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1.

List and identify the normal crystals found in acidic urine

Crystal Appearance/Characteristics Clinical Significance


1. Amorphous urates (calcium, -Precipitate upon standing in -Amorphous urates have no clinical
magnesium, sodium and potassium) concentrated urine of a slightly acid significance and are distinguished from
pH. amorphous phosphates on the basis of
-When large quantities are present, the urine pH, their macroscopic
urine sediment may appear pink- appearance, and their solubility
orange to reddish brown on characteristics
macroscopic examination; this
appearance has been referred to as
brick dust.
-Microscopically, this amorphous
material appears as yellow-brown
small granules that can form clumps
and adhere to fibers and mucous
threads.
-Convert to uric acid crystals with
acidification with acetic acid, and will
dissolve with heat (60° C) and with
dilute alkali.
2. Crystalline Uric Acid - Seen in a variety of shapes, including -Large numbers of uric acid crystals
rhombic or four-sided flat plates, and urates may reflect increased
prisms, oval forms with pointed ends nucleoprotein turnover, especially
(lemon-shaped), wedges, rosettes, and during chemotherapy of leukemia or
irregular plates lymphoma. Increased quantities may
-Most are colored, typically yellow or be seen with Lesch-Nyhan syndrome
reddish brown. Rarely, they are and may provide circumstantial
colorless and hexagonal, resembling evidence of the nature of small stones
cystine. Unlike cystine, they show lodged in the ureters, especially when
birefringence with radiolucent and found in conjunction
polarized light. with raised serum uric acid levels. They
may also herald the urate nephropathy
of gout.
3. Calcium Oxalate - Dihydrates may appear at pH 6 or in - Oxalate crystals in large numbers may
neutral urine. Their classic form is that reflect severe chronic renal
of a small, colorless octahedron that disease or ethylene glycol or
resembles an envelope methoxyflurane toxicity
- Dumbbell shapes and ovoid forms - Oxaluria has come
may occur into prominence as a reflection of the
- Longer forms occur in calcium oxalate increased absorption of oxalates from
monohydrate. Oxalate crystals are food following small bowel disease and
insoluble in acetic acid. resection, notably for Crohn’s disease.
- Oxaluria may also be present in
genetically susceptible persons
following large doses of ascorbic acid.
4. Monosodium Urate - A distinct form of a uric acid salt, - Have no clinical significance and
appear as colorless to light-yellow usually are reported as “urate crystals.”
slender, pencil-like prisms.
- They may be present singly or in
small clusters, and their ends are not
pointed.
- Can be present when the urine pH is
acid and dissolve at 60° C.
5. Hippuric Acid - Yellow–brown or colorless elongated - Rarely seen in the urine and have
prisms or plates practically no clinical significance.
- They may be so thin as to resemble
needles, and they often cluster together
- More soluble in water and ether than
are uric acid crystals
6. Calcium Sulfate - Long, thin, colorless needles or - Rarely seen in the urine and they have
prisms that are identical in appearance no clinical significance.
to calcium phosphate.
- Found in acidic urine, whereas
calcium phosphate is usually found in
alkaline urine.
- Extremely soluble in acetic
acid
2. List and identify the normal crystals found in alkaline urine

Crystal Appearance/Characteristics Clinical Significance


1. Amorphous Phosphates (calcium and - have a granular appearance - Have no clinical significance and can
magnesium) microscopically; unlike the former, make the microscopic examination
they tend to be colorless and will difficult when a large quantity is
produce a fine or lacy white precipitate present.
macroscopically.
- Clumps or masses can often be seen
by light microscopy. Large amounts of
this material may precipitate out upon
prolonged standing at room
temperature or in a refrigerator.
- Calcium and magnesium
monohydrogen phosphates are the
least soluble in alkaline urine, although
the dihydrogen phosphates may be
soluble at a similar pH
- Phosphates, in general, will dissolve
in acids such as dilute hydrochloric and
nitric acids and vary in solubility in
acetic acid.
2. Crystalline phosphates (Triple - They are colorless, three to - Triple phosphate crystals have little
phosphate/ Ammonium magnesium six-sided prisms with oblique ends clinical significance but have been
phosphate) referred to as coffin lids. They may associated with UTIs characterized
form colorless sheets or flakes by an alkaline pH and have been
implicated in the formation of renal
calculi.
3. Calcium Carbonate - These uncommon crystals are small - Present primarily in alkaline urine,
and colorless, with dumbbell or calcium carbonate crystals are not
spherical shapes. They may form pairs, found frequently in the urine sediment
fours, or clumps. They are and have no clinical significance
distinguished from other
crystals/amorphous material by their
production of carbon dioxide in the
presence of acetic acid.
4. Ammonium Biurate - yellow-brown color and appear as - Ammonium biurate is a normal urine
spheres with radial or concentric solute. These crystals occur most
striations and irregular projections or frequently in urine specimens that
thorns. Referred to as thorn apples, have undergone prolonged storage.
they may also be seen in neutral and However, when they precipitate out of
occasionally in slightly acid urine. They solution in fresh urine specimens (e.g.,
dissolve with heat at 60° C and with following iatrogenically induced
acetic acid, reappearing as typical uric alkalinization), they are clinically
acid crystals after about 20 minutes. significant, because in vivo
precipitation can cause renal tubular
damage. Their presence most often
indicates inadequate hydration of the
patient. Therefore when ammonium
biurate crystals are encountered in a
urine specimen, investigation is
required to determine whether (1) the
integrity of the urine specimen has
been compromised (improper storage),
or (2) in vivo formation is taking place.
5. Calcium Phosphate - Dibasic calcium phosphate crystals, - Calcium phosphate crystals are
sometimes called stellar phosphates, common and have no clinical
appear as colorless, thin, wedge like significance.
prisms arranged in small groupings or
in a rosette pattern.
- Monobasic calcium phosphate
crystals usually appear microscopically
as irregular, granular sheets or flat
plates that can be large and may be
noticed floating on the top of a urine
specimen. These colorless crystalline
sheets can resemble large degenerating
squamous epithelial cells.
3. Describe and state the significance of cystine, cholesterol, leucine, tyrosine, bilirubin, sulfonamide, radiographic dye and
ampicillin crystals

Crystal Appearance/Characteristics Clinical Significance


1. Cystine - Cystine crystals are colorless, - Cystine crystals are among the most
refractile, hexagonal plate, which important crystals identified in
appear in acid urine. They are soluble urine sediment. They occur in patients
in water at pH less than 2 or greater with cystinuria and may be associated
than 8, and they may be confused with with cystine calculi. Confirmatory
hexagonal forms of uric acid testing consists of the cyanide-
nitroprusside reaction.
2. Cholesterol - Cholesterol crystals appear as clear, - Cholesterol crystals can be seen with
flat, rectangular plates with notched the nephrotic syndrome and in
corners. These crystals can be present conditions resulting in chyluria: the
in acidic urine and, because of their rupture of lymphatic vessels into the
organic composition, are soluble in renal tubules as a result of tumors,
chloroform and ether. filariasis, and so on.
3. Leucine - These crystals are also rare, occurring - Present in the urine of patients with
as yellow, oily-appearing spheres with overflow aminoacidurias—rare
radial and concentric striations. They inherited metabolic disorders. In these
are soluble in both acids and alkalis. disorders, the concentrations of these
Leucine and tyrosine crystals may amino acids in the blood are high
occur together; leucine may be (aminoacidemia), resulting in
precipitated with tyrosine crystals if increased renal excretion. Although
alcohol is added to the urine. rare, these crystals have been observed
in the urine of patients with severe
liver disease.
4. Tyrosine - In acidic urine, tyrosine forms fine - Present in the urine of patients with
silky needles that may be arranged in overflow aminoacidurias—rare
sheaves or clumps, especially after inherited metabolic disorders. In these
refrigeration. These may be colorless disorders, the concentrations of these
or yellow, appearing black as the amino acids in the blood are high
microscope is focused. (aminoacidemia), resulting in
- They are soluble in alkali (ammonia increased renal excretion. Although
and potassium hydroxide) rare, these crystals have been observed
and in dilute hydrochloric acid; they in the urine of patients with severe
are not soluble in alcohol or ether. liver disease.
5. Bilirubin - Bilirubin crystals usually appear as - They are classified as abnormal
small clusters of fine needles (20 to 30 crystals because bilirubinuria indicates
μm in diameter), but granules and a metabolic disease process.
plates have been observed. Always
characteristically yellow-brown, these
crystals indicate the presence of large
amounts of bilirubin in the urine.
Bilirubin crystals are confirmed by
correlation with the chemical
examination, that is, the crystals can be
present only if the chemical screen for
bilirubin is positive.
- Bilirubin crystals only form in an
acidic urine. They dissolve when alkali
or strong acids are added.
6. Sulfonamide - These crystals may be seen in urine of - These crystals could be seen in the
acid pH and may take on various urine of patients on sulfonamide
morphologies, depending on the form therapy who were inadequately
of drug involved. They may be seen as hydrated. This could result in renal
yellow-brown sheaves of wheat with tubular damage if crystal formation
central bindings, striated sheaves with occurred within the nephron.
eccentric bindings, rosettes, Currently, sulfamethoxazole (Bactrim,
arrowheads, petals, needles, and round Septra) is seen with some regularity.
forms with radial striations. They are
occasionally colorless. Confirmatory
testing is by the diazo reaction.
- Sulfa crystals are not as frequently
found in urine, especially when urine is
examined at 37° C.
7. Radiographic Dye - Crystals of radiographic contrast - They may be found in urine of acid pH
media following retrograde shortly after intravenous radiographic
administration appear as colorless, studies (particularly if the patient has
long, rectangular needles that occur not been well hydrated)
singly or clustered in sheave; when - The presence of radiographic crystals
administered intravenously, they should correlate with a high specific
appear as flat, elongated rectangular gravity (>1.040).
plates.
8. Ampicillin - Ampicillin may crystallize in the urine - Present in acidic urine, ampicillin
under conditions of high dosage. These crystals indicate large doses of
crystals appear in urine of acid pH as ampicillin and are rarely observed with
long, fine, colorless structures . They adequate hydration.
may form coarse sheaves after
refrigeration.

REFERENCES. Fundamentals of Urine and Body Fluids by Nancy Brunzel

Graff’s Textbook of Urinalysis and Body Fluids

Henry’s Clinical Diagnosis and Management by Laboratory Methods, 23 rd ed.

4. Differentiate between actual sediment constituents and artifacts