urine microscopy cases - echo360

Urine Microscopy Cases

Mark A. Perazella, MDYale University School of Medicine

Case 1• 69 year old man presents to the ED with 1 week of 3‐4 episodes

of N/V per day, lower abdominal pain and 10 days of intermittent gross hematuria

• PMH: OA of hands and knees, mild COPD and GERD

• Medications: Aspirin, occ NSAID, albuterol inhaler, omeprazole

• Social Hx: 50 pack‐year smoking, no ETOH, no herbal remedies

• Examination: BP 150/89, P 87, afebrile

– H&N: pale conjunctiva, normal JVD, no bruit

– Chest: clear

– Heart: RRR, no rub or gallop

– Abd: soft, moderate to severe tenderness on lower abdomen, worst on RLQ, no rebound, no HSM, no bruit , no CVA tenderness

– Ext: no edema or rash

• Laboratory Results:

– Electrolytes: Na+=138, K+=4.1, HCO3=25, Cl‐=103

– BUN=29 mg/dl Cr=1.7 mg/dl

– Glucose=96 mg/dl

– Hb=10.1 mg/dl Plt=195 x1000/uL

– WBCs=6700 per mm3, Eosinophils=3%

– Urinalysis: SG‐1.012, pH‐6.0, Protein‐trace, Blood‐

2+, Glucose‐neg, Leukocyte esterase‐trace

– Urine Na+=25 mEq/L, FENa+=1.1%

Urine sediment

Case 1

• What is present on urine microscopy?

A. Dysmorphic RBCs

B. Yeast

C. Renal tubular epithelial (RTE) cells

D. Isomorphic RBCs

E. WBCs

Case 1


A. Dysmorphic RBCs

B. Yeast

C. Renal tubular epithelial (RTE) cells

D. Isomorphic RBCs

E. WBCs

Case 1

• Based on the urine microscopy, what is the most likely diagnosis?

A. IgA nephropathy

B. Interstitial nephritis

C. Bladder cancer

D. Thin basement membrane disease

E. Acute pyelonephritis

Case 1


A. IgA nephropathy


C. Bladder cancer

D. Thin basement membrane disease


• Renal Ultrasound was

negative

• Renal CT scan was negative

• Fortunately, CT scan included

abdomen & pelvis

Case 1

•Bladder mass is noted on CT

scan (concerning for cancer)

• Cystoscopy/biopsy confirmed

bladder cancer

What if you saw this on urine microscopy?

Case 1a


A. Dysmorphic RBCs

B. Yeast

C. RTE cells

D. Isomorphic RBCs

E. WBCs

Case 1a


A. Dysmorphic RBCs

B. Yeast

C. RTE cells

D. Isomorphic RBCs

E. WBCs

Case 1a


A. IgA nephropathy


C. Bladder cancer

D. Acute tubular necrosis


Case 1a


A. IgA nephropathy


C. Bladder cancer

D. Acute tubular necrosis


Urine MicroscopyHematuria

• Visual exam of urine

– Gross hematuria

– Microscopic hematuria

– Isomorphic vs dysmorphic RBCs

• Dipstick testing for hematuria

– Very sensitive (+ with >2 RBCs/HPF)

– Not specific (+ with heme pigment)

• Definitions of hematuria

– 1 to > 10 RBC/HPF– ≥ 3 RBC/HPF on > 2 separate samples is diagnostic Dysmorphic Red Blood Cells

Acanthocytes (> 5% of RBCs)

‐ sensitivity (52%)

‐ specificity (98%)

Case 2• 48 year old man presents with several days of N/V, and

generalized weakness prompting ED visit. He admits to recently abusing cocaine and bath salts

• PMH: HIV+ , HTN, hyperlipidemia, hyperlipidemia, substance abuse, stage 3 CKD (baseline serum Cr=1.3‐1.6 mg/dl)

• Medications: elvitegravir/cobicistat/emtricitabine/tenofovir(Stribild), statin, oxycontin, neurontin, amlodipine, losartan

• Allergy: sulfa‐based medications

• Examination: BP‐148/88 P‐95 Afebrile

– H&N‐ pink conjunctiva, increased JVP

– Lungs‐ clear

– Heart‐ S1S2, no S3, rub or murmur

– Abdomen‐ benign with normal bowel sounds

– Extremities‐ trace edema


– Electrolytes: Na+=133 mEq/L, K+ =3.2 mEq/L,

HCO3‐ =15 mEq/L, Cl‐ =106 mEq/L, Alb 3.2 g/dl


– Hb=10.9 mg/dl Plt=135 x1000/uL

– WBC=15,500 per mm3, Eosinophils=5%

– Phosphorus 1.8 mg/dl Glucose 96 mg/dl

– Urinalysis: SG‐1.010, pH‐5.5, Protein‐1+, Glucose‐1+, Blood‐negative, Leukocyte esterase‐trace

– Urine Na +=98 mEq/L, FENa+=2.6%

Urine Sediment


A. Dysmorphic RBCs

B. WBCs

C. Transitional epithelial cells

D. RTE cells

E. Oval fat bodies

Case 2


A. Dysmorphic RBCs

B. WBCs

C. Transitional epithelial cells

D. RTE cells

E. Oval fat bodies

Case 2


A. Thrombotic microangiopathy

B. Acute tubular injury/ATN

C. Acute interstitial nephritis

D. Postinfectious glomerulonephritis

E. Uroepithelial (ureteral) cancer

Case 2






E. Uroepithelial (ureteral) cancer

Case 2

Acute Tubular Apoptosis/Necrosis• luminal ectasia, loss of brush border

• tubular dropout, apoptotic figures

Urine MicroscopyCellular Elements

• Urine sediment exam

– RBCs (monomorphic vs dysmorpic)

– Epithelial cells • Squamous epithelial cells, transitional epithelial cells, renal tubular epithelial cells

– WBCs (eosinophils, PMNs, lymphocytes)

– Other cells/organisms• Malignant (lymphoid cells, uropeithelial cancer)

• Decoy cells (BK‐polyoma virus)

• Bacteria, Yeast, Mycobacterium, etc

Epithelial Cells• Squamous• Transitional• Renal Tubular

Renal Tubular Epithelial Cells

Case 3• 71 year old female presents with poor appetite, fatigue and

increased serum Cr that is noted noted on blood draw at office visit

• PMH: HTN, T2 DM, GERD, osteoarthritis, osteoporosis, COPD

• Medications: enalapril, amlodipine, glyburide, combivent inhaler, lansoprazole, calcium tablets, occasional tramadol and naproxen (for hip pain), no OTC or herbal products

• No allergies

• Examination: BP‐128/82 P‐94 T‐98.3

– H&N‐ pale conjunctiva, normal JVP

– Lungs‐ clear

– Heart‐ S1S2, no S3, or rub

– Abdomen‐ benign with normal BS, no flank tenderness

– Extremities‐ trace ankle edema, no rash




– Glucose=110 mg/dl Alb 3.4 g/dl

– Hb=10.1 mg/dl Plt=335 x1000/uL

– WBCs=12,000 per mm3, Eosinophils=1%

– Urinalysis: SG‐1.015, pH‐5.5, Protein‐1+, Blood‐

1+, Glucose‐neg, Leukocyte esterase‐2+


Urine Sediment

Case 3


A. RTE cells

B. WBCs

C. RBCs

D. Transitional epithelial cells

Case 3


A. RTE cells

B. WBCs

C. RBCs


Urine Sediment Case 3


A. Lipid cast

B. RTE cast

C. RBC cast

D. WBC cast

Case 3


A. Lipid cast

B. RTE cast

C. RBC cast

D. WBC cast

Case 3






Case 3






Acute Interstitial Nephritis• Lymphocytes, plasma cells, eosinophils

• Interstitial edema with tubulitis

White Blood Cells White Blood Cells

White Blood Cells White Blood Cell Cast

White Blood Cell Casts

Case 4• 44 year old woman presents with malaise, anorexia, and lower

extremity swelling over the past 3‐4 weeks

• PMH: Obesity, T2 DM, osteoarthritis of knees, asthma

• Medications: glyburide, combivent inhaler, lansoprazole, calcium tablets, celecoxib, naproxen, no OTC or herbal products

• Allergies: PCN (rash)


– H&N‐ pale conjunctiva, increased JVP

– Lungs‐ clear with dullness at bases

– Heart‐ S1S2, no S3, rub or 2/6 holosystolic murmur

– Abdomen‐ obese with normal BS, no flank tenderness

– Extremities‐ 3+ LE edema to the mid thighs, skin erythema with weeping blisters




– Glu=295 mg/dl

– Hb=10.9 mg/dl Plt=435 x1000/uL


– Urinalysis: SG‐1.020, pH‐5.5, Protein‐3+, Blood‐1+,

Glucose‐1+, Leukocyte esterase‐trace


Urine Sediment


A. RTE cell and fine granular cast

B. WBC and hyaline cast

C. OFB and fatty cast

D. RTE cell and hyaline cast

E. RTE cell and RBC cast

Case 4


A. RTE cell and fine granular cast

B. WBC and hyaline cast

C. OFB and fatty cast

D. RTE cell and hyaline cast

E. RTE cell and RBC cast

Case 4


A. Nephritic syndrome



D. Nephrotic syndrome

E. Rapidly progressive GN (RPGN)

Case 4


A. Nephritic syndrome



D. Nephrotic syndrome

E. Rapidly progressive GN (RPGN)

Case 4

Renal Tubular Epithelial Cell with Fat (Oval Fat Body)

Polarization shows “maltese cross”

Lipid casts withpolarization showing

“maltese cross”

Case 5• 59 year old man presents with anorexia, worsening skin rash, and

ankle puffiness; increased serum Cr was noted at clinic visit

• PMH: HTN, severe COPD (home O2), DVT, CAD, GERD, BPH, MAT

• Medications: combivent inhaler, esomeprazole, vitamin D/calcium, intermittent prednisone, diltiazem, no OTC or herbal products

• Allergies: none

• Social: heavy smoker, + ETOH


– H&N‐ pink conjunctiva, normal JVP

– Lungs‐ decreased BS and scattered rhonchi

– Heart‐ distant S1S2, no S3, rub or murmur

– Abdomen‐ normal BS, no flank tenderness

– Extremities‐ 1+ankle edema, petechial skin rash




– Glu=125 mg/dl

– Hb=13.9 mg/dl Plt=550 x1000/uL


– Urinalysis: SG‐1.017, pH‐5.5, Protein‐2+, Blood‐2+,

Glucose‐neg, Leukocyte esterase‐1+


Urine Sediment


A. RTE cell cast

B. WBC cast

C. RBC cast

D. Fatty cast

E. Hyaline cast

Case 5


A. RTE cell cast

B. WBC cast

C. RBC cast

D. Fatty cast

E. Hyaline cast

Case 5

• Based on the urine microscopy, what is the most likely kidney lesion?

A. Proliferative glomerulonephritis



D. Membranous glomerulonephritis

E. Nephrolithiasis with bilateral urinary obstruction

Case 5

• Based on the urine microscopy, what is the most likely kidney lesion?

A. Proliferative glomerulonephritis



D. Membranous glomerulonephritis

E. Nephrolithiasis with bilateral urinary obstruction

Case 5

Proliferative (necrotizing) glomerulonephritis• Segmental necrosis• Cellular proliferation• Crescent formation

Urine MicroscopyCasts


– Cells found admixed with casts• RBCs (isomorphic vs dysmorphic)

• Renal tubular epithelial cells

• WBCs (PMNs, eosinophils, lymphocytes), OFBs

– Non‐cellular Casts• Hyaline, Broad, Waxy, other

– Cellular Casts• RBC casts

• WBC casts

• Renal tubular epithelial cell casts

• Granular casts (muddy brown, pigmented)Red Blood Cell Cast

Red Blood Cell Cast RBC Cast & Dysmorphic RBCs

Case 6• 85 year old woman presents with anorexia, diarrhea, fever, and

left leg pain present to the ED for evalaution

• PMH: HTN, COPD , CAD, peptic ulcer disease, osteoporosis, OA, and atrial fibrillation

• Medications: combivent inhaler, esomeprazole, vitamin D/calcium, warfarin, diltiazem, occasional ibuprofen, and furosemide

• Allergies: None

• Social: nonsmoker, ‐ ETOH



– Lungs‐ decreased BS

– Heart‐ distant S1S2, irreg irreg rhythm, no S3, rub or murmur


– Extremities‐ trace ankle edema, erythema with blisters LLE




– Glu=285 mg/dl

– Hb=11.9 mg/dl Plt=250 x1000/uL


– Urinalysis: SG‐1.018, pH‐5.5, Protein‐1+, Blood‐1+, Glucose‐1+, Leukocyte esterase‐trace


Urine Sediment


A. RTE cell cast

B. WBC cast

C. Waxy cast

D. Hyaline cast

E. Fatty cast

Case 6


A. RTE cell cast

B. WBC cast

C. Waxy cast

D. Hyaline cast

E. Fatty cast

Case 6


A. Progressive CKD

B. Prerenal AKI

C. Acute tubular injury/ATN

D. Acute interstitial nephritis

E. Membranoproliferative GN

Case 6


A. Progressive CKD

B. Prerenal AKI

C. Acute tubular injury/ATN


E. Membranoproliferative GN

Case 6

Prerenal AKI• No biopsy

AKI (serum Cr returned to baseline)resolved over 48 hours with IV fluids

and holding diuretics





• WBCs (eosinophils), OFBs

– Non‐cellular Casts• Hyaline casts

• Broad, Waxy casts


• WBC casts


• Granular casts (muddy brown, pigmented)

Hyaline Casts

Waxy Casts

Case 7• 75 year old man is brought to the ED by his daughter with altered

sensorium, fever/chills, productive cough, SOB and diarrhea; increased serum Cr was noted in the ED

• PMH: Lung cancer s/p lobectomy, COPD, HTN, CAD, GERD, & BPH

• Medications: combivent inhaler, lansoprazole, ASA, amlodipine, tamsulosin, s/p XRT and chemotherapy (8 weeks ago)

• Allergies: None

• Social: former smoker, ‐ ETOH



– Lungs‐ decreased BS, crackles at L base, and scattered wheezes

– Heart‐ distant S1S2, no S3, rub or murmur


– Extremities‐ Trace ankle edema



– BUN=65 mg/dl

– Cr=2.4 mg/dl‐‐>3.3‐‐>4.1‐‐> 5.3

– Hb=8.9 mg/dl Plt=98 x1000/uL


– Urinalysis: SG‐1.020, pH‐6.0, Protein‐1+, Blood‐

trace, LE‐trace


Urine Sediment


A. RTE cells

B. WBCs

C. RBCs


Case 7


A. RTE cells

B. WBCs

C. RBCs


Case 7


A. Hyaline casts

B. Granular casts

C. RBC casts

D. WBC casts

E. Waxy casts

Case 7


A. Hyaline casts

B. Granular casts

C. RBC casts

D. WBC casts

E. Waxy casts

Case 7


A. Acute postinfectious GN


C. Prerenal AKI


E. ANCA vasculitis (pulmonary renal syndrome)

Case 7


A. Acute postinfectious GN


C. Prerenal AKI


E. ANCA vasculitis (pulmonary renal syndrome)

Case 7

Acute Tubular Apoptosis/Necrosis• Luminal ectasia, loss of brush border

• Tubular dropout, apoptotic figures





• WBCs (eosinophils), OFBs

– Non‐cellular Casts• Hyaline, Broad, Waxy, other casts


• WBC casts


• Granular casts (muddy brown, pigmented)Renal Tubular Epithelial Cell Cast

Renal Tubular Epithelial Cell Cast Granular Casts

Case 8• 58 year old obese female presents with malaise,

weakness, and frequent “oily” stools for a few weeks

• PMH: HTN, T2‐DM, arthritis, CKD (baseline serum Cr=2.1 mg/dl), GERD, asthma, gout, hypothyroid

• Medications: diltiazem , singular, furosemide, pantoprazole, orlistat, allopurinol, colchicine prn, synthroid, bactrim for URI for past 7 days, no herbal products or NSAIDs

• Examination: BP‐130/80 P‐82 Afebrile– H&N‐mild conjunctival pallor, elevated JVP

– Lungs‐minimal bibasilar crackles

– Heart‐ S1S2, 1/6 SM, no rub

– Abdomen‐ obese, no flank pain

– Extremities‐ trace edema of ankles

• Laboratory Results:– Electrolytes: Na+‐136 mEq/L, K+‐4.8 mEq/L, HCO3‐‐26 mEq/L, Cl‐‐99 mEq/L

– BUN=52 mg/dl Cr=3.8 mg/dl ‐> 5.8

– Hb=10.2 mg/dl Plt=286 x1000/uL

– WBCs=17 per mm3

– Uric acid=10.6 mg/dl Ca++=8.7 mg/dl PO4=5.5 mg/dl

– Urinalysis: SG=1.018, pH=6.0, Protein‐trace, Blood‐negative, Glucose‐negative, Leukocyte esterase‐negative

– Urine Na += 71 mEq/L, FENa+=2.7%, Pro/Cr ratio=0.45

• Renal Ultrasound:– 10.4 and 10.7 cm kidneys

– Increased cortical echogenicity

Urine Sediment

• What crystals are present on urine microscopy?

A. Sulfonamide crystals

B. Calcium phosphate crystals

C. Calcium oxalate crystals

D. Uric acid crystals

E. Hippurate crystals

Case 8

• What crystals are present on urine microscopy?

A. Sulfonamide crystals

B. Calcium phosphate crystals

C. Calcium oxalate crystals

D. Uric acid crystals

E. Hippurate crystals

Case 8

urine microscopy cases - echo360

Documents