Clinical Microscopy pt 1

Increased

__change occuring in unpreserved urine

• Color

• Odor

• pH

• Nitrite

• Bacteria

Decreased

__change occuring in unpreserved urine

• Clarity

• Glucose

• Ketones

• Bilirubin

• Urobilinogen

• RBC, WBC, & Casts

• Trichomonas

urochrome

Pigment of urine

9

pH of urine is normally 4.5-8.0

pH of unpreserved urine >___

protein

What is least affected by improper preservation

Bilirubin, Urobilin, Phenazopyridine

Dark yellow/ Amber/ Orange urine

Pathologic causes: ___ & ___

Nonpathologic causes: ___

Porphyria, Hematuria, Hemoglobinuria, Myoglobinuria

Red/ Pink/ Brown urine

• Pathologic causes: ___, ___, ___, ___

• Nonpathologic causes:

  • Menstrual contamination

  • Beets and blackberries consumption

  • Medications: Rifampin, Phenothiazine, Phenindione, Phenolphthalein

Alkaptonuria, Melanuria

Brown/ Black urine

• Pathologic causes: ___, ___

• Nonpathologic causes:

  • Menstrual contamination

  • Beets and blackberries consumption

  • Medications: Methyldopa, Levodopa, Phenol derivatives, Metronidazole

UTI, Intestinal tract infection

Blue/ Green urine

• Pathologic causes: ___ by P. aeruginosa, ___ by indican

• Nonpathologic causes:

  • Chlorets

  • Medications: Amitriptyline, Methocarbamol, Methylene blue, Azure A

Acidic

__urine pH

• High protein diet

• Cranberry

• Diabetes mellitus

• Diarrhea

• Dehydration

• Emphysema

• E.coli (acid producing organism)

• UTI medications

• Starvation

Alkaline

__urine pH

• High vegetable and fruit diet

• Hyperventilation

• Renal tubular acidosis

• Vomiting

• Urease-producing bacteria

• Old specimen/ improperly preserved specimen

• Postprandial specimen

Urine Nitrite

Clinical significance

• Cystitis and pyelonephritis

• Evaluate antibiotic therapy

• Monitor patients at high risk of UTI

• Screen urine culture specimen

Leukocyte Esterase

Indicates presence of pyuria and inflammatory process occurring in the kidney or urinary tract

Esterase may be present in:

Clinical significance

• Urinary Tract Infection

• Inflammation of the urinary tract

• Screening of urine culture specimens

Acidic Normal Crystals

Amorphous Urates

Uric Acid

Dihydrate Calcium Oxalate

Monohydrate Calcium Oxalate

Alkaline Normal Crystals

Amorphous Phosphates

Triple Phosphate

Ammonium Biurate

Calcium Carbonate

Acidic Abnormal Crystals

Cystine

Cholesterol

Ampicillin

Sulfonamide

Tyrosine

Bilirubin

Leucine

Casts

• Only element found in the urine that are unique to the kidneys

• Formed primarily within the lumen of distal convoluted tubules and collecting ducts

• Formation is favored by urine stasis, acid urine and sodium and calcium presence

• Tamm-Horsfall protein or uromodulin serves as the matrix of cast formation, produced by the RTE

• Cyclindroids are casts with tapered ends produced at the junction of ALH and DCT

Hyaline, Cellular, Granular, Waxy

Order of cast degeneration

___→___→___→___

Hyaline cast

• Only normal and most frequently seen cast

• Colorless, homogenous and has same RI with urine

• Consist almost entirely Tamm Horsfall protein

• Nonpathologic: strenuous exercise, dehydration, heat exposure, emotional stress

• Pathologic: acute glomerulonephritis, pyelonephritis, chronic renal disease, congestive heart failure

Red blood cell cast

• Orange-red color, cast matrix containing RBC

• Glomerulonephritis, strenuous exercise

White blood cell cast

• Cast matrix containing WBCs

• Pyelonephritis, Acute interstitial nephritis

• Presence indicates the need to perform bacterial cultures

  

Epithelial cell cast

• RTE cells attached to protein matrix

• Renal tubular damage

  

Granular cast

• Coarse and fine granules in a cast matrix

• Glomerulonephritis, Pyelonephritis, stress and exercise

  

Waxy cast

• Highly refractile casts with jagged edges and notches

• Stasis of urine flow, chronic renal failure

  

Fatty cast

• Fat droplets and oval fat bodies attached to a protein matrix

• Nephrotic syndrome, toxic tubular necrosis, diabetes mellitus, crush injuries

Broad cast/ Renal Failure cast

• Wider than normal cast matrix

• Indicates distention of tubular lumen

• Granular and waxy casts are the most common broad casts

• Bile-stained broad, waxy casts are seen in tubular necrosis in viral hepatitis

• Extreme urine stasis and renal failure

  

Sediments

Miscellaneous ___

• Oval fat bodies

• Yeast

• Dysmorphic Red Blood Cells

Oval fat bodies

• RTE that contains lipid, found in lipiduria

• Exhibit maltese cross formation

• Seen in Nephrotic Syndrome

Yeast

• Smooth, colorless, usually ovoid cells with double refractile walls, often showing budding

• Candida albicans is most common isolate

• Mistaken for red cells but can be differentiated by adding acid or alkali

• Seen in UTI especially in patients with DM

  

Dysmorphic Red Blood Cells

• Seen in glomerular membrane damage

• Glomerular bleeding

  

WBC clumps

• Associated with cystitis

• Usually accompanied with packed field WBC

• Cystitis

  

Mucus Threads

• Long, thin, wavy threads composed of Tamm-Horsfall protein

• More frequently present in female urine specimens

• Urine examined under subdued light

Starch Granules

• Highly refractile spheres with dimpled center; use of powdered gloves

• Can be mistaken as fat droplets or RBCs

• Maltese cross formation

  

Schistosoma Haematobium

• Blood fluke

• Ova with terminal spine

• Excreted together with erythrocytes

• Hematuria

  

Chemsitry/Serology, Microbiology, Hematology/Cell counts

Order of CSF collection, testing, & preservation

Tube #1: ___

Tube #2: ___

Tube #3: ___

Monosodium urate, Calcium pyrophosphate dihydrate

Primary crystals seen in synovial fluid

Monosodium urate

Yellow when parallel

Blue when perpendicular

Calcium pyrophosphate dihydrate

Blue when parallel

Yellow when perpendicular

Chylous

• Appearance: milky & white

• Thoracic duct leakage

• Extractable in ether

• Stained by SUDAN III

• >110 mg/dl TAG

• No cholesterol crystals

• Lymphocytes are predominant

Pseudochylous

• Appearance: milky w/ grenish tinge

• Chronic inflammatory conditions

• Not extractable by ether

• Not stained by SUDAN III

• <50 mg/dl TAG

• Cholesterol crystals are present

• Mixed cells

L/S Ratio, Amniostat FLM, Microviscosity Assay

Tests for Fetal Lung Maturity

Lecithin/Sphinomyelin Ratio

• Reference method

• Lecithin is the primary component of the surfactant that maintains alveolar stability

• Sphingomyelin is measured to serve as control

• CANNOT BE USED when contaminated with blood and meconium

Amniostat FLM

• Uses antisera specific for phosphatidylglycerol

• Not affected by blood and meconium contamination

Microviscosity Assay

• Presence of phospholipids decreases the microviscosity of amniotic fluid

• This change in microviscosity is measured using fluorescence polarization by Abbott TDx analyzer

• Albumin is used as internal standard

Alpha 1 Fetoprotein, Acetylcholinesterase, Bilirubin

Tests for Fetal Distress

Alpha 1 Fetoprotein

• A major protein produced by the fetal liver during early gestation

• Found in maternal serum due to combined circulation and amniotic fluid due to fetal urination

• Increased level is associated with neutral tube defect

Acetylcholinesterase

• Done after an elevated AFP level is detected to confirm neural tube defects

• Blood contamination will falsely increase the result

Bilirubin

• Done for the evaluation of HDN

• Bilirubin is measured using spectrophotometry at 450nm and values are plotted on the Liley graph