Introduction to Cells

“Case XVIII. This was a case of anasarca with coagulable urine having all its charac-
ters well marked. There was no evidence either of hepatic disease or of derangement
in the structure of the heart or lungs; but the urine loaded with red particles seemed
to bespeak decided renal affection.”—Richard Bright (1789-1858). Reports of Medi-
cal Cases, vol. 1, 1827. London: Longman.

Cellular elements appearing in the urine can originate
from the bloodstream, the renal parenchyma, or the
epithelium lining the lower urinary tract. In the male,
cells originating within the reproductive organs can
also be present in the urine, as the urethra is a com-
mon conduit for both urine and cells originating in the
male reproductive system. In addition, some cellular
elements can be introduced into the urine from exter-
nal sources, usually by contamination from the female
genital tract, from fecal material, or in patients with
pathologic fistulae. Cells in the urine can also represent
neoplastic elements from solid tumors or lymphomas.
Cellular elements of the blood in small numbers are
often a normal finding in the urine. Although refer-
ences ranges vary, in general one to five erythrocytes
and two to five leukocytes per high-power field are
not considered abnormal in an asymptomatic patient.
Erythrocytes can pass directly through the glomeru-
lus, in which case they may appear dysmorphic, or
through the epithelium, as part of trauma, infection,
or a neoplastic process. They also can be an artifact
of contamination by fecal or vaginal material. Erythro-
cytes exposed to hypertonic urine for a period of time
become crenated and can resemble foreign particles
such as pollen.
Almost all leukocytes in the urine are neutrophils,
introduced across an epithelial surface due to inflam-
mation or neoplasm. Eosinophils are rare except in
cases of interstitial nephritis. Lymphocytes also are
rare and are usually associated with renal transplant
rejection. Both can be extremely difficult to recognize
unless special techniques are used to identify them.
Monocytes and macrophages are also rare except in
cases of chronic hematuria from any cause.
Renal tubular epithelial cells are usually a sign of
renal parenchymal disease, either inflammation or
toxic tubular damage for any reason. In patients with
lipiduria and nephrosis, renal tubular epithelial cells ac-
cumulate fat droplets and are referred to as “oval fat
bodies.”
Other epithelial cells are often not abnormal. Both
squamous and transitional epithelial cells are frequent
findings. Not all laboratories differentiate squamous
and transitional epithelial cells, but there are good
reasons to do so. Although squamous epithelial cells
normally are present only within the urethra, they can
originate from the prostate in patients with old infarcts
and can involve more proximal portions of the urinary
tract as a result of chronic inflammation or injury, or in
rare cases of squamous cell neoplasms of the lower uri-
nary tract. Squamous epithelial cells can also be pres-
ent in the urine as a contaminant, often from vaginal
fluids.
Although cells from the male reproductive system,
particularly the prostate, can appear in the urine, they
are difficult to recognize. The most common cell origi-
nating from this source is the spermatozoon, and not
all laboratories report their presence. However, there
are some clinical circumstances in which they are an
important finding. Neoplastic cells can be recognized
in the urine but usually require special collection and
staining techniques to do so. They are extremely dif-
ficult to recognize by standard methods of urinalysis
employing an unstained urine sediment.

88 Cells
 Matula
of Cells
Polydore Jean Charles Pauquet (after a 1493 manuscript). A physician
89
in traditional garb examines urine flask of female patient in bed.
Erythrocyte
Erythrocytes in urine are similar to those seen in other
Synonyms sites. They generally retain their uniform size and bi-
RBC, red cell
concave disk shape and usually contain hemoglobin.
Vital statistics In older specimens or hypertonic specimens where
size ���������������������������� diameter 7-8 μm analysis is delayed, the cells may become crenated
shape ������������������������ round to slightly oval bi-
concave disk, crenated in
and resemble foreign objects such as pollen grains.
hypertonic specimens with In hypotonic specimens, hemoglobin pigment is vari-
irregular edges and sur- ably lost and cells may be reduced to colorless spheri-
faces, spherical “ghost” cells cal membranes (“ghost cells”) and resemble fat, oil
in hypotonic specimens droplets, or yeast. In situations where identification is
nuclear shape ��������� not applicable
chromatin ���������������� not applicable
ambiguous, use of special imaging techniques such as
cytoplasm ��������������� pale yellow-orange, may be polarization can be helpful. Nucleated red cells or sick-
colorless; shades of red to le cells can rarely be found in patients with sickle cell
purple in stained specimens disease. Macrophages containing ingested red cells
Key differentiating features or hemosiderin may be observed in any patient with
uniform size and general shape chronic hematuria.
variable amounts of hemoglobin pigment
present

Potential look-alikes
yeast cells Erythrocytes
(unstained)
pollen grains
starch granule
sperm heads
free fat droplets
air bubbles thin membrane
small granulocytes (crenated specimens) refractive index varies
calcium oxalate crystals (monohydrate form) by hemoglobin content;
Associated disease states/conditions
“ghost cells” seen with
normal in small numbers (<5 per hpf) low hemoglobin
glomerular diseases
trauma
neoplasms
urinary tract calculi may be colorless, pale
urinary infection pink or pale yellow
systemic coagulopathies
anticoagulants, some chemotherapeutic agents,
other medications
PNH or other intrinsic red cell disorders
contaminated specimen (vaginal, etc.)

hour-glass appearance when

cell is viewed on end
round, refractile,
biconcave disk

90 Cells
CM-14, 2006 (unstained, X160)
Identification Referee % Participant %
Erythrocyte 100.0 97.1
This urine specimen was obtained from a 77-year-old
female who was a resident of a long-term care facility,
with diagnoses of severe osteoporosis and dementia.
She had recently become confused and her urine was
cloudy and foul smelling. Urinalysis showed: pH=6.5;
specific gravity=1.014; leukocyte esterase, blood, glu-
cose and protein=positive; blood, protein, nitrite, glu-
cose, ketones=negative.
Three red cells are clearly seen in this image and
show typical orientations of on edge (clearly demon-
strating the biconcave shape), en face, and slightly
rotated with an eccentric pale zone. All are uniformly
round, contain hemoglobin, and should not be con-
fused with any of the potential look-alikes.
In hypertonic urine, the red cells shrink
and wrinkle, becoming crenated.
Cells 91
CM-13, 2000 (unstained, X160)
Identification Referee % Participant %
Erythrocyte 100.0 98.1
This urine specimen is from an 80-year-old male com-
plaining of right flank pain. Urinalysis showed: pH=6.5;
specific gravity=1.020; protein=2+; blood=2+.
Scattered throughout the field are numerous red
cells containing almost no hemoglobin (ghost cells).
Others have an irregular shape with a suggestion of
spike-like projections and could represent early ex-
amples of crenated red cells. The empty cells can be
identified as red cells by their uniform size, lack of a
thick refractile membrane, and absence of buds. Fi-
nally, occasional cells scattered throughout the field
exhibit internal cytoplasmic folds or creases that could
be confused with starch except for their coloration. If
identification of these cells was of particular concern,
this could be resolved using special imaging tech-
niques such as polarized light or interference contrast
microscopy. Ultimately this patient was found to have
a urinary calculus.
CM-39, 1991 (unstained, X160)
Identification Referee % Participant %
Erythrocyte 100.0 98.4
This urine was obtained from a 67-year-old male com-
plaining of “smoky” urine and weight loss. Urinalysis
showed: pH=5.0; specific gravity=1.012; protein=trace;
blood=positive.
The arrowed objects are erythrocytes. None have
any of the features of casts or crystals and should not
be confused with them. All of the red cells in this field
contain abundant hemoglobin. Isolated cells near the
center and at the bottom of the field are smaller with
small spike-like projections consistent with crenated
forms. The large object near the center is a neutrophil,
identifiable by the folded nucleus and granular cyto-
plasm.
Unexplained hematuria in the absence of casts or
crystals can be seen in patients with urinary tract neo-
plasms.
92 Cells
CM-02, 1989 (unstained, X160)
Identification Referee % Participant %
Erythrocyte 94.7 93.4
Fat – free fat droplets 5.3 2.3
Red blood cell cast - 2.0
This urine sample was obtained from a 34-year-old
parturient patient who subsequently delivered a nor-
mal male child. Her pregnancy was complicated by
hypertension, and she developed renal failure in the
immediate postpartum period.
Both arrowed objects are of yellow-red color indi-
cating they contain hemoglobin, and therefore the
diagnosis of free fat droplets is incorrect. Two of the
unarrowed red cells are deformed and could, in the
right clinical setting, raise some concern as to whether
or not they are “dysmorphic.” Although these par-
ticular cells do not meet the morphologic criteria for
dysmorphic red cells, identification of cells such as this
should result in a critical evaluation of both the urine
and the patient to see if dysmorphic red cells might be
present.
 Additional Examples of Red Blood Cells

This field contains a large mass of erythrocytes, as

seen in the urinary sediment. Erythrocyte clumps in
the urinary sediment can be an artifact of specimen
preparation or can represent a blood clot. Individual
cells are small and frequently have an orange tint due
to the hemoglobin they contain. If trapped WBCs can
be identified, the possibility of a blood clot should be
considered. It is important to not mistake clumps of
red cells for a red cell cast. In this example, there is no
evidence of a protein matrix.

This image is a photomicrograph of the urinary sedi-

ment using interference contrast microscopy. This
technique imparts a three-dimensional appearance to
the image and allows visualization of inclusions or oth-
er internal structural details. These cells are of uniform
size, and the prominent spicules represent infoldings of
the membrane due to loss of intracellular water when
the cells are present in hypertonic urine. Crenated red
cells can be confused with pollen grains or white cells,
especially lymphocytes, but the lack of internal struc-
tural details establishes the origin in this case.

This interference contrast photomicrograph illustrates

several normal red cells. Some cells clearly have a cen-
tral indentation representing a biconcave disk. Two
mucous strands adherent to an unidentified cell can be
seen at the bottom of the photomicrograph.

Cells 93
 Additional Examples of Red Blood Cells

This is a bright-field image of the urinary sediment

from a case of trauma. Several normal erythrocytes are
present, easily recognized by their red-orange color
and biconcave disk shape. A short red cell cast is pres-
ent in the center of the image.

This is a bright-field image of the urinary sediment.

Numerous normal erythrocytes are present, many ap-
pearing as biconcave disks with central pallor. Normal
granulocytes with discrete nuclear lobation are pres-
ent; the one at the lower left edge of the image ap-
pears to have an overlying erythrocyte.

This interference contrast photomicrograph illustrates

several normal red cells. Some cells clearly have a cen-
tral indentation representing a biconcave disk. Bud-
ding yeast would have a capsule and, often, some
internal structure. Fat droplets vary in size and, when
viewed with polarized light, would be birefringent with
“Maltese cross” formation.
Abnormal red cells could have some similarities.
Dysmorphic red cells often form buds and could be
similar to the overlapping normal cells seen to the
left of center. However, dysmorphic red cells vary in
size and, when viewed with ordinary bright-field illu-
mination, would clearly not be normal cells. Another
consideration would be the rare instance where red
cells containing inclusions (Howell-Jolly bodies, para-
sites such as malaria or babesia) were present in the
urinary sediment. These cells would all demonstrate
some internal structure when viewed with interference
contrast microscopy and would likely vary in size. Ex-
amination of a stained specimen could also resolve the
issue if required.

94 Cells
 RBC Mimics

Yeast Sperm Air Bubbles Fat Droplets

Both round and oval Heads of sperma- Bubbles are round, variable Free lipid droplets have
forms are found, but tozoa may become in size, and demonstrate a uniform round appear-
these can vary in size separated from dark refractile periphery. ance but vary in size.
and can show “budding.” the tails and mimic Variability in size dis-
budding dysmorphic tinguishes fat droplets
RBCs. They are gen- from RBCs.
erally smaller than
RBCs.

Neutrophils Starch Pollen Calcium Oxalate

Necrobiotic granulo- Starch granules are Grains of pollen can be Monohydrate form may
cytes may be small small, slightly larger round or oval but are contain oval and round
with an irregular than a RBC, and much larger than RBCs, refractile elements. Find-
surface mimicking often have a central typically 20 µm or more ing dihydrate forms in
crenated RBCs. In indented or slit-like in diameter. adjacent fields will help to
concentrated urine, area. distinguish the crystals
WBCs can also shrink from RBCs.
and resemble RBCs;
granules and nuclei are
usually visible, however.

Cells 95
Erythrocyte, Dysmorphic
A morphologic variant of the red cell, the “dysmor-
Synonyms
RBC, red cell, acanthocyte, G1 cell phic red cell” is considered quite specific for hematuria
associated with glomerulonephritis. Dysmorphic red
Vital statistics
cells may be smaller than normal erythrocytes and ex-
size ���������������������������� diameter 7-8 μm, but may
vary hibit cytoplasmic bulges or projections that may break
shape ������������������������ round to slightly oval, but off and appear as tiny separate red cell fragments. The
exhibit cytoplasmic blebs classic example of this type of cell is one with two small
nuclear shape ����������� not applicable symmetrically positioned cytoplasmic blebs (“Mickey
chromatin ����������������� not applicable
Mouse ears”). This morphology is discussed further in
cytoplasm ����������������� pale yellow-orange, may
be colorless shades of red to the Closer Look section on dysmorphic red blood cells,
purple in stained speci- page 100.
mens

Key differentiating features

cytoplasmic blebs (“Mickey Mouse ears”)
doughnut shape with one or more blebs (G1 cell
of Dinda)
loss of limiting membrane with phase contrast
microscopy

Potential look-alikes
yeast cells
oil droplets
free fat droplets Dysmorphic Red
small granulocytes (crenated specimens)
red cell casts (if cast matrix is not appreciated) Blood Cells
Associated disease states/conditions
glomerular diseases (unstained)
cytoplasmic blebs

Dysmorphic red blood cells in the

urine have proven to be diagnosti-
cally important as an indicator of
glomerular bleeding.
smaller red cell fragments may
accompany dysmorphic cells

cytoplasmic bulges
and projections

Dysmorphic red cells are

typically smaller than RBCs.

96 Cells

CM-06, 1997 (unstained, X160)
Identification Referee % Participant %
Erythrocyte, dysmorphic 15.4 4.8
Yeast/fungi 53.8 84.0
Fat globules 23.0 9.7
Erythrocyte 7.7 0.7
This urine was obtained from a 23-year-old male with
hemoptysis and renal failure who subsequently devel-
oped anuria. Urinalysis showed: specific gravity=1.012;
leukocyte esterase, protein, blood=positive. buds or blebs. There is no evidence of a capsule sug-
The arrowed objects are dysmorphic erythrocytes.
The abnormal red cell membrane, resulting in formation
of cytoplasmic blebs, is particularly well demonstrated
in the right-hand panel using the Nomarski technique
and can be contrasted with membrane details of the
normal red cells in the upper portion of the photo-
micrograph. The symmetric blebs seen in the lower
arrowed cell demonstrate “Mickey Mouse ears.” This
patient was eventually diagnosed with Goodpasture
syndrome, a type of glomerulonephritis with simulta-
neous immune complex deposition involving both the
alveolar and glomerular basement membrane. These
cells should not be confused with budding yeast, since
the cells in question contain hemoglobin and do not
have a thick refractile capsule. Fat globules are highly
refractile and would exhibit bright birefringence when
illuminated with polarized light. Normal erythrocytes
would be of uniform size and would not demonstrate
cytoplasmic blebs.
Cells 97
Additional Examples of
Dysmorphic Red Blood Cells
This case has not been refereed or viewed by the par-
ticipant group but is included as another example of
dysmorphic erythrocytes.
This urinary sediment is from a 21-year-old female
with hypertension and edema of approximately 2
months duration, and significant renal failure with a
BUN = 33 mg/dL (8-18 mg/dL), creatinine = 2.4 mg/
dL (0.35-0.93 mg/dL).
Arrows point to classic examples of dysmorphic
erythrocytes. In each case, they exhibit cytoplasmic
gestive of yeast, and both cells are red in color. These
cells were not identified initially but were noted on
subsequent review, and the physician was notified. Fur-
ther evaluation, including an elevated anti-DNA titer,
established the diagnosis of lupus glomerulonephritis.
It is important for laboratorians to be familiar with this
unusual presentation of glomerular hematuria. Dys-
morphic red cells are a significant abnormality and are
a good candidate for “critical values” in urinalysis.
Additional Examples of Dysmorphic Red Blood Cells

This a photomicrograph of the urine in a patient with

hematuria. Two dysmorphic red cells are present near
the center of the image, with the upper cell having nu-
merous cytoplasmic blebs, some of which are perpen-
dicular to the imaging plane and are actually pointing
directly at the viewer.

This is a bright-field image of a urinary sediment con-

taining dysmorphic red cells. The cell at the top near
the center shows a developing surface bleb; the one
near the bottom shows a fully developed bleb with a
narrow connecting stalk.

These are dysmorphic red blood cells in the urine as

visualized using phase contrast microscopy. This tech-
nique utilizes a special phase condenser to separate
light rays passing through a specimen that are either
unaffected (surround waves) or altered (particle waves)
by various structures, such as membranes or internal
particulate matter. These waves are of different am-
plitudes, and the resolved image sharply contrasts
relatively transparent areas of the object with various
internal elements, rendering internal details visible.
One of the advantages of phase contrast microscopy
is that it can be used with unstained—even living—
specimens. In this image, the cell in the upper right is a
classic dysmorphic red cell with two small surface blebs
representing “Mickey Mouse ears,” and the more cen-
tral cell contains multiple surface blebs.

98 Cells
 Additional Examples of Dysmorphic Red Blood Cells

This bright-field image illustrates several dysmorphic

red cells. The one on the right is a classic “Mickey
Mouse ears” cell, while others manifest only single cy-
toplasmic blebs.

This is a patient, unknown age, with a history of glo-

merulonephritis. The central feature is a large red gran-
ular cast with no clearly identifiable cells. This is a good
example of a blood – hemoglobin pigment cast. The
background contains large numbers of red cells, and
several of these (arrows) are good examples of dys-
morphic red cells, exhibiting prominent surface blebs.

RBC Shapes
isomorphic dysmorphic

Normal Ghost Cell Crenated Dysmorphic

round biconcave disk, low refractive index; hypertonic solution distorted shape; classic exam-
high refractive index, hard to see due produces shrunken ple associated with glomerular
6-8 µm in size to low hemoglobin cell with uniform bleeding has pronounced blebs,
content projections which may detach

Cells 99
Dysmorphic Red Cells
Dysmorphic red cells, initially described in early 19th
century German literature, were “rediscovered” in
1979 by Birch and Fairly [1], who considered them to be
highly specific for glomerular hematuria (i.e., glomeru-
lonephritis). Identification of a specific morphologic
variant of the dysmorphic red cell (G1 cell) by Dinda
[3] is now considered to be somewhat more specific
for hematuria of glomerular origin. Identification of
these cells is based on finding them in suspension in
the urinary sediment. Unfortunately, a few subsequent
publications describing various “poikilocytes” in air
dried and stained urinary sediments as dysmorphic red
cells has confused the classification.
True dysmorphic red cells may be smaller than
normal and exhibit cytoplasmic bulges or projections
that may break off and appear as tiny separate red cell
fragments. The classic example of this type of cell is
one with two small symmetrically positioned cytoplas-
mic blebs (“Mickey Mouse ears”). These cells can be
seen with conventional bright-field microscopy but
are more easily seen with interference contrast (No-
marski) imaging. Initial studies suggested that these
morphologic changes represented disruption of the
limiting membrane of the erythrocyte during transit
into Bowman’s space across a damaged glomerular
basement membrane [2]. Subsequent studies have
shown that high concentrations of uric acid, as well as
exposure to hypotonic osmotic solutions that mimic
100 Cells
those found in the tubules of the nephron, may also be
important in inducing the morphologic changes rec-
ognized as “dysmorphic.”
Dysmorphic red cells may be seen in the urine of
patients with other intrinsic renal diseases, such as
polycystic renal disease, pyelonephritis, and rhabdo-
myolysis with renal failure. These situations not with-
standing, recognition of dysmorphic red cells remains
important as they are a sign of serious renal pathol-
ogy. It is also important not to confuse these cells with
yeasts, free fat, oval fat bodies, or starch, none of which
are red in color (dysmorphic red cells can be easily dif-
ferentiated in confusing cases by using polarized light
microscopy).
The identification of dysmorphic red cells is based
upon light microscopic techniques. Recently the iden-
tification of dysmorphic red cells by conventional light
microscopy was contrasted with their identification by
flow cytometry in group of 206 urine samples from pa-
tients with hematuria (127 with hematuria of glomeru-
lar origin and 79 with nonglomerular hematuria). The
two methods had comparable sensitivities of 99%, but
the specificity was 42% for flow cytometry and 98%
for conventional microscopy [4].
Based on their findings the authors concluded that
microscopic analysis remains the preferred method of
evaluating patients with hematuria.
 Glomerular Hematuria
Bowman’s space Blood in the urine may originate from the
podocyte
capillaries glomerulus or the collecting duct system
and bladder. If the RBCs are dysmorphic,
the bleeding is most likely of glomerular
origin, in which case immune or nonimmune
glomerulonephritis should be ruled out.
This may require a kidney biopsy.
arterioles

hematuria

damaged glomerular
basement membrane; foot
processes are lost (fused)
Glomerulus
protein molecules
podocyte

With minor damage to the

basement membrane, only
large protein molecules are
lost into the urine.
basement
membrane fused foot processes

endothelial Increasing damage to

cell the basement mem-
brane and podocytes
allows RBCs to move
into Bowman’s space.

Glomerular
Capillary RBC membranes are disrupt-
ed if the basement membrane
damage is severe.

As the damaged RBCs

traverse the length of
the nephron, osmotic and
physical forces produce the
dysmorphic appearance.

High concentrations of uric acid

and exposure to hypotonic os-
motic solutions can also induce
dysmorphic RBC morphology.

Cells 101