Body Fluids Analysis

Abuobaida E. E. Abukhelaif
Assistant Prof; Pathology Department, Faculty of Medicine, Albaha University; KSA
 Lecture Objectives

 By the end of this lecture students should be able to know :

 Laboratory exam of body fluids including :

 Physical characteristics

 Chemical constituents

 Microscopic Examination
Introduction

 Body fluids are lubricating fluids present within the body cavities.

 Normally, a small amount of fluid is present within the body cavities which keeps
the surfaces moist and lubricated so that the movement of the adjacent or the
opposing membrane surfaces occurs with minimal friction.
 Increase in the volume of the fluid in these cavities is known as effusion.

 The commonly examined body fluids in the laboratory include pleural,

pericardial, peritoneal and synovial fluid.
 Effusions may be broadly divided into transudate and exudate
Specimen Collection

 The body fluid is collected in a clean, dry container under aseptic precautions and
atraumatically to avoid mixing with fresh blood.
 The fluid is collected in the following three sterile test tubes:

 Chemical examination: Fluoride tube

 Microscopic examination: EDTA tube

 Bacteriological examination: Plain tube (without anticoagulant).

 They should be examined as early as possible to prevent chemical changes,

growth of bacteria and disintegration of cells
Examination of body fluids

 Physical Examination :
 Note volume, color and appearance.
 Color: Pleural, pericardial and ascitic (peritoneal) fluids are usually clear and straw colored.
 Uniform blood stained fluid suggests malignancy involving the organs/tissues surrounding the respective
body cavity.
 Turbid fluid may be due to high cell count or high protein content.
 Chylous with milky appearance usually indicates high lipid content due to lymphatic obstruction.
 Transudate VS. exudate: It is important to differentiate whether the fluid is a transudate or exudate .
 Transudate is usually seen in all body cavities with diseases like heart failure and hypoalbuminemic
conditions (e.g. nephrotic syndrome).
 Cirrhosis results in prominent ascites, but may also cause pleural effusion.
 Exudate usually suggests infection or malignancy
Examination of body fluids
 Chemical Examination
 Protein estimation: This helps to differentiate transudate from exudate
 Glucose estimation: Low glucose in the body fluids usually suggests bacterial infection (including tuberculosis),
malignancy or nonspecific inflammation.
 Measurement of amylase in ascitic fluid in patients with pancreatic lesions.
 Microscopic Examination
 Cell count is done similar to total WBC count using improved Neubauer chamber.
 Normal: Few mesothelial cells (lining cells of body cavities) and lymphocytes are seen.
 Differential WBC count
 Procedure: Centrifuge the body fluid and from the sediment prepare the smears (at least 2).
 Stains:
 Leishman’s stain: Stain one smear with Leishman's stain and count 100 cells and express the differential count.
 Gram’s stain/acid fast stain: These stains are useful in suspected cases of infective/ tubercular infections.
 Cytological examination for malignant cells
 Procedure: The body fluid is centrifuged; smears are made from the sediment and fixed immediately in
absolute alcohol. The smears are stained by Papanicolaou stain . Hematoxylin and eosin stain or Giemsa may
also be used.
 Cytospin is a better alternative for making smears.
 Examination of synovial fluids
 Physiology
 Synovial fluid is located in the cavities between the moveable joints. Synoviocytes secrete
hyaluronic acid, a large molecule that produces the viscosity of the fluid
 •Damage to the joints produces arthritis
 Uses: Examination of synovial fluid is useful in the diagnosis of joint disorders.
 Infective arthritis (septic arthritis, rheumatic)
 Gouty arthritis (metabolic disorder)
 Rheumatoid arthritis (autoimmune disorder)
 Degenerative arthritis.
 Laboratory examination: It consists of
 (1) physical examination,
 (2) microscopic examination,
 (3) chemical examination, and
 (4) microbiological examination.
 Examination of synovial fluids
 Physical Examination
 a. Color and appearance:
Appearance Normal Turbid Purulent Red or brown supernatant
Condition Clear, straw colored and Infection and inflammation of the joint space, due Septic arthritis Hemarthrosis or in a traumatic tap
viscous. It does not clot to the presence of crystals, amyloid and cartilage
fragments

 b. Viscosity test : Synovial fluid is viscous due to the presence of hyaluronic acid. The viscosity of the synovial
fluid decreases in inflammatory joint disorders due to the breakdown of hyaluronic acid by the enzyme
hyaluronidase.
 c. Mucin clot test: Hyaluronic acid forms a compact clot when mixed with the acetic acid. Low concentration of
hyaluronic acid does not allow the formation of a firm clot.
 Add few drops of synovial fluid to 20 mL of 5% acetic acid in a small beaker. A good clot is formed if the
synovial fluid is normal.
 In inflammatory diseases of the joint, there is poor clot formation due to degrading enzymes from the
inflammatory cells (e.g. tuberculous arthritis).
 Noninflammatory joint disorders show good clot formation whereas hemorrhagic synovial fluid prevents
clot formation due to dilution of fluid.
 Fair to poorly formed clot is seen in rheumatoid arthritis, gout and pseudogout.
 Examination of synovial fluids
 Microscopic Examination
 Differential leukocyte count
 If polymorphs are more than 70%, it indicates bacterial arthritis.
 Noninflammatory arthropathies (osteoarthritis) are associated with lymphocytes and macrophages.
 Wet smear examination
 Centrifuge the synovial fluid and take the sediment on a glass slide and cover it with a coverslip. Observe the
slide first under low power objective, then under high power objective with reduced light and carefully note
for the presence of following crystals:
 Urate crystals are needle shaped, highly birefringent and are seen in gouty arthritis.
 Rhomboid calcium pyrophosphate crystals are seen in pseudo-gout.
 Cholesterol crystals are seen in rheumatoid arthritis.
 Crystals can be confirmed using polarized microscopy.
 Chemical Examination
 Glucose estimation: Significance is similar to glucose in the body fluids.
 Protein estimation: Significance is similar to proteins in the body fluids.
 Microbiological Examination
 Synovial fluid culture is recommended in suspected cases of pyogenic/tubercular arthritis.
 Cerebrospinal Fluid Examination
 Importance of CSF examination: Analysis of the CSF is of diagnostic importance in conditions like meningitis or
primary/metastatic tumor of CNS with CSF involvement.
 Collection of CSF: CSF is usually obtained by lumbar puncture (LP) using an LP needle under strict aseptic
conditions.
 Sites : Lumbar puncture: In adults, CSF is normally collected in the midline of the lower back in the 3rd lumbar
space and in children in the 4th lumbar space.
 Ventricular puncture: It is performed in infants who have open fontanella.
 Method of Collection : Normally CSF is collected in three sterile test tubes. The amount of CSF collected should
not exceed 6 to 8 mL.
 Microbiological examination and culture: The first few drops of CSF are collected for culture in the first
tube.
 Biochemical tests and immunological studies: Collect about 2.5 mL of CSF in the second tube for
biochemical tests.
 Cell count, differential count and cytological studies: Collect about 2.5 mL of CSF in the third tube for cell
count and cytological examination.
 Cerebrospinal Fluid Examination
 Physical Examination
 CSF pressure: The normal CSF pressure in adults is 90-180 mm of water in the lateral position, while in infants and
children it ranges from 40-100 mm of water reaching the adult level by 6 to 8 years.
 Causes of raised CSF pressure: Meningitis, cerebral edema, and mass lesions in brain.
 Causes of decreased CSF pressure: Dehydration and circulatory collapse.
 Color and Appearance: Normal CSF is clear and watery.
 Turbidity of CSF is due to pus or RBCs.
 Xanthochromia (yellow CSF) results from:
 Old hemorrhage
 Obstructive jaundice
 Excess of protein.
 Differentiation of subarachnoid hemorrhage from a traumatic puncture
 The presence of blood in CSF may be due to trauma during lumbar puncture or subarachnoid hemorrhage.
 In traumatic tap, first few drops are hemorrhagic and subsequent ones are clear, while in subarachnoid
hemorrhage blood is uniformly mixed with CSF.
 After centrifugation, the supernatant fluid is clear with a traumatic tap, whereas the supernatant appears
xanthochromic (a faint pink, orange or yellow color caused by release of hemoglobin from hemolyzed red blood
cells) in subarachnoid hemorrhage.
 Cerebrospinal Fluid Examination
 Physical Examination
 Clot formation: Normal CSF does not clot. When blood-brain barrier is disturbed, fibrinogen appears in CSF.
Fibrinogen gets converted to fibrin and forms clot.
 Causes of fibrin clot:
 Meningitis
 – In tuberculous meningitis, the clot is fine, delicate and typically described as cob-web appearance.
 – In purulent meningitis, large clot is formed.
 Tumors of CNS
 Polyneuritis.
 Cerebrospinal Fluid Examination
 Microscopic Examination
 Total cell count: Normal CSF usually contains no cells, although cell count of 0-5 lymphocytes/ μL is considered
as normal.
 An increased cell count is known as pleocytosis. Total cell count should be done immediately on undiluted CSF,
since after a few hours, pus cells stick to each other and to the sides of the tube or degenerate.
 Cell counts are performed in a manual counting chamber.
 Significance
 Neutrophils are increased in acute pyogenic meningitis.
 Lymphocytes are increased in viral, syphilitic, tuberculous and fungal meningitis.
 Increased cell count should always be confirmed by bacterial or serological tests.
 India-ink preparation is used for diagnosis of cryptococcal meningitis.
 In tuberculous meningitis, acid fast stain can detect tuberculous bacilli.
 Cerebrospinal Fluid Examination
 Biochemical Evaluation
 Proteins are elevated in meningitis and glucose level is reduced due to utilization by the
microbes.
 These changes are more marked in pyogenic meningitis.
 Chloride reduction in tuberculous meningitis is due to general chloride deficiency because
of dehydration rather than any specific effect of mycobacteria.
Laboratory Tests in Rheumatology
Laboratory Tests in Rheumatology
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