Patient Safety Monitoring in International Laboratories (SMILE)

Urine Sediment Case Studies

By Heidi Hanes

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 Patient Safety Monitoring in International Laboratories (SMILE)

How to use macroscopic results

for possible urine sediment
• pH – help decide what type of crystal
• Hemoglobin- detect RBC intact and lysed
• Leukocyte Esterase – detect WBC
• Nitrite – bacteria
• Protein – cast, epithelium cells

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Patient Safety Monitoring in International Laboratories (SMILE)

Case Study

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 Case 1
This is a sample from 35
year old female as part of a
routine exam. Laboratory
data include:

•Specific Gravity - 1.015

•pH – 7.0
•Ketones – negative
•Glucose – negative
•Protein – negative
•Blood – negative
•Nitrite – negative
•Leukocyte esterase –
negative
Identify the arrowed object

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Case 2
This urine sample is from a
35 year old female as part
of a routine exam.
Laboratory data include:

•Specific gravity = 1.015

•pH = 7.0
•Ketones = negative
•Glucose = negative
•Protein = negative
•Nitrite = negative
•Leukocyte esterase =
negative
Identify the arrowed object

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Case 3
Urine sample from a 71
year old male. Laboratory
data include:

•Specific gravity = 1.015

•pH = 6.0
•Ketones = negative
•Glucose = negative
•Protein = negative
•Nitrite = negative
•Leukocyte esterase =
negative
Identify the arrowed object

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Case 4
This urine sample is from a
60 year old male with
history of kidney nephritis.
Laboratory data include:

•Specific gravity = 1.018

•pH = 5.5
•Ketones = negative
•Glucose = negative
•Protein = positive
•Nitrite = positive
•Blood = positive
•Leukocyte esterase =
positive
Identify the arrowed object

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Case 5
This urine sample is from a 60
year old male with history of
kidney stones. Laboratory
data include:
Yellow and cloudy
•Specific gravity = 1.020
•pH = 5.5
•Ketones = negative
•Glucose = negative
•Protein = positive
•Nitrite = negative
•Blood = positive
•Leukocyte esterase = positive
Birefringence - absent
Identify the arrowed object

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Case 6
This urine sample is from a 60
year old male with history of
kidney stones. Laboratory
data include:
Yellow and cloudy
•Specific gravity = 1.020
•pH = 5.5
•Ketones = negative
•Glucose = negative
•Protein = positive
•Nitrite = negative
•Blood = positive
•Leukocyte esterase = positive
Birefringence - absent
Identify the arrowed object

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Case 7
This urine sample is from a
54 year old male routine
exam. Laboratory data
include:
•Specific gravity = 1.015
•pH = 7.1
•Ketones = negative
•Glucose = negative
•Protein = negative
•Nitrite = negative
•Blood = negative
•Leukocyte esterase =
negative
•Birefringent positive
Identify the arrowed object

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Case 8
This urine sample is from a
12 year old female
evaluated for kidney
disease Laboratory data
include:
•Specific gravity = 1.010
•pH = 6.0
•Ketones = negative
•Glucose = negative
•Protein = positive
•Nitrite = negative
•Blood = positive
•Leukocyte esterase =
positive
Identify the arrowed object

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Case 9
This urine sample is from a
12 year old female
evaluated for kidney
disease Laboratory data
include:
•Specific gravity = 1.010
•pH = 6.0
•Ketones = negative
•Glucose = negative
•Protein = positive
•Nitrite = negative
•Blood = positive
•Leukocyte esterase =
positive
Identify the arrowed objects

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Case 10
This urine sample is from a
48 year old male history of
diabetes mellitus, edema
and new onset renal failure.
Laboratory data include:
•BUN = 35 mg/dl (serum)
•Creatinine = 2.8 mg/dl
(serum)
•Specific Gravity = 1.007
•pH = 7.0
•Glucose = positive (4+)
•Protein = positive (2+)
Identify the arrowed object

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Case 11
This urine sample is from a
45 year old male history of
diabetes mellitus, edema,
hypertension and new
onset renal failure.
Laboratory data include:
Opalescent urine
•Specific Gravity = 1.011
•pH = 6.5
•Glucose = positive (4+)
•Protein = positive (2+)
Identify the object in these
photos

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Case 12
This urine sample is from a
38 year old female history of
three days nausea, vomiting
and diarrhea. Laboratory data
include:
•Specific Gravity = 1.020
•pH = 7.0
•Leukocyte Esterase =
negative
•Glucose = negative
•Protein = positive (1+)
•Ketones = negative
•Nitrite = negative
•Blood = negative
Identify the object in these
photo

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Case 13
This urine sample is from a
14 year old female
asymptomatic Laboratory
data include:
•Specific Gravity = 1.012
•pH = 6.0
•Leukocyte Esterase =
negative
•Glucose = negative
•Protein = positive (1+)
•Ketones = negative
•Nitrite = negative
•Blood = negative
Identify the object

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Case 14
This urine sample is from a 62 year old male
with enlarged prostate and renal failure. Has
fever and dehydrated. Laboratory data
include: BUN = 48 mg/dl (serum)
Creatinine = 3.4 mg/dl (serum)
Cloudy urine
•pH = 6.6
•Leukocyte Esterase = positive
•Glucose = negative
•Protein = positive
•Ketones = negative
•Nitrite = negative
•Blood = negative
Identify the object

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Case 15
This urine sample is from a 31 year old male
routine exam.
Yellow and hazy urine
•pH = 6.8
•Leukocyte Esterase = negative
•Glucose = negative
•Protein = negative
•Ketones = negative
•Nitrite = negative
•Blood = negative
Picture is regular light (left) and polarized
light (right)
Identify the object

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Case 16

This urine sample is from a 55 year old male

with urinary tract infection.
Cloudy urine
Urine culture grows Proteus species

Identify the object

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Case 17

This urine sample is from a 33 year old male

with alcohol induced cirrhosis, ascites, and
jaundice.
Golden brown urine in color
•Specific gravity = 1.015
•pH = 6.0

Identify the object

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Case 18

This urine sample is from a 20 year old

female with minimal change disease.
Golden brown urine in color
•Specific gravity = 1.025
•pH = 7.0
•Protein = positive (4+)
•Blood =negative
•Leukocyte esterase = negative
•Ketones = negative
•Nitrite = negative

Identify the object

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Case 19
This urine sample is from a 56 year old male
with kidney and liver failure. Laboratory data
include:

•Specific Gravity = 1.012

•pH = 5.0
•Blood = positive
•Protein = positive
•Leukocyte esterase = positive
•Glucose = negative
•Ketones = negative
•Nitrite = negative
•Crystals soluble in HCL
Identify the object

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Case 20

This urine sample is from a 45 year old female

routine exam. Laboratory data included:

•Specific gravity = 1.015

•pH = 7.0
•Blood = negative
•Protein = trace
•Leukocyte esterase = negative
•Nitrite = negative
•Glucose = negative
•Ketones = negative

Identify the objects in photo

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Patient Safety Monitoring in International Laboratories (SMILE)

Case Study Results

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 Case 1 - Squamous Cell
• Large, flat, thin cells
• May be round, polygonal,
rectangular or rolled into a tube
• Nucleus size of a RBC usually
centrally located.
• Can contain granules in
cytoplasm.
• Line urethra, bladder and vagina
• Form protective barrier
• Normal finding.
• Increase number indicate not a
clean voided specimen

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 Case 2 - Fiber

• Defined shapes
• Flat
• Refractile
• Frayed ends
• Non-cylindrical
shapes

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 Case 3 – Ammonium biurate

• Neutral or alkaline pH
• Yellow-brown
• Spheres with radial or
concentric striation
• Irregular
projections/thorns

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 Case 4 – Transitional epithelial cell

• Spherical, ovoid,
polyhedral
• Smaller than epithelial,
larger than renal
• Increase with infection,
post renal catheterization,
urinary stones ``

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 Case 5 – Cystine crystal

• Clear, colorless
hexagonal plates(Stop
signs)
• Acidic urine <5.5
• Birefringence absent
• Abnormal crystal

``

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 Case 6 – Erythrocytes

• Round or oval
biconcave disc
• No nucleus
• Abnormal in increase
numbers
• Faint yellow-orange or
red
``

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 Case 7 – Calcium Oxalate
• Usually in acidic but
can be seen neutral or
weakly alkaline
• Colorless
• Common shape
envelop
• Less common
dumbbell, oval and
elongated hexagon
``
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 Case 8 – RBC Cast

• Least common cast

• Most significant
• Tinged red or brown
• Seen in freshly voided
specimens
• Differentiated by
presence intact RBC

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 Case 9 – Leukocytes

• Colorless cells
• Most frequent is PMN
• Normal 3-5 seen
• Increased in
inflammatory conditions

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 Case 10 – Waxy Cast
• High refractive index
• Blunt or broken off ends
• Parallel margins may show
notching
• Colorless, pale yellow, waxy
appearance
• Abnormal finding

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 Case 11 – Cholesterol
• Found in acid and neutral urine
• Regular or irregular transparent
plates
• Birefringent in polarized light
• Corner can be notched- stair
step crystal
• Abnormal finding

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Case 12 – Yeast/fungi, extracellular

• Usually ovoid and colorless

• Refractile appearance
• Can be branching or hyphae
• Can be contaminant
• Urinary tract infection if
increase WBC seen
• Can be confused with RBC

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 Case 13 – Uric Acid Crystals

• Normal and common in urine

• Acidic urine
• Yellow or red-brown in color
• Variety of forms- rhombic,
rosettes, wedges, 4-sided
plates, barrel, lemon shapes

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 Case 14 – Granular Cast

• Fine or coarse
granules
• Can be normal,
especially after
vigorous exercise
• Seen in renal
disease patients

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 Case 15 – Starch granule
• Colorless
• Irregularly round with
dark striation to the
center
• Asymmetric “Maltese
cross” in polarized light.
Can be confused with fat
bodies.
• Frequent contaminant
Starch polarized
Fat droplet
polarized

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 Case 16 – Triple Phosphate
• Also know as Ammonium
Magnesium Phosphate
• Colorless
• 3-6 sided prism shaped
• Resembles “coffin lid”
• Less common as colorless
sheets, flakes, flats, ferns or leaf
form
• Birefringent under polarized light
• Seen highly alkaline urine with
urea-splitting organisms mostly
Proteus species.

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 Case 17 – Leucine Crystal
• Acidic urine
• Spheroids with concentric striations
• Dense
• Highly refractile
• Yellowish brown
• “pseudo” Maltese cross
• Seen severe liver disease
• Hereditary amino acid metabolic
disorders
• Can be seen with tyrosine crystals

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 Case 18 – Fatty Cast
• Yellowish tinge
• Contains large spherical,
highly refractile fat droplets
• Polarized light show
“Maltese-cross” pattern
• Associated with marked
proteinuria and nephrotic
syndrome

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 Case 19 – Tyrosine Crystals
• Rare, always abnormal
• Form clusters of silky needle-like
structures
• Colorless or black on focusing
• Acid urine
• Increase after refrigeration
• Insoluble in alcohol or ether
• Soluble in dilute HCL
• Orange color with nitrosonaphthol
confirmatory
• Tyrosiuria occurs with liver disease

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 Case 20 – Hyaline Cast
• Colorless
• Transparent
• Low refractive index
• Can easily missed with
ordinary bright field light scope
• Cylindrically shaped elements
• Seen in healthy and also with
renal disease
• Small numbers usually

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 References
• Urinary Sediment: A Textbook Atlas, by Meryl H Haber
• Images from
http://www.bing.com/images/search?q=urine+sediment+images&qp
vt=urine+sediment+images&FORM=IGREes
• CAP Participant Summary for Clinical Microscopy

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