CLINICAL MICROSCOPY

Compiled by: Jonathan A. Tiongson Jr,RMT

PHYSICAL EXAMINATION OF URINE
Urochrome The yellow color of urine is caused by the presence of a pigment, which Thudichum named __
Increase Urochrome levels is standing urine sample at room temperature
Increase/ S.G of urine in patient with Diabetes mellitus
Hypersthenuria
Decrease/ S.G of urine in patient with Diabetes insipidus
Hyposthenuria
Bilirubin and Produces yellow foam in urine when shaken
Phenazopyridine
(Pyridium)
Protein/albumin Produces white foam in urine when shaken
Urea Major ORGANIC substance in urine
Chloride Major INORGANIC substance in urine
Creatinine The single most useful substance that identifies a fluid as urine is its uniquely high _________
concentration (approximately 50 times that of plasma).
Procedure for Mixed sample, View the urine against a white background using adequate room lighting
checking both urine
clarity and Color
Checking for urine Examine the specimen under a good light source, looking down through the container against a
color white background
Checking for urine Visually examining the Mixed specimen while holding it in front of a light source. View through a
clarity newspaper print
Specific gravity Defined as the density of a solution compared with the density of a similar volume of distilled
water (SG 1.000) at a similar temperature
Refractive index Principle of refractometer
Refers to the index of the velocity of light in air / velocity of light in solution
Some important PRESERVATIVE MUST KNOW
urine preservatives Refrigeration (up to 24 hours) Most common and easiest Can be used for
microbiological studies PRECIPITATES
AMORPHOUS CRYSTALS
Toluene and Phenol Does not interfere with routine tes
Formalin Excellent sediment preservative Fixative for
Addis counting
Yellow plain UA For automated instrument
Boric acid For culture and sensitivity and protein testing
Saccomano (preferred) and Formalin Used for cytology
(Brunzel,3rd ed.)
Concentrated HCL Catecholamines (e.g epinephrine)
Acids (HCl, glacial acetic acid) For quantitative analysis of steroids,
hormones,
Saccomano fixative 50% ETHANOL + 2%CARBOWAX (POLYETHYLENE GLYCOL)
Protein / albumin Analyte least affected or unaffected in unpreserved urine
Decrease Trichomonads on unpreserved urine will ______ due to loss of characteristic motility and death
Some Important 1. Carotene = Orange
Urine colors 2. Phenol when oxidized = blue-green or Green (Brunzel)
3. Phenol derivatives = Black or Brown (Brunzel)
4. Rifampin = red or orange red
5. Myoglobin (25mg/dl), RBC, and beets = Red
6. Porphyrin = Port-wine or Burgundy Red
7. Fucsin /aniline dye in candy = Red

Urine clarity CLARITY TERM

Reporting CLEAR No visible particulates, transparent
HAZY Few particulates, 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
 Acidic urine Amorphous urates, radiographic contrast media
Alkaline urine Amorphous phosphates, carbonates
LAB CORRELATION Soluble with heat Amorphous urates, uric acid crystals
IN URINE Soluble in dilute acetic acid RBCs, Amorphous phosphates, carbonates
TURBIDITY Insoluble in dilute acetic WBCs, Bacteria, yeast, spermatozoa
acid
Soluble in ether Lipids, lymphatic fluid,chyle
Routine urinalysis Specimen volume: 10 to 15 ml (average of 12ml)
Container capacity: 50 ml
Specimen volume: 30 to 45ml
Drug testing Container capacity: 60ml
Temperature:32.5 to 37.7 ‘C within 4minutes

DONOR /CLIENT Individual who submits urine specimen for drug testing
Types of specimen a. first morning urine sample
for glucose b. second morning urine sample
monitoring c. 2-hours post prandial urine sample
For Culture and a. Midstream clean catch
Sensitivity b. Catheterized urine sample
c. Suprapubic aspiration (especially for anaerobic microbes)
Catheterized, Used to differentiate kidney infections
ureteral collection
technique
Pediatric collection Used with patients (e.g infants and newborn) unable to urinate voluntarily * the patient is checked
bag every 15 minutes to see if an adequate specimen has been collected.
Random urine For ease and convenience, routine screening. It is collected at any time, usually during daytime
hours, and without prior patient preparation
Used for quantitative measurements of analyte that shows diurnal/circardian variation (e.g
hormones, proteins, glomerular filtration rate)
▪ To obtain an accurate timed specimen, the patient must begin and end the collection
Time specimens period with an empty bladder.
▪ All specimens should be refrigerated or kept on ice during the collection period and
may also require addition of a chemical preservative.
▪ A sufficient aliquot (50 mL) is removed for routine testing and possible repeat or
additional testing; the remainder is discarded
Afternoon urine Preferred specimen for Urobilinogen measurement
(2pm to 4pm)
Suprapubic aspiration (1st answer niyo ito dahil galing sa Strasinger )
Urine specimen for First morning = often preferred for cytology studies because the number of epithelial cells
cytology present can be significant
Random urine “clean catch” with prior hydration = ideal for cytology
12 hours urine Ideal specimen for screening microalbuminuria
specimen
For diagnosis of PROSTATIC INFECTION
Three glass 1st container = First portion of urine
collection 2nd container =midstream portion. THIS WILL SERVE AS CONTROL
3rd container= Last portion of urine with prostatic fluid
Refractometer a device used to measure urine S.G in the base of refractive index
Specimen volume: 1 drop
Requires correction for glucose and protein
Temperature corrections are not necessary
The calibration of a refractometer is checked daily, or whenever it is in use
Calibrating solution
a. 3% NaCL = 1.015 +/- 0.001
b. 5%NaCL = 1.022 +/- 0.001
c. 7%NACL = 1.035 +/- 0.001
d. 9% sucrose = 1.034 +/- 0.001
A weighted float attached to a scale
Requires 10 to 15 ml urine volume
Urinometer Requires correction for temp, glucose, and protein
Calibrating solution =water (S.G 1.000) or potassium sulfate (1.015) urinometer is added
 with a spinning motion in the urine sample the reading of urinometer in taken at the lower
meniscus
Calibrating solution:
a. Water = S.G reading should be 1.000
b. Potassium sulfate= S.G reading should be 1.015
Based on the principle that the frequency of a sound wave entering a solution changes
in proportion to the density of the solution
It is rarely used today despite its ability to accurately and precisely determine urine
specific gravity with linearity up to 1.080
This method was initially used on a semiautomated urinalysis workstation known as the
Harmonic Yellow IRIS
oscillation During testing, a portion of the urine sample is held in a U-shaped glass tube that has
densitometry an electromagnetic coil on one end and a motion detector on the other end. An electrical
current applied to the coil generates a sound wave of fixed frequency. This sonic
oscillation is transmitted through the specimen, and the frequency attenuation is
measured. The frequency (the oscillating cycle period) observed is directly
proportionate to the sample density, and a microprocessor converts the frequency
to a corresponding specific gravity value
1.010 Isosthenuric is the term to describe urine with a S.G of
<1.010 Hyposthenuric/Diluted urine – term to describe urine with S.G of
>1.010 Hypersthenuric/Concentrated urine- term to describe urine with S.G of
1.002 to 1.035 Normal random urine S.G
Radiographic Condition Associated with urine S.G of greater than 1.035 or >1.040 (Strasinger ,6th)
contrast dye/x-ray
film, Dextran, and
plasma expanders
METHOD PRINCIPLE
Methods for Refractometer Refractive index
measuring urine Urinometer / Hydrometer Density
S.G Harmonic oscillation densitometry Density
Reagent strip pKa changes of a polyelectrolyte
-0.004 In refractometer and Urinometer S.G reading, for every 1 gram of glucose you need to subtract
___-
-0.003 In refractometer and Urinometer S.G reading, for every 1 gram of protein you need to subtract
1.050 Formula for S.G Dilution = Diluted S.G x dilution Example: A specimen diluted 1:5 with a reading
of 1.010 would have an actual S.G of___

ODOR CAUSE
Pungent odor or distinctive Asparagus, Garlic, Onion ingestion UTI, or increase
Some important urinary urea
recalls in urine Fruity DM, and ketones
ODOR Mousy, musty, or Barny PKU
Odorless Acute tubular necrosis
Urinod- Odor of Mercaptan Asparagus, garlic, and egg
urine Sulfur / rotten egg Cystinuria
Galunggong/ fishy odor/rotten fish Trimetylaminuria
NORMAL AROMATIC, FRAGRANT
AMMONIA-Like, Fetid UTI, Bacterial decomposition
Maple syrup/ Caramel sugar MSUD,
Rancid Tyrosinemia
Sweaty feet Isovaleric acidemia
Cabbage, HOPS Methionine malabsorption
BLEACH CONTAMINATION
Swimming pool Hawkinsinuria
Cat Urine Hydroxymethylglutaric aciduria
Tom Cat Multiple carboxylase deficiency
 CHEMICAL EXAMINATION OF URINE
Handling and ✓ Stored in cool and dry area
storing of ✓ Dark container or bottle
reagent strip ✓ Stored at room temp
✓ Stored in opaque, tightly closed container
✓ With dessicant to protect light and moisture
Edge To ensure against run –over, blot the ___ of the strip with adsorbent paper and holding the strip
horizontally while comparing it with color chart
Parallell When new reagents are prepared, they should be tested in ________ with current “in-use”
reagents to ensure equivalent performance
TEST PRINCIPLE (+) RESULT READING
TIME
Bilirubin Diazo reaction Violet, tan, or pink 30 secs
Glucose Double sequential enzymatic Potassium iodide = blue- 30 secs
reaction green to brown
Ketones Sodium Nitroprusside (Legal’s Purple 40 secs
rxn)
Summary of
S.G pKa change of polyelectrolyte Diluted = blue 45 secs
Reagent strips/ Concentrated =yellow
Dipstick pH Double indicator system Acidic = red to yellow 60 secs
Alkaline = green to blue
Protein Protein (sorensen’s) error of Blue-green 60 secs
indicator
Blood Pseudoperoxidase activity of Green to blue 60 secs
hemoglobin
Urobilinogen Ehrlch’s reaction Red 60 secs
Nitirite Greiss reaction Pink 60 secs
Leukocyte Leukocyte esterase Purple 120 secs
5 to 6 What is the first morning urine pH
4.5 to 8.0 Normal random urine pH
Common reasons for 1. urine specimen that was improperly preserved
urine pH greater 2. old urine specimen
than 8 3. adulterated specimen (i.e., an alkaline agent was added to the urine after collection)
4. patient was given a highly alkaline substance (e.g., medication, therapeutic agent)
CAUSES OF ACID URINE CAUSES OF ALKALINE URINE
Emphysema Renal tubular acidosis
Diabetes mellitus Hyperventilation
Starvation Vomiting
Dehydration Vegetarian diet
Cranberry juice Citrus fruits
Acidic vs alkaline High protein diet Old specimens
urine Presence of acid producing bacteria (E. Presence of urease producing bacteria
coli) Alkaline tide (during and after following
Medications such as Mandelamine and meals)
Fosfomycintro methamine Presence of urease producing bacteria
Ethylene glycol and methanol (Proteus spp. and
Chronic lung disease Pseudomonas spp)
Ionic The reagent strip specific gravity test does not measure the total solute content but only those
solutes that are __
1.010 S.G of urine with end stage renal disease
Normal urine contains very little protein such as albumin: usually, less than 10 mg/dL or 100 mg
Normal amount of per 24 hours is excreted. Due to its low molecular weight, albumin is the major serum protein
protein in normal found in normal urine. Even though it is present in high concentrations in the plasma, the normal
urine urinary albumin content is low because the majority of albumin presented to the glomerulus is not
filtered, and much of the filtered albumin is reabsorbed by the tubules – STRASINGER

Henry’s and Brunzel = <150mg/24hrs or 1 to 14mg/dl for 24 hours

10mg/dl What is the minimum sensitivity for the detection of albumin the urine strip test?
 SSA Grading SSA GRADING
GRADE TURBIDITY PROTEIN RANGE (mg/dl)
Negative No increase turbidity <6
Trace Noticeable turbidity 6-30
1+ Distinct turbidity with no granulation 30-100
2+ Turbidity with granulation, no flocculation 100-200
3+ Turbidity with granulation, and 200-400
flocculation
4+ Clumps of protein >400
10minutes The SSA test is performed on clear supernatant urine following centrifugation. The urine
supernate and the reagent are added together and mixed by inversion. After a ___minute, room
temperature incubation, the tube is inverted and evaluated
5 to 10 mg/dL The SSA method is sensitive to _____ of protein, regardless of the type of protein present.
SSA Interferences False Radiographic contrast dye/x-ray film
increase/positive Drugs (Tulbotamide, Penicillin, Sulfonamide, cepalosphorin)
para-amino-salicylic acid/Salicylates
False Highly alkaline urine Quaternary ammonium compounds (e.g
decrease/negative Detergents, and soap)
BJP It precipitates/coagulates/Insoluble at 40-60’C and dissolves/soluble at 100’C
Proteinuria Amyloidosis, pre-eclampsia/eclampsia, and immune complexes is associated with
Microalbuminuria Earliest indicator of diabetic nephropathy and kidney problem
Refers to the presence of albumin in urine above the normal level but below the detectable
range of conventional urine dipstick methods
20-200ug/min or 30- Albumin Excretion Rate (AER) of microalbuminuria
300mg/24hrs
Test for microalbuminuria
Principle: Enzyme immunoassay
Negative result: white
Micral test Reading time: 60 seconds
Strips are dipped into the urine up to a level marked on the strip and held for 5 seconds
False +: soap or detergent
False -: diluted urine
Test for microalbuminuria
Principle: Immunochromographics
Sensitivity: 1.2 to 8.0 mg/dL
Strips are individually packaged in specially designed containers. The container is placed
Immunnodip in the urine specimen for 3 minutes
APPEARANCE AMOUNT (mg/dl) INTERPRETATION
Darker bottom band <1.2 Negative
Equal band colors 1.2 to 1.8 Borderline
Darker top band 2 to 8 Positive
Albumin creatinine Test for microalbuminuria
ratio Abnormal results for the A:C ratio are 30 to 300 mg/g or 3.4 to 33.9 mg/mmol
Causes of benign Benign proteinuria is usually transient and can be produced by conditions such as strenuous
proteinuria exercise, high fever, dehydration, and exposure to cold.
Albumin The protein reagent strip is sensitive to ___only
Protein error of The reagent pad medium is acidic (pH ≤3) and buffered with citrate Albumin if present, will accept
indicators hydrogen ions from the medium There will be a change in color of the medium from yellow to
blue-green which indicates a positive result
Causes DM, Pheochromocytoma, acromegaly, Cushing’s syndrome, hyperthyroidism, and pancreatitis
hyperglycemia and
glucosuria
It is a test for REDUCING SUGARS
Benedict’s /Clinitest Importance: detection of inborn error of metabolism such as galactosemia
Components: Copper sulfate, sodium hydroxide, sodium citrate, sodium bicarbonate
sodium bicarbonate and citric acid/sodium citrate acts as an effervescent
15 Clinitest results must be evaluated immediately, and any color change that occurs after
_____seconds is ignored
2 gtts urine volume used to prevent pass through phenomenon in Clinitest
200 mg/dL The sensitivity of Clinitest to glucose is reduced to a minimum of _____ so the Clinitest cannot be
used as a confirmatory test for glucose
 Moisture A strong blue color in the unused Clinitest tablets suggests deterioration due to
_______accumulation, as does vigorous tablet fizzing
Forms of ketones 78% Beta Hydroxybutyric acid – major ketone but not detected in reagent strip
20% Acetoacetic acid (AAA) / Diacetic acid – parent ketone, first to be formed by the liver
2 % Acetone – detected only when glycine is present
70 When the blood ketone concentration exceeds ____mg/dL (the renal threshold level), ketones are
excreted in the urine
Hematuria It Produces a mottled/speckled/spotted pattern on blood reagent pad
cloudy or smoky Hematuria is often evident by a _________ urine specimen, whereas with true hemoglobinuria,
the urine is clear
Hemosiderin Rhabdomyolysis, trauma, crush syndromes, prolonged coma, convulsions, muscle-wasting
diseases, alcoholism, heroin abuse, and extensive exertion
Myoglobinuria Normally, myoglobin excretion is less than_____; however, during extreme exercise, it can
increase to 40 times the normal rate without adverse renal effects
0.04 mg/dL Myoglobin concentrations exceeding ______ are associated with a patient’s risk of developing
acute renal failure
Hemoglobin Versus Myoglobin
TEST HEMOGLOBIN MYOGLOBIN
Blondheim’s test (ammonium Precipitated by Not precipitated by
sulfate) ammonium sulfate ammonium sulfate

Procedure: Produce a clear supernatant Produce a red supernatant

a. 5 ml centrifuged Urine + that is negative for blood that is positive for blood
Blondheim’s test 2.8g reagent strip reagent strip
Ammonium sulfate
b. Mix and allow the
specimen to
sit for 5 minutes
c. Filter or centrifuged
d. Test the supernatant with
blood
reagent strip
B2 (conjugated) The only form of bilirubin that can be detected by the reagent strip *Urine bilirubin
increases in case of Hepatic jaundice and Post hepatic jaundice
Bilirubin reagent strip Uses 2,6-dichlorobenzene-diazonium-tetrafluoroborate
Alkalosis Excretion of bilirubin is enhanced by
+ result: Blue to purple
Ictotest If interference in the Ictotest is suspected, it can usually be removed by adding water
directly to the mat after the urine has been added. Interfering substances are washed into the
mat, and only bilirubin remains on the surface.
Composition of reagent: Sodium nitroprusside. Disodium phosphate and
Lactose –gives better color differentiation

Acetest The Acetest tablet test has been used as a confirmatory test for questionable reagent strip
results; however, it was primarily used for testing serum and other bodily fluids and dilutions of
these fluids for severe ketosis
Read for 30 seconds
less than 1 mg/dL or a small amount of urobilinogen, —is normally found in the urine
Ehrlich unit
Causes False porphobilinogen, indican, p-aminosalicylic acid, sulfonamides, methyldopa, procaine, and
positive result on chlorpromazine
Ehrlich’s reaction
Hoesch test Used as a screening test for Porphobilinogen
REAGENT: Ehrlich’s reagent in 6M or 6 N HCL
LYMPHOCYTE WBC that cannot be detected by Leukocyte reagent strip
Nitrite It gives a positive reaction to gram-negative bacilli / coliforms / Enterobacteriaceae
Positive reaction corresponds to >100,000 organisms/ml
Screening test for urine nitrite does not replace a traditional urine culture, which can also
specifically identify and quantify the bacteria present. The nitrite test simply provides a
rapid, indirect means of identifying the presence of nitrate-reducing bacteria in urine at
minimal expense
Vitamin C (reducing Causes False Negative result to BBLNG (Blood, Bilirubin, Leukocyte, Nitrite, Glucose)
agent) Causes False Positive result to Clinitest
Detergent /Soap Causes False Negative result to Clinitest
(Oxidizing agent) Causes False Positive result to LGBP (Leukocyte, Glucose, Blood, Protein)
TIPS LANG ULIT PARAMETER REAGENT
Nitrite ……………….. QUINOLIN
pH Methyl red and bromthymol Blue
Protein Tetra……………
Blood Di……………….tetramethylbenzidine
Bilirubin Dichloro………… diazonium salt or tetrafluoroborate
MICROSCOPIC EXAMINATION OF URINE
ADDIS COUNT The first counting procedure for microscopic sediments in urine, using hemacytometer
Toluidine blue A supravital stain used to differentiate WBC and RTE cell
Hansel (methylene A stain used for urinary eosinophil
blue + Eosin Y)
Perl’s Prussian blue A stain for iron pigments of hemosiderin
400 RCF for 5 mins Centrifugation for routine urinalysis
Pink Color of Hyaline cast in Sternheimer-Malbin or KOVA ‘s stain
Camel hair brush Used to remove dust in the microscope
Lens paper or Used to clean the optical surfaces, lens or objectives of the microscope
commercial lens
cleaner Note
Whereas some manufacturers suggest the use of xylene to clean oil immersion lenses, this
practice is not recommended for several reasons. If residual xylene is left on the objective, it
destroys the adhesive that holds the lens in place. In addition, xylene fumes are toxic and should
be avoided.-Brunzel
Magnifying glass A simple brightfield microscope consisting of only one lens
MICROSCOPE USAGE
Bright field Used for routine urinalysis
Phase contrast Enhances visualization of elements with low refractive indices,
such as hyaline casts, mixed cellular casts, mucous threads, and
Trichomonas
Polarizing Aids in identification of cholesterol in oval fat bodies, fatty casts,
and crystals. It has widespread application in the clinical laboratory
and in pharmaceuticals, forensics, pathology, geology, and other
fields. Anisotropic or birefringent substances such as crystals, fibers,
bones, or minerals can be identified based on their effects on
polarized light.
Darkfield Aids in identification of spirochetes such as Treponema pallidum
Fluorescence Allows visualization of naturally fluorescent microorganisms or
those stained by a fluorescent dye
Bright field objects appear dark against a light background
most frequently used in the clinical laboratory
all other types of microscope are adapted to brightfield
Phase contrast Adaptation of a bright-field microscope with a phase-contrast objective lens and a matching
condenser. Two phase rings that appear as “targets” are placed in the condenser and the
objective.
Light passes to the specimen through the clear circle in the phase ring in the condenser,
forming a
halo of light around the specimen
Polarizing It uses halogen quartz lamp that produces light rays of many different waves
microscopy A substance that rotates the plane of polarized light 90 degrees in a clockwise direction is
said to have
positive birefringence.
substance that rotates the plane in a counterclockwise direction has negative birefringence
Bright-field microscopes can be adapted for polarizing microscopy. Two polarizing filters must
be installed in a crossed configuration. This can be done by the use of two polarizing filters, one
is placed in the condenser and the other is placed on the ocular.
Birefringent a property indicating that the element can refract light in two dimensions at 90 degrees to each
other
 provides a three-dimensional image showing very fine structural detail by splitting the light ray
so
that the beams pass through different areas of the specimen
Two types of interference-contrast microscopy are available: modulation contrast (Hoffman)
and
differential-interference contrast (Nomarski). Bright-field microscopes can be adapted for both
methods.
Interference Converting brightfield microscopy to differential interference contrast microscopy requires (1)
contrast a
polarizer placed between the light source and the condenser, (2) a special condenser containing
modified Wollaston prisms for each objective, (3) a Wollaston prism placed between the objective
and
the eyepiece, and (4) an analyzer (polarizing filter) placed behind this Wollaston prism and before
the
eyepiece
bright-field microscope is easily adapted for dark-field microscopy by replacing the condenser
with
a dark-field condenser that contains an opaque disk
The specimen appears light against the black background or dark-field
aperture diaphragm Microscope component that regulates the angle of light presented to the specimen.
Birefringent The ability of a substance to refract light in two directions.
condenser Microscope component that gathers and focuses the illumination light onto the specimen for
viewing.
Eyepiece The microscope lens or system of lenses located closest to the viewer’s eye. It produces the
secondary image magnification of the specimen. It gives additional magnification to the
objectives
Objectives The lens or system of lenses located closest to the specimen. The objective produces the
primary image magnification of the specimen.
field diaphragm Microscope component that controls/regulates the diameter of light beams that strike the
specimen and hence reduces stray light
Magnification Process of enlarging or magnifying an object’s size without affecting its actual or physical size
RBC in urine More than 3/hpf is considered abnormal (Henry’s)
HypeRsthenuria/ concentrated/S.G greater than 1.010 = cRenated RBC /ecchinocyte
Hyposthenuria /diluted/S.G less than 1.010 = GhOst cell / swOllen RBC
Glomerular bleeding= dysmorphic RBC
Dysmorphic RBC RBCs that vary in size, have cellular protrusions, or are fragmented. They are mainly
acanthocytes
Monohydrate Look-alike crystal of RBC Monohydrate calcium oxalate crystals
calcium oxalate
crystals

WBC in urine The most predominant = NETUROPHIL

Cannot be detected by Leukocyte Esterase = LYMPHOCYTE
Associated with interstitial nephritis = EOSINOPHIL
Urinary eosinophil the percentage of eosinophil in 100 to 500cells is determined >1% = abnormal and is
associated with INTERSTITIAL NEPHRITIS
WBC in urine leukocytes are rapidly lysed in hypotonic or alkaline urine. Approximately 50% are lost following
2–3 hours of standing at room temperature
Viral inclusions in Epithelial cells containing inclusion bodies may be found in the urine sediment.
urine a. Syncytial giant cells containing eosinophilic, intranuclear inclusions = herpes
b. Enlarged and contain basophilic intranuclear inclusions and/or cytoplasmic bodies= CMV
c. Dense, basophilic, homogeneous intranuclear inclusions that often completely fill the nucleus.
=
Polyomavirus
Glitter cells Neutrophil Exposed to hypotonic urine absorb water and swell. Brownian movement of the
granules within these larger cells produces a sparkling appearance
When stained with Sternheimer-Malbin stain, these large cells stain light blue as opposed to
the violet color usually seen with neutrophils.
Squamous epithelial The largest sediment, considered as point of reference. Appear as flagstone-shaped with
distinct cell borders
 RTE Most pathologic and is associated with Tubular injury. They have eccentrically placed nucleus
Squamous Epithelial Squamous epithelial cells originate from the linings of the vagina and female urethra and the
cells lower portion of the male urethra. They represent normal cellular sloughing and have no
pathologic significance
Epithelial cells that originate from the lining of the renal pelvis, calyces, ureters, and bladder, and
from the upper portion of the male urethra.
They may be round, pear-shaped, or may have taillike projections. Occasionally, these cells may
Transitional contain two nuclei.
(Urothelial) epithelial Transitional epithelial cells are smaller than squamous cells and appear in several forms, including
cells spherical, polyhedral, and caudate
Spherical forms of transitional epithelial cells are sometimes difficult to distinguish from
RTE cells. The presence of a centrally located rather than eccentrically placed nucleus, and
supravital staining, can aid in the differentiation
Clue cells Appear as squamous epithelial cells covered with the Gardnerella coccobacillus. They are
pathologic They have granular, irregular appearance sometimes described as “shaggy.”
RTE Precursor of oval fat bodies
Chyluria Milky urine, associated with lymphatic duct obstruction and in cases of Wuchereria bancrofti
infection
Pseudochyluria Occurs with the use of paraffin-based vaginal creams for the treatment of Candida infection.
Bubble cells Non-lipid filled, vacuolated RTE cells mainly associated with Acute tubular necrosis. They
appear to represent injured cells in which the endoplasmic reticulum has dilated prior to cell
death.
Oval fat bodies Refractile RTE cells
>2 Presence of more than _____ RTE/hpf indicates tubular injury
Yeast cells in urine primarily Candida albicans, are seen in the urine of diabetic patients, immunocompromised
patients, and women with vaginal moniliasis
ACIDIC urine and provides an ideal or favorable medium/condition for yeast in urine
with glucose
Parasites in urine Most frequently encountered = Trichomonas vaginalis
Most common contaminant ova =E.vermicularis
Associated with bladder cancer = S.haematobium
UROMODULIN / Unique to the kidney and is found in urine (both normal and abnormal condition)
Tamm-Horsfall Major constituent / mould / matrix of cast and mucus thread
protein A glycoprotein excreted by RTE cells of the DCT and CD
Trichomonas most frequent parasite encountered in urine
vaginalis
Enterobius most common contaminant ova
vermicularis
DCT and CD CASTS are formed within the lumens of the __ and __, providing a microscopic view of
conditions within the nephron
Cylindroids Formed at the ALH and DCT with tapered end or have a tail at the other tail.
They have the same significance as casts (hyaline cast).
Cylindroids are product of incomplete cast formation, or cast disintegration.
Cast matrix Dissolves quickly in dilute, alkaline urine
Hyaline cast Most frequently seen cast
NORMAL value = 0 to 2 / lpf
GRANULAR DIRTY representing hemoglobin degradation products such as methemoglobin are
BROWN CAST associated with the ACUTE TUBULAR NECROSIS often caused by the toxic effects of
massive hemoglobinuria that can lead to
renal failure.
• They are brittle, highly refractile, fragmented, with jagged ends
WAXY CAST • Ground glass appearance, homogenous matrix, with cracks or fissures from
margins or along the length of the cast (Brunzel)
Broad cast Renal failure cast
Granular Two most commonly seen Broad cast
and waxy
Urinary crystals The presence of crystals in freshly voided urine is most frequently associated with
concentrated (high specific gravity) specimens.
Crystals formed in Amorphous urates, Calcium oxalate, uric acid, and all abnormal crystals
acdic urine
Crystals formed in A. phosphates, Ammonium biurate, calcium carbonate, calcium phosphate, and Triple
alkaline urine phosphate
Urates The most common crystals seen in acidic urine are
 Urates crystal Consisting of amorphous urates, uric acid, acid urates, and sodium urates. Microscopically,
most urate crystals appear yellow to reddish brown
Rhombic, wedge, hexagonal, four-sided flat plate (whetsone), lemon shaped, pencil
Uric acid shape (monosodium urates), pleomorphic, rosette, SEEN IN VARIETY OF SHAPE
✓ Soluble with alkali and heat
Brick dust / yellow brown granules, pink sediment (uroerythrin)
It will convert to uric acid crystals with acidification with acetic acid and concentrated
Amorphous urates HCL
✓ Soluble with alkali and heat
Ammonium Resemble other urates in that they dissolve at 60°C and convert to uric acid crystals when
biurate glacial acetic acid is added
crystals
Amorphous Granular in appearance, White precipitate
phosphates ✓ Soluble in dilute acetic acid
Ammonium Biurate Thorny apples and can be seen in old specimens
Bilirubin, Leucine, Crystals associated with Liver disease
and Tyrosine
URIC ACID Crystal that can be mistaken as Cystine
Ampicillin Colorless needles that tend to form bundles following refrigeration
Cholesterol Rectangular plates with a notch in one or more corners (staircase pattern)
Radiographic dye Mistaken as Cholesterol

URIC ACID VS. CRYSTALS

Uric acid Cystine
Color Yellow Colorless
brown
Solubility in ammonia Soluble Soluble
Solubility in dilute HCL Insoluble Soluble
Birefringence Positive Negative
Cyanide nitroprusside reaction Negative Positive
Sulfonamide Sheaves of wheat , rosette formation crystal
Triple phosphate Colorless, prism-shape or “coffin lid”, feathery appearance when they disintegrate. Fern-
leaf shape, flakes
Triple phosphate Associated with the presence of urea-splitting bacteria P. vulgaris
Bilirubin crystals Clumped needles or granules with bright yellow color, Reddish brown; amorphous
needles, rhombic plates, or cubes; may color uric acid crystals
✓ Soluble in alkali, acid, acetone, and chloroform
Lignin’s test Test to differentiate rosette formation of sulfonamide from calcium phosphate
Calcium oxalate Crystal associated with increase vitamin C intake
Calcium oxalate Crystal that are also associated with foods high in oxalic acid, such as tomatoes and
asparagus
Calcium phosphate Apatite crystal
Most common Caox The most common form of calcium oxalate crystals is the dihydrate that is easily
form recognized as a colorless, octahedral envelope or as two pyramids joined at their
bases
Uric acid Associated with Polycythemia, chemotherapy associated with leukemia and lymphoma
Starch granules A urinary artifact: sphere with dimpled center
Oval fat bodies, Fatty Urinary sediments with maltesse cross appearance
cast, Fat droplets,
Starch granules,
Cholesterol
Reporting of normal crystals Rare, few, moderate or many per HPF
Reporting of abnormal crystals Average number per LPF
Reporting of RTE cells Average number per 10 HPF
Squamous epithelial cells Rare, few, moderate, or many per LPF
Transitional epithelial cells Rare, few, moderate, or many per HPF
Casts Average number per LPF
Qualitative terms and descriptions for field of
views (FOVs)
Term Description
Rare (1+) Present, but hard to find
Field of views Few (1+) One (or more) present in almost every field of view (FOV)
Moderate (2+) Easy to find; number present in FOV varies; “more than few, less than
many”
Many (3+) Prominent; large number present in all FOVs
Packed (4+) FOV is crowded by or overwhelmed with the elements
Alport’s syndrome Genetic disorder showing lamellated and thinning of glomerular basement membrane
 Characterized by: LIPIDURIA, PROTEINURIA, and hematuria
Serum findings: Increase Alpha-2-macroglobulin, hypoproteinemia, hyperlipidemia, and
Nephrotic syndrome INCREASE PLASMA SODIUM AND WATER LEVEL DUE TO INCREASE SODIUM AND
WATER REABSORPTION IN THE
KIDNEY that will eventually lead to EDEMA
Acute tubular necrosis Important urinalysis findings: RTE CELLS, RTE CASTS, Odorless urine, and
Isosthenuria
PCT In Fanconi syndrome, there is a generalized failure of tubular reaction in the
Gordon’s syndrome PCT dysfunction characterized by Excessive reabsorption of sodium
Liddle’s syndrome DCT dysfunction characterized by Excessive reabsorption of sodium
Bartter’s syndrome PCT dysfunction characterized by Impaired ability to reabsorb sodium
Acute renal failure (ARF) is characterized clinically by a sudden decrease in the GFR,
azotemia, and
Acute renal failure oliguria (i.e., urine output less than 400 mL). Although the nephrons are “functionally”
abnormal, no histologic
abnormality is usually present.
Progressive loss of renal function caused by an irreversible and intrinsic renal disease
Chronic renal failure Common Urinalysis findings: isosthenuria, presence of all cast especially waxy and broad
cast.
RENAL CALCULI CHARACTERISTICS
Calcium oxalate Major constituent of renal calculi (up to 80%)
Very hard, dark brown color with rough surface
Renal Uric acid Associated with increase intake of foods with high purine content
Yellowish to brownish red and moderately hard
lithiasis or stones Cystine Seen in hereditary disorders of Cysteine metabolism
Yellow brown, greasy and resembles an old soap
Least common calculi (1-2%)
Calcium phosphate Pale and friable
Hematuria Primary urinalysis findings in renal calculi
Conditions favoring/enhancing Urinary pH, Chemical/solute concentration, Urinary stasis,
renalstone formation Metabolic disorders (ex. Gout, and inborn error of metabolism),
Endocrine disorders (ex. Hyperparathyroidism),
Infections (ex. UTI), Nucleation (initial crystal deposition and formation)
Telescoped sediments Used to describe the simultaneous occurrence of elements of
glomerulonephritis and those
of nephrotic syndrome in the same urine specimen.
Athletic pseudonephritis Characterized by “shower of casts”
Cyanide “AKA” Brand’s modification of the Legal nitroprusside reaction
nitroprusside = it is a qualitative test mainly for cysteine
Causes false (+) reaction= Homocysteine, and ketones (dark red) all will give positive
Reactions (+) red purple

Tandem Mass spectrometry / mass GOLD STANDARD test for Newborn Screening Test
spectrometry Specimen: Bloodspot
TELESCOPED Used to describe the simultaneous occurrence of elements of glomerulonephritis and those
SIDEMENTS of nephrotic
syndrome in the same urine specimen.
Guthrie bacterial Test for PKU
inhibition test Positive result: Growth
MSUD Dinitro phenyl hydrazine (DNPH) is a screening test mainly for _
Tyrosine Which of the following substances is associated with Melanuria?
A Second metabolic pathway of tyrosine is responsible for the production of
melanin, thyroxine, epinephrine, protein, and tyrosine sulfate
PKU Increase keto acids, including phenylpyruvate in urine
Alkaptonuria Increase Homogentisic acid in urine
Tyrosinemia Increase tyrosine, its degradation products, p-hydroxyphenylpyruvic acid and p-
hydroxyphenyllactic acid
Cystinuria Increase (COLA) Cystine, Ornithine, Lysine, and Arginine in urine
Melanuria Increase melanin in urine
May indicate melanoma and a disorder of the second metabolic pathway of tyrosine
Phenylalanine hydroxylase Enzyme deficient in PKU
Hartnup’s disease Blue diaper syndrome
Lesch-Nyhan syndrome Orange sand diaper syndrome
Alkaptonuria Associated with brown-stained or black-stained cloth diapers and reddish-stained
disposable diapers
5-HIAA A metabolite that increases in cases of argentaffinoma or carcinoid tumor
Foods avoided in cases of Bananas, Tomato, Avocado, pineapples, chocolate, plums, walnuts, or medications
containing guaifenesin
carcinoid tumor
Defects in the metabolism of the amino acid methionine produce an increase in
Homocystine throughout the body that can result in failure to thrive, cataracts, mental retardation,
thromboembolic problems, and death.
Positive in silver-nitroprusside test
acetyl acetone In screening for porphyrinuria using the Erhlich’s test, must be added to the specimen
prior to testing to convert ALA to porphobilinogen
Type Enzyme deficient Elevated substance
Acute intermittent Porphobilinogen deaminase ALA Porphobilinogen
Porphyria cutanea Tarda Uroporphyrinogen Uroporphyrin
decarboxylase
Porphyria Congenital erythropoietic porphyria Uroporphyrinogen Uroporphyrin
cosynthase Coproporphyrin
Variegate porphyria Protoporphyrinogen oxidase Coproporphyrin
erythropoietic protoporphyria Ferrochelatase or heme Protoporphyrin
synthase
Lead poisoning ALA-synthetase and Protoporphyrin
ferrochelatase
FEP test CDC recommended screening test for lead poisoning
whole blood Increased protoporphyrin is best measured in what sample
Screening test for MPS Acid albumin = (+) turbidity
CTAB (Cetyltrimethylammonium bromide) = (+) turbidity
Metachromatic staining spot test = (+) Blue or Purple

SYNOVIAL FLUID
Synoviocyte Cells that secrete hyaluronic acid, responsible for viscosity of joint fluid
Distribution of Tube order Test Tube type
specimen
1 Chemistry /chemical examination Red Tap or gray tap for glucose
2 Microscopic examination Sodium heparin or liquid EDTA
(Hematology, Crystal identification,
and cytologic studies)
3 Microbiology Sterile Yellow tap, sodium heparin, or
red tap
Milky Appearance of synovial fluid when crystals are present
4 to 6 cm Normal synovial fluid viscosity should able to form cm string long
NORMAL Synovial fluid viscosity forms a string of 6cm
For synovial fluid viscosity Ropes/ Mucin clot test (Hyaluronate polymerization Test) -
uses 2-5 % acetic acid Good = solid clot, Poor = No clot
Toluidine blue test It positively identifies an unknown specimen as synovial fluid
Procedure: a few drops of the suspect fluid are placed onto filter paper
followed by 0.2% toluidine blue stain. If synovial fluid is present, the drops
of fluid will stain blue.
Diluting fluid for cell counting should not contain an acid because it will form a clot
of synovial fluid Used diluting fluid: NSS with methylene blue, Hypotonic saline, Saline with
saponin
Macrophages Most predominant normal cell in synovial fluid (60 to 65%)
<10mg/dl In a normal fasting patient, the glucose concentrations in the blood and in synovial fluid are
equivalent. In other words, the plasma–synovial fluid glucose difference is less than (0.55
mmol/L).
Rice bodies These are fragments of degenerating proliferative synovial cells or microinfarcted
synovium
.D lactate or Lactic acid test A rapid diagnosis of bacterial synovitis. It is increased in septic arthritis
Crystals Milky appearance of synovial fluid is due to the presence of
Compensated polarizing microscope Type of microscope used for identification of crystals and its birefringence in
synovial fluid
Special specimen Specimens for crystal analysis should not be refrigerated because they
consideration for crystal can produce additional crystals that can interfere with the identification of
identification in synovial fluid significant crystals. Avoid using
powderized anticoagulant because it can cause artifacts and may
interfere in crystal identification

CELLS AND INCLUSIONS SEEN IN SYNOVIAL FLUID

Cell /Inclusion Description Significance
Neutrophil Polymorphonuclear leukocyte Bacterial sepsis
Crystal induced inflammation
Lymphocyte Mononuclear leukocyte Non-septic inflammation
Macrophage Large mononuclear leukocyte, may be Normal
vacuolated Viral infections
 Synovial lining cell Similar to macrophage, but may be Normal
multinucleated resembling a
mesothelial cell
LE cell Neutrophil containing characteristic Lupus erythematosus
ingested “round homogenous body”
Reiter cell Vacuolated macrophage with Reiter syndrome
ingested neutrophils Non-specific inflammation

RA cell Neutrophil with dark cytoplasmic Rheumatoid arthritis

(Ragocyte) granules Immunologic inflammation
containing immune complexes
Cartilage cells Large multinucleated cells Osteoarthritis
Rice bodies Macroscopically resembles polished rice Tuberculosis, septic and
Microscopically show collagen and fibrin rheumatoid arthritis
Fat droplets Refractile intracellular and extracellular Traumatic injury
globules Chronic inflammation
stain with Sudan dyes
Hemosiderin Inclusions within clusters of synovial cells Pigmented villonodular
synovitis
Ochronotic Ground pepper appearance Joint prosthesis
shards
. Crystal Shape Compensated Significance
Polarized Light
Monosodium urate Needles Negative Gout
birefringence
Calcium Rhombic squares, Positive birefringence Pseudogout or
Pyrophosphate rods chondrocalcinosis
Cholesterol Notched, rhombic Negative Extracellular
plates birefringence
Corticosteroid Flat, variables- Postive & Negative Injections
shaped birefringence
plates
Calcium oxalate Envelopes Negative Renal dialysis
birefringence
Apatite (Ca Phosphate) Small particles; No birefringence Osteoarthritis
require
electron microscopy
I IIa IIb III IV
GROUP Non inflammatory Inflammatory - Inflammatory- Septic Hemorrhagic
Immunologic Crystal induced
Signific Degenerative Immunologic Gout Microbial Traumatic injury
ance joint disorder disorders Pseudogout infection Coagulation
deficiency
Color Clear, yellow Cloudy, yellow Cloudy or milky Cloudy, Cloudy, red fluid
and fluid yellow-
clarity green
Viscosit Good Poor Low Variable Low
y
WBC <1,000 / ul 2000-75000/ul Up to 100,000 /ul 50K-100K / Equal to blood
count ul

NOTE FOR THE WBC COUNT!!

Normal <200 cells/ul
Non inflammatory 200-999 cells/ul
Inflammatory ≥1000 cells/ ul
Septic Up to 100,000 cells/ul
Normal S.F Glucose The difference between the Blood glucose and Synovial fluid glucose should be less
than 10mg/dl

SEROUS FLUID
An Effusion caused by a systemic disorder that disrupts the fluid production and regulation between
membrane leading to increased capillary hydrostatic pressure or decreased plasma oncotic
pressure
1. Congestive heart failure = increase hydrostatic pressure
Transudate 2. Nephrotic syndrome = decrease oncotic pressure
3. Malnutrition = decrease oncotic pressure
4. Cirrhosis = decrease oncotic pressure
5. Hypoproteinemia = decrease oncotic pressure
 An Effusion caused by direct or localize damage to the membrane. It is associated with
lymphatic blockage or increase capillary permeability.
Exudate 1. Infection = increase capillary permeability
2. Malignancy= increase capillary permeability
3. Inflammation = increase capillary permeability
4. Lymphatic duct obstruction
Transudate Transudates are typically clear, pale yellow to straw-colored, and odorless, and do
not clot. Approximately 15% of transudates are blood tinged.
Anaerobic infections A feculent effusion odor
Eosinophilic effusion One that has 10% or more eosinophils. The most common causes are related to the
presence of air or blood in the pleural cavity (PNEUMOTHORAX OR
HEMOTHORAX)
Most reliable test to Fluid: serum protein
differentiatpleural fluid transudate and ratio and Fluid: serum
exudate LD ratio
serum-ascites Differentiation between ascitic fluid transudates and exudates is more difficult
albumin gradient than for pleural and pericardial effusions. The is recommended
(SAAG)
Specimen distribution EDTA for cell counts and differential
Clotted specimens in plain non-anticoagulated (Red tap) or Heparin for
Chemical analysis Sterile heparin or SPS for microbiology and cytology
cytology examination refrigeration (4° C to 8° C) adversely affects the viability of microorganisms and should
not be used for serous fluid specimens. However, serous fluid samples intended for
cytology examination are an exception and can be refrigerated at 4° C when
storage is necessary.
Milky Chylous and pseudochylous effusion produces appearance
Tuberculostearic acid Was first isolated from the bacillus Mycobacterium tuberculosis. This fatty acid is a
(TSA) structural component of mycobacteria and is not normally present in human tissue.
Anaerobically Serous fluid Specimens for pH must be maintained in ice (ref temperature)
Exudate WBC counts greater than 1000/uL and RBC counts greater than 100,000/uL indicate an
Enterovirus Most common viral etiologic agent of pericardial effusion

Fibronectin and telomerase They can be used as markers of malignant ascites

Rivalta’s test Useful in differentiating exudate from transudate
Acetic acid + water + Unknown fluid --- > (+) heavy precipitation (+) on exudate only
Mononuclear cells Cells that predominate in transudative effusion
Methods of collection Paracentesis for peritoneal fluid, thoracentesis for pleural fluid, and pericardiocentesis
for pericardial fluid
Bacterial peritonitis In peritoneal fluid, a WBC count exceeding 500 cells/μL with a predominance of
neutrophils
(greater than 50%) suggests
Tubercular peritonitis Decrease peritoneal fluid glucose is associated with
CHYLOUS PSEUDOCHYLOUS
EFFUSION EFFUSION
Cause Thoracic duct Chronic inflammation such as
leakage myxedema, tuberculosis, and
rheumatoid pleuritis
Appearance Milky / white Milky / green tinge / gold paint
Leukocytes Increase Mixed cells
Chylous vs lymphocyte
pseudochylous Cholesterol crystals Absent Present
Triglycerides >110 mg/dl <50 mg/dl
Sudan III staining +++ Negative or weakly +
Onset sudden gradual
chylomicrons present absent

Neutrophil Predominant WBC that increases in endocarditis, peritonitis, and pancreatitis

>100,000 RBCs/ul In peritoneal lavage test, a greater than RBCs/ ul indicates blunt trauma injury (intra-
abdominal
bleeding)
Psammoma bodies Contain concentric striations of collagen-like material. Seen in benign conditions
and associated
with ovarian and thyroid carcinomas
Tuberculosis Decrease number of mesothelial cells in pleural fluid indicates what condition
> 40 U/L Significant value of Adenosine deaminase (rich in T cells) = for Tuberculosis
Bile, Gall bladder, and pancreatic Greenish color of peritoneal fluid
disorders
 CEREBROSPINAL
FLUID
Method of collection Lumbar, cisternal, or lateral cervical puncture or through ventricular cannulas or shunts
Manometer A device used to measure opening pressure in collecting CSF sample
*note: elevated opening pressure (above 250mm H2O) is indicative of meningitis
CSFtotal volume Adult – 90 to
150ml Neonates-
10 to 60ml
Choroid plexus Specific part of the brain that produces CSF via Selective filtration
Distribution of tubes Tube number Lab section Storage
temperature
1 Chemistry or serology Frozen
2 Microbiology Room temperature
3 Hematology, or cytology refrigerated
4 Microbiology or serology --
In case of 1 tube/sample only Microbiology > hematology > chemistry/serology
Tube number 1 or 4 Can be used for CSF VDRL testing
-associated with intracranial hemorrhage
a. Yellow = due to
bilirubin b.pink =
Xanthochromic CSF oxyhemoglobin
c.orange = carotinoids
/Hypervitaminosis A d.red orange or
red = rifampin
e.brown = meningeal metastastic melanoma
Oily Appearance of CSF that is associated with Radiographic contrast dye
10% What is the suggested value of eosinophil for Eosinophilic meningitis due to parasitic infection
Temperature Turbidimetric measurements of CSF proteins are sensitive a requires a large
sensitive, 0.5ml volume of CSF
volume
Myelin basic component of the myelin nerve sheath, is released during demyelination
protein as a result of various neurologic disorders
-monitors the course of multiple sclerosis
F2-Isoprostanes are increased in diseased regions of the brain in patients with Alzheimer’s disease
(AD) and are markers of free radical brain injury associated with advanced age and
latent AD
CSF dilution
Appearance Dilution
Clear None
Slightly hazy 1:10
Hazy 1:20
Slightly Cloudy 1:100
Cloudy/ Slightly bloody 1:200
Bloody/Turbid 1:10, 000
Traumatic tap Traumatic Tap Intracranial Hemorrhage
vs intracranial Distribution of blood in 3 Uneven / progressively Even
tubes less bloody
hemmorhage Clot formation Positive Negative
Supernatant Clear Xanthochromia
Erythrophages Negative Positive
D-dimer test Negative Positive
Other cells Cartilage cells Siderophages
Cartilage cells may be seen if the vertebral body is accidentally punctured. These cells
Cartilage cells usually occur singly, are medium to large, and have cytoplasm that stains wine red
with a deep wine red nucleus with Wright stain
Siderophages are macrophages (i.e., monocytes or histiocytes) that have ingested
Siderophages RBCs and, as a result of the breakdown of the RBCs, contain hemosiderin.
Hemosiderin appears as large, rough-shaped, dark blue or black granules in the
cytoplasm of the macrophage. These cells also may contain bilirubin or hematoidin
crystals, which are golden yellow and are a result of further breakdown of the ingested
RBCs. The presence of siderophages indicates a
pathologic hemorrhage
2 hours RBCs must usually remain in the CSF for approximately before noticeable
hemolysis begins; therefore, a xanthochromic supernatant would be the result of
blood that has been present longer than that
 -Subtract 1 WBC for every 700 RBC’s seen
RBC count in CSF -Subtract 8 mg/dl Total protein for every 10,000 RBCs/ul seen
-Subtract 1 mg /dl of TP for every 1,200 RBCs/ul seen
Providing better differentiation between Purpose of adding methylene blue to the diluting fluid for CSF WBC
neutrophils and mononuclear cells count?
Normal WBC in Adult: 0 to 5 /ul (70% lymphocytes, 30% monocytes)
CSF Neonates: 0 to 30 ul (80% monocytes, ≤20% lymphocytes)
Tau protein or A carbohydrate deficient transferrin
Beta-2 Transferrin *it positively identifies fluid as CSF
*Found on CSF but absent in serum
60-70% of blood glucose Normal CSF glucose
15 to 45mg//dl or <1% of plasma Normal CSF protein
protein
8 to 18 mg/dl Normal CSF glutamine
. 10-22 mg/dl Normal CSF lactate
The presence of 2 or more oligoclonal bands in CSF but not in serum is valuable for
the diagnosis of
IgG and some IgA Antibodies that can be found normally in small amount in CSF
Tubercular Type of meningitis associated with pellicle or web like clot formation
meningitis -CSF should be refrigerated for 12 to 24hours
Limulus lysate A test that detects gram negative endotoxin
test Reagent: Horse shoe crab blood (blue color due to the copper present in the hemocyanin)
Snowy or Normal CSF with less than 50cells/ul will exhibit appearance in tyndall’s effect
sparkling
VDRL CDC recommended test for neurosyphilis
Albumin Most abundant protein in CSF
. Coomassie brilliant Dye used for the measurement of CSF protein
blue
SSA = can measure globulins only
Turbidimetric method for Trichloro acetic acid = can measure both albumin ang globulins
CSF protein
In SSA turbidimetric method for CSF protein, the addition of will precipitate the
Sodium sulfate albumin
As little as 0.1 mL of CSF combined with one drop of produces an adequate cell yield
30% albumin when processed
with the cytocentrifuge. Adding 30% albumin increases the cell yield and decreases
the cellular distortion frequently seen on cytocentrifuged specimens
Bacterial Viral Tubercular Fungal
Predominant Neutrophi Lymphoc Lymphocyte Lymphocyte
WBC l yte and and
Monocyte Monocyte
Types of Meningitis Protein Increase Increase Increase Increase
Glucose decrease normal decrease decrease
Lactate Increase normal Increase Increase
Nucleated red blood Neutrophils with pyknotic nuclei indicate degenerating cells. They may resemble but
cells (NRBCs) usually have
multiple nuclei
Turbidimetry (SSA and TCA method) AND The two most routinely/commonly used manual
Dye Binding method (uses Coomassie brilliant blue) techniques for
measuring total CSF protein
Gamma region Presence of oligoclonal band in CSF electrophoresis can be located at what region?
Silver staining In CSF electrophoresis by either IFE (Immunofixation electrophoresis) or IEF (Isoelectric
focusing), what staining technique is usually employed?
CSF Lactate It can be frequently tested on CSF sample to monitor severe head injuries.
Falsely elevated Xantochromic or Hemolyzed CSF can lead to CSF lactate values
SEMENALYSIS
Collection (fasting) 2 to 3 days but no longer 7 days
37 Specimen awaiting for spermanalysis should be kept at °C.
Seminiferous Site of spermatogenesis
tubules
Epididymis Site of sperm maturation (the time they will become motile)
Order of sperm maturation Spermatogonium > Primary spermatocyte > secondary spermatocyte > Spermatid >
Spermatozoa
90 days The entire spermatogenesis process takes approximately
Normal appearance Gray- white, translucent, with musty or bleach odor
Flavin It is responsible for the normal gray appearance of semen

RBC Red or brown coloration of the semen is associated with

7.2 to 8.0 Normal pH
2 to 5 ml Normal volume
Papanicolau’s stain Best stain for sperm morphology
Positive displacement Type of pipette used for manual sperm counting
 CASA Automated determination of sperm velocity, trajectory, concentration and morphology
Size of acrosomal cap ½ of the head and 2/3 of the nucleus
Length x width (5um x 3um) Size of the head of sperm
45 um Size of the tail of sperm
Midpiece Size: 7um. It is the thickest part of the tail
OVAL Then normal morphology of sperm head
Varicocele Most common cause of male infertility
Seminal viscosity grading Pour in droplets
0 =WATERY
4= GEL-LIKE (semen that does not liquefy)
*Droplets that form threads longer than 2 cm are considered highly viscous and are
recorded as abnormal
Long neckpiece An abnormally long may cause the sperm head to bend backward and interfere with
motility
30-60 minutes Liquefaction time
Florence Test for Choline
Reagent: potassium iodide and iodine Positive result: Dark brown rhombic crystals
Test for Spermine (very specific)
Barberio’s test Reagent: Trichloro acetic Acid and picric acid
Positive result: Yellow Fern leaf shaped or needle like crystal
Decrease sperm motility Increase Seminal viscosity
Decrease seminal fructose Decrease sperm concentration and decrease sperm motility
4.0 a Rapid, straight line motility
WHO Sperm b Slower speed, some lateral movement
3.0
motility b Slow forward progression, noticeable lateral
grading 2.0 movement
1.0 c No forward progression
0 d No movement
To immobilize the sperm Purpose of diluting fluid (NSS, Water, formalin, or sodium bicarbonate)
SPERM COUNT FORMULA Sperm concentration x semen volume
Makler Counting chamber Undiluted semen sample should be counted using
Epididymis problem Decrease levels of neutral alpha glucosidase is associated with:
Modified blooms Stain for sperm viability or vitality
Living sperm = unstained, bluish white (at least 50%)
test stain: Eosin-Nigrossin Dead sperm = red with a purple background
Acid phosphatase (ACP) Substance that can be analyzed to positively identify sample as semen
Resorcinol test Test for seminal fructose
Positiveresult: orange-red or
orange
2 hours Seminal fructose should be tested within or frozen to prevent fructolysis
10% In neubauer chamber for sperm counting, the difference of count between the 2 side chambers
should agree within
3 to 5 minutes In neubauer chamber for sperm counting, both sides of hemacytometer are loaded and allowed to
settle for
Mechanical (Positive Displacement) Pipette Pipette used for manual sperm counting
24hrs Motile sperm can be detected for up to after intercourse
72 hours Nonmotile sperm can persist for after intercourse
7 days Dead sperm heads remain and may be present for days after intercourse
Aspermia Complete Absence of semen
Necrospermia Presence of dead or immobilized sperms
azoospermia Absence of sperm cell in semen
Terminologies Oligospermia Decrease or low sperm count
Teratospermia Sperm with abnormal morphology
asthenozoosper Abnormal sperm motility
mia

Abnormal result Possible abnormality Test

Decreased motility VITALITY Eosin-Nigrosin stain
with
normal count
Decreased count LACK OF SEMINAL VESICLE Fructose level
SUPPORT
Decreased motility MALE ANTI-SPERM ANTIBODIES MAR and Immunobead test
with clumping Sperm agglutination with male
serum
Normal analysis with Female Antisperm antibodies Sperm agglutination with female
continued infertility serum
Smokers Decreased sperm counts and motility and increased abnormal morphology have been reported in
male smokers when compared with nonsmokers (Henry’s)
Round cells WBC and spermatids
 Sperm motility To provide continuity in reporting, laboratories should place a consistent amount of semen on a
slide under the
assessment same size cover slip, such as 10 μL under a 22 × 22 mm cover slip using a calibrated
positive- displacement pipette, and allow it to settle for 1 minute. This procedure should be
done in duplicate for
VASECTOMY Done 2 months after vasectomy and continued until 2 consecutive monthly specimen show no
sperm

Ejaculatory duct Part of the male reproductive system that receive both the sperm from ductus deferens and fluid
from
seminal vesicles
Flavin Responsible for the gray appearance of semen.

First Most of the sperm are contained in the portion of the ejaculate, making complete collection
essential for accurate testing of both fertility and post-vasectomy specimens.

Sperm motility Presence of urine in semen sample may affect primarily sperm

Liquefying agent Purpose of Dulbecco’s phosphate-buffered Saline, and proteolytic enzymes such as alpha-
chymotrypsin or bromelain

Tests affected with Sperm motility, sperm concentration, anti-sperm antibody detection, and measurement of
an Increased semen biochemical markers
viscosity and
incomplete
liquefaction
Midpiece It is the thickest part of the tail because it is surrounded by a mitochondrial sheath that produces
the energy
required by the tail for motility.
Oil immersion Sperm morphology is evaluated from a thinly smeared, stained slide under what objective
objective
24 hours Slides for Seminal smear that are air-dried are stable for how many hours?

Retrograde An uncommon but treatable condition in which semen is directed into the urinary bladder which
ejaculation /Dry eventually
can be found in urine instead of being ejaculated.
orgasm
lack of prostatic Decreased zinc, citric acid, glutamyl transpeptidase, and acid phosphatase indicates:
fluid
Disorder of the A decreased neutral a -glucosidase, glycerol-phosphocholine, and L-carnitine suggest
epididymis
Spectrophotometry Methods that can be used to quantitate citric acid and zinc on seminal fluid?

Xylene A reagent that can be added to enhance the sperm under microscopic analysis using phase
contrast
microscope
AMNIOTICFLUID
800-1200ml (average: 1000ml) Normal volume (normohydramnios) of amniotic fluid during 3rd trimester
Maternal blood During first trimester Amniotic fluid is derived from
Fetal urine In second and 3rd trimester, majority of Amniotic fluid is derived from
Amniotic fluid In the early stages of gestation, the water in amniotic fluid is derived mostly from maternal
composition serum; however, at 10 weeks, the fetus begins to produce urine which gets secreted into the
amniotic sac. During late gestation (the second and third trimesters), as the amniotic fluid
expands, fetal urine becomes the largest source to the amniotic fluid. Lung secretions,
gastrointestinal secretions, and excretions from the umbilical cord and placental
surface contribute to the composition of amniotic fluid as well; however, lung secretions
alone make
up as much as one-third amniotic fluid
th
14 In general, amniocentesis is a safe procedure, particularly when performed after the week
of gestation
for fetal genetic assessment or genetic abnormality
for women with three or more
15th to 18th week amniocentesis miscarriage for neural tubedefect
for women with metabolic disorder
20 to 42th week amniocentesis for HDN, Fetal distress, fetal lung maturity, and infection
Colorless Normal
Blood streaked Traumatic tap, abdominal trauma, intra –amniotic
Amniotic fluid color hemorrhage
Yellow HDN Bilirubin
Dark green Meconium
Dark red brown Fetal death
Creatinine (>2mg/dl suggests more than 36 weeks Analyte measure in amniotic fluid that suggest fetal age
of gestation)
Urea and Creatinine More reliable test to differentiate amniotic fluid from maternal urine
level
Fern test positive result “fern-like crystals” indicates the fluid is amniotic fluid
Spectrophotometer Measurement of O.D 45O (bilirubin) is performed using
O.D 450 test A test that can be used to differentiate RH HDN and ABO HDN
Specimen collection Amniocentesis = term for the method of collection of amniotic fluid
A maximum of 30 mL of amniotic fluid is collected in sterile syringes. The first 2
or 3 mL collected can be contaminated by maternal blood, tissue fluid, and cells
and are discarded
Meconium formed in the intestine from fetal intestinal secretions and swallowed amniotic fluid.
Biliverdin is responsible for its dark green color. It may be present in the amniotic fluid
as a result of fetal distress.
Interferences inBilirubin Meconium
Oxyhemoglobin with maximum absorbance of 410nm. This interference can
measurement (O.D 450) be removed by extraction with chloroform
Liley graph Zone 1 = non affected or mildly affected fetus
Zone 2 = moderately affected fetus (requires close monitoring)
Zone 3 = severely affected fetus (requires intervention such as
intrauterine or exchange transfusion)
Test for neural tube defect Screening: AFP
Confirmatory: Acetylcholinesterase Reference value: <2 multiples of median

False decrease Effect of blood contamination to the measurement of L/S ratio using TLC

False decrease (stras) Effect of meconium to the measurement of L/S ratio using TLC

L/S Ratio and Phosphatidyl Reference method for fetal lung maturity
glycerol (Brunzel, 3rd
edition)
≥2 Value of L/S ratio that indicates mature lungs
95% ethanol Reagent used in foam shake test
Amniotic fluid + 95%Ethanol --- shake for 15 seconds --- stand for 15
minutes (+) = foam/bubbles/effervescence = mature lungs

Lamellar bodies These are densely packed layers of phospholipids that represent a storage
form of pulmonary surfactant. They are
found and secreted by TYPE 2 PNEUMOCYTES

Platelets Lamellar bodies are counted as in HEMATOLOGY ANALYZERS

R.V = ≥32,000 /m
FECALYSIS
Not a normal constituent of stool
Blood / RBC -The normal fecal specimen contains bacteria, cellulose, undigested foodstuffs,
GI secretions, bile pigments, cells from the intestinal walls, electrolytes, and
water.
Bacterial metabolism produces the strong odor associated with feces and intestinal gas (flatus).
7 to 8 Normal stool pH
Carbohydrate disorders Stool pH of less than 5.5
Stercobilin The normal brown color of the stool is due to
Mucus-coated stool Colitis, Chron disease, colon tumors, excessive straining
Stool is Pale (alcholic), bulky and frothy, foul odor, may appear greasy Biliary obstruction, steatorrhea
and may float
Black, tarry stool Upper GI bleeding and Melena
Steatorrhea Increase fecal fat content / Presence of increase fats in stool (exceeds 6 g per day)
Creatorrhea Increase fecal muscle fiber content
 Qualitative Neutral Stain for Triglycerides
fecal fat fat stain Procedure: emulsified stool + 95% Ethanol+ Sudan III
test Steatorrhea = ≥60ORANGE DROPLETS/HPF
Split fat Stain for total fat content (including Fatty acids, soaps/fatty acid salts,
stain and cholesterol) Procedure: stool + 36% acetic acid + Sudan III + Heat
Steatorrhea = 100 droplets that are 6-75 um in size
Van De Kamer Quantitative fecal fat test
Gold standard for steatorrhea
Container: paint cans
Titrated with Sodium hydroxide
Stool sample: 3-days stool
Rapid test for steatorrhea Acid steatocrit (gravimetric assay), Near-infrared reflectance spectroscopy
(NIRS), Hydrogen nuclear magnetic resonance spectroscopy
A reliable tool to monitor a patient’s response to therapy and screen for
steatorrhea in pediatric
populations.
A rapid test to estimate the amount of fat
excretion. Similar to microhematocrit
Acid steatocrit
Reagent: 5N perchloric acid
Centrifugation: 13,000 rpm for 15 minutes in a microhematocrit
centrifuge An acid steatocrit of <10% indicates steatorrhea in
children
Requires less stool handling by laboratory personnel. The test requires a 48- to 72-
hour stool collection to exclude day-to-day variability, but it does not require reagents
after homogenization of the sample. The result is based on the measurement and
NIRS computed processing of signal data from reflectance of fecal surface, which is
scanned with infrared light between 1400 nm and 2600 nm wavelength.
The technique quantitates water, fat, and nitrogen in grams per 24 hours
≥3 Presence of neutrophils/hpf in stool indicates invasive condition

Wet Stool + Methylene blue

preparati ▪ Methylene blue staining is the faster procedure but may be more
difficult to interpret
on ▪ Methylene blue is used to differentiate Mononuclear cells and
PMNs
Test for fecal Lactoferrin A test for fecal WBC that gives a positive result in invasive bacterial
leukocyte Latex pathogen
▪ It remains sensitive in refrigerated and frozen specimens
agglutinati ▪ Positive in diarrhea with WBC: Salmonella, Shigella,
on Campylobacter, Yersinia, &
enteroinvasive E. coli.
▪ Negative in diarrhea without WBC: Staphylococcus aureus and
Vibrio spp., viruses, and parasites
Dried Stool stained with either Wright's or Gram stains provide permanent slides
preparati for evaluation.
on
Emulsified stool + 10% eosin in alcohol - coverslip and stand for 3 mins then
observed under HPF for 5 minutes
Test for creatorrhea
Undigested Muscle fiber characterized by striation both horizontally and vertically
Presence of >10 undigested fiber associated with biliary obstruction, cystic
fibrosis, and gastrocolic fistulas
FOBT is a screening test for
Methods for detecting fecal occult blood include the guaiac, immunochemical,
Colorectal cancer and fluorometric porphyrin quantification tests.
Immunochemical tests and fecal porphyrin quantification tests
are more sensitive and specific methods than the guaiac-based fecal occult
blood tests.
Result Interferences Avoided (days)
False + Aspirin and other NSAIDs 7 days (for aspirin &
Red meats, horseradish, melons, raw NSAIDs)
Interferences in guaiac broccoli, cauliflower, radishes, and 3days (for Red meat, etc.)
based FOBT
turnips
False - Reducing agent such as Vitamin C 3 days
(>250mg/d)

Proper obtaining sample for Obtaining samples from the center of the stool avoids false-positive reactions from
gFOBT test external contamination.
In FOBT, Failure to allow stool samples to soak into the filter paper slide for
3 to 5 minutes minutes before
 adding developer may result in a false-negative result.
The immunochemical fecal occult blood test (iFOBT) is specific for the globin portion of
human hemoglobin and uses polyclonal anti-human hemoglobin antibodies
iFOBT It is specific for human blood in feces, thus it does not require dietary or drug
restrictions. Results may be read visually or by an automated photometric
instrument
Hemoquant A porphyrin-based FOBT fluorometric test for hemoglobin based on the conversion of heme to
fluorescent porphyrins.
Detects trypsin enzyme (absent of trypsin is associated with
X-ray film test cystic fibrosis) Trypsin deficiency: gelatin is not digested (no
clearing of the area)
Negative result: gelatin is digested (clearing of the area)
A valuable test for the differential diagnosis of malabsorption.
The xylose absorption test involves the patient’s ingestion of a dose of xylose, followed
D-Xylose test by the collection of a 2-hour blood sample and a 5-hour urine specimen
D-Xylose is a pentose sugar that does not need to be digested but does need to be
absorbed to be present in the urine.
If D-xylose result is low/abnormal, the result indicates a malabsorption condition
Sensitive and specific test for exocrine pancreatic insufficiency
Based on ELISA
- uses monoclonal antibodies against human pancreatic elastase-1; therefore,
the result is specific for human enzyme and not affected by pancreatic enzyme replacement
Elastase 1 therapy
- test is specific in differentiating pancreatic from nonpancreatic causes in patients with
steatorrhea
Similar Under normal condition, the relationship between the fecal electrolyte content is to that
of plasma
APT test Specimen: infant stool, vomitus, emesis, or gastric aspirate
Reagent :1% Sodium Hydroxide (NaOH)
Pink supernatant after standing for 2 minutes =indicates presence of Fetal hemoglobin (HbF)
Yellow brown supernatant after standing for 2 minutes = indicates presence of Maternal
Hemoglobin (HbA)
Lab Osmotic diarrhea Secretory diarrhea
test
Example Maldigestion, malabsorption, Viruses, protozoal infection, or
Osmotic lactose bacterial infection, colitis, ZES
versus secretory intolerance, and amoebiasis
diarrhea Osmotic Gap >50mosm/kg(High) <50mosm/kg(High)
Stool Sodium <60 mmol/L >90 mmol/L
Stool output within 24 hours <200 g >200 g
pH <5.3 >5.6
Reducing substance Positive Negative

URINE FORMATION
Nephrons Functional Units of Kidney
1 to 1.5 million Each kidney contains nephrons
150g Each kidney weighs approximately or equivalent to 0.5% of total body mass
25% The human kidney receives approximately of blood pumped through the heart
Renal artery It supplies blood to the kidney
Hydrostatic pressure The difference of the between the sizes of afferent and efferent arterioles help to
creates pressure
1200ml/min Renal blood flow
600-700ml/min Renal plasma flow
Glomerulus Part of the kidney that resembles as sieve
<70,000 Daltons The glomerulus is a non-selective filter of plasma substances with a molecular weight
of less than
Renin-angiotensin The system that regulates the flow of blood to and within the glomerulus that also
aldosterone responds to changes in blood pressure
system Stimulus: decrease BP and/or decrease plasma sodium level
Macula Densa cells found in the DCT, sensor of change in blood pressure
Juxtaglomerular cells found in the afferent arteriole, secretes the Renin enzyme
160-180mg/dl Renal threshold for glucose
. Increase ADH, Value of ADH and urine volume in dehydration state
decrease urine volume
ALH Passive reabsorption of water takes place in all parts of the nephron except the .
ALH Sodium is actively transport in all part of the nephron except in the
Kidney tubules The major site of removal of non-filtered substances
 Shield of negativity A force that repels molecules with a negative charge even molecules are small
enough to pass in the glomerulus
Podocytes Intertwining foot processes found in the glomerulus that inhibits the filtration of large
molecules
Blood pH: Acidic Blood and Urine pH during in cases of metabolic acidosis/Renal tubular acidosis
Urine pH: Alkaline
The single most useful substance that identifies a fluid as urine is its uniquely
Creatinine high
lev
el (approximately 50 times that of plasma).
Creatinine A waste product of muscle metabolism that is produced enzymatically by creatine
phosphokinase from creatine, which links with ATP to produce ADP and energy.
Creatinine clearance test The most commonly used clearance test for assessing GFR
By far the greatest source of error in any clearance procedure using urine is the
Improperly timed urine use of
urin
e specimens
15% to 20% creatinine clearance results can vary by as much as within a single
individual, 24-hour collections are preferable.
Body wt., age, and Sex, Serum Parameters that are added in Cockroft and Gault formula for
creatinine computing eGFR
BASES Parameters that are added in MDRD formula for
BUN, Age, Sex, Ethnicity, Serum computing eGFR 4- variables = Serum creatinine,
albumin
ethnicity, Age, Sex (SEAS)
6- variables = BUN, Age, Sex, Ethnicity, Serum creatinine, and serum
albumin
MDRD Most frequently used formula for eGFR
Inulin polymer of fructose, is an extremely stable substance that is not reabsorbed or
secreted by the tubules
a small protein (molecular weight 13,359) produced at a constant rate by all
nucleated cells. It is readily filtered by the glomerulus and reabsorbed and broken
Cystatin C down by the renal tubular cells. It has potential as a marker for long-term monitoring
of renal function its plasma
▪ its plasma concentration is inversely related to GFR. (Increase in blood =
Decrease GFR)
▪ The rate of production is not affected by muscle mass, sex, or race
Beta-2-Microglobulin It dissociates from human leukocyte antigens (MHC class I) at a constant
rate and is rapidly removed from the plasma by glomerular filtration.
▪ a better marker of reduced renal tubular function than of glomerular function
PSP dye excretion test An obsolete tubular secretion test
P-ammino Hippurate (PAH) Most commonly used test for renal blood flow and renal secretion
Osmolality This measures only the number of particles or solute in a solution
Specific Gravity This measures number and size of particles or solute in a solution
600-2000 mL Normal random urine volume
Type Description Value Exampl
e
Oliguria decrease urine output <400ml/24 Dehydration, shock, hypotension, Nephrotic
hours syndrome, vomiting, diarrhea, severe burns,
tubular dysfunction
Polyuria increase in daily >2000ml/24h DM, DI, Excessive water intake, Diuretic
urine output ours drugs, caffeine, alcohol, renal disease, Drugs
such as lithium
Volume Nocturia increase excretion >500 ml at Pregnancy (S.G of less than 1.018)
of urine/urine output night
of urine at night
in adults Anuria Cessation /no urine ----- Renal stones, renal tumors, renal failure,
output within 24 Hemolytic transfusion reactions, Urinary
hours obstruction, acute renal
failure

Oliguria can be rather abrupt in onset, as can acute renal failure, or it may be due to a chronic progressive
renal disease.

<400ml at night Normal urine volume at night

Increase / Hypersthenuria S.G of urine in patient with Diabetes mellitus
Decrease / Hyposthenuria S.G of urine in patient with Diabetes insipidus