Urine Sediment Case Studies By Heidi Hanes

How to use macroscopic results for possible urine sediment pH – help decide what type of crystal Hemoglobin- detect RBC intact and lysed Leukocyte Esterase – detect WBC Nitrite – bacteria Protein – cast, epithelium cells For any specimen you should use the patient history if known and the results of the urine dipstick chemistries. Different crystals are seen at either alkaline, acid and/or neutral pH. Acidic crystals include Amorphous Urates, Bilirubin, Calcium Sulfates, Cholesterol, Cystine, Leucine, Sodium Urate, Sulfonamides, Tyrosine, Uric Acid, X-ray dye. Alkaline Crystals include Amorphous Phosphates, Calcium Carbonates, Calcium Phosphates and Triple Phosphates. Cyrstlas that can show up in acidic but may be seen in alkaline are Calcium Oxalates and Hippuric Acid. Those that show up in alkaline but can show up in acid is Ammonium Biurate. Positive Hemoglobin can indicate either intact RBC or lysed RBCs in the urine. Leukocytes Esterase detect WBC Nitrites can indicate bacterial infection Proteins can indicate the present of cast or epithelium cells

Case Study

Case 1 This is a sample from 35 year old female as part of a routine exam. Laboratory data include: Specific Gravity - 1.015 pH – 7.0 Ketones – negative Glucose – negative Protein – negative Blood – negative Nitrite – negative Leukocyte esterase – negative Identify the arrowed object

Case 2 This urine sample is from a 35 year old female as part of a routine exam. Laboratory data include: Specific gravity = 1.015 pH = 7.0 Ketones = negative Glucose = negative Protein = negative Nitrite = negative Leukocyte esterase = negative Identify the arrowed object

Case 3 Urine sample from a 71 year old male. Laboratory data include: Specific gravity = 1.015 pH = 6.0 Ketones = negative Glucose = negative Protein = negative Nitrite = negative Leukocyte esterase = negative Identify the arrowed object

Case 4 This urine sample is from a 60 year old male with history of kidney nephritis. Laboratory data include: Specific gravity = 1.018 pH = 5.5 Ketones = negative Glucose = negative Protein = positive Nitrite = positive Blood = positive Leukocyte esterase = positive Identify the arrowed object

Case 5 This urine sample is from a 60 year old male with history of kidney stones. Laboratory data include: Yellow and cloudy Specific gravity = 1.020 pH = 5.5 Ketones = negative Glucose = negative Protein = positive Nitrite = negative Blood = positive Leukocyte esterase = positive Birefringence - absent Identify the arrowed object

Case 6 This urine sample is from a 60 year old male with history of kidney stones. Laboratory data include: Yellow and cloudy Specific gravity = 1.020 pH = 5.5 Ketones = negative Glucose = negative Protein = positive Nitrite = negative Blood = positive Leukocyte esterase = positive Birefringence - absent Identify the arrowed object

Case 7 This urine sample is from a 54 year old male routine exam. Laboratory data include: Specific gravity = 1.015 pH = 7.1 Ketones = negative Glucose = negative Protein = negative Nitrite = negative Blood = negative Leukocyte esterase = negative Birefringent positive Identify the arrowed object

Case 8 This urine sample is from a 12 year old female evaluated for kidney disease Laboratory data include: Specific gravity = 1.010 pH = 6.0 Ketones = negative Glucose = negative Protein = positive Nitrite = negative Blood = positive Leukocyte esterase = positive Identify the arrowed object

Case 9 This urine sample is from a 12 year old female evaluated for kidney disease Laboratory data include: Specific gravity = 1.010 pH = 6.0 Ketones = negative Glucose = negative Protein = positive Nitrite = negative Blood = positive Leukocyte esterase = positive Identify the arrowed objects

Case 10 This urine sample is from a 48 year old male history of diabetes mellitus, edema and new onset renal failure. Laboratory data include: BUN = 35 mg/dl (serum) Creatinine = 2.8 mg/dl (serum) Specific Gravity = 1.007 pH = 7.0 Glucose = positive (4+) Protein = positive (2+) Identify the arrowed object

Case 11 This urine sample is from a 45 year old male history of diabetes mellitus, edema, hypertension and new onset renal failure. Laboratory data include: Opalescent urine Specific Gravity = 1.011 pH = 6.5 Glucose = positive (4+) Protein = positive (2+) Identify the object in these photos

Case 12 This urine sample is from a 38 year old female history of three days nausea, vomiting and diarrhea. Laboratory data include: Specific Gravity = 1.020 pH = 7.0 Leukocyte Esterase = negative Glucose = negative Protein = positive (1+) Ketones = negative Nitrite = negative Blood = negative Identify the object in these photo

Case 13 This urine sample is from a 14 year old female asymptomatic Laboratory data include: Specific Gravity = 1.012 pH = 6.0 Leukocyte Esterase = negative Glucose = negative Protein = positive (1+) Ketones = negative Nitrite = negative Blood = negative Identify the object

Case 14 This urine sample is from a 62 year old male with enlarged prostate and renal failure. Has fever and dehydrated. Laboratory data include: BUN = 48 mg/dl (serum) Creatinine = 3.4 mg/dl (serum) Cloudy urine pH = 6.6 Leukocyte Esterase = positive Glucose = negative Protein = positive Ketones = negative Nitrite = negative Blood = negative Identify the object

Case 15 This urine sample is from a 31 year old male routine exam. Yellow and hazy urine pH = 6.8 Leukocyte Esterase = negative Glucose = negative Protein = negative Ketones = negative Nitrite = negative Blood = negative Picture is regular light (left) and polarized light (right) Identify the object

Case 16 This urine sample is from a 55 year old male with urinary tract infection. Cloudy urine Urine culture grows Proteus species Identify the object

Case 17 This urine sample is from a 33 year old male with alcohol induced cirrhosis, ascites, and jaundice. Golden brown urine in color Specific gravity = 1.015 pH = 6.0 Identify the object

Case 18 This urine sample is from a 20 year old female with minimal change disease. Golden brown urine in color Specific gravity = 1.025 pH = 7.0 Protein = positive (4+) Blood =negative Leukocyte esterase = negative Ketones = negative Nitrite = negative Identify the object

Case 19 This urine sample is from a 56 year old male with kidney and liver failure. Laboratory data include: Specific Gravity = 1.012 pH = 5.0 Blood = positive Protein = positive Leukocyte esterase = positive Glucose = negative Ketones = negative Nitrite = negative Crystals soluble in HCL Identify the object

Case 20 This urine sample is from a 45 year old female routine exam. Laboratory data included: Specific gravity = 1.015 pH = 7.0 Blood = negative Protein = trace Leukocyte esterase = negative Nitrite = negative Glucose = negative Ketones = negative Identify the objects in photo

Case Study Results

Case 1 - Squamous Cell Large, flat, thin cells May be round, polygonal, rectangular or rolled into a tube Nucleus size of a RBC usually centrally located. Can contain granules in cytoplasm. Line urethra, bladder and vagina Form protective barrier Normal finding. Increase number indicate not a clean voided specimen If numerous the protein may be positive on the urine dipstick

Case 2 - Fiber Defined shapes Flat Refractile Frayed ends Non-cylindrical shapes These can be artifacts seen in urine. They may be confused with hyline cast.

Case 3 – Ammonium biurate Neutral or alkaline pH Yellow-brown Spheres with radial or concentric striation Irregular projections/thorns

Case 4 – Transitional epithelial cell Spherical, ovoid, polyhedral Smaller than epithelial, larger than renal Increase with infection, post renal catheterization, urinary stones `` These can be confused either with WBC or renal epithelial cells.

Case 5 – Cystine crystal Clear, colorless hexagonal plates(Stop signs) Acidic urine <5.5 Birefringence absent Abnormal crystal ``

Case 6 – Erythrocytes Round or oval biconcave disc No nucleus Abnormal in increase numbers Faint yellow-orange or red `` Can be crenated in hypertonic urine and swell to “ghost” forms in hypotonic urine. The Hemoglobin should be positive on the dipstick

Case 7 – Calcium Oxalate Usually in acidic but can be seen neutral or weakly alkaline Colorless Common shape envelop Less common dumbbell, oval and elongated hexagon ``

Case 8 – RBC Cast Least common cast Most significant Tinged red or brown Seen in freshly voided specimens Differentiated by presence intact RBC `` Seen in acute glomerulonephritis, all glomerulopathies and malignant hypertension. The urine dipstick should be positive for hemoglobin

Case 9 – Leukocytes Colorless cells Most frequent is PMN Normal 3-5 seen Increased in inflammatory conditions Most frequent is polymorphonuclear neutrophil of the WBC seen in urine. The leukocyte esterase should be positive on the dipstick

Case 10 – Waxy Cast High refractive index Blunt or broken off ends Parallel margins may show notching Colorless, pale yellow, waxy appearance Abnormal finding The protein should be positive on the dipstick.

Case 11 – Cholesterol Found in acid and neutral urine Regular or irregular transparent plates Birefringent in polarized light Corner can be notched- stair step crystal Abnormal finding

Case 12 – Yeast/fungi, extracellular Usually ovoid and colorless Refractile appearance Can be branching or hyphae Can be contaminant Urinary tract infection if increase WBC seen Can be confused with RBC

Case 13 – Uric Acid Crystals Normal and common in urine Acidic urine Yellow or red-brown in color Variety of forms- rhombic, rosettes, wedges, 4-sided plates, barrel, lemon shapes

Case 14 – Granular Cast Fine or coarse granules Can be normal, especially after vigorous exercise Seen in renal disease patients Protein may be positive on the dipstick

Case 15 – Starch granule Colorless Irregularly round with dark striation to the center Asymmetric “Maltese cross” in polarized light. Can be confused with fat bodies. Frequent contaminant Note how the fate droplet “Maltese cross” is more symmetrical than the starch on the left Starch polarized Fat droplet polarized

Case 16 – Triple Phosphate Also know as Ammonium Magnesium Phosphate Colorless 3-6 sided prism shaped Resembles “coffin lid” Less common as colorless sheets, flakes, flats, ferns or leaf form Birefringent under polarized light Seen highly alkaline urine with urea-splitting organisms mostly Proteus species.

Case 17 – Leucine Crystal Acidic urine Spheroids with concentric striations Dense Highly refractile Yellowish brown “pseudo” Maltese cross Seen severe liver disease Hereditary amino acid metabolic disorders Can be seen with tyrosine crystals

Case 18 – Fatty Cast Yellowish tinge Contains large spherical, highly refractile fat droplets Polarized light show “Maltese-cross” pattern Associated with marked proteinuria and nephrotic syndrome Protein may be positive on the dipstick

Case 19 – Tyrosine Crystals Rare, always abnormal Form clusters of silky needle-like structures Colorless or black on focusing Acid urine Increase after refrigeration Insoluble in alcohol or ether Soluble in dilute HCL Orange color with nitrosonaphthol confirmatory Tyrosiuria occurs with liver disease

Case 20 – Hyaline Cast Colorless Transparent Low refractive index Can easily missed with ordinary bright field light scope Cylindrically shaped elements Seen in healthy and also with renal disease Small numbers usually The protein may be positive on the dipstick

References Urinary Sediment: A Textbook Atlas, by Meryl H Haber Images from http://www.bing.com/images/search?q=urine+sediment+images&qpvt=urine+sediment+images&FORM=IGREes CAP Participant Summary for Clinical Microscopy