Herce, Jolan

BSMT-3B

SYNOVIAL FLUID

PHYSIOLOGY CLASSIFICATION AND PATHOLOGICAL

Synovial Fluid / “Joint Fluid” SIGNIFICANCE OF JOINT DISORDERS
• Viscous liquid found in the cavities of the movable joints. Group Pathological Laboratory Findings
• Lubrication in the joints Classificati Significance
- To reduce friction between joints on
• Provides nutrients to the articular cartilage I. Degenerative Clear, yellow fluid
• Lessen the shock of joint compression that occurs Noninflam joint disorders, Good viscosity
during activities such as walking & jogging matory osteoarthritis WBCs s <1000 µL
• The synovial membrane contains specialized cells Neutrophils <30%
called synoviocytes. Similar to blood glucose
1. Type A cells - macrophage-like cells located in
the superficial layer of the synovial membrane II. Immunologic Cloudy, yellow fluid
2. Type B cells - fibroblast-like cells with prominent Inflammato disorders, Poor viscosity
endoplasmic reticulum located in a deeper layer ry rheumatoid WBCs 2,000—75,000 µL
of the synovial membrane arthritis, Neutrophils >50%
• The synoviocytes secrete a mucopolysaccharide systemic lupus Decreased glucose
containing hyaluronic acid and a small amount of erythematosus, level
protein (approximately one fourth of the plasma scleroderma, Possible autoantibodies
concentration) into the fluid polymyositis, present
• Damage to the articular membranes produces pain ankylosing
and stiffness in the joints, collectively referred to as spondylitis,
arthritis. rheumatic
fever, Lyme
arthritis

Crystal-induced Cloudy or milky fluid

gout, Low viscosity
pseudogout WBCs up to 100,000 µL
Neutrophils <70%
Decreased glucose
level
Crystals present

III. Septic Microbial Cloudy, yellow-green

infection fluid
Variable viscosity
WBCs 50,000 to 100,000
µL
Neutrophils >75%
Decreased glucose
NORMAL SYNOVIAL FLUID VALUES level
Volume <3.5 mL Positive culture and
Color Colorless to pale yellow Gram stain
Clarity Clear
Viscosity High; Able to form a string 4—6 IV. Traumatic injury, Cloudy, red fluid
cm long Hemorrhag tumors, Low viscosity
Leukocyte count <200 cells/µL ic hemophilia, WBCs equal to blood
Neutrophils <25% of the differential other Neutrophils equal to
Crystals None present coagulation blood
Glucose:plasma <10 mg/dL lower than the blood disorders Normal glucose level
difference glucose level Anticoagulant
Total protein <3 g/dL overdose
Lactate <25.0 mg/dL

TRANSCRIBED BY: JOLAN HERCE BSMT-3B

 Herce, Jolan
BSMT-3B

SPECIMEN COLLECTION AND HANDLING • Methylene Blue: Stain WBC nuclei

✓ Volume can increase up to 25 ml with inflammation DON’T USE ACETIC ACID AS DILUTING FLUID -IT WILL CLOT
✓ Normal synovial fluid DOES NOT CLOT. THE SYNOVIALSPECIMEN. USE NSS
✓ Fluid is often collected in a syringe that has been • TO LYSE RBC, USE HYPOTONIC SALINE SOLUTION
moistened with heparin. • Technique: Petri Dish with moist paper and
✓ A nonanticoagulated tube for other tests hemocytometer
✓ Sterile heparinized tube for Gram stain and culture • Automated cell counter: Synovial count
• Incubation with Hyaluronidase- decreases viscosity
✓ Heparin or EDTA for cell counts
✓ A NaF tube for glucose analysis.
DIFFERENTIAL COUNT
REQUIRED TUBE TYPES FOR SYNOVIAL Cytocentrifuged - incubated with hyaluronidase
FLUID TESTS Primary Cells: Mononuclear cells, monocytes,
Synovial Fluid Test Required Tube Type macrophages, tissue Cells
Gram stain and culture Sterile sodium heparin or • Neutrophils - 25%
sodium polyanethol • Lymphocytes - 15%
sulfonate • Monocytes – 65%
Cell counts Sodium heparin or liquid • Eosinophils – 2%
ethylenediaminetetraacetic • Elevated Cell Count -
acid (EDTA) o Nonseptic Inflammation
Glucose analysis Sodium fluoride or • Vacuolated cell
nonanticoagulated o Normal specimen
All other tests Nonanticoagulated o Abnormal Specimen
Pigmented Villonodular Synovitis
COLOR AND CLARITY o Lipid Droplets
COLOR: Colorless to pale yellow
• Synovial comes from the word egg ''ovum" CRYSTAL IDENTIFICATION
• Normal synovial resembles “eggwhite” Crystal Shape Significan Image
- Deeper yellow - Inflammatory& noninflammatory ce
effusions Monosodiu Needle Gout
- Green - Bacterial infection m urate
- Red -Hemorrhagic arthritis
TURBIDITY: Presence of WBC, Synovial cells debris and
fibrin. Can be MILKY (Presence of crystals) Calcium Rhombic Pseudogo
pyrophosph square, ut
VISCOSITY ate rods
Arthritis affects the production of hyaluronidase:
decreasing fluid viscosity Cholesterol Notched, Extracellul
➢ METHODS: rhombic ar
• String test - 4-6 cm plates
• Ropes (Mucin Clot Test)
Synovial + 2% - 5% acetic acid =CLOT Corticosteroi Flat, Injection
• REPORTING: d variable-
• GOOD (Solid clot) shaped
• FAIR (Soft clot) plates
• LOW (Friable clot) Calcium Envelop Renal
• POOR (No clot) oxalate dialysis
– Formation of mucin clot used to identify
questionable fluid (synovial fluid)
Apatite (Ca Small Osteoarthr
CELL COUNTS
phosphate) particles itis
• Total leukocyte count (MOST FREQUENT)
Require
• Viscous fluid -pretreat with a pinch of hyaluronidase to
electron
0.5 mL of fluid or one drop of 0.05% hyaluronidase in
microsco
phosphate buffer per mLof fluid - 37ºC for 5 minutes.
py
• Manual Counts: Neubauer counting chamber
• Diluting fluid: Normal Saline (0.3%)

TRANSCRIBED BY: JOLAN HERCE BSMT-3B

 Herce, Jolan
BSMT-3B

Crystal formation - results in an acute, painful CPPD Crystals:

inflammation caused by metabolic disorders and o perpendicular to the long axis of the crystal;
decreased renal excretion that produce elevated sugar when aligned with the slow axis of the
levels, degeneration of cartilage and bone, and compensator.
injection of medications such as corticosteroids into a o Velocity: Fast
joint. o passing through the crystal is much quicker,
producing a blue color
TYPES OF CRYSTALS o Positive birefringence.
Increased Serum Uric Acid - results from impaired o Cholesterol, oxalate, and corticosteroid crystals
metabolism of purines; increased consumption of high- exhibit birefringence.
purine-content foods, alcohol, and fructose; o Apatite crystals are not birefringent.
chemotherapy treatment of leukemias; and decreased
renal excretion of uric acid are the most frequent
causes of gout.

SLIDE PREPARATION
• Performed ASAP to avoid contamination.
• Monosodium Urate (MSU) and Calcium Pyrophosphate
Dihydrate (CPPD) reported as extracellularly and
intracellularly
• Wrights-stained smears - crystals being observed
• MSU crystals: CHEMISTRY TESTS
o Seen as needle shape crystal Glucose
o Extracellularly • Plasma-synovial fluid glucose difference = within
o Stick to cytoplasm of cell 10mg/dL
• CPPD Crystals • Decreased in various joint diseases -- (Inflammatory
o Rhomboid shape or square but may appear (group II) or septic (group III) disorders)
short rods Protein
o Located at vacuoles of neutrophils. • <3g/dL
o Lyse phagosome membrane • Increased in inflammatory (RA, crystal synovitis) &
o Confirmation: RED septic arthritis
Uric Acid
CRYSTAL POLARIZATION • Establishes the presence of gout
First order red-compensated polarized light - positive • Elevated result should correlate with serum uric acid
identification of crystals, Lactate Test
Control slide -Tamethasone acetate corticosteroid • Provides rapid differentiation between inflammatory
MSU Crystals: and septic arthritic
o More birefringent
o Brighter against dark background MICROBIOLOGICAL TESTS
o Parallel to the axis of crystals when aligned with Gram Stain and Cultures
the slow vibration • Important test being performed
o Velocity: Slow • Performed in all specimens
o Not impeded as much as the fast light, runs • Bacterial Infections frequently seen
against the grain produces yellow color Routine Bacterial Cultures
o Negative birefringence (subtraction of velocity • Enrichment Medium (chocolate agar)
from the fast ray) • Common organisms: Fastidious Hemophilus species
and Neisseria gonorrhoeae

SEROLOGICAL TESTS
Confirmatory Method
• Serum and Synovial Fluid
Serum
• Presence of autoantibodies
• Autoimmune diseases, rheumatoid arthritis, and
systemic lupus erythematosus
• Causative agent Borrelia burgdorferi confirm cause of
Arthritis.

TRANSCRIBED BY: JOLAN HERCE BSMT-3B