Urine Sediment Photomicrographs/Photographs

Transcription

1 Urine Sediment Photomicrographs/Photographs Case History /P-04 This urine sample was obtained by catheterization from a 76-year-old female nursing home resident with diabetes and incontinence. The nursing home sent the specimen to the laboratory this morning with a note indicating that the specimen was collected three days ago and was accidentally left in the refrigerator over the weekend. The urinalysis showed: ph=7.5; specific gravity = 1.007; and positive dipstick results for protein (4+) and glucose (2+). P Performance /P-04 Leukocyte (neutrophil, eosinophil, Good lymphocyte) This urine specimen was inadequately stored refrigerated for a prolonged period of time of three days. Possibly due to this prolonged time before the urinalysis was performed, the leukocyte (polymorphonuclear neutrophil) in this image appears to have a hypolobated nucleus. Indeed, hypolobation of nuclei in neutrophils occurs as a result of degeneration and may make distinction from mononuclear cells difficult. Normally neutrophils appear as 12-μm spheres with granular cytoplasm and multilobated nuclei. More than 5 leukocytes/hpf indicate pyuria and signify infection or inflammation of the urinary tract. If present with leukocyte casts or mixed leukocyte-epithelial casts, increased urinary polymorphonuclear leukocytes are deemed of renal origin. Urinary leukocytes may also be seen in a variety of disorders: cystitis, prostatitis, urethritis, balanitis, renal or urinary tract infection, glomerulonephritis, systemic lupus erythematosus, interstitial nephritis, renal or urinary tract calculi, neoplasms of the kidney or urinary tract, and others. Another consideration in this case is hyposthenuria (low specific gravity below 1.007), proteinuria and glucosuria undoubtedly related to the patient s diabetes mellitus impact on the kidneys. 56

2 Urine Sediment Photomicrographs/Photographs Case History /P-05 This urine sample was obtained by catheterization from a 76-year-old female nursing home resident with diabetes and incontinence. The nursing home sent the specimen to the laboratory this morning with a note indicating that the specimen was collected three days ago and was accidentally left in the refrigerator over the weekend. The urinalysis showed: ph=7.5; specific gravity = 1.007; and positive dipstick results for protein (4+) and glucose (2+). /P-05 P Performance Ammonium biurate crystal Good This dark yellow/brown crystal with spherical shape with horns or apple-thorn appearance is characteristic of old urine, like in this case, otherwise normal urine. Sometimes, it is described as having concentric striations and irregular projections or thorns. Ammonium biurate is soluble at 60 0 C with acetic acid, reappearing as typical uric acid crystals after 20 minutes. They can also be dissolved in strong alkali. Biurate crystals may also change to uric acid crystals with concentrated hydrochloric acid or acetic acid. Ammonium biurate may be confused with sulfamethoxazole crystals. However, unlike sulfamethoxazole crystals (only seen in acid urine), ammonium biurate crystals are only seen in alkaline urine. Biurate crystals are only considered abnormal in freshly voided urine. 57

3 Urine Sediment Photomicrographs/Photographs Case History /P-06 This urinary sediment is from a 15-year-old female with hypertension, edema, and cloudy brownish urine. Two weeks ago, she presented with a sore throat and fever. Urine had a ph of 6.5; specific gravity = 1.012; positive protein (1+), positive leukocyte esterase; negative blood and nitrite. P Performance /P-06 Cellular cast (RTE and/or neutrophil) Good Casts are the only formed elements in the urine that have the kidney as their sole site of origin. Tamm-Horsfall glycoprotein secreted by the thick part of the ascending loop of Henle is the matrix of all casts, including cellular casts. Only hyaline casts are considered normal. Cellular casts are definitely abnormal and indicate renal damage. Red blood cell (erythrocyte) casts indicate bleeding within the nephron, such as glomerulonephritides (like this case), IgA nephropathy, lupus nephritis, renal infarction and subacute bacterial endocarditis. Rarely tubulointerstitial diseases may allow erythrocytes to enter the tubules, such in severe pyelonephritis. In this particular cast one can also see white blood cells or leukocytes, characterized by a refractile appearance, cytoplasmic granules and multilobated nuclei. Leukocytes may enter the nephron lumina through the tubule and may reflect tubulointerstitial disease, such as pyelonephritis. However, leukocyte casts may also be present in cases of glomerular disease (like this case), intertitial nephritis, lupus nephritis and even nephritic syndrome. Leukocyte casts may be difficult to be distinguished from renal tubular epithelial cell casts. 58

4 Urine Sediment Photomicrographs/Photographs Case History /P-07 This urinary sediment is from a 15-year-old female with hypertension, edema, and cloudy brownish urine. Two weeks ago, she presented with a sore throat and fever. Urine had a ph of 6.5; specific gravity = 1.012; positive protein (1+), positive leukocyte esterase; negative blood and nitrite. /P-07 P Performance Squamous epithelial cell Good Squamous epithelial cells are large (30-50 μm). They are the most frequent epithelial cells seen in the urine and, therefore, least significant. The distal one third of the urethra is lined by squamous epithelial cells. In the urine, these cells appear large, flat, with abundant cytoplasm and centrallyplace small round nuclei. The borders of these cells frequently appear rolled or folded. Many of these cells derive form the vagina or vulva in the urine of females. If seen in large numbers they may indicate that the urine collected was not a clean catch. Ramon Blanco, MD Hematology and Clinical Microscopy Resource Committee 59

5 Body Fluid Photomicrographs/Photographs Case History /P-08 The patient is a 78-year-old female with recent trigeminal neuralgia presenting with seizure-like activity and loss of consciousness. CSF sample laboratory findings include: WBC = 171/μL and RBC = 12/μL. /P-08 P Performance Eosinophil, any stage Good The arrowed cell is an eosinophil in the cerebral spinal fluid (CSF). It was correctly identified by 100.0% of referees and 99.0% of participants. Eosinophils are round to oval leukocytes with characteristic granulation. Mature forms are micrometers, similar to the size of neutrophils. The granules filling the abundant cytoplasm are coarse, orange-red, and uniform in size. They exhibit a refractile appearance with light microscopy due to their crystalline structure. The granules may overlie the nucleus. Degranulation may occur rendering the cytoplasm a faint pink. Mature eosinophils have a segmented nucleus with two or three lobes of compact chromatin connected by a chromatin filament. 60

6 Body Fluid Photomicrographs/Photographs Case History /P-09 The patient is a 78-year-old female with recent trigeminal neuralgia presenting with seizure-like activity and loss of consciousness. CSF sample laboratory findings include: WBC = 171/μL and RBC = 12/μL. /P-09 P Performance Plasma cell Educational The arrowed cell is a plasma cell in the CSF. It was correctly identified by 94.0% of referees and 96.9% of participants. They are medium size (10-20 micrometers), round to oval cells with moderate to abundant cytoplasm which stains gray-blue to basophilic. Their nuclei are round to ovoid and eccentric with coarse, clumped chromatin arranged in a cartwheel-like or clock-face pattern. No nucleoli are present. A prominent hof or paranuclear zone of lighter staining cytoplasm is seen towards one side of the nucleus and corresponds to the Golgi zone. Scattered vacuoles as well as immunoglobulin inclusions may be seen in the cytoplasm. 61

7 Body Fluid Photomicrographs/Photographs Case History /P-10 The patient is a 78-year-old female with recent trigeminal neuralgia presenting with seizure-like activity and loss of consciousness. CSF sample laboratory findings include: WBC = 171/μL and RBC = 12/μL. /P-10 P Performance Lymphocyte Educational Lymphocyte, Reactive Educational This arrowed cell is a lymphocyte in the CSF. It was correctly identified by 94.0% of referees and 99.0% of participants. Lymphocytes exhibit a range of morphology. Most lymphocytes are small cells (7-15 micrometers) which may be slightly indented or notched and have round to oval nuclei. Some lymphocytes are medium sized having an increased amount of cytoplasm. The chromatin is diffusely dense or coarse and clumped. No nucleoli are visible, although small, pale chromocenters may be mistaken for nucleoli. The majority of lymphocytes have scant, pale blue, agranular cytoplasm. Fraying of the edges may be seen and is usually artifactual. Occasional lymphocytes have a perinuclear clear zone or halo surrounding the nucleus or even a small hof. 62

8 Body Fluid Photomicrographs/Photographs Case History /P-11 The patient is a 78-year-old female with recent trigeminal neuralgia presenting with seizure-like activity and loss of consciousness. CSF sample laboratory findings include: WBC = 171/μL and RBC = 12/μL. /P-11 P Performance Monocyte/macrophage Good The arrowed cell is a monocyte in the CSF. It was correctly identified by 100.0% of referees and 96.9% of participants. Mature monocytes are micrometers, slightly larger than a neutrophil. Most are round with smooth edges, although pseudopod-like extensions of cytoplasm may be seen. The cytoplasm is abundant and gray to gray-blue with a ground-glass appearance. Fine, evenly distributed pink azurophilic granules and/or vacuoles may be seen, as in the arrowed monocyte. Phagocytized material may be seen in the cytoplasm. The nucleus is indented, but can be folded or band-like. The chromatin is somewhat clumped, but usually less dense than the chromatin in a neutrophil or lymphocyte. 63

9 Body Fluid Photomicrographs/Photographs Case History /P-12 The patient is a 78-year-old female with recent trigeminal neuralgia presenting with seizure-like activity and loss of consciousness. CSF sample laboratory findings include: WBC = 171/μL and RBC = 12/μL. /P-12 P Performance Lymphocyte Good Lymphocyte, Reactive Acceptable The arrowed cell is a lymphocyte in the CSF. It was correctly identified by 100.0% of referees and 92.0% of participants. The image depicts a spectrum of lymphocyte morphologies. Reactive lymphocytes are characterized by a range of morphologic appearances within the specimen. These cells are reacting to an antigenic stimulus and are frequently increased in viral illnesses. They range in size from micrometers. Reactive lymphocytes have more abundant cytoplasm, frequently containing vacuoles. The cytoplasm ranges from gray to pale blue to deeply basophilic; it may be darker at the periphery and lighter near the nucleus. Some reactive lymphocytes contain occasional azurophilic granules in the cytoplasm. The nuclear:cytoplasmic ratio is decreased, and the nucleus is irregular with a more open chromatin pattern. Nucleoli may be seen. 64

10 Body Fluid Photomicrographs/Photographs Case History /P-13 The patient is a 78-year-old female with recent trigeminal neuralgia presenting with seizure-like activity and loss of consciousness. CSF sample laboratory findings include: WBC = 171/μL and RBC = 12/μL. /P-13 P Performance Eosinophil Good The arrowed cell is an eosinophil. It was correctly identified by 100.0% of referees and 97.6% of participants. The surrounding cells include another eosinophil, a red blood cell, and lymphocytes including a reactive lymphocyte. Lydia C. Contis, MD Hematology and Clinical Microscopy Resource Committee 65

11 Clinical Microscopy Miscellaneous Photomicrographs/Photographs M MP Performance M/MP-30 Yeast or other fungal element is present Good The KOH wet preparation demonstrates pseudohyphae which exhibit branching and are consistent with Candida species. A vaginal wet prep is often collected in the evaluation of vaginitis. The three most common types of acute vaginitis are bacterial vaginosis, vulvovaginal candidiasis and trichomoniasis. Most cases of Candida infection are caused by the person s own Candida organisms. Candida yeasts usually live in the mouth, gastrointestinal tract, and vagina without causing symptoms. Symptoms develop only when Candida becomes overgrown in these sites. Vulvovaginal candidiasis occurs more frequently and more severely in people with weakened immune systems. Some other conditions that may put a woman at risk for genital candidiasis include: pregnancy, diabetes mellitus, use of broad-spectrum antibiotics and use of corticosteroids. Nearly 75% of all adult women have had at least one genital "yeast infection" in their lifetime. On rare occasions, men may also experience genital candidiasis. There are many approved topical antifungal treatments and one oral agent, fluconazole (150 mg), in a single dose % of women will have symptomatic relief with either the topical or oral therapy. References: 1. Eckert, LO. Acute Vulvovaginitis. NEJM 2006:355:

12 Clinical Microscopy Miscellaneous Photomicrographs/Photographs M MP Performance M/MP-31 Eosinophils are present Good This nasal smear has eosinophils present, which exhibit the typical bilobed nucleus and numerous cytoplasmic eosinophilic granules. Nasal smears for eosinophils are an aid to distinguishing allergic rhinitis, where eosinophils are present, from non-allergic rhinitis. The clinical differential diagnosis of non-allergic rhinitis and allergic rhinitis is difficult due to the significant overlap of clinical symptomatology. In addition to the nasal smear, skin prick tests, serum IgE levels, and RAST tests may be used in conjunction with the clinical presentation to differentiate allergic and non-allergic rhinitis. References: 1. Scadding GK. Non-allergic rhinitis: diagnosis and management. Curr Opin Allergy Clin Immunol Feb;1(1): Bachert C. Persistent rhinitis-allergic or nonallergic? Allergy. 2005; 59 Suppl 76:11-5; discussion

13 Clinical Microscopy Miscellaneous Photomicrographs/Photographs M/MP-32 M MP Performance No pinworm or pinworm eggs are present Good This stool smear exhibits cellular debris and is negative for pinworm (Enterobius vermicularis). Pinworm infection is seen in children 5-14 years of age who present with anal pruritus. To exclude pinworm infection, either cellophane tape collection or an anal swab collection onto a glass slide is acceptable for microscopic examination. M/MP-33 M MP Performance Ferning is not present Good A vaginal sample collected to evaluate for the presence or absence of ferning is negative for ferning in this specimen. Examination of vaginal secretions for ferning is used to detect rupture of amniotic membranes. The fern test was initially described in 1955 and its ease of use and clinical utility has been confirmed by multiple published studies. 68

14 Clinical Microscopy Miscellaneous Photomicrographs/Photographs M/MP-34 M MP Performance Neutrophils are present Good The stool specimen demonstrates many neutrophils. Neutrophils have a segmented or lobulated (two to five lobes) and pale or colorless cytoplasm with cytoplasmic granules which are difficult to see on this preparation. Stool specimens for neutrophils may be collected in the evaluation of diarrhea. The presence of neutrophils is consistent with, but not diagnostic of, a bacterial infection. Stool cultures are much more sensitive and specific for the evaluation of enteric pathogens. M/MP-35 M MP Performance No spermatozoa are present Good This vaginal wet preparation is hypocellular with a squamous epithelial cell present and no sperm identified. A vaginal secretion specimen is collected from the posterior vaginal pool by a speculum that has not been lubricated with petroleum jelly. The secretions are collected on a cotton or dacron-tipped swab and are mixed with a few drops of saline on a slide. The slide is studied with brightfield or phase microscopy. Deborah A. Perry, MD and Sarah L. Lott, MD Hematology and Clinical Microscopy Resource Committee 69