Clinical Microscopy – TSFT No. 2

Microscopic Examination, Renal Calculi, Metabolic Disorders, Pregnancy Testing, Feces

400, 5, 2500, 5

Urine sediment preparation:

• _____ RCF for _____ minutes

• _____ RPM for _____ minutes

0.5 or 1.0 mL

Volume of urine that stays in the tube after decanting:

20, 0.02

Sediment transferred to glass slide after decanting:

• ___ uL

• ___ mL

22 × 22 mm

Dimensions of coverslip used:

10, 10, reduced

Microscopic examination:

• ___ LPF

• ___ HPF

• under _________ light

Calcium oxalate calculi

• Major constituent of renal calculi

• Very hard, dark in color with rough surfaces

Uric acid and urate calculi

• Associated with increased intake of foods with high purine content

• Also with Uromodulin Kidney Disease

• Yellowish to brown red and moderately hard

Cystine calculi

• Seen in hereditary disorders of cystine metabolism

• Yellow-brown, greasy & resembles old soap

• Least common calculi

Phosphate calculi

• Pale and friable

Triple phosphate calculi

• Accompanied by urinary infections involving urea-splitting bacteria (Proteus vulgaris)

• Branching/staghorn calculi resembling deer antlers

Overflow, renal type

Two types of aminoacidurias:

PKU, tyrosyluria, alkaptonuria, melanuria

Phenylalanine-tyrosine disorders (4)

MSUD, organic acidemias

Branched-chain amino acid disorders (2)

Indicanuria, argentaffinoma

Tryptophan disorders (2)

Cystinuria, cystinosis, homocystinuria

Cystine disorders (3)

Hurler syndrome, Hunter syndrome, Sanfilippo syndrome

Mucopolysaccharide disorders (3)

Lesch-Nyhan disease

Purine disorder (1)

Acute intermittent porphyria, Porphyria cutanea tarda, Congenital erythropoietic porphyria, Variegate porphyria, Erythropoietic porphyria, Lead poisoning

Porphyrias/related (6)

Galactosemia/galactosuria, glucosuria, lactosuria, fructosuria, pentosuria

Carbohydrate disorders (5):

Phenylketonuria

The most well known of the aminoacidurias

Phenylketonuria, phenylpyruvic acid

• Characterized with a MOUSY urine, sweat, and breath odor

• May lead to severe mental retardation

• High ____________ in urine

Tyrosyluria, rancid butter

• Accumulation of excess tyrosine in the plasma producing urinary overflow

• Characterized by ___________ odor

Fumarylacetoacetate hydrolase (FAH)

Type 1 tyrosyluria: (-) gene that codes for?

Tyrosine aminotransferase

Type 2 tyrosyluria: (-) gene that codes for?

Tetrahydrobiopterin

Other forms of PKU are due to a lack of _____________.

Ion Exchange HPLC

PKU confirmatory test

Blue-green, gray to gray-green

PKU screening test:

FeCl3 tube test (+) = ?

Phenistix strip (+) = ?

Bacillus subtilis, B2-thienylalanine

PKU screening test: Guthrie Bacterial Inhibition Test

__________ is cultured with _____________ which inhibits the growth of bacteria; excess phenylalanine counteracts this and allows bacteria to grow (+).

P-hydroxyphenylpyruvic acid dioxegynase

Type 3 tyrosyluria: (-) gene that codes for?

Transient green, orange-red

Tyrosyluria screening test:

FeCl3 tube test (+) = ?

Nitroso-naphthol (+) = ?

Chromatography, quantitative serum assay of tyrosine

Tyrosyluria confirmatory tests (2)

Alkaptonuria, homogentisic acid oxidase

• Aka ALKALI LOVER

• Urine from patients with this condition darkened after becoming alkaline from standing at room temperature

• (-) gene responsible for producing _______________.

Gray or black precipitate, yellow precipitate, alkalinization

Alkaptonuria screening test:

• FeCl3 tube test = ?

• Benedict’s/Clinitest = ?

• _________ of fresh urine

Melanuria, 5,6-dihydroxyindole, air exposure

• Over-proliferation of melanocytes caused by melanoma

• Tumor secretes precursors of melanin, _____________, which oxidizes melanogen and then to melanin, producing dark urine

• Urine darkens upon _____________

• Deficient production leads to albinism

Gray or black precipitate, red, red

Melanuria screening test:

• FeCl3 tube test = ?

• Sodium nitroprusside (+) = ?

• Ehrlich test (+) = ?

Tandem mass spectrophotometry

Testing for many substances is now performed using __________________. It is capable of screening the infant blood sample for specific substances associated with a particular inborn error of metabolism.

Leucine, isoleucine, valine

MSUD isaccumulation of ________, ________, and ________ in blood and urine?

Branched-chain a-keto acid dehydrogenase

MSUD (-) gene that encodes ______________

• maple syrup

• Caramelized sugar

• Curry

MSUD urine odors

MSUD

Most common IEM in the Philippines

2,4-dinitrophenylhydrazine (DNPH)

MSUD test?

Yellow turbid/precipitate

MSUD DNPH result (+)?

Organic acidemias

Symptoms include severe illness, often with vomiting accompanied by metabolic acidosis, hypoglycemia, ketonuria, and increased serum ammonia

Sweaty feet

Isovaleric and glutaric acidemias - what urine odor?

Emerald green

+propionic acidemia

Methylmalonic acidemia p-nitroaniline test (+) = ?

Indicanuria, indigo blue, Hartnup disease, blue diaper syndrome

• __________ urine color upon air exposure

• Seen in ________ disease (______________) and intestinal disorders

Obermeyer’s test, FeCl3, urine, chloroform, violet

Indicanuria screening test: ____________

_________ + _________ + _________ = (+) positive result ?

Argentaffinoma, 5-hydroxyindoleaceticacid (5-HIAA), bananas, pineapples, walnuts, plums, avocados, tomatoes

• Tumor of argentaffin or enterochromaffin cells that produces serotonin metabolized to _________

• Patients must not eat serotonin-rich food (6)

• Prone to emotional imbalance in relation to abnormal levels of serotonin

Blue-green, violet

Argentaffinoma screening tests:

• FeCl3 tube test (+) = ?

• Nitrosonaphthol with nitrous acid (+) = ?

Sulfurous

Cystine disorder urine odor?

Cystinuria, cystine, ornithine, lysine, arginine

• Defect in renal tubular transport of COLA (____, ____, ____, ____)

Cystinosis

• Cystine deposits in many areas of body, like the bone marrow, cornea, lymph nodes, and internal organs

Red-purple

Cystinosis test:

• Cyanide-nitroprusside using sodium nitroprusside (+) = ?

Homocystinuria

• Defects in the metabolism of ___________ produce an increase in __________ throughout the body

• This increase results in failure to thrive, cataracts, mental retardation, thromboembolic problems, and death

Red-purple

Homocystinuria test:

• Silver nitroprusside (+) = ?

Hurler syndrome, Gargoylism, MPS type 1

• aka ____________ or ____________

• MPS accumulate in the cornea

• (+) skeletal abnormalities and mental retardation

Hunter syndrome

• Sex-linked recessive, rarely seen in females

• Characterized to have prominent cheekbones

• (+) skeletal abnormalities and mental retardation

Sanfilippo syndrome

• Only mental retardation (+); no skeletal abnormalities

Lesch-Nyhan disease, hypoxanthine guanine phosphoribosyltransferase, orange sand

• Failure to produce gene that codes for the enzyme ___________________

• High uric acid in the blood and urine = __________ in diapers

• Massive excretion of urinary uric acid crystals, characterized by severe motor defects, mental retardation, tendency for self-destruction, gout, and renal calculi

Porphyrias, colorless

• Disorders of porphyrin metabolism

• Either inherited or acquired from erythrocytic or hepatic malfunctions or exposure to toxins

• Red or port wine color to the urine after air exposure

• ___________ in lead poisoning

ALA porphobilinogen, neurological/psychiatric, urine/Ehrlich reaction

Disease: Acute intermittent porphyria

Elevated compound/s: _______________

Clinical symptoms: _______________

Laboratory testing: _______________

Uroporphyrin, photosensitivity, urine fluorescence

Disease: Porphyria cutanea tarda

Elevated compound/s: _______________

Clinical symptoms: _______________

Laboratory testing: _______________

Uroporphyrin, coproporphyrin, photosensitivity, urine or feces fluorescence

Disease: Congenital erythropoietic porphyria

Elevated compound/s: _______________, _______________

Clinical symptoms: _______________

Laboratory testing: _______________

Coproporphyrin, photosensitivity/neurologic, bile or feces fluorescence

Disease: Variegate porphyria

Elevated compound/s: _______________

Clinical symptoms: _______________

Laboratory testing: _______________

Protoporphyrin, photosensitivity, bile or feces fluorescence, blood FEP

Disease: Erythropoietic porphyria

Elevated compound/s: _______________

Clinical symptoms: _______________

Laboratory testing: _______________, ______________

ALA protoporphyrin, neurologic, Acetoaceticacid + urine/Ehrlich reaction, blood FEP

Disease: Congenital erythropoietic porphyria

Elevated compound/s: _______________

Clinical symptoms: _______________

Laboratory testing: _______________, _______________

Urine, stool, blood, bile

Porphyria screening test specimens (4)

D-ALA, porphobilinogen, 550-600 nm, uroporphyrin, coproporphyrin, protoporphyrin, violet, pink, red fluorescence, FEP

Porphyria screening tests detect:

• Ehrlich’s reaction: ______________, ______________

• Fluorescence @ (______): ______________, ______________, ______________; (+) = ______, ______, ______?

• CDC-recommended test for lead poisoning: _____________

Porphobilinogen, D-ALA, uroporphobilinogen, coproporphyrinogen, protoporphyrinogen, uroporphyrin, coproporphyrin, protoporphyrin

Porphyria screening tests

Colorless, nonfluorescent (5): ?

Dark red or purple, intensely fluorescent (3): ?

-, +, melituria

Carbohydrate disorders:

• ____ glucose strip, ____ copper reduction test

• ___________ = presence of any sugar in urine

Galactosemia/galactosuria, galactose-1-phosphate uridyl transferase, galactokinase, UDP-galactose-4-epimerase

• Inability to metabolize galactose to glucose

• Enzymes absent (3): _____________, _____________, _____________

• Infant failure to thrive, liver disorders, cataracts, and severe mental retardation

GALT, GALK1, GALE, GALM

Galactosemia deficient enzymes:

• Type I:

• Type II:

• Type III:

• Type IV:

Glucosuria, lactosuria, fructosuria, pentosuria

Carbohydrate disorder:

• Diabetes mellitus:

• During pregnancy and lactation:

• Associated with parenteral feeding:

• Associated with ingestion of large amounts of fruits:

Enzyme immunoassays

_______________ are the most popular type of pregnancy test kit.

B-HCG, first morning, B-HCG negative/positive

Substance tested in pregnancy:

Urine specimen of choice:

Reporting of results:

2 to 3 days, 1st

B-HCG secreted in urine within ______ after implantation of embryo; its levels rise rapidly after conception and remain elevated during pregnancy, peaking in the ___ trimester

100 to 200g, 75%, 25%, indole, skatole

• Around ______ of stool is passed per day

• Human feces contain ____ water and ____ solids

• Odor of feces is due to the presence of _______ and _______