Evaluation of Serous Effusions Based on Different Routine Parameters

Original Research Article

Evaluation of serous effusions based on different routine parameters available in our set- up for serous fluid examination at a tertiary care hospital in Konkan region of Maharashtra, India

Shweta Joshi-Warpe1, Bhushan M. Warpe2*, Suvarna N. Patil3, Shraddha S. Desai4, Sujata Pawar5

1Assistant Professor (Pathology), 2*Associate Professor (Pathology), 3Medical Director, 4PG-DMLT (Technician), 5Associate Professor (Paediatric Nursing) at Department of Pathology, B.K.L. Walawalkar Rural Medical College, Shree-Kshetra Dervan, Taluka– Chiplun, District- Ratnagiri- 415606, State- Maharashtra, INDIA. Email:[email protected], [email protected]

Abstract Background: The findings of Serous fluid study on routine examination vary at different regions of the country. Aims and objectives were: 1) To study the spectrum of various disorders diagnosed on routine fluid examination. 2) To identify the utility of different parameters (like Proteins, Glucose, ADA, TLC, DLC, others) used while conducting routine fluid examination. 3) To type the serous effusions whether, transudate or exudate in routine fluid examination. Methods: Inclusion criteria- All serous effusion fluids like ascitic or peritoneal, pleural, pericardial fluids included in this study which came to our Pathology Department for routine fluid examination. Results: Total cases of serous effusion observed during the study were 177 in two years. Out of which, 91 cases were of pleural effusion (51.47%), 83 cases were of ascites (46.89%) and 3 cases with (1.69%) were of pericardial effusion. Pleural effusions were mostly seen in this study. Male cases were 59.3% while female cases were 40.6%, in this study. M:F ratio was 1.45:1. Maximum patients of pleural effusion were in an age group of 61-70 years. Maximum patient of ascites were in an age group of 51-60 years. Total 81 cases of exudative pleural fluid were noted with 56.25% of cases. 62 cases of exudative ascitic fluids were noted with 63.63% of cases. Exudates were more in number than transudates in this study. Conclusion: Body fluids are one of the unique specimens received in the laboratory that require multi-disciplinary testing. Complete fluid analysis can be done with nucleated cell counts with differential diagnosis, biochemistry, culture, cytology and flow cytometry. Accumulation of fluid in body cavities is a common manifestation of a wide range of diseases that frequently present to physicians. Combined analysis of laboratory data of serous fluid samples, clinical and pathological data is essential for establishing a differential diagnosis. Malignancy and tuberculosis having serous effusions were more commonly seen in our Konkan belt. Key Words: Serous effusions, routine

*Address for Correspondence: Dr. Bhushan Malhari Warpe, Associate Professor in Pathology department, B.K.L. Walawalkar Rural Medical College, Shree-Kshetra Dervan, Taluka – Chiplun, District- Ratnagiri, Pincode- 415606, State- Maharashtra, INDIA. Email:[email protected] Received Date: 02/10/2019 Revised Date: 27/10/2019 Accepted Date: 21/11/2019 DOI: https://doi.org/10.26611/1051226

The serous body cavities are mesothelial-lined potential Access this article online spaces that surround the lungs (pleura), heart 1 Quick Response Code: (pericardium), and the abdomen and pelvis (peritoneum). Website: The pleural space normally contains 0.1–0.2 ml/kg body

www.medpulse.in weight of fluid, filtered from systemic capillaries down a small pressure gradient.2 The heart is located within a

protective membrane called the pericardium. The fluid between the pericardial membranes is called serous Accessed Date: pericardial fluid. Normally, only a small amount of fluid 22 November 2019 INTRODUCTION is present because the rates of fluid production and absorption are about the same.3

How to cite this article: Shweta Joshi-Warpe, Bhushan M. Warpe, Suvarna N. Patil, Shraddha S. Desai, Sujata Pawar. Evaluation of serous effusions based on different routine parameters available in our set-up for serous fluid examination at a tertiary care hospital in Konkan region of Maharashtra, India. MedPulse International Journal of Pathology. November 2019; 12(2): 83-90. https://www.medpulse.in/Pathology/ MedPulse International Journal of Pathology, Print ISSN: 2550-7605, Online ISSN: 2636-4697, Volume 12, Issue 2, November 2019 pp 83-90

Diseases which disrupt this balance or damage the sediment was used for smear preparation i.e. Gram, ZN membrane, cause an effusion or accumulation of fluid. A stains for bacteriological examination and Field stain for peritoneal effusion is sometimes referred to as ascites or cellularity and differential count. Wet Films of sample ascitic fluid.3 Effusions may be classified as transudates, were examined. exudates, chylous, or pseudo-chylous.1Serous effusions For Mounting of Neubauer’s chamber, 1:10 dilution of are classified as transudates or exudates on the basis of fluid (1drop of fluid + 9 drops of Turk’s fluid) was done. the fluid protein level. Classically, fluid protein level Waiting for 10 min for the cells to settle down, the >3g/dl is an exudate and <3g/dl is a transudate, in the Neubauer’s chamber was loaded with prepared solution. context of a normal serum protein level.2 In clinical Wet film field smear and Neubauer’s chamber was practice, exudative effusions can be separated effectively checked under microscope for cell morphology, RBCs, from transudative effusions by using Light’s criteria on atypical cells and TLC and DLC of given fluid. Then pleural fluids.4 This criteria classifies an effusion as fluid was sent to biochemistry section for chemical exudate if one or more of the following are present: (1) examination, where protein, glucose and ADA of fluid the ratio of fluid protein to serum protein is greater than were done. Reporting of fluid sample was done by 0.5, (2) the ratio of fluid lactate dehydrogenase (LDH) to pathologist. serum LDH is greater than 0.6, or (3) the fluid LDH level Sample was preserved for 48 hrs after its receiving. is greater than two thirds of the upper limit of normal for Volume-1 to 2 mL of serous fluid is collected in serum LDH.4 Lavender-top (EDTA) tube or green-top (heparin) tube. Fluid should be examined within 2 hours of collection, if AIMS AND OBJECTIVES there is any delay, refrigerate fluid at 2°C to 8°C; it 1. To study the spectrum of various disorders diagnosed remains stable for 48 hours.5 The routine pleural fluid on routine ‘serous’ fluid examination at our set-up of (PF) evaluation usually includes the following: cell count Konkan belt. and differential; tests for protein, LDH, glucose, 2. To identify the utility of different parameters (like adenosine deaminase (ADA), cytology and, if infection is Proteins, Glucose, ADA, TLC, DLC, etc) used while a concern, pH and bacterial and mycobacterial cultures.6 reporting routine serous fluid examination. ADA measurement is cheaper, easier and quicker to 3. To type the serous effusions whether, transudate or perform than interferon gamma levels for diagnosing exudate in routine serous fluid examination. tuberculosis. ADA levels are increased in TB cases due to activated lymphocytes.4All types of peripheral blood cells may be seen in the various body fluids. Additionally, MATERIALS AND METHODS there are cell types that are seen only in specific types of The present study was hospital based, prospective fluid or have clinical significance when seen in that observational study of two years duration from fluid.3 Total leukocyte and RBC counts are of limited 01/07/2017 to 31/06/2019. The total number of cases value in body fluid analysis except in peritoneal fluid obtained in the present study was 177. examination when diagnostic peritoneal lavage is Inclusion criteria: All serous effusion fluids like ascitic performed.1 The differential cell count in pleural aspirates or peritoneal, pleural, pericardial fluids were included in can aid in narrowing the differential diagnosis.2 this study which came to our pathology department for Although other methods are available for detecting and routine fluid examination. differentiating WBCs in body fluids, manual microscopy Exclusion criteria: Fluids other than serous effusions is still considered the gold standard, despite its many like CSF, synovial fluid, fluids from cystic lesions, pus, limitations.6 For completely clotted serous fluid broncho-alveolar lavage (BAL) were excluded from this specimens, actual cell counts will not be performed. study. Morphology will still be assessed by cyto-centrifuged, Serous fluid sample was received to Central clinical stained slides. Routine cytological evaluations would be laboratory (CCL) from different Indoor patient indicated to confirm or rule out suspected neoplastic or department sections. As soon as fluid sample was tumour cells, malignancy.5 received, it was labelled by comparing the sample with requisition form for Patient identification number, Name, OBSERVATIONS AND RESULTS Age, Sex, Lab number. After registration of sample, it  Total cases of serous effusion observed during the was sent to clinical pathology section, where it was study were 177. grossly examined for quantity, colour, appearance, deposit, coagulum, presence of blood. Half quantity of  Out of these, 91 cases were of pleural effusion sample was then taken in a test tube, centrifuged at (51.47%), 83 cases were of ascites (46.89%) and 2000rpm for 1 min. The supernatant was discarded and 3 cases (1.69%) were of pericardial effusion.

MedPulse International Journal of Pathology, Print ISSN: 2550-7605, Online ISSN: 2636-4697, Volume 12, Issue 2, November 2019 Page 84 Shweta Joshi-Warpe, Bhushan M. Warpe, Suvarna N. Patil, Shraddha S. Desai, Sujata Pawar

 Pleural effusions were maximum no in this study. transudate was seen with frank TB and positive 105 cases were males with 59.3 % and 72 cases ADA levels. were females with 40.6% in this study. M:F ratio  Out of 177 cases of serous effusion, (71 cases), was 1.45:1 in this study. maximum number of cases were having  Maximum patients of pleural effusion were in an malignancy with 40.11% followed by tuberculosis age group of 61-70 years. (21.46% with 38 cases) later, followed by 23 cases  Maximum patient of ascites were in an age group (12.99%) of liver pathology, based on clinical of 51-60 years. impression, in this study.  Total 81 cases of exudative pleural fluid were  Exudates were more common than transudate noted with 56.25%. 62 cases of exudative ascitic effusions in malignancy followed by tuberculosis fluid were noted with 63.63%. Exudates were more (40.11% & 17.5% respectively). in number than transudates in this study.  Transudate were more observed in cases with liver  90.90% of transudative effusions were having pathology (10.73%) followed by cardiovascular protein levels <2.5 g/dL. system pathology or heart failure (5%).  93.75% of exudative effusion had >3.5 g/dL of  Amongst the pathological diagnosis of serous protein level. effusions, inflammatory smears were more in  87 % of transudates had > 110 mg/dL of glucose number, that is, 106 cases with 59.88%. levels while 44.44% of exudates had glucose < 70  Among inflammatory smears, lymphocyte rich mg/dL. smears were frequent (45 cases with 59.88%).  96% of transudates had TLC of <350/cumm.  Among the malignant cases (71 cases), serous  90.27% of exudates had TLC of >550/cumm. effusions with impression as negative for  ADA was performed in all 177 cases of serous malignant cells (50 cases with 28.24%) were more effusions in this study. Maximum cases were in number. having normal ADA levels. 38 cases of  In bacteriological examination, Gram and Zn stains tuberculosis observed in this study were showing for AFB reported as negative were more common exudative effusions, 24 TB cases were showing in this study. suspicious of tuberculosis (30 to 60U/L), and 9  Only 10 cases with 5.6% were Gram stain positive cases were of frank tuberculosis positivity bacteria and 14 cases with 7.9% were Zn stain (>60UL). 4 cases were having effusion under positive for AFB, in this study. evaluation which had levels of ADA in a group of  Analyse the following representative tables and suspicious for TB (30-60U/L). Only one case of charts for detailed knowledge of the above narration.

Table 1: Site of serous effusions Site of effusions Total No of cases Percentage Pleural 91 51.47% Ascitic 83 46.89% Pericardial 03 1.69% Total 177 100%

Table2: Gender wise distribution of serous effusions Gender Percentage % Site of effusions Male Female Male Female Pleural 51 40 28.81% 22.5% Ascitic 53 30 29.94% 16.94% Pericardial 1 2 0.56% 1.1% Total 177 177 100% 100%

Copyright © 2019, Medpulse Publishing Corporation, MedPulse International Journal of Pathology, Volume 12, Issue 2 November 2019 MedPulse International Journal of Pathology, Print ISSN: 2550-7605, Online ISSN: 2636-4697, Volume 12, Issue 2, November 2019 pp 83-90

Table 3: Age wise distribution of serous effusions Site of effusion Age group Pleural Ascitic Pericardial 11-20 years 3 0 0 21-30 years 15 8 0 31-40 years 11 9 1 41-50 years 16 18 1 51-60 years 14 21 1 61-70 years 17 17 0 71-80 years 9 8 0 81-90 years 6 2 0 Total 91 83 3

Table 4: Type of serous effusions Type of fluid Percentage % Site of effusion Transudate Exudate Transudate Exudate Pleural 10 81 30.30% 56.25% Ascitic 21 62 63.63% 43.05% Pericardial 2 1 6% 0.6% Total 33 144 100% 100%

Table 5: Parameters analysed to type the serous effusion Site of effusion Protein (g/dl) Total Glucose (mg/dl) Total TLC ( /cumm) Total <2.5 2.5- >3.5 <70 70-110 >110 <350 350-550 >550 3.5 Transudate 30 01 02 33 02 02 29 33 32 01 00 33 Exudate 05 04 135 144 64 70 10 144 03 11 130 144

Table 6: ADA levels analysed in serous effusions Type of effusion ADA levels (U/L) Total Percentage % <30 30-60 >60 <30 >60 Transudate 32 00 01 33 96% 3.03% Exudate 102 33 09 144 70.83% 6.25%

Table 7: Cases of serous effusions with clinical diagnosis Clinical Diagnosis No of clinical cases. Percentage % 1)Tuberculosis(TB) 38 21.46% A)Pulmonary TB 31 17.51% B)Abdominal TB 07 3.9% 2)CVS Pathology 09 5.0% 3)Respiratory Pathology 10 5.6% 4)Liver Pathology 23 12.99% 5)GIT Pathology 07 3.9% 6)Malignancy 71 40.11% 7)Effusion ↓ Evaluaon 13 7.3% 8)Renal Pathology 05 2.8% 9) Others (pregnancy) 01 0.5% Total 177 100%

MedPulse International Journal of Pathology, Print ISSN: 2550-7605, Online ISSN: 2636-4697, Volume 12, Issue 2, November 2019 Page 86 Shweta Joshi-Warpe, Bhushan M. Warpe, Suvarna N. Patil, Shraddha S. Desai, Sujata Pawar

Table 8: Clinical impression associated with type of effusions Clinical Diagnosis Type of effusion Type of effusion (Number) (Percentage) 1)TB Transudate Exudate Transudate Exudate A)Pulmonary TB 0 31 0 17.51% B) Abdominal TB 0 7 0 3.9% 2)CVS Pathology 9 0 5% 0 3)Respiratory Pathology 0 10 0 5.6% 4)Liver Pathology 19 4 10.73% 2.25% 5)GIT Pathology 0 7 0 3.9% 6)Malignancy 0 71 0 40.11% 7)Effusion ↓ Evaluaon 0 13 0 7.3% 8)Renal Pathology 5 0 2.8% 0 9)Others ( Pregnancy) 0 1 0 0.5%

Table 9: Pathological impression on routine examination of effusions Pathological impression Total No. of cases Percentage 1) Inflammatory smears a) Neutrophils rich smears (NRS) 31 17.51% b) Lymphocyte rich smears (LRS) 51 28.81% c) Mixed inflammatory cell smears (MICS) 21 11.86% d) Florid mesothelial reaction (FMCR) 03 1.69% Total Inflammatory cases 106 59.88% 2) Malignancy a)Negative for malignancy (NMC) 50 28.81% b)Suspicious of malignancy (SMC) 04 2.25% c)Positive for malignancy (PMC) 16 9.03% Total Malignant cases 71 40.11% Total 177 100%

Table 10: Bacteriological examination of serous effusions Site of Fluid Gram stain Zn stain Positive Negative positive Negative Pleural 06 85 10 81 Ascitic 04 79 04 79 Pericardial 00 03 00 03 Total 10 137 14 163 Percentage 5.6% 77.40% 7.9% 92.09%

Pie chart 1: Bacteriological examination of serous effusion

DISCUSSION The serous body cavities are mesothelial-lined Transudate-Common causes •Left ventricular failure potential spaces that surround the lungs (pleura), heart •Cirrhotic liver disease •Hypoalbuminaemia •Atelectasis (pericardium), and the abdomen and pelvis (peritoneum).1 •Peritoneal dialysis; Less common transudative causes: Normally, movement of these organs is facilitated by a •Pulmonary embolus (10–20% are transudates) small amount of fluid, an ultra-filtrate of plasma. When •Malignancy (5% are transudates) •Hypothyroidism production and resorption of this plasma ultra-filtrate are •Mitral stenosis •Constrictive pericarditis •Urinothorax not properly balanced, fluid may accumulate within one •Ovarian hyperstimulation •Meig’s syndrome. or more serous cavities, resulting in a true fluid-filled cavity (effusion).1 Exudates are caused by conditions involving the tissue of Normally, there is just enough fluid between the two the membrane itself, such as an infection or malignancy.3 membranes to provide lubrication. The normal adult has Exudate-Common causes •Malignancy – primary / just 5-15 mL of pleural fluid and less than 50 mL of secondary / mesothelioma •Para-pneumonic effusion and peritoneal fluid.3 Serous fluids include pleural, pericardial empyema •Pulmonary embolus (with infarction) and peritoneal fluids.3 •Tuberculosis (TB); Less common exudative causes: Fluid may accumulate in the serous cavity space by a •Rheumatoid arthritis •SLE •Other connective tissue number of mechanisms: increased capillary pressure, disease •Benign Asbestos Pleural Effusion (BAPE) decreased (more negative) intra-cavity pressure (e.g. •Pancreatitis •Oesophageal rupture •After coronary artery atelectasis), decreased plasma oncotic pressure (e.g. bypass surgery •Yellow nail syndrome • Drugs • Fungal hypoalbuminaemia), increased membrane permeability infections and obstructed lymphatic flow (e.g. malignancy or infection).7 Chylothorax/pseudochylothorax: Effusions may be classified as transudates, exudates, Cause: •Hydatid disease (ruptured cyst). Chylous chylous or pseudochylous.1 effusions originate as a result of leakage from the thoracic Transudates are effusions that form as a result of a duct, often secondary to obstruction or trauma. systemic disorder that disrupts the regulation of fluid Pseudochylous effusions are caused by breakdown of balance, such as suspected perforation. cellular lipids in long standing effusions.

Characteristic Transudate Exudate Appearance Clear to pale yellow Cloudy, bloody, or turbid Specific gravity Less than 1.015 Greater than 1.015 Total protein Less than 2.5 g/dL Greater than 3 g/dL Fluid protein–to–serum protein ratio Less than 0.5 Greater than 0.5

Greater than 2/3 the upper limit of normal Lactate dehydrogenase (LDH) Less than 2/3 the upper limit of normal serum serum LDH LDH Fluid LDH–to–serum LDH ratio Less than 0.6 Greater than 0.6 Fluid cholesterol Less than 55 mg/dL Greater than 55 mg/dL WBC count Less than 100 cells/microL Greater than 1,000 cells/microL Fluid/serum cholesterol ratio <0.3 >0.3 Serum-fluid albumin gradient >1.2g/dl 1.2g/dl or less.

If the patient has a transudative effusion, therapy should benign asbestos pleural effusion (BAPE) or effusions be directed toward the underlying heart failure or occurring after coronary artery bypass surgery.1 A pleural cirrhosis. If the patient has an exudative effusion, fluid haematocrit >50% of the individual’s peripheral attempts should be made to define the etiology.4 The blood haematocrit is diagnostic of a haemothorax. concept of transudate versus exudate, as determined by Aspiration of frank pus is diagnostic of empyema, and a total protein measurements, is outdated and the use of putrid odour suggests anaerobic infection. Turbid pleural serum-fluid albumin gradient as an indicator of portal fluid may suggest empyema, although chylothorax may hypertension is more accurate, not done currently at our give rise to this appearance; the presence of a milky set-up. supernatant after centrifuging the sample implies Pleural fluid is commonly straw-coloured; this chylothorax, whereas a clear supernatant (with clearance appearance is typical of transudates but also frequently of cell debris) suggests empyema.4 occurs with exudative effusions. Blood-stained fluid is suggestive of malignancy, pulmonary infarction, trauma,

MedPulse International Journal of Pathology, Print ISSN: 2550-7605, Online ISSN: 2636-4697, Volume 12, Issue 2, November 2019 Page 88 Shweta Joshi-Warpe, Bhushan M. Warpe, Suvarna N. Patil, Shraddha S. Desai, Sujata Pawar

Ascites is defined as pathological fluid accumulation after centrifugation. Pseudochylous effusions may be within the abdominal cavity. The word ascites is derived milky or greenish and have a sparkly sheen from the from the Greek word ‘askos’, which means a bag or sack. accumulation of cholesterol crystals.1 When the fluid is Ascites usually carries an unfavourable prognosis.8 As clear to straw-coloured, further workup is unnecessary many diseases can cause ascites, particularly cirrhosis, unless chemical examinations indicate an exudative samples of ascitic fluid are commonly analysed in order process.1 to develop a differential diagnosis.8 Clinically, ascites is a RBC count is of limited value in body fluids other than consequence or complication of a number of diseases; CSF. CSF is not a serous effusion. RBC counts should including hepatic, cardiac, renal diseases, infection and not be routinely performed on all serous and synovial malignancy.8 Mixed ascites occurs when cirrhosis is fluids. If a haemorrhagic condition is suspected, a combined with a malignant or infectious process, which hematocrit may be used for confirmation. A hematocrit occurs in 5% of patients with ascites. Peritoneal greater than 1 percent in pleural fluid is typically carcinomatosis with or without liver metastases and associated with malignancy. When the hematocrit is tuberculous peritonitis are the most common causes of greater than 50 percent of the peripheral blood mixed ascites.1 hematocrit, a true haemorrhagic condition is indicated.3 Cardiac-related ascites, for example, is a transudative The nucleated cell count or WBC, is diagnostically process with a total protein level typically in the exudate important in CSF and synovial fluid, but has limited range. The serum ascites–albumin gradient (SAAG), value in serous fluids. The type of cells seen in serous determined as the serum albumin concentration minus the fluids has greater significance than the count itself. The ascitic fluid albumin concentration, is a more total leukocyte count may be useful in distinguishing physiologically appropriate test.1 between peritoneal transudates (eg, in uncomplicated The heart is located within a protective membrane called cirrhosis) from spontaneous bacterial peritonitis (SBP) the pericardium. The fluid between the pericardial caused by passage of bacteria from blood to ascitic fluid. membranes is called serous pericardial fluid. Normally, 5 In some diseases, such as peritonitis, the total WBC only a small amount of fluid is present because the rates and differential count has high sensitivity; whereas, in of fluid production and absorption are about the same.3 differentiating pleural effusions, it lacks the sensitivity required to be clinically useful.5 Pericardial Fluid Reference Value Lymphocytes are seen in variable numbers in most Appearance Clear serous effusions. Plasma cells may be seen in fluid Colour Pale yellow specimens of patients with rheumatoid arthritis, Glucose Parallels serum values malignant disorders, tuberculosis, and other conditions Red blood cell (RBC) count None seen associated with lymphocytosis.5 A lymphocytic pleural White blood cell (WBC) count Less than 300 cells/microL effusion is most often the result of viral infections, Culture No growth Gram stain No organisms seen tuberculosis or malignancy. However, up to 10% of Cytology No abnormal cells seen tuberculosis effusions are polymorph predominant and lymphocyte-rich exudates may also be caused by Volume-1 to 2 mL of serous fluid is collected in sarcoidosis, rheumatoid pleuritis, nonspecific 2 Lavender-top (EDTA) tube or green-top (heparin) tube, inflammatory diseases and chylothorax. ideally. If there is any delay in examination, refrigerate Neutrophils may vary in number, but predominance the fluid at 2°C to 8°C; it remains stable for 48 hours.5 suggests a bacterial pneumonia, pulmonary infarction, 5 When specimen volume is not limited, the specimen pancreatitis or bacterial peritonitis. A predominance of 2 should be divided into heparin (7-10 mL) for lactate polymorphonuclear cells reflects an acute process. dehydrogenase, total protein, and glucose; heparin (7-10 Eosinophils can be seen in a wide variety of disorders, mL) for Gram stain and/or acid-fast stain; EDTA (5-7 including pneumothorax, idiopathic effusions, infections, mL) for cell counts and differential; and 25 mL for neoplasms, chronic peritoneal dialysis, congestive heart cytologic examination.1 failure, vasculitis, and malignant lymphomas. Basophils Gross examination can play a vital role in determining are unusual in serous fluid, but usually accompany 5 the pathogenesis of the effusion. Transudates are usually eosinophils. Seldom it is impossible to differentiate clear and pale yellow and do not clot.5 Cloudy or mesothelial cells from malignant cells. Mesothelial cells purulent fluid is most often associated with an are seen in variable numbers in most effusions and are inflammatory process. Hemorrhagic fluid might indicate increased in sterile inflammations caused by conditions a traumatic tap, malignant neoplasm, infarction, or such as pneumonia, pulmonary infarction, and malignant 5 trauma. A chylous fluid will appear turbid or milky, even disorders.

In many inflammatory diseases, the cellular components infections were seen. The maximum serous effusions in body fluids [cerebrospinal fluid (CSF), serous fluids] were exudate. are increased, rendering essential diagnostic information.  Cardiac pathology, liver cirrhosis and alcoholic liver The diagnostic value of the total white blood cell count disease cases were having transudative type of (WBC) and differential count has been evaluated effusions. Similar observations were observed in study extensively over the years and a remarkable amount of done by Jose M. Porcel, et al. in Diagnostic approach to knowledge has been gained; yet, there is a great deal of pleural effusion in adults at Saint Thomas Hospital, clinical uncertainty whether the diagnosis should be Nashville,Tennessee.4 Similar observations were also based solely on these variables. When malignancy is seen in study done by Kristin E. Baer, et al. in serous suspected, the addition of tumour markers to the results body cavity fluid examination.1 of cytological analysis increases the rate of detection. Other biochemical markers are useful in specific CONCLUSION circumstances involving serous effusion, such as  Body fluids are one of the unique specimens received amylase in effusions due to pancreatitis, or oesophageal in the lab that require multidisciplinary testing. rupture and triglycerides in chylothorax. Complete fluid analysis can be done with nucleated To diagnose tuberculous pleuritis among exudates, cell counts with differential diagnosis, biochemistry, Pleural fluid adenosine deaminase (ADA) and Pleural culture, cytology and flow cytology. fluid interferon-gamma exhibit high diagnostic accuracy.  Accumulation of fluid in body cavities is a common ADA is an enzyme that plays an important role in manifestation of a wide range of diseases and lymphoid cell differentiation and produced in increasing frequently presents to physicians. quantities by activated T-lymphocytes in response to  Combined analysis of laboratory data of serous fluid pathogenic tuberculous bacteria. A pleural fluid ADA samples, clinical and pathological data is essential for level greater than 40 U/L has a sensitivity of 90 to 100 establishing a differential diagnosis. percent and a specificity of 85 to 95 percent for the  Malignancy and tuberculosis having serous effusions 4 were more commonly seen in our institute. diagnosis of tuberculous pleurisy. Following were our findings for discussion with respect to other studies:  In study of our institute, we routinely examined serous REFERENCES effusions on the basis of physical examination, 1. Baer KE, Smith GP. Serous body cavity fluid biochemical examination (protein, glucose, ADA), examination. Laboratory medicine 2001;32(2):85-7. microscopic examination (TLC, DLC), cytology. 2. Rahman NM, Chapman SJ, Davies RJ. Pleural effusion : Similar study was done by Najib M Rahman, et al. in a structured approach to case. Br Med Bull. 2005;72:31- 47. pleural effusion: a structured approach to care in 3. Walters J. Hematology and the analysis of body fluids. 2. Churchill Hospital, Oxford, UK 1996 Apr 29;2:4-29.  In our study, ADA levels were high in effusions with 4. Porcel JM, Light RW. Diagnostic approach to pleural tuberculosis cases having exudative type fluid. Similar effusion in adults. Am Fam Physician 2006;73(7):1211- observations were obtained in study done by Jose M. 20. Porcel, et al. in Diagnostic approach to pleural effusion 5. Fleming C, Russcher H, Lindemans J, de Jonge R. Clinical relevance and contemporary methods for in adults, Saint Thomas Hospital, Nashville, counting blood cells in body fluids suspected of Tennessee.4 inflammatory disease. Clin Chem Lab Med.  In our study, in TB cases, serous effusions showing 2015;53;(11):1689-7060. decreased Glucose and raised ADA were observed. 6. Porcel JM. Pearls and myths in pleural fluid analysis. Similar findings were observed in study done by Lin- Respirology 2011;16(1):44-52. 7. Jalal R, Aftab K, Hasan SH, Pervez S. Diagnostic value Lin Huang, et al. in Ascitic fluid analysis in the of clot examination for malignant cells in serous differential diagnosis of ascites: Focus on cirrhotic effusions. Cytopathology 2009;20(4):231-4. ascites.8 8. Lin-Lin Huang, Harry Hua-Xiang Xia, Sen-Lin Zhu. In our study, clinical diagnosis with Tuberculosis, Ascitic fluid analysis in the differential diagnosis of Malignancy, GIT pathology, Respiratory and liver ascites : Focus on cirrhotic ascites. J Clin Transl Hepatol. 2014;2(1):58-64.

Source of Support: None Declared Conflict of Interest: None Declared

MedPulse International Journal of Pathology, Print ISSN: 2550-7605, Online ISSN: 2636-4697, Volume 12, Issue 2, November 2019 Page 90