Urine Sediment Photomicrographs/Photographs

Transcription

1 Urine Sediment Photomicrographs/Photographs Case History CMP-17 This urine sample is from a 48-year-old male with a 30-year history of diabetes mellitus and new onset renal failure. Laboratory data include: Specific gravity 1.010, ph = 6.5, blood, protein, ketones and glucose = positive; leukocyte esterase and nitrites = negative. CMP-17 Uric acid Good The crystal identified by the arrow is a uric acid crystal, as correctly identified by 96.5% of the referees and 86.5% of the participants. Uric acid crystals form at acid ph. They commonly occur as four sided, flat crystals. Other forms include six sided plates, needles, spears, wedges and stars. Uric acid crystals are birefringent. 58

2 Urine Sediment Photomicrographs/Photographs Case History CMP-18 This urine sample is from a 48-year-old male with a 30-year history of diabetes mellitus and new onset renal failure. Laboratory data include: Specific gravity 1.010, ph = 6.5, blood, protein, ketones and glucose = positive; leukocyte esterase and nitrites = negative. CMP-18 Erythrocyte, mature Good The cells identified by the arrows are erythrocytes, as correctly identified by 89.7% of the referees and 96.7% of the participants. Erythrocytes are colorless to pale yellow-orange discs that vary in size, but are usually 7-8 μm in diameter. In this image erythrocytes with smooth membranes (arrows) are accompanied by crenated erythrocytes that have irregular membranes. 59

3 Urine Sediment Photomicrographs/Photographs Case History CMP-19 This urine sample is from a 48-year-old male with a 30-year history of diabetes mellitus and new onset renal failure. Laboratory data include: Specific gravity 1.010, ph = 6.5, blood, protein, ketones and glucose = positive; leukocyte esterase and nitrites = negative. CMP-19 Waxy cast Good The object identified by the arrow is a waxy cast, as correctly identified by 96.5% of the referees and 98.7% of the participants. Waxy casts are colorless broad casts with blunt ends that may appear broken off. They have parallel sides and may appear to be cracked. Waxy casts are associated with severe renal disease. 60

4 Urine Sediment Photomicrographs/Photographs Case History CMP-20 This urine sample is from a 48-year-old male with a 30-year history of diabetes mellitus and new onset renal failure. Laboratory data include: Specific gravity 1.010, ph = 6.5, blood, protein, ketones and glucose = positive; leukocyte esterase and nitrites = negative. CMP-20 Fiber (exogenous)/fecal contamination Good The object identified by the arrow is a fecal/fiber, as correctly identified by 100.0% of the referees and 97.6% of the participants. Fibers from clothing, cotton balls, dressings and diapers may contaminate urine. Fibers are large and are usually long. Fibers may resemble waxy casts, but in contrast to waxy casts, fibers are refractile. Plant structures, muscle fibers and bacteria may be seen in fecal contamination. Vegetable fibers have a regular spiral structure. Individual plant cells may also be seen. Vegetable fibers are long with one pointed end and a central canal. Skeletal muscle fibers from undigested meat are yellow-brown in color. They may have cross striations. Identification of fecal and fiber contaminants is important as they can mimic casts. Joel F. Gradowski, MD Hematology and Clinical Microscopy Resource Committee 61

5 Body Fluid Photomicrographs/Photographs Case History CMP-21 A 42-year-old male admitted through the emergency department because of unusual and bizarre behavior over the past 1½ months. Laboratory data include: CSF Cell count: RBC = 290 cells/ L; WBC = 14 cells/ L. CSF Chemistries: Glucose = normal; Protein = elevated. CBC, urinalysis, and comprehensive chemistry profile were all within range. A VDRL was Positive and was confirmed by a positive Treponema pallidum antibody testing. CMP-21 Erythrocyte, mature Good The arrowed cell is a mature erythrocyte. It was correctly identified by 100.0% of referees and 99.7% of participants. The presence of erythrocytes in the CSF is usually an indication of traumatic spinal tap technique or secondary to a disease state. 62

6 Body Fluid Photomicrographs/Photographs Case History CMP-22 A 42-year-old male admitted through the emergency department because of unusual and bizarre behavior over the past 1½ months. Laboratory data include: CSF Cell count: RBC = 290 cells/ L; WBC = 14 cells/ L. CSF Chemistries: Glucose = normal; Protein = elevated. CBC, urinalysis, and comprehensive chemistry profile were all within range. A VDRL was Positive and was confirmed by a positive Treponema pallidum antibody testing. CMP-22 Lymphocyte Good The arrowed cell is a lymphocyte in the CSF. It was correctly identified by 100.0% of referees and 99.7% of participants. Another slightly larger lymphocyte is present in the field. Mature lymphocytes are relatively small cells which may have round nucleus like the arrowed lymphocyte or slightly indented nucleus as the one in the lower left corner. The nuclear chromatin has mature appearance. In contrast there is also in the field a much larger mononuclear cell with somewhat eccentric nucleus basophilic cytoplasm and a small clear perinuclear zone. This cell has plasmacytoid features and may be classified as a reactive plasmacytoid lymphocyte by some observers and a plasma cell by others. 63

7 Body Fluid Photomicrographs/Photographs Case History CMP-23 A 42-year-old male admitted through the emergency department because of unusual and bizarre behavior over the past 1½ months. Laboratory data include: CSF Cell count: RBC = 290 cells/ L; WBC = 14 cells/ L. CSF Chemistries: Glucose = normal; Protein = elevated. CBC, urinalysis, and comprehensive chemistry profile were all within range. A VDRL was Positive and was confirmed by a positive Treponema pallidum antibody testing. CMP-23 Plasma cell Educational Lymphocyte, reactive Educational Neutrophil, immature Educational The arrowed cell is a plasma cell in the CSF. It was correctly identified by 65.5% of the referees and 70.6% of the participants. The arrowed cell has most features consistent with a plasma cell lineage including round and eccentrically placed nucleus with densely clumped chromatin, abundant basophilic cytoplasm with a distinctive perinuclear clear zone that corresponds to the Golgi area in the cell. 64

8 Body Fluid Photomicrographs/Photographs Case History CMP-24 A 42-year-old male admitted through the emergency department because of unusual and bizarre behavior over the past 1½ months. Laboratory data include: CSF Cell count: RBC = 290 cells/ L; WBC = 14 cells/ L. CSF Chemistries: Glucose = normal; Protein = elevated. CBC, urinalysis, and comprehensive chemistry profile were all within range. A VDRL was Positive and was confirmed by a positive Treponema pallidum antibody testing. CMP-24 Neutrophil, segmented or band Educational The arrowed cell is a neutrophil in the CSF. It was correctly identified by 100.0% of the referees and 98.4%of the participants. The arrowed cell shows clear nuclear segmentation and has the expected lilac-pink granules. 65

9 Body Fluid Photomicrographs/Photographs Case History CMP-25 A 42-year-old male admitted through the emergency department because of unusual and bizarre behavior over the past 1½ months. Laboratory data include: CSF Cell count: RBC = 290 cells/ L; WBC = 14 cells/ L. CSF Chemistries: Glucose = normal; Protein = elevated. CBC, urinalysis, and comprehensive chemistry profile were all within range. A VDRL was Positive and was confirmed by a positive Treponema pallidum antibody testing. CMP-25 Monocyte/macrophage Good The arrowed cell is a monocyte in the CSF. It was correctly identified by 100.0% of the referees and 97.3% of the participants. Monocytes are slightly larger than neutrophils as clearly shown in this photograph. Most frequently the cell is round with smooth edges but like in this arrowed cell pseudopod-like extensions of the cytoplasm may be present. The cytoplasm is abundant and gray to gray-blue. Vacuoles and azurophilic granules may be present. The nucleus may be indented, folded or have a band-like appearance. 66

10 Body Fluid Photomicrographs/Photographs Case History CMP-26 A 42-year-old male admitted through the emergency department because of unusual and bizarre behavior over the past 1½ months. Laboratory data include: CSF Cell count: RBC = 290 cells/ L; WBC = 14 cells/ L. CSF Chemistries: Glucose = normal; Protein = elevated. CBC, urinalysis, and comprehensive chemistry profile were all within range. A VDRL was Positive and was confirmed by a positive Treponema pallidum antibody testing. CMP-26 Eosinophil, any stage Good The arrowed cell is an eosinophil in the CSF. It was correctly identified by 100.0% of the referees and 99.7% of the participants. The arrowed cell is segmented and the cytoplasm shows orange-pink to orange-red granules and is clearly different from the granules previously depicted for the neutrophil (CMP-24). William Koss, MD Hematology and Clinical Microscopy Resource Committee 67

11 Clinical Microscopy Miscellaneous Photomicrographs/Photographs CMMP-36 Referees CMMP Participants Performance Eosinophils present Good This nasal smear demonstrates three eosinophils with the characteristic orange-pink to orange-red granules which are larger than primary or secondary granules in neutrophils. Also present are bacteria overlying a superficial squamous epithelial cell in the upper-right corner. Nasal smears are performed to determine whether discharge not associated with allergies may be acellular or demonstrate neutrophils. CMMP-37 Referees CMMP Participants Performance Yeast/Fungi absent Good This photomicrograph demonstrates amorphous material. No well formed chitinous walls of fungi, yeast or arthrospores are seen. A 10% KOH (potassium hydroxide) solution is excellent for eliminating background proteinaceous material while leaving the other elements behind. 68

12 Clinical Microscopy Miscellaneous Photomicrographs/Photographs CMMP-38 Referees CMMP Participants Performance Sperm present Good This unstained vaginal wet preparation contains a spermatozoa. A wet preparation of vaginal fluid is used to determine the cause of vaginal discharge or to determine the presence of sperm in case of rape investigation. A sample of vaginal fluid is taken from the posterior vaginal pool using a cotton or Dacron tipped swab and mixed with saline on a slide. The sperm head is about 4-6 micra in diameter while the slender tail is about micra in length. Abnormal sperm morphology and motility can also be assessed in a fertility evaluation from a sperm ejaculate. CMMP-39 Referees CMMP Participants Performance Neutrophils absent Good No neutrophils are present in this stool smear which contains only bacteria. A smear of flecks of mucous of generally liquefied stool is placed on a slide and allowed to air dry prior to staining with Wright stain. Neutrophils are associated with invasive gastroinstestinal infections such as Shigella in 70% of cases and with Salmonella and Campylobacter in about 30-50% of the cases. Noninvasive infections with Rotovirus and toxigenic E. coli will show neutrophils in only about 5% of the cases. 69

13 Clinical Microscopy Miscellaneous Photomicrographs/Photographs CMMP-40 Referees CMMP Participants Performance Pinworm eggs present Good This unstained preparation demonstrates an Enterbius vermicularis egg which is known as pinworm. Anal pruritis is due to ova being laid in the perianal region of the human host by the gravid female. Children are the most common hosts and often autoinfect with scratching and subsequent fingersucking. The morphology is characteristic with the thick colorless shell, micra long, micra in diameter and flattened on one end. CMMP-41 Referees CMMP Participants Performance Ferning present Good This vaginal smear demonstrates ferning, a test used to detect ruptured amniotic membranes and the early onset of labor. It may be used to differentiate urine from amniotic fluid. The accuracy of this test is about %. False positives can come from cervical mucous. The ph of amniotic fluid is generally neutral, whereas vaginal fluid is usually acidic. Alice L. Werner, MD Hematology and Clinical Microscopy Resource Committee 70