ANALYSIS OF URINE AND BODY FLUIDS

(WEEK 7 - MICROSCOPIC - LEC MIDTERMS)

1st SEM, 2021
MICROSCOPIC EXAMINATION Red Blood Cells
Importance of Microscopic Analysis
● Detect and identify insoluble materials
present in the urine.
● Formed elements seen in urine:
○ RBC
○ WBC
○ Epithelial cells
○ Cast
○ Bacteria, yeast, parasite
○ Mucus
○ spermatozoa
○ Crystals
○ Artifacts
Disadvantages of microscopic analysis
● Least standardized - that’s why they need to
have protocols.
● Most time-consuming part of the routine ● Smooth, non-nucleated, biconcave disks
urinalysis - becoz we need to prepare the slide ● Identified under HPO.
to be examine (we need to prepare all) ● Concentrated: SHRINK
● Diluted urine: SWELL
Macroscopic Screening Ghost cells - RBC that is characterized as LARGE
● Also referred to as “Chemical sieving.” EMPTY CELL and seen in DILUTED URINE (nag swell
- use to enhance the cause effectiveness of yung RBC di kinaya kaya nag lyse na liberate yung
urinalysis hemoglobin content)
Macroscopic Screening Correlations - Once exposed on diluted urine means mas
mataas ang water content.
Screening Test Significance
● Most difficult to recognized because:
Color Blood ○ Lack of characteristic structures
Clarity Hematuria vs. hemoglobinuria/ ○ Variation in size
myoglobinuria ○ Resemblance to other sediment
Confirm pathologic or constituents.
non-pathologic cause of turbidity ● Adding of ACETIC ACID to apportion of the
Blood RBCs/WBCs casts sediment can be helpful in identification.
Protein Cast/cells ● RBC’s that vary in size, cellular protrusion, or
are fragmented are termed as DYSMORPHIC
Nitrite Bacteria/WBCs
DYSMORPHIC - seen in glomerular bleeding
Leukocyte esterase WBCs/WBC casts/bacteria WRIGHT STAIN - for better analysis and to enhance the
Glucose Yeast cell that DYSMORPHIC RBC.
Confuse RBC/ Resemblance of other sediment: YEAST
Sediment Constituents CELL, OIL DROPLETS, & AIR BUBBLES
● RBC ● Clinical significance:
● WBC ○ Associated w/ damage to the
● Epithelial cells glomerular membrane.
● Bacteria ○ Vascular injury w/in the genitourinary
● Yeast tract.
● Parasites ○ Strenuous exercise
● Spermatozoa ○ Menstrual contamination
● Mucus
● Casts
● Crystals

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 ANALYSIS OF URINE AND BODY FLUIDS
(WEEK 7 - MICROSCOPIC - LEC MIDTERMS)
1st SEM, 2021
White Blood Cells EOSINOPHIL

○ Primarily associated with drug induce

interstitial nephritis.
○ Small amount seen in UTI and renal
transplant rejection.
○ Hansel stain and Wright stain can be
used for differentiation.
○ >1% eosinophil is considered
significant.
● Mononuclear cells
○ Lymphocytes
■ Smallest WBC, resembles as
RBC.
■ Seen in early stage of renal
transplant rejection.
○ Monocytes, Macrophages and
Histiocytes
■ Larger cells
● Larger than RBC ■ Appear vacuolated or contain
● Identified under HPO. inclusions
● NEUTROPHILS ● WBC most common sources of identification
○ Predominant WBC in the urine. error is RTE cells.
○ Lyse in dilute alkaline urine. - that is ● An increase in urinary WBC is termed as
why yung processing time should be: PYURIA
within 2 mins becoz after 2 mins ● Associated with:
tendency the urine sample - tataas ○ Pyelonephritis - one or both kidneys
yung yung pH magiging alkaline. becomes infected
○ GLITTER CELLS are large neutrophils ○ Cystitis - inflammation of the bladder
that produces a sparkling appearance. ○ Prostatitis - inflammation of the
GLITTER CELLS - once expose on HYPOTONIC prostate gland
SOLUTION/DILUTED meaning MORE WATER ON ○ Urethritis - inflammation of the
SOLUTION tendency is to absorb accumulate water urethra
then it will SWELL ○ Glomerulonephritis
Staining for glitter cells - Sternheimer-Malbin Stain ○ Lupus erythematosus
BOWNIAN MOVEMENT - random motion of particles ○ Interstitial nephritis
suspended in a fluid. Granules within these larger ○ tumors
cells.

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 ANALYSIS OF URINE AND BODY FLUIDS
(WEEK 7 - MICROSCOPIC - LEC MIDTERMS)
1st SEM, 2021
Epithelial SQUAMOUS EPITHELIAL CELL

Squamous - flatten & largest cell in the urinary

sediment. (looks like sunny side up eggs with
prominent nucleus on the middle part)

TRANSITIONAL EPITHELIAL CELLS

Left side→ Spherical transitional epithelium

Middle →
Right side→ Clumps of transitional epithelial cell
RENAL TUBULAR EPITHELIAL CELLS

Epithelial - linings
CLUE cells - squamous epithelial cell covered by
GARDNERELLA VAGINALIS
Transitional - hindi normal pag madami transitional.
becoz it indicates damage on lining/indication of
invasive neurologic procedure like catheterization,
malignancy or viral infection.
Renal tubular epithelial cells (RTE cells)
- most significant, directly related with the Left side →Round RTE cells - originate from CT
function of the kidney Middle →Cuboidal - originate from COLLECTING DUCT
- 2 or more for HPO - Indicates tubular injury
(pag nag injured and tubules can lead to Right side→ Oval columna/ rectangular RTE cells with
adaptation/death of cell in tubule) granules and fats globules - originate from PCT

● Clinical Significance

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 ANALYSIS OF URINE AND BODY FLUIDS
(WEEK 7 - MICROSCOPIC - LEC MIDTERMS)
1st SEM, 2021
○ RTE cells Triglyceride and Neural fats - they can be readily
■ MOST clinically significant stained by Sudan III or Oil Red O but NOT Cholesterol.
epithelial cells. Polarized microscopy - use to determine the presence
■ Increase amount is indicative of cholesterol we need to observe→ MALTESE CROSS
of NECROSIS of the renal FORMATION (the black one on the picture) (pag nakita
tubule. ng ganyan that will confirm the presence of
Necrosis - cellular death or death of the renal CHOLESTEROL.
tubules Sudan III or Oil Red O for Triglyceride and Neural fats
■ Condition producing tubular - ORANGE RED DROPLETS
necrosis include: Bubble cells - non lipid filled filled vacuoles
● Drug induced toxicity Oval fat granules - these are RTE cells containing
● Hgb and Mgb toxicity lipids.
● Viral infections
(hepatitis B) Bacteria
● Pyelonephritis ● NOT normally present in the urine.
● Allergic reactions ● Present in the form of cocci or bacilli.
● Malignancy ● Identify using HPO.
● Salicylate poisoning ● Presence of bacteria can be indicative of
either upper or lower UTI.
OVAL FAT BODIES ● Most frequently bacteria causing UTI is
(epithelial cells) ● Enterobacteriaceae (Gram negative rods)
● Staphylococcus and Enterococcus are also
capable of causing UTI.

Yeast
● Appear as small, refractive oval structures that
may or may not contain a bud.
● Reported as rare, few, moderate, many per
HPO.
● Candida albicans are seen in diabetic,
immunocompromised patients and women
with vaginal moniliasis
○ Lipid containing RTE cells ● A true yeast infection should be accompanied
○ Examine using Sudan III or Oil Red O by the presence of WBC.
under polarized microscopy.
○ Identified and reported as average Parasites
number per HPO. ● Trichomonas vaginalis - common
○ Bubble cells are RTE cells containing ○ Most frequently encountered parasite
large NONLIPID filled vacuoles. in the urine.
OVAL FAT BODIES - are variant of RTE cells (variant ○ Sexually transmitted pathogen
means they are RTE cells but meron silang another associated w/ vaginal inflammation.
characteristics - they contain LIPIDS ○ Trophozoite is a PEAR-SHAPED
Lipids: FLAGELLATE with an undulating
● triglycerides membrane.
● Neutral fats ○ Darting movement - motile
● Cholesterol ○ Reported per HPO.
NON MOTILE Trichomonas vaginalis resemble as:
● WBC
● TRANSITIONAL EPITHELIAL CELLS
● RTE cells

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 ANALYSIS OF URINE AND BODY FLUIDS
(WEEK 7 - MICROSCOPIC - LEC MIDTERMS)
1st SEM, 2021
● Schistosoma haematobium Casts
○ Bladder parasite ● Hyaline casts
○ Seldom seen in the US ● Rbc casts
● Enterobius vermicularis ● Wbc casts
○ Most common urine contaminant. ● Bacterial casts
Spermatozoa ● Epithelial cells casts
● Fatty casts
● Mixed cellular casts
● Granular casts
● Waxy casts
● Broad casts
Casts
● Casts are the only urinary sediment that are
UNIQUE to the kidney.
● Their shape is the representative of the
● Appear as Oval, slightly tapered heads and tubular lumen. (the size and shape of the cast
long, flagella like tails. will depend on the tubular lumen)
● Urine is toxic to spermatozoa (so pag naka Tubular lumen - space sa loob ng tubules
kita sa urine sample na SPERM CELLS they are ● It has a parallel side, rounded ends and may
NON MOTILE) contain other elements present in filtrate.
● Clinically significant in cases of male infertility ● Examine under LPO
or retrograde ejaculation. (in this case ● Cast matrix dissolve easily in dilute alkaline
makakakita ng maraming sperm sa urine urine.
sample becoz in retrograde ejaculation the
sperm is expelled into the urinary bladder Casts composition and formation
instead of the urethra) ● Major constituent of casts is Tamm horsfall
● Positive in chemical test for protein when protein - is a glycoprotein excreted by the RTE
increased amount of semen is present. cells
● Laboratory protocols vary with regard to ● Other protein incorporated such as albumin
reporting or NOT the presence of and immunoglobulins.
spermatozoa in urine. ● Step by step formation of tamm horsfall
protein matrix:
Mucus ○ Aggregation
○ Formation of loose fibrillar network
○ Additional network to form a solid
structure.
○ Attachment of urinary constituent
○ Detachment from the epithelial cell
○ Excretion of casts
CASTS - will identify depende sa naka incorporate na
urinary constituents
eg: cast with rbc - RBC CAST
● Protein material produced by the glands and cast matrix with wbc - MUDDY CAST
epithelial cells of the lower genitourinary tract walang naka incorporate na filtrate it is purely
and RTE cells. Tamm horsfall protein - HYALINE CAST
● Major constituent is Tamm Horsfall Protein. Termed is Tamm horsfall protein matrix - becoz cast
● Appears as thread like structure. compose of mainly Tamm horsfall protein
● Reported per LPO.
● Frequently seen in female. ● The presence of urinary cast is termed
CYLINDURIA

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 ANALYSIS OF URINE AND BODY FLUIDS
(WEEK 7 - MICROSCOPIC - LEC MIDTERMS)
1st SEM, 2021
Hyaline casts RBC casts

● Most frequently seen casts

- BASIC TYPE OF CAST ● cast with rbc - RBC CAST
- Purely consists of Tamm horsfall protein ● Presence of RBC cast is much more specific
● Increase numbers in: showing bleeding w/in the nephron.
○ Strenuous exercise ● Primarily associated w/ glomerulonephritis
○ Dehydration ● Seen also in individuals participating in
○ Heat exposure strenuous contact sports.
○ Emotional stress ● Detected under LPO by their ORANGE RED
○ Acute glomerulonephritis COLOR.
○ Pyelonephritis
○ Chronic renal disease
○ Congestive heart failure

● They are more fragile, irregular shape and

may exists as fragments.
● In the presence of massive hemoglobinuria or
myoglobinuria, homogenous orange red or
red brown casts may be observed.

WBC casts

● Colorless
● Stained w/ Sternheimer-Malbin
● Parallel sides and rounded ends.
● Cylindroid forms
● Wrinkled or convoluted shapes indicates
aging of the cast matrix.

● Presence signifies infection or inflammation

w/in the nephron.

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 ANALYSIS OF URINE AND BODY FLUIDS
(WEEK 7 - MICROSCOPIC - LEC MIDTERMS)
1st SEM, 2021
● Associated with: ● Confirmatory: sudan III or oil red using
○ Pyelonephritis polarized microscopy.
○ Acute interstitial nephritis
○ glomerulonephritis Mixed Cellular Casts
● Visible using LPO and identified under HPO Mixed cellular casts (hindi lang iisang population ng
● Mostly composed of neutrophils. cells ang meron sa cast matrix meron combination
● Irregular borders with rbc or wbc)
● Associated with:
Bacterial Casts ○ Glomerulonephritis
● Commonly seen in pyelonephritis (one or ○ Pyelonephritis
both kidneys becomes infected) ● Use of stain and phase microscopy aids in
● Resembles as granular casts identification.
● Considered when increase WBC, bacteria and
WBC casts are seen. Granular Casts
● Confirmatory: Gram stain

Epithelial Cells Casts

● 2 types:
○ Coarsely granular casts
○ Finely granular casts
● Non-Pathologic Condition
● Casts containing RTE cells represent advance ○ Lysosomes - excreted by the RTE cells
tubular destruction. ● Pathologic condition
○ Causes: ○ Disintegration of cellular casts and
■ Heavy metals and chemical tubule cells
toxicity. ○ Protein aggregates
■ Drug induced toxicity ● Seen in conjunction with WBC casts.
■ Viral infection ● Visualized under LPO and identified using HPO
■ Allograft rejection. ● Source of identification ERROR:
■ pyelonephritis ○ Clumps of crystals
○ Fecal debris
Fatty Casts ○ Columnar RTE cells
● When remain to tubule for extended periods,
the granules disintegrade and develop a waxy
appearance.
Waxy Casts

- cast matrix containing LIPIDS

● Seen in conjunction w/ oval fat bodies and
free fat droplets.
● Associated with:
○ Nephrotic syndrome
○ Toxic tubular necrosis ● Indicates chronic renal failure.
○ Diabetes mellitus ● Brittle, highly refractive.

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 ANALYSIS OF URINE AND BODY FLUIDS
(WEEK 7 - MICROSCOPIC - LEC MIDTERMS)
1st SEM, 2021
● Appear fragmented with jagged ends and Amorphous phosphates
notched sides.
● Stains dark pink in supravital stains.

Broad Casts

● Granular in appearance (parang buhangin)

● It causes white precipitate in refrigerated
specimen.
● Dilute in acetic acid.
● It can be in alkaline or neutral pH.
● Referred as Renal failure casts.
● Indicates destruction of the tubular walls
Triple Phosphates
(once na nasira yung tubular walls tendency is
mag widen)
● Most commonly seen broad cast are granular
and waxy.

CRYSTALS
● indicate normal and abnormal
● Crystal identification aim to detect abnormal
● types of crystals seen in pathologic disorders. ● Ammonium magnesium phosphate
● Reported as few, moderate, many per HPO. ● “coffin lid”
● Abnormal crystals may be average and ● Birefringent under polarized light
reported per LPO. ● Associated with the presence of urea splitting
Crystal formation bacteria.
● Crystals are formed by the precipitation of ● Dilute in acetic acid.
urine solutes. Calcium phosphate
○ Precipitation factors:
■ changes in temperature
■ solute concentration
■ pH
● Solutes precipitates more at low
temperatures.
● As the concentration of the solute increases,
● their ability to remain in the solution ● Colorless, flat, rectangular plates or thin
decreases. ● prism often in rosette form.
● pH is valuable in identification of crystals. ● Confused w/ sulfonamides crystals
● Dilute in acetic acid
Normal Crystals ● Common constituent of renal calculi.
● It can be in alkaline or neutral pH.
Calcium carbonate

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 ANALYSIS OF URINE AND BODY FLUIDS
(WEEK 7 - MICROSCOPIC - LEC MIDTERMS)
1st SEM, 2021
● Small, colorless, dumbbell or spherical. ● Refrigerated specimen produce pink
● Resembles amorphous materials. sediments - bind in uroerythrin
● Produce gas after addition of acetic acid ● Appear in clumps
● Birefringent ● Alkali and heat soluble
● No clinical significance
Calcium oxalate
Ammonium biurate

● Frequently seen in acidic pH but may appear

in neutral and alkaline pH.
● 2 types:
○ Dihydrate - most common
● Yellow brown color
○ Monohydrate
● “thorny apples”
● Birefringent
● Dissolves at 60˚c and convert to uric acid
● Associated with
● upon addition of glacialacetic acid.
○ renal calculi
● Encountered in old specimens.
○ Foods high in oxalic acid
Uric acid
○ Ethylene glycol poisoning
● Dilute in HCL

Abnormal urine crystals

● Abnormal urine crystals are found in acidic

urine or rarely in neutral urine.
- but most of the abnormal crystals are in
ACIDIC URINE

● Appear as rhombic, four sided flat plates,

wedges, and rosettes.
● Yellow brown, colorless
● Birefringent
● Increase amount is associated with increase
● levels of purines and nucleic acids.
● Alkali soluble
CYSTINE crystals
Amorphous urates

● Seen in patients with metabolic disorder

● Brick dust or Yellow brown granules CYSTINURIA - in this condition instead ma

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 ANALYSIS OF URINE AND BODY FLUIDS
(WEEK 7 - MICROSCOPIC - LEC MIDTERMS)
1st SEM, 2021
reabsorb si cysteine ng tubules ang nangyayari Radiographic dye crystals
walang re-absorption ng cystine so maisasama
siya sa final urine
● Colorless, hexagonal plates.
● Resembles as uric acid
● Positive confirmation with the use of cyanide
nitroprusside test.
● Soluble to ammonia or dilute HCL
● Resembles as cholesterol crystals
Cholesterol crystals ● Birefringent
● Comparison of urinalysis result and
● patient history for better differentiation.
● Soluble in 10% NaOH
Radiographic dye - meaning it will give an increase
specific gravity
Leucine crystals

● Appear as colorless notched plate

● Associated with disorders causing lipiduria
● eg: Nephrotic syndrome
● Seen in conjunction with fatty cast and oval
fat bodies. ● Yellow brown spheres
● Birefringent ● Concentric circles and radial striations
● Soluble in chloroform. ● Seen in liver disorders and accompanied with
● tyrosine crystals.
Bilirubin crystals ● Soluble in hot alkali or alcohol

Tyrosine crystals

● Present in hepatic disorders.

● Clump of yellow color needles or granules.

● Seen in conjunction with positive chemical ● Appear as fine needles

test for bilirubin. ● Form clumps or rosettes.
CONJUGATED - type of bilirubin is being ● Seen in conjunction with leucine and positive
detected (ito yung pwede mag positive sa chemical test for bilirubin.
chemical test for bilirubin) ● Associated with liver disorders and inherited
● Soluble to acetic acid, HCL, NaOH, ether and ● disorders of amino acid metabolism.
chloroform. ● Soluble in alkali or heat

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 ANALYSIS OF URINE AND BODY FLUIDS
(WEEK 7 - MICROSCOPIC - LEC MIDTERMS)
1st SEM, 2021
Sulfonamides Crystals ● Confused with RBC
Oil droplets and air bubbles

● Seen in patient treated for UTI

● Appearance of sulfonamide crystals in fresh ● Sources can be from immersion oil or lotions
urine can suggest possibility of tubular and creams.
damage. ● Resembles as RBC
● Appear as needles, rhombic, whetstones, ● Air bubbles occur when the specimen is
sheaves of wheat and rosettes w/ color. placed under a cover slip.
● Confirm using diazo reaction (principle use in Pollen grains
the parameter for bilirubin in chemical
reagent strip)
● Soluble w/ acetone

Ampicillin Crystals

● Appear as spheres with a cell wall and

occasional concentric circles.

Fibers
● Seen in massive doses of penicillin compound.
● Appear as colorless needles form bundles
following refrigeration
● Check for patient history.

Urinary artifacts
- these are the contaminants
● Starch ● Mistaken as casts
● Oil droplets ● Longer and more refractile
● Air bubbles ● Use of polarized microscope for
● Pollen grains differentiation of fiber from casts.
● Fibers Fecal contaminants
● Fecal contaminants
Starch

● Corn starch is use to powdered gloves ● Due to improperly collected specimens.

(BEFORE) ● Appearance of plant and meat fibers.
● Highly refractile spheres w/ dimpled
● Center
● Resembles as fat droplets (maltese cross)

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