- Laboratory results of synovial fluid analysis

AUBF: Synovial Fluid can be used to determine the pathologic

origin of arthritis
• Synovial fluid – joint fluid - The beneficial tests most frequently
• Viscous liquid found in the cavities of the performed synovial fluid are:
movable joints (diarthroses) or synovial ➢ WBC count
joints ➢ Differential
• The bones in the synovial joints are lined ➢ Gram stain
with smooth articular cartilage and ➢ Culture
separated by a cavity containing the synovial ➢ Crystal examination
fluid
• The synovial membrane contains specialized Normal Values
cells called synoviocytes Volume <3.5 mL
Color Pale yellow
Importance Clarity Clear
Viscosity Able to form a string 4 – 6
• Reduces friction between the bones during cm long
joint movement RBC count <2000 cells/uL
• Provides lubrication in the joints WBC count <200 cells/uL
• Provides nutrient to the articular cartilage Neutrophils <20% of the differential
• Lessens the shock of joint compression that Lymphocytes <15% of the differential
occurs during activities such as walking and Monocytes and 65% of the differential
jogging macrophages
Crystals None present
Glucose <10mg/dL lower than
blood glucose
Lactate <250 mg/dL
Total protein <3 g/dL
Uric acid Equal to blood volume

Classification of Pathologic Significance of Joint

Disorders
Group Classification Pathologic Significance
Non-inflammatory Degenerative joint
disorders, osteoarthritis
Inflammatory Immunologic disorders,
rheumatoid arthritis,
lupus erythematosus,
scleroderma,
polymyositis, anklylosing
spondylitis, rheumatic
- Synovial fluid is formed as an ultrafiltrate of fever, and Lyme arthritis
plasma across the synovial membrane Crystal induced gout and
- The synoviocytes secrete a pseudogout
mucopolysaccharide containing hyaluronic Septic Microbial infection
acid and a small amount of protein into the Hemorrhagic Traumatic injury, tumors,
fluid hemophilia, other
- The large hyaluronate molecules contribute coagulation disorders
the noticeable viscosity to the synovial fluid Anticoagulant overdose
- Damage to the articular membranes Specimen collection and Handling
produces pain and stiffness in the joints, • Synovial fluid is collected by needle
collectively referred to as arthritis aspiration called ARTHOCENTESIS
• The amount of fluid present varies with the • The fluid may appear milky when crystals are
size of the joint and the extent of fluid present
buildup in the joint
Viscosity
• Normal synovial fluid does not clot;
however, fluid from a diseased joint may • Viscosity of the synovial fluid comes from the
contain fibrinogen and will clot polymerization of the hyaluronic acid and is
• Therefore, fluid is often collected in a syringe essential for the proper lubrication of the
that has been moistened with heparin joints
• When sufficient fluid is collected, it should • Arthritis affects both the production of
be distributed into the following tubes based hyaluronate and its ability to polymerize,
on the required tests: thus decreasing the viscosity of the fluid
➢ A sterile heparinized tube for Gram stain • Several methods are available to measure
and culture the viscosity of the fluid, the simplest being
➢ A heparin or ethylenediaminetetraacetic to observe the ability of the fluid to form a
acid tube foe cell count string from the tip of a syringe and can be
➢ A nonanticoagulated tube for other tests done at the bedside. A string that measures
➢ A sodium fluoride for glucose analysis 4 to 6 cm is considered normal
• Powdered anticoagulants should not be • Measurement of the amount of hyaluronate
used because they may produce artifacts polymerization can be performed using
that interfere with crystal analysis Ropes, or mucin clot, test
• The non-anticoagulated tube for other tests • When added to a solution of 2% to 5% acetic
must be centrifuged and separated to acid, normal synovial fluid forms a solid clot
prevent elements from interfering with around or surrounded by clear fluid. As the
chemical and serologic analyses ability of the hyaluronate to polymerize
• Ideally, all testing should be done as soon as decreases, the clot becomes less firm, and
possible to prevent cellular lysis and possible the surrounding fluid increases in turbidity
changes in crystals • The mucin clot test is reported in terms of
good (solid clot), fair (soft clot), low (friable
Color and clarity
clot), and poor (no clot)
• Normal synovial fluid appears colorless to
Cell counts
pale yellow
• The word “synovial” comes from the Latin • The total leukocyte count is the most
word for egg. Normal viscous synovial fluid frequently performed cell count on synovial
resembles egg white fluid
• The color becomes a deeper yellow in the • RBC counts are seldom requested
presence of non-inflammatory and • To prevent cellular disintegration, counts
inflammatory effusions and may have a should be performed as soon as possible, or
greenish tinge with bacterial infection the specimen should be refrigerated
• As with CSF, in synovial fluid the presence of • Very viscous fluid may need to be pretreated
blood from a hemorrhagic arthritis must be by adding a pinch of hyaluronidase to 0.5 mL
distinguished from blood from a traumatic of fluid or one drop of 0.05% hyaluronidase
aspiration in phosphate buffer per milliliter of fluid and
• Differentiation between hemorrhagic incubating at 37 C for 5 minutes
arthritis and traumatic aspiration by • Manual counts on thoroughly mixed
observing the uneven distribution of blood in specimens are done using the Neubauer
the specimens obtained from a traumatic counting chamber
aspiration • Clear fluids can usually be counted
• Turbidity is frequently associated with the undiluted, but dilutions are necessary when
presence of WBCs; however, synovial cell fluids are turbid or bloody
debris and fibrin also produce turbidity
• WBC diluting fluid cannot be used because it Neutrophils
contains acetic acid that causes the
formation of mucin clots
• Normal saline can be used as a diluent. If it is
necessary to lyse the RBCs, hypotonic saline
(0,3%) or saline that contains saponin is a
suitable diluent
• Methylene blue added to the normal saline
stains that WBC nuclei, permitting
separation of the RBCs and WBCs during
counts performed on mixed specimens
• WBC counts less than 200 cells/uL are
considered normal and may reach 100,000
cells/uL or higher in severe infections
LE cells
• There is, however, considerable overlap of
elevated leukocyte counts between septic
and inflammatory forms of arthritis
• Pathogenicity of the infecting organisms also
produces varying results in septic arthritis, as
does antibiotic administration

Differential count

• Cytocentrifuge specimen and prepare typical

blood smear
• Normal: 60% monocytes and macrophages,
Crystals
neutrophils <20%, lymphocytes <15%
• Increased neutrophils – possible septic • Crystal formation may be due to:
condition ➢ Metabolic disorders
• Increased lymphocytes – indicate non-septic ➢ Decreased renal excretion
inflammation ➢ Cartilage and bone degeneration
➢ Medicinal injection (ex: corticosteroids)
Other cell abnormalities
• Fluid is examined using the wet preparation
• Increased eosinophils – rheumatic fever, technique
parasitic infections, metastatic carcinoma, ➢ ASAP examination as pH and
post radiation therapy or arthrography temperature affect observation
• LE cells - patients with lupus erythematosus ➢ Ideally examined prior to WBC
• Reiter cells – macrophages with ingested disintegration
neutrophils ➢ Examine under both direct and
• RA cells (ragocytes) – precipitated compensated polarizing light
rheumatoid factor appearing as cytoplasmic ➢ May also be observed in Wright stain
granules in neutrophils preparations
• Hemosiderin granules – due to hemorrhagic • Under polarizing light (direct polarization)
process of cases of pigmented villonodular ➢ Birefringent substances appear as bright
synovitis objects on a black background
• Cartilaginous cells – observed in cases of ➢ Intensity varies between substances
osteoarthritis • Under compensated polarized light
• Rice bodies – found in septic and rheumatoid ➢ A red compensator plate is placed
arthritis and tuberculosis between the crystal and slide
• Fat droplets – indicate traumatic injury ➢ Crystals aligned parallel to the
compensator appear yellow (negative
birefringence)
 ➢ Crystals aligned perpendicular to the • May produce an acute inflammatory
compensator appear blue (positive reaction
birefringence) • Intracellular
◼ Monosodium Urate Crystals (MSU) • Not birefringent
• Indicate gouty arthritis due to: • Require an election microscope to examine
➢ Increased serum uric acid • Small, needle shaped
➢ Decreased renal excretion of nucleic acid ◼ Corticosteroid
➢ Impaired metabolism of nucleic acid • Associated with intra-articular injection, NO
• Exhibit negative birefringence clinical significance
• Intracellular (acute stages) and extracellular • Primarily intracellular
location • Exhibit positive and negative birefringence
• Polarized light – strongly birefringent ➢ Can closely resemble MSU and CCPD
• Compensated polarized light – yellow when • Flat, variable shaped plates
parallel blue when perpendicular ◼ Calcium oxalate
• Needle shaped • Following renal dialysis
◼ Birefringent Artifacts:
➢ Anticoagulant crystals (calcium oxalate,
lithium heparin)
➢ Starch granules
➢ Prosthesis fragments
➢ Collagen fibers
➢ Fibrin
➢ Dust particles

Chemistry tests

◼ Glucose
◼ Calcium pyrophosphate • Done simultaneously with blood sample
• Indicates pseudogout due to: (prefer 8 hour fast)
➢ Degenerative arthritis • Difference between blood and synovial
➢ Endocrine disorders with increased glucose values is evaluated
serum calcium ➢ Normal = <10 mg/dL
➢ Calcification of cartilage ➢ Inflammatory conditions - > 25 mg/dL
• Exhibit positive birefringence ➢ Sepsis = > 40 mg/dL
• Seen intracellular and extracellular ➢ Considered low if < ½ serum plasma
• Polarized light – weakly birefringent glucose value
• Compensated polarized light – blue when • Should be run within 1 hour of collection
parallel (yellow when perpendicular) • Draw in sodium fluoride – prevents glycolysis
• Blunt rods or rhombic shapes ◼ Total protein
◼ Cholesterol • Not routinely performed
• Nonspecific indication • Normal = < 1/3 of serum value ( 3g/dL)
- Associated with chronic inflammation ➢ Large molecule, not easily filtered by
• Exhibit negative birefringence (compensated mebrane
polarized light) • Increased protein
• Usually seen extracellular ➢ Changes in membrane permeability
• Polarized light – strongly birefringence ➢ Increased joint synthesis
• Rhombic plates ➢ Indicates an inflammatory process
◼ Hydroxyapatite (HA) (Calcium phosphate) ◼ Uric acid
• Associated with calcific deposition • Alone, not diagnostic
conditions • May determine gout in conjunction with
plasma uric acid, especially when crystals are
undetectable
 • Normal = serum level
◼ 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 test

◼ Gram stain
• Performed on all specimens
• Most infection are bacterial:
➢ Staphylococcus
➢ Streptococcus (S. pyogenes, S.
pneumoniae)
➢ Hemophilus
➢ Neisseria gonorrhea
• Fungal, viral and tubercular agents may also
be observed
◼ Culture
• Routine culture
• Enrichment medium (chocolate agar)
• Specialty media depending on clinician order
and indications

Serological test

◼ Autoantibody detection (same as found in

serum)
• Rheumatoid arthritis (RA)
• Lupus erythematosus (LE)
◼ Antibody detection in patient’s serum
• Borrelia burgdorferi
➢ Causative agent of Lyme disease
➢ Cause of arthritis