NAME: LENARD S.

ABO

COURSE: III BMLS

SUBJECT: AUBF

WHAT IS TELESCOPIC SEDIMENTS?

A ‘telescopic’ urine sediment CONTAINS have equal amounts in regards to QUANTITATION OF

(GRANULAR, WAXY AND BROAD CAST) which occurs in conditions such as Lupus nephritis, malignant
hypertension, diabetic glomerulosclerosis, Acute renal failure and reflects elements of global nephron
(glomerular and tubular) dysfunction with ongoing active disease superimposed on chronic renal -
damage.

CASE STUDIES CHAPTER 6

1. An 85-year-old woman with diabetes and a broken hip has been confined to bed for the past
3 months. Results of an ancillary blood glucose test are 250 mg/dL, and her physician orders
additional blood tests and a routine urinalysis. The urinalysis report is as follows:

Color: pale yellow ketones: negative

Clarity: hazy. Blood:negative
SG: 1.020. bilirubin: negative
pH: 5.5. Urobilinogen: normal
Protein: trace. Nitrite: negative
Glucose: 100 mg/dL. Leukocytes: 2+
Microscopic:
20 to 25 WBCs/hpf
Many yeast cells and hyphae

a. Why are yeast infections common in patients with diabetes mellitus?

The acidic medium, and glucose in the urine of diabetic patient provides good medium for
yeast growth laboratory primarily Candida albicans.

b. With a blood glucose level of 250 mg/dL, should glucose be present in the urine? Why or
why not?
Yes. The level 250 mg/dL exceeded the renal threshold level of glucose.
Glucose is reabsorbed in proximal tubule only in a limited amount. When blood glucose
reaches 180 mg/dL, glucose is excreted in urine. This point is termed as renal threshold of
glucose.

c. Is there a discrepancy between the negative nitrite and the positive leukocyte esterase
results? Explain your answer.
there is no discrepancy between positive leukocyte esterase result, and negative nitrite
result. Yeast does not have ability to reduce nitrate to nitrite

d. What is the major discrepancy between the chemical and microscopic results?
 Moderate presence of blood without red blood cells.The result of microscopic analysis shows
only 20 to 25 WBCs/hpf. Blood contains both WBCs (White Blood Cells), and RBCs

e. Considering the patient’s history, what is the most probable cause for the discrepancy?
Myoglobin caused the positive chemical test result of blood. Due to muscle destruction, the
patient is bed-ridden since 3 months. Myoglobinuria is associated with destruction of muscles.
Patient with conditions related with muscle destruction are suspected for presence of myoglobin in
urine. The conditions associated with muscle destruction are prolonged coma, crush syndrome,
trauma etc.

2. A medical technology student training in a newly renovated STAT laboratory is having

difficulty performing a microscopic urinalysis. Reagent strip testing indicates the presence of
moderate blood and leukocytes, but the student is also observing some large unusual
objects resembling crystals and possible casts. The student is also having difficulty keeping
all of the constituents in focus at the same time.

a. Why is the student having difficulty focusing?

Observation of unusual large objects in different plane resembling casts, and crystals along
with the urinary constituents made it difficult for the student to focus.

b. What is a possible cause of the unusual microscopic constituents?

The contamination of artifacts since artifacts are considered to be larger than the true urinary
sediments

c. Should the student be concerned about the unusual microscopic constituents? Explain your
answer.
Due to fact that artifacts are on different microscopic plane, the student should not be
concerned about it

d. What microscopy technique could be used to aid in differentiating a cast and an artifact?
The usual microsocpy technique that is utilized to differentiate cast and artifact is the
polarising microscopy for example the fiber contamination which particularly are bifrengent
than the cast.

3. A prisoner sentenced to 10 years for selling illegal drugs develops jaundice, lethargy, and
hepatomegaly. A test for hepatitis B surface antigen is positive, and the patient is placed in
the prison infirmary. When his condition appears to worsen and a low urinary output is
observed, the patient is transferred to a local hospital. Additional testing detects a
superinfection with delta hepatitis virus and decreased renal concentrating ability. Urinalysis
results are as follows:

Color: amber ketones: negative

 Clarity: hazy. Blood:negative
SG: 1.011 bilirubin: large
pH: 7.0 Urobilinogen: 4.0 EU
Protein: 2+. Nitrite: negative
Glucose: negative . Leukocytes: negative

Microscopic:
2 to 4 WBCs/hpf
1 to 3 RBCs/ hpf
1 to 2 hyaline cast/lpf
1 to 2 granular casts/lpf
2 to 4 bile stained RTE cells/hpf
0 to 1 RTE casts/lpf
0 to 1 bile stained waxy casts/lpf

a. Based on the urinalysis results, in what area of the nephron is damage occurring?
Renal tubules of the nephron are damaged. Renal tubular epithelial cells originates from
renal tubules. Presence of more than 2 RTE cells per high-power field signifies renal
tubular injury

b. Is this consistent with the patient’s primary diagnosis? Explain your answer.
Yes since viral infections on kidneys can cause tubular damage

c. What is causing the RTE cells to be bile stained?

Because one of the functions of RTE cells is reabsorption of the glomerular filtrate, RTE
cells absorb bilirubin present in the filtrate as the result of liver damage cause by the
virus and may appear a deep yellow color.

d. Why is the urobilinogen level elevated?

The damaged liver cannot process the reabsorbed urobilinogen

e. State a disorder in which the urobilinogen level would be elevated, but the bilirubin result
would be negative.
Common disorder that there is increase urobilinogen level but bilirubin would be negative
is Hemolytic anemia. Since serum bilirubin is present in unconjugated forms and kidney
cannot excreted it.

4. A 30-year-old woman being treated for a UTI brings a urine specimen to the Employee
Health Clinic at 4:00 p.m.
The nurse on duty tells her that the specimen will be refrigerated and tested by the
technologist the next morning.
The technologist has difficulty interpreting the color of the reagent strip tests and reports only
the following results:
Color: amber Clarity: slightly cloudy
Microscopic:
3 to 5 RBCs/hpf
8 to 10 WBCs/hpf
Moderate bacteria
Moderate colorless crystals appearing in bundles
 a. What could have caused the technologist to have difficulty interpreting the reagent strip
results?
The patient intake of phenazopyridine a pigmented medication is mistaken for bilirubin.
Phenazopyridine compound produces yellow-orange urine

b. Could this specimen produce a yellow foam when shaken?

Yes

c. What could the technologist do to aid in the identification of the crystals?

By asking if what medication does the patient are taking
d. What is the probable identification of the colorless crystals?
Ampiciliin crystals which appears as colorless needles that tend to form bundles
following refrigeration.

5. A 2-year-old left unattended in the garage for 5 minutes is suspected of ingesting antifreeze
(ethylene glycol). The urinalysis has a pH of 6.0 and is negative on the chemical
examination. Two distinct forms of crystals are observed in the microscopic examination.

a. What type of crystals would you expect to be present?

Crystal expected in urine specimen is calcium oxalate.

b. What is the other form of this crystal?

The presence of dihydrate calcium oxalate along with the monohydrate of calcium
oxalate

c. Describe the two forms.

dihydrate calcium oxalate (weddelite) in enveloped shaped or pyramid form and the
monohydrate of calcium oxalate (whewellite) in oval or dumpbell form

d. Which form would you expect to be predominant?

The monohydrate forms since it is noticed in the cases of antifreeze component ethylene
glycol poisoning Monohydrate calcium oxalate crystals are often seen in pets, and
children, because antifreeze is sweet in taste. Uncovered containers kept in garage are
very tempting. Hence, the children unknowingly intake the antifreeze.

6. A female patient comes to the outpatient clinic with symptoms of UTI. She brings a urine
specimen with her. Results of the routine analysis performed on this specimen are as
follows:

Color: yellow. ketones: negative

Clarity: hazy. Blood:small
SG: 1.015 bilirubin: negative
pH: 9.0 Urobilinogen: normal
Protein: negative Nitrite: negative
Glucose: negative. Leukocytes: 2+
Microscopic:
1 to 3 RBCs/hpf heavy bacteria
8 to 10 WBCs/hpf. Moderate squamous epithelial cells
 a. What discrepancies are present between the chemical and microscopic test results?
Microscopic results are not in match with the chemical tests for leukocyte esterase,
nitrite, and blood.

b. State a reason for the discrepancies.

The specimen have not been preserved at room temperature for a long period of time
causing the specimen to be alkaline, and diluted alkaline urine causes integration of
blood cells. And since there is now a large number of bacteria the nitrite will be
converted into nitrogen causing a false negative results.

c. Identify a chemical result in the urinalysis that confirms your reason for the
discrepancies.
The pH of the urine which is due to not properly preserved causes a alkalinization.

d. What course of action should the laboratory take to obtain accurate results for this
patient?
Repeat collection and instruct the patient to collect midstream clean catch specimen and
delivered it immediately to the lab.

7. A high school student is taken to the emergency room with a broken leg that occurred during
a football game. The urinalysis results are as follows:
Color: dark yellow ketones: negative
Clarity: hazy. Blood: moderate
SG: 1.030 bilirubin: negative
pH: 5.5 Urobilinogen: normal
Protein: 2+. Nitrite: negative
Glucose: negative. Leukocyte: negative

Microscopic:
0 to 3 WBCs/hpf
0 to 4 hyaline casts/lpf
0 to 3 granular casts/lpf
Few squamous epithelial cells

a. Are these results of clinical significance?

No, because the results obtained are due to strenuous activity. RBC casts are formed
after strenuous sports in a healthy individual.

b. Explain the discrepancy between the chemical and microscopic blood results.
The positive blood reaction is from hemoglobinuria or Myoglobinuria resulting from
participating in sport. The protein is orthostatic.

c. What is the probable cause of the granular casts?

Increase excretion of RTE cell lysosomes in the presence of dehydration and due to normal
metabolism. Increased cellular metabolism occurs during strenuous exercise Which
accounts to the transient increase of granular cast that accompanies increased of hyaline
casts.
8. As supervisor of the urinalysis section, you are reviewing results. State why or why not
each of the following results would concern you.
a. The presence of waxy casts and a negative protein in urine from a 6–month-old girl
Yes, waxy casts are not related with negative urine protein. The presence of waxy casts is
probably due to an artifact. The fiber present in clothes and diapers are artifacts, which are mistaken
for casts.

b. Increased transitional epithelial cells in a specimen obtained following cystoscopy

No, this is normal following invasive urologic procedure and has no clinical significance.
Transitional epithelial cells may become pathologic only if it has abnormal morphology such as
vacuoles and irregular nuclei seen on malignancy and viral infections.

c. Tyrosine crystals in a specimen with a negative bilirubin test result

Yes, it has discrepancies. The bilirubin should be positive because the presence of
tyrosine crystals in urine is the most commonly seen on severe liver disease. The
reported crystals may be mistaken as tyrosine and may actually be an artifact.

d. Cystine crystals in a specimen from a patient diagnosed with gout

Yes, cysteine is not associated with gout disease, the staff may mistaken it as uric acid
which is usually seen on patient with gout disease. The confirmation should be
polarisation microscopy since uric acid are highly birefringent while cysteine is not.

e. Cholesterol crystals in urine with a specific gravity greater than 1.040

Yes, since there is a discrepancy with the identification of the crystals. Radiographic dye
crystals have very similar appearance to cholesterol crystals which is also highly
birefringent. But then radiographic contrast media is associated with markly increase
specific gravity

f. Trichomonas vaginalis in a male urine specimen

No l, because trichomonas is carried asymptomatically by men.

g. Amorphous urates and calcium carbonate crystals in a specimen with a pH of 7.0

No, since amorphous urates are found in acidic urine while calcium carbonate crystals
are found in alkaline urine so clumps of amorphous phosphate may be present. And
normally this crystals are normally found in urine that are alkaline.