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Clin Lab Med Unit 2 > 3 ID And Body Fluids > Flashcards

3 ID And Body Fluids Flashcards

1
Q

Thin smear of material overlaid with crystal violent and rinsed, then safranin and rinsed again

A

Gram stain

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2
Q

Color for gram positive bacteria

A

Dark blue to purple

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3
Q

Color for gram negative bacteria

A

Pink/red

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4
Q

What’s an example of a gram variable organism?

A

Gardnerella vaginosis

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5
Q

Skin scraping, oral or vaginal secretions placed on a slide with a drop of KOH. The slide is heated briefly with a flame, then examined with a low power microscope

A

KOH prep

KOH dissolves host cells and bacteria, sparing FUNGI and elastin fibers

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6
Q

Slides prepared from lesion scrapings are stained with Giemsa or Wright stain preps. Presence of multinucleated giant cells indicates infection.

A

Tzank prep

Tests for Herpes virus

BUT IMMUNOFLUORESENCE MORE COMMONLY USED

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7
Q

A drop of centrifuged CSF is placed on a slide next to a drop of India ink. A cover slip is placed over the drops.

A

India ink, test for Crypotococci

Cryptococcosis are identified by LARGE CAPSULES which exclude the ink

India ink prep of the CSF will demonstrated round encapsulated yeast organisms consistent with Cryptococcus

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8
Q

Evaluation of bacteria too thin to absorb light from traditional microscopy are tested using…

A

Dark field microscopy (dark field illumination)

Useful in diagnosing Syphillis (T. pallidium) b/c it cannot be cultured and gram negative but too thin for staining

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9
Q

Visualization of ________ on dark field microscopy will reveal spirochetes

A

Syphillis (T. pallidum)

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10
Q

Additional testing for syphillis after dark field microscopy

A

Venereal Disease Research Laboratory (VDRL)
• CSF test - good for neuro syphillis
• Fluorescent treponema antibody absorption test (FTA-ABS)

Rapid Plasma Reagin (RPR)
• Serum test

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11
Q

What test should you use if worried about meningococcal meningitis?

A

Latex agglutination assay

Detects pathogen specific antibodies/antigens

CSF is tested for meningococcal capsular antigen

Also used for serum, saliva, or urine testing

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12
Q

What are ELISA tests and what’s the drawback?

A

Enzyme-linked immunoassay

Detects antibodies in serum

Takes up to 2 weeks for immune response, so may need repeat testing if tested too early

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13
Q

Primary test for ANA antibody

A

Indirect immunofluorescent assay (IFA)

Detects antibodies in serum or other body fluid

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14
Q

What is Nuclei Acid Amplification (NAAT)

A

Aka polymerase chain reaction (PCR)

Detects small quantities of bacterial/viral DNA/RNA sequences

Serum, CSF, and other body fluids can be tested

Results faster than ELISA

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15
Q

What is the acid fast bacilli (AFB) stain used for?

A

Specific for TB - sputum smear

Less sensitive than NAAT, but rapid and inexpensive

Mycobacterium culture most sensitive and specific for TB (for definitive Dx)

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16
Q

How is tuberculin skin testing performed?

A

Host cell-mediated immune response, delayed type hypersensitivity

Purified protein derivative (PPD) is injected intradermally, monitored for induration

(+) result means infection or exposure to TB, prior immunization with BCG

(-) can occur in positive patients who are immunocompromised

Individuals with patient contact, repeat at 8-10 weeks

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17
Q

Examples of non-sterile specimens

A

Pus taken off the skin/wound with a swab
Urine that is a “clean” catch
Sputum taken via expectoration
Throat swabs, genital swabs

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18
Q

Examples of sterile specimens

A

CSF, pleural, pericardial, peritoneal, or synovial fluids

All SHOULD be sterile

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19
Q

Inconsistent culture results can be due to…

A

Inadequate sample
Contaminated specimen
Wrong culture medium
Time delay from collection of sample to culture

Specimens should be brought promptly to the lab and plated promptly on the correct medium

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20
Q

What is the broth(tube) microdilution method?

A

For antimicrobial sensitivity testing

Bacteria is incubated in broth with dilutions of common antibiotics

Lowest concentration of abx that inhibits visible growth of bacteria is the MINIMUM INHIBITORY CONCENTRATION

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21
Q

What is the minimum inhibitory concentration (MIC)?

A

Minimum amount of abx you can use to treat patient

Pros:
MICs can be generated, tests standardized so reduced labor

Cons:
High cost compared to other methods
Miniature size of dilutions may result in less bacteria being analyzed

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22
Q

When comparing MICs, which antibiotic do you choose?

A

The one with the lowest MIC value, b/c it requires a small amount to inhibit bacterial growth

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23
Q

How does the agar dilution test work?

A

Each agar plate has a fixed concentration of an abx
Multiple plates with varying concentrations
Multiple samples are tested on a single set of plates

Pros:
MICs can be generated

Cons:
Reserved for resistant species
Species that require special growth conditions
Expensive, labor intensive

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24
Q

What is the Kirby-Bauer method?

A

Disk diffusion test
Bacteria grown on agar plate with filter paper disks containing a fixed concentration of abx
Growth inhibition around each of the abx is measured (can be susceptible, intermediate, or resistant)

Pros:
Inexpensive, simple

Cons:
Not recommended for fastidious or slow growing bacteria
No quantitative MIC

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25
Q

Agar prepared with bacterial suspension, plastic strips imbedded with a graded concentration of antimicrobial is placed on the plate

Growth inhibition along the strip is measured

A

Antimicrobial gradient method

Pros:
MICs obtained by identifying intersection of growth inhibition with gradient
Standardized strips so less labor intensive

Cons:
Inaccuracy with some organisms

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26
Q

Considerations when selecting an antibiotic

A

Sensitivity reports - choose the lowest MIC if possible

Can the abx get to the infected site
Ex - will it cross the BBB in a CNS infection (may rule out use of the abx with the best MIC)

Age of patient

Current meds

Comorbidities

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27
Q

Procedure for blood cultures

A

TWO different specimens, must be drawn for at least TWO different sites (NOT the IV)

If one is positive and the other negative, the positive result is likely due to contaminant - BOTH must be positive

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28
Q

When should you draw the blood for culturing?

A

PRIOR to starting antibiotics

Lab must be notified if abx were initiated prior to the blood draw

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29
Q

How long does it take for blood cultures to return?

A

Typically available in 24 hours, but 48-72 typical for ID of organism

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30
Q

Cases in which blood culture should be repeated within 48 hours of start of abx

A

Bacteremia due to S aureus (b/c worry for MRSA)

Known/suspected endocarditis

Infected site within area of limited antimicrobial penetration (abscess, joint space, CNS, abdomen)

Persistent leukocytosis

Prosthetic vascular grafts or cardiac pacemakers

Pathogens known/suspected to be resistant to standard abx agents

Unknown source for initial bacteremia

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31
Q

Aspiration of fluid from the pleural space

A

Thoracentesis

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32
Q

Aspiration of fluid from the pericardial sac

A

Pericardiocentesis

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33
Q

Aspiration of fluid from the abdominal cavity

A

Paracentesis

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34
Q

Aspiration of fluid from the spinal column

A

Lumbar puncture

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35
Q

Abnormal accumulation of fluid in any body cavity

A

Effusion

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36
Q

What are the two types of effusion?

A

Transudates
Exudates

Can occur in:
Pleural space
Peritoneal space
Pericardial space

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37
Q

Accumulation of fluid in a body cavity due to filtration of blood serum across a physiologically intact vascular wall

A

Transudative effusion

Due to pressure differences between body compartments

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38
Q

Transudative effusions are typically due to …

A

Systemic disease

Examples:
CHF
Hepatic cirrhosis
Nephrotic syndrome

Further Dx testing of fluid usually not needed

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39
Q

Accumulation of fluid within a body cavity due to inflammation and vascular wall damage

A

Exudative effusion - requires further testing to r/o cause

Examples of causes:
Infection
Malignancy 
Inflammatory disorder
Trauma
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40
Q

Normal pleural fluid?

A

50 ml

Should be clear, serous, light yellow

RBCs: None

WBCs: < 300/ml

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41
Q

The most common cause of exudative pleural effusions?

A

Parapneumonic effusion

Usually secondary to:
Bacterial pneumonia
Lung abscess
Bronchiectasis

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42
Q

Second most common cause of exudative pleural effusions

A

Malignancy

75% are caused by:
Lung CA
Breast CA
Lymphoma

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43
Q

Non-infection, non-malignant exudative pleural effusions

A

Autoimmune disease

Ex
Lupus
RA

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44
Q

RBCs in the pleural space is called

A

Hemothorax (usually following trauma)

Fluid is serosanginous, with RBC >100,000 cells/uL

Main causes:
Trauma
Malignancy
Pulmonary Embolism

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45
Q

What’s special about PE and effusions?

A

PE may cause either a transudative or exudative effusion

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46
Q

Chylous effusions

A

Can occur in both pleural and peritoneal effusions

Secondary to thoracic or abdominal lymphatic duct disruption or impairment

Cloudy, milk effusion

(+) triglycerides, lipids

Causes:
Trauma
Malignancy to include lymphoma

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47
Q

Why do we perform thoracentesis?

A

Therapeutically to relieve pain/dyspnea

To allow for better Radiographic imaging of the lung

Diagnostically to establish if infectious, inflammatory, or malignant process

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48
Q

Why do we include the lateral decubitus view on CXR before thoracentesis?

A

Ensure the fluid is accessible by needle aspiration

Check for fluidity

Fluid will “layer” out with the patient in lateral decubitus position

U/S helpful in localizing fluid, CT with contrast for more detail

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49
Q

Generally, a parapneumonic effusion should be sampled if it meets any of the following criteria:

A

It layers out >25mm on a lateral decubitus film

It is loculated (pus—> adhesions)

It is associated with thickened parietal pleura on CT (more indicative of malignancy)

It is clearly delineated by U/s

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50
Q

Contraindications for thoracentesis

A

Use caution with significant thrombocytopenia

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51
Q

Potential complications of thoracentesis

A 
Pneumothorax
Intrapleural bleeding
Hemoptysis
Reflex bradycardia and hypotension
Tumor seeding
Empyema (collection of pus)
Re-expansion pulmonary edema
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52
Q

What do we do to prevent re-expansion pulmonary edema?

A

Do not remove >1L via thoracentesis

Do not perform thoracentesis bilaterally

53
Q

Transudative vs Exudative Pleural Effusions:

Total protein levels

A

< 3 g/dL = Transudative

> 3 g/dL = Exudative

54
Q

Transudative vs Exudative Pleural Effusions:

Protein fluid/protein serum ratio

A

< 0.5 = Transudative

> 0.5 = Exudative

55
Q

Transudative vs Exudative Pleural Effusions:

Color/consistency

A

Clear thin fluid = transudative

Cloudy, thick, viscous fluid = exudative

56
Q

Transudative vs Exudative Pleural Effusions:

WBCs

A

< 300 cells/uL = transudative

> 500 cells/uL = exudative

57
Q

Transudative vs Exudative Pleural Effusions:

LDH fluid/LDH serum ratio

A

< 0.6 = transudative

> 0.6 = exudative

58
Q

What is LDH btw?

A

Marker for infection (from cellular breakdown and hemolysis)

59
Q

Transudative vs Exudative Pleural Effusions:

Glucose (fluid:serum ratio)

A

Fluid and serum levels equal = Transudative

Fluid glucose < serum glucose OR < 60 mg/dL = Exudative

60
Q

Transudative vs Exudative Pleural Effusions:

pH

A

7.4-7.5 = transudative

≤ 7.3-7.4 = exudative

61
Q

Transudative vs Exudative Pleural Effusions:

Amylase Fluid to Serum amylase

A

Equal = transudative

Amylase fluid > amylase serum = exudative

Amylase fluid will be elevated in pancreatic or esophageal injury

62
Q

Pleural fluid analysis consists of …

A 
Gross appearance
Cell count
Gram stain
Protein (serum and fluid)
Glucose (serum and fluid)
Amylase (serum and fluid)
Cytology (looking for malignant cells)
CEA (indicates bowel or breast CA in adults)
Cultures (inc TB and fungal)
63
Q

pH in pleural fluid < 7.3 usually indicates…

A

Infection, esophageal rupture, neoplasm

64
Q

Elevation of amylase in pleural fluid usually indicates…

A

Pancreatitis, esophageal rupture, malignancy

65
Q

Triglycerides or lipids in pleural fluid indicates…

A

Chylous effusion

66
Q

Eosinophilia in pleural fluid indicates…

A

Parasitic infection, malignancy, TB

67
Q

Light’s Criteria Rule for pleural fluid analysis

A

If at least one of the following three criteria is fulfilled, the fluid is defined as EXUDATE:

1) Pleural fluid protein/serum protein ratio > 0.5
2) Pleural fluid LDH/serum LDH ratio > 0.6
3) Pleural fluid LDH > 2/3rd ULN normal serum LDH

68
Q

Describe normal peritoneal fluid

A

<50ml

Clear, serous, light yellow

RBCs: None

WBCs: <300/uL

69
Q

Accumulation of fluid within the peritoneal cavity is called…

A

Ascites

70
Q

Common causes of ascites

A 
Portal hypertension due to:
Hepatic cirrhosis (81%)
• 19% of patients with cirrhosis will have hemorrhagic ascites
Alcoholic hepatitis
Acute liver failure

Can also be caused by malignancy
• 10% (most common of these is ovarian cancer)

71
Q

Other unusual causes of ascites

A 
Heart failure
Infectious (TB or fungal)
Hemodialysis-associated
Pancreatic disease
Nephrotic syndrome
Severe malnutrition
Myxedema (occurs with hyperthyroidism - severe widespread edema)
72
Q

Gold standard for evaluating ascites

A

Abdominal U/s

further evaluation for malignancy, consider CT or MRI

73
Q

Indications for abdominal paracentesis

A 
NEW ONSET ASCITES
Or 
Preexisting ascites with:
Fever
Abdominal tenderness
Mental status change
Hypotension
Peripheral leukocytosis
Worsening renal function
Trauma/severe cirrhosis (to r/o intra-abdominal bleed)
74
Q

Potential contraindications for paracentesis

A

Coagulation abnormalities
Patients with small amount of fluid
Previous abdominal surgeries (b/c difficult to access peritoneal space with a lot of scar tissue)

75
Q

Potential complications of paracentesis

A

Hypovolemia if large amount removed and fluid re-accumulates from intravascular volume

Hepatic coma (patient with chronic liver disease)

Peritonitis

Tumor seeding with malignant ascites

Organ perforation

76
Q

Transudative vs Exudative Peritoneal Fluid:

Appearance

A

Clear, thin fluid = transudative

Cloudy, thick, viscous = exudative

77
Q

Transudative vs Exudative Peritoneal Fluid:

Glucose

A

Glucose equal to serum glucose = transudative

Glucose < serum glucose or < 60 mg/dL = exudative

78
Q

Transudative vs Exudative Peritoneal Fluid:

Protein

A

Total protein levels < 3g/dL or protein fluid/protein serum ratio < 0.5 = transudative

Total protein levels > 3g/dL or protein fluid/protein serum ratio > 0.5 = exudative

79
Q

Transudative vs Exudative Peritoneal Fluid:

WBCs

A

< 300 cells/uL = transudative

> 500 cells/uL = exudative

80
Q

Transudative vs Exudative Peritoneal Fluid:

LDH

A

LDH fluid/LDH serum ratio < 0.6 = transudative

LDH fluid/LDH serum ratio > 0.6 = exudative

81
Q

Transudative vs Exudative Peritoneal Fluid:

Serum to ascitic fluid albumin gradient (SAAG)

A

SAAG > 1.1 g/dL = transudative

SAAG < 1.1 g/dL = exudative

82
Q

SAAG classification for peritoneal fluid analysis

A

Serum-to-ascites albumin gradient

Serum albumin MINUS ascitic fluid albumin = SAAG

Transudative = gradient > 1.1 g/dL
Most commonly caused by portal hypertension from hepatic cirrhosis

Exudative = gradient < 1.1 g/dL
THINK MALIGNANCY, infection, or inflammation

83
Q

LDH fluid/LDH serum ratio > 0.6 can indicate…

A

Bowel perforation, malignancy, infection

84
Q

Amylase elevation in peritoneal fluid can indicate

A

Pancreatic source, bowel perforation, malignancy, infection, esophageal rupture

85
Q

Ammonia elevation in peritoneal fluid can indicate…

A

Ruptured or strangulated bowel

86
Q

Bilirubin (brown effusion) in peritoneal fluid can indicate…

A

Bowel/biliary perforation

87
Q

Urea/creatinine presence in peritoneal fluid indicates…

A

Possible bladder rupture (usually traumatic)

88
Q

Presence of triglycerides in peritoneal fluid indicates…

A

Chylous effusion

89
Q

Spontaneous bacterial peritonitis can occur in patients with…

A

Cirrhosis and ascites

Often no obvious source of infection - likely originates in bowel

Typical features:
Abrupt onset of fever, chills, abdominal pain
Rebound tenderness
Labs will reflect exudative effusion

Important to recognize and treat due to high mortality

90
Q

What does pericardial fluid look like?

A

<50ml
Clear, straw-colored
NO RBCs
NO WBCs***

91
Q

When to suspect a pericardial effusion

A

In all cases of acute pericarditis

Unexplained, new cardio metals on CXR w/o pulmonary congestion

Unexplained persistent fever with no obvious source of infection

Fever in patient with another disease process than can involve pericardium

92
Q

Method of choice for evaluating pericardial effusions

A

ultrasound (echocardiography)

93
Q

When NOT to do a pericardiocentesis

A

MOST OF THE TIME!

If patient has an effusion, hemodynamically stable, and a source is known, can treat cause with serial f/u echos

94
Q

When to consider a pericardiocentesis

A

Pericardial effusion with tamponade to relieve intrapericardial pressure if diastolic filling is inhibited

Indicated if fluid is needed for Dx or if Dx might change management (ie malignancy)

95
Q

Contraindications for pericardiocentesis

A

Caution with coagulopathy

Uncooperative patients

96
Q

Complications of pericardial effusions

A 
Laceration of coronary artery or puncture of myocardium
Dysrhythmias
MI
Pneumothorax
Vasovagal hypotension
Pleural or pericardial infection
97
Q

Why don’t we need to do analysis of protein, LDH, glucose, RBC or WBC for pericardial effusions?

A

Do not reliably differentiate an exudate from a transudative in a pericardial effusion and not helpful in establishing a Dx

98
Q

Normal CSF

A

Normally 150-200ml circulating in spine and around brain

Fluid clear and thin

BBB allows only lipid-soluble, very small molecules to pass

99
Q

What is the classic triad for meningitis?

A

Altered mental status (78%)
Nuchal rigidity (88%)
Fever (95%)

Often rapid onset, patient quite ill
Requires rapid assessment and treatment
High risk of mortality and long term morbidity

100
Q

Gold standard for diagnosing meningitis

A

CSF culture

101
Q

Indications for Lumbar Puncture

A

Infection:
Meningitis
Encephalitis/abscess
Neuro syphillis

Malignant process:
Brain tumor
Spinal cord neoplasms

MS

Cerebral/subarachnoid hemorrhage

102
Q

Contraindications for LP

A

Patients with increased intracranial pressure
Severe vertebral degenerative joint disease
Infection near LP site
Patients taking anticoagulants

103
Q

Complications of LP

A 
CSF leak, headache
Meningitis
Herniation of the brain
Spinal cord puncture
Puncture of aorta or vena cava (retroperitoneal hemorrhage)
Back pain, parasthesia in legs
104
Q

When to do a CT before LP

A

Immunocompromised state

Hx of CNS disease (mass, lesion, stroke, or focal infection)

New onset seizure (within one week of presentation)

Papilledema

ALOC

Focal neurological deficit

105
Q

What to do before an LP

A

Two separate blood cultures should be drawn immediately if CNS infection is a concern

Start empiric abx (remember, these must be able to cross BBB)

Consider CT of head prior to LP based on IDSA guidelines)

ABX should NOT be delayed pending CT scan

106
Q

What should CSF look like?

A 
Clear, colorless
Pressure <20cm H2O
RBCs (adult) 0-5cells/uL 
WBCs (adult) 0-5 cells/uL
Protein: 15-45mg/dL 
Glucose: 50-75 mg/dL (approx 2/3 serum glucose)
LDH < 40 units/L
107
Q

Cloudy CSF indicates…

A

Infection, elevated protein

108
Q

Pink/red CSF indicates

A

Bleeding from procedure or subarachnoid bleeding

109
Q

Yellow CSF indicates

A

Xanthochromia (lysis of RBCs)

110
Q

Decreased pressure with LP indicates

A

Hypovolemia (dehydration, shock), chronic CSF leak, nasal fracture with dural tear

111
Q

Increased pressure with LP indicates…

A

Infection, intra-cranial bleeding, tumor, hydrocephalus

112
Q

Large differences in opening/closing pressures with LP indicates…

A

Spinal cord obstruction (tumor), screaming/breath holding baby or child that then relaxes

113
Q

WBCs > ______ is abnormal in CSF

A

> 5 cells/uL

114
Q

Neutrophils in CSF

A

Bacterial/tubercular meningitis
Cerebral abscess
Subarachnoid bleeding
Tumor

115
Q

Lymphocytes in CSF

A

Viral, tubercular, fungal, syphillitic meningitis
Multiple sclerosis
Guillain-Barré syndrome

116
Q

Eosinophils in CSF

A

Parasitic meningitis

Allergic reaction to radiopaque dyes

117
Q

Macrophages in CSF

A

Tubercular, fungal meningitis
Hemorrhage
Brain infarction

118
Q

RBCs > _____ is abnormal in CSF

A

> 5 cells/uL

119
Q

DDx of RBCs in CSF

A 
Traumatic tap:
• Normal CSF pressure
• Bleeding decreases as CSF is withdrawn
• No blood with repeat LP
• Clotting present
• Centrifuge —> clear fluid
Subarachnoid bleed
• Increased CSF pressure
• Bleeding consistent throughout draw
• Blood on repeat LP
• No clotting
• Centrifuge —> Xanthrochromia
120
Q

_________ is present in >90% of patients within 12 hours of subarachnoid hemorrhage onset

A

Xanthochromia

Hemoglobin —> oxyhemoglobin —> methemoglobin —> bilirubin (yellow)

Can also be present in infections/inflammatory processes

121
Q

Protein in CSF increases with…

A

Infectious/inflammatory processes, meningitis, encephalitis, myelitis

May increase with bleeding/hemolysis

Increased protein can indicate autoimmune disease

122
Q

(+) oligoclonal gamma globulin bands

A

Multiple Sclerosis

123
Q

CSF glucose < 2/3 serum glucose is indicative of

A

Meningitis

Neoplasm

124
Q

Lactate dehydrogenase in CSF

A

Increased in bacterial meningitis/malignancy/intracranial hemorrhage

125
Q

Lactic acid in CSF

A

Increased in bacterial/fungal meningitis BUT NOT VIRAL

126
Q

Glutamine in CSF

A

Elevated in hepatic encephalopathy or coma

127
Q

C-reactive protein (CRP) in CSF

A

Increased in bacterial meningitis

128
Q

What stain do you use on CSF if suspecting toxoplasmosis?

A

Gemma’s/wright stain

129
Q

Where do the four tubes collected during LP go?

A

Tube 1 —> chemistry/immunology analysis

Tube 2 —> microbiology

Tube 3 —> hematology

Tube 4 —> hold

Clin Lab Med Unit 2 (4 decks)

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