Urine Sediment Image Gallery

OUTLINE
Artifacts/Contaminants, 192 Drug Crystals, 202
Blood Cells, 193 Phosphate Crystals, 202
Red Blood Cells, 193 Urate Crystals, 204
White Blood Cells, 194 Uric Acid Crystals, 204
Casts, 194 X-ray Contrast Media Crystals, 205
Cellular Casts, 194 Epithelial Cells, 205
Granular Casts, 197 Fat Droplets and Oval Fat Bodies, 207
Hyaline Casts, 198 Microorganisms, 208
Waxy Casts, 198 Bacteria, 208
Crystals, 199 Trichomonads, 208
Ammonium Biurate Crystals, 199 Yeast, 209
Bilirubin Crystals, 200 Miscellaneous Formed Elements, 210
Calcium Carbonate Crystals, 200 Hemosiderin, 210
Calcium Oxalate Crystals, 200 Mucus, 210
Cholesterol Crystals, 201 Sperm, 210
Cystine Crystals, 201

ARTIFACTS/CONTAMINANTS

FIG. 1 Three air bubbles trapped beneath a coverslip
observed using low-power (100) magnification. Numerous
white blood cells (WBCs) are also present. Note that very
small air bubbles may be mis-identified as RBCs by an inexpe-
rienced microscopist.
FIG. 2 An absorbent fiber (diaper or hygiene product). Note its
flat, wrinkled appearance and strong refractility. For an inexpe-
rienced microscopist, these fibers may be misidentified as
waxy casts.

192

FIG. 3 A clothing fiber. Its strong refractility, frayed ends, and
flatness aid in its proper identification.
FIG. 5 When plastic commercial standardized slides are used,
fragments of plastic (red arrows) can be present in the sedi-
ment. Red blood cells, yeasts, and pseudohyphae are also
present.
BLOOD CELLS
Red Blood Cells
FIG. 7 Numerous intact and ghost red blood cells (arrows). In
this image, intact cells have a characteristic appearance
caused by the hemoglobin within them. In contrast, ghost
red blood cells (RBCs) have intact cell membranes but have
lost their hemoglobin. This urine was hypotonic (dilute; low
specific gravity), and many of the RBCs appear swollen and
rounded because of the diffusion of fluid into the cells.
Urine Sediment Image Gallery 193
FIG. 4 A starch granule (black arrow) demonstrating a charac-
teristic dimple. When glass slides and coverslips are used,
glass fragments (red arrows) can be present. Numerous white
blood cells are also present.
FIG. 6 Three starch granules, all highly refractile, with slightly
differing appearances, yet each has a centrally located dimple.
Fragments of plastic (red arrows) are also present.
FIG. 8 Redbloodcellsinhypertonicurine(concentrated;highspe-
cific gravity). Many of the cells in this field of view have lost their
typical biconcave shape and become echinocytes (i.e., crenated).
This happens when fluid moves out of the cell in an attempt to
achieve balance with the tonicity of the environment. Conse-
quently, the cell membrane shrinks, forming folds or projections;
a process that is reversible. Near the center is a single schizocyte
form—fragmented RBC with three pointed extremities.
194 Urine Sediment Image Gallery

White Blood Cells

FIG. 9 White blood cells and a single squamous epithelial cell. FIG. 10 Five white blood cells. Note that the lobed nuclei in
several of these neutrophils are readily apparent, whereas in
those that are degenerating, the nucleus has become mono-
nuclear.

A B
FIG. 11 A, Three white blood cells, a single red blood cell, and a squamous epithelial cell. Note the
size similarity between the squamous cell nucleus and the diameter of the white blood cells. B,
Numerous white blood cells and two red blood cells (just left of center). Many of the WBCs show
evidence of degeneration.

CASTS
Cellular Casts

FIG. 12 A mixed cellular cast. FIG. 13 Renal tubular epithelial cell cast with one end broken
or incompletely formed.
 Urine Sediment Image Gallery 195

FIG. 14 Renal tubular epithelial cell cast. Note the cuboidal FIG. 15 A renal tubular cell cast and several free-floating renal
shape of the entrapped cells. Also, the nuclei become more tubular cells in a Sternheimer-Malbin stained sediment. A
apparent when adjusting the fine focus up and down during highly refractile glass fragment is present in the center of this
the microscopic examination. field of view.

FIG. 16 A cast with oval fat bodies (i.e., renal tubular cells that FIG. 17 A white blood cell cast. Note the spherical or round
contain fat). In this Sternheimer-Malbin stained sediment, the shape of entrapped cells.
fat droplets take on a yellow or greenish appearance.

FIG. 18 A mixed cell cast. This cast contains both white blood FIG. 19 A mixed cell cast, predominantly red blood cells.
cells and red blood cells (arrow).
196 Urine Sediment Image Gallery

FIG. 20 A red blood cell cast. Red blood cells are dispersed in FIG. 21 A red blood cell cast packed with red blood cells.
the hyaline matrix of this cast.

FIG. 22 A fatty cast with fat droplets of varying size within the FIG. 23 The same fatty cast as in Figure 22. Note that the fat
cast matrix; a fat droplet that resembles an RBC is most nota- droplet mid-cast demonstrates a Maltese-like cross pattern
ble mid-cast. Note the deteriorating renal epithelial cell at the indicating that it is a cholesterol droplet. Polarizing microscopy.
end of the cast.

A B
FIG. 24 A, Oval fat bodies in a hyaline matrix (i.e., a fatty cast). In this sediment stained using Sudan
III, the fat in the oval fat bodies has taken on the characteristic terra-cotta or red-orange color, indi-
cating that it is neutral fat (triglycerides). Brightfield. B, Same cast as in A, note that the hyaline
matrix of the cast is easy to see when using Phase microscopy.
 Urine Sediment Image Gallery 197

Granular Casts

FIG. 25 Granular cast with several disintegrating renal tubular FIG. 26 Granular cast.
cells embedded. One cell now appears as a large 'coarse'
granule that is colored by methemoglobin.

FIG. 27 Coarsely granular (and pigmented) cast. The color and FIG. 28 Cast transitioning from cellular to granular to waxy.
granulation originate from hemoglobin (now methemoglobin) The intense brown color suggests that pigmentation is derived
and red blood cell degeneration, respectively. These casts from hemoglobin (i.e., methemoglobin). This sediment also
are sometimes called blood casts or ‘muddy brown’ casts. contained numerous red blood cells and red blood cell casts.
Also, the two large coarse granules embedded at one end
of the cast are likely renal tubular cells that have disintegrated
and become stained by methemoglobin.

FIG. 29 Granular casts. A broad cast indicative of formation in FIG. 30 A low-power (100 ) field of view of urine sediment
a large collecting duct or in dilated tubules indicates significant containing numerous casts: hyaline, granular, red blood cell,
renal pathology. The granules most likely originated from red and cellular.
blood cells and coloration from hemoglobin or methemoglo-
bin. Hence these casts are sometimes referred to as
blood casts.
198 Urine Sediment Image Gallery

Hyaline Casts

FIG. 31 A low-power (100) field of view of urine sediment FIG. 32 Hyaline cast.
containing numerous hyaline casts. Because their refractive
index is similar to that of urine, they can be difficult to observe
using brightfield microscopy. Focusing up and down during the
microscopic examination aids in the detection of hyaline casts
because they are often more apparent when slightly out
of focus.

FIG. 33 A U-shaped hyaline cast, two white blood cells, and five dihydrate calcium oxalate
(Weddellite) crystals.

Waxy Casts

FIG. 34 A low-power (100) field of view of urine sediment FIG. 35 A long, broad waxy cast predominates in this field of
containing numerous casts, particularly hyaline and waxy view. Also present are other waxy and hyaline casts, as well as
(three predominate). renal tubular cells and oval fat bodies.
 Urine Sediment Image Gallery 199

FIG. 36 A single “broad” waxy cast and two hyaline casts. FIG. 37 A waxy cast (left) lying almost vertical and two red
Note the difference in refractility between these two types blood cell casts (right) lying horizontally.
of casts. In this image, the hyaline casts are actually out of
focus, which makes them easier to see. Brightfield.

FIG. 38 Two waxy casts. One typical in width; one broad and transitioning from granular to waxy.
Note the ground-glass appearance and blunt ends, which are characteristic of waxy casts.

CRYSTALS
Ammonium Biurate Crystals

FIG. 39 Ammonium biurate crystals. Note the characteristic yellow to brown color. With the
passage of time (urine storage), these crystals will grow to form many spicules or thorns.
200 Urine Sediment Image Gallery

Bilirubin Crystals

FIG. 40 Bilirubin crystal. In urine with a very high bilirubin concentration, bilirubin may precipitate
out of solution as small, finely spiculated crystals with a characteristic golden yellow color. These
crystals may form in vitro when the urine is refrigerated and stored.

Calcium Carbonate Crystals

FIG. 41 Calcium carbonate crystals (arrows) and a single dihydrate calcium oxalate crystal.

Calcium Oxalate Crystals

A B
FIG. 42 A, A single dihydrate calcium oxalate (Weddellite) crystal and numerous monohydrate cal-
cium oxalate (Whewellite) crystals that look similar to red blood cells. B, Same field of view using
polarizing microscopy. Rule of thumb: Crystals can polarize light; red blood cells do not.
 Urine Sediment Image Gallery 201

FIG. 43 Calcium oxalate crystals, atypical barrel form. FIG. 44 Calcium oxalate crystals, atypical ovoid form.

Cholesterol Crystals

FIG. 45 Cholesterol crystal (arrow).

Cystine Crystals

FIG. 46 Cystine crystals. A single cystine crystal appears in FIG. 47 Several cystine crystals layered and clustered
the lower left corner, and several cystine crystals are layered together.
and clustered together at the upper right corner. Several red
blood cells are also present.
202 Urine Sediment Image Gallery

Drug Crystals

FIG. 48 A “sulfa” crystal, specifically acetylsulfadiazine,
which is surrounded by many yeast cells.
FIG. 49 Numerous sulfamethoxazole (Bactrim) crystals sur-
rounding a single barrel-shaped uric acid crystal. Note the
yellow-brown color and the similar shape of the many sul-
famethoxazole crystals to those of ammonium biurate
(Fig. 39). Urine pH aids in differentiating these two crystals.

FIG. 50 Indinavir (Crixivan); insoluble at pH > 6.0. These crystals can be present as individual nee-
dles or prisms, which can aggregate into a variety of bundle forms—wing-like bundles, shocks of
wheat, and X-shaped forms. Amorphous phosphates are also present..

Phosphate Crystals

FIG. 51 Triple phosphate crystals and numerous amorphous FIG. 52 Dissolving triple phosphate crystals and numerous
phosphates. amorphous phosphates.
 Urine Sediment Image Gallery 203

FIG. 53 Two atypical triple phosphate crystals and a single FIG. 54 Wedge-shaped calcium phosphate crystals and dihy-
stellate calcium phosphate crystal (upper right). drate calcium oxalate crystals.

FIG. 55 A calcium phosphate sheet. FIG. 56 Calcium phosphate crystals. Unusual flat, platelike
form that layers.

FIG. 57 Calcium phosphate crystals. Uncommon slender FIG. 58 Magnesium phosphate crystals. Elongated rhomboid
wedges or needles. plates; rare.
204 Urine Sediment Image Gallery

Urate Crystals

FIG. 59 Acid urate crystals. Note the yellow to brown color FIG. 60 Monosodium urate crystals.
characteristic of thick urate crystals.

Uric Acid Crystals

FIG. 61 Uric acid crystals in the common diamond shape. FIG. 62 Uric acid crystals, barrel or cube forms.

FIG. 63 A chunk of a uric acid crystal; note the characteristic FIG. 64 A single uric acid crystal in an unusual band form
color. Also present are a squamous epithelial cell and two dihy- and numerous calcium oxalate crystals (mono- and
drate calcium oxalate crystals. dihydrate forms).

X-ray Contrast Media Crystals
FIG. 65 Ionic radiographic contrast media (i.e., meglumine diatrizoate [Renografin]) crystals in urine
after an x-ray procedure.
EPITHELIAL CELLS
FIG. 66 Two squamous epithelial cells covered with bacteria,
known as clue cells, and a single typical or “normal” squa-
mous epithelial cell (lower left). In urine that has been contam-
inated with vaginal secretions, clue cells may be observed.
This is not a common occurrence.
FIG. 68 A squamous epithelial cell (lower left cell) and a transi-
tional epithelial cell (upper right cell). Note the similarity in the size
and central location of their nuclei. It is the amount of cytoplasm
that differs, resulting in different nucleus-to-cytoplasm ratios.
Several large rod-shaped bacteria are also present.
Urine Sediment Image Gallery 205
FIG. 67 Three squamous epithelial cells and a single white
blood cell. Note the keratohyalin granules evident in the cyto-
plasm of squamous cells and the similarity in size between the
white blood cell and the nuclei of these epithelial cells.
FIG. 69 A clump of transitional epithelial cells and several indi-
vidual caudate or club-like transitional epithelial cells. This
urine was collected after catheterization and the cells were
most likely dislodged during the catheterization process. Note
the cytoplasmic blebs forming from some cells of the clump as
they degenerate. Phase contrast microscopy.
206 Urine Sediment Image Gallery

FIG. 70 A fragment of transitional epithelial cells and numer-
ous red blood cells. Note the variation in shape of the transi-
tional epithelial cells—round to caudate.
FIG. 71 Transitional epithelial cell or squamous epithelial cell?
Reasoning could be used to justify classification into either cat-
egory. Cells lining the urinary system convert from squamous
to transitional (urothelial) epithelium. This cell most likely orig-
inated from this area of transition.

FIG. 73 Bilirubin-stained renal tubular epithelial cells. Four

FIG. 72 A transitional epithelial cell (left) and two typical cuboi- cells are free-floating in the urine and two epithelial cell
dal renal tubular (collecting duct) cells (center and right). The casts–each with three renal tubular cells embedded in their
center cell is degenerating. hyaline matrix. Note that renal tubular cells are small; these
cells actually measured 11–18 μm in diameter.

FIG. 74 A single renal tubular cell (arrow) from a large collecting duct. Note the columnar shape and
that the size of the nucleus is similar to that of red blood cells, which are also present.
 Urine Sediment Image Gallery 207

FAT DROPLETS AND OVAL FAT BODIES

FIG. 75 Several free fat droplets and a fatty cast. Note refrac- FIG. 76 An oval fat body in the hyaline matrix of a cast. Also
tility, variation in size, and greenish hue of the fat droplets. present in this field of view are another free-floating oval fat
body, a fat droplet, and a hyaline cast. Note the similarity in size
and shape of the fat droplet to a red blood cell.

FIG. 77 Two oval fat bodies (arrows) loaded with fat, hence FIG. 78 Two oval fat bodies and several renal tubular cells.
their intense refractility. Numerous red blood cells, amorphous
material, and debris are also present.

A B
FIG. 79 Three oval fat bodies. A, As with free-floating fat, the droplets within cells often vary in size,
are highly refractile, and may have a greenish sheen (depends on microscope adjustment). Bright-
field. B, Same field as A using Polarizing microscopy. Note the characteristic Maltese-style cross of
some droplets in the oval fat body on the left, which indicates that they are cholesterol. The other
droplets are neutral fat, which are not birefringent.
208 Urine Sediment Image Gallery

FIG. 80 Several oval fat bodies enmeshed within casts and FIG. 81 An oval fat body engorged with neutral fat (triglycer-
free in the urine sediment. Bacteria and spermatozoa are also ides) stained using Sudan III.
present.

MICROORGANISMS
Bacteria

FIG. 82 Numerous rod-shaped bacteria and a single dihydrate FIG. 83 Numerous bacteria, singly and in chains, with several
calcium oxalate crystal. indicated by blue arrows. Many red blood cells (RBCs); both
normal and ghost forms (red arrows) are present.

Trichomonads

FIG. 84 A trichomonad. Their characteristic rapid flitting motion FIG. 85 Two trichomonads.
results from their undulating membrane (blue arrow), anterior
flagella (two indicated by yellow arrows), and axostyle (red
arrow). Because of their size and granular appearance, nonmo-
tile (or dead) trichomonads may be misidentified as white
blood cells.
 Urine Sediment Image Gallery 209

FIG. 86 A cluster of four trichomonads. It is common to observe trichomonads clustered together

along with white blood cell (WBC) clumps in urine sediment.

Yeast

FIG. 87 Several budding yeast (blastoconidia), bacteria, and a FIG. 88 A branch of pseudohyphae (Candida spp.) and a red
single ghost red blood cell (arrow). Note the refractility and blood cell demonstrating typical pink-red coloration. Several
sheen of the yeast, which is made most evident by focusing ovoid yeasts are present in a different focal plane.
up and down during the microscopic examination.

FIG. 89 Yeast cells and blastoconidia (budding yeast). These FIG. 90 Early germ tube formation and several yeast cells. A
yeast cells appear more round than oval, highlighting the fact single red blood cell is also present.
that different species of yeast will appear differently. A single
dihydrate calcium oxalate crystal is also present.
210 Urine Sediment Image Gallery

MISCELLANEOUS FORMED ELEMENTS

Hemosiderin

FIG. 91 Hemosiderin granules in urine sediment appear FIG. 92 Hemosiderin granules in the hyaline matrix of a cast
yellow-brown. Numerous granules as well as a clump are (i.e., a hemosiderin cast).
present in this field of view. Four granules are identified by
the arrows. Two dissolving dihydrate calcium oxalate crystals
are also present.

Mucus

FIG. 93 A cluster of mucus threads. Because the refractive index of mucus is similar to that of
urine, it can be difficult to observe using brightfield microscopy. Focusing up and down during
the microscopic examination aids in the detection of mucus because it is often more apparent when
slightly out of focus. A couple of squamous epithelial cells and other elements, on a different focal
plane, are also present.

Sperm

FIG. 94 A cluster of sperm trapped in mucus. FIG. 95 Sperm and bacteria in urine sediment. Note that sev-
eral abnormal spermatozoa forms are present.