10/16/2015
Objectives
1. Explain ascorbic acid interference in Urinalysis testing
2. Explain the significance of epithelial cells in urine
microscopy.
3. Correlate myoglobin and hemoglobin and the
appearance of RBC’s in the microscope.
4 Explain
4.
E l i th
the clinical
li i l significance
i ifi
off urine
i RBC’
RBC’s iin males
l
versus females.
5. Differentiate between contaminated and clean catch
specimens
6. List the different lab tests used to differentiate the types
of jaundice.
© 2014 Beckman Coulter, Inc.
Case 1
A 57-year-old man has a routine urinalysis as part of his
company's yearly required physical examination. He has a
chronic cough (50 pack/year smoking history). His only
complaints referable to the urinary tract are some mild
dysuria and hesitancy, but he otherwise feels fine. On
physical examination there are no abnormal findings.
Patient Testing
Chemistry
Color Appearance Leukocyte Esterase Nitrite pH Protein Blood Specific Gravity Ketones Glucose Bilirubin The patient had Bladder Cancer
Result Amber Hazy Microscopic WBC/hpf
<2/hpf
Neg
RBC/hpf 10‐30/hpf
Negg
5.0 Trace 2+ Casts Occasional hyaline casts
hyaline casts Other Atypical urothelial cells present Result • The patient was referred to a Urologist and subsequently
diagnosed with Bladder Cancer.
• The atypical urothelial cells suggested the possibility of a
carcinoma.
• The presence of the RBC's is consistent with that.
1.020 Trace Neg
Neg
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Bladder Cancer Risk Factors
Smoking linked to urothelial
malignancies
Chronic
Schistosoma
hematobium
infection linked
to squamous
cell cancer
Exposure to
betanaphthylamine
and analine
dyes
Case 2
» A 14-year-old girl is brought to the pediatrician by
his mother because she has had a fever with
shaking chills for the past day
day. On physical
examination, she has a temperature of 39.6 C
and has mild lower back pain.
» .
Test Results
Chemistry
Color Appearance Leukocyte Esterase Nitrite pH Protein Blood Result Yellow Turbid Microscopic
Result WBC/hpf
>50/hpf
3+ RBC/hpf
5‐10/hpf
Pos
6.5 Neg
Neg
Casts
Casts Many WBC
Many WBC Other Occasional transitional cells Specific Gravity 1.015 Ketones Glucose Bilirubin The Clues
Positive Positive Leukocyte blood and Esterase RBC’s
and WBC’ss
and WBC
Positive Positive Ketones –
Nitrites
state of Ketosis
1+ Neg
Neg
Urinary Tract Infection
» Acute pyelonephritis, probably as a consequence of an
ascending urinary tract infection.
» Finding WBC's, particularly WBC casts, would suggest
inflammation, particularly of the kidney.
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Differentiating Contamination From UTI
» UTI – Positive Nitrites, WBC, possibly RBCs, bacteria,
typically rods
» Contamination – negative chemistries, numerous
Squamous Epithelial cells, bacteria typically cocci
Case 3
Test Results
Urine Chemistry
Color
yellow
Appearance
hazy
Specific Gravity 1.025
Protein
Glucose
Ketones
300 mg/dL
negative
negative
Blood
Urobiilinogen
Nitrite
negative
negative
negative
pH
Bilirubin
negative
Leukoctye
negative
7.5
A 41 year old woman who is approximately 30 weeks
pregnant reports to her Dr. with several ailments. She
complains of frequent headaches, and edema (swelling) of
her feet and hands. Her blood pressure was found to be
elevated (150/90). She informs her physician that she takes
extra amounts of pre-natal vitamins due to her age.
Ascorbic Acid Interference
Urine Microscopic
20‐50 RBC/hpf
2‐5 WBC/hpf
triple phosphate crystals 10‐20 squamous epithelial cells/hpf
Pre-eclampsia and Acute glomerulonephritis
»
What
would account for the negative blood on the chemical
Whenever
red blood
cells areseen
observed
microscopically yet negative
test and
the 20-50
RBC/hpf
microscopically?
»
on
the chemical test, ascorbic acid (vitamin C) interference should be
suspected.
» *H2O2 + Chromogen --------> Oxidized chromogen +
»
H2O
*(in the presence of Hgb and Mgb)
Symptoms
Urine Chemistry
Microscopic
•
•
•
•
•
• Protein ‐ < 1000mg/day
• Blood
• RBC
• WBC
• Renal Tubular R lT b l
Epithelial cells
• Casts – RBC, Granluar, Hemoglobin
Edema
Hypertension
F
Fever
Malaise
Nausea
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Pre-eclamplsia
» Pre-eclampsia is a rapidly progressive condition
characterized by high blood pressure, edema (swelling)
and protein in the urine. Sudden weight gain, headaches
and changes in vision are typical symptoms.
» The only way to recover from pre-eclampsia is to deliver
the baby and placenta
placenta.
» Some women with pre-eclampsia will develop a more
severe condition, called HELLP syndrome
»
»
»
Hemolysis
Elevated Liver enzyme levels
Low Platelet count
Pre Eclampsia
Toxemia of Pregnancy • Affects mother and baby
• Damage to kidneys D
t kid
and liver
• Affects ~ 5% of pregnancies
Symptoms
• High BP
• Edema
• Protein in Urine
• Weight Gain
• Headaches
• Vision Problems
HELLP Syndrome
Specimen Collection
HELLP
could
account
the 10-20 squamous
-What
Small
numbers
- nonfor
pathological,
improper collection
epithelial
cells? especially in sheets – pathological
- Large numbers
• H – Hemolysis
• EL – Elevated Liver Enzymes
• LP – Low Platelet
Statistics
• Up to 48,000 cases / year
• Global mortality up to 25 %
Can lead to
• Liver rupture
• Stroke
Can be present in absence of high PB or urine protein
Case 4
» Two construction workers manage to dislodge a large
boulder from the path of a new water pipe installation. As
the boulder begins rolling, they suddenly become aware
of a pickup truck parked below them at the bottom of the
hill The boulder smashes through the side window and
hill.
lands on the driver's lap. The injured 44-year-old man has
multiple contusions from the blunt trauma to his thighs
and lower abdomen. Radiographs reveal no bony
fractures. A paracentesis yields no blood. That evening in
hospital, the injured man's urine output begins to drop.
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The Clues
Chemistry
Result Color Yellow‐Brown Appearance Microscopic Slightly Cloudy WBC/hpf
Neg
RBC/hpf
Negg
Leukocyte Esterase Nitrite pH Protein Blood Specific Gravity 0‐1/hpf
7.0 Casts Trace Occasional Occasional
hyaline, granular casts 3+ Other 1.010 Squamous and renal tubular epithelial cells Ketones Neg
Glucose Neg
Bilirubin Neg
Urine Color – Yellow Brown
Result <2/hpf
Positive blood on dipstick
No RBC in Urine microscopic
Rhabdomyolysis
Dying muscles release contents • Creatinine, myoglobin, adolase, potassium, lactate dehydrogenase
• Causes toxic build
Body organ damage
• Kidney failure
Causes
•
•
•
•
Severe muscle injury
Medicines
Toxins
Salmonella and other infections like influenza
Case 5
Test Results
Urine Chemistry
» A 24 year old male suffering from Malaria was put on
Primaquine to treat his malaria. A few days later, he
continued to exhibit fatigue but he was now jaundice and
his hemoglobin had dropped 2 grams
grams.
Color
Dark Orange
Appearance
hazy
Specific Gravity 1.025
Protein
Glucose
Ketones
Negaticve
negative
negative
Blood
Urobilinogen
Nitrite
1+
1+
negative
pH
Bilirubin
negative
Leukocyte
negative
7.5
Urine Microscopic
0‐5 RBC/hpf
2‐5 WBC/hpf
0‐2 squamous epithelial cells/hpf
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Primaquine Induced Hemolysis due G-6-PD deficiency
The Clues
Urine Color – Dark Orange Positive Blood, no significant RBC in micro
Hemolysis causes excessive amounts of Bilirubin
Liver can’t congugate excess Bilirubin causing jaundice
Increased bilirubin levels excreted into bile
Positive Urobilinogen
Increased urine urobilinogen
Categories of Jaundice
Category
Pre‐hepatic/ hemolytic
Hepatic/ hepatocellular
Post‐Hepatic/ cholestatic
Differentiation using Lab Tests
Definition
The pathology is occurring prior to the liver.
The pathology is located within
the liver.
The pathology is located after after the conjugation of bilirubin in the conjugation of bilirubin the liver
Post‐hepatic Jaundice
Increased Increased
Pre‐hepatic Jaundice Hepatic Jaundice
Total bilirubin
Normal / Increased
Conjugated bilirubin Normal
Increased
Increased
Unconjugated bilirubin
Normal / Increased
Increased
Normal
Dark (urobilinogen
D
k ( bili
+ Dark (conjugated D k( j t d
conjugated bilirubin) bilirubin)
Urine Color
Normal
Urine Bilirubin Negative
Present Present
Urobilinogen
Normal / Increased
/ Increased
Decreased
Alk Phos
Normal
Increased Increased
ALT AST
Normal
Increased Increased
Stool Color
Splenomegaly
Normal
Present
Normal/Pale
Present
Decreased / Negative
Pale
Absent
Case 6
A 64 year old female is being seen by the doctor for a
routine physical prior to going on vacation. She had been
very busy planning the vacation and now she is feeling a
little tired. The patient had a history of urinary tract
infections and was concerned that she was developing and
y
g was OK
infection and wanted to make sure everything
before she left for vacation. She no other symptoms other
than being a little tired.
The patient was the last patient of the day and the
specimen was transported via pneumatic tube immediately
after collection.
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Test Results
The Clues
Urine Chemistry
Color
Yellow
Appearance
Clear
Specific Gravitity 1.015
Protein
Glucose
Ketones
negative
negative
negative
Blood
Urobilinogen
Nitrite
Negative
Negative
negative
pH
Bilirubin
negative
Leukocyte
negative
6.0
Lack of clinical symptoms
y p
Urine Microscopic
Negative Nitrites and WBC’s
Large amounts of squamous epi’s
0‐5 RBC/hpf
2‐5 WBC/hpf
10‐20 squamous epithelial cells/hpf
Occ bacteria
Do We Culture?
No
Thank You
Improper Specimen Collection
© 2013 Beckman Coulter, Inc.
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