Cytology of Body Fluid

Accumulation of fluids in body cavities

Transudates

bull Increased hydrostatic pressure Congestive heart failure

bull Decreased oncotic pressure (decreased albumin) liver cirrhosis nephrosis and malnutrition

Exudate

bull Inflammation Infection infarction hemorrhage

bull Tumor

DIFFERENCES BETWEEN TRANSUDATE AND EXUDATE

Feature Transudate Exudate

Gross appearance Watery clear Turbid or cloudy

Specific gravity Less than 1015 More than 1015

Protein Less than 3mgdl More than 3mgdl

Clots No Yes

cells Usually benign

Few mesothelial

cells few histocytes

and lymphocytes

More mesothelial cells

acute or chronic

inflammatory cells

RBCs malignant cells

MODIFIED TRANSUDATE

Moderate protein concentration 2525- 75gdl

Moderate cellularity 1000-7000 cells μg 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 eg TB

Respiratory Tract

Urinary Tract

Oral Cavity

Gastrointestinal Tract

Effusions (pleural pericardial joint)

Cerebral Spinal Fluid

Amniotic fluid

Many other body sites

Non-Gynecological Specimen Collection

EXAMINATION OF BODY FLUID

Gross exam

Total cell count

Microscopic exam

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

NB do not use alcohol in fixation of fluid before

spread cytological smear on glass slides

TYPES OF STAINING SMEARS

PAP

Gram Stain

Hx amp E

Cell block for remnant sediment and histopathological

examination

Other special stains for the most suspected diseases to

confirm diagnosis

Heparinized bottles (3 units heparinml) Unfixed

Alcohol-fixed

Papanicolaou-stained

Cytocentrifuge preparationCell block

Adding plasma and thrombin solution

Wrapped in filter paper

Placed in a cassette

Embedded in paraffin

Cut and HampE stain

Air-dried cytocentrifuge preparation

(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 collection by Lumbar puncture

Collect 3-5 vials each tube has a designated department

Gross exam Turbidity Color microscopic exam cell

count

CSF CELL DIFFERENTIAL

Numerate and differentiate cells seen

Lymphocytes usually are few increased with viral

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

EosinophilsBasophils not normally seen in CSF

Plasma cells not normally present associated with viral disorders

and Hodgkins 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 lt5 RBCrsquos lt5 WBCrsquos Protein 23-38mgdl (can use 14-45) Glucosemdash60 of serum level (75-100)

OPENING PRESSURE

Normal = 80-180 mmHg Obese pts up to 250mmHg can be normal Pathologically elevated gt250mmHg 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 41000 RBC 1 WBC to adjust WBC count in

bloody tap

SAH or HSV Elev RBC in tube 1 AND tube 4

ldquoCrenated RBCsrdquo and xanthochromia (yellow supernatant after centrifuge)Seen in hyperbilirubinemia (ESLD) old SAH

old blood from prior traumatic LP or bleed

WBCrsquoS

Infection PMN predominance likely bacterial

meningitis Lymphocytic predominance viral vs fungal

vs TB vs malignancy

PROTEIN Normal protein is excluded from CSF by

blood-CSF 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 infectionLow glucose Bacterial meningitis TB fungalReally low lt18 is strongly suggestive of bacterial

meningitis

TYPICAL VIRAL MENINGITIS

CSF WBC elevated but lt250 (first PMNs then lymphocytes)

CSF protein elevated but lt150 Glucose gt 50 of serum concentration

TYPICAL BACTERIAL MENINGITIS

CSF WBC gt1000 PMN predominance CSF protein gt500mgdl CSF glucose lt45 mgdl

bull Effusion

bull Transudate

bull Exudates

bull Lab analysis Gross exam cell count etc

bull Differential PMN Lymph Mono etc

2- Pleural Fluid Lung fluid

bull Cells unique to the lungs Mesothelial cells

bull RBCs and WBCs are limited if increased without

traumatic tap ----- indicates infarction

bull 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 ro

chylothorax amylase to ro pancreatitis esoph perf Adenosine deaminase to eval TB

LIGHTrsquoS CRITERIA FOR EXUDATES

Fluid is exudate if it meets 1 of 3 criteria 1 Pleural fluid LDHserum LDH gt 062 Pleural fluid proteinserum protein gt 053 Pleural fluid LDH gt 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 EdemaCHF Cirrhosis with ascites HypoalbuminemiaNephrotic

syndrome ESLD Fluid overload sp aggressive IVF Peritoneal dialysis

EXUDATE

Caused by local not systemic factors Infection Neoplasm Pancreatitis Esoph perf RA SLE Sarcoid Wegeners PE Meigrsquos

Chylothorax

LYMPHOCYTOSIS

Malignancy (50-70 lymphs) Also TB sarcoid RA chylothorax (gt90

lymphs)

PLEURAL EOSINOPHILIA

Pneumothorax Hemothorax Pulm infarct Parasitic disease

Fungal infection Drugs Malignancy Asbestos

WHY IS GLUCOSE LOW(lt60)

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 gt 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 CHF liver cirrhosis nephrotic syndrome

Mesothelial Cells Associated with TB effusions

Malignant cells seen with malignancy

WHAT TO SEND FLUID FOR

Cell count with diff Albumin LDH Total protein

glucose Gram staincx cytology

APPEARANCE OF FLUID

Clearmdashusually indicates uncomplicated ascites ie liver failurecirrhosis

Turbidcloudymdashinfected Pinkbloodymdashtraumatic punctured collateral

vessel malignancy Correct for bloody tap 1 WBC 750 RBC

1 PMN 250 RBC

SERUM-TO-ASCITES ALBUMIN GRADIENT (SAAG)

=Serum albumin ndash ascitic fluid albuminIf the gradient is gt11 Portal HTN (drives fluids into

peritoneum) SBP cirrhosis Alcoholic hepatitis CHFIf the gradient is lt 11(protein leaks into peritoneum and fluid

follows) Peritoneal carcinomatosis peritoneal

TB pancreatitis nephrotic syndrome

SBP SAAG gt 11 Suspect if gt250 PMNs (gt100 PMNs in pt on

peritoneal dialysis) 70 GNR (Ecoli Klebsiella)

30 GPC (S pneumo Enterococcus) Treat with ceftriaxone cefotaxime ldquoCulture negative SBPrdquo if gt250 PMNs but cx

neg treat the same

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)

4- Pericardial Fluid

Measure pH pH less than 70 associated with infection or

rheumatoid disorder

Cell count see limited RBCs and WBCs

Evaluate sedimentation

bull Examine physical chemical and microscopic detail

bull Count number of sperm report morphology and

motility

bull Specimen must be a fresh collection-clean sterile

container

bull Gross Exam Color pH Volume and viscosity

bull Agglutination study

5- Seminal Fluid

bull Joint Fluid normally clear viscous

bull Functions as a lubricate and transports nutrient

bull Arthrocentesis aspirate of the joint fluid aseptic

technique