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Clinical Microscopy > CSF and other body fluids > Flashcards

CSF and other body fluids Flashcards

1
Q

The blood brain barrier is made up of

A

choroid plexus and capillaries

*protects brain from microorganisms

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2
Q

Secretion and filtrate of the choroid plexus

A

Cerebrospinal fluid

*clear, colorless, sterile

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3
Q

Low levels of these are found in CSF

A

complement, antibody and phagocytes

Na, Mg, Cl are more concentrated

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4
Q

Examination of a sample of the fluid surrounding the brain and spinal cord

A

CSF analysis

*also identification of infectious agents during infection

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5
Q

What is the purpose of CSF analysis?

A

(to diagnose medical disorders that affect the CNS)
• Viral and bacterial infections
• Tumors or cancers of the CNS
•Bleeding around the brain and spinal cord
• Multiple sclerosis
• Guillain-Barré syndrome (caused by C. jejuni)

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6
Q

T or F: CSF collection* must be done prior to antimicrobial therapy

*follow institutional SOP

A

true

*Bacterial findings change even after just the first dosage administration of the antibiotic

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7
Q

What is used for preparing puncture site for CSF specimen collection?

A
  • Disinfection of skin

* Use isopropyl alcohol then 2% tincture of iodine (for culture)

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8
Q

CSF collection techniques

A
  • Subdural tap (extraction at fontanelle of infants)
  • Ventricular aspirate (extraction directly from ventricles of the brain through catheters)
  • lumbar puncture or spinal tap
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9
Q

During lumbar puncture, the physician inserts a thin, hollow needle in the space between two vertebra of the lower back and slowly advances it towrards what?

A

subarachnoid space in lumbar spine

*CSF pressure is then measured and fluid is withdrawn

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10
Q

Risks of lumbar puncture or spinal tap

A

paralysis
death
iatrogenic infection

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11
Q

Specimen container (three or more sterile, leak-proof tubes) numbers and analysis

A

1 - Chemistry
2 - Microbiology
3 - Hematology (Microscopy)
4 - Additional (i.e.: immunology, serology)

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12
Q

T or F: The tube that is the most turbid is the one with highest bacterial load

A

true

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13
Q

Where should aspirated material be placed in if specimen will come from brain abscess?

A

anaerobic container

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14
Q

Recommended volume for detection of microorganism

A

5-10 ml (in total); 2 ml for children

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15
Q

Consequence of inadequate volume

A

• Lower sensitivity
• False negative results
Solution: prioritize which laboratory test to be performed (chemical and microbiological analyses)

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16
Q

T or F: delivery after csf collection can be done within an hour

A

false, immediately

*incubate only at room temp.
*delays:
• Room temperature: microbiology
• Refrigerated: hematology (microscopy)
• Frozen: chemistry, immunology, serology
> Viral studies (-70ºC)

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17
Q

Why should specimen be done immediately?

A
  • Neutrophils lyse due to hypotonicity
  • Cell count decreases when kept at room temperature (1 hr= 32%; 2 hrs = 50%)
  • Fastidious organisms may not survive a long delay and variation in temperature (S. pneumoniae: easily autolyzes; N. meningitidis: susceptible to cold temperature)
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18
Q

(see preliminary processing)

A

(see preliminary processing)

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19
Q

T or F: abnormal CSF is crystal clear

A 
false, supernatant : 
(1) turbidity; 
(2) xanthochromia
sediment:
(3) blood clots
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20
Q

Turbidity of CSF indicates

A

presence of WBC, bacteria, increased protein or lipid
• ≥ 200 WBCs per mm3
• 400 RBCs per mm3

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21
Q

Discoloration or xanthochromia is due to

A
  • Lysis of RBCs resulting in hemoglobin breakdown to oxyhemoglobin, methemoglobin, and bilirubin
  • CSF protein ≥ 150 mg/dL
  • Traumatic tap (bloody tap)
  • Newborns
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22
Q

Why do newborns experience xanthochromia?

A

frequent elevation of bilirubin and protein levels (physiologic jaundice)

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23
Q

Interpretation of yellow CSF

A
  • Blood breakdown products
  • Hyperbilirubinemia
  • Increased CSF protein
  • Increased RBC
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24
Q

Orange CSF is most likely due to

A

• Blood breakdown products
• High carotenoid ingestion (especially
in children)

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25
Q

Pink CSF?

A

Blood breakdown products

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26
Q

Brown CSF?

A

meningeal melanomatosis

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27
Q

Green CSF is due to:

A
  • Hyperbilirubinemia

* Purulent CSF (brain abscess)

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28
Q

Clots in CSF wherein there is increased filtration of protein and coagulation factors

A

meningitis

*traumatic tap = plasma fibrinogen

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29
Q

Methods of determining CSF protein

*ref ranges: 15-45 mg/dl

A
  • Turbidimetric method (precipitation of protein: sulfosal acid + TCA, Nonne-Apelt reaction, Pandy’s test, Ross-Jones Test)
  • Dye binding techniques
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30
Q

Method of choice for protein precipitation

A

TCA

ppt albumin and globulin

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31
Q

T or F: a larger sample size is needed in dye binding technique

A

false, smaller

*less interference from external sources

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32
Q

Dye used in dye binding techniques which bind to avariety of proteins and changes color from red to blue

A

Coomasie Brilliant Blue G250

  • Intensity of blue color is related to the concentration of
    protein
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33
Q

When is CSF protein elevated?

A
  • Infections
  • Intracranial hemorrhages
  • Multiple sclerosis
  • Guillain-Barré syndrome
  • Malignancies
  • Some endocrine abnormalities
  • Certain medication use
  • Variety of inflammatory conditions
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34
Q

T or F: presence of rbcs in traumatic tap falsely elevates protein in CSF

A

true

• Correction:
> Subtract 1 mg/dL (0.01 g/L) of protein for every 1,000 RBCs per mm3
> Accurate if the same tube is used for protein analysis and cell counts

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35
Q

Conditions which cause low protein in CSF

A
  • Repeated lumbar punctures
  • Chronic leak
  • Acute water intoxication
  • Idiopathic intracranial hypertension
  • CSF protein levels do not fall in hypoproteinemia
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36
Q

When is CSF glucose measured?

A

during the preceding 2-4 hours

*immediately done because of glycolysis

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37
Q

What is the normal adult value of CSF glucose?

A

2/3 of serum glucose

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38
Q

T or F: Infections usually have high CSF glucose

A

False, low

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39
Q

T or F: normal glucose levels do not rule out infection

A

true

  • Usually normal levels in viral infections
  • Up to 50% of patients with bacterial meningitis will have normal CSF glucose levels
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40
Q

T or F: Viral infections causes elevated CSF glucose

A

false, There is no pathologic process that causes CSF glucose levels to be elevated

*Although elevated siya in elevated blood glucose

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41
Q

When is CSF blood glucose low?

A
  • Meningitis
  • Subarachnoid hemorrhage
  • Inflammatory conditions
  • Hypoglycemia
42
Q

This is more accurate than glucose in diagnosing and managing of meningitis

A

CSF lactate

25 mg/dL in bacterial, fungal and TB meningitis

43
Q

Where is CSF lactate seen?

A

oxygen depravation; falsely elevated in xanthochromic or hemolyzed fluid (lactate that are concentrated in RBCs become released)

44
Q

Normal cell count in adults and newborns in CSF

A

Adult: 0-5 WBCs per mm3
Newborn: 0-20

45
Q

Predominant WBC in adults in CSF

A

lymphocytes

46
Q

Predominant WBC in newborns in CSF

A

neutrophils

47
Q

Elevated WBC in CSF is caused by

A
  • Infections and inflammatory disease
  • Seizures
  • Intracerebral hemorrhage
  • Malignancy
  • Traumatic tap
48
Q

Normal cell differential count in adult CSF

A

70% lymphocytes

30% monocytes

49
Q

T or F: Several PMNs in a neonatal patient’s CSF is normal

A

true

50
Q

Where does abnormal cell diff count depend on

A

type of meningitis

see typical CSF findings in various types of meningitis

51
Q

Staining methods for microbiologic analysis of CSF

A 
• Gram staining
• Acid Fast staining
• Other stains:
- India ink
- Wright or Giemsa
52
Q

percent positive found in untreated cases and partially treated cases of bacterial meningitis

A 
untreated = 60-80%
p.t. = 40-60%
53
Q

Factors affecting sensitivity of gram staining

A
  • Laboratory technique used to concentrate (i.e.: cytocentrifugation = ^ detection; ^CFU = ^+; 200-1000 rpm for 5-10 minutes)
  • Experience of laboratory personnel (up to 10% of initial Gram stains are misread)
54
Q

When is acid fast staining used?

A

if TB is clinically suspected

*increased sensitivity when: 4 smears done; CSF sediment is examined

55
Q

When is india ink used?

A

for encapsulated organisms (i.e.: Cryptococcus)

56
Q

When is Wright or Giemsa stain used?

A

for blood protozoa (i.e.: Toxoplasma sp.)

57
Q

This increases yield as volume of CSF increases

A

culture

  • solid media in bacterial culture: BAP, Chocolate agar (for H. influenzae and Neisseria sp.)
  • Broth media: Thioglycolate, TSB
  • for mycobacteria: Lowenstein-Jensen
58
Q

What can decrease sensitivity of bacterial culture*?

*gold standard

A

antibiotic treatment prior to lumbar puncture

59
Q

Principle of rapid immunologic screen for antigens

A

Clinical diagnosis requires detection of microorganisms as readily as possible; uses panel tax agglutination

60
Q

T or F: rapid immunologic screen for antigens can replace culture

A

false

61
Q

rapid immunologic screen for antigens

RISA

A
  • Direct Antigen Detection Test

* PCR

62
Q

RISA with rapid detection even at low levels of antigen (cases with prior antibiotic therapy)

A

Direct Antigen Detection Test (DADT)

  • supplement to gram stain and culture
  • based on latex agglutination
63
Q

Most commonly isolated pathogens in DADT

A

H. influenza type B

  1. S. pneumoniae
  2. N. meningitidis
  3. Group B strep (S. agalactiae)
64
Q

RISA with high sensitivity and specificity; fast; requires small volume of CSF; expensive and useful in diagnosis of VIRAL INFXNS

A

PCR

65
Q

Other serologic tests for microbiological analysis

A

• Direct neurosyphilis

Venereal Disease Research Laboratory (VDRL) test, Fluorescent Treponemal Antibody Absorption (FTA-ABS) test

66
Q

(see Common organisms causing acute meningitis per patient group)

A

(see Common organisms causing acute meningitis per patient group)

67
Q

Pathologic filtrates of the circulatory system that occur due to
varying causes

A

Transudates and exudates

*during non-pathologic conditions: known as lymph (normal circulatory filtrate)

68
Q

Accumulation of transudates/exudates in serous cavities in the body that can occur due to pathologies

A

Effusion

69
Q

T or F: Diagnosis of pathology can be done by identifying whether the fluid is transudative or exudative

A

true

70
Q

fluids of inflammatory origin which occurs due to increased capillary permeability or decreased lymphatic resorption

A

Exudates

71
Q

Exudates are secondary to

A
  • Infection (usually bacterial)

* Carcinoma/Cancer

72
Q

This requires the use of chest tubes because the fluid (which contains infectious material) must be continuously drained

A

Exudates

73
Q

Fluids of non-inflammatory origin which are ultrafiltrates of plasma through capillary endothelium

A

Transudates

*secondary to: 
• Hypoproteinuria
• Venous obstruction
• Cardiac failure
• Disturbance in circulation with passive congestion
74
Q

Characteristics of transudates

A

Colorless, odorless, negative coagulation, alkaline, sg < 1.018, protein content < 2.5 gm%, N or increased glucose, few cells (lympho), absent mucin

75
Q

Characteristics of exudates

A

Darker, turbid, variable, positive coagulation, acidic, sg > 1.018, protein content >2.5 gm%, low glucose, increased cells (PMNs), present mucin

76
Q

Lymph that is found in the serous cavity surrounding the lungs

A

Pleural fluid

77
Q

Function of pleural fluid

A

• Function: provides a frictionless surface between two pleurae in response to changes in lung volume with respiration; for the proper expansion of the lungs

78
Q

Characteristics of pleural fluid

A
  • Volume = 1 to 10 mL
  • pH 7.60 to 7.64
  • Protein content <2% (1 to 2 g/dL)
  • WBCs ≤ 1000/mm3
  • LDH <50% of plasma
  • Glucose content is similar to that of plasma/blood
  • Sodium, potassium, and calcium concentration similar to that of interstitial fluid
79
Q

This is the abnormal accumulation of fluid in the pleural space which results from the disruption of the fluid production and reabsorption equilibrium that exists across pleural membranes

A

Pleural effusion

*Indicator of a pathologic process that may be of primary pulmonary origin or of an origin related to another organ system or to systemic disease

80
Q

Light’s criteria (if at least one is met; fluid is an exudate; none= transudate) IMPORTANT!!

A
  1. Pleural fluid protein to serum protein ratio > 0.5
  2. Pleural fluid LDH to serum LDH ratio > 0.6
  3. Pleural fluid LDH > 2/3 the upper limits of normal serum LDH

*If the criteria are not satisfied despite of high suspicion, you need to examine serum-to-pleural fluid albumin
® If <1.2, classify as exudate; >1.2, transudate

81
Q

(see mechanisms of pleural effusion)

A

(see mechanisms of pleural effusion)

82
Q

Why is it important to differentiate pleural fluid as exudate or transudate?

A
  • Each fluid type suggests different pathologies, therefore the treatment to be given also varies
  • Also determines whether further testing is needed
83
Q

T or F: Pleural fluid analysis is only done on transudative pleural effusion

A

False, exudative only

*transudatives = no further work up

84
Q

Pleural fluid specimen container used for determination of protein, LDH, amylase, and glucose levels (also triglyceride cholesterol level if needed)

A

Plain red-top tube

85
Q

Pleural fluid specimen container used for CELL COUNT AND DIFF

A

EDTA-treated,

lavender-top tube

86
Q

Pleural fluid specimen container used for pH specimen

A

Heparin-treated blood gas syringe

87
Q

Sterile containers in pleural fluid specimen collection is used for

A

Gram staining and culture (for aerobic and anaerobic organisms,
mycobacteria, fungi)

88
Q

50-ml heparin-treated containers are used for

A

cytologic analysis

89
Q

Further laboratory investigation performed on exudative

effusions:

A
  • Total protein level, glucose level, LDH level, amylase level
  • pH
  • Cell count with differential
  • Cytological analysis
  • Staining, culturing, and sensitivity testing for aerobic/anaerobic organisms
90
Q

T or F: bloody pleural effusions are mostl likely an indication of malignancy in the absence of trauma; can also indicate pulmonary embolism, infection, pancreatitis, tuberculosis, mesothelioma, or spontaneous pneumothorax

A

true

91
Q

T or F: Turbid pleural effusion is due to presence of chyle, cholesterol or empyema

A

false, turbid is due to increased cellular or lipid content

Yellow/whitish, turbid = chyle

92
Q

What causes brown pleural (choco, anchovy paste) effusion?

A

Rupture of amoebic liver abscess into the pleural space (amoebiasis with a hepatopleural fistula)

93
Q

Black pleural effusion is due to

A

aspergillus involvement of pleura

94
Q

Rheumatoid pleurisy causes this pleural effusion

A

Yellow-green with debris

95
Q

T or F: highly viscous pleural fluid is due to anaerobic infxn

A

false, putrid odor = anaerobic infxn.; highly viscous= malignant mesothelioma due to increased levels of hyaluronic acid; long standing pyothorax

96
Q

ammonia odor in pleural effusion is due to

A

urinothorax

97
Q

purulent pleural effusion is due to

A

empyema

98
Q

yellow and thick effusions with melatic stain-like sheen are rich in

A

choletserol (longstanding chyliform effusion, e.g., tuberculous or rehumatoid pleuritis)

99
Q

A low pleural fluid glucos (<60 mg/dL) is seen in

A

TB, malignancy, rheumatoid pleurisy

*otthers: complicated parapneumonic effusion, empyema, hemothorax, paragonimiasis, Churg-Strauss syndrome and lupus pleuritis
(occassionally)

100
Q

This chemical in pleural effusion is an indicator of the degree of pleural inflammation

A

LDH

higher = more inflamed pleural surface

101
Q

This chemical is elevated when greater than the upper limit for serum levels or when pleural fluid to serum amylase ratio is ≥ 1

A

Amylase

• Used for monitoring/detecting: acute pancreatitis, pancreatic pseudocyst, esophageal rupture, malignancy, and ruptured ectopic pregnancy

102
Q

What does a pleural fluid pH <7.2 suggest?

A
  • Empyema
  • Paragonimiasis
  • Esophageal rupture
  • Hemothorax
  • Rheumatoid pleuritic
  • Tuberculous/Lupus pleuritis
  • Malignancy
  • Urinothorax
  • Complicated parapneumonic effusion

Clinical Microscopy (10 decks)

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