AUBF (synovial & serous fluids) Flashcards
aka Joint fluid
synovial fluid
aka synovial joint
diarthroses (freely mobile joint)
synovial fluid is found in
diarthroses
synovial fluid is derived from?
“synovia”
means EGG WHITE (same viscosity as synovial fluid)
aka joint cavity
synovium
a joint cavity that filters blood
SYNOVIUM
T/F
Blood is unselectively filtered –plasma goes inside joint cavity, composed of cells called “SYNOVIOCYTES” which produces Hyaluronic Acid
T
specifically produces hyaluronic acid that contributes to synovial fluid viscosity
synoviocytes (cells of joint cavity)
FUNCTIONS OF SYNOVIAL FLUID
- Lubricate joints
- Reduce friction between bones
- Provides nutrients to the articular cartilage
- Lessen shock of joint compression occurring during activities (e.g., walking, jogging)
method of spx collection of synovial fluid
ARTHROCENTESIS
normal synovial fluid volume
<3.5 mL
synovial fluid volume indicating INFLAMMATION
> 25 mL
tubes for synovial fluid (in order) and its purpose
Na Heparin (STERILE) / SPS - Microbiology
LIQUID EDTA / NA Heparin - hematology
Non-anticoagulated - Chemistry & other tests (serology)
Na Fluoride (antiglycolytic) - Glucose analysis
T/F
Synovial fluid normally clot
F
Synovial fluid shouldn’t clot, if clotted then FIBRINOGEN is present - sign of damage or diseased joints
T/F
Powdered EDTA can be used for synovial fluid analysis
F
only LIQUID EDTA
Powdered can be mistaken as crystals
NORMAL synovial fluid color
colorless to pale yellow
synovial fluid color during INFLAMMATION
deeper yellow
synovial fluid color during BACTERIAL INF. (SEPTIC ARTHRITIS)
greenish tinge
synovial fluid color during TRAUMATIC TAP or HEMORRHAGIC ARTHRITIS
red
used to differentiate red colored synovial fluid due to traumatic tap or hemorrhagic arthritis
color
clot formation
*as to the tube order
accidental puncture of peripheral BV during collection of synovial fluid, blood from BV
traumatic tap
The blood present from red colored synovial fluid is NOT the blood coming from BV. It is the bleeding inside joint cavities.
hemorrhagic arthritis
tube positive for clot formation in traumatic tap
microbio tube (tube 1)
differentiate traumatic tap and hemorrhagic arthritis as to color
traumatic tap - decreasing red discoloration intensity (dark red, light red, yellowish)
hemorrhagic arthritis - consistent red discoloration (dark red, dark red, dark red)
differentiate traumatic tap and hemorrhagic arthritis as to clot formation
traumatic tap - (+, -, -) - blood comes from BV
hemorrhagic arthritis - (-, -, -) - all neg since blood present is NOT the blood coming from BV
normal synovial fluid clarity
CLEAR
turbid synovial fluid clarity indicates presence of
Leukocytes
Fibrin
Cell debris
Opaque, Oily, Shimmering synovial fluid clarity indicates
Radiographic contrast media (RCM)
Milky synovial fluid clarity indicates
CRYSTALS presence
Ground Pepper-like inclusions in synovial fluid (clarity) indicates
Ochronosis (degenerative bone dse)
aka ground pepper like inclusions
ochronotic shards
free floating rice bodies in synovial fluid (clarity) indicates
RA
Degenerative synovium (joint cavity) w/ fibrin
normal synovial fluid viscosity as to string formation
4-6mm (long)
normal synovial fluid viscosity as to hyaluronic acid level
0.3-0.4 g/dL
test for synovial fluid viscosity
Ropes/Mucin Clot Test (Hyaluronate Polymerization)
reagent used in Ropes/Mucin Clot Test (Hyaluronate Polymerization)
2-5% HAc
principle of Ropes/Mucin Clot Test (Hyaluronate Polymerization)
2-5% HAc polymerize Hya. Ad. – forms a CLOT = POSITIVE RXN
reporting of Ropes/Mucin Clot Test (Hyaluronate Polymerization)
Good, Fair, Low, Poor
reporting if mucin clot test result is SOLID CLOT
Good
reporting if mucin clot test result is SOFT CLOT
Fair
reporting if mucin clot test result is FRIABLE CLOT
Low
reporting if mucin clot test result is NO CLOT
Poor
T/F
Hemacytometry is also done in synovial fluid
T
Diluting Fluids used for synovial fluid cell ct.
NSS with Methylene Blue
Hypotonic Saline (0.3%)
Saline with Saponin
Specifically recommended for WBC ct. of synovial fluid due to the ability to lyse RBCs
Hypotonic Saline (0.3%)
Saline with Saponin
Specifically recommended for RBC ct. of synovial fluid
NSS with Methylene Blue
What must NOT used for synovial fluid cell counting?
ACETIC ACID as it POLYMERIZES hyaluronic acid causing it to CLOT
remedy for VERY VISCOUS synovial fluid
pinch of hyaluronidase + 0.5mL SF
or
1 drop of 0.05% hyaluronidase in phosphate buffer per mL of SF
–> incubate at 37C for 5min
RBC count of normal synovial fluid
<2,000 /uL
WBC count of normal synovial fluid
<200 /uL
Most abundant WBC in synovial fluid
monocytes/macrophage
Monocytes/macrophage count of normal synovial fluid
65% (most abundant)
Neutrophil count of normal synovial fluid
<25%
Lymphocyte count of normal synovial fluid
<15%
CELLS AND INCLUSIONS SEEN IN SYNOVIAL FLUID
Neutrophils
Lymphocytes
Macrophage (Monocytes)
Synovial Lining Cell
LE cells
Reiter Cells
RA cells (ragocytes)
Cartilage Cells
Rice bodies
Fat droplets
Hemosiderin
PMN WBCs
Neutrophils
Significance of NEUTROPHIL presence in synovial fluid
Bacterial sepsis (septic arthritis)
Crystal-induced inflammation
MN WBCs
Lymphocytes
Significance of LYMPHOCYTES presence in synovial fluid
Non-septic inflammation
Large MN WBCs may be vacuolated
Macrophage (Monocytes)
Significance of MACROPHAGE/MONOCYTES presence in synovial fluid
NORMAL
if elevated: viral infection
NORMAL cells seen in synovial fluid
Macrophage (Monocytes)
Synovial lining cells
Like macrophage but may be multinucleated resembling a mesothelial cell
Synovial Lining Cell
Significance of SYNOVIAL LINING CELLS in synovial fluid
NORMAL!!
Neutrophil containing characteristic ingested “round body”
LE cells
Significance of LE CELLS in synovial fluid
Lupus erythematosus
Vacuolated macrophage with ingested neutrophil
REITER CELLS
Significance of REITER CELLS in synovial fluid
Reiter syndrome
Non-specific inflammation
Neutrophil w/ dark cytoplasmic granules
containing immune complexes
RA cells (ragocytes)
Significance of RA CELLS (RAGOCYTES) presence in synovial fluid
RA
Immunologic inflammation
Large, multinucleated cells abnormally seen in synovial fluid
Cartilage Cells
Significance of CARTILAGE CELLS in synovial fluid
osteoarthritis
Macroscopically resemble polished rice
Microscopically show collagen & fibrin
Rice bodies
Significance of RICE BODIES in synovial fluid
TB
Septic arthritis
RA
Refractile intracellular & extracellular globules
Stained with SUDAN DYES
Fat droplets
Significance of FAT DROPLETS in synovial fluid
Traumatic injury
Chronic inflammation
Inclusions within clusters of synovial cells
Hemosiderin
Significance of HEMOSIDERIN in synovial fluid
Pigmented villonodular synovitis
needle-shaped crystals abnormally found in synovial fluid
Monosodium Urate (MSU)
Rhombic square & rods crystals abnormally found in synovial fluid
Calcium pyrophosphate dihydrate (CPPD)
Notched, rhombic plate crystals abnormally found in synovial fluid
Cholesterol
Flat, variable-shaped plate crystals abnormally found in synovial fluid
Corticosteroid
Envelope-shaped crystals abnormally found in synovial fluid
Calcium Oxalate
Small crystals abnormally found in synovial fluid; requires EM for visualization
Hydroxyapatite /Apatite
(calcium phosphate)
significance of Monosodium Urate presence in synovial fluid
Gout (inc. UA)
significance of Calcium pyrophosphate dihydrate presence in synovial fluid
Pseudogout – degenerative arthritis
significance of Cholesterol presence in synovial fluid
Extracellular (NOT FROM SYNOVIAL FLUID)
significance of Corticosteroid presence in synovial fluid
Injections
significance of Calcium Oxalate presence in synovial fluid
Renal dialysis
significance of Hydroxyapatite presence in synovial fluid
Osteoarthritis
Calcified cartilage degeneration
only crystal abnormally found in synovial fluid with NO BIREFRINGENCE? why?
Hydroxyapatite / Apatite (calcium phosphate)
-> not visible under polarizing microscope
-> requires EM since these are small particles
uses RED compensator, used to confirm or determine the type of birefringence
COMPENSATED POLARIZING MICROSCOPE
used if we want to detect if there’s presence or absence of birefringence
POLARIZING MICROSCOPE
only crystal abnormally found in synovial fluid with POSITIVE BIREFRINGENCE
Calcium pyrophosphate dihydrate (CPPD)
crystals abnormally found in synovial fluid with NEGATIVE BIREFRINGENCE
Monosodium Urate
Cholesterol
Calcium Oxalate
Corticosteroid (may also be POSITIVE)
only crystal abnormally found in synovial fluid with VARIABLE BIREFRINGENCE
Corticosteroid
due to shape (flat, variable-shaped plates)
relationship between the velocity of light from the microscope & the arrangement of crystal molecules
Birefringence
Arrangement of crystal molecules is PARALLEL to the velocity of light? What is the color?
POSITIVE BIREFRINGENCE (+)
yellow
Arrangement of crystal molecules is PERPENDICULAR to the velocity of light? What is the color?
NEGATIVE BIREFRINGENCE (-)
blue
used for chem exam of synovial fluid
GULP
Glu
Uric Acid
Lactate
Protein
Most frequently tested in chemistry test for synovial fluid
Glucose
formula for glucose analysis of synovial fluid? what is the normal value?
Blood glucose – SF Glucose = <10 mg/dL (NORMAL)
indication of increased lactate in synovial fluid (normal: <250 mg/dL)
infection
indication of increased protein in synovial fluid (normal: <3 g/dL)
inflammatory & hemorrhagic disorders
indication of increased UA in synovial fluid (normal: same as blood UA & serum UA = 6-24 mg/dL)
gout
T/F
Difference of blood GLU from synovial fluid GLU (SFG) is INCREASED if SFG is DECREASED during infections (since GLU is utilized)
T
Check the 2nd example:
99 mg/dL (FBS) - 90 mg/dL (SFG) = 9 mg/dL (Normal)
99 mg/dL (FBS) - 40 mg/dL (SFG) = 59 mg/dL (TOO HIGH)
Common organisms that infect synovial fluid
S. aureus - most abundant
Strep
Haemophilus
N. gonorrheae
presence of N. gonorrheae in synovial fluid indicates
gonococcal arthritis
sero test for synovial fluid
Autoantibody detection (SLE, RA) - ANA, Rf
Serologic Tests for lyme disease - frequent complication: arthritis, caused by Borrelia burgdorferi
Types of arthritis
I - Non-inflammatory
IIa - Inflammatory (Immunologic)
IIb - Inflammatory (crystal-induced)
III - Septic
IV - Hemorrhagic
Significance of type I non-inflammatory
Degenerative joint disorder
(osteoarthritis)
SF Color & clarity of type I non-inflammatory
Clear, yellow fluid
SF Viscosity of type I non-inflammatory
Good
WBC ct. of type I non-inflammatory
<1,000/uL
Neutrophil ct. of type I non-inflammatory
<30%
Glucose of type I non-inflammatory
NORMAL
Significance of type IIa inflammatory (immunologic)
Immunologic disorders (RA, SLE, etc)
SF Color and intensity of type IIa inflammatory (immunologic)
Cloudy, yellow fluid
SF viscosity of type IIa inflammatory (immunologic)
Poor
WBC ct. of type IIa inflammatory (immunologic)
2,000 – 75,000/uL
Neutrophil ct. of type IIa inflammatory (immunologic)
> 50%
Glu of type IIa inflammatory (immunologic)
Decreased
Other testing for type IIa inflammatory (immunologic)
Sero test for AUTOANTIBODIES
Significance of type IIb inflammatory (crystal-induced)
Gout - MSU
pseudogout - CPPD
SF color and clarity of type IIb inflammatory (crystal-induced)
Cloudy or milky fluid
SF viscosity of type IIb inflammatory (crystal-induced)
Low
WBC ct. of type IIb inflammatory (crystal-induced)
Up to 100,000/uL
Neutrophil ct. of type IIb inflammatory (crystal-induced)
<70%
Glu of type IIb inflammatory (crystal-induced)
Decreased
Other tests/indication for presence of type IIb inflammatory (crystal-induced)
(+) crystals
Significance of type III septic
Microbial infection
SF color and intensity of type III septic
Cloudy, green fluid
SF viscosity of type III septic
Variable
WBC ct. of type III septic
50,000 – 100,000/uL
Neutrophil ct. of type III septic
> 75% (highest among other types)
Glu of type III septic
Decreased (highly increased lactate)
other tests for confirming type III septic
(+) gram stain
(+) culture
Significance of type IV hemorrhagic
Traumatic injury
Coagulation deficiencies
SF color and intensity of type IV hemorrhagic
Cloudy, red fluid
SF viscosity of type IV hemorrhagic
Low
WBC ct. and neutrophils of type IV hemorrhagic
Equal to blood
Glu of type IV hemorrhagic
Normal
Other tests to identify type IV hemorrhagic
(+) RBCs
type of arthritis with NORMAL GLUCOSE
type I (non-inflammatory)
type IV (hemorrhagic)
SF clarity for all of the following is CLOUDY, except:
a. type I
b. type IIa and b
c. type III
d. type IV
a. type I - clear SF
Ultra filtrate of plasma, provides lubrication between two membrane (parietal & visceral)
SEROUS FLUID
Fluid between parietal and visceral membranes (only filter blood, doesn’t produce additional substance like synovium)
SEROUS FLUID
3 types of serous fluid and its location
Pleural fluid – lungs
Pericardial fluid – heart <3
Peritoneal fluid – abdominal area
accumulation of excess fluid between the membranes
effusion
types of serous effusion
transudate
exudate
transudate is caused by
Systemic Condition
exudate is caused by
Membrane Damage
All serous fluids are affected
Transudate
Only one serous fluid affected,
specific membrane only
Exudate
causes of TRANSUDATE presence
Hypoproteinemia
Congestive heart failure
Nephrotic syndrome
Cirrhosis
Malnutrition
causes of EXUDATE presence
Infection (e.g., pneumonia, TB, endocarditis)
Inflammation
Malignancy (e.g., adenoma)
differentiates exudates (+) from transudates (-)
RIVALTA’S TEST – SEROSAMUCIN CLOT TEST
how is RIVALTA’S TEST – SEROSAMUCIN CLOT TEST performed? what is the result?
HAc + WATER + Unknown Fluid (effusion)
(+) heavy precipitation = exudates
most reliable tests to differentiate transudates & exudates
Fluid: Serum Protein Ratio
Fluid: Serum LD Ratio
what must be done for pH testing of serous fluid?
stored during transport ANAEROBICALLY in ice
method of collection of pleural fluid
Thoracentesis
method of collection of pericardial fluid
Pericardiocentesis
method of collection of peritoneal fluid
Paracentesis
tubes for serous fluids (in order) and purpose of each
EDTA - Cell / Diff count
Sterile Heparin Tube - Microbiology / Cytology
Heparin Tube - Chemistry
Plain Tube - Clotting test (for spontaneous clotting = (+) exudate)
normal volume of pleural fluid
<30 mL
Significance of clear, yellow pleural fluid
NORMAL!!
Significance of turbid, white pleural fluid
microbial inf
Significance of brown (anchovy sauce-like) pleural fluid
Ruptured amoebic abscess – extraintestinal amoebiasis (Entamoeba histolytica)
Significance of black pleural fluid
Aspergillosis
Significance of viscous pleural fluid
Malignant mesothelioma – produces Hya. Ad
Significance of milky pleural fluid
Chylous material
Pseudochylous material
*differentiated
Significance of bloody pleural fluid
Hemothorax
Hemorrhagic effusion
*differentiated
with INCREASED TAG causing milky pleural fluid
Chylous effusion
with INCREASED CHOLE causing milky pleural fluid
Pseudochylous effusion
cause of chylous effusion
Thoracic duct leakage
appearance of chylous effusion
Milky / white
cause of pseudochylous effusion
Chronic inflammation / infection
appearance of pseudochylous effusion
Milky / green tinge / “gold paint”
green & gold paint - from infection
leukocytes found in chylous effusion
lymphocytes
*lymphatic duct is both rich in lymphocytes and chylomicrons (increases conc. of TAG)
leukocytes found in pseudochylous effusion
mixed cells
cholesterol crystal presence/absence in chylous effusion
ABSENT
cholesterol crystal presence/absence in pseudochylous effusion
PRESENT
TAG value in chylous effusion
> 100 mg/dL
TAG value in pseudochylous effusion
<50 mg/dL
Sudan III staining result in chylous effusion
+
SUDAN III - mainly for TAG staining
Sudan III staining result in pseudochylous effusion
- or weakly +
blood distribution in HEMOTHORAX
Uneven
N PF + Blood
blood distribution in HEMORRHAGIC EFFUSION
Even
inc. PF + Blood
similar with traumatic tap, presence of blood in pleural fluid due to injury)
hemothorax
bleeding in pleural cavity due to membrane defect
hemorrhagic effusion
used to differentiate bloody pleural fluid (hemothorax and hemorrhagic effusion)
hematocrit
pleural fluid HCT indicating hemothorax
PF Hct is ≥1/2 of WB Hct
pleural fluid HCT indicating hemorrhagic effusion
PF Hct is <1/2 of WB Hct
Abnormal pleural fluid cells
Neutrophil
Lymphocyte
Mesothelial cells
Plasma cells
Malignant cells
Eosinophil
Significance of neutrophil presence in pleural fluid
Pneumonia
Pulmonary infarction
Pancreatitis
Significance of lymphocyte presence in pleural fluid
TB
viral infections
autoimmune disorders
malignancy
Significance of Mesothelial cells presence in pleural fluid
NORMAL (regardless of the form - normal/reactive)
DECREASED: TB
lines the serous membrane lining/cavity
mesothelial cells
Significance of plasma cells presence in pleural fluid
TB
Significance of MALIGNANT cells presence in pleural fluid
Primary adenocarcinoma
small cell carcinoma
metastatic carcinoma
Significance of eosinophil presence in pleural fluid
if >10% - trauma resulting from presence of air/blood in PF sample, allergy/parasitic infection
TUMOR MARKERS FOR EFFUSIONS OF MALIGNANT ORIGIN FOR PLEURAL FLUID
CEA
CA 125
CA 15-3, CA 549
CYFRA 21-1
significance of CEA in effusions
colon cancer
significance of CA 125 in effusions
metastatic uterine cancer
significance of CA 15-3, CA, 549 in effusions
breast cancer
significance of CYFRA 21-1 in effusions
lung cancer
concentric striations of collagen-like material found in peritoneal fluid seen in benign conditions
PSAMMOMA BODIES
PSAMMOMA BODIES is associated with conditions such as
ovarian malignancies
thyroid malignancies
chem test for pleural fluid
Glucose
Lactate
TAG
pH
Adenosine deaminase
Amylase
significance of decreased GLU in pleural fluid
rheumatoid inflammation
TB
purulent infection
significance of increased LACTATE in pleural fluid
bacterial infection
significance of increased TAG in pleural fluid
chylous effusion
significance of decreased pH in pleural fluid
pneumonia not responding to antibiotics
complicated parapneumonic effusion (assoc. with empyema)
esophageal rupture
extremely low pH of pleural fluid is associated with? what is the pH?
Esophageal rupture (pH 6.0)
significance of adenosine deaminase in pleural fluid
Malignancy
Tubercular effusion
significance of amylase in pleural fluid
Esophageal rupture
malignancy
pancreatitis (increased)
chem test indicating esophageal rupture using pleural fluid
pH 6.0
amylase
common bacteria causing Pleural Effusion
S. aureus
Enterobacteriaceae
M. tuberculosis
Anaerobic bacteria
normal volume of pericardial fluid
<50 mL
normal color of pericardial fluid
Clear, pale yellow
color of pericardial fluid in presence of TRANSUDATE
Clear, pale yellow (similar to NORMAL)
color of pericardial fluid during infection, malignancy
Blood-streaked
color of pericardial fluid during cardiac puncture, anticoagulant medication
Grossly bloody
inc. neutrophil in pericardial fluid indicates
bacterial endocarditis
malignant cells in pericardial fluid indicates
Metastatic carcinoma
tests for pericardial fluid
glucose
gram stain and culture
acid fast stain
adenosine deaminase
decreased GLU in pericardial fluid indicates
Bacterial infection
Malignancies
+ gram stain and culture using pericardial fluid indicates? what are the common agents causing pericardial effusion?
Bacterial endocarditis
haemophilus, adenovirus, coxsakievirus, strep, staph (HACSS)
tests used to identify TUBERCULAR EFFUSION
Acid-fast Stain
Adenosine deaminase
aka peritoneal fluid
ASCITIC FLUID
ascitis - effusion in peritoneal cavity
normal vol. of peritoneal fluid
<100 mL
(highest vol among other fluids; abdominal area is larger than cardiac and lungs)
normal peritoneal fluid color
clear, pale yellow
peritoneal fluid color in microbial inf.
turbid
peritoneal fluid color in gall bladder and pancreatic disorder
green
peritoneal fluid color in trauma, inf, malignancy
blood-streaked
peritoneal fluid color in lymphatic trauma and leakage
milky
normal WBC count in peritoneal fluid
<500/uL
abnormal WBC count in peritoneal fluid indicating bacterial peritonitis and cirrhosis
> 500/uL
inc. neutrophils in peritoneal fluid indicates
Bacterial peritonitis
test used to indicate blunt trauma injury using peritoneal fluid? what is the value?
peritoneal lavage
>100,000 RBC/uL
CEA in peritoneal fluid indicates
malignancy GI in origin
CA 125 in peritoneal fluid indicates
malignancy ovarian in origin
decreased GLU in peritoneal fluid indicates
Tubercular peritonitis
malignancy
increased AMY in peritoneal fluid indicates
Pancreatitis
increased Alkaline phosphatase in peritoneal fluid indicates
GI perforation
alkaline phosphatase test result using peritoneal fluid during GI perforation
INCREASED ALP
BUN/CREATININE in peritoneal fluid indicates
Ruptured / punctured bladder
+ gram stain & culture in peritoneal fluid indicates
Bacterial peritonitis
tests used to identify TUBERCULAR PERITONITIS
Acid-fast Stain
Adenosine deaminase
dec. Glu