Color Atlas of Clinical Laboratory Medicine. First Version

Transcription

1 Color Atlas of Clinical Laboratory Medicine First Version Addis Ababa, February 2015 Page 1 of 44

2 Table Contents 1. Hematology Cell Maturation Red Blood Cells Morphology Abnormal Red Blood Cell Morphology White Blood Cell Morphology Abnormal White Blood Cell Morphology Bacteriology Gram Positive Cocci Gram Positive Bacilli Gram Negative Cocci Gram Negative Bacilli Acid Fast Bacilli, AFB Spirochetes Parasitology Intestinal Protozoa Intestinal Nematodes Intestinal Cestodes Trematodes Blood Protozoa Tissue (Filarial) Nematodes Urinalysis Urine sediment cells Urine Parasites urine Sediment Crystals Urine sediment Casts Acknowledgments Page 2 of 44

3 The EPHLA is deeply indebted to Tariku Bekele and Tadesse Hailu, both of whom are senior members of our Association and with considerable laboratory experience, for their tireless effort in assembling and systematically arranging the required information for this color atlas to be a reality. Even though almost all the information in the atlas is downloaded from their free internet access, EPHLA still would like to express its appreciation to the World Health Organization for creating such marvelous opportunity. Preparation of laboratory color atlas was first pioneered by MSH (Ethiopian Network for HIV/AIDS Treatment, Care & Support Program) whose management group unreservedly encouraged us to proceed with compilation of the current atlas and therefore our gratitude also goes to them. Unreserved support and the funding of this project by the Ethiopian Public Health Association (EPHA) and the CDC (through the grant # GH001039) are greatly acknowledged. Preface Diagnostic laboratory service is not only an indispensable part but the backbone of the health care delivery system which often determines the outcome of patient care for better or worse. Unfortunately, Page 3 of 44

4 however, laboratory service in this country like the rest of many others in Africa has never received the attention it deserves. We often hear that constraints of financial and human resources, among others, being put forward as the reasons for the apparent gaps. It is true that there is limitation of resources but it is not the whole truth. Frankly speaking most health care providers don't care while many others including from the management side don't really much understand that test results generated by the labs constitute evidence-based scientific medicine which pinpoint a better or even the right treatment option(s). Whether we are health care providers or health managers, sooner or later we all are patients and thus beneficiaries of laboratory services and therefore concerted effort and commitment by all towards promoting quality laboratory standards is the order of the day. With this kind of mind set and with concerted effort from all stakeholders, significant qualitative change in our laboratory systems is not only plausible but achievable too. Gradually but surely such changes are on the way to many of our labs in health facilities across the tier, thanks to the effort of governmental and non-governmental institutions. The Ethiopian Public Health laboratory Association (EPHLA) is a non-for-profit and a non-governmental organization established to contribute towards the national effort of strengthening public health laboratories and to help them render quality standard diagnosis and services to the patient population. To this end, the Association adopted several strategies, chief among them being human capacity building by increasing access to information so that laboratorians could keep themselves abreast with current scientific developments. It is in this spirit that this color laboratory atlas was developed which is mainly intended for facilities in remote locations with limited or no access to scientific information. This atlas by no means should be considered as a silver bullet and hence as a substitute to the ultimate decision based primarily on the discretion of the technician and on further verification and/or validation of the test procedures whenever this is applicable or feasible. This is particularly evident considering the similarities in micro-morphological or phenotypic characteristics between less related or even unrelated organisms depicted in the atlas. Caution must therefore be exercised against sweeping conclusion and hence wrong diagnosis that could be detrimental to patient outcome. Thus, it is worth a while reiterating that the color atlas is meant to serve not as the only but as one of the many possible tools at the disposal of the lab professionals in the diagnosis of the major pathogenic agents and/or organisms that are prevalent in the country. This color atlas being the first of its kind to our Association, the EPHLA intends to update it through follow up of new editions. Thus, the kind cooperation of our laboratory colleagues in providing feedback on gaps and weaknesses noted in the publication or on any other relevant issues is vital in strengthening and increasing the output of the EPHLA towards our common goal of achieving quality standards in all of our labs. EPHLA February, 2015 Page 4 of 44

5 1. Hematology 1.1. Cell Maturation Hematopoiesis is a process of blood cell production and maturation in the bone marrow. The process begins with the pluripotent stem cell. The stem cell is capable to proliferate, differentiate and replicate. The differentiation into a myeloid or lymphoid stem cell takes place in response of growth factors (cytokines) Page 5 of 44

6 1.2 Red Blood Cells Morphology Normocytic Normochromic Microcytic Hypochromic 1.3 Abnormal Red Blood Cell Morphology Target Cells Bite/Schistocyte Page 6 of 44

7 Ovalocytes (Elliptocytes) Tear drop cells Stomatocyte Sickle cells Page 7 of 44

8 Roulex fromed RBCs Spherocyt Acanthocytes (Spur Cells) Howell-Jolly Bodies Page 8 of 44

9 Cabot ring (Ring shaped, thin, may be figure of 8 shaped) 1.4 White Blood Cell Morphology Band and Segmented WBC Basophil Page 9 of 44

10 Eosnophil Monocyte Lymphocyte Page 10 of 44

11 Platelets (Normal) 1.5 Abnormal White Blood Cell Morphology Toxic granulation Dohle bodies Toxic granulation, vacuolization, & Dohle bodies are seen during bacterial infections, burns, cancer, and toxic or inflammatory states Page 11 of 44

12 Vacuoles 2. Bacteriology 2.1 Gram Positive Cocci Gram-positive cocci in &outside neutrophils (Clustered) Gram-positive diplococci with capsule neutrophils Page 12 of 44

13 Gram positive cocci cluster Gram positive streptococci 2.2 Gram Positive Bacilli Gram positive Bacilli Page 13 of 44

14 2.3. Gram Negative Cocci Gram-negative diplococci phagocytized by neutrophils Gram Negative extracellular diplococcic 2.4 Gram Negative Bacilli Gram-negative rods with capsule, Large-sized Gram-negative rods Page 14 of 44

15 2.5. Acid Fast Bacilli, AFB Fluorochrome stained smear numerous green AFB Ziehl Neelson stained AFB Fluorochrome stained smear numerous green AFB Fuorochrome stained non AFB Page 15 of 44

16 Fluorochrome stained smear showing numerous green acid-fast bacilli Ziehl-Neelsen (ZN) stained Acid Fast Bacill acid-fast 2.6 Spirochetes Borellia spps are long and spiral-shaped. The circular objects are red blood cells. The irregular purple object in the top right corner is a white blood cell Page 16 of 44

17 Borrelia spps stained in a blood sample with a Wright stain. Page 17 of 44

18 3. Parasitology 3.1. Intestinal Protozoa Trophozoite of E. histolytica/e. dispar in a direct wet mount stained with iodine Cyst E. histolytica/e. dispar in an unstained wet mount of stool Cyst E. histolytica/e. dispar in an unstained wet mount of stool with Iodine Page 18 of 44

19 Fig. A: B. coli trophozoite in a wet mount, 400 magnification. Fig. B: B. coli trophozoite in a Mann's hematoxylin stained smear, 500 magnification. Figure A: B. hominis cyst-like forms in a wet mount, unstained Figure B: Cryptosporidium spp. oocysts (pink arrows) in Wet mount. A budding yeast (brown arrow) is in the same field Page 19 of 44

20 Figure A: Cryptosporidium sp. oocysts stained with trichrome. Oocysts may be detected, but should not be confirmed by this method. Trichrome staining is inadequate for a definite diagnosis because oocysts will appear unstained. Here the Cryptosporidium oocysts are represented by red arrows; the blue arrow represents yeast Fig A: Immature oocyst of C. belli in an unstained wet mount, containing a single sporoblast Fig B: Immature oocyst of C. belli stained with safranin, containing a single sporobla Page 20 of 44

21 Fig. A Tachyzoites (trophozoites) of Toxoplasma gondii are approximately 4-8 µm long by 2-3 µm wide, with a tapered anterior end, a blunt posterior end and a large nucleus. Fig. B Cysts of Toxoplasma gondii usually range in size from 5-50 µ in diameter 3.2. Intestinal Nematodes Egg of T. trichiura in an iodine-stained wet mount and also the presence of a cyst of Entamoeba coli (arrow). Page 21 of 44

22 Fig. A: Eggs of E. vermicularis in a wet mount mount Fig. B: Egg of E. vermicularis in an iodine-stained wet Unfertilized and fertilized eggs of A. lumbricoides in an unstained wet mount of stool 200x Page 22 of 44

23 Hookworm egg in an unstained wet mount, taken at 400x magnification. Rhabditiform larva of S. stercoralis in unstained wet mounts of stool. Notice the short buccal canal and the genital primordium (red arrows). Rhabditiform larva of S. stercoralis in an unstained wet mount of stool. Notice the prominent genital primordium (blue arrow), rhabditoid esophagus (red arrow) and short buccal canal (green arrow). Page 23 of 44

24 3.3. Intestinal Cestodes Taenia sp. eggs in unstained wet mounts. Iodine-stained wet mount of a Taenia sp. egg Egg of H. diminuta in a wet mount stained with iodine. Four of the hooks are visible at this level of focus Page 24 of 44

25 Eggs of D. latum in an iodine- stained wet mount; Eggs of D. latum in an unstained wet mount 3.4.Trematodes Egg of S. mansoni in an unstained wet mount Page 25 of 44

26 Egg of S. hematobium in an unstained wet mount Egg of F. hepatica in an unstained wet mount, taken at 400x and 100 x magnification Page 26 of 44

27 3.5. Blood Protozoa Fig. A: Leishmania sp. amastigotes in a Giemsa-stained tissue scraping Fig. B : Leishmania (Viannia) panamensis amastigotes in a Giemsa-stained tissue scraping. Identification to the species level is not possible based on morphology and other diagnostic techniques such isoenzyme assay or PCR are needed. Fig. C: Leishmania sp. amastigotes; touch-prep stained with Giemsa. Fig. D: Leishmania tropica amastigotes from an impression smear of a biopsy specimen from a skin lesion. In this figure, amastigotes are being freed from a rupturing macrophage. Patient had traveled to Egypt, Africa, and the Middle East. Based on culture in NNN medium, followed by isoenzyme analysis, the species was identified as L. tropica. Page 27 of 44

28 Fig. A : Trypansoma brucei spp. in a thick blood smear stained With Giemsa Fig. B : Trypansoma brucei spp in a thick blood smear stained with Giemsa. Fig. C : Trypanosoma brucei spp. in a thin blood smear stained with Wright-Giemsa. Fig. D: Trypanosoma brucei ssp. in a thin blood smear stained with Wright-Giemsa. Page 28 of 44

29 T. cruzi trypomastigote in a thin blood smear stained with Giemsa Rings of P. falciparum in a thick blood smear Page 29 of 44

30 Rings of P. falciparum in a thin blood smear Ring-form trophozoites of P. falciparum in a thin blood smear, exhibiting Maurer's clefts. Page 30 of 44

31 Gametocyte of P. falciparum in a thick blood smear. Note also the presence of many ring-form trophozoites. Gametocyte of P. falciparum in a thin blood smear and thick Giemsa stain Page 31 of 44

32 Schizont of P. falciparum in a thin blood smear. Trophozoites are also seen in this image Ring-form trophozoites of P. vivax in a thick blood smear. Page 32 of 44

33 Ring-form trophozoite of P. vivax in a thin blood smear. Trophozoite of P. vivax in a thick blood smear. Trophozoites of P. vivax in a thin blood smear Note the amoeboid appearance, Schüffner's dots and enlarged infected RBCs. Page 33 of 44

34 Fig. 1: Gametocyte (upper) and trophozoite (lower) of P. vivax in a thick blood smear Fig. 2: Macrogametocytes of P. vivax in a thin blood smear. Note the enlargement of the gametocytes compared to uninfected RBCs Fig. 1: Schizont of P. vivax in a thick blood smears Fig. 2: Ruptured schizont of P. vivax in a thin blood smear, showing free merozoites and pigment Page 34 of 44

35 Fig. 1: Ring-form trophozoite of P. malariae in a thin blood smear. Fig. 2: Trophozoite of P. malariae in a thick blood smear. Fig. 1: Basket-form trophozoite of P. malariae in a thin blood smear smear Fig. 2: Gametocyte of P. malariae in a thin blood Page 35 of 44

36 Fig. 1: Schizonts of P. malariae in a thick blood smear. Fig. 2: Schizont of P. malariae in a thin blood Fig. A: Ring-form trophozoites of P. ovale in a thin blood smear. Note the multiple-infected RBC in this image. Fig. B: Ring-form trophozoite of P. ovale in a thick blood smear. Page 36 of 44

37 Fig. 1: Infected RBCs showing developing (lower) and ringform (upper two) trophozoites of P. ovale in a thin blood smear. Fig. 2: Trophozoite of P. ovale in a thick blood smear. Fig. 1: Gametocyte of P. ovale (red arrow) nestled between two white blood cells in a thick blood smear. Fig. 2: Macrogametocyte of P. ovale in a thin blood smear. Note the fimbriation. Page 37 of 44

38 Fig. 1: Schizont of P. ovale in a thick blood smear. Fig. 2: Schizont (upper right) and ring-form trophozoite (lower left) of P. ovale in a thin blood smear 3.6. Tissue (Filarial) Nematodes Microfilaria of W. bancrofti in a thick blood smear stained with Giemsa Page 38 of 44

39 Larvae of Trichinella, freed from their cysts, typically coiled. tissue. Encysted larvae of Trichinella in pressed muscle 4. Urinalysis 4.1. Urine sediment cells Ghost RBC RBC s showing rouleaux Page 39 of 44

40 White Blood Cells in urine with 200X and 400x magnification, respectively Pus cell Yeasts cells (hyphae) Page 40 of 44

41 4.2. Urine Parasites Trophozoite of T.vaginalis in wet mount Trophozoites of T. vaginalis, stained with Giemsa Egg of S. haematobium in a wet mount of urine concentrates, showing the characteristic terminal spine. Page 41 of 44

42 4.3. urine Sediment Crystals Amorphous Urate crystals Amorphous phosphate Crystals Uric Acid Crystals Calcium Oxalate Crystals Page 42 of 44

43 4.4. Urine sediment Casts Granular Cast hyaline casts WBC Casts Fatty Wax Page 43 of 44

44 Cholesterol cast Page 44 of 44