CHAPTER 14

Cell counts on CSF and other

body fluids
 Objectives
At the end of this chapter, students will
be able to:
 Define terms related to body fluids.
 Identify different types of body fluids.
 Define CSF.
 Define Serous fluids: pleural, pericardial,
peritoneal (Ascetics), and Synovial fluid.
 Explain the analysis of CSF.
 Perform cell counts on different body fluids.
 Undertake QC measures in body fluid
examination.
 Outline
 Introduction
 CSF
 Other body fluids
 Analysis of CSF and other body
fluids
 QC in body fluid analysis
 14.1. Introduction to Body Fluids
 Are ultra filtrates of plasma.
 Fluids serve as lubricants as membranes move
against each other.
 Body fluids commonly analyzed in hematology
lab include: -
CSF
Serous fluid
Synovial fluid (fluid from the joints)
 Introduction Cont’d
Serous fluids: -
 Arefluids from closed body cavities such as
pleural, pericardial, peritoneal/ascetic
cavities:
Pleural fluid are from the pleural cavity
of lungs.
Pericardial fluid fare rom around the
heart.
Peritoneal fluid are from around the
abdominal and pelvic organs.
 Definition of terms
 Effusion: - an increase in volume of any
serous fluid.
 Transudates: - effusion as a result of a
mechanical disorder affecting movement
of fluid across a membrane.
 Exudates: - are effusions resulting from
inflammatory responses that directly affect
the serous cavity (includes infections and
malignancies).
 Characteristics of Serous Effusions:
Transudates versus Exudates
Observation/Test Transudates
Appearance Watery, clear, pale
yellow, does not clot
Exudates
Cloudy, turbid, purulent, or bloody;
may clot (fibrinogen present)

WBC count Low, < 1,000/µL with 500-1,000 cells/µL or more, with
> 50% mononuclear increased PMNs, increased
cells lymphocytes with TB or rheumatoid
arthritis
Red cell count Low, unless from a > 100,000/µL, especially with a
traumatic tap malignancy
Total protein Low >3g/dl (or > than half the serum
level)
Lactate Varies with serum Increased (>60% of serum level
dehydrogenase level because of cellular debris)
Glucose Not applicable Lower than serum level with some
infections and high cell counts
14.2. Cerebrospinal fluid (CSF) Analysis
I. CSF
 Fluid in the space called sub-arachnoids
space between the arachnoids mater and pia
mater.
 Protects the underlying tissues of the central
nervous system (CNS).
 Serve as mechanical interface to: -
Prevent trauma.
 CSF cont’d..
Regulate the volume of intracranial pressure.
Circulate nutrients.
Remove metabolic waste products from the
CNS.
Act as lubricant.
 Has composition similar to plasma except

that it has less protein, less glucose and

more chloride ion.
 Maximum volume of CSF: -
Adults 150 mL
 Neonates 60 mL
 CSF cont’d..
 Rate of formation in adult is 450-750 mL per day
or 20 ml per hour.
 Reabsorbed at the same rate to maintain
constant volume.
 Collection by lumbar puncture/tap done by
experienced medical personnel.
 About 1-2ml of CSF is collected for examination.
Lumbar puncture is made from the space
between the 4th and 5th lumbar vertebrae under
sterile conditions.
 Fig. Collecting a CSF specimen
 Collected in three
sequentially labeled tubes: -
 Tube 1-for Microbiology.
 Tube 2- for chemical and
immunologic tests.
 Tube 3- for Hematology.
(gross examination, total Location
of CSF
WBC & Diff).
 This is the list likely to
contain cells introduced by
the puncture procedure.
 CSF Cont’d…
II. Clinical Significance
 Diagnosis of meningitis of bacterial, fungal,
mycobacterium and amoebic origin or
differential diagnosis of other infectious diseases.
 Subarachnoid hemorrhage or intracerebral
hemorrhage.
III. Principle of CSF analysis
 CSF specimen examined visually and
microscopically and total number of cells can be
counted and identified.
 CSF cont’d..
IV. Specimen: -
 The three sequentially collected tubes.*
 Must be counted within 1 hour of collection
(cells disintegrate rapidly).
If delay is unavoidable not store at 2-8oC.
 All specimens should be handled as biologically
hazardous.
V. Equipment and Reagents:
 Same as for WBC counting on whole blood.
 CSF Cont’d…
VI. Method
Gross appearance: -
 Is visual assessment of CSF for turbidity, color
and viscosity.
Normal CSF is crystal clear in appearance
with viscosity comparable to water.
Abnormal CSF may appear.
 Cloudy, smoky, hazy, opalescent, turbid

or grossly bloody.
 CSF Cont’d…
 Turbidity may be graded from 0 to 4+ as
follows: -
• 0 = Crystal clear fluid.
• 1+ = Faintly cloudy, smoky or hazy with slight
(barely visible) turbidity.
• 2+ = Turbidity clearly present but news print easily
read through tube.
• 3+ = News print not easily read through tube.
• 4+ = Grossly turbid, news print cannot be seen
through tube.
 CSF Cont’d…
 Note:- Slight haziness indicates WBC count of
200-500/μL.
 Turbidity indicates WBC count of > 500/μL.
 Turbidity in general could result from large
number of leukocytes or bacteria, or increase in
proteins or lipids.
 Bloody specimens: -
 Can result from a traumatic a spinal tap (often
occur in children).
16
 CSF Cont’d…
 Grossly blood specimen: may indicate
subarachnoid hemorrhage or intracerebral
hemorrhage.
 Note: -
 There is a need to differentiate between a
traumatic tap and a patient’s clinical condition.
 If the specimen in the 1 st tube is bloody and is
clear in the last tube, it indicates traumatic tap.
 If the specimen has the same bloody color in all
the three tubes, it indicates clinical condition.
 Gross appearance cont’d…
2. Color: - Any color should be reported,
(N.B. normal CSF is crystal clear).
 Xanthochromia: -is yellow coloration of
CSF.
 Yellow color could be due to: -
 Result of release of hemoglobin from lyzed red
blood cells increase in bile pigments.
 Specimen collected 2 hours post arachnoids
hemorrhage.
 Gross appearance cont’d…
3. Viscosity: - Normal CSF has viscosity
comparable to that of water.
 Clotting may occur: - From increased
fibrinogen.
Resulting from a traumatic tap.
Or rarely may be associated with meningitis or
subarachnoid block.
Microscopic cellular enumeration
 Cellcount is performed by manual method.
 Electronic methods should be used with
 Microscopic cont`d…
 RBC counts are of limited value.
 WBC counts are useful in developing
differential diagnosis.
NR: - 0-5 WBC/µL or 0-5 x 106/L
 Neonates have higher value of 0-30 cells/µL
 Low WBC with turbidity could indicate
high concentration of bacteria.
 WBC between 100-10,000 x 106/L could
indicate acute untreated bacterial
meningitis.
 Microscopic Cont’d..
 WBC >50,000 x 106/L are unusual and suggest
intraventricular rupture of a brain abscess.
 Differential count is performed when WBC >30
cells/ µL.
 Smear is prepared from centrifuged CSF sediment.

Total Leukocyte Count on CSF: -

 If CSF is clear
 Mix well the undiluted CSF and properly charge
the improved Neubauer counting chamber.
 Count the cells in 9mm2 area.
 Microscopic Cont’d…
 Multiply the number by 10/9 to get the number of
WBC/mm3
 If CSF is slightly turbid: -
 Prepare a 1:10 dilution with 10% acetic acid (1
drop CSF and 9 drops 10% acetic acid).
 Count the cells in 9mm2 area in the improved
Neubauer counting chamber.
 Multiply counted cells by 100/9.
 If CSF is purulent, proceed with the dilution and
counting as for a blood sample.
Technique for Counting Mixture of WBC and RBC
 This is done to find the true WBC count when the
CSF is bloody due to traumatic tap.
 Perform the WBC and RBC counts on the
patient’s blood and CSF.
 Multiply the ratio of RBC count on CSF to RBC
count on blood by the WBC in blood count and
subtract this product from the WBC count of CSF.
RBCCSF x WBCblood= WBCADDED
RBCBLOOD
Corrected WBCCSF = WBCCSF – WBCADDED
 Exercise
 Example:
RBCBLOOD = 5 x 106/mm3
RBCCSF = 2,500/mm3
WBCBLOOD = 12 x 103/mm3
WBCCSF = 70/mm3
WBCADDED = 2,500 x 12,000
5 x 106
= 6/mm3
Corrected WBCCSF = 70 – 6 = 64/mm3
 Differential Leukocyte Count on CSF
1. Centrifuge the CSF at 2500 rpm for 10 min.
2. Remove supernatant (can be saved for other
analysis).
3. Re-suspend the sediment.
4. Prepare a smear from the re-suspended
sediment.
5. Stain using Wright stain.
6. Wash off stain with water and air-dry.
7. Identify the types of leucocytes (PMNs or
mononuclear cells) and their number may be
expressed as percentage of the total count.
 Differential cont`d..
8. Count at least 100 cells using the oil immersion
objective.
 Artifacts due to distortion of cells can lead to
misidentification.
VII. Quality control
 Count both sides of counting chamber (18 mm 2
area) for the total WBC.
 Increasing the number of cells to be counted for
differential count (instead of 100 cells count 200 cells).
 Check staining quality (e.g. staining time, pH, filtering).
 Proper centrifugation (Speed and time ).
 Differential cont`d..
 Properly follow SOP.
VIII. Sources of error
 General sources of error in dilution, charging,
counting , calculating etc that were discussed for
WBC count also apply here.
 Delay in analysis.
 Centrifugation time and speed during sediment
preparation for Diff count
 Staining time.
 Improper handling of sample.
 Differential Leukocyte Cont`d..
Cells in the spinal fluid may include:
 Granulocytes.
 Mature or reactive lymphocytes, mononuclear
phagocytes.
 Plasma cells, blast cells and malignant cells
(indicating primary tumors of brain and spinal
cord).
 Others like nucleated red cells, and intracellular bacteria.
 Lupus erythematosus (LE) cells are rarely found.
 Other rare cells unique to spinal fluid (ependymal cells,
choroidal cells) may be found.
 IX. Interpretation of CSF diff count
 Normal range <5 cells/mm3
 Increased PMN indicate bacterial infection.
 Increased lymphocytes indicate:
 Viral infections.
 Viral meningeal encephalitis.
 Aseptic meningitis syndrome (majority of the cases).
 Fungal meningitis.
 Partially treated bacterial meningitis.
 Syphilitic meningeal encephalitis.
 Non-infectious cases of increased lymphocytes may
indicate multiple sclerosis.
 Interpretation Cont`d..
 Increased  Increased basophiles
Eosinophils indicate:
indicate:-  Chronic basophilic

 Systemic parasitic leukemia.

and fungal infection.  Chronic granulocytic
 Systemic drug leukemia.
reaction.  Purulent meningitis.
 Idiopathic  Inflammatory processes.
eosinophilic  Parasitic infections
meningitis.
 Interpretation Cont`d..
 Increased Monocytes
(>2%) indicate: -
 Tuberculosis meningitis.
 Syphilis and viral
encephalitis.
 Meningeal irritation.
 Subarachnoid hemorrhage.
 Leukemic infiltration of
the meanings and
infectious state.
 Increased
macrophages: -
 Infectious diseases.
 CNS leukemia.
 Lymphoma.
 Malignant myeloma,
and other metastatic
tumors spreading to
the brain.
 Interpretation Cont`d..
 Plasma cells  Erythrocytes

increased in:- increased in:-

 Viral disorders such as
herpes simplex
infection.
 Meningeal encephalitis.
 Syphilitic involvement
of the CNS.
 Hodgkin's disease.
 Post subarachnoid
hemorrhage.
 Traumatic tap specimens.
 Patients with a bleeding
subarachnoid hemorrhage
or intracerebral
hemorrhage.
 Chronic myelogenous
leukemia or
erythroleukoblastic
conditions.
 Associated findings
 Glucose and protein values should be correlated
with macro and microscopic hematological
findings.
Generally decreased glucose in CSF with
normal blood glucose indicates bacterial
utilization correlates with increased PMNs in
the Diff.
Elevated protein suggestive of inflammatory
reaction or bacterial infection.
Viral infections will not have dramatic effect
on either CSF glucose or protein levels.
 14.3. Other body fluids
 Pleural fluid, pericardial fluid, peritoneal/
ascetic fluid, synovial fluid, semen.
Same protocol followed as with CSF.
 Macroscopic examination for:
Turbidity, Color, Viscosity.
 Microscopic
Total white cell count.
Differential.
 Gram stain and culture is done in bacteriology
laboratory.
 Review Questions
1. What is the function of body fluids in general?
2. What is the role of CSF in our body?
3. Mention at least three different types of body fluids
4. What is the difference between Transudates and exudates?
5. Define serous fluids?
6. Define CSF?
7. How do you perform the total leukocyte count on a:
a) clear CSF b) slightly turbid CSF c) purulent CSF.
8) How do you correct the total leukocyte count to a true value when
the count is performed on a sample of CSF that is slightly turbid
due to traumatic tap?
9) How is the differential leukocyte count performed on a sample of
CSF?
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