Urine Sediment Photomicrographs

Transcription

1 Urine Sediment Photomicrographs Case History CM-17 The patient is a 33-year-old male with alcohol induced cirrhosis, ascites, and jaundice. The urine ph was 6.0, specific gravity = 1.015, and the urine was golden brown color. Leucine crystal Not Graded CM-17 There was nonconsensus among program participants. CM-17 was an unstained urine containing leucine crystals. Leucine crystals are very rare. They are seen in patients with severe liver disease and certain hereditary amino acid metabolic disorders. They may be seen with tyrosine crystals. Leucine crystals are yellow spheres with radial or concentric striations, often described as "oily-appearing". They occur in acid urine. They are birefringent with polarized light, with a pseudo maltese cross pattern. They dissolve in acid and alkali. Chemical confirmation is by liquid chromatography. Acetylsulfadiazine crystals resemble wheat sheaves with eccentric binding. Acetylsulfamethoxazole crystals are brown dense spheres with irregular divisions, not the radial concentric striations seen in leucine. Uric acid may form lemon-shaped structures or rosettes, but have not been described as spheres with striations. Bilirubin crystals are red-brown and form rhombic plates or cubes, or amorphous crystals, not spheres. The classic form of ammonium biurate is the so-called "thorn apple", a sphere with irregular thorny projections. Striations are not seen. Starch crystals differ from leucine in that they tend to have an irregular outline and a central depression or "dimple". Not graded due to lack of participant consensus. 37

2 Urine Sediment Photomicrographs Case History CM-18 The urine sample is from an 82-year-old woman resident of a long-term care facility who developed urinary incontinence. Urinalysis showed: ph = 5.0; specific gravity = 1.015; protein = negative; glucose = 2+; ketone = negative; blood = negative; leukocyte esterase = postive; and nitrite = negative. CM-18 Squamous epithelial cell Good Epithelial cell Acceptable Squamous epithelial cells are large (30-50 microns) flat cells with a single well-defined nucleus about the size of a red cell. They are round or rectangular with abundant cytoplasm and sometimes roll into a tubular shape. Nuclei are small, round and centrally located. They line the female urethra and bladder trigone, vagina and distal male urethra. They are continually sloughed off and are a normal finding in urine. If they are present in large numbers, they indicate that the specimen was not a clean catch. 38

3 Urine Sediment Photomicrographs Case History CM-19 The patient is a 47-year-old female who was being evaluated for fever, chills and flank pain. She has a history of prior urinary tract infections with pregnancy. The urine ph was 7.5, specific gravity = and the urine was slightly cloudy. The dipstick was positive for leukocyte esterase, nitrite and protein. CM-19 Granular cast Good Granular casts are a later stage of cellular casts. The fine or coarse granules are the degenerated remnants of white cells, red cells or epithelial cells. The matrix is composed of plasma proteins, fibrinogen, or immune complexes in a Tamm-Horsfall matrix. Healthy people may have an occasional granular cast, especially following extreme stress or vigorous exercise. Increased numbers indicate glomerular, tubular or tubulointerstitial kidney disease, as well as renal transplant rejection. 39

4 Urine Sediment Photomicrographs Case History CM-20 The patient is a 70-year-old diabetic male with a recent cystectomy for carcinoma of the bladder. The urine sample was taken from an ileal pouch. Urinalysis showed a cloudy pale yellow urine with specific gravity = 1.017; ph = 6.5; glucose 3+; ketones = negative; leukocyte esterase = positive; blood = trace; protein = 2+; remaining dipstick tests normal or negative. CM-20 Hyphae/Yeast fungi Good Yeast have an ovoid shape, are colorless, smooth and refractile. They may be mistaken for red blood cells. They are slightly smaller (5-7 microns), with a thick cell wall and more variability in size. Budding and/or pseudohyphae formation helps to differentiate them from red blood cells. They are also strongly Gram positive. Elongated cells resembling mycelia are termed pseudohyphae. They are usually associated with infection rather than contamination. Yeast in the urine are most often Candida species. They are often the result of contamination from vaginal yeast infections. True renal yeast infections may be seen in the immunocompromised. Yeast may indicate increased sugar in the urine, such as in diabetes. Roberta L. Zimmerman, MD Hematology and Clinical Microscopy Resource Committee 40

5 Body Fluid Photomicrographs Case History CM-21 through CM-25 A 51-year-old woman presented with lethargy and confusion. Chest x-ray showed a right lower lobe infiltrate. A lumbar puncture was done. Analysis of CSF showed glucose = 51 mg/dl and protein = 87 g/dl. Blood cultures subsequently grew S. pneumoniae. CM-21 Neutorphil/macrophage w/phagocytized bacteria Good The arrow points to a neutrophil containing phagosomes (vacuoles) which contain bacteria that appear to be small cocci % of referees and 97.0% of participants chose the correct answer neutrophil/macrophage with phagocytized bacteria. Participants in proficiency testing need to remember that the most specific identification should be made and in this case it is the recognition that this phagocytic cell contains ingested bacteria rather than the type of cell that is most important. Bacteria within an intracellular vacuole are a much more certain indication of bacterial infection then extracellular bacteria that can result also result from stain or slide contamination. All types of bacteria appear purple in Wright stains. Gram stains are needed to specify the type of bacteria (gram positive or negative), but should be interpreted with caution for intracellular bacteria, as enzymes within the phagosomes may alter the character of the bacterial wall and hence the gram staining characteristics. 41

6 Body Fluid Photomicrographs Case History CM-21 through CM-25 A 51-year-old woman presented with lethargy and confusion. Chest x-ray showed a right lower lobe infiltrate. A lumbar puncture was done. Analysis of CSF showed glucose = 51 mg/dl and protein = 87 g/dl Blood cultures subsequently grew S. pneumoniae. CM-22 Bacteria, extracelluar Good The arrows point at extracellular bacteria which appear to be small cocci or diplococci. There are also phagocytic cells in the field with the same type of bacteria present within phagosomes (vacuoles) making the extracellular bacteria a true finding rather then the result of contamination % of referees and 99.4% of participants choose the correct answer, extracellular bacteria. Extracellular bacteria need to be distinguished from stain precipitate. Stain precipitate consists of dense granules that may not be uniform in size and tends to overlap cells and other structures. Staining of another slide after filtering the stain or performing a gram stain are both reasonable ways to exclude or confirm stain precipitate. 42

7 Body Fluid Photomicrographs Case History CM-21 through CM-25 A 51-year-old woman presented with lethargy and confusion. Chest x-ray showed a right lower lobe infiltrate. A lumbar puncture was done. Analysis of CSF showed glucose = 51 mg/dl and protein = 87 g/dl Blood cultures subsequently grew S. pneumoniae. CM-23 Degenerating cell, NOS Educational The arrow indicates a cellular structure that is smoothly rounded, basophilic and contains pyknotic nuclear fragments. 90.9% of referees and 97.1% of participants made the correct identification degenerating cell. Neutrophils that have entered a body space often after a period of time undergo degeneration most clearly recognized by an increase in cytoplasmic density and condensation and fragmentation of the nucleus (karyorrhexis). 43

8 Body Fluid Photomicrographs Case History CM-21 through CM-25 A 51-year-old woman presented with lethargy and confusion. Chest x-ray showed a right lower lobe infiltrate. A lumbar puncture was done. Analysis of CSF showed glucose = 51 mg/dl and protein = 87 g/dl Blood cultures subsequently grew S. pneumoniae. CM-24 Macrophage/Neutrophil containing erythrocyte(s) Good The arrow indicates a phagocytic cell that contains an ingested red cell immediately beneath its nucleus. It is somewhat difficult in this case to specify the specific type of this phagocyte % of referees and 94.7% of participants made the correct identification of macrophage/neutrophil containing erythrocyte. When there is hemorrhage into a body fluid the erythrocytes can be removed by phagocytosis and digestion in phagocytes. Later these phagocytic cells may display hemosiderin or hematin crystals. The red color of the ingested erythrocyte distinguishes it from an LE cell which contains basophilic nuclear material. A rare condition, hemophagocytic syndrome, is characterized by prominent erythrocyte phagocytosis in bone marrow and the phenomenon of erythrocyte phagocytosis may be seen in other sites such as CSF. 44

9 Body Fluid Photomicrographs Case History CM-21 through CM-25 A 51-year-old woman presented with lethargy and confusion. Chest x-ray showed a right lower lobe infiltrate. A lumbar puncture was done. Analysis of CSF showed glucose = 51 mg/dl and protein = 87 g/dl Blood cultures subsequently grew S. pneumoniae. CM-25 Lymphocyte Educational Lymphocyte, reactive Educational Lymphoma cell Educational The arrow points to a cell with a round uniform nucleus and agranular cytoplasm which is smaller then a neutrophil. 45.5% of referees and 68.0% of participants made the correct identification of lymphocyte. The size and the character of the cell allow one to identify it as a lymphocyte. It is not phagocytic like other cells in the field that show vacuoles. Finding bacteria both in cells and outside cells is a much more common phenomenon in a bacterially infected body fluid than finding bacteria in the blood in a patient with sepsis. This likely occurs because the fluid is enclosed and does not circulate through sinusoids lined be phagocytic cells like the spleen which remove organisms. Robert W. Novak, MD Hematology and Clinical Microscopy Resource Committee 45

10 Body Fluid Photomicrographs Case History CM-26 The patient is a 65-year-old male with soft tissue mass in the right foot. Needle aspiration performed with a small amount of moist, grey-white material expressed on slide. This was sent to the laboratory for examination. When examined by polarized light using a red plate compensator, the objects indicated by arrow showed negative birefringence. CM-26 Monosodium urate crystals Good The arrows point to needle-like crystals that are not present within cells. 93.3% of referees and 94.0% of participants made the correct identification of monosodium urate crystals. The crystals have the morphology of monosodium urate crystals and exhibit by history the characteristic birefringence pattern. Other needle-like crystals can be seen such as CPPD and steroid crystals following a steroid injection. CPPD can be distinguished by its birefringence pattern but steroid crystals can be difficult to distinguish from pathologic crystals. Lydia C. Contis, MD Hematology and Clinical Microscopy Resource Committee 46

11 Clinical Microscopy Miscellaneous Photomicrographs CMM-36 Pinworm or pinworm eggs are present Good This stool specimen has Enterobius vermicularis (pinworm) present. Enterobius vermicularis is also called human pinworm. (Adult females: 8 to 13 mm, adult male: 2 to 5 mm.) Humans are considered to be the only hosts of E. vermicularis. 47

12 Life Cycle: CMM-36 Eggs are deposited on perianal folds. Self-infection occurs by transferring infective eggs to the mouth with hands that have scratched the perianal area. Person-to-person transmission can also occur through handling of contaminated clothes or bed linens. Enterobiasis may also be acquired through surfaces in the environment that are contaminated with pinworm eggs (e.g., curtains, carpeting). Some small number of eggs may become airborne and inhaled. These would be swallowed and follow the same development as ingested eggs. Following ingestion of infective eggs, the larvae hatch in the small intestine and the adults establish themselves in the colon. The time interval from ingestion of infective eggs to oviposition by the adult females is about one month. The life span of the adults is about two months. Gravid females migrate nocturnally outside the anus and oviposit while crawling on the skin of the perianal area. The larvae contained inside the eggs develop (the eggs become infective) in 4 to 6 hours under optimal conditions. Retroinfection, or the migration of newly hatched larvae from the anal skin back into the rectum, may occur but the frequency with which this happens is unknown. 48

13 Clinical Microscopy Miscellaneous Photomicrographs CMM-37 Ferning is present Good This vaginal wet prep is positive for the presence of ferning. Ferning, used in conjunction with the Nitrazine test, is highly sensitive and specific for the detection of ruptured amniotic membranes. The elaborate ferning pattern seen here is readily identifiable at low power. 49

14 Clinical Microscopy Miscellaneous Photomicrographs CMM-38 Yeast/fungal element is present Good This KOH prep demonstrates many branched pseudohyphae, which have terminal buds and are characteristic of infection with Candida species. Infection with Candida is one of the most common causes of vaginitis % of women will have symptomatic relief with treatment with either a topical antifungal agent or oral fluconazole (150 mg) in a single dose. CMM-39 Neutrophils are present Good This Wright-Giemsa stained stool smear preparation demonstrates many neutrophils, along with bacteria and debris. A smear preparation for neutrophils can be used as an adjunct (but not a substitute) for stool culture. Neutrophils are seen in the stool specimens of patients with bacterial enteritis; however, this finding is neither sensitive nor specific. Stool culture is the standard diagnostic test. 50

15 Clinical Microscopy Miscellaneous Photomicrographs CMM-40 Eosinophils are present Good Eosinophils are present on this nasal smear preparation. The finding of nasal eosinophils is supportive of the diagnosis of allergic rhinitis. The slide is prepared by having the patient blow his/her nose in a nonabsorbent material (waxed paper, plastic wrap). A swab is used to transfer the mucus to a glass slide. After the slide is air dried, it can be stained with either Wright- Giemsa or Hansel stain and then evaluated. 51

16 Clinical Microscopy Miscellaneous Photomicrographs Trichomonas vaginalis Good CMM-41 This vaginal preparation is positive for the presence of Trichomonas vaginalis. This pyriform or pear-shaped protozoan has a single nucleus, 4 anterior flagella and an undulating membrane in the anterior half from which projects a single posterior flagellum. Trichomoniasis is one of the most common sexually transmitted diseases, mainly affecting sexually active women. In women, the signs and symptoms of infection range from having no symptoms (asymptomatic) to very symptomatic. Typical symptoms include foul smelling or frothy green discharge from the vagina, vaginal itching or redness. Other symptoms can include painful sexual intercourse, lower abdominal discomfort, and the urge to urinate. Most men with this infection do not have symptoms. When symptoms are present, they most commonly are discharge from the urethra, the urge to urinate, and a burning sensation with urination. The drugs of choice for treatment are metronidazole and tinidazole. References: Eckert LO. Acute Vulvovaginitis. NEJM 2006; Deborah A. Perry, MD Hematology and Clinical Microscopy Resource Committee 52