Effusions

Question 1

Effusion

Answer 1

Accumulation of fluid within anatomic space
* pleural: thorax
* peritoneal/ascites: abdomen
* pericardial: heart

Question 2

Pleural Effusion Removal

Answer 2

Thoracocentesis
* removal of fluid from chest
* go between 7-8th intercostal space (avoids intercostal vessel)
* do prior to taking rads - gives better vision, helps patient feel better, starts diagnostics

Question 3

Abdominal Effusion Removal

Answer 3

Abdominocentesis
* removal of fluid from abdomen
* go right of and cranial to umbilicus (best if ultrasound guided)
* perform rads or ultrasound first - ensures fluid is there and something else is not being poked

Question 4

Effusion Sample Collection

Answer 4

• IV catheter placed in site (decreases trauma)
• Use of 3-way stop-cock beneficial
• Sedation normally not required (may be contraindicated due to being compromised)

Question 5

Effusion Sample Testing

Answer 5

• Place some sample into EDTA tube - prevents clotting and allows for further testing
• Place some in No Additives tubes - culture
• Make fresh smear directly from fluid

Question 6

Effusion Analysis

Answer 6

• Protein content
• TNCC
• Types of cells present
  (inflammatory vs neoplastic)

Question 7

Protein Count

Answer 7

Done with Refractometer
* same way that would do with blood

Question 8

TNCC

Answer 8

Can do either automated or manual method
* count and differentiate 100 nucleated cells
* nucleated cells: leukocytes and mesothelial cells

Question 9

Identify Cell

Answer 9

Mesothelial Cell
* lines the body cavities
* large cells

Question 10

Types of Fluids

Answer 10

• Transudate
• Modified Transudate
• Exudate

Question 11

Transudate
Basic

Answer 11

• Low Protein
• Low TNCC

Question 12

Modified Transudate
Basic

Answer 12

• High Protein
• Low-Mod TNCC

Question 13

Exudate
Basic

Answer 13

• High Protein
• High TNCC

Question 14

Normal Fluid

Answer 14

• Hard to get due to being scant amounts
• Colorless / Clear / Odorless
• Protein: <2.5 g/dL
• TNCC: <3000 /uL
• Mix of macrophages, lymphocytes, and mesothelial cells

Question 15

Transudate

Answer 15

• Large amount (or normal fluid)
• Clear / Colorless or Red-tinged
• Protein: <2.5 g/dL
• TNCC: <1500 /uL
• Mix of macrophages, lymphocytes, mesothelial cells (normal or reactive)
• Happens when blocked blood flow or lymphatic chanel; low protein or pressure

Question 16

Modified Transudate

Answer 16

• Variable amount
• Variable color, usually clear
• Protein: 2.5-7 g/dL
• TNCC: 1000-7000 /uL
• Mostly lymphocytes, some mesothelial cells, non-degenerate neutrophils
• See with chylous or lymphatic effusions

Question 17

Exudate

Answer 17

• Variable amount
• Turbid, white or slightly yellow
• Protein: >3 g/dL
• TNCC: >7000 /uL
• Neutrophils, macrophages, lymphocytes, eosinophils
• See with inflammation response - increasing permeability of capillaries (infection, necrosis)

Question 18

Cell Cytology

Answer 18

• Use fresh direct sample
• If low TNCC (<5000/uL), use fluid sediment
• Stain slide
• Note predominant cell type, distribution of other cell types, any microorganisms

Question 19

Neutrophil Morphology Change

Answer 19

• Non-septic inflammation
• Aging neutrophils
• Septic inflammation

Question 20

Non-septic Inflammation

Neutrophil Morphology Change

Answer 20

• Fairly normal appearance
• Inflammation without bacteria

Question 21

Aging Neutrophils

Neutrophil Morphology Change

Answer 21

• Hypersegmented
• Pyknotic

Question 22

Septic Inflammation

Neutrophil Morphology Change

Answer 22

• Bacterial infection along with inflammation
• Neutrophils dying quickly
• Karyolysis

Question 23

Lymphocytes

Answer 23

• Appear as they do in blood
• Lymphoblasts may be seen

Question 24

Identify Cell
(not myeloblasts)

Answer 24

Lymphoblasts
* Large size and nucleolus
* Not normal to be seen in effusions

Question 25

Identify Cell

Answer 25

Plasma Cells * Similar to small lymphocytes * Nuclear chromatin more dense * Cytoplasm is blue and abundant * Golgi apparatus (perinuclear clear zone)

Question 26

Identify Cell

Answer 26

Macrophage * monocytes in blood, macrophages in tissue * round / oval nucleus * may have nucleolus * light blue, usually vacuolated cytoplasm * eat debris from surroundings and other cells; may see this or microorganisms within cell

Question 27

Lymph Node Aspirates

Answer 27

If enlarged, need to do a FNA to diagnose * reactivity - hyperplasia or inflammation * neoplasia - primary or metastatic

Question 28

What is this from? Normal or Not?

Answer 28

Normal Lymph Node * small mature lymphocytes are 3/4th TNCC * small numbers of immature lymphocytes, lymphoblasts, and macrophages * occasional plasma cells * tell it is lymph tissue by the lymphoglandular bodies - small cytoplasmic fragments in background

Question 29

Identify Cell

Answer 29

Mott Cell * "plasma cell on steroids" * filled with immuno-globulins * creates vacuoles

Question 30

What is this from? Normal or Not?

Answer 30

Reactive LN * responding to antigentic stimulation * still mainly small mature lymphocytes * but more medium lymphocytes, lymphoblasts, and plasma cells * inflammatory cells may be present

Question 31

What is this from? Normal or Not?

Answer 31

Malignant Neoplasia (Lymphoma) * primary lymphoid neoplasia * mainly has lymphoblasts with mitotic figures

Question 32

Normal or Not?

Answer 32

Malignant Neoplasia - Metastatic LN Associated * large clusters * may see "granulation" within the cluster

Question 33

Normal or Not?

Answer 33

Malignant Neoplasia - Metastasis LN associated * Mast Cells * nucleus/nucleolus within cell * abundant cytoplasm * small granuoles throughout

Question 34

Normal Synovial Fluid Color and Turbidity

Answer 34

* Light yellow color * Non-turbid * Increased turbidity caused by cells, protein, or cartilage

Question 35

Normal Synovial Fluid Viscosity

Answer 35

Quality and concentration of hyaluronic acid (joint lubrication) * assess prior to EDTA additive (degrades HA) * normal: 1-2 inch before breaking * decreased = septic or significant effusion

Question 36

Normal Synovial Fluid Cellularity

Answer 36

90% mononuclear cells * lymphocytes, monocytes (nonvaculated and non-phagocytic) <10% neutrophils

Question 37

What is this from? Normal or Not?

Answer 37

Normal synovial fluid - Background mucin * gives eosinophilic granular background * cells align in direction of smear (windrow) * fluid is so viscous, cells pulled in same direction

Question 38

Synovial Fluid Normal or Not?

Answer 38

Abnormal - infectious arthropathy * windrow (cells pulled in one direction) * neutrophils predominant * culture recommended if neutrophils seen

Question 39

Synovial Fluid Identify Cells

Answer 39

Non-Infectious Arthropathy - Rheumatoid Arthritis * increased neurophils * arrows: vacuolated / phagocytic macrophages * arrowhead: lupus erythematous cells (nuclear chromatin within neutrophils)