Cerebrospinal Fluid Lecture Notes PDF

Cerebrospinal Fluid Carlo Ace D. De Belen Introduction  Cerebrospinal fluid (CSF) is a body fluid that surrounds and protects the brain and spinal cord.  Flows through the subarachnoid space located between the arachnoid and pia mater.  Produced by the choroid plexus in...

Cerebrospinal Fluid Carlo Ace D. De Belen Introduction  Cerebrospinal fluid (CSF) is a body fluid that surrounds and protects the brain and spinal cord.  Flows through the subarachnoid space located between the arachnoid and pia mater.  Produced by the choroid plexus in the ventricles of the brain, with a small contribution from the ependymal cells lining the ventricles and the subarachnoid space.  It is continuously circulated and reabsorbed into the venous system via the arachnoid villi.  Normal production rate: ____________  Total volume:_______________ Functions  Mechanical protection: Acts as a cushion for the brain and spinal cord.  Chemical stability: Regulates the environment of the CNS by removing metabolic waste.  Intracranial pressure regulation: Maintains consistent pressure within the skull. Formation  Produced by: The majority of CSF (approximately 70%) is produced by the choroid plexus located in the ventricles of the brain. The remaining 30% comes from the ependymal cells lining the brain ventricles and other CNS tissues through passive diffusion.  Rate of Production: Around ______________ in adults.  Mechanism: The production involves active secretion by the choroid plexus cells, where plasma is filtered, and selective solutes are transported across the blood-brain barrier (BBB). Composition  Water: Makes up the majority of CSF, providing a medium for solutes.  Glucose: Approximately 60-80 mg/dL; it is lower than plasma glucose due to selective transport.  Proteins: Typically very low, 15-45 mg/dL, as the BBB limits protein entry.  Cells: Normally acellular, with fewer than 5 white blood cells (WBCs)/μL.  Electrolytes:  Sodium (Na+): Similar to plasma levels (~145 mEq/L).  Potassium (K+): Lower than plasma (~2.5 mEq/L).  Chloride (Cl-): Slightly higher than plasma (~120-130 mEq/L).  Calcium and Magnesium: Present in low concentrations but essential for neural activity.  Other Components: Lactate, urea, and enzymes like LDH (lactate dehydrogenase) are present in small amounts and may rise in pathological conditions. Specimen Collection  CSF is obtained through lumbar puncture or ____________ typically between the L3-L4 or L4-L5 vertebrae. 1. The fluid is collected in three or four sterile tubes: 1. Tube 1: Used for chemical and serologic tests. 2. Tube 2: Used for microbiological studies. 3. Tube 3: Used for cell counts. 4. (Optional) Tube 4 for specialized tests.  Tests should be performed within 1 hour of collection.  If delays are unavoidable, specific portions should be refrigerated for ___________________ or frozen for ____________________ Physical Examination  Appearance: Normal CSF is clear and colorless.  Cloudy or turbid CSF: Indicates an increased number of cells.  Xanthochromia: A yellow or pink discoloration, typically seen in subarachnoid hemorrhage or high protein levels. Traumatic Tap vs. Subarachnoid Hemorrhage: Traumatic tap: Uneven blood distribution in tubes, presence of clots, and clear supernatant after centrifugation. Subarachnoid hemorrhage: Even blood distribution in all tubes, no clots, and xanthochromic supernatant. Physical Examination Microscopic Analysis Cell Count: Performed using a hemocytometer.Normal adult CSF contains 0-5 white blood cells/μL and no red blood cells. Differential Cell Count: Neutrophils: Bacterial meningitis. Lymphocytes: Viral, tubercular, or fungal meningitis. Eosinophils: Parasitic infections or allergic reactions. Microscopic Analysis Microscopic Analysis Microscopic Analysis  Microbiological Testing Gram Stain: Directly detects bacteria in cases of meningitis. Sensitivity depends on bacterial concentration. Culture: Identifies bacterial, fungal, or parasitic organisms. Molecular Testing: PCR tests for viral pathogens like herpes simplex virus (HSV). Serologic Testing  Used for conditions like neurosyphilis, where specific antibodies are detected in the CSF.  Although many different serologic tests for syphilis are available when testing blood, the procedure recommended by the CDC to diagnose neurosyphilis is the Venereal Disease Research Laboratories (VDRL) Chemical Analysis  Protein Levels: Normal range: 15-45 mg/dL. Elevated levels indicate conditions such as meningitis, hemorrhage, or multiple sclerosis.  Glucose Levels: Normal: 60-70% of plasma glucose. Decreased glucose suggests bacterial or fungal infections.  Lactate: Increased levels are associated with bacterial or fungal meningitis. Normal lactate levels are observed in viral meningitis.  Glutamine: Elevated in liver failure or other metabolic disorders affecting the CNS. Chemical Analysis Seminal Fluid (Semen) Analysis Leslee Anne Cortez, RMT, LPT, MPH Faculty, School of Medical Technology Emilio Aguinaldo College Cavite Physiology Semen consists of four components contributed separately by the following: a. testes and epididymis b. seminal vessels c. prostate gland SEMEN COMPOSITION d. bulbourethral glands Spermatozoa 5% Seminal fluid 60 – 70% Prostate fluid 20 – 30% Bulbourethral fluid 5% Physiology Testes Paired, located in scrotum Seminiferous tubules: produce spermatozoa Sertoli cells provide support and nutrients for the germ cells as they undergo spermatogenesis Sperm cells mature and are stored in the epididymis Physiology Seminal vessels Produce majority of fluid (60% to 70%) for transport medium Provide fructose and flavin for sperm metabolism Fructose: motility Flavin: gray appearance of semen Physiology Prostate gland Aids in propelling semen through the urethra Produce acidic fluid (20% to 30%) Contains acid phosphatase, citric acid, zinc, and proteolytic enzymes Enzymes coagulate semen after ejaculation then cause liquefaction afterwards Physiology Bulbourethral glands Produce thick, alkaline fluid (5%) to neutralize acid from prostate and acid pH of vagina Absence of fluid = diminished sperm motility Specimen Collection 2 to 3 days abstinence; no longer than 7 days Laboratory provides containers and a room for collection Home: deliver to laboratory within 1 hour; keep specimen 37°C Collected by masturbation into the container Specimen Handling Standard precautions must be observed at all times during analysis. Specimens are discarded as biohazardous waste. Sterile materials and techniques must be used. Semen Analysis Macroscopic and microscopic Appearance Volume Viscosity pH Sperm concentration and count Motility Morphology Appearance Normal is gray-white, translucent with musky odor White turbidity = infection Red = blood cells, abnormal Yellow = urine, prolonged abstinence, medications Urine is toxic to sperm: no motility Liquefaction Fresh semen specimen is clotted and should liquefy within 30 to 60 minutes after collection Analysis cannot begin until liquefaction has occurred To aid in liquefaction, an equal volume of Dulbecco’s phosphate-buffered saline (DPBS) or proteolytic enzymes, such as alpha- chymotrypsin or bromelain may be added to the specimen Volume and Viscosity Normal: 2 to 5 mL Increased volume = prolonged periods of abstinence Decreased volume = infertility, incomplete collection Specimens that are liquefied incompletely are clumped and highly viscous Normal viscosity: droplets with thin threads from a pipette that do not appear clumped or stringy Reporting: 0 (watery) to 4 (gel-like) pH Measure within 1 hour of ejaculation Normal: 7.2 to 8.0 Over 8.0 = infection Decreased pH = increased prostate fluid, ejaculatory duct obstruction, or poorly developed seminal vesicles Check with pH pad of a urinalysis reagent strip Sperm Concentration and Count Valid measurement of fertility Concentration = number of sperm / mL Normal value for sperm concentration: >20 to 250 million sperm per milliliter Count = sperm conc. x specimen volume Normal value for total sperm count: >40 million / ejaculate Sperm Concentration and Count Sperm concentration is performed in Neubauer counting chamber Common dilution = 1:20 Diluting fluid = sodium bicarbonate and formalin Sperm is counted in the four corner and center squares of the large center square; counts must agree within 10%; use the average Only fully developed sperm should be counted; do not count “round cells” Calculating Sperm Concentration and Sperm Count Using a 1:20 dilution, an average of 60 sperm cells are counted in the five RBC counting squares on both sides of the hemocytometer. Calculate the sperm concentration per milliliter and the total sperm count in a specimen with a volume of 4 mL. Sperm Concentration 60 sperm cells counted × 1,000,000 = 60,000,000 sperm / mL Sperm Count 60,000,000 sperm / mL × 4 mL = 240,000,000 sperm / ejaculate Calculating Sperm Concentration and Sperm Count In a 1:20 dilution, 600 sperm cells are counted in four WBC counting squares. Calculate the sperm concentration per milliliter and the total sperm count in a specimen with a volume of 2 µL. In a 1:20 dilution, 400 sperm cells are counted in two WBC counting squares. Calculate the sperm concentration per milliliter and the total sperm count in a specimen with a volume of 4 µL. Sperm Motility Well-mixed, liquefied semen specimen examined within 1 hour Estimate percentage with progressive, forward motion in 20 hpf Grading: 4 (rapid, straight-line movement) to 0 (no movement) NORMAL: A minimum motility of 50% with a rating of 2.0 after 1 hour Sperm Motility Sperm Motility Grading Grade WHO Criteria Sperm Motility Action 4 a Motile with rapid, straight line motility 3 b Motile with slower speed, some lateral movement 2 b Motile with slow forward progression, noticeable lateral movement 1 c Motile without forward progression 0 d No movement Alternative Sperm Motility Grading Progressive motility (PM) Sperm moving linearly or in a large circle Nonprogressive motility (NP) Sperm moving with an absence of progression Immotility (IM) No movement Sperm Morphology Evaluate head, midpiece, tail Head: oval with acrosomal cap at end and covering half of the head 5 µm long and 3 µm wide Midpiece: 7.0 µm long, surrounded by sheath of mitochondria for tail movement Flagellar tail: ~45 µm Sperm Morphology Observe on thin smear under oil immersion Wright’s, Giemsa, Shorr, or Papanicolaou stain Count 200 sperm and report percentage of abnormal Routine criteria measures Head abnormalities: double heads, giant and amorphous heads, pinheads, tapered heads, and constricted heads Tail abnormalities: doubled, coiled, or bent Sperm Morphology Kruger’s strict criteria include Measuring head, neck, and tail size Measuring acrosome size Evaluating for the presence of vacuoles Routine criteria: >30% normal forms Strict criteria: >14% normal forms Sperm Vitality Must be assessed within 1 hour of ejaculation Eosin-nigrosin stain Dead cells stain red; normal are blue-white Count number/100 cells Normal: 50% living sperm Corresponds to motility Seminal Fluid Fructose Low sperm concentration due to lack of the support medium (low to absent fructose level in the semen) Resorcinol test → orange red color (+) fructose Tested using spectrophotometric methods Specimens for fructose levels should be tested within 2 hours of collection or frozen to prevent fructolysis. Normal: > 13 umol per ejaculate Antisperm Antibodies Present in both men and women Male more common: surgery, vasectomy reversal, trauma and infections Sperm normally do not encounter the immune system, so body considers them foreign Damaged sperm may create production of antibodies in a female partner Suspect male antibodies when clumps of sperm are seen Agglutination is graded as few, moderate, or many Microbial and Chemistry Testing >1 million WBCs usually indicate prostate infection Culture and test for Mycoplasma hominis, Chlamydia trachomatis, Ureaplasma urealyticum Chemistry tests: neutral α-glucosidase, free L-carnitine, glycerophosphocholine, zinc, citric acid, glutamyl transpeptidase, prostatic acid phosphatase Reference Semen Chemical Values Neutral a-glucosidase ≥20 mU/ejaculate Zinc ≥2.4 µmol/ejaculate Citric acid ≥52 µmol/ejaculate Acid phosphatase ≥200 units/ejaculate Microbial and Chemistry Testing Determination of semen present in specimen Observe microscopically for sperm Enhance with xylene; use phase microscopy Motile sperm detection = up to 24 hours Non-motile sperm detection = up to 3 days Detection of prostatic acid phosphatase and seminal glycoprotein, p30 Postvasectomy Analysis Only concern is presence of sperm Takes several months for all sperm to be gone, based on time and ejaculations Begin in 2 months; continue until 2 months are negative Wet preparation under phase; if negative, centrifuge for 10 minutes, examine again Only one sperm is required for fertilization Synovial Fluid Leslee Anne Cortez, RMT, LPT, MPH Faculty, School of Medical Technology Emilio Aguinaldo College Cavite Learning Objectives At the end of this session, students should be able to: Describe the formation and function of synovial fluid. Relate laboratory test results to the four common classifications of joint disorders. State the five diagnostic tests most routinely performed on synovial fluid. Determine the appropriate collection tubes for requested laboratory tests on synovial fluid. Describe the appearance of synovial fluid in normal and abnormal states. Discuss the normal and abnormal cellular composition of synovial fluid. Learning Objectives At the end of this session, students should be able to: List and describe six crystals found in synovial fluid. Explain the differentiation of monosodium urate and calcium pyrophosphate crystals using polarized and compensated polarized light. State the clinical significance of glucose and lactate tests on synovial fluid. List four genera of bacteria found most frequently in synovial fluid. Describe the relationship of serologic serum testing to joint disorders.  Physiology Synovial fluid functions Lubrication for the movable joints: diarthroses Nutrients for articular cartilage Lessens shock of joint compression Formation Ultrafiltrate of plasma across synovial membrane No high weight molecules Synoviocytes in synovial membrane secrete hyaluronic acid that makes the fluid viscous (lubrication) Type A and B cells synoviocytes  Physiology Arthritis: pain and stiffness in the joints as a result of damage to articular membranes Test commonly performed on synovial fluid WBC count Differential Gram stain Culture Crystal examination  Joint Disorders Group Classification Pathological Significance Laboratory Findings Degenerative joint disorders, osteoarthritis Clear, yellow fluid Non- Good viscosity WBCs inflammatory Neutrophils 50% Decreased glucose level Possible autoantibodies present Inflammatory Crystal-induced gout, pseudogout Cloudy or milky fluid Low viscosity WBCs up to 100,000 µL Neutrophils 75% Decreased glucose level Positive culture and Gram stain Traumatic injury, tumors, Cloudy, red fluid hemophilia, other Low viscosity Hemorrhagic coagulation disorders WBCs equal to blood Anticoagulant overdose Neutrophils equal to blood Normal glucose level Specimen Collection and Handling Needle aspiration called arthrocentesis Normal knee fluid amount 3.5 mL Normal fluid does not clot; diseased fluid clots Syringe moistened with heparin Specimen Collection and Handling Tube No. Description Amount of Purpose Synovial Fluid Tube 1 Plain, non-anticoagulated First 4 – 5 mL chemical or (red stopper tube) immunological analyses Tube 2 Heparinized Next 4 – 5 mL cell count, (green stopper tube) differential count, Liquid EDTA crystal identification (lavender stopper tube) Tube 3 Heparinized Last 4 – 5 mL microbiological (green stopper tube) studies Sodium polyanethol sulfonate (yellow stopper tube) Color and Clarity Normal = clear and pale yellow (egg white) Deeper yellow = noninflammatory and inflammatory effusions Green = infection Red = hemorrhagic arthritis or traumatic tap Milky = crystal induced Turbid = blood cells (WBCs) or cellular debris, fibrin Viscosity Polymerization of hyaluronic acid Arthritis decreases polymerization Normal = 4 – 6 cm string from aspirating needle Ropes (mucin clot test) Add fluid to 2 – 5% acetic acid to form clot Reported: good (solid clot), fair (soft clot), low (friable clot), poor (no clot) Cell Counts WBC count is most common Perform ASAP or refrigerate Do not use normal WBC diluting fluid; use normal saline/methylene blue For heavily viscous fluid: add one drop of 0.05% hyaluronidase, then 37°C incubation for 5 minutes Perform on a Neubauer counting chamber Automated instrument Normal: 100,000 WBCs/μL  Cell Counts Counting procedure Line petri dish with moist filter paper. Place hemocytometer on two small sticks above paper. Fill and count both sides of the hemocytometer for compatibility. For counts less than 200 WBCs/μL, count all nine large squares. For counts greater than 200 WBCs/μL in the above count, count the four corner squares. For counts greater than 200 WBCs/μL in the above count, count the five small squares used for a RBC count. Differential Count Incubate with hyaluronidase, then cytocentrifuge Primary cells: monocytes, macrophages, synovial tissue cells Neutrophils: 50% blood HCT is hemothorax: more blood Membrane damage: low blood  Differentiate chylous and pseudochylous Chylous is triglycerides; stain with Sudan III Pseudochylous is cholesterol; polarize and crystals also seen in wet bright-field view Hematology Tests Differential: primary cells are neutrophils, lymphocytes, macrophages, eosinophils, mesothelial cells, plasma cells, and malignant cells Macrophages are often the highest 64%-80%  ↑ Neutrophils: bacterial infection, pancreatitis, pulmonary infarction  ↑ Lymphocytes: TB, viral infections, autoimmune disorders, malignancy  Eosinophils: trauma introducing air and blood, allergic reactions, parasites  Mesothelial cells: single cell layer lines membranes, common to see in serous fluid, pleomorphic, dark blue cytoplasm, round nuclei, normal and reactive; “fried egg appearance”  Reactive cells may be multinucleated Chemistry Tests  Glucose: ↓levels with TB, rheumatoid inflammation, malignant effusion, esophageal rupture, lupus pleuritis, and purulent infections; have blood comparison  pH: 1000/μL is bacterial endocarditis  Malignant cells are metastatic from lung and breast  Gram stains and cultures for endocarditis often caused by previous respiratory infections  TB smears and cultures done in AIDS  PCR  Metastatic giant mesothelioma cell also seen in pleural fluid as a primary malignancy in persons with asbestos contact Peritoneal Fluid  Effusion between the peritoneal membranes is called ascites   Fluid is often called ascitic fluid  Transudates: hepatic origin (cirrhosis)  Exudates: bacterial peritonitis from intestinal perforation, ruptured appendix, and malignancy  Performed to detect early abdominal bleeding and need for surgery  Blunt trauma injuries  Normal saline injected into cavity, withdrawn, and red blood cell (RBC) count performed  RBC count >100,000 indicates blunt trauma case  Radiographic procedures also available Transudates and Exudates Differentiation between ascitic fluid transudates and exudates is more difficult than for pleural and pericardial effusions. The serum–ascites albumin gradient (SAAG) is recommended Levels of fluid and serum albumin are measured concurrently, and then the fluid albumin level is subtracted from the serum albumin level. A difference (gradient) of 1.1 or greater suggests a transudate effusion of hepatic origin, and lower gradients are associated with exudative effusions. EXAMPLE Serum albumin of 3.8 mg/dL – fluid albumin of 1.2 mg/dL = gradient of 2.6 = transudate effusion Serum albumin of 3.8 mg/dL – fluid albumin of 3.0 mg/dL = gradient of 0.8 = exudate effusion Appearance  Like pleural and pericardial fluids, normal peritoneal fluid is clear and pale yellow.  Exudates are turbid with bacterial or fungal infections.  Green or dark-brown color indicates the presence of bile, which can be confirmed using standard chemical tests for bilirubin.  Chylous or pseudochylous material may be present with cases of trauma or blockage of lymphatic vessels.  Blood-streaked fluid is seen after trauma and with cases of tuberculosis, intestinal disorders, and malignancy. Laboratory Test   Normal WBC counts are less than 500 cells/µL, and the count increases with bacterial peritonitis and cirrhosis  Absolute neutrophil count: >50% of total WBC count or greater than 250 cells indicates infection  Lymphocytes elevated in TB and peritoneal carcinomatosis Cellular Examination  Cells: WBCs, mesothelial cells, macrophages (lipophages)  Yeast cells and Toxoplasma gondii  Malignant cells, often contain mucin vacuoles Chemical Tests Chemical examination of ascitic fluid consists primarily of glucose, amylase, and alkaline phosphatase determinations. Glucose is decreased below serum levels in bacterial and tubercular peritonitis and malignancy. Amylase is determined on ascitic fluid to ascertain cases of pancreatitis, and it may be elevated in patients with gastrointestinal perforations. An elevated alkaline phosphatase level is also highly diagnostic of intestinal perforation. Measurements of blood urea nitrogen and creatinine in the fluid are requested when a ruptured bladder or accidental puncture of the bladder during the paracentesis is of concern. Note: Bilirubin is measured when leakage of bile into the peritoneum is suspected after trauma or surgery. Bile contains primarily conjugated bilirubin; therefore, a test for total bilirubin is acceptable. Microbiology Tests  Gram stains and aerobic and anaerobic cultures  Aerobic and anaerobic cultures: inoculate blood culture bottle at bedside  Acid-fast smear, adenosine deaminase and culture for TB  PCR – M. tuberculosis Serological Tests Measurement of the tumor markers CEA and CA 125 is a valuable procedure for identifying the primary source of tumors producing ascitic exudates. The presence of CA 125 antigen with a negative CEA suggests the source is from the ovaries, fallopian tubes, or endometrium. Bronchoalveolar Lavage Fluid Leslee Anne Cortez, RMT, LPT, MPH Faculty, School of Medical Technology Emilio Aguinaldo College Cavite  Learning outcomes State the indications for performing a bronchoalveolar lavage (BAL). Describe the procedure for performing a BAL. Explain the procedures for collecting, handling, and transport of specimens for BAL. Describe the appearance of BAL fluid in normal and abnormal conditions. Discuss the normal and abnormal cellular composition of BAL fluid. Clinical Significance Bronchoalveolar lavage (BAL) is particularly useful in evaluating patients who are immunocompromised or patients with any number of possible diagnoses in the respiratory tract. BAL is used in conjunction with high-resolution computerized tomography (HRCT), medical history, and physical examination to determine the need for a biopsy. Specimen Collection Fiber-optic bronchoscope is used. Alveolar ground-glass opacity, prominent nodular profusion, or fine reticulation are optimal targets Aliquots of sterile saline are instilled into the alveolar spaces, mixed with bronchial contents, and aspirated for cellular examination and culture. Specimen Collection Instillation volume is between 100-300 mL of sterile saline in 20-50 mL aliquots. First aliquot is discarded; remaining aliquots are sent individually or pooled for analysis Desired volume 10-20 mL (minimum is 5 mL) Optimal sampling retrieves ≥ 30%, typical recovery range 50%-70% Low-volume recovery ≤ 25% Specimen Handling and Transport Specimens should be kept at room temperature when transporting to laboratory; process immediately If delivery is delayed longer than 30 minutes specimens must be transported on ice (4°C). Clarity of BAL Color of BAL Clear Cloudy Colorless Hazy Turbid Milky white Light-brown beige Gray-beige Red Color Clinical Significance Red (bloody) acute diffuse alveolar hemorrhage Orange-red older hemorrhagic syndrome Milky (light pulmonary alveolar brown-beige) proteinosis Cell Counts Counts for WBCs and RBCs are done using a hemocytometer. Cell viability determined by adding Trypan blue. WBC counts may be diluted using the BMP LeukoChek. Count all cells in the 18 squares on both sides and calculate the average of the two sides WBC/µL = Average number of cells x dilution factor x 10 9 squares Cell Counts RBC counts diluted with isotonic saline using an MLA pipette Count both sides of the hemocytometer Cells must be distributed evenly over the hemocytometer surface RBC/µL = Number of cells x dilution factor x 10 Number of squares counted REMEMBER! WBC count: There should be no more than a 15-cell difference between the highest and lowest total number of cells counted. RBC count: There should be no more than a 30-cell difference between the highest and lowest total number of cells counted. Cells counted on each side of the counting chamber should be within 10% of each other. Leukocytes Differential Count Differential slides are prepared by cytocentrifugation along with staining. At least 300 cells, but more often 500-1000 cells are counted and classified. Cells noted are macrophages, lymphocytes, CD4/CD8 ratio, neutrophils, eosinophils, ciliated columnar bronchial epithelial cells, and squamous epithelial cells. Normal BAL Differential Count Cells Percentage Alveolar 50 – 80% macrophages Lymphocytes 10 – 15% Neutrophils 7 diagnostic of bacterial vaginosis Culture Gold standard test for detecting yeast and Trichomonas Diamond medium is required for T. vaginalis Commercial transport and culture pouch system for the detection of Trichomonas Specimen must be inoculated into the pouch within 30 minutes of collection Incubated for 5 days at 37°C in a CO2 atmosphere DNA Testing DNA hybridization probe is method to identify the causative pathogen for vaginitis Results are available in 1 hour with a sensitivity of 95% Trichomonas can also be detected by DNA probes amplified by polymerase chain reaction (PCR) Most accurate method Advantage of detecting nonviable organisms Point of Care Tests Rapid diagnostic tests to quickly screen for the causative agents of vaginitis Proline aminopeptidase activity in vaginal secretions for G. vaginalis OSOM trichomonas rapid test T. vaginalis antigen from vaginal swabs in 10 minutes Visible blue line and a red internal control indicate positive result OSOM BVBLUE test detects vaginal fluid sialidase Enzyme produced by Gardnerella, Bacteroides, Prevotella, and Mobiluncus 1 minute to perform Blue or green=positive result, Yellow=negative result Vaginal Disorders Bacterial Vaginosis (BV) is the most common cause of vaginitis Due to imbalance in the ratio of normal vaginal bacterial flora Lactobacilli is the predominant organism = pH 3.8 - 4.2 Malodor and increased abnormal vaginal discharge result from this mix of organisms and is more apparent after intercourse Vaginal Disorders Three out of four features must be present to diagnose BV: 1. Thin, white homogeneous discharge 2. Vaginal fluid pH greater than 4.5 3. Positive amine (whiff) test 4. Presence of clue cells on microscopic examination Trichomoniasis Causative agent: Trichomonas vaginalis Infection classified as a sexually transmitted infection (STI) Frequently occurs with gonorrhea or Chlamydia infections Vaginitis in women and sometimes urethritis in men S/S: green-to-yellow frothy vaginal discharge, malodor, irritation, dysuria and dyspareunia, vaginal mucosa erythema, “strawberry cervix” Trichomoniasis Diagnosed with a wet mount and microscopic examinations WBCs and lactobacilli are present pH is > 4.5 Amine test will be positive Treatment: metronidazole Vulvovaginal Candidiasis Common cause of vaginitis Causative agent: Candida albicans Change in the vaginal environment that permits the overgrowth of Candida Broad-spectrum antibiotics, oral contraceptives, or estrogen replacement therapy, hormonal changes that occur with pregnancy, ovulation, menopause, patients with diabetes mellitus, iron deficiency, and HIV infection Vulvovaginal Candidiasis S/S: genital itching or burning, dyspareunia, dysuria, abnormal thick, white, curd-like vaginal discharge pH remains normal (3.8 - 4.2) Saline and KOH wet prep and Gram stain Budding yeast and pseudohyphae forms, large numbers of WBCs, lactobacilli, and large clumps of epithelial cells Vulvovaginal Candidiasis Culture and DNA hybridization probe OTC Treatment: butoconazole, clotrimazole, tioconazole, and miconazole Other treatment: oral fluconazole or intravaginal butoconazole, nystatin, and terconazole Not transmitted through sexual intercourse Desquamative Inflammatory Vaginitis (DIV) Causative agent: Beta hemolytic Gram (+) streptococci S/S: profuse purulent vaginal discharge, vaginal erythema, and dyspareunia pH >4.5, amine test negative Can occur secondary to atrophic vaginitis in postmenopausal women High WBCs, RBCs, rare parabasal and basal cells, squamous epithelial cells, reduced or absent lactobacilli Treatment: 2% clindamycin, hormone replacement therapy Atrophic Vaginitis Syndrome found in postmenopausal women Thinning of the vaginal mucosa due to decreased estrogen and glycogen S/S: vaginal dryness and soreness, dyspareunia, inflamed vaginal mucosa, and purulent discharge Microscopic evaluation is similar to DIV Treatment: estrogen replacement