39

Urine Sediment Photomicrographs/Photographs Case History CM/CMP-17

A 66-year-old woman has history of urinary incontinence. A urinalysis is performed at the request of her primary care physician because a concern of urinary tract infection. Her urinalysis reveals amber, hazy urine, specific gravity 1.020, pH 7.0, no protein, no glucose, no ketones, negative for red or white blood cells, no bilirrubin, and no nitrites.

Referees CM

Participants CMP

Participants

Performance Identification No. % No. % No. % Evaluation

Fiber 32 100.0 2380 96.3 2126 97.5 Good C

M/C

MP-

17

The presence of contaminants such as fiber indicates poor collection (wood fiber from applicator stick) or contamination from disposable diapers (as in this case). Fibers should be distinguished from casts. Features that allow recognition of fibers are dark edges (casts do not have dark edges) and their flat appearance (casts are cylindrical). Unlike casts, fibers polarize brightly. Fibers are usually longer than casts are more refractile than casts. Fibers can be the result of clothing or diapers (such as in the current case). Fibers can also occur as a result of intestinal contamination (at collection, or as a result of a fistula between the intestinal and urinary tracts). Fecal contaminants may appear as plant or meat fibers or a brown amorphous material in different forms and sizes.

40

Urine Sediment Photomicrographs/Photographs Case History CM/CMP-18

A 31-year-old man applies for life insurance. Urinalysis is performed as part of his pre-insurance exam and reveals pH of 6.8 and is negative for red and white blood cells, protein, nitrites or glucose. The urine is yellow and hazy. Regular light (left), Polarized light (right).

Referees CM

Participants CMP

Participants

Performance Identification No. % No. % No. % Evaluation

Starch granule 31 96.9 2415 97.7 2151 98.6 Good

CM

/CM

P-18

Starch particles or granules are a frequent contaminant in urine and other body fluids and result as contamination from the powder used in exam or surgical powdered gloves. They are frequently found in urine and reveal a spherical or oval, sometimes hexagonal, highly retractile appearance. Size may vary (up to several times the size of a RBC) and they typically reveal a dimpled or indented center that resembles a “Maltese cross”. They can be confused with microorganisms, fat, starch granules or even cholesterol droplets. They relatively large size, “central dimple” and refractile nature are useful in their identification.

41

Urine Sediment Photomicrographs/Photographs Case History CM/CMP-19

A 72-year-old woman in a nursing home complains of burning during urination. The nursing home staff report fever of 101.3°F and chills. Urinalysis reveals pH of 9.0, specific gravity of 1.016, urine was “milky” with 2+ leukocytes and heavy bacteria.

Referees CM

Participants CMP

Participants

Performance Identification No. % No. % No. % Evaluation

Erythrocyte 20 100.0 1922 80.0 1811 83.2 Good

CM

/CM

P-19

Hematuria is the presence of red blood cells in the urine. We distinguish macroscopic hematuria (the urine is grossly red) from microscopic hematuria (red blood cells are found in the urinalysis, but the urine is not grossly red). Microscopic examination of the urine is performed to detect RBCs, WBCs, formed elements (casts), bacteria, crystals, etc. This procedure gives insight into the pathological processes that affect the upper and lower urinary tract. Zero to 2 RBCs/hpf are considered within normal limits. Causes for red blood cells/bleeding in urine include infection (like the urinary tract infection in this case), tumor in the kidneys or urinary tract, or urinary tract infection, calculi or urinary tract/kidney stones, derangements of blood clotting or renal disease (for example glomerulonephritis). Red blood cells in the urine appear as colorless disks, approximately seven microns in diameter. Sometimes, they may reveal a biconcave shape when seen from the side. They should be distinguished from yeast, lacking budding seen in yeast, or from fat droplets, which unlike RBCs are highly refractile. Positive identification may be accomplished by use of dilute (2%) acetic acid added to the urine sediment that will result in lysis of RBCs.

42

Urine Sediment Photomicrographs/Photographs

CM

/CM

P-19 co

n’t

In concentrated (hypersthenuric) urine, the cells may shrink due to loss of water and appear crenated or irregularly shaped. In dilute (hyposthenuric) urine, the cells absorb water, swell, and lyse rapidly, releasing their hemoglobin, leaving only the cell membrane (ghost cells). Ghost red cells may be missed if the specimen is not examined under reduced light. Of all sediments, red blood cells are the most difficult in recognition. Red blood cells may be confused with yeast cells, oil droplets or air bubbles. Yeast can be identified because they frequently exhibit budding. Yeast cells also appear in a different plane than the other sediment constituents. The rough appearance of crenated red blood cells may resemble granules in white blood cells; however, much smaller than white blood cells. Dilute acetic acid will lyse red blood cells and aid in the distinction from yeast cells, oil droplets, or white blood cells. Supravital stains may also be helpful. Dysmorphic RBCs with spheroid surface protrusions are seen in renal/glomerular bleeding while eumorphic RBCs are seen in post renal bleeding. Normally, red cells do not appear in the urine, although the presence of 1-2 RBC/HPF is usually not considered abnormal. The mechanism by which RBCs enter the urine is not entirely clear. Unlike WBCs, RBCs do not exhibit ameboid characteristics, and therefore, they must stay within blood vessels. Injury or rupture of the blood vessels of the kidney or urinary tract releases red cells into the urine, but this does not account for the acceptance of “the normal” presence of a few RBCs in the urine. The arrowed objects were correctly identified as red blood cells by 83.2% of participants. Incorrect responses included: yeast/fungi (7.9%), leukocyte neut /eos /lymph (6.8%) and fat globules (5.8%). Identification of red cells in the urine may be difficult, as they do resemble other structures. Red blood cells are colorless non-refractile discs that are fairly uniform. If they are seen sideways, they are in the form of a biconcave disc. If the urine is concentrated, they may lose water and become crenated. Yeast are often smaller than red cells, and may be ovoid or round with budding. White cells generally have a visible nucleus, compared to red cells, and are usually larger than red cells. Neutrophils and eosinophils have granular cytoplasm and measure approximately 12 microns in diameter. Fat globules usually vary in size and are highly refractile. The arrowed objects in the test image were round and uniform. They were small, non-refractile and uniform, with agranular cytoplasm, no nuclei and no budding.

43

Urine Sediment Photomicrographs/Photographs Case History CM/CMP-20

A 55-year-old man presents with a urinary tract infection. Urinalysis reveals a cloudy specimen with a pH of 9.0 and urine cultures grow Proteus species.

Referees CM

Participants CMP

Participants

Performance Identification No. % No. % No. % Evaluation

Ammonium magnesium phosphate

(triple phosphate) 32 100.0 2399 97.5 2140 98.2 Good

CM

/CM

P-20

Triple phosphate crystals (TPC) are commonly seen in alkaline urine. Typically they are colorless, three- to six-sided prism-shaped resembling a “coffin lid”. As they lyse they may develop a feathery appearance. Less commonly, they may appear as colorless sheets, flakes, flats, ferns, or leaf forms. TPC are birefringent under polarized light. Although they do not have significance by themselves (they are considered “normal” crystals), they are frequently associated with highly alkaline urine seen with urea-splitting organisms (mostly Proteus species, and other such as Pseudomonas and others). They are soluble in dilute acetic acid that helps to distinguish them from other particles.

Ramon Blanco, MD Hematology and Clinical Microscopy Resource Committee

44

Body Fluid Photomicrographs/Photographs

Case History CM/CMP-21 The patient is a forty-nine-year old male with long-standing cardiac disease and history of recurrent pleural effusions (abnormal accumulation of fluid in the pleural space). He recently presented to the emergency room with a cough and increased difficulty in breathing. Radiological studies revealed large bilateral pleural effusions. The patient underwent pleural aspiration in which a needle was inserted in to the pleural space to obtain fluid. The fluid specimen appeared cloudy and was sent to the laboratory for biochemical, microbiological and cell evaluation. The patient was subsequently diagnosed with pneumonia.

Referees CM

Participants CMP

Participants

Performance Identification No. % No. % No. % Evaluation

Neutrophil 30 100.0 1629 99.0 1583 99.0 Good

CM

/CM

P-21

The arrowed cell is a mature neutrophil. It was correctly identified by all of the referees and 99.0% of participants. The arrowed neutrophil has characteristic nuclear and cytoplasmic features. The nucleus shows segmentation and is connected by thin condensed chromatin filaments. The cytoplasm shows small pink specific granules. In the arrowed neutrophil, vacuoles are present. Vacuoles are also noted in other white blood cells in the field. The presence of these vacuoles may indicate cellular degenerative changes.

45

Body Fluid Photomicrographs/Photographs

Case History CM/CMP-22 The patient is a forty-nine-year old male with long-standing cardiac disease and history of recurrent pleural effusions (abnormal accumulation of fluid in the pleural space). He recently presented to the emergency room with a cough and increased difficulty in breathing. Radiological studies revealed large bilateral pleural effusions. The patient underwent pleural aspiration in which a needle was inserted in to the pleural space to obtain fluid. The fluid specimen appeared cloudy and was sent to the laboratory for biochemical, microbiological and cell evaluation. The patient was subsequently diagnosed with pneumonia.

Referees CM

Participants CMP

Participants

Performance Identification No. % No. % No. % Evaluation

Lipophage 9 30.0 692 41.9 626 39.2 Good Monocyte/macrophage 17 57.0 590 35.7 644 40.4 Acceptable

CM

/CM

P-22

The arrowed cell is a lipophage. It was correctly identified by 87.0% of referees and 79.6% of participants. A lipophage is a macrophage containing small uniform lipid vacuoles in the cytoplasm. The lipophage is a rather large cell. The nucleus is round to oval with a chromatin pattern ranging from dense and reticular to coarsely clumped. The vacuoles of a lipophage are filled with fat. The lipid/ fat is derived from the breakdown of cells secondary to injury or disease.

46

Body Fluid Photomicrographs/Photographs

Case History CM/CMP-23 The patient is a forty-nine-year old male with long-standing cardiac disease and history of recurrent pleural effusions (abnormal accumulation of fluid in the pleural space). He recently presented to the emergency room with a cough and increased difficulty in breathing. Radiological studies revealed large bilateral pleural effusions. The patient underwent pleural aspiration in which a needle was inserted in to the pleural space to obtain fluid. The fluid specimen appeared cloudy and was sent to the laboratory for biochemical, microbiological and cell evaluation. The patient was subsequently diagnosed with pneumonia.

Referees CM

Participants CMP

Participants

Performance Identification No. % No. % No. % Evaluation

Plasma cell 12 41.0 839 51.0 855 53.7 Educational

CM

/CM

P-23

The arrowed cell is a plasma cell. It was correctly identified by 41.0% of referees and 53.7% of participants. Clues to the identity of this cell include its eccentrically located nucleus and its cytoplasmic inclusions. The inclusions have a grape-like appearance and are known as morula or Mott cells. The inclusions represent immunoglobulin. This identification is challenging since the arrowed cell and other cells in the field show degenerating changes.

47

Body Fluid Photomicrographs/Photographs

Case History CM/CMP-24 The patient is a forty-nine-year old male with long-standing cardiac disease and history of recurrent pleural effusions (abnormal accumulation of fluid in the pleural space). He recently presented to the emergency room with a cough and increased difficulty in breathing. Radiological studies revealed large bilateral pleural effusions. The patient underwent pleural aspiration in which a needle was inserted in to the pleural space to obtain fluid. The fluid specimen appeared cloudy and was sent to the laboratory for biochemical, microbiological and cell evaluation. The patient was subsequently diagnosed with pneumonia.

Referees CM

Participants CMP

Participants

Performance Identification No. % No. % No. % Evaluation

Basophil, mast cell 20 69.0 905 55.1 1140 71.5 Educational

CM

/CM

P-24

The arrowed cell is a basophil/ mast cell. It was correctly identified by 69.0% of referees and 71.5% of participants.Identifying characteristics of these cells are their large metachromatic cytoplasmic granules. These granules can be unevenly distributed in the cytoplasm. Basophils / mast cells are not commonly found in body fluids although they can be present in inflammatory conditions and parasitic infections.

48

Body Fluid Photomicrographs/Photographs

Case History CM/CMP-25 The patient is a forty-nine-year old male with long-standing cardiac disease and history of recurrent pleural effusions (abnormal accumulation of fluid in the pleural space). He recently presented to the emergency room with a cough and increased difficulty in breathing. Radiological studies revealed large bilateral pleural effusions. The patient underwent pleural aspiration in which a needle was inserted in to the pleural space to obtain fluid. The fluid specimen appeared cloudy and was sent to the laboratory for biochemical, microbiological and cell evaluation. The patient was subsequently diagnosed with pneumonia.

Referees CM

Participants CMP

Participants

Performance Identification No. % No. % No. % Evaluation

Mesothelial cell 30 100.0 1599 96.8 1528 95.9 Good C

M/C

MP-

25

The arrowed cells represent mesothelial cells. These were correctly identified by all of the referees and 96.8% of participants. They are rather large cells, as seen in comparison to the neutrophils in the field. A mesothelial cell may have a single nucleus or multiple nuclei. The nuclei are round to oval and are either centrally or slightly eccentrically placed. Sometimes a lighter staining around the nucleus (pseudo-halo effect) can be seen. The cytoplasm is abundant with a bluish color and with a grainy texture. The edges of mesothelial cells may be smooth or show a fringed pattern due to the presence of long microvilli. Mesothelial cells line the pleural cavity. In chronic effusions or inflammatory conditions, mesothelial cells can proliferate, become large in size, and have a varied appearance.

49

Body Fluid Photomicrographs/Photographs

Case History CM/CMP-26 The patient is a 63-year-old Caucasian male with rheumatoid arthritis and a chronic right pleural effusion. WBC=33,000/μL; RBC=1,518,000/μL; Protein=5.5 g/dL; LD=2298 IU/L; Triglyceride=16 mg/dL.

Referees CM

Participants CMP

Participants

Performance Identification No. % No. % No. % Evaluation

Cholesterol crystal 27 96.4 1633 99.5 1590 99.6 Good

CM

/CM

P-26

The arrow shows a cholesterol crystal. It was correctly identified by 96.4% of the referees and 99.6% of participants. Cholesterol crystals are generally flat, transparent and plate-like. These crystals can be single or form stacks. Cholesterol crystals are not commonly found in pleural effusions, but can be seen in patients with rheumatoid arthritis, tuberculosis or parasitic lung infections.

Patricia A. Devine, MD

Hematology and Clinical Microscopy Resource Committee

50

Clinical Microscopy Miscellaneous Photomicrographs/Photographs

Referees CMM

Participants CMMP

Participants

Performance Identification No. % No. % No. % Evaluation

Ferning is present 15 100.0 1136 99.8 1081 99.2 Good

CM

M/C

MM

P-36

This air dried slide of vaginal pool fluid demonstrates "ferning" or an elaborate arborized crystallization pattern indicating the presence of amniotic fluid. This test is used to detect rupture of amniotic membranes and the early onset of labor.

Referees CMM

Participants CMMP

Participants

Performance Identification No. % No. % No. % Evaluation

Neutrophils are present 19 100.0 1473 99.1 1457 99.4 Good

CM

M/C

MM

P-37

This Wright-Giemsa stained stool smear demonstrates neutrophils present. In stool, the presence of neutrophils is suggestive of certain enteric pathogens. Shigella, Salmonella and Campylobacter infections often have neutrophils present in stool.

Sarah L. Lott, MD Hematology and Clinical Microscopy Resource Committee

51

Clinical Microscopy Miscellaneous Photomicrographs/Photographs

Referees CMM

Participants CMMP

Participants

Performance Identification No. % No. % No. % Evaluation

No pinworm or pinworm eggs are

present 18 94.7 1316 97.5 1247 98.0 Good

CM

M/C

MM

P-38

This stool specimen is negative for Enterobius vermicularis (pinworm). Enterobius vermicularis is also called human pinworm. (Adult females: 8 to 13 mm, adult male: 2 to 5 mm.) To make the diagnosis of pinworm in a patient who presents with anal itching, place either a piece of transparent tape or a pinworm paddle on the anal skin. This is ideally done first thing in the morning, when the number of eggs on the skin surface is highest. The tape is then applied to a glass slide. Following additional of toluidine blue, the slide is examined for pinworm. The eggs are elongated, flattened on

one side, 50-60 μm long by 20-32 μm wide, with a thick shell. Multiple samples may be required to make the diagnosis.

52

Clinical Microscopy Miscellaneous Photomicrographs/Photographs

Referees CMM

Participants CMMP

Participants

Performance Identification No. % No. % No. % Evaluation

No eosinophils are present 17 100.0 1342 99.2 1315 98.6 Good C

MM

/CM

MP-

39

This nasal smear is negative for eosinophils. Nasal eosinophils are seen in patients with clinical allergic rhinitis. In nonallergic causes of nasal discharge, either acellular mucus or neutrophils will be present on the nasal smear. Nasal smears for eosinophils are prepared by having the patient blow his/her nose in a nonabsorbent material (wax paper, plastic wrap). A swab is then used to transfer the mucus to a glass slide. A thin smear is prepared and let air dry. Staining may be performed using a Wright-Giemsa stain or a Hansel stain. The advantage to the Hansel stain is that the eosinophils stain bright red, whereas with a Wright-Giemsa stain the eosinophil granules may take on a more bluish appearance.

53

Clinical Microscopy Miscellaneous Photomicrographs/Photographs

Referees CMM

Participants CMMP

Participants

Performance Identification No. % No. % No. % Evaluation

No yeast or other fungal element is

present 21 91.3 1522 95.7 1537 98.1 Good

CM

M/C

MM

P-40

This KOH wet preparation is negative for the presence of yeast. Vaginal wet preparations are a useful tool in the evaluation of suspected vulvovaginitis. Candida species and Trichomonas organisms are readily identifiable on wet preparations.

Referees CMM

Participants CMMP

Participants

Performance Identification No. % No. % No. % Evaluation

Spermatoza are present 19 100.0 1477 98.8 1498 99.4 Good

CM

M/C

MM

P-41

Sperm are present on this vaginal wet preparation. In wet preparations, the sperm head is 4-6 μm

long and usually tapers anteriorly. Slender tails are 40-60 μm long. A vaginal secretion specimen is collected from the posterior vaginal pool by a speculum that has not been lubricated with petroleum jelly. The secretions are collected on a cotton or dacron-tipped swab and are mixed with a few drops of saline on a slide. The slide is studied with brightfield or phase microscopy.

Deborah A. Perry, MD

Hematology and Clinical Microscopy Resource Committee