Case 1: History

CASE 1
History:
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:
Characteristic Result
Color Yellow
Appearance Turbid
Leukocyte Esterase 3+
Nitrite Pos
pH 6.5
Protein Neg
Blood Neg
Specific Gravity 1.015
Ketones 1+
Glucose Neg
Bilirubin Neg
Microscopic Urinalysis:
WBC/hpf >50/hpf
RBC/hpf 5-10/hpf
Casts Many WBC
Other Occasional transitional cells
Questions:
1. How do you explain the appearance of the urine? How do you relate this to
other findings?
The urine is cloudy (turbid). This could result from increased numbers
of suspended particles (cells or cell fragments, casts, crystals, or
amorphous semicrystalline material). The presence of the blood
suggests that RBC's are present. The postive leukocyte esterase
suggests that WBC's are present. The 1+ ketones likely represent a state
of ketosis from lack of dietary intake of carbohydrates from the illness.
2. What is the significance of the finding on physical examination?
The CVA tenderness suggests inflammation in the kidney.
3. Is there a relation between the color of the urine and the diagnosis?
The color is not obviously red, though there are microscopic RBCs
present, and the color is mainly due to the presence of the neutrophils
imparting a yellow color along with the cloudiness.
4. What findings on microscopic urinalysis would be of help?
Finding WBC's, particularly WBC casts, would suggest inflammation,

particularly of the kidney.
5. What is the suspected diagnosis?
Acute pyelonephritis, probably as a consequence of an ascending

urinary tract infection.
6. What else should you do?
Urine culture. Later, one would do an intravenous pyelogram (IVP) and

voiding cystourethrogram (VCUG)--very useful in a boy with a urinary
tract infection (UTI), which is not common. He may have urinary tract
abnormalities leading to increased risk for infection.
CASE 2
Case Study 2
A 34 year old Korean woman is admitted to the emergency room with the major complaint of "not feelin
from extreme fatigue and headaches, but did not feel the need to have it checked out until she has noticed t
taking any medications, she responds a low dosage birth control, a women's daily multivitamin and prednis

An urinalysis is ordered. The nurse notices that the urine has a "sweet" odor to it as she conducts the poi

Yellow
Color
Appearance Clear
Specific 1.010
Gravity
pH 7.0
Protein Trace
Glucose 500
mg/dL
Ketones Small
Bilirubin Negative
Blood Negative
Urobilinogen 0.2 mg/dL
Nitrite Negative
Leukocyte
Negative

Microscopic Results
RBC 2-10/hpf
WBC 0-5/hpf
1. What is the diagnosis of this patient? What results from the urinalysis
(both stix and 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 2 Diabetes.
The results from the urinalysis result that support this diagnosis is the
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.
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. 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.
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.
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).
5. What is a probable treatment for this patient?

An ideal treatment for this patient would be to discontinue her use of
prednisone and another medication should be used for her SLE symptoms.
With
CASE 3
History:
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:
Color Yellow
Appearance Hazy
Leukocyte Esterase Neg
Nitrite Neg
pH 6.0
Protein 4+
Blood Neg
Specific Gravity 1.020
Ketones Neg
Glucose Neg
Bilirubin Neg
Microscopic Urinalysis:
WBC/hpf 1-2/hpf
RBC/hpf None
Casts None
Other 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?
The protein is markedly positive. The dipstick protein test uses

bromphenol blue, which is more sensitive to albumin than to globulin.
Thus, a semiquantitative sulfosalicylic acid test, which precipitates all
proteins, would be helpful if one suspected globulins (such as Bence-
Jones protein with myeloma) were present. The presence of proteins
other than albumin would make this a 'non-selective' proteinuria less
likely to be minimal change disease.
2. What is suggested by the child's physical findings?
The loosest skin in a child is periorbital, so this is the first place that
edema is often noticed.
3. What other laboratory test(s) would be useful?
A 24 hour urine protein test would help establish a diagnosis of

nephrotic syndrome. One could get a serum creatinine to estalish that
the child's "renal function" is normal. In reality, obtaining a reliable 24
hour urine sample on a child is difficult, and depends in large measure
on how compulsive his mother is. Since the amount of creatinine
excreted in the urine is relatively constant for body size, one could do a
protein/creatinine ratio on what sample was obtained, and a ratio of 0 to
0.2 is likely to be normal, 0.2 to 2.0 is pathologic proteinuria, and >2 is
nephrotic. Hypoalbuminemia below 2.5 g/dL is often present with
childhood nephrotic syndrome. Hyperlipidemia with increased serum
cholesterol may be present. This lipid can be taken up into renal tubular
cells, which slough and degenerate to form the oval fat bodies seen
microscopically.
Of course, a blood pressure measurement is part of the physical

examination, and an elevated blood pressure would cast some doubt on
a presumed diagnosis of nephrotic syndrome from minimal change
disease in a child, as would an increasing blood urea nitrogen or
creatinine, and would suggest a more serious renal disease.
4. What is the diagnosis?
Nephrotic syndrome. The most likely etiology in this setting is minimal

change disease leading to nephrotic syndrome.

Case 1: History

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CASE 1

A 14-year-old boy is brought to the pediatrician by his mother because he has

Specific Gravity 1.015

Casts Many WBC

Other Occasional transitional cells

2. What is the significance of the finding on physical examination?

The CVA tenderness suggests inflammation in the kidney.

4. What findings on microscopic urinalysis would be of help?

Finding WBC's, particularly WBC casts, would suggest inflammation,

5. What is the suspected diagnosis?

Acute pyelonephritis, probably as a consequence of an ascending

6. What else should you do?

Urine culture. Later, one would do an intravenous pyelogram (IVP) and

Urobilinogen 0.2 mg/dL

5. What is a probable treatment for this patient?

Leukocyte Esterase Neg

Specific Gravity 1.020

Other Occasional oval fat bodies

The protein is markedly positive. The dipstick protein test uses

2. What is suggested by the child's physical findings?

3. What other laboratory test(s) would be useful?

A 24 hour urine protein test would help establish a diagnosis of

Of course, a blood pressure measurement is part of the physical

4. What is the diagnosis?

Nephrotic syndrome. The most likely etiology in this setting is minimal

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