SYNOVIAL FLUID

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hua yue

Presented by:
Nathaniel Sim Myca Pua

PHYSIOLOGY & COMPOSITION

PHYSIOLOGY & COMPOSITION

Movable joints (diarthroses) composed of:
Bones lined with articular cartilage Separated by a cavity containing synovial fluid enclosed in a synovial membrane

Synovial membrane
synoviocytes:
Phagocytic Synthesizes hyaluronate

Connective tissue
Blood vessels, lymphatics & nerves

PHYSIOLOGY & COMPOSITION

Fluid formation
Ultrafiltrate of plasma across synovial membrane
Non selective Excludes proteins of high molecular weight

Synoviocytes
Secrete mucopolysaccharides which contains: Hyaluronic acid protein

SYNOVIAL FLUID NORMAL VALUES

Volume <3.5 mL Color pale yellow Clarity clear Viscosity forms string 4-6 cm long Erythrocytes <2000 cells/uL Leukocytes <200 cells/uL Neutrophils <20% of diff. Lymphocytes <15 % of diff. Monocytes & macrophages 65% of diff. Crystals NONE Glucose <10 mg/dL (lower than blood glucose) Lactate <250 mg/dL Total protein <3 g/dL Uric acid = blood value

JOINT DISORDER CLASSIFICATION

JOINT DISORDER CLASSIFICATION

Group Classification
I. II.
III. IV.

Significance
Degenerative joint disorders Immunologic problems (RA , LE) Gout & pseudogout (crystal induced) Microbial infection Traumatic injury Coagulation deficiency

Noninflammatory Inflammatory
Septic Hemorrhagic

Note: * categories overlap * multiple conditions can occur simultaneously * disease stage can vary laboratory results

SPECIMEN COLLECTION
Arthrocentesis
joint aspiration Arthos joint + Kentesis puncture Aspiration of synovial fluid using a syringe in a joint capsule

SPECIMEN COLLECTION
Volume:
Normal= 3.5 mL Diseased / inflamed = up to 25 mL

Collect in the following tubes

Sterile Heparin tube : microbiology Plain top: chemistry and immunology EDTA (liquid) : hematology Sodium fluoride tube: glucose analysis *Avoid all powdered anticoagulants interfere with crystal analysis

SPECIMEN COLLECTION
Fluid verification
Mucin clot test Add fluid to dilute acetic acid turbidity (clot formation) due to hyaluronate

Metachromatic staining
Place fluid on filter paper + few drops of toluidine blue metachromatic staining

PHYSICAL EXAMINATION
Color:
Normal clear, pale yellow Red to brown: indicates trauma of procedure or disorder Turbidity: associated with presence of WBCs Milky: may indicate presence of crystals

Viscosity:
Measured at bedside by ability to form a string from tip of syringe
Normal: 4-6 cm

PHYSICAL EXAMINATION

PHYSICAL EXAMINATION
Ropes test (mucin clot test) measurement of hyaluronate polymerization
Fluid forms a clot surrounded by clear fluid when added to acetic acid Clot quality is reported:
Good = solid clot Fair = soft clot Poor = friable clot Very poor = no clot

Test is of questionable precision and seldom used

MICROSCOPIC EXAMINATION
Cell Count WBCs
Method
Use Neubauer counting chamber May pretreat viscous fluids with hyaluronidase & incubate at 37 oC for 5 min. Dilution with hypotonic saline is used to lyse any RBCs OR Dilute with normal saline/methylene blue mixture to differentiate WBCs from RBCs

Normal = <200 / uL

MICROSCOPIC EXAMINATION
Differential Count
Cytocentrifuge specimen and prepare typical blood smear Normal: 60% monocytes, macrophages neutrophils: <20% lymphocytes: <15% Increased neutrophils possible septic condition Increased lymphocytes indicate non spetic inflammation

MICROSCOPIC EXAMINATION
Cell/inclusio Significance Cell/inclusio Significance n n Neutrophil Lymphocyte
Bacterial sepsis Crystal induced inflammation Nonspetic inflammation

Synovial lining cell LE cell

Normal

Lupus erythematosus

Macrophage

Normal Viral infection

Reiter cell

Reiter syndrome Nonspecific inflammation

MICROSCOPIC EXAMINATION
Cell/inclusio Significance Cell/inclusio Significance n n RA cell (Ragocyte) Cartilage cells Rice bodies
Rheumatoid arthritis Immunologic inflammation Osteoarthritis

Fat droplets

Traumatic injury Chronic inflammation Pigmented villonodular synovitis

Hemosiderin

Tuberculosis Septic and rheumatoid arthritis

Neutrophils in synovial fluid

Lymphs in synovial fluid

Synovial lining cell

LE cell in synovial fluid

CRYSTAL IDENTIFICATION
Important diagnostic test in the evaluation of arthritis. Crystal formation in a joint is frequently acute, painful inflammation
Crystal formation may be due to:
1. 2. 3. 4. Metabolic disorders Decreased renal excretion Cartilage and bone degeneration Medicinal injection (ex: corticosteroids)

CRYSTAL POLARIZATION
Under Polarizing Light (Direct Polarization) Birefringent substances appear as bright objects on a black background

CRYSTAL POLARIZATION
Under Compensated Polarizing Light A red compensator plate is placed between the crystal and slide Crystals aligned parallel to the compensator appear yellow (negative birefringence) Crystals aligned perpendicular to the compensator appear blue (positive birefringence)

SLIDE PREPARATION
Fluid is Examined Using the Wet Preparation Technique (unstained)
1. ASAP examination as pH and temperature affect observation 2. Ideally examined prior to WBC disintegration 3. Examine under both direct and compensated polarizing light 4. May also be observed in Wright stain preparations

TYPES OF CRYSTALS
Monosodium Urate Crystals (MSU)
1. Indicate gouty arthritis due to: Increased serum uric acid Decreased renal excretion of uric acid Impaired metabolism of nucleic acid 2. Exhibit negative birefringence (yellow color) 3. Extracellular or located within the cytoplasm of the neutrophils 4. Needle shaped

TYPES OF CRYSTALS
Calcium pyrophosphate (CCPD)
1. Indicates pseudogout due to: Degenerative arthritis Endocrine disorders with increased serum calcium Calcification of cartilage 2. Exhibit positive birefringence (blue color) 3. Located within the vacuoles of the neutrophil 4. Rhombic or square but may appear as short rods

TYPES OF CRYSTALS
Hydroxyapatite (HA) (Calcium Phosphate) Crystals
1. Associated with calcified cartilage deposition 2. No birefringence 3. Small particles require an electron microscope to examine 4. Usually seen in osteoarthritis

TYPES OF CRYSTALS
Cholesterol Crystal
1. Associated with chronic inflammation 2. Exhibit negative birefringence 3. Notched, Rhombic plates

TYPES OF CRYSTALS
Corticosteroid Crystals
1. Associated with intra-articular injections 2. Exhibit positive and negative birefringence 3. Flat, variable shaped plates

TYPES OF CRYSTALS
Calcium Oxalate Crystals
Associated with renal dialysis patient Envelope Negative birefringes

Birefringence Artifacts
Precipitated anticoagulant Talc and Starch (gloves) Scratches on slides and coverslips Dust particles

Acute gout (uric acid crystals)

Uric acid crystals

Corticosteroid in Synovial Fluid

CHEMISTRY TEST
Glucose determination -Most frequently requested -Markedly decrease values indicates Inflammatory (group 2) and Septic (group 3) disorders -Fasting: 8hours -Normal synovial glucose = not more than 10 mg/dL lower than blood value -Analyzed within 1 hour or preserved with sodium fluoride

OTHER CHEMISTRY TEST

1. Total Protein Determination
-Normal synovial fluid protein = less than 3 g/dL -Elevated in Inflammatory and Hemorrhagic disorders

2. Uric Acid Determination

-Performed as first evaluation of gout -Confirm gout when crystals cannot be demonstrated in fluid

OTHER CHEMISTRY TEST

3. Lactate
May differentiate between inflammatory and septic arthritis Septic arthritis = >250 mg/dL Gonococcal arthritis = normal to low levels Production results from :
Increased demand for energy Tissue hypoxia Severe inflammatory conditions

MICROBIOLOGY TESTS
Most important test: Grams Stain and Culture Bacterial (most frequently seen), fungal, tubercular, viral infections Routine bacterial culture should include enrichment medium like chocolate agar
Staphylococcus , streptococcus , haemophilus, N.gonorrhoeae

SEROLOGY TESTS
Diagnosis of joint disorders Autoimmune disease is demonstrated by autoantibodies on serum
1. Rheumatoid arthritis (RA) 2. Lupus erythematosus (LE)

SEROLOGY TESTS
Antibody detection in patients serum
1. Borrelia burgdorferi
Causative agent of Lyme disease Confirm the cause of arthritis

Extent of inflammation is determined by concentration of acute phase reactants (like fibrinogen and C-reactive protein)