Clinical Microscopy

0-2 or 0-3/HPF

Normal Value of RBCs

ghost cell or shadow cell

In hypotonic urine, what is the characteristic of RBCs under the microscope?

glomerular membrane damage

In what condition does RBCs become dysmorphic, with projections, fragmented (acanthocytes)?

0-5 or 0-8/HPF

Normal value of WBCs in urine

neutrophils

what is the most predominant WBC found in urine and is granulated and multi-lobed?

Brownian movement

in hypotonic urine, neutrophils swell and its granules undergo____ producing a sparkling appearance

Glitter cells

produces a sparkling appearance in hypotonic urine and its granules undergo Brownian movement

> 1%

what percentage does eosinophils become significant in the urine

acute interstitial nephritis

Eosinophils become significant at >1% and is seen in what condition?

Sternheimer-Malbin stain

stain used for glitter cells and leukocytes in urine sediments

Pale Blue

what color does glitter cells show when stained with sterheimer-malbin stain

leukocytes

urine sediment that shows pale pink when stained with sternheimer-malbin stain

squamous epithelial cells

largest cell with abundant, irregular cytoplasm and prominent nucleus

transitional epithelial (urothelial) cells or bladder cells

a urine sediment that is spherical, polyhedral, or caudate with CENTRALLY located nucleus with a low N:C ratio

renal tubular epithelial cells

most clinically significant epithelial cells with an eccentric nucleus (high N:C ratio) and its origin is the nephron

tubular injury

>2 RTE/HPF indicates what condition?

Collecting ducts

which part of the nephron does RTE shows a columnar, polygonal or cuboidal with flat edge appearance?

oval fat bodies

a variation of RTE cells that is highly refractive, seen in lipiduria such as nephrotic syndrome, and is identified by lipid stains

bubble cells

RTE cell with non-lipid vacuoles and is seen in acute tubular necrosis

Enterobacteriaceae (E. coli)

most common cause of UTI

T. vaginalis

most frequently encountered parasite in urine

ping-pong disease

T. vaginalis is the agent of this disease

E. vermicularis egg

most common fecal contaminant

S. haematobium egg

a blood fluke with terminal spine that causes hematuria and is associated with bladder cancer

Tamm-Horsfall protein

major constituent of mucus threads

DCT and CD

which part of the nephron does casts primarily formed

uromodulin or tamm-horsfall protein

major constituent of casts and is produced by RTE cells

hyaline, degenerating cellular, coarsely granular, finely granular, waxy

what is the order of cast degeneration?

hyaline cast

most frequently encountered and the most difficult cast to discover due to its colorless and translucent appearance and requires a subdued light when using BF microscope

0-2/LPF

normal value of a hyaline cast

stress and strenuous exercise

what physiologic condition does hyaline cast occur

RBC cast

easily identified by its orange-red color and is the most fragile cast; it indicates bleeding within the nephron

glomerulonephritis, strenuous exercise

RBC casts are significant in what conditions

Blood or Hemoglobin Cast

this cast contains hemoglobin from lysed RBCs and has a homogenous appearance with orange-red color

WBC/leukocyte/pus cast

this cast indicates inflammation or infection within the nephron

phase microscopy and supravital stain

WBC cast resembles RTE cast. How to distinguish the two?

Bacterial Cast

confirmation of this cast is done by performing gram stain

strenuous exercise

what is the significance of granular cast (coarse and fine)

fatty cast

a cast wherein the fat globules are not stained by sternheimer-malbin stain

waxy cast

final degenerative form of all types of casts with a brittle appearance, highly refractive, and jagged ends

chronic renal failure

significance of waxy cast

renal failure cast

broad cast are often referred as

granular and waxy

any type of cast can be broad but the two most common are

broad cast

this cast indicates destruction of the tubular walls due to widening and is 2-6x wider than ordinary cast

crystalluria

excretion of crystals in urine is termed as

pH, solute concentration, and temperature

3 factors that contribute to crystal formation

LPF

abnormal crystals may be averaged and reported per ______

amorphous urates, uric acid, calcium oxalate

what are the normal ACID crystals?

amorphous urates

fluffy orange or pink sediment (brick dust) due to uroerythrin

yellow brown granules

appearance of amorphous urates under the microscope

heat (60 C) and alkali

amorphous urates is soluble in what condition

uric acid

a crystal that is a product of purine metabolism with appearances of rhombic or diamond, 4-sided flat plate, lemon-shaped

Lesch-Nyhan syndrome, chemotherapy, and gout

increased uric acid is present in what condition

Weddellite

other term for calcium oxalate dihydrate with an enveloped/ bipyramidal/ octahedron/ emerald-cut diamond

Whewellite

other term for calcium oxalate monohydrate with an oval/ dumbbell appearance

spinach

CaOx is increased in foods rich in oxalic acid such as

normal alkaline crystals

what type of crystals do these belong: amorphous phosphates, ammonium bitrate, triple phosphate, magnesium phosphate, calcium phosphate, calcium carbonate

amorphous phosphates

most common cause of turbidity in normal alkaline urine with a granular appearance a has a fine or lace white precipitatea

yellow-brown thorny apples

appearance of ammonium biurate

triple phosphate

color

magnesium ammonium phosphate and struvite

two other terms of triple phosphate

magnesium phosphate

a crystal that is colorless, elongated rectangular or rhomboid plates, end or corner may be notched

apatite

other term for calcium phosphate

dibasic calcium phosphate

a type of calcium phosphate that has a colorless, flat plates, thin prisms in rosette form

calcium carbonate

a crystal that has a small, colorless, dumbbell, tetrads, or spherical-shaped appearance

cystine

a crystal that is colorless, refractile hexagonal plates, often laminated and is elevated in cystinuria and cystinosis

cystine

a crystal that is positive in cyanide-nitropusside reaction

cholesterol

a crystal that has a rectangular plate with notch in one or more corners and has a staircase pattern and is elevated in nephrotic syndrome

tyrosine

a crystal that is elevated in liver disease and has a fine colorless to yellow needles in clumps or rosette appearance

leucine

yellow-brown oily-looking spheres with concentric circles and radial striations. precipitated with tyrosine after adding alcohol

bilirubin

a crystal that has an appearance of clumped granules or needles with bright yellow color and is also elevated in liver disease

sulfonamide

a crystal that has a fan-shaped needles, sheaves of wheat, rosettes arrowhead, petals, round, and whetstone appearance

ampicillin

a crystal that has an appearance of colorless needles that tend to form bundles following refrigeration and is elevated in massive doses of penicillin

starch granules

urinary sediment artifact that has spheres with dimpled center (“Y” indentation)

pollen grain

a urinary sediment artifact that has spheres with cell wall and concentric circles and is mistaken for parasitic ova and is also known as seasonal artifacts

oval fat bodies, fatty casts, fat droplets, starch granules

4 maltese cross formation

sternheimer-malbin stain

most commonly used supra vital stain that identifies WBCs, epithelial cells and casts

crystal violet and safranin o

components of sternheimer-malbin stain

toluidine blue

a supra vital stain that enhances nuclear detail and differentiates WBCs and RTE cells

2% acetic acid

lyses RBCs, enhances nuclei of WBCs and distinguishes RBCs from WBCs, yeast, oil droplets and crystals

Lipid Stains

stains triglycerides and neutral fats orange red except cholesterol

oil red o and Sudan III

components of lipid stains

gram stain

differentiates gram pos from gram neg and identifies bacterial casts

Hansel stain

stains eosinophilic granules and identifies urinary eosinophils

eosin y and methylene blue

components of Hansel stains

Prussian blue

stains structures containing iron and identifies hemosiderin granules

overflow type

a type of aminoaciduria with elevated amino acids in both blood and urine and is seen in PKU and MSUD

renal type

a type of aminoaciduria caused by defective tubular reabsorption of amino acids and shows normal levels of AA in blood but elevated in urine

phenylketonuria

most well-known of the aminoacidurias and may lead to severe mental retardation

mousy

what is the urine, sweat, and breath odor of patients with PKU

blue-green

Positive reaction in FeCl3 tube test (screening test) in PKU

ion exchange HPLC

confirmatory test of PKU

Type 1 FAH

most severe type of enzyme absent in tyrosyluria or tyrosinemia

rancid butter

urine odor in patients with tyrosiluria

transient green

Positive reaction in FeCl3 tube test (screening test) in tyrosiluria

tandem mass spectrophotometry or MS/MS

a principle that is capable of screening the infant blood sample

homogentisic

alkaptonuria

this disorder shows initial yellow color in urine but darkens after being alkaline from standing at RT

melanuria

caused by melanoma and the urine darkens upon air exposure