SYNOVIAL FLUID

INTRODUCTION
 Often referred to as the “ Joint Fluid”  BEST ANTICOAGULANT TO USE: Sodium Heparin and Liquid EDTA
 Formed as an ultrafiltrate of the across synovial membrane, into which hyaluronic  Anticoagulants to be avoided: Oxalate, Powdered EDTA, Lithium Heparin because they
acid produced by synovial cells is secreted may produce artifacts that interfere with crystal analysis
 Viscous fluid acting as lubricant and adhesive, and provides nutrients for the  Synovial fluid specimens should be handle like STAT specimens and delivered
avascular articular cartilage immediately to the laboratory for testing to avoid alteration of chemical constituents, cell
 ULTRAFILTRATE OF PLASMA with a very mucoidal substance - HYALURONIC lysis, and problems in microorganisms detection and identification
ACID  If a glucose test is to be performed, the patient should be fasting for at least 6 hours prior
 Largest amount in the knee cavity to collection of joint fluid. A 6 - hour fast is necessary to establish an equilibrium
between plasma and joint glucose levels
REASONS FOR ANALYSIS:
1. Diagnosis of infectious arthritis and other joint disease
2. Diagnosis and identification of SF crystals MACROSCOPIC EXAMINATION

SPECIMEN COLLECTION & HANDLING Normal Synovial Fluid Values

COLLECTION Volume <3.5 mL
1. By Arthrocentesis Color Colorless to pale yellow
2. Routinely collected in three (3) tubes per CLSI recommendation Clarity Clear
- 1st tube: No anticoagulant; For chemical and immunologic evaluation Viscosity High; Able to form a string 4
- 2nd tube: Anticoagulated; For microscopic analysis —6 cm long
- 3rd tube: Sterile anticoagulant; For microbiologic studies Leukocyte count <200 cells/µL
Neutrophils <25% of the differential
SYNOVIAL FLUID ANALYSIS AND SPECIMEN REQUIREMENTS Monocyte 60 -70 %
Collection Tube Test Volume Tube Type Lymphocyte 20 - 30 %
Order Crystals None present
All tubes Physical examination: 1 ml Glucose: plasma difference <10 mg/dL lower than the
Color, Clarity, Viscosity blood glucose level
Tube # 1 Chemical examination: 1 to 3 ml No anticoagulant Total protein <3 g/dL
Lactate, Lipids (red top) or Sodium Lactate <25.0 mg/dL
Protein, Uric Acid fluoride (gray top) Synovial cells 4%
Glucose
Tube # 2 Microscopic examination: 2 to 5 ml Sodium heparin or
Total cell count liquid EDTA Variations in Color and their Clinical Significance
Differential Cell count Color/Appearance Clinical Significance
Crystal Identification 1. Turbid Presence of many cells
2. Milky/Cloudy Many crystals
Cytologic Studies 5 to 50 ml Sodium Heparin 3. Deep Inflammation
Tube # 3 Microbiologic Examination 3 to 10 ml Sterile tube; No Yellow/Cloudy
anticoagulant (red 4. Greenish tinge Due to Pseudomonas aeruginosa
top), sodium 5. Viscous Due to hyaluronic acid
heparin, or sodium 6. Red, brown or Hemorrhage into the joint
polyanethole xanthochromic
sulfonate (yellow)
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 SYNOVIAL FLUID

o Presence of tissue cells can falsely elevate counts

TEST FOR VISCOSITY
- Synovial fluids with poor viscosity will form shorter strings (< 3 cm) or run out of the DIFFERENTIALCOUNT
syringe and down the side of the test of the test tube like water - Performed on thinly smeared Wright stained slides or cytocentrifuged specimens that
- Low viscosity of synovial indicates the presence of an inflammatory process have been incubated with hyaluronidase
1. STRING TEST
- Ability of the fluid to form a string from the tip of a syringe Cells and Inclusions Seen in Synovial Fluid
- Normal: 4 - 6 cm string-like substance Cell/Inclusion Description Significance
Neutrophil Polymorphonuclear leukocyte Bacterial sepsis
2. ROPE OR MUCIN CLOT TEST Crystal-induced
- Estimation of the integrity of the hyaluronic acid-protein complex inflammation
(mucin) Lymphocyte Mononuclear leukocyte Nonseptic inflammation
- Normal synovial fluid forms a tight ropy clot upon the addition of acetic Macrophage Large mononuclear leukocyte, may be Normal
acid (monocyte) vacuolated Viral infections
- Add a solution of 2 to 5 % acetic acid to synovial fluid Synovial Similar to macrophage, but may be Normal
lining cell multinucleated, resembling a mesothelial Disruption from
APPERANCE INTERPRETA CONDITIONS cell arthrocentesis
TION LE cell Neutrophil containing characteristic Lupus erythematosus
Solid Clot Good/Normal Osteoarthritis, Trauma, and ingested “round body”
surrounded by clear hemophilic arthritis Reiter cell Vacuolated macrophage with ingested Reactive arthritis
fluid neutrophils (infection in another part
Soft clot Fair Subacute and chronic of the body)
inflammatory diseases such as RA cell Neutrophil with dark cytoplasmic granules Rheumatoid arthritis
lupus or rheumatoid arthritis (ragocyte) containing immune complexes Immunologic
Friable clot Poor Septic and acute crystalline inflammation
No clot Very Poor arthritis Cartilage cells Large, multinucleated cells Osteoarthritis
Rice bodies Macroscopically resemble polished rice Tuberculosis
Microscopically show collagen and fibrin Septic and rheumatoid
MICROSCOPIC EXAMINATION arthritis
Fat droplets Refractile intracellular and extracellular Traumatic injury
TOTAL CELL COUNT globules
- Total leukocyte count - Most frequently performed cell count on synovial fluid
Stain with Sudan dyes Chronic inflammation
- Manual using the Neubauer counting chamber (same as CSF) Hemosiderin Inclusions within clusters of synovial cells Pigmented villonodular
- For very viscous specimen: synovitis
o Add pinch of hyaluronidase to 0.5 mL of fluid,or Tart cell Monocyte that have engulfed nuclear material
o One drop of 0.05% hyaluronidase in phosphate buffer per mL of fluid Ochronotic Debris from metal and plastic joint prosthesis
o Incubate at 370C for 5 minutes shards LOOK LIKE GROUD PEPPER
- Diluent:
o Normal Saline
o If necessary to lyze RBCs, hypotonic saline (0.3%) or saline with saponin Characteristics of Synovial Fluid Crystals
o 0.1 N HCl Crystal Shape Compensated Significance
- Methylene Blue - will stain WBCs Polarized Light
- Automated counters should not be used, because the viscous fluid will be the tubing. Monosodium urate Needles Negative Gout

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 SYNOVIAL FLUID

10 crystal birefringence
(YELLOW) LACTATE
Calcium pyrophosphate Rhomboid Positive Pseudogout - Levels > 250 mg/dL typically associated with septic arthritis
10 crystal square, rods birefringence
(BLUE) PROTEIN
Cholesterol Notched, Negative Extracellular - Synovial fluid contains all proteins found in plasma except fibrinogen, beta 2
rhomboid plates birefringence macroglobulin and alpha 2 macroglobulin
Corticosteroid Flat, variable- Positive and Injections - Normal: 1-3 g/dL (approxiamately 1/3 of the serum value)
shaped plates negative - Increased synovial fluid protein levels:
birefringence o Ankylosing spondylitis
Calcium oxalate Envelopes Negative Renal dialysis o Arthritis
birefringence o Arthropaties that accompany Chrohn disease
Apatite (basic calcium Small particles No birefringence Osteoarthritis o Gout
phosphate) Require electron o Psoriasis
microscopy o Reiter syndrome
o Ulcerative colitis
POSITIVE AND NEGATIVE BIREFRINGENCE
 Compensated polarizing microscopy uses a red compensator or full-wave plate and is URC ACID
placed between the crystal and the analyzer.The compensator separates the light ray - Parallels serum level in gout
into slow-moving and fast-moving vibrations and produces a red background
- Normal: 6 to 8 mg/dL
o NEGATIVELY BIREFRINGENT CRYSTALS
 Appear YELLOW
ENZYMES
 Longitudinal axes are parallel to the axis of the red-compensator
- Lactate dehydrogenase - Increased in RA, Gout, Failed arthroplasties, and infectious
plate (slow vibration)
arthritis
- Lactic acid:
o POSITIVELY BIREFRINGENT CRYSTALS
o Helpful in diagnosing septic arthritis
 Longitudinal axes are perpendicular to the axis of the red-
compensator plate (slow vibration) o Normal: < 25 mg/dL
o In septic arthritis, it can be s high as 1000 mg/dL
 Crystals in synovial fluid
o Normally no crystals found in the synovial fluid MICROBIOLOGIC EXAMINATION
o Causes of formation: STAINING
 Decreased renal excretion that produce elevated blood levels of - Gram stain
crystallizing chemicals - Acid Fast Stain
 Degeneration of cartilage and bone
 Injection of medication (corticosteroid) CULTURE AND SENSITIVITY
- Routine - use to enrichment medium (Chocolate agar)
CHEMICAL EXAMINATION - Special media/culture procedure - Fungal or tubercular
GLUCOSE
- Normal: 10 mg/dL lower than blood value JOINT DISORDER
- 20 - 60 mg/dL in septic arthritis and inflammatory
- 20 - 100 mg/dL less thhan serum levels - seen in joint disorders that are classified as Classification and Pathological Significance of Joint Disorder
infectious Group Classification Pathological Significance
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 SYNOVIAL FLUID

I. Noninflammatory Degenerative joint disorders, osteoarthritis

II. Inflammatory Immunologic disorders, rheuma- toid arthritis, systemic lupus
erythematosus, scleroderma, polymyositis, ankylosing
spondylitis, rheumatic fever, Lyme arthritis
Crystal-induced gout,
pseudogout
III. Septic Microbial infection
IV. Hemorrhagic raumatic injury, tumors, hemophilia, other coagulation
disorders
Anticoagulant overdose

Laboratory Findings in Joint Disorders

Group Classification
I. Noninflammatory
Laboratory Findings
Clear, yellow fluid
Good viscosity
WBCs <1000 µL
Neutrophils <30% Similar to blood glucose

II. Inflammatory
Immunologic origin
Cloudy, yellow fluid
Poor viscosity
WBCs 2,000—75,000 µL Neutrophils >50%
Decreased glucose level
Possible autoantibodies present

Crystal-induced origin Cloudy or milky fluid

Low viscosity
WBCs up to 100,000 µL Neutrophils <70%
Decreased glucose level Crystals present
III. Septic Cloudy, yellow-green fluid
Variable viscosity
WBCs 50,000 to 100,000 µL
Neutrophils >75%
Decreased glucose level
Positive culture and Gram stain
IV. Hemorrhagic Cloudy, red fluid
Low viscosity
WBCs equal to blood
Neutrophils equal to blood Normal glucose level

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