-osmolarity
-pH
- <5.6 indicates sugar malabsorption
Explain secretory diarrhea
-caused by increased water and electrolytes
-no reabsorption in the large intestine
Explain osmotic diarrhea
-caused by poor absorption
-incomplete digestion of food increased in large intestine
-disaccharide deficiency
-malabsorption
-poorly absorbed sugars
-laxatives
-magnesium antiacids
-antibiotics
Explain steatoeehea
-increased data in stool >6 g/day
-Stained with Sudan or Red O stain
-lack of bile salts or pancreatic enzymes
Brown color of feces
Stercobilinogen—> urobilin
What does pale feces indicate
Blockage of the bile duct
What did bright red and dark red color of feces indicates?
Bright red —> lower GI bleed
Dark red—> upper GI bleed
Why are microscopic examinations performed on feces?
-To detect leukocytes associated with microbial diarrhea
- to look for muscle fibers and fats
What is most commonly found in microscopic exams of feces
Neutrophil (worn out)
-can be seen with gram or Wright stain and or wet mount
Who can muscle fibers be seen in fecal matter?
-patients with biliary obstruction, malabsorption and gastrocolic fistulas
Explain qualitative fecal fats test
-screen for fats
-two part test
—>neutral fat and split fat
—> large red-orange droplets =/> 60 per hpf indicative of steatorrhea
Explain neutral test
-1 part stool, 2 parts water
-mix emulsified stool with 95% ethyl alcohol on slide
-add two drops of Sudan III
Explain split fat test
-mix specimen with acetic acid and heat
-greater the size of the droplets, the more positive the test
-cholesterol forms after heating and cooling
What does an increase split fat indicate?
Malabsorption
What does a normal split and increase neutral indicate?
Maldigestionn
What is the most frequent test performed on stool?
Occult blood
-explains unexplained anemia
What are the most specific and sensitive test for screening for blood in feces
-guaiac (most frequent)
-immunochemical
-fluorometric porphyrins quantification
What is a false positive of guaiac
-myoglobin/hemoglobin
-food
-medicine
What is a false negative of guiaic?
Didn’t test areas with blood present
What could be a false positive for porphyrins based
Due to red meat
Describe quantitative fecal fat test
Use to confirm steatorrhea
- collect for 3 days
-gold standard - van de kamer titration
What is a Reiter cell
Macrophage ingested neutrophil
What is a ragocytes?
Neutrohils with dark granuales
What is ATP test
Used on vomitus or stool from neonate to distinguish fetal and maternal hemoglobin
What does a high semen pH indicate?
Prostatic infection
