Note: The work of Dr Harsh Mohan as author of this book was performed outside the The revision of Pathology Practical Book (first published in ) had. Harsh mohan pathology practical book 2nd edition. Kavya Mudigonda. PATHOLOGY PRACTICAL BOOK PATHOLOGY PRACTICAL BOOK Harsh Mohan MD. This new edition has been fully revised to help pathology trainees acquire practical knowledge in diagnostic pathology. Divided into eight.
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Pathology Practical Book for Undergraduates. Front Cover. Harsh Mohan. Jaypee Brothers, Medical Publishers, Jan 1, - pages. 0 Reviews. Results 1 - 16 of 24 Practical Pathology (Includes 10 CPCs & Quick Review of Museum . Pathology Practical Book by Harsh Mohan(). Read (Old) Pathology Practical Book Includes 10Cpcs & Quick Review Of Harsh Mohan MD FAMS FICPath FUICC Founder, Professor and Head.
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East Dane Designer Men's Fashion. Shopbop Designer Fashion Brands. Physical and Chemical Procedure 2. Reagent Strip Test Interpretation Blue or green colour indicates presence Principle It is based on coupling reaction of bilirubin with diazonium salt with which strip is coated.
Dip the strip in of blood in urine. Reagent Strip Test Causes of bilirubinuria The reagent strip is coated with orthotoluidine. Dip the i Obstructive jaundice strip in urine. If it changes to blue colour then blood is ii Hepatocellular jaundice present see Fig. Tests for Blood in Urine Causes of blood in urine Tests for detection of blood in urine are as under: Renal stones 1.
Benzidine test ii. Renal tumours 2. Orthotoluidine test iii. Polycystic kidney 3. Reagent strip test iv. Bleeding disorders v. Interpretation Appearance of blue colour indicates The end result readings can be taken as a print-out.
Benzidine is, however, carcinogenic and this test is not commonly used. Urine Examination II: Phase contrast three headings: Collection of sample elements.
Rarely, polarizing microscopy is used to B. Preparation of sediment distinguish crystals and fibres from cellular or protein C. Examination of sediment casts. Automation in urine analysis Following categories of constituents are frequently reported in the urine on microscopic examination: It provides 2.
Casts an acidic and concentrated sample which preserves the 3. Miscellaneous structures otherwise tend to lyse in a hypotonic or alkaline urine. The specimen should be examined fresh or within 1.
Examination of Cells hours of collection. But if some delay is anticipated, the sample should be preserved as described in the RBCs preceding exercise. The WBCs are larger in size and are granular. Yeast cells appear round but show budding. Air bubbles and oil droplets vary in size. RBCs in excess of this number are seen in the light microscope. This is done by keeping the urine in the following conditions: First Physiological examine it under low power objective, then under high i.
Following severe exercise power and keep on changing the fine adjustment in ii. Smoking order to visualise the sediments in different planes and iii. Squamous epithelial cells in urine, frequently seen in females. Pathological i. Renal stones ii. Tumours Significance Normally a few epithelial cells are seen in iii. Glomerulonephritis normal urine, more common in females and reflect iv.
Polycystic kidney normal sloughing of these cells Fig. UTI When these cells are present in large number vi. Trauma alongwith WBCs, they are indicative of inflammation. WBCs 2. These are formed due to moulding in renal tubules of In fresh urine nuclear details are well visualised Fig.
Their shape depends upon their site 5. For differen- of origin. In general casts are cylindrical in shape with tiating, add a drop of dilute acetic acid under coverslip. Casts more clear. WBCs can also be stained by adding a drop appear in urine only in renal diseases. WBCs are seen in urine in following i. Hyaline cast conditions: Red cell cast iii. Leucocyte cast Pathological iv. Granular cast i. UTI v. Waxy cast ii. Cystitis vi. Fatty cast iii. Prostatitis vii. Epithelial cast iv.
Chronic pyelonephritis viii. Pigment cast v. Renal stones vi. These are cylindrical, These are round to polygonal cells with a round to oval, colourless homogeneous and transparent Fig.
Epithelial cells in urine can be They are passed in urine in the following conditions: Fever cells i. Exercise and sometime it is difficult to distinguish between different iii. Acute glomerulonephritis types of these cells. At times, these cells can be confused iv.
Malignant hypertension 26 with cancer cells. Various types of casts in urine. They are passed in Fig. They are passed in urine in the following urine in the following conditions: Acute glomerulonephritis i.
Acute pyelonephritis ii. Renal infarct ii. Acute glomerulonephritis iii. Goodpasture syndrome iii. Nephrotic syndrome iv. Lupus nephritis iv. Lupus nephritis v. Microscopy Granular Casts iii. Amorphous urate iv. Tyrosine Granular casts have coarse granules in basic matrix. Cystine Granules form from degenerating cells or solidification vi. Cholesterol crystals of plasma proteins Fig. They are passed in vii. Sulphonamide urine in the following conditions: Pyelonephritis i Calcium Oxalate ii.
Chronic lead poisoning iii. Viral diseases These are colourless refractile and have octahedral iv. Renal papillary necrosis envelope-like structure. They can also be dumb-bell shaped Fig. Waxy Casts ii Uric Acid Waxy casts are yellowish homogeneous with irregular blunt or cracked ends and have high refractive index. They are yellow or brown rhomboid-shaped seen singly These are also known as renal failure casts.
They are or in rosettes. They can also be in the form of prism, passed in urine in the following conditions: Chronic renal failure iii Amorphous Urate ii. End-stage kidney iii. Renal transplant rejection They appear as yellowish brown granules in the form of clumps Fig. They dissolve on heating. When Fatty Cast they are made of sodium urate, they are needle-like in the form of thorn-apple. They are passed more often in They contain fat globules of varying size which are patients having gout.
Fat in the cast is cholesterol or trigly- cerides. These are passed in urine in the following iv Tyrosine conditions: They are yellowish in the form of silky needles or sheaves i. Nephrotic syndrome Fig. They are passed in urine in jaundice. Fat necrosis v Cystine Epithelial Cast They are colourless, hexagonal plates which are highly Epithelial casts contains shed off tubular epithelial cells refractile Fig.
They are passed in urine in an and appear as two parallel rows of cells. Sometimes inborn error of metabolism, cystinuria.
They are passed in urine in following conditions: Acute tubular necrosis ii. Heavy metal poisoning These are rare and are seen in urinary tract infection, iii. Renal transplant rejection rupture of lymphatic into renal pelvis or due to blockage of lymphatics Fig. Pigment Cast Pigment casts include haemoglobin casts, haemosiderin vii Sulphonamide casts, myoglobin casts, bilirubin cast, etc. They appear as yellowish sheaves, rosettes, or rounded with radial striations Fig.
They appear in urine Crystals after administration of sulphonamide drugs. Formation and appearance of crystals in urine depends upon pH of the urine, i. Crystals in Alkaline Urine These are as under Fig. Crystals in Acidic Urine i. Amorphous phosphate These are as under Fig. Triple phosphate i. Calcium oxalate iii. Calcium carbonate 28 ii. Uric acid iv. Various types of crystals in acidic urine.
Various types of crystals in alkaline urine. They dissolve on heating the urine or by ii Triple Phosphate making it acidic. They are in the form of prisms and sometimes in fern leaf pattern Fig. They dissolve when urine is 4. Miscellaneous Structures in Urine made acidic.
These include the following Fig. Spermatozoa They are in the form of granules, spheres or rarely ii. Parasite dumbbell-shaped Fig. They again dissolve in iii. Fungus acidic urine. Miscellaneous structures in urine. This subject is discussed in detail later in Exercise 43 of cytology. They can be seen in normal urine in males. They have a head and tail and can be motile Fig. Urine may contain Trichomonas vaginalis which is more common in females Fig.
Eggs of Schistosoma Urine Strip Analysers hematobium or Entamoeba histolytica can also be seen in urine. These are commercially available electronic urine strip readers. These strips may include various parameters iii Fungus of physical, chemical and microscopic constituents. After analysis, the results are obtained as print-out. Candida which are budding yeast cells can be seen in urine in patients with UTI or as contaminant Fig.
Flow Cytometry iv Tumour Cells Just as flow cytometry is used for blood and other body fluids, urine can be analysed by flow cytometry. In this Tumour cells having all the characteristics of malig- method, DNA and membranes of formed elements are nancy may be seen singly or in groups in urine.
These stained and pass as a laminar flow through a laser tumour cells could be from kidney, ureter, bladder or beam and the light scatter is measured by fluorescence urethra. These cells are examined after staining of urine impedance. The volume is slightly more in patients of infertility. Infertility The volume does not vary with the period of abstinence. Success of vasectomy Viscosity When ejaculated, semen is fairly viscid and it 3.
Medicolegal cases e. Analysis of semen consists of the following: Sample collection Reaction Normally it is slightly alkaline with pH between B. Gross examination 7 and 8. Microscopic examination Liquefaction Liquefaction occurs because of presence D.
Chemical examination of fibrinolysin. Normally liquefaction occurs within E. Immunological assays minutes. Sperm function tests G. Microbiological assays. Motility 2. Count Patient is instructed to collect the specimen by mastur- 3. Morphology bation after days of sexual abstinence. The sample is collected in a clean glass tube, wide-mouthed container Motility or in a properly washed dry condom.
The sample is submitted in the laboratory immediately but preferably Place a drop of liquefied semen on a clean glass slide.
Two Put a coverslip over it and examine it under the specimens collected at weeks interval are used for microscope, first under low power and then under high evaluation.
Red dye accumulates in the 1. Colour heads of non-motile sperms. Volume 3. Viscosity Count 4. Liquefaction pipette. Draw liquefied semen in WBC pipette upto mark Colour Normally it is whitish, grey-white or slightly 0.
The 32 yellowish. Exercise 6: Appearance of spermatozoa. A, Wet unstained B, Wet preparation stained with methylene blue. Observe at least spermatozoa for any Formalin neutral 1 ml abnormality in their morphology. Also chamber. Com- minutes. Examine under microscope and count the puter-mediated morphologic screening is particularly number of spermatozoa in two large peripheral squares useful in samples with very low numbers of normal used for TLC counting and multiply the number by 1 sperm count which may otherwise remain undetected.
Semen Analysis Interpretation Appearance of red colour indicates F. Genital tract infections by bacteria, yeast and sexually- transmitted diseases may have significant adverse effect Acid Phosphatase Test on male infertility. If the concentration of bacteria exceeds CFUs per ml, the colonies should be identified and This test is used for seminal stain and on vaginal aspirate tested for antibiotic sensitivity. These are detected by and formation of male pronucleus, and accordingly direct or indirect mixed agglutination reaction tests.
Cisternal puncture in the lateral, third and fourth ventricle while the remainder iii. Ventricular cannulas or shunts is produced by the surface of brain and spinal cord. CSF iv. Lateral cervical puncture examination is an important part of neurologic evaluation Normally upto 2 ml of CSF is withdrawn.
Most often, in non-neoplastic and neoplastic diseases of CNS. CSF tap is done by lumbar puncture for which indications can be divided into following 4 categories: Meningeal infection Appearance: Clear and colourless b.
Subarachnoid haemorrhage Rate of production: CNS malignant tumours Total volume: Demyelinating diseases. In mm water in infants case delay in examination of CSF is anticipated, the Sugar: Nil i. Manual method Examination of CSF is discussed under the following ii. Automated method headings: Specimen collection Manual Method B. Microscopic examination Diluting fluid It has the following composition: Chemical examination D.
Microbiological examination Crystal violet 0. Immunological examination Glacial acetic acid 5 ml Distilled water 45 ml A. Charge the Fuchs- 35 i. The result ii. Tuberculous meningitis is expressed as: Parasitic meningitis iv. Tuberculous meningitis With automated method if counts are low the results are ii.
Syphilitic meningoencephalitis not good. The method employs use of electronic particle iii. Multiple myeloma counter as for TLC in blood. Stain one of the i. Viral meningitis smears with any of the Romanowsky stain and examine ii. Degenerative brain disorders under high power and oil immersion of microscope for iii. Tuberculous meningitis the presence of various cells. The various cells which iv. Fungal meningitis may be seen in CSF are: Sarcoidosis of meninges i.
Metastatic cancers v. Leukaemias iii.
Medulloblastoma v. Ependymoma i. Bacterial meningitis ii. Brain abscess C. Brain infarct Sugar, proteins, chloride and enzymes, ammonia and iv. Repeated lumbar puncture amines, electrolytes and acid-base balance and tumour markers can be estimated in CSF.
Viral meningitis Table 7. Table 7. CSF findings in health and various types of meningitis. Feature Normal Acute pyogenic Acute lymphocytic Chronic bacterial meningitis viral meningitis tuberculosis meningitis 1. Naked eye Clear and Cloudy or frankly Clear or slightly Clear of slightly turbid, forms appearance colourless purulent turbid fibrin coagulum on standing 2. CSF pressure mm Elevated above Elevated above Elevated above mm water mm water mm water water 3.
Viral inclusions by immunostains ink for the capsule of Cryptococcus. ELISA for tuberculosis i. Bacteria iv. VDRL for syphilis. Tubercle bacilli iii. Vacuolar nephropathy is the initial or reversible change ii.
These vacuoles are watery in character hydropic seen grossly as "cloudy change" and microscopically as change and donot stain for fat or glycogen; they well-defined "hydropic vacuoles" in the convoluted tubules represent distended endoplasmic reticulum. Most commonly, it is due to hypokalaemia iii. The tubular epithelial cells are ballooned out and e. The cut surface has cloudy, The word hyaline simply refer to morphologic appear- opaque appearance.
The epithelial cells of proximal convoluted tubules and eosin. Vacuolar nephropathy. The tubular epithelial cells are distended with cytoplasmic vacuoles while the interstitial 41 vasculature is compressed. General Pathology Exercise 8: Degenerations an end-stage of many diverse and unrelated lesions. It may be intracellular or extracellular. Hyaline degene- ration in leiomyoma, a benign smooth muscle tumour, is an example of extracellular hyaline in the connective tissue.
Uterine leiomyomas may be subserosal, intra- mural or submucosal. Cut surface presents a whorled appearance. The hyalinised area in the tumour appears glassy and homogeneous Fig. There is mixture of smooth muscle fibres and fibrous tissue in varying proportions. Some of the muscle fibres may be cut longitudinally and some transversely.
Whorled arrangement of muscle fibres admixed with fibrous tissue is seen at places. Nuclei of the smooth muscle fibres are short, plump and fusiform while those of the fibroblasts are longer, slender and curved Fig.
Hyaline degeneration which is the commonest change due to insufficient blood supply appears as pink, homogeneous and acellular. Leiomyomas uterus. While mucus is the normal watery secretion of mucous glands epithelial mucin or by certain connective tissue FIGURE 8. Microscopy shows whorls of smooth muscle cells which are spindle-shaped, having abundant cyto- 42 plasm and oval nuclei and mixed with fibrous tissue.
The hyaline material appears homogeneous, pink and glassy. Exercise 8: Degenerations General Pathology cells, especially in foetus connective tissue mucin , myxoid or mucoid degeneration refers to exaggerated form of the process and may involve both these types of mucin. In the early stages of a ganglion of the wrist, connective tissue mucin develops in the synovial membrane in connection with the tendon sheath.
The cyst of ganglion is composed of fibrous wall devoid of any specialised lining. Centre of the cyst contains a mass of acellular basophilic myxoid material Fig. Connective tissue mucin stains positively with colloidal iron and alcian blue. Cyst of ganglion. The wall shows areas of basophilic myxoid material.
The causes include alcohol abuse most common cause in industrialised world , protein malnutrition, obesity, diabetes mellitus, anoxia, and various toxins carbon tetrachloride, chloroform, ether, etc. The cut surface bulges slightly and is pale-yellow and greasy to touch Fig. Fat in the cytoplasm of the hepatocytes is seen as clear area which may vary from minute droplets in the cytoplasm of a few hepatocytes microvesicular to distention of the entire cytoplasm of most cells by coalesced droplets macrovesicular pushing the nucleus to periphery of the cell.
When the steatosis is mild, centrilobular hepato- cytes are mainly affected, while the progressive accumulation of fat involves the entire lobule. Occasionally, the adjacent cells containing fat rupture producing fatty cysts Fig.
Fatty liver. The organ is enlarged. The external ing of collection of macrophages, lymphocytes and surface shows tense capsule, rounded margins and pale-yellow multinucleate giant cells. Cut surface shows yellow parenchyma greasy to touch.
Special stains such as Sudan III, Sudan IV, Sudan black and oil red O can be employed to demonstrate clinical and histologic types of nevocellular naevi and fat in the tissue. There are numerous circular or oval outline. Fatty change liver.
Many of the hepatocytes are distended with fat vacuoles pushing the nuclei to the periphery, while others show multiple small vacuoles in the cytoplasm. The melanocytes forming naevi are round to oval i.
The lesion is composed of melanocytes forming cells and have round or oval nuclei. The cytoplasm aggregates or nests at the dermo-epidermal junction of naevus cells is homogeneous and contains abun- junctional naevus which subsequently migrate to dant granular brown-black melanin pigment Fig. The 9. The pigment is more marked in the naevus cells in dermal naevus.
Intradermal naevus. Melanin-containing naevus cells form clusters in the upper dermis. A coal macule composed of aggregates of dust- laden macrophages is seen surrounding a respiratory bronchiole. The alveoli and respiratory bronchioles surrounding the coal macule are distended. Anthracosis is thus not a lung disease in true sense. Brown atrophy of the heart.
The lipofuscin pigment granules are seen in the cytoplasm of the myocardial fibres, 46 especially at the poles of nuclei. Exercise 9: The cut section shows blackish the myocardial fibres. This pigment is also known as mottling due to aggregates of anthracotic pigment. Anthracotic pigment, black in colour, is deposited in patients with severe malnutrition and cancer cachexia. The myocardial fibres contain yellow-brown, finely pneumoconiosis is characterised by coal macule granular, intracytoplasmic pigment, often in and coal nodule consisting of carbon-laden perinuclear location.
The myocardial fibres show changes of atrophy collagen Fig. The amyloid deposits in the tubules begin close to deposits in the kidneys are found in most cases of the tubular epithelial basement membrane. The walls of small arteries and arterioles in the terminally contracted due to ischaemic effect of narrowing interstitium of the kidney are narrowed due to of vascular lumina. The cut surface is pale, waxy and amyloid deposit Fig. The amyloid is seen as amorphous, eosinophilic, trates green birefringence when viewed under hyaline extracellular material.
It is deposited mainly polarising microscopy Fig. The cut surface of the spleen shows one of the two patterns of deposition— lardaceous spleen characterised by diffuse map-like areas of pale, waxy translucency Fig. In lardaceous spleen the amyloid deposits are seen in the walls of splenic sinuses and the region of the red pulp. Amyloidosis of kidney. The kidney is small and ii. In sago spleen, the amyloid deposits begin in the pale in colour. Cut section shows pale waxy translucency with walls of the arterioles of the white pulp and eventually 48 loss of cortico-medullary distinction arrow.
Exercise Amyloidosis kidney. The amyloid deposits are seen mainly in the glomerular capillary tuft. Amyloidosis kidney, Congo Red stain. A, The amyloid deposits are seen mainly in the glomerular capillary tuft showing red pink color.
B, When viewed under polarising microscopy, it shows green birefringence. Lardaceous amyloidosis spleen.
The sectioned surface shows presence of pale waxy translucency seen as map-like areas arrow. Amyloidosis spleen. A, The pink acellular amyloid material is seen in the red pulp causing atrophy of white pulp. B, Congo-Red staining seen under polarising microscopy shows apple-green birefringence in the amyloid containing areas. Amyloidosis of the liver.
The deposition is extensive in the space of Disse causing compression and pressure atrophy of hepatocytes. Congo red staining gives pink or red colour to amyloid by light microscopy and when viewed in polarising light shows green birefringence Fig. Respiratory and metabolic acidosis. UTI by E. Alkaline urine is due to following: Citrus fruits. Respiratory and metabolic alkalosis.
UTI by Proteus, Pseudomonas. Specific Gravity This is the ratio of weight of 1 ml volume of urine to that of weight of 1 ml of distilled water. Specific gravity is used to measure the concentrating and diluting power of the kidneys. It can be measured by urinometer, refractometer or reagent strips. Insert urinometer into it so that it floats in urine without touching the wall and bottom of container Fig.
Read the graduation on the arm of urinometer at lower urinary meniscus. Add or substract 0. Refractometer It measures the refractive index of urine. This procedure requires only a few drops of urine in contrast to urinometer where approximately ml of urine is required.
Urinometer and the container for floating it for measuring specific gravity. Physical and Chemical 19 3. Reagent Strip Method This method employs the use of chemical reagent strip see Fig. Significance of Specific Gravity The normal specific gravity of urine is 1.
Low specific gravity urine occurs in: Excess water intake ii. Diabetes inspidus High specific gravity urine is seen in: Dehydration ii. Albuminuria iii. Glycosuria Fixed specific gravity 1.
ADH deficiency ii. Chronic nephritis C. Tests for Proteinuria If urine is not clear, it should be filtered or centrifuged before testing. Urine may be tested for proteinuria by qualitative tests and quantitative methods. Qualitative Tests for Proteinuria 1. Heat and acetic acid test 2. Sulfosalicylic acid test 3. Reagent strip method. Heat and Acetic Acid Test Heat causes coagulation of proteins. The procedure is as under: Take a 5 ml test tube. Boil upper portion for 2 minutes lower part acts as control.
Interpretation If turbidity or precipitation disappears on addition of acetic acid, it is due to phosphates; if it persists after addition of acetic acid then it is due to proteins. Depending upon amount of protein the results are interpreted as under Fig. Sulfosalicylic Acid Test This is a very reliable test. Make urine acidic by adding acetic acid. Interpretation Appearance of turbidity which persists after heating indicates presence of proteins. Add urine drop by drop by the side of test tube.
Interpretation Appearance of white ring at the junction indicates presence of protein. Reagent Strip Method Bromophenol coated strip is dipped in urine. Change in colour of strip indicates presence of proteins in urine and is compared with the colour chart provided for semiquantitative grading Fig.
Heat and acetic acid test for proteinuria. Note the method of holding the tube from the bottom while heating the upper part. Turbidimetric method. Stopper the tube, mix it and let it stand for 24 hours. Take the reading from the level of precipitation in the albuminometer tube and divide it by 10 to get the percentage of proteins.
Turbidimetric method Take 1 ml of urine and 1 ml standard in two separate tubes. Add 4 ml of trichloroacetic acid to each tube. After 5 minutes take the reading with red filter nm. Nephrotic syndrome ii. Renal vein thrombosis iii. Diabetes mellitus iv. Chronic glomerulonephritis ii. Strip method for testing various constituents in urine. Physical and Chemical 21 iii. Multiple myeloma iv. Hypertension ii. Polycystic kidney iii. Chronic pyelonephritis iv. UTI v. These are excreted in multiple myeloma and other parapro- teinaemias.
In heat and acetic acid test performed under temperature control, these proteins are precipitated at lower temperature 56oC and disappear on further heating above 90oC but reappear on cooling to lower temperature again.
In case both albumin as well as Bence-Jones proteins are present in urine, the sample of urine is heated to boiling. Precipitates so formed due to albumin are filtered out and the test for Bence-Jones proteins is repeated under temperature control as above. Test for Glucosuria Glucose is by far the most important of the sugars which may appear in urine. Normally approximately mg of glucose per 24 hours is passed in urine which is undetectable by qualitative tests.
Tests for glucosuria may be qualitative or quantitative. Qualitative Tests These are as under: Reagent strip test 1. Add 8 drops or 0. Heat to boiling for 2 minutes Fig. Cool in water bath or in running tap water. Reagent Strip Test These strips are coated with glucose oxidase and the test is based on enzymatic reaction. Physical and Chemical 22 for glucose. The strip is dipped in urine. If there is change in colour of strip it indicates presence of glucose.
The colour change is matched with standard colour chart provided on the label of the reagent strip bottle see Fig. Add to it 15 gm of sodium carbonate crystalline and some pieces of porcelain and heat it to boil. Note the volume of urine used. Calculate the amount of glucose present in urine as under: Causes of Glucosuria i.
Diabetes mellitus ii. Renal glucosuria iii. Severe burns iv. Administration of corticosteroids v. Severe sepsis vi. Pregnancy Tests for Ketonuria These are products of incomplete fat metabolism. The three ketone bodies excreted in urine are: Tests for Ketonuria 1. Procedure Take 5 ml of urine in a test tube. Saturate it with solid ammonium sulphate salt.
Add a few crystals of sodium nitroprusside and shake. Add liquor ammonia from the side of test tube. Interpretation Appearance of purple coloured ring at the junction indicates presence of ketone bodies Fig.
Filter it and add more ferric chloride. Interpretation Brownish red colour indicates presence of ketone bodies. Reagent Strip Test These strips are coated with alkaline sodium nitroprus- side.
When strip is dipped in urine it turns purple if ketone bodies are present See Fig. Causes of ketonuria i. Diabetic ketoacidosis ii. Dehydration iii. Hyperemesis gravidarum iv. Fever v.
Cachexia vi. After general anaesthesia Test for Bile Derivatives in Urine Three bile derivatives excreted in urine are: Physical and Chemical 23 normally excreted in urine in small amounts, bile salts and bile pigments appear in urine in liver diseases only. Tests for Bile Salts Bile salts excreted in urine are cholic acid and chenodeoxycholic acid. Sprinkle finely powdered sulphur powder over it Fig. Interpretation If bile salts are present in the urine then sulphur powder sinks, otherwise it floats.
Strip Method Coated strips can be used for detecting bile salts as for other constituents in urine see Fig. Causes for bile salts in urine: The sample should always be collected in a dark coloured bottle as urobilinogen gets oxidised on exposure to light. The test is positive in beaker in the centre contrasted with negative control in beaker on right side. Procedure Take 10 ml of urine in a test tube. Wait for minutes. Interpretation Development of red purple colour indicates presence of urobilinogen.
A positive test is subsequently done in dilutions; normally it is positive in upto 1: Reagent Strip Test These strips are coated with p-dimethyl-amino- benzaldehyde.
When strip is dipped in urine, it turns reddish-brown if urobilinogen is present see Fig. Significance Causes of increased urobilinogen in urine i. Haemolytic jaundice and haemolytic anaemia Causes for absent urobilinogen in urine ii.
Normally no bilirubin is passed in urine. Following tests are done for detection of bilirubin in urine: Foam test 3. Filter through filter paper. Interpretation Development of green colour indicates bilirubin. Foam Test It is a non-specific test. Shake it vigorously. Interpretation Presence of yellow foam at the top indicates presence of biluribin. Reagent Strip Test Principle It is based on coupling reaction of bilirubin with diazonium salt with which strip is coated. Dip the strip in urine; if it changes to blue colour then bilirubin is present see Fig.
Causes of bilirubinuria i Obstructive jaundice ii Hepatocellular jaundice Tests for Blood in Urine Tests for detection of blood in urine are as under: Benzidine test 2. Orthotoluidine test 3. Benzidine Test Procedure Take 2 ml of urine in a test tube. Add 2 ml of saturated solution of benzidine with glacial acetic acid. Add 1 ml of H2O2 to it. Interpretation Appearance of blue colour indicates presence of blood. Benzidine is, however, carcinogenic and this test is not commonly used.
Orthotoluidine Test Procedure Take 2 ml of urine in a test tube. Add a solution of 1 ml of orthotoluidine in glacial acetic acid. Add a few drops of H2O2. Interpretation Blue or green colour indicates presence of blood in urine.
Reagent Strip Test The reagent strip is coated with orthotoluidine. Dip the strip in urine. If it changes to blue colour then blood is present see Fig. Causes of blood in urine i. Renal stones ii. Renal tumours iii. Polycystic kidney iv. Bleeding disorders v. The end result readings can be taken as a print-out.
Clinical PathologyExercise 5: Urine Examination II: Collection of sample B. Preparation of sediment C. Examination of sediment D. It provides an acidic and concentrated sample which preserves the formed elements RBCs, WBCs and casts which otherwise tend to lyse in a hypotonic or alkaline urine. The specimen should be examined fresh or within hours of collection. But if some delay is anticipated, the sample should be preserved as described in the preceding exercise.
Centrifuge for 5 minutes at rpm. Discard the supernatant. Resuspend the deposit in a few ml of urine left. Place a drop of this on a clean glass slide. Place a coverslip over it and examine it under the microscope. This is done by keeping the condenser low with partial closure of diaphragm. First examine it under low power objective, then under high power and keep on changing the fine adjustment in order to visualise the sediments in different planes and report as …..
Phase contrast microscopy may be used for more transluscent formed elements. Rarely, polarizing microscopy is used to distinguish crystals and fibres from cellular or protein casts. Following categories of constituents are frequently reported in the urine on microscopic examination: Casts 3. Crystals 4. Miscellaneous structures 1. Examination of Cells RBCs These appear as pale or yellowish, biconcave, double- contoured, disc-like structures, and when viewed from side they have an hour-glass appearance.
In hypotonic urine, RBCs swell up while in hypertonic urine they are crenated. The WBCs are larger in size and are granular. Yeast cells appear round but show budding. Air bubbles and oil droplets vary in size. When edge of the coverslip is touched with a pencil, oil droplets tumble while RBCs do not.
RBCs in excess of this number are seen in urine in the following conditions: Physiological i. Following severe exercise ii. Smoking iii. Lumbar lordosis Clinical Pathology Exercise 5: Microscopy 26 Pathological i. Tumours iii. Glomerulonephritis iv. Polycystic kidney v. UTI vi. In fresh urine nuclear details are well visualised Fig. For differen- tiating, add a drop of dilute acetic acid under coverslip. WBCs can also be stained by adding a drop of crystal violet or safranin stain.
WBCs are seen in urine in following conditions: Pathological i. UTI ii. Cystitis iii. Prostatitis iv. Chronic pyelonephritis v.
Renal stones vi. Renal tumours Epithelial Cells These are round to polygonal cells with a round to oval, small to large nucleus. Epithelial cells in urine can be squamous epithelial cells, tubular cells and transitional cells i.
At times, these cells can be confused with cancer cells. Significance Normally a few epithelial cells are seen in normal urine, more common in females and reflect normal sloughing of these cells Fig.
When these cells are present in large number alongwith WBCs, they are indicative of inflammation. Casts These are formed due to moulding in renal tubules of solidified proteins. Their shape depends upon their site of origin. In general casts are cylindrical in shape with rounded ends. The basic composition of casts is Tamm- Horsfall protein which is secreted by tubular cells.
Casts appear in urine only in renal diseases. Depending upon the content, casts are of following types Fig. Hyaline cast ii. Red cell cast iii. Leucocyte cast iv. Granular cast v. Waxy cast vi. Fatty cast vii.
Epithelial cast viii. Pigment cast Hyaline Cast Hyaline cast is basic protein cast. These are cylindrical, colourless homogeneous and transparent Fig. They are passed in urine in the following conditions: Fever ii. Exercise iii. Acute glomerulonephritis iv. Malignant hypertension v. Squamous epithelial cells in urine, frequently seen in females.
Glomerular damage results in appearance of RBCs into tubules. Acute glomerulonephritis ii. Renal infarct iii. Goodpasture syndrome iv. WBCs enter the tubular lumina from the interstitium Fig.
Acute pyelonephritis ii. Acute glomerulonephritis iii. Nephrotic syndrome iv. Lupus nephritis v. Various types of casts in urine. Microscopy 28 Granular Casts Granular casts have coarse granules in basic matrix. Granules form from degenerating cells or solidification of plasma proteins Fig. Pyelonephritis ii.
Chronic lead poisoning iii. Viral diseases iv. Renal papillary necrosis Waxy Casts Waxy casts are yellowish homogeneous with irregular blunt or cracked ends and have high refractive index. These are also known as renal failure casts. Chronic renal failure ii. End-stage kidney iii. Renal transplant rejection Fatty Cast They contain fat globules of varying size which are highly refractile. Fat in the cast is cholesterol or trigly- cerides.
These are passed in urine in the following conditions: Fat necrosis Epithelial Cast Epithelial casts contains shed off tubular epithelial cells and appear as two parallel rows of cells. Sometimes these are difficult to differentiate from WBC casts. They are passed in urine in following conditions: Acute tubular necrosis ii. Heavy metal poisoning iii.
Renal transplant rejection Pigment Cast Pigment casts include haemoglobin casts, haemosiderin casts, myoglobin casts, bilirubin cast, etc. Crystals Formation and appearance of crystals in urine depends upon pH of the urine, i.
Crystals in Acidic Urine These are as under Fig. Calcium oxalate ii. Uric acid iii. Amorphous urate iv. Tyrosine v. Cystine vi. Cholesterol crystals vii. Sulphonamide i Calcium Oxalate These are colourless refractile and have octahedral envelope-like structure.
They can also be dumb-bell shaped Fig. They can also be in the form of prism, plates and sheaves Fig. They dissolve on heating. When they are made of sodium urate, they are needle-like in the form of thorn-apple.
They are passed more often in patients having gout. They are passed in urine in jaundice. They are passed in urine in an inborn error of metabolism, cystinuria. They appear in urine after administration of sulphonamide drugs. Crystals in Alkaline Urine These are as under Fig. Amorphous phosphate ii. Triple phosphate iii. Calcium carbonate iv. Ammonium biurate Various types of crystals in acidic urine. Microscopy 30 i Amorphous Phosphate They are seen as colourless granules in the form of clumps or irregular aggregates Fig.
They dissolve when urine is made acidic. They again dissolve in acidic urine. They dissolve on heating the urine or by making it acidic. Miscellaneous Structures in Urine These include the following Fig. Spermatozoa ii. Parasite iii. Fungus iv. Various types of crystals in alkaline urine. Miscellaneous structures in urine. They have a head and tail and can be motile Fig.
Eggs of Schistosoma hematobium or Entamoeba histolytica can also be seen in urine. These tumour cells could be from kidney, ureter, bladder or urethra. These cells are examined after staining of urine sediment. This subject is discussed in detail later in Exercise 43 of cytology. Urine Strip Analysers These are commercially available electronic urine strip readers.
These strips may include various parameters of physical, chemical and microscopic constituents. After analysis, the results are obtained as print-out. Flow Cytometry Just as flow cytometry is used for blood and other body fluids, urine can be analysed by flow cytometry.
In this method, DNA and membranes of formed elements are stained and pass as a laminar flow through a laser beam and the light scatter is measured by fluorescence impedance.
Clinical Pathology Exercise 6: Infertility 2. Success of vasectomy 3. Medicolegal cases e. Sample collection B. Gross examination C. Microscopic examination D. Chemical examination E. Immunological assays F. Sperm function tests G. Microbiological assays. The sample is collected in a clean glass tube, wide-mouthed container or in a properly washed dry condom. The sample is submitted in the laboratory immediately but preferably within one hour of collection for examination.
Two specimens collected at weeks interval are used for evaluation. Colour 2. Volume 3. Viscosity 4. Reaction 5.