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Renal Physiology (review)

kidney function
kidneys to clear waste products selectively from the blood maintain the bodys essential water and electrolyte balances

renal blood flow glomerular filtration, tubular reabsorption tubular secretion

Renal Physiology (review)

85%; on kidney cortex removal of waste products and reabsorption of nutrients

with longer loops of Henle that extend deep into the medulla of the kidney primary function is concentration of the urine.

Renal Blood Flow

Ave body size = 1.73m2
Renal Blood flow = 1.2L/min Total Renal Plasma Flow = 600-700 mL/min

Factors Affecting Glomerular Filtration

Renin-Angiotensin System

Renal Concentration

Urine Formation

Urinalysis- the physical, chemical, and

microscopic analysis of urine

Urine- a fluid continuously formed by the

- an ultrafiltrate of plasma from which glucose, amino acid, water, and other substances essential to the body metabolism have been reabsorbed

I. Water 2. Organic Solids Urea, Creatinine, Uric Acid 3. Inorganic Solids Chloride, Sodium, Potassium Trace amounts of: magnesium, calcium, iron, ammonia, etc. 4. Other components (may be present or not): hormones, vitamins, medications 5. Formed Elements (not part of the original plasmas filtrate): cells, casts, crystals, mucus, and bacteria

1. Fluid Intake 2. Fluid loss from nonrenal sources 3. Variations in Secretions of antidiuretic hormone (ADH) Substances that affect ADH secretion: caffeine, diuretics, alcohol 4. Necessity to excrete amounts of dissolved solids (ex. Glucose or salts) Volume: Average Daily Output: 1200-1500ml Normal Range: 600-2000ml

1. Specimen must be collected in a clean, dry container 2. Container must be properly labeled w/ : patients name, date and time of collection, hospital #, doctors name 3. the specimen must be delivered to the laboratory w/in 1 hour after collection, or refrigerate it or add preservatives

Refrigeration Thymol Boric Acid Formaldehyde Chloroform Toluene Sodium fluoride Phenol Commercial Preservative Tablets Urine C + S Transport Kit

NORMAL COLOR: yellow, pale yellow, light yellow, dark yellow and amber (due to the presence of urochrome)

Urine Appearance

Non Pathogenic Causec

Pathogenic Cause

measures the ability of the kidneys to reabsorb essential chemicals and water from the glomerular filtrate
detects possible dehydration or abnormalities in ADH used to determine whether specimen concentration is adequate for chemical tests

plasma filtrate= 1.010 s.g

normal random specimen = 1.001-1.035 (depending on patients degree of dehydration) >1.035- patients who have recently undergone intravenous pyelogram resulting to excretion of radiographic contrast media
Use reagent strip because this is not affected by the presence of the dye

Not part of the routine analysis

1. pH
Clinical Significance:

1. Respiratory or metabolic acidosis 2. Respiratory or metabolic alkalosis 3. Defects in renal tubular secretion and reabsorption of acids and bases 4. Precipitation of crystals and calculi 5. Treatment of urinary tract infections 6. Determination of unsatisfactory specimen

2. Proteins
Normal Urine Protein: < 10 mg/dL or 100 mg/24 hours

Commonly Found Proteins: albumin, serum and tubular microglobulins, Tamm-Horsfall proteins produced by the tubules, proteins from prostatic, seminal and vaginal secretions

2. Proteins
Clinical Significance: 1. Glomerular Membrane Damage a. Immune complex disorders (SLE, Streptococcal glomerulonephritis) b. Amyloidosis c. Toxic Agents 2. Impaired tubular reabsorption 3. Multiple Myeloma 4. Diabetic nephropathy 5. Pre-eclampsia 6. Orthostatic or postural proteinuria

3. Glucose
Clinical Significance: 1. Diabetes Mellitus 2. Impaired Tubular Reabsorption Fanconis Syndrome Advance tubular renal disease 3. CNS damage 4. Thyroid Disorders 5. Pregnancy w/ possible latent DM

4. Ketones
Clinical Significance: 1. Diabetes mellitus 2. Insulin dosage monitoring 3. Starvation 4. Excessive carbohydrate loss

5. Blood
Clinical Significance: A. Hematuria 1. Renal calculi 2. Glomerulonephritis 3. Pyelonephritis 4. Tumors 5. Trauma 6. Exposure to toxic chemicals or drugs 7. Strenuous exercise B. Hemoglobinuria 1. Transfusion reactions 2. Hemolytic Anemias 3. Severe burns 4. Infections 5. Strenuous exercises/ RBC trauma C. Myoglobinuria 1. Muscular trauma 2. Prolonged coma 3. Convulsions 4. Muscle wasting diseases 5. Extensive exertions

6. Bilirubin
Clinical Significance: 1. Hepatitis 2. Cirrhosis 3. Other Liver disorders 4. Biliary obstruction

7. Urobilinogen
Clinical Significance: 1. Early detection of liver disease 2. Hemolytic disorders

URINE BILIRUBIN AND UROBILINOGEN IN JAUNDICE Urine Bilirubin Urine Urobilinogen Bile duct obstruction +++ Normal Liver damage + or ++ Hemolytic Disease negative +++

8. Nitrite
Clinical Significance 1. Cystitis 2. Pyelonephritis 3. Evaluation of antibiotic therapy 4. Monitoring of patients of high risk for UTI 5. Screening of urine culture specimen

9. Leukocytes
Clinical Significance: 1. UTI 2. Screening of Urine culture specimen

10. Specific Gravity

Clinical Significance:

1. Patients hydration and dehydration 2. Loss of renal tubular concentrating ability 3. Diabetes insipidus 4. Determination of unsatisfactory specimen due to low concentrations

TEST Color Turbidity Specific Gravity pH Glucose Ketones Blood Protein Bilirubin Urobilinogen Nitrate for Bacteria Leukocyte Esterase Casts Red Blood Cells

NORMAL VALUES Pale yellow to amber Clear to slightly hazy 1.015-1.025 4.5-8.0 Negative Negative Negative Negative Negative 0.1-1.0 Negative Negative Occasional hyaline casts Negative or rare

TEST Crytals

NORMAL VALUES Acid Urine: Amorphous urates Uric acid Calcium oxalate Sodium acid Urates Alkaline Urine Amorphous phosphates Calcium phosphate Ammonium blurate Triple phosphates Calcium carbonate

White Blood Cells Epithelial Cells

Negative or rare Few

Microscopic Examination of Urine Methodology

Pour 10-15 ml well-mixed fresh urine in the test tube Centrifuge at low speed for 5-10 minutes u Decant supernatant The sediment (0.5 1 ml) is resuspended Pour a drop of resuspended sediment in the glass slide Place a coverslip

Microscopic Examination of Urine Methodology

Examine slide first under LPO RBCs and WBCs range per HPO Casts reported as range per LPO Epithelial cells, crystals and others reported as 1+, 2+, 3+ and 4+ or (rare, occasional, few, moderate, many and packed (heavy) Casts, epithelial and crystals are reported as to their type

Correlate Microscopic results with physical and chemical

Microscopic elements

Turbidity Red color Turbidity

+Blood +Protein +Nitrite +Leukocyte

Number Hemolysis Number Lysis Number

Epithelial cells


Bacteria Turbidity

pH +nitrite +leukocytes

Number and type


Turbidity Color


Umber and type

Normal Values:

RBCs = 0-2/hpf WBCs = 0-5/hpf

Hyaline casts = 0-2/slide

Microscopic Examination of Urine

Hematuria Glomerulonephritis, acute infections, toxic immunologic reactions, malignancies, circulatory disorders Essential to renal calculi diagnosis Physiological: menstruation, strenuos exercise (hyalin, granular and rbc casts Confused with yeast and oil droplets RBC dissolved in acetic acid

Red blood cells in urine appear as refractile disks. With hypertonicity of the urine, the RBC's begin to have a crenated appearance

Microscopic Examination of Urine

RBC's normal shaped, swollen by dilute urine crenated by concentrated urine red cell ghosts may simulate yeast dysmorphic RBC's in urine suggests a glomerular disease such as a glomerulonephritis

Note the irregular outlines of many of these RBC's, compared to two relatively normal RBC's at the center left of the right panel. These abnormal RBC's are dysmorphic RBC's

Microscopic Examination of Urine

Dilute urine - RBC's may swollen (cell ghosts and free hemoglobin may remain) concentrated urine crenated RBCs In addition, red cell ghosts may simulate yeast.

Microscopic Examination of Urine

white blood cells
Pyuria - abnormal numbers of leukocytes usually granulocytes Bacterial infections (pyelonephritis, cystitis, prostatitis, urethritis) Non-bacterial infections (glomerulonephritis, tumors) If 2 or more leukocytes/HPO appear in non-contaminated urine, the specimen is probably abnormal

Microscopic Examination of Urine

White blood cells

These white blood cells in urine have lobed nuclei and refractile cytoplasmic granules.

Microscopic Examination of Urine

Epithelial cells

From the linings of the genitourinary system Not pathologic unless present in large numbers
Squamous epithelial cells in urine - Large polygonal cells with small nuclei, contamination with skin flora

Microscopic Examination of Urine

transitional epithelial cells

Transitional epithelial cells from the renal pelvis, ureter, or bladder have more regular cell borders, larger nuclei, and smaller overall size than squamous epithelium.

Microscopic Examination of Urine

Transitional epithelial cells

Microscopic Examination of Urine

Renal epithelial cells
smaller and rounder than transitional epithelium, and their nucleus occupies more of the total cell volume. Most significant Tubular necrosis (tubular damage), pyelonephritis, viral infections, allograft rejection, toxic reactions

Microscopic Examination of Urine

Lipiduria occurs, tahese cells contain endogenous fats When filled with numerous fat droplets, such cells are called oval fat bodies

Microscopic Examination of Urine

Oval Fat bodies

Oval fat bodies exhibit a "Maltese cross"configuratio n by polarized light microscopy

Microscopic Examination of Urine Casts

Unique to the kidney formed only in the distal convoluted tubule (DCT) or the collecting duct The proximal convoluted tubule (PCT) and loop of Henle are not locations for cast formation Hyaline casts are composed primarily of a mucoprotein (Tamm-Horsfall protein) secreted by tubule cells.

Microscopic Examination of Urine casts

glomerular injury increased glomerular permeability to plasma proteins with resulting proteinuria most matrix or "glue" that cements urinary casts togethera is TammHorsfall mucoprotein example of glomerular inflammation with leakage of RBC's to produce a red blood cell cast

Microscopic Examination of Urine Types of casts

Factors which favor protein cast formation are: 1. low flow rate a 2. high salt concentration 3. low pH all favor protein denaturation and precipitation, particularly that of the Tamm-Horsfall protein Protein casts with long, thin tails formed at the junction of Henle's loop and the distal convoluted tubule are called cylindroids

Microscopic Examination of Urine

Hyaline casts
Hyaline casts, which appear very pale and slightly refractile, are common findings in urine

Microscopic Examination of Urine Hyaline casts

may be seen in healthy patient Clinical significance: glomerulonepritis, pyeloneprhitis, chronic renal disease Normal value: 0-2/hpf

Microscopic Examination of Urine RBC casts

Red blood cells may stick together anad form red blood cell casts Indicative of glomerulonephritis, with leakage of RBC's from glomeruli, or severe tubular damage.

Microscopic Examination of Urine WBC casts

White blood cell casts are most tyapical for acute pyelonephritis may also be present with glomerulonephritis Presence indicates inflammation of the kidney, because such casts will not form except in the kidney.

Microscopic Examination of Urine Granular cast

Desintegration of cellular casts Tubule cell lysosomes protein aggregates glomerulonephritis, pyelonephritis, stress and exercise

Microscopic Examination of Urine Waxy cast

Hyaline and granular casts Stasis of urine flow Broad casts emanate from damaged and dilated tubules and are therefore seen in endstage chronic renal disease.

Microscopic Examination of Urine

Microscopic Examination of Urine Renal cast

Microscopic Examination of Urine Bacteria common - abundant normal

microbial flora of the vagina or external urethral meatus rapidly multiply in urine standing at room temperature bacteriuria generally, more than 100,000/ml Multiple organisms reflect contamination presence of any organism in catheterized or suprapubic tap specimens should be considered significant.

Microscopic Examination of Urine Yeast

Yeast cells may be contaminants or represent a true yeast infection often difficult to distinguish from RBCs distinguished by their tendency to bud Most often they are Candida, which may colonize bladder, urethra, or vagina.

Microscopic Examination of Urine Crystals

Common crystals -seen even in healthy patients include: calcium oxalate, triple phosphate crystals and amorphous phosphates.

Uncommon crystals include: 1. cystine crystals in urine of neonates with congenital cystinuria or severe liver disease 2. tyrosine crystals with congenital tyrosinosis or marked liver impairment, 3. leucine crystals in patients with severe liver disease or with maple syrup urine disease.

Microscopic Examination of Urine

Envelope shape clorless Acid/alkaline/neutral urine Soluble in dilute HCl

Calcium oxalate

Microscopic Examination of Urine Calcium oxalates

Microscopic Examination of Urine Triple phosphates crystals

Coffin-lids appearance Colorless Alkaline urine Soluble in dilute acetic acid

Microscopic Examination of Urine triple phosphate crystals

Microscopic Examination of Urine Amorphous crystals

Amorphous urates - acid urine - brick dust or yellow brown - alkali and heat soluble Amorphous phosphates - alkaline or neutral urine - white colorless - dilute acetic acid soluble

Microscopic Examination of Urine Uric Acid crystals

Yellowish brown Acid urine Alkali soluble

Microscopic Examination of Urine Uric acid crystals

Microscopic Examination of Urine Crystals

Major abnormal urinary crystals 1. Cystine (acid) 2. Cholesterol (acid) 3. Leucine (acid/neutral) 4. Tyrosine (acid/neutral) 5. Bilirubin (acid) 6. Sulfonamides (acid/neutral) 7. Radiographic dye (acid) 8. Ampicillin (acid/neutral)

Cystine crystals

Microscopic Examination of Urine

Miscellaneous urinary elements

Microscopic Examination of Urine

Miscellaneous urinary elements

Microscopic Examination of Urine

Miscellaneous urinary elements

Microscopic Examination of Urine

Miscellaneous urinary elements
Air Bubbles

Microscopic Examination of Urine

Miscellaneous urinary elements

Microscopic Examination of Urine

Miscellaneous urinary elements
Glove powder


Accumulation of abnormal metabolic substances in the urine overflow type: increased production of metabolites
due to defects in normal metabolic pathway

inherited metabolic renal type: malfunctions in the tubular reabsorption


mousy odor urine absence of gene that codes for the enzyme phenylalanine hydroxylase increased keto acids including phenylpyruvate decreased tyrosine and its pigmentation metabolites normal conversion of phenylalanine to tyrosine is disrupted results to severe mental retardation phenylalanine should be eliminated in the diet

o TESTS: 1.Bacteria (Bacillus subtilis) inhibition tests: counteract of -2 thienylalanine that inhibits B. subtilis 2.Chemical and immunologic test 3.Automated (Fluorescence) 4.Phenixtix: blue-gray green-gray color 5.Ferric chloride tube test: blue-green color

o excess tyrosine or its degradation product: phydroxyphenylpyruvic acid and p-hydroxyphenyllactic acid o transitory tyrosinemia in premature infants due to underdevelopment of the liver function necessary to complete the tyrosine metabolism o TESTS:
1. Ferric chloride: green color that fades rapidly (to distinguished from PKU)

recommended screening tests

1. Nitroso-naphthol test: orange-red recommended screening tests: 1. Nitroso-naphthol test: orange-red 2. Millons test: red color

Alkaptonuria (alkali-lover )
o urine darkens upon standing at room temperature o failure to produce the enzyme homogentisic acid oxidase o not clinically manifested in early childhood o brown or black stained cloth diapers or reddish-skinned diapers (disposable) o lead to arthritis, liver, and cardiac disorders

Alkaptonuria (alkali-lover )
1. Ferric chloride tube test: transient deep blue color 2. Phenixtix: negative 3. Benedicts test for Clinitest: yellow precipitate 4. Addition of alkali to freshly voided urine: darkening color (more specific)- interfere by the presence of ascorbic acid 5. Addition of silver nitrate and ammonium hydroxide: produce black urine 6. Spectrophotometric method

o Increased urinary melanin (dark urine after exposure to air) o Overprolifertaion of normal melanin-producing cells (eg. Malignant melanoma) o Secretion of 5,6-dihydroxyindole (precursor of melanin) oxidizes to melanogen, then to melanin o TESTS:
1. Ferric chloride tube test: gray or black precipitate 2. Sodium nitroprusside (nitroferricyanide): red color


Amino acid with methyl group that branches from the main aliphatic carbon chain Accumulation of one or more of the early amino acid degradation products Accumulation of organic acids produced further down in the amino acid metabolic pathway Presence of ketonuria in the newborn

Maple Syrup Urine Disease

o Autosomal recessive trait o Failure to produce an enzyme to produce oxidative decarboxylation of the following keto acids: - ketoisovaleric, -ketoisocaprioc, -keto-methylvaleric o Amino acids involved: leucine, isoleucine, and valine o maple syrup urine odor o May result to sever mental retardation or death

Maple Syrup Urine Disease

1.2,4 dinitrophenylhydrazine (DNPH) reaction: yellow turbidity or precipitate (screening tests) 2.Amino acid chromatography: confirmatory test 3.Leukocyte decarboxylase test- detects heterozygous carriers for the disease

Organic Acidemia
o symptoms sever illness, vomiting, hypoglycemia, ketonuria, increased serum ammonia, o 3 most frequent disorders: 1. Isovaleric acidemia
sweaty-feet odor Accumulation of isovalerylglycine due to deficiency of isovaleryl CoA in the leucine pathway No screening test; isovalerylglycine detected by chromatography

Organic Acidemia
2 proionic academia 3. methylmalonic acidemia
Screening test for mathylmalonic acid:
o One drop of urine is placed in the test tube followed by 15 drops of 0.1% -nitroaniline in 0.16M HCl and 5 drops of 0.5% nitrite. The solution is mixed resulting to the partial decolorization and 1 ml of 1M sodium acetate buffer st pH 4.5 is added. The solution is the boiled for one minute and 5 drops of 8N NaOH are added. The presence of methylmalonic acid is indicated by the appearance of emerald green color


o Occurs in intestinal obstruction, presence of abnormal bacteria, malabsorption syndrome, and hartnup disease (inherited disorder) o Presence of indicant in the urine, colorless to dye indigo blue upon air exposure
urinary indicant reacts w/ acidic ferric chloride to form a deep blue or violet color that can subsequemtly extracted into chloroform

o Hartnup disease: blue-staining of infants diaper (blue diaper syndrome)

Renal tubular reabsorption of amino acid defect resulting to general aminoaciduria

5-Hdroxyindoleacetic acid (5-HAA)

o Degeneration product of serotonin o Serotonin are produced from tryptophan by argentaffin cells of intestines o Results from malignant tumors involving argentaffin cells o TESTS:
a. Nitrous acid and 1-nitroso-2-naphthol: purple to black color
i. Normal excretion: 2-8 mg/day ii.Argentaffin cell tumors: 160-628 mg/ 24 hours

b. First morning urine is used for 24-hour urine preserved w/HCl or Boric Acid c. Interference: serotonin-rich foods (bananas, pineapples, tomatoes), medications (phenothiazines & acetanilids)

o Defect in renal tubular transport of amino acids o Elevated amounts of acid cystine in the urine o Primary clinical consideration: defective reabsorption of all 4 amino acids (cystine, lysine, arginine, ornithine); formation of calculi o TEST: cystine crystals in the first morning specimen Cyanide nitroprusside: red to purple color Interference: presence of ketones & homocystines

Cystinosis o genuine error of metabolism o Crystalline deposits of cystine in many parts of the body (including: cornea, bone marrow, lymph nodes, internal organs) o Fanconis syndrome: major defect in renal tubular reabsorption occurs o Inability to reabsorb amino acids, sugars, phosphorus, potassium, and water o Polyuria, general aminoaciduria, positive test for reducing substances, lack of urinary concentration

o Defects in the metabolism of homocystine o Results in: cataract, mental retardation, thromboemboli problems, and deaths o TESTS:
o Cyanide-nitroprusside: red to purple color o Silver-nitroprusside test: red to purple

Porphyrin disorders
o porphyries : collective term in the appearance of porphyrinuria o Causes:
Hereditary Acquired- erythrocytic and hepatic malfunction (eg. Metabolic disease, toxic agents)

o Lead poisoning: most common cause o Red discoloration of an infants diapers (congenital porphyria) o TESTS:
Ehrlichs reaction: only for detection of ALA and porpobilinogen Fluorescence- other porphyrias Watson-Schwartz test- differentiates between the presence of urobilinogen and porpobiliogen Hoesch test: rapid method to detect porpobilinogen

Mucopolysaccharde disorders
o Mucopolysaccharide or glycosaminoglycans found in the connective tissue o Inherited disorders o Accumulation of degradation products (eg. Dermatan sulfate, keratin sulfate, and heparin sulfate) o Best known type of mucopolysaccharaoidosis

Mucopolysaccharde disorders
o Abnormal skeletal structures and cause severe mental retardation
Hurlers syndrome- also accumulates in the cornea of the eye Hunters syndrome Sanfilippos syndrome- only cause mental retardation

Acid albumin and cetyltrimethyl ammonium bromide (CTAB) turbidity test: thick white turbidity Metachromatic staining spot test: blue spots; cant be washed out by dilute acidified methanol solution

Purine Disorders
o Known as Lesch-Nyhan disease o Inherited disorder which results to massive excretion of urinary uric acid crystals o Failure to produce enzyme hypoxanthine guanine phosphoribosyl transferase o Severe motor defects, mental retardation, self destruction tendency, gout, renal calculi o Orange sand diapers in infants 6-8 months old


Functions: 1. Supply nutrients to the nervous tissues 2. Remove metabolic wastes 3. Procedure mechanical barrier: cushions the brain and the spinal cord against trauma Volume: - 20 ml produced every hour in choroids plexus and reabsorbs by the arachnoid villi - 140-170 ml in adults - 10-160 ml in neonates

Specimen collection - Lumbar puncture between 3rd 4th or between 4th & 5th lumbar vertebrae - Collection in 3 sterile tubes
o Tube 1: for chemical and serologic tests (frozen if not done immediately) o Tube 2: for microbiology (tested as soon as possible) o Tube 3: for cell count (refrigerate if can not be done within an hour)

Cell Count 1. WBC Count routinely performed 2. RBC Count: perform only for traumatic puncture to correct WBC count Normal value: 0-5 WBC/ L in adults ; 0-30 WBC/ L in newborns 3. improved neubauer counting chamber is used # of cells counted X dilution --------------------------------------------------# squares counted X volume of 1 square

Cells/ L =

4. Total Cell Count - no overlapping of cells is seen (undiluted count) - overlapping cells (diluted count in NSS) 5. WBC Count - 3% acetic acid, tolouidine blue O and saponin sodium solution (lyses RBCs and stain WBCs) 6. RBC Count - total cell count/ L WBC count/ L 7.Differential count - should only e done when there is sufficient amount - Wrights stain, count 100 cells (classify and report)

CSF in Hemtaology Lab

Appearance: crystal clear, cloudy or turbid, milky, xanthochromic, and hemolyzed/bloody

1. Cloudy, Turbid, milky - high protein or lipid concentration, WBCs - indicates infections

CSF in Hemtaology Lab

2. Xanthochromia - pink, orange or yellow Pink: slight amount of oxygenated hemoglobin Orange: heavy hemolysis Yellow: oxyhemoglobin converted to unconjugated bilirubin Others: high bilirubin, pigment carotene, protein concentration, melanoma pigment, immature liver functions

CSF in Hemtaology Lab

3. Grossly bloody CSF - intracranial hemorrhage (cerebellar) - traumatic collection: puncture of blood vessels

VISUAL EXAMINATION OF GROSSLY BLOODY CSF 1. Uneven distribution of blood - cerebral hemorrhage: even distribution of blood in all tubes - traumatic tap: tube1 w/ heaviest concentration of blood; streaks of blood may be seen 2. Clot Formation - cerebral: not contain enough fibrinogen t clot - traumatic: clots due to plasma fibrinogen 3. Xanthochromic supernatant (2 hours noticeable hemolysis) - cerebral: finding of macrophages ingested RBCs Presence of RBC is unreliable

Significance of Normal Cells

1. Normal CSF cells: lymphocytes and monocytes Adult: 70% lymphocytes 30% monocytes Occasional neutrophils Children: more prevalent in monocytes 2. Pleocytosis- increased number of normal cells; abnormality 3. High WBC count particularly neutrophils: bacterial meningitis 4. Moderately elevated WBC, high % of lymphocytes and monocytes: viral meningitis, tubercular, fungal, or parasitic origin 5. Low WBC count (below 25 WBC / L), increased lymphocytes: Multiple Sclerosis

Significance of abnormal cells: Immature leukocytes eosinophils, plasma cells, macrophages, increased tissue cells, malignant cells 1. Increased macrophage- previous hemorrhage 2. Ependymal cells- pneumoencephalograohy 3. Eosinophils- parasitic infections, reactions to foreign proteins in the CSF, intracranial shunt malfunctions 4. Nucleated RBCs- bone marrow contamination during spinal tap 5. Reactive lymphocytes- ( increased cytoplasm and clumped chromatin): viral infection, MS 6. Blast formation and immature WBCs- leukemias and lymphomas