13 - CSF And BCF Flashcards
Causes of the accumulation of fluids is different cavities - Non-inflammatory causes
1️⃣ increase of hydrostatic pressure of the blood due to:
🔺 right sided heart failure
🔺liver hypertension, failure, cirrhosis 🔺blockage of a blood vessel
🔺renal fibrosis
2️⃣ decrease of plasma colloid oncotic pressure (⬇️ albumin)
🔺 type and quantity of protein intake
🔺gastric, pancreatic (EPI), intestinal digestion (specific intestinal diseases), 🔺malabsorption
🔺synthesis (liver failure),
🔺utilisation (growth, pregnancy, work, exercise, tumour)
🔺loss (renal - glomerulonephropathy, intestinal - PLE)
3️⃣impeded lymphatic flow (backward stasis)protein into interstitium
4️⃣ hormonal effects (aldosterone, AHD - primary or secondary case increased circulatory
volume)
Causes of the accumulation of fluids is different cavities -inflammatory causes
1️⃣bacterial toxins (endotoxins, exotoxins)
2️⃣viral effects (immune complexes)
3️⃣parasitic toxins
4️⃣inflammatory mediators (histamine etc., immune complexes)
Types of BSF fluids
transudate (hydro-) exudate (pyo-) modified transudate blood chylus (lymph)
Lymph
Can look like milk, NGs dominate -> inflammation
Blood; what to do, how do we know its blood?
Need to act quick! Look for origin(surgery)
Thrombocytes present=fresh bleeding (diss. Within 2-3h)
Hematocrit: blood ok means it havent reacted yet, while incr. Hematocrit in fluid = fresh bleeding
Sampling of BCF
1️⃣ taken in sterile environments,
2️⃣using syringe, iv. catheters, or vacuum bottles,
3️⃣ into glass tube (in order to evaluate coagulation ability) and Na(K)2EDTA containing tubes.
4️⃣ 3 may be needed: biochemical and cytological analysis, microbiology examination (in this case special tubes are provided)
Course of sample preparation of BCF
1️⃣ gross examination
2️⃣ Rivalta-test
3️⃣ total and nucleated cell count (by using automatic cell counters or
haemocytometer)
4️⃣ centrifuging by cytospin
5️⃣ separating upper layer: biochemical analysis
6️⃣ separation of sediment for cytological analysis - smear is made
How do we figure out origin of sample?
1️⃣ exudate or transudate? Eg. Rivalta
2️⃣A EXUDATE - NGs dominate, septic or non-septic? Cytology:
- septic(mostly bacteria) phagocytesed bacteria, if bacteria outside og cell=contamination
- non-septic: karyopicnosis
2️⃣B TRANSUDATE - mesoth cells, lymphocytes, tissue cells, tumor cells, ng(non dominant) - neoplastic or reactive? Further tests
- neoplastic: modified transudate
- reactive: modified transudate and/or transudate (might be tumor but not shedding cells, well encapsulated.)
🍏Parameters determined from body cavity fluids - how do we evaluate BCF
1️⃣ outlook physical parameters (colour, odour, consistency) 2️⃣ Rivalta-test 3️⃣ coagulation ability 4️⃣ specific gravity 5️⃣ pH 6️⃣ red blood cell count 7️⃣ nucleated cell count 8️⃣ total protein concentration 9️⃣ albumin/globulin ratio 1️⃣0️⃣ creatinine, urea concentration 1️⃣1️⃣ alpha-amylase, lipase activity 1️⃣2️⃣ LDH activity 1️⃣3️⃣ triglycerol, cholesterol concentration 1️⃣4️⃣ cytological analysis
How to make smear from different BCF
Few cells ex CSF, bronchoalveolar lavage)
🔺 use upper layer to re-suspend sediment and use to make smear
Many cells
🔺 sediment directly onto slide to make smear
🔺if too many RBC use sample from buffy coat layer instead
🍏Rivalta test
1️⃣ 1/2 drops of non-centrifuged sample(BCF) into 3% (only fibr, glob not alb)acetic acid solution in Na-EDTA tube, dont hit side of tube!
2️⃣ coagulation - there is exudate
🔺 weak acid will coagulate fibrinogen/globulin
3️⃣ no coag - transudate
🔺 weak acid cannot coag albumin(only strong)
3️⃣ loads of globulins: honey like sample in FIP. The sample drop will not dissolce in acetic acid, but remain as drop formed. ((best fip test!) globulins coag on surface of dense surface of drop)
transudate: 1️⃣color 2️⃣odour 3️⃣consistency 4️⃣rivalta 5️⃣coagulation ability 6️⃣SG 7️⃣pH 8️⃣nucl. Cell count 9️⃣TP
1️⃣bloody (heart failure, stasis of vessels) watery or yellowish (liver failure) 2️⃣no smell 3️⃣watery 4️⃣ neg rivalta 5️⃣ no coag 6️⃣ hypothenuric (<1017) 7️⃣ slightly alkaline or 7 8️⃣ <1-10 9️⃣ <25
modified transudate 1️⃣color 2️⃣odour 3️⃣consistency 4️⃣rivalta 5️⃣coagulation ability 6️⃣SG 7️⃣pH 8️⃣nucl. Cell count 9️⃣TP
1️⃣bloody, opaque, grey-white, reddish, yellowish, sometimes transparent sometimes 2️⃣watery sometimes 3️⃣slightly viscous 4️⃣ +/- rivalta 5️⃣ +/- coag 6️⃣ 1017-1025 7️⃣ slightly alkaline, acidic or 7 8️⃣ 10-50 9️⃣ 25-35
What causes coagulation
Fresh blood, innflammation
exudate 1️⃣color 2️⃣odour 3️⃣consistency 4️⃣rivalta 5️⃣coagulation ability 6️⃣SG 7️⃣pH 8️⃣nucl. Cell count 9️⃣TP
1️⃣generally opaque, bloody, grey- white, yellow-white, light brown 2️⃣often penetrating 3️⃣often viscous !4️⃣ +/++/+++ rivalta !5️⃣ + coag 6️⃣ >1025 7️⃣ acidic !8️⃣ >50 9️⃣ >35
How do we do biochemical analysis of BCF
1️⃣ Albumin/globulin ratio
• (Globulin conc more than 50 in cat - suggests FIP)
2️⃣ Creatinine, urea concentration
• when conc is higher than in blood suggest rupture of bladder, kidney pelvis, ureter)
3️⃣ Alpha-amylase, lipase activity
• when conc is higher than in blood suggest rupture of gall bladder, bladder, esophageus, duodenal perforation)
4️⃣ LDH activity
• when conc is higher than in blood suggest neoplasias, peritonitia, pleuritis)
5️⃣ Triglycerol (TG)/cholesterol (Chol) ratio
• if milky fluid we suspect lymph. Compaire sample to lymph, lymph will have more TG than cholesterol, if opposite its pseudolymph; thorax mostly, pleuritis! Looks like lymph)
How do we do Cytological analysis of BCF
1️⃣ smear, dry, stain(eg. Giemsa)
2️⃣ microscopic analysis on low then high power(immersion lens)
3️⃣ we can check if:
🔺 inflammatory, septic or not
🔺 non-inflammatory, reactive or neoplastic
🍏Causes of transudate and cytological picture
Increased vessel permeability due to:
1️⃣ increased hydrostatic pressure of the blood
2️⃣ Decreased plasma colloid oncotic pressure
3️⃣ Impeded lymphatic flow
4️⃣ Hormonal effects
Cytology:
🔺Basic cell types are small lymphocytes.
🔺More RBC and WBC in cavities in case of heart disease.
🔺In case of long term stasis, increase in neutrophils and macrophages.
🍏Causes of exudate and cytological picture (septic)
🔺general causes:
1️⃣ Increased permeability of vessels due to inflammatory causes (bacterial, viral, parasitic, inflammatory)
2️⃣ Increased migration of phagocytes
3️⃣ Increased proliferation of mesothelial cells
4️⃣ Increased production of inflammatory proteins
🔺Septic:
1️⃣ Trauma of pleural, peritoneal, pericardial wall
2️⃣ Internal perforation of organs
3️⃣ Hematogenous of lymphatic spreading of bacteria
Cytology of septic exudates
🔺Neutrophils, macrophages and reactive mesothelial cells are seen.
🔺Cells might show nuclear degeneration (karyolysis, karyohexis, sometimes karyopinosis)
🔺Visible bacterias in the IC phagycytosed form.
🔺If bacteria can be seen out of cell – process worsening.
🔺If only bacterias out of cell – bacterial contamination
Major causes of non septic exudates, cytological picture
1️⃣ viruses - FIP
2️⃣parasites -, Dirofilaria immitis and repens larvae, echynococcus
3️⃣fungi - systemic mycosis on pleural wall
4️⃣gall bladder, urinary bladder rupture
5️⃣ neoplasms, tissure necrosis eg. Pancreatitis
6️⃣ decr lymph flow (blockage, dilation, trauma)
🔺neutrophils, reactive macrophages and mesothelial cells
🔺 Phagocytic cells might contain inclusion bodies i.e. bile pigment, haemosiderin granules, viral inclusion bodies, tissue necrotic products.
🔺 pathologic micoorganisms
🔺 extracellular matrix may be highly azurophilic, showing the high protein content of the fluid.
🔺 chylus origin - small and medium sized lymphoid cells,
Major causes of modified transudates, cytological picture
1️⃣ long term stasis of BCF ➡️ tissue necrosis neighbouring tissue ➡️ secondary inflammation
2️⃣ can be highly exudative process in the beginning, severe plasma fluid accumulation
3️⃣blood in body cavities due to (rupture, mechanical, injury, coagulo-thrombocytopathies)
4️⃣ neoplastic processes - carcinoma, lymphoma…
Cytology
🔺 neutrophils, macrophages and highly reactive mesothelial cells. If the process is neoplastic, tumour cells appear in the smear.
🔺look at trombocytes to diagnose acute bleeding
🔺 look at phagocytized RBC to diagnose chronic bleeding
🍏Sampling of CSF
When CNS signs
1️⃣ Before sampling it is advisable to perform retina observation, whether there is increased intracranial pressure. If yes, it is necessary to reduce it first
2️⃣ sample from occipital zona or lumbal zone
🔺 lumbal zone contain more proteins and cells
3️⃣ Na(K)2EDTA containing tubes
4️⃣During sampling it is necessary to check the speed of dripping of CSF samples to evaluate intracranial pressure.
🍏How do we analyse CSF
CNS inflamm/injury: sampling and cytology!
1️⃣ physical examination: color, turbidity, coagulation
2️⃣ cell count ⬆️
3️⃣ cytology ⬆️neutrophils, ep, macroph, neoplastic cells
4️⃣ protein content examination⬆️
5️⃣ glucose content examination ⬇️
6️⃣ lactate concentration ⬆️
7️⃣ enzyme activity examination ⬆️
Physical examination of CSF
1️⃣ colour (red - fresh bleeding, yellow - bleeding in the past, opaque - in highly inflammatory or neoplastic conditions)
2️⃣ turbidity (slight, severe)
3️⃣ coagulation (coagulative in highly inflammatory processes)
Should look like water: no color, smell, viscosity
Cell count of CSF
1️⃣Total cell count: bürker chamber or Fuchs-rosenthal chamber (all cells are counted, no machine can cope with such small no.)
2️⃣ Nucleated cell count: türk solution into liqour cerebrospimalis in haemocytometer: count the cells in 50 large squares, multiply the number with 5, result in microliter-s (normal 25 cell/microliter)
Normal cell count: 5-10/μl
Burker chamber vs Fuchs-Rosenthal chamber, method
Bürker: - 1 full square = 1microL Fuchs-Rosenthal - 3x more reliable since count more! 1 full square = 3microL (Divide by 3 to get per microL)
native (non centrifuged) samples are obtained. Cells is counted above the whole network. Max 5microL in occipital region, max 10 in lumbar region
Nucleated cell count: 0,1 ml Türk solution into 0,9 ml liquor cerebrospinalis in haemocytometer: count the cells in 50 large squares, multiply the number with 5, result in microL - normal is 24cells per microL
Cell count interpretation
From the cytologist we will get 2 answers:
1️⃣ if there is pleiocytosis (incr of cells, csf term)
2️⃣ what cell type(s)
From this we look for inflammation, or rarely neoplasm
Eg.
Stereoid responsive meningitis(NG)
FIP neurological form (mixed plei)
Canine lymphoma metastasis to CSF
General CSF biochemistry
Protein and glucose aalways, lactate and enzymes are extras
Pándy test
1️⃣ evaluate CSF protein concentration
2️⃣ CNS inflammation
3️⃣ CSF
4️⃣ put pándys reagent in a tray, add 1 DROP of csf to the side
5️⃣ very little, 0.2-0.4g/L
6️⃣ (mostly globulin) +/++/+++ incr. Globulin during cns inflammation(ppt
Glucose
Glucose: decr in septic inflammation as NG and bacteria “eat” it (in CSF is 80-60% of the plasma glucose concentration)
Lactate
Increase in case of bacteria, ischemia
Enzyme activity examinations:
Brain isoenzymes are released in case of injury
Ceratine kinase
Lactate dehydrogenase (LDH)
AST
