Cerebrospinal fluid

CSF
 Cerebrospinal fluid (CSF) is a clear colourless
body fluid found in the brain and spinal cord.
 It nourishes the tissue of CNS and helps to protect
the brain and spinal cord from injury.

 Entry of many substances into CSF is controlled by

blood brain barrier which allows free entry of
glucose, some protein, fat soluble lipid in CSF . and
inhibits entry of bacteria etc. This barrier is deranged
in inflammation.
BLOOD BRAIN BARRIER
CSF is responsible for:
- Protection of the brain
- Removal of waste products from the brain
- Transport of hormones to specific endocrine
gland receptors in the brain
 The brain produces roughly 500 mL of cerebrospinal
fluid per day.

 The volume of CSF 100-150 mL is present at any

one time .
LUMBAR
PUNCTURE
 * A 16 guage LP needle introduced in intervertebral
disc space between L3 and L4 and about 6-8 ml of CSF
is aspirated.

 CSF should be taken in four tubes ( Do not refrigerates)

 Discard Ist tube because of the presence of blood
which may be traumatic and do not give accurate
results.
 Perform DR from 2nd tube
 Perform C/S from 3rd tube.
 If TB meningitis is suspected refrigerates it and check
coagulum formation
 Appearance:

 If blood seen in Ist tube indicates trauma, and it will not

give true results.
 If blood seen in all tubes shows brain hemorrhage and test
results are not true
 XANTHOCHROMIA (YELLOW COLOUR)
 It is due to
 - subarachnoid hemorrhage
 - in neonatal jaundice
 - brain tissue destruction
 - long standing jaundice.
 Turbidity indicates high WBC count.
 NORMAL VALUES OF CSF

CSF opening pressure: 50–180 mmH2O

Glucose: 40–85 mg/dL.

Protein (total): 15–45 mg/dL.

Leukocytes (WBC): 0–5/µL (adults / children); up to 30/µL (newborns).

Gram stain: negative.

Gross appearance: Normal CSF is clear and colorless.

Differential: 60–70% lymphocytes; up to 30% monocytes 

    and macrophages; other cells 2% or less.
 Bacterial Meningitis

 Glucose (mg/dL): Normal to marked decrease.  <40

mg/dL.
 Protein (mg/dL) (Marked increase)  > 250 mg/dL.
 WBCs (cells/µL) >500 (usually > 1000).  Early: May be <
100.
 Cell differential: Predominance of Neutrophils

 Culture: Positive
 Opening Pressure Elevated
 Tubercular Meningitis

 Glucose (mg/dL): <40 mg/dL (Low)

 Protein (mg/dL) (moderate to marked increase) 50 -500

mg/dL
 WBCs (cells/µL) Variable (10 -1000 cells/µL)
<500cells/µL.
 Cell differential: Predominance of Lymphocytes
 Culture: Positive for AFB
 Opening Pressure Variable
 Viral Meningitis

 Glucose (mg/dL): Normal   (> 40 mg/dL.)

 Protein (mg/dL) <100 mg/dL (moderate increase)

 WBCs (cells/µL) < 100 cells/µL.

 Cell differential: Early: neutrophils. Late: lymphocytes.

 Culture: Negative

 Opening Pressure Usually normal

 Fungal Meningitis

 Glucose (mg/dL): <40 mg/dL (Low)

 Protein (mg/dL) (moderate to marked increase) 25 -500 mg/dL

 WBCs (cells/µL) Variable (10 -1000 cells/µL) <500cells/µL.

 Cell differential: Predominance of Lymphocytes

 Culture: Positive (fungal)

 Opening Pressure Variable

DISEASES GLUCOSE PROTEIN WBC DIFFERENTIA CULTURE OPENING
L CELLS PRESSURE

Bacterial Decrease Increase >500 Neutrophils Positive increase

Viral Normal Increase < 100 Early – Negative Normal

Neutrophils

Late-
Lymphocytes

Fungal Decrease Increase 10-1000 Lymphocytes Positive Variable

Variable

Tuberculo Decrease Increase 10-1000 Lymphocytes AFB Normal

us Variable Positive
FLUIDS
 Fluids in Body

Bile
Blood serum

Breast milk

Cerebrospinal fluid

Cerumen (earwax)

Feces
Gastric acid

Gastric juice

Mucus (including nasal drainage and phlegm)
 Saliva
Sebum (skin oil)

Semen

Sputum Tears

Sweat

Vaginal secretion

Vomit

Urine

 DEFINATION
Transudate is produced through pressure filtration
without capillary injury

 Exudate is "inflammatory fluid" leaking between

cells.
Transudates are formed during the early phase of
inflammation and it consists of fluid with very little
protein.
The pressure toward the outside increases and the
pressure toward the inside of the vessels decrease,
thereby forcing (clear) fluid out and leading to
oedema (swelling).
Exudates are formed during inflammation because
of the increased pore sizes within the vessels.

 exudates are rich in proteins and can appear yellow

when extracted.
the hydrostatic pressure (the pressure from within
the vessels to the outside) .

the colloid osmotic pressure (the pressure from

outside the vessels pressing inside) is always
equalised. are formed.
 TRANSUDATIVE VS EXUDATIVE

 Appearance Clear Cloudy

 Specific gravity < 1.012 > 1.020
 Protein < 25 g/L > 29 g/L
serum protein < 0.5 > 0.5
 Difference of
albumin content
with blood albumin > 1.2 g/dL < 1.2 g/dL
 fluid LDH
upper limit for serum < 0.6 or < 2⁄3 > 0.6 or > 2⁄3
PLEURAL FLUID
 Pleural effusion is excess fluid that accumulates
between the two pleural layers, the fluid-filled space
that surrounds the lungs

 Pleural fluid is secreted by the parietal layer of the

pleura
 Transudative Pleural Effusions:

 Conditions associated with transudative pleural

effusions:
 Congestive Heart Failure (CHF)
 Hepatic cirrhosis
 Nephrotic syndrome
 Myxedema
 Peritoneal dialysis
 Obstructive uropathy
 Exudative Pleural Effusions

 Conditions associated with exudative pleural effusions:

 Malignancy
 Infection
 Trauma
 Pulmonary infarction
 Pulmonary embolism
 Autoimmune disorders
 Pancreatitis
 Ruptured esophagus
 Tuberculosis
Pleural effusion is likely Exudative if at
least one of the following exists:
 The ratio of pleural fluid protein to serum protein is
greater than 0.5

 The ratio of pleural fluid LDH and serum LDH is

greater than 0.6

 Pleural fluid LDH is greater than 0.6 or 2⁄3 times the

normal upper limit for serum( 200and 300IU/l.)
ASCITIC FLUID
 Greek askites, "baglike"

 accumulation of fluid in the peritoneal cavity

 Exudative Asitic Fluid

 exudates are high in protein,

 have a low pH (<7.30),
 a low glucose level,
 more white blood cells.
 Trasudative Ascitic Fluid

 . Transudates have low protein

 low LDH,
 high pH,
 normal glucose,
 low white cell

 Clinically, the most useful measure is the difference

between ascitic and serum albumin concentrations. A
difference of less than 1 g/dl (10 g/L) implies an
exudate.
 Causes of Exudative Ascitic Fluid

 Cancer (primary peritoneal carcinomatosis and metastasis)

 Infection: Tuberculosis -or
Spontaneous bacterial peritonitis
 Pancreatitis

 Other Rare causes:

 Meigs syndrome
 Vasculitis
 Hypothyroidism
 Renal dialysis
 Causes of Trasudative Ascitic Fluid

 Cirrhosis - (alcoholic ,viral )

 Heart failure
 Constrictive pericarditis
 Kwashiorkor (childhood protein-energy
malnutrition)
 Nephrotic syndrome
 Spontaneous bacterial peritonitis (SBP)

 Spontaneous bacterial peritonitis (SBP) is the

development of peritonitis (infection in the
abdominal cavity) despite the absence of an obvious
source for the infection
 The fluid contains bacteria or large numbers of
neutrophil granulocytes .

 bacteremia secondary to compromised host

defences, intrahepatic shunting of colonized blood