CHAPTER 1

Safety and Quality

Management
LEARNING OUTCOMES
Upon completing this chapter, the reader will be able to:
1-1 Define and give an example of the types of safety haz- 1-9 Describe the use of the Globally Harmonized
ards encountered in the laboratory. System (GHS).
1-2 List the six components of the chain of infection and 1-10 Recognize standard hazard warning symbols.
the laboratory safety precautions that break the chain.
1-11 State and interpret the components of the National
1-3 State the purpose of the Standard Precautions policy, Fire Protection Association (NFPA) hazardous material
and describe its guidelines. labeling system.
1-4 State the requirements mandated by the Occupational 1-12 Describe precautions that laboratory personnel should
Exposure to Bloodborne Pathogens Compliance take with regard to radioactive, electrical, fire, and
Directive. physical hazards.
1-5 Describe the types of personal protective equipment 1-13 Explain the RACE and PASS actions to be taken when
(PPE) that laboratory personnel wear, including when, a fire is discovered.
how, and why each article is used.
1-14 Explain the role of quality management (QM) in the
1-6 Correctly perform hand-hygiene procedures following urinalysis laboratory.
guidelines provided by the Centers for Disease Control
1-15 Define the preexamination (preanalytical), examina-
and Prevention (CDC).
tion (analytical), and postexamination (postanalytical)
1-7 Describe the acceptable methods for handling and dis- components of QM.
posing of biological waste and sharp objects in the uri-
1-16 Distinguish among internal, external, and electronic
nalysis laboratory.
quality control, as well as external quality assessment
1-8 Discuss the components and purpose of a chemical (proficiency testing) in a QM program.
hygiene plan and a Safety Data Sheet (SDS).

KEY TERMS
Accreditation Clinical and Laboratory Standards Globally Harmonized System (GHS)
Accuracy Institute (CLSI) Infection control
Autoverification Delta check Internal quality control
Biohazardous Electronic quality control Occupational Safety and Health Ad-
Chain of infection Examination variable ministration (OSHA)
Chemical hygiene plan (CHP) External quality assessment (EQA) Personal protective equipment
External quality control (PPE)
Clinical Laboratory Improvement
Amendments (CLIA) Fomite Postexamination variable
Continued
 Chapter 1 | Safety and Quality Management 71

10. NIOSH Alert. Preventing Allergic Reactions to Natural Rubber 16. Clinical and Laboratory Standards Institute (CLSI): Quality
Latex in the Workplace. DHHS (NIOSH) Publication 97-135. Practices in Noninstrumented Point of Care Testing: An In-
National Institute for Occupational Safety and Health, structional Manual and Resources for Health Care Workers.
Cincinnati, OH, 1997. Approved Guideline. CLSI Document POCT08-A, Wayne, PA,
11. Centers for Disease Control and Prevention. Guideline for 2010.
Hand Hygiene in Health-Care Settings: Recommendations of 17. College of American Pathologists: Commission on Laboratory
the Healthcare Infection Control Practices Advisory Committee Accreditation, Urinalysis Checklist. College of American
and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force, Pathologists, Skokie, IL, 2007. Web site: [Link]
MMWR 51(pages 21-26), 2002. Web site: [Link] org/apps/docs/laboratory_accreditation/checklists/urinalysis_
mmwr/preview/mmwrhtml/[Link]. Accessed April 18, clinical_microscopy_sep07.pdf. Accessed April 18, 2019.
2019. 18. Clinical and Laboratory Standards Institute (CLSI), Urinalysis:
12. Centers for Disease Control and Prevention. Guideline for Approved Guideline – Third Edition, CLSI Document GP16-A3,
Disinfection and Sterilization in Healthcare Facilities, 2008. Wayne, PA, 2009.
Web site: [Link] 19. Clinical and Laboratory Standards Institute (CLSI): Preparation
[Link]. Accessed April 18, 2019. and Testing of Reagent Water in the Clinical Laboratory: Ap-
13. Occupational Exposure to Hazardous Chemicals in Laboratories proved Guideline, Fourth Edition, CLSI Document GP40-A4-
(Non-Mandatory Appendix); Technical Amendment. January 22, AMD, Wayne, PA 2006.
2013. Office of the Federal Register. Web site: [Link] 20. Centers for Medicare & Medicaid Services, Clinical Laboratory
[Link]/documents/2013/01/22/2013-00788/ Improvement Amendments (CLIA). Proficiency Testing and PT
occupational-exposure-to-hazardous-chemicals-in-laboratories- Referral. Dos and Don’ts. Web site: [Link]
non-mandatory-appendix-technical. Accessed April 18, 2019. Regulations-and-Guidance/Legislation/CLIA/Downloads/
14. National Fire Protection Association: Hazardous Chemical [Link]. Accessed April 18, 2019.
Data, No. 49. Boston, NFPA, 1991. 21. Centers for Medicare & Medicaid Services (CMS). Clinical
15. Centers for Medicare & Medicaid Services, Department of Laboratory Improvement Amendments (CLIA). Individualized
Health and Human Services: Clinical Laboratory Improvement Quality Control Plan (IQCP). Web site: [Link]
Amendments. Web site: [Link]/CLIA/05_CLIA_ Regulations-and-Guidance/Legislation/CLIA/Individualized_
[Link] Accessed April 18, 2019. Quality_Control_Plan_IQCP.html. Accessed April 15, 2019.

Study Questions
1. Which of the following organizations publishes 4. The best way to break the chain of infection is:
guidelines for writing procedures and policies in A. Hand sanitizing
the urinalysis?
B. Personal protective equipment
A. CDC
C. Aerosol prevention
B. OSHA
D. Decontamination
C. CLSI
5. The current routine infection control policy developed by
D. CLIA
CDC and followed in all health-care settings is:
2. Exposure to toxic, carcinogenic, or caustic agents is what A. Universal Precautions
type of laboratory safety hazard?
B. Isolation Precautions
A. Biological
C. Blood and Body Fluid Precautions
B. Sharps
D. Standard Precautions
C. Chemical
6. An employee who is accidentally exposed to a possible
D. Fire/explosive
bloodborne pathogen should immediately:
3. In the urinalysis laboratory, the primary source in the A. Report to a supervisor
chain of infection would be:
B. Flush the area with water
A. Patients
C. Clean the area with disinfectant
B. Needlesticks
D. Receive HIV prophylaxis
C. Specimens
D. Biohazardous waste
72 Part One | Basic Principles

7. Personnel in the urinalysis laboratory should wear 14. When combining acid and water, ensure that:
laboratory coats that: A. Acid is added to water
A. Do not have buttons B. Water is added to acid
B. Are fluid-resistant C. They are added simultaneously
C. Have short sleeves D. Water is slowly added to acid
D. Have full-length zippers
15. An employee can learn the carcinogenic potential of
8. All of the following should be discarded in biohazardous potassium chloride by consulting the:
waste containers except: A. Chemical hygiene plan
A. Urine specimen containers B. Safety Data Sheet
B. Towels used for decontamination C. OSHA standards
C. Disposable laboratory coats D. Urinalysis procedure manual
D. Blood collection tubes
16. Employees should not work with radioisotopes
9. An employer who fails to provide sufficient gloves for if they are:
the employees may be fined by the: A. Wearing contact lenses
A. CDC B. Allergic to iodine
B. NFPA C. Sensitive to latex
C. OSHA D. Pregnant
D. FDA
17. All of the following are safe to do when removing the
10. An acceptable disinfectant for decontamination of blood source of an electric shock except:
and body fluids is: A. Pulling the person away from the instrument
A. Sodium hydroxide B. Turning off the circuit breaker
B. Antimicrobial soap C. Using a glass container to move the instrument
C. Hydrogen peroxide D. Unplugging the instrument
D. Sodium hypochlorite
18. The acronym PASS refers to:
11. Correct hand washing includes all of the following A. Presence of vital chemicals
except:
B. Operation of a fire extinguisher
A. Using warm water
C. Labeling of hazardous material
B. Rubbing to create a lather
D. Presence of radioactive substances
C. Rinsing hands in a downward position
19. The system used by firefighters to assess the risk
D. Turning on the water with a paper towel
potential when a fire occurs in the laboratory is:
12. Centrifuging an uncapped specimen may produce a A. SDS
biological hazard in the form of:
B. RACE
A. Vectors
C. NFPA
B. Sharps contamination
D. PASS
C. Aerosols
20. A class ABC fire extinguisher contains:
D. Specimen contamination
A. Sand
13. An employee who accidentally spills acid on his arm
B. Water
should immediately:
C. Dry chemicals
A. Neutralize the acid with a base
D. Acid
B. Hold the arm under running water for 15 minutes
C. Consult the SDS 21. The first thing to do when a fire is discovered is to:
D. Wrap the arm in gauze and go to the emergency A. Rescue people in danger
department B. Activate the alarm system
C. Close doors to other areas
D. Extinguish the fire if possible
 Chapter 1 | Safety and Quality Management 73

22. If a red rash is observed after removing gloves, the 30. During laboratory accreditation inspections, procedure
employee: manuals are examined for the presence of:
A. May be washing her hands too often A. Critical values
B. May have developed a latex allergy B. Procedure references
C. Should apply cortisone cream C. Procedures for specimen preservation
D. Should not rub her hands so vigorously D. All of the above
23. Pipetting by mouth is: 31. As the supervisor of the urinalysis laboratory, you have
A. Acceptable for urine but not serum just adopted a new procedure. You should:
B. Not acceptable without proper training A. Put the package insert in the procedure manual
C. Acceptable for reagents but not specimens B. Put a complete, referenced procedure in the manual
D. Not acceptable in the laboratory C. Notify the microbiology department
D. Put a cost analysis study in the procedure manual
24. The NPFA classification symbol contains information on
all of the following except: 32. Indicate whether each of the following would be
A. Fire hazards considered a 1) preexamination, 2) examination, or
3) postexamination factor by placing the appropriate
B. Biohazards
number in the blank:
C. Reactivity
Reagent expiration date
D. Health hazards
Rejecting a contaminated specimen
25. The GHS requires the following on a chemical label: Constructing a Levy-Jennings chart
A. Biohazard symbol, warning sign, environmental Telephoning a positive Clinitest result on a
impact newborn
B. Hazard pictogram, signal words, hazard statement Calibrating the centrifuge
C. Biological symbol, hazard pictogram, long-term Collecting a timed urine specimen
effects
33. The testing of a specimen from an outside agency and
D. Signal words, hazard statement, biological symbol
the comparison of results with participating laboratories
26. The classification of a fire that can be extinguished with is called:
water is: A. External QC
A. Class A B. Electronic QC
B. Class B C. Internal QC
C. Class C D. Proficiency testing
D. Class D
34. A color change indicating that a sufficient amount of a
27. Employers are required to provide free immunization for: patient’s specimen or reagent is added correctly to the
A. HIV test system would be an example of:
B. HTLV-1 A. External QC
C. HBV B. Equivalent QC
D. HCV C. Internal QC
D. Proficiency testing
28. A possible physical hazard in the hospital is:
A. Wearing closed-toed shoes 35. What steps are taken when the results of reagent strip
QC are outside the stated confidence limits?
B. Not wearing jewelry
A. Check the expiration date of the reagent strip
C. Having short hair
B. Run a new control
D. Running to answer the telephone
C. Open a new reagent strips container
29. Quality management refers to:
D. All of the above
A. Analysis of testing controls
B. Increased productivity
C. Precise control results
D. Quality of specimens and patient care
74 Part One | Basic Principles

36. When a new bottle of QC material is opened, what 37. When a control is run, what information is
information is placed on the label? documented?
A. The supervisor’s initials A. The lot number
B. The lot number B. Expiration date of the control
C. The date and the laboratory worker’s initials C. The test results
D. The time the bottle was opened D. All of the above

Case Studies and Clinical Situations

1. State a possible reason for an accreditation team to report scientist was waiting too long to read the glucose results
a deficiency in the following situations: and therefore reporting erroneous results.
a. The urine microscopic reporting procedure has been a. What is wrong with this scenario?
recently revised. b. Who should run the QC for each test? Why?
b. An unusually high number of urine specimens are c. When should controls be run?
being rejected because of improper collection.
d. What do you do when the QC is out of range?
c. A key statement is missing from the Clinitest
e. When can you report patient results?
procedure.
d. Open control bottles in the refrigerator are examined. 4. An outpatient urine specimen was delivered to the labora-
tory at 0800 and placed on the counter in the urinalysis
2. As the new supervisor of the urinalysis section, you en- department. The medical laboratory scientist performed
counter the following situations. Explain whether you urinalysis on the specimen at 1130. The following results
would accept them or take corrective action. were abnormal:
a. You are told that the supervisor always performs the Clarity: Cloudy
CAP proficiency survey.
pH: 9.0
b. QC is not performed daily on the reagent strips.
Nitrite: Positive
c. The urinalysis section is primarily staffed by personnel
assigned to other departments for whom you have no The patient was a known diabetic; however, the glucose
personnel data. result was negative.
a. What could be a possible cause for the abnormal
3. The medical laboratory scientist was assigned to test 10
results?
urine specimens chemically. She removed 10 strips from
the container and proceeded with testing. Several pa- b. Where would the information concerning what
tients’ urine indicated a trace positive glucose in the should have been done with this specimen be found,
urine. She then opened a new bottle of reagent dipsticks as well as the criteria for rejection?
and proceeded to perform the QC. The negative control c. What QM procedure may have detected this error?
also tested as a trace positive for glucose. The medical d. What form will need to be completed for this
laboratory scientist consulted the supervisor. The supervi- scenario?
sor ran the QC, and the results were in the correct range.
e. How might this affect this patient’s care?
After observing the medical laboratory scientist’s tech-
nique, the supervisor realized that the medical laboratory f. How will the corrected results be documented?
 CHAPTER 2
Urine and Body Fluid
Analysis Automation
LEARNING OUTCOMES
Upon completing this chapter, the reader will be able to:
2-1 Explain the principle of reflectance photometry. 2-4 Describe laser-based flow cytometry, digital imaging,
and auto particle recognition technologies used in auto-
2-2 Differentiate between semiautomated urine chemistry
mated urine microscopy analyzers.
analyzers and fully automated urine chemistry analyzers.
2-5 Discuss the advantages of automated body fluid analyz-
2-3 State the advantages of automated microscopy methods
ers over the Neubauer hemocytometer for body fluid
over manual microscopy methods for analyzing urine
cell counts.
sediment.

KEY TERMS
Auto-checks Digital imaging Light-emitting diode (LED)
Auto particle recognition (APR) Flow cytometry Reflectance photometry
Autovalidated Histograms Scattergrams
 Chapter 2 | Urine and Body Fluid Analysis Automation 89

77 Elektronika Kft, Budapest, Hungary: [Link]/products/ Roche Diagnostics, Indianapolis, IN: [Link]/products
urine-analyzer Siemens Healthcare Diagnostics Inc., Deerfield, IL: [Link].
Iris Diagnostics – Beckman Coulter, Brea, CA: www. [Link]/diagnostics
[Link] Sysmex Corporation, Kobe, Japan: [Link]/usa

Study Questions
1. The principle commonly used to measure the concentra- 7. Which automated urine particle counter combines urine
tion of a particular analyte in the chemical examination of flow cytometry with digital image analysis?
urine is: A. UN-2000
A. Reflectance photometry B. iRICELL
B. Digital imaging C. UF-1000i
C. Flow cytometry D. iQ 200
D. Auto particle recognition
8. Which of the following urine sediment particles cannot
2. In automated urinalysis, the specific gravity is measured by: be autovalidated but will be flagged and must be
A. Light transmittance reviewed by laboratory personnel?
B. Light scattering A. RBCs
C. Refractometry B. WBCs
D. Turbidity C. RTEs
D. Squamous epithelial cells
3. All of the following are true concerning fully automated
urine chemistry analyzers, except: 9. Which of the automated body fluid analyzers does not
A. They are designed for a high-volume urinalysis need to dilute or pretreat body fluids before analysis?
laboratory. A. ADVIA 2120i
B. The reagent strip is dipped into the well-mixed urine. B. XN Series
C. The urine tube moves through the instrument. C. iQ 200
D. A sample probe aspirates the urine. D. None of the above
4. The advantages of an automated urine microscopy 10. What is a disadvantage of counting body fluid cells
analyzer over manual microscopy includes: using an automated instrument versus a Neubauer
A. Cost-effective hemocytometer?
B. Centrifugation not required A. Less labor-intensive and time-consuming
C. Standardized results B. More precise
D. All of the above C. Unable to count low WBC numbers and
malignant cells
5. Which of the following is a complete urinalysis auto-
D. Able to perform a WBC differential
mated urinalysis system?
A. AUTION ELEVEN AE 4022
B. Clinitek Atlas
C. iQ200 Automated Urine Microscopy
D. Clinitek AUWi Pro System
6. What two technologies are used for urine sediment
analysis?
A. Light scattering and refractometry
B. Light scattering and flow cytometry
C. Flow cytometry and digital imaging
D. Digital imaging and refractometry
90 Part One | Basic Principles

Case Studies and Clinical Situation

1. A medical laboratory scientist student is being trained on 2. A patient in the emergency department (ED) presented
the laboratory automated urinalysis system that performs with a high temperature, headache, and stiff neck. The
both the chemical and microscopic examination of urine. doctor suspected meningitis and performed a lumbar
The student poured 12 mL of urine into the urine tube puncture to obtain a cerebrospinal fluid (CSF) specimen
that was labeled correctly and placed it on the instru- for analysis in the laboratory.
ment. The reagent strip results indicated that there was a a. What instruments would be used to count the number
large amount of blood and leukocytes; however, the of white blood cells in the CSF?
microscopic results reported 0 to 2 RBC/hpf and 0 to
b. Which instrument would require that the specimen be
2 WBC/hpf.
pretreated?
a. Do the reagent strip and microscopic results correlate?
c. How long is the prepared CSF specimen stable?
b. What mistake in the procedure may have caused these
results?
c. What should be performed to ensure that the instru-
ment was functioning properly?
 CHAPTER 3
Introduction to Urinalysis
LEARNING OUTCOMES
Upon completing this chapter, the reader will be able to:
3-1 List three major organic and three major inorganic 3-8 Discuss the actions of bacteria on a urine specimen
chemical constituents of urine. that is unpreserved.
3-2 Describe a method for determining whether a fluid in 3-9 Briefly discuss five methods for preserving urine speci-
question is urine. mens, including the advantages and disadvantages
of each.
3-3 Recognize normal and abnormal daily urine volumes.
3-10 Instruct a patient in the correct procedure for collect-
3-4 Describe the characteristics of the specimen containers
ing the following specimens: random, first morning,
recommended for urine.
24-hour timed, catheterized, midstream clean-catch,
3-5 Describe the correct procedure for labeling urine suprapubic aspiration, three-glass collection, four-glass
specimens. collection, and pediatric. Identify a diagnostic use for
each collection technique.
3-6 State four possible reasons why a laboratory would
reject a urine specimen. 3-11 Describe the type of specimen needed for optimal re-
sults when a specific urinalysis procedure is requested.
3-7 List the changes that may take place in a urine speci-
men that remains at room temperature for more than
2 hours.

KEY TERMS
Albuminuria Midstream clean-catch specimen Random specimen
Anuria Nocturia Suprapubic aspiration
Catheterized specimen Oliguria Timed specimen
Chain of custody (COC) Polydipsia
First morning specimen Polyuria
 Chapter 3 | Introduction to Urinalysis 101

PROCEDURE 3-4—cont’d
5. The collector completes step 1 of the COC form and 12. The specimen must remain in the sight of the donor
has the donor sign it. and collector at all times.
6. The donor leaves his or her coat, briefcase, and/or 13. With the donor watching, the collector peels off the
purse outside the collection area to avoid the possibil- specimen identification strips from the COC form
ity of concealed substances contaminating the urine. (COC step 3) and puts them on the capped bottle,
7. The donor sanitizes his or her hands and receives a covering both sides of the cap.
specimen cup. 14. The donor initials the specimen bottle seals.
8. The collector remains in the restroom but outside the 15. The collector writes the date and time on the
stall, listening for unauthorized water use, unless a bottle seals.
witnessed collection is requested. 16. The donor completes step 4 on the COC form.
9. The donor hands the specimen cup to the collector. 17. The collector completes step 5 on the COC form.
The transfer is documented.
18. Each time the specimen is handled, transferred, or
10. The collector checks the urine for abnormal color and placed in storage, every individual must be identified
for the required amount (30 to 45 mL). and the date and purpose of the change recorded.
11. The collector checks that the temperature strip on the 19. The collector follows laboratory-specific instructions
specimen cup reads 32.5°C to 37.7°C. The collector for packaging the specimen bottles and laboratory
records the in-range temperature on the COC form copies of the COC form.
(COC step 2). If the specimen temperature is out of
20. The collector distributes the COC copies to appropri-
range or the specimen is suspected of having been
ate personnel.
diluted or adulterated, a new specimen must be
collected and a supervisor notified.

Product Circular, 2014. Becton, Dickinson and Company,

For additional resources please visit 1 Becton Drive, Franklin Lakes, NJ 07417. Web site: [Link].
[Link] com/vacutainer/referencematerial. ©2014 BD 8606531 Mfg
by BD, USA 04/2014. Accessed April 25, 2019.
5. Baer, DM: Glucose tolerance test: Tips from the clinical experts.
Medical Laboratory Observer, Sept. 2003.
References 6. Rous, SN: The Prostate Book. Consumers Union, Mt. Vernon,
NY, 1988.
1. Herman, JR: Urology: A View Through the Retrospectroscope.
7. Stevermer, JJ, and Easley, SK: Treatment of prostatitis. Am Fam
Harper & Row, Hagerstown, MD, 1973.
Physician 61(10):2015–3022, 2000.
2. Clinical and Laboratory Standards Institute, Urinalysis:
8. Kraemer, Samantha, MD: Chronic Bacterial Prostatitis Workup.
Approved Guideline, ed 3, CLSI Document GP16-A3: Wayne,
Medscape. Web site: [Link]
PA, 2009, CLSI.
458391-workup. Published January 15, 2019. Accessed
3. Torora, GJ, and Anagnostakos, NP: Principles of Anatomy and
April 22, 2019.
Physiology, ed 6, Harper & Row, New York, 1990, p. 51.
4. Becton, Dickinson and Company: BD Vacutainer Urine Products
for Collection, Storage, and Transport of Urine Specimens.

Study Questions
1. The primary inorganic substance found in urine is: 2. An unidentified fluid is received in the laboratory with a
A. Sodium request to determine whether the fluid is urine or another
body fluid. Using routine laboratory tests, which substances
B. Phosphate
would determine that the fluid is most probably urine?
C. Chloride
A. Glucose and ketones
D. Calcium
B. Urea and creatinine
C. Uric acid and amino acids
D. Protein and amino acids
102 Part One | Basic Principles

3. The average daily output of urine is: 10. For general screening, the specimen collected most
A. 200 mL frequently is a:
B. 500 mL A. Random one
C. 1200 mL B. First morning
D. 2500 mL C. Midstream clean-catch
D. Timed
4. A patient presenting with polyuria, nocturia, polydipsia,
and a low urine specific gravity is exhibiting symptoms of: 11. The primary advantage of a first morning specimen over
A. Diabetes insipidus a random specimen is that it:
B. Diabetes mellitus A. Is less contaminated
C. Urinary tract infection B. Is more concentrated
D. Uremia C. Is less concentrated
D. Has a higher volume
5. A patient with oliguria might progress to having:
A. Nocturia 12. If a routine urinalysis and a culture are requested on a
catheterized specimen, then:
B. Polyuria
A. Two separate containers must be collected
C. Polydipsia
B. The routine urinalysis is performed first
D. Anuria
C. The patient must be recatheterized
6. All of the following are characteristics of recommended
D. The culture is performed first
urine containers except:
A. A flat bottom 13. If a patient fails to discard the first specimen when
collecting a timed specimen, then the:
B. A capacity of 50 mL
A. Specimen must be re-collected
C. A snap-on lid
B. Results will be falsely elevated
D. Are disposable
C. Results will be falsely decreased
7. Labels for urine containers are:
D. Both A and B
A. Attached to the container
14. The primary cause of unsatisfactory results in an
B. Attached to the lid
unpreserved routine specimen not tested for 8 hours is:
C. Placed on the container before collection
A. Bacterial growth
D. Not detachable
B. Glycolysis
8. A urine specimen may be rejected by the laboratory for all C. Decreased pH
of the following reasons except the fact that the:
D. Chemical oxidation
A. Requisition form states the specimen is catheterized
15. Prolonged exposure of a preserved urine specimen to
B. Specimen contains toilet paper
light will cause:
C. Label and requisition form do not match
A. Decreased glucose
D. Outside of the container has contamination from fecal
B. Increased cells and casts
material
C. Decreased bilirubin
9. A cloudy specimen received in the laboratory may have
D. Increased bacteria
been preserved using:
A. Boric acid 16. Which of the following would be least affected in a
specimen that has remained unpreserved at room
B. Chloroform
temperature for more than 2 hours?
C. Refrigeration
A. Urobilinogen
D. Formalin
B. Ketones
C. Protein
D. Nitrite
 Chapter 3 | Introduction to Urinalysis 103

17. Bacterial growth in an unpreserved specimen will: 19. Which of the following would not be given to a patient
A. Decrease clarity before the collection of a midstream clean-catch
specimen?
B. Increase bilirubin
A. Sterile container
C. Decrease pH
B. Iodine cleanser
D. Increase glucose
C. Antiseptic towelette
18. The most sterile specimen collected is a:
D. Instructions
A. Catheterized
20. Urine specimen collection for drug testing requires the
B. Midstream clean-catch
collector to do all of the following except:
C. Three-glass
A. Inspect the specimen color
D. Suprapubic aspiration
B. Perform reagent strip testing
C. Read the specimen temperature
D. Fill out a chain-of-custody form

Case Studies and Clinical Situations

1. A patient brings a first morning specimen to the labora- 4. The laboratory receives a urine preservative tube for cul-
tory at 1:00 p.m. ture containing a volume of specimen that is considerably
a. How could this affect the urinalysis results? below the minimum fill line.
b. If the patient is a known diabetic, what results would a. Could this affect the culture?
be most suspect? b. Why?
c. What is the best course of action? 5. A worker suspects that he or she will be requested to col-
d. What could the patient have said that would have lect an unwitnessed urine specimen for drug analysis. He
made the specimen satisfactory for testing? or she carries a substitute specimen in his or her pocket
for 2 days before being told to collect the specimen.
2. A patient collecting a midstream clean-catch specimen
Shortly after the worker delivers the specimen to the col-
voids immediately into the container.
lector, he or she is instructed to collect another specimen.
a. How could this affect the clarity of the specimen?
a. What test was performed on the specimen to deter-
b. How could this affect the microscopic examination? mine possible specimen manipulation?
3. A patient brings a 24-hour-timed specimen to the labora- b. How was the specimen in this situation affected?
tory and reports that he or she forgot to collect a speci- c. If a specimen for drug analysis tests positive, state a
men voided during the night. possible defense related to specimen collection and
a. How will this affect the results of a quantitative test for handling that an attorney might employ.
creatinine? d. How can this defense be avoided?
b. What should the patient be told to do?
 CHAPTER 4
Renal Function
LEARNING OUTCOMES
Upon completing this chapter, the reader will be able to:
4-1 Identify the components of the nephron, kidney, and 4-10 Given hypothetical laboratory data, calculate a creati-
excretory system. nine clearance and determine whether the result is
normal.
4-2 Trace the flow of blood through the nephron, and state
the physiological functions that occur. 4-11 Discuss the clinical significance of the glomerular
filtration rate tests.
4-3 Describe the process of glomerular ultrafiltration.
4-12 Describe and contrast the Modification of Diet in Renal
4-4 Discuss the functions and regulation of the
Disease (MDRD), cystatin C, and beta2-microglobulin
renin–angiotensin–aldosterone system (RAAS).
tests for performing estimated glomerular filtration
4-5 Differentiate between active and passive transport in rates (eGFR).
relation to renal concentration.
4-13 Define osmolarity, and discuss its relationship to urine
4-6 Explain the function of antidiuretic hormone in the concentration.
concentration of urine.
4-14 Describe the basic principles of freezing-point
4-7 Describe the role of tubular secretion in maintaining osmometers.
acid–base balance.
4-15 Given hypothetic laboratory data, calculate a
4-8 Identify the laboratory procedures used to evaluate free-water clearance and interpret the result.
glomerular filtration, tubular reabsorption and secre-
4-16 Given hypothetic laboratory data, calculate a PAH
tion, and renal blood flow.
clearance and relate this result to renal blood flow.
4-9 Describe the creatinine clearance test.
4-17 Describe the relationship of urinary ammonia and
titratable acidity to the production of an acidic urine.

KEY TERMS
Active transport Creatinine clearance Glomerular filtration rate (GFR)
Afferent arteriole Cystatin C Glomerulus
Aldosterone Density Juxtaglomerular apparatus
Antidiuretic hormone (ADH) Distal convoluted tubule Loops of Henle
Beta2-microglobulin (B2M) Endogenous procedure Macula densa
Clearance tests Efferent arteriole Maximal reabsorptive capacity (Tm)
Collecting duct Exogenous procedure Metabolic acidosis
Concentration tests Fenestrated endothelium Nephron
Countercurrent mechanism Free water clearance Osmolality
Creatinine Glomerular filtration barrier Osmolar clearance
Continued
120 Part One | Basic Principles

editors: Clinical Diagnosis and Management by Laboratory

HISTORICAL NOTE Methods, ed 22, Elsevier, Philadelphia, 2011.
3. Gounden, V, and Jialad, I: Renal Function Tests. Nation Center
Phenolsulfonphthalein Test for Biotechnology Information (NCBI), U. S. National Library
of Medicine. PMID 29939598 Web site: [Link]
Historically, excretion of the dye phenolsulfonphthalein [Link]/books/NBK507821/ Bethesda, MD. Published April 2,
2019. Accessed May 3, 2019.
(PSP) was used to evaluate these functions. Standardiza- 4. Levey, AS, et al: A new equation to estimate glomerular
tion and interpretation of PSP results are difficult, how- filtration rate. Ann Intern Med 150(9):601–612, 2009.
ever, because of interference by medications, elevated 5. Laterza, OE, Price, CP, and Scott, MG: Cystatin C: An improved
waste products in patients’ serum, the necessity to obtain estimator of glomerular filtration rate? Clin Chem 48(5):
several very accurately timed urine specimens, and the 699–707, 2002.
6. Tan, GS, et al: Clinical usefulness of cystatin C for the estima-
possibility of producing anaphylactic shock. Therefore, tion of glomerular filtration rate in type 1 diabetes. Crit Care
the PSP test is not currently performed. 9(2):139–143, 2005.
7. Inker, LA: Estimating glomerular filtration rate from
serum creatinine and cystatin C. N Engl J Med 367:20–29,
2012.
8. Beta-2 Microglobulin Kidney Disease. Lab Tests Online.
For additional resources please visit American Association for Clinical Chemistry. Web site:
[Link] [Link]
disease. Accessed April 29, 2019.
9. Foley, K: Beta 2 microglobulin: a facultative marker. Advance
for MLP, Sept 30, 2008, p 13.
References 10. Chachati, A, et al: Rapid method for the measurement of differ-
1. Berger, A: Renal function and how to assess it. Brit J Med ential renal function: Validation. J Nucl Med 28(5): 829–836,
321:1444, 2000. 1987.
2. Pincus, MR, Bock, JL, Bluth, MH: Evaluation of renal function, 11. Davis, BB, and Zenser, TV: Evaluation of renal concentrating
water, electrolytes, and acid-base. In McPherson RA, Ben-Ezra J, and diluting ability. Clin Lab Med 13(1):131–134, 1993.

Study Questions
1. The type of nephron responsible for renal concentration 4. Filtration of protein is prevented in the glomerulus by:
is the: A. Hydrostatic pressure
A. Cortical B. Oncotic pressure
B. Juxtaglomerular C. Renin
C. Efferent D. The glomerular filtration barrier
D. Afferent
5. The renin–angiotensin–aldosterone system is responsible
2. The function of the peritubular capillaries is: for all of the following except:
dilation
A. Reabsorption A. Vasoconstriction of the afferent arteriole
B. Filtration B. Vasoconstriction of the efferent arteriole
C. Secretion C. Reabsorbing sodium
D. Both A and C D. Releasing aldosterone
3. Blood flows through the nephron in the following order: 6. The primary chemical affected by the renin–angiotensin–
A. Efferent arteriole, peritubular capillaries, vasa recta, aldosterone system is:
afferent arteriole A. Chloride
B. Peritubular capillaries, afferent arteriole, vasa recta, B. Sodium
efferent arteriole C. Potassium
C. Afferent arteriole, efferent arteriole, peritubular D. Hydrogen
capillaries, vasa recta RAGE PV
D. Efferent arteriole, vasa recta, peritubular capillaries,
afferent arteriole
 Chapter 4 | Renal Function 121

7. Secretion of renin is stimulated by: 14. ADH regulates the final urine concentration by
A. Juxtaglomerular cells controlling:
B. Angiotensin I and II A. Active reabsorption of sodium ( SIADH ✓
DM

C. Macula densa cells B. Tubular permeability 9 ADH taurine / de ADH purine

-

-
-

D. Circulating angiotensin-converting enzyme C. Passive reabsorption of urea

D. Passive reabsorption of chloride
8. The hormone aldosterone is responsible for:
A. Hydrogen ion secretion 15. Decreased production of ADH: Itt ADH -
-
A urine

B. Potassium secretion A. Produces a low volume of urine

C. Chloride retention B. Produces a high volume of urine
D. Sodium retention C. Increases excretion of ammonia
D. Affects active transport of sodium
9. The fluid leaving the glomerulus has a specific gravity of:
A. 1.005 16. Bicarbonate ions filtered by the glomerulus are returned
to the blood: v0 needed to maintain pH balance
B. 1.010
A. In the proximal convoluted tubule
C. 1.015 not released from blood
B. Combined with hydrogen ions wolf acidic blood seen in

RT-A-telt -fuvinepH-teblo [Link]

D. 1.020 =

Alkaline urine
=
}
C. By tubular secretion
10. For active transport to occur, a chemical must: } bicarbonate
D. All of the above blood pit

A. Combine with a carrier protein to create

electrochemical energy 17. If ammonia is not produced by the distal convoluted
tubule, the urine pH will be:
B. Be filtered through the proximal convoluted tubule
A. Acidic
C. Be in higher concentration in the filtrate than in the
blood B. Basic
D. Be in higher concentration in the blood than in the C. Hypothenuric
filtrate D. Hypersthenuric
11. Which of the tubules is impermeable to water? 18. Place the appropriate letter in front of the following
A. Proximal convoluted tubule clearance substances:
B. Descending loop of Henle A. Exogenous
despite being GOLD standard
go
,

C. Ascending loop of Henle B. Endogenous creatinine is

* Inulin A still preferred
=
B beta2-microglobulin
D. Distal convoluted tubule
* PAH A endogenous
= =
=

B creatinine
12. Glucose will appear in the urine when the: constant
B cystatin C
A. Blood level of glucose is 200 mg/dL
A 125I-iothalmate
B. Tm for glucose is reached ( Threshold)
C. Renal threshold for glucose is exceeded 1160 -180mg 1dL) 19. The largest source of error in creatinine clearance
tests is:
D. All of the above
A. Secretion of creatinine
13. Concentration of the tubular filtrate by the
B. Improperly timed urine specimens
countercurrent mechanism depends on all of the
following except: C. Refrigeration of the urine
A. High salt concentration in the medulla D. Time of collecting blood specimen
B. Water-impermeable walls of the ascending loop of 20. Given the following information, calculate the creatinine
Henle clearance:
C. Reabsorption of sodium and chloride from the
ascending loop of Henle [Link]
24-hour urine volume: 1000 mL; serum creatinine:
2.0 mg/dL; urine creatinine: 200 mg/dL
D. Reabsorption of water in the descending loop of
[Link]?-zzmp/or/UpV-p-- ✓ 1000mL /
=

Henle a. omg 1dL

car =
(
20°mH¥m¥¥ÉÑ =
69.4mV min
122 Part One | Basic Principles

21. Clearance tests used to determine the glomerular 28. The normal serum osmolarity is:
filtration rate must measure substances that are: A. 50 to 100 mOsm
A. Not filtered by the glomerulus B. 275 to 300 mOsm
B. Completely reabsorbed by the proximal convoluted C. 400 to 500 mOsm
tubule
D. 3 times the urine osmolarity
C. Secreted in the distal convoluted tubule → osmolality
29. After -
controlled fluid intake, the urine-to-serum
D. Neither reabsorbed nor secreted by the tubules
osmolarity ratio should be at least:
22. Performing a clearance test using radionucleotides: A. 1:1
A. Eliminates the need to collect urine B. 2:1
B. Does not require an infusion C. 3:1
C. Provides visualization of the filtration D. 4:1
D. Both A and C
30. Calculate the free water clearance from the following
23. Variables that are included in the MDRD-IDSM results: I 0.5
estimated calculations of creatinine clearance include all
urine volume in 6 hours: 720 mL; urine osmolarity:
of the following 0
except:
225 mOsm; plasma osmolarity: 300 mOsm
A. Serum creatinine
, BM
31. To provide an accurate measure of renal blood flow, a
B. Weight → Coekgroftqgault / Age , gender=
test substance should be completely:
C. Age
A. Filtered by the glomerulus
D. Gender test LEGER)
→ modified B. Reabsorbed by the tubules
24. An advantage to using cystatin C to monitor GFR is that: C. Secreted when it reaches the distal convoluted
A. It does not require urine collection tubule
RPAH test
B. It is not secreted by the tubules D. Cleared on each contact with functional renal tissue
C. It can be measured by immunoassay 32. Given the following data, calculate the effective renal
D. All of the above plasma flow:
25. Solute dissolved in solvent will: urine volume in 2 hours: 240 mL; urine PAH: 150 mg/dL;
A. Raise the vapor pressure plasma PAH: 0.5 mg/dL
B. Lower the boiling point 33. Renal tubular acidosis can be caused by the:
C. Decrease the osmotic pressure A. Production of excessively acidic urine due to
D. Lower the freezing point increased filtration of hydrogen ions
B. Production of excessively acidic urine due to
26. Substances that may interfere with freezing-point
increased secretion of hydrogen ions
measurement of urine and serum osmolarity include all
of the following except: C. Inability to produce an acidic urine due to impaired
production of ammonia
A. Ethanol
D. Inability to produce an acidic urine due to increased
B. Lactic acid
production of ammonia
C. Sodium
34. Tests performed to detect renal tubular acidosis after
D. Lipids
administering an ammonium chloride load include all of
27. Clinical osmometers use NaCl as a reference solution the following except:
because: A. Urine ammonia ✓ kidneys ability to

&
A. 1 g molecular weight of NaCl will lower the freezing measures
B. Arterial pH secrete Ht
point 1.86°C
C. Urine pH
B. NaCl is readily frozen
D. Titratable acidity ✓
C. NaCl is partially ionized, similar to the composition
of urine
D. 1 g equivalent weight of NaCl will raise the freezing
point 1.86°C
 Chapter 4 | Renal Function 123

Case Studies and Clinical Situations

1. A 44-year-old man diagnosed with acute tubular necrosis 4. A laboratory is obtaining erratic serum osmolarity results
has a blood urea nitrogen of 60 mg/dL and a blood on a patient who is being monitored at 6 a.m., 12 p.m.,
0
glucose level of 100 mg/dL. A 2+ urine glucose is also
-
6 p.m., and 12 a.m. Osmolarities are not performed on
reported. the night shift; therefore, the midnight specimen is run at
a. State the renal threshold for glucose. 160 -180mg 1dL the same time as the 6 a.m. specimen.
b. What is the significance of the positive urine glucose a. What two reasons could account for these
and normal blood glucose? Reached renal threshold discrepancies?① luntetrigeratedfunseparatcdplaomapromaeot
b. What substance is causing the erratic results?
2. A patient develops a sudden drop in blood pressure. (RAAS)
Gomaliladensaalts ←
c. If a friend were secretly bringing the patient a pint of
a. Diagram the reactions that take place to ensure
Angiotensin /I whiskey every night, would this affect the results?
adequate blood pressure within the nephrons. ntuldreoet
Explain your answer. ugecntostaticosmometer
b. How do these reactions increase blood volume?
5. After overnight (6 p.m. to 8 a.m.) fluid deprivation, the
c. When blood pressure returns to normal, how does the
urine-to-serum osmolarity ratio in a patient who is ex-
kidney respond? Production of Renin stops
hibiting polyuria and polydipsia is 1:1. The ratio remains
3. A physician would like to prescribe a nephrotoxic antibi- the same when a second specimen is tested at 10 a.m.
otic for a 60-year-old white man. The patient has a serum Then ADH is administered subcutaneously to the patient,
creatinine level of 1.5 mg/dL. and the fluid deprivation is continued until 2 p.m., when
a. How can the physician determine whether it is safe to another specimen is tested.
prescribe this medication before the patient leaves a. What disorder do these symptoms and initial labora-
the office? MDRD Msm tory results indicate?
[Link]
-

b. State two additional blood tests that the physician b. If the urine-to-serum osmolarity ratio on the 2 p.m.
could use to continue monitoring this [Link] specimen is 3:1, what is the underlying cause of the
c. If the patient has a history of prostate malignancy, patient’s disorder?
would both of the methods listed in answer choice 3b c. If the urine-to-serum osmolarity ratio on the 2 p.m.
provide reliable results? Explain your answer. specimen remains 1:1, what is the underlying cause of
results the patient’s disorder?
NO -
Brdmwillinterlerewlimmunologic
 CHAPTER 5
Physical Examination
of Urine
LEARNING OUTCOMES
Upon completing this chapter, the reader will be able to:
5-1 List the common terminology used to report normal 5-10 List three pathological and four nonpathological
urine color. causes of cloudy urine.
5-2 Discuss the relationship of urochrome to normal urine 5-11 Define specific gravity, and tell why this measurement
color. can be significant in the routine analysis.
5-3 State how the presence of bilirubin, biliverdin, uroery- 5-12 Describe the principles of the refractometer, reagent
thrin, and urobilin in a specimen may be suspected. strip, and osmolality for determining specific gravity.
5-4 Discuss the significance of cloudy red urine versus 5-13 Given the concentration of glucose and protein in a
clear red urine. specimen, calculate the correction needed to compen-
sate for these high-molecular-weight substances in the
5-5 Name two pathological causes of black or brown urine.
refractometer reading of specific gravity.
5-6 Discuss the significance of phenazopyridine in a
5-14 Name two nonpathogenic causes of abnormally high
specimen.
readings of specific gravity using a refractometer.
5-7 State the clinical significance of urine clarity.
5-15 Describe the advantages of measuring specific gravity
5-8 List the common terminology used to report clarity. using a reagent strip and osmolality.
5-9 Describe the appearance and discuss the significance 5-16 State possible causes of abnormal urine odor.
of amorphous phosphates and amorphous urates in
urine that was freshly voided.

KEY TERMS
Clarity Refractive index Urochrome
Hypersthenuric Refractometry Uroerythrin
Hyposthenuric Specific gravity
Isosthenuric Urobilin
 191M Chapter 5 | Physical Examination of Urine 135

Study Questions

=
1. The concentration of a normal urine specimen can be 8. Microscopic examination of a clear urine that produces a
-
estimated by which of the following? white precipitate after refrigeration will show:
A. Color A. Amorphous urates pink
B. Clarity B. Porphyrins portwine
C. Foam C. Amorphous phosphates
D. Odor D. Yeast
2. The normal yellow color of urine is produced by: 9. The color of urine containing porphyrins will be:

=
A. Bilirubin A. Yellow-brown
B. Hemoglobin B. Green
C. Urobilinogen C. Orange
D. Urochrome D. Port wine
3. The presence of bilirubin in a urine specimen produces a: 10. Which of the following specific gravities would be most
A. Yellow foam when shaken likely to correlate with a urine that is pale yellow?
B. White foam when shaken A. 1.005
C. Cloudy specimen B. 1.010 ( normal / isosthenuric)
D. Yellow-red specimen C. 1.020
D. 1.030
-
4. A urine specimen containing melanin will appear:
A. Pale pink
B. Dark yellow
-
11. A urine specific gravity measured by a refractometer is
1.029, and the temperature of the urine is 14°C. The
specific gravity should be reported as:
C. Blue-green
A. 1.023
D. Black
[Link] B. 1.027 temperature does not
5. Specimens that contain hemoglobin can be visually require correction

:
C. 1.029
distinguished from those that contain RBCs because:
D. 1.032
A. Hemoglobin produces a clear yellow specimen
B. Hemoglobin produces a cloudy pink specimen
C. RBCs produce a cloudy red specimen
-
12. The principle of refractive index is to compare:
A. Light velocity in solutions with light velocity
in solids
D. RBCs produce a clear red specimen
B. Light velocity in air with light velocity in solutions
6. A patient with a viscous orange specimen may have been: C. Light scattering by air with light scattering by
A. Treated for a urinary tract infection solutions
B. Taking vitamin B pills D. Light scattering by particles in solution
C. Eating fresh carrots 13. A correlation exists between a specific gravity by a
D. Taking antidepressants refractometer of 1.050 and a:
7. The presence of a pink precipitate in a refrigerated speci- A. 2+ glucose
men is caused by: B. 2+ protein
A. Hemoglobin C. First morning specimen
B. Urobilin D. Radiographic dye infusion
C. Uroerythrin
D. Beets
 136 Part Two | Urinalysis

-
✓
14. A cloudy urine specimen turns black upon standing and 20. Which of the following colligative properties is not
has a specific gravity of 1.012. The major concern about stated correctly?
this specimen would be: A. The boiling point is raised by solute (A) freezing
And Vapor
A. Color B. The freezing point is raised by solute lowered
B. Turbidity C. The vapor pressure is lowered by solute Cte)
C. Specific gravity D. The osmotic pressure is raised by solute IN
D. All of the above

I
21. An osmole contains:
✓15. A specimen with a specific gravity of 1.035 would be
considered:
A. One gram molecular weight of solute dissolved in 1
liter of solvent
A. Isosthenuric 1.010 B. One gram molecular weight of solute dissolved in 1
B. Hyposthenuric 4-010
C. Hypersthenuric 51-010
① kilogram of solvent
C. Two gram molecular weights of solute dissolved in 1
D. Not urine It -002 liter of solvent

✓
16. A specimen with a specific gravity of 1.001 would be
considered:
D. Two gram molecular weights of solute dissolved in 1
kilogram of solvent

A. Hyposthenuric 22. The unit of osmolality measured in the clinical

laboratory is the:
B. Not urine
A. Osmole
C. Hypersthenuric
B. Milliosmole
D. Isosthenuric

=
C. Molecular weight
17. A strong odor of ammonia in a urine specimen could
D. Ionic charge
indicate:
A. Ketones 23. In the reagent strip specific gravity reaction, the
polyelectrolyte:
B. Normalcy
A. Combines with hydrogen ions in response to ion
C. Phenylketonuria
concentration
D. An old specimen
B. Releases hydrogen ions in response to ion
18. The microscopic examination of a clear red urine is concentration
reported as many WBCs and epithelial cells. What does C. Releases hydrogen ions in response to pH
this suggest?
D. Combines with sodium ions in response to pH
A. Urinary tract infection naclerio
24. Which of the following will react in the reagent strip
B. Dilute random specimen
specific gravity test?
C. Hematuria Rbcs
A. Glucose
D. Possible mix-up of specimen and sediment
B. Radiographic dye
19. Which of the following would contribute the most to a C. Protein
urine osmolality?
D. Chloride
A. One osmole of glucose
B. One osmole of urea
C. One osmole of sodium chloride
D. All contribute equally
 Chapter 5 | Physical Examination of Urine 137

Case Studies and Clinical Situations

1. Given the following physical urinalysis results, determine 3. State two pathological causes of a clear red urine.
additional urinalysis results that may be abnormal. a. State a method that could distinguish between the two
a. A green specimen with a strong foul odor of ammonia causes that does not require laboratory testing.
b. A pale yellow urine with a specific gravity of 1.030 4. A woman frequently shops at the farmer’s market near her
c. A dark yellow specimen with yellow foam home. She notices her urine has a red color and brings a
d. A cloudy red urine specimen to her physician. The specimen tests negative
for blood.
2. The urology clinic questions a urinalysis report from the
a. What is a probable cause of the woman’s red urine?
laboratory.
b. The woman collects a specimen at the physician’s of-
The laboratory report states a reagent strip reading of a fice. The color is yellow, and the pH is 5.5. Is this con-
specific gravity of 1.020, protein 3 g/dL, and glucose sistent with the previous answer? Why or why not?
2 g/dL. The specific gravity in the urology clinic was
greater than 1.035. 5. Is a clear urine always normal? Explain your answer.
a. Correct the refractometer reading to account for the
concentrations of protein and glucose. What is the
corrected specific gravity?
b. Do the specific gravities correlate?
c. If the specific gravity was also checked using osmome-
try, should the result agree with the laboratory or the
urology clinic results? Why or why not?
 Chapter 6 | Chemical Examination of Urine 161

SUMMARY 621 Clinical Significance

For additional resources please visit
of Urine Specific Gravity [Link]
Monitoring patient hydration and dehydration
Loss of renal tubular concentrating ability
Diabetes insipidus References
1. Chemstrip 10UA product Insert, Roche Diagnostics, Indianapo-
Determination of unsatisfactory specimens due to low lis, IN, 2004.
concentration 2. Multistix Reagent Strips Product Insert. Siemens Healthcare
Diagnostics, Inc., Tarrytown, NY 2010-2017.
3. Clinical and Laboratory Standards Institute. Urinalysis;
Approved Guideline-Third Edition. CLSI document GP16-A3.
Clinical and Laboratory Standards Institute, Wayne, PA,
2009, CLSI.
SUMMARY 622 Urine Specific Gravity 4. Bleyer, AJ, Kmoch, S: Tamm Horsfall glycoprotein and
Reagent Strip Uromodulin: It is all about the Tubules! Clin J Am Soc Nephrol.
2016 Jan 7; 11 (1): 6-8. Doi: 10.2215/CJN.12201115. Web
Reagents Multistix: Poly (methyl vinyl ether/maleic site: [Link]
anhydride) bromothymol blue Published December 18, 2015. Accessed May 6, 2019.
5. Pugia, MJ, and Lott, JA: New developments in urinalysis strip
Chemstrip: Ethylene glycol diaminoethyl tests for proteins. In Bayer Encyclopedia of Urinalysis. Bayer
ether tetra-acetic acid, bromothymol Diagnostics, Elkhart, IN, 2002.
blue 6. Bhuwnesh, A, et al: Microalbumin screening by reagent strip
Sensitivity 1.000–1.030 predicts cardiovascular risk in hypertension. J Hypertens 14:
223–228, 1992.
Interference False positive: High concentrations of 7. Bianchi, S, et al: Microalbuminurea in essential hypertension.
protein J Nephrol 10(4):216–219, 1997.
8. Clinitek Microalbumin Reagent Strip Product Insert. Bayer
False negative: Highly alkaline urines Diagnostics, Elkhart, IN, 2006.
(greater than 6.5) 9. Multistix Pro Reagent Strips Product Insert. Siemens Healthcare
Diagnostics, Inc. Tarrytown, NY, 2008.
10. Benedict, SR: A reagent for the detection of reducing sugars.
J Biol Chem 5:485–487, 1909.
11. College of American Pathologists. CAP Today, Q&A Column
media and plasma expanders that are included in physical 9/16. [Link]
measurements of specific gravity. This difference must be con- Accessed May 6, 2019.
sidered when comparing specific gravity results obtained by a 12. Lane R, and Phillips, M: Rhabdomyolysis has many causes
different method. Elevated concentrations of protein slightly including statins and may be fatal. Brit J Med 327:115–116,
increase the readings as a result of protein anions. 2003.
13. Hager, CB, and Free, AH: Urine urobilinogen as a component
Specimens with a pH of 6.5 or higher have decreased read- of routine urinalysis. Am J Med Technol 36(5):227–233, 1970.
ings caused by interference with the bromothymol blue indi- 14. Wise, KA, Sagert, LA, and Grammens, GL: Urine leukocyte es-
cator (the blue-green readings associated with an alkaline pH terase and nitrite tests as an aid to predict urine culture results.
Lab Med 15(3):186–187, 1984.
-

correspond to a low reading for specific gravity). Therefore,

manufacturers recommend adding 0.005 to specific gravity
readings when the pH is 6.5 or higher. The correction is per-
formed by automated strip readers.
If pH is 6-5 or 9 = add 0.005 to SG

Study Questions
1. Leaving excess urine on the reagent strip after removing it 2. Failure to mix a specimen before inserting the reagent
from the specimen will: strip will primarily affect the:
A. Cause runover between reagent pads A. Glucose reading
B. Alter the color of the specimen B. Blood reading
C. Cause reagents to leach from the pads C. Leukocyte reading
D. Not affect the chemical reactions D. Both B and C
162 Part Two | Urinalysis
Before
3. Testing a refrigerated specimen that has not warmed to
kidney
/ -1 in kidney
10. Indicate the source of the following proteinurias bygaster kidney
room temperature will adversely affect:
-0
placing a 1 for prerenal, 2 for renal, or 3 for postrenal in
-

front of the condition.

A. Enzymatic reactions
2 * know
B. Dye-binding reactions A. Microalbuminuria
1 the location !
C. The sodium nitroprusside reaction B. Acute-phase reactants
C. 2 Preeclampsia
D. Diazo reactions
3
D. Vaginal inflammation
4. The reagent strip reaction that requires the longest 1
reaction time is the: E. Multiple myeloma
F. 2 Orthostatic proteinuria
A. Bilirubin 60 secs
G. 3 Prostatitis
B. pH 60 secs
C. Leukocyte esterase 120 secs 11. The principle of the protein error of indicators reaction
D. Glucose 30 secs is that:
A. Protein keeps the pH of the urine constant
5. Quality control of reagent strips is performed:
B. Albumin accepts hydrogen ions from the indicator
A. Using positive and negative controls
C. The indicator accepts hydrogen ions from albumin
B. When results are questionable
D. Albumin changes the pH of the urine
C. Per laboratory policy
D. All of the above 12. All of the following will cause false-positive protein
values on a reagent strip except:
6. All of the following are important to protect the integrity
A. Microalbuminuria False
of reagent strips except: negative
B. Highly buffered alkaline urines
A. Removing the desiccant from the bottle
C. Delay in removing the reagent strip from the
B. Storing in an opaque bottle
specimen
C. Storing at room temperature
D. Contamination by quaternary ammonium
D. Resealing the bottle after removing a strip compounds
7. The principle of the reagent strip test for pH is the: 13. A patient with a 2+ protein reading in the afternoon is
A. Protein error of indicators protein asked to submit a first morning specimen. The second
B. Greiss reaction nitrite specimen has a negative protein reading. This patient is:
C. Dissociation of a polyelectrolyte 56 A. Positive for orthostatic proteinuria
D. Double indicator reaction B. Negative for orthostatic proteinuria
C. Positive for Bence Jones protein
8. A urine specimen with a pH of 9.0:
D. Negative for clinical proteinuria
A. Indicates metabolic acidosis
B. Should be re-collected 14. Testing for microalbuminuria is valuable for early detec-
tion of kidney disease and monitoring patients with:
C. May contain calcium oxalate crystals
A. Hypertension
D. Is seen after drinking cranberry juice
B. Diabetes mellitus
9. In the laboratory, a primary consideration associated
C. Cardiovascular disease risk
with pH is:
D. All of the above
A. Identifying urinary crystals acidic Saiilkaline crystals
B. Monitoring vegetarian diets 15. The primary chemical on the reagent strip in the Micral-
Test for microalbumin binds to:
C. Determining specimen acceptability
A. Protein
D. Both A and C
B. Antihuman albumin antibody
C. Conjugated enzyme
D. Galactoside
 Chapter 6 | Chemical Examination of Urine 163

16. All of the following are true for the ImmunoDip test for 23. The principle of the reagent strip tests for glucose is the:
-

microalbumin except: A. Peroxidase activity of glucose

A. Unbound antibody migrates farther than bound B. Glucose oxidase reaction
antibody Bound migrates farther than
unbound C. Double sequential enzyme reaction
B. Blue latex particles are coated with antihuman
D. Dye-binding of glucose and chromogen
albumin antibody
C. Bound antibody migrates farther than unbound 24. All of the following may produce
☐ false-negative glucose
antibody reactions0 except:
D. It utilizes an immunochromographic principle A. Detergent contamination
B. Ascorbic acid Ascorbic acid on
17. The principle of the protein-high pad on the Multistix
C. Unpreserved specimens glucose
Pro reagent strip is the: blood glucose,
,

D. Low urine temperature false @ -0 nitrites bilirubin

=
,
A. Diazo reaction leukocytes
B. Enzymatic dye-binding reaction 25. The primary reason for performing a Clinitest is to:
-

C. Protein error of indicators A. Check for high ascorbic acid levels

D. Microalbumin-Micral-Test B. Confirm a positive reagent strip glucose
18. Which of the following is not tested on the Multistix Pro C. Check for newborn galactosuria
reagent strip? D. Confirm a negative glucose reading
A. Urobilinogen 26. The three intermediate products of fat metabolism
B. Specific gravity include all of the following except: ketones
C. Creatinine A. Acetoacetic acid
D. Protein-high B. Ketoacetic acid
19. The principle of the protein-low reagent pad on the C. β-hydroxybutyric acid
Multistix Pro is the: D. Acetone
A. Binding of albumin to sulphonphthalein dye 27. The most significant reagent strip test that is associated
B. Immunological binding of albumin to antibody with a positive ketone result is:
C. Reverse protein error of indicators reaction A. Glucose
D. Enzymatic reaction between albumin and dye B. Protein
20. The principle of the creatinine reagent pad on C. pH
microalbumin reagent strips is the: D. Specific gravity
A. Double indicator reaction 28. The primary reagent in the reagent strip test for
B. Diazo reaction ketones is:
C. Pseudoperoxidase reaction A. Glycine
D. Reduction of a chromogen B. Lactose
21. The purpose of performing an albumin:creatinine ratio C. Sodium hydroxide
is to: D. Sodium nitroprusside
A. Estimate the glomerular filtration rate 29. Ketonuria may be caused by all of the following except:
B. Correct for hydration in random specimens A. Bacterial infections
C. Avoid interference for alkaline urines B. Diabetic acidosis
D. Correct for abnormally colored urines C. Starvation
22. A patient with a normal blood glucose and a positive D. Vomiting
urine glucose should be further checked for:
30. Urinalysis is frequently performed on a patient with
A. Diabetes mellitus both should be⑧ severe back and abdominal pain to check for:
B. Renal disease A. Glucosuria
C. Gestational diabetes B. Proteinuria
D. Pancreatitis C. Hematuria
D. Hemoglobinuria
164 Part Two | Urinalysis

31. Place the appropriate number or numbers in front of 37. The primary cause of a false-negative bilirubin reaction is:
each of the following statements. Use both numbers for A. Highly pigmented urine
an answer if needed.
B. Specimen contamination
1. Hemoglobinuria
C. Specimen exposure to light
2. Myoglobinuria
D. Excess conjugated bilirubin
A.
B.
& Associated with transfusion reactions
Clear red urine and pale yellow plasma
38. The purpose of the special mat supplied with the
I Ictotest tablets is that:
C. Clear red urine and red plasma
2 A. Bilirubin remains on the surface of the mat
D. Associated with rhabdomyolysis
I B. It contains the dye needed to produce color
E. Produces hemosiderin granules in
C. It removes interfering substances
urinary sediments
F.
2 Associated with acute renal failure D. Bilirubin is absorbed into the mat
39. The reagent in the Multistix reaction for urobilinogen is:
32. The principle of the reagent strip test for blood is based
on the: A. A diazonium salt
A. Binding of heme and a chromogenic dye B. Tetramethylbenzidine
B. Peroxidase activity of heme C. p-Dimethylaminobenzaldehyde
C. Reaction of peroxide and chromogen D. Hoesch reagent
D. Diazo activity of heme 40. The primary problem with urobilinogen tests using
Ehrlich reagent is:
33. A speckled pattern on the blood pad of the reagent strip
indicates: A. Positive reactions with porphobilinogen
A. Hematuria B. Lack of specificity roporpnobilinogen
most clinically significant
✓ C. Positive reactions with Ehrlich reactive substances
-

B. Hemoglobinuria
C. Myoglobinuria }fUH colors
D. All of the above
D. All of the above 41. The reagent strip test for nitrite uses the:
-

34. List the following products of hemoglobin degradation A. Greiss reaction

in the correct order of metabolism by placing numbers 1 B. Ehrlich reaction
to 4 in the blank, where 1 indicates the beginning and C. Peroxidase reaction
4 indicates the end product.
D. Pseudoperoxidase reaction
A. I Conjugated bilirubin
3 42. All of the following can cause a negative nitrite reading
B. Urobilinogen and stercobilinogen
C. 4 Urobilin
0except:
A. Gram-positive bacteria
①
D. 2 Unconjugated bilirubin
35. The principle of the reagent strip test for bilirubin is the:
B. Gram-negative bacteria gram④{ ④ [Link]
C. Random urine specimens A- should bet -
-
LE

"
.

A. Diazo reaction "•

D. Heavy bacterial infections
nitrite -0 oforgram@
B. Ehrlich reaction urobilinoqey -
only
43. A0positive nitrite test and a negative leukocyte esterase
C. Greiss reaction nitrite test is an indication of a:
D. Peroxidase reaction A. Dilute random specimen④ it
36. An elevated urine bilirubin with a normal urobilinogen B. Specimen with lysed leukocytes⑦LE
is indicative of: C. Vaginal yeast infection④LE
A. Cirrhosis of the liver D. Specimen older than 2 hours nitrate → nitrite →nitrogen
B. Hemolytic disease nitrite is now converted to nitrogen causing
44. All of the following can be detected by the leukocyte false -0
C. Hepatitis
D. Biliary obstruction
0
esterase reaction except:
A. Neutrophils
All leukocytes Granular )S
B. Eosinophils
C. Lymphocytes monocytes (except lymphocytes )
D. Basophils
 Chapter 6 | Chemical Examination of Urine 165
→ alkaline urine
45. Screening tests for urinary infection combine the 48. A specific gravity of 1.005 would produce the reagent
leukocyte esterase test with the test for: strip color:
A. pH A. Blue
B. Nitrite B. Green
C. Protein C. Yellow
D. Blood D. Red
46. The principle of the leukocyte esterase reagent strip test 49. Specific gravity readings on a reagent strip are affected by:
uses a: A. Glucose
A. Peroxidase reaction B. Radiographic dye
B. Double indicator reaction C. Alkaline urine
C. Diazo reaction D. All of the above
D. Dye-binding technique
47. The principle of the reagent strip test for specific gravity
uses the dissociation constant of a(n):
A. Diazonium salt
B. Indicator dye
C. Polyelectrolyte
D. Enzyme substrate

Case Studies and Clinical Situations

1. A patient taken to the emergency department after an pH: 6.0 UROBILINOGEN: Normal
episode of syncope has a fasting blood glucose level of PROTEIN: Negative NITRITE: Negative
450 mg/dL. Results of the routine urinalysis are as
GLUCOSE: Negative LEUKOCYTES: Negative
follows:
a. What would be observed if this specimen were shaken?
COLOR: Yellow KETONES: 2+
b. Explain the correlation between the patient’s sched-
CLARITY: Clear BLOOD: Negative
uled surgery and the normal urobilinogen.
SP. GRAVITY: 1.015 BILIRUBIN: Negative
c. If blood were drawn from this patient, how might the
pH: 5.0 PROTEIN-LOW: 15 mg/dL appearance of the serum be described?
PROTEIN-HIGH: 30 mg/dL NITRITE: Negative d. What special handling is needed for specimens of
GLUCOSE: 250 mg/dL LEUKOCYTES: Negative serum and urine from this patient?
CREATININE: 200 mg/dL 3. Results of a urinalysis on a patient who is very anemic
a. Explain the correlation between the patient’s blood and jaundiced are as follows:
and urine glucose results. COLOR: Red KETONES: Negative
b. What is the most probable metabolic disorder CLARITY: Clear BLOOD: Large
associated with this patient?
SP. GRAVITY: 1.020 BILIRUBIN: Negative
c. Considering the patient’s condition, what is the
pH: 6.0 UROBILINOGEN: 8 EU
significance of the reading of the patient’s protein-to-
creatinine ratio? PROTEIN: Negative NITRITE: Negative
d. If the patient in this study had a normal blood glucose GLUCOSE: Negative LEUKOCYTES: Negative
level, as well as normal results for protein and creati- a. Would these results be indicative of hematuria or
nine, to what would the urinary glucose level be hemoglobinuria?
attributed? b. Correlate the patient’s condition with the urobilinogen
2. Results of a urinalysis performed on a patient scheduled result.
for gallbladder surgery are as follows: c. Why is the urine bilirubin result negative in this jaun-
COLOR: Amber KETONES: Negative diced patient?
CLARITY: Hazy BLOOD: Negative d. Would this method also measure urine porphobilino-
gen? Why or why not?
SP. GRAVITY: 1.022 BILIRUBIN: Moderate
 CHAPTER 7
Microscopic Examination
of Urine
LEARNING OUTCOMES
Upon completing this chapter, the reader will be able to:
7-1 List the physical and chemical parameters included 7-9 Discuss the significance of white blood cells (WBCs) in
in macroscopic urine screening, and state their urine sediment.
significance.
7-10 Name, describe, and give the origin and significance
7-2 Discuss the advantages of commercial systems over of the three types of epithelial cells found in urine
the glass-slide method for sediment examination. sediment.
7-3 Describe the recommended methods for standardizing 7-11 Discuss the significance of oval fat bodies.
specimen preparation and volume; centrifugation;
7-12 Describe the process of cast formation.
sediment preparation, volume, and examination;
and reporting results. 7-13 Describe and discuss the significance of hyaline, RBC,
WBC, bacterial, epithelial cell, granular, waxy, fatty,
7-4 State the purpose of Sternheimer-Malbin, acetic acid,
and broad casts.
toluidine blue, Sudan III, Gram, Hansel, and Prussian
blue stains. 7-14 List and identify the normal crystals found in acidic
urine.
7-5 Identify specimens that should be referred for
cytodiagnostic testing. 7-15 List and identify the normal crystals found in alkaline
urine.
7-6 Describe the basic principles of bright-field, phase-
contrast, polarizing, dark-field, fluorescence, and inter- 7-16 Describe and state the significance of cystine, cholesterol,
ference-contrast microscopy and their relationship to leucine, tyrosine, bilirubin, sulfonamide, radiographic
sediment examination. dye, and ampicillin crystals.
7-7 Differentiate between normal and abnormal sediment 7-17 Differentiate between actual sediment constituents and
constituents. artifacts.
7-8 Discuss the significance of red blood cells (RBCs) in 7-18 Correlate physical and chemical urinalysis results with
urine sediment. microscopic observations and recognize discrepancies.

KEY TERMS
Birefringent Fluorescence microscopy Polarizing microscopy
Bright-field microscopy Interference-contrast microscopy Pyuria
Casts Köhler illumination Resolution
Clue cell Lipiduria Syncytia
Cylindruria Maltese cross formation Uromodulin
Dark-field microscopy Oval fat bodies
Dysmorphic Phase-contrast microscopy
212 Part Two | Urinalysis

7. McPherson, RA, Ben-Ezra, J, Zhao S.: Basic examination of 16. Schumann, GB: Utility of urinary cytology in renal diseases.
urine. Henry’s Clinical Diagnosis and Management by Labora- Semin Nephrol 5(34) Sept, 1985.
tory Methods. Eds. McPherson, RA, Pincus, MR. 22nd Ed. 17. Graber, M, et al: Bubble cells: Renal tubular cells in the urinary
Philadelphia: Elsevier Saunders, 2011, p.465. sediment with characteristics of viability. J Am Soc Nephrol
8. Olympus Microscopy Resource Center: Specialized Microscopy 1(7):999–1004, 1991.
Techniques: Fluorescence. Web site: [Link] 18. Baer, DM: Tips from clinical experts: Reporting of spermatozoa
com/primer/techniques/fluorescence/[Link]. Accessed in microscopic urine exams. MLO 12:12, 1997.
May 10, 2019. 19. Bleyer, AJ, and Stanislav, K: Tamm Horsfall Glycoprotein and
9. Simpson, LO: Effects of normal and abnormal urine on red cell Uromodulin: It is All about the Tubules! Clin J Am Soc Nephrol.
shape. Nephron 60(3):383–384, 1992. 2016 Jan 7; 11(1): 6-8. Doi: 10.2215/CJN.12201115. Web site:
10. Stapleton, FB: Morphology of urinary red blood cells: A simple [Link]
guide in localizing the site of hematuria. Pediatr Clin North Am Accessed May 11, 2019.
34(3):561–569, 1987. 20. Kumar, S, and Muchmore, A: Tamm-Horsfall protein—
11. Fassett, EG, et al: Urinary red cell morphology during exercise. Uromodulin, 1950–1990. Kidney Int 37:1395–1399, 1990.
Am J Clin Pathol 285(6353):1455–1457, 1982. 21. Haber, MH: Urinary Sediment: A textbook Atlas. American
12. Kohler, H, Wandel, E, and Brunch, B: Acanthocyturia: A Society of Clinical Pathologists, Chicago, 1981.
characteristic marker for glomerular bleeding. Int Soc Nephrol 22. Lindner, LE, and Haber, MH: Hyaline casts in the urine:
40:115–120, 1991. Mechanism of formation and morphological transformations.
13. Tomita, M, et al: A new morphological classification of urinary Am J Clin Pathol 80(3):347–352, 1983.
erythrocytes for differential diagnosis of hematuria. Clin 23. Lindner, LE, Jones, RN, and Haber, MH: A specific cast in acute
Nephrol 37(2):84–89, 1992. pyelonephritis. Am J Clin Pathol 73(6):809–811, 1980.
14. Haber, MH, Lindner, LE, and Ciofalo, LN: Urinary casts after 24. Haber, MH, and Lindner, LE: The surface ultrastructure of
stress. Lab Med 10(6):351–355, 1979. urinary casts. Am J Clin Pathol 68(5):547–552, 1977.
15. Corwin, HL, Bray, RA, and Haber, MH: The detection and 25. Linder, LE, Vacca, D, and Haber, MF: Identification and
interpretation of urinary eosinophils. Arch Pathol Lab Med composition of types of granular urinary cast. Am J Pathol
113:1256–1258, 1989. 80(3):353–358, 1983.

Study Questions
1. Macroscopic screening of urine specimens is used to: 5. When using the glass-slide and cover-slip method,
A. Provide results as soon as possible which of the following might be missed if the cover slip
is overflowed?
B. Predict the type of urinary casts present
A. Casts
C. Increase cost-effectiveness of urinalysis
B. RBCs
D. Decrease the need for polarized microscopy
C. WBCs
2. Variations in the microscopic analysis of urine include all
D. Bacteria
of the following except:
A. Preparation of the urine sediment 6. Initial screening of the urine sediment is performed using
an objective power of:
B. Amount of sediment analyzed
A. 4×
C. Method of reporting
B. 10×
D. Identification of formed elements
C. 40×
3. All of the following can cause false-negative microscopic
D. 100×
results except:
A. Braking the centrifuge 7. Which of the following should be used to reduce light
intensity in bright-field microscopy?
B. Failing to mix the specimen
A. Centering screws
C. Diluting alkaline urine
B. Aperture diaphragm
D. Using midstream clean-catch specimens
C. Rheostat
4. The two factors that determine relative centrifugal force
D. Condenser aperture diaphragm
are:
A. Radius of rotor head and RPM 8. Which of the following are reported as number per lpf?
B. Radius of rotor head and time of centrifugation A. RBCs
C. Diameter of rotor head and RPM B. WBCs
D. RPM and time of centrifugation C. Crystals
D. Casts
 Chapter 7 | Microscopic Examination of Urine 213

9. The Sternheimer-Malbin stain is added to urine 17. Leukocytes that stain pale blue with Sternheimer-Malbin
sediments to do all of the following except: stain and exhibit brownian movement are:
A. Increase visibility of sediment constituents A. Indicative of pyelonephritis
B. Change the constituents’ refractive index B. Basophils
C. Decrease precipitation of crystals C. Mononuclear leukocytes
D. Delineate constituent structures D. Glitter cells
10. Nuclear detail can be enhanced by: 18. Sometimes mononuclear leukocytes are mistaken for:
A. Prussian blue A. Yeast cells
B. Toluidine blue B. Squamous epithelial cells
C. Acetic acid C. Pollen grains
D. Both B and C D. Renal tubular cells
11. Which of the following lipids is/are stained by Sudan III? 19. When pyuria is detected in a urine sediment, the slide
A. Cholesterol should be checked carefully for the presence of:
B. Neutral fats A. RBCs
C. Triglycerides B. Bacteria
D. Both B and C C. Hyaline casts
D. Mucus
12. Which of the following lipids is/are capable of polarizing
light? 20. Transitional epithelial cells are sloughed from the:
A. Cholesterol A. Collecting duct
B. Neutral fats B. Vagina
C. Triglycerides C. Bladder
D. Both A and B D. Proximal convoluted tubule
13. The purpose of the Hansel stain is to identify: 21. The largest cells in the urine sediment are:
A. Neutrophils A. Squamous epithelial cells
B. Renal tubular cells B. Urothelial epithelial cells
C. Eosinophils C. Cuboidal epithelial cells
D. Monocytes D. Columnar epithelial cells
14. Crenated RBCs are seen in urine that is: 22. A squamous epithelial cell that is clinically significant
A. Hyposthenuric is the:
B. Hypersthenuric A. Cuboidal cell
C. Highly acidic B. Clue cell
D. Highly alkaline C. Caudate cell
D. Columnar cell
15. Differentiation among RBCs, yeast, and oil droplets may
be accomplished by all of the following except: 23. Forms of transitional epithelial cells include all of the
A. Observation of budding in yeast cells following except:
B. Increased refractility of oil droplets A. Spherical
C. Lysis of yeast cells by acetic acid B. Caudate
D. Lysis of RBCs by acetic acid C. Convoluted
D. Polyhedral
16. A finding of dysmorphic RBCs is indicative of:
A. Glomerular bleeding 24. Increased transitional cells are indicative of:
B. Renal calculi A. Catheterization
C. Traumatic injury B. Malignancy
D. Coagulation disorders C. Pyelonephritis
D. Both A and B
214 Part Two | Urinalysis

25. A primary characteristic used to identify renal tubular 33. A person submitting a urine specimen after a strenuous
epithelial cells is: exercise routine normally can have all of the following in
A. Elongated structure the sediment except:
B. Centrally located nucleus A. Hyaline casts
C. Spherical appearance B. Granular casts
D. Eccentrically located nucleus C. RBC casts
D. WBC casts
26. After an episode of hemoglobinuria, RTE cells may
contain: 34. Before identifying an RBC cast, all of the following
A. Bilirubin should be observed:
B. Hemosiderin granules A. Free-floating RBCs
C. Porphobilinogen B. Intact RBCs in the cast matrix
D. Myoglobin C. A positive reagent strip blood reaction
D. All of the above
27. The predecessor of the oval fat body is the:
A. Histiocyte 35. WBC casts are associated primarily with:
B. Urothelial cell A. Pyelonephritis
C. Monocyte B. Cystitis
D. Renal tubular cell C. Glomerulonephritis
D. Viral infections
28. A structure believed to be an oval fat body produced a
Maltese cross formation under polarized light but does 36. The shape of the RTE cell associated with RTE casts is
not stain with Sudan III. The structure: primarily:
A. Contains cholesterol A. Elongated
B. Is not an oval fat body B. Cuboidal
C. Contains neutral fats C. Round
D. Is contaminated with immersion oil D. Columnar
29. The finding of yeast cells in the urine is commonly 37. When observing RTE casts, the cells are primarily:
associated with: A. Embedded in a clear matrix
A. Cystitis B. Embedded in a granular matrix
B. Diabetes mellitus C. Attached to the surface of a matrix
C. Pyelonephritis D. Stained by components of the urine filtrate
D. Liver disorders
38. The presence of fatty casts is associated with:
30. The primary component of urinary mucus is: A. Nephrotic syndrome
A. Bence Jones protein B. Crush injuries
B. Microalbumin C. Diabetes mellitus
C. Uromodulin D. All of the above
D. Orthostatic protein
39. Nonpathogenic granular casts contain:
31. The majority of casts are formed in the: A. Cellular lysosomes
A. Proximal convoluted tubules B. Degenerated cells
B. Ascending loop of Henle C. Protein aggregates
C. Distal convoluted tubules D. Gram-positive cocci
D. Collecting ducts
40. All of the following are true about waxy casts except they:
32. Cylindruria refers to the presence of: A. Represent extreme urine stasis
A. Cylindrical renal tubular cells B. May have a brittle consistency
B. Mucus-resembling casts C. Require staining to be visualized
C. Hyaline and waxy casts D. Contain degenerated granules
D. All types of casts
 Chapter 7 | Microscopic Examination of Urine 215

41. Observation of broad casts represents: 48. Match the following crystals seen in alkaline urine with
A. Destruction of tubular walls their description/identifying characteristics:
B. Dehydration and high fever Triple phosphate 1. Yellow granules
C. Formation in the collecting ducts Amorphous phosphate 2. Thin prisms
D. Both A and C Calcium phosphate 3. “Coffin lids”
Ammonium biurate 4. Dumbbell shape
42. All of the following contribute to urinary crystals
formation except: Calcium carbonate 5. White precipitate
A. Protein concentration 6. Thorny apple
B. pH 49. Match the following abnormal crystals with their
C. Solute concentration description/identifying characteristics:
D. Temperature Cystine 1. Bundles after
refrigeration
43. The most valuable initial aid for identifying crystals in a
Tyrosine 2. Highly alkaline pH
urine specimen is:
Cholesterol 3. Bright yellow clumps
A. pH
Leucine 4. Hexagonal plates
B. Solubility
Ampicillin 5. Flat plates, high spe-
C. Staining
cific gravity
D. Polarized microscopy
Radiographic dye 6. Concentric circles,
44. Crystals associated with severe liver disease include all radial striations
of the following except: Bilirubin 7. Notched corners
A. Bilirubin 8. Fine needles seen in
B. Leucine liver disease
C. Cystine 50. Match the following types of microscopy with their
D. Tyrosine descriptions:
45. All of the following crystals routinely polarize except: Bright-field 1. Indirect light is reflected off
the object
A. Uric acid
Phase 2. Objects split light into two
B. Cholesterol
beams
C. Radiographic dye
Polarized 3. Low-refractive-index ob-
D. Cystine jects may be overlooked
46. Casts and fibers usually can be differentiated using: Dark-field 4. Three-dimensional images
A. Solubility characteristics Fluorescent 5. Forms halo of light around
B. Patient history object
C. Polarized light Interference 6. Detects electrons emitted
contrast from objects
D. Fluorescent light
7. Detects specific wave-
47. Match the following crystals seen in acidic urine with lengths of light emitted
their description/identifying characteristics: from objects
Amorphous urates 1. Envelopes
Uric acid 2. Thin needles
Calcium oxalate 3. Yellow-brown,
monohydrate whetstone
Calcium oxalate 4. Pink sediment
dihydrate 5. Ovoid
216 Part Two | Urinalysis

Case Studies and Clinical Situations

1. An 85-year-old woman with diabetes and a broken hip decreased renal concentrating ability. Urinalysis results are
has been confined to bed for the past 3 months. Results as follows:
of an ancillary blood glucose test are 250 mg/dL, and COLOR: Amber KETONES: Negative
her physician orders additional blood tests and a routine
CLARITY: Hazy BLOOD: Negative
urinalysis. The urinalysis report is as follows:
SP. GRAVITY: 1.010 BILIRUBIN: Large
COLOR: Pale yellow KETONES: Negative
pH: 7.0 UROBILINOGEN: 4.0 EU
CLARITY: Hazy BLOOD: Moderate
PROTEIN: 2+ NITRITE: Negative
SP. GRAVITY: 1.020 BILIRUBIN: Negative
GLUCOSE: Negative LEUKOCYTES: Negative
pH: 5.5 UROBILINOGEN: Normal
Microscopic:
PROTEIN: Trace NITRITE: Negative
2 to 4 WBCs/hpf 1 to 2 hyaline casts/lpf
GLUCOSE: 100 mg/dL LEUKOCYTES: 2+
1 to 3 RBCs/hpf 1 to 2 granular casts/lpf
Microscopic:
2 to 4 bile-stained RTE
20 to 25 WBCs/hpf
cells/hpf
Many yeast cells and hyphae
0 to 1 RTE casts/lpf
a. Why are yeast infections common in patients with dia-
0 to 1 bile-stained waxy
betes mellitus?
casts/lpf
b. With a blood glucose level of 250 mg/dL, should glu-
a. Based on the urinalysis results, in what area of the
cose be present in the urine? Why or why not?
nephron is damage occurring?
c. Is there a discrepancy between the negative nitrite and
b. Is this consistent with the patient’s primary diagnosis?
the positive leukocyte esterase results? Explain your
Explain your answer.
answer.
c. What is causing the RTE cells to be bile stained?
d. What is the major discrepancy between the chemical
and microscopic results? d. Why is the urobilinogen level elevated?
e. Considering the patient’s history, what is the most e. State a disorder in which the urobilinogen level would
probable cause for the discrepancy? be elevated but the bilirubin result would be negative.

2. A medical laboratory science student training in a newly 4. A 30-year-old woman being treated for a UTI brings a
renovated STAT laboratory is having difficulty performing urine specimen to the employee health clinic at 4:00 p.m.
a microscopic urinalysis. Reagent strip testing indicates The nurse on duty tells her that the specimen will be re-
the presence of moderate blood and leukocytes, but also frigerated and tested by the medical laboratory scientist
the student is observing some large unusual objects re- (MLS) the next morning. The MLS has difficulty inter-
sembling crystals and possible casts. In addition, the stu- preting the color of the reagent strip tests and reports
dent is having difficulty keeping all of the constituents in only the following results:
focus at the same time. COLOR: Amber CLARITY: Slightly cloudy
a. Why is the student having difficulty focusing? Microscopic:
b. What is a possible cause of the unusual microscopic 3 to 5 RBCs/hpf
constituents? 8 to 10 WBCs/hpf
c. Should the student be concerned about the unusual Moderate bacteria
microscopic constituents? Explain your answer.
Moderate colorless crystals appearing in bundles
d. What microscopy technique could be used to aid in
a. What could have caused the technologist to have diffi-
differentiating a cast and an artifact?
culty interpreting the results on the reagent strip?
3. A prisoner sentenced to 10 years for selling illegal drugs b. Could this specimen produce a yellow foam when
develops jaundice, lethargy, and hepatomegaly. A test for shaken?
hepatitis B surface antigen is positive, and the patient is
c. What could the technologist do to aid in the identifi-
placed in the prison infirmary. When his condition ap-
cation of the crystals?
pears to worsen and a low urinary output is observed, the
patient is transferred to a local hospital. Additional testing d. What is the probable identification of the colorless
detects a superinfection with delta hepatitis virus and crystals?
 Chapter 7 | Microscopic Examination of Urine 217

5. A 2-year-old left unattended in the garage for 5 minutes is SP. GRAVITY: 1.030 BILIRUBIN: Negative
suspected of ingesting antifreeze (ethylene glycol). The pH: 5.5 UROBILINOGEN: Normal
urinalysis has a pH of 6.0 and is negative on the chemical
PROTEIN: 2+ NITRITE: Negative
examination. Two distinct forms of crystals are observed
in the microscopic examination. GLUCOSE: Negative LEUKOCYTE: Negative
a. What type of crystals would you expect to be present? Microscopic:
b. What is the other form of this crystal? 0 to 3 WBCs/hpf
c. Describe the two forms. 0 to 4 hyaline casts/lpf
d. Which form would you expect to be predominant? 0 to 3 granular casts/lpf
Few squamous epithelial cells
6. A female patient comes to the outpatient clinic with
symptoms of UTI. She brings a urine specimen with her. a. Are these results of clinical significance?
Results of the routine analysis performed on this speci- b. Explain the discrepancy between the chemical and
men are as follows: microscopic blood results.
COLOR: Yellow KETONES: Negative c. What is the probable cause of the granular casts?
CLARITY: Hazy BLOOD: Small 8. As supervisor of the urinalysis section, you are reviewing
SP. GRAVITY: 1.015 BILIRUBIN: Negative results. State why or why not each of the following results
pH: 9.0 UROBILINOGEN: Normal would concern you.
PROTEIN: Negative NITRITE: Negative a. The presence of waxy casts and a negative protein in
urine from a 6-month-old girl
GLUCOSE: Negative LEUKOCYTE: 2+
b. Increased transitional epithelial cells in a specimen
Microscopic:
obtained after cystoscopy
1 to 3 RBCs/hpf Heavy bacteria
c. Tyrosine crystals in a specimen with a negative
8 to 10 WBCs/hpf Moderate squamous bilirubin test result
epithelial cells
d. Cystine crystals in a specimen from a patient
a. What discrepancies are present between the chemical diagnosed with gout
and microscopic test results?
e. Cholesterol crystals in urine with a specific gravity
b. State a reason for the discrepancies. greater than 1.040
c. Identify a chemical result in the urinalysis that con- f. Trichomonas vaginalis in a urine specimen from a male
firms your reason for the discrepancies. patient
d. What course of action should the laboratory take to g. Amorphous urates and calcium carbonate crystals in a
obtain accurate results for this patient? specimen with a pH of 7.0
7. A high school student is taken to the emergency room
with a broken leg that occurred during a football game.
The urinalysis results are as follows:
COLOR: Dark yellow KETONES: Negative
CLARITY: Hazy BLOOD: Moderate
 CHAPTER 8
Renal Disease
LEARNING OUTCOMES
Upon completing this chapter, the reader will be able to:
8-1 Differentiate among renal diseases of varying 8-9 Compare and contrast nephrotic syndrome and mini-
origins, including glomerular, tubular, interstitial, mal change disease with regard to laboratory results
and vascular. and the course of the disease.
8-2 Describe the processes by which immunologic damage 8-10 State two causes of acute tubular necrosis.
is caused to the glomerular basement membrane.
8-11 Name the constituent of urinary sediment that is most
8-3 Describe the clinical features of glomerulonephritis. indicative of renal tubular damage.
8-4 Describe the characteristic clinical symptoms, etiology, 8-12 Describe Fanconi syndrome, Alport syndrome,
and urinalysis findings in acute poststreptococcal and uromodulin-associated renal disease, and renal
rapidly progressive glomerulonephritis, Goodpasture glucosuria.
syndrome, granulomatosis with polyangiitis, and
8-13 Differentiate between diabetic nephropathy and
Henoch-Schönlein purpura.
nephrogenic diabetes insipidus.
8-5 Name three renal disorders that also involve acute
8-14 Compare and contrast the urinalysis results in patients
respiratory symptoms.
with cystitis, pyelonephritis, and acute interstitial
8-6 Differentiate between membranous and membranopro- nephritis.
liferative glomerulonephritis.
8-15 Differentiate among causes of laboratory results associ-
8-7 Discuss the clinical course and significant laboratory ated with acute renal failure at each stage: prerenal,
results associated with immunoglobulin A nephropathy. renal, and postrenal.
8-8 Relate laboratory results associated with nephrotic 8-16 Discuss the formation of renal calculi, composition of
syndrome to the disease process. renal calculi, and patient management techniques.

KEY TERMS
Acute glomerulonephritis (AGN) Glomerulonephritis Membranoproliferative
Acute interstitial nephritis (AIN) Goodpasture syndrome glomerulonephritis (MPGN)
Acute tubular necrosis (ATN) Granulomatosis with polyangiitis Minimal change disease (MCD)
Antiglomerular basement (GPA) Nephrotic syndrome (NS)
membrane antibody Henoch-Schönlein purpura Pyelonephritis
Antineutrophilic cytoplasmic IgA nephropathy Rapidly progressive (or crescentic)
antibody (ANCA) Lithiasis glomerulonephritis (RPGN)
Chronic glomerulonephritis (CGN) Lithotripsy Systemic lupus erythematosus (SLE)
Cystitis Membranous glomerulonephritis Tubulointerstitial disease
Focal segmental glomerulosclerosis (MGN) Uromodulin-associated kidney
(FSGS) disease
230 Part Two | Urinalysis

in conjunction with hereditary disorders of cystine metabo- StatPerarls (Internet). Web site: [Link]
lism (see Chapter 9). Patient management techniques include books/NBK499865/. Published February 15, 2019. Accessed
May 19, 2019.
maintaining the urine at a pH incompatible with crystalliza-
7. Wasserstein, AG: Membranous glomerulonephritis. In
tion of the particular chemicals, maintaining adequate hydra- Jacobson, HR, et al: Principles and Practice of Nephrology.
tion to lower chemical concentration, and suggesting possible BC Decker, Philadelphia, 1991.
dietary restrictions. 8. Kathuria, P: Membranoproliferative Glomerulonephritis.
Urine specimens from patients suspected of passing or Medscape. Web site: [Link]
article/240056-overview. Published June 23, 2016. Accessed
being in the process of passing renal calculi are received in the
May 19, 2019.
laboratory frequently. The presence of microscopic hematuria 9. Donadio, JV: Membranoproliferative glomerulonephritis. In
resulting from irritation to the tissues by the moving calculus Jacobson, HR, et al: Principles and Practice of Nephrology.
is the primary urinalysis finding. BC Decker, Philadelphia, 1991.
10. Bricker, NS, and Kirschenbaum, MA: The Kidney: Diagnosis
and Management. John Wiley, New York, 1984
11. Mansur, A: Minimal-Change Disease. Medscape. Web site:
For additional resources please visit [Link]
[Link] Published December 24, 2018. Accessed May 19, 2019.
12. Sherbotle, JR, and Hayes, JR: Idiopathic nephrotic syndrome:
Minimal change disease and focal segmental glomerulosclerosis.
In Jacobson, HR, et al: Principles and Practice of Nephrology.
References BC Decker, Philadelphia, 1991.
1. Forland, M (ed): Nephrology. Medical Examination Publishing, 13. Rao, STK: Focal Segmental Glomerulosclerosis. Medscape.
New York, 1983. Web site: [Link]
2. Couser, WG: Rapidly progressive glomerulonephritis. In overview#a5. Published October 2, 2018. Accessed May 19,
Jacobson, HR, et al: Principles and Practice of Nephrology. 2019.
BC Decker, Philadelphia, 1991. 14. Bleyer, AJ, Zivna, M, and Kmoch, S: Uromodulin-associated
3. Tracy, CL: Granulomatosis with Polyangiitis (Wegener Granulo- kidney disease. Nephron Clin Prac 118(1):c31–c36, 2011.
matosis). Medscape. Web site: [Link] 15. Finnigan, NA, Bashir, K: Allergic Interstitial Nephritis (AIN).
article/332622-overview. Published January 4, 2019. Accessed National Center for Biotechnology Information (NCBI). Stat-
May 19, 2019. Pearls [Internet]. Bookshelf ID: 4882323 PMID: 29493948.
4. Kallenberg, CG, Mulder, AH, and Tervaert, JW: Antineutrophil Web site: [Link]
cytoplasmic autoantibodies: A still-growing class of autoantibod- Accessed May 20, 2019.
ies in inflammatory disorders. Am J Med 93(6):675–682, 1992. 16. Bennett, WM, Elzinga, LW, and Porter, GA: Tubulointerstitial
5. Frasier, LL, and Hoag, KA: Differential diagnosis of Wegener’s disease and toxic nephropathy. In Brenner, BM, and Rector, FC:
granulomatosis from other small vessel vasculitides. LabMed The Kidney: Physiology and Pathophysiology. WB Saunders,
38(7):437–439, 2007. Philadelphia, 1991.
6. Raza, A, and Aggarwal, S: Membranous Glomerulonephritis. 17. Hallson, PC, and Rose, GA: Seasonal variations in urinary
National Center for Biotechnology Information. NCBI Resources. crystals. Br J Urol 49(4):277–284, 1977.

Study Questions
1. Most glomerular disorders are caused by: 3. Occasional episodes of macroscopic hematuria over peri-
A. Sudden drops in blood pressure ods of 20 or more years are seen in patients with:
B. Immunologic disorders A. Crescentic glomerulonephritis
C. Exposure to toxic substances B. IgA nephropathy
D. Bacterial infections C. Nephrotic syndrome
D. GPA
2. Dysmorphic RBC casts would be a significant finding
with all of the following except: 4. Antiglomerular basement membrane antibody is seen
A. Goodpasture syndrome with:
B. AGN A. GPA
C. Chronic pyelonephritis B. IgA nephropathy
D. Henoch-Schönlein purpura C. Goodpasture syndrome
D. Diabetic nephropathy
 Chapter 8 | Renal Disease 231

5. ANCA is diagnostic for: 13. The only protein produced by the kidney is:
A. IgA nephropathy A. Albumin
B. GPA B. Uromodulin
C. Henoch-Schönlein purpura C. Uroprotein
D. Goodpasture syndrome D. Globulin
6. Respiratory and renal symptoms are associated with all 14. The presence of RTE cells and casts is an indication of:
of the following except: A. AIN
A. IgA nephropathy B. CGN
B. GPA C. MCD
C. Henoch-Schönlein purpura D. ATN
D. Goodpasture syndrome
15. Differentiation between cystitis and pyelonephritis is
7. The presence of fatty casts is associated with all of the aided by the presence of:
following except: A. WBC casts
A. Nephrotic syndrome B. RBC casts
B. FSGS C. Bacteria
C. Nephrogenic DI D. Granular casts
D. MCD
16. The presence of WBCs and WBC casts with no bacteria
8. The highest levels of proteinuria are seen with: is indicative of:
A. Alport syndrome A. Chronic pyelonephritis
B. Diabetic nephropathy B. ATN
C. IgA nephropathy C. AIN
D. NS D. Both B and C
9. Ischemia frequently produces: 17. ESRD is characterized by all of the following except:
A. Acute renal tubular necrosis A. Hypersthenuria
B. MCD B. Isosthenuria
C. Renal glycosuria C. Azotemia
D. Goodpasture syndrome D. Electrolyte imbalance
10. A disorder associated with polyuria and low specific 18. Prerenal acute renal failure could be caused by:
gravity is: A. Massive hemorrhage
A. Renal glucosuria B. ATN
B. MCD C. AIN
C. Nephrogenic DI D. Malignant tumors
D. FSGS
19. The most common component of renal calculi is:
11. An inherited disorder producing a generalized defect in A. Calcium oxalate
tubular reabsorption is:
B. Magnesium ammonium phosphate
A. Alport syndrome
C. Cystine
B. AIN
D. Uric acid
C. Fanconi syndrome
20. Urinalysis on a patient with severe back pain being
D. Renal glycosuria
evaluated for renal calculi would be most beneficial if it
12. A teenage boy who develops gout in his big toe and has showed:
a high serum uric acid should be monitored for: A. Heavy proteinuria
A. Fanconi syndrome B. Low specific gravity
B. Renal calculi C. Uric acid crystals
C. Uromodulin-associated kidney disease D. Microscopic hematuria
D. Chronic interstitial nephritis
232 Part Two | Urinalysis

Case Studies and Clinical Situations

1. A 14-year-old boy who has recently recovered from a sore Microscopic:
throat develops edema and hematuria. Significant labora- >100 RBCs/hpf 2–4 hyaline casts/lpf
tory results include a BUN of 30 mg/dL (normal 8 to
8–10 WBCs/hpf 1–5 granular casts/lpf
23 mg/dL) and a positive group A streptococcal antibody
test. Results of a urinalysis are as follows: 0–2 waxy casts/lpf 0–2 broad waxy
Color: Red Ketones: Negative a. What specific disease do the patient’s laboratory
results and history suggest?
Clarity: Cloudy Blood: Large
b. Which laboratory result is most helpful in diagnosing
Sp. gravity: 1.020 Bilirubin: Negative
this disease?
pH: 5.0 Urobilinogen: Normal
c. What additional diagnosis does his current condition
Protein: 3+ Nitrite: Negative suggest?
Glucose: Negative Leukocyte: Trace d. What is the significance of the positive result for urine
Microscopic: glucose?
100 RBCs/hpf—many dysmorphic forms e. Is the specific gravity significant? Why or why not?
5–8 WBCs/hpf f. What is the significance of the waxy casts?
0–2 granular casts/lpf 3. A 45-year-old woman is recovering from injuries received
0–1 RBC casts/lpf in an automobile accident that resulted in her being taken
a. What disorder do these results and history indicate? to the emergency department with severe hypotension.
She develops massive edema. Significant laboratory re-
b. What specific characteristic was present in the
sults include a BUN of 30 mg/dL (normal 8 to 23 mg/dL),
organism causing the sore throat?
cholesterol of 400 mg/dL (normal 150 to 240 mg/dL),
c. What is the significance of the dysmorphic RBCs? triglycerides of 840 mg/dL (normal 10 to 190 mg/dL),
d. Are the WBCs significant? Why or why not? serum protein of 4.5 mg/dL (normal 6.0 to 7.8 mg/dL),
e. What is the expected prognosis of this patient? albumin of 2.0 mg/dL (normal 3.2 to 4.5 mg/dL), and a
total urine protein of 3.8 g/d (normal 100 mg/d). Urinaly-
f. If these urinalysis results were seen in a 5-year-old boy
sis results are as follows:
who has developed a red, patchy rash after recovery
from a respiratory infection, what disorder would you Color: Yellow Ketones: Negative
suspect? Clarity: Cloudy Blood: Moderate
2. A seriously ill 40-year-old man has a history of several Sp. gravity: 1.015 Bilirubin: Negative
episodes of macroscopic hematuria in the past 20 years. pH: 6.0 Urobilinogen: Normal
The episodes were associated with exercise or stress. Protein: 4+ Nitrite: Negative
Until recently, the macroscopic hematuria had reverted
Glucose: Negative Leukocyte: Negative
spontaneously to asymptomatic microscopic hematuria.
Significant laboratory results include a BUN of 80 mg/dL Microscopic:
(normal 8 to 23 mg/dL), serum creatinine of 4.5 mg/dL 15–20 RBCs/hpf Moderate free fat droplets
(normal 0.6 to 1.2 mg/dL), creatinine clearance of 0–5 WBCs/hpf Moderate cholesterol
20 mL/min (normal 107 to 139 mL/min), serum calcium crystals
0–2 granular casts/lpf
of 8.0 mg/dL (normal 9.2 to 11.0 mg/dL), serum phos-
phorus of 6.0 mg/dL (normal 2.3 to 4.7 mg/dL), and an 0–2 fatty casts/lpf
elevated level of serum IgA. Results of a routine urinalysis 0–2 oval fat bodies/hpf
are as follows: a. What renal disorder do these results suggest?
Color: Red Ketones: Negative b. How does the patient’s history relate to this disorder?
Clarity: Slightly cloudy Blood: Large c. What physiological mechanism accounts for the
Sp. gravity: 1.010 Bilirubin: Negative massive proteinuria?
pH: 6.5 Urobilinogen: Normal d. What is the relationship of the proteinuria to the edema?
Protein: 300 mg/dL Nitrite: Negative e. What mechanism produces the oval fat bodies?
Glucose: 250 mg/dL Leukocyte: Trace
 Chapter 8 | Renal Disease 233

4. A routinely active 4-year-old boy becomes increasingly 6. A 25-year-old pregnant woman comes to the outpatient
less active after receiving several preschool immuniza- clinic with symptoms of lower back pain, urinary frequency,
tions. His pediatrician observes noticeable puffiness and a burning sensation when voiding. Her pregnancy has
around the eyes. A blood test shows normal BUN and cre- been normal up to this time. She is given a sterile container
atinine results and markedly decreased total protein and and asked to collect a midstream clean-catch urine speci-
albumin values. Urinalysis results are as follows: men. Routine urinalysis results are as follows:
Color: Yellow Ketones: Negative Color: Pale yellow Ketones: Negative
Clarity: Hazy Blood: Small Clarity: Hazy Blood: Small
Sp. gravity: 1.020 Bilirubin: Negative Sp. gravity: 1.005 Bilirubin: Negative
pH: 6.5 Urobilinogen: Normal pH: 8.0 Urobilinogen: Normal
Protein: 4+ Nitrite: Negative Protein: Trace Nitrite: Positive
Glucose: Negative Leukocyte: Negative Glucose: Negative Leukocyte: 2+
Microscopic: Microscopic:
10–15 RBCs/hpf 0–1 hyaline casts/lpf 6–10 RBCs/hpf Heavy bacteria
0–4 WBCs/hpf 0–2 granular casts/lpf 40–50 WBCs/hpf Moderate squamous
Moderate fat droplets 0–1 oval fat bodies/hpf epithelial cells
a. What disorder do the patient history, physical a. What is the most probable diagnosis for this patient?
appearance, and laboratory results suggest? b. What is the correlation between the color and the
b. What other renal disorders produce similar urinalysis specific gravity?
results? c. What is the significance of the blood and protein tests?
c. What is the expected prognosis for this patient? d. Is this specimen suitable for the appearance of glitter
cells? Explain your answer.
5. A 32-year-old construction worker experiences respira-
tory difficulty followed by the appearance of blood- e. What other population is at a high risk for developing
streaked sputum. He delays visiting a physician until this condition?
symptoms of extreme fatigue and red urine are present. f. What disorder might develop if this disorder is not
A chest radiograph shows pulmonary infiltration, and treated?
sputum culture is negative for pathogens. Blood test re-
7. A 10-year-old patient with a history of recurrent UTIs is
sults indicate anemia, increased BUN and creatinine, and
admitted to the hospital for diagnostic tests. Initial urinal-
the presence of antiglomerular basement membrane anti-
ysis results are as follows:
body. Urinalysis results are as follows:
Color: Yellow Ketone: Negative
Color: Red Ketones: Negative
Clarity: Cloudy Blood: Small
Clarity: Cloudy Blood: Large
Sp. gravity: 1.025 Bilirubin: Negative
Sp. gravity: 1.015 Bilirubin: Negative
pH: 8.0 Urobilinogen: Normal
pH: 6.0 Urobilinogen: Normal
Protein: 2+ Nitrite: Positive
Protein: 3+ Nitrite: Negative
Glucose: Negative Leukocyte: 2+
Glucose: Negative Leukocyte: Trace
Microscopic:
Microscopic:
6–10 RBCs/hpf 0–2 WBC casts/lpf
100 RBCs/hpf 0–3 hyaline casts/lpf
Many bacteria
10–15 WBCs/hpf 0–3 granular casts/lpf
>100 WBCs/hpf 0–1 bacterial casts/lpf with
0–2 RBCs casts/lpf
clumps
a. What disorder do the laboratory results suggest?
A repeat urinalysis a day later has the following results:
b. How is this disorder affecting the glomerulus?
Color: Yellow Ketones: Negative
c. If the antiglomerular membrane antibody test is nega-
Clarity: Cloudy Blood: Small
tive, what disorder might be considered?
Sp. gravity: >1.035 Bilirubin: Negative
d. What is the diagnostic test for this disorder?
pH: 7.5 Urobilinogen: Normal
e. By what mechanism does this disorder affect the
glomerulus? Protein: 2+ Nitrite: Positive
Glucose: Negative Leukocyte: 2+
234 Part Two | Urinalysis

Microscopic: Sp. gravity: 1.010 Bilirubin: Negative

6–10 RBCs/hpf Many bacteria pH: 7.0 Urobilinogen: Normal
0–2 WBC casts/lpf Protein: 3+ Nitrite: Negative
>100 WBCs/hpf Moderate birefringent, flat Glucose: 2+ Leukocyte: Negative
crystals Microscopic:
0–1 bacterial casts/lpf 50–60 RBCs/hpf 2–3 granular casts/lpf
a. What diagnostic procedure was performed on the 3–6 WBCs/hpf 2–3 RTE cell casts/lpf
patient that could account for the differences in the
3–4 RTE cells/hpf 0–1 waxy casts/lpf
two urinalysis results?
0–1 broad granular
b. Considering the patient’s age and history, what is the
casts/lpf
most probable diagnosis?
a. What diagnosis do the patient’s history and labora-
c. What microscopic constituent is most helpful to this
tory results suggest?
diagnosis?
b. What is the most probable cause of the patient’s
d. What is the most probable cause of this disorder?
disorder? Is this considered to be of prerenal, renal,
e. How can the presence of the bacterial cast be or postrenal origin?
confirmed?
c. What is the significance of the specific gravity
f. What is the most probable source of the crystals result?
present in the sediment?
d. What is the significance of the RTE cells?
g. Without surgical intervention, what is the patient’s
e. State two possible reasons for the presence of the
prognosis?
broad casts.
8. A 35-year-old patient being treated for a sinus infection
10. A 40-year-old man develops severe back and abdomi-
with methicillin develops fever, a skin rash, and edema.
nal pain after dinner. The pain subsides during the
Urinalysis results are as follows:
night but recurs in the morning, and he visits his fam-
Color: Dark yellow Ketones: Negative ily physician. Results of a complete blood count and an
Clarity: Cloudy Blood: Moderate amylase test are normal. Results of a routine urinalysis
Sp. gravity: 1.015 Bilirubin: Negative are as follows:
pH: 6.0 Urobilinogen: Normal Color: Dark yellow Ketones: Negative
Protein: 3+ Nitrite: Negative Clarity: Hazy Blood: Moderate
Glucose: Negative Leukocyte: 2+ Sp. gravity: 1.030 Bilirubin: Negative
Microscopic: pH: 5.0 Urobilinogen: Normal
20–30 RBCs/hpf 1–2 WBC casts/lpf Protein: Trace Nitrite: Negative
>100 WBCs/hpf 1–2 granular casts/lpf Glucose: Negative Leukocytes: Negative
Microscopic
After receiving the urinalysis report, the physician orders
a test for urinary eosinophils. The urinary eosinophil 15–20 RBCs/hpf
result is 10%. 0–2 WBCs/hpf
a. Is the urinary eosinophil result normal or abnormal? Few squamous epithelial cells
b. What is the probable diagnosis for this patient? a. What condition could these urinalysis results and
c. Discuss the significance of the increased WBCs and the patient’s symptoms represent?
WBC casts in the absence of bacteria. b. What would account for the crenated RBCs?
d. How can this condition be corrected? c. Is there a correlation between the urine color and
specific gravity and the patient’s symptoms?
9. After surgery to correct a massive hemorrhage, a 55-year-
old patient exhibits oliguria and edema. Blood test results d. Based on the primary substance that causes this
indicate increasing azotemia and electrolyte imbalance. condition, what type of crystals might have been
The glomerular filtration rate is 20 mL/min. Urinalysis present?
results are as follows: e. What changes will the patient be advised to make in
Color: Yellow Ketones: Negative his lifestyle to prevent future occurrences?
Clarity: Cloudy Blood: Moderate
 CHAPTER 9
Urine Screening
for Metabolic Disorders
LEARNING OUTCOMES
Upon completing this chapter, the reader will be able to:
9-1 Explain abnormal accumulation of metabolites in the 9-10 State the significance of increased urinary 5-hydrox-
urine in terms of overflow and renal disorders. yindoleacetic acid.
9-2 Discuss the importance of and the MS/MS testing 9-11 Differentiate between cystinuria and cystinosis, includ-
methods for newborn screening. ing the differences found during analysis of the urine
and the disease processes.
9-3 Name the metabolic defect in phenylketonuria, and
describe the clinical manifestations it produces. 9-12 Describe the components in the heme synthesis path-
way, including the primary specimens used for their
9-4 State three causes of tyrosyluria.
analysis, and explain the cause and clinical significance
9-5 Name the abnormal urinary substance present in of major porphyrias and the appearance of porphyrins
alkaptonuria, and explain how its presence may be in urine.
suspected.
9-13 Define mucopolysaccharides, and name three syndromes
9-6 Discuss the appearance and significance of urine that in which they are involved.
contains melanin.
9-14 State the significance of increased uric acid crystals in
9-7 Describe a basic laboratory observation that has newborns’ urine.
relevance in maple syrup urine disease.
9-15 Explain the reason for performing tests for urinary-
9-8 Discuss the significance of ketonuria in a newborn. reducing substances on all newborns.
9-9 Differentiate between the presence of urinary indican
due to intestinal disorders and Hartnup disease.

KEY TERMS
Alkaptonuria Homocystinuria Melituria
Aminoaciduria Inborn error of metabolism (IEM) Ochronosis
Cystinosis Indicanuria Organic acidemias
Cystinuria Lesch-Nyhan disease Phenylketonuria (PKU)
Galactosuria Maple syrup urine disease (MSUD) Porphyrinuria
Hartnup disease Melanuria Tyrosyluria
272 Part Three | Other Body Fluids

Improved Detection of Bacterial Central Nervous System 35. Albright, RE, et al: Issues in cerebrospinal fluid management.
Infections by Use of Broad-Range PCR Assay. J Clin Microbiol Am J Clin Pathol 95(3):397–401, 1991.
52(5):1751–1753, 2014. DOI: 10.1128/JCM.00469-14. https:// 36. Lofsness, KG, and Jensen, TL: The preparation of simulated
[Link]/content/52/5/1751. Accessed June 29, 2019. spinal fluid for teaching purposes. Am J Med Technology
34. Davis, LE, and Schmitt, JW: Clinical significance of cere- 49(7):493–496, 1983.
brospinal fluid tests for neurosyphilis. Ann Neurol 25:50–53,
1989.

Study Questions
1. CSF is produced mainly in the: 7. Place the appropriate letter in front of the statement that
A. Bone marrow best describes CSF specimens in these two conditions:
B. Peripheral blood A. Traumatic tap
C. Choroid plexuses B. Intracranial hemorrhage
D. Subarachnoid space Even distribution of blood in all tubes
Xanthochromic supernatant
2. The functions of the CSF include all of the following
except: Concentration of blood in Tube 1 is greater
than in Tube 3
A. Removing metabolic wastes
Specimen contains clots
B. Producing an ultrafiltrate of plasma
C. Supplying nutrients to the CNS 8. The presence of xanthochromia can be caused by all of
the following except:
D. Protecting the brain and spinal cord
A. Immature liver function
3. The CSF flows through the:
B. RBC degradation
A. Choroid plexus
C. A recent hemorrhage
B. Pia mater
D. Elevated CSF protein
C. Subarachnoid space
9. A web-like pellicle in a refrigerated CSF specimen
D. Dura mater
indicates:
4. Substances present in the CSF are controlled by the: A. Tubercular meningitis
A. Arachnoid granulations B. Multiple sclerosis
B. Blood–brain barrier C. Primary CNS malignancy
C. Presence of one-way valves D. Viral meningitis
D. Blood–CSF barrier
10. Given the following information, calculate the CSF WBC
5. What department is the CSF tube labeled 3 routinely count: cells counted, 80; dilution, 1:10; large Neubauer
sent to? squares counted, 10.
A. Hematology A. 8
B. Chemistry B. 80
C. Microbiology C. 800
D. Serology D. 8000
6. The CSF tube that should be kept at room temperature is: 11. A CSF WBC count is diluted with:
A. Tube 1 A. Distilled water
B. Tube 2 B. Normal saline
C. Tube 3 C. Acetic acid
D. Tube 4 D. Hypotonic saline
 Chapter 10 | Cerebrospinal Fluid 273

12. A total CSF cell count on a clear fluid should be: 20. Hemosiderin granules and hematoidin crystals are seen in:
A. Reported as normal A. Lymphocytes
B. Not reported B. Macrophages
C. Diluted with normal saline C. Ependymal cells
D. Counted undiluted D. Neutrophils
13. The purpose of adding albumin to CSF before 21. Myeloblasts are seen in the CSF:
cytocentrifugation is to: A. In bacterial infections
A. Increase the cell yield B. In conjunction with CNS malignancy
B. Decrease the cellular distortion C. After cerebral hemorrhage
C. Improve the cellular staining D. As a complication of acute leukemia
D. Both A and B
22. Cells resembling large and small lymphocytes with
14. The primary concern when pleocytosis of neutrophils cleaved nuclei represent:
and lymphocytes is found in the CSF is: A. Lymphoma cells
A. Meningitis B. Choroid cells
B. CNS malignancy C. Melanoma cells
C. Multiple sclerosis D. Medulloblastoma cells
D. Hemorrhage
23. The reference range for CSF protein is:
15. Neutrophils with pyknotic nuclei may be mistaken for: A. 6 to 8 g/dL
A. Lymphocytes B. 15 to 45 g/dL
B. Nucleated RBCs C. 6 to 8 mg/dL
C. Malignant cells D. 15 to 45 mg/dL
D. Spindle-shaped cells
24. CSF can be differentiated from serum by the presence of:
16. The presence of which of the following cells is increased A. Albumin
in a parasitic infection?
B. Globulin
A. Neutrophils
C. Transthyretin
B. Macrophages
D. Tau transferrin
C. Eosinophils
25. In serum, the second most prevalent protein is IgG; in
D. Lymphocytes
CSF, the second most prevalent protein is:
17. Macrophages appear in the CSF after: A. Transferrin
A. Hemorrhage B. Transthyretin
B. Repeated spinal taps C. Prealbumin
C. Diagnostic procedures D. Ceruloplasmin
D. All of the above
26. Elevated values for CSF protein can be caused by all of
18. Nucleated RBCs are seen in the CSF as a result of: the following except:
A. Elevated blood RBCs A. Meningitis
B. Treatment of anemia B. Multiple sclerosis
C. Severe hemorrhage C. Fluid leakage
D. Bone marrow contamination D. CNS malignancy
19. After a CNS diagnostic procedure, which of the 27. The integrity of the blood–brain barrier is measured
following might be seen in the CSF? using the:
A. Choroidal cells A. CSF/serum albumin index
B. Ependymal cells B. CSF/serum globulin ratio
C. Spindle-shaped cells C. CSF albumin index
D. All of the above D. CSF IgG index
274 Part Three | Other Body Fluids

28. Given the following results, calculate the IgG index: 34. Measurement of which of the following can be replaced
CSF IgG, 50 mg/dL; serum IgG, 2 g/dL; CSF albumin, by CSF glutamine analysis in children with Reye
70 mg/dL; serum albumin, 5 g/dL. syndrome?
A. 0.6 A. Ammonia
B. 6.0 B. Lactate
C. 1.8 C. Glucose
D. 2.8 D. !-Ketoglutarate
29. The CSF IgG index calculated in Study Question 28 35. Before performing a Gram stain on CSF, the specimen
indicates: must be:
A. Synthesis of IgG in the CNS A. Filtered
B. Damage to the blood–brain barrier B. Warmed to 37°C
C. Cerebral hemorrhage C. Centrifuged
D. Lymphoma infiltration D. Mixed
30. The finding of oligoclonal bands in the CSF and not in 36. All of the following statements are true about
the serum is seen with: cryptococcal meningitis except:
A. Multiple myeloma A. An India ink preparation is positive
B. CNS malignancy B. A starburst pattern is seen on Gram stain
C. Multiple sclerosis C. The WBC count is over 2000
D. Viral infections D. A confirmatory immunology test is available
31. Which condition is suggested by the following results: 37. The most sensitive and specific method to detect the
a CSF glucose of 15 mg/dL, WBC count of 5000, causative organism in meningitis is:
90% neutrophils, and protein of 80 mg/dL? A. Gram stain
A. Fungal meningitis B. Culture and sensitivity
B. Viral meningitis C. India ink stain
C. Tubercular meningitis D. PCR assay
D. Bacterial meningitis
38. The test of choice to detect neurosyphilis is the:
32. A patient with a blood glucose of 120 mg/dL would A. RPR
have a normal CSF glucose of:
B. VDRL
A. 20 mg/dL
C. FAB
B. 60 mg/dL
D. FTA-ABS
C. 80 mg/dL
D. 120 mg/dL
33. CSF lactate will be more consistently decreased in:
A. Bacterial meningitis
B. Viral meningitis
C. Fungal meningitis
D. Tubercular meningitis
 Chapter 10 | Cerebrospinal Fluid 275

Case Studies and Clinical Situations

1. Three tubes of CSF containing evenly distributed visible a. Name and perform the calculation to determine the
blood are drawn from a 75-year-old disoriented patient integrity of the patient’s blood–brain barrier.
and delivered to the laboratory. Initial test results are as b. Does the patient have an intact barrier?
follows:
c. Name and perform the calculation used to determine
WBC count: 250 µL Protein: 150 mg/dL whether IgG is being synthesized within the CNS.
Glucose: 70 mg/dL Gram stain: No organisms d. What does this result indicate?
seen
e. Considering the patient’s clinical symptoms and the
Differential: Neutrophils, 68%; monocytes, 3%; lympho- calculation results, what diagnosis is suggested?
cytes, 28%; eosinophils, 1%
f. If immunofixation electrophoresis is performed on
Many macrophages containing ingested RBCs the patient’s serum and CSF, what findings would be
a. What is the most probable condition indicated by expected?
these results? State two reasons for your answer. g. What substance in the CSF can be measured to
b. Are the elevated WBC count and protein significant? monitor this patient?
Explain your answer.
4. A 5-year-old female patient is admitted to the pediatric
c. Are the percentages of the cells in the differential of ward with a temperature of 105°F, lethargy, and cervical
any significance? Explain your answer. rigidity. A lumbar spinal tap is performed, and three tubes
d. What two other structures besides RBCs might be of cloudy CSF are delivered to the laboratory. Preliminary
contained in the macrophages? test results are as follows:
e. If the blood was distributed unevenly and nucleated Appearance: Cloudy
RBCs and capillary structures were seen instead of WBC count: 800 cells/"L
macrophages, what would this indicate?
Differential: 80% lymphocytes, 15% monocytes,
2. A patient with AIDS is hospitalized with symptoms of high 5% neutrophils
fever and rigidity of the neck. Routine laboratory tests on Protein: 65 mg/dL
the CSF show a WBC count of 100/µL with a predomi-
Glucose: 70 mg/dL
nance of lymphocytes and monocytes, glucose of 55 mg/dL
(plasma: 85 mg/dL), and a protein of 70 mg/dL. The Gram Gram stain: No organisms seen
stain shows a questionable starburst pattern. a. From these results, what preliminary diagnosis could
a. What additional microscopic examination should be the physician consider?
performed? b. Is the Gram stain result of particular significance?
b. If the test is positive, what is the patient’s diagnosis? Why or why not?
c. If the results of the test are questionable, what addi- c. Are the lymphocytes significant? Why or why not?
tional testing can be performed? d. Would a CSF lactate test be of any value for the diag-
d. What could cause a false-positive reaction in this test? nosis? Why or why not?
e. If the tests named in a and c are negative, the glucose 5. State possible technical errors that could result in the fol-
level is 35 mg/dL, and a pellicle is observed in the lowing discrepancies:
fluid, what additional testing should be performed? a. An unusual number of Gram stains reported as gram-
f. If CSF and serum IEF was performed on this patient, positive cocci fail to be confirmed by positive cultures.
what unusual findings might be present? b. A physician complains that CSF differentials are being
3. A 35-year-old woman is admitted to the hospital with reported only as polynuclear and mononuclear cells.
symptoms of intermittent blurred vision, weakness, and c. Bacteria observed on the cytospin differential cannot
loss of sensation in her legs. A lumbar puncture is per- be confirmed by Gram stain or culture.
formed with the following results: d. The majority of CSF specimens sent to the laboratory
Appearance: Colorless, clear from the neurology clinic have glucose readings of less
WBC count: 35 cells/µL (90% lymphocytes) than 50% of the corresponding blood glucose results
performed in the clinic.
Glucose: 60 mg/dL (plasma: 100 mg/dL)
Protein: 60 mg/dL (serum: 8 g/dL)
Albumin: 40 mg/dL (serum: 6 g/dL)
IgG globulin: 20 mg/dL (serum: 2 g/dL)
 CHAPTER 11
Semen
LEARNING OUTCOMES
Upon completing this chapter, the reader will be able to:
11-1 State the structures involved in sperm production 11-10 Describe the appearance of normal sperm, including
and their function. structures and their functions.
11-2 Describe the four components of semen with regard 11-11 Differentiate between routine and strict criteria for
to source and function. evaluating sperm morphology.
11-3 Explain the procedures for collecting and handling 11-12 Given an abnormal result in a routine semen analysis,
semen specimens. determine additional tests that might be performed.
11-4 Describe the normal appearance of semen and three 11-13 Describe the two methods routinely used to detect
abnormalities in appearance. antisperm antibodies.
11-5 State two possible causes of low semen volume. 11-14 List two methods for identifying a questionable fluid
as semen.
11-6 Discuss the significance of semen liquefaction and
viscosity. 11-15 State the World Health Organization reference values
for routine and follow-up semen analysis.
11-7 Calculate a sperm concentration and count when
provided with the number of sperm counted, the di- 11-16 Discuss the types and significance of sperm function
lution, the area of the counting chamber used, and tests.
the ejaculate volume.
11-17 Describe methods of quality control appropriate for
11-8 Define round cells, and explain their significance. semen analysis.
11-9 State the two parameters to consider when evaluating
sperm motility.

KEY TERMS
Acrosomal cap Prostate gland Spermatozoa
Andrology Semen Testes
Bulbourethral gland Seminal vesicles Vasectomy
Epididymis Seminiferous tubules Viscosity
Liquefaction Spermatids
288 Part Three | Other Body Fluids

Sperm Function Tests

For additional resources please visit
Advances in assisted reproduction and IVF have resulted in a [Link]
need for more sophisticated semen analysis to assess not only
the characteristics of sperm but also the functional ability. The
tests are performed most commonly in specialized andrology
laboratories and include the hamster egg penetration assay, cer- References
vical mucus penetration test, hypo-osmotic swelling test, and 1. Noureddine, M: Forensic Tests for Semen: What you should
know. Bodily Fluids and Forensics. Web site: [Link]
the in vitro acrosome reaction (Table 11-7).16 [Link]/2011/10/19 forensic-tests-for-semen-what-you-
should-know/. Accessed July 1, 2019.
Semen Analysis Quality Control 2. WHO Laboratory Manual for the Examination and Processing
of Human Semen. World Health Organization. WHO Press,
Traditionally, routine semen analysis has been subject to very little Geneva, Switzerland, 2010.
quality control,17 a situation that has resulted from a lack of ap- 3. Sarhar, S, and Henry, JB: Andrology laboratory and fertility
propriate control materials and the subjectivity of the motility assessment. In Henry, JB (ed): Clinical Diagnosis and Manage-
and morphology analyses. The analysis is rated as a high com- ment by Laboratory Methods. WB Saunders, Philadelphia,
plexity test under the Clinical Laboratory Improvement Amend- 1996.
4. Lopez, A, et al: Suitability of solid-phase chemistry for quantifi-
ments, and standards for testing personnel must be observed. cation of leukocytes in cerebrospinal, seminal and peritoneal
Increased interest in fertility testing has promoted the de- fluid. Clin Chem 33(8):1475–1476, 1987.
velopment of quality control materials and in-depth training 5. Overstreet, JW, and Katz, DF: Semen analysis. Urol Clin North
programs. The standardized procedures developed by the Am 14(3):441–449, 1987.
WHO have provided a basis for laboratory testing and report- 6. World Health Organization: WHO Laboratory Manual for the
Examination of Human Semen and Sperm-Cervical Interaction.
ing. The use of CASA has aided in reducing the subjectivity of Cambridge University Press, London, 1999.
the analysis. However, even computerized analysis has been 7. Sampson, JH, and Alexander, NJ: Semen analysis: A laboratory
shown to vary among operators.18 approach. Lab Med 13(4):218–223, 1982.
Now laboratories can participate in proficiency testing 8. Lammers, J, Splingart, C, Barriere, P, Jean, M, and Freour, T:
programs offered by the College of American Pathologists and Double-blind prospective study comparing two automated
sperm analyzers versus manual semen assessment. J Assist
the American Association of Bioanalysts that include sperm Reprod Genet 31:35, 2014. doi: 10.1007/s10815-013-0139-2.
concentration, vitality, and morphology. Commercial quality- Web site: [Link]
control materials and training aids are available and should be PMC3909144/. Accessed July 1, 2019.
incorporated into laboratory protocols. 9. Sperm Class Analyzer® CASA System Product Brochure.
Microptic Automatic Diagnostic [Link]://www.
[Link]/products/sperm-class-analyzer-casa-system/.
Accessed March 31, 2020.
Table 11–7 Sperm Function Tests 10. Kruger, T, et al: Predictive value of sperm morphology in IVF.
FertilSteril 112–117, 1988.
Test Description 11. Harr, R: Characterization of spermatozoa by planar morphome-
try. Clin Lab Sci 10(4):190–196, 1997.
Hamster egg penetration Sperm are incubated with 12. Cearlock, DM: Autoimmune antispermatozoa antibodies in men:
species-nonspecific ham- Clinical detection and role in infertility. Clin Lab Sci 2(3):
ster eggs, and penetration 165–168, 1989.
is observed microscopically 13. Marshburn, PB, and Kutteh, WH: The role of antisperm
antibodies in infertility. Fertil Steril 61:799–811, 1994.
Cervical mucus Observation of sperm’s abil- 14. Fraysier, HD: A rapid screening technique for the detection of
penetration ity to penetrate partner’s spermatozoa. J Forensic Sci 32(2):527–528, 1987.
midcycle cervical mucus 15. Graves, HC, Sensabaugh, CF, and Blake, ET: Postcoital
detection of a male-specific semen protein, application to
Hypo-osmotic swelling Sperm exposed to low- the investigation of rape. N Engl J Med 312(6):338–343,
sodium concentrations are 1985.
evaluated for membrane in- 16. Yablonsky, T: Male fertility testing. Lab Med 27(6):378–383,
tegrity and sperm viability 1996.
17. Baker, DJ, et al: Semen evaluations in the clinical laboratory.
In vitro acrosome Evaluation of the acrosome Lab Med 25(8):509–514, 1994.
reaction to produce enzymes essen- 18. Krause, W, and Viethen, G: Quality assessment of computer-
tial for ovum penetration assisted semen analysis (CASA) in the andrology laboratory.
Andrologia 31(3):125–129, 1999.
 Chapter 11 | Semen 289

Study Questions
1. Maturation of spermatozoa takes place in the: 8. An increased semen pH may be caused by:
A. Sertoli cells A. Poorly developed seminal vesicles
B. Seminiferous tubules B. Increased prostatic secretions
C. Epididymis C. Obstruction of the ejaculation duct
D. Seminal vesicles D. Prostatic infection
2. Enzymes for the coagulation and liquefaction of semen 9. Proteolytic enzymes may be added to semen specimens to:
are produced by the: A. Increase the viscosity
A. Seminal vesicles B. Dilute the specimen
B. Bulbourethral glands C. Decrease the viscosity
C. Ductus deferens D. Neutralize the specimen
D. Prostate gland
10. The normal sperm concentration is:
3. The major component of seminal fluid is: A. Less than 20 million/µL
A. Glucose B. More than 20 million/mL
B. Fructose C. Less than 20 million/mL
C. Acid phosphatase D. More than 20 million/µL
D. Citric acid
11. Given the following information, calculate the sperm
4. If the first portion of a semen specimen is not collected, concentration: dilution, 1:20; sperm counted in
the semen analysis will have which of the following? five RBC squares on each side of the hemocytometer,
A. Decreased pH 80 and 86; volume, 3 mL.
B. Increased viscosity A. 80 million/mL
C. Decreased sperm count B. 83 million/mL
D. Decreased sperm motility C. 86 million/mL
D. 169 million/µL
5. Failure of laboratory personnel to document the time a
semen specimen is collected primarily affects the interpre- 12. Using the information from question 11, calculate the
tation of semen: sperm concentration when 80 sperm are counted in
A. Appearance 1 WBC square and 86 sperm are counted in another
WBC square.
B. Volume
A. 83 million/mL
C. pH
B. 166 million per ejaculate
D. Viscosity
C. 16.6 million/mL
6. Liquefaction of a semen specimen should take place
D. 50 million per ejaculate
within:
A. 1 hour 13. The primary reason to dilute a semen specimen before
performing a sperm concentration is to:
B. 2 hours
A. Immobilize the sperm
C. 3 hours
B. Facilitate the chamber count
D. 4 hours
C. Decrease the viscosity
7. A semen specimen delivered to the laboratory in a con-
D. Stain the sperm
dom has a normal sperm count and markedly decreased
sperm motility. This indicates:
A. Decreased fructose
B. Antispermicide in the condom
C. Increased semen viscosity
D. Increased semen alkalinity
290 Part Three | Other Body Fluids

14. When performing a sperm concentration, 60 sperm 21. Normal sperm morphology when using the WHO
are counted in the RBC squares on one side of the criteria is:
hemocytometer and 90 sperm are counted in the A. >30% normal forms
RBC squares on the other side. The specimen is
B. <30% normal forms
diluted 1:20. The:
C. >15% abnormal forms
A. Specimen should be rediluted and counted
D. <15% normal forms
B. Sperm count is 75 million/mL
C. Sperm count is greater than 5 million/mL 22. Additional parameters measured by Kruger’s strict
morphology include all of the following except:
D. Sperm concentration is abnormal
A. Vitality
15. Sperm motility evaluations are performed:
B. Presence of vacuoles
A. Immediately after the specimen is collected
C. Acrosome size
B. Within 1 hour of collection
D. Tail length
C. After 3 hours of incubation
23. Round cells that are of concern and may be included in
D. At 6-hour intervals for 1 day
sperm counts and morphology analysis are:
16. The percentage of sperm showing average motility that A. Leukocytes
is considered normal is:
B. Spermatids
A. 25%
C. RBCs
B. 50%
D. Both A and B
C. 60%
24. If 5 round cells per 100 sperm are counted in a sperm
D. 75%
morphology smear and the sperm concentration is
17. The purpose of the acrosomal cap is to: 30 million, the concentration of round cells is:
A. Penetrate the ovum A. 150,000
B. Protect the nucleus B. 1.5 million
C. Create energy for tail movement C. 300,000
D. Protect the neckpiece D. 15 million
18. The sperm part containing a mitochondrial sheath is the: 25. After an abnormal sperm motility test with a normal
A. Head sperm count, what additional test might be ordered?
B. Neckpiece A. Fructose level
C. Midpiece B. Zinc level
D. Tail C. MAR test
D. Eosin–nigrosin stain
19. All of the following are associated with sperm motility
except the: 26. Follow-up testing for a low sperm concentration would
A. Head include testing for:
B. Neckpiece A. Antisperm antibodies
C. Midpiece B. Seminal fluid fructose
D. Tail C. Sperm vitality
D. Prostatic acid phosphatase
20. The morphological shape of a normal sperm head is:
A. Round 27. The immunobead test for antisperm antibodies:
B. Tapered A. Detects the presence of male antibodies
C. Oval B. Determines the presence of IgG, IgM, and IgA
antibodies
D. Amorphous
C. Determines the location of antisperm antibodies
D. All of the above
 Chapter 11 | Semen 291

28. Measurement of α-glucosidase is performed to detect a 30. After a negative postvasectomy wet preparation, the
disorder of the: specimen should be:
A. Seminiferous tubules A. Centrifuged and reexamined
B. Epididymis B. Stained and reexamined
C. Prostate gland C. Reported as no sperm seen
D. Bulbourethral glands D. Both A and B
29. A specimen delivered to the laboratory with a request 31. Standardization of procedures and reference values for
for prostatic acid phosphatase and glycoprotein p30 was semen analysis is provided primarily by the:
collected to determine: A. Manufacturers of instrumentation
A. Prostatic infection B. WHO
B. Presence of antisperm antibodies C. Manufacturers of control samples
C. A possible rape D. Clinical Laboratory Improvement Amendments
D. Successful vasectomy

Case Studies and Clinical Situations

1. A repeat semen analysis for fertility testing is reported as 3. A yellow-colored semen specimen is received in the labo-
follows: ratory. The analysis is normal except for decreased sperm
VOLUME: 3.5 mL SPERM COUNT: 6 million/mL motility. Explain the possible connection between the two
abnormal findings.
VISCOSITY: Normal SPERM MOTILITY: 30%—
grade 1.0 4. Abnormal results of a semen analysis are volume = 1.0 mL
pH: 7.5 MORPHOLOGY: <30% normal and sperm concentration = 1 million/mL. State a non-
forms—30 spermatids/ pathological cause of these abnormal results.
100 sperm 5. A semen specimen with normal initial appearance fails to
The results correspond with the first analysis. liquefy after 60 minutes.
a. List three abnormal parameters. a. Would a specimen pH of 9.0 be consistent with this
b. What is the sperm concentration? Is this normal? observation? Why or why not?
c. What is the spermatid count? Is this normal? b. State three chemical tests that would be of value in
this analysis.
d. Could the sperm concentration and the spermatid
count be related to the infertility? Explain your c. How does this abnormality affect fertility?
answer. 6. A specimen is delivered to the laboratory with a request
2. A semen analysis on a vasovasostomy patient has a nor- to determine whether semen is present.
mal sperm concentration; however, motility is decreased, a. What two chemical tests could be performed on the
and clumping is observed on the wet preparation. specimen?
a. Explain the possible connection between these obser- b. What additional examination could be performed on
vations and the patient’s recent surgery. the specimen?
b. What tests could be performed to further evaluate the
patient’s infertility?
c. Briefly explain the different interpretations offered by
these two tests.
d. State three ways in which a positive result on these
tests could be affecting male fertility.
 CHAPTER 12
Synovial Fluid
LEARNING OUTCOMES
Upon completing this chapter, the reader will be able to:
12-1 Describe the formation and function of synovial fluid. 12-7 List and describe six crystals found in synovial fluid.
12-2 Relate laboratory test results to the four common 12-8 Explain the differentiation of monosodium urate and
classifications of joint disorders. calcium pyrophosphate crystals using polarized and
compensated polarized light.
12-3 State the five diagnostic tests performed most rou-
tinely on synovial fluid. 12-9 State the clinical significance of glucose and lactate
tests on synovial fluid.
12-4 Determine the appropriate collection tubes for re-
quested laboratory tests on synovial fluid. 12-10 List four genera of bacteria found most frequently in
synovial fluid.
12-5 Describe the appearance of synovial fluid in normal
and abnormal states. 12-11 Describe the relationship of serological serum testing
to joint disorders.
12-6 Discuss the normal and abnormal cellular composi-
tion of synovial fluid.

KEY TERMS
Arthritis Hyaluronic acid Synovial fluid
Arthrocentesis Pseudogout Synoviocytes
Gout
302 Part Three | Other Body Fluids

Study Questions
1. The functions of synovial fluid include all of the following 7. Before testing, very viscous synovial fluid should be
except: treated with:
A. Lubrication for the joints A. Normal saline
B. Removal of cartilage debris B. Hyaluronidase
C. Cushioning joints during jogging C. Distilled water
D. Providing nutrients for cartilage D. Hypotonic saline
2. The primary function of synoviocytes is to: 8. The color of the synovial fluid from a patient with a
A. Provide nutrients for the joints bacterial infection may be:
B. Secrete protein A. Yellow tinged
C. Regulate glucose filtration B. Green tinged
D. Prevent crystal formation C. Red streaked
D. Opalescent
3. Which of the following tests is not performed frequently
on synovial fluid? 9. Which of the following could be affected most
A. Uric acid significantly if a synovial fluid is refrigerated before
testing?
B. WBC count
A. Glucose
C. Crystal examination
B. Crystal examination
D. Gram stain
C. Mucin clot test
4. The procedure for collecting synovial fluid is called:
D. Differential
A. Synovialcentesis
10. The highest WBC count can be expected to be seen in
B. Arthrocentesis
patients with:
C. Joint puncture
A. Noninflammatory arthritis
D. Arteriocentesis
B. Inflammatory arthritis
5. Match the following disorders with their appropriate C. Septic arthritis
group:
D. Hemorrhagic arthritis
A. Noninflammatory
11. When diluting a synovial fluid WBC count, all of the
B. Inflammatory
following are acceptable except:
C. Septic
A. Acetic acid
D. Hemorrhagic
B. Isotonic saline
Gout
C. Hypotonic saline
Neisseria gonorrhoeae infection
D. Saline with saponin
Systemic lupus erythematosus
12. The lowest percentage of neutrophils would be seen in
Osteoarthritis
patients with:
Hemophilia
A. Noninflammatory arthritis
Rheumatoid arthritis
B. Inflammatory arthritis
Heparin overdose
C. Septic arthritis
6. Normal synovial fluid resembles: D. Hemorrhagic arthritis
A. Egg white
13. All of the following are abnormal when seen in synovial
B. Normal serum fluid except:
C. Dilute urine A. Neutrophages
D. Lipemic serum B. Ragocytes
C. Synovial lining cells
D. Lipid droplets
 Chapter 12 | Synovial Fluid 303

14. Synovial fluid crystals that occur as a result of purine 20. If crystals shaped like needles are aligned perpendicular
metabolism or chemotherapy for leukemia are: to the slow vibration of compensated polarized light,
A. Monosodium urate what color are they?
B. Cholesterol A. White
C. Calcium pyrophosphate B. Yellow
D. Apatite C. Blue
D. Red
15. Synovial fluid crystals associated with inflammation in
patients on dialysis are: 21. Negative birefringence occurs under red-compensated
A. Calcium pyrophosphate dihydrate polarized light when:
B. Calcium oxalate A. Slow light is impeded more than fast light
C. Corticosteroid B. Slow light is impeded less than fast light
D. Monosodium urate C. Fast light runs against the molecular grain of the
crystal
16. Crystals associated with pseudogout are:
D. Both B and C
A. Monosodium urate
22. Often synovial fluid cultures are plated on chocolate
B. Calcium pyrophosphate dihydrate
agar to detect the presence of:
C. Apatite
A. Neisseria gonorrhoeae
D. Corticosteroid
B. Staphylococcus agalactiae
17. Synovial fluid for crystal examination should be C. Streptococcus viridans
examined as a/an:
D. Enterococcus faecalis
A. Wet preparation
23. The chemical test performed most frequently on
B. Wright’s stain
synovial fluid is:
C. Gram stain
A. Total protein
D. Acid-fast stain
B. Uric acid
18. Crystals that have the ability to polarize light are: C. Calcium
A. Corticosteroid D. Glucose
B. Monosodium urate
24. Which of the following chemistry tests can be performed
C. Calcium oxalate on synovial fluid to determine the severity of RA?
D. All of the above A. Glucose
19. In an examination of synovial fluid under compensated B. Protein
polarized light, rhomboid-shaped crystals are observed. C. Acid phosphatase
What color would these crystals be when aligned
D. Uric acid
parallel to the slow vibration?
A. White 25. Serological tests on patients’ serum may be performed to
detect antibodies causing arthritis for all of the following
B. Yellow
disorders except:
C. Blue
A. Pseudogout
D. Red
B. Rheumatoid arthritis
C. Systemic lupus erythematosus
D. Lyme arthritis
304 Part Three | Other Body Fluids

Case Studies and Clinical Situations

1. A 50-year-old man presents in the emergency department 3. Fluid obtained from the knee of an obese 65-year-old
with severe pain and swelling in the right knee. Arthro- woman being evaluated for a possible knee replacement
centesis is performed, and 20 mL of milky synovial fluid has the following results:
is collected. The physician orders a Gram stain, culture, APPEARANCE: Pale yellow and hazy
and crystal examination of the fluid, as well as a serum
WBC COUNT: 500 cells/µL
uric acid. She requests that the synovial fluid be saved for
possible additional tests. GRAM STAIN: Negative
a. Describe the tubes into which the fluid would be GLUCOSE: 110 mg/dL (serum glucose: 115 mg/dL)
placed. a. What classification of joint disorder do these results
b. If the patient’s serum uric acid level is elevated, what suggest?
type of crystals and disorder are probable? b. Under electron microscopy, what crystals might be
c. Describe the appearance of these crystals under direct detected?
and compensated polarized light. c. How does the glucose result aid in the disorder
d. Why were the Gram stain and culture ordered? classification?

2. A medical laboratory science student dilutes a synovial 4. A synovial fluid specimen delivered to the laboratory for a
fluid specimen before performing a WBC count. The fluid cell count is clotted.
forms a clot. a. What abnormal constituent is present in the fluid?
a. Why did the clot form? b. What type of tube should be sent to the laboratory for
b. How can the student perform a correct dilution of the a cell count?
fluid? c. Could the original tube be used for a Gram stain and
c. After the correct dilution is made, the WBC count is culture? Why or why not?
100,000/µL. State two arthritis classifications that
could be considered.
d. State two additional tests that could be run to deter-
mine the classification.
 CHAPTER 13
Serous Fluid
LEARNING OUTCOMES
Upon completing this chapter, the reader will be able to:
13-1 Describe the normal formation of serous fluid. 13-8 List three common chemistry tests performed on
pleural fluid, and state their significance.
13-2 Describe four primary causes of serous effusions.
13-9 State the common etiologies of pericardial effusions.
13-3 Differentiate between a transudate and an exudate,
including etiology, appearance, and laboratory tests. 13-10 Discuss the diagnostic significance of peritoneal
lavage.
13-4 Differentiate between a hemothorax and a hemor-
rhagic exudate. 13-11 Calculate a serum–ascites gradient, and state its
significance.
13-5 Differentiate between a chylous and a pseudochylous
exudate. 13-12 Differentiate between ascitic effusions of hepatic and
peritoneal origin.
13-6 State the significance of increased neutrophils,
lymphocytes, eosinophils, and plasma cells in 13-13 State the clinical significance of the carcinoembryonic
pleural fluid. antigen and CA 125 tests.
13-7 Describe the morphological characteristics of 13-14 List four chemical tests performed on ascitic fluid,
mesothelial cells and malignant cells. and state their significance.

KEY TERMS
Ascites Oncotic pressure Serous fluid
Ascitic fluid Paracentesis Serum-ascites albumin gradient
Chylous effusion Parietal membrane (SAAG)
Effusion Pericardiocentesis Thoracentesis
Exudate Pericarditis Transudate
Hydrostatic pressure Peritonitis Visceral membrane
Mesothelial cell Pseudochylous effusion
 Chapter 13 | Serous Fluid 317

Study Questions
1. The primary purpose of serous fluid is to: 8. Fluid: serum protein and lactic dehydrogenase ratios are
A. Remove waste products performed on serous fluids:
B. Lower capillary pressure A. When malignancy is suspected
C. Lubricate serous membranes B. To classify transudates and exudates
D. Nourish serous membranes C. To determine the type of serous fluid
D. When a traumatic tap has occurred
2. The membrane that lines the wall of a cavity is the:
A. Visceral 9. Which of the following requires the most additional
testing?
B. Peritoneal
A. Transudate
C. Pleural
B. Exudate
D. Parietal
10. An additional test performed on pleural fluid to classify
3. During normal production of serous fluid, the slight ex-
the fluid as a transudate or exudate is the:
cess of fluid is:
A. WBC count
A. Absorbed by the lymphatic system
B. RBC count
B. Absorbed through the visceral capillaries
C. Fluid:cholesterol ratio
C. Stored in the mesothelial cells
D. Fluid-to-serum protein gradient
D. Metabolized by the mesothelial cells
11. A milky-appearing pleural fluid indicates:
4. Production of serous fluid is controlled by:
A. Thoracic duct leakage
A. Capillary oncotic pressure
B. Chronic inflammation
B. Capillary hydrostatic pressure
C. Microbial infection
C. Capillary permeability
D. Both A and B
D. All of the above
12. Which of the following best represents a hemothorax?
5. An increase in the amount of serous fluid is called a/an:
A. Blood HCT: 42 Fluid HCT: 15
A. Exudate
B. Blood HCT: 42 Fluid HCT: 10
B. Transudate
C. Blood HCT: 30 Fluid HCT: 10
C. Effusion
D. Blood HCT: 30 Fluid HCT: 20
D. Malignancy
13. All of the following are normal cells seen in pleural fluid
6. Pleural fluid is collected by:
except:
A. Pleurocentesis
A. Mesothelial cells
B. Paracentesis
B. Neutrophils
C. Pericentesis
C. Lymphocytes
D. Thoracentesis
D. Mesothelioma cells
7. Place the appropriate letter in front of the following state-
14. A differential observation of pleural fluid associated with
ments describing transudates and exudates.
tuberculosis is:
A. Transudate
A. Increased neutrophils
B. Exudate
B. Decreased lymphocytes
Caused by increased hydrostatic pressure
C. Decreased mesothelial cells
Caused by increased capillary permeability
D. Increased mesothelial cells
Caused by decreased oncotic pressure
Caused by congestive heart failure
Malignancy related
Tuberculosis related
Endocarditis related
Clear appearance
318 Part Three | Other Body Fluids

15. All of the following are characteristics of malignant cells 21. The recommended test for determining whether
except: peritoneal fluid is a transudate or an exudate is the:
A. Cytoplasmic molding A. Fluid:serum albumin ratio
B. Absence of nucleoli B. Serum ascites albumin gradient
C. Mucin-containing vacuoles C. Fluid:serum lactic dehydrogenase ratio
D. Increased nucleus:cytoplasm ratio D. Absolute neutrophil count
16. A pleural fluid pH of 6.0 indicates: 22. Given the following results, classify this peritoneal fluid:
A. Esophageal rupture serum albumin, 2.2 g/dL; serum protein, 6.0 g/dL; fluid
albumin, 1.6 g/dL.
B. Mesothelioma
A. Transudate
C. Malignancy
B. Exudate
D. Rheumatoid effusion
23. Differentiation between bacterial peritonitis and
17. Plasma cells seen in pleural fluid indicate:
cirrhosis is done by performing a/an:
A. Bacterial endocarditis
A. WBC count
B. Primary malignancy
B. Differential
C. Metastatic lung malignancy
C. Absolute neutrophil count
D. Tuberculosis infection
D. Absolute lymphocyte count
18. A significant cell found in pericardial or pleural fluid
24. Detection of the CA 125 tumor marker in peritoneal
that should be referred to cytology is a:
fluid indicates:
A. Reactive lymphocyte
A. Colon cancer
B. Mesothelioma cell
B. Ovarian cancer
C. Monocyte
C. Gastric malignancy
D. Mesothelial cell
D. Prostate cancer
19. Another name for a peritoneal effusion is:
25. Chemical tests primarily performed on peritoneal fluid
A. Peritonitis include all of the following except:
B. Lavage A. Amylase
C. Ascites B. Glucose
D. Cirrhosis C. Alkaline phosphatase
20. A test performed primarily on peritoneal lavage fluid D. Calcium
is a/an:
26. Cultures of peritoneal fluid are incubated:
A. WBC count
A. Aerobically
B. RBC count
B. Anaerobically
C. Absolute neutrophil count
C. At 37°C and 42°C
D. Amylase
D. Both A and B
 Chapter 13 | Serous Fluid 319

Case Studies and Clinical Situations

1. Fluid from a patient with congestive heart failure is 4. Paracentesis is performed on a patient with ascites. The
collected by thoracentesis and sent to the laboratory for fluid appears turbid and has an elevated WBC count.
testing. It appears clear and pale yellow and has a WBC Additional tests ordered include an absolute granulocyte
count of 450/µL, fluid:serum protein ratio of 0.35, and count, amylase, creatinine, CEA, and CA 125.
fluid:serum LD ratio of 0.46. a. What is the purpose for the absolute granulocyte
a. What type of fluid was collected? count? If it is less than 250 cells/µL, what condition is
b. Based on the laboratory results, would this fluid be indicated?
considered a transudate or an exudate? Why? b. If the amylase level is elevated, what is its significance?
c. List two other tests that could be performed to aid in State an additional test that might be ordered.
classifying this fluid. c. Explain the significance of an elevated creatinine level.
2. A cloudy pleural fluid has a glucose level of 30 mg/dL d. What is the purpose of the CEA and CA 125 tests?
(serum glucose level is 100 mg/dL) and a pH of 6.8. 5. Describe a situation in which paracentesis might be per-
a. What condition do these results indicate? formed on a patient who does not have ascites. If the RBC
b. What additional treatment might the patient receive, count is 300,000/µL, what does this indicate?
based on these results? 6. Microscopic examination of an ascitic fluid shows many
3. The following results were obtained on a peritoneal fluid: cells with nuclear and cytoplasmic irregularities contain-
serum albumin, 2.8 g/dL; fluid albumin, 1.2 g/dL. ing psammoma bodies. The CEA test result is normal.
What additional test would be helpful?
a. Calculate the SAAG.
b. Is this a transudate or an exudate? Why?
c. What is the most probable cause of the effusion?
 CHAPTER 14
Bronchoalveolar Lavage
Fluid
LEARNING OUTCOMES
Upon completing this chapter, the reader will be able to:
14-1 State the indications for performing a bronchoalveolar 14-4 Describe the appearance of BAL fluid in normal and
lavage (BAL). abnormal conditions.
14-2 Describe the procedure for performing a BAL. 14-5 Discuss the normal and abnormal cellular composition
of BAL fluid.
14-3 Explain the procedures for the collecting, handling,
and transport of specimens for BAL.

KEY TERMS
Bronchoalveolar lavage (BAL) Bronchoscopy Flow cytometry
 Chapter 14 | Bronchoalveolar Lavage Fluid 325

Red O stain, and lipid-laden alveolar macrophages using a

Sudan III stain. Periodic acid–Schiff staining or Oil Red O stain-
ing may be useful in diagnosing cases of pulmonary alveolar
proteinosis or aspiration.1 Dust particle inclusions indicate
pneumoconioses or asbestos exposure. Specimens are evaluated
by a pathologist in cytology whenever malignancy is suspected.

For additional resources please visit

[Link]

References
1. Meyer, KC, Raghu, G, Baughman, RP, et al: An official American
Figure 14–3 Bronchoalveolar lavage: Amorphous material associ- Thoracic Society clinical practice guideline: The clinical utility of
ated with P. carinii when examined under low power (×100). bronchoalveolar lavage cellular analysis in interstitial lung disease.
Am J Respir Crit Care Med 185(9):1004–1014. DOI:10.1164/
rccm.201202-0320ST. [Link]
10.1164/rccm.201202-0320ST. Published May 1, 2012.
Accessed: October 29, 2019.
2. Clinical and Laboratory Standards Institute: Body Fluid Analysis
for Cellular Composition; Approved Guideline. CLSI document
H56-A. Clinical and Laboratory Standards Institute. Wayne, PA
2006, CLSI.
3. Bronchoalveolar Lavage, BAL Cell Count and Differential.
Methodist Hospital: Clinical Laboratory Procedure Manual.
Omaha, NE, January 5, 2012.
4. Jacobs, JA, DeBrauwer, EI, et al: Accuracy and precision of quan-
titative calibrated loops in transfer of bronchoalveolar lavage
fluid. J Clin Micro 38(6):2117–2121, 2000.
5. Baldassarri, RJ, Rebecca, Kumar, D, Baldassarri, S, and Cai, G:
Diagnosis of Infectious Diseases in the Lower Respiratory Tract.
A Cytopathologist’s Perspective. Arch Pathol Lab Med. 2019;143:
683–694; DOI: 10.5858/ arpa.2017-0573-RA. Web site: https://
[Link]/doi/pdf/10.5858/arpa.2017-0573-
Figure 14–4 Bronchoalveolar lavage: Characteristic cup-shaped RA. Accessed September 10, 2019.
organisms indicating P. carinii (×1000). 6. Linder, J: Bronchoalveolar Lavage. ASCP, Chicago, 1988.

Study Questions
1. All of the following could be diagnosed by collecting and 3. In bronchoalveolar lavage, the targeted area of the lung is:
analyzing a BAL except: A. Flushed with antibiotics
A. Asbestos-related pulmonary disease (dust particles) B. Rinsed with sterile saline
B. Interstitial lung disease C. Rinsed with water
C. Alveolar hemorrhage D. Flushed with a fluorometric stain
D. Meningitis
4. A BAL fluid that appears orange-red is an indication of
2. What procedure is used for bronchoalveolar lavage? which of the following:
A. Bronchoscopy A. Acute diffuse alveolar hemorrhage
B. Arthrocentesis B. Alveolar proteinosis
C. Colonoscopy C. Patient who is a heavy smoker
D. Thoracentesis D. Older hemorrhage syndrome
326 Part Three | Other Body Fluids

5. Cell counts from a BAL fluid must be performed within: 9. What is an opportunistic pathogen in patients with
A. 1 hour AIDS that can be recovered in BAL fluid?
B. 3 hours A. Toxoplasma gondii
C. 24 hours B. Legionella pneumophila
D. 36 hours C. Cryptococcus neoformans
D. Mycobacterium tuberculosis
6. An elevated CD4/CD8 lymphocyte ratio indicates:
A. Sarcoidosis 10. The stain used in cytology for the diagnosis of lipid-
laden alveolar macrophages is:
B. Tuberculosis
A. Periodic acid stain
C. HIV infection
B. Oil Red O stain
D. Silicosis
C. Sudan III stain
7. Immunological study of cells is typically performed by:
D. Iron stain
A. Cytocentrifugation
B. Flow cytometry
C. Differential count
D. Hemocytometer cell count
8. The cell in a BAL fluid seen most frequently is:
A. Eosinophil
B. Neutrophil
C. Lymphocyte
D. Macrophage

Case Studies and Clinical Situations

1. A patient presented in the emergency department with a 2. A 35-year-old male with a history of HIV infection is ad-
cough, shortness of breath, and hemoptysis (coughing up mitted to the hospital with fever, dyspnea, and a cough.
blood). A bronchoscopy with bronchoalveolar lavage was BAL is performed.
performed. a. Which of the following findings from the BAL may be
a. What would the specimen possibly look like indicative of his condition?
macroscopically? 1. Presence of lymphocytes with increased ratio of
b. How would an acute diffuse alveolar hemorrhage CD4 and CD8
appear? 2. Presence of lymphocytes with decreased ratio of
c. What cellular element would suggest that the alveolar CD4 and CD8
hemorrhage occurred within the past 48 hours? 3. Increase in eosinophils
d. How would an older hemorrhagic syndrome appear? 4. >5% of epithelial cell counts
e. What intracellular content would be present in the b. What opportunistic organism is often seen in
case of an older hemorrhagic syndrome? HIV/AIDS patients?
f. What procedure would be used to identify the c. What is a confirmatory test?
intracellular content?
 CHAPTER 15
Amniotic Fluid
LEARNING OUTCOMES
Upon completing this chapter, the reader will be able to:
15-1 State the functions of amniotic fluid. 15-7 Interpret a Liley graph.
15-2 Describe the formation and composition of amniotic 15-8 Describe the analysis of amniotic fluid for the detec-
fluid. tion of neural tube disorders.
15-3 Differentiate maternal urine from amniotic fluid. 15-9 Explain the physiological significance of the lecithin-
sphingomyelin (L/S) ratio.
15-4 State indications for performing an amniocentesis.
15-10 State the relationship of phosphatidyl glycerol to FLM.
15-5 Describe the specimen-handling and processing pro-
cedures for testing amniotic fluid for bilirubin, fetal 15-11 Define lamellar bodies and describe their significance
lung maturity (FLM), and cytogenetic analysis. to FLM.
15-6 Discuss the principle of the spectrophotometric 15-12 Discuss the principle of and sources of error for the
analysis for evaluation of hemolytic disease of the L/S ratio, Amniostat-FLM, lamellar body count, and
fetus and newborn. Foam Stability Index for FLM.

KEY TERMS
Amniocentesis Hemolytic disease of the fetus and Meconium
Amnion newborn (HDFN) Oligohydramnios
Amniotic fluid Lamellar bodies Polyhydramnios
Cytogenetic analysis Lecithin-sphingomyelin ratio (L/S Respiratory distress syndrome (RDS)
ratio)
Fetal lung maturity (FLM) Surfactants
336 Part Three | Other Body Fluids

19. Kulovich, MV, Hallman, MB, and Gluck, L: The lung profile: 24. Khazardoost, S, et al: Amniotic fluid lamellar body count and
Normal pregnancy. Am J Obstet Gynecol 135:57–60, 1979. its sensitivity and specificity in evaluating of fetal lung maturity.
20. Eisenbrey, AB, et al: Phosphatidyl glycerol in amniotic fluid: J Obstet Gynaecol 25(3):257–259, 2005.
Comparison of an “ultrasensitive” immunologic assay with TLC 25. Sbarra, AJ, et al: Correlation of amniotic fluid optical density at
and enzymatic assay. Am J Clin Pathol 91(3):293–297, 1989. 650 nm and lecithin/sphingomyelin ratios. Obstet Gynecol 48:
21. Chapman, JF: Current methods for evaluating FLM. Lab Med 613, 1976.
17(10):597–602, 1986. 26. Lu Ji, Gronowski, AM, Eby, C: Lamellar Body Counts Performed
22. Saad, SA, et al: The reliability and clinical use of a rapid phos- on Automated Hematology Analyzers to Assess Fetal Lung
phatidyl glycerol assay in normal and diabetic pregnancies. Am Maturity. LabMedicine 39(7): 419–423, 2008.
J Obstet Gynecol 157(6):1516–1520, 1987.
23. Clinical and Laboratory Standards Institute. Assessment of fetal
lung maturity by the lamellar body count; approved guideline,
CLSI document C58-A. Wayne, PA, 2011, CLSI.

Study Questions
1. Which of the following is not a function of amniotic fluid? 6. How are specimens for FLM testing delivered to and
A. Allows movement of the fetus stored in the laboratory?
B. Allows exchange of carbon dioxide and oxygen A. Delivered on ice and refrigerated
C. Protects the fetus from extreme temperature changes B. Immediately centrifuged
D. Acts as a protective cushion for the fetus C. Kept at room temperature
D. Delivered in a vacuum tube
2. What is the primary cause of the normal increase in am-
niotic fluid as a pregnancy progresses? 7. Why are amniotic specimens for cytogenetic analysis
A. Fetal cell metabolism incubated at 37°C before analysis?
B. Fetal swallowing A. To detect the presence of meconium
C. Fetal urine B. To differentiate amniotic fluid from urine
D. Transfer of water across the placenta C. To prevent photo-oxidation of bilirubin to biliverdin
D. To prolong fetal cell viability and integrity
3. Which of the following is not a reason for decreased
amounts of amniotic fluid? 8. Match the following colors in amniotic fluid with their
A. Fetal failure to begin swallowing significance.
B. Increased fetal swallowing A. Colorless 1. Fetal death
C. Membrane leakage B. Dark green 2. Normal
D. Urinary tract defects C. Red-brown 3. Presence of bilirubin
D. Yellow 4. Presence of meconium
4. Why might a creatinine level be requested on an amniotic
fluid? 9. A significant rise in the OD of amniotic fluid at 450 nm
A. Detect oligohydramnios indicates the presence of which analyte?
B. Detect polyhydramnios A. Bilirubin
C. Differentiate amniotic fluid from maternal urine B. Lecithin
D. Evaluate lung maturity C. Oxyhemoglobin
D. Sphingomyelin
5. Amniotic fluid specimens are placed in amber-colored
tubes before sending them to the laboratory to prevent 10. Plotting the amniotic fluid OD on a Liley graph represents
the destruction of: the severity of hemolytic disease of the fetus and newborn.
A. Alpha-fetoprotein A value that is plotted in zone II indicates what condition
of the fetus?
B. Bilirubin
A. No hemolysis
C. Cells for cytogenetics
B. Mildly affected fetus
D. Lecithin
C. Moderately affected fetus that requires close
monitoring
D. Severely affected fetus that requires intervention
 Chapter 15 | Amniotic Fluid 337

11. The presence of a fetal neural tube disorder may be 16. True or False: Phosphatidyl glycerol is present with an
detected by: L/S ratio of 1.1.
A. Increased amniotic fluid bilirubin 17. A rapid immunologic test for FLM that does not require
B. Increased maternal serum alpha-fetoprotein performance of thin-layer chromatography is:
C. Decreased amniotic fluid phosphatidyl glycerol A. AFP levels
D. Decreased maternal serum acetylcholinesterase B. Amniotic acetylcholinesterase
12. True or False: An AFP MoM value greater than two times C. Amniostat-FLM
the median value is considered an indication of a neural D. Bilirubin scan
tube disorder.
18. Does the failure to produce bubbles in the Foam
13. When severe HDFN is present, which of the following Stability Index indicate increased or decreased lecithin?
tests on the amniotic fluid would the physician not order A. Increased
to determine whether the fetal lungs are mature enough
B. Decreased
to withstand a premature delivery?
A. AFP levels 19. The presence of phosphatidyl glycerol in amniotic fluid
fetal lung maturity tests must be confirmed when:
B. Foam stability index
A. Hemolytic disease of the fetus and newborn is
C. Lecithin/sphingomyelin ratio
present
D. Phosphatidyl glycerol detection
B. The mother has maternal diabetes
14. True or False: Before 35 weeks’ gestation, the normal L/S C. Amniotic fluid is contaminated by hemoglobin
ratio is less than 1.6.
D. A neural tube disorder is suspected
15. When performing an L/S ratio by thin-layer
20. A lamellar body count of 50,000 correlates with:
chromatography, a mature fetal lung will show:
A. Absent phosphatidyl glycerol and L/S ratio of 1.0
A. Sphingomyelin twice as concentrated as lecithin
B. L/S ratio of 1.5 and absent phosphatidyl glycerol
B. No sphingomyelin
C. OD at 650 nm of 1.010 and an L/S ratio of 1.1
C. Lecithin twice as concentrated as sphingomyelin
D. OD at 650 nm of 0.150 and an L/S ratio of 2.0
D. Equal concentrations of lecithin and sphingomyelin

Case Studies and Clinical Situations

1. Amniocentesis is performed on a woman believed to be in 2. Amniocentesis is performed after a maternal serum AFP
approximately the 31st week of gestation. This is the sec- level of 2.2 MoM at 15 weeks’ gestation.
ond pregnancy for this Rh-negative woman with diabetes. a. What fetal condition is suspected?
Spectrophotometric analysis of the fluid shows a ∆A450
b. If the amniotic fluid AFP is 2.5 MoM, what additional
of 0.3.
test could be performed?
a. Based on the Liley graph, should the physician
c. In what situation would this additional test not be
consider inducing labor?
performed?
b. What else must the physician consider before
inducing labor? 3. How might a dark green amniotic fluid affect the results
of the following tests?
The physician decides to induce labor based on a
positive Amniostat-FLM. a. Foam Stability Index
c. What information did this test provide for the physician? b. L/S ratio
d. Why did the physician prefer an Amniostat-FLM to an c. Amniostat-FLM
L/S ratio in this situation? d. OD650
338 Part Three | Other Body Fluids

4. How might a blood-streaked amniotic fluid affect the re- c. Specimen was exposed to light
sults of the following tests? d. Specimen reached the reference laboratory within
a. L/S ratio 30 minutes
b. AChE 6. A woman was in the 35th week of pregnancy and had a
c. Bilirubin analysis feeling like she could not stop urinating. She noticed a
d. Amniostat-FLM vaginal discharge or wetness that was more than she
thought normal. She immediately called her obstetrician
5. Amniocentesis is performed on a woman whose last two and was told to come into the clinic.
pregnancies resulted in stillbirths due to hemolytic dis-
a. What could possibly have occurred?
ease of the fetus and newborn. A screening test performed
at the hospital is positive for bilirubin, and the specimen b. Name five tests that could be performed to confirm
is sent to a reference laboratory for a bilirubin scan. this condition.
Physicians are concerned when the report comes back c. What biomarkers have been identified that can con-
negative. What factors would be considered in evaluating firm this condition?
this result? d. Which test is not affected by the presence of blood?
a. Incorrect specimen was sent
b. Specimen was refrigerated
 CHAPTER 16
Fecal Analysis
LEARNING OUTCOMES
Upon completing this chapter, the reader will be able to:
16-1 Describe the normal composition and formation of 16-11 Describe a positive microscopic examination for
feces. muscle fibers.
16-2 Differentiate between secretory and osmotic diarrhea 16-12 Name the fecal fats stained by Sudan III, and give the
using fecal electrolytes, fecal osmolality, and stool pH. conditions under which they will stain.
16-3 List three causes of secretory and osmotic diarrhea. 16-13 Describe and interpret the microscopic results
that are seen when a specimen from a patient with
16-4 Describe the mechanism of altered motility and at
steatorrhea is stained with Sudan III.
least three conditions that can cause it.
16-14 Discuss the collection procedure for a quantitative
16-5 List three causes of steatorrhea.
fecal fat, as well as methods for analysis.
16-6 Differentiate malabsorption from maldigestion syn-
16-15 Explain the methods used to detect fecal occult
dromes, and name a test that distinguishes the two
blood.
conditions.
16-16 Instruct a patient in the collection of specimens for
16-7 Instruct patients in the collection of random and
occult blood, including an explanation of dietary
quantitative stool specimens.
restrictions for the guaiac test.
16-8 State a pathogenic and a nonpathogenic cause for
16-17 Briefly describe a chemical screening test performed
stools that are red, black, and pale yellow.
on feces for each of the following: fetal hemoglobin,
16-9 State the significance of stools that are bulky, ribbon- pancreatic insufficiency, and carbohydrate intolerance.
like, or contain mucus.
16-10 State the significance of increased neutrophils in a
stool specimen.

KEY TERMS
Acholic stools Malabsorption Secretory diarrhea
Constipation Maldigestion Steatorrhea
Diarrhea Occult blood
Dysentery Osmotic diarrhea
 Chapter 16 | Fecal Analysis 351

26. Elphick, DA, and Kapur, K: Comparing the urinary pancreolau- 29. Thorne, D, and O’Brien, C: Diagnosing chronic pancreatitis.
ryl ratio and faecal elastase-1 as indicators of pancreatic insuffi- Advance 12(14):8–12, 2000.
ciency in clinical practice. Pancreatology 5:196–200, 2005. 30. Robayo-Torres, CC, Quezada-Calvillo, R, and Nichols, BL:
27. Symersky, T, et al: Faecal elastase-I: Helpful in analysing Disaccharide digestion: Clinical and molecular aspects. Clin
steatorrhoea? Neth J Med 62(8):286–289, 2004. Gastroenterol Hepatol 4(3):276–287, 2006.
28. Phillips, IJ, et al: Faecal elastase I: A marker of exocrine
pancreatic insufficiency in cystic fibrosis. Ann Clin Chem
36:739–742, 1999.

Study Questions
1. In what part of the digestive tract do pancreatic enzymes 7. Diarrhea can result from all of the following except:
and bile salts contribute to digestion? A. Addition of pathogenic organisms to the normal
A. Large intestine intestinal flora
B. Liver B. Disruption of the normal intestinal bacterial flora
C. Small intestine C. Increased concentration of fecal electrolytes
D. Stomach D. Increased reabsorption of intestinal water and
electrolytes
2. Where does the reabsorption of water take place in the
primary digestive process? 8. Stools from people with steatorrhea will contain excess
A. Large intestine amounts of:
B. Pancreas A. Barium sulfate
C. Small intestine B. Blood
D. Stomach C. Fat
D. Mucus
3. Which of the following tests is not performed to detect
osmotic diarrhea? 9. Which of the following pairings of stool appearance and
A. Clinitest cause do not match?
B. Fecal fats A. Black, tarry: blood
C. Fecal neutrophils B. Pale, frothy: steatorrhea
D. Muscle fibers C. Yellow-gray: bile duct obstruction
D. Yellow-green: barium sulfate
4. The normal composition of feces includes all of the
following except: 10. Stool specimens that appear ribbon-like are indicative of
A. Bacteria which condition?
B. Blood A. Bile duct obstruction
C. Electrolytes B. Colitis
D. Water C. Intestinal constriction
D. Malignancy
5. What is the fecal test that requires a 3-day specimen?
A. Fecal occult blood 11. A black tarry stool is indicative of:
B. APT test A. Upper GI bleeding
C. Elastase I B. Lower GI bleeding
D. Quantitative fecal fat testing C. Excess fat
D. Excess carbohydrates
6. The normal brown color of the feces is produced by:
A. Cellulose 12. Chemical screening tests performed on feces include all
of the following except:
B. Pancreatic enzymes
A. APT test
C. Undigested foodstuffs
B. Clinitest
D. Urobilin
C. Pilocarpine iontophoresis
D. Quantitative fecal fats
352 Part Three | Other Body Fluids

13. Secretory diarrhea is caused by: 21. Which of the following tests would not be indicative of
A. Antibiotic administration steatorrhea?
B. Lactose intolerance A. Fecal elastase I
C. Celiac sprue B. Fecal occult blood
D. Vibrio cholerae C. Sudan III
D. Van de Kamer
14. The fecal osmotic gap is elevated in which disorder?
A. Dumping syndrome 22. The term “occult” blood describes blood that:
B. Osmotic diarrhea A. Is produced in the lower GI tract
C. Secretory diarrhea B. Is produced in the upper GI tract
D. Steatorrhea C. Is not visibly apparent in the stool specimen
D. Produces a black, tarry stool
15. Microscopic examination of stools provides preliminary
information as to the cause of diarrhea because: 23. What is the recommended number of specimens that
A. Neutrophils are present in conditions caused by should be tested to confirm a negative occult blood
toxin-producing bacteria result?
B. Neutrophils are present in conditions that affect the A. One random specimen
intestinal wall B. Two samples taken from different parts of three stool
C. Red and white blood cells are present if the cause is specimens
bacterial C. Three samples taken from the outermost portion of
D. Neutrophils are present if the condition is of the stool specimen
nonbacterial etiology D. Three samples taken from different parts of two stool
specimens
16. True or False: The presence of fecal neutrophils would be
expected with diarrhea caused by a rotavirus. 24. The immunochemical tests for occult blood:
17. Large orange-red droplets seen on direct microscopic A. Test for human globulin
examination of stools mixed with Sudan III represent: B. Give false-positive reactions with meat hemoglobin
A. Cholesterol C. Can give false-positive reactions with aspirin
B. Fatty acids D. Are inhibited by porphyrin
C. Neutral fats 25. Guaiac tests for detecting occult blood rely on the:
D. Soaps A. Reaction of hemoglobin with hydrogen peroxide
18. Microscopic examination of stools mixed with Sudan III B. Pseudoperoxidase activity of hemoglobin
and glacial acetic acid and then heated will show small C. Reaction of hemoglobin with ortho-toluidine
orange-red droplets that represent:
D. Pseudoperoxidase activity of hydrogen peroxide
A. Fatty acids and soaps
26. What is the significance of an APT test that remains pink
B. Fatty acids and neutral fats
after the addition of sodium hydroxide?
C. Fatty acids, soaps, and neutral fats
A. Fecal fat is present.
D. Soaps
B. Fetal hemoglobin is present.
19. When performing a microscopic stool examination for C. Fecal trypsin is present.
muscle fibers, the structures that should be counted:
D. Vitamin C is present.
A. Are coiled and stain blue
27. In the Van de Kamer method for quantitative fecal fat
B. Contain no visible striations
determinations, fecal lipids are:
C. Have two-dimensional striations
A. Converted to fatty acids before titrating with sodium
D. Have vertical striations and stain red hydroxide
20. A value of 85% fat retention would indicate: B. Homogenized and titrated to a neutral endpoint with
A. Dumping syndrome sodium hydroxide
B. Osmotic diarrhea C. Measured gravimetrically after washing
C. Secretory diarrhea D. Measured by spectrophotometer after addition of
Sudan III
D. Steatorrhea
 Chapter 16 | Fecal Analysis 353

28. A patient whose stool exhibits increased fats, undigested 30. Which of the following tests differentiates a malabsorption
muscle fibers, and the inability to digest gelatin may cause from a maldigestion cause in steatorrhea?
have: A. APT test
A. Bacterial dysentery B. D-xylose test
B. A duodenal ulcer C. Lactose tolerance test
C. Cystic fibrosis D. Occult blood test
D. Lactose intolerance
29. A stool specimen collected from an infant with diarrhea
has a pH of 5.0. This result correlates with a:
A. Positive APT test
B. Negative trypsin test
C. Positive Clinitest
D. Negative occult blood test

Case Studies and Clinical Situations

1. Microscopic screening of a stool from a patient exhibiting 3. A physician’s office laboratory is experiencing inconsisten-
prolonged diarrhea shows increased fecal neutrophils and cies in the results of patient-collected specimens for FOBT.
normal qualitative fecal fats and meat fibers. Patients are instructed to submit samples from two areas of
a. What type of diarrhea do these results suggest? three different stool specimens. Positive and negative con-
trols are producing satisfactory results. Patient #1 is a
b. Name an additional test that could provide more diag-
30-year-old woman taking over-the-counter medications
nostic information.
for gastric reflux who has reported passing frequent, black
c. Name one probable result for this test and one im- stools. The results of all three specimens are negative for
probable result. occult blood. Patient #2 is a 70-year-old woman suffering
d. If the test for fecal neutrophils were negative and the from arthritis. She is taking the test as part of a routine
fecal fat concentration increased, what type of diarrhea physical. The results of all three specimens are positive for
would be suggested? occult blood. Patient #3 is a 50-year-old man advised by
the doctor to lose 30 lb. He has been doing well on a high-
2. Laboratory studies are being performed on a 5-year-old
protein, low-carbohydrate diet. Two of his three specimens
boy to determine whether there is a metabolic reason for
are positive for occult blood.
his continued failure to gain weight. In addition to having
blood drawn, the patient has a sweat chloride collected, a. What is the possible nonpathological cause of the un-
provides a random stool specimen, and is asked to collect expected results for Patient #1? Patient #2? Patient #3?
a 72-hour stool specimen. b. How could the physician’s office staff avoid these
a. How can the presence of steatorrhea be screened for discrepancies?
by testing the random stool specimen? c. What testing methodology could be used for Patients
b. How does this test distinguish among neutral fats, #2 and #3?
soaps, and fatty acids? 4. A watery black stool specimen from a neonate is received
c. What confirmatory test should be performed? in the laboratory with requests for an APT test, fecal pH,
d. Describe the appearance of the stool specimens if and a Clinitest.
steatorrhea is present. a. Can all three tests be performed on this specimen?
e. If a diagnosis of cystic fibrosis is suspected, state the Why?
screening test that could be performed on a stool b. If the Clinitest is positive, what pH reading can be
specimen to aid in the diagnosis. expected? Why?
f. State a possible reason for a false-negative reaction in c. The infant’s hemoglobin remains constant at 18 g/dL.
this test. What was the significance of the black stool?
g. What confirmatory test could be performed? d. Would this infant be expected to have ketonuria? Why
or why not?
 CHAPTER 17
Vaginal Secretions
LEARNING OUTCOMES
Upon completing this chapter, the reader will be able to:
17-1 State the indications for collecting vaginal specimens. 17-6 Describe the microscopic constituents for the common
syndromes associated with vaginitis.
17-2 Describe the procedures for specimen collection and
handling for vaginal specimens, and explain how devi- 17-7 Identify the most common causes of vaginitis, includ-
ations from the correct practice will affect test results. ing the cause, clinical signs and symptoms, laboratory
tests, and treatment.
17-3 Describe the appearance of normal and abnormal vagi-
nal secretions. 17-8 Describe tests that can be performed on vaginal secre-
tions to predict conditions of premature delivery and
17-4 Explain the significance of vaginal pH values.
rupture of fetal membranes.
17-5 List the diagnostic tests performed on vaginal secre-
tions, and explain the appropriate use for each.

KEY TERMS
Atrophic vaginitis Dysuria Trichomonas vaginalis
Bacterial vaginosis (BV) Gardnerella vaginalis Trichomoniasis
Basal cells Lactobacilli Vaginal pool
Clue cells Mobiluncus spp. Vaginitis
Desquamative inflammatory Parabasal cells Vulvovaginal candidiasis
vaginitis (DIV) Pruritus Yeast
Dyspareunia
 Chapter 17 | Vaginal Secretions 367

IGFBP-1 concentration in amniotic fluid is between 10,500 Microbiology, ed 4. Saunders Elsevier, Maryland Heights, MO,
and 350,000 ng/mL. AFP concentration in amniotic fluid is from 2011.
8. Seattle STD/HIV Prevention Training Center. Examination of
2,800 to 26,000 ng/mL. Serum IGFBP-1 concentration is from
vaginal wet preps (video). Web site: [Link]
55 to 242 U/mL (equivalent to 33 to 290 ng/mL). Concentra- watch?v=8dgeOPGx6YI. Accessed July 27, 2019.
tions of IGFBP-1 in amniotic fluid can be 100 to 1,000 times 9. Smith, LA: Diagnostic Parasitology. In Mahon, CR, Lehman,
higher than that in maternal serum.17 DC, Maneselis, and Maneselis, G: Textbook of Diagnostic
Microbiology, ed 4. Saunders Elsevier, Maryland Heights, MO,
2011.
10. Patil, MJ, Magamoti, JM, and Metgud, SC: Diagnosis of
For additional resources please visit Trichomonas vaginalis from vaginal specimens by wet mount
[Link] microscopy, in pouch TV culture system, and PCR. J. Global
Infect Dis [serial online] [cited 2012 Jul 6] 4:22–25, 2012.
Web site: [Link] 93756.
Accessed July 23, 2019.
11. Keen, EF, and Aldous, WK: Genial infections and sexually
References transmitted diseases. In Mahon, CR, Lehman, DC, Maneselis, G:
1. Egan, MA, and Lipsky, MS: Diagnosis of vaginitis, Am Fam Textbook of Diagnostic Microbiology, ed 4, Saunders Elsevier,
Physician 62(5):1095–1104, 2000. Web site: [Link] Maryland Heights, MO, 2011.
org/afp/2000/0901/[Link]. Accessed October 4, 2019. 12. Lockwood, CJ, Senyei, AE, Dische, MR, Casal, DC, et al:
2. Clinical and Laboratory Standards Institute. Provider-Performed Fetal fibronectin in cervical and vaginal secretions as a
Microscopy Testing: Approved Guideline, ed. 2. CLSI document predictor of preterm delivery. New Engl J Med 325:669–674,
POCT10-A2. CLSI, Wayne, PA, 2011, CLSI. 1991.
3. Metzger, GD: Laboratory diagnosis of vaginal infections. Clin 13. Fetal Fibronectin Enzyme Immunoassay and Rapid fFN for the
Lab Sci 11:47–52, 1998. TLiIQ System. AW-04196-002 Rev.002, Hologic, Inc. Web site:
4. Woods, GL, and Croft, AC: Specimen collection and handling [Link] Accessed
for diagnosis of infectious diseases. In Henry, JB (ed): Clinical July 23, 2019.
Diagnosis and Management by Laboratory Methods, ed 22. 14. Cousins, LM, et al: AmniSure Placental Alpha Microglobulin-1
Elsevier Saunders, Philadelphia, 2011. Rapid Immunoassay versus standard diagnostic methods for
5. Centers for Disease Control and Prevention: Diseases character- detection of rupture of membranes. Am J Perinatol 22(6):
ized by vaginal discharge. Sexually Transmitted Diseases 317–320, Aug 2005.
Treatment Guidelines, 2010. Web site: [Link] 15. Abdelazim, IA: Insulin-like growth factor binding protein-1
treatment/2010/[Link]. Accessed April 14, (Actim PROM test) for detection of premature rupture of fetal
2020. membranes. J. Obstet Gynaecol Res. 2014 Apr;40(4):961–967.
6. French, L, Horton, J, and Matousek, M: Abnormal vaginal Doi: 10.1111/jog.12296. Epub 2014 Feb 26. [Link]
discharge: Using office diagnostic testing more effectively, [Link]/pubmed/24612210. Accessed July 23,
J Fam Practice 53(10):805–814, 2004. Web site: [Link] 2019.
[Link]/familymedicine/article/60266/womens-health/ 16. Actim PROM brochure. Cooper Surgical. [Link].
abnormal-vaginal-discharge-using-office-diagnostic. Accessed com. 2014. Accessed July 23, 2019.
July 23, 2019. 17. ROM Plus Fetal Membranes Rupture Test Instructions for
7. Fader, RC: Anaerobes of clinical importance. In Mahon, CR, Use brochure. (Package insert). Clinical Innovations. www.
Lehman, DC, and Maneselis, G: Textbook of Diagnostic [Link]. Accessed July 23, 2019.

Study Questions
1. Which of the following would not be a reason to collect a 3. The appearance of the vaginal discharge in vulvovaginal
vaginal fluid for analysis? candidiasis is described as:
A. Vaginitis A. Clear and colorless
B. Complications of pregnancy resulting in preterm B. Thin, homogeneous, white-to-gray discharge
delivery C. White, curd-like
C. Forensic testing in a sexual assault D. Yellow-green and frothy
D. Pregnancy testing
4. A normal range for a vaginal pH is:
2. Which of the following organisms might not be detected A. 3.8 to 4.5
if the specimen for vaginal secretion analysis had been
B. 5.0 to 6.0
refrigerated?
C. 6.0 to 7.0
A. Prevotella bivia
D. 7.0 to 7.4
B. Lactobacillus acidophilus
C. Trichomonas vaginalis
D. Candida albicans
368 Part Three | Other Body Fluids

5. Which of the following tests differentiates budding yeast 11. Which of the following organisms produces lactic acid
cells from RBCs? and hydrogen peroxide to maintain an acidic vaginal
A. pH environment?
B. Saline wet mount A. Gardnerella vaginalis
C. KOH prep B. Mobiluncus spp.
D. Whiff test C. Lactobacilli spp.
D. β-Hemolytic streptococci
6. Which of the following constituents is normal in healthy
vaginal fluid secretions? 12. All of the following are diagnostic of vulvovaginal
A. Lactobacilli candidiasis except:
B. Basal cells A. Large numbers of WBCs
C. Trichomonas vaginalis B. Presence of clue cells
D. Pseudohyphae C. Positive KOH test
D. Vaginal pH of 4.0
7. Vaginal specimens collected for a saline wet prep
should be: 13. All of the following are diagnostic of trichomoniasis
A. Refrigerated to preserve motility except:
B. Prepared as soon as possible A. Vaginal pH of 6.0
C. Mailed to a reference laboratory B. Positive amine test
D. Preserved with potassium hydroxide C. Positive KOH test
D. Motile trichomonads present
8. A positive amine (whiff) test is observed in which of the
following syndromes? 14. The bacteria associated with desquamative inflammatory
A. Bacterial vaginosis vaginitis is:
B. Vulvovaginal candidiasis A. β-Hemolytic streptococci
C. Atrophic vaginitis B. Trichomonas vaginalis
D. Desquamative inflammatory vaginitis C. Gardnerella vaginalis
D. Mycoplasma hominis
9. A squamous epithelial cell covered with coccobacilli that
extends beyond the cytoplasm margin is a: 15. The protein present in vaginal secretions that can identify
A. Basal cell patients who are at risk for preterm delivery is:
B. Parabasal cell A. Human chorionic gonadotropin
C. Clue cell B. Estrogen
D. Blastospore C. PAMG-1
D. Fetal fibronectin
10. All of the following are diagnostic of bacterial vaginosis
except: 16. Which of the following immunochromatographic tests
A. Vaginal pH of 3.8 detects both AFP and IGFBP-1 proteins to diagnose
PROM?
B. Presence of clue cells
A. AmniSure ROM test
C. Positive amine (whiff) test
B. Actim PROM
D. Thin, homogeneous, white-to-gray vaginal
discharge C. ROM Plus
D. Fetal fibronectin
 Chapter 17 | Vaginal Secretions 369

Case Studies and Clinical Situations

1. A 30-year-old woman has symptoms of dysuria, vaginal c. What is the best course of treatment?
itching, and a white, curd-like discharge. During her visit d. Should her sexual partner be treated?
at the women’s clinic, the patient revealed that she had re-
e. List three complications that can occur with this
cently completed a regimen of broad-spectrum antibiotics
disorder.
as treatment for a urinary tract infection. Her health-care
provider takes a swab of the vaginal secretions for analysis. 3. During a routine visit with the gynecologist, a 60-year-old
a. What tests will be performed on the vaginal specimen? woman complained of vaginal dryness and soreness.
During the examination, the health-care provider noted
b. Based on the patient history and observation of the
erythema of the vaginal mucosa. The pH of the vaginal
vaginal secretion, which test will be diagnostic for the
secretions was 6.0. The KOH and amine (whiff) tests were
probable diagnosis?
negative. The microscopic examination revealed epithelial
c. What confirmatory test can be performed? cells, basal cells, decreased lactobacilli, and increased
d. What is the probable diagnosis? gram-positive cocci and gram-negative rods.
e. What is the first choice of treatment? a. What is the name of this condition?
2. A sexually active teenager visited the women’s clinic com- b. Explain how this condition can occur.
plaining of vaginal itching and soreness. She indicated c. What is the treatment for this condition?
that she was experiencing increased vaginal secretions
that were frothy and yellow to green. Upon examination,
the health-care provider noted a strawberry-like cervix
and performed a pH test on the secretions. The pH
was 5.5, and the wet prep demonstrated “swimming”
organisms.
a. What is the probable diagnosis?
b. What other tests can be performed to confirm this
diagnosis?
Answers to Study Questions,
Case Studies, and Clinical Situations
Chapter 1 c. At the beginning of each shift, when a new bottle of
reagent is opened, or as stated in the procedure
Study Questions manual.
d. Refer to the procedure manual. Check expiration
1. C 14. A 27. C dates of controls and reagents. Open and test a new
2. C 15. B 28. D bottle of control or reagents.
3. C 16. D 29. D e. When the controls are within range.
4. A 17. A 30. D 4. a. Delay in testing the specimen.
5. D 18. B 31. B b. Procedure manual.
6. A 19. C 32. 2, 1, 2, 3, c. Delta check.
7. B 20. C 2, 1 d. Incident report.
8. A 21. A 33. D e. Treatment of the patient will be delayed because the
9. C 22. B 34. C specimen will need to be recollected and tested. Extra
10. D 23. D 35. D expense incurred.
11. D 24. B 36. C f. Errors should be corrected as soon as possible
37. D following the facility’s policy. The original result must
12. C 25. B not be erased.
13. B 26. A

Case Studies and Clinical Situations

Chapter 2
1. a. Review of the procedure by a designated authority Study Questions
has not been documented.
1. A 5. D 9. B
b. Instructions and training are not being provided to
2. C 6. C 10. C
personnel performing collections.
3. B 7. A
c. A safety statement about the heat produced by the
reaction is not in the procedure manual. 4. D 8. C
d. The bottles have not been dated and initialed.
Case Studies and Clinical Situations
2. a. Corrective action; proficiency survey tests should be
rotated among personnel performing the tests. 1. a. No. The large amount of blood and leukocytes on the
b. Accept; quality control (QC) on the Clinitest tablets chemical reagent strip does not correlate with 0 to
must be performed only when they are used to 2 RBCs/hpf and the 0 to 2 WBCs/hpf for the
perform a test. microscopic result.
c. Corrective action; documentation of technical b. The MLS student may not have mixed the specimen
competency should be performed on all personnel before pouring the urine into the aliquot tube,
working in the section and educational qualifications causing the cellular constituents to reside at the
assessed. bottom of the original urinalysis container.
3. a. The procedure was being performed incorrectly. The c. The quality control specimens should be tested for
correct timing of the glucose reaction was not being precision and accuracy before patient specimens are
done. tested and the results reported.
b. The technologist performing the test. QC ensures that 2. a. Sysmex XN, Glocyte, iQ200, and Advia 2120i.
the reagents and instrument are working properly b. Advia 2120i.
and that the technologist is performing the test c. Up to 4 hours.
correctly.

371
372 Answers to Study Questions, Case Studies, and Clinical Situations

Chapter 3 21. D 26. C 31. D

22. D 27. C 32. 600 mL/min
Study Questions 23. B 28. B 33. C
1. C 8. A 15. C 24. D 29. A 34. B
2. B 9. C 16. C 25. D 30. +0.5
3. C 10. A 17. A
4. A 11. B 18. D Case Studies and Clinical Situations
5. D 12. D 19. B 1. a. 160 mg/dL to 180 mg/dL.
6. C 13. D 20. B b. Renal tubular reabsorption is impaired.
7. C 14. A 2. a. Juxtaglomerular apparatus → Angiotensinogen →
Renin → Angiotensin I → Angiotensin II.
Case Studies and Clinical Situations b. Vasoconstriction, increased sodium reabsorption, and
increased aldosterone to retain sodium.
1. a. It could have increased pH, nitrite, and bacteria and
decreased clarity, glucose, ketones, bilirubin, c. Production of renin decreases and, therefore, the
urobilinogen and WBCs, RBCs, and casts. actions of the RAAS.
b. Decreased glucose and decreased ketones. 3. a. The physician can calculate the approximate creatinine
clearance using the MDRD-IDMS-traceable formula.
c. Reject the specimen and recollect.
b. The cystatin C test and the beta2-microglobulin test
d. The specimen was refrigerated and was brought serum tests.
immediately to the laboratory.
c. No. The beta2-microglobulin test requires a normal
2. a. It would be less clear. immune system, and malignancies can affect the
b. Additional epithelial cells and bacteria (making it not immune system; therefore, the test cannot be reliable
acceptable for a culture). in patients with immunologic disorders and
3. a. The results would be decreased falsely. malignancies.
b. The patient needs to collect another 24-hour 4. a. Yes. Serum from the midnight specimen is not being
specimen. separated from the clot and refrigerated in a timely
4. a. Yes. manner.
b. The correct ratio of additive to urine must be b. Lactic acid will be present in serum that is not
maintained. The excess preservative can be toxic to separated from the clot and will affect the freezing-
bacteria, causing false-negative results. point osmolarity readings.
5. a. Specimen temperature. c. If the laboratory is using a freezing-point osmometer,
results will be affected by alcohol ingestion; vapor
b. The temperature would be lower than body pressure results would not be affected and could be
temperature. used as a comparison.
c. The specimen tested was not from the defendant. 5. a. Diabetes insipidus.
d. A chain-of-custody form (COC) that is filled out b. Neurogenic diabetes insipidus.
accurately. The specimen could be collected as a
“witnessed” collection. c. Nephrogenic diabetes insipidus.

Chapter 4 Chapter 5
Study Questions Study Questions
1. B 9. B 17. B 1. A 9. D 17. D
2. D 10. A 18. B: Beta2- 2. D 10. A 18. D
3. C 11. C microglobulin; 3. A 11. C 19. C
B: Creatinine; 4. D 12. B 20. B
4. D 12. D
B: Cystatin C; 5. C 13. D 21. B
5. A 13. D A: 125I-
6. B 14. B iodothalamate 6. A 14. A 22. A
7. C 15. B 19. B 7. C 15. C 23. B
8. D 16. D 20. 69 mL/min 8. C 16. B 24. D
 Answers to Study Questions, Case Studies, and Clinical Situations 373

Case Studies and Clinical Situations Case Studies and Clinical Situations
1. a. An elevated pH and a positive reagent strip reaction 1. a. The blood glucose is elevated and has exceeded the
for nitrite. renal tubular maximum (Tm) for glucose.
b. The reagent strip specific gravity would be much b. Diabetes mellitus.
lower if the patient had been given radiographic dye. c. It indicates diabetes mellitus–related renal disease.
c. The reagent strip test for bilirubin would be positive. d. Renal tubular reabsorption disorders.
d. The reagent strip reaction for blood would be 2. a. Yellow foam.
positive, and RBCs would be seen in the microscopic
b. Possible biliary duct obstruction preventing bilirubin
examination.
from entering the intestine.
2. a. 1.018.
c. Icteric.
b. Yes.
d. Protection from light.
c. It would agree with the reagent strip reading because,
3. a. Hemoglobinuria.
like the osmometer, the reagent strip is not affected
by high-molecular-weight substances. b. Increased hemoglobin presented to the liver results
in increased bilirubin entering the intestine for
3. Hemoglobin and myoglobin.
conversion to urobilinogen.
a. Examine the patient’s plasma/serum. The breakdown
c. The circulating bilirubin is unconjugated.
of red blood cells to hemoglobin produces a red
serum/plasma. Myoglobin is produced from skeletal d. It would if a Multistix reagent strip is used and would
muscle and is rapidly cleared from the plasma/serum. not if a Chemstrip is used. A Watson-Schwartz test is
The serum/plasma color would not be affected. more specific for porphobilinogen.
4. a. The woman has been eating fresh beets. 4. a. Negative chemical reactions for blood and nitrite.
Ascorbic acid interference for both reactions. A
b. Yes. The pH of the woman’s urine is acidic or she has
random specimen or further reduction of nitrite
not recently consumed fresh beets.
could cause the negative nitrite.
5. No. The urine can contain increased pH, glucose,
b. Glucose, bilirubin, LE. Ascorbic acid is a strong
ketones, bilirubin, urobilinogen, nitrite, and small
reducing agent that interferes with the oxidation
amounts of cellular structures.
reaction in the glucose test. Ascorbic acid combines
with the diazo reagent in the bilirubin and LE tests,
Chapter 6 lowering the sensitivity.
c. The dark yellow color may be caused by beta-
Study Questions carotene and vitamin A, and some B vitamins also
1. A 17. C 33. A produce yellow urine.
2. D 18. A 34. 1, 3, 4, 2 d. Nonnitrite–reducing microorganisms; lack of dietary
nitrate; antibiotic administration.
3. A 19. A 35. A
5. a. To check for possible exercise-induced abnormal
4. C 20. C 36. D
results.
5. D 21. A 37. C
b. Negative protein and blood, possible changes in color
6. A 22. B 38. A and specific gravity.
7. D 23. C 39. C c. Renal.
8. B 24. A 40. D 6. a. No, the specimen is clear.
9. D 25. C 41. A b. Myoglobinuria.
10. 2, 1, 2, 3, 1, 26. B 42. B c. Muscle damage from the accident (rhabdomyolysis).
2, 3 27. A 43. D d. Yes. Myoglobin is toxic to the renal tubules.
11. B 28. D 44. C 7. a. Laboratory personnel are not capping the reagent
12. A 29. A 45. B strip containers tightly in a timely manner.
13. A 30. C 46. C b. Personnel performing the CLIA-waived reagent strip
14. D 31. 1, 2, 1, 2, 47. C test are not waiting 2 minutes to read the LE reaction.
15. B 1, 2 48. A c. The student is not mixing the specimen.
16. A 32. B 49. C d. The reagent strips have deteriorated, and the quality
control on the strips was not performed before
reporting the results.
374 Answers to Study Questions, Case Studies, and Clinical Situations

Chapter 7 5. a. Calcium oxalate.

b. Monohydrate and dihydrate calcium oxalate.
Study Questions c. Oval: monohydrate; envelope: dihydrate.
1. C 19. B 37. C d. Monohydrate.
2. D 20. C 38. D 6. a. Microscopic results do not match the chemical tests
3. D 21. A 39. A for blood, nitrite, and leukocyte esterase.
4. C 22. B 40. C b. The specimen has been unpreserved at room
temperature for too long, the cells have disintegrated,
5. A 23. C 41. D and the bacteria have converted the nitrite to
6. B 24. D 42. A nitrogen.
7. C 25. D 43. A c. The pH.
8. D 26. B 44. C d. Ask the clinic personnel to instruct the patient to
9. C 27. D 45. D collect a midstream clean-catch specimen and have
10. D 28. A 46. C the specimen delivered to the laboratory immediately.
11. D 29. B 47. 4, 3, 5, 1 7. a. No, because they are associated with strenuous
exercise.
12. A 30. C 48. 3, 5, 2, 6, 4
b. The positive blood reaction is from hemoglobinuria
13. C 31. C 49. 4, 8, 7, 6, 1, or myoglobinuria resulting from participating in a
14. B 32. D 5, 3 contact sport. The protein is orthostatic.
15. C 33. D 50. 3, 5, 2, 1, c. Increased excretion of RTE cell lysosomes in the
7, 4 presence of dehydration.
16. A 34. D
17. D 35. A 8. a. Yes, the waxy casts are probably an artifact, such as a
18. D 36. C diaper fiber. Waxy casts are not associated with
negative urine protein.
Case Studies and Clinical Situations b. No, this is normal after an invasive procedure.
c. Yes, tyrosine crystals are seen in patients with severe
1. a. Yeast grows best at a low pH with an increased liver disease; therefore, the bilirubin should be
concentration of glucose. positive. The crystals may be an artifact or from a
b. Yes, this exceeds the renal threshold. medication.
c. No, yeast is not capable of reducing nitrate to nitrite. d. Yes, uric acid crystals may be mistaken for cystine
d. Moderate blood with no RBCs. crystals.
e. Myoglobin is the cause of the positive chemical test e. Yes, radiographic dye crystals associated with a high
result for blood. The patient has been bedridden for specific gravity resemble cholesterol crystals.
an extended period, causing muscle destruction. f. No, Trichomonas is carried asymptomatically by men.
2. a. The large objects are in a different plane from that of g. No, calcium carbonate crystals are found in alkaline
the urinary constituents. urine; therefore, clumps of amorphous phosphates
b. Contamination by artifacts. may be present.
c. No, because they are in a different plane.
d. Polarizing microscopy. Chapter 8
3. a. Renal tubules.
Study Questions
b. Yes, viral infections can cause tubular damage.
c. RTE cells absorb the bilirubin-containing urinary 1. B 8. D 15. A
filtrate. 2. C 9. A 16. C
d. Liver damage inhibits processing of reabsorbed 3. B 10. C 17. A
urobilinogen. 4. C 11. C 18. A
e. Hemolytic anemia. 5. B 12. C 19. A
4. a. The patient is taking a pigmented medication, such as 6. A 13. B 20. D
phenazopyridine.
7. C 14. D
b. Yes.
c. Ask what medications the patient is taking.
d. Ampicillin.
 Answers to Study Questions, Case Studies, and Clinical Situations 375

Case Studies and Clinical Situations e. Female children.

f. Pyelonephritis.
1. a. Acute glomerulonephritis.
7. a. Intravenous pyelogram.
b. M protein in the cell wall of the group A
streptococcus. b. Chronic pyelonephritis.
c. Glomerular bleeding. c. WBC cast.
d. No, they are also passing through the damaged d. Reflux nephropathy.
glomerulus. e. Performing a Gram stain.
e. Good prognosis with appropriate management of f. Radiographic dye.
secondary complications. g. Permanent tubular damage and progression to
f. Henoch-Schönlein purpura. chronic, end-stage renal disease.
2. a. IgA nephropathy. 8. a. Abnormal.
b. Serum IgA level. b. Acute interstitial nephritis.
c. Chronic glomerulonephritis/end-stage renal disease. c. This disorder is an inflammation, not an infection.
d. Impaired renal tubular reabsorption associated with d. Discontinue the medication because it is causing the
end-stage renal disease. allergic reaction.
e. The specific gravity is the same as that of the 9. a. Acute renal failure.
ultrafiltrate, indicating a lack of tubular b. The prerenal sudden decrease in blood flow to the
concentration. kidneys.
f. The presence of extreme urinary stasis. c. Lack of renal concentrating ability.
3. a. Nephrotic syndrome. d. Tubular damage.
b. Nephrotic syndrome may be caused by sudden, e. The increased diameter of the damaged distal
severe hypotension. convoluted tubule and extreme urinary stasis,
c. Changes in the electrical charges of the shield of allowing casts to form in the collecting ducts.
negativity produce increased membrane permeability. 10. a. Renal lithiasis.
d. Decreased plasma albumin lowers the capillary b. The high specific gravity.
oncotic pressure, causing fluid to enter the interstitial
c. Yes, the dark yellow color and high specific gravity
tissue.
indicate a concentrated urine, which induces the
e. Reabsorption of filtered lipids by the RTE cells. formation of renal calculi.
4. a. Minimal change disease. d. Calcium oxalate.
b. Nephrotic syndrome, focal segmental e. Increased hydration and dietary changes.
glomerulosclerosis.
c. Good prognosis with complete remission.
Chapter 9
5. a. Goodpasture syndrome.
b. The autoantibody attaches to the glomerular Study Questions
capillaries, causing complement activation and
1. C 11. D 21. D
destruction of the capillaries.
2. A 12. B 22. D
c. Granulomatosis with polyangiitis.
3. C 13. C 23. D
d. Antineutrophilic cytoplasmic antibody.
4. B 14. A 24. C
e. Granuloma formation resulting from autoantibodies
binding to neutrophils in the vascular walls and 5. A 15. D 25. B
initiating an immune response. 6. A 16. B, A, B, B, A 26. D
6. a. Cystitis, UTI. 7. C 17. D 27. D, F, A, E,
b. The specimen is very dilute. 8. B 18. B C, B
c. Irritation of the urinary tract will cause a small 9. D 19. B
amount of bleeding. The cells and bacteria may cause 10. D 20. B
a trace protein, or it may be a false-positive due to the
high pH.
d. Yes, glitter cells are seen in hypotonic urine.
376 Answers to Study Questions, Case Studies, and Clinical Situations

Case Studies and Clinical Situations 25. C 30. C 35. C

26. C 31. D 36. C
1. a. Underdevelopment of the liver.
27. A 32. C 37. D
b. Yes, with severe acquired liver disease.
28. C 33. B 38. B
c. Tyrosine crystals; leucine crystals, bilirubin crystals.
29. A 34. A
d. Protect the specimen from light.
2. a. Isovaleric acidemia.
Case Studies and Clinical Situations
b. Maple syrup urine disease.
1. a. Cerebral hemorrhage because of the presence of
c. Yes, the MS/MS screen would be positive.
erythrophagocytosis, even distribution of blood,
3. a. Renal lithiasis. and patient’s history.
b. Impaired renal tubular reabsorption of cystine. b. No, they would be consistent with peripheral blood
c. Lysine, arginine, ornithine. entering the CSF.
d. They are more soluble than is cystine. c. No, they are consistent with the percentages seen in
e. The disorder is inherited cystinuria. peripheral blood.
4. a. Yes. d. Hemosiderin granules and hematoidin crystals.
b. Yes, uric acid crystals accumulating on the surface of e. A traumatic tap.
the diaper could have an orange color. 2. a. An India ink preparation.
c. Lesch-Nyhan disease. b. Cryptococcus meningitis.
d. Yes, the disease is inherited as sex-linked recessive. c. Immunologic testing for Cryptococcus.
e. Hypoxanthine guanine phosphoribosyltransferase. d. Rheumatoid factor.
5. a. Yes. The urine may contain melanin or homogentisic e. Acid-fast staining and culture.
acid. f. Noticeable oligoclonal bands in both the CSF and
b. Yes. Melanin will react with sodium nitroprusside, the serum.
reagent used on reagent strips for the detection of 3. a. CSF/serum albumin index = 6.7.
ketones.
b. Yes.
c. Yes. Homogentisic acid turns black in alkaline urine.
c. IgG index = 1.5.
6. a. Yes, the blue color could indicate the presence of
d. Immunoglobulin synthesis within the CNS.
indican in the urine.
e. Multiple sclerosis.
b. Hartnup disease.
f. Oligoclonal banding only in the CSF.
c. Good with proper dietary supplements.
g. Myelin basic protein.
7. a. The Ehrlich reaction.
4. a. Viral, tubercular, or fungal meningitis.
b. Acetylacetone.
b. No, the Gram stain would be negative in viral and
c. Porphobilinogen.
tubercular and not always positive in fungal
d. Blood. meningitis.
e. Free erythrocyte protoporphyrin (FEP). c. Yes. Lymphocytes are very predominant in viral
meningitis.
Chapter 10 d. Yes, a CSF lactate level of 25 mg/dL or less would aid
in confirming viral meningitis. The lactate level
Study Questions would be higher in cases of bacterial, tubercular, and
fungal meningitis.
1. C 9. A 17. D
5. a. Stain precipitate is being confused with gram-positive
2. B 10. C 18. D
cocci.
3. C 11. C 19. D
b. Differentials are being reported from the counting
4. B 12. D 20. B chamber.
5. A 13. D 21. D c. The albumin is contaminated.
6. B 14. A 22. A d. The specimens are not being delivered promptly to
7. B, B, A, A 15. B 23. B the laboratory.
8. C 16. C 24. D
 Answers to Study Questions, Case Studies, and Clinical Situations 377

Chapter 11 9. B 15. B 21. C

10. C 16. B 22. A
Study Questions 11. A 17. A 23. D
1. C 12. C 23. D 12. A 18. D 24. C
2. D 13. A 24. B 13. C 19. B 25. A
3. B 14. A 25. D 14. A 20. C
4. C 15. B 26. B
5. D 16. B 27. D Case Studies and Clinical Situations
6. A 17. A 28. B 1. a. Sterile, heparinized tube, liquid EDTA tube,
7. B 18. C 29. C nonanticoagulated tube.
8. D 19. A 30. A b. MSU crystals are seen in gout.
9. C 20. C 31. B c. Highly birefringent, needle-shaped crystals under
polarized light that turn yellow when aligned with the
10. B 21. A
slow vibration of red compensated polarized light.
11. B 22. A
d. Infection is frequently a complication of severe
inflammation.
Case Studies and Clinical Situations 2. a. WBC diluting fluid containing acetic acid was used.
1. a. Sperm concentration, motility, and morphology. b. Normal, hypotonic, or saponin-containing saline
b. 21,000,000; no. should be used.
c. 1,800,000; no. c. Crystal-induced inflammatory and septic.
d. Yes. The normal sperm concentration is 20 to 60 d. Gram stain and culture, crystal examination.
million/mL. Spermatid counts over 1 million are 3. a. Noninflammatory.
considered abnormal. Both of these abnormal results, b. Hydroxyapatite crystals.
as well as the abnormal motility, are related to defects
in sperm maturation. c. Glucose. A normal result is consistent with
noninflammatory arthritis.
2. a. Male antisperm antibodies may form after
vasovasostomy procedures. 4. a. Fibrinogen.
b. The MAR test and the immunobead test. b. EDTA or heparinized tube.
c. The MAR test detects the presence of IgG male sperm c. No, the bacteria will be trapped in the clot.
antibodies. The immunobead test delineates the areas
of the sperm (head, tail, neck) that are affected by the Chapter 13
antibodies.
d. Clumping, ovum penetration, and motility. Study Questions
3. The specimen contains urine, which is toxic to sperm, 1. C 9. B 18. B
therefore decreasing viability.
2. D 10. C 19. C
4. The specimen was collected improperly, and the first
3. A 11. D 20. B
part of the ejaculation was lost.
4. D 12. D 21. B
5. a. Yes, insufficient prostatic fluid is present.
5. C 13. D 22. B
b. Zinc, citrate, and acid phosphatase.
6. D 14. C 23. C
c. Sperm motility is affected severely.
7. B, A, A, A, B, 15. B 24. B
6. a. Acid phosphatase and seminal glycoprotein p30 tests.
B, B, A 16. A 25. D
b. Microscopic examination for the presence of sperm.
8. B 17. D 26. D

Chapter 12 Case Studies and Clinical Situations

Study Questions 1. a. Pleural fluid.
1. B 4. B 6. A b. Transudate because all the test results are consistent
with those of a transudate.
2. A 5. B, C, B, A, D, 7. B
B, D c. Pleural fluid-to-serum ratios of cholesterol and
3. A 8. B
bilirubin.
378 Answers to Study Questions, Case Studies, and Clinical Situations

2. a. Pneumonia. 13. A 16. True 19. B

b. Chest tube drainage. 14. True 17. C 20. D
3. a. 1.6. 15. C 18. B
b. Transudate. The SAAG is above 1.1.
c. Hepatic disorder. Case Studies and Clinical Situations
4. a. To differentiate between cirrhosis and peritonitis; 1. a. Yes.
cirrhosis. b. FLM.
b. Pancreatitis or gastrointestinal perforation; alkaline c. The level of phosphatidylglycerol present in the fetal
phosphatase. lungs.
c. Rupture or accidental puncture of the bladder. d. Phosphatidylglycerol is essential for FLM, and levels
d. To detect the presence of gastrointestinal (CEA) and do not always parallel lecithin levels in fetuses of
ovarian (CA 125) cancers. diabetic mothers.
5. The patient has been a victim of blunt trauma, and the 2. a. A neural tube disorder, such as spina bifida or
physician wants to determine whether abdominal anencephaly.
bleeding is occurring; abdominal bleeding. b. An acetylcholinesterase level.
6. Thyroid profile; CA 125. c. The amniotic fluid specimen contains blood.
3. a. False-positive result.
Chapter 14 b. False-positive result.
c. No effect.
Study Questions
d. False-positive result.
1. D 5. A 9. C
4. a. False-positive result.
2. A 6. A 10. C
b. False-positive result.
3. B 7. B
c. False-positive or test interference.
4. D 8. D
d. No effect.
5. Both a and c are correct. The incorrect specimen was
Case Studies and Clinical Situations sent, or the specimen was exposed to light.
1. a. Red and cloudy. 6. a. Premature rupture of the membranes.
b. Bloody fluid with increasing intensities during b. Fern test, pH test, nitrazine test, AmniSure ROM test,
sequential aliquots. Actim PROM test, and ROM+ test.
c. Phagocytosed erythrocytes. c. PAMG-1, IGFBP-1, AFP.
d. Orange-red fluid. d. Actim PROM test.
e. Hemosiderin-laden macrophages.
f. Prussian blue for hemosiderin-laden macrophages; Chapter 16
Sudan III stain for lipid-laden alveolar macrophages.
2. a. Presence of lymphocytes with decreased ratio of CD4 Study Questions
and CD8.
1. C 11. A 21. B
b. Cryptococcus neoformans.
2. A 12. C 22. C
c. Demonstration of a positive cryptococcal antigen in
3. C 13. D 23. B
the BAL specimen. The extent of the cryptococcal
infection correlates with the antigen titer. 4. B 14. B 24. A
5. D 15. B 25. B
Chapter 15 6. D 16. False 26. B
7. D 17. C 27. A
Study Questions 8. C 18. C 28. C
1. B 5. B 9. A 9. D 19. C 29. C
2. C 6. A 10. C 10. C 20. D 30. B
3. A 7. D 11. B
4. C 8. 2, 4, 1, 3 12. True
 Answers to Study Questions, Case Studies, and Clinical Situations 379

Case Studies and Clinical Situations Chapter 17

1. a. Secretory diarrhea.
Study Questions
b. Stool culture.
c. Probable: Salmonella, Shigella, Campylobacter, Yersinia, 1. D 7. B 13. C
Escherichia coli; Improbable: Staphylococcus, Vibrio. 2. C 8. A 14. A
d. Osmotic diarrhea. 3. C 9. C 15. D
2. a. Microscopic examination for fecal fats. 4. A 10. A 16. C
b. Neutral fats stain directly and appear as large, orange- 5. C 11. C
red droplets; soaps and fatty acids appear as smaller 6. A 12. B
orange-red droplets after pretreatment of the
specimen with heat and acetic acid. Case Studies and Clinical Situations
c. Quantitative fecal fat test.
1. a. Vaginal pH, saline and KOH wet preps, Gram stain.
d. Bulky and frothy.
b. KOH will reveal budding yeast.
e. Muscle fiber screening and the gelatin test for trypsin.
c. Culture and DNA direct hybridization probe (Affirm
f. Muscle fiber: failure to include red meat in the diet. VPIII).
g. Chymotrypsin or elastase I. d. Vulvovaginal candidiasis caused by Candida albicans.
3. a. Patient #1: gastric reflux medication containing e. Antifungal agents.
bismuth may produce black stools. Patient #2:
medications, such as aspirin and other NSAIDs, may 2. a. Trichomoniasis caused by Trichomonas vaginalis.
cause gastric bleeding. Patient #3: red meat was not b. Wet mount, vaginal pH, amine test from KOH prep,
avoided for 3 days before specimen collection. DNA probe (Affirm VPIII), OSOM Trichomonas
b. Provide dietary and medication instructions to Rapid Test.
patients. c. Metronidazole.
c. The Hemoccult ICT immunochemical test. d. Yes.
4. a. The APT test cannot be performed because the e. Complications include low birth rate, premature
hemoglobin is already denatured. It must be red rupture of membranes, and preterm delivery during
blood. pregnancy.
b. The pH will be low because increased carbohydrates 3. a. Desquamative inflammatory vaginitis secondary to
are available for bacterial metabolism. atrophic vaginitis.
c. The infant had ingested maternal blood. b. Reduced estrogen production in postmenopausal
d. Yes, adequate carbohydrates are not present, and fats women.
are being metabolized for energy. c. Hormone replacement therapy (estrogen).