Microscopic Examination of Urine for Studes by Maam Clong 2012

San Pedro College

Department of Medical Laboratory Science Urinalysis and other Body Fluids as compiled by Sophia Ainin, RMT, MSMT

(ALL REFERENCES FOR THIS COMPILATION ARE ATTACHED AT THE LAST TWO PAGES)

Sediments Red Blood Cells Ghost cells

Crenated cells

Dysmorphic cells

Description Other name: ghost cell (in hypotonic urine)  Smooth, non-nucleated, biconcave disks, 7m in diameter  Identified using HPO and reported as ave. # per field  Diffcult to identify: 1. Lack characteristic structures 2. Variations in size 3. Close resemblance to other sediments  Closely resembles: yeast cells, oil droplets, and air bubbles

Normal Value/s

Conditions and other related disease

0-2/hpf

 Dysmorphic cells are more clinically significant because it has been associated with glomerular bleeding with a more specific type of dysmorphic cell for glomerular bleeding is G1  Malignancy of the urinary tract

Sediments White Blood Cells

Eosinophils

Mononuclear Cells  Lymphocytes  Monocytes  Macropahges  Histiocytes

Description

Normal Value/s

Conditions and other related disease

Other Names: Pus cells, Glitter cells  Contain granules and is multilobed, measures 12 m in diameter  Neutrophils predominate  Identified using HPO and reported as ave. # per field  Lyse rapidly in alkaline urine  Glitter cells because of the brownian movement occuring in the cytoplasm as the granules move producing a sparkling appearance  Pyuria – increase number of pus in urine  Preferred stain is Hansel’s stain

0-5/hpf

 May be present in various kinds of urogenital infections oe diseases  Pyelonephritis  Cystitis Pyuria, bacterial in origin  Prostatitis  Urethritis  Glomerulonephritis Pyuria, non-bacterial  Lupus erythematosus  Interstitial nephritis in origin  tumors

None

 Drug-induced interstitial nephritis  UTI  Renal transplant rejection

 Not usually identified in wet prep of urinalysis  Lymphocytes may resemble rbcs  Monocytes, macrophages and histiocytes – large cells appearing vacuolated or may contain inclusions

None

 Early stages of renal transplant rjection

Sediments Epithelial Cells Squamous Epithelial Cells

Transitional Epithelial Cells

Description  Derived from the linings of the urinary system  Represent old sloughing of cells  SEC – largest EC o Abundant, irregular cytoplasm, prominent nucleus about the size of rbc o Reported under lpo through rare, few, occasional and in plusses o Disintegrates in urine that is not fresh o Denotes improper collection especially in female patients

 TEC – also called urothelial cells o Smaller than SEC and may appear in shapes like: spherical, polyhedral and caudate because of its ability to absorb water o With centrally located nuclei o Reported under hpo (depending on lab protocol) through rare, few, occasional and in plusses o Originates from the lining of renal pelvis, calyces, ureters, bladder and upper portion of male urethra o Syncytia – TEC in clumps; following catheterization

Normal Value/s

Conditions and other related disease

If sides are obscurred with G. vaginalis, strong indication of vaginitis

Malignancy or viral infection (should immediately be referred for cytologic examination)

Sediments

Description

Epithelial Cells Renal Tubular Epithelial Cells

 Larger than wbcs  If occuring in groups of 3-4; indicative of renal damage o Reported under hpo (depending on lab protocol) through rare, few, occasional and in plusses  Eccentrically located nuclei

Oval fat Bodies

 Other Name: Bubble cells  RTE cells with absorbed lipids from the glomerular filtrate  Seen in conjunction with free-floating fat droplets  Stains with Sudan III, Oil Red O fat stains and examine through polarizing microscopy for maltese cross formation  Droplets are composed of triglycerides, neutral fats, and cholesterol producing orange-red droplets  Reported as average # per field  May be present as a result of vaginal, urethral, external genitalia or collectioncontainer contamination  Multiplies rapidly at room temp. for extended periods of time  May be present as cocci or as rods (Enterobacteriaceae)  Reported using hpo

Bacteria

Normal Value/s 0-2/hpf

Conditions and other related disease  Tissue destruction  Necrosis of the renal tubules o Exposure to heavy metals o Drug-induced toxicity o Hemoglobin and myoglobin toxicity o Viral infections (hepatitis B) o Pyelonephritis o Allergic reactions o Malignant infiltrations o Transplant rejections

None

   

Lipiduria Nephrotic syndrome Severe tubular necrosis DM

None

 UTI

Sediments

Description

Normal Value/s

Yeast

 Small, refractile oval structures that may or may not contain bud  May appear branched, mycelial forms in severe infection o Reported under hpo (depending on lab protocol) through rare, few, occasional and in plusses  Primarily Candida albicans

None

 DM  Vaginitis/ Vaginal moniliasis  Immunocompromised patients

Parasites

 Trichomonas vaginalis – pear-shaped flagellate with undulating membrane and easily identified with its rapid, darting movement  Reported under hpo (depending on lab protocol) through rare, few, occasional and in plusses  Difficult to identify when not moving because it may resemble: wbc, TEC, RTEC  Sexually transmitted  Schistosoma haematobium  Enterobius vermicularis  Oval, slightly tapered heads and long flagella-like tails  More motile in semen rather than urine since pH of urine is toxic to sperms  Found in either men or women following sexual intercourse, masturbation or nocturnal emission  Reporting will vary in every lab

None

If not for infection, possibility of fecal contamination should also be considered

Spermatozoa

None

Conditions and other related disease

 Rare clinical significance except in cases of infertility or retrograde ejaculation wherein sperm is expelled into the bladder instead of the urethra o

Sediments Mucus

Description

Normal Value/s

Conditions and other related disease

 Produced by the glands and epithelial cells of the lower UGT and the RTEC  Major constituent: Tamm Horsfall protein or Uromodulin  Thread-like structures with low refractive index  Reported under hpo (depending on lab protocol) through rare, few, occasional and in plusses

CASTS Legend: A: Hyaline cast; B: Fatty cast; C: Hyaline to finely granular cast; D: Cellular cast; E: Cellular to coarsely granular cast; F: Coarsely granular cast; G: Finely granular cast; H: Granular to waxy cast, I: Waxy cast.

Sediments

Description

Normal Value/s

Hyaline Cast

 Consists almost entirely of Uromodulin  Colorless with the same refractive index with that of urine  Normal parllel sides and rounded ends, cylindroid forms, wrinkled or convoluted shapes

0-2/lpf

Red Blood Cell Cast

 Tightly packed orange-red cells adhering to the protein matrix  Reported under hpo (depending on lab protocol) in average # per field   Reported under hpo (depending on lab protocol) in average # per field

None

None

 Infection and inflammation within the nephron  Pyelonephritis (upper UTI)

 May resemble granular casts but may be confirmed through Gram stain on dried or cytocentrifuged specimen  Will depend on the EC attached to the protein matrix

None

 Pyelonephritis

None

 Seen in conjunction with oval fat bodies  Highly refractile

None

 Advanced Tubular Destruction leading to urinary stasis– RTE Casts  Heavy metal, chemical or drug-induced toxicity  Viral infections  Pyelonephritis with accompanying wbc  Lipiduria  Nephrotic syndrome  Toxic tubular necrosis  DM  Crush injuries

White Blood Cell Casts

Bacterial Casts Epithelial Cell Casts

Fatty Casts

Conditions and other related disease  Strenuous exercise *Chronic renal disease  Dehydration *Congestive heart failure  Heat exposure  Emotional stress  Acute glomerulonphritis  Pyelonephritis  Bleeding in the UGT most specifically within the nephrons  Damage to the glomerulus

Mixed Cellular Casts

 Variety of cells may be seen  Observe for free-floating cells surrounding the cast matrix

None

 Depending on the type of cells present

Granular Casts Finely Granular Casts Coarsely Granular Casts

 Not necessary to distinguish one from the other  May be seen with hyaline casts  May become waxy in appearance if allowed to remain in the tubule for extended periods of time  Represents extreme urine stasis  Fragmented with jagged ends and have notches on their sides

None

 Strenuous exercise  Urinary stasis

None

 Chronic renal failure

   

None

 Destruction of the tubular walls

Waxy casts

Broad Casts

2-6x larger than other casts Renal Failure casts Represents extreme urine stasis Most commonly seen: granular and waxy

CRYSTALS

Sediments

Description

Normal Value/s

Conditions and other related disease

NORMAL CRYSTALS Uric Acid Crystals

 Seen in variety of shapes (rhombic, foursided flat planes or whetstones, wedges and rosettes)  Yellow-brown in color but may be colorless and have six-sided shape similar to cystine crystals (uric acid to be highly birefringent compared to the latter)

 Can be normal occurence  May be seen in patients with Leukemia receiving chemotherapy  Lesch-Nyhan syndrome  Gout • Associated with increased purine metabolism

Amorphous Urate Crystals

 May appear as yellow-brown granules  May resemble granular casts when occuring in clumps  May appear as brick red precipitates after refrigeration

 none

Calcium Oxalate Crystals

 seen also in neutral urine  CaOx dihydrate – most commonly seen as colorless, octahedral envelope or as 2 pyramids joined together at their bases  CaoX monohydrate – oval or dumbbellshaped

 May be normal  Associated with urinary calculi  Associated with foods high in oxalic acid (tomatoes, asparagus, ascorbic acid)  In monohydrate forms – ethylene glycol (antifreeze) poisoning produced in massive amounts

Sediments

Description

Normal Value/s

Conditions and other related disease

NORMAL CRYSTALS Amorphous Phosphates Crystals

 Similar to amorphous urates  After refrigeration, forms as white precipitate that does not dissolve on warming  Differentiated from urates through pH

Calcium Phosphate Crystals

 Not frequently encountered  May appear as flat rectangular plates or thin prisms often in rosette forms  Dissolves in dilute acetic acid

 Common constituent of renal calculi

Triple Phosphate Crsytals

    

 Associated with urea-splitting bacteria

Struvite Ammonium Magnesium Phosphate Triple Phosphate “coffin lid” basing it on its structures

None

Sediments

Description

Normal Value/s

Conditions and other related disease

NORMAL CRYSTALS Ammonium Biurate Crystals

 Also known as “thorny apples”  Yellow-brown spicules crystals  May resemble other urate crystals when they dissolve at 600C, converts to uric acid crystals in the addition of acetic acid

Encountered in old specimen especially in ureasplitting organisms

Calcium Carbonate Crystals

 Small and colorless with dumbbell or spherical shapes  Differentiated from other amorphous materials by the formation of gas in the addition of acetic acid

 None

Sediments

Description

Normal Value/s

Conditions and other related disease

ABNORMAL CRYSTALS Cystine Crystals

 May be found in persons with inherited metabolic disorder that prevents reabsorption of cystine by the renal tubules (cystinuria)  Colorless, hexagonal plates may be thick or thin  Differentiated from uric acid crystals through cyanide-nitroprusside test

 May have the tendency to form renal calculi particularly at an early age

Cholesterol Crystals

 Seen more pronounced after refrigeration since lipids remain in droplet form  Rectangular plates with a notch in one or more corners  Seen in conjunction with fatty casts and oval fat bodies

 Lipiduria  Nephrotic syndrome  Excessive tissue breakdown • Obstructed lymphatic flow

Leucine Crystals

 Yellow-brown spheres associated with liver disorders  Demonstrates concentric circles and radial striations  Seen accompnying tyrosine crystals

 Maple Syrup Urine Disease  Oasthouse Urine disease  Liver disorders

Sediments

Description

Normal Value/s

Conditions and other related disease

ABNORMAL CRYSTALS Tyrosine Crystals

 Fine colorless to yellow needles that frequently occur as clumps or rosettes and is associated with liver disorders in conjunction with positive chemical test results for bilirubin

 Liver disorders  Inherited disorders of amino-acid metabolism

Bilirubin Crystals

 Clumped needles or granules with characteristic yellow color  Positive chemical test results for bilirubin will be expected

 Hepatic disorders  Viral hepatitis

Sulfonamide Crystals

 Seen in patients under medication for UTI who are also inadequately hydrated  May appear as needles, rhombics, whetstones, sheaves of wheat, and rosettes from colorless to yellow-brown  Further confirmation through Diazo reaction

 Associated with tubular damage if crystals are seen in the nephron