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Welcome to Tails from the Lab where.

An ever optimistic veterinarian and slightly salty.

Technician entertain listeners with true stories and tall tales revolving around laboratory diagnostics.

Names have been changed to protect the innocent, but the lab work is real.

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Each episode we hope to leave you a little smarter, a little brighter and feeling more empowered in the lab.

Welcome to today’s Tale from the Lab. Maximizing Diagnostics Part two Effusion Confusion. Welcome back.

I’m Jessica.

And I’m Holly. So where we left you last?

Oh, we aren’t going to talk a little bit first?

I’m sorry, anything, Any update?

It’s hot.

It’s hot again.

It’s summer.

It’s wonderful.

It is wonderful. It was Tank’s birthday. He turned three years old. His poor little crispy tongue. He slept on it wrong on his birthday. And there were wrinkles in it. It was like kind of bent and.

Yeah.

Does it when he goes around the house where there’s like hair and fuzz on it?

Oh yeah. I have linen sheets on my bed and there are little fuzzies from them and in the mornings I have to like pull them off and they’re all dry and stuck to his tongue.

You need, you know when you’ve been anesthetized and you’re recovering in the swabs.

Yeah.

You need swamps.

Yeah. Our dogs, they’re always a mess.

Yeah, yours are.

Yours are.

Is she.

Willow broke her. That was the one thing you told your husband?

Yeah, like I have no time. It’s too much. It’s right around Christmas and she went out for a run in the woods and broke her toe.

Yeah.

And then you struggled with it for months.

Yes.

She was in, wasn’t she in like a cast?

Yes, she got wounds from the cast.

Yeah.

Yeah. I really. It was the night before we were leaving for Christmas break and he said, I want to take you to the field. I was like, look it, we have put nothing else on my plate.

I have no time for this. Thinking I might have to bathe her. I was thinking I have no time for a bath. It was far worse.

And Brian has three legs diabetes.

I was saying my dog’s not a mess, my cat is a hot mess. They’ve heard those stories.

Yeah, it’s hot in here.

It’s really hot.

Okay, so we left you with in suspense. Well, we hope in suspense to catch up to speed.

Mac is a 12 year old male neutered Sighthound greyhound mix.

Yep.

He had presented to the hospital for an acute abdomen, essentially. We had seen his laboratory diagnostics and we are now moved on to imaging as far as his diagnostic process, trying to figure out what is the source of of his inflammatory leukogram and a mastocythemia mast cells in circulation.

And the doctor doing his due diligence was completing the minimum database by getting a urine sample and then also performing an abdominal ultrasound while he was going to get the urine sample.

The cystocentesis. Excellent.

We already described this at the end of the last episode, but he notices a diffusely irregular spleen. Right. This undulating margin, mixed echogenicity throughout, and then this pocket of fluid. So then we saw an effusion that we will show on our website and on our Instagram page.

I get really excited because we can get so much information from just even one drop of fluid.

We could get information because what an opportunity, right. In the super sick patient where we’re trying to get as much diagnostic information as possible. What a window of opportunity to look at what’s going on inside of him.

That’s minimally invasive. Right. So I think historically, certainly without ultrasound, you would have been in exploratory surgery from the get go. Right. You would have to define this out. Now, we have some details about the spleen, but in particular on an effusion, there’s a wealth of information we can glean from that.

I think historically at our animal hospital, we’ve recognized effusions, we’ve evaluated them grossly. I think the doctors would and form an opinion maybe based on the gross observation, because until we came up with a protocol and you and I were at the hospital, they would have been sent out to the reference lab and they would not have had those results till the next day.

And a lot of times we’re trying to figure out what’s happening now. Right. Whether it’s actionable based on what we see.

I think that makes a really good point, Holly, is that there is a place for the reference lab and also for point of care. And I think it really is what is right for the pet right now.

And when you have a critical patient like Mac who has acute abdominal pain, we’ve got a lot of stuff going on. We really do need to make decisions, not hastily, but we need to move forward with what our plan is going to be to relieve his discomfort.

And whether that’s going to surgery or medically managing a patient, not in Mac’s case, but really surgery is going to be our Next option. But what is going on inside that abdomen so that we can give the owner the most information before they make this huge financial decision to take their pet to surgery.

It’s really what’s right for them right now.

And it moves us further along in that diagnostic process. Because sometimes we have an infusion because of heart failure, sometimes we have it because the liver’s failing. Right. There are things that can happen that would say don’t go to surgery right now.

Right. Hold off. Because we’re worried about the anesthetic protocol. We are concerned for the heart. So it can be a turning point in the case as well.

And I think the nice thing about the way that we prepare fluids in house, you can kind of stop at the slide preparation and send your pathologist either through a slide scanner or whether, you know, you’re overnighting it to them.

You can send them a cytology slide rather than sending them fluid, which with transport, things happen, cells swell, you know, bacteria dies. Things look different in an age sample versus in a fresh sample.

And if you can make a cytology slide and even send that with your fluid sample, I think it’s really helpful to the pathologist, at least I feel like it would be helpful 100%.

And just getting, as we will talk about with effusion analysis, and we have a tech talk, which I’ll let you introduce in a bit,

that will follow on the heels of this so that they can get some more detailed information about how we process these fluids. Is that getting a total nucleated cell count from the fluid and getting a protein from the fluid even before cytology often can get us down the right diagnostic pat.

Right. Even without that finalized review from a pathologist, which would be ensuing the next day or if you scan it within an hour or two.

Okay, so 22 gauge inch and a half needle with a 6ml syringe is how we collect samples at the hospital.

Again, the doctor is using this technique, is going to be ultrasound guided. So we’re not kind of going in blind. He’s visualizing where the needle is, where the pocket of fluid is, and then he hands it to my anxiously waiting little hands.

And what am I going to put it in? So as Holly said, we have a new kind of bonus episode that are called tech talks. Kind of like TikTok, but not as fun because I’m not dancing and there’s no video.

But in the tech talk, I’m going to talk about, you know, in detail, what types of tubes to use, how to get your Protein measurements, all the different technical components of the in house fluid analysis.

And I love fluids, I think because I have the most to do as far as the lab goes with in house fluid analysis, I am taking it from collection the whole way through to a 100 count cell differential and then handing it off to Holly for kind of the icing on the cake.

And when she is not in the hospital, because I typically was there earlier than her and would get the morning fluid,

I would oftentimes let the doctor know, here’s what I’m seeing. She comes in and gives the official stamp of approval as I’m like hyperventilating because, Sammy, I’m always nervous that I’m messing something up.

Yeah, I’m testing you.

Yeah.

My whole life is a test.

Oftentimes I’m bright. I see the same thing that you do. I just don’t have the confidence to say this is. This is what I. This is the official.

Yeah, well,

yeah,

necessarily a lack of confidence in it. You do know what you’re seeing, but you’re also not a board certified pathologist. Right. So you don’t have to be the final say on it.

Right.

Thank God.

And even from my perspective, I feel so fortunate to be part of a team of providers. Right. Who are working for his medical care, surgical care, so that it does. Not everything rests on me either.

Right. We get a whole bunch of information from a bunch of the technicians and doctors involved in the case, everyone adding their expertise. Right. I wanted to share when you mentioned getting there early in the morning and getting the morning fluid.

Right. Made me think. And telling our ER doctors in particular or ER staff is that it is really common when an animal presents really sick, they’re commonly dehydrated. Right. They’re not eating, maybe not drinking at home, they might be vomiting.

And when they get their flash ultrasound or detailed ultrasound, they do. The ultrasonographer does not appreciate any effusion. And so our overnight doctors see this all the time. And then in the morning when they get transferred to the specialist and they repeat the ultrasound, now there’s fluid.

And I see the frustration from the ER doctors say, I looked, there was no fluid. And now we’re sure they’re actually correct and that they’re so dehydrated they don’t show their effusion.

Right. But once we rehydrate them, they’ve been on IV fluids overnight. Check again,

because again, it’s an opportunity for a wealth of information of what’s going on inside that patient that’s minimally invasive. And you have them in your presence. Right. If you’ve hospitalized them overnight, flashing them again in the morning to look for an infusion because what an opportunity.

Yep.

So the parts of a fluid analysis are going to be color and turbidity. The other part of it includes our protein measurement and then also our total nucleated cell count and then our hundred cell count differential to really visualize what those cells look like.

So let me tell you what the total nucleated cell count in the protein is. Which would you prefer first?

I like the cell count first.

Okay, so the cell count is 58,000 cells per microliter. And the total protein, which you want second is 5.8 grams per deciliter.

So when we have an elevated cell count and elevated protein level, that puts us into an exudative category. So this is an exudate and meaning high number of nucleic cells, high level of protein.

And when I think about what’s happening in the body then. Right, so somewhere outside the vasculature, some tissue source in the body cavity, in this case in the abdomen, there’s a source of inflammation.

And the inflammatory cytokines are calling in the cells to this focus of inflammation. So the neutrophils are extravasating from the blood, they’re coming to the site of inflammation. Macrophages will get called there as well to try to help remodel the tissue or, or serve as antigen presenting cells if there’s an infection in the area.

And then we have big gaps in the endothelial cells that’s allowing these proteins to fall through as well. So you can picture this inflammatory focus there in the abdomen now with these inflammatory cytokines calling in the neutrophils or mixed inflammatory cells, allowing those proteins to drop through as well.

When we sample that fluid, we see those nucleated cells, we see the high neutrophil count, we see, we see the high protein that we can measure. So now we’re in an exudative category.

And so now we say now we need to find within this body cavity, within the abdomen, what is the tissue source of that inflammation.

These are really, in my mind, the fun fluids. They’re when I go on a search for something, why oftentimes we’re looking for bacteria, we can see biopigment.

Sometimes it’s because of pancreatitis. So we’ll see really kind of vacuolated macrophages that are just full of all this fluid, frothy, lippity looking stuff.

And I think what becomes so neat about them?

A.

Because you’re looking for something, as you said, and it’s a big call to say whether this needs to go to surgery because there’s bacteria in there, no matter the cause. Right.

We know that’s a problem. There’s biopigments in there, there’s compromise of the biliary tree, the gallbladder we need to cut as well. Or if it’s just pancreatitis, we are not cutting.

Right. So it’s a huge bifurcation on how we’re going to handle this case and again, why we get so much opportunity to sample that fluid and process it in clinic.

So as you said, for Mac’s case, he has a highly cellular fluid. So just a direct smear is adequate for us to evaluate the cell types that are in there and the vast majority of nucleated cells as they look under the microscope.

So stained routinely. Right. Are neutrophils and then there’s macrophages in there. Right. They’re there. They’re trying to clean up and assist in the immune stimulation.

And whenever we have a rich neutrophilic inflammation, as you said, I’m going through the same thought process. Right. So we’re looking for bacteria especially. He’s got this acute abdomen or looking for bile pigments.

We have some chemistry tests that we can do to help us with that. That you’ll talk about in the part two of the effusion analysis in his case, it was pretty obvious and pretty quickly.

We came across a lot of rod shaped bacteria. So they were present intracellularly in some of the cells. Some of the neutrophils, as well as some of the extracellular fluid and rod shaped bacteria almost invariably originated in the GI tract.

I would like to say that it’s important to try to find them intercellularly. If I see them kind of in the background, it’s a, it’s a note in my mind that I saw them, but I’m really looking for them inside of neutrophils because then I am sure that it’s not an artifact from my stain.

Yeah, that’s great. Wasn’t some contamination of something.

Right.

Any of those are possible in the lab where fecals are being run nearby. Any of that stuff is. Is a consideration.

I mean, really, you should have a clean and dirty set of stain. But I realize that that may not be possible in all places. So there could be bacterial contamination from like a fecal smear.

And one thing that I like to use As a, as a tip to feel confident in my identification of bacteria intracellularly is that they, the bacteria stain blue, Right. The nuclei are more of a purple.

And I want to see those discordant because another thing that can be tricky is apoptotic cells. And so those are neutrophils or other nucleated cells going through their programmed cell death.

And they’ll break into, they call it karyorexis and karyolysis. And the nucleus breaks down into blebs and so they can end up looking like cocci or other infectious agents as these smaller purple.

Right. Inclusions in the cytoplasm. But for to confirm bacteria, I want to see the purple nucleus intact or it could be degenerate and then blue staining, bacteria included.

And we will show you pictures of max fluid and also I’ll pop up some on Instagram of epitotic cells because I think that is a really important point because with chronicity of the fluid, so if it’s been hanging out in the abdomen for a while, we can see a lot of those cells.

And I have had doctors who say, oh look, I found an organism. And then I have to say, oh, okay, well I think that’s an epitotic cell. But we’ll have Dr.

Brown confirm.

So now what we know on Mac’s case. Right. Again, presented with an acute abdomen, anorexic, lethargic and painful. And now we know a couple more things, right? Indeed, we did find a septic focus in his abdomen, likely slump, compromise of the GI tract that allows for these free bacteria.

And those phagocytosis are the neutrophils. And we know he has an irregular spleen, lumpy, bumpy spleen throughout. Not sure how that relates to it yet. And he has amastocythemia, which may or may not be a non specific inflammatory response.

Or maybe they’re neoplastic. There’s a lot, you know, we know for a septic abdomen, it’s surgical, right. We have to fix whatever, compromise the GI tract to allow that translocation into the abdominal cavity.

So one is surgical. It would give us an opportunity to look at the spleen, remove the spleen as potentially as indicated. But we don’t know the outcome. Right. We don’t know what we’re gonna find if we go in there.

And mom said, well, we know he’s a septic abdomen, some compromise of his GI tract. He has an irregular spleen.

If these are fixable, Right. If you think we can go in there and we can find something in the GI tract that we can surgically repair. If we can remove that irregular spleen, I’m all for it.

Right. I know he’s older. Right. But he means a lot to me. It’s worth it to me.

And she thought he was. Well recently,

sort of just recently. So her hope was she could get him back to how he felt a couple weeks ago.

But we truly call it an exploratory because if it was the same disease process and there was metastatic neoplasia, she would choose to euthanize on the table.

Correct.

So gets placed on fluids, pain control, and then gets anesthetized, prepped for surgery. And I’m still creepily waiting because I know a spleen is coming out. And they did indeed get the spleen out.

And I hope I can post an image of the spleen and Instagram, not get angry at me for sensitive content.

It’s amazingly bumpy. Bumpy, yeah. Throughout the likes of which I had never seen.

Yeah. I feel like spleens, we oftentimes maybe have one good size or there’s like four. And you can, if you palpate the spleen, once it’s kind of out, you can find some.

Some nodules. But this was all over. You’re right. I had never really seen before or since.

I have not. It was. It was pretty remarkable. And then they found the source. Right. Of the septic peritonitis and that he had a perforation near his pylorus.

So now we have two samples. Two more samples. Right. We have the spleen to look at as well as this area of perforation. Mom was going to make decisions on the outcome based on what we could figure out.

And so in looking at one of those nodules, when Jessica made the slide preparation for me and put under the microscope. So as you said, stain routinely. It is wall to wall mast cells.

So he had splenic or maybe visceral mast cell neoplasia. At least splenic mast cell neoplasia, which makes sense of how all these mast cells got into circulation. Right. Easily coming out of the spleen.

So we know one diagnosis, splenic mass cell neoplasia. So then the question is, is that also what is in the stomach Right near the pylorus that has created that perforation?

So we also. You also scrape the tissue from that area. And in truth, I hadn’t seen cytology from a perforated tissue. That’s not a typical section that I get to look at.

And so I wasn’t sure What I’d see cytologically, um,

from a perforation. But what I was looking for in my mind was, does this dog have lymphoma? Does it have gastric adenocarcinoma? Does it have mast cell neoplasia? Those are the three things I was worried about.

That underlying neoplasia from which mom may have euthanized because he’s involved in multiple tissues. Um, and I felt confident that round cells exfoliate really well. And so if he had lymphoma or mast cell neoplasia in that section, likely it would be sampled and.

And I would expect otherwise, maybe to see the atypia of gastric carcinoma. What I saw was degenerate neutrophils, bacteria, fibrin, macrophages, maybe. Exactly what I would expect if there was just a perforation.

So it is possible there’s a foreign body or something related. But more likely, knowing how many mast cells, neoplastic mast cells, he has in his body, that this was an ulceration, that in perforation as a result of the increased histamine from his mast cell neoplasia, that was the hope.

And you and I both remember. Well, you know, we sent off both those samples for confirmation from a histopathologist, but mom said if that’s possible and we don’t have overt evidence for metastatic disease or systemic involvement,

she was willing to take them through recovery and wait for the histopathology.

And that’s what they came back as.

Yeah.

Which was. I was, like, waiting with bated breath.

Yeah. Cause that’s a big difference in diagnosis. If they had found either mast cells or lymphoma or adenocarcinoma in that second site.

Yeah. And I think I would have felt terrible that Mac would have gone through that full recovery from surgery. Mom’s wallet would have gone through everything that took only to find out that he had metastatic disease.

But he did get two doses of chemotherapy for any residual mast cells that were in circulation or other tissues, and he completely recovered with no mast cells detectable.

It’s a happy case.

It’s a wonderful case.

Yeah.

Sarte comes from Mac’s case.

Or don’t throw away your fluids.

Oh, my gosh. What an opportunity.

Yep. Even one drop, you can make a direct slide. If you had two drops, you can make a direct slide and get a protein. And that would give you the information you needed to,

like, classify the fluid, determine what’s going on inside there. You could send the cytology off to the reference lab or scan it in if you had a slide scanner. So one drop of fluid can give you information.

Yeah. And especially if you determine that it’s an exudate like it is a max case, then you have a cytology prep to start looking for these things that require surgery. Right.

It’s not a passive effusion. There’s an active inflammatory focus. Look for bacteria, look for bile pigments or image the pancreas. Do your chemistry testing. Right. And see if you have support for pancreatitis.

That’s the biggest take home.

Yep.

You don’t know unless you look.

You don’t see you next time.

And you want to promote the tech talks.

Yes, I would love to promote the tech talks. So tech talks will be coming out intermittently paired with cases like this, where we don’t want to completely focus on the technical aspect of it.

We want to tell the story, but we still want to give you the tools that you need in your toolkit to be able to do these things on your own.

So you’ll have a tech talk, a part one and a part two correct on effusion analysis that they can follow up on. Max case.

Yep.

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