Download - Fluids
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FLUIDS :CSF, SYNOVIAL, LYMPH
DR.RITTU CHANDELMD BIOCHEMISTRY (SECOND YR)
GRANT GOVT MEDICAL COLLEGE, BYCULLA, MUMBAI – 400008
29 – 10 -2013
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Apr 12, 2023 Dr.Rittu Chandel 2
Cerebrospinal fluid
Total volumes:– Adults:140 - 170 ml cerebral ventricles – 30ml
subarachnoid space - 120 ml – Children: 10 - 60 ml
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Apr 12, 2023 Dr.Rittu Chandel 3
hydrocephalus
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Apr 12, 2023 Dr.Rittu Chandel 4
Functions of CSF1. Buoyancy2. Protective effect3. Metabolic4. homeostasis
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Apr 12, 2023 Dr.Rittu Chandel 5
Specimen collection
Cisternal (occipital)In paralysis
Ventricular puncture (lateral occipital)For infants
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Apr 12, 2023 Dr.Rittu Chandel 6
CSF analysisCSF
Gross
microbiology pathology biochemistry
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Apr 12, 2023 Dr.Rittu Chandel 7
Polypropylene tubes
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Apr 12, 2023 Dr.Rittu Chandel 8
composition• Colour - Colourless• PH - 7.28 – 7.32• Appearance - Clear• Sp. Gravity - 1.003 – 1.004• No clot formation on standing• Proteins - 10 – 45 mg/dl• Glucose - 45 – 100 mg/dl• Chlorides - 120 -130 mEq/l
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Apr 12, 2023 Dr.Rittu Chandel 9
Urea - 6.0 - 16 mg/dL Uric acid - 0.5 - 3.0 mg/dL Creatinine - 0.6 - 1.2 mg/dL Cholesterol - 0.2 - 0.6 mg/dL Ammonia - 10 – 35 μg/dL A:G ratio - 3:1 Serum:CSF protein – 200:1
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Apr 12, 2023 Dr.Rittu Chandel 10
Gross examination AppearanceNormal – crystal clear, colourless and no
coagulum1.ColourAny change in colour is always pathologicalRedYellow
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Apr 12, 2023 Dr.Rittu Chandel 11
xanthochromiaPale pink to yellow colour in supernatant of
CSF
Froin’s syndrome
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Apr 12, 2023 Dr.Rittu Chandel 12
D/D of bloody CSFTraumatic tap - hemorrhagic fluid clears
between first and third tubes; remains uniform in SAH
Pathological - RBC have crenated appearance
Xanthochromia, erythrophagocytosis and hemosedrin laden macrophages indicate a subarachnoid bleed in absence of prior trauma
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Apr 12, 2023 Dr.Rittu Chandel 13
Gross examination(contd)2. Turbidityo WBC >200 cell/μlo RBC >400 cell/μlo Microorganisms, radiographic contrasts, aspirated
epidural fato Protein > 150 mg/dlClot formationViscous CSF
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Apr 12, 2023 Dr.Rittu Chandel 14
Pressure of CSF
Normal Adults – 90 – 180 mm waterInfants and children – 10 – 100 mm water
>250 mm waterIntracranial hypertensionTumors
Decreased pressureDehydrationCirculatory collapseCSF leakage
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Apr 12, 2023 Dr.Rittu Chandel 15
Biochemical analysis of CSF1. GlucoseNormal – 45 – 100 mg/100 mldecreased – coccal meningitis TB meningitis intrathecal streptomycinIncreased – diabetic hyperglycemia
In assessing response to treatment
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Apr 12, 2023 Dr.Rittu Chandel 16
2.ProteinsNormal – 15 – 45 mg/dlTerm infants – 90 – 150 mg/dlPre term - 115 – 170 mg/dlIncreased CSF proteinI. Increased permeability of blood brain
barrierII. Increased intrathecal IgG secretion
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Apr 12, 2023 Dr.Rittu Chandel 17
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Apr 12, 2023 Dr.Rittu Chandel 18
electrophoresis
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Apr 12, 2023 Dr.Rittu Chandel 19
Permeability of blood brain barrierCSF/serum albumin index
Index slightly elevated in infants up to 6 months of age
index permeability
< 9 intact barrier
9 – 14 slight impairment
14 – 30
>30
moderate impairment
severe impairment
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Apr 12, 2023 Dr.Rittu Chandel 20
CSF serum immunoglobulin ratio
Increases in multiple sclerosisIncreased CSF IgM and kappa light chains –
marker of multiple sclerosis
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Apr 12, 2023 Dr.Rittu Chandel 21
CSF proteins and CNS diseasesproteins Diseases or disorders
Α2 - macroglobulin Subdural hemorrhage, bacterial meningitis
Β – amyloid protein 42 and ζ protein Alzheimer’s disease
Β 2 - microglobulin Leukemia/lymphoma, bechets syndrome
C- reactive protein Bacterial and viral meningitis
fibronectin Lymphoblastic leukemia, AIDS, meningitis
methemoglobin Mild subarachnoid/subdural hemorrhage
Mylein basic protein
Protein 14- 3 -3
transferrin
Multiple sclerosis, tumors
Creutzfeldt – jacob disease
CSF lekage (otorrhea, rhinorrhea)
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Apr 12, 2023 Dr.Rittu Chandel 22
CSF leak (rhinorrhea)
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Apr 12, 2023 Dr.Rittu Chandel 23
CSF lactateCSF and blood lactate are largely independentNormal newborn – 10 – 60 mg/dlChild and adult – 9 – 26 mg/dlDifferentiating meningitis
Persistently elevated - poor prognosis in patients with severe head injury
CSF lactate (mg/dl)
meningitis
< 25 mg/dlAlmost always less than 35 mg/dl
viral
>35 mg/dl bacterial
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Apr 12, 2023 Dr.Rittu Chandel 24
CSF phenylalanineCSF copper
Total cell count –Normal - 0 – 5 cells/ μl
Neonate – 0 -30 cells/ μl
No RBCDifferential countLymphocytes: monocytes = 70:30Neutrophils – 7%
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Apr 12, 2023 Dr.Rittu Chandel 25
Lumbar puncture findingstest bacterial viral fungal tuberculous
Opening pressure
elevated Usually normal
variable variable
Leukocyte count
> Or =1000/μl
<100/μl variable variable
Differential count
Mainly neutrophils
Mainly lymphocytes
Mainly lymphocytes
Mainly lymphocytes
protein Mid – marked increase
Normal – mild increase
increased increased
glucose < or = 40 mg/dl
normal decreased Decreased ;<45 mg/dl
CSF/serum glucose ratio
Normal – marked decrease
Usually normal
low low
Lactic acid Mild – marked increase
Normal – mild increase
Mild – moderate increase
Mild – moderate increase
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Apr 12, 2023 Dr.Rittu Chandel 26
CSF enzymesCSF enzymes disease
Adenosine deaminase Tubercular meningitis
Creatine kinase ( CK – BB ) Hydrocephalus, cerebral infarction, primary brain tumors, subarachnoid hemorrhage
LDH CNS leukaemia, lymphoma, metastatic carcinoma, bacterial meningitis, SAH
lysozyme Bacterial and tuberculous meningitis
Aspartate transaminase Cerebral abscess, cerebral hemorrhage, primary or metastatic malignancy
Placental alkaline phosphatase Germ cell tumor
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Apr 12, 2023 Dr.Rittu Chandel 27
CSF tumor markersCarcinoembryonic antigen Metastatic carcinoma of
leptomeninges
Human chorionic gonadotropin Choriocarcinoma, malignant germ cell tumors
Alpha feto protein Germ cell tumors
CSF ferritin CNS malignancy
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Apr 12, 2023 Dr.Rittu Chandel 28
Synovial fluid
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Apr 12, 2023 Dr.Rittu Chandel 29
resilience
Surrounded by shell of water molecules
A slippery consistencyCompressed – occupy
smaller volumeRelaxed – occupy
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Apr 12, 2023 Dr.Rittu Chandel 30
functionsReduce friction between bonesLubricates jointsFluid provides nutrients to cartilageLessens shock of walking and jogging impact
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Apr 12, 2023 Dr.Rittu Chandel 31
Composition Volume <3.5 mL
Color pale yellowClarity clear
Neutrophils <20% of diff.Lymphocytes <15 % of diff.Monocytes & macrophages 65% of diff.Crystals NONEGlucose <10 mg/dL (serum synovial
difference) Lactate <250 mg/dLTotal protein <3 g/dLUric acid = blood value
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Apr 12, 2023 Dr.Rittu Chandel 32
collection
*Avoid all powdered anticoagulants – interfere with crystal analysis
Fluid verificationMucin clot test-
Add fluid to dilute acetic acid turbidity (clot formation) due to hyaluronate
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Apr 12, 2023 Dr.Rittu Chandel 33
examinationSynovial fluid
Gross
microbiology pathology biochemistry
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Apr 12, 2023 Dr.Rittu Chandel 34
Gross examinationTotal volume – recorded at bedside
Normal= 3.5 mLDiseased / inflamed = up to 25 mL
Colour – colourless xanthochromia red brown Clarity –transparent opaque oily floating rice bodies ground pepper appearance
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Apr 12, 2023 Dr.Rittu Chandel 35
Biochemical analysisMucin clot testNon specific findingGlucoseSerum synovial difference < 10 mg/dlSeptic arthritis – difference 20 – 60 mg/dlProteinNormal – 1-3 g/dlIncreased in inflammationUric acidRF ANA
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Apr 12, 2023 Dr.Rittu Chandel 36
Cell countTotal countNormal – 150 – 200 / μl
abnormal >10,000/ μlDLC
Normal - Neutrophils – 20%
Gout - >50%Acute bacterial arthritis – 75%
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Apr 12, 2023 Dr.Rittu Chandel 37
Differential countNormalNeutrophils – 20%Lymphocytes – 15%Monocytes and macrophages – 65%AbnormalReiters cellEosinophilia >2%
Microscopic examination
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Apr 12, 2023 Dr.Rittu Chandel 38
Uric acid crystals
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Apr 12, 2023 Dr.Rittu Chandel 39
crystals
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Apr 12, 2023 Dr.Rittu Chandel 40
lymphThe lymphatic system is an extensive
vascular network responsible for the transport of fluid ,
immune cells , proteins and lipids . The failure to transport lymph fluid results in
a number of disorders and diseases . Lymphedema , for example , is a pathology
characterized by the retention of fluid in limbs creating extreme discomfort , reduced mobility.
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Apr 12, 2023 Dr.Rittu Chandel 41
slightly basic fluidResembles plasma in its contentProtein content varies widely from 2% to 8%
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Apr 12, 2023 Dr.Rittu Chandel 42
bibliographyHarrisons internal medicineRanna shindeVasudevanHenrys clinical diagnosis
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