URINARY CRYSTALS

by Geoffrey K. Dube and Robert S. Brown

A 26 year-old man presents with a fever and weakness. His WBC is 133,000, with 83% blasts. Creatinine is 2.0 mg/dl and serum uric acid is 15.4 mg/dl.

© 2004, Beth Israel Deaconess Medical Center, Inc.

Assuming that this patient has uric acid crystalluria. Creatinine is 2. with 83% blasts.0 mg/dl and serum uric acid is 15.A 26 year-old man presents with fever and a rash. which of the following might you find on urine dipstick? a. Urine pH 5.4 mg/dl. 4+ glucose d. 4+ heme c. His WBC is 133.0 b.000. 4+ protein .

. Uric acid crystalluria is not associated with significant amounts of hematuria. preventing the precipitation of urate crystals. Uric acid is soluble in alkaline urine. typically with a urine pH < 5.Uric acid crystals invariably form in acidic urine. The inability of uric acid to crystallize at urine pH > 7.0 is the rationale for urinary alkalinization in patients at risk for acute uric acid nephropathy. glycosuria or proteinuria.5.

as can occur in the presence of infection due to urea-splitting organisms. . Crystal precipitation after micturition is most commonly due to changes in temperature. Crystals can continue to form after micturition. as can occur if the urine is stored at room temperature or in a refrigerator. or changes in urinary pH.Although crystals can be seen in certain clinical scenarios. visualizing crystals under the microscope does not guarantee that the crystals were present in the urinary system. such as kidney stone disease or acute crystal nephropathy.

Assuming that this patient has uric acid crystals. Colorless. Amber-colored rhomboid crystals b. hexagonal crystals c. Colorless. "coffin-lid"-shaped crystals d. dumbbell-shaped crystals e. "Shocks of wheat" . Colorless. what would you expect to see on microscopy? a.

needles or hexagonal plates. irrespective of the size or shape of the individual crystal. rosettes. urate crystals may assume the color of any pigments (such as bilirubin or the medication pyridium) that are present in the urine. although they are much more common in patients with urate nephrolithiasis or acute urate nephropathy. However. as can be seen in the slide above.Uric acid crystals can vary in both size and shape. rhomboids. They are usually amber in color. . Urate crystals can occasionally be seen in normal subjects. They can look like barrels.

Their bright colors under polarized light distinguishes uric acid crystals from other types of crystals. The slide on the right shows the same crystal as viewed under polarized light.The slide on the left shows a a uric acid crystal as viewed with light microscopy. Uric acid crystals are birefringent and beneath polarized light assume a polychromatic appearance. .

They occur in the sediment of patients with cystinuria. . Cystine crystals may be isolated or may be heaped upon one another.0. a genetic defect in renal cystine transport. The urine sediments from two patients with cystine crystals are shown above. They are found in acidic urine. cystine crystals are monomorphic. typically with a urine pH < 6. colorless hexagonal plates which look similar to benzene rings.In contrast to polymorphic urate crystals.

0. Struvite crystals are composed of magnesium ammonium phosphate. with a urine pH > 7.Triple phosphate. . Several struvite crystals are shown above. crystals are described as having a "coffin-lid"-shaped appearance. They are typically seen in alkaline urine. or struvite.

and are frequently found in the urine of patients with infected calculi (struvite stones). In addition to triple phosphate crystals.Triple phosphate crystals are seen in patients with urinary tract infections caused by urea-splitting bacteria. such as Proteus mirabilis. microscopy in these patients with urinary tract infections may show significant leukocyturia (arrows. above right) and bacteriuria. .

They may occur as either bihydrated or monohydrated calcium oxalate. Calcium oxalate monohydrate crystals are colorless and can assume several shapes. biconcave disks. rods and dumbbells (above right. Calcium oxalate bihydrate crystals appear as colorless bipyramids of various sizes (“envelope form”. et al. including ovoids. yellow arrows). Above right. They can be seen in normal individuals with high dietary oxalate ingestion. Coe F.L. and in patients with acute renal failure due to ethylene glycol ingestion.. reprinted with permission. above left). New Engl J Med 327:1141-1152. in patients with nephrolithiasis.Calcium oxalate crystals are usually found in acidic urine. .

Gagnon.128:321 . intravenous acyclovir. Ann Intern Med 1998. and triamterene. R. the crystals can cause acute renal failure by crystalline blockage of the renal tubules. densely packed needles. while the bottom panel shows indinavir crystals in a sheaf of numerous. Indinavir crystals reprinted with permission. When these medications are given in high doses or to volume depleted patients. Other medications that can cause urine crystals to form include indinavir. F. et.“ A sulfadiazine crystal is shown on the left. An example of an indinavir crystal is shown on the right: the top panel shows rectangular plates of various sizes containing needle crystals.Urinary crystals can also be seen in patients taking certain medications. al. One example is sulfadiazine: these crystals appear as striated shells or "shocks of wheat.

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