PERC CLINICAL MICROSCOPY REVIEW MARCH 2013

Lecturer: JUDE ANTHONY C. TRINIDAD, RMT

Part I: SAFETY AND AUTOMATION IN THE CLINICAL LABORATORY

A. Hazard –

Safety Hazard
o Biological
o Sharps Page
o Chemical |1
o Radioactive
o Electrical
o Fire/ explosive
o Physical

Remember:
MSDS -
RACE -
PASS -
B. Automation
Semi automated

Fully automated

PART II: URINALYSIS

A. Renal Physiology
NEPHRON
o functional unit of the kidney
o 1-1.5 million nephron / kidney
o independent from each other

2 TYPES
1. Cortical
 situated in the cortex of the kidney

2. Juxtamedullary
 situated in the medulla

B. URINE
-ultrafiltrate of the plasma

URINE COMPOSITION
 extreme aqueous solution

Influenced by
Dietary intake
Body position
Physical activity
Endocrine function
Body metabolism

URINE TYPES
1. kidney
2. Bladder

RENAL FUNCTIONS

1. RENAL BLOOD FLOW

 Total Renal Blood Flow
 Total Renal Plasma Flow

2. GLOMERULAR FILTRATION
 glomerulus
 factors involved during glomerular filtration
o cellular structure of capillary
o glomerular pressure
o RAAS

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3. TUBULAR REABSORPTION

SUBSTANCE LOCATION
ACTIVE TRANSPORT Glucose, amino acids, salts Proximal Convoluted Tubule
Chloride Ascending Loop of Henle
Sodium Proximal and Distal CT
PASSIVE TRANSPORT Water PCT, Descending Loop of Henle
Collecting Duct
Urea PCT, Ascending Loop of Henle Page
Sodium Ascending Loop of Henle |2

4. TUBULAR SECRETION
2 major functions
1. Elimination of waste products
2. Regulation of acid base balance

RENAL FUNCTION TEST

1. Glomerular Filtration test

Characteristics of Substance to be tested

A. Should not be reabsorbed or secreted
B. Subs must be stable for 24 hours
C. Plasma level should be constant
D. Subs should be available in the body
E. Availability of the test

A.UREA CT
 2hr sample
 earliest clearance test
 problem: reabsorbed by the tubule

B. INULIN CT
 polymer of fructose
 MOST ACCURATE

C. CREATININE CT
 24hr sample
 most SENSITIVE

Formula:
URINEcreatinine X VOLUME X 1.73
BLOODcreatinine A

D. CYSTATIN C CT
 produced by all nucleated cell at constant rate
 indicated to: pediatric patients, elders, DM, Critically-ill

E. BETA-MICROGLOBULIN CT
 most sensitive indicator of a decrease in GFR

2. TUBULAR REABSORPTION TEST

A. Mosenthal test
 uses night and day urine
 specific gravity of night urine will be at least 1.018

B. Fishberg
 patients are deprived of water for 24hr
 abnormal: specific gravity of < 1.025

C.Specific Gravity Determination - ability of the kidney to reabsorb

D.Osmolarity – osmotic pressure of a solution

E.Free Water Clearance - check the response of the kidney if there is body hydration
Formula:
“C”= URINEosm X VOLUME
BLOODosm “
FREE WATER CLEARANCE = VOLUME – “C”

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3. TUBULAR SECRETION TEST

A. Phenosulfonapthalein Excretion Test (PSP)
B. P-aminohippuric acid (PAH)

SPECIMEN COLLECTION

METHODS
1. Midstream Page
2. Catheterized |3
3. Suprapubic Aspiration
4. Glass Technique (3 Glass)
5. Pediatric specimen
6. Drug Specimen Collection

TYPES of SPECIMEN

1. Random/occasional/single
2. First Morning Specimen
3. Timed specimen
 24hr urine
 12hr urine
 2hr urine
 4hr urine
4. Fasting specimen
5. 2hr postprandial urine

SPECIMEN HANDLING
 should be delivered in the lab within 2 hrs
 refrigerated if there will be delay

CHANGES IN UNPRESERVED URINE

ANALYTE CHANGE CAUSE
Color Modified/darkened Oxidation or Reduction
Clarity Decreased Bacterial growth & of amorphous
material
Odor Increased Bacterial multiplication or
breakdown of urea to ammonia
pH Increased Breakdown of urea to ammonia by
urease-producing bacteria/ loss of
CO2
Glucose Decreased Glycolysis and bacterial use
Ketones Decreased Volatilization and bacterial
metabolism
Bilirubin Decreased Exposure to light/ photo oxidation
to biliverdin
Urobilinogen Decreased Oxidation to urobilin
Nitrite Increased Multiplication of nitrate-reducing
bacteria
RBC , WBC and Casts Decreased Disintegration in dilute alkaline
urine
Bacteria Increased Multiplication

URINE PRESERVATIVES
Characteristic of an Ideal Preservative
-inhibit urease
-not bactericidal
-not interfere with chemical analysis
-preserves the elements

1. Physical
a. refrigeration
b. Freezing
2. Chemical
a. Thymol f. Phenol
b. Boric acid g. Commercial preservative tablets
c. Formalin) h. Saccomano’s
d. Toluene
e. Sodium fluoride

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URINALYSIS PROPER

A. PHYSICAL EXAMINATION
I.VOLUME
 depends on the amount of water that the kidney excrete
 depends on the hydration status of the body
 Normal daily urine output:
Oliguria – decrease in urine output
Anuria – Cessation of urine flow Page
Nocturia – increase in nocturnal excretion of urine |4
Polyuria – increase in urine excretion

II. COLOR
PIGMENTS
 Urochrome
 Uroerythrin
 Urobilin
Laboratory Correlations of Urine Color
COLOR CAUSE CLINICAL/ LABORATORY CORRELATIONS
Colorless Recent Fluid Intake Commonly observed with random specimen
Pale Yellow Polyuria or DI Increased 24 hr volume
DM Elevated specific gravity and positive glucose test
Dilute random specimen Recent fluid consumption
Dark yellow Concentrated specimen May be normal after strenuous exercise or in 1 st morning
specimen
Amber Dehydration from fever or burns
Orange Bilirubin Yellow foam when shaken and positive chemical test results
for bilirubin
Acriflavine Negative bile test results and possible green fluorescence
Phenazopyridine (pyridium) Drug commonly administered for urinary tract infections
May have orange foam and thick orange pigment that can
obscure with reagent strip readings
Nitrofurantoin Antibiotic administered for UTI
Phenidione Anticoagulant, orange in alkaline urine, colorless in acid urine
Yellow green Bilirubin oxidized to biliverdin Colored foam in acidic urine and false-negative chemical test
Yellow brown results bilirubin
Green Pseudomonas infection Positive urine culture
Blue-green Amitriptyline Antidepressant
Methocarbamol (Robaxin) Muscle relaxant, may be green-brown
Clorets None
Indican Bacterial infection
Methylene blue Fistulas
Phenol When oxidized
Pink RBC’s Cloudy urine with positive chemical test results for blood and
Red RBC’s visible microspically
Hemoglobin Clear urine with positive chemical test for blood; intravascular
hemolysis
Myoglobin Clear urine with positive chemical test for blood;
Porphyrins Negative chemical test result for blood
Detect with Watson-Schwartz screening test or fluorescence
under ultraviolet light
Beets Alkaline urine of genetically susceptible persons
Rifampin Tuberculosis medication
Menstrual contamination Cloudy specimen with RBCs, mucus, and clots
Brown RBC’s oxidized to Seen in acidic urine after standing; positive chemical test
Black methemoglobin result for blood
Methemoglobin Denatured hemoglobin
Homogentisic acid(alkaptonuria) Seen in alkaline urine after standing
Melanin or melanogen Urine darkens on standing and reacts with nitroprusside and
ferric chloride
Phenol derivatives Interfere with copper reduction test
Argyrols(antiseptic) Color disappears with ferric chloride
Methyldopa or levodopa Antihypertensive
Metronidazole(flagyl) Darkens on standing
III. CLARITY

CLARITY TERM
Clear No visible particle, transparent
Hazy Few particles, print easily seen through urine
Cloudy Many particulates, print blurred through urine
Turbid Print cannot be seen through urine
milky May precipitate or be clotted
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NON PATHOLOGIC CAUSES OF URINE TURBIDITY PATHOLOGIC CAUSES OF URINE TURBIDITY

Squamous epithelial cells RBCs
Mucus WBCs
Amorphous phosphates, carbonates, urates Bacteria
Semen, spermatozoa Yeast
Fecal contamination Non sqaumous epithelial cells
Radiographic contrast media Abnormal cells Page
Talcum powder Lymph fluid |5
Vaginal creams lipids

Laboratory Correlations in Urine Turbidity

SOLUBLE INSOLUBLE IN
WITH HEAT IN DILUTE ACETIC ACID ETHER DILUTE ACETIC ACID

IV. pH
Range:

ACID URINE ALKALINE URINE

Emphysema Hyperventilation
Diabetes mellitus Vomiting
Starvation Renal tubular acidosis
Dehydration Presence of urease-producing bacteria
Diarrhea Vegetarian diet
Presence of acid-producing bacteria(E.coli) Old specimens
High protein diet Proteus infection
Cranberry juice
Medications

Clinical significance
1. Aid in determining acid base disorder
a. Respiratory/ metabolic acidosis
b. Respiratory/ metabolic alkalosis
2. Renal tubular acidosis- defect in renal tubular secretion and reabsorption of acid and bases
3. Renal calculi formation
4. Precipitation/ identification of crystals
5. Determination of unsatisfactory specimens

Method: reagent strip/ litmus paper (found on the last 2 pages)

V. ODOR

Common causes of urine odor

ODOR CAUSE
Aromatic Normal
Foul-ammonia like Bacterial decomposition, UTI
Fruity, sweet Ketones
Maple syrup Maple syrup urine disease
Rancid Tyrosinemia
Sweaty feet Isovaleric academia
Cabbage Methinonine malabsorption
Bleach Contamination
Fecaloid Recto-vesical fistula
Putrid/ extreme foul Necrosis of GUT
Dried Celery odor a-butyric hydroxic acid

VI. SPECIFIC GRAVITY

 measures the concentrating and diluting ability of the kidney
 defined as the density of solution compared with the density of a similar volume of distilled water at a similar temp

Methods:

1. Osmometer
o less accurate
o Disadvantage= requires large volume
o affected by glucose and protein
o Temperature correction is necessary

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2. Refractometer
 uses refractive index
 temperature correction is not necessary
 Calibrators = distilled water
5% NaCl
9% sucrose

3. Harmonic Oscillation Densitometry Page

o used in YELLOW IRIS |6
o principle: frequency of a sound wave entering a solution will change in proportion to the density of the solution

4. Reagent strip (found in the last 2 pages)

5.Falling drop

Pointers
o 1.010 – isosthenuria
o >1.010 – hypersthenuria
o 1.010 - hyposthenuria
o Normal = 1.003 to 1.035

B. CHEMICAL EXAMINATION

I. Protein
 most indicative of renal disease
 normal value: < 10mg/dL or 100mg/24hr
 Consists of low molecular wt proteins that have been filtered by the glomerulus and produced in the GUT.
 proteins found in the urine
o Albumin
o Serum/ tubular macroglobulin
o Tamhorsfall
o Proteins from prostatic, seminal and vaginal secretions

Clinical Significance
PROTEINURIA (≥ 30mg/dL)
Old Classification
a. Physiologic or functional or transient
b. Cadet/cyclic/postural/orthostatic
c. Lordotic
d. Accidental/false/pseudoproteinuria
e. True renal, Pathologic

New Classification
a. Pre Renal
o condition affecting the plasma prior to its reaching the kidney
o Transient, caused by increased level of low molecular weight plasma proteins such as hemoglobin,
myoglobin,mucoproteins and acute phase reactants
o not usually discovered in routine urinalysis

Example: Bence Jones in Multiple Myeloma

Plasmacytic Leukemia
Macroglobulinemia
Malignant lymphoma

b. Renal
o associated with true renal disease
o results of either glomerular or tubular damage

Glomerular Proteinuria
 glomerulus is damaged
 some cases: amyloid material, toxic substances, and immune complexes

Tubular Proteinuria
o filtered substances can no longer be reabsorbed
o causes: exposure to toxic substance
Fanconi Syndrome
Heavy metals
severe viral infections
Microalbuminuria
 increased risk of cardiovascular disease and diabetic nephropathy
 reported as albumin/24hr or AlbuminExcretion Ratio (AER) in ug/min
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 Significant if 30-300mg of albumin/24hr or AER = 20-200ug/min

c. Post Renal
o addition of protein as it passes through the structures of the low GUT
o bacterial/ fungal infections
o Contamination of blood, large amount of spermatozoa and prostatic fluid

Methods Page
1. Reagent strip |7
2. SSA

GRADE TURBIDITY PROTEIN RANGE (mg/Dl)

Negative No increase in turbidity
Trace Niticeable turbidity
1+ Distinct turbidity with no
granulation
2+ Turbidity with granulation with no
flocculation
3+ Turbidity with granulation and
flocculation
4+ Clumps of protein

II. Glucose
o most frequent chemical analysis performed in urine
o DM monitoring
o Threshold: 160 – 180 mg/dL

Clinical Significance
o almost all filtered glucose are reabsorbed in Proximal Convoluted tubule
o fasting sample

Summary of Clinical Significance of Urine Glucose

Hyperglycemia-Associated Renal-Associated
DM Fanconi syndrome
Pancreatitis Advanced Renal Disease
Pancreatic cancer Osteomalacia
Acromegaly Pregnancy
Cushing syndrome
Hyperthyroidism
Pheochromocytoma
Central nervous System damage
Stress
Gestational Diabetes

Methods
1. Reagent strip
2. Copper Reduction Test
o earliest chemical test performed on urine
o principle: ability of the glucose to reduce copper sulphate to cuprous oxide
o Reagents: copper sulphate, sodium carbonate, sodium carbonate, sodium citrate, and sodium Hydroxide
o blue to green, yellow, and orange/red
o pass through (>2g/dL)

Glucose Oxidase vs Clinitest

Glucose Oxidase
Clinitest Interpretation
Small amount is present
Possible oxidizing agent, interference on reagent strip
Non glucose reducing substance
Possible interfering susbstance for reagent strip

III. Ketones
product of fat metabolism

B-hydroxy butyric acid ↔ acetoacetic acid → acetone

Clinical Siginificance
a. Diabetic acidosis
b. Insulin dosage monitoring
c. Starvation
d. Malabsorption/ pancreatic disorders
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e. Strenuous exercise
f. Vomiting
e .Inborn errors of amino acid metabolism

Methods
1. Reagent strip
2. ACETEST – Sodium nitroprusside, glycine, disodium phosphate and lactose

Page
IV. Blood |8

o Intact RBC
o Hemoglobin
o Myoglobin

Clinical Significance
HEMATURIA MYOGLOBINURIA HEMOGLOBINURIA
Renal calculi Muscular trauma/ crush syndromes Transfusion Reactions
Glomerulonephritis Prolonged coma Hemolytic anemias
Pyelonephritis Convulsions Severe burns
Tumors Muscle-wasting diseases Infection/ malaria
Trauma Alcoholism/ overdose Strenuous exercise/ red blood cell
trauma
Exposure to toxic chemicals Drug abuse Brown recluse spider bites
Anticoagulants Extensive exertion
Strenuous exercise
Cholesterol-lowering stain
medications

Methods
1. Blondheim’s Test
2.8 g of ammonium sulphate + 5ml urine –centrifuged/filtered→ supernatant (used in the reaction)
2. Reagent strip

V. Bilirubin
o provide an early indication of liver disease
o detected long before the development of jaundice
o yellow compound
o degradation product of haemoglobin

Clinical Significance
o Hepatitis
o Cirrhosis
o Biliary Obstruction

Methods:
1. Reagent strip
2. ICTOTEST

VI. Urobilinogen
o Urobilin
o Normal < 1ug/dL or Ehrlich unit
o 2 to 4pm

Clinical Significance
o Early detection of liver disease
o Liver disorders, hepatitis, cirrhosis, carcinoma (increased values)
o Hemolytic disorders

Urine bilirubin and Urobilinogen in Jaundice

URINE BILIRUBIN URINE UROBILINOGEN
Bile duct obstruction
Liver damage
Haemolytic disease

Methods:
1. Ehrlich Tube Test
o Ehrlich reagent + Urine + Na Acetate → Red (+)

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2. Watson-Schwartz Differentiation Test

o Classic method of differentiating urobilinogen, porphobilinogen and Ehrlich reactive substances
INTERPRETATION
UROBILINOGEN OTHER EHRLICH- PORPHOBILINOGEN Page
REACTIVE SUBSTANCES |9
Chloroform Extraction
Urine (top) Colorless Red Red
Chloroform(bottom) Red Colorless Colorless
Butanol Extraction
Butanol(top) Red Red Colorless
Urine(bottom) Colorless Colorless Red

3.Hoesch Test
o Rapid screening test for porphobilinogen (≥2mg/dL)
o 2 drops of urine + Hoesch rgt → red (+)

VII. Nitrite
o rapid screening test for UTI
o designed to detect cases in which the need of culture may not be apparent
o Valuable in detecting initial bladder infection

Greiss reaction – nitrite at an acidic pH reacts with an aromatic amine to form a diazonium compound

VIII. Leukocyte esterase test

o neutrophils = most common WBC in the urine
o with esterases = neutrophils, monocytes, eosinophils, and basophils
o others: Trichomonas, histiocytes

Other Chemical Constituents/metabolites of Urine

1. Serotonin (5-HIAA)
2. 17-ketosteroid
3. 17-hydroxycorticosteroids
4. Catecholamine
5. Indican
6. Melanin
7. Sulfonamides
8. Porphyrin
9. Hemosiderin

C. MICROSCOPIC EXAMINATION

A. Sediment Stains
o increases the over-all visibility of sediment element being examined using brightfield microscopy by changing their
refractive index
STAIN ACTION FUNCTION
Sternheimer-Malbin Delineates structure and contrasting Identifies WBCs, epithelial cells and
colors of the nucleus and cytoplasm casts
Toluidine Blue Enhances nuclear detail Differentiates WBCs and RTE
2% Acetic acid Lyses RBC and enhances nuclei of Distinguishes RBCs from WBCs,
WBCs yeast, oil droplets, and crystals
Lipid stains: Oil Red O, SudanIII Stains TG and neutral fats orange- Identifies free fat droplets and lipid-
red containing cells and casts
Gram Stain Differentiates gram positive from Identifies bacterial casts
gram negative bacteria
Hansel Stain Methylene blueand eosin Y stains Identifies urinary eosinophils
eosinophilic granules
Prussian Blue Stain Stains structure containing iron Identifies yellow-brown granules of
hemosiderin in cells and casts

B. Urinalysis Microscopic techniques

TECHNIQUE
Bright-field microscopy
Phase-contrast microscopy
Polarizing microscopy
FUNCTION
For routine urinalysis
Enhances visualization of elements with low refractive indices such as hyaline
casts, mixed cellular casts ,mucous threads and Trichomonas
Aids in the identification of cholesterol in oval fat bodies, fatty casts and crystals
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Dark-field microscopy Aids in the identification of Treponema pallidum

Fluorescence microscopy
Interference-contrast
C. SEDIMENT CONSTITUENTS
Allows visualization of naturally fluorescent microorganisms or those stained by a
fluorescent dye
Produces a three-dimensional microscopy-image and layer-by-layer imaging of a
specimen

1. RBC
o reported as the average number seen in 10 HPFs Page
| 10
o confused with:
o Yeast cells
o oil droplet
o air bubbles
o calcium oxalate crystals

Clinical significance: Bleeding, renal calculi, damage to glomerular membrane

2. WBC
o reported as the average number seen in 10 HPFs
o neutrophils = most common
o larger than RBC

3. Epithelial Cells
Typesaccording to site of origin
a. Squamous epithelial cells

b. Transitional EC

c. RTE

4.Bacteria
5.Yeast
6.Parasites
7.Spermatozoa
8.Mucus
9.Casts

Types
a. Hyaline cast
 most frequently seen/prototype of all casts
 ↑during strenuous exercise, dehydration, heat exposure and emotional stress
 glomerulonephritis, Pyelonephritis, Chronic renal disease, and congestive heart disease

b. RBC cast
c. WBC cast
d.Bacterial cast
e.Epithelial cast
f. Fatty cast
g.Coarse/Fine granular Cast
h.Waxy Cast
i.Broad cast

9. URINARY CRYSTALS

Normal Urinary Crystals

CRYSTAL pH COLOR SOLUBILITY
Uric acid Acid Yellow-brown Alkali soluble
Amorphous urate Brick dust or yellow brown Alkali and heat
Calcium oxalate Acid/neutral Colorless Dilute HCl oval

Amorphous Alkaline/neutral White-colorless Dilute acetic acid

phosphate
Calcium Phosphate Colorless Dilute acetic acid
Triple phosphate Alkaline Colorless Dilute acetic acid
Ammonium biurate Yellow-brown Acetic acid with
heat
Calcium carbonate Colorless Gas from acetic
acid

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ABNORMAL CRYSTALS
Page
CRYSTAL Ph COLOR SOLUBILITY | 11
Cystine Acid Colorless Ammonia, dilute HCl
Cholesterol Acid Colorless chloroform
Leucine Acid/ Neutral Yellow Hot alkali or alcohol
Tyrosine Acid/neutral Colorless-yellow Alkali or heat
Bilirubin Acid Yellow Acetic acid, HCl, NaOH,
ether, chloroform
Sulfonamides Acid/neutral Varied Acetone
Radiographic dye acid Colorless 10% NaOH
Ampicillin Acid/ Neutral Colorless Refrigeration forms
bundles

URINARY SEDIMENTS ARTIFACTS

a. Starch
b. Oil droplets
c. Air bubbles
d. Pollen grains
e. Hair and fibers
f. Fecal contamination

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 PERC
GLOMERULAR, TUBULAR AND INTERSTITIAL DISORDERS
DISORDER
Acute golerulonephritis
Rapidly progressive
glomerulonephritis
Goodpasture syndrome
Henoch-Schonlein purpura
Wegener’s granulomatis
Membranous
glomerulonephritis
Membranoproliferative
golmerulonephritis
Chronic
Glomerulonephritis
IgA nephropathy
Nephrotic syndrome
Minimal Change Disease
Focal segemental
glomerulosclerosis
Alport Syndrome (early
stages) (late stages)
Acute tubular Necrosis
Fanconi Syndrome
Nephrogenic Diabetes
Insipidus
Renal Glucosuria
Cystitis
Acute Pyelonephritis
Chronic Pyelonephritis
Acute Interstitial Nephritis
CLINICAL MICROSCOPY REVIEW
ETIOLOGY
Deposition of immune complexes,
formed in conjunction with group
A Streptococcus infection, on
glomerular membranes
Deposition of immune complexes
from systemic immune disorders
on the glomerular membrane
Attachment of a cytotoxic antibody
formed during viral respiratory
infections to glomerular and
alveolar basement membranes
Occurs primarily in children
following viral respiratory infection
Antineutrophilic cytoplasmic auto-
antibody binds to neutrophils in
vascular walls producing damage
to small vessels in the lungs and
glomerulus
Thickening of the glomerular
membrane following IgG Immune
complexes depositon associated
with systemic disorders
Cellular proliferation affecting the
capillary walls or the glomerular
basement membrane, possibly
immune-mediated
Marked decrease in renal function
resulting from glomerular damage
precipitated by other renal
disorders
Deposition of IgA on the
glomerular membrane resulting
from increased levels of serum IgA
Disruption of the electrical charges
that produce the tightly fitting
podocyte barrier resulting in
massive loss of protein and lipids
Disruption of the podocyte
occurring primarily in children
following allergic reactions and
immunizations
Disruption of podocyte in certain
areas of glomeruli associated with
heroin and analgesic abuse and
AIDS
Genetic disorder showing
lamellated and thinning of
glomerular basement membrane
Damage to therenal tubular cells
caused by ischemia or toxic agents
Inherited in association with
cystinosis and Hartnup disease or
acquired through exposure to toxic
agents
Inherited defect of tubular
response to ADH or acquired from
medications
Inherited autosomal recessive trait
Ascending bacterial infection of
the bladder
Infection of the renal tubules and
interstitium related to
interference of urine flow to the
bladder, reflux of urine from the
bladder, and unrelated cystitis
Recurrent infection of renal
tubules and interstitium caused by
structural abnormalities affecting
the flow of urine
Allergic Inflammation of renal
MARCH 2013
CLINICAL COURSE Page
Rapid onset of hematuria and edema
Permanent renal damage seldom occurs
| 12
Rapid onset with glomerular damage and possible
progression to end-stage renal failure
Hemoptysis and dyspenea followed by hematuria
Possible progression to end-stage renal failure
Initial appearance of purpura followed by blood in
sputum and stools and eventual renal involvement
Complete recovery is common, but may progress to
renal failure
Pulmonary symptoms including hemoptysis develop first
followed by renal involvement and possible progression
to end-stage renal failure
Slow progression to the nephrotic syndrome or possible
remission
Slow progression to chronic glomerulonephritis or
nephritic syndrome
noticeable decrease in renal function progressing to
renal failure
Recurrent macroscopic hematuria following exercise
with slow progression to chronic glomerulonephritis
Acute onset following systemic shock
Gradual progression from other glomerular disorders
and then to renal failure
Frequent complete remission following corticosteroid
treatment
May resemble nephrotic syndrome or minimal change
disease
Slow progression to nephrotic syndrome
Acute onset of renal dysfunction usually resolved when
the underlying cause is corrected
Generalized defect in renal tubular reabsorption
requiring supportive therapy
Requires supportive therapy to prevent dehydration
Benign disorder
Acute onset of urinary frequency and burning resolved
with antibiotics
Acute onset of urinary frequency, burning, and lower
back pain resolved with antibiotics
Frequently diagnosed in children; requires correction of
the underlying structural defect
Possible progression to renal failure
Acute onset of renal dysfunction often accompanied by a
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interstitium in response to certain skin rash

medications Resolves following discontinuation of medication and
treatment with corticosteroids

URINE SCREENING FOR METABOLIC DISORDER

Page
 OVERFLOW
| 13
 RENAL DISORDER

A. Amino Acid Disorders

a. Phenylalanine – tyrosine disorders
1. Phenylketonuria
Tests: Ferric Chloride test
Phenistix
Guthrie Bacterial Inhibition test
DNPH
2. Tyrosyluria
Tests: DNPH
Millon’s test
Nitrosonaphthol test
Ferric Chloride test
Phenistix
3. Melanuria
Tests: Sodium Nitroprusside test
Ferric Chloride Test
Acetest
Ehrlich’s test
Wanger test
4. Alkaptonuria
Tests: ferric chloride test
Alkali test
Addition of Silver Nitrate or ammonium hydroxide
Benedict’s
b. Branched Amino Acid Disorders
1. Maple Syrup Urine Disease(LIV)
Tests: DNPH
Actest
Nitrosonaphthol
Amino acid Chromatography
Ferric Chloride test

2. Organic Acidemias
2.a Isovaleric
2.b Propionic Acidemia
2.c Methylmalonic Acidemia
c. Tryptophan Disorders
1. Indicanuria
2. Hartnups
3. 5-HIAA
d.Cystine disorders
1. Cystinuria (LOCA)
2. Cystinosis
3. Homocystinuria

B.Mucopolysccharide disorders
Hurler’s tests: Acid albumin
Hunter’s CTAB turbidity test
San Filippo Metachromatic Staining Spot test

C. Purine Disorders
Lesh-Nyhan Disease

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PART 2: OTHER BODY FLUIDS

Page
I.CEREBROSPINAL FLUID | 14
 produced in the choroid plexuses
 3rd major fluid of the body
 Functions
o Physical support
o Protection against sudden changes in venous and arterial blood pressure
o Excretory waste function

 Specimen collection
Lumbar puncture
20ml normally removed; 90-180mmHg
Tube 1
Tube2
Tube3

 Gross Examination
o Crystal clear, colorless, and has a viscosity similar to water
o oily
o viscous
o Xanthochromic
o Turbid
-
 Xanthochromia
o describes CSF supernatant that is pink, orange, or yellow

 Total Cell count

+normal adult CSF contains 0-5 WBCs/uL; neonates: 0-30
+clear specimen may be counted undiluted
+dilutions: normal saline
+counted on 4 corner squares and the center square on both sides of the hemocytometer

 WBC count
+3% glacial acetic acid
+methylene blue: enhances differentiation between mononuclear and neutrophils

Correction for contamination

+to correct for WBCs and protein artificially introduced into the CSF as a result of a traumatic tap

WBC (added) = WBC (blood) x RBC (CSF)

RBC (blood)

 Sample Dilution method

CLARITY DILUTION
Slightly hazy 1:10
Hazy 1:20
Slightly cloudy 1:100
Slightly bloody 1;200
Cloudy, bloody,turbid 1:1000

 Cells found in CSF

o lymphocytes:monocytes
o Neutrophils
o Blastforms
o Plasma cells
o Macrophages
o Ependymal, Choroidal, and spindle –shaped cells
o malignant cells

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 Chemistry Test

1. CSF protein
 most frequently performed chemical test on CSF
 normal value: 15 to 45 mg/dL
a. Protein Fractions
-CSF/ serum albumin index Page
| 15
CSF/SERUM ALBUMIN INDEX = CSF ALBUMIN (mg/dL)
SERUM ALBUMIN(g/dL)

IgG Index
IgG INDEX = CSF IgG (mg/dL) / SERUM IgG (g/dL)
CSF ALBUMIN (mg/dL) / serum albumin (g/dL)

b. Electrophoresis
 for the detection of oligoclonal bands representing inflammation within the CNS
 useful in the diagnosis of leukemia, lymphoma, viral infections, multiple sclerosis etc

c. Myelin Basic Protein (MBP)

 presence of MBP in CSF is indicative of recent destruction of the myelin sheath that
 Protects axons of the neurons (demyelination)

PROTEINS FRACTIONS OF CSF

1. Albumin

2. Prealbumin

3. Alpha globulin

4. Transferrin

5. Gamma globulin

TESTS FOR PROTEIN CSF

Turbidimetry nephelometry dye binding method Biuret reaction
SRoss-Jones None-Appelt Pandy reaction Lange Colloidal

TESTS FOR TB MENINGITIS

Levinsion tryptophan Adenosine Deaminase

2. CSF GLUCOSE
 60 – 70% of the plasma concentration
 decrease in patients with bacterial, tubercular, and fungal meningitis

 PRECAUTIONS FOR ACCURATE EVALUATION OF CSF GLUCOSE

a. Run a blood glucose for comparison
b. Blood glucose should be drawn about 2 hrs prior to spinal tap to allow time of equilibration between the bloods
and the fluid
c. CSF glucose is analyzed using the same procedures employed for the blood glucose
d. STAT

3. CSF LACTATE
4. CSF GLUTAMINE
5. CK BB Isoenzyme
6. CHLORIDES

 MICROBIOLOGY TESTS
1. Gram Stain
 Accurate, rapid method
 Classic starburst pattern: Cryptococcus neoformans
 Organisms most commonly encountered
o Group B streptococcus
o N. meningitides
o S. pneumonia
o E. coli
o H. influenza

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o L. monocytogenes
o Staphylococcus species/ Propionebacterium species

2. Limulus Lysate Test

+Very accurate for the presence of endotoxin
+Regt: horse shoe crab (Limulus polyphemus)
+Incubated within 1 hr at 37 degrees C

3. India Ink Preparation Page

II.SYNOVIAL FLUID (joint fluid) | 16
 Synovium – refers to the tissue lining synovial tendon sheaths, bursae, and diarthrodial joints except for the articular surface
 Synovial Fluid
o an imperfect ultrafiltrate of the plasma combined with hyaluronic acid

 Specimen Collection: Arthrocentesis

Tube 1
Tube 2
Tube 3

 NORMAL SYNOVIAL VALUES

VOLUME <3.5 ml
COLOR PALE YELLOW
CLARITY CLEAR
VISCOSITY ABLE TO FORM A STRING 4-6cm
ERYTHROCYTE COUNT <2000CELLS/Ul
WBC COUNT <200CELLS/Ul
NEUTROPHILS <20% OF THE DIFFERENTIAL COUNT
LYMPHOCYTES <15% OF THE DIFFERENTIAL
MONOCYTES 65% OF THE DIFFERENTIAL
CRYSTALS NONE PRESENT
GLUCOSE <10mg/Dl
LACTATE <250MG/DL
TOTAL PROTEIN <3G/DL
URIC ACID EQUAL TO BLOOD VALUE
FIBRINOGEN AND GLOBULIN LOW

 APPEARANCE AND VISCOSITY

o Deeper yellow
o Greenish
o Traumatic aspiration
o Turbid
o Milky

 Rope Test/ Mucin Clot test

 Measurement of the degree
 Reagent: 2-5% acetic acid

 CLASSIFICATION AND PATHOLOGIC SIGNIFICANCE OF JOINT DISORDERS

GROUP CLASSIFICATION PATHOLOGIC SIGNIFICANCE

I.NON INFLAMMATORY Degenerative joint disorders
II.INFLAMMATORY Immunologic problems, including rheumatoid arthritis and
Lupus Erythematosus
Crystal-Induced gout and pseudo gout
IIISEPTIC Microbial infection
IV.HEMORRHAGIC Coagulation disorders

 CELL COUNTS
 Very viscous fluid may need to be pre-treated by adding a pinch of hyaluronidase
 cell counts <200 cells/L are considered normal
 Diluents: normal saline hypotonic saline

 OTHER CELLS
o LE cells neutrophil containing characteristic ingested “round body”
o Reiter cell vacuolated macrophages with ingested neutrophil
o RA cell/ragocyte neutrophils with small, dark, cytoplasmic granules that contains precipitated rheumatoid factor
o Cartilage cell large, multi nucleated cell

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o Rice bodies resembles polished rice, collagen and fibrin

o Fat droplets
o Hemosiderin
 CRYSTAL IDENTIFICATION
o Monosodium urate
o Calcium pyrophosphate
o Hydroxyapatite
o Cholesterol crystals
o Corticosteroids Page
o Calcium oxalate | 17
 CHEMICAL ANALYSIS
o Glucose determination
o Lactate levels

 MICROBIOLOGY TESTS
o Hemophilus
o Neisseria gonorrhoea

III. SEMEN
SEMEN COMPOSITION

 SPECIMEN COLLECTION
 Majority of the sperm are contained in the first portion of ejaculate
 Sexual abstinence of from 2 to 3 days to not longer* than 5 days
 time of specimen collection and specimen receipt is recorded
 2 or 3 samples are usually tested at 2-week intervals, with 2 abnormal samples considered significant
 should be kept at 37 degrees C

 Methods: masturbation
Common condom collection
Aspiration of seminal fluid from the vaginal vault after coitus

 Terms:
 aspermia
 Azospermia
 Necrospermia
 Oligospermia

 SEMEN ANALYSIS
1. Appearance
Gray
Red
Yellow
Turbid
2. Liquefaction
Within 30 – 60 minutes after collection
3. Volume
NV: 2-5ml
4. Viscosity
Pours in droplets, easily be drawn in pipettes
5. pH
7.2-8.0
6. Sperm Concentration
20 – 160 million/mL
Diluting fluids: cold water, formalin, sodium bicarbonate, 0.5% in Chlorazene
Improved Neubauer Counting Chamber, Makler Counting Chamber(for undiluted sx, heat)
Using 5 RBC squares no. Of sperm counted X 1million = sperms (millions)/mL
Using 2 wbc squares no. Of sperm counted X 100,000 = sperms (millions)/mL

7.Motility
> 50% motile
Grade
4.0 - rapid motility
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3.0 – slower speed, some lateral movement

2.0 – slow, forward progression plus lateral movement
1.0 – no forward progression
0 - no movement at all

8.Sperm Morphology
 At least 200 sperm should be evaluated and the percentage of abnormal sperm reported
 Routine criteria: >30% normal morphology
 Kruger’s Strict Criteria: >14% normal morphology Page
| 18
 Stains:
o Giemsa
o Wright’s
o Papanicolau’s

o Other Tests
o Calculation of Round Cells
C=NXS N-number of spermatids or neutrophils counted per 100 mature sperm
100 S-Sperm concentration in millions / mL
o Fructose Test
o Florence Test
o Barbiero’s
o Spinbarkeit
o Sim Huhner
o Sperm Viability

o Mixed Agglutination Reaction (MAR)

o detects presence of immunoglobulin (IgG)
o incubated with AHG

o Immunobead test
o more specific procedure
o demonstrates what area of the sperm the autoantibodies are affecting

o Post Vasectomy Semen Analysis

o specimens are routinely tested at monthly intervals, beginning at 2 months post vasectomy and continuing until
2 consecutive monthly specimen show no spermatozoa

IV. SEROUS FLUID

Parietal membrane – lines cavity wall

Visceral membrane – covers the organs within the cavity
Serous fluid – fluids between the membranes
Mesothelium- lining epithelium of the serous membranes

 FORMATION
o formed as an ultra filtrate of plasma, with no additional material contributed by the mesothelial cells that lines
Membrane
o Effusion: disruption of the mechanisms of serous fluid formation and reabsorption causes an increase in fluid between
the membranes

 Specimen Collection
o Thoracentesis
o Pericardiocentesis
o Paracentesis

 Transudates and Exudates

o Transudates
 effusion that form because of a systemic disorder that disrupts the balance in the regulation of fluid filtration
and reabsorption
 not NECESSARY to test

o Exudates
 produced by conditions that directly involve the membranes of the particular cavity
 WBC > 1000/L and RBC >1000, 000/L are indicative of an EXUDATES

TRANSUDATES EXUDATES
Appearance Clear Cloudy
Fluid: Serum protein ratio <0.5 >0.5
Fluid: Serum LD ratio <0.6 >0.6
WBC count <1000/uL >1000/uL

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Spontaneous clotting No Possible

Pleural Fluid cholesterol <45-60 mg/dL >45-60 mg/dL
Pleural Fluid: Serum cholesterol ratio <0.3 >0.3
Pleural Fluid: Bilirubin ratio <0.6 >0.6
Serum-ascites albumin gradient >0.11 <0.11

 RIVALTA’S test/ Serosa Mucin Clot Test

Acetic acid + water + unknown fluid
Positive: heavy precipitation Page
| 19

 Pleural Fluid
o differentiates between a hemothorax and hemorrhagic exudates
o hemothorax = fluid hematocrit is more than 50% of the whole blood hematocrit

o Correlation of Pleural Fluid Appearance and Disease

APPEARANCE DISEASE
Clear, pale yellow normal
Turbid, White Infection
Bloody Hemothorax
Hemmorhagic effusion, Pulmonary embolis, TB
Malignancy
Milky Chylous material from thoracic duct leakage
Pseudochylous material from chroic inflammation
Brown Rupture of amoebic abscess
Black Aspergillous
Viscous Malignant mesothelioma

 Chylous vs. Pseudochylous Pleural Effusion

CHYLOUS EFFUSION PSEUDOCHYLOUS EFFUSION
CAUSE Thoracic duct leakage Chronic inflammation
APPEARANCE Milky/ white Milky/ green tinge
LEUKOCYTES Predominantly lymphocytes Mixed cells
CHOLESTEROL CRYSTALS Absent Present
TRIGLYCERIDES >110 mg/dL <50 mg/dL
SUDAN III STAINING Strongly positive Negative/ weakly positive

 Chemistry tests
o Glucose
o pleural fluid lactate levels
o pleural fluid pH
o pleural fluid amylase
o Adenosine deaminase(ADA)

 Pericardial Fluid
 lubricant for the movement of the heart
 found in small quantities

 Appearance
o Normal/ transudate
o Grossly bloody
o Milky

 Peritoneal fluid
o accumulation of fluid in peritoneal cavity = ascites

o Ascitic fluid
 transudative effusions
 exudative fluids

o serum:ascites albumin gradient

COLOR
Clear and Pale yellow Normal
Turbid Bacterial or fungal infections
Green or dark brown Bile: confirmed using standard chemical test for bilirubin
Blood-streaked Trauma with TB
Intestinal disorders, and malignancy
Chylous or Pseudochylous Trauma or blockage of lymphatic vessels
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V. AMNIOTIC FLUID

 formed from the metabolism of fetal cells and fetal urine

 Amnion – membranous sac that surrounds the fetus
 during the first trimester: approx. 35 ml derived from maternal circulation
 after the 1st trimester: fetal urine is the major contributor to the amniotic volume
Page
| 20

 Functions
o Provide a protective cushion for the fetus
o Allow fetal movement
o Stabilize the temperature to protect the fetus from extreme temperature changes
o To permit proper lung development

o Tests for Fetal well-Being and Maturity

NORMAL VALUES
TEST AT TERM SIGNIFICANCE
Blirubin scan ∆ A450 > 0.025 Haemolytic disease of the newborn
Alpha-fetoprotein <2.0 MoM Neural tube disorders
Lecithin- Sphingomyelin ratio ≥2.0 Fetal Lung Maturity
Amniostat-fetal lung Maturity Positive Fetal Lung Maturity/phosphatidyl glycerol
Foam Stability index ≥47 Fetal Lung Maturity
Microviscosity (FLM-TDx) ≥55mg/g Fetal Lung Maturity
Optical density 650 nm ≥0.150 Fetal Lung Maturity
Lamellar Body Count ≥ 32,000/ml Fetal Lung Maturity

o Volume
o Balance between
+production of fetal urine and lung fluid
+absorption from fetal swallowing and intramembranous flow
o Polyhydramnios
o Oligohydramnios

o Chemical Composition
+similar to that of the maternal plasma
+contains small amount of sloughed fetal cells from the skin, digestive system, and urinary tract
+creatinine has been used to determine fetal age

o Differentiating Maternal Urine from Amniotic Fluid

+Determine possible premature membrane rupture (PROM) or accidental puncture of the maternal bladder during
specimen collection
>creatinine does not exceed 3.5 mg/dL
>urea does not exceed 30mg/dL
>fern Test

o Specimen Collection
method: amniocentesis (most frequently performed)is a transabdominal amniocentesis
-2nd trimester – for assessment of genetic defects (Down Syndrome)
-3rd trimester – assessment of fetal pulmonary maturity or fetal haemolytic disease
o Specimen Handling and Processing
+FLM tests
>should be placed in ice for delivery to the laboratory and refrigerated up to 72 hours prior to testing
Or kept frozen and tested within 72 hours

o Amniotic fluid color

Colorless
Blood-streaked
Yellow
Dark green
Dark red-brown

o Neural Tube Disorders

>anencephaly
>spina bifida
>multiple pregnancy
o Tests for Fetal Maturity
+Lecithin-Sphingomyelin ratio
Prior to 35 weeks gestation
- L/S ratio is usually < 1.6 because large amounts of lecithin are not being produced at this time

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-will rise to 2.0 or higher when lecithin production increases to prevent alveolar collapse
-threfore, when L/S ratio reaches 2.0, pre term delivery is usually considered to be a relatively
safe procedure

+Phosphatidyl glycerol immunoassay

-Amniostat FLM
-not affected by meconium and blood

+Foam Test or “shake test” Page

>fluid + 95% ETOH, shaken for 15 seconds, and allowed to sit undisturbed for 15 minutes | 21
>Positive result: continuous line of bubbles around the outside edge
>indicates that a sufficient amount of phospholipid even in the presence of alcohol(antifoaming)

+Microviscosity: Fluorescence Polarization Assay

>presence of phospholipids decreases the microviscosity of the amniotic fluid
>Dye bound to surfactant has a longer fluorescence lifetime and exhibits low polarization
Dye bound to albumin has a decreased fluorescence lifetime and has high polarization

+Lamellar Bodies and Optical Density

>the number of lamellar bodies present in the amniotic fluid correlates with the amount of phospholipids
Present in the fetal lungs
>an OD of 0.150 = correlates well with an L/S ratio of ≥ to 2.0 and presence of phosphatidyl glycerol

o ASSESSMENT OF HDN
+increased optical density at 45o nm
+OD plotted in Liley Graph
+Liley graph plots the change in OD at 450nm versus gestational age in weeks
ZONE 1 observe fetus for stress
ZONE 2 moderate diseases
ZONE 3 Severe problems

VI. FECALYSIS

Diarrhea
+an increase in daily stool weight above 200 g with increased liquidity and frequency of more than 3x/day
>less than 4 weeks is defined as acute
>more than 4 weeks is termed as chronic

Major Mechanisms
Secretory Override the reabsorptive ability of the large intestine
Enterotoxin-producing organisms
Drugs, stimulant laxatives, hormones, inflammatory bowel disease, endocrine disorders
Osmotic Incomplete breakdown or reabsorption of food presents increased fecal material to the large
intestine, resulting in the retention of water and electrolytes in the large intestine
Maldigestion (impaired digestion of food) and malabsorption (impaired absorption of nutrients
by the intestines)
Presence of unabsorbable solute increases the stool osmolality and the concentration of
electrolytes is lower, resulting in an increased osmotic gap
Altered motility Enhanced motility (hypermotility) or slow motility(constipation)

Macroscopic Screening
+Color
-Intestinal oxidation of stercobilinogen to urobilin
-pale stool
*hematochezia
-frank blood
-lower GI bleeding
*melena
-tarry stool
-Upper GI bleeding
+Consistency
-rice water stool – cholera
-pea soup stool – Typhoid
-Butter like – cystic fibrosis (thick mucus)
-scybalous/ goat droppings – constipation

Microscopic Examination of Feces

+Leukocytes
-seen in the feces in conditions that affect the intestinal mucosa

+Muscle fibers
-undigested striated muscle fibers
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-monitoring of patients with pancreatic insufficiency

+Qualitative Fecal Fats

-monitors px undergoing treatment for malabsorption disorders
-staining with dyes Sudan III, Sudan IV or Oil Red O
- >60 droplets/HPF = can be indicative of steatorrhea

+Quantitative Fecal Fats

-Near Infrared Reflectance Spectroscopy (NIRA) Page
-requires a 48 – 72 hour stool collection | 22
-Van de Kamer

+Occult Blood testing (Hidden Blood)

-Pseudoperoxidase activity of blood (blue)
-bleeding in excess of 2.5ml/150g of stool is considered pathologically significant
-2 samples from 3 different stools should be tested before a negative result is confirmed
-patients should avoid eating red meats, horseradish, melons, raw broccoli, cauliflower, radishes and
Turnips for 3 days prior to specimen collection (false positive)
-Vitamin C (false negative)
-methods
>benzidine
>ortho-tolidine
>gum guaiac

+APT test (fetal haemoglobin)

-distinguishes maternal haemoglobin AS, CS and SS, and fetal haemoglobin
-use 1% NaOH = added to haemoglobin-containing emulsions
-alkali resistant fetal haemoglobin (pink) maternal haemoglobin not alkali resistant (yellow brown)

+Carbohydrates
-most valuable in assessing cases of infant diarrhea and may be accompanied by pH determination
-normal stool ph 7 and 8, dec. In CHO disorders (inc. Lactic acid)
-copper reduction test
-0.5 g/dL is considered indicative of CHO intolerance

VII. SWEAT

-test: Iontophoretic sweat test

-to diagnose cystic fibrosis (mucoviscidosis)
> autosomal recessive inherited disease that affects the exocrine glands and causes electrolyte and mucous
abnormalities

VIII. GASTRIC FLUID

o Composition: 99% water, 1% solid

+0.2 – 0.4% HCl – production by the parietal cells (oxyntic cells), for the activation of pepsinogen
>Gastrin – hormone stimulating secretion of HCl
>Zollinger - Ellison = high secretion of gastrin due to gastrin-secreting tumor of the pancreas
+digestive enzymes – produced by the chief cells
>pepsin – protein
>lipase – fats
>rennin – to curdle milk
+electrolytes
+Mucin
+Intrinsic factor of Castle

o Collection: Intubation
*specimens are collected at 15 mins interval for 1hr
Ewald’s or Boa’s
Levin tube – nose
rehfus – mouth

o Stimulants
+pentagastrin
+histalog – when used, collection must continue for 2 hours because maximum output is delayed
+histamine

o Test meals
Ewald’s – bread and tea or water
Boa’s – oat meal
Riegel – beef steak and mashed potatoes

o Ratio BAO/MAO
BAO BAO/MAO
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Normal 2.5 10%

Pernicious Anemia 0 0
Gastric Carcinoma 1.0 25%
Duodenal Ulcer 5.0 17%
Z-E syndrome 18.0 72%
o Chemical = primary acidity = 0.00365% HCl
+free HCl
+lactic acid: normally absent
+occult blood: normally none Page
+bile: small amount | 23

o Terms euchlorhydia normal acidity

Hyperchlorhydria inc. Free HCl
Hypochlorhydria dec. Free HCl
Achlorhydria absence of free HCl
Achylia gastrica absence of HCl and rennin in gastric juice
Anacidity inability to produce a pH less than 6.0 following gastric stimulation

IX. SPUTUM

o secretion of the goblet cells (lining respiratory tract)

o DUST cells -hallmark of sputum
o Collection: 1st morning
o Colors: transparent – normal
Yellow green – TB, bronchiectasis
Red – TB
Rusty Red – lobar pneumonia
Brown – congestive heart failure
Black – heavy smokers
Olive green – carcinoma of the lungs

o Physical
+Quantity – very few amount; nothing at all
+Consistency – watery

o Odor: normal- odorless

Foul/ putrid – TB, lung abscess, gangrene
Fruity odor – P. Auruginosa

o pH: 6.5 – 7.0

o Macroscopic structure
+bronchial casts – made of fibrin
+Cheesy masses
+Dittrich’s plug – grayish to yellowish
+Pneumoliths – seen in histoplasmosis
+Curschmann’s spiral – mucoid threads that are twisted
o Microscopic
+elastic fibers
+Curschmann’s spiral
+Heart Failure cells – blood pigmented cells, chiefly hemosiderin
+carbon laden crystals
+myelin globules
+Creola bodies - clusters of ciliated columnar cells found in the sputum of asthmatic patients

o PREGNANCY TEST
-HCG – produced by the cytotrophoblast cells of the placenta
-alpha subunits of HCG = identical to FSH, LH and TSH

THANK YOU AND GOD BLESS =D

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