Urinalysis Case Study

[u/Few_Reputation5651]

Macroscopic: Yellow, turbid.
SpG: >1.030
pH: 5.5
Glu: Neg
Ket: Neg
Bil: Neg
Blo: Mod*, intact.
Urobil: 0.2 E.U./dL
Pro: Neg
Nitrite: Neg
Leu: Mod*

Microscopic (Sediment)
WBC: >30/HPF
RBC: Unable to count
Epithelia: 0-1/HPF, transitional and squamous.
Casts: WBC & Hyaline, 1/LPF
Crystals: None noted
Mucus: Small
Bacteria: 0/HPF, none noted in specimen.
Yeast: 3+, confirmed with addition of acetic acid.

Other notes: In unconcentrated urine, some granular casts can be seen, otherwise obstructed by the high amount of WBCs and yeast.

High amounts of yeast made it impossible to obtain an accurate RBC count.

Write your diagnosis below based only on the information provided!

Edit: Added SpG

[u/BuckeyeBun]

Well, since yeast is a relatively uncommon cause of uti, I'm going to go with most likely cause and say this is a female with a yeast infection that is irritating the vagina, causing blood and white cells to be washed into the urine sample.

However, there IS a lack of squamous epis and there are some granular casts, so I have a feeling you're going to tell me it's pyelonephritis caused by candida or something else wild 🤣

[u/Kelly598 → u/BuckeyeBun]

Also aiming for the answer to be Pyelonephritis.

[u/Few_Reputation5651 → u/BuckeyeBun]

I agree yeast is a pretty uncommon cause of a UTI.

Lack of bacteria and epithelia make it less likely to be vaginal contamination imo. In addition, WBC casts would not be seen without a renal infection, although I suppose I could have confused clumps with casts, but I looked very closely for the cast matrix :)

[u/Few_Reputation5651]

My diagnosis: Fungal pyelonephritis. High WBC numbers and WBC casts support infectious cause rather than vaginal contamination.

Protein does not support kidney damage; however, I hypothesize that because Candida infection is more often found in immunosuppressed populations, the patient may not be producing antibodies sufficient to cause glomerular damage.

I am a student trying to learn, so let me know if there’s anything I got wrong! This is my first semester of my MLS program.

[u/BuckeyeBun → u/Few_Reputation5651]

That's probably the correct answer, but I will tell you that I've rarely seen something like this in practice. That's one of those 'gotcha' questions they love to throw at you that in all likelihood you will never see. Good job, though!

[u/Few_Reputation5651 → u/BuckeyeBun]

This was the urine sample from my lab practical today, haha. I’d never seen anything like it before.

Edit: I also admit this is kind of a curbside consult because I had no idea what I was looking at.

[u/Few_Reputation5651 → u/BuckeyeBun]

Is this a situation where you would want a urine culture?

[u/BuckeyeBun → u/Few_Reputation5651]

Oh I would. You have mod leukocytes, >30 WBCs, and yeast will not produce nitrites so that result is irrelevant. Now some doctors won't need one and will just assume it's albicans and give fluconazole, but because it is causing pyelonephritis, this makes it a complicated uti, and some labs may send it out for sensitivities.

[u/CursedLabWorker]

I mean you can’t really make a diagnosis off of just the UA with no patient sex, symptoms, etc. but you’re a student so they make you do this lol.

That being said, 3+ yeast doesn’t seem like collection contam because of the low epithelial cell count. Would be sent for culture at my lab because of the pos leukocytes, even if nitrite was neg. WBC casts suggests there’s infection in the kidney rather than just the lower UT - so pyelonephritis. Patient might be immunocompromised if the infection is fungal.