Urinalysis and Body Fluids CRg Unit 2; Session 3 WBCs in the Urine Microscopic

Microscopic Sediment – White Blood Cells WBCs can enter anywhere in the urinary system (diapedesis). Men 0-2 /hpf ; Women < 5 /hpf Increased numbers. (pyuria / leukocyturia) Without bacteria Inflammation – trauma / certain disease states / appendicitis / pancreatitis / malignancy /allergic reaction / dehydration / stress/ fever/non-infectious irritation to urinary structures With increased bacteria Likely infection -/ UTI @ 7 WBC identifiable, ones at arrows are best examples. Others possible, but need to change focus for better evaluation. 3-5 RBCs.

Microscopic Sediment – White Blood Cells Increased numbers. (pyuria / leukocyturia) Quantitating WBC in urine Ave. number seen in 10-15 hpf This example 11-20 WBC/hpf

Microscopic Sediment – White Blood Cells Detection High dry objective (10x ocular + 40x objective = 400x total mag.) Fine adjustment Description Grayish-blue / yellowish-green in color – depending on microscope @ 10-12 microns in diameter, but affected by specific gravity of urine Fine cytoplasmic granulation, rough surface, may have irregular edges. Usually polynuclear, but may be mononuclear, but often hard to see detail.

Microscopic Sediment – White Blood Cells WBCs -larger than RBCs WBCs - smaller than renal epithelial cells. WBCs – usually neutrophils WBCs – may be in clumps

Microscopic Sediment – White Blood Cells Neutrophil is predominant Identify under high power Glitter cells Hypotonic urine Brownian movement Swell; granules sparkle Pale blue if stained Nonpathologic http://www.agora.crosemont.qc.ca/urinesediments/Imdoceng/d12d002.html

Microscopic Sediment – White Blood Cells Eosinophils Hansel stain preferred over Wrights to demonstrate presence of eosinophils in urine. Increases seen in variety of conditions, Drug-induced interstitial nephritis Renal transplant rejection / acute graft rejection most allergic reactions schistosomiasis, & acute allergic interstitial nephritis

Microscopic Sediment – White Blood Cells Mononuclear cells – more rarely encountered than segmented neutrophils Lymphocytes Monocytes Macrophages Histiocytes Differentiate from renal tubular epithelial (RTE) cells Lymphocytes may resemble RBCs; seen in early transplant rejection May need to refer to cytodiagnostic testing

Microscopic Sediment – White Blood Cells Lymphocytes Occasionally seen in normal sediment Increased numbers reported in acute allergic interstitial nephritis, graft rejection, etc. Requires special staining (PAP) to verify identity

Microscopic Sediment – White Blood Cells Monocytes Also can be found in conditions listed for lymphocytes Also requires special staining to verify identity Macrophages Usually of normal size with inclusions in cytoplasm. Occasionally enlarged with one or more smaller cells engulfed. Seen in acute inflammatory processes ***When filled with fat droplets would be called oval fat bodies.

Microscopic Sediment – White Blood Cells Review of identification Grayish-blue sheen, @ 10-12 microns in diameter Polynuclear neutrophils most seen Fine cytoplasmic granulation, rough surface, may have irregular edges. Few lymphs seen as well, but hard to ID Enhancement techniques Stains Sternheimer- Malbin for general Hansel for eosinophils Toluidine blue PAP Microscopy Light microscope Phase contrast Review of WBC identification Using regular light microscopy the white blood cells in the urine sediment usually appear dull gray / Grayish-blue or maybe yellowish in color. As was for the RBCs, the exact coloring of the cells in the unstained sediment varies slightly depending on the characteristics, and filters in the microscope you are using. They are @ 10-12 microns in diameter – but size is affected by the specific gravity of the urine Polynuclear neutrophils or segs, are the WBC most often seen in the urine sediment. They have fine cytoplasmic granulation and – if urine is water-like - the granules will shiver back and forth and in the past they would have been identified as glitter cells A Few lymphocytes may be seen in the urine sediment as well, but harder to specifically identify. Enhancement techniques used to aid in the ID of wbcs in urine include the use of stains, such as Sternheimer- Malbin for general analysis; and Hansel stain - which is specific for identification of eosinophils. Other stains sometimes used include Toluidine blue & PAP We generally use the Light microscope for routine evaluation but may find the phase contrast microscope to also be useful . Proceed to the next slide for more information – picture on next slide

Microscopic Sediment – White Blood Cells Phase contrast

Microscopic Sediment – White Blood Cells WBC / leukocytes This slide has higher level of magnification than normally used in routine examination.

Microscopic Sediment – White Blood Cells WBCs, RBCs, cell debris, bacteria

References Dr Andre Audet, Leukocytes & Glitter Cells Lillian Mundt & Kristy Shanahan, Graff’s Textbook of Urinalysis and Body Fluids, 2nd Ed. Susan Strassinger & Marjorie Di Lorenzo, Urinalysis and Body Fluids, 5th Ed. Mery Haber, MD, A Primer of Microscopic Urinalysis, 2nd Ed. Zenggang Pan, MD, PhD., Dept of Pathology, U of Alabama at Birmingham http://www.enjoypath.com/cp/Chem/Urine-Morphology/Urine-morphology.htm Shih-Yung Medical Instruments Co., Ltd http://www.symic.com.tw/member/ova.htm Dr Andre Audet, Leukocytes & Glitter Cells http://www.agora.crosemont.qc.ca/urinesediments/doceng/doc_012.html Department of the Army, Landstuhl Regional Medical Center http://www.dcss.cs.amedd.army.mil/field/FLIP%20Disk%204.2/FLIP42.html I have used many references and sources in the development of the slides in these units. I want to provide appropriate credit to all of those who have made their work available for use in the educational setting. This listing is just the beginning and I will continue adding to it as we go along. CRg This concludes the session on wbcs in the urine sediment.