ANALYSIS OF URINE AND BODY FLUIDS (LECTURE)

- Clear, colorless body fluid found within the tissue

that surrounds the brain and spinal cord;
Replaces the body fluid found outside the cells of
bilateral animals
- 3rd major body fluid

• Supply nutrients to the nervous system

• Remove metabolic wastes
• Produce a mechanical barrier to cushion the
brain and spinal cord against trauma

- CSF provides a physiologic system to supply

nutrients to the nervous tissue, remove
metabolic wastes, and produce a mechanical BLOOD BRAIN BARRIER
barrier to cushion the brain and spinal cord - Tight-fitting structure of the endothelial cells in
against trauma the choroid plexuses that prevents molecule
- It occupies the subarachnoid space between the passage
arachnoid and pia mater - Protect the brain from chemicals and other
substances circulating in the blood that could
MENINGES harm the brain tissue.
- Lines the brain and spinal cord o Also prevent the passage of helpful
- Provides supportive framework for the cerebral substances including Ig and medications
cranial vasculature - Disruption of the blood-brain barrier by diseases
such as meningitis and multiple sclerosis allows
Three Layers WBC, Proteins, and additional chemicals to enter
➢ Dura Mater – outer layer that lines the skull and the CSF.
vertebral canal - CSF is considered as ultrafiltrate of plasma
o Latin word: hard mother
➢ Arachnoid Mater – spider web-like which lines
the inner membrane - Lumbar puncture or spinal tap between the
➢ Pia Mater – thin membrane lining the surfaces of third, fourth, or fifth lumbar vertebra
the brain and spinal cord - Precautions:
o Latin word: gentle mother o measurement of intracranial pressure
▪ normal: 5 to 15 mmHg
▪ mild intracranial hypertension:
20 to 30 mmHg
o careful technique to prevent infection or
Neural Tissue damage
o Fluid collected: CSF (ultra filtrate)

CSF TUBES
• Tube 1: Chemistry/Serology (freezer temp.)
• Tube 2: Microbiology (room temp.)
• Tube 3: Hematology (refrigerated)
• Tube 4: Microbiology/Serology
CHOROID PLEXUSES
- Specialized ependymal cells in the area produces Note:
CSF If single tube is collected, the specimen should be send
- rate of CSF production: 20mL per hour first at the microbiology section, followed by the
- CSF total Volume hematology section, and last for chemistry and serology
o Adults: 90-150 mL section
o Neonates: 10-60 mL
- To maintain CSF normal value, the fluid is
reabsorbed back into the capillaries in the
Arachnoid granulations/villae
- Production of CSF via selective filtration under
hydrostatic pressure and active transport
secretion
 ANALYSIS OF URINE AND BODY FLUIDS (LECTURE)

CSF APPEARANCE
APPEARANCE CLINICAL SIGNIFICANCE
Crystal Clear Normal
↑ WBC (>200 /uL)
Hazy/ Turbid/ ↑ RBC (>400 / uL)
Cloudy/ Milky ↑ Lipids and Proteins
(+) Microorganisms
Due to hemoglobin degradation product
Xanthochromic
• Pink: Slight amount of oxyhemoglobin
(Pink/Yellow/
• Yellow: Oxyhemoglobin → Bilirubin
Orange)
• Orange: Heavy Hemolysis
Oily Radiographic Contrast Media
Protein and clotting factors
Clotted
Disrupted blood brain barrier
Pellicle Tubercular meningitis
↑ RBC (>6,000/uL)
Traumatic Tap (puncture of blood vessel)
Bloody
Intracranial Hemorrhage (bleeding within the
braincase)

TRAUMATIC TAP VS. INTRACRANIAL HEMORRHAGE

Traumatic Tap Intracranial Hemorrhage
Distribution of
Uneven Even
blood in 3 tubes
Clot Formation + (fibrinogen) –
Supernatant Clear Xanthochromic
Erythrophages – + PREDOMINANT CELLS IN THE CSF
- Predominant: Lymphocytes and Monocytes
- Occasional: Neutrophils
- Any cell count should performed Immediately o Lymphocytes-monocytes ratio in adults
- WBC and RBC begin to lysed within 1 hour (70:30)
- 40% of WBC begin to lysed within 2 hours o Neonates (inversed ratio)
- Formula: ▪ Up to 80% monocytes is
# 𝑜𝑓 𝑐𝑒𝑙𝑙𝑠 𝑐𝑜𝑢𝑛𝑡𝑒𝑑 𝑥 𝑑𝑖𝑙𝑢𝑡𝑖𝑜𝑛 considered normal
𝑾𝑩𝑪 𝒄𝒐𝒖𝒏𝒕/𝒖𝑳 =
# 𝑜𝑓 𝑠𝑞𝑢𝑎𝑟𝑒𝑠 𝑐𝑜𝑢𝑛𝑡𝑒𝑑 𝑥 𝑑𝑒𝑝𝑡ℎ - Pleocytosis: Increased number of normal cells in
the CSF
WBC COUNT o Increased white blood cell in the CSF
- Routinely performed
- Normal Values: OTHER CELLS
o Adults: 0-5 WBC/uL ➢ Eosinophil – parasitic and fungal (Coccidioides
o Neonates: 0-30 WBC/uL immitis)
- Diluting fluid: 3% acetic acid with methylene ➢ Macrophages
blue o remove cellular debris and foreign
CSF DILUTION objects such as RBC
Appearance Dilution o Appear within 2-4 hours after RBC enters
Appearance Dilution the CSF
Clear Undiluted o Indicates previous hemorrhage
Slightly Hazy 1:10
o Degradation of RBC- appearance of dark
Hazy 1:20
Slightly Cloudy 1:100 blue or black iron hemosiderin granules
Cloudy/ Slightly bloody 1:200 o Further degradation= Yellow
Bloody or Turbid 1:10,000 hematoidin- iron free, with hemoglobin
and unconjugated bilirubin
RBC COUNT
- Done only in cases of traumatic tap NON-PATHOLOGICALLY SIGNIFICANT CELLS
- To correct for WBC Count and total protein - Seen after pneumoencephalography and
concentration neurosurgery
o -1 WBC for every 700 RBC seen - Uniform in appearance
o -8 mg/dL Total protein for every 10,000 - Choroidal cells: linings of choroid plexus
RBCs/uL - Ependymal cells: linings of ventricles and neural
o -1 mg/dL Total protein for every 1,200 canal
RBCs/uL o It produces CSF
- Spindle-shaped cells: linings of arachnoid

- Performed on stained smear Malignant Cells of Hematologic Origin

- Specimen should be concentrated before - Lymphoblast, myeloblasts, and monoblasts
smearing by using the following methods: - Found in acute leukemias
o Cytocentrifugation (most common) - Lymphoma cells: indicates dissemination of
o Centrifugation lymphoid tissues
o Sedimentation
o Filtration
 ANALYSIS OF URINE AND BODY FLUIDS (LECTURE)

Malignant cells of Nonhematologic Origin o Normal Value: <9

- Metastatic Carcinoma Cells: primarily from o Abnormal: >9
lungs, breast, renal, and gastrointestinal ▪ Correlates with the degree of
malignancies the damage
- Usually seen in clusters and have tendency to ▪ Index of 100 = complete damage
fuse the cell to BBB
- Cells from CNS tumors: ➢ IgG Index
o Astrocytomas o Assess the condition of IgG production
o Retinoblastomas within the CNS (e.g. Multiple Sclerosis)
o Medulloblastomas
𝐶𝑆𝐹 𝐼𝑔𝐺 (𝑚𝑔/𝑑𝐿) ÷ 𝑠𝑒𝑟𝑢𝑚 𝐼𝑔𝐺 (𝑔/𝑑𝐿)
𝑰𝒈𝑮 𝒊𝒏𝒅𝒆𝒙 =
𝐶𝑆𝐹/𝑆𝑒𝑟𝑢𝑚 𝐴𝑙𝑏𝑢𝑚𝑖𝑛 𝐼𝑛𝑑𝑒𝑥

o Normal Value: <0.77

o Abnormal: >0.77
▪ Indicative of IgG production
within the CNS
▪ Possible that the patient has
multiple sclerosis

CSF ELECTROPHORESIS
- Done in conjunction with serum electrophoresis
- For the detection of the oligoclonal bands
(Gamma Region)
- The presence of two or more oligoclonal bands
in the CSF but not in serum is valuable for the
diagnosis of Multiple Sclerosis
CSF PROTEIN - Other conditions:
CSF PROTEIN o Encephalitis
• Adult: 15-45 mg/dl
o Neurosyphilis
Normal Values • Infants: 150 mg/dl
• Immature: 500 mg/dl
o Guillain-Barre Syndrome
Damage to BBB (most common) o neoplastic syndrome
• Meningitis
Increased in • Hemorrhage Detection of TAU Protein
Production in immunoglobulins within the
CNS → Multiple Sclerosis - Isoelectric Focusing and Immunofixation test are
Decreased in CSF Leakage used to check the presence of TAU protein
Major CSF Protein Albumin - Normal: Low protein levels in the CSF
2nd Most Prevalent Prealbumin - Abnormal: High protein levels in the CSF
Protein - Method of choice when determining whether a
Alpha globulins Haptoglobin and ceruloplasmin
fluid is actually CSF
Beta transferrin (TAU Protein)
Beta-globulins • Carbohydrate-deficient transferrin
• Found in CSF but not in Serum
Gamma globulins IgG and some IgA (monomer)
• IgM
Not found in
• Fibrinogen
normal CSF
• B-Lipoprotein

Total Protein
Multiple Sclerosis
➢ Turbidimetric
Trichloroacetic acid Sulfosalicylic Acid Method - Autoimmune disorder
- Preferred method - Precipitates albumin - Most common demyelinating disease of the CNS
- Precipitates both - To precipitate globulin, add - The body produces immunoglobulin G to attack
albumin and globulins sodium sulfate the cells in the myelin sheath
➢ Dye Binding using Coomasie Brilliant Blue - Findings:
o Protein binds to dye → dye turns from o (+) Anti-myelin sheath autoantibody
red to blue o (+) Oligoclonal band in the CSF but not in
o Increased protein = increased blue color serum
▪ Short and less intense bands
Protein Fractions o (+) Myelin Basic Protein CSF
➢ CSF/Serum Albumin Index o Increased IgG
o Assess the integrity of the blood brain - Myelin Basic Protein
barrier o Protein Component of the lipid-protein
complex that insulate the nerve fibers
𝐶𝑆𝐹 𝑆𝑒𝑟𝑢𝑚 𝐴𝑙𝑏𝑢𝑚𝑖𝑛 (𝑚𝑔/𝑑𝐿) o Presence of MBP in the CSF indicates
𝑪𝑺𝑭/𝑺𝒆𝒓𝒖𝒎
= destruction of Myelin Sheath
𝑨𝒍𝒃𝒖𝒎𝒊𝒏 𝑰𝒏𝒅𝒆𝒙 𝑆𝑒𝑟𝑢𝑚 𝐴𝑙𝑏𝑢𝑚𝑖𝑛 (𝑔/𝑑𝐿)
o Used to monitor the course of Multiple
Sclerosis
 ANALYSIS OF URINE AND BODY FLUIDS (LECTURE)

▪
Neurological abnormalities: LD 2
>1
▪ Bacterial Meningitis: LD 5 > 4 > 3
>2>1
• LD 4 and 5 are seen in
neutrophils
➢ Creatine Kinase (CK) – Increase in stroke, MS,
Degenerative disorders, Brain tumors, Viral and
Bacterial meningitis, and seizures
➢ Aspartate Amonitransferase (AST) – Increase in
intracerebral and subarachnoid hemorrhage and
CSF GLUCOSE
bacterial meningitis
- Glucose is normally seen in the CSF because it o Not common in the CSF
serves as a fuel or the energy source of the brain
- Done in the conjunction with Blood Glucose
- Specimen for blood glucose should be drawn 2
hours prior to spinal tap - Identify the causative agent in Meningitis
- Normal values: - Confirmatory: 24 hours to 6 weeks
o 60-70% of blood glucose - Preliminary Diagnosis: Gram staining –
o 50-80 mg/dL CSF glucose organisms most frequently encountered include
- Increased: due to increased plasma glucose o Streptococcus pneumoniae (gram-
- Decreased: positive cocci)
o Bacterial meningitis o Haemophilus influenzae (pleomorphic
o Tubercular meningitis gram-negative rods)
o Fungal meningitis o Escherichia coli (gram-negative rods)
- Normal: Viral Meningitis o Neisseria meningitidis (gram-negative
cocci)
o Streptococcus agalactiae
CSF LACTATE
o Listeria monocytogenes may be
- There will be an increased lactic acid due to the encountered in newborns
tissue destruction within the CNS, causing tissue
hypoxia, which results to oxygen deprivation. Major Laboratory Results for the
- Lactic acid (lactate): end product of glycolysis Differential Diagnosis of Meningitis
- Normal values: 10-22 mg/dl Bacterial Viral Tubercular Fungal
Predominant Lymphocytes Lymphocytes
- Increased: WBC
Neutrophil Lymphocytes
Monocytes Monocytes
o Bacterial meningitis Protein
Glucose
↑
↓
↑
N
↑
↓
↑
↓
o Tubercular meningitis Lactate ↑ N ↑ ↑
(+) Gram stain Agents: Agent: MTB Agent: C.
o Fungal meningitis (+) Culture Enteroviruses (+) AFB neoformans
(+) Limulus • Poliovirus (+) Pellicle or (+) Gram stain
- Normal: Other Info Lysate test • Echovirus web-like Starburst pattern
o Viral meningitis • Coxsackievirus (+) India ink
(+) Immunologic
o offering a sensitive method for test

evaluating the effectiveness of antibiotic

therapy Limulus Lysate Test
- Detects Gram negative bacterial endotoxin in the
CSF GLUTAMINE body fluids and surgical equipment
- Product of Ammonia and Alpha-Ketoglutarate - Reagent: Blood horse-shoe crab (hemolyn)
- It is an indirect test for the presence of excess - Principle:
ammonia in the CSF o In the presence of endotoxin, the
Amoebocytes (WBC) will release lysate
- Normal value: 8-18 mg/dL
- Increased in: (protein)
o Liver disorder that causes blood and CSF o Blue color
ammonia o (+) presence of clot/clumping and
o Disturbance of consciousness (comatose erythrophages
patient)
o Reye’s syndrome AGENTS OF BACTERIAL MENINGITIS
Age Group Causative Agent
Birth to 1 month old Streptococcus agalactiae
CSF ENZYMES 1 month to 5 yrs old Haemophilus influenzae
➢ Lactate Dehydrogenase (LDH): 5 – 29 years old,
Neisseria meningitis
immunocompromised
Isoenzymes: LD1, 2, 3, 4, 5 >29 years old Streptococcus pneumoniae
o Serum LDH Infants, elderly,
Listeria monocytogenes
▪ Normal: LD 2 > 1 > 3 > 4 > 5 immunocompromised
▪ Flipped Pattern: LD 1 > 2
• Associated with Acute
Myocardial Infarction • Latex agglutination test and ELISA: detection of
o CSF LDH bacterial antigens
▪ Normal: LD 1 > 2 > 3 > 4 > 5
• VDRL: recommended by CDC for the detection of
neurosyphilis