SYNOPSIS
OF
DISSERTATION
Dr. MAMATHA. S.V.
P.G. IN PATHOLOGY
SREE SIDDHARTHA MEDICAL COLLEGE AND RESEARCH CENTRE
AGALAKOTE, TUMKUR – 572 107.
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARNATAKA.
ANNEXURE – II
PROFORMA FOR REGISTRATION OF SUBJECTS FOR
DISSERTATION
NAME AND ADDRESS OFTHE CANDIDATE / DR. MAMATHA .S.V
POST GRADUATE IN PATHOLOGY
[DEPT. OF PATHOLOGY ]
SREE SIDDHARTHA MEDICAL COLLEGE
AND RESEARCH CENTRE, TUMKUR – 7
KARNATAKA
NAME OF THE INSTITUTION / SREE SIDDHARTHA MEDICAL COLLEGE
AND RESEARCH CENTRE,
AGALAKOTE, TUMKUR – 7
COURSE OF STUDY AND SUBJECT / M.D. in PATHOLOGY
TITLE OF THE TOPIC / STUDY OF SYNOVIAL FUILD ANALYSIS IN DIAGNOSIS OF JOINT DISEASES
6. BRIEF RESUME OF THE INTENDED WORK
6.1 NEED FOR THE STUDY
· Synovial fluid analysis is one of the most important diagnostic tests in Medicine. Yet it is not routinely practiced in most of the laboratories1
· Microscopic analysis for the number and type of cells, as well as presence or absence of crystals is equally important2
· The addition of bacteriological, chemical and immunological tests further enhances the ability to discriminate between vast number of disorders that may affect the knee2
· We are receiving many synovial fluid samples with joint effusions of various etiologies.
The present study is taken to examine fresh synovial fluid aspirates with standard protocol of gross and microscopic examination with wet mount preparations to specify the cytomorphological features of abnormal synovial fluid and to evaluate the contribution of various cytomorphological features observed in synovial fluid with addition of serological, immunological and culture studies in the diagnosis of various arthropathies.
6.2 REVIEW OF LITERATURE
1. Dieppe PA et al (1979)3 have analysed synovial fluid in patients suffering from rheumatoid arthritis 30 cases, osteoarthritis 34 cases, pyrophosphate arthropathy 25 cases and gout 6 cases. Synovial fluid from patients with rheumatoid arthritis had a higher cell counts and greater proportion of ploymorphonuclear cells.There was no difference in cell counts in patients with osteoarthritis and chronic pyrophosphate arthropathy.
2. Zaharopoulos P et al (1979)4 have examined 19 fresh synovial fluid samples from 19 cases of arthritis. Cases of gout and pseudogout presented an acute inflammatory appearance with numerous polymorphonuclear leukocytes. In gout monosodium urate (MSU) crystals were identified.In cases of pseudogout calcium pyrophosphate dihydrate (CPPD) crystals were identified.
- Davis MJ et al (1988)5 have examined synovial fluid cytology of 77 patients with Rheumatoid arthritis which showed the following cytology.Differential leucocyte count; polymorphs 65% lymphocytes 23% monocytes 12% and ragocytes 4%.
4. Shmerling R.H et al (1990)6 have analysed synovial fluid test results of 100 consecutive patients undergoing diagnostic arthrocentesis. In 69 patients a definite inflammatory or noninflammatory categorization could be made. Sensitivity 0.84 and specificity 0.84.
- SwanA et al (2002)7 have studied the sensitivity and specificity of synovial fluid microbiological test. These were estimated from a study, comparing synovial fluid results from 19 patients with septic arthritis with those of 100 samples from patients with other disorders. The sensitivity was estimated to be 75 to 95 % for culture. 50 to 75% for gram stain and specificity was estimated to be over 90% for culture and quite high for gram stain.
6. Kulkarni SB et al (2004)8 have examined 30 cases prospectively of joint diseases, on whom synovial biopsies was done during arthroscopy and in 50% of the cases synovial fluid was analysed during arthroscopy. Synovial fluid analysis showed noninflammatory 3 and inflammatory 12 cases. Synovial biopsy was categorized non inflammatory in three cases (all baker’s cyst), chronic nonspecific inflammation 20 cases, tuberculosis 4 cases and rheumatoid arthritis 3 cases. This study revealed synovial fluid analysis and synovial biopsy are complementary to each other for arriving at a specific diagnosis.
7. Abdullah S et al (2007)9 have analysed 80 synovial fluid samples. Gross analysis was performed in all samples. Gross analysis was found better than cell count to determine a potentially septic joint fluid.
6.3 objectives of study
1. to analyse the gross, microscopic, biochemical and microbiological variations in the synovial fluid in various causes of joint effusions.
2. To correlate synovial fluid cytology with biopsies whenever possible to increase the accuracy of diagnosis.
7. MATERIALS AND METHODS
7.1 SOURCE OF DATA
Patients attending OPD and admitted patients in the Orthopaedic department at
1. Sri Siddhartha Medical College and Research Centre, Tumkur.
2. Government District Hospital (General Hospital) Tumkur.
7.2 METHODS OF COLLECTION OF DATA
3. Sample size approximately 100 synovial fluids.
4. Duration of study- from October 2007 to October 2009.
All the patients with one or more joint effusions will be taken up for study. Patients details with reference to age, sex, symptoms and their duration with clinical findings, their association with trauma, history of steroid injection into the joint and previous history of joint aspiration will be noted in addition to various other lab investigations when contributory.
SPECIMEN COLLECTION
Synovial fluid must be collected with sterile, disposable needles and plastic syringes to avoid contamination by birefringent particulates. The syringe may be heparinized with 25 U of sodium heparin/ml of Synovial fluid in routine arthrocentesis. Oxalate, lithium heparin and powdered ethylenediaminetetraacetic acid (EDTA) anticoagulants should be avoided because they form crystal artifacts that may be misleading during aspiration. Turn or manipulate the joint to ensure mixing of its contents10
GROSS EXAMINIATION
Of synovial fluid is done for total volume, colour and clarity10.
MICROSCOPIC EXAMINATION
Cell counts are usually performed in a standard hemocytometer10
Neubauer hemocytometer is used.
MUCIN CLOT TEST
Addition of acetic acid to synovial fluid precipitates hyaluronate into mucin clot which may be graded as good, fair and poor10
STRING TEST
To test for viscosity of synovial fluid2.
CRYSTAL EXAMINATION
POLARISING MICROSCOPE
A high quality polarizing microscope with a first order red plate compensator should be used. The polarizer filter is placed directly above the light source. The analyser (another polarizing filter) is placed between the specimen slide and microscope oculars, oriented 90 degrees from the polarizer to produce a dark background. The compensator is placed between the polarizer and analayzer usually oriented 45 degrees (halfway) between the planes of the 2 polarizing filters10.
Examination of the crystals is also done by placing a few drops of specimen carefully on a precleaned glass slides, wet mounting them, sealing the edges with nailpolish to prevent rapid dehydration and examining then under light microscope. Lowering the condenser facilitated the identification of crystals by increasing their refractility10.
7.3 INCLUSION CRITERIA
All the patients with one or more joint effusions will be included in the study.
7.4 EXCLUSION CRITERIA
Whether by arthrocentesis or arthroscopy to prevent septic contamination of the sterile joint in patients with septicemia or with cutaneous soft tissue infection mimicking acute arthritis should not be subjected to arthrocentesis to avoid direct introduction of the offending organisms into the joint space2.
7.5 DOES THE STUDY REQUIRE ANY INVESTIGATIONS ARE INTERVENTIONS TO BE CONDUCTED ON PATIENTS OR OTHER HUMANS OR ANIMALS?
No interventions, the study only requires investigations.
7.6 HAS THE ETHICAL CLEARENCE BEEN OBTAINED FROM YOUR INSTITUTION?
yes
8. LIST OF REFERENCES
1. Shariff S. Synovial fluid. In: Text Book of Pathology. Ed. Nagalotimath, SJ, Deodhar K.P, Talib VH, 1st edn. Delhi: CBS Publishers, 1998: 101-04
2. Franks AG, Mor A. Inflammatory Arthritis of the Knee. In: Insall and Scott Surgery of the Knee. Ed. Scott WN, Clarke HD, O’Connor MI et al. 4th edn. Vol 2. Philadelphia: Elsevier, 2006: 989-94
3. Dieppe PA, Crocker PR, Corke CF, Doyle DV, Huskisson EC and Willoughby DA. Synovial fluid Crystals. Quarterly Journal of Medicine. New Series XL VIII, 1979; 192: 533-53.
4. Zaharopoulos P, Wong J. Identification of Crystals in Joint Fluids. Acta cytol 1980; 24(3): 197- 202.
5. Davis MJ, Denton J, Freemont AJ and Holt PJL. Comparison of Serial Synovial fluid cytology in rheumatoid arthritis. Ann Rheum Dis 1988; 47:559-62.
6. Shmerling RH, Delbanco TL, Tosteson AN, Trenthan DE. Synovial Fluid tests. What should be ordered. JAMA 1990; 264(8): 1009-14.
7. Swan A, Amer H, Dieppe P. The value of Synovial fluid assays in the diagnosis of joint disease: a literature Survey. Ann Rheum Dis 2002;61:493-98.
8. Kulkarni SB, Vora IIa, Abraham S, Srivastava S, Sheth J, Jignesh S, Chaturvedi R. Role of Synovial fluid analysis and Synovial Biopsy in Joint Diseases. Bombay hospital journal/research. 2004; Oct 1-5.
9. Abdullah S, Young Min SA, Hudson SJ, Kelly CA, Heycock and Hamilton JD. Gross synovial fluid analysis in the differential diagnosis of joint effusions. J Clin Pathol. 2006; 60(10):1144.
10. Knight JA, Kjeldsberg CR. Cerebrospinal, Synovial and Serous Body fluids. In: Henry’s Clinical Diagnosis and Management by Laboratory Methods. Ed. McPherson RA, Pincus MR. 21st edn. New Delhi: Saunders, 2007: 437-41.
8