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7/29/2019 URINANLYSIS Microscopic Examination
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URINANLYSIS & BODYFLUIDS (HLD 22403)
URINE MICROSCOPIC SEDIMENTEXAMINATION
By
Mr.Hanan
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INTRODUCTION
The third part of urinalysis the microscopic examination of urinary
sediment.
The purpose is to detected and to identify insoluble material present
in the urine.
The blood ,kidney , lower genitourinary tract , and externalcontamination all contribute formed elements to the urine.
These include
RBCs, WBCs, epithelial cells , casts ,bacteria, yeast , parasites ,
mucus , spermatozoa, crystals and artifacts.
Some of these components are of no clinical significance andothers are considered normal unless present in increased amounts.
Examination of urine sediment must include both identification &
quantification.
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MICROSCOPIC EXAMINATION
Qualitative technique:
The urine must be freshly voided
Examined without excessive delay in order toprevent cellular deterioration.
Cellular debris from the urethral meatus and
secretions from the vagina may contaminate theurine specimen.
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Figure 28.1
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10-15 ml of urine ----from freshly mixed urine
specimen and centrifuged at a standard speed, usually
1500 to 2000 rpm for 5 minutes.
This is sufficient to bring to the bottom casts, pus cells,blood and crystals. For bacteria however a higher speedof 3,000 rpm is required.
The sediment resuspended in 1 ml of the same fluid.
A drop of resuspended sediment is placed directly
on a microscope slide and covered with a coverslip.
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low power-
Casts tend to congregate at the edges of the
cover slip. A minimum of10 15 high power fields should
be scanned for this examination.
Red blood cells, leucocytes, epithelial cells---
per high power field(/hpf);
casts --- per low power fields(/lpf).
Other elements such as bacteria, parasites,
crystals and spermatozoa are reported as well
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NORMAL SEDIMENT
Normal sediment contains a limited number offormed elements. It can be divided into two
classes.
Unorganized sedimentUnorganized sediment - these are the crystals ofvarious substances present in the urine and they
vary with the pH of the urine .Crystals of normal
urine is formed as the specimen cools
Organized sediment
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URINARY CRYSTALS
Crystals are frequently found in the urine
& are rarely of clinical significance.
They may appear as :
Geometrically formed or as amorphous
material.
Primary reason of detecting crystals is to
detect the abnormal types that may
represent disorders.
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URINARY CRYSTALSCRYSTAL FORMATION
Crystals are formed by the precipitation of
urine solutes, including :
Organic compounds, inorganic salts &
medication (iatrogenic compounds).
Precipitation is subject to changes:
In temperature
Solute concentration
pH
which affect solubility
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Solutes precipitate more readily at lowtemperatures.
Crystals formation takes place in
specimen that have remained in roomtemperature or refrigerated prior to testing.
A valuable aid in the identification of
crystals is the pH of the specimen
because it determines the type of
chemicals precipitated.
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URINARY CRYSTALS
ACIDIC URINE
Common crystals seen in acidic urine are
Urates consisting ofamorphous urates,
Uric acid , &sodium urates.
Microscopically urate crystals appear
yellow to reddish brown & are normalcrystals found in acidic urine
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Amorphous urates yellow brown
granules. Appearlike clumps resembling granular
casts. Found in specimen that has been
refrigerated. Amorphous urates appear asfine pink orbrownish-tangranules.
Accumulation ofuroerythrin on
the surface of the granules is the
cause of the pink colorThey are salts of uric acid (lower
pH) and are normally found in
acid or neutral urine. pH greater
than 5.5.
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URINARY CRYSTALS
URIC ACID CRYSTALS
Uric acid crystals exhibit extreme pleomorphism
in size and in shape. They appear readily in acid
urine allowed to stand at room temperature.
Increased amounts- increase levels ofpurines
& nucelic acidin patients with leukemia or
receiving chemotherapy, Lesh-Nyhan
syndrome (disorder of purine metabolism) &sometimes in patients with gout.
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Uric acid crystals Notice the whetstone, not hexagonal , shape that
differinciate uric acid crystal with cystine crystals
extreme pleomorphism- including rhombic,4sided flat
plates (whetstone )wedges &rosettes
Coloryellow brown but may also appear colorless
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URINARY CRYSTALS
CALCIUM OXALATECRYSTALS
Seen in acidic urine but also found in neutralurine.
Most common form of calcium oxalateis the
dihydrate- colorless, octahendral or as 2pyramids joined together.
Monhydrate- dumbell shape.
Calcium oxalate- sometimes seen in clumps
attached to mucous-may resemble casts. Findings of calcium oxalate clumps formation
of renal calculi-compose of calcium oxalate
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Also found with foodhigh in oxalic acid
(tomatoes, asparagus & ascorbic acid)
oxalic acid- end product of ascorbic acid.
Pathological significance-very noticeablemonohydrate form in cases of ethylene glycol
poisoning .Massive amounts
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commonly appear octahedral, dumbbell shape
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URINARY CRYSTALS
ALKALINE URINE
Phosphates- majority seen in alkaline urine.
Amorphous phosphates-granular +/- to urates.
Large quantities- after refrigerationform white
precipitate-does not dissolve on warming.
Triple phosphates,& calcium phosphates.
Others are calcium phosphates & ammonium
biurrates.
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URINARY CRYSTALSAMORPHOUS PHOSPHATES
Amorphous phosphates appear in neutral to alkaline urine as fine,
colorless or slightly brown granules. White precipitate is observed
on centrifugation. (Brightfield microscopy, 160X magnification.)
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URINARY CRYSTALSTRIPLE PHOSPHATE
Triple phosphate crystals, viewed here with interference-contrast
microscopy (160X magnification), resemble prisms or "coffin lids".
They are found normally in alkaline or neutral urine.
They are colorless, no clinical significance-seen in highly alkaline
urine associated with presence of urea spliting bacteria
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URINARY CRYSTALSCALCIUM PHOSPHATE
Calcium phosphate crystals assume various forms including the
rosette and pointed fingerforms shown here with bright field
microscopy (160X magnification). They appear most often in alkaline
urine.
Common constituent of renal calculi
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URINARY CRYSTAL
CALCIUM CARBONATE
Calcium carbonate crystals are small and colorless and
appear in alkaline urine as granules or as small
dumbbells.
They appears as clumps- resembels amorphous
material.
Formation of gases- when added acetic acid , to
differentiate
Also birefringentwhich differentiate from bacteria
No clinical significance.
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Calcium carbonate crystals are small and colorless and appear in
alkaline urine as granules or as small dumbbells. Bacteria are also
present in this field (brightfield microscopy, 250X magnification).
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URINARY CRYSTAL
AMONIUM BIURATE
Color yellow brown seen in acidic urine
They are the only urate crystals that appear in alkaline
urine.
Describe as thorny apples- presences of spicule
covered sphere
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Encountered in old specimens associated with the
presence of ammonia produce by urea splitting
bacteria. Dissolves at 60cconvert to uric acid crystals when
glacial acetic acid is added.
Ammonium urate crystals are easily distinguished by
their golden brown color and "thorn apple" shape. Theyare seen here under bright field microscopy (160X
magnification).
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URINARY CRYSTAL
ABNORMAL CRYSTALS
Cystine crystals- person inherit a metabolic
disorder.
Cystinuria-prevents reabsorption of cystine by the
renal tubules. Tendency to form renal calculi Rarely seen, these crystals are found in acid urine
and are seen as thin, colorless, hexagonal plates.
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Only thick cystine have polarizingcapability- mistaken with uric acid .
Conformationusing cynaide
nitroprusside test.
C S
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URINARY CRYSTAL
ABNORMAL CRYSTALS
Cholesterol crystals rarely seen unless
specimen has been refrigerated- lipids remain in
droplet form.
Observation-rectangular plate in shape withnotch in or more corners .
Disorders producing lipiduria such as nephrotic
syndrome. Seen usually with fatty cast & oval fat
bodies
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Cholesterol crystals are seen in the center of this field
with squamous epithelial cells on either side. Cholesterol
crystals are found in acid or neutral urine. They appear
as regular orirregular transparent plates. They mayoccur singly or in large numbers. Usually one or more
corners are cut off ornotched, justifying their
description as "stair step crystals".
URINARY CRYSTAL
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URINARY CRYSTAL
ABNORMAL CRYSTALS (LIVER
DISODERS) Tyrosine crystals are not normally found in urine.
They are products of protein metabolism and appear in
urine of people with tissue degeneration or necrosis
(acute liver disease, severe leukemia, typhoid fever, andsmallpox).
They are present only when urine is acid.
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Colorless to yellowish brown, needle shaped crystals
and have a fine silky appearance.
The needles may be single or arranged in sheaves or
rosettes.
Tyrosine crystals usually appear in urinary sedimenttogether with leucine crystals
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URINARY CRYSTAL
ABNORMAL CRYSTALS (LIVER DISODERS)
Leucine crystals are not normally found in urine
Appear in urine in association with tyrosine and are
manifestations of the same clinical conditions.
When found, leucine crystals are in acid urine in the form
ofspheroids with concentric striations.
They are dense, highly refractive and appear as
yellowish brown bodies.
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URINARY CRYSTAL
ABNORMAL CRYSTALS (LIVER DISODERS)
Bilirubin crystals- In hepatic disorders.
Appears as clump needles or granules with
yellow color
Disorders that produce renal tubular damage,viral hepatits , bilirubin crystals may be found
incorporated into the matrix of casts.
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URINARY CRYSTAL
ABNORMAL CRYSTALS
Sulfonamide crystals form primarily in acid urine.
The shape and color of these crystals are extremely
variable, depending on the particular sulfonamide being
administered to the patient.
The most common forms encountered include rosettes,
fan shapes and those resembling shocks of wheat.
Sulfa crystals have pathologic significance, since they
tend to form renal calculi that may damage renal tubules.
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Sulfoamide- In patient being treated for
UTI.
Inadequate hydration is the primary cause
of sulfoamide crystallization.
Can suggest-possibility of tubular damage
if crystal are forming in the nephrones
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forms encountered include rosettes, fan shapes and
those resembling shocks of wheat.
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URINARY CRYSTAL
ABNORMAL CRYSTALS
Ampicilin crystals rarely encountered-
massive dose of ampicilin compound with
poor hydration.
Knowledge of the patient Hx can aide the
identification.
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ORGANIZED SEDIMENT
Organized Sediment
The components of organized sediment
include casts, red blood cells, white bloodcells, epithelial cells, bacteria, yeast,
parasites, spermatozoa and artifacts.
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CASTS
Casts are formed in the tubules and iscomposed ofproteinaceous material.
They are washed out by the glomerular
secretion into the collecting tubules and thebladder.
They are cylindrical in shape with round or
broken ends with uniform diameter but varying inlength. They require acidic conditions, high saltconcentration, reduced urine flow and protein tobe formed.
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Practically all casts have a hyaline matrix,which may or may not contain inclusions such as
desquamated cells.
The casts are named according to the matrixof the inclusions contained in them e.g. red
blood cell casts.
Casts Suggest Kidney pathology.
Casts can be made up of Protein, lipid, cells ormixed
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HYALINE CASTS
Are colorless, semi-transparent and occasionally
refractile cylinders and are soluble in acetic acid.
They are seen when there is damage to theglomerular capillary membrane, permitting leakage
of proteins through the glomerular filtrate.
They are seen in fever, orthostatic proteinuria, and
emotional stress or strenuous exercise.
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Granular casts
are casts containing large or fine granules
embedded in coagulated protein. They are notfound in normal urine and their presences indicate
pyelonephritis. They are also seen in chronic lead
poisoning.
Epithelial casts are formed of fused desquamated
tubular cells. They are coagulated protein in which are
embedded desquamated epithelial cells from the renal
tubules .They are seen in diseases where there is damageto the tubular epithelium as in nephrosis, eclampsia,
amyloidosis and heavy metal poisoning.
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Red Blood Cell Casts:
are casts with red blood cells embedded in
the coagulated protein in the tubule. Their
presences indicate acute inflammation or
vascular disorder in the glomerulus causinghematuria. They are seen in pathological
conditions such as acute glomerulonephritis,
renal infarction and collagen vasculardisorder.
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WHITE BLOOD CELL CASTS
Indicative ofinflammation orinfection,
pyelonephritis
acute allergic interstitial nephritis,
nephrotic syndrome, or post-streptococcalacute glomerulonephritis
http://en.wikipedia.org/wiki/Inflammationhttp://en.wikipedia.org/wiki/Infectionhttp://en.wikipedia.org/wiki/Pyelonephritishttp://en.wikipedia.org/wiki/Interstitial_nephritishttp://en.wikipedia.org/wiki/Interstitial_nephritishttp://en.wikipedia.org/wiki/Pyelonephritishttp://en.wikipedia.org/wiki/Infectionhttp://en.wikipedia.org/wiki/Inflammation7/29/2019 URINANLYSIS Microscopic Examination
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FATTY CASTS
Formed by the breakdown of lipid-rich
epithelial cells, these are hyaline casts
with fat globule inclusions
They can be present in various disorders,
including
nephrotic syndrome,
diabetic or lupus nephropathy,
Acute tubular necrosis
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WAXY CASTS
Waxy casts suggest severe, longstanding kidney
disease such as renal failure(end stage renal disease). They appear fragmented with jagged ends &have
notches at the side. Supravital stain waxy cast stain ahomogenus dark pink
S h t i t???
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Sowhat is a cast???
Lets Review
Protein based cylindrical molds of the renal
tubule
Form in distal tubules and collecting ducts
Result of damage to the renal tubule
Can contain cells and other material Dehydration and acidic urine especially
predisposes to cast formation
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Types of casts
Acellular casts
Hyaline casts
Granular casts
Waxy casts
Fatty casts
Crystal casts
Cellular casts
Red cell casts
White cell casts
Epithelial cell cast
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ACELLULAR CASTS
Appears colorless in undstained sediment , refractive
index, sternheimer-malbin stain produce pink color.l
Normal parallel sides, rounded ends, cylindroid
forms,&wrinkled or convoluted shapes indicate aging of
the cast matrix.
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Granular Casts
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Granular cast
Non-specific but
usually pathologic
Usually the
granules are from
the degeneration of
cellular casts
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Waxy cast
Thought to result
from the
degeneration ofcellular casts
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FATTY CAST
The cast matrix contain a few ormany oil droplet. Intact
oval fat bodies may be attach to the matrix.
Stain with Sudan iii or Oil Red O Fat Stain
CELLULAR CAST
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CELLULAR CAST
RED CELL CAST
Almost always
associated with
glomerulonephritis
or vasculitis
Virtually exclude
extra-renal causesof bleeding
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RBC
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EPITHELIAL CASTS IN URINE:
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TUBULAR EPITHELIAL CAST
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WBC in Urine
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WBC
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WBC CAST URINE:
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WHITE BLOOD CELL CAST
Seen in interstitial
disease most
commonly
Also seen in
glomerulonephritis
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White blood cell cast
This is a white blood cell cast with intact
leukocytes. The leukocytes have
multilobed nuclei. (Bright field microscopy)
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EPITHELIAL CELLS
Epithelial Cells: Normally a few epithelial
cells occur in the urine .
A marked increase in these cells in the
urine is seen destruction of the tissues inthe urinary tract
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Microscopic ExaminationSquamous Cells
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Squamous epithelial cell in urine
This is a squamous epithelial cell under brightfield microscopy
(250X magnification).Squamous epithelial cells are
characterized by a small, round, central nucleus with a large
amount of granular or wrinkled cytoplasm (a "fried egg"
appearance).
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Microscopic ExaminationTubular Epithelial Cells
R l E ith li l C ll
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Renal Epithelial Cells
A group of attached renal tubular epithelial
cells are seen in the center of this slide.
The background contains white blood cells
and red blood cells (bright field microscopy,
250X magnification)
Mi i E i ti
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MicroscopicExamination
Transitional Cells
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MicroscopicExaminationTransitional Cells
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Bacteria- Bacteriuria More than 10 per HPF
Yeasts- Candidiasis Most likely a contaminant
but should correlate with
clinical picture.
MicroscopicExamination
Bacteria & Yeasts
Bacteria and white blood cells
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This is a low power view (100Xmagnification) of urine with bacteria and
several leukocytes in the field. Bacteria are
bacillary and diffusely scattered
throughout. The urine is stained with
Sternheimer-Malbin stain.
White blood cells and bacteria
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These are white blood cells and bacteria found in urinarysediment using interference-contrast microscopy. The cell
in the center has a pseudopod extending from its
cytoplasm indicating amoeboid motion.
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Microscopic ExaminationLE Cell
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Microscopic ExaminationYeasts
Budding yeast cells
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Budding yeast are visible on the left side of this slide with a
squamous epithelial cell on the right. There are no segmented
neutrophils seen. This suggests the yeast are a contaminant and not
causing a urinary tract infection (bright field microscopy, 200X).
Mucus
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Mucus
This slide shows mucus in urine with two entrapped white cells. There are
also two red cells present, one within the mucus and one above it. Mucus
fibers are fibrillar and delicate. They have a very low refractive index.
(Bright field microscopy, 160X magnification.)
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URINARY SEDIMENT ARTIFACTS
Contaminants that are found in the urine Specimen collected improperly or in dirty
containers.
Most frequent: Oil droplet
Starch
Pollen Grains and fibers
F l t i l i i
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Fecal material in urine
Fecal material can usually be identified by its brown coloration, and
the assortment of bizarre shapes and sizes of component elements.
Fecal contamination of urine most often occurs in incontinent babies
or elderly persons. (Brightfield microscopy, 40X magnification)
Talc in urine
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Talc in urine
Talcum powder, commonly used as a dusting powder to prevent
chafing or heat rash, appears as a contaminant in urine as crystals.
(Brightfield microscopy, 128X magnification.)
Starch in urine
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A derivative of cornstarch is used as a dusting powder for surgical gloves.
It can enter the urine during catheterization. The starch granules areusually identifiable by their size, shape and high refractive index.
(Brightfield microscopy, 100X magnification.)
Cotton fiber in rine
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Cotton fiber in urine
A cotton fiber is easily identified by its size. A cotton fiber is seen here withsquamous epithelial cells and white blood cells.(Brightfield microscopy,
51X magnification.)
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Fiber in urine
This slide depicts a fiber artifact found in urine under brightfield
microscopy at 200X magnification.
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Home work
Mixed cast and oval fat bodies