Clinical Microscopy Notes PDF

CLINICAL MICROSCOPY NOTES COMPILED BY: EFREN II C. DEOCADES, RMT, MSMT Renal Physiology Af...

CLINICAL MICROSCOPY NOTES COMPILED BY: EFREN II C. DEOCADES, RMT, MSMT Renal Physiology Afferent Arterioles: carries the blood to the glomerulus Efferent Arterioles: carries blood from the glomerulus Kidneys − two bean-shaped organs located under the diaphragm Peritubular Capillaries on either side of the aorta in the posterior, upper − surround the PCT and DCT abdominal region − provides immediate reabsorption of essential − 150 g. each (adult male) substances from the fluid in the PCT and final − 135 g. each (adult female) adjustment of the urinary composition in the DCT Urethra Vasa Recta − delivers the urine for excretion outside the body − located adjacent to the loops of Henle in − 20 cm. (male) juxtamedullary nephrons − 3-4 cm. (female) − major exchanges of water and salts take place Nephrons Renal Functions − basic functional/ structural unit of the kidney 1. Glomerular Filtration − 1 to 1.5 million in one kidney 2. Tubular Reabsorption 3. Tubular Secretion 1. GLOMERULAR FILTRATION Glomerulus − coil of 8 capillary lobes collectively referred as the capillary tuft − nonselective filter/ sieve of plasma substances with molecular weight of Creatinine) before measuring specific gravity b. Inorganic: 25g Cl- (no. 1) > Na+ > K+ − SG ≥ 1.026 Average Daily Urine Output: 1,200 mL 2. Mosenthal test Normal Daily Urine Output: 1200-1500mL/ 600-2000mL Night: Day ratio = 1:2 to 1:3 − compared the volume and specific gravity of day and night urine samples to evaluate Polyuria: increase in daily urine output concentrating ability − Children: >2.5-3.0 mL/kg/day 3. Specific Gravity − Adults: >2.5 L/day − Influenced by number and density of particles in a solution Oliguria: decrease urine output − is most useful as a screening procedure − Infants: 100 Pathologic: Crystals (HPF) 0-2 2-5 5-20 >20 − Glomerulonephritis Bacteria (HPF) 0-10 10-50 50-200 >200 − Pyelonephritis − Congestive Heart Failure URINARY SEDIMENT ARTIFACTS 1. Starch granules (gloves): 2. RBC casts − Most common − signifies bleeding w/in the nephron − Maltese cross (O, FC, S) − present in Glomerulonephritis and Strenuous − Dimpled center exercise (HC, GC, RC) 2. Oil droplets 3. Air bubbles 3. WBC casts 4. Pollen grains: spheres w/ concentric circles − Inflammation w/in the nephron 5. Hair and fibers:(+) Birefringence (polarizing − Differentiates upper UTI (pyelonephritis, w/ cast) microscope) from lower UTI (cystitis, no cast) 6. Fecal contaminants − Seen in: Pyelonephritis and Acute Interstitial Nephritis Renal Diseases To differentiate from EC cast: Disease Laboratory Results − Phase contrast microscopy − Supravital stain Cystitis 1. WBCs − inflammation of 2. RBCs 4. Bacterial casts: seen in Pyelonephritis urinary bladder 3. Bacteria 5. Epithelial cell casts − Ascending bacterial 4. NO CAST − seen in Renal tubular damage and Advanced infection of the tubular destruction bladder Acute Interstitial 1. RBCs 6. Coarse/Fine granular casts Nephritis 2. WBCs − Formed from the disintegration of cellular cast − Infection of the renal 3. WBC casts − seen in Glomerulonephritis, Pyelonephritis and interstitium 4. NO BACTERIA Strenuous exercise (HC, GC, RC) 1. WBCs 2. RBCs 7. Fatty casts Pyelonephritis 3. Bacteria − seen in Nephrotic syndrome: lipiduria − Infection of renal 4. RBC Casts − Not stained by Sternheimer-Malbin tubules 5. WBC Casts 6. Hyaline Cast 8. Waxy casts 7. Granular casts − Final degenerative form of all types of casts 1. RBCs − Brittle, highly refractile, w/ jagged ends Glomerulonephritis 2. WBCs − indicate stasis of renal flow and chronic renal − Inflammation of the 3. RBC Casts failure glomerulus 4. WBC Casts − Immune-mediated 5. Hyaline Casts 6. Granular Casts 9. Broad casts 1. WBCs − known as the “Renal failure casts” 2. RBCs − seen in extreme urine stasis due to widening and Urethritis destruction of tubular walls − inflammation of Male: GS of urethral exudates − Any type of cast can be broad urethra [Gram (-) diplococci] Female: pelvic exam for vaginitis and cervicitis SUMMARY OF REPORTING OF URINE I. Serum (Chemistry) SEDIMENTS Nephrotic syndrome − ↓Albumin, alpha1, beta and A. Average number per 10 HPF: RBCs, WBCs, − Disruption of the gamma globulins RTE cells shield of negativity − ↑alpha2 (AMG) B. Average number per HPF: Oval Fat Bodies and damage to the C. Average number per LPF: Casts, Abnormal tightly fitting II. Urine (CM) podocyte barrier Crystals − ↑Albumin, alpha1, beta and resulting in massive D. Rare, Few, Moderate or Many per HPF: gamma globulins proteinuria and Bladder Cell, Transitional EC, *Bacteria, *Yeast, lipiduria − (-)alpha2 (AMG) Trichomonas, Normal Crystals − Oval fat bodies, fatty and Page 11 of 13  CLINICAL MICROSCOPY NOTES COMPILED BY: EFREN II C. DEOCADES, RMT waxy casts Insipidus or acquired from medications GLOMERULAR DISORDERS Inherited defect in the production of Uromodulin- normal uromodulin by the renal Associated Disorders Etiology tubules and increased uric acid Kidney Disease Deposition of immune complexes causing gout Rapidly Progressive from systemic Glomerulonephritis immune disorders on the METABOLIC DISORDERS glomerular membrane (Phenylalanine-Tyrosine Disorders) Deposition of immune complexes, Acute formed in conjunction with group 1. Phenylketonuria (deficient in Phenylalanine Glomerulonephritis A Streptococcus infection, hydroxylase/ PAH) on the glomerular membranes − causes severe mental retardation Attachment of a cytotoxic antibody formed during viral Screening: FeCl3 → (+) Blue-green Goodpasture Confirmatory: Guthrie test (Bacterial inhibition) respiratory infections to Syndrome glomerular and alveolar − B. subtilis basement membranes − Inhibitor: Beta2-thienylalanine (neutralized by Antineutrophilic cytoplasmic phenylalanine) autoantibody (ANCA) binds to − Growth = (+) PKU Wegener neutrophils in vascular walls − No growth = (-) PKU Granulomatosis producing damage to small vessels in the lungs and 2. Tyrosyluria (deficient in Tyrosine aminotransferase glomerulus and p-Hydroxyphenylpyruvate oxidase ) Occurs primarily in children − Rancid butter odor Henoch-Schönlein following viral respiratory Purpura infections; a decrease in platelets Screening Test: FeCl3 →(+) Transient green disrupts vascular integrity Confirmatory: Nitroso-naphthol → (+) Orange-red Thickening of the glomerular membrane following IgG immune 3. Alkaptonuria (deficient in Homogentisic acid oxidase) Membranous complex deposition − Urine darkens after a period of standing Glomerulonephritis associated with systemic − ↑↑ Homogentisic acid in blood and urine disorders Cellular proliferation affecting the Screening Test: FeCl3 → (+) Transient blue Membranoproliferative capillary walls or the glomerular Confirmatory: Clinitest/Benedict’s →(+) Yellow ppt. Glomerulonephritis basement membrane, possibly immune-mediated 4. Melanuria Marked decrease in renal function − Overproliferation of melanocytes Chronic resulting from glomerular damage Glomerulonephritis precipitated by other renal Screening: FeCl3 → Gray or black ppt. disorders Confirmatory: Ehrlich’s → Red Deposition of IgA on the Iga Nephropathy glomerular membrane (Berger’s disease) resulting from increased levels of serum IgA Disruption of the podocytes Minimal Change occurring primarily in children Disease following allergic reactions and immunizations Disruption of podocytes in certain Focal Segmental areas of glomeruli associated with Glomerulosclerosis heroin and analgesic abuse and AIDS Genetic disorder showing Alport Syndrome lamellated and thinning glomerular basement membrane METABOLIC AND TUBULAR DISORDERS Acute Tubular Damage to renal tubular cells Necrosis caused by ischemia or toxic agents Inherited in association with cystinosis and Hartnup disease or Fanconi Syndrome acquired through exposure to toxic agents Renal Glucosuria Inherited autosomal recessive trait Nephrogenic Inherited defect of tubular Diabetes response to ADH Page 12 of 13  CLINICAL MICROSCOPY NOTES COMPILED BY: EFREN II C. DEOCADES, RMT METABOLIC DISORDERS 3. Homocystinuria (Branched-Chain Amino Acid Disorders) − Defect in the metabolism of homocystine − Silver nitroprusside →(+) Red-purple 1. Maple Syrup Urine Disease (MSUD) − Accumulation of leucine, isoleucine and valine in METABOLIC DISORDERS blood and urine (Mucopolysaccharide Disorders) − 2,4-DNPH → (+) Yellow turbidity/ppt. − mucopolysaccharides (Dermatan Sulfate, Keratan Sulfate, Heparan Sulfate) 2. Organic Acidemias (NBS: MS/MS) A. Isovaleric acidemia = sweaty feet 1. Alder-Reilly syndrome B. Propionic acidemia 2. Hurler syndrome: MPS →cornea of the eye C. Methylmalonic academia 3. Hunter syndrome: Sex-linked recessive 4. Sanfilippo syndrome: Mental retardation only METABOLIC DISORDERS (Tryptophan Disorders) METABOLIC DISORDERS (Porphyrin Disorders) 1. Indicanuria − Intestinal disorder − Hartnup disease: “Blue diaper syndrome” − Obermayer’s test: FeCl3 → (+) Violet w/ chloroform 2. Argentaffinoma − carcinoid tumor involving argentaffin cells − ↑ 5-HIAA: metabolite of serotonin Screening: FeCl3 → (+) Blue-green (PKU) Confirmatory: Nitrosonaphthol → (+) Violet w/ HNO3 − Be sure patient should avoid banana, pineapple, tomatoes (serotonin-rich) METABOLIC DISORDERS (Cystine Disorders) 1. Cystinuria (Renal type) − Defect in renal tubular transport of: ✓ Cystine (least soluble→urine) ✓ Ornithine ✓ Lysine ✓ Arginine 2. Cystinosis − Inborn error of metabolism − Cystine deposits in many areas of the body − Cyanide-nitroprusside →(+) Red-purple Page 13 of 13