Anisocytes and poikilocytes in the urine.

Two main types of erythrocytes can be found in the urine, i.e.dysmorphic erythrocytes, which are a marker of glomerular bleeding,and isomorphic erythrocytes, which are a marker of urologicaldisorders     

How to improve the teaching of urine microscopy.

BACKGROUND: Urinary microscopy is difficult to teach. This paper describes a 1-day course on urine microscopy, which was based on both theoretical and practical sessions at the microscope, during which real urine samples were examined. METHODS: The course was based on: a) an introductory presentation with slides on the main components of urinary sediments and their clinical correlates; b) examination of fixed urine samples under the guidance of two experts; and c) the use of two microscopes, each equipped with a co-observation device for up to 15 observers. RESULTS: Throughout 2005, four courses were held in four Italian towns. Altogether, there were 97 participants (20-27 per course) from 75 laboratories, all graduates with wide but variable experience in the field. During each course, 17-22 urinary sediment components were shown by both bright-field and phase-contrast microscopy and, when indicated, by polarized light. Tests set before and after the course showed a significant improvement (p<0.01) in the identification of erythrocyte subtypes, epithelial cells, fatty components, various types of casts and drug crystals. A questionnaire conducted with participants by phone several months after the course demonstrated that 51.6% and 32.3% of laboratories have introduced or formally requested phase-contrast and polarized-light microscopy, respectively; 45.2% have changed the terminology for urinary epithelial cells; and 87.1% have identified for the first time urinary sediment components that were not recognized or not considered before the course. CONCLUSIONS: Our course demonstrates that it is possible to improve the teaching of urinary microscopy.     

Skin infection due to Alternaria species in kidney allograft recipients: report of a new case and review of the literature

A kidney allograft recipient developed a cutaneous infection 29 months after transplantation, due to the dematiaceous fungus Alternaria infectoria on his right forearm and left leg. Since the lesions were too large to be excised, the patient was treated only with systemic itraconazole and a reduction of the immunosuppressive therapy. After 4 months, the lesions were completely healed, and no relapses were observed at follow-up of 22 months. Twenty-seven other cases of cutaneous alternariosis have been described so far in renal transplant recipients. All types of immunosuppressive treatment can be associated with Alternaria infection, for which predisposing factors are jobs with frequent contact with earth, diabetes mellitus and skin trauma. In 70% of cases the infection occurred within the first year after transplantation. More frequently the lower limbs were involved and the lesions were multiple. Alternaria alternata was the commonest causative agent, followed by Alternaria tenuissima,Alternaria infectoria and Alternaria chartarum. The treatment is far from being standardized, but the best results are obtained with the surgical excision of the lesion(s) associated with systemic antifungal therapy. Since relapses are possible, strict control of the patients over time is essential.     

Rituximab therapy for primary glomerulonephritis: Report on two cases

The evidence in the medical literature on the efficacy and safety of rituximab therapy for primary glomerulonephritis is limited and controversial. We describe two male Caucasian patients with rapidly progressive kidney failure due to primary proliferative glomerulonephritis. Both of them received high-dose intravenous corticosteroids and oral cyclophosphamide with limited benefit. The first patient(hepatitis C virus-negative mixed cryoglobulinemia) underwent plasma-exchange with intravenous immunoglobulins; he showed significant benefit on kidney function(he became dialysis independent with serum creatinine going back to 1.6 mg/d L) after one rituximab pulse even if urinary abnormalities were still present. No improvement in renal function or urinary changes occurred in the second patient. Both these individuals developed sepsis over the follow-up, the first patient died two months after rituximab therapy. This report is in keeping with the occurrence of severe infections after rituximab therapy in patients with renal impairment at baseline and concomitant high-dose steroids.     

Don't forget sickled cells in the urine when investigating a patient for haematuria

Haematuria is a well-known complication of sickle cell disease.A South African coloured patient with repeated episodes of grosshaematuria is described in whom the diagnosis of sickle celldisease was suggested after the finding of sickled erythrocytesin the urine sediment. The diagnosis was then confirmed by haemoglobin electrophoresis, which revealed sickle cell trait (Hb-AS).It is concluded that sickled erythrocytes must be looked forwhen urine is microscopically scrutinized to determine the sourceof a haematuria.     

Crystalluria: a neglected aspect of urinary sediment analysis

Crystalluria is a frequent finding in the routine examinationof urine sediments. In most instances the precipitation of crystalsof calcium oxalate, uric acid, triple phosphate, calcium phosphateand amorphous phosphates or urates is caused by transient supersaturationof the urine, ingestion of foods, or by changes of urine temperatureand/or pH which occur upon standing after micturition. In aminority of cases, however, crystalluria is associated withpathological conditions such as urolithiasis, acute uric acidnephropathy, ethylene glycol poisoning, hypereosinophilic syndrome.In addition, crystalluria can be due to drugs such as sulphadiazine,acyclovir, triamterene, piridoxylate, primidone, which underthe influence of various factors can crystallize within thetubular lumina and cause renal damage. In all these instancesthe study of crystalluria is diagnostically useful and is alsoimportant to follow the course of the disease. However, a propermethodological approach is necessary. This includes the handlingof freshly voided urine, the knowledge of the urinary pH, andthe use of a contrast phase microscope equipped with polarizingfilters.