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Diagnostic Medlab
Auckland
August 2000
Mike Gill
Paul Ockelford
Arthur Morris
Tony Bierre
Cam Kyle
First edition 1992
Second edition 1994
Third edition 2000
Copyright 2000 by
Diagnostic Medlab Limited
No part of this publication may be reproduced by any process without written permission from
Diagnostic Laboratory Holdings Ltd.
PO Box 5728, Auckland 1,
New Zealand.
TERMS OF USE
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by accessing this handbook:
Use of Information
We have developed this handbook to provide you with information relating to our services. The information in this
handbook is general information only and is provided free to you. It is not intended as, nor is it capable of being,
advice on any specific problem or a replacement for individual professional medical advice, opinions or therapies
advised to you by your medical practitioner. We endeavour to keep the information in this handbook up to date
however, we make no warranty as to the accuracy, reliability, suitability or currency of information in this handbook.
All information in this handbook is subject to change at any time. Always seek the advice of a qualified medical
professional before acting on the information in this handbook.
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PREFACE TO THE FIRST EDITION
The starting-point for this Handbook, which has been written for doctors, midwives, practice
nurses, receptionists, laboratory staff, students, and other health care workers, was a file of
questions phoned through to Diagnostic Medlab over the past decade or so. Often the question
has been about a relatively minor abnormality: What does it mean? Can it be ignored? Should
the test be repeated? When will follow-up be necessary? This may help to explain what might
otherwise appear to be an unusually capricious selection of information. Once upon a time
someone asked about it.
Along with the enormous increase in types of laboratory tests over the past 30 years there has
been an increase in the sophistication we apply to interpretation of results. Age, sex, biological
variation, posture, diurnal rhythm, pregnancy all have major effects quite apart from those of
disease. Medications, singly or in combination, add a further set of variables; and any serious or
even trivial illness can have non-specific effects on a wide range of laboratory values.
As well as presenting factual information, we have attempted, with some tests, to give an opinion
on their value, particularly where their usefulness is limited or even non-existent. There will
undoubtedly be errors and omissions; we apologise for these and for opinions which turn out to
be wrong.
Comments received about the Handbook since the last edition was published in 1994 suggest that
we have provided a useful resource for practitioners in primary health care, always our target
audience. The more one works in the primary sector, the more one realises it is a different entity
from secondary and tertiary healthcare where either the diagnosis is known before the patient
reaches hospital or at least they have been recognised as being seriously ill. In primary
healthcare the problems are often more nebulous. The serious acute problems are small in
number beside those with vague symptoms which might be due to early disease, resolving
disease, transient disease or sometimes no disease at all.
One of the roles of laboratory medicine is to look at the possibility of early disease and provide
evidence for or against, before the classical picture has had time to develop. Many of the
laboratory abnormalities themselves will be equivocal and a goal of the Handbook has been to
help practitioners when deciding what to do next — treat, refer, investigate further, watch and
repeat in weeks or months, ring and discuss with a pathologist — or no action at all.
When we first embarked on this edition we thought revision would be a simple process, an extra
sentence here, a revised reference range there but laboratory medicine has, in the event, moved a
long way, even in five years, and the text has grown by a third.
For this edition the contributors have been:
The other contributors are all those general practitioners, practice nurses, midwives, and others,
who have rung us at the laboratory to talk over a problem, ask for information, make a
suggestion. Having entered the new millennium, the role of the laboratory is not just to provide a
result but to help practitioner and patient understand what that result means. The Handbook will
help, we believe, and beyond that we suggest a phone call to the pathologist - one of the quickest,
simplest and most under-utilised of all consultations.
The last and most important acknowledgement is to Annie Curran for her painstaking care as she
typed draft after draft after draft.
Mike Gill
Editor
August 2000
How To Use This CD ROM
To find a Handbook entry, e.g. “CK (creatine kinase) total”, expand the “C' file by clicking on
the plus sign (+) beside the C in the left-hand “Bookmarks” window. All the C items are now
displayed. Use the scroll bar in the Bookmarks window to take you to “CK (creatine kinase)
total”. Click the words “CK (creatine kinase) total”. Use the scroll bar in the right-hand window
to take you through the pages of the CK entry.
At the end of the CK entry are two lines in blue indicating hyperlinks. Clicking on the 2nd line
for example takes you to "Myocardial Markers for Infarction". Clicking the - box beside “C”
shrinks the C entries back to a single line.
Specimen Collection
More detail than the minimum information provided can be obtained by ringing the lab or asking
for our detailed Collection Manual.
Reference Ranges
For the common analytes, reference ranges are roughly the same throughout New Zealand or,
indeed internationally, but for hormones and other tests where methodology can vary from one
lab to another, the reference ranges can differ quite markedly. Even within the same lab, ranges
may change from time to time as new methods are introduced.
Reference ranges are at best only a guide and results which are found unexpectedly to lie outside
their stated range should be treated with circumspection.
Units
Enzymes and some other tests, including some hormones and antibodies, are expressed in
International Units (IU)/litre (L), or Units/litre or simply Units. IU/L are particularly misleading,
implying as they do that the reference range given is applicable world-wide. The reality is that
International Units for the same test can vary widely depending on the method used whilst still
calling themselves IU/L.
Interfering Drugs
The lists are not meant to be complete but will cover the most common interferences. Additional
queries about a specific drug/test combination should be directed to a pathologist.
Notes on Interpretation
These are not claimed to be comprehensive. Again, additional queries should be directed to a
pathologist. Brief clinical details (usually one line only) help immeasurably with interpretation
e.g. routine, wt-loss 1/12, pale and tired 3/12, on T4, on phenytoin,
? hepatitis and so on.
A
Abiotrophia
ABO type
ABS
specimen: serum
Although ACE levels can be used in the diagnosis of sarcoidosis (two thirds of
patients with active disease have elevated ACE), elevations are also found in other
chronic inflammatory disorders, giving the test poor specificity.
Acetaminophen
Acetone
see Ketones
Acid-base investigations
specimen: serum
ref. range: males 0.1 – 0.6 U/L
Acid phosphatase is an obselete test and no longer available, PSA being a superior
prostatic tumour marker. PAP is not usually elevated until a tumour has spread
outside the prostatic capsule whereas PSA is usually elevated while the tumour is still
localised to the gland.
Non-prostatic acid phosphatase is found in bone marrow, platelets, red cells and liver
and can be elevated in diseases affecting these tissues.
Acinetobacter
specimen: plasma (EDTA) Collect 0700 – 1000 hr along with simultaneous cortisol
level.
It is not used in the early investigation of Cushing's syndrome (qv) but may help in
evaluating proven hypercortisolism where a high ACTH suggests pituitary adenoma
or, uncommonly, ectopic ACTH production, e.g. by small cell carcinoma of lung.
Actinomyces
Activated protein C resistance occurs in patients with the Factor V mutation known as
Factor V Leiden (FVQ506). This mutation is present in 5% of a normal Caucasian
population. It is the commonest of the recognised thrombophilia markers. It is
detected in 16-20% of consecutive patients presenting with thromboembolism but the
frequency is higher in selected patient groups. Although it increases the thrombotic
risk 5-10 fold, it is generally regarded as a relatively weak risk factor.
APCr is measured using an APTT ratio with and without activated protein C. The
normal ratio is 2.4 - 4.0. Heterozygous positive patients with the Factor V mutation
have ratios of 1.6 or less. Homozygosity, which is much less common, is associated
with a higher thrombotic risk and a lower APCr.
The diagnosis is usually obvious because of blast cells in the blood film, raised total
white count, anaemia, thrombocytopenia and neutropenia, but one or more of these
features can be absent at the time of diagnosis.
The more common leukaemia in adults. AML may arise de novo or through
transformation of chronic myeloid leukaemia or myelodysplastic syndromes.
Transformed AML responds poorly to treatment.
In de novo AML, first remission is achieved in 70-80% of patients with 30-40% long
term survivors when treated with chemotherapy alone. With allogeneic bone marrow
transplantation for patients aged less than 55 years there is a 50-60% five year
survival.
Plasma analytes which decrease with inflammation include albumin, transferrin, iron,
total cholesterol and HDL cholesterol.
see also separate entries for each acute phase protein
Addison's disease
Adrenal antibodies
specimen: serum
see Catecholamines
HMMA (hydroxy methyl mandelic acid)
Metanephrines
Hypofunction - see
Addison's disease
Synacthen stimulation test
Hyperfunction - see
Cortisol, serum, Cortisol, urine free
Cushing's syndrome
Dexamethasone suppression test
Conn's syndrome
Hirsutism/virilism
Congenital adrenal hyperplasia (CAH)
Adrenocortical insufficiency
Usually autoimmune (70%), less often due to TB, haemorrhage, iron overload, HIV,
infiltration.
Adrenocorticotrophic hormone
(adrenocorticotropin)
Aeromonas
Aeromonads are widely distributed in stagnant or flowing fresh water and in soil.
Aeromonads are mostly resistant to the penicillins but are often susceptible to
trimethoprim/sulphamethoxazole and quinolones, e.g. ciprofloxacin. Nalidixic acid
or nitrofurantoin may be used for urinary tract infection. Although there are no data
tumour marker – large elevations (>100) can be found in hepatomas and testicular
tumours and are used for monitoring treatment and in diagnosis.
Smaller non-diagnostic elevations are found in many forms of liver disease and
malignancy.
screening for neural tube defects and Down's syndrome – serum AFP is measured
in conjunction with hCG and oestriol to give a risk estimate. Definitive diagnosis
requires measurement of AFP in amniotic fluid.
see Maternal serum testing for foetal Down's syndrome and neural tube defects
(NTD)
AIDS
Alanine aminotransferase
Albumin
specimen: serum
ref. range: 35 – 45 g/L
Decreases
• acute or chronic inflammatory illnesses
• urinary protein loss
• advanced liver disease
• gastrointestinal loss
• severe malnutrition
Identifying alcoholism
After a heavy weekend's drinking, levels rise about 50%, peaking on about the
third day.
An elevated GGT due to alcohol should fall by about half after two weeks
abstinence and reach baseline by about six weeks.
• other liver enzymes: alk. phos, AST, ALT, ratio AST/ALT >1.5
• triglyceride elevated – fatty liver
• urate elevated
• ferritin elevated – alcoholic hepatitis
• CK elevated – alcoholic myopathy
• thrombocytopenia
Effect of drugs:
The test is fairly robust with other drugs but the aldosterone/renin ratio may
sometimes be altered by:
ACE inhibitors lower the aldosterone/renin ratio in normals, but in those with Conn's
syndrome, the ratio usually remains high.
• hypertension
• hypokalaemia, with s. potassium classically <3.5 mmol/L but often in the range
3.5-3.9 mmol/L.
• elevated aldosterone/renin ratio. This is the most sensitive test.
A negative screening test is a ratio <20, especially if the renin is >25 mU/L. A
negative test is valid in patients who continue taking diuretics, ACE inhibitors or
calcium-channel blockers.
Secondary hyperaldosteronism
This is found in oedematous and hypertensive states where the plasma aldosterone
increase is secondary to an increased renin, e.g. diuretic therapy, renal artery stenosis.
In the liver, ALP is found in biliary canaliculi, increased production being stimulated
by biliary obstruction and to a lesser extent other liver pathology.
Liver disease
• Growth in childhood, particularly the pubertal growth spurt when levels can
go up to 650 U/L.
Assessment of other laboratory tests and the clinical picture will usually explain
elevations of ALP without resorting to isoenzyme fractionation – which usually
provides a clear-cut answer only when the answer is already obvious.
A useful generalisation is that where both ALP and GGT are raised, liver is the
source. When GGT is normal, the raised ALP is probably from bone.
These are all tests for Type I immediate hypersensitivity reactions mediated by IgE
antibodies as seen in allergic rhinitis, anaphylaxis, allergic skin reactions, food
allergies, drug allergies.
Alopecia
The common age and gender related variant does not warrant laboratory investigation
but specific aetiologies to be considered include:
• hypothyroidism
• hyperthyroidism
• drugs : cytotoxics, lithium
• dermatological pathology
• any severe illness
• zinc deficiency
• warfarin hypersensitivity (rare)
• polycystic ovary syndrome
When associated with a severe but correctable illness, the alopecia is likely to be
transient.
alpha-1-antitrypsin
alpha-foetoprotein
ALT elevations, which are common and usually accompanied by other enzyme
elevations, are found in:
Aluminium
specimen: blood in trace metal tube (navy blue stopper)
Amenorrhoea
Consider:
Amino acids
specimen: serum
or urine, fresh random specimen for screen test
Aminophylline
Amiodarone
specimen: serum
therapeutic range: 1.5 – 3.9 µmol/L (trough level)
Amitriptyline
Ammonia
A specialist test sometimes used in hepatic failure, Reye's syndrome and some inborn
errors of metabolism.
Amoeba
Amylase, serum
specimen: serum
ref.range: 25 - 135 U/L
Amylase, found mainly in pancreas and salivary glands, is used in the differentiation
of acute pancreatitis from other causes of the acute abdomen.
In acute pancreatitis, amylase typically rises above 400 U/L, returning to normal in
about 4 days.
The enzyme pattern is inconsistent, however, and failure to detect an elevation does
not preclude the diagnosis even when there is severe infarction.
Acute peritonitis, causing inflammation of the serosal surfaces of the pancreas and
other organs, can elevate amylase but usually not above 400 U/L.
Other causes of hyperamylasaemia include mumps, diabetic ketoacidosis, biliary tract
disease, renal insufficiency, shock, some drugs (particularly narcotics), hypoxia,
pelvic infection, macroamylasaemia.
Chronic pancreatitis does not raise amylase except sometimes during acute
exacerbations.
ur . amylase s . creatinine
ACCR(%) = x x 100
s . amylase ur . creatinine
Amylase, urine
specimen: random or 24-hr urine without preservative
ref. range: <650 U/L or U/day
Urine amylase is elevated in all conditions where serum amylase is raised except
renal failure and macroamylasaemia. It is not often used except perhaps in the
diagnosis of macroamylasaemia where the ACCR is calculated.
see Amylase, serum
The main indication for ANA is as a screen test in suspected SLE where it will be
positive in 95% of cases. A negative ANA makes SLE unlikely. A positive ANA
requires follow up by anti-DNA, which has a much higher specificity for SLE, and
ENA to check specificity of the antibody.
The only certain statement is that positive ANAs are fairly common in healthy people
and should never, as an isolated finding, be represented as possibly indicating SLE
which requires additional laboratory and clinical features before the diagnosis can be
made.
The clinical manifestations of drug-related SLE are mild and subside within six
weeks of drug withdrawal.
ANA patterns
ANA is detected by adding patient serum to a layer of cells on a slide, then adding a
fluorescent detection system. If ANA is present it shows up as a fluorescent pattern
illuminating various nuclear structures. Usually the pattern is not specific for a
particular disorder but associations have been suggested:
nucleolar pattern — diffuse scleroderma
centromere — limited scleroderma, CREST
speckled — MCTD, Sjogren's, polymyositis, RA
peripheral, diffuse — SLE
(homogeneous)
Investigating an anaemia
These are typically normocytic, normochromic anaemias but there may be mild
microcytosis and hypochromia.
Anaerobic infections
Anaerobic organisms, which are widely distributed in soil and as part of the normal
flora of mouth, gut, and vagina, grow readily in deeply-placed abscesses in the
abdomen, wounds, pleural cavities, brain, oropharynx and in peritonitis or
endometritis. Foul-smelling discharge indicates anaerobic infection.
Routine cultures do not grow anaerobes which require special media and an oxygen-
reduced environment. Anaerobic cultures are set up only on specific request or when
clinical details indicate the need for them. Swabs are not the ideal specimen, tissue
obtained at debridement being the ideal. Aspirated pus or fluid is best collected and
transported in a syringe which should not be refrigerated. IUCDs (intrauterine
contraceptive devices) are routinely cultured for Actinomyces.
Anaesthetic allergy
Allergy to local anaesthetic is rare but often suspected by patients who may request
skin tests in a specialist allergy laboratory to exclude the possibility – before dental
anaesthesia for example.
see Variation
Errors
ANCA
Ancylostoma duodenale
Androgens
see Testosterone
DHEAS (dehydroepiandrosterone sulphate)
Androstenedione
Androstenedione
specimen: serum
ref. range: adult female 3.5 - 9.0 nmol/L
adult male 3.0 - 8.5 nmol/L
Androstenedione is secreted by the adrenal cortex, testis and ovary and is a precursor
of testosterone and oestrone. In pre-menopausal women, the adrenal cortex and
ovaries contribute equally but after the menopause androstenedione is almost entirely
of adrenal origin.
In hirsutism and polycystic ovary syndrome it can be elevated but testosterone is the
preferred test.
Angioedema
Anion gap
specimen: serum
ref. range: 8 – 16 mmol/L
The anion gap is a simple calculation which, if increased above 16 mmol/L, gives a
crude (very crude) indication of metabolic acidosis as in salicylate or methanol
poisoning, ketoacidosis, lactic acidosis, renal acidosis.
The calculation and its derivation are as follows:
The anion gap, at 30 mmol/L is increased, with acidic salicylate anions being the
cause of the increased gap.
Ankylosing spondylitis
A seronegative spondyloarthropathy causing low back pain and reduced spinal
mobility due to sacroileitis and spondylitis. Typically it occurs in younger males with
95% positivity for HLA B27 (qv).
tests: • CBC
• ABO and Rh group
• red cell antibodies
• hepatitis Bs antigen
• rubella antibodies
• syphilis antibodies
tests: • CBC
• red cell antibodies
Antiarrhythmic drugs
specimen: serum
therapeutic ranges:
see also Urinalysis (routine biochemistry and microbiology) and UTIs (urinary tract
infections).
If gentamicin is given as a single daily dose (4-5 mg/kg/day) the trough level should
be <0.5 mg/L. Peak levels are not necessary for single daily dosing.
Vancomycin
Trough levels should be <15 mg/L. It is seldom necessary to do peak levels.
Anticardiolipin
Anticholinesterase insecticides
see Cholinesterase
Anticoagulant therapy
see Heparin therapy
INR (international normalised ratio) for warfarin therapy
Anticonvulsants
specimen: serum
The therapeutic range is a guide only. Levels below the range may control seizures;
levels above the range may not be toxic and may be necessary for control. When
changing doses, retesting should be delayed a week or so till a new equilibrium
develops.
Overdose screen
Detects overdose of amitriptyline, nortriptyline, imipramine, desipramine,
trimipramine, protriptyline, doxepin or dothiepin, but is nonspecific.
Therapeutic ranges:
Drug nmol/L
amitriptyline 550-1290
clomipramine 830-2000
desipramine 470-1130
doxepin 550-1300
imipramine 610-1670
nortriptyline 280-570
protriptyline 430-1430
trimipramine 400-1000
The method is generic for all tricyclics so cannot distinguish one drug from another.
Knowing which drug has been given is essential when assessing whether a level is in
the therapeutic range.
Antidiuretic hormone
AntiDNA
Antimicrobials
Antimitochondrial antibodies
see Mitochondrial antibodies
An initial ANCA screen test has 95% sensitivity for these conditions and is followed
by the more specific antiproteinase 3 (PR3) and myeloperoxidase (MPO) tests.
Antinuclear antibodies
· cardiolipin (qv) antibodies which are used as the initial test when APS is suspected
· lupus anticoagulant (qv)
· biological false positive RPR/VDRL
The aetiology of these antibodies, which may be transient, is unknown but the
presence of elevated titres of anticardiolipin antibodies and/or the lupus
anticoagulants, six months after an episode of venous thromboembolism is a predictor
for an increased risk of recurrence with probable benefit from long-term oral
anticoagulation therapy.
Antistreptokinase
Antistreptolysin-O-titre (ASOT)
ATIII can be spuriously reduced in the presence of heparin and after a thrombotic
event, as well as in nephrotic syndrome, liver disease and pregnancy. Elevated levels
are of no clinical significance.
ZZ, and to a lesser extent SZ are associated with emphysema and cirrhosis, and both
smoking and alcohol should be strongly discouraged. The importance of MS, MZ
and SS is uncertain but avoiding smoking is a wise precaution.
APCr
The APTT is a basic test used to detect abnormalities of coagulation involving the
intrinsic pathway. It is used to screen for deficiencies of plasma coagulation factors
(except Factors VII and XIII) or for the presence of an acquired inhibitor. The '1+1'
test is performed to distinguish between a deficiency and an inhibitor.
Marked prolongation of the APTT (>80 secs) is usually due to haemophilia if the
patient presents with bleeding, or due to Factor XII deficiency if the patient is
asymptomatic.
The lupus anticoagulant, found in the antiphospholipid antibody syndrome (qv), can
prolong the APTT markedly. It is usually associated with an increased thrombotic
tendency rather than bleeding.
Heparin therapy
Arcanobacterium haemolyticum
Arsenic
Acute poisoning
specimens: random urine
and whole blood (heparin)
Chronic exposure
specimen: 24 hr-urine with 10 ml HCl in plastic container
or early morning urine collected at end of working week
Arsenic is the 20th most common element in the earth's crust and is found in most
living organisms and in low concentration in water. Because a high urine level can be
Arthritis
- septic arthritis – immediate joint aspiration (see Synovial aspirate) will give
definitive diagnosis of septic arthritis and differentiate it from gout
- gout and pseudogout – see Synovial aspirate and Uric acid
- rheumatoid arthritis, SLE and other connective tissue diseases. see under
disease heading
- reactive arthritis – see Arthritis, reactive
Arthritis, reactive
Aspartate transaminase
Aspergillus
A fungus common in soil and decaying material and the cause of an invasive disease
in immuno-compromised patients. Diagnosis is by demonstration of hyphae in tissue
biopsy, sputum or culture.
We often recover A. fumigatus and occasionally other Aspergillus species from ear
swabs taken from patients with otitis externa. There is no easily applied antifungal
agent for this situation. Management requires thorough debridement and keeping the
ear dry. Adequate ear toilet is often possible only at an ENT clinic.
If the volume of specimen is small, (<1ml) collect it all into the plain tube.
Cytology
– add up to 25ml aspirate or fluid to 3ml 3.8% sodium citrate or 20ml EDTA.
Submit to lab as soon as possible, storing in fridge meanwhile; or
– add 50-75ml fluid to an equal volume of ethyl or methyl alcohol and add 3 units
of heparin/ml body fluid. Submit to lab as soon as possible, storing in fridge
meanwhile.
AST is found in high concentrations in liver, skeletal muscle and cardiac muscle. It is
also found in red cells and small increases (up to 100 U/L) are found in haemolysed
specimens or those left standing for more than 6 hours after collection. Small
increases may be seen in the last trimester of pregnancy.
ATIII
Atypical pneumonia
see Pneumonia
Mycoplasma pneumoniae
Legionella
Psittacosis (Chlamydia psittaci)
Chlamydia pneumoniae
Specificities for particular diseases are seldom absolute and low titre auto-antibodies
can be found in apparently disease-free people. Observation over months or years
may show regression, no change or progression to clinical disease.
Each autoantibody is described in more detail under its own alphabetic entry.
IA2
insulin (IAA)
thyroglobulin
parietal cell
endomysial (EMA)
reticulin
mitochondrial (AMA)
crescentric glomerulonephritis
lymphocyte
SLE ANA
polydermatomyositis ds DNA
scleroderma ENA
see beta
B12
Bacterial swabs
Details about collecting swabs from specific sites will be found under their own
alphabetic headings.
• cervical • skin
• ear • sputum
• eye • throat
• nasal • urethral
• rectal • vaginal
Bacterial vaginosis
Bacteroides
Bacteroides other than B. fragilis are grouped as Bacteroides species. Some may be
sensitive to penicillin. Antibiotic susceptibility testing should be discussed with a
clinical microbiologist.
Some species in the genus have recently been reclassified as Prevotella and
Porphyromonas species.
Barbiturates
Bartonella henselae
Base excess
Basophils
specimen: whole blood (EDTA)
ref. range: 0-0.20 x 109/L
The basophil count is part of a routine blood count (qv).
These tests are generally done in a specialist rather than general laboratory setting.
– honey bee
– paper wasp (polistes)
– German or common wasp (vespula)
Of the two, skin tests are the more sensitive and are preferred when performed by an
experienced allergist. A negative result using allergen at a concentration of 7µg/ml
RAST tests are graded on a scale 0 to 4+ with a crude correlation between the result
and the severity of the patient's response.
Clinically the allergic response varies from local pain and inflammation at the site of
the sting, through an extended local reaction over a larger area, to a generalised
anaphylactic response with urticaria, flushing, angio-edema, and sometimes severe
bronchospasm and cardiovascular collapse. Any generalised response requires
referral to a specialist allergy physician for consideration of immunotherapy
(desensitisation) which can be highly effective.
Benign paraprotein
see Immunoglobulins, IgA, IgG, IgM
Beta carotene
see Carotene
Beta hCG
Beta-hydroxybutyrate
specimen: serum
ref. range: 0 - 200 µmol/L
Bicarbonate
specimen: serum
ref. range: <2 yrs 18 – 28 mmol/L
>2 yrs 22 - 32 "
Also known as total CO2, this is a crude acid-base measure. In metabolic acidosis,
bicarbonate is reduced, e.g. in diabetic ketoacidosis. In metabolic alkalosis, it is
increased – as in pyloric stenosis or the compensated respiratory acidosis of chronic
obstructive airways disease.
This old test was used in the diagnosis of liver disorders in the first half of this
century before liver enzyme assays were developed. Bilirubin is found in the dark
urine of obstructive jaundice and later in the course of hepatitis. Urobilinogen is
found in early hepatitis. It is colourless but darkens on standing. Bile pigments are
included in the routine strip used in urinalysis. Positive results are an indication for
measuring s. bilirubin and liver enzymes.
Bilharzia
see Schistosomiasis
Biliary calculi
see Gallstones
specimen: serum
ref. range: conjugated bilirubin is about 10% of total but precision is not good
below a total of 50 µmol/L and at low levels 20% conjugated or even
30% may be normal.
• Isolated hyperbilirubinaemia
• Haemolytic anaemias
– uncommon but important. Check blood count, film,
reticulocytes, haptoglobins
• Other
– thyroid disease, iron overload, drug reaction, resolving
hepatitis
These are a rough guide to indicate levels that are likely to be comfortably
within healthy limits for most neonates. Acceptable limits are lower for
premature babies.
The problem with neonatal bilirubins is that many healthy, thriving babies
have levels higher than the above because of two common benign conditions;
physiological jaundice and the jaundice of breast-feeding.
Physiological jaundice
Jaundice of breast-feeding
Bilirubins can stay high for a long time. In about 2-5%, levels reach
250-350 µmol/L by the 3rd week, remain high for 3-4 weeks, falling
to normal over another 1-3 months.
Despite being yellow, the infant thrives, feeds and grows. Changing to
bottle-feeding results in a prompt and sustained fall in bilirubin levels
and cessation of breast-feeding for 24-48 hours, with bilirubins before
and after, can be used as a diagnostic test whilst maintaining lactation
by manual expression.
2. Pathological jaundice
Rhesus incompatibility
The most severe forms of this previously dreaded disease were due
to rhesus incompatibility between mother, (Rh -ve and with anti-Rh
antibodies) and baby (Rh +ve). The Rhesus system was first
described in 1940. Before that time, and until modern methods of
prevention and treatment were developed, these babies were born
Over the past 40 years this sensitisation process has been prevented
by injecting the mother at delivery with enough anti-Rh immune
globulin to render the foetal cells non-antigenic.
The at-risk mother is Rh-ve and will have red cell autoantibodies
when screened ante-natally,
— Rh+ve infant
— +ve Coombs test
— hyperbilirubinaemia using this table as a guide:
µmol/L
full term premature
Maternal antibody tests are of no use and often the direct Coombs test on cord
blood is negative.
Other blood groups include Kell (K), Duffy (Fya, Fyb) and Kidd (Jka, Jkb). For
these incompatibilities, maternal antibodies will be present and the direct
Coombs on cord blood positive.
As always, clinical judgement and experience are more important than rigid guide-
lines.
A healthy term baby, growing and feeding well, without visible jaundice, does not
need to have its bilirubin measured.
If the jaundiced baby is unwell, the underlying cause must be identified urgently.
If bilirubin levels continue rising after the first week or so, a cause should be sought.
The short answer to this is "not very". At a level of 325, repeated tests on the same
baby will show results varying between 300 and 350 which is the difference between
referring to hospital for treatment under lights or leaving at home. Reasons for this
variance are:
Once it has been decided the jaundice is benign, the baby is treated under lights if the
bilirubin exceeds cut-off limits, usually 350 µmol/L in a full-term baby more than 3
days old. The threshold may be lower in premature babies and where the bilirubin is
rising rapidly e.g. >250 @ 48 hrs.
For reasons given above, a baby with a result of 350 will sometimes be referred to
hospital only to be sent back home because its in-hospital result is 320.
Levels above 400, sometimes found in infants who have escaped observation, always
require urgent and immediate referral.
Biological variation
see Variation
Send in sterile container with sterile saline and label clearly "for culture".
Blastocystis hominis
Bleeding disorders
Bleeding time
ref. range: up to 8 minutes
The test is performed using a template to make a standard incision in the forearm.
The time taken for bleeding to stop is a measure of platelet plug formation. The test
is operator dependent and sensitive to technical variables.
Blood count
specimen: whole blood (EDTA)
ref. range:
• red cells
• white cells
Age WBC b/L Band. Neut. Seg. Neut. Lymphs Baso. Eos. Mono.
0—7 days 10.0-25.0 0-0.6 2.0-13.0 2.0-8.5 0-0.2 0-2.0 0.3-2.5
1 wk—2yrs 5.0-17.0 0-0.6 0.5-7.0 2.5-12.0 0-0.2 0-1.0 0-1.0
2—12 yrs 4.5-14.0 0-0.6 1.2-8.3 1.5-7.3 0-0.2 0-0.5 0-0.9
>12 yrs 4.0-11.0 0-0.6 2.2-7.5 1.0-3.9 0-0.2 0-0.5 0-0.9
Antenatal 4.0-15.0 0-0.6 3.4-10.5 1.4-3.2 0-0.2 0-0.5 0-1.0
Excess or deficiency of each cell type is described under individual alphabetic entries.
0 - 12 150 − 500 x 10 9 / L
>12 female 150 − 450 x 10 9 / L
male 150 − 400 x 10 9 / L
Blood culture
Blood cultures should always be considered before starting antimicrobial therapy for
an undifferentiated febrile illness in a patient with a prosthetic heart valve.
Blood culture collection protocols vary from one laboratory to another. For adults
two sets of adequately filled bottles, depending on clinical situation, will isolate the
organism in >95% of bacteraemias. In this laboratory two sets are drawn with each
collect, an aerobic and an anaerobic bottle from each arm. Standard aseptic technique
must be rigidly adhered to if contamination by skin flora is to be avoided.
Blood films are not routinely examined unless one or more of the blood count
parameters is shown to be abnormal by the electronic cell counting analyser. In
practice this means that films from 20% of blood counts are checked. The film report
describes the morphological appearance of red cells, white cells and platelets. Where
appropriate, the film comment will suggest a diagnosis and recommend follow-up. A
blood film examination will always be performed if specifically requested even if the
CBC (complete blood count) parameters are normal.
Blood grouping
ABO and Rh (D) phenotype are done routinely. The frequencies of the four main
groups in the ABO system and their naturally occurring antibodies are:
Blood in faeces
Blood in urine
see Haematuria
Blood volume
see Polycythaemia
weight in kg
BMI =
( height in metres ) 2
Bone marrow
Bone marrow trephine is performed routinely together with bone marrow cytology
(aspirate) and clot section. Chromosomes and cell marker analysis will be performed
whenever appropriate.
Bone marrow transplantation is being used more often. Allogeneic BMT from a
matched sibling donor is still a risky procedure with mortality up to 30% primarily
from graft versus host disease and infection. Autologous BMT, where the patients
are their own donor, has a much lower mortality risk. Stem cells, collected from
peripheral blood, are increasingly used in place of conventional autologous
transplantation. They are associated with rapid engraftment and reduced hospital stay
and cost. Autologous transplantation is also used in the treatment of solid tumours.
Longer term complications of BMT include infertility, secondary neoplasms and
endocrine dysfunction.
When bone is resorbed, collagen cross-links are released as part of the break-down
process and excreted in urine where they provide a measure of bone turnover rate in
conditions such as Paget's disease, thyrotoxicosis, bone cancer, renal bone disease
and hyperparathyroidism. Tests include:
– N-Telopeptide
– deoxypyridinoline (DPD, Pyrilinks D)
– hydroxyproline — no longer used
Serum alkaline phosphatase (ALP) and urine calcium excretion, though less specific,
may also give a useful measure of bone turnover and the effectiveness of therapy.
Bordetella pertussis
Adults with a chronic cough may have chronic pertussis infection which can be
detected by measuring serum antibodies.
Erythromycin may reduce the duration of the disease if administered early and will
reduce infectivity. A fourteen day course of erythromycin is also recommended for
household and other close contacts.
Borrelia
Branhamella catarrhalis
More than half of all breast cancers have oestrogen receptors indicating the need for
endocrine therapy. They have a better prognosis than receptor negative tumours. The
test uses an immunoperoxidase labelled antibody applied directly to tissue sections.
Breath test
no longer done
Cytology Smears are made from brushes and fixed in Cytofix immediately.
Washings are submitted to the laboratory as soon as possible for
cytocentrifugation.
Acute bronchitis is often a viral disease and sputum evaluation is seldom useful.
Brucella antibodies
specimen: serum
Brucellae are gram-negative bacilli infecting domestic animals, particularly cattle and
pigs. Human infection occurs in farmers and meat-workers as an occupational hazard
or by ingestion of contaminated milk products.
Over the past 30 years, brucellosis has been virtually eliminated from New Zealand
cattle and human brucellosis, when found here, will almost invariably have been
contracted abroad, including the Pacific Islands.
Agglutination and Coombs antibody tests detect both IgM and IgG antibodies.
Results may be negative in the early stages of acute disease and sometimes antibodies
are not detected at any stage. Seroconversion, however, or a >4-fold increase in
antibody titre, strongly suggests active infection.
no longer done
Buccal smears
This test for sex chromatin (the 2nd X chromosome in females) has been replaced by
karyotype analysis.
see Cytogenetics
Bulimia
Butyrate
see Beta-hydroxybutyrate
C1 (esterase) inhibitor
C3
C4
CA 15-3
specimen: serum
ref. range: <30 U/ml
CA 19-9
specimen: serum
ref. range: <37 U/ml
CA 72-4
specimen: serum
ref. range: <4.6 u/ml
CA 125
specimen: serum
ref. range: <35 U/ml
Mainly used for monitoring treatment and progress in established ovarian cancer.
Values >65 are consistent with ovarian malignancy in a patient with an ovarian mass.
Eating contaminated shellfish may raise levels. If in doubt, repeat after two weeks
abstention from seafood.
Caeruloplasmin
Calciferol
see Vitamin D
Calcitonin
specimen: plasma (EDTA)
ref. ranges: female <17 pg/ml
male <26 pg/ml
Calcium (total)
specimen: serum
ref. range:
Hypercalcaemia
The two most important causes are:
• drugs – vitamin D
thiazides
lithium
antacids
• thyrotoxicosis
• sarcoidosis
• familial hypocalciuric hypercalcaemia
• renal transplantation
• Paget's disease with immobilisation
Hypocalcaemia
• chronic renal failure
• vitamin D deficiency
• hypoparathyroidism (usually post-thyroidectomy)
• drugs — anticonvulsants
— frusemide
— biphosphonates
— oral phosphate
• malabsorption
• pancreatitis
• hypomagnesaemia
About half of total serum calcium is bound to albumin and inactive. The other,
ionised half is the physiologically active fraction. Ionised calcium levels are raised in
sera with an acid pH and lowered when alkaline.
For most clinical purposes, adjusted total calcium is adequate but in severe protein
abnormalities, including malignant paraproteinaemias and chronic renal failure,
ionised calcium may be more useful.
Calcium, urine
specimen: 24-hr urine collected into HCl
ref. range: 2.5–7.5 mmol/day
Some patients with recurrent renal calculi have a high urinary calcium output –
idiopathic hypercalciuria. Serum calcium must be checked to exclude
hypercalcaemia.
Calculi, biliary
see Gallstones
Calculi, renal
Campylobacter jejuni/coli
Campylobacter pylori
Candida
Skin Infection occurs in warm moist areas such as the groin, perianal region, axillae,
the breasts or in interdigital webs. It is often seen in those who frequently immerse
their hands in warm water, such as dishwashers.
Nails Candida can cause a painful red swelling of the nail fold resembling pyogenic
paronychia, This may progress to nail involvement (onychomycosis).
Mouth Infections are found mainly in infants and show up as white adherent patches.
Laboratory identification is not usually necessary but a swab will grow the yeast.
Cannabinoids
specimen: random urine (no preservative)
Cannabis
see Cannabinoids
Carbamates
see Cholinesterase
Carbamazepine (Tegretol)
see Anticonvulsants
see Carboxyhaemoglobin
Carboxyhaemoglobin
Levels fall about 15% per hour in air after removal of the CO source. Oxygen
treatment, particularly hyperbaric, accelerates clearance of CO.
Carcinoid syndrome
Cardiac enzymes
A first indication of aCL may be a "false positive" VDRL or RPR test during routine
antenatal screening.
• Myocardial infarct (MI), angina, cardiac death, congestive heart failure (CHF)
A 5-year absolute risk of say 10% means that of 100 patients with a similar risk
profile, 10 will have a CVD event in the next 5 years.
Or, put another way, a patient with a 10% absolute risk has a 1 in 10 chance of a
CVD event within 5 years.
Absolute risk is automatically assessed as very high (>20%) if the patient has any of
the following:
Otherwise risk is calculated using the tables overleaf; or using the appropriate
programme in your computer; or by having the laboratory add it your patient's lipid
profile in which case you will have to add information on the laboratory request form
– diabetes yes/no
– systolic BP
– smoker yes/no
Age is a potent risk factor and above 70, risk is always high.
If total cholesterol is >8 mmol/L or total/HDL ratio is >8, the patient is always
classified as at least high risk (i.e. >15%).
MEN
No diabetes Diabetes
nonsmoker smoker nonsmoker smoker
ratio of total cholesterol:HDL ratio of total cholesterol:HDL
4 5 6 7 8 4 5 6 7 8 4 5 6 7 8 4 5 6 7 8
180/105 180/105
160/95 AGE 160/95
140/85 70 140/85
120/75 120/75
180/105 180/105
AGE
Blood Pressure
160/95 160/95
Blood Pressure
140/85 60 140/85
120/75 120/75
180/105 180/105
160/95 AGE 160/95
140/85 50 140/85
120/75 120/75
180/105 180/105
160/95 AGE 160/95
140/85 40 140/85
120/75 120/75
4 5 6 7 8 4 5 6 7 8 4 5 6 7 8 4 5 6 7 8
ratio of total cholesterol:HDL ratio of total cholesterol:HDL
To use tables:
— identify table relating to person's gender, diabetic status, smoking status, age.
— within the selected table, find the cell nearest to the person's blood pressure
and ratio of total cholesterol : HDL.
— use cell shading from key on opposite page to identify risk level.
180/105 180/105
160/95 AGE 160/95
Blood Pressure
Blood Pressure
140/85 60 140/85
120/75 120/75
180/105 180/105
160/95 AGE 160/95
140/85 50 140/85
120/75 120/75
180/105 180/105
160/95 AGE 160/95
140/85 40 140/85
120/75 120/75
4 5 6 7 8 4 5 6 7 8 4 5 6 7 8 4 5 6 7 8
ratio of total cholesterol:HDL ratio of total cholesterol:HDL
high >30%
25-30%
2.5-5%
low <2.5%
Casts in urine
see Urinalysis (routine biochemistry and microbiology) and UTIs (urinary tract
infections)
Catecholamines
Indications
Phaeochromocytoma 25% of the population have hypertension but only a fraction of
these can or should be screened for a phaeochromocytoma. Particular indications are:
Interpretation
The typical phaeochromocytoma gives a noradrenaline level of 1.0 – 2.0 µmol/day.
Occasionally the adrenaline level is elevated but usually it and the dopamine are near
normal. In malignant phaeochromocytomas (10% of the total), dopamine tends to be
elevated as well as noradrenaline.
Medication
Noradrenaline is increased by amphetamines, alpha- and beta-blockers, vasodilators,
theophylline, phenothiazines and tricyclic antidepressants.
2. serology
– paired sera, 2-3 weeks apart
3. histology, cytology
– formalin-fixed tissue, usually lymph node, for histology
– FNA material for cytology
Although CSD was first reported in 1931, it is only recently that B. henselae, a
fastidious slow-growing, gram-negative rod, was identified as the pathogen
responsible. A study of cats in Auckland found 17% with B. henselae bacteraemia.
Fleas transfer the organism from cat to cat and flea control is a useful preventive
measure.
Treatment. Pain relief may be required. Steroids are generally ineffective. There are
no controlled trials to help choose an antibiotic but for those with prolonged fever
and/or severe lymphadenitis, erythromycin, doxycycline, clarithromycin,
ciprofloxacin, aminoglycosides and sulphamethoxazole/trimethoprim have been used.
Therapy should be discussed with an infectious disease specialist.
CD4 T-lymphocytes
The CD4 count (or CD4/CD8 ratio) is used to monitor the T-lymphocyte status in
HIV patients and the immune defect induced by the adenosine analogues used to treat
some haematological malignancies. As counts fall below 200/cmm, opportunistic
infections become increasingly common.
CD59
An absence of CD59 activity on the cell surface of red cells characterises paroxysmal
nocturnal haemoglobinuria (PNH).
see PNH
CEA
Celiac disease
Cerebrospinal fluid
Cervical cytology
specimen:
The cells must be representative of the cells lining the cervix. Squamous cell cancer
of the cervix, which accounts for 60-80% of invasive cancers, begins as cervical
intraepithelial neoplasia at the squamocolumnar junction. It is important to sample
this site to detect early changes.
The ideal sample consists almost entirely of squamous cells which line the ectocervix
and a small number of endocervical glandular cells to indicate that the
squamocolumnar junction has been sampled.
Essentially unchanged for the last 50 years, this test has saved the lives
of many women reducing mortality from cervical cancer by more than
70%.
Preparation
Write the patient’s name on the frosted end of the slide in pencil (HB
is fine) and have the fixative (Cytofix or Cytospray) ready for use.
The tip of the spatula is inserted into the cervical canal and carefully
rotated through 360º obtaining cells from the ectocervix,
transformation zone and lower endocervix. The spatula must make
sustained contact with the cervix throughout the whole rotation if
segments are not to be missed.
Cytobrush smear
• where the anatomy of the canal has been altered by age as in post-menopausal
women or by treatment such as cone or Lletz biopsy.
• abnormal bleeding
The specimen, once smeared, needs to be fixed within 4-5 seconds to prevent fixation
artefact.
Fixation
1. Coplin jar
This is a glass or plastic jar with slots in the side of the jar to ensure the slides
stand up in the jar and do not touch their neighbours. The Coplin jar is filled
with cytofix.
It is important to keep the lid on the jar as this prevents evaporation of the
cytofix which should be changed every 3-4 days or every 15-20 slides.
2. Cytospray
It is important to hold the spray bottle at least 20 cm from the slide and
produce a good powerful fine droplet spray. If the spray bottle is held too
close to the slide or large droplets are created then the cells may be damaged
and the slide rendered uninterpretable. The slide may be placed in the plastic
slide mailers, sprayed and the mailer closed and sent to Diagnostic.
Can the cytobrush smear go on the same slide as the spatula smear?
The answer is yes, provided you take precautions to ensure there is no delay in
fixation.
• Spread the spatula specimen on one half of the slide. Immediately cover
the other half with a layer of paper and spray the spatula smear taking care
that no fixative runs under the paper or through it onto the unused half. If
this happens cells will not stick to the slide and will be lost during
processing. Now collect the cytobrush smear and spread it on the
remaining half slide. Spray with fixative.
Cervix broom
• The central bristles of the broom are inserted into the endocervical canal deep
enough to allow the shorter bristles to fully contact the ectocervix. Push
gently, and rotate the broom in a clockwise direction 2 to 3 times.
• Gently wipe the cell sample onto the glass slide as if one were using a
paintbrush, first n one direction then in the other direction making sure all the
bristles and both sides come in contact with the slide. Repeated brushing back
and forth is not recommended as this will damage the cells.
This is a new way of processing cells taken from the cervix, utilising fluid-
based specimen collection.
The sample is collected in the normal way but instead of smearing the sample
on a slide, it is rinsed in a fluid containing fixative. The sample is put into a
machine which filters out most of the blood and inflammatory exudate and
prepares a smear with a thin even layer of cells. The smear is then screened in
the normal way by a cytology screener.
1. Nearly all the cells collected are transferred to the sample providing a
representative homogeneous smear.
In clinical trials the Thin Prep Pap Test has been shown to have the following
advantages
Specimen collection
3. The cap of the vial should be tightened so that the tongue line on the cap
passes the tongue line on the vial.
4. Record the patient's name on the vial and then place with the completed
cytologyrequest form in a biohazard bag for collection by the laboratory.
1. Adequacy of specimen
2. Description of findings
3. Recommended follow-up
Cervical swabs
Swabs are collected from the cervical canal when testing for Neisseria or Chlamydia
trachomatis – see entries under these headings.
Chicken pox
Chilomastix mesnili
Spectrum of disease
Many adults have antibodies indicating that the infection is common, initial infection
being typically at age 5-15 years. It can cause pneumonia, severe pharyngitis,
hoarseness, fever, cervical lymphadenopathy. Infection in young adults is usually of
mild to moderate severity but can be sub-clinical or, in immunocompromised
patients, severe. Incubation period averages 21 days and infection can recur. Its most
recent (and surprising) association is with coronary artery disease, suggested by
seroepidemiologic studies and finding the organism in atheromatous plaques.
specimens:
1. antibodies - serum, preferably paired sera 2-3 weeks apart
interpretation:
single specimen <1:16 negative
1:16-1:32 indeterminate
>1:32 past or present infection
paired sera 4-fold or greater increase indicates
current infection
C. psittaci is a pathogen endemic in all bird species. When a human inhales dust
from fomites from infected birds, they can develop an infection which may present as
an atypical pneumonia, headache, fever, rash, myalgia. Severity ranges from mild to
moderate, occasionally severe.
Chlamydia trachomatis
In New Zealand the term "chlamydia" commonly refers to genital infections with C.
trachomatis. They are widespread in the community.
Swabs must be placed in the purple top tube provided for transport.
Female specimens Use one of the large swabs to clean secretions away from the
cervical os. Now insert the second large swab 1-2cm into the endocervical canal and
rotate for 15-30 secs. Chlamydia are located inside cells, not secretions, hence the
need to rotate the swab against the cells lining the cervical canal.
Now insert the thin swab into the urethra and rotate to collect the second specimen.
Sampling both cervix and urethra, only one of which may be infected, increases
recovery rate by 15-20%.
Male specimens If there is a urethral discharge, swab the inside of the urethral
meatus. Insert the swab 2-4cm into the urethra and rotate for 3-5 seconds to ensure
adequate sampling.
Tests should not be performed until 3 weeks after treatment to prevent false positives
due to persisting dead antigen, or false negatives due to persisting live organisms
being too small in number to register positive.
All results reported as positive have been confirmed using a different methodology to
eliminate most false positives. The current literature gives the predictive value of a
confirmed positive as >99%. As with all laboratory tests the possibility of both false
positives and false negatives needs to be kept in mind when a result seems not to fit
the clinical situation.
Treatment
Chlamydia is treated with doxycycline, 100mg 12-hourly, for 7–10 days except in
pregnant women where amoxycillin, 500mg 8-hourly, or erythromycin, 500mg base
6-hourly, is used. Recently azithromycin as a 1g single dose has been approved. This
is likely to become the standard treatment of genital C. trachomatis infection in New
Zealand.
Genital infections
Chloride
specimen: serum
ref. range: 95 – 110 mmol/L
Formerly, chloride was measured as part of the electrolyte group but it has now fallen
into disuse except for a few specialised situations in renal medicine. Those who
calculate anion gaps will need a chloride level.
Cholesterol
Total cholesterol is made up of three fractions:
triglyceride
VLDL =
2.2
triglyceride
LDL = total − HDL −
2.2
The formula is inaccurate and not used when the triglyceride is above 4.5.
Cholesterol, HDL
specimen: serum
The current NHF (National Heart Foundation) recommended level is >1.0 which is
relatively easily achieved, 80% of females being above this level and 60% of males.
HDL cholesterol is protective against atherosclerosis and a low HDL is an
independent risk factor separate from LDL cholesterol.
increased by
• exercise
• alcohol
• drugs – oestrogens
– fibrates, statins, nicotinic acid
– anticonvulsants
decreased by
Athletes using anabolic steroids can have dramatically low HDL levels.
LDL cholesterol is calculated using the Friedewald formula – see under Cholesterol
above.
Quantitatively it makes up about 80% of total cholesterol in a normal person and for
this reason the terms total and LDL cholesterol are often used interchangeably, even
though there are significant differences.
• genetic inheritance – responsible for more than half the LDL level and not
modifiable except by drugs
• diet
elevated by:
• polygenic hypercholesterolaemia
• familial hyperlipoproteinaemia
• high fat diet
• diabetes
• hypothyroidism
• alcohol
• nephrotic syndrome
lowered by:
• ideal diet
• oestrogens
• drugs: statins, fibrates, nicotinic acid, bile resins
specimen: serum
ref. range: NHF ideal levels – total cholesterol <5.0
– total/HDL ratio <4.5
Fasting or non-fasting?
A reasonable approach is to make the first profile non-fasting. If levels are higher
than ideal, a second fasting specimen is ordered to complete the baseline.
The graph below shows "observed" total cholesterol ranges in 80,000 unselected sera
in the Auckland population 1997 - 1998. It can be seen that in the 45-70 age-group,
about 70% lie above the ideal level at 5.0 mmol/L.
Female and male mean levels are shown separately but the 5th and 95th percentile
lines are for male and female combined.
Because the LDL fraction makes up about 80% of total cholesterol, those factors
which raise or lower LDL cholesterol (qv) will have the same effect on total
cholesterol.
It can be seen that a high triglyceride has an important effect on total levels whilst
LDL is relatively unaffected by triglyceride – hence the importance of examining a
full lipid profile, not just total cholesterol.
The full profile is also essential to measure HDL as an important independent risk
factor and to measure triglyceride which is also being recognised as a risk factor, e.g.
in women and diabetics.
This ratio integrates the contributions of HDL and LDL into a single figure, showing
the magnification of risk when LDL is high and HDL low; and also how a high HDL
can diminish the importance of a high LDL.
At a level of 6.5 mmol/L the biological variance is about ± 0.5 mmol which means
that changes between 6.0 and 7.0 are not necessarily significant. Serial
measurements, say monthly or 3-monthly, are necessary to smooth out these random
oscillations and show whether the trend is down, up or unchanged.
• whole blood (heparin) is preferred because it can be used for both red cell and
plasma cholinesterase measurements when checking for insecticide poisoning
and can be used in detecting scoline sensitivity.
• serum can, however, be used for all tests except red cell cholinesterase.
• please include clinical details.
Indications:
Organophosphates Carbamates
malathion carbaryl
acephate methiocarb
coumaphos methomyl
chlopyrifos propoxur
2. Acute poisoning
4. Other Cholinesterase levels are reduced in chronic liver disease, renal disease,
pregnancy/oestrogens, acute illness.
Choriocarcinoma
Chorionic gonadotrophin
Chromium
specimen: random urine with added HCl
When the test is being done in welders, the specimen should be collected towards the
end of the working week.
Chromosome analysis
see Cytogenetics
This relatively common condition (1-2 per 1000) continues to attract attention in both
the lay and medical press.
We are sometimes asked by patients if there is a simple yes/no diagnostic test and so
far there is none, despite occasional claims to the contrary. The diagnosis is based on
the history of debilitating fatigue for at least 6 months in the absence of any clinical
or laboratory evidence of identifiable organic disease.
Typically CLL is an indolent disorder with a median survival of 10-14 years. In the
early stages the patient does not require therapy but regular blood counts are
performed to monitor the disease for increased activity.
CML is predominantly a disorder of middle life but the diagnosis is being made
increasingly in younger patients. The disorder is characterised by a leucocytosis
which is left shifted, typically showing the major increases in myelocytes and
segmented neutrophils giving a bimodal differential white cell distribution. Blast
cells are also present. The majority of patients are Philadelphia chromosome positive.
The NAP score is low or absent.
CML is a state of bone marrow instability and after a variable time, median 3-4 years,
the disease transforms into an acute leukaemia which is unresponsive to standard
chemotherapy. The only potentially curative treatment is bone marrow
transplantation. This may use a matched sibling donor or a matched unrelated donor
transplant. Interferon is the treatment of choice in patients who cannot undergo bone
marrow transplantation. Hydroxyurea is frequently used for cytoreduction.
Chyluria
see Flavobacterium
A gram-negative bacillus resembling Pseudomonas, formerly known as
Flavobacterium. A pathogen in the urinary tract, it may also cause superficial skin
infections after contact with soil or fresh water. C. meningosepticum is known as a
cause of neonatal meningitis. Isolates are susceptible to vancomycin which is
unusual for gram-negative species.
Citrobacter
specimen: serum
ref. range: female 30-180 U/L
male 60-220 U/L
Elevations of CK
These are common and most arise from skeletal muscle. Clinically the elevations in
myocardial infarction are important.
In MI (myocardial infarction), CK typically starts to rise 4-12 hours after chest pain
commences and returns to normal in 2-3 days. Myocarditis can cause more
prolonged elevations of CK.
This test has now been superseded by Troponin T or Troponin I which have better
specificity and stay high for 7-10 days.
CK-MB rises 4-10 hours after MI and stays high for 36-48 hours.
CLL
Clostridium difficile
A normal inhabitant of the bowel which can proliferate when other organisms are
suppressed by antibiotics, particularly clindamycin or ampicillin. C. difficile
produces toxins causing bloody diarrhoea and pseudomembranous colitis visible on
endoscopy. Less severe forms of antibiotic-associated diarrhoea may also be
associated with C.difficile.
Management
Stopping the precipitating antibiotic treatment may be enough. The most commonly
used treatment is metronidazole, 400mg 8-hourly for 7-10 days. Up to 20% of
patients relapse. This is not due to metronidazole resistance but is explained by the
ability of C. difficile to form antibiotic resistant spores. The treatment for relapse is
again metronidazole.
CML
CO
CO2
see Bicarbonate
Blood gases & pH
• platelet count
• bleeding time for platelet function
• PR (prothrombin ratio) for extrinsic pathway
• APTT (activated partial thromboplastin time) for intrinsic pathway
• TCT or fibrinogen assay for final common pathway
These tests may miss mild abnormalities but they will detect major disorders. More
detailed investigations may more fully characterise an abnormality and are indicated
where there is a strong bleeding history.
This laboratory does about 6000 screens each year. Diagnoses and their frequencies
are:
A careful history is the most valuable part of an assessment. If the history of bleeding
is convincing, a minor disorder may exist even if the laboratory tests are normal.
see Variation
Coeliac disease, affecting at least 1:3000 (1:300 in some populations) is by far the
commonest cause of intestinal malabsorption.
In severe cases it presents in infancy or childhood with failure to thrive and fatty
diarrhoea.
Milder cases are more common and can easily be overlooked, particularly as many do
not have intestinal symptoms. Features of these milder cases can be one or more of:
• anaemia
• iron deficiency
• folate deficiency
• fatigue
• diarrhoea, abdominal discomfort
The disease is due to an intolerance to gliadin (gluten) found in wheat, barley and rye.
Diagnostic antibodies are found in serum, and the mucosa of the small intestine
shows flattened villi on biopsy. Withdrawal of gluten from the diet usually results in
Diagnosis
1. Antibodies
These simple, relatively specific tests developed over the past few years have
improved the detection rate in patients whose symptoms do not justify
intestinal biopsy.
— reticulin antibodies are less often used but have a high degree of pecifity
when positive
All three are measured as the IgA antibody, which correlates with disease better
than the IgG, except in patients with selective IgA deficiency (10x more
common in coeliac patients) where the IgG antibody must be used. To identify
IgA deficiency, immunoglobulins must be measured.
If both AGA and EMA antibodies are positive, predictive value for coeliac
diseaseis >99%. Where only one test is positive, the likelihood of coeliac
disease is less.
2. Other tests
– malabsorption
Cold agglutinins
specimen: serum from blood collected at laboratory and stored at 37ºC prior to
analysis.
Cold agglutinins are autoantibodies that cause red cell agglutination in the
temperature range 0-37ºC. Clinically harmless cold agglutinins in low titre may be an
incidental laboratory finding.
These cold autoantibody diseases can be either primary, when they are usually found
in older patients, or secondary. The secondary associations are infections (infectious
mononucleosis, mycoplasma, CMV); lymphomas or CLL; or connective tissue
diseases. The prognosis of secondary cold haemagglutinin disease is that of the
underlying disorder.
A group of inherited adrenal disorders due to enzyme defects, the commonest being
21-hydroxylase deficiency. Neonatal blood screens check for severe forms of 21-
hydroxylase deficiency by measuring 17 OH-progesterone.
A milder and more common form of CAH can present as hirsutism in adult women.
It can be detected by measuring serum 17 OH-progesterone on a morning specimen
collected during the follicular phase of the menstrual cycle.
Conjugated bilirubin
Tests associated with these conditions are described under the disease headings.
Diagnosis can be difficult or impossible in the early stages of these conditions which
can evolve over months or years before enough features develop to establish the
diagnosis.
Conn's syndrome
Coombs test
specimen: serum
The direct Coombs test detects antibodies or complement which are coated on red
cells as in autoimmune haemolytic anaemia, haemolytic disease of the newborn,
The indirect Coombs test detects red cell antibodies in serum, as in maternal antibody
screens in pregnancy or some autoimmune haemolytic anaemias. It is also used in
cross-matching.
Copper
specimen: serum
or urine, 24-hr in special plastic bottle from laboratory containing 25ml
purified HCl
Coproporphyrin
see Porphyrias
When haemolytic disease of the newborn (qv) is suspected, Hb, blood group, direct
Coombs and bilirubin must be checked. Otherwise cord blood samples are not
routinely tested though some collect the samples and store them for up to a week at
4°C in case they should be needed.
When the direct Coombs is positive, Rh typing must be confirmed and the coating
antibody identified. The initial Rh typing will sometimes be found to be incorrect
when the direct Coombs is positive, due to interference by the antibody.
Cord blood reference ranges for a wide variety of tests differ markedly from those
found in the next few hours, days and weeks of life. See individual test entries for
particular ranges. The three commonest tests on cord blood and their reference
ranges are:
Hb 136–196 g/L
bilirubin full-term up to 50 µmol/L
premature up to 25 µmol/L
direct Coombs negative
Cortisol, serum
specimen: serum collected at 07.00 – 10.00 hrs
ref. range: 200–700 nmol/L
There is marked diurnal variation, the peak at 09.00 hrs being 50-100% higher than
the trough at 23.00 hrs.
An isolated 09.00 serum cortisol is a crude diagnostic tool. A rough guide to
interpretation:
Decreased levels
Elevated levels
Because only the unbound fraction of serum cortisol reaches the urine, this is a good
screen test for Cushing's syndrome and a clearly normal result makes the diagnosis
unlikely. In perhaps 10% of cases cortisol hypersecretion is intermittent.
The latest Auckland case was in July 1998. A special medium is required to recover
C. diphtheriae so the possibility of diphtheria must be specifically mentioned on the
request form.
Corynebacterium haemolyticum
Corynebacterium minutissimum
see Erythrasma
Coxsackie viruses
These are widely distributed enteroviruses associated with many different types of
illness including minor febrile illnesses, the common cold, herpangina, pleurodynia,
aseptic meningitis, myocarditis, post-viral fatigue syndrome, conjunctivitis, Type I
diabetes and others. Infections are more common in summer and autumn. Virus can
be recovered from throat swabs or rectal swabs and also conjunctival or vesicular
swabs if lesions are present.
C-peptides are fragments derived from endogenous, but not exogenous, insulin.
Formerly used to check residual islet cell function in Type 1 diabetes or in the
investigation of unexplained hypoglycaemia but now rarely used.
mg/L
<5 normal
10 - 40 mild inflammation, some viral infections
40 - 200 acute inflammation, bacterial infections
>200 severe bacterial infection or extensive trauma
CRP is the most useful of the acute phase reactants, rising sharply 4-8 hours after
tissue damage by infection, infarction, inflammation or trauma. It returns to normal
2–3 days after disease activity has ceased. It can be regarded as a fast-changing ESR
which, by contrast, rises and falls more slowly. It can be used as an indication of
occult bacterial infection, suspected rheumatic fever, inflammatory bowel disease or
other conditions where there is uncertainty whether symptoms are functional or due to
organic disease. Chronic inflammatory diseases such as SLE can be monitored using
serial CRPs and for this purpose it is a more useful test than the ESR. It has also been
used in the diagnosis of myocardial infarction.
Creatine kinase
Creatinine, serum
specimen: serum
ref. ranges:
age mmol/L
newborn 0.020 - 0.090
child 0.020 - 0.070
adolescent 0.040 - 0.090
adult female 0.050 - 0.105
adult male 0.060 - 0.120
Some laboratories use µmol/L which would make the adult female range, for
example, 50 - 105.
GFR steadily reduces with increasing age but this is offset, though not completely, by
diminishing muscle bulk and creatinine excretion.
The use of a population-based reference range is even less satisfactory for creatinine
than for other analytes because the individual creatinine range for a person remaining
in good health is narrower than the traditional population range. When monitoring a
potentially nephrotoxic process, reference should always be made to the individual's
own range, as shown by creatinine results when disease-free, rather than to the
population range.
Method interference
Pre-renal disease
When shock, cardiac failure, fluid & electrolyte depletion, reduce renal blood flow, s.
creatinine will rise.
Post-renal obstruction
Creatinine, urine
specimen: 24-hr urine, no preservative
ref.ranges:
Wide variations in creatinine output for an individual are due to biological variation
of ± 20%, sometimes compounded by incomplete (or over-complete) urine collects.
Creatinine clearance
specimens: 24–hr urine, no preservative – must be accurately timed to 24 hrs, no more, no less.
plus serum obtained within collection period
CREST syndrome
• Calcinosis
• Raynaud's phenomenon
• Esophageal hypomotility
• Sclerodactyly
• Telangiectases
Also called limited scleroderma. The ANA is usually positive showing the
centromere pattern.
Crohn's disease
• iron deficiency
• vitamin B12 deficiency
• anaemia due to combinations of chronic disease and iron and B12 deficiency
• raised ESR and CRP
• reduced albumin
• hypokalaemia
For routine pre-operative cross-matches for cold surgery, the specimen must be
collected at least 24 hours in advance. There are some essential prerequisites:
• The request must be made on cross-match request forms in duplicate (one can
be a carbon copy).
• Full ID on request form – full patient name, dob, sex, NHI number if known.
• Full patient ID on specimen tube and date and time of collection.
• Doctor's name and signature and date of request on both copies.
• Time and date of specimen collection. If the patient has been transfused in the
past 14 days, specimen collection and cross-match must be done within 24
hours of operation.
• Patient's hospital
• Indicate whether 'group and hold' only
• If packed cells or whole blood required, indicate number of units
• Time and date required
• Give previous transfusion history, history of red cell antibodies, obstetric
history.
Laboratory procedure The donor red cells are tested for compatibility with the
patient's serum.
Specimens must be kept collected at the laboratory to maintain them at 37°C prior to
analysis.
Cryptosporidium
Diagnosis is by use of a special stain for oocysts in faeces and will be done on
specific request. The typically watery diarrhoea usually settles without treatment
within 10 days (range 1-20 days). In immunocompromised patients (especially those
CSF cytology
CSF specimens for cytology need to reach the laboratory within 30 minutes of
collection. Please contact the laboratory prior to lumbar puncture if CSF cytology is
required.
Cushing's syndrome
The main causes are:
Isolated serum cortisol is not recommended as a screen test though a level below 500
nmol/L in a specimen collected before 10.00 hrs makes Cushing's unlikely.
CV (coefficient of variation)
see Variation
Cyclical neutropenia
Cyclospora cayetanensis
C. cayetanensis is a recently described protozoan which causes diarrhoea in travellers
to endemic areas. It is common in Nepal. The incubation period is 3-11 days,
median 8 days. It causes a protracted and relapsing diarrhoea. Range of illness is 9-
40 days. Diarrhoea may last for months in the immunocompromised. Diagnosis is by
Cystic fibrosis
Affects 1:3000 infants. Cystic fibrosis is carried on a recessive gene which can be
identified in 70% of carriers by DNA testing. The underlying defects of exocrine
gland function show up in respiratory tract, pancreas and sweat glands. Typically,
presentation is in infancy or childhood with recurrent pulmonary infections and
sometimes with malabsorption.
All newborns in New Zealand are screened for cystic fibrosis by measuring blood
trypsinogen on the NTC (National Testing Centre); (qv) blood spots collected in the
first week of life. Pick up rate is 98%. The test can be used up to the age of 6 weeks.
Because false positives are relatively common, positive tests must be checked at 6
weeks.
see Haemochromatosis
Cystinuria with an incidence of 1:10,000 is the one of the commonest of the inborn
errors of metabolism. Failure of the renal tubules to reabsorb cystine from urine
results in excretion of a high concentration of poorly soluble cystine which can
precipitate to form cystine stones – 1-2% of all renal calculi.
Cytogenetics
Three major areas of testing are carried out:
3. Cancer cytogenetics:
— leukaemia
— lymphomas
Cytology
see Cervical cytology
Aspirated fluids, synovial, pleural,
ascitic etc from cysts or pleural or
ascitic fluid
Bronchial brushings or washings
CSF (cerebrospinal fluid)
Fine needle aspirate (FNA)
Frozen section/rapid smears
Gastric and oesophageal
brushings/washings for cytology
Sputum cytology
Ulcer scrapings for cytology particularly
from the oral cavity
Urine cytology
Cytomegalovirus (CMV)
specimen: serum
Interpretation
IgM antibodies, reported as +ve or –ve, are detectable for a period of about 6 months
from the time of commencement of a CMV infection. False positives occur during
some other viral infections, notably those due to EBV.
The virus itself persists in latent form throughout life after recovery from the initial
infection and can be reactivated in an immunocompromised patient.
D-dimer is a fibrin break-down product and elevated levels can be found in any
situation where there is thrombosis.
Clinically the test is used when DVT (deep vein thrombosis) with or without PE
(pulmonary embolism) is suspected. A normal D-dimer level makes DVT/PE
unlikely.
Elevated levels have a poor predictive value for DVT/PE as they are found in many
clinical situations including chronic inflammatory disorders, malignancy, post-
operative states and acute rheumatic conditions.
Dehydroepiandrosterone sulphate
Demodex folliculorum
This is an extremely small mite (0.3-0.4mm), which inhabits the hair follicles and
sebaceous glands of humans. They feed on sebaceous secretions, especially sebum.
They are particularly common on the nose, eyelids and cheeks.
The life cycle from egg to larvae to nymphs to adults takes around two weeks and
occurs within the hair follicle or sebaceous gland. A high proportion of adults,
They do not normally appear to produce disease. There are conflicting reports on
their association with rosacea.
It has been associated with ocular itching and blepharitis in the elderly but its
importance as a cause is disputed.
Treatment: There is little to suggest that treatment is indicated for this endemic
human infestation.
Dengue antibodies
specimen: serum
Microsporum species are usually transmitted by animals and are the common cause of
scalp ringworm in children.
Epidermophyton is transmitted from person to person and most commonly affects the
groin.
Trichophyton has three modes of transmission from soil, animals or humans and is
found in hair, nails and skin.
The clinical picture and treatment are, however, determined more by site than by
species and in the discussion that follows, the dermatophytes will be treated as if they
were a single fungus.
The task of the laboratory is to answer the question "Is this skin lesion due to a
fungus?". False positive answers and false negatives are equally undesirable. A false
positive may subject the patient to a long and expensive course of treatment. A false
negative answer may lead to unsuitable treatment such as a steroid which will
exacerbate the underlying fungal infection. There are three important steps in
laboratory diagnosis:
Specimen collection An adequate amount of keratin must be collected from the area
of the lesion where fungal growth is most likely to be active. The importance of
collecting an optimum specimen cannot be over-emphasised.
The typical fungal skin infection is an irregular expanding ring with a raised
serpiginous border thought to resemble a worm, hence the old term ringworm or tinea
(latin for worm). Scrapings of keratin must be collected from the periphery where the
infection is active. Sometimes there is a secondary bacterial infection obscuring the
fungus, a situation seen particularly in athlete's foot.
These usually present the classical appearance described above. They are usually
cured within 2 weeks by topical antifungals such as terbinafine, clotrimazole,
miconazole or econazole. It is recommended to continue treatment for several days
after full resolution of the lesions. Where chronic or widespread infection is present,
oral terbinafine, itraconazole or fluconazole may be considered.
Infected hair may break leaving a bald area. Fluorescence under a Woods lamp
sometimes helps establish the diagnosis and indicates which hairs should be taken for
microscopy and culture. Treatment with an oral agent is recommended, e.g.
terbinafine or itraconazole.
Lesions may be on the inside of the thighs, inguinal area, pubic hair or scrotum.
Candida infections are common here as in other moist warm folds and a swab should
also be collected and placed in transport medium. Topical imidazoles are effective
against both Candida and dermatophytes. Erythrasma (qv) may be found in the groin
and is sometimes mistaken for tinea.
Although the initial infection can be dry and scaling, added bacterial infection and
accumulation of soggy debris may occur. Treatment requires attention to hygiene and
local applications. Bear in mind Candida can be implicated as well as bacterial
superinfection.
Dermatophytes may affect the nails alone or they may spread from a nearby skin
infection. The nail often becomes thickened, discoloured and friable. Scrapings,
clippings and debris should be collected. Collection of a good specimen is of
particular importance in this site because long-term oral treatment may be needed.
Treatment options include oral terbinafine or itraconazole. Yeast species such as
Candida (qv) and other non-dermatophyte fungi may also cause nail infections.
Dermatophytes can be the cause of dry scaly lesions of palms and soles. Specimens
need to be collected with care to avoid false negatives. Treatment is topical.
Tinea versicolor
specimen: serum
• Cushing's syndrome
• endogenous depression
• chronic alcoholism
• drugs – phenytoin, barbiturates, oestrogens
• significant stress or illness
DHEA
DHEA and its sulphate DHEAS are the most abundant androgenic steroids secreted
by the adrenal cortex. DHEAS is more commonly measured than DHEA and for
practical purposes the two estimations provide the same information. Its uses are:
• in the investigation of virilism - levels are usually >3x upper limit of normal
In people taking DHEA supplements to restore youth and beauty, the DHEAS levels
may be increased 2-3x.
These autoantibodies are markers for Type 1 diabetes and typically can be detected
months or years before the development of clinical disease.
Indications
As yet a generally accepted preventive treatment for pre-clinical diabetes has not been
found but when it is there will be screening programmes and preventive treatment for
those who have significant levels of one or more antibodies.
The preferred initial screen is for GAD and IA2 antibodies which are the easier tests
technically and the ones most likely to be elevated.
The autoantibody pattern is variable from one patient to the next and varies with time
for an individual patient. GAD antibodies have a higher positivity rate (~80%) than
the others and stay elevated for longer
ICA and IA appear earlier in the pre-clinical course of the disease and disappear
earlier.
One antibody just above the level of significance may disappear without diabetes
developing.
A high level – they can be up to 50 times the significant level – is more likely to
progress to diabetes.
— diabetes mellitus
— hypercalcaemia
— renal disease
— medication: lithium, diuretics
The person with diabetes insipidus will be excreting a large volume of dilute urine
throughout the night compared with the normal person's diminishing volume of
increasingly concentrated urine. An osmolality <200 mmol/kg is consistent with
diabetes insipidus whereas a value above 400, or better still above 600, makes the
diagnosis unlikely.
Water deprivation should not be attempted in the person with a very high urine
volume because of the danger of serious dehydration.
Classification
Diagnosis of diabetes
The symptomatic patient almost invariably has a glucose level above 15 mmol/L.
An interim diagnosis can be made immediately using a urine dipstick, followed by
a definitive laboratory blood glucose.
Where there is less urgency, a random glucose result above 11.0 mmol/L at the
laboratory will confirm the diagnosis.
• A fasting glucose is a good screen test and can be combined with fasting
lipids to check risk factors.
• Random bloods – A level between 7.0 and 11.0 is an indication for a GTT
(glucose tolerance test) or a fasting test. Below 7.0 can be accepted as
probably non-diabetic. Above 11.0 should be followed by a second random
glucose, two values above 11.0 being diagnostic of diabetes.
• HbA1c (qv) is a useful test where a random glucose is equivocal and GTT is
impractical e.g. the very busy, the needle-shy or the elderly person in a rest
home.
Diagnostic criteria
Monitoring diabetes
Type 2s require fewer tests for monitoring, their glucose levels being generally more
stable and their treatment regimens more fixed. A four times daily insulin regimen,
by contrast, in an unstable diabetic, requires frequent monitoring.
Plasma glucose Patients who are self-monitoring establish their daily glucose profile
by testing before breakfast (fasting), before lunch, before dinner and before bed.
When using the laboratory, bearing in mind its more limited availability, the most
useful times are before lunch, often the lowest level of the day, and late afternoon.
HbA c (qv), which gives a measure of the mean blood glucose level over the past 2
1
months, is the essential base-line measure of glycaemic control and should be done at
least annually in all diabetics.
Fructosamine (qv) may have a role when looking for more recent changes in
glycaemic control or when red cell turnover is increased as in chronic bleeding or
haemolysis but in general it is a considerably less satisfactory test than HbA c.
1
Urine microalbumin (qv) is used at annual review for detecting early nephropathy.
Diarrhoea, infectious
Campylobacter 55%
Salmonella 17%
Giardia 14%
Yersinia 10%
Shigella 4%
Travellers' diarrhoea
Chronic diarrhoea – can be due to giardiasis. Treat with metronidazole 2g daily for 3
days, or tinidazole 2g as a single dose.
Prophylactic antibiotics – these are not recommended as a routine but some travellers
suffering repeated bouts of diarrhoea may be helped by doxycycline 100mg daily or
cotrimoxazole 480 mg daily.
Diastase
The old name for urinary amylase (qv).
Diazepam
Dibucaine number
see Cholinesterase
Tests for DIC include FBC (with blood film for fragments), platelet count (as part of
FBC), prothrombin time (PR), APTT, fibrinogen assay and D-dimers.
Dientamoeba fragilis
specimen: faeces in PVA fixative obtainable from lab.
Digoxin
specimen: serum
therapeutic range: 1.2–2.6 nmol/L (trough level)
Specimen should be taken at least 6 hours after last dose. Half-life is 36 hours, time
to steady state 8 days. Where toxicity is suspected, digoxin administration should
cease until the serum level has been measured – the long half-life means the decline
to sub-therapeutic levels is slow whereas a move higher into the toxic range can be
lethal.
Because digoxin is 85% eliminated by the kidney, renal impairment (as in the elderly)
is a potent cause of toxicity. Low K+ and high Ca++ levels potentiate toxicity.
Hypothyroidism and some drugs raise digoxin levels.
Diphtheria
Diphyllobothrium latum
A tapeworm found in the human small intestine where it can live for 20 years and
reach 10 metres in length. By competing for vitamin B12 it can cause megaloblastic
anaemia. It is acquired by eating larvae in raw fish flesh. Even when fish is cooked
adequately, humans may become infected by sampling the flesh during preparation.
Distribution is mainly in Scandinavia but also in Japan and the Pacific Coast of the
USA. Diagnosis is by finding characteristic eggs or proglottids in faeces. Final
control will only occur by prohibiting the discharge of untreated sewage into lakes
and streams. Treatment is praziquantel, 10mg/kg as a stat dose.
Disaccharidases
specimen: small bowel mucosal biopsy transported immediately to the laboratory
on ice – do not place on paper.
ref. ranges:
U/g
lactase 2-8
maltase 8 - 40
sucrase 3 - 18
DM
specimen: serum
interpretation: <1:20 negative
1:20 or 1:40 equivocal
>1:80 supports diagnosis of SLE
Anti-ds DNA is positive at 1:80 or higher in 60-80% of SLE. Low titres may be seen
in rheumatoid arthritis, autoimmune hepatitis and in other immunological disorders.
Donath-Landsteiner test
Dopamine
see Catecholamines
Drug allergy
Overdose screens are usually for persons admitted to hospital. The panel of drugs to
be tested will depend on the history and clinical findings.
• amphetamines
• barbiturates
• benzodiazepines
• cannabinoids
• cocaine
• opiates
• phencyclidine (angel dust)
Results are reported as +ve or -ve using internationally recognised cut-off limits.
Serum is not used for screening.
When results are to be used medico-legally, there has to be a secure audit trail
beginning with direct observation of specimen collection.
As a general rule, trough levels are measured, i.e. the low point reached before the
next dose is taken. Patients can defer their morning dose, attend the laboratory at
09.00 hrs to have blood off and then take their daily dose after that.
The exception is theophylline where the peak is monitored: the blood specimen
should be collected 4 hours after a sustained-release preparation or 2 hours after the
shorter-acting 6 hourly preparation.
The half-life (t½) is the time for a serum level to drop by 50%. When a drug is
started, or the dosage changed, the time to reach a new steady state = t½ x 5.
E1 (oestrone)
see Oestrogens
E2
Otitis media
It is not possible to sample the middle ear routinely and the flora of the external
meatus bears no relation to that behind the drum. Antibacterial treatment is therefore
empirical, based on studies which show the role of H.influenzae, Strep. pneumoniae,
Moraxella (previously Branhamella) catarrhalis, and Strep. pyogenes. Amoxycillin,
cotrimoxazole and amoxycillin-clavulanate provide effective treatment. Cefaclor has
insufficient activity against Strep. pneumoniae for it to be recommended in this
situation.
Otitis externa
Ear swabs are taken from just inside the external meatus. The commonest pathogens
are Staph. aureus and Pseudomonas aeruginosa. H. influenzae and S. pneumoniae
are also frequently isolated.
Most cases respond to keeping the ear clean and dry.
Echinococcus
see Hydatids
PR ER cause
prolonged normal vitamin K deficiency/warfarin
prolonged prolonged reduced factor synthesis (liver disease)
The test is based on the ability of the Echinus carinatum venom, from the saw-
toothed viper, to activate factors II and X.
Echoviruses
see Enteroviruses
An important member of the normal flora of the intestine and the cause of 80% of
urinary tract infections.
% susceptible
norflox nitrof aug trimeth cotrim amox
E. coli 100 99 96 77 79 44
Culture for E.coli 0157/H7, which is associated with haemorrhagic colitis, a severe
form of diarrhoea, and with haemolytic-uraemic syndrome, can be arranged on
request.
Ectopic pregnancy
Electrolytes
specimen: serum
The standard electrolyte group consists of Potassium (K+), serum and Sodium (Na+),
serum – see separate entries on these.
EPP pattern
Additional Bands
• Benign or malignant paraproteins (qv) are usually in the gamma zone but
some, particularly IgA, may overlie the beta band or occasionally lie between
the alpha 2 and beta bands.
• Free light chains (Bence Jones protein) being of relatively low MW are found
mainly in urine but occasionally form a band, usually in the beta-gamma zone,
particularly in patients with renal impairment.
• If the specimen is haemolysed, Hb will show as a band between the alpha-2
and beta
• In plasma (as distinct from serum), fibrinogen forms a band between the beta
and gamma zones.
• A markedly elevated CRP can sometimes be seen as a weak band in the
gamma zone.
• Beta-gamma bridging is sometimes seen in inflammatory conditions.
Electrophoresis of lipoproteins
Electrophoresis of urine
specimen: random urine
This is a test for free light chains (Bence Jones protein) in IgG or IgA myeloma and
occasionally with IgM-associated malignancies. After concentrating the urine, free
light chains show up as a well-defined band in the beta or gamma zone.
In Bence Jones myeloma (10-20% of all myelomas) a heavy band of free light chains
in urine is the diagnostic feature, usually with no band on serum EPP.
see also Immunoglobulins, IgA, IgG, IgM : malignant paraproteins
specimen: serum
interpretation: results are given as +ve or -ve, not as a titre
Some nuclear antigens can be extracted into solution and patients’ serum tested for
presence of antibodies against those antigens. ENA screen is used as a follow-up test
on positive ANA's or where one of the connective tissue diseases other than
rheumatoid arthritis is suspected.
Endolimax nana
EMA have very high sensitivity and specificity for untreated coeliac disease and
dermatitis herpetiforms.
see Coeliac disease (gluten sensitive enteropathy) for interpretation
Entamoeba dispar
Entamoeba hartmanni
Entamoeba histolytica
As far back as the early 1900s it was suspected that there were two "types" of
Entamoeba hystolytica, one which causes disease and one which was non-pathogenic.
Work over the past 25 years has proven this early suspicion to be true. There are two
morphologically indistinguishable Entamoeba species : E. histolytica, the cause of
intestinal and extra-intestinal amoebiasis; and E. dispar, its non-invasive relative.
Almost all reportings of E. histolytica are based on finding typical cysts. It is not
uncommon to find them in the faeces of people who have been to, or have originated
from, third world countries and it is likely that a good proportion of these are E.
dispar rather than E. histolytica. Treatment is generally not indicated because if the
cysts are E. dispar they are not pathogenic and if they are E. histolytica the risk of
developing invasive disease during asymptomatic carriage is low. Treatment of cyst
carriage is indicated if there is reason to suspect infection with E. histolytica, e.g. high
titres of specific antibody, history of close contact with a case of invasive amoebiasis,
or an outbreak of amoebiasis (unlikely in New Zealand). Some would treat cysts if
the patient was receiving steroids which are a risk factor for amoebiasis.
diloxanide furoate,
or paromomycin,
or iodoquinol
These agents are not registered in New Zealand and can be provided only on a named
patient basis.
Common cause of pruritis ani. Spread from person to person by faecal-oral route.
Adult worms live attached to the mucosa of the caecum. Gravid females migrate to
the anus. The cream coloured adult female worm, approximately 10mm long, lays
eggs on the perianal skin. Each female deposits approximately 20,000 eggs on the
host, bed clothes and linen. Eggs are infectious shortly after laying, are relatively
resistant to drying and remain viable in linen, bedclothes, or house dust for several
days. Eggs can be demonstrated using a swab or cellotape imprint. Usually
anthelmintics are prescribed on clinical grounds alone, e.g. mebendazole or pyrantel.
Many recommend that all family members should be treated simultaneously.
Enterococcus
Enterococci 99 99 0 99 82
A large group of viruses including polio, coxsackie and echoviruses affecting a wide
variety of organ systems. Their name is derived from their ability to infect the gut
and be shed in faeces.
Eosinophils
specimen : blood (EDTA)
ref. range: 0 – 0.5 x 109/L
Eosinophilia
Eosinophil counts are part of a routine blood count. The common causes of
eosinophilia are drug effect, allergy or parasitic infestation of the gut.
• allergic disorders
• parasitic colonisation – hookworm, filaria, hydatids, toxocara
• drug administration
• skin disease, e.g. eczema, psoriasis, pemphigus
• collagen disorders, especially polyarteritis nodosa
• infections, e.g. TB, scarlet fever
• malignant disease, e.g. lymphoma, Hodgkins disease, ovarian Ca.
• pulmonary eosinophilia
Epidermophyton
see Dermatophytes
Epilim
EPP
Epstein-Barr virus
Errors
There is a distinction between errors, which are due to human fallibility, and
variance (qv) which is the sum of the unavoidable fluctuations due to biological
changes (e.g. diurnal rhythms) and the analytical imprecision of the method.
• Clerical error This is the commonest error, the hardest to detect and
potentially the most serious. It includes mislabelling of specimens,
transposition of specimens in an analyser rack, transcription errors when
entering data into a computer, and so on. We do our best to devise systems
that will avoid these errors but we will never, alas, achieve perfection.
• Specimen collection errors The specimen collection procedure may have
failed to pick up the cells or microorganism it was aiming for. The specimen
may have deteriorated on standing e.g. microorganisms have died; potassium
has leached out of red cells into serum
• Analytical error is where the analyst or reagent manufacturer has made a
mistake but in practice this is the least important source of error, thanks to
modern technology and use of quality control procedures.
• Antibody error Immunoassays – methods incorporating an antibody to detect
the analyte being measured, rather than using chemical reactivity – are used in
many of the exciting new assays now available, particularly for hormones,
antibodies and drugs. Specificity of the antibody is not always absolute.
Anti-digoxin antibodies are an example. The term DLIF (digoxin-like
immuno-reactive factor) is used to describe substances found in serum which
are identified by the analytical antibody as "digoxin" but which in reality are
something else. Thus a "digoxin" level may be measured in a healthy person
taking no medication at all. The same antibody error can occur potentially in
any method and can be the explanation of a result which is wildly astray as
shown by finding a much lower or higher level when repeated in a laboratory
using a different method.
Important Rule: "If an abnormal result, or a normal result, does not fit the clinical
picture, or if it has important diagnostic, therapeutic, or social consequences, don't
act on the result until the test has been repeated on a second specimen." If you
suspect an error, please phone us. We can often help – and we can make sure that
error doesn't happen again.
Erythrocyte
= red cell
Erythromycin sensitivity
Erythropoietin (EPO)
specimen: serum
ref. range: 5-30 mIU/ml
Escherichia coli
The ESR is an antique test that still has a place as a non-specific indicator of
inflammatory disease and abnormal protein states.
In an acute illness, the ESR may take a week or more to start to rise and stay elevated
for some weeks after its resolution. The CRP (qv) by contrast rises and falls more
quickly and is in some ways a better marker for acute inflammation.
Interpretation
• ESR 20 - 50
Values in this range may have an obvious explanation but sometimes,
particularly in the elderly, they persist for no obvious reason. In the absence
of any other leads, investigation need not be too intensive. Pregnancy
elevations are usually in this range.
• ESR 50-100
These usually have an explanation and should
be pursued.
• ESR >100
The "3-figure ESR" nearly always indicates
serious disease such as a serious infection,
malignant paraproteinaemia or connective tissue
disease.
Essential thrombocythaemia
Essential thrombocythaemia is a myeloproliferative disorder characterised by a
sustained increase in the platelet count, particularly above 600 x 109/L.
Estradiol/Estriol/Estrogens
Ethosuximide (Zarontin)
see Anticonvulsants
Euthyroid hyperthyroxinaemia
see GTT
Eye swabs
If the eye is moist, use a dry swab; if the eye is dry, moisten the swab in transport
medium. After pulling the lower lid down roll the swab across the inner part of the
lower lid. If there is pus in the corner of the eye, get some of this onto the swab as
well.
see Hypercoagulability
Factor XII
Mild Factor XII deficiency causes a mild prolongation of the APTT. A significant
prolongation of the APTT (e.g. >80 seconds) which corrects with the 1+1 test and
which is not associated with bleeding symptoms is usually due to more marked Factor
XII deficiency but even low levels are of no clinical significance.
Faecal fat
specimen: faeces collected over a 3-day period into a container supplied by the
laboratory and stored in the refrigerator during collection. Extraneous
material such as toilet paper, plastic bags or nappies, must be excluded.
The patient should be eating 70-100g fat per day for at least three days
ref. range:
<1 yr 1.5g/day
1-10 yrs <3g/day
>10 yrs <5g/day
1g = 3.5 mmol
Indications
• for documenting steatorrhoea
• for monitoring treatment in patients with known steatorrhoea
This is an unpleasant test for both patient and laboratory and should not be used as a
screening test in patients with chronic diarrhoea or other non-specific gastrointestinal
symptoms.
Steatorrhoea should be suspected when stools are pale, loose, bulky and greasy. It
will seldom be found in formed brown stools. In this laboratory, the mean weight of
normal 3-day faecal collects is 350g compared with a mean of 940g for those with
steatorrhoea (>5g fat/day).
specimen: 1-3 random fresh faeces collected into small clean jars, each of which
should be delivered to the lab as soon as possible, preferably within 4
hours.
We have recently analysed our results for patients who have had three specimens sent
for bacterial culture for enteric pathogens:
Therefore a single specimen detects the majority of positives. Three specimens may
be requested in chronic intermittent diarrhoeas or in food handlers where it is
essential they be established as being free of infection. The three specimens should
be collected on three different days and each taken to the lab on the day of collection.
Routine examination includes culture and examination of a wet film for red or white
blood cells.
Examination for Giardia antigen, or of a faecal concentrate for ova and parasites, is
performed only when specifically asked for on the request form.
Indications
However, because of low sensitivity for detecting small, often intermittent bleeding, a
negative result does not exclude GI blood loss as from a tumour. Further evaluation
(e.g. colonoscopy) is still therefore indicated in at-risk patients with unexplained iron
deficiency.
Non-specific guaiac tests These, the most commonly used tests, detect the peroxidase
activity of haem whether of human or animal origin.
They can give false positives with high meat diets, peroxidase-containing foods such
as horse-radish or turnip, or sometimes with iron supplements. Gastric irritants such
as NSAIDSs can give positives because of the minor bleeding they induce.
High dose vitamin C or E supplements can give false negatives.
Specific immunochemical tests Most of these detect intact human Hb but others are
based on human haem, porphyrin or even albumin. Although these tests avoid dietary
false positives, there is still the large problem of positives due to minor benign
bleeding.
The ova and parasites box must be ticked if these are required in addition to faecal
culture.
Fanconi syndrome
Fat, faecal
Fe
see Iron
specimen: serum
ref. range:
Age µg/L
<6 mths 50-400
6 mths-15 yrs 12-140
adult female 20-160
adult male 20-250
Low levels
Ferritin is a measure of total body iron stores and levels below 12 indicate seriously
deficient or absent stores. Results between 12 and 20 suggest reduced stores. Iron
stores are often marginal in infancy, adolescence and in women during their child-
bearing years, especially if diet is deficient. At other times they should prompt a
search for sites of blood loss.
High levels
• haemochromatosis – (qv)
• liver disease – in viral hepatitis the ferritin can rise above 4000.
• alcohol
• chronic inflammation – connective tissue diseases, bacterial infections
• malignancy, particularly leukaemias, lymphomas and myeloma
Fetal
see Foetal Hb
Fetoprotein
Fibrinogen
specimen: plasma (citrate)
Filariasis
specimen: whole blood (EDTA)
Filariasis occurs in Africa, Latin America, Asia and the Pacific Islands where the
most common cause is Wuchereria bancrofti. Diagnosis is by finding microfilaria in
peripheral blood. An eosinophilia may be the only evidence of filarial infestation.
Lymphatic filariasis occurs when host inflammation and fibrosis lead to lymphatic
occlusion and in patients heavily and repeatedly infected, elephantiasis may develop.
Bacterial cellulitis contributes to tissue damage. The syndrome of tropical
eosinophilia is an extreme reaction to filariasis.
Treatment with diethyl carbamazine or ivermectin clears microfilaria from the blood.
Dying microfilaria can stimulate a severe allergic reaction requiring treatment.
Flavobacterium
see Chryseobacterium
Flushing attacks
FNA
Foetal Hb
see Hb ( haemoglobin)
Although the terms folate and folic acid are often used interchangeably, another usage
is to apply folate to the serum analyte and naturally-occurring vitamin found
particularly in green vegetables, while using folic acid to refer to the synthetic
chemical used in vitamin supplements.
• cardiovascular disease
The evidence is circumstantial only and concerns the plasma
homocysteine levels which appear to be a graded independent
risk factor for cardiovascular disease. When plasma folate is
maintained consistently above 15 nmol/L, using a supplement
of 400µg folic acid daily, plasma homocysteine falls to a low
• Inadequate diet – the commonest cause. Folate comes particularly from green
vegetables and is destroyed by cooking. Deficiency is associated with old
age, poverty, alcoholism, anorexia
• Malabsorption – coeliac disease, tropical sprue, giardiasis
• Drugs – anticonvulsants, pyrimethamine, methotrexate and others
High folate levels are due to vitamin supplements or a recent meal high in folate.
Total body stores in a healthy individual approximate 10mg, enough to last about 6
months if all dietary folate is removed. Recommencement of folate intake restores
serum levels in a few days but replenishment and maintenance of body stores
requires sustained intake.
Food allergy
Skin tests and RAST tests are less helpful in food allergy than in allergy caused by
inhaled allergens and can give both false negatives and false positives. Peanuts, cows
milk and eggs are included in most standard batteries of skin tests. Specificity is not
particularly high but a -ve test makes allergy less likely and a +ve test, particularly in
the context of a positive history, makes the diagnosis more likely. Testing the patient
with an ill-defined history of vague complaints against a wide range of foods will
seldom be productive.
Free T3
see T3, free (tri-iodothyronine)
Free T4
Free testosterone
see Testosterone
Fructosamine is glycated albumin and gives a measure of the mean glucose level over
the preceding 1–3 weeks in diabetes. For the laboratory, fructosamine is a cheaper
test than HbA1c but it has major disadvantages.
• in obese patients, who make up the bulk of the Type 2 diabetic population, it
is falsely low.
• it is lowered in any condition where there is increased albumin turnover, most
notably by the proteinuria of diabetic nephropathy.
• its correlation with HbA1c is not good.
• –diabetologists don't like it.
Physiological actions
The complex cyclical variations in FSH, LH, oestradiol and progesterone in the
menstrual cycle are shown in the diagram.
Specimens are collected outside the mid-cycle peak except when timing ovulation.
Release of both hormones is episodic and can lead to biological variation throughout
the day.
Applications
• Identifying the menopause – the FSH rises from a base-line of less than 8 to
above 20. FSH rises relatively more than LH. see also Menopause.
specimen: serum
Fusobacterium
GAD autoantibodies
Galactosaemia
A screen test for galactosaemia is part of the standard neonatal screen in the first
week of life.
Gallstones
Gardnerella vaginalis
Gastric antibodies
Smears should be made from brushes and fixed in Cytofix immediately. Washings
should be submitted to the laboratory as soon as possible.
Gastrin
specimen: serum, separated and frozen immediately
ref. range: 0-75 pmol/L, fasting
Gastrin, released from the gastric mucosa, is a potent stimulant of gastric acid
secretion.
Vagotomy, non-fasting state, renal failure, or the gastric acid hyposecretion due to
pernicious anaemia and chronic atrophic gastritis, are associated with an increase in
gastrin levels.
GDM
see Cytogenetics
Molecular genetics - genetic studies
Genotype
The genetic constitution of an individual with definition of both dominant and
recessive genes in a gene pair. By contrast the phenotype defines only the dominant
member. In relation to rhesus blood grouping the phenotype CDE could have, for
example, the genotype CDE/CDE or CDe/cdE.
Gentamicin
GDM is a form of glucose intolerance that develops during the 2nd half of pregnancy
and disappears after parturition.
It is associated with increased foetal risk which is reduced if the GDM is treated
successfully with diet or, in the few where hyperglycaemia persists, with insulin. A
mother with GDM is at increased risk for developing diabetes in later life.
The test is usually done in the morning. No booking is required and the patient does
not need to fast before the tests. A suspension of 50grams of polycose is given and a
single blood collected 1 hour later. If the glucose is above 7.8 mmol/L, a 2-hour GTT
is ordered as the definitive test.
If the post-polycose glucose is less than 7.8 but risk factors are present – obesity,
family history of diabetes, history of GDM, macrosomia, intrauterine or neonatal
death – another polycose screen test or a GTT should be considered at 32-34 weeks to
check whether glucose tolerance has deteriorated.
specimen: serum
ref. range: female 0-50 U/L
male 0-60 U/L
GH
Giardia
specimen: 1-3 random faeces samples.
Giardia lamblia is a protozoan infesting the upper small bowel where it can cause
acute or chronic diarrhoea and sometimes fat and vitamin malabsorption.
It is now the commonest cause of water-borne diarrhoea in the world with vast
reservoirs in humans and wild and domestic animals and in rivers and water supplies.
Although more common in third world countries with poor sanitation it is
increasingly being found in developed countries including New Zealand. At this
laboratory it is the third commonest faecal pathogen after Campylobacter and
Salmonella.
It is commonly taught that three stool specimens are required to detect intestinal
parasites such as Giardia but several studies have shown that >85% of cases are
Gilbert's syndrome
This common, harmless, inherited condition, in which the liver has reduced ability to
conjugate bilirubin, was first described in 1901 by the Frenchman Gilbert whose
name is usually, though not always, pronounced in the English fashion.
It affects somewhere between 2 and 10% of the male population depending whether
the cut-off is taken as 25 or 20 µmol/L. The male/female ratio is about 4:1.
Features are:
• elevation of bilirubin is the only laboratory abnormality and the level seldom
exceeds 80 µg/L.
• liver enzymes are normal.
Anti-gliadin antibodies (AGA) have a high degree of sensitivity and specificity for
untreated coeliac disease and dermatitis herpetiforms.
Glucose
specimen : plasma (fluoride)
ref. range :
Age (yrs) mmol/L
fasting glucose 3.5-6.0
random glucose 0-1 2.0-6.0
>1yr 3.5-7.0
If the specimen is collected in a plain tube the glucose level will tend to be low by an
unpredictable amount because red cells consume glucose causing the serum level to
fall at a rate of 0.1-0.5 mmol/L/hr. Fluoride prevents this glycolysis.
Indications
The GTT is the traditional test for the diagnosis of border-line diabetes mellitus.
For the patient who does not want to go through the 2-hour GTT, an alternative,
recommended by the American Diabetes Association in 1997, is to measure two
fasting glucoses on two separate days.
Contraindications
A GTT is unnecessary in a person who has symptoms of diabetes (thirst, polyuria,
tiredness), and random glucose levels >11.1. An HbA1c above 6% further confirms
the diagnosis in this situation and gives an indication of mean glucose level.
The GTT is not a useful test for monitoring treatment and is never used in a diabetic
on oral hypoglycaemics or insulin.
Test protocol
The patient makes an appointment and fasts overnight (10-14 hrs). Excessive fasting
worsens tolerance.
The glucose load is given in the form of polycose, a relatively non-emetic polymer of
glucose.
Bloods are collected fasting and at 1 and 2 hours. The patient stays in the collection
room throughout and should not smoke.
Interpretation
The ADA (American Diabetes Association) has recommended that the GTT be
replaced by 2 fasting glucose levels or by random glucose levels.
Subsequent analyses have shown that screening based on 2 fasting glucose levels will
give a significantly lower diabetic prevalence than when the 2 hr GTT is used, the 2
hr level >11.1 being a more sensitive criterion than the fasting level of 7.0.
WHO will be making its definitive recommendation on the use of the GTT in 2000
but meanwhile the GTT retains its position as an accepted diagnostic measure for
borderline diabetes.
When diabetic symptoms (thirst, polyuria, weight loss) are present, a single random
glucose >11.1 establishes the diagnosis.
As with any biological test, glucose tolerance varies from week to week and month to
month and any result in the region of a cut-off limit can switch back and forth
between normal, impaired and diabetic under the influence of stress, illness, change
of diet, or simply unexplained variance.
Lag storage curve has a 1-hour glucose peak in the 11-15 mmol/L range, then returns
to normal at 2 hours. This is seen post-gastrectomy, and sometimes in normal people,
when a carbohydrate load rapidly reaches the small intestine and is absorbed before
insulin action has time to bring down the glucose peak.
Glucose, urine
see Glycosuria
see Gliadin (gluten) antibodies (AGA) and Coeliac disease (gluten sensitive
enteropathy)
Glycated Hb
Glycosuria
Glucose appears in the urine when the renal threshold has been exceeded; this
typically being at a blood glucose level around 11mmol/L.
With advancing age, or renal impairment, the renal threshold rises so that some
diabetics have glucose-free urine even with blood glucose levels in the 12-15 mmol/L
range.
• As a side-room test for suspected diabetes when a blood test is not available.
• As a home test for children whose parents worry about diabetes but don't want
blood tests.
Gonadotropins
Gonorrhoea
see Neisseria
GPH syndrome
= gestational proteinuria and hypertension
GPT
Gram stain
The gram stain, described as the single most useful procedure in diagnostic
microbiology, was perfected by the Danish microbiologist Christian Gram in 1884.
When a microbiological specimen reaches the laboratory there are typically two
initial procedures.
Some examples:
gram-positive organisms
cocci Staphylococcus
gram-negative organisms
cocci Neisseria
bacilli enteric bacteria: Escherichia, Salmonella, Shigella,
Enterobacter, Klebsiella, Serratia, Proteus,
Citrobacter,Yersinia
Graves disease
see Crossmatch
specimen: serum
ref. range: There is no defined range for random HGH which can vary between 0
and 24 µg/L in healthy people. Suppression or stimulation tests are
used in preference to random HGH.
GTT
Guthrie card
Gynaecomastia
Transient gynaecomastia is normal in the newborn and in adolescence and minor
degrees of persistent gynaecomastia are common in the elderly male as testosterone
levels decline with an increase in the oestrogen/testosterone ratio.
Haematocrit (PCV)
Haematuria
see Urinalysis (routine biochemistry and microbiology) and UTIs (urinary tract
infections)
Haemochromatosis
Iron overload can also be acquired due to repeated transfusions for refractory anaemia
or to inappropriate parenteral iron over a long period of time.
In HH the iron overload is due to excessive absorption which steadily increases the
total body mass of iron throughout life. Women are protected during child-bearing
years by menstrual loss of iron.
HH is carried on a recessive gene with the remarkably high prevalence of 1:10 in the
general population for the heterozygous (carrier) state and 1:400 for the homozygous
(affected) state.
In 1996 the HFE gene, also known as the cys282 tyr mutation, was identified as a
marker for at least 90% of HH.
Heterozygotes may have mild or moderate elevations of ferritin and iron but will not
develop clinical disease.
Homozygotes will not always develop disease but because their risk is so much
higher, they are treated by venesection to reduce body iron, as measured by ferritin, to
normal levels.
Diagnosis
HH is suspected when iron saturation is consistently above 55% and ferritin above
400 µg/L.
The HFE gene should be tested for and if present the test will show whether the
patient is a hetero- or homo-zygote.
Homozygotes should be further tested for tissue damage by measuring glucose, liver
enzymes, TSH, and LH, FSH and testosterone if hypogonadism is suspected.
Before the HFE test became available, a liver biopsy was taken to measure liver iron
content and also look for cirrhosis. The hepatic iron index is an expression of liver
iron that compensates for the normal increase in iron that occurs with age. An iron
index >2.0 µmol iron/ g liver/year of age is indicative of HH. Liver biopsy is seldom
performed if the ferritin is <1000 µg/l, liver enzymes are normal and there is no
hepatomegaly. Hepatic fibrosis is rare when these criteria are met. Liver biopsy
may still have a place where clinical suspicion of haemochromatosis is strong but
HFE negative.
Monitoring treatment
Venesection is performed at weekly intervals until ferritin is below 100-200 µg/L and
then frequently enough to hold the ferritin at this level.
Hb EPP detects abnormal and unstable haemoglobins and gives an indication whether
HbA2 or HbF are increased.
Haemoglobin pigments
specimen: whole blood (heparin or EDTA)
This term usually refers to metHb and sulphHb which can be found following
exposure to some drugs, notably phenacetin, sulphonamides, sulphones, antimalarials;
and to some occupational and household chemicals.
When metHb and/or sulphHb exceed 15% of total Hb, the patient appears cyanosed.
Indications
The haemoglobin (Hb) molecule consists of two pairs of polypeptide chains with
a haem attached to each. The porphyrias are due to disorders of haem synthesis.
The haemoglobinopathies are due to disorders in the globin chain pairs which are
labelled á â ä ã etc. In the haemoglobinopathies, the amino acid sequence in a
globin chain can be abnormal, or there can be a quantitative abnormality in globin
chain production.
HbF á2ã2 foetal Hb comprises 70-90% of the total at birth falling to 1% by age
2. It is increased in ß thalassaemia and hereditary persistance of HbF
(HPFH).
HbA2 á2ä2 the minor component of adult Hb comprising 1.5-3.2% of the total. It
is increased in ß cell thalassaemia.
HbS the cause of sickle cell anaemia (HbSS) found in South Africans and
occasionally in those of Mediterranean or Middle Eastern origin. The
heterozygous state HbAS, is asymptomatic.
Haemoglobinuria
Haemolysis
The features of haemolysis are:
• anaemia
• polychromasia – reticulocytosis
• haptoglobins - reduced or absent
• hyperbilirubinaemia
The haemophilias are due either to Factor VIII deficiency (classical haemophilia) or
Factor IX deficiency (Christmas disease). Spontaneous mutations account for 30% of
new cases in the absence of a family history. Severe haemophilia presents early in
infancy but mild haemophilia can present later in life following surgery or trauma.
Diagnosis is from:
Haemosiderin
see Dermatophytes
This is a rare form of B cell leukaemia (1-2%) with a 5:1 male predominance. It is
characterised by pancytopenia, circulating 'hairy cells' and splenomegaly (80%).
Treatment is highly effective with ≥ 80% complete remission after one course of one
week followed by a long period of complete remission.
Ham's test
Hansen's bacillus
see Leprosy
Haptoglobins
specimen: serum
ref. range: 0.5 - 3.0 g/L
It is reduced by:
It is elevated by:
• biliary obstruction
• many acute or chronic inflammatory disorders – following recovery from an
infective episode the level falls to normal within 10-14 days.
• specific genotype
Hb ( haemoglobin)
ref. ranges: %
Non-diabetic range: 4-6
Diabetic range:
excellent control 6-7
good control 7-8
indifferent control 8-9
poor control 9 - 10
exceptionally poor control >10
HbA1c is a measure of the mean blood glucose level over the previous 2-3 months
and particularly the previous 4 weeks. It provides the essential baseline measure of
glycaemic control in a diabetic and should be measured at least annually in all
diabetics and more often (say 3-monthly) when assessing the affect of changes in
therapy or compliance.
The central role of HbA1c in assessing glycaemic control arose out of the DCCT
(Diabetes Control and Complications Trial) which followed 1441 insulin dependent
diabetics between 1983 and 1993. Intensive control compared with standard control
reduced the risk of development and progression of retinopathy, nephropathy and
neuropathy by approximately 60%. Risk of complications rose with increasing
HbA1c with a significant steepening of the curve above a value of 8%.
HBV
specimen:
• quantitative hCG serum
• qualitative pregnancy test serum (preferably)
or random urine
Adding a second hCG or a series and plotting them on the hCG graph gives valuable
information on the health of the embryo.
In a normal pregnancy, the hCG doubles every 1½ days between weeks 3½ and 6 and
the trajectory rises parallel to the graph's percentile lines with remarkably little
deviation.
A plot which is rising parallel to the percentile lines but outside the 5th-95th range
indicates a healthy pregnancy with incorrect dates.
A graph rising more slowly, or flattening, usually indicates the onset of spontaneous
abortion or an ectopic pregnancy and is an indication for proceeding with vaginal
ultrasound looking for an intra-uterine gestational sac.
Levels may be
hCG quantitation must be combined with ultrasound which will detect an intra-
uterine sac after 5 weeks in a normal pregnancy. Using an abdominal probe, the
intrauterine sac is visible with an hCG above 2000 units; with a trans-vaginal probe,
the sac can be visible at 1000 units. In ectopic pregnancy there is, of course, no intra-
uterine sac.
After evacuation of a mole, the hCG is measured weekly until it has been normal (<5)
for at least a month; and then monthly for at least 6 more months.
HDL cholesterol
Heaf test
see Tuberculin test (Mantoux test)
Health reforms
These are in progress all over the world, which is waiting expectantly.
Heavy metals
Heinz bodies are red cell inclusions seen in haemolytic anaemias due to drugs, in
haemoglobinopathies, and sometimes in normal people after splenectomy.
Helicobacter pylori
H. pylori, first described in 1984, lives in the mucus layer on the surface of the gastric
mucosa where it causes gastritis and in some people, peptic ulcer disease (PUD),
either duodenal or gastric. Antimicrobial therapy is usually curative. H. pylori is also
a significant factor in the aetiology of gastric malignancy.
The organism, confined almost solely to humans and primates, is commonly acquired
in childhood and persists for life. In Western countries the incidence of infection, like
PUD, is decreasing – <30% below age 30, whereas in developing countries, which
have high rates of PUD and gastric cancer, the incidence is above 80%, perhaps due
to poor nutrition and hygiene.
13
2. Curea breath test
The urea breath test is the preferred test of eradication, 4-6 weeks after anti-
microbial therapy.
To perform the test, the patient takes a measured dose of 13C urea (non-
radioactive). If H. pylori is present in the stomach its associated urease splits
the molecule releasing 13CO2. A breath sample collected after 30 minutes is
subsequently analysed for presence of 13C. The result is reported as positive
or negative.
Antibiotics, bismuth and proton pump inhibitors can give false negative
results.
3. Antibodies
A variety of tests are in use, all of them with significantly poorer
performance than the breath test. Laboratory-based tests typically have a
sensitivity/specificity of 85-95% whereas the office-based tests fall as low as
65%.
The suggestion, sometimes made in the past, that a single positive office-
based test is indication for eradication therapy, is not valid.
Treatment
Non-ulcer dyspepsia
Different regimens are being trialled all the time, particularly the newer short course
regimens. They can vary greatly in cost.
• 2-week course
– colloidal bismuth 120mg 6hrly
– metronidazole 400mg 8 hrly
– tetracycline 500mg 6 hrly
or
amoxycillin 500 mg 6 hrly
• 1-week course
– omeprazole (or other PPI) 20mg bd
– amoxycillin 500mg 6hrly
– clarithromycin 500mg 6hrly
– metronidazole 400mg 8hrly
Henoch-Schönlein Purpura
Heparin therapy
IV Heparin
The dose of LMWH is calculated from body weight and is given subcutaneously once
or twice daily on an outpatient basis. Clexane (enoxaparin) and Fragmin are the two
most commonly used LMW heparins in New Zealand.
Heparin tubes
• Viral infection
• autoimmune hepatitis
• alcoholic hepatitis
• drug-associated hepatitis
• other
It is difficult to know the relative frequency of the common viral causes but indicative
figures from a 1992 Christchurch study are:
EB virus 50%
hepatitis A 15%
In general an IgM antibody develops first and then disappears within 3-12 months. It
is the marker for current or recent infection.
IgG antibodies start soon after IgM, rise more slowly, but then persist indefinitely.
They are a marker for both current and past infection but will not distinguish between
the two. IgG antibodies are used to indicate immune status – has this person been
infected in the past? Has this person's vaccination been effective?
"Total" antibodies measures both IgM and IgG in a single test. When IgM, IgG are
not specified, e.g. anti-HAV, this means "total", i.e. both IgG and IgM.
Others do not indicate immunity, only past or current infection, e.g. anti HCV,
antiHBc.
Antigens show the presence of virus indicating current infection, carrier status or
chronic hepatitis, e.g. HBs antigen, HBe antigen, HCV-RNA, HDV-RNA.
Hepatitis A (HAV)
Interpretation:
The IgM antibody appears at about the time clinical symptoms develop and persists
for 6-12 months. This anti-HAV IgM is the marker for current or recent infection.
The IgG appears not long after the IgM but persists for life and is thus the marker for
HAV immune status.
Active Immunisation:
Havrix, the HAV vaccine, became available in 1992 and provides solid immunity.
It should be recommended to any traveller going to countries where hygiene might be
suspect. Travellers with previous experience may find they are already immune, as
shown by presence of anti-HAV IgG, even though they have no recollection of
clinical disease.
Two IM injections 6-12 months apart provide immunity for many years. When there
is urgency, a single double-strength injection just before departure has been shown to
provide useful protection for up to two years. A second injection provides long-lived
immunity even when given years after the initial injection.
Passive Immunisation
Contacts of a person with active HAV infection should be given passive protection
with immune globulin 0.02 ml/kg IM provided it can be given within two weeks of
exposure.
Clinical course
Infectivity due to faecal shedding of virus, is at its height one week before clinical
symptoms develop and persists for about 4 weeks.
Hepatitis A can relapse up to 6 (or even 12) months after the first bout but does not
persist thereafter, so is never a cause of chronic hepatitis, cirrhosis, or hepatocellular
carcinoma.
1. HBs antigen
If positive indicates
– acute HBV infection (enzymes elevated)
or – chronic HBV infection (enzymes fluctuate)
or – HBV carrier (enzymes not elevated)
2. HBe antigen
This should be checked whenever HBs antigen is positive. If HBe antigen
(Ag) is present, it indicates greater infectivity of the HBV infection towards
sexual partner or foetus and greater likelihood of developing chronic
hepatitis. HBe Ag is found only in association with Hbs Ag, never on its
own.
4. Anti-HBc IgM
Is measured when current HBV infection is strongly suspected but HBs Ag
and anti-HBs are both negative. Anti-HBc IgM rises early in HBV infection
and persists for about 6 months. It fills the one month "window" between
disappearance of HBsAg and the appearance of anti-HBs. Positive anti-HBc
does not confer immunity.
5. Anti-HBc total
Indicates past infection but unlike anti-HBs it does not indicate immunity and
can coexist with HBs Ag in carriers or chronic hepatitis.
6. Anti-HBe
In chronic HBV infection, anti-HBe indicates low infectivity.
7. HBV - DNA
If positive indicates HBV viraemia which is an indication for considering
interferon treatment in chronic infections.
HBs Ag is routinely checked antenatally. If positive, this indicates carrier state or,
less often,current infection.
The infant of an HBs Ag positive mother will need immune globulin (anti-HBV) at
birth and the first dose of a course of HBV immunisation.
Epidemiology of HBV
4% of the world population carry HBV but most of those infected are in Asia. In
New Zealand about 0.4% of European blood donors are HBV positive compared with
about 5% of Maori and Pacific Islanders.
About 1-2 % of HBV infected adults fail to eradicate infection and become carriers or
develop chronic hepatitis with its possible sequelae of cirrhosis and hepato-cellular
carcinoma. The risk of developing chronic infection is much higher in children and
particularly in neonates.
ALT is the test used to decide whether the patient has active disease that should be
considered for anti-viral therapy.
If the ALT >60 units, it should be repeated in 4 months. If the elevation >60 persists,
the patient should be referred for specialist follow-up.
specimen : serum
1. Anti-HCV
Used when hepatitis C is a possibility, e.g. IV drug users, raised liver
enzymes of unknown cause.
Anti-HCV starts to rise 1-6 months after the initial infection and persists for
life. Presence of anti-HCV indicates either past infection or continuing
chronic infection.
2. HCV-RNA
This is a follow-on test when anti-HCV is positive. It is also used when
clinical suspicion of HCV infection is high but anti HCV is negative because
infection is recent or the patient immuno-suppressed.
HCV was identified in 1989 having previously been included in the non-A non-B
hepatitis category. 0.25% of people presenting as blood donors in New Zealand are
positive for HCV. A random population sample in the United States shows 1.8%
positiviity.
More than 50% of HCV infections become chronic with potential to develop cirrhosis
and hepatocellular carcinoma.
Treatment with a combination of interferon and ribavirin clears the virus in about
50% of patients.
There is no vaccine yet.
A positive HCV Ab test should be followed by HCV RNA test and ALT.
If HCV RNA is positive, the patient should be referred for consideration of anti-viral
therapy.
An ALT >60 units indicates active disease but a level <60 does not exclude activity.
The patient who is HCV Ab +ve but HCV RNA –ve is presumed to be free of active
hepatitis provided the ALT is <60. The ALT should be monitored annually and the
HCV RNA for at least 2 years to confirm it is staying -ve.
specimen : serum
tests : · anti Delta IgG
· HDV RNA
HDV infections once established, will persist for as long as HBV carriage continues,
but if HBV is eliminated HDV will go with it.
Anti-delta antibodies indicate either current active infection or past infection with
immunity.
Hepatitis E (HEV)
specimen: serum
test: anti HEV IgG
Presence of HEV antibodies does not distinguish current from past infection.
Hepatitis, autoimmune
specimen: serum
tests: • smooth muscle antibodies
• antimitochondrial antibodies
• liver/kidney microsomal antibodies
• ANA
• anti ds DNA
• immunoglobulins
Autoimmune hepatitis, formerly known as chronic active hepatitis and before that
lupoid hepatitis, affects predominantly young women. The hepatitis can be of all
grades of severity ranging from minor enzyme elevations in a well person to a clinical
laboratory picture like that of severe viral hepatitis. Diagnosis is by excluding viral
causes; by finding specific autoantibodies; by markedly elevated IgG; and by liver
biopsy.
see Elliptocytosis
Hereditary spherocytosis
A relatively common haemolytic disorder found in all races and typically inherited as
an autosomal dominant. In the 25% of individuals who have unaffected parents, the
disease is assumed to be due to autosomal recessive inheritance or a spontaneous
mutation.
More severe forms present in the first 10 years of life but milder forms may be
discovered incidentally either on a blood count or because of a minimally elevated
bilirubin resembling Gilbert's Syndrome.
The spots are air-dried and the slide labelled with the patient's name, date of
collection and the word 'herpes'. In the laboratory, an immunofluorescent stain is
used to detect virus.
HSV 1 commonly gives rise to recurrent oral infections ("cold sores") and HSV 2 to
recurrent genital infections but either can be found at either site.
Other tests – the virus can be cultured (use the special transport swab) and antibody
tests can differentiate HSV-1 from HSV-2.
Herpes zoster
Heterophile antibodies
Avoid the following drugs and foods for 3 days before collecting the urine.
In carcinoid syndrome the HIAA is usually >80. Results in the 50-80 range should be
repeated.
Hirsutism/virilism
The spectrum of hirsutism ranges from the upper percentiles of normal hair growth
through to the male-pattern hair growth, amenorrhoea and genital virilisation of
androgenic tumours.
Containers must be carefully labelled with name of patient, date of birth, nature of
specimen, date, name of doctor.
Special fixatives for biopsy specimens, e.g. Bouins fixative for testicular biopsies, are
also available.
Oestrogen and progesterone receptors on breast cancers are now routinely performed
on formalin fixed tissue rather than using a specimen forwarded on ice.
Skin for direct immunofluorescence microscopy (DIF), usually for the investigations
of blistering or bullous disorders, needs to be submitted to the laboratory fresh on
damp saline-soaked gauze inside a specimen pot packed in ice. The specimen needs
to be snap frozen in the laboratory within 2 hours of the specimen being taken. The
pathologist should be contacted 24 hours before taking the biopsy to ensure rapid
handling of the specimen.
specimen: serum
tests: an initial screen test with >99% sensitivity followed by a
confirmatory test for those who screen positive. The screen test
detects both HIV-1 (the commonest) and HIV-2. A DNA-based test
is available for babies born to seropositive mothers.
Patient ID
Test interpretation
The screen test has a cut-off level of 1 unit.
Below this the test is reported as negative. Above 1 unit, the serum is referred for the
more specific Western Blot test. Results in the 1-1.5 unit range can be false positive
screen results due to cross-reactivity with other viral antigens and the level may fall
below 1, i.e. become negative, on subsequent testing. Patients with established HIV
infection typically have results in the 5-20 range. A screen result of 1-2 with negative
Western Blot should be repeated in a month.
A negative antibody test does not exclude HIV infection during the first few months
after transmission of the virus but for practical purposes, all those infected will test
HIV positive within 6 months.
The median time from infection to the development of AIDS is about 10 years.
Presentation
GPs are the group who most frequently test for and diagnose HIV infection in New
Zealand, far more than hospital, sexual health clinics or special clinics combined.
Early symptoms of HIV include exacerbation of previous skin disease, e.g. eczema,
somewhat recalcitrant tinea, surprising shingles, oral candidiasis, recalcitrant vaginal
candidiasis : in other words, common or ordinary events occurring oddly or
excessively.
Pneumocystis carinii pneumonia (found only when patients have CD4 counts
<200/cmm and essentially preventable) is most often a creeping, slow illness with dry
cough, fever and shortness of breath which may not be easy to diagnose or confirm.
Monitoring
Viral load The concentration of virus in the plasma can now be measured. As a
generalisation the higher the concentration (max. 1,000,000 or 10 6 copies/ml) the
more rapid will be progression in time to clinical illness and AIDS. The lower the
concentration (at present the lowest level of detection is 500 or 10 27 copies/ml), the
slower the disease progression.
The aims of treatment are to suppress this level as low as possible.
CD4 counts The concentration of this lymphocyte subset correlates with the stage the
patient's immune system has reached in its battle with HIV. The lower it is (normal
>500 cells/cmm) the more likely will that individual have illness, with the risk rising
progressively as it falls below 200 and then below 100 cells/cmm.
Treatment
The moment to begin treatment is ill defined : with CD4 counts <350 cells/cmm and a
high viral load, few would not wish to treat or be treated. At higher CD4 counts and
lower viral loads, everyone has a different opinion and individual patient views are
often the ultimate determinant for the decision.
HLA B27 has a frequency of 7-10% in the general population but a much higher
frequency in the sero-negative spondyloarthropathies which are characterised by:
– sacroileitis and spondylitis, causing low back pain and loss of lumbar
mobility
– tendonitis, including heel pain and other pain at muscle and tendinous
insertion
– oligoarthritis
– urethritis
– iritis and conjunctivitis
The principal members of the group with the % positivity for HLA B27 are:
Also known as VMA, vanilly mandelic acid. This is a follow-up test for suspected
phaeochromocytoma, usually used only when catecholamine fractions, particularly
noradrenaline, have shown equivocal elevations.
Homocysteine, plasma
Increasing intake of folic acid and to a lesser extent vitamin B6 and perhaps B12 may
lower homocysteine levels. A daily supplement of 400 µg folic acid will in most
patients increase serum folate above 15 nmol/L and drop plasma homocysteine to a
low plateau. As yet there is no proof of a favourable affect on cardiovascular
outcomes.
Homocysteine elevation above 20 µmol/L is also a risk factor for venous thrombosis
(2-3 x increase).
Homocystinuria/homocysteinuria
The screen tests are plasma homocysteine and a urine screen test for elevated
homocystine/cystine.
Hookworm
Howell-Jolly bodies
These are residual nuclear remnants seen in red cells after splenectomy and
sometimes in megaloblastic anaemia or haemolysis.
HPV causes sexually transmitted genital warts and is associated with dysplastic
changes and sometimes carcinoma in the cervix.
Human genome
Some statistics:-
There are 50,000 - 1,000,000 different genes of which 3,000 have been mapped.
The human genome project aims to develop a powerful genetic and then physical map
and subsequently to determine the complete nucleotide sequence.
Hydatids
specimen: serum
ref. range: negative
25-hydroxy calciferol
see Vitamin D
17-hydroxy corticosteroids
Test no longer done. It has been replaced by the 24-hr urine free cortisol in the
diagnosis of Cushing's syndrome.
nmol/L
male female
before puberty 0.4-1.0 0.6-2.0
adult 0.6-5.5 0.6-2.5 (follicular)
1.5-15 (luteal)
17-OHP has replaced urinary pregnanetriol as the best screening test for the most
common form of congenital adrenal hyperplasia (CAH) and is checked in the
National Testing Centre neonatal screening programme.
Hydroxybutyrate
see Beta-hydroxybutyrate
Hyper
Greek for over, beyond.
Most hyper- entries are listed under the term they qualify, e.g. hypermagnesaemia is
described under magnesium.
Hyperbilirubinaemia
Hypercoagulability
One of the first four of these inherited abnormalities is found in about 50% of cases of
thrombosis. The Factor V Leiden abnormality is ten times more common than each
of the other three.
The "other" category includes rare disorders such as homocysteinuria and the
prothrombin 20210 G-A variant. There are also other as yet unidentified
abnormalities which are presumed to exist.
Hyperparathyroidism
Hypersplenism
Hyperthyroidism
Hypo
Greek for under, below
Hypo-words are mainly entered under the terms they qualify, e.g. hypocalcaemia is
under calcium.
Hypochromia
see Microcytosis
Hypogammaglobulinaemia
myeloma
chronic lymphocytic leukaemia
lymphoma
non-selective protein loss
transiently with a recent viral infection
congenital deficiency
Hypoglycaemia
This common but elusive syndrome with its symptoms of irritability, tremulousness
and hunger ("faint with hunger") is not easily diagnosed by the laboratory. It is seen
in children, young adults, and to a lesser extent older people. The symptoms are felt
some 2-5 hours after food, not while fasting.
The extended GTT (4½-5 hrs) has been the traditional test but is a burden to the
patient and has too many false positives and false negatives.
A marginally more useful test is the measured blood glucose during an attack but the
logistics of this are often not easy.
The best test is a trial of diet which, if successful, combines diagnosis with therapy.
Sweet refined carbohydrates are changed to unrefined carbohydrates with one or two
snacks added between meals.
Fasting hypoglycaemias
These are much less common than the non-fasting varieties and much more likely to
have an identifiable organic basis.
The first test is to measure a fasting glucose. If low it should be followed by a fasting
insulin and repeat glucose:
• raised or inappropriately normal fasting insulin
— insulinoma
Neonatal hypoglycaemia
• low birth-weight
• infants of diabetic mothers
In both, blood glucose levels should be monitored, beginning an hour after birth, and
treatment given if levels are below 2.0-2.5 mmol/L. Glucose levels can rise and fall
quickly during the neonatal period. Clinical signs are an inadequate indication of
hypoglycaemia.
Hypopituitarism
Thyroid T4 low but TSH usually normal. The TSH measured in this situation can
co-exist with clinical hypothyroidism so is assumed to be biologically inert.
Hyposplenism
After splenectomy, red cells show Howell-Jolly bodies, targeting and spherocytosis
and there is thrombocytosis and leukocytosis which may or may not persist.
A hyposplenic blood picture can also be seen in other conditions associated with
splenic atrophy :
• coeliac disease
• inflammatory bowel disease
• autoimmune disease, particularly with haemolysis
• sickle cell disease
After splenectomy a patient may have increased susceptibility to infection which can
be overwhelming in children. Pneumococci are the usual cause but other organisms
such as Haemophilus or meningococcus may be responsible. Pneumococcal and
meningococcal vaccines can be given every 5-7 years or penicillin prophylaxis in
susceptible patients.
see
IBC
IEP
IF (immunofixation)
IgA deficiency
Anaphylaxis may occur as a result of IgG antibodies to IgA when the individual is
exposed to blood transfusion or gammaglobulin therapy.
IgE total
specimen: serum
IgE antibodies mediate Type I allergic reactions – allergic rhinitis, asthma, atopic
dermatitis, anaphylaxis.
Total IgE is elevated in patients with multiple allergies and parasitic infestations.
Very high levels, above 1000 IU/L, are found with atopic dermatitis, fungal sinusitis
and allergic pulmonary aspergillosis.
see also RAST (Radioallergosorbent test) for specific IgE antibody tests
The action of human growth hormone (HGH) from the pituitary is mediated through
IGF-1 which is formed in the liver. As well as its effects on growth, it has insulin-
IGF-1 and HGH are measured in suspected acromegaly and in pituitary dwarfism.
Immune paresis
This term refers to reduction in normal immunoglobulins
Immunoelectrophoresis (IEP)
specimen: serum
Immunofixation is used:
Immunofixation, urine
specimen: urine, random
A test for free light chains (Bence Jones Protein), whether they are present and
whether kappa or lambda.
Immunoglobulin G subclasses
The four IgG subclasses are numbered 1 to 4. In some patients, recurrent respiratory
tract infections are associated with Ig subclass deficiency even though the total IgG is
within the usual range.
Malignant paraproteins
These consist either of IgG or IgA (multiple myeloma) or IgM
(Waldenstrom's macroglobulinaemia or lymphoma) and show the invasive
characteristics of malignancy with infiltration and destruction of bone
marrow.
Asymptomatic or stable myeloma does not benefit from early therapy which is
indicated only for progressive disease with symptoms. Treatment involves the
use of alkylating agents such as melphalan with a trend in younger (<55 years)
patients to high dose therapy with autologous bone marrow transplantation.
Polyclonal increases
Pacific Islanders and South East Asians almost invariably show a moderate
polyclonal increase in immunoglobulins reflecting exposure to a different
range of microbiological antigens compared with temperate climates.
Polyclonal decreases
Imprecision
A word now replacing the older term "precision" which refers to the analytical scatter
(variance) of results when a single sample is tested repeatedly. The imprecision of a
test is expressed as the coefficient of variation (qv).
Indirect bilirubin
Infection control
Infectious mononucleosis
Although EBV infections are common in children, they are often mild and pass
undiagnosed. The peak incidence for infectious mononucleosis is in adolescence and
early adult life, but a few individuals who remain uninfected succumb in later life.
Blood picture
Variant (atypical) lymphocytes appear in the film during the first week of illness
increasing typically to more than 20% of the total WBC during the second week and
declining over ensuing weeks.
Variant lymphocytes are found in many viral illnesses including CMV and infectious
hepatitis and the protozoan illness toxoplasmosis. Because CMV and toxoplasmosis
have a similar clinical picture to infectious mononucleosis, they are sometimes
included in the "glandular fever syndrome".
EBV can invade the liver causing elevation of liver enzymes to levels of 200-500
units/L or occasionally higher. Alkaline phosphatase and GGT often show relatively
greater elevations than the AST and ALT when compared with infectious hepatitis.
EBV antibodies
VCA (viral capsid antigen) IgM antibodies appear at 4-7 days after symptoms
develop and persist for 2-4 months, occasionally up to 1 year. Their presence
indicates current or recent infection.
VCA IgG antibodies appear at the same time as IgM but persist for life.
EBNA (anti EB nuclear antigen) antibodies appear 3-6 weeks after onset and also
persist for life. 80% of the population are EBNA +ve, indicating past infection. A
minority of people infected with EBV never develop EBNA antibodies but will have
a positive VCA IgG test to indicate their past exposure.
Infertility
see Amenorrhoea
FSH (follicle stimulating hormone) and LH (luteinising hormone) for ovarian
failure
Progesterone for confirmation of ovulation
Prolactin for hyperprolactinaemia
Polycystic ovary syndrome (PCOS)
Influenza
Virus can be recovered from a posterior pharyngeal swab during the first 3 days of
illness. The swab must be placed in viral transport medium and transported on ice.
Antibodies can be measured in paired sera.
Inorganic phosphorus
see Phosphate
The INR is the test used to monitor warfarin anticoagulant therapy which is being
increasingly widely used across the range of thromboembolic disease. Warfarin is a
vitamin K antagonist and acts by reducing levels of Factors II (prothrombin) VII, IX
and X. The INR is a standardised prothrombin ratio calibrated so that INR results
from one laboratory are directly comparable with those from another.
The ½-life of warfarin is 36 hours and those of Factors II, VII, IX and X vary
between 7 and 60 hours and for this reason, response to a dose change is slow
with a lag of 3-4 days before a new equilibrium is achieved.
predicted
maintenance dose
4 <1.4 >8
1.4-1.7 6-8
1.8-2.3 5
2.4-3.0 4
3.1-3.5 <3
3.6-4.0 <2
Note: If 3.6-4.0, miss next day's dose, then give 2.0 mg.
If >4.1, miss 2 days' doses, then give 1.0 mg.
B. Target INR
The recommended target in the table below is a guide only and in selected
patients a different level may be recommended.
D. Management of overcoagulation
The urgency of correcting a high INR (above 4 if the target is 2.5) will depend
on whether there is any bleeding and whether major or minor.
2. Vitamin K
clinical guideline
INR 6-8 without bleeding • stop warfarin
• restart in reduced dose when INR <5
• give 0.5-1mg oral/sc vitamin K if INR
fails to shorten, or if reversal required
within 24-48 hrs.
INR >8 with bleeding • stop warfarin
• restart in reduced dose when INR <5.
• give 1-2 mg oral/sc vitamin K (repeat
in 24hrs if necessary).
Insecticides
see Disaccharidases
Iron
specimen: serum
ref. range: child 7-21 µmol/L
adult 10-30 µmol/L
Serum iron levels show a marked diurnal variation with morning levels higher by
30%.
They are also rapidly depressed to low levels by acute or chronic infections or any
other chronic disorder.
Because of these large fluctuations, serum iron is of little diagnostic use on its own
but when combined with iron-binding capacity/transferrin and ferritin, total body iron
deficiency or excess can usually be defined.
Fe
saturation = x 100%
IBC
IBC and saturation are routinely done with requests for iron. IBC reflects the iron
transport protein transferrin, a globulin travelling in the beta band on electrophoresis.
• iron deficiency
• oestrogens, oral contraceptives and pregnancy, to an upper level of about 90
µmol/L
• hypothyroidism
• ineffective erythropoiesis e.g. B12, folate deficiency
The treatment of iron deficiency must always be accompanied by a search for the
cause. Deficiency is so common in women of child-bearing age that it is easy to
attribute all deficiencies in women to menstrual loss while forgetting this is not
possible after the menopause – nor in males of any age. Deficiencies fall into three
broad groups.
gastrointestinal loss:
• oesophagus, stomach, duodenum – peptic ulcer,
NSAIDS, hiatus hernia,varices
• large bowel – tumours (iron deficiency is a common
presentation), ulcerative colitis, haemorrhoids
• small bowel – hookworm, congenital vascular
malformations, Meckel's diverticulum
other:
• epistaxis, haematuria, haemoptysis, telangiectasia
Dietary insufficiency
Mainly in infants, adolescents and the elderly.
Malabsorption
Coeliac disease particularly.
For these reasons many athletes take oral iron supplements when their ferritins are
towards the lower end of the reference range.
see Thrombocytopenia
IUCD
see Actinomyces
Hyperbilirubinaemia becomes visible in the skin and sclera of most individuals when
the bilirubin is above 40 µg/L. The skin is yellow in carotenaemia also, but not the
sclera.
Joint aspirate
K+ (kalium)
Karyotype
This test, which is part of routine urinalysis, is usually done by a dipstick method.
Mild positives occur with starvation or illness. Moderate or strong positives in Type I
diabetics indicate poor control requiring additional insulin and rehydration - urgently
if there is significant acidosis.
"Ketostix" detects acetoacetate which accounts for only a small percentage of "ketone
bodies", the greater portion being beta-hydroxy-butyrate (qv).
Klebsiella pneumoniae
see Thalassaemias
Klinefelter syndrome
XXY is the usual karyotype. Testosterone levels are typically reduced and FSH and
LH increased. Other pituitary tests are usually normal.
Laboratory error
see Errors
Variation
Lactase deficiency
see Disaccharidases
Reducing substances in faeces
Lactose tolerance test (LTT)
Protocol
A fasting blood glucose is taken and then a loading dose of lactose is given, 1.5g/kg
to a maximum of 50g and blood samples taken each quarter hour for 1 hour with a
final sample at 2 hrs. The test cannot be used in diabetics.
Interpretation
In a normal person, s. glucose (derived from the lactose) rises more than 1 mmol/L
above the fasting level, usually peaking at 15 or 30 mins. Because of its indifferent
sensitivity and specificity, the LTT is not often performed.
LD (lactate dehydrogenase)
specimen: serum
ref. range: 120 - 250 IU/L
• lymphomas, up to 2-3x the upper limit of the reference range. The level gives
an estimate of tumour bulk.
• other tumours, especially germ cell
• myocardial infarction, increase commences 12-24 hrs after infarction,
disappearing after 7-12 days
• megaloblastic anaemias due to B12 or folate deficiency
• haemolytic anaemia
• artefactual haemolysis due to faulty specimen storage or collection
• liver disease, particularly hepatitis
• skeletal muscle damage
LDH
LDL cholesterol
Lead, blood
specimen: whole blood (EDTA)
Industrial workers exposed to lead are put off work if their blood lead is >3.2 on one
occasion or >2.6 on three consecutive occasions.
Domestic exposure occurs when old lead-based paints are being sanded or burnt off.
Children are at risk when they ingest paint fragments or dust; as are pets when they
lick their fur.
Lead, urine
specimen: 24-hr urine in special container with added HCl
ref. range: <0.25 µmol/day
Urine leads are used for monitoring chelation therapy in lead poisoning after the
diagnosis has been established using blood lead levels.
LE cells
ANA and anti-DNA (qv) antibodies have replaced this test in the diagnosis of SLE.
Legionella
specimen: sputum for culture
serum for antibodies
ref. range: antibody level
There are more than 30 species of Legionella, the cause of Legionnaire's disease.
Culture is the diagnostic method of choice. Legionella culture must be asked for
specifically as it requires the use of specially prepared media. Specimens
contaminated with sodium e.g. saline-induced sputum and bronchial washings, are
not suitable for Legionella culture.
Most healthy adults have an antibody titre of <1.128. Rising antibodies in paired sera
provide good evidence of active infection. Paired sera should ideally be collected two
weeks apart.
Leprosy
Leptospirosis
specimen: serum
Since vaccination of cattle was introduced several years ago, the incidence of
leptospirosis has dropped to the point where it is now rare in Auckland and
For diagnosis an antibody screen test is performed followed by (on sera that are
positive) specific agglutination testing against the common strains of leptospira.
After infection, titres rise sharply into the thousands in those who have been infected
in the past. The highest titre may not indicate the cause of the latest illness.
Leucocyte count
Leucocytosis
Refers to an increase in the total white cell count. Its significance depends on which
cell type is increased.
• metastatic malignancy
• primary haematological malignancy
• myelofibrosis
• acute haemolysis
• thalassaemia major, especially after splenectomy
Leukaemias
Leukaemoid reaction
A peripheral blood picture resembling leukaemia in a patient who does not have
leukaemia. The increased numbers of white cells can be of either lymphoid or
myeloid type. Atypical response to infection in a child is the commonest cause. It is
seen particularly in Down's syndrome. Other causes include non-haematological
malignancies and acute haemolysis.
LH (luteinising hormone)
Lignocaine
Lipaemia
Lipid disorders
When classifying a lipid disorder for the purposes of treatment, two questions need to
be asked:
Secondary disorders
These are easily identified and when treated may entirely correct the lipid
abnormalities.
• obesity
• alcohol
• diabetes
Primary disorders
Lipid tests
see Cholesterol
Triglyceride
Lipoproteins
Lipoproteins
In serum, lipids are carried as lipoprotein particles which are grouped in four
fractions:
Typing of hyperlipoproteinaemias
The WHO classification is that of Fredericksen who recognised six types: I, IIa, IIb,
III, IV, V. The classification has limitations. Familial hyperlipoproteinaemias can
present as different types in different family members. A single aetiology (e.g.
hypothyroidism) can be associated with several types. Treatment can convert one
type to another. Nevertheless the terms are still used. Types II and IV, and to a lesser
extent V, are the commonest.
IIa IIb IV V
total cholesterol +++ +++ + +
triglyceride n ++ +++ +++
LDL cholesterol ++ ++ n n
VLDL cholesterol n + +++ ++
chylomicrons - - - ++
turbid serum - ++ ++ ++
Lipoprotein (a)
specimen: serum
ref. range: <300 mg/L
Levels are largely genetically determined but tend to rise after the menopause or with
renal impairment. Fasting, exercise or statins have little effect. Levels may be
lowered by niacin and perhaps by fibrates. Acute illness can have an effect
andlipoprotein (a) should not be measured within 3 months of a myocardial
infarction.
Lipoprotein electrophoresis
specimen: serum
Lipid EPP is a specialist investigation. For most clinical purposes a lipid abnormality
is defined by quantitation of cholesterol fractions and triglyceride on a fasting
specimen.
Listeria monocytogenes
specimen: blood cultures, CSF, for acute infection stool for carrier state
Lithium
The specimen must be taken 12 hours after the last dose. Steady state levels are
achieved 2-5 days after a dose change, or longer in older patients with renal
impairment. When lithium is stopped, the level falls with a ½-life of 1-3 days.
Manifestations of toxicity
General
ALP and GGT are the cholestatic enzymes so are particularly elevated in:
AST and ALT are the hepatocellular enzymes and are particularly elevated in viral
hepatitis.
• hepatitis A
• hepatitis B
• hepatitis C
• hepatitis B
• hepatitis C
• HIV
3. other infections
• malaria
• leptospirosis
• typhoid
• TB
• brucellosis
• analgesics salicylates
paracetamol
propoxyphene
• anticonvulsants phenytoin
carbamazepine
sodium valproate
phenobarbitone
• hormones oestrogens
• other phenothiazines
halothane
cytotoxic drugs
allopurinol
methyldopa
chlorpropamide
some herbal remedies
5. alcohol:
affects range from minor elevation of one (classically GGT) enzyme, through
massive elevations in acute alcoholic hepatitis down to minor or no elevations
in end-stage cirrhosis.
6. obesity:
7. diabetes:
8. gall-stones:
9. malignancy:
• SLE
• rheumatoid arthritis - raised ALP
• ulcerative colitis
• Crohn's disease
12. haemochromatosis
15 Wilson's disease
the enzyme molecule is too large to leave the circulation via the glomerulus
with the result that an enzyme level is permanently elevated in the absence of
any disease process.
– serial tests over weeks, months or years will define the time-course of the
underlying process. Is it:
specimen: serum
LKM antibodies
Lipoproteins
The APTT is prolonged in patients with LAC and fails to correct in the APTT 1+1
test.
The tests performed routinely as the LAC screen are KCT (Kaolin Clotting time),
APTT, PR, DRVVT (dilute Russell's viper venom time) and DTTA (dilute tissue
thromboplastin assay).
see Borrelia
After air drying, the imprint slides should have the patient's name written in
pencil on the frosted end and be placed in a cytology request envelope or
other envelope.
Lymphocyte antibodies
specimen: serum
Lymphocytes
Lymphocytes play a central role in the immune response. The two main types of cell,
identified by cell marker studies are:-
Lymphocytosis
An absolute lymphocytosis (>4.0 x 109/L) is typically found in two situations.
Lymphopenia
• viral illnesses
• pancytopenia due to any cause
• advanced Hodgkin's disease
• congestive heart failure
• steroid therapy
• AIDS
Variant lymphocytes
Macrocytosis
Macrocytes are red cells with an MCV (mean cell volume) be divided into three
groups:
3. Other
In this large group of normoblastic processes, the macrocytes are round. The
list includes:
- alcoholism
Macroglobulinaemia
Benign IgM paraproteinaemia The commonest cause. The blood picture is normal,
the patient asymptomatic and IgM levels are static and usually <10g/L.
Magnesium (Mg)
specimen: serum
decreased by
increased by
• renal insufficiency
• dehydration
• Addison's disease
• haemolysis
Malabsorption
Malabsorption particularly involves iron, folic acid, vitamin B12, vitamin K, vitamin
D and fats.
Follow-up tests
• the Pacific west of Fiji. This includes Papua New Guinea, the Solomon
Islands, Indonesia. It does not include Fiji, Samoa, Tonga, New Caledonia,
Niue, Tahiti or Hawaii.
• SE Asia and India
• Africa and S. America
The diagnosis needs to be considered in any visitor to these areas with unexplained
fever, sweats, headache, malaise, anaemia, abnormal liver enzymes.
Diagnosis is established by detecting parasites in thick and thin films. Serial blood
specimens may be required. Leucopenia is usual but there can be leucocytosis.
Variant lymphocytes are occasionally seen. Malaria can be accompanied by anaemia
which may be caused by haemolysis, marrow depression or hypersplenism.
Of the four subtypes of Plasmodium, only two, P. falciparum and P. vivax, are
commonly identified in New Zealand.
P. ovale and P. malariae are the two less commonly found subtypes.
Treatment should be discussed with those who have experience in treating malaria.
A fungus causing tinea versicolor (pityriasis versicolor) which shows as brown scaly
patches on white skin or pale patches on dark skin. Microscopy of skin scrapings
shows grape-like clusters of cells. The organism is not readily cultivated. Diagnosis
is based on clinical features, direct microscopy and absence of fungal growth on
culture.
Malignant melanoma
Classification
1. In situ
– this is melanoma before it has invaded the dermis. It has 100% 5-year
survival.
– this is early melanoma which has invaded the superficial dermis but
still has an excellent prognosis.
– this is melanoma which invades the dermis and may invade deeper
tissues. Prognosis is dependent mainly on tumour thickness which is
reported as both Clark level and Breslow thickness. Breslow thickness
is more important than Clark level. Few melanomas less than 0.76mm
in thickness give rise to metastases. Other prognostic factors of
importance are sex of the patient, anatomic site, mitotic rate,
Mantoux
specimen: serum
Maternal testing programmes require careful pre-test discussion with the mother to
explain diagnostic limitations and consideration of termination of an affected foetus.
The specimen should be collected at 15-16 weeks gestation (up to 20 weeks at latest)
and ideally an ultra-sound will be performed at about the same time to confirm
gestational age.
The combination of foetal age, maternal age and 2-4 maternal serum constituents are
entered into a computer programme which estimates foetal risk. Maternal serum tests
can include:
First trimester screening at 9-13 weeks has been shown to be as effective as 2nd
trimester screening in some centres and allows a decision to be made several weeks
earlier.
The result is presented as an estimated risk for discussion with the mother who may
elect to proceed with amniocentesis for possible Down's syndrome or ultra-sound for
NTD.
Maternal serum testing detects about 60% of Down's and 80% of NTD.
Down's has an overall incidence of 1:650 pregnancies rising quickly after 35 years to
1:100 at age 40. Two thirds of Down's occur at a maternal age below age 35.
MDS
The test can be for immune status (IgG antibody) or acute illness (IgM).
Measles, German
see Rubella
Megaloblastic anaemia
see Macrocytosis
Folate (folic acid), serum
Vitamin B12
Melanin
Meningitis
Patients with suspected meningitis belong in hospital but if you have a CSF which
might show infection, please notify us so that it can be handled urgently.
see Neisseria
Menopause
The term menopause refers to cessation of menses, a diagnosis that can be made only
in retrospect.
The interval between regular menstrual cycles and the menopause is the peri-
menopause, usually of about 2-3 years duration and variably associated with
symptoms of reduced oestrogen secretion.
Menstrual disorders
see Amenorrhoea
Mercury
specimen: 24-hr urine in special plastic container with HCl
ref. range: acceptable <0.25 µmol/day
toxic >0.5 µmol/day
Most of the public interest in mercury toxicity centres on amalgam in teeth but studies
have not shown harmful effects. After an exhaustive investigation, the U.S. Public
Health Service concluded there is no serious health risk. Urine mercury levels in
people with filled teeth are less than 5% of the stated acceptable limit.
ME syndrome
Metanephrines
specimen: 24-hr urine collected into HCl.
Methadone
Methaemalbumin
specimen: serum
Methaemoglobin
Methyl bromide
Methyl bromide is used for fumigation. Agricultural officers who use these
chemicals are checked annually.
Mg
Microalbumin
ref. range:
Microalbumin is a test currently used only in diabetics where it is a marker for early
nephropathy at a stage where it is reversible with good control of hypertension and
hyperglycaemia. In Type 2 diabetes, it is a powerful risk marker for vascular disease.
The term microalbumin refers to ordinary albumin (not a tiny albumin) found in urine
at concentrations below 300 mg/L, the cut-off point for conventional urine dipsticks.
Concentrations above this are called macroalbuminuria or persistent proteinuria or
clinical proteinuria and indicate irreversible nephropathy.
Microcytosis
Microcytes are red cells with an MCV mean cell volume below 80. Causes are:
Iron deficiency The commonest cause. In severe cases the MCV can be in the 50-60
range.
Thalassaemia The MCV, which lies in the 63-80 range, is disproportionately low,
relative to the degree of anaemia and is not altered by iron therapy.
Anaemias of chronic disorders The MCV is usually normal but sometimes falls in the
75-80 range.
Microfilaria
see Filariasis
Microhaematuria
see Urinalysis (routine biochemistry and microbiology) and UTIs (urinary tract
infections): haematuria
Microsomal antibodies
Microsporum canis
see Dermatophytes
Patients with a bleeding history but with a variable prolongation of the bleeding time
are often classified as having a "minimal bleeding disorder". The isolated long
bleeding time is presumed to be secondary to a platelet function defect. The same
condition is sometimes referred to as a long bleeding time syndrome. Patients with
suspected von Willebrand's disease can be placed in this group if they do not fulfill all
the criteria for von Willebrand's but have a bleeding syndrome characterised by
cutaneous bleeding.
Mitochondrial antibodies
specimen: serum
Mitochondrial antibodies are seldom found in normal people. Their main use is in the
diagnosis of primary biliary cirrhosis - 90% of patients are positive. They are
sometimes present in chronic active hepatitis and occasionally in other autoimmune
disorders.
Fragile X syndrome
Myotonic dystrophy
Prader Willi syndrome & Angelman syndrome
Huntington disease
Spinocerebellar ataxia
Familial adenomatous polyposis
Multiple Endocrine Neoplasia Type 2
Spinocerebellar muscular atrophy
Spinal muscular atrophy
Duchenne muscular dystrophy
Cystic fibrosis
Breast cancer testing
Adrenoleukodystrophy
Hereditary haemochromatosis
Monoclonal bands
Mononucleosis
Moraxella catarrhalis
Morphine
see Staphylococci
see Urinalysis (routine biochemistry and microbiology) and UTIs (urinary tract
infections)
Multiple myeloma
Mumps
specimen: serum
interpretation:
The diagnosis of mumps is usually an easy one on clinical grounds without a blood
test.
Muscle disease
Myasthenia gravis
Mycobacteria
Otherwise normal children may also present occasionally with cervical adenopathy
due to MAC. It is sometimes recovered from sputum specimens sent for TB culture.
Although it can cause true respiratory tract disease it is often just a coloniser in an
abnormal respiratory tract. Evidence for it being a pathogen includes repeated
isolation, a positive smear result and CXR changes. Treatment regimens include
ethambutol and clarithromycin with or without rifabutin. Decisions on whether to
treat and with what, require specialist advice.
Mycology
see Dermatophytes
Candida
Malassezia furfur
Mycoplasma pneumoniae
specimen: paired sera
These conditions are primary bone marrow disorders which usually behave as slowly
evolving bone marrow failure syndromes. Most often they present insidiously and in
an older population. A variety of peripheral blood findings may be noted including
pancytopenia, refractory anaemia, macrocytosis with anaemia, neutropenia and
thrombocytopenia. Diagnosis is by excluding vitamin deficiency (B12, folate) and
demonstrating dysplastic features in the bone marrow. Chromosome analysis and cell
marker studies may also be performed on the bone marrow. Management is usually
by supportive care but in selected patients more aggressive therapy maybe indicated.
Myelofibrosis
Myeloma
Myocardial enzymes
see Myocardial markers for infarction (MI) and ischaemia
Myoglobin, though relatively nonspecific, is the earliest to rise and can appear within
the first 6 hours.
The remaining four typically start to rise 4-12 hours after infarction, reach a peak and
return to baseline over a period which differs between the four.
elevated for
CK - MB 2-3 days
total CK 2-3 days
troponin I 4-7 days
troponin T 4-10 days
CK-MB is falling into disuse since the troponins arrived, though it may be useful in
plotting successive reinfarctions.
Mycoplasma hominis
Myoglobin
specimen: 10ml random urine
Mysoline (primidone)
specimen: serum
Films must be made within a few hours of collecting the specimen. Although the test
is of low specificity it is of some value in the following conditions:
Narcotic screen
After moistening the swab with transport medium, it is gently inserted up to 2cm into
the nostril, upwards and backwards, and rotated against the midline nasal septum.
Nasal swabs are taken when looking for carriers of Staph aureus, particularly MRSA.
Usually only one swab is collected per patient, inserted consecutively into each
nostril.
Nasopharyngeal swab
ee Neonatal screening
Necator americanus
see Hookworm
Investigations
Bloods from the exposed workers and the source specimen should be tested for
markers of infection and immunity.
• HIV antibody
• HBs antigen
• HBs antibody
• HCV antibody
The event must be fully documented and the exposed worker counselled and kept
informed.
Hepatitis B
• No action is required if
worker is antibody +ve – they are already immune
source is antigen –ve – the blood is not infective for HBV
worker is antigen +ve – they are already infected from some other
source, follow-up is as for any HBs ag
positive patient.
• Action is required if worker is antibody -ve and antigen -ve AND source is
antigen +ve or not known
• no prophylaxis is available
• if the source is HCV -ve – no risk for HCV
• if source is +ve and worker -ve, the worker is at risk. Do follow-up tests at 3
and 6 months. If they seroconvert, refer for specialist follow-up.
• if worker is HCV +ve, they are already infected.
Refer for specialist follow-up.
HIV
Of the three viruses, HBV is the most infective (30%) followed by HCV (3%), then
HIV (0.3%).
This means, for example, that if no PEP is used in a known HIV +ve needlestick, the
risk to the worker is 0.3%.
Neisseria
A. Neisseria gonorrhoeae
Male STD Urethritis and sometimes epididymitis. The organism can also
sometimes be recovered from the rectum and throat.
Treatment
B. Neisseria meningitidis
These tests are usually done only when the infant is at risk for haemolytic disease
(qv), not as a routine.
Neonatal jaundice
see Jaundice
Neonatal screening
Tests are performed at the National Testing Laboratory, National Women's Hospital,
phone (09) 6310 705. All infants born in New Zealand, about 60,000/year, are tested
for the following:
Condition Test Incidence
cystic fibrosis trypsin 1 : 3,000
hypothyroidism TSH 1 : 5,000
phenylketonuria phenyl alanine 1 : 15,000
galactosaemia galactose 1 : 50,000
biotinidase deficiency biotinidase 1 : 60,000
congenital adrenal hyperplasia 17-OH progesterone 1 : 225,000
maple syrup urine disease leucine 1 : 250,000
The infant must have been feeding on milk for at least 2 days before specimen
collection, the usual age being 5 days. Cards collected up to the age of 1 month give
valid results or up to 2 months for cystic fibrosis.
Blood spot cards can be tested by the lab up to 1 month after collection. The NTL
completes the tests within 1 week of arrival at the lab. At present they notify positive
results only.
A single screening test giving an apparently normal result can never exclude the
above conditions. If a neonate or infant is unwell or not developing normally,
appropriate tests should be repeated or added.
Netilmicin
see Catecholamines
Neutrophils (polymorphs)
Neutrophil counts are expressed and interpreted in terms of the absolute count rather
than % of total white cell count.
A. Neutropenia
Mild neutropenia, 1.5 - 2.2 x 109/L is a common finding, often suspected to be caused by
an immune mediated mechanism (immune neutropenia) when drugs are not implicated.
– phenylbutazone, indomethacin
– chlorpromazine, promazine, other phenothiazines
– carbamazepine
– propylthiouracil, carbimazole
– sulphonamides, cotrimoxazole
– dapsone
– thiazides
– captopril
Cyclical neutropenia
Characterised by periodic fluctuations in the neutrophil count with the nadir occurring
usuallyat three weekly intervals. In the most severe cases the neutropenia may be
extremely low, < 0.1x10.9/L , with infective complications, malaise and fever.
Hospital admission may be required as occasionally these may be life-threatening
events. In some patients, due to the severity of the neutropenic episodes and the
infective complications, growth factor support with granulocyte colony stimulating
factor (G-CSF) is required.
B. Neutrophilia
Causes of neutrophilia
- Bacterial infection – there may be a shift to the left and with more severe
infections there may be toxic granulation and eventually neutropenia as the
marrow is overwhelmed.
At the other end of the scale is the leukaemoid reaction, a massive outpouring
of cells in response to infection with counts up to 80 x 109/L and a striking
shift to the left.
- Tissue injury – due to infarction, burns, surgery, trauma and other processes
causing necrosis.
- Malignancy
Chlamydia is the main pathogen but Trichomonas vaginalis can also cause symptoms.
In about half of NGU's an organism is not isolated.
Treatment is doxycycline, 100mg 12-hourly for 7-10 days.
Noradrenaline
see Catecholamines
Normal range
Nose
Nosocomial infection
NSAIDs can cause acute renal insufficiency, usually reversible, due to inhibition of
vasodilatory prostaglandins.
Susceptible patients are the elderly and those with pre-existing renal disease,
cardiovascular disease, an oedematous state or concomitant use of diuretics or aspirin.
These should be monitored 1-3 weeks after commencing NSAIDs and then 3-monthly
for long-term use, looking for:
• rising s. creatinine
• hyperkalaemia
• proteinuria
N-telopeptide
The female range is for pre-menopausal women. After the menopause, developing
osteoporosis can double N-telopeptide levels.
Occult blood
Oestradiol (E2)
specimen: serum
ref. range:
pmol/L
adult female during cycles —
see diagram under FSH
early follicular <300
ovulatory surge 500-2000
luteal phase 150-1400
post-menopausal <160
adult male <160
It is not used during the early investigation of infertility, for diagnosing menopause,
for monitoring HRT (hormone replacement therapy), or for investigating irregular
menstruation.
Oestriol (E3)
Serum or urine oestriols were once used for 3rd trimester foeto-placental monitoring.
They have not been replaced routinely by any other biochemical test.
Unconjugated serum oestriol is used when testing for Down's syndrome during the
first or second trimester.
see Maternal serum testing for foetal Down's syndrome and neural tube defects
(NTD)
Oestrogens
- Oestradiol (E2) (qv), is the major endogenous oestrogen during child-bearing
years
OH
OGTT
Onychocola canadensis
Oral contraceptives
see Cholinesterase
Osmolality
Urine osmolality, which is under the control of pituitary ADH, varies over a wide
range to ensure that alterations in fluid intake have little effect on the tightly
controlled serum osmolality. Urine osmolality is typically highest on rising in the
morning because of the absence of fluid intake during sleep. An osmolality >600
(especially >800) makes diabetes insipidus unlikely.
This is a test for spherocytes which are more sensitive to lysis in hypotonic saline
solutions than are normal red cells. The figures refer to strength of saline solutions at
which initial and complete haemolysis occur, 0.9% being isotonic. Sensitivity is
increased by pre-incubation of red cells for 24 hours at 37°C.
Osteoporosis/Osteomalacia
In old age, osteoporosis and Vitamin D deficiency can act together to accelerate loss
of bone density.
Otitis
Ova in faeces
Ovarian function
see FSH (follicle stimulating hormone) and LH (luteinising hormone) for ovarian
failure and menopause
Progesterone for detection of ovulation
Oestradiol (E2) for oestrogenic activity
Polycystic ovary syndrome (PCOS)
Ovulation
see Progesterone
Oxalate
About 10% of urine oxalate normally comes from the diet but this fraction increases
with excessive intake of oxalate rich foods including spinach, rhubarb, strawberries,
tomatoes, prunes and tea.
Pancreatitis
Pancytopenia
A reduction in all three cellular elements in blood i.e. anaemia, leucopenia
(neutropenia) and thrombocytopenia. An unexplained pancytopenia is always an
indication for a bone marrow biopsy.
Causes include:
PAP
see Cervical cytology (PAP smear)
Acid phosphatase, prostatic (PAP) (prostatic acid phosphatase)
Paracetamol (acetaminophen)
specimen: serum, for quantitative measurement and assessment of risk
urine, a qualitative test where ingestion is suspected but not known
About 4 hours after an overdose of paracetamol, the serum level reaches its peak and
then declines. Charting the serum level against time elapsed since ingestion gives a
measure of risk of liver toxicity and determines whether antidote should be given. At
4 hours, a paracetamol level above about 1mmol/L is an indication for giving N-
acetylcysteine.
Paraprotein
Paraquat
Parasites in faeces
• lithium therapy
• vitamin D deficiency
About 90% of patients with pernicious anaemia have parietal cell antibodies. These
can be found in other organ-specific autoimmune disorders such as thyroiditis and in
10-15% of apparently healthy elderly people.
• intravascular haemolysis
• venous thrombosis
• marrow hypoplasia
PNH is due to an acquired mutation giving rise to a clone of abnormal stem cells
affecting erythrocytes, leucocytes and platelets.
Pasteurella multocida
A gram-negative bacillus that is isolated from skin lesions. The organism is a
common inhabitant in the mouths of cats and dogs and infection is frequently
associated with animal bites or scratches. Regional lymphadenopathy, chills and
fever can result. It is susceptible to penicillin and amoxycillin. Wound debridement
may also be necessary.
Paternity testing
specimen: whole blood (EDTA) from:
PBG (porphobilinogen)
see Porphyrias
pCO2
PCOS
PCR
Polymerase chain reaction
Penicillin allergy
When a patient says they are allergic to penicillin, the diagnosis can be confirmed by
skin tests conducted in a specialist setting and desensitisation achieved if penicillin
therapy is regarded as essential.
It is more usual to accept the patient's diagnosis and avoid penicillin, particularly
injections which cause more severe reactions than oral forms.
Penicillin allergic status can change over time, from positive to negative and back
again and for this reason even a negative skin test in a person who claims sensitivity,
cannot be relied on to stay negative.
Percentage hypochromia
The percentage of hypochromic red cells is a useful guide to iron status in patients
with chronic renal failure who are being treated with recombinant erythropoietin
(EPO).
Peripheral neuropathy
Pertussis
pH, blood
pH, urine
A non-contributory test except in renal tubular acidosis where a useful screen is to
collect a first morning urine in a filled, well-sealed container which should be
delivered to the laboratory without delay. A urine pH below 6.0 makes renal tubular
acidosis very unlikely.
Phaeochromocytoma
see Catecholamines
Phenobarbitone
specimen: serum
therapeutic range: 65-170 µmol/L trough level
Phenylalanine
specimen: blood spots on Guthrie card
screening for PKU – see Neonatal screening
monitoring PKU – quantitative phenylalanine levels are also done on blood spot
specimens
Phenylketonuria (PKU)
see Phenylalanine
Phosphatases
Phosphate
specimen: serum
ref. range:
Age (yrs) mmol/L
0-1 1.4-2.4
2-10 1.0-2.0
>10 0.7-1.5
A wide range of other disorders cause hyper- or hypo phosphataemia but diagnostic
value is limited.
Phospholipid antibodies
see Anticardiolipin
Lupus anticoagulant (LAC)
Antiphospholipid antibody syndrome (APS)
Pinworm
Pituitary hormones
see Hypopituitarism
PKU (phenylketonuria)
see Phenylalanine
Plasma volume
Platelet aggregation
Platelet antibodies
specimen: serum
blood (EDTA)
Platelet antibody tests are most often performed in the investigation of an isolated
thrombocytopenia. Both platelet-associated (PAA) and serum platelet (SPA)
antibodies are measured. A positive result for either test supports an immune
aetiology though immune thrombocytopenia may be present in patients with negative
PAA and SPA.
Platelet count
specimen: whole blood (EDTA)
ref. range:
Platelet dysfunction
This is suspected in patients presenting with a bleeding history and a normal platelet
count, normal coagulation factor screen but prolonged bleeding time. The term
“minimal bleeding disorder” (qv) is sometimes used. Occasionally, platelet
aggregation and other studies are used where further investigation is required.
Pleural fluid
Pneumococcus
see Streptococci
Pneumonia
Pneumocystis carinii
Pneumonia
At the time of clinical diagnosis an attempt, often unsuccessful, should be made to
obtain a sputum sample. Culture may show Strep. pneumoniae in classical lobar
pneumonia; or Haemophilus influenzae and/or S. pneumoniae in pneumonia
associated with chronic bronchitis.
% susceptible
amox tetra cotr amox-clav eryth pen
H. influenzae 81 99 91 100 0¹ —
S. pneumoniae —² 71 67 —² 76 68
Treatment: With the exception of viruses, the agents causing atypical pneumonia are
susceptible to erythromycin, though doxycycline is the preferred treatment for
psittacosis.
PNH
Polychromasia
Bluish staining of some red cells in a blood film suggesting an increase in
reticulocytes (qv).
• amenorrhoea or oligomenorrhoea
• infertility / anovulation with oestrogen present
• hirsutism, acne, alopecia
Not all these features are necessarily present. The combination of androgen excess
and obesity leads to increased extra-ovarian oestrogen production which increases LH
and decreases FSH.
Polycythaemia
Is defined as a haemoglobin concentration above the reference range for age and sex.
Laboratory features
The red cell mass is elevated (usually >36mls/kg in males) but the plasma
volume is normal. By convention the packed cell volume is used to monitor
the treatment response.
• White cells – there is an increase in neutrophils often with a shift to the left
with band neutrophils, metamyelocytes and occasionally myelocytes.
• Platelets – 400 - 800 x 109/L in most cases with counts over 1000 x 109/L
occasionally. Giant forms may be present.
B. Secondary polycythaemia
Increase in the red cell mass due to tissue hypoxia caused by:
• chronic respiratory disease
• congenital heart disease
• high altitude
Polydipsia/polyuria
Urinary frequency due to UTI (urinary tract infection) or lower urinary tract
problems, can be distinguished from polyuria by collecting a 24-hr specimen to
document urine volume. Causes of polyuria include:
see PCR
Polymyalgia rheumatica
ESR and CRP are almost invariably (but not always) raised.
Porphyrias
specimens: all must be protected from light and delivered to the lab as soon as
possible.
• Acute porphyria
Attacks are provoked by drugs that induce liver enzymes – barbiturates, alcohol,
oestrogens, sulphonamides, anticonvulsants, and others. In women, neuropathic
symptoms may be cyclical, associated with oestrogen peaks.
• Cutaneous porphyria
Investigations
During a suspected acute attack, e.g. recurrent acute abdominal pain not otherwise
explained, a fresh urine sample should be taken to the lab urgently for PBG.
Cutaneous photosensitivity is most often due to PCT (porphyria cutanea tarda) which
is diagnosed by increases in urine and faecal porphyrins. Diagnosis of the rare
erythropoietic porphyrias requires a blood specimen.
The table below lists the names of the main porphyrias in their order of frequency –
PCT is the commonest, then variegate porphyria and so on.
The second column indicates whether that porphyria is cutaneous or acute or both.
The test columns show the tests that should be ordered in the acute and latent phases
of each porphyria.
see Hyposplenism
Elevated potassiums are one of the most vexing problems faced by a laboratory
because of the difficulty knowing whether a level of 7.5 mmol/L, for example,
is harmless artefact or imminently lethal hyperkalaemia.
• Artefactual elevation
These are comon due to leakage of potassium from red cells into serum or
plasma. Causes are:
• iscard elevated potassium results when the specimen has been stored
more than 5 hours.
• never put electrolyte specimens in the fridge.
• have the repeatd specimen collected by a skilled venepuncturist before
the morning courier collect and label it "Immediate" so that it will be
analysed soon after arrival at the lab.
• Physiological elevations
• Pathological states
– renal failure
– adrenocortical insufficiency
– metabolic acidoses
– very high platelet or white cell counts
- Levels between 5.0 and 6.0 will seldom be a danger. Between 6.0 and 7.0 risk
is increasing, particularly when the hyperkalaemia is of acute onset, as when starting
Values in the range 3.0-3.4 are common, and may remain unexplained even
after investigation. Below 3.0, the cause needs to be found.
• Liquorice
• Diarrhoea and vomiting
• Metabolic alkalosis
• Corticosteroid excess – Conn's syndrome
Cushing's syndrome
steroid medication
• Oedematous states – hepatic failure
renal disease
congestive heart failure
• Anorexia nervosa/bulimia
Potassium, urine
When there is hypokalaemia, normal renal and adrenal function will reduce output to
<30 mmol/day after 2-3 days. A higher value is consistent with adrenocortical excess
(e.g. Conn's syndrome), vomiting or diuretic therapy.
PR (prothrombin ratio)
PCT (patient )
PR =
PCT (normal plasma pool)
The term prothrombin ratio (PR) is still retained when referring to the extrinsic
pathway test for Factors II, VII, IX, X when the patient is not on a vitamin K
antagonist such as warfarin. It is used for evaluating coagulation disturbances in liver
dysfunction and clotting factor deficiency due to vitamin K depletion. For practical
purposes, PR and INR are the same test.
see Imprecision
Variation
Predictive value
The predictive value of a test gives the probability that it will give the correct answer
for a population. It combines sensitivity or specificity of the test with prevalence of
the condition being tested for.
A test with a positive predictive value of 80% for a population, will give 80% true
positives and 20% false positives.
A test with a negative predictive value of 97% will give true negatives in 97% and
false negatives in 3%.
Pregnancy tests
Pregnanediol, urine
The old method for assessing progesterone, now replaced by serum progesterone.
Prevalence
Primidone
Procainamide
17-OH progesterone
• To detect ovulation a specimen is taken 6-9 days after presumed ovulation, i.e.
days 20-23 of a 28-day cycle. Serum levels rise sharply during the luteal
phase to reach a plateau. See diagram under FSH.
• Because hormone release is episodic, levels can vary considerably throughout
the day.
• Pregnancy – levels rise steadily to reach a peak of 200-700 nmol/L by term.
• Ectopic pregnancy – the diagnosis of ectopic pregnancy is supported by a
level below 15 nmol/L in the presence of symptoms.
Prolactin
specimen: serum
ref. ranges: adult female 40-600 mU/L
adult males 30-450 mU/L
Causes of hyperprolactinaemia
Physiological
• stress
• sleep
• pregnancy – starts to rise at 6 weeks, peaks at up to 10,000 mU/L by term.
• lactation – peaks occur during episodes of breast-feeding with levels up to
5000 mU/L. Prolactin is essential for normal lactation.
• early morning collection — trough levels occur late morning.
• eating — small rises
Drugs
• psychotropics • cimetidine
• metoclopramide • tricyclic antidepressants
• methyldopa • opiates
• reserpine • haloperidol
• oestrogens, including oral contraceptives • androgens
Pathological
• pituitary adenomas and micro-adenomas
• other hypothalamic-pituitary disorders
• polycystic ovary syndrome
• hypothyroidism
• renal failure
• seizures
• anorexia nervosa
• Addison’s disease
• hypoglycaemia
• idiopathic
Prostate cancer is graded using the Gleason system based on the glandular pattern
seen microscopically. The predominant pattern is selected and given a grade of 1 to 5
and the second commonest pattern is also given a grade of 1 to 5. The two grades are
added to give a Gleason score of 2 to 10.
A Gleason score of 2-4 is a low grade tumour, 5-7 is intermediate grade, 8-10 is high
grade. Higher scores usually mean a more aggressive tumour.
The Gleason score and the clinical stage of the tumour are predictive of long-term
outcome.
Protein electrophoresis
Acquired causes of Protein C deficiency are liver disease, warfarin therapy, vitamin K
deficiency.
see Hypercoagulability
Protein S
specimen: plasma (EDTA)
ref. range: 70-130%
Acquired causes of Protein S deficiency are liver disease, warfarin therapy, vitamin K
deficiency, oral contraceptives, pregnancy.
specimen: serum
ref. range:
Age g/L
0-6 mths 45-75
6-12 mths 50-75
1-2 yrs 55-75
>2 yrs 60-84
Total proteins, consisting of albumin and globulins, is a crude test, but a raised value
can be a pointer towards raised immunoglobulins; a low value can be due to reduced
albumin or globulins or both. Variations in protein concentration can be due to
dehydration, diuretics, fluid retention or diurnal changes. On changing from the
recumbent to the upright position, fluid is redistributed to tissues from the circulation
causing an increase of up to 10% in protein concentrations.
Test methods
Renal proteinuria
Causes include the whole differential diagnosis of renal disease.
Glomerular proteinuria is by far the most common and serious type. The protein is
predominantly albumin and when daily output >3 g/day, nephrotic syndrome
Causes include:
• infection
• fever
• stress
• exercise
• heart failure
• orthostatic proteinuria, found particularly in young men, disappears when the
patient is recumbent. Protein is absent from a morning specimen collected on
first getting up.
• iodiopathic
Prothrombin ratio
Protoporphyrins
see Porphyrias
specimen: serum
PSA, an enzyme that liquefies the seminal coagulum, is found only in prostatic tissue
and is an excellent tumour marker for monitoring treatment and progress of prostatic
carcinoma.
Controversy surrounds the use of PSA as a screening test, however, and the usual
recommendation outside the United States is that PSA should not be offered to
asymptomatic males unless they specifically request it – and if they do, they need to
understand the diagnostic and therapeutic implications of an elevated level.
Some centres measure the free fraction as well as total PSA, a higher free/total ratio,
e.g. >0.2, being more suggestive of benign enlargement.
In BPH (benign prostatic hypertrophy) the PSA is sometimes elevated but seldom
above 10 µg/L. The PSA velocity (annual rate of rise of PSA) is usually less than in
Ca prostate and a patient who chooses watchful waiting of a level below 10, may use
PSA velocity as a deciding factor before requesting prostatic biopsy. Allowance must
be made for a biological variation of 10-15% when observing serial PSA levels.
PSA levels also rise for up to 24 hours after sex, especially in older men.
Up to 30% of patients with early Ca will have a PSA within the reference range.
Annual monitoring, as recommended by US urologists, would show a rising PSA in
this group.
A PSA above the upper reference limit but below 10 is in a zone of uncertainty where
only a biopsy will provide the diagnosis. Annual monitoring rather than biopsy will
be the chosen option for some patients.
When the PSA has risen above 10, the probability of carcinoma is rising steeply and
most patients proceed to biopsy.
Prostatic Ca is usually an indolent tumour presenting in later life and most affected
males die with the tumour rather than of it.
It is a common tumour – 40% of males over the age of 75 are affected when
examined at autopsy.
Pseudomonas aeruginosa
Psittacosis
PTH
Pus swabs
Pyuria, sterile
see Urinalysis (routine biochemistry and microbiology) and UTIs (urinary tract
infections)
Q Fever
specimen: serum
Quinidine
RA
Rapid smears
specimen: serum
Individual allergens required must be listed. RAST screens for multiple allergens are
not done because of the high cost per test.
RAST tests use the patient’s serum to diagnose specific allergies by identifying the
presence of an IgE antibody against that allergen. They are used as a second-line
investigation, the first-line being the standard battery of skin tests (qv). Specific
indications for RAST tests are:
Reactive arthritis
Reactive hypoglycaemia
see Hypoglycaemia
specimen: serum
Indications:
The patient's red cells are labelled with 51Cr and their survival in the circulation
determined.
specimen: fresh sample of faeces in small jar delivered to lab as soon as possible,
stored in fridge if delay is unavoidable.
The test is a simple qualitative test for reducing substances which include lactose,
glucose and fructose but not sucrose.
The diagnosis can be confirmed by improvement after withdrawal of lactose from the
diet.
In the dawn of laboratory medicine, before 1969, before the invention of the
biochemistry Auto-Analyser or the flow-through haematology blood counter, we
believed a sharp line divided normal from abnormal results. This was always too
simplistic. Some results are almost certainly normal, others almost certainly
abnormal, and separating these is a broad grey zone where interpretation depends on
consideration of clinical history and findings and a host of other variables.
The term “normal range” was replaced by “reference range” (or “reference interval”)
to indicate that we make no judgement on whether a result is normal. We simply
provide a range that covers the values of 95% of a group (e.g. blood donors) who are
Most of the interpretative notes in this handbook are directed towards defining the
variables that influence this decision. Whenever there is doubt about the significance
of a result, the test should be repeated immediately if the clinical situation demands it
or in a week or a month or even a year if there is no urgency. The temporal pattern
provides an extra dimension by showing whether a result is increasing, decreasing or
staying the same, whilst at the same time the clinical picture has the opportunity to
move in one direction or the other.
Some reference ranges, such as those for cholesterol or uric acid, are not 95%
population ranges but "ideal" ranges that we should strive to attain.
Reiter's disease
Renal calculi
Most calculi are of unknown origin but four aetiologies need to be remembered.
The reason for analysing calculi is to detect pure uric acid (5-10% of all stones) or
cystine. In the case of uric acid stones, the causes of increased uric acid (qv)
excretion need to be looked for. Allopurinol is effective in preventing further stone
formation.
The remaining 90% of stones are composed of calcium oxalate or phosphate and in
half of these there is hypercalciuria due to increased intestinal absorption of calcium.
A 24-hr urine should be analysed for calcium, phosphate, urate and oxadate.
Renal glycosuria
see Glycosuria
Creatinine clearance (qv) is not a useful screen test because of the inaccuracies
associated with 24-hour urine collections.
Because of tubular defects, the kidney has impaired ability to secrete an acid urine.
A useful screen test is to measure the pH of a spot urine on first rising. A pH <6.0
suggests normal acidification. An acid load test is used for follow-up.
Renin
Reticulin antibodies
specimen: serum
ref. range: not present
Reticulocyte count
Rhesus incompatibility
Rheumatic fever
New Zealand still has a high incidence of acute rheumatic fever with Maori and
Pacific Islanders making up 84% of the total. 60% of cases are in the 5-14 age
group. It is a notifiable disease. Diagnosis is based on the revised Jones criteria:
carditis clinical
polyarthritis previous rheumatic fever
The commonest of the connective tissue diseases with an incidence of 1-2% in the
general population. The American Rheumatology Association (1982) recommends
that the diagnosis be applied to those who are positive for four of the following seven
criteria:
Note that 20% of patients with rheumatoid arthritis are negative for rheumatoid
factor.
specimen: serum
ref. range: latex test <20 u/ml
Rose-Waaler <30 u/ml
Rheumatoid factor is an antibody, or rather a group of IgM, IgG and IgA antibodies,
directed againtst IgG. Most methods detect the same IgM rheumatoid factor but
specificities vary somewhat and for this reason a test that is positive in one laboratory
may be negative in another and the quantitations may differ.
2% of the healthy population are positive for RF, rising to 5-10% in the elderly.
In rheumatoid arthritis (RA) qv, RF is present in only 80% of cases. RF on its own
does not signify rheumatoid arthritis and conversely a clear clinical presentation of
RA does not require RF to establish the diagnosis. RF is often absent during the first
• Sjogrens (90%)
• SLE (30%)
• other connective tissue disorders
• chronic inflammatory/infectious disorders
• malignancy
Ringworm
see Dermatophytes
Rochalimaea henselae
Rose-Waaler test
Rotavirus
specimen: fresh faeces
Symptoms may be severe but usually settle within 7 days with oral fluid and
electrolyte replacement.
Rubella
specimen: serum
tests: IgG for immune status
IgM for current infection
ref. ranges :
Immune Status
The person with an IgG antibody level >10 µ/ml, can be assumed to have solid
immunity.
With levels between 5 and 10, immunity probably exists but a rubella vaccine booster
is recommended except in pregnancy when the booster should be delayed till after
delivery.
Because 85% of mothers infected during the 1st trimester give birth to infants with
congenital defects (eyes, ears, heart, brain), termination of pregnancy must always be
discussed when infection has been established.
If the woman develops signs or symptoms consistent with rubella, IgM antibodies
should be collected at weekly intervals for 3 or 4 weeks to check for presence of IgM
and subsequent rise in titre which will confirm infection.
S.
= serum
Salicylate
specimen: serum
ref. range: therapeutic 1.0-2.0 mmol/L
toxic >3.6 mmol/L
specimen: serum
specimen: serum
A test of limited value in the diagnosis of typhoid fever, blood culture being the
preferred diagnostic method.
Interpretation
O antigens titre >1:160 and rising sharply over 7-14 days suggests current
infection.
H antigen >1:160 suggests immunity
Vi antigen high titre sometimes indicates the carrier state.
Salmonella culture
specimen: faeces for diarrhoea
blood culture for suspected typhoid fever
Salmonella species make up 15% of the pathogens cultured from faeces in this
laboratory, the main reservoir being domestic animals (including poultry and eggs)
and infected humans, both symptomatic and carriers. Species causing enterocolitis
include S. typhimurium, S. choleraesuis and S. enteritidis. In healthy persons the
episode usually resolves in 2-3 days. Patients with impaired defences may require
antibiotic treatment, usually with cotrimoxazole, amoxycillin or ciprofloxacin. The
chronic carrier state can be treated with ciprofloxacin.
Typhoid Fever
Only a few cases occur in Auckland each year, S. typhi being the usual cause or
occasionally S. paratyphi A or B.
During the early stages, diagnosis is by blood culture which should be done
repeatedly when clinical suspicion is strong. From the second week on, faeces
cultures may be positive.
Sarcoidosis
Serum ACE (angiotensin converting enzyme) is elevated in 2/3 of patients but the test
is not specific enough to be of diagnostic value, nor does it have prognostic
significance.
Saturation, iron
Scabies
Caused by the mite Scarcoptes scabiei and transmitted by direct skin to skin contact.
Transfer from clothes is possible but only if worn by infected people immediately
beforehand.
Incubation period 2-6 weeks without previous exposure but only 1-4 days in those
who have been infected before.
Burrows are characteristic in scabies. These consist of skin-covered ridges 0.5 - 1.0
cm in length, often with a small vesicle at the end.
Schilling test
It measures the absorption of orally ingested labelled B12 with and without added
intrinsic factor. Normally >10% of the orally administered vitamin B12 is excreted in
the urine. An intramuscular loading dose of vitamin B12 is given to ensure that stores
are replete.
Schistosomiasis
specimens : — random faeces
— urine, full volume (not just an aliquot)
preferably collected between noon and 3pm when there is peak egg
excretion
— serum for antibody tests
Request examination for schistosome ova. Eggs may be found in urine and stool as
early as five weeks after infection. Patients with a low worm burden may have few or
no eggs in urine or stool.
Although over 200 million people in Africa, the Middle East, S. America and the
Caribbean are infected with these blood flukes, schistosomiasis is rare in travellers to
these areas. Infection requires skin contact with contaminated fresh water as in
swimming or wading bare-foot in paddy fields, water-holes, local streams, etc. The
infective form penetrates human skin, passes through a migratory phase in the lung
and liver and then moves to its final habitat in the portal venous system (S. mansoni)
Many New Zealanders have acquired infection in Lake Malawi in South East Africa.
It is stated in some travel guides that this lake is free of infection risk. This is not the
case and travellers should be advised against swimming in this lake.
The usual problem is the traveller who requires reassurance. Examination of faeces
for the highly characteristic ova; urine for ova and red cells; serum for serology, and
perhaps liver function tests, are adequate for this purpose.
Positive serology indicates present or past infection. Persons with negative stool
and/or urine tests but positive serology require treatment to avoid the uncommon but
catastrophic spinal cord complication of transverse myelitis.
Treatment with praziquantel and follow-up are best managed by those with
experience treating schistosomiasis.
Scleroderma, diffuse
Scleroderma, limited
Calcinosis
Raynaud's phenonemon
Esophageal dysmotility
Sclerodactyly
Telangiectasia
Tests that are often positive include ANA (80%) usually centromere pattern.
This autosomal recessive disorder renders the carrier apnoeic for an abnormally long
period after administration of scoline. Family members of an infected individual
should be tested. The dibucaine number is an additional test used in identifying
carriers.
see Cholinesterase
It has been suggested that lesser degrees of deficiency contribute to health problems
in western countries including subfertility, cancer and heart disease. Although New
Zealand soils are low in selenium, documented human deficiency is rare except when
there is another cause such as prolonged parenteral nutrition.
Seminal fluid
A. Post-vasectomy specimens
This is a test for sperm count only, not motility. The specimen should be delivered to
the laboratory on the day of collection but without the urgency necessary for fertility
specimens.
Most post-vasectomy specimens have a zero sperm count but a small percentage have
a low count of non-motile spermatozoa even months after successful surgery. They
are believed to be sequestered spermatozoa stored in the recesses of seminal vesicles
or other parts of the male GU system.
2. The specimen should be delivered to the main laboratory within 2-3 hours of
collection and preferably before 3pm. Many people collect the specimen at home
at 7-8am and deliver the specimen before work.
3. You should refrain from sexual intercourse or ejaculation for 3 days before
collecting the sample.
Interpretation
Volume correlates least well with fertility. A high volume (>6ml) can be
associated with oligospermia or a low volume with normal fertility.
Sensitivity/Specificity
As applied to a laboratory test, sensitivity refers to the ability of the test to detect a
condition or analyte. A test with a sensitivity of 97% will fail to detect the condition
in 3% of those who have it, i.e. there will be 3% false negatives.
Specificity is the ability of a test to give a positive result only when the condition or
analyte being tested for is present. A test with a specificity of 97% will give a false
positive result in 3% of persons tested. A test must have a high degree of specificity
when searching for an important or uncommon condition in a large population, e.g.
when searching for HIV in a community.
In carcinoid tumours (qv) the plasma serotonin levels are elevated but 24-hr urinary
5-HIAA is the test used in diagnosis.
SGOT
the old name for AST
SGPT
the old name for ALT
specimen: serum
ref. ranges: adult female 50-80 nmol/L
adult male 40-60 nmol/L
SHBG is a serum globulin that binds testosterone and, to a lesser extent oestradiol.
On its own, it has little diagnostic value but it is required when measuring the
biologically active free testosterone fraction as distinct from the 98% of total
testosterone which is bound and inactive.
Shigella
Mild cases are treated with oral rehydration alone but more severe infections may
require antibiotics – cotrimoxazole or ampicillin (not amoxycillin) or norfloxacin
(adults only) – and IV fluids. Shigellosis is a notifiable disease.
Shingles
conversion
SI Unit mass unit factor
alcohol 1 mmol/L = 4.5 mg/100ml 0.22
bilirubin 1 µmol/L = .06 mg/100ml 17.1
calcium 1 mmol/L = 4 mg/100ml 0.25
cholesterol 1 mmol/L = 38.5 mg/100ml 0.026
creatinine 1 mmol/L = 11.4 mg/100ml 0.088
glucose 1 mmol/L = 17.9 mg/100ml 0.056
potassium 1 mmol/L = 1 meq/L 1.0
protein 1 g/L = .1 g/100ml 10.0
sodium 1 mmol/L = 1 meq/L 1.0
triglyceride 1 mmol/L = 91 mg/100ml 0.011
urate 1 mmol/L = 16.7 mg/100ml 0.060
urea 1 mmol/L = 5.9 mg/100ml 0.17
Sickle cell haemoglobinopathies are hereditary disorders due to HbS, found in blacks
of African descent. The homozygous state (sickle cell disease) causes a chronic
haemolytic anaemia and during crises, episodes of pain and multi-system organ
damage. Heterozygotes (sickle cell trait) are free of clinical disease and have normal
red cell indices but HbS can be demonstrated by appropriate tests including Hb
electrophoresis.
Sideroblastic anaemia
Sjogren's syndrome
It may exist on its own or be associated with rheumatoid arthritis or other connective
tissue disease.
When collecting the swab, aim to get pus or exudate from the base of an actively
inflamed lesion. Remove scab if present and open infected blisters. Avoid getting
bacteria from normal skin. 80% of skin/wound/pus swabs in the Auckland
community grow Staph. aureus. Strep. pyogenes makes up most of the remainder.
The latter is the usual pathogen in impetigo and cellulitis.
% susceptibilities
fluclox amox-clav cefaclor pen eryth cotrim cipro tet
S.aureus¹ 93 93 93 12 85 99 100² 97
S. pyogenes 100 100 100 100 99 99 — 83
1. There has been an increase in MRSA in Auckland from 0.2% in 1990, 0.7% in 1993.
to 7% in 1998. MRSA is more common in South Auckland than in other areas of the region.
2. Quinolones are not recommended for treating S. aureus infection because the MIC's are
close to the cutoff for susceptibility and the common emergence of resistance.
Chronic leg and foot ulcers are commonly associated with vascular insufficiency,
and, in the diabetic foot, with loss of pain and touch sensation. Swabs usually show a
mixed growth of gram-positive cocci and gram-negative bacilli. Cellulitis confined to
the rim of the ulcer can be treated with an oral agent such as amoxycillin-clavulanate
but a spreading cellulitis, particularly in a diabetic foot, needs urgent admission for
parenteral antibiotics.
All chronic ulcers require careful daily cleansing with warm saline and debridement
of dead tissue down to a healthy base.
2. Punch biopsy
This technique is useful for:
• inflammatory dermatoses
• suspected basal or squamous cell carcinomas prior to definitive
treatment
3. Shave biopsy
This usually results in epidermis only or epidermis and superficial
dermis. Shave biopsy should not be used if there is any suspicion of
malignant melanoma. In acral sites (soles of feet, palms of hands)
usually only keratin is obtained in a shave biopsy.
B. Site selection
This is of critical importance particularly in:
• Inflammatory dermatoses — biopsy should be from a fully developed
lesion and if the lesions are in different stages of evolution, multiple
biopsies should be taken. Treated areas should be avoided.atypical
pigmented lesions
• Vesiculobullous lesions, ulcers, pustules — biopsies should be taken
from very early lesions and should include normal skin.
see Dermatophytes
Where skin tests are not feasible, serum RAST (qv) tests for specific allergens can be
used.
Preparation
The patient must discontinue antihistamines or sympathomimetics for three days.
Steroids and cromoglycate can be continued.
Method
A drop of dilute allergen is placed on the skin; a needle prick through the drop
introduces a minute amount of allergen into the dermis; if it encounters specific IgE
antibodies bound to mast cells, histamines are released and a wheal and flare develop.
Interpretation
A relatively common (1:1000) connective tissue disease which can affect a wide
variety of systems and is characterised by auto-antibodies directed against nuclear
components.
There is no single specific test but rather a list of diagnostic criteria. The American
Rheumatology Association (1982) recommend that if four of the following criteria
are positive, the diagnosis can be made:
During active SLE, complement (C3 & C4) are reduced and the ESR is raised.
Smear cells
specimen: serum
Values in the range 130-134 are common and sometimes difficult to explain. Below
130, an explanation must be sought.
The cause of the low serum sodium is water retention due to inappropriate secretion
of ADH in the face of a serum osmolality below 270 mosmol/L.
Sodium, urine
specimen: 24-hr urine, no preservative
ref. range: 40-220 mmol/day
In a well person, urine sodium output reflects dietary intake. A low output, <20
mmol/day, may be an indicator of a total body sodium deficit but interpretation
requires consideration of all fluid and electrolyte parameters.
Somatomedin C
Somatotropin
This outdated measure of urine concentration has been replaced by urine osmolality
(qv).
Specificity
see Sensitivity/Specificity
Sperm antibodies
Spermogram
Spherocytes
• congenital spherocytosis
• autoimmune haemolytic anaemia
• microangiopathic haemolysis
• severe burns
• after splenectomy
Splenectomy specimens
Sputum culture
Pneumonia If the patient can produce sputum – often a problem – the examination
is worthwhile provided it is collected before antibiotics are commenced.
Sputum cytology
Early morning deep cough specimens should be collected on 3 separate days and each
one delivered to the laboratory that day to prevent the cell deterioration that occurs if
specimens are stored for more than a few hours. Refrigeration at 4°C slows
deterioration. 65% of lung tumours are picked up by three good specimens and 85%
by five specimens.
Staphylococci
Coagulase-positive staphylococci
Staph. aureus The common pyogenic organism of skin and wound infections and a
variety of serious systemic infections. About 30% of normal people carry Staph.
aureus in their anterior nares.
% susceptibilities
fluclox amox-clav cef cotrim eryth pen
staph. aureus 93¹ 93 93 99 86 9
1. There has been a significant increase in the prevalence of MRSA in
Auckland in recent years.
2. Quinolones are not recommended for treating S. aureus infection
because the MIC's are close to the cutoff for susceptibility and
the common emergence of resistance.
• multi-resistant MRSA Until 1995 these were the only variety known. They
are resistant not only to penicillin and cephalosporins but also alternative oral
agents such as erythromycin, tetracycline and cotrimoxazole. They are found
infrequently but when identified require action:
MRSA Screening
This is done on patients coming from outside New Zealand for surgery or from parts
of New Zealand where there is known to be an MRSA problem.
Coagulase-negative staphylococci
The two main pathogens causing urethral or vaginal discharge and pain are Neisseria
gonorrhoeae and Chlamydia trachomatis. Collection of specimens is described under
Neisseria and Chlamydia. The list of sexually transmitted organisms includes:
• Candida species
• Chlamydia trachomatis
• Gardnerella vaginalis
• hepatitis B
• herpes simplex virus
• HIV
• HPV
• Neisseria gonorrhoeae
• syphilis (Treponema pallidum)
• Trichomonas vaginalis
It is essential that the sexual partner(s) be investigated and treated as well as the
person who presents with symptoms.
Sterile pyuria
see Urinalysis (routine biochemistry and microbiology) and UTIs (urinary tract
infections): white cells
Steroid estimations
This classical sign of lead poisoning (qv) is also a non-specific finding in other
haemopoietic disorders including aplastic anaemia, thalassaemia, myelodysplasia and
megaloblastosis.
ref. ranges:
These tests are used when searching for evidence of recent streptococcal infection in
suspected post-streptococcal glomerulonephritis (PSGN) or rheumatic fever (RF).
Serial tests should be done, looking for rising titres. A high level is more likely to be
significant and sustained levels may indicate persisting infection. PSGN or RF can
easily be over-diagnosed when an isolated, equivocal, titre is used as evidence.
Streptococci cause a wide spectrum of common diseases. Three species or groups are
commonly isolated.
1. Streptococcus pyogenes
% susceptible
pen amox-clav cef eryth tetra
Strep. pyogenes 100 100 100 99 80
2. Streptococcus pneumoniae
% susceptibilities
pen eryth tetra cotri chlor
Strep. pneumoniae 71 80 81 52 96
Pneumococcal vaccine
Splenectomised patients are at significant risk for invasive pneumococcal disease and
should receive vaccine.
Pneumococcal vaccine contains 23 of the most common serotypes and covers 90% of
strains causing invasive diseases. 90% of adults respond to a single dose. The
vaccine is also recommended for persons >65 years, persons at increased risk of
complications such as those mentioned above, immunocompromised patients,
including those with HIV. It is ineffective in children under the age of 2 years. The
vaccine is under utilised. Greater use will probably require a change in its funding.
see Enterococcus
Strongyloidiasis
Sulphaemoglobin
Sweat electrolytes
In the absence of DNA testing, this is the definitive test for cystic fibrosis (qv).
Sodium and chloride levels in the range 80-190 mmol/L are consistent with the
diagnosis.
The sweat specimen is collected into a patch of blotting paper taped to an area of skin
to which a weak electric current is applied. Sodium and chloride are present in sweat
in approximately equal concentrations. The test turns positive in affected infants at
age 3-5 weeks.
specimens: serum
– collect baseline specimen
– inject 0.25 mg Synacthen (synthetic ACTH) IM
– collect specimens ½ hr and 1 hr after Synacthen injection. The peak level is
usually reached at 1 hr rather than ½hr.
Indications:
Used in suspected Addison's disease or for assessment of adrenal reserve after long-
term steroid therapy.
Interpretation:
The criterion for adequate adernal reserve or Synacthen testing is a peak level of 700
nmol/L or more. The degree of rise is not useful to confirm or refute an adequatre
response.
A basal level >500 nmol/L almost always indicates adequate adrenal reserve unless
the patient is on steroid treatement or under severe stress.
In the rare situation where there is pituitary disease of recent onset, the Synacthen test
may be normal, becoming abnormal later as the adrenal atrophies.
Synovial aspirate
Synovial fluid examination provides definitive diagnosis of septic arthritis, gout and
pseudogout, and places other effusions into the broad categories of non-inflammatory
• volume
• Gram stain
• crystals — polarised light is used to look for the urate crystals of gout or the
pyrophosphate crystals of pseudogout.
Syphilis
Syphilis is uncommon in New Zealand and most genital ulcers have other aetiologies.
Where there is a possibility of syphilis, serological tests (see Treponemal serology
(STS, serological tests for syphilis)) should be performed. If a lesion is strongly
Elevated by:
Lowered by:
• hypothyroidism – but is a poor test for this
• T4 therapy — though T3 is usually within the reference range when T4 dose
is appropriate
• non-thyroidal illness see Thyroid disease — diagnosis and monitoring,
paragraph D1
• drugs : amiodarone (qv), propranolol, steroids,
• lithium, iodine in tonics or contrast medium
• hypopituitarism (secondary hypothyroidism)
specimen: serum
ref. ranges:
pmol/L
4 - 7 days 16 - 40
1 - 4 wks 15 - 35
1 - 12 mths 11 - 32
Over 1 year 10 - 24
pregnancy 1st trimester 10 - 23
2nd 10 - 19
3rd 8 - 19
Elevated by:
• hyperthyroidism
• T4 (Eltroxin) therapy — because the half-life is long, time of sampling for
monitoring is unimportant.
• non-thyroidal illness see Thyroid disease — diagnosis and monitoring,
paragraph D1
• drugs: amiodarone, NSAIDS, propranolol, steroids, iodine-containing contrast
medium, heparin
• heterophilic antibodies, protein-binding abnormalities see Thyroid disease —
diagnosis and monitoring, paragraph D2
• sub-acute thyroiditis – early stage see Thyroid disease — diagnosis and
monitoring, paragraph D4
• Hashimoto's thyroiditis – early stage see Thyroid disease — diagnosis and
monitoring, paragraph C4
• self-administration of T4 e.g. for attempted weight reduction
Lowered by:
Target cells
These are cells with a "target" appearance due to a stained centre within the normal
hypochromic zone. They are seen in liver disease, thalassaemia, after splenectomy
and in severe iron deficiency.
TB
TCT
see Anticonvulsants
Telopeptide
see N-telopeptide
Testosterone
specimen: serum
ref. ranges:
Note :
• These are peak values measured at 7-9 am. Late afternoon and evening values
can be substantially (20-30%) lower, especially in young men.
• The lower ends of these ranges are not well-defined. A total testosterone of
say 9 or 10 in a male may be transient or may be normal for that person.
Free testosterone, the biologically active fraction, is derived from total testosterone
using the value for SHBG which is the serum binding protein. Where the increase in
testosterone is small, as in minor degrees of hirsutism in the polycystic ovary
syndrome, it may be found that only the free testosterone is above its reference limit.
The male embryo has high levels of testosterone falling to female levels at time of
birth but with a second peak during the first few months of life. Throughout
childhood male levels are not much higher than in females until at about age 11 the
pubertal rise commences, reaching adult levels at about age 17. Levels decline
slowly from about age 40 on, the decline being more marked in free testosterone than
total testosterone which is partially sustained by a rise in SHBG.
About 50% of males aged over 60 have free testosterone levels below the young male
reference limit. Level of sexual activity and libido are not usually correlated with
testosterone levels until total testosterone falls below 8.
Decreased levels
• obesity
• alcoholism
• debilitating disease
• primary hypogonadism - LH is elevated
• secondary hypogonadism - hypopituitarism (qv)
• hyperprolactinaemia
• hypothyroidism
• haemochromatosis
• hepatic insufficiency
• drugs
– synthetic androgens
– steroid therapy
– high dose oestrogens
– phenothiazines and others
– oral contraceptives
Thalassaemias
Clinical presentation
The major thalassaemia syndromes usually come under specialist care early in life
with moderate or severe haemolytic anaemias.
The thalassaemia trait disorders, which are usually asymptomatic, will for the most
part be discovered incidentally on a routine blood film:
— the blood film may show other suspicious abnormalities; and the histogram of
red cell size distribution may show a pattern typical of thalassaemia.
When iron deficiency coexists with thalassaemia, the diagnosis may not become
apparent until iron replacement has been achieved.
The thalassaemias are complex and diverse and under certain circumstances may
require specialised DNA and globin chain analyses to characterise them fully. In
Alpha Thalassaemias
Each parent contributes two a genes giving a total of four. Alpha thalassaemia
results from deletion of 1 or more of these 4 genes.
--/aa two gene (cis) ± occas. more severe than trans.Asian type
--/-a three gene numerous HbH disease
--/-- four gene - - - intrauterine death
Beta thalassaemias
Beta thalassaemias arise from point mutations in the coding genes rather than
deletions and more than 300 mutations have been identified. The first thalassaemia to
be described, by Cooley in 1925, was severe ß thalassaemia found in a patient of
Mediterranean descent, thalassa being the Greek for sea.
Once a thalassaemia has been identified it is essential that the patient be told of the
diagnosis and that they should not be given iron unless there is coexisting iron
deficiency.
Testing of a partner and genetic counselling may be required for a woman planning a
family.
Theophylline (Nuelin)
specimen: serum
therapeutic range: 55-110 µmol/L
The therapeutic range refers to peak levels. The specimen is collected 4-6 hours after
the last dose for long-acting preparations, 2 hrs after those that are short-acting.
Thirst
see Polydipsia/polyuria
Threadworms
Swabs are taken from the tonsillar area for a sore throat, or the posterior pharyngeal
wall for sinus trouble so as to collect post-nasal discharge.
The most common indication for a throat swab is to detect Group A streptococcus (S.
pyogenes). Culture results take 1-2 days to be reported.
Rapid streptococcal antigen tests are not performed in the laboratory. Their general
use increases the cost of testing as it is commonly recommended that all patients with
a negative rapid antigen test require a culture.
9
A reduction in platelets below 150 x 10 /L. The lower the platelet count, the stronger
the possibility of spontaneous bleeding.
Thrombocytopenia in pregnancy can put the foetus at risk and should be referred for a
specialist opinion.
Causes of thrombocytopenia:
· leukaemias
Thrombocytosis
Refers to an increase in the platelet count above 450 x 109/L.
Transient reactive thrombocytoses up to about 800 x 109/L are common. Causes are:
• blood loss
• surgery, trauma
• infection, including viral infection
• other inflammatory disorders
• malignancy – an important cause of persistent thrombocytosis
• myeloproliferative disorders
• essential thrombocythaemias
• polycythaemia vera
• myelofibrosis
• myelodysplasia
see Hypercoagulability
Venous thromboembolism (VTE)
Antiphospholipid antibody syndrome (APS)
Thrombophilia
Thyroglobulin
specimen: serum
ref. range: <25 µg/L
Thyroglobulin antibodies
specimen: serum
ref. range: not present
Graves' disease and primary hypothyroidism are both autoimmune diseases and are
associated with a variety of antibodies.
These are the standard "thyroid antibodies" requested and they give the same
information; when only one is elevated, it is more likely to be anti-microsomal.
Elevated in:
· euthyroid normals – 10% have antibodies usually in low titre. Annual follow up
will show progression to thyroid disease in some, indicating that these elevations
can be a marker for an early autoimmune state.
This IgG antibody, formerly known as LATS, is the marker for autoimmune
thyrotoxicosis (Graves' disease).
TSH is the one-test screen for patients with non-specific symptoms such as
tiredness. A level between 0.4 and 4 mU/L gives 99% exclusion of hyper- or
hypothyroidism.
T4 is added:
• suspected hypopituitarism
The combination of clinical and laboratory features will indicate probable status
as hyperthyroid, hypothyroid or euthyroid.
B. Hyperthyroid states
1. Aetiology of thyrotoxicosis
Thyroid tests
Non-thyroid tests
C. Hypothyroid states
1. Primary hypothyroidism
• Thyroid tests
• Non-thyroid tests
– elevated cholesterol
– elevated triglyceride
– elevated CK due to myopathy
– elevated liver enzymes
– normocytic or macrocytic anaemia due to direct effect on
erythropoiesis
– macrocytosis due to associated pernicious anaemia
– iron-deficiency anaemia due to associated menorrhagia
– elevated creatinine
The dose range for thyroxine is usually in the range 0.05-0.15 mg/day,
depending on body weight. A healthy younger person weighing 70 kg
could start at 0.10 mg/day.
3. Pregnancy
5. Subacute thyroiditis
TSH is the thyroid screen test of choice – a level between 0.4 and 5 mU/L gives 99%
exclusion of hyper- or hypothyroidism.
The third generation assays now in common use measures down to 0.03 mU/L. A
level below this, described as an undetectable TSH, is strongly supportive of a
diagnosis of thyrotoxicosis.
TSH is elevated by
Thyroiditis, sub-acute
Thyrotropin
see TSH
Thyroxine
Tinea
see Dermatophytes
Tobramycin
TORCH(es) antibodies
A yeast which closely resembles Candida albicans (q.v.) in both symptoms and
treatment.
Total CO2
see Bicarbonate
Total protein
Toxic granulation
An ascarid worm found in dogs and passed on to young children who ingest egg-
contaminated dust and soil. Eggs passed in dog faeces are not infective and require 2-
5 weeks under favourable conditions to mature. Ingested mature eggs hatch,
releasing larvae which traverse gut mucosa and may migrate to any organ, in
particular eye and lung. Antibodies to Toxocara are common throughout the world
but clinical infections (visceral larva migrans) are rare. Eosinophilia, often marked,
may be present. A limited serology study in New Zealand revealed <5% of adults
and teenagers were seropositive.
Treatment is of unknown value.
Toxoplasma
specimen: serum
IgM antibodies become detectable 5 days after infection and remain for months or
occasionally years. A positive IgM result does not separate current from past
infection except when a rising titre can be demonstrated. Approximately 2% of
women tested antenatally are +ve for IgM but most do not have active infection.
IgG antibodies become positive 1-2 weeks after infection and remain positive for
life. A strongly rising titre over a 3-week interval is good evidence of current
infection. 30 - 60% of the population have IgG antibodies.
Toxoplasmosis in pregnancy
About one third of women acquiring toxoplasmosis during pregnancy will transmit
the parasite to the foetus. In the first trimester the incidence of infection is about 10%
but with a high risk of serious or fatal disease in the foetus. In the second and third
trimesters the foetal infection rate rises to 30% and 60%, respectively, but with less
serious effects in the foetus where the disease may not be apparent until later in
childhood with CNS impairment or chorioretinitis.
If antibodies were known to be present at least one month before conception, the
foetus will be safe.
Sometimes a mother will ask for toxoplasma tests during pregnancy and about 2% of
these will test +ve for IgM antibodies, most of them derived from pre-pregnancy
infections.
Transferrin
specimen: serum
ref. range: 2.4 - 3.6 g/L
Trephine biopsy
1. Screen test
The RPR and VDRL (venereal disease research lab) are the most widely used
of the older, non-specific reagin tests. They can be transiently positive in a
wide range of viral and autoimmune diseases as well as syphilis and yaws.
After successful treatment of syphilis, the RPR/VDRL titre declines and may
become negative.
The RPR/VDRL is used as a screening test for syphilis and for monitoring
response to treatment. A positive result may be due to:
• current infection – rare in New Zealand. The titre will nearly always be
>1:16
• past, inactive, treponemal infection – the titre is usually <1:16, often 1:1 or
1:2.
• SLE – the "biological false positive RPR" is found in 10-20% of SLE and
is one of the serological markers
• aging
The TPHA and FTA are much more specific for treponemal infections but
unexplained, weakly reactive, false positives of one or both tests are sometimes
found.
After a treponemal infection, the TPHA and FTA stay positive indefinitely
without indicating whether disease is current or past.
In true treponemal infections, all three tests, VDRL or RPR, TPHA and FTA,
will usually be clearly reactive.
Antibody tests cannot distinguish between yaws and syphilis infections which
are both due to Treponema pallidum species.
WHO attempted to eradicate yaws from the Pacific Islands in 1961 but without
success, there having been numerous new outbreaks since then.
Formerly used as a test for borderline hyperthyroidism but now replaced by sensitive
TSH estimation. In hyperthyroidism, the TSH response to TRH is reduced.
Trichinosis
Diagnostic tests include eosinophil count, CK, serological tests and muscle biopsy.
Trichophyton
see Dermatophytes
Tricyclic antidepressants
Triglyceride
specimen: serum
ref. range: <2.0 mmol/L (fasting)
Fasting specimens (>8 hours after food): The above comment not withstanding, it is
usual to measure triglyceride in the fasting state and with abstention from alcohol for
the previous 24 hours.
2. Secondary • obesity
• alcohol
• diabetes
• hypothyroidism
• liver disease, particularly obstructive
• nephrotic syndrome
• pancreatitis
• pregnancy
• significant illness
• drugs: oestrogen, oral contraceptives, beta blockers, corticosteroids,
thiazides, retinoic acid, anti-viral agents, valproic acid
A patient with a triglyceride above 10.0 mmol/L is at risk for acute pancreatitis and
requires immediate restriction of dietary fat and alcohol, treatment of any other
underlying cause such as diabetes, and addition of a triglyceride-lowering drug such
as a fibrate if other measures fail.
With massive hypertriglyceridaemias, serum can have the appearance and consistency
of cream. Often there is more than one aetiology, e.g. diabetes and alcohol.
Tri-iodothyronine
Trophoblastic disease
specimen: serum
ref. ranges: Troponin I <2.0 µg/L
Troponin T <0.1 µg/L
Elevation of one of the cardiac troponins, which are almost identical in their clinical
usage, is more sensitive and specific for myocardial infarction than CKMB.
Concentrations rise within 4 - 12 hours of commencement of cardiac pain and remain
elevated for 7 days in the case of TnI or 10 days for TnT.
If the specimen was obtained less than 12 hours after commencement of chest pain, a
follow up should be collected 6-12 hours after the first.
TnT can be elevated in chronic renal failure in the absence of known myocardial
damage whereas TnI is largely unaffected.
Absence of rise doesn't exclude ischaemic cause for chest pain — may warrant
specialist follow-up.
Trypsin, blood
Trypsin, faeces
An old and unsatisfactory test for cystic fibrosis in infants, now replaced by the blood
test
TSH
Indications
Method
When reading the test, the arm is palpated to define an area of induration and the
diameter of this induration, if present, is measured in mm transverse to the long axis
of the forearm.
Interpreting results
These are usually due to operator error, particularly reading errors where the area of
erythema rather than induration has been read.
Although a -ve Mantoux usually indicates that person has never been exposed to TB,
there are important exceptions.
• the person has had TB in the past but the immune response has faded.
• overwhelming infection or illness of any type, including overwhelming TB.
• patients with immune suppression – HIV, immunosuppressive drugs,
sarcoidosis, renal failure, malignancy, malnutrition.
• acute viral infections, recent live virus vaccinations.
• neonates.
• operator error, improperly stored PPD.
The positive predictive value is the % of people with a positive tuberculin reaction
who are actually infected with TB.
Figures are not available for New Zealand, but the Canadian figures below are
indicative. They are for young adults vaccinated with BCG after age 5.
The test has much stronger predictive power in recent immigrants from a TB endemic
country. In these, the prevalence of past or present TB infection was 50-60%.
see also MOH Guidelines for Tuberculosis Control in New Zealand, 1996.
Tuberculosis (TB)
One third of the world's population is infected with TB, the majority of them in the
developing world.
High risk groups are those who have arrived from Asia or the Pacific Islands in the
past few years and those with other family members who have been infected.
Specimens
Sputum ZN stain and culture of sputum is the most effective test for diagnosing
infectious TB. Three specimens should be examined, preferably early
morning on separate days. Automated liquid-based culture methods
grow TB from most smear-positive specimens within a week.
Treatment
– Pyrazinamide is now the most commonly used third initial drug. Tablets are
500 mg and common doses are 1500mg - 2000mg. Hepatotoxicity,
gastrointestinal tract disturbance and skin rash are seen.
– Ethambutol was the most usual oral third drug but has now been relegated.
Usual dosing is 15 mg/kg/day and tablets are 400mg and 100mg. At higher
doses it causes retrobulbar neuritis.
Haematologists, when doing blood counts, are interested in the cellular components
and therefore add an anticoagulant, usually EDTA, to prevent clotting.
Biochemists and immunologists are interested in serum components and use clotted
specimens. Sometimes, however, plasma is the preferred specimen rather than serum
and a heparin anticoagulant is used.
A further point is that blood cells are a living tissue and continue to live in the tube.
As the specimen stands at room temperature, red cells consume energy, converting
glucose to lactic acid thus reducing the blood glucose. These processes are slowed
but not prevented, by storage in a refrigerator. After a few hours, the red cells
become increasingly sick, releasing their potassium, haemoglobin, phosphate and
enzymes into the surrounding serum or plasma.
Types of tube
The colour of the stopper denotes the preservative or anticoagulant within the
vacutainer. Recently the trend has been to smaller volumes (10 or 7ml tubes
changing to 5ml) and from glass tubes with rubber stoppers to all-plastic. As
analytical systems evolve, the tubes change but currently, the tubes in use are:
Provides a clotted specimen from which serum can be poured. Used mainly for
immunology tests where antibodies are to be measured. It can be used for
biochemistry tests but the SST is preferred because of its superior qualities of
separation.
Citrate tube blue top (also called sodium citrate or buffered citrate)
Used for INRs and other coagulation tests. The tube must be allowed to fill
completely to achieve optimum citrate:blood ratio.
Used only for glucose. The SST or plain tube can be used for glucose provided the
specimen is analysed within 2 or at the most 4, hours. Fluoride is an enzyme poison
which blocks red cell metabolism and thus prevents the consumption of glucose.
Tumour markers
Because of their low specificity, most tumour markers are not used as screening tests
– there are just too many false positives.
Their main use is in monitoring treatment and progress in established disease but they
are also used when a particular malignancy is suspected on clinical grounds or when
the site of the primary lesion is unknown in disseminated malignancy.
Typhoid
These are collected particularly from lesions in the oral cavity suspected of
malignancy. Scrape the surface firmly with a wooden spatula or cytobrush. Fix at
least one slide with Cytofix as for a cervical smear. Another slide should be left to
air-dry if lymphoid neoplasia is suspected.
Units
Urate, serum
specimen: serum
0.42 mmol/L has been chosen as the upper end of the male range because this is the
level above which the risk of gout begins to rise from 1 in 1000 below 0.42 to 1in 20
at a level above 0.54. About 20% of Auckland males have a urate above 0.42.
0.36 mmol/L is used for women because on average their levels, before the
menopause, are 0.06 mmol/L lower than men. After menopause, levels in women
approach those in men and their risk of gout increases.
Elevated urate
Like cholesterol, baseline serum urate levels are genetically determined but elevated
by secondary factors:
Raised serum urate levels are contributory but not diagnostic. During an acute
attack of gout, serum urate may actually fall below the levels that will be
found between attacks.
Increased levels are due to high purine diet or endogenous over-production of urate.
Urea
specimen: serum
ref. range: < 4 yrs 1.4 – 5.4 mmol/L
> 4 yrs 2.6 – 7.7 mmol/L
Elevated by:
As a routine measure of renal function, creatinine has almost entirely replaced urea.
Nephrologists, however, measure urea as well as creatinine in dialysis patients, the
preferred urea level being below 20-30 mmol/L.
Urethral swabs
Male
Where there is a discharge, swabs for Chlamydia (qv) and gonococci (qv) should be
collected by the doctor at the time of examination. Alternatively, a specimen can be
collected by a male nurse or microbiologist at the laboratory – or, as a last resort, the
patient can be given swabs in one of our other rooms and asked to collect the
specimen himself. Our female nurses do not collect urethral specimens from males.
Female
The urethra should be swabbed for gonococci and Chlamydia when looking for STD.
Uric acid
A. Component tests
• bacterial count
• culture
• dipstick analysis
— protein
— red cells/Hb
— white cells as shown by leucocyte esterase activity
— gram-negative infection as shown by nitrite activity which
has excellent specificity but only 40-80% sensitivity for
infection
— glucose
— ketones
— bilirubin/urobilinogen
B. Interpretation
Sterile pyuria describes the finding of increased white cells but with no
bacterial growth on routine media.
Causes include:
• calculi
• age: elderly men and women may have pyuria, 20-40 WBC/cmm, and
sterile urine
4. Haematuria — red cells and/or free Hb have been detected in the urine.
Normal urine has less than 10 x 106 red cells/L which is approximately at
the limit of detection of a urine dipstick.
When the dipstick is positive for blood we do a red cell count using phase
contrast microscopy. There are 8 possible results : nil, 10, 25, 50, 100,
250, 500, >500. At about the 500 level, blood just becomes visible to the
naked eye. Results below this, detectable only by dipstick or microscope,
are termed microhaematuria.
40% of our routine urinalyses test positive for blood. Most of these are
microhaematuria and most are transient and benign. Sometimes the
dipstick is positive but the red cell count nil. On very rare occasions this is
due to haemoglobinuria (qv) or myoglobinuria but for practical purposes it
can be treated as if it were microhaematuria with red cells present.
These include the haematurias that have an identifiable benign cause, e.g. UTI
and which disappear with elimination of the cause.
• vigorous exercise
Some workers recommend examination of a fresh urine (less than 1 hour old)
under phase-contrast microscopy to allow distinction of dysmorphic (distorted)
red cells, which are entirely of glomerular origin, from eumorphic (normal-
looking) red cells which can originate anywhere in the urinary tract. Presence
The dipstick detects mainly albumin and may entirely miss other proteins such
as free light chains.
6. Casts Hyaline protein casts are found relatively frequently and are not
regarded as significant. Granular (white cell) and red cell casts on the other
hand are strong indicators for renal disease, particularly glomerular disease.
7. Glucose Positives indicate diabetes or renal glycosuria (qv) and require blood
glucose estimations as follow-up.
Urine cytology
Urine, pigmented
Causes include:
Red urine
• haematuria
• phenolphthalein – containing purgatives, which are red when alkaline. Fresh
urine is acid but turns alkaline on standing
• diet – beetroot, rhubarb turn red on standing, particularly with coexisting iron
deficiency
• some porphyrias – turn red/brown on standing
• haemoglobinuria (qv)
• myoglobinuria (qv)
Orange/brown urine
Yellow urine
Blue/green urine
Milky urine
• infection
• chyluria (qv)
• nephrotic syndrome
• oxaluria
Factitious additives (something the patient has added) are another source of
pigmentation.
Some tests require special preservatives, the commonest being 10mls of concentrated
acid. It is absolutely essential that the patient be warned that any apparently
innoccuous-looking fluid in the bottom of the bottle may be dangerous and corrosive.
The fluid must not be touched and children must not be allowed to get near the bottle.
Urobilinogen in urine
Urobilinogen is sometimes reported positive on routine urinalysis by dipstick. Viral
hepatitis and haemolytic disease should be excluded by checking liver enzymes,
reticulocyte count and haptoglobins. If these are normal, the positive urobilinogen
can be ignored.
Uroporphyrins
see Porphyrias
see Urinalysis (routine biochemistry and microbiology) and UTIs (urinary tract
infections)
Vaginal discharge
specimen: routine swab collected from 5 cm inside the vagina and placed in
transport medium.
specimen: serum
Serum levels are generally unhelpful and should not be done except to check
compliance. There is no accepted therapeutic range though levels below 300 µg/L
are said to be more likely to be associated with poor seizure control and levels above
700 more likely to be associated with hepatotoxicity.
Variant lymphocytes
see Lymphocytes
Variation
= variance
Analytical variation
This is the "noise" in a method, the sum of the technical imperfections that prevent it
producing a perfect result every time. Modern methods are vastly better than those in
use 20, or even 10, years ago and analytical variation is generally overshadowed by
biological variation.
Biological variation
Serum concentrations in the body are controlled by physiological mechanisms which
are, not surprisingly, never perfect. This biological variation is typically about twice
as large numerically as analytical variation though this varies from test to test.
Here are some indicative examples of biological variation for results within the
reference range:
• sodium ± 4 mmol/L
It should be noted that reference ranges are made wide enough to allow for variation
and that is one reason they are such crude indicators of what is "normal".
Coefficient of variation (CV) The CV is the commonly used method for expressing
the analytical or biological variation of a test.
If the serum is tested 100 times, 95% of the analyses will lie in the range
2.40 ± 2cv
= 2.40 ± 2x2%
= 2.40 ± 4%
= 2.40 ± 0.10 mmol/L
= 2.30 – 2.50 mmol/L
The same virus is responsible for both chicken-pox (varicella) and shingles (herpes
zoster) the latter being a reactivation of dormant virus acquired during a childhood
attack of chickenpox.
Diagnosis is clinically obvious in most cases but the virus can be identified by a
fluorescent antibody applied to a suitable smear.
To collect the specimen, open a fresh vesicle, scrape the base with a spatula, smear on
a slide, air-dry and send to the lab in a labelled envelope.
Although varicella-zoster takes several weeks to grow, culture can be attempted. Use
the special viral transport swab (Virocult).
VDRL
Primary heparin therapy is essential for VTE and until recently this was administered
by continuous intravenous infusion in hospital followed by outpatient warfarin. Low
molecular weight heparins (qv) are now available which enable many patients with
both DVT and PE to be treated on an outpatient basis. The low molecular weight
heparin (LMWH) with dose adjusted for body-weight, is given subcutaneously once
or twice each day for a minimum period of five days followed by warfarin. Using
this approach more than 75% of patients will not require admission to hospital.
The duration of warfarin therapy depends on a variety of factors including extent and
site of DVT (above or below the knee), and whether there is a temporary precipitating
risk factor such as surgery, immobilisation or pregnancy:
Vibrio alginolyticus
Vibrio cholerae
The causative organism of cholera. Occasionally found in Asian immigrants and on
rare occasions in visitors to endemic areas. Fluid replacement is paramount.
Treatment shortens the illness, reduces the volume of stools and fluid requirements,
and decreases organism secretion. Treatment options are ciprofloxacin, 1g as a single
dose; norfloxacin, 400mg 12-hourly for 3 days; or doxycycline, 300mg as a single
dose.
Vibrio parahaemolyticus
Found in New Zealand and Japan in shell fish which, when eaten raw, can cause food
poisoning. Treatment is fluid replacement. Most infections are self-limiting. Severe
disease may benefit from treatment, using a cholera regime, but the benefit is likely to
be small.
see Hirsutism/virilism
Virology
Despite the vast spectrum of disease caused by viruses, they are less often
investigated by the laboratory than bacteria. They are harder to grow, harder to treat
and the trivial viral infections tend to be self-limiting.
Specific tests are described under the alphabetic entry for each disease.
Virus or its antigen Specimens can be faeces, throat swab, serum, vesicle fluid or
CSF.
Antibodies IgM antibodies usually indicate current infection. IgG antibodies indicate
past or present infection.
Viscosity
Blood viscosity is increased in polycythaemia vera, macroglobulinaemia and in the
late stages of myeloma. The test is not much used now.
Vitamin B12
specimen: serum
ref range: 160-600 pmol/L
140-160 pmol/L, borderline low
Causes include:
• vegetarian diet
If there are no haematological abnormalities and the patient seems healthy, there is
less urgency. The level may be normal for that person or it may indicate early
deficiency. It is a matter of clinical judgement and patient choice whether to
investigate further at once; or follow-up in 6 months or so; or, for the person who
believes in vitamin supplements, start a course of oral vitamin B12 or multivitamin
supplements. There is also the group of patients who have unshakeable faith in B12
by injection.
The elderly often have low B12 and folate levels and may benefit from supplements.
Vitamin C
Vitamin D
specimen: serum
ref. range: 25-hydroxy-cholecalciferol 14-76
µg/L
1a, 25-dihydroxy-cholecalciferol 18-62
ng/L
Vitamin D levels decline with advancing age and many very elderly people,
particularly women living in rest-homes, have levels low enough to contribute
significantly to decrease in bone density.
There is debate whether vitamin D levels should be measured routinely in this group.
Most will have low levels and it is probably more cost-effective to provide the
cheaper forms of vitamin D supplement with calcium.
(sunlight on skin)
(in liver)
25-hydroxy-cholecalciferol
(in kidney)
Vitamin K
Deficiencies of vitamin K and Factors II, VII, IX and X can be due to pre-hepatic or
hepatic causes.
The Echis ratio (qv) helps distinguish between pre-hepatic and hepatic causes.
The prothrombin ratio (PR) and its standardised presentation, INR, are used to
monitor vitamin K-dependent factor deficiencies and the anticoagulant effect of
warfarin.
VTE
see Venous thromboembolism (VTE)
vWD, discovered in 1926 and the commonest inherited bleeding disorder, is due to a
defect in the plasma von Willebrand factor (vWF) causing a secondary abnormality of
platelet adhesion.
von Willebrand Factor (vWF) Measured as the von Willebrand factor antigen
(vWF:Ag). This large glycoprotein normally stabilises factor VIIIC and is variably
reduced in vWD. vWF is essential for normal adhesion of platelets and therefore for
a normal bleeding time.
Collagen binding assay (CBA) The functional assay which measures the vWF's
ability to bind to collagen. A discrepancy between the vWF antigen and the CBA
suggests a variant form of vWD.
• Bleeding time
• Platelet count
• APTT
• FVIII : C
• FVIII : C
• vWF Activity
• CBA
• Blood group
• Ristocetin platelet aggregation (not routinely performed in all patients)
One or more of these tests are usually abnormal in patients who have vWD but the
results may vary in the same patient with repeat testing. It is essential that the
patient not be taking drugs which could affect the bleeding time. Most frequent
offending agents are aspirin or other NSAIDs. Many conditions such as pregnancy,
hypo- or hyperthyroidism, uraemia, recent exercise, infection or diabetes can affect
the FVIII:C activity and vWF antigen levels. Individuals with blood group O have
significantly reduced levels of the vWF:Ag and vWF activity compared with blood
groups A, B or AB.
Normal Ν Ν Ν Ν Ν
Type 1 vWD Ν−↓ ↓ ↓ ↓ Ν
Type 3 vWD Absent Absent Absent Absent —
Weight loss
Consider:
• thyrotoxicosis
• diabetes
• eating disorder
• malignancy
• HIV
Widal test
see Salmonella antibodies (Widal Test)
Wound swabs
see Skin and wound swabs.
Where clinical details indicate a deep-seated infection, anaerobic cultures will be set
up.
WR (Wasserman Reaction)
replaced by VDRL/RPR
Wuchereria bancrofti
see Filariasis
X-match
see Crossmatch
d-Xylose test
A test formerly used for malabsorption but now discontinued because of lack of
specificity and sensitivity.
All STS (serological tests for syphilis: RPR/VDRL, TPHA FTA) are positive in those
who have had yaws which is endemic in the Pacific, and positive STS in a Pacific
Islander are often due to yaws.
Yeasts
Yeasts grow readily from ordinary bacterial swabs and cultures. Candida albicans
(qv), the principle human pathogen, is a member of the normal flora of the gut. Other
species of Candida are also common and may cause clinical infection.
Yersinia enterocolitica
Yersinia spp. are frequently present in the intestinal tract of wild and domesticated
clinically healthy birds and animals. In New Zealand, Y. enterocolitica has been
recovered from pigs, cattle and dogs. Processed meat ready for sale has only rarely
be shown to be contaminated with Yersinia. The source of most cases of Yersinia
infection is unknown.
Some patients develop an abdominal pain syndrome which may last for weeks. The
most likely cause for this is intra-abdominal lymphadenopathy.
Infections tend to be sporadic rather than epidemic and are found world-wide. It can
cause terminal ileitis which mimics acute appendicitis presenting as right lower
quadrant pain, fever and leucocytosis. Some patients develop a reactive arthritis.
Zarontin (ethosuxiamide)
see Anticonvulsants
Zinc, plasma
specimen: blood, trace metal tube, patient must be fasting
ref. range: 12 - 20 - µmol/L
Health food shops sell zinc supplements to boost the immune system and cure colds
and topical preparations may promote healing of wounds and ulcers. Plasma levels
do not give useful information in these situations - better to try the products and see if
they work.
More serious levels of zinc deficiency are found in developing countries where the
high phytate content of cereal diets binds zinc. In 1961a group of anaemic clay-
eating Iranian dwarfs with rough dry skin and absent secondary sex characteristics
were shown to be zinc deficient and their troubles corrected by oral zinc sulphate.
Zinc toxicity has been described in welders inhaling zinc oxide fumes causing metal-
fume fever or brass chills.