Body fluids

Major functions of CSF

Supply nutrients to the nervous tissue
Remove metabolic waste
Produce a mechanical barrier to cushion the brain and spinal cord against trauma\

Describe the collection process for CSF

Lumbar puncture between the 3rd, 4th, or 5th lumbar vertebra
Needle first enters subarachnoid space and fluid is extracted based on opening pressure

Where do tubes of CSF go if you have 3 tubes

Tube 1: Chemistry or immunology
Least affected by blood or bacteria contamination from spinal tap
Tube 2: Microbiology
Tube 3: Hematology
Least contamination of cell count from the puncture

Where do tubes of CSF go if you have 4 tubes

Tube 1: hematology: gives you a comparison with the 4th to see if it is a traumatic tap or hemorrhage
Tube 2: Chemistry
Tube 3: Microbiology
Tube 4: Hematology: results compared with those
of tube 1 for possible outside interference from the tap

Where is CSF formed

choroid plexus

What cells form the blood brain barrier?

tight fitting endothelial cells

Compare and contrast traumatic collection from an intracranial hemorrhage.

Traumatic tap
Blood will be heaviest in the first specimen and with diminished amounts later
Fluid forms clot due to introduction of plasma fibrinogen
Will not contain xanthochromic supernatant
Intracranial hemorrhage
Blood from a cerebral hemorrhage will

What are causes of hazy/cloudy CSF

WBCs and microorganisms
Proteins
Lipids

Clinical significance of WBCs and Microorganisms in CSF

Menigitis

Clinical significance of proteins in CSF

Blood-brain barrier disorders
IgG production in the CNS

What are causes of bloody CSF

RBCs from hemorrhage or traumatic tap

What are causes of Xanthochromic CSF

Hemoglobin
Bilirubin
Protein
Carotene

What color is xanthochromic CSF

Pink, orange, and yellow

What does a pellicle in CSF indicate

tuberculosis meningitis

How many WBCs should be in CSF in an adult? Lymphs? Monos?Neutrophils? Plasma Protein? RBCs?

WBC count is 0 to 5/ul
Lymphs: 40-80%
Monos: 15-45%
Neutrophils: 0-6%
Plasma protein: 15 to 45 mg/dL
RBC count is 0

What is the ratio of monos to lymphs for a child compared to an adult

70:30 mono to lymph for children. Reverse for adults

What are cells that are unique to CSF

Ependymal cells
Choroid Plexus cells

Describe the function and features of ependymal cells

line cavities of the brain and spinal cord
They have less defined cell membranes and are frequently seen in clusters. Nucleoli are often present

Function and features of choroidal cells

Epithelial lining of the choroid plexus. They are seen singularly and in clumps. Nucleoli are usually absent and nuclei have a uniform appearance
Produce CSF

Why would you see lymphocytes in CSF

All types of meningitis and MS

Why would you see neutrophils in CSF

Bacterial meningitis and cerebral hemorrhage

Why would you see monocytes

All types of meningitis and MS

Why would you see plasma cells in CSF

MS

Why would you see blast forms in CSF

Acute leukemias

How would you differentiate normal CSF cells from malignant cells

Normal cells are seen in clusters with distinct nuclei and cell walls
Malignant cells are seen in clusters with fusing nuclei and cell walls

What would increased macrophages indicate in CSF

Previous hemorrhage
Macrophages eat up the junk

What inclusions would indicate degeneration of phagocytized RBCs

dark blue or black iron- containing hemosiderin granules
Yellow hematoidin crystals

What protein is only found in CSF

Tau transferrin protein is only found in CSF

How would you determine a specimen is CSF

Detection of t transferrin protein identifies a fluid as CSF

What would elevated levels of tau protein indicate

Damage to the blood-brain barrier (meningitis, tumor, hemorrhage) or MS

What would decreased levels of tau protein indicate

CSF leakage and trauma

What is the CSF/Serum Albumin index used for?

Detects damage to the blood-brain barrier
An index value less than 9 is normal

How do you calculate the CSF/Serum albumin index

CSF albumin (mg/dL) / Serum albumin (g/dL)

What is the IgG index?

Detects production of IgG within the CNS which could indicate an autoimmune disorder like MS
Normal values are approximately 0.7 or lower

How do you calculate IgG index

(CSF IgG/serum IgG) / (CSF/serum albumin index)

What is CSF electrophoresis and its main function?

Detects oligoclonal bands that represent inflammation in the CNS
Primary testing is for MS\

What does MS look like on CSF electrophoresis

Two or more bands are seen in the CSF and no bands in the serum

What is Myeline basic protein and why would someone monitor its presence?

The presence of myelin basic protein indicates destruction of myelin sheath that protects axons of the neurons
Monitors the course of MS

Why would you test CSF glucose?

Differentiates type of meningitis
Decreased levels indicate damage to transport of glucose across blood-brain barrier or increased use of glucose by the brain cells

What is the normal amount of CSF glucose and what does an increased amount mean

Glucose is 60-70% of blood serum level
Increased CSF levels occur when serum level is elevated

What is CSF glutamine?

A test that looks for increased glutamine that indicates increased ammonia in the CNS

What is a normal CSF glutamine

Normal value is 8 to 18 mg/dL
Value greater than 35 mg/dL disrupt consciousness

What can an abnormally high CSF glutamine indicate

Reye's syndrome that affects the liver in children

What are some microorganisms that are seen in CSF

Neisseria meningitidis
Cryptococcus neoformans

What is serous fluid?

Fluid that lines the closed body cavities and acts as a lubricant

What are the different serous fluids

Pleural, pericardial, and peritoneal

What is a throacentesis?Pericardiocentesis? Paracentesis?

These aspiration procedures are thoracentesis (pleural), pericardiocentesis(pericardial), and paracentesis (peritoneal).

What is transudate and the values associated

Systemic disorders
Clear appearance
Fluid to serum protein ratio<0.5
Fluid to serum LD ratio <0.6
WBC <1000 uL
SAAG: Difference of 1.1 or greater

What is exudate and the values associated

Membrane disorders
Cloudy
Fluid to serum protein ratio >0.5
Fluid to serum LD ratio >0.6
WBC >1000 uL
SAAG: Less than 1.1

What is the SAAG for peritoneal fluid useful for

Helps determine the cause of ascites
Discriminates transudate vs exudate

Significance of blood in pleural fluid

Indicative of a Hemothorax or hemorrhagic effusion (embolus, tuberculosis, malignancy)

What is a hemothorax?

blood in the pleural space from a traumatic injury
Fluid hematocrit is high

What is a Hemorrhagic exudate

Contains both blood and increased pleural fluid, resulting in a much lower hematocrit

Description?
Indicative of what disorder?
Sudden or gradual onset?
What type of cells are present?
Chylomicrons present or absent?
Cholesterol crystals present or absent?
Triglycerides present or absent?
Chylous exudate

Milky white
Damage to thoracic duct
Sudden onset
Contains predominantly lymphocytes
Chylomicrons present
Does not contain cholesterol crystals
Elevated triglycerides

Description?
Indicative of what disorder?
Sudden or gradual onset?
What type of cells are present?
Chylomicrons present or absent?
Cholesterol crystals present or absent?
Triglycerides present or absent?
Pseudochylous exudate

Milky/Green tinge
Chronic infection or lymphatic obstruction
Gradual onset
Contains mixed WBCs cells
Contains cholesterol crystals
trigs absent
Causes tuberculosis and Rheumatoid disease

What are characteristics of malignant cells

Increased size with variability
Irregular nucleus
Increased N:C ratio
Large and multiple nucleoli
Hyperchromatic chromatin and irregularly distributed
Cytoplasm is variable with cellular crowding
Vacuolated cytoplasm and mucin production

What color and clarity of synovial fluid

Colorless to pale yellow
Clear
Should be viscous

Function of synovial fluid

Reduce friction between the bones during joint movement.
Provides nutrients to the articular cartilage
Lessens the shock of joint compression that occurs during activities such as walking and jogging.

What does damage to the joints cause

arthritis

How viscous should synovial fluid be

Able to form a string 4 to 6 cm long

What cells produce hyaluronic acid

Synoviocytes secrete hyaluronic acid, a large molecule that produces the viscosity of the fluid

What test is used to measure viscosity

mucin clot test to detect and measure hyaluronic acid

How can you tell a specimen is synovial fluid if its unknown

Adding acetic acid will cause it to clot i.e synovial fluid

How do you do the mucin clot test

Addition of acetic acid to normal synovial fluid will
form a firm mucin clot surrounded by clear liquid;
clots become less firm as the viscosity decreases

What are the 4 categories of joint disorders

Noninflammatory
Inflammatory/immunologic
Inflammatory/crystals
Septic
Hemorrhagic

What is an example of Noninflammatory joint disorder? Visual description, viscosity, and neutrophil level

Osteoarthritis
Clear, yellow, good viscosity
WBCs <1k /uL
Neutrophils <30%

What is an example of an inflammatory/immunologic joint disorder? Visual description, viscosity, and neutrophil levelterm-75

Autoimmune disorders
Cloudy, yellow, poor viscosity
WBCs 2k - 75k /uL
Neutrophils >50%

What is an example of an inflammatory/crystal joint disorder? Visual description, term-66viscosity, and neutrophil level

Gout or Pseudogout
Clear or milky, low viscosity
WBCs up to 100k
Neutrophils <75%

What is an example of a septic joint disorder?Visual description, viscosity, and neutrophil level

Infection
Cloudy, yellow-green, low viscosity
WBCs 50k - 100k /uL
Neutrophils >75%

What is an example of a hemorrhagic joint disorder? Visual description, viscosity, and neutrophil level

Trauma or coag disorders
Cloudy, red, low viscosity
WBCs and neutrophils equal to blood values

What are the different crystals found in synovial fluid

Monosodium urate i.e gout
Calcium pyrophosphate i.e pseudogout
Cholestrol

What does a monosodium urate crystal look like

Needle-shape

Strong or weak birefringence for Monosodium urate
Positive or negative birefringence

Strong birefringence under polarized light
Negative birefringence

What color is monosodium urate when aligned with the polarized light vs vertical

Yellow when aligned with slow vibration of compensated polarized light
Blue when vertical to slow vibration

What does a calcium pyrophosphate crystal look like

Rhombic, often seen intracellularly in neutrophil vacuoles

What color is calcium pyrophosphate when aligned with the polarized light vs vertical

Blue when aligned with slow vibration of compensated polarized light and yellow when vertical to slow vibration

Positive or negative birefringence for calcium pyrophosphate

Positive birefringence

What does cholesterol look like and its birefringence

Notched, rhomboid plates
Negative birefringence

What are the different components of Semen

Spermatozoa
Seminal fluid
Prostate fluid
Bulbourethral gland fluid

Function of spermatozoa

Germ cell that fertilizes egg

Function of seminal fluid

Provides nutrients and fructose for sperm energy

Function of prostatic fluid

Provides substances for coagulation and liquifaction

Function of Bulbourethral gland fluid

Provides alkaline mucus to
neutralize the acidity of prostate fluid and the vagina

Appearance of normal semen

gray-white and translucent

If semen is white or turbid, what does that indicate

WBCs and associated infections

If semen is red, what does that indicate

RBCs

If semen is yellow what does that indicate

urine contamination

How does urine affect sperm

Urine is toxic to sperm

What is a normal volume for sperm ejaculation

2 to 5 mL

What does a decreased volume of semen indicate

Infertility
May indicate improperly functioning seminal vesicle

What is a normal viscosity for sperm

ability to form discrete droplets from a pipette

Why is an increased viscosity and delayed liquefaction for sperm bad

Increased viscosity and delayed liquefaction impede testing for sperm motility, sperm concentration, antisperm antibody detection, and measurements of biochemical marker

What is a normal pH for sperm

Normal: 7.2 to 8

What does an increased pH for sperm indicate

infection within the reproductive tract

What does a decreased pH for sperm indicate

prostatic fluid, ejaculation duct obstruction, or poorly developed seminal vesicle

What is normal liquefaction time

Fresh semen is clotted
Normal liquefaction takes place within 30 to 60 minutes

What does an abnormal liquefaction indicate

Deficiency of prostate enzymes

What is the criteria for abstinence for sperm testing

period of sexual abstinence of 2-7 days

What is the criteria for fertility studies in terms of amount of samples and timing

2-3 sample no less than 7 days apart but no more than 3 weeks apart

What temperature should sperm waiting to be analyzed be held at

Specimens waiting analysis should be kept at 37C

What disease can semen be a reservoir for

HIV or hepatitis

What is a normal sperm concentration

>20 million/mL

What would a value of > 1 million spermatids indicate

disrupted spermatogenesis

What is a normal sperm counter per ejaculation

Normal is >40 million/ejaculation

What is The Who rating scale for semen motility

A: Rapid, straight line (4)
B: Slower speed, some lateral movement (3)
B: Slow forward movement, noticeable lateral movement (2)
C: No forward movement (1)
D: No movement (0)

What is the normal range for motility

Normal is >50%

What are the components of the sperm

Head
Neckpiece
Midpiece
Tail

Function of the head of sperm

contains nucleus
contains the acrosome with enzymes for ovum penetration

Function of neckpiece of sperm

Attaches the head to the midpiece

Function of midpiece of sperm

contains mitochondria to provide energy for the tail

Function of tail of sperm

Acts as a flagella to propel the sperm

What are some abnormal forms of sperm

double head
giant head
amorphous head
pinhead
tapered head
constricted head
double tail
coiled tail
spermatid

What are some criteria in the routine examination of sperm morphology

Identifies abnormalities in head structure

Differentiate routine criteria and strict criteria for sperm morphology

Routine criteria: >30% normal sperm
Strict criteria: >14% normal sperm

What stain can be used to test sperm for viability

Stain smears with eosin-nigrosin, non viable sperm absorb the stain and appear red

What is a normal range for sperm viability

75% normal sperm/100 cells counted

What are two methods used to detect anti-sperm antibodies

Mixed agglutination reaction (MAR)
Immunobead test

What is amniotic fluid?

The fluid surrounding the embryo/fetus that protects the unborn baby

What is the amnion?

Protective membranous sac that surrounds the fetus
Amnion is metabolically active and involved in exchange of water and chemicals between fluid, fetus, and maternal circulation

Function of amniotic fluid

Protective cushion for fetus
Allow fetal movement
Stabilize temperature
Permits proper lung formation

How is amniotic fluid collected

amniocentesis

When collecting HDN amniotic fluid specimens what precaution must be taken?

Protected from light

When collecting FLM amniotic fluid specimens what precaution must be taken?

Must be delivered on ice and refrigerated or frozen

When collecting cytogenetic amniotic fluid specimens what precaution must be taken?

delivered immediately at RT

What is the normal appearance of amniotic fluid

colorless

If amniotic fluid is red, what does that indicate

trauma / traumatic tap

If amniotic fluid is yellow, what does that indicate

increased bilirubin due to HDN

If amniotic fluid is dark green what does that indicate

meconium

If amniotic fluid is dark-red/brown what does that indicate

fetal death

What are test done on amniotic fluid for fetal distress

Spectrophotometric analysis at optical densities between 365 and 550 nm

What would be increased in neural tube defects

increased maternal serum a-
fetoprotein

How are amniotic fluid and maternal serum levels useful in neural tube defect testing of amniotic fluid

Amniotic fluid levels are measured first between
gestational weeks 12 to 15 and compared to maternal serum levels
Report both serum and fluid levels in multiples of
the mean (MOM)
Abnormal value: Two times the laboratory median
value in both serum and flu

Confirmatory test for neural tube defect

measurement of amniotic acetylcholinesterase

What test can be done to determine fetal maturity

Amniostat-FLM
Lamellar bodies
Lecthin-sphinogmyelin ratio
Foam stability index

What causes respiratory distress syndrome in a fetus

decreased lung surfactant

What are lung surfactants

lecithin
Sphinomyelin
Phosphatidylglycerol

What is a normal lecithin-sphingomyelin ration

Normal ?2.0

What is the foam stability index procedure and what is a positive result

Amniotic fluid is mixed with 95% ethanol, shaken for 15 seconds, and allowed to sit undisturbed for 15 minutes.
Should see bubbles
The presence of bubbles indicates that a sufficient amount of phospholipid is available to reduce the surface tension of the

How does the amniostat-FLM work

Immunologic agglutination test for phosphatidylglycerol

What are lamellar bodies?

The storage form of phospholipids in the lungs that secrete surfactants

Location and function of lamellar bodies

Secreted by the type II pneumocytes
Secrete surfactants

Normal amount of lamellar bodies

32,000 to 35,400 based on the instrument

Normal color of stool

brown

If stool is black what does that indicate

Upper GI bleeding, iron therapy, and antacids

If stool is red what does that indicate

Lower GI bleeding

If stool is pale yellow/white what does that indicate

Bile duct obstruction

If stool is bulky or frothy what does that indicate

Bile duct obstruction, steatorrhea

If stool contains blood-streaked mucus what does that indicate

Colitis, dysentery, malignancy

What is the fecal leukocyte test for

Detects invasive non-toxin-
producing microorganisms

What would finding muscle fiber indicate in stool

Detects undigested striated fibers
seen with pancreatic insufficiency

If you find fecal fats in stool what does that indicate

malabsorption

What stain would be used for fecal fat observation and what does it look like

Sudan III
large orange-red droplets

What is occult blood?

Microscopic blood from the intestinal tract that screens for colorectal cancer and lower GI bleeding

How does FOBT testing work?

Pseudoperoxidase activity of hemoglobin liberates oxygen from hydrogen peroxide to oxidize guaiac reagent
Blue color indicates gastrointestinal bleeding

How does IFOBT testing work

Uses polyclonal anti-human antibodies specific for the globin portion of human hemoglobin
Positive test and control lines indicate GI bleeding

What microorganism cause diarrhea

Salmonella, Shigella, Campylobacter, Yersinia, and ETEC

What organism secrete toxins that cause diarrhea

Vibrio and Staphylococcus aureus