San Pedro College

Department of Medical Laboratory Science

Urinalysis and other Body Fluids by Sophia Ainin, RMT, MSMT Topic: Microscopic Examination of Urine

Sediments
Red Blood Cells Ghost cells

Description
Other name: ghost cell (in hypotonic urine) Smooth, non-nucleated, biconcave disks, 7m 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
0-2/hpf

Conditions and other related disease

Dysmorphic cells are more clinically significant because it has been associated with glomerular bleeding Malignancy of the urinary tract

Crenated cells

Dysmorphic cells

Sediments
White Blood Cells

Decsription
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 Hansels stain

Normal Value/s
0-5/hpf

Conditions and other related disease

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

Eosinophils

None

Drug-induced interstitial nephritis UTI Renal transplant rejection

Mononuclear Cells Lymphocytes Monocytes Macropahges Histiocytes

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

Decsription
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 o May be called clue cells if the borders are obscurred with Gardnerella vaginalis indicating vaginitis

Normal Value/s

Conditions and other related disease

If obscurred with G. vaginalis, strong indication of vaginitis

Transitional Epithelial Cells

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

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

Sediments
Epithelial Cells Renal Tubular Epithelial Cells

Decsription
Larger than wbcs If occuring in groupd 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

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

Oval fat Bodies

Bacteria

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

None

Lipiduria Nephrotic syndrome Severe tubular necrosis DM

None

UTI

Sediments
Yeast

Decsription
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

Normal Value/s

Conditions and other related disease

DM Vaginitis Immunocompromised patients

Parasites

Spermatozoa

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

None

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

Decsription
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

Normal Value/s
None

Conditions and other related disease

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
Hyaline Cast

Decsription
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 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 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

Normal Value/s
0-2/lpf

Conditions and other related disease

Strenuous exercise Dehydration Heat exposure Emotional stress Acute glomerulonphritis Pyelonephritis Chronic renal disease Congestive heart failure Bleeding in the UGT most specifically within the nephrons Damage to the glomerulus Infection and inflammation within the nephron Pyelonephritis (upper UTI) Pyelonephritis 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

Red Blood Cell Cast

None

White Blood Cell Casts Bacterial Casts Epithelial Cell Casts

None None None

Fatty Casts

Seen in conjunction with oval fat bodies Highly refractile

None

Mixed Cellular Casts Granular Casts Finely Granular Casts Coarsely Granular Casts

Waxy casts

Variety of cells may be seen Observe for free-floating cells surrounding the cast matrix 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 None

Depending on the type of cells present Strenuous exercise Urinary stasis

None

Chronic renal failure

Broad Casts

Renal Failure casts Represents extreme urine stasis Most commonly seen: granular and waxy

None

Destruction of the tubular walls

CRYSTALS

Sediments NORMAL CRYSTALS

Uric Acid Crystals

Decsription
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)

Normal Value/s

Conditions and other related disease

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 Associsted 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 NORMAL CRYSTALS

Amorphous Phosphates Crystals

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

Normal Value/s
None

Conditions and other related disease

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

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

Associated with urea-splitting bacteria

Sediments NORMAL CRYSTALS

Ammonium Biurate Crystals

Decsription
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

Normal Value/s

Conditions and other related disease

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 ABNORMAL CRYSTALS

Cystine Crystals

Decsription
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

Normal Value/s

Conditions and other related disease

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 ABNORMAL CRYSTALS

Tyrosine Crystals

Decsription
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

Normal Value/s

Conditions and other related disease

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

Photo credits to authors of their corresponding fields. I do not claim ownership on photos and facts stated in this compilation.

Normal values may vary with references.