AUBF (synovial & serous fluids) Flashcards by LEDESMA, Anne Gelika

aka Joint fluid

synovial fluid

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aka synovial joint

diarthroses (freely mobile joint)

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synovial fluid is found in

diarthroses

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synovial fluid is derived from?

“synovia”
means EGG WHITE (same viscosity as synovial fluid)

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aka joint cavity

synovium

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a joint cavity that filters blood

SYNOVIUM

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T/F

Blood is unselectively filtered –plasma goes inside joint cavity, composed of cells called “SYNOVIOCYTES” which produces Hyaluronic Acid

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specifically produces hyaluronic acid that contributes to synovial fluid viscosity

synoviocytes (cells of joint cavity)

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FUNCTIONS OF SYNOVIAL FLUID

Lubricate joints
Reduce friction between bones
Provides nutrients to the articular cartilage
Lessen shock of joint compression occurring during activities (e.g., walking, jogging)

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method of spx collection of synovial fluid

ARTHROCENTESIS

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normal synovial fluid volume

<3.5 mL

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synovial fluid volume indicating INFLAMMATION

> 25 mL

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tubes for synovial fluid (in order) and its purpose

Na Heparin (STERILE) / SPS - Microbiology
LIQUID EDTA / NA Heparin - hematology
Non-anticoagulated - Chemistry & other tests (serology)
Na Fluoride (antiglycolytic) - Glucose analysis

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T/F

Synovial fluid normally clot

Synovial fluid shouldn’t clot, if clotted then FIBRINOGEN is present - sign of damage or diseased joints

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T/F

Powdered EDTA can be used for synovial fluid analysis

only LIQUID EDTA
Powdered can be mistaken as crystals

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NORMAL synovial fluid color

colorless to pale yellow

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synovial fluid color during INFLAMMATION

deeper yellow

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synovial fluid color during BACTERIAL INF. (SEPTIC ARTHRITIS)

greenish tinge

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synovial fluid color during TRAUMATIC TAP or HEMORRHAGIC ARTHRITIS

red

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used to differentiate red colored synovial fluid due to traumatic tap or hemorrhagic arthritis

color
clot formation

*as to the tube order

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accidental puncture of peripheral BV during collection of synovial fluid, blood from BV

traumatic tap

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The blood present from red colored synovial fluid is NOT the blood coming from BV. It is the bleeding inside joint cavities.

hemorrhagic arthritis

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tube positive for clot formation in traumatic tap

microbio tube (tube 1)

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differentiate traumatic tap and hemorrhagic arthritis as to color

traumatic tap - decreasing red discoloration intensity (dark red, light red, yellowish)

hemorrhagic arthritis - consistent red discoloration (dark red, dark red, dark red)

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differentiate traumatic tap and hemorrhagic arthritis as to clot formation

traumatic tap - (+, -, -) - blood comes from BV hemorrhagic arthritis - (-, -, -) - all neg since blood present is NOT the blood coming from BV

normal synovial fluid clarity

CLEAR

turbid synovial fluid clarity indicates presence of

Leukocytes Fibrin Cell debris

Opaque, Oily, Shimmering synovial fluid clarity indicates

Radiographic contrast media (RCM)

Milky synovial fluid clarity indicates

CRYSTALS presence

Ground Pepper-like inclusions in synovial fluid (clarity) indicates

Ochronosis (degenerative bone dse)

aka ground pepper like inclusions

ochronotic shards

free floating rice bodies in synovial fluid (clarity) indicates

RA Degenerative synovium (joint cavity) w/ fibrin

normal synovial fluid viscosity as to string formation

4-6mm (long)

normal synovial fluid viscosity as to hyaluronic acid level

0.3-0.4 g/dL

test for synovial fluid viscosity

Ropes/Mucin Clot Test (Hyaluronate Polymerization)

reagent used in Ropes/Mucin Clot Test (Hyaluronate Polymerization)

2-5% HAc

principle of Ropes/Mucin Clot Test (Hyaluronate Polymerization)

2-5% HAc polymerize Hya. Ad. – forms a CLOT = POSITIVE RXN

reporting of Ropes/Mucin Clot Test (Hyaluronate Polymerization)

Good, Fair, Low, Poor

reporting if mucin clot test result is SOLID CLOT

Good

reporting if mucin clot test result is SOFT CLOT

Fair

reporting if mucin clot test result is FRIABLE CLOT

Low

reporting if mucin clot test result is NO CLOT

Poor

T/F Hemacytometry is also done in synovial fluid

Diluting Fluids used for synovial fluid cell ct.

NSS with Methylene Blue Hypotonic Saline (0.3%) Saline with Saponin

Specifically recommended for WBC ct. of synovial fluid due to the ability to lyse RBCs

Hypotonic Saline (0.3%) Saline with Saponin

Specifically recommended for RBC ct. of synovial fluid

NSS with Methylene Blue

What must NOT used for synovial fluid cell counting?

ACETIC ACID as it POLYMERIZES hyaluronic acid causing it to CLOT

remedy for VERY VISCOUS synovial fluid

pinch of hyaluronidase + 0.5mL SF or 1 drop of 0.05% hyaluronidase in phosphate buffer per mL of SF --> incubate at 37C for 5min

RBC count of normal synovial fluid

<2,000 /uL

WBC count of normal synovial fluid

<200 /uL

Most abundant WBC in synovial fluid

monocytes/macrophage

Monocytes/macrophage count of normal synovial fluid

65% (most abundant)

Neutrophil count of normal synovial fluid

<25%

Lymphocyte count of normal synovial fluid

<15%

CELLS AND INCLUSIONS SEEN IN SYNOVIAL FLUID

Neutrophils Lymphocytes Macrophage (Monocytes) Synovial Lining Cell LE cells Reiter Cells RA cells (ragocytes) Cartilage Cells Rice bodies Fat droplets Hemosiderin

PMN WBCs

Neutrophils

Significance of NEUTROPHIL presence in synovial fluid

Bacterial sepsis (septic arthritis) Crystal-induced inflammation

MN WBCs

Lymphocytes

Significance of LYMPHOCYTES presence in synovial fluid

Non-septic inflammation

Large MN WBCs may be vacuolated

Macrophage (Monocytes)

Significance of MACROPHAGE/MONOCYTES presence in synovial fluid

NORMAL if elevated: viral infection

NORMAL cells seen in synovial fluid

Macrophage (Monocytes) Synovial lining cells

Like macrophage but may be multinucleated resembling a mesothelial cell

Synovial Lining Cell

Significance of SYNOVIAL LINING CELLS in synovial fluid

NORMAL!!

Neutrophil containing characteristic ingested “round body”

LE cells

Significance of LE CELLS in synovial fluid

Lupus erythematosus

Vacuolated macrophage with ingested neutrophil

REITER CELLS

Significance of REITER CELLS in synovial fluid

Reiter syndrome Non-specific inflammation

Neutrophil w/ dark cytoplasmic granules containing immune complexes

RA cells (ragocytes)

Significance of RA CELLS (RAGOCYTES) presence in synovial fluid

RA Immunologic inflammation

Large, multinucleated cells abnormally seen in synovial fluid

Cartilage Cells

Significance of CARTILAGE CELLS in synovial fluid

osteoarthritis

Macroscopically resemble polished rice Microscopically show collagen & fibrin

Rice bodies

Significance of RICE BODIES in synovial fluid

TB Septic arthritis RA

Refractile intracellular & extracellular globules Stained with SUDAN DYES

Fat droplets

Significance of FAT DROPLETS in synovial fluid

Traumatic injury Chronic inflammation

Inclusions within clusters of synovial cells

Hemosiderin

Significance of HEMOSIDERIN in synovial fluid

Pigmented villonodular synovitis

needle-shaped crystals abnormally found in synovial fluid

Monosodium Urate (MSU)

Rhombic square & rods crystals abnormally found in synovial fluid

Calcium pyrophosphate dihydrate (CPPD)

Notched, rhombic plate crystals abnormally found in synovial fluid

Cholesterol

Flat, variable-shaped plate crystals abnormally found in synovial fluid

Corticosteroid

Envelope-shaped crystals abnormally found in synovial fluid

Calcium Oxalate

Small crystals abnormally found in synovial fluid; requires EM for visualization

Hydroxyapatite /Apatite (calcium phosphate)

significance of Monosodium Urate presence in synovial fluid

Gout (inc. UA)

significance of Calcium pyrophosphate dihydrate presence in synovial fluid

Pseudogout – degenerative arthritis

significance of Cholesterol presence in synovial fluid

Extracellular (NOT FROM SYNOVIAL FLUID)

significance of Corticosteroid presence in synovial fluid

Injections

significance of Calcium Oxalate presence in synovial fluid

Renal dialysis

significance of Hydroxyapatite presence in synovial fluid

Osteoarthritis Calcified cartilage degeneration

only crystal abnormally found in synovial fluid with NO BIREFRINGENCE? why?

Hydroxyapatite / Apatite (calcium phosphate) -> not visible under polarizing microscope -> requires EM since these are small particles

uses RED compensator, used to confirm or determine the type of birefringence

COMPENSATED POLARIZING MICROSCOPE

used if we want to detect if there’s presence or absence of birefringence

POLARIZING MICROSCOPE

only crystal abnormally found in synovial fluid with POSITIVE BIREFRINGENCE

Calcium pyrophosphate dihydrate (CPPD)

crystals abnormally found in synovial fluid with NEGATIVE BIREFRINGENCE

Monosodium Urate Cholesterol Calcium Oxalate Corticosteroid (may also be POSITIVE)

only crystal abnormally found in synovial fluid with VARIABLE BIREFRINGENCE

Corticosteroid due to shape (flat, variable-shaped plates)

relationship between the velocity of light from the microscope & the arrangement of crystal molecules

Birefringence

Arrangement of crystal molecules is PARALLEL to the velocity of light? What is the color?

POSITIVE BIREFRINGENCE (+) yellow

Arrangement of crystal molecules is PERPENDICULAR to the velocity of light? What is the color?

NEGATIVE BIREFRINGENCE (-) blue

used for chem exam of synovial fluid

*GULP* Glu Uric Acid Lactate Protein

Most frequently tested in chemistry test for synovial fluid

Glucose

formula for glucose analysis of synovial fluid? what is the normal value?

Blood glucose – SF Glucose = <10 mg/dL (NORMAL)

indication of increased lactate in synovial fluid (normal: <250 mg/dL)

infection

indication of increased protein in synovial fluid (normal: <3 g/dL)

inflammatory & hemorrhagic disorders

indication of increased UA in synovial fluid (normal: same as blood UA & serum UA = 6-24 mg/dL)

gout

T/F Difference of blood GLU from synovial fluid GLU (SFG) is INCREASED if SFG is DECREASED during infections (since GLU is utilized)

T Check the 2nd example: 99 mg/dL (FBS) - 90 mg/dL (SFG) = 9 mg/dL (Normal) 99 mg/dL (FBS) - 40 mg/dL (SFG) = 59 mg/dL (TOO HIGH)

Common organisms that infect synovial fluid

S. aureus - most abundant Strep Haemophilus N. gonorrheae

presence of N. gonorrheae in synovial fluid indicates

gonococcal arthritis

sero test for synovial fluid

Autoantibody detection (SLE, RA) - ANA, Rf Serologic Tests for lyme disease - frequent complication: arthritis, caused by Borrelia burgdorferi

Types of arthritis

I - Non-inflammatory IIa - Inflammatory (Immunologic) IIb - Inflammatory (crystal-induced) III - Septic IV - Hemorrhagic

Significance of type I non-inflammatory

Degenerative joint disorder (osteoarthritis)

SF Color & clarity of type I non-inflammatory

Clear, yellow fluid

SF Viscosity of type I non-inflammatory

Good

WBC ct. of type I non-inflammatory

<1,000/uL

Neutrophil ct. of type I non-inflammatory

<30%

Glucose of type I non-inflammatory

NORMAL

Significance of type IIa inflammatory (immunologic)

Immunologic disorders (RA, SLE, etc)

SF Color and intensity of type IIa inflammatory (immunologic)

Cloudy, yellow fluid

SF viscosity of type IIa inflammatory (immunologic)

Poor

WBC ct. of type IIa inflammatory (immunologic)

2,000 – 75,000/uL

Neutrophil ct. of type IIa inflammatory (immunologic)

>50%

Glu of type IIa inflammatory (immunologic)

Decreased

Other testing for type IIa inflammatory (immunologic)

Sero test for AUTOANTIBODIES

Significance of type IIb inflammatory (crystal-induced)

Gout - MSU pseudogout - CPPD

SF color and clarity of type IIb inflammatory (crystal-induced)

Cloudy or milky fluid

SF viscosity of type IIb inflammatory (crystal-induced)

Low

WBC ct. of type IIb inflammatory (crystal-induced)

Up to 100,000/uL

Neutrophil ct. of type IIb inflammatory (crystal-induced)

<70%

Glu of type IIb inflammatory (crystal-induced)

Decreased

Other tests/indication for presence of type IIb inflammatory (crystal-induced)

(+) crystals

Significance of type III septic

Microbial infection

SF color and intensity of type III septic

Cloudy, green fluid

SF viscosity of type III septic

Variable

WBC ct. of type III septic

50,000 – 100,000/uL

Neutrophil ct. of type III septic

>75% (highest among other types)

Glu of type III septic

Decreased (highly increased lactate)

other tests for confirming type III septic

(+) gram stain (+) culture

Significance of type IV hemorrhagic

Traumatic injury Coagulation deficiencies

SF color and intensity of type IV hemorrhagic

Cloudy, red fluid

SF viscosity of type IV hemorrhagic

Low

WBC ct. and neutrophils of type IV hemorrhagic

Equal to blood

Glu of type IV hemorrhagic

Normal

Other tests to identify type IV hemorrhagic

(+) RBCs

type of arthritis with NORMAL GLUCOSE

type I (non-inflammatory) type IV (hemorrhagic)

SF clarity for all of the following is CLOUDY, except: a. type I b. type IIa and b c. type III d. type IV

a. type I - clear SF

Ultra filtrate of plasma, provides lubrication between two membrane (parietal & visceral)

SEROUS FLUID

Fluid between parietal and visceral membranes (only filter blood, doesn’t produce additional substance like synovium)

SEROUS FLUID

3 types of serous fluid and its location

Pleural fluid – lungs Pericardial fluid – heart <3 Peritoneal fluid – abdominal area

accumulation of excess fluid between the membranes

effusion

types of serous effusion

transudate exudate

transudate is caused by

Systemic Condition

exudate is caused by

Membrane Damage

All serous fluids are affected

Transudate

Only one serous fluid affected, specific membrane only

Exudate

causes of TRANSUDATE presence

Hypoproteinemia Congestive heart failure Nephrotic syndrome Cirrhosis Malnutrition

causes of EXUDATE presence

Infection (e.g., pneumonia, TB, endocarditis) Inflammation Malignancy (e.g., adenoma)

differentiates exudates (+) from transudates (-)

RIVALTA’S TEST – SEROSAMUCIN CLOT TEST

how is RIVALTA’S TEST – SEROSAMUCIN CLOT TEST performed? what is the result?

HAc + WATER + Unknown Fluid (effusion) (+) heavy precipitation = exudates

most reliable tests to differentiate transudates & exudates

Fluid: Serum Protein Ratio Fluid: Serum LD Ratio

what must be done for pH testing of serous fluid?

stored during transport ANAEROBICALLY in ice

method of collection of pleural fluid

Thoracentesis

method of collection of pericardial fluid

Pericardiocentesis

method of collection of peritoneal fluid

Paracentesis

tubes for serous fluids (in order) and purpose of each

EDTA - Cell / Diff count Sterile Heparin Tube - Microbiology / Cytology Heparin Tube - Chemistry Plain Tube - Clotting test (for spontaneous clotting = (+) exudate)

normal volume of pleural fluid

<30 mL

Significance of clear, yellow pleural fluid

NORMAL!!

Significance of turbid, white pleural fluid

microbial inf

Significance of brown (anchovy sauce-like) pleural fluid

Ruptured amoebic abscess – extraintestinal amoebiasis (Entamoeba histolytica)

Significance of black pleural fluid

Aspergillosis

Significance of viscous pleural fluid

Malignant mesothelioma – produces Hya. Ad

Significance of milky pleural fluid

Chylous material Pseudochylous material *differentiated

Significance of bloody pleural fluid

Hemothorax Hemorrhagic effusion *differentiated

with INCREASED TAG causing milky pleural fluid

Chylous effusion

with INCREASED CHOLE causing milky pleural fluid

Pseudochylous effusion

cause of chylous effusion

Thoracic duct leakage

appearance of chylous effusion

Milky / white

cause of pseudochylous effusion

Chronic inflammation / infection

appearance of pseudochylous effusion

Milky / green tinge / “gold paint” green & gold paint - from infection

leukocytes found in chylous effusion

lymphocytes *lymphatic duct is both rich in lymphocytes and chylomicrons (increases conc. of TAG)

leukocytes found in pseudochylous effusion

mixed cells

cholesterol crystal presence/absence in chylous effusion

ABSENT

cholesterol crystal presence/absence in pseudochylous effusion

PRESENT

TAG value in chylous effusion

>100 mg/dL

TAG value in pseudochylous effusion

<50 mg/dL

Sudan III staining result in chylous effusion

+ SUDAN III - mainly for TAG staining

Sudan III staining result in pseudochylous effusion

- or weakly +

blood distribution in HEMOTHORAX

Uneven N PF + Blood

blood distribution in HEMORRHAGIC EFFUSION

Even inc. PF + Blood

similar with traumatic tap, presence of blood in pleural fluid due to injury)

hemothorax

bleeding in pleural cavity due to membrane defect

hemorrhagic effusion

used to differentiate bloody pleural fluid (hemothorax and hemorrhagic effusion)

hematocrit

pleural fluid HCT indicating hemothorax

PF Hct is ≥1/2 of WB Hct

pleural fluid HCT indicating hemorrhagic effusion

PF Hct is <1/2 of WB Hct

Abnormal pleural fluid cells

Neutrophil Lymphocyte Mesothelial cells Plasma cells Malignant cells Eosinophil

Significance of neutrophil presence in pleural fluid

Pneumonia Pulmonary infarction Pancreatitis

Significance of lymphocyte presence in pleural fluid

TB viral infections autoimmune disorders malignancy

Significance of Mesothelial cells presence in pleural fluid

NORMAL (regardless of the form - normal/reactive) DECREASED: TB

lines the serous membrane lining/cavity

mesothelial cells

Significance of plasma cells presence in pleural fluid

Significance of MALIGNANT cells presence in pleural fluid

Primary adenocarcinoma small cell carcinoma metastatic carcinoma

Significance of eosinophil presence in pleural fluid

if >10% - trauma resulting from presence of air/blood in PF sample, allergy/parasitic infection

TUMOR MARKERS FOR EFFUSIONS OF MALIGNANT ORIGIN FOR PLEURAL FLUID

CEA CA 125 CA 15-3, CA 549 CYFRA 21-1

significance of CEA in effusions

colon cancer

significance of CA 125 in effusions

metastatic uterine cancer

significance of CA 15-3, CA, 549 in effusions

breast cancer

significance of CYFRA 21-1 in effusions

lung cancer

concentric striations of collagen-like material found in peritoneal fluid seen in benign conditions

PSAMMOMA BODIES

PSAMMOMA BODIES is associated with conditions such as

ovarian malignancies thyroid malignancies

chem test for pleural fluid

Glucose Lactate TAG pH Adenosine deaminase Amylase

significance of decreased GLU in pleural fluid

rheumatoid inflammation TB purulent infection

significance of increased LACTATE in pleural fluid

bacterial infection

significance of increased TAG in pleural fluid

chylous effusion

significance of decreased pH in pleural fluid

pneumonia not responding to antibiotics complicated parapneumonic effusion (assoc. with empyema) esophageal rupture

extremely low pH of pleural fluid is associated with? what is the pH?

Esophageal rupture (pH 6.0)

significance of adenosine deaminase in pleural fluid

Malignancy Tubercular effusion

significance of amylase in pleural fluid

Esophageal rupture malignancy pancreatitis (increased)

chem test indicating esophageal rupture using pleural fluid

pH 6.0 amylase

common bacteria causing Pleural Effusion

S. aureus Enterobacteriaceae M. tuberculosis Anaerobic bacteria

normal volume of pericardial fluid

<50 mL

normal color of pericardial fluid

Clear, pale yellow

color of pericardial fluid in presence of TRANSUDATE

Clear, pale yellow (similar to NORMAL)

color of pericardial fluid during infection, malignancy

Blood-streaked

color of pericardial fluid during cardiac puncture, anticoagulant medication

Grossly bloody

inc. neutrophil in pericardial fluid indicates

bacterial endocarditis

malignant cells in pericardial fluid indicates

Metastatic carcinoma

tests for pericardial fluid

glucose gram stain and culture acid fast stain adenosine deaminase

decreased GLU in pericardial fluid indicates

Bacterial infection Malignancies

+ gram stain and culture using pericardial fluid indicates? what are the common agents causing pericardial effusion?

Bacterial endocarditis haemophilus, adenovirus, coxsakievirus, strep, staph (HACSS)

tests used to identify TUBERCULAR EFFUSION

Acid-fast Stain Adenosine deaminase

aka peritoneal fluid

ASCITIC FLUID ascitis - effusion in peritoneal cavity

normal vol. of peritoneal fluid

<100 mL (highest vol among other fluids; abdominal area is larger than cardiac and lungs)

normal peritoneal fluid color

clear, pale yellow

peritoneal fluid color in microbial inf.

turbid

peritoneal fluid color in gall bladder and pancreatic disorder

green

peritoneal fluid color in trauma, inf, malignancy

blood-streaked

peritoneal fluid color in lymphatic trauma and leakage

milky

normal WBC count in peritoneal fluid

<500/uL

abnormal WBC count in peritoneal fluid indicating bacterial peritonitis and cirrhosis

>500/uL

inc. neutrophils in peritoneal fluid indicates

Bacterial peritonitis

test used to indicate blunt trauma injury using peritoneal fluid? what is the value?

peritoneal lavage >100,000 RBC/uL

CEA in peritoneal fluid indicates

malignancy GI in origin

CA 125 in peritoneal fluid indicates

malignancy ovarian in origin

decreased GLU in peritoneal fluid indicates

Tubercular peritonitis malignancy

increased AMY in peritoneal fluid indicates

Pancreatitis

increased Alkaline phosphatase in peritoneal fluid indicates

GI perforation

alkaline phosphatase test result using peritoneal fluid during GI perforation

INCREASED ALP

BUN/CREATININE in peritoneal fluid indicates

Ruptured / punctured bladder

+ gram stain & culture in peritoneal fluid indicates

Bacterial peritonitis

tests used to identify TUBERCULAR PERITONITIS

Acid-fast Stain Adenosine deaminase dec. Glu

AUBF (synovial & serous fluids) Flashcards

(249 cards)