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Test Bank for Fundamentals of Urine and Body Fluid Analysis, 3rd Edition : Brunzel

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This is completed downloadable of Test Bank for Fundamentals of Urine and Body Fluid Analysis, 3rd Edition : Brunzel

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ISBN-10 ‏ : ‎ 1437709893
ISBN-13 ‏ : ‎ 978-1437709896
Author: Nancy A. Brunzel

Renowned for its clear writing style, logical organization, level and depth of content, and excellent color illustrations, “Fundamentals of Urine & Body Fluid Analysis, 3rd Edition” covers the collection and analysis of urine, fecal specimens, vaginal secretions, and other body fluids such as cerebrospinal, synovial, seminal, amniotic, pleural, pericardial, and peritoneal fluids. Expert author Nancy Brunzel shares her extensive knowledge and expertise in the field, presenting key information and essential techniques and procedures, as well as easy-to-grasp explanations of how to correlate data with basic anatomy and physiology to understand pathological processes.

Table of Content:

Chapter 1 Microscopy
Learning Objectives
Key Terms
Brightfield Microscope
FIGURE 1-1 A, A schematic representation of a brightfield microscope and its components. B, Path of illumination using Köhler illumination.
FIGURE 1-2 Drawing depicting changes in numerical aperture. Note the increase in light angle (µ) attained and therefore in the numerical aperture when immersion oil is used.
Eyepiece
FIGURE 1-3 Schematic representation of a binocular eyepiece shows the location of the diopter adjustment ring.
Mechanical Stage
Condenser
FIGURE 1-4 Schematic diagram of a condenser and an aperture diaphragm located beneath the mechanical stage of the microscope.
FIGURE 1-5 Two types of aperture diaphragms. A, An iris diaphragm. B, A disk diaphragm.
Illumination System
Objectives
FIGURE 1-6 Engravings on this objective indicate that it is a planachromat lens (SPlan); the initial magnification is 40×; the numerical aperture is 0.70; the objective is designed for a microscope with an optical tube length of 160 mm; and the coverslip thickness should be 0.17 ± 0.01 mm.
Box 1-1 Binocular Microscope Adjustment Procedure With Köhler Illumination
Preparing the Microscope
Interpupillary Adjustment
Diopter Adjustment
Condenser Adjustment
Condenser Height and Centration
Field Diaphragm Adjustment
Condenser Aperture Diaphragm Adjustment
FIGURE 1-7 An illustration of chromatic aberration. Each wavelength of light is bent to a different focal point after passing through an uncorrected lens.
FIGURE 1-8 An illustration of spherical aberration. Each light ray is bent toward a different focal point, depending on where the ray enters an uncorrected lens.
Ocular Field Number
Microscope Adjustment Procedure
Care and Preventive Maintenance
Box 1-2 Microscope Dos and Don’ts
Dos
Don’ts
Types of Microscopy
Brightfield Microscopy
Phase-Contrast Microscopy
FIGURE 1-9 The effect of the phase of light waves on the light intensity observed. A, All light waves are in phase, and light intensity is maximal. B, Some light waves are slower or are partially out of phase, resulting in a decrease in the light intensity observed. C, Equal numbers of light waves are in phase and out of phase. As a result, the net intensity observed is zero (i.e., the light waves cancel each other out).
FIGURE 1-10 Schematic representation of (A) an annular diaphragm (placed below the condenser) and (B) the phase-shifting element (placed in back of the objective).
FIGURE 1-11 Phase ring alignment. A schematic representation of the view at the back of the objective when one is looking down the eyepiece tube with the eyepiece removed. The dark annulus is formed by the phase-shifting element in the objective; the light annulus is formed by the annular diaphragm. Phase ring alignment is obtained by adjusting the light annulus until it is centered and superimposed on the dark annulus.
FIGURE 1-12 An example of phase-contrast microscopy. This low-power (100×) view of urine sediment includes a highly refractile fiber revealed by its brightly haloed image. The hyaline casts and mucus threads are less refractile and have haloes of decreased intensity compared with the highly refractile fiber.
FIGURE 1-13 Comparison of light ray orientation in (A) regular light (vibrating in all directions) and (B) polarized light (vibrating in only one plane).
Polarizing Microscopy
FIGURE 1-14 A, Schematic diagram of a polarizing microscope and its components. B, The change in the polarized light rays caused by a birefringent specimen. The polarizer and the analyzer are in a crossed position.
Interference Contrast Microscopy
FIGURE 1-15 An example of differential interference contrast (Nomarski) microscopy and its optical sectioning ability. The different plane of focus captured in each photomicrograph allows for greatly detailed imaging.
Modulation Contrast Microscopy (Hoffman)
FIGURE 1-16 Schematic representation of a modulation contrast microscope and its components.
FIGURE 1-17 Example of the three-dimensional image produced by differential interference. This view shows a waxy cast at a magnification of 200×.
Differential Interference Contrast Microscopy (Nomarski)
Darkfield Microscopy
FIGURE 1-18 Schematic representation of a differential interference contrast (Nomarksi) microscope and its components.
FIGURE 1-19 Schematic representation of a darkfield microscope and its components.
FIGURE 1-20 Schematic representation of a reflected illumination fluorescence microscope and its components.
Fluorescence Microscopy
TABLE 1-1 Comparison of Microscopic Capabilities
Study Questions
References
Bibliography
Chapter 2 Quality Assurance and Safety
Learning Objectives
Key Terms
Quality Assurance
Quality Assurance: What Is It?
Preanalytical Components of Quality Assurance
Table 2-1 Definitions and an Example of Policy for Handling Unlabeled or Mislabeled Specimens
Box 2-1 Criteria for Urine Specimen Rejection
Analytical Components of Quality Assurance
Equipment
Table 2-2 Urinalysis Equipment Performance Checks
Reagents
Procedure Manuals
Box 2-2 Guidelines for Standardizing Microscopic Urinalysis
Procedural Factors
Reporting Factors
Monitoring
Monitoring Analytical Components of Quality Assurance
Postanalytical Components of Quality Assurance
Safety in the Urinalysis Laboratory
Biological Hazards
Table 2-3 Selected Evolution History of Isolation Precautions in Hospitals7,8
Personal Protective Equipment
FIGURE 2-1 The universal biohazard symbol.
Specimen Processing
Disposal of Waste
Decontamination
Chemical Hazards
FIGURE 2-2 A, Label used by the Department of Transportation to indicate hazardous chemicals. B, The label identification system developed by the National Fire Protection Association.
Handling Chemical Spills
Disposal of Chemical Waste
Other Hazards
Study Questions
Case 2-1
Results
References
Bibliography
Chapter 3 Urine Specimen Types, Collection, and Preservation
Learning Objectives
Key Terms
Why Study Urine?
Specimen Types
First Morning Specimen
Random Urine Specimen
FIGURE 3-1 Urine as a fountain of information.
TABLE 3-1 Urine Specimen Types
Timed Collection
Box 3-1 Timed Urine Collection Protocol
Collection Techniques
Routine Void
Midstream “Clean Catch”
Catheterized Specimen
Suprapubic Aspiration
TABLE 3-2 Urine Collection Techniques
Pediatric Collections
Box 3-2 Reasons for Urine Specimen Rejection
Reasons for Urine Specimen Rejection
Urine Volume Needed for Testing
Urine Specimen Storage and Handling
Containers
Labeling
Handling and Preservation
Changes in Unpreserved Urine
TABLE 3-3 Potential Changes in Unpreserved Urine
Preservatives
Timed Collections
TABLE 3-4 Urine Preservatives*
TABLE 3-5 Commercial Urine Transport Tubes With Preservative
Is this Fluid Urine?
Study Questions
References
Bibliography
Chapter 4 The Kidney
Learning Objectives
Key Terms
Renal Anatomy
FIGURE 4-1 A schematic representation of the urinary tract. The relationship of the kidneys to the nephrons and the vascular system is shown.
FIGURE 4-2 A diagram of a nephron.
Renal Circulation
Box 4-1 Outline of the Nephron and Its Components (As Used Throughout This Text)
Glomerulus (or Renal Corpuscle)
Tubules
TABLE 4-1 Forces Involved in Glomerular Filtration
FIGURE 4-3 The vascular circulation of a cortical and juxtamedullary nephron.
Renal Physiology
Urine Formation
TABLE 4-2 Comparison of the Initial Ultrafiltrate and the Final Urine Composition of Selected Solutes per Day
Glomerulus
FIGURE 4-4 A schematic overview of a glomerulus. The afferent arteriole enters the glomerulus and the efferent arteriole exits the glomerulus at the vascular pole. Also at the vascular pole, a portion of the thick ascending limb of the distal tubule, the macula densa, is in contact with the glomerular mesangium. Bowman’s space is formed from specialized epithelial cells (Bowman’s capsule) at the end of a renal tubule. At the urinary pole, Bowman’s space becomes the tubular lumen of the proximal tubule. Podocytes are the epithelial cells that cover the glomerular capillaries and derive their name from their characteristic footlike processes. The glomerular capillaries are lined with fenestrated endothelial cells (i.e., epithelium with pores). The basement membrane, which separates the capillary endothelium and the podocytes (the epithelium of Bowman’s space), is continuous throughout the glomerulus. The basement membrane is absent between the capillary endothelium and the mesangium. The mesangial cells of the glomerular tuft form the structural core of the glomerulus and are continuous with the extraglomerular mesangial cells located at the vascular pole between the afferent and efferent arterioles. The secretory granules of the granular cells contain large amounts of renin. The afferent arteriole is innervated by sympathetic nerves.
FIGURE 4-5 A scanning electron micrograph of the glomerular capillary endothelium as viewed from the capillary lumen. The openings or fenestrations of the endothelium resemble a dotted swiss pattern.
FIGURE 4-6 A transmission electron micrograph of a glomerular filtration barrier. From left to right, capillary lumen (CL), fenestrated capillary endothelium, basement membrane, foot processes of podocytes separated by slit diaphragms, Bowman’s space, and portion of an overarching podocyte cell body (CB). The basement membrane consists of three distinct layers: the lamina rara interna (next to the capillary endothelium), the lamina densa, and the lamina rara externa (next to the epithelium or podocytes). The arrows indicate slit diaphragms that lie between the interdigitating foot processes.
FIGURE 4-7 A scanning electron micrograph of podocytes and their interdigitating foot processes on glomerular capillaries as viewed from Bowman’s space. A, Epithelial or podocyte cell body (CB) and podocyte foot processes (P) on glomerular capillaries. B, An enlargement of interdigitating foot processes (F) of adjacent epithelial cells (podocyte). The arrows indicate primary processes and show the alternating pattern between epithelial cells.
Tubules
FIGURE 4-8 The general histologic characteristics of the renal tubular epithelium. Representative cross-sections of the various tubular segments roughly indicate their cellular morphology and the relative size of the cells, the tubules, and the tubular lumens.
Tubular Function
Transport
FIGURE 4-9 A transmission electron micrograph of cross-sections of the medullary collecting duct epithelium. A, The intercellular spaces are narrow. B, The intercellular spaces are dilated. The observed dilation is probably due to the effect of antidiuretic hormone on the epithelium, enabling the passive reabsorption of water.
Reabsorption
Secretion
TABLE 4-3 Summary of Tubular Reabsorption of Ultrafiltrate Components
TABLE 4-4 Summary of Tubular Secretion of Important Ultrafiltrate Components
Regulation of Acid-Base Equilibrium
FIGURE 4-10 Hydrogen ion secretion and the mechanism of filtered bicarbonate reabsorption in the proximal tube. CA, Carbonic anhydrase.
FIGURE 4-11 Hydrogen ion secretion and the formation of titratable acids. This is a mechanism of urine acidification in the collecting ducts. CA, Carbonic anhydrase.
Tubular Transport Capacity
FIGURE 4-12 Hydrogen ion secretion and the formation of ammonium ions. This is a mechanism of urine acidification in the collecting ducts. CA, Carbonic anhydrase; G, glutaminase.
Proximal Tubular Reabsorption
FIGURE 4-13 Tubular reabsorption of solutes and water in various segments of the nephron.
Water Reabsorption
Renal Concentrating Mechanism
FIGURE 4-14 The countercurrent multiplier mechanism and the urea cycle maintain the hypertonicity of the medulla. A, In the loop of Henle, note that the fluid leaving the loop is slightly hypo-osmotic (100) compared with the fluid entering the loop (300). Numbers indicate osmolality in milliosmoles per kilogram H2O. B, Countercurrent mechanisms in an entire nephron. As H2O leaves the collecting duct (under antidiuretic hormone [ADH] regulation), the solutes become concentrated in the remaining filtrate, and osmolality increases. At the same time, a urea concentration gradient causes it to passively diffuse from the collecting duct into the interstitial fluid (IF) of the medulla. Some urea is eventually secreted back into the tubular lumen by the descending limb of the loop of Henle—the urea cycle (dashed line). The hypertonicity of the medulla enables the formation of hypertonic (concentrated) urine, with a maximum urine osmolality of 1200 to 1400 mOsm/kg (i.e., the same osmolality as is seen in the medullary interstitial fluid). Numbers indicate osmolality in milliosmoles per kilogram H2O.
FIGURE 4-15 A schematic representation of the renin-angiotensin-aldosterone system and its role in the tubular reabsorption of sodium.
FIGURE 4-16 A schematic representation of the mechanism controlling antidiuretic hormone secretion.
TABLE 4-5 Tubular Lumen Fluid Osmolality* Throughout the Nephron
Study Questions
References
Bibliography
Chapter 5 Renal Function
Learning Objectives
Key Terms
Urine Composition
Solute Elimination
TABLE 5-1 Composition of Selected Components in an Average 24-Hour Urine Collection
Measurements of Solute Concentration
Osmolality
Specific Gravity
FIGURE 5-1 A, Production of hypotonic urine. Hypotonic urine is produced by a nephron by the mechanism shown here. The isotonic (300 mOsm) tubule fluid that enters the Henle loop becomes hypotonic (100 mOsm) by the time it enters the distal convoluted tubule. The tubule fluid remains hypotonic as it is passes through remaining portions of the nephron, where the walls of the distal tubule and collecting duct are impermeable to H2O, Na+, and Cl−. Values are expressed in milliosmoles. B, Production of hypertonic urine. Hypertonic urine can be formed when antidiuretic hormone (ADH) is present. ADH, a posterior pituitary hormone, enables water reabsorption by the distal tubule and collecting duct. Thus hypotonic (100 mOsm) tubule fluid leaving the Henle loop can equilibrate first with the isotonic (300 mOsm) interstitial fluid (IF) of the cortex, then with the increasingly hypertonic (400 to 1200 mOsm) IF of the medulla. As H2O leaves the collecting duct by osmosis, the filtrate becomes more concentrated with the solutes left behind. The concentration gradient causes urea to diffuse into the IF, where some of it is eventually picked up by tubule fluid in the descending limb of the Henle loop (long arrow). This countercurrent movement of urea helps maintain a high solute concentration in the medulla. Values are expressed in milliosmoles.
FIGURE 5-2 A comparison of urine specific gravity and urine osmolality. Specific gravity measurements were determined by a direct method (falling drop) and an indirect method (refractometry). The straight lines represent the specific gravity and osmolality results obtained with solutions of varying sodium chloride concentrations. A, A comparison of urines obtained from healthy medical students. B, A comparison of urines obtained from patients on renal service.
TABLE 5-2 Comparison of Specific Gravities of Different Solutions
Urine Volume
FIGURE 5-3 A flowchart for the evaluation of polyuria. ADH, Antidiuretic hormone; U/S, urine-to-serum osmolality ratio.
Box 5-1 Differentiation of Polyuria
Assessment of Renal Concentrating Ability/Tubular Reabsorptive Function
Osmolality Versus Specific Gravity
Fluid Deprivation Tests
Osmolar and Free-Water Clearance
Assessment of Glomerular Filtration
Renal Clearance
Clearance Tests
Inulin Clearance
Creatinine Clearance
FIGURE 5-4 The formation of creatinine from creatine and phosphocreatine. ADP, Adenosine diphosphate; ATP, adenosine triphosphate.
TABLE 5-3 Variation in Reference Intervals for Serum Creatinine and Creatinine Clearance According to Age and Gender*
Advantages and Disadvantages
Importance of Time Interval
Box 5-2 Creatinine Clearance
Example
Discussion
Alternate Approaches to Assessing Glomerular Filtration Rate
Estimated GFR (eGFR)
Equation 5-7 Original
Equation 5-8 IDMS–traceable
β2-Microglobulin and Cystatin C
Screening for Albuminuria
Assessment of Renal Blood Flow and Tubular Secretory Function
Determination of Renal Plasma Flow and Renal Blood Flow
Assessment of Tubular Secretory Function for Acid Removal
Measurement of Titratable Acid Versus Urinary Ammonia
Oral Ammonium Chloride Test
Study Questions
Case 5-1
Patient Information
Case 5-2
Results
References
Bibliography
Chapter 6 Physical Examination of Urine
Learning Objectives
Key Terms
Color
TABLE 6-1 Urine Color Terms and Common Causes*
TABLE 6-2 Urine Color Changes With Some Commonly Used Drugs
Box 6-1 Recommendations for the Evaluation of Urine Physical Characteristics
Foam
FIGURE 6-1 A, Distinctive coloration of urine foam due to the high bilirubin concentration in the urine specimen. B, Large amount of urine foam due to a high concentration of protein, specifically albumin, in the urine specimen.
Clarity
TABLE 6-3 Clarity Terms
Box 6-2 Classification of Substances Causing Urine Turbidity
Odor
TABLE 6-4 Causes of Urine Odors
Taste
Concentration
Specific Gravity
Urinometry
FIGURE 6-2 A urinometer (hydrometer).
FIGURE 6-3 A schematic diagram illustrates the refraction (or bending) of light as it passes from one medium to another of differing density. The velocity of the light beam also changes.
Harmonic Oscillation Densitometry
Refractometry
FIGURE 6-4 A refractometer with the pathway of light superimposed.
TABLE 6-5 Calibration Solutions for Refractometry
Reagent Strip Method
FIGURE 6-5 A schematic representation of the viewing field and scale in the refractometer.
Equation 6-3
SG Result Discrepancies Between Reagent Strip and Refractometry
Osmolality
TABLE 6-6 Urine Concentration Assessment: Specific Gravity and Osmolality
Freezing Point Osmometry
FIGURE 6-6 A time-temperature curve during freezing point depression osmometry.
Vapor Pressure Osmometry
Volume
TABLE 6-7 Urine Volume Terms, Definitions, and Clinical Correlations
Study Questions
Case 6-1
Case 6-2
References
Bibliography
Chapter 7 Chemical Examination of Urine
Learning Objectives
Key Terms
Reagent Strips
FIGURE 7-1 A commercial reagent strip or dipstick consists of reagent-impregnated test pads that are fixed to an inert plastic strip. After the strip has been appropriately wetted in a urine sample, chemical reactions cause the reaction pads to change color. At the appropriate “read time,” results are determined by comparing the color of each reaction pad with the appropriate analyte on the color chart.
TABLE 7-1 Comparison of Reagent Strip Principles
Care and Storage
Quality Control Testing
Tablet and Chemical Tests
Care and Storage
Quality Control Testing
Chemical Testing Technique
Reagent Strips
Box 7-1 Appropriate Manual Reagent Strip Testing Technique
TABLE 7-2 Comparison of the Sensitivity and Specificity of Reagent Strips
Tablet and Chemical Tests
Chemical Tests
Specific Gravity
Clinical Significance
Principle
Box 7-2 Clinical Significance of Urine Specific Gravity Results
pH
Clinical Significance
TABLE 7-3 Clinical Correlation of Urine pH Values
Methods
Reagent Strip Tests
pH Meter
pH Test Papers
Blood
Clinical Significance
Hematuria and Hemoglobinuria
Box 7-3 Clinical Significance of Positive Blood Reaction
TABLE 7-4 Comparison of Selected Urine and Plasma Components in Mild and Severe Hemolytic Episodes
Myoglobinuria
Differentiation of Hemoglobinuria and Myoglobinuria
TABLE 7-5 Differentiation of Hemoglobinuria and Myoglobinuria
Method
Leukocyte Esterase
Clinical Significance
Box 7-4 Diagnostic Utility of Positive Leukocyte Esterase Reaction
Methods
Nitrite
Clinical Significance
Methods
Box 7-5 Diagnostic Utility of Nitrite* Reaction
Protein
Clinical Significance
Box 7-6 Classification of Proteinuria
Box 7-7 Principal Proteins in Glomerular Proteinuria
Box 7-8 Principal Proteins in Tubular Proteinuria
Methods
TABLE 7-6 Characterization of Renal Proteinuria
Sulfosalicylic Acid Precipitation Test
Reagent Strip Tests
TABLE 7-7 Sulfosalicylic Acid Precipitation Grading Guideline
TABLE 7-8 Comparison of Reagent Strip and SSA Protein Test Results
Sensitive Albumin Tests
TABLE 7-9 Sensitive Albumin (Microalbumin) Tests
Glucose
Clinical Significance
Box 7-9 Presentations of Glucosuria and Associated Disorders
FIGURE 7-2 A schematic diagram comparing the filtration and reabsorption of glucose by proximal tubular cells normally and in conditions of hyperglycemia and renal tubular disease.
FIGURE 7-3 A series of albumin standards analyzed using the sulfosalicylic acid precipitation test.
Box 7-10 Diagnostic Utility of Urine Glucose Testing
Methods
Reagent Strip Tests
Copper Reduction Tests
FIGURE 7-4 A, A series of glucose standards analyzed using the Clinitest 2-drop method. Note that the tube with greater than 5000 mg/dL glucose has demonstrated the “pass-through” effect (i.e., after reaction, the mixture returns to a greenish color). B, Clinitest color charts. Note the subtle differences between the 5-drop and 2-drop color charts. It is essential that reaction mixtures be compared with the proper color chart to obtain accurate results. Do not use these color charts for diagnostic testing.
Box 7-11 Reducing Substances in Urine That Cause Copper Reduction Tests
Comparison of the Clinitest Method and Glucose Reagent Strip Tests
TABLE 7-10 Comparison of the Glucose Reagent Strip Test and the Clinitest Tablet Test
Ketones
Formation
Clinical Significance
FIGURE 7-5 The formation of ketones from fatty acid metabolism. ATP, Adenosine triphosphate; CoA, coenzyme A; SCoA, succinyl coenzyme A.
Box 7-12 Causes of Ketonuria
Methods
Reagent Strip Tests
Nitroprusside Tablet Test for Ketones (Acetest)
Bilirubin and Urobilinogen
Formation
FIGURE 7-6 A, A positive Acetest for ketones. B, An Acetest color chart. Do not use this color chart for diagnostic testing.
FIGURE 7-7 A schematic diagram of hemoglobin catabolism.
Clinical Significance
TABLE 7-11 Diagnostic Utility of Urine Bilirubin, Urobilinogen, and Fecal Color
Bilirubin Methods
Physical Examination
Reagent Strip Tests for Bilirubin
FIGURE 7-8 Bilirubin metabolism and alterations in normal metabolism caused by disease. A, Normal bilirubin metabolism. B, Prehepatic alteration of bilirubin metabolism. C, Hepatic alteration of bilirubin metabolism. D, Posthepatic alteration of bilirubin metabolism.
Diazo Tablet Test for Bilirubin (Ictotest Method)
FIGURE 7-9 A, A negative Ictotest. B, A positive Ictotest for bilirubin. C, A negative Ictotest showing an atypical color.
Urobilinogen Methods
Box 7-13 Some Ehrlich’s Reactive Substances Found in Urine
Classic Ehrlich’s Reaction
Reagent Strip Tests for Urobilinogen
Multistix Reagent Strips
Equation 7-16 Ehrlich’s Reaction
Chemstrip and vChem Reagent Strips
FIGURE 7-10 A schematic diagram of heme synthesis.
Porphobilinogen
Clinical Significance
Methods
Physical Examination
Hoesch Test for Porphobilinogen
FIGURE 7-11 The Hoesch test (urine + reagent) before the tube is mixed. A, A negative test. B, A positive test.
Watson-Schwartz Test for Porphobilinogen and Urobilinogen
Equation 7-19
Equation 7-20
TABLE 7-12 Watson-Schwartz Test Result Summary
FIGURE 7-12 A, A positive Ehrlich’s reaction, which indicates the presence of an Ehrlich reactive substance in the urine. B, A modified Watson-Schwartz test using the same urine: tube 1 is the chloroform extraction; tube 2 is the butanol extraction. The test is positive for porphobilinogen.
Ascorbic Acid
Clinical Significance
FIGURE 7-13 Ascorbic acid. The highlighted ene-diol group of ascorbic acid is responsible for its strong reducing ability (i.e., as a hydrogen donator). Normally, the principal metabolite of ascorbic acid—oxalate—accounts for approximately 50% of the urinary oxalate excreted daily.
Mechanisms of Interference
TABLE 7-13 False Negative or Decreased Reagent Strip Results Due to Ascorbic Acid Interference
Method
Equation 7-21
TABLE 7-14 Findings That Can Initiate Reflex Testing
Reflex Testing and Result Correlation
TABLE 7-15 Correlation Between Chemical and Microscopic Examinations
TABLE 7-16 Typical Reference Intervals for Chemical Examination of Urine*
Study Questions
Case 7-1
Results
Case 7-2
Results
Case 7-3
Results
Case 7-4
Serum Chemistry Results
Urine Results
Case 7-5
Chemistry Results
Results
Case 7-6
Results
References
Bibliography
Chapter 8 Microscopic Examination of Urine Sediment
Learning Objectives
Key Terms
Standardization of Sediment Preparation
TABLE 8-1 Factors That Require Standardization in the Microscopic Examination
TABLE 8-2 Comparison of Selected Standardized Urinalysis Systems
Commercial Systems
FIGURE 8-1 A commercial urine sediment preparation system. The KOVA System consists of a KOVA tube (2), a KOVA Pettor (3), and a KOVA cap (1). The clear plastic centrifuge tube is filled to the appropriate graduation mark with well-mixed urine and is capped. After centrifugation, the specially designed KOVA Pettor is gently slid into the tube, and the end is firmly seated into the base (4). The bulblike end fits snuggly, such that all but 1 mL of urine can be easily decanted (red arrow). The retained supernatant urine is used to resuspend the sediment for the microscopic examination.
Specimen Volume
FIGURE 8-2 The rotor radius (R) is the distance measured from the rotor’s axis of rotation to the bottom of the specimen tube at its greatest horizontal distance from the rotor axis. A, The radius when a horizontal rotor is used. B, The radius when a fixed-angle rotor is used.
Centrifugation
Sediment Concentration
Volume of Sediment Viewed
FIGURE 8-3 Commercial microscope slides. A, A 10-position UriSystem slide with integrated coverslips. B, A plastic 10-chamber KOVA Glasstic slide.
Reporting Formats
TABLE 8-3 Qualitative Terms and Descriptions for Fields of View (FOVs)
Box 8-1 Conversion of the Number of Formed Elements Present in a Microscopic Field to the Number of Formed Elements Present in a Volume of Urine
TABLE 8-4 Visualization Techniques to Aid in the Microscopic Examination of Urine Sediment
Enhancing Urine Sediment Visualization
Staining Techniques
Supravital Stains
FIGURE 8-4 Two squamous epithelial cells stained with Sternheimer-Malbin stain. Brightfield, 100×.
FIGURE 8-5 Fragment of renal collecting duct epithelial cells stained with 0.5% toluidine blue. Brightfield, 400×.
FIGURE 8-6 Leukocytes stained with 0.5% toluidine blue. Brightfield, 400×.
FIGURE 8-7 Oval fat body stained with Sudan III stain. Note the characteristic orange-red coloration of neutral fat globules. Brightfield, 400×.
Acetic Acid
Fat or Lipid Stains
Gram Stain
FIGURE 8-8 Bacteria. Gram stain of gram-negative rods and gram-positive cocci. Brightfield, 1000×.
FIGURE 8-9 Eosinophil (arrow) in urine stained with Hansel stain. Cytospin, 400×.
Prussian Blue Reaction
Hansel Stain
FIGURE 8-10 Waxy cast. A, Brightfield, 100×. B, Phase contrast, 100×. Note the central fissure and increased detail revealed using phase-contrast microscopy.
Microscopy Techniques
Phase-Contrast Microscopy
Polarizing Microscopy
FIGURE 8-11 A, Cholesterol droplets displaying their characteristic Maltese cross pattern using polarizing microscopy, 400×. B, Polarizing microscopy with a first-order red compensator plate, 400×.
Interference Contrast Microscopy
FIGURE 8-12 Three-dimensional image of the waxy cast in Figure 8-7 using differential interference contrast (Nomarski) microscopy, 100×. Compare images obtained in these two figures.
Cytocentrifugation and Cytodiagnostic Urinalysis
Cytocentrifugation
Cytodiagnostic Urinalysis
Formed Elements in Urine Sediment
TABLE 8-5 Reference Intervals for Microscopic Examination*
Blood Cells
Red Blood Cells (Erythrocytes)
Microscopic Appearance
FIGURE 8-13 Three red blood cells: Two viewed from above appear as biconcave disks, and one viewed from the side appears hourglass-shaped (arrows). Also present are budding yeast and several white blood cells. Brightfield, Sedi-Stain, 400×.
FIGURE 8-14 Dysmorphic and crenated red blood cells. A single ghost red blood cell is located at top of view. Phase contrast, 400×.
Correlation With Physical and Chemical Examinations
TABLE 8-6 Red Blood Cells: Microscopic Features and Correlations
Look-Alikes
Clinical Significance
White Blood Cells (Leukocytes)
Neutrophils
Microscopic Appearance
FIGURE 8-15 Several white blood cells with characteristic cytoplasmic granules and lobed nuclei surrounding a squamous epithelial cell. Budding yeast cells are also present. Brightfield, Sedi-Stain, 400×.
FIGURE 8-16 A clump of white blood cells. One red blood cell and budding yeast are also present. Brightfield, Sedi-Stain, 400×.
FIGURE 8-17 Disintegrating white blood cells with the formation of blebs. Phase contrast, 400×.
FIGURE 8-18 Formation of myelin filaments in disintegrating white blood cells. Phase contrast, 400×.
Correlation With Physical and Microscopic Examinations
Look-Alikes
TABLE 8-7 White Blood Cells (WBCs): Microscopic Features and Correlations
Clinical Significance
Eosinophils
FIGURE 8-19 Two renal collecting duct cells stained with 0.5% toluidine blue. Their polygonal shape and nuclear detail distinguish them from leukocytes. Brightfield, 400×.
FIGURE 8-20 Eosinophil (arrow) in a cytospin of urine stained with Hansel stain. Brightfield, 400×.
FIGURE 8-21 Lymphocyte (arrow) in a cytospin of urine sediment. Brightfield, 400×.
Lymphocytes
Monocytes and Macrophages (Histiocytes)
FIGURE 8-22 Macrophages and several other white blood cells. A, Brightfield, 400×. B, Brightfield, Sedi-Stain, 400×.
Epithelial Cells
FIGURE 8-23 Oval fat body. A cell with numerous highly refractile fat globules and other inclusions. Brightfield, 400×.
TABLE 8-8 Epithelial Cells: Microscopic Features and Clinical Significance
FIGURE 8-24 Squamous epithelial cells: one large clump and several individual cells. Note their large, thin, flagstone-shaped appearance, centrally located nuclei, and stippled cytoplasm (stippling increases with cellular degeneration). A few ribbon-like mucous threads are also present. Phase contrast, 100×.
Squamous Epithelial Cells
FIGURE 8-25 Two squamous epithelial cells. The cell on the left is presenting a side view, demonstrating how flat these cells are. The upper edge of the cell on the right is curled, producing an unusual form. A, Brightfield, Sedi-Stain, 200×. B, Phase contrast, 200×.
Transitional (Urothelial) Epithelial Cells
FIGURE 8-26 Two transitional (urothelial) epithelial cells. A, Phase contrast, 400×. B, Interference contrast, 400×.
FIGURE 8-27 Four transitional (urothelial) epithelial cells. Phase contrast, 400×.
Renal Tubular Epithelial Cells
Convoluted Renal Tubular Cells
Proximal Convoluted Tubular Cells
Distal Convoluted Tubular Cells
FIGURE 8-28 Convoluted tubular epithelial cells. A, Numerous proximal convoluted tubular cells. Note the similarity in shape to granular casts and that their nuclei are not readily apparent in many cells. Phase contrast, 200×. B, Sediment stained with 0.5% toluidine blue. A large, castlike proximal tubular cell and a smaller, round distal tubular cell are present with two hyaline casts and other debris. Brightfield, 400×. C, A single proximal tubular cell stained with 0.5% toluidine blue. Note the indistinct cell margins, granular cytoplasm, and small eccentric nucleus. Brightfield, 400×.
FIGURE 8-29 Renal collecting duct epithelial cells. A, Two cells with an intact edge. Brightfield, toluidine blue stain, 400×. B, A single cell. Interference contrast, 400×.
Collecting Duct Cells
FIGURE 8-30 A, Fragment of renal collecting duct epithelial cells. Brightfield, 400×. B, Fragment of renal collecting duct epithelial cells in “spindle” form, indicative of regeneration of the tubular epithelium after injury. Interference contrast, 400×.
Renal Tubular Cells With Absorbed Fat
FIGURE 8-31 Oval fat body. Note the size variation of the fat globules. Brightfield, 400×.
Casts
Formation and General Characteristics
FIGURE 8-32 Three hyaline casts and several mucous threads. Phase contrast, 100×.
FIGURE 8-33 Three hyaline casts. The cast with a tapered end is frequently called a cylindroid. Phase contrast, 100×.
FIGURE 8-34 Two broad, granular to waxy casts. A, Brightfield, 100×. B, Interference contrast, 100×.
FIGURE 8-35 Convoluted hyaline cast, initially formed in a tubule and later compressed in a tubule of larger diameter. Phase contrast, 200×.
FIGURE 8-36 Coarsely granular going to waxy cast. Brightfield, 100×.
FIGURE 8-37 One intact finely granular/waxy cast and two broken pieces of a cast. Brightfield, 100×.
Clinical Significance
FIGURE 8-38 A low-power field of view revealing casts of various types: cellular, granular, and mixed. Brightfield, Sedi-Stain, 100×.
Classification of Casts
Box 8-2 Classification of Urinary Casts
Homogeneous Matrix Composition
Hyaline Casts
FIGURE 8-39 Hyaline casts. Three hyaline casts and mucous threads. Brightfield, 200×.
FIGURE 8-40 Hyaline cast. Note the appearance of the fibrillar protein matrix and the presence of fine granulation. Phase contrast, 400×.
Waxy Casts
TABLE 8-9 Casts: Microscopic Features and Correlations
FIGURE 8-41 Waxy cast. A, Brightfield, 100×. B, Interference contrast, 100×.
FIGURE 8-42 Cast, part granular and part waxy. Note the difference in cast diameter at one end compared with the other. This indicates initial cast formation in a narrow tubular lumen followed by stasis in a tubule with a wider lumen and further cast formation. A, Brightfield, Sedi-Stain, 200×. B, Interference contrast, 200×.
Cellular Inclusion Casts
Red Blood Cell Casts
FIGURE 8-43 Red blood cell cast. Red blood cells are embedded in the cast matrix. Brightfield, 400×.
FIGURE 8-44 A pigmented granular cast or blood cast. The granules and pigmentation originate from hemoglobin and red blood cell degeneration. Brightfield, 200×.
FIGURE 8-45 Red blood cell cast. This cast is packed with intact red blood cells. A, Brightfield, 200×. B, Interference contrast, 400×.
FIGURE 8-46 White blood cell cast. Brightfield, 400×.
White Blood Cell Casts
FIGURE 8-47 Renal tubular cell cast. Brightfield, 200×.
Renal Tubular Cell Casts
FIGURE 8-48 Two casts, one hyaline, the other with coarsely granular inclusions. Brightfield, 200×.
Mixed Cell Casts
Bacterial Casts
Casts With Inclusions
Granular Casts
FIGURE 8-49 Finely granular and coarsely granular casts. Pigmentation from hemoglobin degradation. Brightfield, 200×.
Fatty Casts
FIGURE 8-50 A fatty cast. Note the globules and their characteristic refractility. Brightfield, 400×.
FIGURE 8-51 Fatty cast. Note the high refractility of the fat globule inclusions in the matrix of the cast. A, Phase contrast, 400×. B, Polarizing microscopy, 400×. The highly refractile fat globules apparent in A do not exhibit a Maltese cross pattern, identifying them as neutral fat; those with a Maltese cross pattern are cholesterol.
FIGURE 8-52 Cast with sulfamethoxazole crystal inclusions. Brightfield, 200×.
Other Inclusion Casts
Pigmented Casts
FIGURE 8-53 Cast with monohydrate calcium oxalate crystal inclusions. A, Brightfield, 400×. B, Polarizing microscopy with first-order red compensator, 400×.
Size
Correlation With Physical and Chemical Examinations
FIGURE 8-54 Pigmented granular cast. A, Brightfield, 200×. B, Phase contrast, 200×. Note the enhanced visualization of low-refractile components such as the hyaline matrix and mucus using phase-contrast microscopy.
FIGURE 8-55 Bile-stained cellular cast. Brightfield, 200×.
FIGURE 8-56 Broad waxy cast and numerous hyaline casts. Brightfield, 200×.
Look-Alikes
FIGURE 8-57 A, Diaper fiber demonstrating anisotropism (strong birefringence) with polarizing microscopy, 200×. B, Polarizing microscopy with first-order red compensator, 200×.
Crystals
Contributing Factors
Acidic Urine
Amorphous Urates
TABLE 8-10 Crystals of Normal Urine Solutes Arranged According to pH
TABLE 8-11 Abnormal Crystals of Metabolic and Iatrogenic* Origin Arranged According to pH
FIGURE 8-58 Amorphous urates. A, Two uric acid crystals are also present. Brightfield, 400×. B, Polarizing microscopy, 400×.
FIGURE 8-59 Acid urate crystals. Brightfield, 200×.
FIGURE 8-60 Monosodium urate crystals. Brightfield, 200×.
Acid Urates
Monosodium Urate
Uric Acid
FIGURE 8-61 Uric acid crystals (diamond-shaped) and a few calcium oxalate crystals. Note the darker coloration as the crystals layer and thicken. Brightfield, 200×.
FIGURE 8-62 Uric acid crystals. Single and cluster forms. Brightfield, 200×.
FIGURE 8-63 Uric acid crystals. Less common barrel forms. Brightfield, 200×.
FIGURE 8-64 Uric acid crystals. Barrel form. Brightfield, 200×.
FIGURE 8-65 Uric acid crystals. These crystals can layer or laminate on top of one another. Brightfield, 100×.
Calcium Oxalate
FIGURE 8-66 Calcium oxalate crystals. Octahedral (envelope) form of dihydrate crystals. Brightfield, 200×.
FIGURE 8-67 Calcium oxalate crystals. An unusual barrel form and a typical dehydrate form. Brightfield, 400×.
FIGURE 8-68 Calcium oxalate crystals. Small ovoid monohydrate crystals that resemble erythrocytes, and two large typical envelope forms of dihydrate crystals. A, Brightfield, 400×. B, Polarizing microscopy, 400×. The birefringence of these small ovoid crystals helps distinguish them from erythrocytes.
Alkaline Urine
Amorphous Phosphate
FIGURE 8-69 Amorphous phosphates. Note the lack of birefringence under polarizing microscopy. A, Brightfield microscopy, 400×. B, Polarizing microscopy with first-order red compensator, 400×.
FIGURE 8-70 Triple phosphate crystals. Typical “coffin lid” form. Brightfield, 100×.
Triple Phosphate
FIGURE 8-71 Calcium phosphate crystals. Prisms are arranged singly and in rosette forms. Brightfield, 100×.
Calcium Phosphate
FIGURE 8-72 Calcium phosphate crystals. Uncommon slender needles arranged in bundles or sheaves. Other crystals present in background include ammonium biurate, calcium carbonate, and a single calcium oxalate. Brightfield, 400×.
FIGURE 8-73 Calcium phosphate sheet or plate. Brightfield, 100×.
Magnesium Phosphate
FIGURE 8-74 Magnesium phosphate crystals. Brightfield, 400×.
FIGURE 8-75 Ammonium biurate crystals. Spheres and a “thorny apple” form. Brightfield, 200×.
FIGURE 8-76 Ammonium biurate crystals. Several “thorny apple” forms. Brightfield, 200×.
Ammonium Biurate
Calcium Carbonate
FIGURE 8-77 Calcium carbonate. A, Numerous single crystals. Brightfield, 400×. B, Aggregate of calcium carbonate crystals. Brightfield, 400×.
Crystals of Metabolic Origin
Bilirubin
Cystine
FIGURE 8-78 Bilirubin crystal. Brightfield, 400×.
Tyrosine and Leucine
FIGURE 8-79 Cystine crystals. Brightfield, 400×.
Cholesterol
FIGURE 8-80 Tyrosine crystals. Brightfield, 400×.
FIGURE 8-81 A, View of urine sediment with a cholesterol crystal, free-floating fat, and oval fat bodies. Brightfield, 200×. B, Cholesterol crystal. Phase contrast, 400×.
FIGURE 8-82 Radiographic contrast medium, meglumine diatrizoate (Renografin). The crystals appear as plates. Brightfield, 100×. Compare with cholesterol crystals (intravenous administration), Figure 8-71.
Crystals of Iatrogenic Origin
Medications
FIGURE 8-83 Ampicillin crystals. Brightfield, 400×.
Ampicillin
Indinavir
Sulfonamides
FIGURE 8-84 Indinavir sulfate crystals. A, Brightfield, 200×. B, Polarizing microscopy with first-order red compensator, 200×.
FIGURE 8-85 Sulfadiazine crystals. Brightfield, 400×.
FIGURE 8-86 Sulfamethoxazole (Bactrim) crystals. Brightfield, 400×.
FIGURE 8-87 Radiographic contrast medium following retrograde administration; meglumine diatrizoate (Renografin). The crystals appear in needle forms. Brightfield, 100×.
Radiographic Contrast Media
Microorganisms in Urine Sediment
Bacteria
FIGURE 8-88 Intravenous radiographic contrast medium. A, Interference contrast microscopy, 100×. B, Polarizing microscopy, 100×.
Yeast
FIGURE 8-89 Urine sediment with bacteria (rods), two erythrocytes, and a leukocyte. Phase contrast, 400×.
TABLE 8-12 Microorganismsin Urine Sediment
FIGURE 8-90 Budding yeast and pseudohyphae. Leukocytes are also present singly and as a clump. Brightfield, Sedi-Stain, 400×.
FIGURE 8-91 Pseudohyphae development by yeast. A, Interference contrast, 400×. B, Brightfield, 400×.
FIGURE 8-92 Leukocytes with intracellular yeast. Interference contrast, 400×.
Trichomonas Vaginalis
FIGURE 8-93 Schematic diagram of Trichomonas vaginalis.
FIGURE 8-94 A trichomonad in urine sediment. Because of their rapid flitting motion, only one of the flagella is visible in this view (arrow). Mucus, white blood cells, and other trichomonads are present but are not in focus at this focal plane. Phase contrast, 400×.
Clue Cells and Gardnerella Vaginalis
FIGURE 8-95 The slightly larger squamous epithelial cell with indistinct, shaggy cytoplasmic edges is a clue cell. The cell with well-defined cytoplasmic edges is a normal squamous epithelial cell. A, Brightfield, 200×. B, Phase contrast, 200×.
Parasites
FIGURE 8-96 An Enterobius vermicularis egg, unstained wet mount. Note its oval shape with a slightly flattened side and the developing larva within.
Miscellaneous Formed Elements
Mucus
FIGURE 8-97 Cysts of Giarda lamblia. A, A single Giardia lamblia cyst, unstained. B, Two Giardia lamblia cysts, trichrome stained.
Fat
FIGURE 8-98 A Schistosoma haematobium egg, unstained wet mount Note the terminal spine on this large, American football shaped egg.
FIGURE 8-99 Mucus. A, Several mucous threads and two hyaline casts. Phase contrast, 100×. B, A mass of mucus surrounding a fiber (contaminant). Brightfield, 400×.
FIGURE 8-100 Chemical structures of triglyceride (triacylglycerol or neutral fat), cholesterol, and cholesterol esters.
FIGURE 8-101 Three oval fat bodies stained with Sudan III stain. Note the characteristic orange-red staining of neutral fat globules. Brightfield, 400×.
FIGURE 8-102 Cholesterol droplets demonstrating the characteristic Maltese cross pattern. Polarizing microscopy with first-order red compensator, 400×.
Hemosiderin
Sperm
FIGURE 8-103 A, Hemosiderin granules floating free in urine sediment. Brightfield, 400×. B, Hemosiderin granules after staining with Prussian blue. Brightfield, 400×.
FIGURE 8-104 Spermatozoa in urine sediment. One typical and two atypical forms. Phase contrast, 400×.
FIGURE 8-105 Hyaline cast and a fiber. Note the difference in form and refractility. A, Brightfield, 100×. B, Phase contrast, 100×.
Contaminants
Fibers
Starch
FIGURE 8-106 Starch granules. Brightfield, 400×.
FIGURE 8-107 Starch granules. A, Demonstration of a Maltese cross pattern using polarizing microscopy, 400×. B, Polarizing microscopy with first-order red compensator, 400×.
FIGURE 8-108 Charcoal granules (arrows) in urine sediment. Numerous leukocytes are present. Cytospin preparation, Wright’s stain, brightfield microscopy, 400×.
Fecal Matter
Correlation of Urine Sediment Findings With Disease
TABLE 8-13 Urine Sediment Findings With Selected Diseases
Study Questions
Case 8-1
Results
Case 8-2
Results
Case 8-3
Results
Case 8-4
Results
Case 8-5
Results
Case 8-6
Results
Case 8-7
Results
References
Bibliography
Urine Sediment Image Gallery
Artifacts/Contaminants
FIGURE 1 Three air bubbles trapped beneath a coverslip observed using low-power (100×) magnification. Numerous white blood cells (WBCs) are also present.
FIGURE 2 A diaper fiber. Note its flat, wrinkled appearance and strong refractility. For an inexperienced microscopist, these fibers may be misidentified as waxy casts.
FIGURE 3 A clothing fiber. Its refractility, frayed ends, and flatness aid in its proper identification.
FIGURE 4 A starch granule (black arrow) demonstrating a characteristic dimple. When glass slides and coverslips are used, glass fragments (red arrows) can be present. Numerous white blood cells are also present.
FIGURE 5 When plastic commercial standardized slides are used, fragments of plastic (red arrows) can be present in the sediment. Red blood cells, yeasts, and pseudohyphae are also present.
FIGURE 6 Three starch granules, all highly refractile, with slightly differing appearances, yet each has a centrally located dimple. Fragments of plastic (red arrows) are also present.
Blood Cells
Red Blood Cells
FIGURE 7 Numerous intact and ghost red blood cells (black arrows). In this image, intact cells have a characteristic appearance caused by the hemoglobin within them. In contrast, ghost red blood cells (RBCs) have intact cell membranes but have lost their hemoglobin. This urine was hypotonic (dilute; low specific gravity), and many of the RBCs appear swollen and rounded because of the diffusion of fluid into the cells.
FIGURE 8 Red blood cells in hypertonic urine (concentrated; high specific gravity). Many of the cells in this field of view have lost their typical biconcave shape and are crenated. This happens when fluid within the cell is transferred into the urine to balance the tonicity of the environment. Consequently, the cell membrane shrinks, forming folds or projections.
White Blood Cells
FIGURE 9 White blood cells and a single squamous epithelial cell.
FIGURE 10 Five white blood cells. Note that the lobed nuclei in several of these neutrophils are readily apparent, whereas in those that are degenerating, the nucleus has become mononuclear.
FIGURE 11 Three white blood cells, a single red blood cell, and a squamous epithelial cell.
Casts
Cellular Casts
FIGURE 12 A mixed cellular cast.
FIGURE 13 Renal tubular epithelial cell cast with one end broken or incompletely formed.
FIGURE 14 Renal tubular epithelial cell cast. Note the cuboidal shape of the entrapped cells. The nuclei were also apparent when focusing up and down during the microscopic examination.
FIGURE 15 A renal tubular cell cast and several free-floating renal tubular cells in a Sternheimer-Malbin stained sediment. A highly refractile glass fragment is present in the center of this field of view.
FIGURE 16 A cast with oval fat bodies (i.e., renal tubular cells that contain fat). In this Sternheimer-Malbin stained sediment, the fat globules take on a yellow or greenish appearance.
FIGURE 17 A white blood cell cast. Note the spherical or round shape of entrapped cells.
FIGURE 18 A mixed cell cast. This cast contains both white blood cells and red blood cells (arrow).
FIGURE 19 A mixed cell cast, predominantly red blood cells.
FIGURE 20 A red blood cell cast. Red blood cells are dispersed in the hyaline matrix of this cast.
FIGURE 21 A red blood cell cast packed with red blood cells.
FIGURE 22 A fatty cast. Note the refractility, color, and size variation of fat globules in this cast.
FIGURE 23 A fatty cast loaded with fat. With the passage of time and cooling (this urine specimen was stored in a refrigerator), a cholesterol crystal (arrow) has started to form from the fat (cholesterol) in this cast.
FIGURE 24 Oval fat bodies in a hyaline matrix (i.e., a fatty cast). In this sediment stained using Sudan III, the fat in the oval fat bodies has taken on the characteristic terra-cotta or red-orange color, indicating that the fat present is neutral fats (triglycerides).
Granular Casts
FIGURE 25 Granular cast.
FIGURE 26 Granular cast.
FIGURE 27 Coarsely granular cast.
FIGURE 28 Cast transitioning from cellular to granular to waxy. The intense brown color suggests that pigmentation is derived from hemoglobin. This sediment also contained numerous red blood cells and red blood cell casts.
FIGURE 29 Granular casts. A broad cast indicative of formation in a large collecting duct or in dilated tubules indicates significant renal pathology. The granules in these casts most likely originated from red blood cells/hemoglobin.
FIGURE 30 A low-power (100×) field of view of urine sediment containing numerous casts: hyaline, granular, red blood cell, and cellular.
Hyaline Casts
FIGURE 31 A low-power (100×) field of view of urine sediment containing numerous hyaline casts. Because their refractive index is similar to that of urine, they can be difficult to observe on brightfield microscopy. Focusing up and down during the microscopic examination aids in the detection of hyaline casts because they are often more apparent when slightly out of focus.
FIGURE 32 Hyaline cast.
FIGURE 33 A U-shaped hyaline cast, two white blood cells, and several dihydrate calcium oxalate crystals.
Waxy Casts
FIGURE 34 A low-power (100×) field of view of a urine sediment containing numerous casts, particularly hyaline and waxy (three predominate).
FIGURE 35 A long, broad waxy cast predominates in this field of view. Also present are other waxy and hyaline casts, as well as renal tubular cells and oval fat bodies.
FIGURE 36 A single waxy cast and two hyaline casts. Note the difference in refractility between these two types of casts. In this image, the hyaline casts are actually out of focus, which makes them easier to see.
FIGURE 37 A waxy cast (left) lying almost vertical and two red blood cell casts (right) lying horizontally.
FIGURE 38 Two waxy casts. One typical in size and one broad cast that is transitioning from granular to waxy. Note ground-glass appearance and blunt end, which are characteristics of waxy casts.
Crystals
Ammonium Biurate Crystals
FIGURE 39 Ammonium biurate crystals. Note the characteristic yellow to brown color. With the passage of time (urine storage), these crystals will grow to form spicules or thorns.
Bilirubin Crystals
FIGURE 40 Bilirubin crystals. Small, finely spiculated crystals with the characteristic golden yellow color indicative of bilirubin. These crystals may form when urine with large amounts of bilirubin is refrigerated and stored.
Calcium Carbonate Crystals
FIGURE 41 Calcium carbonate crystals (arrows) and single dihydrate calcium oxalate crystal.
Calcium Oxalate Crystals
FIGURE 42 A, A single dihydrate calcium oxalate crystal and numerous monohydrate calcium oxalate crystals that look similar to red blood cells. B, Same field of view using polarizing microscopy. Rule of thumb: Crystals can polarize light; red blood cells do not.
FIGURE 43 Calcium oxalate crystals, atypical barrel form.
FIGURE 44 Calcium oxalate crystals, atypical ovoid form.
Cholesterol Crystal
FIGURE 45 Cholesterol crystal (arrow).
Cystine Crystal
FIGURE 46 Cystine crystals. A single cystine crystal appears in the lower left corner, and several cystine crystals are layered and clustered together at the upper right corner. Several red blood cells are also present.
FIGURE 47 Several cystine crystals layered and clustered together.
Drug Crystals
FIGURE 48 Acetylsulfadiazine crystal surrounded by numerous yeasts.
FIGURE 49 Numerous sulfamethoxazole (Bactrim) crystals surrounding a single barrel-shaped uric acid crystal. Note the yellow-brown color and the similar shape of sulfamethoxazole crystals to those of ammonium biurate. Urine pH aids in differentiating these two crystals.
Phosphate Crystals
FIGURE 50 Triple phosphate crystals and numerous amorphous phosphates.
FIGURE 51 Dissolving triple phosphate crystals and numerous amorphous phosphates.
FIGURE 52 Two atypical triple phosphate crystals and a single stellate calcium phosphate crystal (upper right).
FIGURE 53 Wedge-shaped calcium phosphate crystals and dihydrate calcium oxalate crystals.
FIGURE 54 A calcium phosphate sheet.
FIGURE 55 Calcium phosphate crystals. Unusual flat, plate-like form that layers.
FIGURE 56 Calcium phosphate crystals. Uncommon slender wedges or needles.
FIGURE 57 Magnesium phosphate crystals. Elongated rhomboid plates; rare.
Urate Crystals
FIGURE 58 Acid urate crystals. Note the yellow to brown color characteristic of thick urate crystals.
FIGURE 59 Monosodium urate crystals.
Uric Acid Crystals
FIGURE 60 Uric acid crystals in the common diamond shape.
FIGURE 61 Uric acid crystals, barrel or cube forms.
FIGURE 62 A chunk of a uric acid crystal. Note the characteristic color.
FIGURE 63 A single uric acid crystal in an unusual band form and numerous calcium oxalate crystals (mono- and dihydrate forms).
X-Ray Contrast Media Crystals
FIGURE 64 X-ray contrast media following intravenous (IV) administration (i.e., meglumine diatrizoate [Renografin]) crystals.
Epithelial Cells
FIGURE 65 Two squamous epithelial cells covered with bacteria, known as clue cells and a single typical or “normal” squamous epithelial cell. In urine that has been contaminated with vaginal secretions, clue cells may be observed. This is not a common occurrence.
FIGURE 66 Three squamous epithelial cells and a single white blood cell. Note the similarity in size between the white blood cells and the nuclei of these epithelial cells.
FIGURE 67 A squamous epithelial cell (lower left cell) and a transitional epithelial cell (upper right cell). Note the similarity in sizes of their nuclei, yet the difference in the amount of cytoplasm (i.e., different nucleus-to-cytoplasm ratios). Several large rod-shaped bacteria are also present.
FIGURE 68 A typical transitional epithelial cell and a hyaline cast.
FIGURE 69 A fragment of transitional epithelial cells.
FIGURE 70 Transitional epithelial cell or squamous epithelial cell? Reasoning could be used to justify classification into either category. Cells lining the urinary system convert from squamous to transitional (urothelial) epithelium. This cell most likely originated from this area of transition.
FIGURE 71 A transitional epithelial cell (left) and two typical cuboidal renal tubular (collecting duct) cells.
FIGURE 72 Renal tubular epithelial cells. These cells came from a small collecting duct based on their cuboidal shape and their nucleus-to-cytoplasm ratio.
FIGURE 73 Renal tubular epithelial cells. This fragment of columnar epithelial cells with their eccentric nuclei derived from a large collecting duct. Numerous red blood cells are also present.
FIGURE 74 A single renal tubular cell (arrow) from a large collecting duct. Note the similarity in size of the nucleus of this cell to that of the red blood cells that are present.
Fat GLOBULES AND OVAL FAT BODIES
FIGURE 75 Several free fat globules and a fatty cast. Note refractility, variation in size, and greenish hue of the fat globules.
FIGURE 76 An oval fat body in the hyaline matrix of a cast. Also present in this field of view are another free-floating oval fat body, a fat globule, and a hyaline cast. Note the similarity in size and shape of the fat globule to a red blood cell.
FIGURE 77 Two oval fat bodies (arrows) loaded with fat, hence their intense refractility. Numerous red blood cells, amorphous materials, and debris are also present.
FIGURE 78 Two oval fat bodies and several renal tubular cells.
FIGURE 79 Three oval fat bodies. As with free-floating fat, the globules within cells often vary in size, are highly refractile, and have a greenish sheen.
FIGURE 80 Several oval fat bodies enmeshed within casts and free in the urine sediment. Bacteria and spermatozoa are also present.
FIGURE 81 An oval fat body engorged with fat (triglycerides or neutral fat) stained using Sudan III.
Microorganisms
Bacteria
FIGURE 82 Numerous rod-shaped bacteria and a single dihydrate calcium oxalate crystal.
FIGURE 83 Numerous bacteria, singly and in chains, with several indicated by blue arrows. Many red blood cells (RBCs) and intact and ghost cells (red arrows) are present.
Trichomonads
FIGURE 84 A trichomonad. Their characteristic rapid flitting motion results from their undulating membrane (blue arrow), anterior flagella (two indicated by yellow arrows), and axostyle (red arrow). Because of their size and granular appearance, nonmotile (or dead) trichomonads may be misidentified as white blood cells.
FIGURE 85 Two trichomonads.
FIGURE 86 A cluster of four trichomonads. It is common to observe trichomonads clustered together along with white blood cell (WBC) clumps in urine sediment.
Yeast
FIGURE 87 Several budding yeast (blastoconidia), bacteria, and a single ghost red blood cell. Note the refractility and sheen of the yeast, which is made most evident by focusing up and down during the microscopic examination.
FIGURE 88 A branch of pseudohyphae (Candida spp.) and two red blood cells demonstrating typical pink-red coloration. Several ovoid yeasts are present in a different focal plane.
FIGURE 89 Yeast cells and blastoconidia (budding yeast). These yeast cells appear more round than oval, highlighting the fact that different species of yeast will appear differently. A single dihydrate calcium oxalate crystal is also present.
FIGURE 90 Early germ tube formation and several yeast cells. A single red blood cell is also present.
Miscellaneous Formed Elements
Hemosiderin
FIGURE 91 Hemosiderin granules in urine sediment appear yellow-brown. Numerous granules as well as a clump are present in this field of view. Four granules are identified by the arrows. Two dissolving dihydrate calcium oxalate crystals are also present.
FIGURE 92 Hemosiderin granules in the hyaline matrix of a cast (i.e., a hemosiderin cast).
Mucus
FIGURE 93 A cluster of mucous threads. Because the refractive index of muous is similar to that of urine, it can be difficult to observe using brightfield microscopy. Focusing up and down during the microscopic examination aids in the detection of mucus because it is often more apparent when slightly out of focus. A couple of squamous epithelial cells and other elements, on a different focal plane, are also present.
Sperm
FIGURE 94 A cluster of sperm trapped in mucus.
FIGURE 95 Sperm and bacteria in urine sediment. Note that several abnormal spermatozoa forms are present.
Chapter 9 Renal and Metabolic Disease
Learning Objectives
Key Terms
Renal Diseases
Glomerular Disease
Box 9-1 Glomerular Diseases
Primary Glomerular Diseases
Secondary Glomerular Diseases
Systemic Diseases
Hereditary Disorders
Morphologic Changes in the Glomerulus
Pathogenesis of Glomerular Damage
Clinical Features of Glomerular Diseases
TABLE 9-1 Syndromes That Indicate Glomerular Injury
TABLE 9-2 Typical Urinalysis Findings With Selected Glomerular Diseases
Nephrotic Syndrome
Types of Glomerulonephritis
Acute Glomerulonephritis
TABLE 9-3 Summary of Predominant Forms of Primary Glomerulonephritis
Rapidly Progressive Glomerulonephritis
Membranous Glomerulonephritis
Minimal Change Disease
Focal Segmental Glomerulosclerosis
Membranoproliferative Glomerulonephritis
IgA Nephropathy
Chronic Glomerulonephritis
TABLE 9-4 Percentage of Glomerular Diseases Resulting in Chronic Glomerulonephritis
Systemic Diseases and Glomerular Damage
FIGURE 9-1 A composite drawing showing the course of diabetic nephropathy. Exercise and other stress cause intermittent proteinuria before a sustained protein leak, which may lead to nephrotic syndrome. Initial regulation indicates initiation of insulin therapy.
Tubular Disease
Acute Tubular Necrosis
Tubular Dysfunction
Fanconi Syndrome
TABLE 9-5 Proximal Tubular Dysfunctions
TABLE 9-6 Distal Tubular Dysfunctions
Cystinosis and Cystinuria
TABLE 9-7 Typical Urinalysis Findings With Selected Tubular Diseases
Renal Glucosuria
Renal Phosphaturia
Renal Tubular Acidosis
Tubulointerstitial Disease and Urinary Tract Infections
Urinary Tract Infections
TABLE 9-8 Typical Urinalysis Findings in Selected Urinary Tract Infections and Tubulointerstitial Diseases
Box 9-2 Causes of Tubulointerstitial Diseases
Acute Pyelonephritis
Chronic Pyelonephritis
Acute Interstitial Nephritis
Yeast Infections
Vascular Disease
Acute and Chronic Renal Failure
Acute Renal Failure
Chronic Renal Failure
Calculi
Pathogenesis
TABLE 9-9 Renal Calculi Composition
Factors Influencing Calculi Formation
Prevention and Treatment
Metabolic Diseases
TABLE 9-10 Qualitative Tests Used to Screen for Metabolic Disorders
Amino Acid Disorders
Cystinosis
Cystinuria
Maple Syrup Urine Disease
FIGURE 9-2 Major and minor pathways of phenylalanine metabolism.
Phenylketonuria
Alkaptonuria
FIGURE 9-3 Pathways of tyrosine metabolism.
Tyrosinuria
Melanuria
Carbohydrate Disorders
Glucose and Diabetes Mellitus
TABLE 9-11 Characteristics of Type 1 and Type 2 Diabetes Mellitus
Galactosemia
Diabetes Insipidus
FIGURE 9-4 Schematic diagram of heme synthesis.
Porphyrias
FIGURE 9-5 The basic structure of porphyrins.
TABLE 9-12 Classification of Porphyrias
TABLE 9-13 Summary of Porphyria Characteristics
Study Questions
Case 9-1
Results
Case 9-2
Results
Case 9-3
Results
Case 9-4
Urinalysis Results
Case 9-5
Urinalysis Results
Case 9-6
Urinalysis Results
References
Chapter 10 Fecal Analysis
Learning Objectives
Key Terms
Fecal Formation
Diarrhea
TABLE 10-1 Classification of Diarrhea
Steatorrhea
TABLE 10-2 Comparison of Diarrhea and Steatorrhea
Specimen Collection
Patient Education
TABLE 10-3 Causes of Steatorrhea
Specimen Containers
FIGURE 10-1 An algorithm to aid in the evaluation of diarrhea and steatorrhea. WBC, White blood cell.
Type and Amount Collected
Contaminants to Avoid
Gas Formation
Macroscopic Examination
Color
Consistency and Form
TABLE 10-4 Fecal Macroscopic Characteristics
TABLE 10-5 Fecal Reference Intervals
TABLE 10-6 Disease Differentiation Based on the Presence of Fecal Leukocytes (WBCs)
Mucus
Odor
Microscopic Examination
Fecal Leukocytes
Fecal Fat, Qualitative
FIGURE 10-2 Numerous globules of neutral fat stained with Sudan III. The orange-red coloration is characteristic. Fat present in fecal suspension during qualitative fecal fat microscopic examination. Brightfield microscopy, 200×.
FIGURE 10-3 Large globule of neutral fat stained with Sudan III. The orange-red coloration is characteristic. Brightfield microscopy, 200×.
Meat Fibers
FIGURE 10-4 Meat fiber (note striations on fiber) present in fecal suspension during qualitative fecal fat microscopic examination. Brightfield microscopy, 400×.
Chemical Examination
Fecal Blood
TABLE 10-7 Fecal Occult Blood Tests
TABLE 10-8 Ingested Substances Associated With Erroneous Guaiac-Based Fecal Occult Blood Tests
Guaiac-Based Fecal Occult Blood Tests
FIGURE 10-5 Positive guaiac-based fecal occult blood test.
Immunochemical Fecal Occult Blood Tests
Porphyrin-Based Fecal Occult Blood Test
Fetal Hemoglobin in Feces (Apt Test)
Quantitative Fecal Fat
Fecal Carbohydrates
Study Questions
Case 10-1
Urinalysis Results
Microbiological Examination
Blood Chemistry Results
Case 10-2
Microbiological Examination of Stool
Case 10-3
References
Chapter 11 Seminal Fluid Analysis
Learning Objectives
Key Terms
FIGURE 11-1 A schematic diagram of the male reproductive tract.
Physiology
FIGURE 11-2 A schematic diagram of spermatogenesis from germ cells in the seminiferous tubules.
Specimen Collection
TABLE 11-1 Semen Characteristics Associated With Fertility
Physical Examination
Appearance
Volume
Viscosity
Microscopic Examination
Motility
TABLE 11-2 Sperm Motility Grading Criteria
Concentration and Sperm Count
FIGURE 11-3 Spermatozoon or sperm. A, A schematic of a mature sperm. B, An enlarged view of head and midpiece. C, A photomicrograph of a single sperm using phase-contrast microscopy, 400×.
Postvasectomy Sperm Counts
Morphology
FIGURE 11-4 Sperm morphology. A, Normal spermatozoon: 1, acrosome; 2, postacrosomal cap; 3, midpiece; 4, tail. B, Large head. C, Tapered head. D, Tapered head with acrosome deficiency. E, Acrosomal deficiency. F, Head vacuole. G, Midpiece defect—cytoplasmic extrusion mass. H, Bent tail. I and J, Coiled tails. K, Double tail. L, Pairing phenomenon. M, Sperm precursors (spermatids). N, Double-headed (bicephalic) sperm.
FIGURE 11-5 Sperm vitality using eosin-nigrosin (Blom’s) stain. White sperm were alive; pink-stained sperm were dead. Brightfield microscopy, 400×.
Vitality
Cells Other Than Spermatozoa
Agglutination
Chemical Examination
pH
Fructose
Other Biochemical Markers
Study Questions
Case 11-1
Semen Analysis
Case 11-2
Semen Analysis
References
Bibliography
Chapter 12 Amniotic Fluid Analysis
Learning Objectives
Key Terms
Physiology and Composition
Function
FIGURE 12-1 Schematic diagram of a fetus in utero.
Formation
Volume
Specimen Collection
Timing of and Indications for Amniocentesis
TABLE 12-1 Indications for Amniocentesis
Collection and Specimen Containers
Specimen Transport, Storage, and Handling
Differentiation From Urine
Physical Examination
Color
Turbidity
Chemical Examination
Fetal Lung Maturity Tests
TABLE 12-2 Fetal Lung Maturity Tests
Lecithin/Sphingomyelin Ratio
FIGURE 12-2 Changes in the concentrations of lecithin and sphingomyelin and changes in the lecithin/sphingomyelin ratio during normal pregnancy.
Phosphatidylglycerol
Foam Stability Index
Fluorescence Polarization Assay
Lamellar Body Counts
Amniotic Fluid Bilirubin (or ΔA450 Determination)
FIGURE 12-3 The determination of A450 in amniotic fluid. A, Normal amniotic fluid. B, Amniotic fluid with a bilirubin peak at 450 nm. C, Amniotic fluid with a bilirubin peak at 450 nm and contaminated with oxyhemoglobin, which peaks at 412 nm. The dashed line indicates the baseline drawn between the linear portions of the curve (i.e., between 365 and 550 nm). The red line indicates oxyhemoglobin absorbance.
FIGURE 12-4 Liley’s three-zone chart (with modification) for the interpretation of amniotic fluid A450 values. The dark line extending from 22 to 38 weeks’ gestation represents the upward revision of the “danger line” by Irving Umansky.
TABLE 12-3 Amniotic Fluid Reference Intervals
Study Questions
Case 12-1
Amniotic Fluid Results
References
Chapter 13 Cerebrospinal Fluid Analysis
Learning Objectives
Key Terms
Physiology and Composition
FIGURE 13-1 A schematic representation of the spinal cord and the meninges that surround it.
FIGURE 13-2 A schematic representation of the brain and spinal cord, including the circulation of the cerebrospinal fluid.
Specimen Collection
Box 13-1 Indications and Contraindications for Lumbar Puncture and Cerebrospinal Fluid Examination
Indications
Infections
Hemorrhage
Neurologic Disease
Malignancy
Tumor
Treatments
Contraindications
TABLE 13-1 Cerebrospinal Fluid Reference Intervals*
FIGURE 13-3 A schematic representation of a lumbar puncture procedure.
TABLE 13-2 Cerebrospinal Fluid Specimen Handling and Storage Temperature
Box 13-2 Causes of Xanthochromia in Cerebrospinal Fluid
Physical Examination
TABLE 13-3 Features That Aid in Differentiating Hemorrhage From Traumatic Tap
Microscopic Examination
Total Cell Count
Red Blood Cell (Erythrocyte) Count
White Blood Cell (Leukocyte) Count
Differential Cell Count
Techniques
Pleocytosis
Neutrophils
Lymphocytes
TABLE 13-4 Cell Types and Causes of Cerebrospinal Fluid Pleocytosis
TABLE 13-5 Normal Cerebrospinal Fluid Differential Count*
Plasma Cells
FIGURE 13-4 Low-power fields of view of cerebrospinal fluid (CSF) with tumor cell clumps. A, Rare tumor clump with numerous red blood cells (RBCs). B, Numerous cells with rare tumor clump.
FIGURE 13-5 A, Macrophage with intracellular yeast (cerebrospinal fluid [CSF], ×1000). B, Bacteria engulfed by neutrophils (CSF, ×1000).
FIGURE 13-6 Normal lymphocytes with monocyte (arrow) and red blood cell (RBC) (cerebrospinal fluid [CSF], ×1000).
FIGURE 13-7 Reactive lymphocytes (cerebrospinal fluid [CSF], ×1000).
FIGURE 13-8 Monocytes and a single neutrophil (cerebrospinal fluid [CSF], ×1000).
FIGURE 13-9 Eosinophilia in cerebrospinal fluid (CSF).
Monocytes
Eosinophils
FIGURE 13-10 Macrophage with engulfed (intracellular) red blood cells (RBCs); can also be called an erythrophage.
Macrophages
FIGURE 13-11 Hemosiderin-laden macrophage; also called a siderophage.
FIGURE 13-12 Siderophage with intracellular hematoidin crystal (cerebrospinal fluid [CSF], ×1000).
FIGURE 13-13 Clumps of ependymal or choroid plexus cells. A, Cerebrospinal fluid (CSF), ×200. B, CSF, ×500.
Other Cells
Malignant Cells
FIGURE 13-14 Lymphoblasts in cerebrospinal fluid (lymphoma).
FIGURE 13-15 Myeloblasts in cerebrospinal fluid (acute myelogenous leukemia).
Chemical Examination
Protein
Total Protein
Albumin and Immunoglobulin G
Protein Electrophoresis
FIGURE 13-16 Cerebrospinal fluid protein patterns using high-resolution electrophoresis. A, A “normal” cerebrospinal fluid protein pattern. The presence in the β2-region of τ transferrin, a protein unique to cerebrospinal fluid, is noteworthy. B, An “abnormal” cerebrospinal fluid protein pattern demonstrating the presence of oligoclonal bands in the γ region. These bands will not be present on electrophoresis of the patient’s serum. TTR, Transthyretin (previously called prealbumin).
Myelin Basic Protein
Glucose
Lactate
Microbiological Examination
Microscopic Examination of CSF Smears
Culture
Immunologic Methods
Study Questions
Case 13-1
Blood Chemistry Results
Cerebrospinal Fluid Results
Case 13-2
Blood Chemistry Results
Cerebrospinal Fluid Results
References
Chapter 14 Synovial Fluid Analysis
Learning Objectives
Key Terms
Physiology and Composition
FIGURE 14-1 A schematic representation of the knee: a diarthrodial joint.
FIGURE 14-2 Synoviocytes in synovial fluid, ×400. Note similarity to mesothelial cells.
TABLE 14-1 Synovial Fluid Reference Intervals*
Classification of Joint Disorders
TABLE 14-2 Classification of Synovial Fluid Based on Laboratory Examination
Specimen Collection
TABLE 14-3 Synovial Fluid Analysis and Specimen Requirements
Physical Examination
Color
Clarity
Viscosity
Clot Formation
Microscopic Examination
Total Cell Count
Differential Cell Count
TABLE 14-4 Synovial Fluid Crystal Identification, Microscopic Characteristics, and Associated Clinical Conditions
Crystal Identification
Microscope Slide Preparations
Monosodium Urate Crystals
FIGURE 14-3 A, A diagrammatic representation of monosodium urate and calcium pyrophosphate crystals when viewed using polarizing microscopy with a red compensator. The axis indicated is that of the compensator. B, Monosodium urate crystals in joint fluid. The crystals with their longitudinal axis parallel to the red compensator plate axis as indicated in the lower left corner are yellow. C, With the axis of the red compensator plate perpendicular to the longitudinal axis, the same monosodium urate crystals are blue (polarizing microscopy).
Calcium Pyrophosphate Dihydrate Crystals
FIGURE 14-4 A, Calcium pyrophosphate dihydrate crystal in joint fluid; brightfield microscopy. B, Calcium pyrophosphate dihydrate crystal appears yellow; its axis is perpendicular to the axis of the red compensator plate (polarizing microscopy). C, Calcium pyrophosphate dihydrate crystal appears blue; its axis is parallel to that of the red compensator plate (polarizing microscopy).
Cholesterol Crystals
Hydroxyapatite Crystals
FIGURE 14-5 Cholesterol crystals in joint fluid; brightfield microscopy.
FIGURE 14-6 Synovial fluid with corticosteroid drug (triamcinolone diacetate [Aristocort]) crystals present. Note their conflicting morphology (suggests calcium pyrophosphate dihydrate [CPPD]) and strong negative birefringence (suggests monosodium urate [MSU]). Wet preparation, unstained; polarizing microscopy, 400×. A, Many strongly birefringent drug crystals that morphologically resemble CPPD using polarizing microscopy. B, Drug crystals with their long axes parallel to that of the red compensator plate are yellow—suggesting MSU crystals.
Corticosteroid Crystals
Artifacts
FIGURE 14-7 Synovial fluid with mass of hyaluronate, small monosodium urate (MSU) crystals, starch granule, and fibers. Cytocentrifuged preparation, Wright’s stain, 400×. A, Brightfield microscopy; starch granule and fiber. Note that no crystals are evident in the pink mass. B, Polarizing microscopy; presence of MSU crystals is evident, fibers have strong birefringence, and the starch granule shows a typical Maltese cross-pattern. C, Compensated polarizing microscopy; crystals with their long axis perpendicular to the red compensator plate are blue, which indicates that the crystals are MSU.
Chemical Examination
Glucose
Total Protein
Uric Acid
Lactate
Microbiological Examination
Gram Stain
Culture and Molecular Methods
Study Questions
Case 14-1
Blood Chemistry Results
Synovial Fluid Results
Case 14-2
Blood Chemistry Results
Synovial Fluid Results
Case 14-3
Blood Chemistry Results
Synovial Fluid Results
References
Bibliography
Chapter 15 Pleural, Pericardial, and Peritoneal Fluid Analysis
Learning Objectives
Key Terms
Physiology and Composition
FIGURE 15-1 Parietal and visceral membranes of the pleural, pericardial, and peritoneal cavities. Parietal membranes line the body wall, whereas visceral membranes enclose organs. The two membranes are actually one continuous membrane. The space between opposing surfaces is identified as the body cavity (i.e., pleural cavity, pericardial cavity, peritoneal cavity).
Box 15-1 Forces Involved in Normal Pleural Fluid Formation and Absorption
TABLE 15-1 Suggested Serous Fluid Specimen Requirements
Specimen Collection
Transudates and Exudates
TABLE 15-2 Differentiation of Transudates and Exudates
Physical Examination
TABLE 15-3 Serous Effusions: Types, Mechanism of Formation, and Associated Conditions
TABLE 15-4 Differentiation of Chylous and Pseudochylous Effusions
Microscopic Examination
Total Cell Counts
Differential Cell Count
Microscope Slide Preparation
Cell Differential
FIGURE 15-2 Mesothelial cells, macrophages, neutrophils, and lymphocytes in peritoneal fluid, Wright’s stain, 200×.
FIGURE 15-3 Macrophages in peritoneal (ascites) fluid. Cytocentrifuged smear, Wright’s stain, 500×.
FIGURE 15-4 A signet ring macrophage and some red blood cells (RBCs) in pleural fluid. Cytocentrifuged smear, Wright’s stain, 400×.
FIGURE 15-5 Plasma cells in pleural fluid (1000×).
FIGURE 15-6 Lupus erythematosus (LE) cell in pleural fluid, 1000× (Wright’s stain). The engulfed homogeneous mass pushes the nucleus of the neutrophil to the periphery of the cell.
FIGURE 15-7 A, Mesothelial cell in pleural fluid, 1000× (Wright’s stain). B, Binucleated mesothelial cell with basophilic cytoplasm, pleural fluid, 1000× (Wright’s stain). C, Clump of mesothelial cells in pleural fluid, 500× (Wright’s stain).
Cytologic Examination
Chemical Examination
FIGURE 15-8 Adenocarcinoma in peritoneal fluid. Cytocentrifuged smear, Wright’s stain, 400×.
Total Protein and Lactate Dehydrogenase Ratios
Glucose
Amylase
Lipids (Triglyceride and Cholesterol)
pH
Carcinoembryonic Antigen
Microbiological Examination
Staining Techniques
Culture
Study Questions
Case 15-1
Blood Chemistry Results
Pleural Fluid Results
Case 15-2
Blood Chemistry Results
Peritoneal Fluid Results
References
Bibliography
Chapter 16 Analysis of Vaginal Secretions
Learning Objectives
Key Terms
TABLE 16-1 Vaginal Secretion Findings and Associated Conditions
Specimen Collection and Handling
pH
Microscopic Examinations
Wet Mount Examination
TABLE 16-2 Quantification Criteria for Microscopic Examinations
Blood Cells
Bacterial Flora
FIGURE 16-1 Large rods characteristic of Lactobacillus spp. surrounding a typical squamous epithelial cell from a healthy vagina.
Yeast
Epithelial Cells
FIGURE 16-2 Yeast and pseudohyphae in the wet mount of a vaginal secretions specimen. A, Budding yeast (blastoconidia) and two squamous epithelial cells. B, Pseudohyphae.
FIGURE 16-3 Several squamous epithelial cells from a healthy vagina. Keratohyalin granulation is most pronounced in the centrally located cell. Numerous large rods characteristic of Lactobacillus spp. are also present.
FIGURE 16-4 Two clue cells (arrows) and several normal squamous epithelial cells in the wet mount of a vaginal secretions specimen.
FIGURE 16-5 A single parabasal cell surrounded by numerous squamous epithelial cells.
Trichomonads
FIGURE 16-6 Schematic diagram of Trichomonas vaginalis.
FIGURE 16-7 Two trichomonads. Visible on the upper organism are three of the four anterior flagella (upper arrow), a portion of the undulating membrane (lower arrow), and the posterior axostyle.
KOH Preparation and Amine Test
Clinical Correlations
Bacterial Vaginosis
Candidiasis
Trichomoniasis
Atrophic Vaginitis
Study Questions
Case 16-1
Vaginal Secretion Results
References
Bibliography
Chapter 17 Automation of Urine and Body Fluid Analysis
Learning Objectives
Key Terms
Automation of Urinalysis
Urine Chemistry Analyzers
Principle of Reflectance Photometry
Semi-Automated Chemistry Analyzers
TABLE 17-1 Selected Urine Chemistry Analyzers
FIGURE 17-1 Diascreen 50 semi-automated urine chemistry analyzer.
FIGURE 17-2 iChem 100 semi-automated urine chemistry analyzer.
FIGURE 17-3 CLINITEK Advantus semi-automated urine chemistry analyzer.
Fully Automated Chemistry Analyzers
FIGURE 17-4 Rack of specimen tubes at the barcode reading and sampling station on the iChem Velocity.
TABLE 17-2 Typical Features of Semi-automated Urine Chemistry Analyzers
Automated Microscopy Analyzers
FIGURE 17-5 CLINITEK Atlas, an automated urine chemistry analyzer.
FIGURE 17-6 AUTION Max AX-4030, an automated urine chemistry analyzer.
FIGURE 17-7 iChem Velocity fully automated urine chemistry analyzer.
FIGURE 17-8 iQ200 microscopy analyzer.
FIGURE 17-9 Sysmex UF1000i analyzer.
FIGURE 17-10 Diagram of the iQ200 digital flow capture process.
iQ200 Urine Microscopy Analyzer
FIGURE 17-11 Auto-Particle Recognition (APR) process.
FIGURE 17-12 Displays of iQ200 urinalysis results. A, On-screen review of iQ200 results. The results for this sample did not auto-release because the amount of some microscopic elements resided in the “Particle Verification Range” set by the user. These results appear “yellow” and require review as established by this laboratory. Results that appear “green” are in the normal range and those that appear “red” are considered abnormal but do not need verification (as established by the user-defined criteria). When no yellow results are present, results can be automatically released without review or verification. B, On-screen display of automatically classified images of budding yeast (BYST).
TABLE 17-3 iQ200 Autoclassification and Subclassification Categories for Urine Sediment Particles
Sysmex UF-1000I and UF-100 Flow Cytometers
FIGURE 17-13 Diagram of urine particle analysis in the Sysmex UF-1000i.
FIGURE 17-14 Sysmex UF-1000i urine particle results. A, Scattergram of forward scatter (S_FSC) versus fluorescent light intensity-high sensitivity (S_FLH). B, Scattergram of forward scatter (S_FSC) versus fluorescent light intensity–low sensitivity (S_FLL). EC, Epithelial cells; RBC, red blood cells; WBC, white blood cells; YLC, yeastlike cells.
TABLE 17-4 UF-1000i Particle Detection Categories
Fully Automated Urinalysis Systems
TABLE 17-5 Fully Automated Urinalysis (UA) Systems
iRICELL Urinalysis Systems
CLINITEK AUWi System
FIGURE 17-15 iRICELL3000, a Fully Automated Urinalysis System that combines the iChem Velocity urine chemistry analyzer and the iQ200 microscopy analyzer.
FIGURE 17-16 AUWi, a Fully Automated Urinalysis System that combines the Siemens CLINITEK Atlas chemistry analyzer and the Sysmex UF-1000i particle analyzer.
Automation of Body Fluid Analysis
Body Fluid Cell Counts Using Hematology Analyzers
TABLE 17-6 Selected Automated Body Fluid Analyzers
Body Fluid Cell Counts Using iQ200
Study Questions
References
Chapter 18 Body Fluid Analysis: Manual Hemacytometer Counts and Differential Slide Preparation
Learning Objectives
Using A Hemacytometer
Diluents and Dilutions
TABLE 18-1 Body Fluid Dilution Guideline for Cell Counts Based on Visual Appearance
Box 18-1 Enhancing Visualization of WBCs When Analyzing Clear Fluids
TABLE 18-2 Diluents for Body Fluid Blood Cell Counts*
Pretreatment and Dilution of Synovial Fluid Specimens
Semen Dilution and Pretreatment of Viscous Specimens
Hemacytometer Cell Counts
Box 18-2 Manual Cell Count Using a Hemacytometer
FIGURE 18-1 Top, View of a hemacytometer chamber with an “improved” Neubauer etched grid or rulings. Middle, A single “W” square that is 1 mm2; notation derived from the use of 5 “W-sized” squares to enumerate white blood cells. A single “R” square that is 0.04 mm2; notation derived from the used of 5 “R-sized” squares to enumerate red blood cells. Bottom, Side view of hemacytometer chamber demonstrating how glass coverslip rests on ridges of hemacytometer and that when properly filled, the volume of liquid in the chamber has a fixed depth of 0.1 mm.
Calculations
Hemacytometer Calculation Examples
Example A: Using Undiluted Body Fluid
Example B: Using Diluted Body Fluid
Example C: Sperm Count Using Diluted Semen
Preparation of Slides for Differential
FIGURE 18-2 Thermo-Scientific Cytospin 4 cytocentrifuge
Cytocentrifugation
FIGURE 18-3 A, The components of an assembly for the Cytospin 4 cytocentrifuge consist of a stainless steel holder (Cytoclip), a chamber with attached filter card (Cytofunnel), and a microscope slide. Note that the opening in the filter paper is the site where sample flows from the chamber to the glass slide. B, Assembly ready for addition of body fluid and then placement onto the rotor of the cytocentrifuge.
FIGURE 18-4 Cytocentrifuge prepared slides of two body fluids stained using Wright stain. The upper slide shows a visually evident cell button in the area circled by a wax pencil. In contrast, the cell button is not macroscopically evident on the lower slide. On this slide, the wax pencil circle greatly aids the microscopist in locating the proper area of the slide for viewing.
TABLE 18-3 Guideline for Body Fluid Volume When Preparing Slide by Cytocentrifugation
TABLE 18-4 Distortions Associated With Cytocentrifugation
Slide Preparations
Study questions
References
Glossary
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R
S
T
U
V
X
Y
Answer Key
Chapter 1
Chapter 2
Case 2-1
Chapter 3
Chapter 4
Chapter 5
Case 5-1
Case 5-2
Chapter 6
Case 6-1
Case 6-2
Chapter 7
Case 7-1
Case 7-2
Case 7-3
Case 7-4
Case 7-5
Case 7-6
Chapter 8
Case 8-1
Case 8-2
Case 8-3
Case 8-4
Case 8-5
Case 8-6
Case 8-7
Chapter 9
Case 9-1
Case 9-2
Case 9-3
Case 9-4
Case 9-5
Case 9-6
Chapter 10
Case 10-1
Case 10-2
Case 10-3
Chapter 11
Case 11-1
Case 11-2
Chapter 12
Case 12-1
Chapter 13
Case 13-1
Case 13-2
Chapter 14
Case 14-1
Case 14-2
Case 14-3
Chapter 15
Case 15-1
Case 15-2
Chapter 16
Case 16-1
Chapter 17
Chapter 18
Appendix A Reagent Strip Color Charts
FIGURE A-1 A, vChem strip. B, vChem 10SG color chart. Do not use this color chart for diagnostic testing; use chart provided with product.
FIGURE A-2 A, Multistix strip. B, Multistix 10SG color chart. Do not use this color chart for diagnostic testing; use chart provided with product.
FIGURE A-3 Manufacturers vary in the proper orientation of the reagent strip to the color chart on the container when reading results. A, vChem 10SG Reagent Strips. B, Multistix 10SG Reagent Strips.
Appendix B Reference Intervals
Urine (Random Specimen) Reference Intervals
Fecal Reference Intervals
Semen Characteristics Associated With Fertility
Amniotic Fluid Reference Intervals
Synovial Fluid Reference Intervals*
Cerebrospinal Fluid Reference Intervals*
Appendix C Body Fluid Diluent and Pretreatment Solutions
Outline
Saline, Isotonic (0.85%) or “Normal Saline”
Saline, Hypotonic (0.30%)
Dilute Acetic Acid (3.0%)
Turk’s Solution2
0.5% Methylene Blue Solution (Used to Prepare Turk’s Solution)
TABLE C-1 Common Uses and Limitations of Diluents
Synovial Fluid Solutions
Hyaluronidase Pretreatment for Synovial Fluid3
0.05% Buffered Hyaluronidase
Hyaluronidase (0.1 g/L) Diluent for Cell Counts in Synovial Fluid2
Semen Solutions
Semen Pretreatment Solutions
A Dilution With Physiologic Solution
Dulbecco’s Phosphate-Buffered Saline (pH 7.4)4
B Digestion With Bromelain
Bromelain Solution (10 IU/mL)4
Semen Diluent for Sperm Counts
References
Index
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R
S
T
U
V
W
X
IFC
Quick Guide to Figures
Blood Cells
Casts
Crystals (according to pH)
Epithelial Cells
Fat
Microorganisms (alphabetical order)
Miscellaneous Elements

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