Urine Sediment Photomicrographs/Photographs

Transcription

1 Urine Sediment Photomicrographs/Photographs Case History /P-04 This urinary sediment is from a 48-year-old male with a 30-year history of diabetes mellitus, edema and new onset of renal failure. BUN = 35 mg/dl (8-18 mg/dl) and creatinine = 2.8 mg/dl ( mg/dl). Urine ph = 7.0; specific gravity = 1.007; positive for protein (4+) and glucose (2+) /P-04 P Performance Waxy cast Good The arrowed item is a waxy cast. It was correctly identified by 95.5% of all participants. Waxy casts are the end-stage of degenerated cellular casts. They are broad and usually short. The sides have sharp margins and the ends may appear broken off. They are colorless or pale yellow with a dense, waxy character. They are always significant because they are usually seen with more severe kidney disease. Fibers from disposable diapers may have a similar appearance, but are birefringent with polarized light. Waxy casts are not. 38

2 Urine Sediment Photomicrographs/Photographs Case History /P-05 The patient is a 45-year-old male with diabetes, edema, hypertension and renal failure. Urine ph = 6.5, specific gravity = 1.011, and the urine was opalescent. Dipstick was positive for glucose and strongly positive for protein. P Performance /P-05 Cholesterol crystals Not Graded Uric acid crystals Not Graded There was non-consensus for this specimen. The arrowed object was identified correctly as cholesterol crystals by 48.2% of all participants. Fifty percent of the participants incorrectly identified the arrowed object as uric acid crystals. Uric acid crystals are seen only in acid urine and take a variety of forms, including four-sided plates. These usually appear square, thick and do not have notched edges, as the rectangular cholesterol crystals usually do. They are typically colored yellow or red-brown, compared to the colorless cholesterol crystals.. They show strong and brilliant birefringence with polarized light, whereas cholesterol crystals show weaker birefringence. Cholesterol crystals are virtually never seen in patients with normal renal function, and may be seen with oval fat bodies or fatty casts. Uric acid crystals are a common finding in normal urine. Not graded due to lack of 90% participant consensus. 39

3 Urine Sediment Photomicrographs/Photographs Case History /P-06 The patient is a 62-year-old man with an enlarged prostate and renal failure. BUN = 45 mg/dl (8-18 mg/dl), creatinine = 3.4 mg/dl ( mg/dl). He presents with fever and dehydration. The urine is cloudy with a ph of 6.6 and positive reactions for protein and leukocyte esterase. /P-06 P Performance Granular cast Good The arrowed object is a granular cast and was correctly identified by 99.2% of all participants. This type of cast may contain fine or coarse granules and they are often mixed or unevenly distributed. It is not necessary to sub classify fine and granular casts. These casts may be seen in normal urine, especially after vigorous exercise, or in patients with renal disease. 40

4 Urine Sediment Photomicrographs/Photographs Case History /P-07 The patient is a 34-year-old man who submitted a urine sample as part of an employment physical examination. Urinlaysis results include: ph = 6.4; specific gravity = /P-07 P Performance Calcium oxalate Good This is an example of calcium oxalate crystals and was correctly identified by 99.7% of all participants. They are present at acid or neutral ph, vary in size and form, and may be smaller than red cells. The dihydrate formsare described as colorless octahedrons, stars, two pyramids joined at the base, or envelopes. The rarer monohydrate form may be very small and oval, elliptical or dumbbell-shaped. All are birefringent. Their formation is increased in patients who eat foods rich in oxalic acid (e.g. tomatoes, asparagus, oranges, rhubarb). They are seen in normal urine, but may be related to kidney stone formation in some patients and seen with ethylene glycol (antifreeze) poisoning. Roberta L. Zimmerman, MD Hematology and Clinical Microscopy Resource Committee 41

5 Body Fluid Photomicrographs/Photographs Case History /P-08 A markedly premature three-month-old infant with hydrocephalus required replacement of a previously inserted shunt. CSF obtained during the procedure showed a WBC of 30 x 10 9 /L with a differential count of 3% lymphocytes, 91% macrophages and 6% other. /P-08 P Performance Macrophage containing hemosiderin (Siderophage) Good Immature/abnormal cell Good /P-08 demonstrates a macrophage containing hemosiderin (siderophage). Ninety-three percent of referees and 77.2% of all participants provided the correct response. The siderophage has an irregular border, an eccentric oval nucleus and contains numerous coarse, dark blue hemosiderin granules in clumps that fill the cytoplasm. In unstained slides these hemosiderin granules have a golden brown appearance, but demonstrate a dark blue color in Wright stains. They are a result of hemorrhage into the CSF. Siderophages can be confused with melanophages and melanoma cells, an unlikely possibility in this case considering the clinical history. 42

6 Body Fluid Photomicrographs/Photographs Case History /P-09 A markedly premature three-month-old infant with hydrocephalus required replacement of a previously inserted shunt. CSF obtained during the procedure showed a WBC of 30 x 10 9 /L with a differential count of 3% lymphocytes, 91% macrophages and 6% other. P Performance Germinal matrix cell Educational /P-09 /P-09 demonstrates a cluster of germinal matrix cells. This was an ungraded challenge. In the fetus and premature neonates there is a subependymal layer of primitive cells that is the source of neuronal precursor cells, which migrate along radial glia and populate the gray matter of the central nervous system. The germinal matrix is cellular with a delicate vasculature that is easily disrupted, especially in circumstances of hypoxic ischemia. Hemorrhages occur in the germinal matrices that can be limited and associated with a reasonable outcome or can be extensive with spread into adjacent brain and rupture into the ventricles and associated with a poor outcome or death. Hemorrhage into the ventricles can lead to post-hemorrhagic hydrocephalus, which may be treated by repeated ventricular or lumbar puncture. Clumps of germinal matrix cells can be seen in the CSF associated with intraventricular hemorrhage or with placement of shunts into the ventricle of a premature infant. The germinal matrix cells are found in aggregates that have all the feature of a malignant neoplasm including a high nuclear/cytoplasmic ratio, scant basophilic cytoplasm and finely dispersed nuclear chromatin often with a nucleolus. To correctly interpret these cells one must consider the clinical context (premature infant with intraventricular hemorrhage) and the presence of other correlates of intraventricular hemorrhage such as hemosiderin-laden macrophages. Application of immunohistochemistry to these clumps is generally not useful as they demonstrate the characteristics of primitive neuronal cells just as primitive neuroectodermal tumor cell clumps would. Reference: 1. Fernandes SP, Penchansky L: Tumorlike clusters of immature cells in cerebrospinal fluid of infants. Pediat Pathol Lab Med 1996; 16:

7 Body Fluid Photomicrographs/Photographs Case History /P-10 Prior to surgery for removal of a brain tumor, this three-year-old child had a lumbar puncture performed after the child s mother had noticed a white reflection through the infant s pupil. These images are from the cerbrospinal fluid removed at that time. P Performance Malignant cell (non-hematopoietic) Educational /P-10 /P-10 demonstrates a cluster of retinoblastoma cells in the cerebrospinal fluid of a child with evidence of retinoblastoma of the eye with spread to the central nervous system. This is an ungraded challenge and is presented in conjunction with the previous challenge to emphasize the importance of context in interpretation of clumps of primitive cells in the CSF of infants and children. The tumor cells are in aggregates, have a high nuclear/cytoplasmic ratio, scant basophilic cytoplasm and fine nuclear chromatin. It is common when staging a patient with retinoblastoma to perform both a lumbar puncture and bone marrow aspiration to seek the presence of tumor cells. Tumor cells are found relatively infrequently (5% in a recent large series) and are correlated with extensive ocular involvement with spread to the sclera and extension of tumor into the optic nerve. Recent studies have suggested that such evaluations may not be indicated in all cases. Obviously, extension into the cerebral spinal fluid is associated with a poorer prognosis and the need for more aggressive therapy. References: 1. Moschinski LC, Pendergrass TW, Weiss A, Hvizdala E, Buckley KS, Kalina A: Recommendations for the use of routine bone marrow aspiration and lumbar puncture in the follow-up of patients with retinoblastoma. J Pediat Hematol Oncol 1996; 18: Azar D, Donaldson C, Dalla-Pozza L: Questioning the need for routine bone marrow aspiration and lumbar puncture in patients with retinoblastoma. Clin Experiment Ophthalmol 2003; 31:

8 Body Fluid Photomicrographs/Photographs Case History /P-11 Prior to surgery for removal of a brain tumor, this three-year-old child had a lumbar puncture performed after the child s mother had noticed a white reflection through the infant s pupil. These images are from the cerbrospinal fluid removed at that time. /P-11 P Performance Lymphocyte Good /P-11 demonstrates a lymphocyte. All of the referees and 92.1% of participants choose this answer. The cell is only slightly larger than the surrounded red cells. It is round and has an eccentric round nucleus with clumped chromatin and blue cytoplasm. The finding of a small nucleolus is a common result of cytocentrifugation. Lymphocytes need to be distinguished from lymphoma and leukemia cells. 45

9 Body Fluid Photomicrographs/Photographs Case History /P-12 Prior to surgery for removal of a brain tumor, this three-year-old child had a lumbar puncture performed after the child s mother had noticed a white reflection through the infant s pupil. These images are from the cerbrospinal fluid removed at that time. P Performance /P-12 Monocyte/macrophage Not Graded Neutrophil Seg or Band Not Graded /P-12 is a monocyte. Ninety-three percent of referees and only 70.7% of participants made this identification. It is a larger cell relative to the adjacent red cells and has an indented nucleus with relatively open chromatin and a vacuolated cytoplasm. Its size, nuclear indentation, chromatin pattern and lack of significant cytoplasmic granules allow it to be distinguished from a normal lymphocyte or mature neutrophil. In some circumstances the differentiation of a monocyte/macrophage from an activated lymphocyte in a body fluid is not trivial, although vacuolation of cytoplasm to this extent would be unusual for a lymphocyte. Sometimes monocytes and myelocytes are confused although the myelocyte usually has prominent granules. One would not ordinarily expect to see myelocytes in body fluids but in small children CSF samples may be contaminated with bone marrow due to the small space through which the needle must pass. In such a case one would expect to see nucleated red cells also present. Some participants may have assumed that the nuclear appearance of this cell is that of a neutrophil that is artifactually expanded due to cytocentrifuge distortion but this seems unlikely in view of the appearance of the adjacent lymphocyte. This case is not graded by scientific committee decision considering the lack of participant consensus. Not graded due to Scientific Committee decision. 46

10 Body Fluid Photomicrographs/Photographs Case History /P-13 The patient is an 86-year-old woman who presents to the emergency room with a swollen, tender right knee. Analysis of aspirated synovial fluid shows: WBC = 29,000/uL and RBC = 7,500/ ul. P Performance /P-13 Neutrophil/macrophage containing Good crystal Neutrophil Seg or Band Acceptable /P-13 is a neutrophil/macrophage containing a crystal. Eighty-two percent of referees and 77.0% of participants made this identification with 12% of participants making the less specific identification of neutrophil, which the cell certainly is. One should always try to make the most specific identification possible. Particularly in a synovial fluid, finding an intracellular crystal is of considerable diagnostic significance. It suggests that the patient may have arthritis because of gout or pseudogout. The cell in this case contains a blunt ended crystal in a large vacuole. Uric acid crystals tend to be more needle-like and extend beyond the profile of the cell whereas calcium pyrophosphate crystals are blunt and within the cell, suggesting this is a case of pseudogout. However, compensated polarizing microscopy should be used to confirm the nature of crystals and could be readily applied to cytocentrifuge preparation in such a case. Robert W. Novak, MD Hematology and Clinical Microscopy Resource Committee 47

11 Clinical Microscopy Miscellaneous Photomicrographs/Photographs M/MP-30 M MP Performance No spermatozoa are present Good This vaginal wet preparation is negative for sperm. 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. M/MP-31 M MP Performance No neutrophils are present Good This stool specimen is negative for neutrophils. Assessment of stool specimens for neutrophils is a test that is sometimes used in conjunction with a bacterial culture in the evaluation of enteritis/colitis. While the presence of neutrophils is consistent with a bacterial infection, the findings are not specific. A stool culture is necessary for the complete evaluation of enteric pathogens. 48

12 Clinical Microscopy Miscellaneous Photomicrographs/Photographs M/MP-32 M MP Performance Ferning is present Good This vaginal wet preparation exhibits ferning. The fern test is used to detect ruptured amniotic membranes and the early onset of labor. A vaginal pool sample is collected and the fluid is allowed to air dry on a glass slide. The slide is examined using a microscope to detect ferning, an elaborate arborized crystallization pattern. Ferning, in conjunction with the Nitrazine test and the medical history, is highly sensitive for the detection of ruptured membranes. 49

13 Clinical Microscopy Miscellaneous Photomicrographs/Photographs M MP Performance M/MP-33 Pinworm or pinworm eggs are present Good This stool specimen has Enterobius vermicularis (pinworm) present. Pinworm is the most common worm infection in the United States. School-age children, followed by preschoolers, have the highest rates of infection. In some groups nearly 50% of children are infected. Infection often occurs in more than one family member. Adults are less likely to have pinworm infection, except mothers of infected children. Childcare centers, and other institutional settings often have cases of pinworm infection. Enterobiasis is frequently asymptomatic. The most typical symptom is perianal pruritus, especially at night, which may lead to excoriations and bacterial superinfection. Occasionally, invasion of the female genital tract with vulvovaginitis and pelvic or peritoneal granulomas can occur. Other symptoms include anorexia, irritability, and abdominal pain. The drug of choice is pyrantel pamoate. Measures to prevent reinfection, such as personal hygiene and laundering of bedding, should be discussed and implemented in cases where infection affects other household members. 50

14 Clinical Microscopy Miscellaneous Photomicrographs/Photographs M/MP-34 M MP Performance No eosinophils are present Good This nasal smear is negative for eosinophils. Nasal eosinophils correlate with clinical allergic rhinitis. In patients with nonallergic causes of nasal discharge either acellular mucus or neutrophils will be present on the nasal smear. M/MP-35 M MP Performance No yeast or other fungal element is present Good This KOH wet preparation is negative for the presence of yeast. Vaginal wet preparations are a useful tool in the evaluation of suspected vulvovaginitis. Candida species and Trichomonas organisms are readily identifiable on wet preparations. References: Deborah A. Perry, MD Hematology and Clinical Microscopy Resource Committee 51