Spinal Information and Courses from MediaLab, Inc.

Leukemia and lymphoma cells can be found in cerebrospinal, pleural, peritoneal and pericardial fluids at the time of diagnosis as well as anytime during the course of the disease. They can be found in any of these fluids, even when there are not abnormal cells present in the peripheral blood. Just as there are many morphological variations of leukemia and lymphoma in the peripheral blood and bone marrow, there are as many variations of leukemia/lymphoma in cytospins from fluids.Once the diagnosis is made from the initial tissue samples, there may be frequent spinal taps performed to monitor disease status and to instill intrathechal chemotherapy to prevent the development of central nervous system involvement by the leukemia or lymphoma.Cytospins are made for each sample and must be meticulously scrutinized. If any display abnormalities indicative of a disease state, or if there are any suspicious cells, then they should be sent for hematology or pathology review in compliance with your hospital's policy.

When a spinal tap is performed correctly, the cell types found in the cytospin present a "snapshot" of the cerebrospinal fluid cell content. When there is difficulty obtaining a clean tap, the cell types present will reflect the type of fluids that are co-mingled with the cerebrospinal fluid. In traumatic taps, the cell types and proportions of red and white blood cells present will mirror that found in the patient's peripheral blood, as there has been a contamination of peripheral blood (from the trauma) mixed into the cerebrospinal fluid during the sample collection.In patients with softer bones (infants and osteopenic patients), it is not uncommon for the contamination to come, not from peripheral bleeding, but from bone marrow found inside the softened spinous process that was penetrated inadvertently during the procedure. When this occurs, any or all of cell types found within the bone marrow can be present in the cytospin.In the image shown here there are early nucleated RBC and WBC precursors, typical of contamination with bone marrow.

Gelfand MS. Bakhtian BJ. Simmons BP.: Spinal sepsis due to Streptococcus milleri (anginosus): two cases and review. Reviews of Infectious Diseases. 13:559-63, 1991 We have recently cared for two patients with spinal sepsis secondary to infection with Streptococcus milleri (anginosus). One patient had a spinal epidural abscess and the other had meningitis as well as a spinal subdural empyema. A review of the English-language literature revealed only two previously reported cases of spinal epidural abscess due to S. milleri (anginosus) and no cases of spinal subdural empyema due to S. milleri (anginosus). We report two cases of spinal sepsis due to S. milleri (anginosus) and discuss pertinent literature.

The volume of spinal fluid in an adult is about one ml per pound, or approximately 150 ml. In babies up to 4 weeks, there is an average of 10 - 60 ml of fluid.

Examination of CSF provides vital information which aids in the diagnosis of a wide variety of disorders: benign disordersmeningitisencephalitisbrain abscesssubarachnoid hemorrhagecerebral infract vs. intracerebral hemorrhagemultiple sclerosisGuillian-Barre's syndromespinal cord tumormalignant disordersleukemia CNS involvementmalignant tumors of the brain or spinal cordmetastasis of malignant tumors

A syringe is used to remove 6 - 15 ml of spinal fluid. Less fluid is removed in babies and small children. The CSF sample is divided among 3 - 4 tubes, with 2 - 4 ml in each tube. Glass tubes should be avoided due to cell adhesion which may affect the cell counts or differential. The tubes are numbered in the order in which the CSF is obtained.

Spinal fluid samples are either clear or turbid. Some sources use the following rating system for turbid CSF specimens: 0 = crystal clear fluid 1+ = faintly cloudy, smoky, or hazy 2+ = turbidity clearly visible but newsprint read easily through tube 3+ = newsprint not easily read through tube 4+ = newsprint cannot be seen through the tubeTurbidity may be caused by leukocytes, erythrocytes, fungi, bacteria, amoebae, contrast media, or aspiration of epidural fat during puncture.200 leukocytes/mm3 will cause slight turbidity (1+); increased numbers of WBCs will cause increased turbidity. At least 400 erythrocytes/mm3 are needed to produce 1+ turbidity.Occasionally CSF will have an oily appearance due to the presence of substances remaining in the CSF after radiologic (x-ray) procedures have been performed.

Four blast cells are seen in this field. Notice the smooth chromatin pattern, nucleoli, high NC ratio and irregularly shaped nuclei. These blasts were observed in a spinal fluid sample from a patient with acute lymphocytic leukemia.

Tissue cells that are never seen in peripheral blood but are often seen in spinal fluid samples are presented in the table below: Cells Causes macrophages RBC's in CSF viral meningitis tubercular meningitis ependymal normal - due to shedding of cells that line the ventricles pia arachnoid mesothelial cells (PAM) normal - due to shedding of cells lining the arachnoid space These cells are important because they must be differentiated from tumor cells and blast cells.

Malignant cells that have broken away from a tumor within the brain or meninges may also be present in spinal fluid. Tumor cells may be difficult to distinguish from macrophages or pia arachnoid mesothelial cells. While blasts in the CSF also indicate malignancy, in particular leukemia, for the purposes of this discussion, they are considered separately.

Four small mature lymphocytes are seen in this picture. Sixty percent of the cells found in normal adult spinal fluid are lymphs.

Blast cells may be seen in the spinal fluid when cell proliferation in acute leukemia or lymphoma spreads to the central nervous system. The arrows indicate the two blasts in this field. Notice the smooth chromatin pattern in the nucleus and prominent nucleoli in both cells. Notice that an Auer rod is present in the cytoplasm in the blast to the right. The Auer rod indicates that these blasts are myeloblasts rather than lymphoblasts. A segmented neutrophil and several red cells can also be seen.

Malignant cells that have broken away from tumors located in other areas of the body may be seen in spinal fluid. All of the cells in this field are tumor cells. The cells in this slide are characterized by an open, loose chromatin pattern, nucleoli and vacuoles. Notice that the vacuoles are present in both the nucleus and the cytoplasm. Vacuoles in the nucleus are an unusual finding even in tumor cells. Tumor cells are often found in clumps and may have more than one nucleus due to their erratic mitotic patterns. Malignant cells sometimes have an irregular nuclear shape. Bizarre granules may be found in malignant cells but are absent in mesothelial cells.

Specialists in immunohematology perform all testing prior to blood transfusions and work to prevent transfusion infections. They also investigate any post-transfusion reactions. This specialty includes all lab procedures performed in the specialty of histocompatibility. Specialists in clinical chemistry analyze body fluids such as blood, urine, and spinal fluid to determine the chemical makeup, including the amount of carbohydrates, proteins, enzymes, and trace elements. The special covers urine microscopics and chemical evaluation of the liver, kidneys, lungs, heart, and other vital organ systems. This specialty also covers all testing performed in the specialties of radioassay and blood gas analysis. Specialists in blood banking can perform all immunohematology testing as well as testing from the specialties of clinical chemistry, hematology and serology/immunology that relates to donor blood. Clinical laboratory personnel who are licensed in the specialties of immunohematology, clinical chemistry, hematology, and serology / immunology may perform all tests in the blood banking specialty.

Epithelial cells in large numbers within sputum smears means that the specimen is predominantly oral saliva, rather than true sputum from the lung. Epithelial cells in urine smears indicate that the sample has been contaminated by organisms found on the vulva or distal urethra. Bacteria found near or on epithelial cells are usually normal contaminating bacterial flora.White blood cells indicate inflammation and possible infection. The direct smear examination should focus within and around these cells.Red blood cells in a direct smear are not usually significant.Yeast may be present as normal flora in upper respiratory tract or genital tract. They may be significant if they predominate, or if budding yeast forms are seen.Hyphae are more likely to indicate the presence of fungal infection, but this determination requires correlation with clinical findings.Bacteria found in spinal fluid, blood, tissue and specimens from other sterile sites are always significant.Body fluids which are normally sterile must be examined carefully. If only one organism per oil immersion field is identified, then there are about 105 organisms per mL present in the sample! Bacteria observed in specimens from the throat, genital tract and other areas containing normal flora suggest infection only if their composition and type varies significantly from the norm.