Urine Sediment Photomicrographs

Urine Sediment Photomicrographs Case History CM-03 and CM-04 This urine sample is from a 63-year-old male with lower back pain, believed to be musculoskeletal in origin. Urinalysis showed ph = 5.0, nitrite = positive; protein, blood, leukocyte esterase, glucose, ketones = negative. Identify the arrowed object(s). CM-04 Fiber Fecal Contamination 21 84.0 3,553 87.1 Good Waxy Cast 2 8.0 69 1.7 Unacceptable RBC/HGB Cast 1 4.0 2 0.1 Unacceptable Fat Globules 1 4.0 6 0.2 Unacceptable The arrowed object is fecal/fiber contamination. Note the irregular ends, slight variation in width, and non-homogenous interior. This type of contamination most often occurs during collection, but may indicate a fistula between the bowel and genitourinary tract. It should be reported. Red cell/hemoglobin casts are usually very fragile, red-tinged, with intact red cells or remnants visible within the cast. Because they are so fragile, large intact red cell casts are rare. Waxy casts are wide with parallel edges, homogenous interiors and sharp, refractile margins. The ends appear blunt with breaks or small cracks. 29

Urine Sediment Photomicrographs Case History This urine sample is from a 73-year-old male with diabetes mellitus and hypertension. Urinalysis showed ph = 5.0; specific gravity = 1.017; protein = 3+; and glucose, ketone, blood, nitrate, and leukocyte esterase = negative. Identify the arrowed object(s). CM-05 Waxy cast 20 80.0 3,912 95.8 Good Hyaline Cast 3 12.0 42 1.0 Unacceptable Fiber Fecal Contamination 2 8.0 87 2.1 Unacceptable The arrowed object is a waxy cast. Waxy casts are usually seen in severe renal disease, including renal amyloidosis. They are formed due to renal stasis. This results in dense, wide or broad casts. They are homogenous, refractile, and tend to have blunt ends which look broken or cracked. Hyaline casts are narrow, colorless, homogenous non-refractive casts. They have rounded, sometimes tapering ends and may be difficult to visualize. Fecal/fiber contamination is rarely homogenous. It lacks the blunt or broken ends and cracks seen in waxy casts and may vary in width. 30

Body Fluid Photomicrographs Case History CM-06 through CM-10 A prematurely born 6-month old infant was admitted to the hospital because of decreased appetite and vomiting. He was lethargic with a temperature of 36.4 C. Kernig s sign was positive. A lumbar puncture showed cloudy fluid. Analysis of the CSF fluid showed 10.0 x 10 12 /L RBCs and 2.8 x 10 9 /L WBCs. The CSF protein was 255 mg/dl (reference range, 15-45 mg/dl) and glucose 2 mg/dl. Identify the arrowed object(s). CM-10 Lymphocyte 18 85.7 2,381 79.0 Educational Lymphocyte, Reactive 2 9.5 361 12.0 Educational Plasma Cell 1 4.8 139 4.6 Educational The identified cell is a lymphocyte (lymphocyte) and was correctly identified by 85.7% of the referees and 79% of participants. The cell measures 5-7 microns in diameter with a round nucleus. The chromatin is coarse, with a moderate amount of basophilic cytoplasm. Secondary to cytocentrifugation, lymphocytes may sometimes have a small nucleolus and more abundant cytoplasm in comparison to lymphocytes seen in the peripheral blood. Although the nucleus is eccentric, this cell lacks the characteristics of a plasma cell including a paranuclear hof, and sharply condensed, clock-face chromatin. A reactive lymphocyte would have more abundant cytoplasm and/or a larger nucleus, possibly with prominent nucleoli. Discussion CM-06 CM-10 This case illustrates several characteristic features of bacterial meningitis. Clinical signs in infants are often non-specific, but in this case include classic features of infection such as, decreased appetite, vomiting, and fever. Kernig s sign is a physical examination technique in which each hip is flexed and then the knee is straightened. In cases of meningitis, the hamstring muscle is in spasm, causing limited motion and reflexive forward bending of the head. Brudzinski s sign is a similar test. The head in flexed toward the chest; in meningitis, the knees will passively rise toward the chest. This is in response to inflammation of the spinal roots. The CSF in bacterial meningitis may be cloudy due to the presence of numerous inflammatory cells (typically predominantly neutrophils), as seen in this case. CSF protein is typically increased and glucose is typically decreased. Intracellular bacteria are only occasionally seen. 34

Discussion CM-06 CM-10 Continued Although preliminary identification can be made based on morphology of bacteria, the definitive results should be based on complete microbiologic examination. The most common bacterial agents that cause meningitis are Haemophilus influenzae, Streptococcus pneumoniae, Neisseria meningitidis and group B streptococci. Kjeldsberg CR, Knight JA. Body Fluids. Third edition, ASCP Press: 1992. Dennis P. O Malley, MD Body Fluid Photomicrographs Case History CM-11 The patient is a 63-year old Caucasian male with rheumatoid arthritis and a chronic right pleural effusion. WBC=33,000/μL; RBC=1,518,000/μL; Protein=5.5 g/dl; LD=2298 IU/L; Triglyceride=16 mg/dl. Identify the arrowed object(s). CM-11 Cholesterol crystal 27 96.4 2,917 99.3 Good Squamous Epithelial Cell 1 3.6 - - Unacceptable Discussion CM-11 The identified material is a cholesterol crystal and was correctly identified by 96.4% of the referees and 99.3% of participants. The classic appearance of cholesterol crystals is characteristic; they appear as square or rectangular plates, often with notched corners. Although not illustrated in this photomicrograph, when polarized, cholesterol crystals often have a multicolored, stained glass appearance. Less commonly, cholesterol crystals may be in the form of long needle-like structures or rhomboidal forms. Cholesterol crystals are most commonly seen in joint fluids of patient s with rheumatoid arthritis or those with chronic effusions. Kjeldsberg CR, Knight JA. Body Fluids. Third edition, ASCP Press: 1992. Dennis P. O Malley, MD Hematology and Clinical Microscopy Resource Committee 35

Clinical Microscopy Miscellaneous Photomicrographs Trichomonas vaginalis 26 100.0 2,525 98.8 Good CMM-30 This is an unstained vaginal specimen. The arrowed object is a Trichomonas. The organism in this preparation can be identified by its characteristic flagella. On close observation the flagella can be seen in the six o clock position. Trichomonas vaginalis is a microscopic parasite found worldwide. Trichomoniasis is one of the most common sexually transmitted diseases, mainly affecting sexually active women. In North America, it is estimated that more than 8 million new cases are reported yearly. Trichomoniasis is spread through sexual activity. Infection is more common in women who have had multiple sexual partners. The normal incubation period is 4-28 days. The onset of symptoms such as vaginal or vulval pruritus and discharge is often sudden and occurs during or after menstruation as a result of the increased vaginal acidity. The diagnosis of this infection in children may indicate the following: Infants: If an infant is infected, it is possible that the mother spread infection during childbirth. The mother should be checked for infection. Young children: Because trichomoniasis is an STD, infection in a young child may indicate sexual abuse. If sexual abuse is suspected, an evaluation for other STDs is recommended. Teenagers: Because trichomoniasis is an STD, infection in a teenager may indicate sexual activity or sexual abuse. An evaluation for other STDs is recommended. Source: CDC 36

Clinical Microscopy Miscellaneous Photomicrographs CMM-31 No eosinophils present 26 100.0 2,094 96.7 Good This is a nasal smear for eosinophils. There are no eosinophils present. Wright-Giemsa stain will stain the granules within the eosinophils red. Eosinophils are granulocytes named because of their intense staining with 'eosin'. Under the microscope, eosinophils typically have a bilobed nucleus and contain many bright orange-red granules in their cytoplasm. The granules are eosinophil mediators that are toxic to many organisms and also to tissues as in asthma. Eosinophils are motile and phagocytic and are particularly active in parasitic infection. Nasal smears showing eosinophils are often caused by allergic disease like asthma, hay fever etc. 37

Clinical Microscopy Miscellaneous Photomicrographs CMM-32 Pinworm or pinworm eggs present 26 100.0 2,174 99.8 Good The specimen is an unstained pinworm prep. A pinworm egg is present just off center. The nematode (roundworm) Enterobius vermicularis (previously Oxyuris vermicularis) 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. A second species, Enterobius gregorii, has been described and reported from Europe, Africa, and Asia. For all practical purposes, the morphology, life cycle, clinical presentation, and treatment of E. gregorii is identical to E. vermicularis. 38

Life Cycle: CMM-32 Eggs are deposited on perianal folds(1). Self-infection occurs by transferring infective eggs to the mouth with hands that have scratched the perianal area(2). 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(3) and the adults establish themselves in the colon(4). 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(5). The larvae contained inside the eggs develop (the eggs become infective) in 4 to 6 hours under optimal conditions(6). 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. Source: CDC 39

Clinical Microscopy Miscellaneous Photomicrographs CMM-33 No yeast/ fungal element is present 26 100.0 2,382 96.7 Good This is an unstained KOH prep that is negative for the presence of yeast/fungi. Deborah A. Perry, MD Hematology and Clinical Microscopy Resource Committee 40