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Laboratory evaluation of joint disease

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Abstract

Laboratory evaluation of joint disease is based on examination of synovial fluid. Synovial fluid analysis rarely yields a definitive aetiological diagnosis but it does help to confirm the presence of an arthropathy, to discriminate between broad categories of joint disease, and to guide the choice of further tests (e.g. serology, culture, polymerase chain reaction (PCR), antinuclear antibody titre, rheumatoid factor titre, etc.). This chapter considers physiology and composition, pathogenesis of joint effusion, indications and contraindications for arthrocentesis, arthrocentesis technique, synovial fluid analysis and further tests. Case examples can be found at the end of this section.

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Figures

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23.1 Schematic representation of a joint. (Reproduced from the )
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23.2 Histology of normal synovium showing the synovial space (SS) limited by a sparse layer of synovial cells (SC) embedded among a fibrous subintima (SI) with vessels (V). (Haematoxylin and eosin stain; original magnification X200) (Courtesy of Joelle Pinard)
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23.3 Cytology specimen with a fragment of synovial membrane showing a membrane lined by synovial cells (SC) and small numbers of large mononuclear cells (LM), small lymphocytes (L) and moderate numbers of erythrocytes (E). (Wright–Giemsa stain; original magnification X200)
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23.6 Sites for arthrocentesis. (a) Lateral view of the shoulder. The needle is inserted distal to the acromion at the end of the scapular spine (dotted line) and slightly caudal to the greater tubercle of the humerus (solid line). (b) Lateral view of the elbow. With the elbow extended, the needle is inserted between the olecranon (solid line) and the medial aspect of the lateral epicondyle (dotted line) into the olecranon fossa. (c) Craniolateral view of the carpus. To perform an antebrachial carpal bone arthrocentesis, the joint is flexed and the needle is inserted between the distal aspect of the radius (dotted line) and the cranioproximal aspect of the radial carpal bone (solid line), either medial or lateral to the midline in order to avoid vascular structures. (d) Lateral view of the hip. The needle is inserted cranial and proximal to the greater trochanter (dotted line) and directed ventrally and caudally. (e) Craniolateral view of the stifle. With the stifle partially flexed, the needle is inserted medial or lateral to the patellar tendon (dotted line) midway between the tibial tuberosity and the patella and directed medially and proximally towards the patella. (f) Cranial view of the left hock. With the hock slightly flexed, palpate the space between the tibia and the tibiotarsal bone adjacent to the flexor tendons and insert the needle perpendicular to the long axis of the tibia. (Reproduced from )
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23.8 Macroscopic evaluation of synovial fluid viscosity. If viscosity is normal a string at least 2.5 cm long should form when a small amount of the fluid is pulled from the tube with a stick.
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23.9 Extensive crystallization of haemoglobin deforming erythrocytes, probably due to thermal shock caused by storage of the slide in the fridge before staining. (Wright–Giemsa stain; original magnification X100)
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23.11 Direct smear of normal synovial fluid. Note the characteristic pink homogeneous background in which rare small mononuclear cells (arrowed) are embedded. (Wright–Giemsa stain; original magnification X100)
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23.12 Direct smear of synovial fluid. Note the crescents due to folding of the mucoproteinaceous material with scattered large mononuclear cells and few erythrocytes. (Wright–Giemsa stain; original magnification X200)
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23.13 Direct smear of synovial fluid from a cat with an inflammatory arthropathy. Many neutrophils, one multinucleated large mononuclear cell and a few erythrocytes are present. Note the clear spaces separating the pink granules. This finding suggests a decreased concentration of glycosaminoglycans. (Wright–Giemsa stain; original magnification X200)
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23.14 Direct smear of synovial fluid from a dog with suppurative arthritis, containing many neutrophils and fewer large mononuclear cells. Note the decreased density of pink granules in the background but persistence of cell windrowing. (Wright–Giemsa stain; original magnification X200) (Courtesy of Roger Powell)
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23.15 Fragment of cartilage appearing as dense bright pink material in which chondrocytes are embedded. (Wright–Giemsa stain; original magnification X200)
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23.16 Fragment of bone appearing as a spicule of dense acellular pink material. (Wright–Giemsa stain; original magnification X100)
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23.17 The large cell with fine granular cytoplasm with square edges and multiple oval nuclei is an osteoclast. This cell is seen rarely in joint fluid. Its presence may indicate erosion of cartilage and subchondral bone. (Wright–Giemsa stain; original magnification X1000) (Courtesy of Roger Powell)
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23.18 Cells with an oval shape, eccentric oval nuclei and moderate amounts of deeply basophilic cytoplasm are compatible with osteoblasts. Their presence indicates bone remodelling. Compared with plasma cells they are larger and have less prominent paranuclear clearing. The major axis of their nuclei is orthogonal to the major axis of the cell. (Wright–Giemsa stain; original magnification X1000) (Courtesy of Roger Powell)
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23.19 Normal canine joint fluid with a finely stippled eosinophilic background and small numbers of large mononuclear cells lined up in a row (cell windrowing). Large mononuclear cells have an oval shape and a slightly eccentric round to oval nucleus with fine mature chromatin and indistinct nucleoli. (Wright–Giemsa stain; original magnification X200)
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23.20 Normal canine joint fluid. The large mononuclear cell has an oval shape and a scant to moderate amount of light blue cytoplasm, with a few fine pink granules and rare vacuoles. (Wright–Giemsa stain, original magnification X1000)
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23.21 Synovial fluid from a dog with osteoarthritis, with more than 10% of large mononuclear cells appearing ‘vacuolated’. (Wright–Giemsa stain; original magnification X500)
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23.22 Diagnostic algorithm for the interpretation of synovial fluid cytology. CCLR = cranial cruciate ligament rupture; IMPA = immune-mediated polyarthritis; PCR = polymerase chain reaction; RBC = red blood cell.
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23.23 Synovial fluid from a dog with suppurative arthritis due to immune-mediated polyarthropathy. The nucleated cellularity is markedly increased and predominated by neutrophils. The granular background appears less dense, consistent with reduced glycosaminoglycan content. (Wright–Giemsa stain; original magnification X1000)
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23.24 Synovial fluid from the stifle of a dog with septic arthritis. One degenerate neutrophil is seen, with an intracellular chain of bacterial cocci. Rare chains of cocci are also noted extracellularly, scattered in the mucoproteinaceous background. Culture was positive for beta-haemolytic . (Wright–Giemsa stain; original magnification X1000) (Courtesy of Roger Powell)
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23.25 Elbow synovial fluid from a 4-month-old German Shepherd Dog with septic arthritis due to infection. Increased cellularity is seen, predominated by neutrophils admixed with many erythrocytes scattered amid a pink granular background. Several neutrophils appear degenerate with swollen chromatin and vacuolated cytoplasm. Two neutrophils contain several phagocytosed coccobacilli. (Wright–Giemsa stain; original magnification X1000) (Courtesy of Marta Dell’Orco)
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23.26 Synovial fluid from a dog living in the USA. Increased cellularity is observed, predominated by non-degenerate neutrophils and rare mononuclear cells. The lightly basophilic round slightly granular structures within the neutrophil cytoplasm (arrowed) are compatible with morulae of or . (Wright–Giemsa stain; original magnification X1000) (Courtesy of Raquel Walton)
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23.27 Numerous non-degenerate neutrophils, occasional small lymphocytes and one large macrophage with intracellular organisms, compatible with amastigotes of in synovial fluid from a dog with arthritis. (Diff-Quik stain; original magnification X1000)
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23.28 Synovial fluid from an 8-year-old female German Shepherd Dog with fungal osteomyelitis of the patella due to infection. Note the negative-staining branched structure surrounded by multinucleated macrophages and degenerate neutrophils. (Wright–Giemsa stain; original magnification X1000)
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23.29 Synovial fluid from a dog with immune-mediated polyarthritis. The increased nucleated cellularity is predominated by non-degenerate neutrophils and a few large mononuclear cells. The extracellular, variably sized and shaped, deep purple granules are stain precipitate and not microorganisms. (Wright–Giemsa stain; original magnification X1000)
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23.31 Synovial fluid from a dog with rheumatoid arthritis. A large mononuclear cell and a neutrophil containing variably sized deep purple granules are seen. Neutrophils with these inclusions are often called ragocytes. (Wright–Giemsa stain; original magnification X500) (Courtesy of Roger Powell)
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23.32 LE cell in the synovial fluid from a dog with confirmed systemic lupus erythematosus. Note the large intracytoplasmic pink glassy round inclusion displacing the nucleus to the periphery. (Wright–Giemsa stain; original magnification X1000) (Courtesy of Marta Dell’Orco)
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23.35 Synovial fluid from a dog with osteoarthritis, characterized by mildly increased nucleated cellularity. In this field there are a few large vacuolated mononuclear cells admixed with a small lymphocyte and a neutrophil. (Wright–Giemsa stain; original magnification X500)
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23.37 Synovial fluid from the elbow of a dog. There are a few windrowing large mononuclear cells (LM) including a group of vacuolated cells (VLM) and rare small lymphocytes (L), amid a background of many erythrocytes. Platelets are also present in a small clump (arrowed). The presence of platelets is indicative of very recent haemorrhage or contamination of the fluid with peripheral blood at sampling. (Wright–Giemsa stain; original magnification X200)
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23.38 Synovial fluid from a dog with haemarthrosis. In the field there is a macrophage with erythrophagocytosis and globular gold–green pigment, consistent with haemosiderin breakdown products. (Wright–Giemsa stain; original magnification X1000) (Courtesy of Roger Powell)
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23.39 Synovial fluid from a dog with a synovial cell sarcoma. In this field there is a large atypical spindleoid cell and one neutrophil admixed with many erythrocytes. The atypical cell is extremely large compared with the neutrophil, has very high nuclear:cytoplasmic ratio and contains multiple giant nucleoli (arrowed). The cell population has many features of atypia, including an increased nuclear:cytoplasmic ratio, multinucleation, the presence of multiple often giant nucleoli, and anisokaryosis. (Wright–Giemsa stain; original magnification X200)
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23.40 Synovial fluid from a dog with a periarticular histiocytic sarcoma. The neoplastic cells have oval to spindleoid discrete morphology and prominent criteria of malignancy including marked anisocytosis and anisokaryosis, angular nucleoli and atypical mitoses. (Wright–Giemsa stain; original magnification X1000) (Courtesy of Roger Powell)
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23.41 Blood culture bottles. The bottle on the right was inoculated with synovial fluid from a patient with septic arthritis. Note the cloudy appearance of the medium due to bacterial growth after 24 hours incubation at 37°C. (Courtesy of Marta Dell’Orco)
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23.42 Synovial fluid from the right carpus. (Wright–Giemsa stain; original magnification X1000)
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23.43 Synovial fluid from the right stifle. (Diff-Quik stain; original magnification X1000)

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