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ACC MLAB 1311 - Synovial Fluid

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Urinalysis and Body Fluids CRg Unit 4Synovial FluidSynovial Fluid• Composition and formation• Secreted by cells of synovial membrane• Very viscous, clear ultrafiltrate of plasma• Contains• Hyaluronic acid• Mucopolysaccharides• Limited amount of plasma protein• Glucose & uric acid levels equivalent to plasmaSynovial Fluid• Functions• – supplies nutrients• - lubrication of joint• Reasons for analysis• Infection• Hemorrhage• Degenerative disorders (arthritis)• Inflammatory disease (SLE)Synovial Fluid• Collection• ArthrocentesisSynovial Fluid• Collection• Tubes• Heparin – chemistries, immunological tests• Sterile tube – culturing and crystal evaluation• EDTA – hematology Laboratory TestingMacroscopicMicroscopicChemicalOtherVolumeCell countsProteinAerobiccultureColor & ClarityDifferentialGlucoseAnaerobic cultureInclusionsCrystalsUric AcidViscosityCytologyLactic AcidClottingLDHMucin ClotRheumatoid FactorClassification of Synovial Fluid• Normal• Non-Inflammatory• Degenerative joint diseases• Inflammatory• Immunologic disorders ( ie lupus, RA, gout crystals, ETC)• Septic• Microbial infections• Hemorrhagic • Traumatic injury, tumors, hemophilia, anticoagulant overdose, etc.Synovial Fluid - Laboratory procedures• Hematology• Physical properties • Color & clarity = light yellow / straw & clear• Abnormal colors/ clarity as for other fluids *• Bloodyo Hemarthrosiso Traumatic tap• White / opaque with turbidityo Indicate pus cells or debris• Xanthrochromia term not used!• Physical properties • Viscosity • Screening – ‘String Test’ drop from pipette• Evaluates viscosity• Normal = @ 5+ cm long before breaking• Rope’s test for mucin clot• measures degree of hyaluronate polymerization• Good / normal = tight ropey mass• Poor = appears friable or fails to formSynovial Fluid - Laboratory procedures• Hematology• Cell counts• 0 RBCs / uL• <200 WBC / uL• Must let hemacytometer sit longer to allow cells to settle before counting.• If dilution needed must use salineIf you use diluent with an acid, such as Unopettes, the sample will clot.Synovial Fluid - Laboratory procedures• Cell differential - Wright’s stain• Cells of peripheral circulation• neutrophils 7%,• lymphocytes 24%,• Monocytes 48%, macrophages 10%, • and synovial lining cells 4%.Synovial Fluid - Laboratory procedures• Synovial lining cells • (look somewhat similar to mesothelial cells)Synovial Fluid - Laboratory procedures• LE cells• Tart cellsSynovial Fluid - Laboratory procedures• Other cells• Reiter cells•• Malignant cells• OrganismsSynovial Fluid - Laboratory procedures• Microscopic exam for crystals• Use regular and polarized light• Crystals may be intra-cellular or extra-cellular• Monosodium urate – gout artheritis• Calcium pyrophosphate – pseudo gout• Cholesterol – non specific; chronic inflammatory• Apatite – calcific artheritis (mineral change in cartilage)• Corticosteroid – drug injectionsSynovial Fluid - Laboratory procedures• Chemistries • Total protein NV = 1.07 – 2.13 g/dL• Increases seen in inflammatory conditions and following joint hemorrhage .• Glucose - similar to current blood level• Decreased in inflammation or sepsis• Lactate – assist in differentiation of septic and inflammatory arthritis• Uric acid – increased in gouty arthritis.• if gout is suspected, but no crystals, may need uric acid level.Synovial Fluid - Laboratory procedures• Microbiology• Gram stain, acid fast stain & cultures • Certain organisms associated with age groups• Children - H. influenzae• Adults 16-50 – Staph., Strep. Pneumoniae, Strep pyogenes, Neisseria gonorrhea • Adults > 50 – Staph. aureusSynovial Fluid - Laboratory procedures• Serology• Serum results more reliable, so not often done for diagnosis of RA or LE• Autoantibodies• Complement levels• QC – no commercial controls available, use serum controls if appropriateSynovial Fluid - Laboratory proceduresSynovial fluid classification Classification of Synovial Fluid by Test ResultsNormalNon-inflammatoryInflammatorySepticHemorrhagicVolume< 3.5 (mL)> 3.5 (mL)> 3.5 (mL)> 3.5 (mL)> 3.5 (mL)ColorStrawStraw / yellowYellowVariableRedClarityClearClearCloudyCloudyVariable ViscosityHighHighLowVariableLowCell count/uL< 200200-2,0002,000-75,000> 100,000Same as bld. % PMNs< 25 %< 25 %> 50 %> 75%Same as bld.Gram stain / cultureNegativeNegativeNegative> 50% PosNegativeCrystalsNegativeNegativeFrequentlyNegativeNegativeAssociated conditionDegenerativejoint diseaseImmunologic disorders- LE, RA, Gout, pseudo gout Non-gonococcalor gonoccalseptic arthritisTrauma, hemophilia,Anticoagulant overdose, etc.Review of Key Points• Synovial fluid analysis - Plasma ultrafiltrate secreted by synovial membrane- Hyalurinic acid and mucopolysaccharides make it viscous - Lubricates and nourishes joints - Infection, hemorrhage, degenerative & inflammatory diseases are reasons for analysis- Collection is by arthrocentesis- EDTA (hematology), heparinized (chemistries and serology) and sterile (cultures and crystals) are collected - Straw yellow , clear and viscous are normal characteristics- 0 RBC and < 200 WBC/uL are normal- Cell counts requiring dilution must be made with saline.- Any peripheral circulating cell can be seen as well as synovial lining cells in normal patients. - Abnormals are classified as non-inflammatory, inflammatory, septic or hemorrhagic• 1989 CAP CM 23 Synovial fluid, segs, & macrophagesSynovial Fluid - Laboratory procedures• Lupus erythematosus (LE) cells• Just below center of field• Neutrophil has engulfed a homogenous nuclear mass.• ASCP 130 synovial fluid with LE cellSynovial Fluid - Laboratory procedures• Lupus erythematosus cell – far right side @ 3 o’clockSynovial Fluid - Laboratory procedures• 1993 CAP CM 21 synovial fluid. Segs and leukophageSynovial Fluid - Laboratory procedures• 1993 CAP CM 20 synovial fluid. Monosodium urate crystalsSynovial Fluid - Laboratory proceduresMicroscopic Analysis: Crystals-Uric AcidSynovial fluid with acute inflammation and monosodium uratecrystals. (Wright–Giemsa stain and polarized light).Synovial fluid with acute inflammation and monosodium urate crystals. The needle-shaped crystals demonstrate negative birefringence, because they are yellow when aligned with the compensator filter and blue when perpendicular to


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ACC MLAB 1311 - Synovial Fluid

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