CYTOLOGY OF BODY FLUID

DR SHABNEEZ HUSSAIN HAEMATOLOGY RESIDENT

CAVITY FLUIDS

Abdominal Pleural Synovial CSF

Pericardial

Schematic representation of the three body cavities

CAVITY FLUIDS
Sampling techiques appearance during collection EDTA to prevent clotting direct smear delayed processing Cell concentration Protein concentration

TRANSUDATE EXUDATE MODIFIED TRANSUDATE

Accumulation of fluids in body cavities

Transudates

Increased hydrostatic pressure: Congestive heart failure

Decreased oncotic pressure (decreased albumin) : liver cirrhosis, nephrosis, and malnutrition Exudate

Inflammation: Infection, infarction, hemorrhage

Tumor

DIFFERENCES BETWEEN TRANSUDATE AND EXUDATE

Feature
Gross appearance Specific gravity

Transudate
Watery, clear

Exudate
Turbid or cloudy

Less than 1015

Less than 3mg/dl

More than 1015

More than 3mg/dl

Protein
Clots cells

No
Usually benign: Few

Yes
More mesothelial cells, or chronic

mesothelial acute

cells, few histocytes inflammatory

and lymphocytes

cells,

RBCs, malignant cells

MODIFIED TRANSUDATE
Moderate protein concentration: 2,52,5- 7,5g/dl Moderate cellularity 1000-7000 cells/ g Cardiovascular disease Neoplastic disease Rupture of urinary bladder Hepatic disease

DIAGNOSTIC ROLE OF EFFUSION CYTOLOGY

It

is very useful for diagnosis of premalignant and

malignant tumors, especially metastatic tumors.

It

is very useful for diagnosis of inflammatory

conditions (septic effusion, or chronic specific

inflammation e.g. TB

Non-Gynecological Specimen Collection

Respiratory Urinary Oral

Tract

Tract

Cavity Tract

Gastrointestinal Effusions

(pleural, pericardial, joint)

Cerebral

Spinal Fluid
fluid

Amniotic

Many other body sites

EXAMINATION OF BODY FLUID

Gross Total

exam

cell count exam

Microscopic Any

other special test (Chemistry, Microbiology,

cytology(
Test

are performed in various areas of lab based on what

the physician orders.

Body

fluids sterile vs. non-sterile

SAMPLE COLLECTION

FNA of effusion fluids Tapping

Collection and preparation of specimen

FIXATION
1ml

of heparin + 100ml of effusion fluid to prevent

clotting
N.B.:

do not use alcohol in fixation of fluid before

spread cytological smear on glass slides

TYPES OF STAINING SMEARS

PAP Gram

Stain

Hx

&E
block for remnant sediment and histopathological

Cell

examination.
Other

special stains for the most suspected diseases, to

confirm diagnosis.

Cell block
Adding plasma and thrombin solution Wrapped in filter paper Placed in a cassette

Heparinized bottles (3 units heparin/ml) Unfixed

Cytocentrifuge preparation Alcohol-fixed Papanicolaou-stained

Air-dried cytocentrifuge preparation

Embedded in paraffin
Cut and H&E stain

(Hematologic malignancy is suspected)

Adequacy: on site Background: necrotic, mucinous Cell concentration: high, low Cell preservation: lysis Inflammatory cells: which? dominant? Lining cells: mesothelial, epithelial Cells of interest: tumor cells

1- CEREBROSPINAL FLUID
Fluid

surrounding brain and spinal cord

Sterile Specimen Collect Gross

collection: by Lumbar puncture

3-5 vials, each tube has a designated department.

exam: Turbidity, Color, microscopic exam, cell

count

CSF CELL DIFFERENTIAL

Numerate

and differentiate cells seen usually are few; increased with viral,

Lymphocytes:

fungal, bacterial meningitis, or nervous system disease

Monocytes:

Less than 2% of normal CSF, increased

with TB meningitis, viral encephalitis, subarachnoid hemorrhage.

PMN: are few, associated with Viral and acute bacterial

inflammation.

Macrophages: are few in number associated with malignancy,

hemorrhage, inflammation

Eosinophils/Basophils:

not normally seen in CSF

Plasma cells: not normally present; associated with viral disorders, and Hodgkin's diseases.

Red Blood Cells: Few to none present

Mesothelial cells: not present

Malignant cells: will see with malignant disease and infiltrate.

CSF EVALUATION
Tube 1-cell count and differential Tube 2-glucose, protein Tube 3-cultures, gram stain, cytology, (HSV PCR, West Nile, India ink, Crypto Antigen, VDRL, Lyme Ab, AFB...) Tube 4-cell count and differential

NORMAL CSF COMPOSITION

Clear color <5 RBCs <5 WBCs Protein 23-38mg/dl (can use 14-45) Glucose60% of serum level (75-100)

OPENING PRESSURE
Normal = 80-180 mmHg Obese pts: up to 250mmHg can be normal Pathologically elevated: >250mmHg If elevated, likely due to cerebral edema from intracranial pathology Infection (cryptococcal meningitis), tumor, benign ICH (pseudotumor)

RBCS
Always send tube #1 and #4 for cell count and compare RBCs Traumatic tap: Elev RBC in tube 1, nl in tube 4

1000 RBC : 1 WBC to adjust WBC count in bloody tap

SAH or HSV: Elev RBC in tube 1 AND tube 4 Crenated RBCs and xanthochromia (yellow supernatant after centrifuge)

Seen in hyperbilirubinemia (ESLD), old SAH, old blood from prior traumatic LP or bleed

WBCS
Infection! PMN predominance: likely bacterial meningitis Lymphocytic predominance: viral vs. fungal vs. TB vs. malignancy

PROTEIN
Normal: protein is excluded from CSF by bloodCSF barrier Increased: nonspecific Elevated in all infectious meningitis

May remain elevated for months post-meningitis (viral or bacterial)

Increased in malignancy and inflammatory conditions (ie Guillain-Barre)

GLUCOSE
Normal Viral infection Low glucose Bacterial meningitis, TB, fungal Really low <18 is strongly suggestive of bacterial meningitis

TYPICAL VIRAL MENINGITIS

CSF WBC elevated, but <250 (first PMNs, then lymphocytes) CSF protein elevated, but <150 Glucose > 50% of serum concentration

TYPICAL BACTERIAL MENINGITIS

CSF WBC >1000, PMN predominance CSF protein >500mg/dl CSF glucose <45 mg/dl

2- Pleural Fluid: Lung fluid

Effusion:

Transudate

Exudates

Lab analysis: Gross exam, cell count, etc.

Differential: PMN, Lymph, Mono, etc.

Cells unique to the lungs: Mesothelial cells RBCs and WBCs: are limited, if increased without

traumatic tap ----- indicates infarction

Cytology exam: useful in identifying malignancy or abnormal morphological cells.

WHAT TO ORDER?
Serum LDH, total protein (Add on to am labs) Pleural fluid: Total Protein, LDH Glucose, cell count and diff, pH (on ice) Gram stain, culture, fungal stain and culture, AFB Cytology Other: triglyceride level to r/o chylothorax; amylase to r/o pancreatitis, esoph perf; Adenosine deaminase to eval TB

LIGHTS CRITERIA FOR EXUDATES

Fluid is exudate if it meets 1 of 3 criteria: 1. Pleural fluid LDH/serum LDH > 0.6 2. Pleural fluid protein/serum protein > 0.5 3. Pleural fluid LDH > upper limit of normal serum LDH If all 3 negative, fluid is Transudate

TRANSUDATE
Result

from imbalances in oncotic and hydrostatic pressure Usually low oncotic +/- high hydrostatic pressure Pulm Edema/CHF Cirrhosis with ascites Hypoalbuminemia/Nephrotic syndrome, ESLD Fluid overload s/p aggressive IVF Peritoneal dialysis

EXUDATE
Caused by local, not systemic, factors Infection Neoplasm Pancreatitis Esoph perf RA SLE Sarcoid, Wegeners, PE, Meigs, Chylothorax

LYMPHOCYTOSIS
Malignancy (50-70% lymphs) Also TB, sarcoid, RA, chylothorax (>90% lymphs)

PLEURAL EOSINOPHILIA
Pneumothorax Hemothorax Pulm infarct Parasitic disease

Fungal infection Drugs Malignancy Asbestos

WHY IS GLUCOSE LOW? (<60)

RA TB Empyema SLE Malignancy Esophageal rupture

3- PERITONEAL FLUID
Abnormal

accumulation of fluid (effusion) in peritoneal

cavity: Ascites
Ascites:

a condition in which fluid accumulates within

the peritoneal space.

Must have an accumulation of > 100ml (several 100) before effusion can be detected on physical exam.

Removal procedure-

paracentesis

Lab analysis: distinguish between transudate and exudates,

gross exam, cell count, sedimentation, chemical analysis

PHYSICAL CHARACTERISTICS
Peritoneal

Fluid Appearance: Color and clarity.

Color and clarity can indicate certain infections and diseases.

Total

Cell Count: Assist in diagnosis of certain

diseases by determining total RBC and WBC number.

 Lymphocytes: Mesothelial Malignant

CHF, liver cirrhosis, nephrotic syndrome

Cells: Associated with TB effusions

cells: seen with malignancy

WHAT TO SEND FLUID FOR

Cell count with diff Albumin LDH Total protein

glucose Gram stain/cx cytology

APPEARANCE OF FLUID
Clearusually indicates uncomplicated ascites, ie liver failure/cirrhosis Turbid/cloudyinfected Pink/bloodytraumatic, punctured collateral vessel, malignancy

Correct for bloody tap: 1 WBC: 750 RBC

1 PMN: 250 RBC

SERUM-TO-ASCITES ALBUMIN GRADIENT (SAAG)

=Serum albumin ascitic fluid albumin If the gradient is >1.1: Portal HTN (drives fluids into peritoneum) SBP, cirrhosis, Alcoholic hepatitis, CHF If the gradient is < 1.1: (protein leaks into peritoneum and fluid follows) Peritoneal carcinomatosis, peritoneal TB, pancreatitis, nephrotic syndrome

SBP
SAAG > 1.1 Suspect if >250 PMNs (>100 PMNs in pt on peritoneal dialysis) 70% GNR (E.coli, Klebsiella) 30% GPC (S. pneumo, Enterococcus) Treat with ceftriaxone, cefotaxime Culture negative SBP if >250 PMNs but cx neg; treat the same

4- Pericardial Fluid
Pericardial

Fluid: accumulation of fluid of the lining of

the heart (effusion)

Cause:

neoplasm, infections, collagen disease, renal

disease, Cardiovascular disease.

Gross

Exam: Report appearance (bloody, clear, cloudy)

Measure pH: pH less than 7.0 associated with infection or rheumatoid disorder.

Cell count: see limited RBCs and WBCs Evaluate sedimentation

5- Seminal Fluid

Examine physical, chemical and microscopic detail Count number of sperm, report morphology and motility

Specimen must be a fresh collection-clean, sterile container.

Gross Exam: Color, pH, Volume, and viscosity. Agglutination study

6- Synovial Fluid:

Joint Fluid: normally clear, viscous

Functions as a lubricate and transports nutrient

Arthrocentesis: aspirate of the joint fluid, aseptic technique

Lab Assay: Gross exam, microscopic exam, Gram stain, cultures,...

Appearance: clear, transparent, viscous

Viscosity test Mucin Clot test Note crystals (intracellular vs. extra cellular)

Slide exam: usually performed on concentration of the fluid using Giemsa or Papnicolaou

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