Microscopic-Examination-topic-6.pptx

URINALYSIS and BODY FLUIDS OBJECTIVE Topic: ANALYSIS OF URINE & OTHER BODY FLUIDS Recognize the importance and different Biosafety in clinical laboratory. Recognize the importance of the different body fluids. o Distinguish their function Microscopic Examination...

URINALYSIS and BODY FLUIDS OBJECTIVE Topic: ANALYSIS OF URINE & OTHER BODY FLUIDS Recognize the importance and different Biosafety in clinical laboratory. Recognize the importance of the different body fluids. o Distinguish their function Microscopic Examination of Urine INTRODUCTIO N present in the urine. These include red blood cells  To detect and to identify insoluble materials (RBCs), white blood cells (WBCs), epithelial cells, casts, bacteria, yeast, parasites, mucus, spermatozoa, crystals, and artifacts.  Because some of these components are of no clinical significance and others are considered normal unless they are present in increased amounts, examination of the urinary sediment must include both identification and quantitation of the elements present.  MACROSCOPIC SCREENING AND MICROSCOPIC CORRELATIONS SCREENING SIGNIFICANCE TEST COLOR Blood CLARITY Hematuria versus hemoglobinuria/ myoglobinuria Confirm pathologic or non-pathologic cause of turbidity BLOOD RBCs, RBC Casts PROTEIN Casts, Cells NITRITE Bacteria, WBCs Specimen Preparation  Examine the fresh specimens or well preserved is recommended.  RBCs, WBCs, and hyaline casts are the main components that break down quickly, especially in diluted alkaline urine.  Amorphous urates, phosphates, and other non-pathologic crystals may precipitate after refrigeration, obscuring other components in the urine sediment.  A temperature increase of 37°C before centrifuging might cause some of the Specimen Volume  A standard amount of urine, usually between 10 and 15 mL, is centrifuged in a conical tube. It provides an adequate volume from which to obtain a representative sample of the elements present in the specimen.  A 12-mL volume is frequently used because multiparameter reagent strips are easily immersed in this volume, and capped centrifuge tubes are often calibrated to this volume Centrifugation  The speed of the centrifuge and the length of time the specimen is centrifuged should be consistent.  Centrifugation for 5 minutes at a relative centrifugal force (RCF) of 400 produces an optimum amount of sediment with the least chance of damaging the elements.  The RPM value shown on the centrifuge tachometer can be converted to RCF using nomograms available in many laboratory manuals or by using the formula: RCF = 1.118 × 10–5 × radius in centimeters × RP Sediment Preparation  A uniform amount of urine and sediment should remain in the tube after decantation.  Volumes of 0.5 and 1.0 mL are frequently used. Volume of Sediment Examined  The volume of sediment placed on the microscope slide should be consistent for each specimen.  When using the conventional glass-slide method, the recommended volume is 20uL (0.02 mL) covered by a 22 x 22 mm glass cover slip. URINE SEDIMENT PREPARATION 1. Transfer 10-15 mL of urine in a test tube (recommended volume = 12 mL). 2. Centrifuge tube at 400 RCF for 5 minutes 2 3. 3. Decant urine (0.5 or 1.0 mL urine remains in the tube) 4. Transfer 20 ul (0.02 mL) sediment to glass slide with 22 x 22 mm coverslip 5. Examine microscopically (10 LPF, 10 HPF, under reduced light) Addis Count  Quantitative measure of formed elements of urine using hemacytom  Specimen = 12-hour urine  Preservative = Formalin Normal values: RBCS = 0-500,000/12-hr urine Reporting the Microscopic Examination The terminology and methods of reporting may differ slightly among laboratories but must be consistent within a particular laboratory system. Routinely, casts are reported as the average number per low-power field (lpf) following examination of 10 fields, and RBCs and WBCs, as the average number per 10 high-power fields (hpf). Epithelial cells, crystals, and other elements are frequently reported in semiquantitative terms such as, rare, few, moderate, and many, or as 1+, 2+, 3+, and 4+.  MICROSCOPIC TECHNIQUES  Bright-field (BF) Microscopy  For routine urinalysis  Phase-contrast (PC) Microscopy  Enhances visualization of translucent elements (ie. with low refractive indices [e.g. casts)).  To convert BF into PC, replace objective lens & condenser with PC objective lens & PC condenser.  Polarizing Microscopy  Detects the presence or absence of birefringence.  Birefringence is the ability of an element to refract light in 2 dimensions at 90º to each other.  For identification of cholesterol in oval fat bodies, fatty casts and crystals.  To convert Binto polarizing, add 2 filters (below the condenser, 1 between objective & oculars) Dark-field (DF) Microscopy  For identification of Treponema pallidum.  To convert BF into DF, replace the condenser with a DF condenser that contains an opaque disk. Fluorescence Microscopy  For visualization of fluorescent substances and microorganism Interference-contrast Microscopy o 3-D microscopy-image & layer-by-layer imaging of a specimen. o Bright-field microscopes can be adapted for interference contrast o Two types: Nomarski (Differential interference contrast) Care of the Microscope 1. Carry microscope with two hands, supporting the base with one hand. 2. Always hold the microscope in a vertical position. 3. Clean optical surfaces only with a good quality lens tissue and commercial lens cleaner. 4. Do not use the 10× and 40× objectives with oil. 5. Clean the oil immersion lens after use. 6. Always remove slides with the low-power  SEDIMENT STAINS Sternheimer-Malbin (SM) Delineates structure & contrasting colors of the nucleus (Crystal violet + Safranin O) & cytoplasm Available as KOVA & Sedi stain Identifies WBCS, epithelial cells and casts Most commonly used supravital stain Toluidine blue (Supravital Enhances nuclear detail Differentiates WBCs and RTE stain) cells 2% acetic acid Lyses RBCs, enhances nuclel of WBC Distinguishes RBCs from WBCs, yeast, oil droplets & crystals Lipid stains (Oil Red O and Stains triglycerides and neutral fats Identifies free fat Sudan III) droplets & lipid-containing cells & casts Gram stain Differentiates Gram-positive & -negative bacteria Identifies bacterial casts Hansel stain (Eosin Y+ Stains eosinophilic granules Methylene blue) Identifies urinary eosinophils Prussian blue (Rous test) Stains structures containing iron Identifies hemosiderin granules Phenathridine (orange) Stains DNA SEDIMENT CONSTITUENTS CELLS 1.RBCs (Hematuria)  NV= 0-2 or 0-37HPEs  Smooth, non-nucleated, biconcave disks  Hypertonic urine  Hypotonic urine  Glomerular RBC’s membrane damage  Sources of error - Yeasts, Oil droplets, Air bubbles, Monohydrate calcium oxalate crystals  Remedy - Add 2% acetic acid. It will lyse the RBCs but not the others.  MICROSCOPIC RBCs Appearance Non-nucleated biconcave disks. Crenated in hypertonic urine Ghost cells in hypotonic urine Dysmorphic with glomerular membrane damage Sources of identification Yeast cells error: Oil droplets Air bubbles Reporting: Average number per 10 hpfs Complete urinalysis Color correlations: Reagent strip blood reaction 2. WBCs (Pyuria or Leukocyturia) NV-05 or 0-8/HPF Increased number indicates presence of infection or inflammation A.Neutrophils Most predominant Granulated and multilobed In hypotonic urine, they swell, and g granules undergo Brownian movement, producing a sparkling B. Eosinophils Normal value = 1%  Significant = >1% (seen in↑ acute interstitial nephritis) C. Mononuclear cells (lymphocytes, monocytes, macrophages, histiocytes) Normally present in small numbers ↑ Lymphocytes = Renal transplant rejection ↑ Monocytes, histiocytes = chronic inflamm: & radiation therapy  MICROSCOPIC WBCs Appearance Larger than RBCs Granulated, multilobed neutrophils Glitter cells in hypotonic urine Mononuclear cells with abundant cytoplasm Sources of Renal tubular epithelial cells identification error: Reporting: Average number per 10 hpfs Complete urinalysis Leukocyte esterase correlations: Nitrite Specific gravity 3. Epithelial Cells A.Squamous epithelial cell (S.E.C.) Largest cell w/ abundant, irregular cytoplasm & prominent nucleus Cell size is about 30-50 um (5-7x the size of an RBC) The nucleus is about the size of an RBC May occasionally appear folded, resembling a cast From linings of vagina, female urethra & lower male urethra Variation: CLUE CELL  S.E.C. covered with Gardnerella vaginalis  Associated with bacterial vaginosis B. Transitional Epithelial (Urothelial) cell (T.EC)  Cell size is about 20-30 um (6ox the size of an RBC)  Spherical polyhedral or caudate with CENTRALLY located nucleus  They tend to take on water and can look like large round balloons  Derived from the renal pelvis, calyces, ureter, urinary bladder & upper male urethra,  ↑ ff. catheterization may be singly, in pairs, or in clumps (syncytia)  If exhibiting abnormal morphology - malignancy or viral infection  EPITHELIAL CELLS SQUAMOUS CELLS Appearance Largest cells in the sediment with abundant, irregular cytoplasm and prominent nuclei Sources of error Rarely encountered, folded cells may resemble casts reporting Rare, few, moderate, or many per lpf Complete urinalysis Clarity correlations  EPITHELIAL CELLS Transitional Cells Appearance Spherical, polyhedral, or caudate with centrally located nucleus Sources of error Spherical forms resemble RTE cells reporting Rare, few, moderate, or many per lpf Complete urinalysis Clarity correlations Blood, if malignancy associated  EPITHELIAL CELLS RTE Cells Appearance Rectangular, columnar, round, oval or, cuboidal with an eccentric nucleus possibly bilirubinstained or hemosiderin-laden Sources of error Spherical transitional cells Granular casts reporting Average number per 10 hpfs Complete urinalysis Leukocyte esterase and nitrite correlations (pyelonephritis) Color Clarity Protein  EPITHELIAL CELLS Oval Fat Bodies Appearance Highly refractile RTE cells Sources of error Confirm with fat stains and polarized microscopy reporting Average number per hpf Complete Clarity urinalysis Protein correlations Blood Free fat droplets/fatty casts I. Oval fat bodies (Renal tubular fat bodies) Lipid containing RTE cell (may also be a monocyte/macrophage) Highly refractile RTE cell Seen in lipiduria (Ex: nephrotic syndrome) Identified by: Lipid stains (TAG and neutral fats) Polarizing microscope (Cholesterol - MALTESE CROSS" formation) II. Bubble cell RTE cell with non-lipid vacuoles Injured cells in which the endoplasmic reticulum has dilated prior to cell death Seen in acute tubular necrosis 4. Bacteria True UTI = Bacteria + WBCs Enterobacteriaceae (Ex E. coli) - most common cause of UTI Staphylococcus, Enterococcus Motility differentiates them 5. Yeasts True yeast infection = Yeast +WBCs Small, refractile oval structure that may or may not bud Branched, mycelial forms are seen in severe infections Candida albicans = seen in DM and vaginal moniliasis 6. Parasites A.Trichomona vaginalis  Most frequently encountered parasite in urine  Pear-shaped flagellate s w/ undulating membrane & jerky motility  Agent of PING PONG Diseases  Reported as rare, few, moderate, or many per HPF  if not moving, may resemble WBC/T.EG/RTE cell(use PC micro.) B.Enterobius vermicularis egg  Most common fecal contaminant. C. Schistosoma haematobium egg Blood fluke with terminal spine Causes hematuria Associated with bladder cancer Urinary Bladder Cancer Markers : NMP – Nuclear Matrix Protein BTA – Bladder Tumor Antigen 7. Spermatozoa  Oval, slightly tapered head Long, flagella-like tail After sexual intercourse 8. Mucus threads  Has low refractive index Major constituent: Tamm- Horsfall Protein  Miscellaneous Structures Bacteria Appearance Small spherical and rod-shaped structures Sources of error Amorphous phosphates and urates reporting Few, moderate, or many per hpf, the presence of WBCs may be required Complete pH urinalysis Nitrite correlations LE WBCs  Miscellaneous Structures Yeast Appearance Small, oval, refractile structures with buds and/or mycelia Sources of error RBCs reporting Rare, few, moderate, or many per hpf, the presence of WBCs may be required Complete Glucose urinalysis LE correlations WBCs  Miscellaneous Structures Trichomonas Appearance Pear-shaped, motile, flagellated Sources of error WBCs, renal tubular epithelial cells reporting Rare, few, moderate, or many per hpf Complete LE urinalysis WBCs correlations  Miscellaneous Structures Spermatozoa Appearance Tapered oval head with long, thin tail Sources of error None reporting Present, based on laboratory protocol Complete Protein urinalysis correlations  Miscellaneous Structures Mucus Appearance Single or clumped threads with a low refractive index Sources of error Hyaline casts reporting Rare, few, moderate, or many per lpf Complete None urinalysis correlations  MICROSCOPIC QUANTITATIONS (Strasinger) Quantitate an average of 10 representative fields. Do not quantitate budding yeast, mycelia elements, trichomonas, or sperm, but do note their presence with the appropriate LIS code Quantitated None Rare Few Moderat Many e Epithelial cells per LPF 0 0-5 5-20 20-100 >100 Crystals (normal) per HPF 0 0-2 2-5 5-20 >20 Bacteria per HPF 0 0-10 10-50 50-200 >200 Mucus threads per LPF 0 0-1 1-3 3-10 >10 Casts per LPF 0 Numerical ranges: 0-2, 2-5, 5-10, >10 RBCs per HPF 0 Numerical ranges: 0-2, 2-5, 5-10, WBCs per HPF 0 10-25, 25-50, 50-100, >100 Squamous epithelial cells Rare, few, moderate or many per LPF Transitional epithelial cells, yeasts Rare, few, moderate, or many per HPF Renal tubular epithelial cells Average number per 10 HPFs Oval fat bodies Average number per HPF THAN K CAST Unique to the kidney Represents a biopsy of an individual tubule The most difficult & the most important urinary sediment constituent Primarily formed in the DCT collecting duct Major constituent (produced by RTE cells) Other proteins such as albumin & immunoglobulins are also incorporated into the cast matrix Cylindroids have the same significance as casts HYALINE CAST Prototype cast (beginning of all types of cast) Most frequently encountered & the most difficult cast to discover Colorless and translucent Normal value= 0-2/lpf Physiologic = Stress, strenuous exercise Pathologic = Glomerulonephritis, pyelonephritis, CHF, CKD  URINE CASTS HYALINE Appearance Colorless, homogenous matrix Sources of error Mucus, fibers, hair, increased lighting Reporting Average number per lpf Complete urinalysis Protein correlations: Blood (exercise) Color (exercise) Clinical significance: Glomerulonephritis Pyelonephritis Chronic renal disease Congestive heart failure FORMATION OF CAST RBC CAST - Most fragile cast. Indicates bleeding within the nephron. Easily identified by its orange-red color Significance: Glomerulonephritis, strenuous exercise Blood Cast or Hemoglobin Cast - Contains hemoglobin from lysed RBCs. Homogeneous appearance with orange-red color. Same significance as RBC cast.  URINE CASTS RBC Appearance Orange-red color, cast matrix containing RBCs Sources of error RBC clumps Reporting Average number per lpf Complete urinalysis RBCs correlations: Blood Protein Clinical significance: Glomerulonephritis Strenuous exercise WBC/LEUKOCYTE/PUS CAST - Indicates inflammation on infection within the nephron. Resembles RTE cast. To distinguish, use phase microscopy and supravital stain Significance: Pyelonephritis, acute Pseudoleukocyte interstitial nephritis Cast – Not a true cast DO NOT report as cast. Clump of leukocytes. Seen in lower UTI. BACTERIAL CAST - Confirmation is done by performing Gram stain. Significance = Pyelonephritis  URINE CASTS WBC Appearance Cast matrix containing WBCs Sources of error WBC clumps Reporting Average number per lpf Complete urinalysis WBCs correlations: Protein LE Clinical significance: Pyelonephritis Acute interstitial nephritis GRANULAR CAST (COARSE AND FINE)  Granules are derived from the lysosomes of RTE-cells during normal metabolism (non- pathologic)  Cells disintegrate when the cast is retained in the tubule be being flushed out  Finely granular cast has a sandpaper appearance  Significance = Glomerulonephritis, pyelonephritis, stress, strenuous exercise FATTY CAST  Fat globules not stained by Sternheimer - Malbin stain (only the cast matrix is stained)  Identification:  TAG & neutral fats = Lipid stains  URINE CASTS Granular Appearance Coarse and fine granules in a cast matrix Sources of error Clumps of small crystals Columnar RTE cells Reporting Average number per lpf Complete urinalysis Protein correlations: Cellular casts RBCs WBCs Clinical significance: Glomerulonephritis Pyelonephritis Stress and exercise WAXY CAST  Final degenerative form of all types of casts  Brittle, highly refractile, with jagged ends  Ground glass appearance  Tend to look like paraffin shavings sitting on top of the urine Significance urinary stasis, BROAD chronic CAST renal failure, ESRD  Often referred to as renal failure cast  Indicates destruction (widening) of the tubular walls  Any type of cast can be broad (most common are granular & waxy)  2-6x wider than ordinary cast  Significance: Extreme urine stasis, renal  URINE CASTS Waxy Appearance Highly refractile cast with jagged ends and notches Sources of error Fibers and fecal material Reporting Average number per lpf Complete urinalysis Protein correlations: Cellular casts Granular casts RBCs WBCs Clinical significance: Stasis of urine flow Chronic renal failure  MISCELLANEOUS CASTS Pigmented Cast  Hyaline matrix with coloration due to pigment  Incorporation Incorporated bilirubin Mixed Cellular Cast (golden-brown)   Hemoglobin or myoglobin (yellow Cast containing multiple cell typesto red  brown). Glomerulonephritis (RBC & WBC casts)  Pyelonephritis (WBC & RTE casts or WBC and bacterial casts) Crystal Cast  Casts containing urates, calcium oxalate and sulfonamides are occasionally seen.  Deposition of crystals in the tubule or collecting duct  URINE CASTS Bacterial Appearance Bacilli bound to protein matrix Sources of error Granular casts Reporting Average number per lpf Complete urinalysis WBC casts (pyelonephritis) correlations: WBCs LE Nitrite Protein Bacteria Clinical significance: Pyelonephritis  URINE CASTS Epithelial Cell Appearance RTE cells attached to protein matrix Sources of error WBC cast Reporting Average number per lpf Complete urinalysis RTE cells correlations: Protein Clinical significance: Renal tubular damage  URINE CASTS Fatty Appearance Fat droplets and oval fat bodies attached to protein matrix Sources of error Fecal debris Reporting Average number per lpf Complete urinalysis Protein correlations: Free fat droplets Oval fat bodies Clinical significance: Nephrotic syndrome Toxic tubular necrosis Diabetes mellitus Crush injuries  URINE CASTS Broad Appearance Wider than normal cast matrix Sources of error Fecal material, fibers Reporting Average number per lpf Complete urinalysis Protein correlations: WBCs RBCs Granular casts Waxy casts Clinical significance: Extreme urine stasis Renal failure II. SEDIMENT CONSTITUENTS - Chemical or Unorganized Sediment (Crystals) CRYSTALS  Excretion is termed crystalluria  The most recognized but the most insignificant part of urine sediment (Turgeon)  Formed by precipitation of urine solutes (salts, organic compounds, medication)  Presence of crystals in fresh urine is most frequently associated w/concentrated specimen (SG)  Factors that contribute to crystal formation: 1. pH 2. Solute concentration 3. Temperature  Usually reported as rare, few, moderate or many per HPF  Abnormal crystals may be averaged and reported per LPR  Abnormal crystals generally require confirmation before they are reported to the physician  NORMAL ACID CRYSTALS 1.Amorphous Urates (Ca, Mg, Na, & K-urates) Fluffy orange or pink sediment (brick dust) due to uroerythrin Yellow brown granules (microscopic) Chumps resemble granular casts (termed "pseudocasts) Turns into uric acid after adding acetic acid Turns into a ammonium biurate after adding ammonium hydroxide ↑in Gout, Chemotherapy 2. Uric Acid Product of purine metabolism Rhombic (diamond), 4-sided flat plate (whetstone) lemon-shaped Wedges, football, barrel, rosettes, Ircegular plates, laninated forms Hexagonal forms may be mistaken as cystine crystals Present at pH5.7, it is in its ionized form as urate ↑Lesch-Nyhan syndrome, Chemotherapy, Gout Soluble in alKali 3. Calcium Oxalate (Dihydrate and Monohydrate)  The most frequently observed urinary crystal  Dihydrate (Weddellite) = Envelope/bipyramidal/emerald-cut diamond  Monohydrate (Whewellite) = oval/dumbbell  ↑Foods rich in oxalic acid (tomato, asparagus) and ascorbic acid  ↑ Ethylene glycol (anti-freeze agent)or methoxyflurane poisoning (MH) OTHER NORMAL ACID CRYSTALS: 4. Calcium Sulfate Cigarette-butt appearance Soluble in acetic acid 5. Hippuric Acid Yellow-brown/colorless elongated prism Soluble in water and ether 6. Acid Urates (Na, K, NH) Rare form of uric acid. Brown spheres or clusters. Resembles ammonium biurate, leucine & sulfamethoxazole crystals Turns into uric acid after adding acetic acid 7. Monosodium or Sodium Urates Rare form of uric acid Tiny, slender, colorless needles, spherulite c or beachball (rare); "pick-up sticks" when in clusters ↑in Acute gout (intracellular crystals) and Chronic gout  NORMAL ALKALINE CRYSTALS 1. Amorphous Phosphates (Ca & Mg) Most common cause of turbidity in alkaline urine Fine, or lacy' white precipitate (macroscopic) Granular in appearance (microscopic) Soluble in dilute acetic acid 2. Ammonium Biurate Alkaline counterpart of uric acid and amorphous urates Yellow-brown thorny apples" Seen in old specimens ↑Presence of urea-splitting bacteria (urea→ ammonia) Turns into uric acid after adding HCl or acetic acid Soluble in acetic acid  3. Triple Phosphate (Magnesium Ammonium Phosphate, Struvite) Colorless, prism-shaped or coffin-lid. fern-leaf (Harr) Feathery appearance when they disintegrate ↑Presence of urea-splitting bacteria (urea→ ammonia) Soluble in dilute acetic acid 4. Magnesium Phosphate Colorless elongated rectangular or rhomboid plates End or corner may be notched Edges can be irregular or eroded Soluble in acetic acid 6. Calcium Carbonate Small, colorless, dumbbell tetrads or spherical- shaped Forms gas (effervescence) after adding acetic acid Misidentified as bacteria 5. Calcium Phosphate (Apatite) Dibasic calcium phosphate (stellar phosphate) Colorless, flat plates, thin prisms in rosette form Rosettes may resemble sulfonamide crystals Monobasic calcium phosphate Irregular, granular-appearing sheets or plates Less common than dibasic form Other forms: Hydroxyapatite (basic calcium phosphate)  ABNORMAL ACID CRYSTALS 1. Cystine  Colorless, refractile hexagonal plates, often laminated  Sides are not always even, resembling a six-sided stop sign  Mistaken as hexagonal uric acid crystals Uric  ↑in Cystinuria and Acid Cystinosis Cystine Color Yellow-brown Colorless Solubility in Soluble Soluble ammonia Solubility in Insoluble Soluble dilute HCI Birefringence Present Absent/weak Cyanide- NEGATIVE POSITIVE nitroprusside 2. Cholesterol Rectangular plate with notch in one or more corners (staircase pattern) Seen after refrigeration Resembles crystals of radiographic dye ↑in Nephrotic syndrome (lipiduria) Soluble in chloroform 3. Radiographic dye (Meglumine diatrizoate, Renografin, Hypaque) Flat, four-sided, plates often with a notched corner Other forms include long thin prisms or rectangles Resembles cholesterol crystals. To differentiate: Check patient history Correlate with other UA results (Ex: S.G.1.040 using refractometer)  4. Tyrosine Fine colorless to yellow needles in clumps or rosettés ↑in Liver disease (more commonly found than leucine) Soluble in alkali or heat 5. Leucine  Yellow-brown oily-looking spheres with concentric circles & radial striations  Wagon wheels resembling a tree's growth pattern or striations of a tree  Precipitated with tyrosine after adding alcohol  May resemble fat globules  Under polarization, they produce a pseudo-Maltese cross pattern  ↑in Liver disease  Soluble in hot alkali or alcohol. 6. Bilirubin Clumped granules or needles with bright yellow.color (Strasinger) Reddish brown needles that cluster in clumps or spheres (Turgeon) Granules and plates have been observed (Brunzel) ↑in Liver disease Soluble in acetic acid, d, HCI, NaOH, acetone and 7. Sulfonamide  Fan-shaped needles, sheaves of wheat, rosettes, arrowheads, petals, Found shaped, whetstones  Mistaken as calcium phosphate crystals. To differentiate:  Calcium phosphate soluble in acetic acid  Sulfonamide = (+) Lignin test & Diazo reaction  Possible tubular damage (may deposit in nephrons)  Currently, they are modified and their solubility is no longer a problem  Soluble in acetone  Forms:  Sulfamethoxazole = brown rosettes or spheres w/ irregular radial striations  Acetylsulfadiazine = yellow-brown sheaves of wheat w/eccentric binding  Sulfadiazine = yellow-brown sheaves of 8. Ampicillin Colorless needles that tend to form bundles following refrigeration ↑in massive doses of penicillin OTHER ABNORMAL CRYSTALS 9. Hemosiderin Coarse, yellow-brown granules Resembles amorphous urates (+) Rous test (Prussian blue stain) 10. Acyclovir May be seen in alkaline urine Colorless slender needles Strongly birefringent with polarized light 11. Indinavir Sulfate Slender colorless needles or slender rectangular plates Feather-like crystals that aggregate into wing-like bundles Arranged in fan-shaped or starburst forms, bundles, or sheaves Associated with renal blockage & stone formation in HIV-positive individuals URINARY SEDIMENT ARTIFACTS 1.Starch granules Maltese Spheres with dimpled center ("Y" Cross indentation) Formation "Maltese cross-formation on Oval fat bodies polarizing microscope →→ Fatty cast 2. Oil droplets 3. Air bubbles Fat droplets 4. Pollen grains = spheres with cell wall Starch granules & concentric circles 5. Hair and fibers = mistaken for casts 6. Fecal contamination Major Characteristics of Normal Urinary Crystals CRYSTAL pH COLOR APPEARANC E Uric acid Acid Yellow-brown (rosettes, wedges) Amorphous Acid Brick dust or urates yellow brown Calcium Acid/neutral Colorless oxalate (alkaline) (envelopes, oval, dumbbell) Major Characteristics of Normal Urinary Crystals CRYST pH COLOR APPEARANC AL E Calcium Alkaline/ Colorless phosphat neutral e Triple Alkaline Colorless (“coffin phosphat lids”) e Ammoniu Alkaline Yellow-brown m (“thorny apples”) biurate  Major Characteristics of Abnormal Urinary Crystals Cryst pH Color/ Disorde Appearance al Form rs Cystin Acid Colorless Inherited e (hexagonal cystinuria plates) Choles Acid Colorless Nephrotic terol (notched syndrome plates) Leucin Acid/ Yellow Liver e neutral (concentric disease circles)  Major Characteristics of Abnormal Urinary Crystals Crystal pH Color/ Disord Appearan Form ers ce Bilirubin Acid Yellow Liver disease Sulfonami Acid/ Varied Infection des neutral treatment Radiograp Acid Colorless Radiograp hic dye (flat plates) hic procedure Ampicillin Acid/ Colorless Infection THANK YOU