CLS 1113

Introduction to Clinical
Laboratory Practices

Microscopic Examination
Formed Elements:
Crystals
 Urinary Crystals
• Most crystals form after urine sits
– urinary solutes precipitate(ppt) out of solution
• Clinical Significance
– MOST are clinically INsignificant
– Generally clinically significant crystals are present
on freshly voided urine (body temp.)
– Crystal composition may imply urinary calculi
 Urinary Crystals

• Clinical Significance Continued

– May indicate metabolic disorder
• Cystinuria - inherited metabolic condition
– Crystals of some drugs may precipitate(ppt)
out, especially in high doses
• Sulfonamides
 Urinary Crystals
• Formation
– crystals ppt out of solution when the
concentration in solution is greater than the
solubility threshold for that solute
– Factors that affect crystal formation
• pH, solute concentration, filtrate volume passing
through kidneys
 Urinary Crystals
• Classification
– Normal and Abnormal
• Normal Acidic crystals
• Normal Alkaline crystals
• Abnormal crystals - metabolic origin or iatrogenic origin
– Morphology
• Based on pH
• Generally reported based on morphology alone
 Normal Acidic Crystals
• Amorphous urates
– amorphous:
– salt of uric acid (Na, Mg, Ca or K)
– yellow/red to red/brown
• Uric Acid
– along with amorphous urates, most common
– pH <6.0
Amorphous Urates and
Phosphates
 Normal Acidic Crystals
• Uric Acid
– concentration depends on dietary intake of purines
and breakdown of nucleic acids
• seen in leukemia patients receiving chemotherapy
– when accompanies by increased serum uric acid
may be associated with gout
– pathologic only when seen in freshly voided urine
– Most varied of morphologically
Uric Acid
Uric Acid
Uric Acid:

Polarized
 Normal Acidic Crystals
• Calcium oxalate
– may also been seen in neutral or alkaline urine
– dihydrate form is easily recognized
– monohydrate uncommon - oval shape
– when present with symptoms of urinary calculi
may indicate composition of stone (lithiasis)
• 75% composed of CaOx
– Excess Oxalate
• Spinach, rhubarb, ascorbic acid, ethylene glycol
poisoning
Calcium Oxalate
CaOx cont...
 Normal Alkaline Crystals
• Amorphous Phosphates
– ditto from amorphous urate...except it is
alkaline urine
– unable to distinguish...only by pH
• Triple Phosphate (ammonium magnesium)
– Also referred to as struvite
• 10-20% urinary calculi
– Coffin lid
Triple Phosphate
 Triple
Phosphate
 Normal Alkaline Crystals
• Ammonium Biurate
– Rarely seen in freshly voided urine - common
in old specimens
– Dark yellow or brown
Ammonium
Biurate
 Abnormal Crystals
of Metabolic Origin
• Cystine
– Cystinuria: metabolic disorder
• inherited amino acid transport disorder affecting
cystine
• may form cystine stones - kidney damage - may fill
renal collecting system, resulting in staghorn calculi
causing stasis, etc.
– Colorless, refractile hexagonal plate
Cystine
 Abnormal Crystals
of Metabolic Origin
• Cystine continued
– May confuse with uric acid
• both are acid pH crystals
• confirmatory for cystine: Nitroprusside Reaction
• Tyrosine
– Severe liver disease
– Rarely seen
– Colorless needles, acidic pH
Tyrosine
 Abnormal Crystals
of Metabolic Origin
• Leucine (Rare)
– Liver disease (with tyrosine)
– Yellow, oily-looking spheres, acidic pH,
birefringent (pseudo Maltese cross when
polarized)
• Cholesterol
– Seen as free fat, in renal epi’s, fatty casts in
cases of nephrotic syndrome
 Abnormal Crystals
of Metabolic Origin
• Cholesterol
– Acidic pH, colorless, large, flat, rectangular
plates with one or more corners notched.
– May be mistaken for radiologic dyes
• Specific gravity
Cholesterol
 Abnormal Crystals of
Iatrogenic Origin
• Sulfonamides
– Renal damage as these ppt out in nephron
– Acidic pH, yellow to brown, needles in sheaves
but have a variety of shapes
• Ampicillin
– High dose
– Acidic pH, thin colorless needles
 Abnormal Crystals of
Iatrogenic Origin
• Radiologic Contrast Media
– renografin, hypaque
– Look like cholesterol (variety of shape)
Radiologic
Dye
Sulfonamides
Bilirubin Crystals
Bilirubin Crystals Cont…