Body Fluids

BODY FLUIDS
CEREBROSPINAL FLUID (CSF)

-It is the liquid surround the brain and spinal cord.
It fills the ventricles, cisternae and bathes the spinal cord
-It is reabsorbed into the blood through the arachnoid villi
 Volume: about 150 mL
 Functions of the CSF:
-physical support and protection

-to supply nutrients and removal of wastes
-intra and extracerebral transport
 Source of CSF:
It is formed by secretion and filtration from choroid plexus

 Blood Brain Barrier (BBB):
 Occurs due to tight fitting endothelial cells.
 It controls / restricts entry of large molecules cells / filters blood
components
 Specimens collection:
by lumbar puncture usually at the inter space of lumbar vertebrae 3rd
& 4th, or 4th & 5th
The pressure is measured with a manometer and
3 - 4 ml of fluid allowed to drip in 3 aliquots for:
1.Chemistry & serology 2. Microbiology 3. Hematology
 Cautions:
CSF specimen is of limited volume and

should be handled with care, analyzed immediately, any
remaining sample should be preserved
 Testing is considered STAT
 Indications for laboratory investigation of CSF:

Suspected cases of CNS infection, demyelinating disease,
hemorrhage and malignancy.
 CSF Examinations
I. Physical or visual examination: first and most important
a. Normal CSF is clear, colorless, free of clots and blood.
b. Cloudy fluids require microscopic examination
c. Yellow to brown or red color indicate the presence of blood
 Two most common reasons for blood and hemoglobin pigments in

CSF are:
a. Traumatic tap b. Subarachnoid hemorrhage
 Traumatic tap:
is the artefactual presence of blood or derivatives due to injury of
blood vessels during the lumbar puncture.
 Differentiation between traumatic tap and hemorrhage

- Traumatic tap: later tubes is gradually clearing
-Subarachnoid hemorrhage:
all tubes collected show the same degree of blood
II. Chemical analysis:
CSF and other body fluids chemical analysis values should
compared with serum/plasma sample collected at same time
Before analysis, the CSF should be centrifuged to avoid
contamination by cellular elements.
CSF glucose, total protein, and specific proteins are most reliable
diagnostically.
A. CSF glucose:
Normal CSF glucose is 60% to 70% (two-thirds) that of the blood
glucose.
a plasma sample should obtained 2 to 4 h prior to the tap
 CSF/plasma glucose ratio:
Normal ratio: ≥ 0.6
-Ratio less than 0.6 is considered pathological
 Causes of hypoglycorrhachia (low CSF glucose levels):

a. Disorder in carrier-mediated transport of glucose into
CSF (tuberculous meningitis and sarcoidosis).
b. Active metabolism of glucose by organisms
(acute purulent, amebic, fungal, trichinosis meningitis)
 In aseptic (viral) meningitis:

CSF glucose level is normal (not decreased)
2. LACTATE
 CSF Lactate normally parallels conc. in the blood but not in
children.
 Normal reference range is ˂ 1- 2.9 mmol /L
 Causes of Increased CSF conc.:

bacterial meningitis, stroke with severe hypoxia, intracranial
hemorrhage
CSF lactate discriminate between viral and bacterial meningitis

 In aseptic (viral) meningitis, CSF lactate level is normal (not
increased)
 Inherited metabolic disease in children:

high CSF lactate and normal plasma lactate
3. CSF PROTEINS
 Total protein normal level:
15~45mg/dl, about100-fold lower than plasma
 Source:
>80% from plasma by ultrafiltration, the rest from intrathecal

synthesis
 Electrophoresis of normal CSF show two features:
a prealbumin band and two transferrin bands:

one at β2 ('tau' protein) in addition to the usual β1 position.
 Hyperphosphorylation of tau protein:
is associated with Alzhaymer’s diseases
 Causes of decreased level of CSF total protein:

leakage of CSF from a tear in the dura:
Otorrhea: leakage from the ear
Rhinorrhea: leakage from the nose is most common
 Diagnosis of CSF leakage:
by analysis for β2-transferrin and prostaglandin D
synthase a protein unique to the CSF.
 Causes of increased level of CSF protein:

increased permeability of the blood brain barrier to plasma proteins in:
a.-Inflammation; bacterial or viral meningitis, encephalitis, -brain tumor,
intracerebral hemorrhage or traumatic injury (increase intra cranial pressure).
b-increased production of specific proteins by CNS tissue:
as multiple sclerosis (immunoglobulins)
 Marked elevation (>500 mg/dl):

in complete spinal block by a tumor, bacterial meningitis
CSF/serum albumin index:
an index of BBB integrity
Reference range:
Adult 16-40 year : up to 6.4
Adult 40-65 year: up to 9
Normal CSF/serum albumin index: indicates an intact BBB
Increased CSF/serum albumin index:
means BBB dysfunction.
To identify intrathecal production by:
CSF IgG/albumin ratio:
Normal CSF IgG (mg/dL) / CSF albumin (mg/dL) is ˂ 0.27

A ratio >0.27 : indicate an increased synthesis as
multiple sclerosis (70% of cases) (diagnosis)
 CSF immunoglobulin (IgG) index:
(CSF IgG x serum albumin) / (CSF albumin x serum IgG)
The reference interval is 0.30 to 0.70.
Values >0.70 indicate increased IgG synthesis;
 Diagnosis of Multiple Sclerosis:

A. CSF IgG/ albumin ratio
B. Oligoclonal bands
 by CSF protein electrophoresis
-Two or more discrete IgG bands in the gamma region in CSF only
not in the serum.
-In 90% of patients with multiple sclerosis
C. Myelin basic protein (MBP):
-Abnormal protein indicates demyelination of neuron axons
-It used to monitor course of disease and effectiveness of treatment
Assay of total protein CSF:
Low conc. of protein in CSF limits the methods used
The most commonly:
Turbidimetric and Coomassie brilliant blue (CBB) dye-binding
methods
The most disadvantage of turbidimetric:
it requires 0.2 to 0.5 ml of sample
CBB methods are sensitive enough and use samples as small as 25
l
4. ENZYMES OF DIAGNOSTIC IMPORTANCE
Lactate dehydrogenase (LDH):

-Normal reference range: ≤ 40 units/l for adults
-Elevation of CSF LDH occurs in all pathological lesions of CNS
Creatine kinase (CK-BB):

It is isoenzyme of CK
specific and elevated for nervous system diseases
Adult CK-BB reference range is absent
MICROSCOPIC EXAMINATION OF CSF
 CSF white cell count:
Reference range:
a. Polymorphnuclear (neutrophils) is 0
b. Lymphocytes ≤ 5 106/L
 In meningitis:
Bacterial meningitis:
the neutrophils count 100-10.000 and lymphocytes
count is ˂100
Viral meningitis:
the lymphocytes count 10-1000 and neutrophils count ˂100
 If the infection is suspected, CSF gram stain and culture is

necessary.
SYNOVIAL FLUID
 It is a clear fluid in a joint, tendon sheath or bursa.
 Is formed by ultrafiltration of plasma across the synovial
membrane.
 Specimen: by arthrocentesis under aseptic conditions.
 Normal fluid: clear, colorless to pale yellow, viscous non clotting

and of a very small amount
Changed to viscous (inflammation), cloudy (infection) with reddish
or greenish colour
 Functions:
a lubricant, provide nutrients, remove wastes

 Uses of synovial fluid analysis:
characterization of the type of arthritis

to differentiate non inflammatory effusions from inflammatory
fluids.
 Sample: collected in
-EDTA tube for total leukocyte, differential, RBCs
-Fluoride tube for glucose analysis.
-Plain for culture and protein
 Chemical analysis for:
1-Protein: most commonly, normal range: 1 - 3 g/dL

Increased protein level in :
inflammatory conditions & following joint hemorrhage,
arthropathies (gout, Crohn’s disease and ulcerative colitis).
2- Glucose level:
Normally, synovial fluid glucose level is lower than
serum level by less than 10 mg/dL
In infectious disorders of joint:
it 20 to 100 mg/dL less than serum levels.
 Ratio of synovial fluid to plasma glucose:
it the most useful normally 0.9:1
Decreased in:
inflammatory :gout, rheumatoid arthritis [RA]
septic : bacterial and viral arthritis.
3- uric acid:
Normally 6 - 8 mg/dL , It increased in gouty arthritis
Microscopic: needle shaped monosodium urate crystals
4- Lactate dehydrogenase (LD):

increased in RA, infectious arthritis and gout
5- Rheumatoid factor (RF):

Is an antibody to immunoglobulins
 It is important to diagnose RA cases where RF is only produced
by joint tissue (positive synovial fluid RF, negative serum RF) .
SEROUS FLUIDS
 The small amount of fluid between the membranes that line the
enclosed body parietal cavities (lungs, heart and abdominal
cavities) and those covering the organs within
-It is an ultra filtrate of the plasma
 Functions:
acts as lubricant, provide nutrients, remove wastes
 Specimen collection:
- EDTA tube for cell count & differential
-Heparin tube for chemistry, serology, microbiology and cytology.
 Effusions:
are excessive accumulations of fluids
It occurs in the pericardium, pleural & abdominal cavities
 Transudate:
-It is a result of a systemic disorder
-reflect reduced plasma oncotic pressure or increased plasma
hydrostatic pressure
 Exudates:
due to conditions that directly involve the membranes of the
particular cavity as infections, inflammation and malignancy
 Laboratory testing is required to differentiate exudate from

transudate.
Differentiation Between Transudate and Exudate
EXUDATE TRANSUDATE CHARACTERISTIC / TEST
Any abnormal color Pale yellow Color

Bloody cloudy, purulent, turbid Clear Clarity
>1.015 < 1.015 Specific gravity

Over 30 mg less than serum level Equal to serum Glucose
>3.0 g/dL <3.0 g/dL Protein

>0.5 <0.5 Fluid / serum protein ratio
>2.0 <2.0 Fluid / serum amylase
>0.6 <0.6 Fluid / serum bilirubin ratio
> 60% of serum < 60% of serum Lactate dehydrogenase
>0.6 <0.6 Fluid/ serum LD ratio

>1000/L <300/L Cell counts (total)
PLEURAL FLUID
 It is removed from the pleural space by thoracentesis
 Pleural transudate: in congestive heart failure

 Pleural exudates: infection, pleuritis, pulmonary embolism,
malignancy
 Chemistry results:
-An increased amylase suggests pancreatitis.

-Grossly elevated triglyceride levels (2 to 10 × serum) indicate
thoracic duct leakage or rupture.
-pH less than 7.2 suggests empyema (purulent effusion): infection
pH close to 6.0 indicates esophageal rupture.
PERITONEAL FLUID
The exudative causes of ascites are mainly metastatic cancer
(ovarian, prostate, colon) and infective peritonitis.
Collected by paracentesis
 Serum-ascites albumin gradient (SAAG):
the difference between serum and peritoneal fluid albumin

-Importance: differentiate transudate from exudate
 A gradient of 1.1 g/dL or more indicate transudates,
as in portal hypertension from cirrhosis

 lower than 1.1 g/dL means exudate
 Diagnosis of secondary peritonitis (infection):
-Low glucose
-High lactate & LDH
-Low pH
-High total protein conc.
CASE STUDY:
Laboratory results of a lumbar puncture from 31-year-old man
revealed:
CSF Clear, colorless fluid, apparently free of debris; culture yields
no growth
WBC Normal
Glucose 60 mg/dL (plasma = 80 mg/dL)
Total protein: 59 mg/dL
Albumin index 1.7 IgG index: 0.97
CSF IgG/albumin ratio: 0.8
CSF electrophoresis: Oligoclonal bands present
Questions
1. What is the significance of the albumin index, IgG/albumin ratio,
the IgG index?
2. What pathology is consistent with these results?

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Body Fluids

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BODY FLUIDS

CEREBROSPINAL FLUID (CSF)

 Functions of the CSF:

-physical support and protection

It is formed by secretion and filtration from choroid plexus

CSF specimen is of limited volume and

 Testing is considered STAT

 Indications for laboratory investigation of CSF:

 Two most common reasons for blood and hemoglobin pigments in

 Differentiation between traumatic tap and hemorrhage

 Causes of hypoglycorrhachia (low CSF glucose levels):

 In aseptic (viral) meningitis:

 Causes of Increased CSF conc.:

CSF lactate discriminate between viral and bacterial meningitis

 Inherited metabolic disease in children:

>80% from plasma by ultrafiltration, the rest from intrathecal

a prealbumin band and two transferrin bands:

 Causes of decreased level of CSF total protein:

 Causes of increased level of CSF protein:

 Marked elevation (>500 mg/dl):

Normal CSF IgG (mg/dL) / CSF albumin (mg/dL) is ˂ 0.27

 Diagnosis of Multiple Sclerosis:

Lactate dehydrogenase (LDH):

Creatine kinase (CK-BB):

 If the infection is suspected, CSF gram stain and culture is

 Normal fluid: clear, colorless to pale yellow, viscous non clotting

a lubricant, provide nutrients, remove wastes

characterization of the type of arthritis

1-Protein: most commonly, normal range: 1 - 3 g/dL

4- Lactate dehydrogenase (LD):

5- Rheumatoid factor (RF):

 Laboratory testing is required to differentiate exudate from

Any abnormal color Pale yellow Color

>1.015 < 1.015 Specific gravity

>3.0 g/dL <3.0 g/dL Protein

>2.0 <2.0 Fluid / serum amylase

>0.6 <0.6 Fluid / serum bilirubin ratio

> 60% of serum < 60% of serum Lactate dehydrogenase

>0.6 <0.6 Fluid/ serum LD ratio

 Pleural transudate: in congestive heart failure

-An increased amylase suggests pancreatitis.

the difference between serum and peritoneal fluid albumin

as in portal hypertension from cirrhosis

 Diagnosis of secondary peritonitis (infection):

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