Angeles University Foundation

College of Allied Medical Profession

Clinical Microscopy:
Case Study Analysis

In partial fulfillment of the requirements in

Clinical Microscopy

Group 8

Guevarra, Sonny

Mungcal, Lilibeth

Sarmiento, Norilie

Tayag, Joseph

BSMT 3-A

Submitted to:

Ms. Crizelda Liwanag

March 04, 2010

 Summary of the case

Thoracentesis was performed on a 60-year old female in –patient at the local hospital. She
has been complaining of fatigue and inability to perform her favorite hobby which is gardening
for a period longer than 10 minutes without experiencing any shortness of breath. Her ankles
and legs seem edematous. She says that in some instances, she has awakened at night, gasping
for air. On other nights, she was unable to sleep unless sitting upright. Upon hospitalization, the
nurse has noticed that she is also exhibiting signs of nocturia, distended neck veins and distant
heart sounds. The results of the pericardial specimen are as follows:

Color: Reddish-yellow
Appearance: Clear
WBC count: 450/ul
Fluid to serum protein ratio: 0.38
Serum to fluid LD ratio: 0.45
Answer to guide questions

1. Is the specimen collected is classified as an exudate or transudate? Why?

 The specimen is classified as transudate because all the test results are
consistent with those of a transudate. It is classified as such because the WBC
count is less than 1000/ul. Also the fluid serum ratio and the serum to fluid LD
ratio are less than 0.5 and 0.6 respectively.

2. List two other tests that could be performed to aid in classifying the fluid.

 Determining the cholesterol ratio and bilirubin ratio of the sample. To be able to
classified the fluid as a transudate, the cholesterol should be less than 0.3 and
the bilirubin ratio should be less than 0.6.

3. What could be the patient diagnosis? Explain.

 The diagnosis could be likely a congestive heart failure. To diagnose congestive

heart failure, the physical examination is focused on detecting the presence of extra
fluid in the body (breath sounds, leg swelling, or neck veins) as well as carefully
characterizing the condition of the heart (pulse, heart size, heart sounds, and murmurs).
Also pericardial effusion is classified to be a transudate which is evident on systemic
disease such as congestive heart failure

4. In which other body cavity can effusion accumulate in these type of patients?

 Effusion can also accumulate in peritoneal and pleural cavity.

5. If the WBC count is 10,000/uL would the diagnosis change? What other results will be
expected to change with this finding?

 Yes. It will become exudate. Because the exudates has a WBC count of more
than 1,000. Also the the fluid serum ratio and the serum to fluid LD ratio would
be greater than 0.5 and 0.6 respectively.

Pertinent Information
 Serous fluids are formed as ultrafiltrate of plasma, which results in an increased oncotic
pressure in the capillaries that reabsorption of fluid back into the capillaries; it produces a
continuous exchange of serous fluid and maintains the normal volume of fluid between the
membranes. This fluid serves as lubricant between the membranes, permitting free movement
of the enclosed organ.

Transudates – are effusions that have accumulated because of systemic diseases such as
congestive heart failure and liver cirrhosis

Exudates- usually form in association with a localized process involving the membranes, such as
inflammation, malignancy or infection.

Note: characterizing an effusion as transudate or exudates useful in making a decision

concerning the need for further laboratory evaluation and testing.

Differentiation of Transudates and Exudates

Transudates Exudates

Appearance Clear Cloudy

Specific gravity < 1.015 >1.025

Fluid: serum protein ratio <0.5 >0.5

Fluid: serum LD ratio <0.6 >0.6

WBC count <1000/uL >1000/Ul

Spontaneous clotting No Possible

Pleural fluid cholesterol <45-60 >45-60

mg/dl mg/dl

Pleural fluid: serum cholesterol <0.3 >0.3

ratio
Pleural fluid: bilirubin ratio <0.6 >0.6

Serum – ascites albumin gradient >1.1 <1.1

Pericardial fluid

The pericardial fluid is a serous fluid that is secreted by the visceral pericardium into the
pericardial cavity. The normal appearance he normal appearance of a sample of pericardial
fluid is straw colored and clear. Abnormal results may give clues to the conditions or diseases
present and may include: Milky appearance may point to lymphatic system involvement.
Reddish color may indicate the presence of blood. Cloudy thick pericardial fluid may indicate
the presence of microorganisms and/or white blood cells. Pericardial fluid is made up of a high
concentration of lactate dehydrogenase (LDH), protein and lymphocytes. In a healthy
individual there is usually 15-50ml of clear, straw-coloured fluid.

 Function

It reduces friction within the pericardium by lubricating the epicardial surface

allowing the membranes to glide over each other with each heart beat

 Clinical significance and diseases

Pericardial fluid analysis is used to help diagnose the cause of inflammation of

the pericardium called pericarditis and/or fluid accumulation around the heart
(pericardial effusion) and other specific diseases such as:

 Infectious diseases – caused by viruses, bacteria, or fungi.

 Bleeding – bleeding disorders and/or trauma can lead to blood in the pericardial
fluid.
 Inflammatory conditions – pericarditis may follow a heart attack, radiation
treatment, or be part of autoimmune disorders such as rheumatoid arthritis and
systemic lupus erythematosus.
 Cancer – such as mesothelioma that has arisen in the pericardium or metastatic
cancer that has spread to it.
  Collection
Pericardiocentesis is the removal of pericardial fluid from the pericardial sac with a
needle and syringe.

Procedure:

o An intravenous (IV) line may be started and the person may be given medications
prior to the sample collection. The patient is positioned lying down. A local
anesthetic is applied, then the doctor inserts the needle into the space between
the ribs (fifth to sixth intercostals space) on the left side of the chest and into the
pericardial sac and removes a fluid sample. An ultrasound may be used to help
guide the needle.

 Laboratory tests
Two most common tests done in pericardial fluid are LDH and protein ratio. These
are primarily used to differentiate from exudates and transudate

Transudate Exudate
LDH ratio <0.6 >0.6
Protein ratio <0.5 >0.5

o Cytologic examinations – primarily used in initial investigations of pericardial

effusions of unclear etiology
o WBC count – elevated leukocytes is usually associated with bacterial or
rheumatic cause

Significance of the findings

Physical characteristics – the normal appearance of a sample of pericardial fluid is straw
colored and clear. Abnormal results may give clues to the conditions or diseases present and
may include:

 Milky appearance—may point to lymphatic system involvement

 Reddish pericardial fluid may indicate the presence of blood
 Cloudy thick pericardial fluid may indicate the presence of microorganisms and/or white
blood cells

Chemical tests –in addition to protein or albumin, a glucose test may be performed. Glucose in
pericardial fluid samples is typically about the same as blood glucose levels. It may be lower
with infection.

Microscopic examination – Normal pericardial fluid has small numbers of white blood cells
(WBCs) but no red blood cells (RBCs) or microorganisms. Laboratories may examine drops of
the pericardial fluid and/or use a special centrifuge (cytocentrifuge) to concentrate the fluid’s
cells at the bottom of a test tube. Samples are placed on a slide, treated with special stain, and
an evaluation of the different kinds of cells present is performed.

1. Total cell counts—quantity of WBCs and RBCs in the sample. Increased WBCs may be seen
with infections and other causes of pericarditis.
2. WBC differential—determination of percentages of different types of WBCs. An increased
number of neutrophils may be seen with bacterial infections.
3. Cytology – a cytocentrifuged sample is treated with a special stain and examined under a
microscope for abnormal cells. This may be done when a mesothelioma or metastatic
cancer is suspected. The presence of certain abnormal cells, such as tumor cells or
immature blood cells, can indicate what type of cancer is involved.

Congestive Heart Failure

  Pathophysiology

Congestive heart failure (CHF) refers to the inability of the heart to supply adequate
blood output relative to the body's needs. In CHF, the heart suffers from decreased pumping
ability, volume overload, and impaired filling of its chambers. It may affect either the right or
left ventricle. Left heart failure is the inability of the heart to meet the blood and oxygen needs
of the body. It occurs if the left ventricle has an overload of fluid due to the inability to pump
out the blood it receives from the lungs to the rest of the body. Right heart failure is a result of
left heart failure and occurs when the left ventricle has failed completely to contract.

The most common underlying heart conditions associated with CHF are cardiac ischemia
(ischemic cardiomyopathy), dilated cardiomyopathy, valvular regurgitation, aortic stenosis, and
severe hypertension.

 Signs and symptoms

o Shortness of breath – Blood backs up in the pulmonary veins (the vessels that
return blood from the lungs to the heart) because the heart can't keep up with the
supply. This causes fluid to leak into the lungs.
o Edema (legs and ankle) - The kidneys are less able to dispose of sodium and
water, also causing fluid retention in the tissues because of the failure of the right
ventricle leads to congestion of systemic capillaries.
o Distended neckveins – The distended neck veins reflect the accumulation of blood in
the veins that are returning blood to the heart.
o Nocturia – may occur when fluid from the legs is returned to the bloodstream while
lying down at night.
o Distant heart sounds – Auscultation of the heart reveals an S3 heart sound.
o Fatigue - The heart can't pump enough blood to meet the needs of body
tissues. The body diverts blood away from less vital organs, particularly muscles in the
limbs, and sends it to the heart and brain.
o Lack of appetite, nausea - The digestive system receives less blood, causing
problems with digestion.

 Treatment

o Diuretics (for example, Lasix) - to reduce total blood volume

o Digoxin - to strengthen contractility of the heart muscle
o Vasodilators - to reduce ventricular load
o Inotropic Drugs – to increase the contractile force of the myocardium
 o Antiarrhythmic therapy
o Oxygen supplementation
o Endotracheal intubation and mechanical ventilation

References:

Urinalysis and body fluids by S.K. Strasinger and M. di Lorenzo

Urinalysis and body fluids by Landy J. Mcbride
Essetials of Clinical Cardiology by: Emmanuel Goldbeger
http://www.labtestsonline.org/understanding/conditions/chf-2.html
http://emedicine.medscape.com/article/354666-overview
http://en.wikipedia.org/wiki/Heart_failure
http://www.medicinenet.com/congestive_heart_failure/page3.htm

Questionnaire
1. Classify the unknown fluid collected if the Fluid to serum protein ratio: is 0.45 and the
Serum to fluid LD ratio 0.52

a. Transudate
b. Exudate
c. The findings are discrepant
d. either

2. If a thick cloudy appearance is seen in the fluid, it may be caused by:

a. Bleeding
b. Bacteria and white blood cell
c. The fluid is normal
d. Cancer

3. This condition refers to the inability of the heart to supply adequate blood output relative to
the body's needs.

a. Pericarditis
b. Myocardial infarction
c. Congestive Heart Failure
d. Endocarditis

4. The edema in the patient is best explained by

a. Increased fluid intake

b. The heart pumps too much fluid into the systemic circulation causing edema
c. The kidneys are less able to dispose of sodium and water causing fluid retention in the
tissues
d. Bacteria causes inflammation evidenced by edema

5. It is best used in laboratories to concentrate a fluid’s cells at the bottom of the test tube

a. Serofuge
b. Cytocentrifuge
c. Microhematocrit centrifuge
d. None of the above
6. The main function of pericardial fluid is to

a. reduce friction within the pericardium by lubricating the epicardial surface

b. provide nutrients to the heart
c. allow extra space for the beating of the heart
d. act as a chemical barrier to toxins and medications

7. If malignant cells are present in a pericardial fluid, the fluid may be classified as

a. Exudate
b. Transudate
c. The findings are discrepant
d. Either

8. Most frequent malignant cells encountered in pericardial fluid are

a. Metatastic brain cancer cells

b. Metatastic lung and breast carcinoma
c. Proliferated cells caused by leukemia
d. None of the above

9. A normal pericardial fluid is characterized by

a. Volume of 30-35ml and milky appearance

b. Volume of 60-70 ml and clear straw colored
c. Volume of 10-50 ml and clear straw colored
d. Volume of 60-70 ml and milky appearance

10. These are effusions that have accumulated because of systemic diseases such as congestive
heart failure and liver cirrhosis

a. Transudates
b. Exudates
c. Pericardialeffusions
d. Pleural effusions
Answer Key

1. A
2. B

3. C

4. C

5. B

6. A

7. A

8. B

9. C

10. A