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Nephron
Urethra
Urine formation (order)
PCT
ADH
Urine composition
60g

Clearance tests

Creatinine clearance

Tubular Reabsorption
Concentration tests
Fishberg test (Old)
Mosenthal test (Old)
Specific Gravity (New)
Osmolarity

PAH test
PSP test
Midstream/Catheterized
Suprapubic aspiration

MUST TO KNOW IN CLINICAL MICROSCOPY
URINALYSIS
Basic structural unit of kidney
1M/kidney
F: 3-4 cm
M: 20 cm
Glomerulus  Bowman’s capsule  PCT  Loop of Henle  DCT  CD
65% of reabsorption
Regulate H2O reabsorption in DCT and CD
95-97% H2O
3-5% solids
TS in 24 hrs
35g: Organic = Urea (major)
25g: Inorganic = Cl (#1) > Na+ > K+
Glomerular Filtration
Evaluate glomerular filtration
1
...
Creatinine clearance = most common
3
...
Beta2-microglobulin
5
...
73
P
A
Normal values:
M = 107-139 mL/min
F = 87-107 mL/min
Tubular Reabsorption
1st function to be affected in renal disease
Evaluate tubular reabsorption
Patient is deprived of fluid for 24hrs then measure urine SG
(SG ≥ 1
...
86’C
- FP = Osm
Example:
Determine Osm in mOsm/kg
Temp
...
90’C
Solution:
1000 mOsm/kg = _ _x____
-1
...
90’C
x = 484 mOsm/kg
Tubular Secretion and Renal Blood Flow
p-aminohippuric acid
Phensulfonphthalein test
Obsolete, results are hard to interpret
Methods of Collection
Urine culture
Anaerobic urine culture
lec
...
1st portion of voided urine
2
...
Urine after prostatic massage
Compare WBC and Bacteria of specimen 1 and 3
Prostatic infection: 1 < 3 (10x)
Wee bag
Chain of custody: step by step documentation of handling and testing of legal
specimen
Required amount: 30-45 mL
Temperature (urine): 32
...
7’C (w/in 4 mins)
Blueing agent  Toilet bowl (to prevent adulteration)
Types of Urine Specimen
Routine
Qualitative UA
1st voided urine  discarded
w/ preservative
Ex
...
8AM  8PM
Addis count: measure of formed elements in the urine using hemacytometer
Urobilinogen (alkaline tide)
Nitrite determination (1st morning/4 hr)
NO3  NO2 = (+) UTI
Pregnancy test (hCG)
Ideal specimen for routine UA
Most concentrated and most acidic = preservation of cells and casts
Glucose determination
2nd voided urine after a period of fasting
Changes in Unpreserved Urine
Bacterial multiplication
Precipitation of AU/AP
Glycolysis
Volatilization
Photooxidation
Oxidized to urobilin
Disintegrate in alkaline urine
Urea ---(Urease)---> NH3
Multiplication
Urea ---(Urease)---> NH3
Bacterial multiplication
Contamination:  Bacteria
True infection:  Bacteria and WBCs
Preservation
2-8’C
 SG (hydrometer/urinometer)
Precipitate AU/AP
Addis count
Urine culture
lec
...
018
Pregnancy
Roughly indicates the degree of hydration
Should correlate w/ urine SG
 fluid intake: Dark urine,  SG
1
...
Uroerythrin
-Pink pigment
-May deposit in amorphous urates and uric acid crystals
3
...
mt 04 |Page | 136

Red/Purple/Burgundy red/
purplish red/Portwine
Brown/black

Cola-colored
Yellow
Red to brown
Orange-red (acid)
Bright orange-red (acid)
Bright yellow
Nubecula
Bilifuscin (Dipyrrole)
Clear
Hazy
Cloudy
Turbid
Milky
Bacteria
Chyluria
Squamous epithelial cells
Radiographic contrast
media
Vaginal cream
Acidic urine
Alkaline urine
Soluble w/ heat
Soluble w/ dilute acetic
acid
Insoluble in dilute acetic
acid
Soluble in ether

Porphyria
(Lead poisoning: normal color)
Methemoglobin (acid urine)
Homogentisic acid: Alkaptonuria
-Urine darkens after a period of standing
-(-) Homogentisic acid oxidase
Urine Color Changes w/ Commonly Used Drugs
Levodopa (Tx: Parkinsonism)
Red  Brown (alkaline)
Mepacrine/Atabrine (Tx: Malaria, Giardiasis)
Metronidazole/Flagyl (Tx: Trichomoniasis, Amoebiasis, Giardiasis)
Methyldopa/Aldomet (Antihypertensive)
Phenazopyridine/pyridium (Tx: UTI)
Rifampin (Tx: TB) = all body fluids are red
Riboflavin (Multivitamins)
Faint cloud in urine after a period of standing
WBCs, epithelial cells and mucus
Hemoglobin Köln = unstable
Red-brown urine
Clarity/Transparency/Turbidity
Transparent, no visible particulates
Few particulates, print easily seen through urine
Many particulates, print blurred through urine
Print cannot be seen through urine
May precipitate or clot
Uniform turbidity NOT cleared by acidification or filtration
Lymph fluid in urine
Filariasis
 females
 SG by refractometer (>1
...
mt 04 |Page | 137

SG

Refractometer (TS meter)

Urinometer

Rf < U by 0
...

Harmonic Oscillation
Densitometry
Normal

Specific Gravity
Density of solution compared w/ density of similar volume of distilled H2O at a
similar temperature
NV = 1
...
035 (random)
SG <1
...
1g/dL glucose: (-0
...
1g/dL protein: (-0
...
Distilled H2O = 1
...
5% NaCl = 1
...
001
c
...
034 ± 0
...
 3’C calibration temperature (20’C) = (+0
...
 3’C calibration temperature (20’C) = (-0
...
002
K2SO4 solution: 1L H2O + 20
...
015
SG = 1
...
010
SG > 1
...
UTI (Proteus:  urease)
DM (Ketones)
Trimethylaminuria
Isovaleric acidemia
Phenylketonuria
Methionine malabsorption
MSUD
Contamination
Cystine disorder
Chemical Examination of Urine
Specific Gravity
pKa dissociation constant
 concentration =  H+
Indicator: Bromthymol blue = () Blue  Green  Yellow ()
Not affected by glucose, protein and RCM
Frequency of soundwave entering a solution will change in proportion to the
density (SG) of the solution
-Yellow IRIS (Automated): International Remote Imaging System
pH
Random = 4
...
0
1st morning = 5
...
0
pH 9
...
mt 04 |Page | 138

Acid urine

Alkaline urine

Principle (Rgt Strip)

Protein

Normal value
Pre-renal proteinuria

Renal proteinuria

Post-renal proteinuria
Principle (Rgt Strip)

Sulfosalicylic acid
precipitation test

DM (Ketone bodies)
Starvation (Ketone bodies)
High protein diet
Cranberry juice (Tx: UTI)
After meal
Vomiting
Renal tubular acidosis: inability to produce an acid urine
Vegetarian diet
Old specimen: Urea ---(Urease)---> NH3
Double indicator system (Methyl red & Bromthymol blue)
MR + H+ ------------> BTB – H+
pH 4
...
0
pH 6
...
0
(Red-Yellow)
(Yellow-Blue)
Protein
White foam
Analyte indicative of renal disease
1
...
Serum and tubular microglobulins
3
...
Proteins derived from prostatic and vaginal secretions
< 10 mg/dL or < 100 mg/24 hrs
< 150 mg/24 hrs (Henry)
Prior to reaching the kidney
1
...
Muscle injury (Mgb)
3
...
Multiple myeloma: proliferation of Ig-producing plasma cells (BJP)
Bence-Jones protein: Ig light chains (Identical: κ-κ, λ-λ)
-ID: Serum IEP
-Urine: precipitates at 40-60’C and dissolves at 100’C
-Seen in MM, macroglobulinemia, malignant lymphoma
Glomerular and tubular disorders
1
...
Orthostatic/Postural/Cadet: proteinuria when standing due to pressure to
renal veins
-1st morning urine: (-) protein
-2 hrs after standing: (+) protein
3
...
0)---> (-) Yellow
(+)[] Green  Blue []
Sensitive to albumin
Indicators:
a
...
Tetrachlorophenol tetrabromosulfonphthalein
Cold precipitation test that reacts equally to all types of protein
If (-) rgt strip, (+) SSA = presence of other proteins
lec
...
Fructose (Levulose):  fruits, honey syrup
2
...
Lactose
-During lactation
-Towards the end of pregnancy
-Patient on strict milk diet
-(+) Rubner’s test (Lead acetate)
4
...
Sucrose
- Intestinal disorders
-Nonreducing sugar
-(-) Copper reduction test
 Blood glucose,  Urine glucose
1
...
Cushing’s syndrome/disease =  cortisol
3
...
Acromegaly =  GH
5
...
Fanconi’s syndrome: defective tubular reabsorption of glucose and amino
acids
Double sequential enzyme reaction:
-Glucose oxidase
-Peroxidase
Chromogen:
-KI (Brown)
-Tetramethylbenzidine (Blue)
Blue tablet
Relies on the ability of glucose and other substances to reduce CuSO4 to Cu2O in
the presence of alkali and heat
CuSO4 (Blue) -------------> Cu2O (Brick red)
lec
...
Mgb

Hemolytic anemia
Principle (Rgt Strip)
Hgb/Mgb
Hematuria
Extravascular lysis

Occurs if >2 g/dL sugar is present in urine
Blue  Green  Yellow  Brick red  Blue (Pass through)
To prevent, use 2 gtts urine (instead of 5 gtts) + 10 gtts H2O + Clinitest
(+) Nonglucose reducing substance
True glucosuria
Small amount of glucose present
False (+)
Possible oxidizing agent interference on reagent strip
Ketones
Result from increased fat metabolism due to inability to metabolize CHO
78% BHA = major ketone but not detected
20% AA/Diacetic acid = parent ketone
2% Acetone
Diabetic acidosis
Insulin dosage monitoring
Starvation
Vomiting
Legal’s test (Sodium nitroprusside reaction)
AAA + Sodium nitroprusside
--------------> (+) Purple
(Acetone)
(Glycine)
Sodium nitroprusside
Glycine
Disodium phosphate
Lactose
Blood
Cloudy red urine (Intact RBCs)
Renal calculi
GN
Strenuous exercise
Anticoagulants
Clear red urine
Intravascular hemolysis
Clear red urine
Rhabdomyolysis
1
...
Blondheim’s test (Ammonium SO4): Precipitates Hgb
Urine + 2
...
) ---(Filter/Centrifuge)---> Supernatant
Supernatant:
Red = Myoglobin = (+) Rgt strip
Clear w/ red ppt
...
mt 04 |Page | 141

Intravascular lysis
Bilirubin
Significance
Principle (Rgt Strip)

Ictotest

Urobilinogen
Principle (Rgt Strip)
Watson-Schwartz test

Hoesch test (Inverse
Ehrlich reaction)

Hemolytic (ex
...
Urobilinogen: soluble to both chloroform and butanol
2
...
Other Ehrlich’s reactive compounds: soluble to butanol only
Rapid screening test for urine porphobilinogen (≥2mg/dL)
Hoesch reagent: Ehrlich reagent in 6M (6N) HCl
2 gtts urine + Hoesch rgt -------------> (+) Red
Urine Bilirubin and Urobilinogen in Jaundice
Urine Bilirubin
Urobilinogen

/N/

/N (never report as negative)
Nitrite
1st morning/4 hr urine
Detection of bacteriuria
(+) NO3: 100,000 orgs
...
mt 04 |Page | 142

Principle (Rgt strip)

30 seconds
40 seconds
45 seconds
60 seconds

120 seconds
Vitamin C (Ascorbic acid)

SG
pH
Protein

Glucose

Ketones

Indoxyl carbonic acid ester + Diazonium salt ---(LE)---> Indoxyl + Acid indoxyl
----------> (+) Purple
Strip can detect even lysed WBCs
Reading Time (Reagent Strips)
Glucose
Bilirubin
Ketones
SG
“PPBUN”
pH
Protein
Blood
Urobilinogen
Nitrite
Leukocytes
11th reagent pad
Reducing property
False (-) rgt strip: “BB LNG”
-Blood
-Bilirubin
-Leukocytes
-Nitrite
-Glucose
Rgt: Phosphomolybdate
Phosphomolybdate + Vitamin C (≥5 mg/dL) --------> (+) Molybdenum blue

Sources of Error/Interference (Reagent Strips)
False-positive
False-negative
High concentrations of protein
Highly alkaline urines (>6
...
mt 04 |Page | 143

Blood

Bilirubin
Urobilinogen

Nitrite

Leukocytes

False-positive
Strong oxidizing agents
Bacterial peroxidases
Menstrual contamination

Highly pigmented urines, phenazopyridine
Indican (intestinal disorders)
Metabolites of Lodine
Porphobilinogen
Indican
p-aminosalicylic acid
Sulfonamides
Methyldopa
Procaine
Chlorpromazine
Highly pigmented urine
Improperly preserved specimens
Highly pigmented urine

Strong oxidizing agents
Highly pigmented urine, nitrofurantoin

Phase-contrast microscopy

Polarizing microscopy
Interference contrast
microscopy
Sternheimer-Malbin
Toluidine blue (Supravital)
Lipid stains:
ORO and Sudan III
Gram stain
Hansel stain
Prussian blue stain

False-negative
High specific gravity/crenated cells
Formalin
Captopril
High concentration of nitrite
Ascorbic acid >25 mg/dL
Unmixed specimens
Specimen exposure to light
Ascorbic acid >25 mg/dL
High concentrations of nitrite
Old specimens
Preservation in formalin

Nonreductase-containing bacteria
Insufficient contact time between bacteria and
nitrate
Lack of urinary nitrate
Large quantities of bacteria converting nitrite
to nitrogen
High concentrations of ascorbic acid
High specific gravity
High concentrations of protein, glucose, oxalic
acid, ascorbic acid, gentamicin, cephalosporins,
tetracyclines

Microscopic Exam of Urine
Visualization of elements w/ low refractive indices:
-Hyaline casts
-Mixed cellular casts
-Mucous threads
-Trichomonas
ID of cholesterol in OFB, FC and crystals
Produces 3D microscopy-image and layer-by-layer imaging of a specimen
1
...
Nomarski microscope: differential interference contrast microscope
Crystal violet and safranin
Nucleus and cytoplasm
ID: WBCs, ECs, casts
Enhances nuclear detail
Differentiates WBCs and RTE
Stain TG and neutral fats orange red
ID: free fat droplets and lipid-containing cells and casts
Differentiates Gram (+) and Gram (-) bacteria
ID: bacterial casts
Eosin Y and Methylene blue
ID: Eosinophils
Stains structures containing iron
lec
...
vaginalis

ID: yellow-brown granules of hemosiderin in cells and casts
Sediment Constituents
NV = 0-2 or 0-3/hpf
Hypertonic: crenated, shrink
Hypotonic: Ghost cells, swell, hemolyzed
Dysmorphic: glomerular membrane damage, w/ projections, fragmented
Sources of error:
-Yeasts
-Oil droplets
-Air bubbles
-CaOx crystals
♫ Remedy: add 2% acetic acid
-RBCs: lysed
-Other cells: intact
NV = 0-5 or 0-8/hpf
Glitter cells (Hypotonic urine)
-Granules swell
-Brownian movement
>1% eosinophils: significant
- Drug-induced allergic reaction
- Inflammation of renal interstitium
Quantitative measure of formed elements of urine using hemacytometer
Specimen: 12 hr urine
Preservative: Formalin
NV:
a
...
WBCs: 0-1,800,000/12 hr urine
c
...
vaginalis = HBT medium
Spherical, polyhedral, or caudate w/ centrally located nucleus
Derived from the linings of the renal pelvis, ureter, urinary bladder, male
urethra (upper portion)
Not clinically significant in small numbers
Rectangular, polyhedral, cuboidal or columnar w/ an eccentriac nucleus,
possibly bilirubin stained or hemosiderin laden
From nephron:
-PCT: rectangular, columnar/convoluted
-DCT: round/oval
>2 RTE/hpf: tubular injury
Lipid containing RTE cells
Lipiduria (Ex
...
albicans (DM, vaginal moniliasis)
Flagellate w/ jerky motility
lec
...
haematobium
E
...
Physiologic:
- Strenuous exercise (HC, GC, RC)
- Heat
b
...
GN
b
...
Phase contrast microscopy
2
...
5mL/1
...
02 mL)
-10 lpf
-10 hpf
-Reduced light
1
...
mt 04 |Page | 146

Amorphous Urates
(Normal)
(pH: acid)

Calcium Oxalate
(Normal)
(pH: acid/alkaline/neutral)

Amorphous Phosphates
(Normal)
(pH: alkaline/neutral)
Ammonium Biurate
(Normal)
(pH: alkaline)
Triple Phosphate
(Normal)
(pH: alkaline)
Calcium Phosphate
(Normal)
(pH: alkaline/neutral)

Calcium Carbonate
(Normal)
(pH: alkaline)
Cystine
(Abnormal)
(pH: acid)
Cholesterol
(Abnormal)
(pH: acid)

Tyrosine
(Abnormal)
(pH: acid/neutral)
Leucine
(Abnormal)
(pH: acid/neutral)
Bilirubin
(Abnormal)
(pH: acid)

Urine Crystals
Yellow-brown granules
Pink sediment (Uroerythrin)
Mistaken as cystine crystals
Rhombic, wedge, rosette, hexagonal, four-sided plate (whetstone)
Lemon-shaped (Henry)
 Lesch-Nyhan syndrome: orange sands in diaper
 Gout
 Chemotherapy
1
...
Whewellite = monohydrate
-Oval, dumbbell
-Ethylene glycol poisoning (antifreeze agent)
Most renal stones consist of CaOx
White precipitate
Granular appearance
 After meal (alkaline tide)
Yellow-brown
Thorny apples
Old specimen: due to the presence of urea-splitting bacteria
A
...
a
...
Calcium Phosphate = Apatite
2
...
Calcium Hydrogen Phosphate = Brushite
Small and colorless
Dumbbell or spherical shapes
Acetic acid: (+) Effervescence
Colorless hexagonal plates
Cystinuria
Rectangular plate w/ notch in one or more corners
Staircase pattern
Lipiduria (Nephrotic syndrome)
Resemble crystals of RCM, to differentiate
a
...
Correlate w/ other UA results
c
...
040
Colorless to yellow needles
Liver disease (more common)
(+) Nitroso-naphthol
Yellow-brown spheres w/ concentric circles and radial striations
Liver disease
Clumped needles or granules w/ yellow color
(+) Diazo reaction
Liver disease
lec
...
CaPO4 rosette)
♫ Lignin test:
Newspaper = urine + 25% HCl  (+) Yellow orange color
Massive doses
Colorless needles

Uric Acid
Cystine
Color
Yellow brown
Colorless
Solubility in NH3
Soluble
Soluble
Solubility in dilute HCl
Insoluble
Soluble
Birefringence (Polarizing microscope)
+
Cyanide-Nitroprusside test
+
Urinary Sediment Artifacts
1
...
Oil droplets
3
...
Pollen grains = spheres w/ concentric circles
5
...
Fecal contaminants
Cystitis

Urethritis

Glomerulonephritis
Pyelonephritis
Acute Interstitial Nephritis
Renal carcinoma
Nephrotic syndrome

Renal Diseases
Inflammation of urinary bladder
Infection
WBCs, RBCs, bacteria
NO CAST
Inflammation of urethra
WBCs, RBCs
Usually NO BACTERIA on routine UA
a
...
Female: pelvic exam for vaginitis and cervicitis
Inflammation of the glomerulus
Immune-mediated
RBCs, WBCs, RBC CASTS, WBC casts, hyaline and granular casts
Infection of renal tubules
WBCs, RBCs, bacteria, RBC casts, WBC CASTS, hyaline and granular casts
Infection of the renal interstitium
RBCs, WBCs, WBC casts, NO BACTERIA
1’ = RCC
2’ = Transitional CC
RBCs and WBCs
Massive proteinuria and lipiduria
a
...
Urine (CM)
- Albumin, alpha1, beta and gamma globulins
-(-) alpha2 (AMG)
lec
...
Lupus nephritis
b
...
coli = 90% cases of UTI
S
...
vaginalis = bacterial vaginosis
S
...
Overflow type
 AA in blood
 AA in urine
Ex
...
mt 04 |Page | 149

2
...
Cystinuria (COLA), Fanconi’s syndrome
Phenylalanine-Tyrosine Disorders
Phenylalanine

(-)

PAH

PKU

Phenylpyruvic acid

Tyrosinemia

Tyrosyluria:

Tyrosine
Tyrosine transaminase

(-)

p-Hydroxyphenylpyruvic acid
p-Hydroxyphenylpyruvic acid oxidase

Homogentisic acid

p-OHPPA

(-)

Homogentisic acid oxidase

Maleylacetoacetic acid

p-OHPLA
Alkaptonuria
Homogentisic acid

Fumarylacetoacetic acid
Fumaric acid and Acetoacetic acid

Phenylketonuria

Tyrosyluria

Alkaptonuria

Melanuria

MSUD
Organic acidemias

Indicanuria

Severe mental retardation
Mousy odor
(-) PAH
Screen: FeCl3  (+) Blue-green
Confirm: Guthrie test (Bacterial inhibition)
-B
...

Overproliferation of melanocytes
FeCl3  Gray or black ppt
...

1
...
Propionic acidemia
3
...
mt 04 |Page | 150

Argentaffinoma

Cystinuria (Renal type)

Cystinosis
Homocystinuria
Brand’s modification of
Legal’s nitroprusside
MPS
Clinical significance

CTAB
Lesch-Nyhan disease
D-ALA
Porphobilinogen
Uroporphyrinogen

Coproporphyrinogen
Protoporphyrinogen
Protoporphyrin IX
Heme
Porphyrias

Hartnup disease: “Blue diaper syndrome”
Obermayer’s test: FeCl3  (+) Violet w/ chloroform
Carcinoid tumor involving argentaffin cells
 5-HIAA: metabolite of serotonin
FeCl3  (+) Blue-green (PKU)
Nitrosonaphthol  (+) Violet w/ HNO3
Be sure patient should avoid banana, pineapple, tomatoes (serotonin-rich)
Cystine Disorders
Defect in renal tubular transport of:
-Cystine (least soluble  urine)
-Ornithine
-Lysine
-Arginine
Inborn error of metabolism
Cystine deposits in many areas of the body
Cyanide-nitroprusside  (+) Red-purple
Defect in the metabolism of homocystine
Silver nitroprusside  (+) Red-purple
Rxn: Cyanide-nitroprusside  (+) Red-purple
Mucopolysaccharide Disorders
Dermatan SO4
Keratan SO4
Heparan SO4
Alder-Reilly syndrome
Hurler syndrome = MPS  cornea of the eye
Hunter syndrome = Sex-linked recessive
Sanfilippo syndrome = Mental retardation only
(+) White turbidity
Purine Disorders
 Urinary uric acid crystals
Porphyrias
Glycine + Succinyl CoA ----(ALA synthetase)----> D-ALA
D-ALA ----(ALA synthetase)----> Porphobilinogen
Lead poisoning: inhibits ALA synthase
Porphobilinogen -----(Uroporphyrinogen synthase/
Uroporphyrinogen cosynthase)----> Uroporphyrinogen
Acute intermittent porphyria: (-) Uroporphyrinogen synthase
Congenital erythropoietic porphyria: (-) Uroporphyrinogen cosynthase
Uroporphyrinogen ---------(Uroporphyrinogen
decarboxylase)---------------> Coproporphyrinogen
Porphyria cutanea tarda: (-) Uroporphyrinogen decarboxylase
Coproporphyrinogen ---------(Coproporphyrinogen
oxidase)-------------------> Protoporphyrinogen
Hereditary coproporphyria: (-) Coproporphyrinogen oxidase
Protoporphyrinogen ---(Protoporphyrinogen oxidase)---> Protoporphyrin IX
Variegate porphyria: (-) Protoporphyrinogen oxidase
Protoporphyrin IX + Fe2+ ----(Ferrocheletase)--------------> Heme
Lead poisoning: inhibits Ferrocheletase
Vampire disease
Disorders of porphyrin metabolism
lec
...
Ehrlich reaction
= (+) D-ALA and porphobilinogen
2
...
Free Erythrocyte Protoporphyrin (FEP)
= CDC recommended test for Lead poisoning
Urine: red/purple/portwine (normal: Lead poisoning)
Stool
Blood
Bile
RBC inclusion coarse basophilic stippling
Qualitative Tests for Protein
Heller’s
Robert’s
Spiegler’s
Biuret (Albumin)
Heat and acetic acid
SSA
Purdy’s
Potassium ferrocyanide
Picric acid
Kingsbury-Clark (Rgt: SSA)
Esbach’s
-Rgt: Picric acid + Citric acid
Tsuchiya’s
Kwilecki’s
-Rgt: Esbach’s + 10% FeCl3
Qualitative Tests for Sugars
Reducing substances
Rgt: Resorcinol
Fructose  (+) Red
Rgt: Lead acetate, NH3 H2O
Lactose  (+) Bright red w/ red ppt
...

Pentose  (+) Green
Pentose  (+) Green
Osazone or phenylhydrazine (Kowarsky)
Nylander’s
Moore Heller
Borchardt’s
Qualitative Tests for Ketones
Acetone  (+) Purplish red ring
Acetone & AAA  (+) Purple ring
Acetone & AAA  (+) Purple ring
Acetone  (+) Purple
AAA  Bordeaux red
Qualitative Tests for Bile Pigments
Bile  (+) Play of colors
Bile  (+) Emerald green
Bile  (+) Blue to green
lec
...
Zinc acetate
Urobilin  (+) Greenish fluorescence
Qualitative Tests for Hemoglobin
(+) Green-blue
(+) Blue
(+) Blue
Qualitative Tests for Melanin
(+) Black (after 24 hrs)
(+) Dark green or blue color (fresh urine)
(+) Brown to black ppt
...
026
Patient deprived of fluid for 12 hrs = SG ≥1
...
Urea: Urease, DAM (NV = 6-17 g/24 hr urine)
2
...
Uric acid: Uricase, PTA (NV = 0
...
75 g/24 hr urine)
a
...
Renal disease: Normal ratio
 BUN,  Crea
c
...
mt 04 |Page | 153

Sodium hypochlorite soln
...
mt 04 |Page | 154

Care of Reagent Strips

QC (Reagent Strips)

Resolution (Microscope)
Parfocal (Microscope)
Centering and Köhler
illumination (condenser)
Camel-hair brush
Quality assessment

1
...
Store below 30’C
...
Do not expose to volatile fumes
4
...
Do not use if chemical pads become discolored
6
...
Test open bottles of reagent strips w/ known positive and negative controls
every 24 hr (some: at the beginning of each shift)
2
...
Test reagents used in backup tests w/ positive and negative controls
4
...
Record all control results and reagent lot numbers
Ability to visualize fine details
Ability of the lens to distinguish two small objects that are a specific distance
apart
Require only minimum adjustment when switching among objectives
Provide optimal viewing of the illuminated field

Removes dust coating the optical surface of the microscope
Overall process of guaranteeing quality patient care and is regulated
throughout the total testing system
Quality system
Refers to all of the laboratory’s policies, processes, procedures, and resources
needed to achieve quality testing
Accreditation agencies
JCAHO (Joint Commission on the Accreditation of Healthcare Organizations)
CAP (College of American Pathologists)
AABB (American Association of Blood Banks)
AOA (American Osteopathic Association)
ASHI (American Association of Histocompatibility and Immunogenetics)
COLA (Commission on Laboratory Assessment)
NCCLS (National Committee New: CLSI (Clinical and Laboratory Standards Institute)
for Clinical Laboratory
Standards)
Policy for Handling
1
...
Do NOT relabel an incorrectly labeled specimen
3
...
Leave specimen EXACTLY as you receive it; put in the refrigeration for
preservation until errors can be resolved
5
...
of problem and why it must
be corrected for analysis to continue
6
...
Make person responsible for specimen collection participate in solution of
problem(s)
...
Report all mislabeled specimens to the quality assurance board
Preanalytical Factors
Test requests
Patient preparation
Specimen collection, handling and storage
Analytical Factors
Reagents
Instrumentation and equipment
Testing procedure
QC
Preventive maintentance
lec
...
mt 04 |Page | 156

CSF

Production
Functions
CSF glucose
Brain
Meninges (Sing
...
Dura Mater = outermost
- Meningeal layer next to the bone
2
...
Pia Mater = innermost
Skin  Skull  Dura Mater  Arachnoid mater  Subarachnoid space  Pia
mater  Brain
Reabsorbs CSF
If it can’t absorb CSF, CSF accumulates  Hydrocephalus
Produce CSF at approximately 20 mL/hr
Adults:
5th ed
...
Protects brain from organisms
2
...
Maintains homeostasis for brain
Regions of the brain where BBB is weak
1
...
Neurohypophysis (posterior pituitary): ADH, oxytocin
3
...
Subfornical organ
5
...
Median eminence
Lumbar tap: routine (collected by physician)
-Bet
...
mt 04 |Page | 157

Collection

Note

Low volume specimen
Crystal clear
Turbidity/cloudiness

Oily
Hemolyzed/Bloody
Clotted, pellicle
Xanthochromia

Causes of Visible CSF
Xanthochromia

CSF Protein

Distribution of Blood
Clot
Xanthochromia
(+) Clot
(-) Blood
(+) Weblike pellicle
(+) D-dimer
Recent hemorrhage

3 Sterile Tubes
1
...
Microbiology (Room temp)
3
...
Microbiology]
Do not use glass tubes (Henry): Cells will adhere to glass surface producing
erroneous low counts on Tube 3
Excess CSF ---(DO NOT)--> Discard
Left-over supernatant  Chemistry/Serology
CSF specimen  STAT
If STAT not possible, specimens are stored
Collected on 1 tube
Microbiology  Hematology  Chemistry/Serology
CSF Appearance
Normal
WBC > 200μL
RBC > 400μL
(+) Microorganisms
RCM
Aspirated fat
 Protein (>45 but <150mg/dL)
RCM
RBCs
 Protein
 Clotting factors
Pink: very slight amount of HbO2
Orange: heavy hemolysis
Yellow: HbO2  Unconjugated bilirubin
RBC degradation products: most common cause
HbO2 from artifactual RBC lysis
Bilirubin in jaundiced patients
CSF protein >150mg/dL
Merthiolate contamination
Carotenoids (orange)
Melanin (brownish): meningeal metabolic melanoma
Collection of CSF 2-5 days after traumatic tap
In normal neonates: because of immature BBB
NV = 15-45mg/dL
>45 but <150mg/dL (cloudy/turbid)
>150mg/dL (xanthochromic)
Intracranial Hemorrhage vs
...
mt 04 |Page | 158

Erythrophagocytosis/
Hemosiderin granules
CSF Cell count
WBC count

Total CSF cell count
RBC count
Clarity/Appearance
Slightly Hazy
Hazy
Slightly Cloudy
Cloudy/Slightly Bloody
Bloody/Turbid
CSF WBC Count Correction
Differential Count
Methods for specimen
concentration
Cytocentrifugation

CSF Differential count

To examine a bloody fluid for xanthochromia:
Microhematocrit tube ---(Centrifuge)---> Examine supernatant against white BG
Indicates intracranial hemorrhage
Done immediately
WBCs and RBCs lyse w/in 1 hr
Refrigerate if cannot be processed immediately
Routinely performed on CSF
Diluting fluid: 3% Acetic acid
NV (adults) = 0-5 WBC/μL
NV (neonate) = 30 mononuclear WBCs/μL
Vol
...
1 μL
Formula (Improved Neubauer counting chamber):
WBC count = No
...
of sq
...
of 1 sq
...
85% (0
...
1 mL of 1:100 dilution
9
...
)
50-90% monocytes
5-35% lymphocytes
0-8% neutrophils
Children (2 mos
...
o
...
mt 04 |Page | 159

Normal
Adult
Neonates
Pleocytosis
Lymphocytes
Monocytes
Neutrophils
nRBCs (metarubricytes)
Eosinophils

Plasma cells
Macrophages
Nonpathologically
significant cells
Malignant cells

Biweekly basis
Monthly basis
CSF protein

Adults (>18 y
...
)
40-80% lymphocytes
15-45% monocytes
0-6% neutrophils
Cells in the CSF
Lymphocytes
Monocytes
Neutrophils (occasional)
Lymphocytes > Monocytes (70:30)
Monocytes > Lymphocytes
 no
...
immitis)
 medications and shunts
Protozoans do not induce eosinophilia
Charcot-Leyden crystals (E
...
mt 04 |Page | 160

Transthyretin (prealbumin)
Tau Transferrin
 CSF protein
 CSF protein

Correction for traumatic
tap
Measurement of Total CSF
protein

CSF IgG index
 CSF IgG
CSF/Serum Albumin index

IgG index

Oligoclonal bands

Oligoclonal bands (not seen
in serum)

Oligoclonal bands in serum
but not in CSF

TRANSports THYroxine and RETINol
2nd most prevalent
CHO-deficient β2-transferrin
Seen in CSF and not in serum
Electrophoresis: method of choice when determining if a fluid is actually CSF
Damage: BBB (most common)
Production of Ig in CNS (multiple sclerosis)
CSF leakage
Recent puncture
Rapid CSF production
Water intoxication
If blood Hct and serum protein are normal:
= -1 mg/dL protein/1,200 RBCs
1
...
TCA = precipitates albumin and globulins (preferred)
b
...
Dye-binding technique
-Principle: protein error of indicators
-Coomassie Brilliant blue G250 (red)
-Beer’s law
-Protein binds to dye = red to blue
In MS:  CNS IgG
CNS IgG must be differentiated from serum IgG (damage to BBB)
Damage to BBB
Active production w/in CNS (MS)
_CSF Albumin (mg/dL)_
Serum Albumin (g/dL)
a
...
Index ≥9 = BBB is damaged
c
...
Index >0
...
Index <0
...
mt 04 |Page | 161

HIV
Multiple sclerosis
Myelin basic protein
Protein 14-3-3
Prions
β-amyloid protein 42

S
...
influenzae
N
...
pneumoniae
L
...
10%)
In patients w/ dementia
Suggests CJD – caused by prions
“Mad cow disease” in cattle
Live proteins
Infectious protein
Spongiform encephalopathy (CJD)
 CSF levels of microtubule associated Tau protein and decreased levels of βAP42 have been shown to significantly increase the accuracy of Alzheimer’s
disease
Meningitis
Neonates – 1 month
1 month – 5 years old
5 – 29 years old
>29 years old
Infants
Elderly
Immunocompromised patients
CSF Glucose
NV = 60-70% of the plasma glucose concentration
A plasma glucose must also be run for comparison
Diagnostic significance:
- values
- CSF glucose values = result of  plasma glucose
Bacterial, TB, fungal meningitis
Viral meningitis
CSF Lactate
Frequently used to monitor severe head injuries
False elevations: Xanthochromia/hemolysis (RBC contains lactate)
Normal lactate
Bacterial meningitis
Fungal and TB meningitis
Viral meningitis
CSF Enzymes
Serum: LD 2 > 1 > 3 > 4 > 5 [MI: LD 1 > 2 > 3 > 4 > 5]
CSF (normal): LD 1 > 2 > 3 > 4 > 5
Neurologic abnormalities: LD 2 > 1
Bacterial meningitis: LD 5 > 4 > 3 > 2 > 1
 Postcardiac arrest (poor prognosis)
<17 mg/mL = recovery
CSF Glutamine
Product of ammonia and α-ketoglutarate
NV = 8-18 mg/dL
Requested for patients w/ coma of unknown origin
Associated w/ some disturbances of consciousness
lec
...
neoformans

Limulus lysate test

CSF serology
PAM (Henry)

L
...
pneumoniae
-H
...
coli
-N
...
agalactiae (NB)
-L
...
neoformans
India ink
GS: Starburst pattern
-seen more often than a (+) India ink
Latex agglutination test
Diagnosis of Gram (-) bacteria
Reagent:
-Blood cells (Amoebocytes) of horse-shoe crab (Limulus polyphemus)
-Amoebocytes: contain copper complex that gives them blue color
Principle: In the presence of endotoxin, amoebocytes (WBCs) will release lysate
(protein)  (+) Clumping/Clot formation
All materials must be sterile (Tap water: endotoxin)
Det
...

Acridine orange stain: useful to differentiate amoeba (brick-red) from
leukocytes (bright green)
The only Gram (+) that produces endotoxin
(-) Limulus lysate test
Seminal Fluid
Secrete testosterone
Outside the seminiferous tubules
Site of spermatogenesis
Stores and concentrates sperm
Sperm maturation
Zn3+, enzymes and proteins (coagulation and liquefaction)
Fluid:  fructose
Transports sperm  ejaculatory duct
Secretes alkaline mucus  neutralize prostatic and vaginal acidity
Serve as nurse cells for developing sperm cells
Inside the seminiferous tubules
Spermatogonia  1’ Spermatocytes  2’ Spermatocytes  Spermatids 
Sperm
Either WBCs or spermatids
Seminal Fluid Composition
60-70%
20-30%
lec
...
Masturbation: best
2
...
Common condom collection
-Condoms for sperm collection:
a
...
Polyurethane condoms: called the Male Factor Pak
4
...
Specimen should be delivered in the lab w/in 1 hr (RT’)
Specimen kept at 37’C awaiting analysis
For artificial insemination, it can be preserved in frozen state and stored at
-85’C (seminal banks)
Fresh specimen is clotted
Semen Analysis
30-60 mins
If not yet liquefied after 2 hrs, use α-chymotrypsin
Color = grayish white
Volume = 2-5 mL
Viscosity = pour in droplets
pH = 7
...
0
Sperm concentration = >20,000,000/mL
Sperm count = >40,000,000/ejaculate
Motility = >50% w/in 1 hr
Motility quality = >2
...
mt 04 |Page | 164

Sperm concentration

Diluting fluid:
1
...
Formalin
3
...
0
...
1% formalin in 3% trisodium citrate
1:20 = mechanical positive displacement pipette
Counting chamber
1
...
Makler chamber = undiluted w/ heating processes
Purpose of Dilution
To immobilize the sperm
Det
...
(Short-cut) 1
...
2 WBC squares
# sperms counted x 100,000 = sperms in million/mL
Sperm count
Sperm concentration x volume of specimen
Motility quality (20/hpf)
4
...
0 (b) = Slower speed, some lateral movement
2
...
0 (c) = No forward progression
0 (d) = No movement at all
CASA
Computer-Associated Semen Analysis
-Sperm concentration
-Sperm velocity and trajectory
Sperm morphology
At least 200 sperms evaluated
1
...
Kruger’s strict criteria = >14% normal morphology
-measure head, neck, tail using micrometer
Head morphology
Poor ovum penetration
abnormalities
Tail abnormality
Poor motility
Sperm head
Oval, approximately 5 μm x 3 μm wide
Tail
45 μm long
Midpiece
Contains mitochondria
Connects head and tail
Acrosomal cap
Ovum penetration
Covers approximately 2/3 of sperm nucleus and ½ of the head
Tapered head
Varicocele
-Common cause of male sterility
-Hardening of veins that drains the testes
Stains
Giemsa
Papanicolau = method of choice
Wright’s
Fructose test
If sperm count is low
Rgt: Resorcinol
End-color: Orange-red
Specimens should be tested in 2 hrs or frozen
 neutral-α-glucosidase
Epididymis disorder
Florence test
Choline
(+) Dark brown rhombic crystals
Barbiero’s test
Spermine
(+) Yellow leaf-like crystals
lec
...
5 mL
Color = pale yellow
Clarity = clear
Viscosity = 4-6 cm long
Crystals = none present
Glucose = <10 mg/dL lower than the blood glucose
Lactate = <250 mg/dL
Total protein = <3 mg/dL
Uric acid = equal to blood value
lec
...
3%)
-Saline w/ saponin
Do not use WBC diluting fluid
65% = Monocytes & Macrophages
<25% = Neutrophils
<15% = Lymphocytes
Add hyaluronidase  0
...
05% hyaluronidase in PO4 buffer/mL of fluid
37’C for 5 mins
Neutrophil
Vacuolated macrophage w/ ingested neutrophils
Neutrophil w/ dark cytoplasmic granules
Large multinucleated cells
Macroscopically resembles polished rice
Ochronotic shards = debris
Metal and plastic joint prosthetic
Pigmented villonodular synovitis
Osteoarthritis
Crystals
No crystals
Hydroxyapatite crystals
Cholesterol
Corticosteroid
MSU = needle-like (gout)
CPP = needle-like/rods (pseudogout)
(-) Birefringence (yellow) on compensated (red) polarizing microscopy
(+) Birefringence (blue) on compensated (red) polarizing microscopy
Joint Disorders
OA
Traumatic arthritis
Neuroarthropathy
Immunologic: RA, SLE
Crystal-induced: milky synovial fluid
Yellow green
Low viscosity
>50,000 WBC/μL (highest)
lec
...
gonorrhoeae (gonococcal arthritis)
S
...
burgdorferi: Lyme disease (Stage 3: Lyme arthritis)
Sickle cell disease
Glucose = Blood
Serous Fluids
Fluids that are formed between the parietal and visceral membrane
Ultrafiltrate of plasma
Provides lubrication
Increase in serous fluid amount between the membranes
Either transudate or exudates
From disturbances of fluid production and regulation between serous
membranes
-Hypoproteinemia
-Nephrotic syndrome
-CHF
Testing of transudates is not necessary
Purulent fluid that forms in any body cavity as a result of inflammatory
processes
-Infection
-Malignancies
>100 mL is usually collected
EDTA = cell counts and differential
Heparin = chemistry, serology, microbiology, cytology
Differentiates transudates from exudates
Acetic acid + H2O + unknown fluid  heavy ppt
...
mt 04 |Page | 168

Normal volume
Mesothelial cells
Function
Normal appearance
Grossly bloody
Milky
Bacterial endocarditis
Paracentesis
Peritoneal lavage
WBC <500/μL
RBC >100,000/μL
Serum Ascites Albumin
Gradient (SAAG)
Psammoma bodies
(+) CA 125
(-) CEA
Glucose
ALP
AMS
BUN
Creatinine
Cystic fibrosis
(mucoviscidosis)

Gibson and Cooke
Pilocarpine Iontophoresis
Sodium
Chloride
During 1st trimester
After 1st trimester
3rd trimester
Oligohydramnios

Hydramnios/
Polyhydramnios
Amniocentesis
Fern test

10-50 mL
Produces pericardial fluid
Reduces friction
Clear/pale yellow
Accidental cardiac puncture
Misuse of anticoagulant medicatios
Chylous/pseudochylous effusions
>1000 WBCs/μL (% neutrophils)
Peritoneal Fluid (Ascites)
Method of collection
Sensitive test for the detection of intra-abdominal bleeding
Normal
Blunt trauma cases
Recommended to differentiate transudates from exudates
a
...
1 = Transudate
b
...
1 = Exudate
Contains concentric striations of collagen materials
Ovarian and thyroid malignancies
Tumor of ovaries, fallopian tubes or endometrium
 TB peritonitis
Intestinal perforation
Pancreatitis
GI perforation
Ruptured bladder or accidental puncture of the bladder
Sweat Test
Autosomal recessive
Pancreatic insufficiency
Respiratory distress
Intestinal obstruction
-Bulky offensive greasy stools (butter-like)
 Sweat Cl- and Na+ = >70 mEq/L
Borderline = 40 mEq/L
Pilocarpine w/ mild current = stimulates sweat glands
FEP, IEE
Manual or automated titration
Amniotic Fluid
35 mL: derived from maternal circulation/plasma
Fetal urine
Peak: 1L amniotic fluid
 amniotic fluid
Urinary tract deformities
Membrane leakage
 fetal swallow of urine
 amniotic fluid
 fetal swallow of urine
Neural tube defects
Method of collection
2nd trimester: assess genetic defects
3rd trimester: FLM or HDN
Specimen: Vaginal fluid
lec
...
Zone 1: observe fetus for stress
2
...
Zone 3: severe disease
Ex
...
0 = mature fetal lungs
Disadvantage: can’t be done on specimen contaminated w/ meconium
Surfactant for alveolar stability
Produced by type II alveolar pneumocytes (stored as lamellar bodies = about
the size of platelets)
Detect the presence of phosphatidyl glycerol
Advantage: not affected by blood or meconium
Amniotic fluid + 95% ethanol  shake for 15 secs  stand (15 mins)
(+) Continuous line of bubbles
Can be done bedside
Creatinine ≥2
...
Levine tube = nose
2
...
Pentagastrin = most preferred
2
...
mt 04 |Page | 170

Test Meals
Yeast cells in Gastric fluid
Free HCl

Total Acidity

Combined HCl
(bound to proteins)
Euchlorhydria
Hyperchlorhydria
Hypochlorhydria
Achlorhydria
Diagnex tubeless test

Lactic acid

Creatorrhea

Celiac disease
Steatorrhea

3
...
Alcohols
5
...
Ewald’s meal = bread and tea/H2O
2
...
Riegel’s = mashed potato and beef steak
Fermentation in stomach because large amounts of food have been retained
Quantitative Tests for Gastric Acidity (Topfer’s)
Titration: NaOH
pH indicator: Dimethylaminoazobenzol
(+) Canary yellow
NV = 25-50O
Titration: NaOH
pH indicator: phenolphthalein
(+) Faint pink
NV = 50-75O
Titration: NaOH
pH indicator: sodium alizarin
(+) Violet
NV = 10-15O
Normal free HCl
 free HCl
Ex
...
carcinoma of the stomach
(-) free HCl
Ex
...
Modified Uffelmann’s
-Rgt: FeCl3 and phenol
-(+) Yellow
2
...
Kelling’s
-Rgt: FeCl3
-(+) Yellow
Fecalysis
Undigested muscle fibers in feces
Stain: Eosin
a
...
Partially digested: striation in one direction
c
...
lamblia
lec
...
5 mL blood/150g stool
Least sensitive but the most preferred
Most sensitive
Pseudoperoxidase activity of Hgb
(+) Blue
Vitamin C
Turnips, broccoli, cauliflower, banana, apple, melon, horseradish (to avoid, 3
days free)
Aspirin, aspilet (promote GIT bleeding; to avoid, 7 days free)
Red meat (to avoid, should be 3 days free)
Distinguish fetal blood and maternal blood in an infant’s stool
Specimen: infant stool/vomitus
Rgt: 1% NaOH
HbF: alkali-resistant
Maternal Hgb: not alkali-resistant
lec
...
Trypsin
= X-ray paper
= Trypsin deficiency (CF): inability to digest gelatin on the X-ray paper
2
...
Elastase I = pancreas specificity
Stool pH = 7
...
0
pH 5
...
5 g/dL = CHO intolerance
Follow up tests:
a
...
Lactose intolerance test: maldigestion
Primarily neutrophils
 Neutrophils:
-Salmonella
-Shigella
-Campylobacter
-Yersinia
-EIEC
(-) Fecal leukocytes:
-Parasites
-Viruses
-S
...
mt 04 |Page | 173

Duodenal fluid
Secretin
Pancreozymin
Secretin test
Pancreatic cancer
Chronic pancreatitis

1st morning
24 hr
Throat swab
Tracheal aspirate
Transparent
White/yellow
Gray
Yellow-green
Green
Red or Bright red
Anchovy sauce/rusty
brown
Rusty red
Brown
Black
Prune juice
Olive green/grass green
Causes of blood-stained
sputum
Heart failure cells
Odorless
Foul/putrid

-intake of fat = 100g/day
Prior to and during collection  paint cans
Van de Kamer titration = NaOH
Duodenal Fluid
Physiologically acidic pH stimulates mucosal cells to produce secretin
Stimulates watery pancreatic secretions w/ bicarbonate
Provokes enzyme production of pancreas (AMS, LPS)
Secreted by mucosal cells
(-) Pancreozymin = (-) AMS & LPS
Most sensitive test for impaired pancreatic function
Secretin is administered IV, then duodenal fluid HCO3- is tested
 volume
N-HCO3N-AMS
 volume
 HCO3 AMS
Sputum
Most ideal
Volume measurement:
 vol = bronchiectasis, lung abscess, edema, gangrene, TB
 vol = bronchial asthma, acute bronchitis, early pneumonia
Pediatric patients
Debilitated patients
Sputum Color
Normal
Mucus only
(+) Pus
(+) Pus, EC
TB, bronchiectasis
P
...
Rusty, (+) pus = pneumococcal pneumonia
b
...
Bright streaks in viscid sputum = K
...
Spurious hemoptysis = nosebleed
Hemosiderin laden macrophages in the alveolar spaces
Sputum Odor
Normal
Cavitary TB
lec
...
aeruginosa
TB, Bronchiectasis
Consistency
Asthma and bronchitis
Lung edema
TB, bronchiectasis
Macroscopic Structures in Sputum
Made of fibrin
Branching tree-like casts
Lobar pneumonia
Fragments of necrotic pulmonary tissue
Pulmonary TB
Pulmonary gangrene
Grayish to yellowish material
Size of pinhead
Foul odor when crushed
Cellular, fatty acids, fat globles, some bacteria
Bronchiectasis
Chronic bronchitis
Bronchial asthma (3C’s)
From calcified pulmonary tissue
Histoplasmosis
Mucoid threads that are twisted/coiled
Bronchial asthma (3C’s)
Bronchitis
Bronchiectasis
Lung abscess
Gangrene
Top = Frothy mucus
Middle = opaque H2O material
Bottom = pus, bacteria, tissues
Microscopic Elements
Alveolar proteinosis
P
...
albicans
C
...
immitis
1
...
P
...
E
...
mt 04 |Page | 175

Clinical significane
Macrophages (56-80%)
Lymphocytes (1-15%)
Neutrophils (<3%)
Eosinophils (<1 to 2%)
hCG

Specimen
Ascheim-Zondek
Hogben
Galli-Mainini
Friedmann’s
Frank-Bermann

4
...
gingivalis
5
...
tenax
Bronchoalveolar Lavage
P
...
mt 04 |Page | 176



---