CHAPTER

6: MICROSCOPIC EXAMINATION OF URINE • Macroscopic hematuria: cloudy with red to brown color
o Frequently associated with advanced glomerular damage
URINE SEDIMENT CONSTITUENTS o Also seen w/ damage to vascular integrity of urinary tract
caused by trauma, infection or coagulation disorders
Red Blood Cells
• Microscopic hematuria: for early diagnosis of glomerular
• Appear as smooth, non-nucleated, biconcave disks bleeding and malignancy of urinary tract
measuring approximately 7 mm in diameter o Also confirms presence of renal calculi
• Identified using HPO (x400 magnification) • Presence of not only RBCs but also hyaline, granular, and
• Routinely reported as average number seen in 10 HPFs RBC casts may be seen following strenuous exercise
o Nonpathologic and disappear after rest
• Possibility of menstrual contamination must also be
considered from specimens in female patients
• Presence of Hgb: also gives red color in urine with a positive
result in chemical test for blood in the absence of
microscopic hematuria
• Specimen appearing macroscopically normal may contain a
small but pathologically significant number of RBCs when
examined microscopically

White Blood Cells

• 12 mm in diameter

• Concentrated urine: will result to crenated RBC
• Dilute urine: RBC will lyse = ghost cells
o Easily missed if specimen is not examined under
reduced light
• Most difficult to recognize
o Lack of characteristic structures, variations in size
o Confused with yeast cells, oil droplets and air bubbles
§ Yeast cells: exhibit budding
§ Oil droplets and air bubbles: highly refractile when
the fine adjustment knob is focused up and down
o Crenated RBCs: resembles WBCs (granules) due to
rough appearance
§ Adding acetic acid: lyses RBCs, leaving WBCs, yeast, • Neutrophil: predominant WBC in urine sediment
oil droplets intact o Contain granules and multilobed nucleus
§ Supravital stain may also be helpful o Identified using HPO; reported as the average
§ number seen in 10 hpfs
o Lyse rapidly in alkaline urine = lose nuclear detail
o When exposed to hypotonic urine: swelling >
Brownian movement of granules > glitter cells
(sparkling appearance)
§ No pathologic significance

• Dysmorphic RBCs: associated with glomerular bleeding
o Also seen in strenuous exercise (glomerular origin)
o Acanthocyte: dysmorphic cell most closely associated
with glomerular bleeding
§ Difficult to observe under BF microscopy • When stained with Sternheimer-Malbin stain, these large
o Wright stain: shows the cells to e hypochromic and cells stain light blue
better delineates presence of cellular blebs Eosinophils
Clinical Significance • Primarily associated with drug-induced interstitial nephritis
• Indicative of extent of glomerular damage or vascular injury • May be seen in renal transplant rejection and UTI
within the genitourinary tract • Concentrated, stained urine sediment: required for urinary
eosinophil test
 o Sediment: concentrated by routine centrifugation or Squamous Epithelial Cells
cytocentrifugation
o Hansel: preferred stain
§ Wright’s can also be used

• Not normally seen in urine; finding of >1% = significant

Mononuclear cells

• Lymphocytes: smallest; may resemble RBCs

o Increased in early stages of renal transplant rejections
• Monocytes, macrophages and histiocytes: large cells that
• Largest cells in urine sediment
may appear vacuolated with inclusions
• Contain abundant, irregular cytoplasm and a prominent
• Increased in renal transplant rejections
nucleus about the size of a RBC
• WBCs: Mistaken as RTE
o RTE: larger with eccentric nucleus • Examined under LPO or HPO based on lab protocols
• May appear folded, possibly resembling casts, clumps of
• Supravital stain & acetic acid: enhance nuclear detail
cells = difficulty identifying smaller pathologic elements,
• Normal: fewer than 5 WBCs/hpf
such as RBCs and WBCs
o Higher numbers present on females
• Originates in the linings of the vagina and female urethra
• Appearance in urine: due to glomerular trauma or ameboid
and lower portion of male urethra
migration through the tissues to sites of infection
• Increased amounts: female patients
• Pyuria: increased WBC in urine
• Midstream clean catch: will contain fewer squamous cells
o Can also be present in glomerulonephritis, LE, tumors
and interstitial nephritis • Clue cell: pathologic (infection by Gardnerella vaginalis)
o Squamous cell covered with Gardnerella cocobacillus
Epithelial Cells o Gives granular, irregular appearance
o Examined by a vaginal wet preparation
• Derived on lining of genitourinary system
• Represent normal sloughing of old cells (unless abnormal) Transitional Epithelial cells
• Classified according to site of origin

• Smaller than squamous
• Several forms: Spherical, polyhedral or caudate
o Due to ability to absorb large amount of water
o Cells in direct contact with the urine absorb water,
becoming spherical in form and much larger than the
polyhedral and caudate cells
§ Mistaken as RTE: nucleus is eccentric in RTE cells
• All forms have distinct, central nuclei

• Examined under HPO
 • Originate in lining of renal pelvis, calyces, ureters and Clinical Significance
bladder
• May present in small numbers in urine (normal sloughing) • RTE: most clinically significant epithelial cells
• Increased numbers: seen singly, pairs or in clumps • Tubular necrosis causes: heavy metals, drugs, Hgb and
(syncytia) following invasive procedures (catheterization) myoglobin toxicity, hepa B, pyelonephritis, acute transplant
o No clinical significance rejection, salicylate poisoning
• May be present in clumps (syncytia), pairs, singly • Renal fragment: indication of severe tubular injury with
• Clumps: seen after catheterization basement membrane disruption
• Increase of this cell with abnormal morphology (vacuoles • Single cuboidal cells: seen in salicylate poisioning
and irregular nuclei): malignancy or viral infection • RTE cells functions in reabsorption in glomerular filtrate
o Absorb bilirubin (result of liver damage seen in hepatitis)
Renal Tubular Epithelial Cells § Appear a deep yellow color
• Hgb in filtrate, absorbed by RTE converted to hemosiderin
• From PCT: larger, rectangular, coarsely granular cytoplasm o Episodes of hemoglobinuria: RTE may contain yellow
o Referred to as columnar or convoluted cells brown hemosiderin granules
o Mistaken as a cast (fatty or granular) § These granules may be seen free-floating in the
§ Cast: no nucleus sediment
§ Confirmed by Prussian blue stain

• From DCT: smaller, round or oval f
o Mistaken as WBC or spherical transitional cells
Oval Fat bodies
§ Aid: Eccentric nucleus

• Collecting duct RTE: cuboidal, never round, eccentric
nucleus, presence of at least one straight edge
(differentiate it from spherical, polyhedral transitional cells)
o Often seen in tissue necrosis
o Nucleus: not easily visible unstained

• Lipid containing RTE cells (due to its absorption in the
glomerular filtrate)
• Appear highly refractile, and the nucleus may be more
difficult to observe
• Seen in conjunction with free-floating fat droplets
• Stain: Sudan III or Oil Red O
o Sediment examined under polarized microscopy
o Triglycerides, neutral fats: orange-red droplets
• Collecting duct cells: can be seen in groups (3 or more called o Cholesterol: maltese cross formations
renal fragments) • Urine sediments negative for fat after staining should still
o Frequently seen as large sheets of cells be checked using polarized light in case only cholesterol is
o PCT and DCT cells: not seen in large sheet of cells present (vice versa)
• Identified under HPO • Report: average number/hpf
o Presence of >2 RTE/hpf: tubular injury
 • Lipiduria: associated with damage to the glomerulus caused Yeast
by the nephrotic syndrome
o Also seen in severe tubular necrosis, DM, and
trauma that causes BM to release fat
• Lipid storage dx: large fat-laden histiocytes present
o Differentiated from oval fat bodies by their large size
• Acute Tubular necrosis: RTE cells referred as bubble cells
o Bubble cells: RTE cells containing large, nonlipid-
filled vacuoles
o Appear to represent injured cells in which the ER
has dilated prior to cell death

Bacteria

• Few bacteria may be present: result of urethral, external

genitalia, or collection-container contamination
o These bacteria may multiply under RT for
extended periods
o May produce (+) nitrite test, frequently result in
pH above 8 = unacceptable specimen

• Small, refractile, oval; may or may not contain a bud
• Severe infections: appear as branched, mycelial forms
• Candida albicans: seen in urine of patients with DM, vaginal
moniliasis and immunocompromised patients
o Acidic, glucose-containing urine in DM: ideal
medium for yeast growth
• Small amount of yeast entering a specimen as a
contaminant multiplies rapidly if the specimen is not
examined while fresh (same with bacteria)
o True yeast infection: accompanied by WBC

Parasites

• Trichomonas vaginalis: most frequent

• Observed in HPO
• To consider UTI, bacteria must be accompanied with WBCs
• Presence of motile organisms in a drop of fresh urine
collected under sterile conditions correlates well with a
positive urine culture
• Observing bacteria motility: useful in differentiating them
from similarly appearing amorphous phosphates & urates
• Phase microscopy: aids in visualization of bacteria o Pear shaped flagellate with an undulating membrane
o Rapid darting movement in wet preparations of urine
• Specimens containing increased bacteria and leukocytes
sediment
are routinely followed up with a quantitative urine culture
o Associated with vaginal inflammation
• Enterobacteriaceae: most frequently assoc. with UTI
• If not moving: may resemble a WBC, transitional, or RTE cell
o Staphylococcus and Enterococcus: can also cause
o Phase microscopy: enhance visualization of flagella or
o Cannot be identified in microscopic examination
undulating membrane
• Sexually transmitted (Males can be asymptomatic carriers)
• S. haematobium ova: seen in urine
o Can be associated with bladder cancer
o Eggs are often contained in the last few drops or

urine expelled from the bladder

 o Glycoprotein excreted by RTE cells of DCT and upper
collecting ducts
• Appear as thread-like structures with low refractive index
• Irregular appearance of mucus threads: differentiang factor
from casts
• Observed in LPF
• Subdued lght: required wen using bright field micro
• No clinical significance (more common in F than M)

Casts

• Only elements found in the urinary sediment that are

unique to the kidney
• Formed within lumen of DCT and collecting ducts
o Providing microscopic view of nephron condition
• Shape: represents tubular lumen (parallel sides and round
• Fecal contamination: can result in the presence of ova from ends)
intestinal parasites in the urine sediment
• May contain additional elements present in the filtrate
o E. vermicularis: most common contaminant
• Examination: performed using LPO
Spermatozoa • When glass coverslip is used: low power scanning should be
performed along the edges of the cover slip
• Has low refractive index
o Thus, subdued light is essential
• Cast matrix dissolves quickly in dilute, alkaline urine
o Once detected, it is further identified using HPO

Cast composition and formation

• Uromodulin: major constituent of casts

o Forms a meshwork of fibrils that can potentially trap any
elements present in the tubular filtrate, including cells,
cell fragments, or granular material
• Rarely exhibit motility due to urine toxicity o Albumin, Ig: also incorporated on matrix
o Uromodulin: excreted at a constant rate (normal)
• Clinical significance: Retrograde ejaculation (sperm to
bladder instead to urethra) and infertility § Rate of excretion: increases in exercise and stress =
appearance of hyaline cast
• Positive reagent strip test for protein may be seen when
• Cast formation increases with lower pH or increased ionic
increased amounts of semen are present
concentration and with stasis or obstruction of the nephron
Mucus by cells or cell debris
o Increased when larger than normal quantities of
plasma proteins enter the tubules
o Albumin: usual protein in excess
o Bence-Jones protein: globulin that can also cause casts
o Hemoglobin & myoglobin: capable of cast formation
• Uromodulin protein is found in both normal and abnormal
urine (not detected by reagent strip protein methods)
• As the cast forms, urinary flow within the tubule decreases
as the lumen becomes blocked
• Accompanying dehydration of the protein fibrils and
internal tension may account for the wrinkled and
convoluted appearance of older hyaline casts
• Width of the cast depends on the size of the tubule in which
it is formed
o Broad casts may result from tubular distension or, in
the case of extreme urine stasis, from formation in the
collecting ducts
• Formation of casts at the junction of the ascending loop of
Henle and the distal convoluted tubule may produce
structures with a tapered end
o Referred as cylindroids
• Cylinduria: presence of urinary casts
• Any elements present in the tubular filtrate, including cells,
• Protein produced by glands and epithelial cells in the lower
bacteria, granules, pigments, and crystals, may become
genitourinary tract and RTE cells
embedded in or attached to the cast matrix
• Uromodulin: major constituent of mucus
Hyaline casts • Primarily associated with damage to the glomerulus
(glomerulonephritis) that allows passage of the cells
through the glomerular membrane
o However, any damage to the nephron capillary can
cause their formation
• RBC casts associated with glomerular damage are usually
associated with proteinuria and dysmorphic erythrocytes
• Detected in LPO by their orange-red color
• More fragile than other casts and may exist as fragments or
have a more irregular shape as the result of tightly packed
cells adhering to the protein matrix
• Examination under high-power magnification should
concentrate on determining that a cast matrix is present
• Most frequently seen cast (almost entirely uromodulin) o Differentiating it from RBC clumps
• 0-2 hyaline casts per lpf: normal • Highly improbable that RBC casts will be present in the
o Increased in sternous exercise, dehydration, heat absence of free-standing RBCs and a positive reagent strip
exposure and emotional stress test for blood
• Pathologic increase: acute glomerulonephritis, • As an RBC cast ages: cell lysis begins and the cast develops
pyelonephritis, chronic renal disease, and CHF a more homogenous appearance, but retains the
• Colorless in unstained sediments characteristic orange-red color from the released Hgb
• Refractive index similar to that of urine o Indicates greater stasis of urine flow
o Overlooked when not used with subdued light • Massive hemoglobinuria or myoglobinuria: homogenous
o Phase microscopy orange-red or red-brown casts may be observed
• Sternheimer-Malbin stain: produces a pink color in hyaline o Granular, dirty, brown casts representing hemoglobin
casts degradation products such as methemoglobin may also
o Phase microscopy: for increased visualization be present
• Morphology: normal parallel sides and rounded ends, § Must be present in conjunction with other pathologic
cylindroid forms, and wrinkled or convoluted shapes that findings (RTE cells, (+) for blood in RS)
indicate aging of the cast matrix § Associated with acute tubular necrosis caused by toxic
effects of hemoglobinuria that can lead to renal failure

WBC casts

RBC casts

• Signifies infection or inflammation within the nephron
• Most frequently associated with pyelonephritis
• Primary marker for distinguishing pyelonephritis (upper
UTI) from cystitis (lower UTI)
• Also present in nonbacterial inflammations such as acute
interstitial nephritis
o May accompany RBC casts in glomerulonephritis
• Visible in LPO, must be positively identified using HPO
• Most frequently composed of neutrophils
o Thus, may appear granular, and, unless disintegration
• Represents bleeding within the nephron has occurred, multilobed nuclei will be present
• Observed in healthy individuals following participation in • Supravital stain: to characterize nuclei
strenuous contact sports o To differentiate it from RTE casts
 § Observation of free WBCs in the • Singular round nuclei:most reliable distinguishing
sediment is also essential characteristic of renal tubular cells
• Bacteria are present in cases of pyelonephritis, but are not • Bilirubin-stained RTE cells are seen in cases of hepatitis
present with acute interstitial nephritis
o Eosinophil casts may be present in appropriately Fatty Casts
stained specimens (Hansel and Wright’s stains)
• Have irregular borders
• WBCs frequently form clumps, and these do not have the
same significance as casts
o Cast matrix: have irregular borders

Bacterial Casts
• Seen in conjunction with oval fat bodies and free fat
• Bacterial casts containing bacilli both within and bound to droplets in disorders causing lipiduria
the protein matrix: seen in pyelonephritis • Most frequently associated with the nephrotic syndrome
• May be pure bacterial casts or mixed with WBCs o Also seen in in toxic tubular necrosis, DM & crush injuries
• Packed casts with bacteria can resemble granular casts • Morphology: contain few or many fat droplets, and intact
• Presence should be considered when WBC casts and many oval fat bodies may be attached to the matrix
free WBCs and bacteria are seen in the sediment • Highly refractile under bright-field microscopy
• Confirmation: Gram stain on the dried or cytocentrifuged • Confirmation: polarized microscopy and Sudan III or Oil Red
sediment O fat stain
• Cholesterol: maltese cross formation (polarized light)
Epithelial Cell Casts
• Triglycerides and neutral fats: orange with fat stains
• Fats do not stain with Sternheimer-Malbin stain

Mixed Cellular Casts

• Most frequently encountered: RBC and WBC casts in

glomerulonephritis and WBC and RTE cell casts, or WBC and
bacteria casts in pyelonephritis (predominant (WBC)
• Staining or microscopy: aids in identification
• When mixed casts are present, there should also be
homogenous casts of at least one of the cell types, and they
will be the primary diagnostic marker
o Ex: Glomerulonephritis: RBC casts (predominant)
§ Pyelonephritis: WBC casts (predominant)

Granular Casts

• Casts containing RTE cells: represents presence of advanced
tubular destruction = urinary stasis with disruption of
tubular linings
o Associated with heavy metal and chemical or drug-
induced toxicity, viral infections, and allograft rejection
• Accompany WBC casts in cases of pyelonephritis
• When tubular damage is present, some cells may be
incorporated into the cast matrix, but the majority will be
very noticeably attached to the cast surface
• Owing to the formation of casts in the DCT, the cells visible
on the cast matrix are the smaller, round, and oval cells
• May be difficult to differentiate from WBCs, particularly if
degeneration has occurred
o Solution: Papanicolau staining, phase microscopy

 • Not considered necessary to distinguish between coarsely • Referred to as renal failure casts, broad casts like waxy
and finely granular casts casts represent extreme urine stasis
• The origin of the granules in nonpathologic conditions: • Indicates destruction (widening) of the tubular walls
from the lysosomes excreted by RTE cells during normal • Considering the accompanying urinary stasis, the most
metabolism commonly seen broad casts are granular and waxy
o It is not unusual to see hyaline casts containing one or • Bile-stained broad, waxy casts: seen in tubular necrosis by
two of these granules viral hepatitis
o Increased cellular metabolism caused by exercise:
increase in granular casts = increased hyaline casts Urinary crystals
• In disease states: granules may represent disintegration of
• Averaged and reported per lpf
cellular casts and tubule cells or protein aggregates filtered
by the glomerulus Crystal Formation
• Urinary stasis = casts to remain in the tubules = granules to
result from disintegration of cellular casts • Formed by precipitation of urine solutes (inorganic salts,
• Artifacts (clumps of small crystals and fecal debris), may organic compounds and medications (iatrogenic)
occur in shapes resembling casts, must be differentiated o Precipitation: subject to changes in temperature,
• Recognizable in LPO; final ID: HPO solute concentration and pH (affect solubility)
• When granular casts remain in the tubules for extended • Solutes precipitates more readily at low temp (RT/ref temp)
periods, the granules further disintegrate, and the cast • Increasing urinary solutes = decreased ability to remain in
matrix develops a waxy appearance solution = crystal formation
o More rigid, ends appear jagged or broken, and o Presence of crystals in freshly voided urine:
diameter is wider associated with high SG specimens
• pH of specimen: valuable aid in crystals identification
Waxy cast st
o 1 consideration in identifying crystals
o Determines type of chemicals precipitated
• Representative of extreme urine stasis, indicating chronic
o Ex: organic and iatrogenic compounds: crystalize
renal failure
more easily in acidic pH
• Waxy casts are more easily visualized than hyaline casts
§ Inorganic salts: less soluble in neutral and
because of their higher refractive index
alkaline solutions
• Often appear fragmented with jagged ends and have
• Exception: calcium oxalate: precipitates in
notches in their sides (result of brittle consistency of matrix)
both acidic and neutral urine
• Homogenous, dark pink in supravital stain
General Identification Techniques

• All abnormal crystals are found in acidic urine

• Polarized microscopy and solubility characteristics of the
crystals: additional aids in crystal identification
o Geometric shape of a crystal determines its
birefringence and, therefore, its ability to polarize light
o Although the size of a particular crystal may vary
(slower crystallization produces larger crystals), the
basic structure remains the same

§ Thus, polarization characteristics for a particular
Broad Casts crystal are constant for identification
• Reversal of contributing factors for crystal formation can
cause crystals to dissolve
o Amorphous urates: frequently form in refrigerated
specimens and obscure sediments may dissolve if the
specimen is warmed
o Amorphous phosphates: require acetic acid to dissolve
§ Not practical; RBCs may be destroyed

 o Highly birefringent under polarized light = aids in
distinguishing them from cystine crystals

• Increased amounts of uric acid crystals (fresh urine):
chemotherapy, Lesch-Nyhan syndrome
o Sometimes in patients with gout
• Acid urates and sodium urates: rarely encountered;
frequently seen with amorphous urates and have little
clinical significance
Normal Crystals Seen in Acidic Urine o Acid urates: appear as larger granules and may have
spicules similar to the ammonium biurate crystals seen
• Urates: most common crystals seen in acidic urine in alkaline urine
o Most urate crystals appear yellow to reddish brown o Sodium urates: needle-shaped and are seen in synovial
o Only normal crystals found in acidic urine that appear fluid during episodes of gout, may also appear in urine
colored • Calcium oxalate: both forms are birefringent (helpful to
• Amorphous urates: appear as yellow-brown granules distinguish them from non-polarizing RBCs)
o Dihydrate: most common form; colorless, octahedral
envelope or as 2 pyramids joined at their bases

oMay occur in clumps resembling granular casts and
attached to other sediment structure
o Frequently encountered in specimen refrigerated and
o Monohydrate: less frequent; oval/dumbbell shaped
produce a very characteristic pink sediment
§ Due to accumulation of pigment uroerythrin on
the surface of the granules
o Found in acidic urine with a pH of greater than 5.5
§ Uric acid crystals can appear when pH is lower
• Uric acid crystals: usually appear yellow-brown, but may be
colorless & have a 6-sided shape, similar to cystine crystals

o Sometimes seen in clumps attached to mucous strands
and may resemble casts
§ Related to the formation of renal calculi (majority
of renal calculi are composed of calcium oxalate)
§ Also associated with foods high in oxalic acid
(tomatoes and asparagus), ascorbic acid and
Crohn’s disease

 § Oxalic acid: end product of ascorbic acid • Calcium carbonate: small and colorless, dumbbell/spherical
metabolism
o Primary pathologic significance of calcium oxalate
crystals: presence of monohydrate forms in cases of
ethylene glycol (antifreeze) poisoning
§ Most frequently seen in children and pets

Normal Crystals Seen in Alkaline Urine

• Phosphates: majority of crystals seen in alkaline urine

o Others: Calcium carbonate and ammonium biurate
• Amorphous phosphates: granular in appearance, cause a
o Occur in clumps that resemble amorphous material
white precipitation that does not dissolve in warming
§ Distinguished by formation of gas after addition
(when present in large quantities following refrigeration)
of acetic acid
o Differentiated from amorphous urates by color of
§ Birefringent, differentiates them from bacteria
sediment and urine pH
• Ammonium biurate: yellow-brown color of the urate
crystals seen in acidic urine; thorny apple appearance
o Except for their occurrence in alkaline urine, it resembles
other urates in that they dissolve at 60°C and convert to
uric acid crystals when glacial acetic acid is added
o Almost always encountered in old specimens
§ Associated with presence of ammonia
produced by urea-splitting bacteria

• Triple phosphate (ammonium magnesium phosphate):
commonly seen in alkaline urine
o Easily identified by their prism shape that frequently
resembles a coffin lid
o As they disintegrate, crystals may develop a feathery
appearance
o Birefringent under polarized light; often seen in
alkaline urine with presence of urea-splitting bacteria

• Calcium phosphate: not frequently encountered

o Appear as colorless, flat rectangular plates or thin prisms
often in rosette formations
§ Rosette forms: may be confused with sulfonamides
crystals when the urine pH is neutral
o Dissolve in dilute acetic acid and sulfonamides do not
o Common constituent of renal calculi
Abnormal Urine Crystals o Lipids: remain in droplet form
• Appearance: rectangular plate with a notch in one or more
• Found in acidic urine or rarely in neutral urine corners
• Associated with disorders causing lipiduria (nephrotic
syndrome)
• Seen in conjunction with fatty casts and oval fat bodies
• Highly birefringent with polarized light

Radiographic Dye Crystals

• Highly birefringent; may have a very similar appearance to

cholesterol crystals
o Differentiation: best made by comparison of the other
urinalysis results and the patient history
o Cholesterol crystals should be accompanied by other
lipid elements and heavy proteinuria
• SG of a specimen containing radiographic contrast media:
markedly elevated when measured by refractometer

Crystals Associated with Liver Disorders

• Iatrogenic crystals: caused by a variety of compounds • Tyrosine crystals: appear as fine colorless to yellow needles
o Particularly when administered in high concentrations that frequently form clumps or rosettes
• Clinically significant when they precipitate in the renal o Usually seen in conjunction with leucine crystals in
tubules specimens with positive chemical tests for bilirubin
o Seen in inherited disorders of amino acid metabolism
Cystine Crystals

• Seen in cystinuria (prevents cystine reabsorption in tubules)

• Appear as colorless, hexagonal plates and may be thick or
thin
• Disintergrating forms may be seen in the presence of NH3

• Leucine crystals: yellow-brown spheres that demonstrates
concentric circles and radial striations
o Seen less frequently than tyrosine crystals and, when
present, should be accompanied by tyrosine crystals

• May be difficult to differentiate from colorless uric acid
crystals
o Uric acid crystals: very birefringent under
polarized microscopy
o Thick cystine crystals: have polarizing capability
• Positive confirmation: cyanide-nitroprusside test

Cholesterol crystals • Bilirubin crystals: present in hepatic disorders

o Appear as clumped needles or granules with the
• Rarely seen unless specimens have been refrigerated characteristic yellow color
 o Resemble fat droplets when polarized, producing a
Maltese cross formation
o Occasionally confused with RBCs

• Viral hepatitis: disorder that produce renal tubular damage
o Result: bilirubin crystals may be found
incorporated into the matrix of casts

Sulfonamides Crystals

• Oil/fat droplets and air bubbles: may resemble RBCs
o Oil droplets: result from contamination by immersion
oil or lotions and creams and maybe seen with fecal
contamination

• Finding of these crystals in the urine of patients being
treated for UTIs was common
• Inadequate hydration: primary cause of this crystallization
• Appearance of sulfonamide crystals in fresh urine can
o Air bubbles: occur when the specimen is placed under a
suggest the possibility of tubular damage if crystals are
cover slip
forming in the nephron
• Pollen grains: appear as spheres with a cell wall and
• Shapes most frequently encountered: needles, rhombics,
occasional concentric circles
whetstones, sheaves of wheat, and rosettes with colors
ranging from colorless to yellow-brown

Ampicillin Crystals

• Hair and fibers from clothing and diapers: mistaken for
casts; but are usually longer and more refractile
o Fibers often polarize, whereas casts, other than
fatty casts, do not polarize

• Cause: massive doses of this penicillin compound without • Presence of a fistula between the intestinal and urinary
adequate hydration tracts may produce fecal specimen contamination
• Appear as colorless needles that tend to form bundles o May appear as plant and meat fibers or as brown
following refrigeration amorphous material in a variety of sizes and shapes
Urinary Sediment Artifacts

• Caused by specimens collected under improper conditions

or in dirty containers
• Frequently resemble pathologic elements (RBCs and casts)
• Often very highly refractile
• Reporting of artifacts is not necessary
• Starch granule: occur when cornstarch is the powder used
in powdered gloves
o Highly refractile spheres, usually with a dimpled center