urinanlysis microscopic examination

7/29/2019 URINANLYSIS Microscopic Examination

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URINANLYSIS & BODYFLUIDS (HLD 22403)

URINE MICROSCOPIC SEDIMENTEXAMINATION

By

Mr.Hanan


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INTRODUCTION

The third part of urinalysis the microscopic examination of urinary

sediment.

The purpose is to detected and to identify insoluble material present

in the urine.

The blood ,kidney , lower genitourinary tract , and externalcontamination all contribute formed elements to the urine.

These include

RBCs, WBCs, epithelial cells , casts ,bacteria, yeast , parasites ,

mucus , spermatozoa, crystals and artifacts.

Some of these components are of no clinical significance andothers are considered normal unless present in increased amounts.

Examination of urine sediment must include both identification &

quantification.


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MICROSCOPIC EXAMINATION

Qualitative technique:

The urine must be freshly voided

Examined without excessive delay in order toprevent cellular deterioration.

Cellular debris from the urethral meatus and

secretions from the vagina may contaminate theurine specimen.


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Figure 28.1


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10-15 ml of urine ----from freshly mixed urine

specimen and centrifuged at a standard speed, usually

1500 to 2000 rpm for 5 minutes.

This is sufficient to bring to the bottom casts, pus cells,blood and crystals. For bacteria however a higher speedof 3,000 rpm is required.

The sediment resuspended in 1 ml of the same fluid.

A drop of resuspended sediment is placed directly

on a microscope slide and covered with a coverslip.


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low power-

Casts tend to congregate at the edges of the

cover slip. A minimum of10 15 high power fields should

be scanned for this examination.

Red blood cells, leucocytes, epithelial cells---

per high power field(/hpf);

casts --- per low power fields(/lpf).

Other elements such as bacteria, parasites,

crystals and spermatozoa are reported as well


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NORMAL SEDIMENT

Normal sediment contains a limited number offormed elements. It can be divided into two

classes.

Unorganized sedimentUnorganized sediment - these are the crystals ofvarious substances present in the urine and they

vary with the pH of the urine .Crystals of normal

urine is formed as the specimen cools

Organized sediment


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URINARY CRYSTALS

Crystals are frequently found in the urine

& are rarely of clinical significance.

They may appear as :

Geometrically formed or as amorphous

material.

Primary reason of detecting crystals is to

detect the abnormal types that may

represent disorders.


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URINARY CRYSTALSCRYSTAL FORMATION

Crystals are formed by the precipitation of

urine solutes, including :

Organic compounds, inorganic salts &

medication (iatrogenic compounds).

Precipitation is subject to changes:

In temperature

Solute concentration

pH

which affect solubility


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Solutes precipitate more readily at lowtemperatures.

Crystals formation takes place in

specimen that have remained in roomtemperature or refrigerated prior to testing.

A valuable aid in the identification of

crystals is the pH of the specimen

because it determines the type of

chemicals precipitated.


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URINARY CRYSTALS

ACIDIC URINE

Common crystals seen in acidic urine are

Urates consisting ofamorphous urates,

Uric acid , &sodium urates.

Microscopically urate crystals appear

yellow to reddish brown & are normalcrystals found in acidic urine


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Amorphous urates yellow brown

granules. Appearlike clumps resembling granular

casts. Found in specimen that has been

refrigerated. Amorphous urates appear asfine pink orbrownish-tangranules.

Accumulation ofuroerythrin on

the surface of the granules is the

cause of the pink colorThey are salts of uric acid (lower

pH) and are normally found in

acid or neutral urine. pH greater

than 5.5.


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URINARY CRYSTALS

URIC ACID CRYSTALS

Uric acid crystals exhibit extreme pleomorphism

in size and in shape. They appear readily in acid

urine allowed to stand at room temperature.

Increased amounts- increase levels ofpurines

& nucelic acidin patients with leukemia or

receiving chemotherapy, Lesh-Nyhan

syndrome (disorder of purine metabolism) &sometimes in patients with gout.


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Uric acid crystals Notice the whetstone, not hexagonal , shape that

differinciate uric acid crystal with cystine crystals

extreme pleomorphism- including rhombic,4sided flat

plates (whetstone )wedges &rosettes

Coloryellow brown but may also appear colorless


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URINARY CRYSTALS

CALCIUM OXALATECRYSTALS

Seen in acidic urine but also found in neutralurine.

Most common form of calcium oxalateis the

dihydrate- colorless, octahendral or as 2pyramids joined together.

Monhydrate- dumbell shape.

Calcium oxalate- sometimes seen in clumps

attached to mucous-may resemble casts. Findings of calcium oxalate clumps formation

of renal calculi-compose of calcium oxalate


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Also found with foodhigh in oxalic acid

(tomatoes, asparagus & ascorbic acid)

oxalic acid- end product of ascorbic acid.

Pathological significance-very noticeablemonohydrate form in cases of ethylene glycol

poisoning .Massive amounts


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commonly appear octahedral, dumbbell shape


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URINARY CRYSTALS

ALKALINE URINE

Phosphates- majority seen in alkaline urine.

Amorphous phosphates-granular +/- to urates.

Large quantities- after refrigerationform white

precipitate-does not dissolve on warming.

Triple phosphates,& calcium phosphates.

Others are calcium phosphates & ammonium

biurrates.


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URINARY CRYSTALSAMORPHOUS PHOSPHATES

Amorphous phosphates appear in neutral to alkaline urine as fine,

colorless or slightly brown granules. White precipitate is observed

on centrifugation. (Brightfield microscopy, 160X magnification.)


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URINARY CRYSTALSTRIPLE PHOSPHATE

Triple phosphate crystals, viewed here with interference-contrast

microscopy (160X magnification), resemble prisms or "coffin lids".

They are found normally in alkaline or neutral urine.

They are colorless, no clinical significance-seen in highly alkaline

urine associated with presence of urea spliting bacteria


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URINARY CRYSTALSCALCIUM PHOSPHATE

Calcium phosphate crystals assume various forms including the

rosette and pointed fingerforms shown here with bright field

microscopy (160X magnification). They appear most often in alkaline

urine.

Common constituent of renal calculi


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URINARY CRYSTAL

CALCIUM CARBONATE

Calcium carbonate crystals are small and colorless and

appear in alkaline urine as granules or as small

dumbbells.

They appears as clumps- resembels amorphous

material.

Formation of gases- when added acetic acid , to

differentiate

Also birefringentwhich differentiate from bacteria

No clinical significance.


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Calcium carbonate crystals are small and colorless and appear in

alkaline urine as granules or as small dumbbells. Bacteria are also

present in this field (brightfield microscopy, 250X magnification).


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URINARY CRYSTAL

AMONIUM BIURATE

Color yellow brown seen in acidic urine

They are the only urate crystals that appear in alkaline

urine.

Describe as thorny apples- presences of spicule

covered sphere


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Encountered in old specimens associated with the

presence of ammonia produce by urea splitting

bacteria. Dissolves at 60cconvert to uric acid crystals when

glacial acetic acid is added.

Ammonium urate crystals are easily distinguished by

their golden brown color and "thorn apple" shape. Theyare seen here under bright field microscopy (160X

magnification).


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URINARY CRYSTAL

ABNORMAL CRYSTALS

Cystine crystals- person inherit a metabolic

disorder.

Cystinuria-prevents reabsorption of cystine by the

renal tubules. Tendency to form renal calculi Rarely seen, these crystals are found in acid urine

and are seen as thin, colorless, hexagonal plates.


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Only thick cystine have polarizingcapability- mistaken with uric acid .

Conformationusing cynaide

nitroprusside test.

C S


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URINARY CRYSTAL

ABNORMAL CRYSTALS

Cholesterol crystals rarely seen unless

specimen has been refrigerated- lipids remain in

droplet form.

Observation-rectangular plate in shape withnotch in or more corners .

Disorders producing lipiduria such as nephrotic

syndrome. Seen usually with fatty cast & oval fat

bodies


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Cholesterol crystals are seen in the center of this field

with squamous epithelial cells on either side. Cholesterol

crystals are found in acid or neutral urine. They appear

as regular orirregular transparent plates. They mayoccur singly or in large numbers. Usually one or more

corners are cut off ornotched, justifying their

description as "stair step crystals".

URINARY CRYSTAL


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URINARY CRYSTAL

ABNORMAL CRYSTALS (LIVER

DISODERS) Tyrosine crystals are not normally found in urine.

They are products of protein metabolism and appear in

urine of people with tissue degeneration or necrosis

(acute liver disease, severe leukemia, typhoid fever, andsmallpox).

They are present only when urine is acid.


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Colorless to yellowish brown, needle shaped crystals

and have a fine silky appearance.

The needles may be single or arranged in sheaves or

rosettes.

Tyrosine crystals usually appear in urinary sedimenttogether with leucine crystals


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URINARY CRYSTAL

ABNORMAL CRYSTALS (LIVER DISODERS)

Leucine crystals are not normally found in urine

Appear in urine in association with tyrosine and are

manifestations of the same clinical conditions.

When found, leucine crystals are in acid urine in the form

ofspheroids with concentric striations.

They are dense, highly refractive and appear as

yellowish brown bodies.


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URINARY CRYSTAL

ABNORMAL CRYSTALS (LIVER DISODERS)

Bilirubin crystals- In hepatic disorders.

Appears as clump needles or granules with

yellow color

Disorders that produce renal tubular damage,viral hepatits , bilirubin crystals may be found

incorporated into the matrix of casts.


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URINARY CRYSTAL

ABNORMAL CRYSTALS

Sulfonamide crystals form primarily in acid urine.

The shape and color of these crystals are extremely

variable, depending on the particular sulfonamide being

administered to the patient.

The most common forms encountered include rosettes,

fan shapes and those resembling shocks of wheat.

Sulfa crystals have pathologic significance, since they

tend to form renal calculi that may damage renal tubules.


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Sulfoamide- In patient being treated for

UTI.

Inadequate hydration is the primary cause

of sulfoamide crystallization.

Can suggest-possibility of tubular damage

if crystal are forming in the nephrones


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forms encountered include rosettes, fan shapes and

those resembling shocks of wheat.


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URINARY CRYSTAL

ABNORMAL CRYSTALS

Ampicilin crystals rarely encountered-

massive dose of ampicilin compound with

poor hydration.

Knowledge of the patient Hx can aide the

identification.


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ORGANIZED SEDIMENT

Organized Sediment

The components of organized sediment

include casts, red blood cells, white bloodcells, epithelial cells, bacteria, yeast,

parasites, spermatozoa and artifacts.


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CASTS

Casts are formed in the tubules and iscomposed ofproteinaceous material.

They are washed out by the glomerular

secretion into the collecting tubules and thebladder.

They are cylindrical in shape with round or

broken ends with uniform diameter but varying inlength. They require acidic conditions, high saltconcentration, reduced urine flow and protein tobe formed.


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Practically all casts have a hyaline matrix,which may or may not contain inclusions such as

desquamated cells.

The casts are named according to the matrixof the inclusions contained in them e.g. red

blood cell casts.

Casts Suggest Kidney pathology.

Casts can be made up of Protein, lipid, cells ormixed


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HYALINE CASTS

Are colorless, semi-transparent and occasionally

refractile cylinders and are soluble in acetic acid.

They are seen when there is damage to theglomerular capillary membrane, permitting leakage

of proteins through the glomerular filtrate.

They are seen in fever, orthostatic proteinuria, and

emotional stress or strenuous exercise.


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Granular casts

are casts containing large or fine granules

embedded in coagulated protein. They are notfound in normal urine and their presences indicate

pyelonephritis. They are also seen in chronic lead

poisoning.

Epithelial casts are formed of fused desquamated

tubular cells. They are coagulated protein in which are

embedded desquamated epithelial cells from the renal

tubules .They are seen in diseases where there is damageto the tubular epithelium as in nephrosis, eclampsia,

amyloidosis and heavy metal poisoning.


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Red Blood Cell Casts:

are casts with red blood cells embedded in

the coagulated protein in the tubule. Their

presences indicate acute inflammation or

vascular disorder in the glomerulus causinghematuria. They are seen in pathological

conditions such as acute glomerulonephritis,

renal infarction and collagen vasculardisorder.


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WHITE BLOOD CELL CASTS

Indicative ofinflammation orinfection,

pyelonephritis

acute allergic interstitial nephritis,

nephrotic syndrome, or post-streptococcalacute glomerulonephritis
http://en.wikipedia.org/wiki/Inflammationhttp://en.wikipedia.org/wiki/Infectionhttp://en.wikipedia.org/wiki/Pyelonephritishttp://en.wikipedia.org/wiki/Interstitial_nephritishttp://en.wikipedia.org/wiki/Interstitial_nephritishttp://en.wikipedia.org/wiki/Pyelonephritishttp://en.wikipedia.org/wiki/Infectionhttp://en.wikipedia.org/wiki/Inflammation


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FATTY CASTS

Formed by the breakdown of lipid-rich

epithelial cells, these are hyaline casts

with fat globule inclusions

They can be present in various disorders,

including

nephrotic syndrome,

diabetic or lupus nephropathy,

Acute tubular necrosis


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WAXY CASTS

Waxy casts suggest severe, longstanding kidney

disease such as renal failure(end stage renal disease). They appear fragmented with jagged ends &have

notches at the side. Supravital stain waxy cast stain ahomogenus dark pink

S h t i t???


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Sowhat is a cast???

Lets Review

Protein based cylindrical molds of the renal

tubule

Form in distal tubules and collecting ducts

Result of damage to the renal tubule

Can contain cells and other material Dehydration and acidic urine especially

predisposes to cast formation


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Types of casts

Acellular casts

Hyaline casts

Granular casts

Waxy casts

Fatty casts

Crystal casts

Cellular casts

Red cell casts

White cell casts

Epithelial cell cast


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ACELLULAR CASTS

Appears colorless in undstained sediment , refractive

index, sternheimer-malbin stain produce pink color.l

Normal parallel sides, rounded ends, cylindroid

forms,&wrinkled or convoluted shapes indicate aging of

the cast matrix.


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Granular Casts


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Granular cast

Non-specific but

usually pathologic

Usually the

granules are from

the degeneration of

cellular casts


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Waxy cast

Thought to result

from the

degeneration ofcellular casts


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FATTY CAST

The cast matrix contain a few ormany oil droplet. Intact

oval fat bodies may be attach to the matrix.

Stain with Sudan iii or Oil Red O Fat Stain

CELLULAR CAST


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CELLULAR CAST

RED CELL CAST

Almost always

associated with

glomerulonephritis

or vasculitis

Virtually exclude

extra-renal causesof bleeding


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RBC


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EPITHELIAL CASTS IN URINE:


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TUBULAR EPITHELIAL CAST


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WBC in Urine


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WBC


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WBC CAST URINE:


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WHITE BLOOD CELL CAST

Seen in interstitial

disease most

commonly

Also seen in

glomerulonephritis


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White blood cell cast

This is a white blood cell cast with intact

leukocytes. The leukocytes have

multilobed nuclei. (Bright field microscopy)


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EPITHELIAL CELLS

Epithelial Cells: Normally a few epithelial

cells occur in the urine .

A marked increase in these cells in the

urine is seen destruction of the tissues inthe urinary tract


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Microscopic ExaminationSquamous Cells


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Squamous epithelial cell in urine

This is a squamous epithelial cell under brightfield microscopy

(250X magnification).Squamous epithelial cells are

characterized by a small, round, central nucleus with a large

amount of granular or wrinkled cytoplasm (a "fried egg"

appearance).


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Microscopic ExaminationTubular Epithelial Cells

R l E ith li l C ll


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Renal Epithelial Cells

A group of attached renal tubular epithelial

cells are seen in the center of this slide.

The background contains white blood cells

and red blood cells (bright field microscopy,

250X magnification)

Mi i E i ti


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MicroscopicExamination

Transitional Cells


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MicroscopicExaminationTransitional Cells


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Bacteria- Bacteriuria More than 10 per HPF

Yeasts- Candidiasis Most likely a contaminant

but should correlate with

clinical picture.

MicroscopicExamination

Bacteria & Yeasts

Bacteria and white blood cells


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This is a low power view (100Xmagnification) of urine with bacteria and

several leukocytes in the field. Bacteria are

bacillary and diffusely scattered

throughout. The urine is stained with

Sternheimer-Malbin stain.

White blood cells and bacteria


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These are white blood cells and bacteria found in urinarysediment using interference-contrast microscopy. The cell

in the center has a pseudopod extending from its

cytoplasm indicating amoeboid motion.


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Microscopic ExaminationLE Cell


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Microscopic ExaminationYeasts

Budding yeast cells


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Budding yeast are visible on the left side of this slide with a

squamous epithelial cell on the right. There are no segmented

neutrophils seen. This suggests the yeast are a contaminant and not

causing a urinary tract infection (bright field microscopy, 200X).

Mucus


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Mucus

This slide shows mucus in urine with two entrapped white cells. There are

also two red cells present, one within the mucus and one above it. Mucus

fibers are fibrillar and delicate. They have a very low refractive index.

(Bright field microscopy, 160X magnification.)


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URINARY SEDIMENT ARTIFACTS

Contaminants that are found in the urine Specimen collected improperly or in dirty

containers.

Most frequent: Oil droplet

Starch

Pollen Grains and fibers

F l t i l i i


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Fecal material in urine

Fecal material can usually be identified by its brown coloration, and

the assortment of bizarre shapes and sizes of component elements.

Fecal contamination of urine most often occurs in incontinent babies

or elderly persons. (Brightfield microscopy, 40X magnification)

Talc in urine


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Talc in urine

Talcum powder, commonly used as a dusting powder to prevent

chafing or heat rash, appears as a contaminant in urine as crystals.

(Brightfield microscopy, 128X magnification.)

Starch in urine


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A derivative of cornstarch is used as a dusting powder for surgical gloves.

It can enter the urine during catheterization. The starch granules areusually identifiable by their size, shape and high refractive index.

(Brightfield microscopy, 100X magnification.)

Cotton fiber in rine


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Cotton fiber in urine

A cotton fiber is easily identified by its size. A cotton fiber is seen here withsquamous epithelial cells and white blood cells.(Brightfield microscopy,

51X magnification.)


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Fiber in urine

This slide depicts a fiber artifact found in urine under brightfield

microscopy at 200X magnification.


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Home work

Mixed cast and oval fat bodies

urinanlysis microscopic examination

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