SYNOVIAL FLUID

Physiology and Purpose of Examination

 Synovium

- Tissue lining synovial tendon sheaths, bursae, and diarthrodial joints except for the articular surface. - One to three cell layers: surface overlying fatty, fibrous, or periosteal joint tissue.
 Synovial

Fluid

joints.

- Viscous liquid found in the cavities of the movable

- Imperfect ultrafiltrate  blood plasma and hyaluronic acid (synoviocytes) - synoviocytes secrete the hyaluronic acid and a small amount of protein into the fluid - Lubrication and adhesion - Provides nutrients for the avascular articular cartilage

 Examination

- Arthritis - Acute or chronic inflammation of a joint

of Synovial Fluid

- Having diverse causes, such as: infection, crystal deposition or injury - Causes deformities much like the ones seen in the xray.
 Arthrocentesis

- Often accompanied by pain and structural changes

- Needle aspiration of synovial fluid

 Purpose

- Differentiate infectious from noninfectious arthritis - Classify pathological significance of joint disorders

of Examination

4

classifications
- Non inflammatory - Inflammatory - Septic - Hemorrhagic

 Specimen

Collection and Handling

Arthrocentesis Volume – not always constant, should be recorded TUBES USED:
- Sterile heparin tube (Gram stain and culture)

- Heparin or EDTA tube (cell counts) - Nonanticoagulated tube (chemical and serological tests) - Sodium Fluoride tube (glucose analysis)
Powdered anticoagulants should not be used. They produce artifacts that may interfere with crystal analysis. NORMAL SYNOVIAL FLUID does not clot – diseased joints may contain fibrinogen, which will clot Aspirate using syringe moistened with heparin

Color Normal color: colorless to pale yellow Pale yellow – diapedesis Straw to yellow – xanthochromia and Clarity White blood cells escape from the vessels and enter the synovium Indicative of synovial hemorrhage Deeper yellow – noninflammatory and/or inflammatory effusions Greenish tinge – bacterial infection Red – traumatic tap versus hemorrhage Note distribution of blood to distinguish Traumatic tap – uneven. consistent distribution of blood across tubes Red/brown. post-centrifuge – pathologic hemarthrosis (bleeding into the joints) . receding distribution of blood in tubes Hemorrhage – even.

synovial cell debris and fibrin Milky – presence of crystals Oily. Normal consistency: resembles the viscosity of egg white Turbidity – presence of WBCs. Synovial comes from the Latin word for egg. shimmering – cholesterol crystals .

or mucin clot test – chemically measures the amount of hyaluronate polymerization  Ropes . 46cm is normal. Viscosity From the polymerization of hyaluronic acid For proper lubrication of the joints Note: Arthritis affects both the production of hyaluronate and its ability to polymerize (decreasing viscosity) Methods:  String method – form a string with the tip of the syringe.

0.    Total Leukocyte Count Perform ASAP or refrigerate to prevent cellular disintegration Manual counts use Improved Neubauer Clear specimens are counted without dilution.3% hypotonic saline or saline with saponin for RBC lysis (when necessary) .Cell Counts   EXTREMELY viscous specimens: pre-treated with a pinch of hyaluronidase per 0.Methylene blue may be added to stain WBC nuclei (separation from RBC)  Count 5 secondary squares (4 corners + center) .05% hyaluronidase in phosphate buffer per mL of fluid and incubate at 37°C for 5mins.5mL of fluid or 1 drop of 0. Diluents: . Turbid or bloody specimens are first diluted prior to counting.Normal saline .

septic and rheumatoid arthritis Osteoarthritis Traumatic injury Chronic inflammation Villonodular synovitis Cartilage cells Lipid/Fat droplets Hemosiderin granules .Abnormal cells Cell/Inclusion LE cells Description Neutrophil containing a characteristic ingested round body Vacuolated macrophages with ingested neutrophils Neutrophils with small dark cytoplasmic granules that consist of precipitated rheumatoid factor Resemble polished rice macroscopically.and extracellular globules Inclusions within clusters of synovial cells Significance Lupus erythematosus Reiter cells RA cells or ragocytes Reiter syndrome Nonspecific inflammation Rheumatoid arthritis Immunologic inflammation Rice bodies TB. multi-nucleated cell Refractile intra. show collagen and fibrin microscopically Large.

 Crystals – useful in the diagnosis and evaluation of cases of arthritis formation causes acute or chronic pain and affects both bone and cartilage. causes of crystal formation: Metabolic disorders Decreased renal excretion Medications that are injected into the joints  Crystal  Main .

Standard: Nelson-Somogyi method .Chemical Tests: Glucose Determination -Most frequently requested chemical test –Blood and synovial fluid samples obtained simultaneously (correlation) sample .Requires 8 hours fasting .NV: <10mL lower than blood glucose .Synovial fluid is handled similar to serum .

Increased in inflammatory and hemorrhagic disorders .Measurements are nonspecific .Methods – same as serum protein determinations . Total Protein Determination .Refractometers – used to estimate the synovial fluid protein concentration .NV: <3 g/dL .

.Correlated with serum uric acid. Uric Acid Determination .Confirms status if uric acid crystals are not demonstrated microscopically Suspected but unconfirmed gout .Little clinical value other than correlation. .Elevated in gout .

Fair to poor ratings reflect dilution and depolymerization of hyaluronic acid  nonspecific finding in several inflammatory arthrites .Semi-quantitatively grades viscosity .Add acetic acid to specimen to precipitate hyaluronidase into a mucin clot . Mucin Clot Test .

Testing on synovial fluid is only done as a confirmatory measure due to the sensitivity of the arthrocentesis procedure.Routine bacterial cultures use enriched medium such as chocolate agar. etc) .Associated Autoimmune Diseases: RA and SLE Cause serious inflammation of the joints Autoantibodies are found in both serum and synovial fluid .Majority of serologic tests are performed on serum.Most frequent infection of the synovial joints is bacterial by origin. .Important in joint disorder diagnosis (as in serologic testing for rheumatoid factor. which supports the Haemophilus species and Neisseria gonorrheae. . systemic lupus erythematosus.  SEROLOGIC TESTS . MICROBIOLOGIC TESTS 2 important tests: Gram stain and culture . .

SEROUS FLUID .

 Closed Cavities of body Pleural Pericardial Peritoneal cavities  Parietal membrane – in between (serous fluid) – provides lubrication  Visceral membrane – lines the organ within cavity  Lubrication – to prevent fiction between 2 membranes .

 Formation       Serous fluid – ultra filtrates of plasma Production and reabsorption – hydrostatic and colloidal (oncotic) pressure capillaries – serves cavities and the capillary permeability Normal : same colloidal pressure from serum proteins in the capillaries on both sides ( hydrostatic pressure in the parietal and visceral capillaries to enter between the membranes) Filtration of plasma – ↑ oncotic pressure (favors reabsorption of fluid back into the capillaries) Slight different amount of positive pressure in the parietal and visceral capillaries creates small excess of fluid that is reabsorbed by the lymphatic capillaries located in the membranes Effusion: disruption of the mechanism of serous fluid formation and reabsorption that causes ↑ in fluid between the membrane .

infection Membrane inflammations Malignancy Malignant tumor.Pathologic causes of effusion 1. ↓ Oncotic pressure • Hypoproteinemia • • • • Nephrotic syndrome Hepatic cirrhosis Malnutrition Protein-losing enteropathy 1. ↑ Capillary hydrostatic pressure • • Congestive heart failure Salt and fluid retention 1. ↑ Capillary permeability • Inflammation and infection • • • • • • Microbial. Lymphatic obstruction . lymphomas Infection and inflammation Thoracic duct injury 1.

Chemistry test – clotted specimens ( plain tubes or heparinized tubes) .pH – maintained anaerobically in ice . Specimen .Sterile heparinized evacuated tubes – microbiology and cytology .>100 ml .Blood specimens also collected Collection and Handling .Centrifugation (better recovery of microorganisms ) .Needle aspiration  Thoracentesis (pleural)  Pericardiocentesis (pericardial)  Paracentesis (peritoneal) .Chemical test – compared with plasma chemical concentrations .EDTA tube – cell counts and differential .

General classification of the cause of an effusion – separating the fluid into category of : Transudates • Systemic disorder – disrupt balance in regulation of fluid filtration and reabsorption .Hydrostatic pressure – congestive heart failure Hypoproteinemia – nephritic syndrome Directly involved Infections Malignancies • Exudates • • • .

 Classification : for initial diagnostic step (NO testing for transudate fluids)  Laboratory tests: Appearance Total protein most reliable Lactic dehydrogenase Cell counts Spontaneous clotting determination: fluid-toblood ratio .

 General       Evaluation of the appearance and differentiation between transudate and exudates Effusion of exudates – presence of microbiologic and cytologic abnormalities RBC and WBC counts – not performed on serous fluid (little diagnosis) WBC <1000/mircoliter = Transudate > 1000/mircoliter =exudates Serous cell counts – manually ( Neubauer counting chamber) Differential counts –Wright’s-stained. cytocentrifuged specimens Examine: WBC. normal and malignant cell tissue Laboratory Procedures .

PLEURAL FLUID .

Pleural fluid cholesterol – >60mg/dl exudates .Pleural fluid:serum total bilirubin ratio – ≥ 0. PLEURAL FLUID .6 – exudates .3 . located between parietal pleural membrane lining the chest wall and the visceral membrane covering the lungs .Fluid:serum cholesterol – >0.Obtained from the pleural cavity.

pale yellow Turbid white (related to presence of WBC) Bloody Disease Normal Microbial infection(tuberculosis) Immunologic disorders : Rheumatoid arthritis Hemothorax ( traumatic injury – occurs in malignancy or traumatic aspiration) • Traumatic tap : streaked and uneven Hemorrhagic effusion.Pleural Fluid Appearance and Disease Appearance Clear. pulmonary embolism. Tuberculosis malignancy Chylous material from thoracic duct leakage Pseudochylous material from chronic inflammation Rupture of amoebic liver abscess Aspergillous Malignant mesothelioma (increase hyaluronic acid) Milky Brown Black Viscous .

Difference of Hemothorax and Hemorhagic Exudates Hemothorax Hematocrit >50% of the whole blood hematocrit • effusion occurs from the INPOURING of blood from the injury Hemorhagic exudates <50% • Chronic membrane disease: contains both blood and increased pleural fluid. .

Differentiation Between Chylous Effusion and Pseudochylous Effusion Chylous Effusion Cause Appearance Leukocyte Cholesterol crystals Triglycerides Sudan III staining Thoracic duct leakage Milky/white Predominantly Lymphocytes Absent >110 mg/dl Strongly positive • High cholesterol conc. Pseudochylous Effusion Chronic inflammation Milky/green tinge Mixed cells Present <50mg/dl Negative/weakly positive • Cholesterol crystals .

Most significant hematology test performed. HEMATOLOGY TEST  Differential Count . ( also seen in pericardial and peritoneal fluids) Neutrophils Lymphocytes Pneumonia Pancreatitis Pulmonary infarction Tuberculosis Viral infection Autoimmune disorder ( RA and SLE) Malignancy Trauma ( presence of air or blood) • Pneumothorax and hemothorax Allergic reactions Parasitic infections Increase: pneumonia and malignancy Decrease : mesothelial cells are associated with Tuberculosis • Primary concern of examination Eosinophils Mesothelial cells Malignant cells Plasma cells Tuberculosis .

Significance of Chemical Testing of Pleural Fluid Test Significance Glucose • • • • Parallel plasma levels with values <60 mg/dl considered ↓ Fluid values vs.0 ( need for chest-tube drainage) In cases of acidosis : pleural fluid pH should be compared to blood pH. esophageal rupture and malignancy Amylase . plasma values Considered in addition to glucose level ↓ in rheumatoid inflammation ↓ in tuberculosis ↓ in purulent infection ↑ in bacterial infection ↑ in chylous effusions ↓ in pneumonia not responding to antibiotics Marked ↓ with esophageal rupture • <pH 6.30 or lower than blood pH : SIGNIFICANT Ph • • • ADA(adenosine deaminase) • • • 40U/L Elevated 1st in the pleural fluid Salivary amylase ↑ in tuberculosis and malignancy ↑ in pancreatitis.0 • Allowing influx of gastric fluid Lactate Triglyceride To confirm the presence e of chylous effusion ↓than pH7. Pleural pH at least 0.

 MICROBIOLOGIC TESTS Staphylococcus aureus Enterobacteriaceae Anaerobes Mycobacterium tuberculosis Tests: Gram stains Cultures ( aerobic and anerobic) Acid-fast stains .

 SEROLOGICAL TESTS To differentiate effusions of immunologic origin from noninflammatory processes. Tests : Antinuclear antibody (ANA) Rheumatoid factore (RF) Detection of tumor markers ( diagnostic information for malignant origin): Carcinoembryonic antigen (CEA) CA 125 ( metastic uterine cancer) CA15.3 CA 549(breast cancer) .

PERITONIAL FLUID .

 PERITONEAL FLUID Characteristics .An ultrafiltrate of plasma .Normal peritoneal fluid is clear and pale yellow  *Ascites – pathologic accumulation of excess fluid in the peritoneal cavity .50 mL of fluid is normally present in this mesothelial-lined space .

high protein content .012).Increased hydrostatic pressure or deceased plasma oncotic pressure . CHF. low protein content .Cirrhosis.Low specific gravity(<1.Bacterial infections (peritonitis) and malignancy AND EXUDATES  .Increased capillary permeability or decreased lymphatic resorption .High specific gravity(>1.020). nephrotic syndrome Exudates . TRANSUDATES  Transudates .

. Serum–ascites albumin gradient .A difference of 1.1 are associated with exudative effusions.Widely considered as the most reliable method to differentiate peritoneal transudates from exudates.Lower than 1. .1 or greater suggests a transudate effusion of hepatic origin .The serum albumin concentration minus the ascitic fluid albumin concentration .

 SPECIMEN     COLLECTION Paracentesis Minimum of 30 mL is needed for complete evaluation Samples for cell counts should be placed in an EDTA-anticoagulated tube Culture specimens inoculated at the bedside with ascitic fluid (10 mL per culture bottle) .

. Lymphocytes are the predominant cell in tuberculosis. MICROSCOPIC   EXAMINATION   Normal WBC counts are less than 350 cells/uL An absolute neutrophil count greater than 250 cells/uL or greater than 50% of the total WBC count is indicative of infection. Eosinophilia (>10%) is most commonly associated with the chronic inflammatory process associated with chronic peritoneal dialysis.

CHEMICAL ANALYSIS Chemical examination of ascitic fluid consists primarily of glucose. GLUCOSE  Decreased below serum levels in bacterial and tubercular peritonitis and malignancy  Low sensitivity and specificity AMYLASE  To ascertain cases of pancreatitis. . amylase. and alkaline phosphatase determinations. and it may be elevated in patients with gastrointestinal perforations ALKALINE PHOSPHATASE  An elevated level is highly diagnostic of intestinal perforation.

PERICARDIAL FLUID .

Pericardial effusions may be due to viral. renal failure. autoimmune disorders. drugs or may be idiopathic .Normally. PERICARDIAL FLUID . bacterial or fungal infections. 10-50 mL is present in the pericardial space .HIV patients have asymptomatic pericardial effusions . myocardial infarction.

hematocrit and blood gas analysis .Specimen Collection       Pericardiotomy – the process wherein the pericardial fluid is obtained Pericardiocentesis – sterile needle aspiration Normal pericardial fluid is clear and pale yellow. Turbid – infection is present Clear and straw colored – uremia is present Bloody – hemorrhagic effusion or due to aspiration of blood from the heart Cause may be differentiated by observing clots.

pcO2 is higher  Does not clot Milky color – chylous or pseudochylous  The difference is similar to other serous fluids .Aspiration  Hematocrit is similar to that of the peripheral blood  Blood gas analysis similar to venous or arterial blood  The blood forms clots Hemorrhagic effusions  Hematocrit is lower than peripheral blood  Blood gas pH and pO2 are lower.

6  Pleural fluid LD level >200 U/L .Exudates and Transudates – similar difference with other serous fluids  Exudates are diagnosed by Light’s criteria ( the most reliable diagnostic tool for identifying exudates and transudates) Light’s criteria  Pleural fluid/serum LD ratio >0.

ROUTINE TESTING OF PERICARDIAL EFFUSIONS  Cell count  Glucose  Total protein  Lactate dehydrogenase (LD)  Bacterial culture  Cytology .

3. 2. . pH Decreased pH (<7.10) – rheumatic or purulent pericarditis Moderate decreases (7. Effusions facilitated by triglyceride and cholesterol measurements.30) – malignancy. Thus.20-7. pseudochylous same difference as serous fluids. Protein a value of > 3. uremia or tuberculosis. Lipids Chylous vs. tuberculous.CHEMICAL 1. no discriminating power in pericardial diagnosis.0 g/dl has a sensitivity of 97% for exudates effusions but with only 22% specificity which limits its usefulness. rheumatic or malignant effusions. Glucose < 60 mg/dl has a diagnostic accuracy of only 36% in identifying pericardial exudates <40 mg/dL is indicative of bacterial. Idiopathic disorders 4.

CK-MB. specificity is 97%. specificity is 97%. Cut off value 40 U/L = sensitivity is 93%.000 pg/L). myoglobin and Troponin I in postmortem pericardial fluid is increased in myocardial infarction Adenosine deaminase is increased in tuberculosis pericarditis than pathologic effusions and is a better marker than acid fast stain. Interferon gamma High levels in tuberculosis serous effusions (1. . Negative test in acid fast stain does not rule out tuberculosis. If cut off value is 200 pg/L. Enzymes     Lactate dehydrogenase > 200 U/L (pericardial exudates cutoff) LD and CK measurement is important in postmortem death after 48 hours may be useful in establishing Acute myocardial infarction in cases wherein injury cannot be established by usual histologic methods.5. sensitivity and specificity is 100% 7. Higher than effusions from pathologic conditions. Cut off value 30 U/L = sensitivity is 94%. PCR   A more sensitive diagnosis in tuberculous pericarditis than Adenosine deaminase. 6.

Beta hemolytic group A streptococcus and Gram negative bacilli.  Viral pericarditis is difficult to diagnose because they are rarely isolated from pericardial fluid.pyogenes. S. High ANA titers lack specificity in pericardial exudates. MICROBIOLOGICAL  Gram stain sensitivity is similar to serous body fluids  Important aerobic bacteria: S.  Viral infection accounts for most idiopathic HIV associated pericardial exudates  Sensitivity of culture and acid fast stain for tuberculous pericarditis is about 50% . S. aureus.IMMUNOLOGIC  Negative ANA means a diagnosis of lupus serositis is unlikely. malignancy should be considred. If there is a high ANA titer is unexplained. pneumonia.  Aerobic bacteria not often recognized due to inconsistent methods used for their isolation and identification.

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