CLIN PATH: OTHER BODY FLUIDS & DISCHARGES - OTHER SPECIAL TESTS

 Caused by:
 Traumatic tap (bleeding into the subarachnoid space at the puncture site)
 Contamination of the bacterial culture by skin germs or flora.

GROSS EXAMINATION OF CSF

COLOR INDICATION
a) Straw pink,  Presence
yellow, or amber  Bilirubin
pigments  Hemoglobin
(xanthochromia)  RBC
 Increase proteins
b) Turbidity – has  INCREASED number of cells
suspended
particles
c) Differentiating a
 subarachnoid
hemorrhage from
a traumatic tap
CEREBROSPINAL FLUID (CSF)
 Ultrafiltrate of plasma containing glucose, electrolytes, amino acids, and other small molecules  (+)
Plasma
 Contains – very little proteins & Few cells

 WITHDRAW – from the Subarachnoid space 

 By performing a LUMBAR puncture or Spinal tap  Traumatic tap  often associated with sequential clearing of CSF as it is
 By inserting the needle between the 4th or 5th lumbar vertebrae (L4-L5) collected, streaks of blood in an otherwise clear fluid; or a sample that
 This location – Used because the spinal cord stops near L2 & Needle introduced below clots
this level will miss the cord.

LUMBAR PUNCTURE
PRECAUTIONS:
 Only a small amount of CSF for analysis
 Only if the benefits are thought to outweigh the risks.
A. In Bleeding Disorder  Lumbar puncture can cause hemorrhage that can compress the spinal
cord
B. In Patients that have INCREASED spinal column pressure – such as brain tumor  Removal
of CSF can cause the brain to herniate  compressing the brain stem and other vital structures 
 Leading to irreversible brain damage or death
C. Meningitis may be caused by bacteria introduced during the puncture CSF ABNORMALITIES
D. Avoid contamination with skin flora GLUCOSE  2/3 accounts the Fasting plasma glucose
E. CSF should be refrigerated – If analysis is Delayed  <40 mg/dL – indicates:
 (1) Bacterial & fungal Meningitis
AFTERCARE:  (2) Malignancy
 Puncture site covered with STERILE bandage PROTEIN  Normal:
 Total protein  Very low
 Patient should remain lying for four to six hours after the lumbar puncture  Albumin 2/3 of total protein
 Vital signs – Should be monitored every 15 mins for 4 hours
 Then every 30 minutes for another 4 hours  High levels of protein – seen:
 PUNCTURE Site – Observed for signs of weeping or swelling for 24 hours  (1) Bacterial & fungal Meningitis
 Neurologic status of the patient should be evaluated – symptoms:  (2) Tumors
 Numbness  (3) Subarachnoid hemorrhage
 Tingling in the lower extremities  (4) Traumatic tap
LACTATE  Increased levels – lactate
 Bacterial & fungal Meningitis
RISK OF LUMBAR TAP
 (1) Headache – Dull or Throbbing sensation
 No increase levels – lactate
 Most common S/E  Viral meningitis
 Due to Decreased CSF pressure  related to a small leak of CSF through the puncture site LACTATE  LD – Elevated
 Typically – Begins within 2 days after procedure & persist from a few days to several weeks or DEHYDROGENASE  (1) Bacterial & fungal Meningitis
months  (2) Malignancy
 (2) Stiff neck and nausea  (3) Subarachnoid Hemorrhage
 (3) Puncture site leak WBC Count  Normal
 (4) Puncture appears – red & swollen  WBC – very low  predominated by Lymphocytes
 INCREASE WBC
 (5) Puncture site infection  Infection
 Allergy
NORMAL RESULT: CSF  Leukemia
GROSS Appearance Clear & Colorless  Hemorrhage
Specific gravity 1.006-1.009  Traumatic tap
Glucose 40-80 mg/dL  Encephalitis
 Guillain-Barré syndrome
Total protein 15-45 mg/dL
RBC Count  RBC – CSF
LD 1/10 of serum level
 Subarcachnoid hemorrhage
Lactate <35 mg/dL  Stroke
Leukocytes (WBC) Adults & children – 0-6/microL  Traumatic tap
Infants – up to 19/microL
Newborn – up to 30/microL WBC DIFFERENTIAL COUNTING OF CSF
Differentials 60-80% - Lymphocytes 1) Viral infection  Lymphocytosis
30% - Monocytes & Macrophages 2) Bacterial &  Neutrophilia
<2% - Other cells Fungal infections
Culture Sterile 3) Allergy &  Eosinophilia
RBC Normal – NONE - unless the needle passes though a blood Ventricular
vessel on route to the CSF shunts
4) Meningitis  Macrophages with ingested bacteria
5) Hemorrhage  RBCs
6) Possible Cerebral  LIPIDS
infraction
7) Leukemia  Blasts or Immature cells

RBC COUNT
 RBC count - used to correct the WBC count so that it reflects conditions other than hemorrhage or a
traumatic tap.
 (1) Counting RBCs and WBCs in both blood and CSF
 (2) The ratio of RBCs in CSF to blood is multiplied by the blood WBC count
 (3) This value is subtracted from the CSF WBC count to eliminate WBCs derived from hemorrhage
or traumatic tap

GRAM STAIN
 Used for – Bacterial Meningitis
 Culture
 1st tube: chemical or serologic tests  performed for both aerobic and anaerobic bacteria
 Other stains - Acid-fast stain for Mycobacterium tuberculosis
 2nd tube: microbiological tests including molecular diagnostics
 Other tests: Fungal culture, and rapid identification tests = tests for bacterial and fungal antigens.
 3rd tube: microscopic examination, Differential Count
 4th tube: cytological examination
SYPHYLIS SEROLOGY
 This tube assignment reduces the chances of a falsely elevated white cell count
 CLIN PATH: OTHER BODY FLUIDS & DISCHARGES - OTHER SPECIAL TESTS
 Testing for antibodies  Indicates Neurosyphilis
 VDRL test and fluorescent treponemal antibody-absorption (FTA-ABS) test
 Often -Used and are positive in persons with active and treated syphilis

PLEURAL/PERICARDIAL/ASCITIC/ SYNOVIAL
 TRANSUDATE
 Fluid pushed through the capillary due to HIGH PRESSURE within capillary
 ↑ hydrostatic pressure, ↓ colloid osmotic pressure

 EXUDATE
 Fluid that leaks around the cells of the capillaries by the inflammation
 According to the Light’s criteria – Fluid is exudate if:
 (1) Effusion protein/serum protein ratio >0.5
 (2) Effusion (LDH)/serum LDH ratio > 0.6
 (3) Effusion LDH >2/3 upper limits of serum normal
 (4) Pleural-fluid/serum cholesterol ratio >0.3

TRANSUDATE EXUDATE
APPEARANCE Clear Cloudy
SPECIFIC GRAVITY < 1.012 > 1.020
PROTEIN CONTENT < 2.5 g/dL > 2.9 g/dL
SAAG = Serum >1.2 g/dL <1.2 g/dL
(albumin) – Effusion
(albumin)

LEADING CAUSES OF PLEURAL EFFUSION

TRANSUDATE EXUDATE Possible BOTH
 CHF  Pneumonia  Pulmonary Embolus
 Cirrhosis with ascites  Cancer  Infectious - TB
 Viral disease
 Coronary-artery bypass
surgery

ASCITIC FLUID
 SAAG – Serum-ascites albumin gradient or gap
 Calculation – determine cause of ascites
 FORMULA: Ideally variables – should be measure at the same time
 (serum albumin) – (albumin level of ascitic fluid)
 Principle: result of Starling's forces between the fluid of the circulatory system and ascitic fluid.
 NORMAL Value – SAAG - <1.7
 Because serum oncotic pressure is exactly counterbalanced by the serum hydrostatic pressure
 Protein <3g/dL
 Oncotic pressure – pulling fluid back into circulation
 Serum hydrostatic pressure - which pushes fluid out of the circulatory system

HIGH GRADIENT SAAG LOW GRADIENT SAAG

 Value: > 1.1 g/dL, >11 mmol/L  Value: < 1.1 g/dL, <11 mmol/L

 Cause of Ascites Due to PORTAL  Cause of ascites is not associated portal

HYPERTENSION pressure:
 Conditions that cause portal hypertension:  TB
 Cirrhosis of the liver  Pancreatitis
 Heart failure  Infection
 Buddi-Chiarri Syndrome  Serositis
 Portal vein thrombosis  Peritoneal carcinomatosis
 Idiopathic portal fibrosis  Pulmonary infracts
 Nephrotic syndrome

SAAG vs TOTAL ASCITES PROTEIN

SAAG Total Protein
Nephrotic syndrome <1.1 <2.5
Cancer, TB <1.1 >2.5
Cirrhosis >1.1 <2.5
 CLIN PATH: OTHER BODY FLUIDS & DISCHARGES - OTHER SPECIAL TESTS
Right HF, Budd-Charri >1.1 >2.5

SYNOVIAL FLUID ANALYSIS

 Help diagnose the cause of joint inflammation, pain, swelling, and fluid accumulation
 Conditions such as Acute & Chronic septic arthritis
 Causes:
 (1) Infectious disease  bacteria, fungi, or viruses
 (2) Bleeding  bleeding disorders and/or joint injury
 (3) Inflammatory diseases  gout, synovitis, or other immune responses
 Include: autoimmune disorders such as rheumatoid arthritis and systemic lupus
erythematosus
 (4) Degenerative disease  osteoarthritis

SPECIAL DIAGNOSTIC TESTS

RENAL STONE ANALYSIS
 Evaluation of stone disease
 (1) Routine blood & urine tests
 (2) Stone Analysis
 (3) 24 hours urine metabolic profile

 New advances – stone analysis

PERICARDIAL FLUID ANALYSIS  Bloody & Urinary Chemical test can find out  90-95% cause
 Help diagnosis:
 Cause of inflammation of the pericardium  Pericarditis  Renal stone analysis
 Fluid accumulation around the heart  Pericardial effusion  Essential step in the examination & initial treatment of urolithiasis
 Yield fundamental information about:
CAUSES – pericarditis or/& Pericardial effusion  (1) Metabolic abnormality
TRANSUDATE EXUDATE  (2) Presence of infection
 CHF  Infectious disease  (3) Possible artifacts
 Cirrhosis  viruses, bacteria, or fungi  (4) Drug Metabolism
 may originate in pericardium or from other
parts A. CALCIUM STONES
PURE calcium stones Mixed Stone Formers
 Bleeding  More acid urine  pH – HIGHER
 bleeding disorders and/or trauma  Low urine volume  High calcium
 High oxalate excretion  High calcium excretion
 Inflammatory conditions  High recurrence rate
 follow a heart attack,
 Radiation treatment Ca-Oxalate Monohydrate Ca-oxalate Dihydrate
 Be part of autoimmune disorders such as  Hypomagnesuria  Hypercalciuria
rheumatoid arthritis and systemic lupus  Acidic Urine  Alkaline urine
erythematosus  Low urine volume  Hypocitraturia
 Hardness (+)  Hardness; Less
 Cancer
 such as mesothelioma [pericardium] or B. RENAL TUBULAR ACIDOSIS
metastatic cancer. Calcium apatite Brushite stones
 Consider RTA  Consider RTA
SPUTUM  Increases with amount
 5-39%

C. STRUVITE STONE – Magnesium ammonium phosphate

 Mixed stone – due to infection  Proteus
 Strains of Staphylococci, Pseudomonas, & Klebsiella
 Rare – E. coli
 Urine pH - <7.5

D. AMMONIUM URATE
 Calcium oxalate – containing calculi  may start hyperuricosuria
 Elders – associated with infection
 Children – May result of hyperuricosuria – BUT NO UTI

E. DAHILITE (CARBONATE APATITE)

  Phosphate stone
 Infection in body
 May be Asymptomatic
 Consider RTA
 Disorder of phosphate metabolism
 Rare – pure form  2-3%
F. URIC ACID
 Hyperuricemia, Hyperuricosuria
 Low urine – pH <6.2
 Causes:
 Gout
 Myeloproliferative disease
 Chemotherapy & Radiotherapy
G. CYSTINE
CYSTINE XENTHENE
 Cystinuria  Most frequent causes:
 Autosomal recessive disorder  Xanthinuria
 Occurs predominantly in pure form  Absence – xanthene oxidase
 Genetic autosomal hereditary recessive
 enzyme disorder
 Trigger  Allopurinol (treatment for gout)
 CLIN PATH: OTHER BODY FLUIDS & DISCHARGES - OTHER SPECIAL TESTS
 The detection of antinuclear antibodies (ANA) in serum
 Facilitates – Diagnosis of patients with systemic lupus erythematosus (SLE) and related autoimmune
diseases.
 Conversely, the absence of ANA in the serum of a patient with suspected SLE also provides important
information in that it makes the diagnosis much less likely.

 ANA TITERS- >1/500

 Often found in spontaneous or drug-induced SLE and few other Auto-immune diseases.
 97% - people with Lupus
D-DIMER TEST  Test positive for ANA
 D-dimer
 Is a FIBRIN degradation product (FDP) RHEUMATOID FACTOR (RH FACTOR TEST)
 a small protein fragment present in the blood  Rheumatic factor
 After blood clot is degraded through fibrinolysis, by enzyme plasmin  Immunologic marker – body
 Name due: contains two crosslinked D fragments of the fibrin protein  Low titer – number of disease:
 infectious mononucleosis
 D-DIMER TEST USED: Suspicion  other viral diseases
 DVT – Deep venous thrombosis  chronic bacterial infections
 PE – Pulmonary embolism  other acute and chronic conditions.
 DIC – Disseminated intravascular coagulation  Found in approximately 5 percent of healthy elderly persons.
 Aortic dissection but still under investigation  RF – High titer
 Suggest - rheumatic disease
 Negative D-dimer test will virtually rule out thromboembolism.  HIGHEST levels - rheumatoid arthritis  detectable in the blood about 80% of adult cases

 Clinically, higher titers tend to correlate with more severe and sustained disease, joint deformities,
rheumatoid nodules, and other extraarticular features of the disease

ANTI-CYCLIC CITRULLINATED PEPTIDE (ANTICCP) TEST

 ANTI-CCP - Present in an estimated 60 to 80% of people with RA, according to the Arthritis
Foundation.

 INTERPRET – results
 Increased risk of Rheumatoid arthritis
  anti-CCP >20 units per milliliter (u/ml)
 Anti-CCP test
MICRAL TEST  similar to the rheumatoid factor antibody test
 Microalbuminuria  preferred recently by physicians
 Defined: Excretion of albumin – 20-200 mcg/min  Often using it in preference to the rheumatoid factor test for greater accuracy

 Persistent – microalbuminuria  Indicates high probability of damage to the glomerular filtration of C-REACTIVE PROTEIN (CRP) TEST
the kidney & great diagnostic relevance:  Detects the presence of CRP - which the liver produces in response to inflammation in the body
 (1) Diabetes  use for early diagnosis of diabetic nephropathy  INTERPRETING – Results
 (2) Hypertension  use as INDICATOR of end organ damage associated with a lowered life  (+) CRP  indicate inflammation anywhere in the body – just like RA
expectancy  Certain medical conditions,
 (3) Pregnancy  Possible indicator of developing pre-eclampsia  such as obesity and infection  can also increase CRP in the blood

 FOR screening: PROCALCITONIN TEST

 Concentration - 0-200 mg/L of albumin in the first morning urine  Evaluates the risk that a seriously ill person is developing a systemic bacterial infection
 Suitable indicator  including chronic bacterial diseases such as tuberculosis

 The Micral-Test is a test strip now available that makes a semiquantitative assessment of the albumin
concentration in the urine at various levels (0, 10, 20, 50, 100 mg/L).
 ADVANTAGE: Micral test
 No influence on the measurement from interfering factors such as glucose concentration, pH value,
ketonuria, storage of the sample, or bacterial contamination in the urine
MULTICOLOUR FLOW CYTOMETRY TEST
 Utilizes – Monoclonal antibodies tagged with fluorochromes which
 Which bind specifically to ‘GPI-AP’ on peripheral blood cells or FLAER which binds directly to
GPI anchor itself.
 FLAER - bacterial aerolysin tagged with fluorescent antibody
 It is rapid, sensitive
 gives better assessment of clone size and delineation of type I, II and III cells.
 MULTICOLOUR FLOW CYTOMETRY TEST
 Now the gold standard test – for PNH - paroxysmal nocturnal hemoglobinuria
 (1) It helps detect or rule out sepsis
 Best used - during the first day of presentation
 (2) Distinguish - between viral & bacterial meningitis
 (3) Detect/Rule out bacterial pneumonia  seriously ill and in fever of unknown origin
 (4) in post- trauma or post-operative patient with viral pneumonia
 Used to detect the development of a secondary bacterial infection.
 (5) may be used to monitor the effectiveness of antimicrobial treatment.
 LOW LEVELS of PROCALCITONIN
 low risk of sepsis but do not exclude it.
 Can indicate a localized infection that has not yet become systemic
 Or a systemic infection that is less than six hours old
 the person's symptoms are likely due to another cause
 HIGH levels of PROCALCITONIN
 May indicate  SEPSIS

THE LE CELL
 The name lupus was derived from the Latin for ”wolf ”.
 Autoantibodies are a characteristic feature of systemic lupus erythematosus (SLE)
 Abortive nucleus in the process of being extruded, undergoes ‘nucleophagocytosis’ by Neutrophils 
LE cells
 LE CELLS
 seen in bone marrow, peripheral blood, synovial fluid, cerebrospinal fluid and pericardial and
pleural effusions from patients with SLE.

ANA – Antinuclear antibodies

CLIN PATH: OTHER BODY FLUIDS & DISCHARGES - OTHER SPECIAL TESTS