SYNOVIAL FLUID

• Also known as joint fluid found in diarthrosis

• Ultrafiltrate of Plasma with Hyaluronic acid
• Synovium – joint cavity; composed of cells called as “synoviocytes” which
produces hyaluronic acid
• Hyaluronic acid – contributes to the viscosity of the synovial fluid
• Came from the word “Synovia” – came from the word “egg white”
• Functions:
o Lubricates joints
o Reduce friction between bones
o Provides nutrients to the articular cartilage
o Lessen shock of joint compression occurring during activities (e.g. walking,
jogging)

SPECIMEN COLLECTION
• Method of Collection: arthrocentesis
• Synovial fluid do not clot ; if clotted therefore there is presence of fibrinogen which
occurs if there is damage/disease joints
• Volume:
o NORMAL: <3.5 mL
o INFLAMMATION: >25 mL
• Distributed in the following tubes:
o Na Heparin (sterile)/SPS: Microbiology
o LIQUID EDTA/Na Heparin: Hematology
▪ Powdered EDTA may be mistaken for crystal, that is why it is not used
o Non-anticoagulated: Chemistry, other tests
o Na Fluoride: antiglycolytic agent for glucose analysis

SYNOVIAL FLUID – COLOR

Colorless to pale Normal

yellow

Deeper Yellow Inflammation

Greenish tinge Bacterial Infection such as septic arthritis

Red Traumatic tap – accidental puncture of the peripheral blood
vessels in the joint area
Hemorrhagic arthritis – bleeding occurs inside the joint cavity
without accidental puncture

TRAUMATIC TAP

COLOR Dark Red Light Red Yellowish

CLOT FORMATION – Positive Negative Negative

occurs if there is
fibrinogen (occurs
when there is
damage in joint)

HEMORRHAGIC ARTHRITIS

COLOR Dark Red Dark Red Dark Red

CLOT FORMATION – Negative Negative Negative

occurs if there is
fibrinogen (occurs
when there is
damage in joint)

SYNOVIAL FLUID – CLARITY

CLEAR Normal

TURBID Leukocytes, Fibrin, Cell Debris

OPAQUE, OILY,
SHIMMERING
Radiographic contrast media (RCM)

MILKY Crystals

GROUND PEPPER-
LIKE INCLUSIONS –
Ochronosis
called as
ochronotic chards

FREE-FLOATING Rheumatoid arthritis, degenerative synovium with fibrin

RICEBODIES

SYNOVIAL FLUID – VISCOSITY

NORMAL Able to form string – 4-6 mm

Normal Hyaluronic Acid Level: 0.3-1.4 g/dL

ROPES/MUCIN CLOT TEST (Aka Hyaluronate Polymerization

test)
REAGENT: 2-5% HAC
Principle: Acetic acid will polymerize hyaluronic acid then forms
TEST
a clot (positive reaction)
 REPORTING OF CLOT:
• GOOD – Solid clot
• FAIR – Soft clot
• LOW - Friable clot
• POOR – No clot

SYNOVIAL FLUID CELL COUNT – use hemacytometry to count cells in synovial fluid
• DILUTING FLUIDS:
o NSS with Methylene Blue
o Hypotonic Saline (0.3%) – may result in RBC lysis; can be used to count WBC
o Saline with Saponin – may result in RBC lysis; can be used to count WBC
o TAKE NOTE: do not use acetic acid because it will polymerize the hyaluronic
acid causing the synovial fluid to clot
• For very viscous fluid
o Add a pinch of Hyaluronidase to 0.5 mL synovial fluid
o Add 1 drop of 0.05% hyaluronidase in phosphate buffer per mL of fluid
▪ Incubate at 37C for 5 minutes

SYNOVIAL FLUID – DIFFERENTIAL COUNT

NORMAL VALUES

RBC <2000/uL

WBC <200/uL

WBC DIFFERENTIAL

Monocytes/Macrophages Most abundant

65%

Neutrophils <25%

Lymphocytes <15%

CELLS AND INCLUSIONS SEEN IN SYNOVIAL FLUID

 CELLS DESCRIPTION SIGNIFICANCE

Neutrophils Polymorphonuclear leukocytes Bacterial sepsis / septic arthritis /

crystal induced inflammation

Lymphocyte Mononuclear leukocytes Non-septic inflammation

s

Macrophage Large mononuclear leukocytes Normally seen in synovial fluid

(Monocytes Maybe vacuolated If elevated – indicates viral infection
)

Synovial Similar to macrophage, but Normal

Lining Cells maybe multinucleated,
resembling a mesothelial cell

LE Cells Neutrophil containing Lupus Erythematosus

characteristic ingested
“Round Body”

Reiter Cells Vacuolated macrophage with Reiter Syndrome

ingested Neutrophil
Non-specific inflammation

RA Cells Neutrophil with dark Rheumatoid arthritis

(Ragocytes) cytoplasmic granules containing
Immunologic inflammation
immune complexes

Cartilage Large, multinucleated cells Osteoarthritis

Cells

Rice Bodies Macroscopically resembles Tuberculosis, septic and rheumatoid

polished rice Microscopically arthritis
show collagen & fibrin

Fat Droplets Refractile intracellular & Traumatic injury Chronic inflammation

extracellular globules.
Stained with Sudan dyes

Hemosideri Inclusions within clusters of Pigmented villonodular synovitis

n synovial cells

CRYSTAL IDENTIFICATION
 CRYSTAL SHAPE COMPENSATED SIGNIFICANCE
POLARIZ
ED LIGHT

Monosodium Needles Negative Gout – associated

Urate (MSU) birefringence with increased uric
acid

Calcium Rhombic square, rods Positive Pseudogout –

Pyrophosphat birefringence associated with
e dihydrate degenerative
(CPPD) arthritis

Cholesterol Notch, Rhombic plates Negative Extracellular

birefringence

Corticosteroid Flat, variable-shaped plates Positive & Injections

Negative
birefringence

Calcium Envelope shape Negative Renal dialysis

oxalate birefringence

Hydroxyapatit Small particles No birefringence Osteoarthritis

e/Apatite – because it is not
Requires electron Calcified cartilage
(Calcium visible under
microscope for degeneration
phosphate) polarizing
visualization
microscope

POSITIVE VS NEGATIVE BIREFRINGENCE – use compensated polarizing microscope to

identify the type of birefringence ; uses red compensator

NEGATIVE POSITIVE
• Shows yellow color • Shows blue color
• Molecules are Parallel to the • Molecules are Perpendicular to the
velocity of light velocity of light
SYNOVIAL FLUID – CHEMICAL EXAMINATION

SIGNIFICANCE

GLUCOSE Most frequently tested chemistry test

Blood Glucose – SF Glucose = should be <10mg/dL (Normal)

Example:
99 mg/dL (FBS) – 90 mg/dL (SFG) = 9 mg/dL
99 mg/dL (FBS) – 40 mg/dL (SFG) = 59 mg/dL

LACTATE – Normal: <250 mg/dL

byproduct of
Increased: Infection
glucose

PROTEIN Normal: 3g/dL

Increased: Inflammatory & hemorrhagic disorders

URIC ACID Normal: Same as the blood uric acid

Increased: Gout

MICROBIOLOGY TEST
Common organisms that infect Synovial Fluid:
1. Staphylococcus aureus
2. Streptococcus
3. Haemophilus
4. Neisseria gonorrhea – called gonococcal arthritis

SEROLOGIC TESTS:
1. Autoantibody detection (SLE, RA) - antinuclear antibodies and rheumatoid factor
2. Serologic tests for Lyme Disease – arthritis (frequent complication of lyme disease)
• Lyme disease – caused by bacteria Borrelia burgdorferi

I IIa IIb III IV

Non- Inflammato Inflammat Septic Hemorrhagi

inflammat ry ory (Crystal- c
ory (Immunolog induced)
ic)

Significanc Degenerativ Immunologic Gout – Traumatic

e e joint Monosodium injury
disorders Microbial
urate
disorder (RA, SLE, etc) infection Coagulation
(osteoarthri Pseudogout deficiencies
tis) - CPPD

Color & Clear, Cloudy, Cloudy or Cloudy, Cloudy, red

Clarity green fluid fluid
Yellow fluid Yellow fluid Milky fluid

Viscosity Good Poor Low Variable Low

WBC Count <1,000/uL 2,000- Up to 50,000- Equal to

75,000/uL 100,000/uL 100,000/uL Blood

Neutrophil <30% >50% <70% >75% Equal to

s Blood

Glucose Normal Decreased Decreased Decreased à Normal

increase
lactate

Others NA Autoantibodi (+) Crystals (+) gram (+) RBC

es stain, culture
SEROUS FLUID
• Fluid between parietal (lines the cavity wall) & visceral membranes (covers the
organ)
• Function: provide lubrication between the 2 membranes
• Also, an ultrafiltrate of plasma
• 3 types:
o Pleural Fluid – found in lungs
o Pericardial Fluid – found in cardiac muscle
o Peritoneal Fluid – found in bdominal

EFFUSION – accumulation of excess fluid between the membranes

TRANSUDATE EXUDATE

Caused by: Systemic condition Caused by: Membrane damage/problems

Causes: Causes:
1. Hypoproteinemia 1. Infection (e.g., Pneumonia, TB,
2. Congestive Heart Failure Endocarditis)
3. Nephrotic Syndrome 2. Inflammation
4. Cirrhosis 3. Malignancy (e.g., Adenoma)
5. Malnutrition

TRANSUDA EXUDATE
TE

Appearance Clear Cloudy

Fluid: Serum Protein Ratio - <0.5 >0.5

Most reliable test to differentiate
exudates and transudate

Fluid: Serum LD Ratio - Most <0.6 >0.6

reliable test to differentiate
exudates and transudate

WBC Count <1,000/uL >1,000/uL

Spontaneous Clotting No Possible

 Pleural Fluid Cholesterol <45-60 >45-60
(mg/dL)

PF: Serum Cholesterol Ratio <0.3 >0.3

PF: Bilirubin Ratio <0.6 >0.6

Serum-Ascites Albumin >1.1 <1.1

Gradient

Glucose Increased Decreased

Rivalta’s Test (aka Serosa Negative Positive

Musin Clot Test) – test that
differentiates exudates from
transudate

RIVALTA’S TEST
Unknown fluid + Water + Acetic Acid --> (+) Heavy Precipitation, Then it is an
EXUDATES

METHOD OF COLLECTION – needle aspiration

SEROUS FLUID METHOD OF COLLECTION

PLEURAL FLUID Thoracentesis

PERICARDIAL FLUID Pericardiocentesis

PERITONEAL FLUID Paracentesis

TUBES FOR SEROUS FLUID TESTS/LABORATORY

SECTION

EDTA Cell count and differential count

STERILE HEPARIN TUBE Microbiology and cytology

HEPARIN TUBE – stored Chemistry

anaerobically in ice during
transport
PLAIN TUBE Clotting test

PLEURAL FLUID
1. NORMAL VOLUME: <30mL

APPEARANCE SIGNIFICANCE

Clear, pale yellow Normal

Turbid, white Microbial infection

Brown – anchovy sauce-like Ruptured Amoebic Abscess – type of extraintestinal

appearance amoebiasis

Black aspergillosis

Viscous Malignant Mesothelioma – produces hyaluronic acid

causing viscous pleural fluid

Milky Chylous material, pseudochylous material

Bloody Hemothorax, Hemorrhagic effusion

MILKY PLEURAL FLUID

CHYLOUS EFFUSION – increase PSEUDOCHYLOUS – increase in

in triglyceride cholesterol

CAUSE Thoracic duct leakage Chronic inflammation/infection

Thoracic duct – lymphatic duct
(both rich in lymphocytes and
chylomicrons)
Chylomicrons – lipoproteins
that have high TAG

APPEARANCE Milky/white Milky/green tinge/” gold paint”

- may be due to infection

LEUKOCYTES Increase Lymphocytes Mixed cells

CHOLESTEROL Absent Present
CRYSTAL

TRIGLYCERIDES >100 mg/dL <50 mg/dL

SUDAN III Positive Negative

STAINING – stain
Sometimes weakly positive
for TAG

BLOODY PLEURAL FLUID

HEMOTHORAX – bleeding HEMORRHAGIC

due to injury; normal EFFUSION – increase
pleural fluid with blood pleural fluid with blood

DISTRIBUTION OF BLOOD Uneven Even

PF Hct is ≥1/2 of WB Hct PF Hct is <½ of WB Hct

Example: ≥25% Example: <25%

HEMATOCRIT

PLEURAL FLUID CELLS

CELLS SIGNIFICANCE

NEUTROPHIL Pneumonia, pancreatitis, pulmonary infarction

LYMPHOCYTE TB, viral infections, autoimmune disorders, malignancy

 MESOTHELIAL
CELLS
Normal
2 forms:
Decrease – in cases of TB
1. Normal
2. Reactive

PLASMA CELLS
TB

MALIGNANT Primary adenocarcinoma, small cell carcinoma, metastatic

CELLS carcinoma

EOSINOPHIL >10% - due to trauma resulting from presence of air or blood in

pleural fluid sample
May be due to allergy or parasitic infection

Tumor markers for effusions of malignant origin

TUMOR MARKER SIGNIFICANCE

CEA Colon cancer

CA125 Metastatic uterine cancer

CA 15-3, CA 549 Breast cancer

CYFRA 21-1 Lung cancer

PLEURAL FLUID CHEMISTRY

TEST SIGNIFICANCE

Glucose Rheumatoid inflammation, TB, purulent infection

Lactate
↑ Bacterial Infection

Triglyceride
↑ Chylous effusion
 pH ↓ pneumonia not responding to antibiotics
↓ complicated parapneumonic effusion (assoc. with
emphyema)
pH 6.0 - highly associated with ↓ ↓ ↓ ↓ esophageal rupture

Adenosine Malignancy, tubercular effusion

deaminase

Amylase Esophageal rupture, malignancy, ↑ pancreatitis

MICROBIOLOGIC TEST
Common bacteria that cause Pleural Effusion:
1. S. aureus
2. Enterobacteriaceae
3. M. tuberculosis
4. Anaerobic bacteria

PERICARDIAL FLUID

SIGNIFICANCE

NORMAL VOLUME <50mL

APPEARANCE:

Clear, pale yellow Normal, transudate

Blood-streaked Infection, malignancy

Grossly Bloody Cardiac puncture, anticoagulant medication

DIFFERENTIAL:

↑ Neutrophil Bacterial Endocarditis

Malignant Cells Metastatic carcinoma

TESTS
↓Glucose Bacterial infection, malignancies
 Gram Stain and Culture Bacterial endocarditis
Bacteria: Haemophilus, staphylococcus, streptococcus
Virus: Adenovirus, Coxsackievirus

Acid-fast Stain Tubercular effusion

Adenosine deaminase Tubercular effusion of the pleural, pericardial, and

peritonealfluid

PERITONEAL FLUID – also known as Ascitic fluid

Ascites – if there is effusion in peritoneal cavity

SIGNIFICANCE

NORMAL VOLUME
<100mL

APPEARANCE:

Clear, pale yellow Normal

Turbid Microbial infection

Green Gall bladder, pancreatic disorder

Blood-streaked Trauma, infection, malignancy

Milky Lymphatic trauma and leakage

PERITONEAL FLUID – CELL COUNT

SIGNIFICANCE

WBC COUNT

<500/uL Normal

>500/uL Bacterial peritonitis, cirrhosis

DIFFERENTIAL
COUNT

↑Neutrophils Bacterial peritonitis

 Malignant Cells Malignancy

PERITONEAL FLUID TESTS

SIGNIFICANCE

PERITONEAL LAVAGE >100,00RBCs/uL - Indicates blunt trauma injury

– sensitive test to
detect intraabdominal
bleeding

CEA Malignancy – GI origin

CA 125 Malignancy – Ovarian origin

Glucose ↓ Tubercular peritonitis, malignancy

Amylase
↑ Pancreatitis

↑ in GI perforation
ALKALINE
PHOSPHATASE

BUN/Creatinine Ruptured/punctured bladder

Gram Stain & Culture Bacterial peritonitis

Acid-fast Stain Tubercular peritonitis

Adenosine
deaminase
Tubercular peritonitis

PSAMMOMA BODIES
• Contains concentric striations of collagen-like material
• Seen in benign conditions and associated with:
o Ovarian malignancy
o Thyroid malignancy
READING ASSIGNMENT: Strasinger 6th Edition

• Chapter 10: Page 203-213: Seminal Fluid

• Chapter 15: Page 269-279: Vaginal Fluid