23 Cerebrospinal, pleural and ascitic fluids
Cerebrospinal fluid 332
Pleural fluid 335
This chapter looks at various important biological
fluids and how their biochemical analysis can be useful
clinically.
CEREBROSPINAL FLUID
In adults, the total volume of cerebrospinal fluid (CSF)
is about 135 mL, produced at a rate of 500 mL/day.
This is predominantly formed by plasma ultrafiltration
through the capillary walls of the choroid plexuses in
the brain’s lateral ventricles. These plexuses also actively
secrete small amounts of substances such as chloride.
The fluid passes from the lateral, through the
third and fourth ventricles, into the subarachnoid
space between the pia and subarachnoid mater, from
where much is reabsorbed into the circulation by
arachnoid villi. The remaining fluid flows through the
subarachnoid space, completely surrounding the brain
and spinal cord; thus it supports and protects these
structures against injury. Like lymph, CSF removes
waste products of metabolism.
Cerebrospinal fluid circulates very slowly, allowing
contact with cells of the central nervous system (CNS).
The uptake of glucose by these cells probably results in
lower concentrations relative to plasma. Concentrations
of analytes in the CSF should always be compared with
those in plasma because alterations in the latter are
reflected in the CSF even when CNS metabolism is
normal.
Flow is slowest, and therefore contact longest, in the
lower lumbar region, where the subarachnoid space
comes to an end; therefore, the composition of CSF
from lumbar puncture is different from that of cisternal
or ventricular puncture.
Examination of the cerebrospinal fluid
Although biochemical investigation of the CSF is
important, so is microbiological and cytological
examination. Textbooks of microbiology and cytology
should be consulted for further diagnostic details if
required.
Ascitic fluid 336
CASE 1
A 17-year-old female student was admitted to hospital
with fever, neck stiffness, headache, photophobia and
a purpuric rash. She had the following cerebrospinal
fluid (CSF) laboratory results:
CSF glucose 2.0 mmol/L (concomitant plasma
glucose 5.6 mmol/L)
CSF protein 0.98 g/L(< 0.4 g/L)
Cerebrospinal fluid microscopy showed elevated
leucocytes, and Gram staining showed gram-negative
Meningococcus.
DISCUSSION
A lumbar puncture to obtain CSF is potentially a
dangerous, invasive investigation. It carries the risk
of cerebral herniation, bleeding and infection. In this
case, meningitis was suspected, which was confirmed
by the CSF results. Note the raised protein and low
glucose concentrations relative to plasma due to
bacteria. The presence of bacteria is confirmed by
microscopy. Meningococcus can rapidly cause death,
and is associated with massive haemorrhagic adrenal
destruction, as in Waterhouse–Friderichsen syndrome.
Sample collection
Cerebrospinal fluid is usually collected by lumbar
puncture. This procedure may be dangerous if the
intracranial pressure is raised (potentially lethal
brainstem herniation through the foramen magnum
may occur), and the clinician should therefore check that
there is no papilloedema before proceeding; sometimes
brain imaging, for example computerized tomography
(CT) scanning, may be indicated. Small-bore needles
may reduce the risk of post-lumbar puncture headache.
Usually a total of about 5 mL of CSF should be
collected as 1–2 mL aliquots into sterile containers
and sent first for microbiological examinations; if

necessary, any remaining specimen can then be used
for biochemical analysis. If a CSF glucose concentration
is indicated, 0.5 mL should be collected into a fluoride
tube and promptly sent to the laboratory with a blood
sample taken at the same time. The CSF is potentially
highly infectious and must be handled and transported
with care.
Appearance
Normal CSF is completely clear and colourless; slight
turbidity is most easily detected by visual comparison
with water.
Spontaneous clotting
Clotting occurs when there is excess fibrinogen in the
specimen, usually associated with a very high protein
concentration. This finding occurs with tuberculous
meningitis or with tumours of the CNS.
Colour
A bright red colour may result from damage to a blood
vessel during lumbar puncture (traumatic tap) or a
recent haemorrhage into the subarachnoid space.
If CSF is collected as three separate aliquots, blood
staining will be progressively less in the aliquots if
bleeding is due to the lumbar puncture itself, whereas
all aliquots would be expected to be bloody if there was
a subarachnoid bleed.
Xanthochromia is defined as a yellow coloration
of the CSF and results from altered haemoglobin, the
colour appearing several days after a subarachnoid
haemorrhage and, depending on the extent of the
bleeding, lasting for up to a week or more or jaundice
(which will be clinically obvious and may impart a
yellow colour to the CSF).
Visual appraisal of CSF is not sufficiently sensitive
to detect subtle degrees of xanthochromia for the
diagnosis of subarachnoid haemorrhage. In such
cases spectrophotometric examination of CSF is
important. Spectrophotometric analysis may reveal
an oxyhaemoglobin absorption peak of 413–415 nm;
bilirubin shows an additional peak at 450–460 nm. This
test is particularly useful in patients with subarachnoid
haemorrhage who have a negative brain CT scan.
The presence of methaemoglobin or bilirubin is
strongly suggestive of a subarachnoid haemorrhage, as
oxyhaemoglobin alone is not necessarily confirmatory
because it may simply reflect a ‘bloody’ CSF tap. The test
should be done at least 12 h after initiation of headache.
Cerebrospinal fluid 333
CSF bilirubin can, however, also be raised when serum
bilirubin is elevated.
Turbidity
Turbidity is usually due to infection or high CSF protein
content. It may also occur after haemorrhage.
Biochemical estimations
The following are the most commonly requested CSF
biochemical tests.
Glucose
The CSF glucose concentration is slightly lower than
that in plasma and, under normal circumstances, is
rarely less than 50 per cent of the plasma concentration.
Provided that CSF for glucose assay has been preserved
with fluoride, an abnormally low glucose concentration
occurs in the following:
● Hypoglycaemia The CSF glucose concentration
parallels that of plasma, although there is a delay
before changes in plasma glucose concentrations are
reflected in the CSF. Hypoglycaemia may cause coma
and low CSF glucose concentrations in the absence
of any primary cerebral abnormality (see Chapter
12). Both plasma and CSF concentrations must be
measured.
● Infection If there is an increased polymorphonuclear
leucocyte count or a bacterial infection, the CSF
glucose concentration may be very low because of
increased metabolism of glucose. The CSF glucose
concentration may be particularly low in pyogenic
meningitis and tuberculous meningitis; in viral
meningitis, it is often normal. The estimation of
CSF glucose does not reliably distinguish between
different forms of infective meningitis because the
result may be normal in any form.
● Widespread malignant infiltration of the meninges
may also be associated with low CSF glucose
concentrations.
Protein
The CSF protein concentration in the lumbar spine
is up to three times higher than that in the ventricles;
the normal lumbar concentration is below 0.4 g/L. In
newborn infants, because of the relatively high vascular
permeability, the CSF protein concentration is about
three times that of the adult.
Changes in concentration of, for example,
immunoglobulin G (IgG) do not necessarily indicate
334 Cerebrospinal, pleural and ascitic fluids
cerebral disease, but may simply reflect changes in
plasma (normally 80 per cent of total CSF protein has
transferred across from the plasma). Therefore the
results of assays can only be interpreted if those of the
two fluids are compared.
Cerebral disease may change the total concentration
of CSF protein and the proportions of its constituents,
for two reasons:
● The vascular and meningeal permeabilities can
increase, allowing more protein to enter the CSF.
● Proteins (immunoglobulins) may be synthesized
within the cerebrospinal canal by inflammatory or
other invading cells.
Measurement of total cerebrospinal fluid protein concentration
Measurement of CSF total protein is a relatively
insensitive test for the diagnosis of cerebral disease,
because early changes in the concentration of a specific
protein do not always cause a detectable rise in the total
protein concentration.
The CSF total protein concentration may be
increased in the following situations.
● In the presence of blood, due to haemoglobin and
plasma proteins.
● In the presence of pus, due to cell protein and to
exudation from inflamed surfaces.
● In non-purulent inflammation of cerebral tissue,
when there may be a definite rise in total protein
concentration despite the absence of detectable cells
in the CSF. Cells may also be undetectable in some
cases of bacterial meningitis, particularly in children,
in immunocompromised patients, or if antibiotics
have been given before lumbar puncture.
● If there is blockage of the spinal canal which, by
impairing the flow of CSF distal to the block, allows
longer for equilibrium with the circulation and so
brings the composition of CSF slightly nearer to that
of plasma (Froin’s syndrome). Increased pressure in
the CSF may also increase protein. Such blockage
may be caused by:
– spinal tumours,
– vertebral fractures,
– spinal tuberculosis.
● Where there is local synthesis of immunoglobulins by
plasma cells within the CSF.
Measurement of individual cerebrospinal fluid protein
concentrations
In the presence of blood or pus, tests for individual CSF
proteins are not useful and may even be misleading. They
may, however, detect abnormalities when the total protein
concentration is equivocally raised or normal, and may
help to elucidate the cause of a high concentration.
Increased capillary permeability, with a similar
increase in the permeability of the blood–brain
barrier, may be demonstrated by finding relatively
high-molecular-weight proteins not normally present
in CSF. This non-specific pattern is associated with a
large number of inflammatory conditions, but may
sometimes facilitate diagnosis.
Abnormal cerebrospinal fluid protein synthesis
The identification of immunoglobulins synthesized
within the CSF, particularly IgG and IgA, may help
with the diagnosis of multiple sclerosis or other
demyelinating disorders. Abnormal immunoglobulin
synthesis may be detected by the following.
● The finding of a characteristic electrophoretic
pattern with multiple (‘oligoclonal’) bands in the
g-globulin region. Oligoclonal bands signify cerebral
disease only if they are found in the CSF and not
in the serum. Although such bands can be detected
in more than 90 per cent of patients with multiple
sclerosis, the finding is not specific for this condition.
Occasionally, intrathecal malignant B lymphocytes
produce a local monoclonal band.
● Comparison of the IgG and albumin CSF to plasma
ratio. Albumin has a lower molecular weight than IgG
and its concentration increases disproportionately
in CSF if increased vascular permeability due to
CASE 2
A 43-year-old man attended the ear, nose and throat
(ENT) department because of a nasal discharge. He
had had brain surgery 3 years previously following a
head injury. Although he had initially been treated
as having allergic rhinitis, the ENT consultant sent
some of the nasal fluid to the clinical biochemistry
laboratory for tau protein analysis. The results
returned showed the presence of tau protein in his
nasal fluid.
DISCUSSION
Nasal fluid should not normally contain tau
(asialotransferrin) protein, as this is usually found
in cerebrospinal fluid (CSF). Therefore, the findings
suggest that the nasal discharge contained CSF. The
previous head injury had resulted in a dura tear,
allowing CSF to leak from the nose.

inflammation is the cause of the high protein
concentration. In this case the CSF to plasma ratio
of IgG to albumin will be low or, if permeability is so
increased that the two proteins diffuse at almost the
same rate, normal. In conditions such as multiple
sclerosis in which IgG has been synthesized within the
CSF, the ratio is high. This method is less sensitive than
the detection of oligoclonal bands (see Chapter 19).
Increased CSF immunoglobulin synthesis, with
oligoclonal bands, may be found in:
● multiple sclerosis (the most important indication for
the test),
● viral infections:
– meningitis,
– encephalitis,
– subacute sclerosing panencephalitis,
● prion disease, for example Creutzfeldt–Jakob disease,
● bacterial meningitis,
● tuberculosis,
● neurosyphilis,
● acute idiopathic polyneuropathy (Guillain–Barré
syndrome),
● systemic lupus erythematosus,
● cerebral sarcoidosis,
● cerebral tumours (rarely).
Tau protein
As in any ultrafiltrate, the concentration of high-
molecular-weight CSF proteins is very much lower
than in plasma. Also, electrophoresis shows that the
proportions of individual proteins are slightly different
in CSF from those in serum. For example, in the CSF, the
concentration of pre-albumin is higher and of g-globulin
lower relative to other proteins than in plasma. The tau
protein, detectable in the b–g region in CSF, is a variant
of transferrin (asialotransferrin), which cannot be
absorbed as the ultrafiltrate passes through the choroid
plexus; this modified form cannot be reabsorbed into the
circulation and therefore is not found in plasma.
In plasma, the asialotransferrin concentration is very
low, as desialylated glycoproteins are rapidly removed
from the circulation by the hepatic asialoglycoprotein
receptor. A nasal secretion (rhinorrhoea) containing
tau protein is suggestive of the source being CSF, as
normal nasal secretions do not contain tau protein.
Other cerebrospinal fluid analytes
C-reactive protein and lactate have also been used in
certain circumstances to indicate bacterial infection.
Pleural fluid 335
However, these tests are not specific, as both can be
elevated in other conditions. Microbiological tests are
often more useful if infection is suspected.
Procedure for examination of the cerebrospinal fluid
Consider the following:
● Heavily bloodstained (assuming a non-traumatic
lumbar puncture) in three consecutive specimens:
there has probably been a cerebral haemorrhage.
● Send for microbiological examination and for
estimation for glucose and protein concentrations.
● Xanthochromic: in addition to the above tests, send
the specimen for spectrophotometric examination.
● If indicated, intrathecal immunoglobulin synthesis
may be confirmed, either using the CSF to plasma
ratio of IgG to albumin or by the detection of
multiple (oligoclonal) bands in the CSF.
PLEURAL FLUID
This is a plasma ultrafiltrate; there is usually less than
10 mL of this fluid in each pleural cavity. If the rate of
removal is less than the rate of formation, pleural fluid
will accumulate. Decreased removal may be due to
decreased pleural space pressure, for example bronchial
obstruction, or impaired lymphatic drainage, for
example neoplasms (Fig 23.1). Pleural fluid production
CASE 3
A 69-year-old male smoker presented to the chest
clinic with shortness of breath, haemoptysis, cough
and weight loss. A chest radiograph revealed a left-
sided pleural effusion and upper zone ‘shadow’. The
effusion was ‘tapped’ and the following results were
obtained:
Pleural fluid lactate dehydrogenase (LDH) 566 U/L
(< 200)
Pleural fluid protein 114 g/L, with concomitant
plasma protein 60 g/L
DISCUSSION
These biochemical tests suggest a pleural exudate.
Note the raised pleural fluid LDH and considerably
raised pleural fluid protein (more than 30 g/L)
concentrations. The cytology showed malignant
cells. A lung carcinoma was found on bronchoscopy.
Exudate pleural fluid is associated with malignant
lung disease.
336 Cerebrospinal, pleural and ascitic fluids
Figure 23.1 Chest radiograph showing a pleural
effusion (white arrow). Reproduced with kind
permission from Kinirons M and Ellis H. French’s
Index of Differential Diagnosis, 15th edition. London:
Hodder Arnold, 2011.
is increased if there is decreased colloid osmotic
pressure (for example hypoproteinaemia), increased
capillary vessel permeability (for example infection) or
hydrostatic pressure elevation (as in cardiac failure).
Pleural effusion fluid can be divided into exudates
and transudates (Box 23.1).
Pleural fluid is often ‘tapped’ with a needle
(thoracentesis) and samples sent to the laboratory
for analysis. A pleural fluid protein concentration of
greater than 30 g/L is suggestive of an exudate. Raised
lactate dehydrogenase (LDH) activity in pleural fluid
Box 23.1 Some causes of a pleural effusion
Exudates
Infective inflammatory, e.g. pneumonia or tuberculosis
Non-infective inflammatory, e.g. pulmonary
embolism, rheumatoid arthritis, drugs such as
amiodarone
Neoplasm, e.g. primary lung or secondaries
Miscellaneous, e.g. trauma, chylothorax
Transudates
Congestive cardiac failure
Nephrotic syndrome
Cirrhosis and ascites
Hypothyroidism
is indicative of a malignancy or inflammatory process
and is more in keeping with an exudate.
Light and colleagues used these observations to
devise Light’s criteria for the identification of exudates,
for which both pleural and plasma analyses for protein
and LDH are needed.
A pleural fluid is defined as an exudate if any one of
the following three conditions is satisfied:
● pleural fluid LDH more than 0.6 the upper normal
reference range for plasma,
● pleural fluid to plasma protein ratio more than 0.5,
● pleural fluid to plasma LDH ratio more than 0.6.
Other biochemical tests (in addition to
microbiological tests and cytology) on pleural fluid
may include the following:
● Amylase activity may be raised in pleural effusions
secondary to acute pancreatitis, although other
causes include some malignant effusions and
oesophageal rupture.
● A raised pleural triglyceride concentration, in
comparison with plasma, is suggestive of chylo-
thorax. This occurs when lymph or chyle leaks from
the thoracic duct into the pleural space.
● A low pleural fluid glucose concentration, below
1.2 mmol/L, may be found in effusions due to
rheumatoid arthritis, although this may also be seen
with bacterial infections.
● Tumour markers such as carcinoembryonic antigen
(CEA), carbohydrate antigen (CA)-125, CA-15-3 and
CA-19-9 may sometimes be used to help diagnose
malignant pleural effusions. However, cytological
examination may be more useful.
● Adenosine deaminase is released from activated
lymphocytes. A raised pleural fluid adenosine
deaminase activity is suggestive of tuberculosis.
This test is useful if organisms cannot be cultured.
Interferon-g can also be used as an alternative to
adenosine deaminase.
● A raised pro-brain natriuretic peptide (pro-BNP)
concentration in pleural fluid may suggest a cardiac
failure as a cause
● A pleural fluid pH < 7.2 is predictive of the need for
pleural fluid drainage if infected.
ASCITIC FLUID
● This is fluid in the peritoneal cavity. Sometimes fluid
accumulation can be huge, occasionally exceeding
20 L, and may cause pressure symptoms such as

abdominal distension and breathing difficulties.
Ascitic fluid drainage (paracentesis) may be necessary
to facilitate diagnosis and relieve symptoms.
● Like pleural fluid, ascites can be divided into
exudates and transudates. Similar tests to those
done for pleural fluid can be requested. However,
it has been suggested that, rather than classifying
into transudate or exudate, it may be more
useful to classify the ascitic fluid upon the basis
of the serum ascites albumin gradient (serum
albumin concentration minus ascites albumin
SUMMARY
● In adults, the total volume of CSF is about
135 mL, produced at a rate of 500 mL/day. This is
predominantly formed by plasma ultrafiltration
through the capillary walls of the choroid plexuses
in the brain’s lateral ventricles.
● Laboratory analysis of CSF can be useful in the
diagnosis of various diseases, including meningitis
and subarachnoid haemorrhage.
Ascitic fluid 337
concentration). A high gradient of > 11 g/L suggests
portal hypertension, e.g. cirrhosis, Budd–Chiari
syndrome, constrictive pericarditis, kwashiorkor or
cardiac failure, and a gradient < 11 g/L is indicative
of a non-portal hypertensive aetiology, e.g.
carcinoma, infection such as spontaneous bacterial
peritonitis, nephrotic syndrome or pancreatitis
(see Chapter 17).
● Meig’s syndrome is the triad of pleural effusion,
ascites and ovarian tumour (fibroma).
● Pleural fluid can also be analysed in the laboratory
and divided into transudates (protein less than
30 g/L) and exudates (protein more than 30 g/L).
This may be useful when searching for the cause of
the effusion.
● Laboratory tests, including the serum to ascites
albumin gradient, can also help in the diagnosis of
ascitic fluid accumulation.