fluids

FLUIDS :CSF, SYNOVIAL, LYMPH

DR.RITTU CHANDELMD BIOCHEMISTRY (SECOND YR)

GRANT GOVT MEDICAL COLLEGE, BYCULLA, MUMBAI – 400008

29 – 10 -2013

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


hydrocephalus


Functions of CSF1. Buoyancy2. Protective effect3. Metabolic4. homeostasis


Specimen collection

Cisternal (occipital)In paralysis

Ventricular puncture (lateral occipital)For infants


CSF analysisCSF

Gross

microbiology pathology biochemistry


Polypropylene tubes


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


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


Gross examination AppearanceNormal – crystal clear, colourless and no

coagulum1.ColourAny change in colour is always pathologicalRedYellow


xanthochromiaPale pink to yellow colour in supernatant of

CSF

Froin’s syndrome


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


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


Pressure of CSF

Normal Adults – 90 – 180 mm waterInfants and children – 10 – 100 mm water

>250 mm waterIntracranial hypertensionTumors

Decreased pressureDehydrationCirculatory collapseCSF leakage


Biochemical analysis of CSF1. GlucoseNormal – 45 – 100 mg/100 mldecreased – coccal meningitis TB meningitis intrathecal streptomycinIncreased – diabetic hyperglycemia

In assessing response to treatment


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


electrophoresis


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


CSF serum immunoglobulin ratio

Increases in multiple sclerosisIncreased CSF IgM and kappa light chains –

marker of multiple sclerosis


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)


CSF leak (rhinorrhea)


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


CSF phenylalanineCSF copper

Total cell count –Normal - 0 – 5 cells/ μl

Neonate – 0 -30 cells/ μl

No RBCDifferential countLymphocytes: monocytes = 70:30Neutrophils – 7%


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


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


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


Synovial fluid


resilience

Surrounded by shell of water molecules

A slippery consistencyCompressed – occupy

smaller volumeRelaxed – occupy


functionsReduce friction between bonesLubricates jointsFluid provides nutrients to cartilageLessens shock of walking and jogging impact


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


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


examinationSynovial fluid

Gross

microbiology pathology biochemistry


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


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


Cell countTotal countNormal – 150 – 200 / μl

abnormal >10,000/ μlDLC

Normal - Neutrophils – 20%

Gout - >50%Acute bacterial arthritis – 75%


Differential countNormalNeutrophils – 20%Lymphocytes – 15%Monocytes and macrophages – 65%AbnormalReiters cellEosinophilia >2%

Microscopic examination


Uric acid crystals


crystals


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.


slightly basic fluidResembles plasma in its contentProtein content varies widely from 2% to 8%


bibliographyHarrisons internal medicineRanna shindeVasudevanHenrys clinical diagnosis

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