HANDS-ON COURSE |
BEDSIDE URINARY MICROSCOPY |
GIOVANNI BATTISTA FOGAZZI LECTURES SERIES |
URINARY SEDIMENT: Part 6 and last:
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G.B. Fogazzi, Milan, Italy
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Dr G.B Fogazzi
Research Laboratory on Urine, Unità Operativa di Nefrologia Fondazione IRCCS, Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena Milan, Italy
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PART VI
Slide 176
A large number of particles can contaminate the
urine, whose identification is important to avoid misclassifications and
misdiagnoses.
Slide 177
Contaminants from the patient derive especially from genital secretions. These can contain different components such as erythrocytes, leukocytes, squamous epithelial cells, bacteria, candida, trichomonas vaginalis, or spermatozoa.
Slide 178
During menstruation, the urine can easily be contaminated with blood. Therefore, a urine sample from a woman during menstruation should always be considered as non suitable for examination and should be discarded. The erythrocytes which contaminate the urine during menstruation are typically isomorphic, i.e., of non glomerular origin (slide 178 and slide 26 of Part II). Before basing the diagnosis of microscopic haematuria on a urine sample supplied by a woman in fertile age, urine contamination from menstruation should always be ruled out. Contamination of the urine with blood can also occur during ovulation or for all gynaecological disorders associated with bleeding. It may also occur in men due to bleeding of the glans, foreskin, or urethra.
Slide 179
Slide 180
Slide 181
Slide 182
Vaginitis also causes the shedding in the urine of large-to-massive amounts of squamous epithelial cells of vaginal origin (slide 182). We consider this last finding as a practical and simple way to distinguish leukocyturia and bacteriuria due to contamination from leukocyturia and bacteriuria due to urinary tract infection. In this last condition squamous epithelial cells are absent or in mild amounts.
Slide 183
Candida can also be a finding of vaginitis. It is easily identifiable for the presence of “buds”, which are the daughter cells.
Slide 184
Trichomonas vaginalis is another possible causative agent of vaginitis. This protozoon is oval to round, somewhat larger than a polymorphonuclear leukocyte.
Slide 185
Its distinguishing morphological feature is the
presence of five flagella one of which, bent backward, is linked to the body by
an undulating membrane.
Slide 186
When alive, T. vaginalis can readily be
identified due to the motility of the flagella and the rapid and irregular
movements of the body across the microscopic field (slide 186). The same findings caused by vaginitis, in men
can be due to urethritis or balanoposthitis.
Slide 187
Spermatozoa are often found in the urine after sexual intercourse (both in men and women) or after ejaculation. However, all the conditions associated with spermatorrhea (= involuntary discharge of semen without orgasm) can cause the presence of spermatozoa in the urine. Due to their unique shape, spermatozoa can easily be identified in the urine. During courses on urinalysis, I have often been asked whether the presence of spermatozoa in the urine can cause proteinuria. Recently, we have had the opportunity to follow a patient who had a massive and transient spermatorrhea (slide 187), during which urinalysis performed by dipstick showed +/++ albumin. The day after, when spermatorrhea reversed, the dipstick for albumin turned out to be negative. Thus, the answer to the above question would be yes, spermatorrhea may be associated with (non renal) albumin in the urine.
Slide 188
Slide 189
Pubic hair and even hair (slide 190) can
occasionally be found in the urine. Due to their large size, their
identification under the microscope is easily confirmed by the macroscopic
examination of the specimen.
Slide 190
Slide 191
Microscopic fragments of cloth (slide 191) or synthetic (slide 192) fibres are not a rare finding in the urine. They usually derive from underclothes. Cloth fibres can still exhibit the texture of the cloth and can be coloured. Synthetic fibres are often birefringent under polarized light (slide 193).
Slide 192
Slide 193
Slide 194
Talcum powder, when applied to the genital or pubic area, may find its way into the urine. Talcum particles have a crystalline structure, have pleomorphic shape and size, and are birefringent under polarized light (slide 195).
Slide 195
Slide 196
Slide 197
Slide 198
Starch is the most common contaminant from the
laboratory. It comes from the dusting powder used for the gloves worn by lab
personnel. It has a crystalline structure, a polygonal to roundish shape, and a
nucleus-like centre (often with a “Y” shape). Size can be very variable.
Slide 199
Under polarized light, starch structures are birefringent and show the so-called “pseudo Maltese crosses” which is, crosses similar to those due to lipids but with arms of irregular length.
Slide 200
Glass fragments are not rare in the urine. They
derive especially from coverslips, which are made of very thin, and therefore
fragile, glass. Glass fragments have very variable size and shape. With some
experience, they are easily identified.
Slide 201
Air bubble are rather common, being due to the entrapment of air between the slide and the coverslip (see also slide 190). The skilful microscopist of the urine should be able to reduce the formation of air bubbles by placing the coverslip on the slide with gentle and aimed movements of the hands…
Slide 202
Dust, sand, and earth particles can all
contaminate the urine, especially in some geographic areas in some periods of
the year (an example based on personal experience: the period of the wind “harmattan”
in
But even in western and rich world the urine
can be contaminated with particles deriving from the environment.
Slide 203
This is the case with pollens, which in Milan where I work, are more common during the spring season. Due to the large variety of trees and plants, pollens come with a large variety of shape and size. The slide shows the same type of pollen in three different conditions, “hairy” on the left, “semi hairy” in the middle, and “bald” on the right.
Slide 204
Alternaria, helmithosporium (slide 205), and cladosporium (slide 206) are all fungal spores which can contaminate the urine from the soil
and plants, especially in some periods of the year (for alternaria, the
period June to October in our experience).
Slide 205
Slide 206
Slide 207
Under this heading I have put a number of structures with a funny
appearance, which I have found in the urine over the years. I have named these
structures according to their appearance. The nature of some of these particles
is clear to me, while for others I’m unable to find an identification. I hope
that some readers of NDT-Educational will be able to help me to find a proper
name for these mysterious particles.
Slide 208
This a cast, which contains packed cells
(leukocytes, renal tubular epithelial cells), has taken the appearance of a
question mark. As if it wanted to say “what renal disease does this patient
have?”
Slide 209
I really don’t know what this shell-like
structure is. Does anybody have an hypothesis?
Slide 210
This “elf hat” is nothing but a transitional cell from the deep layers of the urothelium with a vesicle coming out from the lower part of the cell. The vesicle is the result of degenerative processes.
Slide 211
These “specs” are in reality two transitional cells from the superficial layers of the urothelium, which are linked by a bridge of unclear nature.
Slide 212
This nice “butterfly” is a crystal of sulfadiazine which we found in the urine of patient under treatment with this drug for an HIV-related encephalitis.
Slide 213
This “swan neck” is probably a cell. However
which cell it is I really don’t know. Again, I ask the help of the readers.
Slide 214
This is a classic “tadpole” cell as it may found in the urine of patients with an urothelial malignancy.
Slide 215
This “frog” id a dysmorphic erythrocyte as seen
be transmission electron microscopy (a technique which I used extensively to
investigate the urine sediments 12 years ago, when I spent a period of study in
the renal unit of Guy’s Hospital, London, which at that time was directed by
famous Professor Stewart Cameron).
Slide 216
These “daisies” are crystals made up of an unusual type of calcium carbonate. According to some authors they appear in the urine only once every 130 years! (see: Fogazzi GB, et al. Nephrol Dial Transplant 2004;19:1907-09).
Slide 217
What is this “star”? I guess it is a vegetal particle, but for a proper identification I would like to ask, once again, the help of the readers.
Slide 218
And now a “flower”. This is due to squamous epithelial cells gently arranged at the top of a mucus thread. This is the last slide of my last series. I thank everybody for the patience and the attention.
Slide 219
