Color Atlas of Clinical Laboratory Medicine First...

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Color Atlas of Clinical Laboratory Medicine

First Version

Addis Ababa, February 2015

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Table Contents

1. Hematology ................................................................................................................................. 5

1.1. Cell Maturation .................................................................................................................... 5

1.2 Red Blood Cells Morphology ............................................................................................... 6

1.3 Abnormal Red Blood Cell Morphology ................................................................................ 6

1.4 White Blood Cell Morphology .............................................................................................. 9

1.5 Abnormal White Blood Cell Morphology .......................................................................... 11

2. Bacteriology .............................................................................................................................. 12

2.1 Gram Positive Cocci............................................................................................................ 12

2.2 Gram Positive Bacilli .......................................................................................................... 13

2.3. Gram Negative Cocci ......................................................................................................... 14

2.4 Gram Negative Bacilli ....................................................................................................... 14

2.5. Acid Fast Bacilli, AFB ....................................................................................................... 15

2.6 Spirochetes .......................................................................................................................... 16

3. Parasitology............................................................................................................................... 18

3.1. Intestinal Protozoa .............................................................................................................. 18

3.2. Intestinal Nematodes .......................................................................................................... 21

3.3. Intestinal Cestodes .............................................................................................................. 24

3.4.Trematodes .......................................................................................................................... 25

3.5. Blood Protozoa ................................................................................................................... 27

3.6. Tissue (Filarial) Nematodes ............................................................................................... 38

4. Urinalysis .................................................................................................................................. 39

4.1. Urine sediment cells ........................................................................................................... 39

4.2. Urine Parasites.................................................................................................................... 41

4.3. urine Sediment Crystals ..................................................................................................... 42

4.4. Urine sediment Casts .......................................................................................................... 43

Acknowledgments

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The EPHLA is deeply indebted to Tariku Bekele and Tadesse Hailu, both of whom are senior

members of our Association and with considerable laboratory experience, for their tireless effort

in assembling and systematically arranging the required information for this color atlas to be a

reality.

Even though almost all the information in the atlas is downloaded from their free internet access,

EPHLA still would like to express its appreciation to the World Health Organization for creating

such marvelous opportunity.

Preparation of laboratory color atlas was first pioneered by MSH (Ethiopian Network for

HIV/AIDS Treatment, Care & Support Program) whose management group unreservedly

encouraged us to proceed with compilation of the current atlas and therefore our gratitude also

goes to them.

Unreserved support and the funding of this project by the Ethiopian Public Health Association

(EPHA) and the CDC (through the grant # GH001039) are greatly acknowledged.

Preface Diagnostic laboratory service is not only an indispensable part but the backbone of the health care

delivery system which often determines the outcome of patient care for better or worse. Unfortunately,

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however, laboratory service in this country like the rest of many others in Africa has never received the

attention it deserves. We often hear that constraints of financial and human resources, among others,

being put forward as the reasons for the apparent gaps. It is true that there is limitation of resources but it

is not the whole truth. Frankly speaking most health care providers don't care while many others including

from the management side don't really much understand that test results generated by the labs constitute

evidence-based scientific medicine which pinpoint a better or even the right treatment option(s). Whether

we are health care providers or health managers, sooner or later we all are patients and thus beneficiaries

of laboratory services and therefore concerted effort and commitment by all towards promoting quality

laboratory standards is the order of the day. With this kind of mind set and with concerted effort from all

stakeholders, significant qualitative change in our laboratory systems is not only plausible but achievable

too. Gradually but surely such changes are on the way to many of our labs in health facilities across the

tier, thanks to the effort of governmental and non-governmental institutions.

The Ethiopian Public Health laboratory Association (EPHLA) is a non-for-profit and a non-governmental

organization established to contribute towards the national effort of strengthening public health

laboratories and to help them render quality standard diagnosis and services to the patient population. To

this end, the Association adopted several strategies, chief among them being human capacity building by

increasing access to information so that laboratorians could keep themselves abreast with current

scientific developments. It is in this spirit that this color laboratory atlas was developed which is mainly

intended for facilities in remote locations with limited or no access to scientific information.

This atlas by no means should be considered as a silver bullet and hence as a substitute to the ultimate

decision based primarily on the discretion of the technician and on further verification and/or validation

of the test procedures whenever this is applicable or feasible. This is particularly evident considering the

similarities in micro-morphological or phenotypic characteristics between less related or even unrelated

organisms depicted in the atlas. Caution must therefore be exercised against sweeping conclusion and

hence wrong diagnosis that could be detrimental to patient outcome. Thus, it is worth a while reiterating

that the color atlas is meant to serve not as the only but as one of the many possible tools at the disposal

of the lab professionals in the diagnosis of the major pathogenic agents and/or organisms that are

prevalent in the country.

This color atlas being the first of its kind to our Association, the EPHLA intends to update it through

follow up of new editions. Thus, the kind cooperation of our laboratory colleagues in providing feedback

on gaps and weaknesses noted in the publication or on any other relevant issues is vital in strengthening

and increasing the output of the EPHLA towards our common goal of achieving quality standards in all of

our labs.

EPHLA

February, 2015

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1. Hematology

1.1. Cell Maturation

Hematopoiesis is a process of blood cell production and maturation in the bone marrow. The process

begins with the pluripotent stem cell. The stem cell is capable to proliferate, differentiate and replicate.

The differentiation into a myeloid or lymphoid stem cell takes place in response of growth factors

(cytokines)

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1.2 Red Blood Cells Morphology

Normocytic Normochromic Microcytic Hypochromic

1.3 Abnormal Red Blood Cell Morphology

Target Cells Bite/Schistocyte

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Ovalocytes (Elliptocytes) Tear drop cells

Stomatocyte Sickle cells

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Roulex fromed RBCs Spherocyt

Acanthocytes (Spur Cells) Howell-Jolly Bodies

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Cabot ring (Ring shaped, thin, may be figure of 8 shaped)

1.4 White Blood Cell Morphology

Band and Segmented WBC Basophil

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Eosnophil Monocyte

Lymphocyte

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Platelets (Normal)

1.5 Abnormal White Blood Cell Morphology

Toxic granulation Dohle bodies Toxic granulation, vacuolization, &

Dohle bodies are seen during bacterial infections,

burns, cancer, and toxic or inflammatory states

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’

Vacuoles

2. Bacteriology

2.1 Gram Positive Cocci

Gram-positive cocci in &outside neutrophils (Clustered) Gram-positive diplococci with capsule neutrophils

http://www.fujita-hu.ac.jp/~tsutsumi/photo/photo071-2.htm


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Gram positive cocci cluster Gram positive streptococci

2.2 Gram Positive Bacilli

Gram positive Bacilli

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2.3. Gram Negative Cocci

Gram-negative diplococci phagocytized by neutrophils Gram Negative extracellular diplococcic

2.4 Gram Negative Bacilli

Gram-negative rods with capsule, Large-sized Gram-negative rods



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2.5. Acid Fast Bacilli, AFB

Fluorochrome stained smear numerous green AFB Ziehl Neelson stained AFB

Fluorochrome stained smear numerous green AFB Fuorochrome stained non AFB

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Fluorochrome stained smear showing numerous green Ziehl-Neelsen (ZN) stained Acid Fast Bacill acid-fast

acid-fast bacilli

2.6 Spirochetes

Borellia spps are long and spiral-shaped. The circular objects are red blood cells. The irregular purple

object in the top right corner is a white blood cell

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Borrelia spps stained in a blood sample with a Wright stain.

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3. Parasitology

3.1. Intestinal Protozoa

Trophozoite of E. histolytica/E. dispar in a direct wet mount stained with iodine

Cyst E. histolytica/E. dispar in an unstained

wet mount of stool

Cyst E. histolytica/E. dispar in an unstained wet

mount of stool with Iodine

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Fig. A: B. coli trophozoite in a wet mount, 400× magnification. Fig. B: B. coli trophozoite in a Mann's hematoxylin stained

smear, 500× magnification.

Figure A: B. hominis cyst-like forms in a wet mount ,

unstained

Figure B: Cryptosporidium spp. oocysts (pink arrows) in

Wet mount. A budding yeast (brown arrow) is in the same

field

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Figure A: Cryptosporidium sp. oocysts stained with trichrome. Oocysts may be detected, but should not be

confirmed by this method. Trichrome staining is inadequate for a definite diagnosis because oocysts will appear

unstained. Here the Cryptosporidium oocysts are represented by red arrows; the blue arrow represents yeast

Fig A: Immature oocyst of C. belli in an unstained

wet mount, containing a single sporoblast

Fig B: Immature oocyst of C. belli stained with safranin,

containing a single sporobla

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Fig. A Tachyzoites (trophozoites) of Toxoplasma gondii

are approximately 4-8 µm long by 2-3 µm wide, with a

tapered anterior end, a blunt posterior end and a large

nucleus.

Fig. B Cysts of Toxoplasma gondii usually range in size

from 5-50 µ in diameter

3.2. Intestinal Nematodes

Egg of T. trichiura in an iodine-stained wet mount and also the presence of a cyst of Entamoeba coli

(arrow).

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Fig. A: Eggs of E. vermicularis in a wet mount Fig. B: Egg of E. vermicularis in an iodine-stained wet

mount

Unfertilized and fertilized eggs of A. lumbricoides in an unstained wet mount of stool 200x

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Hookworm egg in an unstained wet mount, taken at 400x magnification.

Rhabditiform larva of S. stercoralis in unstained wet mounts of stool. Notice the short buccal canal and

the genital primordium (red arrows).

Rhabditiform larva of S. stercoralis in an unstained wet mount of stool. Notice the prominent genital

primordium (blue arrow), rhabditoid esophagus (red arrow) and short buccal canal (green arrow).

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3.3. Intestinal Cestodes

Taenia sp. eggs in unstained wet mounts. Iodine-stained wet mount of a Taenia sp. egg

Egg of H. diminuta in a wet mount stained with iodine. Four of the hooks are visible at this level of focus

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Eggs of D. latum in an iodine- stained wet mount; Eggs of D. latum in an unstained wet mount

3.4.Trematodes

Egg of S. mansoni in an unstained wet mount

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Egg of S. hematobium in an unstained wet mount

Egg of F. hepatica in an unstained wet mount, taken at 400x and 100 x magnification

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3.5. Blood Protozoa

Fig. A: Leishmania sp. amastigotes in a Giemsa-stained

tissue scraping

Fig. B : Leishmania (Viannia) panamensis amastigotes

in a Giemsa-stained tissue scraping. Identification to the

species level is not possible based on morphology and

other diagnostic techniques such isoenzyme assay or

PCR are needed.

Fig. C: Leishmania sp. amastigotes; touch-prep stained with Giemsa. Fig. D: Leishmania tropica amastigotes from an impression smear of a

biopsy specimen from a skin lesion. In this figure, amastigotes are

being freed from a rupturing macrophage. Patient had traveled to

Egypt, Africa, and the Middle East. Based on culture in NNN medium,

followed by isoenzyme analysis, the species was identified as L.

tropica.

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Fig. A : Trypansoma brucei spp. in a thick blood smear stained Fig. B : Trypansoma brucei spp in a thick

With Giemsa blood smear stained with Giemsa.

Fig. C : Trypanosoma brucei spp. in a thin blood smear

stained with Wright-Giemsa. Fig. D: Trypanosoma brucei ssp. in a thin blood smear stained

with Wright-Giemsa.

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T. cruzi trypomastigote in a thin blood smear stained with Giemsa

Rings of P. falciparum in a thick blood smear

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Rings of P. falciparum in a thin blood smear

Ring-form trophozoites of P. falciparum in a thin blood smear, exhibiting Maurer's clefts.

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Gametocyte of P. falciparum in a thick blood smear. Note also the presence of many ring-form

trophozoites.

Gametocyte of P. falciparum in a thin blood smear and thick Giemsa stain

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Schizont of P. falciparum in a thin blood smear. Trophozoites are also seen in this image

Ring-form trophozoites of P. vivax in a thick blood smear.

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Ring-form trophozoite of P. vivax in a thin blood smear.

Trophozoite of P. vivax in a thick blood smear. Trophozoites of P. vivax in a thin blood smear

Note the amoeboid appearance, Schüffner's dots and enlarged infected RBCs.

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Fig. 1: Gametocyte (upper) and trophozoite (lower) of P. vivax

in a thick blood smear Fig. 2: Macrogametocytes of P. vivax in a thin blood smear.

Note the enlargement of the gametocytes compared to

uninfected RBCs

Fig. 1: Schizont of P. vivax in a thick blood smears Fig. 2: Ruptured schizont of P. vivax in a thin

blood smear, showing free merozoites and pigment

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Fig. 1: Ring-form trophozoite of P. malariae in a thin blood smear. Fig. 2: Trophozoite of P. malariae in a thick blood smear.

Fig. 1: Basket-form trophozoite of P. malariae in a thin blood smear Fig. 2: Gametocyte of P. malariae in a thin blood

smear

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Fig. 1: Schizonts of P. malariae in a thick blood smear. Fig. 2: Schizont of P. malariae in a thin blood

Fig. A: Ring-form trophozoites of P. ovale in a thin blood

smear. Note the multiple-infected RBC in this image. Fig. B: Ring-form trophozoite of P. ovale in a thick

blood smear.

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Fig. 1: Infected RBCs showing developing (lower) and ring-

form (upper two) trophozoites of P. ovale in a thin blood

smear.

Fig. 2: Trophozoite of P. ovale in a thick blood smear.

Fig. 1: Gametocyte of P. ovale (red arrow) nestled between

two white blood cells in a thick blood smear. Fig. 2: Macrogametocyte of P. ovale in a thin blood smear.

Note the fimbriation.

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Fig. 1: Schizont of P. ovale in a thick blood smear. Fig. 2: Schizont (upper right) and ring-form

trophozoite (lower left) of P. ovale in a thin blood smear

3.6. Tissue (Filarial) Nematodes

Microfilaria of W. bancrofti in a thick blood smear stained with Giemsa

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Larvae of Trichinella, freed from their cysts, typically coiled. Encysted larvae of Trichinella in pressed muscle

tissue.

4. Urinalysis

4.1. Urine sediment cells

Ghost RBC RBC’s showing rouleaux

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White Blood Cells in urine with 200X and 400x magnification, respectively

Pus cell Yeasts cells (hyphae)

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4.2. Urine Parasites

Trophozoite of T.vaginalis in wet mount Trophozoites of T. vaginalis , stained with Giemsa

Egg of S. haematobium in a wet mount of urine concentrates, showing the characteristic terminal spine.

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4.3. urine Sediment Crystals

Amorphous Urate crystals Amorphous phosphate Crystals

Uric Acid Crystals Calcium Oxalate Crystals

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4.4. Urine sediment Casts

Granular Cast hyaline casts

WBC Casts Fatty Wax

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Cholesterol cast

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