OTHER BODY FLUIDS

1 PART
ST
SPUTUM
Sputum
• it is from the upper and lower respiratory tract
• Tracheobronchial secretions(mixture of plasma, electrolytes,
mucin and water) with cellular exfolations, nasal and salivary
gland secretions & normal oral flora

Sputum collection

First morning Most preferred (routine)

24-hour For volume measurement
Throat swab for pediatric patients
Sputum induction For non-cooperative patients
Trachael aspiration For debilitated patients
 Macrocopic Examination

VOLUME In bronchial asthma, acute bronchitis, early pneumonia, stage of healing

In Bronchiectasis, lung abscess, edema, gangrene, tuberculosis, pulmonary hemorrhage
Odorless normal
Foul or putrid Lung gangrene, advance necrotizing tumors
ODOR
Sweetish Bronchiectasis, tuberculosis
Cheesy Necrosis, tumors, empyema
Fecal Liver abscess, enteric Gram negative bacterial infection
Mucoid Asthma, bronchitis
CONSISTENCY
Serous or Frothy Lung edema
Mucopurulent Bronchiectasis, tuberculosis with cavities
 Macrocopic Examination

Colorless or Made up of mucus only

translucent
White or yellow Pus (TB, chronchitis, jaundice, pneumonia)
gray Pus & epithelial cells
Bright green or Bile, P. aeruginosa infection, Lung abscess
greenish
COLOR
Red or Bright red Fresh blood or hemorrhage, TB, bronchiectasis
Anchovy sauce or Old blood, pneumonia, gangrene
rusty brown
Prune juice Pneumonia, chronic lung cancer
Olive green or grass cancer
green
Black Inhalation of dust or dirt, carbon, charcoal, anthracosis, smoking
Rusty (with pus) Lobar pneumonia (S. pneumoniae)
Rusty (without pus) Congestive heart failure
Currant Jelly -like K. pneumoniae infection
 Macrocopic Examination Clinical significance

Dittrich’s plugs -Yellow or gray amterial size of a pinhead Bronchitis, Bronchiectasis

- Produces foul odor when crushed Bronchial asthma
Lung stones -Hard concretion in a bronchus Histoplasmosis( most common)
Pneumolith’s or -yellow or white calcified TB structures or Chronic tuberculosis
Broncholiths foreign material
Bronchial casts Branching tree-like casts of the bronchi Lobar pneumoniae, bronchitis, diptheria

Foreign bodies Bonchial calculi(calcium carbonate & pnuemoconiosis

phosphate asbestos bodies, silica particles
1st TOP - frothy mucus
Layer formation
(3 layers) 2nd Middle - opaque, water material Bronchietasis, lung abscess, gangrene

3rd Bottom - pus, bacteria, tissues

 Microcopic Examination Clinical significance

Plastic fibers Slender fibrils w/double contour & curled ends Tuberculosis

Charcot-leyden Colorless, hexagonal, double pyramid, often needle- Bronchial asthma

crystals like, arise from disinteg. Of eosinophils
Pigmented cells Heart failure vells; hemosiderin-laden macroph. Congestive heart failure
Carbon-laden cells; angular black granules Heavy smokers
Curschman spirals Coiled mucus strands Bronchial asthma
Can also be observed macroscopicaly
Myelin Globules Colorless globules occurring in a variety of sizes and No significance
bizzare forms Mistaken as Blastomyces
Epithelia cells Clusters of columnar cells Bronchial asthma
Creola bodies
Fungi Candida albicans, crytococcus neoformans, coccidiodes immitis, Histoplasma
capsulatum,
Blastomyces dermatitidis, Aspergillus fumigatus
Parasites Migrating larva “ASH” E. histolitica, T. tenax, T. canis
E. gingivalis, P.westermani(egg) E. granulosus
Others Neoplastic cells, bacteria, leukocytes
BRONCHOALVEOLAR
LAVAGE
 BRONCHOALVEOLAR LAVAGE (BAL)
• A procedure for collecting the cellular milieu of the alveoli by use of a
bronchoscopes through which saline is instilled into distal bronchi and
then withdrawn
• Important diagnostic test for Pneumocystis carinii (jiroveci) in
immunocompromised patients

Cells seen in bronchoalveolar lavage

56-80% Alveolar macrophages Most predominant

1-15% Lymphocytes Interstitial dss, pulmonary lymphoma, non bacterial infections
<3% Neutrophils (primary Cigarette smokers, bronchopneumonia, toxin exposure
granulocyte)
<1 to 2% Eosinophils Hypersensitivity reaction
4-17% Ciliated columnar bronchial epithelia cells
AMNIOTIC FLUID
 Amniotic fluid
Primary functions of amniotic fluid
1) cushion for the fetus 3) Stabilizes temperature
2) Allows fetal movement 4) Proper lung development
Amniotic fluid volume
• From fetal urine and lung fluid
• Normal = 800-1200 ml, (3rd trimester)
• Fetal urine is the major contributor to the AF volume after the 1st Trimester

Polyhydramnios Oligohydramnios

Decreased fetal swallowing of urine Increase fetal swallowing of urine

Neural tube defects Membrane leakage, urinary tract deformities

Specimen collection

Method of Collection Amniocentesis (up to 30 ml collected in sterile syringe)

2nd trimester amniocentesis Assess genetic defects ( Trisomy 21/down syndrome)
3rd trimester amniocentesis Fetal lung maturity (FLM), Fetal hemolytic disease (HDN)
 Specimen Handling

Test for FLM Placed on ice on delivery, Kept refrigerated or frozen

Filtration = prevents loss of phospholipids
Test for Cytogenetic Studies Kept at room temperature or at 37C
Test for HDN Protected by light

Amniotic fluid vs Maternal urine Fern Test

Analyte Amniotic fluid Maternal urine Detects ruptured amniotic membranes
Less Protein + -
reliable Also used to diagnose early pregnancy ( Estrogen)
Glucose + -
Procedure:
Urea <30 >300
More (mg/dl) Specimen(Vaginal fluid)
reliable
Creatinine <3.5 >10 Slide (air dry)
(mg/dl) (+) fern-like crystals – Amniotic fluid
 AMNIOTIC FLUID COLOR
Color Clinical Significance
Colorless Normal
Blood-streaked Traumatic tap, trauma, intra amniotic hemorrhage
Yellow HDN (Bilirubin)
Dark green Meconium – fetal’s first bowel movement
Dark red-brown Fetal death

Test for HDN

• Aka O.D. 450 = optical density 450
• Absorbance of amniotic fluid
• -Normal = at 365nm, at 550nm
• -HDN = at 450nm, (bilirubin)
• Results are plotted on a Liley graph:
• Zone 1 - Nonaffected/mildly affected fetus
• Zone 2 – Moderately affected fetus (requires close monitoring)
• Zone 3 - severly affected fetus (requires intervention)
 Test for Neural tube defects (NTD)
Spina bifida – Split spine is a birth defect where there is a incomplete closing of the backbone &
membranes around the spinal cord
Anencephaly – is the absence of a major protion of the brain, skull, and scalp that occus during the
embryonic development.
Screening test = Alpha-fetoprotein (AFP)
• Increased in neural tube defects
• Decrease in Down syndrome
Confirmatory test = Acetylcholinesterase

Test for Fetal Lung Maturity

Respiratory distress syndrome
• Most frequent complication of early delivery
• 7th most common cause of Morbidity and mortality in the premature infant
• Caused by insufficiency of lung surfactant(phospholipids) production & fetal lung immaturity
 Test Information
Lecithin – for alveolar stability
Spingomyelin – serves as a control( due to constant production)
Lecthin
L/S ratio is measured using thin later chromatography (TLC)
Ration of >2.0 = mature fetal lungs
Cannot be done on a specimen contaminated by blood or meconium
Amniostat-FLM Immunologic test for phosphatidylglycerol (PG)
Note affected by blood or meconium
Production of PG is delayed among diabetic mothers
Foam stabilit(foam/shake test) Amniotic fluid + 95%Ethanol –shake for 15 secs – stand for 15 minutes
(+) Foam/bubbles = Mature Fetal lungs
Human Chorionic Gonadotropin
(HCG)
 HCG
• Produced by the synctiotrophoblast cells of the placenta
• Peaks during 1st trimester of pregency ( increase blood, urine, amniotic fluid)
• Composed of 2 subunits:
- Alpha – hCG, LH, FSH, TSH
- Beta – Confers specify for hCG

Home-Based HCG Pregnancy Test Kit

• Principle = Enzyme immunoassay
• Specimen = 1st morning urine
• Cut-off point = 25ml U/ml
• Anti-hCG source = Rabbit
 HCG Bioassays (biological Pregnancy Test)
Test Animal Used Mode of Injection Positive Result Sentivity
Hogben Female frog Lymph sac urine Oogenesis 75-100 IU/mL
Galli-Manini Male frog Subcutaneous Spermatogenesis Variable
(urine/serum)

Friedman/Hoffman Virgin female rabbit Marginal ear vein Corpora lutea & 10-15 IU/mL
(urine) corpora hemorrhagica

Ascheim-Zondek Immature female rats Subcutaneous (urine) Formation of 1-6 IU/ mL

hemorrhagic follicles
& corpora lutea

Frank-Berman Immature female rats Subcutaneous (urine) Ovarian hyperemia 1 IU/mL

Kupperman Female Virgin rat Intraperitoneal (urine) Ovarian hyperemia 1 IU/mL
Kelso Female virgin rat Subcutaneous (urine) Ovarian hyperemia 1 IU/mL
CEREBROSPINAL FLUID
 Cerebrospinal fluid
• 3rd Major body Fluid
• Functions
- Supply nutrients to the nervous system
- Remove metabolic waste
- Produce a mechanical barrier to cushion the brain and spinal cord against trauma

Meninges
v• Line the brain and spinal cord
• 3 layers
• - Dura mater (Outer layer) = Lines the skull and vertebral canal
• - Arachnoid mater (Spiderweb-like) = Filamentous inner membrane
- subarachnoid space (Below arachnoid) = Portion where CSF flows
• - Pia mater (Innermost layer) = Lines the surface of brain & spinal cord

• Choroid plexus = produce CSF by selective filtration ( at a rate of 20 ml/hour)

• Arachnoid villi/Granulations = reabsorbs CSF
 Blood Brain Barrier
• Protects brain from chemicals & other subs. Circulating in the blood that can harm the brain tissue
• Disrupts of BBB allows WBC’s, proteins & other chemicals to enter the CSF ( ex. Meningitis, M.S.)
• Up to 20 ml of CSF can be collected
• Method of collection = lumbar puncture ( between 3rd , 4th or 5th lumbar vertebrae)
CSF Total Volume
• Adults = 90-150 ml
• Neonates =10-60 ml

3 CSF tubes Test Storage

Tube 1 Chemistry/ Serology Freezing Temp
Tube 2 Microbiology Room Temp
Tube 3 Hematology Refrigeration Temp
Tube 4 Microbiology or Serology
If 1 CSF tube only = Micro – Hema – CC/Sero
 Blood Brain Barrier
• Protects brain from chemicals & other subs. Circulating in the blood that can harm the brain tissue
• Disrupts of BBB allows WBC’s, proteins & other chemicals to enter the CSF ( ex. Meningitis, M.S.)
• Up to 20 ml of CSF can be collected
• Method of collection = lumbar puncture ( between 3rd , 4th or 5th lumbar vertebrae)
CSF Total Volume
• Adults = 90-150 ml
• Neonates =10-60 ml

3 CSF tubes Test Storage

Tube 1 Chemistry/ Serology Freezing Temp
Tube 2 Microbiology Room Temp
Tube 3 Hematology Refrigeration Temp
Tube 4 Microbiology or Serology
If 1 CSF tube only = Micro – Hema – CC/Sero
 CSF apperance

Appearance Clinical significance

Crystal clear Normal
Hazy/Turbid/Milky/Cloudy Increase of WBC (>200/uL), RBC(>400/uL), lipids & protein, microorganisms

Xanthochromic Due to hemoglobin degradation products

(pink/Yellow/Orange) Pink – slight amount of oxyhemoglobin
Yellow – Oxyhemoglobin – Bilirubin
Orange – Heavy Hemolysis
Other causes: Increase in carotene,rifampin,melanin,protein
Bloody Increase in RBC’s (>6000/uL)
Traumatic tap (puncture of blood vessel
Intracranial hemmorrhage
Oily Radiographic contrast media

Clotted Protein & clotting factors; meningitis, blockage of CSF circulation

Pellicle Tubercular mengitis

 CSF dilution
Appearance Dilution
clear undiluted
Slightly hazy 1:10
Hazy 1:20
Slightly cloudy 1:100
Cloudy/Slightly bloody 1:200
Bloody/Turbid 1:10000

Predominant Cells in CSF

Predominant = Lymphocytes and Monocytes
Occasional = Neutrophils
Adults: (70:30 ratio)
-70% = lymphocytes
-30% =Monocytes
Neonates(inversed ratio)
Up to 80% monocytes is considered normal
 CSF protein
Normal values Adult – 15-45mg/dl
Infants – 150 mg/dl
Immature – 500 mg/dl
Increased on Damage to the BBB(most common)
-meningitis
-hemorrhage
Production of immunoglobulins within the CSF
Ex. Multiple sclerosis
Decreased normal protein clearance form the fluid
Neural degeneration
Decreased in CSF leakage, Recent puncture, Rapid CSF production, Water intoxication
Major CSF protein Albumin
2nd Most prevalent Pre albumin
Alpha-globulins Haptoglobulin, cerulosplasmin
Beta globulin Beta2transferrin AKA Tau – bcarbohydrate deficient transferrin, found in the CSF not in Serum
Gamma globulin IgG and some IgA
Not found in normal CSF IgM, Fibrinogen, Lipids
 CSF protein determination
Turbidimetric 1) Trichloroacetic acid (TCA)
-preferred method, precipitates Both Albumin & globulins
2) Sulfosalicylic acid (SSA)
-precipitates albumin only
-precipitate globulins, add some sodium sulfate (Na2SO4)
Dye binding Coomassie Brilliant blue
-Protein binds to dye --------- Dye turns from red to blue
-Increased Protein = Increased in Blue color

CSF Electrophoresis
• For the detection of oligoclonal bands (in the Gamma region)
• Indicates immunoglobulin production
• Done in conjunction w/ serum electrophoresis to ensure that banding is due to neurologic inflamm.
• The presence of 2 or more oligoclonal bands in CSF but NOT in serum is valuable for the
diagnosis of MULTIPLE SCLEROSIS
• Other conditions like multiple sclerosis are Neurosyphilis, encephalitis, neoplastic disorders,
Gullian-Barre syndrome
 CSF Glucose
Determination Done in conjuction with blood glucose. Specimen for blood glucose should be drawn 2 hours
prior to spinal tap
Normal values 60-70% of blood glucose or (50-80 mg/dl)
Increased in Due to increased plasma glucose
Decreased in Bacterial, tubercular
Normal in Viral meningitis

CSF Lactate
Notes Inverly proportional to glucose
Normal value 10-22 mg/dl
Increased in Bacterial meningitis (>35mg/dl). Tubercular and fungal meningitis (>25mg/dl)
Normal in Viral meningitis

CSF Glutamine
Notes Production of ammonia & alpha-ketoglutarate
Indirect test for he presence of excess ammonia in the CSF
Normal value 8-18 mg/dl
Increased in Disturbance of consciousness (coma) Reye’s Syndrome
 Bacterial meningitis Viral meningitis Tubercular meningitis Fungal meningitis

Predominant WBC Increase neutrophils Increase lymphocytes Increase lymphocytes Increase lymphocytes
and monocytes and monocytes

Protein Increase Increase Increase Increase

Glucose Decrease Normal Decrease Decrease

Lactate Increase Normal Increase Increase
Other information (+) gram stain, culture, Agents: Enteroviruses Agent: M. tuberculosis Agent: C. neoformans
And limulus lysate test Poliovirus, echovirus (+) AFB stain (+) Gram stain – classic
Coxsackie virus (+) pellicle/weblike clot starburst appearance
formation after 12-24 (+) India Ink
hrs refrigeration -Capsule (unstained)
-Background (Black)
(+)Immunologic test
for C. neoformals
Semenalysis
 Reasons for Seminal Fluid Analysis Note:
1) Fertility testing Leydig cells secrete testosterone
2) Post vasectomy semenalysis Sertoli cells secrete inhibin which inhibit
FSH synthesis
3) Forensic analysis (alleged rape)

Composition of semen
5% spermatozoa 1) Semineferous tubules (testes)
- Spermatogenesis
- Sertoli cells – serves as nurse cells for developing sperms
2) Epididymis
-Sperm maturation (Sperm becomes motile)
60-70% seminal fluid Seminal vesicles
-Provide nutrients for sperm & fluid
-Rich in Fructose = for sperm motility
20-30% Prostate fluid Acidic fluid that contains ACP, zinc, citric acid & other enzymes
For coagulation and liquefaction
5% bulbourethral gland Secretes thick alkaline mucus that neutralizes acidity from the protatic
secretions & vagina
 Seminalysis Specimen Collection
1) Abstinence of 2-3 days but not >7 days (increase abstinence – decrease volume and motility)
2) Collect the entire ejaculation
-Methods of collection
a) Masturbation
b) Coitus interruptus
c) Condom method – use nonlubricant containing rubber or silastic condom
3) Specimens must be delivered to the lab within 1 hr of collection (room temp)
4) Take note of the time of specimen collection, specimen receipt and liquefaction
5) Analysis should be done after liquefaction(usually 30-60 minutes)
-specimens that do not liquefy must be treated with amylase or bromelune or alpha-chymotrypsin
to break up the mucus in order to obtain accurate sperm counts
6)Specimen awaiting analysis should be kept at 37C
 Sperm concentration 2)
1) Normal value = 20-160 million/ml 1) Makler countaing chamber
2) Methods using Neubauer counting chamber – for undiluted specimens
• Dilution: 1:20 -uses heat to immobilize sperms
• Diluents – formalin sodium bicarbonate (NaHCO3), saline,
distilled water, Tap water (cold)

Shortcut method (sperm concentration computation)

2 WBC squares = # sperms counted x # sperms ctd x 100,000
Sperm Count
5 RBC squares = # sperms counterd x # sperms ctd x 1,000,000
1) Normal value = >40 million
per ejaculate
Long method for sperm concentration computation 2) Formula sperm count =
(standard neubauer formula) sperm conc X specimen
volume
Sperm Concentration = # sperms counter x dilution
(per ml) area X (depth) 0.1
 Sperm motility Sperm Motility Grading
Grade WHO criteria
Read in 20 HPF
4.0 a Rapid, straight-line motility
Normal values 3.0 b Slower speed, some lateral movement
>50% motile 2.0 b Slow forward progression, noticeable lateral movement
(within 1 hour)
1.0 c No forward progression
Quality = > 2.0
0 d No movement

Computer- Assisted Varicocele Sperm viability (vitability)

Semen Analysis (CASA)
- Provides objective
determination of both
sperm Velocity &
Trajectory (direction of
motion)
- Sperm concentration and
morphology are also
included In the Analysis
- Hardening of veins that Modified Blooms test
drains the testes
- Reagent = Eosin & Nigrosin
- Most common cause of
- Living sperms = unstained, bluish white
male infertility
- Dead sperms = RED
- Sperm head- tapered
head - Normal value = 50% living sperms
Acrosomal cap
• ½ head
• 2/3 of the
nucleus
 Medico Legal test
- Test for detection of semen
- 1) Microscopic exam
- 2) Fluorescence under UV light
- 3) Acid phosphatase determination
- 4) Glycoprotein p30 = more specific method to detect semen
- 5) Florence Test (not specific)
- Test for choline
- Reagents :Iodine crystals + Postassium iodide
- (+) Dark brown rhombic crystals
- 7) Barbiero’s Test (very specific)
- Test for Spermine
- Reagents: saturated picric acid + Trichloroacetic acid
- (+) Yellow leaf-like crystals
- 8) ABO blood grouping
- DNA analysis
 Post Vasectomy semen analysis
1) Vasectomy – cutting of vas deferens so that the ejaculate will not contain any sperm cells
2) The only concern is the presence or absence of sperm
3) Done 2 months after vasectomy & continued until 2 consecutive monthly speciemens show no sperm

Terminologies
Aspermia - No ejaculate
Azoospermia - Absence of sperm cells
Necrospermia - Immotile or dead sperm cells8
Oligospermia - Decrease sperm concentration
Sweat
 Sweat Test
1) Used to diagnose Cystic Fibrosis (mucoviscidosis)
- Autosomal recessive metabolic disorder affecting the mucous secreting glands of the body
- Associated with pancreatic insufficiency, respiratory distress & intestinal obstruction
- Increase Na & CL due to inability of the sweat glands to reabsorb them before the sweat is secreted

Gibson and cooke pilocarpine iontophoresis

Pilocarpine + mild current = induce sweat production
Sweat is tested for sodium and chloride
Na = flame photometry, Ion exchange electrode
Cl = Manual or automated titration

Sweat Na and Cl values

>70 mEq/L = Diagnostic for CF
40 mEq/L = Borderline for CF
OTHER BODY FLUIDS
2 PART
ND
Synovial fluid
 Synovial fluid
- Aka joint fluid
- “synovial” = Latin word for egg
- Viscous fluid circulating in diarthroses ( movable joint)
- Viscosity is due to polymerization of hyaluronic acid produces by synoviocytes
Functions:
- Lubricates joints
- Reduces friction between bones
- Provides nutrients to the articular cartilage
- Lessen shock of joint compression occurring during activities such as walking and jogging
 Specimen collection

Arthrocentesis
Method of collection Normal synovial fluid does not clot (diseased joints may clot)

Normal = <3.5 ml
Volume Inflammation = >25 ml

1) Plain red top tube (no anticoagulant) = chemical & immunogoic evaluation
NOTE: Sodium fluoride = glucose analysis
2) Microscopic examinations
Distributed in the - Sodium heparin/ Liquid EDTA for hematology cell count
following tubes (CLSI) - Do Not Use powdered anticoagulants and lithium heparin – they interfere with crystal
identifications
3) Sterile anticoagulant tube = micro biological studies
 Color and Clarity
Appearance Significance
Colorless to pale yellow Normal
Deeper yellow Inflammation
Greenish tinge Bacterial infection
Red Traumatic tap; hemorrhagic arthritis
Turbid WBCs synovial cell debris or fibrin
Milky Presence of crystals

Synovial fluid Viscosity

Normal Able to form a string 4-6 cm long (normal hyaluronic acid level of 0.3-0.4g/dl)
Ropes/Mucin clot test (Hyaluronate Polymerication Test)
Test Reagent: 2-5% acetic acid
As the ability of the hyaluronate to polymerize decreases, the clot becomes less firm
Good Solid clot
Fair Soft clot
Low Friable clot
Poor No clot
 Cell count Note:
- WBC count - Do NOT use acetic acid
Most frequently performed count as WBC diluting fluid for
synovial fluid cell count
Diluting fluids:
- It can cause Clot
- NSS with methylene blue Formation
- Hypotonic saline (0.3%)
- Saline with saponin
- For very viscous fluid:
- Add a pinch of hylaronidase to ).5 ml fluid; or
- Add 1 drop of 0.05% hyaluronidase in phosphate buffer
per mL of fluid
- Incubate at 37C for 5 mins
 Cells and inclusions seen in synovial fluid
Cell/ Inclusion Polymorphonuclear leukocye Bacterial sepsis, crystal induced inflam
Neutrophil Polymorphonuclear leukocye Nonseptic inflammation
Lymphocytes Mononuclear leukocyte nonseptic inflammation
Macophage (monocyte) Large mononuclear leukocyte, may be vacuolated Normal, Viral inflammation
LE cell Neutrophil containing ingested “round body” Lupus erythematosus
Reiter cell Vacuolated macrophage with ingested neutrophils Reiter Syndrome
Nonspecific inflammation
RA cell (ragocyte) Neutrophil with dark cytoplasmic granules containing immune Rheumatoid arthritis
complexes Immunologic Inflammation
Rice bodies Macroscopically resemble polished rice Tuberculosis, Septic and rheumatoid
Microscopically show collagen & fibrin arthritis
Ochronotic shards Debris from metal & plastic joint prosthesis Ochronotic arthropathy, Alkaptonuria,
“Ground pepper” appearance Ochronosis
Cartilage cells Large, multinucleated cells Osteoarthritis
Synovial lining cell Similar to macrophage, but may be multinucleated, Normal
resembling mesothelial cell
Fat droplets Refractile, intra and extracellular globules, stains with sudan Traumatic injury, chronic inflamation
Hemosiderin Inclusions within clusters of synovial cells Pigmented villonodular synovitis
 Characteristics of Synovial Fluid Crystals
Crystal Shape Compensated Polarized Significance
light
Monosodium urate Needles (-) birefringence Gout
Calcium pyrophosphate Rhombic, rods (+) birefringence Pseudogout
Cholesterol Notched, rhombic plates (-) birefringence Extracellular
Corticosteroid Flat, variable-shaped plates (+) and (-) birefringence Injections
Calcium Oxalate Envelopes (-) birefringence Renal dialysis
Apatite (Ca phosphate) Small particles; req. electron microscopy no birefringence Osteoarthritis

Polarizing microscope – detects for the presence or absence of birefringence

Compensated Microscope – confirms the type of birefringence (positive or negative BR)
- Red compensator is placed between crystals & analyzer
- -Owing to differences in the linear structure of the molecules in MSU & CPPD crystals, the color produces by
each crystal when it is aligned w/ the slow vibration can be used for identification.
- MSU – (runs parallel) and produces yellow color & is a negative birefringence
- - CPPD (runs perpendicular) and produces blue color & positive birefringence
 Chemistry Tests
Glucose Most frequently tested chemistry test
Done in conjunction w/ blood glucose (8 hrs fasting)
Blood glucose –SF glucose = <10 mg/dl (normal)
Example:
99mg/dL – 90mg/dL = 9 mg/dL (normal)
99mg/dl – 40 mg/dL = 59 mgdL (infection)
Lactate Normal value = <250 mg/dL (increased in infection)
Protein Normal value = <3 g/dL
Increased in inflammation
Uric acid Normal value = same as blood (increased in gout)

Microbiology Test
Commo organisms that infect the synovial fluid Serologic Test
S. aureus predominant Autoantibody detection (SLE, RA)
Detection of auntoantibodies to
Streptococcus Borrelia burgdorferi (Lyme disease)
Haemophilus
N. gonorrheae Gonococcal arthritis
 laboratory Finding in Joint Disorders

Group I IIa IIb

Non-inflammatory Inflammatory (immunologic) Inflammatory

(crystal – induced)
Significance Degenerative joint disorders Immunologic disorders Gout
(osteoarthritis) (RA, SLE, etc) Pseudogout
Color & Clarity Clear, yellow fluid Cloudy, yellow fluid Cloudy or milky fluid

Viscosity Good Poor Low

WBC count < 1,000/ul 2000-75,000/uL Up to 100,000/uL

Neutrophils < 30% >50% <70%

Glucose Similar to blood glucose Decreased Decreased

Others (+) Autoantibodies (+) Crystals

 laboratory Finding in Joint Disorders

Group III IV

Septic Hemorrhagic
Significance Microbial infection Traumatic injury, Coagulation deficiencies

Color & clarity Cloudy, Yellow – green fluid Cloudy, red Fluid

Viscosity Good Low

WBC Count 50,000 – 100,000/uL Equal to blood

Neutrophils >75 % Equal to blood

Glucose Decreased Normal

Others (+) Culture and Gram stain (+) RBC’s

Serous Fluid
Serous Fluid
- Fluid between parietal & visceral membranes
- Function: to provide Lubrication between the 2 membranes as te surfaces move against each other

Effusion
-Accumulation of fluid between the membranes
Classified as exudate or transudate

Transudate(pressure)
Disruption of fluid production & regulation between membranes
Changes In hydrostatic and oncotic pressure (HP, OP)
Examples: Hypoproteinemia, Congestive Heart Failure, Nephrotic Syndrome

Exudate
Direct damage to the membrane of a particular cavity
Examples: Infection, Inflammation, Malignancy
 Transudate vs. Exudate
Transudate Exudate
Appearance Clear Cloudy
Fluid: serum protein ratio (most reliable) <0.5 > 0.5
Fluid: serum LD (most reliable) <0.6 > 0.6
WBC count < 1000/uL > 1000/uL
Spontaneous clotting No Possible
Pleural fluid cholesterol (mg/dL) < 45-60 > 45-60
Pleural fluid: serum cholesterol ratio < 0.3 > 0.3
Pleural fluid: bilirubin ratio < 0.6 > 0.6
Serum-ascites albumin gradient (SAAG) > 1.1 < 1.1
Glucose Equal to serum Possible low
Protein (g/dL) < 3.0 >3.0
Rivalta’s Test (-) (+)
 Rivalta’s Test
(Serosamucin clot test)
- Differentiates exudates from transudates
- Acetic acid + Water + Unknown fluid
(+)Heavy precipitation
Exudate
Serum-Ascites Albumin Gradient
(SAAG)
- Recommened to detect transudates of hepatic origin
- SAAG= Serum Albumin – Peritoneal Fluid Albumin
- > 1.1 = Transudate
- < 1.1 = Exudate
 Method of Collection
3 P’s (Pleural, Pericardial, Peritoneal fluid)
Normal appearance = clear, pale yellow
Pleural fluid = thoracentesis
Pericardial fluid = Pericardiocentesis
Peritoneal (ascitic) fluid = Paracentesis
Normal Volume (Graff’s Textbook)
- Pleural fluid = cell counts and differential
- Sterile heparin tubes = Microbiology and cytology
- Plain/heparin tubes = Chemistry ( spx for pH must be maintained anaerobically in ice
 Pleural Fluid
Appearance Significance
Clear, pale yellow Normal
Turbid, white Microbial Infection (TB)
Brown Rupture of amoebic liver abscess
Black Aspergillosis
Viscous Malignant mesothelioma (increased hyaluronic acid)
Milky Chylous material, pseudochylous material
Bloody Hemothorax hemorrhagic effussion

Milky pleural fluid

Chylous effusion Pseudochylous effusion
cause Thoracic duct leakage Chronic inflammation
Appearance Milky/white Milky/green tinge/ ‘gold paint’
Leukocytes Increase in lymphocytes Mixed cells
Cholesterol crystals Absend Present
Triglycerides > 110 mg/dl <50 mg/dl
Sudan III staining (+++) (-)/ weakly (+)
 Bloody pleural fluid
Hemothorax Hemorrhagic effusion
Distribution of blood uneven even

Pleural fluid Hct is >1/2 of whole blood Hct Pleural fluid Hct <1/2 of whole blood Hct

Hematocrit A chronic

Whole Blood
Pleural fluid
Whole Blood
In hemothorax,

Pleural fluid
membrane
the effusion is disease effusion
actually ouring contains both
from the blood and
impouring of increased
blood form the pleural fluid
injury

35% 50% 15% 50%

 Significance of cells seen in pleural fluid
Cell Significance
Neutrophil Pneumonia, pancreatitis, pulmonary infarction
lymphocyte TB, viral infection, autoimmune disorders, malignancy
Mesothelial cell Normal and reactive forms have no significance
(lines the serous membranes) Decreased in TB
Plasma cells TB
Malignant cells Primary adenocarcinoma, small cell carcinoma

Tumor markers for effusion of malignant origin

Tumor marker significance
CEA(carcinoembryonic antigen) Colon cancer
CA 125 Ovarian/metastatic uterine cancer
CA15-3, CA 549 Breast cancer
CYFRA 21-1 Lung cancer, breast cancer
(CYtokeratin FRAgment Urinary bladder cancer
 Significance of Testing of pleural fluid
Test Significance
Glucose Rheumatoid inflammation, purulent infection
Lactate Bacterial infection
Triglyceride Chylous effusions
pH Pneumonia not responding to antibiotics
Esophageal rupture
Complicated parapneumonic effusion( loculated or associated with empyema)
Adenosine deaminase (ADA) Tuberculosis, malignancy
Amylase Pancreatitis, esophageal rupture, malignancy
 Significance of Testing of pericardial fluid testing
Appearance Significance
Clear,pale yellow Normal, transudate
Blood-streaked Infection, malignancy
Grossly Bloody Cardiac puncture, Anticoagulant medications
Differential significance
Neutrophils Bacterial endocarditis
Malignant cells Metastatic carcinoma
Test significance
Gram stain & Culture Bacterial endocarditis
Acid-fast stain Tubercular effusion
Adenosin deaminase (ADA) Tubercular effusion
 Significance of Testing of pericardial fluid testing
Appearance Significance
Clear, pale yellow Normal, transudate
Turbid Microbial infection
Green Gall Bladder/ Pancreatic disorders
Blood-streaked Trauma. Infection, malignancy
Milky Lymphatic trauma & blockage
WBC count significance
< 500 cells/uL Normal
> 500 cells/ uL Bacterial peritonitis, cirrhosis
Differential significance
Neutrophils Bacterial peritonitis
Malignant cells Malignancy
Peritoneal lavage >100,000 RBC’s/ uL indicates blunt trauma injury (intra-abdominal bleeding)
 Psammoma bodies
- contain coencentric striation of collagen-like material
- Seen in benign conditions and associated with ovarian & thyroid carcinomas
Gastric Fluid
 Gastric Fluid
Zollinger-Ellision Syndrome
Non-beta islet cell
G CELLS GASTRIN
Adenoma of the pancreas
Gastrin
HCL
PARIETAL CELLS HCL
-Hyperchlorhydria
Hyperacidity
Pernicious Anemia
PEPSINOGEN PEPSIN
-anti parietal cell Ab
-Anti-Intrinsic factor Ab
(-)HCL
DIGEST PROTEINS
-Achlorhydria
-Anacidity
 Cells in the stomach Specimen collection
PARIETAL CELLS Method of collection = Gastric aspiration
- Produces HCL and intrinsic factor - Gastric tubes
- Instrinsic factor = needed for Vitamin B12 1) Leving tube – passed through the nose
absorbtion
2) Rehfuss tube – passed through the mouth
CHIEF CELLS
3) Lavacuator tube – for evacuating gastric
- Produces pepsinogen contents & stilling an irrigant (mouth)
SPECIALIZED G CELLS 4) Ewald’s tube – for aspirating large amounts of
- Produces gastrin gastric contents quickly(mouth)
5) Erlich tube – For aspirating large amounts of
Foveolar Cells
gastric contents quickly (mouth)
- Mucus- producing cells that cover the inside of
the stomach
Basal Acid Output (BAO)
- total gastric secretion during unstimulated fasting state
Duration of collection
- 1 hour collection (consists of four 15 minutes specimens, but a single 1-hour can be used)
- 2 hours collection – for insulin hypoglycemia test
Maximum Acid Output (MAO)
- Total gastric secretion after gastric stimulation
Duration of collection
- 1 hour collection 9 at 15 minute intervals) – when Pentagastrin and Histamine are used
- 2 hour collection – for insulin hypoglycemia test and when Histalog is used
GASTRIC STIMULANTS Chemical stimulants
1) Ewald’s - bread, weak tea, or water a)Pentagastrin(most preferred)
2) Boa’s - oatmeal b) Insulin – assess vagotomy procedure
3) Riegel’s – Beef steak, mashed potato
c) Histalog (Betazole)
d) Histamine
 Represntative normal, and abnormal gastric analysis results
Basal Acid Output Maximum Acid Output BAO/MAO ratio
(BAO) (mEq/hr) (MAO) (mEq/hr) (BAO+MAO)x100
Normal 2.5 25.0 10%
Pernicious anemia 0 0 0
Duodenal ulcer 5.0 30.0 17%
Zollinger - Ellison syndrome 18.0 25.0 72%

Macroscopic Examination
Color Significance
pale gray w/mucus Normal
Yellow-green Large amounts of bile
red Small amount of fresh blood
Coffee ground Large amount of blood
Volume Significance
Fasting state 20 – 50 ml Normal (fasting specimen)
>50 ml Abnormal (fasting specimen)
20-60 ml – 120 ml After Ewald’s test meal
45-150 ml After alcohol test meal or histamine stimulation
 Terminologies
Term Definition Significance
Euchlorhydria Normal free HCL ..
Hyperchlorhydria Increased Free HCL Zollinger-Ellison dss, peptic ulcer
Hypochlorhydria Gastric fluid >3.5 but falls after gastric Carcinoma of the stomach
stimulation (decreased free HCL)
Achlorhydria Gastric fluid . 3.5 and does not fall even after Pernicious anemia
gastric stimulation (Absence of free HCL)
Anacidity Failure to produce a pH <6.0 following gastric Pernicious anema
stimulation

Diagnex Tubeless Test (Diagnex Blue test)

- Uses Urine as specimen. Its Principle, Uses Azure blue or Azure A
- Blue colored dye azure-A is complexed with an ion exchange resin
- The granules are ingested by the patient in the morning
- The granules exchange the dye for H+ ions of the free HCL in the stomach
- Azure-A is released in proportion to free HCL, w/ is absorbed in the blood & excreted in urine
- The amount of dye excreted in urine is an indicator of gastric HCL secretory activity
Fecalysis
 FECES
Contains bacteria, cellulose & other undigested foodstuffs, GI secretions, Bile pigments, cells, electrolytes and H2O
Around 100-200g of stool is passed per day
Human feces contains around 75% water & 25% solids

FECES
Type1 – separate, hard lumps like nuts
(hard to pass)
Type 2 – Sausage-shaped but lumpy
Type 3 – Like a sausage but with cracks
Type 4 – Like a sausage or snake,
smooth & soft
Type 5 – Soft blobs with clear – cut
edges (passed easily)
Type 6 – fluffy pieces with ragged
edges, a mushy stool
Type 7 – Watery, no solid pieces
 Macroscopic Stool Characteristics
Color / Appearance Clinical Significance
Brown Normal (urobilin/stercobilin)
Black Upper GI bleeding, iron, charcoal, bismuth(melena)
Red Lower GI bleeding, beets, food coloring, rifampin, (Hematochezia)
Pale Yellow, white, gray Bile duct obstruction, barium sulfate
Green Biliverdin, oral antibiotics, green vegetables
Blue Prussian blue , grape soda
Violet/purple Prophyria
Bulky/frothy Bile duct obstruction, Pancreatic disorders, steatorrhea
Butter-like Cystic fibrosis (increase in mucus)
Mucus, blood- streaked mucus Colitis, dysentery, malignancy, constipation
Ribbon-like Intestinal constriction
Rice watery Cholera
Pea-soup Typhoid
Scybalous (“goat droppings) Constipation
 Microscopic examination
FATS
- Steatorrhea – increased fats in stool (>6g/day)
Test:
- Screening test = microscopic examination of feces for fat globules
- Definitive test = fecal fat determination
Fecal Fat determination
Qualitative Test
1) Neutral fat stain (Triglycerides) 2) Split fat stain (Fatty acid)
- Stool suspension + 95% Ethanol + Sudan III - Emulsified stool + 36% Acetic acid + Sudan III
- Orange droplets (Neutral fats/Triglycerides) - Orange droplets (Fatty acids)
- > 60 droplets/hpf = steatorrhea - normal = 100 droplets (<4um)
- Slightly increased = 100 droplets (1-8um)
- Increased = 100 droplets (6-75 um)
Qualitative Test
Van de Kamer titration
- Gold standard for fecal determination Sample = 3 day stool (72 hrs)
- For definitive diagnosis of steatorrhea Normal value = 1-6g fats/day
- Titration with NaOH Steatorrhea = >6 fats/day
 Muscle fibers
Abnormal:
Creatorrhea = abnormal excretion of muscle fibers in feces
>10 undigested muscle fibers
Determination:
- Biliary obstruction
- the patient should include meat in the diet
- Cystic fibrosis
- Emulsified stool + 10% Eosin – Coverslip & stand for 3 minutes
- Count the number of undigested fibers (HPF)

Completely digested Partially digested Undigested

No striations Striation in one direction Striation in Both direction

 Fecal Leukocytes
>3 neutrophils/hpf = invasive condition
Determination: Diarrhea with WBC
Salmonella, Shigella, Yersinia, Enteroinvasive E.coli, Campylobacter
- Wet preparation = stool + loeffler’s methylene blue
Diarrhea without WBC
• Dried preparation = stool + Wright’s/Gram stain
Toxin producing (S. aureus, V. cholera, virus, parasites)
• Qualitative Test
• Neutral fat stain (Triglycerides)

Fecal Carbohydrates
Most valuable in assessing cases of infant diarrhea (ex. Lactose Intolerance)
determination
Clinitest Fecal pH
- Test for reducing sugars - Normal stool pH = 7.0 – 8.0
> 0.5g/dL = carbohydrate intolerance - Carbohydrate disorders
 Fecal Occult Blood Test
Notes Occult = hidden
Screening test for colorectal cancer
Significant = > 2.5mL blood/150 g stool
Sample = center portion of the stool
Principle Hemoglobin
H2O2 + Guaiac Oxidised Guaiac (blue) + H2O
Pseudoperoxidase
Chromogens Considering that a normal stool can contain up to 2.5 mL of blood, a less sensitive chemical reactant is
understandably more desirable (to avoid false positive rxns)
- Benzidine (most sensistive)
- Guaiac – (preferred)
- O-toluidine
False (+) FOBT Avoid for 3 days: Red meat, Melon, Broccoli, Cauliflower, Horseradish, Turnip
Avoid for 7 days: Aspirin, NSAIDs other than paracetamol
False (-) FOBT Avoid for 3 days: Vitamin C, Iron supplements containing Vitamin C
Failure to wait specified time after sameple is applied to add the developer reagent
 APT TEST( Apt – Downey Test) APT TEST ( Apt – Downey Test)

- Bloody stools & vomitus are sometimes seen in Emulsified stool

neonates as a result of swalling maternal blood Centrifuge
during delivery
Add 1% NaOH to supernatant
- Differentiates fetal blood & maternal blood
Pink solution = (+) Fetal Blood (HbF)
- Specimen = Infant stool/vomitus Yellow-brown supernatant = (+) Maternal Blood (HbA)

- Note:
Hemoglobin F is Alkali – Resistant
Hemoglobin A is denatured bu NaOH
X-ray Film Test Procedure

X-Ray Film Test (Gelatin Test) Emulsified stool + X-ray film

Detects trypsin enzyme (proteolytic enzyme secreted Clearing of film = (+) Trypsin
by the pancreas) No clearing of film = (-) Trypsin

(-) Trypsin = seen in Cystic Fibrosis

X-ray Film has gelatin
 Diarrhea
- Stool weight of > 200 g/day with increased liquidity and frequency of more than 3x day
- Acute diarrhea = < 4 weeks
- Chronic diarrhea = > 4 weeks
- Major mechanisms are Secretory, Osmotic & Altered Motility
- Laboratory test used to differentiate these mechanisms are fecal electroly (fecal sodium and potassium), fecal osmolarity
and stool pH
Secretory Diarrhea
- Increased secretion of water and electrolytes, which override the reabsorptive ability of the large Intestine
- Causes: Bacterial, Viral and protozoan Infections, drugs, laxatives, hormones, Inflammatory Bowel disease, endocrine
disorder, neoplasms, collagen vascular dss.
Osmotic Diarrhea
- Retention of water and electrolytes in the large intestine due to incomplete breakdown or reabsorption of food
- Causes: Maldigestion, malabsorption, dissaccharidase defieciency (lactose intolerance) laxatives, antacids, amoebiasis,
Altered Motility
- Enhanced (hypermotility) or slow (Constipation) motility
- Causes: Irritable bowel syndrome (IBS), Rapid (accelerated) gastric empyting (RGE), dumping syndrome