1. CYTOLOGY OF
BODY FLUID
DR SHABNEEZ HUSSAIN
HAEMATOLOGY RESIDENT

3. CAVITY FLUIDS
 Abdominal 􀂄 Pleural 􀂄 Pericardial 􀂄
Synovial 􀂄 CSF

4. Schematic representation of the three body cavities

5. CAVITY FLUIDS
 Sampling techiques
 appearance during collection EDTA to
prevent clotting
 direct smear -
 delayed processing
 Cell concentration
 Protein concentration

6.  TRANSUDATE
 EXUDATE
 MODIFIED TRANSUDATE

7. Accumulation of fluids in body cavities
Transudates
• Increased hydrostatic pressure: Congestive heart
failure
• Decreased oncotic pressure (decreased albumin) :
liver cirrhosis, nephrosis, and malnutrition
Exudate
• Inflammation: Infection, infarction, hemorrhage
• Tumor

8. DIFFERENCES BETWEEN TRANSUDATE AND
EXUDATE
Feature Transudate Exudate
Gross appearance Watery, clear Turbid or cloudy
Specific gravity Less than 1015 More than 1015
Protein Less than 3mg/dl More than 3mg/dl
Clots No Yes
cells Usually benign:
Few mesothelial
cells, few histocytes
and lymphocytes
More mesothelial cells,
acute or chronic
inflammatory cells,
RBCs, malignant cells

9. MODIFIED TRANSUDATE
 Moderate protein concentration: 2,52,5-
7,5g/dl
 Moderate cellularity 1000-7000 cells/ μg
 Cardiovascular disease
 Neoplastic disease
 Rupture of urinary bladder
 Hepatic disease

10. DIAGNOSTIC ROLE OF EFFUSION
CYTOLOGY
 It is very useful for diagnosis of premalignant and
malignant tumors, especially metastatic tumors.
 It is very useful for diagnosis of inflammatory
conditions (septic effusion, or chronic specific
inflammation e.g. TB

11.  Respiratory Tract
 Urinary Tract
 Oral Cavity
 Gastrointestinal Tract
 Effusions (pleural, pericardial, joint)
 Cerebral Spinal Fluid
 Amniotic fluid
 Many other body sites
Non-Gynecological Specimen Collection

12. EXAMINATION OF BODY FLUID
 Gross exam
 Total cell count
 Microscopic exam
 Any other special test (Chemistry, Microbiology,
cytology (
 Test are performed in various areas of lab based on what
the physician orders.
 Body fluids sterile vs. non-sterile

13. SAMPLE COLLECTION
 FNA of effusion fluids
 Tapping

14. Collection and preparation of specimen

15. FIXATION
 1ml of heparin + 100ml of effusion fluid to prevent
clotting
 N.B.: do not use alcohol in fixation of fluid before
spread cytological smear on glass slides

16. TYPES OF STAINING SMEARS
 PAP
 Gram Stain
 Hx & E
 Cell block for remnant sediment and histopathological
examination.
 Other special stains for the most suspected diseases, to
confirm diagnosis.

17. Heparinized
bottles (3 units
heparin/ml)
Unfixed
Alcohol-fixed
Papanicolaou-stained
Cytocentrifuge preparationCell block
Adding plasma and thrombin
solution
Wrapped in filter paper
Placed in a cassette
Embedded in paraffin
Cut and H&E stain
Air-dried cytocentrifuge preparation
(Hematologic malignancy is
suspected)

18.  Adequacy: on site
 Background: necrotic, mucinous
 Cell concentration: high, low
 Cell preservation: lysis
 Inflammatory cells: which? dominant?
 Lining cells: mesothelial, epithelial
 Cells of interest: tumor cells

33. 1- CEREBROSPINAL FLUID
 Fluid surrounding brain and spinal cord
 Sterile
 Specimen collection: by Lumbar puncture
 Collect 3-5 vials, each tube has a designated department.
 Gross exam: Turbidity, Color, microscopic exam, cell
count

34. CSF CELL DIFFERENTIAL
 Numerate and differentiate cells seen
 Lymphocytes: usually are few; increased with viral,
fungal, bacterial meningitis, or nervous system disease
 Monocytes: Less than 2% of normal CSF, increased
with TB meningitis, viral encephalitis, subarachnoid
hemorrhage.

35.  PMN: are few, associated with Viral and acute bacterial
inflammation.
 Macrophages: are few in number associated with malignancy,
hemorrhage, inflammation
 Eosinophils/Basophils: not normally seen in CSF

36.  Plasma cells: not normally present; associated with viral disorders,
and Hodgkin's diseases.
 Red Blood Cells: Few to none present
 Mesothelial cells: not present
 Malignant cells: will see with malignant disease and infiltrate.

37. CSF EVALUATION
 Tube 1-cell count and differential
 Tube 2-glucose, protein
 Tube 3-cultures, gram stain, cytology, (HSV PCR,
West Nile, India ink, Crypto Antigen, VDRL,
Lyme Ab, AFB...)
 Tube 4-cell count and differential

38. NORMAL CSF COMPOSITION
 Clear color
 <5 RBC’s
 <5 WBC’s
 Protein 23-38mg/dl (can use 14-45)
 Glucose—60% of serum level (75-100)

39. OPENING PRESSURE
 Normal = 80-180 mmHg
 Obese pts: up to 250mmHg can be normal
 Pathologically elevated: >250mmHg
 If elevated, likely due to cerebral edema from
intracranial pathology
 Infection (cryptococcal meningitis), tumor, benign
ICH (pseudotumor)

40. RBCS
Always send tube #1 and #4 for cell count
and compare RBCs
Traumatic tap: Elev RBC in tube 1, nl in
tube 4
1000 RBC : 1 WBC to adjust WBC count in
bloody tap
SAH or HSV: Elev RBC in tube 1 AND
tube 4
 “Crenated RBCs” and xanthochromia
(yellow supernatant after centrifuge)
Seen in hyperbilirubinemia (ESLD), old SAH,
old blood from prior traumatic LP or bleed

41. WBC’S
 Infection!
 PMN predominance: likely bacterial meningitis
 Lymphocytic predominance: viral vs. fungal vs.
TB vs. malignancy

42. PROTEIN
 Normal: protein is excluded from CSF by blood-
CSF barrier
 Increased: nonspecific
 Elevated in all infectious meningitis
 May remain elevated for months post-meningitis
(viral or bacterial)
 Increased in malignancy and inflammatory
conditions (ie Guillain-Barre)

43. GLUCOSE
Normal
 Viral infection
Low glucose
 Bacterial meningitis, TB, fungal
Really low
 <18 is strongly suggestive of bacterial meningitis

44. TYPICAL VIRAL MENINGITIS
 CSF WBC elevated, but <250 (first PMNs, then
lymphocytes)
 CSF protein elevated, but <150
 Glucose > 50% of serum concentration

45. TYPICAL BACTERIAL MENINGITIS
 CSF WBC >1000, PMN predominance
 CSF protein >500mg/dl
 CSF glucose <45 mg/dl

46. • Effusion:
• Transudate
• Exudates
• Lab analysis: Gross exam, cell count, etc.
• Differential: PMN, Lymph, Mono, etc.
2- Pleural Fluid: Lung fluid

47. • Cells unique to the lungs: Mesothelial cells
• RBCs and WBCs: are limited, if increased without
traumatic tap ----- indicates infarction
• Cytology exam: useful in identifying malignancy or
abnormal morphological cells.

48. WHAT TO ORDER?
Serum LDH, total protein (Add on to am
labs)
Pleural fluid:
 Total Protein, LDH
 Glucose, cell count and diff, pH (on ice)
 Gram stain, culture, fungal stain and
culture, AFB
 Cytology
 Other: triglyceride level to r/o
chylothorax; amylase to r/o pancreatitis,
esoph perf; Adenosine deaminase to eval
TB

49. LIGHT’S CRITERIA FOR EXUDATES
Fluid is exudate if it meets 1 of 3 criteria:
1. Pleural fluid LDH/serum LDH > 0.6
2. Pleural fluid protein/serum protein > 0.5
3. Pleural fluid LDH > upper limit of normal
serum LDH
 If all 3 negative, fluid is Transudate

50. TRANSUDATE
 Result from imbalances in oncotic and
hydrostatic pressure
 Usually low oncotic +/- high hydrostatic
pressure
 Pulm Edema/CHF
 Cirrhosis with ascites
 Hypoalbuminemia/Nephrotic syndrome,
ESLD
 Fluid overload s/p aggressive IVF
 Peritoneal dialysis

51. EXUDATE
Caused by local, not systemic, factors
 Infection
 Neoplasm
 Pancreatitis
 Esoph perf
 RA
 SLE
 Sarcoid, Wegeners, PE, Meig’s,
Chylothorax

52. LYMPHOCYTOSIS
 Malignancy (50-70% lymphs)
 Also TB, sarcoid, RA, chylothorax (>90% lymphs)

53. PLEURAL EOSINOPHILIA
 Pneumothorax
 Hemothorax
 Pulm infarct
 Parasitic disease
 Fungal infection
 Drugs
 Malignancy
 Asbestos

54. WHY IS GLUCOSE LOW?
(<60)
 RA
 TB
 Empyema
 SLE
 Malignancy
 Esophageal rupture

55. 3- PERITONEAL FLUID
 Abnormal accumulation of fluid (effusion) in peritoneal
cavity: Ascites
 Ascites: a condition in which fluid accumulates within
the peritoneal space.
 Must have an accumulation of > 100ml (several 100) before effusion
can be detected on physical exam.

56. 
Removal procedure- paracentesis
 Lab analysis: distinguish between transudate and exudates,
gross exam, cell count, sedimentation, chemical analysis

57. PHYSICAL CHARACTERISTICS
 Peritoneal Fluid Appearance: Color and clarity.
 Color and clarity can indicate certain infections and diseases.
 Total Cell Count: Assist in diagnosis of certain
diseases by determining total RBC and WBC number.

58.  Lymphocytes: CHF, liver cirrhosis, nephrotic syndrome
 Mesothelial Cells: Associated with TB effusions
 Malignant cells: seen with malignancy

59. WHAT TO SEND FLUID FOR
 Cell count with diff
 Albumin
 LDH
 Total protein
 glucose
 Gram stain/cx
 cytology

60. APPEARANCE OF FLUID
 Clear—usually indicates uncomplicated ascites,
ie liver failure/cirrhosis
 Turbid/cloudy—infected
 Pink/bloody—traumatic, punctured collateral
vessel, malignancy
 Correct for bloody tap: 1 WBC: 750 RBC
1 PMN: 250 RBC

61. SERUM-TO-ASCITES ALBUMIN
GRADIENT (SAAG)
=Serum albumin – ascitic fluid albumin
If the gradient is >1.1:
 Portal HTN (drives fluids into
peritoneum)
 SBP, cirrhosis, Alcoholic hepatitis, CHF
If the gradient is < 1.1:
(protein leaks into peritoneum and fluid
follows)
 Peritoneal carcinomatosis, peritoneal TB,
pancreatitis, nephrotic syndrome

62. SBP
 SAAG > 1.1
 Suspect if >250 PMNs (>100 PMNs in pt on
peritoneal dialysis)
 70% GNR (E.coli, Klebsiella)
30% GPC (S. pneumo, Enterococcus)
 Treat with ceftriaxone, cefotaxime
 “Culture negative SBP” if >250 PMNs but cx neg;
treat the same

63.  Pericardial Fluid: accumulation of fluid of the lining of
the heart (effusion)
 Cause: neoplasm, infections, collagen disease, renal
disease, Cardiovascular disease.
 Gross Exam: Report appearance (bloody, clear, cloudy)
4- Pericardial Fluid

64.  Measure pH: pH less than 7.0 associated with infection or
rheumatoid disorder.
 Cell count: see limited RBCs and WBCs
Evaluate sedimentation

65. • Examine physical, chemical and microscopic detail
• Count number of sperm, report morphology and
motility
• Specimen must be a fresh collection-clean, sterile
container.
• Gross Exam: Color, pH, Volume, and viscosity.
• Agglutination study
5- Seminal Fluid

66. • Joint Fluid: normally clear, viscous
• Functions as a lubricate and transports nutrient
• Arthrocentesis: aspirate of the joint fluid, aseptic
technique
• Lab Assay: Gross exam, microscopic exam, Gram
stain, cultures,...
6- Synovial Fluid:

67. • Appearance: clear, transparent, viscous
• Viscosity test
• Mucin Clot test
• Note crystals (intracellular vs. extra cellular)
• Slide exam: usually performed on concentration of the fluid
using Giemsa or Papnicolaou

68. THANK YOU