Download - Fluids
FLUIDS :CSF, SYNOVIAL, LYMPH
DR.RITTU CHANDELMD BIOCHEMISTRY (SECOND YR)
GRANT GOVT MEDICAL COLLEGE, BYCULLA, MUMBAI – 400008
29 – 10 -2013
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Cerebrospinal fluid
Total volumes:– Adults:140 - 170 ml cerebral ventricles – 30ml
subarachnoid space - 120 ml – Children: 10 - 60 ml
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hydrocephalus
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Functions of CSF1. Buoyancy2. Protective effect3. Metabolic4. homeostasis
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Specimen collection
Cisternal (occipital)In paralysis
Ventricular puncture (lateral occipital)For infants
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CSF analysisCSF
Gross
microbiology pathology biochemistry
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Polypropylene tubes
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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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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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Gross examination AppearanceNormal – crystal clear, colourless and no
coagulum1.ColourAny change in colour is always pathologicalRedYellow
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xanthochromiaPale pink to yellow colour in supernatant of
CSF
Froin’s syndrome
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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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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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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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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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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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electrophoresis
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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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CSF serum immunoglobulin ratio
Increases in multiple sclerosisIncreased CSF IgM and kappa light chains –
marker of multiple sclerosis
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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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CSF leak (rhinorrhea)
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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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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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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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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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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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Synovial fluid
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resilience
Surrounded by shell of water molecules
A slippery consistencyCompressed – occupy
smaller volumeRelaxed – occupy
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functionsReduce friction between bonesLubricates jointsFluid provides nutrients to cartilageLessens shock of walking and jogging impact
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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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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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examinationSynovial fluid
Gross
microbiology pathology biochemistry
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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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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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Cell countTotal countNormal – 150 – 200 / μl
abnormal >10,000/ μlDLC
Normal - Neutrophils – 20%
Gout - >50%Acute bacterial arthritis – 75%
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Differential countNormalNeutrophils – 20%Lymphocytes – 15%Monocytes and macrophages – 65%AbnormalReiters cellEosinophilia >2%
Microscopic examination
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Uric acid crystals
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crystals
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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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slightly basic fluidResembles plasma in its contentProtein content varies widely from 2% to 8%
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bibliographyHarrisons internal medicineRanna shindeVasudevanHenrys clinical diagnosis
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