CASE STUDY DISCUSSION

Case 1.
A 28 year old man visits his physician complaining of an intense, sharp pain in his back and
side. In a conversation with his physician, the patient confesses to eating a diet high in animal
proteins such as meat, cheese, and fish. Results of a complete urinalysis are shown below.
Chemical/Physical Analysis
Color
Yellow
Appearance
Clear
Specific Gravity
1.025
pH
5.0
Microscopic Analysis
>100 RBC/hpf
0-3 WBC/hpf
20-30 Bacteria/hpf
0-5 Squamous Epithelial Cells/hpf
Unidentified Crystals

Glucose
Protein
Ketones
Bilirubin

Negative
Trace
150mg/dL
Negative

Urobilinogen
Blood
Nitrite
Leukocyte

Normal
Large
Negative
Negative

Questions
1. Is there a discrepancy between the leukocyte and nitrite counts on the reagent stix compared
to the results reported in the microscopic analysis?
No. The leukocyte test pad on the reagent stix has a sensitivity of >10WBC/uL. Therefore,
while there may have been some WBCs present, there was not a sufficient number to cause
a positive reaction on the reagent stix. A similiar type of thinking can be applied to the
nitrite pad to explain the negative nitrite result even though bacteria were seen. The nitrite
pad requires 100,000 organisms/mL for a positive result to be given. 20-30 bacteria/hpf are
not sufficient to give a positive result on the reagent stix.
2. Is the presence of WBCs with bacteria clinically significant?
No. Ordinarly, bacteria in the presence of WBCs would suggest a urinary tract infection.
However, the 0-3 WBC/hpf is within the reference range and therefore is of no clinical
significance. The relatively low levels of bacteria are also of no clinical significance. Their
presence may be due to contamination
3. Suggest an explanation for blood in the urine.
Case 2.
A 10 year old boy, who recently recovered from a streptococcal infection, was taken to the doctor
with symptoms including fever, nausea, and malaise. Physical examination reveals edema
around the eyes and the knees. Blood tests reveal a decrease in serum complement. A routine
urinalysis reveals the following results.
Chemical/Physical Analysis
Color

Yellow

Blood

Moderate

Clarity
Glucose
Bilirubin
Ketones
Specific Gravity

Hazy
Negative
Negative
Negative
1.015

pH
Protein
Urobilinogen
Leukocyte Esterase
Nitrite

6.5
300mg/dL
Normal
Small
Negative

Microscopic Analysis
20-50 RBC/hpf
10-20 WBC/hpf
2-5 RBC casts/lpf
2-5 Granular casts/lpf
Questions
1. What is the significance of a positive leukocyte esterase?
A positive leukocyte esterase indicates the presence of WBCs. These are present due to an
inflammation or infection of some kind.
2. How could there be a positive leukocyte esterase and a negative nitrite?
a) Non gram negative enteric bacteria present
b) Yeast
c) Inflammation
d) A and C
e) A, B, and C
3. What is the significance of the presence of blood along with protein in the urine?
If the glomerulus was in some way damaged, its efficiency as a filter may be somewhat
compromised. As a result, RBCs, protein, and other larger particles could get into the urine.
4. What disease are the results indicative of?
Acute Glomerulonephritis. The recent streptococcal infection is a cause of glomerulonephritis.
The physical examination of the patient also indicates an inflammatory disease. This is further
supported by the presence of WBCs in the urine without any bacteria. The presence of blood
along with protein in the urine suggests that the problem is occurring at the glomerulus itself.
Case 3.
A 10-year old girl had a routine urine exam at the time of her school physical. Results follow:

Questions
1. Identify the abnormal test results highlighted
2. What is the most probable diagnosis for this patient? Support your answer (include in
your discussion the physical, chemical and microscopic findings).
3. Based on your diagnosis, what follow up testing should be done on this urine?
4. What single microscopic finding is most helpful in differentiating an upper UTI from a
lower UTI?

Case 4.
A 14-year-old boy is brought to the pediatrician by his mother because he has had a fever
with shaking chills for the past day. On physical examination, he has a temperature of
39.6 C and has mild right costovertebral angle tenderness.

Macroscopic Urinalysis:

Microscopic Urinalysis:

Characteristic

Result

Color

Yellow

Appearance

Turbid

Leukocyte Esterase

3+

Nitrite

Pos

pH

6.5

Characteristic

Result

WBC/hpf

>50/hpf

RBC/hpf
Protein

5-10/hpf

Neg

Blood
Casts
Specific Gravity
Other
Ketones

Many WBC

Neg

Occasional transitional cells

1.015
1+

Glucose

Neg

Bilirubin

Neg

Questions:
1. How do you explain the appearance of the urine? How do you relate this to other
findings?
2. What is the significance of the finding on physical examination?
3. Is there a relation between the color of the urine and the diagnosis?
4. What findings on microscopic urinalysis are of help in this case?
5. What is the suspected diagnosis?
6. What else should you do?

Case 5
A 34 year old Korean woman is admitted to the emergency room with the major complaint of
"not feeling herself." For the past week, she has been suffering from extreme fatigue and
headaches, but did not feel the need to have it checked out until she has noticed that her vision is
"a little fuzzy". When asked if she is taking any medications, she responds a low dosage birth
control, a women's daily multivitamin and prednisone for her systemic lupus erythematosus
(SLE).
An urinalysis is ordered. The nurse notices that the urine has a "sweet" odor to it as she
conducts the point of care testing. The urinalysis results are:

Macroscopic Urinalysis:

Microscopic Urinalysis:
Color

Yellow

Appearance

Clear

Specific Gravity

1.010

RBC 2-10/hpf
WBC 0-5/hpf

Questions
7.0 of this patient? What results from the urinalysis (both stix and
1.What pH
is the diagnosis
microscopic) support your answer? The diagnosis for this patient is prednisone induced
diabetes. Prednisone, in this case used to treat the symptoms of SLE, is known to cause
type 2Protein
Diabetes. The
results from the urinalysis result that support this diagnosis is the
Trace
fruity odor of the urine, the low specific gravity, and the elevated glucose and ketone levels.
The elevated protein levels are common in patients that have renal involvement associated
with SLE.
Glucose
500 mg/dL
2. Is it normal for a patient with SLE to have red and white blood cells in the urine? Why or why
not? The
microscopic
finding for white blood cells (0-5/hpf) is normal for any individual.
Ketones
Small
The blood result however is not normal (normal range 0-2/hpf), but is common to see in
patients that have renal involvement associated with SLE.
Bilirubin

Negative

Blood

Negative

3. Does the stix result for leukocytes correlate with the microscopic findings? Why or why not?
Yes, the results correlate because it takes about 10 intact WBC/hpf to get a trace reading
for leukocytes.

Urobilinogen
0.2 mg/dL
4. Does
the stix result
for blood correlate with the microscopic findings? Why or why not?No,
these results do not correlate because it takes about 5 intact RBC/hpf to get a trace reading
for blood, and there were 2-10/hpf. The most likely cause for this discrepancy is the
ascorbic
acid that the
patient is taking (daily multi-vitamin)
Nitrite
Negative

Case 6
Leukocyte

Negative

A 5-year-old boy usually drove his mother crazy by running around the house all day long, but
he has been lethargic for the past 2 weeks. On physical examination he is afebrile, but there is
puffiness around his eyes.
Macroscopic Urinalysis:

Microscopic Urinalysis:

Characteristic

Result

Color

Yellow

Appearance

Hazy
Characteristic
Neg

Leukocyte Esterase
Nitrite
Protein

Neg
WBC/hpf
6.0
RBC/hpf4+

Blood

Casts

pH

Specific Gravity
Ketones

Other

Neg
1.020
Neg

Glucose

Neg

Bilirubin

Neg

Result
1-2/hpf
None
None
Occasional oval fat bodies

Questions:
1. What key abnormal finding is present? Just what does the dipstick measure here, and
what other test could be done on the urine?
2. What is suggested by the child's physical findings?
3. What other laboratory test(s) would be useful?
4. What is the diagnosis?