Quick Compendium of Clinical Pathology [4 ed.] 0891896678, 9780891896678

Table of contents :
Cover
Contents
1. Chemistry
1.1 The liver
1.1.1 Liver function tests
1.1.1.1 Aspartate aminotransferase & alanine aminotransferase (liver transaminases)
1.1.1.2 Lactate dehydrogenase
1.1.1.3 Alkaline phosphatase
1.1.1.8 Prothrombin time (PT)
1.1.1.9 Gammaglobulins
1.1.2 Neonatal jaundice t1.5
1.2 The pancreas
1.2.1 Pancreatic enzymes
1.2.1.1 Amylase
1.2.1.2 Lipase
1.2.2 Tests of pancreatic exocrine function
1.2.2.1 Secretincholecystokinin test
1.2.2.2 Noninvasive tests
1.3 The heart
1.3.1 Myocardial markers
1.3.1.1 Cardiac enzymes
1.3.1.2 Troponin
1.3.1.3 Myoglobin
1.3.1.4 B type natriuretic peptide
1.3.2 Acute coronary syndrome/Acute myocardial infarction
1.3.3 Myocarditis
1.4 Proteins
1.4.1 Major serum proteins t1.7
1.4.1.1 Albumin
1.4.1.2 Prealbumin
1.4.1.3 c^-antitrypsin (AAT)
1.4.1.4 d-j-acid glycoprotein
1.4.1.5 a2-macroglobulin
1.4.1.6 Ceruloplasmin
1.4.1.7 Haptoglobin
1.4.1.8 Transferrin
1.4.1.9 Fibrinogen
1.4.1.10 C reactive protein
1.4.2 Patterns in serum protein electrophoresis
1.4.2.1 Normal serum f1.2
1.4.2.2 Bisalbuminemia
1.4.2.3 a^antitrypsin (AAT) deficiency f1.3
1.4.2.4 Nephrotic syndrome
1.4.2.5 Acute inflammation f1.4
1.4.2.6 P-Y bridging
1.4.2.7 Monoclonal gammopathy f1.5-f1.8
1.4.3 CSF protein electrophoresis
1.4.4 Urine protein electrophoresis f1.10
1.4.4.1 Glomerular proteinuria pattern
1.4.4.3 Overflow proteinuria pattern
1.4.4.2 Tubular proteinuria pattern
1.4.5 Cryoglobulinemia
1.4.5.1 Cryoglobulins
1.4.5.2 Mixed cryoglobulinemia (types II & III)
1.4.6 Laboratory methods
1.4.6.1 Protein electrophoresis
1.4.6.2 Immunofixation & immunotyping
1.5 Acid-base & electrolytes
1.5.1 Sodium
1.5.1.1 Hyponatremia
1.5.1.2 Hypernatremia
1.5.2 Potassium
1.5.2.1 Potassium measurement
1.5.2.2 Hypokalemia
1.5.2.3 Hyperkalemia
1.5.3 Calcium
1.5.3.1 Calcium measurement
1.5.3.2 Hypercalcemia
1.5.3.3 Hypocalcemia t1.11
1.5.4 Acid-base disorders
1.5.4.1 Definitions
1.5.4.2 Henderson-Hasselbalch equation
1.5.4.3 Methods
1.5.4.4 Classifying an acid-base disorder
1.5.6 Renal function
1.5.6.1 Renal function tests
1.5.7 Laboratory screening for chronic kidney disease
1.5.8 Laboratory evaluation in acute renal failure
1.6 Laboratory tests in pregnancy
1.6.1 Amniotic fluid bilirubin
1.6.2 Human chorionic gonadotropin
1.6.3 Prenatal screening for trisomy & neural tube defects
1.6.4 Assessing risk of preterm birth
1.6.5 Determination of fetal lung maturity
1.6.6 Laboratory evaluation of diseases in pregnancy
1.6.6.1 Physiologic changes & altered reference ranges in
1.6.6.2 Medical conditions of particular importance in pregnancy
1.7 Toxicology
1.7.1 Pharmacokinetics
1.7.1.1 Half-life
1.7.1.2 Free vs bound
1.7.1.3 Volume of distribution (Vd)
1.7.2 Drugs of abuse screening (forensic toxicology)
1.7.2.1 Cocaine
1.7.2.2 Opiates
1.7.2.3 Barbiturates
1.7.2.4 Amphetamines and methamphetamine
1.7.2.5 Phencyclidine
1.7.2.6 Ethanol
1.7.3 Overdose
1.7.3.1 General aspects of laboratory evaluation
1.7.3.2 Toxic alcohol (ethylene glycol, methanol & isopropyl alcohol) poisoning t1.23
1.7.3.3 Lead poisoning (plumbism)
1.7.3.4 Carbon monoxide poisoning t1.24
1.7.3.5 Acetaminophen (Tylenol) poisoning
1.7.3.6 Cyanide poisoning
1.7.3.7 Salicylate (aspirin)
1.7.3.8 Arsenic
1.7.3.9 Tricyclic antidepressants
1.7.3.10 Organophosphates & carbamates
1.7.3.11 Mercury
1.7.4 Therapeutic drug monitoring
1.7.4.1 Digoxin
1.7.4.2 Procainamide
1.7.4.3 Aminoglycosides
1.8 Lipids & carbohydrates
1.8.1 Lipids
1.8.1.1 Brief review of lipids
1.8.1.2 Methods
1.8.1.3 Lipid disorders
1.8.2 Carbohydrates
1.8.2.2 Hypoglycemia
1.8.2.3 Types of diabetes mellitus
1.8.2.4 Diagnosis & monitoring
1.8.2.5 Diabetic ketoacidosis (DKA)
1.8.2.6 Hyperosmolar hyperglycemic state
1.9 Tumor markers
1.9.1 Prostate specific antigen
1.9.1.1 Prostate cancer screening
1.9.1.2 Adjunctive PSA indices
1.9.2 Colorectal carcinoma screening and CEA
1.9.3 Thyroglobulin
1.9.4 Cancer antigen 125
1.9.5 CA27.29 & 15-3
1.9.6 CA19-9
1.9.7 a fetoprotein
1.9.8 Human chorionic gonadotropin (hCG)
1.9.9 p2 microglobulin
1.9.10 Alkaline phosphatase
1.9.11 Markers of neuroendocrine tumors
1.9.11.1 Carcinoid tumors
1.9.11.2 Markers of medullary thyroid carcinoma
1.9.11.3 Paraganglioma & pheochromocytoma
1.9.11.4 Neuroblastoma
1.9.12 Urine markers for urothelial carcinoma
1.10 Endocrine
1.10.1 Thyroid chemistry
1.10.1.1 Thyroid function tests (TFTs) t1.32
1.10.1.2 Hyperthyroidism
1.10.1.3 Hypothyroidism
1.10.1.4 Neonatal hypothyroidism
1.10.1.5 Nonthyroidal illness syndrome (euthyroid sick syndrome)
1.10.1.6 Exogenous estrogens
1.10.1.7 Medications
1.10.2 Adrenal cortex
1.10.2.1 Tests
1.10.2.2 Cushing syndrome (hypercortisolism)
1.10.2.3 Addison disease (primary adrenal insufficiency)
1.10.2.4 Secondary adrenal insufficiency
1.10.2.5 Primary aldosteronism
1.10.2.6 Congenital adrenal hyperplasia t1.33
1.10.2.7 Renal artery stenosis
1.10.3 Pituitary
1.10.3.1 Growth hormone
1.10.3.2 Follicle stimulating hormone & leutinizing hormone
1.10.3.3 Prolactin
1.10.3.4 Adrenocorticotrophic hormone
1.10.3.5 Antidiuretic hormone
1.11 Postmortem chemistries
1.11.1 Samples
1.11.2 Analytes
1.11.2.1 Glucose
1.11.2.2 BUN & creatinine
1.11.2.3 Sodium & chloride
1.11.2.4 Potassium
1.11.2.5 Digoxin
1.11.2.6 Tryptase & the postmortem diagnosis of anaphylaxis
1.12 Body fluids
1.12.1 Urine
1.12.1.1 Macroscopic examination
1.12.1.2 Urine chemistry
1.12.1.2.1 Glucose
1.12.1.3 Bilirubin & urobilinogen
1.12.1.4 Nephrolithiasis (kidney stones)
1.12.1.5 Urine microscopy
1.12.1.6 Urine microscopy in the patient with acute renal failure
1.12.2 Cerebrospinal fluid
1.12.2.1 Cerebrospinal fluid chemistry
1.12.2.2 Cerebrospinal fluid microscopy
1.12.3 Pleural fluid
1.12.3.1 Pleural fluid chemistry
1.12.3.2 Pleural fluid microscopy
1.12.4 Peritoneal fluid (ascites fluid)
1.12.4.1 Peritoneal fluid chemistry
1.12.4.2 Peritoneal fluid microscopy
1.12.5 Synovial fluid
1.12.5.1 Synovial fluid chemistry
1.12.5.2 Synovial fluid microscopy
1.13 Selected readings
Books
Additional journals
2. Blood Banking/Transfusion Medicine
2.1 Blood donation
2.1.1 Donor history & physical examination t2.1, t2.2
2.1.1.1 Registration & donor identification
2.1.1.2 History & physical
2.1.2 Autologous donor requirements
2.1.3 Apheresis donor requirements
2.1.3.1 Plasmapheresis
2.1.3.2 Plateletpheresis
2.1.3.3 For RBC apheresis & multicomponent donations
2.1.4 Blood obtained from therapeutic phlebotomy
2.1.5 Collecting blood from donor
2.1.5.1 Information given to donor
2.1.5.2 Blood collection system
2.1.5.3 Volume drawn
2.1.5.4 After collection
2.1.5.5 Donor adverse reactions t2.3
2.1.6 Laboratory testing of donor blood
2.1.6.1 ABO & Rh testing
2.1.6.2 Antibody screen
2.1.6.3 Infectious disease screening
2.2 Pretransfusion procedures t2.6
2.2.1 Routine pretransfusion procedures
2.2.1.1 Blood collection from recipient
2.2.1.2 ABO & Rh testing of recipient blood
2.2.1.3 The antibody screen
2.2.1.4 Comparison with prior transfusion records
Pretransfusion procedures>Routine pretransfusion procedures
2.2.1.5 The crossmatch
2.2.1.6 Selection of compatible products t2.7-t2.9
2.2.1.7 Visual inspection of blood prior to issue
2.2.1.8 Transfusion
2.2.1.9 Pediatric considerations
2.2.2 Nonroutine pretransfusion procedures: positive antibody screen or crossmatch
2.2.2.1 The reagent red cell panel t2.10
2.2.2.3 The nonroutine panel
2.2.2.4 Special techniques
2.2.2.5 Likelihood of finding compatible blood
2.2.2.6 The positive crossmatch
2.2.2.7 Illustrative nonroutine cases t2.14, t2.15
2.2.2.8 Other unusual findings
2.2.3 Autoantibodies in the blood bank
2.2.3.1 When to consider autoantibody
2.2.3.2 Warm reacting autoantibodies
2.2.3.3 Cold reacting autoantibodies t2.17
2.2.3.4 Mixed type autoantibodies
2.2.3.5 Paroxysmal cold hemoglobinuria (PCH) t2.18
2.2.3.6 Blood banking considerations with a cold autoantibody
2.2.37 Mechanisms of drug induced positive DAT t2.19
2.3 Transfusion in special clinical circumstances
2.3.1 Transfusion in sickle cell disease
2.3.1.1 Unique considerations
2.3.1.2 ASPEN syndrome
2.3.1.3 Indications for emergency transfusion/exchange transfusion in sickle cell disease
2.3.1.4 Indications for elective chronic transfusion
2.3.1.5 Alloimmunization in multiply transfused sickle cell patients
2.3.2 Shock: fluid resuscitation,
emergency release & massive transfusion
2.3.2.1 Shock caused by acute blood loss
t2.20
2.3.2.2 Principles of fluid resuscitation t2.21
2.3.2.3 Emergency release
2.3.2.4 Massive transfusion
2.4 Therapeutic apheresis
2.4.1 Definition
2.4.2 Indications
2.4.3 Replacement fluid
2.4.4 Vascular access
2.4.5 Medication interactions
2.5 Neonatal & intrauterine transfusion
2.5.1 Special blood requirements for neonatal & intrauterine transfusion
2.5.1.1 Red cells for intrauterine or neonatal exchange transfusion
2.5.1.2 Plasma or plasma containing products (platelets)
2.5.2 Maternal immune thrombocytopenic purpura (ITP)
2.5.2.1 There is a risk of neonatal thrombocytopenia
2.5.2.2 Management
2.5.3 Neonatal alloimmune thrombocytopenia (NAIT)
2.5.3.1 Caused by maternal antiplatelet alloantibodies that cross the placenta & cause destruction of fetal platelets
2.5.3.2 NAIT can affect the first pregnancy
2.5.3.3 Management
2.5.4 Hemolytic disease of the fetus & newborn (HDF/HDN)
2.5.4.1 Rh HDF/HDN
t2.26
2.5.4.2 Non-Rh HDF/HDN
2.5.4.3 Lab testing for HDF/HDN
2.6 Blood components t2.29
2.6.1 Red blood cell components
2.6.1.1 Preparation & storage
2.6.1.2 Storage lesion
2.6.1.3 Transport and reissue
2.6.1.4 Whole blood
2.6.1.5 Frozen red blood cells
2.6.1.6 Indications
2.6.1.7 Contraindications
2.6.2 Platelets
2.6.2.1 Preparation & storage
2.6.2.2 Indications
2.6.2.3 Contraindications
2.6.2.4 Dosing
2.6.2.5 Prevention of platelet transmitted infection
2.6.3 Granulocyte concentrates
2.6.3.1 Preparation & storage
2.6.3.2 Indications
2.6.3.3 Dosing
2.6.4 Plasma
2.6.4.1 Preparation & storage
2.6.4.2 Indications
2.6.4.3 Dosing
2.6.5 Cryoprecipitated antihemophilic factor (cryoprecipitate or cryo)
2.6.5.1 Preparation & storage
2.6.5.2 Indications
2.6.5.3 Dosing
2.6.6 Selected plasma derivatives
2.6.6.1 Rh immune globulin (Rhlg)
2.6.6.2 Factor VII concentrate
2.6.6.3 Factor VIII (fVIII) concentrate
2.6.6.4 Factor IX (fIX) concentrate
2.6.7 Manipulated products
2.6.7.1 Irradiated products
2.67.2 Leukoreduced products
2.67.3 Washed products
2.7 Blood group antigens
2.7.1 ABO & the carbohydrate antigens
27.1.1 Antigens
2.7.1.2 ABO phenotypes
2.7.1.3 Review of the relationship of Le, Se, H, I, i & ABO
2.7.1.4 ABO antibodies
2.7.2 P/GLOB blood group
2.7.2.1 Antigens & phenotypes
27.2.2 Antibodies
2.7.3 Rh
2.7.3.1 Rh antigens & phenotypes
2.7.3.2 Rh antibodies
2.7.4 Kidd blood group system
2.7.4.1 Kidd antigen
2.7.4.2 Kidd antibodies
2.7.5 Duffy
2.7.5.1 Duffy antigens
27.5.2 Duffy antibodies
2.7.6 MNS system
2.7.6.1 MNS antigens
27.6.2 MNS antibodies
2.7.7 Kell blood group
2.77.1 Kell antigens
2.11.2 Kell antibodies
2.7.8 Lutheran
2.7.8.1 Lutheran antigens
2.7.8.2 Lutheran antibodies
2.7.9 Human leukocyte antigens (HLA)
2.7.9.1 HLA is encoded on the major histocompatibility complex (MHC), a group of loci on 6p
2.8 Transfusion complications
2.8.1 Suspected transfusion reaction
2.8.1.1 Clinical signs & symptoms
2.8.1.2 What to do
2.8.2 Types of transfusion complications
2.8.2.1 Febrile, nonhemolytic transfusion reactions (FNHTRs)
2.8.2.2 Allergic transfusion reactions
2.8.2.3 Acute hemolytic transfusion reactions
2.8.2.4 Delayed hemolytic transfusion reactions (DHTR) & delayed serologic transfusion reactions (DSTR)
2.8.2.5 Bacterial contamination (transfusion transmitted sepsis)
2.8.2.6 Transfusion associated graft vs host disease
2.8.2J Transfusion associated acute lung injury (TRALI)
2.8.2.8 Posttransfusion purpura (PTP)
2.8.2.9 Platelet refractoriness
2.8.2.10 Infections t2.40
2.8.2.11 Transfusion associated metabolic derangements
2.8.3 Records t2.42
2.8.3.1 Blood bank regulatory authority
2.9 Selected readings
2.9.1 Books
Other references
3. Microbiology
3.1 Clinical syndromes & causative agents
3.1.1 Urinary tract infection (UTI)
3.1.1.1 Characteristics
3.1.1.2 Laboratory evaluation
3.1.2 Infectious diarrhea
3.1.2.1 Characteristics
3.1.2.2 Laboratory evaluation
3.1.2.3 Infectious diarrhea in immunodeficiency
3.1.3 Pneumonia
3.1.3.1 Characteristics
3.1.3.2 Laboratory evaluation
3.1.4 Infective endocarditis (IE)
3.1.4.1 Characteristics
3.1.4.2 Laboratory evaluation
3.1.5 Meningitis
3.1.5.1 Characteristics
3.1.6 Prosthetic joint infections
3.1.6.1 Characteristics
3.1.6.2 Laboratory evaluation
3.1.7 Vectors t3.4
3.2 Virology
3.2.1 Viral structure & classification t3.5
3.2.1.1 Obligate intracellular organisms
3.2.1.2 Surrounded by a capsid
3.2.1.3 Envelope
3.2.2 Laboratory evaluation
3.2.3 DNA viruses
3.2.3.1 Adenoviridae: adenovirus; no envelope, double
stranded, linear DNA
3.2.3,2 Hepadnaviridae: hepatitis b virus (HBV); enveloped, double stranded, circular DNA with single strand breaks
3.2.3.3 Herpesviridae: enveloped; double stranded, linear DNA t3.10
3.2.3.4 Parvoviridae: parvovirus B19; no envelope, single stranded, linear DNA
3.2.3.5 Papovaviridae: no envelope, double stranded, circular DNA
3.2.3.6 Poxviridae: enveloped, double stranded, linear DNA
3.2.3.6.1 Variola: causes smallpox
3.2.4 Positive sense RNA viruses
3.2.4.1 Coronaviridae
3.2.4.2 Flaviviridae: enveloped, single stranded RNA
3.2.4.3 Picornaviridae: no envelope, single stranded RNA
3.2.4.4 Retroviridae: enveloped, single stranded RNA
3.2.4.5 Togaviridae: enveloped, single stranded RNA
3.2.4.6 Caliciviridae: Norwalk virus; no envelope, single stranded RNA
3.2.4.7 Astroviridae
3.2.4.8 Hepeviridae: nonenveloped, single stranded RNA
3.2.5 Negative sense RNA viruses
3.2.5.1 Bunyaviridae: enveloped, single stranded RNA
3.2.5.2 Orthomyxoviridae; influenza; enveloped, single stranded RNA
3.2.5.3 Paramyxoviridae: enveloped, single stranded RNA
3.2.5.3.1 Parainfluenza: croup
3.2.5.3.5 Human metapneumovirus (hMPV)
3.2.5.4 Rhabdoviridae: rabies vims; enveloped, single stranded RNA
3.2.5.5 Filoviridae: enveloped, single stranded RNA
3.2.5.6 Arenaviridae
3.2.6 Reoviridae: double stranded RNA; no envelope
3.2.7 Other viruses
3.27.1 Hepatitis D virus
3.27.2 Prions
3.2.8 Vaccines
3.2.9 Implicated viruses by disease states
3.2.9.1 Pregnancy
3.3 Parasitology
3.3.1 Laboratory methods
3.3.1.1 Direct examination: body sites and possible parasites recovered are summarized in t3.14
3.3.1.2 Serology
3.3.1.3 Culture
3.3.1.4 Molecular methods
3.3.2 Protozoa
3.3.2.1 Gastrointestinal protozoa i3.9
3.3.2.2 Blood and tissue protozoa
3.3.2.2.1 Babesia
3.3.3 Helminths
3.3.3.1 Tapeworms (Cestodes) i3.24
3.3.3.2 Flukes (Trematodes) i3.25
3.3.3.3 Roundworms (Nematodes)
3.3.4 Additional pearls of parasitology t3.18-t3.20
3.4 Mycology
3.4.1 Fungal structure
3.4.1.1 Characteristics
3.4.1.2 2 morphologic forms: yeasts and molds
3.4.1.3 Subcellular structure
3.4.1.4 Hyphal pigment
3.4.2 Diagnostic techniques
3.4.3 Yeasts
3.4.3.4 Black piedra
3.4.3.5 Trichosporon
3.4.3.5.1 Diseases
3.4.4 Dimorphic fungi t3.21
3.4.4.1 Characteristics of thermally dimorphic fungi
3.4.5 Dermatophytes & other superficial mycoses
3.4.5.1 Diseases
3.4.5.2 Diagnosis
3.4.5.3 Organisms
' 3.4.6 Dematiaceous molds & other
I a subcutaneous infections
3.4.6.1 Background
3.4.6.2 Diseases
3.4.6.3 Other subcutanous infections
3.4.7 Hyaline molds
3.4.8 Zygomycetes
3.4.8.4 Treatment—prompt to prevent tissue necrosis. This is an emergency!
3.4.9.1 Background
3.4.9.2 Disease: pneumonia
3.4.9.3 Diagnosis
3.4.10 Prototheca
3.4.10.1 Background
3.4.10.2 Disease: protothecosis
3.4.10.3 Lifecycle
3.4.10.4 Diagnosis
3.4.10.5 Treatment
3.4.11 Notes about antifungal agents
3.5 Bacteriology
3.5.1 Specimen processing
3.5.1.1 Gram stain t3.22
3.5.2 Gram positive cocci
3.5.2.1 Staphylococcus: Gram positive cocci in clusters; catalase positive f3.4
3.5.2.2 Streptococcus and Enterococcus: Gram positive cocci in pairs or chains; catalase negative; Lancefield typing can be performed by latex agglutination i3.72, f3.5, t3.24
3.5.3 Gram positive rods
3.5.3.1 Spore forming Gram positive rods
3.5.4 Gram negative cocci
3.5.5 Gram negative rods
3.5.5.1 Enterobacteriaceae (the enterics)
3.5.5.2 Nonfermentative bacilli: do not ferment glucose (Red/ Red in TSI); most are environmental
3.5.5.4 HACEK organisms
3.5.6 Anaerobes
3.5.6.2 Clostridium: Gram positive rod, spore forming
3.5.7 Spirochetes
3.5.7.2 Leptospira
3.57.3 Borrelia
3.5.7.4 Spirillum minus: tightly coiled, small spirochete with bipolar tufts of flagella
3.57.5 Intestinal spirochetes
3.5.8 Chlamydia
3.5.8.1 Background: obligate intracellular pathogen
Bacteriology>Chlamydia
3.5.8.2 Chlamydia trachomatis
3.5.8.3 Chlamydophila psittaci
3.5.8.4 Chlamydophila pneumoniae
3.5.9 Rickettsia t3.32
3.5.9.1 Background
3.5.9.2 Rickettsia rickettsii: Rocky Mountain spotted fever
3.5.9.3 Rickettsia akari\ rickettsialpox
3.5.9.4 Rickettsia prowazekii: epidemic typhus
3.5.9.5 Rickettsia typhi: endemic typhus (murine typhus)
3.5.9.6 Orientia (formerly Rickettsia) tsutsugamushi; scrub typhus
3.5.12 Bartonella: pleomorphic, Gram negative bacilli
3.6 Mycobacteria
3.6.1 Background
3.6.2 Laboratory evaluation
3.6.2.1 Specimen collection and processing
3.6.2.1.1 Sputum
3.6.2.2 Direct examination
3.6.2.5 Identification from positive culture
3.6.3.5 Susceptibility testing
3.6.4 Nontuberculous Mycobacteria:
categorized based on Runyon classification
3.6.4.4 Rapid growers (Runyon Group IV): growth on solid media in -val)
4.1.3.2 Hemoglobin C (P6 glu—>lys)
4.1.3.3 Hemoglobin E (P6 glu—>lys)
4.1.3.4 Hemoglobins D&G
4.1.3.5 Hemoglobin Lepore
4.1.3.6 Hemoglobin constant spring (HbCS)
4.1.3.7 Altered oxygen affinity hemoglobins
4.1.3.8 Unstable hemoglobins
4.1.3.9 Methemoglobin (Hi, hemoglobin)
4.1.4 Thalassemia
4.1.4.2 a thalassemia syndromes
4.1.4.3 p thalassemia syndromes
4.1.4.5 Hereditary persistence of fetal hemoglobin
4.1.5 Immune hemolytic disorders
4.1.5.1 Warm autoimmune hemolytic anemia
4.1.5.2 Cold autoagglutinins
4.1.5.3 Paroxysmal cold hemoglobinuria (PCH)
4.1.5.4 Cryoglobulinemia
4.1.5.5 Paroxysmal nocturnal hemoglobinuria
4.2 Disorders of marrow production
4.2.1 Iron deficiency
4.2.2 Folate & vitamin B12 t4.11, t4.12
4.2.2.1 Folate
4.2.2.2 Vitamin B12
4.2.2.3 Effects of B12 and folate deficiency
4.2.2.4 Diagnosis of folate deficiency
4.2.2.5 Diagnosis of B12 deficiency
4.2.3 Anemia of chronic disease
4.2.4 Sideroblastic anemia
4.2.5 Congenital dyserythropoietic anemia
4.2.6 Fanconi anemia
4.2.7 Dyskeratosis congenita (Zinsser-Engman- Cole syndrome)
4.2.8 Pure red cell aplasia (PRCA)
4.2.8.1 Congenital PRCA (Diamond-Blackfan syndrome)
4.2.8.2 Acquired PRCA
4.2.8.3 Parvovirus B19 causes transient arrests of RBC production in healthy children and adults
4.2.8.4 Transient erythrocytopenia of childhood (TEC)
4.2.9 Congenital amegakaryocytic thrombocytopenia (CAMT)
4.2.10 Thrombocytopenia with absent radii syndrome
4.2.11 Congenital neutropenia
(Kostmann syndrome) & cyclic neutropenia
4.2.12 Shwachman-Diamond syndrome
4.2.13 Myelokathexis (& WHIM syndrome)
4.2.14 Autoimmune neutropenia
4.2.15 Aplastic anemia
4.2.16 Approach to the diagnosis of quantitative abnormalities
4.2.16.1 Anemia
4.2.16.3 Neutrophilia
4.2.16.4 Lymphocytosis
4.2.16.5 Monocytosis
4.2.16.6 Eosinophilia
4.2.16.7 Neutropenia (agranulocytosis)
4.2.16.8 Lymphopenia
4.2.16.9 Monocytopenia
4.2.16.10 Thrombocytopenia
4.3 Neoplastic hematopathology
4.3.1 B cell neoplasms
4.3.1.1 General clinical considerations
4.2.16.11 Thrombocytosis
4.3.1.2 Small lymphocytic lymphoma/chronic lymphocytic leukemia
4.3.1.3 Mantle cell lymphoma
4.3.1.4 Follicular lymphoma
4.3.1.5 Marginal zone lymphoma
4.3.1.7 Prolymphocytic leukemia
4.3.1.8 Lymphoplasmacytic lymphoma/Waldenstrom macroglobulinemia
4.3.1.9 Heavy chain disease
4.3.1.10 Diffuse large B cell lymphoma
4.3.1.12 Immunodeficiency associated lymphoproliferative disorders
4.3.1.13 Burkitt lymphoma/leukemia
4.3.2 Precursor neoplasms (lymphoblastic leukemia & lymphoma), B and T
4.3.2.1 General features
4.3.2.3 B acute lymphoblastic leukemia/lymphoblastic lymphoma with recurrent genetic abnormalities t4.32
4.3.2.4 T acute lymphoblastic leukemia
4.3.2.2 Precursor B acute lymphoblastic leukemia/ lymphoblastic lymphoma, not otherwise specified
4.3.2.5 Acute leukemia with mixed lineage
4.3.3 Plasma cell neoplasms
4.3.3.1 Plasma cell myeloma/multiple myeloma
4.3.3.2 Plasma cell leukemia
4.3.3.3 Solitary plasmacytoma (SP)
4.3.3.4 Monoclonal gammopathy of unknown significance
4.3.3.5 Osteosclerotic myeloma (POEMS syndrome)
4.3.4 T cell neoplasms
4.3.4.1 Peripheral T cell lymphoma, NOS
4.3.4.2 Adult T cell leukemia/lymphoma
4.3.4.3 Angioimmunoblastic T cell lymphoma
4.3.4.4 Anaplastic large cell lymphoma, ALK+
4.3.4.5 T cell large granular lymphocytic leukemia
4.3.4.7 Aggressive NK cell leukemia
4.3.4.8 Nasal type natural killer/T cell lymphomas
4.3.4.9 Enteropathy associated T cell lymphoma
4.3.4.10 Hepatosplenic T cell lymphoma
4.3.4.11 Subcutaneous panniculitic T cell lymphoma
4.3.4.12 Cutaneous T cell lymphoma, mycosis fungoides, and Sezary syndrome
4.3.5 Hodgkin lymphoma
4.3.5.1 Nodular lymphocyte predominant Hodgkin lymphoma
4.3.5.2 Classic Hodgkin lymphoma
4.3.6 Myeloid neoplasms
4.3.6.1 Assessment
4.3.6.2 Myelodysplastic syndromes
4.3.6.3 Myelodysplastic/myeloproliferative neoplasms
4.3.6.3.1 Chronic mylomonocytic leukemia (CMML)
4.3.6.5 Myeloid & lymphoid neoplasms with eosinophilia with abnormalities of PDGFRa, PDGFR/i, or FGFR1
4.3.6.6 Acute myelogenous leukemia
4.3.6J Myeloid neoplasms with germline predisposition
4.3.6.8 Blastic plasmacytoid dendritic cell neoplasm
4.3.6.9 Mast cell neoplasms
4.4 Methods
4.4.1 Red blood cell indices
4.4.1.1 Manual techniques
4.4.1.2 Automated techniques
4.4.1.3 Counting reticulocytes
4.4.2 Leukocyte indices
4.4.2.1 Total leukocyte count
4.4.2.2 Leukocyte differential
4.4.3 Platelet indices
4.4.4 Detection of normal & variant hemoglobins
4.4.4.1 Rapid detection of hemoglobin S
4.4.4.2 Detection of hemoglobin F
4.4.4.3 Hemoglobin electrophoresis
4.4.4.4 High pressure liquid chromatography (HPLC)
4.4.4.5 Molecular methods for hemoglobin identification
4.4.4.6 Hemoglobin oxygen saturation
4.4.5 Histochemistry & cytochemistry
4.4.5.1 Wright stain
4.4.5.2 Cytochemical stains for typing blasts t4.48
4.4.5.3 Leukocyte alkaline phosphatase score
4.4.6 Immunophenotyping
4.4.6.1 Antigens
Methods>lmmunophenotyping
4.4.6.2 Immunophenotypic evolution in hematolymphoid cells
4.4.7 Conventional cytogenetics & molecular techniques
4.4.7.1 Molecular examination of lymphocytes
4.4.8 Bone marrow biopsy
4.4.8.1 Sites of hematopoiesis
4.4.8.2 Peripheral blood
4.4.8.3 Bone marrow aspirate & touch imprints
4.4.8.4 Bone marrow biopsy & clot section
4.5 Selected readings
4.5.1 Books
Additional journal articles
5. Coagulation
5.1 Hemostasis
5.1.1 Normal hemostasis occurs in 3 steps
5.1.1.1 Primary hemostasis
5.1.1.2 Contribution of the blood vessel
5.1.1.3 Platelet activation
5.1.1.4 Plasma coagulation (fibrin formation)
5.1.1.6 Fibrinolysis
5.2 Laboratory evaluation of hemostasis
5.2.1 Laboratory evaluation of platelets
5.2.1.1 The bleeding time
5.2.1.2 PFA100
5.2.1.3 Platelet aggregometry
5.2.2 Laboratory evaluation of coagulation
5.2.2.1 Activated clotting time
5.2.2.2 Activated partial thromboplastin time (aPTT)
5.2.2.3 Heparin assay (antifactor Xa assay)
5.2.2.4 Bethesda assay (coagulation factor inhibitor assay)
5.2.2.5 D-dimer & fibrin degradation products
5.2.2.6 Factor assays (II, V, VII, VIII, IX, X, XI, XII)
5.2.27 Fibrinogen assay
5.2.2.8 Prothrombin time
5.2.2.9 Thrombin time (TT)
5.3 Excessive bleeding (hemophilia)
5.3.1 Laboratory evaluation f5.4
5.3.1.1 Clinical clues
5.3.1.2 Morphologic examination of platelets
5.3.2 Platelet disorders t5.8
5.3.2.1 Inherited platelet disorders
5.3.2.2 Platelet storage pool disorders
5.3.2.3 Glanzmann thrombasthenia
5.3.2.4 von Willebrand disease (vWD)
5.3.2.5 Acquired platelet disorders
5.3.3 Coagulation defects t5.10, t5.11
5.3.3.1 Inherited factor deficiencies
5.3.3.2 Fibrinogen defects: afibrinogenemia, hypofibrinogenemia & dysfibrinogenemia
5.3.3.3 Acquired factor deficiencies
5.3.3.4 Disseminated intravascular coagulation
5.3.4 Nonhemostatic causes of excessive bleeding
5.3.4.1 Vascular & connective tissue disorders
5.4 Thrombosis & thrombophilia
5.4.1 Clinical considerations
5.4.1.1 Clinical clues
5.4.1.2 Laboratory evaluation
5.4.2 Specific causes of thrombophilia
5.4.2.1 Activated protein C resistance (factor V Leiden)
5.4.2.2 Prothrombin variant (prothrombin G20210A mutation)
5.4.2.3 Antithrombin (AT) deficiency
5.4.2.4 Protein C & Protein S deficiency
5.4.2.5 MTHFR gene mutation & hyperhomocysteinemia
5.4.2.6 Paroxysmal nocturnal hemoglobinuria
5.4.27 JAK2 mutation
5.4.2.8 Antiphospholipid syndrome t5.15
5.4.2.9 Heparin induced thrombocytopenia (HIT)
5.4.2.10 Thrombotic thrombocytopenia purpura (TTP)
5.5 Therapeutic agents & monitoring
5.5.1 Anticoagulants
5.5.1.1 Warfarin (coumadin)
5.5.1.2 Other oral anticoagulants
5.5.1.3 Unfractionated heparin (UH)
5.5.1.4 Low molecular weight heparin
5.5.1.5 Fondaparinux (arixtra)
5.5.1.6 Direct thrombin inhibitors (DTIs)
5.5.2 Antiplatelet agents
5.5.2.1 Aspirin
5.5.2.2 Thienopyridines
5.5.2.3 Dipyridamole
5.5.2.4 GPIIb/llla receptor antagonists
5.6 Selected readings
5.6.1 Books
Additional journal articles
6. Immunology
6.1 Immune system
6.1.1 B cells
6.1.1.1 B cells originate & mature in the marrow in a stepwise process t6.1
6.1.1.2 Immunoglobulin (Ig)
6.1.1.3 Immunoglobulin genes
6.1.2 T cells
6.1.2.1 T cells undergo stepwise maturation in the thymus
6.1.2.2 T cell receptor (TCR)
6.1.3 NK cells
6.1.4 Antigen presenting cells
6.1.5 Granulocytes
6.1.5.1 Neutrophils
6.1.5.2 Basophils & mast cells
6.1.5.3 Eosinophils
6.1.6 Complement
6.1.6.1 Effects
6.1.6.2 Pathways f6.3
6.1.7 Human leukocyte antigens (HLAs)
6.1.7.1 HLA genes are categorized into classes
6.1.7.2 Each MHC complex is closely linked and inherited
6.2 Evaluation of immune function
6.2.1 Screening tests
6.2.1.1 History and physical examination
6.2.2 Global tests of immune system
6.2.2.1 Cell counts
6.2.2.2 Radiographs
6.2.3 Specific testing of B cell function
6.2.3.1 Specific antibody response, eg, to vaccine
6.2.3.2 g levels
6.2.3.3 RAST (radioallergosorbent test)
6.2.4 Specific testing of T cell function
6.2.5 Testing NK cell function
6.2.6 Testing neutrophil function
6.2.7 Testing complement
6.2.7.1 CH50
6.2.7.2 Antigenic assays are undertaken for quantitation of specific complement components
6.2.8 HLA testing
6.2.8.1 Used primarily in
6.2.8.2 The complement dependent cytotoxicity (CDC) assay is the gold standard for
6.2.8.3 Mixed lymphocyte culture (MLC)
6.2.8.4 Cross reactive antigen groups (CREGs)
6.2.8.5 Public antigens
6.2.8.6 DNA assays
6.2.8.7 Transplantation testing
6.2.8.8 Transplant rejection
6.3 Primary immunodeficiency disorders
6.3.1 B cell defects
6.3.1.1 Bruton (X linked) agammaglobulinemia
6.3.1.2 Common variable immunodeficiency (CVID)
6.3.1.3 Selective IgA deficiency
6.3.1.4 Hyper IgE syndrome (Job syndrome)
6.3.2 T cell defects
6.3.2.1 DiGeorge syndrome
6.3.2.2 Severe combined immunodeficiency (SCID)
6.3.2.3 Hyper IgM syndrome (X linked immunodeficiency with hyper IgM)
6.3.2.4 Wiskott-Aldrich syndrome (WAS)
6.3.2.5 Ataxia telangiectasia (Louis-Bar syndrome)
6.3.2.6 Chronic mucocutaneous candidiasis
6.3.2.7 Duncan disease (X linked lymphoproliferative disease)
6.3.3 Neutrophil/phagocytic defects
6.3.3.1 Chronic granulomatous disease (CGD)
6.3.3.2 Chediak-Higashi syndrome
6.3.3.3 May-Hegglin anomaly
6.3.3.4 Alder-Reilly anomaly
6.3.3.5 Pelger-Huet anomaly
6.3.3.6 Jordan anomaly
6.3.4 Complement deficiencies
6.4 Autoimmunity & rheumatologic disease
6.4.1 Pathophysiology
6.4.1.2 Triggering agents include both microorganisms & medications
6.4.1.3 Laboratory testing, general
6.4.1.4 Autoantibody detection by immunofluorescence
6.4.1.5 Anti-nuclear antibodies (ANA)
6.4.1.6 Antibodies to cytoplasmic constituents
6.4.1.7 Other tests for autoimmune diseases
6.4.2 Autoimmune diseases
6.4.2.1 Systemic lupus erythematosus (SLE)
6.4.2.2 Rheumatoid arthritis
6.4.2.3 Seronegative spondyloarthropathies
6.4.2.4 Celiac disease
6.4.2.5 Progressive systemic sclerosis (scleroderma)
6.4.2.6 lgG4 related sclerosing disease
6.4.27 Autoimmune hepatitis (AIH)
6.4.2.8 Primary biliary cirrhosis (PBC)
6.4.2.9 Primary sclerosing cholangitis (PSC)
6.4.2.10 Sjogren syndrome (SS)
6.4.2.11 Vasculitis
6.4.2.12 Inflammatory myopathies
6.4.2.13 Myasthenia gravis (MG)
6.4.2.14 Familial Mediterranean fever (FMF)
6.4.3 Hypersensitivity reactions
6.4.3.1 Type I hypersensitivity (immediate type hypersensitivity)
6.4.3.2 Type II hypersensitivity (antibody mediated cellular cytotoxicity)
6.4.3.3 Type III hypersensitivity
6.4.3.4 Type IV hypersensitivity (delayed type hypersensitivity)
6.5 Selected readings
7. Molecular Pathology
7.1 Brief review of molecular biology
7.1.1 The structure of nucleic acids
7.1.1.4 Types of nucleic acids
7.1.2 Nucleic acid modifying enzymes
7.1.2.1 Polymerase
7.1.2.2 Ligase
7.1.2.3 Nuclease
7.1.3 Mitochondrial DNA
7.1.3.1 Mitochondrial genome
7.1.3.2 Heteroplasmy/homoplasmy
7.1.3.3 Maternal inheritance
7.1.4 Gene expression
7.1.4.1 Cell signaling
7.1.4.2 Genes
7.1.4.3 Chromosome structure & nomenclature
7.1.4.4 Transcription & its regulation
7.1.4.5 Translation & its regulation
7.1.5 DNA replication & cell division
7.1.5.1 DNA replication
7.1.5.2 Cell cycle
7.1.5.3 Mitosis
7.1.5.4 Meiosis
7.1.6 Classification of genetic anomalies
7.1.6.1 Classification schemes
7.1.6.2 Function
7.1.6.3 Structure
7.1.6.4 Effect on organism
7.1.7 Patterns of inheritance
7.1.7.1 Inherited vs acquired genetic disorders
7.1.7.2 Inheritance patterns
7.2 Techniques & applications
7.2.1 Cytogenetics & karyotyping
7.2.1.1 Preparation of cells
7.2.1.2 Preparation of chromosomes
7.2.2 Molecular techniques
7.2.2.1 Isolation of nucleic acid
7.2.2.2 Restriction enzymes
7.2.2.3 Gel electrophoresis
7.2.2.4 Blotting
7.2.2.5 Hybridization techniques
7.2.2.6 Amplification techniques
7.2.27 DNA sequencing
7.2.3 Applications
7.2.3.1 Clonality assessment in lymphoid neoplasms
7.2.3.2 Chimerism in engraftment, parentage testing, & forensic identity testing
7.2.3.3 Pharmacogenomics
7.2.3.4 Practical aspects of molecular pathology
7.3 Genetics of nonneoplastic disease
7.3.1 Renal
7.3.1.1 Inherited nephritic syndrome
7.3.1.2 Inherited nephrotic syndrome
7.3.1.3 Inherited tubular disorders
7.3.1.4 Polycystic kidney disease
7.3.1.5 Sporadic & multifactorial congenital renal disorders
7.3.2 Cardiovascular
7.3.2.1 Channel conduction disorders
7.3.2.2 Myocardial disorders
7.3.2.3 Structural cardiac disorders as a part of a larger genetic syndrome
7.3.3 Endocrine
7.3.3.1 Adrenal cortex
7.3.3.2 Pituitary gland
7.3.3.3 Parathyroid gland
7.3.3.4 Thyroid gland
7.3.3.5 Diabetes mellitus
7.3.4 Gastrointestinal, hepatobiliary & pancreatic
7.3.4.1 Hirschsprung disease
7.3.4.2 Osler-Weber-Rendu syndrome (hereditary hemorrhagic telangiectasia)
7.3.4.3 Microvillus inclusion disease
7.3.4.4 Multifactorial disorders & syndromic disorders affecting the Gl tract
7.3.4.5 Biliary fibrocystic diseases (Caroli disease & congenital hepatic fibrosis)
7.3.4.6 Syndromic paucity of bile ducts (Alagille syndrome, arteriohepatic dysplasia)
7.3.47 Hereditary hemochromatosis
7.3.4.8 Wilson disease (hepatolenticular degeneration)
7.3.4.9 a1 antitrypsin deficiency
7.3.4.10 Bilirubin excretion disorders
7.3.4.11 Inherited pancreatitis
7.3.5 Neuromuscular
7.3.5.1 Central neurodegenerative disease
7.3.5.2 Peripheral neuropathy
7.3.5.3 Skeletal muscle diseases
7.3.5.4 Congenital hearing loss
7.3.6 Disorders of mitochondria
7.3.6.1 Background
7.3.7 Microdeletion disorders t7.11
7.4 Genetics of neoplastic disease
7.4.1 Gastrointestinal tract tumors
7.4.1.1 Colorectal adenocarcinoma
histology suggestive of MSI-high tumor
7.4.1.2 Gastrointestinal stromal tumor
7.4.2 Pancreatic tumors
7.4.2.1 Ductal adenocarcinoma
7.4.3 Hepatobiliary tumors
7.4.3.1 Hepatocellular carcinoma
7.4.3.2 Cholangiocarcinoma
7.4.4 Breast cancer
7.4.4.1 HER2 (Neu, ERB-B2)
7.4.4.2 TP53 tumor suppressor gene
7.4.4.3 Steroid receptors
7.4.4.4 BRCA associated tumors
7.4.4.5 Other inherited influences on breast cancer
7.4.4.6 Molecular classification of breast carcinoma (gene expression profiling)
7.4.5 Genitourinary tumors
7.4.5.1 Renal cell carcinoma syndromes
7.4.5.2 Sporadic renal cell carcinoma
7.4.5.3 Wilms tumor
7.4.5.4 Urothelial (transitional cell) carcinoma
7.4.5.5 Testicular tumors
7.4.6 Soft tissue & bone
7.4.6.1 Ewing sarcoma family of tumors
7.4.6.2 Neuroblastoma
7.4.6.3 Rhabdomyosarcoma
7.4.6.4 Synovial sarcoma
7.4.6.5 Low grade fibromyxoid sarcoma/hyalinizing spindle tumor with giant rosettes
7.4.6.6 Tumors of adipocytes
7.4.7 Head & neck tumors
7.4.7.1 Squamous cell carcinoma
7.47.2 Salivary gland tumors
7.47.3 Thyroid
7.4.8 Skin tumors
7.4.8.1 Melanoma
7.4.8.2 Dermatofibrosarcoma protuberans (DFSP)
7.4.9 Central nervous system tumors
7.4.9.1 Gliomas
7.4.9.2 Retinoblastoma
7.4.9.3 Meningioma
7.4.9.4 Embryonal tumors
7.4.10 Pulmonary tumors
7.4.11 Gynecologic tumors
7.4.11.1 Inherited gynecologic tumor syndromes
7.4.11.2 Cervix
7.4.11.3 Gestational trophoblastic disease
7.4.12 Other tumor syndromes
7.4.12.1 Tuberous sclerosis complex (Bourneville syndrome)
7.4.12.2 Nevoid basal cell carcinoma syndrome (Gorlin Goltz syndrome)
7.4.12.3 Neurofibromatosis type 1 (von Recklinghausen disease)
7.4.12.4 Neurofibromatosis type 2 (bilateral acoustic neuroma syndrome)
7.4.12.5 Li-Fraumeni syndrome
7.4.12.6 Aniridia/WAGR syndrome
7.4.12.7 Beckwith-Wiedemann syndrome
7.4.12.8 Chromosomal breakage syndromes
7.4.12.9 PTEN related disorders: Cowden syndrome, Bannayan-Riley-Ruvalcaba syndrome & Proteus syndrome
7.4.12.10 Carney complex
7.5 Selected readings
7.5.1 Books
7.5.2 Online references
Additional journal references
8. Medical Directorship
8.1 Legislation & regulation, agencies & oversight
8.1.1 Legislation & regulations relating to laboratories
8.1.1.1 Clinical Laboratory Improvement Amendment of 1988
t8.1 Clinical Laboratory Improvement Amendments levels of test complexity
8.1.1.2 Medical devices & biologies
8.1.1.3 Medicare, Medicaid & the prospective payment system
8.1.1.4 Billing & reimbursement
8.1.1.5 Direct billing law, physician self referral law (Stark law)
8.1.1.6 The Privacy Act & the Privacy Rule (HIPAA)
8.1.1.7 The Occupational Safety & Health Administration (OSHA)
8.2 Financial considerations in the laboratory
8.2.1 Types of costs f8.1 & calculation of the breakeven point
8.2.2 Budgeting
8.3 Statistical considerations in the laboratory
8.3.1 Definitions
8.3.1.1 Gaussian distribution, estimates of central tendency & estimates of variation
8.3.1.2 Reliability: analytical accuracy & precision
8.3.1.3 Clinical sensitivity & specificity
8.3.1.4 Predictive value
8.3.1.5 Relative risk
8.3.2 Diagnostic accuracy: receiver operating characteristic curves
8.3.2.1 Diagnostic accuracy
8.3.2.2 Receiver operating characteristic curves
8.3.3 Reference intervals
8.3.3.1 Purpose of reference intervals
8.3.3.2 Establishing & adopting reference intervals
8.4 Implementation of new methods
8.4.1 Overview
t8.3 Validation plan checklist
8.4.2 Elements of method verification
8.4.2.1 Calibration & calibration verification
8.4.2.2 Precision & establishment of quality control ranges
8.4.2.3 Accuracy, inaccuracy (bias) & method comparison
8.4.2.4 Analytic specificity, interference & carryover
8.4.2.5 Analytical sensitivity, limit of detection & functional sensitivity
8.4.2.6 Linearity, analytical measuring range & clinical reportable range
8.4.27 Specimen stability
8.4.2.8 Information systems
8.4.2.9 Written procedures
8.4.2.10 Education of laboratory staff & clinical staff
8.5 Quality management
8.5.1 Definitions
8.5.1.1 Quality management and quality control
8.5.2 Statistical quality control
8.5.2.1 Traditional QC
8.5.2.2 Alternatives to traditional QC
8.5.3 Proficiency testing (external quality assessment)
8.5.3.1 Overview
8.6 Nonanalytic variables in laboratory medicine: preanalytic & postanalytic
8.6.1 Preanalytic variables
8.6.1.1 Patient identification
8.6.1.2 Age
8.6.1.3 Gender
8.6.1.4 Food intake
8.6.1.5 Exercise
8.6.1.6 Cigarette smoking
8.6.1.7 Posture
8.6.1.8 Time of day
8.6.1.9 Tourniquet
8.6.1.10 Order of draw
8.6.1.11 Storage & transport conditions
8.6.1.12 Serum vs plasma
8.6.1.13 Underlying hematologic malignancy
8.6.2 Postanalytic variables
8.6.2.1 The postanalytic phase
8.6.2.2 Result reporting
8.6.2.3 Critical values reporting
8.7 Selected readings
Books
Additional journal references
Index
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R
S
T
U
V
W
X
Y
Z

Citation preview

ASCP QUICK COMPENDIUM OF

CLINICAL PATHOLOGY 4E

Editor-in-Chief

Daniel D Mais, MD Associate Professor Director of Surgical Pathology University of Texas Health San Antonio, Texas

Acknowledgement I a m fo rtu n a te to h a v e h a d D r J a m e s L K e lle y a s m en to r, a p a th o lo g is t w ith g re a t s k ill, tire le s s n e s s , a n d e n th u s ia s m . I a m g ra te fu l to m y p u b lis h e r, J o s h u a W e ik e rs h e im e r, w h o s a w th e v a lu e in th is id e a a n d a s s is te d m e th ro u g h to its c o m p le tio n . I a m in d e b te d to D r D a v id F K e re n fo r h is te a c h in g a n d e n c o u ra g e m e n t. I th a n k E m ily fo r h e r a s s is ta n c e , frie n d s h ip , a n d lo v e , a n d I d e d ic a te th is b o o k to o u r fo u r c h ild re n : S a ra h , D ia n a , a n d th e D a v id s .

P u b lis h in g Team E rik N Tanck (production) J o s h u a W e ike rshe im e r (p ublishing d irection)

N o tic e

T ra de nam es fo r e qu ipm e nt and su pp lie s d escrib e d are included as suggestions only. In no way does their inclusion constitute an e n d o rs e m e n t o f p reference by th e A u th o r o r th e ASCP. The A uthor and ASC P urge all readers to read and follow all m anufacturers’ in s tru c tio n s and package inse rt w a rn in g s co nce rnin g the proper and safe use o f products. The Am erican Society for Clinical P a th olog y, having exercised a pp rop riate and reasonable effort to research m aterial current as o f publication date, does not assum e a n y lia b ility fo r any loss o r d am a ge caused by e rro rs and om issions in this publication. Readers must assum e responsibility for c o m p le te and th o ro u gh research o f any h aza rdo u s conditions they encounter, as this publication is not intended to be all inclusive, and re co m m en d atio n s and re gu la tio ns ch an g e o v e rtim e .

PRESS

Copyright © 2018 by the American Society for Clinical Pathology. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, database, online or otherwise, without the prior written permission of the publisher. ISBN 978-089189-6678 P rin te d in C a n a d a 2 2 21 2 0 19 18

Table of

C o n ten ts Preface...........................................................................................................viii Contributing E ditors..................................................................................... viii

1.8 Lipids & carbohydrates......................................................................24 1.8.1 L ip id s .....................................................................................................24 1.8.2 Carbohydrates......................................................................................26 1.9 Tumor m arkers......................................................................................28

Chapter 1

1.9.1 Prostate specific antigen.....................................................................29

Chemistry

1.9.2 Colorectal carcinomascreening and C E A .......................................... 29

1.1 The liver....................................................................................................2

1.9.3 Thyroglobulin........................................................................................ 29

1.1.1 Liver function tests................................................................................ 2

1.9.4 Cancer antigen 1 2 5 ............................................................................. 30

1.1.2 Neonatal jaundice

.............................................................................. 4

1.9.5 CA27.29 & 1 5-3 ....................................................................................30

1.2 The pancreas...........................................................................................5

1.9.6 CA19-9...................................................................................................30

1.2.1 Pancreatic enzymes.............................................................................. 5 1.2.2 Tests of pancreatic exocrine fu n c tio n ................................................ 5

1.9.7 a fetoprotein.........................................................................................30

1.3 The h e a rt...............................................................................................5 1.3.1 Myocardial m arkers.............................................................................. 5 1.3.2 Acute coronary syndrome/acute myocardial infarction.................... 6

1.9.9 p2 microglobulin....................................................................................31 1.9.11 Markers of neuroendocrinetu m o rs ...................................................31

1.3.3 Myocarditis............................................................................................6

1.9.12 Urine markers for urothelialcarcinom a............................................ 32

1.4 Proteins................................................................................................. 6 1.4.1 Major serum proteins ..........................................................................6 1.4.2 Patterns in serum protein electrophoresis..........................................8

1.10 Endocrine.............................................................................................. 32

1.4.3 CSF protein electrophoresis............................................................... 10 1.4.4 Urine protein electrophoresis ........................................................... 10

1.10.3 P ituita ry.............................................................................................. 38 1.11 Postmortem chem istries...................................................................39

1.4.5 Cryoglobulinemia................................................................................ 10

1.11.1 Samples.............................................................................................. 39

1.4.6 Laboratory methods............................................................................ 11

1.11.2 Analytes.............................................................................................. 40

1.5 Acid-base & electrolytes....................................................................11

1.12 Body fluids............................................................................................ 40

1.5.1 Sodium................................................................................................. 11 1.5.2 Potassium............................................................................................. 12

1.12.1 Urine.................................................................................................... 40

1.5.3 C a lcium ............................................................................................... 13 1.5.4 Acid-base disorders............................................................................ 14

1.12.3 Pleural flu id ........................................................................................45

1.5.6 Renal fu n ctio n .....................................................................................15 1.5.7 Laboratory screening for chronic kidney d is e a s e ........................... 16

1.12.5 Synovial flu id ..................................................................................... 46

1.5.8 Laboratory evaluation in acute renal failure......................................16

1.9.8 Human chorionic gonadotropin (hCG )............................................... 31 1.9.10 Alkaline phosphatase.........................................................................31

1.10.1 Thyroid chemistry............................................................................... 32 1.10.2 Adrenal c o rte x ....................................................................................35

1.12.2 Cerebrospinal flu id .............................................................................44 1.12.4 Peritoneal fluid (ascites fluid)............................................................46 1.13 Selected readings............................................................................... 47 1.13.1

B o o k s ................................................................................................47

1.6 Laboratory tests in pregnancy......................................................... 17 1.6.1 Amniotic fluid b iliru b in ........................................................................17 1.6.2 Human chorionic gonadotropin.........................................................17 1.6.3 Prenatal screening for trisomy & neural tube defects.....................17 1.6.4 Assessing risk of preterm birth........................................................... 18 1.6.5 Determination of fetal lung maturity...................................................18 1.6.6 Laboratory evaluation of diseases in pregnancy............................. 18 1.7

Toxicology.......................................................................................... 19

1.7.1 Pharmacokinetics................................................................................ 19 1.7.2 Drugs of abuse screening (forensic toxicology)............................... 19 1.7.3 Overdose.............................................................................................21 1.7.4 Therapeutic drug m onitoring.............................................................24 © A S C P 2018

Chapter 2

Blood Banking/Transfusion Medicine 2.1 Blood donation......................................................................................56 2.1.1 Donor history & physical examination , ......................................... 56 2.1.2 Autologous donor requirements..........................................................57 2.1.3 Apheresis donor requirements............................................................ 57 2.1.4 Blood obtained from therapeutic phlebotom y................................ 57 2.1.5 Collecting blood from donor................................................................ 57 2.1.6 Laboratory testing of donor b lo o d ..................................................... 58

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2.2 P retransfusion procedures ........................................................... 2.2.1 Routine pretransfusion procedures................................................... 2.2.2 Nonroutine pretransfusion procedures: positive antibody screen or crossm atch................................................ 2.2.3 Autoantibodies in the blood bank.......................................................

59 59

Chapter 3

62 67

3.1 Clinical syndromes & causative a g e n ts .......................................... 96 3.1.1 Urinary tract infection (U T I)............................................................... 96 3.1.2 Infectious diarrhea.............................................................................. 97 3.1.3 Pneumonia........................................................................................... 97 3.1.4 Infective endocarditis (IE)....................................................................98 3.1.5 Meningitis............................................................................................. 99 3.1.6 Prosthetic joint infections....................................................................99 3.1.7 Vectors ..............................................................................................102

2.3 T ransfusion in special clinical circu m sta nce s.............................. 69 2.3.1 Transfusion in sickle cell disease....................................................... 69 2.3.2 Shock: fluid resuscitation, emergency release & massive transfusion............................................ 69 2.4 Therapeutic a p h e re s is ......................................................................... 2.4.1 D e fin itio n ............................................................................................... 2.4.2 In d ica tion s............................................................................................ 2.4.3 Replacement fluid ............................................................................... 2.4.4 Vascular access................................................................................... 2.4.5 Medication intera ction s......................................................................

70 70 70 72 72 72

2.5 Neonatal & intrauterine tra n s fu s io n ................................................ 2.5.1 Special blood requirements for neonatal & intrauterine transfusion 2.5.2 Maternal immune thrombocytopenic purpura (IT P )........................ 2.5.3 Neonatal alloimmune thrombocytopenia (N A IT )............................ 2.5.4 Hemolytic disease of the fetus & newborn (HDF/HDN).................

72 72 72 72 73

74 74 76 77 78 78 2.6.6 Selected plasma d erivative s............................................................. 79 2.6.7 Manipulated products........................................................................... 79

2.6 B lood com ponents ............................................................................. 2.6.1 Red blood cell com ponents................................................................ 2.6.2 P latelets................................................................................................. 2.6.3 Granulocyte concentrates.................................................................. 2.6.4 P lasm a................................................................................................... 2.6.5 Cryoprecipitated antihemophilic factor (cryoprecipitate or cryo) ..

2.7 B lood group a n tig e n s.......................................................................... 2.7.1 ABO & the carbohydrate antigens.................................................... 2.7.2 P/GLOB blood g ro u p .......................................................................... 2.7.3 R h............................................................................................................ 2.7.4 Kidd blood group system .................................................................... 2.7.5 Duffy....................................................................................................... 2.7.6 MNS system .......................................................................................... 2.7.7 Kell blood group................................................................................... 2.7.8 Lutheran................................................................................................. 2.7.9 Human leukocyte antigens (H L A )....................................................

80 80 83 84 85 86

86

Microbiology

3.2 3.2.1 3.2.2 3.2.3 3.2.4 3.2.5 3.2.6 3.2.7 3.2.8 3.2.9

V iro lo g y .............................................................................................102 Viral structure & classification......................................................... 102 Laboratory evaluation........................................................................ 103 DNA viruses....................................................................................... 103 Positive sense RNA viruses............................................................. 110 Negative sense RNA viruses........................................................... 113 Reoviridae: double stranded RNA; no envelope........................... 115 Other viruses..................................................................................... 116 Vaccines..............................................................................................116 Implicated viruses bydisease states................................................116

3.3 3.3.1 3.3.2 3.3.3 3.3.4

Parasitology...................................................................................... 116 Laboratory methods.......................................................................... 116 Protozoa..............................................................................................117 Helminths........................................................................................... 124 Additional pearls of parasitology.....................................................128

3.4 M y c o lo g y ............................................................................................. 128 3.4.1 Fungal structure.................................................................................128 3.4.2 Diagnostic techniques......................................................................129 3.4.3 Y e a s ts ................................................................................................130 3.4.4 3.4.5 3.4.6 3.4.7 3.4.8

Dimorphic fu n g i.................................................................................133 Dermatophytes & other superficial m ycoses..................................137 Dematiaceous molds & other subcutaneous infections...............138 Hyaline molds.....................................................................................140 Zygomycetes.....................................................................................143

86 87 87

3.4.9 Pneumocystis p r o v e d ......................................................................144 3.4.10 Prototheca.......................................................................................145 3.4.11 Notes about antifungal agents.......................................................146

2.8 Transfusion c o m p lic a tio n s ............................................................... 88 2.8.1 Suspected transfusion reaction......................................................... 88 2.8.2 Types of transfusion com plications.................................................. 89 2.8.3 Records .............................................................................................. 93 2.8.4 Blood bank regulatory authority..........................................................94

3.5 Bacteriology...................................................................................... 146 3.5.1 Specimen processing........................................................................146 3.5.2 Gram positive c o c c i..........................................................................150 3.5.3 Gram positive rods............................................................................ 156 3.5.4 Gram negative c o c c i........................................................................162 3.5.5 Gram negative ro ds.......................................................................... 164 3.5.6 Anaerobes......................................................................................... 176 3.5.7 Spirochetes.......................................................................................180 3.5.8 Chlam ydia......................................................................................... 182 3.5.9 Rickettsia........................................................................................... 184 3.5.10 Coxiella burnetii (formerly a Rickettsia s p p ) ............................... 184 3.5.11 Ehrlichia & anaplasma....................................................................185

2.9 Selected re a d in g s ................................................................................. .94 2.9.1 B o o k s .................................................................................................. .94

IV

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Contents

3.5.12 Bartonella: pleomorphic, Gram negative bacilli........................... 185 3.5.13 Mycoplasma..................................................................................... 185 3.6 Mycobacteria..................................................................................... 186 3.6.1 Background....................................................................................... 186 3.6.2 Laboratory evaluation........................................................................ 186 3.6.3 Mycobacterium tuberculosis complex.............................................. 188 3.6.4 Nontuberculous Mycobacteria: categorized based on Runyon classification............................................................................ 190 3.6.5 Mycobacterium lep rae......................................................................192 3.6.6 Mycobacteria ulcerans ....................................................................192 3.7

Selected readings............................................................................ 192

3.7.1 Books..................................................................................................192 3.7.2 Online references.............................................................................. 193

Chapter 4

Hematopathology 4.1 Diseases of red blood cells............................................................. 200 4.1.1 Cytoskeletal disorders......................................................................200 4.1.2 Enzyme d isorders............................................................................201 4.1.3 Structurally abnormal hemoglobin variants (hemoglobinopathies)............................................................................202 4.1.4 Thalassemia.......................................................................................206 4.1.5 Immune hemolytic disorders...........................................................208 4.2 Disorders of marrow production...................................................210 4.2.1 Iron deficiency.................................................................................. 210 4.2.2 Folate & vitamin B12, ..................................................................... 212 4.2.3 Anemia of chronic disease............................................................... 213 4.2.4 Sideroblastic anem ia........................................................................214 4.2.5 Congenital dyserythropoietic anemia.............................................. 214 4.2.6 Fanconi anem ia................................................................................ 214 4.2.7 Dyskeratosis congenita (Zinsser-Engman-Cole syndrome)........ 215 4.2.8 Pure red cell aplasia (PRCA)...........................................................215 4.2.9 Congenital amegakaryocytic thrombocytopenia (CAMT).............. 215 4.2.10 Thrombocytopenia with absent radii syndrome...........................215 4.2.11 Congenital neutropenia (Kostmann syndrome) & cyclic neutropenia........................................216 4.2.12 Shwachman-Diamond syndrome.................................................. 216 4.2.13 Myelokathexis (& WHIM syndrome).............................................. 216 4.2.14 Autoimmune neutropenia............................................................... 216 4.2.15 Aplastic anem ia.............................................................................. 216 4.2.16 Approach to the diagnosis of quantitative abnormalities............217 4.3 Neoplastic hematopathology.........................................................223 4.3.1 B cell neoplasm s..............................................................................223 4.3.2 Precursor neoplasms (lymphoblastic leukemia & lymphoma), B and T ...........................................................236 4.3.3 Plasma cell neoplasm s................................................................... 237 4.3.4 T cell neoplasm s.............................................................................. 240 4.3.5 Hodgkin lym phom a..........................................................................243 4.3.6 Myeloid neoplasm s..........................................................................246 © A S C P 2018

4.4 4.4.1 4.4.2 4.4.3 4.4.4 4.4.5 4.4.6 4.4.7 4.4.8

M ethods.............................................................................................. 258 Red blood cell in d ice s..................................................................... 258 Leukocyte indices..............................................................................258 Platelet indices....................................................................................259 Detection of normal & variant hemoglobins.................................... 259 Histochemistry & cytochemistry........................................................261 Immunophenotyping........................................................................... 261 Conventional cytogenetics & molecular techniques....................... 264 Bone marrow b io p s y .........................................................................265

4.5 Selected re a d in g s.............................................................................267 4.5.1 Books...................................................................................................272 4.4 M ethods.................................................................................................203 4.4.1 Red blood cell ind ice s..................................................................... 203 4.4.2 Leukocyte indices..............................................................................204 4.4.3 Detection of normal & variant hemoglobins.................................... 204 4.4.4 Histochemistry & cytochemistry........................................................206 4.4.5 Immunophenotyping...........................................................................207 4.4.6 Conventional cytogenetics & molecular techniques....................... 210 4.5 Recommended re a d in g .................................................................... 210

Chapter 5

Coagulation 5.1 Hem ostasis..........................................................................................274 5.1.1 Normal hemostasis occurs in 3 s te p s .............................................274 5.2 Laboratory evaluation of hemostasis............................................275 5.2.1 Laboratory evaluation of platelets.................................................... 275 5.2.2 Laboratory evaluation of coagulation................................................276 5.3 Excessive bleeding (hemophilia)......................................................278 5.3.1 Laboratory evaluation .................................................................... 278 5.3.2 Platelet disorders .............................................................................280 5.3.3 Coagulation defects , ...................................................................... 283 5.3.4 Nonhemostatic causes of excessivebleeding................................. 285 5.4 Thrombosis & thrombophilia........................................................... 285 5.4.1 Clinical considerations...................................................................... 285 5.4.2 Specific causes of thrombophilia..................................................... 285 5.5 Therapeutic agents & monitoring................................................... 288 5.5.1 Anticoagulants................................................................................... 288 5.5.2 Antiplatelet agents.............................................................................289 5.6 Selected readings............................................................................... 290 5.6.1 Books................................................................................................. 290

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Contents

C h a pter 6

C hapter 7

Immunology

Molecular Pathology

6.1 Immune system ............................................ 6.1.1 B cells........................................................... 6.1.2 T cells........................................................... 6.1.3 NK c e lls ....................................................... 6.1.4 Antigen presenting cells............................. 6.1.5 G ranulocytes.............................................. 6.1.6 Complement................................................ 6.1.7 Human leukocyte antigens (H L A s ).........

296 296 297 297 298 298 298 299

7.1 Brief review of m olecular b io lo g y ...................................................318 7.1.1 The structure of nucleic a c id s ......................................................... 318 7.1.2 Nucleic acid modifying enzym es.....................................................320 7.1.3 Mitochondrial D N A............................................................................ 320 7.1.4 Gene expression.............................................................................. 321 7.1.5 DNA replication & cell division......................................................... 323 7.1.6 Classification of genetic anom alies................................................ 324 7.1.7 Patterns of inheritance......................................................................325

6.2 6.2.1 6.2.2 6.2.3 6.2.4 6.2.5 6.2.6 6.2.7 6.2.8

Evaluation of immune function............. Screening te s ts .......................................... Global tests of immune syste m ............... Specific testing of B cell function............. Specific testing of T cell function............. Testing NK cell function............................. Testing neutrophil function........................ Testing complement................................... HLA testing...................................................

300 300 300 300 300 300 300 301 301

7.2 7.2.1 7.2.2 7.2.3

6.3 6.3.1 6.3.2 6.3.3 6.3.4

Primary immunodeficiency disorders... B cell d e fe cts.............................................. T cell d e fe c ts.............................................. Neutrophil/phagocytic d e fe c ts ................. Complement deficiencies..........................

303 303 304 305 306

6.4 Autoimmunity & rheumatologic disease 6.4.1 Pathophysiology.......................................... 6.4.2 Autoimmune d iseases............................... 6.4.3 Hypersensitivity re a c tio n s........................

306 306 309 316

6.5 Selected readings........................................

316

Techniques & applications............................................................ 325 Cytogenetics & karyotyping............................................................. 325 Molecular techniques........................................................................326 Applications.......................................................................................333

7.3 Genetics o f nonneoplastic disease................................................334 7.3.1 R e n al..................................................................................................334 7.3.2 Cardiovascular...................................................................................338 7.3.3 Endocrine........................................................................................... 340 7.3.4 Gastrointestinal, hepatobiliary & pancreatic....................................343 7.3.5 Neuromuscular...................................................................................350 7.3.6 Disorders of m itochondria............................................................... 355 7.3.7 Microdeletion disorders ................................................................. 356 7.4 Genetics of neoplastic dise ase ....................................................356 7.4.1 Gastrointestinal tract tu m o rs ........................................................... 356 7.4.2 Pancreatic tu m o rs ............................................................................ 362 7.4.3 Hepatobiliary tu m o rs ........................................................................363 7.4.4 Breast cancer.....................................................................................364 7.4.5 Genitourinary tum ors........................................................................366 7.4.6 Soft tissue & b o n e ............................................................................ 368 7.4.7 Head & neck tu m o rs ........................................................................371 7.4.8 Skin tu m o rs .......................................................................................372 7.4.9 Central nervous system tum ors.......................................................373 7.4.10 Pulmonary tu m o rs..........................................................................375 7.4.11 Gynecologic tum ors........................................................................376 7.4.12 Other tumor syndromes................................................................. 377 7.5 Selected re ad in g s........................................................................... 380 7.5.1 Books................................................................................................. 380 7.5.2 Online references.............................................................................. 380

VI

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

Contents

Chapter 8

Medical Directorship 8.1 Legislation & regulation, agencies & oversight..........................396 8.1.1 Legislation & regulations relating to laboratories..........................396 8.1.1.1 Clinical Laboratory Improvement Amendment of 1988............. 396 8.1.1.2 Medical devices & biologies....................................................... 398 8.1.1.3 Medicare, Medicaid & the prospective payment system...........399 8.1.1.4 Billing & reimbursement..............................................................399 8.1.1.5 Direct billing law, physician self referral law (Stark law) & antikickback law.................................................................................. 400 8.1.1.6 The Privacy Act & the Privacy Rule (HIPAA)............................400 8.1.1.7 The Occupational Safety & Health Administration (OSHA) . . . 400 8.2 Financial considerations in the laboratory................................ 401 8.2.1 Types of costs & calculation of the breakeven point................... 401 8.2.2 Budgeting...........................................................................................401 8.3 Statistical considerations in the laboratory............................... 402 8.3.1 Definitions...........................................................................................402 8.3.1.1 Gaussian distribution, estimates of central tendency & estimates of variation..........................................................................402 8.3.1.2 Reliability: analytical accuracy & precision................................. 402 8.3.1.3 Clinical sensitivity & specificity.................................................... 402 8.3.1.4 Predictive value.............................................................................. 402 8.3.1.5 Relative risk.................................................................................... 403 8.3.2 Diagnostic accuracy: receiver operating characteristic curves .. 403 8.3.2.1 8.3.2.2 8.3.3 8.3.3.1 8.3.3.2

Diagnostic accuracy..................................................................... 403 Receiver operating characteristic cu rve s................................... 403 Reference intervals....................................................................... 403 Purpose of reference intervals.................................................... 403 Establishing & adopting reference intervals............................... 404

8.4 Implementation of new m ethods...................................................404 8.4.1 O verview ...........................................................................................404 8.4.2 Elements of method verification...................................................... 405 8.4.2.1 Calibration & calibration verification............................................405 8.4.2.2 Precision & establishment of quality control ranges.................405 8.4.2.3 Accuracy, inaccuracy (bias) & method comparison.................. 405 8.4.2.4 Analytic specificity, interference & carryover.............................405 8.4.2.5 Analytical sensitivity, limit of detection & functional sensitivity 406

8.5 Quality management...........................................................................407 8.5.1 Definitions............................................................................................407 8.5.1.1 Quality management andquality control........................................407 8.5.2 Statistical quality control.................................................................... 408 8.5.2.1 Traditional Q C ................................................................................. 408 8.5.2.2 Alternatives to traditional Q C ........................................................410 8.5.3 Proficiency testing (external quality assessm ent)......................... 410 8.5.3.1 Overview..........................................................................................410 8.6 Nonanalytic variables in laboratory medicine: preanalytic & postanalytic.........................................................................411 8.6.1 Preanalytic variables.........................................................................411 8.6.1.1 Patient identification.......................................................................411 8.6.1.2 A g e .................................................................................................. 411 8.6.1.3 G e n d e r............................................................................................411 8.6.1.4 Food intake..................................................................................... 411 8.6.1.5 Exercise............................................................................................411 8.6.1.6 Cigarette smoking...........................................................................411 8.6.1.7 Posture............................................................................................ 411 8.6.1.8 Time of d a y ..................................................................................... 411 8.6.1.9 Tourniquet........................................................................................411 8.6.1.10 Order of d ra w ............................................................................... 411 8.6.1.11 Storage & transport conditions................................................... 412 8.6.1.12 Serum vs p la sm a .........................................................................412 8.6.1.13 Underlying hematologic malignancy.......................................... 412 8.6.2 Postanalytic va ria ble s.................................................................... 412 8.6.2.1 The postanalytic phase.................................................................. 412 8.6.2.2 Result reporting............................................................................... 412 8.6.2.3 Critical values reporting.................................................................. 412 8.7 Selected readings............................................................................. 413 8.7.1 Books................................................................................................413

In d ex ............................................................................................................414

8.4.2.6 Linearity, analytical measuring range & clinical reportable ra n g e ................................................................... 406 8.4.2.7 Specimen stability..........................................................................406 8.4.2.8 Information system s..................................................................... 406 8.4 2.9 Written procedures.................................................................... 407 8.4.2.10 Education of laboratory staff & clinical s ta ff........................... 407

© A S C P 2018

ISBN 9 7 8 -08 9189-6678

VII

P re fa c e T h e Q u ic k C o m p e n d iu m S e rie s w a s c re a te d to e n c o m p a s s c o n c is e y e t c o m p re h e n s iv e s o u rc e s fo r th e re v ie w o f p a th o lo g y . T h is p a rtic u la r b o o k is in te n d e d to b e s e rv e th a t p u rp o s e fo r c lin ic a l p a th o lo g y , in c lu d in g d ia g n o s tic m o le c u la r p a th o lo g y . It is b e s t s u ite d fo r th o s e w h o a re c o n c e p tu a lly fa m ilia r w ith th e m a te ria l a n d d e s ire e ith e r a g u id e b o o k fo r b o a rd p re p a ra tio n o r a “ju s t th e fa c ts ” e v e ry d a y re fe re n c e . T h e to p ic s a re o rg a n iz e d a c c o rd in g to th e tra d itio n a l c lin ic a l p a th o lo g y s e c tio n s , a n d w ith in e a c h I h a v e in c lu d e d , a s b e s t I c o u ld ju d g e , w h a t it is e s s e n tia l to k n o w fo r th o s e p u rp o s e s . E a c h v e rs io n o f th e Q u ic k C o m p e n d iu m o f C lin ic a l P a th o lo g y h a s b e e n g re e te d w ith e q u a l p a rts a p p re c ia tio n a nd c o n s tru c tiv e c ritic is m , le a d in g to a m u ltitu d e o f im p ro v e m e n ts a lo n g th e w a y. T h is 4 th e d itio n is n o e x c e p tio n . A ll s e c tio n s h a v e b e e n u p d a te d to re fle c t c u rre n t fin d in g s in th e lite ra tu re , n e w ly p u b lis h e d g u id e lin e s , n e w te s ts , a n d fre s h k n o w le d g e a b o u t o ld te s ts . T h e h e m a to lo g y s e c tio n h a s b e e n b ro u g h t in to s y n c h w ith th e 2 0 1 6 W H O c la s s ific a tio n . A n d o n c e a g a in m y c o n trib u tin g /re v ie w in g c o lle a g u e s h a v e e n s u re d th e a c c u ra c y o f th e c o n te n t w h ile a ls o c o n trib u tin g h ig h q u a lity o rig in a l im a g e s , re v is e d ta b le s , a n d u s e fu l fig u re s .

Contributing Editors to QCCP 4e Stacy G Beal, MD D e p a rtm e n t o f P a th o lo g y , Im m u n o lo g y & L a b o ra to ry M e d ic in e U n iv e rs ity o f F lo rid a C o lle g e o f M e d ic in e G a in e s v ille , F lo rid a

Alia Nazarullah, MD A s s is ta n t P ro fe s s o r D e p a rtm e n t o f P a th o lo g y U n iv e rs ity o f T e x a s H e a lth S a n A n to n io , T e xa s

Kim W Sanford, MD, MASCP M e d ic a l D ire c to r, T ra n s fu s io n M e d ic in e M e d ic a l D ire c to r, S to n y P o in t L a b o ra to ry U n d e rg ra d u a te M e d ic a l D ire c to r D e p a rtm e n t o f P a th o lo g y V irg in ia C o m m o n w e a lth U n iv e rs ity R ic h m o n d , V irg in ia

v iii

T ra in in g in la b o ra to ry m e d ic in e te n d s to be in te rm itte n t, so th a t s o m e ite m s a re fo rg o tte n , a nd u n e ve n , so th a t o th e rs a re n e v e r a c tu a lly le a rn e d . T h e re is m e rit in a o n c e -o v e r re vie w o f e v e ry th in g to w a rd s th e e nd o f re sid e n c y , b u t th e re is a lso m u c h w a s te d e ffo rt ju s t s o rtin g th ro u g h d iv e rs e m a te ria ls th a t w e re n e v e r in te n d e d fo r th is p u rp o s e . I c o m p ile d th is Q u ic k C o m p e n d iu m o f C lin ic a l P a th o lo g y h o p in g to im p ro ve th is p ro c e s s by b rin g in g tig h t fo c u s a n d c o n s is te n c y o f p re s e n ta tio n . W ith a b e tte r to o l, p e rh a p s th e o n c e -o v e r re v ie w can re ta in all o f its m e rit w h ile s h e d d in g s o m e o f th e b u rd e n . T h e 4 th e d itio n o f th e Q u ic k C o m p e n d iu m o f C lin ic a l P a th o lo g y is o ffe re d as an aid in m e e tin g th is im m e n s e c h a lle n g e .

Daniel Mais

Contributors to previous volumes John A Branda, MD Associate Director, Clinical Microbiology Laboratories Massachusetts General Hospital Assistant Professor of Pathology Harvard Medical School Boston, Massachusetts

Anand S Dighe, MD, PhD Director, Core Laboratory Massachusetts General Hospital Associate Professor of Pathology Harvard Medical School Boston, Massachusetts

Dina N Greene, PhD, DABCC Scientific Director, Chemistry Northern California Kaiser Permanente Regional Laboratories Berkeley, California

Daniel T Holmes, MD, FRCPC Division Head, Clinical Chemistry St Paul's Hospital Clinical Associate Professor of Pathology & Laboratory Medicine University of British Columbia Vancouver, Canada

George T Leonard, MD, PhD LTC, MC, USA Chief, Department of Pathology Madigan Army Medical Center Tacoma, Washington Assistant Professor of Pathology Uniformed Services University of Health Sciences Bethesda, Maryland

Mary M Mayo, PhD, DABCC, MT(ASCP) Director of Clinical Chemistry, Special Chemistry, POCT Associate Professor of Pathology, Pathology Residency Training Program St Louis University School of Medicine St Louis, Missouri

Bobbi S Pritt, MD, MSc, (D)TMH Director, Clinical Parasitology Division of Clinical Microbiology Mayo Clinic Rochester, Minnesota

Patricia J Simner, PhD Clinical Microbiology Fellow Department of Laboratory Medicine & Pathology Mayo School of Graduate Medical Education Rochester, Minnesota

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

Chapter 1

C h em istry 1.1 The liver....................................................................................................2

1.7 Toxicology.............................................................................................19

1.1.1 Liver function tests................................................................................ 2

1.7.1 Pharmacokinetics................................................................................. 19

1.1.2 Neonatal ja u n d ic e ................................................................................ 4

1.7.2 Drugs of abuse screening (forensic toxicology)...............................19

1.2 The pancreas...........................................................................................5

1.7.3 Overdose.............................................................................................. 21

1.2.1 Pancreatic enzymes.............................................................................. 5

1.7.4 Therapeutic drug m onitoring..............................................................24

1.2.2 Tests of pancreatic exocrinefu n ctio n ..................................................5

1.8 Lipids & carbohydrates......................................................................24

1.3 The h e a rt.................................................................................................5

1.8.1 L ip id s .................................................................................................... 24

1.3.1 Myocardial m arkers.............................................................................. 5

1.8.2 Carbohydrates..................................................................................... 26

1.3.2 Acute coronary syndrome/Acute myocardialinfarction...................... 6

1.9 Tumor m arkers......................................................................................28

1.3.3 Myocarditis............................................................................................. 6

1.9.1 Prostate specific antigen.................................................................... 29

1.4 Proteins...................................................................................................6 1.4.1 Major serum proteins ..........................................................................6 1.4.2 Patterns in serum protein electrophoresis..........................................8 1.4.3 CSF protein electrophoresis............................................................... 10 1.4.4 Urine protein electrophoresis ........................................................... 10 1.4.5 Cryoglobulinemia................................................................................ 10 1.4.6 Laboratory methods...........................................................................11 1.5 Acid-base & electrolytes....................................................................11 1.5.1 Sodium................................................................................................. 11 1.5.2 Potassium............................................................................................. 12 1.5.3 C a lcium ............................................................................................... 13 1.5.4 Acid-base disorders............................................................................ 14 1.5.6 Renal fu n ctio n .....................................................................................15 1.5.7 Laboratory screening for chronic kidney d is e a s e ........................... 16 1.5.8 Laboratory evaluation in acute renal failure......................................16 1.6 Laboratory tests inpregnancy...........................................................17 1.6.1 Amniotic fluid b iliru b in ........................................................................17

1.9.2 Colorectal carcinoma screening andC E A ..........................................29 1.9.3 Thyroglobulin........................................................................................29 1.9.4 Cancer antigen 1 2 5 .............................................................................30 1.9.5 CA27.29 & 15-3................................................................................... 30 1.9.6 CA19-9.................................................................................................. 30 1.9.7 a fetoprotein.........................................................................................30 1.9.8 Human chorionic gonadotropin(hCG ).................................................31 1.9.9 p2 microglobulin....................................................................................31 1.9.10 Alkaline phosphatase.........................................................................31 1.9.11 Markers of neuroendocrinetu m o rs .................................................. 31 1.9.12 Urine markers for urothelialcarcinom a............................................32 1.10 Endocrine.............................................................................................. 32 1.10.1 Thyroid chemistry...............................................................................32 1.10.2 Adrenal c o rte x ................................................................................... 35 1.10.3 P ituita ry..............................................................................................38 1.11 Postmortem chem istries...................................................................39 1.11.1 Samples..............................................................................................39 1.11.2 Analytes..............................................................................................40

1.6.2 Human chorionic gonadotropin.........................................................17

1.12 Body fluids............................................................................................ 40

1.6.3 Prenatal screening for trisomy & neural tubedefects.....................17

1.12.1 Urine.................................................................................................... 40

1.6.4 Assessing risk of preterm birth...........................................................18

1.12.2 Cerebrospinal flu id .............................................................................44

1.6.5 Determination of fetal lung maturity...................................................18

1.12.3 Pleural flu id ........................................................................................45

1.6.6 Laboratory evaluation of diseases in pregnancy............................. 18

1.12.4 Peritoneal fluid (ascitesfluid)............................................................46 1.12.5 Synovial flu id ..................................................................................... 46 1.13 Selected readings............................................................................... 47 1.13.1

© A S C P 2018

B o o k s ................................................................................................47

ISBN 9 7 8 -08 9189-6678

1

1: Chemistry

The liver>Liver function tests ■ A n a d d itio n a l LD , L D 6 , is s o m e tim e s s e e n m ig ra tin g c a th o d a l to L D 5 . It is fo u n d in s o m e s e v e re ly ill p a tie n ts

1.1 The liver 1.1.1 Liver function tests 1.1.1.1 A spartate am inotransferase & alanine aminotransferase (liver transam inases) ■ A s p a r ta te a m in o tra n s fe ra s e (A S T ) a n d a la n in e a m in o tra n s fe ra s e (A L T ) a re h e p a tic e n z y m e s ■ A S T a n d A L T a re m a rk e rs o f h e p a to c y te in ju ry , ra th e r th a n m a rk e rs o f h e p a to c y te fu n c tio n ■ A p p ro x im a te ly 8 0 % o f A S T is c o n c e n tra te d in m ito c h o n d ria , a n d A L T is e x c lu s iv e ly c y to p la s m ic ■ A S T is e x p re s s e d in c a rd ia c m u s c le , live r, s k e le ta l m u s c le , k id n e y , b ra in , lu n g , a n d p a n c re a s (in d e c re a s in g o r d e r o f c o n c e n tra tio n ). S tre n u o u s e x e rc is e ra is e s th e A S T , a n d m a rk e d m u s c le in ju ry s u c h a s rh a b d o m y o ly s is c a n e le v a te b o th A S T a n d A L T ■ A L T is c o n fin e d p rim a rily to live r, k id n e y , a n d m u s c le . T h e le v e l o f A L T in c re a s e s lin e a rly w ith th e b o d y m a s s in d e x . A L T le v e ls a re h ig h e r in m a le s th a n fe m a le s . A L T flu c tu a te s in c h ro n ic h e p a titis C v iru s h e p a titis , a n d m a y a t tim e s b e n o rm a l d e s p ite e le v a te d A S T ■ T h e A S T .A L T ra tio is c a lle d th e D e R itis ra tio . In m o s t fo rm s o f liv e r in ju ry th e A L T e x c e e d s th e A S T ; a lc o h o lic s te a to h e p a titis , W ils o n d is e a s e , a n d c irrh o s is o fte n e x h ib it re v e rs a l o f th e D e R itis ra tio

1.1.1.2 Lactate dehydrogenase ■ L a c ta te d e h y d ro g e n a s e (L D ) is w id e ly d is trib u te d a n d n o n s p e c ific , b u t it is c o m m o n ly e le v a te d b y liv e r in ju ry ■ T o ta l L D a c tiv ity is e le v a te d in h e m o ly s is , m e g a lo b la s tic a n e m ia , a n d d is o rd e rs o f m u s c le , liver, k id n e y , a n d lun g ■ L D m a y a ls o b e e le v a te d in n e o p la s tic s ta te s in c lu d in g le u k e m ia , ly m p h o m a , g e rm c e ll tu m o rs , a n d a w id e v a rie ty o f c a rc in o m a s ■ L D c a n b e s e p a ra te d in to 5 is o e n z y m e s b y e le c tro p h o re s is , th o u g h th is is n o t c o m m o n ly d o n e □ T h e fa s te s t m o v in g is o e n z y m e s , LD1 a n d L D 2 , a re a b u n d a n t in h e a rt, re d b lo o d c e lls , a n d k id n e y □ L D 4 a n d L D 5 a re fo u n d in liv e r a n d s k e le ta l m u s c le □ L D 3 is fo u n d in lu n g , s p le e n , ly m p h o c y te s , a nd p a n c re a s □ T h e c o m p a ra tiv e c o n c e n tra tio n s in n o rm a l s e ru m a re LD 2>LD 1>LD 3>LD 4>LD 5 LD1 e le v a tio n , p a rtic u la rly w h e n th e re is a “flip p e d LD ra tio ” s u c h th a t LD1 > L D 2 , is fo u n d in a c u te m y o c a rd ia l in fa rc tio n , h e m o ly s is , o r re n a l in fa rc tio n . In th e s e ttin o f m y o c a rd ia l in fa rc tio n LD b e g in s to ris e a t - 1 0 h o u rs a fte r A M I, p e a k s - 2 4 - 4 8 h o u rs , a n d re m a in s e le v a te d fo r up to 14 d a y s

1.1.1.3 Alkaline phosphatase ■ T h e re a re 2 c la s s e s o f p h o s p h a ta s e s , a lk a lin e (o p tim u m pH o f 9) a nd a c id (o p tim u m pH o f 5) ■ A c id p h o s p h a ta s e s (A C P s) a re fo u n d in g re a te s t c o n c e n tra tio n s in p ro s ta te , red b lo o d c e lls , a n d b o n e □ T ra d itio n a lly , red c e ll A C P w a s d is tin g u is h e d fro m o th e r A C P s by its s u s c e p tib ility to in h ib itio n by 2% fo rm a ld e h y d e a nd re s is ta n c e to in h ib itio n b y ta rtra te □ Red ce ll A C P , a ls o k n o w n a s ta rtra te re s is ta n t A C P (T R A P ), m a y be fo u n d in h a iry c e ll le u k e m ia ■ A lk a lin e p h o s p h a ta s e a c tiv ity is e s p e c ia lly c o n c e n tra te d in bone, liver, in te s tin e , a n d p la c e n ta , a nd e le v a te d s e ru m a lk a lin e p h o s p h a ta s e c o m m o n ly o rig in a te s fro m th e live r o r b o n e ■ B y e le c tro p h o re s is , a lk a lin e p h o s p h a ta s e ca n be re s o lv e d into 4 is o e n z y m e s □ E ach o f th e s e d is p la y s c h a ra c te ris tic d e g re e s o f in a c tiv a tio n w ith h e a t, u re a in c u b a tio n , a nd L -p h e n y la la n in e t1.1. H e a tin g p ro d u c e s s ig n ific a n t (9 0% ) in a c tiv a tio n o f b o n e a lk a lin e p h o s p h a ta s e (“ b o n e b u rn s ” ), 5 0 % in a c tiv a tio n o f b ilia ry a lk a lin e p h o s p h a ta s e , a n d 0% in a c tiv a tio n o f p la c e n ta l a lk a lin e p h o s p h a ta s e . S e n s itiv ity to u re a in c u b a tio n p a ra lle ls h e a tin g

t1 .1 Characteristics of alkaline phosphatase isoenzyme Source Biliary Bone Placenta Intestinal

Heat/urea inhibition L-phe inhibition Anodal mobility + 1 +++ 2 +++ 3 + +++ 4

□ A fo rm o f a lk a lin e p h o s p h a ta s e k n o w n a s th e R e g an is o e n z y m e is o b s e rv e d in a s m a ll p ro p o rtio n o f in d iv id u a ls w ith m a lig n a n t d is e a s e □ A s s e s s m e n t o f a lk a lin e p h o s p h a ta s e is o e n z y m e s has la rg e ly b e e n s u p p la n te d by th e u s e o f a d ju n c tiv e te s ts (see b e lo w ), in c lu d in g G G T a n d 5' n u c le o tid a s e . If th e s e a n a ly te s a re w ith in th e n o rm a l ra n g e , th e n th e e x c e s s a lk a lin e p h o s p h a ta s e is m o s t lik e ly o f b o n e o rig in ■ A lk a lin e p h o s p h a ta s e a c tiv ity is a ffe c te d by a w id e ra n g e o f n o n p a th o lo g ic c o n d itio n s □ N o rm a l g ro w th (in c h ild h o o d ) a nd p re g n a n c y are c a u s e s o f s ig n ific a n t e le v a tio n in a lk a lin e p h o s p h a ta s e ; s e p a ra te re fe re n c e in te rv a ls a re re q u ire d fo r c h ild re n

E le v a te d L D 4 a n d L D 5 s u g g e s t liv e r d a m a g e b u t ca n a ls o b e c a u s e d b y s k e le ta l m u s c le in ju ry 2

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

1: Chemistry

The liver>Liver function tests □ In te s tin a l a lk a lin e p h o s p h a ta s e ca n be th e c a u s e o f fa c titio u s e le v a tio n in n o n fa s tin g in d iv id u a ls , p a rtic u la rly in L e w is p o s itiv e g ro u p B o r O s e c re to rs . In g e s tin g a m e a l ca n e le v a te th e a lk a lin e p h o s p h a ta s e by 3 0 % fo r up to 12 h o u rs in su ch in d iv id u a ls □ M e d ic a tio n s in c lu d in g o ra l c o n tra c e p tiv e s m a y e le v a te a lk a lin e p h o s p h a ta s e □ A lk a lin e p h o s p h a ta s e is ty p ic a lly s lig h tly h ig h e r in m en th a n w o m e n . In w o m e n , v a lu e s in c re a s e in th e p e rim e n o p a u s a l p e rio d to le v e ls s im ila r to th o s e fo u n d in m en ■ C o m p a re d to o th e r liv e r fu n c tio n te s ts , a lk a lin e p h o s p h a ta s e is th e m o s t s e n s itiv e m a rk e r o f h e p a tic m e ta s ta s e s ■ B o n e a lk a lin e p h o s p h a ta s e is p ro d u c e d by o s te o b la s ts a n d re fle c ts b o n e fo rm in g a c tiv ity ; o n e o f th e m o s t c o m m o n c a u s e s o f a ra is e d b o n e a lk a lin e p h o s p h a ta s e in a d u lts is P a g e t d is e a s e ■ D e c re a s e d a lk a lin e p h o s p h a ta s e is fo u n d in h y p o p h o s p h a ta s ia (an in b o rn d e fic ie n c y ) a nd m a ln u tritio n . H e m o ly s is m a y fa ls e ly lo w e r a lk a lin e p h o s p h a ta s e . L o w le ve ls h a ve a ls o b e e n re p o rte d in W ils o n d is e a s e , th e o p h y llin e th e ra p y , a nd e s tro g e n th e ra p y

1.1.1.4 Y-glutamyl transferase (GGT) ■ G G T m a y be u sed to c o rro b o ra te an e le v a te d a lk a lin e p h o s p h a ta s e o r a s a s ta n d a lo n e te s t ■ H e p a tic G G T is d e riv e d p rim a rily fro m th e b ilia ry e p ith e lia l c e lls lin in g th e s m a ll in te rlo b u la r b ile d u c ts a n d th e h e p a to c y te s o f th e lim itin g p late, b u t G G T is n o n s p e c ific and m a y be fro m a v a rie ty o f tis s u e s o u rc e s ■ G G T is a h ig h ly s e n s itiv e in d ic a to r o f h e p a to b ilia ry inju ry, p rin c ip a lly in v o lv in g b ilia ry tra c t, a n d m a y b e e le v a te d in a v a rie ty o f c h e m ic a l e x p o s u re s in c lu d in g w a rfa rin , b a rb itu ra te s , d ila n tin , v a lp ro a te , m e th o tre x a te , a nd a lc o h o l (G G T m a y be e le v a te d to 2 - 3 * th e U LN in h e a v y d rin k e rs )

1.1.1.5 5' nucleotidase ■ B ilia ry e p ith e liu m is th e m a in s o u rc e o f 5 ' n u c le o tid a s e , a n d le v e ls a re h ig h e s t in c h o le s ta tic c o n d itio n s

1.1.1.6 Ammonia ■ T h e m ain s o u rc e s o f s e ru m a m m o n ia a re s k e le ta l m u s c le (u re a cy c le ) a n d th e g u t (fro m e n te ric b a c te ria th ro u g h th e b re a k d o w n o f p ro te in ) ■ T h e n o rm a lly fu n c tio n in g liv e r re m o v e s a m m o n ia fro m th e p o rta l c irc u la tio n a n d d is c a rd s it in th e fo rm o f urea, w h ic h is e x c re te d in th e u rin e

© A S C P 2018

■ D y s fu n c tio n a l liv e rs m ay b e o v e rw h e lm e d , e s p e c ia lly w h e n th e re is e x c e s s p ro te in in th e g u t (eg, e x c e s s h e m o g lo b in fro m v a ric e a l b le e d ), o r c irc u m v e n te d b y c o lla te ra l c irc u la tio n ■ In a d u lts , h y p e ra m m o n e m ia is n e a rly a lw a y s th e re s u lt o f liv e r fa ilu re o r p re a n a ly tic e rro r (s e e b e lo w ) ■ In c h ild re n , h y p e ra m m o n e m ia s h o u ld ra is e s u s p ic io n fo r an in b o rn e rro r o f m e ta b o lis m , e s p e c ia lly u re a c y c le e n z y m e d e fic ie n c ie s . A d d itio n a l c a u s e s o f h y p e ra m m o n e m ia a re lis te d in t1.2

t1 .2 Causes of hyperammonemia Liver failure Inborn errors of metabolism affecting urea cycle (eg, ornithine transcarbamoylase (OTC) deficiency), fatty acid oxidation (eg, carnitine deficiency), organic acidemias (eg, carboxylase deficiency) Total parenteral nutrition Atonic bladder with superimposed urinary tract infection with urease producing bacteria (eg, Proteus) Ureterosigmoidostomy Valproic acid therapy Cigarette smoking___________________________________________________

■ S p e c im e n s fo r a m m o n ia m e a s u re m e n t s h o u ld be c h ille d on ice d u rin g tra n s p o rt a n d h e m o ly s is s h o u ld be m in im iz e d ■ S p e c im e n s s h o u ld b e im m e d ia te ly te s te d ; th e a m m o n ia leve l in a b lo o d s a m p le in c re a s e s o v e r tim e , - 2 0 % in th e firs t h o u r ■ P a tie n ts w h o s m o k e s h o u ld a b s ta in fo r s e v e ra l h o u rs p re c e d in g th e b lo o d d ra w

1.1.1.7 Bilirubin ■ T otal, u n c o n ju g a te d (in d ire c t) a n d c o n ju g a te d (d ire c t) b iliru b in □ C o n ju g a te d b iliru b in is w a te r s o lu b le □ U n c o n ju g a te d b iliru b in is w a te r in s o lu b le □ C o n ju g a te d b iliru b in is m e a s u re d in d ia z o c o lo rim e tric m e th o d s w ith o u t a d d itio n o f an a c c e le ra to r (d ire c t) □ U n c o n ju g a te d b iliru b in is th e c a lc u la te d d iffe re n c e b e tw e e n to ta l a nd c o n ju g a te d (in d ire c t), w ith to ta l b iliru b in m e a s u re d by d ia z o c o lo rim e tric m e th o d w ith a c c e le ra to r is a d d e d o r b y d ire c t s p e c tro p h o to m e try (4 5 4 nm ) □ C o n ju g a te d h y p e rb iliru b in e m ia t1.3, t1.4 (said to be p re s e n t w h e n > 3 0 % o f s e ru m b iliru b in is c o n ju g a te d ) is c a u s e d b y an e x c re to ry d e fe c t o f a lre a d y c o n ju g a te d b iliru b in □ U n c o n ju g a te d h y p e rb iliru b in e m ia is c a u s e d by in c re a s e d p ro d u c tio n (h e m o ly s is ) o r a h e p a tic d e fe c t th a t p re v e n ts u p ta k e o r c o n ju g a tio n

ISBN 978-08 9189-6678

3

1: Chemistry

The liver>Liver function tests | Neonatal jaundice t1 .3 Pathophysiologic differential diagnosis of hyperbilirubinem ia Step of bilirubin metabolism excess conversion of heme to unconjugated bilirubin (hemolysis)

excess delivery of unconjugated bilirubin to liver poor uptake of unconjugated bilirubin into hepatocyte impaired conjugation of bilirubin in hepatocyte impaired transmembrane secretion of conjugated bilirubin into canaliculus (hepatocellular jaundice) t1.4 impaired flow of conjugated bilirubin through canaliculi & bile ducts (cholestatic jaundice) t1.4

Type of Pathologic processes hyperbilirubinemia hemolysis (extravascular) unconjugated ineffective hematopoiesis hyperbilirubinemia (intramedullary hemolysis) large hematoma (resorbed heme) blood shunting (cirrhosis) unconjugated hyperbilirubinemia right heart failure Gilbert syndrome drugs, especially rifampin & probenecid Crigler-Najjar syndrome Hypothyroidism hepatitis/hepatic injury endotoxin (sepsis) pregnancy (estrogen) drugs: estrogen, cyclosporine Dubin-Johnson syndrome Rotor syndrome intrahepatic: primary biliary cirrhosis, medication, alcohol, pregnancy, sepsis extrahepatic: primary sclerosing cholangitis, tumor, stricture, stone, AIDS choledochopathy

unconjugated hyperbilirubinemia unconjugated hyperbilirubinemia conjugated hyperbilirubinemia

Hepatocellular jaundice 3x upper limit of normal normal absent

conjugated hyperbilirubinemia

□ Type 1 is s e v e re a nd p re s e n ts in in fa n cy, c a u s e d by c o m p le te a b s e n c e o f U D P -g lu c u ro n id a s e □ Type 2 is le s s s e v e re a n d c a u s e d by d im in is h e d U D P g lu c u ro n id a s e a c tiv ity ■ G ilb e rt s y n d ro m e , C rig le r-N a jja r ty p e 1, and C rig le r-N a jja r ty p e 2 a re c a u s e d by m u ta tio n s in th e UG T1A1 g e n e

1.1.1.8 Prothrombin time (PT) ■ T h e PT c a n be u sed a s a m a rk e r o f im p a ire d h e p a tic s y n th e tic fu n c tio n

1.1.1.9 Gammaglobulins ■ In a u to im m u n e h e p a titis , th e re is a m a rk e d p o ly c lo n a l in c re a s e in IgG ■ In p rim a ry b ilia ry c irrh o s is , th e re is a p o ly c lo n a l in c re a s e in IgM

Cholestatic jaundice >3* upper limit of normal Pancreatic enzymes | Tests of pancreatic exocrine function | The heart>Myocardial markers ■ B enign p h y s io lo g ic ja u n d ic e (1) is u s u a lly noted b e tw e e n d ays 2 and 3 o f n e o n a ta l life, (2) ra re ly ris e s a t a rate >5 m g/dL /d a y, (3) u su a lly p e a ks by d a y 4 -5 , and (4) is >20 m g /d L ■ T h e m o s t c o m m o n c a u s e s o f s e v e re h y p e rb iliru b in e m ia a re h e m o ly tic d is e a s e o f th e fe tu s a n d n e w b o rn (H D F N ) a n d s e p s is ■ If s e v e re e n o u g h , u n c o n ju g a te d b iliru b in ca n c ro s s th e b lo o d -b ra in b a rrie r and c a u s e d a m a g e to th e c e n tra l n e rv o u s s y s te m (k e rn ic te ru s )

■ T h e “ s p o t” fe c a l fa t, a s s e s s e d b y S u d a n b la c k s ta in in g o f a ra n d o m s to o l s a m p le , is re la tiv e ly in s e n s itiv e , ■ N o te th a t th e D -x y lo s e te s t is a m e a s u re o f s m a ll b o w e l m u c o s a l a b s o rp tiv e c a p a c ity a n d n o t a te s t o f p a n c re a tic e x o c rin e fu n c tio n

1.2.2.2.1 L a b o ra to ry eva lu a tio n o f p a n c re a tic c y s t flu id ■ P a n c re a tic c y s t a s p ira te s a re u s u a lly s u b m itte d fo r la b o ra to ry a n a ly s is . t1.6 t1 .6 Pancreatic cyst evaluation Cyst type Clinical findings Cyst aspirate

1.2 The pancreas

pseudocyst

1.2.1 Pancreatic enzymes 1.2.1.1 Amylase ■ In u n c o m p lic a te d a c u te p a n c re a titis , a m y la s e ris e s w ith in 12-24 h o u rs a nd re tu rn s to n o rm a l in 2 -3 d a y s ■ H ig h e r le v e ls a re m o re s p e c ific fo r th e d ia g n o s is o f a c u te p a n c re a titis ■ P e rs is te n c e o f e le v a te d s e ru m a m y la s e b e y o n d 5 d a y s s u g g e s ts a c o m p lic a tio n ■ U p to 10% o f c a s e s o f a c u te p a n c re a titis a re a s s o c ia te d w ith n o rm a l a m y la s e , w ith s e n s itiv ity p a rtic u la rly lo w in a lc o h o lic p a n c re a titis ■ U p to 3 0 % o f a m y la s e e le v a tio n s a re c a u s e d by n o n p a n c re a tic d is o rd e rs , in c lu d in g d ia b e tic k e to a c id o s is , p e p tic u lc e r d is e a s e , a c u te c h o le c y s titis , e c to p ic p re g n a n c y , s a lp in g itis , b o w e l is c h e m ia , in te s tin a l o b s tru c tio n , m a c ro a m y la s e m ia , a nd re n a l in s u ffic ie n c y ■ A m y la s e is p rim a rily c le a re d by k id n e y s ; re na l in s u ffic ie n c y is a c a u s e o f s p u rio u s h y p e ra m y la s e m ia ■ M a c ro a m y la s e m ia is d u e to im m u n o g lo b u lin -a m y la s e c o m p le x e s th a t c a n n o t be c le a re d by th e k id n e y s

1.2.1.2 Lipase ■ M o re s p e c ific th a n a m y la s e b u t it re m a in s e le v a te d fo r up to 14 d a y s

associated with amorphous pancreatitis, ovoid material, unilocular lesion with inflammatory thick wall adjacent to cells; no pancreas epithelium serous elderly female, bland cuboidal microcystic lesion epithelial cells cystadenoma within pancreas mucinous middle aged female, bland mucinous cystadenoma macrocystic lesion epithelial cells (mucinous cystic within pancreas neoplasm) intraductal papillary elderly male or female,bland to atypical mucinous tumor variable appearance, mucinous dilated duct epithelial cells solid cystic (solid adult female, solid & bland, pseudopapillary cystic lesion neuroendocrine tumor) like cells, myxoid stroma

Chemistry (amylase Nl CEA |C A 19-9 (amylase (CEA (CA 19-9 Nl amylase t CEA TCA19-9 | amylase t CEA N I-tC A 19-9 (.amylase (CEA (CA19-9

1.3 The heart 1.3.1 Myocardial markers 1.3.1.1 Cardiac enzymes ■ C re a tin e k in a s e (C K ) has 3 is o e n z y m e s by e le c tro p h o re s is : C K M M , C K M B , C K B B . T h e fa s te s t m ig ra tin g is B B (CK1), fo llo w e d by M B (C K 2 ), th e n M M (C K 3 ) f1.1

■ It is le s s d e p e n d e n t on re na l c le a ra n c e th a n a m y la s e

1.2.2 Tests of pancreatic exocrine function 1.2.2.1 Secretincholecystokinin test ■ A n e n d o s c o p e is u sed to m e a s u re p a n c re a tic e x o c rin e p ro d u c ts a fte r a d m in is tra tio n o f C C K

1.2.2.2 Noninvasive tests ■ Fecal fa t a na lysis, fe ca l ch y m o try p s in , and fe ca l e la s ta s e 1 ■ G o ld s ta n d a rd is 72 h o u r fe c a l fa t q u a n tita tio n a fte r in g e stio n o f a h ig h fa t d ie t fo r 6 d ays

© A S C P 2018

□ C K B B is in n e a rly all tis s u e ty p e s , w ith h ig h e s t c o n c e n tra tio n in brain, b la d d e r, s to m a c h , a n d p ro s ta te , b ut n o rm a lly th e re is no d e te c ta b le C K B B in s e ru m

ISBN 9 7 8 -08 9189-6678

5

1: Chemistry

The heart>Myocardial markers | Acute coronary syndrome/Acute myocardial infarction | Myocarditis Proteins>Major serum proteins □ C K M M is fo u n d in s k e le ta l a n d c a rd ia c m u s c le , w ith s k e le ta l m u s c le h a v in g - 9 9 % M M a n d c a rd ia c m u s c le 7 0 % , a n d n o rm a lly a b o u t 1 0 0 % o f s e ru m C K is m a d e up o f M M □ C K M B is fo u n d in c a rd ia c a n d s k e le ta l m u s c le , c o m p ris in g - 3 0 % o f c a rd ia c C K a n d 1% o f s k e le ta l, w ith s k e le ta l m u s c le b e in g th e s o u rc e o f n e a rly all s e ru m C K M B in n o rm a l a d u lts ■ M a c ro C K (m a c ro C K ty p e 1) is a C K im m u n o g lo b u lin c o m p le x th a t m ig ra te s b e tw e e n M M a n d M B a n d is fo u n d in s o m e h e a lth y e ld e rly w o m e n ■ M ito c h o n d ria l C K (m a c ro C K ty p e 2) is s e e n in s o m e p a tie n ts w ith a d v a n c e d m a lig n a n c y □ T o ta l C K ty p ic a lly ris e s w ith in 3 -6 h o u rs a fte r M l, p e a k s a t 12-2 4 h o u rs , a n d re tu rn s to n o rm a l w ith in 7 2 -9 6 h o u rs □ T o ta l C K is n o n s p e c ific a n d c a n b e e le v a te d fo llo w in g in ju ry to s k e le ta l m u s c le o r b ra in , a s w e ll a s v a rie tie s o f n o n is c h e m ic c a rd ia c in ju ry □ T h e ra tio o f C K M B to to ta l C K (re la tiv e in d e x o r C K in d e x ) im p ro v e s s p e c ific ity . R e la tiv e in d e x o f > 5 % is s u g g e s tiv e o f a c a rd ia c s o u rc e

1.3.1.2 Troponin ■ G ro u p o f p ro te in s th a t c o n s is ts o f tro p o n in T (TnT), tro p o n in I (T n l) a n d tro p o n in C (T n C ) ■ A fte r M l, tro p o n in ris e s w ith in 4 - 8 h o u rs , p e a k s a t 12-24 h o u rs , a n d re m a in s e le v a te d fo r up to 14 d a y s ■ B o th cTnl a n d cTnT a re h ig h ly c a rd io s p e c ific , th o u g h b o th m a y b e e le v a te d in n o n is c h e m ic fo rm s o f c a rd ia c in ju ry in c lu d in g c a rd ia c c o n tu s io n , m y o c a rd itis ■ N o rm a l tro p o n in is d e fin e d a s v a lu e s up to th e 9 9 th p e rc e n tile o f h e a lth y a d u lts ■ “ F a ls e p o s itiv e ” tro p o n in m a y b e s e e n in p u lm o n a ry e m b o lis m , m y o c a rd itis , p e ric a rd itis , h e a rt fa ilu re , in tra c ra n ia l in s u lts , rh a b d o m y o ly s is , s e p s is , s h o c k , a n d re n a l in s u ffic ie n c y

1.3.2 Acute coronary syndrome/Acute myocardial infarction ■ A c u te c o ro n a ry s y n d ro m e e n c o m p a s s e s u n s ta b le a n g in a , A M I, a n d s u d d e n c a rd ia c d e a th ■ H ig h s e n s itiv ity C R P (h s C R P ) a p p e a rs to be an in d e p e n d e n t p re d ic to r fo r th e d e v e lo p m e n t o f a c u te c o ro n a ry s y n d ro m e in h e a lth y in d iv id u a ls a nd p re d ic t s h o r tte r m p ro g n o s is ■ T h e c u rre n t u n iv e rs a l d e fin itio n o f a c u te m y o c a rd ia l in fa rc tio n (A M I) □ A lte ra tio n in tro p o n in (ris e a n d /o r fa ll in cTn w ith a t le a s t 1 v a lu e a b o v e th e 9 9 th p e rc e n tile ) □ O n e o f th e fo llo w in g : s y m p to m s o f is c h e m ia , n e w s ig n ific a n t S T-T c h a n g e s o r n e w le ft b u n d le b ra n c h b lo ck, d e v e lo p m e n t o f p a th o lo g ic a l Q w a v e s , im a g in g s h o w in g n e w lo s s o f v ia b le m y o c a rd iu m o r n e w re g io n a l w a ll m o tio n a b n o rm a lity , id e n tific a tio n o f an in tra c o ro n a ry th ro m b u s by a n g io g ra p h y o r a u to p s y ■ T ro p o n in e le v a tio n s re la te d to c o n d itio n s s u c h a s c h ro n ic re n a l fa ilu re o r C H F m ay be m a rk e d b u t d o n o t c h a n g e a cutely. H o w e ve r, a ris in g o r fa llin g p a tte rn is in d ic a tiv e o f AMI

1.3.3 Myocarditis ■ C a u se s: m o s t c o m m o n is v iru s , e s p e c ia lly C o x s a c k ie B, a d e n o v iru s , HIV, and p a rv o v iru s B19; o th e rs in c lu d e T ry p a n o s o m a c ru z i (C h a g a s d ise a se ), B o rre lia b u rg d o rfe ri (L ym e d is e a s e ), m e d ic a tio n s a nd s a rc o id o s is . G ia n t c e ll m y o c a rd itis s h o u ld be c o n s id e re d in p a tie n ts w ith s y s te m ic a u to im m u n e d is e a s e s a n d /o r th y m o m a ■ L a b o ra to ry fin d in g s in in c lu d e e le v a te d C K M B and tro p o n in , b u t th e s e n s itiv ity o f th e s e a s s a y s is lo w

1.4 Proteins 1.4.1 Major serum proteins t1.7

1.3.1.3 Myoglobin ■ M y o g lo b in is a h ig h ly s e n s itiv e c a rd ia c m a rk e r a n d is a n e a rly m a rk e r o f A M I, b e in g e le v a te d w ith in 1-2 h o u rs a fte r s y m p to m o n s e t. H o w e v e r, it is n o n s p e c ific

1.4.1.1 Album in ■ T h e m o s t a b u n d a n t s e ru m p rote in ■ T h e m ost p ro m in e n t a n d fa s te s t m ig ra tin g b an d on S P E P ■ S y n th e s iz e d p rim a rily in th e liv e r

1.3.1.4 B type natriuretic peptide ■ B ty p e n a triu re tic p e p tid e is d e riv e d fro m v e n tric u la r m y o c y te s ■ Its s y n th e s is c o rre la te s d ire c tly w ith v e n tric u la r w a ll te n s io n ■ H a lf-life is 2 0 m in u te s . T h e N te rm in a l p e p tid e fra g m e n t (N T -p ro B N P ) h a s h a lf-life o f 1-2 h o u rs

6

■ B N P a nd N T -p ro B N P a re e le v a te d in p a tie n ts w ith h e a rt fa ilu re

■ C o n g e n ita l a b s e n c e (a n a lb u m in e m ia ) c h a ra c te riz e d by m ild e d e m a a n d c o m p e n s a to ry h y p e rlip id e m ia ■ S e ve ra l a lle le s e x is t, th e m o s t c o m m o n o f w h ic h is a lb u m in A. W h e n a v a ria n t a lb u m in is p re s e n t, it m ay p re s e n t e le c tro p h o re tic a lly a s b is a lb u m in e m ia

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

1: Chemistry

Proteins>Major serum proteins t1 .7 Serum proteins Electrophoretic Major constituent(s) band prealbumin

prealbumin

Notes indicator of nutritional status binds thyroid hormones, binds retinol binding protein negative acute phase reactant maintains serum oncotic pressure binds numerous substances negative acute phase reactant HDL

albumin

albumin

alb-a, interface

a1-lipoprotein

°1

a^antitrypsin

c^-dj interface

Gc globulin

positive acute phase reactant a1 antitrypsin deficiency detectable with serum protein electrophoresis (SPEP) binds vitamin D

a^antichymotrypsin

positive acute phase reactant

°2

c^-acid glycoprotein

positive acute phase reactant

a2-macroglobulin

elevated in nephrotic syndrome

Haptoglobin Ceruloplasmin

Positive acute phase reactant Binds copper Low ceruloplasmin not detectable with SPEP Positive acute phase reactant hemoglobin, usually absent from serum, may be present here when there is hemolysis—a possible pseudo M spike transferrin may be high in iron deficiency—a possible pseudo M spike LDL

a2-p interface

usually empty

Pi

transferrin

P1-P2 interface

P-Iipoprotein

P2

IgA

C3 y globulins CRP

Yi y2

fibrinogen, usually absent from serum, may be present in the p-y interface when there is incomplete clotting—a possible pseudo M spike positive acute phase reactant, C3 breakdown products—a possible pseudo M spike positive acute phase reactants positive acute phase reactant

■ C lin ic a l u tility in a s s e s s m e n t o f h e p a tic s y n th e tic fu n c tio n , n u tritio n a l s ta tu s ■ H a lf-life o f a lb u m in is 17 d a y s

t1 .8 Acute phase reactants (APR) Protein Acute inflammation prealbumin 1 albumin 1 a1 0,-antitrypsin t a^antichymotrypsin t 0,-acid glycoprotein t a2 Haptoglobin T Ceruloplasmin T P Complement (C3) T Transferrin 1 Fibrinogen T y

lg (IgA, IgM) lg (IgG, IgA, IgM) CRP

-i t

Chronic inflammation

l i

t T T T T T T T T T T

■ R e a d ily c ro s s e s th e b lo o d -b ra in b a rrie r a n d a c tiv e ly s e c re te d into th e c e re b ro s p in a l flu id , th u s a p ro m in e n t c o m p o n e n t o f C S F p ro te in e le c tro p h o re s is

1.4.1.3 c^-antitrypsin (AAT) ■ la is th e m a jo r c o m p o n e n t o f th e a 1 b a n d ■ M ain fu n c tio n is p ro te a s e in a c tiv a tio n ■ A A T g e n e (S E R P IN A 1 ) is h ig h ly p o ly m o rp h ic , w ith m o s t c o m m o n a lle le P iM and m o s t c o m m o n g e n o ty p e P iM M ■ In h e rita n c e o f h o m o z y g o u s Z a lle le (“ P iZ Z ” ) le a d s to A A T d e fic ie n c y ■ A A T d e fic ie n c y m a y be d e te c ta b le on S P E P

1.4.1.4 d-j-acid glycoprotein ■ P o sitiv e a c u te p h a s e re a c ta n t a n d a m a jo r c o m p o n e n t o f th e in c re a s e d a 1 ban d in a c u te in fla m m a to ry s ta te s

1.4.1.5 a2-macroglobulin ■ R e la tiv e 1 0 -fo ld in c re a s e in n e p h ro tic s y n d ro m e (la rg e s ize p re c lu d e s filtra tio n )

■ M a rk e d re d u c tio n s in n e p h ro tic s y n d ro m e

1.4.1.6 Ceruloplasmin

■ N e g a tiv e a c u te p h a s e re a c ta n t t1.8

■ F u n c tio n s in c o p p e r tra n s p o rt

1.4.1.2 Prealbumin ■ N o t n o rm a lly se e n on S P E P b u t m ig ra te s fa s te r th a n a lb u m in ■ B in d s ~ 1 0% o f c irc u la tin g th y ro x in e (it is a ls o c a lle d tra n s th y re tin [T T R ] and th y ro x in e b in d in g p re a lb u m in ) a nd b in d s re tin o l b in d in g p ro te in :v ita m in A c o m p le x ■ C lin ic a l u tility in th e a s s e s s m e n t o f n u tritio n a l s ta tu s , h a lf-life o f 4 8 h o u rs

■ In a d d itio n to W ils o n d is e a s e , th e d e c re a s e d c e ru lo p la s m in in h e p a tic fa ilu re , m a ln u tritio n , a nd M e n k e s s y n d ro m e ■ F a ls e ly n o rm a l o r e le v a te d c e ru lo p la s m in m a y be s e e n in in fla m m a to ry s ta te s (is a n a c u te p h a s e re a c ta n t)

1.4.1.7 Haptoglobin ■ T h ird m a jo r c o m p o n e n t o f th e a 2 b a n d ■ B in d s fre e h e m o g lo b in ; ra p id ly d e p le te d in h e m o ly s is

© A S C P 2018

ISBN 978-08 9189-6678

7

1: Chemistry

Proteins>Major serum proteins | Patterns in serum protein electrophoresis ■ D o e s n o t b in d m y o g lo b in

a

■ A c u te p h a s e re a c ta n t

1.4.1.8 Transferrin

*

m

■ T h e m a jo r p g lo b u lin ■ T ra n s p o rts fe r r ic (F e 3+) iro n ■ M a rk e d ly in c re a s e d in iro n d e fic ie n c y , b u t a ls o in c re a s e d in p re g n a n c y a n d e s tro g e n th e ra p y ■ E le v a te d w ith c h ro n ic in fla m m a tio n (d e c re a s e s in th e e a rly s ta g e s o f an a c u te p h a s e re s p o n s e ) ■ M o d ifie d w h e n c ro s s e s b lo o d -b ra in b a rrie r to a s ia la te d tra n s fe rrin (so c a lle d t p ro te in ); th u s , a h a llm a rk o f C S F p ro te in e le c tro p h o re s is is a d o u b le tra n s fe rrin p e a k ■ C a rb o h y d ra te d e fic ie n t tra n s fe rrin is u s e d a s a m a rk e r o f c h ro n ic a lc o h o l u s e

1.4.1.9 Fibrinogen ■ A p g lo b u lin th a t, n o rm a lly c o n s u m e d in th e fo rm a tio n o f th e c lo t, is n o t p re s e n t in s e ru m p ro te in e le c tro p h o re s is ■ In c o m p le te c lo ttin g m a y le a d to p s e u d o p a ra p ro te in

1.4.1.10 C reactive protein ■ P ro d u c e d in th e liv e r a n d m ig ra te s in y re g io n , w h e re it c a n p ro d u c e a s m a ll p s e u d o p a ra p ro te in ■ A m a rk e r o f s y s te m ic in fla m m a tio n

Fractions Albumin

% 57.6

Ref. % 52.9-66.9

q/dL 3.8

Ref. q/dL 3.7-4.9

a,

4.5

0.3

0.2-0.4

0.8

0.5-0.9

P

12.0 13.4

3.0-5.8 7.5-13.4

Y

12.5

8.5-13.7 8.8-19.2

0.9 0.8

0.6-1.0 0.6-1.4

f1.2 Normal high resolution serum protein electrophoresis; the most anodal band is albumin, followed by a,, a2, p2, and the broad, faint y region

■ H ig h s e n s itiv ity C R P (h s C R P ) a s s a y s m a y in d ic a te c a rd io v a s c u la r ris k ■ S e a s o n a l v a ria tio n s w ith h ig h e s t le v e ls in w in te r

1.4.2 Patterns in serum protein electrophoresis 1.4.2.1 Normal serum f1.2 ■ N e a rly in v is ib le p re a lb u m in b a n d , la rg e a lb u m in b a n d , s m a ll p e a k e d a1 b a n d , a s o m e w h a t b ro a d a 2 b a n d , b im o d a l p, a n d b ro a d y

1.4.2.2 Bisalbuminemia ■ B is a lb u m in e m ia is s e e n in h e te ro z y g o te s fo r a lb u m in a lle le s . N o c lin ic a l c o n s e q u e n c e

1.4.2.3 a^antitrypsin (AAT) deficiency f1.3 ■ A A T d e fic ie n c y c a n b e d e te c te d w ith S P E P (th o u g h it is n o t a s e n s itiv e o r s p e c ific a s s a y ), s in c e A A T is th e m a jo r c o m p o n e n t o f th e a 1 b a n d

1.4.2.4 Nephrotic syndrome ■ M a s s iv e lo s s o f s m a ll s e ru m p ro te in s , p a rtic u la rly a lb u m in 8

f1.3 SPEP showing patient with a1 antitrypsin deficiency (top) & normal SPEP for comparison (bottom) ■ D e c re a s e o f all b a n d s, e s p e c ia lly a lb u m in , w ith th e e x c e p tio n o f th e a 2 ban d th a t c o n ta in s a 2 m a c ro g lo b u lin

1.4.2.5 Acute inflammation f1.4 ■ In c re a s e d a c u te p h a s e re a c ta n ts lea d to in c re a s e s in a 1 a n d a 2 b a n d s . A lb u m in is s lig h tly d e c re a s e d ■ W ith p ro lo n g e d in fla m m a tio n th e g a m m a g lo b u lin s a re p o ly c lo n a lly in c re a s e d

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

1: Chemistry

Proteins>Patterns in serum protein electrophoresis

Fractions Albumin

Ref % 52.9-66.9 3.9-5.8 7.5-13.4 8.5-13.7 8.8-19.2

g/dL 2.5 L 0.6 H 1.7 H

oo CZ3

a, a2 P Y

% 38.1 9.9 25.4 11.6 15.0

1.0

Ref g/dL 3.7-4.9 0.2-0.4 0.5-0.9 0.6-1.0 0.6- 1.4

ft,4 Acute inflammation pattern

1.4.2.6 P-Y bridging ■ T h is is th e h a llm a rk o f c irrh o s is , p rim a rily d u e to in c re a s e d s e ru m IgA

Fractions

■ A d d itio n a l fe a tu re s in c lu d e h y p o a lb u m in e m ia and b lu n te d a 1 a n d a 2 b a n d s

1.4.2.7 Monoclonal gammopathy f1 .5 -f1 .8 ■ M o n o c lo n a l g a m m o p a th y (p a ra p ro te in e m ia o r M p ro te in ) re fe rs to a h o m o g e n o u s im m u n o g lo b u lin in th e s e ru m ■ P ro m in e n t, d is c re te , d a rk b an d (M sp ike ) in th e y re g io n , s o m e tim e s in p o r a 2

Albumin Alpha 1 Alpha 2 Beta Gamma

1

%

Ref. %

35.1 9.3

50.9 - 65.5 4 .4 - 9.9 6 .3 -1 3 .1 8 .6 -1 4 .2 8 .8 -1 9 .2

11.6 7.9 36.1 35.1

g/dl 3.0 L 0.8 H 1.0

0.7 3.1 H 3.0

Ref. g/dl 3 .6 0 .3 0 .5 0.6 0. 6 -

4.8 0.7 1.0

1.0 1.4

fl.5 SPEP showing typical M spike; most IgG paraproteins are found in the y region on the gel (above) & densitometry tracing (below)

■ M o s t c o m m o n ly th e re s u lt o f a p la s m a c e ll n e o p la s m , b u t m a y be p re s e n t in ly m p h o m a , e s p e c ia lly ly m p h o p la s m a c y tic ly m p h o m a o r c h ro n ic ly m p h o c y tic le u k e m ia /s m a ll ly m p h o c y tic ly m p h o m a ■ T h e M p ro te in is u s u a lly c o m p o s e d o f 2 h e a v y a n d 2 lig h t c h a in s , s o m e tim e s a lig h t c h a in o n ly and ra re ly a h e a v y c h a in o n ly ■ B ic lo n a l g a m m o p a th y o c c u rs in 3 % -4 % o f c a s e s (a p p a re n t Ig A b ic lo n a lity is m o s t fre q u e n tly c a u s e d by d im e riz a tio n , w h ic h ca n be e lim in a te d by p re tre a tm e n t w ith a re d u c in g a g e n t su ch as P -m e rc a p to e th a n o l)

f1,6 SPEP & IFE showing IgM k M protein; note that IgM paraproteins tend to

migrate near the p-y interface

■ -1 0 % o f p a tie n ts w ith m y e lo m a h ave an S P E P s h o w in g o n ly h y p o g a m m a g lo b u lin e m ia . T h is is ty p ic a l o f p a tie n ts w ith lig h t c h a in o n ly m y e lo m a s

1 2 3 4 5

■ Im m u n o fix a tio n o r im m u n o s u b tra c tio n is in d ic a te d to c h a ra c te riz e th e M p ro te in

6 7

SPE 1 1:2

■ P s e u d o M s p ik e s ■ F ib rin o g e n (in c o m p le te ly c lo tte d s a m p le ) □ H e m o g lo b in (h e m o ly z e d s a m p le ) □ E le va te d C R P © A S C P 2018

SPE 2 1:5

IgA 3 1:10

IgM 4 N

K 5 1:5

X

6 1:5

f1.7 SPEP & IFE showing IgA A M protein; note that IgA paraproteins tend to migrate into the p region ISBN 978-08 9 1 8 9 -6 6 7 8

9

1: Chemistry

Proteins>Patterns in serum protein electrophoresis | CSF protein electrophoresis | Urine protein electrophoresis | Cryoglobulinemia

f1.8 SPEP (upper left), serum IFE (upper right), UPEP (lower left), urine IFE (lower right) showing K light chain only M protein

□ E le v a te d tra n s fe rrin □ C e rta in a n tib io tic s a n d s o m e ra d io c o n tra s t a g e n ts

f1.9 CSF protein electrophoresis a CSF (left) & serum (right) from the same patient, neither demonstrating oligoclonal bands b CSF (left) & serum (right) from the same patient, in which oligoclonal bands are present in the CSF but not in the serum, a result supportive of the diagnosis of MS c CSF (left) & serum (right), both with oligoclonal bands, in which case the CSF bands would be discounted

□ V e ry h ig h le v e ls o f s e ru m tu m o r m a rk e rs ■ M p ro te in q u a n tita tio n c a rrie d o u t b y n e p h e lo m e try (or tu rb id im e try )

1

a,

■ S e ru m v is c o s ity m a y b e in c re a s e d in p a tie n ts w ith IgM o r Ig A p a ra p ro te in s

(3 ( t r a n s f e r r i n )

Y

2b

ilia II 1

a lb u m i n

■ S e ru m fre e lig h t c h a in s im p o rta n t b o th d ia g n o s tic a lly a nd in th e m o n ito rin g o f d is e a s e

2a

2c

—

1.4.3 CSF protein electrophoresis ■ E le c tro p h o re s is o f n o rm a l C S F □ R e la tiv e ly p ro m in e n t p re a lb u m in b a n d □ D o u b le p (tra n s fe rrin ) b a n d

f1,10 Urine protein electrophoresis (UPEP); patterns representing normal (1), glomerular proteinuria (2a), tubular proteinuria (2b) & overflow proteinuria (2c) are shown

■ T h e s e fin d in g s m a y b e u s e d to d ia g n o s e C S F le a k ■ H ig h re s o lu tio n C S F e le c tro p h o re s is m a y be u s e d to s u p p o rt a d ia g n o s is o f m u ltip le s c le ro s is f1.9

1.4.4 Urine protein electrophoresis f1.10 1.4.4.1

Glom erular proteinuria pattern

1.4.4.3

Overflow proteinuria pattern

■ M o s t c o m m o n ly th is is a m o n o c lo n a l lig h t c h a in (B e n c e J o n e s p ro te in u ria ) ■ O th e r p o s s ib ilitie s in c lu d e m y o g lo b in a nd h e m o g lo b in

■ P ro m in e n t a lb u m in , (31 a n d (B b a n d s

1.4.5 Cryoglobulinemia

■ R e fle c ts in c re a s e d p ro te in p e rm e a b ility in g lo m e ru lo n e p h ritis

1.4.5.1 Cryoglobulins

1.4.4.2

Tubular proteinuria pattern

■ C ry o g lo b u lin s a re im m u n o g lo b u lin s th a t p re c ip ita te re v e rs ib ly a t lo w te m p e ra tu re

■ S m a ll a lb u m in b a n d , w ith p ro m in e n t a1 a n d p b a n d s

■ O n c e d e te c te d , c ry o g lo b u lin s m a y be c h a ra c te riz e d by e le c tro p h o re s is and im m u n o fix a tio n

■ R e fle c ts im p a ire d tu b u la r re a b s o rp tio n in tu b u lo in te rs titia l in ju ry

■ 3 ty p e s o f c ry o g lo b u lin

10

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

1: Chemistry

Proteins>Cryoglobulinem ia | Laboratory methods Acid-base & electrolytes>Sodium □ T yp e I c ry o g lo b u lin s a re m o n o c lo n a l im m u n o g lo b u lin s fo u n d in a s s o c ia tio n w ith p la s m a ce ll o r ly m p h o id n e o p la s m □ T yp e II c ry o g lo b u lin s a re a m ix tu re o f a m o n o c lo n a l IgM and p o ly c lo n a l IgG . T h e IgM h a s rh e u m a to id fa c to r a c tiv ity (a n ti-Ig G ). T h is is th e m o s t c o m m o n ty p e o f c ry o g lo b u lin □ T yp e III c ry o g lo b u lin s a re a m ix tu re o f 2 p o ly c lo n a l im m u n o g lo b u lin s , ty p ic a lly IgG a n d IgM

1.4.5.2 Mixed cryoglobulinemia (types II & III) ■ F o un d in a v a rie ty o f c lin ic a l c o n d itio n s , m o s t c o m m o n ly h e p a titis C v iru s in fe c tio n , in a d d itio n to ly m p h o p ro life ra tiv e d is o rd e rs , c h ro n ic in fe c tio n s , c h ro n ic liv e r d is e a s e s , a n d a u to im m u n e d is e a s e s (e s p e c ia lly s y s te m ic lu p u s e ry th e m a to s u s [S L E ]) ■ C ry o g lo b u lin e m ia is a s y s te m ic im m u n e c o m p le x d is e a s e c h a ra c te riz e d by p a lp a b le p u rp u ra (le u k o c y to c la s tic v a s cu litis ), a rth ra lg ia s , h e p a to s p le n o m e g a ly , ly m p h a d e n o p a th y , a n e m ia , s e n s o rin e u ra l d e fic its , a nd g lo m e ru lo n e p h ritis . M o s t p a tie n ts a re h y p o c o m p le m e n te m ic ■ R e n al b io p s ie s s h o w m e m b ra n o p ro life ra tiv e g lo m e ru lo n e p h ritis (M P G N ) ty p e II, a nd in th e a c u te p h a s e m a y s h o w th ro m b o tic m ic ro a n g io p a th y . E le c tro n m ic ro s c o p y d e m o n s tra te s la rg e s u b e n d o th e lia l im m u n e c o m p le x d e p o s its w ith a fib rilla ry o r tu b u la r s tru c tu re in a fin g e rp rin tlik e p a tte rn

f1.12 Immunofixation electrophoresis (IFE) demonstrating an IgG k monoclonal

protein

1.4.6 Laboratory methods 1.4.6.1 Protein electrophoresis ■ M o s t p ro te in s b e a r a n e t n e g a tiv e c h a rg e a t pH 8.6, c a u s in g a ttra c tio n to th e a n o d e (p o s itiv e pole), b u t a c o u n te ra c tiv e fo rc e , e n d o s m o s is , m a y pull th e m to w a rd s th e c a th o d e . In th e c a s e o f y g lo b u lin s , w h ic h h ave a w e a k n et n e g a tiv e c h a rg e , th e e n d o s m o tic fo rc e p re v a ils and th e y a re m o v e d to w a rd s th e c a th o d e ■ C a p illa ry z o n e e le c tro p h o re s is is s im ila r in m a n y re s p e c ts to g el e le c tro p h o re s is b u t is c a p a b le o f g re a te r re s o lu tio n

1.4.6.2 Immunofixation & immunotyping ■ Im m u n o fix a tio n e le c tro p h o re s is (IF E ), im m u n o ty p in g , a n d im m u n o e le c tro p h o re s is (IE P ) a re m e th o d s fo r c h a ra c te riz in g a s u s p e c te d m o n o c lo n a l b an d ■ IE P f1.11 is no lo n g e r in ro u tin e c lin ic a l u se ■ IFE f1.12 in v o lv e s p la c in g p a tie n t s e ru m into e a c h o f 6 w e lls in a gel. A fte r e le c tro p h o re s is , 5 d iffe re n t a n tis e ra a re a p p lie d to th e gel: a n ti-Ig G , Ig A , Ig M , k , and A ■ Im m u n o ty p in g (IT, im m u n o s u b tra c tio n ) f1.13 is o fte n u sed in c o n ju n c tio n w ith c a p illa ry e le c tro p h o re s is © A S C P 2018

f1.13 Immunotyping (IT) or immunosubtraction demonstrating an IgG k monoclonal protein

1.5 Acid-base & electrolytes 1.5.1 Sodium 1.5.1.1 Hyponatremia ■ A c o m m o n a b n o rm a lity o c c u rrin g in up to 3 0 % o f h o s p ita liz e d p a tie n ts □ E x c lu d e s p u rio u s h y p o n a tre m ia , p s e u d o h y p o n a tre m ia , a n d h y p e rg ly c e m ia ■ S p u rio u s h y p o n a tre m ia re s u lts w h e n b lo o d is d ra w n p ro x im a l to an in tra v e n o u s in fu s io n

ISBN 978-08 9189-6678

11

1: Chemistry

Acid-base & electrolytes>Sodium | Potassium □ P s e u d o h y p o n a tre m ia is a n a rtifa c t o f th e “ in d ire c t” m e th o d o f m e a s u re m e n t in th e p re s e n c e o f h y p e rtri g ly c e rid e m ia , h y p e rc h o le s te ro le m ia , o r h y p e rp ro te in e m ia . In th is s c e n a rio th e s e ru m o s m o la lity is n o rm a l, o s m o la l g a p is in c re a s e d , a n d b lo o d g a s a n a ly z e rs c a n c o rre c tly d e te rm in e th e s e ru m s s o d iu m □ In h y p e rg ly c e m ia , th e re is a tru e p h y s io lo g ic s h ift in s o d iu m io n s . E x c e s s g lu c o s e d ra w s w a te r in to th e e x tra c e llu la r s p a c e , p ro d u c in g h y p o n a tre m ia th a t is re a l b u t u n re la te d to a n y in trin s ic d e fe c t in s o d iu m h o m e o s ta s is ■ T ru e (h y p o to n ic ) h y p o n a tre m ia is c la s s ifie d a c c o rd in g to th e v o lu m e s ta tu s o f th e p a tie n t □ H y p o v o le m ic : re n a l o r e x tra re n a l lo s s e s ■ R e n a l lo s s e s : e le v a te d u rin e s o d iu m (U Na> 3 0 m m o l/L ); d iu re tic s , re n a l m e d u lla ry d is e a s e , p rim a ry a d re n a l in s u ffic ie n c y (A d d is o n d is e a s e ), re n a l tu b u la r a c id o s is ty p e I, a n d c e re b ra l s a lt w a s tin g s y n d ro m e ■ E x tra re n a l lo s s e s : g a s tro in te s tin a l (v o m itin g , d ia rrh e a ) o r re s u lt fro m th ird s p a c in g □ E u v o le m ic : S IA D H , p s y c h o g e n ic p o ly d ip s ia , h y p o th y ro id is m , p rim a ry a d re n a l in s u ffic ie n c y (A d d is o n d is e a s e ), a n d d ru g s w ith A D H like (v a s o p re s s in like) e ffe c t. To a v o id m is d ia g n o s is , th e d ia g n o s is o f S IA D H s h o u ld b e m a d e o n ly w h e n th e re is n o rm a l re n a l fu n c tio n , no re c e n t u s e o f d iu re tic s , a n d n o rm a l a d re n a l fu n c tio n □ H y p e rv o le m ic : c o n g e s tiv e h e a rt fa ilu re , c irrh o s is , and n e p h ro tic s y n d ro m e

1.5.1.2 Hypernatremia

1.5.2 Potassium 1.5.2.1 Potassium measurement ■ S p u rio u s re s u lts a re c o m m o n a n d m o s t o fte n d u e to s p e c im e n h e m o ly s is ■ P s e u d o h y p e rk a le m ia m a y be d u e to □ R e le a s e fro m d e g e n e ra tin g c e lls (im m e d ia te c e n trifu g a tio n is in te n d e d to a v o id this); th is is p ro n o u n c e d in le u k o c y to s is o r th ro m b o c y to s is □ Im p ro p e r c o lle c tio n : p ro lo n g e d to u rn iq u e t tim e, e x c e s s iv e fis t c le n c h in g , tra u m a tic d raw , in a p p ro p ria te o rd e r o f tu b e s d ra w n , v e n ip u n c tu re p ro x im a l to in tra v e n o u s in fu s io n , s m a ll g a u g e n e e d le s □ R a re ly p o ta s s iu m le a k in g fro m fa u lty tra n s m e m b ra n e c h a n n e ls o f e ry th ro c y te s in fa m ilia l p s e u d o h y p e rk a le m ia

1.5.2.2 Hypokalemia ■ T h e d iffe re n tia l d ia g n o s is in c lu d e s p o ta s s iu m lo s s th ro u g h th e G l tra c t, p o ta s s iu m lo s s th ro u g h th e k id n e y s , a n d tra n s c e llu la r s h ifts o f e x tra c e llu la r p o ta s s iu m to th e in tra c e llu la r s p a c e ■ T ra n s c e llu la r s h ifts : m e ta b o lic a lk a lo s is , tre a tm e n t fo r d ia b e tic k e to a c id o s is ■ G l loss

■ M o s t c o m m o n ly s e e n in p a tie n ts w h o a re b o th d e h y d ra te d (d ia rrh e a o r in s e n s ib le w a te r lo s s e s ) a n d u n a b le to o b ta in w a te r (in fa n ts , IC U p a tie n ts , d e b ilita te d a d u lts ) ■ H y p o v o le m ic p a tie n ts : e x tra re n a l w a te r lo s s (d ia rrh e a , v o m itin g , b u rn s ) o r re n a l w a te r lo s s (o s m o tic d iu re tic s , lo o p d iu re tic s , p o s to b s tru c tiv e d iu re s is , in trin s ic m e d u lla ry re n a l d is e a s e ) ■ E u v o le m ic : d ia b e te s in s ip id u s (D l) m u s t b e c o n s id e re d in a d d itio n to th e c o n s id e ra tio n s a p p lic a b le to h y p o v o le m ic p a tie n ts □ D l re s u lts fro m in s u ffic ie n t A D H a c tiv ity ■ C e n tra l (to o little A D H m a d e in th e p o s te rio r p itu ita ry ): d a m a g e to th e h y p o th a la m u s o r n e u ro h y p o p h y s is , s p a c e o c c u p y in g le s io n s in th e re g io n o f th e s e lla , h e a d tra u m a , e o s in o p h ilic g ra n u lo m a a n d s a rc o id o s is

12

■ N e p h ro g e n ic (A D H is p ro d u c e d n o rm a lly , b ut th e c o lle c tin g d u c ts a re re s is ta n t to its a ction ): s ic k le c e ll d is e a s e , tu b u lo in te rs titia l n e p h ritis , h y p o k a le m ia a n d h y p e rc a lc e m ia , F a n c o n i re na l s y n d ro m e , lith iu m , d e m e c lo c y c lin e , c o lc h ic in e , a m p h o te ric in B, g e n ta m ic in , a n d fu ro s e m id e

□ U rin a ry p o ta s s iu m is lo w (U K < 3 0 m E q /d a y ) □ V o m itin g , n a s o g a s tric tu b e s u c tio n , d ia rrh e a , o r (th e o re tic a lly ) a la rg e v illo u s a d e n o m a ■ R e n a l lo ss □ E leva te d u rin a ry p o ta s s iu m (U K > 3 0 m E q /d a y ) □ D iu re tic s , h y p o m a g n e s e m ia , a n tib io tic s (c a rb e n ic illin , a m p h o te ric in B), m in e ra lo c o rtic o id e x c e s s , re na l tu b u la r a c id o s is ty p e s I and II, s e v e re C u s h in g s y n d ro m e , c o n g e n ita l a d re n a l h y p e rp la s ia , B a rtte r s y n d ro m e , L id d le s y n d ro m e , G ite lm a n s y n d ro m e , lic o ric e (g ly c y rrh iz in ) c o n s u m p tio n , a nd h y p e rre n in is m

1.5.2.3 Hyperkalemia ■ T h e d iffe re n tia l d ia g n o s is in c lu d e s a c id o s is , re n a l fa ilu re , p o ta s s iu m s p a rin g d iu re tic s (s p iro n o la c to n e , tria m te re n e , a m ilo rid e , e p le re n o n e ), a d re n a l in s u ffic ie n c y , ia tro g e n ic , a n d rh a b d o m y o ly s is

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

1: Chemistry

Acid-base & electrolytes>Potassium | Calcium ■ N e a rly all c a s e s o f a c id o s is a re a s s o c ia te d w ith h y p e rk a le m ia . T h e m ain e x c e p tio n s a re R TA ty p e s I and II, in w h ic h th e p o ta s s iu m is low

■ S e c o n d a ry h y p e rp a ra th y ro id is m □ E x c e s s iv e P T H s e c re tio n in re s p o n s e to h y p o c a lc e m ia o f a n y c a u s e □ M o s t c o m m o n ly th e re su lt o f c h ro n ic re n a l fa ilu re

1.5.3 Calcium

□ C a lc iu m is low , P T H is n o rm a l to h ig h

1.5.3.1 Calcium measurement ■ Total c a lc iu m in c lu d e s fre e a nd b o u n d c a lc iu m ; m u s t be in te rp re te d in lig h t o f th e c o n c e n tra tio n o f a lb u m in and o th e r s e ru m p ro te in s (p a ra p ro te in e m ia ) ■ F ree c a lc iu m (io n iz e d c a lc iu m ) is b io lo g ic a lly a c tiv e a nd a m o re a c c u ra te re fle c tio n o f th e c lin ic a l c a lc iu m s ta tu s □ T h e s a m p le m u s t n o t be e x p o s e d to air, m u s t n o t be d ra w n in c a lc iu m c h e la tin g a n tic o a g u la n ts (E D T A , citra te ), and fis t c le n c h in g a n d p ro lo n g e d to u rn iq u e t a p p lic a tio n m u s t be a v o id e d

□ P h o s p h a te is re ta in e d b y th e k id n e y s , c re a tin g d e p o s itio n (c a lc ip h y la x is ) □ M a rk e d a c tiv a tio n o f o s te o c la s ts le a d s to re n a l o s te o d y s tro p h y ■ T e rtia ry h y p e rp a ra th y ro id is m □ A u to n o m o u s p a ra th y ro id h y p e rs e c re tio n th a t fo llo w s p ro lo n g e d p e rio d s o f s e c o n d a ry h y p e rp a ra th y ro id is m □ H u m o ra l h y p e rc a lc e m ia o f m a lig n a n c y ■ M e d ia te d by P TH re la te d p ro te in (P T H rP )

□ T h e s a m p le m u s t be k e p t c o o l a nd d e liv e re d to th e la b o ra to ry ra p id ly

□ S q u a m o u s ce ll c a rc in o m a o f lu n g a n d o th e r s ite s , b re a s t c a rc in o m a , T c e ll ly m p h o m a

□ T h e m e a s u re m e n t is u s u a lly p e rfo rm e d on a b lo o d g a s a n a ly z e r

□ Im m u n o a s s a y s fo r PTH d o n o t d e te c t P T H rP , a n d P T H rP m u s t be s p e c ific a lly a s s a y e d ■ H y p e rv ita m in o s is D

1.5.3.2 Hypercalcemia ■ T h e m o s t c o m m o n c a u s e o f h y p e rc a lc e m ia t1.9 is p rim a ry h y p e rp a ra th y ro id is m t1 .9 Differential diagnosis of hypercalcemia Notes Etiology parathyroid adenoma (most common), 4 primary hyperparathyroidism gland hyperplasia, parathyroid carcinoma post renal transplant tertiary hyperparathyroidism squamous cell carcinoma, multiple malignancy myeloma, breast carcinoma, islet cell tumors, paraganglioma, renal cell carcinoma, hepatocellular carcinoma, T acute lymphoblastic lymphoma, small cell carcinoma of ovary (hypercalcemic type) familial hypocalciuric hypercalcemia CASR gene on 3q thiazides, calcium containing antacids drugs or calcium supplements (milk alkali syndrome), hypervitaminosis D hyperthyroidism, Addison, acromegaly other endocrine sarcoidosis, primarily granulomatous disease only if the patient is immobilized Paqet disease □ E x c e s s p a ra th y ro id h o rm o n e (P T H ) t1.10 re s u lts in ■ In c re a s e d s e ru m c a lc iu m

□ R e s u lts fro m lo n g te rm in g e s tio n o f v ita m in s u p p le m e n ts □ V ita m in D e n h a n c e s re a b s o rp tio n o f b o th c a lc iu m a n d p h o s p h a te b y th e k id n e y s , p o te n tia lly le a d in g to c a lc ip h y la x is ■ S a rc o id o s is □ T h e h is tio c y te s o f s a rc o id a l g ra n u lo m a s a p p e a r to h ave th e c a p a c ity to a c tiv a te v ita m in D ■ M ilk a lk a li s y n d ro m e □ H ig h d o s e c a lc iu m s u p p le m e n ta tio n t1 .1 0 Forms of parathyroid hormone (PTH) Half-life Biologic activity + short intact PTH + short N terminal PTH long midregion PTH long C terminal PTH

1.5.3.3 Hypocalcemia t1.11 ■ P rim a ry h y p o p a ra th y ro id is m is m o s t o fte n ia tro g e n ic (s u rg ica l) ■ H e re d ita ry h y p o p a ra th y ro id is m , e ith e r is o la te d o r in a s s o c ia tio n w ith th e D iG e o rg e s y n d ro m e

■ D e c re a s e d s e ru m p h o s p h a te ■ In c re a s e d c h lo rid e :p h o s p h a te ra tio

■ H y p o m a g n e s e m ia if p e rs is te n t c a n le a d to s u p p re s s e d P T H s e c re tio n

■ In c re a s e d u rin a ry c A M P ■ T h e m o s t c o m m o n c a u s e o f p rim a ry h y p e rp a ra th y ro id is m is a s o lita ry p a ra th y ro id a d e n o m a , fo llo w e d by 4 g la n d h y p e rp la s ia a nd p a ra th y ro id c a rc in o m a

© A S C P 2018

ISBN 978-08 9189-6678

13

1: Chemistry

Acid-base & electrolytes>Calcium | Acid-base disorders t 1 .11 Differential diagnosis of hypocalcem ia Notes Etiology hypoproteinemia chronic renal failure drugs

due to low albumin; ionized calcium usually normal hyperphosphatemia present heparin, glucagon, osmotic diuretics, loop diuretics (eg, furosemide), aminoglycosides, mithramycin hypoparathyroidism postsurgical, hypomagnesemia, DiGeorge syndrome, autoimmune medullary thyroid carcinoma rarely affects serum calcium calcium chelation hyperphosphatemia vitamin D deficiency most patients with vitamin D deficiency have normal calcium levels pancreatitis extensive calcium deposition massive transfusion citrate

□ E m its 4 w a v e le n g th s to d ire c tly m e a s u re o x y h e m o g lo b in , d e o x y h e m o g lo b in , m e th e m o g lo b in , and c a rb o x y h e m o g lo b in □ M ay fa il to d e te c t s u lfh e m o g lo b in e m ia ■ T ra d itio n a l A B G a n a ly z e rs □ U se a pH e le c tro d e , C 0 2 e le c tro d e , a n d 0 2 e le c tro d e to m e a s u re pH , P C 0 2, a nd P 0 2 d ire c tly □ D e rive p e rc e n t s a tu ra tio n th ro u g h a c a lc u la tio n th a t a s s u m e s a n o rm a l h e m o g lo b in o x y g e n a ffin ity □ E x p o s u re to a tm o s p h e ric a ir h as th e e ffe c t o f lo w e rin g th e p C 0 2 ra is in g th e 0 2, a nd ra is in g th e pH □ D e la ys in te s tin g a llo w g ly c o ly s is to o ccu r, h a v in g th e o p p o s ite e ffe c ts □ A rte ria l v e rs u s v e n o u s b lo o d : in h e a lth y p a tie n ts , th e a rte ria l b lo o d p 0 2 is h ig h e r by a b o u t 6 0 m m H g and p C 0 2 lo w e r by a b o u t 6 -8 m m H g .

1.5.4 Acid-base disorders 1.5.4.1 Definitions ■ A c id e m ia : a rte ria l p H < 7 .3 5 ■ A c id o s is : a c o n d itio n th a t te n d s to lo w e r th e pH (th e pH m a y n o t a c tu a lly be lo w e re d , b e c a u s e o f c o m p e n s a tio n ) ■ A lk a le m ia : a rte ria l p H >7.45

1.5.4.4 Classifying an acid-base disorder ■ D e te rm in e th e p rim a ry a b n o rm a lity □ A c id o s is

■ A lk a lo s is : a c o n d itio n th a t te n d s to ra is e th e pH (th e pH m a y n o t a c tu a lly b e ra is e d , b e c a u s e o f c o m p e n s a tio n )

■ M e ta b o lic a c id o s is : pH a nd [H C 0 3] g o in th e s a m e d ire c tio n (b ic a rb u s u a lly < 2 5 m E q /L )

■ C o m p le x a c id -b a s e d is o rd e r: m o re th a n 1 p rim a ry a c id -b a s e d is tu rb a n c e

■ R e s p ira to ry a c id o s is : pH a n d [H C 0 3] g o in o p p o s ite d ire c tio n s ( P C 0 2 u s u a lly > 4 4 m m Hg)

■ M e ta b o lic a c id o s is /a lk a lo s is : e x c e s s iv e in ta k e of, e x c e s s iv e p ro d u c tio n of, o r in s u ffic ie n t re n a l e lim in a tio n o f a n a c id o r a b a s e ; th e p rim a ry c h a n g e is in b ic a rb o n a te ( H C O j) ; c o m p e n s a tio n in v o lv e s a lte ra tio n s in p u lm o n a ry h a n d lin g o f C 0 2 ■ R e s p ira to ry a c id o s is /a lk a lo s is : a lte re d e lim in a tio n o f C 0 2 b y th e lu n g s (h y p o v e n tila tio n /h y p e rv e n tila tio n ); th e p rim a ry c h a n g e is in C 0 2; c o m p e n s a tio n in v o lv e s a lte re d re n a l h a n d lin g o f b ic a rb o n a te ( H C 0 3 )

1.5.4.2 Henderson-Hasselbalch equation ■ p H = p K a + lo g (b a s e /a c id )

□ A lk a lo s is ■ M e ta b o lic a lk a lo s is : pH a nd [H C 0 3] g o in th e s a m e d ire c tio n (b ic a rb u s u a lly >25 m E q /L ) ■ R e s p ira to ry a lk a lo s is : pH a nd [H C 0 3] g o in o p p o s ite d ire c tio n s ( P C 0 2 u s u a lly < 4 0 m m H g ) ■ D e te rm in e if th e c o m p e n s a tio n is a p p ro p ria te □ M e ta b o lic a c id o s is : fo r e a c h 1.3 m E q fa ll in [H C 0 3], th e P C 0 2 d e c re a s e s b y 1.0 m m H g □ M e ta b o lic a lk a lo s is : fo r e a c h 0 .6 m E q ris e in [H C 0 3], th e P C 0 2 in c re a s e s by 1.0 m m H g □ R e s p ira to ry a lk a lo s is o r a c id o s is

■ In n o rm a l in d iv id u a ls p H = 7.4, p K a = 6.1, th e b a se , b ic a rb o n a te ( H C O j) = 2 4 m o l/L , a n d th e a c id , c a rb o n ic a c id (H 2C 0 3) = 0 .0 3 * P a C 0 2 = 0 .0 3 * 4 0 m m H g = 1.2 m o l/L ■ T h u s , pH = 6.1 + lo g (b ic a rb /[0 .0 3 * P a C 0 2])

■ A c u te : fo r e a c h 1 m m H g c h a n g e in P C 0 2, th e [H C 0 3] c h a n g e s by 0.1 in th e s a m e d ire c tio n ■ C h ro n ic : fo r e a ch 1 m m H g c h a n g e in P C 0 2, th e [H C 0 3] c h a n g e s by 0 .4 in th e s a m e d ire c tio n ■ D iffe re n tia ls □ M e ta b o lic a c id o s is : d is o rd e rs a re c a te g o riz e d by p re s e n c e o r a b s e n c e o f a n io n g a p t1.12 a n d o s m o la i g a p t1.13

1.5.4.3 Methods ■ P u ls e o x im e te r □ M e a s u re s o x y - a n d d e o x y h e m o g lo b in d ire c tly , by m e a s u rin g th e a b s o rb a n c e o f tra n s m itte d lig h t □ E m its 2 w a v e le n g th s o f lig h t: 1 fo r d e o x y h e m o g lo b in a n d 1 fo r o x y h e m o g lo b in

■ C a lc u la te th e a n io n gap: anion gap = [Na] - [Cl] - [HC03] ■ N o rm a l is Acid-base disorders | Renal function t1 .12 Metabolic acidosis Increased anion gap (>12) methanol uremia ketoacidosis (diabetic, ethanol, starvation) paraldehyde lactic acidosis ethylene glycol salicylate

Normal anion gap (10)

diuretic therapy vomiting nasogastric tube suction villous adenoma carbenicillin contraction alkalosis

hyperaldosteronism cushing syndrome exogenous steroids licorice (glycyrrhizin) bartter syndrome milk alkali syndrome

1.5.6 Renal function

t1.13 Increased osmolal gap with metabolic acidosis

t1 .14 Metabolic alkalosis Chloride responsive (UCK10)

methanol propylene glycol ethylene glycol paraldehyde ethanol (sometimes) isopropanol glycerol sorbitol mannitol acetone ethanol (sometimes)

1.5.6.1 Renal function tests 1.5.6.1.1 B lood urea nitrog en ■ N itro g e n c o m p o u n d s in b lo o d a re p rin c ip a lly d e riv e d fro m th e b re a k d o w n o f p ro te in a n d n u c le ic a c id s ■ T h e m a jo r c o m p o n e n t o f n o n p ro te in n itro g e n N P N in b lo o d is u rea

■ In n o n a n io n g a p a c id o s is , th e c h lo rid e level is o fte n e le v a te d (h y p e rc h lo re m ic m e ta b o lic a c id o s is ) ■ N o te th a t a lo w a n io n g a p m a y be c a u s e d by h y p o a lb u m in e m ia a nd p a ra p ro te in e m ia ■ C a lc u la te th e o s m o la l gap: osmolal gap = osmmeasured - (2[Na] + [glucose]/18 + [BUN]/2.8) ■ In th is fo rm o f th e c a lc u la tio n , [N a ] is in m E q /L , [g lu c o s e ] is in m g /d L , a nd [B U N ] is in m g /d L . W h e n in te rn a tio n a l u n its (m m o l/L ) a re u sed , th e o s m o la lity is c a lc u la te d by °smmeasured-2 [N a ]-[g lu c o s e ]-[B U N ]

■ U re a is fre e ly filte re d and p a rtia lly re a b s o rb e d b y th e n e p h ro n ; th is h a s th e c o n s e q u e n c e th a t B U N s lig h tly u n d e re s tim a te s g lo m e ru la r filtra tio n ra te, a n d e ffe c t th a t in c re a s e s w ith h y p o v o le m ia ■ A n in c re a s e in B U N is c a lle d a z o te m ia , a n d u re m ia re fe rs to h ig h B U N and its to x ic e ffe c ts

1.5.6.1.2 C re a tin in e & g lo m e ru la r filtra tio n rate ca lc u la tio n s ■ C re a tin in e c o n c e n tra tio n w a s c la s s ic a lly d e te rm in e d , a n d o fte n still is, by th e J a ffe re a c tio n — a lk a lin e p ic ra te fo rm s a c o lo re d c o m p le x w ith c re a tin in e ■ S e ru m c re a tin in e c o n c e n tra tio n s lig h tly o v e re s tim a te s G F R ■ T h e s im p le s t w a y to c a lc u la te G F R is b a s e d on th e c re a tin in e c le a ra n c e n

■ N o rm a l o s m o la l g a p is Renal function | Laboratory screening for chronic kidney disease | Laboratory evaluation in acute renal failure □ F o rm u la c a lc u la te s e G F R o n th e b a s is o f s e ru m c re a tin in e a n d a g e ; re s u lt is m u ltip lie d b y 0.742 if th e p a tie n t is fe m a le , a n d b y 1 .2 10 if A fric a n A m e ric a n ■ C K D -E P I s tu d y e q u a tio n □ F o rm u la c a lc u la te s e G F R o n th e b a s is o f s e ru m c re a tin in e , a g e , s e x , a n d ra c e □ C a n re lia b ly d e te rm in e e G F R h ig h e r th a n 6 0 m L / m in /1 .7 3 m 2

□ G F R < 6 0 m L /m in u te /1 .7 3 m 2 o f b o d y s u rfa c e a re a o r □ A lb u m in u ria fo r 3 o r m o re c o n s e c u tiv e m o n th s

1.5.8 Laboratory evaluation in acute renal failure ■ C a u s e s o f a c u te re n a l fa ilu re (A R F ) a re c a te g o riz e d as p re re n a l, re n a l, o r p o s tre n a l t1.15, t1.16

t1 .15 Acute renal failure (ARF): prerenal vs renal 1.5.6.1.3 B U N rc re a tin in e ratio ■ N o rm a l B U N :c re a tin in e ra tio is -1 0 :1 ■ In c re a s e d B U N :c re a tin in e ra tio s u g g e s ts re n a l h y p o p e rfu s io n ( p re re n a l a z o te m ia ) m N o rm a l o r d e c re a s e d B U N :c re a tin in e ra tio is p re s e n t in

m o s t c a s e s o f in tra re n a l d is e a s e

Parameter

Prerenal ARF

Renal ARF

BUN:creatinine ratio urine specific gravity urine osmolarity FE Na FE urea

>20:1 high (>1.020) high (>500 mOsm/kg) Amniotic fluid bilirubin | hCG | Prenatal screening for trisomy & neural tube defects ■ G ra n u la r c a s ts s u g g e s t A T N , g lo m e ru lo n e p h ritis , o r in te rs titia l n e p h ritis ■ W h ite b lo o d ce ll c a s ts a re s u g g e s tiv e o f p y e lo n e p h ritis

1.6

■ O n c e a b o v e a c e rta in th re s h o ld , a ro u n d 6 0 0 0 m lU / m L, th e a b s e n c e o f a g e s ta tio n a l s a c d e te c ta b le b y u ltra s o u n d is d ia g n o s tic o f e c to p ic p re g n a n c y ■ h C G in g e s ta tio n a l tro p h o b la s tic d is e a s e

■ E o s in o p h ils s u g g e s t a c u te in te rs titia l n e p h ritis

□ h C G le v e ls a re g e n e ra lly h ig h e r a n d s h o w s h o w s a b n o rm a l d o u b lin g tim e

Laboratory tests in pregnancy

□ A v e ra g e h C G le ve ls a re h ig h e r in c o m p le te m o le s th a n p a rtia l m o le s

1.6.1 Amniotic fluid bilirubin ■ C o n c e n tra tio n o f u n c o n ju g a te d b iliru b in in a m n io tic re fle c ts d e g re e o f h e m o ly s is in h e m o ly tic d is e a s e o f th e fe tu s /n e w b o rn ■ B iliru b in a b s o rb s lig h t m a x im a lly a t 4 5 0 nm . T h e c h a n g e in a b s o rb a n c e c o m p a re d to th a t o f a th e o re tic a l b la n k (d e lta O D 4 5 0 ) re fle c ts th e b iliru b in c o n c e n tra tio n ■ T h e A O D 4 5 0 is p lo tte d a g a in s t th e e s tim a te d g e s ta tio n a l a g e on a L ile y c h a rt o r s im ila r n o m o g ra m to d e te rm in e th e d e g re e o f fe ta l h e m o ly s is and a s s e s s fe ta l risk ■ A m n io tic flu id s h o u ld be o b ta in e d w ith m in im a l b lo o d c o n ta m in a tio n , b e c a u s e th is ca n a ffe c t re su lts , a nd p ro te c te d fro m lig h t

1.6.2 Human chorionic gonadotropin ■ H u m a n c h o rio n ic g o n a d o tro p in (h C G ) □ A g ly c o p ro te in h e te ro d im e r c o m p o s e d o f an a a nd a (3 c h a in □ P ro d u c e d by th e p la c e n ta , by c e rta in tu m o rs , and in s m a ll q u a n tity by th e p itu ita ry , p a rtic u la rly d u rin g m enopause □ T h e a s u b u n it is id e n tic a l to th a t fo u n d in th y ro id s tim u la tin g h o rm o n e (T S H ), fo llic le s tim u la tin g h o rm o n e (F S H ), a nd lu te in iz in g h o rm o n e (LH ), w h ile th e p s u b u n it is u n iq u e ■ “ F a lse p o s itiv e ” h C G □ H e te ro p h ile a n tib o d y in te rfe re n c e □ “Q u ie s c e n t” g e s ta tio n a l tro p h o b la s tic d is e a s e □ P itu ita ry p ro d u c tio n ■ h C G in n o rm a l g e s ta tio n

□ A fte r e v a c u a tio n o f a m o la r p re g n a n c y , h C G le v e ls m u s t be m o n ito re d s e ria lly

1.6.3 Prenatal screening for trisomy & neural tube defects ■ T h e o v e ra ll ris k fo r h a vin g a n e o n a te w ith tris o m y is 1:700 ■ T h e ris k in w o m e n w h o a re 3 5 o r o ld e r a t th e tim e o f d e liv e ry is 1:270 ■ A v a ila b le a p p ro a c h e s to s c re e n in g □ T h e “q u a d s c re e n ” c o m b in e s h C G , a lp h a fe to p ro te in (A F P ), u n c o n ju g a te d e s trio l (uE), a n d d im e ric in h ib in A (D IA ). T h e s e n s itiv ity o f th is p a n e l fo r D o w n s y n d ro m e is -7 8 % □ T h e “firs t trim e s te r te s t,” p e rfo rm e d b e tw e e n 11 a nd 13 w e e k s , c o n s is ts o f h C G , p re g n a n c y a s s o c ia te d p la s m a p ro te in A (P A P P -A ), a nd u ltra s o u n d a s s e s s m e n t o f n u c h a l fo ld tra n s lu c e n c y (N T ) th ic k n e s s (in c re a s e d in D o w n s y n d ro m e ). W h e n c o m b in e d w ith m a te rn a l a g e , th e o v e ra ll s e n s itiv ity o f th e firs t trim e s te r te s t is 8 3 % □ T h e “s e ru m in te g ra te d s c re e n ” c o m b in e s firs t a n d s e c o n d trim e s te r s e ru m te s tin g . P A P P -A a n d h C G a re m e a s u re d in th e firs t trim e s te r, id e a lly b e tw e e n w e e k s 10 a n d 13; later, a s e c o n d trim e s te r m e a s u re m e n t o f AFP, uE , a n d D IA is m a d e , a n d th e d a ta c o m b in e d . W h e n c o m b in e d w ith m a te rn a l a g e , th e s e n s itiv ity fo r D o w n s y n d ro m e is - 8 5 % . If c o m b in e d w ith s o n o g ra p h ic m e a s u re m e n t o f n u c h a l fo ld th ic k n e s s (th e “fu ll in te g ra te d s c re e n ” ), th e s e n s itiv ity c a n be im p ro v e d to 8 8 % ■ A n a ly te s & ris k c a lc u la tio n

□ B e c o m e s d e te c ta b le ~ 6 -8 d a y s fo llo w in g c o n c e p tio n □ D o u b le s ro u g h ly e v e ry 4 8 h o u rs u n til - 1 0 w e e k s □ P e a k s n e a r th e e n d o f th e firs t trim e s te r

□ T h e s e ru m m a rk e rs used in th is c o n te x t a re d y n a m ic w ith g e s ta tio n a l age; th e ir c o n c e n tra tio n s a re o fte n th e re fo re e x p re s s e d as m u ltip le s o f m e d ia n (M o M )

□ D e c re a s e s s o m e w h a t a nd p la te a u s by e a rly s e c o n d trim e s te r

□ T h e ris k c a lc u la tio n b e g in s w ith th e ris k b a s e d on m a te rn a l a g e a t d e live ry, d e riv e d fro m e p id e m io lo g ic s tu d ie s

□ A fte r d e live ry , h C G n o rm a lly re m a in s d e te c ta b le fo r 2 w eeks

□ N e xt, a lik e lih o o d ra tio fo r e a c h a n a ly te ’s M o M is d e te rm in e d , b a s e d on c lin ic a l s tu d ie s

■ h C G in e c to p ic p re g n a n c y ■ T h e d y n a m ic s o f n o rm a l p re g n a n c y a re n o t se en ; h C G d o e s n o t ris e a t a n o rm a l rate o r in fa c t d e c re a s e s © A S C P 2018

□ T h e s e a re m u ltip lie d by th e a g e a s s o c a te d ris k to a rriv e a t an a d ju s te d risk

ISBN 9 7 8 -08 9189-6678

17

1: Chemistry

Laboratory tests in pregnancy>Prenatal screening for trisomy & neural tube defects | Determination of fetal lung maturity | Laboratory evaluation of diseases in pregnancy □ A d ju s tm e n ts a re m a d e fo r m a te rn a l w e ig h t, ra ce , a n d d ia b e te s

□ L:S ra tio is le s s re lia b le in m a te rn a l d ia b e te s m e llitu s (P G c o n c e n tra tio n m o re re lia b le in th is s e ttin g )

o A s c re e n is u s u a lly d e fin e d a s “ p o s itiv e ” o r “ n e g a tiv e ” in re la tio n to th e ris k o f a 3 5 -y e a r-o ld fe m a le , ie, 1:270

□ C o n ta m in a tio n b y m e c o n iu m fa ls e ly d e c re a s e s th e L:S ra tio

■ M a te rn a l s e ru m A F P (M S A F P ) □ V a lu e is a ffe c te d b y m a te rn a l w e ig h t, m a te rn a l d ia b e te s , a n d m u ltip le g e s ta tio n s □ M S A F P > 2 .5 M o M is fo u n d in > 8 0 % o f p re g n a n c ie s c o m p lic a te d b y n e u ra l tu b e d e fe c t (N T D ) □ In c re a s e d M S A F P is a ls o p re s e n t in o m p h a lo c e le , g a s tro s c h is is , re n a l a n o m a lie s , s a c ro c o c c y g e a l te ra to m a , c y s tic h y g ro m a , h y d ro p s fe ta lis , T u rn e r s y n d ro m e , b o w e l o b s tru c tio n , tw in g e s ta tio n s , fe ta l d e m is e , a n d fe ta l-m a te rn a l h e m o rrh a g e □ M S A F P is lo w in D o w n s y n d ro m e ■ M a te rn a l s e ru m h C G □ - 2 * h ig h e r in fe ta l D o w n s y n d ro m e □ A d ju s tm e n ts a re ty p ic a lly m a d e fo r m a te rn a l w e ig h t, m u ltip le g e s ta tio n , m a te rn a l d ia b e te s , a n d ra c e > uE □ R e la tiv e ly in s e n s itiv e to D o w n s y n d ro m e b u t a g o o d in d ic a to r o f tris o m y 18 (E d w a rd s y n d ro m e ), S m ith -L e m li-O p tiz s y n d ro m e (S L O S ), a n d in h e rite d (fe ta l) d e fic ie n c ie s o f s te ro id s u lfa ta s e □ D IA □ U n lik e th e o th e r a n a ly te s , le v e ls o f D IA a re re la tiv e ly c o n s ta n t th ro u g h o u t th e s e c o n d trim e s te r te s tin g p e rio d , w h ic h m in im iz e s th e e ffe c t o f e rro n e o u s g e s ta tio n a l a g e e s tim a te s

1.6.4 Assessing risk of preterm birth ■ F e ta l fib ro n e c tin □ T h e a b s e n c e o f d e te c ta b le fe ta l fib ro n e c tin in c e rv ic o v a g in a l flu id la rg e ly e x c lu d e s im p e n d in g p re te rm b irth □ O v e ra ll p o s itiv e p re d ic tiv e v a lu e is lo w □ S p e c im e n s s h o u ld be c o lle c te d > 2 4 h o u rs a fte r th e la s t c e rv ic a l e x a m in a tio n o r in te rc o u rs e

1.6.5 Determination of fetal lung maturity ■ L e c ith in , th e p re d o m in a n t c o m p o n e n t o f m a tu re s u rfa c ta n t, is c o m p o s e d o f d is a tu ra te d p h o s p h a ti d y lc h o lin e (D S P C ), p h o s p h a tid y lg ly c e ro l (P G ), p h o s p h a tid y lin o s ito l (P I), p h o s p h a tid y le th a n o la m in e (P E ), a n d s p h in g o m y e lin

■ P h o s p h a tid y lg ly c e ro l c o n c e n tra tio n □ P G is is in d ic a tiv e o f lun g m a tu rity □ N e ith e r b lo o d n o r m e c o n iu m in te rfe re s w ith it □ H ow ever, PG is a la te m a rk e r o f p u lm o n a ry m a tu rity , w h ic h lim its its u tility ■ L a m e lla r b o d y c o u n t (L B C ) □ S u rfa c ta n t la m e lla r b o d ie s a re a p p ro x im a te ly th e size o f p la te le ts , a n d th e p la te le t c h a n n e l o f a c e ll c o u n te r m ay be u s e d to q u a n tify th e m □ H ig h e r L B C c o u n ts in d ic a te m a tu rity □ B lo o d c o n ta m in a tio n d e c re a s e s th e la m e lla r b o d y c o u n t, a n d m e c o n iu m in c re a s e s it

1.6.6 Laboratory evaluation of diseases in pregnancy 1.6.6.1 Physiologic changes & altered reference ranges in pregnancy ■ E x p e c te d la b o ra to ry te s t c h a n g e s d u rin g p re g n a n c y a re lis te d in t1.17 t 1 .17 Common laboratory values in pregnancy Analyte Change in pregnancy albumin calcium (total) creatinine fibrinogen albumin BUN urine protein Hot Hgb

J.1 g/dL 110% J,0.3 mg/dL T1-2 g/L 10.5-1.0 g/dL 150% approximately doubles 14-7% 11.5-2.0 g/dL

■ H e m o d ilu tio n re s u lts in d e c re a s e d a lb u m in , to ta l p ro te in , h e m a to c rit, a n d h e m o g lo b in ■ E s tro g e n c a u s e s an in c re a s e in tra n s p o rt p ro te in s su ch a s th y ro id b in d in g g lo b u lin (T B G ) ■ G F R is in c re a s e d , w ith d e c re a s e d B U N a n d c re a tin in e ■ R e la tive in s u lin re s is ta n c e ; h u m a n p la c e n ta l la c to g e n has a n ti-in s u lin e ffe c ts s im ila r to g ro w th h o rm o n e ■ S o d iu m a n d p o ta s s iu m re m a in re la tiv e ly c o n s ta n t

■ L e c ith in :s p h in g o m y e lin (L :S ) ra tio □ Im m a tu re s u rfa c ta n t h a s a ra tio o f a b o u t 1:1 □ M a tu re s u rfa c ta n t h a s a ra tio o f o v e r 2.5:1

18

□ C o n ta m in a tio n by b lo o d n o rm a liz e s th e L:S ra tio to - 1 .5

■ Total c a lc iu m le v e ls fall d u rin g p re g n a n c y d u e to p h y s io lo g ic h y p o a lb u m in e m ia ; io n ize d c a lc iu m re m a in s unchanged

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

1: Chemistry

Laboratory tests in pregnancy>Laboratory evaluation of diseases in pregnancy Toxicology>Pharm acokinetics | Drugs o f abuse screening (forensic toxicology) ■ S e ru m trig ly c e rid e s a re o fte n in c re a s e d , a n d lo w level ke to sis is o fte n p re s e n t

1.6.6.2 Medical conditions of particular importance in pregnancy 1.6.6.2.1 A u to im m u n e d iseas es

■ In tra h e p a tic c h o le s ta s is o f p re g n a n c y □ T h ird trim e s te r, p re s e n tin g w ith ja u n d ic e a n d p ru ritu s □ Z o n e c h o le s ta s is w ith d ila te d c a n a lic u li c o n ta in in g b ile p lu g s

1.7

Toxicology

■ P re g n a n c y h a s a p a llia tiv e e ffe c t on m a n y a u to im m u n e d is e a s e s , th o u g h p o s tp a rtu m e x a c e rb a tio n s m a y o c c u r

1.7.1 Pharmacokinetics

■ S y s te m ic lu p u s e ry th e m a to s u s

1.7.1.1 Half-life ■ T h e tim e it ta k e s fo r th e c o n c e n tra tio n o f d ru g to re a c h h a lf o f its s ta rtin g c o n c e n tra tio n

□ O fte n e x a c e rb a te d b y p re g n a n c y □ In c re a s e d in c id e n c e o f p re g n a n c y in d u ce d h y p e rte n s io n

■ S te a d y sta te

□ C a u s e s re c u rre n t m is c a rria g e , a b o rtio n , a nd p re te rm labor, th o u g h t m e d ia te d by lu p u s a n tic o a g u la n t

□ T h e a m o u n t o f d ru g le a v in g th e b o d y e q u a ls th e a m o u n t e n te rin g ,

□ In c re a s e d in c id e n c e o f in tra u te rin e g ro w th re ta rd a tio n , p re te rm labor, c o n g e n ita l h e a rt b lo c k

□ T y p ic a lly a c h ie v e d a fte r 5 h a lf-liv e s (ie, a fte r 5 d o s e s g iv e n a t in te rv a ls o f 1 h a lf-life e a c h )

■ Id io p a th ic th ro m b o c y to p e n ic p u rp u ra (U P ) a n tib o d ie s ca n c ro s s th e p la c e n ta a n d lea d to n e o n a ta l th ro m b o c y to p e n ia ; m u s t be d is tin g u is h e d fro m n e o n a ta l a llo im m u n e th ro m b o c y to p e n ia (N A T P )

□ D ru g c o n c e n tra tio n is lo w e s t rig h t b e fo re a d o s e (tro u g h ), a n d h ig h e s t s h o rtly a fte r a d o s e (p e a k )

1.7.1.2 Free vs bound ■ A fra c tio n o f d ru g is b o u n d , u s u a lly to p ro te in (su ch a s a lb u m in ), a nd th e re m a in in g d ru g is fre e

1.6.6.2.2 G e n ito u rin a ry d iseas es ■ In c re a s e d ris k fo r u rin a ry tra c t in fe c tio n , w ith h ig h ra te o f p ro g re s s io n to p y e lo n e p h ritis ■ T h e re fo re , a s y m p to m a tic b a c te riu ria is a g g re s s iv e ly tre a te d in p re g n a n t w o m e n

1.6.6.2.3 E n d o crin e d iso rd ers ■ S h e e h a n s y n d ro m e (p o s tp a rtu m p itu ita ry a p o p le x y ) □ C o m m o n c a u s e o f h y p o p itu ita ris m in w o m e n o f c h ild b e a rin g a g e □ 9 0 % o f a ffe c te d w o m e n h a ve a h is to ry o f s e v e re p u e rp e ra l b le e d in g ■ H y p o th y ro id is m is re la tiv e ly c o m m o n in p re g n a n c y ■ S y n d ro m e o f tra n s ie n t h y p e rth y ro id is m o f h y p e re m e s is g ra v id a ru m , th o u g h t m e d ia te d by T S H like e ffe c t o f H C G

1.6.6.2 .4 H ep atic d isease

■ W h e n b in d in g p ro te in is d e c re a s e d , m o re fre e d ru g is a v a ila b le fo r a g ive n dose; c o n v e rs e ly , w h e n th e b in d in g p ro te in is in c re a s e d , le ss fre e d ru g is a v a ila b le fo r a g iv e n d o s e ■ O th e r s m a ll m o le c u le s c o m p e te fo r b in d in g , a n d a s e c o n d d ru g m a y d is p la c e th e firs t, le a d in g to in c re a s e d fre e d ru g c o n c e n tra tio n

1.7.1.3 Volume of distribution (Vd) ■ S o m e d ru g s — h y d ro p h ilic — re m a in c o n fin e d w ith in th e v a s c u la r s p a c e . O th e rs a re d is trib u te d w ith in th e v a s c u la r a n d e x tra v a s c u la r a q u e o u s (in te rs titia l) s p a c e s , a nd o th e rs (h y d ro p h o b ic ) a re p rim a rily s e q u e s te re d in to a d ip o s e tis s u e ■ T h e Vd is th e th e o re tic a l v o lu m e in w h ic h th e to ta l a m o u n t o f d ru g w o u ld need to b e u n ifo rm ly d is trib u te d to p ro d u c e th e m e a s u re d p la s m a c o n c e n tra tio n o f a d ru g ■ H y d ro p h ilic d ru g s have lo w V d, w h ile h y d ro p h o b ic d ru g s h ave h ig h Vd

■ A c u te fa tty liv e r o f p re g n a n c y □ A m e d ic a l e m e rg e n c y u s u a lly c o m p lic a te d by d is s e m in a te d in tra v a s c u la r c o a g u la tio n (D IC ) □ A ffe c ts 1 in 1 0 ,0 0 0 p re g n a n c ie s ; fa ta lity ra te 3 0 % □ T h ird trim e s te r, p re s e n tin g w ith n a u s e a , v o m itin g , rig h t u p p e r q u a d ra n t te n d e rn e s s , ja u n d ic e , a n d a lte re d m e n ta l s ta tu s □ M ic ro v e s ic u la r s te a to s is , a c c e n tu a te d p a ra c e n tra lly (z o n e 3)

1.7.2 Drugs of abuse screening (forensic toxicology) ■ U rin e is th e u su a l s p e c im e n o f c h o ic e fo r s c re e n in g □ C o m p a re d to se ru m , o ffe rs a d v a n ta g e o f s a m p le s ta b ility a n d lo n g e r w in d o w o f d e te c tio n □ D is a d v a n ta g e is s u s c e p tib ility to ta m p e rin g

□ Im m e d ia te d e liv e ry is th e tre a tm e n t o f c h o ic e © A S C P 2018

ISBN 978-08 9189-6678

19

1: Chemistry

Toxicology>D rugs o f abuse screening (forensic toxicology) □ T o d e te c t a d u lte ra n t s u b s ta n c e s , it is ro u tin e to c h e c k th e s p e c im e n c o lo r, o d o r (eg, fo r b le a c h ), te m p e ra tu re (s u s p ic io u s if c o o l), p H (s u s p ic io u s if < 4 .5 o r > 8 .0 ), s p e c ific g ra v ity (s u s p ic io u s fo r d ilu tio n if < 1 .0 0 5 ), c re a tin in e (s u s p ic io u s if < 2 0 m g /d L ), a n d /o r n itrite (s u s p ic io u s if > 5 0 0 pg/m l_) ■ S e ru m fo r to x ic o lo g y te s tin g is u s u a lly c o lle c te d in a red to p tu b e w ith n o a d d itiv e s . W in d o w s o f d e te c tio n a re s h o rte r th a n w ith u rin e ■ S a liv a is an in c re a s in g ly p o p u la r s p e c im e n ty p e . It is b e s t fo r d o c u m e n tin g re c e n t u s e , b u t h a s a s h o rt w in d o w o f d e te c tio n s im ila r to s e ru m ■ Im m u n o a s s a y is th e u s u a l ty p e o f te s t fo r s c re e n in g ; c ro s s re a c tin g s u b s ta n c e s a re c o m m o n , a n d p o s itiv e te s ts re q u ire c o n firm a tio n ■ G a s c h ro m a to g ra p h y /m a s s s p e c tro m e try (G C /M S ) o r liq u id c h ro m a to g ra p h y /m a s s s p e c tro m e try (L C /M S ) a re th e ty p ic a l m e th o d s fo r c o n firm a to ry te s tin g ■ C h a in o f c u s to d y p re c a u tio n s m a y b e re q u ire d in s o m e in s ta n c e s . T h e s p e c im e n c a n n o t b e le ft u n a tte n d e d u n le s s in lo c k e d s to ra g e ■ W h e n d ru g s c re e n in g is p e rfo rm e d , q u e s tio n s a re c o m m o n ly a s k e d re g a rd in g th e d u ra tio n th a t a n a g e n t m a y b e d e te c te d (w in d o w o f d e te c tio n ); g e n e ra l g u id e lin e s a re p ro v id e d in t1.18 t 1 .18 Approxim ate detection periods for urine drugs of

abuse screening tests Drug cannabinoids (THC) benzodiazepines amphetamines, methamphetamines, opiates, cocaine barbiturates alcohol

Window of detection (in urine) 3 (single use) to 30 (chronic user) days 2-10 days, depending on agent 2-3 days 3-15 days, depending on agent 1 day

1.7.2.2 Opiates ■ A c u te in to x ic a tio n □ S e d a tio n , p in p o in t p u p ils , c o n s tip a tio n , b ra d y c a rd ia , and h y p o te n s io n ; □ S e ve re in to x ic a tio n ca n p re s e n t w ith a lte re d m e n ta l sta tu s a n d re s p ira to ry a rre s t □ N a lo x o n e (N a rc a n ) a n d n a lm e fe n e a re o p io id a n ta g o n is ts th a t ca n be u se d to tre a t in to x ic a tio n ■ A c u te w ith d ra w a l ■ L a c rim a tio n , rh in o rrh e a , d ia p h o re s is , d ila te d p up ils, ta c h y c a rd ia , irrita b ility , a nd re s tle s s n e s s ■ P ro p o x y p h e n e is a n o p io id th a t, in a d d itio n to p ro d u c in g th e u sual o p io id re la te d to x ic itie s , ca n c a u s e u n u s u a l to x ic itie s , s u c h a s c a rd ia c c o n d u c tio n a b n o rm a litie s and s e iz u re s

1.7.2.3 Barbiturates ■ A c t by fa c ilita tin g th e e ffe c ts o f y -a m in o b u ty ric a cid (G A B A ), an in h ib ito r in th e C N S ■ In to x ic a tio n re s u lts in s u p p re s s io n o f c o n s c io u s n e s s and re s p ira to ry s u p p re s s io n ; im p a ire d m y o c a rd ia l fu n c tio n ; a lte re d m e n ta l s ta tu s , h y p o te n s io n , h y p o th e rm ia , p u lm o n a ry e d e m a , o r re s p ira to ry a rre s t

1.7.2.4 Amphetamines and methamphetamine ■ In d u c e re le a s e o f d o p a m in e in th e C N S ■ A c u te in to x ic a tio n m a n ife s ts w ith h y p e rp n e a , h y p e rth e rm ia , ta c h y c a rd ia , h y p e rte n s io n , a n x ie ty , a nd irrita b ility ; s e v e re in to x ic a tio n m a y p re s e n t w ith a lte re d m e n ta l s ta tu s, c e re b ra l b le e d s , o r s e iz u re

1.7.2.5 Phencyclidine ■ B lo c k s c a te c h o la m in e re u p ta k e

1.7.2.1 Cocaine ■ U s u a l ro u te s o f a d m in is tra tio n a re s n iffin g , in je c tio n , a n d s m o k in g (c ra c k , fre e b a s in g ) ■ M a y p re s e n t w ith c h e s t p a in o r a c u te in to x ic a tio n □ C o c a in e in d u c e d c h e s t p a in ■ C o ro n a ry v a s o c o n s tric tio n , c o m p o u n d e d by v e n tric u la r h y p e rtro p h y , in c re a s e d h e a rt ra te a nd a rte ria l b lo o d p re s s u re ■ B e c a u s e o f c o c a in e ’s s k e le ta l m u s c le e ffe c ts , th e s p e c ific ity o f m y o g lo b in a n d C K M B is lo w e r b u t s p e c ific ity o f tro p o n in is u n c h a n g e d □ A c u te in to x ic a tio n in d u c e s th e s y m p a th e tic n e rv o u s s y s te m , le a d in g to ta c h y c a rd ia , h y p e rte n s io n , d ia p h o re s is , m y d ria s is , a n d a g ita tio n ; o fte n h a ve ra is e d c o re te m p e ra tu re a n d m a y p re s e n t w ith h y p e rth e rm ia ; h y p e rte n s io n m a y be s e v e re 20

■ A c u te in to x ic a tio n in c lu d e s h y p e rp n e a , h y p e rte n s io n , a n d ta c h y c a rd ia ; h o riz o n ta l n y s ta g m u s ; a g ita tio n , a g g re s s io n , a n d in c o o rd in a tio n ; s e v e re in to x ic a tio n m ay p re s e n t w ith h y p o g ly c e m ia , h y p o te n s io n , b ra d y c a rd ia , h y p o p n e a , a lte re d m e n ta l s ta tu s , s e iz u re s , a n d /o r life th re a te n in g h y p e rth e rm ia ; m a y c a u s e rh a b d o m y o ly s is

1.7.2.6 Ethanol ■ M e ta b o liz e d b y a lc o h o l d e h y d ro g e n a s e to a c e ta ld e h y d e , w h ic h is c o n v e rte d by a ld e h y d e d e h y d ro g e n a s e to a c e tic a c id ■ B lo o d a lc o h o l level ■ C a n u se s e ru m , p la s m a , o r w h o le b lo o d ■ E n z y m a tic a s s a y u tiliz in g a lc o h o l d e h y d ro g e n a s e is m o s t o fte n e m p lo y e d ; s p e c ific fo r e th a n o l and d o e s n ot m e a s u re o th e r a lc o h o ls s u c h a s m e th a n o l

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

1: Chemistry

Toxicology>Drugs of abuse screening (forensic toxicology) | Overdose ■ B re a th a lc o h o l te s tin g ■ B a se d on p rin c ip le th a t b lo o d a lc o h o l d iffu s e s a c ro s s a lv e o la r s e p ta a nd is e x c re te d in e x p ire d a ir ■ T h e ra tio o f b lo o d :b re a th a lc o h o l is 2100:1 ■ M o s t s ta te s d e fin e th e leg a l lim it fo r o p e ra tio n o f a m o to r v e h ic le a s 8 0 -1 0 0 m g /d L (0 .0 8 % -0 .1 0 % ) in w h o le b lo o d t1.19. W h o le b lo o d e th a n o l te n d s to run lo w e r th a n s e ru m o r p la s m a e th a n o l c o n c e n tra tio n , and le g a l d e fin itio n s a re u s u a lly in te rm s o f w h o le b lo o d . O n e s h o u ld n o t a tte m p t to u se a c o n v e rs io n fo rm u la , a s c o n v e rs io n v a rie s w ith h e m a to c rit

t1 .19 Clinical effects of blood alcohol Clinical effects Blood alcohol concentration (%) 0.4

t1 .20 Common toxidromes Signs Class

sobriety euphoria excitement confusion stupor coma & death

Agents

anticholinergic

1.7.3 Overdose 1.7.3.1 General aspects of laboratory evaluation ■ T o x id ro m e s a re c o n s te lla tio n s o f fin d in g s th a t s u g g e s t a p a rtic u la r a g e n t o r g ro u p o f a g e n ts t1.20, t1.21 ■ T h e N a tio n a l A c a d e m y o f C lin ic a l B io c h e m is try has p u b lis h e d g u id e lin e s fo r to x ic o lo g y s c re e n in g in w h ic h so c a lle d tie r 1 te s ts a re a d v is e d fo r all la b o ra to rie s th a t s u p p o rt e m e rg e n c y m e d ic in e d e p a rtm e n ts t1.22 ■ In a d d itio n to th e s e , th e re is o fte n a ro le fo r a s s e s s m e n t o f th e a n io n g ap , o s m o la r gap, a n d o x y g e n g a p □ A n io n g ap ■ A n io n g a p = N a + - (C l- + H C O j); n o rm a l 8-16; in c re a s e > 20 m E q /L is s ig n ific a n t ■ L o w e re d a n io n g a p is c a u s e d by h y p o a lb u m in e m ia ■ T o xin s th a t c a u s e an in c re a s e d a n io n g a p in c lu d e a c e ta m in o p h e n , s a lic y la te s , a s c o rb a te , h y d ro g e n s u lfid e , e th y le n e g ly c o l, p ro p y le n e g ly c o l, m e th a n o l, e th a n o l, fo rm a ld e h y d e , c a rb o n m o n o x id e , n itro p ru s s id e , e p in e p h rin e , a n d p a ra ld e h y d e □ T h e d iffe re n c e b e tw e e n th e m e a s u re d s e ru m o s m o la rity a n d th e c a lc u la te d o s m o la rity is th e o s m o la l g a p

hyperthermia, dry skin, atropine, antihistamines, flushing, altered mental tricyclic antidepressants, status, psychosis (“hot as a scopolamine hare, dry as a bone, red as a beet, mad as a hatter”), __________________ mydriasis, constipation____________________________ salivation, lacrimation, urination, organophosphates, cholinergic diarrhea, Gl cramps, emesis pilocarpine, carbamate (“SLUDGE”); diaphoresis, miosis & wheezing amphetamines, cocaine, hypertension, tachycardia, adrenergic pseudoephedrine mydriasis, anxiety, ephedrine, PCP hyperthermia altered mental status, slurred barbiturates, alcohols, sedative opiates speech, hypopnea/apnea opiates altered mental status, narcotic hypopnea/apnea LSD, PCP, amphetamines, hallucinations, anxiety, hallucinogenic cocaine hyperthermia

t1 .21 Signs or sym ptom s associated with toxic agents Associated agents Sign or symptom pinpoint pupils (miosis)

dilated pupils (mydriasis)

■ T h e o s m o la rity is c a lc u la te d a s fo llo w s : (2 x Na) + (BUN + 2.8) + (glucose + 18) ■ In c re a s e d o s m o la l g a p s u g g e s ts u n a c c o u n te d fo r s o lu te s su ch as in g e s te d to xin

note: A unilateral dilated pupil is indicative of an anatomic defect such as brain stem herniation, glaucoma, or cranial nerve palsy. It also may be caused by topical atropine. diaphoresis

□ O x y g e n s a tu ra tio n g a p ■ T h e d iffe re n c e b e tw e e n th e s a tu ra tio n g iv e n by c o -o x im e try and th e s a tu ra tio n g ive n by p u lse o x im e try ■ D iffe re n c e o v e r 5% is s ig n ific a n t ■ C a u s e s o f an in c re a s e d o x y g e n s a tu ra tio n g a p in c lu d e c a rb o n m o n o x id e p o is o n in g (c a rb o x y h e m o g lo b in ), m e th e m o g lo b in , h y d ro g e n s u lfid e p o is o n in g (s u lfm e th e m o g lo b in ), a nd c y a n id e p o is o n in g

© A S C P 2018

cholinergics (organophosphates, pilocarpine, carbamate) opiates benzodiazepines anticholinergics (atropine, antihistamines, tricyclics, scopolamine) sympathomimetics (cocaine, amphetamines) carbon monoxide

red skin tremor dystonia bitter almond odor mothball odor qarlic odor

ISBN 978-08 9189-6678

sympathomimetics (cocaine, amphetamines) organophosphates carbon monoxide cyanide anticholinergics lithium vs withdrawal neuroleptics (antipsychotics) cyanide camphor orqanophosphates, arsenic

21

1: Chemistry

Toxicology>O verdose

t1.22 National A cadem y o f Clinical Biochem istry tier 1 test recom m endations Testing category_________________ Specific agents______________ stat quantitative serum assays acetaminophen (paracetamol) lithium salicylate theophylline valproic acid carbamazepine digoxin phenobarbital iron transferrin (or UIBC) ethanol methanol ethylene glycol cooximetry stat qualitative urine assays cocaine opiates barbiturates amphetamines propoxyphene tricyclics PCP

■ T h e te rm o x y g e n s a tu ra tio n g a p s o m e tim e s u se d to re fe r to th e d iffe re n c e b e tw e e n th e p e rc e n t o x y h e m o g lo b in g iv e n b y th e A B G a n a ly z e r a n d th a t g iv e n b y th e p u ls e o x im e te r ■ T h e d iffe re n c e b e tw e e n a rte ria l a n d v e n o u s o x y g e n te n s io n c a n b e a b n o rm a lly n a rro w (“ a rte ria liz a tio n o f v e n o u s b lo o d ” ) in in c y a n id e a n d h y d ro g e n s u lfid e p o is o n in g

1.7.3.2 Toxic alcohol (ethylene glycol, methanol & isopropyl alcohol) poisoning t1.23 ■ A to x ic a lc o h o l in g e s tio n is s u s p e c te d if th e o s m o la l g a p is in c re a s e d □ E th y le n e g ly c o l (fo u n d in a n tifre e z e ), m e th a n o l (w in d s h ie ld w a s h e r flu id , p a in t re m o v e rs , w o o d a lc o h o l), o r is o p ro p y l a lc o h o l (ru b b in g a lc o h o l) □ E th y le n e g ly c o l o r m e th a n o l c a n c a u s e b o th in c re a s e d a n io n g a p m e ta b o lic a c id o s is a n d in c re a s e d o s m o la l g a p ; Is o p ro p y l a lc o h o l d o e s n o t c a u s e a c id o s is , b u t d o e s c a u s e an o s m o la l g a p

t1 .23 Toxic alcohol poisoning Anion gap Osmolal Increased acidosis ketones Metabolite gap + -/+ -/+ + + oxalate & glycolate + acetone

Alcohol Source ethanol ethylene antifreeze glycol isopropanol rubbing alcohol methanol windshield + washer fluid

+

—

formate & formaldehyde

■ E th y le n e g ly c o l is m e ta b o liz e d to g ly c o la ld e h y d e , g ly o x a l, g ly c o la te , g ly o x y la te , a n d o x a la te u n d e r th e a c tio n o f a lc o h o l d e h y d ro g e n a s e . O x a la te b in d s c a lc iu m to p ro d u c e c a lc iu m o x a la te , w h ic h is d e p o s ite d in tis s u e s a n d fo u n d in u rin e , w h e re th e y a p p e a r e n v e lo p e sh a p e d , tra n s lu c e n t, a n d b ire frin g e n t ■ M e th a n o l is m e ta b o liz e d to fo rm a ld e h y d e a nd th e n to fo rm ic a c id by a lc o h o l d e h y d ro g e n a s e . T h e s e m e ta b o lite s re s u lt in o c u la r to x ic ity , a n io n g a p a c id o s is , a n d an o s m o la l g a p ■ Is o p ro p y l a lc o h o l (is o p ro p a n o l) is m e ta b o liz e d to a c e to n e ■ T re a tm e n t o f m e th a n o l o r e th y le n e g ly c o l p o is o n in g c o n s is ts o f in h ib itin g th e a c tiv ity o f a lc o h o l d e h y d ro g e n a s e , s in c e m e ta b o lite s c a u s e th e to x ic ity ; a c c o m p lis h e d w ith th e a d m in is tra tio n o f e th a n o l o r fo m e p iz o le

1.7.3.3 Lead poisoning (plumbism) ■ Lea d e n te rs th e b o d y th ro u g h in h a la tio n and in g e stio n , a n d in h ib its c e rta in e n z y m e s □ In h ib its key e n z y m e s in v o lv e d in h e m e s y n th e s is , p a rtic u la rly 5 -A L A -d e h y d ra ta s e a n d fe rro c h e la ta s e ■ L e a d s to a c c u m u la tio n o f th e p re c u rs o r p ro to p o rp h y rin (fre e e ry th ro c y te p ro to p o rp h y rin [P E R ]) ■ F E P b in d s to z in c , y ie ld in g z in c p ro to p o rp h y rin (Z P P ) □ In h ib its s o d iu m c h a n n e l A T P a s e s , e n h a n c in g o s m o tic fra g ility a n d s h o rte n in g red ce ll s u rv iv a l □ B a s o p h ilic s tip p lin g re s u lts fro m th e in h ib itio n o f 5' n u c le o tid a s e ■ M a n ife s ta tio n s in c lu d e a m ic ro c y tic , h y p o c h ro m ic a n e m ia w ith b a s o p h ilic s tip p lin g , c o g n itiv e im p a irm e n t, e n c e p h a lo p a th y , p ro x im a l tu b u la r re n a l d y s fu n c tio n , and p e rip h e ra l n e u ro p a th y ■ B y re c o m m e n d a tio n o f th e C e n te rs fo r D is e a s e C o n tro l, a b lo o d lea d leve l >10 p g /d L is c o n s id e re d e le v a te d ■ C h e la to rs in c lu d e d im e rc a p ro l (a lso k n o w n a s B ritis h a n ti-L e w is ite ), C a N a -E D T A , D -p e n ic illa m in e , and d im e rc a p to s u c c in ic a cid

1.7.3.4 Carbon monoxide poisoning t1.24 ■ C a rb o n m o n o x id e (C O ) b in d s tig h tly to h e m o g lo b in fo rm in g c a rb o x y h e m o g lo b in (H b -C O ) ■ H b -C O is in c a p a b le o f b in d in g o x y g e n ■ C O is p ro d u c e d in th e e n v iro n m e n t w h e n th e re is p a rtia l c o m b u s tio n o f fo s s il fu e ls ; it is p ro d u c e d e n d o g e n o u s ly fro m th e b re a k d o w n o f h em e , re s u ltin g in e n d o g e n o u s H b -C O o f Overdose t i .24 Clinical effects of carbon monoxide poisoning Level of CO 0.4%-2.0% 2%-6% 10%-20% 20%-50% >50%

Clinical findings normal nonsmoker normal smoker mild symptoms: dyspnea on exertion severe symptoms: intoxication, with headache, lethargy, loss of consciousness coma & death

■ P u lse o x im e try m a y g iv e a n o rm a l p e rc e n t o x y g e n s a tu ra tio n in th e p re s e n c e o f H b -C O ■ T h e h a lf-life o f C O d e p e n d s on th e o x y g e n te n s io n o f in s p ire d air; on ro o m a ir th e h a lf-life 6 h o u rs , w h ile th e h a lf-life on 1 00 % 0 2 is 1 h o u r

1.7.3.5 Acetaminophen (Tylenol) poisoning ■ T h e c lin ic a l c o u rs e o f a c u te a c e ta m in o p h e n o v e rd o s e is p o ly p h a s ic □ In itia lly (p h a s e I), th e re m ay be m ild n a u s e a and a b d o m in a l d is c o m fo rt, w h ic h a b a te s o v e r se v e ra l h o u rs □ L iv e r in ju ry p ro g re s s e s o v e r th e n e x t 24 to 4 8 h o u rs (p h a s e II) □ T h is m ay lea d to fu lm in a n t h e p a tic fa ilu re (p h a s e III) ■ In p h a s e I th e R u m a c k -M a tth e w n o m o g ra m f1.14 ca n be u se d to p re d ic t ris k o f liv e r fa ilu re □ In itial b lo o d s a m p le s s h o u ld be d ra w n no e a rlie r th a n 4 h o u rs fo llo w in g in g e s tio n

□ T h e n o m o g ra m s tra tifie s p a tie n ts in to 3 g ro u p s : p ro b a b le h e p a tic to x icity , p o s s ib le h e p a tic to x ic ity , a n d n o h e p a tic to x ic ity ■ T h e liv e r h a n d le s a c e ta m in o p h e n in 2 m a in p a th w a y s □ C o n ju g a tio n w ith g lu c u ro n id e o r s u lfa te to fo rm n o n to x ic m e ta b o lite s □ M e ta b o lis m by th e P450 s y s te m in to th e to x ic m e ta b o lite N -a c e ty l-p -b e n z o q u in o n e im in e (N A P Q I) ■ W -a c e ty lc y s te in e (M u c o m y s t) is th e m a in s ta y o f tre a tm e n t. M u c o m y s t p ro m o te s m e ta b o lis m v ia th e c o n ju g a tio n p a th w a y s , th e re b y d e c re a s in g th e fo rm a tio n o f th e to x ic m e ta b o lite N A P Q I

1.7.3.6 Cyanide poisoning ■ M a y be d u e to in h a la tio n o f s m o k e fro m a fire , in d u s tria l e x p o s u re , o r in g e s tio n ■ C y a n id e in h ib its c y to c h ro m e a 3, th u s u n c o u p lin g th e e le c tro n tra n s p o rt syste m □ T h is re s u lts in s e v e re a n io n g a p m e ta b o lic (la c tic ) a c id o s is □ U n u tiliz e d o x y g e n re m a in s in b lo o d , g iv in g ris e to a b rig h t c h e rry -re d skin c o lo r ■ H C N g a s g iv e s th e p a tie n t a b itte r a lm o n d o d o r; o n ly 5 0 % o f th e p o p u la tio n is c a p a b le o f d e te c tin g th is o d o r ■ C y a n id e is ra p id ly m e ta b o liz e d to th io c y a n a te , w h ic h ca n be m e a s u re d to d e te c t e x p o s u re , b u t th e te s t is n o t c o m m o n ly a v a ila b le ■ E x p o s e d p a tie n ts h a ve e le v a te d s e ru m la c ta te a n d an a n io n g a p m e ta b o lic a c id o s is , e le v a te d s e ru m g lu c o s e (d ue to d e c re a s e d u tiliz a tio n ), d e c re a s e d a rte ria l-v e n o u s o x y g e n g a p (d u e to d e c re a s e d u tiliz a tio n ) ■ T re a tm e n t in v o lv e s th e a d m in is tra tio n o f s o d iu m n itrite a n d a m y l n itrite , w h ic h le a d s to fo rm a tio n o f m e th e m o g lo b in , w h ic h b in d s a v a ila b le c y a n id e

1.7.3.7 Salicylate (aspirin) ■ A s p irin e x e rts c o n flic tin g e ffe c ts on a c id -b a s e b a la n c e □ D ire c tly s tim u la te s th e re s p ira to ry c e n te r p ro m o tin g re s p ira to ry a lk a lo s is □ U n c o u p le s o x id a tiv e p h o s p h o ry la tio n a n d in h ib its th e K re b s c y c le , le a d in g to m e ta b o lic a c id o s is w ith a n io n g a p (la c tic a c id o s is ) ■ C N S d e p re s s io n m a y c o n trib u te to h y p o v e n tila tio n a n d a c o m p o u n d in g re s p ira to ry a c id o s is f1.14 Acetaminophen (Rumack-Matthew) nomogram for determination of toxicity severity; if the time of ingestion is known, plotting a single serum acetaminophen level, drawn >4 hours after ingestion, can triage the patient as being at high or low risk for toxicity

1.7.3.8 Arsenic ■ A rs e n ic is la rg e ly e x c re te d in u rin e , w ith m o s t o f th e re m a in d e r d is trib u te d into s k in , n a ils, a n d h a ir ■ In h ib its o x id a tiv e p ro d u c tio n o f A T P

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Toxicology>Overdose | Therapeutic drug monitoring Lipids & carbohydrates>Lipids ■ A c u te to x ic ity in itia lly m a n ife s ts w ith n a u s e a , v o m itin g , “ ric e w a te r ” d ia rrh e a , a b d o m in a l p a in , e n c e p h a lo p a th y ■ C h ro n ic to x ic ity re s u lts in p e rip h e ra l n e u ro p a th y , n e p h ro p a th y , s k in h y p e rp ig m e n ta tio n a n d h y p e rk e ra to s is (p a rtic u la rly p a lm s a n d s o le s ), a n d tra n s v e rs e M e e s lin e s in th e n a ils . T h e m a rro w is a ffe c te d , c a u s in g c y to p e n ia s (w ith e ry th ro c y te b a s o p h ilic s tip p lin g s im ila r to th a t s e e n in le a d to x ic ity )

1.7.4.2 Procainamide ■ C le a re d p re d o m in a n tly by th e liv e r ■ M e ta b o liz e d to N -a c e ty lp ro c a in a m id e (N A P A ), w h ic h a ls o h as p h a rm a c o lo g ic a c tiv ity □ R a te o f c o n v e rs io n to N A P A is g e n e tic a lly d e te rm in e d □ “ F a st a c e ty la to rs ” h a ve h ig h le v e ls o f a c e ty ltra n s fe ra s e a n d h ig h e r le v e ls o f N A P A □ N A P A is re n a lly c le a re d

1.7.3.9 Tricyclic antidepressants

■ B oth p ro c a in a m id e and N A P A s h o u ld be m o n ito re d

■ A n tic h o lin e rg ic e ffe c ts d o m in a te s y m p to m s o f to x ic ity , in c lu d in g d ry m o u th , c o n s tip a tio n , u rin a ry re te n tio n , p u p illa ry d ila tio n , h y p e rth e rm ia , le th a rg y , c o n fu s io n ■ T C A s c a u s e Q R S p ro lo n g a tio n th a t c a n le a d to v e n tric u la r a rrh y th m ia s

1.7.3.10 Organophosphates & carbamates ■ F o u n d in in s e c tic id e s ■ In h ib it a c e ty lc h o lin e s te ra s e ■ T h e c la s s ic p re s e n ta tio n is a fa rm e r w h o p re s e n ts w ith m io s is (p in p o in t p u p ils ), d ia p h o re s is , e x c e s s s a liv a tio n , la c rim a tio n , G l h y p e rm o tility , b ra d y c a rd ia a nd b ro n c h o s p a s m (m u s c a rin ic to x id ro m e ) ■ D e c re a s e d e ry th ro c y te o r p la s m a c h o lin e s te ra s e a c tiv ity

1.7.4.3 Aminoglycosides ■ M a in ly c le a re d by th e k id n e y s ■ T o x ic ity is m a n ife s te d p rim a rily a s n e p h ro to x ic ity and o to to x ic ity ■ M o n ito rin g re c o m m e n d e d fo r p a tie n ts w h o w ill re c e iv e th e ra p y fo r o v e r 7 d a y s

1.8 Lipids & carbohydrates 1.8.1 Lipids 1.8.1.1 Brief review of lipids ■ L ip id s a re p a c k a g e d into lip o p ro te in p a rtic le s t1.25 ■ In g e s te d lip id s a re p a c k a g e d into c h y lo m ic ro n s w h ic h c o n ta in th e a p o lip o p ro te in B 4 8 ; th e y e n te r h e p a to c y te s v ia th e re c e p to r fo r a p o lip o p ro te in E

1.7.3.11 Mercury ■ “ M a d h a tte r d is e a s e ” ■ T o x ic e x p o s u re u s u a lly o c c u rs th ro u g h in h a la tio n o f th e vapor ■ C h ro n ic m e rc u ry to x ic ity □ A c ro d y n ia (F e e r s y n d ro m e ) m a n ife s ts w ith a u to n o m ic m a n ife s ta tio n s (s w e a tin g , h e m o d y n a m ic in s ta b ility ) a n d a d e s q u a m a tiv e e ry th e m a to u s ra s h o n th e p a lm s a n d s o le s ; a s s o c ia te d w ith in c re a s e d u rin a ry c a te c h o la m in e s a n d c a n m im ic p h e o c h ro m o c y to m a □ E re th is m is a C N S d is o rd e r m a n ife s tin g a s p e rs o n a lity c h a n g e s , irrita b ility , a n d fin e m o to r d is tu rb a n c e s

1.7.4 Therapeutic drug monitoring 1.7.4.1 Digoxin ■ M o n ito rin g m a y b e in d ic a te d fo llo w in g d o s e m o d ific a tio n s o r if th e re is im p a ire d re n a l fu n c tio n ■ P rim a rily e x c re te d b y th e k id n e y s ; re n a l fu n c tio n te s ts s h o u ld b e p e rfo rm e d in itia lly to g u id e d o s in g ■ E n d o g e n o u s s u b s ta n c e s th a t c ro s s re a c t w ith d ig o x in , te rm e d d ig o x in lik e im m u n o re a c tiv e s u b s ta n c e s , a re fo u n d in th e s o m e p a tie n ts ; m o s t c o m m o n in n e o n a te s , p re g n a n t w o m e n , liv e r fa ilu re , a n d re n a l fa ilu re

* L ip id s a re s e c re te d b y liv e r in th e fo rm o f v e ry low d e n s ity lip o p ro te in (V L D L ) w h ic h is rich in trig ly c e rid e ■ V L D L u n d e rg o e s p ro g re s s iv e h y d ro ly s is by e n d o th e liu m b o u n d lip o p ro te in lip a s e (LP L), o v e r tim e lo s in g s u ffic ie n t trig ly c e rid e to b e c o m e in te rm e d ia te d e n s ity lip o p ro te in (ID L ) a nd , e v e n tu a lly , lo w d e n s ity lip o p ro te in (L D L ) ■ L D L is rich in p h o s p h o lip id , c h o le s te ro l, a nd a p o lip o p ro te in B 100; it is th e m a in v e h ic le fo r tra n s p o rtin g c h o le s te ro l fro m th e b lo o d s tre a m to s o m a tic ce lls, w h e re th e y a re ta k e n in v ia th e L D L re c e p to r and a p o lip o p ro te in B 100 ■ T h e liv e r a ls o p ro d u c e s h ig h d e n s ity lip o p ro te in (H D L ) th a t c o n ta in s a s m a ll a m o u n t o f lip id a nd is rich in le cith in c h o le s te ro l a c y l tra n s fe ra s e (L C A T ) and a p o lip o p ro te in s A1

1.8.1.2 Methods ■ T o ta l c h o le s te ro l, H D L , a n d T G a re m e a s u re d □ LD L is u s u a lly c a lc u la te d u sin g th e F rie d e w a ld e q u a tio n ; n ot c o n s id e re d v a lid fo r TG > 4 0 0 , if c h y lo m ic ro n s a re p re s e n t, in c h o le s ta s is , o r in ty p e III d y s lip id e m ia LDL cholesterol = total cholesterol - HDL cholesterol - TG

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Lipids & carbohydrates>Lipids t1 .25 Lipoprotein classes Lipoprotein

Electrophoretic mobility

Average density (g/mL)

Protein (%)

Major lipid

Apolipoproteins

B48, A1, CM, E 1 TG 0.95 origin chylomicrons B100, C, E 8 TG 1 pre-|3 VLDL B100, E 15 cholesterol 1.02 pre-p/p IDL 20 B100 cholesterol 1.04 LDL P 50 A1,C, E cholesterol 1.1 a HDL HDL = high density lipoprotein; IDL = intermediate density lipoprotein; LDL = low density lipoprotein; TG = triglyceride; VLDL = very low density lipoprotein

□ V L D L c h o le s te ro l is o fte n e s tim a te d b y c a lc u la tio n a s w e ll ■ T h e in d iv id u a l lip o p ro te in s d iffe r in d e n s ity fro m o n e a n o th e r, so th a t by u ltra c e n trifu g a tio n , th e y ca n be s e p a ra te d into th e v a rio u s ty p e s a n d q u a n tifie d ■ L ip o p ro te in e le c tro p h o re s is is e m p lo y e d a s a b a s is fo r q u a lita tiv e a n a ly s is o f lip o p ro te in c la s s e s b u t is n ot s u ita b le fo r q u a n tita tiv e a n a lys is ■ O v e rn ig h t re frig e ra tio n p ro d u c e s c h a ra c te ris tic p a tte rn s in p la s m a ; a c re a m y la y e r a to p th e p la s m a in d ic a te s th e p re s e n c e o f e x c e s s c h y lo m ic ro n s ; tu rb id ity o f th e p la s m a in d ic a te s a b u n d a n t V L D L . L D L a nd H D L , e ve n w h e n p re s e n t in e x c e s s , d o n o t v is ib ly a lte r th e p la s m a ■ Im m u n o a s s a y s a re a v a ila b le fo r th e m e a s u re m e n t o f e a c h a p o lip o p ro te in

t1 .26 Classification of lipid disorders by predom inant lipids Clinical Phenotype Cholesterol TG features Disorder familial LPL deficiency

I

T

nr

familial APOC-II deficiency familial hypercholesterolemia

I or V

t

TTT

lla

m

-*T

TTT

TTT

TT

TT

T

TTT

III familial dysbetalipoproteinemia lib or IV familial combined hyperlipidemia IV orV familial hypertriglyceridemia

eruptive xanthomas, pancreatitis pancreatitis tendinous xanthomas, premature atherosclerosis

premature atherosclerosis eruptive xanthomas, pancreatitis

1.8.1.3 Lipid disorders ■ Lipid d is o rd e rs ca n be c la s s ifie d in 2 m a jo r w a y s - by lip o p ro te in p ro file o r by th e s e ru m c o n c e n tra tio n s o f c h o le s te ro l a nd TG ; if o n e re c a lls th a t V L D L and c h y lo m ic ro n s c o n ta in p re d o m in a n tly TG , w h ile LD L c o n ta in s p re d o m in a n tly c h o le s te ro l, th e 2 c o n c e p ts c o rre la te fa irly w e ll ■ P re m a tu re a th e ro s c le ro s is is th e m o s t n o to rio u s c o n s e q u e n c e o f h y p e rlip id e m ia t1.26. T h is is o b s e rv e d in th e s e ttin g o f h ig h L D L o r ID L, ie, w h e n th e c h o le s te ro l is h ig h , b u t is n o t a p ro m in e n t fe a tu re w h e n o n ly T G is e le v a te d ■ E ru p tiv e x a n th o m a s a re se e n w ith e le v a te d TG (c h y lo m ic ro n s o r V L D L )

■ P la s m a to ta l c h o le s te ro l is > 2 0 0 m g /d L ; u s u a lly re la te d to e le v a te d L D L , u s u a lly p a tte rn s II o r III ■ S e c o n d a ry c a u s e s a re h y p o th y ro id is m , d ia b e te s m e llitu s , n e p h ro tic s y n d ro m e , c h o le s ta s is , c y c lo s p o rin e , th ia z id e d iu re tic s , o r lo o p d iu re tic s ■ T h e m o s t c o m m o n p rim a ry c a u s e o f h y p e rc h o le s te ro le m ia is fa m ilia l h y p e rc h o le s te ro le m ia , an a u to s o m a l d o m in a n t d e fic ie n c y o f L D L re c e p to r a c tiv ity

1.8.1.3.2 P re d o m in a n t h y p e rtrig ly c e rid e m ia ■ T h is is re la te d to e le v a te d c h y lo m ic ro n s o r V L D L

■ T e n d in o u s x a n th o m a s a re s e e n w h e n th e re a re e le v a tio n s in T G and c h o le s te ro l (e le va te d ID L) ■ X a n th e la s m a a re a re a s s o c ia te d w ith h ig h c h o le s te ro l (L D L ) ■ A c u te p a n c re a titis is a s s o c ia te d w ith e le v a te d TG (c h y lo m ic ro n s o r V L D L ), p a rtic u la rly w h e n TG is > 5 0 0 m g /d L

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1.8.1.3.1 P re d o m in a n t h y p e rc h o le s te ro le m ia

■ N o t an in d e p e n d e n t ris k fa c to r fo r c o ro n a ry a rte ry d is e a s e ■ C o m m o n s e c o n d a ry c a u s e s in c lu d e h e a v y a lc o h o l c o n s u m p tio n , o b e s ity , d ia b e te s m e llitu s , h e p a titis , p re g n a n c y , re n a l fa ilu re , (B b lo c k e rs , is o tre tin o in , c o rtic o s te ro id s , n e p h ro tic s y n d ro m e , a n d g o u t ■ P rim a ry c a u s e s in c lu d e fa m ilia l c o m b in e d h y p e rlip id e m ia , fa m ilia l LP L d e fic ie n c y , fa m ilia l a p o C -ll d e fic ie n c y , a n d fa m ilia l h y p e rtrig ly c e rid e m ia

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1: Chemistry

Lipids & carbohydrates>Lipids | Carbohydrates 1.8.1.3 .3 M ixe d h y p e rtrig ly c e rid e m ia & h y p e rc h o le s te ro le m ia ■ M o s t c o m m o n in s e v e re d ia b e te s m e llitu s , h y p o th y ro id is m , o r n e p h ro tic s y n d ro m e ■ P rim a ry c a u s e s in c lu d e fa m ilia l c o m b in e d h y p e rlip id e m ia a n d ty p e III h y p e rlip id e m ia (d y s b e ta lip o p ro te in e m ia )

1 .8 .1 .3 .4 Low levels o f H D L c h o le s te ro l ■ H D L < 3 5 m g /d L ■ In d e p e n d e n t ris k fa c to r fo r p re m a tu re a th e ro s c le ro s is ■ T a n g ie r d is e a s e is an a u to s o m a l re c e s s iv e d is o rd e r c h a ra c te riz e d b y lo w c h o le s te ro l, n o rm a l T G , a b s e n t H D L , a n d a b s e n c e o f a po A 1 ; c h o le s te ro l e s te rs d e p o s it in th e to n s ils , ly m p h n o d e s , v a s c u la tu re , a n d s p le e n , a n d c o rn e a l o p a c itie s d e v e lo p ■ H D L re d u c e d by s m o k in g , o b e s ity , s e d e n ta ry life s ty le , a n d a n a b o lic s te ro id s

1.8.1.3.5 L ip id s in th e a s s e s s m e n t o f c o ro n a ry a rte ry d is e a s e risk ■ N a tio n a l C h o le s te ro l E d u c a tio n P ro g ra m th ird A d u lt T re a tm e n t P a n e l (A T P III) g u id e lin e s t1.27, t1.28

1.8.2 Carbohydrates ■ In s u lin le a d s to an in c re a s e in c e llu la r u p ta k e o f g lu c o s e , in c re a s e d o v e ra ll a n a b o lic a c tiv ity , c o n v e rs io n o f g lu c o s e to g ly c o g e n (g ly c o g e n e s is ), a n d in c re a s e d c o n v e rs io n o f c a rb o h y d ra te s to fa tty a c id s (lip o g e n e s is ) w ith n e t e ffe c t o f d e c re a s e d p e rip h e ra l b lo o d g lu c o s e ■ S e v e ra l a g e n ts a c t c o u n te r to th e e ffe c ts o f in s u lin , in c lu d in g g lu c a g o n , e p in e p h rin e , g lu c o c o rtic o id s , g ro w th h o rm o n e , th y ro x in e , s o m a to s ta tin , a n d in p re g n a n c y , h u m a n p la c e n ta l la c to g e n (H P L ) ■ In s u lin is s y n th e s iz e d a s p ro in s u lin , a s in g le 51 a m in o a c id c h a in □ Its fir s t (a m in o te rm in u s ) s e v e ra l a m in o a c id s a re c a lle d th e B c h a in , th e n e x t s e v e ra l th e C p e p tid e , a n d th e re m a in in g c a lle d th e A c h a in □ D is u lfid e b o n d s fo rm b e tw e e n th e A & B c h a in s , a n d th e C p e p tid e is p ro te o ly tic a lly c le a v e d □ T h u s e q u im o la r a m o u n ts o f in s u lin a n d C p e p tid e s a re p ro d u c e d ; re la tiv e ly ra p id d e g ra d a tio n o f in s u lin re s u lts in a C p e p tid e :in s u lin ra tio o f 5 -5:1 1.8.2.1 M e th o d s ■ Im m u n o m e tric a s s a y s fo r m e a s u re m e n t o f in s u lin a n d C p e p tid e ■ G lu c o s e is u s u a lly m e a s u re d b y e n z y m a tic a s s a y

t1 .27 aTP III cholesterol classification total cholesterol (mg/dL)

desirable 240 LDL (mg/dL) optimal 190 HDL (mg/dL) low 60 ATP III = the third Adult Treatment Panel report of the National Cholesterol Education Program; HDL = high density lipoprotein; LDL = low density lipoprotein

t1 .28 ATP III recommended LDL targets Risk group

Notes

Target LDL

presence of coronary heart disease (CHD) or CHD equivalents CHD equivalents include diabetes, 20% (a complex formula determines this risk) 2 or more major risk major risk factors include smoking, factors hypertension (>140/90), HDL Nonroutine pretransfusion procedures: positive antibody screen or crossmatch t2 .14 Unusual findings in forward & reverse grouping Case

Forward grouping

Reverse grouping

Anti-A

Anti-B

Anti-RH

A cells

B cells

1

0

0

4+

4+

4+

2 3 4 5

1-2+ 4+ 4+ 0

4+ 1-2+ 4+ 0

0 0 0 0

4+ 0 1-2+ 4+

0 4+ 0 4+

Antibody screen Ab screening or panel cells reacts with all D+ RBCs negative negative negative 4+

t2 .15 Unusual findings in antibody screen and/or panel Case

Finding__________________________________________________

6______ all cells in panel and autocontrol positive at AHG only________________ 7______all cells in panel, except autocontrol, positive at AHG only, weak (1+ to 2+) 8______all cells in panel and autocontrol positive at IS only___________________ 9______all cells in panel and autocontrol positive at IS and 37°C, not at AHG 10 antibody screen negative, but transfusion records show previous _________alloantibody_________________________________________________

■ C a s e 2 t2.14 is a g ro u p B in d iv id u a l m a n ife s tin g th e B (A ) p h e n o ty p e . C e rta in b lo o d ty p e B in d iv id u a ls h a ve s u c h h ig h le v e ls o f g lu c o s y ltra n s fe ra s e th a t a s m a ll a m o u n t o f A a n tig e n is p ro d u c e d , a n d th e ir red c e lls re a c t w e a k ly w ith a n ti-A re a g e n t. T h e s e p a tie n ts h a ve a p g ly c o s y ltra n s fe ra s e w ith an in c re a s e d a b ility to u se U D P -N -a c e ty l g a la c to s a m in e a n d U D P -g a la c to s e th a t c a u s e s p ro d u c tio n o f A a n tig e n in s m a ll a m o u n ts ■ C a s e 3 t2.14 s h o w s a g ro u p A p a tie n t w ith a c q u ire d B p h e n o ty p e . T h e g ro u p A p a tie n t a c q u ire s re a c tiv ity w ith a n ti-B re a g e n t a n d th u s ty p e a s A B , d e s p ite h a v in g s e ru m a n ti-B a n tib o d ie s . T h is o c c u rs in A1 in d iv id u a ls w h e n th e A1 a n tig e n is a c te d u p o n b y b a c te ria l d e a c e ty la s e s , w h ic h w ill d e a c e ty la te th e A a n tig e n (N -a c e ty l-g a la c to s a m in e ) to th e B a n tig e n (g a la c to s e ). T h u s , th e a c q u ire d B p h e n o ty p e is a s s o c ia te d w ith c o n d itio n s th a t g iv e ris e to tra n s ie n t o r p e rs is te n t b a c te re m ia s u c h a s c o lo n c a n c e r, c o lo n ic o b s tru c tio n , a n d G r a m - s e p s is . D u e to th e p re s e n c e o f a n ti-B in s e ru m , th is c a n a ls o re s u lt in a p o s itiv e DAT. To c o n firm a c q u ire d B, s e v e ra l a v e n u e s a re a v a ila b le . A d iffe re n t m a n u fa c tu re r ’s m o n o c lo n a l a n ti-B ty p in g re a g e n t ca n s im p ly b e u s e d to re s o lv e th is d is c re p a n c y . T h e a lte re d A1 a n tig e n w ith B a n tig e n ic a c tiv ity c a n be re a c e ty la te d in v itro w ith a c e tic a n h y d rid e

■ C a s e 4 t2.14 illu s tra te s a g ro u p A B p a tie n t w h o has a nti-A 1 a n tib o d ie s . T h is is c o m m o n ly id e n tifie d in in d iv id u a ls w ith A 2 B b lo o d g ro u p . - 1 - 8 % o f A 2 p a tie n ts w ill have anti-A 1 a n tib o d ie s a n d 2 2 -3 5 % o f A 2 B in d iv id u a ls h a ve anti-A 1 a n tib o d y . A n ti-A 1 is u s u a lly a c lin ic a lly in s ig n ific a n t Ig M a n tib o d y re a c tin g a t ro o m te m p e ra tu re o r b e lo w ; c o m p a tib le b lo o d c a n be fo u n d w ith a p re w a rm e d c ro s s m a tc h . A n y anti-A 1 a n tib o d ie s re a c tin g a t 37°C a re c lin ic a lly s ig n ific a n t a n d p a tie n ts s h o u ld re c e iv e O o r A 2 c o m p a tib le b lo o d ■ C a s e 5 t2,14 s h o w s th e B o m b a y p h e n o ty p e . T h e s e p a tie n ts h ave a n ti-H in th e ir p la s m a a nd th e re fo re re a c t w ith all g ro u p O s c re e n in g c e lls ■ C a s e 6 t2.15 d e s c rib e s th e ty p ic a l re a c tio n p a tte rn o f a w a rm a u to a n tib o d y . W a rm a u to a n tib o d ie s m a y a ls o be p o s itiv e a t 37°C p h a s e . A n a d s o rp tio n te c h n iq u e m ay s u c c e e d in re m o v in g th e s e a n tib o d ie s , p e rm ittin g fu rth e r te s tin g ■ C a s e 7 t2.15 is th e ty p ic a l p a tte rn o f a h ig h titer, lo w a v id ity a n tib o d y to a fre q u e n tly o c c u rrin g a n tig e n (eg, C h ido , R o d g e rs ). T h e s e c a n o fte n be n e u tra liz e d w ith s e ru m ■ C a s e 8 t2.15 s h o w s th e u su a l re a c tio n p a tte rn o f a c o ld a u to a n tib o d y . If th e a n tib o d y h a s b ro a d th e rm a l a m p litu d e , it m a y a ls o b e p o s itiv e in th e 37° p ha se . S in c e u s u a lly th e s e a re IgM a n tib o d ie s , th e y a re not re a c tiv e a t A H G (IA T ) p h a s e . A p re w a rm e d a n tib o d y s c re e n a n d p re w a rm e d c ro s s m a tc h m a y be u sed so th e s e c lin ic a lly in s ig n ific a n t a n tib o d ie s do n ot in te rfe re w ith p re tra n s fu s io n te s tin g ■ C a s e 9 t2.15 d e s c rib e s th e w a y an a n tib o d y to e n h a n c e m e n t m e d ia o r o th e r re a g e n ts , su ch a s LIS S , P EG , g el o r s o lid p h a s e m e d ia , m a y re a c t ■ C a s e 10 t2.15 d e s c rib e s a c o m m o n s c e n a rio in w h ic h a p re v io u s ly id e n tifie d a llo a n tib o d y is n o t d e te c te d in th e p re s e n t s c re e n . T h is is th e re s u lt o f re d u c e d tite r o f a llo a n tib o d y b e lo w th e level o f d e te c tio n o f th e a n tib o d y scre e n ; th e a llo a n tib o d y re m a in s c lin ic a lly s ig n ific a n t, how ever. In su ch c a s e s , a n tig e n n e g a tiv e u n its s h o u ld be s e le c te d , a nd th e c ro s s m a tc h m u s t be c a rrie d th ro u g h th e a n tig lo b u lin p h a s e

2.2.2.8 Other unusual findings ■ In p a tie n ts w ith h e m a to ly m p h o id n e o p la s m s , th e re is o fte n w e a k e n e d e x p re s s io n o f A o r B a n tig e n s w ith m ixe d fie ld a g g lu tin a tio n ■ In p a tie n ts w ith g a s tric a d e n o c a rc in o m a , e x c e s s fre e A o r B a n tig e n s m a y be p re s e n t in th e s e ru m . T h is m ay h a ve th e e ffe c t in v itro o f b in d in g a n ti-A o r a n ti-B re a g e n ts th e re b y n e u tra liz in g th e m a n d th u s g iv in g th e fa ls e im p re s s io n th a t th e p a tie n t has ty p e O red c e lls

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© A S C P 2018

2: Blood Banking/Transfusion Medicine

Pretransfusion procedures>Autoantibodies in the blood bank • S o m e w a rm re a c tin g IgG a u to a n tib o d ie s c a n p ro d u c e e x tra v a s c u la r h e m o ly s is

2.2.3 Autoantibodies in the blood bank 2.2.3.1

When to consider autoantibody

■ A u to a n tib o d ie s a re s u s p e c te d in 1 o f s e v e ra l s c e n a rio s □ W h e n th e re is a p o s itiv e D AT □ A n e m ia w ith re tic u lo c y to s is o r m ic ro s p h e ro c y to s is

■ T ra n s fu s io n s a re b e s t a v o id e d ; th e re is a g re a te r ris k o f tra n s fu s io n re la te d c o m p lic a tio n s in th e s e p a tie n ts , a n d tra n s fu s io n m a y e x a c e rb a te th e u n d e rly in g h e m o ly tic a n e m ia □ W h e n tra n s fu s io n is re q u ire d , th e m a jo r c h a lle n g e is to id e n tify u n d e rly in g a llo a n tib o d ie s

■ A D A T w ill c o n firm /e x c lu d e a u to im m u n e h e m o ly s is □ P o sitiv e a u to c o n tro l in th e a n tib o d y pan e l

■ T h is m a y re q u ire an a u to a d s o rp tio n p ro c e d u re , in p a tie n ts w h o h a ve n ot b e e n tra n s fu s e d w ith in 3 m o n th s

■ A D A T w ill e n s u re th a t th e re a c tio n is im m u n e m e d ia te d ■ A p o s itiv e D AT

■ If th e p a tie n t h as bee n re c e n tly tra n s fu s e d , an a llo a d s o rp tio n m a y be a tte m p te d u s in g c e lls o f k n o w n p h e n o ty p e s

□ F o u n d in 1% o f o u tp a tie n ts a n d up to 15% o f h o s p ita liz e d p a tie n ts □ If fo u n d u sin g p o ly s p e c ific re a g e n t (C 3 a n d IgG ), th is s h o u ld be fo llo w e d by in c u b a tio n w ith m o n o s p e c ific a n ti-Ig G and a n ti-C 3 a n tis e ra ■ D AT re a c tiv e w ith a n ti-Ig G o n ly o r w ith both a n ti-Ig G a n d a n ti-C 3 ■ M o s t lik e ly c a u s e d by a w a rm a u to a n tib o d y (Ig G ) ■ D A T re a c tiv e a n ti-C 3 o n ly ■ t2.16 lis ts th e c a u s e s o f p o s itiv e D A T re a c tio n s

DAT results

Causes

lgG+/C3+, lgG+/C3—

acute/delayed hemolytic transfusion reaction, delayed serologic transfusion reaction, warm autoantibody, hemolytic disease of the fetus/newborn, medication induced, ABO incompatible stem cell transplant, passive immunoglobulins or monoclonal therapies cold autoantibody, medications transfused RBCs

■ A n e lu tio n s h o u ld be p e rfo rm e d fo r all p o s itiv e IgG D AT re su lts

Warm reacting autoantibodies

■ W a rm re a c tin g a n tib o d ie s re a c t o p tim a lly a t 37°C ■ T yp ica lly, th e y re a c t w ith th e p a tie n t’s o w n red c e lls (p ro d u c e a p o s itiv e a u to c o n tro l/D A T ) and a re p a n re a c tiv e w ith all c e lls te s te d in th e s c re e n , p a n e l, a nd c ro s s m a tc h ■ W a rm re a c tin g a n tib o d ie s a re u s u a lly IgG ■ T h e A H G p h a s e is p o s itiv e w ith p o ly s p e c ific a n tis e ra and m o n o s p e c ific a n ti-Ig G a n tis e ra □ In 3 0 -5 0 % o f c a s e s a n ti-C 3 is a ls o p o s itiv e □ T h e p re s e n c e a n d s tre n g th o f C 3 c o rre la te s w ith th e lik e lih o o d o f h e m o ly s is ■ R ed ce ll a u to a n tib o d ie s m a y d e m o n s tra te a n ti-R h s p e c ific ity © A S C P 2018

■ R e a c t m o s t s tro n g ly a t 4°C, b u t th e y h a v e w id e th e rm a l a m p litu d e up to 22°C ■ M a y in te rfe re w ith ro u tin e te s ts w h e n th e y re a c t a t o r n e a r ro o m te m p e ra tu re ■ M o s t a re IgM a nd ca n a c tiv a te c o m p le m e n t in v itro

t2.16 Causes of positive DAT reactions

2.2.3.2

■ B e n ig n c o ld a g g lu tin in s are th e m o s t c o m m o n ly e n c o u n te re d a u to a n tib o d ie s

■ T h e tite r o f b e n ig n c o ld a g g lu tin in s is u s u a lly < 6 4 a t 4°C

■ M o s t lik e ly c a u s e d by c o ld a u to a n tib o d y (Ig M )

IgG—/C3+ mixed field positive DAT

2.2.3.3 Cold reacting autoantibodies t2.17

□ R e a c tio n s m a y be se e n a t th e A H G p h a s e u s in g p o ly s p e c ific a n tis e ra □ W ith m o n o s p e c ific re a g e n ts , c e lls a re a g g lu tin a te d by a n ti-C 3 d b u t n o t a n ti-Ig G

t2.17 Cold reacting autoantibodies Specificity

Associations

anti-l

adult RBCs

anti-i anti-Pr

cord RBCs Pr+ RBCs

anti-H

group 0 RBCs

Mycoplasma infections, lymphoproliferative disorders, cause Raynaud/acrocyanosis Epstein-Barr virus infections monoclonal antibody causing agglutination and fixing complement in the extremities and can cause intravascular hemolysis cold reacting and not anti-H in Oh Bombay patients, which is warm reacting and causes severe hemolysis

anti-A1

qroup A RBCs

2.2.3.4 Mixed type autoantibodies ■ B o th c o ld re a c tin g IgM and w a rm re a c tin g IgG a u to a n tib o d ie s ■ N o p a rtic u la r a n tig e n s p e c ific ity h a s b e e n c o n s is te n tly show n ■ C lin ic a lly , th e s e p a tie n ts p re s e n t w ith an a c u te o n s e t h e m o ly tic a n e m ia , u s u a lly id io p a th ic o r a s s o c ia te d w ith lu p u s

ISBN 978-08 9 1 8 9 -6 6 7 8

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2: Blood Banking/Transfusion Medicine

P retransfusion procedures>A utoantibodies in the blood bank

2.2.3.5 Paroxysmal cold hem oglobinuria (PCH) t2.18

□ A n tib o d y c o a ts th e red c e ll a n d is c a p a b le o f c a u s in g e x tra v a s c u la r h e m o ly s is

■ T h e le a s t c o m m o n ty p e o f A IH A , 1 -2 % o f c a s e s

□ P e n ic illin is th e p ro to ty p ic a g e n t. 3% o f p a tie n ts on p e n ic illin d e v e lo p a p o s itiv e DAT; 5% o f th o s e w ith a p o s itiv e D A T e x p e rie n c e h e m o ly s is . T h e e ffe c t is d o s e dependent

■ It m o s t c o m m o n ly a ffe c ts c h ild re n w ith b a c te ria l in fe c tio n (o titis m e d ia ) o r v ira l in fe c tio n (u p p e r re s p ira to ry v ira l in fe c tio n s , m e a s le s , m u m p s , c h ic k e n p o x , a n d in fe c tio u s m o n o n u c le o s is ). O rig in a lly d e s c rib e d in p a tie n ts w ith c o n g e n ita l o r te rtia ry s y p h ilis

□ L ab c o n firm a tio n in v o lv e s d e m o n s tra tin g th a t th e s e ru m a n d e lu a te re a c t w ith d ru g tre a te d red c e lls b ut n ot w ith u n tre a te d red c e lls

■ T re a tm e n t c o n s is ts o f k e e p in g th e p a tie n t w a rm a n d tra n s fu s in g a s n e c e s s a ry

■ T h e d ru g d e p e n d e n t a n tib o d y m e c h a n is m

t2.18 Paroxysm al cold hem oglobinuria stimulus antibody class reactive temperature antigen specificity DAT reactions testing reactions confirmatory testing

□ D ru g b e c o m e s a d s o rb e d to th e red ce ll m e m b ra n e and s u b s e q u e n tly b e c o m e s c o a te d w ith a n tib o d y th a t can a c tiv a te c o m p le m e n t

viral upper respiratory infections, vaccinations, bacterial otitis media, congenital/tertiary syphillis IgG: biphasic hemolysin 0°C and then 37°C P antigen IgG-, C3 + may react at 37°C with screen and crossmatches direct or indirect DL test

■ T h e d ire c t D L te s t m a y b e p e rfo rm e d o n a d u lts u sin g 2 v ia ls o f b lo o d a t 2 d iffe re n t te m p e ra tu re s : 4°C and 3 7°C . A p o s itiv e te s t is o b ta in e d if o n ly in c u b a tio n o f th e p a tie n t’s R B C s a t 4° th e n 37° le a d s to h e m o ly s is . T h e in d ire c t D L te s t u s e s p a tie n t p la s m a w ith re a g e n t R B C s . S e rie s o f tu b e s a re in c u b a te d a t 9 0 m in u te s a t 0°C a n d 37°C ; 1 s e t is in c u b a te d fo r 3 0 m in u te s a t 0°C a n d tra n s fe rre d to 3 7°C fo r 6 0 m in u te s . If p o s itiv e fo r th e D L a n tib o d y , h e m o ly s is s h o u ld b e o b s e rv e d o n ly in th e s e t o f tu b e s in c u b a te d a t 0°, th e n tra n s fe rre d to 37°C .

2.2.3.6 Blood banking considerations with a cold autoantibody ■ T h e firs t o b je c tiv e is to d e te rm in e w h e th e r th e a u to a n tib o d y is p a th o lo g ic

□ C o m p le m e n t a c tiv a tio n le a d s to in tra v a s c u la r h e m o ly s is , o fte n c o m p lic a te d by re n a l fa ilu re □ T a kes s m a ll d o s e to in itia te th is re a c tio n a n d u p o n re e x p o s u re b ris k h e m o ly tic re a c tio n s ca n be se en □ P ip e ra c illin a n d c e p h a lo s p o rin s a re p ro to ty p e s □ Lab c o n firm a tio n in v o lv e s d e m o n s tra tin g a p o s itiv e DAT, w ith C 3 and p o s s ib ly IgG , a n d th a t d ru g m u s t be p re s e n t in th e s p e c im e n to d e m o n s tra te th e re a c tiv e a n tib o d y

t2.19 Drug induced DAT Type

DAT Serum reactions antibody

Hematologic Associated manifestations drugs

drug lgG+, C3d --Ab reacts with moderate adsorption drug coating hemolysis, RBC extravascular drug IgG—/C3d+ Ab to drug and abrupt, severe dependent RBC membrane intravascular hemolysis autoimmune lgG+/C3— autoab to RBC induction membrane

□ M o s t p a th o lo g ic e x a m p le s h a v e h ig h tite r (> 1 ,0 0 0 )

mild-moderate, extravascular hemolysis

□ M o s t p a th o lo g ic e x a m p le s re a c t o v e r a b ro a d te m p e ra tu re ra n g e (> 3 0 °C ) ■ T h e s e c o n d o b je c tiv e is to s e a rc h fo r m a s k e d a llo a n tib o d ie s □ K e e p b lo o d a t 3 7°C a n d p e rfo rm all te s ts a t 37°C (p re w a rm e d s c re e n a n d p a n e l) □ U s e m o n o s p e c ific a n ti-Ig G A H G re a g e n t □ C o n s id e r c o ld a u to a n tib o d y a d s o rp tio n w ith a u to lo g o u s red c e lls

nonimmune

lgG+ but eluates negative

nonspecific ?? adsorption of albumin or immunoglobulins on RBC membrane, no antibody production occurs

penicillin piperacillin, 2nd/3rd generation cephalosporins methyldopa, levodopa, procainamide, fludarabine, 2nd/3rd generation cephalosporins cephalothin (Keflin), piperacillin, tazobactam sodium, cisplatin, and amoxicillin

2 .2 .3 7 Mechanisms of drug induced positive DAT t2.19 ■ T h e d ru g a d s o rp tio n (h a p te n ) m e c h a n is m □ N o n c o v a le n t c o a tin g o f red b lo o d c e lls w ith d ru g to w h ic h th e p a tie n t h a s a n tib o d y

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Transfusion in special clinical circum stances>Transfusion in sickle cell disease | Shock: fluid resuscitation, em ergency release & m assive transfusion

2.3.1.4 Indications for elective chronic transfusion

■ T h e a u to im m u n e in d u c tio n m e c h a n is m □ D rug in d u ce s red cell a u to im m u n ity th a t p ersists a fte r w ith d ra w a l o f th e a g e n t (drug ind e pe n de nt); d rug w ith d ra w a l is o fte n a s s o c ia te d w ith a b a te m e n t o v e r tim e

■ C h ild re n w ith a b n o rm a l flo w v e lo c ity b y tra n s c ra n ia l D o p p le r, fo r s tro k e p re v e n tio n

□ M e th y ld o p a , le v o d o p a , p ro c a in a m id e , flu d a ra b in e , 2 nd a n d 3 rd g e n e ra tio n c e p h a lo s p o rin s a re ty p ic a l c a u s e s

■ C o m p lic a te d p re g n a n c y

□ In th is m e c h a n is m , th e d ru g s tim u la te s fo rm a tio n o f an a u to a n tib o d y d ire c te d a g a in s t an in n a te c o m p o n e n t o f th e red ce ll m e m b ra n e □ In th e la b o ra to ry , an a u to a n tib o d y is d e te c te d th a t is in d is tin g u is h a b le fro m th o s e th a t c a u s e id io p a th ic w a rm a u to im m u n e h e m o ly tic a n e m ia ■ T h e n o n im m u n e p ro te in a d s o rp tio n m e c h a n is m □ D ru g in d u c e d n o n s p e c ific , n o n im m u n e , b in d in g o f im m u n o g lo b u lin to th e red ce ll s u rfa c e □ C e p h a lo th in (K e flin ) is th e p ro to ty p e □ T h e s e m e d ic a tio n s c a u s e th e n o n s p e c ific a d s o rp tio n o f a lb u m in , IgG , Ig A , Ig M a n d c o m p le m e n t o n to th e R B C m e m b ra n e . T h e re is no a n tib o d y p ro d u c tio n th a t o c c u rs □ A n tib o d y s c re e n s a nd DATs a re p o s itiv e , b u t e lu a te s a re n e g a tiv e e ve n w h e n d ru g c o a te d R B C s a re u sed

2.3

■ P ro g re s s iv e re n a l o r c a rd io p u lm o n a ry d is e a s e ■ U s u a l ta rg e t H b S is < 3 0 % in c h ild re n , a n d < 5 0 % in a d u lts

2.3.1.5 Alloimmunization in multiply transfused sickle cell patients ■ W ith n o n p h e n o ty p ic a lly m a tc h e d b lo o d , ra te o f a llo im m u n iz a tio n p e r tra n s fu s io n is 3 % , o v e ra ll ra te o f a llo im m u n iz a tio n is b e tw e e n 1 9 -4 7 % ■ T h e m o s t c o m m o n a llo a n tib o d ie s a re a n ti-K , C, E, F ya and Jkb ■ W ith b lo o d m a tc h e d fo r C c , D, Ee, a n d K e ll, th e a llo im m u n iz a tio n ra te /u n it tra n s fu s e d c a n be re d u c e d fro m 3% to 0 .5 %

2.3.2 Shock: fluid resuscitation, emergency release & massive transfusion 2.3.2.1

Shock caused by acute blood loss

■ A c u te b lo o d lo s s is c a te g o riz e d c lin ic a lly in to 4 c la s s e s

Transfusion in special clinical circumstances

t2.20

t2.20 Classes of acute hemorrhage

2.3.1 Transfusion in sickle cell disease

class I hemorrhage

2.3.1.1 Unique considerations ■ M u ltip le tra n s fu s io n s p o s e a ris k o f iron o v e rlo a d

class II hemorrhage

■ M u ltip le tra n s fu s io n s p o s e a ris k o f a llo im m u n iz a tio n ■ E x c h a n g e vs s im p le tra n s fu s io n s h o u ld be c o n s id e re d ■ T h e e n d p o in t, in s te a d o f a ta rg e t h e m o g lo b in , is a ta rg e t p ro p o rtio n o f H b S , u s u a lly < 3 0 %

class III hemorrhage

2.3.1.2 ASPEN syndrome ■ A n a d v e rs e re a c tio n a fte r e x c h a n g e tra n s fu s io n in s ic k le ce ll d is e a s e

class IV hemorrhage

■ A S P E N (a s s o c ia tio n o f s ic k le c e ll d is e a s e , p ria p is m , e x c h a n g e tra n s fu s io n , a nd n e u ro lo g ic e v e n ts ) p re s e n ts a s h e a d a c h e , s e iz u re s , a lte re d m e n ta l s ta tu s, a n d /o r h e m ip a re s is w ith in 11 d a y s o f e x c h a n g e tra n s fu s io n

2.3.2.2 2.3.1.3 Indications for emergency transfusion/exchange transfusion in sickle cell disease ■ S tro ke , re tin a l a rte ry o c c lu s io n , s p le n ic s e q u e s tra tio n c ris is , a c u te c h e s t s y n d ro m e , a p la s tic c ris is ; p ria p is m is tre a te d m e d ic a lly u n le s s u n s u c c e s s fu l, th e n tra n s fu s e d

© A S C P 2018

loss of 2,000 mL), results in severe manifestations of shock, including thready pulse and the risk of imminent death fluid resuscitation is the first priority, but transfusion will be necessary

Principles of fluid resuscitation t2.21

■ F luid re s u s c ita tio n c o m e s firs t □ A ru le o f th u m b : red b lo o d c e lls in itia te d o n c e a d m in is te re d flu id s e x c e e d 3 0 m L /k g o f b o d y w e ig h t (~2 L)

ISBN 978-08 9189-6678

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Transfusion in special clinical circum stances>Shock: fluid resuscitation, em ergency release & massive transfusion T herapeutic apheresis>D efinition | Indications ■ A ll flu id s h a v e s o m e c a p a c ity to im p a ir h e m o s ta s is , m a in ly th ro u g h h e m o d ilu tio n

t2.21 Fluid rescuscitation Intravascular characteristics

Solution

Sources

crystalloid

saline, glucose 20% remains in concentrations can intravascular be hypotonic, space isotonic or hypertonic

colloids

Adverse reactions

hemodilution, impair hemostasis, risk of pulmonary/tissue edema but low risk of intravascular overload albumins, gelatins, remains in hemodilution, impair dextrans, intravascular hemostasis, hydroxyethyl space for 24 hours; anaphylactoid starch (HES) unless extensive reactions vascular damaqe

2.3.2.3 Emergency release ■ R e le a s e o f b lo o d w ith o u t c o m p le tio n o f re c ip ie n t te s tin g ■ W h e n tra n s fu s io n re q u ire d im m e d ia te ly to p re v e n t m o rta lity ■ U n c ro s s m a tc h e d O - b lo o d c a n be re le a s e d to fe m a le s o f c h ild b e a rin g a g e □ R h + b lo o d c a n b e re le a s e d to m a le s a n d o ld e r fe m a le s ■ R e le a s e o f A B O /R h c o m p a tib le b lo o d w ith A B O /R h te s tin g o n ly s h o u ld b e d is c o u ra g e d ■ R e le a s e o f A B O /R h c o m p a tib le b lo o d b a s e d s o le ly u p o n h is to ric a l A B O /R h ty p in g s h o u ld be s tric tly fo rb id d e n ■ W h e n e v e r e m e r g e n c y re le a s e is u n d e rta k e n , th e tr e a tin g p h y s ic ia n m u s t s ig n , w ith in 2 4 h o u rs , a s ta te m e n t in d ic a tin g th a t h e /s h e is a w a re o f th e n a tu re o f th e b lo o d re le a s e d , ie, th a t it h a s n o t b e e n fu lly te s te d fo r c o m p a tib ility . T h is is n o t re q u ire d p rio r to re le a s e o f b lo o d ■ T h e b lo o d p ro d u c t la b e l m u s t in d ic a te th a t c o m p a tib ility te s tin g w a s n o t c o m p le te d ■ W h e n R h + b lo o d p ro d u c ts m u s t b e g iv e n to an R h re c ip ie n t, R h im m u n e g lo b u lin (Ig) s h o u ld be c o n s id e re d to p re v e n t R h im m u n iz a tio n in w o m e n o f c h ild b e a rin g p o te n tia l t2.22

t2.22 Principles of Rh im mune globulin adm inistration for Rh incom patible blood products Rhlg should be given within 72 hours of transfusion_________________________ IV Rhlg dosage: 90 IU/1 mL of transfused Rh+ RBCs or/2 mL of transfused whole blood Administer entire dose of IV Rhlg into suitable vein >3-5 minutes; if dilution is preferred prior to IV administration use only normal saline as diluent__________ IV Rhlg is discouraged for transfusion of a quantity of Rh+ blood that exceeds 20% of blood volume, as this may cause severe hemolysis_________________

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■ W h e n a p a tie n t w h o re q u ire s e m e rg e n c y re le a s e R B C s h a s a k n o w n a n ti-E o r a n ti-C a n tib o d y , th e n R h - b lo o d s h o u ld be g ive n ■ W h e n a p a tie n t w h o re q u ire s e m e rg e n c y re le a s e R B C s w ith a k n o w n a n ti-C and is R h+, th e n R h+ b lo o d s h o u ld be g iven

2.3.2.4 Massive transfusion ■ D e fin itio n s o f m a s s iv e tra n s fu s io n v a ry a n d in c lu d e □ P a tie n t is tra n s fu s e d to ta l b lo o d v o lu m e (10-15 u n its o f P R B C in a 70 kg p a tie n t) □ 1/2 o f th e p a tie n t’s b lo o d v o lu m e is re p la c e d w ith in 3 h o u rs □ >4 u n its o f red b lo o d c e lls a re tra n s fu s e d w ith in 4 h o u rs ■ C e rta in p o te n tia l c o m p lic a tio n s a tte n d tra n s fu s io n o f a la rg e v o lu m e o f b lo o d □ T ra n s fu s e d b lo o d d o e s n o t im m e d ia te ly h ave th e o x y g e n c a rry in g c a p a c ity o f in n a te b lo o d , b e c a u s e o f d e p le tio n o f 2 ,3 -D P G a nd ATP. T h is re s u lts in a s h ift of th e o x y g e n d is s o c ia tio n c u rv e to th e le ft (im p a ire d re le a s e o f o x y g e n fro m h e m o g lo b in ) □ T ra n s fu s in g m a s s iv e a m o u n ts o f b lo o d m ay lo w e r pH and ra ise p o ta s s iu m , lo w e r th e b o d y te m p e ra tu re and ra ise th e fre e h e m o g lo b in □ C o a g u lo p a th y d u e to c o a g u la tio n fa c to rs a n d p la te le t c o n s u m p tio n , d y s fu n c tio n , o r d ilu tio n . M a s s iv e tra n s fu s io n p ro to c o ls (M T P s ) h ave b e e n im p le m e n te d in tra u m a c e n te rs to p re v e n t th e d e v e lo p m e n t o f c o a g u lo p a th y , w h e re in a p re s e t p ro p o rtio n o f R B C , p la s m a a nd p la te le ts a re g ive n

2.4 Therapeutic apheresis 2.4.1 Definition ■ W h o le b lo o d is re m o v e d fro m th e p a tie n t, a c o m p o n e n t o f th e b lo o d is s e p a ra te d , a n d th e re m a in d e r o f th e b lo o d is re tu rn e d to th e p a tie n t a lo n g w ith a re p la c e m e n t flu id

2.4.2 Indications ■ T h e A m e ric a n S o c ie ty fo r A p h e re s is h as e s ta b lis h e d c a te g o ry in d ic a tio n s t2.23, t2.24

t2.23 Cytapheresis with category indications babesiosis, severe marked leukocytosis with leukostasis (cytapheresis) malaria, severe SCD, acute stroke SCD stroke prophylaxis or prevention of iron overload thrombocytosis, symptomatic SCO = sickle cell disease

ASCP Quick Compendium of Clinical Pathology 4e

category II category II category III category I category I category II

© A S C P 2018

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Therapeutic apheresis>lndications t2.24 Categorical indications for apheresis Category

Definition

Indications

category I

apheresis is standard and acceptable as a primary therapy or first line adjunct therapy this designation does not imply that apheresis is mandatory in all cases

ABO incompatible kidney or liver transplant desensitization acute inflammatory demyelinating polyneuropathy (Guillain-Barre syndrome) antineutrophil cytoplasmic antibodies associated rapidly progressive glomerulonephritis diffuse alveolar hemorrhage antiglomular basement membrane disease (Goodpasture syndrome) with diffuse alveolar hemoorhage or dialysis independence chronic inflammatory demyelinating polyneuropathy cryoglobulinemia: severe or symptomatic focal segmental glomerulosclerosis, recurrent in transplanted kidney

hyperviscosity due to monoclonal gammopathies (best results when hyperviscosity is caused by IgM paraprotein) myasthenia gravis (apheresis generally reserved for severe exacerbations with respiratory difficulty; apheresis may significantly reduce pyridostigmine, causing paradoxical respiratory depression following treatment) N-methyl D-aspartate receptor antibody encephalitis paraproteinemic polyneuropathies renal transplantation, antibody mediated rejection thrombotic thrombocytopenic purpura and associated TMA with ticlid Wilson disease

category II

apheresis is generally accepted but considered to be supportive or adjunctive to other, more definitive treatments, rather than a primary firstline therapy

babesiosis cardiac transplant desensitization catastrophic antiphospholipid syndrome chronic focal encephalitis (Rasmussen encephalitis) cold agglutinin disease, severe cryoglobulinemia Hashimoto encephalopathy: steroid responsive encephalopathy associated with autoimmune thyroiditis Lambert-Eaton syndrome lupus nephritis, severe

multiple sclerosis: acute central nervous system inflammatory demyelinating disease refractory to steroids mushroom poisoning myeloma cast nephropathy neuromyelitis optica (Devic syndrome), acute PANDAS exacerbation phytanic acid storage disease (Refsum disease) systemic lupus erythematosus, severe

category III

apheresis may be beneficial; however, there is insufficient evidence to establish the efficacy or to clarify the risk or benefit

acute hepatic failure burn shock resuscitation cardiac transplantation, antibody mediated rejection cardiac neonatal lupus chronic focal encephalitis (Rasmussen encephalitis) coagulation factor autoantibody inhibitors hematopoietic stem cell transplant, HLA desensitization HELLP syndrome, postpartum hemophagocytic lymphohistiocytosis Henoch-Schonlein purpura heparin induced thrombocytopenia, thrombosis or precardiopulmonary bypass hypertriglyceridemic pancreatitis immune thrombocytopenia, refractory IgA nephropathy, cresentic or chronic progressive liver transplant, antibody mediated rejection (ABO and HLA)

lung transplant, antibody mediated rejection and desensitization multiple sclerosis, chronic progressive nephrogenic systemic fibrosis paraneoplastic neurogenic syndromes pemphigus vulgaris, severe posttransfusion purpura pruritis due to hepatobiliary diseases, treatment resistant scleroderma sepsis with multiorgan failure stiff person syndrome thyroid storm toxic epidermal necrolysis, refractory vasculitis, Behget warm autoimmune hemolytic anemia, severe

category IV

controlled trials have not shown benefit, or coagulation factor inhibitors, alloantibody psoriasis anecdotal reports have been discouraging. dermatomyositis polymyositis systemic lupus erythematosus, nephritis Should seek Institutional Review Board HELLp syndrome, antepartum ________________ approved research protocol, if at all___________________________________________________________________________________

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Therapeutic apheresis>lndications | Replacement fluid | Vascular access | Medication interactions Neonatal & intrauterine transfusion>Special blood requirements for neonatal & intrauterine transfusion | ITP | NAIT

2.4.3 Replacement fluid

t2.25 Doses for neonatal & intrauterine transfusion

■ 3 re p la c e m e n t flu id s m a y be u s e d in th e ra p e u tic a p h e re s is □ N o rm a l (0 .9 % ) s a lin e □ 5 % a lb u m in □ A llo g e n e ic p la s m a (fre s h fro z e n p la s m a [F F P ] o r c ry o p o o r F F P ) in th ro m b o tic th ro m b o c y to p e n ic p u rp u ra (T T P )

2.4.4 Vascular access

RBCs fresh frozen plasma platelets cryoprecipitate

15 mL/kg 10 mL/kg 5 mL/ kg (for a 10 kg infant, this is ~1 random donor unit or 1/6 of an apheresis unit) 10-20 mL/kq

2.5.2 Maternal immune thrombocytopenic purpura (ITP) 2.5.2.1 There is a risk of neonatal thrombocytopenia

■ A la rg e b o re , s tiff w a lle d d ia ly s is ty p e c a th e te r is re q u ire d fo r a p h e re s is . A c e n tra l lin e , u s u a lly p la c e d into th e in te rn a l ju g u la r v e in , is d e s ira b le

2.4.5 Medication interactions ■ S o m e m e d ic a tio n s m a y b e re m o v e d b y a p h e re s is , e s p e c ia lly th o s e w ith h ig h p ro te in b in d in g , > 8 0 % a n d lo w v o lu m e o f d is trib u tio n (V d ) p ro p e rtie s , V d < 0 .2 L /kg

■ C a u s e d b y a u to a n tib o d ie s c ro s s in g th e p la c e n ta ■ M a y be c o m p lic a te d by s e v e re n e o n a ta l th ro m b o c y to p e n ia (< 5 0 ,0 0 0 ) a n d s e rio u s h e m o rrh a g e

2.5.2.2 Management ■ S u p p o rtiv e p la te le t tra n s fu s io n s a re s p a rin g ly g ive n, ty p ic a lly in th e c a s e s o f a c tiv e b le e d in g

■ D o s in g im m e d ia te ly a fte r a p h e re s is s h o u ld be c o n s id e re d fo r s u c h m e d ic a tio n s

■ It is re c o m m e n d e d th a t s e ria l n e o n a ta l p la te le t c o u n ts be m o n ito re d fo r a fe w d a y s a fte r d e liv e ry

■ A C E in h ib ito rs s h o u ld b e d is c o n tin u e d fo r th e 2 4 h o u rs p re c e d in g a p h e re s is , s in c e th e y p o s e a s ig n ific a n t ris k o f s e v e re h y p o te n s io n d u rin g a p h e re s is

■ A fte r d e live ry , th e n e o n a ta l p la te le t c o u n t w ill p ro g re s s iv e ly in c re a s e

2.5 Neonatal & intrauterine transfusion 2.5.1 Special blood requirements for neonatal & intrauterine transfusion 2.5.1.1 Red cells for intrauterine or neonatal exchange transfusion ■ S h o u ld be □ F re s h (< 5 d a y s o ld ); if n o t a v a ila b le , c o n s id e r w a s h e d

2.5.3 Neonatal alloimmune thrombocytopenia (NAIT) 2.5.3.1 Caused by maternal antiplatelet alloantibodies that cross the placenta & cause destruction of fetal platelets ■ M o s t c o m m o n ly th e m a te rn a l a llo a n tib o d ie s a re d ire c te d a g a in s t H PA1a □ 2% o f in d iv id u a ls a re F IP A 1 a □ C an d e v e lo p a n ti-H P A 1 a a n tib o d ie s if e x p o s e d th ro u g h tra n s fu s io n o r p re g n a n c y

□ Irra d ia te d

2.5.3.2 NAIT can affect the first pregnancy

□ G ro u p O □ N e g a tiv e fo r a n y m a te rn a l a n tib o d y (eg, a n ti-D ) th a t is a c tiv e

■ T h e lik e lih o o d o f re c u rre n c e in s u b s e q u e n t p re g n a n c ie s is high

□ P re fe ra b ly s e ro lo g ic a lly te s te d C M V - o r C M V ris k re d u c e d (le u k o re d u c e d ) in in tra u te rin e tra n s fu s io n o r in n e o n a te s < 1 2 0 0 g w h o a re C M V -

■ M o re s e v e re w ith e a c h s u c c e s s iv e p re g n a n c y

2.5.1.2 Plasma or plasma containing products (platelets) ■ M u s t b e c o m p a tib le w ith n e o n a te 's re d c e lls ■ D o s in g m u s t be c a lc u la te d o n th e b a s is o f w e ig h t t2.25

2.5.3.3 Management ■ T h e re is a 2 0 % in c id e n c e o f in tra c ra n ia l h e m o rrh a g e o vera ll; a b o u t h a lf o f h e m o rrh a g e s o c c u r in u te ro ■ T re a tm e n t s h o u ld b e g in a s s o o n a s th e d ia g n o s is is s u s p e c te d ■ H igh d o s e IV Ig a n d /o r c o rtic o s te ro id s ■ In tra u te rin e p la te le t tra n s fu s io n m a y b e g in a t 18-20 w e e k s g e s ta tio n , w ith a n tig e n n e g a tiv e p la te le ts. M a te rn a l p la te le ts m a y be u se d if th e y have been w a s h e d a n d irra d ia te d

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Neonatal & intrauterine transfusion>Neonatal alloimmune thrombocytopenia (NAIT) | Hemolytic disease of the fetus & newborn (HDF/HDN) ■ D e liv e ry by C s e c tio n is re c o m m e n d e d , if p o s s ib le ■ A fte r b irth , th e ris k o f h e m o rrh a g e is g re a te s t d u rin g th e firs t 2 4 -3 6 h o u rs o f life, so e x p e d ie n t p la te le t tra n s fu s io n is d e s ira b le

2.5.4 Hemolytic disease of the fetus & newborn (HDF/HDN) ■ R e s u lts fro m m a te rn a l a llo a n tib o d ie s c ro s s in g th e p la c e n ta ■ C a n lea d to th e a p p e a ra n c e o f b iliru b in in th e a m n io tic flu id , p ro g re s s iv e fe ta l a n e m ia a n d e v e n tu a l h y d ro p s fe ta lis ■ To be s ig n ific a n t, th e m a te rn a l a llo a n tib o d y m u s t b e o f th e lgG 1, lg G 3 , o r lg G 4 c la s s

2.5.4.1 Rh HDF/HDN ■ C a u s e d by m a te rn a l a n ti-D a n tib o d ie s □ A n ti-D a n tib o d ie s a re n o t n a tu ra lly o c c u rrin g ; e x p o s u re to D + e ry th ro c y te s , e ith e r th ro u g h p rio r p re g n a n c y o r tra n s fu s io n re q u ire d

t2.27 Prevention of Rh HDFN is achieved by the administration of Rhlg Scenario_____________ Recommendation

Notes

____________

D - women bearing D+ or D unknown fetus

prophylactic 300 pg (1 full without Rhlg, the risk of dose vial) at 28 weeks developing anti-D is 16%; and at term with Rhlg at 28 weeks and term, the risk is 0.1% fetal maternal hemorrhage in the first 12 weeks of of unknown quantity due gestation, if available, a mini dose (50 pg) or a to ectopic pregnancy, full dose (300 pg) can be trauma, amniocentesis, chorionic villus sampling, administered spontaneous abortion, after 12 weeks, a full dose (300 pg) vial is given delivery The quantity of fetomaternal hemorrhage should be determined and additional doses of Rhlg given as indicated (see t2.28)___________ D+ women_____________ Rhlg not indicated_______ no benefit_______________ D - women who have Rhlg not indicated no benefit already formed anti-D antibodies__________________________________________________________

t2.28 Calculating the dose of Rhlg

□ T h u s , a n ti-D H D N is u s u a lly n o t se e n w ith th e firs t p re g n a n c y

step____________________________________________________________

□ S e n s itiz a tio n m a y o c c u r as a re s u lt o f o th e r e v e n ts

1

t2.26

t2.26 Sources of fetomaternal hemorrhage and Rh(D) sensitization_______________________________________ normal pregnancy____________________________________________ chorionic villus sampling______ _________________________________ amniocentesis_______________________________________________ cordocentesis_______________________________________________ abortion, threatened or completed (spontaneous or elective)__________ placental abruption___________________________________________ trauma_____________________________________________________

□ W ith o u t R h lg , th e in c id e n c e o f s e n s itiz a tio n in an R h - w o m a n b e a rin g an R h+ fe tu s is -1 5 % . T h e in c id e n c e is lo w e r if th e m o m a nd fe tu s a re a ls o A B O in c o m p a tib le P re v e n tio n

maternal whole blood volume is often assumed to be around 5,000 mL otherwise, it is calculated as the mother's body weight (kg) times 70 mL/kg (assuming a weight of 70 kg and a blood volume of 5,000 mL may cause ______ underdosing)__________________________________________________ 2 the proportion of fetal cells is determined by a Kleihauer-Betke (or other) test in the Kleihauer-Betke, fetal and maternal cells are counted separately for a total of 2,000 cells percentages are converted into decimals (if, for example, fetal cells ______ comprise 3% of maternal blood, then substitute 0.03 into the formula) 3 calculate dose (number of vials) according to formula dose (vials) = (maternal blood volume in mL) * (proportion fetal cells in maternal blood) + 30 Why divide by 30? Each full dose vial (300 pg) protects against 30 mL ______ whole blood or 15 mL of RBCs___________________________________ 4 a lw a y s a d d 1 v ia l to d o s a g e if the number after the decimal is 5 round up and add 1 vial for example, if the result is 3.3, then round down to 3 and add 1 vial; the patient will receive 4 vials if the result is 3.6, then round up to 4 and add 1 vial so the patient will ______ receive 5 vials_________________________________________ 5 no more than 5 vials should be given IM at one time; larger doses may be ______ divided or given IV_____________________________________________

■ B e g in s w ith c h e c k in g p re g n a n t w o m a n ’s D s ta tu s and c h e c k in g D - w o m e n fo r a n ti-D a n tib o d ie s ■ D - w o m e n w ith o u t a n tib o d ie s : p ro p h y la c tic R h im m u n e g lo b u lin (R h lg ) is a t s e t in te rv a ls and w h e n e v e r a fe ta l m a te rn a l h e m o rrh a g e o c c u rs t2.27, t2.28

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Neonatal & intrauterine transfusion>Hemolytic disease of the fetus & newborn (HDF/HDN) Blood components>Red blood cell components □ T e s ts fo r fe to m a te rn a l h e m o rrh a g e (F M H )

■ If the co rd b lo o d D AT is p o sitive

■ T h e ro s e tte te s t (q u a lita tiv e ): m a te rn a l b lo o d is in c u b a te d w ith a n ti-D a n tib o d y a n d D + in d ic a to r c e lls , w h ic h fo rm ro s e tte s a ro u n d D + fe ta l c e lls . W ill d e te c t a s little a s 10 m L o f fe ta l b lo o d . If th is te s t is n e g a tiv e , a n d F M H is s u s p e c te d c lin ic a lly , th e n th e s in g le 3 0 0 pg d o s e o f R h lg is a d e q u a te . If p o sitive , th e n a q u a n tita tiv e te s t (K le ih a u e r-B e tk e , ELAT, o r flo w c y to m e try ) is in d ic a te d ■ T h e K le ih a u e r-B e tk e (acid e lu tio n ) te s t w o rk s on th e p rin c ip le th a t fe ta l h e m o g lo b in (H b F ) is re s is ta n t to a c id e lu tio n . M a te rn a l b lo o d is s u b je c te d to a c id e lu tio n th e n e o s in s ta in e d ; a n y c e lls th a t ta k e up sta in (ra th e r th a n a p p e a rin g “g h o s te d ” ) re p re s e n t red c e lls c o n ta in in g HbF. A ce ll c o u n t is p e rfo rm e d to d e te rm in e th e p e rc e n ta g e o f fe ta l red c e lls (see b e lo w ) ■ D - w o m e n w ith a n ti-D a n tib o d ie s : d e te rm in e th e m a te rn a l a n tib o d y titer. If tite r is 5 0 g (or -1 5 0 m L o f red cell v o lu m e ) in a t le a s t 9 5% o f u nits te ste d

□ A m a te rn a l c ritic a l tite r fo r a n ti-K e ll a n tib o d y is 8 ■ A n ti-C is th e s e c o n d m o s t c o m m o n c a u s e o f s e v e re H D F / HDN

■ A n tic o a g u la n t p re s e rv a tiv e s o lu tio n s t2.30 □ B lood is c o lle c te d into b a g s c o n ta in in g - 6 0 m L o f an a n tic o a g u la n t p re s e rv a tiv e s o lu tio n □ A ll co n ta in d e x tro s e a s a c a rb o h y d ra te s o u rc e fo r th e p ro d u c tio n o f A TP

2.5.4.3 Lab testing for HDF/HDN ■ A ty p e a n d s c re e n is p e rfo rm e d on th e m a te rn a l b lo o d u p o n a d m is s io n to la b o r a n d d e liv e ry

□ C P D A c o n ta in s a d e n in e (fo r ATP), c itra te (an a n tic o a g u la n t th a t c h e la te s ca lcium ), and s o d iu m p h o s p h a te (a pH b uffe r)

■ C o rd b lo o d fro m e a c h n e w b o rn s h o u ld be s u b je c te d to A B O /R h te s tin g a n d a DAT. R h te s tin g s h o u ld in c lu d e te s tin g fo r w e a k D s in c e w e a k D fe ta l R B C s ca n s e n s itiz e D - m o th e rs 74

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Blood components>Red blood cell components t2.29 Summary of blood products Blood product

Composition

Volume

whole blood

RBCs (Hct 40%), plasma, WBCs, platelets

500 mL

RBCs

RBCs (Hct 55-80%), minimal plasma, WBC, platelets and preservative solution

300 mL

frozen RBCs

RBCs and 40% glycerol (deglycerolized when thawed)

250 mL

irradiated RBCs

RBCs

250 mL

Indications (I) and contraindications (Cl)

Storage

I: need for increase in both RBC 1-6°C mass and plasma volume relative Cl: volume overload 1-6°C I: symptomatic anemia relative Cl: AIHA or hyperhemolysis in SCD patients same as RBCs, usually rare 3 * 1011) reduced amount of 300 mL apheresis platelets gentle agitation; may donor) agitation: 24 hrs) plasma, WBCs, RBCs (1 * 1o10) documented infection (granulocytes pheresis) unresponsive to standard medical therapy AIHA = autoimmune hemolytic anemia; HIT = heparin induced thrombocytopenia; SCD = sickle cell disease; TA-GVHD = transfusion associated graft vs host disease; TTP = thrombotic thrombocytopenic purpura; vWF = von Willebrand factor platelets (random donor)

platelets (>5.5 x 1010), minimal plasma, WBC, RBC (6.2

50 mL

Storage time varies with preservative

t2.30 RBC preservatives Solution

Allowable storage

Usual hematocrit

Comments

citrate phosphate dextrose (CPD), ACD, CP2D citrate phosphate dextrose adenine 1 (CPDA1) additive solutions (AS1, AS3 or AS5), added to CPD

21 days 35 days 42 days

70% 70% 60%

whole blood or RBCs whole blood or RBCs must be added within 72 hours of collection used for RBCs only

m T h e a d d itiv e s o lu tio n s , AS1 (A d so l), A S 3 (N u tric e l),

A S 5 , e tc, c o n ta in d iffe re n t c o n c e n tra tio n s o f a d d itio n a l d e x tro s e , a d e n in e , b u ffe r, a n d s o d iu m c h lo rid e ; AS1 and A S 5 c o n ta in m a n n ito l, w h ic h h as d iu re tic e ffe c ts

2.6.1.2

■ R e fe rs to p ro g re s s iv e c h a n g e s th a t o c c u r w ith in s to re d red c e lls , in c lu d in g □ In c re a s e d fre e p o ta s s iu m © A S C P 2018

□ R e d u c e d A TP □ In c re a s e d fre e h e m o g lo b in ■ A fte r tra n s fu s io n , n o rm a l 2 ,3 -D P G , ATP, a n d pH a re re s to re d w ith in 24 h o u rs

Storage lesion

□ R e d u c e d 2 ,3 -D P G (2 ,3 -d ip h o s p h o g ly c e ra te )

□ D e c re a s e d pH

2.6.1.3

Transport and reissue

■ R ed c e lls m u s t be tra n s p o rte d in a m o n ito re d , re frig e ra te d d e v ic e ISBN 978-08 9189-6678

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Blood components>Red blood cell components | Platelets ■ U n its th a t h a v e le ft th e b lo o d b a n k a n d h a v e b e e n re tu rn e d m a y b e re is s u e d if □ T h e u n it h a s n o t b e e n “ s p ik e d ” (e n te re d ), a n d □ T h e u n it h a s b e e n m a in ta in e d c o n tin u o u s ly b e tw e e n 1 -1 0 ° C , a n d □ T h e a m o u n t o f tim e th e u n it c a n b e o u ts id e th e c o n tin u o u s ly m o n ito re d s to ra g e d e v ic e , ie, th e a m o u n t o f tim e it ta k e s fo r th e u n it to e x c e e d 10°C w h e n o u ts id e o f it ■ M u s t b e d e te rm in e d b y th e tra n s fu s io n s e rv ic e ■ G e n e ra lly , th is ta k e s - 3 0 m in u te s □ A t le a s t 1 s e g m e n t o f s e a le d tu b in g re m a in s

2.6.1.7 Contraindications ■ T h e re a re no a b s o lu te c o n tra in d ic a tio n s ■ R e la tiv e c o n tra in d ic a tio n s in c lu d e a u to im m u n e h e m o ly tic a n e m ia a n d h y p e rh e m o ly s is s y n d ro m e in s ic k le cell d is e a s e

2.6.2 Platelets 2.6.2.1 Preparation & storage ■ W h e n w h o le b lo o d is s lo w c e n trifu g e d , it s e p a ra te s into red b lo o d c e lls a n d p la te le t rich p la s m a . W h e n th e p la te le t rich p la s m a is fa s t c e n trifu g e d , it s e p a ra te s into p la te le t c o n c e n tra te a nd p la s m a ■ P la te le ts m a y a ls o be c o lle c te d by a p h e re s is , a n d m a n y b lo o d c e n te rs p ro v id e s o le ly a p h e re s is p la te le ts

2.6.1.4 W hole blood ■ N o t ro u tin e ly u s e d

■ S to ra g e : 2 0 -2 4 °C w ith g e n tle a g ita tio n

■ M u s t be A B O id e n tic a l to th e re c ip ie n t

■ T ra n s p o rt: ca n g o w ith o u t a g ita tio n fo r no >24 h o u rs ■ E x p ira tio n

2.6.1.5 Frozen red blood cells

□ 5 days

■ S o m e tim e s p re p a re d to p re s e rv e ra re d o n o r ty p e s o r to p re s e rv e b lo o d fo r a u to lo g o u s d o n a tio n

□ If th e s y s te m is o p e n e d (such a s fo r p o o lin g ), th e u nit e x p ire s in 4 h o u rs

■ M u s t b e fro z e n w ith in 6 d a y s if n o a d d itiv e s o lu tio n is p re s e n t; w ith a d d itiv e s o lu tio n , m u s t be fro z e n b e fo re th e e x p ira tio n d a te a p p ro p ria te fo r th e a d d itiv e s o lu tio n

■ L e u k o re d u c e d p la te le ts m u s t c o n ta in < 8 .3 x 105 le u k o c y te s (le u k o re d u c e d a p h e re s is p la te le ts m u s t c o n ta in < 5 * 10 6 le u k o c y te s )

■ C ry o p ro te c tiv e a g e n ts a re re q u ire d . 4 0 % g ly c e ro l is c o m m o n ly u s e d

■ E a ch s in g le d o n o r d e riv e d u n it h as a v o lu m e o f - 5 0 m L

■ S to re d in a - 8 0 ° C fre e z e r, a n d k e p t a t < 6 5 °C , fo r up to 10 y e a rs ■ W h e n th a w e d □ W a s h e d in h y p o to n ic s o lu tio n s to re m o v e th e g ly c e ro l □ S to re d a t 1 -6 ° C a n d m u s t be tra n s fu s e d w ith in 24 h o u rs □ F ro z e n /d e g ly c e ro liz e d re d c e lls a re c o n s id e re d b o th le u k o re d u c e d a n d w a s h e d

□ In c lu d e s s o m e p la s m a , a fe w w h ite c e lls ( - 1 0 7) □ - 8 0 m g fib rin o g e n □ M in im u m o f 5 .5 * 10 10 p la te le ts (in a t le a s t 9 0 % o f u nits te s te d ) □ pH > 6 .2 (in a t le a s t 9 0 % o f u n its te s te d ) ■ A p h e re s is p la te le ts h ave a v o lu m e o f - 1 0 0 m L □ In c lu d e s p la s m a , w h ite c e lls (< 5 .0 * 106) □ - 1 5 0 m g o f fib rin o g e n □ M in im u m o f 3 .0 * 1011 p la te le ts (in a t le a s t 9 0 % o f u n its te s te d )

2.6.1.6 Indications ■ T h e m a in in d ic a tio n fo r re d c e lls is d e c re a s e d o x y g e n c a rry in g c a p a c ity ■ A “ re s tric tiv e ” tra n s fu s io n s tra te g y (ie, th e u s e o f a tra n s fu s io n “ tr ig g e r ” o f h e m o g lo b in 7 g /d L in s te a d o f 8) h a s b e e n re p e a te d ly d e m o n s tra te d to re s u lt in s im ila r o r im p ro v e d m o rb id ity a n d m o rta lity in a w id e ra n g e o f p a tie n t g ro u p s ■ T h e e x p e c te d e ffe c t o f a u n it o f red c e lls is a 1 g /d L in c re a s e in h e m o g lo b in a n d 3 % in c re a s e in h e m a to c rit ■ A p e d ia tric d o s e o f - 4 m L /k g w ill a c h ie v e th e s a m e e ffe c t

□ T h u s , a p h e re s is p la te le t u n it h a s ~ 6 x th e n u m b e r o f p la te le ts in a s in g le d o n o r d e riv e d u n it

2.6.2.2 Indications ■ In th e n o n b le e d in g p a tie n t w ith th ro m b o c y to p e n ia □ P ro p h y la c tic p la te le t tra n s fu s io n s m ay be in d ic a te d at a c e rta in th re s h o ld □ A th re s h o ld o f 1 0 ,0 0 0 /p L is c u rre n tly a d v o c a te d in th e a b s e n c e o f fever, s e p s is , c o a g u lo p a th y , h y p e rs p le n is m , a n d le s io n s th a t p o s e a ris k o f b le e d in g ■ In th e b le e d in g p a tie n t w ith th ro m b o c y to p e n ia

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Blood components>Platelets | Granulocyte concentrates □ P la te le ts a re o fte n a d m in is te re d fo r p la te le t c o u n ts < 5 0 ,0 0 0 /p L fo r e x tra c ra n ia l b le e d s , 1 0 0 ,0 0 0 fo r in tra c ra n ia l b le e d in g

□ If an R h - in d iv id u a l m u s t re c e iv e R h + p la te le ts , a d m in is tra tio n o f R h lg s h o u ld be c o n s id e re d , e s p e c ia lly fo r fe m a le s o f c h ild b e a rin g p o te n tia l

■ In th e s u rg ic a l p a tie n t w ith th ro m b o c y to p e n ia □ T a rg e t p la te le t c o u n t o f 5 0 ,0 0 0 /p L is d e s ira b le fo r n o n n e u ro s u rg ic a l p a tie n ts , 1 0 0 ,0 0 0 fo r n e u ro s u rg ic a l p a tie n ts ■ F u n c tio n a l p la te le t d e fe c ts □ T h e re is s o m e ro le fo r p la te le ts in p a tie n ts w ith G la n z m a n n th ro m b a s th e n ia , B e rn a rd -S o u lie r s y n d ro m e , a s p irin in g e stio n , a nd re na l fa ilu re □ In re n a l fa ilu re , a tria l o f D D A V P o r c ry o p re c ip ita te is firs t in d ic a te d

2.6.2.5 Prevention of platelet transmitted infection ■ A A B B re q u ire s th a t m e th o d s be e m p lo y e d to lim it a nd d e te c t p la te le t c o n ta m in a tio n b y b a c te ria . P la te le t a d d itiv e s o lu tio n s a nd p a th o g e n in a c tiv a tio n s y s te m s a re n o w a v a ila b le in th e U S, b u t th e y h a v e a s h e lf life still lim ite d to 5 d a y s a n d a re n o t re a d ily a v a ila b le in all lo c a tio n s in th e c o u n try at th e tim e o f th is w ritin g . S e e d is c u s s io n u n d e r “ 2 .8 T ra n s fu s io n c o m p lic a tio n s .”

2.6.3 Granulocyte concentrates 2.6.3.1 Preparation & storage

2.6.2.3 Contraindications

■ G ra n u lo c y te s a re o fte n o b ta in e d by a p h e re s is

■ R e la tiv e c o n tra in d ic a tio n s

■ T h e y a re s to re d w ith o u t a g ita tio n a t 2 0 -2 4 ° C fo r up to 2 4 h o u rs

□ Im m u n e th ro m b o c y to p e n ic p u rp u ra (ITP ) ■ A b s o lu te c o n tra in d ic a tio n s

■ E a ch u n it c o n ta in s a c e rta in a m o u n t o f c o n ta m in a tin g red c e lls , a la rg e n u m b e r o f p la te le ts , a n d - 1 0 10 w h ite b lo o d c e lls

□ H e p a rin in d u c e d th ro m b o c y to p e n ia (H IT ) □ TTP

2.6.3.2 Indications

2.6.2.4 Dosing ■ A d u lts a re g iv e n 4 o r 6 p o o le d ra n d o m d o n o r p la te le ts (R D P ) o r 1 s in g le d o n o r a p h e re s is p la te le t (S D P ) a t a tim e

■ G ra n u lo c y te s a re u s u a lly e m p lo y e d fo r n e u tro p e n ic s e p s is o r fu n g a l in fe c tio n s th a t a re u n re s p o n s iv e to s ta n d a rd th e ra p y

■ N e o n a te s a re g ive n 10-15 m L /k g o r 1 u n it/1 0 kg ■ T h e e x p e c te d re su lt, in a d u lts , o f tra n s fu s in g 1 ra n d o m d o n o r u n it (5 .5 x 1010) o f p la te le ts is an in c re a s e in th e p la te le t c o u n t o f ~ 5 ,0 0 0 /p L ; h e n c e , th e a v e ra g e p la te le t d o s e w ill in c re a s e th e p la te le t c o u n t - 3 0 - 6 0 ,0 0 0 /p L

2.6.3.3 Dosing ■ T h e re is no a g re e d u po n d o s e ■ U n its s h o u ld b e A B O c ro s s m a tc h c o m p a tib le w ith th e re c ip ie n t

■ T h e a v e ra g e p la te le t life sp a n is 9 .5 d a y s

■ U n its s h o u ld be irra d ia te d

■ L ike red c e lls , p la te le ts m u s t a lw a y s be tra n s fu s e d th ro u g h a t le a s t a 170 pm filte r

■ U n its s h o u ld n e v e r be le u k o re d u c e d

■ P la te le ts n e e d n ot be c ro s s m a tc h e d u n le s s th e y c o n ta in >2 m L o f red b lo o d ce lls; s u c h u n its a re v is ib ly b lo o d y ■ It is d e s ira b le th a t th e p la s m a in th e p la te le t u n it be c o m p a tib le w ith th e re c ip ie n t red ce lls; th e d a n g e r o f A B O in c o m p a tib le p la s m a w ith in th e p la te le t d o s e is o f p a rtic u la r c o n c e rn in c e rta in in s ta n c e s □ R e c ip ie n ts w ith s m a ll b lo o d v o lu m e s , s u c h a s in fa n ts □ M u ltip ly tra n s fu s e d re c ip ie n ts □ A p h e re s is u n its w ith h ig h tite r is o h e m a g g lu tin in s ; th e s e a re n o t ro u tin e ly m e a s u re d , so th a t th e re c o m m e n d e d a p p ro a c h is A B O c o m p a tib ility in th e p re c e d in g 2 h ig h ris k p o p u la tio n s ■ R h m a tc h in g is re c o m m e n d e d fo r p la te le ts □ T h e p la te le ts th e m s e lv e s d o n o t b e a r R h a n tig e n s , b ut c o n ta m in a tin g red c e lls do © A S C P 2018

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Blood components>Granulocyte concentrates | Plasma | Cryoprecipitated antihemophilic factor (cryoprecipitate or cryo)

2.6.4 Plasma

2.6.4.3 Dosing ■ U s u a lly 2 u n its a re g iv e n a t a tim e fo r a d u lt p a tie n ts

2.6.4.1 Preparation & storage ■ W h e n w h o le b lo o d is s lo w c e n trifu g e d , it s e p a ra te s into re d b lo o d c e lls a n d p la te le t ric h p la s m a . P la te le t rich p la s m a , w h e n fa s t c e n trifu g e d , c a n b e s e p a ra te d into p la te le t c o n c e n tra te a n d p la s m a ■ T h e p la s m a m u s t b e p la c e d in to a - 1 8 ° C o r c o ld e r fre e z e r w ith in 8 h o u rs o f b lo o d c o lle c tio n to m a k e FF P ■ P la s m a n o t fro z e n w ith in 8 h o u rs m a y b e fro z e n w ith in 24 h o u rs a n d la b e le d “ P la s m a fro z e n w ith in 24 h o u rs a fte r p h le b o to m y ” o r “ F P 2 4 ” ■ F P 2 4 is re la tiv e ly d e p le te d o f fa c to rs V a n d V III ■ It is u s e fu l fo r all in d ic a tio n s fo r FFP, e x c e p t D IC ■ F F P e x p ire s in 1 y e a r a t 2 h o u rs b e fo re in c is io n ■ Each u n it is e x p e c te d to in c re a s e fa c to r a c tivitie s by -2 0 % ■ P la s m a m u s t b e g iv e n th ro u g h a s ta n d a rd 170 pm filte r ■ T he p la sm a, w h ic h c o n ta in s A B O a n tib o d ie s, sh ou ld be co m p a tib le w ith th e re cip ie n t red cells. Type A B is th e universa l p la sm a d o n o r; how ever, th e firs t c h o ic e sh ould be p la sm a th a t is A B O ide n tica l. D o n o r Rh ty p e sh ou ld not a ffe c t p ro d u c t c h o ice , and th e re is no need to g ive R hlg

2.6.5 Cryoprecipitated antihemophilic factor (cryoprecipitate or cryo) 2.6.5.1 Preparation & storage ■ W h e n FF P is th a w e d to 1 -6 ° C th e n c e n trifu g e d , a p re c ip ita te (th e so c a lle d c o ld in s o lu b le p o rtio n o f p la s m a ) fo rm s . A fte r re m o v a l o f th e th a w e d p la s m a , th e p re c ip ita te m u s t be re p la c e d , w ith in 1 hour, in a -1 8 ° C o r c o ld e r fre e z e r to m a k e c ry o p re c ip ita te ■ C ry o e x p ire s in 1 y e a r w h e n s to re d a t th is te m p e ra tu re

2.6.4.2 Indications ■ P la s m a is g iv e n fo r c o a g u lo p a th ie s c a u s e d by m u ltip le fa c to r d e fic ie n c ie s ■ In th is s c e n a rio , a P T o r P T T th a t is 1 .5 * n o rm a l (o r IN R th a t is 2 * n o rm a l) a re g e n e ra lly c o n s id e re d a tra n s fu s io n “ tr ig g e r ”

■ A fte r th a w in g , c ry o e x p ire s in 6 h o u rs u n le s s p o o le d , th e n e x p ire s in 4 h o u rs ■ E ach u n it o f c ry o p re c ip ita te c o n ta in s - 1 5 m L o f to ta l v o lu m e , in c lu d in g □ A m in im u m o f 150 m g fib rin o g e n in all u n its te s te d

■ In c a s e s o f s in g le fa c to r d e fic ie n c ie s (eg, fa c to r V III)

□ 80 IU o f fa c to r V III in all u n its te s te d

■ R e c o m b in a n t fa c to r o r fa c to r c o n c e n tra te s a re p re fe rre d

□ It is a ls o ric h in v W F a n d fa c to r X III

■ If th a t is n o t a v a ila b le , th e n c ry o p re c ip ita te is th e s e c o n d c h o ic e

□ It d o e s n o t h ave a p p re c ia b le q u a n titie s o f fa c to r V

■ P la s m a is a fin a l c h o ic e ; w h ile it c o n ta in s all fa c to rs th a t m a y be d e fic ie n t in p la s m a (eg, c lo ttin g fa c to rs , AT, p ro te in C), it c o m e s w ith h ig h v o lu m e ■ R a p id in fu s io n o f p la s m a m a y b e in d ic a te d fo r tre a tm e n t o f w a rfa rin s k in n e c ro s is ■ F o r w a rfa rin re v e rs a l ■ T h e A m e ric a n C o lle g e o f C h e s t P h y s ic ia n s h a s s p e c ific g u id e lin e s ■ P la s m a is an o p tio n o f la s t re s o rt ■ N o te th a t p la s m a is n o t in d ic a te d fo r re v e rs a l o f h e p a rin (p ro ta m in e s u lfa te is) ■ T re a tm e n t o f C1 e s te ra s e in h ib ito r d e fic ie n c y ■ A s re p la c e m e n t s o lu tio n in p la s m a e x c h a n g e fo r T T P □ If p la s m a e x c h a n g e c a n n o t b e p e rfo rm e d im m e d ia te ly , th e n tra n s fu s io n o f p la s m a s h o u ld b e in s tig a te d in th e in te rim

78

■ N o te th a t e a c h u n it o f c ry o c o n ta in s th e a m o u n t o f fa c to rs p re s e n t in 1-2 u n its o f FFP, b u t in a s ig n ific a n tly s m a lle r v o lu m e (1 u n it o f F F P h as th e v o lu m e o f - 2 0 u nits o f c ryo )

2.6.5.2 Indications ■ In u n u s u a l s itu a tio n s , u se d in th e tre a tm e n t o f h e m o p h ilia A (fa c to r V III d e fic ie n c y ) □ T h e tre a tm e n t o f c h o ic e is fa c to r V III c o n c e n tra te o r re c o m b in a n t fa c to r V III □ T h e d o s e m u s t be c a lc u la te d (see b e lo w ) □ T h e h a lf-life o f fa c to r V III is 12 h o u rs , a n d th is d o se w ill be re p e a te d in 12 h o u rs □ A lte rn a tiv e ly , a c o n tin u o u s in fu s io n to run o v e r 12 h o u rs m a y be a d m in is te re d

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

2: Blood Banking/Transfusion Medicine

Blood components>Cryoprecipitated antihemophilic factor (cryoprecipitate or cryo) | Selected plasma derivatives | Manipulated products ■ F ib rin o g e n d e fic ie n c y (< 1 00 m g/d L ), a s is c o m m o n ly s e e n in D IC □ S h o u ld n o t be u sed a lo n e in D IC , a s it la c k s c e rta in fa c to rs , n o ta b ly fa c to r V □ F F P s h o u ld be g iv e n a s w e ll

■ D o s e c a lc u la tio n is s im ila r to fV III, b u t s o m e o f th e a s s u m p tio n s d iffe r □ T h e h a lf life o f fIX is - 2 4 h o u rs □ In tra v a s c u la r re c o v e ry o f fIX is o n ly - 5 0 % ■ E s tim a tin g th e d o s e o f fV III

□ 1 u n it o f c ry o ca n ra ise th e fib rin o g e n level by - 7 m g / dL; th u s , a d o s e o f 10 p o o le d c ry o u n its is e x p e c te d to ra is e th e fib rin o g e n by 70 m g /d L ■ B le e d in g in u re m ic p a tie n ts ■ F a c to r X III d e fic ie n c y ■ C a n be u se d fo r vo n W ille b ra n d d is e a s e , b u t initial tre a tm e n t o f c h o ic e is u s u a lly D D A V P ■ F ibrin “g lu e ”

□ 3 0 % a c tiv ity d e s ire d : 15 lU /k g □ 5 0 % a c tiv ity d e s ire d : 25 lU /k g □ 100 % a c tiv ity d e s ire d : 50 lU /k g ■ L e s s p u rifie d fo rm s o f fIX , s u c h a s a 9 -S D , h a v e v a ria b le q u a n titie s o f o th e r v ita m in K d e p e n d e n t fa c to rs (II, V II, a n d X ) and a re a ls o c a lle d “ p ro th ro m b in c o m p le x c o n c e n tra te s .” T h is s h o u ld be d is tin g u is h e d fro m th e n e x t p ro d u c t. ■ F a c to r IX c o m p le x , a ka a n ti-in h ib ito r c o a g u la n t c o m p le x (A IC C ), u n d e r th e b ra n d n a m e F E IB A -V H , c o n ta in s fa c to r IX, fa c to r II, fa c to r X , a n d a c tiv a te d fa c to r V II (fa c to r V ila ). T h is ca n be u s e d in p a tie n ts w ith h ig h d o s e a n tifa c to r V III o r a n tifa c to r IX in h ib ito rs .

2.6.5.3 Dosing ■ T h e u sua l d o s e fo r a d u lts is 10 b ag s, p o o le d

2.6.6 Selected plasma derivatives 2.6.7 Manipulated products

2.6.6.1 Rh immune globulin (Rhlg) ■ R h lg is a v a ila b le in fo rm s fo r in tra m u s c u la r and in tra v e n o u s a d m in is tra tio n

2.6.7.1 Irradiated products

■ F o r p re v e n tio n o f h e m o ly tic d is e a s e o f th e n e w b o rn a n d fo r tre a tm e n t (in tra v e n o u s fo rm o n ly ) o f im m u n e th ro m b o c y to p e n ic p u rp u ra in R h+ p a tie n ts o n ly

■ A m e th o d m u s t be u se d to e n s u re th a t irra d ia tio n h a s o c c u rre d

2.6.6.2 Factor VII concentrate ■ T re a tm e n t o f in h e rite d fa c to r V II d e fic ie n c y ■ T re a tm e n t o f p a tie n ts w ith a n ti-fV III o r a n ti-fIX in h ib ito rs

■ F o r red c e lls , th e s to ra g e tim e b e c o m e s 2 8 d a y s o r th e o rig in a l o u td a te , w h ic h e v e r is s o o n e r ■ In d ic a tio n : irra d ia tio n is in d ic a te d s o le ly fo r p re v e n tio n o f tra n s fu s io n a s s o c ia te d g ra ft v s h o s t d is e a s e (T A -G V H D ) in a t ris k p a tie n ts , in c lu d in g

2.6.6.3 Factor VIII (fVIII) concentrate ■ F V III is u se d in th e tre a tm e n t a n d p ro p h y la x is o f h e m o p h ilia A

□ B o n e m a rro w /s te m cell tra n s p la n t re c ip ie n ts / c a n d id a te s

■ T h e h u m a te -P fo rm u la tio n c o n ta in s s u ffic ie n t vo n W ille b ra n d fa c to r to be u se d in th e tre a tm e n t o f von W ille b ra n d d is e a s e ■ D o s e o f fV III d e p e n d s u p o n th e s ta rtin g fV III a c tiv ity and ta rg e t fV III a c tivity . To c a lc u la te th e d o se , th e fo llo w in g p rin c ip le s a p p ly □ 1 in te rn a tio n a l u n it (IU ) o f fV III is d e fin e d as th e a c tiv ity o f fV III in 1 m L o f n o rm a l p la s m a (the p la s m a o f s o m e o n e w ith fV III a c tiv ity o f 100% ), a nd is th e e x p e c te d a c tiv ity o f 1 m L o f p o o le d p la s m a □ T h e in tra v a s c u la r re c o v e ry o f fV III is n e a rly 100% □ T h e h a lf life o f fV III is ~12 h o u rs

■ A A B B S ta n d a rd s s tip u la te s th a t 2 5 G y (2 5 0 0 c G y ) a re d e liv e re d to th e m id p la n e o f th e p ro d u c t. T h e m in im u m d o s e to a n y p o rtio n o f th e p ro d u c t s h a ll be 15 G y (1 5 0 0 cG y)

□ N e o n a te s a n d fe tu s e s □ R e c ip ie n ts o f b lo o d fro m b lo o d re la tiv e s □ Im m u n o s u p p re s s e d p a tie n ts w ith H o d g k in a n d n on H o d g k in ly m p h o m a □ P a tie n ts re c e iv in g p u rin e a n a lo g s □ P a tie n ts w ith c o n g e n ita l T c e ll d e fe c ts b u t n o t B c e ll o r m a c ro p h a g e d e fe c ts □ P a tie n ts w ith a p la s tic a n e m ia , in c lu d in g a p la s tic a n e m ia re s u ltin g fro m in te n s iv e c h e m o th e ra p y □ P a tie n ts ta k in g c h e m o th e ra p y w ith p u rin e a n a lo g s (flu d a ra b in e , m e rc a p to p u rin e , th io g u a n in e , c la d rib in e ) □ R e c ip ie n ts o f g ra n u lo c y te tra n s fu s io n

2.6.6.4 Factor IX (fIX) concentrate ■ fIX is used in p a tie n ts w ith h e m o p h ilia B © A S C P 2018

ISBN 978-08 9189-6678

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2: Blood Banking/Transfusion Medicine

Blood components>Manipulated products Blood group antigens>ABO & the carbohydrate antigens 2.67.2 Leukoreduced products ■ F iltra tio n is th e u s u a l m e th o d o f le u k o re d u c tio n ■ T o b e la b e le d a s le u k o re d u c e d , 9 5 % o f te s te d u n its m u s t c o n ta in □ < 5 » 10 6 w h ite c e lls (re d b lo o d c e lls a n d a p h e re s is d e riv e d p la te le ts ) □ < 8 .3 x 1 0 5 w h ite c e lls (w h o le b lo o d d e riv e d p la te le ts ) ■ T h e le u k o re d u c e d re d c e ll u n it m u s t re ta in > 8 5 % o f th e o rig in a l re d c e lls (w h o le b lo o d d e riv e d u n its ) o r >51 g o f h e m o g lo b in (a p h e re s is u n its )

t2.31 Some hard to rem em ber shelf lives (outdates) RBCs, saline washed or thawed and deglycerolized thawed fresh frozen plasma

24 hour shelf life, refrigerated

24 hour shelf life, refrigerated (after 24 hours, relabeled as “thawed plasma") thawed plasma 5 day shelf life, refrigerated pooled platelets in open system 4 hour shelf life, room temperature pooled platelets in closed system 5 days or shortest outdate of RDP in pool, room temperature thawed cryoprecipitated AHF, unpooled 6 hour shelf life, room temperature thawed and pooled cryoprecipitated AHF 4 hour shelf life, room temperature in open system

■ N o te th a t b o th w a s h e d a n d fro z e n , d e g ly c e ro liz e d red c e lls a re c o n s id e re d le u k o re d u c e d ■ C u rre n tly , m a n y b lo o d c e n te rs p ro v id e s o le ly le u k o re d u c e d p ro d u c ts , w h ic h w e re filte re d a t th e tim e o f c o lle c tio n (“ p re s to ra g e le u k o re d u c tio n ” ). B e d s id e le u k o re d u c tio n (“ p re tra n s fu s io n le u k o re d u c tio n ” ) is le s s d e s ira b le ■ In d ic a tio n s □ P re v e n tio n o f H L A a llo im m u n iz a tio n (p la te le t re fra c to rin e s s ) □ P re v e n tio n o f fe b rile , n o n h e m o ly tic , tra n s fu s io n re a c tio n s □ P re v e n tio n o f C M V tra n s m is s io n ; le u k o re d u c tio n is e ffe c tiv e in re d u c in g th e ris k o f tra n s m is s io n o f C M V , b u t it is c o n tro v e rs ia l w h e th e r th is is a s s a fe a s u s in g C M V - u n its □ P re v e n tio n tra n s fu s io n re la te d im m u n e m o d u la tio n (T R IM ) □ L e u k o re d u c tio n is n o t e ffe c tiv e in p re v e n tin g tra n s fu s io n a s s o c ia te d g ra ft v s h o s t d is e a s e

2.67.3 W ashed products ■ C e llu la r p ro d u c ts m a y b e w a s h e d to re m o v e p la s m a , a n d re s u s p e n d e d in n o rm a l s a lin e ■ T h e p rim a ry in d ic a tio n is p re v e n tio n o f re c u rre n t o r s e v e re a lle rg ic re a c tio n s , p a rtic u la rly in Ig A d e fic ie n t re c ip ie n ts ■ M a y b e u s e d in p a tie n ts s u ffe rin g re c u rre n t s e v e re fe b rile n o n h e m o ly tic tra n s fu s io n re a c tio n s ■ M a y be in d ic a te d w h e n tra n s fu s in g n e o n a te s w ith c e llu la r p ro d u c ts b e a rin g in c o m p a tib le p la s m a ■ F ro z e n , d e g ly c e ro liz e d p ro d u c ts a re c o n s id e re d w a s h e d ■ T h e s h e lf life o f w a s h e d re d c e lls is 2 4 h o u rs ; fo r p la te le ts , 4 h o u rs t2.31

2.7 Blood group antigens 2.7.1 ABO & the carbohydrate antigens 27.1.1 Antigens ■ A B O , Lew is, H, I, a nd i a re c a rb o h y d ra te a n tig e n s t2.32 ■ C a rb o h y d ra te a n tig e n s a re a ffe c te d by g e n e s th a t e n c o d e enzym es □ G e n e s fo r p ro te in a n tig e n s e n c o d e s tru c tu ra l p ro te in s □ T h e e n z y m e s (g ly c o s y ltra n s fe ra s e s ) c a ta ly z e th e tra n s fe r o f s p e c ific s a c c h a rid e s to s p e c ific c a rb o h y d ra te p re c u rs o r c h a in s

t2.32 Comparison of carbohydrate and protein antigens Carbohydrate antigens

Protein antigens

ABO, Le, I, M, N, P1

all others, including Rh, Kidd, Kell, S, s and Duffy antibodies acquired only after exposure to products containing antigen antibodies usually IgG antibodies usually reactive at 37°C

naturally occurring antibodies antibodies usually igm antibodies usually reactive at room temperature “agglutinating” antibodies react at immediate spin (IS)

“coating” antibodies react at AHG phase

■ H a n tig e n is m a d e fro m ty p e 1 and ty p e 2 p re c u rs o r c a rb o h y d ra te s by th e e n z y m e p ro d u c ts o f th e H (FU T 1) and S e (F U T 2 ) g e n e s □ In s e c re tio n s (saliva, te a rs) a nd in p la sm a, ty p e 1 c h a in s a re c o n v e rte d into H a n tig e n by th e e n z y m a tic a ction (fu c o s y la tio n ) o f th e S e g e n e p ro d u c t □ On th e s u rfa c e s o f red ce lls, ty p e 2 c h a in s a re co n v e rte d to H a n tig e n by th e e n z y m a tic a ctio n (fu c o s y la tio n ) o f th e FI g e n e p ro d u c t □ L ew is a n tig e n s a re m a d e fro m ty p e 1 p re c u rs o r (see b elow ) by th e e n z y m e p ro d u c t o f th e Le (F U T 3) g e n e □ S e cre te d L e b a nd L e c a re re c e p to rs fo r N o rw a lk v iru s and FI p y lo ri □ Lea is th e C A 1 9 -9 e p ito p e

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© A S C P 2018

2: Blood Banking/Transfusion Medicine

Blood group antigens>ABO & the carbohydrate antigens ■ T h e A and B a n tig e n s a re m a d e fro m H a n tig e n by th e e n z y m e p ro d u c ts o f th e A B O g e n e □ T h e A a lle le e n c o d e s an e n z y m e (N -a c e ty lg a la c to s a m in y l tra n s fe ra s e ) th a t a d d s N -a c e ty l g a la c to s a m in e (N A G ) to H, re su ltin g in th e A a n tig e n □ T h e B a lle le e n c o d e s an e n z y m e (g a la c to s y l tra n s fe ra s e ) th a t a d d s D -g a la c to s e (G A L ) to H a n tig e n , re su ltin g in th e B a n tig e n

t2.33 Distribution of blood groups by ethnicity Group

White (%)

Black (%)

Hispanic (%)

0 A B AB D+ D-

45 40

50 25 20 5 92 8

55 30

10 5 82 18

□ T h e O a lle le d o e s n ot e n c o d e a fu n c tio n a l e n z y m e , a nd g ro u p O red c e lls c o n ta in a b u n d a n t u n a lte re d H a n tig e n ■ T h e I a nd i a n tig e n s a re e p ito p e s w ith in th e A B H a n tig e n s □ U n b ra n c h e d ty p e 1 a n d 2 o lig o s a c c h a rid e s re p re s e n t i a n tig e n □ B ra n c h e d ty p e 1 and 2 o lig o s a c c h a rid e s a re I a n tig e n s □ B ra n c h e d o lig o s a c c h a rid e s (I) in c re a s e w ith a g e □ In n e o n a te s a nd c o rd b lo o d , i a n tig e n p re d o m in a te s □ A d u lts h ave m o s tly I a n tig e n □ In high red c e ll tu rn o v e r s ta te s , a re s u rg e n c e o f i is s o m e tim e s o b s e rv e d

10 3 92 8

■ A n ti-A 1 ca n be fo u n d in th e s e ru m o f 5 % o f b lo o d g ro u p A 2 a n d 3 5% o f g ro u p A 2 B in d iv id u a ls . U s u a lly c lin ic a lly in s ig n ific a n t ■ T h e B b lo o d g ro u p re su lts fro m th e B B o r B O g e n o ty p e ■ T h e A B b lo o d g ro u p re s u lts fro m th e A B g e n o ty p e ■ T h e B o m b a y p h e n o ty p e □ E x tre m e ly ra re , e ven in B o m b a y , b u t h a s b e e n s e e n in all p o p u la tio n s □ R e s u lts w h e n th e h g e n e (an a m o rp h ) is in h e rite d in s te a d o f H □ N o H p ro d u c e d in b lo o d ■ H p ro d u c e d in s e c re tio n s if th e S e g e n e is p re s e n t ■ T h e H d e fic ie n t s e c re to r is o fte n c a lle d th e p a ra -B o m b a y p h e n o ty p e

n In c re a s e d p o s tn a ta l i a n tig e n e x p re s s io n is c h a ra c te ris tic o f ■ C o n g e n ita l d y s e ry th ro p o ie tic a n e m ia (C D A ) ty p e II

□ S u c h in d iv id u a ls p ro d u c e a d a n g e ro u s a n ti-H

■ B la c k fa n -D ia m o n d s y n d ro m e

2.7.1.3 2.7.1.2 ABO phenotypes ■ T h e O b lo o d g ro u p is th e re s u lt o f in h e ritin g n e ith e r A nor B genes □ O n ly H a n tig e n is p re s e n t □ P ro d u c e n a tu ra lly o c c u rrin g IgM a n ti-A a nd a n ti-B □ A ls o p ro d u c e IgG a n ti-A B , w h ic h c a n c a u s e o f A B O re la te d h e m o ly tic d is e a s e o f th e n e w b o rn , w h ic h is ty p ic a lly m ild ■ T h e A b lo o d g ro u p re s u lts fro m th e A A o r A O g e n o ty p e t2.33 □ T h e 2 p rin c ip a l s u b g ro u p s a re A1 a nd A 2 ■ A1 c e lls e x p re s s m o re A s u b s ta n c e th a n A 2 c e lls ■ 8 0 % o f b lo o d g ro u p A in d iv id u a ls h ave th e A1 p h e n o ty p e ■ A1 a nd A 2 c e lls ca n be d is tin g u is h e d by s tre n g th o f re a c tio n w ith ■ A n ti-A 1 re a g e n t fro m th e s e ru m o f b lo o d g ro u p B in d iv id u a ls ■ D o lic h o s b iflo ru s le c tin , w h ic h h a s anti-A1 a c tiv ity ■ U le x e u ro p a e u s , w h ic h h as a n ti-H a c tiv ity (re a c ts w ith A 2 m o re th a n A1) © A S C P 2018

Review of the relationship of Le, Se, H, I, i & ABO

■ T h e re a re 2 p re c u rs o r o lig o s a c c h a rid e s : ty p e 1 a n d ty p e 2 p re c u rs o r s u b s ta n c e □ T yp e 1 is u n b o u n d and is fo u n d in s e c re tio n s a n d in p la s m a □ T yp e 2 is fo u n d o n ly on th e red c e ll s u rfa c e □ U n b ra n c h e d ty p e 1 and 2 o lig o s a c c h a rid e s re p re s e n t i a n tig e n □ B ra n c h e d ty p e 1 a nd 2 o lig o s a c c h a rid e s a re I a n tig e n s ■ T h e H (F U T 1 ) g e n e e n c o d e s a fu c o s y l tra n s fe ra s e : s u b s tra te is ty p e 2 p re c u rs o r, p ro d u c t is H (2 H ) □ W h e n no fu rth e r m o d ific a tio n s a re m a d e to th e H a n tig e n , th e b lo o d is g ro u p O □ W h e n th e A g e n e p ro d u c t a c ts o n th e H a n tig e n , a d d in g N A G , th e A a n tig e n re s u lts a W h e n th e B g e n e p ro d u c t a c ts o n th e H a n tig e n , a d d in g G A L , th e B a n tig e n re s u lts □ T h e re la tiv e a m o u n t o f H a n tig e n is a s fo llo w s : O » A 2 > B > A 2 B > A1 > A1B ■ T h e S e (F U T 2 ) g e n e e n c o d e s a fu c o s y l tra n s fe ra s e : s u b s tra te is ty p e 1 p re c u rs o r, p ro d u c t is H (1H )

ISBN 978-08 9 1 8 9 -6 6 7 8

81

2: Blood Banking/Transfusion Medicine

Blood group antigens>ABO & the carbohydrate antigens □ T h u s , it p ro d u c e s th e s e c re tio n a n d p la s m a e q u iv a le n t o f H s u b s ta n c e a n d is re s p o n s ib le fo r th e a p p e a ra n c e o f A , B, a n d H s u b s ta n c e s in s e c re tio n s □ T h e s e g e n e is an a m o rp h □ 8 0 % o f th e p o p u la tio n h a s th e S e a lle le a n d a re s e c re to rs ; 2 0 % a re h o m o z y g o u s fo r s e /s e a n d a re n o n s e c re to rs ■ T h e Le (F U T 3 ) g e n e e n c o d e s a fu c o s y l tra n s fe ra s e : s u b s tra te is ty p e 1 p re c u rs o r a n d 1H, p ro d u c t is L e a a nd Leb □ T h e Le fu c o s y l tra n s fe ra s e a d d s fu c o s e to ty p e 1 p re c u rs o r (in a d iffe re n t lin k a g e th a n th a t c a ta ly z e d by S e ) to m a k e L e a a n tig e n □ T h e L e fu c o s y l tra n s fe ra s e a ls o c a n a d d fu c o s e to 1H a n tig e n to m a k e L e b a n tig e n

t2.35 Lewis & secretor genotypes & phenotypes Lewis Secretor ABO RBC Substances in genes H gene genes genes phenotype saliva Le le Le le Le le Le le Le le Le le

H H H H H H H H H H H H

Se Se se se Se Se se se Se Se se se

0 0 0 0 At At At At B B B B

H, Le(a-b+) H, J,Lea, Leb H, Le(a-b-) H H, Le(a+b-) Lea 0, Le(a-b-) None A 1,Le(a-b+)U H ,A , |Lea, Leb A1, Le(a-b-) J.|H, A A1, Le(a+b-) Lea A1, Le(a-b-) None B, Le(a-b+) J.H, B, |Lea, Leb B, Le(a-b-) |H, B B, Le(a+b-) Lea B, Le(a+b-) None

□ N o te fro m th e fo re g o in g th a t □ L e a c a n b e m a d e if Le is p re s e n t

2.7.1.4 ABO antibodies

□ L e b is m a d e o n ly if b o th th e S e a n d Le a re p re s e n t □ In L e ( a - b + ) in d iv id u a ls , a m in u te a m o u n t o f L e a is still m a d e , s u c h th a t a n ti-L e a a n tib o d ie s d o n o t fo rm □ T h o u g h L e w is a n tig e n is s y n th e s iz e d o n fre e ty p e 1 p re c u rs o r s u b s ta n c e , it b e c o m e s p a s s iv e ly a d s o rb e d o n to re d c e ll s u rfa c e s □ L e g e n e e x p re s s io n in c re a s e s w ith a g e □ T h e L e w is ty p e c a n n o t b e re lia b ly d e te rm in e d u n til th e 2 n d b irth d a y □ P e rs o n s d e s tin e d to b e L e ( a - b + ) a re a s n e o n a te s L e ( a - b - ) th e n L e ( a + b - ) th e n L e (a + b + ) a n d fin a lly L e (a -b + ) □ L e w is a n tig e n e x p re s s io n is d e c re a s e d d u rin g p re g n a n c y a n d th e L e ( a - b - ) p h e n o ty p e is tra n s ie n tly e x p re s s e d □ L e w is p h e n o ty p e fre q u e n c ie s t2.34 a re n o ta b le fo r th e p re s e n c e o f L e ( a - b - ) m a in ly in b la c k s a n d th e ra rity o f L e (a + b + )

t2 .3 4 Lewis phenotypes Phenotype

Whites (%)

Blacks (%)

Le(a-b+) Le(a+b-) Le(a-b-) Le(a+b+)

72 22 6 0

55 22 23 0

t2 .3 5 a n d f2 .3 s u m m a riz e th e re la tio n s h ip s b e tw e e n A B H , Le, H a n d S e g e n o ty p e s a n d p h e n o ty p e s

■ A B O a n tib o d ie s a re n a tu ra lly o c c u rrin g (do n ot re q u ire a n tig e n e x p o s u re fo r fo rm a tio n ) □ D e te c ta b le in in fa n ts by 3 -6 m o n th s , b ut m a y n ot re ach a d u lt tite rs u n til 2 y e a rs □ A B O in c o m p a tib ility re s u lts in c o m p le m e n t a c tiv a tio n and b ris k in tra v a s c u la r h e m o ly s is □ R e a c tio n s c a n a c c o m p a n y tra n s fu s io n o f in c o m p a tib le red c e lls (so c a lle d m a jo r in c o m p a tib ility ) and tra n s fu s io n o f in c o m p a tib le p la s m a (m in o r in c o m p a tib ility ) ■ L e w is a n tib o d ie s a re n a tu ra lly o c c u rrin g □ F o un d a lm o s t e x c lu s iv e ly in L e ( a - b - ) in d iv id u a ls w h o a re c o m m o n ly b la c k □ L e (a -b + ) p e rs o n s d o n o t m a ke a n ti-L e a a n tib o d ie s □ L e w is a n tib o d ie s a re n e a rly a lw a y s IgM a nd in s ig n ific a n t □ D u rin g p re g n a n c y , w o m e n c a n a c q u ire th e L e ( a - b - ) p h e n o ty p e , a nd th e y ca n d e v e lo p a n ti-L e a o r L e b a n tib o d ie s . T h e s e a n tib o d ie s c a n n o t h a rm th e baby, s in c e fe ta l c e lls d o n ot e x p re s s Le a n tig e n s □ T h e ra re s ig n ific a n t L e w is a n tib o d y is a lw a y s a n ti-L e a. T h e s e a n tib o d ie s a re u s u a lly in c o n s e q u e n tia l, because ■ T ra n s fu s e d red c e lls s h e d th e ir L e w is a n tig e n s a nd a c q u ire th e L e w is p h e n o ty p e o f th e re c ip ie n t ■ L e w is a n tib o d ie s a re q u ic k ly a d s o rb e d by fre e s e ru m L e w is a n tig e n s ■ A n ti-I a n d a n ti-i a n tib o d ie s a re a u to a n tib o d ie s th a t a re u s u a lly c lin ic a lly in s ig n ific a n t □ A n ti-I a n tib o d ie s a re a s s o c ia te d w ith M y c o p la s m a p n e u m o n ia e in fe c tio n □ A n ti-i a n tib o d ie s a re a s s o c ia te d w ith E p s te in -B a rr v iru s in fe c tio n s

82

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

2: Blood Banking/Transfusion Medicine

Blood group antigens>ABO & the carbohydrate antigens | P/GLOB blood group

R e a c t iv it y ( 0 - 4 + ) is r e c o r d e d a t 3 s e p a r a t e p h a s e s . In t h e IS ( i m m e d i a t e s p in ) s e r u m is m i x e d w i t h c e lls a t r o o m t e m p , th e n c e n tr ifu g e d a n d e x a m in e d . T e s t c e ll a n t i g e n

t h e 3 7 ° C p h a s e , t h e s a m e is d o n e a t 3 7 ° C .

e x p r e s s io n is k n o w n

( a n t i h u m a n g l o b u lin ) p h a s e , a ls o c a l l e d IA T

a n d e x p r e s s e d in

Lutheran

MNS

Rh-Hr 1

( i n d i r e c t a g g l u t i n a t i o n t e s t ) , t h e s a m e is d o n e ,

ta b u la r fo rm

T e s t c e lls a r e g r o u p O

In

In A H G

f o llo w e d b y a d d itio n o f A H G .

p

Lew is

Results

Kidd

D uffy

Kell

D

c

c

E

e

M

N

s

s

Lua

Lub

P1

Lea

Leb

K

k

Fya

Fyb

Jka

Jkb

IS

37°

AHG

0

+

0

0

+

+

+

0

+

0

+

+

+

0

0

+

+

0

+

+

0

2+

2+ 1+

2

+

+

+

0

+

+

0

0

+

0

+

+

0

+

+

0

+

+

0

+

0

1+

3

+

+

0

0

+

0

+

+

0

+

0

0

+

0

0

+

+

+

+

+

0

1+

1+

4

+

+

0

+

+

+

0

+

+

0

+

+

0

+

0

+

0

+

0

+

0

0

0

5

+

+

+

0

+

0

0

+

0

+

+

0

+

0

+

+

+

0

+

0

1+

1+

6

0

0 0

+

0

+

+

0

+

0

0

+

+

0

+

0

+

0

+

+

0

0

0

0

7

0

0

+

0

+

0

+

+

0

+

+

0

0

+

0

+

0

+

+

0

0

0

0

8

0

0

+

0

+

0

+

0

+

+

0

+

+

0

+

0

+

0

0

+

0

1+

1+

9

0

0

+

0

+

+

+

+

0

0

+

+

0

+

0

+

0

+

+

0

0

0

0

10

0

0

+

0

+

+

0

0

0

0

+

0

+

0

0

+

0

0

+

+

0

0

0

0

0

0

Pt

P a tie n t RBCs a r e a d d e d t o

N o t i c e t h a t t e s t c e lls 6 , 7 , a n d 9 a r e Jka+ , Jkb- . T h e s e c e lls a r e h o m o z y g o u s f o r Jka.

p a t ie n t s e r u m /p la s m a f o r m in g

I f a K id d a n t i b o d y w e r e p r e s e n t , i t w o u l d r e a c t m o r e s t r o n g l y w i t h t h e s e c e lls t h a n

t h e " a u t o c o n t r o l . " In t h is

w i t h c e lls h e t e r o z y g o u s f o r Jka (c e lls 1 , 3 , a n d 1 0 ) . T h is is a n e x a m p l e o f d o s a g e

e x a m p l e , it is n e g a t i v e ( 0 ) . A

e f f e c t . D o s a g e e f f e c t is a f e a t u r e o f K id d , D u f f y , R h , a n d M N S .

p o s i t iv e a u t o c o n t r o l im p l ie s th e p re s e n c e o f a u to a n tib o d y o r d r u g in d u c e d p o s i t iv e D A T ; a lte r n a tiv e ly , a n tib o d y t o t r a n s f u s e d r e d c e lls m a y c a u s e a p o s i t iv e a u t o , u s u a lly w i t h m ix e d f i e l d ( m f ) r e a c t i v i t y

W h e n t h e r e a c tio n p a t t e r n r e m a in s u n c le a r , te s tin g c a n b e a u g m e n t e d b y t h e u s e o f e n z y m e s . P r e t r e a t i n g t e s t c e lls w i t h e n z y m e s ( e g , f ic in ) c a n a l t e r r e a c t i v i t y in p r e d i c t a b l e w a y s : e n h a n c i n g r e a c t i v i t y o f s o m e a n t ig e n s ( R h , K id d ) , a b o l is h in g r e a c t i v i t y o f o t h e r s ( M N S , D u f f y ) , a n d p r o d u c i n g n o e f f e c t in m a n y m o r e .

f2.3 Antibody panel

■ T h e P a n tig e n is th e ta rg e t o f a n tib o d ie s in p a ro x y s m a l c o ld h e m o g lo b in u ria (P C H )

2.7.2 P/GLOB blood group 2.7.2.1 Antigens & phenotypes ■ P1, P, a nd P k a re 3 d iffe re n t c a rb o h y d ra te a n tig e n s ■ A c c o rd in g to c u rre n t n o m e n c la tu re , P1 a n tig e n is th e o n ly 1 o f th e s e b e lo n g in g to th e P b lo o d g ro u p s y s te m ■ P k a nd P, c o n fu s in g ly , d o n o t b e lo n g to th e P b lo o d g ro u p s y s te m a nd b e lo n g in s te a d to th e G L O B c o lle c tio n ■ T h e P a n tig e n is th e re c e p to r fo r p a rv o v iru s B19 (fifth d is e a s e )

■ T h e P g ro u p p h e n o ty p e s are d e fin e d b y re a c tiv ity w ith th e a n tib o d ie s a n ti-P 1 , anti-P , a n ti-P k , a n d a n ti-P P 1 P k □ 8 0 % o f w h ite s a nd 9 5 % o f b la c k s h a v e th e P1 p h e n o ty p e (P1+, P+, P k -, P P 1P k+ ) ■ T h e ra re p p h e n o ty p e is c h a ra c te riz e d b y a b s e n c e o f P a n tig e n s

27.2.2 Antibodies ■ In d iv id u a ls w ith p p h e n o ty p e m a k e a p o te n t a n ti-P P 1 P k

© ASCP2018

ISBN 9 7 8 -08 9189-6678

83

2: Blood Banking/Transfusion Medicine

B lo o d g r o u p a n tig e n s > P /G L O B b lo o d g r o u p | R h

□ A n ti-P P 1 P k m a y be a s s o c ia te d w ith d e la y e d h e m o ly tic tra n s fu s io n re a c tio n , h e m o ly tic d is e a s e o f th e fe tu s / n e w b o rn , a n d firs t trim e s te r s p o n ta n e o u s a b o rtio n ■ In d iv id u a ls w ith P 2 m a y m a k e a n ti-P 1 □ T h e s e a re u s u a lly Ig M , re a c tiv e a t 4°C , a n d n o t c lin ic a lly s ig n ific a n t □ A n ti-P 1 c a n b e a g g lu tin a te d by ■ H y d a tid c y s t flu id ■ E g g w h ite s fro m p ig e o n e g g s a n d tu rtle d o v e e g g s ■ E c h in o c o c c a l in fe c tio n (h y d a tid c y s t)

□ A ls o h ave d im in is h e d e x p re s s io n o f LW , Fy5, S, s, and U □ A lso h ave e n h a n c e d o s m o tic fra g ility , c h ro n ic h e m o ly s is , a n d s to m a to c y to s is

■ W e a k e x p re s s io n o f D w a s fo rm e rly c a lle d Du, a te rm no lo n g e r used

2.7.3 Rh 2.7.3.1 Rh antigens & phenotypes

□ P o s s e s s th e D a n tig e n in s m a lle r q u a n titie s

■ R h a n tig e n s a re p o ly p e p tid e a n tig e n s e n c o d e d by c lo s e ly lin k e d g e n e lo c i R H D a n d R H C E

□ P e rs o n s w ith w e a k D do n o t fo rm an a n ti-D a n tib o d y

□ T h e g e n e s a re fo u n d on c h ro m o s o m e 1

□ T ra n s fu s io n o f w e a k D c e lls into D - re c ip ie n ts can c a u s e s e n s itiz a tio n

□ T h e p ro d u c ts o f th e R H D a n d R H C E g e n e s fo rm a la rg e c o m p le x o n red c e lls

□ W e a k D d e fin e d h is to ric a lly by w e a k re a c tiv ity w ith a n ti-D re a g e n t, ty p ifie d by th e fo llo w in g re a c tio n s

□ A d d itio n a l p ro te in s a s s o c ia te w ith th e R h c o m p le x , in c lu d in g L W a n d D u ffy (Fy) □ C , D, a n d E a re tra n s m e m b ra n e p ro te in s w ith m u ltip le e x tra c e llu la r d o m a in s □ S iz e a n d in tric a c y re s u lt in a m u ltitu d e o f e p ito p e s a nd a n tig e n s □ M u ltitu d e o f e x tra c e llu la r d o m a in s c re a te th e p o s s ib ility o f “ p a rtia l D ” p h e n o ty p e s ■ T h e m o s t c o m m o n R h - g e n o ty p e is r/r (c d e /c d e ) t2 .3 6

t2.3 6 Rh n o m e n c la t u r e & in c id e n c e Weiner Antigens White (%) DCe DcE Dee DCE dCe dcE dee dCE of Native Americans

Black (%)

40 10 5

15 10 45

rare*

rare

3

3

2

rare

40

30

rare

rare

■ N e g a tiv e a t IS w ith a n ti-D re a g e n t ■ N e g a tiv e a fte r 37°C in c u b a tio n w ith a n ti-D re a g e n t ■ P o sitiv e a t A H G p h a s e w ith a n ti-D re a g e n t ■ M o d e rn m o n o c lo n a l a n ti-D re a g e n ts ca n d e te c t m o s t w e a k D R B C s a t th e IS p h a s e , s u c h th a t w e a k D c e lls s im p ly lo o k s like ty p ic a l D + c e lls □ M e c h a n is m s ■ M o s t c o m m o n ly re s u lts fro m m u ta tio n s in th e R H D g e n e le a d in g to a lte ra tio n in a n tig e n e x p re s s io n ■ L e s s c o m m o n ly re s u lts fro m p re s e n c e o f C e h a p lo ty p e fo r R H C E g e n e is fo u n d on o p p o s ite c h ro m o s o m e , w h ic h e x e rts a d a m p e n in g e ffe c t on D e x p re s s io n (“ C in tra n s to D ” ) □ T ra n s fu s io n o f w e a k D c e lls into D - re c ip ie n ts can c a u s e s e n s itiz a tio n , w h ic h is m o s t im p o rta n t to a void in w o m e n o f c h ild b e a rin g y e a rs. T h e re fo re , A A B B S ta n d a rd s re q u ire s th a t d o n o r s a m p le s be te s te d fo r w e a k D a n d la b e le d D + if fo u n d . T h e re c ip ie n t need n o t b e te s te d fo r w e a k D ■ P a rtia l D is th e te rm u se d fo r a lte ra tio n s in 1 o f th e e p ito p e s e q u e n c e s o f th e D g e n e □ R e s u lts in a D a n tig e n w ith so m e , b ut n ot all, e p ito p e s

□ 1 0 -1 5 % o f b lo o d d o n o rs a re R h □ T h e h ig h e s t in c id e n c e o f R h n e g a tiv ity is fo u n d in th e B a s q u e s (25% ) □ T h e p re v a le n c e o f r/r e x p la in s w h y re c ip ie n ts w ith a n ti-c o r a n ti-e s h o u ld n o t be g iv e n R h - b lo o d

84

■ R h null in d iv id u a ls h ave n o R h a n tig e n s

□ If th e y re c e iv e R h - R B C s , w ill fo rm an a n ti-to ta l Rh a n tib o d y (a n ti-R h 2 9 )

■ B ird h a n d le rs

R2 RO Rz r’ r” r ry *6%

■ T h e D - p h e n o ty p e d e n o te s th e a b s e n c e o f th e D a n tig e n . T h e re is no d a n tig e n

□ P a tie n ts w h o h ave Rh null s h o u ld o n ly re ce iv e Rh null RBCs

□ A n ti-P 1 tite rs m a y be e le v a te d in

R1

■ T h e m o s t c o m m o n R h+ g e n o ty p e s a re R1/R1 o r R 1/r in w h ite s and RO/RO o r RO/r in b la c k s

□ P e rs o n s w ith p a rtia l D m ay fo rm a n ti-D a n tib o d y □ T ra n s fu s io n o f p a rtia l D c e lls into D - re c ip ie n ts can c a u s e s e n s itiz a tio n □ P a rtia l D w o m e n a re a t ris k fo r fo rm in g a n ti-D a n tib o d ie s w ith D + p re g n a n c ie s

ASCP Quick Compendium of Clinical Pathology 4e

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2: Blood Banking/Transfusion Medicine

B lo o d g r o u p a n tig e n s > R h | K id d b lo o d g r o u p s y s te m

□ F o r th e s e re a s o n s , p a rtia l D fe m a le re c ip ie n ts s h o u ld be tre a te d a s D □ P a rtia l D is fre q u e n tly id e n tifie d b e c a u s e o f an a p p a re n t d is c re p a n c y : th e c o e x is te n c e o f D e x p re s s io n a nd a n ti-D a n tib o d ie s

2.7.3.2 Rh antibodies ■ R h a n tib o d ie s a re IgG a n tib o d ie s th a t a re a c q u ire d th ro u g h e x p o s u re ■ D a n tig e n is th e m o s t im m u n o g e n ic o f all th e n o n -A B O a n tig e n s ■ W h e n R h+ b lo o d is tra n s fu s e d to R h - re c ip ie n ts in e m e rg e n c y s e ttin g s , th e rate o f s e n s itiz a tio n is 2 0 -3 0 %

Jk(a+b—) Jk(a+b+) Jk(a-b+) Jk(a-b-)

30 50 20 rare

Blacks (%) 60 30 10 rare

□ T h e J k b- p h e n o ty p e is tw ic e a s c o m m o n in b la c k s a s w h ite s □ T h e J k ( a - b - ) p h e n o ty p e is ra re , e n c o u n te re d p rim a rily in F in n s and P o ly n e s ia n s ■ K id d is a u re a tra n s p o rt p ro te in □ J k ( a - b - ) c e lls a re re s is ta n t to h e m o ly s is in 2 M u re a □ In d iv id u a ls w ith th is p h e n o ty p e h a v e a m ild u rin e c o n c e n tra tin g d e fe c t

■ A ll R h a n tib o d ie s e x c e p t a n ti-D d is p la y d o s a g e ■ A ll R h a n tig e n s a re e n h a n c e d by e n z y m e s ■ R h a n tib o d ie s m a y re s u lt in h e m o ly tic tra n s fu s io n re a c tio n s (H T R ) a n d s e v e re h e m o ly tic d is e a s e o f th e fe tu s o r n e w b o rn (H D F /H D N ) ■ If a n ti-E is d e te c te d in th e s e ru m , th e n th e a d d itio n a l p re s e n c e o f a n ti-c s h o u ld be s u s p e c te d □ B e c a u s e m o s t in d iv id u a ls w h o h ave a n ti-E h ave th e R1R1 p h e n o ty p e (C D e /C D e ), a nd h a ve b e e n like ly tra n s fu s e d w ith R 2 b lo o d (cD E ) □ A n ti-c m ay be u n d e te c ta b le b u t is a c o m m o n c a u s e o f d e la ye d h e m o ly tic tra n s fu s io n re a c tio n s (D H T R ) ■ G a n tig e n is fo u n d on all D + R B C s a nd m o s t C + R B C s □ S e ro lo g ic a lly a n ti-G a n tib o d ie s m im ic a n ti-D a nd a n ti-C □ M u ltip le a b s o rp tio n /e lu tio n s tu d ie s ca n d is tin g u is h a n ti-G fro m a n ti-D a n d a n ti-C □ In p re g n a n t w o m e n , it is im p o rta n t to d is tin g u is h b e tw e e n a n ti-D , a n ti-C , and a n ti-G a n tib o d y s in c e th e y w ill n e e d R h lg to p re v e n t fo rm a tio n o f a n ti-D ■ A n ti-f (a n tib o d y a g a in s t th e c o m p o u n d a n tig e n ce) is th e m o s t c o m m o n a llo a n tib o d y d ire c te d a g a in s t c o m p o u n d R h a n tig e n s . It is fo u n d p rim a rily in p e rs o n s w ith D C e / D c E (R 1R 2)

2.7.4.2 Kidd antibodies ■ K id d a n tib o d ie s a re w a rm re a c tin g Ig G a n tib o d ie s th a t a re a c q u ire d o n ly th ro u g h e x p o s u re ■ K id d a n tib o d ie s a re c lin ic a lly s ig n ific a n t T h e y a re c o m m o n c a u s e s o f tra n s fu s io n re a c tio n s , b oth im m e d ia te a nd d e la ye d , and both in tra v a s c u la r a nd e x tra v a s c u la r ■ K id d a n tib o d ie s a re n o to rio u s fo r b e in g d iffic u lt to d e te c t (“ tric k y K id d ” ) □ T h e y te n d to fa ll b e lo w th e th re s h o ld o f d e te c tio n o v e r tim e □ K id d a n tib o d ie s d im in is h in s to re d b lo o d (eg, w h e n s e n t to a re fe re n c e lab) □ K idd is o n e o f th e m ain re a s o n s to c h e c k b lo o d b a n k re c o rd s p rio r to tra n s fu s io n □ H is to ric a l K id d a n tib o d ie s , d e s p ite th e a b s e n c e o f c u rre n tly d e te c ta b le a n tib o d y , is re a s o n e n o u g h to g iv e K id d a n tig e n n e g a tiv e b lo o d □ K id d a n tib o d ie s d is p la y d o s a g e a n d m a y o n ly re a c t w ith h o m o z y g o u s c e lls □ D o s a g e e ffe c t m a y re su lt in a fa ls e n e g a tiv e c ro s s m a tc h

2.7.4 Kidd blood group system

□ K id d a n tib o d ie s m o s t o fte n re a c t o n ly a t th e A H G phase

2.7.4.1 Kidd antigen ■ R a c e h as a m a jo r im p a c t on K idd a n tig e n fre q u e n c ie s

t2.37

t2.37 Kidd phenotypes Whites (%) Phenotype

■ K id d a n tig e n s a re e n h a n c e d b y e n z y m e s ■ K id d is th e m o s t c o m m o n c a u s e o f d e la y e d h e m o ly tic tra n s fu s io n re a c tio n s (D H T R ) ■ K id d ra re ly c a u s e s h e m o ly tic d is e a s e o f th e n e w b o rn (H D N ); w e a k ly e x p re s s e d by fe tu s

© A S C P 2018

ISBN 9 7 8 -08 9189-6678

85

2: Blood Banking/Transfusion Medicine

B lo o d g r o u p a n tig e n s > D u f fy | M NS s y s te m | K e ll b lo o d g r o u p

2.7.5 Duffy 2.7.5.1 Duffy antigens ■ 2 a n tig e n s , F ya a n d F y b, c o m p ris e th e D u ffy s y s te m ■ D u ffy a n tig e n s a re p re s e n t on D A R C (D u ffy a s s o c ia te d re c e p to r fo r c h e m o k in e s ), w h ic h is a re c e p to r fo r P la s m o d iu m v iv a x

■ M N S a n tib o d ie s d is p la y d o s a g e ■ M and N a n tig e n ic ity is d e s tro y e d by e n z y m e s

■ F y ( a + b - ) is m o re c o m m o n th a n F y (a -b + )

2.7.7 Kell blood group

■ F y ( a - b - ) is ra re in W h ite s , b u t c o m m o n in b la c k s (6 8 % )

2.77.1 Kell antigens

□ T h is p h e n o ty p e c o n fe rs re s is ta n c e to P la s m o d iu m v iv a x m a la ria

■ T h e K e ll g ro u p in c lu d e s th e a n tig e n s K, k, K p a, K p b, J s a, and Jsb

□ B e c a u s e o f d iffe rin g m e c h a n is m s o f D u ffy n e g a tiv ity in w h ite s a n d b la c k s , m o s t F y ( a - b - ) b la c k s d o n ot fo rm a n ti-F y a n tib o d ie s , b u t F y ( a - b - ) w h ite s d o

■ K ell a n tig e n s a re e x p re s s e d o n m a tu re red c e lls a nd e ry th ro id p re c u rs o rs ; th u s, a llo a n tib o d ie s a re c a p a b le o f s u p p re s s in g e ry th ro p o ie s is ■ T h e K e ll a n tig e n s a re e x p re s s e d in c o v a le n t a s s o c ia tio n w ith th e K x a n tig e n

2 7.5.2 Duffy antibodies ■ D u ffy a n tib o d ie s a re w a rm re a c tin g Ig G a n tib o d ie s a c q u ire d th ro u g h e x p o s u re

■ K (KEL1), K p a a n d J s a a re p re s e n t in 9 % , 2 % a n d 0.1% o f d o n o rs , re s p e c tiv e ly

■ D u ffy a n tib o d ie s s h o w d o s a g e e ffe c t ■ D u ffy a n tig e n s a re d e s tro y e d b y e n z y m e s

■ T h e k a n tig e n (a lso c a lle d C e lla n o o r K E L 2 ), K p b, and J s b a re h ig h fre q u e n c y a n tig e n s , e a c h p re s e n t in 9 9 % o f d o n o rs

■ D u ffy a n tib o d ie s a re c a p a b le o f c a u s in g h e m o ly tic tra n s fu s io n re a c tio n s (H T R ) a n d s e v e re h e m o ly tic d is e a s e o f th e n e w b o rn (H D N )

■ T h e K ell null p h e n o ty p e re s u lts fro m h o m o z y g o u s in h e rita n c e o f th e a m o rp h K0, su ch th a t red c e lls have no K e ll a n tig e n s b u t an a b u n d a n c e o f K x ■ T h e M c L e o d p h e n o ty p e t2 .3 8 re s u lts fro m m u ta tio n s in th e K x e n c o d in g (X K ) g e n e

2.7.6 MNS system 2.7.6.1 MNS antigens ■ T h e M N a n d S s U g e n e s d is p la y g e n e tic lin k a g e ■ T h e m o s t fre q u e n t h a p lo ty p e s a re N s a n d M s ■ M a n d N a n tig e n s a re fo u n d o n g ly c o p h o rin A ■ - 2 5 % o f th e p o p u la tio n is M + N - , 2 5 % is M - N + , a n d 5 0 % is M + N + ■ T h e S, s, a n d U a n tig e n s re s id e o n g ly c o p h o rin B ■ s a n d U a re h ig h fre q u e n c y a n tig e n s , p re s e n t in o v e r 9 8 % o f th e p o p u la tio n ■ S is p re s e n t in 5 0 % o f w h ite s a n d 3 0 % o f b la c k s ■ It m a y b e v e ry d iffic u lt to fin d c o m p a tib le b lo o d fo r ra re S - s - U - re c ip ie n ts , w h o a re u s u a lly b la c k

27.6.2 MNS antibodies ■ A n ti-M a n tib o d ie s a re n a tu ra lly o c c u rrin g , c o ld re a c tin g , Ig M a n tib o d ie s th a t a re c lin ic a lly in s ig n ific a n t ■ B e c a u s e an e p ito p e o n g ly c o p h o rin B h a s N like a n tig e n ic ity , a n ti-N a n tib o d ie s a re ra re ■ A n ti- N f a n tib o d ie s m a y b e fo rm e d in d ia ly s is p a tie n ts w h o w e re e x p o s e d to fo rm a ld e h y d e u s e d in c le a n in g d ia ly s is m a c h in e s a n d in d u c e d fo rm a tio n o f N f a n tig e n on R BC s

86

■ A n ti-S , a n ti-s , a n d a n ti-U a n tib o d ie s a re a c q u ire d fo llo w in g e x p o s u re a nd a re w a rm re a c tin g , c lin ic a lly s ig n ific a n t, IgG a n tib o d ie s

□ L a c k o f K x re s u lts in an X lin ke d re c e s s iv e d is o rd e r c a lle d M c L e o d p h e n o ty p e

t2.38 RBC antigen associations Phenotype or antibody Association Fy(a-b-)

Duffy antigen is the receptor for P v/Vax; Duffy- confers resistance to P vivax and is more common in blacks McLeod chronic granulomatous disease acanthocytosis late onset muscular dystrophy like syndrome, lab values: elevated creatine kinase anti-P1 paroxysmal cold hemoglobinuria, viral infections in children, syphilis anti-l Mycoplasma pneumoniae infection, lymphomas anti-i Epstein-Barr virus infection (infectious mononucleosis) anti-Nf Renal dialysis acquired B phenotypecolorectal carcinoma intestinal obstruction Gram- sepsis Rh null hereditary stomatocytosis (HS) Diego negative Diego is an epitope on band 3 protein; band 3 deficiency causes some cases of HS, acanthocytosis and hereditary elliptocytosis (HE) Gerbich negative Gerbich is an epitope on glycophorin C; a cause of HE (Leach phenotype)

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

2: Blood Banking/Transfusion Medicine

B lo o d g r o u p a n tig e n s > K e ll b lo o d g r o u p | L u th e ra n | H u m a n le u k o c y te a n tig e n s (H L A )

□ L a c k o f K x d e p re s s e s th e e x p re s s io n o f K ell a n tig e n s a nd re s u lts in s h o rte n e d red b lo o d c e ll s u rv iv a l □ R ed c e lls d is p la y a c a n th o c y to s is □ F re q u e n tly a s s o c ia te d w ith c o e x is tin g c h ro n ic g ra n u lo m a to u s d is e a s e (C G D ), a late o n s e t ty p e o f m u s c u la r d y s tro p h y (“ n e u ro a c a n th o c y to s is ” ), and re tin itis p ig m e n to s a □ T h e M c L e o d p h e n o ty p e is in c o m p a tib le w ith both n o rm a l a nd K ell null b lo o d (w h ich e x p re s s e s p le n ty o f K x a n tig e n )

2.7.7.1.1 S o m e hard to re m e m b e r a n tig e n /a n tib o d y fa c ts ■ N a tu ra lly o c c u rrin g a n tib o d ie s : I, i, A B O , Le, Lu, M, N, P ■ A n tig e n s th a t d is p la y d o s a g e : M N S , K idd , C /c, E le , D u ffy ■ A n tib o d ie s th a t re a c t a t ro o m te m p e ra tu re : a n ti-M , N, P1, L e a, a nd L e b ■ A n tib o d ie s th a t a re n e a rly a lw a y s c lin ic a lly in s ig n ific a n t: a n ti-M , N, P1, L e w is, L u th e ra n , a n d I

2.7.8 Lutheran 2.7.8.1 Lutheran antigens ■ L u b is a h ig h in c id e n c e a n tig e n , p re s e n t in 9 9 % o f th e p o p u la tio n ■ L u a is p re s e n t in 7% o f th e p o p u la tio n ■ T h u s , - 9 3 % o f p e o p le a re L u (a -b + ), a n d - 7 % a re L u(a + b+ ) ■ L u th e ra n a n tig e n e x p re s s io n is in c re a s e d o n th e s u rfa c e o f s ic k le c e lls

2.7.8.2 Lutheran antibodies ■ L u th e ra n a n tig e n ic ity is d e s tro y e d b y e n z y m e s a n d d e s tro y e d by 2 -M E and D T T ■ L u th e ra n a n tib o d ie s u s u a lly h a v e a n ti-L u a s p e c ific ity a n d a re u s u a lly c lin ic a lly in s ig n ific a n t c o ld re a c tin g Ig M a n tib o d ie s ■ M ixe d fie ld re a c tio n s a re a ty p ic a l fe a tu re

■ T h e 4 m o s t c o m m o n a n tib o d ie s in im m e d ia te H TR : a n ti-A , a n ti-K e ll, a n ti-J k a, and a n ti-F y a

2.7.9 Human leukocyte antigens (HLA)

■ T h e 4 m o s t c o m m o n a n tib o d ie s in d e la ye d H T R : a n ti-J k a, a n ti-E , a n ti-D , a n ti-C

2.7.9.1 HLA is encoded on the major histocompatibility complex (MHC), a group of loci on 6p

■ T h e 4 m o s t c o m m o n a n tib o d ie s in H D F N : a n ti-A B , a n ti-D , a n ti-K e ll, a n ti-C

■ T h e lo ci a re c lo s e ly lin ked a n d in h e rite d en b lo c fro m e a c h p a re n t

■ A n tig e n s th a t a re e n h a n c e d by e n z y m e s : A B , l/i, P1, Le, Rh, K idd

■ E a ch lo c u s h a s a m u ltitu d e o f p o s s ib le a lle le s

■ A n tig e n s th a t a re d e s tro y e d by e n z y m e s : M N S s , Fya, F yb, L u th e ra n , C h id o ■ M ixe d fie ld re a c tio n s a re e x p e c te d w ith : L u th e ra n , S id, A 3 (and p o s t b o n e m a rro w tra n s p la n t) ■ A n tib o d ie s th a t c o m m o n ly p ro d u c e in tra v a s c u la r h e m o ly s is : A B O , K id d , P (p a ro x y s m a l c o ld h e m o g lo b in u ria )

□ C la s s III g e n e s e n c o d e c o m p le m e n t p ro te in s □ A ls o e m b e d d e d in th e M H C re g io n a re ■ T h e H F E g e n e (h e m o c h ro m a to s is ) ■ T h e 2 1 -h y d ro x y la s e g e n e (c o n g e n ita l a d re n a l h y p e rp la s ia ) ■ T h e g e n e fo r tu m o r n e c ro s is fa c to r (T N F )

2.11.2 Kell antibodies ■ M o s t c o m m o n ly th e s e a re a n ti-K a n d a re a c q u ire d th ro u g h e x p o s u re ■ K ell a n tib o d ie s a re w a rm re a c tin g IgG a n tib o d ie s ■ K ell a n tig e n s a re u n a ffe c te d by e n z y m e s (n e ith e r e n h a n c e d n o r d e s tro y e d ) ■ K ell a n tig e n e x p re s s io n is d im in is h e d by a g e n ts th a t d is s o lv e s u lfh y d ry l b on d s; th u s, th e y a re v e ry s e n s itiv e to 2 -m e rc a p to e th a n o l (2-M E ), Z Z A P , a nd d ith io th rie to l (D T T ) ■ Kell a n tib o d ie s a re a s s o c ia te d w ith h e m o ly tic tra n s fu s io n re a c tio n s (H T R ) w ith e x tra v a s c u la r h e m o ly s is a nd h e m o ly tic d is e a s e o f th e fe tu s a nd n e w b o rn (H D F /N ) ■ K ell re la te d H D N is c h a ra c te riz e d by s u p p re s s io n o f e ry th ro p o ie s is

© A S C P 2018

■ T h e M H C c o n s is ts o f M H C c la s s I, c la s s II, a n d c la s s III genes

■ C la s s I g e n e s e n c o d e H L A c la s s I a n tig e n s th a t a re fo u n d on th e s u rfa c e s o f a ll c e lls □ C la s s I g e n e s a re d is trib u te d a m o n g 3 lo ci: H L A -A , H L A -B , a nd H L A -C □ C la ss I g e n e s e n c o d e a s in g le p o ly p e p tid e c h a in th a t is ■ E m b e d d e d a s a tra n s m e m b ra n e p ro te in ■ N o n c o v a le n tly a s s o c ia te d w ith a s in g le m o le c u le o f a 2 m ic ro g lo b u lin □ Y o u n g red b lo o d c e lls e x p re s s C la s s I a n tig e n s b u t lo s e th e m a s th e y a ge ■ T h e e x c e p tio n is a g ro u p o f a n tig e n s c a lle d B g (B e n n e tt G o o d s p e e d ) a n tig e n s , w h ic h a re s tro n g ly e x p re s s e d in m a tu re red c e lls ■ Bg a n tig e n s a re ra re ly th e c a u s e o f h e m o ly tic tra n s fu s io n re a c tio n s

ISBN 9 7 8 -08 9189-6678

87

2: Blood Banking/Transfusion Medicine B lo o d g r o u p a n tig e n s > H u m a n le u k o c y te a n tig e n s ( H L A ) T r a n s fu s io n c o m p lic a tio n s > S u s p e c te d tr a n s fu s io n r e a c tio n

■ T h e m a jo r B g a n tig e n s a re B g a (H L A -B 7 ), B g b (H L A -B 1 7 ), a n d B g c (H L A -A 2 8 /A 2 )

□ If th e re a c tio n c o n s is ts s o le ly o f a m ild a lle rg ic re a c tio n o r m ild c irc u la to ry o v e rlo a d , th e n th e tra n s fu s io n m a y be re s ta rte d a n d th e re a c tio n nee d n o t be re p o rte d to th e la b o ra to ry

■ P la te le ts h a v e g e n e ro u s a m o u n ts o f c la s s I a n tig e n s

□ If a tra n s fu s io n re a c tio n w o rk u p t2 .3 9 is in itia te d , th e n fu rth e r tra n s fu s io n s s h o u ld id e a lly a w a it its c o m p le tio n

■ C la s s II g e n e s e n c o d e H L A c la s s II a n tig e n s th a t a re e x p re s s e d o n a s u b s e t o f c e lls □ T h e s e a re fo u n d o n 3 c e ll ty p e s : B c e lls , m a c ro p h a g e s , a n d a c tiv a te d T c e lls □ C la s s II g e n e s a re fo u n d in 3 lo c i, te rm e d H L A -D R , H L A -D P , a n d H L A -D Q □ T h e c la s s II g e n e s e n c o d e 2 p o ly p e p tid e c h a in s , a a n d (3, e a c h w ith 2 d o m a in s s im ila r to th e im m u n o g lo b u lin lig h t c h a in s , in a d d itio n to a tra n s m e m b ra n e d o m a in

t2.39 Transfusion reaction workup clerical check inspection for hemolysis

□ C la s s II a n tig e n s a re e x p re s s e d on n e ith e r red c e lls n o r p la te le ts ■ H L A p la y s a s m a ll ro le in re d b lo o d c e ll c o m p a tib ility , b u t is p iv o ta l in □ P la te le t re fra c to rin e s s

recheck ABO

□ S o lid o rg a n c o m p a tib ility □ S o m e tra n s fu s io n re a c tio n s : fe b rile re a c tio n s , tra n s fu s io n re la te d a c u te lu n g in ju ry (T R A L I), a n d tra n s fu s io n a s s o c ia te d g ra ft v s h o s t d is e a s e (T A G V H D ) ■ S in c e e a c h M H C c o m p le x is c lo s e ly lin k e d a n d in h e rite d e n b lo c , e a c h p a re n ta l c h ro m o s o m e c a n b e th o u g h t o f a s a h a p lo ty p e . O n e h a p lo ty p e is in h e rite d fro m e a c h p a re n t □ T h e c h a n c e th a t 2 s ib lin g s a re H L A id e n tic a l is 2 5 % □ T h e c h a n c e o f h a v in g a n H L A id e n tic a l s ib lin g g o e s u p w ith th e n u m b e r o f s ib lin g s ; w ith 1 s ib lin g , th e c h a n c e is 2 5 % , w ith 2 it is - 4 5 % , a n d w ith 3 it is n e a rly 6 0 %

2.8

Transfusion complications

2.8.1 Suspected transfusion reaction 2.8.1.1 Clinical signs & symptoms ■ A tra n s fu s io n re a c tio n is s u s p e c te d w h e n e v e r th e p a tie n t e x p e rie n c e s u n u s u a l s ig n s o r s y m p to m s te m p o ra lly re la te d to tra n s fu s io n

2.8.1.2 W hat to do ■ F irs t, s to p th e tra n s fu s io n ■ L e a v e th e in tra v e n o u s lin e o p e n w ith a s a lin e in fu s io n ■ N o tify p h y s ic ia n

DAT

paperwork & bag check to detect obvious clerical errors; the most common cause of severe hemolytic transfusion reaction is clerical error check patient serum/plasma for hemolysis (visually) and check urine for hemoglobin (dipstick) blood drawn too late after the event (>8 hours) may be negative visually for significant hemolysis but may be icteric; in this event, a serum bilirubin will be elevated for up to 24-36 hours free serum myoglobin may give a false positive visual inspection; in this event there should be a clinical history of severe trauma if a urine dipstick is positive, then examine the urine microscopically for hematuria; in an intravascular hemolytic transfusion reaction, there is hemoglobinuria without hematuria; myoglobinuria is another cause of a false positive urine dipstick repeat the recipient ABO group determination on a posttransfusion sample perform a direct antiglobulin test (DAT) and compare results to a pretransfusion sample; in a hemolytic transfusion reaction, the DAT is usually positive due to the presence of antibody on transfused RBCs if the hemolysis was quite severe, the DAT may be negative due to acute destruction of transfused cells

■ T ra n s fu s io n s e rv ic e p h y s ic ia n re v ie w □ A p h y s ic ia n fro m th e tra n s fu s io n s e rv ic e m u s t re vie w th e w o rk u p a n d d e te rm in e th e n a tu re o f th e re a c tio n a n d w h e th e r a d d itio n a l te s tin g is re q u ire d □ If th e re a c tio n is d e e m e d to be n o n h e m o ly tic , th e n a d d itio n a l tra n s fu s io n s c a n be a d m in is te re d w ith c ro s s m a tc h c o m p a tib le b lo o d □ If th e re is e v id e n c e o f h e m o ly s is , th e n a d d itio n a l w o rk u p , in c lu d in g re p e a t A B O a n d R h ty p in g and te s ts s im ila r to th e p re tra n s fu s io n a n tib o d y p a n e l m u s t b e c a rrie d o u t to id e n tify th e re s p o n s ib le a n tib o d y □ T h e n a n tig e n n e g a tive , c ro s s m a tc h c o m p a tib le b lo o d c a n be g iv e n fo r tra n s fu s io n ■ N o tific a tio n □ W h e n a tra n s fu s io n fa ta lity o r tra n s fu s io n re la te d s e rio u s m o rb id ity o c c u rs , th is m u s t be re p o rte d as s o o n as p o s s ib le by te le p h o n e to th e F D A a nd w ith in 7 d a y s in w ritin g □ W h e n a tra n s fu s io n fa ta lity o r tra n s fu s io n re la te d s e rio u s m o rb id ity o c c u rs th a t a p p e a rs to be re la te d to a s in g le d o n o r, th e n th e c o lle c tin g fa c ility m u s t be n o tifie d im m e d ia te ly , fo llo w e d by n o tific a tio n in w ritin g

□ T h e p h y s ic ia n m u s t e v a lu a te th e p a tie n t a nd d e te rm in e w h e th e r to p ro c e e d w ith a tra n s fu s io n re a c tio n w o rk u p 88

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2: Blood Banking/Transfusion Medicine

Transfusion complications>Suspected transfusion reaction | Types of transfusion complications □ W h e n a tra n s fu s io n re la te d in fe c tio n is c o n firm e d o r c a n n o t be e x c lu d e d , th e n th e id e n tity o f th e d o n o r u n its m u s t be c o n v e y e d to th e c o lle c tin g fa c ility , a n y o th e r re c ip ie n ts o f b lo o d c o m p o n e n ts fro m th e d o n o r, a nd e a c h re c ip ie n t’s p h y s ic ia n ■ Lastly, a w ritte n re p o rt s h o u ld be e n te re d into th e c h a rt

2.8.2 Types of transfusion complications 2.8.2.1 Febrile, nonhemolytic transfusion reactions (FNHTRs)

t2.40 Approxim ate risk of transfusion com plications Complication

Risk

HIV HTLV1 HCV HBV EBV CMV

1/2.3 million 1/2.9 million 1/1.5 million 1/300,000 unknown, rare unknown, rare given leukoreduced cellular blood products ABO mismatch: 1/6,000-1/30,000 fatal reactions: 1/100,000-1/600,000 1/5,000-1/190,000 1/3,000 allergic:1/100 anaphylactic: 1/20,000-1/50,000 1/75,000 1/500,000 1/100

ABO-Rh incompatibility

■ M o s t c o m m o n ty p e o f tra n s fu s io n re a c tio n ■ -1 in 2 0 0 tra n s fu s io n s ■ D e fin e d a s an in c re a s e in te m p e ra tu re o f 1°C o r 2° F w ith no o th e r e x p la n a tio n ■ M e d ia te d by c y to k in e s re le a s e d by w h ite b lo o d c e lls in th e s to re d u n it o f b lo o d ■ In c id e n c e ca n be re d u c e d by p re s to ra g e le u k o re d u c tio n ■ T re a tm e n t: a n tip y re tic s a n d /o r tra n s fu s io n w ith le u k o c y te re d u c e d p ro d u c ts

TRALI DHTR allergic reaction septic reactions with platelets septic reactions with RBCs febrile reaction

■ S e c o n d m o s t c o m m o n tra n s fu s io n re a c tio n

□ A c u te in tra v a s c u la r re a c tio n s u s u a lly re la te d to A B O in c o m p a tib ility a nd m o s t o fte n re s u lt fro m c le ric a l e rror. R a re ly, n o n -A B O a n tib o d ie s , n o to rio u s ly K id d , m a y be re s p o n s ib le fo r a c u te in tra v a s c u la r h e m o ly tic re a c tio n s

■ R a n g e fro m m ild (u rtic a ria /h iv e s /p ru ritu s ) to se v e re (a n a p h y la x is )

□ A c u te e x tra v a s c u la r re a c tio n s a re u s u a lly n o n -A B O re la te d

2.8.2.2 Allergic transfusion reactions

■ N o t all h e m o ly s is is im m u n e m e d ia te d

■ T h e in c id e n c e is ~1 in 3 0 0 tra n s fu s io n s ■ M e d ia te d b y a lle rg ic (Ig E m e d ia te d ) re a c tio n to p la s m a p ro te in s □ T h e Ig A d e fic ie n t re c ip ie n t m a y h ave a re a c tio n to IgA in d o n o r p la s m a □ Ig A d e fic ie n c y a ffe c ts 1 in 7 0 0 re c ip ie n ts , b u t s e v e re re a c tio n s in a m in o rity ■ T h e re a re no fin d in g s o n th e tra n s fu s io n re a c tio n w o rk u p ■ T re a tm e n t □ F o r m ild re a c tio n s , tre a tm e n t is s y m p to m a tic ; re a c tio n s d o n o t o fte n re c u r

□ O th e r c a u s e s in c lu d e p ro lo n g e d s to ra g e , im p ro p e r s to ra g e , m a lfu n c tio n o f m e c h a n ic a l in fu s io n d e v ic e s o r b lo o d w a rm e rs , n e e d le s o f to o s m a ll c a lib e r, o r th e a d d itio n o f a n y th in g o th e r th a n n o rm a l s a lin e to th e in fu s io n □ B a c te ria l c o n ta m in a tio n , p a rtic u la rly w ith C lo s trid iu m spp, m a y c a u s e h e m o ly s is □ L astly, th e d o n o r m a y have a n in trin s ic re d c e ll d e fe c t c a u s in g h e m o ly s is ■ C lin ic a l p re s e n ta tio n o f a cu te in tra v a s c u la r h e m o ly s is

■ T ra n s fu s io n m ay be re s ta rte d fo r lo c a liz e d m ild re a c tio n s □ P a tie n ts w ith re c u rre n t m ild re a c tio n s m a y be p re tre a te d w ith a n tih is ta m in e s

□ A b ru p t o n s e t o f fever, c h ills, b a c k p a in , p a in a t in fu s io n site , h y p o te n s io n , D IC ■ C lin ic a l p re s e n ta tio n o f e x tra v a s c u la r h e m o ly s is □ O fte n a s y m p to m a tic

□ F o r a n a p h y la x is , p a re n te ra l e p in e p h rin e is in d ica te d □ Ig A d e fic ie n t p a tie n ts s u ffe rin g a n a p h y la x is s h o u ld re c e iv e Ig A d e fic ie n t u nits. A lte rn a tiv e ly , w a s h e d u n its m a y be p ro v id e d

2.8.2.3 Acute hemolytic transfusion reactions ■ T h e in c id e n c e is b e tw e e n 1 in 6 ,0 0 0 a nd 1 in 3 0 ,0 0 0 tra n s fu s io n s t2 .4 0

□ M a y p re s e n t w ith pallor, h y p e rb iliru b in e m ia , o r a n e m ia ■ L a b o ra to ry fin d in g s □ P o s itiv e D A T (b o th intra a n d e x tra v a s c u la r h e m o ly s is ), p in k s e ru m (in tra v a s c u la r h e m o ly s is ), h y p e rb ili ru b in e m ia (e x tra v a s c u la r h e m o ly s is ), h e m o g lo b in u ria (in tra v a s c u la r h e m o lysis), c o a g u la tio n a b n o rm a litie s (in tra v a s c u la r h e m o lysis), s c h is to c y te s (in tra v a s c u la r h e m o ly s is ), a n d /o r s p h e ro c y te s (e x tra v a s c u la r h e m o ly s is )

■ M a y be in tra v a s c u la r o r e x tra v a s c u la r © A S C P 2018

ISBN 978-08 9189-6678

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2: Blood Banking/Transfusion Medicine

Transfusion complications>Types of transfusion complications ■ T re a tm e n t b e g in s w ith s to p p in g th e tra n s fu s io n , le a v in g th e lin e o p e n w ith a s a lin e in fu s io n ; s u p p o rt th e p a tie n t h e m o d y n a m ic a lly ■ N o te th a t fa ta litie s re la te d to b lo o d tra n s fu s io n m u s t be re p o rte d to th e F D A w ith in 2 4 h o u rs b y p h o n e a n d in w ritin g w ith in 7 d a y s

2.8.2.4 Delayed hem olytic transfusion reactions (DHTR) & delayed serologic transfusion reactions (DSTR) ■ D H T R re fe rs to h e m o ly s is o f tra n s fu s e d b lo o d o c c u rrin g d a y s to w e e k s a fte r tra n s fu s io n ■ D S T R is a n e w ly d e te c ta b le a llo a n tib o d y fo llo w in g tra n s fu s io n , w ith o u t h e m o ly s is ■ D S T R is m o re c o m m o n th a n D H T R b y ~3:1 ■ O v e ra ll in c id e n c e o f D H T R /D S T R is ~1 in 1 5 0 0 tra n s fu s io n s ■ F in d in g s : p o s itiv e D A T (o fte n m ix e d fie ld ), h y p e rb ili ru b in e m ia , m ic ro s p h e ro c y te s □ N e w a n tib o d y s c re e n /p a n e l w ill id e n tify c a u s a tiv e a n tib o d y ■ M o s t c o m m o n ly im p lic a te d a n tig e n s a re K id d , E, c, K ell, a n d D u ffy □ K id d re la te d D H T R ta k e s fo rm o f s e v e re in tra v a s c u la r h e m o ly s is ■ O n s e t is ty p ic a lly b e tw e e n 5 a n d 14 d a y s a fte r tra n s fu s io n □ P re s e n ta tio n v a rie s fro m s y m p to m a tic a n e m ia s e ro lo g ic fin d in g s o n ly □ F in d in g s in c lu d e a p o s itiv e D A T (o fte n w ith a m ixe d fie ld re a c tio n ), w ith o r w ith o u t e v id e n c e o f h e m o ly s is ■ U s u a lly n o tre a tm e n t is in d ic a te d e x c e p t to id e n tify th e re s p o n s ib le a n tib o d y a n d a v o id fu rth e r e x p o s u re to it

2.8.2.5 Bacterial contam ination (transfusion transmitted sepsis) ■ M o rta lity ra te 2 5 % w ith p la te le t tra n s m itte d s e p s is and 7 0 % w ith re d c e ll tra n s m itte d s e p s is ■ B y fa r th e m o s t c o m m o n tra n s fu s io n tra n s m itte d in fe c tio n ■ In c id e n c e o f c o n ta m in a te d u n its is b e tw e e n 1 /1 0 0 0 a n d 1 /4 0 0 0 ■ In c id e n c e o f tra n s fu s io n tra n s m itte d s e p s is is 1 /2 5 ,0 0 0 p la te le t tra n s fu s io n s a n d 1 /2 5 0 ,0 0 0 red c e ll tra n s fu s io n s ■ B a c te ria o rig in a te fro m d o n o r s k in ; le s s c o m m o n ly d o n o r b lo o d (tra n s ie n t b a c te re m ia ) ■ In p la te le ts , w h ic h a re s to re d a t ro o m te m p e ra tu re , s ta p h y lo c o c c a l s p e c ie s a re fre q u e n tly im p lic a te d

■ In red ce lls, im p lic a te d o rg a n is m s a re p s y c h ro p h ilic G r a m - b a c illi, e s p e c ia lly Y e rsin ia e n te ro c o litic a (m o s t c o m m o n ), S e rra tia liq u ifa c ie n s , C itro b a c te r a n d P s e u d o m o n a s m C lin ic a l p re s e n ta tio n

□ S u s p e c t w h e n e v e r th e tra n s fu s io n re c ip ie n t e x p e rie n c e s h ig h fe v e r a n d s h o c k □ H e m o ly tic re a c tio n is a ls o c o n s id e re d in th is s c e n a rio □ T h e b lo o d p ro d u c t m a y be v is ib ly d is c o lo re d , h e m o ly z e d , o r c o n ta in c lo ts □ R e c ip ie n t s e ru m a nd u rin e o fte n c o n ta in s fre e h e m o g lo b in , b u t th e D A T is n e g a tiv e ■ T re a tm e n t □ S to p th e tra n s fu s io n □ B roa d s p e c tru m a n tib io tic s a nd h e m o d y n a m ic s u p p o rt ■ E v a lu a tio n □ P e rfo rm G ra m sta in on th e u n it o f b lo o d □ C u ltu re b o th th e u n it and th e re c ip ie n t b lo o d □ N o tify b lo o d s u p p lie r ■ P re v e n tio n □ P ro p e r s c re e n in g a n d a s e p tic te c h n iq u e a t th e tim e o f d o n a tio n □ D is c a rd in g th e firs t 1 5 -3 0 m L o f b lo o d d ra w n into a d iv e rs io n p o u c h □ M e th o d s to d e te c t b a c te ria l c o n ta m in a tio n ■ T h e A A B B re q u ire s m e th o d s to d e te c t b a c te ria l c o n ta m in a tio n in p la te le ts

2.8.2.6

Transfusion associated graft vs host disease

■ H ig h ly (> 9 0 % ) fa ta l c o m p lic a tio n o f tra n s fu s io n o f c e llu la r b lo o d p ro d u c ts ■ M e c h a n is m □ Im m u n o c o m p e te n t T ly m p h o c y te s fro m th e d o n o r e n g ra ft in im m u n o c o m p ro m is e d re c ip ie n t a n d m o u n t re a c tio n to re c ip ie n t tis s u e □ C a n a ffe c t im m u n o c o m p e te n t re c ip ie n t if d o n o r is H L A s im ila r ■ P re s e n ts w ith te tra d o f □ D e rm a titis (p e ria u ric u la r, p a lm a r a nd p la n ta r e ry th ro d e rm a ) □ E n te ro c o litis (w a te ry d ia rrh e a ) □ H e p a titis (a m in o tra n s fe ra s e e le v a tio n ) □ B o n e m a rro w s u p p re s s io n (p a n c y to p e n ia ) ■ P re ve n tio n □ Irra d ia tio n o f c e llu la r b lo o d p ro d u c ts fo r re c ip ie n ts at risk ■ T h e re is no e ffe c tiv e tre a tm e n t a nd m o s t c a s e s a re fa ta l

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2: Blood Banking/Transfusion Medicine

Transfusion complications>Types of transfusion complications ■ E le v a te d p u lm o n a ry c a p illa ry w e d g e p re s s u re

2 .8.2J Transfusion associated acute lung injury (TRALI) ■ C u rre n tly th e m o s t c o m m o n c a u s e o f tra n s fu s io n re la te d fa ta lity

■ A n a p h y la x is ■ W h e e z in g a n d u p p e r a irw a y e d e m a

■ N o n c a rd ia c p u lm o n a ry e d e m a fo llo w in g tra n s fu s io n o f p la s m a c o n ta in in g b lo o d p ro d u c ts ■ In c id e n c e is 1 in 5 0 0 0 tra n s fu s io n s

■ U s u a lly re s p o n d s ra p id ly to e p in e p h rin e ■ U s u a lly la c k s p u lm o n a ry in filtra te s ■ T ra n s fu s io n re la te d s e p s is

■ C a u s e s -1 5 % o f fa ta l tra n s fu s io n re a c tio n s , w ith m o rta lity 5 -1 0 % o v e ra ll

■ C u ltu re p o s itiv e

■ T h e re is no re a d ily a v a ila b le te s t th a t c o n firm s th e d ia g n o s is o f T R A L I □ C a n be c o n firm e d by fin d in g a n tig ra n u lo c y te , a n ti-H L A c la s s I, o r a n ti-H L A c la s s II a n tib o d ie s in th e d o n o r p la s m a

■ H e m o d y n a m ic fe a tu re s p re d o m in a te o v e r re s p ira to ry ■ H e m o ly tic tra n s fu s io n re a c tio n ■ P o s itiv e D A T a nd h e m o ly s is ■ A c u te re s p ira to ry d is tre s s s y n d ro m e (A R D S ) •

■ N o u n iv e rs a lly a c c e p te d d e fin itio n ; c rite ria h ave b e e n p ro p o s e d t2.41

D iffic u lt to d is tin g u is h

• T e m p o ra l fe a tu re s m o s t im p o rta n t ■ T re a tm e n t

t2.41 Criteria for the diagnosis of TRALI acute onset during or within 6 hours of transfusion__________________________ hypoxemia (eg, Pa02:Fi02 ratio 7 5 0 0 , if c o u n t in c re m e n t is < 7 5 0 0 th is s u g g e s t re fra c to rin e s s Cl = increment (pi) x body surface area (m2) # platelets transfused x 1011 □ T im in g o f th e p o s ttra n s fu s io n c o u n t: w ith in 1 0 -6 0 m in u te s a fte r tra n s fu s io n

■ p 24 a n tig e n te s tin g no lo n g e r re q u ire d > H T LV l/ll □ R e a d ily tra n s m is s ib le b y tra n s fu s io n □ E n d e m ic in J a p a n a n d C a rib b e a n □ C a u s e s late s e q u e la e (a d u lt T c e ll le u k e m ia / ly m p h o m a a n d H T L V a s s o c ia te d m y e lo p a th y (tro p ic a l s p a s tic p a ra p a re s is ) □ S c re e n e d fo r by te s tin g fo r H T LV l/ll a n tib o d ie s ■ C y to m e g a lo v iru s (C M V ) □ T ra n s m itte d by m o n o n u c le a r w h ite b lo o d c e lls □ Im p o rta n t to re d u c e th e tra n s m is s io n o f C M V in C M V - tra n s p la n t c a n d id a te s /re c ip ie n ts a n d lo w b irth w e ig h t n e o n a te s □ P re v e n tio n b y a d m in is te rin g C M V - b lo o d p ro d u c ts , w h e n a v a ila b le . If n o t a v a ila b le , th e n le u k o re d u c tio n is g e n e ra lly c o n s id e re d an a c c e p ta b le a lte rn a tiv e ■ W e s t N ile v iru s (W N V ) □ M o s t in fe c tio n s w ith W N V a re a s y m p to m a tic o r m ild

■ P re v e n tio n □ M in im iz e tra n s fu s io n s □ M in im iz e d o n o r e x p o s u re s (u se p h e re s is p ro d u c ts ) □ L e u k o re d u c tio n filtra tio n

□ S e v e re in fe c tio n in ~1 in 150 c a s e s ; ~1 in 1 0 0 0 c a s e s fa ta l □ V ire m ia p re c e d e s s y m p to m s by s e v e ra l w e e k s □ P re v e n tio n : N A T te s tin g is re c o m m e n d e d d u rin g o u tb re a k s , a n d d o n o rs a re d e fe rre d if th e y h a ve had s y m p to m s c o n s is te n t w ith W N V

Infections t2 .4 0

■ B a b e s io s is

■ H e p a titis C v iru s (H C V ) □ H ig h ly tra n s m is s ib le b y tra n s fu s io n

□ C a n be tra n s m itte d by tra n s fu s io n

□ C u rre n tly s c re e n e d fo r w ith h is to ry a n d lab te s tin g , in c lu d in g

□ C u rre n tly s c re e n e d fo r o n ly by h is to ry

■ T e s t fo r a n ti-H C V •

P o s itiv e a n ti-H C V is c o n firm e d b y R IB A

■ P C R fo r H C V R N A (H C V N A T ) ■ H e p a titis B v iru s (H B V ) □ H ig h ly tra n s m is s ib le b y tra n s fu s io n □ C u rre n tly s c re e n e d fo r b y h is to ry a n d la b te s tin g , in c lu d in g ■ A n ti-H B c ■ H B sA g ■ HBV NAT

92

□ B oth v iru s e s s p re a d by fe c a l o ra l ro u te □ T ra n s m is s io n b y tra n s fu s io n is ra re

□ S e c o n d a ry p la te le t re fra c to rin e s s is m o s t c o m m o n

2.8.2.10

■ H e p a titis A v iru s (H A V ) a n d H e p a titis E v iru s (H E V )

□ In e n d e m ic a re a s , th e ris k o f tra n s fu s io n tra n s m itte d b a b e s io s is is -1 /1 0 0 0 tra n s fu s io n s ■ S y p h ilis □ T re p o n e m a p a llid u m is tra n s m itte d by tra n s fu s io n o n ly v e ry ra re ly □ N o n e w tra n s fu s io n tra n s m itte d c a s e s h ave bee n re p o rte d in d e c a d e s ■ C h a g a s d is e a s e (T ry p a n o s o m a c ru z i) □ C h a g a s d is e a s e ca n be tra n s m itte d by tra n s fu s io n □ It is p re v a le n t in C e n tra l a n d S o u th A m e ric a a n d in im m ig ra n t rich p o p u la tio n s in N o rth A m e ric a □ In M e x ic o , n e a rly 1 in 100 d o n o rs a re p o s itiv e fo r C h a g a s d is e a s e

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

2: Blood Banking/Transfusion Medicine

Transfusion complications>Types of transfusion complications | Records ■ C re u tz fe ld t-J a k o b d is e a s e (C J D ) □ C J D h a s n e v e r b e e n d o c u m e n te d to b e tra n s m itte d by tra n s fu s io n □ L o o k b a c k s tu d ie s fro m 199 5 o f 65 C J D d o n o rs to 8 2 6 tra n s fu s e d re c ip ie n ts w ith 3 9 3 4 p e rs o n -y e a rs o f fo llo w up p e rfo rm e d by th e A m e ric a n R ed C ro s s , h a ve n e v e r d o c u m e n te d a s in g le c a s e o f tra n s fu s io n tra n s m itte d C J D □ H o w eve r, v a ria n t (v C J D ) ca n be tra n s m itte d by tra n s fu s io n . In th e U K , th e re h as b e e n 3 c a s e s o f s y m p to m a tic a n d 1 a s y m p to m a tic c a s e o f tra n s fu s io n tra n s m itte d v C J D □ In th e U n ite d S ta te s , in d iv id u a ls a t ris k fo r v C J D by v irtu e o f h is to ry (th o s e w h o h ave tra v e le d to o r lived in B S E e n d e m ic a re a s ) a re e x c lu d e d fro m d o n a tio n , a s a re th o s e w h o h ave re c e iv e d d u ra l tra n s p la n ts , p itu ita ry d e riv e d g ro w th h o rm o n e o r b o v in e in su lin . R e la tiv e s o f p a tie n ts w ith c la s s ic a l C J D a re d e fe rre d

□ P re w a rm in g re c o m m e n d e d fo r m a s s iv e tra n s fu s io n ; h o w e ve r, A A B B S ta n d a rd s re q u ire s th a t th e te m p e ra tu re n o t e x c e e d 4 2 °C ■ Iron o v e rlo a d □ C h ro n ic a lly tra n s fu s e d p a tie n ts m a y d e v e lo p iro n o v e rlo a d □ E a ch u n it o f red c e lls c o n ta in s - 2 0 0 m g o f iro n □ W h e n th e w h o le b o d y iro n b u rd e n re a c h e s - 5 0 0 m g / kg, c lin ic a l iro n o v e rlo a d c a n d e v e lo p , a ffe c tin g th e h e a rt a n d liv e r fu n c tio n p rim a rily □ Iro n c h e la tio n w ith p a re n te ra l d e fe ro x a m in e o r o ra l d e fe ra s iro x ca n be h e lp fu l to p re v e n t th is c o m p lic a tio n ■ T ra n s fu s io n re la te d im m u n o m o d u la tio n (T R IM ) □ T ra n s fu s io n o f c e llu la r b lo o d p ro d u c ts c a u s e s im m u n o s u p p re s s io n ■ H o w eve r, in v e s tig a tio n is o n g o in g in to th e q u e s tio n o f w h e th e r tra n s fu s e d p a tie n ts h a v e an in c re a s e d ris k o f in fe c tio n o r m a lig n a n c y re c u rre n c e

2.8.2.11 Transfusion associated metabolic derangements ■ T ra n s fu s io n a s s o c ia te d c irc u la to ry o v e rlo a d (T A C O ) □ O fte n m is ta k e n fo r a p o s s ib le h e m o ly tic tra n s fu s io n re a c tio n o r tra n s fu s io n re la te d a c u te lun g in ju ry (T R A L I) □ T A C O is u s u a lly a s s o c ia te d w ith h is to ry o f CH F, e le v a te d BNP, a n d e le v a te d p u lm o n a ry c a p illa ry w e d g e p re s s u re □ C o m m o n in n e o n a te s a n d e ld e rly re c ip ie n ts a nd m a y be p re v e n te d by s lo w o r d iu re tic a s s is te d tra n s fu s io n ■ H y p o c a lc e m ia □ W ith la rg e v o lu m e s o f p ro d u c ts , s u ffic ie n t c itra te ca n be in fu s e d to c a u s e h y p o c a lc e m ia ■ H y p e rk a le m ia □ S to re d c e llu la r b lo o d p ro d u c ts u s u a lly h a ve e x c e s s e x tra c e llu la r p o ta s s iu m □ R is k h ig h e s t fo r n e o n a te s a n d th o s e w ith im p a ire d re na l fu n c tio n ■ H y p o k a le m ia □ S o m e p a tie n ts m a y e x p e rie n c e h y p o k a le m ia d u e to tra n s fu s io n o f c e lls th a t a re in tra c e llu la rly p o ta s s iu m d e p le te d , le a d in g to tra n s c e llu la r s h ifts o f s e ru m p o ta s s iu m ■ H y p o th e rm ia □ W ith la rg e v o lu m e s o f u n w a rm e d p ro d u c ts , c o re b o d y te m p e ra tu re ca n be re d u c e d □ E x a c e rb a te s th e e ffe c ts o f h y p o c a lc e m ia and h y p e rk a le m ia

© A S C P 2018

2.8.3 Records t2.42 ■ A ll d o n o r a n d u n it re c o rd s m u s t be re ta in e d fo r a m in im u m o f 10 y e a rs . T h e e x c e p tio n is re c o rd s p e rta in in g to p e rm a n e n tly d e fe rre d d o n o rs , w h ic h m u s t be m a in ta in e d in d e fin ite ly . F o r p a tie n t (re c ip ie n t) re c o rd s , re q u ire d re te n tio n tim e s a re 5 o r 10 y e a rs , d e p e n d in g on th e n a tu re o f th e re c o rd . E x c e p tio n s a re re c o rd s p e rta in in g to d iffic u lty ty p in g , c lin ic a lly s ig n ific a n t a n tib o d ie s , a d v e rs e re a c tio n s , s p e c ia l tra n s fu s io n re q u ire m e n ts , a n d in v e s tig a tio n /re s o lu tio n o f d is c re p a n c ie s , w h ic h m u s t be m a in ta in e d in d e fin ite ly .

t2.42 Retention of patient records Patient records quality control documents quality management reviews proficiency testing instrument quality control/maintenance including irradiation dose delivery & control systems for patient testing retyping of donor units upon receipt inspection of blood and critical materials annual review of procedures & discontinued procedures patient pretransfusion testing results transfusion records immediate evaluation/interpretation of transfusion reactions therapeutic apheresis/phlebotomy records final unit disposition employee signatures, initials and identification codes transfusion problems, including transfusion reactions, unexpected antibodies & special transfusion requirements

ISBN 978-08 9189-6678

Retention period 5 years 5 years 5 years 5 years 5 years 5 years 5 years 10 years 10 years 10 years 10 years 10 years 10 years 10 years

93

2: Blood Banking/Transfusion Medicine

Transfusion com plications>R ecords | Blood bank regulatory authority S elected readings>B ooks | O ther references

2.8.3.1 Blood bank regulatory authority ■ T h e U S F o o d a n d D ru g A d m in is tra tio n (F D A ) C e n te r fo r B io lo g ie s E v a lu a tio n a n d R e s e a rc h h a s a u th o rity to re g u la te b lo o d c o lle c tio n a n d b lo o d p ro c e s s in g . F D A g u id a n c e a n d m a n d a te s m a y b e fo u n d a t w w w .fd a .g o v . A A B B a c c re d ita tio n is v o lu n ta ry .

2.9

Selected readings

2.9.1 Books ISB N 9 7 8 0 8 0 3 6 2 6 8 2 9 H a rm e n in g D [2012] M odern Blood Banking & Transfusion Practices, 6e. FA D avis IS B N 9 7 8 0 4 7 0 9 8 6 85 1 Klein H G , A n ste e D [2014] M ollison’s Blood Transfusion in Clinical Medicine, 12e. W ile y-B la ckw e ll IS B N 9 7 8 1 563959271 M cK enna D H, ed [2016] Standards for Blood B anks and Transfusion Services, 30e. A A B B ISB N 9 7 8 1 5 6 3 9 5 2 4 3 2 P e trid e s M [2007] Practical Guide to Transfusion Medicine, 2e. A A B B IS B N 9 7 8 1 5 6 3 9 5 9 4 7 9 Fung M K, E d e rA F , S p ita ln ik SL, W e s th o ff C M eds. [2 0 1 7 ] Technical M anual, 19e. A A B B

Other references A A B B [2012] A sso cia tio n B ulletin # 1 2 -0 4 Recom m endations to address residual risk o f bacterial contamination o f platelets. A v a ila b le at h ttp ://w w w .a a b b .o rg /p ro g ra m s /p u b lic a tio n s /b u lle tin s/ P a g e s /a b 1 2 -0 4 .aspx A A B B [2 0 1 3 ] Circular o f Information for the Use o f Hum an Blood an d Blood Components. A va ila b le at h ttp s://w w w .a a b b .o rg /tm /co i/ D ocu m e n ts/co i 1113. p d f A A B B . [2014] Association Bulletin #14-02. TRALI risk mitigation for plasm a an d whole blood for allogenic transfusion. A v a ilable at h ttp s://w w w .a a b b .o rg /p ro g ra m s /p u b lic a tio n s /b u lle tin s /D o c u m e n ts / a b 1 4 -0 2 .p d f C o d e o f Federal R e gulatio ns [2010] Title 21 C F R Part 640— Additional standards for hum an blood and blood products. US G o v e rn m e n t P rinting O ffice U S F ood and D rug A d m in is tra tio n [2015] Fatalities reported to FDA following blood collection and transfusion: annual sum m ary for fiscal y e a r 2015. C B E R Office o f Communication, Outreach, and Developm ent. A va ila b le at https://w w w .fd a .g o v/d o w n lo a d s/ B io lo g icsB Io o d V a ccin e s/S a fe tyA va ila b ility/R e p o rta P ro b le m / T ra n s fu s io n D o n a tio n F a ta litie s /U C M 5 1 8 1 4 8 .pdf U S Fo o d and D rug A d m in istra tio n [2016] Draft guidance for industry: bacterial risk control strategies for blood collection establishments and transfusion services to enhance the safety and availability o f platelets for transfusion. C B E R O ffice o f C o m m u n ica tio n , O u tre a ch , and D e ve lo p m e n t P M ID 2 8 4 4 4 6 8 7 C ro w d e r LA, S c h o n b e rg e r LB, D odd RY, Steele W R [2017] C re u tzfe ld t-Ja ko b d ise a se loo kb a ck study: 21 years o f su rve illa n c e fo r tra n s fu s io n tra n sm issio n risk. Transfusion 5 7 :1 8 7 5 -8

94

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

Chapter 3

M icro b io lo g y 3.1 Clinical syndromes & causative agents........................................96

3.4.11

3.1.1 Urinary tract infection (U T I)............................................................. 96

3.5

3.1.2 Infectious diarrhea............................................................................97

3.5.1 Specimen processing.........................................................................146

3.1.3 Pneumonia.........................................................................................97

3.5.2 Gram positive c o c c i........................................................................... 150

3.1.4 Infective endocarditis (IE)................................................................. 98

3.5.3 Gram positive rods............................................................................. 156

3.1.5 Meningitis...........................................................................................99

3.5.4 Gram negative c o c c i......................................................................... 162

3.1.6 Prosthetic joint infections.................................................................99

3.5.5 Gram negative ro d s...........................................................................164

3.1.7 Vectors ............................................................................................102

3.5.6 Anaerobes..........................................................................................176

3.2

Virology...........................................................................................102

3.5.7 Spirochetes........................................................................................180

3.2.1 Viral structure & classification....................................................... 102

3.5.8 C hlam ydia..........................................................................................182

3.2.2 Laboratory evaluation...................................................................... 103

3.5.9 Rickettsia............................................................................................ 184

3.2.3 DNA viruses..................................................................................... 103

3.5.10 Coxiella burnetii (formerly a Rickettsia s p p ) ................................184

3.2.4 Positive sense RNA viruses............................................................110

3.5.11 Ehrlichia & anaplasma.....................................................................185

3.2.5 Negative sense RNA viruses..........................................................113

3.5.12 Bartonella: pleomorphic, Gram negativebacilli..............................185

3.2.6 Reoviridae: double stranded RNA; no envelope..........................115

3.5.13 Mycoplasma......................................................................................185

3.2.7 Other viruses................................................................................... 116

3.6

3.2.8 Vaccines............................................................................................116

3.6.1 Background........................................................................................186

3.2.9 Implicated viruses by disease states............................................. 116

3.6.2 Laboratory evaluation.........................................................................186

3.3

3.6.3 Mycobacterium tuberculosis complex............................................... 188

Parasitology.....................................................................................116

3.3.1 Laboratory methods.......................................................................... 116 3.3.2 Protozoa..............................................................................................117 3.3.3 Helminths........................................................................................... 124 3.3.4 Additional pearls of parasitology................................................... 128 3.4 Mycology........................................................................................... 128 3.4.1 Fungal structure................................................................................ 128 3.4.2 Diagnostic techniques......................................................................129

Notes about antifungal agents.......................................................146 Bacteriology........................................................................................ 146

M ycobacteria...................................................................................... 186

3.6.4 Nontuberculous Mycobacteria: categorized based on Runyonclassification..............................................................190 3.6.5 Mycobacterium le p ra e .......................................................................192 3.6.6 Mycobacteria ulcerans .....................................................................192 3.7

Selected re ad in g s............................................................................. 192

3.7.1 Books.................................................................................................. 192 3.7.2 Online references............................................................................... 193

3.4.3 Yeasts................................................................................................. 130 3.4.4 Dimorphic fu n g i................................................................................ 133 3.4.5 Dermatophytes & other superficial mycoses................................. 137 3.4.6 Dematiaceous molds & other subcutaneous infections.................138 3.4.7 Hyaline molds.....................................................................................140 3.4.8 Zygomycetes.....................................................................................143 3.4.9 Pneumocystis jiro v e c i......................................................................144 3.4.10 Prototheca.....................................................................................145

© A S C P 2018

ISBN 978-08 9 1 8 9 -6 6 7 8

95

3: Microbiology

Clinical syndromes & causative agents>Urinary tract infection (UTI) Infectious diarrhea

3.1 Clinical syndrom es & causative agents

3.1.1.2

Laboratory evaluation

3.1.1.2.1 S u rro g a te m a rk e rs fo r UTI

3.1.1 Urinary tract infection (UTI)

■ U rin e d ip s tic k h e m o g lo b in

3.1.1.1 Characteristics

■ U rin e d ip s tic k le u k o c y te e s te ra s e

■ E n c o m p a s s e s a s y m p to m a tic b a c te riu ria , u re th ritis , c y s titis , a n d p y e lo n e p h ritis ■ C o m p lic a te d v s u n c o m p lic a te d □ U n c o m p lic a te d U T I u s u a lly u s e d to re fe r to c y s titis in e s s e n tia lly h e a lth y y o u n g (n o n p re g n a n t) w o m e n w ith o u t a n a to m ic g e n ito u rin a ry a n o m a lie s □ C o m p lic a te d U T I is o n e a ris in g w ith p re g n a n c y , d ia b e te s , s to n e , s tru c tu ra l g e n ito u rin a ry a n o m a lie s , s p in a l in ju ry , a s w e ll a s in c h ild re n a n d m e n ■ B a c te ria l c o lo n iz a tio n o f u rin e w ith o u t c lin ic a l s y m p to m s (a s y m p to m a tic b a c te riu ria )

■ U rin e d ip s tic k n itrite ; re q u ire s an o rg a n is m c a p a b le o f re d u c in g n itra te , n e g a tiv e w ith S ta p h y lo c o c c u s s a p ro p h y tic u s a n d e n te ro c o c c i ■ M ic ro s c o p ic d e te c tio n o f h e m a tu ria , p y u ria , o r b a c te riu ria ■ N o te th a t e o s in o p h ilu ria is s u g g e s tiv e o f a c u te in te rs titia l n e p h ritis a n d n o t UTI

3.1.1.2.2 S p e c ific d iag n o sis ■ C u ltu re o r re fle x to c u ltu re if U A is p o s itiv e fo r le u k o c y te e s te ra s e , n itrite a nd W B C 's

□ U s u a lly re q u ire s n o tre a tm e n t □ E x c e p tio n s : p re g n a n t w o m e n a n d p a tie n ts u n d e rg o in g u ro lo g ic in s tru m e n ta tio n □ D ia g n o s is is b a s e d o n s p e c ific c rite ria , e g, > 1 0 5 c o lo n y fo rm in g u n its (cfu ) in a s y m p to m a tic w o m e n , 2 c o n s e c u tiv e v o id e d u rin e s p e c im e n s w ith is o la tio n o f th e s a m e b a c te ria l s tra in

3.1.2.1

Characteristics

■ T h e m o s t c o m m o n c a u s e o v e ra ll a re v iru s e s , e s p e c ia lly N o rw a lk v iru s , e n te ric a d e n o v iru s e s , a n d ro ta v iru s ; m o s t c o m m o n b a c te ria l a g e n ts t3.1 a re E c o li, S a lm o n e lla , S h ig e lla , a n d C a m p y lo b a c te r m In fla m m a to ry (c o litic , d y s e n te ric ) d ia rrh e a vs

3.1.1.1.1 S p e c ific a g e n ts

n o n in fla m m a to ry (w a te ry ) d ia rrh e a

■ E s c h e ric h ia c o li is th e m o s t c o m m o n c a u s e o f UTI o v e ra ll ■ S ta p h y lo c o c c u s s a p ro p h y tic u s is a c o m m o n c a u s e o f U T I in y o u n g s e x u a lly a c tiv e w o m e n ■ E n te ro c o c c u s is a c o m m o n c a u s e in o ld e r m e n w ith o b s tru c tiv e u ro p a th y o r s ta tu s /p o s t u ro g e n ita l p ro c e d u re ■ U re a p la s m a u re a ly tic u m , C h la m y d ia s p p , o r M y c o p la s m a h o m in is a re c o m m o n c a u s e s o f c u ltu re n e g a tiv e U TI ■ C a n d id a is th e m o s t c o m m o n c a u s e o f fu n g a l UTI ■ H e m o rrh a g ic c y s titis is c a u s e d b y a d e n o v iru s e s , e s p e c ia lly ty p e s 11 a n d 21, in im m u n o s u p p re s s e d p a tie n ts

96

3.1.2 Infectious diarrhea

□ In fla m m a to ry d ia rrh e a : n e u tro p h ils in s to o l, fever, b lo o d y s to o l, s e v e re a b d o m in a l p ain , te n e s m u s ; m o s t c o m m o n ly c a u s e d by S h ig e lla , C a m p y lo b a c te r, S a lm o n e lla , E co li, C d iffic ile , A e ro m o n a s , Y e rsinia, a n d V ib rio (n o n c h o le ra ) □ C a u s e s o f n o n in fla m m a to ry d ia rrh e a a re v iru s e s , V ib rio c h o le ra , E c o li (E T E C ), C p e rfrin g e n s , S a u re u s , a n d B c e re u s

t3.1 Foodborne bacterial infections: time to symptom onset O rg anism Tim e from exp o su re to sym ptom s S aureus Salmonella C perfringens B cereus C botulinum E coli (enterotoxigenic) V vulnificus E coli (enterohemorrhagic) C jejuni Shioella

ASCP Quick Compendium of Clinical Pathology 4e

lnfectious diarrhea | Pneumonia | Infective endocarditis (IE) 3.1.2.2 Laboratory evaluation ■ D ia g n o s is o fte n m a d e c lin ic a lly w ith o u t la b o ra to ry ■ S to o l c u ltu re : D e te c ts S h ig e lla , S a lm o n e lla , C a m p y lo b a c te r, A e ro m o n a s , P le s io m o n a s ■ N e e d s p e c ific m e d ia fo r V ib rio a n d Y e rs in ia so th e s e a re o fte n s e p a ra te o rd e rs

• E ld e rly n u rs in g h o m e te n a n ts : S p n e u m o n ia e , H in flu e n z a e , a e ro b ic G ra m n e g a tiv e b a c illi, a n d a n a e ro b e s ■ A ID S p a tie n ts w ith v e ry lo w C D 4 c o u n ts : P n e u m o c y s tis jir o v e c i (fo rm e rly P c a rin ii) a n d C ry p to c o c c u s n e o fo rm a n s

■ S tx to x in a s s a y

■ H o s p ita liz e d v e n tila te d p a tie n ts : S a u re u s , S p n e u m o n ia e , P a e ru g in o s a , K p n e u m o n ia e , S e rra tia sp p, E n te ro b a c te r sp p, E co li, a n d fu n g i

■ O&P

■ V ira l p n e u m o n ia

> V ira l P C R 's

□ V ira l lo w e r re s p ira to ry in fe c tio n m a y ta k e th e fo rm o f b ro n c h itis , b ro n c h io litis , o r p n e u m o n ia

■ M o d ifie d a c id fa s t sta in fo r c o c c id ia ■ A n tig e n te s ts fo r G ia rd ia a n d C ry p to s p o rid iu m ■ M u ltip le x P C R p a n e ls te s tin g fo r m a n y o f th e o rg a n is m s lis te d a re re p la c in g m a n y o f th e a b o v e te s ts ; c o m m e rc ia lly a v a ila b le a n d fa s t (~1 h ou r)

3.1.2.3 Infectious diarrhea in immunodeficiency ■ A g e n ts u n iq u e to o r m o re s e v e re in im m u n o d e fic ie n t p a tie n ts in c lu d e C ry p to s p o rid iu m spp, C y c lo s p o ra c a y e ta n e n s is , m ic ro s p o rid ia , C y s to is o s p o ra b e lli, C M V , a n d M y c o b a c te riu m a v iu m c o m p le x (M A C )

■ E tio lo g y d iffe rs w ith h o s t fa c to rs t3.2 ■ C o m m u n ity a c q u ire d p n e u m o n ia : d iv id e d into ty p ic a l p n e u m o n ia vs a ty p ic a l p n e u m o n ia □ T y p ic a l p n e u m o n ia (a b ru p t o n s e t, fe ve r, p ro d u c tiv e c o u g h , d is tin c t u s u a lly lo b a r in filtra te ): p y o g e n ic b a c te ria (eg, S tre p to c o c c u s p n e u m o n ia e ) □ A ty p ic a l p n e u m o n ia (d ry c o u g h o f p ro lo n g e d d u ra tio n , p a tc h y in filtra te s ): a ty p ic a l a g e n ts (eg, M y c o p la s m a p n e u m o n ia e , C h la m y d o p h ila p n e u m o n ia e )

sandstorm exposure bronchiectasis, cystic fibrosis

■ S a m p le ty p e s : s p u tu m , b ro n c h ia l w a s h , b ro n c h ia l a s p ira te , b ro n c h o a lv e o la r la v a g e c u ltu re ■ C u ltu re

3.1.4 Infective endocarditis (IE) 3.1.4.1 Characteristics ■ In fe c tio n o f a p re v io u s ly n o rm a l n a tiv e v a lv e □ C lin ic a lly a c u te e n d o c a rd itis w ith ra p id d e s tru c tio n a n d a b ru p t o n s e t v a lv e d y s fu n c tio n □ M o s t c o m m o n ly c a u s e d b y S a u re u s □ T ric u s p id e n d o c a rd itis in IV d ru g a b u s e rs ■ In fe c tio n o f a p re v io u s ly a b n o rm a l n a tiv e v a lv e

t3.2 Risk factors for agents of pneumonia

neutropenia animal exposure

3.1.3.2 Laboratory evaluation

■ V ira l P C R s

3.1.3.1 Characteristics

chronic obstructive pulmonary disease alcoholism

□ M u ltip le x P C R b e c o m in g ro u tin e a n d fa s t

□ C y s tic fib ro s is p a tie n ts h a v e a d d itio n a l w o rk up so th e s e o rd e rs a re o fte n s e p a ra te

3.1.3 Pneumonia

Host factor

□ T h e m a jo r p a th o g e n s a re in flu e n z a , re s p ira to ry s y n c y tia l v iru s , p a ra in flu e n z a , rh in o v iru s , a d e n o v iru s , m e ta p n e u m o v iru s , c o ro n a v iru s

Agents suggested Haemophilus influenzae, Moraxella catarrhalis, Legionella pneumophila S pneumoniae, Klebsiella pneumoniae, anaerobes

(aspiration), Gram negative aerobic bacilli Aerobic Gram negative bacilli Coxiella burnetii (cattle, cats), Chlamydophila psittaci (birds), Cryptococcus neoformans (birds), Histoplasma capsulatum (bat or bird droppings, especially pigeons), hantavirus (mouse urine & feces), Francisella tularensis (rabbits)

Coccidioides immitis/posadasii Pseudomonas aeruginosa, Burkholderia cepacia, Staphylococcus aureus

□ C lin ic a lly s u b a c u te e n d o c a rd itis w ith fo rm a tio n o f v e g e ta tio n s □ M o s t c o m m o n ly c a u s e d b y v irid a n s s tre p to c o c c i (S tre p to c o c c u s s a n g u is , S m u ta n s , a n d S m itis), g ro u p B s tre p to c o c c i, g ro u p D s tre p to c o c c i (S tre p to c o c c u s b ovis), e n te ro c o c c i (E n te ro c o c c u s fa e c a iis ), a n d H A C E K o rg a n is m s ■ In fe c tio n o f p ro s th e tic va lve □ V e ry e a rly (w ith in 2 m on th s): S a u re u s , S e p id e rm id is , G ra m n e g a tiv e b a cilli □ E a rly (w ith in th e firs t y e a r); S e p id e rm id is a n d S a u re u s □ L a te (>1 ye a r): th e s a m e a s s u b a c u te a n d o c a rd itis

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Clinical syndromes & causative agents>lnfective endocarditis (IE) | Meningitis | Prosthetic joint infections ■ B lo o d c u ltu re n e g a tiv e e n d o c a rd itis : m o s t c o m m o n ly c a u s e d b y p rio r a n tib io tic s , n o n in fe c tio u s e n d o c a rd itis (L ib m a n -S a c k s , n o n b a c te ria l th ro m b o tic [m a ra n tic ] e n d o c a rd itis , c a rc in o id h e a rt s y n d ro m e ), a n d fa s tid io u s o rg a n is m s (C o x ie lla b u rn e tii, B a rto n e lla , C h la m y d ia , T ro p h e ry m a w h ip p le i)

■ C S F G ra m s ta in : s e n s itiv ity o f 7 0 % -8 0 % fo r th e m o s t c o m m o n a g e n ts s u c h a s S p n e u m o n ia e ■ A n tig e n te s ts fo r S p n e u m o n ia e in C S F — lim ite d s e n s itiv ity

3.1.4.2 Laboratory evaluation ■ C lin ic a l d ia g n o s is is b a s e d o n th e D u k e c rite ria ■ It is p re fe ra b le to id e n tify a n o rg a n is m p rio r to in s tig a tin g a n tib io tic s ■ M u ltip le b lo o d c u ltu re s : 3 s e ts d ra w n a t s e p a ra te tim e s (1 -8 h o u rs a p a rt), e a c h p a ire d (a e ro b ic & a n a e ro b ic ), id e a lly fro m 2 s e p a ra te s ite s (o p p o s ite a rm s ) a n d o f a d e q u a te v o lu m e (id e a lly 2 0 -3 0 m L)

■ M u ltip le x P C R

3.1.6 Prosthetic joint infections 3.1.6.1 Characteristics ■ D e fin itio n □ No u n iv e rs a l d e fin itio n □ S tu d ie s h a ve d e fin e d it a s

3.1.5 Meningitis

■ G ro w th o f th e s a m e m ic ro o rg a n is m in >2 c u ltu re s o f s y n o v ia l flu id o r p e rip ro s th e tic tis s u e

3.1.5.1 Characteristics

■ P u ru le n c e o f s y n o v ia l flu id o r p e rip ro s th e tic tis s u e

3.1.5.1.1 M e n in g itis vs a s e p tic m e n in g itis an d e n c e p h a litis ■ M e n in g itis re fe rs to in fla m m a tio n o f th e m e n in g e s

■ A c u te in fla m m a tio n on h is to lo g ic e x a m in a tio n o f p e rip ro s th e tic tis s u e ■ P re s e n c e o f a s in u s tra c t

□ U s u a lly b a c te ria l □ P re s e n ts w ith m e n in g is m u s a n d n e u tro p h il ric h C S F w ith lo w g lu c o s e □ S p n e u m o n ia e is th e m o s t c o m m o n c a u s e a fte r th e n e o n a ta l p e rio d □ In n e o n a te s , g ro u p B s tre p to c o c c i, G ra m n e g a tiv e a e ro b ic b a c illi, a n d L is te ria m o n o c y to g e n e s ■ A s e p tic m e n in g itis , a ls o in fla m m a tio n o f th e m e n in g e s □ U s u a lly v ira l b u t m a y b e n o n in fe c tio u s □ S o m e w h a t m ild e r c lin ic a l fin d in g s a n d ly m p h o c y te ric h C S F w ith n o rm a l g lu c o s e □ E n te ro v iru s e s (c o x s a c k ie , e c h o v iru s e s , p o lio v iru s ) a re th e m o s t c o m m o n c a u s e o f a s e p tic m e n in g itis in all a g e g ro u p s ■ E n c e p h a litis re fe rs to in fla m m a tio n o f th e b ra in p a re n c h y m a □ U s u a lly v ira l b u t m a y b e n o n in fe c tio u s □ P re s e n ts w ith a lte re d m e n ta l s ta tu s □ M o s t c o m m o n c a u s e s a re H S V 1 , a rb o v iru s e s (S t L o u is e n c e p h a litis , C a lifo rn ia e n c e p h a litis , W e s t N ile v iru s , etc), H H V 6 , m u m p s v iru s , m e a s le s v iru s , a n d v a ric e lla z o s te r v iru s (V Z V )

3.1.5.1.2 L a b o ra to ry e v a lu a tio n

■ C S F c h e m is try a n d c e ll c o u n ts : b a c te ria l m e n in g itis s h o w s lo w g lu c o s e (< 4 5 m g /d L ), h ig h p ro te in (> 5 0 0 m g / d L), a nd h ig h W B C c o u n t (> 1 0 0 0 /m L ), p re d o m in a n tly n e u tro p h ils

■ J o in t fa ilu re a n d /o r jo in t lo o s e n in g is th e m o s t c o m m o n p re s e n ta tio n , b u t b o th in fe c tio u s a n d n o n in fe c tio u s c a u s e s o f jo in t fa ilu re e x is t ■ T h e m o s t c o m m o n c a u s e is c o a g u la s e n e g a tiv e s ta p h y lo c o c c i (3 0 % -4 0 % ); fo llo w e d by S a u re u s , s tre p to c o c c i, G ra m n e g a tiv e b a c illi, e n te ro c o c c i, a nd a n a e ro b e s ■ P ro p io n ib a c te riu m a c n e s is a re la tiv e ly c o m m o n a g e n t in in fe c te d s h o u ld e r p ro s th e s e s

3.1.6.2 Laboratory evaluation ■ C R P h as a s e n s itiv ity o f 7 5 % -9 0 % a n d s p e c ific ity o f 8 0% w h e n a c u to ff o f 13.5 m g /L is u sed ■ S y n o v ia l flu id le u k o c y te c o u n t a n d d iffe re n tia l; s e n s itiv ity 9 0% a nd s p e c ific ity 9 0 % ■ S y n o v ia l flu id c u ltu re h a s a s e n s itiv ity o f o n ly 6 0 % , w ith a s p e c ific ity o f 9 5 % ■ In tra o p c u ltu re o f p e rip ro s th e tic tis s u e ; s e n s itiv ity 6 5 % -9 5 % ■ In tra o p e ra tiv e h is to lo g ic e x a m in a tio n o f p e rip ro s th e tic tis s u e □ C u to ffs v a ry ; in la rg e s t s tu d y d e fin e d a s >5 n e u tro p h ils p e r H P F in 5 d iffe re n t FIPFs □ E x c lu d e s u rfa c e e x u d a te and fib rin

■ B lo o d a n d C S F c u ltu re

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Clinical syndromes & causative agents

t3.3 Clinical syndromes & causative agents Syndrome

Causative agents (most common)

bacteremia in patients with colon cancer

C septicum, S bovis

bacterial meningitis

Neonates , , , „ Infants & young children

S agalactiae (group B Streptococcus), E coti, L monocytogenes

Young adults

S pneumoniae, N meningitidis, H influenzae

Elderly adults

S pneumoniae, N meningitidis, H influenzae, L monocytogenes

S pneumoniae, N meningitidis, H influenzae

fungal meningitis

Cryptococcus

viral (aseptic) meningitis

enteroviruses (Coxsackie, Echovirus, Enterovirus)

viral encephalitis

a-viruses (eastern & western equine encephalitis; flaviviridae (WNV, St Louis encephalitis); herpes simplex virus type 1

impetigo (infection of epidermis)

S aureus, S pyogenes

S aureus, S pyogenes furunculosis (infection of skin adnexa, boils) carbunculosis (draining sinuses from multiple confluent infected skin adnexa) skin infection associated with whirlpools

P aeruginosa

skin infection following dog bite

Capnocytophaga canimorsus, Pasteurella multocida, Staphylococcus intermedius

mycobacterial skin infection

M fortuitum, M chelonae, M marinum, M haemophilum, M ulcerans, M leprae

toxic shock syndrome

S aureus

scalded skin syndrome (Lyells or Ritters syndrome)

S aureus, S pyogenes

erythrasma

Corynebacterium minutissimum

pseudomembranous colitis

C difficile

botryomycosis

S aureus, P aeruginosa

juvenile periodontitis

Aggregatibacter (formerly Actinobacillus) actinomycetemcomitans

ulceroglandular fever

Francisella tularensis

glanders

Burkholderia mallei

melioidosis

Burkholderia pseudomallei

rocky mountain spotted fever

Rickettsia rickettsii

visceral larva migrans (VLM)

Toxocara canis/cati

cutaneous larva migrans (CLM)

Ancylostoma braziliense

bacterial cellulitis

most common overall & the cause of S pyogenes (group A streptococci) erysipelas Erysipelothrix rhusiopathiae erysipeloid animal bite associated

Pasteurella multocida

fresh water associated

Aeromonas hydrophila

salt water associated

Vibrio vulnificus, Mycobacteria marinum

bacterial pharyngitis

S pyogenes (group A streptococci), C diphtheriae

whooping cough

Bordetella pertussis

acute epiglottitis

H influenzae type B (HUB)

chancroid

Haemophilus ducreyi

lymphogranuloma venereum (LGV)

C trachomatis (continued on next page)

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Clinical syndromes & causative agents t3.3 Clinical syndrom es & causative agents (continued) Syndrom e bacterial (“septic”) arthritis

Causative agents (m ost common) children & adults, monoarticular

S aureus, Streptococcus

IV drug abusers

Pseudomonas

young adults, polyarticular

N gonorrhoeae

croup (acute laryngotracheobronchitis)

parainfluenza virus, serotypes 1-3

viral pneumonia Infants/children

respiratory syncytial virus (RSV)

bacterial pneumonia

Adults

Influenza A (orthomyxovirus)

Community acquired

S pneumoniae, L pneumoniae, H influenzae, S aureus, M pneumoniae

Chronic alcoholics

K pneumoniae

Cystic fibrosis

P aeruginosa

“Atypical” or “walking” pneumonia

Mycoplasma pneumoniae, Chlamydia pneumoniae

Nosocomial pneumonia

E coli, P aeruginosa, S aureus, L pneumoniae S pneumoniae, H influenzae, M catarrhalis

otitis media bacterial peritonitis gastroenteritis

spontaneous (cirrhosis with ascites)

S pneumoniae

secondary (ruptured bowel)

mixed: E coli, enterococci, B fragilis, other anaerobes

with short incubation period (1-8 h)

S aureus, B cereus

fried rice

B cereus

traveler’s diarrhea

E coli (ETEC)

hamburgers in fast food restaurants

£ coli (EHEC)

antibiotic associated colitis

C difficile

viral

rotavirus, Norwalk virus, enteric adenoviruses

causing bloody diarrhea

Salmonella enteriditis, Shigella species, Campylobacter jejuni, EHEC, EIEC, K oxytoca, Entamoeba histolytica, Balantidium coli, CMV

diarrhea with systemic disease

Salmonella typhi, other Salmonella species, Yersinia enterocolitica, Campylobacter species

osteomyelitis

S aureus

necrotizing fasciitis

usually polymicrobial

Streptococcus pyogenes & anaerobes such as Bacteroides fragilis

undulant fever

pig associated

Brucella suis

goat associated

Brucella melitensis

dog associated

Brucella canis

rabbit fever or deerfly fever (tularemia)

Francisella tularensis

plague

Yersinia pestis

carrion disease or verruga peruana (bartonellosis)

Bartonella bacilliformis

uterine infection following septic abortion

Clostridium sordellii

leprosy (Hansen disease)

Mycobacterium leprae

rat bite fever

Streptobaciilus moniliformis

San Joaquin Valley fever

Coccidioides immitis (continued on next page)

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(continued)

Syndrome

Causative agents (most common)

superficial dermatophytes (causing tinea capitis, Epidermophyton, Microsporon & Trichophyton species (noninvasive) tinea cruris) mycoses Piedraia hortae black piedra white piedra

Trichosporon beigelii & other Trichosporon species

tinea versicolor

Malassezia furfur

tinea nigra palmaris/plantaris

Hortaea (formerly Phaeoannelomyces) werneckii

cutaneous & chromoblastomycosis subcutaneous mvcoses lobomycosis

Phialophora verrucosa, Fonsecaea pedrosoi Lacazia (formerly Loboa) loboi

Phaeohyphomycosis

Exophiala jeanselmei, Phialophora verrucosa, Wangiella dermatitidis, Alternaria species, many others

sporotrichosis

Sporothrix schenckii

eumycotic mycetoma

Exophiala jeanselmei, Madurella species, Pseudallescheria boydii (Scedosporium)

rhinosporidiosis

Rhinosporidium seeberi

rhinoscleroma

Klebsiella rhinoscleromatis

actinomycotic mycetoma (Madura foot)

Actinomyces, Nocardia, Streptomyces

measles

rubeola virus

erysipelas

S pyogenes (group A streptococci)

German measles

Rubella virus

chicken pox

Varicella zoster virus

labial herpes

herpes simplex virus type 1 (majority)

genital herpes

herpes simplex virus type 2 (majority)

roseola infantum (exanthem subitum)

human herpesvirus 6

Fifth disease (erythema infectiosum, slapped cheek disease)

parvovirus B19

Chagas disease

Trypanosoma cruzi

African sleeping sickness

Trypanosoma brucei

fungal external otitis

Aspergillus niger

subacute sclerosing panencephalitis (SSPE)

measles virus (reactivation)

hand foot mouth disease

coxsackie A

vral myocarditis

coxsackie B

progressive multifocal leukoencephalopathy (PML)

JC virus

scarlet fever

S pyogenes (Group A streptococci)

acute mastitis

S aureus

Q fever

Coxiella burnetii

primary amebic meningoencephalitis (PAM)

Naegleria fowled

granulomatous amebic encephalitis (GAE)

Acanthamoeba species & Balamuthia mandrillaris

postsplenectomy sepsis

S pneumoniae

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C linical syndrom es & causative agents>Vectors V irology>V iral structure & classification

3.1.7 Vectors t3.4 t3 .4 Vectors (continued)

t3 .4 Vectors Vector M osquitoes Anopheles spp

Aedes spp, most commonly

Disease

Organism

dog heartworm malaria lymphatic filariasis lymphatic filariasis arboviral disease

Dirofilaria immitis Plasmodium spp Brugia malayi Wuchereria bancrofti

A aegypti & A albopictus arboviral disease Culex spp

Ticks Ixodes spp

Most common Eastern US: / scapularis Western US: 1pacificus Europe: / ricinus

including dengue virus, yellow fever virus & Chikungunya virus including West Nile virus, systemic lupus erythematosus, Japanese encephalitis virus

lymphatic filariasis lymphatic filariasis

Wuchereria bancrofti Brugia maiayi

Lyme disease babesiosis anaplasmosis

Borretia burgdorferi Babesia spp Anaplasma phagocytophiium

tickborne encephalitis Lone Star tick— ehrlichiosis Amblyomma americanum tularemia southern tick associated illness rocky mountain spotted Dermacentor spp fever Most common Southern & western US: tularemia D andersoni Colorado tick fever Southern & eastern US: D variabilis relapsing fever Ornithodoros spp (soft ticks)

tickborne encephalitis virus Ehrlichia spp

Franciseiia tularensis

Vector Mites Mite (Liponyssoides sanguineus)

Disease

Organism

rickettsial pox

Rickettsia akari

Others Midges—Culicoides spp bug— Triatominae

3.2 Virology 3.2.1 Viral structure & classification t3.5 t3.5 Virus classification DNA viruses Single stranded Nonenveloped Parvoviridae Bocavirus

Double stranded Adenoviridae Papillomaviridae Polyomaviridae

Dung fly— Musca sorbens Sandfly— (Phlebotomus & Lutzomyia spp)

Black fly—Simulium spp Tsetse fly— Glossina spp

tularemia—deerfly fever loiasis trachoma leishmaniasis bartonellosis; carrion disease arboviral disease

(hepatitis E)

Enveloped

Herpesviridae Flaviviridae (HCV, yellow fever, Hepadnaviridae dengue, WNV, St Louis & (HBV)

Poxviridae

Franciseiia tularensis Loa loa Chlamydia trachomatis Leishmania spp Bartonella bacilliformis

plague murine typhus double pored dog tapeworm

Yersinia pestis Rickettsia typhus Dipylidium caninum

Fleas Rat fleas Dog and cat fleas

Japanese encephalitis)

Togaviridae (rubella, EEE, WEE) Retroviridae (HIV, HTLV) Orthomyxoviridae (influenza) Paramyxoviridae (RSV, hMPV,

parainfluenza, mumps, measles)

Rhabdoviridae (rabies) Coronaviridae Arenaviridae Bunyaviridae (hantavirus, California encephalitis)

Deltavirus (hepatitis D)

Vesicular stomatitis virus, toscana & Sicilian virus

Trypanosoma brucei

rotavirus

(norovirus)

Borretia spp

Onchocerca volvulus

(poliovirus, enteroviruses), hepatitis A, rhinovirus)

Hepeviridae

Franciseiia tularensis

onchocerciasis; river blindness African trypanosomiasis

RNA viruses Single Double stranded stranded Picornaviridae Reoviridae:

Calciviridae

Rickettsia rickettsii

Flies Deerfly— Chrysops spp

Mansonella spp Trypanosoma cruzi

filariasis American trypanosomiasis; Chagas disease

unknown etiology

Colorado tick fever virus

Orientia tsutsugamushi

Chigger (Trombiculid mite) scrub typhus

3.2.1.1 Obligate intracellular organisms ■ C a n n o t g e n e ra te th e ir o w n e n e rg y ■ N u c le ic acid □ C o n ta in e ith e r D N A o r R N A □ S in g le s tra n d e d o r d o u b le s tra n d e d □ C irc u la r o r lin e a r

Lice Body lice— Pedicuius

humanus

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Rickettsia prowazekii epidemic typhus liceborne relapsing fever Borrelia recurrentis Bartonella quintana trench fever

3.2.1.2 Surrounded by a capsid ■ H e lica l ■ Ic o s a h e d ra l (s y m m e tric )

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Virology>Viral structure & classification | Laboratory evaluation | DNA viruses 3.2.1.3

Envelope

■ L ip o p ro te in b ila y e r ■ D e rive d in p a rt fro m h o s t ce ll m e m b ra n e o r h o s t n u c le a r m e m b ra n e a nd v ira l p ro te in s

□ C u rre n t u s e s ■ W h e n th e v iru s is n e e d e d fo r s u s c e p tib ility te s tin g ■ S h e ll via l a s s a y (m o d ific a tio n o f tra d itio n a l tu b e c u ltu re )

3.2.2 Laboratory evaluation ■ M o le c u la r d e te c tio n : c u rre n t m a in s ta y in c lin ic a l la b o ra to rie s ; v e ry h ig h s e n s itiv ity a nd s p e c ific ity , e x tre m e ly ra pid □ P C R o r tra n s c rip tio n m e d ia te d a m p lific a tio n ■ eg, q u a n tita tiv e P C R fo r H IV o r H C V

□ T h e sh e ll via l c o n ta in s a m o n o la y e r o f c e lls o n a c irc u la r c o v e rs lip a t th e b a s e o f th e via l □ T h e p a tie n t s a m p le is s lo w ly c e n trifu g e d to e n h a n c e in fe c tio n o f th e c e lls o v e r a s h o rt in c u b a tio n p e rio d (1-3 d ays) □ T h e c o v e rs lip is re m o v e d a n d p la c e d on a s lid e

□ In situ h y b rid iz a tio n ■ eg, H P V in c e rv ic a l s a m p le s , C M V in lun g biopsy, H S V in skin b io p sy, p a rv o v iru s B19 in b o n e m a rro w ■ T ra d itio n a l tu b e c u ltu re s □ T u be c o n ta in s a m o n o la y e r o f liv in g c e lls ■ P rim a ry ce ll lin e s: p a s s e d a fe w tim e s , p re p a re d d ire c tly fro m tis s u e s (can be in fe c te d w ith e n d o g e n o u s v iru s e s ) ■ eg, m o n k e y kidn ey, h u m a n a m n io n , c h ic k e m b ry o ■ M o n k e y k id n e y : in flu e n z a , p a ra in flu e n z a , e n te ro v iru s e s ■ R a b b it k id n e y : H S V ■ H u m a n e m b ry o n ic k id n e y : a d e n o v iru s , e n te ro v iru s

□ T h e s lid e is s ta in e d w ith flu o re s c e n t a n tib o d ie s , v ie w e d w ith flu o re s c e n t m ic ro s c o p e □ C a n s ta rt w ith a re s p ira to ry p o o l (a n tib o d ie s to m a n y v iru s e s ), and if it is p o s itiv e , re p e a t w ith e a c h in d iv id u a l v ira l a n tib o d ie s to s e e w h ic h o n e c a u s e d it to b e c o m e p o s itiv e ■ D ire c t flu o re s c e n t a n tib o d y □ M a ke s lid e d ire c tly fro m p a tie n t s a m p le , w h ic h m u s t c o n ta in in fe c te d c e lls (eg, n a s o p h a ry n g e a l sw a b ) □ S ta in w ith flu o re s c e n t a n tib o d ie s a n d v ie w on flu o re s c e n t m ic ro s c o p e □ G o o d fo r h e rp e s a n d re s p ira to ry v iru s e s ; n o w m o s tly re p la c e d b y P C R ■ S e ro lo g y : d e te c tio n o f a n tib o d ie s in p a tie n t s e ru m

■ D ip lo id ce ll c u ltu re s : p a s s e d m a n y tim e s ■ eg, M R C 5 (d ip lo id fib ro b la s t fro m lun g o f a h u m a n fe tu s) ■ F ib ro b la s ts u se d to is o la te C M V , V Z V , HSV, rh in o v iru s e s , a d e n o v iru s e s , s o m e e n te ro v iru s e s

□ P o s itiv e IgG m a y in d ica te c u rre n t o r p a s t in fe c tio n ; p o s itiv e IgM in d ic a te s c u rre n t (a cu te ) in fe c tio n □ P a ire d s e ra , ta k e n 7-10 d a y s a p a rt s h o w in g 4 fo ld o r g re a te r ris e in IgG tite r □ M a n y d ra w b a c k s : fa ls e p o s itiv e s a n d fa ls e n e g a tiv e s □ U se d p rim a rily fo r EBV, C M V , h e p a titis (A -E ), m e a s le s , m u m p s , ru b e lla , p a rv o v iru s e s , e n c e p h a litis v iru s e s , ra b ie s , h e m o rrh a g ic fe ve r, d e n g u e , HIV, H T LV 1/2

■ C o n tin u o u s , im m o rta l ce ll lin e s ■ eg, H e L a , H E p 2 , A 5 4 9 ■ H E p 2 u se d to is o la te RSV, a d e n o , H S V ■ A 5 4 9 u se d to is o la te HSV, a d e n o □ V iru s fro m p a tie n t s p e c im e n in fe c ts th e m o n o la y e r d u rin g a lon g in c u b a tio n p e rio d (1-20 d ays) □ V ie w th e c e lls (still in th e tu b e ) fo r d e te c tio n o f vira l c y to p a th ic e ffe c t (C P E ) o n a lig h t m ic ro s c o p e t3.6

■ E n z y m e lin ke d im m u n o a s s a y fo r v ira l a n tig e n s ■ H is to lo g y /c y to lo g y : s o m e v iru s e s h a v e c h a ra c te ris tic in c lu s io n s t3.7 ■ E le c tro n m ic ro s c o p y — n ot ro u tin e

3.2.3 DNA viruses

t3.6 Viral CPE Enterovirus

CMV

Tear shaped cells

Focal plaques Grapelike in HDF clusters

Adenovirus

RSV

HSV

Syncytial cells Sweeping, globular cells - •v H r li'w

© A S C P 2018

□ Id e n tify th e v iru s b a se d o n (1) m o rp h o lo g y o f C P E , (2) ty p e s o f c e lls d is p la y in g C P E , a n d (3) tim e fro m in o c u la tio n to d e te c tio n o f C P E

3.2.3.1 Adenoviridae: adenovirus; no envelope, double stranded, linear DNA ■ 4 9 s e ro ty p e s ; c a u s e a w id e v a rie ty o f s y n d ro m e s □ C o n ju n c tiv itis : ty p e s 1-11, 14, 19, 37 ■ U s u a lly b ila te ra l ■ W a te ry d is c h a rg e , p re a u ric u la r ly m p h a d e n o p a th y

ISBN 978-08 9189-6678

103

3: Microbiology

CO bo

*—►

Virology>DNA viruses t3.7 Viral histology Virus

Nuclear Cytoplasmic Syncytia Notes inclusions inclusions

RSV

-

HSV

Adenovirus + CMV + Measles

+

Rabies

+

-

+

+

+

-

-

Virus Transmission Incubation

Chronicity

Comments

HAV

fecal-oral

15-30 days

0%

HBV

parenteral

15-150 days, 2%-10% of all, average 60-90 30%-90% of children D N A viruses □ B e c o m e s la te n t in n e u ro n s □ E n c e p h a litis : te m p o ra l lo b e h e m o rrh a g ic n e c ro s is (can b e s e e n o n M R I) ■ C S F : ly m p h o c y tic p le o c y to s is , e le v a te d p ro te in , R B C s , n o rm a l g lu c o s e ■ D x: P C R ; c u ltu re a n d in tra th e c a l a n tib o d y m e a s u re m e n ts a re n o t h e lp fu l □ M o lla re t m e n in g itis : re c u rre n t a s e p tic m e n in g itis , u s u a lly a s s o c ia te d w ith H S V 2 ■ D ia g n o s is o D F A , E IA , m o le c u la r m e th o d s □ H is to lo g y : m u ltin u c le a te d g ia n t c e lls w ith m o ld e d n u c le i a n d m a rg in a te d c h ro m a tin (id e n tic a l to V Z V ) i3.1 □ C P E c a n b e s e e n on T z a n c k s m e a r (s e n s itiv ity v e ry lo w a n d d e p e n d e n t o f p ro p e r c o lle c tio n ) □ C u ltu re ■ M R C 5 ; A 5 4 9 ; g ro w s q u ic k ly ; C P E : d e v e lo p s w ith in 2 -3 d a y s ; ro u n d e d c e llu la r e n la rg e m e n t (b a llo o n in g ) w ith o c c a s io n a l s y n c y tia

i3.1 a Classic multinucleated cells of HSV infection with nuclear molding & chromatin margination and b Cowdry type A inclusions seen in Pap stained preparations c Necrotizing pneumonitis with d typical cytopathic effect seen in H&E stained sections

■ S h e ll v ia l: 16 h o u rs ■ T re a tm e n t □ A c y c lo v ir: n u c le o s id a s e a n a lo g , b in d s D N A p o ly m e ra s e , D N A c h a in te rm in a tio n □ V a la c y c lo v ir: p ro d ru g o f a c y c lo v ir □ P e n c y c lo v ir: s im ila r to a c y c lo v ir □ F a m c ic lo v ir: p ro d ru g o f p e n c y c lo v ir 3 .2 .3 .3 .2

V a r ic e lla z o s te r v ir u s (V Z V )

■ D is e a s e s □ C h ic k e n p o x in c h ild re n : b e g in s o n fa c e /s c a lp a n d s p re a d s to b o d y /e x tre m itie s ; all le s io n s a t d iffe re n t s ta g e s □ L a te n c y in n e u ro n s □ R e a c tiv a tio n c a u s e s z o s te r (s h in g le s ): p a in fu l ra sh in a d e rm a to m a l d is trib u tio n

i3.2 Neonatal VZV pneumonitis, showing multinucleated cells with viral cytopathic effect

■ P o s th e rp e tic n e u ra lg ia : p a in p e rs is ts a fte r th e ra sh c le a rs ■ R a m s a y H u n t s y n d ro m e : o ta lg ia , u n ila te ra l fa c ia l p a re s is , v e rtig o , h e a rin g lo s s , tin n itu s ; c a u s e d by re a c tiv a tio n in th e g e n ic u la te g a n g lio n o f th e fa c ia l n e rv e □ C a n a ls o c a u s e e n c e p h a litis , m e n in g itis , p a ra ly s is , p n e u m o n ia i3.2, a c u te re tin a l n e c ro s is □ C a n d is s e m in a te in im m u n o c o m p ro m is e d o r p re g n a n t p a tie n ts

106

□ C o n g e n ita l in fe c tio n : m a te rn a l v a ric e lla d u rin g p re g n a n c y , d e rm a to m a l d is trib u tio n o f skin le s io n s in n e w b o rn , a n d s e ro lo g ic e v id e n c e in n e w b o rn (lg M + o r lg G + >7 m o n th s a fte r b irth ) ■ In c id e n c e a nd s e v e rity d e p e n d e n t on tim in g o f m a te rn a l in fe c tio n ; lo w e r in 1st trim e s te r, h ig h e r in 2 nd o r 3 rd trim e s te rs

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

3: Microbiology

Virology>DNA viruses ■ D ia g n o s is □ D ia g n o s e d m a in ly via P C R o f v e s ic le flu id o r C S F □ A ls o ca n u se D F A o f v e s ic le flu id o r T z a n k p re p (b o th h ave lo w s e n s itiv ity ) □ C u ltu re is d iffic u lt (M R C 5 fo r ~14 days); n o t ro u tin e ly p e rfo rm e d □ C y to p a th ic e ffe c t: m u ltin u c le a te d g ia n t c e lls w ith m o ld e d n u c le i a nd m a rg in a te d c h ro m a tin (id e n tic a l to FISV); ca n se e on T z a n c k s m e a r o r h is to lo g y □ S e ro lo g y : n o t o fte n h e lp fu l; lg M + o r 4 fo ld ris e in IgG 3 . 2 . 3 .3 .3 C y to m e g a lo v iru s (C M V ) ■ D is e a s e □ M o n o lik e d is e a s e o r a s y m p to m a tic □ D is s e m in a te d in fe c tio n in in fa n ts a nd tra n s p la n t p a tie n ts (2 -4 m o n th s a fte r tra n s p la n t) ■ S o m e tim e s a ls o h ave a lo c a liz e d in fe c tio n (lu n g s, G l, liver, k id n e ys) □ R e tin itis : re tin a l o p a c ific a tio n fro m e d e m a o r n e c ro s is ; h e m o rrh a g e ; tre a t w ith g a n c ic lo v ir o r fo s c a rn e t □ C M V is th e m o s t c o m m o n v ira l o p p o rtu n is tic in fe c tio n o f H IV a nd tra n s p la n t p a tie n ts ■ A c q u irin g C M V a fte r tra n s p la n t le a d s to se v e re d is e a s e ■ H IV p a tie n ts h ave re a c tiv a tio n w h e n C D 4 < 100; m a n ife s te d w ith C M V re tin itis (“ p iz z a p ie ” ), p n e u m o n ia , c o litis (d ia rrh e a ) □ N e u ro lo g ic a l s y n d ro m e s (eg, v e n tric u lo e n c e p h a litis 5 w e e k s u rv iv a l) □ N e o n a ta l C M V : in tra c e re b ra l c a lc ific a tio n s , m ic ro c e p h a ly , h e p a to s p le n o m e g a ly , ja u n d ic e , p e te c h ia e a nd p u rp u ra ; lo n g te rm s e n s o rin e u ra l h e a rin g lo ss ■ D ia g n o s is : m o s tly s e ru m P C R □ H is to lo g y : e n la rg e d c e ll w ith la rg e b a s o p h ilic in tra n u c le a r in c lu s io n s u rro u n d e d by a c le a r h alo (“o w l’s e y e ” ); a ls o h as a b u n d a n t e o s in o p h ilic c y to p la s m ic in c lu s io n s i3.3 □ S e ro lo g y : lg M + o r 4 fo ld ris e in IgG □ C u ltu re : n ot o fte n h e lp fu l (14 d a y s to se e C P E ) □ p p 6 5 : o ld a n tig e n te s t, n o t p e rfo rm e d a n y m o re 3 .2 .3 .3 .4 E p s te in -B a rr viru s (EB V ) ■ D is e a s e □ E n te rs b o d y th ro u g h p h a ry n g e a l o r g e n ita l m u c o s a □ In fe c ts B ly m p h o c y te s

© A S C P 2018

i3.3 H&E stained histologic sections demonstrating a & b CMV placentitis and c & d CMV colitis. The infected cells are markedly enlarged endothelial cells with cytoplasmic inclusions & nuclear Cowdry type A inclusions (arrows)

■ S o m e o f th e s e w ill re m a in la te n tly in fe c te d a n d s e rv e a s a re s e rv o ir fo r re a c tiv a tio n (E B V g e n o m e is in e p is o m a l fo rm ) ■ C D 8 + T ly m p h o c y te s p ro life ra te a n d a p p e a r a s a ty p ic a l ly m p h o c y te s o n p e rip h e ra l s m e a r □ In fe c tio u s m o n o n u c le o s is : fe ve r, p h a ry n g itis , iy m p h a d e n o p a th y ; o fte n liv e r fu n c tio n te s ts a re a b n o rm a l □ R e a c tiv a tio n ca n be c a rc in o g e n ic in im m u n o c o m p ro m is e d p e o p le : B u rk itt ly m p h o m a , n a s o p h a ry n g e a l c a rc in o m a , F lo d g kin ly m p h o m a , P o s ttra n s p la n t ly m p h o p ro life ra tiv e d is o rd e r, o ra l h a iry le u k o p la k ia ; o th e rs ■ P T L D : h ig h e s t ris k w ith p rim a ry in fe c tio n a fte r tra n s p la n t o r in th e firs t 6 m o n th s a fte r tra n s p la n t (solid o rg a n m o re c o m m o n th a n B M T ) □ X lin ked im m u n o p ro life ra tiv e d is e a s e (D u n c a n d is e a s e , ra re , a ffe c tin g m a le s ) ■ F u lm in a te p rim a ry E B V in fe c tio n th a t is o fte n fa ta l d u e to u n c o n tro lle d T /N K c e ll a c tiv a tio n a n d h e p a tic n e c ro s is ■ S H 2 D 1 A (S A P ) g e n e m u ta tio n ■ D ia g n o s is □ M o n o s p o t: a g g lu tin a tio n o f h o rs e red b lo o d c e lls u p o n e x p o s u re to th e p a tie n t’s h e te ro p h ile a n tib o d ie s (a ka P a u l-B u n n e ll a n tib o d ie s ) ■ F le te ro p h ile a n tib o d ie s : Ig M th a t a g g lu tin a te s h e e p , o x a nd h o rs e R B C s ■ M ix p a tie n t s e ru m w ith g u in e a p ig k id n e y a n d b e e f c e ll s tro m a ; th e n add s h e e p c e lls

ISBN 978-08 9 1 8 9 -6 6 7 8

107

3: Microbiology

Virology>DNA viruses t3.11 EBV Serology C lin ic a l s e ttin g V C A -Ig G Acute mono Conv mono Past EBV No past infection Burkitt NP carcinoma

+ + + - ___________ + + (IgA also)

V C A -Ig M

E A -D

E A -R

EBNA

+ + + /+ + + - ____________ - ________- _______ - ______ + + ____________ +________ + /______

E B V - Epstein-Barr virus; NP = nasopharyngeal carcinoma

i3.4 Malignant spindled cells of Kaposi sarcoma a H&E stained section b HHV8 immunohistochemically stained section

■ N o t d e te c ta b le fo r a t le a s t th e 1st m o n th and p o s s ib ly up to 6 m o n th s ■ P e rs is ts fo r life □ A s s o c ia te d w ith IgM a n ti-i (cold a g g lu tin in ) □ D e m o n s tra tio n o f E B V c e llu la r in fe c tio n in tis s u e ■ IS H w ith E B V e n c o d e d R N A (E B E R ): p o s itiv e in E B V re la te d tu m o rs (eg, R e e d -S te rn b e rg c e lls in H o d g k in ly m p h o m a ) ■ ISH w ith th e B A M H IW s e q u e n c e o f E B V D N A and IH C fo r LM P1 p e rfo rm s n e a rly a s w e ll as E B E R ■ P o s itiv e re s u lt a ls o c a n be s e e n w ith a c u te HIV, S L E , o r ru b e lla ■ M o re s e n s itiv e in a d u lts (8 0 % ); p o s itiv e in 4 0 % o f in fe c te d c h ild re n a n d in < 2 0 % o f in fe c te d c h ild re n < 4 y e a rs o ld □ W h e n th e m o n o s p o t te s t is n e g a tiv e , th e o p tim a l c o m b in a tio n o f E B V s e ro lo g ic te s tin g c o n s is ts o f th e m e a s u re m e n t o f 4 a n tib o d ie s t3.11, f3.3 ■ Ig M a n d Ig G to th e v ira l c a p s id a n tig e n (V C A ): s h o u ld be p re s e n t b y 3 rd w e e k o f illn e s s ■ Ig M : s p e c ific a n d s e n s itiv e m a rk e r o f a c u te p rim a ry in fe c tio n ; s u b s id e s w ith re c o v e ry (a fte r 1-2 m o n th s ) ■ Ig G : d e te c te d w h e n s y m p to m s b e g in a n d p e rs is ts fo r life

3 .2 .3 .3 .5 H um an h e rp e s v iru s 6 (H H V 6) ■ P rim a ry in fe c tio n □ R o s e o la (e x a n th e m s u b itu m ) □ O c c u rs in c h ild re n ~1 y e a r o ld ; a b ru p t o n s e t o f high fe v e r th a t la s ts 3 -5 d a ys, s o m e tim e s w ith fe b rile s e iz u re , ra p id d e fe rv e s c e n c e w ith o n s e t o f ro se c o lo re d m a c u lo p a p u la r ra sh th a t s ta rts on fa c e o r tru n k a n d s p re a d s , la s tin g 1-3 d ays □ C an c a u s e e n c e p h a litis □ E s ta b lis h e s la te n c y in T ly m p h o c y te s □ A lm o s t 100 % o f c h ild re n h ave a n tib o d ie s ■ R e a c tiv a tio n □ Im m u n o c o m p ro m is e d p a tie n ts (B M T o r s o lid o rg a n tra n s p la n t re c ip ie n ts )

■ Ig M to th e e a rly a n tig e n (E A ) ■ E x p re s s e d e a rly in th e E B V life c y c le ■ E A -D (d iffu s e ; c y to p la s m a n d n u c le u s ): 7 0 % o f p a tie n ts p o s itiv e ; a p p e a rs a fe w w e e k s a fte r V C A a n tib o d ie s ; ra p id ly d e c lin e s ; ra re ly p re s e n t a fte r 12 m o n th s ■ E A -R (re s tric te d ; c y to p la s m o n ly ): d e s tro y e d by m e th a n o l fix a tio n o f c e lls u s e d fo r a n tig e n ; u s u a lly p re s e n t d u rin g c o n v a le s c e n c e a n d y e a rs a fte r; n o t u s u a lly d e te c te d d u rin g a c u te d is e a s e ■ A n tib o d y to E p s te in -B a rr n u c le a r a n tig e n (E B N A ) ■ 6 d iffe re n t a n tig e n s fo u n d in th e n u c le u s o f in fe c te d c e lls ■ R is e la te r th a n V C A a n d E A a n tib o d ie s 108

3.2 .3 .3 .6 H um an h e rp e s v iru s 8 (H H V 8) ■ K a p o s i s a rc o m a i3.4 □ R a ised , re d /v io le t s k in /m u c o s a l le s io n s ; h is to lo g y : s p in d le ce ll p ro life ra tio n th a t sta in w ith H H V 8 IH C □ M o s tly s e e n in tra n s p la n t a nd H IV + p a tie n ts □ O th e r ty p e s in c lu d e : ■ A fric a n e n d e m ic : c h ild re n (w ith o r w ith o u t H IV ) ■ M e d ite rra n e a n (C la ssic): o ld e r E u ro p e a n m en w ith o u t im m u n e d y s fu n c tio n ■ P rim a ry e ffu s io n ly m p h o m a (b o d y c a v ity ly m p h o m a ) □ B cell ly m p h o m a th a t o c c u rs in b o d y c a v itie s (e s p e c ia lly th e p le u ra l sp a c e )

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

3: Microbiology

Virology>DNA viruses □ T h e B ly m p h o c y te s a re o fte n c o in fe c te d w ith E B V □ U s u a lly s e e n in A ID S p a tie n ts ■ M u ltic e n tric C a s tle m a n d is e a s e

3.2.3.4 Parvoviridae: parvovirus B19; no envelope, single stranded, linear DNA ■ In fe c ts a n d ly s e s e ry th ro id p ro g e n ito r c e lls ■ C a n c a u s e a p la s tic c ris is in p e o p le w ith h e m o ly tic a n e m ia □ H is to lo g y : g ia n t p ro n o rm o b la s ts ; d e c re a s e d n u m b e rs o f m o re m a tu re e ry th ro id p re c u rs o rs ■ E ry th e m a in fe c tio s u m (F ifth d is e a s e ) in c h ild re n (4-7 y e a rs o ld ): s la p p e d c h e e k s □ In c u b a tio n : 6 -1 8 d a y s □ V ire m ia : 6 -8 d a y s p o s t e x p o s u re □ Im m u n e c o m p le x (Ig M ): 10-14 d a y s p o s t e x p o s u re (sla p p e d c h e e k s , no lo n g e r in fe c tio u s ) □ IgG d e v e lo p s : 14-17 d a y s , la s ts fo r life, c o n fe rs im m u n ity □ S e c o n d s ta g e ra sh on tru n k /lim b s : 1-2 d a y s a fte r c h e e k rash □ R e tic u lo c y to p e n ia la s ts 7-10 d ays; h e m o g lo b in d ro p s 1 g □ O u tb re a k s in la te w in te r/s p rin g ■ P rim a ry in fe c tio n o f p re g n a n t w o m e n ca n c a u s e fe ta l red cell a p la s ia w ith h y d ro p s fe ta lis

3.2.3.5 Papovaviridae: no envelope, double stranded, circular DNA 3.2.3.5.1

H um an p ap illo m a viru s

□ T y p e s 16 a n d 18: c e rv ic a l a n d p e n ile c a n c e rs (s q u a m o u s c e ll c a rc in o m a ) ■ B o w e n o id p a p u lo s is (H P V 1 6 a n d 18): m u ltip le s m a ll p e a rly p a p u le s in a n o g e n ita l re g io n ; h is to lo g ic a lly re s e m b le s s q u a m o u s c e ll c a rc in o m a in situ ; u n lik e C IS , ra re ly p ro g re s s e s to in v a s iv e c a rc in o m a ■ H e a d and n e c k s q u a m o u s c e ll c a rc in o m a : H P V s tro n g p re d ic to r o f fa v o ra b le p ro g n o s is (e s p e c ia lly o ro p h a ry n g e a l tu m o rs ); IH C fo r P16 is a s u rro g a te m a rk e r fo r H P V ■ E p id e rm o d y s p la s ia v e rru c ifo rm is : a u to s o m a l re c e s s iv e d is e a s e w ith im p a ire d d e fe n s e s a g a in s t H P V ; le s io n s o f tru n k a n d a rm s by 10 y e a rs o ld ; m a y u n d e rg o m a lig n a n t tra n s fo rm a tio n ■ C a n n o t c u ltu re ! ■ H is to lo g y : p a p illo m a to s is , a c a n th o s is , p a ra k e ra to s is , h y p e rk e ra to s is , k o ilo c y te s

3 .2 .3 .5 .2 M erkel cell p o lyo m av iru s (M C P y V ) ■ A s s o c ia te d w ith M e rk e l ce ll c a rc in o m a a n d c h ro n ic ly m p h o c y tic ly m p h o m a ■ M u ta te d M C P y V D N A can b e fo u n d in 8 0 % o f M C C ■ N o n m u ta te d M C P y V D N A is fo u n d in 15% o f n o rm a l s k in s a m p le s

3 .2 .3 .5 .3 H um an p o lyo m aviru s: th e s e v iru s e s are a c q u ired in c h ild h o o d and rem ain la te n t until im m u n o s u p p re s s e d ■ J C v iru s : p ro g re s s iv e m u ltifo c a l le u k o e n c e p h a lo p a th y

■ P a th o g e n e s is □ R e p lic a te s in e p ith e lia l c e lls c a u s in g k o ilo c y tic c h a n g e □ In b e n ig n le s io n s H P V D N A is e p is o m a l; in m a lig n a n t le s io n s , it is in te g ra te d into h o s t cell D N A □ E a rly re g io n p ro te in s : E6 a nd E 7 a re c ru c ia l fo r s u b s e q u e n t o n c o g e n e s is ■ E6: b in d s a nd p ro m o te s d e g ra d a tio n o f p 53 ■ E7: b lo c k s R B , re m o v in g c e ll c y c le re s tric tio n ■ T yp es □ T yp e s 1-4: c o m m o n a n d p la n ta r w a rts

□ M a in ly s e e n in H IV p a tie n ts o r o th e r s e v e re ly im m u n o c o m p ro m is e d p a tie n ts □ D e m y e lin a tio n u s u a lly o c c u rs in c e re b ra l h e m is p h e re s a nd le a d s to n e u ro lo g ic s y m p to m s ■ D iffic u lty w ith c o g n itio n , m o to r fu n c tio n , v is io n , speech □ C a n d ia g n o s e w ith b rain im a g in g (M R I s h o w s m u ltip le fo c i o f d e m y e lin a tio n ) a n d /o r b ra in b io p s y (s m u d g y n u c le a r in c lu s io n s in o lig o d e n d ro g lia l c e lls , im m u n o s ta in o r P C R o f th e b ra in tis s u e ) ■ C S F in d ic e s a re n orm a l

□ T yp e s 6 a nd 11 ■ G e n ita l w a rts (c o n d y lo m a a c c u m in a ta ) ■ V e rru c o u s c a rc in o m a (g ia n t c o n d y lo m a o f B u sc h k e a nd L o w e n s te in ) in a n o g e n ita l re g io n

© ASCP2018

■ R e c u rre n t re s p ira to ry p a p illo m a to s is : p a p illo m a s on tru e v o c a l c o rd s th a t c a n le a d to a irw a y o b s tru c tio n ; ju v e n ile (a c q u ire d d u rin g b irth ; p re s e n ts a t 2 -4 y e a rs o ld ) o r a d u lt fo rm (s e x u a lly tra n s m itte d )

■ B K v iru s : re je c tio n in k id n e y tra n s p la n t p a tie n ts ; re n a l fa ilu re in A ID S p a tie n ts □ M o s t p e o p le h ave a s y m p to m a tic in fe c tio n a nd a n tib o d ie s b y 10 y e a rs old

ISBN 978-08 9 1 8 9 -6 6 7 8

109

3: Microbiology

Virology>DNA viruses | Positive sense RNA viruses □ L a te n t in fe c tio n in k id n e y s a n d C N S ; v iru ria ra re in n o rm a l h o s ts □ B M T : h e m o rrh a g ic c y s titis □ R e n a l tra n s p la n t: tu b u lo in te rs titia l n e p h ritis , u re te ra l o b s tru c tio n d u e to u ro e p ith e liitis □ N o d is e a s e a s s o c ia tio n w ith H IV □ D ia g n o s is ■ L a rg e , h o m o g e n o u s , p u rp le in tra n u c le a r in c lu s io n s in tu b u la r e p ith e lia l c e lls ■ C a n u s e an im m u n o s ta in to s e e in fe c te d c e lls in k id n e y b io p s y ■ L o o k fo r d e c o y c e lls in u rin e o f re n a l tra n s p la n t p a tie n ts : s m u d g y u ro th e lia l c e lls ■ C a n q u a n tita te b lo o d a n d u rin e le v e ls w ith P C R

3.2.3.6 3.2.3.6 .1

Poxviridae: enveloped, double stranded, linear DNA V a rio la : c a u s e s s m a llp o x

■ 7-17 d a y s in c u b a tio n ; 2 -4 d a y p ro d ro m e ; e x a n th e m la s ts 1-2 w e e k s ■ A ll le s io n s a re th e s a m e a g e a n d a re m o n o m o rp h ic ■ T h e ra sh s ta rts o n o ra l m u c o s a o r p a la te , s p re a d s to a rm s , la te r to tru n k a n d b a c k □ M o s t p ro m in e n t o n fa c e a n d e x tre m itie s ■ P a lm s a n d s o le s a re a ffe c te d ■ E ra d ic a te d in 1 9 8 0

i3.5 Molluscum contagiosum a H&E stained sections demonstrate a craterlike papilliferous lesion b Characteristic intracytoplasmic molluscum bodies

3 .2 .3 .6 .2 V a ccin ia ■ V a ria n t o f v a rio la th a t p ro d u c e s m ild d is e a s e ■ U se d a s a v e c to r fo r g e n e th e ra p y a n d a s a v a c c in e

3 .2 .3 .6 .3 M o llu sc u m c o n tag io s u m ■ In fe c ts e p ith e lia l c e lls ■ S m a ll w a x y p a p u le s w ith c e n tra l u m b ilic a tio n ■ C h ild re n : fa c e , tru n k , lim b s; y o u n g a d u lts : lo w e r a b d o m e n , p u b is, in n e r th ig h s , g e n ita lia ■ O p p o rtu n is t in H IV ■ R e s o lv e s s p o n ta n e o u s ly in a fe w m o n th s ■ H is to lo g y (h ig h ly c h a ra c te ris tic ): la rg e e o s in o p h ilic c y to p la s m ic in c lu s io n b o d ie s in skin b io p s y (H e n d e rs o n P a te rs o n b o d ie s ) i3.5

■ P o s s ib le a g e n t o f b io te rro ris m t3.12 ■ H is to lo g y : G u a rn ie ri b o d ie s : p in k c y to p la s m ic in c lu s io n s t3 .1 2 CDC classification of agents of bioterrorism

Category A (highest priority)

Category B (2nd priority)

variola (smallpox) Hemorrhagic fever viruses

Category C (3rd priority; emerging threat agents)

Encephalitis viruses (a viruses) influenza viruses Brucella species (brucellosis) Nipah virus Burkholderia mallei (glanders) hantavirus Bacillus anthracis Burkholderia pseudomallei rabies virus (anthrax) (melioidosis) yellow fever virus Yersinia pestis (plague) Chlamydophila psittaci drug resistant TB Clostridium botulinum Coxiella burnetii (Q fever) Rickettsia conorii (botulism) Clostridium perfringens toxin Francisella tularensis food borne bacteria (eg, (tularemia) Salmonella species, E coli 0157:H7, Shigella) waterborne bacteria (eg, Vibrio

cholerae, Cryptosporidium species)

Rickettsia prowazekii (typhus

3.2.4 Positive sense RNA viruses 3.2.4.1 Coronaviridae ■ E n ve lo p e d , s in g le s tra n d e d R N A w ith s u rfa c e p ro je c tio n s ■ D is e a s e s : u p p e r re s p ira to ry in fe c tio n s , in fa n t g a s tro e n te ritis ■ eg, S A R S ■ D o e s n o t g ro w w e ll in c u ltu re ■ No flu o re s c e n t a g e n ts

3.2.4.2 Flaviviridae: enveloped, single stranded RNA 3.2.4.2.1 D e n g u e virus ■ B re a k b o n e fe ve r: fever, m u s c le a nd jo in t pain, c h a ra c te ris tic skin rash; ca n d e v e lo p into h e m o rrh a g ic d is e a s e ■ T ra n s m itte d by A e d e s a e g y p ti o r A e d e s a lb o p ic tu s m o s q u ito e s

fever)

Staphylococcus aureus enterotoxin B

3 .2 .4 .2 .2 St Louis en c e p h a litis virus ■ T ra n s m itte d by m o s q u ito s

110

ASCP Quick Compendium of Clinical Pathology 4e

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3: Microbiology

Virology>Positive sense RNA viruses ■ M a n y p e o p le a re a s y m p to m a tic , c a n c a u s e m ild d is e a s e o r s e v e re e n c e p h a litis

■ E v e n tu a lly le a d s to c irrh o s is in -1 5 % ; 5% o f th o s e w ith c irrh o s is d e v e lo p h e p a to c e llu la r c a rc in o m a ■ A ls o a s s o c ia te d w ith c ry o g lo b u lin e m ia , g lo m e ru lo n e p h ritis , a n d a p la s tic a n e m ia

3 .2 .4 .2 .3 Y ellow fe ver viru s ■ T ra n s m itte d by A e d e s a e g y p ti o r A e d e s a lb o p ic tu s m o s q u ito e s ■ M o s t c a s e s a re m ild , w ith fever, h e a d a c h e , c h ills , n a u s e a a n d v o m itin g la s tin g 3 -4 d a y s ■ 15% o f c a s e s h ave a s e c o n d p h a se : re c u rrin g fever, ja u n d ic e , a nd b le e d in g ■ C o u n c ilm a n b o d ie s a re s e e n in h e p a to c y te s (u su a lly fro m a u to p s y ; liv e r b io p s ie s a re n o t o fte n d o n e d u e to b le e d in g risk) ■ A tte n u a te d v iru s v a c c in e is a v a ila b le

3 .2 .4 .2 .4 W est N ile viru s ■ T ra n s m itte d by C u le x m o s q u ito s ; b ird s a re re s e rv o ir; h u m a n s a re in c id e n ta l h o s t ■ C a u s e s a s p e c tru m o f d is e a s e s : W N fever, W N n e u ro in v a s iv e d is e a s e , W N e n c e p h a litis

■ D ia g n o s is : a n ti-H C V a n tib o d ie s □ H C V R N A by q u a n tita tiv e P C R is u s e d to e s ta b lis h b a s e lin e v ire m ia a nd m o n ito r tre a tm e n t re s p o n s e ■ S u s ta in e d v iro lo g ic re s p o n s e (S V R ): u n d e te c ta b le R N A 24 w e e k s a fte r th e e n d o f tre a tm e n t □ G e n o ty p e : p e rfo rm e d on all p a tie n ts a t th e tim e o f d ia g n o s is b e c a u s e it g u id e s th e ra p e u tic re g im e n ■ In th e U S, G e n o ty p e 1 is th e m o s t c o m m o n ; G e n o ty p e 1 is fu rth e r s u b d iv id e d in to 1a a n d 1b; 1a is m o re c o m m o n a n d m o re lik e ly to d e v e lo p re s is ta n c e to tre a tm e n t □ S o m e p o ly m o rp h y s m s m a y a ls o h e lp g u id e th e ra p y (N S 3 , N S 5 a ) 3 .2 .4 .2 .6 H e p a titis G viru s ■ P a re n te ra lly tra n s m itte d t3.13 ■ R a re c h ro n ic ity ■ N o t c le a rly d e m o n s tra te d to c a u s e h e p a titis

3 .2 .4 .2 .5 H e p atitis C v iru s t3.13 t3.13 Hepatitis viruses Virus Transmission Incubation HAV

fecal-oral

HBV

parenteral

HCV

parenteral

HDV

parenteral

3.2.4.3 Picornaviridae: no envelope, single stranded RNA Chronicity

Comments

Most common viral hepatitis in US; abrupt onset 2%-10% of everyone, Usually 15-150 days, insidious; average 60-90 30%-90% of mortality: children 20 y e a rs

□ E n te ro v iru s D 6 8 ■ R e s p ira to ry in fe c tio n s ; c a u s e d a U S n a tio n w id e o u tb re a k in 2 0 1 4 □ H e p a titis A v iru s

□ A ID S : w h e n C D 4 < 2 0 0 o r th e re is an A ID S d e fin in g illn e s s (p n e u m o c y s tis p n e u m o n ia [40% ], w a s tin g s y n d ro m e /c a c h e x ia [2 0 % ], e s o p h a g e a l c a n d id ia s is )

■ F e c a l-o ra l tra n s m is s io n t3.13

■ O p p o rtu n is tic in fe c tio n s

■ M o re c o m m o n in d e v e lo p in g c o u n trie s d u e to w a te r c o n ta m in a tio n

■ V ira l in d u c e d c a n c e rs : K a p o s i s a rc o m a , B u rk itt ly m p h o m a , c e rv ic a l c a n c e r, m a n y o th e rs

■ In th e U S , s e e n in d a y c a re s a n d o th e r c ro w d e d in s titu tio n s ■ S y m p to m s : fa tig u e , fe ve r, a b d o m in a l p a in , ja u n d ic e ; u s u a lly la s t < 2 m o n th s ■ ~ 5 % o f c a s e s re la p s e , u s u a lly w ith in m o n th s , b u t c h ro n ic ity d o e s n o t o c c u r like o th e r h e p a titis v iru s e s

■ D ia g n o s is : w ritte n c o n s e n t is no lo n g e r re q u ire d ; m a n y s ta te s a d o p tin g o p t o u t a p p ro a c h □ S e ro lo g y : s e e C D C w e b s ite fo r th e m o s t u p d a te d s c re e n in g g u id e lin e s ■ S c re e n w ith E L IS A ■ 4 th g e n e ra tio n a s s a y s a re re c o m m e n d e d by th e C D C a n d c u rre n t s ta n d a rd o f c a re

■ D ia g n o s e o f a c u te in fe c tio n w ith Ig M a n ti-H A V ; IgG a n ti-H A V m a y in d ic a te a c u te o r p a s t in fe c tio n a nd p e rs is t fo r life

■ D e te c t a n tib o d ie s to HIV1 o r 2 a nd th e p24 a n tig e n

■ K ille d v iru s v a c c in e

■ S o m e m a n u fa c tu re rs re q u ire re p e a tin g th e te s t if p o s itiv e

■ R h in o v iru s □ V e ry im p o rta n t c a u s e o f th e c o m m o n c o ld □ - 1 0 2 s e ro ty p e s □ D ia g n o s is : m a in ly P C R

3.2.4.4 3 .2 .4 .4 .1

Retroviridae: enveloped, single stranded RNA H u m a n im m u n o d e fic ie n c y v iru s (H IV )

■ L e n tiv iru s s u b fa m ily ■ T ra n s m itte d p rim a rily v ia se x; a ls o th ro u g h b lo o d tra n s fu s io n , v e rtic a l tra n s m is s io n fro m m o m to in fa n t, n e e d le s tic k , h y p o d e rm ic n e e d le s ■ 3 d is tin c tiv e g e n e s

■ C a n d e te c t in fe c tio n 2 -4 w e e k s a fte r e x p o s u re

■ 5th g e n e ra tio n : n o t c u rre n tly w id e ly u sed, d iffe re n tia te p24 a n tig e n vs HIV1 a nd H IV 2 a n tib o d ie s ; th e th e o re tic a l a d v a n ta g e is th a t if yo u k n o w th e p a tie n t h as p 24 b u t no a n tib o d ie s , yo u k n o w th e y h ave e a rly in fe c tio n ■ If s c re e n is p o s itiv e , p e rfo rm d iffe re n tia tio n im m u n o a s s a y fo r HIV1 a nd H IV 2 a n tib o d ie s ■ If s c re e n is p o s itiv e b u t d iffe re n tia tio n a s s a y is n e g a tive , c o n firm w ith H IV R N A m o le c u la r te s t (P C R ) ■ H is to ric a lly c o n firm e d w ith W e s te rn blot: lo o k fo r a n y 2 o f th e fo llo w in g b a n d s: p24, gp41, g p 1 2 0 /1 6 0 i3.6 ■ O th e r la b o ra to ry a s s a y s

□ G a g : s tru c tu ra l p ro te in s

□ V ira l load: re v e rs e tra n s c rip ta s e P C R ; u sed fo r m o n ito rin g tre a tm e n t o r c o n firm in g d ia g n o s is

□ P ol: re v e rs e tra n s c rip ta s e □ E n v: e n v e lo p e g ly c o p ro te in s ■ In itia te s in fe c tio n by in te ra c tio n o f G P 1 2 0 o n v ira l e n v e lo p e w ith C D 4 ly m p h o c y te re c e p to r, C X C R 4 o r CCR5

112

□ M u ta tio n s in C X C R 4 o r C C R 5 ca n th e o re tic a lly m ake s o m e o n e re s is ta n t to H IV in fe c tio n (in 2007, an H IV + m an w ith le u k e m ia w a s tre a te d w ith a b o n e m a rro w tra n s p la n t fro m s o m e o n e w h o had a m u ta n t C C R 5 a nd w a s c u re d o f H IV )

□ C D 4 c o u n t b y flo w c y to m e try : fo llo w d is e a s e p ro g re s s io n

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

3: Microbiology

Virology>Positive sense RNA viruses | Negative sense RNA viruses 3.2.4.5 Togaviridae: enveloped, single stranded RNA p!8

p24 p31 p40 gp41 p51/55

p65 gpl20/160

3.2.4.5.1 a viru ses: a rb o rv iru s e s w ith m o s q u ito v e c to rs

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■ E a s te rn e q u in e e n c e p h a lo m y e litis v iru s ■ W e s te rn e q u in e e n c e p h a lo m y e litis v iru s ■ V e n e z u e la n e q u in e e n c e p h a lo m y e litis v iru s

3 4

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i3.6 HIV western blot Lane 1 is negative control Lane 2 is weak positive control & lane 6 is the strong positive control Lanes 3-5 are positive patient samples □ G e n o ty p e m u ta tio n s c o n fe rrin g re s is ta n c e : te s t all p a tie n ts a t th e tim e o f d ia g n o s is a nd if tre a tm e n t fa ils; s o m e s tra in s a re re s is ta n t to c e rta in a n tire tro v ira l d ru g s a nd s tra in s ca n d e v e lo p re s is ta n c e (e s p e c ia lly if im p ro p e rly tre a te d , eg, m o n o th e ra p y ) □ P ro vira l D N A P C R : d ia g n o s is o f n e o n a ta l H IV in fe c tio n □ P o in t o f c a re te s ts a v a ila b le ; lo n g e r w in d o w p e rio d th a n lab b a se d a s s a y s

3 .2 .4 .5 .2 R u b iviru s: rubella ■ G e rm a n m e a s le s : m o rb illifo rm ra sh a nd ly m p h a d e n o p a th y ■ P e rs o n to p e rs o n sp re a d ■ C o n g e n ita l in fe c tio n s d u rin g firs t trim e s te r c a n b e v e ry se v e re : s e n s o rin e u ra l d e a fn e s s , c a ta ra c ts , g la u c o m a , m ic ro p h th a lm ia , c o n g e n ita l h e a rt d is e a s e (P D A ), in tra u te rin e g ro w th re s tric tio n , m ic ro c e p h a ly ; te s t all w o m e n o f c h ild b e a rin g a ge fo r Ig G p rio r to p re g n a n c y ; if n o n im m u n e , re v a c c in a te ■ Live, a tte n u a te d v a c c in e

3.2.4.6 Caliciviridae: Norwalk virus; no envelope, single stranded RNA ■ C a u s e s e p id e m ic g a s tro e n te ritis ; no s e a s o n a lity ■ S u rv iv e s fo r d a y s on in a n im a te s u rfa c e s , in w a te r, s h e llfis h , p re p a re d fo o d s ■ D ia g n o s is : e le c tro n m ic ro s c o p y

□ A t h o m e te s ts m a y b e c o m e a v a ila b le

3.2.4.7 Astroviridae 3 .2 .4 .4 .2

■ 7 s e ro ty p e s

H T L V : h u m a n T ly m p h o t r o p ic v ir u s

■ D ia rrh e a ; m o s t s e v e re in p a tie n ts Negative sense RNA viruses o C h a ra c te ris tic p e n ta d : n e u tro p h ilia , N O to x ic g ra n u lo c y te c h a n g e s in n e u tro p h ils , th ro m b o c y to p e n ia , in c re a s e d h e m o g lo b in (h e m o c o n c e n tra tio n ), > 1 0 % o f ly m p h o c y te s h a v e im m u n o b la s tic m o rp h o lo g y ■ O th e r B u n y a v irid a e v iru s e s : R ift V a lle y fe v e r v iru s , C rim e a n C o n g o h e m o rrh a g ic fe ve r, C a lifo rn ia e n c e p h a litis

3.2.5.2 Orthom yxoviridae; influenza; enveloped, single stranded RNA ■ T ra n s m itte d v ia re s p ira to ry d ro p le ts ■ R N A is c o m p o s e d o f 8 s e g m e n ts ■ G ly c o p ro te in s

□ In tra m u s c u la r k ille d v iru s v a c c in e □ In tra n a s a l live a tte n u a te d v iru s v a c c in e (F lu m is t): n ot re c o m m e n d e d b e c a u s e d a ta s h o w e d th a t it d id n ot p ro v id e a p ro te c tiv e b e n e fit ■ T re a tm e n t □ Z a n a m iv ir a nd o s e lta m iv ir (T a m iflu ): n e u ra m in id a s e in h ib ito rs ; th e ra p y a nd p re v e n tio n o f A a nd B □ A m a n tid in e /rim a n tid in e : b lo c k v ira l e n try ; th e ra p y a nd p re v e n tio n o f in flu e n z a A o n ly ; n o t u se d a n y m o re b e c a u s e o f re s is ta n t s tra in s

3.2.5.3 Paramyxoviridae: enveloped, single stranded RNA

□ H e m a g g lu tin in : b in d s c e llu la r re c e p to r site ; b e c o m e s e x p re s s e d o n in fe c te d c e lls w h ic h is w h y th e h e m a d s o rp tio n te s t is p o s itiv e (b u t n o t ro u tin e ly p e rfo rm e d ; o th e r h e m a d s o rp tio n p o s itiv e v iru s e s a re p a ra in flu e n z a a n d m u m p s ) □ N e u ra m in id a s e : re le a s e o f v irio n s fro m in fe c te d c e lls ■ A n tig e n ic c h a n g e s p re v e n t life lo n g im m u n ity □ A n tig e n ic d rift: p o in t m u ta tio n s in th e v ira l g e n o m e (o c c u rs in in flu e n z a A a n d B); p ro d u c e s a n n u a l o u tb re a k s a n d e p id e m ic s □ A n tig e n ic s h ift: re c o m b in a tio n o f h u m a n a n d a n im a l R N A s e g m e n ts (in flu e n z a A o n ly); p ro d u c e s w o rld w id e p a n d e m ic s e v e ry 1 0 -2 0 y e a rs ■ D ia g n o s is

3.2.5.3.1 P a ra in flu en za: cro u p ■ C ro u p : s te e p le s ig n , h o a rs e n e s s , b a rk in g c o u g h ; ca n a lso c a u s e b ro n c h io litis a n d p n e u m o n ia ■ D ia g n o s is : P C R is m o s t c o m m o n ly u sed ; c o u ld a ls o u se DFA, tra d itio n a l c u ltu re , s h e ll via l, h e m a d s o rp tio n te s t (flu, p a ra flu , a n d m u m p s a re p o s itiv e )

3 .2 .5 .3 .2 M um ps ■ E n la rg e d p a ro tid s , te s te s a n d o v a rie s ; p o s s ib ly a ls o m y o c a rd itis a n d m e n in g o e n c e p h a litis ■ R e c e n t o u tb re a k s in c o lle g e s tu d e n ts b e c a u s e v a c c in e p ro te c tio n is n o t c o m p le te ■ Live, a tte n u a te d v a c c in e

□ P re fe rre d s p e c im e n is n a s o p h a ry n g e a l sw a b , a ls o ca n u s e b ro n c h o a lv e o la r la v a g e ; le s s p re fe rre d a re th ro a t a n d n a s a l s w a b s ; a n y s p e c im e n s h o u ld be p la c e d in v ira l tra n s p o rt m e d ia □ P C R : s o m e n e w e r te c h n o lo g ie s a re ra p id ( - 3 0 - 6 0 m in ) a n d v e ry e a s y to p e rfo rm ; s o m e a re C L IA w a iv e d so th e y c a n e a s ily b e p e rfo rm e d in a c lin ic , u rg e n t c a re c e n te r, e tc; e x tre m e ly h ig h s e n s itiv ity a n d s p e c ific ity ; c a n d e te rm in e s u b ty p e a n d s tra in

3 .2 .5 .3 .3 M easles: ru b eo la ■ C la s s ic p ro d ro m e o f c o u g h , c o ry z a (in fla m e d m u c o u s m e m b ra n e s o f n ose, m o u th , eyes), c o n ju n c tiv itis w ith / w ith o u t K o p lik s p o ts ■ D e s c e n d in g ra sh b e g in n in g on th e hea d ■ C an be c o m p lic a te d by o titis m e d ia , p n e u m o n ia , m y o c a rd itis

□ R a p id a n tig e n te s ts : e asy, fa s t ( - 1 0 m in u te s ), d o n o t n e e d e q u ip m e n t; v e ry lo w (a s lo w a s 2 0 % ) s e n s itiv ity

■ A ty p ic a l m e a s le s : p o s s ib le in te e n a g e rs w h o o n ly re c e iv e d 1 v a c c in a tio n d o s e

□ C u ltu re : tra d itio n a l (v e ry lo n g in c u b a tio n re q u ire d ) and s h e ll v ia l (24 h o u rs ); n o t ro u tin e ly u se d

a S u b a c u te s c le ro s in g p a n e n c e p h a litis : v e ry ra re c o m p lic a tio n o f p e rs is te n t in fe c tio n ; o c c u rs - 1 0 y e a rs a fte r in fe c tio n

□ D F A (d ire c t flu o re s c e n t a n tib o d y ): ra p id b u t re q u ire s flu o re s c e n t s c o p e a n d s k ille d s ta ff; m o s tly re p la c e d by PCR □ S e ro lo g y : c a n c o n firm in fe c tio n w ith a c u te a nd c o n v a le s c e n t se ra ; n o w m o s tly u s e d to d e te rm in e v a c c in e re s p o n s e a n d s u s c e p tib ility to in fe c tio n ■ S e v e re m o rb id ity a ttrib u te d to c o m p lic a tio n s o f a c u te in fe c tio n : m o s t c o m m o n c a u s e o f d e a th is p o s tin flu e n z a b a c te ria l p n e u m o n ia ; o th e r c o m p lic a tio n s in c lu d e in flu e n z a p n e u m o n ia , R e y e s y n d ro m e , m y o s itis , m y o c a rd itis , G u illa in -B a rre s y n d ro m e

114

■ V a c c in e s

a W a rth in -F in k e ld e y ce lls: la rg e m u ltin u c le a te d ce lls,

c o n ta in e o s in o p h ilic n u c le a r a nd c y to p la s m ic in c lu s io n s a Live, a tte n u a te d v a c c in e

3 .2 .5 .3 .4 R e s p ira to ry s y n cytial viru s (R SV ) a M a jo r c a u s e o f b ro n c h io litis a n d p n e u m o n ia in infan ts; lo c a liz e d o u tb re a k s (d a y c a re s ) w ith n e a rly 100% a tta c k rate a E o s in o p h ilic c y to p la s m ic in c lu s io n s (n o t n u c le a r)

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

3: Microbiology

Virology>Negative sense RNA viruses | Reoviridae: double stranded RNA; no envelope

i3.8 Classic intracytoplasmic inclusion of rabies virus in the brain

i3.7 RSV pneumonitis with classic syncytia formation

■ D ia g n o s is □ P C R is th e m a in s ta y o f d ia g n o s is □ C P E : c h a ra c te ris tic c y to p a th ic e ffe c t in c e ll cu ltu re : fu s io n o f a d ja c e n t c e lls into la rg e m u ltin u c le a te d s y n c y tiu m ■ C P E an b e s e e n in c u ltu re (H E p 2 ce lls); tra d itio n a l c u ltu re ta k e s a lon g tim e , sh e ll v ia l c u ltu re s ta k e s ~ 4 8 h o u rs; n o t ro u tin e ly p e rfo rm e d ■ C P E an be se e n in lun g h is to lo g y i3.7 ■ Im m u n ity is s h o rt lived so re c u rre n c e ca n o c c u r th ro u g h o u t c h ild h o o d (b u t m o s t s e v e re d is e a s e o c c u rs in in fa n ts)

■ In fe c ts n e rv e fib e rs (e s p e c ia lly th e h ip p o c a m p u s ): tra n s m itte d fro m s ite o f a n im a l b ite to C N S v ia re tro g ra d e fa s t a x o n a l tra n s p o rt ■ C a n a c q u ire fro m a n im a l b ite s (m o s tly d o g s a n d c a ts in a re a s w ith p o o r c o n tro l, in a re a s w ith g o o d c o n tro l, m o s t in fe c tio n s a re fro m b a ts, w o lfs , c o y o te s , fo x e s , s k u n k s , ra c c o o n s )

3.2.5.5 Filoviridae: enveloped, single stranded RNA ■ M a rb u rg a n d E b o la v iru s e s : A fric a n h e m o rrh a g ic fe v e rs

3.2.5.6 Arenaviridae ■ L y m p h o c y tic c h o rio m e n in g itis v iru s ; E n v e lo p e d , s in g le s tra n d e d R N A

■ T re a tm e n t □ S u p p o rtiv e □ P a liv iz u m a b : m o n o c lo n a l a n tib o d y to F g ly c o p ro te in on R S V s u rfa c e ■ G iv e n to c e rta in c h ild re n w h o m e e t c rite ria (eg, p re m a tu re a nd Reoviridae: double stranded RNA; no envelope Parasitology>Laboratory methods □ M o re c o m m o n in w in te r

■ JC : H IV /im m u n o s u p p re s s e d

□ D ia g n o s is : P C R o r E IA (c a n n o t c u ltu re ) O rb iv iru s e s : C o lo ra d o tic k fe v e r

H e p a titis : h e p a titis A , B, C, D, E, H SV, EBV, C M V , A d e n o v iru s

3.2.7 Other viruses 3.27.1 Hepatitis D virus ■ C a n o n ly re p lic a te in th e p re s e n c e o f h e p a titis B ■ If p re s e n t, th e d is e a s e c a u s e d b y h e p a titis B is m o re s e v e re

3.27.2 Prions

■ G a s tro e n te ritis : ro ta v iru s , n o ro v iru s , a d e n o v iru s , e n te ro v iru s e s , C M V

3.2.9.1 Pregnancy ■ T ra n s m is s io n d u rin g p a s s a g e th ro u g h b irth c a n a l: HIV, HPV, H S V ■ T ra n s p la c e n ta l tra n s m is s io n : ru b e lla , HIV, C M V

■ N o t a c tu a lly v iru s e s ■ O n ly m a d e o f p ro te in (no n u c le ic a c id ) ■ P rP : p rio n p ro te in ■ D is e a s e s : s u b a c u te s p o n g ifo rm e n c e p h a lo p a th ie s : K u ru , C J D

■ T ra n s m is s io n in b re a s t m ilk: C M V , H B V

3.3 Parasitology 3.3.1 Laboratory methods 3.3.1.1 Direct examination: body sites and possible parasites recovered are summarized in t3.14

3.2.8 Vaccines ■ L iv e , a tte n u a te d : m e a s le s , m u m p s , ru b e lla , R o ta v iru s , s h in g le s ■ K ille d v iru s : in flu e n z a , p o lio , h e p a titis A , ra b ie s ■ C o n ju g a te : H B V , H P V , p e rtu s s is , p n e u m o c o c c u s ■ T o x o id : d ip h th e ria , te ta n u s

3.2.9 Implicated viruses by disease states ■ M o n o lik e d is e a s e : E B V , C M V , H H V 6 , H IV , T o x o p la s m a g o n d ii • F lu lik e /lo w e r re s p ira to ry tra c t d is e a s e : in flu e n z a A , B, a d e n o v iru s , R S V , h u m a n m e ta p n e u m o v iru s , p a ra in flu e n z a , rh in o v iru s , c y to m e g a lo v iru s , V Z V , H SV, h a n ta v iru s , S A R S ■ E n c e p h a litis □ H S V : te m p o ra l lo b e □ C M V : p a tie n ts w ith H IV □ V Z V : c o n c u rre n t/re c e n t in fe c tio n □ EBV □ A rb o rv iru s e s ■ S t L o u is: T e x a s , Illin o is , In d ia n a , O h io ■ E a s te rn e q u in e : A tla n tic /G u lf ■ W e s te rn e q u in e : w e s t o f M is s is s ip p i R iv e r ■ C a lifo rn ia -L a C ro s s e : M id w e s t ■ R a b ie s : a n im a l b ite o r b a t e x p o s u re ■ E n te ro v iru s e s : s u m m e r/fa ll; ra s h (e ch o , p o lio , c o x s a c k ie ) ■ C h ild re n : M M R ■ L C M : fa ll/w in te r, m o u s e o r h a m s te r e x p o s u re 116

O c u la r in fe c tio n s : e n te ro v iru s , a d e n o v iru s , HSV, V Z V , C M V , v a c c in ia , m e a s le s

t3 .1 4 Most common parasites by body site* Body site Parasites Intestinal tract Entamoeba spp, lodamoeba butschlii, Endolimax nana, Biastocystis hominis, Giardia intestinalis, Chilomastix mesnili, Dientamoeba fragilis, Balantidium coli, Cryptosporidium spp, Cyclospora cayetanensis, Cystoisospora belli, microsporidia, Ascaris lumbricoides, Enterobius vermicularis, hookworm, Strongyloides stercoralis, Trichuris trichiura, Hymenolepis nana, Hymenolepis diminuta, Taenia saginata, Taenia solium, Diphyllobothrium latum, Dipylidium caninum, Schistosoma spp (eggs only), Fasciolopsis buski Blood erythrocytes: Plasmodium spp & Babesia spp leukocytes: Leishmania spp & Toxoplasma gondii whole blood/plasma: Trypanosoma spp, microfilariae Bone marrow Leishmania spp, Plasmodium spp Central nervous Taenia solium (neurocysticercosis), Echinococcus spp, system Naegleria fowled, Acanthamoeba spp, Balamuthia mandrillaris, Toxoplasma gondii, microsporidia* & Trypanosoma brucei Cutaneous ulcer Leishmania spp, Acanthamoeba spp Liver, spleen Echinococcus spp, Entamoeba histolytica, Leishmania spp, microsporidia*Schistosoma mansoni & japonicum (eggs only), Fasciola hepatica, Clonorchis sinensis Muscle Trichinella spp, Taenia solium (cysticerci), Trypanosoma cruzi, microsporidia* Lungs Cryptosporidium spp, Echinococcus spp, Paragonimus spp, Toxoplasma gondii, Strongyloides stercoralis larvae, microsporidia* Skin & Leishmania spp, Onchocerca volvulus, microfilariae, Sarcoptes subcutaneous scabei, Loa loa (adult worm) tissue Urogenital system Trichomonas vaginalis, Schistosoma spp (eggs only), microsporidia* microfilariae Eyes Acanthamoeba spp, Toxoplasma gondii, Loa loa, Onchocerca volvulus, microsporidia* 'Microsporidia are fungi but diagnostically and clinically fit better with protozoan parasites

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

3: Microbiology

Parasitology>Laboratory methods | Protozoa ■ S to o l o va a nd p a ra s ite e x a m in a tio n (h is to ric a lly w a s m a in s ta y o f id e n tific a tio n ) □ 3 s p e c im e n s a t le a s t 24 h o u rs a p a rt re q u ire d to e x c lu d e in fe c tio n

■ G a s tro in te s tin a l P C R p a n e ls m a y in c lu d e p a ra s ite s (G ia rd ia , E n ta m o e b a h is to ly tic a , C y c lo s p o ra , C ry p to s p o rid iu m ) a s a s ta n d a lo n e P C R p a ra s ite G l p a n e l o r in a d d itio n to b a c te ria a n d v iru s e s

□ F re sh s p e c im e n s h o u ld be e x a m in e d w ith in 1 h o u r; if g re a te r tra n s p o rt tim e e x is ts , u s e a p re s e rv a tiv e

3.3.2 Protozoa

□ C o m p o n e n ts o f O & P

3.3.2.1 Gastrointestinal protozoa i3.9

■ C o n c e n tra tio n w ith e x a m in a tio n o f a w e t p rep ■ P e rm a n e n t p re p a ra tio n w ith e x a m in a tio n o f tric h ro m e sta in

3.3.2.1.1 Entamoeba histolytica i3.10 ■ M o rp h o lo g ic a lly in d is tin g u is h a b le fro m th e n o n p a th o g e n ic E d is p a r

□ P ro to z o a th a t a re lik e ly to be m is s e d on a ro u tin e O & P in c lu d e C ry p to s p o rid iu m spp, C y c lo s p o ra c a y e ta n e n s is , and C y s to is o s p o ra (fo rm e rly Is o s p o ra ) b e lli; th e s e re q u ire m o d ifie d a c id -fa s t (K in y o u n , D M S O , o r a u ra m in e -O ) o r m o d ifie d s a fra n in s ta in s

m D ia g n o s is fro m s to o l s p e c im e n : p e rfo rm a n c e o f P C R is

s u p e rio r to E IA w h ic h is s u p e rio r to m ic ro s c o p ic e x a m (O & P ) □ T ro p h o z o ite c h a ra c te ris tic s ■ M e a s u re 1 5-2 0 pm

■ D u o d e n a l c o n te n ts e xa m □ D e te c tio n o f d u o d e n a l in fe c tio n s s u c h a s G ia rd ia o r S tro n g y io id e s

■ N u c le u s h a s s m a ll, c e n tra l k a ry o s o m e a n d fin e p e rip h e ra l c h ro m a tin a p p lie d e v e n ly to th e in n e r n u c le a r m e m b ra n e

□ C o lle c te d u sin g d ire c t a s p ira tio n d u rin g e n d o s c o p y o r v ia s trin g te c h n iq u e

■ C y to p la s m h a s a g ro u n d g la s s a p p e a ra n c e a n d m a y c o n ta in in g e ste d red c e lls

■ T a pe p re p a ra tio n fo r d e te c tio n o f E n te ro b iu s v e rm ic u la ris (p in w o rm )

■ R e s p ira to ry s p e c im e n O & P fo r d e te c tio n o f P a ra g o n im u s sp p (lu n g flu k e ) e g g s , S tro n g y io id e s s te rc o ra lis la rv a e a nd h o o k le ts o f E c h in o c o c c u s s p p fro m ru p tu re d h yd a tid c y s ts

trophozoites

□ M ic ro fila ria e e x is t e x tra c e llu la rly in th e b lo o d (W u c h e re ria b a n c ro fti, B ru g ia m a la yi, L o a loa, M a n s o n e lla spp)

y

3.3.1.4 Molecular methods ■ P C R is a v a ila b le fo r m a n y p a ra s ite s (eg, T o xop lasm a g o n d ii P C R in C S F fo r a p a tie n t w ith FIIV)

Giemsa stain

■J

none known

♦

i3.9 Common intestinal & genitourinary flagellates (modified trichrome stain unless indicated) Entamoeba histolytica/ dispar trophozoites cysts

■ P e rfo rm e d by p la tin g th e s p e c im e n (ie, c o rn e a l s c ra p in g s ) on a p la te w ith a la w n o f E c o li a n d th e n o b s e rv in g th e p la te fo r fe e d tra c k s (the b a c te ria s e rv e as fo o d fo r th e p a ra site )

*

' scale: ,-------------. = 10 pm

3.3.1.3 Culture ■ C u rre n tly lim ite d to fre e livin g a m e b a e (A c a n th a m o e b a and N a e g la ria )

Trichomonas vaginalis

?

none known

3.3.1.2 Serology ■ D ia g n o s is o f a m e b ic liv e r a b s c e s s e s d u e to E h is to ly tic a

i

Dientamoeba fragilis

%, '

' ■ P re n a ta l a nd p re /p o s t tra n s p la n t T o xo p la sm a te s tin g

-

»

cysts

□ P la s m o d iu m a n d B a b e s ia in e ry th ro c y te s (G ie m s a s ta in e d th ic k a nd th in film s )

Chilomastix mesnili

Giardia intestinalis

■ B lo o d

« •

Entamoeba coli

Entamoeba hartmanni

Endolimax nana

lodamoeba butschlii

0 4 m :•> * • * * scale: ,------ , = 10 pm

i3.10 Amebae © A S C P 2018

ISBN 978-08 9 1 8 9 -6 6 7 8

117

3: Microbiology

h

Parasitology>Protozoa

D

iM t r•

* ■/

i3.11 H&E stained sections of amebic colitis a Low magnification shows classic flask shaped ulcer b Higher magnification reveals trophozoites with ingested RBCs

ll® i3.12 Giardia trophozoites

if -

t *

■

'

>S -a

v r*

' :J W

a

■ E ry th ro p h a g o c y to s is th e o n ly fe a tu re th a t ca n d iffe re n tia te E h is to ly tic a fro m E d is p a r ■ In w e t m o u n ts , p ro g re s s iv e u n id ire c tio n a l m o tility □ C y s t c h a ra c te ris tic s ■ H a v e u p to 4 n u c le i, m a y c o n ta in c h ro m a to id a l b o d ie s w ith s m o o th ro u n d e d e n d s ■ C lin ic a l fe a tu re s

i3.13 Balantidium coir, a trophozoite (unstained), b cyst (iron hematoxylin stain)

□ A c q u ire d th ro u g h in g e s tio n o f c y s ts in fe c a lly c o n ta m in a te d fo o d o r w a te r □ D is trib u tio n w o rld w id e □ R a n g e s fro m a s y m p to m a tic to p ro tra c te d d ia rrh e a □ R a re ly in v a d e s in te s tin a l w a ll a n d d is s e m in a te s to th e liv e r □ A m e b ic a b s c e s s e s a re d e s c rib e d a s c o n ta in in g a n c h o v y p a s te lik e m a te ria l □ In te s tin a l fla s k s h a p e d u lce r, u s u a lly in th e c e c u m i3.11 3.3.2.1.2 Giardia lamblia ■ T ro p h o z o ite s (1 0 -2 0 p m in le n g th ) s e e n in sto o l s p e c im e n s o r s m a ll b o w e l b io p s ie s □ W h e n v ie w e d fro m to p , k ite s h a p e d w ith c e n tra l axonem e □ F ro m s id e , c o m m a s h a p e d i3.12

3.3.2.1.3 Balantidium coli ■ T h e o n ly c ilia te d p ro to z o a n h u m a n p a ra s ite i3.13 ■ V e ry larg e, up to 2 0 0 pm ■ C an se e on H & E s ta in e d G l b io p s ie s 3.3.2.1.4 Coccidia ■ In fe c tio n fo u n d p rin c ip a lly in d e v e lo p in g c o u n trie s , but h as b e e n id e n tifie d a s a fo o d b o rn e d is e a s e in th e U n ite d S ta te s fro m im p o rte d s o ft fru its a n d v e g e ta b le s ; a ls o s p re a d in w a te r p a rk s /p u b lic s w im m in g p o o ls; ca n c a u s e se v e re , p ro tra c te d w a te ry d ia rrh e a e s p e c ia lly in im m u n o c o m p ro m is e d h o s ts ■ N e e d to d o m o d ifie d a c id fa s t s ta in , n o t a tric h ro m e sta in as in a ro u tin e O & P

3 . 3 . 2 . 1. 4.1 Cryptosporidium parvum

□ F la g e lla n o t e a s ily s e e n

■ D ia g n o s is

□ In w e t s p e c im e n s , c h a ra c te ris tic fa llin g le a f m o tility ■ C y s ts (1 0-1 4 p m ) o v a l a n d c o n ta in 4 n u c le i lo c a te d a lo n g c e n tra l a x o n e m e

□ S m a ll in te s tin a l b io p sy : d o m e s h a p e d , 8 -15 pm , b a s o p h ilic s tru c tu re s a t th e a p ic a l s u rfa c e o f e n te ro c y te s

■ P C R o r E IA h a v e h ig h e r s e n s itiv ity c o m p a re d w ith m ic ro s c o p ic e x a m (O & P )

□ S to o l sa m p le s : 4 -6 p m o o c y s ts w h ic h a re v is ib le w ith m o d ifie d a cid fa s t sta in

■ C lin ic a l fe a tu re s

□ S to o l P C R and E IA , b o th a re m o re s e n s itiv e th a n O&P

□ M o s t c o m m o n c a u s e o f p ro to z o a l g a s tro e n te ritis □ W o rld w id e d is trib u tio n □ A s s o c ia te d w ith d a y c a re c e n te rs , ski re s o rts , a nd b a c k c o u n try h ik in g /c a m p in g 118

□ M a jo r c a u s e o f p ro tra c te d w a te ry d ia rrh e a in im m u n o c o m p ro m is e d h o s ts

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3: Microbiology

Parasitology>Protozoa 3.3.2.1.4.2 C y c lo s p o ra c a y e ta n e n s is ■ D ia g n o s is □ S m a ll b o w e l b io p sy : d iffe re n t s ta g e s o f th e o rg a n is m in s id e e n te ro c y te s □ S to o l s a m p le s : P C R o r v is ib le w ith m o d ifie d a c id fa s t sta in o r by a u to flu o re s c e n c e 3.3.2.1.4.3 C y s to is o s p o ra (formerly Isospora) b e lli ■ D ia g n o s is □ S m a ll in te s tin a l b io p sy : o val s tru c tu re s w ith in e n te ro c y te s □ S to o l: o o c y s ts , 2 5 -3 0 pm , w ith ty p ic a l e llip s o id a l s h a p e a nd 1 o r 2 s p o ro c y s ts v is ib le w ith m o d ifie d a cid fa s t sta in

3.3.2.2

Blood and tissue protozoa

3.3.2.2.1 Babesia

■ F a ta l d is e a s e o c c u rs m a in ly in s p le n e c to m iz e d a n d im m u n o c o m p ro m is e d h osts

3.3.2.2.1.1 Diagnosis ■ P C R : u sed fo r in itia l s c re e n in g o r c o n firm a tio n d u rin g a c u te illn e s s ■ D ire c t o b s e rv a tio n in b lo o d s m e a r □ T ro p h o z o ite s o fte n m u ltip le in red c e lls i3.14; m a y fo rm d ia d s o r te tra d s (M a lte s e c ro ss); lig h t b lu e rin g fo rm s w ith red c h ro m a tin d o ts □ E x tra e ry th ro c y tic rin g fo rm s o fte n p re s e n t

m 4 m a jo r s p e c ie s c a u s e m a la ria : P fa lc ip a ru m , P v iva x , P o vale, P m a la ria e m H u m a n c a s e s o f P k n o w le s i a ls o re p o rte d in s o u th e a s t A s ia ■ F o u n d in tro p ic s a n d s u b tro p ic s w o rld w id e

□ N o p ig m e n t o r n o n rin g fo rm s se e n

□ P o v a le c o n fin e d to p a rts o f w e s te rn A fric a

■ A n tib a b e s ia l a n tib o d ie s m a y be m is le a d in g , e s p e c ia lly in p la c e s w ith high p re v a le n c e □ A n tib o d y titer, by IFA, o f >1:1024 th o u g h t to in d ica te a c tiv e in fe c tio n □ R e m o te in fe c tio n ty p ic a lly h ave a tite r o f P rotozoa ■ T h e fir s t w e e k is a s y m p to m a tic ■ A fte r firs t w e e k , d u rin g th e in itia l s ta g e s o f e ry th ro c y te s c h iz o g o n y , s y m p to m s a re v a g u e ■ W ith in w e e k s s c h iz o g o n y b e c o m e s s y n c h ro n iz e d and p ro d u c e s fe v e r c y c le s ■ E v e n tu a lly , s y m p to m s a re p a ro x y s m a l, w ith s y m p to m a tic p e rio d s la s tin g 6 -1 2 h o u rs a n d c o rre la tin g w ith in te rm itte n t in tra v a s c u la r h e m o ly s is ■ S o m e c lin ic a l fe a tu re s a re s p e c ie s s p e c ific □ F e v e r s p ik e s e v e ry 4 8 h o u rs (te rtia n fe v e r): P o v a le , P v iva x , P fa lc ip a ru m □ F e v e r s p ik e s e v e ry 7 2 h o u rs (q u a rta n fe v e r): P m a la ria e □ L e th a lity : P fa lc ip a ru m (m a lig n a n t te rtia n m a la ria ) □ N e p h ro tic s y n d ro m e : P m a la ria e □ C N S in v o lv e m e n t: P fa lc ip a ru m □ H e m o s id e rin u ria , h e m o g lo b in u ria , a n d re n a l fa ilu re : P fa lc ip a ru m (b la c k w a te r fe v e r) □ T ru e re la p s e /re c u rre n c e : P viva x, P o v a le m R e in v a s io n o f red b lo o d c e lls b y liv e r m e ro z o ite s (fro m h e p a tic h y p n o z o ite s ), a fte r c o m p le te c le a rin g o f th e b lo o d s tre a m b y th e ra p y o r im m u n ity ■ In c o n tra s t to re c ru d e s c e n c e , w h ic h is re tu rn o f s y m p to m s d u e to in c o m p le te c le a rin g o f th e b lo o d □ M ix e d in fe c tio n s : 5 % o f c a s e s , m o s t o fte n P fa lc ip a ru m a n d P v iv a x ■ E ffe c t o f in h e rite d re d c e ll a n o m a lie s o n m a la ria □ H e m o g lo b in S: p ro te c tiv e a g a in s t P fa lc ip a ru m □ T h a la s s e m ia , H b C , H b E , h e re d ita ry p e rs is te n c e o f H b F : th o u g h t to b e p ro te c tiv e a g a in s t all s p e c ie s □ D u ffy n e g a tiv e b lo o d ty p e : p ro te c tiv e a g a in s t P v iv a x □ G lu c o s e -6 -p h o s p h a te d e h y d ro g e n a s e (G 6 P D ) d e fic ie n c y : p ro te c tiv e a g a in s t a ll s p e c ie s □ H e re d ita ry o v a lo c y to s is : th o u g h t to b e p ro te c tiv e a g a in s t c e re b ra l m a la ria 3.3.2.2.2.3

Laboratory evaluation

t3.15 Plasmodium spp P vivax/P ovale P malariae P falciparum enlarged small to normal all sizes (reticulocyte), may size be oval shaped and fimbriated (P ovale) Ring form 51/3 the size of thick, small (1/3 delicate, small ( 2% p a ra s ite m ia is c o n s id e re d se v e re □ A fte r tre a tm e n t in itia te d , tra n s ie n t in c re a s e in p a ra s ite m ia fo llo w e d by p ro g re s s iv e d im in u tio n

■ R a p id a n tig e n te s t: p e rfo rm e d on w h o le b lo o d ; ca n d iffe re n tia te P fa lc ip a ru m v s n o n fa lc ip a ru m ; h ig h s e n s itiv ity

■ S in g le n e g a tiv e s m e a r in s u ffic ie n t to e x c lu d e m a la ria ; 2 -3 s m e a rs o v e r a 24 h o u r p e rio d a re p re fe rre d

■ T h ic k b lo o d film fo r s c re e n in g ; th in b lo o d film fo r s p e c ie s id e n tific a tio n t3.15, i3.15, i3.16

■ Id e al tim e to o b ta in s p e c im e n is p re c e d in g th e n e x t a n tic ip a te d fe v e r sp ik e

□ E x a m in a tio n o f a t le a s t 1 00 o il im m e rs io n th ic k film fie ld s o r 3 0 0 th in film fie ld s is re q u ire d to a c h ie v e th e re p o rte d s e n s itiv ity (5 p a ra s ite s /p L ) □ D e g re e o f p a ra s ite m ia (% in fe c te d red c e lls ) m o s t im p o rta n t w ith P fa lc ip a ru m

120

■ F o rm s fo u n d in b lo o d □ E a rly tro p h o z o ite s (ring fo rm s ): in e a rly s ta g e s o c c u p y Protozoa P malariae

late stage trophozoite

early stage trophozoite (ring form)

P falciparum

.

0 1L Not usually seen in peripheral blood

IP

4,

i

tjQ m

(

band form schizont

P ovale

P vivax

\ amlboid trophozoite

comet form

$

Not usually seen in peripheral blood

i3.17 Reduviid bug, vector of Trypanosoma cruzi

rosette schizont

Of

CD

O o "(D E CD CD

f banana form

( f t

Qi

..

♦ 3.3.2.2.3 Trypanosoma

i3.15 Malaria forms

■ T ry p o m a s tig o te s ca n be fo u n d in th e p e rip h e ra l b lo o d in a c u te p h a se ; fin d in g p e rip h e ra l b lo o d try p o m a s tig o te s ca n be a id e d b y b u ffy c o a t e x a m □ T c ru z i 2 0 p m a n d C sh a p e d w ith a la rg e p o s te rio r k in e to p la s t □ T b ru c e i 3 0 p m a n d d e lic a te ly c u rv e d w ith a s m a ll p o s te rio r k in e to p la s t ■ C a n be fo u n d in h e a rt o r o th e r a ffe c te d o rg a n in c h ro n ic phase ■ M o re o fte n d ia g n o s e d by s e ro lo g y ■ T c ru z i is th e c a u s e o f C h a g a s d is e a s e (A m e ric a n try p a n o s o m ia s is ) □ C a n in fe c t th e m u s c u la ris o f th e d is ta l e s o p h a g u s re s u ltin g in a c h a la s ia □ C a n in fe c t m y o c a rd iu m ; le a d in g c a u s e o f h e a rt fa ilu re in S o u th a n d C e n tra l A m e ric a i3.16 Thick blood film showing numerous early trophozoite (ring) forms of Plasmodium falciparum □ S c h iz o n t ru p tu re s and re le a s e s th e m e ro z o ite s to in fe c t o th e r R B C s □ S o m e tro p h o z o ite s d e v e lo p to fo rm a g a m e to c y te ; a s o lid m o n o n u c le a r s tru c tu re o c c u p y in g >1/2 th e red cell th a t is th e in fe c tiv e s ta g e fo r th e m o s q u ito □ M a tu re s ta g e s m a y c o n ta in h e m a tin (b ro w n b la ck) p ig m e n t, a h e m e b re a k d o w n p ro d u c t

□ A c q u ire d fro m re d u v iid (k is s in g ) b u g i3.17 ■ In o c u la tio n site (c h a g o m a ) o fte n o n th e fa c e ■ R o rn a h a s ig n (p a lp e b ra l a n d p e rio c u la r s w e llin g ) is a ty p e o f c h a g o m a ■ R e d u v iid b u g s fo u n d in h o m e s c o n s tru c te d o f m u d , a d o b e , th a tc h □ C a n a ls o be tra n s m itte d in o th e r w a y s : m o th e r to c h ild , in g e s tio n , tra n s fu s io n ■ T b ru c e i is th e c a u s e o f A fric a n s le e p in g s ic k n e s s (A fric a n try p a n o s o m ia s is ) □ A c q u ire d fro m ts e ts e (G lo s s in a ) fly

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ISBN 978-08 9 1 8 9 -6 6 7 8

121

3: Microbiology

Parasitology>Protozoa 3 .3 .2 .2 .4 Toxoplasma gondii • D ia g n o s is □ B io p s y i3.18, i3.19: ta c h y z o ite s a re 3 -5 p m c u rv e d s tru c tu re s w ith la rg e e c c e n tric n u c le u s ; n o k in e to p la s t; b ra d y z o ite s a re th e in tra c e llu la r re p lic a tiv e fo rm □ S e ro lo g y : Ig M p o s itiv e in c o n g e n ita l a n d a c u te in fe c tio n ; ris in g o r v e ry h ig h (> 1 :1 0 2 4 ) Ig G a ls o s u g g e s ts re c e n t in fe c tio n ; lo w le v e l Ig G s u g g e s ts p rio r in fe c tio n a n d s u g g e s ts th a t a p re g n a n t w o m a n is n o t a t ris k □ PCR ■ C a t is th e d e fin itiv e h o s t ■ T ra n s m itte d b y in g e s tio n o f c a t fe c e s th a t c o n ta in o o c y s t; in g e s tio n o f u n d e rc o o k e d m e a t o f a n im a ls h a rb o rin g tis s u e c y s ts ; b lo o d /o rg a n tra n s p la n ta tio n ; tra n s p la c e n ta lly ■ C lin ic a l fe a tu re s

i3.18 Toxoplasma gondii, acute toxoplasmosis is characterized by clusters of epithelioid histiocytes (arrow) that impinge upon germinal centers & monocytoid B cell expansion (arrowhead)

□ M o n o n u c le o s is -lik e s y n d ro m e w ith p o s te rio r c e rv ic a l ly m p h a d e n o p a th y □ W h e n a c q u ire d d u rin g p re g n a n c y : in th e firs t trim e s te r, th e re is ris k o f fe ta l lo s s ; in la te p re g n a n c y th e re is ris k o f fe ta l C N S in fe c tio n (p e riv e n tric u la r c a lc ific a tio n a n d c h o rio re tin itis ) □ Im m u n o c o m p ro m is e d p a tie n ts a t ris k fo r C N S to x o p la s m o s is i3,19 Toxoplasma gondii cysts

3 .3 .2 .2 .5 L e is h m a n ia i3.20

t3.1 6 Differential diagnosis for multiple tiny 2-5 pm

Leishmania spp Histoplasma capsulatum

Toxoplasma gondii

Trypanosoma cruzi

Trypanosoma cruzi

promastigote

trypomastigote

Trypanosoma brucei trypomastigote

>• f

c

Cell type infected

amastigotes with a small, histiocytes barlike kinetoplast, GMSsmall oval yeasts with histiocytes narrow based budding, pseudocapsule on H&E, GMS+ somewhat curved multiple cell types tachyzoites, mostly extracellular, some in cysts, GMSamastigotes with a large multiple cell types including prominent kinetoplast, heart muscle (classic) GMS-

. nonmotile form (amastigote)

intracellular organism s i3.2l Differentiating Organism features

Leishmania species

flagellated form

■ B e s t d ia g n o s e d b y b io p s y o f in fe c te d tis s u e : G ie m s a s ta in e d s m e a rs o r H & E s ta in e d s e c tio n s s h o w 2 -5 pm in tra c e llu la r a m a s tig o te s w ith in h is tio c y te s t3.16

*

«

none known

K ,

*

i3.20 Hemoflagellates; images not shown to scale

Leishmania

amastigotes

Trypanosoma cruzi Toxoplasma gondii amastigotes

^ *

• l

tachyzoites

Histoplasma capsulatum yeasts

•

□ O v a l, w ith s m a ll n u c le u s a d ja c e n t to d is tin c t rod s h a p e d k in e to p la s t □ K in e to p la s ts a ls o fo u n d in T ry p a n o s o m a s p p

-

.

w *

i3.21 Intracellular organisms

122

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3: Microbiology

Parasitology>Protozoa | Helminths ■ C u ta n e o u s i3.22 ■ L tro p ic a , L m ajor, L a e th io p ic a (O ld W o rld ); L m e x ic a n a , L b ra z ilie n s is (N e w W o rld ) ■ S o lita ry s e lf lim itin g c u ta n e o u s le s io n a t o r n e a r th e in s e c t b ite ■ M u c o c u ta n e o u s ■ L b ra z ilie n s is c o m p le x ■ O ra l/n a s a l p e rs is te n t a nd h ig h ly d e s tru c tiv e le s io n s ■ V is c e ra l (ka la a z a r) ■ L donovani

i3.22 Cutaneous leishmaniasis; small amastiqotes are visible within histiocytes (arrow) although the detail of the kinetoplast is not easily appreciated in formalin fixed paraffin embedded tissue

■ H e p a to s p le n ic a nd b o n e m a rro w in fe c tio n

3.3.2.2.6

Trichomonas hominis

m S e x u a lly tra n s m itte d ■ T ro p h o z o ite s : p e a r s h a p e d w ith la rg e n u c le u s a t th e a n te rio r e nd o f a c e n tra l a x o s ty le ■ U n d u la tin g m e m b ra n e th a t e x te n d s a b o u t h a lfw a y d o w n th e o rg a n is m ■ C h a ra c te ris tic je rk y n o n d ire c tio n a l m o tility

3.3.2.3

Free living amebae

■ F o un d w id e ly in th e e n v iro n m e n t; ra re o p p o rtu n is tic h u m a n p a th o g e n s ■ S o u rc e : w a te r (a ir c o n d itio n in g , lake s, m e d ic in a l e q u ip m e n t (d ia lysis), d e n ta l e q u ip m e n t, neti pot, c o n ta c t le n s ca se); in fe c tio n o c c u rs via c o n ta c t w ith u lc e ra te d o r b ro ke n skin o r in h a la tio n i3.23

3.3.2.3.1 Naegleria fowleri ■ C a u s e s p rim a ry a m e b ic m e n in g o e n c e p h a litis (P A M ) ■ C h ild re n w h o h ave b e e n s w im m in g o r d iv in g in w a rm s ta g n a n t fre s h w a te r ■ E n te rs th ro u g h th e n a sa l c a v ity a nd tra v e ls to th e fro n ta l lo b e o f th e b ra in v ia th e o lfa c to ry n e rv e ru n n in g th ro u g h th e c rib rifo rm p la te ■ U s u a lly fa ta l

3.3.2.3.2 Acanthamoeba spp and Balamuthia mandrillaris □ C a u s e g ra n u lo m a to u s a m e b ic e n c e p h a litis (G A E ) ■ A c a n th a m o e b a s p p c a n c a u s e a m e b ic k e ra titis in c o n ta c t le n s w e a re rs ■ A s s o c ia te d w ith h o m e m a d e c o n ta c t s o lu tio n , u s e o f ta p w a te r fo r eye d ro p s , a n d e x te n d e d u s e o f c o n ta c ts □ H e m a to g e n o u s d is s e m in a tio n to b ra in ; o rg a n is m s fo u n d in p e riv a s c u la r s p a c e s

■ T ro p h o z o ite s fo u n d in C S F o r in m e n in g e s and s u rro u n d in g b ra in tis s u e ■ 1 0 -3 5 pm tro p h o z o ite s , s m a ll n u c le u s w ith a la rg e d e n s e c e n tra l k a ry o s o m e ■ C a n be m is ta k e n fo r m a c ro p h a g e s

□ C y s ts h ave 2 w a lls , 1 n u c le u s , la rg e k a ry o s o m e □ T ro p h o z o ite s p le o m o rp h ic ; s m a ll n u c le u s w ith a la rg e c e n tra l k a ry o s o m e

■ C a n be c u ltu re d on la w n o f b a c te ria (E coli) ■ C S F s p e c im e n s s h o u ld n ot b e re frig e ra te d p rio r to c u ltu re ■ C y s ts o f Naeglaria a re n o t fo u n d in b ra in tis s u e (.Acanthamoeba and Balamuthia d o fo rm c y s ts in b ra in tis s u e ) ©ASCP2018

ISBN 978-08 9189-6678

123

3: Microbiology

Parasitology>Helminths Taenia species

Hymenolepis nana

Hymenolepis diminuta

es- :

Diphylloboth rium latum

Dipylidium caninum

r )

n#

M-

□ C y s ts in liv e r (s o m e tim e s lu n g s o r C N S ) c o n ta in in g p ro to s c o le c e s a n d h o o k le ts (h yd a tid cyst) □ C y s ts a re fille d w ith n u m e ro u s p ro to s c o le c e s th a t g ro s s ly re s e m b le s a n d , h e n c e it is k n o w n a s h yd a tid sand □ U s u a lly d ia g n o s e d on im a g in g s tu d ie s ; c o n firm e d w ith p o s itiv e a n tib o d y te s ts ■ A c q u is itio n

scale: _ = 10 fjm

□ F o od c o n ta m in a te d w ith e g g s fro m sto o l o f in fe c te d d o g , th e d e fin itiv e h o s t

i3.24 Cestode eggs

□ S h e e p a n d c a ttle a re in te rm e d ia te h o sts, so in fe c tio n is m o re c o m m o n in h e rd in g a re a s

3.3.3 Helminths 3.3.3.1 Tapeworms (Cestodes) i3.24

3.3.3.1.1 Taenia solium (p o rk ta p e w o rm ) ■ D ia g n o s is □ E g g is id e n tic a l to th a t o f T s a g in a ta ; 3 0 -4 0 pm , s p h e ric a l, w ith th ic k ra d ia lly s tria te d w a ll □ P ro g lo ttid lo n g e r th a n it is w id e , w ith 13 la te ra l u te rin e b ra n c h e s ■ A c q u is itio n □ A c q u ire d b y in g e s tio n o f e n c y s te d o rg a n is m s (c y s tic e rc i) in b e e f □ S o u th a n d C e n tra l A m e ric a ; n o t fo u n d in U S ■ In fe c tio n □ S m a ll b o w e l in fe c tio n b y a d u lt w o rm □ E g g s o f T s a g in a ta n o t in fe c tio u s , u n lik e T s o liu m ; th u s c y s tic e rc o s is (la rv a l fo rm o f d is e a s e in h u m a n s ) d u e to T s a g in a ta d o e s n o t o c c u r

3 .3 .3 .1 .3 Echinococcus sp p (h y d a tid o s is ) ■ D ia g n o s is

124

■ D ia g n o s is □ E gg h as th in in n e r a nd o u te r s h e lls ; s p a c e in b e tw e e n c o n ta in s 2 p a irs o f p o la r fila m e n ts ; in n e r shell c o n ta in s e m b ry o w ith h o o k le ts ■ A c q u is itio n □ A c q u ire d fro m a c c id e n ta l in g e s tio n o f in fe c te d a rth ro p o d s (b e e tle s ) □ R e la tiv e ly c o m m o n in U S □ P e rs o n to p e rs o n s p re a d m a y o c c u r

3.3.3.1.6 Diphyllobothrium latum (fish ta p e w o rm or broad ta p e w o rm or broad fish tap ew o rm ) ■ D ia g n o s is □ Egg: 6 0 pm o val s tru c tu re w ith a s m o o th sh ell, u n s h o u ld e re d o p e rc u lu m , and s m a ll a b o p e rc u la r k n o b (s im ila r to P w e s te rm a n i, w h ic h is la rg e r a nd h as a s h o u ld e re d o p e rc u lu m ) □ P ro g lo ttid w id e r th a n it is lon g , w ith c o ile d u te ru s in th e s h a p e o f a ro s e tte ■ A c q u is itio n □ A c q u ire d th ro u g h in g e s tio n o f p o o rly c o o k e d fre s h w a te r fis h , re s u ltin g in in te s tin a l in fe c tio n □ Found in S c a n d in a v ia , R u s s ia , C a n a d a , n o rth e rn US, and A la s k a ■ C an lead to a s e v e re v ita m in B 12 d e fic ie n c y

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P a ra s ito lo g y > H e lm in th s

3.3.3.2

Flukes (Trematodes) i3.25 Schistosom a haem atobium

Schistosom a m a nsoni

S chistosom a ja p o n ic u m ^

species

*

species

. * V

■->k

H-

o

F a s cio la / Fascio-lopsis

P aragonim us

fm m

mm m If

0

, v Clonorchis/ Opisthorchis

species

k

|

m \ m J

V\ v .. .. ' V- . ■. :

scale: —, = 10 pm i3.25 Trematode ova; arrow denotes small lateral spine

i3.26 Partially calcified Schistosom a species eggs lodged in the intestinal wall

3.3.3.2.1

S c h is to s o m es 3 .3 .3 .2 .2 Paragonimus westermani (o rie n ta l lung flu k e )

■ L ife c y c le □ F o un d in s n a il in fe s te d w a te r

■ A c q u ire d by in g e s tio n o f u n d e rc o o k e d c ru s ta c e a n s

□ A c q u ire d th ro u g h p e n e tra tio n o f th e s k in (s w im m e r itch) by fo rk ta ile d c e rc a ria e

■ L u n g in fe c tio n a s s o c ia te d w ith w ith p n e u m o n itis

□ M ig ra te th ro u g h th e b lo o d s tre a m to m e s e n te ric and p e lv ic b lo o d v e s s e ls □ R e le a s e s e g g s into th e b lo o d s tre a m , w h ic h a re lo d g e d in s m a ll c a p illa rie s □ S o m e e g g s p e n e tra te b o w e l i3.26 o r b la d d e r w a ll to be e x c re te d in s to o l o r u rin e ■ C lin ic a l

■ D ia g n o s is : e g g (in s p u tu m o r s to o l) o v a l, 9 0 p m , w ith s h o u ld e re d o p e rc u lu m

3 .3 .3 .2 .3 Chlonorchis sinensis/Opisthorchis spp (liv e r fluke) ■ A c q u ire d th ro u g h in g e s tio n o f u n d e rc o o k e d fre s h w a te r fis h ■ F o u n d in p a rts o f A s ia

□ A c u te s ta g e m e d ia te d by c irc u la tin g im m u n e c o m p le x e s (K a ta y a m a fe v e r)

■ C h ro n ic b ilia ry in fe c tio n , le a d in g to b ilia ry fib ro s is ; ris k fa c to r fo r c h o la n g io c a rc in o m a

□ C h ro n ic s ta g e re fle c ts lo c a l tis s u e re a c tio n to e g g s

■ D ia g n o s is

t3.17 Schistosome species Geographic Tropism/disease distribution Species

□ A d u lts h ave a s n o u tlik e c e p h a la d

Egg appearance (all 75-150 pm)

lateral spine; eggs hepatic portal and South America, can be found in Caribbean, Africa, inferior mesenteric rectal biopsies vessels; resulting Middle East in portal fibrosis, cirrhosis, colitis liver; cirrhosis (rarely small, knoblike spine Far East S ja p o n icu m affects CNS) S haem atobium Africa, Middle East venous plexus of the terminal spine; eggs may be seen in bladder, leading urine or bladder to hematuria and biopsies irritative bladder symptoms; may result in squamous cell carcinoma of the bladder__________

□ Egg o val, 3 0 pm , w ith s h o u ld e re d o p e rc u lu m a n d s m a ll a b o p e rc u la r k n o b

S m ansoni

© A S C P 2018

3 .3 .3 .2 .4 Fasciola hepatica (liver flu k e) ■ A c q u ire d by in g e s tio n o f fre s h w a te r p la n ts (eg, w a te rc re s s ) ■ A s ia a nd th e M id d le E a st ■ In fe c tio n o f th e b ile d u c ts and h e p a tic p a re n c h y m a w ith re s u ltin g fib ro s is /c irrh o s is ■ D ia g n o s is □ A d u lt h a s c e p h a lic c o n e □ Egg 1 0 0 -1 5 0 p m , o val, w ith th in s h e ll, u n s h o u ld e re d o p e rc u lu m , a b o p e rc u la r k n o b (id e n tic a l to th a t o f F b u s k i)

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3: Microbiology

Parasitology>Helminths Enterobius vermicularis

Ascaris lumbricoides fertile infertile

Trichuris trichiura

> ygffl o

hookworm •■to

’’

scale: _ = 10 gm i3.28 Nematode eggs

■ A s c a ris lu m b ric o id e s (ro u n d w o rm )

i3.27 Enterobius vermicularis in cross section

□ L a rg e s t n e m a to d e p a ra s itiz in g th e h u m a n in te s tin e ; a d u lts a v e ra g e 3 5 cm in le n g th and 4 m m in d ia m e te r

3 .3 .3 .2 .5 Fasciolopsis buski ■ A c q u ire d b y in g e s tio n o f fre s h w a te r p la n ts ■ A s ia a n d th e In d ia n s u b c o n tin e n t

□ In fe c tio n re s u lts fro m in g e s tio n o f e g g s w h ic h h a tch to p ro d u c e la rv a e

■ In fe c tio n o f d u o d e n u m ■ D ia g n o s is □ A d u lt h a s p o in te d , b u t n o t c o n ic a l, c e p h a la d □ E g g id e n tic a l to F h e p a tic a

3.3.3.3 3.3.3.3.1

□ L a rv a e p e n e tra te m u c o s a , e n te r b lo o d s tre a m a nd c a rrie d to lu n g s; m a y p ro d u c e tra n s ie n t in filtra te s w ith e o s in o p h ilia (L o ffle r s y n d ro m e ) □ E x p e c to ra te d a nd s w a llo w e d , m a tu re into a d u lts w h ic h in fe s t d u o d e n u m

Roundworms (Nematodes)

□ A s y m p to m a tic o r c o m p lic a te d by b o w e l o b s tru c tio n , c h o la n g itis , o r a p p e n d ic itis

In te s tin a l n e m a to d e s

■ E n te ro b iu s v e rm ic u la ris (p in w o rm ) □ M o s t c o m m o n h e lm in th ic in fe c tio n in A m e ric a n c h ild re n □ In fe c tio n is a c q u ire d fro m in g e s tio n o f e g g s □ A d u lt fe m a le h a s s lig h tly b e n t a n d p o in te d (p in lik e ) ta il □ In c ro s s s e c tio n s , h a s c h a ra c te ris tic la te ra l a la e i3.27 □ E g g is a th in w a lle d 3 0 -5 0 p m o v a l w ith 1 s id e fla tte n e d , “ D -s h a p e d ” □ E g g n o t ro u tin e ly fo u n d in s to o l; c e llo p h a n e ta p e te s t fo r c o lle c tio n □ M a tu re fe m a le s in h a b it c e c u m a n d a p p e n d ix ; n o c tu rn a lly la y e g g s in p e ria n a l re g io n □ C o m m o n s y m p to m s a re a n a l p ru ritu s , v a g in itis , a n d / o r e n u re s is □ A p p e n d ic itis is an o c c a s io n a l c o m p lic a tio n

■ N e c a to r a m e ric a n u s a n d A n c y lo s to m a d u o d e n a le (h o o k w o rm s ) □ A d u lt h o o k w o rm s m e a s u re ~1 cm in le n g th □ M o u th p a rts d iffe r fro m o n e a n o th e r ■ N a m e ric a n u s h as c u ttin g p la te s; A d u o d e n a le has te e th □ E g g s in d is tin g u is h a b le fro m o n e a n o th e r ■ T h in tra n s lu c e n t w a ll e n c lo s e s m o ru la lik e c lu s te r o f s p h e ric a l e m b ry o s □ F o un d in A s ia and su b S a h a ra n A fric a , e s p e c ia lly c o a s ta l re g io n s ■ N a m e ric a n u s (b u t n o t A d u o d e n a le ) fo u n d in s o u th e a s te rn U n ite d S ta te s □ In fe c tio n re s u lts fro m p e n e tra tio n o f skin by la rv a e , u s u a lly s k in o f fe e t ■ L o c a liz e d p ru ritic le s io n (g ro u n d itch)

■ T ric h u ris tric h iu ra (w h ip w o rm ) □ A d u lt w o rm m e a s u re s up to 5 c m a n d h a s a w h ip lik e a n te rio r e n d

■ L a rv a e p a s s th ro u g h lu n g s (L o e ffle r s y n d ro m e ) are e x p e c to ra te d a nd s w a llo w e d

□ E g g s 5 0 * 2 5 p m , b ro w n is h th ic k s h e lls , b a rre l s h a p e d w ith b ila te ra l p o la r p lu g s

■ A d u lts in fe s t s m a ll b ow el; m a y p ro d u c e iron d e fic ie n c y a n e m ia

□ In fe c tio n a s y m p to m a tic to d y s e n te ry lik e ; re c ta l p ro la p s e in y o u n g c h ild re n

126

□ Egg 6 0 pm , b ile s ta in e d , th ic k h y a lin e sh e ll a n d ro u g h m a m m illa te d s u rfa c e i3.28

■ S tro n g y lo id e s s te rc o ra lis (th re a d w o rm ) □ D ia g n o s is

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3: Microbiology

Parasitology>Helminths ■ A d u lt fe m a le s m e a s u re - 3 m m ; b u rro w into in te s tin a l c ry p ts w h ic h ca n s o m e tim e s be s e e n in G l b io p s y ■ E gg id e n tic a l to th e h o o k w o rm e g g b u t u s u a lly n o t fo u n d in sto o l b e c a u s e e g g s h a tch in b ow el; th e re fo re , fe c e s c o n ta in rh a b d itifo rm la rv a e i3.29 ■ S to o l c u ltu re s w ill s h o w la rv a l tra c k s by p u llin g b a c te ria a ro u n d th e a g a r p la te □ F o un d in ■ T ro p ic a l a nd s u b tro p ic a l re g io n s th ro u g h o u t th e w o rld ■ A ls o in p a rts o f th e s o u th e a s te rn U S □ C o u rs e s im ila r to h o o k w o rm : p e n e tra tio n o f skin (g ro u n d itch), m ig ra tio n th ro u g h lu n g s, e x p e c to ra te d a nd s w a llo w e d , re s u ltin g in d u o d e n a l in fe c tio n □ In m a ln o u ris h e d h ost, la rv a e m a y p e n e tra te b ow el w a ll, c irc u la tin g th ro u g h th e lu n g s a n d re in fe c tin g th e d u o d e n u m (a u to in fe c tio n ) □ In im m u n o c o m p ro m is e d h ost, a u to in fe c tio n ca n lea d to h y p e rin fe c tio n , a p o te n tia lly d e a d ly c o m p lic a tio n in w h ic h la rv a e d is s e m in a te w id e ly ■ S u s p e c t h y p e rin fe c tio n w h e n s p in a l flu id c u ltu re g ro w s E c o li

■ C a u s e s tra n s ie n t m ig ra to ry e d e m a (c a la b a r s w e llin g s ) ■ D iu rn a l p e rio d ic ity □ D ra c u n c u lu s m e d in e s is : G u in e a w o rm ■ O b ta in e d b y in g e s tin g in fe c te d fre s h w a te r ■ M ig ra te to th e skin; fo rm a b lis te r ■ C a n g ro w up to 31 in c h e s ■ R e m o v e d by s lo w ly p u llin g th e w o rm o u t o f th e w o u n d by w ra p p in g it a ro u n d a s tic k (1 in c h p e r d ay) ■ Z o o n o tic n e m a to d e s □ T ric h in e lla s p ira lis

3.3 .3 .3 .2 T issu e n em ato d e s ■ L y m p h a tic fila ria s is : W u c h e re ria b a n c ro fti, B ru g ia tim o ri, and B ru g ia m a la y i □ A c q u ire d th ro u g h th e b ite o f m o s q u ito e s

■ C o n s u m p tio n o f u n d e rc o o k e d m e a t, e s p e c ia lly p o rk a n d w ild g a m e ■ In fe c tio n o f th e s k e le ta l m u s c le b y e n c y s te d la rv a e , p ro d u c in g m y o s itis and w e a k n e s s ■ C a n be s e e n o n h is to lo g ic s e c tio n s o f in fe c te d s k e le ta l m u s c le

□ In fe c t th e ly m p h a tic s , c a u s in g e le p h a n tia s is □ S h e d into b lo o d p rim a rily a t n ig h t (n o c tu rn a l p e rio d ic ity ) ■ H ig h e s t lik e lih o o d o f d e te c tio n is b e tw e e n 10 pm a nd 2 am ■ S u b c u ta n e o u s fila ria s is □ O n c h o c e rc a v o lv u lu s is a c q u ire d fro m th e S im u liu m b la c k fly ■ A d u lts ball up in a s u b c u ta n e o u s n o d u le (o n c h o c e rc o m a )

□ T o xoca ra c a n is (dog ro u n d w o rm ) a n d c a ti (c a t ro u n d w o rm ) ■ C a u s e s o f v is c e ra l la rva m ig ra n s a n d o c u la r la rv a m ig ra n s ■ O rg a n is m w a n d e rs th ro u g h o u t v a rio u s o rg a n s ■ P ro d u c e s s y n d ro m e o f h y p e re o s in o p h ilia , h e p a to s p le n o m e g a ly , and p n e u m o n itis □ A n is a k ia s is

■ R e le a s e m ic ro fila ria e into th e s u rro u n d in g skin

■ A c q u ire d fro m in g e s tio n o f ra w o r u n d e rc o o k e d fis h

■ M ic ro fila ria e m ig ra te th ro u g h th e s k in a nd eye

■ B io p s y m a y d is c lo s e an e o s in o p h il ric h g ra n u lo m a c o n ta in in g th e n e m a to d e

■ L e a d in g c a u s e o f b lin d n e s s (riv e r b lin d n e s s ) in c e n tra l A fric a a n d C e n tra l A m e ric a ■ D ia g n o s is is by id e n tify in g c h a ra c te ris tic la rv a e in s k in s n ip s □ L o a loa ■ A c q u ire d fro m th e m a n g o (C h ry s o p s ) fly ■ A d u lts m ig ra te th ro u g h s u b c u ta n e o u s and c o n ju n c tiv a l lo c a tio n s © A S C P 2018

□ D iro fila ria im m itis (d og h e a rtw o rm ) is a c q u ire d fro m a m o s q u ito ■ P re s e n ts a s a g ra n u lo m a to u s n o d u le s u rro u n d in g a d e g e n e ra tin g w o rm (m o s tly s u b c u ta n e o u s o r p u lm o n a ry b u t c a n be fo u n d in n e a rly a n y o rg a n ) ■ C o m m o n in c id e n ta l fin d in g

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3: Microbiology

Parasitology>Helminths Mycology>Fungal structure Cystoisospora belli oocysts (25-30 pm maximum dimension)

Cyciospora cayetanensis oocysts (8-10 pm diameter)

Cryptosporidium species oocysts (4-6 pm diameter)

Microsporidia species spores (0.8-4 pm maximum dimension)

3.4

Mycology

3.4.1 Fungal structure 3.4.1.1 Characteristics ■ E u k a ry o tic

. #„ 4

?

(chromotrope 2R stain)

scale: ,-------, = 10 pm i3.30 Coccidia & microsporidia (modified acid-fast stain unless indicated)

■ F a c u lta tiv e ly a n a e ro b ic o r s tric tly a e ro b ic ■ D e g ra d e o rg a n ic c a rb o n , p ro d u c e C 0 2 ■ L a c k c h lo ro p h y ll, n o n p h o to s y n th e tic

3.4.1.2 2 morphologic forms: yeasts and molds ■ Y e a s ts □ U n ic e llu la r

■ M ic ro s p o ra (M ic ro s p o rid ia ) i3.30 □ S p o re fo rm in g u n ic e llu la r o rg a n is m s , n o w th o u g h t to b e fu n g i

□ M o s t re p ro d u c e by b u d d in g ; d a u g h te r c e ll a ls o c a lle d b la s to c o n id ia

□ S p e c ie s : E n te ro c y to z o o n s p p a n d E n c e p h a lito z o o n spp

□ C o lo n ie s a re u s u a lly s m o o th a nd ro u n d , s im ila r to b a cte ria

□ D ia g n o s is ■ S m a ll in te s tin a l b io p s y : n u m e ro u s o v a l in tra c e llu la r o rg a n is m s in a p ic a l a s p e c t o f e n te ro c y te s ■ S to o l s a m p le s : 1-3 p m s p o re s th a t s ta in d e e p red w ith a m o d ifie d tric h ro m e s ta in

3.3.4 Additional pearls of parasitology t3.18-t3.20

□ P s e u d o h y p h a e : s tru c tu re s p ro d u c e d w h e n a d a u g h te r y e a s t ce ll d o e s n o t c o m p le te ly d e ta c h fro m th e p a re n t; d is tin g u is h fro m tru e h y p h a e by th e p re s e n c e o f a c o n s tric tio n a t th e ju n c tio n o f a d ja c e n t c e lls ■ M o ld s □ M u ltic e llu la r, fila m e n to u s □ C o lo n ie s lo o k w o o lly , flu ffy , v e lv e ty □ H y p h a e : fila m e n to u s s tru c tu re w ith s e p ta tio n , s o m e tim e s c a lle d tru e h y p h a e

t3.18 Parasitic oculocutaneous infections

□ M y c e liu m : m a s s o f h y p h a e

Loa foa—disease is caused by the adult worm________ Onchocerca volvulus—disease is caused by the larvae

□ C o n id io p h o re s : s tru c tu re th a t b e a rs c o n id ia /s p o re s (a se x u a l re p ro d u c tiv e s tru c tu re s )

t3.19 Parasitic infections capable of person to person spread Enterobius vermicularis____________________________ Hymenolepis nana__________________________________________

3.4.1.3 Subcellular structure ■ C ell w a ll: 1 c o m p o n e n t is c h itin ■ C ell m e m b ra n e ■ C y to p la s m

t3.20 Parasitic infections in im m unodeficient patients Type o f im m unodeficiency S usceptibility T cell (cellular) immunodeficiency many, eg, Toxoplasmosis, Cryptosporidium, Cystoisospora, Cyciospora, microsporidia, are more common ____________________________others, eg, Strongyloides, are more severe B cell (humoral) immunodeficiency Giardia more common_________________ Splenectomy_________________ babesiosis more severe_______________

■ S o m e h a ve p o ly s a c c h a rid e c a p s u le (eg, C ry p to c o c c u s )

3.4.1.4 Hyphal pigment ■ H ya lin e : clea r, c o lo rle s s , w ith o u t p ig m e n t □ C o lo n ie s ca n be p ig m e n te d d u e to c o lo r o f re p ro d u c tiv e s tru c tu re s ■ D e m a tia c e o u s : h y p h a e h ave d a rk b ro w n c o lo r □ C o lo n ie s s h o w d a rk p ig m e n t on both fro n t a nd b a c k (re v e rs e ) o f p la te

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3: Microbiology

Mycology>Diagnostic techniques

i3.32 C neoformans: India ink preparation at a low & b high magnification show spherical, narrow-budding yeasts with thick capsule ■ M y c o s e l (BBLO ) and m y c o b io tic (D ifc o ) a g a r: S A B + c h lo ra m p h e n ic o l and c y c lo h e x im id e u s e fu l fo r ta rg e tin g d e rm a to p h y te s o r th e rm a lly d im o rp h ic fu n g i b y in h ib itin g g ro w th o f b a c te ria a n d c e rta in fu n g i (C ry p to c o c c u s , A s p e rg illu s , Z y g o m y c e te s ) i3.31 Fungal hyphae stained with calcofluor white, viewed under UV light

3.4.2 Diagnostic techniques ■ D ire c t e x a m in a tio n □ K O H d is s o lv e s tis s u e (hair, s k in , n ails) to m a ke fu n g a l h y p h a e m o re v is ib le □ C a lc o flu o r w h ite : flu o re s c e s w h ite o r a p p le g re e n i3.31

□ In h ib ito ry m o ld a g a r: a d d e d c h lo ro a n d g e n t to in h ib it c o m m e n s a l b a c te ria ; g o o d fo r d im o rp h ic s ; n o t g re a t fo r d e rm a to p h y te s □ P o ta to d e x tro s e a g a r: g o o d fo r id e n tific a tio n o f fu n g i o n c e th e y h ave b e e n is o la te d b e c a u s e it e n c o u ra g e s fo rm a tio n o f fru itin g s tru c tu re s □ P o ta to fla k e a g a r: s im ila r u s e s to S A B H I □ D e rm a to p h y te te s t a g a r

□ G ra m sta in: p a rtic u la rly fo r y e a s ts , w h ic h u s u a lly sta in G ra m p o s itiv e

■ U se d to re c o v e r d e rm a to p h y te s fro m c o n ta m in a te d c lin ic a l s p e c im e n s

□ G ie m s a o r W rig h t sta in: ro u tin e s ta in u sed fo r b o n e m a rro w o r p e rip h e ra l s m e a rs ; ca n se e y e a s ts su ch a s C a n d id a o r H is to p la s m a

■ D e rm a to p h y te s tu rn th e m e d iu m fro m p in k to red: p re s u m p tiv e ly in d ic a te s th e p re s e n c e o f d e rm a to p h y te s

□ India ink: h is to ric a lly u s e d to d e te c t C ry p to c o c c u s in C S F (n e g a tiv e ly s ta in in g c a p s u le ); n o t u se d a n y m o re b e c a u s e it h as lo w s e n s itiv ity (50% ); a n tig e n te s t has h ig h e r s e n s itiv ity i3.32 a H is to p a th o lo g y ■ H & E : ca n se e h o s t re a c tio n a nd s o m e tim e s se e h y a lin e (b a s o p h ilic ) o r d e m a tia c e o u s (b ro w n ) hyphae

□ C o rn m e a l a g a r w ith T w een 8 0: g o o d fo r m ic ro s c o p ic m o rp h o lo g y o f y e a s ts □ B ird s e e d (n ig e r) a g a r: d e m o n s tra te s m e la n in in C ry p to c o c c u s (c o lo n ie s a p p e a r b ro w n ) □ C H R O M a g a r C a n d id a : e a c h s p e c ie s o f C a n d id a is a d iffe re n t c o lo r

■ P A S a nd G M S : h ig h lig h ts h y p h a e

■ M o ld id e n tific a tio n : re m o v e p ie c e s o f th e c o lo n y fro m a p la te u s in g tw e e z e rs o r s c o tc h ta p e ; p la c e ta p e a n d a d ro p o f d y e (eg, la c to p h e n o l c o tto n b lu e ) o n to a s lid e

■ F o n ta n a -M a s s o n : s ta in s m e la n in in C ry p to c o c c u s a nd d e m a tia c e o u s m o ld s

■ B io c h e m ic a ls : u se d m a in ly fo r y e a s ts ; d o n e on p a n e ls a n d a u to m a te d e q u ip m e n t

■ M u c ic a rm in e : s ta in s th e c a p s u le o f C ry p to c o c c u s m C u ltu re

□ U re a s e te s t: p o s itiv e in C ry p to c o c c u s , C a n d id a k ru s e i, T ric h o p h y to n m e n ta g ro p h y te s ■ S e ro lo g y

□ M e d ia : in c u b a te a t 2 5 ° -3 0 ° C fo r 4 -6 w e e k s □ B ra in -h e a rt in fu s io n a g a r w ith b lo o d : g e n e ra l p u rp o s e m e d ia a nd e n h a n c e d re c o v e ry o f d im o rp h ic fu n g i

□ A n tib o d y d e te c tio n : c o m p le m e n t fix a tio n o r im m u n o d iffu s io n a re th e b e s t te c h n iq u e s

□ S a b o u ra u d d e x tro s e a g a r (S A B ): g e n e ra l p u rp o s e m e d ia

□ A n tig e n d e te c tio n

■ S A B H I: a d d itio n o f h e a rt in fu s io n : b e tte r fo r fa s tid io u s fu n g i © A S C P 2018

■ A s p e rg illu s : s e ru m g a la c to m a n n a n b y E IA fo r in v a s iv e d is e a s e

ISBN 9 7 8 -08 9189-6678

129

3: Microbiology

Mycology>Diagnostic techniques | Yeasts ■ C ry p to c o c c u s : im m u n o c h ro m a to g ra p h ic d ip s tic k a s s a y fo r c a p s u la r a n tig e n in C S F a n d s e ru m ; o ld e r m e th o d is la te x a g g lu tin a tio n ■ H is to p la s m a : E IA on u rin e (b e s t) o r s e ru m in d is s e m in a te d d is e a s e ■ 1 ,3 -P -D -g lu c a n (F u n g ite ll) o n s e ru m in d is s e m in a te d d is e a s e ■ A s p e rg illu s , C a n d id a , F u s a riu m , T ric h o s p o ro n , P n e u m o c y s tis , d im o rp h ic s ■ C r y p to c o c c u s m a k e s v e ry lo w q u a n titie s ■ B la s to m y c e s a n d Z y g o m y c e te s d o n ’t m a k e it ■ M o le c u la r: u s u a lly ta rg e ts rib o s o m a l D N A g e n e c o m p le x ■ M A L D I-T O F m a s s s p e c tro m e try (s e e 3 .5 B a c te rio lo g y )

3.4.3 Yeasts 3.4.3.1 Candida

i3.33 Candida pseudohyphae seen in a GMS stained section

3 .4 .3 .1 .1 B a c k g r o u n d ■ C a n d id a is a p a rt o f th e n o rm a l flo ra o f G l tra c t, m u c o u s m e m b ra n e s , s k in ■ In fe c tio n s a re u s u a lly o p p o rtu n is tic , o c c u rrin g in im m u n o c o m p ro m is e d h o s ts ■ C e llu la r im m u n ity p ro te c ts a g a in s t m u c o c u ta n e o u s c a n d id ia s is ; n e u tro p h ils p ro te c t a g a in s t in v a s iv e c a n d id ia s is ■ S p e c ie s in c lu d e C a lb ic a n s , C g la b ra ta , C p a ra p s ilo s is , C tro p ic a l is, C k ru s e i, a n d C lu s ita n ia e

□ S y m p to m s in c lu d e b u rn in g , itc h in g , c h a ra c te ris tic c u rd lik e d is c h a rg e 3 .4 .3 .1 .3

D ia g n o s is

■ M o rp h o lo g y in tis s u e □ B u d d in g y e a s ts , p s e u d o h y p h a e i3.33, a nd tru e h y p h a e ca n all b e s e e n in tis s u e □ C a n d id a a lb ic a n s : 5 -7 pm

3 .4 .3 .1 .2 D is e a s e s

□ C a n d id a g la b ra ta : s m a lle r, 2 -4 pm

■ B lo o d s tre a m a n d in v a s iv e in fe c tio n

■ C u ltu re s

□ 3 rd m o s t c o m m o n c a u s e o f b lo o d s tre a m in fe c tio n in IC U s (C a lb ic a n s > C g la b ra ta > C p a ra p s ilo s is ) • S k in □ E ry th e m a , s o m e tim e s e x u d a te o r s c a lin g □ C o m m o n s ite s a re m o is t: in th e a re a o f a d ia p e r, in b e tw e e n fin g e rs o r to e s , u n d e r b re a s ts □ C h ro n ic m u c o c u ta n e o u s c a n d id ia s is : in h e rite d s y n d ro m e w ith c o m p ro m is e d le u k o c y te fu n c tio n , e n d o c rin e d y s fu n c tio n ■ T h ru s h

□ C a n d id a a lb ic a n s h as fe e t: fila m e n to u s e x te n s io n s fro m th e e d g e s o f th e co lo n y ; th e s e in d ica te th e p re s e n c e o f p s e u d o h y p h a e (not s e e n in o th e r s p e c ie s ) i3.34 □ M o s t s p e c ie s g ro w w ith in 24 h o u rs ; C g la b ra ta is s lo w e r (2 -3 d ays) □ C a n se e c h la m y d o c o n id ia in a w e t m o u n t m a d e fro m a c o lo n y g ro w n o n c o rn m e a l a g a r; o n ly m a d e by C a lb ic a n s a n d C d u b lin ie n s is i3.35

□ C re a m y w h ite p a tc h e s o n e ry th e m a to u s m u c o s a in th e m o u th

□ C H R O M a g a r: a p la te th a t w ill g ro w c o lo n ie s th a t a re a c e rta in c o lo r d e p e n d in g on th e s p e c ie s

□ C o m m o n in H IV p a tie n ts

□ C g la b ra ta : g ro w s s lo w e r th a n o th e r s p e c ie s ; y e a s t m e d iu m w ill n o t in d u c e s tru c tu re s o th e r th a n b u d d in g y e a s ts (no p s e u d o h y p h a e o r h y p h a e ) i3.36

■ G l: e ro s iv e le s io n s o f th e d is ta l e s o p h a g u s a re p a in fu l a n d a g g ra v a te d b y s w a llo w in g ■ V a g in itis □ P re d is p o s in g c o n d itio n s in c lu d e d ia b e te s , a n tib io tic u s e , p re g n a n c y , s e x u a l a c tiv ity 130

□ T is s u e , s c ra p in g s , s w a b s fro m m o u th o r e ls e w h e re s h o u ld be p la te d on p rim a ry fu n g a l m e d ia

■ G e rm tu b e □ E lo n g a te d , fin g e rlik e e x te n s io n fro m a y e a s t ce ll □ N o c o n s tric tio n a t th e ju n c tio n

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3: Microbiology

Mycology>Yeasts

i3.34 C albicans colonies frequently form filamentous extensions (“feet”) around the edges

i3.35 C albicans on yeast morphology medium: pseudohyphae with clusters of blastoconidia at septations & single terminal chlamydospores

□ R e p re s e n t th e b e g in n in g s o f tru e h y p h a e □ F o rm e d b y C a lb ic a n s a nd C d u b lin ie n s is a fte r g ro w th in s e ru m a t 37°C fo r Yeasts "

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i3.37 Cryptococcus, a GMS stained tissue section showing variably sized, spherical shaped yeasts displaying narrow-based budding, b Gram stained CSF showing a cluster of organisms held together by capsular material. Notice the negatively staining capsule, c Gram stained slide of a positive blood culture bottle after incubation. Cryptococcus stains gram positive and displays narrow based budding. i3.38 C neoformans: mucoid colonies on solid agar

□ CNS ■ M o s t c o m m o n fo c u s o f d is s e m in a te d C ry p to c o c c u s m S y m p to m s in c lu d e c h a n g e s in m e n ta l s ta tu s th a t

w ax and w ane ■ B a s ila r m e n in g itis w ith in v o lv e m e n t o f c ra n ia l n e rv e s ■ F e v e r is lo w g ra d e 3 .4 .3 .2 .3

D ia g n o s is

■ C o lo n ie s tu rn d a rk b ro w n d u e to o x id a tio n o f c a ffe ic a c id by d ip h e n o l o x id a s e e n z y m e , p ro d u c in g m e la n in p ig m e n t □ C G B (c a n a v a n im e -g ly c in e -b ro m o th y m o l) b lu e a g a r is n e e d e d to d iffe re n tia te C n e o fo rm a n s (no c o lo r ch a n g e , y e llo w /g re e n ) a n d C g a ttii (c o lo r c h a n g e to blue) ■ S e ro lo g y

■ T is s u e i3.37 □ L ittle o r n o in fla m m a to ry re s p o n s e is s e e n □ F o n ta n a -M a s s o n s ta in : h ig h lig h ts m e la n in p ig m e n t □ M u c ic a rm in e : s ta in s th e c a p s u le (if p re s e n t; c a p s u le p o o r s tra in s c o m m o n ) □ V a ria b le s iz e s (2 -2 0 pm ), ro u n d , b u d d in g

□ A n tig e n te s t v ia im m u n o c h ro m a to g ra p h ic d ip s tic k ■ E x c e lle n t te s t fo r d e te c tio n o f C ry p to c o c c u s in C S F a n d b lo o d ■ R e s u lts in a tite r w h ic h ca n be fo llo w e d fo r re s p o n s e to tre a tm e n t

□ M a y h a v e g ra n u lo m a to u s re s p o n s e in p o o rly e n c a p s u la te d s tra in s ; y e a s ts c a n b e fo u n d in m a c ro p h a g e c y to p la s m

■ F a lse p o s itiv e s : s y n e re s is flu id (c o n d e n s a tio n o n p la te s), ta lc , T ric h o s p o ro n b e ig e lii, s ilic o n iz e d tu b e s , im p ro p e rly c le a n e d s lid e fo r te st, E D T A , RF in n o n e n z y m e tre a te d s p e c im e n

□ In d ia ink: n o t o fte n u s e d a n y m o re b e c a u s e G ra m s ta in a n d a n tig e n te s t h a v e h ig h e r s e n s itiv ity ; w ill s h o w h a lo o f u n s ta in e d c a p s u le i3.30

■ F a lse n e g a tive s : p ro z o n e e ffe c t, a n tig e n b o u n d in im m u n e c o m p le x e s

■ C u ltu re □ G ro w s w e ll o n b lo o d a g a r p la te s a n d fu n g a l m e d ia □ C o lo n ie s lo o k m u c o id if th e s tra in h a s a la rg e c a p s u le ; m a n y s tra in s h a v e o n ly a s m a ll c a p s u le a n d c o lo n ie s d o n o t a p p e a r m u c o id i3.38 □ U re a s e p o s itiv e □ W e t p re p s fro m c o lo n ie s s h o w b u d d in g y e a s ts w ith o u t pseudohyphae 132

□ P h e n o l o x id a s e te s t: u se e ith e r b ird s e e d a g a r o r c a ffe ic a c id d is k

□ 1 ,3 -p -D -g lu c a n (F u n g ite ll) te s t n o t u seful □ P C R (C S F ): b e c o m in g m o re w id e ly a v a ila b le

3 .4 .3 .2 .4 T reatm en t ■ A m p h o te ric in B (+ flu c y to s in e ) ■ L ife lo n g flu c o n a z o le p ro p h y la x is fo llo w in g m e n in g itis tre a tm e n t in A ID S p a tie n ts

ASCP Quick Compendium of Clinical Pathology 4e

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3: Microbiology

Mycology>Yeasts | Dimorphic fungi 3.4.3.3 Malassezia

□ S o ft, w h ite to y e llo w n o d u le s lo o s e ly a tta c h e d to h a ir

3.4.3.3.1 B ackgroun d

□ T re a tm e n t: h y g ie n e (sh a vin g , c le a n in g ); a z o le s (u su a lly n o t n e e d e d )

■ N o rm a l flo ra o f skin , g ro w th is a s s is te d b y lip id s (like s o ily re g io n s o f skin )

□ F re q u e n t in tro p ic a l a nd te m p e ra te c lim a te s ■ D is s e m in a te d in n e u tro p e n ic p a tie n ts

3 .4 .3 .3 .2 D iseases 3 .4 .3 .5 .2 D iag n o sis

■ C u ta n e o u s d is e a s e

■ S im ila r to C ry p to c o c c u s

□ P ity ria s is (tin e a ) v e rs ic o lo r ■ In fe c tio n o f s tra tu m c o rn e u m

m U re a s e p o s itiv e

■ C a n c a u s e h y p e r o r h y p o p ig m e n ta tio n o f skin

■ P o s itiv e c ry p to c o c c a l a n tig e n te s t

■ K O H p re p a ra tio n s o f skin s c ra p in g s s h o w y e a s t a nd s h o rt h y p h a e (s p a g h e tti a n d m e a tb a lls )

■ M icro : fo rm a tio n o f a rth ro c o n id ia ; p s e u d o h y p h a e

■ B u d d in g y e a s ts h a ve c h a ra c te ris tic c o lla re tte : d a rk e r s ta in in g w h e re th e d a u g h te r c o m e s o ff th e p a re n t

3 .4 .3 .5 .3 Geotrichum candidum • N a tu ra l re s e rv o ir: w a te r, soil, v a rio u s p la n ts , c a n be s k in a n d u p p e r re s p ira to ry flo ra

■ B io p s ie s o f skin s h o w h y p e rk e ra to s is , a c a n th o s is , d e rm a l m o n o n u c le a r in filtra te

■ R is k fa c to rs : n e u tro p e n ia , m a lig n a n c ie s , tra n s p la n ts , c a th e te rs , tra u m a

■ T re a tm e n t: to p ic a l s e le n iu m s u lfid e

■ C a th e te r re la te d b lo o d s tre a m in fe c tio n s , U T Is , w o u n d in fe c tio n s , p n e u m o n ia

□ S e b o rrh e ic d e rm a titis : in v o lv e s an in fla m m a to ry re a c tio n a g a in s t th e y e a s t

3.4.4 Dimorphic fungi t3.21

■ S y s te m ic in fe c tio n □ V e ry c la s s ic a s s o c ia tio n w ith in fa n ts w h o h ave re c e iv e d in tra v a s c u la r in fu s io n s o f lip id (T P N ) □ In fa n ts a re o fte n a s y m p to m a tic , b u t ca n have p n e u m o n ia re s u ltin g fro m e m b o li fro m th e in fe c te d c a th e te r

■ In fe c tio n o f s c a lp h a ir ■ O rg a n is m : P ie d ra ia h o rta e □ S e p ta te p ig m e n te d h y p h a e a nd a sci □ U n ic e llu la r a n d fu s ifo rm a s c o s p o re s w ith p o la r fila m e n ts ■ F re q u e n t in tro p ic a l a re a s

3.4.4.2.1 B ackgroun d

■ C lin ic a l fin d in g s : d is c re te , h ard , d a rk b ro w n to b la c k n o d u le s th a t s u rro u n d a n d p e n e tra te th e h a ir s h a ft ■ T re a tm e n t: to p ic a l s a lic y lic a cid , a z o l c re a m s , h y g ie n e

□ In fe c tio n o f fa c ia l, a x illa ry , o r g e n ita l h a ir © ASCP2018

■ T re a tm e n t: in g e n e ra l, itra c o n a z o le ; a m p h o te ric in in s e v e re in fe c tio n s ; flu c o n a z o le fo r p o s s ib le C N S d is e a s e b e c a u s e g o o d C N S p e n e tra tio n

3.4.4.2 Histoplasma

□ C u ltu re : b ro w n /b la c k c o lo n ie s

■ W h ite p ie d ra (T a s a h ii)

■ C a n c o n firm id e n tific a tio n w ith y e a s t c o n v e rs io n : firs t g ro w a s m o ld in th e lab, th e n in c u b a te a s u b c u ltu re a t 37°C (m o s t la b s d o n o t d o th is ) ■ M o s t d im o rp h ic fu n g i lo o k s im ila r in m o ld fo rm : fu z z y w h ite /ta n c o lo re d c o lo n ie s w ith lig h t re v e rs e a fte r 2 -3 w e e k s o f in c u b a tio n i3.39

3.4.3.4 Black piedra

D iseases

■ M o ld in th e e n v iro n m e n t: 2 5 ° -3 0 ° C (m y c e liu m , fu z z y c o lo n ie s on a p la te ) ■ Y e a s t a t b o d y te m p e ra tu re : 37°C

■ To c u ltu re c a th e te r tip, a d d a d ro p o f s te rile o liv e oil to m e d ia (S a b o u ra u d d e x tro s e o r b lo o d a g a r)

3.4.3.5.1

■ A ll ca n c a u s e d is e a s e in h e a lth y h o s ts

■ W e t m o u n t s h o w s h yph a e, c o n id ia , e tc

□ T re a tm e n t: re m o v e th e c a th e te r; o ra l a z o le (flu c o n a z o le , itra c o n a z o le , k e to c o n a z o le )

3.4.3.5 Trichosporon

3.4.4.1 Characteristics of thermally dimorphic fungi

■ F lis to p la s m a c a p s u la tu m h a s 2 v a rie tie s □ H c a p s u la tu m v a r c a p s u la tu m : th e m a in v a rie ty th a t w e e n c o u n te r in th e U S ; fo u n d m a in ly a lo n g th e M is s is s ip p i R iv e r V a lley; a ls o fo u n d w o rld w id e (th e re s t o f th is d is c u s s io n p e rta in s to th is v a rie ty ) □ H c a p s u la tu m v a rd u b o is ii: lim ite d to e q u a to ria l A fric a ; y e a s t fo rm is s lig h tly la rg e r ■ E n d e m ic a re a : M is s is s ip p i R iv e r V a lle y ( c e n tra l/ e a s te rn U S )

ISBN 978-08 9189-6678

133

3: Microbiology

Mycology>Dimorphic fungi t3.21 Sum m ary of dim orphic fungi

Species

Mold form Route of Yeast form characteristics characteristics infection

H capsulatum 2-4 pm, narrow septate hyphae with tear var based budding shaped capsulatum

B dermatitidis 8-15 pm thick

walied, broad based budding

C immitis

inhalation

microconidia & thick walled, tuberculate macroconidia septate hyphae inhalation with lollipoplike conidia atop unbranched conidiophores barrel shaped inhalation arthroconidia alternating with empty cells

Common sites of disseminated infection reticuloendothelial system, mediastinum

skin, mucous membranes

skin, bone, joints 10-100 pm spherules containing 2-5 pm (nonbudding) endospores septate hyphae inhalation skin, mucous P brasiliensis 10-50 pm or mariner's wheel with intercalary membranes, traumatic bone marrow, (circumferential & terminal budding) chlamydospores inoculation lymphatics traumatic regional S schenckii 4-6 pm elongated rosettes of microconidia inoculation lymphatics (cigars) with narrow based at the apex of swollen, budding delicate conidiophores inhalation bone marrow, skin colonies P marneffei 3-5 pm ovoid, divide by fission producing diffusible red pigment

i3.39 H capsulatum cultured at 25°-30°C colony morphology—powdery or cottony white mold

■ P re s e n t in s o il, w h e re g ro w th is s tim u la te d by b ird g u a n o (th e b ird s a re n o t a c tu a lly in fe c te d ) ■ C o n id ia a re a e ro s o liz e d a n d in h a le d b y h u m a n s □ R is k fo r c e rta in o c c u p a tio n s (c o n s tru c tio n w o rk e rs ) 3 .4 .4 .2 .2 D is e a s e s ■ O fte n a s y m p to m a tic ■ A c u te p u lm o n a ry in fe c tio n □ F lu lik e s y n d ro m e □ O fte n re s o lv e s w ith o u t tre a tm e n t □ If g ra n u lo m a to u s in fla m m a tio n o c c u rs , m a y re s o lv e in to c a lc ifie d n o d u le s ■ G ra n u lo m a to u s a n d fib ro s in g (s c le ro s in g ) m e d ia s tin itis ■ C h ro n ic p u lm o n a ry h is to p la s m o s is □ O c c u rs in p e o p le w ith C O P D □ C a lc ific a tio n a n d c a v ita tio n c a n o c c u r ■ D is s e m in a te d h is to p la s m o s is □ M a in ly s e e n in H IV p a tie n ts ; a ls o in v e ry y o u n g a nd v e ry o ld □ Y e a s ts d is s e m in a te v ia th e re tic u lo e n d o th e lia l s y s te m □ L y m p h a d e n o p a th y , h e p a to s p le n o m e g a ly 134

i3.40 H capsulatum a GMS stained, b PAS stained tissue sections demonstrate small yeasts with narrow based budding; c H&E stained, d Wright stained smears demonstrate intracellular yeast forms

3 .4 .4 .2 .3

D ia g n o s is

■ T is s u e fro m s p u tu m , b o n e m a rro w , b io p s ie s : y e a s t fo rm i3.40 □ Found p re d o m in a n tly in m a c ro p h a g e s □ In tra c e llu la r y e a s ts ca n be s e e n , h ig h lig h te d by PAS and G M S □ 3 -5 pm in d ia m e te r □ N a rro w b a s e d b u d d in g ■ C u ltu re : m o ld (m y c e lia l) fo rm □ C o lo n ie s g ro w s lo w ly in th e lab

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

3: Microbiology

Mycology>Dimorphic fungi

i3.42 B dermatitidis a & b Smears demonstrate uniform, large (8-15 pm) yeasts with broad based budding; the yeast cell walls are thick & double contoured

□ A w e t p re p a ra tio n m a d e fro m a c o lo n y s h o w s th e c h a ra c te ris tic tu b e rc u la te m a c ro c o n id ia a s w e ll as m ic ro c o n id ia i3.41 □ N u c le ic a c id p ro b e on c o lo n ie s ■ S e ro lo g y □ D e te c tio n o f a n tib o d ie s ■ A n tib o d ie s a p p e a r 2 -6 w e e k s a fte r e x p o s u re ■ A n tib o d ie s re m a in d e te c ta b le fo r m a n y y e a rs ■ A n tig e n te s t: u rin e o r C S F ■ B e s t fo r a c u te /d is s e m in a te d d is e a s e ■ L ittle u tility in is o la te d p u lm o n a ry d is e a s e in im m u n o c o m p e te n t ■ S kin te s t (h is to p la s m in a n tig e n ): lim ite d d ia g n o s tic v a lu e

3.4.4.3

Blastomyces

i3.43 C immitis] in culture, mature arthroconidia are barrel shaped & alternate with empty cells

□ T h ic k , re tra c tile w a ll (can lo o k lik e a d o u b le w a ll)

3 .4 .4 .3 .1 B a c k g r o u n d

□ B ro a d b a s e d b u d d in g

■ B d e rm a titid is is th e o n ly s p e c ie s ■ E n d e m ic a re a : M is s is s ip p i R iv e r V a lle y (c e n tra l/e a s te rn US)

■ C u ltu re : m o ld (m y c e lia l) fo rm i3.43 □ G ro w s m o re ra p id ly th a n H is to p la s m a ; lo o k s s im ila r □ W e t p re p a ra tio n fro m m old c o lo n y s h o w s h y p h a e w ith lo llip o p o r p e a r s h a p e d m ic ro c o n id ia

3 .4 .4 .3 .2 D is e a s e ■ A c u te in fe c tio n p u lm o n a ry ; ca n be a s y m p to m a tic , tra n s ie n t, o r p ro g re s s iv e

3.4.4.4

■ D is s e m in a tio n

3 .4 .4 .4 .1

□ O c c u rs m o re fre q u e n tly in im m u n o c o m p ro m is e d p a tie n ts

Coccidioides B a c k g ro u n d

■ 2 s p e c ie s

□ C o m m o n ly g o e s to skin and b o n e s

□ C im m itis : s o u th w e s te rn U S ; A riz o n a a n d S a n J o a q u in V a lle y in C a lifo rn ia

□ C u ta n e o u s le s io n s a re h y p e rtro p h ic , u lc e ra tiv e , and ca n be lo c a lly d e s tru c tiv e

□ C p o s a d a s ii: s o u th w e s te rn U S , M e x ic o , C e n tra l A m e ric a ■ P o te n tia l a g e n t o f b io te rro ris m

3 .4 .4 .3 .3 D ia g n o s is

■ E x tre m e ly in fe c tio u s

■ T is s u e : y e a s t fo rm i3.42

■ D a n g e r fo r la b o ra to ry w o rk e rs

□ T is s u e re a c tio n in c lu d e s a c u te in fla m m a tio n w ith m ic ro a b s c e s s e s a nd g ra n u lo m a to u s in fla m m a tio n □ 8-15 pm in d ia m e te r © A S C P 2018

ISBN 978-08 9189-6678

135

3: Microbiology

Mycology>Dimorphic fungi 3 .4 .4 .4 .2 D is e a s e ■ C a u s e d b y in h a la tio n o f a rth ro c o n id ia fro m so il (a e ro s o liz e d d u rin g c o n s tru c tio n , w in d s to rm s , e tc) ■ O fte n a s y m p to m a tic ■ P rim a ry in fe c tio n c a n c a u s e fe v e r, c o u g h , c h e s t p ain ■ D is s e m in a tio n c a n o c c u r (o fte n im m u n o c o m p ro m is e d o r la rg e in fe c tio u s d o s e ) □ S k in : p a p u le s , u lc e rs , d ra in in g s in u s e s , s u b c u ta n e o u s abscesses □ M e n in g e s : u s u a lly in d o le n t a n d c h ro n ic □ J o in ts : a rth ritis 3 .4 .4 .4 .3 D ia g n o s is ■ T is s u e : y e a s tlik e fo rm i3.44 □ G ra n u lo m a to u s re a c tio n a ro u n d s p h e ru le s , w h ic h m e a s u re up to 2 5 0 p m in d ia m e te r □ E n d o s p o re s a re s e e n in s id e th e s p h e ru le s : 2 -5 pm ; d o n o t b ud □ C a n n o t g ro w y e a s t fo rm in lab □ A n tib o d ie s : s in g le e le v a te d tite r m a y be d ia g n o s tic , p a ire d s a m p le s p re fe rre d □ S k in te s t (c o c c id io id in a n d s p h e ru lin e a n tig e n s ); n o t re a lly u s e d a n y m o re ■ C u ltu re : m o ld (m y c e lia l) fo rm □ G ro w s v e ry ra p id ly , w ith in 1 w e e k □ W e t p re p a ra tio n fro m m o ld c o lo n y s h o w s c h a ra c te ris tic b a rre l s h a p e d a rth ro c o n id ia th a t a lte rn a te w ith e m p ty c e lls i3.43 □ A rth ro c o n id ia a re h ig h ly in fe c tio u s to lab w o rk e rs

Sporothrix

D ia g n o s is

■ T is s u e : y e a s t fo rm □ G ra n u lo m a to u s in fla m m a tio n w ith s m a ll c o lle c tio n s o f n e u tro p h ils □ S p le n d o re -H o e p p li p h e n o m e n o n : e o s in o p h ilic m a te ria l th a t ra d ia te s a ro u n d th e y e a s t c e ll (n o t u n iq u e to th is o rg a n is m ) □ Y e a s t c e lls a re ra re in tis s u e ■ C u ltu re: m o ld (m y c e lia l) fo rm □ W e t p re p a ra tio n m a d e fro m m old c o lo n y sh o w s c o n id ia th a t a re a rra n g e d a s a ro se tte a ro u n d th e c o n id io p h o re , like a flo w e r (d aisy h e a d o r ro se tte s) i3.45a □ Y e a s t c o n v e rs io n ra re ly p e rfo rm e d ; w o u ld s h o w 4 -6 pm c ig a r s h a p e d y e a s ts i3.45b

3 .4 .4 .5 .1 B a c k g r o u n d ■ F o u n d w o rld w id e in s o il a n d p la n ts ■ M o d e o f e n try is u s u a lly tra u m a tic (n o t in h a la tio n like th e o th e r d im o rp h ic fu n g i)

3.4.4.6 Paracoccidioides brasiliensis ■ S o uth A m e ric a n b la s to m y c o s is ■ P rim a ry in fe c tio n is p u lm o n a ry ; a ls o ca n a ffe c t th e skin, lym p h n o d e s , m u c o u s m e m b ra n e s

3 .4 .4 .5 .2 D is e a s e : s p o r o t r ic h o s is ■ C la s s ic a lly a s s o c ia te d w ith in o c u la tio n d u rin g g a rd e n in g w ith ro s e b u s h e s ■ P a p u le a t s ite o f e n try u lc e ra te s ■ S p re a d s v ia ly m p h a tic s ■ L e a d s to a s e rie s o f le s io n s p ro g re s s in g up th e a ffe c te d lim b ■ D is s e m in a tio n c a n o c c u r in im m u n o c o m p ro m is e d

136

a, b-c In tissue sections stained with H&E, it appears as large (10-100 pm) spherules with thick, hyaline walls that enclose numerous tiny (2-5 pm) endospores, which do not bud d The spherules are highlighted by GMS stain 3 .4 .4 .5 .3

■ S e ro lo g y

3.4.4.5

i3.44 C immitis

■ Y e a sts (se e n in tissu e ): c h a ra c te ris tic la rg e (1 0 -5 0 pm ), s p h e ric a l y e a s t w ith m u ltip le p e rip h e ra l b u d s (m a rin e r w h e e l) i3.46

3.4.47

Penicillium marneffei

■ D is e a s e s □ C o m m o n c a u s e o f d is s e m in a te d d is e a s e s im ila r to d is s e m in a te d h is to p la s m o s is o r T B in H IV p a tie n ts w h o a re fro m o r h ave v is ite d s o u th e a s t A s ia

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

3: Microbiology

Mycology>Dimorphic fungi | Dermatophytes & other superficial mycoses

i p - o v • ^

J>* •A

-

• ;

*

*

\ i ;n*

w • ' W

.tt. *' * ' \ •' #* C'V1

i3.45 S schenckii. a Mold form; conidiophores topped by clusters of microconidia (“rosettes”) b yeast form; “cigar bodies”

3.4.5.2 Diagnosis

□ N o n -H IV p a tie n ts ■ F e v e r + / - c h ills ■ P n e u m o n itis , c o u g h , d y s p n e a , th o ra c ic pain ■ C u ta n e o u s a n d s u b c u ta n e o u s le s io n s : p u s tu le s , p a p u le s , n o d u le s ■ L y m p h a d e n o p a th y , h e p a to s p le n o m e g a ly ■ O s te o a rtic u la r le s io n s □ H IV p a tie n ts : a ls o m ay h a ve p u lm o n a ry in filtra te s , G l le s io n s , s e p s is ■ M old (m y c e lia l) fo rm s h o w s d iffu s ib le red p ig m e n t □ W e t p re p a ra tio n o f th e m o ld fo rm s h o w s h y a lin e h y p h a e w ith a tta c h e d c o n id io p h o re s , w h ic h g iv e rise to 3 -5 p h ia lid e s , w h ic h fo rm c h a in s o f le m o n s h a p e d c o n id ia (s k e le to n h an d s) ■ Y e a s t fo rm in tis s u e : o rg a n is m s w ith in h is tio c y te s ; ca n lo o k like H is to p la s m a □ P e n ic illiu m w ill h ave k in e to p la s t (d iv id e by fis s io n ) b u t H is to p la s m a w ill not

3.4.5 Dermatophytes & other superficial mycoses 3.4.5.1

i3.46 P brasiliensis yeast form with circumferential budding

■ D e m o n s tra tio n o f h y p h a e in s k in s c ra p in g s w ith K O H p re p a ra tio n ■ C u ltu re o f s k in s c ra p in g s , hair, n a ils □ W e t p re p a ra tio n m a d e fro m a fu n g a l c o lo n y w ill s h o w s e p ta te , h y a lin e h y p h a e a n d m ic ro c o n id ia a n d /o r m a c ro c o n id ia , w h ic h can be u s e d fo r id e n tific a tio n o f th e s p e c ie s □ M e d ia : c o n ta in c y c lo h e x a m id e to s e le c t fo r d e rm a to p h y te s (eg, m y c o b io tic /m y c o s e l a g a r; d e rm a to p h y te te s t a g a r) ■ In v itro h a ir p e rfo ra tio n te s t (n o t ro u tin e ly p e rfo rm e d ) □ D is tin g u is h e s d iffe re n t d e rm a to p h y te s b y in c u b a tin g p re p u b e rta l b lo n d h a ir w ith th e te s t fu n g u s a nd m ic ro s c o p ic a lly e x a m in in g it fo r p ittin g a n d e ro s io n ■ S p e c ia l a m in o a c id a nd v ita m in re q u ire m e n ts ■ U re a h y d ro ly s is

3.4.5.3 Organisms 3.4.5.3.1 Microsporum m C o m m o n c a u s e o f tin e a c a p itis , tin e a c o rp o ris , a n d tin e a

p e d is

Diseases

■ In fe c tio n o f h air: c a u s e s h a irs to flu o re s c e w ith W o o d la m p (U V lig h t)

■ T in e a ca p itis : s c a lp ■ T in e a c o rp o ris : tru n k a n d lim b s

■ M ic ro s p o ru m c a n is

■ T in e a p ed is: fo o t ■ T in e a c ru ris : g ro in

□ C o lo n ie s : c h a ra c te ris tic le m o n -y e llo w p ig m e n t on fo rw a rd a n d re v e rs e sid e s o f p la te

■ T in e a u n g u iu m , a ls o c a lle d o n y c h o m y c o s is : n a ils

□ W e t p re p a ra tio n o f c o lo n y s h o w s ■ C h a ra c te ris tic m a c ro c o n id ia : th ic k w a lle d , ta p e re d , s p in d le s h a p e d , c o n ta in >6 c e lls

© A S C P 2018

ISBN 978-08 9 1 8 9 -6 6 7 8

137

3: Microbiology

Mycology>Dermatophytes & other superficial mycoses | Dematiaceous molds & other subcutaneous infections

I

'

3.4.6 Dematiaceous molds & other subcutaneous infections

a

3.4.6.1 B a ck g ro u n d ■ C h a ra c te riz e d by m e la n in p ro d u c tio n : d a rk ly p ig m e n te d hyphae ■ Live in so il a n d on p la n ts , ra re ly c a u s e h u m a n d is e a s e 3.4.6.2 D iseases ■ E u m y c o tic m y c e to m a □ L o c a liz e d , c h ro n ic g ra n u lo m a to u s in fe c tio n □ P a in le s s s u b c u ta n e o u s m a s s w ith m u ltip le s in u s e s th a t d ra in p u s a n d g ra in s □ C h ro n ic o n s e t a fte r tra u m a tic in ju ry by s p lin te r, th o rn , o th e r p e n e tra tin g item i3.47 Trichophyton rubrum: a red reverse; b birds on a wire

■ M ic ro c o n id ia ■ T h in , s e p ta te h y p h a e ■ M ic ro s p o ru m g y p s e u n r. m a c ro c o n id ia c o n ta in < 6 c e lls

□ U s u a lly h a n d s o r fe e t (M a d u ra fo o t) □ O rg a n is m s ■ C an b e c a u s e d by b a c te ria (a c tin o m y c o tic m y c e to m a ; o fte n c a u s e d by N o c a rd ia , a lso S tre p to m y c e s , A c tin o m a d u ra , N o c a rd io p s is ) o r fu n g u s (e u m y c o tic m y c e to m a ; ca n be c a u s e d by a h y a lin e o r d e m a tia c e o u s fu n g u s ) ■ W h ite g ra in : S c e d o s p o riu m , A c re m o n iu m , F u s a riu m , A s p e rg illu s n id u la n s

3 .4 .5 .3 .2 Trichophyton m In fe c ts th e s k in , s c a lp a n d n a ils

m B la c k g ra in : M a d u re lla g ris e a , M a d u re lla

■ M a c ro c o n id ia m a y b e p ro d u c e d b u t a re o fte n a b s e n t ■ S p e c ie s □ T ric h o p h y to n to n s u ra n s : th e m o s t c o m m o n c a u s e o f tin e a c a p itis in th e U S □ T ric h o p h y to n r u b r u m : flu ffy w h ite c o lo n ie s w ith d iffu s ib le re d p ig m e n t s e e n o n fo rw a rd a n d re v e rs e s id e s o f th e p la te i3.47a ■ R e d p ig m e n t is e x a g g e ra te d on p o ta to d e x tro s e a g a r (c a n h e lp to d iffe re n tia te fro m T m e n ta g ro p h y te s ) ■ M ic ro c o n id ia lo o k like b ird s on a w ire i3.47b □ T ric h o p h y to n m e n ta g ro p h y te s : fla t c o lo n y w ith ra d ia l fu rro w in g a n d re d /b ro w n p ig m e n t a t th e p e rip h e ry ; c a n p e n e tra te h a ir s h a fts (T ru b ru m c a n n o t)

3 .4 .5 .3 .3 Epidermophyton floccosum m In fe c ts p rim a rily th e s k in ; c o m m o n c a u s e o f tin e a c ru ris ■ C o lo n ie s h a v e s u e d e lik e te x tu re w ith y e llo w /g re e n c o lo r ■ D o e s n o t p ro d u c e m ic ro c o n id ia ■ M a c ro c o n id ia a re c lu b o r b e a v e r ta il s h a p e d

m y c e to m a tis , E x o p h ia la ■ T h e m o s t c o m m o n fu n g a l c a u s e w o rld w id e is M a d u re lla m y c e to m a tis (in th e U S, th e m o s t c o m m o n c a u s e is S ced o sp o riu m -, se e 3 .4 .7 H y a lin e m o ld s ) □ D ia g n o s e s ■ B io p s y o r d ra in a g e m a te ria l s h o w s g ra in s (s u lfu r g ra n u le s ) c o m p o s e d o f b ro a d , in te rw o v e n , s e p ta te hyphae ■ If c a u s e d by d e m a tia c e o u s m o ld , th e h y p h a e a re d a rk ly p ig m e n te d □ C u ltu re ■ D a rk ly p ig m e n te d on s u rfa c e a n d re v e rs e b e c a u s e both h y p h a e and c o n id ia a re m e lo n iz e d i3.48 ■ C a n ta k e s e v e ra l w e e k s ; m a y be a b le to id e n tify th e s p e c ie s b y lo o k in g a t th e re p ro d u c tiv e s tru c tu re s m ic ro s c o p ic a lly (w e t p re p a ra tio n fro m th e c o lo n y ) ■ C h ro m o b la s to m y c o s is (aka c h ro m o m y c o s is ) □ C h ro n ic in fe c tio n o f th e skin a nd s o ft tis s u e w ith fu n g a l s tru c tu re s c a lle d s c le ro tic b o d ie s (c o p p e r p e n n ie s) i3.49 □ T ro p ic a l a n d s u b tro p ic a l a re a s □ P a in le s s v e rru c o u s p la q u e o r n o d u le a t s ite o f tra u m a (s y s te m ic in v o lv e m e n t v e ry rare)

138

ASCP Quick Compendium of Clinical Pathology 4e

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3: Microbiology

Mycology>Dematiaceous molds & other subcutaneous infections

i3.49 Sclerotic bodies (“copper pennies”) seen in an H&E stained section (arrows)

i3.48 Dematiaceous molds are typically pigmented a on the surface & b reverse side of the plate

□ O rg a n is m s a re F o n s e c a e a , P h ia lo p h o ra , C la d o p h ia lo p h o ra , C la d o s p o riu m , E x o p h ia la □ T re a tm e n t: s u rg e ry , a n tifu n g a l th e ra p y (d e p e n d s on o rg a n is m ) ■ P h a e o h y p h o m y c o s is □ S u b c u ta n e o u s a nd s y s te m ic d is e a s e s c h a ra c te riz e d by p ig m e n te d h y p h a e in tis s u e , b u t w ith o u t s u lfu r g ra n u le s o r s c le ro tic b o d ie s □ U s u a lly fo llo w s tra u m a tic im p la n ta tio n by s p lin te r o r o th e r fo re ig n o b je c t

□ R a n g e s fro m in d o le n t s u b c u ta n e o u s le s io n to fa ta l d e s tru c tiv e in fe c tio n s in im m u n o c o m p ro m is e d h o s ts; ca n b e s y s te m ic w ith c e re b ra l in v o lv e m e n t (e s p e c ia lly C la d o p h ia lo p h o ra ) □ O rg a n is m s : E x o p h ia la , W a n g ie lla , B ip o la ris , C u rv u la ria , A tte rn a ria , C la d o s p o riu m a C a n be d iffe re n tia te d b y th e a p p e a ra n c e o f th e ir c o n id ia i3.50 ■ T h e s e o rg a n is m s c a n a ls o c a u s e tin e a n ig ra ■ S u p e rfic ia l in fe c tio n s o f s tra tu m c o rn e u m ■ B ro w n m a c u le s o n p a lm s , fin g e rs , fa c e

© ASCP2018

ISBN 978-08 9189-6678

139

3: Microbiology

Mycology>Dematiaceous molds & other subcutaneous infections | Hyaline molds

i3.51 Lomentospora (previously Scedosporium) prolificans has a gray or black a surface & b reverse

■ B ip o la ris : p ro d u c e d g e rm tu b e s fro m b o th e n d s in s a lin e m o u n ts in c u b a te d fo r 12-2 4 h o u rs □ H is to p a th o lo g y ■ C y s tic g ra n u lo m a s th a t a re e n c a p s u la te d b y d e n s e c o lla g e n o u s c o n n e c tiv e tis s u e ■ C e n tra l g e o g ra p h ic o r s te lla te fo c i o f s u p p u ra tiv e n e c ro s is

i3.52 Lomentospora (previously Scedosporium) prolificans microconidia are oval & truncated, forming clusters at the end of annellides, which have swollen bases & thin necks ■ D ia g n o s is □ S p o ra n g iu m (s p h e ru le s ) u s u a lly 1 0 0 -2 0 0 pm b u t ca n re a c h 3 5 0 p m fille d w ith e n d o s p o re s (in tis s u e ) □ E n d o s p o re s a re im m a tu re a t p e rip h e ry and m a tu re to w a rd c e n te r o f s p o ra n g iu m ■ T re a tm e n t: s u rg e ry is o n ly e ffe c tiv e fo rm o f th e ra p y ; a m p h o te ric in , d a p s o n e

■ B ro w n p ig m e n te d s e p ta te h y p h a e ■ S o m e tim e s b iz a rre th ic k w a lle d v e s ic u la r s w e llin g s a n d irre g u la r h y p h a e ■ Y e a s t-lik e c e lls s o m e tim e s in c h a in s □ T re a tm e n t: s u rg e ry , itra c o n a z o le , v o ric o n a z o le , to p ic a l s a lic y lic a c id , tin c tu re o f io d in e ■ L o m e n to s p o ra p ro lific a n s (p re v io u s ly k n o w n as S c e d o s p o riu m p ro lific a n s ) □ S e rio u s p a th o g e n , e s p e c ia lly in im m u n o c o m p ro m is e d , b e c a u s e it is re s is ta n t to a m p h o te ric in B a n d a ls o to a z o le s a n d e c h in o c a n d in s □ G ra y o r b la c k s u rfa c e a n d re v e rs e i3.51 □ A n n e lid s h a v e c h a ra c te ris tic a lly s w o lle n b a s e s a n d th in n e c k s w ith c lu s te rs o f o v a l m ic ro c o n id ia i3.52

3.4 .6 .3 .2

Lacazia loboi: lo b o m yco sis

■ C h ro n ic in fe c tio n o f s k in a n d s u b c u ta n e o u s tis s u e ■ E n d e m ic in ru ra l re g io n s o f S o u th a nd C e n tra l A m e ric a (B ra z ilia n ra in fo re s t) ■ T ra u m a tic in o c u la tio n o f th e fu n g u s ■ N a tu ra l in fe c tio n in d o lp h in s ■ H ard, p a in le s s n o d u le s on e x tre m itie s , fa c e a n d e a r ■ V e rru c o u s /u lc e ra tiv e le s io n s aaa ■ L e s io n s m im ic th o s e o f c h ro m o b la s to m y c o s is , m y c e to m a a n d c a rc in o m a ■ D ia g n o s is □ M u ltip le b u d d in g y e a s t c e lls fo rm in g s h o rt c h a in s □ G ra n u lo m a s

3.4.6.3 Other subcutanous infections

□ C a n n o t c u ltu re

3 . 4 .6 . 3.1 Rhinosporidium seeberi (a p ro to zo a n p a ras ite,

n o t a fu n g u s ; it is in c lu d e d h ere b e c a u s e it is s im ila r to fu n g i in h is to p a th o lo g y and tre a tm e n t) ■ B a c k g ro u n d □ C h ro n ic in fe c tio n w ith p o ly p o id m a s s e s o f n a s a l m u c o s a , c o n ju n c tiv a , g e n ita lia a n d re c tu m

3.4.7.1 Aspergillus 3.4.7.1.1 S tru ctu re ■ S e p ta te d h y p h a e

□ E n d e m ic in In d ia a n d S ri L a n k a

■ D ic h o to m o u s (Y s h a p e d ) a c u te a n g le b ra n c h in g

□ N a tu ra l re s e rv o ir: fis h , a q u a tic in s e c ts

■ F ru itin g /re p ro d u c tiv e s tru c tu re : u s u a lly o n ly se e n in c u ltu re

□ U s u a lly y o u n g m e n

140

3.4.7 Hyaline molds

□ T h e e x c e p tio n is if a fu n g u s ball h as c o n ta c t w ith air, it m a y d e v e lo p fru itin g h e a d s i3.53

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Mycology>Hyaline molds

i3.53 Aspergillus species, when growing in an air filled space (in this case a paranasal sinus) may demonstrate the formation of fruiting heads; in this case, A niger

i3.54 Allergic fungal sinusitis a A clue is eosinophil permeated mucin containing b fungal hyphae on GMS stained sections

3.4.7.1.2 B ackg ro u n d ■ S p o re s a re p re s e n t in th e e n v iro n m e n t (soil) ■ N e e d to d iffe re n tia te b e tw e e n in v a s iv e vs n o n in v a s iv e in fe c tio n s ■ In v a siv e d is e a s e s a re m o re like ly in im m u n o c o m p ro m is e d h o s ts ■ M o s t c o m m o n s p e c ie s a re A fu m ig a tu s > A fla v u s > A te rre u s m A te rre u s is re s is ta n t to a m p h o te ric in B ■ A fla v u s m a y p ro d u c e a fla to x in (c a rc in o g e n fo r h e p a to c e llu la r c a rc in o m a ) if it c o n ta m in a te s fo o d

3.4.7.1.3 D iseases ■ A lle rg ic b ro n c h o p u lm o n a ry fu n g a l in fe c tio n □ O fte n s e e n in a s th m a tic p a tie n ts □ C a n be c a u s e d by o rg a n is m s o th e r th a n A s p e rg illu s □ H y p e rs e n s itiv ity re s p o n s e to fu n g u s

i3.55 Aspergillus species in tissue (GMS stain)—narrow septate hyphae with acute angle dichotomous evenly spaced branching is characteristic but not genus specific (could also be Fusarium, Scedosporium, some dematiacious molds, etc)

□ E le va te d IgE a nd e o s in o p h ils □ N o t an in v a s iv e in fe c tio n

□ In v a siv e p u lm o n a ry in fe c tio n s

□ O fte n a s s o c ia te d w ith a lle rg ic fu n g a l s in u s itis i3.54

□ D is s e m in a te d in fe c tio n s

■ N o n in v a s iv e lo c a l c o lo n iz a tio n

■ D u e to a n g io in v a s io n

□ A s p e rg illo m a (fu n g u s b all)

■ A n g io in v a s io n le a d s to th ro m b o s is a n d in fa rc ts

■ F o rm w ith in p re -e x is tin g c a v ity

■ B lo o d c u ltu re s a re n e g a tiv e

□ O c u la r in fe c tio n s ■ O fte n fo llo w s tra u m a , e s p e c ia lly in p a tie n ts tre a te d w ith to p ic a l s te ro id s □ E x te rn a l e a r in fe c tio n s

3.4.7.1.4

D iag n o sis

■ T is s u e

m P ain, im p a ire d h e a rin g , d is c h a rg e

□ D o n o t a tte m p t to d iffe re n tia te A s p e rg illu s fro m o th e r h y a lin e m o ld s (F u s a riu m , S c e d o s p o riu m , e tc) in tis s u e b e c a u s e th e y all lo o k th e s a m e

■ F lu ffy g re e n o r b la c k g ro w th in e a r c a n a l

□ H y p h a e a re s u rro u n d e d by a c u te in fla m m a to ry c e lls

■ O fte n c a u s e d by A n ig e r

■ In v a siv e a s p e rg illo s is : u s u a lly a ffe c t im m u n o c o m p ro m is e d h o sts □ In v a siv e fu n g a l s in u s itis © A S C P 2018

□ C a n se e w ith H & E ; h ig h lig h te d w ith P A S o r G M S i3.55 ■ D ire c t e x a m in a tio n fro m c lin ic a l s p e c im e n : c a n s e e h y p h a e on w e t p re p a ra tio n a n d /o r c a lc o flu o r w h ite

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Mycology>Hyaline molds ■ C u ltu re: m a c ro s c o p ic c o lo n y a p p e a ra n c e a s w e ll as m ic ro s c o p ic e x a m in a tio n o f re p ro d u c tiv e s tru c tu re s help id e n tify th e s p e c ie s □ U se S a b o u ra u d d e x tro s e a g a r w ith o u t c y c lo h e x im id e ; id e a lly have 2 p o s itiv e c u ltu re s to p ro v e th a t it is n ot a c o n ta m in a n t; all h ave lig h t re ve rs e s id e s b e c a u s e th e h yp h a e a re n o t p ig m e n te d (h yaline) □ A s p e rg illu s fu m ig a tu s : b lu e -g re e n c o lo n y w ith w h ite a pro n i3.56a; fla s k s h a p e d v e s ic le w ith p h ia lid e s on th e u p p e r 2 /3 o f th e v e s ic le i3.56b i3.56 A fumigatus colonies a are blue-green with a distinct white apron & b swollen vesicles with single row of phialides (uniseriate) that cover only the top 2/3 of the vesicle; A terreus would look similar but has biseriate phialides (difficult to see in this picture)

□ A s p e rg illu s fla v u s : y e llo w -g re e n c o lo n y i3.57a; p h ia lid e s a rise fro m th e w h o le v e s ic le i3.57b □ A s p e rg illu s te rre u s: c in n a m o n b ro w n c o lo n y (“ te rre u s ” = te rra in , like g ro u n d c o lo r) i3.58; b is e ria te p h ia lid e s c o v e rin g 2 /3 o f th e v e s ic le i3.58b s im ila r to A fu m ig a tu s □ A s p e rg illu s n ig e r: d a rk b ro w n , p o w d e ry c o lo n y w ith lig h t c o lo re d re ve rs e s id e b e c a u s e o n ly th e re p ro d u c tiv e s tru c tu re s (s p o re s /c o n id ia ) a re d a rk ly co lo re d i3.59a; th e h y p h a e a re h yalin e ; d a rk b row n, g lo b o s e (all th e w a y a ro u n d ) c o n id ia i3.59b ■ S e ro lo g y : a n tig e n te s ts u sed to d ia g n o s e in va sive in fe c tio n s □ G a la c to m a n n a n : in v a s iv e in fe c tio n s

i3.57 A flavus colonies a are yellow-green to olive with b circumferential phialides

■ F a lse p o s itiv e s c a u s e d by: a m o x ic illin , a m o x ic illin c la v u la n a te , p ip e ra c illin -ta z o b a c ta m , p la s m a ly te , d ie ta ry g a la c to m a n n a n : g u a r a nd lo c u s t b ea n g u m s u se d in ice c re a m a nd c re a m c h e e s e ■ P e n ic illin s a nd c e p h a lo s p o rin s d o n o t c a u s e fa ls e p o s itiv e s □ Fu ng ite ll: (1 -3 )-p -D -g lu c a n ■ F a lse p o s itiv e s : d ie ta ry g lu c a n s , h e m o d ia ly s is filte rs, a lb u m in /p la s m a p ro te in p ro d u c ts , g lu c a n c o n ta in in g gauze □ A lle rg y : d e te c tio n o f s p e c ific IgG in s e ru m ; R A S T te s t 3.4.7.1.5 T re a tm e n t ■ A lle rg ic : ste ro id s , s u rg e ry

i3.58 A terreus colonies a are cinnamon orange with b biseriate phialides that cover only the top 2/3 of the vesicle

■ A s p e rg illo m a : s u rg e ry (if n e e d e d ) ■ In va sive in fe ctio n : s u rg ic a l d e b rid e m e n t, v o ric o n a z o le , a m p h o te ric in B 3.4.7.2 F u sariu m ■ D is e a se s: k e ra titis, b u rn w o u n d s , in va sive d ise a se , d is s e m in a tio n (red skin le s io n s in c h e m o p atie n t) ■ F lis to p a th o lo g y : lo o k s id e n tic a l to A s p e rg illu s : se ptate, a c u te b ra n c h in g , h yalin e h y p h a e w ith a n g io in v a s io n ■ B lo o d c u ltu re s a re p o s itiv e fo r F u s a riu m in d is s e m in a te d in fe c tio n s ; th is is not se e n w ith A s p e rg illu s

i3.59 A niger colonies a are dark brown to black with b circumferential biseriate pigmented phialides; the reverse side is light

142

• C u ltu re : c o lo n ie s g ro w q u ic k ly a nd h ave pink, lavender, o r s a lm o n c o lo r

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Mycology>Hyaline molds | Zygomycetes ■ P re p a ra tio n s m a d e fro m th e c o lo n ie s s h o w c a n o e sh a p e d m a c ro c o n id ia i3.60, a s w ell a s s h o rt o val m ic ro c o n id ia

3.47.3

Scedosporium apiospermum/Pseudallescheria boydii

m C o m m o n ly fo u n d in soil

■ D is e a s e s □ N e a r d ro w n in g v ic tim s □ M o s t c o m m o n c a u s e o f e u m y c o tic m y c e to m a in th e US □ C an c a u s e s e rio u s , in va sive in fe c tio n s in im m u n o c o m p ro m is e d ■ H is to p a th o lo g y : lo o k s id e n tic a l to A s p e rg illu s and F u s a riu m . s e p ta te , a c u te b ra n c h in g , h y a lin e h y p h a e w ith a n g io in v a s io n ■ C o lo n ie s a re “ h o u s e m o u s e ” g ray ■ P re p a ra tio n s m a d e fro m th e c o lo n ie s w ill s h o w lo llip o p s h a p e d c o n id ia ■ R e s is ta n t to a m p h o te ric in

3.4.8 Zygomycetes 3.4.8.1 Background ■ T e rm in o lo g y □ T h e o rg a n is m s b e lo n g to th e o rd e r M u c o ra le s □ R h izop u s, L ic h th e im ia (p re v io u s ly A b sid ia ), M ucor, C u rm in g h a m e lla are g e n u s n a m e s ■ N a tu ra l re s e rv o irs : air, w ater, soil ■ P a th o g e n e s is : in h a la tio n o f s p o ra n g io s p o re s

3.4.8.2 Diseases ■ R isk fa c to rs in c lu d e d ia b e te s (k e to a cid o sis), s te ro id use, n e u tro p e n ia , tra n s p la n t, p re m a tu rity , d e fe ro x a m in e use, se v e re b u rn s ■ S in u s in fe c tio n w ith p o s s ib le e x te n s io n to th e brain ■ P u lm o n a ry in fe c tio n w ith p o s s ib le d is s e m in a tio n ■ S kin and s o ft tis s u e in fe c tio n

3.4.8.3 Diagnosis ■ D o e s n ot m ake 1 ,3 -(3 -D -g lu ca n ■ T is s u e □ In fla m m a to ry re sp o n se : c o a g u la tiv e n e c ro s is d u e to a n g io in v a s io n □ H y p h a e a re p a u c is e p ta te , b roa d, rib b o n like , tw is te d a nd c o lla p s e d , w ith v a ria b le w id th ; b ra n c h in g te n d s to o c c u r a t rig h t a n g le s (te rm in a l b ra n c h in g : b ra n c h e s c o m e o ff o f a c o n tin u o u s h yph a e; c o n tra s t th is to th e d ic h o to m a s Y sh a p e d b ra n c h in g o f th e hyalin e s e p ta te d m o ld s in c lu d in g A s p e rg illu s , F u s a riu m , and S c e d o s p o riu m ) i3.61 © A S C P 2018

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Mycology>Zygomycetes | Pneum ocystis jiro v e c i

i3.62 Rhizopus species in culture: colonies are rapidly growing (lid lifters) & quickly cover the entire agar surface; they are initially cottony & white, turning light brown with sporulation; many genera of Mucorales look like this—differentiate with wet preparation; reverse side is light colored because hyphae are nonpigemented

i3.64 Mucor species: note the absence of rhizoids; sporangiophores can be branched or unbranched, but lack an apophysis; their sporangia are large spherical structures that tend to fall apart, releasing their numerous spores

■ A b s id ia : rh iz o id s a re in te rn o d a l, w h ic h m e a n s th a t th e y a re in b e tw e e n th e p o in t w h e re th e s p o ra n g io p h o re s a ris e fro m th e s to lo n ■ M u c o r: no rh iz o id s i3.64 ■ C u n n in g h a m e lla

3.4.8.4 Treatment— prompt to prevent tissue necrosis. This is an emergency! ■ S u rg ic a l d e b rid e m e n t i3.63 Rhizopus species produce rhizoids & unbranched sporangiophores that arise directly over the rhizoids; their sporangia are prominent spherical structures that tend to collapse when mature, resembling a collapsed umbrella; their sporangiophores lack an apophysis □ C a n o fte n b e s e e n on H & E (u s u a lly e o s in o p h ilic ); G M S o fte n d o e s n o t s ta in th e s e h y p h a e w e ll; P AS s ta in s th e m b e tte r ■ C u ltu re □ G ro w q u ic k ly (4 8 -7 2 h rs) o n fu n g a l m e d ia (S a b o u ra u d d e x tro s e a g a r); ta k e u p th e w h o le p la te (“ lid lifte rs ” ) i3.62 □ C o lo n ie s a re w o o lly a n d d a rk g re y to b la c k a s s p o re s d e v e lo p (th e re v e rs e o f th e p la te re m a in s lig h t c o lo re d b e c a u s e h y p h a e a re n o t p ig m e n te d ) □ W e t p re p a ra tio n fro m a c o lo n y a llo w s d iffe re n tia tio n a m o n g o rg a n is m s (o n ly id e n tify to g e n u s le ve l, n o t s p e c ie s ) ■ R h iz o p u s : rh iz o id s (ro o ts ) a re a d ja c e n t to th e p o in t w h e re th e s p o ra n g io p h o re b ra n c h e s o ff th e s to lo n ; th is lo c a tio n is c a lle d n o d a l i3.63

■ A m p h o te ric in B ■ P o z a c o n a z o le

3.4.9

P n e u m o c y s t is j i r o v e c i

3.4.9.1 Background ■ P re v io u s ly c o n s id e re d a p ro to z o a c a lle d P n e u m o c y s tis c a rin ii ■ A ID S d e fin in g illn e s s ■ A lso s e e n in o th e r im m u n o s u p p re s s e d p a tie n ts

3.4.9.2 Disease: pneumonia ■ A c u te o r in s id io u s o n s e t ■ P re s e n t w ith d y s p n e a , n o n p ro d u c tiv e c o u g h , c h e s t tig h tn e s s ■ U s u a lly s e ru m L D H is v e ry high ■ C la s s ic ra d io g ra p h s h o w s fin e , b ila te ra l, p e rih ila r in te rs titia l s h a d o w in g ■ C an h a ve c o n c u rre n t in fe c tio n s w ith o th e r a g e n ts ■ C an h ave e x tra p u lm o n a ry in v o lv e m e n t (liver, b o n e m arro w , ly m p h n o d e s , s p le e n )

1 44

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3: Microbiology

Mycology>Pneumocystis jiro ve ci | Prototheca ■ D ire c t flu o re s c e n t a n tib o d y on s p u tu m , b ra n c h w a s h , o r BAL

ft, *

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m

9 * i d

../V,V.,;;- ' T ^ _r YA "A *‘V'**T2

T Sr

d

9

3.4.10.1 Background □ A c h lo ro p h y llic a lg a e ; not a fu n g u s b u t in c lu d e d h e re b e c a u s e c lin ic a lly a n d d ia g n o s tic a lly s im ila r to fu n g i

3.4.10.2 Disease: protothecosis

*f

W

■ T h is is th e o n ly a lg a e k n o w n to c a u s e h u m a n d is e a s e ■ F o u n d in fre s h a n d m a rin e w a te rs , w o rld w id e

!.*t

jf> r

3.4.10 Prototheca

□ P ro to th e c a w ic k e rh a m ii is th e m o s t c o m m o n s p e c ie s

9

• %

■ N o t ro u tin e ly c u ltu re d

%

■ In fe c tio n s in v o lv e skin and s u b c u ta n e o u s tis s u e b u t c a n be m o re s e v e re in im m u n o c o m p ro m is e d h o s ts; u s u a lly a c q u ire d via tra u m a o r s u p e rfic ia l w o u n d s □ D is s e m in a te d

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■ P a p u lo n o d u la r o r e c z e m a to id e ru p tio n on lim b s o r fa c e ■ P ath: m ix e d in fla m m a tio n a n d g ra n u lo m a s in d e rm is + / - u lc e ra tio n w ith e p id e rm a l m ic ro a b s c e s s e s

*

:d

■ U s u a lly im m u n o c o m p ro m is e d

□ O le c ra n o n b u rs itis

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■ U s u a lly n o t im m u n o c o m p e te n t b u t h a v e h a d tra u m a to e lb o w ■ P ath: n e c ro tiz in g g ra n u lo m a s in w a ll o f b u rs a

'

:/> i3.65 Pneumocystis: characteristic exudative material is seen within alveolar airspaces on a an H&E stained lung section & b on Pap stained & c Wright stained sputum smears; note the central dot visible within the empty spaces on the Wright stained preparation In GMS stained preparations at d low & e high magnification, the organisms are approximately the size of Histoplasma but do not bud; they tend to cluster & have a central dark staining dot when stained with silver stains; cyst forms are round or cup shaped & have been likened to crushed ping pong balls

3.4.10.3 Lifecycle ■ A s e x u a l re p ro d u c tio n w ith in te rn a l s e p ta tio n s ■ F o rm s a s p o ra n g iu m c o n ta in in g 2 -2 0 d a u g h te r c e lls / s p o ra n g io s p o re s in a m o ru la c o n fig u ra tio n ■ T h e p a re n t ce ll e v e n tu a lly ru p tu re s re le a s in g th e s p o re s

3.4.10.4 Diagnosis ■ L a rg e , n o n b u d d in g , s p h e ro id c e ll w ith p ro m in e n t w a ll a nd m o ru la c a n re a d ily be s e e n in tis s u e

3.4.9.3 D ia g n o sis ■ O rg a n is m s a re 5 -6 pm in d ia m e te r, lo o k like cu p s , c re s c e n ts , b o a ts, o r c ru s h e d p in g p o n g balls; ca n be se e n on m a n y s ta in s s u c h a s H & E , G M S , P ap i3.65 ■ C y to lo g y o f s p u tu m o r B A L is th e m o s t c o m m o n m e th o d o f d ia g n o s is □ L o o k fo r fo a m y e x u d a te ; “c o tto n c a n d y ” a lv e o la r c a s ts

■ N o t e a s ily se en w ith H & E , b u t ca n be s e e n w ith G ra m , G M S o r PAS ■ G ro w s w e ll on a v a rie ty o f m e d ia ; c o lo n ie s lo o k like C a n d id a • C a n be id e n tifie d o n c o m m e rc ia l y e a s t id e n tific a tio n s y s te m s, w ill g ro w in b lo o d c u ltu re b o ttle s ■ In h ib ite d by c y c lo h e x im id e b u t n o t c h lo ro /g e n t

■ L un g b io p sy : ra re ly d o n e □ W o u ld se e fo a m y e x u d a te fillin g a lv e o la r s p a c e s ; a lv e o la r w a lls in ta c t

■ L ik e s 3 0 -3 7 ° C b u t n ot ro o m te m p ■ W e t p rep : s p o ra n g io s p o re s w ith in s p o ra n g ia

■ P C R : B e c o m in g m o re ro u tin e © ASCP2018

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3: Microbiology

Mycology>Prototheca | Notes about antifungal agents Bacteriology>Specimen processing 3.4.10.5 Treatment

t3.22 Gram morphology of selected organisms

■ S u rg ic a l if lo c a tio n is a m e n a b le ■ D is s e m in a te d (rare ): a m p h o te ric in B

3.4.11 Notes about antifungal agents ■ P o ly e n e □ A m p h o te ric in B (IV ) ■ B in d s to s te ro ls , p re fe re n tia lly to th e p rim a ry fu n g a l c e ll m e m b ra n e s te ro l, e rg o s te ro l; d is ru p ts o s m o tic in te g rity o f th e fu n g a l m e m b ra n e ■ A d v e rs e e ffe c ts : n e p h ro to x ic ity ■ B ro a d ra n g e o f a c tiv ity ■ N o ta b le e x c e p tio n s : A s p e rg illu s te rre u s , S c e d o s p o riu m a p io s p e rm u m IP s e u d a lle s c h e ria b o y d ii, C a n d id a lu s ita n ia e □ N y s ta tin (to p ic a l): m u c o s a l/o ro p h a ry n g e a l c a n d id ia s is ■ A z o le s : in h ib it th e s y n th e s is o f e rg o s te ro l b y b lo c k in g th e a c tio n o f 1 4 -a -d e m e th y la s e

O r g a n is m Staphylococcus spp Streptococcus spp Streptococcus pneumonia Neisseria spp Vibrio spp Campylobacter spp Yersinia pestis Corynebacterium Actinomyces, Nocardia Clostridium, Bacillus

G r a m s ta in m o r p h o lo g y Gram positive cocci in grapelike clusters Gram positive cocci in pairs and chains Gram positive lancet shaped diplococci Gram negative coffee bean diplococci Gram negative curved rods Gram negative curved, S or seagull wing shaped rods Gram negative rods with bipolar staining (darker on each end like a safety pin) club shaped; palisade; “Chinese letters” filamentous Gram positive rods large, boxcar Gram positive rods

□ N o t p e rfo rm e d on sto o l a s it is c o m p o s e d o f m a n y n o n p a th o g e n ic b a c te ria ■ A ls o ca n be d o n e on a c o lo n y o r fro m liq u id m e d ia

3.5.1.1.2 C o m p o n e n ts ■ A ir d rie d s m e a r, fix e d w ith h e a t o r m e th a n o l

□ F lu c o n a z o le (P O , IV ) ■ G o o d C N S p e n e tra tio n

■ C ry s ta l v io le t: b in d s to p e p tid o g ly c a n in ce ll w a ll

■ N o ta b le re s is ta n c e : C k ru s e i, C g la b ra ta , C d u b lin ie n s is

■ G ra m io d in e : m o rd a n t c a u s e s c ry s ta l v io le t to p re c ip ita te in s id e th e cell

m N o a c tiv ity a g a in s t m o ld s

□ Itra c o n a z o le (P O , IV ): g o o d fo r d im o rp h ic s

■ D e c o lo riz e r: a c e to n e -a lc o h o l m ix; G ra m p o s itiv e o rg a n is m s re s is t d e c o lo riz a tio n

□ V o ric o n a z o le (P O , IV ): fu n g is ta tic a g a in s t C a n d id a a n d C ry p to c o c c u s

■ S a fra n in : p in k /re d c o u n te rs ta in , s ta in s G ra m n e g a tiv e o rg a n is m s

□ P o s a c o n a z o le (P O ): a c tiv ity a g a in s t z y g o m y c e te s , d im o rp h ic s , d e m a tia c e o u s ■ G lu c a n s y n th e s is in h ib ito rs (e c h in o c a n d in s ): b lo c k ce ll w a ll s y n th e s is b y in h ib itin g th e e n z y m e 1,3-(3 g lu c a n s y n th a s e □ C a s p o fu n g in (IV )

3.5.1.1.3 In te rp re ta tio n ■ E x a m in e a t 1 0 0 0 x (1 0 0 * oil o b je c tiv e ) ■ G o o d s ta in in g : n e u tro p h ils a re p in k (if b lu e , th e s lid e is u n d e rd e c o lo riz e d ) ■ G ra m sta in m o rp h o lo g y ca n g u id e s p e c ie s id e n tific a tio n

□ M ic a fu n g in (IV ) ■ A n tim e ta b o lite s : flu c y to s in e (P O ); in h ib its p ro te in s y n th e s is b y re p la c in g u ra c il w ith 5 -F U in fu n g a l R N A □ U s u a lly g iv e n w ith a m b is o m e fo r c ry p to c o c c a l m e n in g itis ■ A lly la m in e s : te rb in a fin e (P O , to p .); m a in s ta y o f tre a tm e n t o f d e rm a to p h y to s is

3.5

3.5.1.2

Other stains used for bacteria

3.5.1.2.1 M eth yle n e blue ■ N e u tro p h ils a re in sto o l ■ C an s e e m e ta c h ro m a tic g ra n u le s in C o ry n e b a c te riu m d ip h th e ria e

3.5.1.2.2 A c rid in e O ra n g e

Bacteriology

3.5.1 Specimen processing

■ U se fu l in d e te c tin g b a c te ria w h e n th e G ra m sta in fro m b lo o d c u ltu re b o ttle is n e g a tiv e

3.5.1.1 Gram stain t3 .2 2

■ F lu o re s c e n t d y e in te rc a la te s into n u c le ic a cid

3.5.1.1.1 D ire c t fro m s a m p le vs fro m c o lo n y ■ D o n e d ire c tly fro m th e s a m p le o n c e rta in s p e c im e n ty p e s , e s p e c ia lly s te rile s ite s

146

■ B rig h t o ra n g e w h e n v ie w e d w ith flu o re s c e n t s c o p e ■ D o e s n o t d e te rm in e if G ra m p o s itiv e o r n e g a tiv e

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

3: Microbiology

Bacteriology>Specimen processing ■ S h e e p b lo o d a g a r: g ro w s m a n y o rg a n is m s a n d d e fin e s h e m o ly tic p a tte rn s i3.66 □ A : p a rtia l h e m o ly s is ; a g a r lo o k s g re e n a ro u n d c o lo n y □ p: c o m p le te h e m o ly s is ; a g a r is c le a r a ro u n d c o lo n y □ y: no h e m o ly s is ■ C N A (c o lis tin /n a lid ix ic a cid ) a g a r: b lo o d a g a r w ith a n tib io tic s to in h ib it G ra m n e g a tiv e b a c illi ■ C h o c o la te a g a r: g ro w s fa s tid io u s o rg a n is m s s u c h a s H a e m o p h ilu s a nd N e is s e ria □ Lysed R B C s , c o n ta in s h e m in (X ) a n d N A D (V ) □ T h a y e r-M a rtin : c h o c o la te a g a r w ith V C N (v a n c o m y c in , c o lis tin , n y s ta tin ); fo r is o la tio n o f N e is s e ria • M u e lle r-H in to n a g a r: a n tim ic ro b ia l s u s c e p tib ility te s tin g ■ M a n n ito l s a lt a g a r: is o la tio n o f S a u re u s □ S e le c tiv e : c o n ta in s high c o n c e n tra tio n s o f N a C I to in h ib it g ro w th o f G ra m n e g a tiv e s

i3.66 Hemolytic patterns on blood agar

3.5.1.2.3 M o dified K inyoun: aids in d etectio n o f N o cardia due to w e aker d e c o lo rize r co m p ared w ith tra d itio n al Kinyoun ■ K in yo u n sta in is a n e w e r v e rs io n o f th e Z ie h l-N e e ls e n sta in, u sed fo r a cid fa s t m y c o b a c te ria □ K in yo u n is cold; Z ie h l-N e e ls e n re q u ire s h e a tin g ■ N o c a rd ia is c a lle d w e a k ly o r p a rtia lly a cid fa s t

3.5.1.2.4

D irect flu o re s c e n t an tib o d y (DFA) stains:

□ D iffe re n tia l: c o a g u la s e p o s itiv e S ta p h y lo c o c c u s (eg, S a u re u s ) tu rn th e a g a r y e llo w d u e to m a n n ito l fe rm e n ta tio n ; c o a g u la s e n e g a tiv e o rg a n is m s p ro d u c e s m a ll p in k /re d c o lo n ie s w ith n o c h a n g e in th e a g a r c o lo r ■ M a c C o n k e y a g a r: G ra m n e g a tiv e b a c te ria □ S e le c tiv e : b ile s a lts in h ib it G ra m p o s itiv e o rg a n is m s □ D iffe re n tia l: d y e tu rn s p in k fo r la c to s e fe rm e n te rs ( £ co li, K le b s ie lla , C itro b a c te r, E n te ro b a c te r), c le a r fo r n o n fe rm e n te rs

Legionella Bordetella, Chlamydia

■ S o rb ito l M a c C o n k e y a g a r: 0 1 5 7 E c o li

■ L o w s e n s itiv ity ; n o w re p la c e d by P C R

□ C o n ta in s s o rb ito l in ste a d o f la c to s e □ S e le c tiv e : in h ib its G ra m p o s itiv e o rg a n is m s

3.5.1.3 Culture techniques

□ D iffe re n tia l: 0 1 5 7 E c o li d o e s n o t fe rm e n t s o rb ito l, so w ill be c o lo rle s s ; o th e r s tra in s d o fe rm e n t s o rb ito l a n d w ill be p in k

3.5.1.3.1 M edia ■ B lo o d c u ltu re b o ttle s □ F illed d ire c tly fro m p a tie n t s a m p le (w h o le b lo o d ) a t th e b e d s id e □ Fill v o lu m e o f b lo o d c u ltu re b o ttle is th e m o s t im p o rta n t fa c to r fo r re c o v e ry o f b a c te ria ; S h o u ld be 8 -10 m L o r a c c o rd in g to th e m a n u fa c tu re r’s in s tru c tio n s □ Id e a lly a 2 b o ttle s e t (1 a e ro b ic a nd 1 a n a e ro b ic ) is d ra w n fro m e a c h v e n ip u n c tu re □ M u ltip le s e ts s h o u ld be ta k e n s e p a ra te ly (2 a n a to m ic s ite s 2 0 m in u te s a p a rt) □ D o n ot d ire c tly G ra m sta in b lo o d (b e fo re in c u b a tio n ) b e c a u s e it h as e x tre m e ly lo w s e n s itiv ity □ In cu b a te d in re a d e r w h ic h d e te c ts in c re a s e d C 0 2 (so m e ty p e s d e te c t p re s s u re ch a n g e ) □ T h e re a d e r s e ts o ff an a la rm w h ic h a le rts a lab te c h to re m o ve th e b o ttle

■ B ile e s c u lin □ S e le c tiv e : b ile s a lts in h ib it g ro w th o f G ra m p o s itiv e s o th e r th a n e n te ro c o c c u s a n d G ro u p D s tre p to c o c c i; a ls o u se d fo r B a c te ro id e s □ D iffe re n tia l: e n te ro c o c c u s h y d ro ly z e s e s c u lin , tu rn s m e d ia b la c k ■ B C Y E (b u ffe re d c h a rc o a l y e a s t e x tra c t) a g a r: p la te is b la c k ; c o n ta in s c y s te in e and iro n to s u p p o rt g ro w th o f L e g io n e lla ■ T in s d a le : m e d ia c o n ta in s te llu rite to g ro w C o ry n e b a c te riu m d ip h th e ria e m R e g a n -L o w e a n d B o rd e t-G e n g o u : B o rd e te lla p e rtu s s is □ H a s b e e n re p la c e d by P C R □ R e g a n -L o w e m a y be used in o u tb re a k s e ttin g to c o n firm P C R

□ In cu b a te fo r 5 d a y s o r u ntil p o s itiv e © A S C P 2018

ISBN 978-08 9 1 8 9 -6 6 7 8

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3: Microbiology

Bacteriology>Specimen processing ■ T h io g ly c o la te b ro th : e n h a n c e s g ro w th o f m a n y b a c te ria , in c lu d in g m ic ro a e ro p h ilic a n d o b lig a te a n a e ro b ic b a c te ria

■ S e le n ite b ro th : liq u id m e d ia ; in h ib its g ro w th o f o rg a n is m s o th e r th a n S a lm o n e lla

□ L iq u id m e d ia □ O x y g e n te n s io n d e c re a s e s to w a rd s b o tto m o f tu b e , p e rm ittin g g ro w th o f o b lig a te a n a e ro b e s a n d m ic ro a e ro p h ilic b a c te ria w ith o u t in c u b a tio n in a n a n a e ro b ic a tm o s p h e re ■ L im b ro th : u s e d fo r re c o v e ry o f G ro u p B s tre p to c o c c i by s u p p re s s in g g ro w th o f o th e r o rg a n is m s

3.5.1.3.2 G ro w th co n d itio n s ■ M ost o rg a n is m s a re g ro w n a t 37°C in a m b ie n t a ir (21% 0 2) ■ C a m p y lo b a c te r: m a n y (b u t n o t a ll) s p e c ie s g ro w a t 4 2 °C in m ic ro a e ro p h ilic c o n d itio n s (5% 0 2, 10% C 0 2, 8 5 % N itro g e n )

□ L iq u id m e d ia

■ Y e rsinia e n te ro c o litic a : s to re s to o l s a m p le a t 4°C b e fo re p la tin g ; th e n in c u b a te p la te a t ro o m te m p e ra tu re (25°C )

□ C o m m o n ly u s e d w ith v a g in a l/re c ta l s w a b s in p re g n a n t p a tie n ts

■ L is te ria : g ro w s o p tim a lly a t 37°C b u t ca n re p lic a te at re frig e ra to r te m p (4°C) w h ic h le a d s to fo o d b o rn e illn e s s

■ T h a y e r-M a rtin o r M a rtin -L e w is : u s e d fo r re c o v e rin g N e is s e ria s p p fro m n o n s te rile s ite s s u c h a s g e n ita ls o r p h a ry n x ; m o s tly re p la c e d b y P C R ■ E o s in m e th y le n e b lu e (E M B ): s im ila r to M a c C o n k e y ; d iffe re n tia te s la c to s e fe rm e n te rs □ L a c to s e fe rm e n ta tio n le a d s to p u rp le /b la c k /g re e n m e ta llic c o lo n ie s □ N o n la c to s e fe rm e n ta tio n le a d s to tra n s lu c e n t c o lo n ie s ■ H e k to e n e n te ric a g a r a n d X L D : m a in ly u s e d to d iffe re n tia te S a lm o n e lla a n d S h ig e lla fro m o th e r E n te ro b a c te ria c e a e in s to o l c u ltu re s

3.5.1.3.3 D e fin itio n s ■ O b lig a te a e ro b e : n e e d o x y g e n to live ■ F a c u lta tiv e a n a e ro b e : ca n g ro w w ith o r w ith o u t o x y g e n ; w ill u s e o x y g e n if a v a ila b le ■ O b lig a te a n a e ro b e : o x y g e n is to x ic; ca n o n ly g ro w a n a e ro b ic a lly ■ A e ro to le ra n t a n a e ro b e s : g ro w p o o rly in th e p re s e n c e o f o x y g e n ; o x y g e n is n o t to x ic b u t th e y c a n n o t u se it ■ M ic ro a e ro p h ile s : o x y g e n is re q u ire d a t lo w le ve ls

□ H e k to e n is g re e n ; X L D is red □ S e le c tiv e : G ra m p o s itiv e s in h ib ite d □ D iffe re n tia l ■ H 2S p ro d u c tio n : b la c k c o lo n ie s (S a lm o n e lla ) ■ F e rm e n ts la c to s e , s u c ro s e , o r s a lic in : y e llo w /o ra n g e c o lo n ie s (K le b s ie lla ) ■ N o n fe rm e n te r, n o n -H 2S p ro d u c e r: tra n s lu c e n t c o lo n ie s (S h ig e lla ) ■ S a lm o n e lla -S h ig e lla (S S ) a g a r: s to o l c u ltu re s

■ F ra n c is e lla , B ru c e lla , B o rd e te lla , P a s te u re lla , L e g io n e lla , C a m p ylo b a c te r, C a p n o c y to p h a g a c a n im o rs u s , S tre p to b a c illu s m o n ilo fo rm is , H a e m o p h ilu s a nd o th e r H A C E K s, H e lic o b a c te r

3.5.1.4

Workup of cultured isolates

3.5.1.4.1 B io c h e m ic a l tests

□ P la te is lig h t b e ig e /p in k □ S e le c tiv e : G ra m p o s itiv e s a re in h ib ite d

■ O fte n u s e d to g iv e p re s u m p tiv e d ia g n o s e s

□ D iffe re n tia l

■ M an y ca n be d o n e a t th e b e n c h v e ry q u ic k ly

■ H 2S p ro d u c tio n : b la c k c o lo n ie s (S a lm o n e lla ) m F e rm e n ts la c to s e , s u c ro s e , o r s a lic in : p in k c o lo n ie s (K le b s ie lla ) •

N o n fe rm e n te r, n o n -H 2S p ro d u c e r: b e ig e , tra n s lu c e n t c o lo n ie s (S h ig e lla )

■ C IN a g a r: s e le c tiv e fo r Y e rs in ia e n te ro c o litic a (M n e m o n ic : “ Y e r-‘C IN ’-ia ” ) □ C o lo n ie s lo o k like b u ll’s e y e w ith red c e n te r a nd tra n s p a re n t b o rd e r ■ C a m p y lo b a c te r b lo o d a g a r (C a m p y ): c o n ta in s a n tim ic ro b ia ls to s u p p re s s g ro w th o f o rg a n is m s in s to o l o th e r th a n C a m p y lo b a c te r

148

3.5.1.3.4 F as tid io u s o rg an ism s: need s u p p le m e n te d m edia; G ram n eg atives th a t do not g ro w on M acC o nkey, p in p o in t co lo n ies

■ P anels: m a n y s m a ll w e lls th a t e a c h c o n ta in a b io c h e m ic a l re a c tio n □ M a n u a l (eg, A P I): in o c u la te p a n e l w ith b a c te ria and re a g e n ts , in c u b a te , re ad re su lts , a nd in p u t re s u lts into a c o m p u te r d a ta b a s e □ A u to m a te d (eg, V ite k a nd M ic ro s c a n W a lk A w a y ): in o c u la te p a n e l, p la c e on in s tru m e n t, in s tru m e n t p e rfo rm s b io c h e m ic a l te s ts and a n a ly z e s re su lts, g iv e s id e n tific a tio n ■ E x a m p le s (o th e rs w ill be re vie w e d w ith th e o rg a n is m s th e y te s t fo r) □ C a ta la s e i3.67: d iffe re n tia te s S ta p h fro m S tre p

AS CP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

3: Microbiology

Bacteriology>Specimen processing

.4 ,

i3.67 Catalase test Rapid & sustained effervescence (note bubbles on left) after addition of hydrogen peroxide to an isolate indicates the presence of catalase; staphylococci are catalase positive

i3.69 Positive oxidase test denoted by purple/blue color

■ T ra n s fe r c o lo n y to a g la s s s lid e a n d a d d d ro p s o f 3% h y d ro g e n p e ro x id e ■ B u b b le s = p o s itiv e ; no b u b b le s = n e g a tiv e ■ S ta p h y lo c o c c u s a n d M ic ro c o c c u s a re p o s itiv e ; S tre p to c o c c u s is n e g a tiv e ■ O th e r c a ta la s e p o s itiv e o rg a n is m s : C a m p y lo b a c te r, L is te ria , B a c illu s ■ B lo o d ca n c a u s e a fa ls e p o s itiv e , s o d o n o t u s e b lo o d a g a r p la te □ C o a g u la s e i3.68 ■ 2 m e th o d s ■ S lid e c o a g u la s e te s t d e te c ts b o u n d c o a g u la s e ■ T u be c o a g u la s e d e te c ts fre e c o a g u la s e ■ D e fin itiv e te s t b u t s lo w e r; n ot ro u tin e ly p e rfo rm e d ■ In c u b a te fo r 4 h o u rs ; if n e g a tive , c h e c k a g a in a t 2 4 h o u rs ■ S ta p h y lo c o c c u s lu g d u n e n s is : s lid e c o a g u la s e p o s itiv e b u t tu b e c o a g u la s e n e g a tiv e □ P Y R (p y rro lid o n y l a ry la m id a s e ): p o s itiv e o rg a n is m s (S tre p p y o g e n e s lg ro u p A s tre p to c o c c i a n d E n te ro c o c c u s s p p ) w ill tu rn th e d is k p in k /re d ; th e d is k s a re im p re g n a te d w ith L -p y rro lid o n y l-p -n a p h th y la m id e , th e e n z y m e ’s s u b s tra te i3.68 The coagulase test is used to presumptively identify S aureus a The tube coagulase test detects free coagulase, producing a coagulum in the presence of plasma (top tube); to avoid false negative reactions, it is necessary to examine the tube at both 4 & 24 hours b The slide coagulase test detects bound coagulase, producing clumping in the presence of plasma (top slide); the slide test is faster but the tube test is required for confirmation

□ O x id a s e (a lso c a lle d c y to c h ro m e o x id a s e ) i3.69 ■ In itial c la s s ific a tio n o f G ra m n e g a tiv e o rg a n is m s ■ P o sitiv e re s u lt is in d ic a te d b y b lu e p ig m e n t; c a n be p e rfo rm e d o n a sw a b o r a c a rd ■ A ll E n te ro b a c te ria c e a e a re o x id a s e n e g a tiv e ■ O x id a s e p o s itiv e o rg a n is m e x a m p le s : P s e u d o m o n a s , N e is s e ria , C a m p y lo b a c te r, V ib rio

© A S C P 2018

ISBN 9 7 8 -08 9189-6678

149

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Bacteriology>Specimen processing | Gram positive cocci ■ T h e tim e o f flig h t th ro u g h th e v a c u u m tu b e is m e a s u re d and u se d to d e te rm in e th e m a s s o f e a c h p ro te in w ith in a c e rta in s ize ra n g e ■ M a ss s p e c tru m is c o m p ile d , w h ic h s e rv e s a s a fin g e rp rin t to id e n tify th e o rg a n is m

3.5.1.4.3 A n tig e n d etectio n : Legionella, Streptococcus pneumoniae, etc ■ S e n s itiv ity is ok; m a n y o f th e s e a re b e in g re p la c e d by PCR

3.5.1.4.4 N u cle ic acid d e te ctio n ■ P la tfo rm s in c lu d e s ig n a l a m p lific a tio n a nd ta rg e t a m p lific a tio n

i3.70 Urease test, showing positive (top) & negative (bottom) results; rapid (within 4 hours) urease positive organisms include Proteus species & H pylori

■ G re a t fo r o rg a n is m s th a t a re s lo w g ro w in g o r d iffic u lt to c u ltu re (C h la m y d ia a n d N e is s e ria g o n o rrh o e a e ) and th o s e th a t a re n o n c u ltiv a ta b le ( T ro p h e ry m a w h ip p e lii)

□ U re a s e : p o s itiv e re s u lt is p in k /re d (P ro te u s ) i3.70

3.5.2 Gram positive cocci

□ In d o le te s t: E c o li a n d P ro te u s v u lg a ris

3.5.2.1 Staphylococcus: Gram positive cocci in clusters; catalase positive f3.4

□ H u g h -L e ifs o n O F m e d iu m (n o t ro u tin e ly u se d a n y m o re ) ■ D e te rm in e s if o rg a n is m is o x id a tiv e o r fe rm e n tin g a c e rta in s u g a r (u s u a lly g lu c o s e ) ■ In o c u la te a n d in c u b a te 2 tu b e s : o n e e x p o s e d to a ir a n d th e o th e r c o v e re d w ith m in e ra l oil to p re v e n t a ir e x p o s u re

3.5.2.1.1 C o a g u la s e p o s itiv e Staphylococcus ■ S ta p h y lo c o c c u s a u re u s □ O fte n c o lo n iz e th e skin , eye, u p p e r re s p ira to ry tra c t, G l, u re th ra t3.23

t3.23 Carriage rates for a variety of bacterial species

■ A c id p ro d u c tio n tu rn s th e tu b e y e llo w ■ O x id a tiv e o rg a n is m s p ro d u c e a c id (y e llo w ) o n ly in th e o p e n tu b e ■ F e rm e n tin g o rg a n is m s p ro d u c e a c id (y e llo w ) in b o th tu b e s ■ N o n s a c c h a ro ly tic b a c te ria d o n o t p ro d u c e a c id in e ith e r tu b e

3 .5 .1 .4 .2 M a trix a s s o c ia te d la s e r d e s o rp tio n io n iza tio n tim e o f flig h t m a s s s p e c tro m e try (M A L D I-T O F M S) ■ M a y b e u s e d in s te a d o f o r in a d d itio n to b io c h e m ic a l te s ts ■ A n is o la te ta k e n fro m a n a g a r p la te is tra n s fe rre d to a ta rg e t s lid e , o v e rla id w ith a m a trix s o lu tio n , a n d lo a d e d in to th e io n iz a tio n c h a m b e r o f a M A L D I-T O F m a s s s p e c tro m e te r ■ T h e s a m p le is irra d ia te d by a la s e r c a u s in g th e s a m p le / m a trix m ix tu re to v a p o riz e w h ile p ro te in s in th e s a m p le a c q u ire an e le c tric a l c h a rg e ; th is is p u s h e d into a v a c u u m tu b e

O rganism Staphylococcus aureus Streptococcus Adults pneumoniae Children Group B streptococci Pregnant women Clostridium difficile

Healthy infants Healthy adults Adults in long term care facilities

Neisseria meningitidis

Carriage rate 50% 5% 50% 10%-30% 30% Gram positive cocci ■ C h ro m o g e n ic m e d ia fo r M R S A ■ L a te x a g g lu tin a tio n te s t fo r P B P 2 a ■ P C R e g, G e n e X p e rt □ V a n c o m y c in in te rm e d ia te a n d v a n c o m y c in re s is ta n t S ta p h y lo c o c c u s a u re u s (V IS A a n d V R S A ): n o t s e e n o fte n , b u t fe a r o f in c re a s e in th e fu tu re □ In d u c ib le c lin d a m y c in re s is ta n c e (m a c ro lid e re s is ta n c e ) ■ E ry th ro m y c in (m a c ro lid e ) a n d c lin d a m y c in (lin c o s a m id e ) h a ve s im ila r m e c h a n is m s o f a c tio n , b in d in g to 5 0 S rib o s o m a l s u b u n its a n d in h ib itin g p ro te in s y n th e s is ■ R e s is ta n c e to th e s e is m e d ia te d b y e rm g e n e s ■ T h e s e s tra in s w ill a p p e a r c lin d a m y c in s e n s itiv e in v itro b u t u s u a lly a p p e a r e ry th ro m y c in re s is ta n t ■ It is n e c e s s a ry to te s t fo r in d u c ib le c lin d a m y c in re s is ta n c e in s tra in s th a t a re c lin d a m y c in s e n s itiv e a nd e ry th ro m y c in re s is ta n t

f3.4 Algorithm for identification of Staphylococcus species

■ D te s t: n o t o fte n d o n e a n y m o re

□ V iru le n c e fa c to rs

■ M a k e a la w n o f th e o rg a n is m on a p la te

■ S o m e h ave c a p s u le : a n tip h a g o c y tic

■ D ro p a 15 pg e ry th ro m y c in d is k a n d a 2 pg c lin d a m y c in d is k 15 m m a p a rt

■ T o xin s ■ T S S T 1 : to x ic s h o c k s y n d ro m e ■ R e s u lts fro m c o lo n iz a tio n by to xin p ro d u c in g s tra in s o f S a u re u s \ a s s o c ia te d w ith ta m p o n s , s u rg ic a l w o u n d s ■ Fever, m y a lg ia s , v o m itin g , d ia rrh e a p re c e d e h y p o te n s io n /h y p o v o le m ic s h o c k ■ E ry th e m a to u s ra sh th a t in c lu d e s p a lm s and s o le s a n d d e s q u a m a te s in 1-2 w e e k s ■ E n te ro to x in s A -E : fo o d p o is o n in g ; ra p id o n s e t (1 -6 h o u rs a fte r in g e s tio n ) n a u s e a , v o m itin g , a b d o m in a l c ra m p s , d ia rrh e a ■ E x fo lia tiv e to x in s (e p id e rm o ly tic to x in s A and B): s k in e ry th e m a a nd s e p a ra tio n , p re s e n tin g a s s c a ld e d skin s y n d ro m e ■ E n z y m e s th a t d e s tro y tis s u e a nd h elp it sp re a d □ M e th ic illin re s is ta n t S ta p h y lo c o c c u s a u re u s (M R S A ) ■ R e s is ta n t to p e n ic illin s a n d c e p h a lo s p o rin s ((3 la c ta m a n tib io tic s ) ■ p la c ta m a n tib io tic s n o rm a lly kill by b in d in g to P B P (p e n ic illin b in d in g p ro te in ) a nd in h ib itin g p e p tid o g ly c a n c ro s s lin k in g ■ m e c A is th e g e n e th a t e n c o d e s P B P 2 a (p e n ic illin b in d in g p ro te in 2a), a fo rm o f th e p ro te in th a t w ill n ot bind P la c ta m a n tib io tic s ■ O p tio n s fo r d e te c tio n o f M R S A ■ G ro w on p la te w ith 3 0 pg c e fo x itin d isk: M R S A w ill g ro w up to th e d is k (re s is ta n t) ■ P re v io u s ly u sed a 1 pg o x a c illin d isk; th is is no lo n g e r re c o m m e n d e d © ASCP2018

■ In c u b a te o v e rn ig h t ■ P o s itiv e re s u lt s h o w s a D s h a p e d z o n e o f in h ib itio n a ro u n d th e c lin d a m y c in ■ S ta p h y lo c o c c u s lu g d u n e n s is □ S lid e c o a g u la s e p o s itiv e b u t tu b e c o a g u la s e n e g a tiv e (b e c a u s e it o n ly p ro d u c e s b o u n d c o a g u la s e e n z y m e ; S a u re u s p ro d u c e s both b o u n d a n d fre e c o a g u la s e ) □ D iffe re n tia te fro m S a u re u s v ia P Y R a n d o rn ith in e d e c a rb o x y la s e (S lu g d u n e n s is p o s itiv e fo r b o th ) □ A lth o u g h it is u s u a lly c la s s ifie d a s a c o a g u la s e n e g a tiv e S ta p h y lo c o c c u s , it c a n c a u s e s e rio u s in fe c tio n s ■ O s te o m y e litis , n a tiv e va lv e e n d o c a rd itis , etc, c lin ic a lly re s e m b lin g S a u re u s

3.5.2.1.2 C o a g u la s e n eg ative S ta p h y lo c o c c u s : c a ta la s e p o sitive, G ram p o s itiv e cocci in clu s te rs ; c o a g u la s e n eg ative ■ S ta p h y lo c o c c u s e p id e rm id is □ N o v o b io c in s e n s itiv e (d iffe re n tia te s S e p i fro m S s a p ro p h y tic u s ) □ P a rt o f n o rm a l skin flo ra ; o fte n c o n ta m in a te s b lo o d c u ltu re s ■ To d e te c t an a c tu a l in fe c tio n , is o la te th e o rg a n is m fro m 2 c u ltu re s □ T ru e in fe c tio n s a re o fte n a s s o c ia te d w ith im p la n te d p ro s th e tic v a lv e s , jo in ts and s h u n ts , c a th e te rs (U T I)

ISBN 9 7 8 -08 9189-6678

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3: Microbiology

Bacteriology>Gram positive cocci

Streptococcus and Enterococcus

PYR +

i3.71 Micrococcus luteus colonies have a characteristic lemon yellow color (here on blood agar)

Group B Strep

Group A Strep

Non

Streptococcus

Streptococcus

enterococci

agalactiae

pyogenes

Group D Strep

Enterococcus

f3.5 Algorithm for identification of Streptococcus species

3.5.2.1.3

Staph relate d o rg a n is m s (c atala se positive)

■ M ic ro c o c c u s □ G ra m p o s itiv e c o c c i in te tra d s □ N o rm a l flo ra o f skin , m u c o s a , o ro p h a ry n x □ C a n c a u s e o p p o rtu n is tic in fe c tio n s , b u t u s u a lly it is a c o n ta m in a n t □ M ic ro c o c c u s lu te u s : y e llo w c o lo n ie s (can be c o n fu s e d w ith S a u re u s ) i3.71 □ M o d ifie d o x id a s e p o s itiv e ■ R o th ia (fo rm e rly S to m a to c o c c u s ) m u c ila g in o s a □ L a rg e G ra m p o s itiv e c o c c i in p a irs o r c lu s te rs □ N o rm a l flo ra o f m o u th a n d re s p ira to ry tra c t □ C a n c a u s e in fe c tio n s (b a c te re m ia , e n d o c a rd itis , p e rito n itis ) in im m u n o c o m p ro m is e d p a tie n ts i3.72 A latex agglutination test for the identification of streptococcal qroups A, B, C, D, F & G In well 1, S pyogenes was agglutinated using Lancefield group A reagent In well 2, S pyogenes did not agglutinate using Lancefield group B reagent

□ C o lo n ie s a re s tic k y o r m u c o id ; a d h e re n t to a g a r □ W e a k ly c a ta la s e p o s itiv e

3.5.2.2 Streptococcus and Enterococcus: Gram positive cocci in pairs or chains; catalase negative; Lancefield typing can be performed by latex agglutination i3.72, f3.5, t3.24

S ta p h y lo c o c c u s s a p ro p h y tic u s □ N o v o b io c in re s is ta n t □ U rin a ry tra c t in fe c tio n s in s e x u a lly a c tiv e y o u n g w o m e n (“ h o n e y m o o n c y s titis ” ) S ta p h y lo c o c c u s h a e m o ly tic u s

3 .5 .2 .2 .1

(3 h e m o ly t ic

■ S tre p to c o c c u s p y o g e n e s : G ro u p A s tre p □ C h a ra c te ris tic s

□ N o rm a l s k in flo ra □ In fe c tio n s o fte n a s s o c ia te d w ith lin e s

■ G ra m + c o c c i sin g ly, in p a irs, a nd in s h o rt c h a in s ■ S m a ll c o lo n ie s w ith la rg e z o n e o f h e m o ly s is i3.73 ■ B a c itra c in s e n s itiv e (no lo n g e r u se d fo r id e n tific a tio n ) ■ PYR+

152

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

3: Microbiology

Bacteriology>Gram positive cocci □ V iru le n c e fa c to rs ■ M p ro te in s : in te rfe re w ith p h a g o c y to s is ; m ain a n tig e n a g a in s t w h ic h a n tib o d ie s fo rm ■ H y a lu ro n ic c a p s u le : p ro m o te s in v a s iv e n e s s , a n tip h a g o c y tic , n o n a n tig e n ic ■ E ry th ro g e n ic e x o to x in s : c a u s e ra sh in s c a rle t fe ve r; o b ta in e d fro m ly s o g e n ic p h a g e , s u p e r a n tig e n ■ H e m o ly s in s : s tre p to ly s in S (o xy g e n s ta b le , a id s in P h e m o ly s is ) a nd O (o xy g e n lab ile ) □ D is e a s e s c a u s e d by in v a s io n o r e xo to xin ■ S tre p to c o c c a l p h a ry n g itis ■ S o re th ro a t, fever, h e a d a c h e , n a u s e a , c e rv ic a l ly m p h a d e n o p a th y , le u k o c y to s is ■ In te n s e p h a ry n g e a l re d n e s s , e d e m a o f m u c o u s m e m b ra n e s , p u ru le n t e x u d a te ■ C o m p lic a tio n s : to n s illa r a b s c e s s , m a s to id itis , rh e u m a tic fever, g lo m e ru lo n e p h ritis

i3.73 Group A streptococci: small colony surrounded by large zone of (3 hemolysis. Note susceptibility to bacitracin (A) disk.

■ S c a rle t fe v e r ■ P e n ic illin -E a g le e ffe c t: d e c re a s e d e ffe c t a t h ig h d ru g c o n c e n tra tio n s

■ S y m p to m s s im ila r to p h a ry n g itis , b u t a ls o has ra sh c a u s e d by a p h a g e c o d e d e ry th ro g e n ic to xin ■ S kin in fe c tio n s (fo llic u litis , c e llu litis , im p e tig o , n e c ro tiz in g fa s c iitis , e ry s ip e la s ) ■ T o x ic s h o c k s y n d ro m e

■ C lin d a m y c in : n o t a ffe c te d b y in o c u lu m s iz e o r g ro w th p h a s e □ D is e a s e s c a u s e d by a n tib o d ie s (d e la y e d ) ■ R h e u m a tic fe v e r

■ T re a tm e n t

■ F o llo w s p h a ry n g itis o n ly (d o e s n o t fo llo w s k in in fe c tio n s )

t3.24 Catalase-, Gram+ cocci Hemolysis Organism S pyogenes P S dysgalactiae S agalactiae

a

Y

Some strains of enterococci Some strains of anginosus group streptococci S pneumoniae Most viridans streptococci Some strains of S bovis Some strains of enterococci (especially E faecium strains) Most strains of enterococci Most strains of S bovis Some strains of viridans streptococci

©ASCP2018

■ J o n e s c rite ria t3.25

Properties PYR+, bacitracin susceptible, expresses Lancefield group A antigens PYR-, bacitracin resistant (usually), expresses Lancefield group C or G antigens PYR-, bacitracin resistant (usually), CAMP factor+, hippurate hydrolysis+, expresses Lancefield group B antigens PYR+, bile esculin+, bacitracin resistant, expresses Lancefield group D antigens PYR-, bacitracin resistant, small colonies, butterscotch odor, may express Lancefield group A, C, F or G antigens optochin susceptible optochin resistant, PYR-, bile esculin-

t3.25 Jones criteria* Major criteria

M inor criteria

carditis polyarthritis chorea (Sydenham) erythema marginatum subcutaneous nodules Gram- cocci

arthralgia fever elevated ESR or CRP prolonged PR interval

*2 major criteria or 1 major + 2 minor & evidence of antecedent group A streptococcal infection (+ throat culture, + rapid antigen test, or rising streptococcal antibody titer) m S y s te m ic in fla m m a to ry p ro c e s s ■ D a m a g e to h e a rt m u s c le s a n d v a lv e s fre q u e n tly c o m p lic a te d by m itral s te n o s is m a n y y e a rs la te r ■ A n tis tre p to c o c c a l a n tib o d ie s c ro s s re a c t w ith m u s c le a n d kidn ey; a n tig e n -a n tib o d y c o m p le x e s re s u lt in in fla m m a tio n

optochin resistant, PYR-, bile esculin+ optochin resistant, PYR+, bile esculin+ PYR+, bile esculin+

■ R is k re d u c e d w ith tre a tm e n t ■ G lo m e ru lo n e p h ritis : 1 w e e k a fte r s k in O R p h a ry n g e a l in fe c tio n ■ E n la rg e d , h y p e rc e llu la r g lo m e ru li; red c e ll c a s ts in u rin e

PYR-, bile esculin+ PYR-, bile esculin-

■ R is k n o t s ig n ific a n tly re d u c e d w ith tre a tm e n t

ISBN 978-08 9189-6678

153

3: Microbiology

Bacteriology>Gram positive cocci ■ S tre p to c o c c u s a n g in o s u s g ro u p (aka S m ille ri) □ S a n g in o s u s , S c o n s te lla tu s , S in te rm e d iu s □ C h a ra c te ris tic s ■ T in y c o lo n ie s w ith c a ra m e l o r b u tte rs c o tc h o d o r ■ B io c h e m ic a ls : V P + , a rg in in e h y d ro ly s is p ositive , s o rb ito l n e g a tive ■ C a n be a , (3, o r y h e m o ly tic □ N o rm a l flo ra o f o ro p h a ry n x , G l a nd G U tra c ts □ P ro p e n s ity to fo rm d e e p tis s u e a b s c e s s e s (in tra -a b d o m in a l, p u lm o n a ry , a n d brain a b sce sse s), b a c te re m ia , a nd e n d o c a rd itis 3 .5 .2 .2 .2

a h e m o ly tic

■ S tre p to c o c c u s p n e u m o n ia e □ L a n c e t (sha rp ) s h a p e d G ra m p o s itiv e d ip lo c o c c i i3.75 i3,74 Group B streptococci: Gram stain morphology

□ O p to c h in s e n s itiv e : z o n e o f in h ib itio n a ro u n d a P o p to c h in d is k i3.76

■ Streptococcus agalactiae: L a n c e fie ld G ro u p B s tre p (G B S ) □ C h a ra c te ris tic s ■ G ra m + c o c c i s in g ly , in p a irs a n d s h o rt c h a in s i3.74 ■ M e d iu m s iz e d c o lo n ie s w ith v e ry s m a ll z o n e o f P h e m o ly s is (m a y h a v e to re m o v e c o lo n y to se e h e m o ly s is u n d e rn e a th it) ■ B a c itra c in re s is ta n t (N o lo n g e r u s e d fo r id e n tific a tio n ) ■ H y d ro ly z e s h ip p u ra te ■ C A M P p o s itiv e : g ro u p B Streptococcus h a s C A M P fa c to r, w h ic h e n h a n c e s th e z o n e o f h e m o ly s is a ro u n d Staphylococcus aureus □ N e o n a ta l s e p s is , p n e u m o n ia , a n d m e n in g itis d u e to c o lo n iz a tio n o f th e m a te rn a l g e n ita l tra c t ■ T h e C D C re c o m m e n d s th a t a ll p re g n a n t w o m e n g e t te s te d v ia v a g in a l a n d re c ta l s w a b a t 3 5 -3 7 w e e k s g e s ta tio n ■ If p o s itiv e , tre a t w ith IV a n tib io tic s d u rin g la b o r ■ M a jo rity a re e a rly o n s e t (0 -6 d a y s o f life), b u t s o m e a re la te r (7 d a y s to 3 m o n th s ) □ V a rio u s in fe c tio n s in a d u lts : p o s tp a rtu m e n d o m e tritis , U T I, b a c te re m ia , s k in a n d s o ft tis s u e in fe c tio n s , p n e u m o n ia , e n d o c a rd itis , m e n in g itis , o s te o m y e litis ■ G ro u p C a n d g ro u p G s tre p to c o c c i □ C o lo n iz e n a s o p h a ry n x , s k in a n d g e n ita l tra c t □ S o m e p ro d u c e s tre p to ly s in O w h ic h c a n re s u lt in e le v a te d A S O tite rs □ S im ila r c lin ic a l m a n ife s ta tio n s to g ro u p A s tre p (p h a ry n g itis , w o u n d in fe c tio n s ) □ P e n ic illin s u s c e p tib le

154

□ B ile s o lu b le : S p n e u m o n ia e w ill lyse bile; b roth w ill be c le a r (o th e r o rg a n is m s w ill be tu rb id ) □ In fe ctio n s: p n e u m o n ia , m e n in g itis (e sp e c ia lly infan ts a nd e ld e rly ), b a c te re m ia (a s p le n ic p atients), otitis, s in u s itis , p e rito n itis □ N o rm a l flo ra o f u p p e r re s p ira to ry tra ct; c a u s e s d is e a s e w h e n h o s t d e fe n s e s a re im p a ire d □ S o m e s tra in s h ave a th ic k, m u c o id c a p s u le ; th e s e are e s p e c ia lly v iru le n t □ V a c c in e s a re a v a ila b le ■ 2 3 v a le n t p o ly s a c c h a rid e v a c c in e ■ C o n ju g a te v a c cin e : b e tte r th a n p o ly s a c c h a rid e v a c c in e in in d u c in g p ro te c tiv e a n tib o d ie s in c h ild re n Gram positive cocci | Gram positive rods 3 .5 .2 .2 .3

y

h e m o ly t ic

■ Enterococcus (p re v io u s ly c a lle d G ro u p D s tre p b e c a u s e th e y c o n ta in th e L a n c e fie ld D a n tig e n ) □ G ra m p o s itiv e c o c c i th a t o c c u r s in g ly , in p a irs , a nd s h o r t c h a in s □ S m a ll, g re y, y o r a h e m o ly tic c o lo n ie s □ G ro w in 6 .5 % N a C I □ PYR+ □ B ile e s c u lin p o s itiv e : tu rn s m e d ia b la c k □ N o rm a l G I/G U flo ra □ C a n c a u s e m a n y in fe c tio n s : U T Is , b a c te re m ia , e n d o c a rd itis , d iv e rtic u litis , m e n in g itis □ S p e c ie s a n d re s is ta n c e p a tte rn s ■ E faecalis (m o s t c o m m o n : 8 0 % -9 0 % ) a n d Efaecium (1 0 % -1 5 % )

i3.79 Bacillus anthracis: Gram stain morphology: large gram positive rods in chains

■ C a n a c q u ire v a n c o m y c in re s is ta n c e ■ V a n A : h ig h le ve l re s is ta n c e (M IC > 6 4 ) to va ne , a n d c ro s s re a c tio n w ith te ic o p la n in (R e s is ta n t) ■ V a n B : m o d e ra te to h ig h le v e l re s is ta n c e to vane, b u t u s u a lly no c ro s s re a c tio n w ith te ic o p la n in (s e n s itiv e ) ■ E casseliflavus a n d E gallinarum: m o tile , d e m o n s tra te lo w le ve l in trin s ic re s is ta n c e to v a n c o m y c in (c h ro m o s o m a l vanC g e n e )

□ W ill s a te llite a ro u n d S ta p h y lo c o c c u s a u re u s

6.5% NaCI PYR + +

LAP +

-

+

-

■ A b io tro p h ia a n d G ra n u lic a te lla (p re v io u s ly c a lle d n u tritio n a lly v a ria n t S tre p to c o c c u s ) □ R e q u ire p y rid o x o l o r th io l

t3.26 Com parison of Enterococcus, group D strep, and strep related organism s

Enterococcus Other group D, nonenterococci (S bovis) + Leuconostoc +/+ + Pediococcus LAP = leucine amino peptidase test

Strep related organisms (catalase negative)

□ y h e m o ly tic

■ G ro u p D s tre p to c o c c i th a t a re n o t e n te ro c o c c i t3 .2 6

Vane Bile resistance esculin + -/+ +

3.5.2.2.4

■ L e u c o n o s to c . b a c te re m ia a nd c a th e te r in fe c tio n s in im m u n o c o m p ro m is e d h o s ts; in trin s ic a lly re s is ta n t to v a n c o m y c in ■ P e d io c o c c u s \ G ra m p o s itiv e c o c c i in c lu s te rs /te tra d s can lo o k like S ta p h ; a h e m o ly s is on p la te s ca n lo o k like S tre p ; in trin s ic a lly re s is ta n t to v a n c o m y c in ■ G e m e lla : n o rm a l flo ra o f u p p e r re s p ira to ry a n d G l tra c ts ; m ay be m is id e n tifie d a s v irid a n s s tre p

+/+/-

-

+

□ G ra m p o s itiv e c o c c i th a t o c c u r s in g ly , in p a irs , and s h o rt c h a in s □ S m a ll, g re y, y o r a h e m o ly tic c o lo n ie s □ In c lu d e s S tre p to c o c c u s b o v is g ro u p (c o m p o s e d o f m a n y o rg a n is m s ) ■ A s s o c ia te d w ith c o lo n c a n c e r, e s p e c ia lly S g a llo ly tic u s m B a c te re m ia , e n d o c a rd itis , m e n in g itis in n e w b o rn s □ A ls o c o n ta in s L a n c e fie ld D a n tig e n □ A ls o b ile e s c u lin p o s itiv e (lik e E n te ro c o c c u s )

■ A e ro c o c c u s : o p p o rtu n is tic in fe c tio n ; e a s ily c o n fu s e d w ith E n te ro c o c c u s a nd v irid a n s s tre p ; a h e m o ly tic ■ L a c to c o c c u s

3.5.3 Gram positive rods 3.5.3.1 Spore forming Gram positive rods 3.5.3.1.1 Bacillus i3.79 ■ C h a ra c te ris tic s □ A e ro b ic o r fa c u lta tiv e a n a e ro b ic (im p o rta n t d is tin c tio n fro m C lo strid iu m , w h ic h is a n a e ro b ic ) □ S o m e tim e s s p o re ca n be s e e n on a G ra m sta in: lo o k s like a h ole o r an u n s ta in e d p o rtio n o f th e cell

□ P Y R n e g a tiv e a n d d o n o t g ro w in 6 .5 % N a C I (u n like E n te ro c o c c u s )

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Bacteriology>Gram positive rods

i3.80 Bacillus anthracis: the stab mark is clearly visible & the medium is nonturbid, indicative of nonmotility

□ M a n y s p e c ie s o f B a cillu s a re n o n p a th o g e n ic a nd a re u b iq u ito u s in n a tu re (soil, a irb o rn e d u st, v e g e ta tio n , w a te r); th e y a re o fte n a c o n ta m in a n t □ C a ttle , sh e e p , h o rs e s a nd g o a ts a re m o s t c o m m o n s o u rc e s

i3.81 Bacillus anthracis: colony morphology; note a ground glass colonies with irregular borders & b tenaciousness

□ S o m e ca n lo o k G ra m v a ria b le a nd s o m e ca n g ro w on M acC onkey □ M o s t a re h e m o ly tic e x c e p t fo r B an th racis ■ M edusa head

• B acillu s a n th ra c is

■ S ta n d up like b e a te n e g g s if to u c h e d w ith in o c u la tin g lo o p

□ C h a ra c te ris tic s ■ N o n m o tile , n o n h e m o ly tic i3.80 ■ Im p o rta n t b e c a u s e B acillu s sp p a re o fte n s e e n in th e lab, a n d B a n th ra c is is a p o te n tia l a g e n t o f b io te rro ris m , re q u irin g fu rth e r w o rk u p a t th e s ta te h e a lth d e p a rtm e n t o r th e C D C ■ B u t if it is h e m o ly tic o r m otile , B a n th ra c is is e x c lu d e d

■ S p o re s : c e n tra l/s u b te rm in a l, d o n o t e n la rg e ce ll, and w ill n o t be s e e n in d ire c t s m e a r ■ y p h a g e lysis: if a y p h a g e s p e c ific fo r B a n th ra c is is a p p lie d to a la w n o f g ro w th on a b lo o d a g a r p late; th e y p h a g e w ill ly se th e b a c te ria ■ C a ta la s e p o s itiv e

■ C o lo n ie s i3.81 ■ G ro u n d g la s s w ith c o m m a sh a p e d p ro je c tio n s a ro u n d b o rd e r © A S C P 2018

ISBN 9 7 8 -08 9189-6678

157

3: Microbiology

Bacteriology>Gram positive rods □ V iru le n c e

■ S c re e n in g p o s te x p o s u re p a tie n ts ■ N a s a l s w a b s h o u ld o n ly be d o n e to s u p p o rt a c o n firm e d e x p o s u re

■ S p o re s : c a n s u rv iv e in s o il o r s k in o f a n im a l fo r y e a rs

■ O n ly c o lle c t if a d v is e d by p u b lic h e a lth o ffic ia ls

■ S p o re s a re in h a le d b y h u m a n s o r e n te r th ro u g h s k in tra u m a

■ N o t re c o m m e n d e d if p a tie n t is a s y m p to m a tic and h as no k n o w n e x p o s u re

■ S p o re is ta k e n up b y m a c ro p h a g e s a n d tra n s p o rte d to re g io n a l ly m p h n o d e s

■ S h o u ld n o t be u s e d to d e te rm in e le n g th o f p o s t e x p o s u re p ro p h y la x is

■ S p o re s g e rm in a te in to v e g e ta tiv e c e ll ■ P o ly p e p tid e c a p s u le is a n tip h a g o c y tic

■ B a c illu s c e re u s □ C h a ra c te ris tic s

■ 3 to x in s

■ G ra m p o s itiv e ro d s in c h a in s

■ P ro te c tiv e a n tig e n (P A ): fa c ilita te s e n try o f to x in in to c e lls ■ L e th a l fa c to r: s tim u la te s c y to k in e p ro d u c tio n (T N F a a n d IL1p) th a t le a d to s h o c k a n d d e a th ■ E d e m a fa c to r: s tim u la te s c A M P le a d in g to a lte re d w a te r h o m e o s ta s is a n d e d e m a □ D is e a s e s ■ C u ta n e o u s a n th ra x : a c c o u n ts fo r 9 5 % o f c a s e s in th e U S ■ S p o re s e n te r th ro u g h a b ra s io n , u s u a lly h a n d s , a rm s o r h e a d

■ M o tile a n d h e m o ly tic (B a n th ra c is n o n m o tile and n o n h e m o ly tic ) □ D is e a s e s in c lu d e e a r in fe c tio n , o c u la r w o u n d in fe c tio n s , e n d o c a rd itis □ B a c te re m ia a s s o c ia te d w ith IV d ru g u s e o r c o n ta m in a te d in tra v a s c u la r d e v ic e □ S o ft tis s u e in fe c tio n s (tra u m a tic w o u n d s , b u rn s) □ G a s tro e n te ritis : 2 fo rm s ■ H e a t s ta b le to xin

■ S m a ll red le s io n —►v e s ic le —►n e c ro s is —► c h a ra c te ris tic p a in le s s b la c k e s c h a r

■ F o o d s th a t a re n o t re h e a te d p rio r to b e in g s e rv e d (co o ke d ric e in b u ffe t)

■ M a y h a v e re g io n a l ly m p h a d e n o p a th y a n d s e p tic e m ia

■ V o m itin g ; o c c a s io n a lly d ia rrh e a o c c u rrin g 1-6 h o u rs a fte r e a tin g ■ H e a t la b ile e n te ro to x in

■ M o rta lity in u n tre a te d c a s e s is 2 0 %

■ In g e s tio n o f c o n ta m in a te d m e a t a n d v e g e ta b le d is h e s

■ P u lm o n a ry a n th ra x ■ O b ta in e d b y w o rk in g w ith a n im a l h id e s (w o o ls o rte r d is e a s e ) o r v ia te rro ris t a tta c k ■ S p o re s (o n ly n e e d 1 -3 s p o re s ) a re in h a le d into lu n g s

■ C ra m p s a nd w a te ry d ia rrh e a 8 -1 6 h o u rs a fte r e a tin g ■ C lo s trid iu m (s e e “A n a e ro b e s ” )

■ In c u b a tio n 1 -6 0 d a y s

□ C lo s trid iu m te ta n i

■ A b ru p t o n s e t o f h ig h fe v e rs , m a la is e , c o u g h , m y a lg ia s —►d y s p n e a , c y a n o s is , h e m o rrh a g ic m e d ia s tin itis (h e m o rrh a g ic n e c ro s is o f ly m p h nodes)

□ C lo s trid iu m b o tu lin u m

■ N o p e rs o n to p e rs o n s p re a d

□ C lo s trid iu m s e p tic u m

□ C lo s trid iu m p e rfrin g e n s □ C lo s trid iu m d iffic ile

■ H ig h m o rta lity ra te d e s p ite th e ra p y ■ D ia g n o s e w ith b lo o d c u ltu re

3.5.3.2

■ T re a tm e n t: c ip ro flo x a c in o r d o x y c y c lin e ; p lu s rifa m p in o r c lin d a m y c in

3.5.3.2.1 Corynebacterium: d ip h th e ro id s

■ P o s t e x p o s u re p ro p h y la x is : 6 0 d a y s o f c ip ro o r doxy

3.5.3.2.1.1 Characteristics

■ G a s tro in te s tin a l a n th ra x ■ In g e s tio n o f c o n ta m in a te d m e a t ■ N a u s e a , v o m itin g , b lo o d y d ia rrh e a , a b d o m in a l d is te n tio n d u e to a s c ite s , s e p s is

Nonspore forming Gram positive rods

■ G ra m s ta in : c lu b s h a p e d ; p a lis a d e /c lu s te r to g e th e r; “ C h in e s e le tte rs ” i3.82 ■ C a ta la s e p o s itiv e (u se d to d iffe re n tia te fro m A rc a n o b a c te riu m ) ■ M a n y n o n p a th o g e n ic s p e c ie s a re k n o w n

■ C a n h a v e G l b le e d in g , s h o c k , s e p tic e m ia ■ H ig h m o rta lity ra te d e s p ite th e ra p y

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Bacteriology>Gram positive rods

, 9

w

Ts s'

• •

*\ fff

t

• It

i3.83 C orynebacterium diphtheriae on agar containing tellurite

3.5.3.2.1.2

■ S e le c tiv e : in h ib its g ro w th o f o th e r b a c te ria (n e e d e d b e c a u s e s p e c im e n a re fro m th e n a s o p h a ry n x w h e re th e re a re m a n y c o lo n iz in g b a c te ria )

C o ry n e b a c te riu m d ip h th e ria e

■ H u m a n s a re th e o n ly re s e rv o ir ■ S o m e p a tie n ts h a ve a s y m p to m a tic re s p ira to ry o r skin c a rria g e ■ In itia lly in fe c ts e p ith e lia l c e lls o f to n s ils a nd o ro p h a ry n x , w h e re it m a k e s e xo to x in □ C a u s e s lo c a l n e c ro s is a n d in fla m m a tio n —> p s e u d o m e m b ra n e o f n e c ro in fla m m a to ry d e b ris □ D is s e m in a tio n o f th e to xin (N O T th e b a c te ria ) p ro d u c e s d e g e n e ra tiv e c h a n g e s in th e h e a rt, n e rv e s , a nd k id n e y s □ T h e to xin is c o m p o s e d o f 2 fra g m e n ts : A (a ctive ) a nd B (b in d in g ) □ T h e to xin is m a d e o n ly if th e b a c te ria is in fe c te d w ith B c o ry n e p h a g e □ C u ta n e o u s d ip h th e ria : c h ro n ic , n o n h e a lin g u lc e rs w ith g re y m e m b ra n e ; h as b e e n s e e n in a lc o h o lic h o m e le s s m en a n d im p o v e ris h e d N a tiv e A m e ric a n s in th e U S

■ D iffe re n tia l: te llu rite is re d u c e d b y C d ip h th e ria e , fo rm in g b la c k c o lo n ie s o n e ith e r ty p e o f m e d ia ■ L o e ffle r s e ru m m edia: e n h a n c e s m e ta c h ro m a tic g ra n u le fo rm a tio n □ D e te c tio n o f th e to xin ■ E le k im m u n o d iffu s io n te s t: in v itro ■ S c h ic k te s t: in v ivo ■ P C R , im m u n o a s s a y o r im m u n o c h ro m a to g ra p h ic s trip a s s a y 3.5.3.2.1.3 C o ry n e b a c te riu m je ik e iu m • L ip o p h ilic c o ry n e b a c te ria w h ic h c o lo n iz e s k in o f h o s p ita liz e d p a tie n ts ■ N o s o c o m ia l a n d o p p o rtu n is tic in fe c tio n s

■ D ia g n o s is 3.5.3.2.1.4 C o ry n e b a c te riu m u re a ly tic u m

□ A tte m p t to o b ta in a s w a b fro m u n d e r th e p s e u d o m e m b ra n e

■ L ip o p h ilic

□ W ill g ro w on b lo o d agar, b u t o th e r m e d ia p re fe rre d ■ C y s tin e -te llu rite o r T in s d a le (p o ta s s iu m -te llu rite ): s e le c tiv e a n d d iffe re n tia l i3.83

■ U re a s e p o s itiv e ■ C o lo n iz e s skin o f h o s p ita liz e d p a tie n ts ■ U T Is: fo rm a tio n o f s tru v ite c ry s ta ls , a lk a lin e u rin e , a m m o n iu m m a g n e s iu m p h o s p h a te s to n e s ■ B a c te re m ia , w o u n d in fe c tio n s , e n d o c a rd itis

© A S C P 2018

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Bacteriology>Gram positive rods

i3.84 Liste ria m onocytogenes: colony morphology: narrow zone o f beta hemolysis

3 .5 .3 .2 .2

Listeria monocytogenes

■ V iru le n c e

• C h a ra c te ris tic s

□ L is te rio ly s in O

□ F a c u lta tiv e in tra c e llu la r b a c illu s □ Is th e o n ly s p e c ie s o f L is te ria th a t is p a th o g e n ic in hum ans □ G ra m s ta in : m e d iu m s iz e d , G ra m p o s itiv e rod, s in g ly o r in s h o rt c h a in s □ N a rro w z o n e o f p h e m o ly s is (ca n lo o k like G ro u p B s tre p ) i3.84 □ C a ta la s e p o s itiv e : a id s in d is tin g u is h in g fro m G ro u p B s tre p (c a ta la s e n e g a tiv e ) □ CAMP+ □ H y d ro ly z e e s c u lin □ M o tile ■ T u m b lin g m o tility a t 2 5 °C (ro o m te m p e ra tu re ) s e e n o n w e t p re p ■ U m b re lla s h a p e d m o tility in s e m is o lid a g a r i3.85 □ O p tim a l g ro w th o c c u rs a t 3 0 ° -3 7 ° C , b u t c a n g ro w a t 4 °C (P s y c h ro p h ile ) ■ C a n g ro w in th e re frig e ra to r ■ C a n u s e c o ld e n ric h m e n t in th e la b o ra to ry to kill o th e r o rg a n is m s to a id in is o la tio n o f L is te ria : u se d w h e n lo o k in g fo r s o u rc e in o u tb re a k s e ttin g : p la c e s u s p e c te d ite m s (d eli m e a t) in a re frig e ra to r to kill a n y o th e r o rg a n is m s a n d th e n c u ltu re it

160

■ A llo w s o rg a n is m s to ra p id ly g e t into c y to p la s m b e fo re ly s o s o m e -p h a g o s o m e fu s io n ■ R e o rg a n iz e s h o s t a c tin —> p ro p e ls th e o rg a n is m into o th e r c e lls w ith o u t g o in g into d a n g e ro u s e x tra c e llu la r e n v iro n m e n t ■ D is e a s e s □ F o u n d in so il, d ust, w a te r, s e w a g e , m ilk, m e a ts and v e g e ta b le s □ In fe c tio n o c c u rs via in g e s tio n o f d a iry p ro d u c ts , c o le s la w , d e li m e a ts a nd c h e e s e s , u n h e a te d h o td o g s , u n c o o k e d c a b b a g e , etc, th a t w e re c o n ta m in a te d fro m a n im a l fe c e s □ C e p h a lo s p o rin re s is ta n t; tre a t w ith a m p ic illin and g e n ta m ic in □ P re g n a n t w o m e n ■ F lu like s y m p to m s w ith fe v e r ■ C a n lea d to p re m a tu re la b o r o r s e p tic a b o rtio n ■ In fe c tio n u s u a lly o c c u rs in 3rd trim e s te r ■ C an tra n s m it in fe c tio n to fe tu s v ia th e p la c e n ta o r to b a b y v ia m o m ’s fe c e s d u rin g d e liv e ry □ G ra n u lo m a to s is in fa n tis e p tic a : in u te ro in fe c tio n o f fe tu s; w id e ly d is trib u te d a b s c e s s e s a nd g ra n u lo m a s ; high fa ta lity rate; e a rly o n s e t (p re s e n ts a t b irth o r a fe w d a y s a fte r)

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

3: Microbiology

Bacteriology>G ram positive rods

i3.86 N ocardia: a Gram stain morphology: long, thin, beaded rods; b modified acid fast stain

□ M e n in g o e n c e p h a litis /s e p tic e m ia : n e o n a te s (la te r o n s e t: d a y s /w e e k s a fte r b irth , in fe c tio n is a c q u ire d p o s tp a rtu m b u t u s u a lly th e s o u rc e is u n kn o w n ), c a n c e r p a tie n ts , im m u n o c o m p ro m is e d (e s p e c ia lly re na l tra n s p la n t re cip ie n ts ), a ls o ca n o c c u r in n o rm a l a d u lts □ F o cal le s io n s on e y e s /s k in : re s u lts fro m d ire c t c o n ta c t

□ (3 h e m o ly tic o n b lo o d a g a r ■ P h a ry n g itis in o ld e r c h ild re n ; p h e m o ly tic a n d c a ta la s e n e g a tive ; m u s t d is tin g u is h fro m S p y o g e n e s in th ro a t s p e c im e n (s im ila r c lin ic a l a n d lab fe a tu re s ) ■ Id e n tify u sin g re v e rs e C A M P te s t: in h ib its h e m o ly s is a ro u n d th e S a u re u s s tre a k —►s h o w s an in v e rte d tria n g le o f no h e m o ly s is

□ F e b rile g a s tro e n te ritis

3 .5 .3 .2 .5 Nocardia 3 .5 .3 .2 .3 Erysipelothrix rhusiopathiae

■ C h a ra c te ris tic s

m C h a ra c te ris tic s

□ G ra m sta in: lon g , th in , b e a d e d , b ra n c h in g G ra m p o s itiv e ro d s i3.86a

□ G ra m sta in: G ra m p o s itiv e rod □ C a ta la s e a nd o x id a s e n e g a tive ; p ro d u c e s H 2S □ C h a ra c te ris tic a lly s h o w s “ p ip e c le a n e r” p a tte rn o f g ro w th in g e la tin s ta b c u ltu re s a t 22°C □ a h e m o ly tic ■ D is e a s e s □ W id e s p re a d in n atu re ; d o m e s tic p ig s a re re se rvo ir, a ls o fo u n d in h o rs e s , c a ttle , p o u ltry , fis h , s h e llfis h □ In fe c tio n (e ry s ip e lo id ) is u s u a lly a lo c a liz e d c u ta n e o u s in fe c tio n o f h a n d s a nd fin g e rs a fte r e x p o s u re to a n im a ls o r a n im a l p ro d u c ts (o c c u p a tio n a l ris k fo r b u tc h e rs , fis h e rm e n , ve ts, etc)

□ P o s itiv e w h e n s ta in e d w ith m o d ifie d a c id fa s t s ta in 13.86b ■ T h e m o d ifie d a c id fa s t d iffe rs fro m th e tra d itio n a l K in y o u n s ta in by u sing a w e a k e r d e c o lo riz e r (1% s u lfu ric a c id ) ■ Fite sta in p o s itiv e in tis s u e s ■ N o c a rd ia is c a lle d w e a k ly o r p a rtia lly a c id fa s t □ D iffe re n tia te fro m A c tin o m y c e s (w h ic h ca n lo o k s im ila r o n a G ra m s ta in ) ■ N o c a rd ia s ta in s w ith m o d ifie d a c id fa s t a n d is a e ro b ic

■ V a n c o m y c in re sis ta n t; tre a t w ith p e n icillin

■ A c tin o m y c e s w ill n o t sta in w ith m o d ifie d a c id fa s t sta in and is a n a e ro b ic

3 .5 .3 .2 .4 Arcanobacterium haemolyticum

■ B o th ca n fo rm m ic ro c o lo n ie s in tis s u e (g ra n u le s )

m C h a ra c te ris tic s

□ C a ta la s e n e g a tive

□ C u ltu re ■ A v e ra g e g ro w th rate: 3 -5 d a y s

□ N o n m o tile © ASCP2018

ISBN 978-08 9189-6678

161

3: Microbiology

Bacteriology>Gram positive rods | Gram negative cocci

i3.88 Whipple disease: duodenal biopsy

■ C h a ra c te ris tic s □ G ra m sta in: m o rp h o lo g y v a ria b le ; c o c c i, c o c c o b a c illi, o r c o ry n e fo rm ro ds i3.87 R h o dococcus equi: colony morphology: coral pink colonies

□ O fte n s e e n w ith in h is tio c y te s □ W e a k ly a c id fa s t

■ W ill g ro w on n o n s e le c tiv e m e d ia u s e d fo r b a c te ria , fu n g i, m y c o b a c te ria , if y o u g iv e it e n o u g h tim e ■ C a n u s e s e le c tiv e m e d ia (T h a y e r-M a rtin o r B C Y E ) fo r n o n s te rile s ite s ■ P ro d u c e c h a lk y w h ite c o lo n ie s w ith e a rth y /m u s ty basem ent odor ■ D is e a s e s □ U s u a lly a c q u ire d v ia in h a la tio n ; m a y o c c u r d u rin g tra u m a in v o lv in g c o n ta c t w ith c o n ta m in a te d so il; ca n e n te r G l if c o n ta m in a te d m a te ria l c o n ta c ts m u c o s a l u lc e ra tio n

□ P a le p in k /c o ra l c o lo re d m u c o id c o lo n ie s i3.87 ■ D is e a s e s □ F o u n d in so il; p a tie n ts m a y re p o rt in te ra c tio n w ith h o rs e s (e q u in e ) □ T ra n s m itte d v ia re s p ira to ry ro u te o r d ire c t in o c u la tio n o f w o u n d s o r m u c o u s m e m b ra n e s □ O p p o rtu n is tic p a th o g e n c a u s in g a s lo w ly p ro g re s s iv e p n e u m o n ia in im m u n o c o m p ro m is e d h o s t □ H is to lo g ic a lly re s e m b le s m a la k o p la k ia

3.5 .3 .2 .7

□ U b iq u ito u s in s o il a n d w a te r □ P u lm o n a ry d is e a s e (v ia in h a la tio n ) ■ C a n s p re a d b y a d v a n c in g g ro w th le a d in g to e m p y e m a , c h e s t w a ll in v o lv e m e n t, d ra in in g s in u s

Tropheryma whippelii

• C a n n o t c u ltu re ■ C a u s e s W h ip p le d is e a s e : d ia rrh e a , w e ig h t loss, m a la b s o rp tio n

■ C a n s p re a d h e m a to g e n o u s ly , re s u ltin g in d is s e m in a tio n , e s p e c ia lly to th e C N S

□ U s u a lly d ia g n o s e d v ia G l b io p s y i3.88

■ U s u a lly N a s te ro id e s c o m p le x

□ U s u a lly o ld e r m a le s ; m e n :w o m e n 8:1

■ F o a m y m a c ro p h a g e s c o n ta in in g PAS+, A F B - b a cilli

□ S k in d is e a s e (d ire c t in o c u la tio n ) ■ C u ta n e o u s a n d ly m p h o c u ta n e o u s in fe c tio n s

3.5.4 Gram negative cocci

■ U s u a lly o n lo w e r e x tre m itie s

3.5.4.1 Neisseria

■ U s u a lly in C e n tra l a n d S o u th A m e ric a

3.5.4.1.1 C h a ra c te ris tic s

■ A c tin o m y c o tic m y c e to m a : lo c a liz e d in d u ra te d g ra n u lo m a to u s m a s s w ith s in u s tra c ts d ra in in g p u s a n d s u lfu r g ra n u le s (s im ila r d is e a s e c a u s e d by fu n g i is c a lle d e u m y c o tic m y c e to m a ) ■ U s u a lly N b ra s ilie n s is

3 .5 .3 .2 .6

■ N o n m o tile ■ C a ta la s e a n d o x id a s e p o s itiv e ■ G ra m sta in lo o k s like k id n e y o r c o ffe e b e a n s i3.89 ■ S o m e w h a t fa s tid io u s (re q u ire s s p e c ia l h a n d lin g to g ro w in lab) □ N e e d to in c u b a te a t 35°C in C 0 2 q u ic k ly

Rhodococcus

m M o s t c o m m o n s p e c ie s is R h o d o c o c c u s e q u i 162

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

3: Microbiology

□ A c tiv a te s c lo ttin g c a s c a d e , p ro d u c e s h e m o rrh a g e in a d re n a ls a n d o th e r o rg a n s □ A lte rs p e rip h e ra l v a s c u la r re s is ta n c e —►s h o c k a n d d e a th □ C a p s u le : in h ib its p h a g o c y to s is ■ D is e a s e s □ M ild p h a ry n g itis □ M e n in g itis w ith /w ith o u t fu lm in a n t m e n in g o c o c c e m ia ■ O rg a n is m s d is s e m in a te fro m p h a ry n x ■ C a n b e fa ta l in 1 -5 d ays ■ Fever, v o m itin g , h e a d a c h e , s tiff n e c k ■ H a llm a rk is v a s c u litis p u rp u ra (p e te c h ia l e ru p tio n ) □ W a te rh o u s e -F rid e ric h s e n s y n d ro m e : fu lm in a n t m e n in g o c o c c e m ia w ith h e m o rrh a g e , c irc u la to ry fa ilu re , a d re n a l in s u ffic ie n c y i3.89 N gonorrhoeae: Gram stain morphology: Gram negative diplococci □ B e c a u s e o f th e s e d iffic u lt re q u ire m e n ts , N g o n o rrh o e a e is m o s t o fte n d ia g n o s e d v ia m o le c u la r m e th o d s (u su a lly s im u lta n e o u s ly w ith C h la m y d ia ) • G ro w s on b lo o d a n d c h o c o la te a g a r b u t a ls o c a n g ro w in th e p re s e n c e a n tim ic ro b ia ls v a n c o m y c in , c o lis tin , a nd n y s ta tin , so s p e c ia liz e d ty p e o f c h o c o la te a g a r c a lle d T h a y e r-M a rtin o r M a rtin -L e w is ca n be u se d to a id in is o la tio n by in h ib itin g o th e r o rg a n is m s in s p e c im e n (u se d fo r g e n ita l o r p h a ry n g e a l s p e c im e n b u t n o w g e n e ra lly re p la c e d by m o le c u la r m e th o d s ) ■ B oth s p e c ie s m a k e an Ig A p ro te a s e , w h ic h a id s in e s ta b lis h in g in fe c tio n b e c a u s e Ig A is th e m a in a n tib o d y o n th e m u c o u s m e m b ra n e s ■ N m e n in g itid is u s e s m a lto s e a nd g lu c o s e ; N g o n o rrh o e a e u s e s o n ly g lu c o s e t3.27 ■ M a n y N e is s e ria sp p a re n o rm a l in h a b ita n ts o f th e u p p e r re s p ira to ry tra c t

□ S e q u e la : 8 th n e rv e d e a fn e s s , C N S d a m a g e , s k in n e c ro s is □ P le u ritis , p e ric a rd itis , a rth ritis , m e n in g itis ■ V a c c in e : p o ly s a c c h a rid e v a c c in e a g a in s t A , C, Y a n d W 135 □ R e c o m m e n d e d fo r m ilita ry , a s p le n ic p a tie n ts , c o lle g e s tu d e n ts □ O u tb re a k s in U S s till o c c u r b e c a u s e v a c c in e d o e s n o t c o v e r ty p e B ■ T re a tm e n t: p e n ic illin G □ M a n y s tra in s h a ve d e c re a s e d s u s c e p tib ility to p e n ic illin G d u e to a lte re d p e n ic illin b in d in g p ro te in s (P B P 2 a nd P B P 3 ) □ M a y u se rifa m p in , m in o c y c lin e , o r flu o ro q u in o lo n e s fo r p ro p h y la x is a m o n g h o u s e h o ld c o n ta c ts

3.5.4.1.3 Neisseria gonorrhoeae • V iru le n c e : pili

t3.27 Carbohydrate utilization by Neisseria species O rg anism Glucose Maltose Lactose DNase

□ M e d ia te a d h e re n c e to h u m a n c e lls ; m a y in h ib it p h a g o c y to s is

N gonorrhoeae N meningitidis M catarrhalis

□ A re a n tig e n ic a lly h e te ro g e n e o u s : a n tib o d ie s th a t a re m a d e c o n fe r no p ro te c tio n a g a in s t s u b s e q u e n t in fe c tio n s

+____________ - ___________ - ___________ - ________ +____________ +___________ - ___________ - ________ _____________- ___________ - ___________ +_________

■ D is e a s e s

3.5.4.1.2 Neisseria meningitidis m

□ M a n y a re a s y m p to m a tic (1 0% o f m e n a n d 5 0 % o f fe m a le s )

C h a ra c te ris tic s □ C la s s ifie d by th e c a p s u le : in th e US, th e m o s t c o m m o n a re A , B, C, Y, W 1 35 □ C a n c o lo n iz e th e u p p e r re s p ira to ry tra c t; 5 % -1 5% o f h e a lth y a d u lts a re a s y m p to m a tic c a rrie rs

■ V iru le n c e : lip o p o ly s a c c h a rid e -e n d o to x in c o m p le x

© A S C P 2018

□ U re th ritis in m en: e xu d a te , p a in fu l u rin a tio n ; c a n le a d to e p id id y m itis a n d p ro s ta titis ; re p e a t in fe c tio n s c a n lea d to s c a rrin g a n d s te rility □ E n d o c e rv ic itis o r u re th ritis in w o m e n : p u ru le n t v a g in a l d is c h a rg e , p a in fu l u rin a tio n , a b d o m in a l p ain ; c a n le a d to p e lv ic in fla m m a to ry d is e a s e , e c to p ic p re g n a n c y , s te rility

ISBN 978-08 9189-6678

163

3: Microbiology

Bacteriology>Gram negative cocci | Gram negative rods □ R e c ta l in fe c tio n s in h o m o s e x u a l m a le s □ P h a ry n g itis w ith p u ru le n t e x u d a te s □ D is s e m in a te d in fe c tio n : d e rm a titis (p u s tu le s ) o r s e p tic a rth ritis , m ig ra to ry a rth ra lg ia s ■ G ra m s ta in o f s y n o v ia l flu id is p o s itiv e in 1 0 % -3 0 % of cases ■ D is s e m in a te d in fe c tio n o c c u rs in 0 .5 % -3 .0 % o f cases □ In fa n t e y e in fe c tio n s w ith p u ru le n t c o n ju n c tiv itis : ca n ra p id ly le a d to b lin d n e s s , p re v e n t w ith s ilv e r n itra te o r e ry th ro m y c in o in tm e n t to e y e s o f n e w b o rn s □ C o n ju n c tiv itis in a d u lts

t3.28 Enterobacteriaceae: key characteristics reduce nitrate to nitrite strong lactose fermenters (pink or red on MacConkey) hydrogen sulfide (H2S) positive Strongly urease+ nonmotile Voges-Proskauer (VP) positive phenylalanine deaminase (PAD) positive

All Enterobacteriaceae E coli, Klebsiella, Enterobacter Salmonella, Edwardsiella, Citrobacter freundii, Proteus Proteus, Morganella, Providencia rettgerl Shigella, Klebsiella Yersinia are nonmotile at 37°C, but motile at 22°C Klebsiella, Enterobacter, Hafnia, Serratla, Pantoea Proteus, Morganella, Providencia

■ T re a tm e n t: c e ftria x o n e , c e fix im e , c e fp o d o x im e

3 .5 .5

Moraxella catarrhalis (formerly Neisseria and Branhamella catarrhalis)

3.5.4.2

■ C h a ra c te ris tic s □ O x id a s e p o s itiv e

3.5.5.1 Enterobacteriaceae (the enterics) ■ G e n e ra l c h a ra c te ris tic s : th e y m u s t h a v e all 4 o f th e s e c h a ra c te ris tic s t3.28 □ A e ro b ic (fa c u lta tiv e a n a e ro b e s )

□ N o n m o tile

□ O x id a s e n e g a tiv e

□ E n c a p s u la te d w ith pili

□ F e rm e n t g lu c o s e

□ > 9 0 % p ro d u c e p la c ta m a s e □ G ra m s ta in s h o w s in tra a n d e x tra c e llu la r o rg a n is m s □ C a n d iffe re n tia te fro m N e is s e ria by ■ D N a s e p ro d u c tio n (N e is s e ria is n e g a tiv e ) ■ L a c k o f u s e o f g lu c o s e , m a lto s e , o r la c to s e (n o n s a c c h a ro ly tic ) ■ G ro w th on b lo o d a g a r

□ R e d u c e n itra te s to n itrite s ■ V iru le n c e fa c to rs □ O a n tig e n : e n d o to x in s (s o m e tim e s c a lle d lip o p o ly s a c c h a rid e s ); c a u s e fe v e rs , c h ills , g ra n u lo c y to s is , d is s e m in a te d in tra v a s c u la r c o a g u la tio n , s h o c k , etc; b a s is fo r s e ro g ro u p in g □ K a n tig e n : c a p s u la r p o ly s a c c h a rid e p ro d u c e d by e n c a p s u la te d s tra in s

■ B u ty ra te e s te ra s e p o s itiv e □ P o o r o r no g ro w th on M a c C o n k e y □ H o c k e y p u c k c o lo n ie s : c a n p u s h th e m a ro u n d a p la te ■ D is e a s e s □ C o lo n iz e s th e o ro p h a ry n x o f h e a lth y c h ild re n a n d a d u lts ; n o rm a l flo ra o f m u c o s a l s u rfa c e s ; o c c a s io n a l c o lo n iz a tio n o f skin □ C o m m o n c a u s e o f C O P D e x a c e rb a tio n s in a d u lts a nd o titis m e d ia in c h ild re n □ B ro n c h itis , la ry n g itis , tra c h e itis , o titis , s in u s itis , p n e u m o n ia (e s p e c ia lly in p a tie n ts w ith u n d e rly in g lun g d is e a s e ) ■ T re a tm e n t: a s s u m e re s is ta n c e to p e n ic illin d u e to p ro d u c tio n o f p la c ta m a s e ■ O th e r s p e c ie s o f M o ra x e lla

■ E x a m p le s in c lu d e E c o li s tra in s th a t c a u s e n e o n a ta l m e n in g itis , th e c a p s u le o f K p n e u m o n ia e , a nd th e V i a n tig e n o f S a lm o n e lla □ H a n tig e n : fla g e lla r p ro te in s o f m o tile s p e c ie s ■ A n tib io tic re s is ta n c e m e c h a n is m s □ p la c ta m a s e : p la s m id e n c o d e d ; c o n fe r re s is ta n c e to p e n ic illin s b u t n o t e x te n d e d s p e c tru m c e p h a lo s p o rin s □ E x te n d e d s p e c tru m p la c ta m a s e : p la s m id e n c o d e d ; c o n fe r re s is ta n c e to p e n ic illin s a n d e x te n d e d s p e c tru m c e p h a lo s p o rin s (c e fo ta x im e , c e ftria x o n e , c e fta z id im e ) a nd a z tre o n a m ; tre a t w ith c a rb a p e n e m s ; ca n in h ib it w ith c la v u la n ic a cid □ D e te c t in E s c h e ric h ia co li, K le b s ie lla p n e u m o n ia e , K o x y to c a , a n d P ro te u s m ira b ilis

□ M n o n liq u ifa c ta n s (2 n d m o s t c o m m o n ); M o s lo e n s is a n d M p h e n y lp y ru v ic a

□ A m p C ty p e p la c ta m a s e : s im ila r p a tte rn to E S B L , but c a n n o t be in h ib ite d by c la v u la n ic a cid

□ E ye in fe c tio n s

□ C a rb a p e n e m a s e : v a rie ty o f e n z y m e s th a t can h y d ro ly z e c a rb a p e n e m s a nd o th e r p la c ta m s

□ G e n e ra lly s u s c e p tib le to p e n ic illin s

164

G ra m n e g a tiv e ro d s

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

3: Microbiology

Bacteriology>Gram negative rods ■ K lig le r iron a g a r (K IA ) a nd trip le s u g a r iro n (T S I) t3 .2 9

t3.29 KIA slant characteristics In te r p r e ta tio n no fermentation enterobacteriaceae excluded because they all ferment glucose acid/yellow glucose fermented lactose not fermented

P o s s ib le o r g a n is m s Pseudomonas Eikenella Moraxella Campylobacter

S la n t alk/red

B u tt alk/red

alk/red

Shigella Serratia Providencia Yersinia Salmonella Acid/Yellow glucose fermented with H2S lactose not fermented Proteus H2S produced (black)

alk/red

acid/yellow acid/yellow lactose fermented

Escherichia coli

acid/yellow acid/yellow lactose fermented with gas gas produced

Klebsiella Enterobacter

P ic tu r e

i

d

i3.90 Hodge test

■ K P C (K le b s ie lla p n e u m o n ia e c a rb a p e n e m a s e ): A ty p e o f c a rb a p e n e m a s e th a t w a s firs t d e s c rib e d in K le b s ie lla ; n o w fo u n d in m a n y d iffe re n t o rg a n is m s (n ow k n o w n a s c a rb a p e n e m re s is ta n t e n te ro b a c te ria c e a e [C R E ]) ■ T h e m o s t c o m m o n c a rb a p e n e m a s e in th e US ■ D e te c t w ith th e m o d ifie d H o d g e te s t i3.90

i

i □ N e e d fo r th e s e is d e c re a s in g w ith n e w e r te c h n o lo g ie s su ch a s M A L D I-T O F and G l p a th o g e n P C R p a n e ls □ T e s t tu b e s th a t c o n ta in la c to s e , g lu c o s e a n d s u c ro s e (K IA had o n ly la c to s e and g lu c o s e ; T S I u p d a te d it by a d d in g s u c ro s e ); th e re is a ls o a p h e n o l red in d ic a to r a nd s u lfa te □ T h e s la n t is in o c u la te d by s ta b b in g th e a g a r d o w n to th e b o tto m (b u tt) a n d s tre a k in g th e s u rfa c e □ A t th e b o tto m (butt), th e o rg a n is m u n d e rg o e s a n a e ro b ic g ro w th □ A t th e slan t, th e o rg a n is m u n d e rg o e s a e ro b ic g ro w th □ In c u b a te fo r 24 h o u rs : if a s u g a r is fe rm e n te d , th e pH g o e s d o w n = a c id —> tu rn s th e c o lo r y e llo w □ O rg a n is m s th a t p ro d u c e H 2S w ill tu rn th e b u tt b la c k

3.5.5.1.1 Lac to s e p o s itiv e E n te ro b a c te ria c e a e : p in k co lo n ie s on M acC o n key a g a r 3.5.5.1.1.1 E s c h e ric h ia c o li a C h a ra c te ris tic s □ p h e m o ly tic □ In d o le p o s itiv e (d ue to p re s e n c e o f try p to p h a n d e a m in a s e ) ■ G a s tro in te s tin a l d is e a s e □ E n te ro h e m o rrh a g ic E c o li (a ka S h ig a -lik e to x in p ro d u c in g E c o li a nd v e ro to x in p ro d u c in g E c o li) ■ M o s t w e ll k n o w n s tra in is 0 1 5 7 :H 7 (c o lo rle s s c o lo n ie s on S o rb ito l M a c C o n k e y a g a r) © ASCP2018

ISBN 978-08 9 1 8 9 -6 6 7 8

165

3: Microbiology

Bacteriology>Gram negative rods

i3.92 Rhinosderoma in H&E stained sections at a low & b high magnification ■ H e a t la b ile (LT): s im ila r to c h o le ra to x in —> in c re a s e s c A M P —> w a te ry d ia rrh e a ■ H e a t s ta b le (S T ): in c re a s e s c G M P —► h y p e rs e c re tio n o f flu id s a n d e le c tro ly te s into in te s tin a l lu m e n i3.91 Mucoid colonies of Klebsiella turning MacConkey media pink due to lactose fermentation

■ S o m e s tra in s p ro d u c e b a c te rio p h a g e e n c o d e d c y to to x in s stx1 a n d s tx 2 (S h ig a -lik e to x in o r v e ro to x in ) ■ F e v e r is m ild ; n o fe c a l le u k o c y te s ■ C o lo n iz e a n im a ls s u c h a s c a ttle , s h e e p , g o a ts a n d deer ■ T ra n s m is s io n ■ V iru le n c e fa c to rs : lo w in fe c tio u s d o s e , to le ra n c e to a c id ic e n v iro n m e n ts , re s is ta n t to fe rm e n ta tio n a n d d ry in g , c a n b e tra n s m itte d p e rs o n to p e rs o n ■ U s u a lly a c q u ire d fro m e a tin g u n d e rc o o k e d m e a t, fe c a lly c o n ta m in a te d m ilk , fru it a n d v e g e ta b le s , in a d e q u a te ly p a s te u riz e d m ilk p ro d u c ts o r ju ic e s ■ M o re c o m m o n in s p rin g a n d s u m m e r ■ A n tib io tic s c o n tra in d ic a te d ! (C a n in c re a s e to x in e x p re s s io n ) ■ C lin ic a l s y n d ro m e s

■ H e m o rrh a g ic c o litis : s e v e re a b d o m in a l c ra m p s , w a te ry o r b lo o d y d ia rrh e a , little /n o fe v e r □ E n te ro to x ig e n ic £ c o li: tra v e le r d ia rrh e a ■ N o fe v e r, n o n in v a s iv e ; w a te ry d ia rrh e a

166

□ E n te ro in v a s iv e £ co li: p ro d u c e d S h ig a like to xin (T 3 S S ); Id e n tic a l to s h ig e llo s is (p ro fu s e d y s e n te ry / d ia rrh e a w ith W B C s in sto o l a n d h ig h fe ve r); re q u ire s h ig h e r in fe c tio u s d o s e th a n S h ig e lla □ E n te ro a g g re g a tiv e £ co li: w a te ry d ia rrh e a in H IV p a tie n ts ; tra v e le r d ia rrh e a ; in fa n ts /c h ild re n in d e v e lo p in g c o u n trie s ; “s ta c k e d b ric k ” a d h e re n c e to e n te ro c y te s □ S o m e o f th e s e a re p re s e n t on G l p a th o g e n P C R p a n e ls ■ U rin a ry tra c t in fe c tio n s : re s p o n s ib le fo r - 9 0 % o f U T Is in p e o p le w ith n o rm a l a n a to m y ■ M e n in g itis in n e o n a te s : s tra in s c o n ta in th e K1 c a p s u le th a t is in d is tin g u is h a b le fro m N m e n in g itid is g ro u p B c a p s u le ; a ls o h as fim b ria e w h ic h b in d to re c e p to rs on brain e n d o th e lia l c e lls 3.5.5.11.2 K le b s ie lla ■ K le b s ie lla p n e u m o n ia e

■ H e m o ly tic u re m ic s y n d ro m e ■ T ria d o f m ic ro a n g io p a th ic h e m o ly tic a n e m ia , re n a l fa ilu re , a n d th ro m b o c y to p e n ia ■ O c c u rs in ~ 5 % o f s p o ra d ic c a s e s ; 5% o f th e s e w ill d ie a c u te ly ■ U s u a lly c h ild re n < 5 y e a rs o ld ■ 1/3 o f s u rv iv o rs h a v e s e q u e la e : c h ro n ic re n a l in s u ffic ie n c y , h y p e rte n s io n , n e u ro lo g ic d e fic its

■ P ro d u c e s 2 to x in s

□ E n te ro p a th o g e n ic E co li: m o d e ra te ly in v a s iv e —> in fla m m a to ry re s p o n s e (d y s e n te ry ), a tta c h a nd e ffa c e e p ith e lia l c e lls ; p e rs o n to p e rs o n s p re a d is p o s s ib le

□ C h a ra c te ris tic s ■ L a rg e p o ly s a c c h a rid e c a p s u le (K a n tig e n ); c o lo n ie s lo o k m u c o id i3.91 ■ C a n s e e n e g a tiv e s p a c e a ro u n d ro d s in G ra m sta in ■ In d o le n e g a tiv e (K o x y to c a is in d o le p o sitive ) ■ N o n m o tile □ C lin ic a l fe a tu re s ■ N o rm a l flo ra o f m o u th , s k in a n d in te s tin e s ; h ig h e r c a rria g e rate in h o s p ita liz e d p a tie n ts ■ U s u a lly a ffe c ts p a tie n ts w ith u n d e rly in g d is e a s e : d ia b e te s , C O P D , a lc o h o lis m ■ P n e u m o n ia w ith “c u rra n t je lly ” s p u tu m

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

3: Microbiology

Bacteriology>Gram negative rods ■ C a n a ls o c a u s e U TI, b a c te re m ia , a nd p rim a ry liv e r abscess

□ S ty p h i p ro d u c e s s c a n t H 2S —►L o o k s like a b la c k m u s ta c h e in T S I tu b e □ G l p a th o g e n P C R p a n e ls b e c o m in g m o re ro u tin e

□ A n tib io tic re s is ta n c e ■ M o s t s tra in s re s is ta n t to a m p ic illin a n d tic a rc illin

■ S a lm o n e llo s is : e n te ric fe v e rs (ty p h o id fe v e r) □ S a lm o n e lla s e ro ty p e ty p h i a n d p a ra ty p h i

■ E S B L : e x te n d e d s p e c tru m (3 la c ta m a s e

□ T ra n s m itte d v ia s e w a g e c o n ta m in a te d fo o d a n d w a te r, c o n ta c t w ith in fe c te d p e rs o n

□ K P C : K le b s ie lla p n e u m o n ia e c a rb a p e n e m a s e ■ K le b s ie lla rh in o s c le ro m a tis □ C a u s e s rh in o s c le ro m a □ C h ro n ic g ra n u lo m a to u s d is e a s e , u s u a lly a ffe c tin g th e n o se □ L e a d s to s e v e re n a sa l d e fo rm ity (h is to ric a lly c a lle d H e b ra n ose ) □ M ik u lic z ce lls: la rg e v a c u o la te d h is tio c y te s c o n ta in in g th e o rg a n is m in th e s u b m u c o s a i3.92 ■ K le b s ie lla g ra n u lo m a tis □ G ra n u lo m a in g u in a le (D o n o v a n o s is ) □ P a in le s s g e n ita l u lc e rs w h ic h p ro g re s s a n d c a u s e lo c a l tis s u e d e s tru c tio n

□ Fever, a b d o m in a l s y m p to m s ; c o m p lic a tio n s in c lu d e in te s tin a l h e m o rrh a g e o r p e rfo ra tio n , e n d o c a rd itis , s p le n ic /liv e r a b s c e s s e s ; s ig n ific a n t m o rta lity in s o m e re g io n s □ G a llb la d d e r ca n s e rv e as re s e rv o ir: 1 % -4 % o f p a tie n ts b e c o m e c h ro n ic c a rrie rs —> lo n g te rm s h e d d in g (“T y p h o id M a ry ” ) □ M o s t c a s e s in th e U S are in p a tie n ts w ith tra v e l h is to ry (d o m e s tic a lly a c q u ire d c a s e s a re u s u a lly re la te d to c o n ta c t w ith c h ro n ic c a rrie rs w h o c o n ta m in a te fo o d ) □ Id e n tific a tio n

□ D o n o v a n b o d ie s : “s a fe ty p in ” a p p e a rin g , ro d /o va l s h a p e d o rg a n is m s w ith in m o n o n u c le a r c e lls w h e n a fra g m e n t o f th e u lc e r m a rg in is p re s s e d on a s lid e

■ S ty p h i (s e ro g ro u p D): c a rrie s V i a n tig e n , s c a n t p ro d u c tio n o f H 2S (lo o k s like a m u s ta c h e o n T S I slan t), no g a s p ro d u c tio n

□ T re a tm e n t: doxy, trim e th o p rim -s u lfa , m a c ro lid e s

■ S p a ra ty p h i A : no H 2S p ro d u c tio n ■ E n te ro c o litis

3.5.5.1.13 C itro b a c te r m C fre u n d ii, C k o s e ri, C a m a lo n a tic u s a re in v o lv e d in

h u m a n d is e a s e

□ S a lm o n e lla s e ro ty p e ty p h im u riu m a n d S a lm o n e lla s e ro ty p e e n te ritid is (th e s e a re th e m o s t c o m m o n in th e U S) □ S e lf lim ite d d ia rrh e a (p ro lo n g e d c a rria g e is ra re )

■ N o rm a l flo ra o f h u m a n in te s tin e ■ C a n c a u s e U T Is, in fa n t m e n in g itis , b ra in a b s c e s s e s , a nd s e p s is ■ Id e n tific a tio n

□ S o u rc e s : fo o d (p o u ltry , e g g s ), h u m a n c a rrie rs (fo o d s e rv ic e ; fe c a l-o ra l), p e ts (re p tile s ) □ Id e n tific a tio n ■ N o n la c to s e a n d n o n s u c ro s e fe rm e n te rs

□ M o tile

■ A b u n d a n t p ro d u c tio n o f H 2S a n d g a s

□ C itra te p o s itiv e □ C fre u n d ii is H 2S p o s itiv e : n e e d to d is tin g u is h fro m S a lm o n e lla in sto o l c u ltu re s (C itro b a c te r is n o n p a th o g e n ic in sto o l c u ltu re s )

■ C itra te (+) ■ L ysin e a nd o rn ith in e d e c a rb o x y la s e (+) ■ S e p tic e m ia □ S a lm o n e lla ca n lea d to b a c te re m ia

3.5.5.1.2 L acto se n eg ative E n te ro b a c te ria c e a e

□ W ill h ave c h ills , fever, h y p o te n s io n ; h ig h m o rta lity ra te

3.5.5.1.2.1 S a lm o n e lla

□ R is k fa c to rs in c lu d e A ID S , s ic k le c e ll p a tie n ts , in fa n ts , e ld e rly , im m u n o c o m p ro m is e d

m S a lm o n e lla e n te ric a is th e o n ly s p e c ie s th a t a ffe c ts

hum ans ■ N o m e n c la tu re : S a lm o n e lla e n te ric a is th e s p e c ie s ; ty p h im u riu m , p a ra ty p h i, e n te ritis , ty p h i a re s e ro g ro u p s ■ P ro d u c e s H 2S: b la c k c o lo n ie s on H e k to e n , X L D , a n d S S a g a rs ■ T S I: a lk a lin e (red ) s la n t a n d b la c k b u tt d u e to H 2S p ro d u c tio n and no la c to s e fe rm e n ta tio n

© ASCP2018

■ O s te o m y e litis in p a tie n ts w ith s ic k le c e ll a n e m ia 3.5.5.1.2.2 S h ig e lla m E v o lv e d fro m E co li: ca n be d iffic u lt to d is tin g u is h ■ S h ig a to x in —> s e v e re d ia rrh e a w ith m u c u s a n d /o r b lo o d , fever, a b d o m in a l p ain , te n e s m u s ■ 4 s p e c ie s = 4 s e ro g ro u p s

ISBN 978-08 9189-6678

167

3: Microbiology

Bacteriology>Gram negative rods ■ Y e rsin ia e n te ro c o litic a □ C h a ra c te ris tic s ■ C o ld e n ric h m e n t a t 4°C o f th e s p e c im e n b e fo re p la tin g ■ Is o la te a t ro o m te m p e ra tu re (25°C ) on s e le c tiv e m e d ia : C IN a g a r (“ Y e r-C IN -ia ” ); c o lo n ie s lo o k like b u llse y e w ith red c e n te r a n d tra n s p a re n t b o rd e r ■ M o tile a t 25°C b u t n ot 37°C ■ U re a s e p o s itiv e ■ P re s e n t on G l p a th o g e n P C R p a n e ls so d e te c tio n m a y in c re a s e □ C lin ic a l ■ W a te ry /b lo o d y d ia rrh e a ; m ild, s e lf lim itin g , u s u a lly d o e s n o t re q u ire d tre a tm e n t ■ In g e s te d th ro u g h m o u th —» re p lic a te s in P e ye r p a tc h e s (te rm in a l ile itis ) —> s p re a d s to m e s e n te ric ly m p h n o d e s; m e s e n te ric ly m p h a d e n itis ca n be c o n fu s e d w ith a p p e n d ic itis

i3.93 Characteristic brick red colonies of Serratia

□ S h ig e lla d y s e n te ria e (s e ro g ro u p A ): m o s t s e rio u s fo rm o f d ia rrh e a ■ A s s o c ia te d w ith h e m o ly tic u re m ic s y n d ro m e □ S h ig e lla fle x n e ri (s e ro g ro u p B): m o s t c o m m o n in u n d e rd e v e lo p e d c o u n trie s ■ C a n le a d to p o s tin fe c tio u s a rth ritis in H L A -B 2 7 + p a tie n ts

■ S e c o n d a ry m a n ife s ta tio n s in c lu d e re a c tiv e p o ly a rth ritis (m o le c u la r m im ic ry b e tw e e n H L A -B 2 7 a nd Y e rsin ia a n tig e n ) a n d e ry th e m a n o d o s u m ■ S id e ro p h ilic (iro n loving ): p e o p le w ith h e re d ita ry h e m o c h ro m a to s is a nd o th e r iro n o v e rlo a d c o n d itio n s a re m o re s u s c e p tib le to s e p s is □ T ra n s m is s io n

□ S h ig e lla b o y d ii (s e ro g ro u p C)

■ P o rk, beef, lam b , m ilk, s h e llfis h , w a te r; p ig s are m a jo r re s e rv o ir

□ S h ig e lla s o n n e i (s e ro g ro u p D): m o s t c o m m o n in th e US

■ U s u a lly tra n s m itte d by fo o d ; a ls o by d ire c t c o n ta c t w ith a n im a ls o r p a tie n ts ■ S e e n m o re fre q u e n tly in n o rth e rn E u ro p e th a n US

■ T ra n s m is s io n □ V e ry c o n ta g io u s ; s m a ll in fe c tio u s d o s e (10 o rg a n is m s !)

■ M o s t c o m m o n c o n ta m in a n t o f s to re d p a c k e d red b lo o d c e lls (b lo o d b a n k)

□ S p re a d v ia fe c a l c o n ta m in a tio n o f fo o d o r w a te r 3.5.5.1.2.4 S e rra tia : S m a rc e s c e n s and S liq u ifa c ie n s

□ P e rs o n to p e rs o n

■ N o s o c o m ia l in fe c tio n s o f m a n y kin d s

□ M o re c o m m o n in th e s u m m e r ■ T re a tm e n t: s h o rte n s c o u rs e o f fe c a l e x c re tio n ; lim its c lin ic a l c o u rs e o f illn e s s

□ F o u n d in IV s o lu tio n s , c a th e te rs , d is in fe c ta n ts , han d lo tio n s ■ S o m e s tra in s p ro d u c e b ric k red c o lo re d c o lo n ie s i3.93

■ Id e n tific a tio n □ B io c h e m ic a ls a re v e ry s im ila r to E c o li □ N o n m o tile , n o g a s p ro d u c tio n w ith g lu c o s e fe rm e n ta tio n □ N o n la c to s e fe rm e n te r

■ R e s is ta n t to m u ltip le a n tib io tic s 3.5.5.1.2.5 Tribe proteae: normal Gl flora, all associated with UTIs, all can deaminate phenylalanine ■ P ro te u s □ C h a ra c te ris tic s

3.5.5.1.2.3 Y e rs in ia ■ Y e rs in ia p e s tis : th e p la g u e ; s e e s e c tio n on a n im a l a c q u ire d in fe c tio n s

168

■ C a u s e U T Is

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

3: Microbiology

Bacteriology>Gram negative rods ■ C o n ta in th e e n z y m e u re a s e , w h ic h a lk a lin iz e s th e u rin e , le a d in g to fo rm a tio n o f s tru v ite s to n e s ■ C h a ra c te ris tic s w a rm in g p a tte rn on a g a r ■ C a ta la s e a nd n itra te p o s itiv e ■ P ro d u c e s H 2S: c o lo n ie s a re b la c k on c e rta in m e d ia : X L D , H E ; b u tt o f T S I □ P ro te u s v u lg a ris : in d o le p o s itiv e (tu b e tu rn s re d) □ P ro te u s m ira b ilis : in d o le n e g a tiv e (tu be re m a in s y e llo w ) ■ P ro v id e n c ia : U T Is in p a tie n ts w ith in d w e llin g c a th e te rs o r b u rn p a tie n ts ■ M o rg a n e lla : n o s o c o m ia l in fe c tio n s , w o u n d in fe c tio n s , U T Is in p a tie n ts w ith in d w e llin g c a th e te rs

3.5.5.2 Nonfermentative bacilli: do not ferment glucose (Red/ Red in TSI); most are environmental 3.5.5.2.1

Pseudomonas aeruginosa

i3.94 Colonies of a mucoid strain of Pseudomonas, most likely from a patient with cystic fibrosis

■ C h a ra c te ris tic s □ S tric tly a e ro b ic

■ B a c te re m ic p n e u m o n ia in p a tie n ts w ith m a lig n a n c ie s

□ C a ta la s e p o s itiv e

■ C y s tic fib ro s is : c o lo n ie s w ill lo o k v e ry m u c o id i3.94; c a n s e e a lg in a te c a p s u le o n s p u tu m G ra m s ta in

□ O x id a s e p o s itiv e □ O x id a tiv e m e ta b o lis m □ M o tile w ith p o la r m o n o tric h o u s fla g e lla

□ UTI

□ C u ltu re s h a ve g ra p e o r c o rn to rtilla sm e ll

□ C N S in fe c tio n s : u s u a lly s e c o n d a ry to s u rg ic a l p ro c e d u re , tra u m a , o r b a c te re m ia

□ C a n m ake m a n y d iffe re n t p ig m e n ts

□ S k in a nd s o ft tis s u e in fe c tio n s

■ P y o c y a n in : b lu e -g re e n flu o re s c e n t p ig m e n t ■ P y o ru b in : red

■ R isk fa c to rs : skin b re a k d o w n , h ig h m o is tu re c o n d itio n s (d e rm a titis , b u rn s )

■ P y o v e rd in : lig h t g re e n

■ E c th y m a g a n g re n o s u m

□ C o lo n ie s h ave m e ta llic s h e e n , e s p e c ia lly on b lo o d agar n G ro w th a t 4 2 °C (w a rm ) in th e lab a n d in th e e n v iro n m e n t (h o t tu b s) ■ D is e a s e s □ U s u a lly c a u s e s d is e a s e in p a tie n ts w ith u n d e rly in g d is e a s e (o p p o rtu n is tic )

□ B o n e a n d jo in t in fe c tio n s ■ H e m a to g e n o u s sp re a d fro m U T I o r p e lv ic in fe c tio n s ; a ls o se en in IV D A ■ E x te n s io n fro m c o n tig u o u s site: te n n is s h o e p u n c tu re w o u n d (g lu e in s o le o f s h o e h o ld s b a c te ria ; th e n a nail p u n c tu re s th ro u g h th e s o le a n d into th e fo o t)

■ F o un d in m o is t e n v iro n m e n ts (w ater, h o t tu b s, s n e a k e rs , c o s m e tic s )

□ E a r in fe c tio n s : s w im m e r ear, m a lig n a n t o titis e x te rn a , c h ro n ic s u p p u ra tiv e o titis m e d ia

■ U b iq u ito u s in th e h o s p ita l

□ E ye in fe c tio n s : c o m m o n c a u s e o f b a c te ria l k e ra titis ; a s s o c ia te d w ith c o n ta c t le n s u s e

□ E n d o c a rd itis : n a tiv e v a lv e s in IV d ru g a b u s e rs ; p ro s th e tic v a lv e s in o th e rs □ R e s p ira to ry in fe c tio n s ■ V e n tila to r a s s o c ia te d p n e u m o n ia

3 .5 .5 .2 .2 Acinetobacter • C h a ra c te ris tic s □ O x id a s e n e g a tiv e

©ASCP2018

ISBN 9 7 8 -08 9189-6678

169

3: Microbiology

Bacteriology>Gram negative rods □ A e ro b ic

□ D is e a s e

□ C a p s u le □ N o n m o tile , n o n p ig m e n te d □ A b a u m a n n ii is th e m o s t c o m m o n s p e c ie s in h u m a n in fe c tio n s □ G ra m s ta in

■ O rg a n is m fo u n d in so il, s tre a m s , p o n d s , ric e p a d d ie s in e n d e m ic a re a s : s o u th e a s t A s ia and n o rth e rn A u s tra lia ■ A c q u ire d v ia in h a la tio n , in g e s tio n , o r c o n ta c t th ro u g h a b ra d e d skin

■ R o d s h a p e d d u rin g ra p id g ro w th

■ In fe c tio n ca n be a s y m p to m a tic , c h ro n ic , o r fu lm in a n t s e p s is

■ C o c c o id d u rin g s ta tio n a ry p h a s e

■ A g e n t o f b io te rro ris m

■ D ip lo c o c c i: lo o k like M o ra x e lla a n d N e is s e ria

■ M e lio id o s is : w id e s p e c tru m o f d is e a s e ; s k in u lc e rs / a b s c e s s e s , p n e u m o n ia (m o s t c o m m o n ), s e p tic s h o c k w ith a b s c e s s e s in m u ltip le o rg a n s , c h ro n ic p n e u m o n ia like T B

■ G ra m n e g a tiv e , b u t c a n re ta in G ra m s ta in a n d lo o k p u rp le ■ D is e a s e s □ S p e c ie s o th e r th a n A b au m an n ii-. u b iq u ito u s in n a tu re , c o lo n iz e d h u m a n s □ A b a u m a n n ii: n o k n o w n n a tu ra l h a b ita t o th e r th a n h o s p ita ls a n d c lin ic a l a re a s □ C a n b e fo u n d on s k in a n d m u c u s m e m b ra n e s o f h e a lth y p e o p le □ P e rs is ts lo n g te rm in h o s p ita l e n v iro n m e n ts , in c lu d in g d ry s u rfa c e s like c o m p u te r k e y b o a rd s □ O u tb re a k s a m o n g s o ld ie rs w h o re tu rn e d fro m Iraq a n d A fg h a n is ta n a n d a m o n g in d iv id u a ls w o u n d e d d u rin g n a tu ra l d is a s te rs □ P a tie n ts in IC U s , b u rn u n its , o r lo n g te rm fa c ilitie s w ith m u ltip le in d w e llin g m e d ic a l d e v ic e s □ R is k fa c to rs in c lu d e tra c h e o s to m ie s , m e c h a n ic a l v e n tila tio n , p rio r a n tib io tic th e ra p y , re c e n t s u rg e ry , c e n tra l v a s c u la r c a th e te rs , e n te ra l fe e d in g s a n d u n d e rly in g p u lm o n a ry d is e a s e □ In c re a s e d n u m b e r o f in fe c tio n s in w a rm e r m o n th s □ N o s o c o m ia l p n e u m o n ia m o s t c o m m o n □ A ls o , w o u n d , u rin a ry tra c t a n d b lo o d s tre a m in fe c tio n s

■ C a n e s ta b lis h la te n c y w ith re a c tiv a tio n la te r ■ B u rk h o ld e ria c e p a c ia g ro u p (m a n y s p e c ie s ) □ C h a ra c te ris tic s ■ W e a k ly o x id a s e p o s itiv e ■ M o tile ■ P ro d u c e s g re e n -y e llo w p ig m e n t ■ U se m e d ia w ith p o ly m y x in B to a id e in is o la tio n fro m re s p ira to ry s e c re tio n s □ D is e a s e s ■ F o u n d in so il, p la n ts , a n d m o is t e n v iro n m e n ts (p la n t p a th o g e n ) ■ In fre q u e n t n o s o c o m ia l p a th o g e n in n o n -C F p a tie n ts ■ A s s o c ia te d w ith c o n ta m in a te d e q u ip m e n t, m e d ic a tio n , d is in fe c ta n ts , IV flu id s (h o s p ita l o u tb re a k s ) ■ C a n c a u s e b a c te re m ia , U T I, s e p tic a rth ritis , re s p ira to ry tra c t in fe c tio n ■ V e ry im p o rta n t in p a tie n ts w ith c y s tic fib ro s is and c h ro n ic g ra n u lo m a to u s d is e a s e ■ C F p a tie n ts w h o a re fo u n d to h a ve th is o rg a n is m c a n n o t a s s o c ia te w ith o th e r C F p a tie n ts

□ M e n in g itis (n e u ro s u rg e ry o r h e a d tra u m a ) a nd p e rito n itis s e e n ra re ly

■ In c re a s e d m o rb id ity a nd m o rta lity

■ O fte n v e ry d ru g re s is ta n t

■ C a u s e s C e p a c ia s y n d ro m e : n e c ro tiz in g g ra n u lo m a to u s p n e u m o n ia

□ R e s is ta n t to p e n ic illin , a m p ic illin , a n d c e p h a lo th in □ A c q u ire a d d itio n a l d ru g re s is ta n c e q u ic k ly

3 .5 .5 .2 .3

Burkholderia

m B u rk h o ld e ria p s e u d o m a lle i: m e lio id o s is

□ T re a tm e n t: trim e th o p rim s u lfa , m e ro p e n e m , c h lo ra m p h e n ic o l, o r m in o c y c lin e ■ B u rk h o ld e ria m a lle i: G la n d e rs d is e a s e in h o rs e s , m ule s, d o n k e ys

□ C h a ra c te ris tic s

3 .5 .5 .2 .4

■ M o tile

Stenotrophomonas maltophilia

■ N a m in g h is to ry : u sed to be P s e u d o m o n a s , th e n b e c a m e X a n th o m o n a s , n o w S te n o tro p h o m o n a s m a lto p h ilia

■ O x id a s e p o s itiv e ■ B ip o la r s ta in in g ■ W rin k le d c o lo n ie s on M a c a n d b lo o d a g a r

m C h a ra c te ris tic s □ O x id a s e n e g a tiv e □ D N a s e p o s itiv e

1 70

A S C P Q uick Com pendium o f Clinical Pathology 4e

© ASCP 2018

3: Microbiology

Bacteriology>Gram negative rods □ M a y p ro d u c e y e llo w p ig m e n t o r la v e n d e r g re e n d is c o lo ra tio n on b lo o d a g a r

□ H a s g o o d e ffic a c y b ut m a y n o t la s t a s lo n g a s o ld e r v a c c in e s (D P T u sed w h o le c e ll p e rtu s s is )

□ O x id a tiv e m e ta b o lis m o f g lu c o s e a n d m a lto s e ■ D is e a s e s □ U b iq u ito u s e n v iro n m e n ta l b a c te riu m □ N e e d to th in k a b o u t th e s ig n ific a n c e o f fin d in g it in a p a tie n t: c o lo n iz a tio n vs tru e p a th o g e n ? □ S ig n ific a n t n o s o c o m ia l p a th o g e n ; ris k s a re v e n tila tio n , u s e o f b ro a d s p e c tru m a n tib io tic s , c a th e te riz a tio n (lin e in fe c tio n s ), a n d n e u tro p e n ia □ P n e u m o n ia : IC U a n d c a n c e r p a tie n ts

□ N o w s e e in g a re s u rg e n c e o f d is e a s e in te e n a g e rs , a s im m u n ity w a re s o ff □ In te e n s /a d u lts , th e d is e a s e is n o t v e ry s e v e re , b u t th e re is a ris k o f tra n s m ittin g to in fa n ts ■ O th e r s p e c ie s o f B o rd e te lla □ B o rd e te lla p a ra p e rtu s s is : c a n c a u s e p e rtu s s is lik e in fe c tio n in h u m a n s ; a ls o c a u s e s d is e a s e in a n im a ls □ B o rd e te lla b ro n c h is e p tic a : k e n n e l c o u g h in d o g s ; ra re ly c a u s e s p e rtu s s is lik e d is e a s e in im m u n o c o m p ro m is e d p e o p le

□ C a th e te r re la te d b a c te re m ia □ UTI ■ In h e re n tly re s is ta n t to m a n y a n tib io tic s , in c lu d in g a m in o g ly c o s id e s , im ip e n e m , a nd m a n y (3 la c ta m s □ M a n y in v itro s u s c e p tib ility te s tin g is u n re lia b le □ T re a t w ith trim e th o p rim -s u lfa m e th o x a z o le (or tic a rc illin -c la v u la n ic a c id )

3 .5 .5 .2 .5

■ V a c c in e : c u rre n t re c o m m e n d a tio n fo r a d u lts is D T aP : d ip h th e ria a n d te ta n u s to x in s p lu s a c e llu la r p e rtu s s is

3.5.5.3 Other Gram negative rods 3.5.5.3.1 Vibrio ■ C h a ra c te ris tic s □ F a c u lta tiv e a n a e ro b e s □ O x id a s e p o s itiv e

Bordetella pertussis

□ F e rm e n ts s u g a rs

• C h a ra c te ris tic s □ T iny, G ra m n e g a tiv e c o c c o b a c illu s

□ S h o rt, c u rv e d G ra m n e g a tiv e b a c illi

□ V iru le n c e fa c to rs

□ M o tile v ia p o la r fla g e lla

■ F H A (fila m e n to u s h e m a g g lu tin in ) p ro te in on pili: m e d ia te s a tta c h m e n t to e p ith e lia l c e lls

□ S a lt: re q u ire d o r s tim u la te s g ro w th in all p a th o g e n ic V ib rio

■ P e rtu s s is to xin: s tim u la te s a d e n y la te c y c la s e , p ro m o te s ly m p h o c y to s is

m V p a ra h a e m o ly tic u s g ro w s in h ig h s a lt c o n c e n tra tio n s

■ P e rta c tin

■ V c h o le ra e d o e s n o t re q u ire a s a lt c o n ta in in g e n v iro n m e n t

> D is e a s e : p e rtu s s is □ C a ta rrh a l: m ild u p p e r re s p ira to ry s y m p to m s ; m o s t c o n ta g io u s s ta g e ; b e s t tim e to c u ltu re □ P a ro x y s m a l: s e v e re c o u g h —* a n o x ia a nd v o m itin g ; p o s ttu s s iv e “w h o o p ” h e a rd in in fa n ts , ly m p h o c y to s is ; d iffic u lt to is o la te o rg a n is m □ C o n v a le s c e n t: ca n la s t m a n y m o n th s

□ S to o l s a m p le s a re p la te d o n T C B S (th io s u lfa te c itra te b ile s u c ro s e ) a g a r: V c h o le ra e c o lo n ie s a re y e llo w b e c a u s e th e y fe rm e n t s u c ro s e ; V p a ra h a e m o ly tic u s a n d v u ln ific u s d o n o t fe rm e n t s u c ro s e s o it w ill re m a in c o lo rle s s (g re e n ) □ V c h o le ra e lo o k s dry, h e m o ly tic on b lo o d a g a r

■ D ia g n o s is □ P C R is p re fe rre d m e th o d

□ R isk fa c to rs fo r a n y V ibrio illn e s s

□ C u ltu re s (n o t p e rfo rm e d ro u tin e ly a n y m o re ) ■ R e q u ire s s u p p le m e n ts fo r g ro w th : h is to ric a lly use R e g a n L o w e o r B o rd e t-G e n g o u ■ C o lo n ie s a re s m o o th a n d shiny, like a d ro p o f m e rc u ry ■ T re a tm e n t: m a c ro lid e s (e ry th ro m y c in , a z ith ro m y c in , c la rith ro m y c in ); trim e th o p rim -s u lfa

© A S C P 2018

□ V v u ln ific u s is a la c to s e fe rm e n te r; o th e r s p e c ie s a re n o n la c to s e fe rm e n te rs

■ A s s o c ia te d w ith c o n s u m p tio n o f ra w o y s te rs o r o y s te r re la te d in ju ry ■ P re -e x is tin g h e p a tic d is e a s e is u s u a lly p re s e n t in p a tie n ts w ith s e rio u s d is e a s e s d u e to in c re a s e d a v a ila b le iro n s to re s ■ G l p a th o g e n P C R p a n e ls b e c o m in g m o re ro u tin e ■ V ib rio c h o le ra e

ISBN 978-08 9189-6678

171

3: Microbiology

Bacteriology>Gram negative rods □ C h a ra c te ris tic s ■ S tra in 0 1 p ro d u c e s c h o le ra to xin —►e p id e m ic ch o le ra ■ T o xin b in d s e n te ro c y te s a n d a c tiv a te s a d e n y la te c y c la s e —> M a s s iv e in te s tin a l flu id lo ss, d e h y d ra tio n ■ 0 1 is n o n e n c a p s u la te d ■ 0 1 3 9 B e n g a l: n e w a g e n t o f e p id e m ic c h o le ra ■ P ro d u c e s c h o le ra to x in ■ E n c a p s u la te d (u n lik e 0 1 ) ■ N o n -0 1 o r 0 1 3 9 s tra in s : s e lf lim ite d g a s tro e n te ritis ; no c h o le ra to x in ; d o p ro d u c e o th e r to x in s ■ T S I: a c id /a c id (y e llo w /y e llo w ) d u e to s u c ro s e fe rm e n ta tio n □ D is e a s e

■ S o ft tis s u e in fe c tio n s o f e x tre m itie s , e a rs a nd e yes □ V ib rio p a ra h e m o ly tic u s • G a s tro e n te ritis (s e lf lim ite d )

■ C a n a c q u ire v ia fe c a lly c o n ta m in a te d w a te r a nd c o n ta m in a te d s h e llfis h

■ M a rin e e n v iro n m e n ts ; c o n ta m in a te s fis h a nd s h e llfis h

■ H u m a n s a re th e p rim a ry re s e rv o ir d u rin g o u tb re a k s

■ C a n c a u s e o u tb re a k s o f a c u te d ia rrh e a d u e to c o n ta m in a te d fo o d

■ T ra n s m itte d v ia s e w a g e c o n ta m in a te d w a te r ■ P e rs is ts b e tw e e n o u tb re a k s in fre s h a n d s a ltw a te r, b u t m a y n o t be a b le to fin d in c u ltu re s □ E p id e m io lo g y ■ N a tu ra l in h a b ita n ts o f o c e a n s , s a ltw a te r m a rs h e s , fre s h w a te r la k e s ■ H ig h e s t b a c te ria l c o n c e n tra tio n s A p ril th ro u g h O c to b e r ■ S u rv iv e in 5 % -2 5 % s a lin ity (s o m e e x c e p tio n s ) ■ R e p o rte d fro m e v e ry g e o g ra p h ic re g io n in th e U .S ■ A s s o c ia te d w ith s h e llfis h , z o o p la n k to n , fis h a nd s e d im e n t ■ F ilte r fe e d in g b iv a lv e s c o n c e n tra te th e o rg a n is m s in w a te r ■ T ra n s m is s io n th ro u g h in g e s tio n o f ra w o r u n d e rc o o k e d s e a fo o d v ia tra u m a to s k in (eg, s te p p in g on a s e a s h e ll) □ V ib rio v u ln ific u s m W o u n d in fe c tio n s a n d s e p tic e m ia —> ca n be fa ta l! ■ B lis te rs a n d s w e llin g a t lo c a l s ite (o r a n y w h e re in d is s e m in a te d in fe c tio n ) ■ R a p id tis s u e n e c ro s is (e x tra c e llu la r to x in s a nd enzym es) ■ P o s s ib le d e v e lo p m e n t o f s e c o n d a ry b a c te re m ia ■ M o rta lity ra te - 2 4 % □ V ib rio a lg in o ly tic u s m W o u n d in fe c tio n s ■ P o ly m ic ro b ia l in fe c tio n s

3 .5 .5 .3 .2 Aeromonas ■ A s s o c ia te d w ith w a te r: ta p w a te r, rive rs, so il, fis h ta n k s

■ O th e r s p e c ie s

172

i3.95 Helicobacter pylori in Warthin-Starry stained sections at a low & b high magnification

■ P re s e n t in le e c h (H iru d o ) G l tra c k s : in fe c tio n s a s s o c ia te d w ith le e c h u se ■ D ia rrh e a , in fe c tio n o f w o u n d s d u e to tra u m a , s e p s is in im m u n o c o m p ro m is e d

3.5 .5 .3 .3 Campylobacter jejuni ■ C h a ra c te ris tic s □ S m a ll, c u rv e d , s p ira l o r S s h a p e d G ra m n e g a tiv e ro ds □ S e le c tiv e m e d ia to in h ib it g ro w th o f o th e r sto o l o rg a n is m s : c a m p y B A P □ M ic ro a e ro p h ilic : o p tim a lly g ro w in 5 % -1 0 % o x y g e n □ In c u b a te a t 42°C □ P o la r fla g e lla □ G l p a th o g e n P C R p a n e ls b e c o m in g m o re ro u tin e ■ D is e a s e □ F o un d w o rld w id e a s n o rm a l flo ra o f G l tra c t in tu rke ys, c h ic k e n s , c a ttle , s h e e p , e tc □ M o s t c o m m o n c a u s e o f b a c te ria l e n te ritis in th e US □ S u m m e r a n d fall □ U s u a lly a c q u ire d via im p ro p e rly c o o k e d fo o d s , e s p e c ia lly p o u ltry □ O u tb re a k s h ave b ee n a s s o c ia te d w ith u n p a s te u riz e d m ilk a nd p ro b le m s w ith ta p w a te r □ D ia rrh e a w ith o r w ith o u t b lo o d o r le u k o c y te s fo r up to 1 w e e k ; s e lf lim ite d

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

3: Microbiology

Bacteriology>Gram negative rods □ C a n c a u s e G u illa in -B a rre and re a c tiv e a rth ritis in p a tie n ts w ith H L A -B 2 7 ■ Id e n tific a tio n

■ H a e m o p h ilu s in flu e n z a e □ R e q u ire s X (h e m in ) and V (N A D ) ■ S u p p lie d in c h o c o la te a g a r fro m ly se d R B C s

□ G ro w th in m ic ro a e ro p h ilic c o n d itio n s a t 4 2°C on s e le c tiv e m e d ia (C a m p y o r S k irro w ) □ D a rtin g o rg a n is m s in sto o l (a lth o u g h sto o l G ra m sta in is n o t re c o m m e n d e d ) □ C a n h y d ro ly z e h ip p u ra te (d is tin g u is h e s C je ju li fro m o th e r s p e c ie s ) ■ T re a tm e n t: u s u a lly n o n e re q u ire d ; ca n tre a t w ith e ry th ro m y c in

■ O n a b lo o d a g a r plate, H in flu e n z a e w ill s a te llite a ro u n d S ta p h y lo c o c c u s c o lo n ie s b e c a u s e th e y c a n re le a s e th e fa c to rs fro m th e R B C s ■ O th e rw is e , it w ill n o t g ro w on b lo o d a g a r ■ P o rp h y rin te s t: d e te rm in e s X re q u ire m e n t □ V iru le n c e : p o ly s a c c h a rid e c a p s u le ■ 6 s e ro ty p e s o f th e c a p s u le (a -f) ■ S tra in s w ith o u t a c a p s u le a re c a lle d n o n ty p e a b le ■ A s s o c ia te d w ith o titis m e d ia , s in u s itis , b ro n c h itis , c o n ju n c tiv itis a nd C O P D e x a c e rb a tio n s

3 .5 .5 .3 .4 Helicobacter m H e lic o b a c te r p y lo ri □ F o u n d in th e s to m a c h □ A c u te g a s tritis ; le a d in g to c h ro n ic a c tiv e g a s tritis -> G a s tric a nd d u o d e n a l u lc e rs —» G a s tric c a rc in o m a a nd ly m p h o m a □ D ia g n o s is (v e ry d iffic u lt to c u ltu re ) ■ S to m a c h b io p s y w ith W a rth in -S ta rry i3.95, m e th y le n e blue, o r im m u n o h is to c h e m ic a l sta in ■ E IA fro m sto o l: v e ry u s e fu l to d ia g n o s e a n d c o n firm e ra d ic a tio n fo llo w in g tre a tm e n t ■ A n tib o d ie s in b lo o d : n o t v e ry u s e fu l b e c a u s e m a n y p e o p le a re p o s itiv e ■ H e lic o b a c te r h e ilm a n n if. a ls o fo u n d on s to m a c h b io p s ie s , m o re s p ira l/tig h t c o il s h a p e d

m C h a ra c te ris tic s □ O x id a s e p o s itiv e □ M o s t s p e c ie s a re n o rm a l in h a b ita n ts on th e u p p e r re s p ira to ry tra c t □ S p re a d fro m p e rs o n to p e rs o n via re s p ira to ry d ro p le ts □ M o s t w ill n ot g ro w on M a c C o n k e y a nd w ill fo rm sm all c o lo n ie s on c h o c o la te a g a r □ S p e c ie s c la s s ifie d a c c o rd in g to h e m o ly s is a nd g ro w th re q u ire m e n ts t3.30

t3.30 Haemophilus growth requirements G ro w th re q u ire m e n ts H a e m o p h i l u s spp

H aem ophilus aphrophilus

© A S C P 2018

3.5.5.3 .7 Haemophilus ducreyi ■ C a u s e s th e d is e a s e ca lled c h a n c ro id : p a in fu l g e n ita l u lc e r ■ R e q u ire s X (h e m in ; m n e m o n ic : c h a n c ro id is X ra te d ) ■ D ia g n o s is : G ra m sta in fro m le s io n s h o w s “ s c h o o l o f fis h ”

3 .5 .5 .3 .8 Aggregatibacter (Haemophilus) aphrophilus

□ In fe c tio n o fte n p re c e d e d by d e n ta l p ro c e d u re

□ G ra m n e g a tive , s m a ll c o c c o b a c illi

H aem ophilus ducreyi

■ R e q u ire s V (N A D ) fo r g ro w th

m F lo ra o f th e u p p e r re s p ira to ry tra c t; c a n c a u s e e n d o c a rd itis , b ra in a b s c e s s e s , p n e u m o n ia , m e n in g itis , b a c te riu ria

3 .5 .5 .3 .5 Haemophilus

H aem ophilus parainfluenzae

3 .5 .5 .3 .6 Haemophilus parainfluenzae • F lo ra o f th e u p p e r re s p ira to ry tra c t; c a n c a u s e s e rio u s d is e a s e (e n d o c a rd itis )

■ U re a b re a th te s t

H aem ophilus influenzae

■ V a c c in e a g a in s t ty p e b: m a jo r d e c re a s e in th e in c id e n c e o f in va sive in fe c tio n s , like m e n in g itis a n d e p ig lo ttitis

x,v V X neither

■ D o e s n o t re q u ire X o r V fo r g ro w th s o it c a n g ro w on b lo o d a g a r; d o e s re q u ire C 0 2 ■ H a e m o p h ilu s is o ld te rm in o lo g y ; n o w g e n u s is A g g re g a tib a c te r

3 .5 .5 .3 .9 Plesiomonas shigelloides m F o un d in tro p ic a l c o u n trie s ■ C a u s e s g a s tro e n te ritis fo llo w in g in g e s tio n o f u n c o o k e d s h e llfis h □ It ca n a ls o be p re s e n t in s to o l c u ltu re s w ith o u t c a u s in g d is e a s e ■ D ia rrh e a u s u a lly c o n ta in s R B C s a n d W B C s ■ C a n lea d to e x tra in te s tin a l m a n ife s ta tio n s : m e n in g itis , s e p s is , e tc

ISBN 978-08 9 1 8 9 -6 6 7 8

173

3: Microbiology

Bacteriology>Gram negative rods 3 .5 .5 .3 .1 0 Legionella pneumophila ■ G ro w s in a q u a tic e n v iro n m e n ts (a ir c o n d itio n e rs , d e c o ra tiv e in d o o r w a te rfa lls ) ■ D is e a s e is u s u a lly a n a c u te , fib rin o p u ru le n t p n e u m o n ia w ith a lo b u la r d is trib u tio n in a d u lts w ith C O P D , a lc o h o l/ to b a c c o a b u s e , e ld e rly (P o n tia c fe v e r o r le g io n n a ire d is e a s e ) ■ N o p e rs o n to p e rs o n s p re a d ■ C a n s e e o rg a n is m s w ith in a lv e o la r m a c ro p h a g e s ■ D ia g n o s is □ R e q u ire s c y s te in e fo r g ro w th : u s e b u ffe re d c h a rc o a l y e a s t e x tra c t a g a r (B C Y E ); g ro w s in 2 -5 d a y s □ D o e s n o t s ta in w e ll w ith G ra m s ta in ; u s e s ilv e r sta in in s te a d (c o m m o n te s t q u e s tio n b u t n o t ro u tin e ly p e rfo rm e d ) □ U rin e a n tig e n te s t fo r s e ro g ro u p 1 (th e m o s t p re v a le n t s e ro g ro u p )

■ M ic ro la b s u se d to in c u b a te fo r > 5 d a y s w h e n a c lin ic ia n s u s p e c te d th e s e o rg a n is m s ■ T h e y ie ld o f th e a d d itio n a l w e e k s w a s v e ry lo w ■ N e w te c h n o lo g ie s o f b lo o d c u ltu re in c u b a tio n s y s te m s m a k e th is c o m p le te ly u n n e c e s s a ry □ H A C E K is an o ld te rm , so o rg a n is m s h ave c h a n g e d ■ H a e m o p h ilu s a p h ro p h ilu s is n o w A g g re g a tib a c te r a p h ro p h ilu s • A c tin o b a c illu s is n o w A g g re g a tib a c te r m H a e m o p h ilu s : se e a b o v e ■ A g g re g a tib a c te r (A c tin o b a c illu s ) a c tin o m y c e te m c o m ita n s : oral, re s p ira to ry , a nd G U flo ra w ith lo w p a th o g e n ic ity ; o n ly c a u s e s d is e a s e s in im m u n o c o m p ro m is e d o r w h e n th e y a re a c c id e n ta lly in tro d u c e d into h e a lth y tis s u e ■ C a rd io b a c te riu m h o m in is : s u b a c u te b a c te ria l e n d o c a rd itis ; c a n a ls o c a u s e p e rio d o n titis a n d p e rito n itis ■ E ik e n e lla c o rro d e n s □ C h a ra c te ris tic s

3.5.5.3.11 Gardnerella vaginalis ■ T h in , G ra m v a ria b le ro d o r c o c c o b a c illu s

■ C o lo n ie s c o rro d e o r p it th e a g a r; s m e ll like b le a ch , g re e n is h d is c o lo ra tio n o f a g a r

■ A s s o c ia te d w ith b a c te ria l v a g in o s is (b u t m a y n o t be th e c a u s e o f th is d is e a s e )

■ C o lo n y g ro w th e n h a n c e d by C 0 2 ■ N o g ro w th on M a c C o n k e y

3 .5 .5 .3 .1 2 Capnocytophaga ■ C h a ra c te ris tic s : in tra c e llu la r; c o lo n ie s a re s p re a d y d u e to m o tility ■ C a p n o c y to p h a g a o c h ra c e u s : n o rm a l h u m a n flo ra ; tra n s ie n t b a c te re m ia , e n d o c a rd itis , p e rio d o n titis ■ C a p n o c y to p h a g a c a n im o rs u s : n o rm a l flo ra o f d o g s a n d c a ts ; c a n c a u s e fa ta l s e p tic e m ia fo llo w in g w o u n d in fe c tio n s fro m d o g o r c a t b ite a F u s ifo rm , p o in te d e n d s o n G ra m s ta in □ O x id a s e a n d c a ta la s e p o s itiv e (m o s t o th e r s p e c ie s a re n e g a tiv e )

3.5.5.4 HACEK organisms ■ C h a ra c te ris tic s

□ D is e a s e s ■ S u b a c u te e n d o c a rd itis ■ “ F ig h t b ite ” o r “ b a r fig h t” w o u n d s : h u m a n bite w o u n d s ; w h e n o n e h u m a n ’s fis t h its a n o th e r h u m a n in th e m o u th , th e k n u c k le s ca n be w o u n d e d a nd in fe c te d w ith h u m a n m o u th flo ra ■ S kin p o p p e rs : s o ft tis s u e in fe c tio n s d u e to lic k in g n e e d le in IV D A ■ D e n ta l a n d p e rio d o n ta l in fe c tio n s ■ K in g e lla k in g a e : s u b a c u te e n d o c a rd itis ; a ls o an im p o rta n t c a u s e o f s e p tic a rth ritis a n d o s te o m y e litis in c h ild re n

3.5.5.5 Gram negative rods with animal hosts

□ N o rm a l o ra l flo ra

■ B ru c e lla

□ A s s o c ia te d o c c a s io n a lly w ith b a c te ria l e n d o c a rd itis ; ra re ly a s s o c ia te d w ith o th e r d is e a s e s □ O p p o rtu n is tic ; e n te r b lo o d s tre a m w h e n th e y c a n , s e ttle o n d a m a g e d h e a rt v a lv e s —» s lo w ly p ro g re s s iv e , in d o le n t e n d o c a rd itis □ F a s tid io u s o rg a n is m s ; g ro w b e s t on c h o c o la te a g a r in C 0 2 in c u b a to rs □ D o n o t re q u ire a d d itio n a l tim e in b lo o d c u ltu re b o ttle in c u b a tio n

174

■ O x id a s e p o s itiv e , c a ta la s e n e g a tive , n o n fe rm e n te r

□ C h a ra c te ris tic s ■ C h a ra c te ris tic a lly s m a ll, G ra m n e g a tiv e c o c c o b a c illi ■ A ll s p e c ie s e x c e p t B o v is h y d ro ly z e u rea □ D is e a s e s a n d p a th o g e n e s is ■ H u m a n s b e c o m e in fe c te d m o s t c o m m o n ly by in g e s tio n o f u n p a s te u riz e d m ilk o r m ilk p ro d u c ts fro m in fe c te d a n im a ls (e s p e c ia lly im p o rte d c h e e s e fro m u n p a s te u riz e d g o a t m ilk); a ls o by in h a la tio n o r d ire c t c o n ta c t w ith a n im a l c a rc a s s e s , fe tu s e s , o r s k in (o c c u p a tio n a l e x p o s u re )

AS CP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

3: Microbiology

Bacteriology>G ram negative rods ■ B m e lite n s is : s h e e p and g o a ts ; m o s t v iru le n t in hum ans

■ N o g ro w th on M a c C o n k e y

■ 8 a b o rtu s : c a ttle ; c a u s e s a b o rtio n s

■ C o n fu s e d w ith H a e m o p h ilu s ; F ra n c is e lla w ill be s a te llite te s t o r X /V n e g a tiv e

■ B su is: s w in e ■ 8 c a n is : d o g s ; ra re ly c a u s e s h u m a n in fe c tio n ■ H a llm a rk fe a tu re : fe v e r w ith ly m p h a d e n o p a th y , h e p a to s p le n o m e g a ly , a nd m a lo d o ro u s p e rs p e ra tio n ■ L o c a l ly m p h a d e n o p a th y —» d is s e m in a tio n —> g ra n u lo m a s in liver, s p le e n , b o n e , e tc ■ O rg a n is m s a re s e e n w ith in p h a g o c y te s ■ V a ria b le a nd n o n s p e c ific s y m p to m s ; u n d u la n t fe v e r: d iu rn a l ■ M o rta lity : 5% if u n tre a te d □ D ia g n o s is ■ U s u a lly v ia b lo o d and b o n e m a rro w ; ca n se e g ra n u lo m a s if b io p s y is d o n e ■ P u n c ta te c o lo n ie s a t 4 8 h o u rs, fa in tly s ta in in g G ra m n e g a tiv e c o c c o b a c illi ■ O x id a s e p o s itiv e , c a ta la s e p o s itiv e ■ U re a s e p o s itiv e (8 s u is w ith in 15 m in; all o th e rs w ith in 24 h ou rs) ■ C u ltu re s a re d a n g e ro u s to la b o ra to ry w o rk e rs ■ C la s s A b io te rro ris m o rg a n is m ■ S p e c ia tio n d o n e by sta te h e a lth d e p a rtm e n ts □ T re a tm e n t: d o x y c y c lin e + g e n ta m ic in , d o x y + rifa m p in , b a c trim + g e n ta m ic in

■ C u ltu re is d a n g e ro u s !! ■ C la s s A b io te rro ris m o rg a n is m ■ S e ro lo g y : a n tib o d ie s a p p e a r 14 d a y s a fte r o n s e t; p e a k a t 4 -5 w e e k s □ D is e a s e ■ P rim a ry re s e rv o ir is th e ra b b it; a ls o fo u n d in o th e r a n im a ls ■ T ra n s m itte d to h u m a n s v ia tic k , m o s q u ito (A e d e s ), fly (C h ry s o p s ), d ire c t c o n ta c t w ith ra b b it, in g e s tio n o f u n d e rc o o k e d a n im a l m e a t ■ U lc e ro g la n d u la r tu la re m ia : h e a d a c h e , fe ve r, m y a lg ia s —►ly m p h a d e n itis n e a r th e p rim a ry le s io n —» u lc e ra te s ■ T u la re m ia ca n a ls o c a u s e c o n ju n c tiv a l, o ro p h a ry n g e a l, G l, p n e u m o n ic (p rim a ry o r s e c o n d a ry ), ty p h o id a l (s e p tic e m ia w ith o u t a d e n o p a th y ), o c u lo g la n d u la r ■ S o u th /c e n tra l a n d w e s te rn U S s ta te s ; m a in ly in th e sum m er ■ N o p e rs o n to p e rs o n s p re a d □ A n tib io tic s ■ S tre p to m y c in o r g e n ta m y c in ; d o x y o r c ip ro ■ P ro p h y la x is : d o x y or c ip ro

■ P a s te u re lla m u lto c id a

■ S tre p to b a c illu s

□ C h a ra c te ris tic s ■ G ra m n e g a tiv e b a c te ria w ith ra n g e o f m o rp h o lo g ie s fro m c o c c o b a c illi to lon g fila m e n to u s ro d s

□ G ra m n e g a tiv e rod th a t fo rm s lo n g , th in fila m e n ts , w ith b u lb o u s s w e llin g s (L o o k s like a s trin g o f b e a d s ) □ C o lo n ie s lo o k like “ p u ff b a lls ” in th io g ly c o la te b ro th

■ C a n lo o k b ip o la r ■ G ro w s w e ll on b lo o d a g a r b u t n o t M a c C o n k e y

□ D is e a s e s ■ R a t b ite fever, a k a H a v e rh ill fe v e r: lo c a l ly m p h a n g itis —►fever, m a la is e —» ra sh

■ O x id a s e /c a ta la s e /in d o le p o s itiv e □ D is e a s e ■ A c q u ire d fro m c a t a n d d o g licks, b ites, o r s c ra tc h e s (C a ts > d o g s ) ■ R a p id o n s e t o f c e llu litis -> s e p s is , o s te o m y e litis , m e n in g itis

■ In g e s tio n o f c o n ta m in a te d fo o d o r w a te r ■ Is o la te o rg a n is m fro m b lo o d o r jo in t a b s c e s s e s ■ Y e rs in ia p e s tis □ C h a ra c te ris tic s ■ In th e E n te ro b a c te ria c e a e fa m ily : o x id a s e n e g a tiv e , fa c u lta tiv e a n a e ro b e , fe rm e n ts g lu c o s e , re d u c e s n itra te s to n itrite s

■ A ls o ca n c a u s e re s p ira to ry in fe c tio n s ■ T re a t w ith 3 la c ta m s ■ F ra n c is e lla tu la re n s is □ C h a ra c te ris tic s : s m a ll, p le o m o rp h ic , G ra m n e g a tiv e ■ N e e d s c y s tin e o r c y s te in e fo r g ro w th (m ig h t in itia lly g ro w on b lo o d agar, b u t n o t on 2 nd p a s s a g e ; w ill g ro w on c h o c o la te ) ■ S lo w g ro w th a t 35°C ; p o o r g ro w th a t 28°C ; hold p la te s fo r 5 -7 d a y s © A S C P 2018

■ P in p o in t c o lo n ie s o n b lo o d a ga r, fa in t c o c c o b a c illu s

■ B ip o la r s ta in in g : “s a fe ty p in ” ■ S lo w g ro w in g (p in p o in t at 24 h rs o n b lo o d a ga r, h old p la te s 5 -7 d ays); lo o k s lik e frie d e g g ■ N o n la c to s e fe rm e n te r on M A C ■ N o n m o tile □ D is e a s e

ISBN 978-08 9189-6678

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3: Microbiology

Bacteriology>Gram negative rods | Anaerobes ■ T ra n s m itte d b y fle a s

■ M e s e n te ric a d e n itis m o s t c o m m o n

■ H o s ts a re ra ts, s q u irre ls , p ra irie d o g s , ra b b its , o th e r m a m m a ls

■ In fe c tio n m o re fre q u e n t in c h ild re n th a n a d u lts

■ V iru le n c e fa c to rs : fib rin o ly s in , c o a g u la s e (c lo ts b lo o d in u p p e r G l tra c t o f fle a s o o n its n e x t b lo o d m e a l in re g u rg ita te s th e p la g u e in fe c te d b lo o d b a c k in to h u m a n ), a n tip h a g o c y tic c a p s u le , e n d o to x in , fa c to rs V a n d W (a llo w it to g ro w in tra c e llu la rly in m a c ro p h a g e s ) ■ B u b o n ic p la g u e : ly m p h a d e n itis /b u b o e s , e s p e c ia lly in g ro in a re a —* c a n le a d to a b s c e s s e s in m a n y o rg a n s ■ D ia g n o s e v ia ly m p h n o d e a s p ira te ■ 2 -6 d a y in c u b a tio n

□ Z o o n o tic in fe c tio n o f ro d e n ts , ra b b its , d ee r, fa rm a n im a ls , b ird s □ C a u s e s n e c ro tiz in g g ra n u lo m a s re s e m b lin g T B ■ C o x ie lla b u rn e tii (see 3.5.10)

3.5.6 Anaerobes 3.5.6.1 Background ■ C h a ra c te ris tic s □ M a jo r c o m p o n e n t o f n o rm a l flo ra in s k in a nd m u c o u s m e m b ra n e s

■ S u d d e n o n s e t h e a d a c h e , m a la is e , fe v e r

■ S kin: P ro p io n ib a c te riu m , P e p to s tre p to c o c c u s

■ R e g io n a l ly m p h a d e n o p a th y

m O ra l: A c tin o m y c e s , P re v o te lla , P o rp h y ro m o n a s , F u s o b a c te riu m , P e p to s tre p to c o c c u s , V e illo n e lla , E u b a c te riu m

■ 8 0 % b e c o m e b a c te re m ic ■ 6 0 % m o rta lity if u n tre a te d ■ S e p tic e m ic p la g u e : fe v e r, h y p o te n s io n , s h o c k , + / b u b o e s (p e rip h e ra l g a n g re n e ; “ b la c k d e a th ” ) ■ S e v e re e n d o to x in e m ia —►s h o c k , D IC , A R D S ■ D ia g n o s e v ia b lo o d c u ltu re ; o rg a n is m s m a y be in te rm itte n t so ta k e 3 s p e c im e n 1 0 -3 0 m in a p a rt ■ 1 0 0 % m o rta lity if u n tre a te d ■ P n e u m a tic p la g u e : c h e s t p a in , c o u g h , h y p o te n s io n , shock, + /- buboes

■ F e m a le g e n ita l tra c t: L a c to b a c illu s , P re v o te lla , P o rp h y ro m o n a s m C o lo n : C lo s trid iu m , B a c te ro id e s , B ifid o b a c te riu m , F u s o b a c te riu m , L a c to b a c illu s , P re v o te lla , P o rp h y ro m o n a s □ R e q u ire s a tm o s p h e re w ith re d u c e d o x y g e n te n s io n □ M a n y in fe c tio n s a re p o ly m ic ro b ia l ■ M ed ia

■ V ia a e ro s o l o r s e p tic e m ic s p re a d to lu n g s

□ P R A S : p re re d u c e d , a n a e ro b ic a lly s te riliz e d

■ In c u b a tio n : 1-3 d a y s

□ B ro th s: th io g ly c o lla te b ro th (w ith v ita m in K ) o r c o o k e d / c h o p p e d m e a t b ro th

■ S u d d e n o n s e t h e a d a c h e , m a la is e , fe ve r, c o u g h ■ P n e u m o n ia p ro g re s s e s ra p id ly (2 4 -4 8 hrs) ■ D e a th fro m re s p ira to ry c o lla p s e a n d s e p s is ■ 1 0 0 % m o rta lity u n tre a te d ■ P e rs o n to p e rs o n s p re a d ■ A fe w c a s e s e a c h y e a r in th e U S , u s u a lly a s s o c ia te d w ith p ra irie d o g s □ T re a tm e n t ■ A n tib io tic s : g e n ta m ic in , s tre p to m y c in , d o x y c y c lin e , c ip ro flo x a c in ■ S u p p o rtiv e ■ Is o la tio n a n d d ro p le t p re c a u tio n s fo r p n e u m o n ic u n til s p u tu m c u ltu re s n e g a tiv e o r a fte r 3 d a y s o f th e ra p y ■ P ro p h y la x is : d o x y c y c lin e o r c ip ro flo x a c in ; c o n tin u e fo r 7 d a y s a fte r la s t e x p o s u re

□ N o n in h ib ito ry m ed ia: b lo o d a g a r s u p p le m e n te d w ith v ita m in K a n d h e m in ; B ru c e lla , C o lu m b ia , B H I w ith y e a s t e x tra c t; S c h a e d le r b ase □ In h ib ito ry m e d ia : P E A , lake d b lo o d w ith k a n a m y c in a n d v a n c o m y c in (L K V ), B a c te ro id e s b ile e s c u lin , B ru c e lla b lo o d a g a r (B B A ) ■ A n tib io tic s e n s itiv ity te s tin g : u s e p a tte rn s o f re s is ta n c e to k a n a m y c in , v a n c o m y c in , a nd c o lis tin to h e lp id e n tify o rg a n is m s ; B a c te ro id e s fra g ilis is re s is ta n t to all th re e ■ A e ro to le ra n c e te s tin g □ U se c h o c o la te agar, in c u b a te a t 37°C at 5% C 0 2, 4 8 -7 2 h o u rs □ N o n a n a e ro b e s ca n g ro w in a n a e ro b ic e n v iro n m e n ts ; if s o m e th in g g ro w s , d o a e ro to le ra n c e te s t to se e if it is a s tric t a n a e ro b e o r not □ G ro w th m e a n s th a t it is n ot a s tric t a n a e ro b e ■ T re a tm e n t: m e tro n id a z o le (fla g y l)

■ Y e rs in ia p s e u d o tu b e rc u lo s is □ H u m a n in fe c tio n is ra re ■ In fe c te d by d ire c t c o n ta c t w ith a n im a ls o r in g e s tio n o f c o n ta m in a te d fo o d

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3: Microbiology

Bacteriology> Anaerobes 3.5.6.2 Clostridium: Gram positive rod, spore forming

□ In te s tin a l (In fa n t) b o tu lis m ■ In g e s tio n o f th e s p o re —> g e rm in a tio n in G l tra c t — F lo p p y b ab y

□ S p o re s a re u b iq u ito u s in soil

■ R a re ly fa ta l

■ V iru le n c e

□ W o u n d in fe c tio n s : s im ila r to C p e rfrin g e n s b u t ra re ; o rg a n is m re p lic a te s in w o u n d a n d th e n s e c re te s to x in

□ T o x ig e n ic ity m e d ia te d by a la rg e p la s m id □ S e c re te s an e xo to x in c a lle d te ta n o s p a s m in th a t a c ts a t s y n a p to s o m e s , o b lite ra te s th e in h ib ito ry re fle x re s p o n s e o f th e n e rv e fib e rs by b lo c k in g re le a s e o f g ly c in e a nd G A B A —> u n c o n tro lle d s p a s m s ■ M ain s ite s o f a c tio n a re b ra in s te m a n d a n te rio r h o rn s o f s p in a l co rd ■ A ls o im p a irs re le a s e o f a c e ty lc h o lin e ■ D is e a s e : in fe c tio n fo llo w s m in o r tra u m a ; d e a th fro m e x h a u s tio n a nd re s p ira to ry fa ilu re ■ D ia g n o s is : c lin ic a l; no g o o d lab te s t

■ L ab s: d e m o n s tra te th e p re s e n c e o f to x in in th e fo o d , s to o l, b lo o d , o r v o m it by in je c tin g it in to m ic e (n o t ro u tin e ly p e rfo rm e d ) ■ T re a tm e n t: a n tito x in g ive n to e v e ry o n e w h o a te th e fo o d , e ve n if th e y h a v e no s y m p to m s □ In fa n tile b o tu lis m : d o not n e e d a n tito x in ; n e e d s u p p o rtiv e c a re ; d o n o t fe e d in fa n ts h o n e y

3 .5 .6 .2 .3 Clostridium perfringens m C h a ra c te ris tic s

■ T re a tm e n t: a n tito x in is o n ly e ffe c tiv e if th e to x in has n o t b o u n d in tis s u e s y e t (do n o t d ela y); o r p e n icillin , m e tro n id a z o le , d o x y c y c lin e , H T IG , b e n z o d ia z e p in e s ■ V a cc in e : te ta n u s to xo id is p a rt o f D T P o r D T aP v a c cin e ; b o o s te r g ive n e v e ry 10 y e a rs

3 .5 .6 .2 .2 Clostridium botulinum

□ S o il is n a tu ra l h a b ita t; can c o n ta m in a te h o m e c a n n e d g o o d s , s m o k e d fis h , h o n e y n F o u n d as n o rm a l flo ra o f c o lo n a n d fe m a le g e n ita l tra c t □ R e q u ire s g e rm in a tio n o f s p o re s a n d e m e rg e n c e o f v e g e ta tiv e c e lls fo r to xin p ro d u c tio n □ D o u b le z o n e o f h e m o ly s is on b lo o d a g a r

• C h a ra c te ris tic s □ C a n n o t in fe c t h e a lth y tis s u e b e c a u s e it re q u ire s a lo w re d o x p o te n tia l □ S p o re s a re u b iq u ito u s in soil ■ V iru le n c e : p o te n t e n d o to x in th a t a c ts a t m y o n e u ro n a l ju n c tio n , s u p p re s s e s a c e ty lc h o lin e re le a s e fro m a xo n te rm in a l o f p e rip h e ra l n e rv e —►fla c c id p a ra ly s is □ T yp e s o f to x in s : A , B, E, F

□ “ B o x c a r” (s h o rt a n d fa t) ro d s o n G ra m s ta in ; m a y b e in s h o rt c h a in s ■ V iru le n c e □ a to x in : le c ith in a s e d a m a g e s c e ll m e m b ra n e s ; id e n tifie d in v iv o w ith N a g le r re a c tio n □ M a n y o th e r to x in s id e n tifie d ■ D is e a s e s □ S o ft tis s u e (m u s c le ) w o u n d in fe c tio n

■ D is e a s e s

■ F o llo w s tra u m a

□ F o od p o is o n in g ■ In g e s tio n o f p re fo rm e d to x in s in fo o d ; c la s s ic a lly h o m e c a n n e d fru it, v e g e ta b le s , fis h ■ In N o rth A m e ric a , th e m o s t c o m m o n to x in is ty p e A ■ N a u s e a , v o m itin g , d iz z in e s s , c ra n ia l n e rv e palsy, d o u b le v isio n , s w a llo w in g a n d s p e e c h p ro b le m s , m u s c le w e a k n e s s , re s p ira to ry p a ra ly s is ; d e a th in 2 0% ■ S ig n s /s y m p to m s b e g in 8 -2 4 h o u rs a fte r in g e stio n

■ O rg a n is m m a k e s to x in s a n d e n z y m e s —►g as, e d e m a , im p a ire d c irc u la tio n —►v a s c u la r d e s tru c tio n a n d la c tic a c id a c c u m u la tio n lo w e rs th e re d o x p o te n tia l, m a k in g it an e n v iro n m e n t s u ita b le fo r th e o rg a n is m ■ C e llu litis : d e s tru c tio n o f tra u m a tiz e d tis s u e o n ly ■ M y o n e c ro s is : d e s tru c tio n o f tra u m a tiz e d tis s u e a n d s u rro u n d in g h e a lth y tis s u e ; ra p id ly p ro g re s s e s to s h o c k a n d re n a l fa ilu re; d e a th in 3 0 % □ F o o d p o is o n in g : p re fo rm e d e n te ro to x in in fo o d —> a b d o m in a l p ain , s e v e re c ra m p s , d ia rrh e a fo r 1 d a y

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Bacteriology> Anaerobes

i3.96 C difficile causing pseudomembranous colitis, demonstrating volcanolike fibrinopurulent exudate

i3.97 Actinomyces species a Gram stain morphology b Pap stain morphology

3 .5 .6 .2 .4 Clostridium difficile • N o rm a l in te s tin a l flo ra in 3 % o f a d u lts ■ A s y m p to m a tic c a rrie rs s p re a d d is e a s e in h o s p ita ls ■ V iru le n c e □ A n tib io tic s (e s p e c ia lly p e n ic illin s a n d c e p h a lo s p o rin s ) k ill o rg a n is m s th a t u s u a lly re s tric t g ro w th o f C d iffic ile in th e G l tra c t □ T o x in s ■ A : e n te ro to x in —> G l u p s e t, d ia rrh e a ■ B: c y to to x in —> k ills m u c o s a l c e lls ; c a u s e s p s e u d o m e m b ra n e fo rm a tio n □ B I/N A P 1 /0 2 7 s tra in m o re a g g re s s iv e ; h a s d e le tio n o f a re g u la to ry g e n e s u c h th a t it p ro d u c e s in c re a s e d a m o u n ts o f to x in s A a n d B ■ D ia g n o s is : m o s t c lin ic a l la b s u tiliz e e ith e r P C R o r an a lg o rith m w ith a G D H a n d to x in E IA a n d P C R

i3.98 Actinomyces israelii: slow growing, white colonies

□ P C R : to x in B g e n e (e n c o d e d b y tc d B , re g u la te d by tc d C g e n e s ); fa s t, e a s y , h ig h s e n s itiv ity a n d s p e c ific ity □ C o m b in e d e n z y m e im m u n o a s s a y fo r to x in B a n d g lu ta m a te d e h y d ro g e n a s e (G D H ) □ T o x in E IA h a s lo w s e n s itiv ity —> if G D H + b u t to x in n e g a tiv e , re fle x to P C R □ G o ld s ta n d a rd : c y to to x ic c u ltu re (n o t ro u tin e ly p e rfo rm e d ) □ R o u tin e s to o l c u ltu re d o e s n o t re c o v e r C d iffic ile b e c a u s e it is an a n a e ro b e □ If c u ltu re d in a n a e ro b ic c o n d itio n s , it h a s a h o rs e m a n u re o d o r □ G ra m s ta in : s u b te rm in a l a n d fre e s p o re s m a y b e s e e n ■ D is e a s e : p s e u d o m e m b ra n o u s c o litis , s e v e re g a s tro e n te ritis i3.96 □ S e v e re d is e a s e c a n b e c a u s e d b y N A P 1 s tra in ■ T re a tm e n t: o ra l v a n c o m y c in o r m e tro n id a z o le

178

3 .5 .6 .2 .5 Clostridium septicum • W h e n is o la te d fro m b lo o d c u ltu re , m a y in d ic a te a G l m a lig n a n c y ■ C an c a u s e ty p h ilitis (n e u tro p e n ic e n te ro c o litis ), m y o n e c ro s is , b a c te re m ia , g a s g a n g re n e ■ H igh m o rta lity ■ S w a rm in g c o lo n ie s on b lo o d a g a r

3 .5 .6 .2 .6 Clostridium sordellii m T oxic s h o c k like s y n d ro m e in w o m e n a fte r u se o f m ife p ris to n e (R U 8 4 6 )/m is o p ro s to l to g e th e r le a d in g to s lo u g h in g o f u te rin e lin in g and p re v e n tio n o f im p la n ta tio n ■ C h a ra c te ris tic c lin ic a l fe a tu re s : m a rk e d le u k o c y to s is , re fra c to ry h y p e rte n s io n , s e v e re ta c h y c a rd ia , la c k o f fever, c a p illa ry le a k

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

3: Microbiology

Bacteriology> Anaerobes | Spirochetes

i3.100 Fusobaderium necrophorum in placenta on a H&E stained sections & b Gram stained sections show long, slender gram negative rods

■ U s e th e s e d is k s on an a g a r p la te to d iffe re n tia te fro m o th e r B a c te ro id e s sp p

3.5.6.5 Fusobaderium i3.99 Baderoides fragilis colonies turn bile esculin media (right) from yellow to black due to its bile tolerance and ability to hydrolyze esculin

• N o rm a l o ra l flo ra ■ F u s o b a d e riu m n u c le a tu m □ C h a ra c te ris tic G ra m n e g a tiv e ro d s w ith ta p e re d e n d s □ A s s o c ia te d w ith p e rio d o n ta l d is e a s e

3.5.6.3 Actinomyces

■ F u s o b a d e riu m n e c ro p h o ru m

3.5.6.3.1 C h a ra c te ris tic s ■ G ra m sta in: fila m e n to u s ro d s th a t b ra n c h o r lo o k b e a d e d (id e n tic a l to N o c a rd ia ) i3.97 ■ U n like N o c a rd ia , A c tin o m y c e s is a n a e ro b ic ; m o d ifie d a cid fa s t n e g a tiv e ■ D o n ot fo rm s p o re s ■ “ M o la r to o th ” c o lo n ie s i3.98

□ G ra m n e g a tiv e rod w ith ro u n d e d e n d s □ D is e a s e s : s o re th ro a t, p e rito n s illa r a b s c e s s e s , p la c e n ta l in fe c tio n i3.100 □ L e m ie rre s y n d ro m e : a b s c e s s a llo w s fo rm a tio n o f th ro m b o p h le b itis in n e c k v e s s e ls

3.5.6.6 Propionibacterium acnes m G ra m p o s itiv e ro d s

3.5 .6 .3 .2 D iseases

■ C h a ra c te ris tic d is e a s e a s s o c ia tio n s

■ A c tin o m y c o s is : lu m p y ja w w ith s u lfu r g ra n u le s ; a b s c e s s e s in v a rio u s o rg a n s

□ V e n tric u la r s h u n t in fe c tio n s

□ S e e n in p a tie n ts o n b is p h o s p h o n a te th e ra p y

□ J o in t h a rd w a re in fe c tio n s

□ N o c a rd ia ca n c a u s e s im ila r d is e a s e

□ A c n e v u lg a ris

■ In fe c tio n s o f in tra u te rin e d e v ic e

■ C o m m o n c o n ta m in a n t o f b lo o d c u ltu re s

■ In tra -a b d o m in a l in fe c tio n re la te d to a p p e n d ic itis , d iv e rtic u litis , o r s u rg e ry

3.5.6.7 Lactobacillus 3.5.6.7.1

3.5.6.4 Bacteroides

■ S le n d e r, c h a in in g G ra m p o s itiv e ro d s

m G ra m n e g a tiv e b a cilli ■ N o rm a l flo ra o f G l a nd G U tra c ts ; c o m p o s e a s ig n ific a n t p o rtio n o f s to o l b a c te ria

■ a h e m o ly tic ■ C a ta la s e n e g a tiv e ■ N o rm a l flo ra o f o ro p h a ry n x , G l tra c t, v a g in a

■ B a c te ro id e s fra g ilis □ O fte n in v o lv e d in p e rito n e a l in fe c tio n s ; p e lv ic in fla m m a to ry d is e a s e

3.5.6.8 Prevotella

□ G ro w s in th e p re s e n c e o f b ile (b ile e s c u lin m e d ia o r b ile d is k ) i3.99 □ R e s is ta n t to v a n c o m y c in , k a n a m y c in , a n d c o lis tin © A S C P 2018

C h a ra c te ris tic s

m N o rm a l v a g in a l a nd o ra l flo ra ■ In fe c tio n s in c lu d e a s p ira tio n p n e u m o n ia , lu n g a b s c e s s , p u lm o n a ry e m p y e m a , a n d c h ro n ic o titis m e d ia a n d s in u s itis

ISBN 978-08 9 1 8 9 -6 6 7 8

179

3: Microbiology

Bacteriology>Spirochetes ■ C o lo n ie s a re b ro w n /b la c k

3.5.6.9

Porphyromonas gingivalis

m P e rio d o n ta l d is e a s e

3.5.7 Spirochetes 3.5.7.1 Treponema 3.5.7.1.1 S y p h ilis ■ C a u s e d by T re p o n e m a p a llid u m s u b s p e c ie s p a llid u m □ T h in s p iro c h e te ; 6 -2 0 p m in le n g th ; 10-1 3 c o ils ■ T ra n s m is s io n □ M a in ly v ia d ire c t c o n ta c t w ith a c tiv e le s io n s d u rin g s e x u a l c o n ta c t □ V e rtic a l tra n s m is s io n th ro u g h th e p la c e n ta ■ P a th o g e n e s is

i3.101 Treponema pallidum associated necrotizing funisitis

□ P e n e tra te s m u c o u s m e m b ra n e s o r a b ra d e d skin □ M u ltip lie s a t s ite o f in o c u la tio n □ E n te rs ly m p h a tic s a n d c irc u la to ry s y s te m a n d s p re a d s th ro u g h o u t th e b o d y

Stage

□ O b lite ra tiv e e n d a rte ritis ■ C o n c e n tric e n d o th e lia l a n d fib ro b la s tic p ro life ra tio n ■ M o n o n u c le a r c e ll in filtra te w ith m a n y p la s m a c e lls ■ S ta g e s o f d is e a s e t3.31 □ P rim a ry : c h a n c re ■ D e v e lo p s a fte r ~ 3 w e e k s o f in c u b a tio n ■ H e a ls b y its e lf a fte r 2 -8 w e e k s ■ U lc e ra te d w ith ra is e d , firm e d g e s a n d a s m o o th base ■ P a in le s s ■ N o e x u d a te □ S e c o n d a ry : w id e s p re a d h e m a to g e n o u s d is s e m in a tio n ■ A ris e s a s th e c h a n c re h e a ls ■ ~ 6 w e e k s a fte r th e in o c u la tio n ■ C o n d y lo m a la ta : p a le p la q u e s th a t fo rm fro m c o a le s c e n c e o f p a p u le s o n p a lm s , s o le s a n d e ls e w h e re (m u c o u s m e m b ra n e s in c lu d e d ) ■ G e n e ra liz e d ly m p h a d e n o p a th y , fe ve r, a rth ra lg ia , w e ig h t lo s s ■ C N S s y m p to m s a re e s p e c ia lly c o m m o n in H IV p a tie n ts

180

t3.31 Clinical stages of syphilis Definition_________Possible complications Pathology

incubation

period between none none exposure & symptoms is usually 3 weeks _____________ (range: 3-90 days)______________________________________ primary chancre, lasting 1-8 regional lymphadenopathy, obliterative weeks Jarisch-Herxheimer endarteritis & reaction plasmacytic infiltrate typify _______________________________________________________ all phases secondary dissemination skin rash, condyloma lata, aseptic meningitis, hepatitis, arthritis, Jarisch-Herxheimer reaction, immune complex _______________________________ glomerulonephritis____________________ early latent asymptomatic phase relapse _____________ 4 years______________________________________________ tertiary any of 3 neurosyphilis: complications: meningovascular, parenchymatous, tabes dorsalis, general paresis, otitis, optic neuritis cardiovascular: aortic insufficiency and/or coronary artery stenosis gummatous: bones and/ _______________________________ or skin_____________________________ congenital transplacentally chorioamnionitis i3.101, acquired syphilis hepatosplenomegaly, skin rash, rhinitis, periostitis, cytopenias, Clutton joints, saddle nose, sabre shins, _______________________________ Hutchinson teeth

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

3: Microbiology

Bacteriology>Spirochetes

_______________________ _____

□ L a te n t ■ E a rly la te n t: firs t y e a r ■ Late laten t: b e y o n d firs t y e a r; ca n be 1 0 -2 5 y e a rs long; re la p s e s a re u n c o m m o n □ T e rtia ry ■ O c c u rs in 1/3 o f u n tre a te d p a tie n ts ■ C a rd io v a s c u la r: a o rtic tru n k v a s c u litis m a y lead to a n e u ris m o f a s c e n d in g a o rta , a o rtic v a lv e in s u ffic ie n c y , n a rro w e d c o ro n a ry a rte ry o stia ■ G u m m a s : la rg e n e c ro tiz in g g ra n u lo m a s

■ F a lse p o s itiv e s o c c u r w ith EB V , L y m e d is e a s e , a u to im m u n e d is e a s e s , p re g n a n c y , c o n n e c tiv e tis s u e d is e a s e s □ T re p o n e m a l s e ro lo g ic te sts: F T A -A B S , M H A -T P (a lso c a lle d T P -P A ), o r s y p h ilis Ig G b y e n z y m e im m u n o a s s a y (E IA ) ■ C o n firm p o s itiv e s c re e n in g te s ts o r c o n firm d is e a s e in p a tie n ts w ith n e g a tiv e s c re e n in g te s ts ■ B e c o m e p o s itiv e d u rin g p rim a ry s y p h ilis a n d re m a in p o s itiv e fo r life ■ B e c o m e p o s itiv e b e fo re n o n tre p o n e m a l te s ts

■ S kin , b ra in , s k e le ta l s y s te m ■ CNS ■ M e n in g o v a s c u la r (5-10 y e a rs a fte r in fe ctio n ): s e iz u re s , s tro ke , a p h a s ia d u e to m u ltip le sm a ll in fa rc ts ■ P a re n c h y m a to u s (1 5 -3 0 y e a rs a fte r in fe ctio n ): d e g e n e ra tiv e p ro c e s s re s u ltin g in p a re s is , ta b e s d o rs a lis , p up il a b n o rm a litie s (A rg y ll R o b e rts o n p up il) ■ C o n g e n ita l s y p h ilis

■ F a lse p o s itiv e s c a u s e d by: c o n n e c tiv e tis s u e d is e a s e s , e ld e rly , re la te d o rg a n is m s (B o rre lia ) m F T A -A B S : in d ire c t flu o re s c e n t a n tib o d y te s t ■ A d d p a tie n t’s se ru m to a s lid e th a t h as b e e n fix e d w ith T p a llid u m ; th e n a d d F IT C (flu o re s c e n t d ye) ■ L o o k fo r v is ib le s p iro c h e te s w ith flu o re s c e n t m ic ro s c o p y (in d ic a te s p re s e n c e o f a n tib o d y in p a tie n t’s s e ru m ) ■ M H A -T P /T P -P A : m ic ro h e m a g g lu tin a tio n T p a llid u m ■ P re fe rre d by m a n y la b s d u e to s im p lic ity

□ A c q u is itio n d u rin g e a rly g e s ta tio n o fte n le a d s to s tillb irth

■ A d d p a tie n t’s s e ru m to s h e e p red b lo o d c e lls th a t h a ve bee n s e n s itiz e d w ith T p a llid u m

□ C h a ra c te riz e d by n e c ro tiz in g fu n is itis (o nly p re s e n t in s e v e re c a s e s ) i3.101 □ M ay be a s y m p to m a tic o r d iffu s e ra sh w ith skin s lo u g h in g , o s te o c h o n d ritis , p e rio s titis

m A g g lu tin a tio n is in d ic a tiv e o f a n tib o d ie s in th e p a tie n t’s s e ru m ■ IgG E IA ■ B e c o m in g m o re re a d ily a v a ila b le

□ L a te fo rm

■ M a n y in s titu tio n s a re u s in g a re v e rs e a lg o rith m (a p p ro v e d b y th e C D C ), w h ic h s ta rts w ith th is te s t a n d th e n re fle x e s to an R P R

■ H u tc h in s o n te e th ■ 8 th n e rv e d e a fn e s s ■ P e rio s titis , s a b e r sh in s , s a d d le d e fo rm ity o f n o se ■ S y p h ilis a nd H IV c o in fe c tio n : high in c id e n c e o f e ye in v o lv e m e n t 3 .5.7.1.2

D ia g n o s is

3.5.7.1.3 Treatm en t: p en icillin G ■ J a ris c h -H e rx h e im e r re a c tio n : re le a s e o f b a c te ria l p ro te in s a fte r tre a tm e n t p ro m o te s p ro d u c tio n o f e x tre m e ly h ig h le v e ls o f c y to k in e s , w h ic h le a d to a s e p s is lik e re a c tio n (h y p o te n s io n , fe ve r, c h ills )

■ D a rk fie ld m ic ro s c o p y : n o t o fte n used ■ Im m u n o h is to c h e m is try

3.5.7.1.4 N o n ven e re al d iseas es c a u s e d by Treponema

□ N o n tre p o n e m a l s e ro lo g ic te s ts : V D R L a nd R P R ■ N o t s p e c ific to T re p o n e m a ; u se d a s s c re e n in g te s ts ■ A n tib o d ie s d e te c te d by th e s e te s ts d e v e lo p 1-4 w e e k s a fte r a p p e a ra n c e o f p rim a ry c h a n c re ■ T ite rs d e c lin e to n e g a tiv e o v e r tim e , e ven in th e a b s e n c e o f th e ra p y , o fte n n e g a tiv e in te rtia ry

• Y aw s: T re p o n e m a p a llid u m s u b s p e c ie s p e rte n u e \ p re s e n t in A fric a , A s ia , S o u th A m e ric a ■ E n d e m ic s y p h ilis (B e je l): T re p o n e m a p a llid u m s u b s p e c ie s e n d e m ic u m ; p re s e n t in A fric a , A s ia , M id d le E a s t ■ P inta: T re p o n e m a c a ra te u m \ p re s e n t in S o u th A m e ric a

■ C a n u se tite rs to m o n ito r re s p o n s e to th e ra p y ■ F a ls e n e g a tiv e te s ts ca n o c c u r d u rin g s e c o n d a ry s y p h ilis , w h e n e x tre m e ly h ig h tite rs m a y c a u s e a p ro z o n e (h o o k ) a ffe c t

© A S C P 2018

3.5.7.2 Leptospira ■ B a c k g ro u n d /c h a ra c te ris tic s □ T ig h tly c o ile d w ith h o o ke d e n d s

ISBN 978-08 9189-6678

181

3: Microbiology

Bacteriology>Spirochetes | Chlamydia 3 .5 7 .3 .2

R e lap sin g fe ver

■ 2 ty p e s □ E p id e m ic re la p s in g fe v e r: B o rre lia re c u rre n tis , tra n s m itte d by th e lo u s e (P e d ic u lu s h u m a n u s ) □ E n d e m ic re la p s in g fe v e r: B o rre lia h e rm s ii, tra n s m itte d by s o ft tic k s ■ D is e a s e (th e 2 ty p e s a re s im ila r) i3.102 Intestinal spirochetosis: organisms seen as a fringe on surface of colonic epithelial cells a H&E stained section b Steiner stained section □ W id e s p re a d z o o n o s is ; c a rrie d b y m a n y ro d e n ts , e s p e c ia lly ra ts; In th e U S , th e h ig h e s t in c id e n c e is in H a w a ii □ H u m a n s a c q u ire v ia c o n ta c t w ith ro d e n t u rin e c o n ta m in a te d w a te r o r th ro u g h b ro k e n s k in o r m u c o u s m e m b ra n e s (c o n ju n c tiv a ) ■ D is e a s e □ P re s e n ts a s flu lik e illn e s s o r is a s y m p to m a tic □ B ip h a s ic d is e a s e w ith fe v e r/c h ills —> re s o lv e s —> c la s s ic tria d o f m e n in g itis , liv e r d a m a g e , re n a l d y s fu n c tio n (W e il d is e a s e ) ■ D ia g n o s is : ris in g a n tib o d y tite rs

□ 7 d a y in c u b a tio n ; a b ru p t o n s e t o f h ig h fe v e r w ith n o n s p e c ific s y m p to m s ; fe v e r s u b s id e s q u ic k ly a fte r 3 -6 d ays, th e n re tu rn s in 1 w e e k

3.5.7.4 Spirillum minus: tightly coiled, small spirochete with bipolar tufts of flagella ■ R at b ite fe v e r ■ B ite w o u n d in itia lly h e a ls, th e n 1-4 w e e k s later, an in d u ra te d le s io n s a p p e a rs a t th e s a m e site, a c c o m p a n ie d by n o n s p e c ific s y m p to m s , s o m e tim e s a m a c u la r ra sh w ith la rg e p la q u e s ■ T h is re s o lv e s in 3 -8 w e e k s ■ R e la p s e s a n d c o m p lic a tio n s (e n d o c a rd itis , m e n in g itis ) can o c c u r ■ A s ia » > U S

3.57.5 Intestinal spirochetes ■ C an c a u s e d ia rrh e a , a b d o m in a l p ain , re c ta l b le e d in g , d is c h a rg e

3.57.3 Borrelia 3.5.7.3.1 L ym e d is e a s e : Borrelia burgdorferi m B a c k g ro u n d /c h a ra c te ris tic s

□ L o o s e ly c o ile d ; c o rk s c re w m o tility □ T ra n s m itte d b y Ix o d e s s c a p u la ris (p re v io u s ly c a lle d Ix o d e s d a m m in i; a ls o c a lle d d e e r tic k ) a n d Ix o d e s p a c ific u s ■ C o in fe c tio n w ith B a b e s ia a n d A n a p la s m a is com m on □ R e s e rv o ir is th e w h ite fo o te d m o u s e □ F o u n d m a in ly in n o rth e a s te rn U S , a ls o in U p p e r M id w e s t a n d n o rth e rn C a lifo rn ia a n d O re g o n ■ D is e a s e □ E a rly s ta g e : 1 w e e k fo llo w in g tic k bite; P re s e n ts w ith c h a ra c te ris tic p a in le s s e ry th e m a m ig ra n s (“ ta rg e t” o r “ b u lls e y e ” )

■ S e en on b io p s y a s d a rk b lu e frin g e o n s u rfa c e o f c o lo n ic e p ith e lia l c e lls i3.102 ■ C a u s e d by B ra c h y s p ira a a lb o rg i

3.5.8 Chlamydia 3.5.8.1 Background: obligate intracellular pathogen 3.5.8.1.1 S tru ctu re ■ E le m e n ta ry b o d y: in fe c tio u s fo rm ; c a p a b le o f lim ite d e x tra c e llu la r s u rv iv a l ■ R e tic u la te b o d y : in tra c e llu la r, m e ta b o lic a lly a c tive , c a n n o t s u rv iv e o u ts id e a h o s t cell ■ M O M P : m a jo r o u te r m e m b ra n e p ro te in

3.5.8.1.2 R ep licatio n

□ S e c o n d s ta g e : d is s e m in a tio n to m a n y o rg a n s , c a n h a v e m o re s k in le s io n s , n e u ro lo g ic o r c a rd ia c s y m p to m s (m o s t c o m m o n ly fa c ia l n e rv e p a ls y o r a rte rio v e n tric u la r (A V ) b lo c k )

■ E le m e n ta ry b o d y a tta c h e s to a n d e n te rs h o s t ce ll, tra n s fo rm s into re tic u la te b o d y

□ L a te s ta g e : m o s t c o m m o n ly p re s e n ts w ith a rth ritis , u s u a lly ju s t 1 o r a fe w la rg e jo in ts (k n e e )

■ R e tic u la te b o d ie s th e n tra n s fo rm into e le m e n ta ry b o d ie s —►re le a s e d fro m h o s t cell

■ R e tic u la te b o d y re p lic a te s by b in a ry fis s io n u sin g h o s t cell A T P

■ D ia g n o s is : s e ro lo g y (n o t g re a t; m a n y fa ls e p o s itiv e s ) 182

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Bacteriology>Chlamydia 3.5.8.2

3.5.8.3 Chlamydophila psittaci

Chlamydia trachomatis

3.5.8.2.1 T rach o m a (S u b typ e s A, B, Ba, C) ■ C a u s e s b lin d n e s s , e s p e c ia lly in a re a s w ith in a d e q u a te s a n ita tio n a n d p e rs o n a l h y g ie n e ■ T ra n s m itte d a m o n g c h ild re n via fo m ite s a n d flie s

3 .5 .8 .2 .2 LG V (L y m p h o g ra n u lo m a v e n ereu m , S u b ty p es L1-L3)

■ B ird s a re re s e rv o ir, p re s e n t in b lo o d , tis s u e , e x c re ta a n d fe a th e rs ; c a n in fe c t a n d kill b ird s ■ In fe c tio n s a re u s u a lly in o w n e rs o f p e t b ird s , p e t s h o p e m p lo y e e s , v e ts a nd o th e r o c c u p a tio n s th a t h a n d le b ird s ■ E n te rs b o d y v ia re s p ira to ry tra c t, s p re a d s to m a c ro p h a g e s o f liv e r a n d s p le e n , w h e re th e o rg a n is m s re p lic a te , th e n g o to th e lu n g s a n d o th e r o rg a n s

■ T ra n s m itte d s e x u a lly

■ In c u b a tio n o f 1-2 w e e k s , th e n p e rs is te n t d ry, h a c k in g c o u g h and s e v e re h e a d a c h e

■ P a in le s s u lc e r o n e x te rn a l g e n ita lia h e a ls q u ic k ly ; s y s te m ic s y m p to m s 2 -6 w e e k s a fte r e x p o s u re (fever, a rth ra lg ia s , m y a lg ia s )

■ O th e r s ig n s /s y m p to m s in c lu d e ra sh (H o rd e r s p o ts: p in k, b la n c h in g , m a c u lo p a p u la r), a rth ra lg ia s , m y a lg ia s , m a la is e , a n o re x ia

■ L ym ph n o d e b io p s y s h o w s g ra n u lo m a s s u rro u n d in g s te lla te a b s c e s s e s

■ D ia g n o s is : s e ro lo g y is th e m a in s ta y o f d ia g n o s is ; c u ltu re p o te n tia lly h a z a rd o u s , w ill g ro w o n M c C o y c e lls

■ L ym p h n o d e s w ill b e c o m e m a tte d a n d p ro d u c e d ra in in g fis tu la s —> u re th ra l a n d re cta l s tric tu re s

3.5.8.4 Chlamydophila pneumoniae ■ M a n y a d u lts h a ve a n tib o d ie s to th is o rg a n is m

3 .5 .8 .2 .3 U re th ritis /c e rv ic itis (s u b typ es D -K )

■ R e s p o n s ib le fo r m a n y c a s e s o f c o m m u n ity a c q u ire d p n e u m o n ia

■ M o s t c o m m o n b a c te ria l S T D in th e U S ■ 2 5 % o f m e n a n d 7 0 % o f w o m e n a re a s y m p to m a tic ■ M u c o p u ru le n t c e rv ic itis , ca n s p re a d to u re th ra a nd b la d d e r o r e n d o m e triu m a n d fa llo p ia n tu b e s ■ C a n c a u s e p e lv ic in fla m m a to ry d is e a s e ■ T ra n s m itte d s e x u a lly □ C an be tra n s m itte d v e rtic a lly fro m m o th e r to in fa n t d u rin g p a s s a g e th ro u g h b irth c a n a l

■ D is e a s e b e g in s w ith p h a ry n g itis a n d h o a rs e n e s s , fo llo w e d by p e rs is te n t c o u g h ; p n e u m o n ia is u s u a lly m ild ■ D ia g n o s is : s e ro lo g y : 4 * rise in Ig G fro m a c u te a n d c o n v a le s c e n t s a m p le s ; c u ltu re on H e p 2 o r H L c e lls (n o t M c C o y ce lls); P C R is b e c o m in g m o re w id e ly a v a ila b le (n o w d e te c te d by a c o m m e rc ia lly a v a ila b le m u ltip le x re s p ira to ry p a th o g e n P C R p a n e l)

□ C a n lea d to in c lu s io n c o n ju n c tiv itis a n d p n e u m o n itis in th e in fa n t □ 2 5 % -5 0 % o f in fa n ts b o rn to in fe c te d m o th e rs d e v e lo p in c lu s io n c o n ju n c tiv itis ■ T re a tm e n t: d o x y c y c lin e , m a c ro lid e , flu o ro q u in o lo n e

3 .5 .8 .2 .4 D iag n o sis ■ C ell c u ltu re (shell via l w ith M c C o y c e lls ) is re fe re n c e m e th o d b u t n o t ro u tin e ly p e rfo rm e d ■ N u c le ic a c id a m p lific a tio n (c o m m o n ly u sed m e th o d ): P C R , s tra n d d is p la c e m e n t a s s a y (S D A ), o r tra n s c rip tio n m e d ia te d a m p lific a tio n (T M A ) □ C an be d o n e on u rin e in a d d itio n to c e rv ic a l o r v a g in a l s w a b s (fe m a le s) o r u re th ra l s w a b s (m ale s) ■ D ire c t flu o re s c e n t a n tib o d y (D F A ; o ld e r te st): v is u a liz e e le m e n ta ry b o d ie s in c lin ic a l s p e c im e n u sin g m o n o c lo n a l a n tib o d ie s a g a in s t M O M P ; ta k e s 3 0 -6 0 m in u te s ■ S e ro lo g y : n o t u se d fo r g e n ita l in fe c tio n s

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3: Microbiology

Bacteriology>Rickettsia | Coxiella burnetii (formerly a Rickettsia spp)

3.5.9 Rickettsia t3.32 t3.32 Rickettsial diseases D isease Rocky mountain spotted fever Epidemic typhus

O rganism Rickettsia rickettsii

V e ctor Dog tick

Rickettsia prowazekii

Louse

Scrub typhus Murine typhus

Orientia /previously Chigger Rickettsia) tsutsugamushi Rickettsia typhi Flea

Cat scratch disease

Bartonella henselae

Kitten

Bacillary angiomatosis

Bartonella henselae

Kitten

Boutonneuse fever

Rickettsia conorii

Tick

Rickettsialpox

Rickettsia akari

Mite

■ T ra n s m itte d by lice

Human monocytic ehrlichiosis Anaplasmosis

Ehrlichia chaffeensis

Lone star tick (Amblyomma americanum) Deer tick

■ O n ly in h u m a n s (no a n im a l re s e rv o ir); e s p e c ia lly in w a rs and p o v e rty s tric k e n a re a s

Oroya fever bartonellosis

Anaplasma /previously Ehrlichia) phagocytophilium Bartonella bacilliformis

Sandfly

Verruga peruana

Bartonella bacilliformis

Sandfly

Trench fever

Bartonella quintana

Louse

Brill-Zinsser disease

Rickettsia prowazekii

None (recrudescence of epidemic tvphus)

i3.103 Cat scratch disease a H&E stained sections at low magnification showing necrotizing granuloma b At high magnification a suppurative center is seen

3.5.9.4 Rickettsia prowazekii: epidemic typhus

■ R a sh is m o s t p ro m in e n t on tru n k ; ca n c a u s e m e n in g o e n c e p h a litis ■ A g e n t o f b io te rro ris m

3.5.9.5 Rickettsia typhi: endemic typhus (murine typhus) ■ T ra n s m itte d b y fle a s in tro p ic a l a re a s ■ R ash is m o s t p ro m in e n t o n tru n k ; ca n c a u s e m e n in g o e n c e p h a litis

3.5.9.1 Background ■ A tta c h to h o s t c e ll, e n te r v ia p h a g o c y to s is , e s c a p e fro m th e p h a g o s o m e , re s id e in c y to p la s m o f h o s t ce ll ■ R e p ro d u c e b y b in a ry fis s io n ■ C a n liv e e x tra c e llu la rly (u n lik e C h la m y d ia )

3.5.9.2 Rickettsia rickettsii: Rocky Mountain spotted fever ■ T ra n s m itte d b y D e rm a c e n to r (A m e ric a n d o g tic k ); m a in ly fo u n d in th e e a s te rn 2 /3 o f th e U S ■ O rg a n is m s d a m a g e v a s c u la r e n d o th e lia l c e lls ■ F e ver, h e a d a c h e , m y a lg ia —» v o m itin g , d ia rrh e a in firs t 3 d a y s o f illn e s s —►ra sh o n w ris ts a n d a n k le s s p re a d s to a rm s , le g s a n d tru n k ; R a s h on p a lm s a n d s o le s a p p e a rs la te r ■ C a n le a d to re n a l fa ilu re , D IC , a n d C N S in v o lv e m e n t in s e v e re c a s e s ■ R a p id ly fa ta l in p a tie n ts w ith G 6 P D d e fic ie n c y ■ D ia g n o s is h is to ric a lly d o n e w ith W e il-F e lix re a c tio n : a n tiric k e tts ia l a n tib o d y a g g lu tin a te s P ro te u s ■ A g e n t o f b io te rro ris m

3.5.9.6 Orientia (formerly Rickettsia) tsutsugamushi; scrub typhus ■ S p re a d to h u m a n s via c h ig g e rs , w h o a c q u ire it fro m in fe c te d rats ■ B ite o f c h ig g e r le a v e s an e s c h a r

3.5.10

C o x ie lla b u r n e tii R i c k e t t s i a spp)

(formerly a

■ Live s and re p lic a te s in p h a g o ly s o s o m e o f m a c ro p h a g e s (o b lig a te in tra c e llu la r) ■ Q fe v e r □ O c c u p a tio n a l e x p o s u re fro m m a n y a n im a ls (vets, fa rm e rs ) □ A c u te illn e s s ■ N o n s p e c ific flu lik e illn e s s , s o m e tim e s w ith p n e u m o n ia , h e p a titis , th ro m b o c y to p e n ia ■ M a n y p e o p le a re a s y m p to m a tic ■ F ib rin rin g g ra n u lo m a s ca n be s e e n in liv e r and b o n e m a rro w

3.5.9.3 Rickettsia akari\ rickettsialpox ■ T ra n s m itte d b y m ite s in d e n s e ly p o p u la te d c itie s in th e U S ; ra re 184

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3: Microbiology

Bacteriology>Coxiella burnetii \ Ehrlichia & anaplasm a | Bartonella: pleomorphic, Gram negative bacilli | Mycoplasma □ C h ro n ic illn e s s : u s u a lly e n d o c a rd itis ; v e g e ta tio n s a nd fib rin rin g g ra n u lo m a s a re n o t se e n m M a y se e fo a m y h is tio c y te s th a t c o n ta in th e

3.5.12.2 Bartonella quintana m T re n c h fe v e r

□ T ra n s m itte d v ia th e lo u se (P e d ic u lu s h u m a n u s )

o rg a n is m s

□ P ro b le m d u rin g W o rld W a r I; re c e n tly re p o rte d in h o m e le s s a lc o h o lic s

a N o ra sh , u n like o th e r R ic k e tts ia m D ia g n o s is : s e ro lo g y , d e m o n s tra tio n o f fib rin rin g

□ Fever, m y a lg ia s , m a c u la r ra sh ; re la p s e s o c c u r in 4 -5 d a y c y c le s

g ra n u lo m a s in tis s u e ■ T re a tm e n t: d o x y c ly c lin e , m a c ro lid e

3.5.13 3 .5 .1 1 E h r lic h ia & A n a p la s m a

M y c o p la s m a

a B a c k g ro u n d

■ S m a ll, G ra m n e g a tiv e c o c c o b a c illi th a t re s id e in a c y to p la s m ic v a c u o le o f w h ite b lo o d c e lls ■ T h e v a c u o le ca n be s e e n on W rig h t-G ie m s a s ta in e d p e rip h e ra l s m e a rs a nd is c a lle d a m o ru la ■ F e b rile illn e s s e s w ith th ro m b o c y to p e n ia , le u k o p e n ia , e le v a te d tra n s a m in a s e s ■ E h rlic h ia c h a ffe e n s is : h u m a n m o n o c y to tro p ic e h rlic h io s is □ T ra n s m itte d by tic k s , e s p e c ia lly A m b ly o m m a a m e ric a n u m (L o n e S ta r tick), a ls o D e rm a c e n to r a nd Ix o d e s ■ 1 tic k ca n c a rry E h rlic h ia p lu s B o rre lia , R ic k e tts ia ric k e tts ii, a n d /o r B a b e s ia \ □ D e e r a re re s e rv o ir ■ A n a p la s m a p h a g o c y to p h ilu m : h u m a n g ra n u lo c y to tro p ic a n a p la s m o s is

3.5.12 B a r t o n e l l a : pleomorphic, Gram negative bacilli

□ S m a lle s t fre e liv in g o rg a n is m s □ R e p lic a te by b in a ry fis s io n □ U n iq u e fe a tu re s : no ce ll w a ll, c e ll m e m b ra n e c o n ta in s s te ro ls □ R e q u ire c o m p le x m e d ia to g ro w ; g ro w s lo w ly a n d p ro d u c e c h a ra c te ris tic “frie d e g g ” c o lo n ie s ; c u ltu re is n o t ro u tin e ly u se d fo r d ia g n o s is □ S e ro lo g y (E IA is b est): m o re u s e fu l fo r d ia g n o s is □ D o n o t live in tra c e llu la rly ■ M y c o p la s m a p n e u m o n ia e □ T ra c h e o b ro n c h itis m a y p ro g re s s to p n e u m o n ia , e s p e c ia lly in p a tie n ts 5-15 y e a rs o ld □ E x tra p u lm o n a ry c o m p lic a tio n s ■ A s s o c ia te d w ith h e m o ly tic a n e m ia w ith c o ld a g g lu tin in s (Ig M a g a in s t th e I a n tig e n ) ■ S k in ra sh , p e ric a rd itis /m y o c a rd itis , a rth ritis , m e n in g o e n c e p h a litis , p e rip h e ra l n e u ro p a th y , d ia rrh e a

3.5.12.1 Bartonella henselae • C a t s c ra tc h d is e a s e □ P a p u le a t s ite o f s c ra tc h , re g io n a l ly m p h a d e n o p a th y

□ P C R is b e c o m in g m o re w id e ly a v a ila b le (n o w d e te c te d b y a c o m m e rc ia lly a v a ila b le m u ltip le x re s p ira to ry p a th o g e n P C R p a n e l)

□ Im m u n o c o m p ro m is e d p a tie n ts ca n h ave d is s e m in a te d d is e a s e

■ M y c o p la s m a h o m in is : u re th ritis , p o s tp a rtu m fe v e r, p e lv ic in fla m m a to ry d is e a s e

□ B io p s y s h o w s s te lla te m ic ro a b s c e s s e s w ith p a lis a d in g e p ith e lio id h is tio c y te s i3.103; c lu m p s o f b a c illi ca n be se e n w ith in th e a b s c e s s w ith a W a rth in -S ta rry sta in

■ U re a p la s m a u re a ly tic u m : u re th ritis , p o s tp a rtu m fe v e r; u re a s e p o s itiv e

■ B a c illa ry a n g io m a to s is □ C u ta n e o u s a n g io p ro life ra tiv e le s io n s ; s e q u e la e o f a c a t s c ra tc h u s u a lly se e n in H IV p a tie n ts □ C a n a ls o b e c a u s e d by B a rto n e lla q u in ta n a □ W h e n s e e n in v is c e ra (liv e r a nd sp le e n ), it is c a lle d p e lio s is

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3: Microbiology

Mycobacteria>Background | Laboratory evaluation

i3.104 Mycobacteria a AFB stained tissue section b AFB stained BAL specimen

3.6

Mycobacteria

3.6.1 Background ■ A e ro b ic

i3.105 Mycobacteria: auramine-rhodamine fluorochrome stain

■ N o n m o tile ■ C e ll w a ll is ric h in m y c o lic a c id s ■ N o o u te r m e m b ra n e ; c o n s id e re d G ra m p o s itiv e , b u t do n o t ta k e u p G ra m s ta in w e ll

3.6.2 Laboratory evaluation

■ U se in c re a s e d c o n c e n tra tio n o f p h e n o l in p rim a ry s ta in in s te a d o f h e a t ■ F lu o ro c h ro m e s ta in : m o re s e n s itiv e th a n A F B s ta in s

3.6.2.1 Specimen collection and processing

□ 2 ty p e s : a u r a m in e -0 a n d a u ra m in e -rh o d a m in e

3.6.2.1.1 S p u tu m

□ B in d to m y c o lic a c id s

■ C o lle c t 3 s p u tu m s a m p le s , 8 -2 4 h o u rs a p a rt, 1 o f w h ic h is e a rly m o rn in g □ C h ild re n : c o lle c t g a s tric a s p ira te in s te a d ■ N a O H u s e d fo r d e c o n ta m in a tio n (re d u c e s b a c te ria in s p u tu m a n d o th e r n o n s te rile s a m p le s ); m y c o b a c te ria a re re s is ta n t b e c a u s e o f h ig h lip id c o n te n t o f c e ll w a ll

□ R e s is t d e c o lo riz a tio n b y a c id -a lc o h o l □ R e q u ire s flu o re s c e n t m ic ro s c o p e □ A F B a p p e a rs a s g o ld e n flu o re s c e n t ro d s i3.105 □ D e te c t a s fe w a t 104 A F B /m L □ S can at 40x

■ N A L C (N -a c e ty l-L -c y s te in e ): m u c o ly tic a g e n t ■ C e n trifu g e a t > 3 0 0 0 x g fo r m a x im u m re c o v e ry o f A F B

3.6.2.2

Direct examination

■ G ra m s ta in : A F B a p p e a r a s g h o s t c e lls o r b e a d e d G ra m p o s itiv e ro d s ■ A c id fa s t s ta in s (Z ie h l-N e e ls e n o r K in y o u n ) i3.104 □ U s e c a rb o l fu c h s in a s p rim a ry s ta in □ F u s c h in d y e b in d s to m y c o lic a c id in a m a n n e r th a t re s is ts d e c o lo riz a tio n b y a c id -a lc o h o l

3.6.2.3 Nucleic acid amplification techniques ■ T h e C D C re c o m m e n d s th a t n u c le ic a c id a m p lific a tio n te s tin g b e p e rfo rm e d on a t le a s t 1 re s p ira to ry s p e c im e n on all p a tie n ts w h o h ave s ig n s a n d s y m p to m s o f p u lm o n a ry T B (P u b lis h e d in 2 0 0 9 ) ■ D o n e d ire c tly on a s a m p le (s p u tu m , p le u ra l flu id ) a fte r p ro c e s s in g ■ O n ly u sed fo r M y c o b a c te riu m tu b e rc u lo s is

□ S c a n o n 1 0 0 * oil

3.6.2.4 Culture: gold standard; all specimen are put on solid media and inoculated into a broth

□ O p tio n s

3 .6 .2 .4 .1

■ Z ie h l-N e e ls e n s ta in : re q u ire s h e a tin g ■ D e c o lo riz e d w ith a c id -a lc o h o l a n d c o u n te rs ta in e d w ith m e th y le n e b lu e ■ K in y o u n s ta in : c o ld

S o lid m e d ia

■ Egg b a se d : L o w e n s te in -J e n s e n (can u se n o n s e le c tiv e o r add a n tib io tic s to m a ke it s e le c tiv e : G ru ft or M y c o b a c to s e ) ■ S y n th e tic : M id d le b ro o k 7 H 10 a nd 7H11 p la te s ■ H e m e c o n ta in in g m e d iu m fo r M h a e m o p h ilu m

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Mycobacteria>Laboratory evaluation □ U se in c u ltu re s e tu p fo r s k in le s io n s , jo in t flu id , a nd bones □ C h o c o la te agar, M id d le b ro o k a g a r w ith h e m o ly z e d R B C s, h e m in o r fa c to r d is k ■ T e m p e ra tu re □ M o s t m y c o b a c te ria g ro w a t 37°C □ M h a e m o p h ilu m , M m a rin u m , M u lc e ra n s , M m a lm o e n s e p re fe r 3 0 ° -3 2 ° C (set up a p la te fo r th is te m p e ra tu re w h e n c u ltu rin g skin ) □ M x e n o p i g ro w s b e s t a t 42°C 3 .6 .2 .4 .2

B r o th

■ O rg a n is m s g ro w in b ro th q u ic k e r c o m p a re d w ith so lid m e d ia ■ A u to m a te d , c o n tin u o u s ly m o n ito rin g s y s te m s a re a v a ila b le (eg, M y c o b a c te ria G ro w th In d ic a to r T u be [M G IT ] a nd B a c te c 9 0 0 0 M B d e te c t 0 2 c o n s u m p tio n )

i3.106 Mycobacterium tuberculosis (MTB): cording

□ In o c u la te tu b e a n d p u t it in an in s tru m e n t fo r 42 d a y s (6 w e e k s ) □ F lu o re s c e n t o x y g e n s e n s itiv e c o m p o u n d e m b e d d e d in s ilic o n e on b o tto m o f tu b e □ In itially, la rg e a m o u n t o f o x y g e n in b ro th q u e n c h e s flu o re s c e n c e □ M ic ro o rg a n is m s c o n s u m e o x y g e n a n d a llo w flu o re s c e n c e to be o b s e rv e d

3.6.2.5

Identification from positive culture

■ A p p e a ra n c e on a c id -fa s t sta in □ e g, M tu b e rc u lo s is c o rd in g i3.106 ■ P ig m e n ta tio n : R u n yo n g ro u p s (s e e b e lo w ) ■ G ro w th rate: ra p id g ro w e rs w ill g ro w o n s o lid m e d ia w ith in 7 d a y s

□ P o sitiv e tu b e s s ta in e d fo r A F B ■ S e p ti-C h e k : m a n u a l d e te c tio n in 7 H 9 b ro th a nd p a d d le w ith 3 ty p e s o f s o lid m e d ia ■ B a c te c 4 6 0 T B S y te m : s e m ia u to m a te d , d e te c ts C 0 2 p ro d u c tio n □ U se s 14C p a lm itic a c id a s c a rb o n s o u rc e □ If o rg a n is m s a re p re s e n t, th e y w ill u se th is c a rb o n s o u rc e a n d p ro d u c e 14C 0 2 □ P ro d u c tio n is p ro p o rtio n a l to g ro w th rate o f o rg a n is m

■ P rob e : c h e m ilu m in e s c e n t p ro b e fo r th e 1 6S rR N A □ R o u tin e ly a n d fa irly q u ic k ly p e rfo rm e d fo r: M tu b e rc u lo s is c o m p le x , M a v iu m c o m p le x , M k a n s a s ii, M g o rd o n a e □ N o t an a m p lific a tio n te c h n iq u e ■ N ia c in a n d n itra te te s ts □ M tu b e rc u lo s is is n ia c in /n itra te p o s itiv e □ M b o v is a nd M a fric a n u m (a lso in M T B c o m p le x ) a re n e g a tiv e ■ A ll m e m b e rs o f th e M T B c o m p le x p ro d u c e a c a ta la s e th a t is la b ile a t 68°C ; o th e r M y c o b a c te ria p ro d u c e c a ta la s e th a t is h e a t s ta b le ■ H ig h p e rfo rm a n c e liq u id c h ro m a to g ra p h y (H P L C ): id e n tifie s o rg a n is m s b a s e d on ty p e s o f m y c o lic a c id s ■ D N A s e q u e n c in g □ T a rg e ts: 16S rR N A g e n e , H s p 6 5 , rp o B

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Mycobacteria>M ycobacterium tuberculosis complex

3.6.3

M y c o b a c t e r iu m t u b e r c u lo s is

complex t3.33

3.6.3.1

MTB com plex includes M tuberculosis, M bovis,

M africanum et al

■ M y c o b a c te riu m b o v is : a c c o u n ts fo r m o s t e x tra p u lm o n a ry T B in fe c tio n s □ A c q u ire d fro m d rin k in g m ilk (c a n a ls o b e a c q u ire d v ia a e ro s o l d ro p le ts ) —> d is e a s e in th e G l tra c t □ M b o v is is a lw a y s re s is ta n t to p y ra z in a m id e (can a id e in d is tin g u is h in g M b o v is fro m M tu b e rc u lo s is )

t3.33 Im portant m ycobacterial species Site

Most common Mycobacterium species

Lung Lymph node Skin & soft tissue

MAC, M tu b e rcu lo sis, M kansasii, M xenopi, M absce ssu s MAC, M tu b e rcu lo sis, M scro fu la ce u m , M h a em ophilum

Gl

M tu b erculosis,

M fortuitum , M ch e lo n a e , M abscessus, M m a rin u m , M ulcerans, M h a e m o p h ilu m

MAC

i3.107 M ycobacterium tuberculosis (MTB): necrotizing granuloma

3.6.3.2 Pathogenesis ■ T ra n s m itte d v ia in h a la tio n o f d rie d re s p ira to ry d ro p le ts ■ M o s t im p o rta n t ro u te is fro m a n o th e r p e rs o n w ith u n d ia g n o s e d s m e a r p o s itiv e c a v ita ry T B ■ M o s t p e o p le w h o b e c o m e in fe c te d d o n o t d e v e lo p a c tiv e d is e a s e (m o re lik e ly in H IV p a tie n ts )

□ S y m p to m s h ave im p ro ve d

■ P rim a ry in fe c tio n □ O rg a n is m s a re in h a le d a n d in g e s te d b y a lv e o la r m a c ro p h a g e s , w h ic h c a n n o t kill th e o rg a n is m □ G h o n le s io n : p rim a ry fo c u s o f p u lm o n a ry in fe c tio n ■ C o m p o s e d o f c a s e a tin g g ra n u lo m a s (tu b e rc le s ), o fte n in th e u p p e r lo b e i3.107 ■ H IV p a tie n ts d o n o t fo rm g ra n u lo m a s w e ll, a n d m a y h a v e e x te n s iv e n e c ro s is ■ O rg a n is m s m a y be s e e n w ith A F B s ta in □ T h e o rg a n is m s re p lic a te w ith in m a c ro p h a g e s a nd a re tra n s p o rte d to re g io n a l ly m p h n o d e s —> h ila r ly m p h a d e n o p a th y (h ila r ly m p h a d e n o p a th y + p rim a ry fo c u s = G h o n c o m p le x ) □ T h e m a c ro p h a g e s a ls o e n te r ly m p h a tic s a n d b lo o d a n d tra v e l b a c k to th e lu n g s (a p ic e s ) a n d to d is ta n t o rg a n s s u c h a s k id n e y s , lo n g b o n e s , v e rte b ra , m e n in g e s □ M ilia ry tu b e rc u lo s is : s m a ll, d is tin c t le s io n s ; n ot c o m m o n ly s e e n in im m u n o c o m p e te n t p e o p le

188

□ 3 c o n s e c u tiv e n e g a tiv e s p u tu m s m e a rs fro m sp u tu m c o lle c te d in 8 -2 4 h o u r in te rv a ls (at le a s t 1 e a rly m o rn in g s p e c im e n )

3.6.3.4 Diagnosis (see 3.6.2 Laboratory evaluation) ■ C o lo n ie s : “ ru ff a nd b u ff” i3.108

■ O v e r tim e , th e s e c a n c a lc ify

■ R e a c tiv a tio n d is e a s e

■ A p e rso n is no lo n g e r in fe c tio u s (and th e re fo re no lo n g e r n e e d s re s p ira to ry is o la tio n ) w h e n th e y m e e t all o f th e s e re q u ire m e n ts , a c c o rd in g to th e C D C □ R e c e iv e d a d e q u a te tre a tm e n t fo r 2 w e e k s o r lo n g e r

3.6.3.3 Stages of disease

■ L a te n t in fe c tio n

□ O c c u rs in H IV in fe c tio n , p e o p le ta k in g T N F a in h ib ito r th e ra p y, a g e re la te d d e c re a s e in ce ll m e d ia te d im m u n ity, e tc

■ A F B sta in fro m b roth : c o rd in g i3.106 ■ H is to p a th o lo g y □ G ro s s : c a s e a tin g g ra n u lo m a s □ H & E : n e c ro tiz in g g ra n u lo m a s □ A F B sta in n e e d e d to s e e o rg a n is m s : w ill be lo c a te d in s id e g ra n u lo m a s ; s o m e tim e s in s id e m a c ro p h a g e s ■ A d e n o s in e d e a m in a s e in p le u ra l flu id (if p le u ra l e ffu s io n is p re s e n t) ■ D e te c tio n o f p re v io u s e x p o s u re □ T u b e rc u lin s k in te s t (T S T )/P P D ■ In tra d e rm a l in je c tio n o f m y c o b a c te ria l a n tig e n s , w h ic h s tim u la te a d e la y e d ty p e h y p e rs e n s itiv ity re a c tio n m e d ia te d by T ly m p h o c y te s ■ C a u s e s in d u ra tio n w ith in 4 8 to 72 h o u rs

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Mycobacteria>Mycobacterium tuberculosis complex | Nontuberculous Mycobacteria: categorized based on Runyon classification ■ R e s is ta n c e re s u lts fro m s p o n ta n e o u s m u ta tio n s —» s e le c tio n fo r re s is ta n t o rg a n is m s ■ A g a r p ro p o rtio n m e th o d : re fe re n c e m e th o d fo r te s tin g m a jo rity o f d ru g s e x c e p t p y ra z in a m id e □ C o m p a re g ro w th in d ru g c o n ta in in g m e d ia to g ro w th in d ru g fre e m e d ia ■ IN H (0.1 p g /m L ) ■ R ifa m p in (2.0 p g/m L ) ■ E th a m b u to l (2 .5 p g /m L ) ■ P y ra z in a m id e (100 p g /m L ) □ 1% ru le : if >1% o f b a cilli a re re s is ta n t in v itro , th e d ru g is n o t c lin ic a lly u s e fu l ■ D ru g s □ P rim a ry : is o n ia z id , rifa m p in , e th a m b u to l, p y ra z in a m id e (s tre p to m y c in w a s o n c e in th is c a te g o ry b u t is no lo n g e r u se d d u e to high ra te s o f re s is ta n c e )

i3.108 Mycobacterium tuberculosis (MTB): colony morphology

□ S e c o n d a ry : flu o ro q u in o lo n e s (c ip ro flo x a c in , le v o flo x a c in , m o x iflo x a c in ), a m in o g ly c o s id e s (a m ik a c in , k a n a m y c in ), p o ly p e p tid e s (c a p re o m y c in , v io m y c in , e n v io m y c in ); th io a m id e s (e th io n a m id e , p ro th io n a m id e )

■ R e a s o n s fo r fa ls e p o s itiv e re a c tio n ■ B C G im m u n iz a tio n ■ N o n -T B m y c o b a c te ria l in fe c tio n

■ D e fin itio n s

■ R e a s o n s fo r fa ls e n e g a tiv e re a c tio n ■ T e c h n iq u e (n ot p la c e d o r re ad p ro p e rly ) ■ V e ry re c e n t in fe c tio n : d e la y e d ty p e h y p e rs e n s itiv ity h as n o t d e v e lo p e d y e t ■ In fa n t < 6 m o n th s old ■ Im m u n o c o m p ro m is e d (a n e rg y) ■ Lon g s ta n d in g la te n t T B : im m u n e re s p o n s e m ay w a n e (B o o s te r re sp o n s e : p la c e a 2 nd T S T 1-4 w e e k s later; th e 2 nd te s t w ill be p o s itiv e )

□ E x te n s iv e ly d ru g re s is ta n t tu b e rc u lo s is (X D R ): re s is ta n t to is o n ia z id and rifa m p in p lu s re s is ta n t to a n y m e m b e r o f th e q u in o lo n e fa m ily a n d a t le a s t 1 2 nd lin e T B d ru g : k a n a m y c in , c a p re o m y c in , a m ik a c in , c y c lo s e rin e , p a ra -a m in o s a lic y lic a c id ■ G e n e tic d e te c tio n o f re s is ta n c e □ R ifa m p in : rp o B

□ In te rfe ro n y re le a s e a s s a y s (IG R A ) ■ M e a s u re T c e ll re le a s e o f in te rfe ro n y fo llo w in g s tim u la tio n by a n tig e n s u n iq u e to M tu b e rc u lo s is (E S A T 6 a nd C F P 10 ) ■ N o t a ffe c te d by B C G v a c c in e ■ D o n e on a b lo o d s a m p le a nd d o n o t re q u ire a fo llo w up v is it ■ 2 a s s a y s a v a ila b le in th e US: Q u a n tiF E R O N -T B G o ld In-T ube (Q F T -G IT ) a n d T -S P O T ■ P ro c e d u re : 3 w e lls o r tu b e s

□ M u ltid ru g re s is ta n t tu b e rc u lo s is (M D R ): re s is ta n t to a t le a s t is o n ia z id a nd rifa m p in

■ M o n o re s is ta n c e to rifa m p in is ra re , b u t > 9 0 % o f is o la te s w ith rifa m p in re s is ta n c e a re a ls o re s is ta n t to is o n ia z id —> rp o B g e n e m u ta tio n s e rv e s a s a s u rro g a te m a rk e r fo r m u ltid ru g re s is ta n t T B □ P y ra z in a m id e : p n c A e n c o d e s a p y ra z in a m id a s e □ Is o n ia z id : k a tG and in h A

3.6.4 Nontuberculous M y c o b a c t e r ia : categorized based on Runyon classification

■ M ito g e n

3.6.4.1 Photochromogens (Runyon Group I): only pigmented if exposed to light

■ R e c o m b in a n t M T B a n tig e n

3.6.4.1.1 Mycobacterium kansasii

■ C o n tro l

■ D is e a s e s

3.6.3.5

Susceptibility testing

■ R e s is ta n c e is n o t p la s m id m e d ia te d ; it is n ot tra n s m is s ib le a m o n g o rg a n is m s

□ R e s e m b le s T B c lin ic a lly and ra d io g ra p h ic a lly □ P rio r p u lm o n a ry d is e a s e is a ris k fa c to r □ D is s e m in a te d d is e a s e in im m u n o c o m p ro m is e d □ L y m p h a d e n itis in c h ild re n

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Mycobacteria>Nontuberculous M ycobacteria : categorized based on Runyon classification □ C u ta n e o u s in fe c tio n o f s k in , u s u a lly on h a n d s fro m w o rk in g in a fis h ta n k □ S w im m in g p o o l a s s o c ia te d d is e a s e is le s s c o m m o n due to c h lo rin a tio n ■ C u ltu re a t 3 0 °C (in a d d itio n to 37°C ) b e c a u s e th e o rg a n is m p re fe rs lo w e r te m p e ra tu re s (T h u s , it u s u a lly is fo u n d on skin o f e x tre m itie s )

3.6.4.2 Scotochromogens (Runyon Group II): pigmented when grown in dark and in light 3.6.4.2.1 Mycobacterium gordonae m Tap w a te r b a c illu s : p re s e n t in ta p w a te r; w h e n fo u n d in p a tie n t s p e c im e n , it is n e a rly a lw a y s th o u g h t to be a c o n ta m in a n t ■ In te n s e o ra n g e p ig m e n t

3 .6 .4 .2 .2 Mycobacterium scrofulaceum m C e rv ic a l ly m p h a d e n itis in c h ild re n (b u t M a v iu m is th e m o s t c o m m o n e tio lo g y fo r th is )

3 .6 .4 .2 .3 Mycobacterium szulgai: skin in fe ctio n s (rare) ■ S c o to c h ro m o g e n if g ro w n a t 37°C ■ P h o to c h ro m o g e n if g ro w n a t 25°C

3.6.4.3

Nonchromogens (Runyon Group III): not pigmented

3.6.4.3.1 Mycobacterium avium co m p lex ■ In c lu d e s M a v iu m a n d M in tra c e llu la re m U b iq u ito u s in n a tu re , lo w v iru le n c e ■ D is e a s e s i3.109 Mycobacterium kansasii: colonies are nonpigmented when incubated in the dark, but produce bright yellow pigment after light exposure (photochromogenic)

□ Im m u n o c o m p e te n t ■ P u lm o n a ry d is e a s e (c a v ity fo rm a tio n ) in p a tie n ts w ith u n d e rly in g lu n g d is e a s e ■ C la s s ic s itu a tio n : c a v ita ry le s io n s in s m o k e rs w ith C O P D

□ M a n y o th e rs : c u ta n e o u s d is e a s e , m u s c u lo s k e le ta l d is e a s e , m e n in g itis ■ A F B s ta in : lo n g , th ic k , w ith c ro s s b a n d in g ■ C o lo n ie s : b rig h t y e llo w o n ly if e x p o s e d to lig h t i3.109 ■ T re a t w ith IN H , rifa m p in a n d e th a m b u to l ■ A n tib io tic s u s c e p tib ility te s tin g □ O n ly te s t fo r re s is ta n c e to rifa m p in □ O fte n is o n ia z id re s is ta n t

3 .6 .4 .1 .2

■ L a d y W in d e rm e re d is e a s e : e ld e rly w o m e n w ith w e a k c o u g h , no u n d e rly in g lun g d is e a s e (akin to c o lo n iz a tio n ) ■ M o s t c o m m o n c a u s e o f ly m p h a d e n itis (sc ro fu la ) in th e U S, m o s tly in c h ild re n ■ T e n o s y n o v itis ■ H y p e rs e n s itiv ity re a c tio n a fte r e x p o s u re to a h ot tu b c o n ta m in a te d w ith M A C (“ h o t tu b lu n g ” ) ■ Im m u n o c o m p ro m is e d

Mycobacterium marinum

• D is e a s e : fis h ta n k o r s w im m in g p o o l g ra n u lo m a (g ro w s in fre s h - o r s a ltw a te r)

190

■ N o d u la r o r b ro n c h ie c ta tic d is e a s e in n o n s m o k in g

□ P u lm o n a ry d is e a s e : d iffu s e in filtra te s (c a v ita ry d is e a s e is rare) □ D is s e m in a te d d is e a s e in H IV p a tie n ts

ASCP Quick Compendium of Clinical Pathology 4e

© ASCP2018

3: Microbiology

Mycobacteria>Nontuberculous Mycobacteria: categorized based on Runyon classification ■ D is e a s e s □ Im m u n o c o m p ro m is e d : s k in , b o n e , jo in t a n d p u lm o n a ry in fe c tio n s □ L y m p h a d e n itis in c h ild re n

3 .6 .4 .3 .3 Mycobacterium genavense m D is s e m in a te d d is e a s e in A ID S p a tie n ts ■ F a s tid io u s , s lo w g ro w in g m y c o b a c te riu m □ D o e s n o t g ro w on L-J o r u n s u p p le m e n te d 7H11 a g a r □ L im ite d g ro w th in broth

3 .6 .4 .3 .4 Mycobacterium xenopi ■ G ro w s in h o t w a te r: a s s o c ia te d w ith h o t w a te r h e a te rs in h o s p ita ls , h o t w a te r b aths, e tc ■ In fe c tio n s m o s t o fte n a re p u lm o n a ry , e s p e c ia lly in p a tie n ts w ith u n d e rly in g lu n g d is e a s e s u c h a s C O P D ■ W id e ra n g e o f d is e a s e fro m c o m m e n s a l (no s y m p to m s ) to d is s e m in a te d

3.6.4.4 Rapid growers (Runyon Group IV): growth on solid media in C a n be s e e n in c u ltu re s th a t w e re n ’t n e c e s s a rily s p e c ifie d as A F B cu ltu re ; ca n be c o n fu s in g in th e lab

3.6 .4 .4 .2 Mycobacterium cheionae ■ D is s e m in a te d c u ta n e o u s d is e a s e w ith m u ltip le , c h ro n ic , d ra in in g n o d u le s in im m u n o c o m p ro m is e d p a tie n ts

i3.110 a Mycobacterium avium complex: pigmented colony morphology b Mycobacterium avium complex: nonpigmented colony morphology

3.6.4.4 .3 Mycobacterium abscessus □ P u lm o n a ry in fe c tio n s : n o d u la r o r b ro n c h ie c ta tic d is e a s e s im ila r to M A C

□ F e b rile w a s tin g s y n d ro m e (C D 4 < 2 0 ) □ P ro p h y la x H IV p a tie n ts w ith a z ith ro m y c in w h e n C D 4 5 0 ■ C o lo n y m o rp h o lo g y : n o n c h ro m o g e n ic ; m u ltip le c o lo n y m o rp h o lo g ie s on 1 p la te □ S m o o th , o p a q u e , d o m e d c o lo n ie s a n d fla t, tra n s p a re n t c o lo n ie s , “d o n u ts ” i3.110

3.6 .4 .3 .2

□ T re a tm e n t fo r M c h e lo n a e /a b s c e s s u s g ro u p : c la rith ro m y c in (a lso a m ika cin , c e fo x itin , im ip e n e m , to b ra m y c in , lin e zo lid )

□ W o u n d in fe c tio n s ; a s s o c ia te d w ith fo o t b a th s in s p a s (p e d ic u re s) in im m u n o c o m p e te n t p a tie n ts

m N e e d to c u ltu re on m e d ia th a t c o n ta in s h e m in o r o th e r iron c o n ta in in g c o m p o u n d

© ASCP2018

□ D is s e m in a te d c u ta n e o u s d is e a s e

3 .6 .4 .4 .4 Mycobacterium fortuitum g ro u p

Mycobacterium haemophilum

■ In c u b a te c u ltu re a t 30°C

■ A ls o fo u n d in c y s tic fib ro s is p a tie n ts

■ C a n lea d to o s te o m y e litis a n d fu rth e r d is s e m in a tio n in H IV p a tie n ts □ S u rg ic a l s ite in fe c tio n s in c a rd io th o ra c ic s u rg e ry

ISBN 978-08 9189-6678

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Mycobactena>Mycobacterium leprae \ Mycobacteria ulcerans S e le c te d r e a d in g s > B o o k s

□ T a k e s u p iro n ; ru s ty b ro w n a p p e a ra n c e if fe rric a m m o n iu m c itra te is a d d e d ■ U s e d to d is tin g u is h M fo rtu itu m (b ro w n ) fro m M c h e lo n a e a n d M a b s c e s s u s □ T re a tm e n t: c la rith ro m y c in (a lso a m ik a c in , c e fo x itin , im ip e n e m , c ip ro flo x a c in , d o x y c y c lin e , s u lfo n a m id e s , lin e z o lid ) 3 .6 .5

M y c o b a c t e r iu m l e p r a e

■ C a u s e s le p ro s y , a ls o c a lle d H a n s e n d is e a s e ■ P a th o g e n e s is □ T ra n s m itte d fro m p e rs o n to p e rs o n fro m a e ro s o liz e d o rg a n is m s ; a ls o fro m e n v iro n m e n ta l s o u rc e s th ro u g h w ounds □ R e s e rv o ir is m a in ly o th e r h u m a n s , b u t c a n a c q u ire fro m a rm a d illo s □ M o s t p e o p le c a n re s is t in fe c tio n w ith M le p ra e v ia cell m e d ia te d im m u n ity □ P e o p le w ith a n M le p ra e s p e c ific d e fe c t in th e ce ll m e d ia te d im m u n e re s p o n s e m a y d e v e lo p w id e ly d is s e m in a te d d is e a s e (th e y m a y o r m a y n o t h a ve a g e n e ra liz e d im m u n o d e fic ie n c y ) □ B a c illi m u ltip ly w ith in m a c ro p h a g e s

i3.111 Mycobacterium leprae: Fite stained section

3 .6 .6

M y c o b a c t e r iu m u lc e r a n s

a B u ru li u lcer, a ls o c a lle d B a irn e s d a le u lc e r: c h ro n ic , in d o le n t, n e c ro tiz in g d is e a s e o f skin a nd s o ft tis s u e

■ 3 c a rd in a l s ig n s : s k in le s io n s , c u ta n e o u s a n e s th e s ia , e n la rg e d p e rip h e ra l n e rv e s

■ Im p o rta n t c a u s e o f m o rb id ity a n d m o rta lity in th e d e v e lo p in g w o rld ; m o s t c a s e s o c c u r in A fric a

■ L o s s o f e y e b ro w s a n d e y e la s h e s , c la w fin g e rs , a n d a c o lla p s e d n o s e a re c la s s ic s ig n s o f la te d is e a s e

■ E n v iro n m e n ta l p a th o g e n ; a s s o c ia te d w ith w a te r s o u rc e s

■ T y p e s o f d is e a s e : d e p e n d in g on th e h o s t’s im m u n e re s p o n s e , th e d is e a s e p re s e n ts a s a s p e c tru m □ L e p ro m a to u s le p ro s y : w id e s p re a d , no c e llu la r m e d ia te d im m u n e re s p o n s e ■ C u ta n e o u s le s io n s : fille d w ith o rg a n is m s , a re o fte n fo u n d in c o o le r p a rts o f th e b od y, a n d c a n lea d to s e n s o ry lo s s d u e to in v o lv e m e n t o f d e rm a l n e rv e s ■ M ic ro s c o p ic a lly : fo a m y h is tio c y te s c o n ta in in g m a n y A F B (w ith n e rv e in va sio n ), fe w o r no in fla m m a to ry c e lls □ B o rd e rlin e tu b e rc u lo id , m id b o rd e rlin e , b o rd e rlin e le p ro m a to u s : in th e m id d le o f th e s p e c tru m □ T u b e rc u lo id le p ro s y : lo c a liz e d ■ W e ll c irc u m s c rib e d m a c u le s o r p la q u e s w ith lo s s o f s e n s a tio n a n d e n la rg e d p e rip h e ra l n e rv e s ■ M ic ro s c o p ic a lly : n o n c a s e a tin g g ra n u lo m a s w ith fe w A F B p re s e n t □ T h e W H O re c la s s ifie d p a tie n ts in to p a u c ib a c illa ry ( 6 s k in le s io n s )

■ B e g in s a s a p a in le s s d e rm a l p a p u le o r s u b c u ta n e o u s n od u le ; b e c o m e s a s h a llo w , n o n h e a lin g , n e c ro tic u lc e r o v e r w e e k s to m o n th s ■ U s u a lly fo rm s a t th e s ite o f p re v io u s tra u m a on th e lo w e r e x tre m itie s ■ G ro w s o p tim a lly a t 3 0 ° -3 3 ° C

3.7 Selected readings 3.7.1 Books IS B N 9780443068393 M andell GL, B ennett JE, Dolin R, eds [2010] Principles and Practice o f Infectious Diseases, 7e. C hurchill Livingstone IS B N 9780781730143 Konem an EW [2005] Color Atlas and Textbook of Diagnostic Microbiology, 5e. Lippincott W illiam s & W ilkins IS B N 9780838516010 C onnor DH, C handler FW, S chw artz DA et al, ed [1997] Pathology o f Infectious Diseases. A ppleton & Lange IS B N 9781416056805 A n aissie EJ, M cG innis MR, P faller MA, ed [2009] Clinical Mycology, 2e. C hurchill Livingstone IS B N 9781555814632 V ersalovic J, C arroll KC, Funke G et al, eds [2011] M anual o f Clinical Microbiology, 10e. AS M Press

■ D ia g n o s is □ M le p ra e c a n n o t be c u ltu re d □ P C R a n d s k in b io p s ie s a re th e m a in s ta y o f d ia g n o s is □ S ta in b io p s y s e c tio n s w ith F ite s ta in i3.111 192

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S e le c te d re a d in g s > O n lin e re fe r e n c e s | A d d itio n a l jo u r n a l a r tic le s

3.7.2 Online references C enters fo r D isease C ontrol and P revention. Ebola (E bola virus disease). A vailable at h ttps://w w w .cdc.gov/vhf/ebola/pdf/ebolafa ctshe e t.p d f C enters fo r D isease C ontrol and Prevention. M arburg hem orrhagic fever. A vailable at https://w w w .cdc.gov/vhf/m arburg/pd f/factsh eet. pdf C enters fo r D isease C ontrol and P revention [2016] A nnual US HPS C ases and C ase-Fatality, 1993-2015. A vailable at http://w w w .cdc. g ov/hantavirus/surveilla nce /annual-cases.htm l C enters fo r D isease C ontrol and P revention [2017] Zika virus. A vailable at https://w w w .cdc.gov/zika/ Fox M [2014] C ozy insulation blam ed fo r deadly Yosem ite outbreak. NBC News. A vailable at http://www.nbcnews.com/health/healthnews/cozy-insulation-blamed-deadly-yosemite-outbreak-n28571 US Food and Drug A dm inistration. Foodborne Illnesses: W h a t You Need to Know. A vailable at http://www.fda.gov/food/resourcesforyou/consumers/ucm 103263. htm

Additional journal articles P M ID 10065900 Nagai M, U suku K, M atsum oto W [1998] A n alysis of FITLV-I proviral load in 202 FIAM /TSP patients and 243 asym p tom atic HTLV-I carriers: high proviral load strongly predisposes to HAM/TSP. J Neurovirol 4:586-593 P M ID 10360695 S pangehl MJ, M asri BA, O ’C onnell JX et al [1999] P rospective analysis o f preope rative and intraoperative investig a tions fo r the diagnosis o f infection at the sites o f 2 hundred and 2 revision total hip arthroplasties. J Bone Joint Surg Am 81:672-683 P M ID 1046252 Floagland RJ [1975] Infectious m ononucleosis. Prim Care 2:295-307 PM ID 10511517 M ead PS, S lutsker L, D ietz V et al [1999] Food related illness and death in the United States. Em erg Infect Dis 5(5):607-625 P M ID 10534152 Taylor GP, Tosswill JHC , M atutes E [2000] A prospective study o f HTLV-I infection in an initially asym ptom atic cohort. J Acquir Immune Defic Syndr 22:92-100 P M ID 10565920 Liang FT, Steere AC, M arques A R et al [1999] S ensitive and specific serodiagnosis o f Lym e disease by enzym e linked im m unosorbent assay w ith a peptide based on an im m uno dom inant conserved region o f Borrelia burgdorferi vIsE. J Clin Microbiol 37:3990-3996 P M ID 1 0674090 M olyneux EM, W alsh AL, Phiri AJ et al [1999] Does the use o f urinary reagent strip tests im prove the bedside diag nosis o f m eningitis? Trans R Soc Trop M ed Hyg 93:409-410 P M ID 10699161 R aoult D, Birg ML, LaS cola B et al [2000] C ultivation of the bacillus of W hipple disease. N ew Engl J M ed 342:620-625 PM ID 10816147 S venungsson B, Lagergren A, Ekw all E et al [2000] E nteropathogens in adult patients w ith diarrhea and healthy control subjects: a 1-year prospective study in a S w edish clinic fo r infectious diseases. Clin Infect Dis 30:770-778 PM ID 10921499 Salkin I, G raybill JR [2000] N ucleic acid am plifica tion tests fo r tuberculosis. M M W R 49(26):593-594 P M ID 10987697 Bartlett JG, D owell SF, M andell LA et al [2000] Practice guidelines fo r the m anagem ent o f com m unity acquired pneum onia in adults. Clin Infect Dis 31:347-382 PM ID 11002759 Bangham C RM [2000] HTLV-1 infections. J Clin Pathol 53:581-586 P M ID 11136954 Von Eiff C, B e cker K, M achka K [2001] Nasal carriage as a source o f Staphylococcus aureus bacterem ia. N Engl J M ed 344:11-16

© A S C P 2018

PM ID 11170768 G opal R, O z e re k A , Jeanes A [2001] R ational p ro to cols fo r testing fae ce s in th e investig atio n o f sp o ra d ic hospital acquired diarrhoea. J Hosp Infect 47:79-83 PM ID 11170940 G uerrant RL, G ilder TV, S te in e r TS et al [2001] P ractice guidelines fo r the m anagem en t o f infectious diarrhea. Clin Infect Dis 32:3431 -350 PM ID 11187417 D aar E, Little S, Pitt J [2001] D iagnosis o f prim ary HIV1 infection. Ann Intern M ed 134:25-29 P M ID 11228282 M arik PE [2001] A sp ira tio n pn e u m o n itis and a s p ira tion pneum onia. N ew Engl J M ed 34(9):665-671 PM ID 11243954 M archand E, V erellen-D um oulin C, M airesse M et al [2001] Frequency O f cystic fibrosis tra n sm e m b ra n e con d u cta n ce re gulator gene m utations and 5T a llele in p atients w ith a llergic b ro nchopu lm on ary aspergillosis. Chest 119(3):762-767 PM ID 11292640 Levett PN [2001] Leptospirosis. Clin Microbiol R ev 14(2):296-326 PM ID 11336049 O rth G, Favre M, M ajew ski S et al [2001] Epidermodysplasia verruciformis de fin e s a s ubset o f cuta n e o u s hum an papillom aviruse s. J Virol 7 5 :4952 -4953 P M ID 11392888 A vidor B, Varon M, M a rm o r S et al [2001] D N A am plification fo r the diagnosis o f cat-scratch disease in sm allq uantity clinical specim ens. Am J Clin Pathol 115:900-909 P M ID 11419430 Hall CB [2001] R esp ira tory syncytial virus and para influenza virus. N Engl J M ed 344(25):1917-192 8 P M ID 11430326 M ungai M, Tegtm eier G, C ham berland M e t al [2001] Transfusion transm itted m alaria in the U nited S tates from 1963 throug h 1999. N Engl J M ed 344:197 3-1978 P M ID 11476439 S ander A, B erner R, R uess M [2001] S e ro d ia g n o sis o f ca t scratch disease: response to Bartonella henselae in ch il dren and a review o f diagnostic m ethods. E u rJ Clin Microbiol Infect Dis 20:392-401 PM ID 11512081 M aguina C, Garcia PJ, G otuzzo E et al [2001] B artonellosis (C arrion’s disease) in th e m odern era. Clin Infect Dis 33:772-779 P M ID 11586551 R am zan NN [2001] T ra v e le r’s diarrhea. Gastroenterol Clin North Am 30:665-678 PM ID 11704685 Bush LM, A bram s BH, Beall A et al [2001] Index case o f fatal inhalational anthrax due to bioterrorism in th e U nited States. N ew Engl J M ed 345(22):1607-1610 PM ID 11704686 S w arz MN [2001] R ecognition and m a n a g e m e n t o f a nthra x— an update. N Engl J M ed 3 4 5(22 ):1621-16 2 6 PM ID 11729209 G raham JC, G allow ay A [2001] T he laboratory d ia g nosis o f urinary tra ct infection. J Clin Pathol 54:911-919 P M ID 11860301 Podzorski RP [2002] M o le cu la r testin g in the d ia g nosis and m anagem en t o f hepatitis C viru s infection. Arch Pathol Lab M ed 126:285-290 PM ID11923491 Brem an JG, H enderson D A [2002] D iagnosis and m anagem en t of sm allpox. N Engl J M ed 346(17): 1300-1308 P M ID 11961151 R oss AGP, B artley PB, S leigh A C et al [2002] S chisotosom iasis. N Engl J M ed 346(16 ): 1212-1220 P M ID 120371 53 C hen X-M , K eithly JS, P aya C V et al [2002] C ryp tosporidiosis. N Engl J M ed 346(22): 1723-1731 P M ID 12113867 R onald A [2002] The e tio lo g y o f u rinary tract infec tion: traditional and em erging pathogens. A m J M e d 113(S uppl 1A ):14S-19S P M ID 12140299 Stoll BJ, H ansen N, F a n a ro ffA A e t al [2002] C hanges in pathogens causing early o n s e t se p sis in very-low b irthw eight infants. N Engl J M ed 347:240 -7 P M ID 1239342 5 M arr KA, C arter RA, B oeckh M et al [2002] Invasive aspergillosis in allogeneic stem cell tra n s p la n t recipients: changes in epidem iology and risk factors. Blood 100(13 ):4 3 5 8-436 6

ISBN 9 7 8 -0 8 9 1 8 9 -6 6 7 8

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Selected readings>Additional journal articles P M ID 1 2 4 0 7 5 7 8 P a w lo tsky JM [2002] U se and interpreta tio n o f virolo g ica l te sts fo r h e patitis C. H epatology 36 (S u ppl 1 ):S 65-S 73 P M ID 1 2 4 2 6 5 6 7 R a m o z N, R ued a LA, B o u a d ja r B e t al [2002] M u ta tio n s in 2 a d ja c e n t novel g e n e s are associa te d w ith Epiderm odysplasia verruciformis. N at G enet 32:579-581 P M ID 1 2 4 8 9 2 8 8 S h lim DR [2002] C yclo sp o ra ca ye tanensis. Clin Lab M e d 2 2 :9 2 7 -9 3 6 P M ID 1 2 4 8 9 2 8 9 A g a n BK, D olan M J [2002] L abora tory diagnosis of Bartonella infections. Clin Lab M ed 2 2 :9 3 7 -9 6 2 P M ID 1 2 4 8 9 2 8 9 A lk a la y AL, P o m e ra n ce JJ, R im oin D L [1 9 8 7 ] Fetal v a ric e lla syn d ro m e . J P e diatr 111:320-323 P M ID 1 2 5 2 5 2 9 3 G o o d g a m e R W [2 0 0 3 ] E m e rg in g causes o f tra v e le rs d ia rrh e a : Cryptosporidium, Cyclospora, Isospora, and Microsporidia. Curr Infect Dis R ep 5:66-73 P M ID 1 2690091 D rosten C, G u n th e r S, P re ise r W e t al [2003] Id e n tifica tio n o f a novel Coronavirus in patients w ith severe acute re sp ira to ry syn d ro m e . N Engl J M e d 348(20): 1967-1976 P M ID 1 2 6 9 5 9 9 7 B a con RM , B ig g e rsta ff BJ, S c h rie fe r M E et al [2 0 0 3 ] S e ro d ia g n o sis o f Lym e d ise a se by kin e tic en zym e linked im m u n o s o rb e n t a s s a y using re co m b in a n t VlsE1 o r p eptide anti g e n s o f Borrelia burgdorferi co m p a re d w ith 2-tiered testing using w h o le cell lysates. J Infect Dis 187:1187-1199 P M ID 1 2 7 0 0 3 7 4 M artin G S, M a n n in o DM , Eaton S e t al [2003] The e p id e m io lo g y o f se p sis in th e U nited S ta te s from 1979 through 2 0 0 0 . N Engl J M e d 3 4 8 :1 5 4 6 -1 5 5 4 P M ID 1 2 7 0 0 3 7 7 H aque R, H usto n C D, H ughes M et al [2003] A m e b ia s is . N Engl J M e d 3 4 8 :1 5 6 5 -1 5 7 3 P M ID 1 27512 6 1 Q ue iro z-T e lle s F, M cG in n is M R [2003] S u b cu ta n e o u s m yco se s. Infect Dis Clin N A m 17:59-85 P M ID 1 2 8 6 7 6 1 0 Fihn SD [2003] C linical practice. A cu te u n co m p li c a te d u rin a ry tra c t infection in w o m e n . N Engl J M ed 349:2 5 9 -2 6 6 P M ID 1 2 9 0 4 4 0 9 R ebucci C, C e rino A, C ividini A et al [2003] M o n ito rin g resp o n se to an tivira l th e ra p y fo r pa tie n ts w ith ch ro n ic h e p a titis C viru s infe ctio n by a co re -a n tig e n assay. J Clin Microbiol 4 1 :3 8 8 1 -3 8 8 4 P M ID 1 3 4 6 8 8 1 5 K ass EH [1957] B a cteriuria and th e dia g n o sis of in fe ctio n s o f th e u rina ry tract. Arch Intern M e d 100:709 -714 P M ID 1 3 5 0 2 8 2 5 R o be rts A R , H ilbu rg LE [1958] S ickle cell dise a se w ith sa lm o n e lla o ste o m ye litis. J Pediatr 5 3 :1 7 0 -1 7 5 P M ID 1 4 5 0 6 6 3 3 F ranks TJ, C ho n g PY, C hui P et al [2003] Lung p a th o lo g y o f se ve re a cu te re sp ira to ry s y n d ro m e (S A R S ): a study o f 8 a u to p sy ca ses from S in g a p ore. H um Pathol 34(8):743-748 P M ID 1 4 5 6 9 8 1 0 H arris KR, D ighe A S [2002] L a bo ra to ry testin g fo r viral hepatitis. A m J Clin Pathol 118:S 18-25 P M ID 1 4 6 7 1 9 7 0 K oteish A, K a nn an ga i R, A b ra h a m SC et al [2003] C o lo n ic sp iro ch e to sis in c h ild re n and adults. A m J Clin Pathol 120:8 2 8 -8 3 2 P M ID 1 4 6 8 1 5 1 0 P eiris JS, Y uen KY, O ste rh a u s A D et al [2003] The s e v e re a cu te re sp ira to ry syn d ro m e . N Engl J M e d 349(25 ):24312441 P M ID 1 4 7 5 2 0 1 2 C hiesa C, P a nero A, O sb orn JF et al [2004] D ia g n o sis o f n eonatal sepsis: a clinical and lab o ra to ry challenge. Clin Chem 5 0 (2 ):2 7 9 -2 8 7 P M ID 1 4 9 8 6 2 4 5 R ege v-Y o cha y G, R az Meir, D agan R et al [2004] N a so p h a ryn g e a l c a rriag e o f Streptococcus pneum oniae by adults and child re n in c o m m u n ity and fa m ily settings. Clin Infect Dis 38: 6 3 2 -9 P M ID 1 5 0 0 1 9 9 7 L a m p s LW, H a ve n s JM , S jo s te d tA e t al [2004] H is to lo g ic and m o le c u la r dia g n o sis o f tu larem ia: a potential b io te rro rism a g ent e n d e m ic to N orth A m e rica . M od Pathol 17:48 9 -4 9 5

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P M ID 1 5051281 Singh B, Kim Sung L, M a tu s o p A e ta l [2004] A large focus o f naturally acquired Plasmodium knowlesi infections in hum an beings. Lancet 3 6 3 (9 4 14):1017-1024 P M ID 15116293 A rchibald LK, B anerjee SN, Jarvis W R [2004] S ecular trends in hospital acquired Clostridium difficile disease in the United S tates, 1987-2001. J Infect Dis 189:1585-1589 P M ID 15116329 G ranville L, C hirala M, C ernoch P et al [2004] Fungal sinusitis: histologic spectrum and correlation w ith culture. Hum Pathol 35(4):474-481 P M ID 151661 07 C arrigan CD, S cott G, Tabrizian M [2004] Toward resolving th e challenges o f sepsis diagnosis. Clin Chem 50(8): 1301-1314 P M ID 1 5172344 Y agupsy P [2004] Kingella kingae: From m edical rarity to an em erging paediatric pathogen. Lancet Infect Dis 4:358-367 P M ID 1 5238498 Poutanen SM, S im or A E [2004] Clostridium difficile associated diarrhea in adults. CM AJ 171:51-58 P M ID 1 5275980 E nright A M , P rober C G [2004] H erpesviridae infec tions in new borns: varicella zo ste r virus, herpes sim plex virus, and cytom egalovirus. Pediatr Clin N A m 5 1 :889-908 P M ID 153178 93 H otez PJ, B rooker S, B ethony JM et al [2004] H ookw orm Infection. N Engl J M ed 351(8):799-807 P M ID 1 5465503 Tram pu z A, H anssen AD , O sm on DR et al [2004] Synovial fluid leukocyte count and differential fo r the diagnosis of prosthetic knee infection. Am J M ed 117:556-562 P M ID 15480370 C aserta MT, M cderm ott MP, D ew hurst S et al [2004] hum an herpesvirus 6 (H H V 6) D N A persistence and reactivation in healthy children. J Pediatr 145:478-484 P M ID 154832 83 Zim m erli W, Tram pu z A, O chsner PE [2004] P rosthetic-joint infections. N Engl J M ed 351(16):1645-1654 P M ID 15567127 A lbrich W C , Kraft C, Fisk T, A lbre cht H [2004] A m echanic w ith a bad valve: b lood-culture negative endocarditis. Lancet Infect Dis 4:777-784 P M ID 15583303 Lem ee L, D halluin A, Testelin S et al [2004] M ultiplex PC R targeting tpi (triose phosphate isom erase), tcdA (toxin A), and tcdB (toxin B) genes fo r toxigenic culture of Clostridium difficile. J Clin Microbiol 4 2:5710-14 P M ID 15686503 C hng W J, Lai HC, E a rnest A et al [2005] H em atological param ete rs in severe acute respiratory syndrom e. Clin Lab H aem 27:15-20 P M ID 15701555 Pasvol G [2005] M anagem ent o f severe m alaria: interventions and controversies. Infect Dis Clin N Am 19:211-240 P M ID 15745715 K ravetz JD, Federm an DG [2005] Toxoplasm osis in pregnancy. Am J M ed 118:212-216 PM ID 15879906 H oupikian P, R aoult D [2005] Blood culture-negative endocarditis in a refere nce center: etiologic diagnosis o f 348 cases. Medicine 84(3):162-173 PM ID 15879907 Troy SB, R ickm an LS, D avis CE [2005] Brucellosis in San Diego: epidem iology and species related differences in acute clinical presentations. Medicine 84(3):174-187 PM ID 15925663 C havez-B ueno S, M cC racken, GH Jr [2005] Bacterial m eningitis in children. Pediatr Clin N A m 52:795-810 PM ID 15930423 Pappas G, A kritidis N, Bosilkovski M et al [2005] Brucellosis. N Engl J M ed 352:2325-2336 PM ID 15941082 C ohen A, W olf DG, G uttm an-Y assky E et al [2005] K aposi’s sarcom a associated herpesviruses: clinical, diagnostic, and epidem iological aspects. Crit R ev Clin Lab Sci 42(2):101-153 P M ID 15963877 G aydos C A [2005] N ucleic acid am plification tests for gonorrhea and Chlamydia: practice and applications. Infect Dis Clin N A m 19:367-386 PM ID 15989910 M cD onald JR, O laison L, A nderson DJ et al [2005] Enterococcal endocarditis: 107 cases from the International

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Selected readings>Additional journal articles C ollaboration on E ndocarditis m erged database. Am J M ed 118:759-766 PM ID 16005340 C arapetis JR, M cD onald M, W ilson NJ [2005] A cute rheum atic fever. Lancet 366:155-168 PM ID 16020686 A g uero-R osenfeld ME, W ang G, S chw artz I, W orm ser G P [2005] D iagnosis o f lym e borreliosis. Clin Microbiol R ev 18(3):484-509 PM ID 16023971 C hevaliez S, P aw lotsky J-M [2005] Use o f virologic assays in the diagnosis and m anagem en t o f hepatitis C virus infection. Clin Liver Dis 9:37-382 PM ID 16099235 G uleria R, N isar N, C haw la TC et al [2005] Mycoplasma pneumoniae and central nervous system com plica tions: a review. J Lab Clin M ed 146(2):55-63 PM ID 16102656 M assei F, G ori L, M acchia P et al [2005] The expanded spectrum of barton ellosis in children. Infect Dis Clin N Am 19:691-711 PM ID 16126277 De Silva T, C hapm an A, Kudesia G et al [2006] O ngoing queries: interpretation o f se rology in asym ptom atic or atypical chronic Q fever. J Infect 52:e113-e116 PM ID 16168312 N afziger SD [2005] Sm allpox. Crit Care Clin 21:739746 PM ID 1618289 5 W arny M, Pepin J, Fang A et al [2005] Toxin produc tion by an em erging strain o f Clostridium difficile associated w ith outbreaks o f severe disease in N orth A m erica and Europe. Lancet 366:1079-84 PM ID 16192481 M oscona A [2005] N euram inidase inhibitors fo r influ enza. N Engl J M ed 3 5 3 (1 3):1363-1373 P M ID 16192482 Beigel JH, Farrar J, Han AM et al [2005] Avian influ enza A (H 5N 1) infection in hum ans. N Engl J M ed 353(13): 13741385 PM ID 16238016 Karch H, Tarr PI, Bielaszew ska M [2005] E nterohaem orrh agic Escherichia coli in hum an m edicine. Int J of Medical Microbiology 295:405-418 PM ID 16267499 C enters fo r D isease C ontrol and P revention [2005] C ontrolling tuberculosis in the U nited States: recom m endations from the A m erican T hora cic Society, C DC , and the Infectious D iseases Society o f A m erica. M M W R 54(N o. RR-12):1-81 PM ID 16271648 H ughes RA, C ornblath DR [2005] G uillain-B arre syndrom e. Lancet 366:1653-1666 PM ID 16322603 M cD onald LC, Killgore GE, T hom pson A et al [2005] An epidem ic toxin gene variant strain o f Clostridium difficile. N Engl J M ed 353:2433-41 PM ID 16478043 S unenshine RH, M cD onald LC [2006] Clostridicum difficile-assoaciated disease: N ew challenges from an established pathogen. Cleve Clin J M ed 73(2): 187-197 PM ID 16607374 Bori G, S oriano A, G arcia S et al [2006] Low sensi tivity o f histology to predict the presence o f m icroorganism s in suspected loosening o f a jo in t prosthesis. M od Pathol 19:874-877 PM ID 16650976 Kunst H [2006] D iagnosis o f latent tuberculosis infection: the potential role o f new technologies. Resp M ed 100:2098-2106 PM ID 16740443 Pizon AF, B o nner MR, W ang HE et al [2006] 10 years o f clinical experience w ith adult m eningitis at an urban academ ic m edical center. J Em erg M ed 30(4):367-370 PM ID 16760891 C enters fo r D isease C ontrol and P revention [2006] H antavirus pulm onary syndrom e— 5 states, 2006. M M W R 55:627-629 PM ID 16781920 Nguyen HB, R ivers EP, A b raham ian FM et al [2006] Severe sepsis and septic shock: review o f the literature and em ergency departm e nt m anagem ent guidelines. Ann Emerg M ed 48:28-54

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P M ID 1688006 5 G oodgam e R [2006] A B ayesian a p proach to acute infectious diarrhea in adults. Gastroenterol Clin N Am 3 5:249-273 PM ID 16915118 Jensen JU, Heslet TH , E spersen K et al [2006] P rocalcitonin increase in early identification o f c ritically ill patients at high risk o f m ortality. Crit Care M e d 34:2687 -2688 P M ID 16931408 S teingart KR, H enry M, Ng V, H opew ell PC, R am say A, C unningham J, U rbanczik R, P erkins M, A z iz M A, Pai M [2006] Fluorescence vs conventional sp u tu m sm e a r m icros co p y fo r tuberculosis: a system atic review. Lancet Infect Dis 6:570-581 P M ID 16931409 O chola LB, Vounatsou P, S m ith T et al [2006]T he reliability o f d ia g n o stic techniques in th e d ia g n o sis and m a n a g e m ent o f m alaria in the absence o f a gold standard. Lancet Infect Dis 6:582-588 P M ID 169886 43 B ranson BM, H andsfield HH, L a m pe M A e t al [2006] R evised re com m endations fo r HIV testin g o f adults, adolescents, and pregnant w om en in health-care settings. M M W R 55 PM ID 17011318 Z e rr DM, Frenkel LM, H uang H -L e t al [2006] P olym erase chain reaction diagnosis o f p rim a ry hum an herpesvirus-6 infection in the acute care setting. J Pediatr 149:480-485 P M ID 17029141 S halabi M, W hitley RJ [2006] R ecu rrent benign lym phocytic m enigitis. Clin In f Dis 43(9): 1194-7 P M ID 17113007 Saltini, C [2006] C hem otherapy and d ia gnosis o f tuberculosis. Resp M ed 100:2085-2097 P M ID 171479 57 C u tle r SJ, Bouzid M, C u tle r RR [2007] Q fever. J Infect 54:313-318 P M ID 17151365 H ogenauer C, Langner C, B e u b le r E et al [2006] Klebsiella oxytoca as a causative organism o f a n tib io tic a s so ci ated h em orrh agic colitis. N Engl J M ed 355:241 8-24 26 P M ID 171576 19 B rett-M ajor DM, W alsh TE [2006] Lab ora tory d ia g nosis o f tuberculosis in prim ary care. Dis M on 52:45 0-458 P M ID 172768 08 R ay P, B adarou-A cossi G, V ia llo n A [2007] A ccu ra cy o f the cerebrospinal fluid results to d iffe re n tia te bacterial from nonbacterial m eningitis, in case o f negative G ram stained sm ear. Am J Em erg M ed 25:179-184 P M ID 17277290 A m erican Thoracic S o ciety [2007] D iagnosis, tre a t m ent, and prevention o f nontube rculo us m yco b a cte rial disease. Am J Respir Crit Care M ed 175:367-416 P M ID 17278083 M andell LA, W underink RG, A n zu e to A et al [2007] Infectious D iseases S ociety o f A m e rica/A m erican T h o ra cic S ociety consensus guidelines on th e m a n a g e m e n t o f c o m m u n ity acquired pneum onia in adults. Clin Infect Dis 44S u p p l2 :S 2 7 -7 2 P M ID 173176 03 R oss AG , V ickers D, O ld s G R et al [2007] K a taya m a syndrom e. Lancet Infect Dis 7:218-224 P M ID 17448935 Pialoux G, G auzere B, J a u re g u ib e rry S et al [2007] C hikungunya, an epidem ic arbovirosis. Lancet Infect Dis 7:319327 P M ID 17509489 P a ch n e rA R , Steiner I [2007] Lym e neuroborreliosis: Infection, im m unity, and infl anim ation. Lancet Neurol 6:544-552 P M ID 17573670 Pett M, C olem an N [2007] Integration o f high-risk hum an papillom avirus: a key event in cervica l ca rcin o g e n e sis? J Pathol A u g;212(4):35 6-67 P M ID 17576996 US Preventive Services Task Force [2007] S creening fo r Chlamydia\ infection: US P reve ntive S e rvices Task Force recom m endation statem ent. Ann Intern M ed 147:128-133 P M ID 176998 15 Tram pu z A, Piper KE, Ja co b so n M J et al [2007] S onication o f rem oved hip and knee prostheses fo r d ia gnosis o f infection. N Engl J M ed 357:654-663 P M ID 17714672 R eithinger R, D ujardin J, Louzir H et al [2007] C utaneous leishm aniasis. Lancet Infect Dis 7:581-59 6 P M ID 1776548 9 W inn HN [2007] G roup B Streptococcus infection in pregnancy. Clin Perinatol 34:387-392

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Selected readings>Additional journal articles P M ID 1 7 8 9 7 6 0 7 R aad I, H an n a H, M aki D [2007] In tra va scu la r ca th e te r related infe ctions: a d va n c e s in d iagnosis, prevention, and m a n a g e m e n t. Lancet Infect Dis 7:645-657 P M ID 1 7 9 0 4 4 6 3 H urt C, T am m aro D [2007] D ia g n o stic e va lu a tio n o f m o n o n u c le o s is lik e illne sses. A m J M ed 120:911,e1-9 1 1.e8 P M ID 1 7 9 6 1 8 5 8 D antas-T orres F [2007] R o cky M ou n ta in spotted fever. Lancet Infect Dis 7 :724-732 P M ID 1 7 9 7 6 5 0 3 S yed FF, M illa r BC , P re n d e rg a st BD [2007] M o le c u la r te c h n o lo g y in context: a c u rre n t review o f d ia g n o sis a nd m a n a g e m e n t o f in fective en d o ca rd itis. Prog Cardiovasc Dis 5 0 (3 ):1 8 1 -1 9 7 P M ID 1 8 0 3 2 6 2 7 F e n n e r L, W id m e r AF, G o y G et al [2008] R apid and re lia b le d ia g n o s tic a lg o rith m fo r d e tection o f Clostridium difficile. J Clin Microbiol 4 6 :3 2 8 -3 0 P M ID 1 8 0 5 5 2 5 2 A lla n d e r T [2008] H um an bocavirus. J Clin Virol 4 1 :2 9 -3 3 P M ID 1 8 1 5 6 0 0 6 H abib G, T h u n y F, A vie rin o s JF [2008] P rosthetic v a lv e e n d o ca rd itis: c u rre n t a p p ro a ch and th e ra p e u tic options. Progress in C ardiovascular Diseases 50(4):274-281 P M ID 1 8 1 6 2 2 4 8 G in o cch io C C [2007] D etection o f re spira to ry viru s e s using n o n m o le c u la r based m ethods. J Clin Virol 4 0 S u p p l1 :S 1 1 -S 1 4 P M ID 1 8 1 6 2 2 4 9 Fox JD [2007] N ucle ic acid a m p lifica tio n te sts fo r d e te ctio n o f re sp ira to ry viru se s. J Clin Virol 4 0 S u p p l1 :S 1 5 -S 2 3 P M ID 1 8 2 0 1 6 7 9 Larsen JW , S e ve r JL [2008] G ro up B Streptococcus a nd p re g n a n cy: a review . A m J Ob Gyn 4 40-44 8 P M ID 1 8 2 0 2 2 5 6 Feng H, S h ud a M, C han g Y et al [2008] C lonal in te g ra tio n o f a p o lyo m a viru s in hu m a n M erkel cell carcinom a. Science 319:10 9 6-1100 P M ID 1 8 2 9 1 3 3 8 P itout JD D , La up la n d KB [2008] E xten d e d -sp e ctru m (3-lactam ase p ro du cing E n te ro b a cte ria ce a e : an em e rg in g publich e a lth co n ce rn . Lancet Infect Dis 8:159-166 P M ID 1 8 2 9 1 3 3 9 S c h n e id e r T, M oos V, L o d d e n ke m p e r C e t al [2008] W h ip p le d isease : new a sp e cts o f p a th o g e n e sis and treatm en t. Lancet Infect Dis 8:1 7 9 -9 0 P M ID 1 8 2 9 5 6 8 3 M oran G J, Talan DA, A b ra h a m ia n FM [2008] D ia g n o sis and m a n a g e m e n t o f pne u m o n ia in the e m ergen cy d e p a rtm e n t. Infect Dis Clin N A m 22:53-72 P M ID 1 8 3 4 2 6 8 8 H viid A, R ubin S, M u h le m a n n K [2008] M um ps. Lancet 371:9 3 2 -9 4 4 P M ID 1 8 3 5 8 9 6 6 F e rn a n d e z-V a le n cia JA, G arcia S, P rat S [2008] Pasteurella multocida s e p tic s h o c k a fte r a ca t scratch in an e ld e rly o th e rw ise h ealthy w o m a n : A ca se report. Am J Em erg M e d 2 6 :3 8 0 .e 1-3 8 0 .e 3 P M ID 1 8 3 7 4 6 8 0 R othberg M B, H a e s sle r SD, Brow n RB [2008] C o m p lic a tio n s o f viral influ en za. A m J M ed 121:258 -264 P M ID 1 8 4 0 6 6 6 4 S loots TP, W h ile y DM , L a m b e rt SB, N issen M D [2008] E m ergin g re sp ira to ry agents: N ew viru se s fo r old d is e a s e s ? J Clin Virol 4 2 :2 3 3 -2 4 3 P M ID 1 8 4 5 2 8 0 3 A g u e ro -R o s e n fe ld M E [2008] Lym e disease: la b o ra to ry issu es. Infect Dis Clin N A m 22:3 0 1 -3 1 3 P M ID 1 8 4 7 1 7 7 7 P ie rsim o ni C, S c a rp a ro C [2008] P u lm o n a ry in fe c tio n s a sso cia te d w ith n o n tu b e rcu lo u s m yco b a cteria in im m uno c o m p e te n t patients. Lancet Infect Dis 8 :3 2 3 -8 3 4 P M ID 1 8 5 6 5 4 5 7 S ca rb o ro u g h M, T h w a ite s G E [2008] T h e dia g n o sis and m a n a g e m e n t o f a cu te b a cte ria l m e n in g itis in resource poor se ttin g s. Lancet N eurol 7 :6 3 7 -6 4 8 P M ID 1 8 6 5 7 7 2 3 Ja ckso n A C [2008] R abie s. N eurol Clin 2 6 :7 1 7 -7 2 6 P M ID 1 8 7 0 1 4 0 8 K a n n e r W A , S aleh KJ, Frierson H F [2008] R e a s se s s m e n t o f th e u se fu ln e ss o f fro ze n section analysis fo r hip and kn e e jo in t revisions. A m J Clin Pathol 130:363-368

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P M ID 187553 85 V annier E, G ew u rz BE, K rause PJ [2008] Hum an babesiosis. Infect Dis Clin N A m 22:469-488 P M ID 18755387 T issot-D up ont H, R aoult D [2008] Q fever. Infect Dis Clin N A m 22:505-514 P M ID 1881250 3 Shuda M, Feng H, Kw un HJ et al [2008] T antigen m utations are a hum an tu m o r specific signature fo r M erkel cell polyom avirus. Proc Natl A cad Sci US 105:16272-16277 P M ID 1892248 5 Blum JA, Z e llw e g e r MJ, Burri C et al [2008] C ardiac involvem ent in A frican and A m erican trypanosom iasis. Lancet Infect Dis 8:631-641 P M ID 18954694 V incent JL, K orkut H A [2008] D efining sepsis. Clin Chest M ed 29:585-590 P M ID 18954695 V entetuolo CE, Levy MM [2008] Biom arkers: diag nosis and risk assessm e nt in sepsis. Clin Chest M ed 29:591-603 P M ID 18977696 P lanche T, A ghaizu A, H ollim an R et al [2008] D iagnosis o f Clostridium difficile infection by toxin detection kits: a system atic review. Lancet Infect Dis 8:777-784 P M ID 18992406 D alton HR, Bendall R, Ijaz S et al [2008] H epatitis E: an em erging infection in developed countries. Lancet Infect Dis 8:698-709 P M ID 18995875 Jiang M, A bend JR, Johnson SF et al [2009] The role o f polyom aviruses in hum an disease. Virology 384:266-273 P M ID 18996278 Babel BS, D ecker C F [2008] M icrobiology and labo ratory diagnosis o f M RSA. Dis Mon 54:769-773 P M ID 19081392 M ilei J, G uerri-G uttenberg R, G rana D et al [2009] Prognostic im pact o f C hagas disease in the United States. Am Heart J 157:22-29 PM ID 19084472 Patel MM, Hall AJ, V inje J et al [2009] N oroviruses: a com prehensive review. J o f Clin Virol 44:1-8 P M ID 19114163 Jacob JT, M ehta AK, Leonard M K [2009] A cute form s o f tuberculosis in adults. Am J M ed 122:12-17 P M ID 19135917 R ogers KL, Fey PD, R upp M E [2009] C oagulasenegative staphylococca l infections. Infect Dis Clin N Am 23:73-98 P M ID 19281894 G oede M R, C oopersm ith C M [2009] C atheter related bloodstream infection. Surg Clin N A m 89:463-474 P M ID 19375643 W engenack NL, B innicker MJ [2009] Fungal m olec ular diagnostics. Clin Chest M ed 30:391-408 PM ID 19393961 Looney W J, N arita M, M uhlem ann K [2009] Stenotrophomonas maltophilia: an em erging opportunist hum an pathogen. Lancet Infect Dis 9:312-323 P M ID 19495508 Pillai BP, C hong VH , Yong A M L [2009] Purple urine bag syndrom e. Singapore M ed J 50(5):e193 P M ID 1951183 H urlbut TA III, Littenberg B [1991] The diagnostic accuracy o f rapid dipstick tests to predict urinary tract infection. Am J Clin Pathol 96:582-588 P M ID 1 9692690 Del Pozo JL, Patel R [2009] C linical practice: infection associated w ith prosthetic joints. N ew Engl J M ed 361 (8):787-794 PM ID 19807912 M irza NN [2009] Clostridium septicum sepsis and colorectal cancer— a rem inder. World J Surg Oncol 7:73 PM ID 20513539 Loeffelholz MJ [2010] Avian influenza A H5N1 virus. Clin Lab M ed 30:1-20 P M ID 20513543 G arcia LS [2010] M alaria. Clin Lab M ed 30:93-129 P M ID 20513552 Venneti S [2010] Prion diseases. Clin Lab M ed 30:293-309 P M ID 20817850 Pantulu ND, Pallasch CP, Kurz A K et al [2010] D etection o f a novel truncating M erkel cell polyom avirus large T antigen deletion in chronic lym phocytic leukem ia cells. Blood 116:5280-5284

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3: Microbiology

Selected readings>Additional journal articles P M ID 20855487 D ylew ski J, Luterm an L [2010] S eptic arthritis and Clostridium septicum: a clue to colon cancer. CMAJ 182(13):1446-1447 P M ID 20993766 M endelson C L [1946] T he aspiration o f stom ach contents into the lungs during o bstetric anesthesia. Am J Obstet Gynecol 52:191-205 P M ID 21088663 C enters fo r D isease C ontrol and Prevention [2010] P revention o f perinatal group B streptococcal disease. M M W R 59(R R -10):1-32 P M ID 21540020 W ang TS, Byrne PJ, Jacobs LK et al [2011] M erkel cell carcinom a: update and review. Semin Cutan M ed Surg 30:48-56 P M ID 22258769 Parvizi J, Jacovid es C, A n toci V et al [2011] D iagnosis o f periprosthetic jo in t infection: the utility o f a sim ple yet unappreciated enzym e. J Bone Joint Surg Am 21 ;93(24):22422248 PM ID 22402203 O hm ichi T, Takezaw a H, Fujii C et al [2012] M ollaret cells detected in a patient w ith varice lla -zo ste r virus m eningitis. Clin Neurol Neurosurg 114(7): 1086-7 PM ID 25278500 Patel R [2015] M A LD I-TO F MS fo r the diagnosis of infectious diseases. Clin Chem Jan;61(1):100-11 P M ID 25316519 Krause JC, Panning M, Hengel H et al [2014] The role o f m ultiplex PC R in respiratory tra ct infections in children. Dtsch Arztebl Int S ep 19 ;1 11 (38):639-45 PM ID 25387613 G oeijenbier M, van Kam pen JJ, R eusken CB et al [2014] Ebola virus disease: a review on epidem iology, sym ptom s, tre atm en t and pathogenesis. Neth J M ed 72(9):442-8 PM ID 26209388 Thorb urn F, B ennett S, M odha S et al [2015] The use o f next generation sequencing in th e diagnosis and typing of respiratory infections. J Clin Virol A u g;69:96-100 P M ID 26903336 S hankar-H ari M, Phillips GS, Levy M L et al [2016] D eveloping a new definition and assessing new clinical criteria for septic shock: fo r the Third International C onsensus D efinitions fo r sepsis and septic shock (S epsis-3). JAMA Feb 23;315(8):775-87 PM ID 27028561 Petersen LR, Jam ieson DJ, Pow ers AM et al [2016] Zika virus. N Engl J M ed Apr 21;374(16):1552-63 P M ID 2846640 D ealler SF, H aw key PM, M illar M R [1988] E nzym atic degradation o f urinary indoxyl sulfate by Providencia stuartii and Klebsiella pneumoniae causes the purple urine bag syndrom e. J Clin Microbiol 26(10 ):2 1 52-2156 PM ID 3538318 P ow derly W G , S tanley J r SL, M edoff G [1986] P neum ococcal endocarditis: report o f a series and review o f the literature. R ev Infect Dis 8:786-791 PM ID 3766382 U golini V, Pacifico A, Sm itherm an TC et al [1986] Pneum ococcal endocarditis update: analysis o f 10 cases diag nosed betw een 1974 and 1984. Am H eart J 112:813-819 P M ID 6371440 W e b e r DJ, W olfson JS, S w artz MN et al [1984] Pasteurella multocida infections. R eport o f 34 cases and review o f the literature. Medicine 63(3):133-54 PM ID 6377440 H ovelius B, M ardh PA [1984] Staphylococcus saprophyticus as a com m on cause o f urinary tract infections. Rev Infect Dis 6:328-337 PM ID 7629870 C leghorn FR, M anns A, Falk R et al [1995] Effect o f hum an T lym photropic virus type I infection on non H odgkin lym phom a incidence. J Natl C ancer /n sf 87:1009-1014 PM ID 7704889 Larsen SA, S te iner BM, R udolph AH [1995] Laboratory diagnosis and interpretation o f tests fo r syphilis. Clin Microbiol R ev 8:1-21 PM ID 7746063 M o o s a A A , Q uortum HA, Ibrahim M D [1995] Rapid diagnosis o f bacterial m eningitis w ith reagent strips. Lancet 345:1290-1291

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P M ID 7769040 B arlow K, Tosswill J, C le w le y J [1995] A n a lysis and genotyping o f PC R products o f the a m p lic o r HIV1 kit. J Virol Methods 52:65-74 P M ID 780276 7 E nders G, M iller E, C ra d o ck-W a tso n J et al [1994] C onsequences o f Varicella and H erpes zoster in pregna ncy: prospective study o f 1739 cases. Lancet 343:154 8-1551 P M ID 803703 5 Tigges S, Stiles RG, R oberson JR [1994] A p p e a ra n ce o f septic hip prostheses on plain radio g ra p h s. A m J Roentgenol 163:377-380 P M ID 8121458 D uchin JS, K oster FT, P eters CJ et al [1994] H antavirus p u lm onary syndrom e: a clinical de scrip tion o f 17 patients w ith a new ly recognized d isease. N Engl J M ed 330:949 955 PM ID 8292114 M agill AJ, Grogl M, G a s s e r R A et al [1992] V isceral infection caused by Leishmania tropica in ve te ra n s o f O peration D ese rt Storm . N Engl J M ed 328:1384 P M ID 853130 9 Fine MJ, Sm ith MA, C arson C A e t al [1996] P rognosis and o utcom es o f p atients w ith co m m u n ity acquired pneum onia. JAMA 275:134-141 P M ID 861942 5 G utierrez Y, Bhatia P, G a rb a d a w a la S T et al [1996] Strongyloides stercoralis eosinophilic g ra n u lo m a to u s entero colitis. Am J Surg Pathol 20(5):603-612 P M ID 872713 4 Kostm an JR [1996] L a b o ra to ry d ia g n o sis o f rickettsial diseases. Clin Derm atol 14:301-306 P M ID 9041350 S teketee RW, A bram s EJ, Thea DM et al [1997] Early detection o f perinatal hum an im m u n o d e ficie n cy virus ty p e 1 infection using H IV R N A am plification and detection. J Infect Dis 175:707-711 P M ID 904689 4 S ig urdardottir B, B jornsson O M , Jo n sd o ttir KE et al [1997] A cute bacterial m eningitis in adults: a 2 0 -y e a r overview . Arch Intern M ed 157:425-430 P M ID 915716 6 K essler HH, Sanker B, R abenau H et al [1997] R apid d iagnosis o f Enterovirus infection by a new o n e -ste p reverse tran scrip tio n -P C R assay. J Clin Microbiol 35:976 PM ID 9278621 Procop GW, Burchette JL Jr, H ow ell DN et al [1997] Im m unoperoxidase and im m unofluorescent staining o f Rickettsia rickettsii in skin biopsies. A c om parative study. Arch Pathol Lab M ed 121:894-899 P M ID 9395430 S chuachat A, R obinson K, W e n g e r JD et al [1997] B acterial m eningitis in the United S tates in 1995. N Engl J M ed 337:970 -976 P M ID 9738046 A tkins BL, Athanasou N, D eeks JJ et al [1998] P rosp ective evaluation o f criteria fo r m icro b io lo g ica l dia g n o sis o f prosthetic-joint infection at revision arthro pla sty. J Clin Microbiol 36:2932-2939 P M ID 999071 6 G ratz NG [1999] Em erging and resurging vectorborne diseases. Annu R ev Entomol. 44:5 1 -7 5 A m chentsev A, K urugundla N, Saleh A G [2008] Aspergillus related lung disease. Respir M ed 1:205-215 B a renfanger J, D rake C A [2001] Interpretation o f G ram stains fo r the nonm icrobiologist. Lab M ed 7:368-375 Barlow G B, D ickson JA S [1978] Purple urine bags. Lancet 28:220221

Jones TD [1944] The diagnosis of acute rh e u m a tic fever. JAMA 126:481-484 T ram pu z A, S teckelberg JM , O sm on DR et al [2003] A d va n ce s in the laboratory diagnosis o f prosthetic jo in t infection. R ev M ed Microbiol 14:1-14 W eisfelt M, van de Beek D, Spanjaard L, R eitsm a JB, de G ans J [2006] C linical features, com plications, and o u tco m e in adults w ith pneum ococcal m eningitis: a prospective case series. Lancet Neurol 5:123-129 P M ID 16426988

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Selected readings>Additional journal articles W h ip p le G H [1907] A h ith e rto u n d e scrib e d d ise a se characterized a n a to m ic a lly by d e p o sits o f fa t and fa tty acids in the intestinal a nd m e s e n te ric lym p h a tic tissu e s. B ull Johns H opkins Hosp 1 8 :3 8 2 -9 3 W iw a n itk it V [2006] H e m a to lo g ic m a n ife sta tio n s o f bird flu, H 5N1. Infection Infect Dis Clin P ract 14:9-11 W o rko w s k i KA, Levin e W C [2002] S e xu a lly T ra n sm itted D iseases T re a tm e n t G u id e lin e s 2 002. M M W R 5 1 R R -7 :18-30

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Chapter 4

H e m a to p a th o lo g y 4.1 Diseases of red blood cells............................................................. 200

4.4

4.1.1 C yto sk e le ta l d is o rd e r s ................................................................................... 200

4.4.1 R ed b lood cell in d ic e s .................................................................................... 2 58

4 .1 .2 E nzym e d is o r d e r s ...........................................................................................201

4 .4 .2 L e u k o cy te in d ic e s ...............................................................................................2 58

4 .1 .3 S tructurally a b norm al h e m oglobin variants (h e m o g lo b in o p a th ie s )........................................................................................... 202

4 .4 .3 P la te le t in d ic e s ....................................................................................................2 5 9

4 .1 .4 T h a la s s e m ia ........................................................................................................206 4 .1 .5 Im m une h e m o ly tic d is o r d e r s ...................................................................... 208

4.2

Disorders of marrow production................................................. 210

4.2.1 Iron d e fic ie n c y .................................................................................................. 210 4 .2 .2 Folate & v itam in B 12 ......................................................................................212 4 .2 .3 A ne m ia o f c h ro n ic d is e a s e ............................................................................213

Methods............................................................................................ 258

4 .4 .4 D e te ctio n o f n o rm a l & v a ria n t h e m o g lo b in s ........................................... 25 9 4 .4 .5 H is to c h e m is try & c y to c h e m is try ...................................................................261 4 .4 .6 Im m u n o p h e n o ty p in g ......................................................................................... 261 4 .4 .7 C o n v e n tio n a l cyto g e n e tic s & m o le c u la r te c h n iq u e s ............................. 26 4 4 .4 .8 B on e m a rro w b io p s y .......................................................................................26 5

4.5 4.5.1

Selected readings...........................................................................267 B o o k s ....................................................................................................................27 2

4 .2 .4 S id e ro b la s tic a n e m ia ......................................................................................214 4 .2 .5 C o n g e n ita l d y s e ryth ro p o ie tic a n e m ia ....................................................... 214 4 .2 .6 F anconi a n e m ia ................................................................................................214 4 .2 .7 D yske ra to sis c o n g e n ita (Z in s se r-E n g m a n -C o le s y n d ro m e ).......... 21 5 4 .2 .8 P ure red cell a p la s ia (P R C A )...................................................................... 215 4 .2 .9 C o n g e n ita l a m e g a k a ry o c ytic th ro m b o c y to p e n ia (C A M T ).................215 4 .2 .1 0 T h ro m b o c yto p e n ia w ith a b s e n t radii s y n d ro m e ................................ 215 4.2.11 C o n g e n ita l n e u tro p e n ia (K o s tm a nn s yn d ro m e ) & c y c lic n e u tro p e n ia ................................................216 4 .2 .1 2 S hw a c h m a n -D ia m o n d s y n d ro m e ............................................................ 2 1 6 4 .2 .1 3 M ye lo k a th e x is (& W H IM s y n d ro m e )....................................................... 216 4 .2 .1 4 A uto im m u n e n e u tro p e n ia ........................................................................... 216 4 .2 .1 5 A p la stic a n e m ia ............................................................................................. 216 4 .2 .1 6 A p p ro a c h to th e d ia g n o s is o f q u a n tita tive a b n o rm a litie s .............. 217

4.3

Neoplastic hematopathology........................................................223

4.3.1 B cell n e o p la s m s ............................................................................................. 223 4 .3 .2 P re c u rs o r n e o p la s m s (lym p h o b la stic le u kem ia & lym p h o m a ), B and T ...................................................................... 236 4 .3 .3 P lasm a cell n e o p la s m s ................................................................................ 237 4 .3 .4 T cell n e o p la s m s ............................................................................................. 240 4 .3 .5 H odgkin ly m p h o m a ........................................................................................ 243 4 .3 .6 M yeloid n e o p la s m s ........................................................................................ 2 4 6

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4: Hematopathology

Diseases of red blood cells>Cytoskeletal disorders

i4.1 Spherocytes are red cells lacking central pallor; artifact is a common cause, but true spherocytes are most often seen in autoimmune hemolytic anemia & hereditary spherocytosis

4.1 Diseases of red blood cells 4.1.1 Cytoskeletal disorders 4.1.1.1 Hereditary spherocytosis ■ A u to s o m a l d o m in a n t in h e rita n c e m o s t c o m m o n , b u t m in o rity a u to s o m a l re c e s s iv e ■ In c id e n c e in th e U n ite d S ta te s is 1 in 5 0 0 0 ; m o s t c o m m o n red c e ll d is o rd e r in th o s e o f n o rth e rn E u ro p e a n descent ■ C lin ic a l p re s e n ta tio n □ N e o n a ta l ja u n d ic e , o r c o n c e a le d w e ll in to a d u lth o o d □ M ild re tic u lo c y to s is , re fle c tin g lo w g ra d e c h ro n ic h e m o ly s is □ J a u n d ic e , g a lls to n e s , a n d s p le n o m e g a ly ■ A ffe c te d p a tie n ts m a y re q u ire s p le n e c to m y ■ M o s t c o m m o n ly a ffe c te d g e n e is A N K 1 (a n k y rin ), fo llo w e d b y S L C 4 A 1 (b a n d 3), a n d S P T B (a s p e c trin ) ■ In c re a s e d m e a n c o rp u s c u la r h e m o g lo b in c o n c e n tra tio n (M C H C )

i4.2 Elliptocytes are red cells that are twice as long as they are wide

a While they are the hallmark of hereditary elliptocytosis, they are usually seen (in small numbers) in iron deficiency anemia & myelodysplasia b Hereditary pyropoikilocytosis

□ M e re ly in d ic a te s th e p re s e n c e o f s p h e ro c y te s b u t d o e s n o t d is tin g u is h H S fro m o th e r c a u s e s o f s p h e ro c y te s s u c h a s im m u n e m e d ia te d h e m o ly s is □ D A T is n e g a tiv e in H S

4.1.1.2 Hereditary elliptocytosis/hereditary ovalocytosis ■ A u to s o m a l d o m in a n t d is o rd e r d u e to m u ta tio n s in th e s p e c trin a c h a in ■ HE is d ia g n o s e d w h e n > 2 5 % o f c irc u la tin g red c e lls are e llip to c y te s i4.2, d e fin e d a s c e lls tw ic e a s lon g as th e y are w id e ■ L ow p ro p o rtio n s o f e llip to c y te s s e e n c o m m o n ly in iron d e fic ie n c y , B 12 d e fic ie n c y , fo la te d e fic ie n c y , o r m y e lo p h th is is ■ T yp es o f H E

■ P e rip h e ra l b lo o d film s h o w s s p h e ro c y te s i4.1 a nd re tic u lo c y to s is

□ C o m m o n ty p e : A fric a n A m e ric a n s . M ild o r no h e m o ly s is in h e te ro z y g o te s , w h ile h o m o z y g o te s have m o d e ra te to s e v e re a n e m ia

■ L a c ta te d e h y d ro g e n a s e (L D ) a n d b iliru b in a re e le v a te d (e x tra v a s c u la r h e m o ly s is )

□ H e re d ita ry p y ro p o ik ilo c y to s is (H P P ): u n u s u a l s e n s itiv ity o f red c e lls to h e a t

■ E o s in 5 m a le im id e (E M A ) b in d in g b y flo w c y to m e try a nd a u to h e m o ly s is is re c o m m e n d e d fo r a d d itio n a l te s tin g

□ S p h e ro c y tic ty p e : d o u b le h e te ro z y g o s ity fo r H S and HE

□ D e c re a s e d E M A b in d in g is fo u n d in m o s t fo rm s o f H S , th o u g h n o t s p e c ific ■ D ia g n o s is m a y be s u p p o rte d b y g e l e le c tro p h o re s is o f re d c e ll m e m b ra n e p ro te in s ■ O s m o tic fra g ility te s t □ L e s s s e n s itiv e a n d s p e c ific

200

□ S to m a to c y tic ty p e (S o u th e a s t A s ia n o v a lo c y to s is ): M a la y s ia . C o n fe rs p ro te c tio n a g a in s t P v iv a x m a la ria

4.1.1.3 Hereditary stomatocytosis ■ A u to s o m a l d o m in a n t d is o rd e rs in w h ic h red c e lls have an e lo n g a te d , m o u th lik e , c e n tra l p a llo r i4.3

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

4: Hematopathology

Diseases of red blood cells>Cytoskeletal disorders | Enzyme disorders

i4.3 Stomatocytes

M Bite ceHs

■ A b n o rm a l s o d iu m /p o ta s s iu m p e rm e a b ility (d e c re a s e d p ro d u c tio n o f th e m e m b ra n e p ro te in s to m a tin )

■ C lin ic a l c o u rs e : n e o n a ta l ja u n d ic e a n d e p is o d ic h e m o ly tic a n e m ia , trig g e re d by e x o g e n o u s o x id a n t

■ 2 m a in ty p e s

■ P re v a le n c e o f G 6 P D d e fic ie n c y p a ra lle ls P la s m o d iu m fa lc ip a ru m m a la ria , th o u g h t to h a v e a p ro te c tiv e e ffe c t

□

S e ve re h y d ro c y to tic (o v e rh y d ra te d ) typ e : m a c ro c y to s is , m o d e ra te to s e v e re h e m o ly s is , a n d a lo w M C H C

□ X e ro c y to tic : n o rm o c y tic R B C s s e e n a s s p ic u la te d d e s s ic o c y te s , w ith m ild s to m a to c y to s is a nd ta rg e t c e lls ■ S to m a to c y to s is a s s o c ia te d w ith R h null red cell p h e n o ty p e ■ M a rk e d te n d e n c y fo r th ro m b o s is fo llo w in g s p le n e c to m y , so th e ra p e u tic s p le n e c to m y is a v o id e d

■ V a ria n ts □ G 6 P D A - a lle le : A fric a n A m e ric a n s . Y o u n g R B C s (in c lu d in g re tic u lo c y te s ) h a ve a d e q u a te G 6 P D le v e ls ; h ow eve r, G 6 P D is e x c e p tio n a lly fra g ile a n d s h o rt liv e d □ G 6 P D -M e d ite rra n e a n : Italy, G re e c e , S p a in , a n d A ra b ia . S e v e re G 6 P D d e fic ie n c y , b e c a u s e e ve n v e ry y o u n g R B C s a re d e p le te d o f G 6 P D . H e m o ly tic e p is o d e s m a y fu lm in a n t ■ F lu o re s c e n t s p o t te s t: N A D P H p ro d u c tio n is m e a s u re d (w h ich flu o re s c e s ) ■ In th e d a y s fo llo w in g a h e m o ly tic c ris is , re tic u lo c y to s is m a y lea d to a fa ls e ly n o rm a l G 6 P D a c tiv ity . R e p e a t te s tin g in >3 m o n th s

4.1.2 Enzyme disorders 4.1.2.1 Glucose-6-phosphate dehydrogenase (G6PD) deficiency ■ X lin ke d d is o rd e r, s e e n p rim a rily in m en

4.1.2.2 Pyruvate kinase (PK) deficiency

■ G 6 P D d e fic ie n t R B C s a re h y p e rs e n s itiv e to o x id a n t s tre s s , su ch a s c e rta in m e d ic a tio n s (m e th y le n e blue, su lfa c o n ta in in g d ru g s , n itro fu ra n to in , p rim a q u in e ), fa va b e a n s (fa vism ), a nd in fe c tio n

■ A u to s o m a l re c e s s iv e in h e rita n c e

■ O x id iz e d h e m o g lo b in p re c ip ita te s a s H e in z b o d ie s (v is u a liz e d w ith s u p ra v ita l d yes). W h e n R B C s b e a rin g H e in z b o d ie s p a s s th ro u g h th e s p le e n , th e y a re in ju re d by s in u s o id a l m a c ro p h a g e s , p ro d u c in g b lis te r c e lls and b ite c e lls i4.4

■ P K c a ta ly z e s th e ra te lim itin g s te p in th e E m b d e n -M e y e rh o f (g ly c o ly s is ) p a th w a y , w h ic h is th e m a in s o u rc e o f R B C A T P

■ P e rip h e ra l s m e a r: p o ik ilo c y to s is w ith b ite c e lls and b lis te r c e lls

■ P e rip h e ra l s m e a r: e c h in o c y te s (d e s s ic o c y te s ) i4.5

© A S C P 2018

■ H ig h fre q u e n c y in n o rth e rn E u ro p e a n d P e n n s y lv a n ia A m is h

■ C lin ic a l c o u rs e : c h ro n ic h e m o ly s is , m a n ife s te d as g a lls to n e s , ja u n d ic e , a nd s p le n o m e g a ly ■ F lu o re s c e n t s p o t te s t: c h e c k fo r c o n v e rs io n o f N A D H to N A D (w h ich d o e s n o t flu o re s c e )

ISBN 978-08 9189-6678

20 1

4: Hematopathology

Diseases of red blood cells>Enzyme disorders | Structurally abnormal hemoglobin variants (hemoglobinopathies) ■ T h e a g e n e s a re lo c a te d on c h ro m o s o m e 16 (2 c o p ie s on e a c h c h ro m o s o m e ), a n d th e P g e n e s a re lo c a te d on c h ro m o s o m e 11 p15 .5 (1 c o p y on e a c h c h ro m o s o m e ) ■ H e m o g lo b in o p a th y re fe rs to th e p ro d u c tio n o f a s tru c tu ra lly a b n o rm a l g lo b in c h a in t4.2 (th a la s s e m ia re fe rs to q u a n tita tiv e d e fe c ts in a g lo b in c h a in )

t4.2 p c h a in v a r ia n ts Variant S C

Amino acid

^Harlem

E

D (D-Los Angeles, D-Punjab) ®Arab

i4.5 Burr cells

6 6 6 & 73

Alteration glu—>val glu—>lys glu—>val & asp—>asn

26 121 121

glu—>lys glu—»gln glu—►lys

4.1.3.1 Hemoglobin S (P6 glu—>-val)

■ Q u a n tita tiv e P K a s s a y : c o n firm a to ry ■ A u to h e m o ly s is te s t (u n lik e H S ), d o e s n o t c o rre c t w ith a d d itio n o f g lu c o s e . It d o e s n o rm a liz e w ith th e a d d itio n o f ATP

4.1.2.3 Pyrim idine 5’ nucleotidase deficiency ■ R B C p y rim id in e 5 ’ n u c le o tid a s e d e g ra d e s R N A w ith in re tic u lo c y te ■ U n m e ta b o liz e d p y rim id in e s , re c o g n iz a b le a s b a s o p h ilic s tip p lin g , p re c ip ita te w ith in th e c e ll a n d c a u s e h e m o ly s is ■ L e a d in h ib itio n o f p y rim id in e 5 ’ n u c le o tid a s e is th e s o u rc e o f th e b a s o p h ilic s tip p lin g o b s e rv e d in lea d p o is o n in g

■ G e o g ra p h y : p re v a le n c e o f H b S m irro rs h is to ric p re v a le n c e o f P falciparum -, c o m m o n in A fric a n A m e ric a n s ■ S a lle le h as v a lin e in p la c e o f g lu ta m a te a t p o s itio n 6 o f th e h e m o g lo b in p c h a in (P6 g lu —>val) ■ H bS u n d e rg o e s a b n o rm a l p o ly m e riz a tio n w h e n d e o x y g e n a te d a n d s u ffic ie n tly c o n c e n tra te d (o ve r 5 0% ) ■ R B C s in s ic k le c e ll d is e a s e h ave s h o rte n e d s u rv iv a l, w ith an a v e ra g e life s p a n o f 17 d a y s (n o rm a l is 120 d ays) ■ C lin ic a l s e v e rity □ S ic k le c e ll d is e a s e (H b S S ) is a s e v e re h e m o ly tic d is e a s e □ S ic k le c e ll tra it (H b S A ) is g e n e ra lly a s y m p to m a tic □ M a n ife s ta tio n s s im ila r to H b S S s e e n in h o m o z y g o u s s ic k le ce ll P ° -th a la s s e m ia , a nd S C d is e a s e □ H b F e x e rts an in h ib ito ry e ffe c t on H b S p o ly m e riz a tio n

4.1.3 Structurally abnormal hemoglobin variants (hemoglobinopathies) ■ A v a rie ty o f n o rm a l h e m o g lo b in m o le c u le s is s y n th e s iz e d th ro u g h o u t life t4.1

t4.1 Normal hem oglobins Hemoglobin HbA

Chains

Role major adult hemoglobin

■ M a n ife s ta tio n s o f s ic k le ce ll d is e a s e a re n ot a p p a re n t u n til a b o u t 6 m o n th s o f age ■ In c o m b in e d s ic k le c e ll d is e a s e -h e re d ita ry p e rs is te n c e o f fe ta l h e m o g lo b in (S S -H P F H ) a nd H b S a s s o c ia te d w ith a -th a la s s e m ia , c lin ic a l m a n ife s ta tio n s a re m ild ■ C lin ic a l c o u rs e o f s ic k le ce ll d is e a s e

HbA2

@2^2 □2^2

minor adult hemoglobin

□ C h ro n ic h e m o ly tic a n e m ia , th ro m b o s e s , a n d re c u rre n t c ris e s

HbF

a2Y2

major late fetal hemoglobin

□ C ris e s

Hb Gowerl Hb Gower2

f,2i 2 a2£2

major early fetal hemoglobin minor early fetal hemoglobin

■ A p la s tic c ris e s a re c a u s e d by tra n s ie n t a rre s ts o f e ry th ro p o ie s is , u s u a lly d u e to P a rv o v iru s B19 ■ S p le n ic s e q u e s tra tio n c ris is o c c u rs d u rin g a vira l illn e s s

■ H e m o g lo b in A is a te tra m e r c o m p o s e d o f 2 a c h a in s a n d 2 p c h a in s

202

■ H y p e rh e m o ly tic c ris is p re s e n ts a s a su d d e n e x a c e rb a tio n o f a n e m ia ; m a y be c a u s e d by c o n c o m ita n t G 6 P D d e fic ie n c y

A S C P Q uick Com pendium o f Clinical Pathology 4e

© A S C P 2018

4: Hematopathology

Diseases of red blood cells>Structurally abnormal hemoglobin variants (hemoglobinopathies)

oV°

f4.1 Sickle cell trait as seen on alkaline gel

f4.2 Hemoglobin SC disease as seen in hemoglobin electrophoresis on alkaline gel (left) & acid gel (right)

□ E le c tro p h o re s is : 3 5 -4 5 % H b S , Structurally abnormal hemoglobin variants (hemoglobinopathies)

V S S *

*

O 0

• "«• I© • • ft, o o a 't a o

9

.

%

9 «

v

0

°

5

•

° .^ 2

C#

o- * * •

_____________________________ i4.7 Compound heterozygote for hemoglobin S & hemoglobin C (hemoglobin SC disease), showing sickle cell & numerous target cells alkaline

A2

I S

acid

J F

F

A2

S

f4.3 Sickle cell disease as seen on alkaline gel in hemoglobin electrophoresis (left) & acid gel (right)

£ S

i4.8 Hemoglobin C disease (homozygous CC) peripheral blood smear, showing hemoglobin C crystals & numerous target cells

4.1.3.3 Hemoglobin E (P6 glu—>lys) ■ C o m m o n in S o u th e a s t A s ia a n d is th e s e c o n d m o s t c o m m o n a b n o rm a l h e m o g lo b in w o rld w id e (a fte r h e m o g lo b in S) ■ T h a la s s e m ic in d ic e s on C B C ■ P e rip h e ra l s m e a r s h o w s n u m e ro u s ta rg e t c e lls ■ E le c tro p h o re tic p a tte rn : a b n o rm a l b a n d in th e C ban d (w ith A 2 ) ■ T y p ic a lly b e n ig n

■ P e rip h e ra l s m e a r □ S ic k le d c e lls s e e n o n th e p e rip h e ra l s m e a r o f p a tie n ts w ith s ic k le c e ll d is e a s e i4.7. Irre v e rs ib ly s ic k le d ce ll p re c e n t in v e rs e ly c o rre la te w ith R B C s u rv iv a l. S ic k le d c e lls m a y a ls o be s e e n in S-(3 th a la s s e m ia , S -C , S -D , and C ■ H b e le c tro p h o re s is in s ic k le c e ll d is e a s e : > 8 0 % H b S , 1 -2 0 % H bF, 1 -4 % H b A 2 , a n d 0 % H b A f4 .3

■ C o in h e rita n c e w ith p th a la s s e m ia m a y be c lin ic a lly se vere ; d is tin g u s h e d b y e le v a te d H b A 2 , b u t A 2 ru n s w ith E on g el e le c tro p h o re s is a n d on high p re s s u re liq u id c h ro m a to g ra p h y (H P L C ). C a p illa ry e le c tro p h o re s is is c a p a b le o f d is tin g u is h in g H b E fro m H b A 2

4.1.3.4 Hemoglobins D&G ■ H e m o g lo b in s D (H b D ) a nd G (H b G ): c lin ic a lly n o rm a l; but run w ith H b S on a lk a lin e gel

4.1.3.2 H e m o g lo b in C (P6 g lu —>lys) 4.1.3.2.1 Hemoglobin C trait (heterozygous AC) ■ E le c tro p h o re s is : 4 0 -5 0 % o f h e m o g lo b in w ith in th e C b a n d (th e C b a n d c o n ta in s b o th H b A 2 a n d H b C ) ■ A s y m p to m a tic ; p e rip h e ra l s m e a r h a s s c a tte re d ta rg e t c e lls 4.1.3.2.2 Hemoglobin C disease (homozygous CC)

■ A b s e n c e o f H b S ca n be d e te rm in e d by a s ic k le s c re e n s tu d y o r by th e fa c t th a t H b D a nd H b G run w ith H b A on c itra te g e ls ■ Hb D & G ca n be d is tin g u is h e d fro m o n e a no th e r, b e c a u s e H b D is a p c h a in d e fe c t a n d H b G is an a ch ain d e fe c t; H b G p ro d u c e s 2 H b A 2 b a n d s (1 n o rm a l, th e o th e r a b n o rm a l) s e p a ra te d by a d is ta n c e e q u a l to th a t s e p a ra tin g H b A fro m H b G

■ E le c tro p h o re s is : 9 0 % H b C , 7 % H bF, 3 % H b A 2 , 0 % H b A ■ M ild h e m o ly tic a n e m ia , s p le n o m e g a ly , a n d n u m e ro u s ta rg e t c e lls ■ H e x a g o n a l o r ro d s h a p e d c ry s ta ls i4.8 s e e n in R B C s , e s p e c ia lly a fte r s p le n e c to m y 204

4.1.3.5 Hemoglobin Lepore ■ F usion b e tw e e n 5 a nd p g e n e s ; se e n a ro u n d th e M e d ite rra n e a n , e s p e c ia lly Italy

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

4: Hematopathology

Diseases of red blood cells>Structurally abnormal hemoglobin variants (hemoglobinopathies) ■ H b L e p o re ru n s w ith H b S on a lk a lin e gel, b u t is ty p ic a lly p re s e n t in lo w p ro p o rtio n s □ S u s p e c t H b L e p o re w h e n -1 5 % o f “ h e m o g lo b in S ” is p re s e n t on th e e le c tro p h o re s is □ A c tu a l H b S is ra re ly p re s e n t in th is q u a n tity , u n le s s a g g re s s iv e ly tra n s fu s e d

4.1.3.6 Hemoglobin constant spring (HbCS) ■ C o m m o n in S o u th e a s t A s ia ■ T h a la s s e m ic ty p e R B C in d ic e s ■ M u ta tio n in th e a -g lo b in g e n e sto p c o d o n , p ro d u c in g an a b n o rm a lly lon g tra n s c rip t th a t is u n s ta b le ■ If th e a c s a lle le a ris e s in a s s o c ia tio n w ith a -g lo b in g e n e d e le tio n (on th e h o m o lo g o u s c h ro m o s o m e ), h e m o g lo b in H d is e a s e ca n re su lt ■ In h e te ro z y g o te s , th e h e m o g lo b in s p ro d u c e d a re a-(3 (H b A ), a c s -p (H b C S ), a -5 (H b A 2 ), a c s -5 (4 b a n d s a re se e n in th e a d u lt on c e llu lo s e a c e ta te e le c tro p h o re s is ). In th e n e w b o rn , a -y (H b F ), a n d a c s -y a re a ls o s e e n

4.1.3.7 Altered oxygen affinity hemoglobins

■ H b B a rts a nd H b H (se ve re a th a la s s e m ia ) a re a ls o a s s o c ia te d w ith H e in z b o d y a n e m ia

4.1.3.9 Methemoglobin (Hi, hemoglobin)

■ H e m o g lo b in s w ith s h ifte d o x y g e n d is s o c ia tio n c u rv e s f4.4 ■ H igh o x y g e n a ffin ity h e m o g lo b in s □ L e ftw a rd s h ift in th e o x y g e n d is s o c ia tio n c u rv e □ E ry th ro c y to s is □ E x a m p le s in c lu d e H b C h e s a p e a k e , J -C a p e to w n , M a lm o , Y a kim a , Y p sila n ti, R a inie r, a n d H b D e n v e r ■ L o w o x y g e n a ffin ity h e m o g lo b in s □ R ig h tw a rd s h ift in th e o x y g e n d is s o c ia tio n c u rv e □ A n e m ia a nd c y a n o s is □ E x a m p le s in c lu d e H b B e th Isra e l, K a n s a s , and P ro v id e n c e ■ N o t d is tin g u is h e d on g el e le c tro p h o re s is o r H P L C , b ut H b 0 2 d is s o c ia tio n c u rv e (P 5 0 ) is d ia g n o s tic

4.1.3.8 Unstable hemoglobins ■ H e m o g lo b in v a ria n ts w ith u n u s u a l s e n s itiv ity to o x id a tiv e s tre s s ■ A s s o c ia te d w ith H e in z b o d ie s a n d b ite c e lls , m im ic k in g G 6 P D d e fic ie n c y ■ S c re e n in g te s t □ In c u b a te lyse d R B C s w ith 17% is o p ro p a n o l, w h ic h c a u s e s p re c ip ita tio n o f u n s ta b le h e m o g lo b in s ■ E x a m p le s in c lu d e H b H a s h a ro n , K oln, S e a ttle , T a co m a , A n n A rb o r, and Z u ric h ■ C lin ic a l s e v e rity v a rie s fro m s e v e re (H b H a m m e rs m ith , A n n A rb o r, K oln) to m ild (m o s t o th e rs ) © A S C P 2018

f4.4 Hemoglobin-oxygen dissociation (oxygen affinity) curves

■ H e m o g lo b in in w h ic h iro n is in th e o x id iz e d fe rric (F e +++) s ta te in s te a d o f th e u s u a l fe rro u s (F e ++) ■ H e re d ita ry m e th e m o g lo b in e m ia □ R e s u lts fro m d e fic ie n c y in th e m e th e m o g lo b in re d u c ta s e s y s te m o r a b n o rm a l h e m o g lo b in s (H b M ) on w h ic h th is e n z y m e c a n n o t a c t □ D e fe c tiv e m e th e m o g lo b in re d u c ta s e : in h e rite d c y to c h ro m e b 5 R d e fic ie n c y (a u to s o m a l re c e s s iv e ) □ M h e m o g lo b in s ■ U s u a lly run w ith H b A o n ro u tin e g e ls ■ E x a m p le s in c lu d e H b M -lw a te , H b M -B o s to n , H b M -S a s k a to o n , and H b M -H y d e P a rk □ C y a n o s is a p p e a rs a t 6 m o n th s o f a g e , u n le s s th e re is M fe ta l h e m o g lo b in , in w h ic h c a s e c y a n o s is a b a te s a t 6 m o n th s ■ A c q u ire d m e th e m o g lo b in e m ia □ R e s u lts fro m e x p o s u re to d ru g s o r c h e m ic a ls th a t in c re a s e th e fo rm a tio n o f Hi □ C o m m o n e x a m p le s are n itrite s , q u in o n e s , p h e n a c e tin , a n d s u lfo n a m id e s ■ C y a n o s is re s u lts w h e n Hi re a c h e s 10% o f to ta l H b o r 1.5 g /d L ■ T h e b lo o d is g ro s s ly c h o c o la te -b ro w n ■ C o o x im e te r is c a p a b le o f m e a s u rin g m e th e m o g lo b in d ire c tly □ U n d e te c ta b le by p u ls e o x im e try a n d a rte ria l b lo o d g a s a n a ly z e rs

ISBN 978-08 9189-6678

205

4: Hematopathology

Diseases of red blood cells>Structurally abnormal hemoglobin variants (hemoglobinopathies) | Thalassemia ■ H i h a s v e ry h ig h a ffin ity fo r c y a n id e ; tre a tm e n t fo r c y a n id e to x ic ity in v o lv e s a d m in is tra tio n o f n itrite s to g e n e ra te Hi, w h ic h w ill c h e la te c y a n id e ■ T re a tm e n t fo r m e th e m o g lo b in e m ia is m e th y le n e b lu e , w h ic h re d u c e s H i to H b

■ C O is e lim in a te d by o x y g e n re p la c e m e n t. T h e h a lf-life on ro om a ir is ~ 6 h o u rs , w h ile th e h a lf-life on 100 % 0 2 is 1 h ou r

4.1.4 Thalassemia 4.1.4.1 General features

4.1.3.10 Sulfhem oglobin ■ S u lfh e m o g lo b in (S H b ) is fo rm e d w h e n h e m o g lo b in is o x id iz e d in th e p re s e n c e o f s u lfu r ■ S H b c a n n o t tra n s p o rt o x y g e n ■ S H b p re c ip ita te s to fo rm H e in z b o d ie s ■ S H b in c re a s e s a fte r e x p o s u re to s u lfo n a m id e s a n d in th e p re s e n c e o f C p e rfrin g e n s b a c te re m ia (e n te ro g e n o u s c y a n o s is ) ■ U n lik e H i, S H b c a n n o t b e re d u c e d to H b

4.1.3.11 Carboxyhemoglobin

■ Q u a n tita tive a b n o rm a lity o f s tru c tu ra lly n orm a l g lo b in chain ■ P re v a le n t in th e M e d ite rra n e a n , A fric a , a nd S o u th e a s t A sia , p a ra lle lin g p re v a le n c e o f m a la ria ■ 1 c o p y o f th e (3 g e n e (H B B ) is lo c a te d on e a ch c h ro m o s o m e 11, fo r a to ta l o f 2 p ro d u c tiv e p g e n e s □ P° a lle le s re su lt in c o m p le te a b s e n ce o f p chain p rod uctio n ; ca u se d by n o n s e n s e o r fra m e s h ift m utatio n s □ p + a lle le s re s u lt in d im in is h e d p c h a in p ro d u c tio n ; m u ta tio n s in p ro m o te r s e q u e n c e , o r 5 ’ u n tra n s la te d re g io n □ p + M e d ite rra n e a n is m o re s e v e re th a n p + A m e ric a n

■ C O b in d s tig h tly (w ith 2 0 0 * th e a ffin ity o f o x y g e n ) to h e m o g lo b in , fo rm in g c a rb o x y h e m o g lo b in (H b C O ), re d u c in g th e a v a ila b le b in d in g s ite s fo r o x y g e n ■ C O h a s e v e n g re a te r a v id ity fo r fe ta l h e m o g lo b in , p la c in g in fa n ts (a n d fe tu s e s ) a t g re a t ris k

□ D u e to la rg e n u m b e r o f a lle le s , te s tin g b a s e d on e th n ic ity w ith ta rg e te d P C R . G e n e s e q u e n c in g c o n firm a to ry ■ 2 c o p ie s o f th e a g e n e s on e a c h c h ro m o s o m e 16, fo r a to ta l o f 4 a c h a in s

■ C O is d ire c tly to x ic to in tra c e llu la r o x id a tiv e m e c h a n is m s a n d in c re a s e s n itric o x id e c a u s in g v a s o d ila tio n

□ a th a la s s e m ia a lle le s u s u a lly re s u lt fro m la rg e s tru c tu ra l d e le tio n s

■ T h e c lin ic a l e ffe c ts o f c a rb o n m o n o x id e in to x ic a tio n v a ry w ith th e p ro p o rtio n o f H b C O t4 .3

□ a th a la s s e m ia 2 (a+ th a la s s e m ia ): C H R O M O S O M E 16 h as 1 n o rm a l a n d 1 d e le te d a g e n e ( - a / ) ; c o m m o n in A fric a n A m e ric a n s

t4.3 Clinical effects of carbon monoxide poisoning Clinical findings

Level of HbCO (%) 0.4-2

2-6 10-20 20-50 >50

normal nonsmoker normal smoker mild symptoms: dyspnea on exertion severe symptoms: intoxication, with headache, lethargy, loss of consciousness coma & death

■ H b C O is p ro d u c e d e n d o g e n o u s ly fro m b re a k d o w n o f h e m e , re s u ltin g in H b C O le v e ls Thalassemia □ E leva te d R B C c o u n t (> 5 .5 * 10 12 in m en , > 5 .0 * 1012 in w om en) □ R e d u c e d M C V (6 5 -7 5 fL in a th a la s s e m ia , 5 5 -6 5 fL in p th a la s s e m ia ) □ L o w h e m a to c rit □ R B C d is trib u tio n w id th (R D W ) is n o rm a l to s lig h tly in c re a s e d ■ M a rk e d ly in c re a s e d R D W o f iro n d e fic ie n c y □ P la te le t c o u n t ty p ic a lly n o rm a l ■ O fte n in c re a s e d in iro n d e fic ie n c y □ M C V :R B C ra tio (M e n tz e r in d e x) 15 fa v o rs iro n d e fic ie n c y □ P e rip h e ra l s m e a r fin d in g s in c lu d e m ic ro c y tic h y p o c h ro m ic c e lls , o c c a s io n a l ta rg e t c e lls (m o re in 3 th a la s s e m ia th a n a th a la s s e m ia ), a nd b a s o p h ilic s tip p lin g i4.9 ■ D o u b le h e te ro z y g o s ity fo r p th a la s s e m ia a nd an a b n o rm a l p c h a in re s u lts in in c re a s e d p e rc e n ta g e o f a b n o rm a l P ch ain; e g, in S -P th a la s s e m ia , th e re is > 5 0 % H b S w ith 1-15% H bF ■ a th a la s s e m ia le a d s to d e c re a s e d p e rc e n ta g e o f a b n o rm a l p c h a in s ; eg, in S -a th a la s s e m ia th e re is 3 0 -3 5 % H b S w ith 1 a g e n e d e le tio n , a n d 2 5 -3 0 % H bS w ith 2 a g e n e d e le tio n s

■ C o m m o n in s u b -S a h a ra n A fric a a n d S o u th e a s t A s ia ■ a th a la s s e m ia 1 g e n e is p re v a le n t in A s ia n s w h o a re a t ris k fo r th e v e ry s e v e re k in d s o f a th a la s s e m ia (h e m o g lo b in B a rts a n d h e m o g lo b in H d is e a s e s ) ■ a th a la s s e m ia 2 g e n e is p re v a le n t in A fric a n A m e ric a n s ■ S in g le g e n e d e le tio n is a s y m p to m a tic , w ith n o rm a l C B C , a n d n o rm a l e le c tro p h o re s is t4 .5

t4.5 a thalassemia syndromes CBC Genotype Syndrome

Hb Barts disease (hydrops fetalis)

aalaa - alaa -a l-a or - -laa - -/-a or - -/aCSa

normal normal thalassemic thalassemic Heinz bodies hypochromia nucleated RBCs

Electrophoresis normal normal normal fast migrating HbH HbH = (34 tetramers fast migrating Hb Barts Hb Barts = y4 tetramers

CBC - complete blood count; RBCs = red blood cells m a th a la s s e m ia tra it, w ith 2 m u ta te d a g e n e s s h o w s

th a la s s e m ic in d ic e s a nd e le c tro p h o re s is w ith n o rm a l p e rc e n ta g e o f A 2 . In th e a b s e n c e o f iro n d e fic ie n c y , th is ca n be in te rp re te d a s c o n s is te n t w ith a th a la s s e m ia tra it

© A S C P 2018

■ U n lik e p th a la s s e m ia , m a n ife s ta tio n s o f a th a la s s e m ia a re p re s e n t a t b irth ■ H e m o g lo b in H d is e a s e re s u lts fro m 3 m u ta te d a g e n e s ; in te rm e d ia te s e v e rity

4.1.4.3 p thalassemia syndromes ■ p th a la s s e m ia is p re v a le n t in M e d ite rra n e a n p o p u la tio n s

4.1.4.2 a thalassemia syndromes

normal adult silent carrier a thalassemia trait HbH disease

i4.9 Thalassemia blood smear; red cells are microcytic & there are numerous target cells

■ M a n ife s ta tio n s e v id e n t by 6 -9 m o n th s o f a g e ■ p th a la s s e m ia m in o r: in h e rita n c e o f 1 a b n o rm a l p g e n e , e ith e r p + o r p° □ E le c tro p h o re s is : c o m m o n ly h ig h H b A 2 (> 2 .5 % , u s u a lly 4 -8 % ) a n d n o rm a l H bF □ If a ls o iro n d e fic ie n t, n o rm a l H b A 2 s e e n . D o n o t e rro n e o u s ly in te rp re t a s a th a la s s e m ia . E le c tro p h o re s is s h o u ld be re p e a te d fo llo w in g iro n re p le tio n ■ 5 -P th a la s s e m ia (d e le tio n o f b o th th e 5 a n d p g e n e s ): H b A 2 q u a n tity is n o rm a l and H b F e le v a te d (5 -2 0 % ) ■ H e te ro z y g o u s H b L e p o re (fu s io n o f 6 a n d P): H b A 2 q u a n tity is n o rm a l, H b F is s lig h tly e le v a te d , a n d a b a n d in th e S re g io n c o m p ris e s 6 -1 5 % (H b L e p o re ) ■ p th a la s s e m ia m a jo r: in h e rita n c e o f 2 a b n o rm a l p g e n e s su ch as P°P°, p +medp+medi o r p 0p +med □ S e ve re a n e m ia by 1 y e a r o f a g e □ E le c tro p h o re s is : in c re a s e d H b F (5 0 -9 5 % ), n o rm a l to e le v a te d H b A 2 , a n d little to no H b A □ H b F in th is c o n d itio n , as in m o s t th in g s o th e r th a n h e re d ita ry p e rs is te n c e o f fe ta l h e m o g lo b in (H P F H ; b e lo w ) is in a h e te ro c e llu la r d is trib u tio n (s o m e c e lls w ith and s o m e c e lls w ith o u t on th e K le ih a u e r-B e tk e sta in)

ISBN 978-08 9189-6678

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4: Hematopathology

Diseases of red blood cells>Thalassemia | Immune hemolytic disorders 4.1.4.4 H e m o g lo b in A 2 p rim e ■ H e m o g lo b in A 2 p rim e ( H b A 2 ’) is a c lin ic a lly in s ig n ific a n t 5 c h a in v a ria n t th a t o c c u rs in 1 -2% o f A fric a n A m e ric a n s

■ A n tib o d y b o u n d to th e R B C a c ts a s an o p s o n in th a t p ro v o k e s R B C d e s tru c tio n b y s p le n ic m a c ro p h a g e s (e x tra v a s c u la r h e m o ly s is )

■ H b A 2 ’ c h a in s a re b a re ly d e te c ta b le o n e le c tro p h o re s is , le a d in g to u n d e rd ia g n o s is o f (3 th a la s s e m ia tra it

■ T h e D A T (C o o m b s te s t) is th e c ru c ia l te s t in d ia g n o s is , and is p o s itiv e in n e a rly all c a s e s o f W A IH A

■ T o e v a lu a te (3 th a la s s e m ia tra it, H b A 2 a n d H b A 2 ’ le v e ls n e e d e d . A 2 ’ is e a s ily d e te c ta b le b y H P L C , w h e re it p ro d u c e s a m in o r p e a k in th e S a re a

□ R e a c tiv e w ith p o ly s p e c ific a n d a n ti-Ig G re a g e n ts □ M a y be fa ls e ly n e g a tive , d u e to ra p id in tra v a s c u la r d e s tru c tio n o f R B C s o r lo w tite r a n tib o d y ■ P e rip h e ra l s m e a r: m ic ro s p h e ro c y te s

4.1.4.5 Hereditary persistence of fetal hemoglobin ■ y c h a in p ro d u c tio n is h ig h in fe ta l life, re s u ltin g in h ig h H bF ■ H b F is u s u a lly < 1 0 % b y 6 m o n th s o f a g e , < 5 % by 1 year, a n d < 2 % b y 2 y e a rs a n d th e re a fte r ■ D e la y e d s w itc h fro m y to p o r 5 c h a in s ■ C h a ra c te riz e d b y H b F in a p a n c e llu la r d is trib u tio n ■ F c e lls (H b F b e a rin g c e lls ) m a y b e o b s e rv e d in n o rm a l p re g n a n c y , m o la r p re g n a n c y (n u m e ro u s ), b o n e m a rro w fa ilu re s y n d ro m e s , F a n c o n i a n e m ia (FA), ju v e n ile m y e lo m o n o c y tic le u k e m ia , a n d e ry th ro le u k e m ia (F A B M 6) ■ S S -H P F H s h o w s p a n c e llu la r d is trib u tio n o f - 2 5 % H b F a n d s u ffe r fro m n e ith e r a n e m ia n o r v a s o -o c c lu s iv e e p is o d e s ■ A d u lt h e m o g lo b in e le c tro p h o re s is w ith H b S , HbF, a n d H b A 2 h a s 2 m a in c a u s e s S S -H P F H a n d c o m b in e d s ic k le c e ll-P -th a la s s e m ia . T h e s e a re d is tin g u is h e d by p a n c e llu la r d is trib u tio n in th e fo rm e r a n d h e te ro c e llu la r in th e la tte r; S S -H P F H p a tie n t is c lin ic a lly m u c h h e a lth ie r th a n th e S S -p

4.1.5 Immune hemolytic disorders

t4.6 W arm autoim m une hem olytic anem ia (W AIHA), cold agglutinin disease (CAD), paroxysm al cold hemoglobinuria (PCH) WAIHA

CAD

PCH

IgG IgM IgG antibroad Rh anti-l, i anti-P DAT IgG only (2/3); C3 C3 lgG/C3 (1/4) serum all cells in panel most cells in panel antibody panel react (AHG phase ) react (IS/AHG negative phases) biphasic hemolysin setting lymphoma, M pneumoniae young children: viral medications (anti-l), infectious syphilis mono (anti-i), lymphoma AHG = antihuman globulin; DAT = direct antiglobulin test; IS = immediate spin

208

□ M a y be p rim a ry (id io p a th ic ) o r s e c o n d a ry (7 0 % o f cases) □ S e c o n d a ry W A IH A is d u e to ly m p h o m a (ty p ic a lly C L L / S L L), u n d e rly in g s y s te m ic a u to im m u n e d is o rd e r o r c o lla g e n v a s c u la r d is e a s e , th y m o m a , a nd s te m ce ll tra n s p la n ta tio n 4.1.5.2 C o ld a u to a g g lu tin in s ■ M e d ia te d b y Ig M a n tib o d ie s , m o s t c o m m o n ly a n ti-l. t4.7 ■ M o s t a re IgM a n d ca n a c tiv a te c o m p le m e n t ■ C o ld re a c tiv e a n tib o d ie s (cold a u to a g g lu tin in s ) m ay be p a th o lo g ic o r n o n p a th o lo g ic □ L a b o ra to ry fe a tu re s in p re d ic tin g p a th o g e n ic ity a re h ig h tite r a n d b ro a d th e rm a l ra n g e (th e rm a l a m p litu d e ) ■ M ay c a u s e s p o n ta n e o u s a u to a g g lu tin a tio n in a n tic o a g u la te d b lo o d a t ro o m te m p e ra tu re i4.10

0 cord 0 adult

■ M e d ia te d b y a w a rm re a c tin g Ig G a n tib o d y t4 .6 . w ith b ro a d re a c tiv ity w ith R B C a n tig e n s , e s p e c ia lly Rh a n tig e n s

ig

■ E tio lo g ie s

t4 .7 Antibody specificities in cold agglutinin disease

4.1.5.1 Warm autoimmune hemolytic anemia

Syndrome

■ C lin ic a l c o u rs e : v a rie s fro m a b ru p t o n s e t w ith s e v e re s y m p to m a tic a n e m ia to c h ro n ic lo w g ra d e h e m o ly s is

A1 adult A2 adult Specificity Notes

while often benign, anti-l is most common cause of CAIHA; sometimes associated with M pneumoniae; enzymes enhance +++ i — sometimes associated with EBV infectious mono +++ +++ + -/+ H neutralized by saliva; almost always benign ± +++ ± +++ IH neutralized by saliva; almost always benign +++ +++ +++ +++ Pr rare; destroyed by enzymes; do not confuse with anti-P CAIHA = cold autoimmune hemolytic anemia; EBV = Epstein-Barr virus

■ A u to m a te d C B C s a re u s u a lly u n re lia b le , s in c e m o s t re a c t a t ro o m te m p e ra tu re

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

4: Hematopathology

Diseases of red blood cells>lmmune hemolytic disorders

i4.10 Cold agglutinin disease; red cell clumps are the morphologic hallmark

■ M e d ia te d by IgG b ip h a s ic h e m o ly s in w ith a n ti-P s p e c ific ity (D o n a th L a n d s te in e r a n tib o d y )

□ H e m o g lo b in is th e o n ly re lia b le C B C ind e x ■ If m o n o s p e c ific re a g e n ts a re u se d , th e c e lls a re a g g lu tin a te d by a n ti-C 3 d b u t n o t a n ti-Ig G ■ A lw a y s lo o k b e yo n d th e c o ld re a c tin g a n tib o d y fo r m a s k e d a llo a n tib o d ie s □ P re w a rm e d s c re e n , c o ld a u to a d s o rp tio n , o r a d s o rp tio n w ith ra b b it e ry th ro c y te stro m a ■ T h e re a re 2 m a in ty p e s □ Id io p a th ic c o ld a u to im m u n e h e m o ly tic a n e m ia (C A IH A ) o r c o ld a g g lu tin in s y n d ro m e

□ P ro d u c e s h e m o ly s is o n ly w h e n in c u b a te d a t 2 d iffe re n t te m p e ra tu re s in v itro t4 .8 □ C o n firm a to ry D o n a th L a n d s te in e r te s t: p o s itiv e te s t is o b ta in e d if in c u b a tio n o f th e p a tie n t’s R B C s a t 4°C a nd th e n 37°C le a d s to h e m o ly s is ■ L ike C A IH A , D A T is p o s itiv e w ith p o ly s p e c ific a n tih u m a n g lo b u lin , n e g a tiv e w ith a n ti-Ig G , a n d p o s itiv e w ith a n ti-C 3

t4.8 Example positive Donath-Landsteiner test

■ O ld e r in d iv id u a ls p re s e n tin g w ith a c ro c y a n o s is , R e y n a u d p h e n o m e n o n , a n d h e m o ly tic a n e m ia ■ M o n o c lo n a l IgM a n tib o d y , w ith a n ti-l, a n ti-i, a n ti-H , a n ti-IH o r a n ti-P r s p e c ific ity t4 .6 , t4.7 ■ A g g lu tin a tio n a nd c o m p le m e n t fix a tio n o c c u rs in th e e x tre m itie s , le a d in g to in tra v a s c u la r ly sis □ S e c o n d a ry C A IH A ■ A tra n s ie n t c o n d itio n o fte n a s s o c ia te d w ith M pneumonia in fe c tio n (a n ti-l) o r E B V a s s o c ia te d in fe c tio u s m o n o n u c le o s is (a n ti-i) 4.1.5.3 P a ro xysm al c o ld h e m o g lo b in u ria (PCH) ■ A ffe c ts p rim a rily c h ild re n w ith v ira l illn e s s e s such a s m e a s le s , m u m p s , c h ic k e n p o x , a n d in fe c tio u s m o n o n u c le o s is ■ P re s e n ts w ith p a ro x y s m a l e p is o d e s a s s o c ia te d w ith c o ld e x p o s u re □ E p is o d e s c h a ra c te riz e d by s u d d e n fever, c h ills, a b d o m in a l and b a c k pain, a n d h e m o g lo b in u ria □ E ven tu a l ja u n d ic e w ith s e v e re a n e m ia ■ P e rip h e ra l b lo o d s m e a r s h o w s u n iq u e in tra n e u tro p h ilic h e m o p h a g o c y to s is i4.11 ■ T re a tm e n t by k e e p in g th e p a tie n t w a rm a nd tra n s fu s in g p re w a rm e d b lo o d

© A S C P 2018

i4.11 Paroxysmal cold hemoglobinuria; neutrophils with ingested red cells are a rare finding

Procedure 30 minutes 30 minutes results

V ia M 37°C 37°C no hemolysis

V ial 2 4°C 37°C hemolysis

4.1.5.4 Cryoglobulinemia ■ Im m u n o g lo b u lin s th a t p re c ip ita te re v e rs ib ly a t lo w te m p e ra tu re (n ot a g g lu tin a tin g red c e lls o r c a u s in g s ig n ific a n t h e m o ly s is ) ■ C ry o g lo b u lin s a re fo u n d in te m p e ra tu re m a n ip u la te d s e ru m (as o p p o s e d to c ry o fib rin o g e n fo u n d in p la s m a ) □ T yp e I: m o n o c lo n a l im m u n o g lo b u lin fo u n d in m u ltip le m y e lo m a o r W a ld e n s tro m m a c ro g lo b u lin e m ia □ T yp e II ■ M ost com m on ■ M ix tu re o f a m o n o c lo n a l Ig M a n d a p o ly c lo n a l IgG ■ IgM h as rh e u m a to id fa c to r a c tiv ity (a n ti-Ig G ) □ T yp e III: m ix tu re o f 2 p o ly c lo n a l im m u n o g lo b u lin s □ T h e m ixe d ty p e s (ty p e s II a n d III) a ffe c t p a tie n ts w ith ly m p h o p ro life ra tiv e d is o rd e rs , c h ro n ic in fe c tio n s , c h ro n ic liv e r d is e a s e s , and a u to im m u n e d is e a s e s (e s p e c ia lly lupus). H C V is th e m o s t c o m m o n c a u s e o f m ixe d c ry o g lo b u lin e m ia

ISBN 978-08 9189-6678

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4: Hematopathology

Diseases of red blood cells>lmmune hemolytic disorders Disorders of marrow production>lron deficiency ■ P re s e n ta tio n □ P a lp a b le p u rp u ra (le u k o c y to c la s tic v a s c u litis ), a rth ra lg ia , h e p a to s p le n o m e g a ly , ly m p h a d e n o p a th y , a n e m ia , s e n s o rin e u ra l d e fic its , a n d g lo m e ru lo n e p h ritis □ G lo m e ru lo n e p h ritis ■ M a n ife s ts a s e ith e r n e p h ro tic o r n e p h ritic s y n d ro m e ■ H is to lo g ic a lly re s e m b le s m e m b ra n o p ro life ra tiv e g lo m e ru lo n e p h ritis ty p e II i4.12 ■ D e p o s its in s o m e a c u te c a s e s re s e m b le th ro m b o tic m ic ro a n g io p a th y i4.12 ■ E le c tro n m ic ro s c o p y s h o w s s u b e n d o th e lia l im m u n e c o m p le x d e p o s its w ith a fib rilla ry o r tu b u la r s tru c tu re in a fin g e rp rin t-lik e p a tte rn ■ P e rip h e ra l s m e a r: p a le p u rp le c lo u d y a g g re g a te s o f p ro te in ■ C ry o fib rin o g e n s □ M ix tu re o f fib rin , fib rin o g e n , fa c to r V II, a n d fib ro n e c tin th a t p re c ip ita te o u t o f p la s m a s to re d a t 4°C

4.1.5.5 Paroxysmal nocturnal hemoglobinuria ■ A c q u ire d c lo n a l R B C d is o rd e r; d e fe c t in h e m a to p o ie tic s te m c e ll ■ M u ta tio n s o f p h o s p h a tid y l in o s ito l g ly c a n c la s s A (P IG -A ) g e n e o n X c h ro m o s o m e □ L e a d to d e c re a s e d g ly c o s y l p h o s p h a tid y l in o s ito l (G P I) a n c h o rs □ A ffe c te d R B C s d is p la y d im in is h e d c e ll s u rfa c e d e c a y a c c e le ra tin g fa c to r (D A F, C D 5 5 ), d e c re a s e d m e m b ra n e in h ib ito r o f re a c tiv e ly s is (M IR L , C D 5 9 ), d e c re a s e d a c e ty lc h o lin e s te ra s e (A c h E ), d e c re a s e d C D 1 6 , a n d d e c re a s e d C D 4 8 □ A ffe c te d R B C s h a v e in c re a s e d s e n s itiv ity to c o m p le m e n t m e d ia te d ly sis ■ C lin ic a l p re s e n ta tio n □ C la s s ic p re s e n ta tio n o f e p is o d ic h e m o ly s is c h a ra c te riz e d b y a b d o m in a l p a in , b a c k p a in , a n d h e a d a c h e s , e s p e c ia lly a t n ig h t □ C o m m o n ly p re s e n ts s im p ly a s c h ro n ic h e m o ly tic a n e m ia □ H e m o g lo b in u ria (in d ic a tiv e o f in tra v a s c u la r h e m o ly s is ) □ M a y p re s e n t w ith th ro m b o s is , a n d e x c lu s io n o f P N H s h o u ld b e c o n s id e re d in all p a tie n ts w ith u n e x p la in e d th ro m b o p h ilia □ M a y p re s e n t a s a p la s tic a n e m ia

i4.12 Cryoglobulinemia: a The characteristic glomerular lesion has a resemblance to membranoproliferative glomerulonephritis, b At high power, characteristic bland intracapillary thrombi are seen

■ C lin ic a l c o u rs e □ P a tie n ts d e v e lo p w o rs e n in g red b lo o d ce ll d e fe c ts and m a y d e v e lo p th ro m b o c y to p e n ia a n d le u k o p e n ia □ M a y p ro g re s s to a n e m ia a n d /o r a c u te m y e lo g e n o u s le u k e m ia ■ DAT is n e g a tiv e ■ L e u k o c y te a lk a lin e p h o s p h a ta s e (L A P ) s c o re is d e c re a s e d ■ B o n e m a rro w is m ild ly h y p e rc e llu la r, w ith e ry th ro id h y p e rp la s ia , d e p le te d iro n s to re s , a n d p o s s ib ly m ild d y s e ry th ro p o ie s is ■ L a b o ra to ry d ia g n o s is □ T ra d itio n a l s c re e n in g te s ts , H a m a n d s u c ro s e h e m o ly s is , h ave lo w s e n s itiv ity □ F lo w c y to m e try f4 .5 is m o re s e n s itiv e ■ F o r d e fin itiv e d ia g n o s is , d e fic ie n c y o f >2 G PI a n c h o re d a n tig e n s on 2 ce ll lin e s (n e u tro p h ils , m o n o c y te s , o r R B C s) ■ P e rip h e ra l b lo o d is th e s p e c im e n o f c h o ic e ■ F o r R B C a n a ly s is , C D 5 5 a nd C D 5 9 a re s tu d ie d . R B C s a re c la s s ifie d a s ty p e I (n o rm a l a n tig e n e x p re s s io n ), ty p e II (p a rtia l a n tig e n d e fic ie n c y ), and ty p e III (c o m p le te d e fic ie n c y ) ■ F o r a n a ly s is o f g ra n u lo c y te s a n d m o n o c y te s , C D 14, C D 15, C D 1 6, C D 3 3 , flu o re s c e n t a e ro ly s in (F L A E R ) m a y be u sed

4.2 Disorders of marrow production 4.2.1 Iron deficiency ■ T y p ic a lly p re s e n ts a s h y p o c h ro m ic m ic ro c y tic a n e m ia t4.9, i4.13, i4.14 ■ L a b o ra to ry d ia g n o s is

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Disorders of marrow production>lron deficiency

f4 5 Paroxysmal nocturnal hemoglobinuria (PNH) flow cytometry, a Normal & b PNH granulocytes, c normal & d PNH monocytes, and e normal & f PNH red cells For the evaluation of granulocytes, diminished CD24 expression & diminished FLAER binding indicate a subpopulation of abnormal cells. Diminished CD14 & FLAER binding on monocytes is consistent with PNH. Lastly, red cells, identified by CD135 (glycophorin) expression show diminished CD59 in PNH cells. Red cells with normal CD59 expression (red population in f) are classified as type I cells. Red cells with complete CD59 deficiency (green population in f) are classified as type III cells, and cells with partial CD59 deficiency (blue) are classified as type II cells. j

0 7j _ j * * y

4

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O l. ^ o V ® O O * ,*« d • °0Oo, V * < 3 ^ % o *-« d O o ■< % .

°

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i4.14 Iron deficiency deficiencv anemia; anemia: higher magnification image, showing hypochromic red cells & frequent thin elliptocytes (pencil cells)

ISBN 978-08 9189-6678

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4: Hematopathology

Disorders of marrow production>lron deficiency | Folate & vitamin B12 t4.9 M anifestations of iron deficiency

t4.10 Causes of iron deficiency

blood

infants & children adult

microcytosis (J. MCV) hypochromia (J, MCH) anemia anisocytosis ( f RDW) poikilocytosis (pencil cells) thrombocytosis marrow i iron stores mild erythroid hyperplasia chemistries f zinc protoporphyrin (ZPP) i iron t total iron binding capacity (TIBC) l iron saturation | ferritin iron deficiency anemia MCHC = mean corpuscular hemoglobin concentration; MCV = mean corpuscular volume; RDW = red blood cell distribution width; TIBC = total iron binding capacity; ZPP = zinc protoporphyrin

□ E a rlie s t fin d in g is a d e c re a s e in s e ru m fe rritin (m o s t s e n s itiv e te s t) ■ F e rritin is a n a c u te p h a s e re a c ta n t a n d m a y be e le v a te d in h e p a tic in s u ffic ie n c y d u e to im p a ire d c le a ra n c e

decreased intake; increased use with inadequate intake (growth spurts) blood loss (eg, colon cancer, menses); decreased intake (strict vegetarianism); decreased absorption (celiac sprue, small bowel resection); increased use with poor intake (pregnancy, lactation)

□ In c o rp o ra te d into h e m e (h e m o g lo b in , m y o g lo b in , o x id a tiv e e n z y m e s ) o r s to ra g e iro n (fe rritin , h e m o s id e rin ) □ 1 m L w h o le b lo o d c o n ta in s 0 .5 m g iron (1 ml_ R B C s c o n ta in s 1 m g iron) ■ C h ild re n w ith e le v a te d lead le v e ls a re m o re like ly to have iron d e fic ie n c y

4.2.2 Folate & vitamin B12 t4.11, t4.12 t4.11 Causes of folate & vitamin B12 deficiency ____________________Folate deficiency B„ deficiency________ diet malabsorption

common (alcoholics) sprue

□ D e c re a s e d p e rc e n t s a tu ra tio n o f tra n s fe rrin , in c re a s e d to ta l iro n b in d in g c a p a c ity (T IB C ) ■ P e rc e n t s a tu ra tio n o f tra n s fe rrin is c a lc u la te d fro m th e s e ru m iro n a n d th e T IB C

_____ increased demand

■ P e rc e n t s a t = [s e ru m iro n ]/T IB C * 100 ■ In iro n d e fic ie n c y , th e p e rc e n t s a tu ra tio n is g e n e ra lly < 1 5%

drugs inherited

pregnancy hemolysis methotrexate none

■ P e rc e n t s a tu ra tio n a n d T IB C a re in v e rs e ly re la te d □ D e c re a s e d s e ru m iro n , in c re a s e d z in c p ro to p o rp h y rin (Z P P ) a n d fre e e ry th ro c y te p ro to p o rp h y rin (F E P ) ■ Z P P a n d F E P a re in c re a s e d in iro n d e fic ie n c y , a n e m ia o f c h ro n ic d is e a s e , a n d le a d to x ic ity □ In c re a s e d s e ru m s o lu b le tra n s fe rrin re c e p to r (S S T R ) □ M a n y fe a tu rs o v e rla p w ith th a la s s e m ia a n d a n e m ia o f c h ro n ic d is e a s e (A C D ) ■ ID A a n d th a la s s e m ia a re m o re lik e ly to b e m ic ro c y tic a n d d e m o n s tra te ta rg e t c e lls ; A C D is m o re lik e ly to b e n o rm o c y tic a n d s h o w s no ta rg e t c e lls ■ ID A d e m o n s tra te s h ig h e r R D W (o fte n >17) th a n th a la s s e m ia o r A C D ■ P e n c il c e lls a re ty p ic a l o f ID A b u t n o t c o m m o n in th a la s s e m ia o r A C D □ M ic ro s c o p ic e x a m in a tio n o f m a rro w fo r iro n s to re s re m a in s o n e o f th e m o s t a c c u ra te te s ts o f iro n s ta tu s (g o ld s ta n d a rd ) ■ Iro n m e ta b o lis m t4.10 □ A b s o rb e d p re d o m in a n tly in d u o d e n u m □ T ra n s p o rte d in th e b lo o d s tre a m b y tra n s fe rrin

212

rare (strict vegetarians) pernicious anemia postgastrectomy pancreatic insufficiency Crohn disease Diphyllobothrium latum infestation pregnancy hemolysis dilantin transcobalamin II deficiency

t4.12 Manifestations of folate & vitamin B12 deficiency peripheral blood

oval macrocytosis hypersegmented neutrophils pancytopenia (when severe) anisopoikilocytosis (variable) bone marrow hypercelluiarity megaloblastic changes erythroid hyperplasia with left shift chemistry folate deficiency t LD & indirect bilirubin i serum & RBC folate T urinary FIGLU (formiminoglutamic acid) B12 deficiency f LD & indirect bilirubin l serum B12 t urinary methylmalonic acid j RBC folate (2/3 of cases) LD = lactate dehydrogenase; RBC = red blood cell

4.2.2.1 Folate ■ In g e s te d in g re e n v e g e ta b le s , a b s o rb e d in je ju n u m , and re le a s e d fro m e n te ro c y te s a s m e th yl fo la te ■ C o n v e rte d in ta rg e t c e lls to te tra h y d ro fo la te (T H F ) by a B 12 d e p e n d e n t m e th y ltra n s fe ra s e ■ T H F a c ts a s a c o fa c to r in m e th yl tra n s fe r re a c tio n s like c o n v e rs io n o f d U M P to d T M P

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4: Hematopathology

Disorders of marrow production>Folate & vitamin B121Anemia of chronic disease ■ F o la te d e fic ie n c y le a d s to im p a ire d D N A s y n th e s is a nd im p a ire d n u c le a r m a tu ra tio n

4.2.2.2 Vitamin B12 ■ In g e s te d in a n im a l p ro d u c ts , b o u n d to R fa c to r in th e s to m a c h , re le a s e d fro m R fa c to r in th e d u o d e n u m by p a n c re a tic e n z y m e s , a n d b o u n d to g a s tric d e riv e d in trin s ic fa c to r (IF ) ■ IF b o u n d B 12 is a b s o rb e d in th e ile u m , b o u n d to tra n s c o b a la m in I a nd II in e n te ro c y te s , a nd is e x p o rte d to th e b lo o d s tre a m ■ B 12 is a c o fa c to r fo r c o n v e rs io n o f m e th y l fo la te to th e a c tive fo rm T H F ; in B 12 d e fic ie n c y , m e th y l fo la te a c c u m u la te s (the “ m e th yl fo la te tra p ” ) ■ B 12 is a ls o a c o fa c to r fo r m e th y lm a lo n y l C o A m u ta s e , w h ic h c o n v e rts m e th y lm a lo n y l C o A to s u c c in y l C o A ; in B 12 d e fic ie n c y , m e th y lm a lo n y l C o A a c c u m u la te s

4.2.2.3 Effects of B12 and folate deficiency

i4.15 Megaloblastic anemia; note hypersegmented neutrophil & numerous oval macrocytes

■ S c h illin g te s t

■ O va l m a c ro c y to s is , h y p e rs e g m e n te d n e u tro p h ils , and la rg e p la te le ts i4.15

□ N o lo n g e r c o m m o n ly p e rfo rm e d □ P atient given a parenteral d o s e o f u n la b e le d B 12 fo llo w e d by an oral d o s e o f ra diola be led v ita m in B 12. L o w level o f u rin a ry ra d io a ctivity c o n firm s B 12 m a la b s o rp tio n . T h e p atie n t is g iven a n o th e r oral d o s e o f ra d io la b e le d B 12 in a dd itio n to oral IF. P atients w ith p e rn ic io u s a n e m ia s h o w e n h a n ce d a b so rp tio n (in cre ase d u rin a ry ra d io a c tiv ity ) in th is se co n d p a rt o f th e test

■ M a tu re R B C s a re m a c ro c y tic , w ith th e M C V in fu lly d e v e lo p e d m e g a lo b la s tic a n e m ia >115 fL ■ H y p e rc e llu la r m a rro w w ith n u c le a r m a tu ra tio n a rre s t a n d n u c le a rc y to p la s m ic d y s s y n c h ro n y (m e g a lo b la s tic a n e m ia ) ■ M a n y e ry th ro b la s ts p e ris h in th e m a rro w , so th e re is an e le m e n t o f h e m o ly tic a n e m ia , w ith h ig h L D H a nd high s e ru m b iliru b in ■ F o la te d e fic ie n c y d o e s n ot c a u s e n e u ro lo g ic d e fe c ts ; B 12 d e fic ie n c y d o e s

■ A n ti-IF a n tib o d y is a s e n s itiv e a n d s p e c ific m a rk e r o f p e rn ic io u s a n e m ia

4.2.3 Anemia of chronic disease ■ S y s te m ic in fla m m a tio n a lte rs m a rro w iro n u tiliz a tio n , s u p p re s s e s E P O s e c re tio n , a n d s u p p re s s e s R B C s e n s itiv ity to E P O

4.2.2.4 Diagnosis of folate deficiency ■ S e ru m o r R B C fo la te □ B a la n c e d m e a ls ca n n o rm a liz e s e ru m fo la te , b ut R B C fo la te is m o re s ta b le □ B 12 d e fic ie n c y ca n p ro d u c e a fa ls e ly lo w R B C fo la te b ut d o e s n o t a ffe c t th e s e ru m fo la te

4.2.2.5 Diagnosis of B12 deficiency

■ R e s u lts in n o rm o c y tic , n o rm o c h ro m ic o r m ic ro c y tic a n e m ia ■ M o s t c o m m o n c a u s e o f a n e m ia in h o s p ita liz e d p a tie n ts ■ A s s o c ia te d w ith rh e u m a to id a rth ritis , c o lla g e n v a s c u la r d is e a s e s , c h ro n ic in fe c tio n (o s te o m y e litis , b ro n c h ie c ta s is ), o r m a lig n a n c y ■ D is tin g u is h in g A C D fro m iron d e fic ie n c y t4.13

■ S e ru m v ita m in B 12 level □ L o w in H IV in fe c tio n a n d fa ls e ly h ig h in m y e lo p ro life ra tiv e d is e a s e s , h e p a tic and re na l d is e a s e

t4.13 Anemia of chronic disease (ACD) vs iron deficiency

anemia (IDA)

■ S e ru m m e th y lm a lo n ic a cid a n d /o r p la s m a to ta l h o m o c y s te in e

Serum iron TIBC

□ E le v a te d in B 12 d e fic ie n c y a nd u n a ffe c te d by fo la te d e fic ie n c y

© A S C P 2018

IDA ACD

% transferrin saturation

15%

SSTR

Ferritin

T Normal

Normal to f

A C D = a nem ia o f chronic disease; ID A = iron d e ficie n c y a n em ia; S S T R = se ru m soluble transferrin receptor; TIBC = total iron bin d in g ca p a city

ISBN 978-08 9 1 8 9 -6 6 7 8

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Disorders of marrow production>Anemia of chronic disease | Sideroblastic anemia | Congenital dyserythropoietic anemia | Fanconi anemia □ A C D p re s e n ts a s n o rm o c y tic o r m ic ro c y tic a n e m ia w ith lo w re tic u lo c y te c o u n t a n d c h a ra c te ris tic iro n s tu d ie s th a t re fle c t d im in is h e d R B C iro n in th e fa c e o f a d e q u a te to in c re a s e d iro n s to re s (n o rm a l to h ig h s e ru m fe rritin o r in c re a s e d s ta in a b le iro n in a b o n e m a rro w b io p s y ) □ F e rritin m u s t b e in te rp re te d in lig h t o f its p o s itiv e a c u te p h a s e re s p o n s e □ S o lu b le s e ru m tra n s fe rrin re c e p to r a s s a y is in c re a s e d in ID A a n d n o rm a l in A C D

4.2.4 Sideroblastic anemia ■ A g ro u p o f d is o rd e rs w ith a n e m ia a n d rin g e d s id e ro b la s ts i4.16 in th e m a rro w ■ P e rip h e ra l b lo o d □ H y p o c h ro m ic R B C s th a t m a y b e m ic ro c y tic (u s u a lly in h e rite d fo rm s ), n o rm o c y tic , o r m a c ro c y tic (u s u a lly a c q u ire d fo rm s ) □ B im o d a l R B C v o lu m e d is trib u tio n c o m m o n ly s e e n in in h e rite d s id e ro b la s tic a n e m ia

□ M u ltin u c le a te e ry th ro id p re c u rs o rs i4.17 w ith a b n o rm a l m ito s e s a nd in c re a s e d k a ry o rrh e x is

□ B a s o p h ilic s tip p lin g a n d P a p p e n h e im e r b o d ie s

□ P o s itiv e a c id ifie d s e ru m te s t □ A ls o c a lle d H E M P A S (h e re d ita ry e ry th ro c y te m u ltin u c le a rity w ith p o s itiv e a c id ifie d se ru m )

■ B o n e m a rro w □ R in g e d s id e ro b la s ts □ In c re a s e d iro n s to re s □ E ry th ro id h y p e rp la s ia w ith m ild d y s e ry th ro p o ie s is ■ L a b o ra to ry fin d in g s

■ C D A ty p e I is c h a ra c te riz e d b y d y s p la s tic e ry th ro id p re c u rs o rs w ith fre q u e n t in te rn u c le a r b rid g e s i4.17a ■ D is tin c tio n b e tw e e n p o s itiv e a c id ifie d s e ru m te s t in C D A ty p e II a nd P N H

□ E le v a te d s e ru m iro n , h ig h tra n s fe rrin p e rc e n t s a tu ra tio n , a n d h ig h fe rritin (s im ila r to h e re d ita ry h e m o c h ro m a to s is )

□ E n h a n c e d ly sis in C D A ty p e II is o b s e rv e d in h e te ro lo g o u s s e ru m only, w h e re a s th a t in P N H is s e e n in a u to lo g o u s a n d h e te ro lo g o u s s e ru m

□ In e ffe c tiv e e ry th ro p o ie s is a n d in tra m e d u lla ry h e m o ly s is le a d to h y p e rb iliru b in e m ia , h ig h L D H , a n d lo w s e ru m h a p to g lo b in

□ U n lik e P N H , th e s u c ro s e h e m o ly s is te s t is n e g a tiv e in HEMPAS

■ C auses □ A c q u ire d fo rm s in c lu d e m y e lo d y s p la s tic s y n d ro m e , m e d ic a tio n s (is o n ia z id , c h lo ra m p h e n ic o l, c h e m o th e ra p y ), irra d ia tio n , c o p p e r d e fic ie n c y , a n d a lc o h o l a b u s e □ In h e rite d fo rm s a re ra re w ith X lin k e d re c e s s iv e in h e rita n c e ■ S o m e in h e rite d s id e ro b la s tic a n e m ia c a n be o v e rc o m e w ith la rg e d o s e s o f p y rid o x in e (B 6) ■ P e a rs o n s y n d ro m e is in h e rite d s id e ro b la s tic a n e m ia w ith p a n c re a tic in s u ffic ie n c y

4.2.5 Congenital dyserythropoietic anemia ■ C D A ty p e II □ M o s t c o m m o n ty p e □ R e c e s s iv e ly in h e rite d

214

i4.16 Ringed sideroblasts

□ P o s itiv ity in C D A ty p e II is d u e to an a b n o rm a l R B C a n tig e n to w h ic h 1 in 3 n o rm a l in d iv id u a ls h ave a n a tu ra lly o c c u rrin g IgM a n tib o d y ■ R B C S s h o w h ig h d e n s ity o f I a n tig e n a nd i a n tig e n ■ E le c tro n m ic ro s c o p y s h o w s a b n o rm a lly a b u n d a n t e n d o p la s m ic re tic u lu m lo c a te d a d ja c e n t a nd p a ra lle l to th e c e ll m e m b ra n e (re s e m b lin g a d o u b le ce ll m e m b ra n e )

4.2.6 Fanconi anemia ■ A u to s o m a l re c e s s iv e c h ro m o s o m a l b re a k a g e s y n d ro m e th a t is c o m p lic a te d by a p la s tic a n e m ia , u s u a lly by th e age o f 10 y e a rs ■ M a c ro c y tic a n e m ia (or th ro m b o c y to p e n ia ) p re c e d e s p a n c y to p e n ia ■ R isk o f c lo n a l h e m a to p o ie tic d e fe c ts m a y d e v e lo p , in c lu d in g m y e lo d y s p la s tic s y n d ro m e a n d A M L (u su a lly w ith m o n o c y tic d iffe re n tia tio n , M 4 o r M 5)

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4: Hematopathology

Disorders of marrow production>Fanconi anemia | Dyskeratosis congenita (Zinsser-Engman-Cole syndrome) | Pure red cell aplasia (PRCA) | Congenital amegakaryocytic thrombocytopenia (CAMT) | Thrombocytopenia with absent radii syndrome ■ T h e i a n tig e n is o v e re x p re s s e d o n R B C s , e ry th ro c y te a d e n o s in e d e a m in a s e (A D A ) is in c re a s e d , a n d th e H b F is in c re a s e d ■ 7 5% o f p a tie n ts re s p o n d to c o rtic o s te ro id s

4.2.8.2 Acquired PRCA ■ 1 in 3 c a s e s a s s o c ia te d w ith th y m o m a (e s p e c ia lly th e s p in d le c e ll/m e d u lla ry /ty p e A v a ria n t) ■ O th e r c a s e s a s s o c ia te d w ith c o lla g e n v a s c u la r d is e a s e , L P D s o f la rg e g ra n u la r ly m p h o c y te s , o r m e d ic a tio n s

i4.17 Congenital dyserythropoietic anemia (CDA) a Type I demonstrating internudear bridges b Type II demonstrating multinucleated erythroid precursors

■ A fte r E P O th e ra p y, d u e to a n ti-E P O a n tib o d ie s

■ In c re a s e d in c id e n c e o f e p ith e lia l m a lig n a n c ie s , in c lu d in g c u ta n e o u s m a lig n a n c ie s (s q u a m o u s ce ll c a rc in o m a ), h e p a to c e llu la r c a rc in o m a , g a s tric c a rc in o m a , a nd o th e rs ■ A s s o c ia te d fin d in g s in c lu d e a b s e n t th u m b s o r radii, m ic ro c e p h a ly , re n a l a n o m a lie s , s h o rt sta tu re , c a fe au lait s p o ts, a nd e le v a te d H bF ■ M u ta tio n s in F A N C A , F A N C C , a nd F A N C G in v a s t m a jo rity o f c a s e s ■ P a rtic u la rly high in c id e n c e in d e s c e n d a n ts o f w h ite S o u th A fric a n s ■ S c re e n in g te s t: h y p e rs e n s itiv ity o f FA c e lls to D N A c ro s s lin k in g a g e n ts (m ito m y c in C, d ie p o x y b uta n e , c isp la tin ). In c re a s e d c h ro m o s o m a l b re a k s , g a p s, ra d ia ls , a nd re a rra n g e m e n ts a re c o n s is te n t w ith FA

4.2.7 Dyskeratosis congenita (Zinsser-EngmanCole syndrome) ■ P re s e n ts w ith is o la te d c y to p e n ia a n d p ro g re s s e s to p a n c y to p e n ia ■ O th e r fin d in g s in c lu d e re tic u la te d skin h y p e rp ig m e n ta tio n , nail d y s tro p h y , o ra l le u k o p la k ia , la c rim a l d u c t a tre s ia (c a u s in g o v e rflo w la c rim a tio n ), a nd te s tic u la r a tro p h y ■ C o m m o n c a u s e s o f d e a th a re fa ta l o p p o rtu n is tic in fe c tio n s , h e m o rrh a g e , a n d m a lig n a n c y

4.2.8.3 Parvovirus B19 causes transient arrests of RBC production in healthy children and adults ■ In fe c tio n u s u a lly la s ts ~2 w e e k s ; m a y be a s y m p to m a tic in o th e rw is e n o rm a l in d iv id u a ls ■ C a ta s tro p h ic in th o s e w ith c h ro n ic h e m o ly tic a n e m ia ■ In fe c ts e ry th ro id p ro g e n ito rs , c a u s in g a m a tu ra tio n a rre s t a t th e p ro n o rm o b la s t sta g e ■ M a rro w s h o w s g ia n t p ro n o rm o b la s ts , re d u c e d e ry th ro id m a tu ra tio n , a n d n u c le a r in c lu s io n s ■ P a rv o v iru s g a in s a c c e s s to e ry th ro id s v ia th e P a n tig e n

4.2.8.4 Transient erythrocytopenia of childhood (TEC) ■ S e lf lim itin g d is o rd e r a ris in g in p re v io u s ly h e a lth y c h ild re n , 1-4 y e a rs o f a g e ■ R e tic u lo c y to p e n ia , n o rm o c h ro m ic , n o rm o c y tic a n e m ia , a nd th ro m b o c y to s is ■ T h e m a rro w is h y p o c e llu la r d u e to e ry th ro id h y p o p la s ia ■ S o m e c a s e s c a u s e d by p a rv o v iru s B19

4.2.9 Congenital amegakaryocytic thrombocytopenia (CAMT)

■ X lin ke d fo rm s (m o s t c o m m o n ) a nd a u to s o m a l fo rm s (re c e s s iv e & d o m in a n t)

■ A u to s o m a l re c e s s iv e d is o rd e r p re s e n tin g in n e o n a te s w ith s e v e re th ro m b o c y to p e n ia a n d th e a b s e n c e o f m e g a k a ry o c y te s in th e m a rro w

■ D K C 1 (X q 2 8 ) g e n e re s p o n s ib le fo r X lin ked ca s e s ; a u to s o m a l c a s e s re la te d to E R C g e n e

■ P ro g re s s iv e th ro m b o c y to p e n ia p ro c e e d s to p a n c y to p e n ia by th e s e c o n d d e c a d e o f life

■ T e lo m e ra s e fu n c tio n in g is im p a ire d w ith te lo m e re s h o rte n in g s e e n

■ M u ta tio n s o f th e th ro m b o p o ie tin re c e p to r (M P L ) g e n e

4.2.8 Pure red cell aplasia (PRCA) 4.2.8.1 Congenital PRCA (Diamond-Blackfan syndrome) ■ M u ta tio n s in th e R P S 1 9 g e n e (19 q 1 .32) ■ M e d ia n a g e a t d ia g n o s is is 3 m o n th s

4.2.10 Thrombocytopenia with absent radii syndrome ■ D e fe c tiv e d e v e lo p m e n t o f th e b ila te ra l ra d ii a n d th ro m b o c y to p e n ia , th a t is m o s t p ro fo u n d a t b irth a nd b e c o m e s le s s s e v e re d u rin g th e firs t y e a r o f life. T A R d o e s n o t p ro c e e d to a p la s tic a n e m ia

■ L e u k o c y te s a nd p la te le ts u n a ffe c te d ■ M a rro w e ry th ro id p re c u rs o rs a b s e n t © ASCP2018

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Disorders of marrow production>Congenital neutropenia (Kostmann syndrome) & cyclic neutropenia | Shwachman-Diamond syndrome | Myelokathexis (& WHIM syndrome) | Autoimmune neutropenia | Aplastic anemia

4.2.11 Congenital neutropenia (Kostmann syndrome) & cyclic neutropenia ■ N e u tro p e n ia s y n d ro m e s t4.14 u s u a lly p re s e n t w ith re c u rre n t fe ve r, c e rv ic a l ly m p h a d e n o p a th y , o ra l u lc e rs , g in g iv itis , s in u s itis , a n d p h a ry n g itis ■ S e v e re fo rm (K o s tm a n n s y n d ro m e ) m a y p re s e n t in th e n e o n a ta l p e rio d w ith o m p h a litis , fo llo w e d in in fa n c y b y in fe c tio u s c o m p lic a tio n s , c o m p lic a te d b y th e la te r d e v e lo p m e n t o f A M L ■ M ild e r fo rm (c y c lic n e u tro p e n ia ) is m a rk e d b y in te rv a ls o f fe v e r, o fte n a c c o m p a n ie d b y 1 o r m o re fo c i o f in fla m m a tio n s u c h a s o ra l u lc e rs , p h a ry n g itis , s in u s itis , p e ria n a l u lc e ra tio n , o r c o lo n ic u lc e ra tio n — d u rin g w h ic h n e u tro p e n ia c a n be fo u n d . N e u tro p h il c o u n t v a rie s fro m n o rm a l to e s s e n tia lly n o n e in a -2 1 d a y c y c le ■ M u ta tio n s in th e E L A 2 (n e u tro p h il e la s ta s e ) g e n e a re re s p o n s ib le fo r b o th K o s tm a n n s y n d ro m e a n d c y c lic n e u tro p e n ia

■ W H IM re fe rs to a s u b s e t o f m y e lo k a th e x is c a s e s , in w h ic h th e re a re w a rts , h y p o g a m m a g lo b u lin e m ia , in fe c tio n s , a n d m y e lo k a th e x is . M u ta tio n s in th e C X C R 4 (c h e m o k in e re c e p to r) g e n e a re fo u n d in W H IM s y n d ro m e ■ B oth W H IM a n d m y e lo k a th e x is in g e n e ra l a re re la te d to d e fe c tiv e re le a s e o f m a tu re g ra n u lo c y te s fro m th e m a rro w , re d u c e d e x p re s s io n o f b c lx in g ra n u lo c y tic p re c u rs o rs , a n d e n h a n c e d a p o p to s is in c irc u la tin g g ra n u lo c y te s

4.2.14 Autoimmune neutropenia ■ A u to im m u n e n e u tro p e n ia o c c u rs a s p a rt o f a s y s te m ic a u to im m u n e c o n d itio n , p a rtic u la rly rh e u m a to id a rth ritis (F e lty s y n d ro m e ) ■ M o s t a ffe c te d p a tie n ts a re p o s itiv e fo r H L A D R 4 (a lso a fe a tu re o f la rg e g ra n u la r ly m p h o c y te le u k e m ia )

4.2.15 Aplastic anemia

t4.14 Inherited causes of isolated neutropenia

■ P a n c y to p e n ia w ith a h y p o p ro life ra tiv e m a rro w

Kostmann syndrome___________________________________ cyclic neutropenia myelokathexis (WHIM syndrome)________________________ Chediak-Higashi syndrome_____________________________ reticular dysgenesis Shwachman-Diamond syndrome_________________________ glycogen storage disease type 1b________________________ Barth syndrome dyskeratosis congenita common variable immunodeficiency______________________ hyper-IgM syndrome___________________________________ hyper-lgE syndrome___________________________________

■ In h e rite d c a u s e s in t4.15 ■ M o s t c a s e s (6 0 -7 0 % ) a re id io p a th ic

t4.15 Germline causes of aplastic anemia Syndrome Gene Comment Fanconi anemia

FANCA (16q24) FANCC (9q22) FANCG (9p13)

Diamond-Blackfan DBA 1/RPS f 9 (19q 13.2) syndrome

4.2.12 Shwachman-Diamond syndrome ■ A u to s o m a l re c e s s iv e ■ M u ta tio n s in S B D S (S h w a c h m a n -B o d ia n -D ia m o n d s y n d ro m e ) g e n e o n c h ro m o s o m e 7 ■ N e u tro p e n ia o r p a n c y to p e n ia , p a n c re a tic d y s fu n c tio n w ith fa tty re p la c e m e n t o f p a n c re a tic p a re n c h y m a , a nd s k e le ta l a n o m a lie s (m e ta p h y s e a l d y s o s to s is ) ■ D iffe re n t fro m D ia m o n d -B la c k fa n s y n d ro m e (p u re R B C a p la s ia , n o p a n c re a tic o r b o n e d is e a s e )

4.2.13 Myelokathexis (& WHIM syndrome) ■ M y e lo k a th e x is is a n a u to s o m a l d o m in a n t d is o rd e r, w ith n e u tro p e n ia a n d re c u rre n t b a c te ria l in fe c tio n s ■ C irc u la tin g n e u tro p h ils h a v e c h a ra c te ris tic m o rp h o lo g y , a p p e a rin g d e g e n e ra tiv e , w ith p y k n o tic n u c le i, fin e c h ro m a tin fila m e n ts , a n d h y p e rs e g m e n ta tio n (s im ila r m o rp h o lo g y s e e n in m y c o p h e n o la te tre a tm e n t)

216

dyskeratosis congenita

DKC1 (Xq28) TERC

Kostmann syndrome

ELA2 (19p)

congenital CMPL (1p34) amegakaryocytic thrombocytopenia ShwachmanSBDS (7q11) Diamond syndrome Down syndrome

autosomal recessive chromosomal breakage syndrome initially anemia or thrombocytopenia cafe au lait spots thumb & radial anomalies short stature microcephaly autosomal dominant initially anemia thumb & radial anomalies short stature cardiac septal defects X linked recessive nail dystrophy reticulated skin pigmentation oral leukoplakia lacrimal duct atresia testicular atrophy autosomal dominant initially neutropenia, uncommonly progresses to aplastic anemia autosomal recessive initially thrombocytopenia thumb & radial anomalies autosomal recessive pancreatic exocrine insufficiency short stature reticular dysgenesis AR form of SCID

Trisomy 21

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

4: Hematopathology

Disorders of marrow production>Aplastic anemia | Approach to the diagnosis of quantitative abnormalities ■ O th e r c a u s e s in c lu d e m e d ic a tio n o r to xin e x p o s u re , v ira l h e p a titis (h e p a titis C) ■ R u le o u t m im ic s t4.16

t4.16 Mimickers of aplastic anemia paroxysmal nocturnal hemoglobinuria____________________________________ hairy cell leukemia___________________________________________________ T cytotoxic large granular lymphocytic leukemia____________________________ hypoplastic myelodysplastic syndrome___________________________________ hypoplastic acute myelogenous leukemia_________________________________

4.2.16 Approach to the diagnosis of quantitative abnormalities 4.2.16.1 Anemia ■ D e fin itio n s o f a n e m ia t4.17

t4.17 Definitions of anemia Adult men (g/dL)

Author

World Health Organization 13 13.2 Wintrobe 14 Williams

Adult women (g/dL) 12 (11 if pregnant) 11.6 12.3

■ E v a lu a tio n g u id e d by th e m o rp h o lo g ic fin d in g s t4.18 a nd th e re tic u lo c y te c o u n t □ C o rre la tio n o f m o rp h o lo g y w ith a u to m a te d in d ic e s ■ A u to m a te d M C V is th e b e s t d e te rm in a n t o f R B C size , and u se d to g u id e fu rth e r d ia g n o s tic c o n s id e ra tio n s f4.6 ■ V a ria b ility in R B C s ize a n d s h a p e a re te rm e d a n is o c y to s is a n d p o ik ilo c y to s is , t4.18, and is re fle c te d in R D W ■ H y p o c h ro m ia is re fle c te d in M C H C □ R e tic u lo c y te c o u n t ■ P ro d u c tio n d e fe c t s h o w s a lo w o r n o rm a l re tic u lo c y te c o u n t (h y p o re g e n e ra tiv e a n e m ia ) ■ R e tic u lo c y to s is (h y p e rre g e n e ra tiv e a n e m ia ) s u g g e s ts e ith e r h e m o ly s is o r h e m o rrh a g e ■ C a v e a ts ■ P a rtia lly tre a te d iron, fo la te , o r B 12 d e fic ie n c y m ay s h o w re tic u lo c y to s is ■ U n c o m m o n ly , im m u n e h e m o ly s is ta rg e ts m a tu re a n d im m a tu re e ry th ro c y te s , re s u ltin g in re tic u lo c y to p e n ia ■ B oth h e m o ly tic a nd b lo o d lo s s a n e m ia m ay e v e n tu a lly lea d to d e p le tio n o f iron, fo la te , o r B 12 a nd p re s e n t w ith re tic u lo c y to p e n ia ■ S c re e n in g te s ts fo r h e m o ly s is □ S e ru m LD (e le va te d ), h a p to g lo b in (d e c re a s e d ), a nd b iliru b in (e le va te d )

© A S C P 2018

f4.6 Algorithms for anemia: a normocytic, b microcytic, c macrocytic

ISBN 9 7 8 -0 8 9 1 8 9 -6 6 7 8

217

4: Hematopathology

Disorders of marrow production>Approach to the diagnosis of quantitative abnormalities t4.18 M orphologic findings in RBCs

t4.18 Morphologic findings in RBCs

(continued)

Finding

Definition

Associated conditions

Finding

Definition

acanthocytes (spur cells)

RBCs that have unevenly distributed, blunt & spiny projections with bulbous tips i4,18 small blue dots in RBCs, caused by clusters of ribosomes (RNA) do not stain for iron i4.19

liver disease abetalipoproteinemia McLeod (Kell-null) phenotype

rouleaux

adherent RBCs laying side monoclonal immunoglobulin by side, usually caused marked hyperfibrinogenemia by abnormal plasma proteins (immunoglobulin or fibrinogen) unlike RBC aggregates caused by immune phenomena, rouleaux are reversible with dilution & do not affect automated CBC parameters i4.23 fragmented RBCs, taking microangiopathic hemolytic shapes such as helmet anemias (MHA): DIC, TTP, HUS, HELLP shaped cells, due to mechanical RBC mechanical heart valves fragmentation i4.24 58% of normal adults have schistocytes, with mean of 0.05% of RBCs, range 0.00-0.27% RBCs without central pallor, immune hemolytic anemia due to decreased RBC hereditary spherocytosis membrane, often with high MCHC RBCs whose area of central alcohol pallor is elongated in a dilantin mouthlike shape Rh null phenotype (absence of Rh antigens) hereditary stomatocytosis often artifact RBCs with a dark circle thalassemia within the central area of hemoglobin C pallor, reflecting redundant liver disease membrane i4.25

hemolytic anemias lead poisoning arsenic poisoning thalassemia megaloblastic anemia alcoholism pyrimidine 5’ nucleotidase deficiency can be seen in relatively dacrocytes (teardrop teardrop or pear shaped cells) erythrocytes i4.20 benign conditions (thalassemia, megaloblastic anemia) often seen in myelophthisis RBCs that have uremia echinocytes (burr circumferential undulations gastric cancer cells) or spiny projections with pyruvate kinase deficiency pointed tips postsplenectomy often artifact RBCs twice as long as they iron deficiency elliptocytes are wide B12 & folate deficiency myelodysplasia hereditary elliptocytosis oxidative injury: G6PD Heinz bodies Heinz bodies: gray-black round inclusions, seen deficiency or unstable bite cells hemoglobins only with supravital stains (crystal violet) bite cells: sharp bitelike defects in RBCs where a Heinz body has been removed in the spleen both are due to denatured hemoglobin Howell-Jolly bodies Howell-Jolly body: dotlike asplenia dark purple inclusion i4.21 myelodysplasia Cabot rings Cabot ring: ring shaped dark purple inclusion both represent a residual nuclear fragment enlarged RBCs (confirm with reticulocytosis macrocytosis MCV, with age appropriate oval macrocytes: reference range) megaloblastic (folate or B12 deficiency) round macrocytes: chronic liver failure, hypothyroidism, myelodysplasia small RBCs (confirm with iron deficiency microcytosis MCV) thalassemia anemia of chronic disease (usually normocytic) immune hemolysis lead poisoning sideroblastic anemia Pappenheimer bodieslarger, more irregular & asplenia grayer than basophilic sideroblastic anemia stippling, caused by iron containing mitochondria basophilic stippling

i4.22

(continued in next colum n)

218

schistocytes

spherocytes

stomatocytes

target cells

Associated conditions

C B C = com plete b lo o d count; D IC = d issem inated in tra va scu la r coagulation; H U S = h e m olytic urem ic syndrom e; M C H C = m ean corpuscular hem oglobin concentration; M C V = m ean co rp u scu la r volum e; R B C = re d blood cell; TTP throm botic throm bocytopenic purpura

□ B iliru b in a nd LD w ill b e a b n o rm a l in in tra m e d u lla ry h e m o ly s is , su ch a s v ita m in B 12 d e fic ie n c y □ D is tin g u is h in g in tra - a nd e x tra v a s c u la r h e m o ly s is t4.20 ■ In tra v a s c u la r h e m o ly s is is c a u s e d by m ic ro a n g io p a th ic h e m o ly tic a n e m ia (d is s e m in a te d in tra v a s c u la r c o a g u la tio n , h e m o ly tic u re m ic s y n d ro m e , TTP , H E L L P ), c o m p le m e n t fix a tio n on th e R B C s u rfa c e (eg, A B O in c o m p a tib ility , P N H , P C H ), m e c h a n ic a l h e a rt v a lv e s , s n a ke e n v e n o m a tio n , a n d in fe c tio n (m a la ria , b a b e s io s is , C lo s trid iu m ) • N e o n a ta l a n e m ia □ S ig n ific a n t fe to m a te rn a l h e m o rrh a g e (> 30 ml_), tw in -tw in tra n s fu s io n , in tra p a rtu m in ju rie s to th e u m b ilic a l c o rd (v e la m e n to u s c o rd in s e rtio n a nd va sa p re via a re m a jo r p re d is p o s in g fa c to rs ) □ R are in h e rite d c a u s e s in c lu d in g F a n c o n i s y n d ro m e and D ia m o n d -B la c k fa n s y n d ro m e

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

4: Hematopathology

Disorders of marrow production>Approach to the diagnosis of quantitative abnormalities ■ A c u te b lo o d lo s s is u s u a lly a s s o c ia te d w ith a b ru p t s y m p to m s (c h ro n ic s lo w b lo o d lo s s is o fte n a s y m p to m a tic , p re s e n tin g late a s ID A ). S o m e n o n h e m o rrh a g ic c a u s e s o f a n e m ia m a y a ls o p re s e n t a b ru p tly t4.19

o«l° IV v* >o v v V, * ° o

S

t4.19 Nonhemorrhagic causes of acute severe anemia Acute intravascular hemolysis

Acute exacerbation of chronic hemolysis___________________

aplastic crisis (parvovirus B19) microangiopathic hemolytic anemia mechanical hemolysis (eg, heart valve) splenic sequestration crisis hyperhemolytic crisis toxins (eg, venoms) infections (eg, malaria, Clostridium) oxidant stress (especially G6PD deficiency) hemolytic transfusion reaction (usually ABO) paroxysmal nocturnal hemoglobinuria

t4.20 Intravascular vs extravascular hemolysis Intravascular hemolysis

Extravascular hemolysis

schistocytes t LD l haptoglobin t free Hb, f urine Hb hemosiderinuria

microspherocytes T LD normal to J. haptoglobin T indirect bilirubin T urine & fecal urobilinogen

• : •• V

i4.18 Acanthocytes

V

i4.19 Basophilic stippling

,Oo0 f t « V A O Vi ilO/ l

0k

A

£ • •• * ••»• ...V ' «T o | 0 A* *

.

. •

•

r P

i4.20 Teardrop cells (dacrocytes)

i4.21 Howell-Jolly body

• o0°# * *. 4 ’ • o■ >o V • * o? «• °° •o4* °°S o

4.2.16.2 Erythrocytosis t4 .2 1

a e 4> f ° V

t4.21 Polycythemia vera (PV) vs secondary erythrocytosis Parameter

PV

RBC mass PaO, leukocytes & basophils LAP score serum B12 EPO serum iron/stainable iron platelet aqqreqation studies

t normal t

T T 1 i

abnormal

Secondary

,

.

T

o

o

o%*

normal to normal normal normal i4.22 Pappenheimer bodies

T

o ** °

o

i4.23 Rouleaux

normal normal

■ D iffe re n tia l d ia g n o s is in c lu d e s m y e lo p ro life ra tiv e n e o p la s m , re a c tiv e e ry th ro c y to s is , a nd s p u rio u s e ry th ro c y to s is o f d e h y d ra tio n (G a is b o c k s y n d ro m e )

* l *|

■ E P O m e a s u re m e n t p iv o ta l in d iffe re n tia l d ia g n o s is ; n o rm a l in M P N ■ C a u s e s o f re a c tiv e e ry th ro c y to s is a re h y p o x ia (lu n g d is e a s e , s m o k in g , h ig h a ltitu d e ), high o x y g e n a ffin ity h e m o g lo b in s , a nd c e rta in E P O s e c re tin g n e o p la s m s (ren a l ce ll c a rc in o m a , c e re b e lla r h e m a n g io b la s to m a , u te rin e le io m y o m a , a n d h e p a to c e llu la r c a rc in o m a )

i4.24 Schistocytes

i

i4.25 Target cells

■ T ra n s ie n t n e o n a ta l p o ly c y th e m ia m a y be s e e n in in fa n ts o f d ia b e tic m o th e rs a n d D o w n s y n d ro m e

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Disorders of marrow production>Approach to the diagnosis of quantitative abnormalities 4.2.16.3 Neutrophilia 4.2.16.3.1 Reactive neutrophilia ■ U s u a lly d o e s n o t e x c e e d 3 0 * 10 3/p L ■ O fte n a c c o m p a n ie d b y to x ic g ra n u la tio n i4.26, D o h le b o d ie s , a n d c y to p la s m ic v a c u o le s ■ L e ft s h ift m a y b e p re s e n t, b u t m a in ly a s b a n d s a n d fe w m e ta m y e lo c y te s ; no b la s ts s e e n ■ E le v a te d L A P s c o re ■ R e s o lv e s s p o n ta n e o u s ly o r fo llo w in g tre a tm e n t ■ C a u s e s : in fe c tio n , m e d ic a tio n s (e p in e p h rin e , c o rtic o s te ro id s ), tra u m a , b u rn s , s y s te m ic in fla m m a tio n (c o lla g e n v a s c u la r d is e a s e s , g o u t), s e iz u re , e x e rc is e , p o s ts p le n e c to m y , le u k o c y te a d h e s io n d e fe c t, p re g n a n c y , a n d ju v e n ile rh e u m a to id a rth ritis in c h ild re n ■ G ra n u lo c y te m a c ro p h a g e c o lo n y s tim u la tin g fa c to r (G M -C S F ) c a u s e s le u k o c y to s is w ith p ro m in e n t to x ic g ra n u la tio n , n u c le a te d R B C s , a n d a b n o rm a l n u c le a r s e g m e n ta tio n

i4.26 Reactive neutrophil with toxic granulation

■ H a n ta v iru s p u lm o n a ry s y n d ro m e (H P S ): p u lm o n a ry e d e m a w ith p e n ta d o f fin d in g s : th ro m b o c y to p e n ia , le ft s h ifte d n e u tro p h ilia , la c k o f s ig n ific a n t to x ic g ra n u la tio n , in c re a s e d h e m o g lo b in c o n c e n tra tio n (h e m o c o n c e n tra tio n ), a n d >10% o f ly m p h o c y te s h a v in g im m u n o b la s tic m o rp h o lo g y

4.2.16.4 Lymphocytosis 4.2.16.4.1 Causes ■ In fe c tio u s m o n o n u c le o s is s y n d ro m e s

i4.27 Atypical (reactive) lymphocytes having abundant cytoplasm with 'burnt' cytoplasmic edges

□ P ro life ra tio n o f re a c tiv e T ly m p h o c y te s , o fte n w ith m o rp h o lo g ic fe a tu re s o f s o c a lle d “ a ty p ic a l ly m p h o c y te s ” (A T L s i4.27): m o d e ra te to a b u n d a n t c y to p la s m , p o s s ib ly c y to p la s m ic g ra n u le s , and c y to p la s m ic b o rd e rs w ith c h a ra c te ris tic “ b u rn t” e d g e s th a t a re in d e n te d b y a d ja c e n t e ry th ro c y te s □ V ira l in fe c tio n (E B V , C M V , a c u te H IV ) a n d to x o p la s m o s is a re th e m o s t c o m m o n c a u s e s 4.2.16.4.2 Transient stress lymphocytosis ■ P ro life ra tio n o f re a c tiv e T c e lls , B c e lls , a n d N K c e lls

i4.28 Marked lymphocytosis in pertussis a comprises cells with irregular nuclear contours, b some of which are defied, typical of Reider cells

■ S e e n in a c u te ly ill o r tra u m a tiz e d p a tie n ts ■ P re d o m in a n t c e ll ty p e h a s a s m a ll in d e n te d e c c e n tric n u c le u s , a n d th e re m a y b e c y to p la s m ic g ra n u la tio n

4 .2 .16.4.4 R eactive ly m p h o c y to s is in children ■ S m a ll m a tu re ly m p h o c y te s w ith c le fte d n u c le i (R e id e r ce lls) i4.28, c la s s ic a lly s e e n in p e rtu s s is

4.2.16.4.3 Polyclonal B lymphocytosis ■ A ffe c ts y o u n g a d u lt w o m e n w h o s m o k e ■ M ild a b s o lu te in c re a s e in s m a ll ly m p h o c y te s w ith ind e nted to b ilo b e d n u c le i a nd a b u n d a n t p a le s ta in in g c y to p la s m ■ P o ly c lo n a l Ig M h y p e rg a m m a g lo b u lin e m ia ■ H L A DR7+ 220

4.2.16.4.5 A b s o lu te ly m p h o c y to s is in a d u lts over 40 years ■ S u s p ic io u s fo r le u k e m ia ■ C h ro n ic ly m p h o c y tic le u k e m ia (C L L ) is th e m o s t c o m m o n c o n s id e ra tio n

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4: Hematopathology

Disorders of marrow production>Approach to the diagnosis of quantitative abnormalities 4.2.16.5 Monocytosis ■ F re q u e n tly re a c tiv e , b u t p e rs is te n t u n e x p la in e d m o n o c y to s is m a y re p re s e n t c h ro n ic m y e lo m o n o c y tic le u k e m ia (C M M L ) ■ S e ru m ly s o z y m e is e le v a te d in m o n o c y tic p ro life ra tio n s , a n d d o e s n o t d is tin g u is h re a c tiv e fro m n e o p la s tic c o n d itio n s ■ R e a c tiv e m o n o c y to s is s e e n in c o lla g e n v a s c u la r d is e a s e s , c h ro n ic in fe c tio n (c la s s ic a lly L is te ria o r T u b e rc u lo s is ), m a lig n a n c y , a nd n e u tro p e n ia (a c o m p e n s a to ry re s p o n s e ) ■ A n e o p la s m is s u g g e s te d by p ro m o n o c y te s a n d /o r s p le n o m e g a ly ■ C a ve a t: a u to m a te d c o u n te rs m a y m is c la s s ify h a iry c e lls , b la sts, o r im m a tu re h y p o g ra n u la r n e u tro p h ils as m o n o c y te s

4.2.16.8 Lymphopenia ■ Is o la te d ly m p h o p e n ia is ra re b u t m a y be s e e n in s y s te m ic lu p u s e ry th e m a to s u s , H IV in fe c tio n , s e v e re a c u te re s p ira to ry s y n d ro m e , a n ti-C D 2 0 (ritu x a n ) th e ra p y , s te ro id th e ra p y , a n d c o n g e n ita l im m u n o d e fic ie n c y (B ru to n , s e v e re c o m b in e d im m u n o d e fic ie n c y , D iG e o rg e , C V I)

4.2.16.9 Monocytopenia ■ H a iry ce ll le u k e m ia (H C L) o r s te ro id th e ra p y ■ In c h e m o th e ra p y , m o n o c y to p e n ia h e ra ld s o n s e t o f n e u tro p e n ia

4.2.16.6 Eosinophilia ■ A lm o s t a lw a y s re a c tiv e , m o s t c o m m o n ly re la te d to a lle rg y a nd h e lm in th ic in fe c tio n s ■ O th e r c a u s e s in c lu d e c o lla g e n v a s c u la r d is e a s e , m a lig n a n c y (T ce ll n e o p la s m , H o d g k in ly m p h o m a , a nd c o lo n ic c a rc in o m a ), in fla m m a to ry b o w e l d is e a s e , e o s in o p h ilic c e llu litis (W e ll s y n d ro m e ), e o s in o p h ilic p n e u m o n ia (L o e ffle r s y n d ro m e ), e o s in o p h ilic fa s c iitis (S h u lm a n s y n d ro m e ), e o s in o p h ilic v a s c u litis (C h u rg -S tra u s s s y n d ro m e ) a n d G M -C S F th e ra p y ■ In te rle u k in 5 is th e c y to k in e s p e c ific fo r th e e o s in o p h il lin e a g e ■ E x c lu s io n o f re a c tiv e c a u s e s ra is e s p o s s ib ility o f M P N o r h y p e re o s in o p h ilic s y n d ro m e (H E S ); m o rp h o lo g ic a lly a b n o rm a l e o s in o p h ils (trilo b a te , m o n o lo b a te ) a n d /o r s p le n o m e g a ly , in c re a s e s lik e lih o o d o f n e o p la s ia

4.2.16.7 Neutropenia (agranulocytosis) ■ M o s t c o m m o n c a u s e o f n e u tro p e n ia is m e d ic a tio n □ A n tith y ro id a g e n ts (m e th im a z o le , p ro p y lth io u ra c il, c a rb im a z o le ), a n tib io tic s (p e n ic illin s , c h lo ra m p h e n ic o l, s u lfa s a la z in e ), a n tic o n v u ls a n ts (va lp ro a te , c a rb a m a z e p in e ), a n d p ro c a in a m id e ■ C a u s e s o f in c re a s e d n e u tro p h il d e s tru c tio n in c lu d e a u to im m u n ity , s p le n o m e g a ly , m e d ic a tio n s , o r in fe c tio n (ty p h o id fever, b ru c e llo s is , tu la re m ia , ric k e tts ia l in fe c tio n , a nd , in n e o n a te s a nd th e e ld e rly , o v e rw h e lm in g s e p s is o f a ny b a c te ria l ca u s e ) □ A u to im m u n e n e u tro p e n ia : lu p u s o r rh e u m a to id a rth ritis in a d u lts (the tria d o f rh e u m a to id a rth ritis , s p le n o m e g a ly , a n d n e u tro p e n ia is F e lty sy n d ro m e ); id io p a th ic in in fa n ts a nd ch ild re n

© A S C P 2018

■ D e c re a s e d p ro d u c tio n m ay be c a u s e d b y m e d ic a tio n s , la rg e g ra n u la r ly m p h o c y tic le u k e m ia (L G L), a n d th e c o n s titu tio n a l n e u tro p e n ia s (c y c lic n e u tro p e n ia , K o s tm a n n s y n d ro m e , S h w a c h m a n -D ia m o n d s y n d ro m e , C h e d ia k -H ig a s h i, FA, d y s k e ra to s is c o n g e n ita l e tc)

4.2.16.10 Thrombocytopenia ■ A n a lg o rith m ic a p p ro a c h to th ro m b o c y to p e n ia f4.6 ■ In n e o n a te s , c o m m o n c a u s e s a re in fe c tio n in d u c e d b o n e m a rro w s u p p re s s io n (to x o p la s m o s is , ru b e lla , C M V ), n e o n a ta l a llo im m u n e th ro m b o c y to p e n ia (N A IT ), m a te rn a l im m u n e th ro m b o c y to p e n ic p u rp u ra (p a s s iv e tra n s fe r o f a n tib o d ie s ), in h e rite d th ro m b o c y to p e n ia s y n d ro m e s , a n d c h ro m o s o m a l a n o m a lie s (tris o m y 18, tris o m y 13, tris o m y 21, T u rn e r) ■ In c h ild re n im m u n e th ro m b o c y to p e n ic p u rp u ra (IT P ) is th e m o s t c o m m o n c a u s e but is a d ia g n o s is o f e x c lu s io n . R a p id re s p o n s e to s te ro id s is c o n s is te n t w ith IT P ; p o o r re s p o n s e to s te ro id s b u t g o o d re s p o n s e to tra n s fu s e d p la te le ts is c o n s is te n t w ith an in h e rite d s y n d ro m e ■ In a d u lts th ro m b o c y to p e n ia is c a u s e d b y ITP, d ru g (a n tib io tic s , a lc o h o l, a n tia rrh y th m ic s , th ia z id e s , a b c ix im a b , q u in id in e , a nd h e p a rin ), m y e lo d y s p la s ia , T T P o r h y p e rs p le n is m . C o n s id e r h e p a rin in d u c e d th ro m b o c y to p e n ia s y n d ro m e ■ P e rip h e ra l s m e a r e v a lu a tio n □ P s e u d o th ro m b o c y to p e n ia : p la te le t s a te llito s is a nd p la te le t c lu m p in g (E D T A re la te d a rtifa c t). R e c o lle c tio n in c itra te o r a c id -c itra te -d e x tro s e n e c e s s a ry fo r a c c u ra te c o u n ts □ L a rg e a nd v a ria b ly s ize d p la te le ts : B e rn a rd -S o u lie r s y n d ro m e a n d M a y -H e g g lin a n o m a ly t4 .2 2 ; a ls o in d ic a te in c re a s e d m a rro w p ro d u c tio n (IT P ) □ S m a ll p la te le ts in p ro d u c tio n d e fe c ts a n d G la n z m a n n th ro m b a s th e n ia

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Disorders of marrow production>Approach to the diagnosis of quantitative abnormalities t4.22 Inherited throm bocytopenias classified by size Small platelets Wiskott-Aldrich syndrome congenital amegakaryocytic thrombocytopenia syndrome thrombocytopenia with absent radii syndrome

Giant platelets (megathrombocytes) MYH9 syndromes (May-Hegglin, Sebastian, Fechtner, Epstein) Bernard-Soulier syndrome gray platelet syndrome DiGeorge syndrome X linked macrothrombocytopenia Mediterranean macrothrombocytopenia

□ T h ro m b o c y to p e n ia w ith s c h is to c y te s : m ic ro a n g io p a th ic h e m o ly tic a n e m ia (D IC , T T P , H U S , H E L L P ). T h e n u m b e r o f s c h is to c y te s is h ig h e r in T T P (> 3 /h ig h p o w e r fie ld ). C lo ttin g tim e s a re n o rm a l in T T P /H U S a n d p ro lo n g e d in D IC /H E L L P ■ Im m u n e th ro m b o c y to p e n ia : d u e to s p le n ic d e s tru c tio n a n d s e q u e s tra tio n o f p la te le ts □ A n tib o d ie s a g a in s t G P IIb , G P IIIa , G P Ib , o r G P V

i4.29 May-Hegglin anomaly; note numerous Dohle bodies & large platelet

□ C lin ic a l d ia g n o s is o f e x c lu s io n □ S u b s ta n tia l re s p o n s e to im m u n o m o d u la to ry tre a tm e n t is th e b e s t d ia g n o s tic te s t □ > 8 0 % IT P p a tie n ts w ill re s p o n d to in itia l th e ra p y , u s u a lly c o n s is tin g o f m e th y lp re d n is o lo n e w ith o r w ith o u t in tra v e n o u s im m u n o g lo b u lin □ F a ilu re to re s p o n d s u g g e s ts in c o rre c t d ia g n o s is o r re fra c to ry im m u n e th ro m b o c y to p e n ia □ R e fra c to ry d is e a s e : p la te le t c o u n t o f 3 0 ,0 0 0 c a n n o t be a c h ie v e d w ith in itia l th e ra p y □ S p le n e c to m y is c o n s id e re d fo r re fra c to ry c a s e s ■ N e o n a ta l a llo im m u n e th ro m b o c y to p e n ia (N A IT ) is c a u s e d b y a n ti-P L A 1 (H P A 1 a ) a n tib o d ie s in 8 0 % o f cases □ 9 8 % o f th e U S p o p u la tio n h a s p la te le ts th a t a re PLA1 + □ A n tib o d ie s a re o f m a te rn a l o rig in a n d d ire c te d a t fe ta l/ n e o n a ta l p la te le t a n tig e n s □ 1/3 o f c a s e s a ffe c t th e fir s t p re g n a n c y , u n like h e m o ly tic d is e a s e o f th e n e w b o rn , in w h ic h th e firs t p re g n a n c y is u s u a lly s p a re d □ A ffe c te d n e o n a te s s h o u ld be tra n s fu s e d w ith m a te rn a l p la te le ts ■ P o s ttra n s fu s io n p u rp u ra (P T P ), like N A IT , is re la te d to th e PLA1 a n tig e n □ P re s e n ts a s s e v e re th ro m b o c y to p e n ia in a fe m a le re c ip ie n t o f c e llu la r b lo o d p ro d u c ts , -7 -1 0 d a y s fo llo w in g tra n s fu s io n ; o fte n w ith h is to ry o f p re g n a n c y o r tra n s fu s io n

■ M a y -H e g g lin a n o m a ly i4.29 is an a u to s o m a l d o m in a n t d is o rd e r □ T ria d o f g ia n t p la te le ts , th ro m b o c y to p e n ia , a nd D o h le -lik e le u k o c y te in c lu s io n s □ M Y H 9 g e n e , e n c o d in g a n o n m u s c le ty p e o f m yosin h e a v y c h a in □ A g g re g a te s o f th is h e a v y c h a in c o m p ris e th e D o h le -lik e b o d ie s in n e u tro p h ils ■ M e d ite rra n e a n m a c ro th ro m b o c y to p e n ia : m ild th ro m b o c y to p e n ia in s o u th e rn E u ro p e □ M u ta tio n on c h ro m o s o m e 17 re s u lts in d e c re a s e d e x p re s s io n o f th e G P Ib /IX /V c o m p le x (the von W ille b ra n d fa c to r re c e p to r) ■ C o n g e n ita l a m e g a k a ry o c y tic th ro m b o c y to p e n ia s y n d ro m e (C A M T ): a u to s o m a l re c e s s iv e d is o rd e r □ M u ta tio n s o f th e th ro m b o p o ie tin re c e p to r (M P L ) g e n e □ N e o n a te w ith s e v e re th ro m b o c y to p e n ia and th e a b s e n c e o f m e g a k a ry o c y te s in th e m a rro w □ P ro g re s s iv e th ro m b o c y to p e n ia a nd p a n c y to p e n ia by th e s e c o n d d e c a d e o f life □ D iffe re n tia l d ia g n o s is : m a rro w fa ilu re s y n d ro m e s (FA, d y s k e ra to s is c o n g e n ita ) ■ T h ro m b o c y to p e n ia w ith a b s e n t ra d ii (T A R ) s y n d ro m e □ D e fe c tiv e d e v e lo p m e n t o f th e b ila te ra l ra dii a nd se v e re th ro m b o c y to p e n ia □ P ro fo u n d a t b irth a n d le s s s e v e re d u rin g th e firs t y e a r o f life

□ T h ro m b o c y to p e n ia is p ro fo u n d ; p la te le t c o u n ts re c o v e r w ith in s e v e ra l w e e k s ■ Q u in id in e is a s s o c ia te d w ith IT P w ith a n tib o d ie s a g a in s t G P IX c o m p o n e n t o f th e G P Ib /V /IX c o m p le x 222

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4: Hematopathology

Disorders of marrow production>Approach to the diagnosis of quantitative abnorm alities Neoplastic hem atopathology>B cell neoplasms

4.3

Neoplastic hematopathology

4.3.1 B cell neoplasms 4.3.1.1 General clinical considerations ■ B ce ll n e o p la s m s m a y p re s e n t w ith ly m p h a d e n o p a th y , p e rip h e ra l b lo o d ly m p h o c y to s is , c y to p e n ia , M p ro te in , o r B s y m p to m s (fever, d re n c h in g n ig h t s w e a ts , a n d lo s s o f >1 0% b o d y w e ig h t) □ S ite s o f e x tra n o d a l B cell ly m p h o m a : G l tra c t (s to m a c h m o s t c o m m o n ), s k in , b o n e , a n d C N S □ B ce ll n e o p la s m s u s u a lly p re s e n tin g a s le u k e m ia : C L L , p ro ly m p h o c y tic le u k e m ia , h a iry c e ll le u k e m ia , a nd B A L L ■ B c e ll n e o p la s m s h a ve v a ria b le ra te s o f m a rro w / p e rip h e ra l b lo o d in v o lv e m e n t t4 .2 3 ■ R isk fa c to rs fo r B c e ll n e o p la s m s a re im m u n o d e fic ie n c y a n d a u to im m u n ity

t4.23 Frequency of bone marrow & peripheral blood

involvement by B cell neoplasms

f4.7 Algorithm for thrombocytopenia

■ T h ro m b o tic th ro m b o c y to p e n ia p u rp u ra (T T P ) □ P e n ta d o f th ro m b o c y to p e n ia , m ic ro a n g io p a th ic h e m o ly tic a n e m ia , n e u ro lo g ic a b n o rm a litie s , renal d y s fu n c tio n , a n d fe v e r □ P la te le ts u s u a lly n u m b e r < 2 0 ,0 0 0 /p L , and s c h is to c y te s a re n u m e ro u s in th e p e rip h e ra l s m e a r f4.7. F o r m o re , s e e C h a p te r 5 ■ A llo im m u n e th ro m b o c y to p e n ia (p la te le t re fra c to rin e s s ) in re p e a te d ly tra n s fu s e d p a tie n ts □ D e v e lo p m e n t o f a n ti-H L A a n tib o d ie s d ire c te d a g a in s t c la s s I H L A a n tig e n s , e s p e c ia lly H L A -A & B

4.2.16.11 Thrombocytosis ■ R e a c tiv e th ro m b o c y to s is m u s t be d is tin g u is h e d fro m MPN ■ C a u s e s o f re a c tiv e th ro m b o c y to s is in c lu d e iron d e fic ie n c y , s y s te m ic in fla m m a tio n , m a lig n a n c y , and s p le n e c to m y ■ N o th ro m b o s is o r h e m o rrh a g e ris k in re a c tiv e th ro m b o c y to s is , e ven a t v e ry h ig h c o u n ts ■ M y e lo p ro life ra tiv e th ro m b o c y to s is is s u s p e c te d w h e n th e p la te le t c o u n t is v e ry h ig h , a nd h as s ig n ific a n t ris k fo r th ro m b o s is a nd b le e d in g

Frequency of marrow involvement Lymphoma type (predominant pattern)

Peripheral blood involvement

follicular lymphoma 30-40% (paratrabecular)

15-20%

diffuse large B cell lymphoma mantle cell lymphoma lymphoplasmacytic lymphoma marginal zone lymphoma Burkitt lymphoma

15% (diffuse)

20-30%

10-20% (nodular)

40-50%

10% (interstitial)

5-10%

5% (nodular)

70-80%

2-5% (diffuse)

30-40%

Notes discordance in -1/3 discordance in -1/3

4.3.1.2 Small lymphocytic lymphoma/chronic lymphocytic leukemia ■ M o s t c o m m o n B ce ll le u k e m ia in a d u lts in th e w e s te rn h e m is p h e re ■ O f all th e B ce ll n e o p la s m s , C L L d e m o n s tra te s th e s tro n g e s t g e n e tic in flu e n c e □ F a m ilia l c lu s te rin g in 5% o f c a s e s □ 5 * in c re a s e d ris k in firs t d e g re e re la tiv e s o f a ffe c te d in d iv id u a ls ■ In c id e n c e in c re a s e s w ith age, w ith a m e d ia n a g e o f 6 5 y e a rs ■ C lin ic a l p re s e n ta tio n □ G e n e ra liz e d a d e n o p a th y, s p le n o m e g a ly , p e rip h e ra l b lo o d ly m p h o c y to s is □ A u to im m u n ity a nd im m u n o d e fic ie n c y a re c o m m o n

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Neoplastic hematopathology>B cell neoplasms □ C y to p e n ia s (c a u s e d b y a u to im m u n ity ra th e r th a n by m a rro w re p la c e m e n t) □ P o s itiv e D A T w ith fu lly d e v e lo p e d a u to im m u n e h e m o ly tic a n e m ia m a y be s e e n □ M p ro te in is o c c a s io n a lly p re s e n t > S L L i4.30 □ D iffu s e n o d a l e ffa c e m e n t b y s m a ll, m a tu re a p p e a rin g ly m p h o c y te s w ith ro u n d e d n u c le a r c o n to u r, c o a rs e ly c lu m p e d c h ro m a tin , a n d s c a n t c y to p la s m □ P ro life ra tio n c e n te rs (p s e u d o fo llic le s ) n o ta b le at lo w m a g n ific a tio n a s p a le n o d u le s a n d a t h ig h m a g n ific a tio n fo r a la rg e p ro p o rtio n o f p ro ly m p h o c y te s a n d p a ra im m u n o b la s ts □ E x p a n d e d a n d h ig h ly a c tiv e (K i6 7 > 4 0 % ) p ro life ra tio n c e n te rs a re th o u g h t to be a h is to lo g ic s u b ty p e w ith a g g re s s iv e c lin ic a l b e h a v io r ■ C L L i4.31 □ L y m p h o c y to s is c o m p o s e d o f s m a ll, m a tu re a p p e a rin g ly m p h o c y te s w ith s c a n t c y to p la s m , ro u n d e d n u c le a r c o n to u rs , a n d a c o a rs e ly c lu m p e d c h ro m a tin (b lo c k lik e , c h e c k e rb o a rd lik e , c ra c k e d e a rth lik e ), w ith n u m e ro u s s m u d g e d c e lls (an E D T A a rtifa c t n o t s e e n o n h e p a rin s m e a rs )

i4.30 Small lymphocytic lymphoma (SLL) a At low magnification, proliferation centers (pale areas) can be seen b & c At high magnification, a nearly monomorphous population composed largely of small round lymphocytes with occasional prolymphocytes (large cells with nucleoli)

□ B y W H O d e fin itio n , th e a b s o lu te ly m p h o c y te c o u n t m u s t be > 5 * 1 0 9/L (5 ,0 0 0 /p L ) to s e rv e a s th e s o le c rite rio n fo r d ia g n o s is in C L L (ie, in th e a b s e n c e o f tis s u e in v o lv e m e n t) □ M o n o c lo n a l B c e ll ly m p h o c y to s is (M B L ): m o n o c lo n a l B c e ll p o p u la tio n im m u n o p h e n o ty p ic a lly id e n tic a l to C L L < 5 x 1 0 9/L (5 ,0 0 0 /p L ) w ith o u t tis s u e in v o lv e m e n t; M B L c a n b e fo u n d in 3 .5 % o f th e p o p u la tio n o v e r 4 0 y e a rs □ P ro ly m p h o c y te s , c h a ra c te riz e d b y a n in c re a s e d v o lu m e o f c y to p la s m , o p e n c h ro m a tin , a n d c e n tra l p ro m in e n t n u c le o li, c o m p ris e 10% o r le s s o f th e p o p u la tio n □ C L L w ith 1 1 -5 5 % p ro ly m p h o c y te s a re d e s ig n a te d a s C L L w ith in c re a s e d p ro ly m p h o c y te s , a nd p ro ly m p h o c y te c o u n ts >15 * 10 9/L a p p e a r to h a ve p o o r c lin ic a l o u tc o m e ; tru e p ro ly m p h o c y tic le u k e m ia , w ith o v e r 5 5 % p ro ly m p h s , ra re ly e v o lv e s fro m C L L a n d m o re o fte n a ris e s d e n o vo ■ B o n e m a rro w in v o lv e m e n t: n o d u la r (g o o d p ro g n o s is ), in te rs titia l, o r d iffu s e (w o rs e p ro g n o s is ) ■ Im m u n o p h e n o ty p e f4 .8 □ P o s itiv e fo r C D 1 9 , C D 2 0 (dim ), C D 2 2 , C D 5 , C D 2 3 , s lg (dim ), C D 4 3 , C D 7 9 a , a n d C D 1 1 c (d im & v a ria b le ) □ LEF1 e x p re s s io n is h ig h ly s p e c ific fo r C L L /S L L

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i4.31 Chronic lymphocytic leukemia (CLL)

a Usual cytologic features, consisting of small lymphocytes (nuclei not much bigger

than a red cell) with scant cytoplasm & characteristic clumpy (checkerboard or cracked earth) chromatin b 2 typical CLL cells in addition to a single prolymphocyte, with a moderate quantity of eccentric cytoplasm & a prominent nucleolus c shows a single prolymphocyte

■ C y to e g e n tic s □ D e le tio n o f 13q14 (50% ); tris o m y 12 (15-20% ), del(11q), d el(14 q ), a n d del(17p) □ 3 0 % o f c a s e s h ave c o m p le x a b n o rm a litie s

□ C e lls a re n e g a tiv e fo r F M C 7, C D 1 0 b c l6 , a n d b e ll

■ R ic h te r s y n d ro m e , tra n s fo rm a tio n to la rg e cell ly m p h o m a , o c c u rs in 3% to 15% o f c a s e s

□ C D 3 8 a n d /o r Z A P 7 0 e x p re s s io n im p lie s an u n m u ta te d Ig V H s ta tu s a n d a n u n fa v o ra b le p ro g n o s is

■ S ta g in g t4.24

ASCP Quick Compendium of Clinical Pathology 4e

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4: Hematopathology

Neoplastic hematopathology>B cell neoplasms

i4.32 Mantle cell lymphoma (MCL) a At low magnification, note an effaced lymph node with vaguely nodular architecture b & c Typical slightly irregular nuclear contours & small distinct nucleoli; prolymphocytes are absent

coexpression, a feature shared with mantle cell lymphoma (MCL) c Bright expression of CD23, typical of CLL but not seen in MCL d No expression of CD38 in this case, indicating an indolent variety of CLL, with the typically dim CD20 expression e Dim CD11c expression, expected in CLL but rare in MCL f k restriction, with dim expression typical of CLL

t4.24 CLL staging Modified Rai Original Rai

Survival (years) Binet

low risk >13 0. lymphocytosis (>5,000/mL) intermediate 8 I. lymphadenopathy II. hepatosplenomegaly risk 2 III. anemia ( 3 0 % c o rre la te s w ith a d v e rs e p ro g n o s is

□ P le o m o rp h ic v a ria n t h a s a m ix tu re o f c e ll s iz e s a nd m a n y la rg e c e lls w ith n u c le o li i4.33b-c □ B la s to id a n d p le o m o rp h ic v a ria n ts a re c o n s id e re d m o re a g g re s s iv e □ In s itu m a n tle c e ll n e o p la s ia : c y c lin D1 e x p re s s io n in m a n tle z o n e s o f o th e rw is e re a c tiv e fo llic le s ■ Im m u n o p h e n o ty p e f4.9 □ N e o p la s tic c e lls a re p o s itiv e fo r C D 1 9 , C D 2 0 (b rig h t), C D 2 2 , F M C 7 , C D 5 , s lg (b rig h t), C D 4 3 , a n d b e ll (c y c lin D 1 /p ra d 1 ) □ T h e y a re n e g a tiv e fo r C D 2 3 , C D 1 1 c, a n d C D 1 0

4.3.1.4 Follicular lymphoma 4.3.1.4.1 Clinical presentation ■ Is o la te d ly m p h a d e n o p a th y w ith o u t c o n s titu tio n a l s y m p to m s ■ B o n e m a rro w is in v o lv e d in 3 0 % o f c a s e s a t p re s e n ta tio n 4.3.1.4.2 Morphology i4.34

□ M C L is s lig h tly m o re lik e ly to b e la m b d a re s tric te d th a n k a p p a re s tric te d

■ N o d u la r ly m p h o id p ro life ra tio n th a t ty p ic a lly o v e rru n s th e ly m p h n o d e c a p s u le

□ S O X 11, a tra n s c rip tio n fa c to r, h a s in c re a s e d s e n s itiv ity a n d s p e c ific ity fo r M C L , a n d is p a rtic u la rly u s e fu l in c y c lin D 1 -n e g a tiv e c a s e s

■ B a c k to b a c k o r fu s e d fo llic le s w ith a tte n u a te d m a n tle s , lo s s o f p o la rity , a b s e n c e o f tin g ib le b o d y m a c ro p h a g e s , a nd d im in is h e d m ito s e s

■ C y to g e n e tic s

226

□ B la s to id m o rp h o lo g y and p le o m o rp h ic m o rp h o lo g y a re th o u g h t to be a d v e rs e

■ 2 c e ll ty p e s in v a ry in g p ro p o rtio n s : s m a ll c le a v e d c e lls (c e n tro c y te s ) a n d la rg e n o n c le a v e d c e lls (c e n tro b la s ts ) ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

4: Hematopathology

Neoplastic hematopathology>B cell neoplasms ■ In situ fo llic u la r n e o p la s ia □ A rc h ite c tu ra lly re a c tiv e a p p e a rin g g e rm in a l c e n te rs w ith c y to lo g ic fe a tu re s o f F L (re la tiv e ly m o n o m o rp h o u s c e n tro c y te ric h in filtra te ) ■ P rim a ry c u ta n e o u s FL □ N o ta b le fo r v a ria b le C D 1 0 a n d la c k o f b c l2 e x p re s s io n (b c l6 is p o s itiv e ) □ L o w ra te o f ly m p h n o d e in v o lv e m e n t a n d an e x c e lle n t o v e ra ll p ro g n o s is □ If FL in s k in e x p re s s e s o f C D 1 0 a n d /o r b c l2 , s u s p e c t s y s te m ic FL ■ D u o d e n a l ty p e FL □ P re s e n ts a s m u ltip le p o ly p s in 2 n d s ta g e o f d u o d e n u m □ L o w ra te o f ly m p h n o d e d is s e m in a tio n w ith an e x c e lle n t p ro g n o s is ■ T e s tic u la r FL □ H ig h g ra d e FL, e s p e c ia lly in c h ild re n , la c k s B C L 2 tra n s lo c a tio n □ G o o d p ro g n o s is ■ P e d ia tric FL □ O fte n p re s e n ts w ith lo c a liz e d c e rv ic a l ly m p h n o d e e n la rg e m e n t i4.34 Follicular lymphoma (FL) a low magnification; note distinctly follicular proliferation in which follicles are confluent & geographic b high magnification; low grade FL, composed predominantly of small lymphocytes with twisted nuclei (centrocytes) & few large lymphocytes with nucleoli (centroblasts) c high magnification; high grade FL, with numerous large lymphocytes with nucleoli (centroblasts) d FL involving the peripheral blood e FL in marrow, which usually takes the form of paratrabecular lymphoid aggregates

■ G ra d in g t4.25 is b a s e d on th e p ro p o rtio n o f la rg e n o n c le a v e d c e lls (c e n tro b la s ts ) in 4 0 * fie ld s o f 10 ra n d o m ly s e le c te d n e o p la s tic fo llic le s (ra n d o m , n o t w o rs t a re a s ) ■ “ G ra d e 1 -2 ” ca n be a s s ig n e d a s lo w g ra d e

□ L a c k s b c l2 e x p re s s io n , la c k s B C L 2 re a rra n g e m e n t, u s u a lly g ra d e 3 □ E x c e lle n t p ro g n o s is ■ B o n e m a rro w in v o lv e m e n t in FL □ F o c a l p a ra tra b e c u la r a g g re g a te s i4.34d □ O n ly FL a n d T /h is tio c y te ric h B c e ll ly m p h o m a (T C R B C L ) c o m m o n ly d is p la y th is p a tte rn □ B o n e m a rro w d is c o rd a n t m o rp h o lo g y ■ H ig h g ra d e ly m p h o m a e ls e w h e re w ith lo w g ra d e FL in th e m a rro w ; ■ Im p lie s a s lig h tly b e tte r p ro g n o s is th a n c o n c o rd a n t (h ig h g ra d e /h ig h g ra d e ) fin d in g s ■ Im m u n o p h e n o ty p e f4.10, i4.35

t4.25 FL Grade Grade

Centroblast number

grade 1 grade 2 grade 3 3A 3B

0-5/40x field 6-15/40x field >15 per 40x field some residual centrocytes no residual centrocytes

□ P o s itiv e fo r C D 1 9, C D 2 0 , FM C 7, C D 2 2 , C D 1 0 , s lg (b rig h t), b c l2 , a n d b cl6 □ N e g a tiv e fo r C D 5 , C D 4 3 , a n d C D 11c, w ith v a ria b le e x p re s s io n o f C D 2 3 □ H ig h e r g ra d e F L s are u s u a lly n e g a tiv e fo r C D 1 0 a n d / o r b cl2

■ D iffu s e g ro w th in FL □ A re a in w h ic h fo llic u la r a rc h ite c tu re is lo s t a n d th a t la c k s fo llic u la r d e n d ritic c e lls by C D 21 a n d /o r C D 2 3 im m u n o h is to c h e m is try □ G ra d e 3 d iffu s e a re a s a re re n d e re d a d ia g n o s is o f D L B C L (w ith b a c k g ro u n d FL a ls o n o te d ) © A S C P 2018

□ C D 21 and C D 2 3 ca n b e u s e d to h ig h lig h t th e b a c k g ro u n d o f F D C s in fo llic u la r a re a s , a n d a b s e n c e o f C D 21 a n d C D 2 3 c a n be u s e d to s u p p o rt d iffu s e g ro w th ■ C y to g e n e tic s □ t(1 4 ;1 8 )(p 3 2 ;q 2 1 ) re s u ltin g in B C L 2 re a rra n g e m e n t a n d b c l2 p ro te in o v e re x p re s s io n

ISBN 978-08 9189-6678

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f4.10 FL flow cytometry a Gating around cells with bright CD45 & low side scatter (SSC), typical of the lymphocyte gate b Plot of CD5 vs CD19, in which the neoplastic cells strongly express CD19 but lack CD5; occasionally, FL has diminished or absent CD19 c CD23 is absent, but some cases of FL express dim or variable CD23 d Expression of CD38 (typical of FL) & bright CD20 e Distinct CD10 expression by a subset of cells; some FL does not express CD10, and expression is progressively lost with higher grade f Bright K expression

■ P ro g n o s is □ M e d ia n s u rv iv a l o f 8 -1 0 y e a rs ; e v e n tu a lly p ro g re s s (tra n s fo rm ) to h ig h g ra d e F L o r D L B C L □ F a c to rs c o rre la tin g w ith p ro g re s s io n : a g e , s ta g e , b o n e m a rro w in v o lv e m e n t, B s y m p to m s , p e rfo rm a n c e s ta tu s , s e ru m la c ta te d e h y d ro g e n a s e le v e ls , a nd a n e m ia ■ L a rg e B c e ll ly m p h o m a w ith IR F 4 re a rra n g e m e n t □ D iffu s e , fo llic u la r a n d d iffu s e , o r e n tire ly fo llic u la r g ro w th p a tte rn □ U s u a lly in c h ild re n a n d y o u n g a d u lts , in v o lv in g W a ld e y e r’s rin g o r h e a d a n d n e c k ly m p h n o d e s □ E x p re s s M U M 1 a n d B C L 6 ; C D 1 0 p o s itiv e in 6 5 % o f cases □ IR F 4 g e n e re a rra n g m e n e t w ith /w ith o u t B C L 6 re a rra n g e m e n t □ F a v o ra b le p ro g n o s is

□ C lo n a l p la s m a c e lls □ M ay se e D u tc h e r b o d ie s ■ E x tra n o d a l m a rg in a l z o n e B ce ll ly m p h o m a o f m u c o s a a s s o c ia te d ly m p h o id tis s u e (M A L T ly m p h o m a )

4.3.1.5 Marginal zone lymphoma ■ N o d a l m a rg in a l z o n e B c e ll ly m p h o m a □ P ro life ra tio n o f s m a ll ro u n d ly m p h o c y te s w ith a b u n d a n t p a le c y to p la s m a n d in d e n te d n u c le i (m o n o c y to id B c e lls ) i4.36 □ P a tte rn m a y b e d iffu s e , s in u s o id a l, o r in te rfo llic u la r, a n d m a y s h o w fo llic u la r p e rm e a tio n (c o lo n iz a tio n )

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i4.35 FL immunohistochemistry a CD21 reaction, highlighting the residual follicular dendritic cell meshwork; this stain can be used in unclear cases to distinguish diffuse from follicular growth b CD20, highlighting several confluent follicles c BCL2, which is positive in neoplastic follicles but would be negative in reactive follicles d CD3, which highlights a few residual T cells around the follicle e CD10 expression

□ V a ria b ly d e s tru c tiv e a n d /o r tu m e fa c tiv e p ro life ra tio n o f m o n o c y to id B c e lls a nd p la s m a c e lls (s o m e w ith D u tc h e r b o d ie s ) □ C e lls m a y p e rm e a te e p ith e liu m , fo rm in g ly m p h o e p ith e lia l le s io n s i4.37 □ C lo n a l p la s m a c e lls

ASCP Quick Compendium of Clinical Pathology 4e

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4: Hematopathology

Neoplastic hematopathology>B cell neoplasms

i4.36 Marginal zone lymphoma (MZL) usually consists of small lymphocytes with an abundance of clear cytoplasm (“fried eggs"), many of which have bilobed or indented nuclei (“monocytoid”)

□ M A LT ly m p h o m a s a re a s s o c ia te d w ith c h ro n ic a n tig e n ic s tim u la tio n t4.26, u s u a lly fro m in fe c tio u s a g e n ts

t4.26 MZL: associated antigenic stimulation H p y lo ri Gastric MALT C psittaci ocular MALT C jejuni IPSID (a chain disease) B burgdorferi cutaneous MALT Sjogren syndrome salivary MALT Hashimoto thyroid MALT HCV splenic MZL HCV = hepatitis C virus; iPSID = immunoproliferative small intestine disease; MALT = mucosa associated lymphoid tissue; MZL = marginal zone lymphoma m S p le n ic M Z L

□ In v o lv e s th e s p le e n (m a in ly w h ite pulp), s p le n ic h ila r ly m p h n o d e s (b u t n o t o th e r n o d a l sites), liv e r (s in u s o id s) a n d p e rip h e ra l b lo o d (u su a lly a t v e ry low leve ls) □ L e u k e m ic p h a s e o f s p le n ic M Z L , s p le n ic ly m p h o m a w ith v illo u s ly m p h o c y te s (S LV L), in w h ic h le u k e m ic c e lls h ave s m a ll n u c le i, a b u n d a n t p a le c y to p la s m , irre g u la r c y to p la s m ic b o rd e rs , a n d p o la r v illo u s p ro je c tio n s □ D iffe re n c e s w ith H C L in c lu d e a d is tin c t n u c le o lu s (u su a lly a b s e n t in H C L), p o la r v illi (u su a lly c irc u m fe re n tia l in H C L), a nd a n o d u la r p a tte rn o f b o n e m a rro w in v o lv e m e n t (in te rs titia l o r d iffu s e in H C L ) □ B lo o d la k e s a nd re tic u lin fib ro s is , c o m m o n in m a rro w s in v o lv e d by H C L , a re n o t s e e n in S L V L

© A S C P 2018

i4.37 Extranodal MZL

a Gastric extranodal marginal zone lymphoma (MALT lymphoma), low

magnification view, showing an expansile lymphoid proliferation in the deep mucosa & mucosal gastritislike infiltrate in the superficial mucosa b High magnification image of the superficial mucosa of a showing many plasma cells in this region, also depicted is a lymphoepithelial lesion c-e Peripheral blood involvement by splenic lymphoma with villous lymphocytes, in which lymphocytes with distinct nucleoli are associated with voluminous cytoplasm that is bipolar & has polar villi □ In th e s p le e n , H C L d iffu s e ly in v o lv e s red p ulp , w h ile S L V L is fo u n d in w h ite p u lp □ S p le n ic M Z L is a s s o c ia te d w ith H C V in fe c tio n in > 3 0 % of cases □ R e m is s io n ca n o fte n be a c h ie v e d b y s p le n e c to m y ■ Im m u n o p h e n o ty p e □ P o sitiv e fo r C D 1 9, C D 2 0 , C D 7 9 a , F M C 7, b c l2 , a n d s lg (Ig M ) □ N e g a tiv e fo r C D 5 , C D 2 3 , C D 1 0 , C D 1 0 3 , A n n e x in A1, a n d C D 11c

ISBN 978-08 9 1 8 9 -6 6 7 8

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Neoplastic hematopathology>B cell neoplasms

i4.38 Hairy cell leukemia (HCL) a & b Peripheral blood involvement by cells with large nuclei, approximately twice the size of a red cell, no nucleoli & an abundance of cytoplasm with frayed edges (hairy projections) c Marrow involvement by cells with abundant clear cytoplasm (“fried eggs") d Blood lake in the spleen

□ P la s m a c e lls c o n ta in m o n o c lo n a l c y to p la s m ic lig h t c h a in s □ C D 4 3 is re p o rte d in u p to 5 0 % c a s e s ■ C y to g e n e tic s □ t(11;18) tra n s lo c a tio n , re a rra n g e m e n t o f th e A P I2 a nd M A L T 1 g e n e s , is c o m m o n in tu m o rs o f th e s to m a c h a n d lu n g □ t(1 4;18 ) tra n s lo c a tio n re s u lts in a M A L T 1 -IgH g e n e fu s io n , a n d a re fo u n d la rg e ly in o c u la r, p a ro tid , a n d c u ta n e o u s s ite s □ t(3 ;1 4 ) tra n s lo c a tio n (F O X P 1 -M A L T 1 ) is a s s o c ia te d w ith o c u la r, th y ro id , a n d c u ta n e o u s s ite s □ t(1;14) is s e e n in lu n g a n d s m a ll b o w e l □ + 3 a n d +18 a re s e e n n o n s p e c ific a lly in a ll s ite s

f4.11 HCL flow cytometry a Gating around cells with bright CD45 & moderate side scatter (SSC), somewhat removed from the typical lymphocyte gate b Plot of CD5 vs CD19, in which the neoplastic cells have characteristically very bright CD19 expression, lacking CD5 c Very bright CD20 & CD11c expression, in contrast to the dim 11c expression seen in CLL d & e Expression, again very bright, of CD22, CD103 & CD25 4 .3 .1 .6 .2 M o r p h o lo g y i4.38 ■ P e rip h e ra l b lo o d s m e a rs a nd c y to lo g ic p re p a ra tio n s s h o w la rg e ly m p h o id c e lls w ith ro u n d , o val, re n ifo rm , o r b ilo b e d n u c le i, s h a rp n u c le a r o u tlin e , “g ro u n d g la s s ” c h ro m a tin a n d a b s e n t o r in d is tin c t n u c le o li ■ C y to p la s m ic h a iry p ro je c tio n s a re c irc u m fe re n tia l, in d is tin c t a nd fra y e d ■ C y to p la s m is p ale , te x tu re d , a nd flo c c u le n t ■ In b o n e m a rro w a n d s p le e n , h a iry c e lls h ave “ frie d e g g ” m o rp h o lo g y , w ith s m a ll d a rk n u c le i a n d a b u n d a n t p ale c y to p la s m ■ T h e m a rro w m ay be h y p o c e llu la r, m im ic k in g a p la s tic a n e m ia ■ R e ticu lin fib ro s is is c o m m o n , c a u s in g a n in a s p ira b le (d ry tap) s a m p le

4.3.1.6 Hairy cell leukemia

■ “ B loo d la k e s ”: b lo o d fille d s p a c e s w ith o u t e n d o th e lia l lin in g , e s p e c ia lly in s p le n ic red p ulp

4.3.1.6.1 C lin ic a l p re s e n ta tio n

■ In th e liver, th e c e lls in filtra te th e h e p a tic s in u s o id s

■ N e w o n s e t n e u tro p e n ia , m o n o c y to p e n ia , o r a p la s tic a n e m ia ■ S p le n o m e g a ly is p re s e n t a t p re s e n ta tio n a n d m a y be m a s s iv e ■ L y m p h a d e n o p a th y is u n c o m m o n ■ S o m e a u to m a te d a n a ly z e rs c a n m is ta k e h a iry c e lls fo r m o n o c y te s

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■ In lym p h n o d e s , H C L te n d s to be s in u s o id a l ■ U n like H C L , c y to p la s m ic p ro je c tio n s in S L V L te n d to be polar, c y to p la s m la c k s flo c c u le n t q u a lity o f H C L , c h ro m a tin in S L V L la c k s th e d is p e rs e d g ro u n d g la s s q u a lity o f H C L , a nd th e n u c le o lu s is p ro m in e n t in S L V L ■ U ltra s tru c tu ra lly , rib o s o m e la m e lla r c o m p le x e s : a n n u la r s tru c tu re s w ith a c e n tra l e m p ty z o n e s u rro u n d e d by c o n c e n tric tu b u le a n d rib o s o m e s a re th e m o s t d is tin c tiv e fe a tu re o f H C L . T h e s e m a y a p p e a r a s D o h le -lik e in c lu s io n s on lig h t m ic ro s c o p y

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4: Hematopathology

Neoplastic hematopathology>B cell neoplasms t4.27 Immunophenotype of mature B cell neoplasms composed of small lymphocytes FMC7 CD79a CD5 CD23 CD11c CD25 CD10 slg CD20 CD19 ± + + ± + +++ -/+ CLL + +++ +++ + +++ PLL + ++ +++ + + +++ MCL + + + +++ +++ + FL ++/± + + +++ +++ + +++ -/+ MZL/SLVL +++ + ++ +++ +++ + +++ HCL CLL = chronic lymphocytic leukemia, PLL = prolymphocytic leukemia, MCL = mantle cell lymphoma, FL = follicular lymphoma, MZUSLVL - marginal zone lymphoma/ splenic lymphoma with villous lymphocytes, HCL- hairy cell leukemia

4.3.1.6.3 Im m u n o p h e n o ty p e f4.11 ■ P o sitiv e fo r C D 19, C D 2 0 , C D 2 2 , s lg , C D 11c (b rig h t), C D 2 5 (b rig h t), C D 1 0 3 , T R A P , D B A .4 4 , A n n e x in A1, C D 1 2 3 , a nd c y c lin D1 (dim , n u c le a r)

■ S o m e c a s e s a s s o c ia te d w ith h e p a titis C a n d c ry o g lo b u lin e m ia ; th e y re s p o n d to a n tiv ira l th e ra p y ■ W a ld e n s tro m m a c ro g lo b u lin e m ia is L P L w ith an Ig M m o n o c lo n a l g a m m o p a th y a nd m a rro w in v o lv e m e n t

■ N e g a tiv e fo r C D 5 , C D 4 3 , C D 2 3 , a n d C D 1 0 t4.27 ■ M a y be fo u n d in th e m o n o c y te g a te in flo w c y to m e try p lo t w ith s tro n g C D 4 5 a nd m o d e ra te s id e s c a tte r ■ C D 1 0 + in -1 0 % , w ith no c lin ic a l s ig n ific a n c e ■ C D 1 0 3 is e x p re s s e d in S L V L a nd H C L v a ria n t (H C Lv), both o f w h ic h m a y n o t re s p o n d to H C L d ire c te d th e ra p y

4.3.1.8.2 Im m u n o p h e n o ty p e ■ P o s itiv e fo r C D 1 9 , C D 2 0 , C D 3 8 , S ig (b rig h t), a n d c lg (p la s m a c e lls ) ■ C D 5 , C D 2 3 , C D 4 3 , a n d C D 1 0 a re n e g a tiv e o r d im

4.3.1.8.3 G e n e tic s 4.3.1.6.4 G en etic s

■ M Y D 8 8 L 2 6 5 P g e n e m u ta tio n s in > 9 0 % L P L

■ B R A F V 6 0 0 E m u ta tio n s e e n in m a jo rity o f H C L ; n ot p re s e n t in H C L v o r IG V H 4 -3 4 H C L ■ B e ll o v e re x p re s s io n is n ot a s s o c ia te d w ith s tru c tu ra l re a rra n g e m e n ts o f th e BCL1 lo c u s

■ M u ta tio n s in C X C R 4 g e n e a s s o c ia te d w ith p o o r p ro g n o s is a n d re s is ta n c e to th e ra p y

4.3.1.9 Heavy chain disease ■ R a re L P D p ro d u c in g im m u n o g lo b u lin h e a v y (H ) c h a in s o n ly

4.3.1.7 Prolymphocytic leukemia ■ P re s e n ts a b ru p tly w ith a v e ry h ig h w h ite c o u n t > 1 0 0 ,0 0 0 / pL, B s y m p to m s , c y to p e n ia s , a nd s p le n o m e g a ly ■ P ro ly m p h o c y te s > 5 5 % , d e fin e d a s ly m p h o id c e lls w ith p ro m in e n t n u c le o li a nd a m o d e ra te q u a n tity o f s lig h tly e c c e n tric c y to p la s m ■ Im m u n o p h e n o ty p e d iffe rs fro m S L L /C L L , w ith > 8 0 % o f c a s e s n e g a tiv e fo r C D 5 a n d C D 2 3 , e x p re s s in g b rig h t C D 11c, b rig h t s lg , b rig h t C D 2 0 , C D 2 2 , a nd F M C 7 t4.27

4.3.1.8 Lymphoplasmacytic lymphoma/Waldenstrom macroglobulinemia

■ M o s t c o m m o n fo rm is a H c h a in d is e a s e : a s s o c ia te d w ith im m u n o p ro life ra tiv e sm all in te s tin e d is e a s e , a ls o k n o w n as M e d ite rra n e a n ly m p h o m a , s tim u la te d by C a m p y lo b a c te r je ju n i in fe c tio n ■ L e s s c o m m o n a re y h e a v y c h a in d is e a s e , fo u n d in s o m e c a s e s o f L P L , a n d p h e a v y c h a in d is e a s e fo u n d in s o m e cases of CLL ■ 1/3 o f p a tie n ts w ith y h e a v y c h a in d is e a s e , a ls o c a lle d F ra n k lin H c h a in d is e a s e , h a ve a h is to ry o f rh e u m a to id a rth ritis

4.3.1.10 Diffuse large B cell lymphoma

4.3.1.8.1 M o rp h o lo g y ■ S p e c tru m o f c e llu la r m o rp h o lo g y , fro m s m a ll ly m p h o id c e lls to ly m p h o p la s m a c y to id c e lls a nd p la s m a c e lls

4.3.1.10.1 C lin ical p rese n ta tio n

■ D u tc h e r b o d ie s m a y be se e n

■ P re s e n ts as a ra p id ly e n la rg in g n o d a l o r e x tra n o d a l (m o s t o fte n G l) m a s s

■ L ym p h n o d e a rc h ite c tu re m a y be p re s e rv e d (L P L in s in u s e s ) o r e ffa c e d

■ U s u a lly lo c a liz e d a t p re s e n ta tio n , w ith b o n e m a rro w in v o lv e m e n t u n c o m m o n (10% )

■ P e rio d ic a c id -S c h iff (P A S ) p o s itiv e m a te ria l fo u n d in s in u s e s (and D u tc h e r b o d ie s a re PAS+)

■ A b o u t a th ird o f p a tie n ts have B s y m p to m s , a n d a th ird h ave e le v a te d L D H a t p re s e n ta tio n

■ In th e m a rro w , a m a s t ce ll in filtra te a c c o m p a n ie s LP L © A S C P 2018

ISBN 9 7 8 -08 9189-6678

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Neoplastic hematopathology>B cell neoplasms 4.3.1.1 0.2 M o rp h o lo g y i4.39 ■ D iffu s e p ro life ra tio n o f la rg e ly m p h o id c e lls ■ N u c le i a re a t le a s t a s la rg e a s th a t o f a m a c ro p h a g e / h is tio c y te a n d m o re th a n tw ic e th e s iz e o f a n o rm a l ly m p h o c y te ■ T h e m o rp h o lo g y o f th e c e lls m a y be “c e n tro b la s tic ,” w ith v e s ic u la r n u c le i a n d 1 to s e v e ra l p e rip h e ra l n u c le o li, “ im m u n o b la s tic ”, w ith p ro m in e n t s in g le n u c le o li a n d e c c e n tric c y to p la s m , o r “ a n a p la s tic ”

4.3.1.1 0.3 Im m u n o p h e n o ty p e ■ P o s itiv e fo r C D 1 9 , C D 2 0 , C D 2 2 , a n d C D 4 5 ■ U s u a lly p o s itiv e fo r b c l2 , w ith v a ria b le e x p re s s io n o f C D 1 0 , C D 5 , a n d b c l6 ■ C D 5 + D L B C L d is tin g u is h e d fro m b la s to id M C L by la c k o f b e ll o v e re x p re s s io n o r C C N D 1 re a rra n g e m e n t ■ G e rm in a l c e n te r B c e ll (G C B ) p h e n o ty p e v s a c tiv a te d B c e ll (A B C ) p h e n o ty p e □ E x p re s s io n o f C D 1 0 a n d b c l6 c o rre la te s w ith th e m o re fa v o ra b le G C B p h e n o ty p e □ E x p re s s io n o f M U M 1 in th e a b s e n c e o f C D 1 0 in d ic a te s A B C p h e n o ty p e (H a n s m e th o d t4 .2 8 ) □ M o rp h o lo g ic a lly , G C B is m o re lik e ly to h a ve c e n tro b la s tic m o rp h o lo g y , w h ile A B C o fte n h as im m u n o b la s tic m o rp h o lo g y □ B C L 2 , t(14;18), re a rra n g e m e n t is c o m m o n in th e G C B ty p e □ B C L 6 , t(3 ;X ), re a rra n g e m e n t is m o re c o m m o n in th e A B C ty p e

t4.28 Stepwise evaluation of DLBCL subtypes by im m unohistochem istry (Hans method) In te rpretation if CD10+ in >30% of cells, then GCB if CD10-, proceed to step 2 2 BCL6 if BCL6-, then non-GC (ABC) if BCL6+, proceed to step 3 3 MUM1 if MUM1+, then non-GC (ABC) if MUM1-, then GCB ABC = activated B cell; DLBCL = diffuse large B cell lymphoma; GC = germinal center; GCB = germinal center B cell Step 1

M arker(s) CD10

DLBCL subtypes by im m unohistochem istry MUM1 Phenotype CD10 BCL6 + + GCB + GCB + GCB + + non-GC (ABC) + non-GC (ABC) ABC = activated B celt; DLBCL = diffuse large B cell lymphoma; GC = germinal center; GCB = germinal center B cell

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i4.39 Diffuse large B cell lymphoma (DLBCL) a-e A variety of morphologic expressions of DLBCL f Typical CD20 reaction g Nuclear expression of Ki67; typically 30-95% of the cells express Ki67, in contrast to lower rates of expression in indolent lymphomas & higher rates of expression in Burkitt lymphoma

4.3.1.11 Other lymphomas of large B cells 4.3.1.11.1 P rim a ry D LB C L o f th e C N S i4.40 ■ D e fin e d by W H O to s p e c ific a lly e x c lu d e d u ra l ly m p h o m a , in tra v a s c u la r ly m p h o m a , s e c o n d a ry in v o lv e m e n t by s y s te m ic ly m p h o m a , a n d ly m p h o m a a s s o c ia te d w ith im m u n o d e fic ie n c y ■ M e d ia n a g e is 6 0 y e a rs ■ S u p ra te n to ria l m a s s w ith in th e fro n ta l, te m p o ra l, o r p a rie ta l lo b e s ■ S o lita ry o r m u ltifo c a l le s io n w ith ra d io g ra p h ic fe a tu re s th a t m im ic g lio b la s to m a , in c lu d in g a te n d e n c y to sp re a d a lo n g w h ite m a tte r tra c ts a nd c ro s s th e m id lin e ■ M ay p re s e n t o r re c u r a s in tra o c u la r ly m p h o m a ■ N e o p la s tic c e lls a re ty p ic a lly in p e riv a s c u la r c u ffs and e x p re s s p an B ce ll a n tig e n s ■ M o s t e x p re s s M U M 1 a nd a re n e g a tiv e fo r C D 10 ■ M a n y c a s e s d e m o n s tra te a B C L 6 re a rra n g e m e n t and o v e re x p re s s b c l6 , b u t B C L 2 re a rra n g e m e n t is ra re

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4: Hematopathology

Neoplastic hematopathology>B cell neoplasms

i4.40 Primary CNS lymphoma a & b Note the tight perivascular nature of the proliferation c At high magnification, note that the cells are large lymphocytes, in contrast to encephalitis, in which predominantly small lymphocytes are seen d Strong CD20 expression

4.3.1.11.2 T c e ll/h is tio c y te rich large B cell lym p h o m a (TC R B C L) ■ M e a n a g e 4 0 y e a rs ■ D iffu s e p ro life ra tio n ; n e o p la s tic c e lls a re la rg e B c e lls th a t a re s c a tte re d w ith in a b a c k g ro u n d o f re a c tiv e ly m p h o c y te s and h is tio c y te s i4.41 ■ D iffe re n tia tio n fro m N L P H L □ T C R B C L la c k s n o d u la r a rc h ite c tu re □ C D 5 7 + T ce ll ro s e tte s a re a b s e n t □ S m a ll B c e lls a re e s s e n tia lly a b s e n t □ T h e re is no C D 2 1 + /C D 2 3 + F D C m e s h w o rk ■ L a rg e B c e lls e x p re s s p an B m a rk e rs in a d d itio n to b cl6; s o m e e x p re s s b c l2 and E M A , b u t th e y a re n e g a tiv e fo r C D 15, C D 3 0 , and EBV. T h e b a c k g ro u n d ly m p h o c y te s a re p re d o m in a n tly C D 8 + T c e lls ■ L ike FL, T C R B C L in v o lv e s th e m a rro w a s p a ra tra b e c u la r ly m p h o id a g g re g a te s i4.41

4.3.1.11.3 P rim ary m e d iastin al (thym ic) large B cell lym p h o m a ■ A ffe c ts y o u n g a d u lt w o m e n , p re s e n tin g a s m e d ia s tin a l m ass ■ S c le ro s in g p ro c e s s th a t d iffu s e ly in filtra te s m e d ia s tin u m ■ M o rp h o lo g ic a lly , la rg e c e n tro b la s t like B c e lls a re e n tra p p e d w ith in b a n d s o f c o m p a rtm e n ta liz in g s c le ro s is i4.42 ■ N e o p la s tic c e lls a re p o s itiv e fo r C D 4 5 , C D 19, C D 2 0 , C D 7 9 a , M U M 1, a nd C D 3 0 © A S C P 2018

i4.41 T/histiocyte rich B cell lymphoma (TCRBCD a proliferation consisting of small lympnocytes (T cells) & large lymphocytes with rominent nucleoli (B cells) & c Prominent eosinophilia in the background is due to histiocytes d Reaction with CD3 highlighting background cells e CD68, also highlighting background cells f & g CD20 & CD10 reactions, respectively, in the large cells h Marrow involvement with TCRBCL, typically paratrabecular as seen also in FL

■ N e g a tiv e fo r s u rfa c e im m u n o g lo b u lin , C D 1 0 , a n d C D 5 ■ H a rb o rs a lte ra tio n s in th e M A L g e n e , g a in s in 9 p (th e lo c a tio n o f J A K 2 ), a nd la cks re a rra n g e m e n t o f B C L 2 a n d BCL6

4.3.1.11.4 A LK + large B cell ly m p h o m a ■ R a re tu m o r c o m p o s e d o f im m u n o b la s tic /p la s m a b la s tic c e lls th a t e x p re s s A L K , E M A , C D 1 3 8 , a n d c y to p la s m ic Ig (Ig A m o s t o fte n ). C D 3 0 is n e g a tiv e t4.29

ISBN 978-08 9 1 8 9 -6 6 7 8

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4: Hematopathology

Neoplastic hematopathology>B cell neoplasms

i4.42 Primary mediastinal lymphoma a-c Densely sclerotic stroma surrounds compressed groups of large B cells d CD20 reaction

4.3.1.11.5

P la s m a b la s tic ly m p h o m a

i4.43 Intravascular diffuse large B cell lymphoma

4.3.1.11.6 In tra v a s c u la r larg e B cell lym p h o m a i4.43

■ O c c u rs in im m u n o d e fic ie n c y , m o s t c o m m o n ly in H IV in fe c tio n

■ S y m p to m s a re re la te d to s m a ll v e s s e l o b s tru c tio n by la rg e B c e lls

■ A ris e s in e x tra n o d a l s ite s , m o s t c o m m o n ly th e o ra l c a v ity

■ L ym ph n o d e in v o lv e m e n t is ra re , a n d th e tu m o r is o fte n d ia g n o s e d in skin b io p s ie s

■ C o m p o s e d o f la rg e B c e lls w ith im m u n o b la s tic o r p la s m a b la s tic t4.29 m o rp h o lo g y ■ N e o p la s tic c e lls a re C D 3 8 + , C D 1 3 8 + , IR F 4 /M U M 1 + , c lg + , C D 4 5 - n e g a tiv e , C D 2 0 - n e g a tiv e , a n d E B V + ■ C D 5 6 is u s u a lly n e g a tiv e , in c o n tra s t to p la s m a c y to m a ■ H u m a n h e rp e s v iru s 8 (H H V 8 ) is n e g a tiv e , in c o n tra s t to p rim a ry e ffu s io n ly m p h o m a (P E L ) ■ M Y C g e n e a b e rra tio n s a re d e te c te d in 1/3 o f c a s e s t4 .2 9 B cell neoplasm s with plasm ablastic morphology Neoplasm Notes plasmablastic lymphoma extranodal, especially oral cavity HIV+, EBV+ if arising from multicentric Castleman disease, HHV8+ primary effusion lymphoma extranodal, pleural cavity HIV+, EBV+, HHV8+ ALK+ DLBCL nodal not associated with HIV or EBV PTLD polymorphous PTLD EBV+ plasmacytoma, anaplastic medullary not associated with HIV or EBV EBV = Epstein-Barr virus; HHV8 = human herpesvirus 8; DLBCL = diffuse large B cell lymphoma; HIV = human immunodeficiency virus; PTLD = posttransplant lymphoproliferative disorder

234

4.3.1.11.7 P rim a ry effu s io n lym p h o m a ■ S tro n g ly a s s o c ia te d w ith H H V 8 , e s p e c ia lly in A ID S p a tie n ts ■ P re s e n ts w ith e ffu s io n s (p le u ra l, p e ric a rd ia l, p e rito n e a l) c o n ta in in g la rg e a ty p ic a l ly m p h o c y te s w ith im m u n o b la s tic , p la s m a b la s tic , o r a n a p la s tic m o rp h o lo g y and c y to p la s m ic v a c u o liz a tio n i4.44 ■ E x tra c a v ita ry P E L m a y p re s e n t a s s o ft tis s u e o r n od a l m ass ■ Im m u n o p h e n o ty p e □ N e g a tiv e fo r B ce ll, T ce ll, a n d m y e lo id a n tig e n s (C D 2 0 , C D 7 9 , C D 1 9, C D 1 0, C D 3 , C D 5 , C D 13, C D 14, C D 33) ■ P o sitiv e fo r C D 4 5 , C D 3 0 , C D 3 8 , C D 1 3 8 , a n d E M A ■ P o sitiv e fo r H H V 8 a n d E B V

4.3.1.11.8 P rim a ry cu ta n e o u s D L B C L, leg typ e ■ A ffe c ts p re d o m in a n tly e ld e rly w o m e n ■ 9 0% o f c a s e s o n th e lo w e r e x tre m ity ■ D e e p s e a te d (n o n e p id e rm o tro p ic ) in filtra te o f la rg e B c e lls th a t e x p re s s pan B m a rk e rs in a d d itio n to b cl2 (note th a t p rim a ry c u ta n e o u s FL is b c l2 - ) a n d b cl6 ; C D 1 0 is n e g a tive

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

4: Hematopathology

Neoplastic hematopathology>B cell neoplasms

i4.44 Primary effusion lymphoma (PEL) a & b Markedly atypical lymphoid cells with somewhat plasmacytoid morphology c Nuclear expression of HHV8

4.3.1.11.9

4.3.1.11.12 High grade B cell lymphoma with M YC and B C L2 and/ or B C L6 rearrangements

EB V+ D L B C L, N O S

■ A ffe c ts e x tra n o d a l s ite s o f e ld e rly a d u lts in A s ia n p o p u la tio n s

■ D o u b le o r trip le h it ly m p h o m a s

■ N e o p la s m is th o u g h t to be re la te d to im m u n e s y s te m senescence ■ E B V + la rg e B ce ll n e o p la s m s a re lis te d in t4 .3 0

t4.30 EBV+ large B cell neoplasms Neoplasm plasmablastic lymphoma primary effusion lymphoma lymphomatoid granulomatosis DLBCL associated with chronic inflammation EBV+ DLBCL, NOS EBV+ mucocutaneous ulcer

Notes often seen in HIV infection; usually extranodal coinfection with HHV8; usually seen in immunodeficiency usually extranodal (lung, skin, brain) classically arising in longstanding pyothorax usually extranodal; elderly or in immunodeficiency states Usually in oral cavity of elderly or immunosuppressed; Hodgkin-like features; indolent course

DLBCL = diffuse large B cell lymphoma; EBV = Epstein-Barr virus; HHV8 = human herpesvirus 8; HIV = human immunodeficiency virus; NOS = not otherwise specified

4.3.1.11.10 L ym p h o m ato id g ra n u lo m a to s is (LG) ■ N e o p la s tic c e lls th a t d e s tru c tiv e ly in v a d e v e s s e l w a lls in a p a tte rn re s e m b lin g v a s c u litis i4.45 ■ L a rg e n u m b e rs o f re a c tiv e T c e lls , in a d d itio n to p la s m a c e lls a nd h is tio c y te s ■ C o m m o n ly a ffe c ts lu n g s, b u t m a y in v o lv e u p p e r a e ro d ig e s tiv e tra c t, b ra in , k id n e y s , and liv e r ■ A s s o c ia te d w ith b o th E B V a n d im m u n o d e fic ie n c y

4.3.1.11.11 D LB C L as s o c ia te d w ith ch ro n ic in flam m atio n ■ B ce ll ly m p h o m a th a t a ris e s a t s ite s o f lo n g s ta n d in g in fla m m a tio n ■ P ro to ty p e is ly m p h o m a a ris in g w ith in a lo n g s ta n d in g p y o th o ra x ■ N e o p la s tic c e lls e x p re s s E B V © A S C P 2018

i4.45 Lymphomatoid granulomatosis a At low magnification, the process resembles vasculitis b At high magnification, the infiltrate is composed of large atypical B lymphocytes

■ B la s to id , B u rk itt-lik e , o r D L B C L m o rp h o lo g y ■ A g g re s s iv e d is e a s e u s u a lly p re s e n tin g a t a d v a n c e d s ta g e

4.3.1.12 Immunodeficiency associated lymphoproliferative disorders ■ M o s t c o m m o n ly m p h o m a s in H IV in fe c tio n a re B u rk itt ly m p h o m a , D L B C L (e s p e c ia lly in th e C N S ), P E L, p la s m a b la s tic ly m p h o m a , a n d H L ■ P o s ttra n s p la n t ly m p h o p ro life ra tiv e d is o rd e r (P T L D ) □ A b n o rm a l ly m p h o id p ro life ra tio n fo llo w in g tra n s p la n ta tio n , u s u a lly w ith in th e fir s t p o s ttra n s p la n t year □ E B V h a s b e e n im p lic a te d in m o s t c a s e s , e s p e c ia lly in e a rly p o s ttra n s p la n t c a s e s □ E le va te d E B V -D N A viral lo a d is p re d ic tiv e o f an e m e rg in g P T L D □ L a te (>5 y e a rs ) p o s ttra n s p la n t ly m p h o m a s te n d to be E B V -n e g a tiv e a nd m o re a g g re s s iv e □ R e n a l a n d b o n e m a rro w tra n s p la n t re c ip ie n ts h a v e th e lo w e s t in c id e n c e , and h e a rt-lu n g a n d liv e r-b o w e l re c ip ie n ts h a ve th e h ig h e s t □ R is k fu rth e r d e p e n d s on re c ip ie n t a g e (c h ild re n a re m o s t a t risk), re c ip ie n t p re tra n s p la n t E B V s ta tu s (E B V -n e g a tiv e a t h ig h e r risk), a n d d e g re e o f im m u n o s u p p re s s io n (m o st s u p p re s s e d a t g re a te s t risk) □ M o s t P T L D c lo n e s a re o f re c ip ie n t o rig in ; < 1 0 % a re o f d o n o r o rig in □ P T L D o fte n in v o lv e s th e a llo g ra ft its e lf □ S p e c tru m o f B ly m p h o p ro life ra tiv e le s io n s in c lu d e s re a c tiv e p la s m a c y to s is , in fe c tio u s m o n o n u c le o s is like p ro life ra tio n s , p o ly m o rp h o u s (ly m p h o c y te s , im m u n o b la s ts , p la s m a c e lls ) p ro life ra tio n s , H o d g k in -lik e a nd m o n o m o rp h o u s P T L D (m a jo rity h ig h g ra d e B c e ll ly m p h o m a )

ISBN 9 7 8 -0 8 9 1 8 9 -6 6 7 8

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Neoplastic hematopathology>B cell neoplasms | Precursor neoplasms (lymphoblastic leukemia & lymphoma), B and T 4.3.1.13 Burkitt lym phom a/leukem ia 4.3.1.13.1 3 c lin ic o p a th o lo g ic ty p e s ■ A fric a n (e n d e m ic ) B u rk itt ly m p h o m a /le u k e m ia : ja w m a s s in c h ild h o o d a n d s tro n g ly a s s o c ia te d w ith E B V ■ W e s te rn (s p o ra d ic ) B u rk itt ly m p h o m a /le u k e m ia p re s e n ts in n o d a l o r e x tra n o d a l s ite s o f c h ild re n a n d y o u n g a d u lts ; n o t s tro n g ly a s s o c ia te d w ith E B V ■ Im m u n o d e fic ie n c y a s s o c ia te d B u rk itt ly m p h o m a : o fte n H IV a s s o c ia te d

4.3.1.13.2 M o rp h o lo g y

i4.46 Burkitt lymphoma (BL) a Lymph node is diffusely effaced by a proliferation of large lymphoid cells with numerous tingible body macrophages & a high rate of both mitosis & apoptosis b Neoplastic cells express Ki67 in nearly 100% of nuclei c Neoplastic cells are BCL2-

■ D iffu s e p ro life ra tio n o f in te rm e d ia te s iz e d m o n o m o rp h ic c e lls w ith a d is tin c t rim o f b a s o p h ilic c y to p la s m a n d ro u n d n u c le i w ith m u ltip le n u c le o li ■ T in g ib le b o d y m a c ro p h a g e s im p a rt S ta rry s k y a p p e a ra n c e i4.46 ■ In p e rip h e ra l b lo o d o r c y to lo g ic p re p a ra tio n s , d e e p b lu e c y to p la s m (W rig h t s ta in s ) w ith lip id c o n ta in in g v a c u o le s i4.47

4.3.1.1 3.3 Im m u n o p h e n o ty p e ■ P o s itiv e fo r C D 1 9 , C D 2 0 , C D 2 2 , C D 1 0 , b c l6 , s lg (lig h t c h a in re s tric te d ), a n d m y c ■ N e g a tiv e fo r C D 5 , C D 2 3 , b c l2 , Tdt, a n d C D 3 4 ■ P C N A (K i6 7 ) is p o s itiv e in > 9 9 % o f c e lls

4 .3 .1.1 3.4 G e n e tic s ■ P o s itiv e fo r M Y C g e n e re a rra n g e m e n t a s a re s u lt o f M Y C /IG H fu s io n t(8 ;1 4); a ls o re a rra n g e d w ith IgK (2p12) o r IgA (22q11)

4.3.1.1 3.5 B u rk itt-lik e ly m p h o m a w ith 11q a b e rra tio n ■ R e s e m b le B u rk itt ly m p h o m a , b u t la c k M Y C g e n e re a rra n g e m e n t ■ S h o w c h ro m o s o m e 11 q a lte ra tio n ■ C lin ia l c o u rs e s im ila r to B u rk itt ly m p h o m a

4.3.2 Precursor neoplasms (lymphoblastic leukemia & lymphoma), B and T

i4.47 Burkit lymphoma (BL) in peripheral blood (& in touch imprints) has deep blue vacuolated cytoplasm ■ R isk fa c to rs : D o w n s y n d ro m e , F a n c o n i’s A n e m ia , L i-F ra u m e n i s y n d ro m e , a ta n g ia -te la n g ie c ta s ia , B lo o m s y n d ro m e ■ C lin ic a l p re s e n ta tio n □ T L B L ty p ic a lly p re s e n ts a s an a n te rio r m e d ia s tin a l m a s s , m a y be a s s o c ia te d w ith h y p e rc a lc e m ia □ B L B L in v o lv e s ly m p h n o d e s , C N S , liver, s p le e n , and te s te s □ T a nd B A L L p re s e n t w ith fa tig u e a nd c y to p e n ia s , m ay h ave b o n e pain ■ M o rp h o lo g y

4.3.2.1 General features ■ L y m p h o b la s tic ly m p h o m a (L B L ): le s io n s in v o lv in g tis s u e a n d s p a rin g th e p e rip h e ra l b lo o d a n d b o n e m a rro w

□ M o n o to n o u s p ro life ra tio n o f u n d iffe re n tia te d b la s ts i4.48, i4.49

■ A c u te ly m p h o b la s tic le u k e m ia (A L L ): le s io n s h e a v ily in v o lv in g th e m a rro w a n d p e rip h e ra l b lo o d

□ T L B L m ay b e a s s o c ia te d w ith an in filtra te o f e o s in o p h ils

■ A L L p e a k s in in c id e n c e a t 3 y e a rs o f a g e

□ C y to c h e m ic a lly , ly m p h o b la s ts s h o w P AS p o s itiv ity in a b lo c k lik e p a tte rn a nd a re n e g a tiv e fo r m y e lo p e ro x id a s e (M P O ) a nd S u d a n b la c k B (S B B )

236

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Neoplastic hem atopathology>Precursor neoplasms (lym phoblastic leukemia & lymphoma), B and T | Plasma cell neoplasm s 0

ft®

•< >
1 lin e a g e to a s in g le b la s t p o p u la tio n

4.3.2.2 Precursor B acute lymphoblastic leukemia/ lymphoblastic lymphoma, not otherwise specified ■ Im m u n o p h e n o ty p ic a lly , b la s ts a re p o s itiv e fo r C D 19, C D 10, P A X 5 , C D 3 4 , C D 9 9 , H L A D R , a nd n u c le a r TdT

t4.31

t4.31 Immunophenotypes in ALL/LBL & BL Tdt precursor B + Burkitt precursor T +

HLA-DR

CD19

CD20

CD10

+

+

-/+

+/-

+

+

+

+

slg

CD7

□ B lin e a g e : s tro n g C D 1 9 a n d 1 o f th e fo llo w in g : C D 7 9 a , c y to p la s m ic C D 2 2 , and C D 1 0 , o r w e a k C D 1 9 a n d 2 o f th e fo llo w in g : C D 7 9 a , c y to p la s m ic C D 2 2 , a n d C D 1 0 □ T lin e a g e : c y to p la s m ic C D 3 e (b y flo w c y to m e try ) o r s u rfa c e C D 3 (rare ) p la s m a c e ll n e o p la s m s

+ +

■ W ith th e ra p y, B A L L /L B L h as a g o o d p ro g n o s is in c h ild re n (C R in > 9 5 % ) and fa ir p ro g n o s is in a d u lts (C R in -8 0 % ) ■ P ro g n o s tic fa c to rs : in itia l w h ite c o u n t, a ge , g e n d e r, a nd in itia l re s p o n s e to th e ra p y ■ H y p o d ip lo id y (< 4 6 c h ro m o s o m e s ) is a s s o c ia te d w ith a re la tiv e ly p o o r p ro g n o s is © A S C P 2018

□ M y e lo id : m y e lo p e ro x id a s e o r m o n o c y tic d iffe re n tia tio n (at le a s t 2 o f th e fo llo w in g : n o n s p e c ific e s te ra s e [N S E ], C D 14, C D 6 4 , CD 11b, a n d ly s o z y m e )

4.3.3 Plasma cell neoplasms 4.3.3.1 Plasma cell myeloma/multiple myeloma ■ O ld e r a d u lts , w ith m e d ia n a g e a t o n s e t o f 70 y e a rs ■ S ig n ific a n tly m o re c o m m o n in b la c k p o p u la tio n ■ F a m ilia l c lu s te rin g , w ith 3 - 4 * in c re a s e d ris k in firs t d e g re e re la tiv e s ■ W H O 2 01 6 c la s s ific a tio n t4.33

ISBN 978-08 9189-6678

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Neoplastic hematopathology>Plasma cell neoplasms t4.32 B ALL/LBL with recurrent genetic abnorm alities Genetics Age group

t(9;22)(q34;q11.2)

BCR/ABL1

t(v;11q23), usually t(4;11)

KMT2A (MLL)

t(12;21)(p13;q22)

TEL-AML1 (.ETV6-RUNX1) >50; extra copies esp of 21,4,14, X =1 of malignant biomarkers (>=60% bone marrow plasma cells, serum free light chain ratio >100, >1 focal lesion on MRI).________ ________________

both criteria need ot be met 1. Serum M protein >3.0 g/dL (30 g/L) or urinary M protein >500 mg/day and/ or clonal bone marrow plasma cells 10-60% clonal plasma cells in marrow >10% 2. Absence of myeloma defining events or amyloidosis

■ M a n ife s ta tio n s

i4.50 a Myeloma cast nephropathy; b light chain deposition disease

□ F o llo w e d by Ig A (22% ), lig h t c h a in o n ly (18% ), IgD (1% ), b ic lo n a l (1% ), a n d IgE (1 % )

□ R e n a l m a n ife s ta tio n s ■ H y p e rc a lc e m ia a n d h y p e ru ric e m ia d a m a g e th e p ro x im a l tu b u le s , re s u ltin g in a c q u ire d re n a l F a n c o n i s y n d ro m e ■ A L a m y lo id o s is , o fte n a s s o c ia te d w ith A lig h t c h a in s , d e p o s its in v e s s e l w a lls a n d w ith in g lo m e ru li ■ M y e lo m a c a s t n e p h ro p a th y : in tra tu b u la r c ry s ta lliz a tio n o f M p ro te in (d e p o s its a p p e a r a n g u la te d a n d c ra c k e d ) i4.50 □ B le e d in g d ia th e s is ■ M p ro te in in te rfe re n c e w ith c o a g u la tio n fa c to rs ■ T h ro m b o c y to p e n ia d u e to m a rro w in v o lv e m e n t ■ A m y lo id o s is m a y lo w e r fa c to r X □ H y p e rv is c o s ity s y n d ro m e , o fte n w ith Ig M , Ig A , a n d lg G 3 p a ra p ro te in s □ Im m u n o d e fic ie n c y , d u e to h y p o g a m m a g lo b u lin e m ia , p re d is p o s e s to in fe c tio n w ith e n c a p s u la te d o rg a n is m s like S p n e u m o n ia e ■ M p ro te in

□ L ig h t c h a in is m o s t c o m m o n ly k ; IgD m y e lo m a a s s o c ia te d w ith A in 9 0 % o f c a s e s □ U s u a lly d e te c te d by S P E P , b u t q u a n tific a tio n o f s e ru m fre e lig h t c h a in s m o re s e n s itiv e th a n S P E P fo r lig h t c h a in o n ly d is e a s e a nd n o n s e c re to ry m y e lo m a ■ M o rp h o lo g y □ V a rie s fro m ty p ic a l p la s m a c e lls to a n a p la s tic i4.51 □ C y to p la s m ic c h a n g e s m a y in c lu d e M o tt, fla m e , m o ru la , R u s s e ll b o d ie s , a n d G a u c h e r-lik e ; n o n e o f th e s e a re d ia g n o s tic fo r m y e lo m a □ In b o n e m a rro w b io p s ie s , th e p la s m a c e lls are in c re a s e d a n d m a y c lu s te r o r fo rm s h e e ts ; th e s e a re a b n o rm a l, p a rtic u la rly w h e n fo u n d a w a y fro m a rte rio le s w ith in th e in te rs titiu m ■ Im m u n o p h e n o ty p e f4.12 □ P la s m a c e lls e x p re s s C D 3 8 , C D 1 3 8 , C D 5 6 , c y to p la s m ic k o r A, a n d PCA1 □ D o n o t e x p re s s C D 4 5 o r B ce ll a n tig e n s (C D 19, C D 2 0 , C D 2 1, C D 2 2 , slg )

□ H e a v y c h a in is m o s t c o m m o n ly Ig G (5 5 % ) 238

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Neoplastic hematopathology>Plasma cell neoplasms

f4.12 Myeloma flow cytometry a Gating around cells with bright CD38 & dim to absent CD45, typical of the plasma cell gate b Plot of CD56 vs CD19, in which the neoplastic cells have characteristic dim to absent CD 19 but express CD56 c Cytoplasmic A light chain restriction

4.3.3.2 Plasma cell leukemia i4.51 Multiple myeloma in marrow; the tumor often forms sheets of cells ranging from a evidently plasmacytic to b poorly differentiated c There is a spectrum from minimally atypical on the left to moderately atypical on the right d Prominent paranuclear hoffs are evident e A case of plasma cell leukemia in the peripheral blood

□ C D 5 6 e x p re s s io n s u g g e s tiv e o f a g g re s s iv e b e h a v io r; b u t n o ta b ly a b s e n t in p la s m a b la s tic ly m p h o m a and p la s m a ce ll le u k e m ia

■ D e fin e d a s a b s o lu te p la s m a c e ll c o u n t > 2 .0 * 10 9/L o r > 2 0% p la s m a c e lls in b lo o d ■ H igh in c id e n c e o f IgE , IgD, o r lig h t c h a in o n ly m y e lo m a , C D 2 0 e x p re s s io n a nd C D 5 6 n e g a tiv ity ■ A g g re s s iv e d is e a s e w ith p o o r tre a tm e n t re s p o n s e a n d s h o rt s u rv iv a l

4.3.3.3 Solitary plasmacytoma (SP) ■ S P o f b o n e c o m m o n ly in v e rte b ra e , rib s, a n d p e lv is ; 2 v a ria n ts

□ S o m e c a s e s a re bcl1+ (cyclin D1+), c o rre la tin g w ith th e p re s e n c e o f a t(11;14) tra n s lo c a tio n

□ S P w ith no b o n e m a rro w p la s m a c y to s is o f e n d o rg a n d a m a g e ; - 1 0 % p ro g re s s to m y e lo m a

□ 1 0 -3 0 % e x p re s s m y e lo m o n o c y tic m a rk e rs (CD117, C D 13, C D 3 3 , C D 11b, C D 1 5)

□ S P w ith m in im a l m a rro w p la s m a c y to s is (c lo n a l p la s m a c e lls T cell neoplasms 4.3.4.5 T cell large granular lym phocytic leukemia ■ P e rs is te n t (o v e r 6 m o n th s ) in c re a s e in la rg e g ra n u la r ly m p h o c y te s (L G L s ) w ith n o id e n tifia b le c a u s e ■ A s s o c ia te d w ith n e u tro p e n ia ■ A n e m ia a n d p o ly c lo n a l h y p e rg a m m a g lo b u lin e m ia m a y be seen ■ C lo n a lity c a n b e d e m o n s tra te d b y T C R g e n e re a rra n g e m e n t s tu d ie s ■ S T A T 3 m u ta tio n s in 3 0 % ■ Im m u n o p h e n o ty p e f4.14 □ P o s itiv e fo r C D 2 , C D 3 , C D 8 , C D 5 7 , a n d C D 1 6 □ T C R is a p ty p e

f4.14 Large granular lymphocytic (LGL) leukemia flow cytometry a Gating around cells with bright CD45 & low side scatter (SSC), typical of the lymphocyte gate b Plot of CD3 vs CD7, in which there is bright CD3 (indicating Tc rather than NK phenotype) & a subset with anomalously weak CD7 & somewhat weak CD3 c In this plot, the anomalous population is CD4d The anomalous population is CD8+

□ N e g a tiv e fo r C D 4

■ N e o p la s tic c e lls ra n g e fro m s m a ll to la rg e

□ C D 5 a n d /o r C D 7 m a y be d im in is h e d o r a b s e n t; th e d is trib u tio n o f C D 5 in flo w p lo ts is b im o d a l

■ A s ia n a n d N a tiv e A m e ric a n g ro u p s o f C e n tra l a nd S o u th A m e ric a

4.3.4.6 Chronic lym phoproliferative disorder of NK cells (previously large granular lym phocytic leukemia - NK type)

■ C e lls a re E B V + a nd h ave a ty p ic a l N K p h e n o ty p e . C D 16-

4.3.4.9 Enteropathy associated T cell lymphoma

■ P re s e n tin g w ith fe ve r, ja u n d ic e , a n d h e p a to s p le n o m e g a ly ; c y to p e n ia s c o m m o n

■ H igh g ra d e T ce ll ly m p h o m a a ris in g in p a tie n ts w ith lo n g s ta n d in g c e lia c s p ru e

■ E B V is n e g a tiv e , a n d th e d is e a s e is in d o le n t (u n lik e a g g re s s iv e N K c e ll le u k e m ia , w h ic h is E B V +)

■ L y m p h o m a p re c e d e d by re fra c to ry s p ru e w ith m u c o s a l u lc e ra tio n (u lc e ra tiv e je ju n o ile itis )

■ T C R is g e rm lin e ; S T A T 3 m u ta tio n in 3 0 %

■ A ffe c ts th e je ju n u m a n d /o r ile u m

■ T h e c e lls a re p o s itiv e fo r C D 2 , C D 1 6 , a n d C D 5 6 b u t n e g a tiv e fo r s u rfa c e C D 3 (c y to p la s m ic £ c h a in o f C D 3 p o s itiv e b y im m u n o h is to c h e m is try )

■ N o rth e rn E u ro p e a n d e s c e n t, e s p e c ia lly W e ls h a nd Irish, w ith H L A D Q A 1 *0 5 0 1 , D Q B 1 *0 2 0 1 g e n o ty p e

■ V a ria b le e x p re s s io n o f CD 7, C D 8 , a n d C D 5 7 , n e g a tiv e fo r C D 4

4.3.4.7 Aggressive NK cell leukemia ■ S tro n g ly a s s o c ia te d w ith E B V

■ N e o p la s tic c e lls a re C D 3 + a nd u s u a lly C D 4 - /C D 8 - ; C D 3 0 e x p re s s io n is u s u a lly p re s e n t ■ M o n o m o rp h ic e p ith e lio tro p ic in te s tin a l T ce ll ly m p h o m a (e a rlie r c a lle d ty p e II E A T L): n o t a s s o c ia te d w ith c e lia c sp ru e , m o s tly in H is p a n ic s a n d A s ia n s , w ith c y to to x ic p h e n o ty p e (C D 8+ , C D 5 6 + , T C R y5+)

■ A g g re s s iv e c lin ic a l c o u rs e ■ M o re c o m m o n a m o n g A s ia n s , w ith a m e a n a g e o f 4 0 y e a rs ■ C o n s titu tio n a l s y m p to m s , h e p a to s p le n o m e g a ly , le u k e m ic b lo o d p ic tu re , a n d m a rk e d ly e le v a te d L D H ■ H e m o p h a g o c y to s is is c o m m o n ■ U n lik e n a s a l ty p e N K c e ll ly m p h o m a , A N K L is m a in ly le u k e m ic , a ffe c ts y o u n g e r p a tie n ts , e x p re s s e s C D 1 6 , and is u n ifo rm ly fa ta l ■ Im m u n o p h e n o ty p e is th a t o f ty p ic a l N K c e lls ; n o ta b ly, C D 1 6 is p o s itiv e

4.3.4.10 Hepatosplenic T cell lymphoma ■ T h e y b ty p e o f h e p a to s p le n ic T ce ll ly m p h o m a (H S T C L): y o u n g m en w ith c o n s titu tio n a l (“ B ” ) s y m p to m s , h e p a to s p le n o m e g a ly , a n d c y to p e n ia s ■ L y m p h o m a to u s in filtra te s in th e red p u lp o f th e s p le e n i4.54 a n d s in u s o id s o f th e liv e r ■ C D 8 + c y to to x ic T c e lls th a t e x p re s s an yb T C R , and is o c h ro m e 7q ■ A g g re s s iv e c lin ic a l c o u rs e ■ T h e a(3 T ce ll ly m p h o m a s a re v e ry sim ilar, e x c e p t fo r a fe m a le p re d o m in a n c e a nd w id e r a g e d is trib u tio n

4.3.4.8 Nasal type natural killer/T cell lymphomas ■ A ris e b o th n a s a lly a n d e x tra n a s a lly in e x tra n o d a l s ite s ■ A n g io in v a s iv e w ith e x te n s iv e n e c ro s is 242

4.3.4.11 Subcutaneous panniculitic T cell lymphoma ■ S P T L p re s e n ts as a s u p e rfic ia l s o ft tis s u e m ass

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4: Hematopathology

Neoplastic hematopathology>T cell neoplasms | Hodgkin lymphoma ■ P ro life ra tio n o f a ty p ic a l ly m p h o id c e lls w ith in th e s u b c u ta n e o u s fa t, o fte n a s s o c ia te d w ith e x te n s iv e k a ry o rrh e x is ■ N e o p la s tic c e lls e x p re s s C D 3 , C D 8 , a n d T C R aP ■ H e m o p h a g o c y to s is is a c o m p lic a tio n

4.3.4.12 Cutaneous T cell lymphoma, mycosis fungoides, and Sezary syndrome ■ O fte n c o m p o s e d o f C D 4 + T ly m p h o c y te s ■ S m a ll to la rg e ly m p h o id c e lls h a v in g c e re b rifo rm n u c le i i4.55 ■ M y c o s is fu n g o id e s (M F ) is C T C L th a t in v o lv e s lym p h nodes ■ S e z a ry s y n d ro m e : tria d o f e ry th ro d e rm a , g e n e ra liz e d ly m p h a d e n o p a th y a nd c lo n a l T c e lls in skin , ly m p h n o d e s a nd b lo o d . In a d d itio n , 1 o r m o re o f th e fo llo w in g : a b s o lu te S e z a ry ce ll c o u n t > 1 0 0 0 /p L , C D 4 :C D 1 0 ra tio o f >10, lo s s o f >1 T c e ll a n tig e n ■ Im m u n o p h e n o ty p e : e x p re s s io n o f C D 2 , C D 3 , C D 5 , a nd C D 4 , u s u a lly w ith lo s s o f C D 7; n e g a tiv e fo r C D 8 a nd CD25

i4.55 a-b Skin biopsy showing epidermotropic lymphoid infiltrate typical of mycosis fungoides c-d Peripheral blood involvement by mycosis funaoides (Sezary syndrome) consisting of cells with markedly irregular (cerebriform) nuclear contours

4.3.5 Hodgkin lymphoma 4.3.5.1 Nodular lymphocyte predominant Hodgkin lymphoma ■ N o d u la r o r v a g u e ly n o d u la r m ixe d ce ll p ro life ra tio n i4.56 ■ C h a ra c te ris tic c e lls i4.56b □ L y m p h o c y tic a nd h is tio c y tic (L & H ) ce ll □ A b u n d a n t c y to p la s m a n d a la rg e v e s ic u la r c o n v o lu te d (p o p c o rn ) n u c le u s ■ B a c k g ro u n d i4.58 □ N o d u la r a rc h ite c tu re h ig h lig h te d by C D 21 o r C D 2 3 □ P re d o m in a n t s m a ll in filtra tin g ly m p h o c y te s a re C D 2 0 + B c e lls □ W re a th o f C D 3 + (P D 1+ a nd C D 5 7+ ) T c e lls a ro u n d n e o p la s tic L& H c e lls ■ N e o p la s tic (L & H ) c e lls e x p re s s C D 4 5 , C D 2 0 , s u rfa c e Ig, b c l6 , a nd E M A , a nd are n e g a tiv e fo r C D 3 0 , C D 15, O C T 2 , B O B 1, a nd E B V ■ L & H c e lls h ave c lo n a lly re a rra n g e d IG H g e n e s and fre q u e n t b c l6 re a rra n g e m e n t ■ P ro g re s s iv e tra n s fo rm a tio n o f g e rm in a l c e n te rs is th o u g h t to be a p re c u rs o r le s io n i4.57 ■ D iffe re n tia l d ia g n o s is t4.36 □ T h e d is tin c tio n w ith T C R B C L is m a in ly b a se d on th e b a c k g ro u n d □ T h e d is tin c tio n w ith C H L re sts on th e la rg e n e o p la s tic c e lls th e m s e lv e s

i4.56 Nodular lymphocyte predominant Hodgkin lymphoma (NLPHL) a & b Low magnification vaguely nodular appearance c Intermediate magnification shows a mixture of small & large cells d -f The cytologic features of the large (L&H) cells of NLPHL; note the pronounced irregularity of the nuclear membrane

4.3.5.2

■ E p id e m io lo g y □ B im o d a l in c id e n c e , w ith p e a k a t 15 to 3 5 y e a r s a n d s e c o n d p e a k o v e r 5 0 y e a rs ■ P re s e n ta tio n □ L o c a liz e d /c o n tig u o u s ly m p h a d e n o p a th y □ C e rv ic a l ly m p h n o d e s m o s t c o m m o n , fo llo w e d b y m e d ia s tin u m a n d in tra -a b d o m in a l n o d e s □

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Classic Hodgkin lymphoma

“ B ” s y m p to m s c o m m o n

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Neoplastic hematopathology>Hodgkin lymphoma

i4.57 Progressive transformation of germinal centers

i4.58 NLPHL immunohistochemistry a CD3 highlights rings of T cells encircling neoplastic cells b CD21 highlights the residual follicular dendritic cell meshwork c CD20 expression by the neoplastic cells d EMA expression by the neoplastic cells

t4.36 TC R BC L v s NLPHL v s LRCHL TCRBCL NLPHL Nodular Architecture Diffuse classic RS cells CD45 (neoplastic cell) CD30 (neoplastic cell) CD15 (neoplastic cell) CD20 (neoplastic cell) CD79a (neoplastic cell) EBV

i4.59 Classic Hodgkin lymphoma (CHL)

LRCHL Nodular/diffuse +

-/+ +

-/+ +

-

-

-

+

-

-

±

+ +

+

-/+

±

-

-

-

±

background lymphs T»> B B»> T B>T + CD3+/CD57+ rosettes + CD21+ FDC ± bone marrow involved -/+ -/+ EBV = Epstein-Barr virus; FDCs = follicular dendritic cells; LRCHL = lymphocyte rich classic Hodgkin lymphoma; NLPHL = nodular lymphocyte predominant Hodgkin lymphoma; RS = Reed-Sternberg; TCRBCL = T cell/histiocyte rich B cell lymphoma

a & b A mixed hematolymphoid background & several classic Reed-Sternberg

cells c Reed-Sternberg cell in H&E stained alcohol fixed touch imprint d CD30 stains Reed-Sternberg cells in membranous pattern with Golgi accentuation e CD15 stains Reed-Sternberg cells primarily within the Golgi region f CD20 is usually negative in Reed-Sternberg cells but may be positive in up to 20% of cases CD45 is nearly always negative in Reed-Sternberg cells PAX5 demonstrates dim nuclear expression in Reed-Sternberg cells ■ M o rp h o lo g y □ C h a ra c te ris tic c e lls

■ R e e d -S te r n b e rg c e lls o r R e e d -S te r n b e rg v a ria n ts i4.59 ■ E x p re s s C D 3 0 , fa s c in , IR F 4 /M U M 1 , d im P A X 5 , a n d C D15 ■ V a ria b le fo r E B V ■ N e g a tiv e fo r C D 4 5 , C D 2 0 , b c l6 , A L K , a n d E M A ■ 1 0 % -2 0 % o f c a s e s e x p re s s C D 2 0

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4: Hematopathology

Neoplastic hematopathology>Hodgkin lymphoma t4.37 Subtypes of CHL Sites

Subtype

NS (nodular sclerosis)

mediastinum

MC (mixed cellularity)

peripheral nodes

LR (lyphocyte rich)

peripheral nodes

Epidemiology

Hodgkin cell type

Background

EBV (%)

70% of CHL 15-35 years 25% of CHL 25-45 years HIV associated developing nations 5% of CHL 35-55 years

lacunar

mixed

25

classic RS

mixed

75

classic RS mononuclear popcorn classic RS pleomorphic

lymphs

50

mixed

50

1 5 /h p f

□ M o rp h o lo g ic a lly , it is s im ila r to N L P H L b ut has th e ty p ic a l im m u n o p h e n o ty p e o f C H L i4.63

□ B a c k g ro u n d c e lls are m a rk e d ly d e c re a s e d c o m p a re d to M C

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Neoplastic hematopathology>Myeloid neoplasms

i4.62 Mixed cellularity variant of classic Hodgkin lymphoma

i4.63 Lymphocyte rich classic Hodgkin lymphoma

4.3.6 Myeloid neoplasms 4.3.6.1

Assessm ent

■ M a n u a l 2 0 0 c e ll c o u n t o f p e rip h e ra l b lo o d a n d 5 0 0 c e ll c o u n t o f m a rro w fo r e v a lu a tio n fo r m y e lo id n e o p la s m s ■ M o rp h o lo g ic d iffe re n tia l d ia g n o s is s h o u ld g u id e th e u s e o f s p e c ific m o le c u la r a s s a y s t4 .3 8

t4.38 Tyrosine kinase anom alies in m yeloproliferative neoplasm s D is o rd e r

CML PV PMF & ET eosinophilia related disorders mastocytosis

A s s o c ia te d a b n o rm a litie s BCR/ABL translocation JAK2 V617F, JAK2 exon 12 mutation JAK2 V617F, MPL W151L, MPL W151K PDGFRa, PDGFRfl, FGFR1 mutations

M W ;

K/7D816V

CML = chronic myelogenous leukemia; ET =essential thrombocythemia; PMF = primary myelofibrosis; PV = polycythemia vera >» • »

4.3.6.2

Myelodysplastic syndromes

■ M y e lo id n e o p la s m s w ith c y to p e n ia s , d y s p o ie s is , a n d a te n d e n c y to d e v e lo p a c u te le u k e m ia t4 .3 9 ■ E p id e m io lo g y □ U s u a lly a ffe c ts o ld e r a d u lts □ Y o u n g e r a d u lts s e c o n d a ry to c h e m o th e ra p y , ra d ia tio n , b e n z e n e , o r in h e rite d m a rro w c o n d itio n s s u c h a s F a n c o n i’s a n e m ia

?.' ‘ i

• '.• V I ■ M

,

i4.64 Myelodysplastic syndrome (MDS) a-d Peripheral blood in MDS showing a variety of findings, including neutrophils that are hypogranular & hyposegmented, enlarged hypogranular platelets, and erythroid anisopoikilocytosis e-o Bone marrow aspirates in MDS showing a variety of finding, including e abnormal granulocyte granulation, f small mononuclear megakaryocytes, g multinucleated (pawn ball) megakaryocytes, h ringed sideroblasts, i multinudeate erythroid precursors, i irregular nuclear contours & karyorrhexis, k & I intemuclear bridges & nuclear blebs, m karyorrhexis, n erythroid hyperplasia o In most cases the marrow is hypercellular, as is the case with myeloid neoplasms generally, but some cases present as hypoplastic MDS

■ M o rp h o lo g y i4.64 □ M a rro w is h y p e rc e llu la r

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Neoplastic hematopathology>Myeloid neoplasms ■ M a tu re g ra n u lo c y te s s h o w n e u tro p e n ia , a b n o rm a l c y to p la s m ic g ra n u la tio n , o r a b n o rm a l n u c le a r s e g m e n ta tio n (in c lu d in g p s e u d o P e lg e r-H u e t a n o m a ly ) ■ P re c u rs o rs a re le ft s h ifte d a n d /o r m e g a lo b la s to id □ M e g a k a ry o c y tic ■ P e rip h e ra l th ro m b o c y to p e n ia , d y s fu n c tio n a lity , h y p o g ra n u la rity ■ M a rro w m ic ro m e g a k a ry o c y te s , “ p a w n b a ll” (m u ltin u c le a te d ) nuclei, a n d h y p o lo b a te d n u c le i ■ D iffe re n tia l d ia g n o s is o f d y s p o ie s is : v ita m in B 12 a n d fo la te d e fic ie n c y , a lc o h o l c o n s u m p tio n , H IV in fe c tio n , le a d p o is o n in g , a rs e n ic p o is o n in g , c o p p e r d e fic ie n c y /z in c in to x ic a tio n (p ro m in e n t e ry th ro id v a c u o liz a tio n a n d iro n la d e n p la s m a c e lls a re clue s), o r m e d ic a tio n s (is o n ia z id , c h lo ra m p h e n ic o l, c h e m o th e ra p e u tic a g e n ts ) i4.65 Chronic myelomonocytic leukemia (CMML); in the peripheral blood, there is an increased absolute number of monocytes that are mildly atypical

t4 .3 9 General overview of myeloid neoplasm categories Marrow Peripheral Marrow biopsy Splenomegaly aspirate blood Category hypercellular no cytopenia(s) dysplasia myelodysplastic ± blasts syndrome (MDS) (1 * 10 9/L o r > 1 ,0 0 0 / pL), m a rro w d y s p la s ia (u su a lly d y s g ra n u lo p o ie s is ), < 2 0 % b la s ts (In c lu d in g p ro m o n o c y te s ), a n d a b s e n c e o f a P h ila d e lp h ia c h ro m o s o m e ■ M o n o c y te m o rp h o lo g y v a rie s fro m e s s e n tia lly n o rm a l to m ild ly a ty p ic a l i4.65 ■ M a y h a ve c o n c o m ita n t re a c tic e b la s tic p la s m a c y to id d e n d ritic ce ll in filtra te (C D 14+, C D 6 8 + , C D 5 6 + , C D 4 + , CD 2+, and C D 5+) ■ If e o s in o p h ilia (>1.5>Myeloid neoplasms t4.40 M yelodysplastic syndrom es Type________________Peripheral blood______Bone marrow________ MDS with single lineage dysplasia

anemia or unilineage dysplasia thrombocytopenia or 1000>10% (b ut Myeloid neoplasms □ A c c e le ra te d o r b la s t p h a s e h a v e a m u c h h ig h e r in c id e n c e o f im a tin ib re s is ta n c e ■ M in im a l re s id u a l d is e a s e (M R D ) in C M L

□ E ry th ro c y to s is , n e u tro p h ilia a n d s o m e tim e s th e re is b a s o p h ilia a n d /o r th ro m b o c y to s is

□ In c lin ic a l re m is s io n , th e re a re ~ 1 0 9-1 0 1° le u k e m ic c e lls (a b o u t a 2 to 3 log re d u c tio n )

□ T h e m a rro w is h y p e rc e llu la r, u s u a lly w ith a lo w M :E ra tio

□ M R D g e n e ra lly re fe rs to a n u m b e r o f le u k e m ic c e lls < 109- 101 °

□ M e g a k a ry o c y tic h y p e rp la s ia is o fte n q u ite p ro m in e n t

□ A c o m p le te c y to g e n e tic re s p o n s e (u n d e te c ta b le P h ila d e lp h ia c h ro m o s o m e in 2 0 m e ta p h a s e s by c o n v e n tio n a l c y to g e n e tic s ) g e n e ra lly is a c h ie v e d w h e n th e n u m b e r o f le u k e m ic c e lls is < 1 0 9 (a 3 log re d u c tio n ) □ A tru e 3 lo g re d u c tio n a t 12 m o n th s , a s c o n firm e d by q u a n tita tiv e P C R fo r th e B C R -A B L tra n s c rip t, p re d ic ts a n e a rly 0 % lik e lih o o d o f d is e a s e p ro g re s s io n o v e r th e e n s u in g 2 y e a rs □ B C R -A B L q u a n tita tiv e a s s a y b y P C R is u s e d to e s ta b lis h a b a s e lin e fo r fu tu re M R D m o n ito rin g a t d ia g n o s is □ Q u a n tita tiv e P C R (R T -P C R ) is c o n s id e re d th e m e th o d o f c h o ic e fo r M R D d e te c tio n in p a tie n ts w h o h a ve a c h ie v e d a c o m p le te c y to g e n e tic re m is s io n

4 .3 .6 .4 .2 O th e r m y e lo p ro life ra tiv e n e o p la s m s ■ P o ly c y th e m ia v e ra (P V ) □ P re s e n ta tio n ■ H y p e rte n s io n , th ro m b o s is , p ru ritu s , p le th o ra , e ry th ro m e la lg ia , a n d /o r h e a d a c h e ■ S p le e n is ty p ic a lly e n la rg e d a t p re s e n ta tio n ■ B u d d -C h ia ri s y n d ro m e in 10% o f c a s e s ■ T h e c a u s e o f d e a th is m o s t c o m m o n ly th ro m b o s is (31% ), fo llo w e d b y a c u te le u k e m ia (19% ) □ P V m u s t be d is tin g u is h e d fro m re la tiv e p o ly c y th e m ia , s e c o n d a ry p o ly c y th e m ia , a n d C M L t4.42

t4.4 2 Criteria for PV: 3 m ajor criteria or 2 m ajor criterion +

m inor criteria

□ S ta in a b le iro n is c h a ra c te ris tic a lly d e c re a s e d o r absent ■ S p e n t p h a s e o f P V (p o s t p o ly c y th e m ic m y e lo fib ro s is w ith m y e lo id m e ta p la s ia ) □ P e rip h e ra l m y e lo p h th is ic p a tte rn , m a rro w re tic u lin fib ro s is , a n d E M H ■ E n d o g e n o u s e ry th ro id c o lo n y fo rm a tio n is a s s e s s e d in a c u ltu re o f p a tie n t m a rro w . In PV, th e re is s p o n ta n e o u s fo rm a tio n o f e ry th ro id c o lo n ie s (w ith o u t a d d itio n o f E P O ). In o th e rs , e ry th ro id c o lo n y fo rm a tio n re q u ire s e x o g e n o u s EPO ■ J A K 2 (J a n u s k in a s e 2) m u ta tio n □ Id e n tifie d in th e m a jo rity o f n o n -C M L M P N s □ P re s e n t in o v e r > 9 0 % o f PV, 5 0 % o f e s s e n tia l th ro m b o c y th e m ia (E T ), a n d 5 0 % o f p rim a ry m y e lo fib ro s is (P M F ) □ T h e c o m m o n J A K 2 m u ta tio n is a g u a n in e to th y m in e s u b s titu tio n a t n u c le o tid e 1849, re s u ltin g in a v a lin e to p h e n y la la n in e s u b s titu tio n a t c o d o n 617 (V a l6 1 7 P h e ) □ A s e c o n d a c tiv a tin g m u ta tio n , w ith in J A K 2 e xon 12, p ro d u c e s a s m a ll p ro p o rtio n o f P V c a s e s ■ M u ta tio n s in M P L , th e M P L W 5 1 5 L o r M P L W 5 1 5 K m u ta tio n s , p ro d u c e a s m a ll s u b s e t o f P M F and ET, but are n ot se e n in P V ■ C a lre tic u lin e xo n 9 m u ta tio n s h a ve b e e n re c e n tly id e n tifie d in J A K 2 n e g a tiv e P M F (2 5 -3 5 % ) a n d E T (15-24% ). C A L R ty p e 1 m u ta tio n re s u lts fro m a 5 2 b p d e le tio n , a nd ty p e 2 m u ta tio n s re s u lts fro m a 5 b p in s e rtio n ■ E s s e n tia l th ro m b o c y th e m ia (E T ) □ D ia g n o s tic c rite ria t4 .4 3

major criteria

1. Hgt»16.5 g/dL (men), >16 g/dL (women), or increased red blood cell mass (>25%) ______________ 2. JAK2 V617F or JAK2 exon12 mutation__________________ minor criteria 1. Subnormal serum erythropoietin________________________

■ R e la tiv e p o ly c y th e m ia □ S tre s s o r d e h y d ra tio n a n d h a s b e e n c a lle d G a is b o c h s y n d ro m e ■ S e c o n d a ry p o ly c y th e m ia □ L o w P a 0 2 s ta te s (s u c h a s s m o k in g a n d liv in g a t h ig h a ltitu d e s ), h ig h o x y g e n a ffin ity h e m o g lo b in v a ria n ts , a n d c e rta in n e o p la s m s (re n a l c e ll c a rc in o m a , c e re b e lla r h e m a n g io b la s to m a ) th a t p ro d u c e e x c e s s EPO

250

■ P ro life ra tiv e p h a s e o f P V

t4.43 Criteria for essential thrombocythemia (all major or 1st

3 major and minor criteria) Major sustained thrombocytosis >450x 106/pL (>450 * 109/L) bone marrow shows megakaryocytic hyperplasia, without panmyelosis (no significant increase in granulocytic/erythroid precursors)____________________ fails to meet criteria for polycythemia vera, primary myelofibrosis, chronic myelogenous leukemia, or myelodysplastic syndrome JAK2 V617F, MPL or CALR mutation

Minor presence of clonal marker or absence of reactive thrombocytosis______________

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Neoplastic hematopathology>Myeloid neoplasms ■ B im o d a l a g e d is trib u tio n , w ith p e a k s a t a g e 3 0 and a t 60; fe m a le p re p o n d e ra n c e ■ P re s e n ts a s is o la te d th ro m b o c y to s is , w ith s o m e p a tie n ts p re s e n tin g w ith th ro m b o s is o r m u c o s a l h e m o rrh a g e s ■ B o n e m a rro w s h o w s an in c re a s e in m a tu re a p p e a rin g , la rg e , h y p e rlo b a te d m e g a k a ry o c y te s (sta g h o rn like), w h ic h a re p a ra tra b e c u la r and m ay d is p la y m a rk e d e m p e rip o le s is ■ U n lik e P V a nd PM F, th e m e g a k a ry o c y te to p o g ra p h y is n o t a lte re d , a nd m e g a k a ry o c y te c lu s te rin g is n o t s ig n ific a n t ■ S ta in a b le iro n is u s u a lly p re s e n t (h e lp fu l to e x c lu d e iro n d e fic ie n c y ) ■ S ig n ific a n t re tic u lin fib ro s is a t p re s e n ta tio n is n o t a fe a tu re o f E T ■ E T m u s t be d is tin g u is h e d fro m re a c tiv e th ro m b o c y to p e n ia th a t o c c u rs in iro n d e fic ie n c y , c h ro n ic in fla m m a tio n , a s p le n ia , and o th e r h e m a to ly m p h o id m a lig n a n c ie s (such a s C M L ) ■ P rim a ry m u e lo fib ro s is (P M F ) □ C e llu la r (p re fib ro tic ) p h a s e p re s e n ts w ith a n e m ia , m ild le u k o c y to s is , a nd th ro m b o c y to s is ■ T h e m a rro w s h o w s h y p e rc e llu la rity , in c re a s e d g ra n u lo c y tic p re c u rs o rs , a nd in c re a s e d m e g a k a ry o c y te s ■ E ry th ro id p re c u rs o rs a re re la tiv e ly d im in is h e d and m a y d e m o n s tra te m a tu ra tio n a rre s t ■ T h e g ra n u lo c y te s h ave a n o rm a l d is trib u tio n and la c k a m y e lo c y te b u lg e ■ T h e m e g a k a ry o c y te s a re m o rp h o lo g ic a lly a b n o rm a l— a b e rra n tly lo b u la te d w ith c lu m p e d , h y p e rc h ro m a tic , a n d in k y c h ro m a tin — and to p o g ra p h ic a lly a b n o rm a l— in c lu s te rs fo u n d a d ja c e n t to s in u s e s a nd tra b e c u la e □ F ib ro tic p h a s e

i4.68 Bone marrow reticulin fibrosis in myeloproliferative neoplasms, ranging from a mild to b severe, in which one can see gaping sinuses, pulled open by the fibrosis

□ C o m m o n s ite s o f tis s u e in filtra tio n in c lu d e th e h e a rt, G l tra c t, lun g , a n d C N S □ In th e h e a rt, e n d o m y o c a rd ia l fib ro s is m a y re s u lt □ To d ia g n o s e C E L , th e re m u s t be n o id e n tifia b le c a u s e o f s e c o n d a ry e o s in o p h ilia . F u rth e rm o re , th e re m u s t be no e v id e n c e o f o n e o f th e d e fin e d s y n d ro m e s w ith e o s in o p h ilia (ie, no P D G F R a re a rra n g e m e n t, no P D G F R p re a rra n g e m e n t, a n d no F G F R 1 re a rra n g e m e n t— s e e b e lo w ). W h e n e v id e n c e o f c lo n a lity c a n be fo u n d , s u c h a s a c y to g e n e tic a b n o rm a lity o r in c re a s e d b la s ts (b u t n o t > 2 0% ), C E L is d ia g n o s e d . L a c k in g th is, th e d ia g n o s is is H E S □ C o m m o n c a u s e s o f s e c o n d a ry e o s in o p h ilia in c lu d e a lle rg ic re a c tio n s , p a ra s itic in fe s ta tio n s , c o lla g e n v a s c u la r d is e a s e , m a s to c y to s is , a n d o th e r h e m a to ly m p h o id n e o p la s m s

4.3.6.5 Myeloid & lymphoid neoplasms with eosinophilia with abnormalities of PDGFRa, PDGFR/i, or FGFR1 m T h e 2 0 0 8 W H O c la s s ific a tio n s e p a ra te s 3 g e n e re a rra n g e m e n t d e fin e d e n titie s th a t a re a s s o c ia te d w ith e o s in o p h ilia t4.44. E n d o m y o c a rd ia l fib ro s is m a y c o m p lic a te all o f th e s e d is o rd e rs ■ P D G F R a a nd P D G F R p re a rra n g e m e n ts a re re s p o n s iv e to im a tin ib a nd s im ila r ty ro s in e k in a s e in h ib ito rs

■ L e u k o e ry th ro b la s tic p a tte rn in th e p e rip h e ra l b lo o d , w ith d a c ro c y to s is and a n is o c y to s is

4.3.6.6 Acute myelogenous leukemia

■ T h e b o n e m a rro w is in a s p ira b le

4.3.6.6.1 G e n eral featu re s

■ C h a ra c te ris tic b o n e m a rro w fin d in g s in c lu d e re tic u lin a n d /o r c o lla g e n fib ro s is i4.68, in tra s in u s o id a l h e m a to p o ie s is , a nd m o rp h o lo g ic a lly a b n o rm a l, c lu s te re d m e g a k a ry o c y te s ■ C h ro n ic e o s in o p h ilic le u k e m ia (C E L) □ P re d o m in a n tly a d is e a s e o f m en , w ith a 9:1 m a le ife m a le ra tio □ P e rip h e ra l b lo o d e o s in o p h ilia (>1.5 * 109/L), o fte n w ith e v id e n c e o f tis s u e in filtra tio n a n d d a m a g e

■ M o s t a d u lt a nd in fa n tile a c u te le u k e m ia is m y e lo id ■ O n ly 10% o f c h ild h o o d a c u te le u k e m ia is m y e lo id ■ M e d ia n a g e is 6 5 y e a rs ■ A M L o rd in a rily p re s e n ts w ith a v e ry h ig h W B C c o u n t a ttrib u ta b le to a b u n d a n t c irc u la tin g b la s ts i4.69 ■ S o m e tim e s , p re s e n ts w ith p a n c y to p e n ia o r s o ft tis s u e m a s s (so c a lle d c h lo ro m a , e x tra m e d u lla ry m y e lo id c e ll tu m o r, o r m y e lo id s a rc o m a )

□ E o s in o p h ils m ay be h y p o g ra n u la r

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4: Hematopathology

Neoplastic hematopathology>Myeloid neoplasms

i4.70 AML with t(8;21)

i4.69 Acute myelogenous leukemia (AML)

a-c In contrast to lymphoblasts, the cells tend to have more complex nuclei &

cytoplasm, including granulation; the only specific finding, however, is the Auer rod a In some cases, it presents as chloroma with eosinophilic myelocytes being a helpful clue

■ D ia g n o s is o f A M L c a n b e e s ta b lis h e d in 2 w a y s : (1) b la s t p e rc e n ta g e > 2 0 % , o r (2) < 2 0 % b la s ts if th e re is m y e lo id s a rc o m a , o r c e rta in g e n e tic a b n o rm a litie s [eg, re c u rre n t g e n e tic a b n o rm a litie s like t(8 ;2 1 ), t(1 5 ;1 7 ) a n d inv(16)] ■ B la s t p e rc e n ta g e s s h o u ld b e b a s e d o n a 5 0 0 ce ll c o u n t o f m a rro w a n d 2 0 0 c e ll c o u n t o f b lo o d , n o tin g th a t in A P M L , p ro m y e lo c y te s a re in c lu d e d in th e b la s t p e rc e n ta g e , a n d in a c u te m o n o c y tic le u k e m ia , p ro m o n o c y te s a re in c lu d e d ■ Im m u n o p h e n o ty p e f4.15 □ E x p re s s io n o f C D 3 4 , C D 1 3, C D 3 3 , H L A D R , a nd C D 4 5 □ A P M L is u s u a lly n e g a tiv e fo r C D 3 4 a n d H L A D R □ N e g a tiv e fo r ly m p h o id m a rk e rs , b u t a s ig n ific a n t m in o rity e x p re s s e s C D 7 a n d /o r C D 1 9

■ W H O c la s s ific a tio n t4.45 4 .3 .6 .6 .2 A c u te m y e lo g e n o u s le u k e m ia w ith t(8;21) (q 2 2;q 22) ■ 8 % -1 0 % o f all d e n o v o c a s e s o f A M L ■ T h e R U N X 1 g e n e e n c o d e s th e a c h a in o f c o re b in d in g fa c to r (C B F a ) ■ B la s ts a re c h a ra c te riz e d b y p ro n o u n c e d a z u ro p h ilic g ra n u la rity i4.70, s o m e tim e s w ith la rg e (p s e u d o C h e d ia k H ig a s h i) g ra n u le s , a n d A u e r ro d s ■ D y s p la s tic m a tu re g ra n u lo c y te s a re p re s e n t in th e b lo o d a n d m a rro w , d is p la y in g p s e u d o -P e lg e r-H u e t n u c le i a n d h o m o g e n e o u s p in k c y to p la s m ■ Im m u n o p h e n o ty p ic a lly , th e b la s ts c h a ra c te ris tic a lly e x p re s s C D 1 9 , a s ig n ific a n t c lu e to th e p o s s ib ility o f t(8 ;2 1 ) 252

f4.15 AML flow cytometry in a case with monoblastic differentiation a Gating around cells with dim CD45 & moderate side scatter (SSC); depending upon the morphology of the blasts, they may have minimal to moderate side scatter b Plot of HLA-DR vs CD19, in which the neoplastic cells have expression of HLADR but no CD19 expression; most types of AML express HLA-DR, with the notable exception of acute promyelocytic leukemia; CD19 may be anomalously expressed, particularly in AML with t(8;21j c Variable expression of CD13 & no expression of CD7; anomalous CD7 expression is not uncommon in AML d Expression of CD33 & variable CD11b, typical of monoblasts e Variable expression of CD34; CD34 is positive in most cases of AML but may be lost in more differentiated forms, such as acute promyelocytic leukemia & M5

■ L a c k o r d im in u tio n o f C D 1 9 e x p re s s io n , w ith re te n tio n o f C D 5 6 e x p re s s io n , in a t(8 ;2 1 )+ A M L is c o rre la te d w ith th e p re s e n c e o f c o e x is tin g K IT m u ta tio n s (p o o r p ro g n o s is ) ■ A ffe c t y o u n g a d u lts a n d to be re la tiv e ly c h e m o s e n s itiv e

4 .3 .6 .6 .3 A c u te m y elo g en o u s leukem ia w ith inv(16) (p13q22) or t(16;16)(p13;q22) ■ T ra n s lo c a tio n s th a t re s u lt in th e a p p o s itio n o f th e M Y H 11 (m yosin) a n d CBF(3 g e n e s

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Neoplastic hematopathology>Myeloid neoplasms t4.44 Myeloid & lymphoid neoplasms with eosinophilia with abnorm alities of P D G F R a , PDGFR/3, or F G F R 1 Usual presentation

Gene

Other presentations

Epidemiology

Abnormal karyotype

Usual rearrangement

no NFIPILVPDG FRa-cryptic M:F=17:1 CEL like PDGFRa del(4q12) Median 40 years ETV6/PDGFR/3 (TEL/ yes M:F=2:1 CMML like PDGFR/3 PDGFR/3)—1(5;12) Median 40 years ZNF198/FGFR1-1(8;13) yes M:F=1.5:1 CEL like T ALL with eos FGFR1 ____________________________________________________________________ Median 30 years_______________________________________________________ AML = acute myelogenous leukemia; CEL = chronic eosinophilic leukemia; CMML = chronic myelomonocytic leukemia; eos = eosinophilia;T ALL = T acute lymphoblastic leukemia AML with eos T ALL with eos AML with eos

t4.45 Classification of AML Group

Category t(8;21)

C /3 CD CO E oc 03 o 03 0) 03 c: 03 ZD o03

%

_1
20%, granulocytic cells >20% >80% show monocytic differentiation >20% show erythroid differentiation blasts with blebbing

children & adults poor infants

intermediate

adults

poor

T + 5 years

poor

elderly

CD34+, HLA-DR+, CD13+, CD33+, CD117+

no reproducible findings

slowly progressive, unresponsive to treatment poor

CD34+, HLA-DR+, CD13+, CD33+, CD117+ CD34+, HLA-DR+, CD13+, CD33+, CD117+

no reproducible findings

poor

no reproducible findings

variable

no reproducible findings CD34-/+, HLA-DR+, CD13+, CD33+, CD117+, CD14+, CD11b+, CD64+ no reproducible findings CD34-/+, HLA-DR+, CD13+, CD33+, AML, NOS, M5 CD117+, CD14+, CD11b+, CD64+ no reproducible findings CD34-/+, HLA-DR+, CD13+, CD33+, AML, NOS, M6 CD117+, CD235 (glycophorin)+ (erythroleukemia) no reproducible findings CD34-/+, HLA-DR-/+, CD13+, CD33+, AML, NOS, M7 CD117+, CD41+, CD61 + (meqakaryoblastic) MDS = myelodysplastic syndrome; MPO = myeloperoxidase; NOS = not otherwise specified; RS = Reed-Sternberg; SBB = Sudan black B


Myeloid neoplasms

i4.71 AM L with t(16;16); note monocytic differentiation & dysmorphic eosinophils

■ E o s in o p h ils h a v e a b n o rm a lly la rg e b a s o p h ilic g ra n u le s , th a t s ta in p o s itiv e ly w ith a n a p h th y l a c e ta te e s te ra s e (n e g a tiv e in n o rm a l e o s in o p h ils ) ■ Im m u n o p h e n o ty p ic a lly , th e b la s ts e x p re s s C D 1 3 , C D 3 3 , C D 1 4 , C D 6 4 , C D 1 1 b , H L A D R , a n d ly s o z y m e , a n d o fte n e x p re s s C D 2 ■ A ffe c ts y o u n g e r a d u lts a n d is re la tiv e ly c h e m o s e n s itiv e

4.3.6.6.4 Acut e myelogenous leukemia with inv(3) or t (3;3)GATA2-MECOM ■ P o o r p ro g n o s is ; d e n o v o o r fo llo w in g M D S ■ M o rp h o lo g ic a lly , b la s ts a re s e e n in a s s o c ia tio n w ith d y s m o rp h ic s m a ll h y p o lo b a te d m e g a k a ry o c y te s

4.3.6.6.5 Acut e myelogenous leukemia with t(15;17) (q 2 2 ;q 2 1 )— acut e promyelocyt ic leukemia ■ T e n d e n c y to p re s e n t in D IC a n d h ig h ly re s p o n s iv e to all tra n s re tin o ic a c id (A T R A ) ■ A g e a s s o c ia te d in c id e n c e is a p la te a u b e g in n in g in th e la te te e n y e a rs a n d e x te n d in g to th e a g e o f 6 0 y e a rs ■ A b n o rm a l p ro m y e lo c y te s i4.72 w ith k id n e y s h a p e d o r b ilo b e d n u c le i, w ith c y to p la s m v a ry in g fro m in te n s e ly g ra n u la te d to a g ra n u la r (m ic ro g ra n u la r v a ria n t) ■ M ic ro g ra n u la r v a ria n t m a y re s e m b le a c u te m o n o c y tic le u k e m ia ■ M P O re a c tio n is q u ite s tro n g in b o th v a ria n ts , a n d is w e a k o r n e g a tiv e in m o n o b la s ts ■ T y p ic a l (h y p e rg ra n u la r) v a ria n t o fte n p re s e n ts w ith v e ry fe w le u k e m ic c e lls in th e p e rip h e ra l b lo o d , w h ile th e m ic ro g ra n u la r v a ria n t p re s e n ts w ith a h ig h b la s t c o u n t

i4.72 Acute promyelocytic leukemia (APML)

a In the classic variant, there is usually a low blast count & cytoplasmic granules

are prominent b-e In the microgranular variant, there is usually a high blast count & granules are absent; the cells are notable for indented nuclei & occasional Auer rods

■ N e o p la s tic c e lls e x p re s s C D 3 3 a nd C D 1 3 s tro n g ly a nd e x p re s s C D 1 5 w e a k ly (in c o n tra s t to n o rm a l p ro m y e lo c y te s th a t a r C D 1 5 b rig h t). T h e y a re n e g a tiv e fo r H L A D R a n d C D 3 4 f4.16. C D 3 4 and H L A D R e x p re s s io n m a y b e s e e n in m ic ro g ra n u a r v a ria n t, in a d d itio n to e x p re s s io n o f C D 2 ■ V a ria n t tra n s lo c a tio n s in v o lv in g R A R a , th a t is re la tiv e ly in s e n s itiv e to A T R A : t(11;17) a n d t(5 ;1 7) ■ 3 m a jo r R A R a b re a k p o in ts — bcr1 (lo c a te d w ith in intro n 6), b c r2 (exon 6), a nd b c r3 (in tro n 3): b c r3 m a y h ave m ic ro g ra n u la r fe a tu re s ■ D iffe re n tia tio n s y n d ro m e , a ls o c a lle d re tin o ic acid sy n d ro m e , is a p o te n tia lly life th re a te n in g c o m p lic a tio n o f tre a tm e n t w ith A T R A . It p re s e n ts w ith fever, w e ig h t g ain , a n a s a rc a , e ffu s io n s , h y p o te n s io n , and re na l fa ilu re . D e x a m e th a s o n e tre a tm e n t ca n p re v e n t o r a m e lio ra te it. R isk is c o rre la te d w ith in itia l W B C c o u n t > 5 * 109/L

4.3 .6 .6 .6 A c u te m yelo g e n o u s leu kem ia w ith t(6;9) D EKN U P 21 4 ■ A s s o ic a te d w ith b a s o p h ilia a nd m u ltilin e a g e d y s p la s ia ■ O fte n in c h ild re n a nd y o u n g e r a d u lts

4.3 .6 .6 .7 A c u te m y elo g en o u s leu kem ia w ith t(9;11) (p 22;q 23)— A M L w ith K M T 2A (M LL) gen e ano m a lies ■ C o m m o n in c h ild re n ■ M o n o b la s tic (F A B M 4 -M 5 ) d iffe re n tia tio n , w ith e x p re s s io n o f C D 4 , C D 14, C D 6 4 , C D 11b, and ly s o z y m e ■ C D 3 4 is u s u a lly n e g a tiv e

254

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Neoplastic hematopathology>Myeloid neoplasms

a

b

i

4.3.6.6.11 Acut e myelogenous leukemia with biallelic CEBPA mutated

ACUTE PANEL-P2 CD19*/HLADR* BLASTS

Q2-1

CD11b*

c

■M:.

§-

' -.A

SF

'" " " S i

'

..

f

M r L • "iw 1M""\“ CD46 PerCP-A

0

' ■IfSf-

CD33-

HLADfi-

"A-1 ’™'10"’ HT

m n ,50% of 2 cell lines) 3. and absence of prior cytotoxic chemotherapy any of the “AML with recurrent genetic abnormality” abnormalities AML = acute myelogenous leukemia; MDS = myelodysplastic syndrome 1. at least 2. and 1 of

■ A ffe c ts m a in ly th e e ld e rly ; fo llo w s a p e rio d o f a n te c e d e n t M D S , o r a ris e d e novo ■ T y p ic a lly C D 3 4 , C D 13, and C D 3 3 + ■ P ro g n o s is is re la tiv e ly p oo r; th e s e le u k e m ia s a re u n re s p o n s iv e to tre a tm e n t th o u g h s lo w ly p ro g re s s iv e

4.3.6.6 .14 A c u te m yelo g en o u s le u k e m ia , th e ra p y re la te d ■ T re a tm e n t w ith to p o is o m e ra s e II in h ib ito rs , a lk y la tin g a g e n ts , o r io n iz in g ra d ia tio n

■ O fte n in in fa n ts w ith o u t tris o m y 21, w ith fe m a le p re d o m in a n c e

■ A v e ra g e la te n c y o f 5 y e a rs (1 -5 fo r to p o II in h ib ito rs , 5 -1 0 fo r a lk y la tin g a g e n ts and ra d ia tio n ) fo llo w in g tre a tm e n t, a nd th e in c id e n c e is d o s e d e p e n d e n t

■ M e g a k a ry o b la s tic d iffe re n tia tio n , e x p re s s in g C D 41, C D 61 and C D 4 2 b

■ T h e re s p o n s e to tre a tm e n t is p o o r

4.3.6.6.10 Acut e myelogenous leukemia with mutated NPM1 ■ F a v o ra b le p ro g n o s is , in th e a b s e n c e o f F L T 3 -IT D m u ta tio n a n d n o rm a l c y to g e n e tic s ■ "C u p s h a p e d ” n u c le i in b la s t m o rp h o lo g y ■ O fte n C D 3 4 n e g a tiv e

■ M a y h ave K M T 2 A (M L L ) g e n e re a rra n g e m e n ts in to p o II in h ib ito r tre a tm e n t

4.3.6.6.15 A c u te m yelo g en o u s le u k e m ia , n o t o th e rw is e s p e cified ■ A M L , N O S , m in im a lly d iffe re n tia te d (F A B MO) □ B la s ts h a ve a g ra n u la r c y to p la s m w h ic h la c k s c y to c h e m ic a l e v id e n c e o f m y e lo id d iffe re n tia tio n (Myeloid neoplasms □ M y e lo id a n tig e n s in d ic a tiv e o f g re a te r d e g re e s o f m a tu ra tio n (C D 1 4 , C D 1 5 , C D 1 1b ) a re n e g a tiv e □ P ro g n o s is is p o o r ■ A M L , N O S , w ith o u t m a tu ra tio n (F A B M 1) □ > 9 0 % o f b la s ts s h o w n o m a tu ra tio n (m a tu ra tio n in 1 0% o r fe w e r b la s ts ) □ A t le a s t 3% o f th e b la s ts s ta in w ith M P O , c h lo ro a c e ta te e s te ra s e (C A E ), o r S B B □ E x p re s s C D 3 4 , C D 1 3 , C D 3 3 , H L A D R , a n d C D 117 □ P ro g n o s is is p o o r ■ A M L , N O S , w ith m a tu ra tio n (F A B M 2) □ M a tu ra tio n in > 1 0 % o f b la s ts ; u n d iffe re n tia te d m y e lo b la s ts re p re s e n t < 8 9 % o f c e lls □ M o n o c y tic d iffe re n tia tio n is p re s e n t in < 2 0 % o f n o n e ry th ro id c e lls (o r e ls e M 4 /M 5 m u s t be c o n s id e re d ) □ C y to p la s m ic g ra n u la tio n a n d A u e r ro d s a re fre q u e n t

i4.73 AML, NOS, with monoblastic differentiation; the blasts have prominent nucleoli & an abundance of pale blue cytoplasm with occasional vacuoles

□ M 2 b la s ts m a y o r m a y n o t e x p re s s C D 3 4 , b u t th e y a re u s u a lly p o s itiv e fo r H L A D R , C D 1 3 , C D 3 3 , CD117, a n d CD15 □ F re q u e n tly re s p o n s iv e to th e ra p y ■ A c u te m y e lo m o n o c y tic le u k e m ia (F A B M 4) □ A m o n g s t n o n e ry th ro id c e lls , th e re a re > 2 0 % w ith m o n o c y tic a n d > 2 0 % w ith n e u tro p h ilic m a tu ra tio n □ M y e lo m o n o c y tic im m u n o p h e n o ty p e : C D 1 3 , C D 3 3 , C D 4 , C D 1 4 , C D 6 4 , C C 1 1 b p o s itiv e □ F re q u e n tly re s p o n s iv e to th e ra p y ■ A c u te m o n o c y tic /m o n o b la s tic le u k e m ia (F A B M 5 ) □ M o n o c y tic d iffe re n tia tio n i4.73 in > 8 0 % o f n o n e ry th ro id c e lls (in c lu d in g m o n o b la s ts , p ro m o n o c y te s , a n d m o n o c y te s ) □ Im m u n o p h e n o ty p e : H L A D R , m o n o c y tic m a rk e rs (C D 4 , C D 1 4 , C D 6 4 , C D 1 1b , ly s o z y m e ), v a ria b le m y e lo id m a rk e rs (C D 1 3 , C D 3 3 , C D 117), a n d a u s u a lly n e g a tiv e C D 3 4 □ T ra n s lo c a tio n t(8 ;1 6 ) is s o m e tim e s p re s e n t, a n d th is is a s s o c ia te d w ith h e m o p h a g o c y to s is □ M a n ife s ts b le e d in g d is o rd e rs a n d s o m e d e g re e o f s o ft tis s u e in filtra tio n , n o ta b ly g in g iv a l e n la rg e m e n t a n d C N S in filtra tio n □ P ro g n o s is is re la tiv e ly p o o r

□ E x p re s s e s H L A D R , C D 3 4 , g ly c o p h o rin (C D 2 3 5 a ), a nd CD71 (w h ich m a y be a b e rra n tly dim ) □ R e s p o n d s p o o rly to tre a tm e n t a nd h as a p o o r p ro g n o s is ■ A c u te m e g a k a ry o b la s tic le u k e m ia (F A B M 7)

■ P u re e ry th ro id le u k e m ia (F A B M 6 , d iG u g lie lm o s y n d ro m e ) i4.74 □ U n d iffe re n tia te d /p ro ry th ro b la s tic d iffe re n tia tio n □ E ry th ro id c y to p la s m m a y c o n ta in v a c u o le s a n d d is p la y g lo b u la r P A S p o s itiv ity (like A L L b la s ts a re p ro n e to do)

256

i4.74 AML, NOS, with erythroid maturation; note the predominance of erythroid precursors, many of which have dyspoietic morphology

□ > 5 0 % o f b la s ts s h o w m e g a k a ry o c y tic d iffe re n tia tio n □ A s s o c ia tio n w ith m e d ia s tin a l g e rm c e ll tu m o rs , w ith b o th n e o p la s m s d e m o n s tra tin g i(12p) □ A M L s a nd tra n s ie n t m y e lo p ro life ra tiv e d is o rd e rs (T M D s ) th a t a re a s s o c ia te d w ith D o w n s y n d ro m e m o s t o fte n ta k e th e fo rm o f an M 7 A M L

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

4: Hematopathology

Neoplastic hematopathology>Myeloid neoplasms ■ A c u te p a n m y e lo s is w ith m y e lo fib ro s is □ A c u te n e o p la s tic p ro life ra tio n o f p a n m y e lo id e le m e n ts , in c o n ju n c tio n w ith m a rro w fib ro s is □ E nd s ta g e M P N , A M L w ith m y e lo d y s p la s ia re la te d c h a n g e s , a n d M 7 A M L m u s t be e x c lu d e d

4.3.6.6.16 A c u te leukem ia in D ow n syn d ro m e ■ D o w n s y n d ro m e a s s o c ia te d A M L s h o w s in c re a s e d c h e m o s e n s itiv ity , p a rtic u la rly to m e th o tre x a te , a re la tiv e ly fa v o ra b le p ro g n o s is , a nd a p e c u lia r te n d e n c y to w a rd s m e g a k a ry o b la s tic d iffe re n tia tio n ■ D o w n s y n d ro m e a s s o c ia te d A M L a ris e s a t an e a rly a g e (1 -5 y e a rs ) in 1-2% o f c h ild re n w ith D o w n s y n d ro m e ■ T ra n s ie n t a b n o rm a l m y e lo p o ie s is (T A M ) □ A ris e s in th e firs t w e e k o f life, p re s e n tin g w ith a v e ry h ig h w h ite c e ll c o u n t and h e p a to s p le n o m e g a ly □ T h e re is c o m p le te c lin ic o p a th o lo g ic re s o lu tio n w ith o u t th e ra p y □ - 3 0 % o f c h ild re n w ith T M D g o on to d e v e lo p tru e D o w n s y n d ro m e a s s o c ia te d A M L d u rin g c h ild h o o d □ S o m a tic m u ta tio n s in th e GATA1 g e n e a re p re s e n t in th e b la s ts o f b o th T A M a nd D o w n s y n d ro m e a s s o c ia te d A M L □ In b oth D o w n s y n d ro m e a s s o c ia te d A M L a nd T M D , th e b la s ts ty p e a s m e g a k a ry o b la s tic o r m ixe d m e g a k a ry o b la s ts -e ry th ro b la s ts

4.3.6J Myeloid neoplasms with germline predisposition ■ W ith o u t a p re -e x is tin g d is o rd e r o r o rg a n d y s fu n c tio n □ C E B P A and DDX41 m u ta tio n s ■ W ith p re -e x is tin g p la te le t d is o rd e rs □ R U N X 1, A N K R D 2 6 a n d E T V 6 m u ta tio n s

i4.75 Mastocytosis in marrow; sheets of cells with pale granular cytoplasm, in this case demonstrating predominantly round cell morphology; other cases have predominantly spindled morphology

■ N e g a tiv e fo r C D 2 , C D 3 , C D 5 , C D 7, C D 8 , C D 3 0 , C D 1 3 8 , B ce ll a n tig e n s , a nd m y e lo m o n o c y tic a n tig e n s ■ T C R a nd Ig g e n e s a re u s u a lly g e rm lin e

4.3.6.9 Mast cell neoplasms ■ S y s te m ic m a s to c y to s is a p p e a rs in th e m a rro w i4.75 a s s p in d le d o r ro u n d ce ll in filtra te s , u s u a lly a c c o m p a n ie d by fib ro s is a nd a s m a tte rin g o f e o s in o p h ils ■ N o n n e o p la s tic m a s t c e lls a re c o n s is te n tly p o s itiv e fo r L C A , C D 11c, C D 3 3 , C D 4 3 , CD117, a n d FceR I ■ A b n o rm a l p h e n o ty p e w ith a b e rra n t e x p re s s io n o f C D 2 5 a nd C D 2 , o fte n w ith d im in is h e d in te n s ity o f e x p re s s io n o f C D 117 ■ E x p re s s io n o f C D 2 5 c o rre la te s w ith th e p re s e n c e o f C K IT m u ta tio n a n d is in d ic a tiv e o f m a lig n a n c y

■ O th e r o rg a n d y s fu n c tio n

■ M o s t c o m m o n C K IT m u ta tio n is th e D 8 1 6 V m u ta tio n fo u n d in e xo n 816

□ G A TA 2, a s s o c ia te d w ith b o n e m a rro w fa ilu re s y n d ro m e s , te lo m e re b io lo g y d is o rd e rs , n e u ro fib ro m a to s is , N o o n a n s y n d ro m e , D o w n s y n d ro m e e tc

■ D ia g n o s tic c rite ria fo r s y s te m ic m a s to c y to s is (m a jo r c rite rio n a n d 1 m in o r o r > 3 m in o r c rite ria )

■ S u s p e c t if p e rs o n a l h is to ry o f m u ltip le c a n c e rs , th ro m b o c y to p e n ia o r b le e d in g p ro p e n s ity p re c e d in g M D S /A M L , fa m ily h isto ry, o th e r fe a tu re s o f b o n e m a rro w fa ilu re s y n d ro m e s , N F e tc

4.3.6.8 Blastic plasmacytoid dendritic cell neoplasm

□ M a jo r: u ltifo c a l m a s t ce ll in filtra te s (>15 m a s t c e lls in a g g re g a te s ) in b o n e m a rro w o r o th e r o rg a n s □ M in o r: >2 5% m a s t c e lls s p in d le d o r im m a tu re , a c tiv a tin g C K IT m u ta tio n , c h ro n ic e le v a tio n (>20 n g / m L) o f s e ru m try p ta s e , e x p re s s io n o f C D 2 5 w ith / w ith o u t C D 2

■ In vo lve m a in ly th e skin , w ith s o m e c a s e s a ls o in v o lv in g ly m p h n o d e s, p e rip h e ra l b lo o d , a nd b o n e m a rro w ■ C h a ra c te ris tic im m u n o p h e n o ty p e : e x p re s s C D 4 5 , C D 4 , C D 4 3 , C D 5 6 , v a ria b le TC L1, v a ria b le TdT, a nd C D 1 2 3

© A S C P 2018

ISBN 978-08 9 1 8 9 -6 6 7 8

257

4: Hematopathology

M e t h o d s > R e d b lo o d c e ll in d ic e s | L e u k o c y te in d ic e s

4.4

Methods

4.4.1 Red blood cell indices 4.4.1.1 Manual techniques ■ W h e n H c t a n d R B C c o u n t a re d e te rm in e d m a n u a lly , th e fo llo w in g c a lc u la tio n s c a n b e p e rfo rm e d (M C V is e x p re s s e d in fe m to lite rs (fL); 1 fL = 1 0 -9 p L = 10 -15 L; m e a n c o rp u s c u la r h e m o g lo b in c o n c e n tra tio n [M C H C ] is e x p re s s e d in g /d L ) M C V = H ct x 1 0 /R B C (w h e re H ct is e x p re s s e d a s a % , eg, 42% )

i4.76 Reticulocytes on a Wright stained smear & b supravital stain

4.4.1.3 Counting reticulocytes ■ R e tic u lo c y te s a re d iffe re n tia te d fro m m a tu re R B C s b a s e d on a b u n d a n c e o f rib o s o m a l R N A in th e re tic u lo c y te i4.76

M C H C = ( H g b /H c t)x 100 (w h e re H ct is e x p re s s e d a s a % a n d H g b in g/dL)

4.4.1.2 Automated techniques ■ Im m a tu re re tic u lo c y te fra c tio n d e te rm in e d b y a u to m a te d a n a ly s is fo llo w in g in c u b a tio n w ith d y e s th a t b in d R N A ; th e b rig h te r th e s ig n a l, th e m o re im m a tu re th e re tic u lo c y te ■ B a rrin g th e ra re p a tie n t w ith c o n g e n ita l g ia n t p la te le ts , h ig h M P V s u g g e s te d a m a rro w re s p o n s e to p e rip h e ra l p la te le t d e s tru c tio n /c o n s u m p tio n ■ Im m a tu re g ra n u lo c y te (IG ) fra c tio n is th e s u m o f th e m e ta m y e lo c y te s , m y e lo c y te s , a n d p ro m y e lo c y te s and h a s u tility in d ia g n o s in g s e p s is , o ffe rin g a s u p e rio r a lte rn a tiv e to th e m a n u a l “ b a n d ” c o u n t ■ S c h is to c y te s c a n b e e n u m e ra te d u s in g th e p la te le t c h a n n e l, w ith fra g m e n te d R B C s h a v in g s iz e s im ila r to, b u t re fra c tiv e in d e x d iffe re n t fro m , la rg e p la te le ts ■ R e tic u lo c y te h e m o g lo b in c o n c e n tra tio n (C H r o r R e t-H e ) is a re fle c tio n o f th e a v a ila b ility o f m a rro w iro n (fu n c tio n a l iro n d e fic ie n c y a n d a c tu a l iro n d e fic ie n c y )

■ R B C s a re s ta in e d w ith a s u p ra v ita l d y e (eg, n e w m e th y le n e b lu e o r a z u re B) w h ic h h ig h lig h ts re sid u a l c y to p la s m ic R N A ■ R e tic u lo c y te p e rc e n ta g e in n o rm a l a d u lts is b e tw e e n 0.5 % a n d 1.5% . In a n e m ic p a tie n ts , c o rre c tio n s m u s t be m a d e in o rd e r to p ro p e rly in te rp re t th e re tic u lo c y te p e rc e n ta g e Absolute reticulocyte count = % reticulocytes x RBC count Corrected reticulocyte count (CRC) = % reticulocytes x Hct/45 Reticulocyte production index (RPI) = CRC x 1/maturation index

■ T h e m a tu ra tio n in d e x c o rre c ts fo r th e lo n g e r life s p a n o f p re m a tu re ly re le a s e d re tic u lo c y te s in th e b lo o d , w h ic h is a p h e n o m e n o n o f in c re a s e d R B C p ro d u c tio n t4.47

t4.47 Maturation index Maturation index

Hematocrit

■ H e m o g lo b in (H g b ) is c o m m o n ly m e a s u re d by th e c y a n o h e m o g lo b in , o r h e m ig lo b in c y a n id e (H iC N ) m e th o d . H iC N m e th o d d o e s n o t d e te c t s u lfh e m o g lo b in (S H b )

1.0 1.5 2.0 2.5

36-45 26-35 16-25 Leukocyte indices | Platelet indices | Detection of normal & variant hemoglobins

n e u tro p h ils m o n o c y te s

'•

\ ly m p h o cytes

•

/^ e o s in o p h ils

/

' J

W

1 0% H b S to be p o s itiv e ; fa ls e ly n e g a tiv e in n e o n a te s o r th e v e ry a g g re s s iv e ly tra n s fu s e d

□ P a n c e llu la r p a tte rn is s e e n in h e re d ita ry p e rs is te n c e o f fe ta l h e m o g lo b in (H P F H ) ■ A lk a li d e n a tu ra tio n te c h n iq u e ■ H P L C is h ig h ly a c c u ra te m e th o d o f H b F q u a n tita tio n

4.4.4.3 Hemoglobin electrophoresis ■ R o u tin e h e m o g lo b in e le c tro p h o re s is a t pH 8 .6 (a lk a lin e e le c tro p h o re s is ) i4.79 ■ N o rm a l a d u lt h as > 9 7 % H bA , < 3 % H b A 2 (s e e n in th e C b a n d ), a nd n o th in g e ls e

4.4.4.2 Detection of hemoglobin F ■ A c id e lu tio n te c h n iq u e (K le ih a u e r-B e tk e ) m a y be u se d to d e te c t R B C s c o n ta in in g H bF □ S m e a r is e x a m in e d m ic ro s c o p ic a lly fo r c e lls w ith p e rs is te n t e o s in o p h ilia fo llo w in g a c id e lu tio n , to e n u m e ra te th e c e lls c o n ta in in g H b F i4.78 © A S C P 2018

□ H e te ro c e llu la r p a tte rn is ty p ic a l o f fe to m a te rn a l h e m o rrh a g e a n d th a la s s e m ia

■ W h e n th e re is u n c e rta in ty , e le c tro p h o re s is on c itra te a g a r a t pH 6 .2 (acid e le c tro p h o re s is ) i4.80 p ro d u c e s a d iffe re n t s e t o f e le c tro p h o re tic p o s itio n s to id e n tify s o m e a b n o rm a l h e m o g lo b in s

ISBN 9 7 8 -08 9189-6678

259

4: Hematopathology

Methods>Detection of normal & variant hemoglobins

a 5 o r ig in

carbonic anhydrase

aa

E 0

n

A M

F

G

Barts H

Lepore

i4.79 Hemoglobin electrophoresis at pH 8.6 (alkaline electrophoresis), showing the positions of the various hemoglobin variants

PEAK 1 2

i4.80 Hemoglobin electrophoresis at pH 6.8 (acid electrophoresis), showing the positions of the various hemoglobins

■ F a s t h e m o g lo b in s (m ig ra te b e y o n d H b A o n th e a lk a lin e g e l, e .g . H b H a n d H b B a rts ) c a n be m im ic k e d by h y p e rb iliru b in e m ia ■ B a n d in th e S re g io n , c a n b e c o n firm e d b y th e s ic k le s c re e n a s H b S . If th e s c re e n is n e g a tiv e , th is m a y in d ic a te D, G , o r L e p o re ■ p th a la s s e m ia is d ia g n o s e d b y th e p re s e n c e o f “ th a la s s e m ic in d ic e s ” (lo w h e m a to c rit, in c re a s e d R B C c o u n t, lo w M C V ) a n d a q u a n tita tiv e ly in c re a s e d H b A 2 ■ a th a la s s e m ia h a s “ th a la s s e m ic in d ic e s ” a n d n o rm a l HbA2 ■ C a p illa ry e le c tro p h o re s is c a n a c c u ra te ly q u a n tify lo w H b A 2 le v e ls , a n d s e p a ra te ly q u a n tify H b E le v e ls . H b C , if p re s e n t s till ru n s w ith H b A 2

4.4.4.4 High pressure liquid chrom atography (HPLC) ■ L im ita tio n s o f a lk a lin e e le c tro p h o re s is □ In c a p a b le o f s e p a ra tin g H b S fro m H b D , H b G , a nd H b -L e p o re □ D o e s n o t re s o lv e H b C , H b A 2 , H b O Arab, a n d H b E □ A c id e le c tro p h o re s is h e lp s c la rify s o m e a b n o rm a litie s ; b u t d o e s n o t h e lp to s e p a ra te H b D fro m H b G and H b -L e p o re o r H b E fro m H b O Arab

3 4 5 6 7 8 9 10 11

RT 0 .4 0 3 0 .6 3 7 0 .8 2 2 0 .9 3 0 1 .2 0 8 1 .5 6 0 1 .8 9 7 2 .0 9 0 2 .4 0 5 2 .7 5 3 2 .9 9 5

R E L RT 0 .2 6 0 .4 0 0 .5 2 F F 0 .5 9 0 .7 7 F 0 .9 9 F 1 .2 0 F 0 .8 7 A 1 .0 0 A

F F

S

s

0 .9 2 1 .0 0

1 CON C 0 .3 1 1 .1 1 4 .4 4 1 .2 1 0 .6 4 4 3 .8 4 0 .1 4 1 .2 4 2 6 .6 4 1 .7 4 1 8 .8 4

AREA 3475 11518 45973 12944 6285 458899 1369 13041 278824 17892 197237

COM M ENT

6

2 A0 peak A2 peak 3 4

____________________________ T o ta l Area: 1 0 4 7 4 5 6 ________________________________________________

i4.81 High pressure liquid chromatography (HPLC) a HPLC in a patient with normal hemoglobin genotype; 5 major peak regions are present, including some caused by degradation products (peaks 1 & 3), the HbA1c peak (peak 2), the HbA peak (peak 4), and the HbA2 peak (peak 5) D HPLC in a neonate with S trait, showing peaks for F, A & S

□ In d iv id u a l m o le c u le s e lu te a t d iffe re n t and c h a ra c te ris tic ra te s, a llo w in g id e n tific a tio n o f Hb v a ria n ts i4.81 □ D e g re e o f s e p a ra tio n p e rm its a c c u ra te ly q u a n tific a tio n o f A 2 and F □ L im ita tio n : H b E a n d H b A 2 , a nd H b C a nd H b O Arab h a ve s im ila r re te n tio n tim e s , a nd n o t e a s ily s e p a ra te d □ B iliru b in e lu te s w ith H b B a rts on H P L C

4.4.4.5 Molecular methods for hemoglobin identification ■ ~ 1 % -2 % p e rc e n t o f v a ria n t h e m o g lo b in s d e te c te d by H P L C o r g el e le c tro p h o re s is c a n n o t be d e fin itiv e ly id e n tifie d ■ S e q u e n c in g th e h e m o g lo b in g e n e by P C R ca n c h a ra c te riz e th e e x a c t g e n o ty p e

□ E le c tro p h o re s is d o e s n o t p e rm it a c c u ra te q u a n tita tio n of A 2 or F ■ H ig h p e rfo rm a n c e liq u id c h ro m a to g ra p g y (H P L C )

260

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

4: Hematopathology

Methods>Detection of normal & variant hemoglobins | Histochemistry & cytochemistry | Immunophenotyping t4.48 Cytochemical stains for typing blasts SBB PAS Blast type undifferentiated (MO) myeloblasts (M1, M2, M4) promyelocytes (APML) monoblasts (M4, M5) erythroblasts megakaryoblasts lymphoblasts

MPO

CAE

NSE

Auer rods

-

-

-

+

+

+

-

rare 50%

+

+

-

95%

-

+

0%

-

-/+

black

+

-

black -

+

-/+

diffuse granular

+

-/+

resists NaF ± resists NaF

-

diffuse granular

+

-/+

inhibited by NaF

50% rare

—

" block, rosary bead faint grey CAE = chloroacetate esterase; MPO = myeloperoxidase; NSE - nonspecific esterase; PAS = periodic acid Schiff; SBB = Sudan black B

■ N o rm a l a d u lts h ave an L A P s c o re b e tw e e n 4 0 a n d 120

4.4.4.6 Hemoglobin oxygen saturation

■ In C M L , th e s c o re is ty p ic a lly low , b e tw e e n 0 a n d 15

■ P u lse o x im e try □ B y s im u lta n e o u s ly m e a s u rin g d e o x y h e m o g lo b in and o x y h e m o g lo b in a b s o rb a n c e s , th e p u ls e o x im e te r ca n e s tim a te a rte ria l o x y g e n s a tu ra tio n ( S a 0 2) □ It c a n n o t m e a s u re c a rb o x y h e m o g lo b in , m e th e m o g lo b in , o r s u lfh e m o g lo b in and w ill o v e re s tim a te S a 0 2 in th e s e s e ttin g s □ C a lc u la te th e p e rc e n t s a tu ra tio n a fte r d ire c tly m e a s u rin g th e pH , P C 0 2, a nd P 0 2

4.4.6.1 A n tig e n s

□ T h e c a lc u la tio n a s s u m e s a n o rm a l H b - 0 2 s a tu ra tio n c u rv e , n o rm a l 2 ,3 -D P G , a n d an a b s e n c e o f a b n o rm a l h e m o g lo b in s ■ C o o x im e te r □ S p e c ific a lly m e a s u re c a rb o x y h e m o g lo b in and m e th e m o g lo b in (in a d d itio n to o x y h e m o g lo b in and d e o x y h e m o g lo b in ) &

cytochemistry

4.4.5.1 Wright stain ■ R o m a n o w s k y ty p e sta in w ith m e th y le n e b lu e d y e w ith e o s in a nd a lc o h o l

■ A ik is e x p re s s e d in A L C L th a t is t(2 ;5 )+ , in fla m m a to ry m y o fib ro b la s tic tu m o r ■ b e ll (cyclin D1, p r a d l) is e x p re s s e d in M C L , H C L , p la s m a ce ll m y e lo m a , and n u m e ro u s e p ith e lia l n e o p la s m s ■ b cl2 , in n o rm a l a nd re a c tiv e ly m p h n o d e s , is e x p re s s e d by T c e lls a n d m a n tle B ce lls, a n d n e g a tiv e on g e rm in a l c e n te r B c e lls (G C B ). b c l2 is e x p re s s e d b y m o s t lo w g ra d e B ce ll ly m p h o m a s and m a n y h ig h g ra d e B c e ll ly m p h o m a s . b c l2 is u s e fu l in d is tin g u is h in g n e o p la s tic fro m re a c tiv e g e rm in a l c e n te rs , b u t it is n o t u s e fu l to d is tin g u is h F L fro m o th e r B c e ll ly m p h o m a s . b c l2 is e x p re s s e d in a la rg e p ro p o rtio n o f s o lita ry fib ro u s tu m o rs a n d s y n o v ia l s a rc o m a s ■ b c l6 is s tro n g ly e x p re s s e d in n o rm a l G C B c e lls . It is a ls o e x p re s s e d in s o m e ly m p h o m a s , in c lu d in g B u rk itt ly m p h o m a , FL, N L P H L , A L C L , a n d a s u b s e t o f D L B C L

4.4.5.2 Cytochemical stains for typing blasts t4 .4 8 4.4.5.3 Leukocyte alkaline phosphatase score ■ L A P s c o re is d e riv e d b y v isu a l e x a m in a tio n o f 100 b a n d s a n d n e u tro p h ils , s c o rin g e a c h ce ll o n th e b a s is o f th e in te n s ity o f c y to p la s m ic s ta in in g fro m 0 -4 + ; su m o f th e 100 v a lu e s is th e L A P s c o re

© A S C P 2018

■ E le v a te d L A P s c o re is s e e n in le u k e m o id re a c tio n (re a c tiv e n e u tro p h ilia ), PV, PM F, g lu c o c o rtic o id a d m in is tra tio n , a n d th ird trim e s te r o f p re g n a n c y

4.4.6 Immunophenotyping

■ A rte ria l b lo o d g a s a n a ly z e r

4.4.5 Histochemistry

■ O th e r c o n d itio n s w ith lo w L A P s c o re in c lu d e P N H , M D S , n e o n a ta l s e p tic e m ia (L A P p a ra d o x ic a lly d e c re a s e d ), e tc

■ C D 1 a is e x p re s s e d by L a n g e rh a n s c e lls , d e n d ritic re tic u lu m c e lls , in te rd ig ita tin g re tic u lu m c e lls , a n d c o rtic a l th y m o c y te s ■ C D 2 is e x p re s s e d b y T ly m p h o c y te s a n d N K c e lls , e v e n fro m a v e ry e a rly s ta g e

ISBN 978-08 9 1 8 9 -6 6 7 8

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Methods>lmmunophenotyping ■ C D 3 is e x p re s s e d b y T ly m p h o c y te s (m a tu re n o n n e o p la s tic a n d n e o p la s tic ). T h e C D 3 m o le c u le is c o m p o s e d o f 3 c h a in s — y, 5, a n d £. C y to p la s m ic e x p re s s io n is d e te c ta b le b y im m u n o h is to c h e m is try (e g, in im m a tu re T c e lls a n d N K c e lls ) w h e n s u rfa c e e x p re s s io n is d e te c te d b y flo w c y to m e try a n d im m u n o h is to c h e m is try ■ C D 4 is e x p re s s e d b y a s u b s e t o f T ly m p h o c y te s , s p e c ific a lly , T h e lp e r c e lls . It is a ls o e x p re s s e d by m o n o c y te s , h is tio c y te s , a n d d e n d ritic c e lls ■ C D 5 is e x p re s s e d b y n o rm a l a n d n e o p la s tic T c e lls . It is n o t e x p re s s e d b y N K c e lls . C D 5 c o e x p re s s io n in B c e lls is th e h a llm a rk o f S L L /C L L a n d M C L . C D 5 is s o m e tim e s lo s t in T c e ll n e o p la s m s , a h e lp fu l c lu e if p re s e n t. C D 5 is e x p re s s e d in m o s t th y m ic c a rc in o m a s , a fa c t th a t ca n h e lp d is tin g u is h th e m fro m lu n g a n d o th e r p rim a rie s ■ C D 7 is e x p re s s e d b y b o th T c e lls a n d N K c e lls . C D 7 lo s s is a c o m m o n fo rm o f a b e rra n t p h e n o ty p e in T ce ll n e o p la s m s , p a rtic u la rly c o m m o n in C T C L /M F . C D 7 is s o m e tim e s e x p re s s e d in m y e lo b la s ts ( - 1 0 % o f c a s e s — e s p e c ia lly ty p e s M 4 a n d M 5 ) ■ C D 8 is e x p re s s e d b y th e C D 4 - s u b s e t o f T ly m p h o c y te s a n d n e o p la s tic N K , T c y to to x ic a n d T s u p p re s s o r c e lls ■ C D 1 0 (C A L L A ) is th e a n tig e n c h a ra c te ris tic o f fo llic le c e n te r ly m p h o c y te s , in c lu d in g fo llic le c e n te r B c e lls a n d T c e lls , a n d it is e x p re s s e d b y b o th n o rm a l a n d n e o p la s tic fo llic le c e n te r c e lls . It is e x p re s s e d b y FL, N L P F IL , a n d a n g io im m u n o b la s tic T c e ll ly m p h o m a , n e o p la s m s th o u g h t to be d e riv e d fro m fo llic le c e n te r ly m p h o c y te s . C D 1 0 is a ls o p re s e n t o n B c e ll a c u te ly m p h o b la s tic le u k e m ia (B A L L ), n o rm a l g ra n u lo c y te s , a n d n e o p la s tic p la s m a c e lls . C D 1 0 is e x p re s s e d b y a la rg e n u m b e r o f n o n h e m a to ly m p h o id tu m o rs , in c lu d in g re n a l c e ll c a rc in o m a , tu m o rs d e riv e d fro m e n d o m e tria l s tro m a , h e p a to c e llu la r c a rc in o m a (in c a n a lic u la r p a tte rn ), a n d a v a ria b le p ro p o rtio n o f n u m e ro u s o th e r tu m o rs ■ C D 1 1 b (M A C 1 ) is n o rm a lly e x p re s s e d b y m o n o c y te s a n d g ra n u lo c y te s . It is e x p re s s e d b y H C L ■ C D 1 1 c (C 3 r) is n o rm a lly e x p re s s e d b y m o n o c y te s a n d g ra n u lo c y te s . A m o n g s t B c e ll n e o p la s m s , C D 1 1c e x p re s s io n is d is tin c tiv e fo r C L L /S L L (w e a k a n d v a ria b le e x p re s s io n is c h a ra c te ris tic ) a n d H C L (b rig h t e x p re s s io n ) ■ C D 1 3 is e x p re s s e d b y g ra n u lo c y te s a n d p re c u rs o rs . In a c u te le u k e m ia , C D 1 3 e x p re s s io n is c h a ra c te ris tic o f A M L ty p e s M 1, M 2, M 3 (A P M L ), M 4, M 5 , a n d M 6 (n ot M 7) ■ C D 1 4 is a m a rk e r o f m o n o c y tic d iffe re n tia tio n a n d a v a ria b le m a rk e r o f m o n o c y tic p re c u rs o rs . It is o fte n (b u t n o t u n ifo rm ly ) e x p re s s e d in A M L ty p e s M 4 a n d M 5. It is a ls o c o m m o n ly e x p re s s e d in B C L L a n d FL

■ C D 15 (L e u -M 1 ) is e x p re s s e d in m a tu re m o n o c y te s a nd g ra n u lo c y te s , s u b s e t o f R e e d -S te rn b e rg c e lls , and m o s t a d e n o c a rc in o m a s . Its a b s e n c e is a d is tin c tiv e fe a tu re o f A L C L . In th e s e ttin g o f A M L , C D 1 5 in d ic a te s a m a tu rin g p h e n o ty p e ; fo r e x a m p le , it is s tro n g ly e x p re s s e d in A P M L (M 3) ■ C D 1 6 is e x p re s s e d by n o rm a l a n d n e o p la s tic N K c e lls and g ra n u lo c y te s ■ C D 1 9 is e x p re s s e d by B c e lls fro m th e pre B s ta g e o n w a rd . It is e x p re s s e d by n o rm a l p la s m a c e lls , but e x p re s s io n is ty p ic a lly lo s t in n e o p la s tic p la s m a ce lls. C D 1 9 is n o t e x p re s s e d in C H L o r T c e ll n e o p la s m s . It is o fte n d im ly e x p re s s e d in FL. C D 1 9 m ay be p re s e n t on s o m e m y e lo b la s ts , e s p e c ia lly in A M L w ith t(8 ;2 1) (q 22 ;q 22 ) ■ C D 2 0 is e x p re s s e d on th e s u rfa c e o f m a tu re B c e lls ju s t a fte r th e a p p e a ra n c e o f C D 1 9 a n d b e fo re C D 2 2 . It is not e x p re s s e d by p la s m a c e lls . In C H L , R e e d -S te rn b e rg c e lls e x p re s s C D 2 0 in - 2 0 % o f c a s e s (th e s e are C D 7 9 a -). N L P H L is u n ifo rm ly C D 2 0 + . C D 2 0 e x p re s s io n by C L L /S L L is d is tin c tiv e ly d im . F M C 7 is an a n tib o d y th a t re c o g n iz e s a p a rtic u la r e p ito p e o f C D 2 0 . C e lls w ith w e a k C D 2 0 (C L L /S L L ) te n d to be F M C 7 -. C e lls w ith b rig h t C D 2 0 (m o s t o th e r B N H L s) te n d to be FM C 7+ ■ C D 2 3 (th e IgE re c e p to r) is u s e fu l in th e d is tin c tio n o f C L L (C D 2 3 + ) fro m M C L ( C D 2 3 -) ■ C D 2 5 (the IL 2 re c e p to r) is e x p re s s e d by a c tiva te d ly m p h o id c e lls (T & B ). It is c h a ra c te ris tic a lly e x p re s s e d by H C L a n d a d u lt T c e ll le u k e m ia /ly m p h o m a (A TC L). F u rth e rm o re , s o lu b le IL2 re c e p to r is u s u a lly e le v a te d in th e s e ru m o f p a tie n ts w ith A T C L . C D 2 5 e x p re s s io n in m a s t ce ll p ro life ra tio n s is in d ic a tiv e o f c lo n a lity ■ C D 3 0 (Ki1; B e r-H 2 ) is e x p re s s e d by n o rm a l p la s m a ce lls, im m u n o b la s ts (su ch a s in v ira l [E B V ] ly m p h a d e n o p a th y ) and N K c e lls . In n e o p la s m s , it is e x p re s s e d by R e e d -S te rn b e rg c e lls , A L C L , e m b ry o n a l c a rc in o m a , and m e d ia s tin a l B ce ll ly m p h o m a ■ C D 3 3 is e x p re s s e d by n o rm a l a nd n e o p la s tic m y e lo id and m o n o c y tic ce lls, u s u a lly p o s itiv e in A M L ty p e s M 1-M 5 ■ C D 3 4 is a m a rk e r o f im m a tu re m e s e n c h y m a l c e lls . It is e x p re s s e d by n o rm a l a nd n e o p la s tic e n d o th e lia l ce lls, im m a tu re h e m a to ly m p h o id c e lls , G l s tro m a l tu m or, d e rm a to fib ro s a rc o m a p ro tu b e ra n s , a n d s o lita ry fib ro u s tu m o r ■ C D 3 8 is n o rm a lly e x p re s s e d by a c tiv a te d T & B c e lls and p la s m a c e lls . It is c o m m o n ly e x p re s s e d in B ce ll, T ce ll, and p la s m a c e ll n e o p la s m s . C D 3 8 e x p re s s io n in C L L / S LL is, like Z A P 7 0 , in d ic a tiv e o f IgV H n o n m u ta te d s ta tu s and a m o re a g g re s s iv e c lin ic a l c o u rs e ■ CD41 a n d C D 61 a re e x p re s s e d by n o rm a l and n e o p la s tic m e g a k a ry o c y te s

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4: Hematopathology

Methods>lmmunophenotyping ■ C D 4 3 is e x p re s s e d by n o rm a l a nd n e o p la s tic T c e lls a n d is c h a ra c te ris tic a lly u n d e re x p re s s e d in W A S . It is a n o m a lo u s ly e x p re s s e d o n B c e lls in m a jo rity o f c a s e s o f M C L , S L L , a n d s o m e c a s e s o f M Z L (e s p e c ia lly M A LT ty p e M Z L). It is n o t e x p re s s e d in FL

■ C lu s te rin e x p re s s io n in a d is c re te G o lg i p a tte rn a p p e a rs to be u n iq u e to A L C L . C y to p la s m ic s ta in in g m a y be s e e n in s e v e ra l e p ith e lia l n e o p la s m s a n d o c c a s io n a l R e e d -S te rn b e rg c e lls . S tro n g c y to p la s m ic re a c tiv ity is n o te d in m e g a k a ry o c y te s

■ C D 4 5 (le u k o c y te c o m m o n a n tig e n , L C A ) is fo u n d in n e a rly all n o rm a l a n d n e o p la s tic le u k o c y te s . A s th e y d iffe re n tia te C D 4 5 e x p re s s io n by h e m a to ly m p h o id c e lls c h a n g e s , w ith m a tu re ly m p h o c y te s and m o n o c y te s h a v in g b rig h t e x p re s s io n , g ra n u lo c y te s w ith in te rm e d ia te in te n sity, a n d e ry th ro c y te s w ith a lm o s t n o n e . D im to a b s e n t C D 4 5 (u s u a lly w ith s tro n g C D 3 4 ) is th e im m u n o p h e n o ty p ic s ig n a tu re o f b la s ts , a n d d im to a b s e n t C D 4 5 (w ith s tro n g C D 3 8 ) is ty p ic a l o f p la s m a c e lls . C D 4 5 is n o t e x p re s s e d by R e e d -S te rn b e rg c e lls

■ E p ith e lia l m e m b ra n e a n tig e n (E M A ) is e x p re s s e d b y p la s m a c e lls , A L C L , N L P H L , P E L, a n d T C R B C L

■ C D 4 5 R O (U C H L 1) is e x p re s s e d by n o rm a l and n e o p la s tic T c e lls ■ C D 5 6 is e x p re s s e d by n o rm a l a nd n e o p la s tic N K ce lls, p la s m a ce lls, a n d n e u ro e p ith e lia l c e lls (an e x c e lle n t m a rk e r fo r s m a ll ce ll c a rc in o m a ) ■ C D 5 7 (L eu 7) is e x p re s s e d by a s u b s e t o f n o rm a l and n e o p la s tic N K c e lls and n e u ro e p ith e lia l c e lls ■ C D 5 9 is p re s e n t on n e a rly all h u m a n c e lls . D e c re a s e d (a lo n g w ith C D 5 5 -D A F ) c e ll s u rfa c e e x p re s s io n is a fe a tu re o f th e a ffe c te d c lo n e in P N H ■ C D 6 8 is e x p re s s e d b y m a c ro p h a g e s a n d h is tio c y te s , b ut its s p e c ific ity is p o o r ■ CD71 is th e tra n s fe rrin re ce p to r, w h ic h is h ig h ly e x p re s s e d in h ig h ly m e ta b o lic c e lls . In g e n e ra l, h ig h e r le v e ls o f CD71 e x p re s s io n te n d to c o rre la te w ith tu m o r g ra d e in a v a rie ty o f h e m a to ly m p h o id n e o p la s m s ■ C D 7 9 a is e x p re s s e d by n o rm a l a nd n e o p la s tic B c e lls a nd p la s m a c e lls . It is n e g a tiv e in R e e d -S te rn b e rg c e lls ■ C D 9 9 (p 3 0 /3 2 , m ic-2 ; 0 -1 3 ) is e x p re s s e d in ly m p h o b la s tic ly m p h o m a s , P N E T /E w in g , g ra n u lo s a ce ll tu m o rs , s y n o v ia l s a rc o m a , rh a b d o m y o s a rc o m a , s o lita ry fib ro u s tu m o r, and o th e rs ■ C D 1 0 3 is a v e ry s e n s itiv e and s p e c ific m a rk e r fo r H C L ■ C D 117 (c-kit) is a ty ro s in e k in a s e w h o s e g e n e is fo u n d on c h ro m o s o m e 4q12, a d ja c e n t to P D G F R a . It is e x p re s s e d by th e s o c a lle d in te rs titia l ce ll o f C a jal (the p re c u rs o rs o f G l s tro m a l tu m o rs ), m e la n o c y te s (p a rtic u la rly ju n c tio n a l), s e m in o m a s , p ro g e n ito r m ye lo id c e lls (A M L , C M L ) a nd m a s t c e lls (m a s to c y to m a s ) ■ C D 1 3 8 is a m a rk e r o f p la s m a c e lls . A m o n g h e m a to ly m p h o id p ro life ra tio n s , C D 1 3 8 is a v e ry s p e c ific m a rk e r o f p la s m a c e ll d iffe re n tia tio n ; h o w e ve r, C D 1 3 8 is p o s itiv e in a w id e ra n g e o f e p ith e lia l and m e s e n c h y m a l p ro life ra tio n s

© A S C P 2018

■ F a scin is e x p re s s e d by R e e d -S te rn b e rg c e lls a n d d e n d ritic re tic u lu m c e lls ■ F M C 7: s e e C D 2 0 ■ H L A D R is n o rm a lly e x p re s s e d by m o n o c y te s , B c e lls , a nd a c tiv a te d T c e lls . It is e x p re s s e d in m o s t B A L L b u t is n e g a tiv e in T A L L . H L A D R is p o s itiv e in m o s t m y e lo b la s ts b u t n o ta b ly a b s e n t in A P M L ■ P A X 5 is p o s itiv e in n e a rly all B c e ll n e o p la s m s a n d m o s t C H L (dim ). It is n e g a tiv e in T c e ll n e o p la s m s a n d p la s m a c e ll n e o p la s m s . A ll B c e ll lin e a g e n e o p la s m s , fro m th o s e o f p re c u rs o r B c e lls to m a tu re B c e lls , e x p re s s P A X 5 , b u t e x p re s s io n is lo s t a t th e p la s m a c e ll s ta g e . S o m e o th e r s m a ll ro u n d b lu e cell tu m o rs , s u c h a s M e rk e l c e ll c a rc in o m a a nd s m a ll c e ll c a rc in o m a o f lu n g , m a y a ls o e x p re s s P A X 5 ■ S 1 0 0 is a c a lc iu m b in d in g p ro te in th a t is e x p re s s e d in b o th n u c le a r a n d c y to p la s m ic c o m p a rtm e n ts . It is la rg e ly fo u n d in n e u ra l and n e u ra l c re s t tis s u e s (g lia l c e lls , S c h w a n n c e lls , m e la n o c y te s , s u s te n ta c u la r c e lls o f th e a d re n a l m e d u lla ), c h o n d ro c y te s , a d ip o c y te s , m y o e p ith e lia l c e lls (th e cell o f o rig in o f m o s t s a liv a ry a n d skin a d n e x a l tu m o rs ). O f re le v a n c e to h e m a to p a th o lo g y , S 1 00 is e x p re s s e d b y a s u b s e t o f h is tio c y tic c e lls ; in p a rtic u la r, in te rd ig ita tin g re tic u lu m c e lls , d e n d ritic re tic u lu m c e lls , a n d L a n g e rh a n s c e lls ■ Z A P 7 0 is a ty ro s in e k in a s e th a t in n o rm a l c irc u m s ta n c e s is e x p re s s e d p rim a rily b y T a n d N K c e lls . Z A P 7 0 is e x p re s s e d b y s o m e B ce ll n e o p la s m s , n o ta b ly a s u b s e t o f C L L /S L L a n d B A L L , and m o s t T c e ll n e o p la s m s . E x p re s s io n ca n be a s s e s s e d e ith e r b y im m u n o h is to c h e m is try o r flo w c y to m e try , b u t m a n y flo w c y to m e try la b o ra to rie s e x p e rie n c e d iffic u ltie s w ith it. E x p re s s io n in C L L /S L L c o rre la te s w ith im m u n o g lo b u lin h e a v y c h a in v a ria b le re g io n g e n e m u ta tio n a l s ta tu s ; o v e re x p re s s io n is c o rre la te d w ith n o n m u ta te d s ta tu s a n d a m o re a g g re s s iv e c lin ic a l c o u rs e

4.4.6.2 Immunophenotypic evolution in hematolymphoid cells ■ N K c e lls b e a r n e ith e r th e T C R n o r im m u n o g lo b u lin . T h e y la c k s u rfa c e C D 3 ( C D 3 - b y flo w c y to m e try ), b u t c o n ta in c y to p la s m ic 5 and £ c h a in s o f C D 3 (C D 3 + by im m u n o h is to c h e m is try ) □ N K c e lls a re p o s itiv e fo r C D 2 , C D 7, C D 1 6 , C D 5 6 , a n d C D 57. C D 1 6 is th e re c e p to r fo r th e F c p o rtio n o f y h e a v y c h a in s (F cyR )

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Methods>lmmunophenotyping | Conventional cytogenetics & molecular techniques t4.49 B & T cell m aturation B cell stage Features

T cell stage

lymphoid stem cell CD34+, Tdt+, HLA- lymphoid stem cell DR+ IgH gene germline, TCR gene germline pro B cell CD34+, Tdt+, HLA- prothymocyte DR+, CD19+, CD10+ Ig H chain rearranging CD34-, Tdt—, HLA- immature/common pre-B cell DR+, CD19+, thymocyte CD10+, CD20+ cytoplasmic p heavy chains Ig L chain rearranging all of the above plus mature thymocyte B cell surface Ig, CD21+, CD22+ plasma cell

loss of B cell mature T cell markers (CD20-) cytoplasmic (not surface) lq+

Features CD34+, Tdt+, HLADR+ T cell receptor gene germline, IgH gene germline CD34+, Tdt+, CD2+, CD7+

CD34-, Tdt+, CD1+, CD2+ Cytoplasmic CD3+, CD5+, CD7+, CD4+ & CD8+ T cell receptor rearranged all of the above, except T d t-& CD1-, CD4+ or CD8+ all of the above, plus surface CD3+

□ S o m e N K c e lls e x p re s s C D 8 □ T h e T C R g e n e s a re g e rm lin e (n o t re a rra n g e d ) □ N K c e lls u tiliz e a n tib o d y d e p e n d e n t c e llu la r c y to to x ic ity (A D C C ) to kill c e lls b e a rin g fo re ig n a n tig e n ; th e y d is p la y k ille r in h ib ito ry re c e p to rs (K IR s ) a n d a g ro u p o f c y to ly tic m o le c u le s in c lu d in g g ra n z y m e s (eg, g ra n z y m e B a n d g ra n z y m e M ) ■ M y e lo id m a tu ra tio n □ E a rly g ra n u lo c y te s (m y e lo b la s ts ) e x p re s s C D 3 4 , H L A D R , C D 3 8 , CD 117, d im C D 1 3 , a n d C D 3 3 □ P ro m y e lo c y te s b e c o m e n e g a tiv e fo r C D 3 4 a n d H L A D R , c o n tin u e to e x p re s s d im to m o d e ra te C D 1 3 a n d C D 3 3 , a n d a c q u ire b rig h t C D 1 5 □ M e ta m y e lo c y te s a c q u ire C D 1 1b □ A s th e y m a tu re in to m a tu re b a n d s a n d s e g m e n te d n e u tro p h ils , C D 1 0 is e x p re s s e d , a lo n g w ith b rig h t C D 1 3 , C D 1 5 a n d C D 1 1b ■ M o n o c y te m a tu ra tio n □ D e riv e fro m m y e lo b la s ts □ In th e p ro m o n o c y te s ta g e , th e re is lo s s o f C D 3 4 a nd e x p re s s io n o f C D T Ib □ W ith a d d itio n a l m a tu ra tio n , th e re is e x p re s s io n o f C D 6 4 and CD14 □ T h ro u g h o u t m a tu ra tio n , th e y a re C D 1 5 - o r d im

4.4.7 Conventional cytogenetics & molecular techniques 4.4.7.1 Molecular examination of lymphocytes ■ A p rim itiv e B c e ll b e g in s life w ith its g e n e s in a g e rm lin e (e m b ry o n ic ) c o n fig u ra tio n , w h e re th e s e g m e n ts o f D N A th a t w ill e n c o d e th e Ig h e a v y (Ig H ) c h a in a re on c h ro m o s o m e 14 b u t s e p a ra te d by c o n s id e ra b le d is ta n c e s ■ T h e s e p a ra te s e g m e n ts o f D N A a re c a lle d V, D, J& C (v a ria b le [V ] s e g m e n t, d iv e rs ity [D ] s e g m e n t, jo in in g [J] s e g m e n t, and c o n s ta n t [C ] s e g m e n t) ■ A n a lo g o u s ly , th e g e rm lin e k lig h t c h a in g e n e s e g m e n ts , on c h ro m o s o m e 2, c o n s is t o f s e p a ra te ly lo c a te d V, J & C s e g m e n ts (no D), a nd th e g e rm lin e A lig h t c h a in g e n e s e g m e n ts , on c h ro m o s o m e 22, a ls o a re V, J, a n d C ■ In B ce ll m a tu ra tio n , th e IgH g e n e s re a rra n g e firs t, fo llo w e d by th e k a p p a ( k ) lig h t c h a in g e n e s . If th e k re a rra n g e m e n t is n o n p ro d u c tiv e , th e n la m b d a (A) re a rra n g e s . F inally, w ith all th e re a rra n g in g c o m p le te , th e ce ll b e g in s to m a ke im m u n o g lo b u lin in its c y to p la s m (clg+). Later, it w ill in c o rp o ra te th is im m u n o g lo b u lin into its c e ll m e m b ra n e (s lg + ) a nd w ill be d e fin e d a s a m a tu re B cell ■ A c lo n a l re a rra n g e m e n t s u p p o rts a d ia g n o s is o f n e o p la s ia ■ B ce ll n e o p la s m s m a y s o m e tim e s s h o w T C R re a rra n g e m e n ts a nd T ce ll n e o p la s m s m a y do th e s a m e t4.50

t4.50 Rate of detection of clonal receptor gene rearrangements in lymphoid neoplasms Clonal IgH Clonal TCR Neoplasm rearrangement rearrangement mature B NHL mature T NHL BALL TALL

>99% 4-6% >99% 10-15%

5-7% >90% 20-40% 85-95%

A LL = acute lym phoblastic leukem ia; N HL = non-H odgkin lym phom a; TCR receptor

= T cell

■ P o ly m e ra s e c h a in re a c tio n (P C R ) □ D N A is a m p lifie d u sin g a n u m b e r o f c o n s e n s u s p rim e rs to a m p lify s e v e ra l m e m b e rs o f th e V g e n e c la s s a n d s e v e ra l o f th e J g e n e c la s s □ T h e a m p lic o n is th e n s u b je c te d to e le c tro p h o re s is , a n d if th e re is a m a jo r p o p u la tio n o f ly m p h o c y te s h a v in g th e s a m e IgH g e n e re a rra n g e m e n t, it w ill a p p e a r a s a d is tin c t band □ A m ix tu re o f p o ly c lo n a l B c e lls w ill p ro d u c e a la d d e rlik e d is trib u tio n o f b a n d s □ t(11;14) b e ll tra n s lo c a tio n o f M C L is p o o rly s u ite d fo r d e te c tio n by P C R t4.51

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Methods>Conventional cytogenetics & molecular techniques | Bone marrow biopsy ■ E M H (h e m a to p o ie s is ta k in g p la c e o u ts id e th e m a rro w ) c e a s e s a ro u n d th e tim e o f b irth , a n d in d ic a te s a p a th o lo g ic c o n d itio n th e re a fte r

t4.51 Detection of BCL1 rearrangement Sensitivity (%) Method >95 80 70 40-50

FISH cytogenetics Southern blot PCR

■ A t b irth , m e d u lla ry h e m a to p o ie s is is o c c u rrin g in e s s e n tia lly all b o n e s

■ S B H w ith re s tric tio n fra g m e n t le n g th p o ly m o rp h is m s (R F L P ) □ R a d io la b e le d p ro b e s fo r th e IgH g e n e , Igx g e n e , and T C R P g e n e , a re a p p lie d to an a g a ro s e g el th a t c o n ta in s D N A w h ic h h as b e e n e x tra c te d fro m th e c e lls o f in te re s t, a nd c u t w ith re s tric tio n e n z y m e s □ T h e re s u ltin g c lo n a l b a n d (re s tric tio n fra g m e n t), if any, is th e n d is p la y e d on an a u to ra d io g ra p h ■ F IS H , o r in te rp h a s e F IS H , is w e ll s u ite d fo r d e te c tin g m o s t o n c o g e n e tra n s lo c a tio n s □ D e te c tio n o f th e b e ll, b cl2 , b c l6 , a n d C M Y C tra n s lo c a tio n s is m o s t s e n s itiv e by F IS H

t4.52 Selected molecular genetic associations Notes Rearrangement

Disease

Burkitt lymphoma

t(9;22)(q34;q11.2) t(9;22) +Ph, +8,+19, i(17q), del(9q) t(8;14), t(8;22), t(2;8)

chronic lymphocytic leukemia (CLL/SLL)

del(13q), del(11q), +12, del(17p), del(14q)

Follicular lymphoma (FL) Mantle cell lymphoma (MCL) MALT lymphoma lymphoplasmacytic lymphoma (LPL) anaplastic large cell lymphoma (ALCL) myelodysplasia

t(14;18)(q32;q21) t(11;14)(q13;q32)

BCR/ABL indicates progression (clonal evolution) cMyc/IgH; cMyc/lgA; cMyc/lgK 20% have a normal chromosomes 30% of cases have complex abnormalities BCL2/lgH BCL 1/lgH

t(11;18)(q21;q21) & others MLT/API2 PAX5/lgH t(9;14)(p13;q32) t(2;5)(p23;q35) -5, —5q, -7, -7q, o r-8

ALK/NPM good prognosis most commonly seen are complex abnormalities involving 1 or more

4.4.8 Bone marrow biopsy 4.4.8.1 Sites of hematopoiesis ■ H e m a to p o ie s is b e g in s in th e fe tu s d u rin g th e firs t trim e s te r, a nd by e a rly in th e s e c o n d trim e s te r, n u c le a te d R B C s ca n be fo u n d w ith in th e v e s s e ls o f th e c h o rio n ic villi ■ B y th e e nd o f th e firs t trim e s te r, h e m a to p o ie s is o c c u rs in th e liver, s p le e n , th y m u s , lym p h n o d e s , a nd m a rro w © A S C P 2018

4.4.8.2 Peripheral blood ■ A u to m a te d p la te le t c o u n t m a y b e fa ls e ly lo w w h e n p la te le ts a re m a rk e d ly e n la rg e d o r c lu m p e d (E D T A a rtifa c t) ■ A u to m a te d R B C c o u n t m ay be fa ls e ly lo w w h e n R B C s a re c lu m p e d (cold a g g lu tin in s ) ■ A u to m a te d b a s o p h il c o u n ts a re o fte n in a c c u ra te ■ A 2 0 0 c e ll c o u n t s h o u ld be u n d e rta k e n , p a rtic u la rly if m y e lo d y s p la s ia is b e in g c o n s id e re d

■ A s u m m a ry o f im p o rta n t c h ro m o s o m a l a n d g e n e tic a s s o c ia tio n s is p ro v id e d in t4.52

chronic myelogenous leukemia (CML)

■ G ra d u a lly th is re g re s s e s s u c h th a t in a d u lts , m e d u lla ry h e m a to p o ie s is is c o n fin e d to fla t b o n e s , s u c h a s th e iliu m a n d s te rn u m , and th e e p ip h y s e s o f lo n g b o n e s , s u c h a s th e fe m u r a nd c la v ic le

■ L e ft s h ift o f g ra n u lo c y te s u s u a lly in d ic a te s in fe c tio n b u t m a y in d ic a te le u k e m ia (C M L ); a re a c tiv e le ft s h ift ra re ly in c lu d e s p ro m y e lo c y te s o r b la s ts a n d is o fte n a c c o m p a n ie d by “ to x ic ” c h a n g e s p rim a ry /b lu e g ra n u le s , D o h le b o d ie s , v a c u o liz a tio n ) ■ H y p o s e g m e n te d n e u tro p h ils (< 3 lo b e s ) m a y b e s e e n in m y e lo d y s p la s ia , le ft s h ifte d s m e a rs , a n d in h e rite d P e lg e r-H u e t a n o m a ly ■ P e lg e r-H u e t a n o m a ly is an o th e rw is e b e n ig n c o n d itio n in w h ic h n e u tro p h ils h ave 2 lo b e s o f e v e n size ; o c c a s io n a l c e lls w ith a s in g le lo b e m ay be s e e n (S to d tm e is te r c e lls ) ■ H y p e rs e g m e n ta tio n (>6 lo b e s) is s e e n in m e g a lo b la s tic a n e m ia (B 12 o r fo la te d e fic ie n c y ) ■ L y m p h o c y te s w ith c le fte d n u c le i (R e id e r c e lls ) a re s o m e tim e s s e e n in c h ild re n w ith v ira l in fe c tio n o r p e rtu s s is ■ P la te le ts a re “ la rg e " w h e n th e y a re la rg e r th a n u s u a l a n d a s “g ia n t” w h e n th e y are la rg e r th a n a R B C ■ E n la rg e d and v a ria b ly size d p la te le ts m a y b e s e e n in th ro m b o c y to p e n ic p a tie n ts (ITP, ty p ic a lly ), in a c u te p h a s e re a c tio n s , and in M P N s ■ P ale, h y p o g ra n u la r p la te le ts a re o fte n s e e n in M P N s , M D S , a n d ra re in h e rite d c o n d itio n s (g ra y p la te le t s y n d ro m e )

4.4.8.3 Bone marrow aspirate & touch imprints ■ A 5 0 0 c e ll c o u n t s h o u ld be u n d e rta k e n , e n u m e ra tin g b la sts, p ro m y e lo c y te s , m y e lo c y te s , m e ta m y e lo c y te s , m a tu re n e u tro p h ils (s e g m e n te d n e u tro p h ils a n d b a n d s ), m o n o c y te lin e a g e ce lls, ly m p h o c y te s , p la s m a c e lls , m e g a k a ry o c y te s , a nd e ry th ro id p re c u rs o rs

ISBN 978-08 9 1 8 9 -6 6 7 8

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Methods>Bone marrow biopsy ■ T h e a s s e s s m e n t o f iro n s to re s (P ru s s ia n b lu e o r P e ris s ta in ) is b e s t p e rfo rm e d o n th e s p ic u la r a s p ira te , c lo t s e c tio n , o r o n th e tre p h in e b io p s y (th e d e c a lc ific a tio n p ro c e d u re o fte n d im in is h e s th e s ta in a b le iro n ) □ S ta in a b le iro n is o fte n g ra d e d a s in c re a s e d , a d e q u a te , d e c re a s e d , o r a b s e n t □ T h e P ru s s ia n b lu e s ta in is a ls o e x a m in e d fo r th e p re s e n c e o f rin g e d s id e ro b la s ts ; if p re s e n t, th e p e rc e n ta g e s h o u ld b e d e te rm in e d (rin g e d s id e ro b la s ts /1 0 0 e ry th ro id p re c u rs o rs ) ■ A c e ll lin e is c o n s id e re d d y s p la s tic o n ly if d y s p o ie s is is p re s e n t in > 1 0 % o f its c o n s titu e n ts ■ D y s e ry th ro p o ie s is in c re a s e s w ith tim e to fix a tio n (s m e a r p re p a ra tio n )

4.4.8.4 Bone marrow biopsy & clot section ■ T h e o v e ra ll c e llu la rity is b a s e d o n an o v e ra ll im p re s s io n o f th e fa t:c e ll ra tio a n d is u s u a lly g iv e n a s a p e rc e n t c e llu la rity ■ T o ta l fa tty re p la c e m e n t o f th e m a rro w is c o n s is te n t w ith a p la s tic a n e m ia a t a n y a g e , w ith th e c a v e a t th a t if p e rip h e ra l c o u n ts a re n o rm a l, s a m p lin g e rro r s h o u ld be c o n s id e re d ■ A d u lts w ith c e llu la rity > 7 0 % a re c o n s id e re d to h ave h y p e rc e llu la r m a rro w ■ T h e m y e lo id to e ry th ro id (M :E ) ra tio m a y b e a s s e s s e d fro m th e 5 0 0 c e ll c o u n t; th e n o rm a l a d u lt M :E ra tio is b e tw e e n 2:1 a n d 4:1 ■ T h e g e n e ra tiv e z o n e , a rim o f im m a tu re c e lls , is p a ra tra b e c u la r a n d ju s t 1-2 c e lls th ic k ; a n in c re a s e in th e g irth o f th e g e n e ra tiv e z o n e m a y b e s e e n in M P N s a n d m y e lo d y s p la s tic s y n d ro m e s ■ M e g a k a ry o c y te s a re ty p ic a lly s c a tte re d a n d o n ly ra re ly to u c h o n e a n o th e r; in c re a s e d a n d c lu m p e d m e g a k a ry o c y te s a re s e e n in M P N s a n d m a rro w re a c tin g to p e rip h e ra l p la te le t c o n s u m p tio n ■ In tra s in u s o id a l h e m a to p o ie s is is a fe a tu re o f fib ro tic m a rro w , a g a in s e e n in M P N s ■ T h e n o rm a l m a rro w h a s m in im a l re tic u lin fib e rs th a t a re re s tric te d to p a ra tra b e c u la r a n d p e riv a s c u la r s ite s . A n y re tic u lin o u ts id e o f th is d is trib u tio n is a b n o rm a l a n d m a y s u g g e s t an M P N o r a n in filtra tiv e p ro c e s s s u c h a s H C L ■ P a ra tra b e c u la r ly m p h o id a g g re g a te s a re ty p ic a l o f m a rro w in v o lv e m e n t b y F L a n d T C R B C L

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Selected readings>Books | Additional jounal articles

4.5 Selected readings 4.5.1 Books IS B N 9780721660301 M orris MW , D avey FR [1996] Basic exam ination o f blood. In: H enry JB, ed. Clinical Diagnosis and M anagem ent by Laboratory Methods, 19e. W B S aunders IS B N 9780781722025 loachim HL, R atech H, ed [2002] ioachim’s Lymph Node Pathology, 3e. Lippincott W illiam s & W ilkins IS B N 9780891894407 Foucar K [2001] Bone M arrow Pathology, 2e. A S C P ; C hapters 7-18 IS B N 9780891894728 Keren DF, M cC oy JP, C arey JL, ed [2001] Flow Cytometry in Clinical Diagnosis. A m erican S ociety o f Clinical Pathology; C hapters 2, 9, 10 IS B N 9 7892832 2 4 1 12 H arris NL, Jaffe ES, Stein EJ et al, ed [2001] Pathology and Genetics: Tumours o f Hematopoietic and Lymphoid Tissues. IARC IS B N 9789283224310 S w erdlow SH, C am po E, H arris NL et al, ed [2008] Tumours o f Hematopoietic and Lymphoid Tissues, 4e. IARC Press

Additional journal articles P M ID 10339500 G ascoyne RD, Aoun P, W u D et al [1999] P rognostic significance o f a naplastic lym phom a kinase (ALK) protein expression in adults w ith analplastic large cell lym phom a. Blood 93:3913-3921 P M ID 10448597 M eans R T Jr, Allen J, Sears DA et al [1999] Serum soluble transferrin receptor and the prediction o f m arrow aspirate iron results in a hetero geneous group o f patients. Clin Lab Haem 21:161-167 P M ID 10555007 C ataldo KA, Jalal SM , Law M E et al [1999] D etection o f t(2;5) in anaplastic large cell lym phom a com parison o f im m unohistochem ical studies, FISH, and R T-PC R in paraffin em bedded tissue. Am J Surg Pathol 23:1386 -1392 P M ID 10572083 R aim ondi SC, C hang MN, R avindranath Y et al [1999] C hrom osom al abnorm a lities in 478 children w ith acute m yeloid leukem ia: clinical characteristics and tre a tm e n t outcom e in a cooperative P ediatric O ncology G roup study-P O G 8821. Blood 94:3707-3716 P M ID 10587708 D ouglas VK, G ordon LI, G oolsby C L et al [1999] Lym phoid aggreg ates in bone m arrow m im ic residual lym phom a after rituxim ab therap y fo r non H odgkin lym phom a. Am J Clin Pathol 112:844-853 P M ID 10632488 Bohm J [2000] G elatinous transform ation o f the bone m arrow : the spectrum o f underlying diseases. Am J Surg Pathol 24(1):56-65 PM ID 10632491 N atkunam Y, R ouse R V [2000] U tility o f paraffin section im m unohistochem istry fo r C -kit (C D 117) in the differen tial diagnosis o f system ic m ast cell disease involving the bone m arrow . Am J Surg Pathol 24(1 ):81 -91 PM ID 10751367 Baens M, M aes B, Steyls A et al [2000] The product o f the t(1 1 ;18), an A P I2 -M L T fusion, m arks nearly h a lf o f gastric M A LT type lym phom as w itho u t large cell proliferation. Am J Pathol 156:1433-1439 PM ID 10882768 D elves PJ, R oitt IM [2000] The im m une system : first o f 2 parts. N ew Engl J M ed 6;343:37-49 P M ID 10884801 R im sza LM, Larson RS, W in te r SS et al [2000] Benign hem atogone rich lym phoid proliferations can be distin guished from B lineage acute lym phoblastic leukem ia by inte gration o f m orphology, im m unophenotype, adhesion m olecule expression, and architectural features. Am J Clin Pathol 114:66-75 © A S C P 2018

P M ID 1 089152 0 D elves PJ, R oitt IM [2000] T h e im m u n e system : second o f 2 parts. N ew Engl J M ed 13 ;3 4 3 :108-117 P M ID 10954762 C hen FE, Ooi C, Ha S Y et al [2000] G e n e tic and clinical feature s o f hem oglobin H dise a se in C hine se patients. N Engl J M ed 343:544-550 P M ID 10975930 Kiss TL, Ali MAM, Livine M et al[2000] An algorithm to aid in the investigation o f thalassem ia tra it in m ulticu ltural populations. Arch Pathol Lab M ed 1 24:132 0-1323 P M ID 1 1136261 D ohner H, S tilgenbauer S, B e n n e r A et al [2000] G enom ic aberratio ns and survival in C LL. N Engl J M ed 343:191 0-1916 P M ID 1 1144927 M iranda RN, Briggs RC, K inney M C et al [2000] Im m unohistochem ical detection o f cyclin D1 using o p tim ized conditions is highly specific for m antle cell lym p h o m a and hairy cell leukem ia. M od Pathol 13:1308-1314 P M ID 1 1152223 Baner]ee R, Halil O, Bain BJ et al [2000] N eutrophil dysplasia caused by m ycophenolate m ofetil. Transplantation 70:1608 -1610 P M ID 111608 8 Pai M KR, Bedritis I, Z ip u rsky A [1975] M assive tra n s placental hem orrhage: clinical m anife sta tio n s in th e new born. CM AJ 1 12(5):585-589 P M ID 1 1211615 G arcia DP, R ooney M T, A h m a d E, D avis BH [2001] D iagnostic usefulness o f C D23 and FM C -7 antigen expression patterns in B cell lym phom a classification. Am J Clin Pathol 115:258-265 P M ID 1 1224598 M acon W R , Levy NB, Kurtin PJ et al [2001] H epatosplenic a(5 T cell lym phom as: a report o f 14 cases and com parison w ith hepatosplenic y5 T cell lym phom as. Am J Surg Pathol 25(3):285-296 P M ID 1 1238092 Facon T, A vet-Loiseau H, G uillerm G e t al [2001] Intergroupe Francophone du M yelom e. C h ro m o so m e 13 a b n o r m alities identified by FISH analysis and serum (32-m icroglobulin produce a pow erful m yelom a staging system fo r p atients receiving high dose therapy. Blood 97:1566-1571 P M ID 1 1253132 H asserm an RP, H ow ard J, W ood A et al [2001] A cute erythrem ic m yelosis (true e rythroleukem ia): a va ria n t o f A M L FA B-M 6. J Clin Pathol 54:205-209 P M ID 1 1264181 Du M Q, Liu H, Diss TC et al [2001] K aposi sa rcom a associated herpesvirus infects m onotypic (IgM A) but polyclon al naive B cells in C astlem an disease and associa ted lym p h o p ro liferative disorders. Blood 97:2130-2136 P M ID 1 139039 Rai KR, S a w itsky A, C ro n kite EP et al [1975] C linical staging o f chronic lym phocytic leukem ia. Blood 4 6 :2 1 9 -2 3 4 P M ID 1 1392883 Eshoa C, Perkins S, K a m p ala th B et al [2001] D ecreased C D 10 expression in g rade III and in in te rfo llicu la r infil trates o f fo llicu la r lym phom a. Am J Clin Pathol 1 1 5:862-867 P M ID 1 1418478 Ibrahim S, Keating M, Do KA et al [2001] C D 38 expression as an im portant progno stic fa cto r in B cell C LL. Blood 98:181-186 P M ID 1 1601136 Jam al S, P icker LJ, A q u in o DB et al [2001] Im m unophenotypic analysis o f peripheral T cell neoplasm s. A m J Clin Pathol 116:512-526 P M ID 1 1710682 K oster F, Foucar K, H jelle B et al [2001] R apid presum ptive diagnosis o f hantavirus ca rd io p u lm o n a ry syndrom e by peripheral blood sm e a r review. A m J Clin Pathol 1 16(5):665672 P M ID 11764078 O nciu M, Schlette E, M edeiros LJ et al [2001] C ytogenetic findings in m antle cell lym phom a: cases w ith a high level o f peripheral blood involvem ent have a d istinct pattern o f abnorm alities. Am J Clin Pathol 116:886-892 P M ID 1 1789731 W ang LJ, G lasser L [2002] S p urious d yse ryth ro p o iesis. Am J Clin Pathol 117:57-59

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Selected readings>Additional jounal articles P M ID 1 1870241 K a nta rjia n H, S a w ye rs C, H och h a u s A et al [2002] H e m a to lo g ic and cyto g e n e tic re sp o n se s to im atinib m esyla te in c h ro n ic m y e lo g e n o u s leukem ia. N Engl J M e d 3 46:645 -52 P M ID 1 188807 7 T h a lh a m m e r-S c h e rre r R, M itte rb a u e r G, S im onitsch I e t al [2 0 0 2 ] T h e im m u n o p h e n o ty p e o f 325 a d u lt a cute leuke m ias. A m J Clin Pathol 117:380 -389 P M ID 1 193973 6 F o h le m -W a lte r A, Ja co b C, L e co m p te T et al [2002] L a b o ra to ry ide n tifica tio n o f c ryo g lo b u lin e m ia fro m a u tom ated b lood cell counts, fresh blood sam ples, and blood film s. Am J Clin P athol 117:606 -614 P M ID 1 198451 5 Liu H, Y e H, R u sko n e -F o u rm e stra u x A et al [2002] t(1 1; 18) is a m a rk e r fo r all s ta g e g a s tric M A L T lym p h o m a s th a t w ill n o t re sp o n d to H pylori e ra d ica tio n . Gastroenterology 12861294 P M ID 1 2 0 2 8 0 1 7 B resters D, R eus A C W , V e e rm a n A JP et al [2002] C o n g e n ita l le u ke m ia : th e D utch e xp e rie n ce and review o f the lite ra tu re . Brit J H em atol 117:513 -524 P M ID 1 2 0 8 9 1 7 6 T h o m a s C, T h o m a s L [2002] B iochem ical m arkers and h e m a to lo g ic indices in th e dia g n o sis o f fu n ctio n a l iron d e fi cie n cy. Clin C hem 4 8 (7 ):1 0 6 6 -1 0 7 6 P M ID 1 2 0 9 0 4 3 4 K a ra n d ika r NJ, H o tch kiss EC, M cK e n n a R W et al [2 0 0 2 ] T ra n s ie n t stress ly m phocytosis. A m J Clin Pathol 117:819825 P M ID 1 2 1 3 4 4 7 0 W a rd PC J [2002] M odern a p p ro a ch e s to the in ve sti g a tio n o f vita m in B 12 d e ficie n cy. Clin Lab M e d 22:4 3 5 -4 4 5 P M ID 1 2 4 4 6 4 4 9 F ra n co V, F lo re n a A M , la n n itto E [2003] S p lenic m a rg in a l z o n e ly m p h o m a . Blood 101:246 4-2472 P M ID 1 2 4 5 6 2 2 1 S en F, Lai R, A lb ita r M [2002] C h ro n ic lym p h o cytic le u ke m ia w ith t(1 4; 18) and tris o m y 12: re po rt o f 2 cases and re v ie w o f th e literature. Arch Pathol Lab M e d 126:15 4 3 -1 5 4 6 P M ID 1 2 5 0 2 9 3 1 A m in HM , M e d e iro s LJ, M an n in g JT et al [2003] D isso lu tio n o f th e L ym phoid Follicle Is a F e a tu re o f the H H V 8+ V a ria n t o f P la sm a C ell C a stle m a n D isease. A m J Surg Pathol 2 7 (1 ):9 1 -1 0 0 P M ID 1 2 5 2 0 6 9 4 R o ss JS, G in sbu rg G S [2003] T h e integration o f m o le c u la r d ia g n o stics w ith th e ra p e u tics. A m J Clin Pathol 119:2 6 -3 6 P M ID 1 2 5 2 8 8 7 4 K yle RA, G e rtz M A, W itzig TE et al [2003] R eview of 1027 p a tie n ts w ith new ly diag n o se d m u ltip le m yelom a. M ayo Clin Proc 7 8 :2 1 -3 3 P M ID 1 2 6 4 9 1 4 4 O ’B rien LA, Jam es, O thm an M et al [2003] Found er von W ille b ra n d fa c to r ha p lo typ e associa ted w ith type 1 von W ille b ra n d d isease. Blood 102:549-557 P M ID 1 2 6 5 3 5 8 0 S lone SP, Flem ing DR, B u chino JJ [2003] Sinus h istio cyto sis w ith m a ssive lym p h a d e n o p a th y a nd L a n g e rh a n s cell h is tio cy to s is e x p re ss th e c e llu la r a d h e sio n m o le cu le C D 31. Arch P athol Lab M e d 1 2 7 (3 ):341-344 P M ID 1 2 7 2 4 4 8 2 C re sp o M, B osch F, V illa m o r N et al [2003] Z A P -70 e x p re s s io n as a s u rro g a te fo r im m u n o g lo b u lin -va ria b le -re g io n m u ta tio n s in C LL. N Engl J M ed 348:1 7 6 4 -1 7 7 5 P M ID 1 2 7 2 4 4 8 4 S ta u d t LM [2003] M o le cu la r d ia g n o sis o f th e h em a to lo g ic cancers. N e w Engl J M e d 3 4 8 :1 7 7 7 -1 7 8 5 P M ID 1 2 7 3 3 1 0 9 C han W C , H ans C P, Kadin M E [2003] G enetic and m o le c u la r g e n e tic stud ies in the dia g n o sis o f T cell m alignancies. H um Pathol 3 4 (4 ):3 1 4-321 P M ID 1 2 7 3 3 1 1 0 K adin M E [2003] G e n e tic and m o le c u la r genetic stu d ie s in th e d ia g n o sis o f T cell m a lig na ncies. Hum Pathol 3 4 (4 ):3 2 2 -3 2 9 P M ID 1 2 7 3 3 1 11 C a m p o E [2003] G e n e tic and m o le cu la r g e n e tic stu d ie s in th e d ia g n o sis o f B cell lym p h o m a s I: m antle cell lym p h o m a , fo llic u la r lym p ho m a, and B u rkitt lym phom a. Hum Path 3 4 (4 ):3 3 0 -3 3 5

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P M ID 12881439 Tate JR, Gill D, C obcroft R et al [2003] Practical considerations fo r the m easurem ent o f free light chains in serum . Clin Chem 4 9 (8 )4 2 5 2 -1 2 5 7 P M ID 12931553 Jasionow ski TM , H artung L, G reenw ood JH et al [2003] A n alysis o f CD 10+ hairy cell leukem ia. Am J Clin Pathol 120:228-235 P M ID 1333569 M iralles G D, O ’Fallon JR, Talley NJ [1992] Plasm a cell dyscrasia w ith polyneuropathy: the spectrum o f PO E M S syndrom e. N Engl J M ed 327:1919-1923 P M ID 135028 25 R oberts AR , H ilburg LE [1958] Sickle cell disease w ith salm onella osteom yelitis. J Pedlatr 53:170-5 P M ID 13560561 B ouroncle B, W isem an BK, Doan C [1958] Leukem ic reticuloendotheliosis. Blood 13(7):609-30 P M ID 141507 3 R ao SP, M iller ST, C ohen BJ [1992] Transient aplastic crisis in patients w ith sickle cell disease. Am J Dis Child 146:1328 P M ID 142477 13 Franklin EC [1964] Structural studies o f hum an 7S y globulin: fu rth e r o b servations o f a naturally-occurring protein related to th e crystallizable (fast) fragm ent. J Exp M ed 120:691709 P M ID 14504078 H ans CP, W eisenburg er DD, G reiner TC et al [2004] C onfirm ation o f the m olecular classification o f diffuse large B cell lym phom a by im m unohistochem istry using a tissue m icro array. Blood 103:275-282 P M ID 14531486 Tefferi A [2003] A nem ia in adults: a contem porary approach to diagnosis. M ayo Clin Proc 78:1274-1280 P M ID 14560573 O nciu M, Behm FG, R aim ondi SC et al [2003] A lk-positive anap la stic large cell lym phom a w ith leukem ic periph eral blood involvem e nt is a clinicopath ologic entity w ith an unfa vorable prognosis: report o f 3 cases and review o f the literature. Am J Clin Pathol 120:617-625 P M ID 145996 49 A h m e d S [2003] D iagn ostic yield o f bone m arrow exam ination in fe v e r o f unknow n origin. Am J M ed 115(7):591592 P M ID 14608903 D elgado J, M atutes E, M orilla A M et al [2003] D iagnostic significance o f C D 20 and FM C 7 expression in B cell disorders. Am J Clin Pathol 120:754-759 P M ID 14608904 S chlette E, Fu K, M edeiros LJ [2003] C D 23 expres sion in m antle cell lym phom a: clinicopath olog ic features o f 18 cases. Am J Clin Pathol 120:760-766 P M ID 14608906 Xu Y, Dolan MM, Nguyen PL [2003] D iagnostic significance o f detecting dysgranulopoiesis in chronic m yeloid leukem ia. Am J Clin Pathol 120:778-784 PM ID 14657829 W o lf AW , Jim enez E, Lozoff B [2003] Effects o f iron therapy on infant blood lead levels. J Pediatr 143:789-795 P M ID 14671974 K ussick SJ, W ood BL [2003] 4 -color flow cytom etry identifies virtually all cytogenetically abnorm al bone m arrow sam ples in the w orkup of non C M L m yeloproliferative disorders. Am J Clin Pathol 120:854-865 P M ID 14693325 A taga Kl [2003] H ypercoagulability in sickle cell disease: a curious paradox. Am J M ed 115(9):721-728 PM ID 14695628 Burns ER, Lou Y, Pathak A [2004] M orphologic diagnosis o f throm botic th ro m b o cyto p en ic purpura. Am J Hem atol 75:18-21 PM ID 14724303 Lecuit M, A bachin E, M artin A et al [2004] Im m unoproliferative sm all intestinal disease associated with Camplyobacter jejuni. N ew Engl J M ed 350:239-248 P M ID 14726163 O rchard JA, Ibbotson RE, D avis Z et al [2004] ZA P -70 expression and prognosis in C LL. Lancet 363:105-111 P M ID 14746518 N eedlem an H [2004] Lead poisoning. Annu R ev M ed 55:209-222

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4: Hematopathology

Selected readings>Additional jounal articles P M ID 14747447 Bajw a RPS, S kinner R, W in d e b a n k KP et al [2004] D em ographic study o f leukem ia presenting w ithin the first 3 m onths o f life in the northern health region o f England. J Clin Pathol 57:186-188 P M ID 14750238 B ilalovic N, Blystad AK, G olouh R et al [2004] Expression o f bcl6 and CD 10 protein is associated w ith longer overall survival and tim e to tre a tm e n t failure in follicular lym phom a. Am J Clin Pathol 121:34-42 P M ID 14983940 O ’C onnell FP, Pinkus JL, P inkus GS [2004] C D 138 (S yndecan-1), a plasm a cell m arker: im m unohistochem ical profile in hem atopoietic and nonhem atopoietic neoplasm s. Am J Clin Pathol 121:254-263 PM ID 14983942 Li S, Juco J, M ann KP et al [2004] Flow cytom etry in the differential diagnosis o f lym phocyte rich thym om a from p recursor T cell acute lym phoblastic leukem ia/lym phoblastic lym phom a. Am J Clin Pathol 121:268-274 P M ID 15023043 Frost M, Newell J, Lones M A et al [2004] C om parative im m unohistochem ical analysis o f pediatric B urkitt lym phom a and diffuse large B cell lym phom a. Am J Clin Pathol 121:1-9 P M ID 15023045 Lin P, H ao S, M edeiros LJ et al [2004] Expression o f C D2 in acute prom yelocytic leukem ia correlates w ith short form o f P M L-R A R a transcripts and poorer prognosis. Am J Clin Pathol 121:1-9 P M ID 15034233 M atsubara K, Fukaya T, N igam i H et al [2004] A ge dependent changes in the incidence and etiology o f childhood throm bocytopenia. Acta Hem atol 111:132-137 P M ID 15071792 D elaunay J [2004] The hereditary stom atocytoses: genetic disorders o f the red cell m em brane perm eab ility to m onovalent cations. Semin Hem atol 41:165-172 P M ID 15080299 Lin P, O w ens R, Tricot G et al [2004] Flow cyto m etric im m unophenotypic analysis o f 306 cases o f m ultiple m yelom a. Am J Clin Pathol 121:482-488 PM ID 15151211 N ascim ento AF, Pinkus JL, Pinkus GS [2004] C lusterin, a m arker fo r anaplastic large cell lym phom a: im m u nohistochem ical profile in hem atopoietic and nonhem atopoietic m alignant neoplasm s. Am J Clin Pathol 121:709-717 P M ID 15151214 Lesesve J, S a lignac S, A lla F et al [2004] C om parative evaluation o f schistocyte counting by an autom ated m ethod and by m icroscopic determ ination. Am J Clin Pathol 121:739-745 P M ID 15153720 Tim uragaog lua A, Erkan Q, Erbasan F [2004] The im portance o f platelet indexes in discrim inating betw een (3-thalassemia trait and iron deficiency anem ia. Acta Hematol 111:235-236 PM ID 15163314 C lark BE, Thein SL [2004] M olecular diagnosis of haem oglobin disorders. Clin Lab H aem 26:159-176 P M ID 15195107 Ng SB, Lai KW, M urugaya S et al [2004] Nasal type Extranodal natural killer/T cell lym phom as: a clinicopath ologic and genotypic study o f 42 cases in Singapore. Mod Pathol 17:1097-1107 P M ID 15198354 C ook JR, S h ekhter-Levin S, S w erdlow SH [2004] Utility o f routine cla ssic cytogenetic studies in the evaluation o f suspected lym phom as: results o f 279 consecutive lym ph node/ extranodal tissu e biopsies. Am J Clin Pathol 121:826-835 P M ID 15238138 T ischkow itz M, Dokal I [2004] Fanconi anem ia and leukem ia— clinical and m olecular aspects. B r J Hem atol 126:176191 P M ID 15265127 D avoren A, C urtis BR, A ster RH et al [2004] Fluman platelet antigen specific alloantibodies im plicated in 1162 cases o f neonatal alloim m une throm bocytopen ia. Transfusion 44:12201225

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P M ID 15275990 Bizzarro MJ, C olson E, E h re n kra n z FtA [2004] D ifferential dia g n o sis and m an a g e m e n t o f anem ia in the new born. Pediatr Clin N A m 51:1087-1107 P M ID 15323147 C ox MC, Panetta P, Lo-C oco F et al [2004] C hrom osom al aberratio n o f the 11q23 locus in a cu te leukem ia and fre q u e n cy o f MLL gene translocation results in 378 ad u lt patients. Am J Clin Pathol 122:298-306 P M ID 1532569 9 Rai KR, W asil T, Iqbal U et al [2004] C linical staging and prognostic m arkers in chronic lym p h o cytic leukem ia. H em atol Oncol Clin N Am 18:795-805 P M ID 15353484 S aadoun D, Suarez F, Lefrere F et al [2005] S p le n ic lym phom a w ith villous lym phocytes, associa ted w ith ty p e II cry o globulinem ia and FICV infection: A new entity? Blood 105:74-76 P M ID 1535862 6 S teensm a DP, G ibbons RJ, H iggs DR [2005] A cquired a-thalassem ia in association w ith m y elodysp lastic syndrom e and o th e r hem atologic m alignancies. Blood 105(2):443-452 P M ID 15371947 S o tlar K, H orny HP, S im o n itsch I et al [2004] C D 25 indicates the neoplastic phenotype o f m a st cells. Am J Surg Pathol 2 8 (1 0 ):1 319-1326 P M ID 15388656 Joutovsky A, H adzi-N esic J, N ardi M A [2004] H P LC retention tim e as a diagnostic tool fo r hem oglobin v a ria n ts and hem oglobinopath ies: a study of 6 0 ,0 0 0 sa m p le s in a clinical d ia g nostic laboratory. Clin Chem 50(10): 1736-1747 P M ID 1545215 6 H ughes DA, S tu art-S m ith SE, Bain BJ [2004] H ow should stainable iron in bone m arrow film s be a sse s se d ? J Clin Pathol 57:1038-1040 P M ID 15466278 C ournoyer D, Toffelm ire EB, W ells G A e t al [2004] A n ti-e rythropoietin antibody m ediated pure red cell a plasia a fte r treatm en t w ith recom binant erythropoietin products: re c o m m e n dations fo r m inim ization o f risk. J Am Soc Nephrol 15:2728 -2734 P M ID 1548523 Truew orthy R, S huster J, Look T et al [1992] P loidy o f lym phoblasts is the strongest p re d icto r o f tre a tm e n t o u tc o m e in B progen itor cell A L L o f childhood: a P e d ia tric O n co lo g y G roup study. J Clin Oncol 10:606-613 P M ID 1 5561677 B e rliner N, H orwitz M, Loughran TP [2004] C ongenital and acquired neutropenia. Hem atology 63-79 P M ID 1 5592432 Ng A, T a ylo r GM, W ynn RF et al [2005] E ffects o f topo iso m e ra se 2 inhibitors on the MLL ge n e in children receiving chem otherapy: a prospective study. Leukem ia 19:253-259 P M ID 1 5667529 Elliot MA, Tefferi A [2004] T h ro m b o sis and h a e m o r rhage in polycythem ia vera and essential th rom bocythaem ia. Brit J Hem atol 128:275-290 P M ID 1 5686453 D ickinson JD, Sm ith LM , S a n g e r W G et al [2005] U nique gene expression and clinical ch a ra cte ristics are a s s o c i ated w ith the 11 q23 deletion in ch ro n ic lym p h o cytic leukem ia. Brit J Hem atol 128:460-471 P M ID 1 568650 3 C hng W J, Lai HC, E a rn e st A et al [2005] H em atological param eters in severe acute respiratory syndrom e. Clin Lab H aem 27:15-20 P M ID 15767800 W e n t PT, Zim pfer A, P ehrs A C et al [2005] H igh specificity o f com bined TR A P and D B A .44 exp re ssion fo r hairy cell leukem ia. Am J Surg Pathol 2 9:474-478 P M ID 15781101 B a xter EJ, S cott LM, C am pbell PJ et al [2005] C ancer G enom e Project. A cquired m utation o f the tyro sin e kinase JAK 2 in hum an m yeloproliferative disorders. Lancet 365 :1 0 5 4 1061 P M ID 15842043 Lin P, H ao S, H andy BC et al [2005] Lym phoid neoplasm s associa ted w ith IgM paraprotein. Am J Clin Pathol 123:200-205 P M ID 15855274 R ajkum ar SV, Kyle RA, T h e rn e a u TM et al [2005] S erum free light chain ratio is an in d e p e n d e n t risk fa cto r fo r

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Selected readings>Additional jounal articles p ro g re ss io n in m o n o clo n a l g a m m o p a th y o f u n d eterm ine d signifi c a n c e . Blood 106:8 1 2 -8 1 7 P M ID 1 5 8 5 8 1 8 7 K ralo vics R, P a ssam onti F, B u se r A S et al [2005] A g a in -o f-fu n c tio n m utation o f JA K 2 in m ye lo p ro life ra tive disorders. N Engl J M e d 352:1 7 7 9 -1 7 9 0 P M ID 1 5 8 7 0 4 9 4 O ’S h ea J, S h e rlo ck M. P h ilip R [2005] T h ro m b o cy to s is in child ho o d . Acta H em atol 113:212 P M ID 1 5 9 5 6 8 8 9 P rassouli A, P a p a d a kis V, T sa kris A e t al [2005] C la s s ic tra n s ie n t e ry th ro b la s to p e n ia o f ch ild h o od w ith hum an p a rv o v iru s B 19 g e n o m e d e te ctio n in th e blood and bone m arrow . J P e diatr H em ao l Oncol 2 7 (6 ):3 3 3 -3 3 6 P M ID 1 5 9 8 1 8 0 5 V an K irk R, S a n d h a u s LM , H o ye r JD [2005] The d e te ctio n and d ia g n o sis o f h e m o g lo b in A 2 ’ by h ig h-perform ance liquid c h ro m a to g ra p h y. A m J Clin Pathol 123:657-661 P M ID 1 5 9 8 1 8 0 6 P e trella T, B a go t M, W ille m ze R et al [2005] B lastic N K cell lym p h o m a s (a g ra n u la r C D 4+, C D 56+ h e m a to d e rm ic n e o p la sm s). A m J Clin Pathol 123:662 -675 P M ID 1 6 0 4 0 2 8 6 K u ssick SJ, From m JR , R ossini A et al [2005] 4 -c o lo r flo w cy to m e try sh o w s strong co n co rd a n c e w ith bone m a rro w m o rp h o lo g y and c yto g e n e tics in th e e va lu a tio n fo r m ye lo d y sp la sia . A m J Clin Pathol 2005;12 4 :1 7 0 -1 8 1 P M ID 1 6 0 4 0 2 8 8 W illis M S, M cK enna R W , P e terson LC et al [2005] L o w bla st c o u n t m yeloid d iso rd e rs w ith A u e r rods: a clin ico p a th o lo g ic a n a lysis o f 9 cases. A m J Clin Pathol 124:191 -198 P M ID 1 6 0 8 1 6 8 7 Levine RL, Loriaux M, H untly B JP e t al [2005] The J A K 2 V 6 1 7 F a ctiva tin g m utation o ccu rs in ch ro n ic m yelom onoc y tic le u ke m ia a nd a cu te m ye lo id le u ke m ia , but no t in acute ly m p h o b la s tic leukem ia o r ch ro n ic ly m p h o c ytic leukem ia. Blood 1 0 6 (1 0 ):3 3 7 7 -3 3 7 9 P M ID 1 6 1 4 6 8 2 3 R ay S, C raig FE, S w e rd lo w SH [2005] A b n o rm a l p a tte rn s o f a n tig e n ic e xp re ssio n in fo llic u la r lym phom a: a flow c y to m e tric study. A m J Clin Pathol 1 2 4:576 -583 P M ID 1 6 1 8 9 2 6 3 B e utle r E, W aa le n J [2006] T h e d e fin itio n o f anem ia: w h a t is th e lo w e r lim it o f norm al o f th e blood h e m oglobin co n ce n tra tio n ? Blood 107:174 7-1750 P M ID 161915 1 1 E inerson RR, K urtin PJ, D ayh a rsh G A et al [2005] FIS H is s u p e rio r to P C R in d e te ctin g t(1 4; 18 )(q 3 2 ;q 2 1 )—lgH /bcl2 in fo llic u la r lym p h o m a using paraffin e m b e d d e d tissu e sam ples. A m J Clin Pathol 124:421-429 P M ID 1 6 2 4 6 9 8 5 Z a ka i NA, K a tz R, H irsch C et al [2005] A p ro sp e c tive stu d y o f a n e m ia status, hem o g lo b in con ce n tra tio n , and m o rta lity in an e ld e rly cohort: T h e C a rd io v a sc u la r H ealth S tudy. Arch Intern M e d 16 5 :2 2 1 4 -2 2 2 0 P M ID 1 6 3 2 7 4 2 7 A rb e r DA, G e o rg e Tl [2005] B one m a rro w biopsy in v o lve m e n t by non H odgkin ly m phom a. A m J Surg Pathol 2 9 (1 2 ):1 5 4 9 -1 5 5 7 P M ID 1 6 3 9 3 6 7 7 C hen Y, T a llm an M S, G o o lsb y C et al [2005] Im m u n o p h e n o ty p ic va ria tio n s in hairy cell leukem ia. Am J Clin P athol 125:2 5 1 -259 P M ID 1 6 3 9 3 6 8 5 H uang L, A b ru z zo LV, V a lb u e n a JR et al [2006] A c u te m yeloid le u ke m ia a sso cia te d w ith v a ria n t t(8 ;2 1 ) detected by co n ve n tio n a l cyto g e n e tic a nd m o le c u la r stu dies: a report o f 4 c a se s and re vie w o f th e literature. A m J Clin Pathol 125:267 -272 P M ID 1 6 5 7 1 8 7 9 Kyle RA, T h e rn e a u TM , R a jk u m a r S V et al [2006] P re va le n ce o f m o n o clo n a l g a m m o p a th y o f u n d eterm ine d signifi can ce . N e w Engl J M ed 3 5 4 :1 3 6 2 -1 3 6 9 P M ID 1 6 6 2 7 2 7 0 H o w a n itz PJ, K o za rski TB, H o w a n itz JH et al [2006] S p u rio u s h e m o g lo b in barts caused by bilirubin: a com m on inter fe re n c e m im icking an u n co m m o n hem o g lo b in o p a th y. Am J Clin Pathol 1 25:608-614 P M ID 1 6 7 3 7 8 8 8 C ush in g T, C le ric u z io CL, W ilso n C S et al [2006] R isk fo r le u ke m ia in infants w ith o u t D ow n s y n d ro m e w h o have tra n s ie n t m ye lo p ro life ra tive disorder. J Pediatr 148:687-689

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P M ID 1 6753591 W u JM, B o row itz MJ, W e ir EG [2006] The useful ness o f CD71 expression by flo w cytom etry fo r differentiating indolent from aggressive C D 10+ B cell lym phom as. Am J Clin Pathol 126:39-46 P M ID 168580 75 Hill PG, Forsyth JM , Rai B et al [2006] Serum free light chains: an alternative to th e urine Bence Jones proteins screening test fo r m onoclonal gam m opathies. Clin Chem 52(9): 1743-1748 P M ID 16931292 E scribano L, M ontero AC G , N unez R, O rfao A [2006] Flow cytom etric analysis o f norm al and neoplastic m ast cells: role in diagnosis and follow up o f m ast cell disease. Immunol Allergy Clin N Am 26:535-547 P M ID 16990107 H offm an M A [2006] C linical presentations and com plications o f hairy cell leukem ia. Hem atol Oncol Clin N Am 20:1065-1073 P M ID 17001159 S alar A, Juanpere N, B ellosillo B et al [2006] G astrointestinal involvem e nt in m antle cell lym phom a: a prospec tive clinic, endoscopic, and patholoqic study. Am J Surq Pathol 30:1274-1280 P M ID 1 7 0 9 8 1 17 Laran MJ, M cErlean M, W ilner G [2006] M assive hem olysis associa ted w ith Clostridium perfringens sepsis. Am J Em erg M ed 3 (2 ):8 8 1-882 P M ID 17122510 R em stein ED, D ogan A, Einerson RR et al [2006] T he incidence and anatom ic site specificity o f chrom o som al translocations in prim ary extranodal m arginal zone B cell lym phom a o f m ucosa associated lym phoid tissue (M A LT lym phom a) in N orth A m erica. Am J Surg Pathol 30:1546-1553 P M ID 17224656 V yasa P, C rispino JD [2007] M olecular insights into Down syndrom e associa ted leukem ia. C urrO pin Pediatr 19:9-14 P M ID 17369128 Han X, B ueso-R am os CE [2007] P recursor T cell acute lym phoblastic lym phom a and acute biphenotypic leuke mias. Am J Clin Pathol 127:528-544 P M ID 17369142 S o upir CP, V ergilio J, Cin PD et al [2007] P h iladelphia chro m o so m e positive acute m yeloid leukem ia. Am J Clin Pathol 127:642-650 P M ID 17376384 V e rdonck K, G onzalez E,Van D ooren S et al [2007] Hum an T lym photropic virus 1: R ecent know ledge about an ancient infection. Lancet Infect Dis 7:266-281 P M ID 17658408 R ichards SJ, Barnett D [2007] The role o f flow cytom etry in the diagnosis o f paroxysm al nocturnal hem oglobin uria in the clinical laboratory. Clin Lab M ed 27:577-590 P M ID 17875504 De J, Z anjani R, H ibbard M et al [2007] Im m unophenotypic profile predictive o f K IT activating m utations in A M L1-E TO leukem ia. Am J Clin Pathol 128:550-557 P M ID 180246 33 S a lles G A [2007] C linical features, prognosis and treatm ent o f follicular lym phom a. Hematology Am Soc Hem atol Educ Program 216-225 P M ID 180558 68 Kantarjian H, S chiffer C, Jones D et al [2008] M onitoring the response and course o f chronic m yeloid leukem ia in the m odern era o f B C R -A B L tyrosine kinase inhibitors: prac tical advice on the use and interpretation o f m onitoring m ethods. Blood 111 (4): 1174-1180 PM ID 18285271 H arrington A, W ard PCJ, Kroft SH [2008] Iron deficiency anem ia, (M halassem ia m inor, and anem ia o f chronic disease: a m orphologic reappraisal. Am J Clin Pathol 129:466471 P M ID 18343790 R ausei-M ills V, C hang KL, G aal KK et al [2008] A berrant expression o f C D 7 in m yeloblasts is highly associated w ith de novo acute m yeloid leukem ia w ith FLT3/ITD m utation. Am J Clin Pathol 139:624-629 P M ID 18358929 D ighiero G, H am blin TJ [2008] C hronic lym phocytic leukem ia. Lancet 371:1017-1029

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Selected readings>Additional jounal articles PM ID 18794054 C ioc AM , V a n d e rw e rf SM, Peterson BA et al [2008] R ituxim ab induced changes in hem atolym phoid tissues found at autopsy. Am J Clin Pathol 130:604-612 PM ID 18794056 Flanagan MB, S athanoori M, Surti U et al [2008] C ytogenetic abnorm alities detected by fluo re sce n ce in situ hybrid ization on paraffin em bedded chronic lym phocytic leukem ia/sm all lym phocytic lym phom a lym phoid tissue biopsy specim ens. Am J Clin Pathol 130:620-627 P M ID 18794057 Bovio IM, A llan R W [2008] The expression of m yeloid antigens C D 13 and/or C D 33 is a m arker o f ALK+ anaplastic large cell lym phom as. Am J Clin Pathol 130:628-634 PM ID 18812465 Sanz MA, G rim w ade D, Tallm an M S [2009] M anagem ent o f acute prom yelocytic leukem ia: recom m endations from an expert panel on b e half o f the E uropean Leukem ia Net. Blood 113:1875-1891 P M ID 18854277 Keren DF, H edstrom D, G ulbranson R et al [2008] C om parison o f S ebia C apillaryS capillary e lectrophore sis w ith the Prim us high pressure liquid chrom atography in the evaluation o f hem oglobinopathies. Am J Clin Pathol 130:824-831 PM ID 18945964 M ontesinos P, Bergua JM, V ellenga E [2009] D ifferentiation syndrom e in patients w ith acute prom yelocytic leukem ia treated w ith a\\-trans retinoic acid and anthracycline chem otherapy: characteristics, outcom e, and prognostic factors. Blood 113:775-783 PM ID 18976014 R oden AC , M orice W G , H anson C A [2008] Im m unophenotypic attributes o f benign peripheral blood y5 T cells and conditions associated w ith their increase. Arch Pathol Lab M ed 132:1774-1780 P M ID 19036113 S chaa r CG, LeC essie S, S n ijd e r S et al [2008] Long term follow up o f a population based cohort w ith m onoclonal porteinaem ia. Brit J H aem 144:176-184 P M ID 19095561 A l-M aw ali A, G illis D, Lew is I [2009] T he role of m ultiparam eter flo w cytom etry fo r detection o f m inim al residual disease in acute m yeloid leukem ia. Am J Clin Pathol 131:16-26 PM ID 19103851 M osca A, Paleari R, Ivaldi G et al [2009] The role o f haem oglobin A 2 testing in the diagnosis o f thalassaem ias and related haem oglobinopathies. J Clin Pathol 62:13-17 P M ID 19136929 S chraders M, O eschger S, Kluin PM et al [2009] H yperm utation in m antle cell lym phom a does not indicate a clin ical or biological subentity. Mod Path 22:416-425 P M ID 19195968 H errera G [2009] R enal lesions associated w ith plasm a cell dyscrasias: practical approach to diagnosis, new concepts, and challenges. Arch Pathol Lab M ed 133:249-267 P M ID 19195976 K enney B, Stack G [2009] Drug induced th rom bocy topenia. Arch Pathol Lab M ed 133:309-314 P M ID 19289595 Dong HY, W eisberger J, Liu Z et al [2009] Im m unophenotypic analysis o f C D 103+ B lym phoproliferative disorders: hairy cell leukem ia and its m im ics. Am J Clin Pathol 131:586-595 P M ID 19393983 Tsaras G, O w usu-A nsah A, B oateng FO et al [2009] C om plications associated w ith sickle cell trait: a brief narrative review. Am J M ed 122:507-512 P M ID 1947802 6 O ’Keefe EK, R hodes MM, W ood w orth A [2009] A patient w ith previous diagnosis o f hem oglobin S/C disease w ith an unusually severe disease course. Clin Chem 55(6): 1228-1233 P M ID 19762534 Sutherland DR, Kuek N, A zcona-O livera J et al [2009] Use o f a FLA E R based W B C assay in the prim ary screening o f PNH clones. Am J Clin Pathol 132:564-572 P M ID 19864232 Salam a M, Lossos IS, W arnke RA et al [2009] Im m unoarchitectural patterns in nodal m arginal zone B cell lym phom a: a study o f 51 cases. Am J Clin Pathol 132:39-49

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P M ID 1 992658 7 S e e g m ille r AC, Kroft SH , K a ra n d ika r NJ e t al [2009] C h aracterization o f im m unophenotypic a b e rra n cie s in 200 cases o f B acute lym p h o b la stic leukem ia. Am J Clin Pathol 132:940 -949 P M ID 19958891 S aadoun D, Elalam y I, G hillani-D albin P et al [2009] C ryo fibrino genem ia: new insights into clinical and p a th o g e n ic features. Am J M ed 122:1128-1135 P M ID 204212 72 G ine E, M artinez A, V illa m o r N et al [2010] Expanded and highly active proliferation centers identify a histo logic su b typ e o f ch ro n ic lym phocytic le u ke m ia (“a cce le ra te d ” chronic lym phocytic leukem ia) w ith aggressive clinical behavior. Hematologica 9 5 (9 ):1 526-33 P M ID 20551270 S hetty S, Kulkarni B, Pai N et al [2010] JA K 2 m u ta tio n s across a spectrum o f venous th ro m b o sis cases. A m J Clin Pathol 134:82-85 P M ID 205512 77 K elem en K, Braziel RM , G a tte r K et al [2010] Im m unophe notypic variations of B u rkitt lym phom a. A m J Clin Pathol 134:127-138 P M ID 205512 78 Tatsas AD , Jagasia M H, C hen H et al [2010] M onitoring residual m yelom a: high resolution seru m /u rin e e le ctro phoresis or m arrow biopsy with im m u n o h isto ch e m ical analysis? Am J Clin Pathol 134:139-145 P M ID 208070 44 Z uo Z, Polski JM, K a syan A, M edeios J [2010] A cute erythroid leukem ia. Arch Pathol Lab M ed 13 4:126 1-1270 P M ID 214871 09 S a laverria I, Philipp C, O sch lie s I et al [2011] T ranslocations activating IRF4 identify a subtype o f germ inal ce n te r derived B cell lym phom a affecting p re d o m in an tly children and young adults. Blood 7; 118(1): 139-47 P M ID 216634 70 Tiacci E, Trifonov V, S ch ia vo n i G et al [2011] B R A F m utations in hairy cell leukem ia. N Engl J M ed 3 6 4 (2 4 ):2 3 0 5 -1 5 P M ID 22055020 B olton-M aggs PH, L a nger JC, lolascon A et al [2012] G uidelines fo r the diagnosis and m a nagem en t o f he re d i ta ry spherocytosis— 2011 update. B r J H em atol 1 5 6(1):37-49 PM ID 2236481 P agliuca A, M ufti GJ, J a nossa-T ahernia M et al [1990] In vitro colony culture and chrom osom al studies in h epatic and portal vein throm bosis: possible e vid e n ce o f an o ccu lt m ye lo proliferative state. Q J M ed 76(281 ):981 -989 PM ID 2310281 Tajiri J, N oguchi S, M urakam i T et al [1990] A ntithyroid drug induced agranulocytosis: the usefulness o f routine w hite blood cell count m onitoring. Arch Intern M ed 150:621-624 PM ID 2458161 International A g ranulocytosis and A p la stic A n a e m ia S tudy [1998] R isk o f agranulocytosis and aplastic an a e m ia in relation to use o f antithyroid drugs. B M J 2 9 7 :265 1-2665 P M ID 25207766 R oberts KG, Li Y, P a yne -T urner D et al [2014] T arge table kinase-activa ting lesions in P h like acute lym p h o b la stic leukem ia. N Engl J M ed 11 ;371 (11): 1005-15 P M ID 25713417 M enter T, D irnhofer S, T za n ko v A [2015] L E F T a highly specific m arker fo r the diagnosis o f chronic lym p h o cytic B cell leukem ia/sm all lym phocytic B cell lym phom a. J Clin Pathol 68(6):473-8 P M ID 258192 28 S chm idt J, Federm ann B, S ch in d le r N et al [2015] M Y D 88 L265P and C X C R 4 m utations in ly m phopla sm acytic lym phom a identify cases w ith high disease activity. B r J H em atol 169(6):795-803 P M ID 264215 20 C lark S ch n e id e r KM, B a nks PM , C ollie A M et al [2016] Dual expression o f M YC and bcl2 proteins predicts w o rse outcom es in diffuse large B cell lym phom a. Leuk Lymphoma 57(7): 1640-8 P M ID 273544 06 C linton A, M cM ullin M F [2016] T he C alreticulin gene and m yeloproliferative neoplasm s. J Clin Pathol 69(1 0 ):8 4 1 -5 PM ID 4026081 V alla D, C asadevall N, Lacom be C et al [1985] P rim ary m yeloproliferative disorder and hepatic vein throm bosis:

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Selected readings>Additional jounal articles a p ro s p e c tiv e stu d y o f e ryth ro id c o lo n y fo rm a tio n in vitro in 20 p a tie n ts w ith B u d d -C h ia ri syn d ro m e . Ann Int M e d 1 03(3):329-334 P M ID 6 1 7 9 6 7 7 S c o tt JR, W a re n ski JC [1982] T e sts to d e te ct and q u a n tita te fe to m a te rn a l b leeding. Clin O bstet Gynecol 25(2):2772 82 P M ID 6 6 8 7 3 4 5 C o o p e r DS, G o ld m in z D, Levin A A et al [1983] A g ra n u lo c yto sis associa ted w ith antithyroid drug: effects o f p a tie n t a g e and drug dose. Ann Intern M e d 98:26-29 P M ID 7 2 3 7 3 8 5 B inet JL, A u g u ie r A, D ighiero G e t al [1981] A new p ro g n o stic cla ssifica tio n o f C LL derived from a m ultiva ria te su rviva l a n a lysis. C ancer 4 8 :1 9 8 -2 0 6 P M ID 7 6 8 8 9 9 3 R obbins BA, E llison DJ, S p inosa JC et al [1993] D ia g n o stic a p p lica tio n o f 2 -c o lo r flo w cy to m e try in 161 cases o f h a iry cell le u ke m ia. Blood 8 2 :1 2 7 7 -1 2 8 7 P M ID 7 8 0 6 0 8 8 M a u ro FR, D eR ossi G, B u rgio V L e t al [1994] P ro g n o s tic v a lu e o f bon e m a rro w h isto lo g y in C LL: a study o f 335 u n tre a te d case s fro m a sin g le institutio n. Hem atologica 7 9:334341 P M ID 8 08099 1 H ohlfield P, F o re s tie r F, K a plan C e t al [1994] Fetal th ro m b o c y to p e n ia : a re tro sp e ctive s u rve y o f 5194 fetal blood sa m p lin g s . Blood 84(6): 1851-1 856 P M ID 8 1 6 7 3 4 3 H ag la n d U, J u liu sso n G, S te llan B et al [1994] H airy cell le u ke m ia is ch a ra cte rize d by clonal ch ro m o s o m e a b n o rm a li tie s c lu ste re d to sp e c ific regions. Blood 83: 2 6 3 7 -2 6 4 5 P M ID 8 4 1 2 3 5 5 H oye r JD [1993] Leu ko cyte differential. M ayo Clin Proc 6 8 :1 0 2 7 -1 0 2 8 P M ID 8 41725 1 K yle R A [1 9 9 3 ] “B e n ig n ” m o n o clo n a l g a m m o p a th y— a fte r 20 35 y e a rs fo llo w up. M ayo Clin Proc 68:26-36 P M ID 8 41725 1 K yle RA, T h e rn e a u TM , R a jku m a r S V et al [2002] A long term stu d y o f p ro g n o sis in m o n o clo n a l g a m m o p a th y o f unde te rm in e d sig n ifica n ce . N ew Engl J M e d 2 4 6 :5 6 4 -5 6 9 P M ID 8 4 7 1 7 6 0 S h a stri KA, Lo g u e G L [1993] A u to im m u n e ne u tro penia. Blood 81 (8): 1 9 84-1 995 P M ID 8 4 9 9 0 0 3 E m ile C, D anon F, F erm an d JP et al [1993] C a stle m a n d ise a se in P O E M S s y n d ro m e w ith e levated inter le u kin -6 . C ancer 71 (3):87 4 P M ID 8 4 9 9 6 2 2 O gaw a M [1993] D iffe re n tia tio n and proliferation o f h e m a to p o ie tic ste m cells. Blood 8 1 :2 8 4 4 -2 8 5 3 P M ID 8 7 5 7 5 3 6 B ain BJ [1996] T he bone m a rro w aspirate o f healthy su b je cts. B r J H em atol 94:2 0 6 -2 0 9 P M ID 9 2 5 5 2 5 7 D orfm an DM , S h a h sa fa e i A, C han JK et al [1997] T h y m ic ca rcin o m a s, but not th y m o m a s and c a rcin o m a s o f other sites, s h o w C D 5 im m u n o re a ctivity. Am J Surg Pathol 21(8):936940 P M ID 9 6 0 3 7 9 8 R o th en be rg M E [1998] E o sinophilia. N Engl J M ed 3 3 8 :1 5 9 2 -1 6 0 0 P M ID 9 7 1 8 3 5 4 C a re lla M, S te w a rt G, A je tu n m o b i JF et al [1998] G e n o m e w id e search fo r d e h yd ra te d h e re d ita ry sto m a to cyto sis (h e re d ita ry xe ro cyto sis): m a pping o f locus to ch ro m o so m e 16 (1 6 q 2 3 -q te r). A m J Hum G enet 6 3 :8 1 0 -8 1 6 P M ID 9 7 7 7 9 8 8 K raus M D, B a rtle tt NL, Flem ing M D e t al [1998] S p le n ic p a th o lo g y in m y e lo d ysp la sia : a re p o rt o f 13 cases w ith clin ica l c o rre la tio n. A m J Surg Pathol 2 2 (1 0 ):1 2 5 5-12 66 P M ID 9 7 8 8 9 6 4 Fais F, G hiotto F, H a sh im o to S et al [1998] C LL B ce lls e x p re ss restricted sets o f m utated and u nm u ta te d antigen recepto rs. J Clin Invest 102:151 5-1525 P M ID 9 8 0 2 3 4 2 T w o re k JA, S in gleton TP, S ch n itz e r B et al [1998] F low c y to m e tric and im m u n o h isto ch e m ica l a na lysis o f sm all ly m p h o c ytic lym p ho m a , m antle cell lym ph om a, and plasm acytoid s m a ll lym p h o c ytic lym p h o m a . Am J Clin Pathol 110:582-589 C a ra w a y NP, S te w a rt J [2006] P rim a ry e ffusion lym phom a. Pathol C ase R e v 11:78-84

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C o ag u latio n 5.1 Hemostasis.....................................................................................274 5.1.1 N orm al he m o s ta s is o c cu rs in 3 s t e p s .....................................................274

5.2 Laboratory evaluation of hemostasis..........................................275 5.2.1 L a b o ra to ry e v a lu a tio n o f p la te le ts ............................................................ 275 5.2.2 L a b o ra to ry e v a lu a tio n o f c o a g u la tio n ....................................................... 276

5.3 Excessive bleeding (hemophilia).................................................. 278 5.3.1 L a b o ra to ry e v a lu a tio n ................................................................................... 278 5.3 .2 P la te le t d is o rd e rs ............................................................................................. 280 5 .3 .3 C o a g u la tio n d e fe c ts ........................................................................................ 283 5 .3 .4 N o n h e m o sta tic c a u se s o f e xce s sive b le e d in g ..................................... 285

5.4 Thrombosis & thrombophilia........................................................285 5.4.1 C lin ica l c o n s id e ra tio n s ................................................................................... 285 5.4 .2 S pe c ific c a u se s o f th ro m b o p h ilia ...............................................................285

5.5 Therapeutic agents & monitoring................................................ 288 5.5.1 A n tic o a g u la n ts .................................................................................................. 288 5 .5 .2 A n tip la te le t a g e n ts ...........................................................................................289

5.6 Selected readings...........................................................................290 5.6.1

B o o k s ...................................................................................................................290

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H e m o s ta s is > N o r m a l h e m o s ta s is o c c u r s in 3 s te p s

5.1 Hemostasis

■ P la te le ts a re a n u c le a te c e lls c o n s is tin g o f □ C y to s k e le to n

5.1.1 Normal hemostasis occurs in 3 steps

□ C y to p la s m ic g ra n u le s a re o f 2 ty p e s

5.1.1.1 Primary hemostasis

■ P la te le t a g ra n u le s c o n ta in p ro te in s s u c h as fib rin o g e n , p la te le t d e riv e d g ro w th fa c to r (P D G F ), vW F, P -s e le c tin , and p la te le t fa c to r 4 (P F4)

■ D is ru p tio n o f e n d o th e lia l c e lls in itia te s h e m o s ta s is ■ H e m o s ta s is c o n s is ts o f v a s c u la r c o n tra c tio n , p la te le t a c tiv a tio n , a n d fo rm a tio n o f th ro m b u s

■ P la te le t d e n s e b o d ie s c o n ta in n o n p ro te in m o le c u le s su ch a s A D P , a d e n o s in e trip h o s p h a te (ATP), s e ro to n in (5 H T ), a n d c a lc iu m

5.1.1.2 Contribution of the blood vessel

□ C e ll m e m b ra n e . P la te le ts b e a r a lim ite d n u m b e r o f ce ll s u rfa c e p ro te in s t5.1

■ V a s o c o n s tric tio n is m e d ia te d b y v a s c u la r s m o o th m u s c le in re s p o n s e to lo c a l c y to k in e s ■ D is o rd e rs in th is s te p c a n re s u lt in a b n o rm a l b le e d in g , s u c h a s in h e re d ita ry h e m o rrh a g ic te la n g ie c ta s ia (O s le r-W e b e r-R e n d u ) o r a b n o rm a l v a s c u la r c o lla g e n (E h lo rs -D a n lo s S y n d ro m e ) ■ C lin ic a lly , v a s c u la r d is o rd e rs re s e m b le p la te le t ty p e b le e d in g

5.1.1.3 Platelet activation ■ A c tiv a tio n is s tim u la te d b y a g o n is ts □ v o n W ille b ra n d fa c to r (v W F ) □ C o lla g e n

■ P la te le ts a re n o rm a lly s m a lle r th a n red b lo o d c e lls w ith m ea n p la te le t v o lu m e (M P V ) a b o u t 10 fL ; size te n d s to v a ry in v e rs e ly w ith th e p la te le t c o u n t t5 .1

Platelet cell surface

Antigen

Notes GPIb/XI/V complex (CD42) receptor for vWF a2bp3 (GPIIb/llla) complex rintegrin receptor for RGD complex, mostly fibrinogen (CD41 &CD61) Platelet antigens PLA1 & PLA2are epitopes in GPIIIa GPIIb is basis for antigens baka & bakb GPVI; o 2P1 (GPIalla) collagen receptors a2p1 is BrV Brb antigen

□ T h ro m b in

GPIc/lla complex red cell antigens ABO, P, I, i & Le class I MHC antigens IgG & coagulation factors

□ T h ro m b o x a n e A 2 (T X A 2 )

M H C = m ajor histocom patibility com plex; vW F = von W illebrand factor

□ E p in e p h rin e □ A d e n o s in e d ip h o s p h a te (A D P )

fibronectin receptor no Rh antigens no class II antigens passively adsorbed onto platelet surface

■ A c tiv a tio n h a s a trip h a s ic re s p o n s e □ A d h e s io n (a tta c h m e n t to a s u rfa c e ) is m e d ia te d by ■ T h e G P Ib -X I-V c o m p le x o n th e s u rfa c e o f th e p la te le t, w h ic h is th e re c e p to r fo r v W F ■ G P V I and re c e p to rs o n th e s u rfa c e o f th e p la te le t, th e re c e p to r fo r c o lla g e n ■ T h e s e a g o n is ts , v W F a n d c o lla g e n , a re e x p o s e d on th e s u b e n d o th e lia l b a s e m e n t m e m b ra n e ■ T h e re c e p to r G P Ib -X I-V is a c tiv a te d b y s h e a r fo rc e s in v iv o a n d b y ris to c e tin in v itro □ D e g ra n u la tio n (s e c re tio n ) c o n s is ts o f

■ F ibrin fo rm a tio n is m e d ia te d by th e c o a g u la tio n c a s c a d e

f5.1, t5.2 ■ E x trin s ic p a th w a y □ In itia te d by tis s u e fa c to r □ F a c to r V ila is th e “te n a s e ” o f th e e x trin s ic p a th w a y ■ In trin s ic p a th w a y □ C a lc iu m a nd p h o s p h o lip id s a re re q u ire d in m u ltip le ste p s

■ R e le a s e o f a g ra n u le s a n d d e n s e b o d ie s

□ In itia te d by n e g a tiv e ly c h a rg e d s u rfa c e

■ S y n th e s is a n d re le a s e o f T X A 2

□ T h e “te n a s e ” is a c o m p le x c o n s is tin g o f c a lc iu m , V illa , IXa on th e s u rfa c e o f p la te le ts

■ D e g ra n u la tio n is s tim u la te d b y a n y o f th e p la te le t a g o n is ts □ A g g re g a tio n (a tta c h m e n t to o th e r p la te le ts ) is m e d ia te d by ■ T h e a 2bP3 (G P IIb /llla ) re c e p to r on th e s u rfa c e o f th e p la te le t a n d fib rin o g e n ■ F ib rin o g e n c a n c ro s s lin k 2 p la te le ts v ia th e ir re s p e c tiv e G P IIb /llla re c e p to rs

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5.1.1.4 Plasma coagulation (fibrin formation)

■ C o m m o n p a th w a y □ In itia te d by a c tiv a tio n o f fa c to r X to fa c to r X a □ R e s u lts in p ro d u c tio n o f a c tiv a c te d fa c to r II (lla o r th ro m b in ) □ T h ro m b in c o n v e rts fib rin o g e n to fib rin m o n o m e r (la); fib rin m o n o m e rs th e n p o ly m e riz e e nd to end and a s s o c ia te n o n c o va le n tly , u ltim a te ly c ro s s lin k e d c o v a le n tly by fa c to r X III

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5: Coagulation

Hemostasis>Norinal hemostasis occurs in 3 steps Laboratory evaluation of hemostasis>Laboratory evaluation of platelets 5.1.1.6 Fibrinolysis ■ P la s m in is th e p rim a ry a g e n t o f fib rin d e g ra d a tio n ■ T is s u e p la s m in o g e n a c tiv a to r (tP A ) a n d u ro k in a s e c o n v e rt p la s m in o g e n to p la s m in

5.2 Laboratory evaluation of hemostasis 5.2.1 Laboratory evaluation of platelets 5.2.1.1 The bleeding time ■ P ro p o s e d a s a te s t o f p la te le t fu n c tio n , th o u g h d e p e n d e n t u p o n v a s c u la r fu n c tio n a s w e ll ■ P ro lo n g e d in p a tie n ts w ith p la te le t d e fe c ts , s u c h a s vo n W ille b ra n d ’s d is e a s e , a n d v a s c u la r d e fe c ts , s u c h a s O s le r-W e b e r-R e n d u ■ H igh in te ro b s e rv e r v a ria b ility a nd in tra in d iv id u a l v a ria b ility ■ N ot co nside re d a reliable p re d icto r o f p e rio p e ra tive b le e ding f5.1 The clotting cascades. The intrinsic cascade (left) is thought to have a minor in vivo significance. The extrinsic pathway (right) is initiated upon vascular injury, which leads to exposure of tissue factor (TF, factor III). There is thought to be a biologically significant interrelation of the extrinsic & intrinsic pathways, mediated by (1) factor Vila crossing over & activating factor IX and (2) factor Vila activating thrombin, which in fact drives the intrinsic pathway. PK & HMWK were once thought to activate the intrinsic pathway, but their biologic significance is now unclear.

t5.2 Coagulation factors

Factor *

Other names

Vitamin K Where dependent produced

fibrinogen prothrombin + labile factor stable factor + antihemophilic factor Christmas + IX factor Stuart-Prower + X factor partial throm- XI boplastin anticedent Hagemann XII factor fibrin stabiliz- XIII ing factor von WillebrandvWF factor Prekallikrein Fletcher factor Fitzgerald high molecular factor weight kininogen

I II V VII VIII

100-150 liver 50-80 liver 24 liver 6 liver liver (Kiipffer cells) 12

30 30 20 20 30

■ W h o le b lo o d is a s p ira te d th ro u g h a n a p e rtu re th a t is c o v e re d b y a th in m e m b ra n e ■ T h e re a re 2 ty p e s o f m e m b ra n e , o n e th a t is im p re g n a te d w ith c o lla g e n a n d e p in e p h rin e (C o l/E p i), a n d th e o th e r w ith c o lla g e n and A D P (C o l/A D P ) ■ T im e u ntil c lo t o c c lu d e s th e a p e rtu re ( ‘c lo s u re tim e ’) is p ro lo n g e d if p la te le ts a re d e fe c tiv e ■ T e s tin g w ith th e C o l/E p i c a rtrid g e is m o s t s e n s itiv e to d ru g in d u c e d p la te le t d e fe c ts (a s p irin a n d a s p irin lik e a g e n ts), w h ile in trin s ic p la te le t d e fe c ts te n d to p ro lo n g c lo s u re w ith b o th ty p e s o f m e m b ra n e ■ C lo s u re tim e is d e p e n d e n t n o t o n ly o n p la te le t fu n c tio n b u t a ls o on p la te le t n u m b e r a n d h e m a to c rit

5.2.1.3 Platelet aggregometry liver

24

30

liver

25-60

20

liver

40-80

20

liver

50-70

Laboratory evaluation of platelets | Laboratory evaluation of coagulation t5.3 Causes of prolonged aPTT Protime Etiology deficiencies of factors XII, normal XI, IX, VIII, prekallikrein, high molecular weight kininogen deficiencies of factors X, prolonged V, II normal or prolonged lupus anticoagulant (PTT>PT) normal antifactor VIII antibody

T

normal normal

d o e s n o t c orrect w ith m ix in g

abnormal PT or PTT / I \ c o rre cts w ith m ix in g

specific factor assays LAC assay

t5.4 Interpretation of screening coagulation tests Clinical considerations PT aPTT Likely factors involved liver disease factor VII normal T

T

T

specific factor assays

antifactor VIII antibody assay usually normal (PTT>PT) heparin neutralization heparin procedure history prolonged hirudin D-dimer disseminated intravascular prolonged (PT>PTT) coagulation history, liver function tests prolonged (PT>PTT) liver disease assays for II, VII, IX, X prolonged (PT>PTT) vitamin K deficiency/ coumadin NOAC assay novel oral anticoagulant prolonged (NOAC)

normal T

inhibitor or heparin (check throm bin time)

Additional tests

vitamin K deficiency warfarin inherited factor deficiency acquired inhibitors heparin lupus anticoagulant inherited factor deficiency

factor VIII factor IX factor XI factor XII Fitzgerald factor (high molecular weight kininogen) Fletcher factor (prekallikrein) LAC disseminated intravascular factor V coagulation factor X heparin fibrinogen amyloidosis (acquired factor X LAC deficiency) liver disease prematurity (neonate) polycythemia inherited factor deficiency bleeding (with XIII) XIII normal or thrombophilic (with LAC lupus anticoaqulant)

□ W h e n th e h e m a to c rit is h ig h , th e v o lu m e o f p la s m a is p ro p o rtio n a te ly re d u c e d ; th e s a m p le w ill be o v e ra n tic o a g u la te d , a n d th e c lo ttin g tim e m a y be a rtific ia lly p ro lo n g e d □ U n d e rfillin g re s u lts in o v e ra n tic o a g u la tio n and in a p p ro p ria te ly p ro lo n g e d c lo ttin g tim e s , a nd o v e rfillin g d o e s th e o p p o s ite

f5.3 Algorithm for evaluation of prolonged clotting times

t5.5 Sources of error in aPTT aPTT may overestimate the degree of anticoagulation (be inappropriately prolonged)

monitoring of anticoagulation aPTT may underestimate the degree of anticoagulation (be inappropriately shortened)

antiphospholipid syndrome liver disease inherited factor deficiencies disseminated intravascular coagulation low volume blood draw polycythemia

postthrombosis acute phase reaction pregnancy AT deficiency renal disease (acquired ATIII deficiency) congenitally high factor VIII marked anemia

Check

Check

lupus anticoagulant factor levels D-dimer

AT levels factor VIII levels

a P T T = a ctiva te d p a rtia l throm boplastin tim e; A T = antithrom bin

□ C o a g u la tio n te s ts a re re lia b le w ith in 9 0 % -1 1 0 % o f th e id e a l fillin g v o lu m e □ P la s m a s h o u ld b e k e p t c o o l u ntil te s tin g is c o m p le te d (to m in im iz e lo s s o f c o a g u la tio n fa c to rs ); if te s tin g w ill be d e la y e d >4 h o u rs, th e s p e c im e n s h o u ld be fro z e n □ N o rm a l n e o n a te s h ave lo n g e r a P T T th a n a d u lts

5.2.2.3 Heparin assay (antifactor Xa assay) □ C a n be u s e d to m o n ito r e ith e r u n fra c tio n a te d h e p a rin o r lo w m o le c u la r w e ig h t h e p a rin (L M W H ) □ U n lik e u n fra c tio n a te d h e p a rin , L M W H a n d d a n a p a ro id d o n o t re q u ire s tric t m o n ito rin g in m o s t p a tie n ts ; m a y b e re q u ire d in re na l fa ilu re , p re g n a n c y , e x tre m e s o f w e ig h t, a n d in n e o n a te s

5.2.2.4 Bethesda assay (coagulation factor inhibitor assay) ■ U se d to m e a s u re a n tib o d ie s a g a in s t c o a g u la tio n fa c to rs , m o s t c o m m o n ly a n tifa c to r V III a n tib o d ie s ■ P ro c e d u re

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ISBN 9 7 8 -0 8 9 1 8 9 -6 6 7 8

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5: Coagulation

Laboratory evaluation of hemostasis>Laboratory evaluation of coagulation Excessive bleeding (hemophilia)>Laboratory evaluation □ S e ria l d ilu tio n s o f p a tie n t p la s m a a re m a d e □ E a c h m ix e d 1:1 w ith n o rm a l p la s m a a n d a s s a y e d fo r fa c to r V III a c tiv ity □ T h e d ilu tio n a t w h ic h th e fa c to r V III a c tiv ity is 5 0 % re p re s e n ts th e in h ib ito r tite r □ T h e re s u lt is e x p re s s e d in B e th e s d a u n its (eg 1:16 d ilu tio n is e x p re s s e d a s 16 B e th e s d a u n its )

5.2.2.5 D-dim er & fibrin degradation products ■ F a c to r X III c o v a le n tly c ro s s lin k s fib rin b y lin k in g ‘ D ’ re g io n s o f th e fib rin m o le c u le ; w h e n fib rin is c le a v e d by p la s m in th e re s u lt is v a rio u s fib rin d e g ra d a tio n p ro d u c ts (F D P s ), in c lu d in g D -d im e rs ■ D -d im e rs a n d o th e r F D P s a re in c re a s e d in th e p re s e n c e o f th ro m b o s is , c o n s u m p tiv e c o a g u lo p a th y (d is s e m in a te d in tra v a s c u la r c o a g u la tio n [D IC ]) a n d s ig n ific a n t b le e d in g ■ D -d im e rs a n d o th e r F D P s m a y a ls o b e in c re a s e d in a tria l fib rilla tio n , c o n g e s tiv e h e a rt fa ilu re , a n d c irrh o s is ■ D - d im e r in th e d ia g n o s is o f v e n o u s th ro m b o e m b o lis m (V T E ) □ A n o rm a l D -d im e r m e a s u re d b y h ig h s e n s itiv ity a s s a y e x c lu d e s V T E in s e le c te d p a tie n ts □ D -d im e r a s s a y s a re m o s t u s e fu l in p a tie n ts w ith a lo w o r in te rm e d ia te c lin ic a l p ro b a b ility o f V T E , b a s e d on c lin ic a l p a ra m e te rs s u c h a s th e W e ll p re d ic tio n ru le s □ A p o s itiv e D -d im e r is re la tiv e ly n o n s p e c ific

5.2.2.6 Factor assays (II, V, VII, VIII, IX, X, XI, XII) ■ P a tie n t p la s m a is m ix e d w ith re a g e n t p la s m a h a v in g a k n o w n fa c to r d e fic ie n c y ■ T h e re s u ltin g c lo ttin g tim e is c o m p a re d to a s ta n d a rd c u rv e to d e riv e p e rc e n t a c tiv ity

re s u lt in p ro lo n g e d P T a nd a P T T . T h e T T a nd re p tila s e tim e are p ro lo n g e d a s w e ll. T h e c lo ttin g a s s a y s d e s c rib e d a b o v e a re fu n c tio n a l a s s a y s th a t q u a n tify th e to ta l c lo tta b le fib rin o g e n . F ib rin o g e n a n tig e n ca n be q u a n tifie d by im m u n o lo g ic te c h n iq u e s , m e a s u rin g th e to ta l a m o u n t o f fib rin o g e n p ro te in . T h e d is c re p a n c y o f th e to ta l fib rin o g e n p ro te in a n d th e to ta l c lo tta b le fib rin o g e n is u se d to id e n tify d y s fu n c tio n a l p ro te in (d y s fib rin o g e n e m ia )

5.2.2.8 Prothrombin time ■ A s o u rc e o f tis s u e fa c to r (tis s u e e x tra c t o r re c o m b in a n t TF), p h o s p h o lip id , a n d c a lc iu m a re a d d e d to c itra te d p la sm a. T h e tim e to c lo t fo rm a tio n is th e P T ■ P ro lo n g a tio n o f th e P T is c a u s e d by d e fic ie n c ie s o f fa c to rs V II, a s w e ll a s c o m m o n fa c to r d e fic ie n c ie s (X , V, II, o r fib rin o g e n ) a n d in h ib ito rs ■ T h e P T is u s e d to m o n ito r v ita m in K a n ta g o n is t th e ra p y ■ T h e IN R is m e a n t to re d u c e in te rla b o ra to ry v a ria tio n th a t re s u lts fro m d iffe rin g th ro m b o p la s tin s e n s itiv itie s to c o u m a d in ■ C h ro m o g e n ic fa c to r X a s s a y s a re u s e fu l fo r m o n ito rin g w a rfa rin in th e p re s e n c e o f an in h ib ito r su ch a s lu p u s a n tic o a g u la n t o r in th e p re s e n c e o f h iru d in o r a rg a tro b a n

5.2.2.9 Thrombin time (TT) ■ A lim itin g a m o u n t o f th ro m b in (0.1 U /m L) is a d d e d to p a tie n t p la s m a ; tim e to c lo t fo rm a tio n is th e T T ■ T T is p ro lo n g e d in th e p re s e n c e o f e ve n a v e ry lo w c o n c e n tra tio n o f h e p a rin , in th e p re s e n c e o f fib rin o g e n d e g ra d a tio n p ro d u c ts , in th e p re s e n c e o f a b n o rm a l fib rin o g e n s (eg, fe ta l fib rin o g e n in th e n e w b o rn o r in h e rite d and a c q u ire d d y s fib rin o g e n e m ia ), a n d w h e n th e re is s e v e re h y p o fib rin o g e n e m ia

■ F a c to r V III, IX, X I, a n d X II a s s a y s a re a P T T b a s e d ■ F a c to r II, V, V II, a n d X a s s a y s a re P T b a s e d

5.3 Excessive bleeding (hemophilia)

■ A n in h ib ito r is s u g g e s te d if s e ria l d ilu tio n s re s u lt in an a p p a re n t in c re a s e in fa c to r a c tiv ity

5.3.1 Laboratory evaluation f5.4

■ R e s u lts a re e x p re s s e d a s p e rc e n t a c tiv ity ; ‘n o rm a l’ p la s m a c o n ta in s 1 0 0 % a c tiv ity (1 U /m L ) ■ W ith th e e x c e p tio n o f fa c to r V III, all fa c to rs a re re la tiv e ly lo w in n e o n a te s , re a c h in g a d u lt le v e ls b y 6 m o n th s o f a g e

5.3.1.1 Clinical clues 5.3.1.1.1 P latelet typ e b leed in g , c o a g u latio n typ e b leed in g & n o n b le e d in g p atien ts w ith a b n o rm a l la b o ra to ry tests ■ P la te le t ty p e b le e d in g

5 .2 .2 7 Fibrinogen assay

□ P u rp u ra , e a s y b ru is in g a nd p e te c h ia e t5.6

T h e m o s t c o m m o n fib rin o g e n a s s a y (th e C la u s s a s s a y ) is s im ila r to th e T T (s e e b e lo w ). In th e C la u s s a s s a y , th e p a tie n t’s p la s m a is d ilu te d b e fo re th e a d d itio n o f e x c e s s th ro m b in . T h e lim itin g a m o u n t o f th e fib rin o g e n , th e lo n g e r th e c lo ttin g tim e , a n d w h e n c o m p a re d to a s ta n d a rd c u rv e , th e s p e c ific fib rin o g e n a c tiv ity c a n be d e te rm in e d . In a d d itio n to s p e c ific fib rin o g e n a s s a y s , d y s - a n d a fib rin o g e n e m ia

278

□ C a u s e d by th ro m b o c y to p e n ia , d e fe c tiv e p la te le t fu n c tio n , o r v W D □ S im ila r m a n ife s ta tio n s m ay be p ro d u c e d by v a s c u la r d is o rd e rs , in c lu d in g h e re d ita ry h e m o rrh a g ic te la n g ie c ta s ia (O s le r-W e b e r-R e n d u ) a nd v a s c u litis

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5: Coagulation

Excessive bleeding (hemophilia)>Laboratory evaluation

f5.4 Laboratory approach to the bleeding patient

t5.6 Clinical manifestations of bleeding disorders Findings

Coagulation type bleeding disorders

Platelet type bleeding disorders

petechiae hemarthroses deep hematomas delayed bleeding mucosal bleeding qender

rare common common common rare males>females

common rare rare rare common females>males

5 .3 .1 .1 .2 F a m ily h is t o r y ■ A p a tte rn o f X lin k e d in h e rita n c e is c o n s is te n t w ith h e m o p h ilia A a n d h e m o p h ilia B ■ A u to s o m a l in h e rita n c e is ty p ic a l o f v W D a n d all o th e r in h e rite d h e m o p h ilia s

□ T h e m o s t c o m m o n in h e rite d c a u s e o f p la te le t ty p e b le e d in g is v W D □ A c q u ire d d e fe c ts o u tn u m b e r in h e rite d o n e s and in c lu d e id io p a th ic th ro m b o c y to p e n ic p u rp u ra (U P ), a lc o h o l, a s p irin , p e n ic illin , u re m ia , D IC , a n d m y e lo p ro life ra tiv e n e o p la s m s ■ C o a g u la tio n ty p e b le e d in g □ D e e p s e a te d h e m o rrh a g e s , s u c h a s h e m a rth ro s is o r in tra m u s c u la r h e m a to m a □ R e s u lts fro m s in g le o r c o m b in e d c o a g u la tio n fa c to r d e fic ie n c y , e ith e r in h e rite d o r a c q u ire d ■ A b n o rm a l la b o ra to ry te s ts , m o s t c o m m o n ly p la te le t c o u n t, PT, o r a P T T □ D e te rm in e if th e re is a p e rs o n a l h is to ry o f a b n o rm a l b le e d in g □ R e p e a t th e te s t, ta k in g c a re to c o n tro l p re a n a ly tic v a ria b le s

© A S C P 2018

□ If th e te s t re m a in s a b n o rm a l, th e n fu rth e r a n a ly s is m a y b e in d ic a te d f5.3

■ A n e g a tiv e fa m ily h is to ry d o e s n o t e x c lu d e h e m o p h ilia , a s 2 0 % a re th e re s u lt o f new m u ta tio n s 5 .3.1.1.3 In fa n ts ■ O n s e t o f b le e d in g a fte r 1 to s e v e ra l w e e k s o f life s u g g e s ts v ita m in K d e fic ie n c y in c h ild re n w h o d id n o t re c e iv e p e rin a ta l v ita m in K s u p p le m e n ta tio n . P re n a ta l e x p o s u re to p h e n y to in o r p h e n o b a rb ita l m a y e n h a n c e v ita m in K d e fic ie n c y ■ U p p e r e x tre m ity d e fe c ts m ay s u g g e s t th e th ro m b o c y to p e n ia a b s e n t ra dii s y n d ro m e ■ In th e im m a tu re n e o n a ta l c o a g u la tio n s y s te m , o n ly fa c to rs V III, fib rin o g e n , and v W F c a n b e e x p e c te d to h ave n o rm a l a d u lt v a lu e s ; re p e a t te s tin g a fte r 6 m o n th s o f a g e m a y be n e c e s s a ry

5.3.1.2 Morphologic examination of platelets ■ U n e x p e c te d ly lo w p la te le t c o u n ts s h o u ld b e c o n firm e d by e x a m in a tio n o f a p e rip h e ra l s m e a r

ISBN 9 7 8 -0 8 9 1 8 9 -6 6 7 8

279

5: Coagulation

Excessive bleeding (hemophilia)>Laboratory evaluation | Platelet disorders □ P la te le t a g g re g a tio n (p la te le t-p la te le t b in d in g ) a n d /o r s a te llito s is (p la te le t-n e u tro p h il b in d in g ) a re c o m m o n c a u s e s o f p s e u d o th ro m b o c y to p e n ia ; m a rk e d ly e n la rg e d p la te le ts a re a n o th e r □ P la te le t a g g re g a tio n a n d s a te llito s is a re E D T A in d u c e d a rtifa c ts ; p a tie n ts o n a b c ix im a b h a v e b e e n n o te d to be e x c e p tio n a lly p ro n e to th is a rtifa c t

t5.8 Summ ary of platelet disorders Inherited Phase Mediators defects adhesion

release reaction

■ L o o k fo r s c h is to c y te s □ S c h is to c y te s p o in t to m ic ro a n g io p a th ic h e m o ly tic a n e m ia (M H A ), w ith a d iffe re n tia l d ia g n o s is o f D IC , T T P , H E L L P s y n d ro m e , a n d m e c h a n ic a l tra u m a (h e a rt v a lv e )

aggregation

Acquired defects

GPIb & von Bernard-Soulier paraproteinemia Willebrand factor syndrome; von Willebrand disease granules & agonists platelet release aspirin, NSAIDS defect; storage pool disease GPIIb/llla & Glanzmann dysfibrinogenemia fibrinogen thrombasthenia; dysfibrinoqenemia

■ N o te p la te le t s iz e □ In g e n e ra l, c o n s u m p tiv e p la te le t c o n d itio n s (h y p e rp ro life ra tiv e th ro m b o c y to p e n ia s ) a re a s s o c ia te d w ith h ig h e r M P V , a n d h y p o p ro life ra tiv e th ro m b o c y to p e n ia s a re n ot, w ith s o m e e x c e p tio n s t5.7

t5.7 G iant platelet disorders Bernard-Soulier syndrome (BSS) Mediterranean macrothrombocytopenia (mild form of BSS)___________________ May-Hegglin anomaly (giant platelets with Dohle bodies) Fechtner syndrome (giant platelets with hearing loss, cataracts & nephritis) Sebastian syndrome (giant platelets with leukocyte inclusions)________________ gray platelet syndrome Montreal platelet syndrome_____________________________________________

□ T h e M P V is th e a u to m a te d m e a s u re m e n t o f p la te le t s iz e ■ N o te c lu e s to th e u n c o m m o n c o n s titu tio n a l p la te le t d e fe c ts □ In v W D , p la te le ts u s u a lly a p p e a r n o rm a l; la rg e p la te le ts h a v e b e e n d e s c rib e d in ty p e 2B □ B e rn a rd S o u lie r S y n d ro m e a n d o th e rs a re a s s o c ia te d w ith g ia n t p la te le ts t5 .7 □ A g ra n u la r p la te le ts a re s e e n in g ra y p la te le t s y n d ro m e ; a g ra n u la r p la te le ts a re m o s t c o m m o n ly an a rtifa c t o f in v itro p la te le t d e g ra n u la tio n □ D o h le b o d ie s in le u k o c y te s m a y p o in t to M a y -H e g g lin a n o m a ly , F e c h tn e r s y n d ro m e , o r E p s te in s y n d ro m e □ W is k o tt-A ld ric h s y n d ro m e is c h a ra c te riz e d b y v e ry s m a ll p la te le ts

5.3.2 Platelet disorders t5.8

□ P la te le ts a g g re g a te w ith all a g o n is ts e x c e p t ris to c e tin , re s e m b lin g th e p a tte rn o f v W D □ U n lik e v W D , th e p e rip h e ra l s m e a r c o n ta in s la rg e p la te le ts □ U n lik e v W D , B S S fa ils to a g g re g a te e ve n in th e p re s e n c e o f n o rm a l p la s m a ■ In h e rita n c e □ A u to s o m a l re c e s s iv e ■ C a rrie r s ta te ca n m a n ife s t a s M e d ite rra n e a n m a c ro th ro m b o c y to p e n ia , a re la tiv e ly c o m m o n c a u s e o f m ild th ro m b o c y to p e n ia in s o u th e rn E u ro p e

5.3.2.2 Platelet storage pool disorders ■ In c lu d e s a b n o rm a litie s o f d e n s e g ra n u le s (H e rm a n s k y -P u d la k , C h e d ia k -H ig a s h i, W is k o tt-A ld ric h ) and a b n o rm a litie s o f a g ra n u le s (g ra y p la te le t s y n d ro m e , W h ite p la te le t s y n d ro m e , a n d Q u e b e c p la te le t s y n d ro m e ) ■ D e n se g ra n u le d is o rd e rs □ F irs t w a v e a g g re g a tio n is s e e n w ith all a g e n ts , b ut s e c o n d a ry a g g re g a tio n is b lu n te d ■ D e n se g ra n u le s e c re tio n , q u a n tifie d by A T P s e c re tio n u sin g c h e m ilu m in e s c e n c e , is m a rk e d ly d im in is h e d ■ D e n se g ra n u le s a re a b s e n t o n e le c tro n m ic ro s c o p y ■ H e rm a n s k y -P u d la k s y n d ro m e □ C o m m o n in P u e rto R ico □ P re s e n ts w ith e p is ta x is in c h ild h o o d , w ith o c u lo c u ta n e o u s a lb in is m □ P la te le t c o u n ts a re u s u a lly n o rm a l

5.3.2.1 Inherited platelet disorders

□ M a y b e a s s o c ia te d w ith p u lm o n a ry fib ro s is and g ra n u lo m a to u s c o litis

5 .3 .2 .1 .1 B e r n a r d - S o u lie r s y n d r o m e ■ C a u s e d b y d e c re a s e d p la te le t G P Ib /V /IX re c e p to r c o m p le x ■ G P Ib is th e re c e p to r fo r v W F ■ M a n ife s ts w ith th ro m b o c y to p e n ia a n d g ia n t p la te le ts

280

■ A g g re g o m e try

□ M a c ro p h a g e s c o n ta in c e ro id lik e in c lu s io n s □ C h e d ia k -H ig a s h i s y n d ro m e ■ C e ro id b o d ie s in g ra n u lo c y te s , p la te le ts , and m e la n o c y te s

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

5: Coagulation

Excessive bleeding (hemophilia)>Platelet disorders □ W is k o tt-A ld ric h s y n d ro m e

t5.9 Types of vWD

■ X lin ked re c e s s iv e

Type

R is to c e tin c o fa c to r (v W F :R c o )

vW F a n tig e n (v W F :A g )

R a tio vW F R co :A g

F a c to r R IP A V III a c tiv ity

P la te le t M u ltim e r count p a tte rn

1

1

1

Nl

|NI

|NI

Nl

2A

1

1

1

|NI

N l|

Nl

□ G ra y p la te le t s y n d ro m e is a re c e s s iv e ly in h e rite d m ild b le e d in g d is o rd e r

2B

l

1

N l|

|NI

i

□ T h e la c k o f p la te le t a g ra n u le s im p a rts a u n ifo rm p ale g ra y tin c to ria l q u a lity in W rig h t s ta in e d b lo o d film s

Pit type 1

1

Nl

Nl

|NI

Nl

1 |NI ||

fwith low dose t with low dose Nl N l| 1

■ T h ro m b o c y to p e n ia , e c z e m a , a n d im m u n o d e fic ie n c y □ P la te le ts a re s m a l a nd d e m o n s tra te d e c re a s e d a g g re g a tio n w ith A D P , e p in e p h rin e , a n d c o lla g e n □ D e fe c ts in th e W A S P g e n e ■ P la te le t a g ra n u le d is o rd e rs

■ P la te le ts fa il to e x p re s s C D 6 2 fo llo w in g s tim u la tio n by high d o s e th ro m b in , a nd E L IS A s h o w s a b n o rm a lly lo w PF4 ■ T h ro m b o c y to p e n ia is c o m m o n

5.3.2.3 Glanzmann thrombasthenia ■ D e fic ie n t p la te le t G P IIb /llla re c e p to r c o m p le x

1

normal dis tribution, all dimin ished | HMW multimers | HMW multimers | HMW multimers

Nl Nl Nl

normal normal 1 1 1 absent mul Nl || timers Ag = antigen; HMW = high molecular weight; vWF = von Willebrand factor 2N 2M 3

|NI

u

□ T yp e 1

■ G P IIb is th e re c e p to r fo r fib rin o g e n

■ M o s t c o m m o n , 7 0 % -8 0 % o f c a s e s

■ G P IIb /llla c o m p le x is re s p o n s ib le fo r th e PLA1 a n tig e n ; a ffe c te d p a tie n ts a re PLA1 n e g a tiv e

■ O v e ra ll a m ild q u a n tita tiv e d e fe c t in v W F

■ P la te le ts a re m o rp h o lo g ic a lly n o rm a l to s m a ll

■ N o rm a l P T a n d p la te le t c o u n t, n o rm a l to p ro lo n g e d a P T T a n d b le e d in g tim e

■ In a g g re g o m e try s tu d ie s , p la te le ts fa il to a g g re g a te w ith all a g o n is ts e x c e p t ris to c e tin

■ D e c re a s e d fa c to r V III, v W F a n tig e n , a n d v W F a c tiv ity

■ A b n o rm a l in v itro c lo t re tra c tio n te s t

■ T h e d e c re a s e s in th e s e 3 a n a ly te s a re “c o n c o rd a n t,” a n d th e ra tio o f v W F a c tiv ity to v W F a n tig e n a p p ro a c h e s 1:1

5.3.2.4 von Willebrand disease (vWD) ■ C a u s e s s im u lta n e o u s im p a irm e n t o f th e c o a g u la tio n c a s c a d e a nd p la te le t fu n c tio n

■ N o rm a l m u ltim e r p a tte rn □ T yp e 2 A

□ A m a jo r fu n c tio n o f v W F is to m a in ta in h ig h le v e ls o f c irc u la tin g fa c to r V III

■ S e c o n d m o s t c o m m o n , 10 % -1 5% o f c a s e s

□ A n o th e r m a jo r fu n c tio n is in th e fo rm a tio n o f p la te le t th ro m b i

■ N o rm a l PT, w h ile th e a P T T m a y be s lig h tly p ro lo n g e d

■ v W D is th e m o s t c o m m o n in h e rite d b le e d in g d ia th e s is o v e ra ll (h e m o p h ilia A is c o n s id e re d th e m o s t c o m m o n c a u s e o f s e v e re h e m o p h ilia )

■ M o d e ra te ly s e v e re b le e d in g d is o rd e r

■ N o rm a l to d e c re a s e d fa c to r V III a n d v W F a n tig e n , w ith d e c re a s e d v W F a c tiv ity ■ T h e re is “d is c o rd a n c e ,” w ith m a rk e d ly d e c re a s e d v W F a c tiv ity (ris to c e tin c o fa c to r a c tiv ity ) a n d n o rm a l to o n ly m ild ly d e c re a s e d fa c to r V III a n d v W F a n tig e n ; th e ra tio o f v W F a n tig e n to v W F a c tiv ity is u s u a lly < 0 .7

■ P h y s io lo g y □ v W F is s y n th e s is in e n d o th e lia l c e lls a nd m e g a k a ry o c y te s □ S to re d in W e ib e l-P a la d e b o d ie s o f e n d o th e lia l c e lls a nd a g ra n u le s o f m e g a k a ry o c y te s □ S e c re te d by e n d o th e lia l c e lls a lo n g th e b a s e m e n t m e m b ra n e □ S e c re te d into c irc u la tio n a s an u ltra la rg e m u ltim e rs □ B ro k e n d o w n in s e ru m by a p ro te a s e s u c h th a t it c irc u la te s a s v a ria b ly size d m u ltim e rs ■ T y p e s o f v W D t5.9 © A S C P 2018

■ A b s e n c e o f h ig h w e ig h t m u ltim e rs □ T yp e 2B ■ L ike 2 A , h a s d e c re a s e d h ig h m o le c u la r w e ig h t m u ltim e rs ■ E n h a n c e d ris to c e tin in d u c e d p la te le t a g g re g a tio n ■ D D A V P m a y c a u s e s e v e re th ro m b o c y to p e n ia a n d th ro m b o s is

ISBN 9 7 8 -0 8 9 1 8 9 -6 6 7 8

281

5: Coagulation

Excessive bleeding (hemophilia)>Platelet disorders ■ M o s t c a s e s a re th e re s u lt o f a “g a in o f fu n c tio n ” p o in t m u ta tio n in v W F g e n e a ffe c tin g th e G P 1 b b in d in g d o m a in ■ M u s t b e d is tin g u is h e d fro m p la te le t ty p e v W D ■ P la te le t ty p e v W D is c a u s e d b y m u ta tio n s in th e G P1b gene ■ L ik e ty p e 2 B , th e re is e n h a n c e d b in d in g o f v W F to G P 1 b □ Type 2M ■ L o s s o f fu n c tio n m u ta tio n s in th e v W F g e n e a ffe c tin g th e G P 1 b b in d in g d o m a in ■ M u ltim e r a n a ly s is a p p e a rs n o rm a l □ T y p e 2 N (N o rm a n d y ) ■ M u ta tio n s in th e w W F g e n e a ffe c tin g th e d o m a in th a t b in d s fa c to r V III ■ T h is re s u lts in lo w le v e ls o f c irc u la tin g fa c to r V III, m im ic k in g h e m o p h ilia A ■ C lin ic a l p ic tu re re s e m b le s m ild h e m o p h ilia A w ith th e e x c e p tio n o f a u to s o m a l p a tte rn o f in h e rita n c e

f5.5 Algorithm for suspected von Willebrand disease

□ T y p e III ■ S e v e re b le e d in g d is o rd e r ■ B o th v W F a n d fa c to r V III a re v e ry lo w □ P s e u d o , o r p la te le t ty p e , v W D ■ M im ic s s o m e o f th e la b o ra to ry fin d in g s o f ty p e 2 B ■ P la te le ts a g g re g a te if e x p o s e d to c ry o p re c ip ita te , w h ile in 2 B th e y d o n o t □ A c q u ire d v W D ■ R a re ly re p o rte d in a s s o c ia tio n w ith ly m p h o p ro life ra tiv e d is o rd e rs , a u to im m u n e d is e a s e , e s s e n tia l th ro m b o c y th e m ia , a n d a o rtic s te n o s is

5.3.2.4.1 Laborat ory diagnosis of vWD ■ L o w v W F a n tig e n a n d v W F a c tiv ity (is to c e tin c o fa c to r a c tiv ity ) m a k e th e d ia g n o s is o f th e m o s t c o m m o n fo rm s of vW D □ B lo o d g ro u p O h a s lo w e r v W F le v e ls th a n o th e r b lo o d g ro u p s □ V W F is in c re a s e d b y v ig o ro u s e x e rc is e , in fla m m a tio n , p re g n a n c y , a n d e s tro g e n th e ra p y □ N e w b o rn s h a v e h ig h e r v W F a c tiv ity ; v W D m a y n o t be d e te c ta b le u n til 1 y e a r o f a g e □ V W F le v e ls flu c tu a te d a y to d a y a n d in c re a s e w ith age ■ A p a n e l o f te s ts is n e e d e d fo r la b o ra to ry d ia g n o s is o f vW D □ R is to c e tin c o fa c to r (v W F a c tiv ity ), v W F a n tig e n , a nd fa c to r V III a c tiv ity f5.5

282

□ In d ic a to r o f a c u te in fla m m a tio n , s u c h a s th e CRP, p re g n a n c y te s t, a n d a b lo o d g ro u p s tu d y ■ In te rp re ta tio n s □ If v W F a n tig e n , v W F a c tivity , a n d fa c to r V III a re n o rm a l, th e n v W D is u n lik e ly th o u g h in s o m e in s ta n c e s re p e a t te s tin g a fte r an a p p ro p ria te in te rv a l s h o u ld be c o n s id e re d □ If all 3 te s ts a re re d u c e d m ild ly a nd p ro p o rtio n a te ly , m o s t lik e ly ty p e 1 v W D ■ T re a tm e n t is D D A V P (d e s m o p re s s in ) a s n e e d e d ; eg, fo r s u rg e ry □ If all 3 te s ts a re re d u c e d p ro fo u n d ly , m o s t lik e ly ty p e 3 vW D ■ T re a tm e n t by a d m in is tra tio n o f vW F, o fte n in th e fo rm o f fre s h fro z e n p la s m a o r c o m m e rc ia lly a v a ila b le c o n c e n tra te s , w ith o r w ith o u t A m ic a r □ W h e n v W D a c tiv ity is re d u c e d o u t o f p ro p o rtio n to v W F a n tig e n a n d fa c to r V III, it is m o s t c o n s is te n t w ith ty p e 2; m u ltim e r a n a ly s is a nd lo w d o s e ris to c e tin a g g re g a tio n a re n e c e s s a ry to fu rth e r e lu c id a te ■ T re a tm e n t fo r ty p e 2a o r 2 b is s im ila r to ty p e 3; D D A V P is c o n tra in d ic a te d in ty p e 2B □ W h e n fa c to r V III is re d u c e d o u t o f p ro p o rtio n to vW F, c o n s id e r h e m o p h ilia A , fe m a le h e m o p h ilia A ca rrie r, s p e c im e n d e g ra d a tio n (fa c to r V III is s ig n ific a n tly m o re lab ile ), o r ty p e 2N

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

5: Coagulation

Excessive bleeding (hemophilia)>Platelet disorders | Coagulation defects 5.3.2.5 Acquired platelet disorders

t5.10 Inherited factor deficiencies

5.3.2.5.1 Aspirin & NSAIDs ■ In h ib it c y c lo o x y g e n a s e ty p e 1 (C O X1), in v o lv e d in th e p ro d u c tio n o f th ro m b o x a n e A 2 (T X A 2 ); T X A 2 s tim u la te s d e n s e g ra n u le re le a s e a n d th e s e c o n d a ry w a v e o f a g g re g a tio n ■ T h e in h ib ito ry e ffe c t o f a s p irin p e rs is ts fo r th e life tim e o f th e p la te le t; th e e ffe c t o f o th e r N S A ID s is re v e rs ib le ■ T h e a s p irin e ffe c t is d e te c ta b le in a g g re g o m e try re s p o n s e s e p in e p h rin e , A D P , a ra c h id o n a te , lo w d o s e c o lla g e n , a n d lo w d o s e th ro m b in ; th e s e a re c o n s id e re d “w e a k ” a g o n is ts b e c a u s e , by th e m s e lv e s , th e y a re c a p a b le o f p ro d u c in g o n ly th e firs t w a v e o f a g g re g a tio n ; th e y d e p e n d on T X A 2 to g e n e ra te s e c o n d a ry w a v e

5.3.2.5.2 Platelet def ects in myeloprolif erative & myelodysplast ic disorders ■ T h ro m b o s is a nd le s s c o m m o n ly h e m o rrh a g e are c o m m o n in th e s e d is ro d e rs ■ H e p a tic ve in th ro m b o s is (B u d d -C h ia ri s y n d ro m e ) c o m m o n in p o ly c y th e m ia v e ra a n d e s s e n tia l th ro m b o c y th e m ia ■ A b n o rm a l a g g re g o m e try ; m o s t c o m m o n fin d in g is d e c re a s e d a g g re g a tio n and s e c re tio n in re s p o n s e to e p in e p h rin e , A D P , a n d /o r c o lla g e n

5.3.2.5.3 Uremia ■ C a u s e s p la te le t fu n c tio n im p a irm e n t ■ C lin ic a l e ffe c ts a re h e m o rrh a g e , o fte n in th e g a s tro in te s tin a l a nd g e n ito u rin a ry tra c ts

Deficiency

Prevalence

Chromosome

Inheritance

Bleeding

I (fibrinogen) II (prothrombin) V VII VIII IX X XI

1 in 1 million 1 in 2 million 1 in 1 million 1 in 500,000 1 in 10,000 1 in 30,000 1 in 1 million 1 in 1 million (higher in Ashkenazi Jews) 1 in 1 million 1 in 1 million

4 11 1 13 X X 13 4

AR AR AR AR XLR XLR AR AR

variable mild-moderate mild-moderate mild-severe mild-severe mild-severe mild-severe mild-severe

AR 5 6 (XIIIA) AR 1 (XIIIB) AR Combined t5.121 in 1 million 18q & others AR = autosomal recessive; XLR = X linked recessive XII XIII

none postoperative variable

t5 .1 1 Acquired factor deficiencies VIII

factor VIII inhibitors (autoantibodies) in patients with hemophilia A on factor replacement therapy ________ factor VIII inhibitors (autoantibodies) in nonhemophilia patients_____ IX factor IX inhibitors (autoantibodies) in hemophilia B patients on factor __________ replacement therapy______________________________________ X acquired factor X deficiency associated with light chain amyloidosis __________ (adsorption to amyloid)____________________________________ multiple disseminated intravascular coagulation extracorporeal membrane oxygenation fibrinolytic drugs liver disease warfarin neonatal or dietary vitamin K deficiency nephrotic syndrome (usually most pronounced loss of antithrombin, __________ therefore prothrombotic)___________________________________

■ D ia ly s is is th e tre a tm e n t o f c h o ic e ; tra n s fu s e d p la te le ts a c q u ire th e u re m ic a b n o rm a litie s o f in d ig e n o u s p la te le ts

5.3.2.5.4 Cardiopulmonary bypass ■ C a u s e s both th ro m b o c y to p e n ia and p la te le t d y s fu n c tio n

5.3.2.5.5 Paraproteinemia

■ D ia g n o s is

■ P la te le t d y s fu n c tio n p a rtic u la rly c o m m o n in Ig A a n d IgM p a ra p ro te in e m ia b u t m a y be s e e n w ith a n y c la s s

□ N o rm a l p la te le t c o u n t, PT a n d TT; p ro lo n g e d a P T T □ C o rre c ts c o m p le te ly in 1:1 m ix □ F a c to r a s s a y s d e m o n s tra te is o la te d d e fic ie n c y o f fa c to r V III

5.3.3 Coagulation defects t5.10, t5.11 5.3.3.1 Inherited factor deficiencies

■ F e m a le c a rrie rs □ H a v e a b o u t 5 0 % fa c to r V III a c tiv ity

5.3.3.1.1 Hemophilia A ■ M o s t c o m m o n fo rm o f in h e rite d s e v e re h e m o p h ilia ■ In h e rita n c e is X lin ked re c e s s iv e , b u t 2 0 % o f c a s e s are d u e to a n e w s p o n ta n e o u s m u ta tio n

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■ D e fin e d a s s e v e re w h e n s p o n ta n e o u s b le e d in g o c c u rs , w h e n fa c to r V III is Coagulation defects □ A s in g le in v e rs io n m u ta tio n o f in tro n 2 2 , th e ‘c o m m o n p a rtia l in v e rs io n ’, c a u s e s 4 0 -4 5 % o f c a s e s ■ T re a tm e n t □ F a c to r V III c o n c e n tra te , p a re n te ra l a d m in is tra tio n

5.3.3.1.4 Contact f actor def iciency (f actor XII, HMWK, prekallikrein) ■ M a rke d p ro lo n g a tio n o f th e a P T T w ith o u t c lin ic a l b le e d in g

□ H a lf-life is 8 -1 2 h o u rs □ D D A V P (d e s m o p re s s in ) c a n b e u s e d in m ild h e m o p h ilia c s . A m ic a r m a y b e u s e d a s a n a d ju n c t ■ A n tib o d ie s to fa c to r V III □ D e v e lo p in u p to 1 in 5 p a tie n ts w h o re c e iv e fa c to r V III re p la c e m e n t th e ra p y □ S tro n g e s t ris k fa c to r is a g e n o ty p e a s s o c ia te d w ith z e ro p ro d u c tio n o f fa c to r V III □ S u s p e c te d fa c to r V III in h ib ito r c a n b e c o n firm e d w ith a B e th e s d a in h ib ito r a s s a y ■ R a re ly fa c to r V III in h ib ito rs a ris e in n o n h e m o p h ilia c s □ In c id e n c e in c re a s e s w ith a g e

5.3.3.1.5 Inherited combined f actor def iciency ■ M u ta tio n s th a t a ffe c t in tra c e llu la r tra n s p o rt o r p o s ttra n s la tio n a l m o d ific a tio n o f m u ltip le c lo ttin g fa c to rs m ay c a u s e in h e rite d c o m b in e d d e fic ie n c y s ta te s t5.12 t5 .1 2 Familial combined factor deficiencies Type I II III IV V

D eficiencies V, VIII VII, IX II, VII, IX, X, c, s VII, VIII VIII, IX, XI

Gene LMAN1 (ERGIC53) unknown vitamin K carboxylase unknown unknown

□ P re s e n ts w ith s e v e re b le e d in g a n d p ro lo n g e d a P T T □ C h a ra c te ris tic a lly , th e in h ib ito r d is p la y s tim e dependence 5.3.3.1.2 Hemophilia B (Christmas disease) ■ C lin ic a lly in d is tin g u is h a b le fro m h e m o p h ilia A 5.3.3.1.3 Inherited deficiency of factors II, V, VII, X, or XI

5.3.3.2 Fibrinogen defects: afibrinogenemia, hypofibrinogenemia & dysfibrinogenemia ■ F ib rin o g e n a b n o rm a litie s m a y be c o n g e n ita l o r a c q u ire d , a nd in b oth in s ta n c e s m a y be q u a n tita tiv e (a fib rin o g e n e m ia , h y p o fib rin o g e n e m ia ) o r q u a lita tiv e (d y s fib rin o g e n e m ia ) ■ Q u a lita tiv e fib rin o g e n d e fe c ts (d y s fib rin o g e n e m ia ) m ay c a u s e e ith e r b le e d in g o r th ro m b o s is

■ A ll d is p la y a u to s o m a l re c e s s iv e in h e rita n c e

5.3.3.3 Acquired factor deficiencies

■ F a c to r V II d e fic ie n c y □ M o s t c o m m o n a u to s o m a l re c e s s iv e c o a g u la tio n fa c to r d e fic ie n c y

■ A c q u ire d fa c to r X d e fic ie n c y m a y be fo u n d in p a tie n ts w ith a m y lo id o s is

□ P o o r a s s o c ia tio n b e tw e e n fa c to r V II le v e ls a n d b le e d in g s e v e rity

■ L iv e r d is e a s e ca n re s u lt in m u ltip le fa c to r d e fic ie n c ie s , p a rtic u la rly e v id e n t in th e PT, a s w e ll as h y p o - and d y s fib rin o g e n e m ia

□ P ro lo n g e d PT. N o rm a l a P T T a n d T T

■ V ita m in K d e fic ie n c y

■ F a c to r V d e fic ie n c y □ T h e P T a n d a P T T a re p ro lo n g e d , a n d th e T T is n o rm a l ■ F a c to r X d e fic ie n c y □ P ro lo n g e d PT, a P T T , a n d D R V V T . N o rm a l T T ■ F a c to r XI d e fic ie n c y □ H ig h p re v a le n c e in A s h k e n a z i J e w s

□ Im p a ire d p ro d u c tio n o f fa c to rs II, V II, IX, a nd X, p ro te in C, a n d p ro te in S □ H e m o rrh a g ic d is e a s e o f th e n e w b o rn is a c o n g e n ita l fo rm o f v ita m in K d e fic ie n c y □ M ay re s u lt fro m th e p ro lo n g e d a n tib io tic s o r fro m in g e s tio n o f w a rfa rin o r w a rfa rin lik e c o m p o u n d s . S o m e s u c h a g e n ts a re p re s e n t in p e s tic id e s

□ M a y b e a fin d in g in N o o n a n s y n d ro m e

5.3.3.4 Disseminated intravascular coagulation

■ F a c to r X III d e fic ie n c y □ H e te ro z y g o te s c a n h a v e m ild b le e d in g s y m p to m s ; p a rtic u la rly d e la y e d b le e d in g , u m b ilic a l s tu m p b le e d in g , fre q u e n t m is c a rria g e s , d e la y e d w o u n d h e a lin g , a n d h y p o tro p h ic s c a rs □ H o m o z y g o u s fa c to r X III d e fic ie n c y is a s s o c ia te d w ith e s s e n tia lly n o rm a l PT, a P T T , TT, a n d a s e v e re b le e d in g d ia th e s is

284

■ T h e fo rm a tio n o f w id e s p re a d m ic ro v a s c u la r th ro m b i s tim u la te d by a c irc u la tin g s u b s ta n c e c a p a b le o f b e h a v in g like tis s u e fa c to r ■ T h e fib rin o ly tic s y s te m re s p o n d s by d e g ra d in g n e w ly fo rm e d fib rin ■ C o n s u m p tio n o f c o a g u la tio n fa c to rs

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5: Coagulation

Excessive bleeding (hemophilia)>Coagulation defects | Nonhemostatic causes of excessive bleeding Thrombosis & thrombophilia>Clinical considerations | Specific causes of thrombophilia ■ M a y p ro d u c e e x c e s s b le e d in g a nd th ro m b o s is

5.4

■ C a u s e s in c lu d e o v e rw h e lm in g in fe c tio n s (G ra m n e g a tiv e u su a lly), o b s te tric c o m p lic a tio n s (a b ru p tio n , a m n io tic flu id e m b o li), m u c in s e c re tin g a d e n o c a rc in o m a s , e x te n s iv e tra u m a , p ro s ta te s u rg e ry , a n d s o m e v e n o m o u s s n a ke b ite s

Thrombosis & thrombophilia

5.4.1 Clinical considerations 5.4.1.1 Clinical clues

■ D ia g n o s is

t5.14 Thrombophilia: differential diagnosis by type of

■ V e n o u s th ro m b o s is t5.14

thrombosis

□ P T a nd a P T T a re o fte n p ro lo n g e d

Arterial thrombosis, eg, Venous thrombosis, eg, deep myocardial infarction____________ vein thrombosis________________

□ F ib rin o g e n is o fte n d e c re a s e d □ D -d im e r is u s u a lly in c re a s e d □ S c o rin g s y s te m s h a ve b e e n d e v e lo p e d a nd v a lid a te d in s e v e ra l s tu d ie s t5.13

t5.13 International Society of Throm bosis scoring system for

disseminated intravascular coagulation Scoring >100: score 0 2 occasions >12 weeks apart clinical findings separated by 1 ,0 0 0 lU /d L ■ P a th o p h y s io lo g y o f T T P

V K O R C 1 e n c o d e s v ita m in K e p o x id e re d u c ta s e (V K O R ) th a t is th e p rin c ip a l ta rg e t o f w a rfa rin

■ M o n ito rin g □ IN R , w ith ta rg e t u s u a lly in th e ra n g e o f 2 to 3

□ A b n o rm a lly la rg e c irc u la tin g v W F m u ltim e rs □ F re q u e n tly re la te d to d e fic ie n c y o f A D A M T S 1 3 ■ F a m ilia l T T P is c a u s e d b y m u ta tio n s in th e g e n e e n c o d in g A D A M T S 1 3 ■ S p o ra d ic T T P is fre q u e n tly c a u s e d b y a u to a n tib o d y to A D A M T S 1 3 ■ S e c o n d a ry T T P is n o t s tro n g ly a s s o c ia te d w ith d e fic ie n c y o f A D A M T S 1 3 ■ T re a tm e n t □ P la te le t tra n s fu s io n s a re c o n tra in d ic a te d in T T P □ D a ily p la s m a p h e re s is w ith re p la c e m e n t F F P is th e m a in s ta y o f th e ra p y

■ R e ve rsa l □ M a y be in d ic a te d w ith s u p ra th e ra p e u tic IN R and b le e d in g ■ W ith h o ld w a rfa rin w ith o r w ith o u t a d m in is tra tio n o f oral v ita m in K, in tra v e n o u s v ita m in K, o r p ro th ro m b in c o m p le x , d e p e n d in g u p o n th e s itu a tio n

5.5.1.2 Other oral anticoagulants ■ A p ix a b a n a n d riv a ro x a b a n a re d ire c t X a in h ib ito rs w h ic h can be ta k e n o ra lly ■ T h e P T a nd a P T T a re u s u a lly p ro lo n g e d w h e n th e re is a th e ra p e u tic e ffe c t, b u t th e re s p o n s e is n o n lin e a r ■ No re ve rs a l a g e n t

5.5.1.3 Unfractionated heparin (UH) ■ B in d s to AT, e n h a n c in g its c a p a c ity to in a c tiv a te th ro m b in , fa c to r X a, IX a, X la , a nd X Ila ■ M o n ito rin g □ H e p a rin a s s a y (fa c to r X a in h ib ito ry m e th o d ) o r a P T T ■ H e p a rin re s is ta n c e □ M o s t c o m m o n c a u s e is A T d e fic ie n c y 288

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5: Coagulation

Therapeutic agents & monitoring>Anticoagulants | Antiplatelet agents ■ Irre v e rs ib ly in h ib its p la te le t c y c lo o x y g e n a s e (C O X 1), w h ic h is n e e d e d to p ro d u c e th ro m b o x a n e A 2 (T X A 2 ); T X A 2 c a u s e s p la te le t a c tiv a tio n a n d lo c a l v a s o c o n s tric tio n

■ R e v e rsa l □ W ith h o ld h e p a rin w ith o r w ith o u t in tra v e n o u s p ro ta m in e s u lfa te

■ A s p irin re s is ta n c e

5.5.1.4 Low molecular weight heparin ■ A g e n ts in c lu d e e n o x a p a rin , d a lte p a rin , n a d ro p a rin , tin z a p a rin , a nd d a n a p a ro id ■ D a n a p a ro id is c o n s id e re d a “ h e p a rin o id ,” b e c a u s e it is a m ix tu re o f g ly c o s a m in o g ly c a n s , in c lu d in g h e p a ra n s u lfa te , d e rm a ta n s u lfa te , a nd c h o n d ro itin s u lfa te , w ith no h e p a rin ; b u t s im ila r to th e o th e r L M W H in its m e c h a n is m o f a c tio n a n d c lin ic a l u tility ■ M e c h a n is m o f a c tio n is th e s a m e a s u n fra c tio n a te d h e p a rin ■ M o n ito rin g

□ 2 5 % o f a d u lts ■ M o n ito rin g □ U s e d p rim a rily to e s ta b lis h a s p irin re s is ta n c e o r to d o c u m e n t re ve rs a l p rio r to s u rg e ry □ P la te le t a g g re g o m e try ; d e c re a s e d re s p o n s e to a ra c h id o n ic a c id □ P FA 100 □ V e rify N o w p la te le t a s s a y

5.5.2.2 Thienopyridines

□ N o t a lw a y s re q u ire d □ M a y be re q u ire d in s e v e re o b e s ity , re n a l fa ilu re , and c h ild re n □ L M W H a s s a y (fa c to r X a in h ib ito ry m e th o d ) ■ R e v e rsa l □ P ro ta m in e s u lfa te d o e s n o t n e u tra liz e L M W H as e ffe c tiv e ly a s UH

■ A g e n ts in c lu d e tic lo p id in e (T ic lid ), c lo p id o g re l (P la v ix ) a n d p ra s u g re l ■ B lo c k th e P 2Y 12 re c e p to r th a t m e d ia te s A D P in d u c e d p la te le t a c tiv a tio n ■ A g e n ts a re p ro d ru g s th a t a re m e ta b o liz e d b y h e p a tic C Y P 2 C 1 9 into a c tiv e m e ta b o lite s ■ M o n ito rin g

■ S y n th e tic h e p a rin a n a lo g u e a nd X a in h ib ito r

■ N o t u s e d fo r d o s e a d ju s tm e n t, b u t c a n be u s e d to d ia g n o s e d ru g re s is ta n c e a n d to d o c u m e n t re v e rs a l p rio r to s u rg e ry

■ M o n ito re d u sin g an a n ti-X a a s s a y

■ P la te le t a g g re g o m e try ; d e c re a s e d re s p o n s e to A D P

■ N o re ve rs a l a g e n t

■ V e rify N o w p la te le t a s s a y

5.5.1.5 Fondaparinux (arixtra)

5.5.2.3 Dipyridamole

5.5.1.6 Direct thrombin inhibitors (DTIs) ■ A g e n ts in c lu d e d a b ig a tra n , h iru d in , b iv a liru d in , a rg a tro b a n , x im e la g a tra n , a nd m e la g a tra n

■ In h ib its p h o s p h o d ie s te ra s e a n d re d u c e s in tra c e llu la r c a lc iu m c o n c e n tra tio n

■ M o n ito rin g

■ In c o m b in a tio n w ith lo w d o s e a s p irin m a rk e te d as A g g re n o x

□ A s s e s s h e p a tic fu n c tio n (a rg a tro b a n ) a n d /o r re n a l fu n c tio n (all o th e rs ) □ D T Is u s u a lly p ro lo n g th e a P T T ; fo r s o m e a g e n ts re s p o n s e is linear, b u t fo r o th e rs it is n ot ■ S im ila rly , p ro lo n g e d th ro m b in tim e (T T ) is a s s o c ia te d w ith th e ra p e u tic e ffe c t ■ N o re ve rs a l a g e n t; s o m e ca n be re m o v e d b y d ia ly s is

5.5.2.4 GPIIb/llla receptor antagonists ■ A g e n ts in c lu d e a b c ix im a b (R e o P ro ), e p tifib a tid e (In te g rilin ), a n d tiro fib a n (A g g ra s ta t) ■ M a y c a u s e th ro m b o c y to p e n ia ■ M o n ito rin g ■ N o t fo r d o s e a d ju s tm e n t; p rim a rily fo r e s ta b lis h in g re s is ta n c e a n d fo r d o c u m e n tin g re v e rs a l p rio r to s u rg e ry

5.5.2 Antiplatelet agents 5.5.2.1 Aspirin ■ A s p irin (a c e ty ls a lic y lic a c id ) is e ffe c tiv e in p re v e n tio n o f c a rd io v a s c u la r e v e n ts

■ P la te le t a g g re g o m e try ; d e c re a s e d re s p o n s e to c o lla g e n a nd A D P ■ V e rify N o w p la te le t a s s a y ■ N o re v e rs a l a g e n t

© A S C P 2018

ISBN 9 7 8 -0 8 9 1 8 9 -6 6 7 8

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5: Coagulation

Selected readings>Books | Additional journal articles

5.6 Selected readings 5.6.1 Books IS B N 9 7 8 0 7 2 1 660301 a M ille r JL [1996] B lood coa g u la tio n and fib ri n o lysis. In: H e n ry JB, ed. Clinical Diagnosis and M anagem ent by Laboratory Methods, 19e. W B S a u n d e rs IS B N 9 7 8 0 7 2 1 6 6 0 3 0 1 b M ille r JL [1996] B lood p la te le ts In: H enry JB, ed. Clinical Diagnosis and M anagem ent by Laboratory Methods, 19e. W B S a u n d e rs IS B N 9 7 8 0 7 2 1 6 8 2 6 4 8 K itchens C S, A lving BM , K e ssle r C M , ed [2 0 0 2 ] Consultative Hem ostasis and Thrombosis, W B S a u n d e rs

Additional journal articles P M ID 1 0 0 6 6 1 4 5 M ichelson A D [1998] P latelet fu n ctio n in the n e w b o rn . Sem in Thromb H em ost 2 4 (6 ):5 0 7 -5 1 2 P M ID 1 0 1 9 3 7 3 7 M a J, H en n e ke n s C H , R id ke r PM et al [1999] A p ro s p e c tiv e s tu d y o f fib rin o g e n and risk o f m yocardial infarction in th e p h y s icia n ’s health survey. J A m Coll Cardiol 3 3 (5 ):1 347-1352 P M ID 1 0 4 5 1 4 6 5 Levi M, T e n C a te H [2002] D issem in a te d in tra va s c u la r c o a g u la tio n . N ew Engl J M ed 3 4 1 :586-592 P M ID 1 0 4 7 7 7 7 8 De S te fa n o V, M artinelli I, M a n n u cci PM et al [2 0 0 0 ] T h e risk o f re cu rre n t de e p ve n o u s th ro m b o sis am ong h e te ro zy g o u s ca rrie rs o f both fa c to r V L e iden and the G 20210A p ro th ro m b in m u ta tio n . N Engl J M e d 3 4 2 (3 ):2 1 4 -2 1 5 P M ID 1 0 6 6 4 6 2 0 M h a w e ch P, S a le e m A [2000] Inherited gia n t p la te le t d iso rd e rs: cla ssifica tio n and lite ra tu re review . A m J Clin Pathol 113:1 7 6 -190 P M ID 1 0 7 0 6 8 9 9 M e ije rs JC, T e ke le n b u rg W LH , B o um a BN et al [2 0 0 0 ] H igh levels o f coa g u la tio n fa c to r XI as a risk fa c to r fo r v e n o u s th ro m b o sis. N Engl J M e d 3 4 2 (1 0):696-701 P M ID 1 0 8 9 1 4 4 4 N e e rm a n -A rb e z M, de M oe rlo o se P, Bridel C et al [2000] M u ta tio n s in th e fib rin o g e n A a g e n e a cco u n t fo r the m a jo rity o f c a se s o f c o n g e n ita l a fib rin o g e n e m ia . Blood 96:149152 P M ID 1 0 9 3 0 9 8 8 De M o e rlo o se P, R e b e r G, P e rrie r A et al [2000] P re va le n ce o f fa c to r V L e iden a nd p ro th ro m b in G 2 0210A m uta tio n s in u n se le cted p a tients w ith ve n o u s th ro m b o e m b o lism . B r J H em atol 110(1): 125-129 P M ID 1 0 9 5 0 9 4 B e h re n s W E [1975] M e d ite rra n e a n m a cro th ro m b o cy to p e n ia . Blood 4 6 :1 9 9 -2 0 8 P M ID 1 0 9 7 3 2 5 9 S eri M, C u sa n o R, G a n g a ro ssa S et al [2000] M u ta tio n s in M Y H 9 re su lt in th e M a y-H e g g lin anom aly, and F e c h tn e r and S e b a stia n syn d ro m e s. N a t G enet 26(1 ):1 03-105 P M ID 1 0 9 7 3 2 6 0 K e lley M J, Jaw ien W , O rtel T L et al [2000] M utation o f M Y H 9, e n c o d in g n o n m u scle m yosin h e a vy chain A, in M a y-H e g g lin a n o m a ly. N ature G enet 2 6 :1 0 6 -1 0 8 PM 1D 1107902 0 F abris F, A h m a d S, C elia G et al [2000] P a th o p h y s io lo g y o f HIT. Arch Pathol Lab M e d 1 24:165 7-1666 P M ID 1 1157503 E m ilia G, Longo G, Luppi M et al [2001] H elicobacter pylori e ra d ica tio n can ind u ce p la te le t recovery in id io p a th ic th ro m b o c y to p e n ic purpura. Blood 97:812-814 P M ID 1 1157640 H irsh J, D alen JE, A iu le ison D R et al [2001] O ral a n tico a g u la n ts: m e chanism o f action, clinical effectiveness, and o p tim a l th e ra p e u tic range. C hest 119:8S -21S P M ID 1 1161246 M o e lle r A, W e ip p e rt-K re ts c h m e r M, Prinz H, K re ts ch m e r V [2001] Influence o f A B O blood groups on prim ary h e m o sta sis. Transfusion 41:5 6 -6 0

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P M ID 1 1236773 B e rnard G R, V in ce n t JL, Laterre PF [2001] Efficacy and safety o f re co m b in a n t hum an activated protein C fo r severe sepsis. N Engl J M ed 344:699 -709 P M ID 1 1309638 S e ligsohn U, Lubetsky A [2001] G enetic suscepti bility to ve n o u s throm bosis. N ew Engl J M ed 344:1222-1231 P M ID 1 1313240 P ortielje J, W estend orp R, K luin-N elem ans H et al [2001] M orbidity and m ortality in adults w ith idiopathic thro m b o cy topenic purpura. Blood 97:2549-2554 P M ID 1 1320387 W arken tin TE, Kelton JG [2001] T em poral aspects o f HIT. N ew Engl J M ed 344:1286-1292 P M ID 1 1399830 Blackall DP, Uhl L, S pitalnik S L [2001] C ryo precip ita te-reduced plasm a: rationale fo r use and effi cacy in the treatm en t o f throm botic throm bocytopen ic purpura. Transfusion 41:840-844 P M ID 1 1427450 Lehm an CM, B laylock RC, A le xa n d e r DP et al [2001] D iscontinuation o f the bleeding tim e test w itho ut detect able adverse clinical im pact. Clin Chem 47:1204-1211 P M ID 1 1578153 W arkentin TE, Kelton JG [2001] D elayed onset HIT and throm bosis. Ann Intern M ed 135:502-506 P M ID 1 1590545 H eath KE, C am pos-B arros A, Toren A et al [2001] N onm uscle m yosin heavy chain IIA m utations define a spectrum o f autosom al dom in a n t m acrothrom bocytopenias: M ay-H egglin anom aly and Fechtner, Sebastian, Epstein, and A lportlike syndrom es. Am J Hum G enet 69:1033-1045 P M ID 1 1597289 W arren BL, Eid A, S inge r P [2001] H igh-dose anti throm bin III in severe sepsis: a random ized controlled trial. JAMA 1869-1878 P M ID 1 1789732 C hang S, Tillem a V, S cherr D [2002] A percentage correction form ula fo r evaluation o f m ixing studies. Am J Clin Pathol 117:62-73 P M ID 1 1816725 T a ylo r FBJ, Toh CH, H oots W K et al [2001] Tow ards definition, clinical and laboratory criteria, and a scoring system fo r dissem ina ted intravascular coagulation. Thromb Haem ost 86:1327 -1330 P M ID 1 1825107 K o ttke -M archant KK, C orcoran G [2002] The labora tory diagnosis o f platelet disorders: an algorithm ic approach. Arch Pathol Lab M ed 126:133-146 P M ID 11882732 Levine JS, Branch DW , R auch J [2002] The antiphospholipid syndrom e. N ew Engl J M ed 346:752-763 P M ID 1 1900586 C unningham MT, Brandt JT, Laposata M et al [2002] Labora tory diagnosis o f dysfibrinogenem ia. Arch Pathol Lab M ed 126(4):499-505 P M ID 1 1919310 C ines DB, B lanchette V S [2002] Im m une th rom bo cytopenic purpura. N ew Engl J M ed 346:995-1008 P M ID 11953980 C ervera R, Piette JC, Font J et al [2002] A n tiph osp holipid syndrom e: clinical and im m unologic m anifesta tions and patterns o f disease expression in a cohort o f 1,000 patients. Arthritis Rheum 46(4):1019-1027 PM ID 12130481 A riens R AS, Lai TS, W eisel JW et al [2002] Role of factor XIII in fibrin clot form ation and effects o f genetic polym or phism s. Blood 100:743-754 PM ID 12139750 Kohda K, Kuga T, Kogaw a K et al [2002] Effect of Helicobacter pylori e radication on platelet recovery in Japanese patients w ith chronic idiopathic th ro m bocytopen ic purpura and secondary autoim m une th ro m b o cyto p en ic purpura. Br J Hem atol 118:584 PM ID 12192020 M oake JL [2002] Throm b otic m icroangiopathies. N ew Engl J M ed 347:589-600

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Selected readings>Additional journal articles PM ID 1221694 7 R ozm an P [2002] Platelet antigens: the role o f hum an platelet alloantigens (H PA ) in blood transfusion and tra n s plantation. Transpl Immunol 10:165-181 PM ID 12393622 N orm an KE, C otter MJ, S tew art BJ [2003] C om bined anticoagulant and antiselectin treatm ents prevent lethal intravascular coagulation. Blood 101:921-928 P M ID 1 2 4 2 1 136 Van C ott EM, Laposata M, Prins MH [2002] Laboratory evaluation o f hypercoagulability w ith venous or arterial throm bosis. Arch Pathol Lab M ed 126:1281-1294 P M ID 1 2 4 2 1 138 Press RD, B auer KA, Kujovich JL et al [2002] C linical utility o f fa cto r V Leiden (R 506Q ) testing fo r the diagnosis and m anagem ent o f throm b oe m bolic disorders. Arch Pathol Lab M ed 126:1304-1318 P M ID 1 2 4 2 1 139 M cG lennen RC, Key NS [2002] C linical and labora tory m anagem en t o f the prothrom bin G 20210A m utation. Arch Pathol Lab M ed 126:1319-1324 P M ID 12 4 2 1 140 K o ttke-M archant KK, Duncan A [2002] A ntithrom bin deficiency: issues in laboratory diagnosis. Arch Pathol Lab M ed 126:1326-1336 P M ID 1 2 4 2 1 143 Key NS, M cG lennen RC [2002] H yperhom ocysteinem ia and throm bophilia. Arch Pathol Lab M ed 126:1367-1374 P M ID 12421145 K itchens CS [2002] The contact system . Arch Pathol Lab M ed 126:1382-1386 P M ID 1 2 4 2 1 148 Tollefson DM [2002] H eparin cofactor II deficiency. Arch Pathol Lab M ed 126:1394-1400 P M ID 12421149 Francis C W [2002] P lasm inogen a ctivator inhibitor-1 levels and polym orphism s. Arch Pathol Lab M ed 126: 1401-1404 P M ID 12421151 W arkentin TE [2002] Platelet count m onitoring and laboratory testing fo r HIT. Arch Pathol Lab M ed 126:1415-1422 P M ID 12421152 T riplett D A [2002] A ntiph osp holipid antibodies. Arch Pathol Lab M ed 126:1424-1433 P M ID 12 4 2 1 153 M oake JL [2002] TTP and the HUS. Arch Pathol Lab M ed 126:1430-1433 P M ID 12487785 N air S, G hosh K, Kulkarni B et al [2002] G lanzm ann throm basthe nia : updated. Platelets 13:387-393 P M ID 12668507 Hirsh J, F uster V, A nsell J et al [2003] A m erican H eart A ssociation/A m erican C ollege o f C ardiology Foundation guide to w arfarin therapy. Circulation 107:1692-1711 P M ID 12823037 H osier G A, C usum ano AM , H utchins GM [2003] T hrom botic throm b o cyto p e n ic purpura and H US are distinct pathologic entities. Arch Pathol Lab M ed 127:834-839 P M ID 12878737 S a d le r JE [2003] A o rtic stenosis, von W illebrand factor, and bleeding. N Engl J M ed 349;4:323-325 P M ID 12878741 Vincentelli A, S usen S, LeTourneau T et al [2003] A cquired von W illebrand syndrom e in aortic stenosis. N Engl J M ed 349:343-349 P M ID 12928229 S chre cen gost JE, LeG allo RD, Boyd JC et al [2003] C om parison o f d iagnostic accuracies in outpatients and hospital ized patients o f D -dim er testing fo r the evaluation o f suspected pulm onary em bolism . Clin Chem 49(9): 1483-1490 P M ID 14504084 D rachm an JG [2004] Inherited throm bocytopenia: w hen a low platelet count does not m ean ITP. Blood 103:390-398 PM ID 14601697 Frost SD, B rotm an DJ, M ichota FA [2003] R ational use o f D -dim e r m easurem ent to exclude acute venous thro m bo em bolic disease. M ayo Clin Proc 78:1385-1391

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P M ID 146719 82 W ilson DB, Gard KM [2003] E valuation o f an a u to m ated, latex-enhanced turbidim etric D -dim e r te s t (advanced D -dim er) and usefulness in the e xclu sio n o f a cu te th ro m b o e m bolic disease. A m J Clin Pathol 120:930 -937 P M ID 146914 12 Jafri SM [2004] P e rip rocedural th ro m b o p ro p h y la x is in patients receiving ch ro n ic anticoagulation th e ra p y. A m H eart J 147:3-15 P M ID 14695628 Burns ER, Lou Y, P a thak A [2004] M o rphologic diagnosis o f throm botic throm bocytopen ic purpura. Am J H em atol 75:18-21 P M ID 15034233 M atsubara K, Fukaya T, N igam i H et al [2004] A g e d epend ent changes in the incidence and e tio lo g y o f child hood throm bocytosis. Acta Hem atol 1 1 1 :132-137 P M ID 15090997 A nanyeva NM, Lacroix-D e sm azes S, H a u se r C A E et al [2004] Inhibitors in hem ophilia A: m e chanism s o f inhibi tion, m anagem en t and perspectives. Blood Coagul Fibrinolysis 15(2): 109-124 P M ID 151381 62 M annucci PM, Duga S, P eyvandi F [2004a] R ece ssively inherited coagulation d isorders. Blood 104:12431252 P M ID 15142977 H eim SW , Schectm an JM , S ia d a ty M S et al [2004] D -dim e r testing fo r deep venous th ro m b o sis: a m e ta analysis. Clin Chem 50(7): 1136-1147 P M ID 15189943 B e rnard G R, M argolis BD, S h a n ie s HM et al [2004] Extended evaluation o f recom binant hum an activated protein C U nited States Trial (E N H A N C E US): a single-arm , phase 3B, m ultice nter study o f drotrecogin alfa (a ctiva te d ) in severe sepsis. Chest 125:2206-2216 P M ID 1520371 6 G runew ald M, G runew ald A, S chm id A et al [2004] The platelet function defect o f paroxysm al nocturnal h a e m oglobinuria. Platelets 15(3): 145-154 P M ID 152037 48 Passam FH, Krilis S A [2004] L a b o ra tory tests fo r th e antiphospholipid syndrom e: cu rre n t concepts. Pathology 36(2): 129-138 P M ID 15203862 Franchini M, M anzato F [2004] U pdate on the tre a t m ent o f dissem ina ted intravascular coa g u la tion . Hem atology 9(2): 81-85 P M ID 15217831 Kojouri K, V e se ly SK, Terrell D R et al [2004] S p lene cto m y fo r adult patients w ith id io p a th ic th ro m b o cyto p e n ic purpura: a system atic review to a sse ss long term p latelet c ount responses, prediction o f response, and surgical com plications. Blood 104:2623-2634 P M ID 152261 66 D ouketis JD, Johnson JA, T u rp ie A G [2004] L o w -m olecula r-w eight heparin as bridging a n tico a g ulation during interruption o f w arfarin: assessm e nt o f a standardized p e rip ro ce dural anticoagulation regim en. Arch Intern M ed 164:1319-26 P M ID 15306670 M annucci PM [2004b] T re a tm e n t o f vW D . N Engl J M ed 3 5 1 :683-694 P M ID 15509671 H anley JP [2004] W arfarin reversal. J Clin Pathol 57:1132-1139 P M ID 15518060 K arpatkin S [2004] A u to im m u n e th ro m b o cyto p e n ia s. Autoimmunity 34(4):363-368 P M ID 15667529 Elliot MA, Tefferi A [2004] T h ro m b o sis and h a e m o r rhage in polycyth em ia vera and e ssential th ro m b o cyth a e m ia . Brit J Hem atol 128:275-290 P M ID 15699837 D hain aut JF, Shorr A F, M acias W L et al [2005] D ynam ic evolution o f coagulopathy in the firs t d a y o f severe sepsis: relationship w ith m ortality and organ failu re . Crit Care M ed 33:341-348

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Selected readings>Additional journal articles P M ID 1 5 7 0 6 0 2 5 H assell K [2005] T h e m a n a g e m e n t o f p atients w ith H IT w h o re q u ire a n tic o a g u la n t th e ra p y. C hest 1 27(2):1S -8S P M ID 1 5 7 0 6 0 2 9 W a rke n tin T E [2005] N e w a p p ro a ch e s to th e d ia g n o s is o f HIT. C hest 1 2 7 (2):35S -4 5S P M ID 1 5 8 1 7 8 1 8 G e ig e r J, T e ich m a n n L, G ro ssm a n n R et al [2005] M o n ito rin g o f clo p id o g re l action: co m p a riso n o f m ethods. Clin C hem 5 1 (6 ):9 5 7 -9 6 5 P M ID 1 5 8 4 2 0 3 9 Zh o u L, S c h m a ie r A H [2005] P latelet aggreg atio n te s tin g in p la te le t rich plasm a: de scrip tio n o f p ro ce d u re s w ith the aim to d e ve lo p sta n d a rd s in the field. A m J Clin Pathol 123:172183 P M ID 1 5 8 7 0 4 9 4 O ’S h ea J, S h e rlo ck M, P h ilip R [2005] T h ro m b o cy to s is in c hild h o o d [letter], Acta H em atol 113:212 P M ID 1 5 9 0 0 2 6 6 W a rke n tin T E [2005] HIT. Dis Mon 51:141-149 P M ID 1 6 2 1 0 1 4 9 L e d e re r DJ, K a w u t SM , S o ne tt JR et al [2005] S u cc e s s fu l bilateral lung tra n s p la n ta tio n fo r p u lm o n a ry fib ro sis a sso c ia te d w ith th e H e rm a n s k y-P u d la k syn d rom e. J H eart Lung Transplant 2 4 :1 6 9 7 -1 6 9 9 P M ID 1 6 4 5 9 1 6 8 C a so n a to A, P ontara E, S a rto re llo F et al [2006] Id e n tifyin g typ e V ice n za vW D . J Lab Clin M ed 147:96-102 P M ID 1 6 4 6 1 9 6 0 LeG al G, R ighini M, R oy P et al [2006] P rediction o f p u lm o n a ry e m b o lism in th e e m e rg e n cy d e p a rtm e nt: the revised G e n e va score. Ann Int M ed 144:165-171 P M ID 1 6 4 9 1 6 3 2 B aron J M ,B a ro n B W [2005] T h ro m b o tic th ro m b o c y to p e n ic purp u ra and its loo k-a like s. C lin ica l a dvances in h em a to lo g y & o n co lo gy. 3 (1 1):868-874 P M ID 1 6 7 5 3 6 0 3 P o lia k ES, R ussell TT, P ta shkin B et al [2006] A s y m p to m a tic fa c to r VII d e fic ie n c y in A frica n A m ericans. Am J Clin Pathol 1 2 6:128 -132 P M ID 1 6 8 1 9 3 3 6 R u b b ia -B ra n d t L, N e e rm a n -A rb e z M, R ougem ont A L e t al [2 0 0 6 ] F ibrin og en y3 7 5 A rg -T rp m utation (fibrinogen a g u a d illa ) ca use s h e re d ita try h yp o fib rin o n g e n e m ia , hepatic e n d o p la s m ic reticulum sto ra g e d ise a se , and cirrhosis. Am J Surg P athol 3 0 (7 ):9 0 6 -9 1 1 P M ID 1 7 2 1 5 5 3 6 Lap osa ta M, V an C o tt EM , Lev M [2007] C ase re co rd s o f th e M a ssa ch u sse tts G en e ra l H osp ital: a 4 0 ye a r old fe m a le w ith e p istaxis, h e m atem esis, and altered m ental status. N e w Engl J M e d 3 5 6 (2 ):1 7 4 -1 8 2 P M ID 1 7 2 3 9 6 7 4 H ove ns M, S n oe p J, E ike nb oo m J et al [2007] P re va le n ce o f p e rsiste n t p la te le t re a ctivity d e sp ite use o f aspirin: a s y ste m a tic review . A m H eart J 153:175-181 P M ID 1 7 2 6 1 8 6 6 S egal JB, Eng J, T a m a riz LJ, B a ss EB [2007] R e vie w o f th e e vid e n ce on d ia g n o sis o f dee p ve n o u s throm bosis and p u lm o n a ry e m bolism . Ann Fam M e d 5:63-7 3 P M ID 1 7 3 3 2 1 4 9 Ivandic BT, G ian nitsis E, S ch lick P et al [2007] D e te rm in a tio n o f aspirin re s p o n sive n e ss by use o f w h o le blood p la te le t a g g re g o m e try. Clin C hem 53(4 ):6 1 4 -6 1 9 P M ID 1 7644791 D e la n g h e JR, L a n g lo is M R, D e B uyzere M L et al [2 0 0 7 ] V ita m in C d e ficie n cy and scurvy are not o nly a dietary p ro b le m but are co d e te rm in e d by th e h a p to g lo b in polym orphism . Clin C hem 5 3 (8 ):1 3 9 7 -1 4 0 0 P M ID 1 7 7 2 1 3 2 8 Leung A, H uang C K, M uto R et al [2007] C Y P 2C 9 a nd V K O R C 1 g e n e tic polym o rp h ism a n a lysis m ight be n ecessary in patients w ith fa c to r V Leiden and prothrom b in gen e G 20 2 1 A m uta tion(s). Diagn M ol Pathol 16:184-186 P M ID 1 7 8 5 5 8 3 6 Levi M [2007] D isse m in ated in tra va scu la r c o a g u la tion. Crit C are M ed 3 5 (9 ):2 1 9 1 -2 1 9 5

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P M ID 18371464 G ladding P, W ebster M, O rm iston J et al [2008] A ntiplatelet drug nonresponsiveness. Am H eart J 155:591-599 P M ID 18406993 N utescu EA, S hapiro NL, C hevalier A [2008] New anticoagulant agents: direct throm bin inhibitors. Cardiol Clin 26:169-187 P M ID 184633 53 Franchini M, Lippi G [2008] A cquired factor VIII inhibitors. Blood 112:250-255 P M ID 18550475 Shetti S, G hosh K [2008] R educed clinical severity in a m utationally w ell characterized cohort of severe hem ophilia w ith associated throm bop hilia. Am J Clin Pathol 130:84-87 P M ID 185740 25 W ade lius M, C hen LY, Lindh JD et al [2009] The largest prospective w arfarin-treated cohort supports genetic fo re casting. Blood 113:784-792 P M ID 1 8574040 S a d le r JE [2008] Von W illebrand factor, A D A M T S 13, and throm botic throm bocytopen ic purpura. Blood 112(1 ):1 1-18 P M ID 18574264 Hirsh J, B auer KA, Donati MB et al [2008] Parenteral anticoagulants: A m erican C ollege o f C hest Physicians evidence based clinical practice guidelines (8th edition). Chest 133:141 S-I59S P M ID 18574265 A nsell J, H irsh J, H ylek E et al [2008] P harm acology and m anagem en t o f the vitam in K antagonists: A m erican C ollege o f C hest P hysicians evidence based clinical practice guidelines (8th edition). Chest 133:160S -198S P M ID 18574265 A n tithrom botic T ria lists’ C ollaboration [2002] C ollaborative m eta-ana lysis o f random ised trials o f antiplatelet therapy fo r prevention o f death, m yocardial infarction, and stroke in high risk patients. BMJ 324:71-86 P M ID 18574269 D ouketis JD, B e rger PB, Dunn, AS et al [2008] The perioperative m anagem en t o f antithrom botic therapy: A m erican C ollege o f C hest Physicians evidence based clinical practice guidelines (8th edition). Chest 133:299-339S P M ID 18809774 Kelton JG, W arkentin TE [2008] HIT: a historical perspective. Blood 112(7):2607-2615 P M ID 18820129 K em pton CL, W hite GC [2009] H ow w e treat a hem ophilia A patient w ith a fa cto r VIII inhibitor. Blood 113:11-17 PM ID 19071881 Eriksson Bl, Q uinlan DJ, W eitz Jl [2009] C om parative pharm acodynam ics and pharm acokinetics o f oral direct throm bin and factor xa inhibitors in developm ent. Clin Pharmacokinet 48( 1): 1-22 PM ID 19289591 P eershke EIB, C astellone DD, Ledford-K raem er M et al [2009] Laboratory assessm ent o f factor VIII inhibitor titer. Am J Clin Pathol 131:552-558 PM ID 19880491 G arcia D, Libby E, C row ther M A [2010] The new oral anticoagulants. Blood 115(1): 15-20 PM ID 19890132 C uke r A, C onnors JM , Levy BD et al [2009] Clinical problem solving: a bloody m ystery. N ew Engl J M ed 361:18871894 P M ID 2043759 Lind SE [1991] The bleeding tim e does not predict surgical bleeding. Blood 77:2547-2552 P M ID 2406907 R odgers RP, Levin J [1990] A critical reappraisal o f the bleeding tim e. Semin Thromb Hem ost 16(1): 1-20 P M ID 3125864 Kane W H, D avie EW [1988] Blood coagulation factors V and VIII: structural and functional sim ilarities and their relationship to hem orrhagic and th ro m botic disorders. Blood 71(3):539-555

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5: Coagulation

Selected readings>Additional journal articles P M ID 3495304 Gill JC, E ndres-B roo ks J, B a uer PJ et al [1987] T he effect o f A B O blood group on th e diagnosis o f vW D . Blood 69(6): 1691 -1695 P M ID 3593964 A n drew M, Paes B, M ilner R et al [1987] develop m ent o f the hum an coagulation system in th e full term infant. Blood 70:165-172 P M ID 443250 G aray SM , G ardella JE, Fazzini EP et al [1979] H erm ansky-P udlak syndrom e: pulm onary m anifestations o f a ceroid storage disorder. Am J M ed 66:737-747 P M ID 651994 U pshaw JD Jr [1978] C ongenital d eficiency o f a factor in norm al plasm a th a t reverses m icroangiopathic hem olysis and throm bocytopen ia. N Engl J M ed 298:1350-1352 PM ID 6767976 R uggeri ZM, Pareti FI, M annucci PM et al [1980] H eightened interaction betw een platelets and fa cto r V IIl/vW F in a new subtype o f vW D . N Engl J M ed 302:1047-1051 PM ID 6800057 Rao AK, N iew iarow ski S, G uzzo J et al [1981] A ntithrom bin III levels during heparin therapy. Thromb Res 24:181-186 P M ID 6813740 M oake JL, R udy CK, Troll JH et al [1982] U nusually large plasm a factor V IIl:vW F m ultim ers in chronic relapsing throm botic throm b o cyto p e n ic purpura. N Engl J M ed 307:14321435 P M ID 7350869 S chinella RA, G reco MA, C obert BL et al [1980] H erm ansky-P udlak syndrom e w ith g ranulom ato us colitis. Ann Intern M ed 92:20-23 P M ID 7475606 R ees DC, C ox M, C legg JB [1995] W orld distribution of fa cto r V Leiden. Lancet 346:1133-1134 PM ID 779037 Bukow ski RM, H ew lett JS, H arris JW et al [1976] E xchange transfusions in the tre a tm e n t o f th ro m b o tic th ro m bocy topenic purpura. Semin Hem atol 13:219-232 P M ID 7864945 Jorquera Jl, M ontoro JM, Ferna ndez M A [1994] M odified test fo r activated protein C resistance. Lancet 344:11621163 PM ID 7911872 R oelse J, K oopm an R, Buller H et al [1994] A ssociation o f idiopathic venous throm boe m bolism w ith single point-m utation at A rg506 o f factor V. Lancet 343:1535-1539 PM ID 8080991 H ohlfeld P, Forestier F, Kaplan C et al [1994] Fetal throm bocytopenia: a retrospective survey o f 5,194 fetal blood sam plings. Blood 84(6): 1851-1856 P M ID 8259143 H oyer LW [1994] H em ophilia A. N Engl J M ed 330(1 ):38-47 P M ID 8302317 Svensson PJ, D ahlback B [1994] R esistance to acti vated protein C as a basis fo r venous throm bosis. N Engl J M ed 3 30(8):517-522 PM ID 8400251 G riffin JH, Evatt B, W idem an C et al [1993] A n ticoagu la n t protein C pathw ay defective in the m ajority of throm bop hilic patients. Blood 82:1989-1994 PM ID 8526201 Kelton JG, W arken tin TE [1995] D iagnosis o f HIT. Am J Clin Pathol 104:611-613 P M ID 8598867 W eiss EJ, Bray PF, Tayback M et al [1996] The platelet glycoprotein Ilia polym orphism PLA2: an inherited platelet risk fa cto r fo r coronary throm botic events. N Engl J M ed 334:109 0-1094 P M ID 861974 6 G ew irtz AS, M iller ML, Keys TF [1996] The clinical usefulness o f the preoperative bleeding tim e. Arch Pathol Lab M ed 120(4):353-356

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P M ID 8701918 Z e h n d e r JL, Benson R C [1996] S e n sitivity and s p e c i ficity o f the A P C resistance a ssay in detection o f individu als w ith fa cto r V leiden. Am J Clin Pathol 1 0 6 (1 ):1 0 7 -1 11 P M ID 8811825 D eR ossi SS, Glick M G [1996] B leeding tim e: an unreliable predictor o f clinical hem ostasis. J O ral Maxillofac Surg 54(9): 1119-20 P M ID 8822577 M iller JL [1996] P latelet type vW D . Thromb H aem ost 75(6):865-869 P M ID 8917300 D anilenko-D ixon DR, V an W in te r JT, H om burger H A [1996] C linical im plications o f a n tiphospholipid antib o d ie s in obstetrics. M ayo Clin Proc 71:1 118-1120 P M ID 8929467 K apiotis S, Q uehenbe rger P, Jilm a B et al [1996] Im proved characteristics o f A P C -re sista n ce assay: coatest A P C resistance by predilution o f sa m ples w ith fa c to r V d e ficie n t plasm a. Am J Clin Pathol 106(5):588-593 P M ID 9109469 R idker PM, M iletich JP, H ennekens CH et al [1997] E thnic distribution o f factor V Leiden in 40 4 7 m en and w om en. JAMA 277(16):1305-1307 P M ID 9128263 V an O erle R, van P a m p us L, T a n s G et al [1997] T he clinical application o f a new specific fun ctio n a l a ssa y to d e te ct the fa cto r V (Leiden) m utation associa ted w ith activated protein C resistance. Am J Clin Pathol 107(5):521-526 P M ID 919817 6 Bayston TA, Lane D A [1997] A n tith ro m bin: m o lecular basis o f deficiency. Thromb Haem ost 78(1):339-343 P M ID 9245222 M oll S, O rtel TL [1997] M onitoring w arfarin th e ra p y in patients w ith lupus anticoagulants. Ann Intern M ed 127(3): 177185 P M ID 9322598 A d cock DM, Fink L, M arlar R A [1997] A laboratory approach to the evaluation o f hereditary hyp e rco a g ulability. A m J Clin Pathol 108:434-449 P M ID 9420338 lacoviello L, Di C astelnuovo A, de K n ijff P et al [1998] P olym orphism s in the coagulation fa c to r VII g e n e and the risk o f m yocardial infarction. N Engl J M ed 338(2):79-85 P M ID 956918 2 Z o tz RB, W inkelm ann BR, N auck M et al [1998] P olym orphism o f platelet m em brane glycoprotein Ilia: hum an platelet antigen 1b (H P A -1b/P LA 2) is an inherited risk factor fo r prem ature m yocardial infarction in co ro n a ry a rtery disease. Throm H aem ost 79:731-735 P M ID 957954 5 W ildenberg SC, Fryer JP, G a rd n e r JM et al [1998] Identification o f a novel transcript produced by the gene re sp o n sible fo r the H erm ansky-P udlak syndrom e in P uerto R ico. J Invest Dermatol 110:777-781 P M ID 9593344 Strobl FJ, H offm an S, H uber S et al [1998] A ctivated protein C resistance a ssa y perform ance: im p ro ve m e n t by sam ple dilution w ith fa cto r V -d e ficie n t plasm a. Arch Pathol Lab M ed 122(5):430-433 P M ID 974013 6 O lson JD, A rkin CF, B randt JT [1998] C ollege o f A m erican P a thologists conference XX XI on la b o ra tory m onitoring o f anticoagulant therap y: laboratory m onitoring o f UH therapy. Arch Pathol Lab M ed 122(9):782-798 P M ID 9740137 Laposata M, G reen D, V an C ott EM et al [1998] C ollege o f A m erican Pathologists c onference X X X I on laboratory m onitoring o f antico a g u la n t therapy: th e clinical use and la b o ra tory m onitoring o f low -m o lecular w eigh t heparin, danapa roid, hirudin and related com pounds, and argatroban. Arch Pathol Lab M ed 122(9):799-807

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Selected readings>Books P M ID 9 8 0 2 3 5 4 D um enco LL, B lair A J, S w e e n e y JD [1998] The re su lts o f d ia g n o s tic stu d ie s fo r th ro m b o p h ilia in a large g roup o f p a tie n ts w ith a p e rso n a l o r fa m ily h isto ry o f th ro m b o sis. Am J Clin P athol 1 1 0:673 -682 P M ID 9 8 2 8 2 4 5 Furlan M, R oble s R, G a lb u se ra M et al [1998] vW F c le a v in g p ro te a se in th ro m b o tic th ro m b o c y to p e n ic purpura and th e h e m o ly tic-u re m ic syndrom e. N e w Engl J M e d 3 3 9 :157 8-1584 P M ID 9 8 2 8 2 4 6 T sai H M , Lian EC [2002] A n tib o d ie s to v W F -cleaving p ro te a se in a cu te th ro m b o tic th ro m b o c y to p e n ic purpura. N ew Engl J M e d 3 3 9 :1 5 8 5 -1 5 9 4 P M ID 9 9 2 0 8 3 9 C atto A J, K o h le r HP, C oore J et al [1999] A ssociation o f a co m m o n p o ly m o rp h is m in th e fa c to r XIII g e n e w ith ve n o u s th ro m b o s is . Blood 9 3 (3 ):9 0 6 -9 0 8 A d c o c k D M [2002] F a cto r VIII in h ib ito rs in pa tie n ts w ith hem ophilia A. Clin Hem ostasis R ev 16:1 Je n s e n R [2001] T h e a n tip h o sp h o lip id a n tib o d y syn d ro m e . Clin H em ostasis R e v 15 K a n kira w a ta n a S, B e rko w RL, M a rq u e s M B [2006] A neo n a te w ith b le e d in g and m ultiple fa c to r d e ficiencie s. Lab M ed 37(2):95-97 M a c y P A [2003] Ide n tifica tio n and clin ica l sig n ifica n ce o f platelet a n tib o d ie s. Clin Hem ostasis R ev 17:5

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Chapter 6

Im m unology 6.1 Immune system..............................................................................296 6.1.1 B c e lls .................................................................................................................... 296 6 .1 .2 T c e lls .................................................................................................................... 297 6 .1 .3 N K c e lls ............................................................................................................... 297 6 .1 .4 A ntig e n p re se n tin g c e lls .................................................................................298 6 .1 .5 G ra n u lo c y te s ..................................................................................................... 298 6 .1 .6 C o m p le m e n t........................................................................................................298 6 .1 .7 H um an le u ko cyte a n tig e n s ( H L A s ) ..........................................................299

6.2 Evaluation of immune function................................................... 300 6.2.1 S cre e n in g t e s t s ................................................................................................ 300 6 .2 .2 G lobal te s ts o f im m u n e s y s te m ................................................................. 300 6 .2 .3 S pe c ific te stin g o f B cell fu n c tio n ...............................................................300 6 .2 .4 S pe c ific te s tin g o f T cell fu n c tio n ...............................................................300 6 .2 .5 T e s tin g N K cell fu n c tio n .................................................................................300 6 .2 .6 T e stin g n e u tro p h il fu n c tio n ............................................................................300 6 .2 .7 T e stin g c o m p le m e n t........................................................................................ 301 6.2 .8 H LA te s tin g .......................................................................................................... 301

6.3 Primary immunodeficiency disorders......................................... 303 6.3.1 B c e ll d e fe c ts ..................................................................................................... 303 6.3 .2 T cell d e fe c t s ..................................................................................................... 304 6 .3 .3 N e u tro p h il/p h a g o c y tic d e fe c t s ....................................................................305 6 .3 .4 C o m p le m e n t d e fic ie n c ie s .............................................................................. 306

6.4 Autoimmunity & rheumatologic disease................................... 306 6.4.1 P a th o p h y s io lo g y ................................................................................................306 6 .4 .2 A u to im m u n e d is e a s e s ...................................................................................309 6 .4 .3 H yp e rs e ns itiv ity r e a c t io n s ............................................................................316

6.5 Selected readings...........................................................................316

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Immunology

Immune system>B cells

6.1 Immune system 6 .1 .1

B c e lls

6.1.1.1 B cells originate & mature in the marrow in a stepwise process t6.1 ■ D u rin g th is p ro c e s s th e y u n d e rg o re a rra n g e m e n t o f th e ir im m u n o g lo b u lin g e n e s

t6.1 B & T cell m aturation sequences T cell stage B cell stage Definition lymphoid stem cell pro B cell (pre pre B cell) pre B cell

Bcell

CD34+, TdT+, HLA-DR+ CD34+, TdT+, HLA-DR+, CD19+, CD10+, Ig H chain rearranging CD34-, TdT-, HLA-DR+, CD19+, CD10+, CD20+, cytoplasmic p heavy chains + Ig L chain rearranging all of the above plus surface Ig, CD21+, CD22+

surface CD3 becoming +, CD4 or CD8+ plasma cell loss of B cell markers (CD19-, CD20-) & cytoplasmic (not surface) lq+

Definition

lymphoid stem cell CD34+, TdT+, HLA-DR+ CD34+, TdT+, prothymocytes CD7+ immature/common CD34-, TdT+, thymocytes CD1+, CD2+, cytoplasmic CD3+ (surface CD3-), CD5+, CD7+, CD4 & CD8+, TCR rearranged mature thymocyte all of the above, except TdT- & CD1-

mature T cell

all of the above, except surface CD3+

■ H e a v y c h a in g e n e s (y, a, p, 5, e) o n c h ro m o s o m e 14

6.1.1.2 Immunoglobulin (Ig) ■ C o n s is ts o f 4 p o ly p e p tid e c h a in s , in c lu d in g 2 h e a v y c h a in s a n d 2 lig h t c h a in s , b o u n d to g e th e r b y d is u lfid e bonds □ L ig h t c h a in s h a v e 2 d o m a in s : 1 v a ria b le a n d 1 c o n s ta n t □ H e a v y c h a in s h a v e 4 - 5 d o m a in s : 1 v a ria b le a n d 3 -4 c o n s ta n ts f6.1 ■ T h e te rm in a l c o n s ta n t re g io n m a y in s e rt in to th e m e m b ra n e o f B c e lls or, if fre e in s e ru m , is c a lle d th e Fc p o rtio n □ T h is F c m a y b in d to F c re c e p to rs (F c R ) on th e s u rfa c e s o f p h a g o c y tic c e lls □ M a s t c e lls b e a r an Fee re c e p to r th a t re n d e rs th e m c a p a b le o f b in d in g Ig E ■ T h e v a ria b le re g io n s o f a lig h t a n d h e a v y c h a in c o m b in e to fo rm th e a n tig e n b in d in g site , th e p a ra to p e

■ D u rin g B ce ll d e v e lo p m e n t, th e s e g e n e s a re re a rra n g e d □ B e g in s w ith v a ria b le re g io n re a rra n g e m e n t o f V a n d J (lig h t c h a in ) o r V, D, a n d J (h e a v y c h a in ) s e q u e n c e s □ T h e n re a rra n g e d v a ria b le re g io n s e q u e n c e is jo in e d to a lig h t c h a in o r h e a v y c h a in c o n s ta n t re g io n g e n e sequence ■ T h e la tte r is a lw a y s in itia lly a p h e a v y c h a in g e n e , re s u ltin g in a c o m p le te d g e n e th a t e n c o d e s an IgM p ro te in w ith s o m e p a rtic u la r e p ito p e s p e c ific ity ■ M a tu re B c e lls c o e x p re s s s u rfa c e IgM a nd IgD □ O n c e s tim u la te d by a n tig e n in th e p re s e n c e o f T h c e lls ■ T h e m a tu re B c e lls p ro life ra te ■ E a ch p ro g e n y B ce ll re a rra n g e s its D N A ye t a ga in, re jo in in g th e ir p re fa b ric a te d v a ria b le g e n e s w ith a d iffe re n t h e a v y c h a in g e n e (is o ty p e s w itch ) ■ T h e v a ria b le e n d o f th e a n tib o d y is its e lf an e p ito p e □ C a lle d an id io to p e (id io ty p e )

6.1.1.3 Immunoglobulin genes ■ L ig h t c h a in g e n e s o n c h ro m o s o m e s 2 296

f6.1 Structure o f serum immunoglobulin molecules, which are composed of 2 light chains (LC) & 2 heavy chains (HC), linked by disulfide bonds (-S-S-). Light chains are composed of a N-terminal variable region (VL), a J chain (JL), and a C-terminal constant region (CL). Heavy chains are made up of an N-terminal variable region (VH), D chain, J chain, and several constant regions (CH1-CH3).

(k )

a n d 2 2 (A)

□ A n ti-id io to p e (id io ty p e ) a n tib o d ie s m ay be fo rm e d a g a in s t it

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6: Immunology

Immune system>B cells | T cells | NK cells ■ lg c la s s e s

a

P

□ 5 Ig c la s s e s t6 .2 , b a s e d on th e h e a v y c h a in is o ty p e (liste d in o rd e r o f s e ru m c o n c e n tra tio n ) ■ IgG , w ith 4 s u b c la s s e s

Q


9 5% ) T ly m p h o c y te s h a v e T C R a p

6.1.2 T cells 6.1.2.1 T cells undergo stepwise maturation in the thymus ■ U n d e r n o rm a l c o n d itio n s , T ly m p h o c y te s o u tn u m b e r B ly m p h o c y te s in b lo o d by a ra tio o f -2 :1 and re p re s e n t - 6 5 % o f c irc u la tin g ly m p h o c y te s ■ T ce ll re c e p to r (T C R ) g e n e s (a, p, y, 5) a re p re s e n t on c h ro m o s o m e 7; th e y re a rra n g e in a fa s h io n s im ila r to th e im m u n o g lo b u lin s ■ T c e lls d iffe re n tia te in to s e v e ra l ty p e s th a t a re s e p a ra b le on th e b a s is o f c e ll s u rfa c e a n tig e n s ; T h e lp e r ( T h) c e lls b e a r th e a n tig e n C D 4 ; T s u p p re s s o r ( I s) a n d T c y to to x ic (T 0) c e lls b e a r th e a n tig e n C D 8 ; th e u s u a l C D 4 :C D 8 ra tio is -2 :1

□ T C R y6 c e lls a re fo u n d in g re a te s t n u m b e r in m u c o s a l s u rfa c e s a nd skin ■ T C R is e x p re s s e d in n o n c o v a le n t a s s o c ia tio n w ith th e C D 3 m o le c u le

6.1.3 NK cells ■ R e p re s e n t -1 0 % o f p e rip h e ra l b lo o d ly m p h o c y te s a n d h a ve n e ith e r T C R n o r Ig. T C R a n d Ig g e n e s a re in th e g e rm lin e (n o n re a rra n g e d ) s ta te . N K c e lls la c k s u rfa c e C D 3 a nd e x p re s s C D 1 6, C D 5 6 a n d C D 5 7. C D 1 6 is th e re c e p to r fo r th e Fc p o rtio n o f y h e a v y c h a in s (F c y R) ■ T h ro u g h b in d in g o f o p s o n iz e d c e lls w ith th is re c e p to r, th e y m e d ia te a n tig e n d e p e n d e n t c e llu la r c y to to x ic ity (A D C C ); c o m b a t v ira l in fe c tio n a n d tu m o r c e lls ■ S e c re te IF N y a nd a re m o rp h o lo g ic a lly re c o g n iz a b le in p e rip h e ra l b lo o d a s larg e g ra n u la r ly m p h o c y te s (L G L s )

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Immune system>Antigen presenting cells | Granulocytes | Complement

6.1.4 Antigen presenting cells ■ In c lu d e m o n o c y te s , m a c ro p h a g e s , h is tio c y te s , a n d o rg a n s p e c ific c e ll ty p e s s u c h a s K u p p fe r c e lls o f h e p a tic s in u s o id s , H o ffb a u e r c e lls w ith in p la c e n ta l villi, in te rd ig ita tin g ) re tic u lu m c e lls (IR C ) o f th e in te rfo llic u la r p o rtio n s o f ly m p h n o d e s , d e n d ritic re tic u lu m c e lls (D R C ) o f g e rm in a l c e n te rs , a n d L a n g e rh a n s c e lls fo u n d in s u c h p la c e s a s th e e p id e rm is a n d lu n g ■ H a v e p h a g o c y tic p ro p e rtie s a n d c e rta in c e ll a n tig e n s : M H C c la s s II a n tig e n s , C D 6 8 (K P 1 ) a n d ly s o z y m e . A ll e x c e p t th e m o n o c y te m a c ro p h a g e c e lls h a v e S 1 0 0 a n d CD 1a ■ S e c re te IL1

6.1.5 Granulocytes 6.1.5.1 Neutrophils ■ A ttra c te d b y c y to k in e s , p a rtic u la rly IL 8 a n d u p o n a rriv a l a re s tim u la te d to re le a s e th e ir g ra n u le s in to th e s u rro u n d in g s ■ A ls o c a p a b le o f lim ite d p h a g o c y tic a c tiv ity

6.1.5.2 Basophils & mast cells ■ H a v e Fee re c e p to rs u p o n th e ir s u rfa c e s a n d a re th u s a b le to b in d IgE ■ If a n tig e n (a lle rg e n ) is p re s e n t, th e s u rfa c e Ig E m a y b e c o m e c ro s s lin k e d ; th is a c tiv a te s d e g ra n u la tio n

6.1.5.3 Eosinophils ■ S tim u la te d b y a s u b s u b s e t o f C D 4 + T c e lls c a lle d T h2 c e lls th a t s e c re te IL 4 (s tim u la te p ro d u c tio n o f Ig E ) a nd IL 5 (a ttra c t e o s in o p h ilic in filtra tio n ) ■ D e g ra n u la tio n m a y re s u lt in fo rm a tio n o f C h a rc o t-L e y d e n c ry s ta ls (C LC ); C L C p ro te in h a s ly s o p h o s p h o lip a s e a c tiv ity

6.1.6 Complement 6.1.6.1 Effects ■ T h e a tta c h m e n t o f th e c o m p le m e n t p ro te in C 3 b to a fo re ig n s u b s ta n c e (o p s o n iz a tio n ) le a d s to p h a g o c y to s is ■ T h e a tta c h m e n t o f th e c o m p le x o f c o m p le m e n t p ro te in s C 5 -9 (m e m b ra n e a tta c k c o m p le x ) le a d s d ire c tly to th e ly s is o f m e m b ra n e b o u n d s tru c tu re s ■ C o m p le m e n t p ro te in s C 3 a a n d C 5 a (a n a p h y la to x in s ) p ro m o te th e re le a s e o f h is ta m in e fro m b a s o p h ils

6.1.6.2 Pathways f6.3 ■ C la s s ic a l p a th w a y

□ T h e Fc p o rtio n o f Ig in te ra c ts w ith C 1q to in itia te th is p ro c e s s ■ A c tiv a te d C1 c a ta ly z e s th e a s s o c ia tio n o f C 4 and C 2 to m a ke C 4 b 2 a (the C 3 c o n v e rta s e o f th e c la s s ic p a th w a y ) ■ C 4 b 2 a is c a p a b le o f c o n v e rtin g C 3 into C 3 b and C 3 a . T h e n o w a b u n d a n tly a v a ila b le C 3 b a s s o c ia te s w ith C 4 b 2 a to m a ke C 4 b 2 a 3 b (the C 5 c o n v e rta s e o f th e c la s s ic p a th w a y ) c a u s in g d e p o s itio n o f th e te rm in a l c o m p le m e n t c o m p o n e n ts on th e ta rg e t s u rfa c e ■ A lte rn a tiv e p a th w a y

□ A c tiv a te d b y Ig M a n d c e rta in s u b c la s s e s o f IgG (lg G 1 , lg G 2 , lg G 3 ) 298

f6.3 Complement cascades: classical, alternate & MBL (mannan binding lectin). All of the pathways converge, by way of their individual C5 convertases, upon C5, which initiates the formation of the membrane attack complex (MAC). The original complement components are denoted C1-C9. C1 is a complex composed of C1q, C1r & C1s. Additional proteins, particularly those active in the alternate pathway, are called “factors,” including factor B & factor D. Proteolysis results in fragments of the original proteins that are typically called “a” & “b” as in C3a & C3b. An inactive fragment is denoted T as in C3i (or sometimes iC3b). MASP = MBL-associated serine protease

□ A c tiv a te d by b a c te ria l ce ll w a lls , v e n o m s , e n d o to x in , or c o m p le x e d IgA

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© A S C P 2018

6: Immunology

Immune system>Complement | Human leukocyte antigens (HLAs) □ In itia tio n o f th is p a th w a y is th ro u g h d e p o s itio n o f C 3 b o n to a n y o f th e s e s u b s ta n c e s ■ C 3 b is b e in g p ro d u c e d a t lo w le v e ls a t all tim e s in p e rip h e ra l b lo o d a s a re s u lt o f a “ tic k o v e r” p h e n o m e n o n b u t is q u ic k ly d e g ra d e d , if n ot b o u n d , by fa c to r I □ B o u n d C 3 b a s s o c ia te s w ith fa c to r B to m a ke C 3 b B b ■ F a c to r D c le a v e s th e fa c to r B to fo rm th e s u rfa c e b o u n d c o n v e rta s e (th e C 3 c o n v e rta s e o f th e a lte rn a te p a th w a y ), w h ic h is fu rth e r s ta b iliz e d by p ro p e rid in ■ C 3 b B b is c a p a b le o f c o n v e rtin g C 3 to C 3 b and C 3 a , th e re b y a m p lify in g th e re a c tio n ■ T h e n o w a b u n d a n tly a v a ila b le C 3 b a s s o c ia te s w ith C 3 b B b to m a ke C 3 b B b 3 b , w h ic h is s ta b iliz e d by p ro p e rd in , s o m e tim e s w ritte n C 3 b (2 ) B b P (the C 5 c o n v e rta s e o f th e a lte rn a tiv e p a th w a y )

■ T h e h e a v y c h a in is a tra n s m e m b ra n e p o ly p e p tid e c o m p o s e d o f 3 a d o m a in s ■ It is n o n c o v a le n tly a s s o c ia te d w ith a lig h t c h a in th a t is a s in g le m o le c u le o f a 2 m ic ro g lo b u lin □ S o m a tic c e lls th a t e x p re s s fo re ig n a n tig e n o n th e ir s u rfa c e in c o n ju n c tio n w ith c la s s I M H C m o le c u le s in v ite d e s tru c tio n fro m Tc (C D 8 + ) c e lls □ C la s s I a n tig e n s a re fo u n d on th e s u rfa c e s o f m o s t n u c le a te d c e lls ■ C la s s II g e n e s □ D is trib u te d a m o n g H L A -D R , H L A -D P , a n d H L A -D Q □ F o r e a c h lo c u s , th e re are s e v e ra l p o s s ib le a lle le s , te rm e d , eg, H L A -D R 3 , H L A -D w 2 □ T h e s e g e n e s e n c o d e H L A c la s s II a n tig e n s

■ M a n n a n b in d in g le c tin p a th w a y □ U se s m a n n o s e b in d in g le c tin (M B L ) o r m a n n o s e b in d in g p ro te in to b in d o n to th e s u rfa c e s o f m ic ro b e s ■ O n c e th e p ro te in s b in d , th e y u n d e rg o a c o n fo rm a tio n a l c h a n g e a llo w in g th e m to a s s o c ia te w ith 3 M B L a s s o c ia te d s e rin e p ro te a s e s , M A S P 1 , M A S P 2 , a n d M A S P 3 to a c tiv a te th e c o m p le m e n t cascade ■ A fte r a c tiv a tio n , M A S P 2 c le a v e s C 4 a nd C 2 to g e n e ra te C 4 b 2 a , th e C 3 c o n v e rta s e , th e re b y a c tiv a tin g C 3 ■ T h e e n d re s u lt o f th e a lte rn a tiv e , c la s s ic a l a nd M B L p a th w a y s is a llo w in g fo r a s s e m b ly o f th e m e m b ra n e a tta c k c o m p le x by p ro d u c in g C 5 c o n v e rta s e (a m o le c u le c a p a b le o f c o n v e rtin g C 5 into C 5 b a n d C 5a) □ O n c e C 5 b is fo rm e d , it q u ic k ly c o m p le x e s on th e s u rfa c e o f a d ja c e n t c e lls w ith C 6, C7, C 8 a n d C 9 to fo rm C 5 b 6 7 8 9 (th e m e m b ra n e a tta c k c o m p le x o r M AC)

■ E a ch c o n s is t o f 2 p o ly p e p tid e c h a in s , a a n d 3, e a c h w ith 2 d o m a in s s im ila r to th e im m u n o g lo b u lin lig h t c h a in s , in a d d itio n to a tra n s m e m b ra n e d o m a in □ A n tig e n p re s e n tin g c e lls (A P C s ) p re s e n t a n tig e n to T h (C D 4 + ) c e lls in a s s o c ia tio n w ith c la s s II M H C a n tig e n s □ H L A c la s s II a n tig e n s a re e x p re s s e d o n B ly m p h o c y te s , m o n o c y te s , m a c ro p h a g e s , d e n d ritic c e lls , a n d a c tiv a te d T ly m p h o c y te s ■ C la s s III g e n e s □ L a rg e ly e n c o d e n o n -H L A a n tig e n s , m o s t o f w h ic h s till h a ve s o m e th in g to d o w ith im m u n ity □ In c lu d e g e n e s fo r c o m p le m e n t p ro te in s , th e N O T C H 4 g e n e , th e tu m o r n e c ro s is fa c to r (T N F ) g e n e s , a n d o th e rs ■ A ls o e m b e d d e d in th e M H C re g io n a re th e g e n e s fo r h e re d ita ry h e m o c h ro m a to s is a n d 2 1 -h y d ro x y la s e

6.1.7.2 Each MHC complex is closely linked and inherited

6.1.7 Human leukocyte antigens (HLAs) ■ H L A p ro te in s a re e n c o d e d b y g e n e s lo c a te d w ith in th e m a jo r h is to c o m p a tib ility c o m p le x (M H C ) on c h ro m o s o m e 6p

■ E a ch p a re n ta l c h ro m o s o m e c a n be th o u g h t o f a s a h a p lo ty p e ■ T h u s , th e c h a n c e th a t 2 s ib lin g s a re H L A id e n tic a l is e s s e n tia lly 2 5 % □ T h e fo rm u la to c a lc u la te th e p ro b a b ility o f h a v in g a t le a s t 1 H L A m a tc h e d s ib lin g w ith “ N ” s ib lin g s is: 1 - (0 .7 5 ) n

6.1.7.1 HLA genes are categorized into classes ■ C la s s I g e n e s □ D is trib u te d a m o n g H L A -A , H L A -B , a n d H L A -C □ E a ch lo c u s h a s m u ltip le p o s s ib le a lle le s , te rm e d H L A -A 1 , H L A -A 2 , e tc

© A S C P 2018

□ T h e s e g e n e s e n c o d e th e H L A c la s s I a n tig e n s , w h ic h a re h e te ro d im e rs c o m p o s e d o f 1 h e a v y c h a in a n d 1 lig h t c h a in

□ T h e re fo re th e c h a n c e o f h a v in g an H L A id e n tic a l s ib lin g g o e s u p w ith th e n u m b e r o f s ib lin g s : w ith 1 s ib lin g , th e c h a n c e is 2 5% , w ith 2 it is - 4 5 % , a n d w ith 3 it is n e a rly 6 0 %

ISBN 9 7 8 -0 8 9 1 8 9 -6 6 7 8

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6: Immunology

Evaluation of immune function>Screening tests | Global tests of immune system | Specific testing of B cell function | Specific testing of T cell function | Testing NK cell function | Testing neutrophil function

6.2

Evaluation of immune function

6.2.1 Screening tests 6.2.1.1 History and physical examination ■ P rim a ry im m u n o d e fic ie n c ie s d is p ro p o rtio n a te ly a ffe c t m a le s (m a jo rity a re X lin k e d ) ■ Im m u n o g lo b u lin o r B c e ll d e fe c ts p re s e n t w ith re c u rrin g b a c te ria l in fe c tio n s o f th e u p p e r a n d lo w e r re s p ira to ry tra c t, u ltim a te ly re s u ltin g in b ro n c h ie c ta s is , o r re c a lc itra n t in te s tin a l in fe c tio n , e g, w ith G ia rd ia in te s tin a lis • T c e ll d e fe c ts re s u lt in s u s c e p tib ility to v ira l a n d fu n g a l o p p o rtu n is tic in fe c tio n s . M u c o c u ta n e o u s c a n d id ia s is is a n in d ic a tio n o f d e fe c tiv e T c e ll fu n c tio n ■ P h a g o c y te d e fe c ts a re a s s o c ia te d w ith S ta p h y lo c o c c u s s p e c ie s a n d o th e r c a ta la s e p o s itiv e o rg a n is m s ■ T e rm in a l c o m p le m e n t d e fic ie n c ie s p re s e n t w ith s e v e re in fe c tio n s d u e to e n c a p s u la te d o rg a n is m s s u c h a s S tre p to c o c c u s p n e u m o n ia e o r N e is s e ria m e n in g itid e s ■ L y m p h n o d e s m a y b e s m a ll o r u n d e te c ta b le in s o m e o f th e B c e ll d e fe c ts ; a lte rn a tiv e ly , n o d e s m a y be s ig n ific a n tly e n la rg e d in c o m m o n v a ria b le im m u n o d e fic ie n c y o r c h ro n ic g ra n u lo m a to u s d is e a s e ■ P e te c h ia e a n d e a s y b ru is a b ility a re s e e n in W is k o tt-A ld ric h s y n d ro m e

6.2.2 Global tests of immune system 6.2.2.1 Cell counts ■ A b s o lu te ly m p h o p e n ia is m o re c o m m o n in T c e ll d e fe c ts , s in c e th e y c o m p ris e th e m a jo rity o f c irc u la tin g p e rip h e ra l ly m p h o c y te s ■ A b s o lu te n e u tro p e n ia m a y s u g g e s t in h e rite d (c o n s titu tio n a l) o r a c q u ire d (a u to im m u n e , d ru g ) n e u tro p e n ia ■ T h ro m b o c y to p e n ia m a y s u g g e s t s u c h th in g s a s W is k o tt-A ld ric h s y n d ro m e

6.2.3.2 g levels ■ T h e m o s t c o m m o n is o la te d is o ty p e d e fic ie n c y is Ig A d e fic ie n c y ■ IgG s u b c la s s d e fic ie n c y is le s s fre q u e n t ■ Total IgE m a y be e le v a te d in a s u b s e t o f c o n d itio n s (eg, h y p e r IgE [Jo b ] s y n d ro m e )

6.2.3.3 RAST (radioallergosorbent test) ■ A n a lle rg e n s p e c ific IgE m e a s u re m e n t th a t ca n be u s e fu l to e v a lu a te a lle rg y , p rin c ip a lly fo r in h a le d a lle rg e n s

6.2.4 Specific testing of T cell function ■ By flo w c y to m e try , th e p ro p o rtio n o f T c e ll s u b s e ts ca n be d e te rm in e d ■ A te s t o f d e la y e d ty p e h y p e rs e n s itiv ity (D T H ) is th e u sua l s c re e n in g te s t fo r T c e ll fu n c tio n . A tu b e rc u lin skin te s t is c la s s ic ■ P ro life ra tio n a s s a y s ca n b e p e rfo rm e d by e x p o s in g T c e lls to m ito g e n s su ch a s p h y to h e m a g g lu tin in o r c o n c a n a v a lin A . P ro life ra tio n is m e a s u re d by th e u p ta k e o f ra d io a c tiv e D N A p re c u rs o rs (tritia te d th y m id in e )

6.2.5 Testing NK cell function ■ N K c e ll fu n c tio n ca n be a s s e s s e d by c h ro m iu m re le a s e assays ■ A c o lo rim e tric s u b s tra te to d e te c t g ra n z y m e B, a s e rin e p ro te a s e p re s e n t in th e g ra n u le s o f N K c e lls and c y to to x ic T c e lls ca n b e u se d to a s s e s s N K cell fu n c tio n

6.2.6 Testing neutrophil function

6.2.2.2 Radiographs ■ R a d io lo g ic im a g in g m a y d is c lo s e c h a ra c te ris tic b o n y a b n o rm a litie s

6.2.3 Specific testing of B cell function 6.2.3.1 Specific antibody response, eg, to vaccine ■ A n tib o d ie s ra is e d to p ro te in a n tig e n s re q u ire o rc h e s tra tio n o f T a n d B c e ll fu n c tio n , w h e re a s B c e lls a re c a p a b le o f a u to n o m o u s p ro d u c tio n o f a n tib o d y to c a rb o h y d ra te a n tig e n

300

■ A p o o r re s p o n s e to a p ro te in a n tig e n s u c h a s te ta n u s o r d ip th e ro id to x o id c o u ld in d ic a te e ith e r a B ce ll o r a T cell d e fe c t, w h e re a s p o o r re a c tio n to c a rb o h y d ra te a n tig e n s (p n e u m o c o c c a l o r m e n in g o c o c c a l v a c c in e ) is in d ic a tiv e o f a B c e ll d e fe c t

■ A b s o lu te n e u tro p h il c o u n t a nd p e rip h e ra l s m e a r m o rp h o lo g y ■ E x a m in a tio n o f c h e m o ta x is , p h a g o c y to s is , o r o x id a tiv e b u rs t fu n c tio n s w ith v a rio u s a s s a y s ■ C e lls c a p a b le o f a n o rm a l o x id a tiv e b u rs t w ill re d u c e y e llo w N B T to a p u rp le b lu e fo rm a z a n (F ) p re c ip ita te and a re s a id to be F+. N o rm a l in d iv id u a ls w ill h ave n e a rly 100% F+ c e lls . A n a b n o rm a l re su lt, w ith p e rh a p s Testing neutrophil function | Testing complement | HLA testing ■ F lo w c y to m e try ca n d e te c t in tra c e llu la r o x id a tio n o f d ih y d ro rh o d a m in e 123. W h e n th e s e p ro d u c ts a re o x id iz e d th e y w ill flu o re s c e a nd a re o b je c tiv e ly e v a lu a te d by th e in s tru m e n ta tio n , a n im p ro v e m e n t o v e r th e s u b je c tiv e in te rp re ta tio n o f th e N B T d y e te s t ■ M y e lo p e ro x id a s e s ta in in g ca n d is c lo s e m y e lo p e ro x id a s e d e fic ie n c y , an a u to s o m a l re c e s s iv e tra it w h ic h p ro d u c e s a t m o s t m ild im m u n o d e fic ie n c y

■ H u m a n a n tis e ra a re c a p a b le o f b in d in g to m o re th a n 1 H L A a lle lic p ro d u c t (s e ro lo g ic c ro s s re a c tiv ity ) ■ S e ro lo g ic c ro s s re a c tiv ity b e tw e e n a lle le s o f H L A -A a n d H L A -B lo c i a re u s e d to c lu s te r m o le c u le s w ith in th e s a m e c ro s s re a c tiv e a n tig e n g ro u p s (C R E G s )

6.2.8.5 Public antigens ■ H L A a n tig e n s c o n ta in c o m m o n a m in o a c id s e q u e n c e s th a t a re p re s e n t in m a n y d iffe re n t H L A a n tig e n s b u t d e m o n s tra te c o m m o n re a c tiv itie s

6.2.7 Testing complement 6.2.7.1 CH50 ■ T h e C H 5 0 te s t is a fu n c tio n a l a s s a y o f th e c la s s ic a l c o m p le m e n t p athw ay, in w h ic h to ta l h e m o ly tic a c tiv ity is m e a s u re d □ T h e e n d p o in t o f th e a s s a y is th e d ilu tio n o f th e p a tie n t’s s e ru m c a u s in g 5 0 % ly sis o f th e im m u n o g lo b u lin c o a te d s h e e p red c e lls □ T h e re s u lt is e x p re s s e d a s th e re c ip ro c a l o f th is d ilu tio n

6.2.7.2 Antigenic assays are undertaken for quantitation of specific complement components

■ T h e s e “ p u b lic ” a n tig e n s are p re s e n t in th e le s s v a ria b le re g io n s o f th e H L A m o le c u le ■ F o r e x a m p le , H L A -B w 4 and H L A -B w 6 a re 2 p u b lic a n tig e n s th a t a re p re s e n t in a lm o s t all H L A -B m o le c u le s w ith o n ly a fe w e x c e p tio n s . If a p a tie n t la c k s o n e o f th e s e p u b lic a n tig e n s and b e c o m e s im m u n iz e d d u rin g p re g n a n c y o r tra n s fu s io n , it a p p e a rs a s m u ltip le d is c re te H L A a n tib o d ie s . T h e s e a n tib o d ie s c a n im p a c t p a tie n t re s p o n s e s to p la te le t tra n s fu s io n o r th e ir a b ility to re c e iv e a c o m p a tib le so lid o rg a n tra n s p la n t

6.2.8.6 DNA assays ■ H a ve b e c o m e w id e s p re a d in H L A ty p in g

■ D e c re a s e d le v e ls o f C 3 re fle c t e ith e r □ P rim a ry C 3 d e fic ie n c y □ A c tiv a tio n o f th e a lte rn a te c o m p le m e n t p a th w a y ■ L e ve ls o f C 4 o r C 1q a re ty p ic a lly u sed to lo o k a t th e c la s s ic a l p a th w a y

6.2.8 HLA testing

■ P C R te s tin g h as th e a d v a n ta g e o f e lim in a tin g m a n y o f th e b io lo g ic u n c e rta in tie s o f th e “ s e ro lo g ic ” te c h n iq u e s d e s c rib e d a b o v e . F u rth e rm o re , it c a n re s o lv e H L A ty p e s w ith m u c h g re a te r s p e c ific ity th a n th e s e ro lo g ic te c h n iq u e s

6.2.8.7 Transplantation testing ■ P a n e l re a c tiv e a n tib o d y (P R A ) te s ts

6.2.8.1 Used primarily in

□ U se d to m o n ito r p a tie n ts w h o a re w a itin g fo r a tra n s p la n t

■ P re tra n s p la n ta tio n c o m p a tib ility te s tin g ■ P la te le t re fra c to rin e s s

■ T h e s e p a tie n ts m a y b e s e n s itiz e d to H L A a n tig e n s e ith e r th ro u g h tra n s fu s io n o f d o n o r b lo o d p ro d u c ts , p re g n a n c y , o r p re v io u s o rg a n tra n s p la n ta tio n

■ P a te rn ity /fo re n s ic id e n tity te s tin g ■ E v a lu a tio n o f H L A lin ked a u to im m u n e d is o rd e rs

6.2.8.2 The complement dependent cytotoxicity (CDC) assay is the gold standard for ■ D e te c tin g H L A a n tig e n s ■ D e te c tin g H L A a n tib o d ie s ■ P e rfo rm in g H L A c ro s s m a tc h in g

□ P R A a s s e s s e s th e p ro p o rtio n o f th e d o n o r p o p u la tio n th a t th e p a tie n t’s H L A a n tib o d ie s w ill re a c t a g a in s t, g iv in g s o m e g u id a n c e to th e ra te o f c o m p a tib ility o f an u n re la te d d o n o r o rg a n . F o r e x a m p le if th e p a tie n t h as a P R A o f 8 0 % , th is in d ic a te s th e p a tie n t is h ig h ly s e n s itiz e d a nd h a s a b o u t a 2 0 % c h a n c e o f c o m p a tib ility w ith an u n re la te d d o n o r o rg a n th a t b e c o m e s a v a ila b le ■ H L A m a tc h in g fo r tra n s p la n ta tio n

6.2.8.3 Mixed lymphocyte culture (MLC) ■ A s s a y c a p a b le o f d e te c tin g H L A c la s s II (H L A -D ) d iffe re n c e s a m o n g p o te n tia l d o n o r a nd re c ip ie n t ■ T h is te s t d e te c ts m a in ly H L A c la s s II d iffe re n c e s , w h ic h a re o f p a ra m o u n t im p o rta n c e , s e c o n d o n ly to A B O c o m p a tib ility , in o rg a n tra n s p la n ta tio n © A S C P 2018

6.2.8.4 Cross reactive antigen groups (CREGs)

□ U s u a lly in v o lv e s m a tc h in g a t le a s t 3 lo ci ■ H L A -A ■ H L A -B ■ H L A -D R

ISBN 9 7 8 -0 8 9 1 8 9 -6 6 7 8

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6: Immunology

Evaluation of immune function>HLA testing □ S in c e e a c h p e rs o n h a s 2 a lle le s (o n e on e a c h 6 p ) fo r e a c h lo c u s , th e re a re 6 p o s s ib le a lle le s ■ T h e C D C c ro s s m a tc h □ C a n d e te c t p re e x is tin g H L A a llo a n tib o d ie s in th e s e ru m o f th e p o te n tia l re c ip ie n t th a t h a v e s p e c ific ity fo r H L A a n tig e n s in th e p o te n tia l d o n o r ■ T h e s e p re fo rm e d H L A a n tib o d ie s a re th e m e d ia to rs o f s o c a lle d h y p e ra c u te re je c tio n , in w h ic h th e tra n s p la n te d o rg a n is ra p id ly d e s tro y e d by c irc u la tin g a n tib o d ie s □ P o s itiv e re s u lts o f a C D C c ro s s m a tc h b e tw e e n d o n o r a n d re c ip ie n t in d ic a te an in c o m p a tib ility , a n d th e o rg a n s h o u ld n o t b e tra n s p la n te d in to th e p a tie n t ■ T h e flo w c y to m e tric c ro s s m a tc h □ A m o re s e n s itiv e te s t th a n th e C D C a s s a y □ A llo w s fo r d e te c tio n o f lo w e r tite rs fo r b o th c o m p le m e n t d e p e n d e n t a n d c o m p le m e n t in d e p e n d e n t re c ip ie n t a n tib o d ie s to th e d o n o r g ra ft ■ L u m in e x te c h n o lo g y □ H a s b e e n c o rre la te d w ith flo w c ro s s m a tc h e s a nd C D C te s tin g □ L u m in e x v a lu e s ■ > 5 ,0 0 0 M F I c o rre la te s w ith a p o s itiv e T c e ll a n d B c e ll flo w c ro s s m a tc h ■ > 1 0 ,0 0 0 M F I c o rre la te s w ith a p o s itiv e C D C , in d ic a tin g h y p e ra c u te re je c tio n is lik e ly if th e o rg a n is tra n s p la n te d to th e p a tie n t ■ F o r re n a l tra n s p la n ta tio n , o rg a n s s h o u ld be □ A B O c o m p a tib le

■ Im m u n o g lo b u lin is d e p o s ite d a lo n g v e s s e l w a lls , in d u cin g c o m p le m e n t m e d ia te d v a s c u la r in ju ry ■ T h e re s u lt is th e fo rm a tio n o f fib rin a n d p la te le t th ro m b i, c a u s in g is c h e m ic n e c ro s is

6 .2 .8 .8 .2 A c u te c e llu la r rejectio n ■ E vo lve s o v e r d a y s to w e e k s a fte r tra n s p la n t ■ M e d ia te d b y T c e lls □ R e c ip ie n t T c e lls re c o g n iz e fo re ig n H L A a n tig e n s and s tim u la te a p o w e rfu l c e llu la r c y to to x ic re s p o n s e ■ H is to lo g ic a lly , a ly m p h o c y tic in filtra te is s e e n w ith in g ra ft e p ith e liu m (tu b u litis ) a n d e n d o th e liu m (e n d o th e litis ), a lo n g w ith in te rs titia l e d e m a i6.1

6 .2 .8 .8 .3 A c u te h u m o ral rejectio n ■ P re s e n ts w ith in d a y s to w e e k s a fte r tra n s p la n ta tio n ■ M e d ia te d by a n tib o d y ■ Like h y p e ra c u te re je c tio n , th e e n d o th e liu m is th e p rim a ry ta rg e t, w ith re s u ltin g in ju ry ta k in g o n e o f 2 fo rm s □ F irst, th e re m a y be a p a tte rn s im ila r to h y p e ra c u te re je c tio n , w ith fib rin o id n e c ro s is a n d n e u tro p h ilic in filtra tio n o f v e s s e l w a lls a nd re s u ltin g g ra ft in fa rc t □ S e c o n d , th e re m a y be a m o re in s id io u s v a s c u la r s u b e n d o th e lia l in tim a l th ic k e n in g w ith m o re p ro tra c te d g ra ft is c h e m ia ■ P a tie n ts w h o a re H L A a llo im m u n iz e d as a re s u lt o f p re g n a n c y o r tra n s fu s io n a re a t s ig n ific a n tly h ig h e r risk. In e ith e r ca s e , im m u n o h is to c h e m is try d e m o n s tra te s d e p o s itio n o f C 4 d in v e s s e l w a lls i6.2

□ H L A -A , H L A -B , a n d H L A -D R m a tc h e d (6 o f 6 id e a lly )

6 .2 .8 .8 .4 C h ro n ic rejectio n

□ C ro s s m a tc h c o m p a tib le ■ F o r tra n s p la n ta tio n o f h e a rt, lu n g , a n d liv e r □ S u c h s trin g e n c y is n o t re q u ire d □ A B O c o m p a tib ility is th e m a in d e te rm in a n t fo r d o n o r s e le c tio n ; H L A ty p in g m a y b e p e rfo rm e d b u t is n o t a re q u ire m e n t ■ H L A ty p in g re s o lu tio n re q u ire m e n ts fo r a llo g e n ic p ro g e n ito r c e ll tra n s p la n ts □ M o re s trin g e n t th a n fo r re n a l tra n s p la n ts □ It is o p tim a l to m a tc h th e d o n o r a n d re c ip ie n t a lle le s a t th e H L A -A , B, C a n d D R B 1 lo c i

■ M e d ia te d b y a c o m b in a tio n o f ly m p h o c y te s and a n tib o d ie s o v e r m o n th s to y e a rs , le a d in g to e v e n tu a l g ra ft fa ilu re ■ H is to lo g ic fin d in g s in c lu d e in te rs titia l fib ro s is , a rte rio lo s c le ro s is o f v e s s e ls a n d c o m p le m e n t d e p o s its in p e ritu b u la r v e s s e ls

6.2.8.9 Graft vs host disease (GVHD) ■ 3 re q u is ite s fo r th e d e v e lo p m e n t o f G V H D □ Im m u n o c o m p e te n t d o n o r T c e lls □ Im m u n o s u p p re s s e d re c ip ie n t □ A n tig e n ic d iffe re n c e s b e tw e e n d o n o r a nd re c ip ie n t

6.2.8.8 Transplant rejection

■ A c u te G V H D

6 .2 .8 .8 .1 H y p e ra c u te re je c tio n ■ O c c u rs w ith in h o u rs o f tra n s p la n ta tio n ■ M e d ia te d b y p re fo rm e d h ig h tite r a n tib o d ie s to A B O o r H L A a n tig e n s e x p re s s e d b y d o n o r g ra ft e n d o th e liu m

□ O c c u rs w ith in th e firs t 100 d a y s a fte r tra n s p la n t, w ith m o s t c a s e s p re s e n tin g w ith in th e firs t 3 0 d a ys □ 3 m a in ta rg e ts o f a c u te G V H D ■ S kin

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Evaluation of immune function>HLA testing Primary immunodeficiency disorders>B cell defects

i6.2 C4d immunofluorescence detects C4d deposits in the cortical peritubular capillaries indicating the presence of alloantibodies against HLA antigens on the peritubular capillary endothelium; normal kidneys demonstrate C4d deposition in glomeruli only

■ C h ro n ic G V H D □ O c c u rs a fte r th e firs t 100 d a y s □ A ffe c ts th e s k in , h e p a to b ilia ry tra c t, in te s tin a l tra c t, a n d th e m u c o s a o f th e m o u th , v a g in a , e y e , a n d re s p ira to ry tra c t □ T h e s e p a tie n ts e x p e rie n c e e x te n s iv e c u ta n e o u s s c le ro s is th a t re s e m b le s p ro g re s s iv e s y s te m ic s c le ro s is . T h e y m a y e x p e rie n c e e s o p h a g e a l s tric tu re s , b ro n c h io litis o b lite ra n s , s c a rrin g o c u la r le s io n s , a n d c h ro n ic liv e r d a m a g e i6.1 Acute cellular rejection of kidney a, characterized by lymphocytic infiltrate with interstitial edema; at high magnification b, there is evidence of tubulitis, a lesion consisting of T lymphocytes infiltrating into renal tubular epithelium

■ In itia lly c h a ra c te riz e d by an e ry th e m a to u s , p ru ritic rash, h is to lo g ic a lly d e m o n s tra tin g c h a ra c te ris tic e ry th e m a m u ltifo rm e -lik e a p o p to s is th a t is m o s t p ro n o u n c e d a t th e b a s e s o f rete rid g e s

□ T h e ra te o f d e a th in T A -G V H D is o v e r 9 0 % d u e to a p la s tic a n e m ia a n d ca n be p re v e n te d b y irra d ia tin g ly m p h o c y te c o n ta in in g b lo o d p ro d u c ts in im m u n o c o m p ro m is e d p a tie n ts

6.3 Primary immunodeficiency disorders 6.3.1 B cell defects

■ In te s tin a l tra c t ■ P re s e n ts w ith d ia rrh e a . H is to lo g ic a lly , c o lo n b io p s ie s s h o w e c ta tic c ry p ts w ith a tte n u a te d e n te ro c y te s , c ry p t a b s c e s s e s , a nd s trik in g a p o p to s is w ith in th e c ry p t e p ith e liu m ■ H e p a to b ilia ry tra c t ■ L iv e r in v o lv e m e n t p re s e n ts w ith ja u n d ic e , h is to lo g ic a lly c h a ra c te riz e d by m o n o n u c le a r p o rta l in fla m m a to ry in filtra te s w ith e n d o th e lia litis , d u c titis , a n d d u c to p e n ia © A S C P 2018

■ T h is is d iffe re n t fro m tra n s fu s io n a s s o c ia te d G V H D (T A -G V H D ) in w h ic h th e m ain ta rg e t o f th e a tta c k is th e b o n e m a rro w

6.3.1.1 Bruton (X linked) agammaglobulinemia ■ R e c u rre n t b a c te ria l in fe c tio n s , p a rtic u la rly re la te d to e n c a p s u la te d b a c te ria , b e g in n in g ~ 6 m o n th s o f a g e ■ N o rm a l im m u n ity a g a in s t m o s t v ira l a n d fu n g a l p a th o g e n s ; in c re a s e d s u s c e p tib ility to p o lio , h e p a titis , a nd e n te ro v iru s e s ■ H ig h in c id e n c e o f ly m p h o id n e o p la s m s a n d a u to im m u n e d is e a s e s

ISBN 9 7 8 -0 8 9 1 8 9 -6 6 7 8

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6: Immunology

Primary immunodeficiency disorders>B cell defects | T cell defects ■ S e ru m im m u n o g lo b u lin le v e ls (Ig G , Ig A , a n d Ig M ) a re m a rk e d ly re d u c e d , a s is th e n u m b e r o f c irc u la tin g m a tu re C D 1 9 + B c e lls ■ L y m p h n o d e s i6.3 a n d to n s ils a re ru d im e n ta ry ■ T h e re s p o n s ib le g e n e , B T K , is fo u n d on th e X c h ro m o s o m e . It e n c o d e s a ty ro s in e k in a s e c a lle d B tk (B ru to n ty ro s in e k in a s e )

6.3.1.2 Common variable imm unodeficiency (CVID) ■ T y p ic a l o n s e t is in 2 n d o r 3 rd d e c a d e ■ R e c u rre n t u p p e r a n d lo w e r re s p ira to ry tra c t in fe c tio n s , in te s tin a l b a c te ria l o v e rg ro w th a n d G ia rd ia in te s tin a lis in fe c tio n ; b ro n c h ie c ta s is c o m m o n ■ L o w s e ru m im m u n o g lo b u lin (Ig G , Ig M , a n d Ig A ) a n d v a ria b le T c e ll d e fic ie n c y ■ B c e lls la c k th e c a p a c ity to d iffe re n tia te in to p la s m a c e lls ; g e rm in a l c e n te rs a re h y p e rp la s tic . T y p ic a l s m a ll b o w e l m o rp h o lo g y i6.4 in c lu d e s p ro n o u n c e d re a c tiv e fo llic u la r ly m p h o id h y p e rp la s ia w ith lo w n u m b e r o f p la s m a c e lls

i6.3 Lymph node in Bruton agammaglobulinemia; note the absence of lymphoid follicles

6.3.1.3 Selective IgA deficiency ■ R e c u rre n t re s p ira to ry a n d g a s tro in te s tin a l b a c te ria l in fe c tio n s ■ H ig h in c id e n c e o f a u to im m u n ity ■ A t ris k fo r a n a p h y la x is d u e to tra n s fu s io n o f Ig A c o n ta in in g b lo o d p ro d u c ts ■ M o s t c o m m o n in h e rite d im m u n o d e fic ie n c y d is e a s e (1 in 7 0 0 p e o p le )

6.3.1.4 Hyper IgE syndrome (Job syndrome) ■ R e c u rre n t s ta p h y lo c o c c a l in fe c tio n , c o a rs e fa c ia l fe a tu re s , a n d e le v a te d Ig E t6 .3 ■ E o s in o p h ilia a n d e c z e m a

t6.3 Im m unodeficiency syndrom es with abnorm al Ig E levels

decreased IgE

304

6.3.2 T cell defects 6.3.2.1 DiGeorge syndrome

■ A u to s o m a l d o m in a n t a n d a u to s o m a l re c e s s iv e fo rm s

increased IgE

i6.4 Duodenal biopsy in common variable immunodeficiency (CVID) a Note pronounced lymphoid follicular hyperplasia with germinal center formation b At higher power, plasma cells are absent; Giardia was present on the luminal surface

Wiskott-Aldrich syndrome Job syndrome (hyper IgE syndrome) Nezelof syndrome Bruton agammaglobulinemia ataxia-telanqiectasia

■ F a ilu re o f th e 3 rd a nd 4 th p h a ry n g e a l p o u c h e s to d e v e lo p ; h y p o p la s tic th y m u s and p a ra th y ro id , a n o m a lie s o f th e g re a t v e s s e ls , ty p ic a l fa c ie s (h y p e rte lo ris m , lo w s e t e a rs , m a n d ib u la r h y p o p la s ia ), b ifid u v u la , a nd a h ig h e r th a n u su a l in c id e n c e o f e s o p h a g e a l a tre s ia ■ M ay p re s e n t w ith n e o n a ta l h y p o c a lc e m ic te ta n y ■ P a rtia l D iG e o rg e s y n d ro m e m o re c o m m o n th a n c o m p le te D iG e o rg e s y n d ro m e ; s o m e c a s e s p re s e n t as C H A R G E s e q u e n c e (c o lo b o m a , h e a rt d e fe c t, c h o a n a l a tre s ia , re ta rd a tio n o f d e v e lo p m e n t, g e n ita l h y p o p la s ia , and e a r a n o m a lie s )

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

6: Immunology

Primary immunodeficiency disorders>T cell defects | Neutrophil/phagocytic defects ■ T ce ll d e fe c t re s u lts in s u s c e p tib ility to o p p o rtu n is tic fu n g i, v iru s e s , a nd P n e u m o c y s tis jir o v e c i m In c re a s e d ris k o f tra n s fu s io n a s s o c ia te d g ra ft v s h o s t

d is e a s e ■ L ym p h n o d e p a ra c o rtic a l a re a s a re d e p le te d , a n d p o o rly d e v e lo p e d p e ria rte rio la r ly m p h a tic s h e a th s (P A L S ) a re fo u n d in th e s p le e n ■ M ic ro d e le tio n s in v o lv in g c h ro m o s o m e 2 2q11.2 ■ O c c u rs s p o ra d ic a lly ; s o m e c a s e s a s s o c ia te d w ith in u te ro e x p o s u re to A c c u ta n e

6.3.2.6 Chronic mucocutaneous candidiasis ■ S e le c tiv e d e fe c t in T ce ll im m u n ity to c a n d id a l in fe c tio n ■ A s s o c ia te d w ith e n d o c rin o p a th ie s a n d a v a rie ty o f a u to im m u n e d is o rd e rs ■ M u ta tio n s in a u to im m u n e re g u la to r g e n e (A IR E ), c h ro m o s o m e 2 1 q 2 2 .3

6.3.2.7 Duncan disease (X linked lymphoproliferative disease) ■ F u lm in a n t a n d o fte n fa ta l im m u n e re s p o n s e to E p s te in -B a rr v iru s (E B V ) in fe c tio n ■ O fte n h a ve an im m u n e s y s te m d e fe c t like c o m m o n v a ria b le im m u n o d e fic ie n c y

6.3.2.2 Severe combined immunodeficiency (SCID) ■ D e c re a s e d /a b s e n t T ce ll fu n c tio n , lo w /u n d e te c ta b le im m u n o g lo b u lin , a nd th y m ic d y s p la s ia

■ In v e rte d C D 4 :C D 8 ra tio and h y p o g a m m a g lo b u lin e m ia com m on

■ L ife th re a te n in g im m u n o d e fic ie n c y a nd in c re a s e d ris k fo r tra n s fu s io n a s s o c ia te d g ra ft vs h o s t d is e a s e

■ T h e u n d e rly in g g e n e tic a b n o rm a lity is fo u n d in th e S H 2 D 1 A g e n e , X q 2 5 , w h ic h c o d e s fo r an S H 2 d o m a in on a s ig n a l tra n s d u c in g p ro te in c a lle d S L A M a s s o c ia te d p ro te in (S A P )

■ V a rie ty o f g e n e tic d e fe c ts

6.3.2.3 Hyper IgM syndrome (X linked immunodeficiency with hyper IgM) ■ Im p a ire d is o ty p e c la s s s w itc h in g , w ith lo w le v e ls o f IgG , Ig A , IgE a nd in c re a s e d IgM ■ C lin ic a l p ic tu re s im ila r to B ru to n a g a m m a g lo b u lin e m ia ■ X lin ked in h e rite d d is o rd e r c a u s e d by d e fe c t in g e n e th a t e n c o d e s C D 1 5 4 , th e T ce ll lig a n d fo r th e B c e ll re c e p to r CD40

6.3.2.4 Wiskott-Aldrich syndrome (WAS)

6.3.3 Neutrophil/phagocytic defects 6.3.3.1 Chronic granulomatous disease (CGD) ■ D e fe c tiv e in tra c e llu la r o x id a tiv e k illin g o f in g e s te d o rg a n is m s , m o s t c o m m o n ly re s u ltin g fro m d e fic ie n c y o f N A D P H o x id a s e ■ C h ro n ic s u p p u ra tiv e in fe c tio n s w ith c a ta la s e p o s itiv e b a c te ria , e s p e c ia lly S ta p h y lo c o c c i, E n te ro b a c te r, a n d A s p e rg illu s ', s tre p to c o c c a l in fe c tio n s n o t c o m m o n ■ E x te n s iv e g ra n u lo m a fo rm a tio n a t s ite s o f in fe c tio n

■ X lin k e d in h e rite d d is o rd e r th a t p re s e n ts w ith th e tria d o f e c z e m a , th ro m b o c y to p e n ia , a nd im m u n o d e fic ie n c y ■ S u s c e p tib ility to in fe c tio n by P n e u m o c o c c i a n d o th e r e n c a p s u la te d b a c te ria , P n e u m o c y s tis jiro v e c i, and h e rp e s v iru s ■ T h e W A S g e n e is lo c a te d on th e X c h ro m o s o m e , e n c o d e s W is k o tt-A ld ric h s y n d ro m e p ro te in (W A S P )

■ T h e s c re e n in g te s t is th e n itro b lu e te tra z o liu m (N B T ) te s t; o x id a tiv e b u rs t ca n a lso b e m e a s u re d b y c h e m ilu m i n e s c e n c e o r flo w c y to m e try ■ A ffe c te d le u k o c y te s a re d e fic ie n t in C 3 b re c e p to rs . R ed c e lls o fte n b e a r th e M c L e o d p h e n o ty p e (a b s e n c e o f K ell a n tig e n , K x)

6.3.3.2 Chediak-Higashi syndrome 6.3.2.5 Ataxia telangiectasia (Louis-Bar syndrome) ■ C e re b e lla r a ta x ia , o c u lo c u ta n e o u s te la n g ie c ta s ia , re c u rre n t s in o p u lm o n a ry in fe c tio n s , a nd a h ig h in c id e n c e o f m a lig n a n c ie s ■ C o m b in e d T c e ll a n d B c e ll d e fe c t ■ L a b o ra to ry a b n o rm a litie s in c lu d e d e fic ie n t Ig A , a lo n g w ith v e ry h ig h s e ru m A F P a n d C E A ■ A u to s o m a l re c e s s iv e , c a u s e d by m u ta tio n s in th e A T M g e n e , on 11q22.3

© A S C P 2018

■ A u to s o m a l re c e s s iv e c o n d itio n th a t p re s e n ts a s n e u tro p e n ia , re c u rre n t in fe c tio n , th ro m b o c y to p e n ia , a n d o c u lo c u ta n e o u s a lb in is m ■ D e fe c tiv e d e g ra n u la tio n ■ G ra n u lo c y te s , ly m p h o c y te s , a n d m o n o c y te s s h o w g ia n t c y to p la s m ic g ra n u le s ■ M u ta tio n in th e ly s o s o m a l tra ffic k in g re g u la to r (C H S 1 / L Y S T ) g e n e a t 1q42.1-2

ISBN 9 7 8 -0 8 9 1 8 9 -6 6 7 8

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Primary immunodeficiency disorders>Neutrophil/phagocytic defects | Complement deficiencies Autoimmunity & rheumatologic disease>Pathophysiology 6.3.3.3 May-Hegglin anomaly ■ A u to s o m a l d o m in a n t c o n d itio n m a n ife s tin g a s D o h le lik e b o d ie s in g ra n u lo c y te s a n d m o n o c y te s , v a ria b ly s ize d p la te le ts , a n d th ro m b o c y to p e n ia i6.5 ■ D o h le lik e b o d ie s a b o lis h e d b y rib o n u c le a s e

6.3.3.4 Alder-Reilly anomaly ■ M a in ly a m o rp h o lo g ic fin d in g ■ L a rg e a z u ro p h ilic g ra n u le s re s e m b lin g to x ic g ra n u la tio n in a ll w h ite b lo o d c e lls ■ A s s o c ia te d w ith m u c o p o ly s a c c h a rid o s e s

6.3.3.5 Pelger-Huet anomaly ■ A n a u to s o m a l d o m in a n t d is o rd e r ■ D y s fu n c tio n a l s e g m e n ta tio n o f n e u tro p h ils ■ B ilo b e d n e u tro p h ils a re s e e n ; in h o m o z y g o te s m o n o lo b a te d n e u tro p h ils (S to d tm e is te r c e lls ) a re s e e n ■ F u n c tio n a lly , th e c e lls a re n o rm a l

i6.5 May-Hegglin anomaly a Prominent Dohle bodies within granulocytes, in addition to an enlarged platelet b Dohle body within a basophil

■ O th e r th e ra p ie s in c lu d e a k a llik re in in h ib ito r (e c a lla n tid e ) a nd a b ra d y k in in B2 re c e p to r (ic a tib a n t) a n ta g o n is t; a n d ro g e n ic a g e n ts (d a n a z o l, o x a n d ro lo n e a n d m e th y lte s to s te ro n e ) a re u s e d a s p ro p h y la x is

6.4 Autoimmunity & rheumatologic disease 6.4.1 Pathophysiology

6.3.3.6 Jordan anomaly ■ C h a ra c te riz e d b y fa t v a c u o le s in le u k o c y te s

6.3.4 Complement deficiencies ■ D e fic ie n c y o f c la s s ic a l p a th w a y c o m p o n e n ts (C 1q, C 2, C 4 ) is p rim a rily m a n ife s te d b y a u to im m u n e p h e n o m e n a s u c h a s lu p u s ■ D e fic ie n c y o f C 2 a n d C 3 le a d s to re c u rre n t in fe c tio n s w ith G ra m + e n c a p s u la te d o rg a n is m s ■ D e fic ie n c y o f m e m b ra n e a tta c k c o m p le x c o m p o n e n ts (C 5 -C 9 ), a ls o re fe rre d to a s te rm in a l c o m p le m e n t c o m p o n e n ts , le a d s to re c u rre n t s e rio u s s y s te m ic in fe c tio n s , e s p e c ia lly d u e to e s p e c ia lly d u e to N m e n in g itid is a n d N g o n o rrh e a m C1 e s te ra s e in h ib ito r (C1 IN H ) d e fic ie n c y a n d h e re d ita ry

a n g io e d e m a (H A E ) □ C1 e s te ra s e in h ib ito r (C1 Inh) d e fic ie n c y is an a u to s o m a l d o m in a n t d is o rd e r a ls o c a lle d h e re d ita ry a n g io e d e m a (H A E ) □ U rin a ry h is ta m in e le v e ls a n d s e ru m C1 le v e ls a re e le v a te d d u rin g a tta c k s , w h ile s e ru m C H 5 0 , C 4 , and C 2 a re d e c re a s e d . B e tw e e n a tta c k s , C 4 is a lw a y s low , w h ile C 2 le v e ls a re n o rm a l □ T h e ra p ie s ■ In th e p a s t, a c u te e p is o d e s w e re tre a te d w ith in fu s io n s o f d o n o r p la s m a ■ H o w e v e r, re c o m b in a n t C1 in h ib ito r c o n c e n tra te b e c a m e a v a ila b le in 2 0 0 8 a n d is n o w th e firs t lin e th e ra p y fo r th e s e p a tie n ts

306

■ T o le ra n c e a c q u is itio n o c c u rs d u rin g fe ta l d e v e lo p m e n t in th e th y m u s ■ A u to im m u n ity o c c u rs w h e n th e re is a b re a k d o w n in s e lf to le ra n c e ■ M H C d is e a s e a s s o c ia tio n s t6.4 t6 .4 H L A d is e a s e a s s o c ia tio n s

Polygenic disease

MHC gene association

hereditary hemochromatosis 21-hydroxylase deficiency ankylosing spondylitis Behget disease celiac sprue

HLA-A3 HLA-C4 HLA-B27 HLA-B51 HLA-DQ2, DQ8 (specific alleles: DRB1*0301, DQB1*0201, DQAT0501, DRB1*0701, DQB1 *0201, DQAT0501) diabetes mellitus (DM), type 1 increased incidence of DM: HLA-DR3 or DR4 (specific alleles: DQB1*0302, DQA1*0301; specific alleles with decreased incidence: DRB1 *1501, DQB1*0602) multiple sclerosis HLA-DRB1; HLA-DQB1 (specific alleles: DRB1*1501, DQB1*0602, DQA1*0102) narcolepsy HLA-DQ6 (specific allele: DQB1*0602) rheumatoid arthritis (RA) HLA-DR4 (specific alleles: DRB1*0401; DRB1*0404; DRB1*0405; DRB1*0408)

6.4.1.1 Autoimmune diseases are most prevalent in women of reproductive age ■ E x c e p tio n s w o rth n o tin g a re a n k y lo s in g s p o n d y litis and p rim a ry s c le ro s in g c h o la n g itis , w h ic h a ffe c ts m a le s m o re o fte n th a n fe m a le s , a n d S jo g re n s y n d ro m e th a t a ffe c ts p o s tm e n o p a u s a l fe m a le s

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Autoimmunity & rheumatologic disease>Pathophysiology 6.4.1.2 Triggering agents include both microorganisms & medications ■ H e p a titis B v ira l (H B V ) in fe c tio n ca n trig g e r p o ly a rte ritis n o d o s u m (P A N ); in fe c tio n m a y p ro v o k e a n k y lo s in g s p o n d y litis ■ T h e d ru g a ld o m e t ca n lea d to a u to im m u n e h e m o ly tic a n e m ia ; p e n ic illa m in e is lin ked to s y s te m ic v a s c u litis ■ P ro c a in a m id e , h y d ra la z in e a n d is o n ia z id a re a s s o c ia te d w ith d ru g in d u c e d lu p u s

b

JO

.

^

J.

•

jm l l

•

__________ ^4*___ i i6.6 LE cells consisting of a leukocyte with an ingested degenerated nucleus

■ In d ire c t im m u n o flu o re s c e n c e (IIF )

6.4.1.3 Laboratory testing, general ■ C o m m o n fin d in g s in c lu d e a n e m ia o f c h ro n ic d is e a s e and e le v a tio n o f a c u te p h a s e re a c ta n ts ■ P la te le ts m a y b e e le v a te d (a cu te p h a s e re a c ta n t) ■ M a y h ave e ith e r le u k o c y to s is o r le u k o p e n ia , a nd lu p u s in p a rtic u la r is a s s o c ia te d w ith ly m p h o p e n ia ■ T h e a P T T m ay be p ro lo n g e d if th e re is a lu p u s a n tic o a g u la n t

□ In v o lv e s in c u b a tin g p a tie n t s e ru m w ith c e lls /tis s u e k n o w n to c o n ta in s p e c ific a n tig e n s , th e n a d d in g flu o re s c e in la b e le d a n ti-h u m a n g lo b u lin (A H G ) □ P o s itiv e IIF te s ts c o n firm th e p re s e n c e o f c irc u la tin g a u to a n tib o d ie s

6.4.1.5 Anti-nuclear antibodies (ANA)

■ N o n s p e c ific in fla m m a to ry m a rk e rs in c lu d e C R P , E S R , fe rritin , a nd fib rin o g e n ; E S R o fte n u sed to m o n ito r d is e a s e a c tiv ity ■ C o m p le m e n t le v e ls ca n s e rv e a s m a rk e rs o f d is e a s e a c tiv ity in im m u n e c o m p le x d e p o s itio n d is o rd e rs su ch as lu p u s ■ S y n o v ia l flu id a n a ly s is m a y d is c lo s e m o n o n u c le a r cell p re d o m in a n t (R A ), n e u tro p h il p re d o m in a n t (se p tic, g ou t), h is tio c y te p re d o m in a n t (P V N S ), o r p a u c i-in fla m m a to ry (D J D ) p a tte rn s ■ L u p u s e ry th e m a to s u s (L E ) c e lls i6.6 a re n e u tro p h ils w ith in g e s te d ly m p h o c y te n u c le i □ T h e ly m p h o c y te n u c le u s s h o u ld be d e v o id o f c h ro m a tin d e ta il a nd sta in p in k in W rig h t s ta in e d p re p a ra tio n s □ M a y be s e e n in p le u ra l e ffu s io n s , jo in t e ffu s io n s , o r b o n e m a rro w a s p ira te s and p ro v id e s tro n g e v id e n c e fo r S L E □ T h e “ ta r t” ce ll m im ic s th e LE ce ll b u t re ta in s c h ro m a tin d e ta il, and c h ro m a tin s ta in s b lu e p u rp le ■ H is to lo g ic a lly , R A a n d R A like c o n d itio n s d e m o n s tra te m a rk e d p a p illa ry s y n o v ia l h y p e rp la s ia a nd u s u a lly d e n s e in filtra te o f ly m p h o c y te s a n d p la s m a c e lls , o fte n w ith n o d u la r ly m p h o id a g g re g a te s w ith in w h ic h th e re m a y be g e rm in a l c e n te rs

6.4.1.4 Autoantibody detection by immunofluorescence ■ D ire c t im m u n o flu o re s c e n c e (D IF ) □ In v o lv e s in c u b a tin g c ry o s ta t s e c tio n s o f p a tie n t tis s u e w ith flu o re s c e in la b e le d a n ti-h u m a n g lo b u lin (A H G ) □ P o sitiv e D IF te s ts c o n firm th e in v ivo p re s e n c e o f b o u n d a u to a n tib o d ie s in th e p a tie n t’s tis s u e s © A S C P 2018

a

■ C u rre n tly , m e th o d s to d e te c t A N A in c lu d e e n z y m e lin k e d im m u n o s o rb e n t a s s a y (E L IS A ) a n d IIF, in c u b a tin g p a tie n t s e ru m w ith H E p 2 c e lls ; p a tte rn o f flu o re s c e n c e b o th in th e m ito tic a lly a c tiv e a n d re s tin g c e lls is n o te d t6 .5 , f6 .4 , a n d all p o s itiv e s a re s e ria lly d ilu te d to d e te rm in e tite r ■ N e g a tiv e A N A v irtu a lly e x c lu d e s s y s te m ic lu p u s e ry th e m a to s u s (S L E )

t6.5 ANA patterns Fluorescent staining pattern Antigen specificity & disease associations homogeneous or fluorescent mitotic figures distinguish this from a finely peripheral (rim pattern), speckled pattern mitoses + homogeneous pattern: indicate antibodies to ssDNA & histone rim pattern: indicate anti-dsDNA, which are antibodies to nuclear envelope antigens or lamins disease associations: suggestive of SLE, especially if titer is high. Low titer homogeneous pattern: Sjogren syndrome, mixed connective tissues disease (MCTD) & rheumatoid arthritis rim pattern: Primary biliary cirrhosis, chronic liver disease, drug induced SLD anti-Sm, RNP, Ro/SS-A, La/SS-B, PCNA (extractable speckled (mitoses-) nuclear antigens) disease associations: this pattern occurs in CREST, SLE, mixed connective tissue disease (MCTD), Sjogren syndrome, rheumatoid arthritis & scleroderma nucleolar (mitoses-)

antibodies to RNA polymerase I & proteins of small nucleolar RNP complex (fibrillin, hU3-55K, Mpp10) Th/To, B23, PM-Scl & NOR-90 disease associations: scleroderma centromere (mitoses+ in antibodies to Sd-70, the centromeres of chromosomes, centromeric pattern) specifically on active centromere proteins: CENP-A, CENP-B, CENP-C disease associations: CREST (50-80% patients are positive), idiopathic Raynaud phenomenon ______________________(25% patients are positive)______________________ CREST- syndrome of calcinosis, Raynaud, esophageal sclerosis, sclerodactyly & telangiectasia

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Autoimmunity & rheumatologic disease>Pathophysiology

d

r.,®.

antigens: RNA polymerase I, U3-RNP (fibrillarin), PM-Scl

associations: scleroderma, polymyositis/sderoderma overlap

e

antigens: SSA (Ro), SSB (La), Smith,

Sjogren, scleroderma

antigens: CENP- A, B & C (with CREST syndrome), ___________________________________________ Raynaud_____________

U1-RNP, PCNA, Sd-70 (fine speckling)

f

antigens: DNA, histone, dsDNA, ssDNA

induced lupus, rheumatoid arthritis

f6.4 ANA patterns: a negative, b speckled, c homogeneous, d nucleolar, e centromere , f anti dsDNA quantitation with Crithidia luciliae • P o s itiv e A N A is n o t s p e c ific fo r S L E □ 2 0 % o f n o rm a l a d u lts h a v e an A N A tite r o f 1:40, a n d up to 5 % h a v e a p o s itiv e A N A w ith a tite r o f 1:160; fa ls e p o s itiv e s in c re a s e w ith a g e □ N o n -S L E c o n d itio n s a s s o c ia te d w ith a p o s itiv e A N A t6.6 in c lu d e o th e r a u to im m u n e d is e a s e s (S jo g re n s y n d ro m e , s c le ro d e rm a , rh e u m a to id a rth ritis ), m u ltip le s c le ro s is , in fe c tio n , m a lig n a n c y , a n d fib ro m y a lg ia □ W h e n a c u to ff tite r o f 1:40 is u s e d , th e s p e c ific ity is - 8 0 % . W h e n 1:160 is u s e d , th e s p e c ific ity is - 9 5 %

t6.6 Frequency of ANA in various conditions Condition

Approximate frequency (%)

systemic lupus erythematosus progressive systemic sclerosis polymyositis/dermatomyositis Sjogren syndrome drug induced lupus mixed connective tissue disease anti-phospholipid antibody syndrome rheumatoid arthritis normal adults

-100% 95 60 60 100 (by definition) 100 (by definition) 40 40 10 (at cutoff of 1:80)

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■ To h e lp c o n firm th e d ia g n o s is o f S L E , a d d itio n a l te s tin g fo r a n ti-d o u b le s tra n d e d (ds) D N A , a n ti-S m ith (Sm ), and a n ti-p h o s p h o lip id a n tib o d ie s o fte n u n d e rta k e n ; how ever, th e s e te s ts h ave lo w e r s e n s itiv ity fo r S L E ■ H igh tite r a n ti-R N P (> 1 :1 0 ,0 0 0 ) a n tib o d ie s a re c h a ra c te ris tic o f m ixe d c o n n e c tiv e tis s u e d is e a s e (M C T D ), p a rtic u la rly if u n a c c o m p a n ie d by o th e r A N A s . A n ti-R N P is c o m m o n ly s e e n in S L E , b u t tite rs a re u s u a lly m o d e s t ■ A n ti-S S -A /R o a nd a n ti-S S -B /L a a n tib o d ie s w ith n e g a tive d s D N A a nd S m a re c o m p a tib le w ith S jo g re n s y n d ro m e ■ A n ti-S c l-7 0 (a n ti-to p o is o m e ra s e 1) is s e e n e x c lu s iv e ly in p ro g re s s iv e s y s te m ic s c le ro s is (P S S ) ■ A n ti-c e n tro m e re a n tib o d ie s a re s tro n g ly s u g g e s tiv e o f C R E S T s y n d ro m e a nd a re o c c a s io n a lly s e e n in P S S and R a y n a u d s y n d ro m e ■ D ru g in d u c e d lu p u s is u s u a lly n e g a tiv e fo r d s D N A , Sm , and R N P b u t is c h a ra c te riz e d by p o s itiv e A N A and a n ti-h is to n e a n tib o d ie s d ire c te d at th e H 2 A -H 2 B d im e r c o m p le x

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Autoimmunity & rheumatologic disease>Pathophysiology | Autoimmune diseases ■ T h e te rm s “e x tra c ta b le n u c le a r a n tig e n s ” a nd “s ig n a l re c o g n itio n p a rtic le s ” re fe r to s u b g ro u p s o f A N A s □ E x tra c ta b le n u c le a r a n tig e n s in c lu d e S m ith (Sm ), rib o n u c le o p ro te in (R N P ), S S A (R o), a n d S S B (La) □ S ig n a l re c o g n itio n p a rtic le s (S R P s ) in c lu d e Jo1 a n d P M /S c l. S R P s a re s tro n g ly a s s o c ia te d w ith in fla m m a to ry m y o s itis ■ A n ti-d s D N A d e te c tio n by im m u n o flu o re s c e n c e re lie s u p o n th e p re s e n c e o f d s D N A in th e k in e to p la s t o f th e o rg a n is m C rith id ia lu c ilia e

6.4.1.6 Antibodies to cytoplasmic constituents ■ S c re e n in g fo r a n tib o d ie s to c y to p la s m ic c o n s titu e n ts is p e rfo rm e d by IIF u sin g rat tis s u e a s s u b s tra te , ie, ra t liver, kidn ey, and s to m a c h th a t a re “ s a n d w ic h e d ” to g e th e r ■ E x a m in e d fo r p a tte rn o f flu o re s c e n c e t6.7 a n d all p o s itiv e s a re tite re d

t6.7 Cytoplasmic antibodies fluorescent staining Cytoplasmic antibody pattern anti-mitochondrial antibody (AMA) anti-smooth muscle antibody (ASMA) anti-parietal antibody (APA) anti-liver kidney microsomal (LKM) pANCA

cANCA

cytoplasm of gastric parietal cells, renal tubular cells & hepatocytes gastric smooth muscle & renal parenchymal arteries gastric parietal cells

Disease associations primary biliary cirrhosis

autoimmune hepatitis

pernicious anemia, atrophic gastritis cytoplasm of hepatocytes autoimmune hepatitis & renal tubular cells primary sclerosing perinuclear staining of cholangitis, ulcerative neutrophils colitis, microscopic polyangiitis, polyarteritis nodosum (PAN) Wegener granulomatosis, cytoplasmic staining of microscopic polyanqiitis neutrophils

■ In c e rta in in s ta n c e s , th is a p p ro a c h h as b e e n re p la c e d w ith E L IS A ■ A n ti-m ito c h o n d ria l a n tib o d y (A M A ) □ D e m o n s tra te s re a c tiv ity w ith th e c y to p la s m o f g a s tric p a rie ta l c e lls , re n a l tu b u la r c e lls , a nd h e p a to c y te s □ D ire cte d a g a in s t a m ito c h o n d ria l a n tig e n c a lle d M 2 □ A s s o c ia te d w ith p rim a ry b ilia ry c irrh o s is (P B C ) ■ A n ti-s m o o th m u s c le a n tib o d y (A S M A ) re a c ts w ith th e s m o o th m u s c le o f th e g a s tric tis s u e a nd re n a l a rte rio le s . A n ti-liv e r k id n e y m ic ro s o m a l (a n ti-L K M ) a n tib o d y re a c ts w ith th e c y to p la s m o f h e p a to c y te s a nd re na l tu b u la r e p ith e lia l ce lls. B o th A S M A a n d a n ti-L K M a re a s s o c ia te d w ith a u to im m u n e h e p a titis © A S C P 2018

■ A n ti-n e u tro p h il c y to p la s m ic a n tib o d y (A N C A ) □ R e fe rs to a p a tte rn o f re a c tiv ity o b ta in e d w h e n p a tie n t s e ra a re in c u b a te d w ith a lc o h o l fix e d n e u tro p h ils □ T e s tin g fo r A N A s is p e rfo rm e d on all p o s itiv e s to e x c lu d e a fa ls e p o s itiv e A N C A d u e to th e p re s e n c e o f ANAs □ C y to p la s m ic A N C A (c A N C A ) a p p e a rs a s a c y to p la s m ic g ra n u la r p a tte rn w ith p e rin u c le a r a c c e n tu a tio n ; c A N C A has a n ti-p ro te in a s e 3 (P R 3 ) s p e c ific ity . c A N C A is h ig h ly s p e c ific fo r W e g e n e r □ P e rin u c le a r A N C A (p A N C A ) is c h a ra c te riz e d by p re d o m in a n tly p e rin u c le a r im m u n o flu o re s c e n c e , a n d h a s a n ti-m y e lo p e ro x id a s e (M P O ) a c tiv ity . p A N C A is p re s e n t in m ic ro s c o p ic p o ly a n g iitis (M P A ), p o ly a rte ritis n o d o s u m (P A N ), p rim a ry s c le ro s in g c h o la n g itis (P S C ) a n d u lc e ra tiv e c o litis (U C ) ■ A n ti-th y ro id a n tib o d ie s by im m u n o flu o re s c e n c e □ D e te c te d b y in c u b a tin g s e ru m w ith c ry o s ta t s e c tio n s o f th y ro id a n d flu o re s c e in la b e le d A H G □ F lu o re s c e n c e th a t h ig h lig h ts fo llic u la r e p ith e lia l c e ll c y to p la s m is c o n s is te n t w ith a n ti-th y ro id p e ro x id a s e (a n ti-m ic ro s o m a l) a n tib o d y . F lu o re s c e n c e th a t h ig h lig h ts fo llic u la r c o n te n t on m e th a n o l fix e d tis s u e is c o n s is te n t w ith a n ti-th y ro g lo b u lin ■ A u to m a te d te c h n iq u e s su ch a s E IA a re s u p p la n tin g flu o re s c e n c e b a s e d te s tin g in m a n y la b o ra to rie s t6.8

6.4.1.7 Other tests for autoimmune diseases ■ R h e u m a to id fa c to r (R F ) □ A n a u to a n tib o d y th a t b in d s to th e F c p o rtio n o f th e IgG m o le c u le □ A m a rk e r o f rh e u m a to id a rth ritis (R A ) □ C a n be fo u n d in h e a lth y a d u lts a n d a w id e ra n g e o f n o n -R A d is e a s e c o n d itio n s , m o s t c o m m o n ly o th e r rh e u m a to lo g ic d is e a s e s , c h ro n ic in fe c tio n , v ira l in fe c tio n , a n d h e m a to ly m p h o id n e o p la s m s ■ A n ti-c itru llin a te d p ro te in (a n ti-C C P ) a n tib o d ie s h a v e g re a te r s p e c ific ity a n d s e n s itiv ity fo r R A th a n R F ■ A n g io te n s in c o n v e rtin g e n z y m e (A C E ) □ A n e x tre m e ly u se fu l te s t in th e e v a lu a tio n o f p a tie n ts w ith s u s p e c te d s a rc o id o s is , in w h ic h it is n e a rly a lw a y s e le v a te d w h e n th e d is e a s e is a c tiv e □ O th e r c a u s e s o f e le v a te d A C E a re p rim a ry b ilia ry c irrh o s is (P B C ), G a u c h e r d is e a s e , a n d le p ro s y

6.4.2 Autoimmune diseases 6.4.2.1 Systemic lupus erythematosus (SLE) ■ F e m a le :m a le ra tio ~ 8 -9 :1 ; m o s t p a tie n ts d ia g n o s e d b e tw e e n th e a g e s o f 15 and 4 5 y e a rs ; g re a te r p re v a le n c e in A fric a n A m e ric a n s

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6: Immunology

Autoimmunity & rheumatologic disease>Autoimmune diseases t6 .8 Review of clinically useful autoantibodies & specificities Antibody Clinical utility anti-dsDNA anti-Jo1 anti-histone extractable nuclear antigens anti-Smith (Sm) anti-RNP anti-nucleolar anti-SS-B /anti-SS-A anti-mitochondrial (AMA) anti-smooth muscle (ASMA) anti-LKM anti-microsomal anti-endomysial antibody anti-gliadin anti-tissue transglutaminase (tTG) anti-GBM anti-IF anti-Sd-70 anti-PM1 cANCA pANCA anti-thyroglobulin thyroid stimulating antibody anti-RNA polymerase 3 anti-topoisomerase (Scl-70) anti-ribosomal P protein rheumatoid factor (RF) anti-CCP

also called anti-native DNA, has high specificity for SLE; the substrate, Crithidia luciliae, is a flagellate with a giant mitochondrion that contains double stranded DNA concentrated in an area called the kinetoplast; antibodies to ssDNA do not react with C luciliae also called anti-tRNA synthetase polymyositis (PM), especially PM with pulmonary fibrosis high specificity for drug induced systemic lupus; associated drugs include hydralazine, procainamide, isoniazid, dilantin, methyldopa & penicillin a number of antigens, the so called extractable nuclear antigens (ENAs), are present in the extract of calf thymus; ENAs typically give a speckled pattern on fluorescent ANA testing; ENAs include Smith, ribonucleoprotein (RNP), SS-A (Ro) & SS-B(La) virtually diagnostic of SLE mixed connective tissue disease (MCTD), especially if ANA is negative scleroderma (PSS) SS-A (Ro) is present in 70% of patients with Sjogren syndrome & 30% of patients with SLE; SS-B(La) is present in 50% of patients with Sjogren & 15% of patients with SLE; anti-SS-A/SS-B are highly prevalent in neonatal lupus patients who are ANA+, SS-A+ but SS-B- are very likely to have lupus nephritis AMA is detected in 85% of patients with primary biliary cirrhosis (PBC). AMA is reactive with the cytoplasm of parietal cells of the stomach & renal tubular cells in the mouse stomach/kidney substrate lupoid (autoimmune) hepatitis is characterized by titers of >1:80; ASMA are specifically directed at F-actin; ASMA are detected on the mouse stomach/kidney substrate where they are reactive with the muscle underlying the gastric mucosa autoimmune hepatitis high specificity (90%) & sensitivity (95%) for Hashimoto disease, although up to 50% of patients with Graves disease will have antibodies endomysin is present in the reticular investment of muscle fibers; anti-endomysial antibodies are IgA antibodies that are highly sensitive & specific for celiac sprue & dermatitis herpetiformis; antibody titers respond to a gluten-free diet celiac sprue celiac sprue Goodpasture syndrome; the epitope is the M2 subunit of type IV collagen (GBM = glomerular basement membrane) polymyositis/dermatomyositis (IF = intermediate filament) anti-Sd-70 antibody is an anti-topoisomerase Ig seen in 20% of patients with scleroderma overlap syndrome with overlapping features of scleroderma & dermatomyositis high specificity for Wegener syndrome; cANCA is anti-proteinase 3 (PR3) microscopic polyangiitis, Churg-Strauss Hashimoto disease also called LATS, it is present in 90% of individuals with Graves disease scleroderma (PSS) scleroderma (PSS) SLE rheumatoid arthritis rheumatoid arthritis

P re s e n ta tio n is v a ria b le fro m p a tie n t to p a tie n t t6.9 A m e ric a C o lle g e o f R h e u m a to lo g y c rite ria t6.10 fo r d ia g n o s is a re in te n d e d fo r re s e a rc h p u rp o s e s ; 4 o f 11 m u s t b e fu lfille d fo r th e d ia g n o s is o f S L E

■ M o s t c o m m o n c a u s e o f c h ro n ic in fla m m a to ry a rth ritis ; e x tra a rtic u la r m a n ife s ta tio n s in c lu d e in te rs titia l lung d is e a s e , p le u ritis , e n d o c a rd itis , a nd s y s te m ic v a s c u litis

N e g a tiv e A N A e s s e n tia lly e x c lu d e s lu p u s ; o th e r a u to a n tib o d ie s m a y b e p re s e n t t6.11

■ W o m e n a ffe c te d a b o u t tw ic e as o fte n a s m en; initial o n s e t o f s y m p to m s b e tw e e n th e a g e s o f 30 a nd 50 y e a rs; in c re a s e d in c id e n c e in p a tie n ts w ith H L A D R 4

D ru g in d u c e d lu p u s □ G e n e ra lly fo llo w s a b e n ig n c o u rs e □ A s s o c ia te d w ith p ro c a in a m id e , h y d ra la z in e , q u in id in e , is o n ia z id , a n d in te rfe ro n -a □ A n ti-h is to n e a n tib o d ie s a re th e h a llm a rk o f d ru g in d u c e d lu p u s ; u s u a lly d ire c te d a g a in s t th e H 2 A -H 2 B d im e r c o m p le x p ro te in o f th e h is to n e

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6.4.2.2 Rheumatoid arthritis

■ C re a c tiv e p ro te in a nd e ry th ro c y te s e d im e n ta tio n rate are e le v a te d ; R A is a c o m m o n c a u s e o f a n e m ia o f c h ro n ic d is e a s e , a nd p la te le ts a re o fte n m ild ly e le v a te d a s an a c u te p h a s e re a c ta n t ■ P o sitiv e rh e u m a to id fa c to r (R F ) in m o s t p a tie n ts , b u t up to 3 0 % o f p a tie n ts in itia lly h ave a n e g a tiv e RF

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Autoimmunity & rheumatologic disease>Autoimmune diseases 6.4.2.3 Seronegative spondyloarthropathies

t6.9 Frequency of findings in SLE Finding

Frequency (%)

rash arthralgia neurologic serositis hematologic (anemia, thrombocytopenia) Raynaud phenomenon vasculitis glomerulonephritis endocarditis

90 75 65 60 60 45 40 30 15

■ G ro u p o f d is o rd e rs th a t h a v e s y m p to m s in c o m m o n w ith rh e u m a to id a rth ritis b ut a re R F - , in c lu d in g a n k y lo s in g s p o n d y litis , re a c tiv e a rth ritis (p re v io u s ly R e ite r s y n d ro m e ), a n d p s o ria tic a rth ritis ■ A ll a re m o re c o m m o n in m a le s a n d in p e rs o n s w ith th e c la s s I h u m a n le u k o c y te a n tig e n a lle le H L A B 2 7 ■ R e a c tiv e a rth ritis is p ro v o k e d b y a n te c e d e n t m u c o s a l in fe c tio n , ty p ic a lly u re th ritis (C h la m y d ia ) o r g a s tro e n te ritis (S h ig e lla , S a lm o n e lla , Y e rsin ia , a n d C a m p y lo b a c te r)

t6.10 1997 update of the 1982 criteria for systemic lupus

erythematosus 1. malar rash 2. discoid rash 3. rhotosensitivity 4. oral ulcers 5. arthritis (involving 2 or more peripheral joints) 6. serositis (pleuritis, pericarditis) 7. renal dysfunction (proteinuria >0.5 g/day or >3+ or cellular casts) 8, neurologic dysfunction (seizures or psychosis) 9. hematologic disorder (hemolytic anemia with reticulocytosis or leukopenia Autoimmune diseases

i6,7 Celiac sprue showing a blunted villi, b increased intraepithelial lymphocytes

■ A u to a n tib o d ie s fo u n d in P S S in c lu d e A N A , a n ti-c e n tro m e re , a n ti-S c l-7 0 (a n ti-to p o is o m e ra s e ), a n ti-U 1 -R N P (a n ti-fib rilla rin ), a n ti-R N A p o ly m e ra s e 3, a n ti-T h /T o , a n d a n ti-P m /S c I; a n ti-T h /T o a n d a n ti-P m -S c I a re re s p o n s ib le fo r a n ti-n u c le o la r re a c tiv ity id e n tifie d a s s p e c ific fo r P S S ; a n ti-c e n tro m e re , a n ti-T h /T o , a n ti-U 1 -R N P , a n d a n ti-P m -S c I a re a s s o c ia te d w ith lim ite d c u ta n e o u s (C R E S T ) S S

6.4.2.6 lgG4 related sclerosing disease ■ C a u s e s fib ro in fla m m a to ry le s io n s s u c h a s s c le ro s in g m e d ia s tin itis , id io p a th ic re tro p e rito n e a l fib ro s is , R ie d e l th y ro id itis , s c le ro s in g c h o la n g itis , o rb ita l p s e u d o tu m o r, a n d s c le ro s in g p a n c re a titis

i6.8 lgG4 related disorders a Idiopathic retroperitoneal fibrosis, consisting of dense collagenous sclerosis in association with an infiltrate of lymphocytes & plasma cells b Autoimmune pancreatitis, showing ductocentric inflammation c Autoimmune pancreatitis, showing a dense lymphoplasmacytic inflammatory infiltrate d Autoimmune pancreatitis, immunohistochemical staining for lgG4

6.4.2.9 Primary sclerosing cholangitis (PSC)

■ B io p s ie s d is p la y a ly m p h o p la s m a c y tic in filtra te , ric h in lg G 4 p ro d u c in g p la s m a c e lls i6.8

■ M o re c o m m o n in m a le s a nd in p a tie n ts w ith u lc e ra tiv e c o litis

■ E le v a tio n o f s e ru m lg G 4 is fo u n d in m o s t (> 9 0 % ) c a s e s ; lg G 4 is n o rm a lly th e m in o r Ig G s u b c la s s , re p re s e n tin g ~ 5 % o f to ta l IgG

■ p A N C A m ay be p o s itiv e , b u t A M A is n e g a tiv e

6.4.2.10 Sjogren syndrome (SS)

6 .4 .2 7 Autoim m une hepatitis (AIH) ■ L a b o ra to ry fin d in g s in c lu d e h y p e rg a m m a g lo b u lin e m ia (p o ly c lo n a l Ig G ) a n d a b n o rm a l liv e r fu n c tio n te s ts , in c lu d in g p ro lo n g e d P T /IN R a n d ra is e d A S T a n d A L T ■ In A IH T y p e I, A N A , a n ti-s m o o th m u s c le a n tib o d y (S M A ), a n d a n ti-s o lu b le liv e r p ro te in (a n ti-S L P ) m a y be p re s e n t ■ A IH T y p e II is c h a ra c te riz e d b y a n ti-liv e r/k id n e y m ic ro s o m a l a n tib o d y (L K M 1 ), an a n tib o d y a g a in s t C Y P 2D6

6.4.2.8 Primary biliary cirrhosis (PBC) ■ L iv e r fu n c tio n te s t a b n o rm a litie s h a v e a c h o le s ta tic p a tte rn , w ith p ro m in e n c e o f a lk a lin e p h o s p h a ta s e a nd GGT ■ A n ti-m ito c h o n d ria l a n tib o d ie s (A M A ), s u b ty p e M 2, a re p re s e n t in > 9 5 % o f c a s e s ; Ig G a n ti-s p 1 0 0 a n d IgG a n ti-g p 2 1 0 a re a ls o h ig h ly s p e c ific fo r P B C ■ P a tie n ts o fte n h a v e h y p e rc h o le s te ro le m ia a n d p o ly c lo n a l h y p e rim m u n o g lo b u lin M

312

■ D ia g n o s is m a d e by c h o la n g io g ra p h y

■ C h a ra c te riz e d by d ry n e s s o f th e e ye s, m o u th a n d o th e r m u c o u s m e m b ra n e s ■ M ay be p rim a ry o r a s s o c ia te d w ith o th e r s y s te m ic a u to im m u n e d is e a s e s (s e c o n d a ry S S ), p a rtic u la rly rh e u m a to id a rth ritis (R A ), p rim a ry b ilia ry c irrh o s is , s y s te m ic lu p u s e ry th e m a to s u s (S L E ) o r s y s te m ic s c le ro s is ■ A n ti-S S -A /R o a nd a n ti-S S -B /L a a n tib o d ie s are c h a ra c te ris tic ■ H is to lo g ic d ia g n o s is d e p e n d s u p o n m in o r s a liv a ry g la n d b io p s y s h o w in g >1 in fla m m a to ry fo c u s /4 m m 2, w ith a fo c u s d e fin e d as an a g g re g a te o f le a s t 50 m o n o n u c le a r in fla m m a to ry c e lls

6.4.2.11 Vasculitis ■ T h e v a s c u litis s y n d ro m e s ca n be ro u g h ly d iv id e d into th o s e w ith fa irly p re c is e s e ro lo g ic m a rk e rs a nd th o s e w ith o u t; fo rtu n a te ly , th o s e w ith o u t s e ro lo g ic m a rk e rs h ave h ig h ly c h a ra c te ris tic c lin ic a l fe a tu re s t6.12

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6: Immunology

Autoimmunity & rheumatologic disease>Autoimmune diseases t6.12 Vasculitides_______________________________________ Syndrome

Serologic marker Clinical features

giant cell arteritis________________none_____________ older adults_________ temporal headache, tender temporal artery___________________________________________________________ may have visual symptoms, jaw claudication, polymyalgia rheumatica ___________________________________________________ Takayasu arteritis______________ none_____________ children & adolescents pulseless disease (decreased arterial pulses)____________________________________________________ blood pressure difference between extremities_______________________________________________________ angiography diagnostic_______________________________________________ Kawasaki syndrome____________ none_____________ children____________ fever of >4 days duration_____________________________________________ erythema of palms & soles____________________________________________ desquamation within 5 days of fever onset______ bilateral conjunctivitis________________________________________________ cracking of lips & strawberry tongue____________________________________ cervical lymphadenopathy keratitis none Cogan syndrome vestibuloauditory symptoms oral ulcers, genital none Behget disease ulcers, uveitis; pathergy test positive children none Henoch-Schonlein purpura lower extremity palpable purpura, abdominal pain, nephritis young adult smokers none Buerger disease upper extremity ischemia widespread effects, none/HBV± polyarteritis nodosum sparing lungs widespread effects pANCA microscopic polyangiitis widespread effects; pANCA Churg-Strauss syndrome eosinophilia widespread effects cANCA Wegener granulomatosis mainly lung & kidneys anti-GBM Goodpasture affected widespread effects cryoglobulins cryoglobulinemia widespread effects, can RPR syphilis mimic Takayasu eg, RF, ANA, RPR widespread effects rheumatoid or other collagen vascular disease associated

i6.9 Polyarteritis nodosa (PAN) demonstrating the typical lesion, consisting of segmental fibrinoid necrosis of the vessel wall; a similar appearance may be seen in Wegener granulomatosis & microscopic polyangiitis

■ B io p s y o f n e rv e o r o th e r a ffe c te d tis s u e s h o w s s e g m e n ta l fib rin o id n e c ro s is i6.9 o f in fla m e d a rte ria l w a lls , w ith a p re d ile c tio n fo r b ra n c h p o in ts ■ T h e s e g m e n ta l n a tu re o f in v o lv e m e n t, w ith a c tiv e a n d h e a lin g le s io n s n e x t to n o rm a l s e g m e n ts o f b lo o d v e s s e l, is h ig h ly c h a ra c te ris tic ■ T h e re a re no d ia g n o s tic s e ro lo g ic fin d in g s , b u t a s ig n ific a n t m in o rity o f p a tie n ts a re s e ro p o s itiv e fo r H B V

6.4.2.11.2 M ic ro s c o p ic p o lyan g iitis (M PA ) ■ In v o lv e s lu n g s a n d k id n e y s a n d o th e r o rg a n s , te n d in g to a ffe c t s m a ll a rte rio le s a n d v e n u le s ■ A N C A is p o s itiv e in a p e rin u c le a r p a tte rn (p A N C a ) is o fte n p o s itiv e , a s it is in C h u rg -S tra u s s s y n d ro m e

6.4.2.11.3 W e g e n e r g ra n u lo m a to s is (W G ) ■ P re s e n ts w ith in v o lv e m e n t o f th e u p p e r re s p ira to ry tra c t, lo w e r re s p ira to ry tra c t, and k id n e y s ; like M P A , th e ty p ic a l re n a l le s io n is fo c a l s e g m e n ta l n e c ro tiz in g g lo m e ru lo n e p h ritis i6.10, p a u c i-im m u n e ty p e ■ A N C A is p o s itiv e in a c y to p la s m ic p a tte rn (c A N C A ) w ith a n ti-P R 3 a c tiv ity by E L IS A

6.4.2.11.1

P o ly a rte ritis n o d osa (PAN)

■ A m u ltis y s te m v a s c u litis a ffe c tin g m e d iu m o r s m a ll a rte rie s th a t u s u a lly s p a re s th e lu n g s a n d in v o lv e s th e k id n e y s , n e rv e s (m o n o n e u ritis m u ltip le x ), m e s e n te ric v e s s e ls , a n d skin . C a n d e v e lo p fib ro p la s ia and th ro m b o s is , w h ic h c a n lea d to in fa rc tio n , n e c ro s is and p s e u d o a n e u ry s m fo rm a tio n

6.4.2.11.4 C h u rg -S tra u s s s y n d ro m e (alle rg ic a n g iitis an d g ra n u lo m a to s is ) ■ In itia lly p re s e n ts a s a d u lt o n s e t a s th m a a n d , w h e n fu lly d e v e lo p e d , a fu lm in a n t v a s c u litis s y n d ro m e ■ P e rip h e ra l b lo o d e o s in o p h ilia is ty p ic a l ■ C a rd ia c in v o lv e m e n t is th e m a jo r c a u s e o f d e a th ■ S e ru m p A N C A (a n ti-M P O ) is p o s itiv e in m o s t c a s e s

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ISBN 9 7 8 -0 8 9 1 8 9 -6 6 7 8

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Autoimmunity & rheumatologic disease>Autoimmune diseases 6.4.2.11.5 B eh g et d iseas e (BD) ■ T h e tria d o f re c u rre n t o ra l a p h th o u s u lc e rs , g e n ita l a p h th o u s u lc e rs , a n d u v e itis , o fte n in a d d itio n to m u ltis y s te m v a s c u litis ■ In c id e n c e is h ig h e s t in th e M id d le E a st, F a r E a st, a nd M e d ite rra n e a n ■ T h e re is no s p e c ific a u to a n tib o d y te s t; th e p a th e rg y te s t (d e v e lo p m e n t o f e ry th e m a , in d u ra tio n , a nd p u s tu le at th e s ite o f a n e e d le s tic k ~ 4 8 h o u rs la te r) is a m o n g th e d ia g n o s tic c rite ria

6.4.2.11.6 G ia n t cell a rte ritis (tem p o ra l arte ritis ) ■ C h a ra c te riz e d by tra n s m u ra l in fla m m a tio n o f la rg e a nd m e d iu m s ize d b ra n c h e s o f th e a o rta w ith p re d ile c tio n fo r th e e x tra c ra n ia l b ra n c h e s o f th e c a ro tid a rte ry ■ T h e m o s t c o m m o n v a s c u litis in a d u lt p a tie n ts o ld e r th a n 50 y e a rs o ld ■ S tro n g ly a s s o c ia te d w ith p o ly m y a lg ia rh e u m a tic ■ T h e re is no d ia g n o s tic s e ro lo g ic te s t, a n d te m p o ra l a rte ry b io p s y re m a in s th e g o ld s ta n d a rd i6.11

6.4.2.11.7 T akayasu a rte ritis ■ Like G C A in v o lv e s th e m a jo r b ra n c h e s o f th e a o rtic a rch a n d d e m o n s tra te s m o n o n u c le a r in fla m m a tio n w ith g ia n t c e lls c a u s in g a rte ria l s te n o s is , a n e u ry s m s and th ro m b o s is □ T h e d is tin c tio n b e tw e e n th e 2 is la rg e ly a g e b a se d , w ith T a k a y a s u fo u n d in p a tie n ts y o u n g e r th a n 50 y e a rs o ld , m o s tly fe m a le s b e tw e e n 1 0 -4 0 y e a rs old ■ It is m o s t c o m m o n in J a p a n , C h in a , a n d India, w ith a re a s o f h ig h p re v a le n c e in M e x ic o ■ No s p e c ific lab te s ts fo r d ia g n o s is , o n ly in c re a s e d E S R and C R P te s t re su lts

6.4.2.11.8 B u e rg e r d iseas e (th ro m b o a n g iitis o b literan s) ■ P re s e n ts w ith s y m p to m s o f a rte ria l in s u ffic ie n c y a ffe c tin g th e d is ta l u p p e r and lo w e r e x tre m itie s a nd ty p ic a lly o c c u rs in y o u n g m a le s m o k e rs ■ T h e re a re no s p e c ific s e ro lo g ic m a rk e rs

6.4.2.11.9 Kawasaki disease (mucocut aneous lymph node syndrome) ■ Found o n ly in c h ild re n , w ith m e a n a g e a t o n s e t o f 2 -3 y e a rs

i6.10 Wegener granulomatosis a Glomerulus involved by focal segmental necrotizing glomerulonephritis seen in Wegener, Goodpasture & microscopic polyangiitis b Arterial involvement in Wegener, which has an appearance similar to PAN c Nasal biopsy in Wegener

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■ In vo lve s m e d iu m a nd s m a ll a rte rie s a n d o fte n in v o lv e s th e c o ro n a ry a rte rie s , c h a ra c te riz e d by s e g m e n ta l n e c ro tiz in g a rte ritis . T h e a c u te le s io n h as tra n s m u ra l n e c ro tiz in g a rte ritis rich in n e u tro p h ils a nd m o n o c ty e s

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Autoimmunity & rheumatologic disease>Autoimmune diseases 6.4.2.11.10 Ig A v a s c u litis (fo rm e rly kn o w n as H e n o c h S c h o n lein p u rp u ra (HSP) ■ P re s e n ts w ith th e tria d o f p a lp a b le p u rp u ra o n th e lo w e r e x tre m itie s , a b d o m in a l pain, a n d g lo m e ru lo n e p h ritis ty p ic a lly in c h ild re n le s s th a n 10 y e a rs o ld ■ T h e re n a l b io p s y fin d in g s a re s im ila r to th o s e fo r Ig A n e p h ro p a th y ■ S e e in fla m m a tio n in th e v e n u le s , a rte rio le s a n d s m a ll a rte rie s a n d th e s e p a tie n ts h a v e in c re a s e d le v e ls o f Ig A a n d is a b n o rm a lly g ly c o s y la te d in th e h in g e re g io n o f th e Ig A d im e r

6.4.2.12 Inflammatory myopathies ■ D e rm a to m y o s itis a n d p o ly m y o s itis s h a re a c h a ra c te ris tic s e t o f s e ro lo g ic m a rk e rs , in c lu d in g a nti-Jo 1 (a n ti-a m in o a c y l-tR N A s y n th e ta s e ), a n ti-S R P , a n d a n ti-P M /S c I a n tib o d ie s ■ In c lu s io n b o d y m y o s itis is th e m o s t c o m m o n in fla m m a to ry m y o p a th y in o ld e r a d u lts . It is re s is ta n t to c o rtic o s te ro id tre a tm e n t. T h e re is no s p e c ific s e ro lo g ic te s t, m a k in g m u s c le b io p sy m a n d a to ry in m a n y c a s e s

6.4.2.13 Myasthenia gravis (MG) ■ A n tib o d ie s to th e m u s c le a c e ty lc h o lin e re c e p to r (A C h R ) a re p re s e n t in 7 5 % -9 5 % o f p a tie n ts w ith M G , a n d fa ls e p o s itiv e s a re e x tre m e ly ra re t6.13. P a rtic u la rly in th y m o m a a s s o c ia te d d is e a s e , a n tib o d ie s to s k e le ta l m u s c le c o m p o n e n ts (ry a n o d in e re c e p to r a n d titin ) c a n be fo u n d . R e ce n tly, a n tib o d ie s to m u s c le s p e c ific k in a s e (M u S K ) h a ve b e e n fo u n d in s o m e p a tie n ts w ith A C h R a n tib o d y n e g a tiv e (“s e ro n e g a tiv e ” ) M G

t6.13 Myasthenia gravis testing i6.11 Temporal arteritis a Low power image demonstrating mural inflammation & luminal occlusion by intimal hyperplasia b High power image of the inflammatory population, composed of lymphocytes & multinucleated giant cells that are centered upon the elastic lamina

■ B e g in s w ith high fe v e rs , a n d w ith in d a y s to w e e k s th e c h a ra c te ris tic fe a tu re s e m e rg e , in c lu d in g p a lm a r e ry th e m a w ith d e s q u a m a tio n o f th e fin g e rtip s , c e rv ic a l a d e n o p a th y, c o n ju n c tiv itis , s tra w b e rry to n g u e , and c ra c k e d lip s ■ A s m a ll n u m b e r o f p a tie n ts d e v e lo p c o ro n a ry in v o lv e m e n t, w h ic h ca n lea d to a n e u ry s m a l d ila tio n , th ro m b o s is , m y o c a rd ia l in fa rc tio n , a n d d e a th (1% -2% o f u n tre a te d p a tie n ts ) ■ T h e re a re no s p e c ific s e ro lo g ic m a rk e rs , s e e e le v a te d E S R a nd C R P

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Type early onset late onset thymoma associated ocular seronegative

Anti-AChR +

-

+ +

+ +

Anti-MuSK

Anti-titin -

+/-

-

-

-

-

+/-

6.4.2.14 Familial Mediterranean fever (FMF) ■ P ro to ty p e “a u to in fla m m a to ry fe v e r s y n d ro m e ,” a g ro u p o f d is o rd e rs is c h a ra c te riz e d b y a n o m a lie s in th e in n a te im m u n e s y s te m a n d in m o s t c a s e s c a u s e d b y m u ta tio n s in th e g e n e s e n c o d in g pyrin fa m ily p ro te in s ■ A u to s o m a l re c e s s iv e d is o rd e r fo u n d a m o n g p e o p le w h o s e e th n ic ity ca n b e tra c e d to th e M e d ite rra n e a n b a sin ■ C a u s e d by a n o m a lie s in M E F V g e n e , c h ro m o s o m e 16, w h ic h e n c o d e s p y rin /m a re n o s trin p ro te in

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■ C h a ra c te riz e d b y p a ro x y s m s o f fe v e r a n d p a in re la te d to in fla m m a tio n o f th e s e ro s a l m e m b ra n e s (p e rito n e u m , p le u ra , s y n o v iu m , o r tu n ic a v a g in a lis ) ■ A m y lo id o s is w ith re n a l fa ilu re is a c o m p lic a tio n ; a m y lo id A (A A ) ty p e

6.4.3 Hypersensitivity reactions 6.4.3.1 Type I hypersensitivity (immediate type hypersensitivity)

6.5 Selected readings IS B N 9 78032329568 M cP herson RA, Pincus MR eds [2017] H enry’s Clinical Diagnosis and M anagem ent by Laboratory Methods, 25e. E lsevier IS B N 9780387685663 Klippel JH, S tone JH , C rofford LJ, W hite PH [2008] Prim er on the Rheum atic Diseases, 13e. S pringer IS B N 9780815345053 M urphy K, W eaver C [2017] Janew ay’s Immunobiology, 9e. G arland S cience IS B N 9783540785378 R ezai N, A gham oham m adi A, N otarangelo LD [2008] Prim ary Im m unodeficiency Diseases: Definition, Diagnosis, and Management. S p rin ger

■ R e s u lt o f a n tig e n b in d in g to Ig E o n th e s u rfa c e s o f m a s t c e lls (b o u n d b y th e FceR); Ig E in d u c e d c ro s s lin k in g o f F ceR re s u lts in d e g ra n u la tio n , w ith re le a s e o f h is ta m in e , h e p a rin , s e ro to n in , a ra c h id o n a te ■ N e ith e r a n a p h y la c to id re a c tio n s n o r h e re d ita ry a n g io e d e m a a re ty p e I h y p e rs e n s itiv ity re a c tio n s ■ A n a p h y la x is is a ty p e I h y p e rs e n s itiv ity re a c tio n m e d ia te d b y Ig E . S e ru m (o r p la s m a ) is e le v a te d in a n a p h y la x is (c h ro n ic a lly e le v a te d in s y s te m ic m a s to c y to s is ). P la s m a h is ta m in e le v e ls p e a k m o re q u ic k ly th a n try p ta s e , a t ~ 1 0 m in u te s a fte r th e o n s e t o f a n a p h y la x is . L e v e ls re tu rn to n o rm a l w ith in an hour. T h e u rin a ry h is ta m in e , h o w e v e r, m a y b e e le v a te d fo r 24 h o u rs

6.4.3.2 Type II hypersensitivity (antibody mediated cellular cytotoxicity) ■ P ro d u c e d b y a n tib o d y b in d in g to a n tig e n th a t le a d s to tis s u e d a m a g e m e d ia te d b y o p s o n iz a tio n ■ E x a m p le s in c lu d e G o o d p a s tu re s y n d ro m e , m y a s th e n ia g ra v is , im m u n e h e m o ly s is , a n d e ry th ro b la s to s is fe ta lis

6.4.3.3 Type III hypersensitivity ■ M e d ia te d b y th e fo rm a tio n o f im m u n e c o m p le x e s a s a re s u lt o f a n tib o d y a n tig e n in te ra c tio n c o m b in e d w ith a c tiv a tio n o f c o m p le m e n t ■ E x a m p le s in c lu d e S L E , H e n o c h -S c h o n le in p u rp u ra (H S P ), s e ru m s ic k n e s s , p o s ts tre p to c o c c a l g lo m e ru lo n e p h ritis (P S G N ), m e m b ra n o u s g lo m e ru lo n e p h ritis (M G N ) a n d th e a rth ru s re a c tio n

6.4.3.4 Type IV hypersensitivity (delayed type hypersensitivity) ■ M e d ia te d b y T c e lls a n d m a c ro p h a g e s re a c tin g to a n tig e n , u s u a lly w ith g ra n u lo m a fo rm a tio n ■ E x a m p le is th e tu b e rc u lin s k in te s t

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M o le c u la r P athology 7.1 Brief review of molecular biology................................................ 318

7.5

Selected re a d in g s .................................................................................380

7.1.1 T he stru ctu re o f n u cle ic a c id s .................................................................... 318

7.5.1 B o oks....................................................................................................... 380

7.1 .2 N u cle ic acid m o d ifyin g e n z y m e s ...............................................................320

7.5.2 Online references...................................................................................380

7.1 .3 M ito cho n d ria l D N A ........................................................................................... 320 7.1.4 G ene e x p re s s io n ............................................................................................. 321 7.1 .5 D N A rep licatio n & cell d iv is io n ....................................................................323 7.1 .6 C la ss ifica tio n o f g e n e tic a n o m a lie s ..........................................................324 7.1 .7 P atte rn s o f in h e rita n c e ................................................................................... 325

7.2

Techniques & applications......................................................... 325

7.2.1 C yto g e n e tic s & k a ry o ty p in g ......................................................................... 325 7.2 .2 M o le c u la r te c h n iq u e s ......................................................................................326 7.2 .3 A p p lic a tio n s ........................................................................................................333

7.3 Genetics of nonneoplastic disease..............................................334 7.3.1 R e n a l.................................................................................................................... 334 7.3 .2 C a rd io v a s c u la r...................................................................................................338 7.3 .3 E n d o c rin e .............................................................................................................340 7.3.4 G a s tro in te s tin a l, h e p a to b ilia ry & p a n c re a tic .......................................... 343 7.3 .5 N e u ro m u s c u la r...................................................................................................350 7.3 .6 D isorders o f m ito c h o n d r ia ............................................................................355 7 .3 .7 M ic ro d e le tio n d is o r d e r s .................................................................................356

7.4

Genetics of neoplastic disease................................................. 356

7.4.1 G a s tro in te s tin a l tra c t t u m o r s ...................................................................... 356 7 .4 .2 P a n c re a tic t u m o r s ...........................................................................................362 7 .4 .3 H e p a to b ilia ry t u m o r s ......................................................................................363 7 .4 .4 B re a st c a n c e r..................................................................................................... 364 7 .4 .5 G e n ito u rin a ry tu m o r s ......................................................................................366 7 .4 .6 S oft tissu e & b o n e ...........................................................................................368 7 .4 .7 H ead & neck t u m o r s ......................................................................................371 7 .4 .8 S kin t u m o r s ........................................................................................................372 7.4 .9 C entral n e rvo u s syste m tu m o rs ................................................................. 373 7 .4 .1 0 P ulm o n a ry tu m o r s ........................................................................................ 375 7.4.11 G y n e co lo g ic tu m o r s ......................................................................................376 7 .4 .1 2 O th e r tu m o r s y n d ro m e s .............................................................................. 377

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7: Molecular Pathology

Brief review of molecular biology>The structure of nucleic acids

7.1 Brief review of m olecular biology 7.1.1 The structure of nucleic acids 7.1.1.1 Nucleotides D e o x y rib o n u c le ic a c id (D N A ) a n d rib o n u c le ic a c id (R N A ) a re c h a in s o f n u c le o tid e s . A n u c le o tid e h a s 3 m a jo r p a rts : a p e n to s e s u g a r, a p h o s p h a te g ro u p , a n d a n itro g e n o u s b a se f 7 .1 .

T h e p e n to s e s u g a r is e ith e r rib o s e (in R N A ) o r d e o x y rib o s e (in D N A ), a n d e a c h c a rb o n o f th e p e n to s e rin g is n u m b e re d , s ta rtin g w ith th e o n e b o u n d to th e n itro g e n o u s b a s e (th e 1’ p o s itio n ) a n d p ro c e e d in g c lo c k w is e . A t 3' is a h y d ro x y l g ro u p w h ic h is n e e d e d fo r th e fo rm a tio n o f th e p h o s p h o d ie s te r b o n d . T h e d iffe re n c e b e tw e e n rib o s e a n d d e o x y rib o s e is th e p re s e n c e o f a n o th e r h y d ro x y l g ro u p a t 2 ' in rib o s e th a t is a b s e n t in d e o x y rib o s e . T h e 2 ’ h y d ro x y l a llo w s R N A to fo rm a u n iq u e 2 '-5 ' p h o s p h o d ie s te r b o n d , c ritic a l fo r p o s ttra n s c rip tio n a l m e s s e n g e r R N A (m R N A ) s p lic in g . T h e n itro g e n o u s b a s e is b o u n d to th e in itia l (T ) c a rb o n o f th e p e n to s e rin g . B a s e s a re c a te g o riz e d a c c o rd in g to w h e th e r th e re is a s in g le h e te ro c y c lic 6 m e m b e r rin g (p y rim id in e s ) o r a p y rim id in e rin g fu s e d to an im id a z o le rin g (p u rin e s ). T h e p y rim id in e b a s e s o f s ig n ific a n c e to th e n u c le ic a c id are c y to s in e (C), th y m in e (T ), a n d u ra c il (U ), w h ile th e p u rin e b a s e s a re a d e n in e (A ) a n d g u a n in e (G ) f7.2. U ra c il is u n iq u e to R N A , w h e re it s u b s titu te s fo r th y m in e .

nh2

o

T h e fin a l c o m p o n e n t n e e d e d to m a k e a n u c le o tid e is th e p h o s p h a te g ro u p th a t b in d s to th e 5' c a rb o n o f th e p e n to s e rin g . T h e n o m e n c la tu re fo r e a c h o f th e n u c le o tid e s in c lu d e s th e n a m e o f th e n itro g e n o u s b a s e fo llo w e d b y trip h o s p h a te . F or e x a m p le , d A T P is a d e n o s in e trip h o s p h a te (A T P ) f7.3, th e “d ” s ig n ify in g d e o x y rib o s e .

C y to s in e _________________________T h y m in e f7.2 Nitrogenous bases

7.1.1.2 The phosphodiester bond F o rm e d fro m th e h y d ro ly s is o f th e 5' trip h o s p h a te o f 1 n u c le o tid e a n d th e 3' h y d ro x y l g ro u p o f a n o th e r, th e p h o s p h o d ie s te r b o n d is th e b a c k b o n e o f th e n u c le ic a c id s tra n d f7.4. T h e p ro c e s s o f s e q u e n tia l a d d itio n o f b a s e s is c a lle d p o ly m e riz a tio n , a p ro c e s s th a t re s u lts in th e p ro d u c tio n o f a p h o s p h o d ie s te r b o n d e d o lig o n u c le o tid e w ith th e b y p ro d u c t p y ro p h o s p h a te , w h ic h is c o m p o s e d o f th e 2 re m a in in g p h o s p h a te g ro u p s o f th e trip h o s p h a te . S in c e th e b o n d o c c u rs b e tw e e n th e 5' p h o s p h a te a n d th e 3' OFI o f th e s u b s e q u e n t b a s e th e p ro c e s s o f p o ly m e riz a tio n is s a id to be d ire c tio n a l fro m 5' to 3'. f7.3 Adenosine triphosphate

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Brief review of molecular biology>The structure of nucleic acids

1% o f th e p o p u la tio n ), th e te rm p o ly m o rp h is m is u sed. P o ly m o rp h is m s m a y c o n s is t o f a lte ra tio n m u ltip le n u c le o tid e s o r a s in g le n u c le o tid e a t a lo c u s , th e la tte r c a lle d s in g le n u c le o tid e p o ly m o rp h is m s (S N P s). S N P s o c c u r at a fre q u e n c y o f ro u g h ly 1 in e v e ry 6 0 0 b a s e pairs. A p o ly m o rp h is m m a y p ro d u c e c h a n g e s in th e w a y th a t re s tric tio n e n d o n u c le a s e s d ig e s t D N A ; th e s e a re c a lle d re s tric tio n fra g m e n t le n g th p o ly m o rp h is m s (R F L P s). T h e v a ria b le le n g th o f m ic ro s a te llite s is a fu rth e r e x a m p le o f p o ly m o rp h is m . S o m e lo ci a re m a rk e d ly c o n s is te n t fro m o n e in d ivid u a l to th e next; o th e rs a re h ig h ly v a ria b le a nd th e te rm h ig h ly p o ly m o rp h ic is a p p lie d to th e m . M u ta tio n s ca n be c a te g o riz e d a c c o rd in g to th e e ffe c t o f th e m u ta tio n on th e fu n c tio n o f th e p ro te in , th e s tru c tu re o f th e g e n e , o r th e o v e ra ll e ffe c t on th e o rg a n is m .

7.1.6.2 Function M u ta tio n s ca n be c a te g o riz e d a s to its e ffe c t on th e fu n c tio n o f th e prote in: lo s s o r g a in o f fu n c tio n . O n e ty p e o f g ain o f fu n c tio n m u ta tio n , th e d o m in a n t n e g a tiv e m u ta tio n , re su lts in a novel p ro te in th a t in h ib its th e a c tio n o f th e n a tive p rote in o r o p e ra te s in a m a n n e r th a t o v e rc o m e s th e n a tive p ro te in ’s fu n c tio n .

7.1.6.3 Structure M u ta tio n s m a y be c a te g o riz e d a c c o rd in g to th e c h a n g e th e y p ro d u c e in th e g e n e , eg, p o in t m u ta tio n s , in s e rtio n m u ta tio n s , d e le tio n m u ta tio n s , in v e rs io n s, tra n s lo c a tio n s . P o in t m u ta tio n s ca n b e fu rth e r s u b c a te g o riz e d a c c o rd in g to th e ir e ffe ct. N o n s e n s e m u ta tio n s re su lt in p re m a tu re tru n c a tio n o f tra n s la tio n , m is s e n s e m u ta tio n s lead to c h a n g e s

ASCP Quick Compendium of Clinical Pathology 4e

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7: Molecular Pathology

Brief review of molecular biology>Classification of genetic anomalies | Patterns of inheritance Techniques & applications>Cytogenetics & karyotyping in a m in o a cid s e q u e n c e , a n d s ile n t m u ta tio n s c h a n g e th e n u c le ic a c id s e q u e n c e , b u t d o n o t re su lt in th e p ro d u c tio n o f e ith e r a sto p c o d o n o r d iffe re n t a m in o a cid . P o in t m u ta tio n s o f s p lic in g d o n o r o r a c c e p to r s e q u e n c e s ca n c a u s e s p lic e site m u ta tio n s . A n y m u ta tio n th a t le a d s to a c h a n g e in th e re a d in g fra m e o f th e rib o s o m e in tra n s la tio n is c a lle d a fra m e s h ift m u ta tio n . T h e m o s t c o m m o n m u ta tio n s to c a u s e fra m e s h ift a re in s e rtio n s a nd d e le tio n s .

both p arents a re im plied carriers), b oys a nd g irls a re e q u a lly affected, and if a c o u p le has an a ffe cte d child, th e likelihood o f a se con d a ffected child is 25% . R are a u to s o m a l re ce s s ive g e n e tic d e fe cts rely h eavily on co n s a n g u in ity fo r su rviva l in th e population. In g eneral, a utosom al re ce ssive c o n d itio n s d o n ot v a ry in te rm s o f p en e tran ce o r expressivity. A u to so m a l re ce s s ive g e n e tic d e fe cts usua lly involve g e n e s th a t e n c o d e e n z y m e s .

7.1.7.2.3 X linked re ces siv e d is o rd e rs 7.1.6.4 Effect on organism Finally, o n e ca n c a te g o riz e m u ta tio n s a c c o rd in g to th e c h a n g e in th e fitn e s s o f an o rg a n is m . D e le te rio u s m u ta tio n s n e g a tiv e ly a ffe c t fitn e s s , w h ile b e n e fic ia l m u ta tio n s e n h a n c e fitn e ss .

7.1.7 Patterns of inheritance 7.1.7.1 Inherited vs acquired genetic disorders D is o rd e rs th a t re su lt fro m a g e n e d e fe c t a re g e n e ra lly c o n s id e re d g e n e tic d is o rd e rs , b u t n ot all g e n e tic d is o rd e rs a re in h e rite d . S o m e g e n e tic d e fe c ts are s p o ra d ic ; th a t is, th e d e fe c t is a b s e n t in both th e p a te rn a l and m a te rn a l g e n o m e , and is s o m e h o w a c q u ire d d u rin g o o g e n e s is , s p e rm a to g e n e s is , o r e a rly e m b ry o g e n e s is . F o r m o s t g e n e tic d is o rd e rs , th e re a re b oth in h e rite d and s p o ra d ic fo rm s , th e la tte r te rm e d s im p le x c a s e s . S u ch s p o ra d ic d e fe c ts a re u s u a lly “g e rm lin e ” n e v e rth e le s s ; th a t is, th e d e fe c t is p re s e n t in all c e lls o f th e o rg a n is m . O th e r g e n e tic d e fe c ts a ris e w ith in a d iffe re n tia te d cell; su ch “s o m a tic ” d e fe c ts a re n ot fo u n d in g e rm lin e D N A a nd a re u n like ly to be p a s s e d on to o ffs p rin g .

7.1.7.2 Inheritance patterns 7.1.7.2.1 A u to s o m al d o m in a n t d iso rd ers A u to s o m a l d o m in a n t d is o rd e rs have th e fo llo w in g fe a tu re s : at le a s t 1 p a re n t is u s u a lly a ffe cte d ; b o y s a nd g irls a re a ffe c te d w ith e q u a l fre q u e n c y , a nd both m en a nd w o m e n h ave a 5 0 % c h a n c e o f tra n s m ittin g th e c o n d itio n to o ffs p rin g . O f co u rs e , s p o ra d ic e x a m p le s o f a u to s o m a l d o m in a n t c o n d itio n s n ee d n ot fo llo w th e s e ru le s. A u to s o m a l d o m in a n t c o n d itio n s a re m o d ifie d by p e n e tra n c e and e x p re s s iv ity . P e n e tra n c e re fe rs to th e p ro p o rtio n o f p a tie n ts w ith th e m u ta tio n w h o m a n ife s t a p h e n o ty p ic a b n o rm a lity . G e n e tic d e fe c ts th a t a lw a y s re su lt in a b n o rm a l p h e n o ty p e a re sa id to h ave 100% p e n e tra n c e . E x p re s s iv ity re fe rs to th e s e v e rity and ra n g e o f m a n ife s ta tio n s . A u to s o m a l d o m in a n t g e n e tic d e fe c ts o fte n in vo lve g e n e s th a t e n c o d e s tru c tu ra l p ro te in s , re c e p to r p ro te in s , o r tra n s m e m b ra n e c h a n n e ls .

X lin ked re c e s s iv e d is o rd e rs are e x p re s s e d a lm o s t e x c lu s iv e ly in b oys. G irls m a y be a ffe c te d in re g io n s o f v e ry h ig h m u ta n t g e n e fre q u e n c y , such th a t a h o m o z y g o u s fe m a le p a tie n t b e c o m e s a s ta tis tic a l lik e lih o o d . G irls m a y a ls o be a ffe c te d on th e b a s is o f a s y m m e tric ly o n iz a tio n o r T u rn e r s y n d ro m e (m o n o s o m y X). M en c a n n o t p a s s th e tra it to th e ir m a le o ffs p rin g , b u t th e ir d a u g h te rs a re o b lig a te c a rrie rs . W o m e n h ave a 5 0 % c h a n c e o f p a s s in g th e tra it to th e ir m a le o ffs p rin g (w h o w ill be a ffe c te d ) a n d to th e ir fe m a le o ffs p rin g (w h o w ill be c a rrie rs ).

7.2 Techniques & applications 7.2.1 Cytogenetics & karyotyping 7.2.1.1 Preparation of cells S e e “ Is o la tio n o f n u c le ic a c id " belo w .

7.2.1.2 Preparation of chromosomes T h e e a rly a tte m p ts to id e n tify c h ro m o s o m e s w e re b a s e d on th e le n g th o f e a c h c h ro m o s o m e , fro m th e lo n g e s t (c h ro m o s o m e 1) to th e s h o rte s t (c h ro m o s o m e 2 2, w h ic h a c tu a lly is n o t th e s h o rte s t— th a t is 21— b u t a t th e tim e it w a s th o u g h t to be th e s h o rte s t). S u b s e q u e n t e ffo rts fo c u s e d on s ta in in g o f m e ta p h a s e c h ro m o s o m e s w ith G ie m s a s ta in (G b an d in g ), q u in a c rin e (Q b an ding), o r a n u m b e r o f te c h n iq u e s to p ro d u c e a re v e rs e s ta in in g p a tte rn to G b a n d in g (R b an d in g ). G b a n d in g re g io n s th a t s ta in m o re in te n s e ly (AT rich ) o r le s s in te n s e ly (G C rich) a re u s e d to d is tin g u is h c h ro m o s o m a l ide n tity, re gion s, b a n d s , a n d s u b b a n d s . In re la tio n to th e c e n tro m e re , m o s t c h ro m o s o m e s a re d iv id e d into a s h o rt p a rm and a lo n g e r q a rm . D iffe re n t ty p e s o f c h ro m o s o m e s a re c la s s ifie d b y th e lo c a tio n o f th e c e n tro m e re . C h ro m o s o m e s w ith ro u g h ly e q u iv a le n t le n g th a rm s a re c a lle d m e ta c e n tric , th o s e w ith lo n g e r q th a n p a rm s a re s u b m e ta c e n tric , and th o s e w ith o u t s ig n ific a n t p a rm s a re c a lle d a c ro c e n tric . T h e a c ro c e n tric c h ro m o s o m e s c o n ta in s h o rt a re a s in p la c e o f p a rm s th a t e n c o d e th e m a jo rity o f rR N A s a nd a re o fte n th e site o f tra n s lo c a tio n s .

7.1.7.2.2 A u to so m al reces siv e d iso rd ers A u to so m a l recessive d iso rde rs have th e fo llow ing features: g en e ra tio ns are skipped (parents are u sually unaffected, but © A S C P 2018

T h e re g io n s o f th e a rm s a re n u m b e re d in re la tio n s h ip to th e c e n tro m e re . T h e firs t re gion n e a re s t th e c e n tro m e re is la b e le d “ 1” a nd , d e p e n d in g on w h ic h a rm it o c c u p ie s , “ p 1 ” o r

ISBN 9 7 8 -0 8 9 1 8 9 -6 6 7 8

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7: Molecular Pathology

Techniques & applications>Cytogenetics & karyotyping | Molecular techniques “q 1.” E a c h re g io n is fu rth e r d iv id e d into b a n d s a n d , p o s s ib ly , s u b b a n d s . T h e n o m e n c la tu re u s e d is [c h ro m o s o m e ][a rm ] [re g io n ][b a n d ].[s u b b a n d ]. F o r e x a m p le , “s u b b a n d 3 o f b a n d 1 in re g io n 2 o n th e lo n g a rm o f c h ro m o s o m e 1 8 ” w h e re th e b c l2 lo c u s re s id e s is w ritte n “ 1 8 q 2 1 .3 .” T h e m e ta p h a s e s p re a d s ta in e d c h ro m o s o m e im a g e is re fe rre d to a s a k a ry o g ra m f7.10, w h ile its in te rp re ta tio n is th e k a ry o ty p e . T h e n o rm a l h u m a n m a le k a ry o ty p e is 4 6 ,X Y ; n o rm a l fe m a le is 4 6 ,X X , w ith 4 6 re fe rrin g to th e to ta l n u m b e r o f c h ro m o s o m e s a n d X X o r X Y th e s e t o f s e x c h ro m o s o m e s .

7.2.2 Molecular techniques 7.2.2.1 Isolation of nucleic acid N u c le ic a c id c a n b e e x tra c te d fro m a n u m b e r o f d iffe re n t s p e c im e n s , in c lu d in g w h o le b lo o d a n d b lo o d p ro d u c ts , tis s u e (e ith e r fre s h , fre s h fro z e n , o r fo rm a lin fix e d ), b o d y flu id s , s w a b s , w o u n d s , o r h a ir ro o t. C e rta in s p e c im e n s s h o u ld be a v o id e d , s u c h a s h e p a rin c o n ta in in g b lo o d ; h e p a rin has b e e n s h o w n to in h ib it th e p o ly m e ra s e c h a in re a c tio n (P C R ). F ix a tiv e s th a t c o n ta in m e rc u ry , s u c h a s B o u in o r Z e n ke r, s h o u ld b e a v o id e d a s th e y in te rfe re w ith c o m m o n n u c le ic a cid e x tra c tio n p ro to c o ls . L astly, a c id ifie d d e c a lc ific a tio n s o lv e n ts m a y in te rfe re w ith D N A b a s e d te s tin g . W h e n fix e d in a lc o h o l o r 10% n e u tra l b u ffe re d fo rm a lin , th e d u ra tio n o f fix a tio n s h o u ld id e a lly b e 12-24 h o u rs . P a ra ffin s to ra g e tim e its e lf d o e s n o t a p p e a r to a ffe c t th e q u a lity o f D N A . F o rm a lin fix a tio n re s u lts in th e c ro s s lin k in g o f n u c le ic a c id to p ro te in a n d s u b s e q u e n tly le a d s to n u c le ic a c id fra g m e n ta tio n . A v e ra g e D N A fra g m e n ts o b ta in e d fro m fo rm a lin fix e d tis s u e a re 3 0 0 - 4 0 0 b a s e p a irs in le n g th . F o r th is re a s o n a m p lific a tio n a n d a n a ly s is o f D N A fro m fo rm a lin fix e d tis s u e is b e s t lim ite d to s h o rt s e q u e n c e s . D u e to its s tru c tu re a n d th e n e a r o m n ip re s e n c e o f R N A s e s , R N A is le s s s ta b le th a n D N A . F o r th e s e re a s o n s th e c o n d itio n s u n d e r w h ic h o n e p re p a re s R N A m u s t be s tric te r. T is s u e m u s t be b e tte r p re s e rv e d , in h ib ito rs o f R N A s e a nd R N A s e fre e p ro d u c ts a n d s u p p lie s s h o u ld be u se d . A s D N A p re p a ra tio n o fte n in v o lv e s th e u s e o f R N A s e to d e g ra d e u n w a n te d R N A , it is im p o rta n t to s e p a ra te s u p p lie s a nd e q u ip m e n t u s e d fo r D N A p re p a ra tio n fro m th a t w h ic h is u sed to p re p a re R N A . If R N A b a s e d te s tin g is in te n d e d , s n a p fro z e n tis s u e is id e a l. T is s u e s h o u ld n o t be fro z e n in O C T (o p tim a l c u ttin g te m p e ra tu re ), th e m a te ria l u s e d c o m m o n ly fo r fro z e n s e c tio n s . It is b e s t to d ic e tis s u e a n d fre e z e it w ith in 6 h o u rs . W h ile b o th liq u id p h a s e a n d s o lid p h a s e e x tra c tio n te c h n iq u e s h a v e p ro v e n s u c c e s s fu l in th e is o la tio n o f n u c le ic a c id , s o lid p h a s e e x tra c tio n is p re fe rre d d u e to its e a s e o f u s e a n d s c a la b ility . T h e m a jo rity o f liq u id p h a s e n u c le ic a c id is o la tio n te c h n iq u e s ta k e a d v a n ta g e o f th e c h e m is try o f th e p h o s p h a te b a c k b o n e . A s a s tro n g a c id , n u c le ic a c id is s o lu b le

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in w a te r up to a re la tiv e ly h ig h c o n c e n tra tio n a n d ca n be s e le c tiv e ly p re c ip ita te d w ith a lc o h o l. T h e p ro to c o ls fo r m o s t o f th e s e n u c le ic a c id is o la tio n te c h n iq u e s firs t in vo lve d is ru p tin g ce ll and n u c le a r m e m b ra n e s , p re fe re n tia lly d e g ra d in g o r p re c ip ita tin g p ro te in s , c e n trifu g a tio n o r e x tra c tio n to s e p a ra te th e n u c le ic a c id in a q u e o u s p h a s e fro m th e ce ll m e m b ra n e s a n d p re c ip ita te d p ro te in , th e n is o la tin g th e n u c le ic a c id fro m w a te r via th e a lc o h o l p re c ip ita tio n a n d d e h y d ra tio n . For s o lid p ha se e x tra c tio n , n u c le ic a cid s e le c tiv e ly a d s o rb s to a s e le c tiv e m a trix (eg, silica), w h ic h is b o u n d to an im m o b ile s o lid , such a s p la s tic o r m a g n e tic b e a d s o r a filte r m e m b ra n e . T h e initial p ro c e d u re s a re s im ila r to liq u id p h a s e e x tra c tio n , e x c e p t th e p re c ip ita te d n u c le ic a c id b in d s to th e s ilic a u n d e r h ig h io n ic s tre n g th (lo w s trin g e n c y ) c o n d itio n s a nd ca n be w a s h e d a nd s u b s e q u e n tly e lu te d w ith a lo w io n ic s tre n g th e lu a n t. O n c e isolated , n u c le ic a c id ca n be v e rifie d th ro u g h a v a rie ty o f m e th o d s, in c lu d in g s p e c tro p h o to m e tric a b s o rp tio n at 2 6 0 nm. N u c le ic a c id a b s o rb s lig h t a t 2 6 0 nm w a v e le n g th (u ltra v io le t) s to ic h io m e tric a lly , so th a t 1 u n it o f a b s o rb a n c e e q u a ls 5 0 p g /m L o f d o u b le s tra n d e d D N A o r 4 0 p g /m L o f R N A . P rotein a b s o rb s lig h t m a x im a lly a t 2 8 0 nm , so th a t p u rity o f D N A ca n be a s s e s s e d w ith a ra tio o f a b s o rb a n c e at 2 6 0 -2 8 0 nm . A ra tio >1.8 is c o n s id e re d to be re la tiv e ly pure.

7.2.2.2 Restriction enzymes U s in g re stric tio n e n z y m e s on a p a rtic u la r D N A s e q u e n c e re s u lts in a s e t o f D N A fra g m e n ts o f re p ro d u c ib le n u m b e r a n d size. R e s tric tio n e n z y m e s are b a c te ria l e n d o n u c le a s e s (e n z y m e s th a t c u t w ith in a D N A stra n d ) th a t re c o g n iz e a n d clea ve s p e c ific D N A s e q u e n c e s . T h e e n d o n u c le a s e s a re n a m e d a c c o rd in g to th e g e n u s , s p e c ie s , a nd stra in fro m w h ic h th e y w e re iso la te d , H in d lll is fro m H in flu e n za , a n d E coR I is fro m E coli. E a ch e n d o n u c le a s e , in a d d itio n to re c o g n iz in g a s p e c ific s e q u e n c e , w ill c le a v e in a p a rtic u la r fa s h io n to leave a 5', a 3' o v e rh a n g , o r b lu n t e n d s . O v e rh a n g s , o r “s tic k y e n d s ” ca n be u seful fo r m an y p u rp o s e s , su ch a s c lo n in g o r la b e lin g a fra g m e n t w ith a la b e le d n u c le o tid e . B e c a u s e o f th e ir s e q u e n c e s p e c ific c le a v a g e a ctivity, re s tric tio n e n d o n u c le a s e s c le a v e D N A in a p re d ic ta b le

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

7: Molecular Pathology

Techniques & applications>Molecular techniques m a n n e r; m u ta tio n s in a s e q u e n c e ca n re s u lt in lo s s o r g ain o f a re c o g n itio n s e q u e n c e , th e re b y re su ltin g in c le a v a g e p ro d u c ts th a t d iffe r fro m th e w ild ty p e . T h is te n d e n c y is re fe rre d to as R F L P , a nd R F L P a n a ly s is fo rm s th e b a sis o f a g re a t n u m b e r o f m o le c u la r a s s a y s . T h e c le a v a g e p ro d u c ts ca n be a n a ly z e d , su ch a s by S o u th e rn blot. F u rth e rm o re , m e th y la tio n ca n a lte r c le a v a g e site s, a nd th e m e th y la tio n sta tu s o f a g e n e ca n be d e d u c e d fro m re s tric tio n e n d o n u c le a s e p a tte rn s .

7.2.2.3 Gel electrophoresis D N A ca n be s u b je c te d to e le c tro p h o re s is to be s e p a ra te d a nd a n a lyz e d . In th e u sua l s c e n a rio , a fra g m e n t o f D N A is s u b je c te d firs t to d ig e s tio n by re s tric tio n e n z y m e s th e n th e p ro d u c ts a re p la c e d o n to a gel. D N A and R N A m ig ra te to w a rd s th e p o s itiv e pole, b e c a u s e th e y h ave a n et n e g a tive ch a rg e , a nd a re u ltim a te ly s e p a ra te d a c c o rd in g to len g th . Lastly, th e gel is s ta in e d fo r v is u a liz a tio n . F ra g m e n t le n g th is in fe rre d u sin g k n o w n s a m p le s th a t u n d e rg o e le c tro p h o re s is in p ara lle l. G ra d ie n t g el e le c tro p h o re s is is a te c h n iq u e th a t re lie s on th e p rin c ip le th a t p a rtia lly d e n a tu re d d o u b le stra n d e d D N A m ig ra te s a t a d iffe re n t rate th a n fu lly a n n e a le d d o u b le stra n d e d D N A . If s y n th e tic o lig o n u c le o tid e s , m a d e to re p lic a te th e k n o w n s e q u e n c e o f th e w ild ty p e , a re a d d e d to p a tie n t D N A , a nd th e te m p e ra tu re is m a n ip u la te d so th a t D N A d e n a tu re (unzip) and th e n re a n n e a l, se v e ra l th in g s ca n h ap p e n d e p e n d in g on th e p a tie n t’s g e n o ty p e . H e te ro d u p le x e s (w ild ty p e m u ta n t ty p e d u p le x e s ) m ig ra te a t d iffe re n t ra tes th a n h o m o d u p le x e s, re su ltin g in in fo rm a tiv e b a n d s w h e n th e gel is s ta in e d . G ra d ie n t gel e le c tro p h o re s is is th u s a g o o d c h o ic e w h e n m u ta n t s e q u e n c e s a re n ot k n o w n o r w h e n th e re is a la rg e v a rie ty o f p o s s ib le m u ta n t s e q u e n c e s . D e n a tu rin g high p e rfo rm a n c e liq u id c h ro m a to g ra p h y w o rk s on a s im ila r p rin cip le .

7.2.2.4 Blotting T h e p ro c e s s o f tra n s fe rrin g n u c le ic a cid o r p ro te in to a solid s u p p o rt is re fe rre d to as b lo ttin g . T h e n a m in g d e p e n d s on th e ty p e o f m o le c u le b e in g tra n s fe rre d . D N A is S o u th e rn b lo tte d , R N A is n o rth e rn b lo tte d , a n d p ro te in is W e s te rn blo tted . H y b rid s o f th e s e e xist, su ch th a t S o u th w e s te rn b lo ttin g is b lo ttin g o f p ro te in s th a t b in d D N A and N o rth w e s te rn b lo ts a re fo r p ro te in s th a t bind R N A . D ire c t a p p lic a tio n o f th e n u c le ic a cid o r p ro te in is re fe rre d to as d o t b lo ttin g . In S o u th e rn b lo ttin g , th e p ro c e s s o fte n is p re c e d e d by d ig e stio n w ith re s tric tio n e n z y m e s a nd e le c tro p h o re s is to s e p a ra te th e D N A m o le c u le s . In o th e r ca s e s , P C R m a y be p e rfo rm e d firs t to a m p lify th e s e q u e n c e o f intere st, fo llo w e d by d ig e stio n a nd e le c tro p h o re s is . T h e g el is th e n b lo tted to a so lid s u p p o rt m e m b ra n e th ro u g h e ith e r c a p illa ry o r © A S C P 2018

e le c tro p h o re tic a c tio n . O n c e tra n s fe rre d , th e m o le c u le s on th e m e m b ra n e ca n be p ro b e d , o fte n w ith c o m p le m e n ta ry D N A o r R N A p ro b e s . T h e p re s e n c e o f a s ig n a l a n d its lo c a tio n on th e m e m b ra n e w h e n h y b rid iz e d to th e p ro b e c h a ra c te riz e th e m o le c u le o f intere st.

7.2.2.5 Hybridization techniques H y b rid iz a tio n te c h n iq u e s c a p ita liz e on th e te n d e n c y o f n u c le ic a c id s to h y b rid iz e w h e n c o m p le m e n ta ry s tra n d s a re n earby. T e c h n iq u e s in c lu d e flu o re s c e n c e in situ h y b rid iz a tio n (F IS H ), a lle le s p e c ific o lig o n u c le o tid e s , c o m p a ra tiv e g e n o m ic h y b rid iz a tio n (C G H ), a n d (SKI), m ic ro a rra y s .

7.2.2.5.1 F lu o re s c e n c e in situ h y b rid iza tio n M a n y v a ria tio n s i7.1-i7.3 e xist, e s p e c ia lly in th e a re a o f p ro b e d e s ig n , m a k in g F IS H an id e a l te s t fo r a w id e ra n g e o f tra n s lo c a tio n s , d u p lic a tio n s , a n d d e le tio n s . A lte rn a tiv e s fu rth e rm o re e x is t in th e d e te c tio n , s u c h a s c h ro m o g e n ic (C IS H ) o r s ilv e r p a rtic le (S IS H ) m e th o d s . F IS H ca n a c c o m p lis h , w ith o u t th e d iffic u lty o f ce ll c u ltu re , m u c h o f w h a t is d o n e in c o n v e n tio n a l c y to g e n e tic s w h e re s tru c tu ra l re a rra n g e m e n t o f a p a rtic u la r lo c u s is c o n c e rn e d . It h as th e re fo re s o m e tim e s bee n c a lle d “ m o le c u la r c y to g e n e tic s ,” b u t th is te rm h as a ls o b e e n used to e n c o m p a s s o th e r te c h n iq u e s th a t ca n d e te c t tra n s lo c a tio n s , s u c h a s c e rta in P C R a nd R F L P /S o u th e rn b lo t b a s e d a s s a y s . A n d w h ile e a s ie r a nd m o re s e n s itiv e th a n c o n v e n tio n a l c y to g e n e tic s in s o m e re sp e c ts , F IS H d e te c ts o n ly th a t fo r w h ic h is a p ro b e is a p p lie d and m a y m is s o th e r c y to g e n e tic a b n o rm a litie s . T h u s in th e c a s e o f c h ro n ic m yelo id le u k e m ia , it is o fte n d e s ira b le to u s e a F IS H a s s a y to d e te c t th e P h ila d e lp h ia c h ro m o s o m e b u t to run p a ra lle l c y to g e n e tic s to d e te c t le s s c o m m o n a n o m a lie s . N e v e rth e le s s F IS H o ffe rs se ve ra l a d v a n ta g e s . First, u n m a n ip u la te d in te rp h a s e c e lls c a n be u s e d fro m s m e a rs o r tis s u e s e c tio n s . S e c o n d , th e te s t a llo w s o n e to v is u a liz e th e c e lls w h ile in te rp re tin g th e c h ro m o s o m a l s ta tu s . T h ird , c e rta in s m a ll re a rra n g e m e n ts th a t m ay be m is s e d b y c o n v e n tio n a l c y to g e n e tic s ca n be d e te c te d e a s ily w ith F IS H . 3 m a jo r ty p e s o f p ro b e s a re u sed in c o n v e n tio n a l F IS H a n a lys is : c h ro m o s o m e e n u m e ra tio n p ro b e s , lo c u s s p e c ific p ro b e s , a n d s e ts o f p ro b e s th a t c o v e r e n tire c h ro m o s o m e s u sed fo r c h ro m o s o m e “ p a in tin g .” C h ro m o s o m e e n u m e ra tio n p ro b e s a re ta rg e te d to re p e a t re g io n s p re s e n t in th e c e n tro m e ric re g io n o f th e c h ro m o s o m e . T h e y a re o fte n u sed in c o m b in a tio n w ith lo cu s s p e c ific p ro b e s to d e te rm in e id e n tity a n d c o p y n u m b e r o f in d iv id u a l c h ro m o s o m e s . In th e c a s e o f tra n s lo c a tio n s , th e lo c u s s p e c ific p ro b e s c a n be fu rth e r s u b d iv id e d into w h e th e r th e g o a l is to d e te c t fu s io n g e n e s o r b re a k s in g e n e s . F usion p ro b e s a re u s e fu l fo r w e ll d e fin e d tra n s lo c a tio n s w ith c o n s e rv e d b re a k /fu s io n p o in ts . E ith e r d ua l color, s in g le fu sio n (2 d iffe re n t c o lo rs fo r th e

ISBN 9 7 8 -0 8 9 1 8 9 -6 6 7 8

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7: Molecular Pathology

Techniques & applications>Molecular techniques

a

b

i7.1 Break apart probes consist of 2 differently colored probes that hybridize with DNA sequences on either side of a breakpoint in a gene; rearrangement splits the normal (rusion) signal into separate orange & green signals Dual color break apart probes are useful for detecting translocations that may have multiple translocation partners or inversions in single chromosomes, FISH break apart probes for IgH rearrangement a In normal nuclei the IGH break apart probe generates 2 fusion signals (red-green or yellow), indicating 2 normal (unrearranged) IgH genes on chromosomes 14 b In cells with IgH rearrangement, the most common pattern is 1 red-green or yellow fusion (retained normal IgH), 1 red & 1 green signal (the latter 2 representing the broken apart or rearranged IgH)

i7.2 Enumeration (CEP) probes are chromosome specific probes that hybridize to highly repetitive human satellite DNA sequences, usually located near the centromere; in this example, probes for chromosome 9 & 11 show a normal chromosome number in a & polysomy in b

2 f1 G 1 R IG H /C C N D 1 R e a rr a n g e m e n t

n o rm a l g e n e s b e c o m e a s in g le th ird c o lo r w h e n fu s e d ) o r d u a l color, d u a l fu s io n (2 d iffe re n t c o lo rs fo r th e n o rm a l g e n e s b e c o m e 2 d iffe re n t c o lo rs , re p re s e n tin g th e fu s io n g e n e a n d th e d e riv a tiv e g e n e le ft b e h in d ). S in g le fu s io n p ro b e s a re u seful w h e n th e tra n s lo c a tio n is re p re s e n te d in a larg e n u m b e r o f c e lls , b u t a re s u b je c t to fa ls e p o s itiv e s w h e n th e re a re a lo w e r p e rc e n ta g e o f c e lls w ith th e d e fin e d tra n s lo c a tio n . In th a t c a s e d u a l co lo r, d u a l fu s io n p ro b e s a re m o s t h elp fu l. O n th e o th e r h an d , if a g e n e is m o re p ro m is c u o u s and in vo lve d in s e v e ra l d iffe re n t tra n s lo c a tio n s , a b re a k a p a rt p ro b e is a b e tte r c h o ic e . W ith b re a k a p a rt p ro b e s , a s in g le n o rm a l s ig n a l is “ b ro k e n ” into 2 s e p a ra te (s e p a ra te d by s p a c e ) d iffe re n t c o lo re d s ig n a ls.

7.2 .2 .5 .2 C o m p a ra tiv e g e n o m ic h y b rid izatio n C G H is a h y b rid iz a tio n te c h n iq u e th a t p ro v id e s p a n g e n o m ic c h ro m o s o m a l c o p y n u m b e r in fo rm a tio n , p ro v id in g in fo rm a tio n a b o u t c o p y lo s s e s a nd g a in s in c h ro m o s o m e s a n d s u b c h ro m o s o m a l re g io n s . T h e m o s t c o m m o n u ses fo r C G H a re fo r g e n e tic c h a ra c te riz a tio n o f c h ro m o s o m a l a n o m a lie s in d e v e lo p m e n ta l^ d e la ye d , d y s m o rp h ic , o r a u tis tic c h ild re n w ith no re c o g n iz e d k a ry o ty p ic a b n o rm a litie s , o r fo r th e c h a ra c te riz a tio n o f c h ro m o s o m a l g a in s and lo s s e s in c a n c e r c e lls re la tiv e to n o n c a n c e r ce lls. In th e in s ta n c e o f ca n c e r, C G H p ro b e s a re m a d e fro m th e e n tire g e n o m e o f th e c a n c e r ce lls, a s w e ll a s th e n o rm a l g e n o m e . E a ch set o f p ro b e s (c a n c e r vs n o n c a n c e r) is d iffe re n tia lly la b e le d (u su a lly by flu o re s c e n t c o lo rs). T h e s e ts o f p ro b e s a re h y b rid iz e d to a m e ta p h a s e sp re a d o f n o rm a l h um a n c h ro m o s o m e s on a slid e. C o m p e titio n fo r b in d in g s ite s on th e m e ta p h a s e c h ro m o s o m e s b e tw e e n th e c a n c e r p ro b e s a n d th e n o n c a n c e r p ro b e s c re a te s a p a tte rn w h e re c a n c e r p ro b e s a re o v e rre p re s e n te d in re g io n s th a t a re a m p lifie d and u n d e rre p re s e n te d in d e le tio n s . C G H ca n d e te rm in e w h e th e r e n tire c h ro m o s o m e s o r re g io n s o f c h ro m o s o m e s a re e ith e r a m p lifie d o r d e le te d . It is im p o rta n t to re a liz e th a t C G H can o n ly d e te c t q u a n tita tiv e d iffe re n c e s b e tw e e n n o rm a l and “ n o n n o rm a l.” It c a n n o t d e te c t b a la n c e d tra n s lo c a tio n s o r a ny o th e r n o n q u a n tita tiv e a b n o rm a litie s . T h e te rm a rra y C G H re fe rs to a s im ila r te c h n iq u e w h e re in , in s te a d o f h y b rid iz a tio n to m e ta p h a s e h u m a n c h ro m o s o m e s , th e d iffe re n tia lly la b e le d p ro b e s a re h y b rid iz e d to an a rra y re p re s e n tin g th e e n tire h u m a n g e n o m e o r a fo c a l re g io n o f in te re s t. F rom th is a p lo t o f a m p lific a tio n s and d e le tio n s ca n be p re c is e ly m a p p e d to re g io n s o f c h ro m o s o m e s .

7.2.2.5 .3 S p ectra l kary o ty p e im agin g i7.3 Dual color dual fusion FISH is similar to dual color single fusion FISH, except the probe spans across the gene target. Thus, when rearrangement occurs, the probe splits, and translocation results in a dual orange/green (fusion) signal, 1 on each derivative chromosome. This probe greatly reduces the number of normal nuclei exhibiting abnormal signal patterns, and is advantageous in detecting low levels of nuclei possessing a simple balanced translocation. In this figure, an example of lgHC-CCND1 fusion is demonstrated.

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S K I is a h y b rid iz a tio n te c h n iq u e u sin g w h o le c h ro m o s o m e p a in tin g p ro b e s , e a ch p ro b e a d iffe re n t flu o re s c e n t “co lo r.” F lu o re s c e n c e is d ig ita lly c o n v e rte d into c o lo rs w ith in th e v is ib le s p e c tru m fo r a n a lys is , m a k in g it p o s s ib le to id e n tify s tru c tu ra l a nd n u m e ric a l a n o m a lie s .

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

7: Molecular Pathology

Techniques & applications>Molecular techniques 7.2.2.5 .4 A llele s p e c ific o lig o n u c le o tid e probes M a n y e a rly a s s a y s w e re b u ilt on th is te c h n iq u e , w h ic h fo rm s th e b asis fo r so c a lle d “d o t b lo t” a n a lys is . In th e ty p ic a l s c e n a rio , 2 o lig o n u c le o tid e p ro b e s a re used, 1 th a t is c o m p le m e n ta ry to a p a rtic u la r D N A s e q u e n c e o f th e w ild ty p e and a n o th e r th a t is c o m p le m e n ta ry to th e k n o w n m u ta n t typ e . T h e s e a re in c u b a te d w ith D N A fro m a p a tie n t s a m p le . If th e e x a c t s e q u e n c e is p re s e n t, s ta b le h y b rid iz a tio n o c c u rs . If th e s e q u e n c e d iffe rs by 1 o r se v e ra l b ase s, h y b rid iz a tio n is re la tiv e ly u n s ta b le . In th is w a y p a tie n ts ca n be c la s s ifie d a s h o m o z y g o u s fo r n o rm a l a lle le s , h e te ro z y g o u s , or h o m o z y g o u s fo r m u ta n t a lle le s.

7.2.2.5 .5 D N A m ic ro arra ys & gen e exp re ssio n pro filin g

►

denaturation / (95°C) /

re p e a t fo r n c y c le s s u c h th a t a m o u n t of p ro d u c t = 2 n

M a n y D N A p ro b e s a re im m o b iliz e d on a so lid s u rfa c e , su ch a s a g la s s slid e o r chip, a llo w in g s im u lta n e o u s d e te c tio n o f th e p ro d u c ts o f th o u s a n d s o f g e n e s . T h e m R N A e x tra c te d fro m a s a m p le o f in te re s t is te s te d on th is s u b stra te , w ith p o s itiv e h y b rid iz a tio n to p a rtic u la r p ro b e s in d ica tin g e x p re s s io n o f th e c o m p le m e n ta ry g e n e . From this, th e “fin g e rp rin t” o f th e s a m p le ca n be d ig ita lly c o m p a re d to k n o w n tu m o r ty p e s to d e te rm in e s ite s o f o rig in , ty p e o f d iffe re n tia tio n , o r a g g re s s iv e n e s s .

—

—

=1

=

=

F

annealing (~65°C)*

extension (72°C)

i

1

i

1

f7.11 Polymerase chain reaction

7.2.2.6 Amplification techniques W ith o n ly 5-10 pg (trillio n th s o f a g ra m ) o f D N A p e r ce ll, th e re is a n ee d to in c re a s e th e lim ite d a m o u n t o f a s s a y a b le m a te ria l to fa c ilita te d e te c tio n . T h e re a re se ve ra l te c h n iq u e s to do so, e m p lo y in g a m p lific a tio n o f e ith e r ta rg e t o r sign al. T a rg e t a m p lific a tio n te c h n iq u e s a re m e a n t to a m p lify th e D N A o r R N A o f in te re st. S u ch te c h n iq u e s in c lu d e P C R a n d a v a rie ty o f is o th e rm a l te c h n iq u e s , su ch a s s tra n d d is p la c e m e n t a m p lific a tio n , n u c le ic a c id s e q u e n c e b ase d a m p lific a tio n (N A S B A ), tra n s c rip tio n m e d ia te d a m p lific a tio n (T M A ), and lo o p m e d ia te d is o th e rm a l a m p lific a tio n .

7.2.2.6.1 P o lym eras e chain reactio n W h ile th e c o n c e p t o f a m p lify in g D N A w ith D N A p o ly m e ra s e a nd a s e t o f p rim e rs w a s firs t p ro p o s e d >10 y e a rs b e fo re P C R w a s inve nted , th e D N A p o ly m e ra s e w o u ld be d e n a tu re d a fte r e a c h c y c le a nd had to be re in tro d u c e d a fte r c o o lin g . T h u s , th e re w a s no “c h a in ” re a c tio n , o n ly a s e rie s o f te d io u s s in g le re a c tio n s p ro n e to c o n ta m in a tio n . T h e le a p into P C R w a s e n a b le d by th e d is c o v e ry o f a D N A p o ly m e ra s e th a t is s ta b le u n d e r high te m p e ra tu re s . T h e p o ly m e ra s e o f T h e rm u s a q u a tic u s (Taq), a m ic ro b e th a t live s a nd th riv e s n e a r d e e p se a g e o th e rm a l ve nts, is su ch a p o ly m e ra s e . Taq p o ly m e ra s e a llo w e d th e re a c tio n to be s ta rte d a n d fin is h e d in a c lo s e d , te m p e ra tu re c y c lin g syste m .

© A S C P 2018

T h e b a s ic p rin c ip le o f P C R is th e c y c lic p o ly m e riz a tio n o f D N A c o p ie s f7.11. T h e s ta rtin g in g re d ie n ts m u s t c o n ta in a t le a s t a D N A te m p la te o f intere st, a s e t o f c o m p le m e n ta ry p rim e rs , a v a rie ty o f d N T P s , and a h e a t s ta b le p o ly m e ra s e . M o s t p o ly m e ra s e s re q u ire e x o g e n o u s d iv a le n t m a g n e s iu m , and a d d itio n a l b u ffe rin g o r d e n a tu rin g a g e n ts c a n be a d d e d as needed. T h e in itia l step, d e n a tu ra tio n a t 95°C , s p lits th e d o u b le s tra n d e d D N A into s in g le s tra n d s to fa c ilita te th e s e c o n d step, a n n e a lin g . In th e a n n e a lin g p h a s e , th e te m p e ra tu re is lo w e re d to o n e th a t fa v o rs a n n e a lin g o f th e s e q u e n c e s p e c ific p rim e rs . P rim e rs m ust be c a re fu lly c h o s e n s o th a t m e ltin g te m p e ra tu re s o f e ach a re s im ila r a n d th e p a irs h ave n o s e q u e n c e s im ila ritie s b e tw e e n th e m , w h ic h c a n le a d to in h ib ito ry p rim e r-d im e r fo rm a tio n . F o llo w in g a n n e a lin g , th e te m p e ra tu re is a g a in ra is e d to 72°C in o rd e r to fa c ilita te p o ly m e riz a tio n a lo n g th e D N A te m p la te . O n c e e x te n s io n is c o m p le te , th e p ro c e s s b e g in s a n e w w ith 95°C d e n a tu ra tio n . If th e ta rg e t is R N A ra the r than D N A , re ve rse tra n s c rip ta s e (R T ) d erived fro m retrovirus is used in th e p ro c e s s ca lled R T -P C R . T he R N A ta rg e t is firs t converted into c o m p le m e n ta ry D N A , w h ich is th e n a m plified by PC R . T h is p ro c e s s is used to a m p lify R N A viruses, and it is also used to a m p lify m R N A , s o m e th in g th a t can d eterm ine w h a t a cell is a ctive ly tra n s c rib in g (gene e xpre ssio n profiling). R N A is not a s s ta b le a s D N A and th e re fo re re quires fre sh m aterial (archival p araffin e m b e d d e d m ateria l not g e n e ra lly a m e n ab le to RT-PC R).

ISBN 9 7 8 -0 8 9 1 8 9 -6 6 7 8

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7: Molecular Pathology

Techniques & applications>Molecular techniques T h e P C R p ro d u c t, c o n s is tin g o f m a n y (m illio n s ) c o p ie s o f th e ta rg e t D N A o r R N A , c a n th e n b e s u b je c te d to a v a rie ty o f fu r th e r m a n ip u la tio n s , fo r th e p u rp o s e o f m o le c u la r d ia g n o s is , s u c h a s d o t b lo ts (a lle le s p e c ific d e te c tio n ), R F LP , a n d S o u th e rn b lo t a n a ly s is .

7 .2 .2 .6 .2 Q u a n tita tiv e PC R E a c h c y c le o f P C R a m p lifie s th e D N A 2 fo ld . To re p re s e n t th e a m o u n t o f D N A p ro d u c e d u n d e r o p tim a l c o n d itio n s , o n e u s e s th e e q u a tio n [D N A ] = 2n, w h e re n = n u m b e r o f c y c le s . T h e re fo re , a 10 fo ld a m p lific a tio n ta k e s p la c e e v e ry 3 .3 c y c le s (2 3 .3 = 10). F o llo w in g th a t a rith m e tic , if th e re a re 100 c o p ie s in c y c le 7, th e re w ill be 1 0 0 0 c o p ie s in c y c le 10. A t th e e n d o f th e ty p ic a l P C R p ro c e s s , th e re a re m illio n s o f c o p ie s o f th e ta rg e t D N A . B e in g o f e q u a l c h a rg e a nd m o le c u la r w e ig h t, th e y p ro d u c e a d is tin c t b a n d w h e n s u b je c te d to e le c tro p h o re s is . If a la b e l is in c o rp o ra te d , s u c h a s flu o re s c e n tly ta g g e d p rim e rs , a n d e le c tro p h o re s is is b u ilt in to th e c lo s e d s y s te m , th e p ro d u c t c a n b e d e te c te d in real tim e . T h is is th e b a s is fo r q u a n tita tiv e P C R o r re al tim e P C R . In c la s s ic a l (q u a lita tiv e ) P C R , s ta rtin g m a te ria ls (p rim e rs , d N T P s ) a re e x h a u s te d a fte r a s e t n u m b e r o f c y c le s , a nd a “ p la te a u ” p h a s e is re a c h e d . W h ile th e s e a re p re s e n t in e x c e s s , h o w e v e r, a t s o m e p o in t a c ritic a l m a s s o f D N A is re a c h e d a t w h ic h a m p lific a tio n in c re a s e s e x p o n e n tia lly . T h e ra p id ity w ith w h ic h th is e x p o n e n tia l p h a s e is re a c h e d is d ire c tly re la te d to a m o u n t o f s ta rtin g te m p la te ; th a t is, a s a m p le w ith h ig h e r c o p y n u m b e r o f s ta rtin g ta rg e t D N A m a y re a c h th is p o in t d u rin g c y c le 16, w h ile a n o th e r w ith le s s s ta rtin g ta rg e t D N A m a y n o t re a c h th is p o in t u n til c y c le 28. T h is p o in t is re fe rre d to a s th e c ro s s in g th re s h o ld (C t) f7.12. F o llo w in g th e e q u a tio n m e n tio n e d p re v io u s ly (2n), e v e ry 3 .3 c y c le s is e q u iv a le n t to a 10 fo ld d iffe re n c e in s ta rtin g te m p la te . A s e x p e c te d , th e m o re s ta rtin g m a te ria l, th e s o o n e r th e re a c tio n w ill e n te r th e lo g a rith m ic p h a s e o f a m p lific a tio n .

7 .2 .2 .6 .3 M e th y la tio n s p e c ific p o ly m e ra s e c h a in re a c tio n M e th y la tio n o f g e n e s is a s s o c ia te d w ith re p re s s io n o f g e n e e x p re s s io n . T h e re a re a n u m b e r o f w a y s to d e te c t w h e th e r o r n o t a g e n e is m e th y la te d . O n e s u c h te c h n iq u e is m e th y la tio n s p e c ific P C R . M e th y la te d c y to s in e re s id u e s in th e p re s e n c e o f s o d iu m m e ta b is u lfite a re re d u c e d to u ra cil. A fte r p re tre a tm e n t w ith m e ta b is u lfite , P C R p rim e rs s p e c ific to a s e q u e n c e c o n ta in in g u ra c ils in th e p la c e o f c y to s in e s a re u tiliz e d to s e le c tiv e ly a m p lify th e m e th y la te d s e q u e n c e .

7 .2 .2 .6 .4 M e ltin g p o in t a n a ly s is In c re a s e d s p e c ific ity o f P C R p ro d u c t id e n tific a tio n c a n be a c h ie v e d w ith m e ltin g p o in t a n a ly s is . F o llo w in g P C R w ith e ith e r n o n h y d ro ly z a b le p ro b e s o r in te rc a la tin g d ye, a n a ly s is

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o f th e P C R p ro d u c t can be p e rfo rm e d . It is im p o rta n t to n o te th a t w h e n h y d ro ly z a b le p ro b e s a re u sed , m e ltin g c u rv e a n a ly s is c a n n o t be p e rfo rm e d . T h e p ro c e d u re invo lve s m e a s u rin g flu o re s c e n c e w h ile in c re m e n ta lly in c re a s in g th e re a c tio n te m p e ra tu re . T h e m e ltin g p o in t o f a P C R p ro d u c t is d e fin e d as th e p o in t a t w h ic h 5 0 % o f th e p ro d u c t is s in g le s tra n d e d . O n a p lo t o f flu o re s c e n c e vs te m p e ra tu re , th e m e ltin g p o in t is th e p o in t o f th e m a x im a l c h a n g e in rate o f m e ltin g f7.13. T h is m e ltin g p o in t d e p e n d s on a n u m b e r o f c h a ra c te ris tic s o f th e p ro d u c t, eg, le n g th , G :C co n te n t, a m o u n t o f m is m a tc h . W h e n p lo tte d a s th e firs t d e riv a tiv e o f flu o re s c e n c e ch a n g e , a s in g le s p e c ific p e a k ca n be id e n tifie d

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

7: Molecular Pathology

Techniques & applications>Molecular techniques fo r a n y g ive n a m p lic o n . M is m a tc h e s in th e a m p lic o n o r th e p ro b e w ill re s u lt in s h ifte d m e ltin g p oin ts.

7 .2 .2 .6 .5 T ra n s crip tio n m ed iated a m p lific a tio n & n u c leic acid s e q u e n c e based a m p lific a tio n T M A a nd N A S B A a re re la te d te c h n iq u e s fo r is o th e rm a l a m p lific a tio n o f R N A ta rg e ts . T h e y a re p rim a rily u sed fo r in fe c tio u s d is e a s e a p p lic a tio n s , su ch a s th e d e te c tio n o f M y c o b a c te riu m tu b e rc u lo s is . T h e p rin c ip le in e a c h te c h n iq u e is sim ilar, u tiliz in g s p e c ific s e q u e n c e s th a t a re re c o g n iz e d by b a c te rio p h a g e R N A p o ly m e ra s e in o rd e r to m a ke m o re R N A c o p ie s . T h e y d iffe r in th a t N A S B A u s e s a s e p a ra te R N A s e H e n z y m e to d e g ra d e th e R N A in an R N A :D N A h ybrid, w h e re a s th a t a c tiv ity is p re s e n t in th e re ve rs e tra n s c rip ta s e in T M A . T h e R N A c o p ie s p ro d u c e d ca n th e n be p ro b e d w ith s p e c ific p ro b e s , u s u a lly flu o re s c e n tly la b e le d . T h e te c h n iq u e s a re d ia g ra m m e d in f7.14.

7.2.2.6.6 S ignal a m p lific a tio n T e c h n iq u e s th a t a im to d e te c t n u c le ic a c id by a m p lific a tio n o f a s ig n a l ra th e r th a n a m p lific a tio n o f th e s ta rtin g m a te ria l have b e e n le ss s u s c e p tib le to th e p ro b le m o f c o n ta m in a tio n . H ow ever, th e y a re u s u a lly n ot a s s e n s itiv e . O n e ca n a m p lify e ith e r th e p ro b e (th e c le a v a s e re a c tio n o r lig a tio n a m p lific a tio n re a c tio n ) o r th e s ig n a l its e lf (th e b ra n c h e d D N A o r h yb rid c a p tu re te c h n iq u e s ). T h e c le a v a s e te c h n iq u e is c a p a b le o f m u ltip le x in g and is e x q u is ite ly s e n s itiv e . T h e p rin c ip a l is h y b rid iz a tio n o f a s p e c ific p ro b e w ith a s e q u e n c e o f in te re s t th a t is a lre a d y b o u n d to a s e c o n d s e q u e n c e s p e c ific p ro b e , th u s c re a tin g a u n iq u e trip le x s tru c tu re . T h e trip le x is re c o g n iz e d by cle a v a s e , an e n d o n u c le a s e s p e c ific fo r th e trip le x s tru c tu re . U p o n c le a v a g e , a s p e c ific p ro b e s e q u e n c e is re le a s e d . T h e p ro b e ca n be d ire c tly d e te c te d (via re le a s e o f a q u e n c h e r fro m a flu o ro p h o re la b e le d fra g m e n t b y c le a v a s e ) o r d e te c te d w ith an a d d itio n a l p ro b e s p e c ific s e c o n d a ry p rob e. L ig a tio n a m p lific a tio n e m p lo y s a th e rm o s ta b le lig a se and a llo w s th e d is c rim in a tio n o f D N A s e q u e n c e s d iffe rin g in o n ly a s in g le b ase pair. T h e p rin c ip le o f lig a se ch a in re a c tio n is b a se d on th e lig a tio n o f 2 a d ja c e n t o lig o n u c le o tid e p rim e rs , w h ic h have bee n d e s ig n e d to h y b rid iz e w ith th e ta rg e t D N A su ch th a t th e 3' e n d o f o n e sits im m e d ia te ly a d ja c e n t to th e 5' end o f th e next, a n d th e p o in t w h e re th e y m e e t is th e lo c a tio n o f a k n o w n p o te n tia l s in g le b a se p a ir d iffe re n c e in th e ta rg e te d se q u e n c e . T h is s in g le b a se p a ir d iffe re n c e m ay d e fin e 2 d iffe re n t a lle le s o r 2 d iffe re n t b a c te ria l s p e c ie s . If th e n u c le o tid e in th e ta rg e t D N A is c o m p le m e n ta ry to th a t o f th e 3' e nd o f th e u p s tre a m p rim e r, th e 2 p rim e rs w ill be jo in e d by D N A lig a se . If not, lig a se c a n n o t c o m p le te th e jo in in g o f th e 2 p rim e r s tra n d s . 4 s e p a ra te p ro b e s a re u tilize d fo r e ach d o u b le s tra n d e d D N A . T h e d o u b le s tra n d e d ta rg e t D N A is d e n a tu re d w ith h e a tin g , th e n c o o le d to 65°C so th a t © A S C P 2018

f7.14 Transcription mediated amplification (TMA) & nucleic acid sequence based amplification (NASBA)

th e p rim e rs ca n be a n n e a le d . E a ch s tra n d b in d s to a s e t o f p ro b e s . If th e re is a n y m is m a tc h a t th e 3' e n d o f o n e o f th e p ro b e s a d ja c e n t to th e 5' end o f th e s e c o n d p ro b e , lig a tio n c a n n o t o ccur. A fte r m u ltip le cy c le s o f d e n a tu ra tio n , a n n e a lin g , a nd lig a tio n o n ly th e s e q u e n c e w ith o u t th e a fo re m e n tio n e d m is m a tc h , if p re s e n t, w ill be a m p lifie d . B ra n c h e d D N A a m p lifie s th e s ig n a l fro m a n u c le ic a c id m o le c u le th ro u g h an e la b o ra te m u ltila y e re d b ra n c h in g m e c h a n is m . A c a p tu re p ro b e is b o u n d to a s o lid s u p p o rt, u s u a lly e ith e r b e a d s o r th e w e lls o f a p la te . A h y b rid p ro b e c a lle d an e x te n d e r is d e s ig n e d to h y b rid iz e to a n u c le ic a c id o f in te re s t a s w e ll a s th e c a p tu re p ro b e . A s a re s u lt ta rg e t n u c le ic a cid is im m o b iliz e d on th e s o lid s u p p o rt. To th is im m o b iliz e d c o m p le x , a se c o n d h y b rid p ro b e c a lle d a la b e l e x te n d e r is b o u n d . T h e lab e l e x te n d e r re c o g n iz e s b o th th e ta rg e t n u c le ic a c id a nd a m o le c u le c a lle d a p re a m p lifie r. O n c e th e p re a m p lifie r is bou n d to th e la b e l e x te n d e r th e p re a m p lifie r m o le c u le a c ts as th e tru n k o f a tre e on w h ic h an a m p lifie r m o le c u le fo rm s th e b ra n c h e s . T h e a m p lifie r m o le c u le in a d d itio n to re c o g n iz in g th e p re a m p lifie r a ls o is s tu d d e d w ith n u m e ro u s b iotin m o le c u le s . T h e b io tin m o le c u le s a re e a c h re co g n iz e d by a s tre p ta v id in -flu o ro p h o re c o n ju g a te , w h ic h , w h e n excite d , flu o re s c e s lik e th e lig h ts o n a C h ris tm a s tree. H y b rid c a p tu re u s e s a s im ila r a p p ro a c h a s b ra n c h e d D N A , b u t w ith fe w e r s te p s. A se rie s o f R N A p ro b e s d ire c te d

ISBN 9 7 8 -0 8 9 1 8 9 -6 6 7 8

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7: Molecular Pathology

Techniques & applications>Molecular techniques a g a in s t s p e c ific D N A s e q u e n c e s is in c u b a te d w ith s p e c ific a n tib o d ie s th a t re c o g n iz e R N A :D N A h y b rid m o le c u le s . A s a n d w ic h a p p ro a c h is e m p lo y e d : im m o b iliz e th e s e a n tib o d ie s to th e w e lls o f a p la te , b in d h y b rid D N A :R N A m o le c u le s , th e n re c o g n iz e w ith a c o n ju g a te d a n ti-h y b rid a n tib o d y .

G C C G T G A A G AC C T T G A A G G A G G A C A C C A T G G A G G T G G A A G A G T T

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7.2 .2 7 DNA sequencing S e q u e n c in g te c h n iq u e s a re u s e d to d e te rm in e th e n u c le o tid e s e q u e n c e o f a s e g m e n t o f D N A , u s u a lly a s p e c ific g e n e . T e c h n iq u e s in c lu d e S a n g e r s e q u e n c in g , p y ro s e q u e n c in g , a nd a v a rie ty o f “ n e x t g e n e ra tio n ” p la tfo rm s .

7.2.2.7.1 S a n g e r d id e o x y s e q u e n c in g O n e o f th e lo n g e s t la s tin g s e q u e n c in g te c h n o lo g ie s , d id e o x y s e q u e n c in g , is e le g a n t a n d s im p le . T h e p rin c ip le is to p e rfo rm in v itro D N A re p lic a tio n w ith a ra d io la b e le d p rim e r, b u t te rm in a te re p lic a tio n s e le c tiv e ly a t e a c h d iffe re n t b ase . In itia lly , 4 d iffe re n t re a c tio n s w e re p e rfo rm e d , 1 fo r e a c h o f th e b a s e s . In e a c h re a c tio n d e o x y n u c le o tid e s w e re a d d e d , b u t fo r e a c h d iffe re n t tu b e , 1 o f th e b a s e s w a s a d d e d in a m ix o f d e o x y n u c le o tid e a n d d id e o x y n u c le o tid e . S in c e a d id e o x y n u c le o tid e la c k s th e 3 ' h y d ro x y l n e e d e d to fo rm th e p h o s p h o d ie s te r b o n d , re p lic a tio n c e a s e s . A s a re su lt, in e a c h tu b e w o u ld b e a m ix o f s y n th e s iz e d n a s c e n t D N A s tra n d s , e a c h te rm in a te d w h e re v e r th e d id e o x y n u c le o tid e w a s in c o rp o ra te d . S u b je c tin g th is m ix to e le c tro p h o re s is th ro u g h a p o ly a c ry la m id e g e l w o u ld s e p a ra te th e D N A s tra n d s by le n g th a n d p ro v id e a la d d e r, e a c h ru n g re p re s e n tin g an a b o rte d re p lic a tio n d u e to in c o rp o ra tio n o f a c h a in te rm in a tin g d id e o x y n u c le o tid e . W h e n e a c h o f th e 4 re a c tio n s w a s ru n n e x t to o n e a n o th e r th e s e q u e n c e o f th e ta rg e t c o u ld b e re a d fro m th e b o tto m o f th e a u to ra d io g ra p h (s h o rte s t fra g m e n ts ) to th e to p (lo n g e s t fra g m e n ts ). T h is te c h n iq u e w a s g re a tly s im p lifie d (a nd im p ro v e d ) th ro u g h th e u s e o f d id e o x y n u c le o tid e s c o n ju g a te d to d iffe re n t flu o ro p h o re s . T h e re a c tio n s c o u ld b e ru n th ro u g h a s in g le p o ly m e r m a trix c a p illa ry , a n d th e id e n tity o f e a c h flu o ro p h o re d e te rm in e d a s it m ig ra te d p a s t a fix e d d e te c to r f 7.15. T h is a llo w e d fo r a s in g le re a c tio n , no ra d io a c tiv ity , a n d g re a te r le n g th o f s e q u e n c e re ad .

7 .2 .2 7 .2 P y ro s e q u e n c in g (s in g le b as e e x te n s io n ) P y ro s e q u e n c in g re lie s on m e a s u re m e n t o f th e p y ro p h o s p h a te re le a s e d w h e n e v e r a p h o s p h o d ie s te r b o n d is fo rm e d , th u s a llo w in g th e re al tim e d e te c tio n o f n u c le o tid e a d d itio n by D N A p o ly m e ra s e . W h e n a s in g le b a s e is in c o rp o ra te d , a s to ic h io m e tric a m o u n t o f p y ro p h o s p h a te is re le a s e d . T h e re le a s e d p y ro p h o s p h a te c a n be m e a s u re d , u s u a lly th ro u g h a s e c o n d a ry lig h t, p ro d u c in g re a c tio n .

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f7.15 Dideoxysequencing: capillary electrophoresis with fluorescence detection of differentially labeled dideoxy NTPs in cycle sequencing assay; the presence of an additional sequence signal indicates a mixed sample

1 n u c le o tid e ty p e (A, T, C, o r G ) is a d d e d a t a tim e, and if lig h t is p ro d u c e d , th a t n u c le o tid e w a s th e n e x t in th e s e q u e n c e ; if a s e rie s o f th a t n u c le o tid e ty p e is a d d e d , th is c a n be d e te c te d b a se d o n th e a m o u n t o f lig h t e m itte d . A fte r e a c h step, e x c e s s n u c le o tid e is d e g ra d e d by a p y ra s e . T h is p ro c e s s is re p e a te d w ith e a c h o f th e 4 n u c le o tid e ty p e s until th e D N A s e q u e n c e is d e te rm in e d . P y ro s e q u e n c in g is a ra pid m e th o d id e a lly s u ite d fo r c h a ra c te riz in g p o in t m u ta tio n s o r S N P s.

7 .2 .2 7 .3 W h o le g e n o m e te c h n iq u e s & n ext g en e ra tio n seq u en cin g S N P h a p lo typ in g , th e p ro c e s s o f fo rm in g a D N A “fin g e rp rin t” fro m the m u ltitu d e o f S N P s in a p e rs o n ’s g e n e tic co de , w a s th e e a rlie s t e x a m p le o f a w h o le g e n o m e te c h n iq u e in m o le c u la r d ia g n o s tic s . M ic ro a rra y s w e re th e n e x t m a jo r g e n o m e w id e step, p e rm ittin g th e s im u lta n e o u s in te rro g a tio n o f m u ltip le D N A ta rg e ts o f k n o w n c lin ic a l va lu e. T h e p o s s ib ility o f s e q u e n c in g an e n tire h u m a n g e n o m e c o u ld b e im a g in e d , o n c e S a n g e r s e q u e n c in g e m e rg e d in th e late 1970s, b ut o n ly ju s t. T h e p ro c e s s w a s la b o r in te n sive , slow , a n d m an u al. S a n g e r s e q u e n c in g w a s a u to m a te d in th e late 1 9 8 0 s and, c o u p le d w ith c a p illa ry e le c tro p h o re s is , fo rm e d th e in s tru m e n ta l b a s is fo r th e H u m a n G e n o m e P ro je c t in th e la te 1 990s. T h is “ firs t g e n e ra tio n ” s e q u e n c in g w a s c a p a b le o f s e q u e n c in g 8 4 k ilo b a s e s p e r run. N e x t g e n e ra tio n s e q u e n c in g re fe rs to in s tru m e n ts in tro d u c e d a d e c a d e later, c a p a b le o f s e q u e n c in g >1 g ig a b a s e p e r run. M o re re ce n t “ n e x t g e n e ra tio n ” in s tru m e n ts ca n p ro d u c e >1 te ra b a s e p e r run. T h e lea p fro m “firs t” to “ n e x t” w a s e n a b le d by 3 m ain c h a n g e s in a p p ro a c h s u m m a riz e d in th e te rm s h o r t read, m a s s iv e ly p a ra lle l: fra g m e n ta tio n o f th e g e n o m e in to sm all p ie c e s , a u to m a te d s e q u e n c in g o f e a c h o f th e s e in p a ra lle l, a nd c o m p ila tio n o f th e s e q u e n c e d fra g m e n ts into a g e n o m ic s e q u e n c e u sing p o w e rfu l c o m p u tin g .

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

7: Molecular Pathology

Techniques & applications>Applications

7.2.3 Applications 7.2.3.1 Clonality assessment in lymphoid neoplasms C lo n a lity a s s e s s m e n t b y m o le c u la r m e th o d s is s o m e tim e s re q u ire d in th e e v a lu a tio n o f ly m p h o id p ro life ra tio n s . S o u th e rn b lo t a n a ly s is h a s b e e n u se d tra d itio n a lly to a s s e s s fo r c lo n a l re a rra n g e m e n ts in im m u n o g lo b u lin o r T cell re c e p to r g e n e s . P C R is c u rre n tly th e m o s t c o m m o n m e th o d used.

7.2.3.2 Chimerism in engraftment, parentage testing, & forensic identity testing S h o rt ta n d e m re p e a ts (S TR s), a ls o c a lle d m ic ro s a te llite s , are re g io n s o f D N A c o m p o s e d o f a s e rie s o f re p e a tin g d in u c le o tid e s o r trin u c le o tid e s . T h e le n g th o f th e s e re p e a ts v a rie s fro m o n e p e rs o n to a no th e r. S T R s a re in h e rite d as a lle le s, 1 m a te rn a l a nd 1 p a te rn a l, a nd ca n be u sed a s “fin g e rp rin ts ” to id e n tify in d ivid u a ls . F u rth e rm o re , th e y ca n be u sed to id e n tify s u c c e s s fu l e n g ra ftm e n t, w h e re in re p re s e n ta tio n s o f both d o n o r a nd re c ip ie n t S T R s ca n be id e n tifie d . F o r s im ila r re a s o n s a p a n e l o f S T R s ca n be used to d e te rm in e p a re n ta g e a nd to id e n tify re m a in s fo r fo re n s ic p u rp o s e s . N o te th a t e x p a n sio n o f S T R s w ith in c o d in g s e q u e n c e s is a m e c h a n is m o f d is e a s e in se ve ra l d iffe re n t c o n d itio n s , k n o w n as trin u c le o tid e re p e a t d is o rd e rs , su ch a s H u n tin g to n d is e a s e (H D ). In a d d itio n , d iffe rin g le n g th o f S T R s in d iffe re n t c e lls fro m th e s a m e p a tie n t in d ic a te s a n o m a lie s in m is m a tc h re p a ir g e n e s , su ch a s in Lynch sy n d ro m e .

7.2.3.3 Pharmacogenomics P h a rm a c o g e n o m ic s is th e s tu d y o f m u ltip le g e n e tic fa c to rs th a t in flu e n c e an in d iv id u a l’s re s p o n s e to a d ru g (p h a rm a c o k in e tic s ) o r a d ru g ’s e ffe c t on an in d ivid u a l (p h a rm a c o d y n a m ic s ). S tric tly s p e a k in g , p h a rm a c o g e n e tic s is a s u b s e t o f p h a rm a c o g e n o m ic s a nd u s u a lly re fe rs to a s in g le g e n e o r g ro u p o f re la te d g e n e s and th e ir in flu e n c e (s ) on th e a b o v e m e n tio n e d fa c to rs . O n e o f th e m o s t im p o rta n t c o n c e p ts in p h a rm a c o g e n o m ic s is g e n e tic p o ly m o rp h is m . T h e re ca n be p o ly m o rp h is m in re g u la to ry o r c o d in g re g io n s o f g e n e s w h o s e p ro d u c ts are invo lve d w ith d ru g m e ta b o lis m , w h ic h a ffe c ts th e re s p o n s e th a t a p a rtic u la r d ru g e lic its . It is o fte n sa id th a t th e p u rp o s e o f p h a rm a c o g e n o m ic s is to e n s u re th a t a ny g ive n in d ivid u a l g e ts th e rig h t d ru g in th e rig h t a m o u n t to e lic it th e d e s ire d re s p o n s e a nd m in im iz e u n d e s ire d o ne s. O f th e g e n e s in vo lve d w ith d ru g m e ta b o lis m m e m b e rs o f th e c y to c h ro m e P 4 50 (C Y P ) fa m ily hold an e xalte d p o s itio n , e s tim a te d to be invo lve d in th e m e ta b o lis m o f —3/4 o f m e d ic a tio n s. T h e n o m e n c la tu re fo r C Y P g e n e s is s ta n d a rd iz e d so th a t th e n a m e re fle c ts th e s u p e rg e n e © A S C P 2018

fa m ily (C Y P ), th e fa m ily, the s u b fa m ily , th e is o e n z y m e , a n d th e a lle lic v a ria n t. F o r e x a m p le th e w ild ty p e (*1) a lle le o f th e 2 fa m ily, D su bfam ily, 6 is o e n z y m e is tra n s c rib e d a s C Y P 2 D 6 *1 . T h e p u rp o s e o f th e g e n e p ro d u c ts o f th e C Y P fa m ily is th e o x id a tiv e m e ta b o lis m o f to x in s , w h ic h in c lu d e s d ru g s . P o ly m o rp h is m s in C Y P n o t o n ly a ffe c t th e in a c tiv a tio n a n d c le a ra n c e o f d ru g s , b u t c a n a ls o a ffe c t th e a c tiv a tio n o f a p ro d ru g , a s is th e c a s e w ith th e C Y P 2 D 6 m e ta b o lis m o f c o d e in e to the a c tiv e m e ta b o lite m o rp h in e . T h e d iffe re n t a lle le s are c a te g o riz e d a s to w h e th e r th e y re s u lt in p o o r m e ta b o liz e rs , in te rm e d ia te m e ta b o liz e rs , e x te n s iv e m e ta b o liz e rs , o r u ltra ra p id m e ta b o liz e rs . It fo llo w s th a t a p o o r m e ta b o liz e r w ill e x p e rie n c e in c re a s e d to x ic e ffe c ts fro m d ru g s w h o s e c le a ra n c e is re g u la te d b y C Y P a nd d e c re a s e d re s p o n s e to p ro d ru g s a c tiv a te d b y CYP. C Y P 2 D 6 p o ly m o rp h is m s have a ro le in th e m e ta b o lis m o f tric y c lic a n tid e p re s s a n ts , such a s n o rtrip ty lin e . C Y P 2 C 9 p la y s an im p o rta n t ro le in th e m e ta b o lis m o f w a rfa rin a nd p h e n y to in . S e ve ra l a lle le s o f C Y P 2 C 9 a re a s s o c ia te d w ith re d u c e d a c tivity , in c lu d in g th e m o re c o m m o n *2 a n d *3 a lle le s . T h e C Y P 2 C 1 9 g e n e p ro d u c t is re s p o n s ib le fo r th e m e ta b o lis m o f o m e p ra z o le , p h e n y to in , a nd d ia z e p a m . C e rta in p o ly m o rp h is m s o f C Y P 2 C 1 9 le a d to d e c re a s e d a c tiv ity a n d s u b s e q u e n t in c re a s e d to xicity. T h e s e p o ly m o rp h is m s a re m o s t c o m m o n in A s ia n s . T h e ta rg e t o f w a rfa rin is in h ib itio n o f th e v ita m in K e p o x id e re d u c ta s e (V K O R C 1 ). T h e V K O R C 1 g e n e p ro d u c t is in vo lve d in th e m e ta b o lis m o f v ita m in K, a ke y c o fa c to r in y c a rb o x y la tio n o f th e v ita m in K d e p e n d e n t c o a g u la tio n fa c to rs (fa c to rs II, V II, IX, X , p ro te in C, a n d p ro te in S). P o ly m o rp h is m s in th e g e n e n am e d H1 a n d H 2 a re a s s o c ia te d w ith e n h a n c e d s e n s itiv ity to w a rfa rin . T h e H7, H 8, a n d H 9 h a p lo ty p e s a re a s s o c ia te d w ith d e c re a s e d s e n s itiv ity to w a rfa rin (w a rfa rin re sista n ce ). N -a c e ty ltra n s fe ra s e is c e n tra l fo r th e m e ta b o lis m o f is o n ia z id , s o m e p o ly m o rp h is m s re su lt in in c re a s e d o r d e c re a s e d a c tivity . S o m e s tra in s o f M tu b e rc u lo s is e x p re s s NAT, le a d in g to is o n ia z id re sis ta n c e . A d m in is te re d a s p ro d ru g s fo r c h e m o th e ra p y , th io p u rin e s a re a c tiva te d by h y p o x a n th in e g u a n in e p h o s p h o rib o s y l tra n s fe ra s e (H G P R T ). T h io p u rin e m e th y ltra n s fe ra s e ( T P M T ) in a c tiv a te s th io p u rin e s . P o ly m o rp h is m s in th e T P M T g e n e h ave b e e n id e n tifie d a s s o c ia te d w ith in c re a s e d a c tiv ity (re d u c e d th e ra p e u tic e ffe c t) o r d e c re a s e d a c tiv ity (in c re a s e d to xicity). M e th y le n e te tra h y d ro fo la te re d u c ta s e (M T H F R ) is in h ib ite d by th e a n tim e ta b o lite m e th o tre x a te . T h e m o s t c o m m o n p o ly m o rp h is m s o f M T H F R , C 6 7 7 T a n d A 1 2 9 8 C a re b o th a s s o c ia te d w ith an in c re a s e d in c id e n c e o f m e th o tre x a te to x ic ity (and in c re a s e d h o m o c y s te in e levels).

ISBN 9 7 8 -0 8 9 1 8 9 -6 6 7 8

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7: Molecular Pathology

Techniques & applications>Applications Genetics of nonneoplastic disease>Renal 7.2.3.4 Practical aspects of m olecular pathology 7.2.3.4.1 L e g is la tio n & o v e rs ig h t In 2 0 0 3 , C lin ic a l L a b o ra to ry Im p ro v e m e n t A m e n d m e n t (C L IA ) re g u la tio n s w e re re v is e d to in c lu d e s p e c ific re q u ire m e n ts fo r th e c lin ic a l c y to g e n e tic s la b o ra to ry . L a b o ra to rie s c o n d u c tin g m o le c u la r g e n e tic te s tin g w e re n o t s p e c ific a lly a d d re s s e d , b u t s u c h te s tin g is g e n e ra lly c o n s id e re d “ h ig h c o m p le x ity ” u n d e r C L IA re g u la tio n s . P ro fic ie n c y te s tin g s u rv e y s a re a v a ila b le fo r s o m e o f th e m o re c o m m o n m o le c u la r te s ts , b u t in m a n y in s ta n c e s , m o le c u la r la b o ra to rie s m u s t im p le m e n t an a lte rn a tiv e p la n to v e rify a c c u ra c y a t le a s t tw ic e a n n u a lly , in o rd e r to be in c o m p lia n c e w ith C L IA re g u la tio n s . O n e lim ita tio n o f p ro fic ie n c y te s tin g s u rv e y s in m o le c u la r p a th o lo g y is th a t th e s u rv e y m a te ria l o fte n c o n s is ts o f p u rifie d D N A , s u c h th a t th e p ro c e s s o f e x tra c tin g a n d is o la tin g D N A is n o t a s s e s s e d . L e g is la tio n re g a rd in g c o n s e n t fo r m o le c u la r g e n e tic te s tin g is th e re s p o n s ib ility o f th e in d iv id u a l s ta te s . A t th is tim e , in fo rm e d c o n s e n t fo r g e n e tic te s tin g is re q u ire d by la w in A la s k a , A la b a m a , F lo rid a , G e o rg ia , M a s s a c h u s e tts , M ic h ig a n , N e b ra s k a , N e w M e x ic o , N e w Y o rk, S o u th C a ro lin a , S o u th D a k o ta , a n d V e rm o n t. S o m e o f th e s ta te s e x p lic itly d e fin e w h a t in fo rm a tio n m u s t be g iv e n in th e in fo rm e d c o n s e n t, w h ile o th e rs d o n ot. C L IA re g u la tio n s d o n o t s p e c ific a lly re q u ire th a t th e la b o ra to ry d o c u m e n t in fo rm e d c o n s e n t fo r re q u e s te d te s ts . T h e re s p o n s ib ility o f in fo rm e d c o n s e n t re sts w ith th e o rd e rin g p h y s ic ia n . F u rth e rm o re , s o m e s ta te s h a v e p a s s e d le g is la tio n to p ro te c t g e n e tic in fo rm a tio n b e y o n d th e p ro te c tio n s o ffe re d b y fe d e ra l la w (th e H e a lth In s u ra n c e P o rta b ility a n d A c c o u n ta b ility A c t) o f h e a lth in fo rm a tio n in g e n e ra l. T h is tre a tm e n t o f g e n e tic in fo rm a tio n h a s b e e n te rm e d g e n e tic e x c e p tio n a lis m , d e fe n d e d o n th e b a s is o f th e u n iq u e ly p re d ic tiv e a n d p e rs o n a l n a tu re o f g e n e tic in fo rm a tio n . S o m e s ta te s h a v e d e fin e d g e n e tic in fo rm a tio n a s “ p e rs o n a l p ro p e rty .” P a s s e d into fe d e ra l la w in 2 0 0 8 , th e G e n e tic In fo rm a tio n N o n d is c rim a tio n A c t p ro te c ts in d iv id u a ls fro m d is c rim in a tio n fo r e m p lo y m e n t o r g ro u p h e a lth in s u ra n c e (b u t n o t life o r d is a b ility in s u ra n c e ) b a s e d on th e re s u lts o f g e n e tic te s tin g .

7 .2 .3 .4 .2 G e n e tic c o u n s e lin g G e n e tic c o u n s e lin g is a n im p o rta n t fa c e t o f m o le c u la r te s tin g . T h e im p lic a tio n s o f in h e rite d d is e a s e a re fa r re a c h in g to b o th fa m ily m e m b e rs a n d th e te s te d (p ro b a n d ) in d iv id u a l. In a d d itio n to c o n s e n t fo r g e n e tic te s tin g , it is a p p ro p ria te to s e n d p a tie n ts fo r g e n e tic c o u n s e lin g to e x p la in th e ra m ific a tio n s o f a p o te n tia l te s t re s u lt a n d th e s ig n ific a n c e o f a n e g a tiv e re s u lt. G e n e tic c o u n s e lo rs a re u s u a lly m a s te r’s le v e l s u b je c t m a tte r e x p e rts in ris k a s s e s s m e n t a n d c o u n s e lin g . R is k a s s e s s m e n t c a lc u la tio n s a re m a d e b a s e d o n p e d ig re e d fa m ily h is to ry , p e rs o n a l m e d ic a l h istory, a n d th e re s u lts o f g e n e tic o r g e n o m ic te s ts . B a se d on th is 334

in fo rm a tio n , g e n e tic c o u n s e lo rs u tiliz e B a ye s ia n c a lc u la tio n s to a s s e s s fo r re sid u a l risk. B a y e s ia n c a lc u la tio n s ta k e into a c c o u n t p rio r p ro b a b ility a nd c o n d itio n a l p ro b a b ility o f a p a rtic u la r fin d in g to g e n e ra te a jo in t p ro b a b ility a nd p o s te rio r p ro b a b ility . In tuitively, it m a ke s s e n s e th a t a n e g a tiv e te s t re s u lt fro m a p a rtic u la r te s t w ith a d e fin e d s e n s itiv ity d o e s n o t im p ly a z e ro risk. A re sid u a l risk e x is ts b e c a u s e th e te s t d o e s n o t d e te c t all p o te n tia lly a ffe c te d in d ivid u a ls . It a ls o s ta n d s to re a s o n th a t th e s e n s itiv ity o f a te s t v a rie s w ith th e p o p u la tio n b e in g te s te d a n d a s a re su lt s o d o e s th e re sid u a l risk. B a ye s ia n c a lc u la tio n s a re a w a y o f a s s ig n in g a q u a n tita tiv e v a lu e to th a t re sid u a l risk. T h e re s id u a l risk is w h a t is le ft o v e r a fte r o n e c a lc u la te s th e p ro b a b ility o f a te s t re s u lt b e in g “ m e a n in g fu l” (ie, d o e s it s e p a ra te “d is e a s e ” fro m “ n o n d is e a s e ” ?).

7.3 Genetics of nonneoplastic disease 7.3.1 Renal 7.3.1.1 Inherited nephritic syndrome In h e rite d n e p h ritic s y n d ro m e is c a u s e d p rim a rily by m u ta tio n s in th e g e n e s e n c o d in g ty p e IV c o lla g e n . A t th e se ve re e n d o f th e s p e c tru m is A lp o rt s y n d ro m e , w h ic h p re s e n ts w ith th e tria d o f g lo m e ru lo n e p h ritis , s e n s o rin e u ra l h e a rin g lo s s , and o c u la r (c o rn e a l, le n tic u la r, a n d m a c u la r) lesio n s. In itia lly p re s e n tin g w ith h e m a tu ria , a m a n ife s ta tio n o f g lo m e ru lo n e p h ritis , A lp o rt s y n d ro m e w ill p ro g re s s e v e n tu a lly to e n d sta g e re na l d is e a s e . - 8 0 % o f c a s e s h ave a p a tte rn o f X linked re c e s s iv e in h e rita n c e , w ith m o s t re m a in in g c a s e s a u to s o m a l re ce s s ive . F e m a le c a rrie rs fo r th e X lin ked tra it o fte n m a n ife s t a s y m p to m a tic h e m a tu ria . T h e s im p le s t w a y o f m a k in g th e d ia g n o s is o f A lp o rt s y n d ro m e is th ro u g h e x a m in a tio n o f skin o r re na l b io p sie s . T h e a b s e n c e o f im m u n o h is to c h e m ic a l s ta in in g fo r th e a 5 ch a in o f ty p e IV c o lla g e n — a 5 (IV )— s u p p o rts th e d ia g n o s is . In fa c t, im m u n o h is to c h e m ic a l s ta in in g o f k id n e y o fte n s h o w s c o m p le te a b s e n c e o f a 3 , a 4, a n d a 5 c h a in s o f ty p e IV c o lla g e n . T h e im m u n o h is to c h e m ic a l te s ts a re im p e rfe c t, w ith n orm a l s ta in in g se e n in up to 2 0 % o f c a s e s . G lo m e ru la r e x a m in a tio n by e le c tro n m ic ro s c o p y s h o w s a th in, d is ru p te d , a n d in h o m o g e n e o u s la m in a d e n s a , s o m e tim e s a p p e a rin g m u ltila m in a r i7.4, th a t e n tra p s ro u n d e d e le c tro n d e n s e b od ies. E le c tro n m ic ro s c o p y m a y s h o w s c a llo p in g o f th e e p ith e lia l a s p e c t o f th e g lo m e ru la r b a s e m e n t m e m b ra n e . X linked re c e s s iv e A lp o rt s y n d ro m e is c a u s e d by m u ta tio n s in th e C O L 4 A 5 g e n e on X p 2 2 .3 , w h ic h e n c o d e s th e a 5 c h a in o f ty p e IV c o lla g e n . A m ild e r d is o rd e r k n o w n a s b e n ig n fa m ilia l h e m a tu ria o r th in b a s e m e n t m e m b ra n e d is e a s e m a y re p re s e n t a h e te ro z y g o u s v a ria n t o f A lp o rt s y n d ro m e . T h is m a n ife s ts a s p e rs is te n t h e m a tu ria , w ith o u t p ro te in u ria o r p ro g re s s io n to re na l

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

7: Molecular Pathology

Genetics of nonneoplastic disease>Renal

i7.4 Alport syndrome a Glomerular basement membrane thinning b Typical splitting & splintering of the glomerular basement membrane

fa ilu re . T h e s ta in in g fo r a 3 , a 4, and a 5 c h a in s is n o rm a l. E le c tro n m ic ro s c o p y d is p la y s th e d iffu s e u n ifo rm th in n in g o f g lo m e ru la r b a s e m e n t m e m b ra n e s th a t d e fin e s th is e ntity.

g e n e o n c h ro m o s o m e 9 q 3 4 .1 . T h e L M X 1 B g e n e p ro d u c t is a tra n s c rip tio n fa c to r th a t re g u la te s e x p re s s io n o f th e C O L 4 A 3 g e n e . P a tie n ts p re s e n t w ith s k e le ta l, o c u la r, a n d n ail a b n o rm a litie s a lo n g w ith n e p h ro tic s y n d ro m e . T h o s e w h o d o h ave re n a l in v o lv e m e n t (v a ria b le ) h a v e u ltra s tru c tu ra l e v id e n c e o f fib rilla r y c o lla g e n d e p o s its in th e b a s e m e n t m e m b ra n e . D e n y s -D ra s h s y n d ro m e is o n e o f m a n y d is o rd e rs a s s o c ia te d w ith m u ta tio n s in th e W T 1 g e n e o n 11 p1 3. T h o s e a ffe c te d h a v e a h ig h in c id e n c e o f W ilm s tu m o r, m a le p s e u d o h e rm a p h ro d itis m , a n d ra p id ly p ro g re s s iv e re n a l fa ilu re (u s u a lly le a d in g to e n d s ta g e re n a l d is e a s e b y a g e 3). A ls o a s s o c ia te d w ith m u ta tio n s o f W T1 is F ra s ie r s y n d ro m e , w h ic h h a s a s lo w e r p ro g re s s io n to re n a l fa ilu re a n d a n in c re a s e d in c id e n c e o f g o n a d o b la s to m a .

t7.1 Inherited nephrotic syndrome 7.3.1.2 Inherited nephrotic syndrome N e p h ro tic s y n d ro m e is a c o m m o n p e d ia tric illn e ss, c h a ra c te riz e d by m a s s iv e p ro te in u ria , e d e m a , h y p o a lb u m in e m ia , and h y p e rlip id e m ia . T h e m o s t c o m m o n c a u s e o f c h ild h o o d n e p h ro tic s y n d ro m e is m in im a l c h a n g e d is e a s e , an a c q u ire d c o n d itio n th a t u s u a lly a ris e s b e tw e e n a g e s 1 a nd 10. M in im a l c h a n g e d is e a s e is e x q u is ite ly s e n s itiv e to s te ro id s . A s a re su lt, c h ild re n w ith n e p h ro tic s y n d ro m e a re o fte n tre a te d e m p iric a lly w ith s te ro id s , a nd im p ro v e m e n t is ta k e n as p re s u m p tiv e e v id e n c e o f m in im a l c h a n g e d is e a s e . In th o s e w h o d o n ot im p ro ve , o th e r p o s s ib ilitie s a re c o n s id e re d , and a b io p s y m a y be u n d e rta k e n . C o n g e n ita l n e p h ro tic s y n d ro m e is d e fin e d a s n e p h ro tic s y n d ro m e d e te c te d b e fo re 3 m o n th s o f a g e . T h is is o n ly ra re ly c a u s e d by m in im a l c h a n g e d is e a s e . C o n g e n ita l n e p h ro tic s y n d ro m e m a y p re s e n t ju s t a fte r b irth , b u t o fte n b e g in s in u te ro . T y p ic a l fin d in g s in c lu d e d e p e n d e n t e d e m a (d o rs u m fo r a n e o n a te ), a b d o m in a l d is te n s io n , a n d a la rg e p la c e n ta . T h e re is m a rk e d (n e p h ro tic ra n g e ) p ro te in u ria , h y p o a lb u m in e m ia , a n d h y p e rlip id e m ia . T h e d iffe re n tia l d ia g n o s is in c lu d e s c e rta in p e rin a ta l in fe c tio n s (ru b e lla , to x o p la s m o s is , s y p h ilis , c y to m e g a lo v iru s ) a n d a g ro u p o f in h e rite d d is o rd e rs (in h e rite d n e p h ro tic s y n d ro m e s ) t7.1. O n e o f th e m o re c o m m o n c a u s e s o f in h e rite d n e p h ro tic s y n d ro m e is c o n g e n ita l n e p h ro tic s y n d ro m e o f th e F in n is h ty p e , w h ic h is d u e to m u ta tio n s in th e g e n e N P H S 1 lo c a te d on c h ro m o s o m e 19 q 1 3.1 a n d e n c o d in g th e p ro te in n e p h rin . N e p h rin p la y s a key ro le in th e e s ta b lis h m e n t o f th e g lo m e ru la r s lit d ia p h ra g m . P ie rs o n s y n d ro m e (n o t to be c o n fu s e d w ith th e m ito c h o n d ria l d is o rd e r P e a rs o n s y n d ro m e ) is a n o th e r c a u s e o f c o n g e n ita l n e p h ro tic s y n d ro m e th a t is a s s o c ia te d w ith m ic ro c o ria . M u ta tio n s in th e g e n e L A M B 2 on c h ro m o s o m e 3p21 le a d to d e fic ie n c ie s in th e p 2 -la m in in p ro te in , a ke y c o m p o n e n t o f th e g lo m e ru la r b a s e m e n t m e m b ra n e . N a il-p a te lla s y n d ro m e is an a u to s o m a l d o m in a n t d is o rd e r in v o lv in g th e L M X 1 B © A S C P 2018

NPHS1 (19q13.1) gene, which encodes nephrin Nephrin is a key component of the glomerular slit diaphragm Affected children born with markedly enlarged placenta Massive proteinuria begins in utero, nephrotic syndrome by 1 month of age Electron microscopy is notable for an abnormal variation in the size of the slit pores (the space between podocyte foot processes) & rarefaction of the slit diaphragms LAMB2 (3p21) gene, which encodes p2 laminin Pierson syndrome |32 laminin is a component of the glomerular basement membrane Associated with microcoria (fixed, narrow, pupils) Death within several months Renal biopsy shows mesangial sclerosis & crescents Nail-patella syndrome LMX1B (9q34.1) gene, which encodes a transcription factor that regulates transcription of COL4A3 Autosomal dominant disorder manifesting with skeletal & ocular anomalies, abnormalities of the nails & renal disease (variable) Renal biopsy shows basement membrane expansion by fibrillary collagen deposits Denys-Drash WT1 gene (11p13) Wilms tumors, male pseudohermaphroditism & rapidly syndrome/Frasier progressive renal failure syndrome Renal biopsy shows mesangial sclerosis Frasier syndrome similar but less severe, associated with gonadoblastoma Familial autosomal ACTN4 gene, which encodes a-actinin TRPC6 gene, which encodes transient receptor potential dominant focal segmental cation channel 6 glomerulosclerosis Onset of nephrotic syndrome in adolescence or young adulthood Familial autosomal NPHS2 gene, which encodes podocin recessive Onset of proteinuria in early childhood corticosteroid Renal biopsy initially resembles mimimal change disease but transforms into focal segmental glomerulosclerosis resistant nephrotic syndrome Congenital nephrotic syndrome of the Finnish type

7.3.1.3 Inherited tubular disorders R e n a l F a n c o n i s y n d ro m e re fe rs to a ty p e o f p ro x im a l tu b u la r d y s fu n c tio n th a t h a s n u m e ro u s c a u s e s , b o th in h e rite d a n d

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7: Molecular Pathology

Genetics of nonneoplastic disease>Renal a c q u ire d t7.2. G e n e ra liz e d p ro x im a l tu b u la r d y s fu n c tio n m a n ife s ts a s g ly c o s u ria , a m in o a c id u ria , p h o s p h a tu ria , h y p o k a le m ia , a n d m e ta b o lic a c id o s is (b ic a rb o n a te w a s tin g ). P h o s p h a tu ria c a n c a u s e ric k e ts in c h ild re n a n d o s te o m a la c ia in a d u lts . M o s t o f th e a c q u ire d c a u s e s a re to x ic in n a tu re (m y e lo m a k id n e y , h e a v y m e ta ls , a n d u ra te n e p h ro p a th y ). In h e rite d c a u s e s in c lu d e c y s tin o s is , ty ro s in e m ia , a n d g a la c to s e m ia , w h ic h c a u s e s e c o n d a ry tu b u la r d a m a g e , a n d d ire c t in h e rita n c e o f tu b u la r d e fe c ts , s u c h a s D e n t d is e a s e (X lin k e d re c e s s iv e d e fe c t in th e C L C N 5 g e n e e n c o d in g a c h lo rid e c h a n n e l).

t7.2 C auses of tubular dysfunction Inherited Acquired Cystinosis Tyrosinemia type I Galactosemia Glycogen storage disease Hereditary fructose intolerance Wilson disease Idiopathic renal Fanconi syndrome Dent disease

Myeloma kidney Urate nephropathy Heavy metal toxicity Amyloidosis Collagen vascular diseases Renal transplant rejection Medication (antineoplastic agents, antiretroviral agents, aminoglycosides)

7.3.1.4 Polycystic kidney disease 7.3.1.4.1 A u to s o m a l re c e s s iv e p o ly c y s tic kid n e y d is e a s e T h e m a n ife s ta tio n s o f a u to s o m a l re c e s s iv e p o ly c y s tic k id n e y d is e a s e (A R P K D ) ty p ic a lly b e g in in u te ro . T h e firs t m a n ife s ta tio n m a y b e o lig o h y d ra m n io s , th e re s u lt o f d im in is h e d u rin e o u tp u t. H y p e rte n s io n a n d re s p ira to ry d is tre s s a re o fte n p re s e n t a t b irth , th e la tte r a re s u lt o f p u lm o n a ry h y p o p la s ia a s p a rt o f th e o lig o h y d ra m n io s s e q u e n c e . T h e k id n e y s h a v e ra d ia lly o rie n te d c y s ts , c o n s is tin g o f e c ta tic e lo n g a te d c o lle c tin g d u c ts , m a in ta in in g th e ir o v e ra ll re n ifo rm s h a p e i7.5. P a tie n ts w ith A R P K D a lm o s t a lw a y s h a ve h e p a tic in v o lv e m e n t th a t b e c o m e s p ro b le m a tic o n ly in th o s e w h o s u rv iv e in to a d u lth o o d . T h e m o rp h o lo g ic fe a tu re s a re th o s e o f ty p ic a l b ilia ry p la te m a lfo rm a tio n s , c o n s is tin g o f e c ta tic p o rta l b ile d u c ts , c irc u m fe re n tia l p ro life ra tio n o f d u c tu le s , and p e rip o rta l fib ro s is . > 9 5 % o f c a s e s h a v e m u ta tio n s o f th e P K H D 1 g e n e on c h ro m o s o m e 6 p. T h e g e n e is la rg e , w ith o u t s ig n ific a n t c o m m o n m u ta tio n s , s o d ire c t s e q u e n c in g is im p ra c tic a l. M u ta tio n s c a n n in g is th e p re fe rre d te c h n iq u e fo r id e n tify in g m u ta n ts .

7.3.1.4.2 A u to s o m a l d o m in a n t p o ly c y s tic k id n ey d is e a s e A u to s o m a l d o m in a n t p o ly c y s tic k id n e y d is e a s e (A D P K D ) ty p ic a lly b e c o m e s e v id e n t in a d u lth o o d . It is m o re c o m m o n th a n A R P K D , w ith an e s tim a te d p re v a le n c e o f 1 in 5 0 0 b irth s . B y th e fifth d e c a d e , p e n e tra n c e is e s s e n tia lly 1 0 0 % , and - 1 /2 o f p a tie n ts h a v e p ro g re s s e d to e n d s ta g e re n a l d is e a s e b y a g e 6 0 . S y m p to m s s u c h a s im p a ire d u rin e c o n c e n tra tin g

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____ i7.5 Cystic renal diseases a Autosomal recessive polycystic kidney disease demonstrates radiating elongated cystic tubules b Autosomal dominant polycystic kidney disease demonstrates variably sized cysts with prominent glomerulocystic changes c Rarely, autosomal dominant polycystic kidney disease may present in a neonate or fetus; in contrast to cystic renal dysplasia, the overall corticomedullary interface is vaguely preserved & glomerulocystic lesions are evident d Glomerulocystic renal disease, which may be a variant of autosomal dominant polycystic kidney disease e & f Cystic renal dysplasia is markedly disorganized renal parenchyma with fibroblastic mesenchymal cuffs of stroma; cartilage may be present

a b ility (is o s th e n u ria ) a n d h y p e rte n s io n o fte n p re c e d e renal fa ilu re by d e c a d e s . F la n k p ain is c o m m o n a nd m ay be c a u s e d by c y s t h e m o rrh a g e , c y s t in fe c tio n , in tra c y s tic tu m or, a nd renal s to n e s (the p re v a le n c e o f re na l s to n e s is 2 0% , u s u a lly in th e fo rm o f c a lc iu m o x a la te o r u ra te sto n es). T h e c y s ts in A D P K D a re b o th c o rtic a l a n d m e d u lla ry , m a rk e d ly e n la rg in g a n d d is to rtin g th e k id n e y i7.5. T h e re h as b e e n d e b a te re g a rd in g s u s c e p tib ility to re n a l c e ll c a rc in o m a (R C C ; th e o n ly c y s tic d is e a s e u n e q u iv o c a lly a s s o c ia te d w ith an in c re a s e d ris k is th a t a s s o c ia te d w ith lo n g te rm d ia ly s is ), b u t w h e n tu m o rs o c c u r, th e y o c c u r a t a y o u n g e r th a n u s u a l a g e , a re o fte n m u ltic e n tric o r b ila te ra l, and are v e ry d iffic u lt to d e te c t. In 7 5% o f c a s e s , th e re is h e p a tic in v o lv e m e n t in th e fo rm o f p o ly c y s tic liv e r d is e a s e . M itral va lv e p ro la p s e is id e n tifie d in up to 2 5% o f c a s e s , p a n c re a tic c y s ts in -1 0 % , and in tra c ra n ia l b e rry a n e u ry s m s in 1 0 % -2 0 % .

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

7: Molecular Pathology

Genetics of nonneoplastic disease>Renal - 8 5 % o f c a s e s re su lt fro m m u ta tio n s in P K D 1 on c h ro m o s o m e 16p13. T h e P K D 1 g e n e is lo c a te d a d ja c e n t to TSC 2, 1 o f th e g e n e s invo lve d w ith tu b e ro u s s c le ro s is , and re p o rts have b e e n m a d e o f a c o n tig u o u s g e n e s y n d ro m e w h e n both g e n e s a re a ffe cte d . T h e re m a in in g 15% o f c a s e s a re d u e to m u ta tio n s in th e P K D 2 g e n e . T h e d ia g n o s is ca n be c o n firm e d w ith im a g in g s tu d ie s a lo n e, fo r w h ic h s p e c ific c rite ria e xist; how eve r, th e s e fin d in g s a re o fte n n ot fu lly p e n e tra n t u ntil a b o u t a g e 3 0 -5 0 , so m o le c u la r te s tin g m ay be n e e d e d if e a rlie r d ia g n o s is is d e s ire d . W h e n s u ffic ie n t re la tiv e s a re a v a ila b le a nd w illin g to be te ste d , th e d ia g n o s is ca n be m a d e w ith lin k a g e a n a lys is . In fo rm a tiv e m ic ro s a te llite s a re a d ja c e n t to th e P K D 1 and P K D 2 g e n e s , w h ic h ca n be e x p lo ite d fo r th is p u rp o s e . D ire c t s e q u e n c in g o f th e la rg e P K D 1 and P K D 2 g e n e s is d iffic u lt b ut ca n d e te c t up to 8 5% o f d is e a s e c a u s in g m u ta tio n s .

7.3.1.4.3 C y stic renal d y s p la s ia (m u ltic y s tic d y s p la s tic kidney) C y s tic re na l d y s p la s ia (m u ltic y s tic d y s p la s tic kid n e y ) is a fa irly c o m m o n c a u s e o f fla n k m a s s e s in infan ts. It is a n o n in h e rite d (sp o ra d ic) d is o rd e r th a t m a y re su lt fro m in u te ro u rete ra l o b s tru c tio n . K id n e y s a re d is tin c tly n o n re n ifo rm in s h a p e a nd c o n ta in a m ix tu re o f c y s ts a nd lo o s e m e s e n c h y m e , w ith th e la tte r s o m e tim e s c o n ta in in g c a rtila g e . S o m e tim e s th e d is e a s e a ffe c ts o n ly a s e g m e n t o f th e kidney, b u t u s u a lly th e e n tire k id n e y is invo lve d , and o c c a s io n a lly it is b ila te ra l. S o m e tim e s , c y s tic renal d y s p la s ia is fo u n d a s a c o m p o n e n t o f a la rg e r s y n d ro m e , th e M e c k e l-G ru b e r s y n d ro m e . M e c k e lG ru b e r s y n d ro m e is a ra re a u to s o m a l re c e s s iv e d is o rd e r a s s o c ia te d w ith a w id e a nd v a ria b le ra n g e o f a n o m a lie s . T h e m o s t c o n s is te n t o f th e s e a re p o ly c y s tic k id n e y d is e a s e , p o ly d a c ty ly , a nd o c c ip ita l e n c e p h a lo c e le . V a ria b le fe a tu re s o f M e c k e l-G ru b e r s y n d ro m e in c lu d e c le ft p ala te , d u c ta l p la te m a lfo rm a tio n s o f th e liver, and c a rd ia c a b n o rm a litie s . T h e s y n d ro m e is u n ifo rm ly fa ta l as a re su lt o f p u lm o n a ry h y p o p la s ia o r renal fa ilu re . T h e in c id e n c e is -1 in 1 00 ,0 0 0 .

7.3.1.4.4 G lo m e ru lo c y s tic kidney d isease G lo m e ru lo c y s tic k id n e y d is e a s e is a ra re d is o rd e r th a t p re s e n ts in th e n e o n a ta l p e rio d w ith la rg e p a lp a b le fla n k m a s s e s . It m a y be v e ry d iffic u lt to d is tin g u is h , c lin ic a lly a nd ra d io g ra p h ic a lly , fro m A R P K D ; how ever, it a p p e a rs to be m o re re la te d g e n o ty p ic a lly to A D P K D . M ic ro s c o p ic e x a m in a tio n s h o w s d ila tio n o f B o w m a n c a p s u le a nd renal d y s p la s ia i7.5.

7.3.1.4.5 N e p h ro n o p h th is is (ju v e n ile n e p h ro n o p h th isis, m e d u lla ry sp o n g e kidney) N e p h ro n o p h th is is is an a u to s o m a l re c e s s iv e in h e rite d c a u s e o f m e d u lla ry s p o n g e kidney, a d is o rd e r w ith c y s ts at th e c o rtic o m e d u lla ry ju n c tio n . It is a m e m b e r o f th e fa m ily © ASCP2018

o f c ilio p a th ie s , d e fe c ts in c ilia fu n c tio n . M u ltip le g e n e s h ave b e e n im p lic a te d , in c lu d in g N P H P g e n e s 1-8, h a v in g p h e n o ty p e s th a t d iffe r p rim a rily b y th e a g e o f o n s e t.

7.3.1.5 Sporadic & multifactorial congenital renal disorders 7.3.1.5.1 P o tter s e q u e n c e P o tte r s e q u e n c e re fe rs to th e n u m e ro u s , o fte n le th a l e ffe c ts o f lo w u rin e o u tp u t in utero. U rin e is im p o rta n t fo r m a in ta in in g an a d e q u a te v o lu m e o f a m n io tic flu id , a n d it is th e in h a la tio n a nd e x h a la tio n o f a m n io tic flu id th a t p ro m o te s g ro w th a nd d iffe re n tia tio n o f th e lu n g s. F u rth e rm o re , a m n io tic flu id p ro te c ts th e d e v e lo p in g fe tu s fro m c o m p re s s io n by th e s u rro u n d in g u te ru s . T h u s, a n y c o n d itio n th a t m a rk e d ly re d u c e s u rin e v o lu m e ca n lead to a s y n d ro m e c h a ra c te riz e d by p u lm o n a ry h y p o p la s ia a nd a ty p ic a l p h y s ic a l a p p e a ra n c e , k n o w n a s P o tte r s e q u e n c e (or P o tte r s y n d ro m e ). T h e m o s t c o m m o n c a u s e s o f P o tte r s e q u e n c e in c lu d e b ila te ra l re n a l a g e n e s is , u rin e o u tflo w o b s tru c tio n (p o s te rio r u re th ra l v a lve s), p ru n e b e lly s y n d ro m e , b ila te ra l c y s tic re n a l d y s p la s ia , a n d a u to s o m a l re c e s s iv e p o ly c y s tic k id n e y d is e a s e . A s id e fro m A R P K D , th e s e d is o rd e rs a re la rg e ly s p o ra d ic o r m u ltifa c to ria l.

7.3.1.5.2 B ilate ra l renal ag e n esis B ila te ra l re n a l a g e n e s is o c c u rs w ith a fre q u e n c y o f -1 in 3 0 0 0 b irth s , a nd it is th e c a u s e o f -1 in 5 c a s e s o f th e P o tte r s e q u e n c e . It is q u ic k ly fa ta l, o w in g to p u lm o n a ry h y p o p la s ia . B ila te ra l re n a l a g e n e s is is o fte n s u s p e c te d w h e n fe ta l u ltra s o u n d (p e rfo rm e d fo r e v a lu a tio n o f o lig o h y d ra m n io s ) fa ils to v is u a liz e a b la d d e r (c o n tra c te d d u e to la c k o f u rin e ) o r k id n e ys. It is a s p o ra d ic c o n d itio n .

7.3.1.5.3 P run e belly syn d ro m e (E a g le -B a rre tt syn d ro m e) T h e p ru n e b e lly s y n d ro m e c o n s is ts o f th e tria d o f a b d o m in a l w a ll m u s c le fla c c id ity , u rin a ry tra c t d ila tio n , a n d b ila te ra lly u n d e s c e n d e d te s te s . T h o u g h th e g e n e tic b a s is is u n k n o w n , p ru n e b e lly s y n d ro m e is th o u g h t to b e an in h e rite d d is o rd e r. P ru n e b e lly s y n d ro m e is ra re and a ffe c ts m o s tly m e n . A se v e re u re th ra l o b s tru c tio n is b e lie v e d to o c c u r e a rly in fe ta l life, p o s s ib ly d u e to th e tra n s ie n t e x is te n c e o f an o b s tru c tin g u re th ra l m e m b ra n e th a t s u b s e q u e n tly re c a n a liz e s . E a rly o b s tru c tio n is th o u g h t to im p a ir th e d e v e lo p m e n t o f th e a b d o m in a l w a ll m u s c u la tu re . R e -e s ta b lis h m e n t o f u rin a ry o u tflo w p e rm its th e d e v e lo p m e n t o f a d e q u a te (th o u g h h y p o p la s tic ) lu n g s a nd kid n e ys. N o n e th e le s s , th e k id n e y s have s o m e d e g re e o f d y s p la s ia , th e p ro s ta tic u re th ra , b la d de r, a nd u re te rs a re m a s s iv e ly d ila te d , a n d th e te s te s a re u s u a lly in tra -a b d o m in a l. T h e b la d d e r e m p tie s in c o m p le te ly b e c a u s e its m u s c le , like th a t o f th e a b d o m in a l w a ll, is re la tiv e ly fla c cid .

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Genetics of nonneoplastic disease>Renal | Cardiovascular 7.3.1.5 .4 P o s te rio r u re th ra l valv e s P o s te rio r u re th ra l v a lv e s a re th e m o s t c o m m o n c a u s e o f s e v e re u rin a ry o b s tru c tio n in th e n e o n a te , a ffe c tin g p re d o m in a n tly b o y s . P o s te rio r u re th ra l v a lv e s a re m e m b ra n o u s c u s p s o f tis s u e th a t fo rm in th e p ro s ta tic u re th ra a n d , w h ile h a v in g a s litlik e a p e rtu re , c a u s e o b s tru c tio n . U ltim a te ly , th is le a d s to h y d ro n e p h ro s is a n d / o r re n a l d y s p la s ia , in a d d itio n to th e o th e r fe a tu re s o f P o tte r sequence.

7.3.2 Cardiovascular 7.3.2.1 Channel conduction disorders 7.3.2.1.1 B ru g a d a s y n d ro m e In S o u th e a s t A s ia w h e re it is m o s t p re v a le n t, B ru g a d a s y n d ro m e h a s b e e n c a lle d v a rie ty o f n a m e s , in c lu d in g th e “ s le e p d e a th ” (L a o s ), “s u d d e n a n d u n e x p e c te d d e a th in s le e p ” (J a p a n ), a n d “ to ris e a n d m o a n in s le e p ” (P h ilip p in e s ). A s im p lie d b y th e fo re g o in g , th e d is e a s e p re s e n ts in o th e rw is e h e a lth y y o u n g m e n a s s u d d e n d e a th d u rin g s le e p . A c h a ra c te ris tic E C G p a tte rn in c lu d e s rig h t b u n d le b ra n c h b lo c k w ith S T s e g m e n t e le v a tio n in th e rig h t c h e s t le a d s V 1 -V 3 . B ru g a d a s y n d ro m e , in ~1 in 4 c a s e s , is c a u s e d b y a m u ta tio n in th e s o d iu m c h a n n e l g e n e S C N 5 A o n c h ro m o s o m e 3p21.

7.3.2.1 .2 A rrh y th m o g e n ic rig h t v e n tric u la r d y s p la s ia (U hl a n o m a ly ) A r r h y th m o g e n ic rig h t v e n tric u la r d y s p la s ia (A R V D ) a c c o u n ts fo r - 2 0 % o f s u d d e n c a rd ia c d e a th in y o u n g a d u lts . U n lik e B ru g a d a s y n d ro m e , s u d d e n c a rd ia c d e a th in A R V D is m o s t lik e ly to o c c u r d u rin g p h y s ic a l a c tiv ity . T h e c h a ra c te ris tic h is to lo g ic fe a tu re s in c lu d e fib ro u s a n d fa tty re p la c e m e n t o f th e rig h t v e n tric u la r m y o c a rd iu m i7.6. M o s t c a s e s a re d ia g n o s e d b e tw e e n a g e s 15 a n d 4 0 , m o s t c o m m o n ly a s a re s u lt o f s u d d e n c a rd ia c d e a th , s y n c o p e , rig h t h e a rt fa ilu re , o r a n e p is o d e o f v e n tric u la r ta c h y c a rd ia . A n u m b e r o f g e n e s h a v e b e e n a s s o c ia te d w ith A R V D in c lu d in g th e c a rd ia c ry a n o d in e re c e p to r g e n e R Y R 2 (A R V D 2 ) on 1q, th e D S P (A R V D 9 ) g e n e o n 6 p fo r d e s m o p la k in , a n d P K P 2 (A R V D 8 ), a ls o o n 6 p , w h ic h e n c o d e s p la k o p h ilin 2 . N a x o s d is e a s e (n a m e d fo r th e G re e k is la n d o n w h ic h it w a s d is c o v e re d ) is a fo rm o f A R V D a s s o c ia te d w ith c u ta n e o u s m a n ife s ta tio n s a n d w o o ly hair.

7.3.2.1.3 L o n g Q T s y n d ro m e s T h e m a jo rity o f in h e rite d c a rd ia c c o n d u c tio n d is o rd e rs a re c a te g o riz e d a s lo n g Q T (L Q T ) s y n d ro m e s . T h e Q T in te rv a l is th e s e c tio n o n th e E C G tra c in g b e tw e e n th e Q R S c o m p le x (le ft v e n tric u la r c o n tra c tio n ) a n d th e T w a v e (c a rd ia c re p o la riz a tio n ). T h e le n g th o f th e Q T in te rv a l is s o m e w h a t

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i7.6 Arrhythmogenic right ventricular dysplasia, endomyocardial biopsy; in addition to fatty change, there is prominent stromal fibrosis

v a ria b le fro m p e rs o n to p e rs o n a n d w ith in an in d iv id u a l o v e r tim e. T h e Q T in te rv a l in c re a s e s w ith d e c re a s in g h e a rt ra te a s w e ll a n d m u s t be c o rre c te d fo r h e a rt ra te (QTc). P h y s io lo g ic a lly , th e Q T in te rv a l re fle c ts th e tim e it ta k e s fo r ion c h a n n e ls to o p e n , a n d n o t s u rp ris in g ly m a n y o f th e m o le c u la r c a u s e s o f a p ro lo n g e d Q T in te rv a l a re d u e to d e fe c ts in g e n e s e n c o d in g ion c h a n n e ls . P a tie n ts w ith a p e rs is te n tly p ro lo n g e d Q T in te rv a l a re p ro n e to d e v e lo p v e n tric u la r a rrh y th m ia s , in c lu d in g th e ty p e o f v e n tric u la r ta c h y c a rd ia k n o w n a s to rs a d e de p o in te s . V e n tric u la r a rrh y th m ia s m a y m a n ife s t a s s y n c o p e o r s u d d e n c a rd ia c d e a th . T h e Q T in te rv a l is d e te rm in e d by a v a rie ty o f a c q u ire d a n d g e n e tic in flu e n c e s t7.3.

t7.3 Causes of long QT interval Inherited Acquired Romano-Ward syndrome Hypokalemia Jervell Lange-Nielsen syndrome Hypomagnesemia Andersen-Tawil syndrome Hypercalcemia Medications (tricyclic antidepressants, phenothiazines, macrolide antibiotics, class IA antiarrhythmics, class III antiarrhythmics)

M e d ic a tio n s (tric y c lic a n tid e p re s s a n ts , p h e n o th ia z in e s , m a c ro lid e a n tib io tic s , c la s s IA a n tia rrh y th m ic s , c la s s III a n tia rrh y th m ic s ) T h e in h e rite d LQ T s y n d ro m e s h ave tra d itio n a lly bee n d ivid e d , a c c o rd in g to c lin ic a l p re s e n ta tio n , into th e R o m a n o -W a rd s y n d ro m e (a u to s o m a l d o m in a n t, no h e a rin g lo ss) a nd th e J e rv e ll L a n g e -N ie ls e n s y n d ro m e (a u to s o m a l re ce s s ive , w ith h e a rin g loss). M o re re ce n tly, th e re has bee n a te n d e n c y to c la s s ify th e m a c c o rd in g to th e ir g e n o ty p e : LQ TS 1 th ro u g h L Q T S 7 17.4.

ASCP Quick Compendium of Clinical Pathology 4e

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7: Molecular Pathology

Genetics of nonneoplastic disease>Cardiovascular t7.4 Genes underlying inherited long QT syndromes 11 p15.5 Encodes a portion of a voltage gated potassium channel Most commonly mutated gene in the long QT syndrome Exercise (especially swimming) triggered arrhythmias LQT2 (KCNH2, HERG) 7q35-36 Encodes a second voltage activated potassium channel Second most commonly affected gene in LQTS Auditory stimulus or emotional stimulus triggered arrhythmias 3p21 -25 LQT3 (SCN5A) Sleep-triggered arrhythmias 4q25-27 LQT4 (ANKB) 21q22.1 LQT5 (KCNE1) LQT6 (MiRP1, KCNE2) 21q22.1 Encodes portions of a channel shared with skeletal LQT7 (KCNJ2) muscle Mutations cause Andersen-Tawil syndrome (triad of episodic paralysis, long QT interval & dysmorphic features) LQT1 (KCNQ1)

D e s p ite a u to s o m a l in h e rita n c e th e re is a 2:1 fe m a le p re d o m in a n c e in c lin ic a lly s ig n ific a n t lo n g Q T s y n d ro m e . E ven in n o rm a l a d u lts , th e Q T in te rv a l is s o m e w h a t lo n g e r in w o m e n th a n in m en . F u rth e rm o re , e s tro g e n a p p e a rs to d o w n re g u la te th e im p lic a te d c h a n n e ls on c a rd ia c m y o c y te s . T h u s , th e d is e a s e h as g re a te r p e n e tra n c e in w o m e n . In g e n e ra l, h e te ro z y g o u s m u ta tio n s in th e s e g e n e s c a u s e R o m a n o -W a rd s y n d ro m e , a n d h o m o z y g o u s (o r c o m p o u n d h e te ro z y g o u s ) m u ta tio n s c a u s e J L N S . 2 o f th e k n o w n g e n e s (K C N Q 1 & K C N H 2 ) e n c o d e v o lta g e g a te d p o ta s s iu m c h a n n e ls , a n d S C N 5 A e n c o d e s a s o d iu m c h a n n e l. A N K B e n c o d e s an ion c h a n n e l a n c h o r, a p ro te in th a t a s s o c ia te s n o n c o v a le n tly w ith ion c h a n n e ls . In te re s tin g ly , e a c h o f th e m u ta tio n s a re a s s o c ia te d w ith d iffe re n t s tim u li th a t lea d to s u d d e n c a rd ia c a rrh y th m ia s — m u ta tio n s in K C N Q 1 a re a s s o c ia te d w ith s w im m in g , m u ta tio n s in K C N Q 2 w ith a u d ito ry s tim u li, a n d S C N 5 A m u ta tio n s w ith a rrh y th m ia s w h ile s le e p in g .

7.3.2.2 Myocardial disorders 7.3.2.2.1 D ilated (co n g estive) c ard io m yo p ath y T h e c a u s e s o f d ila te d c a rd io m y o p a th y h ave b e e n tra d itio n a lly liste d as in fe c tio n (c o x s a c k ie B, C h a g a s d is e a s e , d ip h th e ria , h u m a n im m u n o d e fic ie n c y virus), s a rc o id o s is , to xin (a lco ho l, a d ria m ycin ), p re g n a n cy, a nd id io p a th ic . N e a rly all id io p a th ic c a s e s a re n o w k n o w n to re s u lt fro m g e n e tic d e fe c ts. X lin ked d ila te d c a rd io m y o p a th y is a s s o c ia te d w ith m u ta tio n s o f th e d y s tro p h in g e n e , th e s a m e g e n e im p lic a te d in D u c h e n n e a nd B e c k e r m u s c u la r d y s tro p h y (in w h ic h h e a rt fa ilu re is c o m m o n in th o s e w h o s u rv iv e to a d u lth o o d ). A u to s o m a l d o m in a n t d ila te d c a rd io m y o p a th y h as b ee n a s s o c ia te d w ith a la rg e n u m b e r o f m u ta tio n s , m o s t c o m m o n ly

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in th e M Y H 7 g e n e e n c o d in g (3-m yosin h e a v y c h a in (a lso in v o lv e d in s o m e c a s e s o f h y p e rtro p h ic c a rd io m y o p a th y ).

7 .3 .2 .2 .2 H y p e rtro p h ic c a rd io m y o p a th y (id io p a th ic h y p e rtro p h ic s u b a o rtic s te n o s is ) H y p e rtro p h ic c a rd io m y o p a th y is o n e o f th e m o s t c o m m o n c a u s e s o f s u d d e n c a rd ia c d e a th in y o u n g a d u lts , w ith an in c id e n c e a p p ro a c h in g 1 in 5 0 0 . G ro s s e x a m in a tio n o f th e h e a rt re ve a ls m y o c a rd ia l h y p e rtro p h y w ith d is p ro p o rtio n a te th ic k e n in g o f th e v e n tric u la r s e p tu m a s c o m p a re d w ith th e le ft v e n tric u la r fre e w a ll (a s y m m e tric s e p ta l h y p e rtro p h y ). T h e s o n o g ra p h ic and g ro s s a n a to m ic fin d in g s ca n be c lo s e ly m im ic k e d by a m y lo id o s is and h y p e rte n s iv e h e a rt d is e a s e . H is to lo g ic a lly , h y p e rtro p h ic c a rd io m y o p a th y d is p la y s m y o c y te h y p e rtro p h y , m y o fib e r d is a rra y w ith p ro m in e n t m y o c y te b ra n c h in g , a nd in te rs titia l fib ro s is . M o s t o f th e m u ta tio n s th a t c a u s e h y p e rtro p h ic c a rd io m y o p a th y a re in g e n e s e n c o d in g s a rc o m e ric s tru c tu ra l p ro te in s , th e m o s t c o m m o n ly a ffe c te d g e n e b e in g M Y H 7 on 14q, a n d th e m o s t c o m m o n ly im p lic a te d m u ta tio n is th e R 4 0 3 Q m u ta tio n . T h e p a tte rn o f in h e rita n c e is a u to s o m a l d o m in a n t.

7.3.2.2 .3 R e s tric tiv e c a rd io m y o p a th y R e s tric tiv e c a rd io m y o p a th y is o v e rw h e lm in g ly an a c q u ire d c o n d itio n , c a u s e d by su ch th in g s a s ra d ia tio n th e ra p y, a m y lo id o s is , and s a rc o id o s is . T h e ra re in h e rite d c a u s e s o f re s tric tiv e c a rd io m y o p a th y in c lu d e in h e rite d m e ta b o lic d is e a s e s and e n d o c a rd ia l fib ro e la s to s is , a ra re X lin k e d re c e s s iv e c o n d itio n .

7.3 .2 .2 .4 F am ilial iso late d card iac a m y lo id o s is M u ta tio n s in th e tra n s th y re tin (T T R ) g e n e c a u s e m o s t c a s e s o f fa m ilia l c a rd ia c a m y lo id o s is . 1 m u ta tio n , V 3 0 M , is p re s e n t in 3 0 % -4 5 % o f a ffe c te d in d iv id u a ls . T h e c lin ic a l s p e c tru m o f tra n s th y re tin a s s o c ia te d a m y lo id o s is m a y in c lu d e p e rip h e ra l n e u ro p a th y , le p to m e n in g e a l a m y lo id o s is , a nd c a rd io m y o p a th y . Is o la te d c a rd ia c a m y lo id o s is is w h a t h a s in th e p a s t b e e n re fe rre d to a s s e n ile c a rd ia c a m y lo id o s is ; like w ise , is o la te d le p to m e n in g e a l a m y lo id o s is h a s b e e n re fe rre d to a s c e re b ra l a m y lo id a n g io p a th y . T ra n s th y re tin a m y lo id o s is d is p la y s a u to s o m a l d o m in a n t in h e rita n c e . T h e d is e a s e s h o w s p o c k e ts o f h ig h p re v a le n c e in P o rtu g a l, S w e d e n , J a p a n , a n d p a rts o f A fric a . T h e fre q u e n c y o f T T R a m y lo id o s is ra n g e s fro m ~1 in 5 0 0 in n o rth e rn P o rtu g a l to -1 in 1 0 0 ,0 0 0 a m o n g C a u c a s ia n A m e ric a n s ; it is e s tim a te d to be m u ch h ig h e r in A fric a n A m e ric a n s .

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Genetics of nonneoplastic disease>Cardiovascular | Endocrine t7 .5 Structural cardiac defects in m ultisystem genetic disorders Category

Genetic defect

Single gene mutation

NKX2-5

Single gene mutation

GATA-4

Single gene mutation

TBX-5

Single gene mutation Single gene mutation

TBX-1

Single gene mutation

JAG1

PTPN11

Structural Trisomy 21 chromosomal (Down disorder syndrome) Structural 45,X (Turner syndrome) chromosomal disorder Microdeletion 22q11

Microdeletion

7q11.23

Multifactorial

Many

Notes The NKX2-5 gene on chromosome 5q34 encodes a transcription factor that is expressed very early in cardiogenesis & appears to be responsible for activating transcription of most genes involved in the process. Mutations in NKX2-5 have been identified in patients with a large variety of structural malformations. GATA-4, a gene located on 8p, encodes a transcription factor that is important in cardiac embryogenesis. Rare kindreds have been identified that carry germline GATA-4 mutations & have autosomally inherited septal defects, especially ostium secundum atrial septal defects. TBX-5 (12q) mutations are responsible for most cases of Holt-Oram syndrome (heart-hand syndrome), an autosomal dominant disorder combining characteristic heart & upper limb anomalies. Upper limb malformations may involve the radius, thumb phalanges, or carpal bones & they range from severe (phocomelia) to minimal (subtle carpal bone deformities). These are usually bilateral & symmetrical & if asymmetrical, the left is more severely affected. Cardiac malformations most commonly take the form of septal defects, especially secundum atrial septal or muscular ventricular septal defects. TBX-1 is found on 22q & is contained within the region commonly deleted in DiGeorge syndrome (see below). Noonan syndrome consists of right sided heart defects, most commonly pulmonic stenosis. Hypertrophic cardiomyopathy is the second most common finding. Lymphatic malformations are also common. While the incidence of Noonan syndrome in the population is only ~1 in 1,500, the incidence amongst children with congenital heart disease may be as high as 1 in 100. Prolonged coagulation times are frequently observed, due to a wide range of defects (eg, vWD phenotypes, factor V deficieny, factor VIII deficiency). PTPN11 has also been implicated in some examples of LEOPARD syndrome & juvenile myelomonocytic leukemia. Alagille syndrome is an autosomal dominant condition caused by mutations in JAG1. Best known for its association with bile duct paucity, Alagille syndrome (arteriohepatic dysplasia) is also a disease of blood vessels & the heart. Most commonly affected is the pulmonary circulation, in the form of pulmonary artery stenosis. Other defects include tetralogy, atrial septal defects, ventricular septal defects, aortic stenosis & coarctation. Structural cardiac anomalies in >1/2 of cases. The classic association is malformation of the endocardial cushion, resulting most commonly in a membranous ventricular septal defect. This is followed in frequency by patent ductus arteriosus, atrial septal defect & atrioventricular septal defect. Cardiac anomalies are present in up to 1/2 of cases. Bicuspid aortic valve is the most common defect, followed by coarctation of the aorta. Aortic root dilation is common & may lead to aortic dissection. DiGeorge syndrome (velocardiofacial syndrome, Shprintzen syndrome) is associated with cardiac anomalies in most cases (75% of affected individuals), especially the conotruncal malformations. These include tetralogy of Fallot, interrupted aortic arch, ventricular septal defects & truncus arteriosus. Among the several genes wiped out by this microdeletion, TBX1 is believed to be responsible for the cardiac anomalies. Williams syndrome is characterized by dysmorphic facial features, mental retardation, short stature, hypercalcemia, abnormalities of connective tissue (hernias, diverticula, joint laxity, skin laxity) & structural cardiac & vascular defects. The most distinctive cardiac anomaly is supravalvar aortic stenosis (hourglass stenosis). Many of the findings in Williams syndrome can be attributed to deletion of the elastin gene. The vast majority of structural cardiac anomalies are “multifactorial” in origin. That is, while a Mendelian pattern of inheritance is inapparent & a specific genetic defect has not been found, there is clustering within families & around particular exposures. Furthermore, it is known that offspring of consanguineous parents are strongly predisposed to “multifactorial” structural cardiac anomalies. Structural cardiac anomalies are prominent among the multifactorial disorders, others being pyloric stenosis, cleft lip & cleft palate.

7.3.2.3 Structural cardiac disorders as a part of a larger genetic syndrome S tru c tu ra l c a rd ia c a n o m a lie s a re a c o m m o n fe a tu re o f g e n e tic m u ltis y s te m d is e a s e t7.5. S o m e c a rd ia c a n o m a lie s a re a s s o c ia te d w ith s in g le g e n e m u ta tio n s , in c lu d in g m u ta tio n s in T B X -5 (H o lt-O ra m s y n d ro m e ), TB X -1 (D iG e o rg e s y n d ro m e ), P T P N 1 1 (N o o n a n s y n d ro m e ), a n d JA G 1 (A la g ille s y n d ro m e ). C h ro m o s o m a l a n o m a lie s su ch as D o w n s y n d ro m e a n d T u rn e r s y n d ro m e h a ve n o ta b le c a rd ia c fe a tu re s . M ic ro d e le tio n s y n d ro m e s , s u c h a s D iG e o rg e a n d W illia m s s y n d ro m e s a ls o h a v e a h ig h in c id e n c e o f s tru c tu ra l c a rd ia c d e fe c ts . T h e m a jo rity o f s tru c tu ra l c a rd ia c a b n o rm a litie s , h o w e v e r, a re m u ltifa c to ria l.

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7.3.3 Endocrine 7.3.3.1 Adrenal cortex 7.3.3.1.1 C o n g e n ita l a d r e n a l h y p e r p la s ia C o n g e n ita l d e fic ie n c y o f o n e o f th e e n z y m e s in th e ste ro id h o rm o n e b io s y n th e tic p a th w a y le a d s to (1) d im in is h e d c o rtis o l a n d /o r m in e ra lo c o rtic o id a nd (2) e x c e s s o f p re c u rs o rs , m an y o f w h ic h h ave a n d ro g e n ic p ro p e rtie s . T h e d is o rd e r g e ts its n am e fro m th e m a s s iv e a d re n a l h y p e rp la s ia th a t re su lts fro m h y p e rs e c re tio n o f a d re n o c o rtic o tro p h ic h o rm o n e (A C T H ) in re sp o n s e to lo w le v e ls o f s e ru m c o rtis o l.

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7: Molecular Pathology

Genetics of nonneoplastic disease>Endocrine Its b ro a d ra n g e o f c lin ic a l s e v e rity ca n b e s t be u n d e rs to o d b a se d on 3 p rin c ip le s . First, m ild e n z y m e d e fic ie n c y a ffe c ts m a in ly th e p ro d u c tio n o f c o rtis o l, w h ile se v e re d e fic ie n c y im p a irs both c o rtis o l a n d m in e ra lo c o rtic o id (a ld o s te ro n e ) p ro d u c tio n . T h u s, m ild d e fic ie n c ie s re su lt in th e so c a lle d s im p le v iriliz in g fo rm o f th e d is e a s e , w h ile se v e re e n z y m e d e fic ie n c ie s re su lt in th e s a lt w a s tin g fo rm o f d ise a se . S e c o n d , th e m o s t p ro fo u n d c o n s e q u e n c e o f h y p o c o rtis o lis m fo r th e d e v e lo p in g fe tu s is n o t th e p a u c ity o f c o rtis o l its e lf b ut ra th e r th e v e ry high A C T H th a t d riv e s th e b u ild u p o f a n d ro g e n s . T h ird , m e n a nd w o m e n h ave d iffe rin g re a c tio n s to a n d ro g e n . A c c o rd in g ly , se v e ra l p o te n tia l p h e n o ty p e s e xist: (1) a girl w h o is v iriliz e d a t b irth o r b e c o m e s v iriliz e d s h o rtly th e re a fte r, (2) a girl w ith p re c o c io u s p u b e rty, (3) a b oy w ith p s e u d o p re c o c io u s p u b e rty (the p re m a rtu re e x te rn a l a p p e a ra n c e o f p u b e rty ), o r (4) an in fa n t w ith s a lt lo s in g crisis. S e ru m 1 7 -h y d ro x y p ro g e s te ro n e (17-O H P ), a p re c u rs o r in th e c o rtis o l b io s y n th e tic pathw ay, is e le v a te d in all fo rm s o f c o n g e n ita l a d re n a l h y p e rp la s ia (C A H ). 1 7-O H P can be m e a s u re d by im m u n o a s s a y , w h ic h ca n be p e rfo rm e d on d rie d b lo o d s p o ts fo r n e o n a ta l s c re e n in g . S in c e s o m e n e o n a te s m ay p re s e n t in th e firs t d a y s o f life w ith a d re n a l in s u ffic ie n c y c ris is , e a rly k n o w le d g e o f th e d ia g n o s is ca n be e x tre m e ly b e n e ficia l. 21 -h y d ro x y la s e d e fic ie n c y is th e m o s t c o m m o n c a u s e o f C A H . It is re s p o n s ib le fo r - 9 0 % o f c a s e s a nd has an e s tim a te d in c id e n c e o f 1 in 1 0 ,0 0 0 -2 5 ,0 0 0 . 2 1 -h y d ro x y la s e (also c a lle d C Y P 2 1 A 2 a nd P 4 5 0 C 2 1 ) is a c y to c h ro m e P -4 5 0 e n z y m e fo u n d w ith in th e s m o o th e n d o p la s m ic re ticu lu m . T h e g e n e e n c o d in g 2 1 -h y d ro x y la s e , C Y P 21, is lo c a te d at 6p21 a nd th u s w ith in th e h u m a n le u k o c y te a n tig e n (H L A ) locu s, a d ja c e n t to g e n e s th a t e n c o d e c o m p le m e n t p rote in C 4. N e a rb y is a g e n e k n o w n a s C Y P 21P, a p s e u d o g e n e (n o n tra n s c rib e d g e n e ) w ith > 9 5 % h o m o lo g y w ith C Y P 21 b u t re n d e re d n o n fu n c tio n a l by v irtu e o f s e ve ra l n u c le o tid e d iffe re n c e s . T h e m o s t c o m m o n d is e a s e c a u s in g m u ta tio n s a re (1) la rg e C Y P 21 g e n e d e le tio n s and (2) g e n e c o n v e rs io n s — re c o m b in a tio n s b e tw e e n C Y P 21 a nd C YP21P, c o n v e rtin g C Y P 21 into a n o n fu n c tio n a l a lle le . S e ve ra l a d d itio n a l p o in t m u ta tio n s h ave b ee n d e s c rib e d . D iffe re n t m u ta tio n s h ave d iffe re n t p h e n o ty p ic e ffe c ts , w ith so m e c a u s in g c o m p le te e n z y m e d e fic ie n c y a nd o th e rs c a u s in g o n ly im p a ire d e n z y m e activity. 11-h yd ro x yla s e d e fic ie n c y is th e se co n d m o s t c o m m o n c a u se o f C A H (5% -7% o f cases). It is ca u se d by m u ta tio n s in th e CYP11B1 g e n e loca te d on c h ro m o s o m e 8 q2 4 and is e s p e c ia lly p ro m in e n t in N o rth A fric a n Jew s. U nlike 21 -h yd ro x yla s e d eficien cy, a sa lt w a stin g fo rm o f 11-h yd ro x yla s e d e fic ie n c y is v e ry u n co m m o n ; instead, h y p e rte n s io n is m uch m ore c o m m o n ly seen. F ind ing s ind ica tive o f a n d ro g e n e x ce ss are e q u a lly c o m m o n in both co nd itio n s.

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7.3.3.1.2 A n d ro g e n in s e n s itiv ity s y n d ro m e A n d ro g e n in s e n s itiv ity s y n d ro m e is an X lin k e d re c e s s iv e d is o rd e r th a t a ffe c ts g e n o ty p ic b o y s (4 6 ,X Y ). T h e d e g re e s o f s e ve rity, ra n g e fro m te s tic u la r fe m in iz a tio n a t b irth to a d u lt in fe rtility, w ith p h e n o ty p e s d e s c rib e d a s c o m p le te , p a rtia l, o r m ild . In c o m p le te a n d ro g e n in s e n s itiv ity s y n d ro m e , th e e x te rn a l g e n ita lia re se m b le th a t o f a w o m a n , w h ile a t th e o p p o s ite e n d o f th e s p e c tru m , th e e x te rn a l g e n ita lia m a y be a m b ig u o u s o r m a le a p p e a rin g . O fte n a m a s s is d e te c te d in th e in g u in a l c a n a l, re p re s e n tin g u n d e s c e n d e d te s te s . T h e re m a y be ru d im e n ta ry m u lle ria n s tru c tu re s (ovary, F a llo p ia n tu b e s , uterus). S e ru m te s to s te ro n e is n o rm a l to e le v a te d , and th e re is n o rm a l c o n v e rs io n o f te s to s te ro n e to d ih y d ro te s to s te ro n e , w ith n o rm a l o r e le v a te d s e ru m lu te in iz in g h o rm o n e (LH ). T h e w o rk u p b e g in s w ith a k a ry o g ra m in d ic a tin g a 4 6 ,X Y k a ry o ty p e t7.6. F o llo w in g th is d ire c t s e q u e n c in g o f th e a n d ro g e n re c e p to r (A R ) g e n e o n th e X c h ro m o s o m e w ill d e m o n s tra te m u ta tio n s in > 9 5 % o f c a s e s w ith c o m p le te in s e n s itiv ity . M u ta tio n d e te c tio n ra te d ro p s to 4 0 % in c a s e s o f p a rtia l o r m ild in s e n s itiv ity .

t7.6 Definitions relating to hermaphroditism & pseudohermaphroditism Genotypic sex

Determined by the status of the Y chromosome—the presence of a single Y chromosome (regardless of the number of X chromosomes) is definitive of a genotypic male Gonadal sex Depends uon the histologic nature of the gonads; the Y chromosome, in particular the SRY gene, influences the genital primordium to develop into testes; in the absence of a Y chromosome, the gonadal primordium will develop into ovaries. Refers to the appearance of the external genitalia, which Phenotypic sex may be ambiguous True hermaphrodite The term implies the presence of both ovarian & testicular tissue, either separately or within the same gonadal structure (ovotestis). This is an extremely rare condition in which the genotype is usually 46,XX, but by fluorescence in situ hybridization, transposed SRY gene material can nearly always be found. In some cases, in fact, true hermaphroditism is associated with 46,XX/46,XY mosaicism. A 46,XY genotype is not associated with true hermaphroditism. Pseudo Refers to discordance between phenotypic sex & gonadal/ hermaphroditism genotypic sex. The presumed sex is that indicated by the gonadal histology; thus, male pseudohermaphrodites have a Y chromosome & testes, but the external genitalia (and often the genital ducts) are either ambiguous or feminized. It has a wide variety of causes, the most common of which are the androgen insensitivity syndromes (testicular feminization). Female pseudohermaphrodites have no Y chromosome (usually 46,XX), ovaries & external genitalia that are either ambiguous or male appearing (virilized). Female pseudohermaphroditism is caused by excessive exposure to androgens during fetal development, most commonly due to congenital adrenal hyperplasia.

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Genetics of nonneoplastic disease>Endocrine 7.3.3.1.3 S te ro id s u lfa ta s e d e fic ie n c y

7.3.3.3 Parathyroid gland

P ro lo n g e d o r n o n p ro g re s s iv e lab o r, u n re s p o n s iv e to o x y to c in , m a y b e th e firs t s ig n o f s te ro id s u lfa ta s e d e fic ie n c y . A fte r b irth , c h o le s te ro l s u lfa te b e g in s to a c c u m u la te in th e b lo o d a n d tis s u e s s u c h a s th e c o rn e a a n d s k in . In s k in , it a p p e a rs to p re v e n t th e d is s o lu tio n o f d e s m o s o m a l a tta c h m e n ts (d e s q u a m a tio n ), le a d in g to th e X lin k e d ic h th y o s is (s c a ly s k in ) p h e n o ty p e . Ic h th y o s is b e c o m e s a p p a re n t s h o rtly a fte r b irth . C o rn e a l o p a c itie s d e v e lo p s o m e w h a t later. M e n h ave a h ig h in c id e n c e o f c ry p to rc h id is m , w h ic h le a d s to a h ig h e r in c id e n c e o f g e rm c e ll tu m o rs .

In h e rita n c e o f is o la te d p a ra th y ro id a n o m a lie s is e x tre m e ly ra re . M ore o fte n , p a ra th y ro id a b n o rm a litie s a re in h e rite d as p a rt o f a la rg e r s y n d ro m e , su ch a s th e D iG e o rg e sy n d ro m e .

It is th e fu n c tio n o f s te ro id s u lfa ta s e to re m o v e s u lfa te m o ie tie s fro m s te ro id s u lfa te s (in c lu d in g c h o le s te ro l su lfa te ), th u s c o n v e rtin g th e m to b io lo g ic a lly a c tiv e fo rm s . T h e g e n e fo r s te ro id s u lfa ta s e {S T S ) is lo c a te d on th e s h o rt a rm o f th e X c h ro m o s o m e (X p 2 2 .3 ). In n e a rly 9 0 % o f c a s e s , s te ro id s u lfa ta s e d e fic ie n c y is d u e to a c o m p le te S T S g e n e d e le tio n , s o m e tim e s in c lu d in g th e e n tire d is ta l s h o rt a rm o f th e X c h ro m o s o m e . M o s t o f th e re m a in in g p a tie n ts h a ve s in g le p o in t m u ta tio n s w ith in th e S T S g e n e . T h e d ia g n o s is m a y b e m a d e in s e v e ra l w a y s . T h e e n z y m e m a y b e s p e c ific a lly a s s a y e d in s a m p le s o f p e rip h e ra l b lo o d le u k o c y te s o r skin . E leva te d c h o le s te ro l s u lfa te le v e ls m a y b e d e m o n s tra te d in s e ru m o r s k in . L astly, th e g e n e d e le tio n m a y b e d e m o n s tra te d by F IS H .

7.3.3.3.1 P s e u d o h y p o p a ra th y ro id is m P s e u d o h y p o p a ra th y ro id is m e n c o m p a s s e s m ultip le d ise a se s sh aring p e rip h e ra l re sista n ce to p ara th yroid h o rm o n e (P TH ). P a tients p re s e n t w ith h y p o c a lc e m ia d e sp ite e le vated P TH . Infantile te ta n y is o fte n th e p re se n tin g feature. O ld e r ch ildren d isp la y s h o rt stature, a round fa ce , d im p lin g o f th e d o rsu m o f th e hand, b ra c h y d a c ty ly (ch a ra cte ristically, th e se co n d d ig it is spared, su ch th a t it is lo n g e r th a n th e third), d y s tro p h ic s o ft tis s u e c a lc ific a tio n , a nd h e te ro to p ic o s s ific a tio n . A lb rig h t h e re d ita ry o s te o d y s tro p h y (p se u d o h y p o p a ra th y ro id is m ty p e IA) is an a u to s o m a l d o m in a n t d is o rd e r ca u s e d by inactivating m u ta tio n s o f th e G N A S 1 g e n e e n c o d in g th e a s u b u n it o f th e s tim u la to ry G p rotein. T h e P TH re ce p to r is co u p le d to a G protein to fa cilita te tra n s m e m b ra n e sign aling , usually th ro u g h a ctiva tio n o f a d e n yla te c ycla se and th e p rod uctio n o f th e se con d m esse n ge r, c y c lic a d e n o s in e m on o p h o sp h a te . M u ta tio n s in th e G protein lead to d e fe ctive sign al tra nsd u ction .

7.3.3.3.2 M c C u n e -A lb rig h t syn d ro m e 7.3.3.2 Pituitary gland 7.3.3.2.1 K a llm a n n s y n d ro m e K a llm a n n s y n d ro m e m o s t o fte n a ffe c ts m e n , a n d c a n p re s e n t w ith h y p o g o n a d o tro p ic h y p o g o n a d is m a n d a n o s m ia . T h e h o rm o n e m o s t c o m m o n ly d e fic ie n t is LH re le a s in g h o rm o n e . K a llm a n n s y n d ro m e c a n be in h e rite d a s X lin k e d , a u to s o m a l d o m in a n t, o r a u to s o m a l re c e s s iv e . M o s t X lin k e d c a s e s (and 1 5% o f c a s e s o v e ra ll) a re d u e to m u ta tio n s in th e K A L 1 g e n e o n X p 2 2 .3 , c lo s e to s te ro id s u lfa ta s e .

7 .3 .3 .2 .2 Is o la te d g ro w th h o rm o n e d e fic ie n c y M u ltip le in h e rite d is o la te d p itu ita ry h o rm o n e d e fic ie n c ie s h a v e b e e n d e s c rib e d , th e m o s t c o m m o n o f w h ic h is is o la te d g ro w th h o rm o n e (G H ) d e fic ie n c y . It m a y be in h e rite d a s a n X lin k e d , a u to s o m a l re c e s s iv e , o r a u to s o m a l d o m in a n t c o n d itio n . A u to s o m a l re c e s s iv e G H d e fic ie n c y is u s u a lly th e re s u lt o f m u ta tio n s in G H re le a s in g h o rm o n e , a u to s o m a l d o m in a n t G H d e fic ie n c y is a s s o c ia te d w ith m u ta tio n s in th e G H g e n e , a n d th e X lin k e d fo rm w ith m u ta tio n s in th e B T K g e n e . B T K is th e g e n e a s s o c ia te d w ith B ru to n a g a m m a g lo b u lin e m ia , a n d in d e e d m a n y a ffe c te d in d iv id u a ls a re a ls o im m u n o c o m p ro m is e d .

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G a in o f fu n c tio n m u ta tio n s o f th e G N A S 1 g e n e ca n lead to M c C u n e -A lb rig h t s y n d ro m e . T h e s e ty p e s o f m u ta tio n s , w h e n in h e rite d a s a g e rm lin e d iso rd e r, a re in c o m p a tib le w ith life; c o n s e q u e n tly all M c C u n e -A lb rig h t c a s e s a re in h e rite d a s s o m a tic m o s a ic s . T h e s e v e rity o f th e d is o rd e r ca n be h ig h ly v a ria b le d e p e n d in g on th e e x te n t o f tis s u e s a ffe cte d by th e m u ta tio n , ra n g in g fro m fu lly d e v e lo p e d M c C u n e A lb rig h t s y n d ro m e to is o la te d fib ro u s d y s p la s ia . M c C u n e A lb rig h t s y n d ro m e c o n s is ts o f c a fe au la it sp ots, p o ly o s to tic fib ro u s d y s p la s ia , p re c o c io u s p u b e rty , and o th e r e n d o c rin e a n o m a lie s . P re c o c io u s p u b e rty is a fe a tu re m a in ly o f g irls w ith th e s y n d ro m e , w ith m a n y a c h ie v in g p u b e rty by a g e 3 y e a rs . Leve ls o f LH a nd fo llic le s tim u la tin g h o rm o n e a re low.

7.3.3.3.3 Fam ilial h yp o c a lc u ric h yp e rc a lc e m ia (benign fam ilia l h y p ercalcem ia ) F a m ilia l h y p o c a lc u ric h y p e rc a lc e m ia is an a u to s o m a l d o m in a n t d is o rd e r p re s e n tin g w ith is o la te d h y p e rc a lc e m ia , w ith n o rm a l p a ra th y ro id g la n d s a nd n o rm a l s e ru m P TH le v e ls . Im p o rta n tly, s u b to ta l p a ra th y ro id e c to m y has no e ffe c t on c a lc iu m levels. T h e c o n d itio n is c a u s e d by m u ta tio n s in a G p rote in g e n e th a t le a d s to la c k o f p a ra th y ro id re s p o n s e to e le v a te d s e ru m c a lc iu m .

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

7: Molecular Pathology

Genetics of nonneoplastic disease>Endocrine | Gastrointestinal, hepatobiliary & pancreatic 7.3.3.4 Thyroid gland 7.3.3.4.1 C o n g e n ita l h yp o th yro id ism C o n g e n ita l h y p o th y ro id is m is a c o m m o n d is o rd e r a ffe c tin g 1 in 3 0 0 0 -4 0 0 0 live b irth s . F e ta l d e v e lo p m e n t is u s u a lly u n a ffe c te d , b e c a u s e o f a m a te rn a l s u p p ly o f th y ro id h o rm o n e . P o s tn a ta l th y ro id d e fic ie n c y ca n lea d to a b n o rm a l b ra in d e v e lo p m e n t a nd be e a s ily tre a te d . B e c a u s e o f th is, all n e w b o rn s in th e U n ite d S ta te s a re te s te d fo r c o n g e n ita l h y p o th y ro id is m . T h e va st m a jo rity (90% ) o f c a s e s a re a s s o c ia te d w ith th yroid h yp o p la sia o r a pla sia , o fte n th e re su lt o f m atern a l a u to a n tib o d ie s. A n u m b e r o f g e n e s have b ee n a s s o c ia te d w ith inh e rite d c a s e s o f c o n g e n ita l h yp o th yro id ism in clu d in g P A X 8 and TS H R , d e fe c ts o f w h ic h lead to d e fe c tiv e g la n d fo rm a tio n .

7.3.3.5 Diabetes mellitus 7.3.3.5.1 Type 1 (insulin d ep e n d e n t) d ia b e te s m ellitu s T yp e 1 d ia b e te s m e llitu s (D M 1) is an a u to im m u n e d is e a s e , a nd c e rta in H L A g e n o ty p e s a re a s s o c ia te d w ith a h ig h e r in c id e n c e . H L A D R 3 a nd H L A -D R 4 h e te ro z y g o te s have a 2 -3 fo ld in c re a s e d risk. H o m o z y g o te s h ave a 10 fo ld in c re a s e d risk. F irst d e g re e re la tiv e s o f a ffe c te d p e rs o n s h ave a h ig h e r th a n a v e ra g e ris k o f d e v e lo p in g DM 1, s ib lin g s have a 5 % -1 0% c h a n c e o f d e v e lo p in g it, a nd id e n tic a l tw in s have - 6 0 % c o n c o rd a n c e . T h e re x a re a v a rie ty o f ra re m o n o g e n e tic c a u s e s o f d ia b e te s m e llitu s. P a n c re a tic a g e n e s is is e x tre m e ly rare, th o u g h t to be th e re su lt o f s p o ra d ic m u ta tio n s w ith in tra n s c rip tio n fa c to r g e n e s. A g e n e s is c a u s e s a b s o lu te insu lin d e fic ie n c y , a fo rm o f DM 1. M u ta tio n s in th e insu lin re c e p to r g e n e (p a rtic u la rly in a s s o c ia tio n w ith in h e rite d le p re c h a u n is m o r R a b s o n M e n d e n h a ll s y n d ro m e ) ca n c a u s e insu lin re s is ta n c e . C y s tic fib ro s is (C F ) le a d s to p ro g re s s iv e p a n c re a tic in s u ffic ie n c y , b oth e x o c rin e and e n d o c rin e , w ith m a n y w h o s u rv iv e into th e te e n a g e y e a rs and n e a rly all w h o s u rv iv e into a d u lth o o d d e v e lo p in g DM 1.

7.3.3.5.2 M a tu rity o n s et d ia b e te s o f th e you ng M a tu rity o n s e t d ia b e te s o f th e y o u n g (M O D Y ) d e riv e s its n a m e fro m tra d itio n a l s y s te m s o f d ia b e te s c la s s ific a tio n in w h ic h DM1 w a s g e n e ra lly c la s s ifie d a s ju v e n ile o n s e t d ia b e te s , a nd ty p e 2 w a s u s u a lly c la s s ifie d a s m a tu rity o n s e t d ia b e te s . It w a s re c o g n iz e d th a t a s u b s e t o f c h ild re n w ith d ia b e te s had a c lin ic a l p ic tu re re s e m b lin g m a tu rity o n s e t d ia b e te s — in th a t th e y w e re n o n in s u lin d e p e n d e n t— a nd th e s e c a s e s w e re n a m e d M O D Y . M O D Y is a fo rm o f n o n in s u lin d e p e n d e n t (typ e 2) d ia b e te s w ith a u to s o m a l d o m in a n t in h e rita n c e th a t u s u a lly a ris e s in c h ild h o o d . It is re s p o n s ib le fo r - 5 % o f ty p e 2 c a s e s . A ffe c te d in d ivid u a ls a re ra re ly o b e se . T h e re a re in fa c t m u ltip le g e n o ty p ic fo rm s o f © A S C P 2018

M O D Y . A c c o u n tin g fo r th e v a s t m a jo rity o f c a s e s a re G C K / M O D Y 2 (g lu c o k in a s e ), H N F 4 a /M O D Y 1 (h e p a to c y te n u c le a r fa c to r 4 a), H N F 1 a /M O D Y 3 (h e p a to c y te n u c le a r fa c to r 1 a), IP F 1 /M O D Y 4 (in su lin p ro m o te r fa c to r 1), a n d H N F 1 b /M O D Y 5 (h e p a to c y te n u c le a r fa c to r 1 (3).

7.3.4 Gastrointestinal, hepatobiliary & pancreatic 7.3.4.1 Hirschsprung disease T h ro u g h o u t th e le n g th o f th e co lo n , w ith th e e x c e p tio n o f th e la s t 1-2 cm o f re ctu m , c lu s te rs o f g a n g lio n c e lls c a n n o rm a lly be fo u n d w ith in th e m u s c u la ris m u c o s a (M e is s n e r s u b m u c o s a l p le xu s) a nd m u s c u la ris p ro p ria (A u e rb a c h m y e n te ric p le xus). E m b ry o lo g ic a lly , p rim itiv e c e lls d e s tin e d to d e v e lo p into g a n g lio n c e lls e m e rg e fro m th e n e u ra l c re s t a n d m ig ra te to th e d e v e lo p in g b o w e l, p o p u la tin g it p ro x im a lly to d ista lly. A n in te rru p tio n in th is p ro c e s s , th e re fo re , a lw a y s a ffe c ts th e d is ta l m o s t p o rtio n s o f b o w e l. H irs c h s p ru n g d is e a s e re s u lts fro m an in te rru p tio n in n e u ra l c re s t m ig ra tio n , a n d in d e e d th e d is ta l m o s t co lo n (re c tu m ) is a lw a y s in v o lv e d w ith o r w ith o u t a v a ria b le len g th o f m o re p ro x im a l c o lo n . D is e a s e is c la s s ifie d a c c o rd in g to th e le n g th o f c o lo n in vo lve d . M o s t c a s e s a re re s tric te d to th e re c tu m o r re c to s ig m o id a nd c o n s id e re d s h o rt s e g m e n t H irs c h s p ru n g d is e a s e . S o m e c a s e s in v o lv e o n ly th e v e ry d is ta l re c tu m a n d a re c o n s id e re d u ltra s h o rt s e g m e n t d is e a s e . In -1 5 % , th e a g a n g lio n o s is e x te n d s p ro x im a l to th e s p le n ic fle x u re (lo n g s e g m e n t H irs c h s p ru n g d ise ase ). R a re c a s e s (2 cm fro m th e d e n ta te line (the n o rm a lly a g a n g lio n ic s e g m e n t s h o u ld n ot be bio p sie d). In a ffe cte d ind ivid u a ls, o n e fin d s an a b s e n c e o f g a n g lio n c e lls in a s s o c ia tio n w ith a x o n a l h y p e rtro p h y . A s tru c tu ra l c h ro m o s o m a l a b n o rm a lity is p re s e n t in - 1 0 % o f ca s e s , m o s t c o m m o n ly tris o m y 21. S in g le g e n e d e fe c ts k n o w n to c a u s e H irs c h s p ru n g d is e a s e a re n ot fo u n d on 21, how ever, a nd in clu d e d e le te rio u s m u ta tio n s in th e R E T g e n e (10q1 1.2), G D N F g e n e (5p), and E D N R B g e n e (13q). N o te th a t s o m e R E T p ro to o n c o g e n e gain o f fu n c tio n m u ta tio n s re s u lt in th e m u ltip le e n d o c rin e n e o p la sia (M E N ) ty p e 2 A (M E N 2 A ) s y n d ro m e , w h ile o th e r R E T m u ta tio n s lead to M E N ty p e 2 B (M E N 2 B ), n e ith e r o f w h ic h is a s s o c ia te d w ith H irs c h s p ru n g

ISBN 9 7 8 -0 8 9 1 8 9 -6 6 7 8

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7: Molecular Pathology

Genetics of nonneoplastic disease>Gastrointestinal, hepatobiliary & pancreatic d is e a s e , in w h ic h th e re a re lo s s o f fu n c tio n R E T m u ta tio n s . In a d d itio n , H irs c h s p ru n g d is e a s e is o fte n a c o m p o n e n t o f a la rg e r s y n d ro m e , s u c h a s n e u ro fib ro m a to s is ty p e 1 (N F1), M E N 2 A , W a a rd e n b u rg s y n d ro m e , c o n g e n ita l c e n tra l h y p o v e n tila tio n (H a d d a d ) s y n d ro m e , fa m ilia l d y s a u to n o m ia (R ile y -D a y ) s y n d ro m e , a n d S m ith -L e m li-O p itz s y n d ro m e .

7.3.4.2 Osler-W eber-Rendu syndrome (hereditary hemorrhagic telangiectasia) T h is is a c o n d itio n in w h ic h v a s c u la r w a lls a re s tru c tu ra lly a b n o rm a l, le a d in g to re c u rre n t e p is o d e s o f b le e d in g , a n d it m a y in itia lly be ta k e n to re p re s e n t a c o a g u la tio n d is o rd e r. T h e in itia l m a n ife s ta tio n in m o s t p a tie n ts , b e g in n in g in c h ild h o o d , is e p is ta x is . In a d o le s c e n c e o r y o u n g a d u lth o o d , s k in le s io n s a p p e a r, ta k in g th e fo rm o f te la n g ie c ta s ia s on th e fa c e , lips, e a rs , a n d c h e s t. S im ila r le s io n s c a n b e fo u n d o n th e o ra l m u c o s a . In th e fo u rth o r fifth d e c a d e , g a s tro in te s tin a l (G l) b le e d in g a ris e s , re s u ltin g fro m b le e d in g te la n g ie c ta s ia s o r a rte rio v e n o u s m a lfo rm a tio n s . A rte rio v e n o u s m a lfo rm a tio n s m a y a ls o fo rm w ith in th e b ra in , lu n g , o r liver. O s le r-W e b e r-R e n d u s y n d ro m e is an a u to s o m a l d o m in a n t d is o rd e r w ith a fre q u e n c y o f ~1 in 5 0 0 0 . It c a n b e c a u s e d by m u ta tio n s in e ith e r th e E N G g e n e o r th e A C V R L 1 g e n e .

7.3.4.3 Microvillus inclusion disease M ic ro v illu s in c lu s io n d is e a s e (M ID ) is a c a u s e o f c h ro n ic m a la b s o rp tiv e m a ln u tritio n in in fa n ts . It is c o n s id e re d th e m o s t c o m m o n c a u s e o f m a la b s o rp tio n to p re s e n t in th e n e o n a ta l p e rio d . It is in h e rite d a s a n a u to s o m a l re c e s s iv e tra it. C h a ra c te ris tic a lly , th e w a ll o f th e s m a ll in te s tin e is p a p e r th in . S m a ll b o w e l b io p s y s h o w s v illu s b lu n tin g , w ith o v e ra ll m u c o s a l a tro p h y , a n d c h a ra c te ris tic a p ic a l in tra c e llu la r in c lu s io n s . U ltra s tru c tu ra lly , th e s e c o n s is t o f v e s ic le s o f in v a g in a te d b ru s h b o rd e r c o n s titu e n ts , a n d tra d itio n a lly u ltra s tru c tu ra l e x a m in a tio n h a s b e e n re q u ire d fo r th e d ia g n o s is . T h e re a re s e v e ra l h is to c h e m ic a l a nd im m u n o h is to c h e m ic a l a lte rn a tiv e s to e le c tro n m ic ro s c o p y . P e rio d ic a c id -S c h iff s ta in in g , p o ly c lo n a l C E A , a n d C D 1 0 n o rm a lly h ig h lig h t th e b ru s h b o rd e r o f in te s tin a l e p ith e lia in a lin e a r a p ic a l p a tte rn . A ll h a v e a ls o b e e n s h o w n to h ig h lig h t th e m ic ro v illu s in c lu s io n s in M ID by d is p la y in g c y to p la s m ic s ta in in g in a g lo b u la r o r g ra in y p a tte rn .

7.3.4.4 Multifactorial disorders & syndromic disorders affecting the Gl tract

(v e rte b ra l, a na l, c a rd ia c , tra c h e a l, e s o p h a g e a l, re na l, and lim b). T E F h a s s e v e ra l fo rm s , th e m o s t c o m m o n b e in g th e d is ta l ty p e (9 0 % o f c a se s), w h ic h c o m m u n ic a te s b e tw e e n th e tra c h e a a nd th e d is ta l e nd o f th e e s o p h a g u s (distal to th e s te n o sis). E s o p h a g e a l a tre s ia m o s t o fte n c o m e s to c lin ic a l a tte n tio n by p ro d u c in g p o ly h y d ra m n io s (a m n io tic flu id is n o rm a lly s w a llo w e d by th e fe tu s). A lte rn a tiv e ly , it m a y p re s e n t a s d iffic u lty w ith fe e d in g . T h e a tre s ia is c o n firm e d by fa ilu re to p ass a n a s o g a s tric tu b e , a nd th e p re s e n c e o f a d is ta l T E F is c o n firm e d by th e ra d io g ra p h ic p re s e n c e o f a g a s tric g a s b ubble.

7.3.4.4 .2 P y lo ric s ten o s is A n a to m ic a lly , p y lo ric s te n o s is re su lts fro m h y p e rtro p h y o f th e s m o o th m u s c le s u rro u n d in g th e p y lo ric c h a n n e l. It p re s e n ts in infan ts, u s u a lly b e tw e e n 1 and 6 w e e k s o f a ge , w ith p ro je c tile v o m itin g fo llo w in g m ea ls. T h e p y lo ric v a lv e m a y be p a lp a b le a s a sm all m a s s (olive) in th e e p ig a s triu m . T h e d ia g n o s is c a n u s u a lly be c o n firm e d by im a g in g . D ye s tu d ie s reveal a c la s s ic s trin g sign , a nd u ltra s o u n d g iv e s a ty p ic a l d o u b le tra c k sign; h ow eve r, th e s e fin d in g s a re n o t s p e c ific (b e in g p o te n tia lly p ro d u c e d by p y lo ro s p a s m ). T h u s , s tric t q u a n tita tiv e u ltra s o u n d c rite ria have b e e n a d o p te d . S u rg ic a l in te rv e n tio n (eg, p y lo ro m y o to m y ) is h ig h ly s u c c e s s fu l. W h ile a s tric t M e n d e lia n p a tte rn o f in h e rita n c e is n ot o b s e rv e d , fa m ilia l c lu s te rin g is, a nd c o n c o rd a n c e a m o n g id e n tic a l tw in s is - 5 0 % . F u rth e rm o re , p y lo ric s te n o s is is o fte n p re s e n t in a s s o c ia tio n w ith T u rn e r s y n d ro m e , tris o m y 18, C o rn e lia d e L a n g e s y n d ro m e , a nd H irs c h s p ru n g d ise a se . T h e o vera ll in c id e n c e is -1 in 3 0 0 live b irth s . T h e in c id e n c e is h ig h e s t a m o n g C a u c a s ia n s , e s p e c ia lly th o s e o f n o rth e rn E u ro p e a n d e s c e n t, a nd b o y s a re d is p ro p o rtio n a te ly a ffe c te d (4:1). In te restin g ly, firs tb o rn c h ild re n a re m o re like ly to be a ffe c te d th a n th e ir s ib lin g s . T h e p a th o g e n e s is is p re s e n tly c o n s id e re d m u ltifa c to ria l.

7.3.4.4.3 In te stin al atresia In te s tin a l a tre s ia is a m o n g th e m o s t c o m m o n c o n g e n ita l d e fe c ts o f th e G l tra c t, w ith an in c id e n c e o f -1 in 5 0 0 -1 0 0 0 live b irth s. T h e te rm re fe rs to a s e g m e n t o f s te n o tic intestin e, th o u g h t to be th e re su lt o f a fa ilu re o f re c a n a liz a tio n o f th e b o w e l at - 1 0 w e e k s . T h e a ffe c te d s e g m e n t is p re s e n t in th e fo rm o f a so lid co rd . T h e m o s t c o m m o n lo c a tio n is th e ile u m , fo llo w e d by je ju n u m and d u o d e n u m . M o s t c a s e s o f in te s tin a l a tre s ia a re iso la te d d e fe c ts , b u t - 3 0 % o f c a s e s are a s s o c ia te d w ith D o w n s y n d ro m e .

7.3.4.4.1 E s o p h a g e a l a tre s ia T h e o v e ra ll in c id e n c e o f c o n g e n ita l s tru c tu ra l a n o m a lie s o f th e e s o p h a g u s is ~1 in 3 0 0 0 live b irth s , m o s t o f th e s e ta k in g th e fo rm o f e s o p h a g e a l a tre s ia , w ith o r w ith o u t a tra c h e o e s o p h a g e a l fis tu la (T E F ). > 9 0 % o f c a s e s a re p a rt o f a la rg e r s y n d ro m e , e s p e c ia lly th e V A C T E R L s e q u e n c e

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7.3.4.4 .4 A b d o m in a l w all defects: o m p h a lo c e le & g astro sc h is is O m p h a lo c e le and g a s tro s c h is is a re c o n g e n ita l a b d o m in a l w a ll d e fe c ts th a t m u s t be d is tin g u is h e d fro m o n e a no th e r, as

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

7: Molecular Pathology

Genetics of nonneoplastic disease>Gastrointestinal, hepatobiliary & pancreatic th e ir c lin ic a l im p lic a tio n s differ. T h e g a s tro s c h is is is ty p ic a lly ju s t to th e rig h t o f th e u m b ilic u s a nd c o m p o s e d o f lo o p s o f in te s tin e w ith o u t c o v e rin g . In c o n tra s t, an o m p h a lo c e le is lo c a te d in th e m id lin e , e s s e n tia lly w ith in th e u m b ilic a l co rd . O m p h a lo c e le is c o m p o s e d o f m u ltip le v is c e ra , in c lu d in g in te stin e , liver, and s p le e n , a nd c o v e re d by a m e m b ra n e c o m p o s e d o f p e rito n e u m a nd a m n io n . A b d o m in a l w all d e fe c ts o c c u r s p o ra d ic a lly , b u t g a s tro s c h is is is s tro n g ly a s s o c ia te d w ith d e c re a s e d m a te rn a l age. Im p o rta n tly , th e in c id e n c e o f a d d itio n a l c o n g e n ita l a n o m a lie s is v e ry high in a s s o c ia tio n w ith o m p h a lo c e le (60% ), b ut re la tiv e ly lo w in a s s o c ia tio n w ith g a s tro s c h is is (10% ). F u rth e rm o re , a n o m a lie s a s s o c ia te d w ith g a s tro s c h is is are la rg e ly intestin al, w h e re a s o m p h a lo c e le is o fte n a s s o c ia te d w ith m a jo r c a rd ia c d e fe c ts, c h ro m o s o m a l a n o m a lie s (tris o m y 21, tris o m y 18, tris o m y 13), o r th e B e c k w ith -W ie d e m a n n s y n d ro m e . A b d o m in a l w a ll d e fe c ts ca n be d ia g n o s e d p re n a ta lly. O fte n th e re is an e le v a te d m a te rn a l s e ru m a fe to p ro te in on ro u tin e p re n a ta l s c re e n in g , b e in g m u ch h ig h e r in g a s tro s c h is is th a n in o m p h a lo c e le . 7.3.4.5 Biliary fibrocystic diseases (Caroli disease & congenital hepatic fibrosis) T h e c o n d itio n s in th is c a te g o ry a re c o n s id e re d d is o rd e rs o f th e d u c ta l p la te (d ucta l p la te m a lfo rm a tio n s). In fa ct, th e c la s s ic h is to lo g ic fin d in g in c o n g e n ita l h e p a tic fib ro s is (C H F )— a s le e v e lik e a n n u la r bile d u c t e n c irc lin g a c e n tra l c o re o f c o n n e c tiv e tis s u e — is th e n o rm a l a p p e a ra n c e o f th e fe ta l liv e r a t - 1 0 w e e ks. In th e u sua l c o u rs e o f even ts, th is d u c ta l p la te b e c o m e s re o rg a n iz e d into th e p o rta l tria d a s w e n o rm a lly e n v is io n it, a p ro c e s s th a t is th o u g h t to be in te rru p te d in d u c ta l p la te m a lfo rm a tio n s . B ilia ry fib ro c y s tic d is e a s e s a re a s s o c ia te d w ith a u to s o m a l re c e s s iv e p o ly c y s tic d is e a s e , n e p h ro n o p h th is is , a nd m u ta tio n s in th e P K H D 1 g e n e on 6p. T h is g e n e e n c o d e s a p ro te in c a lle d fib ro c y s tin (p o lyd u ctin ), w h ic h is th o u g h t to be invo lve d in th e n o rm a l e m b ry o g e n e s is o f th e bile d u c ts a nd re na l tu b u le s. C a ro li d is e a s e is c h a ra c te riz e d by s e g m e n ta l d ila tio n o f th e in tra h e p a tic b ile d u c ts (and to a le s s e r e x te n t e x tra h e p a tic d ucts), n o t re la te d to o b s tru c tio n . D ila tio n m ay be fu s ifo rm early, b ut in its m a tu re fo rm is s a ccu la r. S to n e fo rm a tio n a nd re c u rre n t b o u ts o f b a c te ria l c h o la n g itis ty p ic a lly c o m p lic a te th is s y n d ro m e . C a ro li d is e a s e ca n be d ia g n o s e d w ith u ltra s o u n d o r e n d o s c o p ic re tro g ra d e c h o la n g io p a n c re a to g ra p h y , s h o w in g th e ty p ic a l s a c c u la r o r fu s ifo rm d ila tio n s in th e in tra h e p a tic b ile d u c ts (w ith o u t e v id e n c e o f an o b s tru c tio n ). T h e liv e r b io p s y m a y s h o w fe a tu re s o f a s c e n d in g c h o la n g itis . S tric tly d e fin e d , C a ro li d is e a s e is a te rm th a t re fe rs to b ile d u c tu la r e c ta s ia w ith o u t th e o th e r fin d in g s o f C H F i7.7. C H F is c h a ra c te riz e d by e n la rg e m e n t o f p o rta l tra c ts by in te rs titia l fib ro s is w ith in w h ic h th e re a re s e g m e n ta lly d ila te d and a b n o rm a lly sh a p e d

© A S C P 2018

i7.7 Biliary plate malformations a Trichrome stained section demonstrating mildly ectatic interlobular bile ducts with associated dense fibrosis in Caroli disease b Biliary microhamartoma may be seen alone or in association with malformation syndromes c & d Congenital hepatic fibrosis

i7.8 Alagille syndrome; portal triads with pauci-inflammatory bile duct loss; surrounding hepatic parenchyma is notable for cholestasis & feathery degeneration

(sle e ve like ) bile d u c ts. T h e re su lt is b ilia ry o b s tru c tio n a nd p o rta l h y p e rte n s io n . A u to s o m a l d o m in a n t p o ly c y s tic k id n e y d is e a s e h as a s s o c ia te d h e p a tic c y s ts (and vo n M e y e n b u rg c o m p le x e s ) in - 1 /2 o f p a tie n ts . T h e y d iffe r fro m C a ro li a n d C H F in th a t th e y a re u s u a lly s im p le c y s ts , n o t in c o n tin u ity w ith th e d u c ta l s y s te m . T h e y are m u ch m o re p ro m in e n t in a ffe c te d w o m e n . 7.3.4.6 Syndromic paucity of bile ducts (Alagille syndrome, arteriohepatic dysplasia) A la g ille s y n d ro m e is an a u to s o m a l d o m in a n t d is o rd e r c h a ra c te riz e d by a s e t o f d y s m o rp h ic fe a tu re s in a s s o c ia tio n w ith a n o n in fla m m a to ry lo s s o f in te rlo b u la r b ile d u c ts i7.8. M u ta tio n s in th e JA G 1 g e n e , re s p o n s ib le fo r e n c o d in g th e p ro te in J a g g e d l, h ave bee n id e n tifie d in -7 0 % o f c a s e s . J a g g e d l is a s ig n a lin g p ro te in in v o lv e d in fe ta l d e v e lo p m e n t, s e rv in g a s a lig a n d fo r N o tc h re ce p to rs . A s m a ll p e rc e n ta g e o f p a tie n ts h ave in ste a d a m u ta tio n in th e N O T C H 2 g e n e .

ISBN 9 7 8 -0 8 9 1 8 9 -6 6 7 8

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7: Molecular Pathology

Genetics of nonneoplastic disease>Gastrointestinal, hepatobiliary & pancreatic A la g ille s y n d ro m e u s u a lly p re s e n ts w ith c h o le s ta s is , o fte n in th e n e o n a ta l p e rio d . T o ta l b iliru b in is e le v a te d ( - 5 0 :5 0 c o n ju g a te d :u n c o n ju g a te d ), a n d a lk a lin e p h o s p h a ta s e is e le v a te d . A d d itio n a l fe a tu re s in c lu d e fa c ia l d y s m o rp h is m (b ro a d fo re h e a d , w id e ly s p a c e d e y e s , s m a ll m a n d ib le , p ro m in e n t e a rs , im p a rtin g a n o v e ra ll tria n g u la r p ro file ), b u tte rfly v e rte b ra e , p o s te rio r e m b ry o to x o n o f th e eye, and c o n g e n ita l h e a rt d is e a s e (e s p e c ia lly p e rip h e ra l p u lm o n ic s te n o s is ). A t v e ry e a rly s ta g e s , th e liv e r b io p s y s h o w s h e p a titis re s e m b lin g n e o n a ta l (g ia n t c e ll) h e p a titis . T h e n u m b e r o f b ile d u c ts is n o rm a l a t b irth a n d p ro g re s s iv e ly d im in is h e s th e re a fte r; c h a ra c te ris tic p a u c ity o f b ile d u c ts (d u c t to p o rta l tra c t ra tio < 1:2) m a y n o t b e a p p a re n t u n til a fte r 6 m o n th s o f a g e . H is to lo g ic e x a m in a tio n s h o w s n o e v id e n c e o f d u c ta l in fla m m a tio n a n d no in ju ry to e x is tin g d u c ts . It is th o u g h t th a t th e m e c h a n is m u n d e rly in g b ile d u c t p a u c ity is th e fa ilu re o f d u c ts to c o n tin u e to e lo n g a te fo llo w in g b irth . T h e d iffe re n tia l d ia g n o s is fo r p a u c ity o f in te rlo b u la r b ile d u c ts in in fa n c y in c lu d e s c o n g e n ita l ru b e lla s y n d ro m e a n d a1 a n titry p s in (A A T ) d e fic ie n c y . 7.3.47 Hereditary hemochromatosis T h e b a s ic d e fe c t in h e re d ita ry h e m o c h ro m a to s is (H H ) is e n h a n c e d in te s tin a l iro n a b s o rp tio n . T h e n o rm a l a d u lt a b s o rb s o n ly a s m a ll p e rc e n ta g e o f in g e s te d iro n , a m o u n tin g to - 1 - 2 m g /d a y . A b s o rp tio n is re g u la te d b y th e d e m a n d fo r iro n , th ro u g h a fe e d b a c k lo o p , w h ic h is in te rru p te d in H H . T h e m e c h a n is m s fo r th is h a v e n o t b e e n fu lly e lu c id a te d , b u t a p ro te in h o rm o n e c a lle d h e p c id in a p p e a rs to be in v o lv e d . H e p c id in is s y n th e s iz e d in th e liv e r a t a ra te in flu e n c e d b y iro n s to re s , a n d it e x e rts an in h ib ito ry e ffe c t o n iron a b s o rp tio n . In H H , h e p c id in le v e ls a re low . Iro n a b s o rp tio n is in e x c e s s o f w h a t c a n be u tiliz e d b y th e re tic u lo e n d o th e lia l s y s te m . T h e re s u lt is iro n d e p o s itio n w ith in h e p a to c y te s , p a n c re a s , p itu ita ry , s y n o v iu m , h e a rt, a n d skin. T h is c a u s e s d a m a g e to th e liv e r (u s u a lly p a u c i-in fla m m a to ry fib ro s is p ro g re s s in g to c irrh o s is ), p a n c re a s (fib ro s is w ith im p a irm e n t o f is le t c e ll fu n c tio n le a d in g to d ia b e te s ), p itu ita ry g la n d (h y p o g o n a d o tro p h ic h y p o g o n a d is m le a d in g to in fe rtility — n o t m u c h d ire c t im p a c t o n th e g o n a d s ), jo in ts (o s te o a rth ritis ), h e a rt (d ila te d o r re s tric tiv e c a rd io m y o p a th y ), a n d s k in (b ro n z in g s e c o n d a ry to in c re a s e d m e la n in ). H H is an a u to s o m a l re c e s s iv e in h e rite d d is o rd e r th a t in m o s t c a s e s is c a u s e d b y d e fe c ts in th e H F E g e n e , w h ic h is lo c a te d w ith in th e m a jo r h is to c o m p a tib ility c o m p le x c o d in g re g io n on 6 p 2 1 .3 . T h e p ro d u c t o f th e H F E g e n e is in v o lv e d w ith re g u la tin g iro n u p ta k e in th e in te s tin e . A w id e v a rie ty o f H F E g e n e m u ta tio n s a re k n o w n , m o s t c lin ic a lly in s ig n ific a n t. T h e m o s t c o m m o n c lin ic a lly s ig n ific a n t m u ta tio n , C 282Y , d is ru p ts a c o n s e rv e d d is u lfid e b o n d le a d in g to m is fo ld in g a n d a c c u m u la tio n o f p ro te in in th e G o lg i. T h e s e c o n d m o s t

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c o m m o n m u ta tio n , H 6 3 D , is le s s like ly to c a u s e c lin ic a lly s ig n ific a n t d is e a s e . N e ith e r o f th e m u ta tio n s have a high p e n e tra n c e . G e n e s o th e r th a n H F E , s u c h a s th o s e e n c o d in g th e tra n s fe rrin re c e p to r ( T F R 2 ) a n d fe rritin h e a v y ch a in (.F T H 1 ) h a ve b e e n im p lic a te d in h e m o c h ro m a to s is a s w e ll t7.7. G e n e s e n c o d in g h e p c id in (H A M P ) a nd h e m o ju v u lin (H F E 2 ) a re a s s o c ia te d w ith ju v e n ile o n s e t h e m o c h ro m a to s is . C lin ic a lly a ffe c te d in d iv id u a ls a re m o s t o fte n h o m o z y g o u s fo r th e C 2 8 2 Y m u ta tio n , and m o s t o f th e re m a in in g c a s e s a re d u e to c o m p o u n d h e te ro z y g o s ity fo r C 2 8 2 Y a n d th e H 6 3 D m u ta tio n . R e g a rd le s s o f g e n o ty p e , w o m e n a re h a lf a s like ly a s m en to d e v e lo p c o m p lic a tio n s .

t7 .7 Hemochromatosis associated genes Gene

Location

Disease

HFE (most common variants: C282Y, H63D) HFE2 (hemojuvlin) HAMP (hepcidin) TFR2 (transferrin receptor) FTH1 (ferritin heavy chain)

6p21.3

hereditary hemochromatosis

1q21 19q13 7q22 11 q13

juvenile hemochromatosis A juvenile hemochromatosis B hemochromatosis type 3 familial iron overload

H H is th e m o s t c o m m o n in h e rite d d is o rd e r in n o rth e rn E u ro p e a n s w ith a p re v a le n c e s im ila r to C F (1 in 3 0 0 in A m e ric a n C a u c a s ia n s ). T h e H 6 3 D m u ta tio n (or p o ly m o rp h is m ) is q u ite c o m m o n in C a u c a s ia n s , p re s e n t in 2 5% o f th e p o p u la tio n . It o n ly c a u s e s d is e a s e w h e n c o in h e rite d w ith a C 2 8 2 Y m u ta tio n (c o m p o u n d h e te ro zyg o te ); how ever, th e c o m p o u n d h e te ro z y g o te s re p re s e n t - 2 % o f th e p o p u la tio n , a nd o n ly a sm a ll m in o rity o f th e m w ill d e v e lo p c lin ic a l d is e a s e . S im p le h e te ro z y g o te s fo r e ith e r C 2 8 2 Y o r H 6 3 D are g e n e ra lly hea lth y, w ith th e fo llo w in g c a v e a ts : m a n y h ave a b n o rm a l s e ru m iron s tu d ie s re fle c tin g s o m e d e g re e o f iron o v e rlo a d , and th e re is a g re a te r lik e lih o o d o f p ro g re s s io n in o th e r fo rm s o f h e p a tic inju ry, su ch a s s te a to h e p a titis . E ven in th o s e h o m o z y g o u s fo r C 282Y , c lin ic a lly s ig n ific a n t h e m o c h ro m a to s is a ris e s a t a lo w rate. H o m o z y g o te s fo r H 6 3 D are c lin ic a lly w ell. S c re e n in g in v o lv e s s e ru m iron s tu d ie s , e s p e c ia lly p e rc e n t tra n s fe rrin s a tu ra tio n a nd fe rritin (b oth e le v a te d in H H ). A tra n s fe rrin s a tu ra tio n > 4 5 % h as a s e n s itiv ity o f > 9 5 % , and th is is th e m o s t w id e ly re c o m m e n d e d s in g le s c re e n in g a s s a y (s u g g e s te d c u to ffs v a ry 4 5 % -6 0 % , a nd an e le v a te d v a lu e s h o u ld be re p e a te d ). H ow ever, s p e c ific ity is h a m p e re d by a n u m b e r o f c a u s e s o f s e c o n d a ry s id e ro s is , in c lu d in g s te a to h e p a titis , c h ro n ic h e m o ly tic a n e m ia , d ie ta ry iron o v e rlo a d (eg, e x c e s s iv e iron s u p p le m e n ta tio n , B antu s id e ro s is ), c h ro n ic tra n s fu s io n s , s id e ro b la s tic a n e m ia , and p o rp h y ria c u ta n e a ta rd a . T h e tra d itio n a l c o n firm a to ry te s t h a s been liv e r b io p s y w ith e ith e r q u a lita tiv e o r q u a n tita tiv e iro n a s s e s s m e n t. T h e liv e r b io p s y d is p la y s in c re a s e d h e p a to c e llu la r iro n i7.9, p a rtic u la rly w h e n s ta in e d w ith P ru s s ia n blue, w ith th e g re a te s t d e p o s itio n in p e rip o rta l (z o n e 1) h e p a to c y te s . S e m iq u a n tita tiv e iron g ra d in g (0 -4 + s c a le ) c o rre la te s e x tre m e ly w e ll w ith h e p a tic iron q u a n tita tio n ,

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

7: Molecular Pathology

Genetics of nonneoplastic disease>Gastrointestinal, hepatobiliary & pancreatic

i7.9 Hereditary hemochromatosis a Prussian blue stained section in which a longitudinally oriented portal tract runs diagonally, demonstrating zone 1 predominant siderosis b At high magnification, there is an abundance of iron that is predominantly within hepatocytes, rather than primarily within Kupffer cells (as may be seen in secondaiy forms of siderosis)

i7.10 Wilson disease a Cirrhotic liver of a patient with Wilson disease b At high magnification, the findings include inflammation, pseudoglycogenated nuclei & focal pigment deposition c Copper staining highlights abundant copper within hepatocytes

e s p e c ia lly a t th e e x tre m e s (0-1+ and 4+). H e p a tic iron ca n be m e a s u re d q u a n tita tiv e ly by a to m ic a b s o rp tio n s p e c tro p h o to m e try , a nd e x p re s s e d as e ith e r th e h e p a tic iron c o n c e n tra tio n (p m o l/g o f d ry liv e r w e ig h t) o r th e h e p a tic iron in d e x (h e p a tic iron c o n c e n tra tio n d iv id e d by a g e in years). A n o rm a l h e p a tic iron in d e x is 1.9 is c o n s id e re d d ia g n o s tic o f H H . T h e v a lu e o f th e h e p a tic iron in d e x o n c e c irrh o s is is e s ta b lis h e d is low er. C o n firm a tio n by m o le c u la r m e th o d s , ta rg e te d m u ta tio n a n a lys is fo r C 2 8 2 Y o r H 6 3 D , m ay s u b s titu te fo r liv e r b io p s y in a p p ro p ria te s e ttin g s .

low , n o rm a l, o r high. T h e u rin a ry c o p p e r e x c re tio n is u s u a lly e le v a te d .

7.3.4.8 Wilson disease (hepatolenticular degeneration) W ils o n d is e a s e m ay p re s e n t in 1 o f 3 w a ys: liv e r d is e a s e , n e u ro p s y c h ia tric d is e a s e , o r h e m o ly s is . T h e s e m a n ife s ta tio n s u s u a lly beg in by y o u n g a d u lth o o d . H e p a titis in W ils o n d is e a s e o fte n p re s e n ts a c u te ly w ith ja u n d ic e a nd a b d o m in a l pain, b u t it m ay p re s e n t w ith c h ro n ic h e p a titis . K a yse rF le is c h e r rin g s o fte n d e v e lo p in a s s o c ia tio n w ith n e u ro lo g ic d is e a s e . T h e n e u ro lo g ic m a n ife s ta tio n s , w h ic h fo rm e d th e b a s is fo r th e firs t d e s c rip tio n by S a m u e l A le x a n d e r K in n ie r W ils o n in 1912, a re p ro te a n a nd m a y in c lu d e m o v e m e n t d is o rd e rs (d ys a rth ria , tre m o rs , rig idity, b ra d y k in e s ia , and a b n o rm a l g ait) a nd p s y ch o s is . It is im p o rta n t to th in k o f W ils o n d is e a s e w h e n e x a m in in g a liv e r b io p s y fro m a y o u n g a d u lt w ith h e p a titis . T h e liv e r b io p s y s h o w s g ly c o g e n a te d n uclei, s te a to sis , a nd in fla m m a tio n th a t m ay m im ic th e p a tte rn o f c h ro n ic v ira l h e p a titis i7.10. F ib ro s is u ltim a te ly le a d s to c irrh o s is . U n like liv e r iron s ta in s , h e p a tic c o p p e r s ta in s a re s o m e w h a t u n re lia b le in c o m p a ris o n w ith fo rm a l h e p a tic c o p p e r q u a n tita tio n (w h ich is c o n s id e re d th e g old s ta n d a rd ). F u rth e rm o re , th e fin d in g o f s ta in a b le c o p p e r is h ig h ly n o n s p e c ific a nd m ay be s e e n in s te a to h e p a titis a nd c h o le s ta s is . T h e p la s m a c e ru lo p la s m in m ay s e rv e a s a s c re e n in g test. L o w le ve ls a re fo u n d in W ils o n d is e a s e , b u t th e re a re se ve ra l c a u s e s o f fa ls e ly e le v a te d a nd fa ls e ly d e p re s s e d levels. In fu lly e s ta b lis h e d W ils o n d ise a se , th e s e ru m c o p p e r is e le va te d ; how ever, a t v a rio u s s ta g e s , th e c o p p e r m a y be

© A S C P 2018

W ils o n d is e a s e is c a u s e d b y m u ta tio n s in th e A T P 7 B g e n e , w h ic h e n c o d e s an A T P a s e u tilize d in c o p p e r b in d in g to c e ru lo p la s m in . T h e A T P 7 A g e n e is m u ta te d in M e n k e s k in k y h a ir s y n d ro m e a s w e ll. In h e rita n c e is a u to s o m a l re c e s s iv e , a nd th e d is e a s e is rare, w ith a fre q u e n c y o f -1 in 3 0 ,0 0 0 . 7.3.4.9 a 1 antitrypsin deficiency T h e S E R P IN A 1 (P I) g e n e o n c h ro m o s o m e 1 4 q 3 1 -3 2 .3 is th e site o f m o d e ra te p o ly m o rp h is m . M o s t h e a lth y a d u lts a re h o m o z y g o u s fo r th e M a lle le (d e n o te d P iM M ). - 1 0 % o f th e p o p u la tio n is h e te ro z y g o u s fo r M a n d s o m e o th e r a lle le , o f w h ic h th e re a re >75 t7.8. T h e a lle le s a re n a m e d a c c o rd in g to th e e le c tro p h o re tic m o b ility o f th e e n c o d e d p ro te in , fro m fa s te s t (A) to s lo w e s t (Z). T h e w ild ty p e a lle le is d e n o te d M. C lin ic a lly s ig n ific a n t A A T d e fic ie n c y is u s u a lly c a u s e d by h o m o z y g o s ity fo r th e Z a lle le (P iZ Z ).

t7.8 SERPINA1 (PI) gene alleles Genotype MM MS MZ SS SZ ZZ

Prevalence (%) 90 6 5 2 g e n e ra tio n s o f w o m e n have p re m e n o p a u s a l b re a s t ca ncer, s o m e tim e s a rising b ilaterally. In a d d itio n , th e re is an incre a se d risk o f n e o p la s m s o f th e ovary, F a llo pia n tube, co lo n, u terus, a nd p an cre a s. In p a rticu la r, th e B R C A 2 6 174delT m utatio n is s tro n g ly a s s o c ia te d w ith fa m ilia l p a n c re a tic ca nce r. In fa m ilie s w ith B R C A 2 m uta tio n s, th e rate o f p ro sta te c a n c e r is high. B R C A m u ta tio n s in c re a s e th e lifetim e ris k o f b re a st c a n c e r to 8 0% , c o m p a re d to th e 10% risk se en in th e g e n e ra l p op u la tio n . S u ch m u ta tio n s in c re a s e th e risk o f o varian c a n c e r to 5 0% , e s p e c ia lly B R C A 1 m u ta tio n s. T h e lifetim e risk o f b re a s t c a n c e r in a m an w h o c a rrie s a B R C A m u ta tio n is - 6 % ; B R C A 2 c a rrie s a h ig h e r m a le b re a s t c a n c e r ris k th a n d o e s BR C A 1. In w o m e n w ith a B R C A a s s o c ia te d b re a s t c a n c e r th e risk o f c a n c e r d e v e lo p in g in th e co n tra la te ra l b re a s t is 25% . © A S C P 2018

i7.23 Basal-like invasive breast carcinoma a Low magnification view shows a somewhat circumscribed tumor with central collagenous scarlike zone b Intermediate magnification shows that the tumor is composed of high grade epithelial cells arranged in somewhat syncytial trabecular groups c Strong & diffuse expression of CK5/6

B R C A a s s o c ia te d b re a s t c a n c e rs o fte n h ave d is tin c tiv e th o u g h n o t e n tire ly s p e c ific h is to lo g ic fe a tu re s . T h e tu m o rs te n d to have a high n u c le a r g ra d e , a c e n tra l a c e llu la r s c a rlik e z o n e , p u s h in g ra th e r th a n infiltra ting m a rg in s , and tu m o r in filtra tin g ly m p h o c y te s (m e d u lla ry c a rc in o m a lik e h is to lo g y ) i7.23. T h e y a re m o s tly n e g a tive fo r ER , PR, and H E R 2 (trip le n eg a tive ), n e g a tive fo r lum ina l c y to k e ra tin s (C K 8/18), a n d p o s itiv e fo r b asal ce ll m a rk e rs (C K 5/6). T his c o n s te lla tio n o f fin d in g s h a s b ee n d e s c rib e d a s th e b asa l like p h e n o ty p e . W h ile ty p ic a l o f B R C A a s s o c ia te d tu m o rs , basal like c a rc in o m a is fre q u e n tly se en s p o ra d ica lly. E a ch o f th e B R C A g e n e s is large, w ith th o u s a n d s o f d e s c rib e d m u ta tio n s , m a k in g m u ta tio n d e te c tio n d ifficu lt. B R C A m u ta tio n s a re e s p e c ia lly p re v a le n t in th e A s h k e n a z i J e w is h p o p u la tio n . A q u a rte r o f A s h k e n a z i w o m e n w ith b re a s t c a n c e r h a rb o r B R C A m u ta tio n s . W ith in th is p o p u la tio n , m u ta tio n d e te c tio n is fa c ilita te d by a sm all n u m b e r o f fo u n d e r m u ta tio n s th a t a c c o u n t fo r 9 0 % o f all ca ses: 1 8 5 d e lA G m u ta tio n in B R C A 1 , 5 3 8 5 in s C m u ta tio n in B R C A 1, a n d 6 1 7 4 d e lT m u ta tio n o f BR C A2.

7.4.4.5 Other inherited influences on breast cancer G e rm lin e m u ta tio n s in P 5 3 (L i-F ra u m e n i s y n d ro m e ), P T E N (C o w d e n s y n d ro m e ), C D H 1 (h e re d ita ry d iffu s e g a s tric c a n c e r sy n d ro m e ), a nd STK11 (P JS ) a re a s s o c ia te d w ith an in c re a s e d ris k o f b re a s t cancer.

7.4.4.6 Molecular classification of breast carcinoma (gene expression profiling) It h as lo n g b ee n a c k n o w le d g e d th a t h is to lo g ic s u b ty p e s in b re a s t c a n c e r re la te to c lin ic a l c o u rs e a n d to b e n e fit o f a d ju v a n t c h e m o th e ra p y . C la s s ific a tio n o f b re a s t c a rc in o m a s by g e n e e x p re s s io n p a tte rn s h as g a in e d s u p p o rt a s a m e a n s to c h a ra c te riz e tu m o rs w ith even g re a te r re s o lu tio n a n d th e re b y b e tte r p re d ic t behavior. B ased on gen e e xpression patterns, 4 cla s s e s o f tu m o r w e re recognized: lum inal A , lum inal B, basal like, and H er2+. T h e

ISBN 9 7 8 -0 8 9 1 8 9 -6 6 7 8

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7: Molecular Pathology

Genetics of neoplastic disease>Breast cancer | Genitourinary tumors lu m in a l ty p e s a re tu m o rs th a t a re ER+, e x p re s s lo w m o le cu la r w e ig h t keratins, a nd te n d to have a m o re in d o le n t clinical co u rs e . L u m in a l A tu m o rs te n d to be lo w g ra d e histologically, a nd lum ina l B tu m o rs a re o fte n high g rad e. B asal like tu m o rs e x p re s s high m o le c u la r w e ig h t keratins, a re E R -, have high n u c le a r g ra d e , a nd a re c lin ic a lly a g g re s s iv e b ut h ig h ly c h e m o s e n s itiv e . H E R 2 + tu m o rs a re c h a ra c te riz e d by high g ra d e a n d s e n s itiv ity to inh ibition o f H E R 2 . N o te a ls o th a t “b asal like” a n d “trip le n e g a tive ” a re n ot syn o n y m o u s ; m o s t b asal like tu m o rs a re in fa c t trip le n eg a tive , b ut a w id e v a rie ty o f trip le n eg a tive tu m o rs d o n ot have b asa l like fe a tu re s. T h e s e c la s s e s co rre late fa irly w e ll w ith tu m o r g rad e, E R status, a nd H E R 2 status. It h as b e e n d e m o n s tra te d th a t a co m b in a tio n o f m o rp h o lo g y and im m u n o h is to c h e m ic a l a n a lysis ca n be u sed to d e rive results c o m p a ra b le to th o s e o b ta in e d by g e n e e x p re s s io n p rofiling t7.15. t7 .1 5 Breast cancer subtyping by m orphology & IHC ER, PR,

Subtype Morphology

Her2

Luminal A low grade ductal, NOS

ER+, PR±, low Ki67 Her2CK8/18+

Other IHC Notes

sensitive to endocrine therapy, variable response to chemotherapy, overall good prognosis ER+, PR±, mod to high tend to be sensitive to Luminal B high grade Her2+ Ki67 endocrine therapy, ductal, NOS variable response to CK8/18+ chemotherapy, more aggressive than luminal A sensitive to trastuzumab Her2+ ER-, PR-, high Ki67 Her2+ high Ki67 resistant to everything, Basal like triple negative CK5/6+, require aggressive P63+ chemotherapy BRCA1 related triple Triple neqative negative IHC = immunohistochemistry; NOS = not otherwise specified

B a s a l like tu m o rs a re fu rth e r n o ta b le fo r B R C A 1 g e n e in h ib itio n b y a v a rie ty o f m e c h a n is m s , in c lu d in g p ro m o te r m e th y la tio n a n d tra n s c rip tio n a l in a c tiv a tio n . C o n v e rs e ly , tu m o rs in B R C A 1 fa m ilie s a re c h a ra c te riz e d by b a s a l like m o rp h o lo g y . In c o n tra s t, B R C A 2 tu m o rs a re d is trib u te d in a m a n n e r s im ila r to s p o ra d ic tu m o rs o v e ra ll.

7.4.5 Genitourinary tumors 7.4.5.1 Renal cell carcinoma syndromes v o n H ip p e l-L in d a u s y n d ro m e (V H L s y n d ro m e ) is an a u to s o m a l d o m in a n t c o n d itio n c a u s in g p re d is p o s itio n to a v a rie ty o f tu m o rs , in c lu d in g c le a r c e ll R C C , h e m a n g io b la s to m a o f th e C N S (c e re b e llu m , re tin a , o r s p in a l c o rd ), p h e o c h ro m o c y to m a , p a n c re a tic is le t c e ll tu m o rs and c y s ts , c y s ta d e n o m a s o f th e e p id id y m is o r b ro a d lig a m e n t, a n d th e p a p illa ry tu m o r o f e n d o ly m p h a tic s a c o rig in . G e rm lin e m u ta tio n s in th e g e n e V H L lo c a te d o n c h ro m o s o m e 3 p 2 5 -2 6 a c c o u n t fo r th e m a jo rity o f c a s e s . A lte ra tio n o f

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i7.24 Birt-Hogg-Dube syndrome associated renal tumor 3 p is e x tre m e ly c o m m o n in s p o ra d ic c le a r ce ll R C C . A fo rm o f th e s y n d ro m e w ith all th e u sua l fe a tu re s e x c e p t p h e o c h ro m o c y to m a is k n o w n as ty p e 1 V H L . It is a s s o c ia te d w ith n o n p ro d u c tio n o f th e V H L g e n e p ro d u c t, re su ltin g fro m g e n e d e le tio n o r m is s e n s e m u ta tio n . F o rm s o f th e s y n d ro m e w ith a high ris k o f p h e o c h ro m o c y to m a a re k n o w n a s ty p e 2 V H L , and th e s e a re a s s o c ia te d w ith m is s e n s e m u ta tio n s . T h e V H L g e n e p ro d u c t is a p a rt o f a u b iq u itin d e p e n d e n t c o m p le x th a t is re s p o n s ib le fo r th e d e g ra d a tio n o f th e h ypo xia in d u cib le fa c to r (H IF1). In c re a s e d HIF1 le a d s to in c re a s e d a n g io g e n e s is a nd p ro m o tio n o f tu m o r g ro w th . B irt-H o g g -D u b e s y n d ro m e is an a u to s o m a l d o m in a n t c o n d itio n p re d is p o s in g to R C C . S kin le s io n s and s p o n ta n e o u s p n e u m o th o ra x c o m p le te th e d ia g n o s tic triad . S k in m a n ife s ta tio n s in c lu d e m u ltip le fib ro fo llic u lo m a s , tric h o d is c o m a s , a n d a c ro c h o rd o n s , e s p e c ia lly a ffe c tin g th e h e a d , neck, a n d u p p e r tru n k . T h e lun g c o n ta in s n u m e ro u s c y s tic p a re n c h y m a l s p a c e s in a d d itio n to b le b s and b ullae , c a u s in g re c u rre n t s p o n ta n e o u s p n e u m o th o ra x . T h e s p o n ta n e o u s p n e u m o th o ra c e s te n d to in vo lve th e lo w e r lo b e s o f th e lung, u n like m o s t o th e r c o n d itio n s th a t p re d is p o s e to p n e u m o th o ra x (A A T d e fic ie n c y , ly m p h a n g io m y o m a to s is , L a n g e rh a n s c e ll h is tio c y to s is , E h le rs -D a n lo s s y n d ro m e , M a rfa n sy n d ro m e ). T h e re na l tu m o rs te n d to be b ila te ra l and m u ltifo c a l a nd have fe a tu re s o f a c o m b in e d c h ro m o p h o b e R C C and o n c o c y to m a i7.24. M u ta tio n s o f th e B H D (F L C N ) g e n e on c h ro m o s o m e 17p11.2 e n c o d in g th e p ro te in fo llic u lin a re re sp o n s ib le fo r th e s y n d ro m e . F a m ilia l c le a r cell R C C is a s s o c ia te d w ith m u ta tio n s o f 3p and la c k s th e o th e r fe a tu re s o f th e V H L s y n d ro m e . A h e re d ita ry fo rm o f p a p illa ry R C C is a s s o c ia te d w ith b ila te ra l p a p illa ry R C C s and g ain o f fu n c tio n m u ta tio n s o f th e p ro to o n c o g e n e C -M E T on c h ro m o s o m e 7q31. C -M E T fu n c tio n s in a m a n n e r s im ila r to C -K IT , w ith m u ta tio n re su ltin g in a c o n s titu tiv e ly a c tiva te d ty ro s in e kina se. T u b e ro u s s c le ro s is is a s s o c ia te d

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

7: Molecular Pathology

Genetics of neoplastic disease>Genitourinary tumors 7.4.5.3 Wilms tumor N e p h ro b la s to m a o r W ilm s tu m o r is m o s t o fte n c a u s e d by a m u ta tio n in th e W T1 g e n e on c h ro m o s o m e 11p13. W ilm s tu m o r is a fe a tu re o f W A G R s y n d ro m e , w h ic h is c a u s e d by a m ic ro d e le tio n th a t in v o lv e s th e W T1 g e n e a n d a d ja c e n t P A X 6 g e n e . L o s s o f P A X 6 is a s s o c ia te d w ith th e a n irid ia o f W A G R s y n d ro m e . i7.25 Renal carcinoma with Xp11.2 translocation

7.4.5.4 Urothelial (transitional cell) carcinoma

w ith in c re a s e d in c id e n c e o f R C C , b u t is m u ch m o re c o m m o n ly a s s o c ia te d w ith th e re na l a n g io m y o lip o m a .

7.4.5.2 Sporadic renal cell carcinoma P o rtio n s o f th e s h o rt a rm o f c h ro m o s o m e 3 a re d e le te d in m o s t c a s e s o f c le a r c e ll c a rc in o m a , w ith 1 o f 3 loci m o s t o fte n a ffe c te d : 3p14, 3 p 2 5 .3 (the lo c a tio n o f th e V H L g en e ), and 3 p2 1 .3 . O n ly a s m a ll p e rc e n ta g e o f c a s e s have 3p a n o m a lie s a lo n e , h ow eve r, w ith a d d itio n a l c o m m o n a b n o rm a litie s a t 14q, 9p, 8p, a n d 6q. F u rth e rm o re , d e l(3 p ) by its e lf h as no im p a c t on p ro g n o s is , w h ile lo s s o f 14q, 9p, and 8 p e a ch c o rre la te s w ith h ig h e r s ta g e a n d a w o rs e p ro g n o s is . B o th ty p e 1 a n d ty p e 2 p a p illa ry R C C ca n b e a s s o c ia te d w ith lo s s o f th e Y c h ro m o s o m e a nd g a in s o f c h ro m o s o m e s 7 a n d 17. T h e s e c h ro m o s o m a l a b n o rm a litie s h elp d iffe re n tia te p a p illa ry R C C fro m th e h is to lo g ic a lly s im ila r m u c in o u s tu b u la r a nd s p in d le ce ll c a rc in o m a o f th e kidney. C h ro m o p h o b e c a rc in o m a is o fte n h y p o d ip lo id w ith fre q u e n t lo s s e s o f c h ro m o s o m e s Y, 1, 2, 6, 10, 13, 17, and 21. R e n a l c a rc in o m a w ith X p11.2 tra n s lo c a tio n m o s t c o m m o n ly a ffe c ts c h ild re n a nd y o u n g a d u lts . T h e tu m o r h a s a d is tin c tiv e a p p e a ra n c e w ith a lv e o la r (n e s te d ) a nd p a p illa ry a rc h ite c tu re , c le a r c e lls , a nd p s a m m o m a b o d ie s i7.25. B a se d on th e fo re g o in g , th e re fo re , T F E 3 a s s o c ia te d c a rc in o m a s h o u ld be th o u g h t o f w h e n e v e r (1) a d ia g n o s is o f a R C C w ith a m ixe d h is to lo g ic p a tte rn is e n te rta in e d , o r (2) a n y R C C is s e e n in a c h ild . T h e tu m o r is c h a ra c te ris tic a lly n e g a tiv e fo r EM A b u t p o s itiv e fo r C D 1 0. S e ve ra l X p 11 .2 a b n o rm a litie s h a ve b e e n d e s c rib e d in c o n n e c tio n w ith th e s e tu m o rs , in c lu d in g t(X ;1 )(p1 1 .2 ;q 21 ), p ro d u c in g th e T F E 3 -P R C C fu s io n g e n e , t(X ;1 7 )(p 1 1 .2 ;q 2 5 ), p ro d u c in g T F E 3 -A S P L , a nd t(X ;1 ) (p11.2;p34), p ro d u c in g T F E 3 -P S F . T h e T F E 3 -A S P L g e n e fu s io n o f t(X ;1 7 ) is a ls o s e e n in a lv e o la r s o ft p a rt s a rc o m a (A S P S ); how eve r, a key d iffe re n c e is th a t th e tra n s lo c a tio n in A S P S is an u n b a la n c e d o ne , w h ile th a t in re na l c a rc in o m a is b a la n c e d . T h e T F E -A S P L re na l tu m o rs c h a ra c te ris tic a lly p re s e n t a t a d v a n c e d s ta g e but, like A S P S , fo llo w an in d o le n t c o u rs e m a rk e d b y v e ry late re la p s e s /m e ta s ta s e s .

© ASCP2018

B io lo g ic a lly s p e a k in g , th e re a p p e a r to be 2 d is tin c t p a th w a y s to u ro th e lia l c a rc in o m a . T h e firs t le a d s to lo w g ra d e p a p illa ry tra n s itio n a l ce ll c a rc in o m a , a tu m o r w ith a lm o s t no m e ta s ta tic p o te n tia l. L o w g ra d e le s io n s m a y o c c a s io n a lly be a p re c u rs o r to h ig h g ra d e tu m o rs , b u t m a in ly s e rv e a s a m a rk e r o f risk. T h e o th e r p a th w a y in v o lv e s h ig h g ra d e p a p illa ry c a rc in o m a a nd fla t u ro th e lia l c a rc in o m a in situ, e a c h o f w h ic h m a y g iv e rise to a h ig h g ra d e in va sive tu m o r. T h e lo w g ra d e tu m o rs o fte n h ave lo s s o f P 1 6 on c h ro m o s o m e 9p21 a n d m u ta tio n s in th e F G F R 3 g e n e . W h ile h ig h g ra d e tu m o rs fre q u e n tly h ave lo s s o f P 1 6, th e y u s u a lly la c k F G F R 3 m u ta tio n s . In ste a d th e y d e m o n s tra te in a c tiv a tio n o f P 5 3 , c h ro m o s o m a l in s ta b ility , a nd an o fte n c o m p le x k a ry o ty p e w ith g a in s o r lo s s e s o f 6p, 7, 9, and 17.

t7.16 2004 W HO classification o f renal tumors (m odified) Genetic Behavior Immunophenotype anomalies Tumor Clear cell renal cell carcinoma Papillary renal cell carcinoma Chromophobe renal cell carcinoma Collecting (Bellini) duct carcinoma Renal medullary carcinoma Xp11.2 translocation carcinoma Oncocytoma

Mucinous, tubular & spindle cell carcinoma Angiomyolipoma

ISBN 9 7 8 -0 8 9 1 8 9 -6 6 7 8

CD10+, vimentin+, RCC Ag+ CD10+, vimentin+, AMACR+, CK7+ CD10-/+, vimentinCD117+, CK7+ CD10-, vimentin—, high molecular weight keratin+ CD10-, vimentin-, CEA+ TFE3+ (nuclear) CD10+ CD10-/+, vimentini, CK7 rare focal +, CD117+ CD10-, vimentin+ HMB45+

del(3p)

aggressive

loss of Y; gains of 7 & 17 loss of Y, 1, 2, 6, 10,13,17 & 21 del(1q)

indolent

aggressive

unknown

aggressive

Xp11.2 translocation highly variable: loss of 1,14; t(5;11) loss of 1,4, 6, 8, 13,14

indolent

indolent

benign

indolent

benign loss of heterozygosity at TSC2 on 16p

367

7: Molecular Pathology

Genetics of neoplastic disease>Genitourinary tumors | Soft tissue & bone D ia g n o s is in u rin e s p e c im e n s c a n be fa c ilita te d b y F IS H . E n u m e ra tio n p ro b e s fo r c h ro m o s o m e s 3, 7, a n d 17 a lo n g w ith a lo c u s s p e c ific in d ic a to r fo r th e P 1 6 g e n e o n 9p21 fo rm s th e b a s is o f th e U ro V y s io n a s s a y . E x a m in a tio n o f c y to lo g ic a lly a b n o rm a l c e lls fo r q u a n tita tio n o f F IS H s ig n a ls p ro v id e s h ig h s p e c ific ity a n d s e n s itiv ity . In in itia l re p o rts , s p e c ific ity a p p ro a c h e d 1 0 0 % , w ith p o s itiv e F IS H re s u lts in s o m e p a tie n ts p re c e d in g th e d e v e lo p m e n t o f c lin ic a lly a p p a re n t tu m o r (“a n tic ip a to ry p o s itiv e s ” ). S u b s e q u e n t s tu d ie s h a ve n o t c o n firm e d th is d e g re e o f s p e c ific ity .

7.4.6 Soft tissue & bone T u m o rs o f e c to d e rm a l o r e p ith e lia l o rig in o fte n d e m o n s tra te 1 o r se ve ra l g e n e m u ta tio n s , b ut w ith ra re e x c e p tio n th e y la ck s p e c ific c h ro m o s o m e s tru c tu ra l re a rra n g e m e n ts . In c o n tra s t, tu m o rs o f m e s o d e rm a l o rig in , in c lu d in g th e h e m a to ly m p h o id s y s te m , s o ft tis s u e , a n d b on e , o fte n d e m o n s tra te s p e c ific a n d re p ro d u c ib le s tru c tu ra l re a rra n g e m e n ts , su ch as tra n s lo c a tio n s t7.17.

t7.17 Molecular features of soft tissue tumors 7.4.5.5 Testicular tumors Tumor T h e m a jo rity o f g e rm c e ll tu m o rs a re a s s o c ia te d w ith g a in s o f c h ro m o s o m e 12p, m o s t o fte n a s an is o c h ro m o s o m e , i(12p). G a in o f 12p c a n be s e e n in all ty p e s o f g e rm c e ll tu m o rs a n d m a y re p re s e n t an e a rly s te p in tu m o r d e v e lo p m e n t. C K IT m u ta tio n s a re fre q u e n t in s e m in o m a , a s a re s u lt o f w h ic h m a n y s e m in o m a s e x h ib it s tro n g im m u n o h is to c h e m ic a l s ta in in g fo r c -k it (C D 117). T h e m e m b ra n o u s s ta in in g p a tte rn is s tro n g ly a s s o c ia te d w ith s e m in o m a ; o th e r s ta in in g p a tte rn s c a n b e fo u n d in n o n s e m in o m a to u s g e rm c e ll tu m o rs .

Most common rearrangement(s)

chondroid lipoma schwannoma Ewing/primitive neuroectodermal tumor

t(11;16)(q13;p12-13) del(22q12) t(11;22)(q24;q12) t(21 ;22)(q22;q12) t(7 ;22)(p22;q12) t(17;22)(q21;q12) t(2;22)(q33;q12) neuroblastoma del(1p),+17 alveolar rhabdomyosarcoma t(2;13)(q35;q14) t(1;13)(p36;q14) alveolar soft part sarcoma der(17)t(X;17)(p11;q25) desmoplastic small round cell tumor t(11;22)(p13;q12) myxoid & round cell liposarcoma t(12;16)(q13;p11) low grade fibromyxoid sarcoma, t(7;16)(q33;p11) hyalinizing spindle cell tumor with giant rosettes dermatofibrosarcoma protuberans, t(17 ;22)(q22;q 13) giant cell fibroblastoma infantile fibrosarcoma, congenital t(12; 15)(p12;q25) mesoblastic nephroma myxoid chondrosarcoma, t(9;22)(q22;q12) extraskeletal liposarcoma t(12;16)(q13;p11) angiomatoid fibrous histiocytoma t(12;22)(q13;q12) t(2;22)(q33;q12) clear cell sarcoma t(12;22)(q13;q12) t(2;22)(q33;q12) synovial sarcoma t(X;18)(p11.2;q11.2) t(X;18)(p11.2;q11.2) inflammatory myofibroblastic tumor t(1;2)(q25;p23) t(2;19)(p23;p13)

Genes C11orf95/MKL2 NF2 EWS/FU1 EWS/ERG EWS/ETV1 EWS/ETV4 EWS/FEV MYCN PAX3/FOX01 PAX7/FOX01 ASPSCR1/TFE3 EWS/WT1 FUS/DDIT3 FUS/CREB3L2 COL1A1/PDGFB ETV6/NTRK3 EWS/NR4A3 FUS/CHOP EWS/ATF1 EWS/CREB1 EWS/ATF1 EWS/CREB1 SSX1/SYT SSX2/SYT TPM3/ALK TPM4/ALK

7.4.6.1 Ewing sarcoma family of tumors

i7.26 Ewing family tumors a-c Ewing sarcoma/PNET d Extraskeletal myxoid chondrosarcoma e & f Intraabdominal desmoplastic small round cell tumor

368

E w in g s a rc o m a i7.26 is a m e m b e r o f a la rg e fa m ily o f tu m o rs , all o f w h ic h h ave fu s io n g e n e s in v o lv in g th e E W S gene. E w in g s a rc o m a is 1 o f th e m o s t c o m m o n s o ft tis s u e tu m o rs o f ch ild re n , a c c o u n tin g fo r 2 0 % o f s o ft tis s u e tu m o rs in th is p o p u la tio n . P rim itiv e n e u ro e c to d e rm a l tu m o r (P N E T ) is e s s e n tia lly id e n tic a l to E w in g s a rc o m a w ith th e a d d itio n o f n e u ro e c to d e rm a l fe a tu re s a s d e m o n s tra te d by h is to lo g ic , im m u n o h is to c h e m ic a l, o r u ltra s tru c tu ra l m ea n s.

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

7: Molecular Pathology

: ' ~

Genetics of neoplastic disease>Soft tissue & bone

i7.27 Ewing sarcom a F IS H utilizing dual color break apart probes; the red & green probes flank the region of known breakpoints a A normal nucleus contains 2 red-green fusion signals (2F ) b An abnorm al nucleus dem onstrates 1 red-green fusion signal & separate red & green signals (1 R ,1 G ,1 F )

T h e E W S g e n e o fte n u n d e rg o e s tra n s lo c a tio n to a m e m b e r o f th e E TS tra n s c rip tio n fa m ily i7.27. T h e E T S s ite s fu n c tio n a s D N A b in d in g d o m a in s ; th u s , su ch tra n s lo c a tio n s lo c a liz e th e s tro n g tra n s c rip tio n a l a c tiv a tio n d o m a in o f th e E W S to E TS in d u c ib le g e n e s . A lm o s t 9 5 % o f c a s e s o f E w ing s a rc o m a e x p re s s a p a rtic u la r tra n s lo c a tio n o f th e E W S g e n e o n c h ro m o s o m e 22q12 to th e FLI1 g e n e on 11q24. T h e re is s o m e v a ria tio n in th e e x a c t b re a k p o in ts b u t m o s t c o m m o n ly th e b re a k s o c c u r b e tw e e n e xo n 7 o f E W S a nd e xon 6 o f FLI1. L e s s c o m m o n (5% o f c a s e s ) is th e t(2 1 ;2 2 )(q 2 2 ;q 1 2 ) tra n s lo c a tio n o f E W S w ith E R G . R a re c a s e s h ave b ee n a s s o c ia te d w ith th e tra n s lo c a tio n s t(7 ;2 2), t(17;22), t(2 ;2 2 ), in v e rs io n o f 2 2q , a n d e ven a n o n -E W S tra n s lo c a tio n o f t(1 6;21 )(p1 1 ;q 22 ) re s u ltin g in a T L S -E R G fu s io n . A d d itio n a l c y to g e n e tic a b n o rm a litie s (m o s t o fte n g a in s o f 1q, 8, 12) ca n be fo u n d in 1/2 o f th e c a s e s o f E w in g s a rc o m a a n d p o rte n d a p o o r p ro g n o s is . G e n e tic d ia g n o s is ca n be m a d e w ith R T -P C R , w h ic h p ro v id e s h ig h s e n s itiv ity and s p e c ific ity w h e n p rim e rs a nd p ro b e s to c o v e r all th e d iffe re n t b re a k p o in ts a re u se d . O th e r c o m m o n m o d a litie s u se d fo r d ia g n o s is in c lu d e k a ry o ty p in g , F IS H w ith E W S b re a k a p a rt p ro b e s , o r S o u th e rn b lo ttin g . In tra -a b d o m in a l d e s m o p la s tic s m a ll ro un d ce ll tu m o r m o s t c o m m o n ly p re s e n ts as an a b d o m in a l m a s s in a boy. It is c o n s is te n tly a s s o c ia te d w ith th e tra n s lo c a tio n t(11;22) (p13;q12) fu s in g th e g e n e s E W S w ith W T1. T h e tu m o r a p p e a rs h is to lo g ic a lly as a sm a ll ro u n d b lu e ce ll tu m o r; its o n ly d is tin c tiv e fe a tu re is g ro w th w ith in s trik in g ly d e s m o p la s tic s tro m a . A u n iq u e im m u n o h is to c h e m ic a l p ro file u s u a lly a id s in id e n tify in g th is tu m or, w h ic h is fo u n d to be N S E +, E M A +, ke ra tin + and d e s m in + in th e v a s t m a jo rity o f ca ses. C le a r cell s a rc o m a o f te n d o n s and a p o n e u ro s e s (m a lig n a n t m e la n o m a o f s o ft p a rts ) s h a re s m a n y h is to m o rp h o lo g ic , im m u n o h is to c h e m ic a l, a nd u ltra s tru c tu ra l fe a tu re s w ith m e la n o m a . U n like m a lig n a n t m e la n o m a , n e a rly 9 0 % o f c a s e s o f c le a r cell s a rc o m a a re a s s o c ia te d w ith a s p e c ific tra n s lo c a tio n , t(12,22)(q13;q12) fu s in g E W S to th e tra n s c rip tio n fa c to r ATF1.

© A S C P 2018

i7.28 A drenal neuroblastom a

E x tra s k e le ta l m y x o id c h o n d ro s a rc o m a is a ra re tu m o r w h o s e c h o n d ro id d iffe re n tia tio n is s u b tle , c o n s is tin g la rg e ly o f a c o rd in g p a tte rn o f g ro w th . E x tra s k e le ta l m y x o id c h o n d ro s c a rc o m a is c o m m o n ly a s s o c ia te d w ith th e tra n s lo c a tio n t(9 ;2 2 )(q 2 2 ;q 1 2 ) th a t fu s e s th e E W S g e n e w ith th e C H N (T E C ) g e n e . T h e re m a in in g c a s e s a re fo u n d to h a rb o r 1 o f 2 a d d itio n a l tra n s lo c a tio n s , t(9 ;1 2)(q 22 ;q 1 1) th a t fu s e s C H N to TAF2N , o r t(9 ;1 5 )(q 2 2 ;q 2 1 ) th a t fu s e s C H N to th e g e n e TC F12. T h e s e tra n s lo c a tio n s a re s p e c ific fo r e x tra s k e le ta l m y x o id c h o n d ro s a rc o m a a n d h a v e n o t b e e n se e n w ith a n y o th e r c h o n d ro id re la te d tu m o rs .

7.4.6.2 Neuroblastoma N e u ro b la s to m a i7.28 is th e m o s t c o m m o n m a lig n a n c y in p a tie n ts u n d e r th e a g e o f 5. It p re s e n ts a s an a b d o m in a l m a s s o r a p o s te rio r m e d ia s tin a l m a s s , a s it u s u a lly a ris e s fro m th e a d re n a l m e d u lla o r s y m p a th e tic c h a in . A m p lific a tio n o f th e M Y C N (n -M y c ) p ro to -o n c o g e n e is fo u n d in 3 0 % o f n e u ro b la s to m a s a nd is a m a rk e r o f a g g re s s iv e b e h a v io r. T h e m e c h a n is m o f a m p lific a tio n is p rim a rily a s e x tra c h ro m o s o m a l d o u b le m in u te s , th o u g h in s o m e c a s e s th e re is in situ g e n e d u p lic a tio n , and in o th e rs g e n e d u p lic a tio n a n d in s e rtio n into ra n d o m c h ro m o s o m e s , le a d in g to s e g m e n ta l c h ro m o s o m e g a in th a t m ay be v is ib le a s h o m o g e n e o u s ly s ta in in g re g io n s . >10 fo ld a m p lific a tio n is c o rre la te d w ith p o o r p ro g n o s is . T h e o v e ra ll p ro p o rtio n o f tu m o rs w ith th is d e g re e o f M Y C N a m p lific a tio n is 3 0 % , b u t 4 0 % in h ig h s ta g e tu m o rs a n d o n ly 10% in lo w s ta g e tu m o rs . S e ve ra l m o d a litie s a re a v a ila b le fo r d e te c tin g M Y C N d u p lic a tio n , in c lu d in g F IS H , C IS H , S o u th e rn b lo ttin g , a n d q u a n tita tiv e R T -P C R . In a d d itio n to M Y C N a m p lific a tio n , n e u ro b la s to m a s m a y d is p la y a n e u p lo id y a n d /o r a c o m p le x s e t o f s tru c tu ra l c h ro m o s o m a l a n o m a lie s . A b n o rm a litie s o f 17q23 a re p re s e n t in > 5 0 % o f c a s e s , d e le tio n o f 1p36 in 3 0 % -4 0 % , a nd d e le tio n o f 11q23 in 4 0 % 5 0 % . T h e 1p d e le tio n is a s s o c ia te d w ith p o o r p ro g n o s is . T h e D N A c o n te n t (p lo id y ) o f th e tu m o r h a s b e e n s h o w n to c o rre la te w ith o u tc o m e , p a rtic u la rly in in fa n ts . T h o s e w ith h y p e rd ip lo id tu m o rs (D N A ind e x >1.0) h a ve a m o re fa v o ra b le o u tc o m e (s im ila r to w h a t is se en in a c u te ly m p h o b la s tic ly m p h o m a ).

ISBN 9 7 8 -0 8 9 1 8 9 -6 6 7 8

369

7: Molecular Pathology

Genetics of neoplastic disease>Soft tissue & bone

i7.30 Low grade fibromyxoid sarcom a (L G F M S )— hyalinizing spindle tum or with giant rosettes (H S T G R ) spectrum tumors a T u m o r with predom inantly L G F M S features b T u m o r showing interm ediate features c Tu m o r with predom inantly H S T G R features

p a ra -a rtic u la r d e e p s o ft tis s u e in an e x tre m ity . T u m o rs ca n be m o n o p h a s ic o r b ip h a s ic , b ip h a s ic tu m o rs b e in g le s s c o m m o n . In 9 0 % o f s y n o v ia l s a rc o m a s , th e re is th e c h a ra c te ris tic t(X ;1 8 )(p 1 1 ;q11) tra n s lo c a tio n . M o s t c o m m o n ly th e tra n s lo c a tio n is n o t th e s o le a b n o rm a lity , a nd a n e u p lo id ie s o f 3 - , 7+, 8+, a nd 12+ h a ve been d e s c rib e d . T h e g e n e s in vo lve d a re th e S S X g e n e s (p re d o m in a n tly SSX1, S S X 2, a n d S S X 4 ) on th e X c h ro m o s o m e and S S 18 (aka S Y T o r S S X T ) on c h ro m o s o m e 18. T h e m o s t c o m m o n fu s io n , S S 1 8 -S S X 1 , a c c o u n ts fo r 2 /3 o f ca ses, w h ile S S 1 8 -S S X 2 a c c o u n ts fo r m o s t o f th e re m a in in g c a s e s . R a re c a s e re p o rts d e s c rib e th e S S 1 8 -S S X 4 fu s io n . TLE1 IH C , w h ic h s h o w s s tro n g n u c le a r re a c tiv ity in s y n o v ia l s a rc o m a , ca n a c t as a s u rro g a te m arker, th o u g h TLE1 e x p re s s io n is n ot e n tire ly s p e c ific .

i7.29 S ynovial sarcom a a & b M o nophasic synovial sarcom as c & d B iphasic synovial sarcom as e Im m unohistochem ical expression o f TLE1

7.4.6.3 Rhabdomyosarcoma A lv e o la r rh a b d o m y o s a rc o m a (A R M S ) h a s th e P A X -F O X O I (fo rm e rly F K H R ) fu s io n g e n e . - 6 0 % o f c a s e s a re a s s o c ia te d w ith t(2 ;1 3 )(q 3 5 ;q 1 4 ), w h ic h fu s e s P A X 3 w ith F O X O I, w h ile - 2 0 % o f c a s e s a re a s s o c ia te d w ith t(1 ;1 3 )(p 3 6 ;q 1 4 ), fu s in g P A X 7 w ith F O X O I. S im ila r to E W S - F L I, th e fu s io n p ro te in in A R M S jo in s th e D N A b in d in g re g io n o f th e P A X g e n e s w ith th e tra n s c rip tio n a l a c tiv a tio n re g io n o f F O X O I. T h e b re a k p o in ts in th e tra n s lo c a tio n s a s s o c ia te d w ith a lv e o la r rh a b d o m y o s a rc o m a a re c o n s is te n t, in v o lv in g in tro n 7 o f P A X 3 o r P A X 7 w ith in tro n 1 o f F O X O I. A m p lific a tio n o f th e P A X 7 - F 0 X 0 1 fu s io n g e n e is s e e n in a m a jo rity o f c a s e s w ith th e t(1 ;13) tra n s lo c a tio n a n d to a m u c h le s s e r e x te n t w ith th e P A X 3 - F 0 X 0 1 fu s io n fro m t(2;13). D e te c tio n o f th e tra n s lo c a tio n is v e ry s p e c ific . T u m o rs a s s o c ia te d w ith th e P A X 3 tra n s lo c a tio n a re a s s o c ia te d w ith a v e ry p o o r p ro g n o s is (Soft tissue & bone | Head & neck tumors e n c o d in g M D M 2 a n d C D K 4 , in h ib ito rs re s p e c tiv e ly o f P 53 a nd RB1, a re lo c a te d w ith in th is re g io n . M D M 2 a n d C D K 4 o v e re x p re s s io n by F IS H o r IH C have b e c o m e im p o rta n t d ia g n o s tic m a rk e rs fo r w e ll d iffe re n tia te d lip o s a rc o m a (d is tin c tio n fro m lip o m a v a ria n ts ) a nd d e d iffe re n tia te d lip o s a rc o m a (d is tin c tio n fro m u n d iffe re n tia te d s a rc o m a ). By IH C , in fo rm a tiv e e x p re s s io n o f M D M 2 a nd C D K 4 is n uclea r.

7.4.7 Head & neck tumors 7.4.7.1 Squamous cell carcinoma In cre a sin g ly, h u m a n p a p illo m a v iru s (H P V ) is bein g re co g n iz e d as a c a u s e o f h e a d a nd n e c k s q u a m o u s cell c a rc in o m a s (S C C s). H P V d riv e n tu m o rs o fte n a ris e in y o u n g e r p a tie n ts w h o a re n o n s m o k e rs , a nd th e ir b e h a v io r is m o re in d o le n t. H P V s ta tu s a nd s m o k in g h is to ry m a y in fa c t be s tro n g e r p re d ic to rs o f lon g te rm o u tc o m e th a n tra d itio n a l T N M s ta g in g . A s ra te s o f s m o k in g h ave d e c re a s e d , H P V a s s o c ia te d c a rc in o m a h as b e c o m e re la tiv e ly m o re p re va le n t. H igh risk s e ro ty p e s , e s p e c ia lly H P V 1 6 , a re ty p ic a lly invo lve d . In s m o k in g a s s o c ia te d S C C , th e m o s t c o m m o n m o le c u la r a n o m a lie s a re fo u n d in th e tu m o r s u p p re s s o r g e n e s, in c lu d in g lo s s o f g e n e tic m a te ria l in 3p, 9p, a nd 17p ( T P 5 3 locus). O v e re x p re s s io n o f p 5 3 by IH C is a s s o c ia te d w ith p o o r p ro g n o s is . E G F R is o v e re x p re s s e d in th e m a jo rity o f to b a c c o re la te d h e a d and n e c k S C C ; how ever, E G F R g e n e tic a n o m a lie s a re u n c o m m o n . N e ith e r m o le c u la r n o r im m u n o h is to c h e m ic a l a s s e s s m e n t o f E G F R s ta tu s c o rre la te s w ith re s p o n s e to a n ti-E G F R th e ra p y. H P V a s s o c ia te d S C C (H P V -S C C ) is u s u a lly fo u n d in th e o ro p h a ry n x , in c lu d in g b a se o f to n g u e a nd to n sils. U p to 7 0% o f S C C s in th e s e s ite s a re p o s itiv e fo r H PV. T u m o rs o f th e o ral to n g u e have a lo w in c id e n c e o f HPV. H P V -S C C is s ig n ific a n tly m o re like ly to h ave n o n k e ra tin iz in g a nd b a s a lo id h istolog y. A s in c e rv ic a l H P V d riv e n S C C , in te g ra tio n o f p o rtio n s o f th e H P V g e n o m e , in c lu d in g H P V E 6 and H P V E 7 , le a d s to s u p p re s s io n o f p 5 3 a nd R b and o v e re x p re s s io n o f p16. T P 5 3 is u n m u ta te d and n o t o v e re x p re s s e d by IH C. IH C fo r p16 is c o m m o n ly u sed a s a s u rro g a te fo r H P V in fe c tio n . U p to 15% o f p16+ tu m o rs s h o w no e v id e n c e o f H P V in fe c tio n by in situ h y b rid iz a tio n . S o m e s tu d ie s h ave s h o w n th a t th e s e a p p a re n tly H P V -/p 1 6 + tu m o rs b e h a ve s im ila rly to H P V + /p1 6 + tu m o rs . P16 o v e re x p re s s io n a p p e a rs to be a m o re u seful m a rk e r th a n H P V in situ h y b rid iz a tio n .

7.47.2 Salivary gland tumors T h e m o s t c o m m o n m a lig n a n t tu m o r o f th e s a liv a ry g la n d s is m u c o e p id e rm o id c a rc in o m a . T h e tra n s lo c a tio n t(1 1 ;19) (q21;p13) fu s in g th e tra n s c rip tio n a l a c tiv a to rs M E C T 2 on c h ro m o s o m e 19 to M A M L 2 on c h ro m o s o m e 11. T h is tra n s lo c a tio n ca n be fo u n d by c y to g e n e tic a n a ly s is in —1/2 o f ca s e s , e s p e c ia lly th e lo w a nd in te rm e d ia te g ra d e tu m o rs . © A S C P 2018

R T -P C R d e te c tio n is m o re s e n s itiv e a n d c a n d e te c t th e tra n s lo c a tio n in a lm o s t 9 0 % o f c a s e s . T h e p re s e n c e o f th e tra n s lo c a tio n in W a rth in tu m o rs is c o n tro v e rs ia l. T h e m o s t c o m m o n b e n ig n s a liv a ry g la n d tu m o r is p le o m o rp h ic a d e n o m a (PA). T h e m a jo rity o f c a s e s h ave d e m o n s tra b le k a ry o ty p ic a b n o rm a litie s , m o s t c o m m o n ly re a rra n g e m e n ts o f 8q12 in vo lvin g th e g e n e P L A G 1. T ra n s lo c a tio n t(3 ;8 ) o f P L A G 1 to th e (3-catenin g e n e , C T N N B 1 , is th e m o s t c o m m o n , fo llo w e d by th e tra n s lo c a tio n t(5 ;8 ) o f P L A G 1 to L IF R , th e le u k e m ia in h ib ito ry fa c to r re ce p to r. T h e e n d re s u lt o f th e s e tra n s lo c a tio n s is th e o v e re x p re s s io n o f P L A G 1. S o m e tu m o rs d e m o n s tra te P L A G 1 o v e re x p re s s io n in th e a b s e n c e o f d e m o n s tra b le c h ro m o s o m a l a b n o rm a litie s . T h e s e c o n d m o s t c o m m o n g e n e invo lve d w ith PA is H M G A 2 on c h ro m o s o m e 12q15. It is m o s t c o m m o n ly re a rra n g e d a s t(3;12), re s u ltin g in fu s io n o f H M G A 2 w ith F H IT (fra g ile h is tid in e triad ). N U T m id lin e c a rc in o m a is a tu m o r u n iq u e ly d e fin e d b y its m o le c u la r fe a tu re s . R e a rra n g e m e n ts in th e N U T (n u c le a r p ro te in in te s tis ) g e n e o n c h ro m o s o m e 15q14 a re d e fin itiv e fo r th e tu m o r, a s d e m o n s tra te d b y e ith e r R T -P C R o r F IS H . M o s t c a s e s e x h ib it th e tra n s lo c a tio n t(1 5 ;1 9 )(q 1 4 ;p 1 3.1), fu s in g th e N U T g e n e to B R D 4 . B e c a u s e o f th e re lia n c e o n th e m o le c u la r fe a tu re s fo r a c c u ra te d ia g n o s is , th e tu m o r is o fte n m is d ia g n o s e d . M o s t o fte n th e y a re p o o rly d iffe re n tia te d tu m o rs w ith a b ru p t k e ra tin iz a tio n th a t a re e a s ily c o n fu s e d w ith o th e r s m a ll b lu e ce ll tu m o rs . C u rre n tly , p ro m is in g re s u lts a re b e in g s e e n w ith IH C u sin g a N U T s p e c ific a n tib o d y , w h ic h m a y fa c ilita te a c c u ra te d ia g n o s is .

7.47.3 Thyroid 7.4.7.3.1 F am ilial th yro id c a rcin o m a T h e c a rd in a l m a n ife s ta tio n s o f M E N ty p e 1 (M E N 1; W e rm e r s y n d ro m e ) a re p a ra th y ro id a d e n o m a s , p itu ita ry a d e n o m a s , a nd p a n c re a tic isle t cell tu m o rs. T h e m o s t c o m m o n and e a rlie s t m a n ife s ta tio n is u su a lly p rim a ry h y p e rp a ra th y ro id is m , c a u s e d by a P TH se cre tin g p itu ita ry a d e n o m a . M o s t o f th e p itu ita ry tu m o rs a re p ro la c tin o m a s . P a n c re a tic tu m o rs o fte n p ro d u c e g a s trin (g a strin o m a s) o r in s u lin (in s u lin o m a s ). N o n e n d o c rin e le sio n s in M EN1 in c lu d e fa c ia l a n g io fib ro m a s , c o lla g e n o m a s , lip o m a s, and m e n in g io m a s . A p re d is p o s itio n e x is ts to e n d o c rin e tu m o rs in the lung, a d re n a l c o rte x , th y m u s , a nd G l tra ct. T h e M E N 1 g e n e on c h ro m o s o m e 11q13 e n c o d e s th e p rote in m en in, and 9 0 % o f the tim e a g e rm lin e M E N 1 m u ta tio n ca n be fo u n d in p atie n ts w ith M EN 1 sy n d ro m e . S o m a tic M E N 1 m u ta tio n s are fo u n d in 1 5 % -2 0 % o f s p o ra d ic p a ra th y ro id a d e n o m a s , isle t cell tu m o rs , a n d g a s trin o m a s . M u ta tio n s in th e R E T p ro to o n c o g e n e on c h ro m o s o m e 10q a re a fe a tu re c o m m o n to M E N 2 A (S ip p le s y n d ro m e ), M E N 2 B , a nd fa m ilia l m e d u lla ry th y ro id c a rc in o m a (F M T C ). T h e 3 s y n d ro m e s — M E N 2 A , M E N 2 B , a n d F M T C — h ave s o m e th in g s in c o m m o n , all im p a rtin g a h ig h ris k fo r m e d u lla ry th y ro id c a rc in o m a , all a u to s o m a l d o m in a n t, a nd

ISBN 9 7 8 -0 8 9 1 8 9 -6 6 7 8

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7: Molecular Pathology

Genetics of neoplastic disease>Head & neck tumors

i7.31 Medullary carcinoma of thyroid a ll d u e to a R E T g e n e m u ta tio n . T h e s e fe a tu re s a lo n e c o m p ris e F M T C . T h e s e fe a tu re s p lu s p h e o c h ro m o c y to m a a n d p a ra th y ro id a d e n o m a c o m p ris e th e M E N 2 A s y n d ro m e ; a n d th e s e p lu s p h e o c h ro m o c y to m a , m u c o s a l n e u ro m a s , g a n g lio n e u ro m a to u s in te s tin a l p o ly p s , a n d M a rfa n o id b o d y h a b itu s c o m p ris e M E N 2 B . W h ile th e h is to lo g y o f m e d u lla ry th y ro id c a rc in o m a s i7.31 is n o t p a rtic u la rly d is tin c tiv e in th e s e s y n d ro m e s , th e a p p e a ra n c e o f th e b a c k g ro u n d th y ro id is C c e ll h y p e rp la s ia a n d n u m e ro u s m ic ro s c o p ic fo c i o f m e d u lla ry c a rc in o m a . M E N 2 A is c a u s e d b y m u ta tio n s a ffe c tin g e x o n s 10-11 o f th e R E T g e n e , m o s t o fte n a ffe c tin g a p a rtic u la r c y s te in e re s id u e (6 3 4 C ys). M E N 2 B is m o s t o fte n d u e to a R E T m u ta tio n a ffe c tin g e x o n 16, e n c o d in g th e ty ro s in e k in a s e d o m a in . F M T C is c a u s e d b y R E T m u ta tio n s a ffe c tin g o th e r c y s te in e re s id u e s , p a rtic u la rly 6 0 9 , 611, 618, a n d 6 2 0 C ys. M u ta tio n s o f th e R E T g e n e a re a s s o c ia te d w ith H irs c h s p ru n g d is e a s e (o fte n g a in o f fu n c tio n ), a n d a lm o s t 1/2 o f s p o ra d ic p a p illa ry th y ro id c a rc in o m a . - 4 0 % o f s p o ra d ic p a p illa ry th y ro id c a rc in o m a s h a v e s o m a tic m u ta tio n s in R ET.

7.4.7.3.2 P a p illa ry th y ro id c a rc in o m a P a p illa r y th y ro id c a rc in o m a (P T C ) is th e m o s t c o m m o n s p o r a d ic c a n c e r o f th e th y ro id , a c c o u n tin g fo r > 7 5 % o f a ll th y ro id m a lig n a n c ie s . M u ta tio n s in B R A F , R E T , a n d R A S , a ll o f w h ic h a re c a p a b le o f c a u s in g u n re g u la te d M A P K s tim u la tio n , h a v e b e e n fo u n d in P T C in m u tu a lly e x c lu s iv e d is trib u tio n . T h e m o s t c o m m o n m u ta tio n fo u n d in P T C is th e B R A F V 6 0 0 E m u ta tio n , w h ic h is s e e n in a lm o s t 1/2 o f c a s e s . B R A F m u ta tio n is fo u n d w ith h ig h e s t fre q u e n c y in c o n v e n tio n a l (6 0 % ) a n d ta ll c e ll (8 0 % ) v a ria n ts o f P T C i7.32, a nd it is fo u n d in o n ly 10% o f fo llic u la r v a ria n t. S e v e ra l s tu d ie s h a v e d e m o n s tra te d th a t th e a c c u ra c y o f th y ro id fin e n e e d le a s p ira tio n d ia g n o s is c a n b e s ig n ific a n tly im p ro v e d by a d d in g B R A F te s tin g . In th is s e ttin g , th e B R A F m u ta tio n a p p e a rs to h a v e a s p e c ific ity o f > 9 9 % fo r P T C . L a s tly , B R A F m u ta tio n s e rv e s a s a p ro g n o s tic m a rke r, w ith B R A F p o s itiv e P T C s d e m o n s tra tin g m o re a g g re s s iv e b e h a v io r. S e v e ra l s tru c tu ra l c h ro m o s o m a l re a rra n g e m e n ts in v o lv in g th e R E T g e n e re s u lt in m a rk e d R E T o v e re x p re s s io n . C o lle c tiv e ly , th e s e re a rra n g e m e n ts a re d e n o te d R E T /P T C , b u t in d iv id u a l 372

i7.32 Papillary carcinoma a Classic papillary carcinoma, papillary variant b Tall cell variant c Columnar variant d-f Follicular variant re a rra n g e m e n t p a rtn e rs a re d e n o te d P T C 1 th ro u g h PTC11. T h e v a s t m a jo rity o f P T C s h a rb o rin g su ch a re a rra n g e m e n t h a ve e ith e r R E T /P T C 1 o r R E T /P T C 3 , w ith P T C 1 b e in g th e C C D C 6 g e n e and P T C 3 th e N C O A 4 g e n e . N o n c lo n a l R E T / P T C re a rra n g e m e n ts ca n be fo u n d in b e n ig n th y ro id tissue , a n d c lo n a l re a rra n g e m e n ts a re fo u n d in 2 0 % -3 0 % o f P TC s, b e in g m o re c o m m o n in ra d ia tio n a s s o c ia te d P T C and in P T C a risin g in c h ild re n . T u m o rs w ith R E T /P T C h ave c la s s ic a rc h ite c tu re a nd a high rate o f ly m p h n o d e m e ta s ta s e s . N e a rly all P T C s w ith R A S m u ta tio n s h ave fo llic u la r a rc h ite c tu re (fo llic u la r v a ria n t o f P TC ). In te re stin g ly, n e a rly 1/2 o f fo llic u la r c a rc in o m a s a ls o h ave R A S m u ta tio n s , as do 1/3 o f fo llic u la r a d e n o m a s . R A S m u ta tio n s a p p e a r to c o rre la te w ith m e ta s ta tic p o te n tia l, e s p e c ia lly to bone.

7.4.8 Skin tumors 7.4.8.1 Melanoma L ess c o m m o n th a n e ith e r S C C o r b asa l ce ll c a rc in o m a b ut a c c o u n tin g fo r fa r m o re m o rb id ity a nd m o rta lity than th e 2 c o m b in e d , m e la n o m a is a s s o c ia te d w ith fa ir skin , a te n d e n c y to fre c k le , m u ltip le nevi, e n v iro n m e n ta l e x p o s u re (deep su n b u rn s ), and fa m ilia l p re d is p o s itio n . T h e la tte r is a

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

7: Molecular Pathology

Genetics of neoplastic disease>Head & neck tumors | Skin tumors | Central nervous system tumors fe a tu re o f se v e ra l fa m ilia l m e la n o m a s y n d ro m e s , in c lu d in g fa m ilia l a ty p ic a l m o le a nd m e la n o m a s y n d ro m e c a u s e d by d y s re g u la tio n o f p16, th e p ro d u c t o f th e g e n e C D K N 2 A (cyclin d e p e n d e n t k in a s e in h ib ito r 2A ). —1/3 o f m u c o s a l a nd a cra l m e la n o m a s a re a s s o c ia te d w ith m u ta tio n s in C -K IT . T h is p re s e n ts an a ttra c tiv e th e ra p e u tic ta rg e t s in c e C -K IT m u ta tio n tu m o rs m a y re sp o n d to th e T K I im a tin ib . A d d itio n a lly , s tro n g im m u n o h is to c h e m ic a l s ta in in g fo r c -k it h as bee n s h o w n to have a c lo s e a s s o c ia tio n w ith m u ta tio n sta tu s, o p e n in g a p o te n tia l s c re e n in g te s t fo r C -K IT m u ta tio n a n a lysis. B R A F m u ta tio n s (p V 6 0 0 E p re d o m in a n tly ) a re c o m m o n in c u ta n e o u s m e la n o m a s th a t a re n o t a s s o c ia te d w ith su n d a m a g e . T h e B R A F p V 6 0 0 E m u ta tio n re s u lts in a c o n s titu tiv e ly a c tiv e p ro te in th a t s e n d s p ro life ra tiv e s ig n a ls to th e n u c le u s in th e a b s e n c e o f m ito g e n a c tiv a tio n . S u c c e s s e s in th e tre a tm e n t o f m e ta s ta tic m e la n o m a w ith a s p e c ific s m a ll m o le c u le in h ib ito r o f B R A F k in a s e h e ra ld a n e w e ra in th e ra p y . A n a d d itio n a l issu e w ith m o le c u la r te s tin g in m e la n o m a is lym p h n o d e e v a lu a tio n . A s ly m p h n o d e s ta tu s is a m a jo r d e te rm in a n t in p ro g n o s is , a c c u ra te a s s e s s m e n t fo r th e p re s e n c e o f m e la n o m a is c ritic a l. W ith c u rre n t h is to m o rp h o lo g ic a nd IH C te c h n iq u e s , it is c le a r th a t s o m e p o te n tia lly m ic ro s c o p ic a lly p o s itiv e lym p h n o d e s a re g o in g u n d e te c te d b e c a u s e a s ig n ific a n t n u m b e r o f n o d e n e g a tive c a s e s d e v e lo p re c u rre n t d is e a s e . S p e c ific m R N A m a rk e rs fo r th e d e te c tio n o f m e la n o m a h ave bee n d e v e lo p e d fo r p ara ffin e m b e d d e d tis s u e a nd s h o w s o m e p ro m is e in d e te c tin g o c c u lt m e ta s ta tic m e la n o m a in th e s e lym p h n od e s.

7.4.8.2 Dermatofibrosarcoma protuberans (DFSP) L ik e m a n y o th e r s o ft tis s u e tu m o rs , d e rm a to fib ro s a rc o m a p ro tu b e ra n s (D F S P ) is a s s o c ia te d w ith a c h a ra c te ris tic c h ro m o s o m a l tra n s lo c a tio n . F u s io n o f th e ty p e I c o lla g e n a1 c h a in g e n e , C O L 1 A 1 , to th e p la te le t d e riv e d g ro w th fa c to r p c h a in g e n e , P D G F B , e ith e r v ia lin e a r tra n s lo c a tio n (m o s t c o m m o n ) o r s u p e rn u m e ra ry rin g c h ro m o s o m e fo rm a tio n is th e h a llm a rk o f D F S P. W h ile s e v e ra l s p e c ific b re a k p o in ts le a d to tra n s lo c a tio n h e te ro g e n e ity , th e fu s io n g e n e is p re s e n t in a lm o s t all c a s e s o f D F S P . In a d d itio n , th e s a m e tra n s lo c a tio n is s e e n in th e p e d ia tric g ia n t c e ll fib ro b la s to m a tu m o r, p ro v id in g e v id e n c e th a t in fa c t th a t D F S P a n d g ia n t c e ll fib ro b la s to m a a re th e s a m e tu m o r w ith d iffe re n t a g e s o f p re s e n ta tio n .

7.4.9 Central nervous system tumors 7.4.9.1 Gliomas 7.4.9.1.1 D iffu s e g lio m a s T h e m o s t c o m m o n p rim a ry n e o p la s m s o f th e C N S a re th e d iffu s e g lio m a s (a s tro c y to m a & o lig o d e n d ro g lio m a ). D iffu s e g lio m a s a re c a te g o riz e d b y th e W o rld H e a lth O rg a n z ia tio n into g ra d e s II th ro u g h IV, w ith g ra d e I a s s ig n e d to b e n ig n w e ll c irc u m s c rib e d tu m o rs . G ra d e IV g lio m a , a ls o c a lle d g lio b la s to m a m u ltifo rm e (G B M ), m a y a ris e d e n o vo (p rim a ry G B M ) o r fro m p re -e x is tin g g ra d e ll/lll g lio m a (s e c o n d a ry G B M ). P rim a ry G B M is a ra p id ly p ro g re s s iv e tu m o r th a t g e n e ra lly a ris e s in o ld e r p a tie n ts , w h ile s e c o n d a ry G B M a ris e s in y o u n g e r p a tie n ts and h a s a s o m e w h a t m o re p ro tra c te d c lin ic a l c o u rs e . T h e a c c u m u la te d e v id e n c e s u g g e s ts th a t a s m a ll n u m b e r o f g e n e tic e v e n ts g iv e s ris e to g ra d e II g lio m a , a n d a s e rie s o f a d d itio n a l g e n e tic e v e n ts a c c ru e s in th e p ro g re s s io n fro m g ra d e II to g ra d e IV g lio m a . E a rly e v e n ts in tu m o rig e n e s is in c lu d e m u ta tio n s in th e IDFI1 a n d /o r ID H 2 g e n e s . ID FI m u ta tio n s a re ra re in tu m o rs o u ts id e th e C N S and, im p o rta n tly , not fo u n d in re a c tiv e g lio s is . A d iv e rg e n c e in p a th s o c c u rs s o m e w h a t later, w ith tu m o rs a c q u irin g 17p13 (T P 5 3 ) a n o m a lie s d iffe re n tia tin g into g ra d e II a s tro c y to m a s , a nd th o s e d e v e lo p in g 1p a n d /o r 19q d e le tio n s d iffe re n tia tin g into g ra d e II o lig o d e n d ro g lio m a . N o te th a t b oth ty p e s o f g lio m a re ta in th e ir o rig in a l ID FI m u ta tio n s . A d d itio n a l a n o m a lie s a re fo u n d in g ra d e III le s io n s , in c lu d in g d e le tio n o f 9 p a nd C D K N 2 . Lastly, p ro g re s s io n to g ra d e IV g lio m a (s e c o n d a ry G B M ) is u s u a lly m arke d by th e lo s s o f m a te ria l fro m 10q. A s m ig h t be e x p e c te d , p rim a ry G B M o fte n la c k s m a n y o f th e s e e a rly a b n o rm a litie s , d e m o n s tra tin g in s te a d a m p lific a tio n o f E G F R , m u ta tio n o f P T E N , a n d lo s s o f 10q. —1/3 o f a s tro c y to m a s h a rb o r m u ta tio n s in T P 5 3. T P 5 3 m u ta tio n s a re ra re in o lig o d e n d ro g lio m a s . A s e x p e c te d , L i-F ra u m e n i s y n d ro m e (g e rm lin e T P 5 3 m u ta tio n ) is a s s o c ia te d w ith th e d e v e lo p m e n t o f a s tro c y to m a . Im m u n o h is to c h e m ic a l e v id e n c e o f p 5 3 n u c le a r a c c u m u la tio n c o rre la te s w e ll w ith T P 5 3 m u ta tio n s ta tu s . F u rth e rm o re , T P 5 3 m u ta tio n s a re o p e ra n t in th e d e v e lo p m e n t o f s e c o n d a ry G B M b ut a re n ot fo u n d c o m m o n ly in s e c o n d a ry G B M in w h ic h E G F R a m p lific a tio n is fo u nd . E G F R a m p lific a tio n a nd T P 5 3 m u ta tio n s ra re ly c o e x is t in th e s e tu m o rs . E G F R IH C is an e ffe c tiv e m e a n s o f a s s e s s in g fo r E G F R m u ta tio n s ta tu s . E G F R m u ta te d tu m o rs d is p la y a g g re s s iv e b e h a v io r, a re a s s o c ia te d w ith a s m a ll cell p h e n o ty p e , b u t re s p o n d to s m a ll m o le c u le E G F R k in a s e in h ib ito rs. B e c a u s e o f th e ir in filtra tiv e n atu re , s u rg ic a l c u re is o fte n d iffic u lt to a c h ie v e . A d ju v a n t c h e m o th e ra p y a nd ra d ia tio n th e ra p y h a ve an im p o rta n t ro le , a n d in g e n e ra l, o lig o d e n d ro g lio m a s re s p o n d b e tte r to a d ju v a n t th e ra p y . T h e re fo re it is im p o rta n t to d is tin g u is h b e tw e e n a s tro c y to m a a nd o lig o d e n d ro g lio m a t7.18. W h ile m a n y o lig o d e n d ro g lio m a s a re q u ite s tra ig h tfo rw a rd , p re s e n tin g a s a p ro life ra tio n o f

© A S C P 2018

ISBN 9 7 8 -0 8 9 1 8 9 -6 6 7 8

373

7: Molecular Pathology

Genetics of neoplastic disease>Central nervous system tumors

a

u n m e th y la te d M G M T . T h e s ta tu s o f th e M G M T g e n e can be a s s e s s e d by a v a rie ty o f m e th o d s , in c lu d in g m e th y la tio n s p e c ific P C R .

b

t7.18 Oligodendroglioma vs astrocytoma

c

Astrocytom a

Im aging

peripheral (cortical), well d e m arc ated , calcified

central (subcortical), infiltrative

Histology

round, regu lar nuclei paucity of glial processes perineural satellitosis m icrocysts filled with mucin

elongated, irregular nuclei ab undan t glial processes

W H O types

grad e II (oligodendrogliom a) grad e III (anaplastic oligodendrogliom a)

grade II (low grade astrocytom a) grad e III (anaplastic astrocytom a) grad e IV (G B M )

IH C

not g enerally useful, although astrocytom as a re m ore likely to ex pres s strong G F A P & p53, with considerable overlap

G en e tics (by L O H or F IS H )

loss of 1 p in 8 0 % loss of 1 p in 3 0 -4 0 % loss of 19q in 80 % loss of 19q in 1 0 -1 5 % loss of 1 p & 19q in 6 0 -8 0 % loss of 1 p & 19q in 5% losses in 9p & 10q increase with losses in 9p & 10q increase with grad e grade no E G F R am plification E G F R am plification in high grade astrocytom as (esp G B M )

Prognosis

better, w ith com bined loss of 1 p & 19q associated with chem osensitivitv

d

i7.33 Oligodendroglioma FISH; in a & b there is a red marker for 1p & a green marker for 1q a There is a normal 2 red, 2 green (2R2G) signal, indicative of retention of 1p b There is only 1 red signal (1R2G) indicating 1p deletion Likewise, in c & d red (19q) & green (19p) markers are used to assess the status of 19q, with c a normal result & d 19q deletion c e lls w ith ro u n d e d n u c le a r c o n to u rs a n d p e rin u c le a r h a lo s w ith in a b a c k g ro u n d o f a rb o riz in g “c h ic k e n w ir e ” c a p illa rie s , a s ig n ific a n t n u m b e r o f c a s e s h a v e b o rd e rlin e o r m ix e d fe a tu re s . F o rtu n a te ly , th e lo s s o f th e 1p a n d 19q a re v e ry s p e c ific fo r o lig o d e n d ro g lio m a i7.33. T h e fre q u e n c y 1 p /1 9q c o d e le tio n is up to 9 0 % in g ra d e II o lig o d e n d ro g lio m a s , 6 0 % in g ra d e III (a n a p la s tic ) o lig o d e n d ro g lio m a s , a n d up to 5 0 % in m ix e d o lig o a s tro c y to m a s . T h e p re s e n c e o f th e c o m b in e d lo s s o f 1 p /1 9 q is im p o rta n t, a s th e s e tu m o rs te n d to re s p o n d b e tte r to c h e m o th e ra p y (in c lu d in g te m a z o la m id e ) a n d h a ve a n o v e ra ll b e tte r p ro g n o s is th a n o lig o d e n d ro g lio m a s (and a s tro c y to m a s ) la c k in g th e s e g e n e tic a n o m a lie s . P C R b a s e d a s s a y s fo r m ic ro s a te llite re g io n s w ith in 1p a n d 19q o r lo c u s s p e c ific F IS H p ro b e s c a n b e u s e d to a s s e s s fo r lo s s o f h e te ro z y g o s ity . T h e M G M T (0 6 -m e th y lg u a n in e -D N A m e th y ltra n s fe ra s e ) g e n e , w h ic h is in v o lv e d in D N A re pa ir, p la y s an in te re s tin g ro le in g lio m a m a n a g e m e n t. In s o m e b u t n o t all g lio m a s , th e M G M T g e n e u n d e rg o e s e p ig e n e tic s ile n c in g th ro u g h p ro m o te r h y p e rm e th y la tio n . T h e s ta tu s o f th e M G M T g e n e p ro fo u n d ly im p a c ts c lin ic a l re s p o n s e to tre a tm e n t w ith te m o z o lo m id e a n d ra d io th e ra p y ; th a t is, an u n s u p p re s s e d M G M T g e n e c a n m itig a te th e D N A d a m a g in g e ffe c t o f c o m b in e d th e ra p y , th u s re s c u in g th e tu m o r c e lls fro m h a rm . T h e m e c h a n is m o f a c tio n o f te m o z o lo m id e , an a lk y la tin g a g e n t, is th e a d d itio n o f a m e th y l g ro u p to th e 0 6 p o s itio n o f n u c le o tid e g u a n in e re s id u e s , w h ic h re s u lts in D N A d a m a g e ; th e M G M T p ro te in is c a p a b le o f re p a irin g th is d a m a g e . In 2 0 0 6 , H e g i e t al re p o rte d th a t, in G B M p a tie n ts tre a te d w ith te m o z o lo m id e a n d X R T , 4 9 % o f th o s e w ith m e th y la te d M G M T w e re a liv e a t 2 y e a rs , c o m p a re d to 15% o f th o s e w ith

374

Oligodendrogliom a

w orse, with unclear significance of com bined loss of 1 p & 19q cases

E G F R = epiderm al growth factor receptor; F IS H = fluorescence in situ hybridiztion; G B M = glioblastom a m ultiform e; IH C = im m unohistochem istry; L 0 H = loss of heterozygosity; W H O = W orld H ealth O rganization

7.4.9.1.2 P ilo cytic a s tro c y to m a T h e B R A F g e n e , e n c o d in g th e M A P K p a th w a y p ro te in R A F, is in vo lve d in tu m o rig e n e s is th ro u g h o u t th e body. In m a n y tu m o rs , B R A F a c tiv a tio n a ris e s a s a re s u lt o f a p o in t m u ta tio n , m o s t c o m m o n ly th e B R A F V 6 0 0 E m u ta tio n . In p ilo c y tic a s tro c y to m a , B R A F m u ta tio n a p p e a rs to be th e so le in c itin g g e n e tic e ve n t. B o th B R A F p o in t m u ta tio n s a n d B R A F g e n e d u p lic a tio n have b ee n fo u n d . B R A F a n o m a lie s are fo u n d in up to 8 0 % o f p ilo c y tic a s tro c y to m a s , b u t a re ra re in d iffu s e a s tro c y to m a s .

7.4.9.2

Retinoblastoma

R e tin o b la s to m a is a ra re tu m o r c lo s e ly a s s o c ia te d w ith m u ta tio n s o f th e R B 1 g e n e on c h ro m o s o m e 13q14. > 9 0 % o f c a s e s o f re tin o b la s to m a a re s p o ra d ic ; th e re m a in d e r a re a s s o c ia te d w ith an in h e rite d d e fe c t in 1 c o p y o f th e R B 1 g en e . T h e p re s e n c e o f b ila te ra l re tin o b la s to m a s in a y o u n g p a tie n t s h o u ld ra is e s u s p ic io n o f an in h e rite d c a u s e . P a tie n ts w ith in h e rite d m u ta tio n s in R B 1 a re a t h ig h ris k fo r la te r d e v e lo p m e n t o f o s te o s a rc o m a , p in e a l g la n d tu m o rs , a n d P N E Ts.

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

7: Molecular Pathology

Genetics of neoplastic disease>Central nervous system tumors | Pulmonary tumors 7.4.9.3 Meningioma M o n o s o m y o f c h ro m o s o m e 2 2 is th e m o s t c o m m o n a b n o rm a lity fo u n d in m e n in g io m a s , a n d th is w a s 1 o f th e firs t c h ro m o s o m a l re a rra n g e m e n ts d e s c rib e d in s o lid tu m o rs . T h e key re g io n a p p e a rs to be 2 2 q 1 2 .2 w h e re th e N F 2 g e n e is lo c a te d . R e c a ll th a t m e n in g io m a is 1 o f th e fe a tu re s o f th e n e u ro fib ro m a to s is ty p e 2 (N F 2 ) s y n d ro m e (c a u s e d b y g e rm lin e N F 2 m u ta tio n s ). M e rlin is th e p ro te in e n c o d e d b y th e N F 2 g e n e . M e rlin is fo u n d in th e ce ll m e m b ra n e w h e re its fu n c tio n is to m e d ia te c e ll c e ll c o n ta c t a nd ce ll c o n ta c t in h ib itio n . T h e fre q u e n c y o f N F 2 a n o m a lie s v a rie s fro m 1 h is to lo g ic v a ria n t to th e next. N F 2 a b n o rm a litie s a re fo u n d in 8 0% o f tra n s itio n a l a nd fib ro b la s tic m e n in g io m a s , b u t o n ly 2 5% o f m e n in g o th e lia l m e n in g io m a s a nd v irtu a lly no s e c re to ry m e n in g io m a s . T h e o ve ra ll rate is -5 0 % . N F 2 a n o m a lie s a re an e a rly e v e n t in tu m o rig e n e s is a nd th a t a d d itio n a l m o le c u la r d e fe c ts u n d e rlie tu m o r p ro g re s s io n . H ig h e r g ra d e (a ty p ic a l & a n a p la s tic ) m e n in g io m a s a re fo u n d to have N F 2 a b n o rm a litie s a t ro u g h ly th e s a m e ra te as lo w g ra d e m e n in g io m a s , b u t have a d d itio n a l c o m p le x a n o m a lie s , in c lu d in g n u m e ro u s g e n e tic g a in s and lo sse s. T h e lo s s e s invo lve 1p, 9p, 14, a nd o th e rs , and th e g a in s in c lu d e 1q, 9q, and o th e rs . In fa c t, del 1p is th e s e c o n d m o s t c o m m o n c h ro m o s o m a l a b n o rm a lity fo u n d in m e n in g io m a s . D e le tio n o f 14 (m o n o s o m y 14) a n d /o r d e le tio n o f 9p21 have b ee n a s s o c ia te d w ith s h o rte n e d s u rviva l. P a rtic u la r h is to lo g ic s u b ty p e s a re th o u g h t to h ave a h ig h e r rate o f p ro g re s s io n , in c lu d in g c le a r ce ll, c h o rd o id , rh a b d o id , a nd p ap illary. W ith re g a rd to th e m o re a g g re s s iv e s u b typ e s , o n ly c h o rd o id m e n in g io m a so fa r a p p e a rs to h ave a m o le c u la r s ig n a tu re . A n u n b a la n c e d tra n s lo c a tio n — der(1) t(1;3)(p12-13;q11)— h as b ee n fo u n d in th is v a ria n t and p re lim in a rily p ro m is e s to b e a s p e c ific m arker.

7.4.9.4 Embryonal tumors E m b ry o n a l tu m o rs b e lo n g to a g ro u p d e fin e d by th e p re s e n c e o f u n d iffe re n tia te d a p p e a rin g s m a ll b lu e ce lls, w h ic h a c c o u n t fo r th e m a jo rity o f p rim a ry p e d ia tric brain tu m o rs . 3 o f th e e m b ry o n a l tu m o rs — m e d u llo b la s to m a , P N E T, and a ty p ic a l te ra to id /rh a b d o id tu m o r— have c h a ra c te ris tic m o le c u la r a lte ra tio n s . M e d u llo b la s to m a is a tu m o r o f th e p o s te rio r fo s s a a ffe c tin g th e c e re b e llu m w ith a te n d e n c y to m e ta s ta s iz e w ith in th e C N S . T h e re a re se ve ra l s u b ty p e s w ith v a ry in g h is to lo g ic a p p e a ra n c e s and p ro g n o s e s . C e rta in in h e rite d tu m o r p re d is p o s itio n c o n d itio n s a re a s s o c ia te d w ith a h ig h e r risk o f d e v e lo p in g m e d u llo b la s to m a , in c lu d in g T u rc o t s y n d ro m e s e c o n d a ry to m u ta tio n s in A P C , G o rlin sy n d ro m e , and L i-F ra u m e n i s y n d ro m e . In s p o ra d ic m e d u llo b la s to m a , © A S C P 2018

th e m o s t c o m m o n a b e rra tio n , s e e n in 1/2 o f tu m o rs , is is o c h ro m o s o m e 17q. T h e a lte ra tio n m o s t s tro n g ly a s s o c ia te d w ith p ro g n o s is is lo s s o f c h ro m o s o m e 17p, p re s e n t in 1/3 o f tu m o rs . L o s s o f 17p is a s s o c ia te d w ith m o re a g g re s s iv e tu m o r b eh a vio r, s h o rte n e d s u rv iv a l, a n d a re la tiv e ly p o o r re s p o n s e to c h e m o th e ra p y . A ty p ic a l te ra to id /rh a b d o id tu m o r (A T /R T ) is a p a rtic u la rly a g g re s s iv e p e d ia tric C N S tu m o r th a t u s u a lly a ffe c ts th e v e ry y o u n g (Pulmonary tumors | Gynecologic tumors o f re s p o n s e to E G F R -T K Is b u t a re u n lik e ly to re s p o n d to a n ti-E G F R m o n o c lo n a l a n tib o d ie s . E G F R s ta tu s by IH C a nd F IS H h a s n o t re lia b ly p re d ic te d re s p o n s e , a n d a t th is tim e m u ta tio n a n a ly s is b y P C R is re c o m m e n d e d . A s d is c u s s e d b e lo w , m u ta tio n s in th e g e n e s e n c o d in g d o w n s tre a m p ro te in s in th e E G F R s ig n a lin g c a s c a d e (K R A S , B R A F ) a re fo u n d e x c lu s iv e ly in tu m o rs th a t la c k E G F R m u ta tio n s . L astly, s o m e p a tie n ts d e v e lo p s e c o n d a ry re s is ta n c e to a n ti-E G F R th e ra p y , u s u a lly a s s o c ia te d w ith c e rta in a d d itio n a l m u ta tio n s in E G F R (T 7 9 0 M ) a s w e ll a s m u ta tio n s in o th e r g e n e s s u c h a s M E T. W h ile u n c o m m o n in lu n g c a n c e r o v e ra ll (2 % -5 % ), A L K re a rra n g e m e n ts h a v e b e e n d e s c rib e d in up to 2 0 % o f h ig h s ta g e tu m o rs . A L K w a s o rig in a lly id e n tifie d a s p a rt o f th e t(2 ;5 )(p 2 3 ;3 5 ) tra n s lo c a tio n in a n a p la s tic la rg e ce ll ly m p h o m a a n d s u b s e q u e n tly d e m o n s tra te d in in fla m m a to ry m y o fib ro b la s tic tu m o r. In lu n g c a n c e r, o n c o g e n ic A L K fu s io n is th e re s u lt o f an in te rs titia l in v e rs io n in th e s h o rt a rm o f c h ro m o s o m e 2, re s u ltin g in o v e re x p re s s io n a n d c o n s titu tiv e a c tiv a tio n . T h e E M L 4 -A L K tra n s lo c a tio n is th e m o s t c o m m o n fo rm . IH C c o rre la te s p o o rly w ith re s p o n s e to s m a ll m o le c u le A L K -T K Is , a n d F IS H is re c o m m e n d e d . K R A S m u ta tio n s c a n le a d to s ig n a lin g d o w n s tre a m in d e p e n d e n t o f E G F R . T h e re is a h ig h K R A S m u ta tio n ra te in lu n g a d e n o c a rc in o m a e s p e c ia lly m u c in o u s a d e n o c a rc in o m a , a n d K R A S m u ta tio n c o rre la te s n e g a tiv e ly w ith re s p o n s e to E G F R in h ib ito rs . K R A S its e lf h a s n o t b e e n s u c c e s s fu lly ta rg e te d , b u t in K R A S m u ta te d tu m o rs , th e re is b e n e fit fro m ta rg e tin g M E K , a d o w n s tre a m a c to r in th e a c tiv a tio n p a th w a y. PDL1 (p ro g ra m m e d d e a th lig a n d 1) is e x p re s s e d on th e s u rfa c e o f c e rta in tu m o r c e lls w h e re it h as th e e ffe c t, e s s e n tia lly , o f e v a d in g im m u n e d e te c tio n a n d im m u n e d e s tru c tio n . PD1 (p ro g ra m m e d d e a th 1) is e x p re s s e d on th e s u rfa c e o f c y to to x ic T c e lls ; w h e n PD1 in te ra c ts w ith PDL1, 2 th in g s h a p p e n . F irst, th e in te ra c tio n in h ib its T c e ll m e d ia te d im m u n e d e s tru c tio n . S e c o n d , th e in te ra c tio n b e g in s th e p ro c e s s o f a p o p to tic d e a th o f th e T ce ll. T h is in te ra c tio n is p a rt o f an im m u n e c h e c k p o in t m e c h a n is m th a t h a s b e e n ta rg e te d s u c c e s s fu lly th ro u g h th e u s e o f m o n o c lo n a l a n tib o d ie s in a v a rie ty o f tria ls . F u rth e rm o re , c u rre n t d a ta s h o w th a t o u tc o m e s in th is s c e n a rio a re g e n e ra lly b e tte r w h e n th e re is PDL1 e x p re s s io n b y IH C . H o w b e s t to te s t fo r PDL1 a n d w h a t c u to ffs to a p p ly re m a in s a m a tte r o f d e b a te , how eve r.

7.4.11 Gynecologic tumors 7.4.11.1 Inherited gynecologic tum or syndromes M o s t c a s e s o f in h e rite d p re d is p o s itio n to g y n e c o lo g ic tu m o rs a re d u e to g e rm lin e m u ta tio n s in m is m a tc h re p a ir p ro te in s (L y n c h s y n d ro m e ) o r m u ta tio n s in B R C A 1 /B R C A 2 (h e re d ita ry b re a s t a n d o v a ria n c a n c e r). PJS c a n p re s e n t w ith p a rtic u la r g y n e c o lo g ic m a n ife s ta tio n s , s u c h a s a d e n o m a m a lig n u m o f th e c e rv ix a n d o v a ria n SC TAT.

376

L ynch s y n d ro m e is c a u s e d by an in h e rite d g e rm lin e m u ta tio n in th e g e n e fo r o n e o f th e p ro te in s in v o lv e d in m is m a tc h re pa ir, m o s t c o m m o n ly M LFI1, M S H 2 , o r M S FI6. W o m e n w ith Lynch s y n d ro m e h ave a n e a rly 5 0 % life tim e ris k o f e n d o m e tria l c a n c e r (o fte n o f th e lo w e r u te rin e s e g m e n t) a n d a 10% ris k o f an e p ith e lia l o v a ria n ca n c e r. T h e risk fo r e n d o m e tria l c a n c e r in Lynch s y n d ro m e is e q u iv a le n t to th e risk fo r c o lo re c ta l c a rc in o m a . O v a ria n c a n c e r in Lynch s y n d ro m e te n d s to p re s e n t a t an e a rly a ge , u s u a lly b e fo re 50, and is o fte n o f th e c le a r ce ll ty p e . W h ile m o s t s c re e n in g g u id e lin e s (B e th e s d a , A m s te rd a m ) a re fo c u s e d m o re on c o lo re c ta l c a rc in o m a , th e re a re a ls o g u id e lin e s p ro p o s e d by S o c ie ty o f G y n e c o lo g ic O n c o lo g is ts th a t a d d re s s s c re e n in g fo r an in c re a s e d risk o f e n d o m e tria l a n d o v a ria n c a rc in o m a . S im ila r to c o lo re c ta l c a rc in o m a it h as b e e n p ro p o s e d th a t u n iv e rs a l s c re e n in g o f all e n d o m e tria l c a rc in o m a s fo r d e fe c ts in m is m a tc h re p a ir be p e rfo rm e d . H e re d ita ry b re a s t/o v a ria n c a n c e r is c a u s e d by m u ta tio n s in th e tu m o r s u p p re s s o r g e n e s B R C A 1 o r B R C A 2 . It is e s tim a te d th a t a p a tie n t w ith B R C A m u ta tio n s h as a 10 fo ld in c re a s e d ris k o f d e v e lo p in g an e p ith e lia l o v a ria n c a rc in o m a , a n d -1 0 % o f o v a ria n c a n c e rs a re c a u s e d by u n d e rly in g B R C A m u ta tio n s . T h e m a jo rity o f h ig h g ra d e s e ro u s o va ria n c a rc in o m a s d u e to m u ta tio n s in B R C A a ls o h a rb o r m u ta tio n s in P 5 3. T h e s e h ig h g ra d e o r ty p e II s e ro u s c a rc in o m a s a re d iffe re n t fro m lo w g ra d e o r ty p e I s e ro u s c a rc in o m a in b e h a vio r, a p p e a ra n c e , a nd u n d e rly in g m u ta tio n s . Type I tu m o rs a re le s s like ly to be a s s o c ia te d w ith m u ta tio n s in B R C A , in s te a d h a rb o rin g m u ta tio n s in K R A S o r B R A F . R e ce n tly, it h a s b e c o m e c le a r th a t th e s e h ig h g ra d e tu m o rs in B R C A p a tie n ts a ris e fro m a p re c u rs o r le s io n in th e F a llo pia n tu b e , s e ro u s tu b a l in tra e p ith e lia l c a rc in o m a (S TIC ). S T IC le s io n s o fte n p re d a te high g ra d e s e ro u s tu m o rs a nd have s im ila r m u ta tio n s in P 53. P ro p h y la c tic b ila te ra l s a lp in g o o o p h o re c to m y is re p o rte d to re d u c e th e ris k o f d e v e lo p in g p e lv ic c a n c e r by a s m u c h as 9 0 % .

7.4.11.2 Cervix In th e U nited S ta te s, th e in c id e n c e o f in v a s iv e c e rv ic a l c a n c e r is re la tiv e ly lo w d u e to th e s u c c e s s o f P ap s c re e n in g . S till, in s o m e c o u n trie s o f s o u th e rn A s ia , C e n tra l A m e ric a , a nd s u b S a h a ra n A fric a , c e rv ic a l c a n c e r is still fo r w o m e n th e m o s t c o m m o n c a u s e o f d e a th fro m ca n c e r. T h e m o s t c o m m o n c a u s e o f c e rv ic a l c a rc in o m a is H P V in fe c tio n . H P V is a d o u b le stra n d e d D N A v iru s w ith m a n y d iffe re n t s e ro lo g ic s u b ty p e s . T h e s e s u b ty p e s a re g ro u p e d a c c o rd in g to th e ir ris k fo r d e v e lo p in g s q u a m o u s c a rc in o m a . T h e H P V ty p e s th a t a re c o n s id e re d c a rc in o g e n ic a re re fe rre d to as h ig h risk H P V (H R H P V ) and in c lu d e H P V 1 6 , 18, 31, 33, 35, 39, 4 5, 51, 52, 56, 58, 59, 68, 73, a nd 82. O th e rs , su ch a s 6 a n d 11, a re e x tre m e ly c o m m o n c a u s e s o f h u m a n in fe c tio n but d o n o t p o se a g re a t c a n c e r risk. T h e lik e lih o o d o f m a lig n a n t tra n s fo rm a tio n a p p e a rs to re la te to 2 v a ria b le s : (1) th e e a se

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

7: Molecular Pathology

Genetics of neoplastic disease>Gynecologic tumors | Other tumor syndromes w ith w h ic h th e v ira l g e n o m e b e c o m e s in te g ra te d into th e h o s t g e n o m e , a nd (2) th e p a rtic u la r g e n e s e q u e n c e (a llele s) o f th e v ira l E6 a nd E 7 g e n e s. T h a t is, H P V in fe c tio n s th a t re su lt in b e n ig n p ro c e s s e s a re u s u a lly a s s o c ia te d w ith an e p is o m a l vira l D N A , w h e re a s H P V in fe c tio n s th a t re su lt in m a lig n a n c y a re u s u a lly a s s o c ia te d w ith in te g ra tio n o f th e v ira l D N A into th e h o s t g e n o m e . In te g ra tio n re su lts in u n c h e ck e d tra n s c rip tio n o f 2 v ira l g e n e s in p a rticu la r, E6 a nd E7, th a t trig g e r m a lig n a n t tra n s fo rm a tio n . T h e E 6 and £ 7 g e n e p ro d u c ts a c t th ro u g h se vera l m e c h a n is m s , im p o rta n t a m o n g th e m b e in g th e in h ib itio n o f th e re tin o b la s to m a (R b) a nd p 5 3 tu m o r s u p p re s s o r p rote ins. T h e E6 p ro te in is k n o w n to b in d to th e p 5 3 p ro te in , le a d in g to its s u b s e q u e n t d e g ra d a tio n th ro u g h th e u b iq u itin p athw ay. T h e E7 p rote in in te ra c ts w ith th e R b -E 2 F co m p le x , b lo c k in g R b in h ib itio n . U n in h ib ite d , E 2 F ca n fu n c tio n as a tra n s c rip tio n a l a c tiv a to r o f th e g e n e s in vo lve d in ce ll c y c le p ro g re s s io n . T h is b ip h a s ic a tta c k on th e re g u la to ry a p p a ra tu s o f th e cell le a d s to u n re g u la te d cell d ivisio n . V a rio u s s e ro ty p e s d iffe r in th e e ffe c tiv e n e s s o f th e ir re s p e c tiv e E6 a nd E7 p ro te in s to a b ro g a te c e llu la r re g u la to ry m a c h in e ry . A s u rro g a te m a rk e r o f u n re g u la te d cell c y c le p ro g re s s io n , p16, ca n be used to d e te c t c e lls th a t m ay be in fe cte d w ith H R H P V su b typ e s . T h e a p p ro a c h m o s t w id e ly a d v o c a te d fo r H P V s c re e n in g is c e rv ic a l c y to lo g y. W h e n a c y to lo g ic d ia g n o s is o f e ith e r low o r high g ra d e s q u a m o u s in tra e p ith e lia l le s io n is re n d e re d , c o lp o s c o p y is in d ica te d . W h e n a c y to lo g ic d ia g n o s is o f a ty p ic a l s q u a m o u s c e lls is re n d e re d , m o le c u la r te s tin g fo r th e p re s e n c e o f H R H P V is in d ica te d , fo llo w e d by c o lp o s c o p y a nd b io p s y if th is is p o sitive . In all 3 in s ta n c e s , th e p u rp o s e o f c o lp o s c o p y is to e x c lu d e a high g ra d e lesion . S e ve ra l a s s a y s a re c u rre n tly a v a ila b le fo r th e m o le c u la r d e te c tio n o f H P V in c e rv ic a l s a m p le s , m o s t o f w h ic h a re p e rfo rm e d on th e s a m e liquid b a se d c o lle c tio n s y s te m u sed to p re p a re th e s lid e fo r c y to lo g ic s c re e n in g . T h e m o s t c o m m o n a s s a y is a s o lu tio n p h a se h y b rid iz a tio n u sin g la b e le d R N A p ro b e s. S u c c e s s fu l h y b rid iz a tio n o f th e p ro b e s (w ith a ny vira l D N A p re s e n t in th e s a m p le ) is d e te c te d by e n z y m a tic re a ctio n . T h is a s s a y m ay be u sed to d e te c t H R H P V s p e c ific a lly , o r it m a y be used to d e te c t lo w ris k H PV. S u ch a s s a y s h ave m uch h ig h e r s e n s itiv ity th a n c y to lo g y , b u t th e y a re p o s itiv e in a la rg e n u m b e r o f w o m e n w ith no le s io n (lo w s p e c ific ity ); h e n c e th e re c o m m e n d a tio n fo r te s tin g o n ly in th e p re s e n c e o f an a ty p ic a l c yto lo g y.

7.4.11.3 Gestational trophoblastic disease P a rtia l m o le s a re m o s t c o m m o n ly d e riv e d fro m th e fe rtiliz a tio n o f an e gg by 2 s p e rm . P a rtia l m o le is trip lo id (u su a lly 69, X X Y ) a nd m ay be fo u n d in a s s o c ia tio n w ith a trip lo id fe tu s. C o m p le te m o le s a re d e riv e d fro m th e fe rtiliz a tio n o f a b lig h te d o v u m (w ith o u t g e n e tic m ateria l), e ith e r by a s in g le s p e rm fo llo w e d by d u p lic a tio n o f g e n e tic m a te ria l o r by 2 s p e rm . C o m p le te m o le s a re d ip lo id , © A S C P 2018

i7.34 Lymphangiomyomatosis of lung

b u t c o m p o s e d e n tire ly o f p a te rn a l g e n e tic in fo rm a tio n . H is to ric a lly , m o rp h o lo g y a nd p lo id y a n a ly s is h a s b e e n u sed to d is tin g u is h b e tw e e n th e c o m p le te a n d p a rtia l m o le . C h ro m o s o m a l e n u m e ra tio n can d is tin g u is h p a rtia l m o le s fro m h y d ro p ic a b o rtu s e s . H ow ever, h y d ro p ic p ro d u c ts o f c o n c e p tio n ca n re s e m b le c o m p le te m o la r p re g n a n c ie s , a n d b oth a re d ip lo id . IH C s ta in s fo r a p a te rn a lly im p rin te d g e n e , P 5 7 h a ve s h o w n p ro m is e a s a w a y o f d is tin g u is h in g c o m p le te m o la r p re g n a n c ie s . C o m p le te m o le s s h o w no s ta in in g fo r P57, w h ile th e n u c le i o f in te rm e d ia te tro p h o b la s tic c e lls w ill s ta in in a p a rtia l m o le o r h y d ro p ic p re g n a n c y . In a d d itio n , s h o rt ta n d e m re p e a t (S T R ) a n a lys is o f p o te n tia l m o la r p re g n a n c ie s h as b e e n u se d fo r c la s s ific a tio n p u rp o s e s . B y c o m p a rin g th e S T R h a p lo ty p e o f th e p re s u m e d m o la r p re g n a n c y to m a te rn a l tis s u e o r b lo o d , o n e ca n d e te rm in e th e o rig in o f th e g e n e tic m a te ria l in th e p ro d u c ts o f c o n c e p tio n . If a d ip lo id c o n c e p tu s h as e v id e n c e o f m a te rn a l S T R s, o n e c a n e x c lu d e a c o m p le te m ole.

7.4.12 Other tumor syndromes 7.4.12.1 Tuberous sclerosis complex (Bourneville syndrome) N a m e d fo r 2 c a rd in a l fe a tu re s , tu b e rlik e le s io n s o f th e c e re b ra l c o rte x a nd p e riv e n tric u la r s c le ro s is w ith c a lc ific a tio n , tu b e ro u s s c le ro s is p re s e n ts w ith a m y ria d o f fin d in g s . T h e T u b e ro u s S c le ro s is A llia n c e h a s p ro p o s e d c rite ria fo r th e c lin ic a l d ia g n o s is o f tu b e ro u s s c le ro s is . T h e m a jo r c rite ria in c lu d e fa cial a n g io fib ro m a (“a d e n o m a s e b a c e u m ” ), s u b u n g u a l o r p e riu n g u a l fib ro m a (“ K o e n e n tu m o r” ), >3 h y p o m e la n o tic m a c u le s (“a s h le a f s p o ts ” ), c o n n e c tiv e tis s u e n e v u s (“ S h a g re e n p a tc h ” ), re tin a l h a m a rto m a s , c e re b ra l c o rtic a l tu b e r, s u b e p e n d y m a l n o d u le , s u b e p e n d y m a l g ia n t c e ll a s tro c y to m a , c a rd ia c rh a b d o m y o m a s , ly m p h a n g io le io m y o m a to s is (L A M ) i7.34, a nd re n a l a n g io m y o lip o m a . M in o r c rite ria in c lu d e d e n ta l e n a m e l pits, h a m a rto m a to u s re cta l p olyp s, b o n e c y s ts , c e re b ra l w h ite m a tte r ra dial m ig ra tio n lines, g in g iv a l fib ro m a s , n o n re n a l h a m a rto m a s , re tin a l a c h ro m ic p a tch , c u ta n e o u s s y m m e tric h y p o p ig m e n te d m a c u le s , and m u ltip le re n a l c y s ts . A s is e v id e n t fro m th e listed c rite ria , tu b e ro u s s c le ro s is is a m u ltis y s te m d is o rd e r w ith a p re d ile c tio n to d e v e lo p m e n t o f

ISBN 9 7 8 -0 8 9 1 8 9 -6 6 7 8

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7: Molecular Pathology

Genetics of neoplastic disease>Other tumor syndromes m o s tly b e n ig n tu m o rs . T h e re is, h o w e v e r, an in c re a s e d ris k o f m a lig n a n t re n a l n e o p la s m s , in c lu d in g c le a r c e ll R C C . T u b e ro u s s c le ro s is c o m p le x is c a u s e d b y a u to s o m a l d o m in a n t in h e rita n c e o r s p o ra d ic m u ta tio n in 1 o f 2 g e n e s . M o s t (8 0% ) c a s e s a re d u e to m u ta tio n s in th e TS C 1 g e n e , lo c a te d on c h ro m o s o m e 9 q 3 4 , w h ic h e n c o d e s th e p ro te in h a m a rtin . T h e re m a in in g c a s e s a re d u e to m u ta tio n s in th e T S C 2 g e n e , lo c a te d o n c h ro m o s o m e 16p13, w h ic h e n c o d e s th e p ro te in tu b e rin . - 6 0 % o f tu b e ro u s s c le ro s is c o m p le x c a s e s a ris e s p o ra d ic a lly , re fle c tin g th e h ig h ra te o f d e n o v o m u ta tio n s .

7.4.12.2 Nevoid basal cell carcinoma syndrome (Gorlin Goltz syndrome) N e v o id b a s a l c e ll c a rc in o m a s y n d ro m e , a s firs t d e s c rib e d by G o rlin a n d G o ltz , is c h a ra c te riz e d p rim a rily b y o d o n to g e n ic k e ra to c y s ts , m u ltip le b a s a l c e ll c a rc in o m a s , a n d b ifid ribs. A d d itio n a l a n a to m ic fin d in g s m a y in c lu d e c a lc ific a tio n o f th e fa lx c e re b ri, p a lm o p la n ta r p its , a n d fro n ta l b o s s in g w ith c o a rs e fa c ie s . T h e tu m o r p re d is p o s itio n a ls o in c lu d e s a h ig h ra te o f m e d u llo b la s to m a , rh a b d o m y o s a rc o m a , and m e n in g io m a . In a la rg e s tu d y o f a ffe c te d in d iv id u a ls , fe a tu re s p re s e n t in > 1 /2 o f p a tie n ts in c lu d e d p a lm a r p its , o d o n to g e n ic k e ra to c y s ts , b a s a l c e ll c a rc in o m a s , a n d c a lc ific a tio n o f th e fa lx c e re b ri. A n o m a lie s in th e P T C H 1 g e n e on c h ro m o s o m e 9 q 2 2 .3 u n d e rlie n e a rly all c a s e s o f G o rlin -G o ltz s y n d ro m e . M u ta tio n s in th e P T C H 1 g e n e a re in h e rite d in a n a u to s o m a l d o m in a n t m a n n e r; p e n e tra n c e a p p ro a c h e s 1 0 0 % , b u t e x p re s s io n is v a ria b le .

7.4.12.3 Neurofibromatosis type 1 (von Recklinghausen disease) NF1 is c a u s e d b y m u ta tio n s in th e N F 1 g e n e e n c o d in g n e u ro fib ro m in o n c h ro m o s o m e 17q 11.2. N e u ro fib ro m a to s is is in h e rite d in an a u to s o m a l d o m in a n t fa s h io n , a lth o u g h 1/2 o f c a s e s a re s p o ra d ic . It is m o s t o fte n d ia g n o s e d b y a c o n s te lla tio n o f c lin ic a l fe a tu re s . T h e s e fe a tu re s , c o d ifie d in an N a tio n a l In s titu te s o f H e a lth c o n s e n s u s s ta te m e n t in 1 9 8 8 , in c lu d e th e p re s e n c e o f > 6 c a fe au la it s p o ts , >2 n e u ro fib ro m a s o r a n y s in g le p le x ifo rm n e u ro fib ro m a , g ro in / a x illa fre c k lin g (C ro w e sign ), > 2 o c u la r L is c h n o d u le s , o n e o f th e d is tin c tiv e b o n y le s io n s (eg, d y s p la s ia o f th e s p h e n o id w in g ), a n d a firs t d e g re e a ffe c te d re la tiv e . In c h ild h o o d , NF1 in itia lly p re s e n ts w ith m u ltip le c a fe au la it s p o ts a n d in te rtrig in o u s (g ro in , a x illa ) fre c k lin g . N e u ro fib ro m a s ty p ic a lly b e g in to e m e rg e in a d o le s c e n c e o r e a rly a d u lth o o d (d ia g n o s is is o fte n d e la y e d in to th e s e c o n d d e c a d e a s a re su lt). M a n y w o m e n w ith NF1 e x p e rie n c e a ra p id in c re a s e in th e n u m b e r a n d s iz e o f n e u ro fib ro m a s d u rin g p re g n a n c y . O c u la r L is c h n o d u le s a re fa irly c o m m o n b u t in n o c u o u s . In c o n s is te n t fe a tu re s in c lu d e v e rte b ra l d y s p la s ia , s p h e n o id w in g d y s p la s ia , s c o lio s is , b o n e c o rtic a l th in n in g , p s e u d a rth ro s is , m e n ta l re ta rd a tio n , p u lm o n ic

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s te n o s is , a nd NF1 v a s c u lo p a th y . T h e la tte r m o s t o fte n m a n ife s ts a s re n a l a rte ry s te n o s is (a rte ria l d ysp la sia ), w ith a s s o c ia te d h y p e rte n s io n . A n a p p e a ra n c e re s e m b lin g N o o n a n s y n d ro m e is s e e n in -1 2 % o f in d iv id u a ls w ith NF1. NF1 re su lts in a p re d is p o s itio n to w a rd c e rta in tu m o rs , in c lu d in g m a lig n a n t p e rip h e ra l n e rv e s h e a th tu m o r (M P N S T ), o p tic g lio m a , le u k e m ia , m e d u llo b la s to m a , p h e o c h ro m o c y to m a , a m p u lla ry a d e n o c a rc in o m a o f th e sm a ll in te stin e , a nd b re a s t ca n c e r. T h e life tim e ris k fo r M P N S T is 10% . O p tic g lio m a s n e a rly a lw a y s ta k e th e fo rm o f p ilo c y tic a s tro c y to m a s a nd m a y c a u s e v is u a l loss.

7.4.12.4 Neurofibromatosis type 2 (bilateral acoustic neuroma syndrome) M u ta tio n s in th e N F 2 g e n e on c h ro m o s o m e 2 2q , w h ic h e n c o d e s th e p ro te in m e rlin , is th e c a u s e o f N F 2. U p to 1/3 o f N F 2 c a s e s a re s p o ra d ic (sim p le x) c a s e s . M u ch a b o u t th e n o m e n c la tu re o f th is s y n d ro m e is c o n fu s in g . N F 2 is c h a ra c te riz e d by b ila te ra l v e s tib u la r n e rv e (not a c o u s tic n e rv e ) s c h w a n n o m a s (n e ith e r n e u ro fib ro m a s n o r n e u ro m a s o c c u r), a n d it h a s a lm o s t no re la tio n s h ip to NF1. T h e d is e a s e firs t m a n ife s ts a ro u n d a g e 20, a n d n e a rly all a ffe c te d in d iv id u a ls h ave b ila te ra l v e s tib u la r s c h w a n n o m a s by a g e 30. S c h w a n n o m a s m a y a ris e in a s s o c ia tio n w ith o th e r n e rv e s a s w e ll, a nd th e re is an in c re a s e d te n d e n c y to d e v e lo p m e n in g io m a s , e p e n d y m o m a s , a n d p ilo c y tic a s tro c y to m a s .

7.4.12.5 Li-Fraumeni syndrome M u ta tio n s in th e tu m o r s u p p re s s o r g e n e T P 5 3 (p 5 3 ) a re fo u n d in - 5 0 % o f m a lig n a n c ie s , re g a rd le s s o f ty p e , and a re th e m o s t c o m m o n g e n e tic a n o m a ly fo u n d in m a lig n a n t tu m o rs . A n in h e rite d (g e rm lin e ) m u ta tio n in T P 5 3 c a u s e s L i-F ra u m e n i s y n d ro m e ; a s m ig h t be p re d ic te d , L i-F ra u m e n i is a s s o c ia te d w ith a te n d e n c y to d e v e lo p n u m e ro u s w id e s p re a d m a lig n a n c ie s , E a rly re p o rts fo c u s e d o n th e a s s o c ia tio n o f L i-F ra u m e n i s y n d ro m e w ith o s te o s a rc o m a , s o ft tis s u e s a rc o m a , b re a s t c a n c e r, a d re n a l c o rtic a l c a rc in o m a , and a c u te le u k e m ia . It s e e m s n ow th a t th e v a rie ty o f tu m o rs h as no lim it, w ith w ell d o c u m e n te d in c re a s e d ris k fo r g a s tric a d e n o c a rc in o m a , c o lo re c ta l c a rc in o m a , p a n c re a tic c a rc in o m a , e s o p h a g e a l c a rc in o m a , g e rm c e ll tu m o rs , m e la n o m a , W ilm s tu m or, and m a lig n a n c y o f th e C N S . P e rh a p s th e o n ly c h a ra c te ris tic fe a tu re s o f L i-F ra u m e n i a re (1) th a t a n y g ive n tu m o r ty p e a ris e s a t a y o u n g e r a g e th a n w o u ld be e x p e c te d fo r a s p o ra d ic tu m o r o f th e s a m e ty p e , a nd (2) th a t m u ltip le d is p a ra te tu m o rs m a y a ris e in th e s a m e p e rs o n . - 4 0 % o f th o s e w ith L i-F ra u m e n i h ave d e v e lo p e d a m a lig n a n c y by a g e 20, 6 0% by a g e 40, a nd 9 0 % by a g e 60. E s p e c ia lly c o n c e rn in g fo r L i-F ra u m e n i is th e a p p e a ra n c e o f a d re n o c o rtic a l c a rc in o m a in a c h ild o r y o u n g a dult; >1/2 o f s u c h c a s e s a re a s s o c ia te d w ith L i-F ra u m e n i sy n d ro m e .

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

7: Molecular Pathology

Genetics of neoplastic disease>Other tumor syndromes - 8 5 % o f c a s e s a re d u e to T P 5 3 m u ta tio n s (c h ro m o s o m e 17p); m u ta tio n s in th e C H E K 2 g e n e (w h o s e p ro d u c t is 1 o f th e in tra c e llu la r ta rg e ts o f p 5 3 ) h a s b e e n id e n tifie d in a m in o rity o f ca s e s . W h ile th e re a re a v a rie ty o f T P 5 3 m u ta tio n s , m o s t a ris e b e tw e e n e x o n s 4 th ro u g h 9 (or a m in o a c id s 91 th ro u g h 3 09 ). T h is p e rm its g o o d (95% ) s e n s itiv ity fo r s e q u e n c in g a n a ly s e s c o n fin e d to th is p o rtio n o f th e g en e . IH C ca n be p e rfo rm e d fo r p 5 3 e x p re s s io n . M o s t m u ta te d fo rm s o f p 53 , th o u g h n o n fu n c tio n a l a s tu m o r s u p p re s s o r p ro te in s , have a p ro lo n g e d h a lf-life w ith in th e ce ll (the m u ta te d fo rm s a re a b le to a void p ro te in d e g ra d a tio n ). T h u s, tu m o rs w ith T P 5 3 m u ta tio n s (and d e c re a s e d p 5 3 a c tiv ity ) h ave o v e re x p re s s io n o f p53.

7.4.12.6 Aniridia/WAGR syndrome A n irid ia m ay be a s p o ra d ic o r in h e rite d tra it, u s u a lly o c c u rrin g a s an is o la te d fin d in g ; how ever, in s o m e it o c c u rs a s p a rt o f a M e n d e lia n s y n d ro m e th a t in c lu d e s W ilm s tu m o r, a n irid ia , g e n ito u rin a ry a n o m a lie s , a nd m e n ta l re ta rd a tio n (W A G R sy n d ro m e ). T h e W A G R s y n d ro m e is a c o n tig u o u s g e n e s y n d ro m e in w h ic h a m ic ro d e le tio n s p a n n in g 11 p13 a ffe c ts se ve ra l g e n e s . In ~ 2 0 % -3 0 % o f c a s e s , th e d e le tio n is d e te c ta b le by high re so lu tio n c h ro m o s o m e s tu d ie s . FISH s tu d ie s , u tilizin g se ve ra l p ro b e s th a t s p a n th e a ffe c te d band, ca n a ls o b e d ia g n o s tic a lly u seful.

7.4.12.7 Beckwith-Wiedemann syndrome B e c k w ith -W ie d e m a n n s y n d ro m e ca n be c a u s e d by a ny 1 o f se ve ra l d e fe c ts, th e c o m m o n th re a d b e in g a b n o rm a l tra n s c rip tio n o f g e n e s w ith in th e 11p15.5 band. 11 p n o rm a lly is an im p rin te d d o m a in (e xp re s sio n d e p e n d s on w h e th e r in h e rite d fro m th e m o th e r o r fro m th e fa th e r), o n e in w h ic h m a te rn a lly d e riv e d a lle le s a re p re fe re n tia lly e x p re s s e d . S e ve ra l g e n e s a re lo c a te d w ith in 11 p, in c lu d in g (1) K C N Q 1, e n c o d in g a p o ta s s iu m ch a n n e l, a nd th e s a m e g e n e im p lic a te d in R o m a n o -W a rd and J e rv e ll L a n g e -N ie ls e n s y n d ro m e s , (2) IG F 2, e n c o d in g an in s u lin lik e g ro w th fa cto r, (3) H19, e n c o d in g a n o n tra n s la te d m R N A , a nd (4) C D K N 1 C , e n c o d in g a cyclin d e p e n d e n t k in a s e inhibitor. E m b ry o n a l tu m o rs (W ilm s tu m o r and h e p a to b la s to m a , in p a rtic u la r) o c c u r w ith a high rate in B e c k w ith -W ie d e m a n n sy n d ro m e . T h e s y n d ro m e m ay b e c o m e a p p a re n t in utero, w ith a fe tu s th a t is la rg e fo r g e s ta tio n a l a g e a nd has p o ly h y d ra m n io s . A t b irth , th e p la c e n ta is larg e, and th e u m b ilic a l c o rd is a b n o rm a lly long. A d d itio n a l fe a tu re s th a t m ay be id e n tifie d a t b irth in c lu d e m a c ro s o m ia , m a c ro g lo s s ia , h e m ih y p e rtro p h y (a s y m m e tric g ro w th ), o m p h a lo c e le (e xo m p ha lo s), a nd a n te rio r e a r c re a s e s o r pits. A p e c u lia r a d re n o c o rtic a l c y to m e g a ly has b e e n d e s c rib e d in p a tie n ts w ith B e c k w ith -W ie d e m a n n , a nd re na l a n o m a lie s (renal m e d u lla ry d y s p la s ia , n e p h ro c a lc in o s is , m e d u lla ry s p o n g e kidney, and n e p h ro m e g a ly ) are v e ry c o m m o n . © A S C P 2018

- 8 0 % o f c a s e s a re in h e rite d , a n d th e re m a in in g a re s p o ra d ic (s im p le x ) c a s e s . B e c k w ith -W ie d e m a n n is p rim a rily a c lin ic a l d ia g n o s is . T h e m o le c u la r d ia g n o s is is p ro b le m a tic , a s no s in g le fin d in g d e fin e s it. C o n v e n tio n a l c y to g e n e tic s ca n id e n tify a n a n o m a ly a t 11 p15 in o n ly -1 % o f c a s e s . F IS H ca n id e n tify a n o th e r 1% -2 % . M e th y la tio n a s s a y s a re c a p a b le o f fin d in g a b n o rm a litie s in >1/2 o f p a tie n ts (e ith e r g a in o r lo s s o f m e th y la tio n ). U n ip a re n ta l d is o m y s tu d ie s c a n id e n tify a b n o rm a litie s in -1 5 % o f ca s e s . L astly, a s in g le g e n e d e fe c t in C D K N 1 C a p p e a rs to u n d e rlie - 1 0 % o f s im p le x c a s e s a n d up to 4 0 % o f fa m ilia l ca s e s .

7.4.12.8 Chromosomal breakage syndromes A m o n g th is g ro u p o f d is o rd e rs , w h ic h a re u s u a lly tra n s m itte d in an a u to s o m a l re c e s s iv e fa s h io n , th e u n ify in g fe a tu re is a te n d e n c y in c e ll c u ltu re to e x h ib it e le v a te d ra te s o f c h ro m o s o m a l b re a k a g e o r in s ta b ility. U n d e rly in g th is te n d e n c y a re d e fe c ts in D N A re p a ir m e c h a n is m s , a n d th e c lin ic a l e ffe c t is a p re d is p o s itio n to c a n c e r. C h ro m o s o m a l b re a k a g e d is o rd e rs a re n u m e ro u s a n d in c lu d e B lo o m s y n d ro m e , a ta x ia te la n g ie c ta s ia , N ijm e g e n s y n d ro m e , F a n c o n i s y n d ro m e , and x e ro d e rm a p ig m e n to s a . T h is g ro u p o f d is o rd e rs s h o u ld be c o n c e p tu a lly d is tin g u is h e d fro m th e trin u c le o tid e re p e a t d is o rd e rs a s s o c ia te d w ith th e p re s e n c e o f “fra g ile s ite s ” th a t d o n ot c a u s e a c a n c e r p re d is p o s itio n . X e ro d e rm a p ig m e n to s a (X P ) is c h a ra c te riz e d b y a 1 0 0 0 fo ld in c re a s e d ris k o f c u ta n e o u s m a lig n a n c y , in c lu d in g b a s a l ce ll c a rc in o m a , S C C , a n d m e la n o m a , re s u ltin g fro m e x tre m e s e n s itiv ity to u ltra v io le t (U V ) light. F re c k lin g b e g in s b y a g e 2 y e a rs , a nd a c u ta n e o u s tu m o r ty p ic a lly a ris e s b y a g e 20. X P is c a u s e d b y a u to s o m a l re c e s s iv e in h e rita n c e o f a m u ta tio n in 1 o f th e g e n e s o f th e n u c le o tid e e x c is io n re p a ir c o m p le m e n ta tio n g ro u p s , in c lu d in g X P A th ro u g h X P G , w h o s e fu n c tio n is to re p a ir U V in d u ce d D N A d a m a g e . S o m e fo rm s o f X P a re a s s o c ia te d w ith n e u ro lo g ic d e fic its a n d o th e rs w ith o c u la r m a n ife s ta tio n s . A ffe c te d p a tie n ts m u s t a s s id u o u s ly a void U V lig h t e x p o s u re .

7.4.12.9 PTEN related disorders: Cowden syndrome, Bannayan-Riley-Ruvalcaba syndrome & Proteus syndrome T h is fa m ily o f d is o rd e rs is a s s o c ia te d w ith m u ta tio n s in th e g e n e P T E N o n 1 0q 2 3. P T E N , w h ic h s ta n d s fo r p h o s p h a ta s e a nd te n s in h o m o lo g , e n c o d e s a p h o s p h a tid y lin o s ito l 3 ,4 ,5 -tris p h o s p h a te 3 -p h o s p h a ta s e n e g a tiv e ly re g u la tin g a key c o m p o u n d in th e A K T s ig n a lin g p a th w a y . A ll th e P T E N re la te d d is o rd e rs d e m o n s tra te a te n d e n c y to fo rm h a m a rto m a to u s tu m o rs . In C o w d e n s y n d ro m e , th e s e are m o s t c o m m o n ly h a m a rto m a to u s in te s tin a l polyps. In a d d itio n th e re ca n b e m u ltip le lip o m a s a nd fib ro m a s , m a lfo rm a tio n s o f th e g e n ito u rin a ry tra ct, a nd m u c o c u ta n e o u s le s io n s s u c h as fa c ia l tric h ile m m o m a s , p a p illo m a s , p a lm o p la n ta r k e ra to s e s ,

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a n d c o n ju n c tiv a l m u c o s a ), v a g in a , a nd p en is. B lu e nevi a re c o m m o n , p a rtic u la rly th e c e llu la r b lu e n evu s. C a rd ia c m y x o m a s o c c u r fre q u e n tly , a t a y o u n g age, a nd m ay a ffe c t a n y ch a m b e r. In a d d itio n to th e p re v io u s ly m e n tio n e d fe a tu re s , th e re m a y a ls o be m y x o m a s o f th e b re a s t, fe m a le g e n ita l tra ct, a n d skin , a s w e ll a s e n d o c rin e tu m o rs su ch as fo llic u la r a d e n o m a s o f th e th y ro id g la n d , p itu ita ry a d e n o m a s , a n d p rim a ry p ig m e n te d n o d u la r a d re n o c o rtic a l d ise a se , w h ic h p re s e n ts a s C u s h in g d is e a s e . L a rg e ce ll c a lc ify in g S e rto li cell tu m o rs a ris e in m o s t a ffe c te d m en . N o te th a t th is u n u s u a l tu m o r is a ls o s e e n in PJS; h ow eve r, th e S C T A T o f PJS is not se e n in fe m a le p a tie n ts w ith C a rn e y c o m p le x . P s a m m o m a to u s m e la n o tic s c h w a n n o m a , ra re as a s p o ra d ic tu m o r, is c o m m o n in th e C a rn e y c o m p le x . N e a rly 1/2 th e c a s e s o f C a rn e y c o m p le x a re d u e to m u ta tio n s in th e P R K A R 1 A g e n e on 17q24. N o o th e r g e n e s have ye t to be im p lic a te d in th e re m a in in g c a s e s . N o te th a t th e s im ila rly n a m e d C a rn e y tria d is an e n tire ly d iffe re n t s y n d ro m e (triad o f g a s tric G IST, p u lm o n a ry c h o n d ro m a , a nd e x tra -a d re n a l p a ra g a n g lio m a ). i7.35 Lhermitte-Duclos lesion a MRI shows cerebellar thickening with enlarged folia & cystic appearing areas b-d Histology demonstrates a thickened molecular & internal granular area in which there are nodular collections of dysplastic ganglion cells

a n d p a lm o p la n ta r h y p e rk e ra to tic p its. M ic ro c e p h a ly a nd m e n ta l re ta rd a tio n a re c o m m o n , a n d a re s tro n g ly a s s o c ia te d w ith c e re b e lla r d y s p la s tic g a n g lio c y to m a (L h e rm itte D u c lo s le s io n ) i7.36, w h ic h is c o n s id e re d p a th o g n o m o n ic . P a tie n ts w ith C o w d e n s y n d ro m e a re a t a n in c re a s e d ris k o f c a rc in o m a , in c lu d in g fo llic u la r c a rc in o m a o f th e th y ro id g la n d a n d c a rc in o m a s o f th e b re a s t, c o lo n , a n d e n d o m e triu m . B a n n a y a n -R ile y -R u v a lc a b a s y n d ro m e h a s a d iffe re n t p re s e n ta tio n w ith m a c ro c e p h a ly a n d m e n ta l re ta rd a tio n , h ig h b irth w e ig h t, m y o p a th y , jo in t h y p e rm o b ility , p e c tu s e x c a v a tu m , a n d s c o lio s is . A s s o c ia te d tu m o rs in c lu d e h a m a rto m a to u s in te s tin a l p o ly p s a n d p ig m e n te d m a c u le s o f th e g la n s p en is. A s th e n a m e s u g g e s ts , P ro te u s s y n d ro m e h a s a h ig h ly v a ria b le p re s e n ta tio n a n d d e m o n s tra te s a p a tte rn o f a ffe c te d in d iv id u a ls c o n s is te n t w ith m o s a ic is m ; ie, s o m e o rg a n s a re h e a v ily a ffe c te d , w h e re a s o th e rs a re e n tire ly s p a re d . S o m e e x a m p le s o f th e s y n d ro m e m a n ife s t c o n n e c tiv e tis s u e nevi (c o n s id e re d p a th o g n o m o n ic ), a s y m m e tric lim b g ro w th , sku ll h y p e ro s to s is , m e g a s p o n d y lo d y s p la s ia o f th e v e rte b ra e , o r v is c e ra l o v e rg ro w th (e s p e c ia lly o f s p le e n a n d th y m u s ).

7.4.12.10 Carney complex C a rn e y c o m p le x is an a u to s o m a l d o m in a n t c o n d itio n a ls o k n o w n a s L A M B s y n d ro m e (an a c ro n y m d e n o tin g le n tig in e s , a tria l m y x o m a , a n d b lu e n e v i) o r N A M E s y n d ro m e (nevi, a tria l m y x o m a , m y x o id n e u ro fib ro m a , a n d e p h e lid e s ). C u ta n e o u s le n tig in e s (s im p le le n tig o s ) a re th e m o s t c o m m o n p re s e n tin g fin d in g , lo c a te d o n th e fa c e (p a rtic u la rly th e o ra l

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7.5 Selected readings 7.5.1 Books IS B N 9780721601649a B onnardeaux A, B ichet DG [2004] Inherited disorders o f the renal tubule. In: B renner BM, ed. Brenner & Rector’s the Kidney, 7e, V ol 1. S aunders IS B N 97807216 0 1 649b Falk RJ, Jennette JC, N achm an PH [2004] Prim ary glom erular disease. In: B renner BM, ed. Brenner & Rector’s the Kidney, 7e, Vol 1. Saunders: 1293-380 IS B N 9780721695563a Bates MD, B alistreri W F [2004] The liver and biliary system . In: B ehrm an RE, K liegm an RM, Jenson HB, ed. Nelson Textbook o f Pediatrics, 17e. S aunders IS B N 9780721695563b B ernstein D [2004] C ongenital heart disease. In: Behrm an RE, K liegm an RM, Jenson HB, ed. Nelson Textbook o f Pediatrics, 17e. S aunders IS B N 9780721695563c LaFranchi S [2004] D isorders o f the thyroid gland. In: B ehrm an RE, K liegm an RM, Jenson HB, ed. Nelson Textbook o f Pediatrics, 17e. S a unders IS B N 9780721695563d R apaport R [2003] D isorders o f the gonads. In: Behrm an RE, K liegm an RM, Jenson HB, ed. Nelson Textbook o f Pediatrics, 17e. S aunders IS B N 9780808923053 P yeritz RE [2005] G enetics and cardiovascular disease. In: Zipes DP, Braunw ald E, ed. Braunwald’s Heart Disease: A Textbook o f Cardiovascular Medicine, 7th ed, Vol 2. Philadelphia: E lsevier S aunders IS B N 9 780891899990 M ais, DD, N ordberg, M [2008] Quick Compendium o f Molecular Pathology. A S C P Press IS B N 9781416002451a B urdick JS, Tom pson ML [2006] Anatom y, histology, em bryology, and developm ental anom alies of the pancreas. In: Feldm an M, Friedm an LS, Brandt LJ, ed. Sleisenger & Fordtran’s Gastrointestinal and Liver Disease, 8e. Saunders IS B N 9781416002451b Forsm ark CE [2006] C hronic pancreatitis. In: Feldm an M, Friedm an LS, Brandt LJ, ed. Sleisenger & Fordtran’s Gastrointestinal and Liver Disease, 8e. Saunders IS B N 9789283224150 Eble JN, S auter G, Epstein Jl et al, ed. [2004] Tumours o f the Urinary System and M ale Genital Organs. IARC Press

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7.5.2 Online references

P M ID 103488 29 V asen HF, W a tso n P, M ecklin JP et al [1999] N ew clinical criteria for h e re d ita ry n o n p o lyp o sis colorectal can ce r (H N P C C , Lynch s yn d ro m e ) proposed by the International C ollaborative g roup on H N P C C . Gastroenterology 1999;116:1453-6 P M ID 10 3 5615 5 Kirk JM W , Brain C E, C arson DJ et al [1999] C ushing syndrom e caused by no d u la r adrenal h yperplasia in ch il dren w ith M cC une -A lbright syn d ro m e . J Pediat 134:789-792 P M ID 10360391 B ie s e c k e rL G , H apple R, M ulliken JB et al [1999] P roteus syndrom e: diagnostic criteria, d ifferential diagnosis, and patient evaluation. A m J M ed G enet 84:389-95 P M ID 10369249 Z ielenski J, C orey M, R ozm ahel R [1999] D etection o f a cystic fib ro sis m odifier locus fo r m e conium ileus on hum an chrom osom e 19 q 1 3. N at G enet 22:128-9 P M ID 1 036971 8 Sm ith W , Eng C, M illa PJ [1999] Intestinal g a n g lio n eurom a tosis and m ultiple e n d o crin e neoplasia type 2B: im p lica tions fo r treatm en t. Gut 45:143-6 P M ID 103826 96 H oogerw aard EM, B a kke r E, Ippel PF et al [1999] Signs and sym ptom s o f D uchenne m uscular d ystrophy and B e cker m uscular d ystrophy a m ong ca rriers in T he N etherlands: a co h o rt study. Lancet 353:2116-9 P M ID 1039372 5 V an K essel AG, W ijn h o ve n H, B o d m e r D et al [1999] R enal cell cancer: chrom osom e 3 tra n slo ca tio n s as risk factors. J N atl C ancer Inst 9 1:1159 -60 P M ID 104308 28 B ushby KM [1999] M aking se n se o f the lim b-girdle Additional journal references m uscular dystrophies. Brain 122(8): 1403-20 P M ID 10023895 H ateboer N, Dijk MA, B ogdanova N et al [1999] P M ID 10477433 G uilford PJ, H opkins JB, G ra d y W M et al [1999] C om parison o f phenotypes o f polycystic kidney disease types 1 E-cadherin germ line m utations define an inherited cancer and 2. Lancet 353:103-7 syndrom e dom inated by diffuse g astric cancer. Hum M utat P M ID 10047972 R uijter E, Van De Kaa C, M iller G et al [1999] 14:249-55 M olecular genetics and epidem iology o f prostate carcinom a. P M ID 104990 74 K ashtan CE [1999] A lp o rt syndrom e: an inherited Endocr R ev 20(1 ):22-45 d isorder o f renal, ocular, and co ch le a r b a sem ent m em branes. P M ID 10071047 Brett M, Persey MR, R eilly M M et al [1999] Medicine 78:338-60 T ransthyretin Leu12P ro is associated w ith system ic, neuropathic P M ID 10539900 Frank TS [1999] La b o ra to ry d e te rm ination o f he re d i and leptom eningeal am yloidosis. Brain 122(2): 183-90 tary susceptibility to breast and ovarian cancer. Arch Pathol Lab P M ID 10071056 De Jonghe P, Tim m erm an V, C euterick C et al M ed 123:1023-1026 [1999] The T hr1 2 4 M e t m utation in the peripheral m yelin protein P M ID 105399 04 G rody W W [1999] C ystic fibrosis: m o lecular d ia g zero (M P Z) gene is associated w ith a clinically distinct C harcotnosis, population screening, and p u b lic policy. Arch Pathol Lab M arie-Tooth phenotype. Brain 122(2):281-90 M ed 123:1041-1046 P M ID 10077519 C hen Q, Zhang D, G ingell RL et al [1999] P M ID 10539907 Press RD [1999] H e reditary hem ochrom atosis: H om ozygous deletion in KVLQT1 associated w ith Jervell and im pact o f m olecular and iron based testin g on the diagnosis, Lange-N ielsen syndrom e. Circulation 1999;99:1344-7 treatm ent, and prevention o f a com m on, chronic disease. Arch P M ID 10099144 Farfel Z, Bourne HR, liri T [1999] The expanding Pathol Lab M ed 123:1053-1059 spectrum o f G protein diseases. N Eng J M ed 340:101 2-1020 P M ID 1 0549772 Inoue K, S h im otake T, Inoue K et al [1999] P M ID 10194428 M ura C, R aguenes O, Ferec C [1999] H FE m utation M utational analysis o f the R ET protoo nco gene in a kindred analysis in 711 hem ochrom ato sis probands: evidence fo r S65C w ith m ultiple endocrine neoplasia type 2 A and H irsch sp ru n g ’s im plication in mild form o f hem ochrom atosis. Blood 93:2502-5 disease. J Pediatr Surg 34:1552-4 P M ID 10211478 Parm an Y, P lante-B ordeneuve V, G uiochon-M antel P M ID 105959 14 Loukola A, S alovaara R, K risto P et al [1999] A et al [1999] R ecessive inheritance o f a new point m utation M icrosatellite instability in adenom as as a m a rke r fo r hereditary o f the P M P 22 gene in D ejerine -S ottas disease. Ann Neurol nonpolyposis colorectal cancer. Am J Pathol 155:1849-53 45:518-22 P M ID 10614538 de S anctis C, Lala R, M atarazzo P et al [1999] PM ID 10235148 Nilsson O, Tisell LE, Jansson S et al [1999] A drenal M cC une -A lbright syndrom e: a longitudinal clinical study o f 32 and extra adrenal pheochrom o cytom as in a fam ily w ith germ line patients. J Pediat Endocr M etab 12:817-826 R ET V 804L m utation. JAMA 281:1587-8 P M ID 10631274 G ryfe R, Kim H, Hsieh E TK et al [2000] T u m o r P M ID 10323733 Lin AE, H erring AH , Scharenberg K [1999] m icrosatellite instability and clinical o utcom e in young patients C ardiovascular m alform ations: changes in prevalence and birth w ith colorectal cancer. N Engl J M ed 342:69-77 status, 1972-1990. Am J M ed G enet 84:102 P M ID 10632107 N um akura C, Lin C, O ka N et al [2000] H em izygous P M ID 10331471 R inaldo P, Yoon HR, Yu C et al [1999] S u dden and m utation o f the peripheral m yelin protein 22 gen e associa ted w ith unexpected neonatal death: a protocol fo r the postm ortem diag C harcot-M arie-T ooth disease type 1. Ann Neurol 47:101-3 nosis o f fatty acid oxidation disorders. Semin Perinatol 23:204-10 P M ID 1065531 8 M ak V, Zielenski J, Tsui LC et al [2000] C ystic P M ID 10341275 M astrianni JA, Nixon R, Layzer R et al [1999] Prion fibrosis gene m utations and infertile m en w ith prim ary te sticu la r protein conform ation in a patient w ith sporadic fatal insom nia. N failure. Hum Reprod 15(2):436-9 Engl J M ed 340:1630-8 A ssociation o f M olecular Pathology. A vailable at http://w w w .am p.org Bird TD [2005] M yotonic dystrophy type 1 (S te in e rt’s disease). In: G eneR eview s at G eneTests: M edical G enetics Inform ation R esource. A vailable at http://w w w .genetests.org Dell KM, A vne r ED [2006] A utosom al recessive polycystic kidney disease. In: G eneR eview s at G eneTests: M edical G enetics Inform ation R esource. A vailable at http://www.genetests.org Forest MG [1998] Prenatal diagnosis, treatm ent, and outco m e in infants w ith congenital adrenal hyperplasia. Curr Opin Endocrinol D /ab 4:209-217 Friedm an JM [2007] N eurofibrom atosis 1. In: G eneR eview s at G eneTests: M edical G enetics Inform ation R esource. A vailable at http://w w w .genete sts.org G eneTests: M edical G enetics Inform ation R esource. A vailable at http://w w w .genetests.org Harris PC, Torres VE [2006] A utosom al dom inant polycystic kidney disease. In: G eneR eview s at G eneTests: M edical G enetics Inform ation R esource. A vailable at http://www.genetests.org O nline M endelian Inheritance in Man. N ational C enter for B iotechnology Inform ation w ebsite. A vailable at http://www.ncbi. nlm.nih.gov/omim

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Selected readings>Additional journal references P M ID 1 0 6 5 7 3 7 1 R ossi E, O lyn yk JK, C ullen DJ et al [2000] C o m p o u n d h e te ro zyg o u s h e m o ch ro m a to sis: g e n o ty p e predicts in c re a s e d iron and e ryth ro cyte in d ice s in w om en. Clin Chem 4 6 (2 ): 162-16 6 P M ID 1 0 6 5 8 9 0 8 Jim e n e z RE, W a llis T, T a b a s c z k a P e t al [2000] D e te rm in a tio n o f H er-2/N eu s ta tu s in b re a st c arcinom a: co m p a ra tiv e a n a ly s is o f im m u n o h is to c h e m istry and flu o re s c e n t in situ h yb rid iza tio n . M od Pathol 13(1):37-45 P M ID 1 0 6 7 9 9 3 7 W u y ts W , V a n Hul W [2 0 0 1 ] M o le c u la r basis of m u ltip le exostose s: M u ta tion s in th e E X T 1 a nd E X T2 genes. Hum M utat 15:220-7 P M ID 1 0 6 8 5 1 4 6 S ka n d a la kis JE, Ellis H [2 0 0 0 ] E m b ryo lo g ic and a n a to m ic basis o f e s o phagea l surgery. Surg Clin North Am 80:85 P M ID 1 0 6 9 9 1 17 D e B e lla K, S zu d e k J, F rie dm a n JM [2000] U se o f th e n a tio n a l in stitutes o f health crite ria fo r dia g n o sis o f neurofibro m a to s is 1 in ch ild ren . Pediatrics 105:6 0 8 -1 4 P M ID 1 0 7 0 1 5 2 7 W a tso n JC, S tra ta kis C A , B rya n t-G re e n w o o d PK e t al [2000] N e u ro su rg ica l im p lica tio n s o f C a rn e y com plex. J Neurosurg 92 :413-8 P M ID 1 0 7 1 0 0 4 6 M cG a rrity TJ, K ulin HE, Z a in o RJ [2000] P eutzJ e g h e rs syn d ro m e . Am J Gastroenterol 9 5 :5 9 6 -6 0 4 P M ID 1 0 7 1 1 9 3 3 Priori SG , N a politan o C, G io rd a n o U et al [2000] B ru g a d a s y n d ro m e and su d d e n ca rd ia c death in children. Lancet 3 5 5 :8 0 8 -9 P M ID 1 0 7 1 6 2 6 3 Joutel A, D odick D D, P arisi JE et al [2000] D e novo m u ta tio n in th e N otch 3 g e n e ca u sin g C A D A S IL . Ann Neurol 47:388-91 P M ID 1 0 7 6 2 5 0 7 D e B e lla K, P o skitt K, S zu d e k J, F riedm an JM [2000] U se o f “u n id e n tifie d b right o b je c ts ” on M RI fo r d ia g n o sis o f n e u ro fib ro m a to s is 1 in child ren. Neurology 54:1646-51 P M ID 1 0 7 7 0 4 3 7 M isago N, N arisaw a Y [2000] S e b a ce o u s n e o p la s m s in M u ir-T o rre syn d ro m e . A m J Derm atopathol 22:155-61 P M ID 1 0 7 7 3 7 8 3 Z ie le n ski J [2000] G e n o typ e and p h e n o typ e in cystic fib ro sis. Respiration 67:117-33 P M ID 107744 81 B u xba um JN, T a g o e C E [2000] T he g e n e tics o f the a m ylo id o se s. Annu R ev M ed 5 1 :543-69 P M ID 1 0 7 7 7 6 6 6 Legoix P, S a rkissia n H D, C a ze s L et al [2000] M o le c u la r c h a ra cte riza tion o f g e rm lin e N F 2 gene rearrange m e n ts. Genom ics 65:62-6 P M ID 1 0784581 Ja rvinen HJ, A a rn io M, M u sto n e n H et al [2000] C o n tro lle d 1 5 -year trial on scre e n in g fo r c olore cta l ca n ce r in fa m ilie s w ith he re d ita ry n o n p o ly p o s is c olorecta l cancer. Gastroenterology 1 18:829 -34 P M ID 1 0 7 9 0 2 0 2 M cC arthy TV , Q ua n e KA, Lynch PJ [2000] R ya n o d in e re ce p to r m u ta tio n s in m a lig n a n t hypertherm ia and cen tra l core disease. Hum M utat 15: 4 1 0 -4 1 7 P M ID 1 0 7 9 4 7 4 0 Lee HH, C hang JG , T sai C H et al [2000] A n alysis o f th e ch im e ric C Y P 2 1 P /C Y P 2 7 g e n e in steroid 2 1 -h yd ro xyla se d e ficie n cy. Clin Chem 4 6 (5 ):6 0 6 -6 1 1 P M ID 1 08 2 2 4 4 6 Finckh U, A lb e rici A, A n to n ia zz i M et al [2000] V a ria b le e xp re ssio n o f fa m ilia l A lz h e im e r dise ase associa ted w ith p re se n ilin 2 m utation M 239I. Neurology 54:2 0 06 -8 P M ID 1 0 8 2 3 1 4 8 G ra s E, M atia s-G u iu X, C a ta sus L et al [2000] A p p lic a tio n o f m icro sa te llite P C R te c h n iq u e s in the identification o f m ixed up tissu e sp e cim e n s in su rgical pathology. J Clin Pathol 5 3 :2 3 8 -2 4 0 P M ID 1 0 8 2 4 0 7 4 L ucking CB, D u rr A, B onifa ti V et al [2000] A ss o c ia tio n b e tw een e a rly o n s e t P a rkin s o n ’s disease and m uta tio n s in th e parkin gene. N Engl J M e d 342:1 5 6 0-7 P M ID 1 0851361 R o senberg RN [2000] T h e m o lecu la r and genetic basis o f A D : th e end o f the beginning. Neurology 54:2045-54

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P M ID 10861262 lino H, S im m s L, Y oung J et al [2000] D N A m icro satellite instability and m ism atch repair protein loss in adenom as presenting in hereditary nonpolyposis colorectal cancer. Gut 47:37-42 P M ID 1 0862080 A lg a r E, Brickell S, D eeble G et al [2000] A n alysis of C D K N 1 C in B eckw ith W iedem ann syndrom e. Hum M utat 15:497508 P M ID 1 0869060 A d am s D, S am uel D, G oulon-G oeau C et al [2000] T he course and p rogno stic factors o f fam ilial am yloid polyneu ro p a th y after liver transplantation. Brain 123:1495-504 P M ID 1 0869062 K rajew ski KM, Lew is RA, Fuerst DR et al [2000] N eurological d ysfunction and axonal degeneration in C harcotM arie-Tooth disease type 1A. Brain 123(7): 1516-27 PM ID 10874301 B oardm an LA, C ouch FJ, Burgart LJ et al [2000] G e n e tic heterogeneity in P eutz-Jeghers syndrom e. Hum Mutat 16:23-30 P M ID 1 0889174 S chuppan D [2000] C urrent concepts o f celiac disease pathogenesis. Gastroenterology 119:234-42 P M ID 1 0923032 Bonneau D, Longy M [2000] M utations o f the hum an P T E N gene. Hum M utat 16:109-22 P M ID 10946353 Inoue K, S him otake T, Iwai N [2000] M utational analysis o f R E T /G D N F /N T N genes in children w ith total colonic aganglionosis w ith sm all bow el involvem ent. Am J M ed G enet 93:278-84 P M ID 1 0973849 S p law ski I, Shen J, T im o thy KW et al [2000] Spectrum o f m utations in long Q T syndrom e genes: KVLQ T1, H ER G , SC N 5A , KC N E 1, and KC NE2. Circulation 102:1178-85 P M ID 1 0976645 Lippa CF, S w earer JM , Kane KJ et al [2000] Fam ilial A lz h e im e r disease: site o f m utation influences clinical phenotype. Ann Neurol 4 8:376-9 P M ID 1 1030407 C headle JP, R eeve MP, S am pson JR et al [2000] M olecular genetic advances in tuberous sclerosis. Hum G enet 107:97-114 P M ID 1 1047756 R eynolds DM, Falk CT, Li A et al [2000] Identification o f a locus fo r autosom al dom inant polycystic liver disease, on chrom osom e 19p13.2-13.1. Am J Hum G enet 67:1598-604 P M ID 1 1051298 M astrianni JA, R oos RP [2000] The prion diseases. Semin Neurol 20:337-52 P M ID 1 1061281 C urless RG [2001] Use o f “unidentified bright objects” on M RI fo r diagnosis o f neurofibrom atosis 1 in children. Neurology 55:1067-8 P M ID 1 1063719 M onnier N, R om ero NB, Lerale J et al [2000] An autosom al dom inant congenital m yopathy w ith cores and rods is associated w ith a neom utation in the R YR1 gene encoding the skeletal m uscle ryanodine receptor. Hum Mol G enet 9:2599-608 P M ID 1 1064676 Forster LF, D efres S, G oudie DR et al [2000] An investigation o f the P eutz-Jeghers gene (LK B 1) in sporadic breast and colon cancers. J Clin Pathol 53:791-793 P M ID 11070098 E steller M, G arcia-Foncillas J, Andion E et al [2000] Inactivation o f the D N A repair gene M G M T and the clinical response o f gliom as to alkylating agents. N Engl J M ed 343(19):1350-1354 P M ID 1 1073365 P lante -B orde neuve V, Said G [2000] Transthyretin related fam ilial am yloid polyneuropathy. Curr Opin Neurol 13:569-73 P M ID 1 1078482 Parkes M, B arm ada MM, S atsangi J et al [2000] The IBD2 locus show s linkage hetero geneity betw een ulcerative colitis and C rohn disease. Am J Hum G enet 67:1605-10 P M ID 11095461 M antovani G, R om oli R, W ebe r G et al [2000] M utational analysis o f GNAS1 in patients w ith pseudo-hypo parathyroidism : Identification o f 2 novel m utations. J Clin Endocr M etab 85:4243-4248

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Selected readings>Additional journal references P M ID 1 1106284 Parisi MA, K a pur RP [2000] G enetics of H irschsprung disease. Curr Opin Pediatr 12:610-7 P M ID 11106352 Evans DG, S ainio M, B aser M E [2000] N eurofibrom atosis type 2. J M ed G enet 37:897-904 P M ID 11106718 K am isago M, S harm a SD, D ePalm a SR et al [2000] M utations in sarcom ere protein genes as a cause o f dilated cardiom yopathy. N ew Engl J M ed 343:1688-96 P M ID 11113065 G iardiello FM, B rensinger JD, Tersm ette A C et al [2000] V e ry high risk o f cancer in fam ilial P eutz-Jeghers syndrom e. Gastroenterology 119:1447-53 P M ID 11114636 Inabnet W B, C araglia no P, P ertsem lidis D [2000] P heochrom ocytom a: inherited associations, bilaterality, and cortex presentation. Surgery 128:1007-11 P M ID 11115377 R ossetti S, S trm ecki L, G am ble V et al [2001] M utation analysis o f the entire PKD1 gene: G enetic and d iag nostic im plications. Am J Hum G enet 68:46-63 P M ID 11127261 G affney D, Fell GS, O ’R eilly D [2000] W ilson disease: acute and presym ptom atic laboratory diagnosis and m onitoring. J Clin Pathol 53:807-812 P M ID 11136691 S chw artz PJ, Priori SG , S pazzolini C et al [2001] G enotype-ph enotype correlation in th e long Q T syndrom e: gene specific triggers fo r life threate nin g arrhythm ias. Circulation 103:89-95 P M ID 11150363 D eA ngelis LM [2001] M edical progress: brain tum ors. N Engl J M ed 3 4 4 (2 ):1 14-123 P M ID 1 1151920 Bhatia E, D urie P, Zielenski J et al [2000] M utations in the cystic fibrosis tran sm e m b ra n e regulator gene in patients w ith tropical calcific pancreatitis. Am J Gastroenterol 95(12):3658-9 P M ID 11157710 Laitinen PJ, Brown KM, Piippo K et al [2001] M utations o f th e cardiac ryanodine receptor (R yR 2) gene in fam ilial polym orphic ve ntricular tachycardia. Circulation 103:485-90 P M ID 11159936 Tiso N, S tephan DA, Nava A et al [2001] Identification o f m utations in the cardiac ryanodine receptor gene in fam ilies affected w ith a rrhythm ogenic right ventricular cardio m yopathy type 2 (A R V D 2). Hum M ol G enet 10:189-94 P M ID 11207349 H edenfalk I, D uggan D, C hen Y et al [2001] G eneexpression profiles in hereditary breast cancer. N Engl J M ed 344:539-48 P M ID 1 1207349 P M ID 11208676 Priori SG , N apolitano C, Tiso N et al [2002] M utations in the cardiac ryanodine receptor gene (hR yR 2) underlie catecholam inergic polym orphic ventricular tachycardia. Circulation 102:r49-r53 P M ID 11216980 Piippo K, Sw an H, P asternack M et al [2001] A founder m utation o f the potassium channel KCNQ1 in long Q T syndrom e: im plications fo r estim ation o f disease prevalence and m olecular diagnostics. J Am Coll Cardiol 37:562-8 P M ID 1 1227066 W orsham MJ, W olm an SR, Zarbo RJ [2001] M olecular approa che s to identification o f tissu e contam ination in surgical pathology sections. J M ol Diagn 3:11-15 P M ID 1 1263929 Brown GJ, St John DJ, M acrae FA et al [2001] C ancer risk in young w om en at risk o f hereditary nonpolyposis colorectal cancer: im plications fo r gynecologic surveillance. Gynecol Oncol 80:346-9 P M ID 11287975 Joensuu H, R oberts PJ, S arlo m o -R ikala M, A ndersson LC, Tervahartia la P, Tuveson D, S ilberm an SL, C apdeville R, D im itrijevic S, D ruker B, D em etri G [2001] Effect of the tyrosine kinase inhibitor STI571 in a patient w ith a m etastatic gastrointestinal strom al tum or. N Engl J M ed 344(14):1052-1056

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P M ID 1 1290543 N igro JM, T akahashi M A, G in zin g e r DG e t al [2001] D etection o f 1p and 19q loss in o lig o d e n d ro g lio m a by qua n tita tive m icrosatellite analysis, a real tim e qu a n tita tive polym e ra se chain reaction assay. Am J Pathol 1 58:125 3-1262 P M ID 1 1302967 G ath R, G oessling A, K e ller KM et al [2001] A n alysis o f th e RET, G DNF, E D N 3, and E D N R B genes in patients w ith intestinal neuronal d ysp la sia and H irschsprung disease. Gut 4 8:671-5 P M ID 1 1309634 W ata nabe T, W u TT, C atalano PJ et al [2001] M olecular p redictors o f survival a fte r a d ju va n t c h e m o th e ra p y fo r colon cancer. N Engl J M ed 344:119 6-206 P M ID 1 1340278 N elson W G , D eM arzo A M , D e W e e se T L [2001] T he m olecular patho g e n e sis of p rostate cancer: fo c u s on the ea rlie st steps. Eur Urol 39:8-11 P M ID 1 1343262 Tavill AS [2001] D ia g n o sis and m a n a g e m e n t o f h em ochrom ato sis. Hepatology 33:1321-8 P M ID 1 1391482 C heung PK, M cC o rm ick C, C raw ford BE, Esko JD, T ufaro F, D uncan G [2001] Etiological point m u tations in the hereditary m ultiple exostoses gene EX T1: a fu nctional a n a lysis o f heparan sulfate polym erase activity. Am J Hum G enet 69:5 5 -6 6 P M ID 1 1393164 K eegan CE, Killeen A A [2001] A n ove rvie w o f m o le cu la r d iagnosis o f steroid 2 1 -h yd ro xyla se deficiency. J M ol Diagn 3(2):49-54 P M ID 1 1409868 Zschocke J, S chulze A, Lindner M, Fiesel S, O lg e m o lle r K, H offm ann GF, P enzien J, R uite r JP, W a n d e rs RJ, M ayatepek E [2001] M olecular and fu nctional c h a racterisation o f m ild M C A D deficiency. Hum G enet 108:404-8 P M ID 1 1414765 Li M, Squire J, S hum an C et al [2001] Im printing status o f 11 p15 genes in B eckw ith-W iedem ann syndrom e patients w ith C D K N 1C m utations. Genom ics 74:370-6 P M ID 1 1432960 Francannet C, C ohen-T anug i A, Le M e rre r M et al [2001] G enotype-phenotype correlation in hereditary m ultiple exostoses. J M ed G enet 38:430-4 P M ID 1 1449389 R osenblatt A, B rinkm an RR, Liang KY et al [2001] Fam ilial influence on age o f onset am ong siblings w ith H untington disease. Am J M ed G enet 105:399-403 P M ID 1 1461078 A llinen M, H uusko P, M antyniem i S et al [2001] M utation analysis o f the CHK2 gene in fa m ilie s w ith h ereditary breast cancer. B r J C ancer 85:209-12 P M ID 1 1476841 Zhou X, Ham pel H, T hie le H et al [2001] A ssociation o f germ line m utation in the PTEN tu m o u r s u p p re sso r gene and P roteus and P roteuslike syndrom es. Lancet 358:210-1 P M ID 1 1486912 A lbers S, Levy HL, Irons M et al [2001] C om pound heterozygosity in 4 asym ptom atic sib lin g s w ith m e dium -chain a cyl-C oA dehydroge nase deficiency. J Inherit M etab Dis 24:4 1 7 -8 P M ID 1 1498785 Birch JM , A lston RD, M cN ally RJ et al [2001] R elative freq u e n cy and m orphology o f ca n ce rs in carriers o f germ line T P 53 m utations. Oncogene 20:4621 -8 P M ID 1 1524404 Huang FD, C hen J, Lin M et al [2001] Long Q T syndrom e associated m issense m utations in the pore helix o f the H ER G potassium channel. Circulation 104:107 1-5 P M ID 1 1524701 C unningham JM, Kim C Y, C hristen sen ER et al [2001] T he freque ncy o f hereditary de fe ctive m ism atch repair in a prospective series o f unselected colorectal carcinom as. Am J Hum G enet 69:780-90 P M ID 1 1549642 B oehm er AL, Brinkm ann O, B ruggenw irth H et al [2001] G enotype vs phenotype in fam ilie s w ith androgen insensi tivity syndrom e. J Clin Endocrinol M etab 86:4 1 5 1 -60 P M ID 1 1558785 Farrer M, Chan P, Chen R et al [2001] Lew y bodies and parkinsonism in fam ilie s w ith parkin m utations. Ann Neurol 50:293-300

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Selected readings>Additional journal references P M ID 1 155878 7 R yan M M , S chnell C, S tricklan d C D et al [2001] N e m a lin e m yo p ath y: a clinical s tu d y o f 143 cases. Ann Neurol 5 0 :3 1 2 -2 0 P M ID 1 157121 3 R o sso SM , K a m p h o rs t W , de G ra a f B et al [2001] F a m ilia l fro n to te m p o ra l dem e n tia w ith ubiq u itin -p o sitive inclu sions is linke d to c h ro m o s o m e 17q21-22. Brain 124:1 9 4 8 -5 7 P M ID 1 169152 6 P ro to n o ta rio s N, T sa tso p o u lo u A, A n a sta sa kis A et al [2 0 0 1 ] G e n o ty p e -p h e n o ty p e a s s e s sm e n t in a u to so m a l re ce s sive a rrh y th m o g e n ic right v e n tric u la r ca rd io m y o p a th y (N axos d is e a s e ) caused by a d e letion in plakoqlobin. J A m Coll Cardiol 3 8 :1 4 7 7 -8 4 P M ID 1 1710892 A c ke rm a n M J, Siu BL, S tu rn e r W Q et al [2001] P o stm o rte m m o le c u la r a n a lysis o f S C N 5 A d e fe cts in sudden in fa n t d e a th syndrom e. JAM A 2 8 6 :2 2 6 4 -9 P M ID 1 1729114 P h aroah PD, G uilford P, C ald a s C [2001] Incidence o f g a s tric c a n c e r and b re a st c a n c e r in CDH1 (E -ca d h e rin ) m u ta tio n ca rrie rs from he re d ita ry diffuse g a stric c a n c e r fam ilies. G astroenterology 1 2 1 :1348-13 53 P M ID 1 173941 6 B randi M L, G agel RF, A n g e li A et al [2001] G u id e lin e s fo r d ia g n o sis and th e ra p y o f M EN ty p e 1 and typ e 2. J Clin Endocrinol M etab 86:5658-71 P M ID 1 1751681 W e ksb e rg R, N ishikaw a J, C a lu se riu O et al [2001] T u m o r d e v e lo p m e n t in th e B e ckw ith -W ie d e m a n n syndrom e is a sso c ia te d w ith a va rie ty o f co n stitu tio n a l m o le c u la r 11 p15 a lte ra tio n s in clu d in g im printing d efects o f K C N Q 1 0 T 1 . Hum M ol G enet 1 0 :2 9 8 9 -3 0 0 0 P M ID 1 1778003 C a rrell R W , L om a s D A [2002] a 1-antitrypsin d e fi c ie n cy: a m odel fo r c o n fo rm a tio n a l dise a se s. N Engl J M ed 346(1 ):45-5 3 P M ID 1 1804990 W an g D W , V isw a n a th a n PC, B a lse r JR et al [2002] C lin ica l, ge n e tic, and bio ph ysica l ch a ra cte riza tio n o f S C N 5 A m u ta tio n s a ssocia ted w ith a trio v e n tric u la r co n d u ctio n block. Circulation 105:341 -6 P M ID 1 1812557 B e u tle r E, Felitti VJ, K oziol JA et al [2002] P e n e tra n ce o f 8 4 5 G —>A (C 28 2Y ) H FE he re d ita ry ha e m o ch ro m a to s is m utation in the U SA. Lancet 3 5 9 :2 1 1 -8 P M ID 1 1823453 V a tta M, D u m a in e R, V a rg h e s e G et al [2002] G e n e tic and b io p h ysica l b asis o f su d d e n u n e x pla in e d nocturnal d e a th s y n d ro m e (S U N D S ), a d ise a se a lle lic to B rugada syn d ro m e . H um M ol G enet 11 :337-45 P M ID 1 1826187 A n to n e scu C R, T s c h e rn y a v s k y SJ, W o o d ru ff JM et al [2002] M o le c u la r dia g n o sis o f cle a r cell sarco m a : de te ctio n o f E W S -A TF1 and M IT F -M tra n scrip ts and histo pathological and u ltra stru ctu ra l a n a lysis o f 12 cases. J M ol D iag 4:44-5 2 P M ID 1 1826188 O g in o S, L eonard D G B, R e nn ert H et al [2002] S p inal m u s c u la r a tro p h y g e n e tic te stin g e xp e rie n ce at an a c a d e m ic m edical center. J M ol Diagn 4(1 ):5 3 -5 8 P M ID 1 1826189 B ijw a ard KE, Fetsch JF, P rzygo d zki R et al [2002] D e te ctio n o f S Y T -S S X fu sio n tra n scrip ts in a rchival synovial s a rc o m a s by real tim e re ve rse tra n scrip ta s e -p o ly m e ra s e chain reaction. J M ol Diag 4:59-6 4 P M ID 1 1826276 R in ald o P, M atern D, B e n ne tt M J [2002] Fatty acid o xid a tio n d iso rd ers. Annu R ev Physiol 6 4 :4 7 7 -502 P M ID 1 1835375 B o erkoel C F, T a ka sh im a H, G arcia C A et al [2002] C h a rc o t-M a rie -T o o th d ise a se and related n europ athies: M utation d istrib u tio n and g e n o ty p e -p h e n o ty p e correlation . Ann Neurol 51:190-201 P M ID 1 1839719 R idolfi RL, J a m e h d o r M R, A rb e r JM [2000] H E R -2/ neu te sting in breast c arcinom a: a c o m bined im m u n o h isto ch e m ical and flu o re s c e n c e in situ hyb rid iza tio n approa ch. M od Pathol 13(8 ):8 6 6 -8 7 3

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P M ID 1 1839719 R ijcken FEM , H ollem a H, K leibeuker JH [2002] P roxim al adenom as in h e reditary nonpolyposis colorectal cancer are prone to rapid m alig n a n t transform ation. Gut 50:382-386 P M ID 1 1897209 V iitasalo M, O ikarinen L, V aananen H et al [2002] D ifferentiation betw een LQT1 and LQ T2 patients and unaffected sub je cts using 2 4 -h o u r e le ctro ca rd io g raph ic recordings. Am J Cardiol 89:679-85 P M ID 1 1910337 C uthbert AP, Fisher SA, M irza MM et al [2002] T he contribution o f N O D 2 gene m utations to the risk and site o f disease in inflam m atory bow el disease. Gastroenterology 122:867-74 P M ID 1 1966387 W right TC Jr, C ox JT, M assad LS et al [2002] 2001 C onsensus guidelines fo r th e m anagem ent o f w om en w ith cervical cytologic abnorm alities. JAMA 287:2120-9 P M ID 1 1967008 R ossetti S, C hauveau D, W alker D et al [2002] A com plete m utation screen o f the A D P K D genes by DHPLC. Kidney Int 61:1588-99 P M ID 12000816 N eum ann HP, Bausch B, M cW hinney SR et al [2002] G erm -line m utations in nonsyndrom ic pheochrom ocytom a. N Engl J M ed 346:1459-66 P M ID 12020527 H am pe J, G rebe J, N ikolaus S et al [2002] A ssociation o f N O D 2 (C A R D 15) g enotype w ith clinical course o f C rohn disease: a co h o rt study. Lancet 359:1661-5 P M ID 12023992 K a uff ND, S atagopan JM , R obson ME et al [2002 R isk-reducing salpingo-oophorectom y in w om en w ith a BRCA1 or BR C A 2 m utation. N Engl J M ed 346:1609-15 P M ID 120601 40 De G obbi M, R oetto A, Piperno A et al [2002] N atural history o f ju ve n ile haem ochrom atosis. Br J Hematol 117:973-9 P M ID 1 2073072 Lanterm a nn A, H am pe J, Kim W H et al [2002] Investigation o f H LA-D PA1 genotypes as predictors o f inflam m atory bow el disease in the G erm an, South A frican, and South Korean populations. Int J Colorectal Dis 17(4):238-44 P M ID 1 2 1 14723 K ovacs K, G iannini C, S cheithau er BW et al [1997] Pituitary changes in ataxia-telangiectasia syndrom e: an im m unocytochem ical, in situ hybridization, and D N A cytom etric study o f 3 cases. Endocr Pathol 8:195-203 P M ID 12116240 B urger B, U hlhaas S, M angold E et al [2002] Novel de novo m utation o f M A D H 4/S M A D 4 in a patient w ith juvenile polyposis. Am J M ed G enet 110:289-91 P M ID 12130528 M attm an A, H untsm an D, Lockitch G et al [2002] Transferrin receptor 2 (TfR 2) and HFE m utational analysis in non C 282Y iron overload: identification o f a novel TfR 2 m utation. Blood 100:1075-1077 P M ID 12131150 Lae ME, R oche PC, Jin L et al [2002] D esm oplastic small round cell tum or. A clinicopath ologic, im m unohistochem ical, and m o le cu la r study o f 32 tum ors. Am J Surg Pathol 26(7):823835 P M ID 12131157 G roism an GM, A m a r M, Livne E [2002] C D10: A valuable tool fo r the light m icrosco pic diagnosis o f m icrovillous inclusion disease (fam ilial m icrovillous atrophy). Am J Surg Pathol 26(7):902-907 PM ID 12139636 M achin P, C atasus L, Pons C et al [2002] M icrosatellite instability and im m unostaining fo r M SH -2 and MLH-1 in cutaneous and internal tum ors from patients w ith the M uir-Torre syndrom e. J Cutan Pathol 2 9 :415-20 PM ID 12170083 Hegi ME, D iserens AC , G orlia T et al [2005] M G M T gene silencing and benefit from tem ozolom ide in glioblastom a. N E n g lJ M ed 352(10):997 -1003p— P M ID 12170083 Hill DA, O ’Sullivan MJ, Zhu X et al [2002] Practical application o f m olec ular genetic testing as an aid to the surgical pathologic diagnosis of sarcom as: a prospective study. Am J Surg Pathol 26(8):965977

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Selected readings>Additional journal references P M ID 12373648 R am pazzo A, N ava A, M alacrida S et al [2002] M utation in hum an desm oplakin dom ain binding to plakoglobin causes a do m in a n t form o f arrhythm og enic right ventricular cardiom yopathy. Am J Hum G enet 71:1200-6 P M ID 12395806 M arkus HS, M artin RJ, S im pson M A et al [2002] D iagnostic strategies in C A D A S IL. Neurology 59:1134-8 PM ID 12417552 W ilde AA, A ntzelevitch C, B orggrefe M et al [2002] Proposed d iagnostic criteria fo r the B rugada syndrom e. Circulation 106:2514-9 P M ID 12421895 G u ttm a cher A, C ollins FS [2002] G enom ic m edi cine— a prim er. N Engl J M ed 347(19 ):1 512-1520 P M ID 1243282 5 W a g n e r KR [2002] G enetic diseases o f m uscle. Neurol Clin N Am 20:645-678 P M ID 12432830 H edera P, T u rn e r RS [2002] Inherited dem entias. Neurol Clin N Am 20:779-808 P M ID 12459622 Argani P, A n tonescu CR, C outurier J et al [2002] P R C C -TFE 3 renal carcinom as m orphologic, im m unohistochem ical, ultrastructural, and m olecular analysis o f an entity associated w ith the t(X ;1)(p11.2;q21). Am J Surg Pathol 26(12): 1553-1566 PM ID 12471211 Sm ith JM , Kirk EP, T heodosopoulos G et al [2002] G erm line m utations o f the tu m o u r sup p re sso r PTEN in Proteus syndrom e. J M ed G enet 39:937-40 PM ID 12473753 N ishino I, N oguchi S, M urayam a K et al [2002] Distal m yopathy w ith rim m ed vacuoles is allelic to hereditary inclusion body m yopathy. Neurology 59:1689-93 PM ID 12477701 Hattori N, Y a m a m oto M, Y o shihara T et al [2003] D em yelinating and axonal fea tu re s o f C harcot-M arie-Tooth disease w ith m utations o f m yelin related proteins (P M P22, M P Z and C x32): a clinicopatholog ical study o f 205 Japanese patients. Brain 126:134-51 PM ID 12478627 M ao R, N elson L, Kates R et al [2002] Prenatal diagnosis o f 2 1 -hydro xylase d eficiency caused by gene conver sion and rearrangem ents: pitfalls and m olecular diagnostic solu tions. Prenat Diagn 22:1171 -6 PM ID 12496757 B oocock G R, M orrison JA, P opovic M et al [2003] M utations in SB D S are associated w ith S hw achm an-D iam ond syndrom e. N at G enet 33:97-101 PM ID 12500201 Q ian Q, Li A, King BF et al [2003] C linical profile o f autosom al dom inant polycystic liver disease. Hepatology 37:164-71 PM ID 12500226 G higgeri G M , C aridi G, M agrini U et al [2003] G enetics, clinical and pathological feature s o f glom erulonephrite s associated w ith m utations o f nonm uscle m yosin IIA (Fechtne r syndrom e). Am J Kidney Dis 4 1 :95-104 PM ID 12502929 Torlakovic E, S kovlund E, S n ove r DC et al [2003] M orpholoqic reappraisal o f serrated colorectal polyps. Am J Surg Pathol 27(1):65-81 PM ID 12510036 Shevell M [2003] H allervorden and history. N Engl J M ed 348(1 ):3-4 PM ID 12510040 H ayflick SJ, W estaw ay SK, Levinson B et al [2003] G enetic, clinical, and radiographic delineation o f H allervordenSpatz syndrom e. N Engl J M ed 348:33-40 PM ID 12512026 S chw ab M, S chae ffele r E, M arx C et al [2003] A ssociation betw een the C 3 4 3 5 T M DR 1 gene polym orphism and susceptibility fo r ulcerative colitis. Gastroenterology 124(1):26-33 PM ID 12552037 Janssen JC, Beck JA, C am pbell TA et al [2003] Early onset fam ilial A lzh e im e r disease: m utation freq u e n cy in 31 fam ilies. Neurology 60:235-9 PM ID 12589117 Finsterer J, S tollberger C [2003] The heart in hum an dystrophinopathies. Cardiology 99:1-19

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P M ID 12598313 S jogren H, M eis-K indblom JM, O rndal C et al [2003] S tudies on the m olecular p a thoge nesis o f extraskeletal m yxoid chondrosarcom a— cytogenetic, m o le cu la r g enetic, and cD N A m icroarray analyses. Am J Pathol 162(3):781-792 P M ID 1 260096 4 Lovicu M, Dessi V, Z a p p u A et al [2003] E fficient strategy fo r m olecular diagnosis o f W ilson dise a se in the S ardinian population. Clin C hem 4 9 (3 ):4 9 6 -4 9 8 P M ID 12606733 S ieber O M , Lipton L, C rabtree M et al [2003] M ultiple colorectal adenom as, c la ssic a d e n o m a to u s polyposis, and germ line m utations in M YH . N Engl J M ed 348:791 -9 P M ID 1 261565 0 Squitieri F, G ellera C, C annella M et al [2003] H o m ozygosity fo r C AG m utation in H untington d isease is a s so ci ated w ith a m ore severe clinical course. Brain 126:946-55 P M ID 1 2 6 2 1 137 Lynch HT, de la C h a p e lle A [2003] H ereditary colorectal cancer. N Engl J M ed 348:919 -932 P M ID 12629341 C zene K, H em m inki K [2003] Fam ilial p a pillary renal cell tu m o rs and subsequent cancers: A na tio n w id e e p id e m io logical study from Sw eden. J Urol 169:127 1-5 P M ID 126311 10 Buzza M, D agher H, W ang Y Y et al [2003] M utations in the COL4A4 gene in thin b a se m e n t m em brane disease. Kidney Int 63:447-53 P M ID 12637487 Peltom aki P [2003] R ole o f D N A m ism atch repair defects in the pathogenesis o f hum an cancer. J Clin Oncol 21:1174 -9 P M ID 126634 37 G anz T [2003] H epcidin, a key re g u la to r o f iron m etabolism and m e diator of anem ia o f inflam m ation. Blood 1 0 2 (3 )7 8 3 -7 8 8 P M ID 12675859 Belz MM, F ick-B rosnah an GM , H ughes R L et al [2003] R ecurrence o f intracranial a n e u rysm s in a u to so m a l-d o m i nant p olycystic kidney disease. Kidney Int 63:1824 -30 P M ID 127093 67 T am m aro A, Bracco A, C o zzo lin o S et al [2003] S canning fo r m utations o f the ryan o d in e rece p to r (R Y R 1) g e n e by denaturing HPLC: D etection o f 3 novel m alignant hypertherm ia alleles. Clin Chem 49(5): 761-768 P M ID 1 2 7 1 1741 B e n-Y osef T, Ness SL, M a d e o A C et al [2003] A m utation o f P C D H 15 am ong A sh ke n a zi Je w s w ith the T yp e 1 U sher syndrom e. N Engl J M ed 348:166 4-70 P M ID 1271724 2 G reenson JK, Bonner JD, B e n -Y zh ak O et al [2003] P henotype o f m icrosatellite unstable colorectal ca rcinom as w ell differentiated and focally m ucinous tum ors and the a bsence o f dirty necrosis correlate w ith m icrosatellite instability. Am J Surg Pathol 27(5):563-570 P M ID 12728091 G uay-W ood ford LM, D esm on d R A [2003] A u toso m al recessive polycystic kidney disease: th e clinical e x p e rience in North A m erica. Pediatrics 111:1072-80 P M ID 127432 42 A rgov Z, Eisenberg I, G ra b o v-N a rd ini G et al [2003] H ereditary inclusion body m yopathy: th e M iddle E astern g enetic cluster. Neurology 60:1519-1523 P M ID 12746391 Johnson CA, G issen P, S ergi C [2003] M olecular pathology and genetics o f congenital hepatorenal fib ro cystic syndrom es. J M ed G enet 40:311-9 P M ID 1275595 7 C ohen MS, M oley JF [2003] S u rgical tre a tm e n t o f m edullary thyroid carcinom a. J Intern M e d 253:616 -26 P M ID 12767644 A ntzelevitch C, Brugada P, B rugada J et al [2003] B rugada syndrom e 1992-2002: a historical p erspective. J A m Coll Cardiol 41:1665-71 P M ID 12807981 A rs E, K ruyer H, Morell M et al [2003] R ecu rrent m utations in the NF1 gene are com m on am ong n e u rofibrom a tosis type 1 patients. J M ed G enet 40:e 8 2 P M ID 1280932 5 Sm ith RJH, H one S [2003] G e n e tic screening fo r deafness. Pediatr Clin N Am 50:315-329

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Selected readings>Additional journal references P M ID 1 2 8 1 0 4 8 6 T e u n isse n LL, N o te rm a n s NC, F ranssen H et al [2 0 0 3 ] D ise a se c o u rse o f C h a rc o t-M a rie -T o o th disease type 2: a 5 -y e a r fo llo w up study. Arch N eurol 6 0 :8 2 3 -8 P M ID 1 2 8 1 5 1 4 1 H udson BG , T ryg g v a s o n K, S u n d a ra m o o rth y M et al [2 0 0 3 ] A lp o rt’s syn d ro m e , G o o d p a s tu re ’s syn drom e, and type IV c o lla g e n . N Engl J M e d 3 4 8 :2 5 4 3 -5 6 P M ID 1 2 8 4 2 3 7 3 R o sse tti S, C h a u ve a u D, K u b ly V et al [2003] A s s o c ia tio n o f m utation position in po ly c ys tic kidney disease 1 (P K D 1 ) g e n e and d e v e lo p m e n t o f a v a s c u la r phenotype . Lancet 361:219 6-201 P M ID 1 2 8 4 5 3 3 3 G arg V, K a th iriya IS et al [2003] G A T A 4 m utations ca u s e hum an con g e n ita l heart d e fe cts and reveal an interaction w ith T B X 5 . N ature 4 2 4 :4 4 3 -7 P M ID 1 2 8 4 6 7 3 4 R ossetti S, T orra R, C oto E et al [2003] A com plete m u ta tio n screen o f PKHD1 in a u to s o m a l-re c e s s iv e polycystic k id n e y d ise a se (A R P K D ) p e d ig re e s. Kidney Int 6 4:391-403 P M ID 1 2 8 6 7 6 0 8 R ibic C M , S a rg e n t DJ, M oore MJ et al [2003] T u m o r m ic ro s a te llite -in s ta b ility s ta tu s as a p re d ic to r o f ben e fit from flu o ro ura cil based a d ju v a n t c h e m o th e ra p y fo r colon cancer. N Engl J M e d 3 4 9 :2 4 7 -57 P M ID 128757 7 1 A lca la i R, M e tz g e r S, R o se n h e ck S et al [2003] A re ce ssive m uta tio n in d e sm o p la kin ca u se s a rrh yth m o g e n ic right v e n tric u la r d ysp lasia, skin d isorder, and w o o lly hair. J Am Coll Cardiol 4 2 :3 1 9 -2 7 P M ID 1 2 8 8 1 4 4 3 G a rcia -C a stro M, R e g u e ro JR, B atalla A et al [2003] H yp e rtro p h ic ca rd io m yo p a th y: low fre q u e n cy o f m utations in the m yosin heavy chain (M Y H 7 ) and ca rd ia c tro p on in T (T N N T 2) g e n e s a m ong S p a n ish patients. Clin C hem 49(8): 1279-1285 P M ID 1 2 9 0 7 8 8 9 C h u rch J, S im m a n g C [2003] P ractice param ete rs fo r th e tre a tm e n t o f pa tie n ts w ith d o m in a n tly inherited colorectal c a n c e r (fam ilial a d e n o m a to u s p olyposis and he re d ita ry non p o l y p o s is c o lo re cta l can ce r). Dis Colon R ectum 4 6:1 0 0 1 -1 2 P M ID 1 2 9 2 7 4 3 1 C hen L, Lee L, K u d lo w B A et al [2003] LM N A m uta tio n s in a typ ica l W e rn e r s yndrom e. Lancet 3 6 2:440 -5 P M ID 1 2 9 2 8 4 8 6 K riau cionis S, Bird A [2003] D N A m e thylation and R e tt syn d ro m e . H um M ol G en 12(R eview Issue 2):R 2 2 1 -R 2 2 7 P M ID 129309 3 1 S p e is e r PW , W h ite PC [2003] C ongenital adrenal h y p e rp la sia . N Engl J M e d 349 :7 7 6 -8 8 P M ID 1 2 9 6 0 2 2 0 S a nca nd i M, G riseri P, P e sce B et al [2003] S ingle n u cle o tid e p o lym o rp h ic a lle le s in th e 5 ’ region o f th e R E T pro to o n c o g e n e d e fin e a risk ha p lo typ e in H irs c h s p ru n g ’s disease. J M e d G enet 4 0 :7 1 4 -8 P M ID 1 2 9 6 0 8 0 7 R eid R, de S ilva M, P a terson L et al [2003] Low g ra d e fib ro m yxo id sa rco m a and h ya lin izin g sp in d le cell tu m o r w ith g ia n t rosettes share a co m m o n t(7 ;1 6 )(q 3 4 ;p 1 1 ) translocation. A m J Surg Pathol 2 7 :1 2 2 9 -1 2 3 6 P M ID 1 2 9 7 0 2 6 3 M an to va n i G, M a ghnie M, W e b e r G et al [2003] G row th h o rm o n e -re le a sin g ho rm o n e resista n ce in pse u d o h yp o p a ra th yro id ism ty p e 1a: N ew e v id e n ce fo r im p rinting o f the G s-a g ene. J Clin Endocr M etab 8 8 :4 0 7 0 -4 0 7 4 P M ID 1 2 9 7 0 3 1 8 C ollins M T, S arlis NJ, M erino MJ et al [2003] T h y ro id c a rcin o m a in the M cC u n e -A lb rig h t syndrom e: con trib u to ry role o f activa tin g G (s)-a m utations. J Clin Endocr M etab 88:4413 44 1 7 P M ID 1 3 0 9 1 8 2 B rugada P, B rugada J [1992] R ight b u ndle-branch block, p e rs is te n t S T se g m e n t ele va tio n and sudden cardiac de a th : a d istin ct clinical and e le c tro c a rd io g ra p h ic syndrom e. A m u ltice n te r report. J A m Coll Cardiol 2 0 :1 3 9 1 -6 P M ID 1 34 3 5 2 0 3 Jervell A, L a n g e -N ie lse n F [1957] C ongenital deafm u tism , fu n ctio na l he a rt dise a se w ith p ro lo ng a tio n o f th e Q -T interval and su d den death. Am H eart J 5 4:59-68

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P M ID 1 355534 Phillips AD , S chm itz J [1992] Fam ilial villous atrophy: a clinicopathological survey o f 23 cases. J Pediatr Gastroenterol N utr 14:380 P M ID 138513 19 G orlin RJ, G oltz R W [1960] M ultiple nevoid basal cell epitheliom a, ja w cysts and bifid rib. A syndrom e. N Engl J M ed 262:908-912 P M ID 143325 45 Eng C, M ulligan LM [1997] M utations o f the RET protoo nco gene in th e m ultiple endo crine neoplasia type 2 syndrom es, related sp oradic tum ours, and H irschsprung disease. Hum Mutat 9:97-109(3— P M ID 143325 45 E n zinger F [1968] C lear cell sarcom a o f tendons and aponeuroses: an analysis o f 21 cases. Cancer 18:1163-1172 P M ID 143654 2 Shevell M [1992] R acial hygiene, active euthanasia, and Julius H allervorden. Neurology 4 2:2214-9 P M ID 144028 57 H olt M, O ram S [1960] Fam ilial heart disease w ith skeletal m alform ations. B r H eart J 22:236-42 P M ID 145180 66 C elli J, van Bokhoven H, B runner HG [2003] Feingold syndrom e: clinical review and genetic m apping. Am J M ed G enet 122:294-300 P M ID 14560536 A ltiok S. M olecular m arkers in cervical cytology [2003] Clin Lab M ed 23:709-728 P M ID 145625 76 S te w art DR, Von A llm en D [2003] The genetics of H irschsprung disease. Gastroenterol Clin N Am 32:819-837 P M ID 145625 78 Kam ath BM, Piccoli D A [2003] H eritable disorders of th e bile ducts. Gastroenterol Clin North Am 32:857-75 P M ID 145708 18 H eckm ann JM , Low W C , de V illiers C et al [2004] Novel presenilin 1 m utation w ith profound neurofibrillary pathology in an indigenous S outhern A frican fam ily w ith early o nset A lzheim er disease. Brain 127:133-42 P M ID 14576472 W right CL, S tew art ID [2003] H istopathology and m ism atch repair status o f 458 consecutive colorectal carcinom as. Am J Surg Pathol 27:1393-1406 P M ID 14600022 Fitze G, A p pelt H, Konig IR et al [2003] Functional haplotypes o f the R ET p rotoo nco gene prom oter are associated w ith H irschsprung disease (H SC R ). Hum M ol G enet 12:3207-14 P M ID 14623800 B rugada J, B rugada R, B rugada P [2003] D eterm inants o f sudden ca rd ia c death in individuals w ith the elec trocardiographic pattern o f B rugada syndrom e and no previous cardiac arrest. Circulation 108:3092-6 P M ID 14633923 G arcia-B arcelo M, Sham M, Lee W et al [2004] Highly recurrent R ET m utations and novel m utations in genes o f the receptor tyrosine kinase and endothelin receptor B pathw ays in C hinese patients w ith sp oradic H irschsprung disease. Clin Chem 50(1):93-100 P M ID 14640030 C onnors LH, Lim A, P rokaeva T et al [2003] Tabulation o f hum an transthyretin (TTR ) variants, 2003. Amyloid 10:160-84 PM ID 14657531 V lahovic G, C raw ford J [2003] A ctivation o f tyrosine kinases in cancer. Oncologist 8 (6 ):5 3 1-538 PM ID 14662701 T abib A, Loire R, C halabreysse L et al [2002] C ircum stances o f death and gross and m icroscopic observa tions in a series o f 200 cases o f sudden death associated with arrhythm og enic right ve n tricu la r card iom yopathy and/or dysplasia. Circulation 108:3000-5 PM ID 14680306 H sieh K, A lbertsen PC [2003] P opulations at high risk fo r prostate cancer. Urol Clin N Am 30:669-676 PM ID 14695542 A riyurek Y, Lantinga-van Leeuw en I, S pruit L et al [2004] Large deletions in the p olycystic kidney disease 1 (P KD 1) gene. Hum M utat 23:99 PM ID 14711914 W ilson PD [2004] M echanism s o f disease: poly cystic kidney disease. N Engl J M ed 350:151-64

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Selected readings>Additional journal references P M ID 14722160 M cC arthy Ml [2004] P rogress in defining the m olec ular basis o f type 2 diabetes m ellitus through susceptibility-gene identification. Hum M ol G enet 13, R eview lssue:R 33-R 41 P M ID 14746508 S piegel AM , W einstein LS [2004] Inherited diseases involving G proteins and G protein-coupled receptors. Annu R ev M ed 55:27-39 PM ID 14755011 Thull DL, V ogel V G [2000] R ecognition and m anagem en t o f hereditary breast can ce r syndrom es. Oncologist 9:13-24 P M ID 14764623 Bertram L, Tanzi RE [2004] A lzh e im e r disease: one disorder, too m any genes? Hum an Molecular Genetics 13(R eview Issue 1):R135-R141 P M ID 14764625 M athew CG, Lew is C M [2004] G enetics o f inflam m atory bowel disease: progress and prospects. Hum M ol G enet 13:R 161-R 168 PM ID 14986482 H attori T, Takei Y, K oyam a J et al [2003] C linical and pathological studies o f ca rd ia c am yloidosis in transthyretin type fam ilial am yloid polyneuropathy. Amyloid 10:229-39 P M ID 15053891 P ugliese A [2004] G enetics o f type 1 diabetes. Endocrinol M etab Clin N A m 33:1-16 P M ID 15087661 O ’Brien MJ, Y ang S, C lebanoff JL et al [2004] H yperplastic (serrated) polyps o f the colorectum : relationship of C pG island m ethylator phenotype and K-ras m utation to location and histologic subtype. Am J Surg Pathol 28:423-434 P M ID 15087667 Y a m a m oto H, O da Y, Kaw aguchi K et al [2004] C -kit and P D G FR A m utations in extragastrointestinal strom al tum o r (gastrointestinal strom al tu m o r o f the soft tissue). Am J Surg Pathol 28:479-488 P M ID 15108277 Bergm ann C, S e nderek J, K u pper F et al [2004] PKHD1 m utations in autosom al recessive polycystic kidney disease (A R P KD ). Hum M utat 23:453-63 P M ID 15108281 B ergm ann C, S e nderek J, S chne ider F et al [2004] PKHD1 m utations in fam ilie s requesting prenatal diagnosis for autosom al recessive p olycystic kidney disease (A R P KD ). Hum Mutat 23:487-95 P M ID 1 5 1 11691 Fabrizi G M , C avallaro T, A ngiari C et al [2004] G iant axon and neurofilam ent accum ulation in C harcot-M arie-Tooth disease type 2E. Neurology 62:1429-31 P M ID 15120667 D eutsch E, M aggiorella L, Eschw ege P et al [2004] E nvironm ental, genetic, and m olecular feature s o f prostate cancer. Lancet Oncol 5:303-13 P M ID 15126527 Lum broso S, Paris F, Sultan C [2004] A ctivating G s-a m utations: A n alysis o f 113 patients w ith signs o f M cC uneA lbright syndrom e. J Clin Endocr M etab 89:2107-2113 PM ID 15143298 A m berla K, W aljas M, Tuom inen S et al [2004] Insidious cognitive decline in C A D A S IL. Stroke 35:1598-602 P M ID 15166662 V an den Bos M, V an den H oven M, Jongejan E et al [2004] M ore differences betw een H N P C C -related and sporadic carcinom as from the endom etrium as com pared to the colon. Am J Surg Pathol 28:706-711 P M ID 15169807 Johnson DH, F e hre nbacher L, N ovotny W F et al [2004] R andom ized phase II trial com paring bevacizum ab plus carboplatin and paclitaxel w ith carboplatin and paclitaxel alone in previously untreated locally advanced or m etastatic non sm all cell lung cancer. J Clin Oncol 2 2 (1 1):2184-2191 P M ID 15175440 P ietrangelo A [2004] H ereditary hem ochrom atosis: a new look at an old disease. N Engl J M ed 350(23):2383-2397 P M ID 15184603 M argallo-Lana M, M orris CM , G ibson AM et al [2004] Influence o f the am yloid p recursor protein locus on dem entia in Down syndrom e. Neurology 62:1996-8 PM ID 15187773 G ariepy E [2004] D evelopm ental disorders o f the enteric nervous system : G enetic and m olecular bases. J Pediatr Gastroenterol Nutr 39:5-11 © A S C P 2018

P M ID 151901 40 Looser RR, Kim J, B u tm an JA et al [2004] T u m o rs o f the e n dolym phatic sac in von H ippel Lindau disease. N Engl J M ed 350:2481-6 P M ID 15190457 B aser ME, K uram oto L, Joe H et al [2004] G enotype-ph enotype correlations fo r nervous system tu m o rs in n eurofibrom atosis 2: a population based study. Am J H um G enet 75:231-9 P M ID 15223958 M edeiros F, C orless C L, D uensing A et al [2004] K IT -negative gastrointestinal strom al tum ors. P ro of o f con ce p t and thera p e u tic im plications. Am J Surg Pathol 28:889-894 P M ID 1522516 4 Kam boh Ml [2004] M o le cu la r g e n e tics o f late o nset A lzh e im e r disease. Ann Hum G enet 6 8:381-404 P M ID 1523399 3 Du M, Zhou W , B e atty LG et al [2004] The K C N Q 1 0 T 1 prom oter, a key re g u la to r o f g e n o m ic im printing in hum an chro m o so m e 11 p15.5. Genom ics 8 4:288-3 00 P M ID 1524815 3 W ijsm an EM, Daw EW , Yu C E et al [2004] E vidence fo r a novel late o nset A lzheim er disease locus on chro m o so m e 19p13.2. Am J Hum G enet 75:398-409 P M ID 1524961 2 A ylw ard EH, Sparks BF, Field KM et al [2004] O nset and rate o f striatal atrophy in preclinical H untington disease. Neurology 63:66-72 P M ID 1526621 2 H w ang PJ, K o usseff BG [2004] O m p halocele and gastroschisis: an 18-year review study. G enet M ed 6(4):2 32-6 P M ID 15282353 V e ugelers M, Bressan M, M cD e rm o tt D A et al [2004] M utation o f perinatal m yosin heavy chain associa ted w ith a C arney com plex variant. N Engl J M ed 3 5 1 :460-9 P M ID 1530248 5 Fradet Y, Saad F, A p rikia n A et al [2004] U P M 3, a new m olecular urine test for th e detection o f prostate cancer. Urology 64:311-316 P M ID 15316311 B ruder E, Passera O, H arm s D et al [2004] M o rphologic and m olecular ch aracterization o f renal cell c a rc i nom a in children and young adults. A m J Surg Pathol 28 :1 1 1 7 1132 P M ID 1532743 5 K ashtan CE [2004] D ia g n o sis o f A lp o rt syndrom e. Kidney Int 66:1290-1 P M ID 15331282 T ow bin JA [2004] M o le cu la r g e n e tic basis o f sudden cardiac death. Pediatr Clin N A m 2004;5 1 :1 2 2 9 -1 2 5 5 P M ID 15331579 S antoro M, M elillo RM, C a rlom agno F et al [2004] RET: norm al and abnorm al functions. Endocrinology 145:5448-51 P M ID 15358725 Irobi J, De Jonghe P, T im m e rm a n V [2004] M o le cu la r genetics o f distal hereditary m o to r n e urop athies. Hum M ol G enet 13(R eview Issue 2):R 1 9 5 -R 2 0 2 P M ID 15389252 D ong SM , Lee EJ, Jeon ES et al [2005] P rogressive m ethylation during the serrated neoplasia pathw ay o f the colorectum . M od Pathol 18:170-178 P M ID 15454881 G arner HP, Phillips JR, H erron JG et al [2004] P eroxidase activity w ithin circulating neutrophils correlates w ith pulm onary phenotype in cystic fibrosis. J Lab Clin M ed 144:127-33 P M ID 1546771 3 Brunelli M, Eble JN, Z h a n g S e t al [2005] E o sinophilic and classic ch rom ophob e renal cell carcin o m a s have sim ila r fre q u e n t losses of m ultiple ch ro m o so m e s from am ong chrom osom es 1 , 2 , 6, 10, and 17, and this pattern o f g e n e tic abnorm a lity is not present in renal o n cocytom a. M od Pathol 18:161-169 P M ID 15489648 Yang S, Farraye FA, M ack C e t al [2004] B R A F and KR AS m utations in hyperplastic polyps and serrated aden o m a s o f the colorectum relationship to h isto lo g y and C pG island m e th ylation status. Am J Surg Pathol 2 8 :1452 -1459 P M ID 15489853 G erull B, H euser A, W ic h te r T et al [2004] M u tations in the desm osom al plakophilin-2 a re com m on in a rrh yth m o g e n ic right ve ntricular cardiom yopathy. N a t G enet 36:1162-4

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Selected readings>Additional journal references P M ID 1 5528021 Ellis I [2004] G e n e tic co u n se lin g fo r hereditary p a n c re a titis — th e role o f m o le c u la r g e n e tic s te sting fo r the c a tio n ic tryp sin o g e n gene, c ystic fib ro s is and se rin e protea se in h ib ito r K azal typ e 1. G astroenterol Clin N A m 33:839-854 P M ID 1 5 5 4 0 1 1 9 S ch m id t H, B artel F, K a p p le r M et al [2005] G ains o f 13q are co rrelated w ith a p o o r p ro g n o sis in lip o sa rco m a . M od Pathol 18:63 8 -6 44 P M ID 1 5 5 6 1 8 0 2 R eed M J, P u rohit A, W o o LW L et al [2005] Steroid s u lfa ta s e : m o le c u la r biology, re gulation, and inhibition. Endocr R e v 2 6(2): 171-202 P M ID 1 5 5 7 7 6 7 3 C h a p u s o t C, M artin L, P uig PL et al [2004] W h a t is th e b e st w a y to a sse ss m icro sa te llite in sta b ility status in c o lo re c ta l c a n ce r? S tu d y on a p o p u la tio n base o f 462 colorectal ca n ce rs. Am J Surg Pathol 2 8 :1 5 5 3 -1 5 5 9 P M ID 1 5 6 1 3 8 5 6 M iettinen M, S o bin LH, Laso ta J [2005] G a stro in te s tin a l strom al tu m o rs o f the stom ach : a clin ico p a th o logic, im m u n o h isto ch e m ica l, and m o le c u la r g e n e tic stu d y o f 1765 c a s e s w ith long te rm fo llo w up. Am J Surg Pathol 29:52-68 P M ID 1 5 6 3 7 1 3 0 D uffy MJ [2005] P re d ictive m a rke rs in bre a st and o th e r cancers: a review . Clin C hem 5 1 (3 ):4 9 4 -5 0 3 P M ID 1 5644781 A rg a n i P, Lae M, H u tch in so n B et al [2005] Renal c a rc in o m a s w ith th e t(6 ;1 1 )(p21 ;q12): clin ic o p a th o lo g ic feature s and d e m o n s tra tio n o f th e sp e c ific a -tfe b g e n e fusion by im m un o h isto ch e m istry, R T -P C R , and D N A PC R . Am J Surg Pathol 2 9 :2 3 0 -2 4 0 P M ID 1 5 6 4 4 7 8 4 C a rn e y JA [2005] Fam ilial m u ltip le endo crin e n e o p la sia : th e firs t 100 years. A m J Surg Pathol 29:254-274 P M ID 1 5 6 4 5 6 4 2 Ikeda S [2004] C a rd ia c a m ylo id o sis: h e tero genous p a th o g e n ic b a ckg ro u n d s. Intern M e d 4 3 :1 1 0 7 -1 4 P M ID 1 5 6 6 0 5 2 6 R o w le y PT [2005] In herited su sce p tib ility to c o lo re c ta l cancer. A nnu R ev M ed 56:539-54 P M ID 1 5 6 9 0 6 5 7 O ncel M, C hurch JM , R em zi FH et al [2005] C o lo n ic s u rg e ry in p a tie n ts w ith ju v e n ile p o lyp o sis syn drom e: a case se rie s. Dis Colon and Rectum 48:4 9 -5 6 P M ID 1 5 6 9 8 4 2 3 B e rg m a n n C, S e n d e re k J, W in d e le n E et al [2005] C lin ica l co n s e q u e n c e s o f PKHD 1 m u ta tio n s in 164 patients w ith a u to s o m a l-re c e s s iv e po ly c ys tic k idney dise a se (A R P K D ). Kidney Int 6 7 :8 2 9 -4 8 P M ID 1 5 7 1 4 0 5 7 K e lley TW , T u b b s RR, P rayson R A [2005] M o le cu la r d ia g n o s tic te ch n iq u e s fo r the clinical e valuation o f gliom as. Diagn M o l Pathol 14:1-8 P M ID 1 5728811 K o b a ya sh i S, B o g g o n TJ, D aya ram T et al [2005] E G F R m uta tio n and re sista n ce o f non sm all cell lung c a n ce r to g e fitin ib . N Engl J M e d 3 52:786 -92 P M ID 1 5 7 3 1 7 7 5 H a lva rsso n B, L in d b lo m A, Jo h a n sso n L et al [2005] Lo ss o f m ism a tch re p a ir protein im m u n o sta in in g in colorectal a d e n o m a s from patients w ith h e re d ita ry n o n polyp o sis colorectal c a n ce r. M od Pathol 18:1095-1101 P M ID 1 5 7 4 3 7 3 7 La P, T an LK, C hen B [2005] C orre la tio n o f H ER -2 s ta tu s w ith e stro g e n a nd p ro g e ste ro n e re ce p to rs and histologic fe a tu re s in 3,655 invasive b re a st carcinom as. Am J Clin Pathol 1 2 3 :5 4 1 -5 4 6 P M ID 1 5 7 4 5 9 7 6 Bird TD [2005] G e n e tic fa cto rs in A lz h e im e r disease. N Engl J M ed 3 52(9 ):8 6 2 -8 6 4 P M ID 1 5 7 4 7 1 1 9 F ra n ch in i M, V e n e ri D [2005] R e ce nt advances in h e re d ita ry h e m o ch ro m a to sis. Ann H em atol 8 4 (6):347-352 P M ID 1 5 7 4 9 2 3 5 H ahn SA, B a rtsch D K [2005] G e n e tics o f hereditary p a n c re a tic c arcinom a. Clin Lab M e d 2 5 :1 1 7 -1 3 3 P M ID 1 5 7 4 9 2 3 7 G o logan A, S e p u lve d a A R [2005] M icrosatellite in s ta b ility and D N A m ism atch repair d e fic ie n c y testin g in he re d i ta ry and sp o ra d ic ga stro in te stin a l cancers. Clin Lab M ed 25:179196

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P M ID 1 5767813 M oskaluk C A [2005] V a nishing prostate cancer syndrom e: sym ptom o f a la rg e r clinical issue. Am J Surg Pathol 29:561-563 P M ID 1 5780076 Ong AC, H arris PC [2005] M olecular pathogenesis o f A D PK D : the polycystin com plex gets com plex. Kidney Int 67:1234-47 P M ID 1 5832087 Y a tabe Y, Kosaka T, T akahashi T et al [2005] EG FR m utation is specific fo r term inal respiratory unit type adenocarcinom a. Am J Surg Pathol 29:633-639 P M ID 1 5848737 Jones TD , Eble JN, C heng L [2005] A pplication of m olecular d iagnostic te ch n iq u e s to renal epithelial neoplasm s. Clin Lab M ed 25:279-303 P M ID 1 5858144 S chuetz AN , Y in-G oen Q, A m in M B et al [2005] M olecular classification o f renal tum ors by gene expression profiling. J M ol Diagn 7(2):206-18 P M ID 15872200 H am pe J, Frenzel H, M irza MM et al [2002] E vidence fo r a N O D 2-independ ent susceptibility locus fo r inflam m atory bow el disease on chro m o so m e 16p. Proc Natl A cad Sci 99(1 ):321-6(3— P M ID 15872200 H am pel H, Frankel W L, M artin E et al [2005] S creening fo r the Lynch syndrom e (hereditary nonpolyposis colorectal cancer). N Engl J M ed 352:1851-60 P M ID 1 5888700 R ow e SM, M iller S, S o rscher EJ [2005] C ystic fibrosis. N ew Engl J M ed 352:1992-2001 P M ID 1 5897742 T akazaw a Y, S akurai S, S akum a Y et al [2005] G astrointestinal strom al tum ors o f neurofibrom atosis Type I (von R ecklinghausen’s disease). Am J Surg Pathol 29:755-763 P M ID 159123 65 Poki HO, H olland AJ, Pitkin J [2005] D ouble bubble, double trouble. Pediatr Surg Int 2 1 :428-31 P M ID 1 5922438 R am asam y R, H aviland M, W oodard JR, Barone JG [2005] Patterns o f inheritance in fam ilial prune belly syndrom e. Urology 65:1227,e26-1227.e27 P M ID 1 5939196 V on M ehren M, W atson JC [2005] G astrointestinal strom al tum ors. Hem atol Oncol Clin N Am 19:547-564 P M ID 1 5944708 Lu J, G etz G, M iska EA et al [2005] M icroR N A expression profiles classify hum an cancers. Nature. 2005; 435(70 43):834-8 P M ID 1 5954103 Nagel M, N agorka S, G ross O [2005] Novel C O L4A5, C O L4A4, and C O L4 A 3 m utations in A lport syndrom e. Hum Mutat 26 P M ID 1 5956637 Litm an RS, R osenberg H [2005] M alignant hyper therm ia: update on susceptibility testing. JAMA 293:2918-2924 P M ID 1 5981814 Tabernero MD, E spinosa AB, M aillo A et al [2005] C haracterization o f chrom osom e 14 abnorm alities by interphase in situ hybridization and com parative genom ic hybridization in 124 m eningiom as: correlation w ith clinical, histopathologic, and prognostic features. Am J Clin Pathol 123:744-751 P M ID 1 5983293 Ng B, C onnors LH, D avidoff R et al [2005] Senile system ic am yloidosis presenting w ith heart failure: a com par ison with light chain associated am yloidosis. Arch Intern M ed 165:1425-9 P M ID 15990899 Laakso M, Lom an N, Borg A, Isola J [2005] C K 5/14positive breast cancer: true basal phenotype confined to BRCA1 tum ors. Mod Pathol 18:1321-1328 P M ID 16009758 A ndo Y, N akam ura M, A raki S [2005] Transthyretin related fam ilia l am ylo id o tic polyneuropathy. Arch Neurol 62:1057-62 P M ID 16014887 Krause DS, Van Etten R A [2005] Tyrosine kinases as targets fo r can ce r therapy. N Engl J M ed 353:172-87 P M ID 16049303 P rior TW , Bridgem an SJ [2005] D uchenne m uscular dystrophy. J M ol Diagn 7(3):3 17-326

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Selected readings>Additional journal references P M ID 16096413 D ow ns-K elly E, Y o d e r BJ, S taler M et al [2005] The influence o f polysom y 17 on H E R 2 gene and protein expression in adenocarcinom a o f the breast: a flu o re sce n t in situ hybridiza tion, im m unohistochem ical, and isotopic m R N A in situ hybridiza tion study. Am J Surg Pathol 29:1221 -1227 P M ID 16118624 O gino S, B rahm andam M, C an to r M et al [2006] D istinct m olecular features o f colorectal carcinom a w ith signet ring cell com ponent and colorectal carcinom a w ith m ucinous com ponent. M od Pathol 19:59-68 P M ID 16191506 S nover DC, Jass JR, Fenog lio-P reiser C et al [2005] S errated polyps o f th e large intestine: a m orphologic and m olec ular review o f an evolving concept. Am J Clin Pathol 124:380-391 P M ID 1620328 5 G upta M, D jalilvand A, Brat DJ [2005] C larifying the diffuse gliom as: an update on the m orphologic feature s and m arkers th a t discrim inate oligodendrog liom a from astrocytom a. Am J Clin Pathol 124:755-768 P M ID 16207846 D rum m ML, K onstan MW , S chluchter MD et al [2005] G enetic m odifiers o f lung disease in cystic fibrosis. N Engl J M ed 353:1443-53 P M ID 16236735 Burstein HJ [2005] The distinctive nature o f H ER2positive breast cancers. N Engl J M ed 353(16): 1652-1654 P M ID 16253016 Burgart LJ [2005] T esting fo r defective DNA m ism atch repair in colorectal carcinom a: a practical guide. Arch Pathol Lab M ed 129:1385-1389 P M ID 16253017 G ologan A, K rasinskas A, H unt J et al [2005] P erform ance o f the revised B ethesda guidelines fo r identification of colorectal carcinom as w ith a high level o f m icrosatellite insta bility. Arch Pathol Lab M ed 129:1390-1397 P M ID 16258500 Patel RM, D ow ns-K elly E, W eiss SW et al [2005] D ual-color, break-apart fluorescence in situ hybridization fo r E W S gene rearrangem ent distinguish es clea r cell sarcom a o f soft tissue from m alignant m elanom a. M od Pathol 18:1585-1590 P M ID 16311597 Z e n ke r M, M ayerle J, Lerch MM et al [2005] D eficiency o f U B R 1, a ubiquitin ligase o f the N-end rule pathw ay, causes pancreatic dysfunction, m alform ations and m ental retar dation (Johanson-B lizzard syndrom e). N at G enet 37:1345-50 P M ID 16327429 Lefevre M, C outurier J, S ibony M et al [2005] A d ult papillary renal tu m o r w ith onco cytic cells: clinicopathologic, im m u nohistochem ical, and cytogenetic features o f 10 cases. Am J Surg Pathol 29:1576-1581 PM ID 16344347 Boito CA, M elacini P, V ianello A et al [2005] C linical and m olecular characterization o f patients w ith lim b-girdle m uscular d ystrophy type 2I. Arch Neurol 62:1894-9 PM ID 16393683 N ichols L, Dickson G, Phan PG et al [2006] Iron binding saturation and gen o typ ic testing fo r hereditary hem ochro m atosis in patients w ith liver disease. Am J Clin Pathol 125:236240 P M ID 16436638 Pyatt RE, Pilarski R, P rior TW [2006] M utation screening in ju ve n ile polyposis syndrom e. J Mol Diagn 8(1):84-8 PM ID 16470553 Jaaskelain en J, M ongan NP, H arland S et al [2006] 5 novel androgen receptor gene m utations associated with com plete androgen insensitivity syndrom e. Hum Mutat 876:O nline PM ID 16523049 A d eva M, E l-Y oussef M, R ossetti S et al [2006] Clinical and m olecular characterization defines a broadened spectrum o f autosom al recessive polycystic kidney disease (A R P KD ). Medicine 85:1-21 PM ID 16530074 Jones JS [2006] D N A based m olecular cytology for bladder cancer surveillance. Urology 67(S uppl 3A ):35-47 PM ID 16531766 Kazam a Y, W ata nabe T, Kanazaw a T et al [2006] M ucinous colorectal cancers w ith chrom osom al instability. A biologically distinct and aggressive subtype. Diagn Mol Pathol 15:30-34 © A S C P 2018

P M ID 16534111 B a ser ME, Friedm an JM , E vans DG [2006] Increasing the specificity o f d iagnostic criteria fo r sch w a n n o m a tosis. Neurology 66:730-2 P M ID 16538061 B u tnor KJ, G uinee DG [2006] P le u ropulm onary pathology o f B irt-H ogg-D ube syndrom e. Am J Surg Pathol 30:395-399 P M ID 16571431 N ew m an EA, M ulholland M W [2006] P rophyla ctic gastrectom y fo r hereditary diffuse ga s tric c a n c e r syndrom e. J Am Coll Surg 202:612-617 P M ID 1657188 2 T ryggvason K, P a trakka J, W a rtio va ara J [2006] H ereditary proteinuria syndrom es and m e chanism s o f proteinuria. N Engl J M ed 354:1387-401 P M ID 1658092 2 Led b e tte r DJ [2006] G a stro sch isis and o m phalocele. Surg Clin N Am 86:249-260 P M ID 1660691 2 R ose nbla tt A, Liang KY, Zh o u H et al [2006] T he association o f C AG repeat length w ith clinical progression in H untington disease. Neurology 66:1 0 1 6 -1 0 2 0 P M ID 1663209 0 Z e n ke r M, M ayerle J, R eis A et al [2006] G e n e tic basis and p a ncreatic biology o f Jo h a n so n -B lizza rd syndrom e. Endocrinol M etab Clin N Am 3 5:243-253 P M ID 166320 93 W e iss FU, Sim on P, M a ye rle J et al [2006] G e rm line m utations and gene polym orphism a sso cia te d w ith hum an pancreatitis Endocrinol Metab Clin N A m 35:28 9 -302 P M ID 1663209 8 Trajkovskia M, M ziauta H, S ch w a rz PE et al [2006] G enes o f type 2 diabetes in |3 cells. Endocrinol M etab Clin N Am 35:357-369 P M ID 16632099 V axillaire M, Froguel P [2006] G e n e tic basis o f m aturity-onset d iabetes o f the young. Endocrinol M etab Clin N Am 35:371-384 P M ID 1668388 8 H aas M [2006] Thin g lo m e ru la r basem ent m em brane nephropathy: incidence in 3471 c o n se cutive renal biopsies exam ined by electron m icroscopy. Arch Pathol Lab M ed 130:699-706 P M ID 16699319 T h o rn e r PS, Ho M, C h ilton-M a cN eill S et al [2006] U se o f chrom ogenic in situ hybridization to identify M Y C N gene copy num ber in neuroblastom a using routine tissu e sections. Am J Surg Pathol 30:635-642 P M ID 16707747 Pritchard Kl, S hepherd LE, O ’M alley FP et al [2006] H ER 2 and re sponsiveness of bre a st c a n c e r to a d ju va n t c h e m o therapy. N Engl J M ed 354:2103-11 P M ID 1673177 B ushby KM, T ham byayah M, G a rdner-M edw in D [1991] P revalence and incidence o f B e cker m u scu la r dystrophy. Lancet 337:1022-4 P M ID 167380 2 Keating MT, A tkinson D, D unn C et al [1991] Linkage o f a cardiac arrhythm ia, the long Q T syn d ro m e , and the H arvey ras-1 gene. Science 252:704-6 P M ID 16740032 Trpkov K, G ao Y, H ay R et al [2006] N o residual cancer on radical prostatectom y a fte r p o sitive 10-core biopsy: incidence, biopsy findings, and D N A sp e cim e n identity analysis. Arch Pathol Lab M ed 130:811-816 P M ID 167536 05 O akley GJ, Tubbs RR, C ro w e J et al [2006] H E R -2 am plification in tu bular carcinom a o f the breast. Am J Clin Pathol 126:1-4 P M ID 167751 20 del C astillo I, V illa m a r M, M o re n o -P elayo M A et al [2002] A deletion involving the connexin 30 gene in nonsyn d ro m ic hearing im pairm ent. N Engl J M e d 346:2 4 3 -9 P M ID 16775120 D elahunt B, Eble JN [1997] P a pillary renal cell carcinom a: a clinicopath olog ic and im m u n o h isto chem ical study o f 105 tum ors. M od Pathol 10:537-44 P M ID 16775120 D eLeeuw W J, D ierssen J, V a se n H F et al [2001] P rediction o f a m ism atch repair ge n e d e fe c t by m icrosatellite instability and im m unohistochem ical analysis in endom etrial tum o u rs from H N PC C patients. J Pathol 192:328 -35

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Selected readings>Additional journal references P M ID 1 6 7 7 5 1 2 0 D e L e n g W W J, W e s te rm a n A M , W e te rm a n M A et al [2007] N asal p o lyp o sis in P e u tz-Je g h e rs syn d ro m e : a d istin ct h isto p a th o lo g ic a l a nd m o le c u la r g e n e tic e ntity. J Clin Pathol 6 0 :3 9 2 -3 9 6 P M ID 1 6 7 9 0 6 9 3 S a n to s G C, Z ie le n ska M, P rasad M et al [2007] C h ro m o s o m e 6 p a m p lifica tio n and c a n c e r pro gression. J Clin Pathol 60 :1 -7 P M ID 1 6 8 3 1 0 3 7 F rede rick J [2006] P ick d isease: a b rie f overview . Arch Pathol Lab M e d 1 3 0 :106 3-1066 P M ID 1 6 8 6 1 1 1 4 B a lakum ara n BS, F ebbo PG [2006] N ew insights into p rostate c a n c e r biology. H em atol O ncol Clin N Am 2 0 :7 7 3 796 P M ID 1 6 8 6 4 6 4 3 V a n D e V o o rd e R, W itte D, K ogan J et al [2006] P ie rso n syn d ro m e : a novel ca u se o f cong e n ita l nephro tic syn d ro m e . Pediatrics 1 1 8 ;e 5 0 1 -e 5 0 5 P M ID 1 6 9 3 9 7 3 6 B ranski D, F a sa n o A, T ro n c o n e R [2006] Latest d e v e lo p m e n ts in th e p a th o g e n e sis a nd tre a tm e n t o f celiac d ise a se . J Pediatr 149:2 9 5 -3 0 0 P M ID 1 6 9 4 8 5 2 2 N etto G J, S aad R D [2006] D ia g n o stic m ole cu la r p a th o lo g y: an in cre a sin g ly in d isp e n sib le tool fo r th e practicing p a th o lo g ist. Arch Pathol Lab M e d 130 :1 3 3 9 -1 3 4 8 P M ID 1 7 0 6 3 0 7 4 F arshid G, B a lle in e RL, C u m m in g s M et al [2006] M o rp h o lo g y o f b re a st c a n c e r as a m e an s o f tria g e o f pa tie n ts fo r BR C A 1 g e n e tic testing. A m J Surg Pathol 3 0 :1 3 5 7 -1 3 6 6 P M ID 1 7 0 8 0 1 8 0 A n d re F, P usztai L [2006] M o le c u la r classification o f b re a s t cance r: im p lica tio n s fo r se le ctio n o f a d ju va n t c h e m o th e ra p y. N at Clin P rac One 3(11 ):6 2 1-632 P M ID 1 7 0 9 0 1 8 7 P arham D M , E llison D A [2006] R h a b d o m y o s a rc o m a s in ad ults a nd child ren: an update. Arch Pathol Lab M ed 13 0 :1 4 5 4 -1 4 6 5 P M ID 1 7 0 9 0 1 8 8 M iettinen M, Lasota J [2006] G astro in te stin a l stro m a l tu m o rs: review on m o rp ho lo gy, m o le c u la r pathology, p ro g n o sis, and d ifferential d iagnosis. Arch Pathol Lab M ed 1 3 0 :1 4 6 6 -1 4 7 8 P M ID 1 7098511 B e rn ie r FP, S p a e tg e n s R [2006] T h e g e n e tic is t’s role in a d u lt co ng e n ita l heart d isease. Cardiol Clin 24: 557-56 9 P M ID 1 7 1 2 2 5 0 4 O ’B rien M J, Y a n g S, M ack C et al [2006] C o m p a riso n o f m icro sa te llite instability, C pG island m ethylation phen o typ e , B R A F and K R A S s ta tu s in s errated polyps and tra d itio n a l a d e n o m a s ind ica te s se p a ra te p a thw a ys to d istin ct co lo re cta l c a rcin o m a end points. A m J Surg Pathol 30:1491-1501 P M ID 1 7 1 6 7 1 3 7 S a n d le r A, G ra y R, P erry M C et al [2006] P a clitaxelc a rb o p la tin a lo n e o r w ith b e va cizu m a b fo r non sm all cell lung ca n ce r. N Engl J M e d 3 5 5 (2 4 ):2 5 4 2 -2 5 5 0 P M ID 1 7 1 9 2 5 3 9 Im boden M, S w an H, D enjo y I et al [2006] Fem ale p re d o m in a n ce and tra n sm issio n d is to rtio n in the long Q T s yn d ro m e . N Engl J M e d 355:2744-51 P M ID 1 7 1 9 7 9 2 8 B a ne AL, B e ck JC , B le iw e iss I et al [2007] B R C A 2 m utation associa te d bre a st ca n ce rs e x h ib it a distinguish ing p h e n o ty p e based on m o rp h o lo g y and m o le c u la r profiles from tis su e m icro a rrays. A m J Surg Pathol 3 1 :1 2 1 -128 P M ID 1 7 2 2 7 1 18 D iF o nzo A, R ohe C F, F erreira J e t al [2005] A fre q u e n t L R R K 2 ge n e m utation associa ted w ith autosom al d o m i n a n t P a rkin s o n ’s d isease. Lancet 365:412-5(3— P M ID 172271 18 D im DC, C o o le y LD, M ira n d a RN [2007] C le a r cell sarcom a o f te n d o n s and a p o n e u ro se s. Arch Pathol Lab M ed 131:152-156 P M ID 1 7 2 2 7 1 2 7 P a ner G P, Lindgren V, Ja cobson K et al [2007] High in cid e n ce o f ch ro m o s o m e 1 a b n o rm a litie s in a series o f 27 renal o n co c y to m a s : cyto g e n e tic and flu o re s c e n c e in situ hybridization stu d ie s. Arch Pathol Lab M ed 131:81-85 P M ID 1 7 3 0 1 3 0 0 H itchins M P, W ong JJL, S u thers G et al [2007] In h e rita n ce o f a c a n c e r associa ted M LH1 ge rm lin e epim utation. N Engl J M e d 3 56 :6 9 7 -7 0 5

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P M ID 1 7336732 M ullis PE [2007] G enetics o f grow th horm one defi ciency. Endocrinol M etab Clin N Am 36:17-36 P M ID 1 7362838 F e rn e r RE [2007] N eurofibrom atosis 1 and neuro fibrom atosis 2: a 20-first century perspective. Lancet Neurol 6:340-51 P M ID 1 7516746 Li SC, B urgart L [2007] H istopathology of serrated adenom a, its variants, and differentiation from conventional adenom atous and hyperplastic polyps. Arch Pathol Lab M ed 131:440-445 P M ID 1 7550311 G ulley M L et al [2007] C linical laboratory reports in m olecular pathology. Arch Path Lab M ed 131:852-863 P M ID 1775402 B ennett MJ, R inaldo P, M illington DS et al [1991] M edium -chain a cyl-C o A dehyd ro g e n a se deficiency: postm ortem diagnosis in a case o f sudden infant death and neonatal diag nosis of an affect sibling. Pediatr Pathol 11:889-95 P M ID 1 7950381 L ancaster JM , Pow ell CB, K auff ND et al [2007] Society o f G ynecologic O ncologists E ducation C om m ittee state m e n t on riskassessm ent fo r inherited gynecologic cancer predis positions. Gynecol Oncol 107:159-62 P M ID 191251 26 Berg AO , A rm strong K, Botkin J et al [2009] R eco m m e ndations from the EG A P P W orking G roup: genetic testing strategies in new ly diagnosed individuals w ith colorectal cancer aim ed at reducing m orbidity and m ortality from Lynch syndrom e in relatives. G enet M ed 11(1 ):35-41 P M ID 19415949 Jennings L, V an D eerlin VM , G ulley M L [2009] R ecom m ended principles and practices fo r validating clinical m olecular pathology tests. Arch Path Lab M ed 133:743-755 P M ID 194446 9 W einstein LS, S h enker A, G ejm an PV et al [1991] A ctivating m utations o f the stim ula tory G protein in the M cC uneA lbright syndrom e. N Engl J M ed 325:1688-1695 P M ID 195483 75 W o lff AC, H am m ond M EH, S chw artz JN et al [2007] A m erican S ociety o f C linical O ncology/C ollege o f A m erican P athologists guideline recom m endations fo r hum an epiderm al grow th fa cto r receptor 2 testing in breast cancer. Arch Pathol Lab M ed 131:18-43 P M ID 19701074 Shia J, T ang LH, V akiani E, G uillem JG et al [2009] Im m unohistochem istry as first-line screening fo r detecting colorectal cancer patients at risk fo r hereditary nonpol yposis colorectal cancer syndrom e: a 2-antibody panel m ay be as predictive as a 4 -a n tib o d y panel. Am J Surg Pathol. 33(11): 1639-45 P M ID 19809052 W est H, H arpole D, T ravis W [2009] H istologic considerations fo r individualized system ic therap y approaches fo r the m anagem ent o f non sm all cell lung cancer. Chest 136(4): 1112-1118 PM ID 1992371 H aw ley RJ, M ilner MR, G ottdiener JS et al [1991] M yotonic heart disease: a clinical fo llo w up. Neurology 41:259-62 P M ID 20530316 A ng KK, H arris J, W h e e le r R, W ebe r R et al [2010] hum an papillom avirus and survival o f patients w ith oropharyngeal cancer. N Engl J Med. 363(1 ):24-35 P M ID 20588174 Lew is JS Jr, Thorstad W L, C hernock RD et al [2010] P16+ oropha ryngeal sq uam ous cell carcinom a: an entity w ith a favorable prognosis regardless o f tu m o r H PV status. Am J Surg Pathol 34(8): 1088-96 P M ID 206232 07 C heng H, Xu C, C osta DB et al [2010] M olecular testing in lung cancer: the tim e is now. Curr Oncol Rep 12:335348 P M ID 206295 13 Pino MS, C hung DC [2010] A pplication of m olecular diagnostics fo r the detection o f Lynch syndrom e. Expert Rev Mol Diagn 10(5):651-65

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Selected readings>Additional journal references P M ID 206650 45 R uschoff J, D ietel M, Baretton G et al [2010] H ER2 d iagnostics in ga stric cancer— guideline validation and d e ve lo p m ent o f standardized im m unohistochem ical testing. Virchow Arch 457(3):299-307 P M ID 20728210 Bang YJ, V an C utsem E, Feyereislova A et al [2010] T rastuzum ab in com bination w ith chem othera py vs chem otherapy alone fo r H E R 2 -positive advanced gastric o r gastro-oeso phageal junction cancer (ToG A ): a phase 3, open-label, random ised controlled trial. Lancet 376: 687-697 P M ID 20816579 G erstenblith MR, G oldstein AM , T u cke r M A [2010] H ereditary genode rm atoses w ith cancer predisposition. Hem atol Oncol Clin N A m 24:885-906 P M ID 2 1 125669 Farazi TA, S p itze r Jl, M orozov P et al [2011] m iR N A s in hum an cancer. J Pathol 223:102-115 P M ID 21125678 Ko JM , Fisher DE [2010] A new era: m elanom a genetics and therap eutics. J Pathol 223:241 -250 P M ID 21160525 Leem ans CR, Braakhuis BJM , B rake nhoff RH [2011] The m olecular biology o f head and neck cancer. N at R ev C ancer 11:9-21 P M ID 21204713 Igbokw e A, Lopez-Te rrada DH [2011] M olecular testing o f solid tum ors. Arch Pathol Lab M ed 135:67-82 P M ID 21238915 Bhaijee F, P e pper DJ, Pitm an KT et al [2011] New developm ents in the m ole cu la r pathoge nesis o f head and neck tum ors: a review o f tu m o r specific fusion oncogenes in m ucoepi derm oid carcinom a, adenoid cystic carcinom a, and N UT m idline carcinom a. Ann Diagn Pathol 15(1):69-77 P M ID 21526955 N ikiforov YE [2011] M olecular diagnostics o f thyroid tum ors. Arch Pathol Lab M ed 135:569-577 P M ID 21526958 H ulot JS, Jouven X, E m pana JP et al [2004] Natural history and risk stratification o f arrhythm og enic right ventricular dysplasia/cardiom yopa thy. Circulation 110:1879-84(3— P M ID 21526958 H unt JL [2011] An update on m olecular d iag nostics o f squam ous and salivary gland tum ors o f the head and neck. Arch Pathol Lab M ed 135:602-609 P M ID 21526960 D acic S [2011] M olecular diagnostics o f lung carci nom as. Arch Pathol Lab M ed 135:622-629 P M ID 21538283 N ault JC, Zucm an-R ossi J [2011] G enetics o f hepa tobiliary carcinogenesis. Semin Liver Dis 31:173-187 P M ID 21557225 T anaka R, K oyanagi K, Narita N et al [2011] P rognostic m olecular biom arkers fo r cutaneous m alignant m ela nom a. J Surg Oncol 104:438-446 P M ID 21631264 Hong S-M, Park JY, H ruban R et al [2011] M olecular signatures o f pancreatic cancer. Arch Pathol Lab M ed 135:716-727 P M ID 21732770 G eram i P, Z em bow icz A [2011] U pdate on fluores cence in situ hybridization in m elanom a— state o f the art. Arch Pathol Lab M ed 135:830-837 P M ID 21732775 D adras SS [2011] M olecular diagnostics in m ela nom a— current status and perspectives. Arch Pathol Lab M ed 135:860-869 P M ID 21768580 Ladabaum U, W ang G, Terdim an J et al [2011] Strategies to identify the Lynch syndrom e am ong patients w ith colorectal cancer: a cost-effectiveness analysis. Ann Intern M ed 155:69-79 P M ID 2185632 G ershoni-B aruch R, Lerner A, Braun J et al [1990] Johanson-B lizzard syndrom e: C linical spectrum and furthe r delin eation o f the syndrom e. Am J M ed G enet 35:546-51 P M ID 2186644 Longacre TA, Fenog lio-P reiser CM [1990] M ixed hyperplastic adenom atous polyps/serrated adenom as: a distinct form o f colorectal neoplasia. Am J Surg Pathol 14:524-537 P M ID 2187341 Hall JG [1990] G enom ic im printing: review and rele vance to hum an diseases. Am J Hum G enet 46:857-873 © A S C P 2018

P M ID 229551 0 Ishibashi-U eda H, Im akita M, Y u ta n i C e t al [1990] C ongenital nem aline m yo p a th y w ith dila te d c a rd io m yopathy: an a utopsy study. Hum Pathol 2 1 :77-82 P M ID 290987 4 T iebosch A T, Fre d e rik PM , van Breda V rie sm a n PJ et al [1989] T h in -basem en t-m em brane nep h ro p a th y in adults w ith persistent hem aturia. N Engl J M e d 320:14-18 P M ID 312896 5 No A u th o r [1988] N e u ro fib ro m a to sis. C on fe re n ce statem ent. N ational Institutes o f H ealth C o n se n su s D eve lopm e nt C onference. Arch Neurol 4 5:575-578 P M ID 320261 7 Sethi KD, A d a m s RJ, Loring D W et al [1988] H allervord en-S patz syndrom e: clinical a nd m a g n etic resonance im aging correlations. Ann Neurol 24:692-4 P M ID 357436 9 Berko BA, S w ift M [1987] X -lin ke d dilated ca rd io m y opathy. N Engl J M ed 316:1186-91 P M ID 3673943 Evans HL [1987] Low grade fib ro m yxo id sarcom a: a report o f 2 m etastasizing ne o p la sm s having a d e ce p tive ly benign appearance. Am J Clin Pathol 88:615-9 P M ID 372001 0 H apple R [1986] T he M cC u n e -A lb rig h t syndrom e: a lethal ge n e surviving by m osaicism . Clin G enet 2 9:321-324 P M ID 388792 0 D ische FE, W eston M J, P a rso n s V [1985] A b n o rm a lly thin glo m e ru la r basem ent m em branes associa ted w ith hem aturia, proteinuria or renal failure in adults. A m J Nephrol 5:103-9 P M ID 394511 6 C arney JA, H ruska LS, B e a u ch a m p G D et al [1986] D om ina nt inheritance of the co m p le x o f m yxom as, spotty p ig m e n tation, and endo crin e overactivity. M ayo Clin Proc 61:165-72 P M ID 5360287 Li FP, Fraum eni JF J r [1969] S o ft-tissue sarcom as, breast cancer, and other neoplasm s. A fam ilia l s yndrom e? Ann Intern M ed 71:747-52 P M ID 596896 Birt AR, Hogg G R, D u b A © W J [1977] H ereditary m ultiple fibrofollicu lom as w ith trich o d isco m a s and acrochordon s. Arch Derm atol 113:1674-1677 P M ID 661430 6 C hung EB, E nzinger FM [1983] M a lig nant m elanom a o f soft parts: a reassessm ent o f cle a r cell sa rco m a. Am J Surg Pathol 7:405-413 P M ID 662504 8 M azur MT, C lark HB [1983] G a stric strom al tum ors. R eappraisal o f histogenesis. Am J Surg Pathol 7(6):5 07-19 PM ID 7486861 G riggs RC, A skanas V, D iM auro S et al [1995] Inclusion body m yositis and m yopathies. Ann Neurol 38:705-13 P M ID 7563486 N eum ann HP, Eng C, M ulligan LM et al [1995] C onsequences o f d irect genetic testing fo r g erm lin e m utations in the clinical m anagem ent o f fam ilie s w ith m ultiple e n docrine neoplasia, type II. JAMA 274:1149-51 PM ID 7565971 Bosm a PJ, C how dhury JR, B a kke r C et al [1995] The genetic basis o f the reduced expression o f bilirubin U D P -glu curonosyltransferase 1 in G ilb e rt’s syndrom e. N Engl J M ed 333(18): 1171-5 P M ID 760824 8 M ercado AB, W ilson RC, C he n g KC et al [1995] Prenatal treatm en t and diagnosis o f congenital adrenal h yper plasia ow ing to steroid 21-hydroxylase deficiency. J Clin Endocrinol M etab 80:2014-20 PM ID 7633441 A n grist M, Bolk S, Thiel B et al [1995] M utation a n a l ysis o f the R ET receptor tyrosine kinase in H irschsprung disease. Hum M ol G enet 4:821-30 P M ID 7661930 H am ilton SR, Liu B, P arsons R E et al [1995] The m olecular basis o f T urcot syndrom e. N Engl J M e d 332:839 -47 P M ID 767524 4 lonasescu W , lonasescu R, S e a rb y C et al [1995] D ejerine -S ottas disease w ith de novo d o m in a n t point m utation o f the P M P 2 2 gene. Neurology 45:1766-7

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Selected readings>Additional journal references P M ID 7 6 8 7 4 5 4 B ia ggioni I, G o ldstein DS, A tkin so n T et al [1990] D o p a m in e -p -h y d ro x y la s e d e fic ie n c y in hum ans. Neurology 4 0 :3 7 0 -3 p — P M ID 7 6 8 7 4 5 4 B iegel JA, C onard K, B rooks JJ [1 9 9 3 ] T ra n s lo c a tio n (11 ;2 2 )(p 1 3 ;q 1 2): p rim a ry ch a n g e in in tra a b d o m in a l d e s m o p la s tic sm all round cell tu m o r. G enes Chrom osom es C ancer 7:119-21 P M ID 7 7 0 2 0 9 5 W icklund C L, P auli R M , J o hnston D, H ech t JT [1995] N a tu ra l h isto ry study o f h e re d ita ry m ultiple exostoses. A m J M ed G en et 5 5 :4 3 -6 P M ID 7 7 1 5 2 9 7 A o n o S, A d a ch i Y, U yam a E et al [1995] A n alysis o f g e n e s fo r bilirubin U D P -g lu cu ro n o s y ltra n s fe ra s e in G ilb e rt’s syn d ro m e . Lancet 3 4 5 (8 9 5 5 ):9 5 8 -9 P M ID 7 7 8 3 4 1 2 G u b le r M C, K n e b e lm a n n B, B eziau A et al [1995] A u to so m a l d o m in a n t A lp o rt syndrom e: im m unohistochem ical stu d y o f ty p e IV co lla g en chain d istrib ution . Kidney Int 4 7:1142 -7 P M ID 7 8 0 2 1 3 8 Y o u n g S, G o o n e ra tn e S, S tra u s FH et al [1995] F e m in izin g S e rtoli cell tu m o rs in boys w ith P eutz-Je g h e rs s yn d ro m e . A m J Surg Pathol 19:50-8 P M ID 7 8 1 5 4 1 7 C a m p b e ll R, G osd en C M , B o nthron D T [1994] P a re n ta l o rigin o f tra n scrip tio n fro m th e hum an G NAS1 gene. J M ed G enet 3 1:6 0 7 -6 1 4 P M ID 7 8 8 9 5 7 3 C u rran M E, S p la w ski I, T im o th y K W et al [1995] A m o le c u la r basis fo r ca rd ia c a rrhythm ia: H E R G m u ta tio n s cause long Q T syn d ro m e . Cell 8 0 :7 9 5 -8 0 3 P M ID 7 9 0 8 0 7 8 R a vine D, G ibson RN, W a lk e r RG et al [1994] E valuation o f u ltra s o n o g ra p h ic d ia g n o s tic criteria fo r a u tosom al d o m in a n t p o ly c ys tic k id n e y d ise a se 1. Lancet 343:824 -7 P M ID 7913021 R aue F, F ra n k-R a u e K, G ra u e r A [1994] M ultiple e n d o c rin e n e op la sia typ e 2. C linical fe a tu re s and screening. Endocrinol M etab Clin North A m 23:1 3 7 -5 6 P M ID 7 9 3 6 2 8 0 E b ly EM , P arhad IM, H ogan DB et al [1994] P re va le n ce and typ e s o f dem e n tia in the very old. Neurology 4 4 :1 5 9 3 -6 0 0 P M ID 7 9 6 9 3 6 2 R ustg i A K [1994] H e re d ita ry g a s trointestinal polyposis and n o n p o lyp o sis syn d ro m e s. N Engl J M e d 331:169 4-702 P M ID 8 0 7 1 7 4 9 Jo n e s NL, H o fle y PM , D urie PR [1994] P a th o p h y s io lo g y o f th e p a n cre a tic d e fe c t in Jo h a nson-B lizzard syn d ro m e : a d is o rd e r o f a c in a r d e v elopm ent. J Pediatr 125:406-8 P M ID 8 0 7 8 0 0 5 S p itz L, K ie ly EM , M o re croft JA, D rake DP [1994] O e so p h a g e a l atresia: a t-ris k g ro u p s fo r th e 1990s. J Pediatr Surg 2 9 :7 2 3 -5 P M ID 808139 1 W h ite PC, T u sie -L u n a M T, N ew M l et al [1994] M u tations in s te ro id 2 1 -h yd ro x y la s e (C Y P 21). Hum M utat 3:373-8 P M ID 8 1 14858 B a sson C T, C o w le y G S, S o lom on SD et al [1995] T h e clinical and g e n e tic sp e ctru m o f th e H olt-O ram syndrom e (h e a rt-h a n d syn d ro m e ). N Engl J M e d 330:885-91 P M ID 8 2 1 3 7 8 9 T o rre s VE, W ilson DM , H attery R R et al [1993] Renal s to n e d ise a se in a u to so m a l d o m in a n t p o lycystic kidney disease. A m J Kidney Dis 22:513-9 P M ID 8 2 3 0 5 9 5 Lupski JR , C ha nce PF, G arcia C A [1993] Inherited p rim a ry p e riphera l ne u ro p a th ie s: m o le cu la r g e netics and clinical im p lica tio n s o f C M T 1 A and H N P P . JAM A 270:232 6-30 P M ID 8 3 0 9 5 6 4 B rugge KL, N ichols SL, S a lm on DP et al [1994] C o g n itive im p a irm e n t in a d u lts w ith D o w n ’s syndrom e: sim ila ri tie s to e a rly co g n itive ch anges in A lz h e im e r disease. Neurology 4 4 :2 3 2 -8 P M ID 8 3 3 3 5 5 8 E va n s H L [1993] Low g rade fib ro m yxoid sarcom a: a re p o rt o f 12 cases. A m J Surg Pathol 17:595-600 P M ID 8 4 6 4 1 2 7 R edm an JB, F enw ick RG Jr, Fu YH et al [1993] R e la tio n sh ip b e tw ee n paren ta l trin u cle o tid e G C T repeat length and s e ve rity o f m yo to n ic d ystro p h y in offspring. JAMA 269:196 0-5

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P M ID 8 5 2 8 2 4 4 W ang Q, C urran ME, S p law ski I et al [1996] P o sitional cloning o f a novel potassium channel gene: KVLQT1 m uta tio n s cause cardiac a rrhythm ias. N at G enet 12:17-23 P M ID 855024 6 A a rnio M, M ecklin JP, A altonen LA et al [1995] Lifetim e risk o f different cancers in hereditary nonpolyposis colo re cta l ca n ce r (H N P C C ) syndrom e. Int J C ancer 64:430-3 P M ID 8 5 7 9 0 9 6 Benson M D [1996] Leptom eningeal am yloid and va ria n t transthyretins. Am J Pathol 148:351-4 P M ID 8 6 0 9 7 8 0 B rauckho ff M, G im m O, H inze R et al [2002] Papillary thyroid carcinom a in patients w ith R E T protooncogene germ line m utation. Thyroid 12:557-61(3— P M ID 8609780 B reitner JC [1996] A P O E genotyping and A lz h e im e r disease. Lancet 347:1184-5 P M ID 8 6 1 4 5 2 6 Brandt J, B ylsm a FW , G ross R et al [1996] T rin u cle o tid e repeat length and clinical progression in H u ntington’s disease. Neurology 46:527-31 P M ID 862683 4 Frank-R aue K, H oppner W , Frilling A et al [1996] M utations o f the ret protoo nco gene in G erm an m ultiple endocrine neoplasia fam ilies: relation betw een genotype and phenotype. J Clin Endocrinol M etab 81:1780-3 P M ID 8 6 7 6 7 2 3 S aunders AM , H ulette O, W elsh-B ohm er KA et al [1996] Specificity, sensitivity, and predictive value o f apolipop rotein-E genotyping fo r sp o ra d ic A lzh e im e r disease. Lancet 348:90-3 P M ID 875185 6 Filla A, De M ichele G, C avalcanti-F et al [1996] The relationship betw een trinucleotide (G A A ) repeat length and clin ical features in Friedreich ataxia. Am J Hum G enet 59:554-60 P M ID 8800037 Saito M, Kaw ai H, A kaike M et al [1996] C ardiac dysfunction w ith B e cker m uscular dystrophy. Am H eart J 132:642-7 P M ID 881593 8 D urr A, C ossee M, A gid Y et al [1996] C linical and ge n e tic abnorm alities in patients w ith Friedreich’s ataxia. N Engl J M ed 335:1169-75 P M ID 8896568 A ngrist M, Bolk S, H alushka M et al [1996] G erm line m utations in glial cell line derived neurotrophic fa cto r (G D N F) and R ET in a H irschsprung disease patient. N at G enet 14:341-4 P M ID 8900282 B arhanin J, Lesage F, G uillem are E et al [1996] KVLQT1 and IsK (m inK ) proteins a ssociate to form the IKs cardiac potassium current. Nature 384:78-80 P M ID 8931572 Van d e r Kooi AJ, Barth PG, Busch HF et al [1996] T h e clinical spectrum o f lim b girdle m uscular dystrophy. A survey in The N etherlands. Brain 119(5): 1471-80 P M ID 8940267 K nebelm ann B, B reillat C, Forestier L et al [1996] Spectrum o f m utations in the C O L4A 5 collagen gene in X-linked A lport syndrom e. Am J Hum G enet 59:1221-32 P M ID 8942739 M ack DR, F orstner G G, W ilschanski M et al [1996] S hw achm an syndrom e: exocrine pancreatic dysfunction and vari able phenotypic expression. Gastroenterology 111:1593-602 PM ID 8943161 Bulaj ZJ, G riffen LM, Jorde LB et al [1996] Clinical and biochem ical abnorm alities in people heterozygous fo r hem o chrom atosis. N Engl J M ed 335:1799-805 PM ID 8985284 A d am s PC, D eugnier Y, M oirand R et al [1997] The relationship betw een iron overload, clinical sym ptom s, and age in 410 patients w ith genetic hem ochrom atosis. Hepatology 25(1): 162-166 PM ID 9003111 M oers AM , Landsvater RM, S chaap C et al [1996] Fam ilial m edullary thyroid carcinom a: not a distinct entity? Am J M ed 101:635-41 PM ID 9017939 Jacobson DR, Pastore RD, Y aghoubian R et al [1997] V a ria nt-sequence transthyretin (isoleucine 122) in late onset cardiac am yloidosis in black A m ericans. N Engl J M ed 336:466-73

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Selected readings>Additional journal references P M ID 904072 8 A ylw ard EH, Li Q, Stine O C et al [1997] Longitudinal change in basal ganglia volum e in patients w ith H u n tin g ton’s disease. Neurology 48:394 9 PM ID 9096761 K im onis VE, G oldstein AM , Pastakia B et al [1997] C linical m anifestations in 105 persons w ith nevoid basal cell carcinom a syndrom e. Am J M ed G enet 69(3):299-308 P M ID 9126060 Fox NC, K ennedy AM , H arvey RJ et al [1997] C linicopathological feature s o f fam ilial A lzh e im e r disease associ ated w ith the M 139V m utation in the presenilin 1 gene. Brain 120 (3):491 -501 P M ID 9128932 Friedm an JM , Birch PH [1997] Type 1 n eurofibrom a tosis: a descriptive analysis o f the diso rd e r in 1,728 patients. Am J M ed G enet 70:138-43 P M ID 9164815 A ckerm an MJ, C lapham DE [1997] Ion ch a n n e ls-1— basic science and clinical disease. N Engl J M ed 336:157 5-86 P M ID 9207339 G utm ann DH, A ylsw orth A, C arey JC et al [1997] The diagnostic evaluation and m ultidisciplinary m anagem ent o f neuro fibrom atosis 1 and neurofibrom atosis 2. JAMA 278:51-7 P M ID 9207787 O da T, Elkahloun AG , Pike BL et al [1997] M utations in the hum an J a g g e d l gene are responsible fo r Alagille syndrom e. N at G enet 16:235-42 P M ID 9218725 V a rle y JM , Evans DG, Birch JM [1997] Li-Fraum eni syndrom e— a m olecular and clinical review. B r J C ancer 76:1-14 P M ID 9228977 C arrell RW, Lom as DA [1997] C onform ational disease. Lancet 350:134-8 P M ID 9229998 M oirand R, A d am s PC, B icheler V et al [1997] C linical features o f genetic hem ochrom ato sis in w om en com pared w ith m en. Ann Intern M ed 127:105-10 PM ID 9243091 C ossu-R occa P, Eble JN, D elahunt B et al [2006] Renal m ucinous tu bular and spindle carcinom a lacks the gains o f ch rom osom es 7 and 17 and losses o f chrom osom e Y that are prevalent in papillary renal cell carcinom a. Mod Pathol 19:488493(3— PM ID 9243091 C ox GF, Kunkel LM [1997] D ystrophies and heart disease. Curr Opin Cardiol 12:329-43 PM ID 9300201 Pang S, Shook M K [1997] C urrent status o f neonatal screening fo r congenital adrenal hyperplasia. Curr Opin Pediatr 9:419-23 P M ID 930724 7 G reenberg D A [1997] C alcium channels in neuro logical disease. Ann Neurol 42:275-82 P M ID 9382094 S am pson JR, M aheshw ar MM, A spinw all R et al [1997] Renal cystic disease in tubero us sclerosis: role o f the poly cystic kidney disease 1 gene. Am J Hum G enet 61:843-51 P M ID 9409359 G abriel JM , Erne B, P areyson D et al [1997] G ene dosage effects in hereditary peripheral neuropathy: expression of peripheral m yelin protein 22 in C harcot-M arie-Tooth disease type 1A and hereditary neuropathy w ith liability to pressure palsies nerve biopsies. Neurology 4 9:1635 -40 P M ID 9414192 Lane KL, S hannon RJ, W eiss S W [1997] H yalinizing spindle cell tum our w ith giant rosettes: A distinctive tum or closely resem bling low grade fibrom yxoid sarcom a. Am J Surg Pathol 21:1481-8 P M ID 9429863 Pang S [1997] C ongenital adrenal hyperplasia. Endocrinol M etab Clin North Am 26:853-91 P M ID 9445133 S chra ger CA, S ch n e id e r D, G rue n e r A C et al [1998] C linical and pathological features o f breast disease in C ow den syndrom e: An underrecognized syndrom e w ith an increased risk o f breast cancer. Hum Pathol 29:47-53 P M ID 9468467 M ayeux R, S aunders AM , Shea S et al [1998] U tility o f the apolipoprotein E genotype in the diagnosis o f A lzh eim er disease. N Engl J M ed 338:506-11 P M ID 9482292 Estivill X, Fortina P, S u rrey S et al [1998] C onnexin-26 m utations in sporadic and inherited sensorineural deafness. Lancet 35 1 :394-8 © A S C P 2018

P M ID 955444 3 H isada M, G arber JE, Fung C Y et al [1998] M ultiple prim ary cancers in fa m ilie s with Li-F raum e ni syndrom e. J Natl C ancer Inst 90:606-11 P M ID 9570196 Li H, C hen Q, Moss AJ et al [1998] N ew m u tations in the KVLQ T1 potassium channel th a t ca u se long Q T syndrom e. Circulation 97:1264 -9 P M ID 959355 6 F ontaine G, Fontaliran F, Frank R [1998] A rrhythm ogenic right ventricular cardiom yopathies: clinical form s and m ain differential diagnoses. Circulation 9 7 :1 532 -5 P M ID 9593786 A a lton en LA, Salovaara R, K risto P et al [1998] Incidence o f hereditary nonpolyposis colorectal c a n ce r and the feasibility o f m o lecular screening fo r the disease. N Engl J M ed 338:1481-7 P M ID 959599 4 M arrosu M G, V accargiu S, M arrosu G et al [1998] C harcot-M arie-T ooth disease type 2 a sso cia te d w ith m utation o f the m yelin protein zero gene. Neurology 50:1397-401 PM ID 9626031 Loke J, M acLennan DH [1998] M alignant h yper therm ia and central core disease: disorders o f calcium release channels. Am J M ed 104:470-486 P M ID 962676 7 G utm ann DH [1998] R ece nt insig hts into n e u ro fib ro m atosis type 1: clear genetic progress. Arch Neurol 5 5:778-80 P M ID 962758 0 Boles RG, Buck EA, B litzer M G et al [1998] R etrospective biochem ical screening o f fa tty acid oxidation d is o r ders in postm ortem livers of 4 18 cases o f sudden death in the first year o f life. J Pediatr 132:924-33 P M ID 9633692 S tevens M, van Duijn CM , K a m p h o rst W et al [1998] Fam ilial aggreg atio n in frontotem poral d em entia. Neurology 50:1541-5 P M ID 963442 7 B o ardm an LA, T hibodeau SN, S chaid DJ et al [1998] Increased risk fo r cancer in patients w ith th e P e utz-Je ghers syndrom e. Ann Intern M ed 128:896-9 P M ID 9634524 K ruse R, Rutten A, Lam berti C et al [1998] M uir-T orre phenotype has a fre q u e n cy of D N A m is m atch -repair-gene m uta tions sim ila r to th a t in hereditary nonpo lyp o sis colorectal can ce r fam ilie s defined by th e A m sterd am criteria. Am J Hum G enet 63:63-70 PM ID 9681851 T akahashi M, Asai N, Iw ashita T et al [1998] M olecular m echanism s o f deve lo p m e n t o f m ultiple e n docrine neoplasia 2 by R E T m utations. J Intern M ed 243:509 -13 P M ID 968185 2 R om eo G, C eccherini I, C elli J et al [1998] A ssociation o f m ultiple endocrine neoplasia type 2 and H irschsprung disease. J Intern M ed 2 43:515 -20 P M ID 969110 2 C orrado D, Basso C, S chiavon M et al [1998] Screening fo r hypertrop hic cardiom yopathy in you ng athletes. N Engl J M ed 339:364-9 P M ID 9710018 C habriat H, Levy C, T aillia H et al [1998] P a tterns o f MRI lesions in C A D A S IL. Neurology 5 1 :452-7 P M ID 9712016 D avenport M, Tizzard SA, U nderhill J et al [2006] The biliary atresia splenic m alform ation syndrom e: a 2 8 -y e a r sing le -ce n te r retrospective study. J Pediatr 149:393-400(3— P M ID 9712016 D avies S, R am sden DB [2001] H u n tin g to n ’s disease. M ol Pathol 54:409-413(3— P M ID 971201 6 de D ie-S m ulders CE, H ow eler CJ, T hijs C et al [1998] A g e and causes o f death in adult-onset m yotonic dystrophy. Brain 121 (8):1557-63 PM ID 9725921 S harer N, S chw arz M, M alone G et al [1998] M utations o f the cystic fibrosis gen e in patients w ith ch ro n ic pancreatitis. N Engl J M ed 339:645-52 PM ID 9753711 Z areb a W , M oss AJ, S ch w a rtz PJ et al [1998] Influence o f g enotype on the clinical co u rse o f th e long Q T syndrom e. N Engl J M ed 339:960-5 PM ID 9770561 Lang AE, Lozano A M [1998] P a rkin so n ’s disease: second o f 2 parts. N Engl J M ed 339:1 1 3 0 -4 3

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Selected readings>Additional journal references P M ID 9 7 8 1 9 0 4 Li M, S q uire JA, W e ksb e rg R [1998] M olecular g e n e tic s o f W ie d e m a n n -B e c k w ith syndrom e. A m J M e d G enet 7 9 :2 5 3 -9 P M ID 9 7 8 1 9 0 7 H o ym e HE, S e a ve r LH, Jo n e s KL et al [1998] Iso la te d h e m ih yp e rp la sia (he m ih yp e rtro p h y): re p o rt o f a pro sp e c tiv e m u ltice n te r stu d y o f th e in cid e n ce o f n e o p lasia and review . A m J M e d G enet 79:274-8 P M ID 9 8 1 1 3 2 5 S p illantini M G , C ro w th e r RA, K a m p h o rs tW et al [1 9 9 8 ] T a u p a th o lo g y in 2 D utch fa m ilie s w ith m u tations in the m ic ro tu b u le b inding region o f tau. Am J Pathol 153:1359-63 P M ID 9 8 1 8 9 2 8 D ichgans M, M a ye r M, U ttn e r I et al [1998] The p h e n o ty p ic sp e ctru m o f C A D A S IL : clin ica l fin d in g s in 102 cases. A nn N eurol 4 4 :7 3 1 -9 P M ID 9 8 2 4 6 1 2 B u rt M J, G e o rg e PM , U pton JD et al [1998] The s ig n ific a n c e o f h a e m o ch ro m a to sis g e n e m u ta tions in the general p o p u la tio n : im p lica tio n s fo r screening. Gut 4 3 :8 3 0 -6 P M ID 9 8 4 3 4 6 3 C a rte r BS, B e a ty TH , S te in b e rg G D et al [1992] M e nd e lia n in h e rita n ce o f fa m ilia l p ro sta te cancer. Proc Natl A cad Scl USA 89:3367-3371(3— P M ID 9 8 4 3 4 6 3 C a se y M, Mah C, M e rliss A D et al [1998] Ide n tifica tio n o f a novel g e n e tic locus fo r fa m ilia l c a rd ia c m yxo m a s and C a rn e y co m plex. Circulation 9 8 :2 5 6 0 -6 P M ID 9 8 5 8 2 4 3 N ielsen P, C a rpinteiro S, F isch e r R e t al [1998] P re va le n ce o f th e C 2 8 2 Y and H 63D m u ta tio n s in the H F E gene in p a tie n ts w ith h e re d ita ry h a e m o ch ro m a to sis and in control s u b je c ts from N o rthern G erm a n y. B r J H em atol 1 0 3 (3 ):842-845 P M ID 9 8 6 0 7 7 7 A h m a d F, Li D, K a rib e A et al [1998] Localiza tio n o f a g e n e resp o n sib le fo r a rrh y th m o g e n ic rig h t v e n tric u la r d ysp la sia to c h ro m o s o m e 3p23. Circulation 98:2 7 9 1 -5 P M ID 9 8 6 7 7 4 8 P h atak PD, S ham RL, R aubertas R F et al [1998] P re va le n ce o f h e re d ita ry h e m o ch ro m a to sis in 16031 prim ary care p a tie n ts. Ann Intern M ed 129:954-61 P M ID 9 8 6 9 5 2 3 H ow e JR , M itros FA, S u m m e rs R W [1998] T he risk o f g a s tro in te s tin a l carcin o m a in fam ilia l ju v e n ile polyp o sis. Ann Surg O ncol 5:7 51-6 P M ID 9 8 6 9 6 1 8 B acon BR, P ow ell LW , A d a m s PC et al [1999] M o le c u la r m e d icin e and h e m o ch ro m a to sis: at th e crossroads. Gastroenterology 116:193 -207 P M ID 9 8 8 7 1 5 8 H artm a nn LC, S chaid DJ, W o o d s JE et al [1999] E ffica cy o f bilateral p ro p h yla ctic m a ste cto m y in w o m e n w ith a fa m ily h isto ry o f b re a st cancer. N Engl J M ed 340:77-84 P M ID 9 9 7 3 2 7 9 R izzu P, V an S w ieten JC, Jo o sse M et al [1999] High p re v a le n c e o f m u ta tio n s in th e m icro tu b u le associa ted protein ta u in a p o p u la tion study o f fro n to te m p o ra l dem e n tia in the N e th e rla n d s. A m J H um G enet 64:414-21 A lb rig h t F, B u tle r A M , H am pton A O et al [1937] S yn d ro m e char a c te riz e d by o ste itis fib ro sa d isse m in a ta , a re a s o f pigm entation and e n d o c rin e d y sfu n ctio n , w ith p re co cio u s p u b e rty in fem ales: R e p o rt o f 5 cases. N Engl J M e d 216: 727 -7 4 6 D u b b in k HJ, D ean s ZC , T o p s BBJ, et al. N ext g e n e ra tio n d ia g n o stic m o le c u la r p athology: C ritical ap p ra isa l o f q u a lity assu ra n ce in E u ro pe. M olecular Oncology 2 0 1 4 ;8 :8 3 0 -8 3 9 G ia rd e llo FM, A llen Jl, A xilb u n d JE, et al. G u id e lin e s on G e n e tic E v a lu a tio n and M a n a g e m e n t o f Lynch S yn d ro m e: A C onsensus S ta te m e n t by th e U S M u lti-S o cie ty T a sk F orce on C olorectal C a n ce r. A m J Gastroenterol a d va n ce o n lin e publication, 29 July 2014. G u rzu S, S z e n tirm a y Z, T oth E, et al. S e rrated P a thw ay A d e n o c a rc in o m a s : M o le c u la r and Im m u n o h isto ch e m ica l Insights into T h e ir R eco gnition . PLoS O N E 2 0 1 3;8(3): e57699 K o rp a n ty G, G ra h am DM , V in c e n t M D, Leighl NB. B io m a rke rs that c u rre n tly a ffe ct clinical p ra ctice in lung cancer: E G FR , A L K , M ET, R O S -1 , and K R A S . J Clin Oncol 2 0 1 4 ;4 (2 0 4 ):1 -8

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Leidy J, Khan A, Kandil D. B asal-Like Breast C ancer: U pdate on C linicopathologic, Im m unohistochem ical, and M olecular Features. Arch Pathol Lab M ed 2 0 1 4 ;1 38(1 ):37-43. Leighl NB, R ekhtm an N, B ierm ann W A , et al. M olecular Testing fo r Selection o f P atients W ith Lung C a ncer fo r Epiderm al G row th F actor R e ce p to r and A n a p la stic Lym phom a Kinase Tyrosine Kinase Inhibitors: A m erican S ociety o f Clinical O ncology E ndorsem ent o f the C ollege o f A m erican P athologists/ International S ociety fo r the S tudy o f Lung C ancer/A ssociation of M olecular P a thologists G uideline. J Clin Oncol advance online publication, 2014. M cC and less SE, M illington DS, A n dresen BS et al [2002] Clinical findings in M C A D patients heterozygous fo r the com m on m uta tion identified by M S /M S new born screening. Am J Hum G enet 71(S uppl):419 R am irez-S eijas F, G ranado-V illar D, C epero-A kselrad A et al [2000] C ongenital n ephro tic syndrom e. Int Pediatr 15(2): 121 -122 S holl LM, Lindem an Nl [2010] M o le cu la r diagnostics testing fo r lung adenocarcinom a— state o f the art in 2010. Pathol Case R ev 15:103-110 S ipple JH [1961] T he associa tion o f p h eochrom ocytom a w ith carci nom a o f the thyroid gland. Am J M ed 31:163-166 Shi C, W ashington K. M olecular Testing in C olorectal C ancer: D iagn osis o f Lynch S yndrom e and P ersonalized C ancer M edicine. Am J Clin Pathol (2015) 137 (6): 847-859. S n o ve r DC, Jass JR, F enoglio-P reiser C, Batts KP. S errated Polyps o f th e Large Intestine: A M o rphologic and M olecular R eview o f an Evolving C oncept. Am J Clin Pathol 20 1 5;124 (3): 380-391. T ang P, Tse G M . Im m unohistochem ical S urrogates fo r M olecular C lassification o f B reast C arcinom a: A 2015 Update. Arch Pathol Lab M ed 2016;140(8):806-814. T orto relli S, Toku n a g a C, S trauss AW , W inters J, Hahn SH, M atern D, R inaldo P [2004] C orrelation o f g enotype and biochem ical phenotype in 106 patients w ith M C A D deficiency. J Inherit Metab Dis 27S uppl1:102. U dager AM, M ehra R. M orphologic, M olecular, and T axonom ic Evolution o f Renal Cell C arcinom a: A C onceptual Perspective W ith E m phasis on U pdates to the 2016 W orld H ealth O rg a n iza tio n C lassification. Arch Pathol Lab M ed 2016; 140(10): 1026-1037. Zhu Z, G andhi M, N ikiforova MN, et al. M olecular Profile and C linical-P athologic Features o f the Follicular V a ria nt o f Papillary Thyroid C arcino m a : An U nusually High P revalence o f ras M utations. Am J Clin Pathol 2015;120(1): 71-77.

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

Chapter 8

M e d ic a l D irec to rsh ip 8.1 L e g is la tio n & re g u la tio n , a g e n c ie s & o v e r s ig h t...............................396

8 .4 .2 .7 S p e c im e n s ta b ility ......................................................................................... 4 06

8.1.1 L e g isla tio n & re g u la tio n s re la tin g to la b o ra to rie s ...............................396

8 .4 .2 .8 In fo rm a tio n s y s te m s .................................................................................... 4 0 6

8.1.1.1 C lin ic a l L a b o ra to ry Im p ro v e m e n t A m e n d m e n t o f 1 9 8 8 ............... 396

8 .4 .2 .9 W ritte n p r o c e d u r e s .......................................................................................4 0 7

8 .1 .1 .2 M edical d e v ice s & b io lo g ie s .................................................................. 398

8 .4 .2 .1 0 E d u ca tio n o f la b o ra to ry sta ff & clin ic a l s t a f f ..................................... 4 0 7

8 .1 .1 .3 M edicare, M edicaid & th e p ro sp e c tiv e p a y m e n t s y s te m .............399

8.5 Quality management...........................................................................407

8 .1 .1 .4 B illing & re im b u rs e m e n t............................................................................399

8.5.1 D e fin itio n s ..............................................................................................................4 0 7

8 .1 .1 .5 D irec t billing law , physicia n s e lf re fe rra l law (S ta rk law ) &

8.5.1.1 Q u a lity m a n a g e m e n t an d q u a lity c o n tro l............................................... 4 0 7

a n tikic k b a ck l a w ..................................................................................................... 4 0 0 8 .1 .1 .6 T h e P rivacy A c t & the P riva cy R ule ( H IP A A ) ................................. 40 0 8 .1 .1 .7 The O ccu p a tio n a l S afe ty & H e a lth A d m in is tra tio n (O S H A ) . . . 40 0 8.2

F in a n c ia l c o n s id e r a tio n s in th e la b o r a to r y ........................................ 401

8.2.1 T yp e s o f co sts & c a lcu la tio n o f th e bre a ke ve n p o in t.......................401 8.2.2 B u d g e tin g .............................................................................................................401

8 .5 .2 S ta tistica l q u a lity c o n tro l..................................................................................4 0 8 8.5.2.1 T ra d itio n a l Q C .................................................................................................4 0 8 8 .5 .2 .2 A lte rn a tiv e s to tra d itio n a l Q C .................................................................4 1 0 8 .5 .3 P ro ficie nc y te s tin g (e xte rn a l q u a lity a s s e s s m e n t) ................................4 1 0 8.5.3.1 O v e rv ie w ........................................................................................................... 4 1 0

S ta tis tic a l c o n s id e r a tio n s in th e la b o r a to r y ......................................402

8.6 Nonanalytic variables in laboratory medicine: preanalytic & postanalytic.................................................................. 411

8.3.1 D e fin itio n s .............................................................................................................4 0 2

8.6.1 P re a n a ly tic v a r ia b le s .......................................................................................411

8.3.1.1 G a u ssia n d is trib u tio n , e s tim a te s o f central te n d e n c y & e s tim a te s o f v a ria tio n ........................................................................................ 4 0 2

8.6.1.1 P a tie n t id e n tific a tio n .................................................................................... 411

8.3

8 .3 .1 .2 R e liability: a n a ly tic a l a c cu ra cy & p re c is io n ........................................4 0 2 8 .3 .1 .3 C lin ica l s e n sitiv ity & s p e c ific ity ...............................................................4 0 2 8 .3 .1 .4 P redictive v a lu e ............................................................................................. 4 0 2 8 .3 .1 .5 R elative ris k .....................................................................................................4 0 3 8.3 .2

D ia g n o stic a ccu ra cy: re c e iv e r o p e ra tin g c h a ra c te ris tic cu rve s . . 40 3

8.3.2.1 D ia g n o stic a c c u r a c y ...................................................................................4 0 3 8 .3 .2 .2 R e ce ive r o p e ra tin g c h a ra c te ris tic c u r v e s .......................................... 40 3 8.3 .3

R e fe re n ce in t e r v a ls ......................................................................................403

8.3.3.1 P urpose o f re fe re n ce in te r v a ls ...............................................................4 0 3 8 .3 .3 .2 E sta b lish in g & a d o p tin g re fe re n ce in te rv a ls ..................................... 404 8.4

Im p le m e n ta tio n o f n e w m e th o d s ............................................................ 40 4

8.4.1 O v e r v ie w ............................................................................................................ 404 8.4.2 E lem ents o f m e th o d v e rific a tio n ................................................................. 40 5 8.4.2.1 C a lib ra tio n & c a lib ratio n v e rific a tio n .....................................................4 0 5 8 .4 .2 .2 P recision & e s ta b lis h m e n t o f q u a lity co n tro l ra n g e s .................... 40 5 8 .4 .2 .3 A ccu ra cy, in a c cu ra c y (b ia s) & m e th o d c o m p a r is o n ......................40 5 8 .4 .2.4 A n a lytic sp e cificity, in te rfe re n ce & c a r r y o v e r ...................................40 5

8 .6 .1 .2 A g e ..................................................................................................................... 411 8 .6 .1 .3 G e n d e r ..............................................................................................................411 8 .6 .1 .4 Food in ta k e ...................................................................................................... 411 8 .6 .1 .5 E x e rc is e ..............................................................................................................411 8 .6 .1 .6 C ig a re tte s m o k in g ......................................................................................... 411 8 .6 .1 .7 P o s tu r e ..............................................................................................................411 8 .6 .1 .8 T im e o f d a y ...................................................................................................... 411 8 .6 .1 .9 T o u rn iq u e t.........................................................................................................411 8 .6 .1 .1 0 O rd e r o f d r a w .............................................................................................. 411 8.6.1.11 S to ra g e & tra n s p o rt c o n d itio n s ............................................................. 4 1 2 8 .6 .1 .1 2 S e ru m vs p la s m a .......................................................................................4 1 2 8 .6 .1 .1 3 U n d e rlyin g h e m a to lo g ic m a lig n a n c y .................................................... 4 1 2 8 .6 .2

P o s ta n a lytic v a r ia b le s .................................................................................4 1 2

8.6.2.1 Th e p o s ta n a ly tic p h a s e ...............................................................................4 1 2 8 .6 .2 .2 R e su lt re p o rtin g .............................................................................................. 4 1 2 8 .6 .2 .3 C ritica l v a lu e s re p o rtin g ...............................................................................4 1 2

8.7 8.7.1

Selected readings.............................................................................413 B o o k s ..................................................................................................................4 1 3

8 .4 .2 .5 A nalytical sensitivity, lim it o f detection & functional sensitivity . . 40 6 8 .4 .2 .6 Linearity, a n a ly tic a l m e a su rin g range & clinical re portable r a n g e ................................................................................ 40 6

© A S C P 2018

ISBN 9 7 8 -0 8 9 1 8 9 -6 6 7 8

395

Medical Directorship

Legislation & regulation, agencies & oversight>Legislation & regulations relating to laboratories

8.1 Legislation & regulation, agencies & oversight 8.1.1 Legislation & regulations relating to laboratories 8.1.1.1 Clinical Laboratory Improvement Am endm ent of 1988 ■ C L IA ’8 8 w a s e n a c te d a s a n a m e n d m e n t to th e C lin ic a l L a b o ra to ry A c t o f 196 7 ■ E n fo rc e d b y C e n te rs fo r M e d ic a re a n d M e d ic a id S e rv ic e s (C M S ), a d iv is io n o f th e U S D e p a rtm e n t o f H e a lth a n d H u m a n S e rv ic e s (D H H S )

■ N e e d n o t be a b o a rd c e rtifie d p a th o lo g is t. If n o t a b o a rd c e rtifie d p a th o lo g is t th e n s p e c ific re q u ire m e n ts fo r o th e r e d u c a tio n a n d /o r e x p e rie n c e a p p ly ■ M u s t h ave lic e n s e in th e s ta te w h e re lab is lo c a te d ■ R e s p o n s ib ilitie s ■ L a b o ra to ry s ta ffin g , e n s u rin g th a t th e n um b e r, tra in in g , a nd c o m p e te n c y o f p e rs o n n e l a re a d e q u a te ■ P h y s ic a l fa c ility , e n s u rin g th a t it is a d e q u a te fo r te s tin g a nd s a fe fo r s ta ff

■ A p p lie s to all la b o ra to rie s th a t p e rfo rm te s tin g on “ m a te ria ls d e riv e d fro m th e h u m a n b o d y ," w h e th e r o r n ot th e y p a rtic ip a te in M e d ic a re

■ A ll p h a s e s (p re a n a ly tic , a n a ly tic , p o s ta n a ly tic ) o f te s tin g

■ D o e s n o t s p e c ific a lly re g u la te c o lle c tio n k its , w o rk p la c e d ru g te s tin g , te s tin g fo r re s e a rc h p u rp o s e s , o r n o n in v a s iv e te s tin g

■ S e le c tio n o f s u p p lie s , re a g e n ts , c a lib ra to rs , a nd in fo rm a tio n s y s te m s

■ C L IA re q u ire m e n ts o fte n d iffe r fro m re q u ire m e n ts o f a c c re d itin g a g e n c ie s (C A P , etc); re q u ire m e n ts o f a c c re d itin g a g e n c ie s m u s t b e a t le a s t a s s trin g e n t a s th o s e in C L IA

■ T e s t m e n u a nd th e in s tru m e n ts to p e rfo rm th e m

■ C h o ic e o f re fe re n c e la b o ra to rie s ■ Q u a lity a s s u ra n c e p ro g ra m ■ C L IA s p e c ifie s w h a t ca n be d e le g a te d a n d w h a t m u s t b e o v e rs e e n d ire c tly ■ T e c h n ic a l s u p e rv is o r/c lin ic a l c o n s u lta n t

8.1.1.1.1 T est c o m p le x ity ■ C L IA a s s ig n e d to th e F o o d a n d D ru g A d m in is tra tio n (F D A ) th e re s p o n s ib ility fo r c la s s ify in g la b o ra to ry te s ts a c c o rd in g to c o m p le x ity t8.1

□ C lin ic a l c o n s u lta n t re q u ire d if th e L a b o ra to ry D ire c to r is n o t a p h y s ic ia n o r P hD and is re s p o n s ib le fo r c lin ic a l c o n s u lta tio n ; m u s t h a ve d o c to ra l d e g re e w ith b o a rd c e rtific a tio n

■ A la b o ra to ry is c la s s ifie d a c c o rd in g to th e h ig h e s t c o m p le x ity te s tin g it p e rfo rm s

□ T e c h n ic a l s u p e rv is o r re s p o n s ib le fo r te c h n ic a l o v e rs ig h t; m u s t h a ve a t le a s t a b a c h e lo r’s d e g re e □ T e sting p e rs o n n e l

□ W a iv e d te s ts ■ T h e re a re no s p e c ific re q u ire m e n ts fo r w h o m a y p e rfo rm w a iv e d te s ts ■ T h e p e rfo rm in g la b o ra to ry m u s t be in p o s s e s s io n o f a t le a s t a c e rtific a te o f w a iv e r ■ N o te th a t w a iv e d te s ts a re n o t s y n o n y m o u s w ith p o in t o f c a re te s ts , w h ic h m a y be w a iv e d o r n o n w a iv e d

8.1.1.1.2 T h e M e d ic a l D ire c to r and o th e r C L IA d e fin e d ro le s ■ C L IA d e fin e d ro le s fo r a n d lis ts q u a lific a tio n s fo r L a b o ra to ry M e d ic a l D ire c to r, T e c h n ic a l C o n s u lta n t, C lin ic a l C o n s u lta n t, a n d T e s tin g P e rs o n n e l. W ith a d e q u a te tra in in g a n d e x p e rie n c e th e L a b o ra to ry M e d ic a l D ire c to r c o u ld fu lfill a ll d e fin e d ro le s □ M e d ic a l D ire c to r

8.1.1.1.3 C e rtific a tio n & a c c re d ita tio n ■ C L IA re q u ire s fe d e ra l c e rtific a tio n fo r all la b o ra to rie s th a t p e rfo rm te s tin g on h u m a n s a m p le s □ M u s t be re n e w e d e v e ry 2 y e a rs □ C e rtific a te h o ld e r is th e la b o ra to ry m e d ic a l d ire c to r; can h old no m o re th a n 5 c e rtific a te s a t a n y g iv e n tim e □ T yp es o f c e rtific a tio n in c lu d e ■ C e rtific a te o f re g is tra tio n ■ C e rtific a te o f w a iv e r ■ C e rtific a te fo r p ro v id e r p e rfo rm e d m ic ro s c o p y ■ C e rtific a te o f c o m p lia n c e ■ C e rtific a te o f a c c re d ita tio n

■ Q u a lific a tio n s ■ M a y be an M D , D O , D P M , o r P h D . W h ile C L IA a llo w s fo r le s s e r e d u c a tio n le v e ls in s o m e in s ta n c e s , C A P d o e s n o t

396

□ M u s t h ave a t le a s t a h ig h s c h o o l d ip lo m a

■ O n c e a lab s u c c e s s fu lly a p p lie s fo r c e rtific a tio n , it re c e iv e s a c e rtific a te o f re g is tra tio n , a t w h ic h tim e te s tin g c a n begin ■ If in s p e c te d by C L IA /C M S , it w ill re c e iv e c e rtific a te o f c o m p lia n c e u p o n s u c c e s s fu l c o m p le tio n o f firs t in s p e c tio n

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

8: Medical Directorship

Legislation & regulation, agencies & oversight>Legislation & regulations relating to laboratories

t8.1 Clinical Laboratory Improvement Amendments levels of test complexity Test com plexity_________________________________________________________________________________________________________________________ W aive d

If a lab perform s only w aived testing, it m ust have certificate o f w aiver; w aiv ed tests are sim ple tests that h a ve b een cleared by the U S Food and Drug A dm inistration for hom e use, a re sim ple and accurate enough to be largely error free, and "pose no rea so n a b le risk o f harm to th e patient if the test is perform ed incorrectly” Exam ples include the com m on urine dipstick tests, fecal occult blood testing, urine pregnancy tests, hom e glucose monitoring tests, spun hem atocrit _______________________R equirem ents o f those conducting w aived testing a re only th at they follow m anufacturer’s instructions________________________________________________ N onw aived (m od erate & high com plexity)

A scoring system is applied to nonw aived tests to determ ine w h eth e r they are o f m oderate or high complexity; in ge n e ra l, m ost a u to m ate d tests are considered m oderate, while those that have a significant m anual com ponent are high com plexity (eg, parasite identification) If a test of m od erate com plexity is m odified, it generally is considered a high com plexity test R equirem ents include qualified laboratory director & testing personnel, w ritten procedures to assure proper sp ecim en collection & procedure perform ance, the testing of positive & negative controls ea ch d a y patient sa m ples are tested, enrollm ent in proficiency testing, stipulations regarding record keeping & biennial (every other ye ar) inspection _______________________R equirem ents of m od erate & high com plexity testing differs m ainly in the personnel requirem ents______________________________________________________ Provider perform ed P P M is a subcategory of m od erate com plexity testing m icroscopy (P P M ) To be regarded as P P M , a procedur e m ust be perform ed by a physician, dentist, o r m idlevel practitioner u nder physician supervision, an d it m ust be perform ed during the patient visit during which the sp ecim en is procured T h e prim ary instrum ent for perform ing the test m ust be a m icroscope, limited to bright field or phase contrast m icroscopy T h e specim en m ust be of the sort th at a delay (in taking to a lab) w ould com prom ise it; control m aterials a re not a v ailab le fo r this type o f test, and there is limited specim en processing required P P M exam inatio ns include, direct w e t m ounts (eg, for fungi, parasites, bacteria), K O H preparations, pinworm ex am inatio ns, ferning tests, exam inations of urine sedim ent_________________________________________________________________________________________________________________________

■ A c e rtific a te o f a c c re d ita tio n is a w a rd e d upo n s u c c e s s fu l c o m p le tio n o f in s p e c tio n by an a c c re d itin g a g e n c y □ L ab m u s t be e x te rn a lly in s p e c te d e v e ry 2 y e a rs and c o n d u c t an in te rn a l (in te rv a l) in s p e c tio n d u rin g th e in te rv e n in g y e a r; C M S e x te n d s “d e e m e d ” s ta tu s to a c c re d itin g a g e n c ie s su ch a s C AP, TJC , C O L A □ C A P in s p e c tio n s a re “ u n a n n o u n c e d ” b u t ta k e p la c e w ith in a k n o w n 3 m o n th w in d o w th a t e n d s on th e a n n iv e rs a ry d a te o f th e la s t a c c re d ita tio n □ C A P in s p e c tio n s a re p e rfo rm e d a c c o rd in g to a c h e c k lis t o f s ta n d a rd s , a nd e a ch ite m is a s s ig n e d a w e ig h t o f e ith e r “ p h a s e I” o r “ p h a s e II.” □ P h a s e II c ita tio n s a re m o re s e v e re a n d re q u ire d o c u m e n te d c o rre c tiv e a c tio n w ith in 3 0 d ays □ P h a s e I c ita tio n s m u s t be c o rre c te d b e fo re th e n e x t in te rn a l in s p e c tio n □ “ P h a s e 0 ” c h e c k lis t ite m s a re n ot o ffic ia lly g ra d e d and u s u a lly re p re s e n t ite m s u n d e r d e v e lo p m e n t ■ O th e r in s p e c tio n s □ L a b o ra to rie s m a y a ls o b e in s p e c te d a s p a rt o f a h o s p ita l w id e in s p e c tio n by T h e J o in t C o m m is s io n (TJC ) □ L a b o ra to rie s in v o lv e d w ith b lo o d p ro d u c ts w ill be in s p e c te d by th e FD A □ L a b s th a t p e rfo rm fo re n s ic d ru g te s tin g a re c e rtifie d u n d e r a s e p a ra te D H H S re g is try

■ S tip u la te s q u a lity c o n tro l p ra c tic e s ■ S tip u la te s m in im u m re q u ire m e n ts fo r re s u lt re p o rtin g (m u s t be re p o rte d w ith a s ta te m e n t o f th e re fe re n c e ra n g e on a fo rm th a t p ro p e rly id e n tifie s th e p a tie n t) ■ R e q u ire s re c o rd s re te n tio n fo r s p e c ifie d d u ra tio n s □ S lid e re te n tio n ■ H is to lo g y : 10 y e a rs (fro m d a te o f e x a m in a tio n , u s u a lly in te rp re te d a s d a te c a s e re p o rte d ) ■ C y to lo g y : 5 y e a rs (C A P re q u ire s 10 y e a rs fo r F N A s lid e s ) ■ A u to p s y : 10 y e a rs (n o n fo re n s ic ) o r in d e fin ite (fo re n s ic) □ B lo c k re te n tio n : 2 y e a rs (C A P re q u ire s 10 y e a rs ; fo re n s ic a u to p s y b lo c k s s a v e d in d e fin ite ly ) □ W e t tis s u e re te n tio n : u ntil re p o rt c o m p le te d (C A P re q u ire s 2 w e e k s a fte r re p o rt c o m p le te d ) □ T e s t re q u is itio n a n d te s t re p o rt re te n tio n : 2 y e a rs (p a th o lo g y re p o rts 10 y e a rs ) □ P ro fic ie n c y te s tin g re co rd s , q u a lity m a n a g e m e n t/ q u a lity c o n tro l re co rd s: 2 y e a rs □ D is c o n tin u e d p ro c e d u re s : 2 y e a rs ■ A d d itio n a l C A P re q u ire m e n ts fo r re te n tio n □ B lo o d a nd b o d y flu id s lid e s (s m e a rs ), m ic ro b io lo g y s lid e s (eg, G ra m sta ins): 7 d a y s □ F lo w c y to m e try p lo ts:1 0 y e a rs □ B lo o d b a n k re c o rd s

8.1.1.1.4 Other CLIA provisions ■ R e q u ire s w ritte n o r e le c tro n ic re q u is itio n s to d o c u m e n t p h y s ic ia n o rd e rs

■ Q C re co rd s : 5 y e a rs ■ D o n o r a n d re c ip ie n t re c o rd s :1 0 y e a rs

■ R e q u ire s w ritte n p ro c e d u re s © A S C P 2018

ISBN 9 7 8 -0 8 9 1 8 9 -6 6 7 8

397

8: Medical Directorship

Legislation & regulation, agencies & oversight>Legislation & regulations relating to laboratories ■ R e c o rd o f in d e fin ite ly d e fe rre d d o n o rs k e p t in d e fin ite ly ■ R e q u ire s p ro fic ie n c y te s tin g (P T ) a n d d e fin e s a c c e p ta b le p e rfo rm a n c e □ P T v e n d o rs m u s t b e a p p ro v e d b y C M S , a n d o n c e a la b o ra to ry s e le c ts a v e n d o r, it m u s t re m a in w ith th e s a m e v e n d o r fo r 1 fu ll y e a r b e fo re s w itc h in g to a n o th e r 8.1.1.2 Medical devices & biologies ■ T h e F D A re g u la te s m e d ic a l d e v ic e s a n d b io lo g ie s □ M e d ic a l d e v ic e s in c lu d e te s tin g in s tru m e n ts a nd re a g e n ts □ B io lo g ie s in c lu d e b lo o d p ro d u c ts ■ M e d ic a l d e v ic e s □ D e fin e d a s “a n y in s tru m e n t, a p p a ra tu s , o r o th e r a rtic le th a t is u s e d to p re v e n t, d ia g n o s e , m itig a te , o r tre a t a d is e a s e o r to a ffe c t th e s tru c tu re o r fu n c tio n o f th e b o d y, w ith th e e x c e p tio n o f d ru g s .” □ M u s t b e re v ie w e d b y th e F D A b e fo re m a rk e tin g a n d g iv e n c le a ra n c e o r a p p ro v a l ■ F D A c le a ra n c e ■ P re m a rk e t n o tific a tio n o r 5 1 0 (k ) m u s t b e file d by th e m a n u fa c tu re r to d o c u m e n t th a t th e d e v ic e is s u b s ta n tia lly e q u iv a le n t to a n o th e r F D A a p p ro v e d d e v ic e ■ F D A a p p ro v a l ■ F o rm a l v a lid a tio n file d in th e fo rm o f a p re m a rk e t a p p ro v a l (P M A ) a p p lic a tio n ; m u c h m o re rig o ro u s th a n th e 5 1 0 (k ) p ro c e s s □ S o m e m e d ic a l d e v ic e s d o n o t re q u ire F D A re v ie w (510 [k ] e x e m p t m e d ic a l d e v ic e s ) ■ P ro p e rly la b e le d w ith s ta te m e n t th a t th e d e v ic e is n o t F D A c le a re d o r a p p ro v e d ■ In c lu d e s th o s e th a t w e re m a rk e te d b e fo re e n a c tm e n t o f th e la w o n M a y 2 8 , 1976 (p re a m e n d m e n t o r g ra n d fa th e re d d e v ic e s ) a n d n e w e r d e v ic e s th a t h a v e b e e n s p e c ific a lly e x e m p te d b y re g u la tio n (m ic ro s c o p e s a n d m ic ro s c o p e a c c e s s o rie s , fo r e x a m p le ) ■ H u m a n ita ria n u s e d e v ic e s (H U D s ), d e v ic e s in te n d e d to be u s e d in ra re s c e n a rio s — fo r d ia g n o s in g o r tre a tin g a c o n d itio n th a t a ffe c ts < 4 0 0 0 in d iv id u a ls in th e U n ite d S ta te s /y e a r— s u c h th a t th e c o s t o f re s e a rc h a n d d e v e lo p m e n t w o u ld e x c e e d its m a rk e t re tu rn . T h e in s titu tio n in w h ic h an H U D is u s e d m u s t h a v e in s titu tio n a l re v ie w b o a rd a p p ro v a l o f th e d e v ic e

□ C la s s e s o f m e d ic a l d e v ic e s ■ C la s s I d e v ic e s a re d e e m e d to be lo w ris k and re p re s e n t th e v a s t m a jo rity o f 5 10 (k) e x e m p t d e v ic e s (eg, d e n ta l flo s s), in c lu d in g m o s t a n a ly te s p e c ific re a g e n ts o r A S R s (se e b e lo w ) ■ C la s s II d e v ic e s h a ve h ig h e r ris k a n d a re s u b je c t to tig h te r re g u la to ry c o n tro l. R e a g e n ts a nd A S R s used in b lo o d b a n k te s tin g , fo r e x a m p le , a re g e n e ra lly c la s s II d e v ic e s ■ C la s s III d e v ic e s in c lu d e s u c h th in g s a s h e a rt v a lve s. C la s s III A S R s in c lu d e th o s e used in d e p e n d e n tly to d ia g n o s e a c o n d itio n th a t is like ly to be fa ta l fo r w h ic h p ro m p t a n d a c c u ra te d ia g n o s is h a s p u b lic h e a lth im p a c t (eg, tu b e rc u lo s is ), fo r d o n o r s c re e n in g o f b lo o d p ro d u c ts , o r fo r d ia g n o s is o r m o n ito rin g o f h u m a n im m u n o d e fic ie n c y v iru s (H IV ) in fe c tio n ■ A n a ly te s p e c ific re a g e n ts (A S R s ) a nd la b o ra to ry d e v e lo p e d te s ts (LD Ts) □ A S R d e fin e d a s “a n tib o d ie s , b o th p o ly c lo n a l and m o n o c lo n a l, s p e c ific re c e p to r p ro te in s , lig a n d s , n u c le ic a c id s e q u e n c e s , a n d s im ila r re a g e n ts w h ic h , th ro u g h s p e c ific b in d in g o r c h e m ic a l re a c tio n s w ith s u b s ta n c e s in a s p e c im e n , a re in te n d e d fo r use in a d ia g n o s tic a p p lic a tio n fo r id e n tific a tio n a nd q u a n tific a tio n o f an in d iv id u a l c h e m ic a l s u b s ta n c e o r ligand in b io lo g ic a l s p e c im e n s ” (in c o n tra s t to g e n e ra l p u rp o s e re a g e n ts th a t a re n o n s p e c ific ) □ A re a g e n t d e v e lo p e d by a m a n u fa c tu re r fo r s o le u se in its te s t s y s te m (ie, re a g e n t n o t s e p a ra te ly m a rk e te d by its e lf) is n o t an A S R □ A n a n tib o d y u s e d in im m u n o h is to c h e m is try (IH C ), fo r e x a m p le , m a y be an A S R ; th e e n tire p ro c e s s , in c lu d in g m o u n tin g th e s e c tio n , d e p a ra ffin iz in g it, in c u b a tio n w ith a n tib o d y , p e ro x id a s e re a c tio n , and in te rp re ta tio n , c o m p ris e s th e LD T □ W h e th e r an a n tib o d y is o r is n o t an A S R d e p e n d s on its la b e lin g : th o s e la b e le d a s “fo r in v itro d ia g n o s tic u s e ” a re n o t A S R s □ T h e F D A c o n s id e rs A S R s to be m e d ic a l d e v ic e s and th e re fo re s u b je c t to its re g u la tio n ; u n d e r th is a u th o rity , it p u b lis h e d “ th e A S R ru le ” in 1997 ■ C la s s ifie s A S R s , im p o s e s re s tric tio n s on th e ir s a le a n d use, a n d d e lin e a te s la b e lin g re q u ire m e n ts ■ R e p o rts o f te s t re s u lts m u s t in c lu d e th e s ta te m e n t, “ T h is te s t w a s d e v e lo p e d a nd its p e rfo rm a n c e c h a ra c te ris tic s d e te rm in e d by (la b o ra to ry nam e). It h as n o t b e e n c le a re d o r a p p ro v e d by th e U S Food a n d D ru g A d m in is tra tio n .”

□ R e p o rtin g re q u ire m e n t ■ D u ty o f u s e rs a n d /o r m a n u fa c tu re rs to re p o rt d e v ic e m a lfu n c tio n

398

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

8: Medical Directorship

Legislation & regulation, agencies & oversight>Legislation & regulations relating to laboratories ■ T h e A S R m u s t be la b e le d “A n a ly te S p e c ific R e a g e n t.” A n a ly tic a l a nd p e rfo rm a n c e c h a ra c te ris tic s a re n o t e s ta b lis h e d .” (if a m a n u fa c tu re r w is h e s to m a ke p e rfo rm a n c e c la im s , th e n th e A S R m u s t be s u b m itte d th ro u g h th e u sua l P M A p ro c e s s ) □ M o s t IH C a n tib o d ie s a re c la s s I A S R s ■ C la s s I s ta tu s a p p lie s to th o s e IH C th a t are a d ju n c tiv e , ie, th a t c la rify h is to p a th o lo g ic fin d in g s

■ A c u rre n t C L IA c e rtific a te is re q u ire d fo r la b o ra to rie s to b e re im b u rs e d b y M e d ic a re ■ M e d ic a re c la im s are u s u a lly p ro c e s s e d by n o n g o v e rn m e n ta l c o n tra c to rs re fe rre d to a s “ fis c a l in te rm e d ia rie s ,” w h o p ro c e s s p a rt A c la im s , a n d “c a rrie rs ,” w h o p ro c e s s p a rt B c la im s ■ M e d ic a id

■ C la s s II IH C s a re g e n e ra lly th o s e th a t a re p ro g n o s tic o r p re d ic tiv e

□ F e d e ra l p ro g ra m th a t is a d m in is te re d b y s ta te s

■ C la s s III IH C s re q u ire P M A and m a y be a p p ly to th o s e a ffe c tin g ta rg e te d th e ra p y ■ B lo o d a n d b lo o d d e v ic e s fa ll u n d e r th e F D A ’s C e n te r fo r B io lo g ie s E v a lu a tio n a n d R e s e a rc h (C B E R ) □ T h e F D A in s p e c ts all b lo o d fa c ilitie s a t le a s t a n n u a lly , a nd p a rtic ip a tio n is m a n d a to ry 8.1.1.3 Medicare, Medicaid & the prospective payment system ■ S o cia l S e c u rity A c t o f 1 9 6 5 e s ta b lis h e d M e d ic a re and M e d ic a id

□ S ta te s s e t e lig ib ility re q u ire m e n ts a n d fe e s c h e d u le s □ In te n d e d to e x te n d b e n e fits to lo w in c o m e fa m ilie s

8.1.1.4 Billing & reimbursement ■ P a ye rs u tiliz e 2 c o d in g s y s te m s □ T h e In te rn a tio n a l C o d in g o f D is e a s e (IC D ) s y s te m d e s c rib e s th e p a tie n t’s m e d ic a l p ro b le m ■ T h is is u se d to e s ta b lis h th e “ m e d ic a l n e c e s s ity ” o f th e b ille d p ro c e d u re □ T h e H e a lth C a re P ro c e d u ra l C o d in g S y s te m (H C P C S ) s y s te m d e s c rib e s th e s e rv ic e s re n d e re d .; H C P C S c o d e s a re d iv id e d into le v e ls I a n d II

■ M e d ic a re □ A d m in is te re d by C M S , a d iv is io n o f D H H S □ E x te n d s b e n e fits to 3 g ro u p s : (1) 6 5 a nd older, (2) p e rm a n e n tly d is a b le d , a n d (3) e n d s ta g e re na l d is e a s e □ C a re is re im b u rs e d u n d e r p a rts A & B ■ P a rt A c o v e rs in p a tie n t c a re , h o s p ic e ca re , s k ille d n u rs in g fa c ility c a re , a nd h o m e h e a lth c a re , w ith th e e x c e p tio n o f p h y s ic ia n p ro fe s s io n a l s e rv ic e s ■ O p e ra te s u n d e r th e P ro s p e c tiv e P a y m e n t S y s te m ■ In p a tie n t c a re re im b u rs e d a c c o rd in g to d ia g n o s is re la te d g ro u p s (D R G s) ■ H o s p ita ls g e t a fix e d su m fo r a h o s p ita liz a tio n , d e te rm in e d by D R G ■ In e ffe c t, c o s ts o f h o s p ita liz a tio n in c lu d in g lab te s tin g a re n o t in d iv id u a lly b ille d to M e d ic a re ■ In p a tie n t p h y s ic ia n s e rv ic e s a re c o v e re d s e p a ra te ly u n d e r p a rt B ■ T h e C M S “ 3 d a y ru le ” a ffe c ts p re h o s p ita l te s tin g : d ia g n o s tic s e rv ic e s fu rn is h e d to a M e d ic a re b e n e fic ia ry by a h o s p ita l d u rin g th e 3 c a le n d a r d a y s im m e d ia te ly p re c e d in g a d m is s io n are b u n d le d into th e h o s p ita l D R G p a y m e n t, ie, c a n n o t be s e p a ra te ly b ille d to M e d ic a re ■ T h e C M S “ 14 d a y ru le ” p e rta in s to te s tin g p e rfo rm e d a fte r d is c h a rg e : te s tin g p e rfo rm e d w ith in 14 d a y s a fte r d is c h a rg e , on s p e c im e n s o b ta in e d d u rin g a d m is s io n , is b u n d le d into th e D R G p a y m e n t, ie, c a n n o t be s e p a ra te ly b ille d to M e d ic a re © A S C P 2018

■ P a rt B c o v e rs o u tp a tie n t s e rv ic e s a n d in p a tie n t p h y s ic ia n s e rv ic e s a c c o rd in g to a fe e s c h e d u le (fe e fo r s e rv ic e )

■ L eve l I is d e s c rib e d b y c u rre n t p ro c e d u ra l te rm in o lo g y (C P T ) c o d e s (5 d ig it c o d e s , s u c h a s th e 8 8 3 0 5 ), w h ic h a re p u b lis h e d b y th e A m e ric a n M e d ic a l A s s o c ia tio n (A M A ) ■ L eve l II c o d e s (a le tte r a n d 4 d ig its ) a re p u b lis h e d a n n u a lly by C M S and a d d re s s s e rv ic e s n o t c o v e re d b y C P T (le ve l I) c o d e s □ B o th IC D c o d e s a nd H C P C S c o d e s m u s t be u tiliz e d in s u b m itte d b ills ■ D e n ie d c la im s fo r o u tp a tie n t la b o ra to ry te s ts m a y b e b ille d d ire c tly to M e d ic a re b e n e fic ia rie s if th e p a tie n t w a s in fo rm e d in a d v a n c e th a t th is m a y o c c u r; d o c u m e n ta tio n o f th is is in th e fo rm o f an a d v a n c e d b e n e fic ia ry n o tic e (A B N ) ■ P ro fe s s io n a l c o m p o n e n t b illin g ■ M e d ic a re P a rt B p ro g ra m c o v e rs p a y m e n ts fo r p h y s ic ia n s e rv ic e s (p ro fe s s io n a l c o m p o n e n t o r “ P C ” p a y m e n ts ) ■ T h e P h y s ic ia n F ee S c h e d u le (P F S ) is b a s e d o n th e R e s o u rc e B a se d R e la tive V a lu e S c a le (R B R V S ), a m u ltitu d e o f v a ria b le s , c a lle d re la tiv e v a lu e u n its (R V U s ) u se d to c a lc u la te p a y m e n t fo r e a c h C P T c o d e ■ L a b o ra to ry te s t p a n e ls □ T h e A M A h as a p p ro v e d p a n e ls th a t, w h e n p e rfo rm e d , m u s t be b ille d a s a pan e l (n o t a s in d iv id u a l te sts). B illin g s e p a ra te ly in th is s c e n a rio is re fe rre d to a s “ u n b u n d lin g .”

ISBN 9 7 8 -0 8 9 1 8 9 -6 6 7 8

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8: Medical Directorship

Legislation & regulation, agencies & oversight>Legislation & regulations relating to laboratories □ L a b o ra to ry d e s ig n e d p a n e ls th a t a re o ffe re d a s a c o h e s iv e g ro u p fo r o rd e rin g p u rp o s e s b u t b ille d s e p a ra te ly m u s t b e a p p ro v e d b y th e m e d ic a l s ta ff a n d p u b lis h e d a n n u a lly 8.1.1.5 Direct billing law, physician self referral law (Stark law) & antikickback law ■ T h e d ire c t b illin g la w □ C o n ta in e d in th e S o c ia l S e c u rity A c t □ R e q u ire s th a t M e d ic a re b e b ille d d ire c tly b y th e la b o ra to ry p ro v id in g th e s e rv ic e ■ T h e S ta rk la w (s e lf re fe rra l law ) □ O rig in a lly to o k e ffe c t in 1 9 9 2 (S ta rk I) □ P ro h ib its p h y s ic ia n s fro m re fe rrin g M e d ic a re p a tie n ts to la b o ra to rie s in w h ic h th e y o r an im m e d ia te fa m ily m e m b e r h a s a fin a n c ia l re la tio n s h ip □ S ta rk w a s e x p a n d e d in 1 9 9 5 to a p p ly to a d d itio n a l “d e s ig n a te d h e a lth s e rv ic e s ” in c lu d in g p h y s ic a l th e ra p y , ra d io lo g y , d is p e n s in g o f m e d ic a tio n s , a n d o th e rs □ S ta rk a llo w s a n u m b e r o f e x c e p tio n s , o n e o f w h ic h is th e “ in o ffic e a n c illa r y ” e x c e p tio n th a t a llo w s b illin g fo r in o ffic e la b te s tin g u n d e r c e rta in c irc u m s ta n c e s ■ T h e a n tik ic k b a c k la w □ A s p a rt o f th e a n tik ic k b a c k law , a la b o ra to ry m a y n o t d is c o u n t la b te s tin g , fo r n o n -M e d ic a re p a tie n ts , b e lo w th e c o s t o f te s tin g 8.1.1.6 The Privacy Act & the Privacy Rule (HIPAA) ■ T h e P riv a c y A c t (1974) □ P ro te c ts re c o rd s th a t c a n be re trie v e d b y p e rs o n a l id e n tifie rs a n d p ro h ib its d is c lo s u re s w ith o u t w ritte n c o n s e n t u n le s s a s p e c ifie d e x c e p tio n a p p lie s □ A p p lie s o n ly to fe d e ra l a g e n c ie s a n d re c o rd s h e ld by th e m

■ S h a rin g o f PHI is re q u ire d w h e n re q u e s te d by D H H S as p a rt o f a le g a l in v e s tig a tio n ■ C o v e re d e n titie s □ H e a lth c a re p ro v id e rs , h e a lth p la n s, a nd h e a lth c a re c le a rin g h o u s e s □ M u s t n o t o n ly lim it th e s h a rin g o f in fo rm a tio n m u s t p ro a c tiv e ly s e c u re in fo rm a tio n to p re v e n t u n a u th o riz e d a c c e s s , in c lu d in g e n c ry p tio n o f d a ta a n d s h re d d in g o f p a p e r c o n ta in in g PHI

8.1.1.7 The Occupational Safety & Health Administration (OSHA) ■ C re a te d by O c c u p a tio n a l S a fe ty a n d H e a lth A c t o f 1970 ■ A d iv is io n o f th e D e p a rtm e n t o f L a b o r ■ M e a n t to p ro te c t w o rk e rs fro m w o rk p la c e h a z a rd s ■ E m p lo y e rs a re re q u ire d to be in c o m p lia n c e w ith O S H A re g u la tio n s a n d O S H A a p p ro v e d s ta te re g u la tio n s (m ust m e e t o r e x c e e d fe d e ra l O S H A s ta n d a rd s fo r a p p ro v a l) ■ H a z a rd o u s c h e m ic a ls □ O S H A re q u ire s th a t la b o ra to rie s c re a te a nd e x e c u te a h a z a rd o u s c h e m ic a ls h y g ie n e plan ■ T h e p la n s p e c ifie s th e u s e o f p e rs o n a l p ro te c tiv e e q u ip m e n t a n d p ro c e d u re s to e n s u re th a t p ro te c tiv e e q u ip m e n t (eg, fu m e h o o d s ) is fu n c tio n in g c o rre c tly ■ T h e p la n d e s c rib e s th e p ro v is io n s fo r p o s te x p o s u re e v a lu a tio n ■ T h e p la n s p e c ifie s a C h e m ic a l H y g ie n e O ffic e r and d e s c rib e s th e re c o rd k e e p in g re q u ire m e n ts ■ T h e p la n in c lu d e s e m p lo y e e tra in in g □ O S H A re q u ire s e m p lo y e rs to e n s u re th a t e m p lo y e e e x p o s u re s re m a in a t o r b e lo w p e rs o n a l e x p o s u re lim ite s (P E L s ) e s ta b lis h e d by O S H A ■ B lo o d b o rn e p a th o g e n s

■ T h e P riv a c y R u le (1 9 9 6 ) □ A p p lie s to a ll h e a lth c a re e n titie s □ T h is ru le o r s e t o f ru le s w a s is s u e d b y th e D H H S fo r th e im p le m e n ta tio n o f th e H e a lth In s u ra n c e P o rta b ility a n d A c c o u n ta b ility A c t (H IP A A ) □ E n fo rc e d b y th e O ffic e o f C iv il R ig h ts w ith in th e DHHS □ T h e P riv a c y R u le d e fin e s “ p ro te c te d h e a lth in fo rm a tio n ” a n d “c o v e re d e n titie s .” ■ P ro te c te d h e a lth in fo rm a tio n (P H I) ■ R e fe rs to a n y in d iv id u a lly id e n tifia b le h e a lth in fo rm a tio n ; h e a lth in fo rm a tio n in c lu d e s d e m o g ra p h ic d a ta , h e a lth c o n d itio n , o r th e fa c t th a t h e a lth c a re w a s p ro v id e d

400

■ S h a rin g o f PH I is p e rm itte d fo r th e p u rp o s e s o f tre a tm e n t, p a y m e n t, o r fo r la b o ra to ry o p e ra tio n s (eg, q u a lity c o n tro l [Q C ])

□ O S H A re q u ire s th a t la b o ra to rie s c re a te a nd e x e c u te an e x p o s u re c o n tro l plan ■ T h e p la n s p e c ifie s u se o f p e rs o n a l p ro te c tiv e e q u ip m e n t and u n iv e rs a l p re c a u tio n s (s ta n d a rd p re c a u tio n s ) ■ T h e p la n s p e c ifie s p ro v is io n o f h e p a titis B v a c c in a tio n by th e e m p lo y e r ■ T h e p la n s h o u ld c o n s id e r e n g in e e rin g a nd p ro c e s s c o n tro ls to m in im iz e ris k o f e x p o s u re as w e ll as p ro c e d u re s fo r id e n tify in g e x p o s u re s , p o s te x p o s u re e v a lu a tio n , a n d in v e s tig a tio n

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8: Medical Directorship

Financial considerations in the laboratory>Types of costs & calculation of the breakeven point | Budgeting

8.2

Financial considerations in the laboratory

total revenue

8.2.1 Types of costs f8.1 & calculation of the breakeven point ■ S o m e c o s ts a re fix e d a n d s o m e a re v a ria b le n F ixed c o s ts a re la rg e ly u n a ffe c te d by th e n u m b e r o f te s ts p e rfo rm e d ■ In s tru m e n t p u rc h a s e , re n t fo r la b o ra to ry s p a c e , a nd s u p e rv is o r w a g e s □ V a ria b le c o s ts a re a ffe c te d by th e n u m b e r o f te s ts p e rfo rm e d ■ R e a g e n ts , te c h n o lo g is t w a g e s ■ S o m e c o s ts a re d ire c t a nd s o m e a re in d ire c t □ D ire c t c o s ts a re in c u rre d d ire c tly fro m th e p e rfo rm a n c e o f th e te s t ■ In s tru m e n t p u rc h a s e , te c h n o lo g is t w a g e s , re a g e n ts □ In d ire c t c o s ts a re n ot

f8.1 T y pes of costs

Net income = revenue (R) - fixed cost (FC) - variable cost (VC)

■ R e n t fo r la b o ra to ry s p a ce , c u s to d ia l s e rv ic e s , a nd d e p re c ia tio n

So, we seek the point at which net income is 0, or the point at which 0 = R - FC - VC If Z is the number of tests performed, then the point we seek is

■ U n it c o s t is th e c o s t in c u rre d in p e rfo rm in g 1 te s t (c o s t p e r re p o rta b le )

0 = R x Z - FC -VC x Z

□ D e te rm in e d by a d d in g th e fix e d a n d v a ria b le c o s ts in vo lve d in p e rfo rm in g th e te s t

FC = R x Z - VC x Z or

This can be rearranged to

FC = (R - VC) x Z

□ N o te th a t v a ria b le c o s ts p e r u n it a re th e s a m e re g a rd le s s o f th e n u m b e r o f te s ts p e rfo rm e d

then rearranged to

□ F ixed c o s ts p e r u n it d e c re a s e a s th e n u m b e r o f te s ts p e rfo rm e d in c re a s e s t8.2

So, if we repeat the assumptions of T8.2 and assume we will charge $9 per test, then

■ T h e b re a k e v e n p o in t is th e n u m b e r o f te s ts th e la b o ra to ry m u s t p e rfo rm to re a c h th e p o in t w h e re to ta l re ve n u e e q u a ls to ta l c o s t, ie, th e p o in t a t w h ic h n et in c o m e is 0 □ T h e la b o ra to ry is n ot a lw a y s p aid e x a c tly w h a t it c h a rg e s (th e d iffe re n c e is re fe rre d to a s a llo w a n c e s ), a nd in s o m e in s ta n c e s it is n o t p aid a t all (b ad d e b t) ■ R e v e n u e is th e n to ta l c h a rg e s m in u s a llo w a n c e s and b ad d e b t

t8.2 Relationship of total cost to unit cost Assumptions: fixed cost is $500, variable cost is $5/test Tests 300 200 performed 100 Total cost

$500 + $500 = $1000

$500 + $1000 = $1500

$ 5 0 0 + $1500 = $2000

U nit cost

$ 1 0 0 0 - 1 0 0 tests = $ 1 0/test

$ 1 5 0 0 - 2 0 0 tests = $ 7 .5 0 /te s t

$ 2 0 0 0 + 3 0 0 tests = $ 6 .6 6 /te s t

Z = FC-MR-VC)

Z = $500 h- ($9 —$5) = 125 tests

f8.2 Calculation of the breakeven point

■ F o r la b o ra to rie s , th e re are g e n e ra lly 4 m a jo r p a rts o f th e b u d g e t: c a p ita l, p e rs o n n e l, o p e ra tin g , a n d a llo c a tio n □ C a p ita l b u d g e t is fo r “big tic k e t” ite m s w h o s e c o s t a n d re tu rn o n in v e s tm e n t m ay be m a p p e d o v e r m o re th a n 3 y e a rs □ P e rs o n n e l b u d g e t is th e p ro je c tio n o f p e rs o n n e l n e e d s , g e n e ra lly e x p re s s e d in fu ll tim e e q u iv a le n ts (F T E s ) □ O p e ra tin g b u d g e t c o n s id e rs all th e c o s ts o f d a y to d a y o p e ra tio n s , in c lu d in g re a g e n ts a n d o th e r c o n s u m a b le s , th e c o s t o f re fe re n c e lab te s ts , th e c o s ts o f b lo o d fo r th e tra n s fu s io n s e rv ic e , p ro fe s s io n a l fe e s , d e p re c ia tio n , m a in te n a n c e , a n d n o n c o n s u m a b le e q u ip m e n t (“ s m a ll tic k e t” ite m s s u c h a s c o m p u te r m o n ito rs ) □ A llo c a tio n b u d g e t is th e la b o ra to ry 's a llo c a te d s h a re o f th e h o s p ita l’s fix e d c o s ts (eg, e le c tric ity , a d m in is tra tio n , m a rk e tin g )

8.2.2 Budgeting ■ M a n y in s titu tio n s b u d g e t a c c o rd in g to a fis c a l y e a r th a t b e g in s on O c to b e r 1 © A S C P 2018

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8: Medical Directorship

Statistical considerations in the laboratory>Definitions

8.3

Statistical considerations in the laboratory

8.3.1 Definitions 8.3.1.1 Gaussian distribution, estimates of central tendency & estimates of variation ■ G a u s s ia n re fe rs to a d is trib u tio n o f d a ta s y m m e tric a lly a ro u n d th e m e a n w ith m o s t v a lu e s c lo s e s t to th e c e n te r □ E s tim a te s o f c e n tra l te n d e n c y : m e a n , m e d ia n , and m ode □ In a p e rfe c t G a u s s ia n d is trib u tio n , m e a n , m e d ia n , a nd m o d e a re id e n tic a l

-3 SD

- 2 SO

-1 SD

mean

+1 SO

+2SD

+3SD

f8.3 Gaussian curve

■ M e a n is th e a rith m e tic a v e ra g e . M e a n = I x '/ n ■ M e d ia n is th e m id d le v a lu e o f a ra n g e o f v a lu e s ■ M o d e is th e m o s t fre q u e n tly o c c u rrin g v a lu e in a ra n g e o f v a lu e s ■ S o m e d a ta s e ts a re n o n -G a u s s ia n — s k e w e d p o s itiv e ly o r n e g a tiv e ly — s k e w s a lte r th e m e a n a n d m e d ia n b u t do n o t a ffe c t th e m o d e . In a p o s itiv e ly s k e w e d s e t o f d a ta , m e a n > m e d ia n > m o d e ■ E s tim a te s o f v a ria tio n □ T h e s ta n d a rd d e v ia tio n (S D ) is a re fle c tio n o f v a ria tio n □ T h e S D is th e a v e ra g e d is ta n c e o f an in d iv id u a l v a lu e fro m th e m e a n □ S D = V Z (x' - m e a n )2/(n - 1) ■ In th e id e a l G a u s s ia n d is trib u tio n , 6 8 .2 % o f th e p o p u la tio n fa lls w ith in -1 S D a n d +1 S D , 9 5 .5 % fa lls w ith in - 2 S D a n d +2 S D , a n d 9 9 .7 % fa ll w ith in - 3 S D a n d +3 S D f8 .3 8.3.1.2 Reliability: analytical accuracy & precision ■ Im p re c is io n a n d in a c c u ra c y re s u lt re s p e c tiv e ly fro m ra n d o m e rro r a n d s y s te m a tic e rro r ■ T o ta l a n a ly tic e rro r is th e s u m o f ra n d o m a n d s y s te m a tic e rro r □ A n a ly tic a l a c c u ra c y is th e e x te n t to w h ic h a te s t re s u lt a p p ro x im a te s th e “ tr u e ” v a lu e □ A c c u ra c y h a s n o n u m e ric a l v a lu e , b u t is re fle c te d in th e c o rre la tio n c o e ffic ie n t o f b ia s p lo ts □ A n a ly tic a c c u ra c y is c o n tro lle d th ro u g h re g u la r c a lib ra tio n □ D ia g n o s tic a c c u ra c y (c lin ic a l a c c u ra c y ) re fe rs to th e a b ility o f a te s t to d is c rim in a te p a tie n t g ro u p s □ P re c is io n re fe rs to th e re p ro d u c ib ility o f a re s u lt ■ Im p re c is io n is re fle c te d in d is p e rs io n ; it is e x p re s s e d in te rm s o f th e c o e ffic ie n t o f v a ria tio n (C V ) ■ C V = S D /m e a n * 100 ■ S in c e th e C V is a fu n c tio n o f th e m e a n , it re fe rs to th e p re c is io n a t a p a rtic u la r a n a ly te c o n c e n tra tio n

402

□ P re c is io n is c o n tro lle d th ro u g h re g u la r te s tin g o f Q C re a g e n ts □ A s a ru le o f th u m b , d e s ira b le p re c is io n fo r m o s t a n a ly te s is S p e c ific ity = T N /(T N + FP) ■ T h e c lin ic a l s e n s itiv ity a n d s p e c ific ity s h o u ld be d is tin g u is h e d fro m th e a n a ly tic a l s e n s itiv ity and s p e c ific ity , w h ic h re fe r to th e a b ility o f th e a s s a y to d e te c t s m a ll q u a n titie s o f th e a n a ly te (a n a ly tic a l s e n s itiv ity ) a n d its a b ility to a c c u ra te ly m e a s u re th e a n a ly te in th e p re s e n c e o f o th e r s u b s ta n c e s (a n a ly tic a l s p e c ific ity )

8.3.1.4 Predictive value ■ P o sitiv e p re d ic tiv e v a lu e (P P V ) □ P ro b a b ility o f d is e a s e w h e n te s t is p o s itiv e f8.4 □ P P V = T P /(T P + FP) ■ N e g a tiv e p re d ic tiv e v a lu e □ P ro b a b ility o f n o d is e a s e w h e n th e te s t is n e g a tiv e □ N P V = T N /(T N + FN ) ■ T h e p re v a le n c e o f th e d is e a s e in th e p o p u la tio n a ffe c ts p re d ic tiv e v a lu e □ W h en d is e a s e p re v a le n c e is low , th e P P V d e c lin e s , and th e N P V in c re a s e s

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8: Medical Directorship

Statistical considerations in the laboratory>Definitions | Diagnostic accuracy: receiver operating characteristic curves | Reference intervals disease

no disease

positive test

true positive (TP)

false positive (FP)

negative test

false negative (FN)

true negative (TN)

f8,4 Punnett square

f8.5 R O C curve. O n the left is a typical R O C curve with 3 arbitrarily selected points, a-c, labeled. O n the right is a representation of 2 theoretical populations with the sa m e points, a-c, labeled. It can b e seen that if “a ” is the selected cutoff, the test will have high sensitivity (all people with disease w ould be detected), but low specificity (a good num ber of people without dis ea se test positive). If “c ’ w ere selected, the opposite would apply. Point “b” is an “ideal” cutoff, but, of course, this depends on w hat you w an t the test to accom plish.

□ N o te th a t s e n s itiv ity and s p e c ific ity a re n o t in flu e n c e d by p re v a le n c e 8.3.1.5 Relative risk ■ R e la tiv e ris k is th e ra tio o f th e ris k in th e p re s e n c e o f a fa c to r to th e b a s e lin e risk ■ It is th e ris k o f an o u tc o m e “Y ” in th e p re s e n c e o f c o n d itio n “X ” a s c o m p a re d to th e g e n e ra l p o p u la tio n R e la tiv e ris k = (# w ith X w h o d e v e lo p Y/# w ith X ) (# in p o p u la tio n w h o d e v e lo p Y/# in p o p u la tio n )

8.3.2 Diagnostic accuracy: receiver operating characteristic curves 8.3.2.1 Diagnostic accuracy ■ D ia g n o s tic a c c u ra c y re fe rs to th e a b ility o f a te s t to d is tin g u is h b e tw e e n g ro u p s o f p a tie n ts (d is e a s e vs no d is e a s e ) ■ D is tin c t fro m a n a ly tic a c c u ra c y , w h ic h re fe rs to th e a b ility o f a te s t to c o rre c tly m e a s u re a n a ly te ■ T h e re c e iv in g o p e ra tin g c h a ra c te ris tic (R O C ) f8.5 c u rv e a n d th e d o t d ia g ra m f8.6 a re c o m m o n ly u se d to illu s tra te te s t a c c u ra c y

□ A te s t w ith p e rfe c t d is c rim in a tio n h a s a c s ta tis tic o f 1.0, a nd a te s t w ith no d is c rim in a tio n h a s a c s ta tis tic o f 0 .5

8.3.3 Reference intervals

8.3.2.2 Receiver operating characteristic curves ■ V a rio u s te s t c u to ffs (d e c is io n p o in ts ) a re p lo tte d a g a in s t s e n s itiv ity (tru e p o s itiv e rate) on th e y a x is a nd 1 s p e c ific ity (fa ls e p o s itiv e rate) on th e x a x is ■ D is p la y s te s t a c c u ra c y o v e r a ra n g e o f d iffe re n t c u to ffs ■ C a n d e riv e q u a n tita tiv e m e a s u re s o f a c c u ra c y , s u c h as th e a re a u n d e r th e R O C c u rv e (the c s ta tis tic ) □ A te s t w ith no a b ility to d is c rim in a te w o u ld h a ve an R O C p lo t th a t is a 45° d ia g o n a l lin e fro m th e lo w e r le ft c o rn e r to th e u p p e r rig h t c o rn e r

© A S C P 2018

f8.6 D ot plot

8.3.3.1 Purpose of reference intervals ■ L a b o ra to rie s a re re q u ire d to re p o rt a re fe re n c e in te rv a l w ith e v e ry te s t re su lt □ E a ch la b o ra to ry is re q u ire d b y C L IA to “v e rify th a t th e m a n u fa c tu re r’s re fe re n c e in te rv a ls ...a re a p p ro p ria te fo r th e la b o ra to ry ’s p a tie n t p o p u la tio n .” □ In e ffe c t, th e la b o ra to ry m u s t e ith e r v e rify s u c h re fe re n c e in te rv a ls o r e s ta b lis h its o w n , a t th e d is c re tio n o f th e m e d ic a l d ire c to r, a n d d o c u m e n t h o w its re fe re n c e in te rv a l w a s e s ta b lis h e d

ISBN 9 7 8 -0 8 9 1 8 9 -6 6 7 8

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8: Medical Directorship

Statistical considerations in the laboratory>Reference intervals Implementation of new methods>Overview 8.3.3.2 Establishing & adopting reference intervals ■ E s ta b lis h in g re fe re n c e in te rv a ls □ A re fe re n c e p o p u la tio n is a g ro u p o f h e a lth y in d iv id u a ls d e m o g ra p h ic a lly c o m p a ra b le to th e p a tie n t p o p u la tio n ) □ C L S I re c o m m e n d s te s tin g a t le a s t 120 s u c h in d iv id u a ls , a p p ly in g e x c lu s io n c rite ria a s a p p ro p ria te a n d c o n tro llin g p re a n a ly tic v a ria b le s □ T h e re fe re n c e in te rv a l m a y be ta k e n a s th e c e n tra l 9 5 % o f v a lu e s o r a s all v a lu e s fa llin g w ith in + 2 S D a n d -2 S D □ S o m e a n a ly te s (eg, s e ru m p ro s ta te s p e c ific a n tig e n ) h a v e n o re le v a n t lo w e r lim it ■ A d o p tin g re fe re n c e in te rv a ls □ L a b o ra to rie s u s u a lly a d o p t re fe re n c e in te rv a ls ra th e r th a n e s ta b lis h th e m

■ M e th o d v a lid a tio n c o n s is ts o f e x p e rim e n ts to p rove b o th th e c lin ic a l v a lu e o f a te s t a n d p e rfo rm a n c e c h a ra c te ris tic s . V a lid a tio n h as all th e c o m p o n e n ts o f v e rific a tio n b u t h a s (1) g re a te r s ta tis tic a l p o w e r (u s u a lly in v o lv e s la rg e r s a m p le n u m b e rs ), and (2) a s s e s s m e n t o f a d d itio n a l p a ra m e te rs (clin ica l s e n s itiv ity , c lin ic a l s p e c ific ity , a n d P P V ) ■ V a lid a tio n is re q u ire d w h e n im p le m e n tin g a la b o ra to ry d e v e lo p e d te st, a n o n -F D A c le a re d te st, o r a n y m o d ific a tio n o f an F D A a p p ro v e d te s t ■ V a lid a tio n is n ot re q u ire d w h e n F D A a p p ro v e d te s ts a re u se d w ith in th e s c o p e fo r w h ic h th e y w e re a p p ro v e d a nd w ith o u t m o d ific a tio n □ M e th o d v e rific a tio n

□ T h e s o u rc e o f th e re fe re n c e in te rv a l m a y be lite ra tu re , m a n u fa c tu re r, o r th e la b o ra to ry ’s o w n p re v io u s ly e s ta b lis h e d re fe re n c e in te rv a l (w h e n a n e w in s tru m e n t o r m e th o d is b e in g im p le m e n te d )

■ U s u a lly in v o lv e s th e fo llo w in g e le m e n ts : (1) p re c is io n , (2) a c c u ra c y , (3) re p o rta b le ra n g e , (4) re fe re n c e in te rv a ls , (5) a n a ly tic s e n s itiv ity , (6) a n a ly tic s p e c ific ity

□ A d o p te d re fe re n c e in te rv a ls s h o u ld be v e rifie d w ith in th e la b o ra to ry

■ C L IA s p e c ific a lly m a n d a te s e le m e n ts 1-4 fo r all te s ts a nd 1-6 fo r LD Ts

□ C L S I re c o m m e n d s te s tin g a t le a s t 2 0 h e a lth y in d iv id u a ls

■ C L IA d o e s n o t s p e c ify h o w th e s e e le m e n ts a re to be d o n e o r w h a t is c o n s id e re d a c c e p ta b le

□ If 2 0 te s ts a re c o n d u c te d , a t le a s t 18 s h o u ld fa ll w ith in th e e s ta b lis h e d re fe re n c e ra n g e u n d e r c o n s id e ra tio n

■ T h e m e d ic a l d ire c to r is re s p o n s ib le fo r o u tlin in g a v e rific a tio n p la n t8 .3

8.4

Im plem entation of new methods

8.4.1 Overview ■ W h e n a n e w m e th o d o r n e w in s tru m e n t is in tro d u c e d to th e la b o ra to ry a p ro c e s s is u n d e rta k e n th a t in c lu d e s a s s e s s m e n t o f p e rfo rm a n c e , w ritin g a p ro c e d u re , in te g ra tio n in to th e in fo rm a tio n s y s te m , tra in in g , a nd e d u c a tio n ■ T h e e x te n t o f m e th o d p e rfo rm a n c e a s s e s s m e n t d e p e n d s o n th e s ta tu s o f th e m e th o d — w h e th e r F D A a p p ro v e d o r n o t, a n d if a p p ro v e d , w h e th e r w a iv e d o r n o t □ W a iv e d te s ts p e rfo rm e d in w a iv e d te s t o n ly la b o ra to rie s m a y n o t re q u ire s ig n ific a n t v a lid a tio n ; h o w e v e r, m o d e ra te c o m p le x ity la b o ra to rie s , e v e n if p e rfo rm in g a “w a iv e d ” te s t, a re h e ld to th e h ig h e r m o d e ra te c o m p le x ity s ta n d a rd s □ A s s a y s th a t d o n o t h a v e F D A a p p ro v a l re q u ire fo rm a l v a lid a tio n , w h e re a s F D A a p p ro v e d te s ts m a y re q u ire o n ly v e rific a tio n ■ V a lid a tio n v e rs u s V e rific a tio n □ M e th o d v a lid a tio n is a m u c h m o re e x te n s iv e p ro c e s s th a n m e th o d v e rific a tio n

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■ M e th o d v e rific a tio n c o n s is ts o f e x p e rim e n ts p e rfo rm e d to c o n firm th a t, w ith in th e la b o ra to ry , a te s t p e rfo rm s a s th e m a n u fa c tu re r c la im s

■ T h e v e rific a tio n e x p e rim e n t s a m p le s m ay be d e riv e d fro m p a tie n t s a m p le s , s a m p le s o b ta in e d fro m h e a lth y s u b je c ts (la b o ra to ry te c h n o lo g is t b lo o d ), Q C m a te ria ls , o r p ro fic ie n c y te s tin g s a m p le s

t8.3 Validation plan checklist Calibration & calibration verification______________________ Precision verification & establishment of quality control ranges Establishment of reference intervals & critical values (if any)____________ Determination of analytic sensitivity Determination of analytic specificity_______________________________ Determination of accuracy/interferences Method comparison (primary)____________________________________ Method comparison (secondary), if any____________________________ Carryover tests________________________________________________ Establishment of analytical measurement range & clinical reportable range Establishment of parameters for calibration and quality control Determination of specimen stability________________________________ Verification of interfaces & reports Procedure written & approved by medical director____________________ Application for proficiency testing_________________________________ Training of laboratorians & competency assessment Notification of clinicians_________________________________________

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8: Medical Directorship

Implementation of new methods>Elements of method verification

8.4.2 Elements of method verification 8.4.2.1 Calibration & calibration verification ■ C a lib ra tio n is th e p ro c e s s o f a d ju s tin g th e in s tru m e n t to re ad o u t th e k n o w n a c tu a l c o n c e n tra tio n o f a c a lib ra to r ■ C a lib ra tio n v e rific a tio n in v o lv e s th e u se o f s e v e ra l s p e c im e n s w ith k n o w n c o n c e n tra tio n s (p a tie n t s a m p le s , c o m m e rc ia l c a lib ra to rs , p ro fic ie n c y te s tin g m a te ria l, c o n tro ls ) to e n s u re th e v a lid ity o f th e c a lib ra to r o v e r a w id e r ra n g e o f re su lts ■ C a lib ra tio n is a n a lo g o u s to “z e ro in g ” a s c a le , a nd c a lib ra tio n v e rific a tio n is a n a lo g o u s to th e n te s tin g th e s c a le u sin g a s e rie s o f k n o w n w e ig h ts ■ C a lib ra tio n v e rific a tio n m u s t be c a rrie d o u t a t le a s t o n c e e v e ry 6 m o n th s a n d m o re fre q u e n tly u n d e r s o m e c irc u m s ta n c e s , eg, a fte r m a jo r p re v e n tiv e m a in te n a n c e

8.4.2.2 Precision & establishment of quality control ranges

f8.7 Correlation study: 1 constant bias, 2 proportional bias, 3 mixed

■ P re c is io n re fe rs to th e re p ro d u c ib ility o f a re su lt; im p re c is io n is re fle c te d in th e d e g re e to w h ic h re p e a te d m e a s u re m e n ts d is p e rs e in re la tio n to th e m e a n

■ A c a lc u la tio n o f a v e ra g e b ia s , th e d iffe re n c e b e tw e e n e a c h re su lt a n d th e re fe re n c e re s u lt, is c o m p a re d to s o m e p re s e le c te d a llo w a b le lim it

■ P re c is io n is v e rifie d by re p lic a tin g m e a s u re m e n ts on s a m e s p e c im e n s , both s im u lta n e o u s ly (w ith in run p re c is io n ) a n d c o n s e c u tiv e ly (b e tw e e n run p re c is io n )

■ L in e a r re g re s s io n a n a ly s is p e rm its a lin e to be d ra w n th a t “ b e s t fits ” th e s e t o f x a n d y d a ta p o in ts

■ T h e m e a n a nd s ta n d a rd d e v ia tio n o f th e s e m e a s u re m e n ts ca n be u se d to e s ta b lis h Q C ra n g e s fo r s ta tis tic a l Q C ■ T h e “ ru le o f th u m b ” is 2 0 s a m p le s fo r m o s t e x p e rim e n ts

8.4.2.3 Accuracy, inaccuracy (bias) & method comparison ■ A c c u ra c y re fe rs to th e c o rre c tn e s s o f a re su lt, a s c o m p a re d to a k n o w n “tru e ” v a lu e ■ T h is ca n be v e rifie d in 2 w a y s □ R e c o v e ry e x p e rim e n t, in w h ic h c e rtifie d re fe re n c e m a te ria ls o f k n o w n q u a n tity a re a n a ly z e d □ M e th o d c o m p a ris o n (m e th o d c o rre la tio n ) e x p e rim e n t, in w h ic h re s u lts o b ta in e d by th e n e w m e th o d a re c o m p a re d w ith re s u lts fro m a p re v io u s ly v a lid a te d m e th o d o r a re fe re n c e m e th o d ■ R e c o m m e n d e d th a t a t le a s t 4 0 s a m p le s a re u sed fo r c o m p a ris o n ■ P a ire d re s u lts p lo tte d , w ith re s u lts fro m th e n e w m e th o d on th e y a x is a nd th o s e fro m th e re fe re n c e m e th o d on th e x a x is f8.7 ■ T h e s lo p e m a y in d ic a te a p ro p o rtio n a l b ias, o n e th a t is in itia lly n e g lig ib le b u t in c re a s e s in m a g n itu d e in re la tio n to th e v a lu e o f th e re su lt ■ T h e in te rc e p t m a y in d ic a te a c o n s ta n t b ias, o n e th a t is ro u g h ly th e s a m e th ro u g h o u t th e ra n g e o f v a lu e s © A S C P 2018

■ T h e c o rre la tio n c o e ffic ie n t (r) is a n u m b e r ra n g in g fro m -1 to +1 th a t e x p re s s e s th e d e g re e o f lin e a rity b e tw e e n th e 2 d a ta s e ts ■ Id e ally, s lo p e e q u a ls 1, in te rc e p t is 0, a n d r is 1 ■ If m o re th a n 1 in s tru m e n t is in s e rv ic e , th e n m e th o d c o m p a ris o n s h o u ld be c a rrie d o u t b e tw e e n in s tru m e n ts (s e c o n d a ry m e th o d c o m p a ris o n ); s e c o n d a ry m e th o d c o m p a ris o n m u s t be p e rfo rm e d in itia lly a n d a t le a s t tw ic e p e r y e a r

8.4.2.4 Analytic specificity, interference & carryover ■ A n a ly tic a l s p e c ific ity re fe rs to th e d e g re e to w h ic h th e a n a ly te ca n be d e te c te d in th e p re s e n c e o f in te rfe rin g s u b s ta n c e s (b iliru b in e m ia , lip e m ia , h e m o g lo b in e m ia ) ■ C a n be te s te d in “ re c o v e ry ” e x p e rim e n ts , in w h ic h q u a n titie s o f in te rfe re n t a re a d d e d to k n o w n s a m p le s , a n d th e a m o u n t o f a n a ly te m e a s u re d (“ re c o v e re d ” ) is c o m p a re d to th e k n o w n a m o u n t □ T y p e s o f in te rfe re n c e ■ H e te ro p h ile a n tib o d y in te rfe re n c e is a m a jo r p ro b le m in im m u n o a s s a y b a s e d te s tin g ■ S e ria l d ilu tio n s o f s a m p le s c o n ta in in g h e te ro p h ile a n tib o d y do n ot lead to p re d ic ta b le c h a n g e s in a n a ly te m e a s u re m e n t; in fa c t, th e m e a s u re m e n t m a y a c tu a lly in c re a s e w ith d ilu tio n ■ S o lv e n t e x c lu s io n e ffe c t □ F a ls e ly lo w a n a ly te c o n c e n tra tio n th a t re s u lts fro m a h ig h e r th a n n o rm a l “so lid p h a s e .”

ISBN 9 7 8 -0 8 9 1 8 9 -6 6 7 8

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8: Medical Directorship

Implementation of new methods>Elements of method verification □ A n “ in d ire c t IS E ” in s tru m e n t m e a s u re s a n a ly te c o n c e n tra tio n w ith in th e a q u e o u s p h a s e a nd c a lc u la te s th e c o n c e n tra tio n fo r th e e n tire v o lu m e o f b lo o d ; w h e n th e s o lid p h a s e is in c re a s e d as, fo r e x a m p le , in lip e m ia o r p a ra p ro te in e m ia , th e n th e c a lc u la tio n u n d e re s tim a te s th e tru e v a lu e

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2

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□ A p ro b le m fo r a n a ly te s th a t c a n h a v e a w id e ra n g e o f c o n c e n tra tio n , s u c h a s |B-hCG

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low

□ C a rry o v e r fro m 1 s a m p le in to a n o th e r c o u ld h a ve m a jo r im p a c t u p o n th e s e c o n d s a m p le

4

high

□ C a rry o v e r s tu d ie s a re p e rfo rm e d u s in g a s a m p le o f k n o w n h ig h a n a ly te c o n c e n tra tio n a n d a s a m p le o f lo w c o n c e n tra tio n f8.8. P e rc e n t c a rry o v e r o f < 1 .5 % is d e s ira b le

5

high

6

low

■ C a rry o v e r

□ H ig h c a rry o v e r s u g g e s ts a p ro b le m in th e d is p e n s in g / p ip e ttin g s y s te m

8.4.2.5 Analytical sensitivity, limit of detection & functional sensitivity ■ A n a ly tic a l s e n s itiv ity re fe rs to th e lo w e s t a n a ly te c o n c e n tra tio n th a t is re lia b ly d e te c ta b le ■ L im it o f b la n k (L o B ) a n d lim it o f d e te c tio n (L o D ) a re s im ila r, re fe rrin g to th e lo w e s t c o n c e n tra tio n th a t c a n be d is tin g u is h e d fro m b a c k g ro u n d (b la n k ) ■ F u n c tio n a l s e n s itiv ity , a ls o c a lle d lim it o f q u a n tita tio n (L o Q ), is th e lo w e s t a n a ly te c o n c e n tra tio n re lia b ly q u a n tifie d w ith a n a c c e p ta b le C V

8.4.2.6 Linearity, analytical measuring range & clinical reportable range ■ T h e a n a ly tic a l m e a s u rin g ra n g e (A M R )

8.4 .2 7 Specimen stability ■ S p e c im e n s ta b ility re fe rs to th e le n g th o f tim e th a t a s to re d s p e c im e n w ill c o n tin u e to p ro d u c e re lia b le re s u lts ■ M ay be a s s e s s e d fo r s p e c im e n s s to re d a t ro o m te m p e ra tu re , a t re frig e ra to r te m p e ra tu re , a n d /o r fo r fro z e n s p e c im e n s ■ To d e te rm in e , p a tie n t s a m p le s a re te s te d im m e d ia te ly a nd a t in te rv a ls u n d e r th e d e fin e d s to ra g e c o n d itio n s ■ M a x im u m s to ra g e tim e is d e fin e d a s th e la s t tim e b e fo re s ig n ific a n t, p re d e fin e d , v a ria tio n is n o te d . F o r e x a m p le , o n e m a y c h o o s e to u s e 2 o r 3 S D a s d e fin in g s ig n ific a n t v a ria tio n

8.4.2.8 Information systems

□ R a n g e o v e r w h ic h re lia b le m e a s u re m e n t c a n be o b ta in e d w ith o u t m a n ip u la tio n (w ith o u t d ilu tio n )

■ W h e n v e rify in g a n e w in s tru m e n t o r te s t, th e re lia b ility o f in te rfa c e s s h o u ld be v e rifie d

□ U s u a lly d e te rm in e d b y lin e a rity e x p e rim e n t

■ K ey in te rfa c e s in c lu d e th o s e b e tw e e n th e in s tru m e n t a nd th e la b o ra to ry in fo rm a tio n s y s te m (LIS ) a n d th o s e b e tw e e n a ny “m id d le w a re " (b e tw e e n in s tru m e n t a nd LIS )

■ S a m p le s o f k n o w n c o n c e n tra tio n s e ria lly d ilu te d a n d a s s a y e d , a n d re s u lts p lo tte d ■ A t le a s t 5 d iffe re n t p o in ts w ith in th e re p o rta b le ra n g e is id e a l ■ T h e p lo t is e x a m in e d fo r lim its o f lin e a rity ■ T h e c lin ic a l re p o rta b le ra n g e (C R R ) a ls o c a lle d m a x im u m d ilu tio n /c o n c e n tra tio n (M D /C ) ■ H ig h e s t a n d lo w e s t v a lu e s th a t c a n b e re p o rte d a c c u ra te ly ■ T h e ra n g e o f q u a n tita tiv e re s u lts th a t m a y be re p o rte d , ta k in g in to a c c o u n t th e a b ility to d ilu te s a m p le s th a t fa ll o u ts id e th e u p p e r lim it o f th e A M R , if a p p lic a b le ■ L o w e n d o f th e C R R is ty p ic a lly id e n tic a l to th e lo w e nd o f th e A M R

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f8.8 Example of carryover test: rack loading order

■ O fte n , th e re is th e n a n in te rfa c e b e tw e e n th e LIS and th e h o s p ita l in fo rm a tio n s y s te m a n d p o s s ib ly n u m e ro u s a d d itio n a l p ro p rie ta ry in fo rm a tio n s y s te m s ■ A n a p p ro a c h is to s im p ly re p o rt a n u m b e r o f “ te s t” p a tie n ts a c ro s s th e v a rio u s in te rfa c e s , o rig in a tin g w ith th e in s tru m e n t. A w id e v a rie ty o f p o s s ib le re s u lts s h o u ld be g e n e ra te d , e g, n o rm a l re su lts , a b n o rm a l low, a b n o rm a l h ig h , c ritic a l (if a p p lic a b le ) ■ R e p o rts g e n e ra te d a c ro s s e a c h in te rfa c e s h o u ld be c h e c k e d fo r fid e lity a nd fo r in te g rity o f in te rp re tiv e c o m m e n ts , p a tie n t id e n tific a tio n , u n its o f m e a s u re , and re fe re n c e ra n g e s

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8: Medical Directorship

Implementation of new methods>Elements of method verification Quality management>Definitions 8.4.2.9 Written procedures ■ E a ch te s t m u s t be h a ve w ritte n p ro c e d u re , w h ic h m u s t a d d re s s all a s p e c ts o f th e te s tin g p ro c e s s ■ S h o u ld fo llo w a s ta n d a rd fo rm a t a n d in c lu d e th e in fo rm a tio n liste d in t8 .4 ■ P ro d u c t in s e rts m a y be a s o u rc e fo r s o m e o f th e in fo rm a tio n in th e p ro c e d u re , b u t th e y s h o u ld n o t be u se d in s te a d o f a p ro c e d u re ■ P ro c e d u re s m u s t be re v ie w e d by th e m e d ic a l d ire c to r initially, e a c h tim e a c h a n g e is m a d e , a n d b ie n n ia lly (e ve ry 2 ye a rs ) □ T e s tin g p e rs o n n e l m u s t re a d and u n d e rs ta n d th e p ro c e d u re s p rio r to te s tin g and a t re g u la r in te rv a ls th e re a fte r (a nn ua lly, u su a lly); e v e ry c h a n g e to th e p ro c e d u re m u st, lik e w is e , be re a d a n d u n d e rs to o d □ Ideally, w ritte n p ro c e d u re s s h o u ld be m a in ta in e d on a c o m p u te riz e d d o c u m e n t c o n tro l p ro g ra m . S u ch p ro c e d u re s a re u s u a lly a c c e s s ib le th ro u g h an “ in tra n e t.” A b a c k u p d a ta s o u rc e s h o u ld be a v a ila b le fo r s y s te m d o w n tim e s . P rin te d c o p ie s s h o u ld be a v o id e d , b u t c e rta in p rin te d “w o rk a id s ” m a y be n e c e s s a ry

8.4.2.10 Education of laboratory staff & clinical staff ■ L a b o ra to ry s ta ff □ A tra in e r is s e le c te d , u s u a lly th e te c h n o lo g is t w h o h as p e rfo rm e d th e m e th o d v e rific a tio n /v a lid a tio n □ C o m p e te n c y is e s ta b lis h e d a n d d o c u m e n te d by h a vin g s ta ff re ad th e p ro c e d u re , a tte s t th a t th e y h ave re ad a nd u n d e rs to o d it, a n d by d e m o n s tra tin g c o m p e te n c y if a p p lic a b le □ In s o m e in s ta n c e s c lin ic a l s ta ff s h o u ld be n o tifie d o f th e n e w a s s a y □ T h e la b o ra to ry m e d ic a l d ire c to r s h o u ld c o m p o s e a c o m m u n iq u e (te c h n ic a l b u lle tin ) t8.5

8.5

Quality management

8.5.1 Definitions 8.5.1.1 Quality management and quality control ■ T h e fo llo w in g te rm s a re u sed in c o n s is te n tly in lite ra tu re a n d d e fin itio n s va ry, b ut th e y d e s c rib e v a rio u s a p p ro a c h e s th a t fo c u s on im p ro v in g p ro c e s s e s o r s y s te m s in o rd e r to im p ro v e p ro d u c t □ Q u a lity a s s u ra n c e (Q A )” ■ S y s te m o r p ro c e s s in te rv e n tio n s a im e d a t fu lfillin g q u a lity e x p e c ta tio n s o r re q u ire m e n ts ■ Id e n tify in g a nd re m o v in g b a rrie rs o r v a ria tio n w ith in th e s y s te m o r p ro c e s s a n d m o n ito rin g th e e ffe c t

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t8.4 Elements of a laboratory procedure Element

Notes

Test principle

An overview of the analyte, the methodology the test is based on, and clinical utility of the test Patient preparation eg, fasting, nonfasting, preparation of venipuncture site Specimen collection, What specimen is appropriate, how collected & into what labeling, handling & container? transport Should the specimen be inverted several times immediately after collection? Can it be mailed, pneumatically tubed? Under what conditions & how quickly must it be transported to the laboratory? Specimen storage, Room temperature, refrigerator, or freezer storage, preservation & stability stability of analyte under various conditions, how quickly must it be centrifuged Criteria for specimen General “rejection criteria” are often discussed in a acceptability separate “labwide” procedure; herein list any criteria particular to this analyte or assay Referral instructions The laboratory must refer specimens for testing only to a CLIA certified or CMS approved laboratory If the laboratory accepts referral specimens, written instructions must be available to clients, and must include the items listed above Reagents List of reagents, including proper storage (as applicable, temperature, humidity), concentrations, expiration dates Procedures for If applicable, including the detection of inadequately microscopic prepared slides examinations Test procedure Step by step Reportable range Determined at time of method verification/validation Test calibration How performed, how often Quality control (QC) How performed, how often procedures Steps to be taken when eg, retest the unacceptable control (1 time only) calibration or QC fails If repeat acceptable, no further action; if the repeat unacceptable, what actions are to be taken? This should include evaluating all patient test results obtained since the last acceptable QC to determine if the patient test results were adversely affected (before reporting the results and if necessary issuing corrected reports); at what point to notify clinicians of an anticipated delay? Limitations of procedure eg, interfering substances Reference range Determined at time of method verification/validation Critical values A labwide procedure should address the steps to be taken in reporting critical values; herein list the values considered critical, if any Results reporting & How results are entered into laboratory information calculations, if any system and any calculations that must be carried out References Sources of information for the procedure, including product insert, standard texts, published studies

□ Q u a lity im p ro v e m e n t (Q l) ■ S y s te m o r p ro c e s s in te rv e n tio n s a im e d a t ra is in g p ro d u c t q u a lity ■ A d e riv a tiv e c a lle d C o n tin u o u s Q u a lity Im p ro v e m e n t (C Q I) s e e k s to c y c lic a lly id e n tify o p p o rtu n itie s , m ake c h a n g e s , a n d m e a s u re im p ro v e m e n t

ISBN 9 7 8 -0 8 9 1 8 9 -6 6 7 8

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8: Medical Directorship

Quality management>Definitions | Statistical quality control

t8.5 Suggested elements of test change communique (technical bulletin) Element

Note

Examples

BHS laboratory will discontinue the use of the Headline A 1 line X assay for measurement of Y and will be statement of performing this measurement on the Z what is about to happen or BHS laboratory will discontinue sending out testing for Y and will implement in house testing on the Z instrument or BHS laboratory introduces the Z assay for measurement o f___ Background A brief paragraph The manufacturer no longer provides reagents for use on the X, and new instrumentation (Z) has about the reason for the been acquired or change The performance of the Z assay for Y has been deemed superior to that of the X; for this reason, BHS laboratory has acquired the Z analyzer or BHS laboratory volume of testing for Y has been deemed sufficiently high to bring testing in house; testing will be performed on the Z analyzer or Studies have determined that___can be accurately diagnosed/excluded by measurement of serum Y; BHS laboratory has acquired the Z analyzer for measurement of Y Turnaround time will be significantly improved What will this Impact or mean to the medical staff? Test performance will be significantly improved or There will be a change in the reference range for Y from ___(old reference range) to ___ (new reference range) or Specimen requirements differ significantly as follows:___ Date of “Go live” date change How ordered The “test code” The Z test may be ordered by the name___

■ Q u a lity m a n a g e m e n t ■ C a n b e d e fin e d a s th e s u m to ta l o f a ll e ffo rts to m e a s u re a n d in flu e n c e q u a lity ■ A lte rn a tiv e ly , is th e n a m e g iv e n to an a p p ro a c h in w h ic h a s y s te m o r p ro c e s s is m a n a g e d in o rd e r to a c h ie v e m a x im a l c u s to m e r s a tis fa c tio n □ T o ta l Q u a lity M a n a g e m e n t (T Q M ) is a p h ilo s o p h y th a t s e e k s to in te g ra te a ll o rg a n iz a tio n a l fu n c tio n s (p ro d u c tio n , fin a n c e , in fo rm a tio n s y s te m s , e tc) to fu lfill c u s to m e r n e e d s □ Q u a lity c o n tro l (Q C ) a n d W a lte r S h e w h a rt ■ F o c u s e s on p ro d u c t in o rd e r to d e te c t s y s te m e rro rs ■ S h e w h a rt p ro m u lg a te d th e c o n c e p t o f a c c e p ta b le v a ria tio n

408

■ V a ria b ility is in h e re n t in all p ro c e s s e s ; lim its o f a c c e p ta b ility s h o u ld b e d e fin e d by s ta tis tic a l m e a n s , a n d p ro c e s s e s s h o u ld n o t be a d ju s te d w h e n p ro d u c ts fa ll c o n s is te n tly w ith in th e m ■ W h e n o u ts id e d e fin e d lim its , th e p ro c e s s s h o u ld be in s p e c te d fo r “a s s ig n a b le c a u s e s .” ■ To d e fin e lim its , S h e w h a rt p lo tte d d a ta on a c o n tro l c h a rt, a g ra p h w ith lin e s d e m a rc a tin g th e m e a n and s e v e ra l SD ■ W h e n L e ve y a n d J e n n in g s p ro p o s e d th e u se o f S h e w h a rt c o n tro l c h a rts in th e c lin ic a l la b o ra to ry , th e c h a rts b e c a m e k n o w n a s “ L e v e y -J e n n in g s ” c h a rts ■ T h e p ro c e s s b e c a m e k n o w n a s s ta tis tic a l q u a lity c o n tro l (S Q C o r s im p ly Q C ) ■ 6 S ig m a is an e x te n s io n o f th e S Q C c o n c e p t, th e n a m e re fe rrin g to 6 S D fro m th e m ea n ■ T h e p re m is e in 6 S ig m a is th a t a p ro c e s s d e s ig n in w h ic h lim its o f a c c e p ta b ility a re 6 S D fro m th e m e a n h as a v e ry lo w lik e lih o o d o f fa ilu re ; s p e c ific a lly , 3 .4 d e fe c ts p e r m illio n (2 s ig m a p ro d u c e s 3 0 8 ,0 0 0 p e r m illio n )

8.5.2 Statistical quality control 8.5.2.1 Traditional QC ■ T h is re fe rs to p a ra lle l te s tin g o f k n o w n s a m p le s in o rd e r to e n s u re th a t th e te s t s y s te m is w o rk in g p ro p e rly and th a t re s u lts o b ta in e d fro m p a tie n t s a m p le s a re re lia b le ■ S p e c im e n s u se d fo r Q C a re m o s t o fte n s a m p le s p ro v id e d by an o u ts id e v e n d o r ■ F o r e a c h ty p e o f q u a n tita tiv e te s t, th e re a re u s u a lly 2 o r 3 c o n tro ls u sed : a “ lo w ” Q C re a g e n t a n d a “ h ig h ” Q C re a g e n t, s o m e tim e s a “ m id ra n g e ” Q C re a g e n t, o fte n re fe rre d to a s le v e l /, le v e l II, a n d le v e l III c o n tro ls ■ W h e n a n e w c o n tro l lo t is re ce iv e d , it is te s te d se v e ra l tim e s (u s u a lly 20). T h e re s u lts fro m th e s e te s ts a re used to c a lc u la te a m e a n a n d s ta n d a rd d e v ia tio n (SD ). B a se d on th e se , a L e v e y -J e n n in g s (S h e w h a rt) c h a rt is c re a te d f8.9. O n ly 1 L e v e y -J e n n in g s c h a rt is illu s tra te d , b ut u s u a lly th e re is 1 fo r e a c h level o f c o n tro l ■ F re q u e n c y o f c o n tro l s a m p le a s s a y □ U s u a lly o n c e p e r leve l p e r run b u t m ay be d o n e o n ly o n c e o e r day, d e p e n d in g on th e ty p e o f te s t a nd its fre q u e n c y □ A t m in im u m , C L IA re q u ire s 2 le v e ls o f Q C e v e ry 24 h o u rs (if te s tin g is p e rfo rm e d d u rin g th e 24 h o u r p e rio d ) o r a s fre q u e n tly a s re c o m m e n d e d by th e m a n u fa c tu re r, w h ic h e v e r is m o re fre q u e n t, u n le s s an a lte rn a tiv e p la n is im p le m e n te d

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© A S C P 2018

8: Medical Directorship

Quality management>Statistical quality control

t8.6 Selected Westgard rules

Interpretation

Day A ccept run

C ontrol v a lu e is < 2 S D ; run is in control

3

A ccept run

C ontrol v a lu e is < 2 S D ; run is in control

4

A ccept run

C ontrol v a lu e is < 2 S D ; run is in control

5

A ccept run

C ontrol v a lu e exceeds 2SD; No rules v io la te d ; run is in control

6

Reject run

C ontrol v a lu e exceeds 2SD 2:2s ru le v io la te d

A ccept run

C ontrol v a lu e is < 2 S D ; run is in control

8

Reject run

C ontrol v a lu e exceeds 2SD 1 :3s ru le v io la te d

9

A ccept run

C ontrol v a lu e is < 2 S D ; run is in control

10

A ccept run

C ontrol v a lu e is < 2 S D ; run is in control

11

A ccept run

C ontrol v a lu e is < 2 S D ; run is in control

12

A ccept run

C ontrol v a lu e exceeds 2SD; no rules v io la te d ; run is in control

13

Reject run

C ontrol v a lu e exceeds 2SD 2:2s (a n d 1 0 :m e a n ) rule v io la te d

14

A ccept run

C ontrol v a lu e is < 2 S D ; run is in control

15

A ccept run

C ontrol v a lu e is < 2 S D ; run is in control

16

A ccept run

C ontrol v a lu e exceeds 2SD; no rules v io la te d ; run is in control

17

A ccept run

C ontrol v a lu e is < 2 S D ; run is in control

18

Reject run

C ontrol v a lu e exceeds 2SD; 4:1 s rule v io la te d

7

D efinition P urpose 1 value is found to be ± 3 Detects imprecision SD from the mean 2 consecutive values found Detects imprecision & to be >2 SD on the same systematic bias side of the mean 2 values within the same Detects random error run are found to be >4 SD from each other 4 consecutive values are Detects systematic bias found to be >1 SD on the same side of the mean 10 consecutive values are Detects systematic bias found to be on the same side of the mean

Rule 1:3s

2

2:2s R:4s

4:1s 10:mean

SD = sta n d a rd deviation

m D rift: g ra d u a l m o v e m e n t a w a y fro m th e m e a n ; c a u s e s o f d rift in c lu d e s lo w d e te rio ra tio n in a lig h t s o u rc e , c o rro s io n o f e le c tro d e s , a c c u m u la tio n o f d e b ris w ith in tu b in g , o r re a g e n t d e te rio ra tio n

• •

*

9

ad

0

9

•

9

• •

■ S h ift: ra p id a n d s u s ta in e d m o v e a w a y fro m th e m e a n ; c a u s e s in c lu d e a lte re d te m p e ra tu re o r h u m id ity , lo t c h a n g e s , in s tru m e n t m a in te n a n c e , o r fa ilu re in a n y n u m b e r o f s y s te m c o m p o n e n ts

•

-1 s d

• •

9 -2 a d

9

•

-3 a d

2

3

4

5

6

7

N

9

10 Day

11

12

13

14

15

16

17

18

■ T h e R :4s a n d 1:3s ru le s a re m o s t s e n s itiv e to ra n d o m e rro r ■ R a n d o m e rro r m ay b e c a u s e d b y b u b b le s , u n d e rfille d tu b e s, te c h n o lo g is t e rro r, a nd a u to p ip e ttin g e rro rs

f8.9 Statistical quality control

■ A p p lic a tio n o f c o n tro l s a m p le te s t re su lt

■ W h e n an “o u t o f c o n tro l” ru n is d e te c te d

□ T h e re s u lt o b ta in e d is p lo tte d on th e L e v e y -J e n n in g s c h a rt

□ E v a lu a te th e te s t s yste m , in c lu d in g re a g e n ts a n d in s tru m e n t

□ If th e c o n tro l s a m p le re s u lt fa lls w ith in 2 S D o f th e m e a n , th e run is c o n s id e re d “ in c o n tro l,” a n d th e re s u lts o f p a tie n t s a m p le s ca n b e re p o rte d

□ A fte r d o in g th is , it is a c c e p ta b le to re p e a t Q C te s tin g on a n e w a liq u o t o f th e Q C re a g e n t

□ If th e re s u lt fa lls o u ts id e 2 S D o f th e m ea n , th e L e v e y -J e n n in g s c h a rt is in te rp re te d in te rm s o f W e s tg a rd ru le s o B a se d on th is , th e run is d e te rm in e d to be “ in c o n tro l” o r “o u t o f c o n tro l.” □ T h e re s u lts o f “o u t o f c o n tro l” ru n s s h o u ld n ot g e n e ra lly be re p o rte d ■ W e s tg a rd ru le s □ 2 S D rule ■ A n in d ic a tio n fo r fu rth e r re v ie w o f th e Q C d a ta ■ It is e x p e c te d th a t a b o u t 5% o f Q C re s u lts w ill fa ll o u ts id e 2 S D □ M o s t c o m m o n ly e m p lo y e d ru le s d e s c rib e d in t8.6 ■ T h e 2 :2 s, 4:1s, a n d 1 0:m e a n ru le s a re s e n s itiv e to s y s te m a tic e rro r, w h ic h c o u ld re s u lt in s h ifts o r d rifts (tre nd s) © ASCP2018

□ If th is is s u b s ta n tia lly w ith in a c c e p ta b le lim its , th e n it is p o s s ib le th a t Q C re a g e n t h a n d lin g o r d e te rio ra tio n w a s th e c u lp rit, a nd p a tie n t re s u lts fro m th e ru n m a y be re p o rte d □ If re p e a t te s tin g is n o t w ith in a c c e p ta b le lim its , a th o ro u g h c h e c k o f th e in s tru m e n t a n d re a g e n ts m u s t b e u n d e rta k e n . S u s p e c te d p ro b le m s a re c o rre c te d , a nd Q C re a g e n ts a re re te s te d to e n s u re re s o lu tio n . If th is c o rre c ts th e p ro b le m , p a tie n t s a m p le s m u s t be re p e a te d b e fo re re p o rtin g □ If Q C re s u lts a re still n ot a c c e p ta b le , th e n th e n e x t ste p is to re p e a t c a lib ra tio n a n d re p e a t te s tin g on th e Q C re a g e n ts , th e n re p e a t p a tie n t te s tin g if a p p ro p ria te a P e rs is te n c e o f an o u t o f c o n tro l a s s a y m a y re q u ire fo rm a l in s tru m e n t m a in te n a n c e . T e s tin g s h o u ld be s h ifte d to th e b a c k u p in s tru m e n t o r s e n t to a n o th e r la b o ra to ry in th e m e a n tim e

ISBN 9 7 8 -0 8 9 1 8 9 -6 6 7 8

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8: Medical Directorship

Quality management>Statistical quality control | Proficiency testing (external quality assessment) ■ Q C s p e c im e n s □ M a y d e m o n s tra te m a trix e ffe c ts □ M a y re q u ire re c o n s titu tio n o r d ilu tio n , w h ic h c a n be a s o u rc e o f e rro r □ M a y u n d e rg o d e te rio ra tio n d u rin g s to ra g e □ M a y b e c o m m u ta b le o r n o n c o m m u ta b le ; c o m m u ta b le Q C re a g e n ts a re th o s e th a t a re b io lo g ic a lly s im ila r to p a tie n t s a m p le s w h o s e re s u lts a re d ire c tly c o m p a ra b le to th e m , w h ile n o n c o m m u ta b le re a g e n ts h a v e a lte re d c o n s titu e n ts s u c h a s th e m a trix

8.5.2.2 Alternatives to traditional QC ■ B e g in n in g in 2 0 0 4 C M S b e g a n to p e rm it in d iv id u a liz e d Q C p la n s (IQ C P ) a s an a lte rn a tiv e to tra d itio n a l Q C . A s o f 2 0 1 6 e q u iv a le n t Q C (E Q C ) w a s d is c o n tin u e d a s an a lte rn a tiv e to tra d itio n a l Q C > IQ C P □ A Q C p la n c u s to m iz e d fo r a te s t o n th e b a s is o f ris k m a n a g e m e n t p rin c ip le s □ R is k a n a ly s is m u s t be p e rfo rm e d u p o n th e te s t p rio r to im p le m e n ta tio n □ R is k a n a ly s is m a y ju s tify a Q C p la n th a t is le s s s trin g e n t th a n tra d itio n a l Q C □ L a b s a re re q u ire d to p e rfo rm 2 le v e ls o f liq u id Q C p e r d a y (o r m o re if re c o m m e n d e d b y m a n u fa c tu re r) fo r all n o n w a iv e d te s ts u n le s s a n IQ C P a n a ly s is h a s b e e n c o n d u c te d th a t p e rm its a n a lte rn a te p la n (w h ile s till s a tis fy in g a t a m in im u m th e m a n u fa c tu re r’s re c o m m e n d a tio n ) □ T h e re q u ire m e n ts fo r IQ C P in c lu d e o n g o in g ris k a s s e s s m e n t a n d e ffe c tiv e n e s s m o n ito rin g

8.5.3 Proficiency testing (external quality assessment) 8.5.3.1 Overview ■ C L IA re q u ire m e n t □ E a c h la b m u s t e n ro ll in a p ro fic ie n c y te s tin g (P T ) p ro g ra m fo r e a c h a re a in w h ic h it p e rfo rm s te s tin g □ P T m u s t be a d m in is te re d b y an a g e n c y a p p ro v e d by CMS ■ P T p ro g ra m s □ P a rtic ip a n ts re c e iv e 3 s u rv e y s p e r ye ar, e a c h s u rv e y c o n s is tin g o f 5 s a m p le s □ T h e la b p e rfo rm s th e in d ic a te d te s tin g a n d re p o rts re s u lts to th e s u rv e y in g a g e n c y □ T h e la b m u s t tre a t th e s u rv e y s a m p le a s it w o u ld a n y o th e r s a m p le

410

□ T h e s a m p le m u s t n o t be s e n t o u t o f th e la b o ra to ry , even if u n d e r n o rm a l c irc u m s ta n c e s c o n firm a to ry te s tin g m ig h t be s o u g h t o u ts id e th e la b o ra to ry □ T h e re m u s t be no c o m m u n ic a tio n w ith o th e r la b o ra to rie s th a t d o n o t s h a re th e s a m e C L IA c e rtific a te ■ P T g ra d in g □ S a m p le s ■ C o m m u ta b le s a m p le s ■ C o m m u ta b le P T s a m p le s c a n be tra c e d to a re fe re n c e m e th o d , a n d a “tru e ” v a lu e ca n be a s s ig n e d to th e s a m p le ■ T h e m e a n a nd S D o f th e re fe re n c e m e th o d is u sed to g ra d e re s u lts ■ N o n c o m m u ta b le s a m p le s ■ T h e “ p e e r g ro u p ” in c lu d e s all p a rtic ip a tin g labs u sin g th e s a m e m e th o d o lo g y ■ T h e m e a n a nd S D o f th e p e e r g ro u p re s u lts is u sed to g ra d e re s u lts □ P a rtic ip a n t re s u lts a re g ra d e d a s a c c e p ta b le (w ith in 2 S D o f th e m ean), n e e d s im p ro v e m e n t (2 -3 S D ) o r u n a c c e p ta b le (>3 S D ) □ S a tis fa c to ry p e rfo rm a n c e on a P T s u rv e y is a c h ie v e d if a t le a s t 4 o f 5 (8 0% ) s a m p le re s u lts a re g ra d e d as a c c e p ta b le □ U n a c c e p ta b le P T re s u lts m u s t be in v e s tig a te d , even if s a tis fa c to ry p e rfo rm a n c e is a c h ie v e d fo r a surve y. C o rre c tiv e a c tio n m u s t be ta k e n w ith a p p ro p ria te d o c u m e n ta tio n □ T h e c a u s e s o f P T fa ilu re a re s im ila r to th o s e th a t c a u s e Q C fa ilu re , e g, re a g e n t p ro b le m s , in s tru m e n t m a lfu n c tio n , c a lib ra tio n p ro b le m s , a nd c lim a te c o n tro l p ro b le m s □ In v e s tig a tio n s h o u ld in c lu d e e v a lu a tio n o f Q C d ata, m a in te n a n c e d a ta , a n d re a g e n t lo g s a ro u n d th e tim e o f P T p e rfo rm a n c e □ In g e n e ra l, a la b o ra to ry ’s lik e lih o o d o f fa ilin g P T on a p u re ly a n a ly tic b a s is is s ta tis tic a lly u n lik e ly if th e la b o ra to ry ’s S D fo r th e s u rv e y e d a n a ly te is < 3 3 % o f th e S D a llo w e d □ Lastly, e ve n s u c c e s s fu l P T p e rfo rm a n c e ca n be a s o u rc e o f u s e fu l in fo rm a tio n . Is b ias, d rift o r s h ift im p lie d by th e re p o rte d S D Is ? C e m b ro w s k i a nd c o lle a g u e s re c o m m e n d a W e s tg a rd lik e m e th o d o f e v a lu a tin g th e d a ta t8.7 □ F o r s o m e a s s a y s , P T is n ot a v a ila b le (u n re g u la te d a n a lyte s ). T h is m ay be th e re s u lt o f th e n a tu re o f th e s a m p le te s te d o r th e n o v e lty o f th e assay. In su ch in s ta n c e s , th e la b o ra to ry m u s t e n g a g e in an a lte rn a tiv e m e a n s o f a s s u rin g p ro fic ie n c y

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

8: Medical Directorship

Quality management>Proficiency testing (external quality assessment) Nonanalytic variables in laboratory medicine: preanalytic & postanalytic>Preanalytic variables 8.6.1.5 Exercise

t8.7 Cembrowski rules for evaluation of proficiency testing data Rule

Description

Screening rule

Do 2 or more of the 5 results exceed 1 SDI?

Mean rule 3 SDI rule 4 SDI rule

■ In c re a s e s th e s e ru m c o n c e n tra tio n o f c re a tin e k in a s e , la c ta te d e h y d ro g e n a s e , a n d A S T

Implication

proceed to evaluate data according to the following rules Does the average of the 5 systematic error is SDIs exceed ± 1.5? significant Any result beyond 3 SDI? random error is significant random error is significant Any 2 results >4 SDI apart?

SDI = sta n d a rd deviation index

■ M a y c a u s e n e u tro p h il d e m a rg in a tio n re s u ltin g in re la tiv e n e u tro p h ilia

8.6.1.6 Cigarette smoking ■ In c re a s e s c a rb o n m o n o x id e , C E A , a n d s e ru m c a te c h o la m in e s ■ O v e r th e lo n g te rm , th e h e m a to c rit m a y in c re a s e

8.6.1.7 Posture

8.6 Nonanalytic variables in laboratory medicine: preanalytic & postanalytic 8.6.1 Preanalytic variables 8.6.1.1 Patient identification ■ T h e e s tim a te d fre q u e n c y o f “w ro n g b lo o d in tu b e ” is 4 0 0 p e r m illio n (1 in 2 5 0 0 ) s p e c im e n s ■ B oth C A P a nd T JC re q u ire 2 p a tie n t id e n tifie rs on all s a m p le s (roo m n u m b e r is n o t a p a tie n t id e n tifie r) and re q u ire th a t s p e c im e n s be la b e le d in th e p re s e n c e o f th e p a tie n t ■ 6 c h e c k s m ay d e te c t s o m e p a tie n t id e n tific a tio n e rro rs 8.6.1.2 Age ■ N e o n a te s h ave a re la tiv e in c re a s e in p e rip h e ra l b lo o d m o n o n u c le a r c e lls a s c o m p a re d to a d u lts ■ A d o le s c e n ts h ave e le v a te d a lk a lin e p h o s p h a ta s e , up to 5 * th e u p p e r lim it o f n o rm a l fo r a d u lts ■ E ld e rly p a tie n ts o fte n h ave d e c re a s e d c re a tin in e c le a ra n c e , d e c re a s e d g lu c o s e to le ra n c e , in c re a s e d re le a s in g h o rm o n e s (T R H , A C T H ), a n d in c re a s e d lip id s

■ A s c o m p a re d to s u p in e , s ittin g o r s ta n d in g re s u lts in in c re a s e d h y d ro s ta tic p re s s u re a n d m o v e m e n t o f w a te r a n d s m a ll m o le c u le s o u t o f th e c irc u la tio n ■ T h is re s u lts in re la tiv e in c re a s e in th e c o n c e n tra tio n o f p ro te in s , s u b s ta n c e s la rg e ly b o u n d to p ro te in s (to ta l c a lc iu m ), a nd b lo o d ce lls

8.6.1.8 Time of day ■ S e ru m c o rtis o l h a s w id e d iu rn a l v a ria tio n , p e a k in g a t a ro u n d 8 A M

8.6.1.9 Tourniquet ■ If a p p lie d fo r a p ro lo n g e d tim e , c re a te s h e m o c o n c e n tra tio n a n d a n a e ro b ic m e ta b o lis m

8.6.1.10 Order of draw ■ It is im p o rta n t to d ra w tu b e s t8 .8 in a p a rtic u la r o rd e r, v a ry in g s o m e w h a t if u sin g p la s tic tu b e s t8 .9

t8.8 Selected blood collection tubes Tube

Additive

Red

serum chemistry & glass—none plastic—silica clot activator serology heparin plasma chemistry citrate coagulation tests

8.6.1.3 Gender ■ M a le s h ave in c re a s e d c re a tin e k in a s e (C K ) a n d low d e n s ity lip o p ro te in c h o le s te ro l a s c o m p a re d to fe m a le s 8.6.1.4 Food intake ■ In c re a s e s s e ru m g lu c o s e c o n c e n tra tio n a n d trig ly c e rid e s ■ G a s trin a nd in s u lin a re a ls o in c re a s e d ■ B iliru b in is d e c re a s e d fo llo w in g a m ea l ■ P ro lo n g e d fa s tin g a n d /o r s ta rv a tio n m a y c a u s e e le v a te d ke to n e s , e le v a te d b iliru b in , d e c re a s e d a lb u m in , d e c re a s e d p o ta s s iu m , a n d d e c re a s e d m a g n e s iu m

© A S C P 2018

Green Blue

Used for

N ote: A 1:9 ratio o f anticoagulant:blood is ideal; h ig h e r ratios le a d to in cre a se d coagulation tim es, affecting the aPT T>P T; fo r p o lycyth e m ic p a tie n ts w ith H ct>60% , the P T a nd P T T can be p ro lo n g e d d ue to d e cre a s e d effective p la s m a

Black Lavender (purple) Yellow Gray

citrate (calcium chelation) ESR EDTA (calcium chelation) cell counts citrate & dextrose (ACD) blood bank tests, HLA typing sodium fluoride (inhibits glucose, lactate glycolysis)

a P T T = a ctivated p a rtia l throm boplastin tim e; E S R = eryth ro cyte sed im e n ta tio n rate; H LA = hum an leukocyte antigen; P T = p ro th ro m b in tim e; P T T = p a rtia l throm boplastin tim e

ISBN 9 7 8 -0 8 9 1 8 9 -6 6 7 8

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8: Medical Directorship

N o n a n a ly t ic v a r ia b le s in la b o r a to r y m e d ic in e : p r e a n a ly tic & p o s ta n a ly tic > P r e a n a ly tic v a ria b le s | P o s ta n a ly tic v a ria b le s

t8.9 Order of draw Priority First

Last

Glass

Plastic

culture

culture

no ad ditive tu b e s (red )

co agulation te s t tubes

co agulation tes t tu b e s

no ad ditive tube s (red)

serum s e p a ra to r tube s

se ru m s e p a ra to r tubes

additive tu b e s (g ree n then la v e n d e r th en gray)

ad ditive tube s (green then la v e n d e r then gray)

8.6.1.11 Storage & transport conditions D u rin g s to ra g e , b lo o d c e lls c o n tin u e to m e ta b o liz e a n d s lo w ly u n d e rg o ly sis, s e ru m p ro te in s p ro g re s s iv e ly d e g ra d e , a nd a d s o rp tio n to tu b e s m a y o c c u r. S o m e te s ts a re p e rfo rm e d o n a n tic o a g u la te d w h o le b lo o d (eg, h e m a to lo g y ), o th e rs on s e ru m (c lo tte d w h o le b lo o d ), a n d o th e rs o n p la s m a (clo t in h ib ite d c e n trifu g e d w h o le b lo o d ). F o r m o s t p u rp o s e s , s e ru m a n d p la s m a g iv e e s s e n tia lly s im ila r re su lts ; s e ru m m u s t be u s e d fo r s e ru m p ro te in e le c tro p h o re s is a n d s e ro lo g ic a s s a y s , w h ile p la s m a is re q u ire d fo r c o a g u la tio n te s ts . If n o t s e p a ra te d fro m b lo o d c e lls , s e ru m and p la s m a p ro g re s s iv e ly c h a n g e in s e v e ra l w a y s s u c h th a t th e y no lo n g e r a c c u ra te ly re fle c t th e in v ivo sta te ; fo r e x a m p le , g lu c o s e p ro g re s s iv e ly d im in is h e s a n d la c ta te in c re a s e s . Ideally, all te s ts s h o u ld b e run w ith in 1-2 h o u rs o f b lo o d c o lle c tio n , b u t th is is n o t a lw a y s p ra c tic a l. B lo o d n o t te s te d im m e d ia te ly s h o u ld be s ta b iliz e d . In th e c a s e o f p la s m a te s ts , fo r e x a m p le b lo o d s h o u ld b e c e n trifu g e d w ith in 1 h o u r a n d s to re d a t 4 -6 °C ,

P atients w ith high leukem ic cell co un ts (acute lym phocytic leukem ia, acute m yeloid leukem ia), and those w ith th rom bocytosis (reactive & neoplastic), m ay have factitious hyperkalem ia. Factitious hyperkalem ia in this setting is significantly greater in se ru m than in plasm a; w h e re a s true hyperkalem ia should be ro ug hly equivalent in th e 2 specim ens. C h ro nic m yeloid leukem ia is notorious fo r spuriously high vitam in B12 levels.

8.6.2 Postanalytic variables 8.6.2.1 The postanalytic phase ■ T h is p h a s e c o n s is ts o f th e re p o rtin g a n d in te rp re ta tio n o f te s t re s u lts ■ P o s ta n a ly tic e rro rs in c lu d e e rro rs in re p o rts (tra n s c rip tio n a n d p ro o fre a d in g e rro rs ), e rro rs in re a d in g re p o rts (m is re a d in g o r in c o rre c tly h e a rin g th e re su lt), e rro rs in in te rp re ta tio n o f th e re p o rt, a nd in c o rre c t re a c tio n s to th e in fo rm a tio n

8.6.2.2 Result reporting ■ C L IA re q u ire s th e fo llo w in g e le m e n ts in la b o ra to ry re p o rts □ P a tie n t id e n tific a tio n □ D ate re s u lt is re p o rte d □ S p e c im e n s o u rc e

8.6.1.12 Serum vs plasma

□ Test p e rfo rm e d

F o r m o s t m e a s u re d a n a ly te s , s e ru m a n d p la s m a a re in te rc h a n g e a b le . T h e c lo ttin g p ro c e s s in w h ic h p la sm a is c o n v e rte d to s e ru m , h ow eve r, re s u lts in th e re le a s e o f s u b s ta n c e s in w h ic h p la te le ts a re rich , in c lu d in g c a lciu m , m a g n e s iu m , LD, a n d p o ta s s iu m ; th u s , o n e s h o u ld e x p e c t th e s e a n a ly te s to be h ig h e r in s e ru m th a n in p la s m a . F u rth e rm o re , th e c lo ttin g p ro c e s s u tiliz e s p la s m a p ro te in s (n o ta b ly fib rin o g e n ), s u c h th a t to ta l p ro te in is h ig h e r in p la sm a .

8.6.1.13 Underlying hematologic malignancy U n d e rly in g c o n d itio n s o r th e m e d ic a tio n s u sed to tre a t th e m ca n a lte r la b o ra to ry va lu e s. M a n y o f th e s e e ffe c ts have not b e e n w e ll stu d ie d, w ith m o s t a tte n tio n h aving b ee n fo cu se d on u n d e rly in g h e m a to lo g ic d is e a s e . It is w ell know n, fo r e x a m p le , th a t p a ra p ro te in e m ia ca n d ra s tic a lly a lte r th e m e a s u re m e n t o f a v a rie ty o f a n a ly te s — e ith e r th ro u g h d ire ct in te rfe re n c e w ith th e a s s a y o r by a lte rin g th e relative a m o u n t o f th e a q u e o u s p h a se o f p la sm a. H igh levels o f p araprotein ca n lead to fa c titio u s h y p e rb iliru b in e m ia , h ypo n atre m ia , h yp o u ric e m ia , h y p o a lb u m in e m ia , and h yp e rca lce m ia . W ith re g a rd to h y p e rc a lc e m ia , a p a tie n t w ith p a ra p ro te in e m ia m ay

412

have fa ctitious h ype rca lce m ia ca use d by th e tu rb id ity o f the paraprotein; tru e total h ype rcalce m ia , w ith norm al ionized ca lciu m , ca use d by increased ca lciu m tra n s p o rt by paraprotein; and tru e total and ionized ca lciu m ca use d by th e m yelom a itself.

□ T e st re s u lt w ith u n its (if any) □ R e fe re n c e ra n g e □ N a m e a n d a d d re s s o f th e la b o ra to ry

8.6.2.3 Critical values reporting ■ C ritic a l v a lu e s a re te s t re s u lts th a t in d ic a te th e p re s e n c e o f a c o n d itio n th a t is im m e d ia te ly life th re a te n in g ■ T h e lis t o f c ritic a l v a lu e s is s e le c te d by th e m e d ic a l s ta ff and m a y d iffe r fro m o n e la b o ra to ry to a n o th e r ■ TJC re q u ire s th a t la b o ra to rie s h ave a w ritte n p ro c e d u re fo r c ritic a l v a lu e s th a t a d d re s s e s □ T h e list o f c ritic a l v a lu e s fo r th e la b o ra to ry □ W h o is re s p o n s ib le fo r re p o rtin g c ritic a l v a lu e s , a nd w h o is a u th o riz e d to a c c e p t th e m □ W h a t is th e a c c e p ta b le le n g th o f tim e to re p o rt a c ritic a l v a lu e ■ S o m e la b o ra to rie s re q u ire th a t c ritic a l v a lu e s be re p e a te d b e fo re a le rtin g th e c lin ic ia n , b u t th is p ra c tic e is n ot u n iv e rs a l

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

8: Medical Directorship

S e le c te d re a d in g s > B o o k s | A d d itio n a l jo u rn a l re fe re n c e s

8.7 Selected readings Books IS B N 9 78030904230 7 Institute o f M edicine, C om m ittee to Design a S trategy fo r Q uality R eview and A ssurance in M edicare, Lohr K, ed [1990] Medicare: A Strategy for Quality Assurance, vol 1. N ational A cade m y Press IS B N 9780309072809 C om m ittee on the Q uality o f H ealth C are in A m erica [2001] Crossing the Quality Chasm: A N ew Health System for the 21st Century. N ational A ca d e m y Press IS B N 9 78072165610 6 W estgard JO, Klee GG [1999] Q uality m anagem ent. In: Burtis CA, A shw ood ER, Tietz, NW, ed. Tietz Textbook o f Clinical Chemistry, 3e. W B Saunders IS B N 9 780721660301 Pincus M R [1996] Interpreting laboratory results: reference values and decision m aking. In: H enry JB, Todd, JC, ed. Clinical Diagnosis and M anagem ent by Laboratory Methods, 19e. W B S aunders ISB N 9780930304881 V a lenstein P [2005] Quality M anagem ent in Clinical Laboratories: Promoting Patient Safety through Risk Reduction and Continuous Improvement. C ollege o f A m erican P athologists Press IS B N 978189088328 7a Boyd JC [1999] Laboratory statistics. In: D ufour DR, ed. Professional Practice in Clinical Chemistry: A Companion Text. A m erican A ssociation fo r C linical C hem istry IS B N 978189088328 7b Boyd JC [1999] R eference lim its in the clin ical laboratory. In: D ufour DR, ed. Professional Practice in Clinical Chemistry: A Companion Text. A m erican A ssociation fo r Clinical C hem istry IS B N 978189088328 7c Boyd JC [1999] Statistical aids fo r test inter pretation. In: D ufour DR, ed. Professional Practice in Clinical Chemistry: A Companion Text. A m erican A ssociation fo r Clinical C hem istry IS B N 9781890883287d D ufour DR [1999] P reanalytic variation, or w hat causes abnorm al results (besides disease). In: Professional Practice in Clinical Chemistry: A Companion Text. A m erican A ssociation fo r C linical C hem istry IS B N 978189088328 7e M iller W G [1999] Q uality control. In: D ufour DR, ed. Professional Practice in Clinical Chemistry: A Companion Text. A m erican A ssociation fo r C linical C hem istry

Additional journal references P M ID 10172547 C em brow ski GS, A n derson PG, C ram pton C A et al [1996] P um p up yo u r PT IQ. M LO M ed Lab Obs Jan:46-51 P M ID 10620565 C em brow ski G S, C arey RN [2000] A d ding value to proficiency testing program s. Clin Chem 46:7-8 PM ID 10705825 N arayanan S [2000] The preanalytic phase: an im portant com ponent o f laboratory m edicine. Am J Clin Pathol 113:429-452 PM ID 10747304 H ow anitz PJ, C em brow ski G S [2000] Postanalytical quality im provem ent. Arch Pathol Lab Med. 124:504-510 PM ID 10975932 Kroll MH, Praastgaard J, M ichaliszyn E et al [2000] Evaluation o f the e xte n t o f nonlinearity in reportable range studies. Arch Pathol Lab Med. 124:1331-1338 P M ID 1 1805016 Lahti A, P etersen PH, Boyd JC, Fraser CG, Jorgensen N [2002b] O bjective criteria fo r partitioning G aussian distributed reference values into subgroups. Clin Chem 48(2):338-352 P M ID 11978595 Bonini P, Plebani M, C eriotti F, Rubboli F [2002] Errors in laboratory m edicine. Clin Chem 48(5):691-698 P M ID 12406985 Lahti A, Petersen PH, Boyd JC [2002a] Im pact of subgroup prevalences on partitioning o f G aussian-distributed reference values. Clin Chem 48(11):1987-1999 © A S C P 2018

PM ID12446483 Boyanton L.BIick K [2002] Stability studies o f 20-4 analytes in human plasm a and serum . Clin Chem 48(12):2242-2247 P M ID 14692813 Jhang JS, C hang C C, Fink DJ et al [2004] Evaluation o f linearity in the clinical laboratory. Arch Pathol Lab M ed. 128:44-48 P M ID 1 514297 8 O buchow ski NA, Lie b e r ML, W ia n s FH J r [2004] R O C curves in clinical chem istry: uses, m isuse s, and possible solutions. Clin Chem 50:1118 -1125 P M ID 1 561370 5 B jern er J, B o rm er O P, N ustad K [2005] T he w a r on heterophilic antibody interference. Clin Chem 51(1 ):9 -1 1 P M ID 156137 12 P re issn e r C M , D odge LA, O ’K ane DJ et al [2005] P reva len ce o f hetero philic antibody in te rfe re n ce in 8 autom ated tu m o r m arker im m unoassays. Clin Chem 5 1 (1 ):2 08-210 P M ID 161965 13 H ow anitz PJ [2005] Errors in la b o ra tory m edicine: practical lessons to im prove patient safety. Arch Pathol Lab M ed 129:1252-1261 P M ID 175167 37 Friedberg RC, S ouers R, W a g a r EA et al [2007[T he origin o f reference intervals: a C ollege o f A m erican P a thologists Q -probes study o f “norm al ranges” used in 163 clinical la b o ra to ries. Arch Pathol Lab M ed 131:348-357 P M ID 1752510 3 C arraro P, Plebani M [2007] Errors in a s ta t la b o ra tory: types and fre q u e n cie s 10 ye a rs later. Clin Chem 53(7): 13381342 P M ID 1795090 3 W e iss R L [2007] C oding, cove ra g e , and c o m p e n s a tion fo r pathology and laboratory m edicine service s. Clin Lab M ed 27:875-891 P M ID 1881826 2 S o re id e K. [2009 ]R e ce ive r-o p e ra tin g c h a ra cte ristic curve analysis in diagnostic, prognostic, and predictive bio m a rke r research. J Clin Pathol 62:1-5 P M ID 1885285 7 A rm b ru ste r DA, Pry T [2008] Lim it o f blank, lim it o f detection and lim it o f q uantitation. Clin Biochem R ev 29(S upplem ent (i)):S 49-S 52 P M ID 191413 80 Dalai Bl, Brigden M [2009]. F actitious biochem ical m easurem ents resulting from h e m a to lo g ic conditions. Am J Clin Pathol 131:195-204 P M ID 1949289 3 Killeen A A [2009] La b o ra to ry sa n ctions fo r p ro fi cie n cy testing sam ple referral and result co m m u n ication: a review o f actions from 1993-2006. Arch Pathol Lab M e d 133:979-982 P M ID 21965556 M iller W G , Jones G R D , H orow itz G L e t al [2011] P roficiency testing/external quality a sse ssm e n t: c urrent ch a l lenges and future directions. Clin Chem 57:12 P M ID 250158 53 Branda JA, Dighe AS, D zik W et al [2014] T h e p ra c tice o f clinical pathology, a quantitative d e scrip tio n o f laboratory d ire cto r activities at a large a cadem ic m edical center. Am J Clin Pathol 142:144-149 P M ID 26230597 M iller I [2015] D evelopm ent and evaluation o f a logical 5 ch e ck fo r identifying e rro n e o u s blood c o unt results in a tertiary care hospital. Arch Pathol Lab M ed 139:104 2-1047 P M ID 3657876 M osteller RD [1987] S im plified calculation o f body surface area. N Engl J M ed 317(17):1098 [letter] P M ID 7471403 W estgard JO, Barry PL, H unt M R [1981] A m ultirule S h e w h a rt chart fo r quality control in clinical chem istry. Clin Chem 27:493-501 P M ID 8472349 Zw eig MH, C am pbell G [1993] R ece iver-o perating cha ra cte ristic (R O C ) plots: A fun d a m e n ta l e va lu a tion tool in clin ical m edicine. Clin Chem 39(4):561-577 P M ID 9267312 C arraro P, Plebani M [1997] Errors in a stat la b o ra tory: Types and frequency. Clin Chem 43(1):1348-1351 Edson DC, Russell D, M assey LD [2007] P roficiency testing: a guide to m aintaining successful perform ance. Lab M ed 38(3): 184-186

ISBN 9 7 8 -0 8 9 1 8 9 -6 6 7 8

413

In d e x P a g e n u m b e rs w ith V in d ic a te fig u re s ; w ith / in d ic a te im a g e s , a n d t in d ic a te ta b le s .

A A A B B , 77 A a lle le , 80

re n a l fu n c tio n , 15-1 6 blood u rea n itro g e n , 15 B U N c re a tin in e ratio, 16 c re a tin in e a nd g lo m e ru la r filtra tio n ra te c a lc u la tio n s , 15-16 c y sta tin C, 16 u rin e p ro te in a nd u rin e a lb u m in , 16 s o d iu m , 11-12 h y p e rn a tre m ia , 12 h y p o n a tre m ia , 11-12

A A T d e fic ie n c y , 3 6 6 A b d o m in a l w a ll d e fe c ts , 3 4 4 -3 4 5 A B G a n a ly z e rs , 14

A c id e lu tio n te c h n iq u e , 2 5 9

A B O a n d c a rb o h y d ra te a n tig e n s , 80

A c id e m ia , 14

A B O a n tib o d ie s , 82

a 1 -A c id g ly c o p ro te in , 7, 7 f

A B O g ro u p in g , 58, 5 8 f

A c id o s is , 14

A B O p h e n o ty p e s , 81 A B O te s tin g o f re c ip ie n t b lo o d , 5 8 -6 0 , 5 8 t

m e ta b o lic , 14, 1 5 1 re sp ira to ry , 14, 15

A b s id ia , 143

A c in e to b a c te r, 169

A b s o lu te ly m p h o c y to s is , 2 2 0

A c in e to b a c te r b a u m a n n ii, 170

A b s o lu te ly m p h o p e n ia , 3 0 0

A c q u ire d fa c to r d e fic ie n c ie s , 2 8 4

A b s o lu te n e u tro p e n ia , 3 0 0

A c q u ire d m e th e m o g lo b in e m ia , 2 0 5 -2 0 6

A c a n th a m o e b a s p p , 116, 123

A c q u ire d p la te le t d is o rd e rs , 2 8 3

A c a n th o c y to s is , 87

A c tin o m y c e s , 179

A c c u ra c y , 4 0 5

A c tin o m y c e s is ra e li, 179/

A c e ta m in o p h e n p o is o n in g , 23

A c tin o m y c o s is , 179

A c id -b a s e a n d e le c tro ly te s , 1 1 -1 7

A c tin o m y c o tic m y c e to m a , 1 38 ,1 6 2

a c id -b a s e d is o rd e rs , 1 4-1 5 H e n d e rs o n -H a s s e lb a lc h e q u a tio n , 14 c a lc iu m , 1 3 -1 4 h y p e rc a lc e m ia , 13, 1 3 f

A c tiv a te d c lo ttin g tim e , 2 76 A c tiv a te d p a rtia l th ro m b o p ls tin tim e (a P T T ), 2 76 d e te rm in in g c a u s e o f p ro lo n g e d , 2 76 , 2 7 7 ft A c tiv a te d p rote in C re sis ta n c e , 2 8 5 -2 8 6

h y p o c a lc e m ia , 13, 1 4 /

A c u te c e llu la r re je c tio n , 302

m e a s u re m e n t, 1 3 -1 4

A c u te c h e s t s y n d ro m e , 2 03

la b o ra to ry e v a lu a tio n in a c u te re n a l fa ilu re , 1 6 -1 7 , 1 6 1 fo r c h ro n ic k id n e y d is e a s e , 16 p o ta s s iu m , 1 2 -1 3 h y p e rk a le m ia , 1 2 -1 3

A c u te c h o le c y s titis , 5 A c u te c o ro n a ry s y n d ro m e , 6 A c u te fa tty live o f p re g n a n c y , 19 A c u te h e m o ly tic tra n s fu s io n re a c tio n s , 8 9 -9 0 , 897 A c u te h em o ra l re je c tio n , 3 02

h y p o k a le m ia , 12

A c u te in fla m m a tio n , 8, 9 f

m e a s u re m e n t, 12

A c u te le u ke m ia in D ow n s y n d ro m e , 2 57 w ith m ixed lin e a g e , 2 3 7 A c u te m e g a k a ry o b la s tic le u k e m ia , 2 5 6 -2 5 7 A c u te m o n o c y tic /m o n o b la s tic le u k e m ia , 2 56 A c u te m y e lo g e n o u s le u k e m ia , 2 5 1 -2 5 6 , 252/, 2 5 3 t, 254/, 2 5 5 ft, 2 5 6 /

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Index

Acute— Anaerobe A c u te m y e lo m o n o c y tic le u k e m ia , 2 5 6

A lc o h o lic s te a to h e p a titis , 2

A c u te m y o c a rd ia l in fa rc tio n , 6

A ld e r-R e illy a n o m a ly , 3 06

A c u te p ain crisis, 2 0 3

A ld o m e t, 3 07

A c u te p a n c re a titis , 25

A ld o s te ro n is m , p rim a ry , 37

A c u te p a n m y e lo s is w ith m y e lo fib ro s is , 2 57

A lk a le m ia , 14

A c u te p h a s e re a c ta n ts , I t

A lk a lin e p h o s p h a ta s e , 2-3, 2 1, 31

A c u te re na l fa ilu re , 1 6 f

A lk a lo s is , 14

c a u s e s of, 1 6f

m e ta b o lic , 14, 15, 15 1

la b o ra to ry e v a lu a tio n of, 16-17, 1 6f

re sp ira to ry , 14, 15

A d d is o n d is e a s e , 3 6-3 7

A L K + la rg e B ly m p h o m a , 233, 2 3 4 f

A d e n in e (A), 318, 319

A lle le s p e c ific o lig o n u c le o tid e p ro b e s , 3 2 9

A d e n o c a rc in o m a

A lle rg ic a n g iitis a nd g ra n u lo m a to s is , 3 1 3

c o lo re c ta l, 3 5 6 -3 6 2 , 357/', 3 58 f, 359/'f, 360/, 361 ft, 3 6 2 /

A lle rg ic b ro n c h o p u lm o n a ry fu n g a l in fe c tio n , 141, 1 42 /

d uctal, 363

A lle rg ic tra n s fu s io n re a ctio n s, 8 9

g a stric, 66

A llo a d s o rp tio n , 64

A d e n o h y p o p h y s is , 38

A llo c a tio n b u d g e ts , 401

A d e n o v iru s e s , 6, 96, 103 -10 4

A llo im m u n e th ro m b o c y to p e n ia , 2 2 3

A d ip o c y te s , tu m o rs of, 370-371

A lly la m in e s , 146

A d ju n c tiv e P S A ind ice s, 29

a1 a n titry p s in d e fic ie n c y , 3 4 7 -3 4 8 , 3 4 7 f

A d re n a l c o rte x , 3 5 -3 8

a th a la s s e m ia , 2 07 , 2 60

A d d is o n d is e a s e , 3 6-3 7

A lp o rt s y n d ro m e , 3 55

co n g e n ita l a d re n a l h y p e rp la s ia , 3 7 -3 8 , 3 7 f

A lte re d o x y g e n a ffin ity h e m o g lo b in s , 2 0 5 , 2 0 5 f

C u s h in g sy n d ro m e , 36

A lz h e im e r d is e a s e , 350

e n d o c rin e d is o rd e rs in vo lvin g , 3 4 0 -3 4 2

A m e n o rrh e a -g a la c to rrh e a s y n d ro m e , 39

p rim a ry a ld o s te ro n is m , 37 s e c o n d a ry a d re n a l in s u ffic ie n c y , 37

A m e ric a n M e d ica l A s s o c ia tio n (A M A ), a p p ro v a l o f la b o ra to ry te s t p a n e ls , 3 9 9 -4 0 0

te sts, 3 5 -3 6

A m e ric a n S o c ie ty fo r A p h e re s is , 70

A d re n a l in s u ffic ie n c y , s e c o n d a ry , 37

A m in o a c id u ria , 3 36

A d re n o c o rtic o tro p h ic h o rm o n e (A C T H ), 39

A m in o c y la tio n , 320

e c to p ic , 36

A m in o g ly c o s id e s , 24

A d u lt T cell le u k e m ia /ly m p h o m a , 2 4 0

A m io d a ro n e , 34

A e ro m o n a s , 97, 172

A m m o n ia , 3

A fib rin o g e n e m ia , 2 84

A m n io tic flu id b iliru b in , 17

A fric a n B u rk itt ly m p h o m a /le u k e m ia , 2 36

A m o rp h o u s c ry s ta ls , 43

A g g lu tin a tio n , 63

A m p h e ta m in e s , 20

A g g re g a tib a c te r (H a e m o p h ilu s ) a p h ro p h ilu s , 173

A m p lific a tio n te c h n iq u e s , 3 2 9 -3 3 2

A g g re g a tio n , 2 74

m e ltin g p o in t a n a lys is , 3 3 0 - 3 3 1 ,3 3 1 f

A g g re g o m e try , a b n o rm a l, 2 7 6

m e th y la te d s p e c ific p o ly m e ra s e c h a in re a c tio n , 3 30

A g g re s s iv e N K ce ll le u k e m ia , 242

n u c le ic acid s e q u e n c e b ase d , 3 2 9 , 3 31 , 331 f

A g ile sy n d ro m e , 340, 345/, 3 4 5 -3 4 6

p o ly m e ra s e c h a in re actio n, 3 2 9 -3 3 0 , 3 2 9 f

A g ra n u lo c y to is , 221

q u a n tita tiv e P C R , 3 30 , 3 3 0 f

A lb e rt s y n d ro m e , 3 3 4 -3 3 5 , 3 3 5 /

s ig n a l, 3 3 1 -3 3 2

A lb u m in , 6 -7, I t

tra n s c rip tio n m e d ic a te d , 331, 3 3 1 f

A lb u m in :g lo b u lin (A :G ) ratio, 4

A m y la s e , 5

A lco h o l d e h y d ro g e n a s e , 22

A n a e ro b e s , 1 7 6 -17 9

© A S C P 2018

ISBN 9 7 8 -0 8 9 1 8 9 -6 6 7 8

415

Index

A nalyte— Antiphospholipid A n a ly te s p e c ific re a g e n ts , 3 9 8 -3 9 9

a n ti-n u c le a r, 3 0 7 -3 0 9 , 3 0 7 f, 3 0 8 /f

A n a ly tic a l m e a s u rin g ra n g e (A M R ), 4 0 6

a n ti-s m o o th m u scle , 309, 3 0 9 1

A n a ly tic a l s e n s itiv ity , 4 0 6

a n ti-tis s u e tra n s g lu ta m in a s e , 311

A n a ly tic a l s p e c ific ity , 4 0 5

to c y to p la s m ic c o n s titu e n ts , 309, 3 0 9 1

A n ap h ase , 324

D u ffy, 86

A n a p h y la x is , 3 1 6

H T LA , 63 K ell, 87

p o s tm o rte m d ia g n o s is o f, 4 0

K idd , 85

A n a p la s m a , 185

L ew is, 82

A n a p la s m a p h a g o c y to p h ilu m , 185 A n a p la s tic la rg e ce ll ly m p h o m a , A L K + , 2 4 1 ,2 4 1 / A n c y lo s to m a d u o d e n a le , 126

M N S , 86 A n tib o d y s c re e n , 59, 60

A n d ro g e n in s e n s itiv ity s y n d ro m e , 341

A n ti-c e n tro m e re a n tib o d ie s , 3 08

A n e m ia , 11

A n ti-c itru llin a te d p ro te in a n tib o d ie s , 3 09

a p la s tic , 2 1 6 -2 1 7 , 2 1 6 1. 2 1 7 1

A n tic o a g u la n t p re s e rv a tiv e s o lu tio n s , 7 4 -7 5 , 7 5 1

o f c h ro n ic d is e a s e , 2 1 3 -2 1 4 , 2 1 3 f c o n g e n ita l d y s e ry th ro p o ie tic , 2 1 4 , 2 1 5 / d e fin itio n s of, 21 I t

A n tic o a g u la n ts d ire c t th ro m b in in h ib ito rs , 2 8 9 fo n d a p a rin u x (a rixtra ), 2 8 9

F a n c o n i, 2 1 4 -2 1 5 , 3 1 6 f

lo w m o le c u la r w e ig h t h e p a rin , 2 8 9

iro n d e fic ie n c y , 2 1 3 f

o ra l, 288

m ic ro c y tic , h y p o c h ro m ic , 22

u n fra c tio n e d h e p a rin , 2 8 8 -2 8 9

n e o n a ta l, 2 1 8 -2 1 9 n o n h e m o rrh a g ic c a u s e s o f a c u te s e v e re , 2 1 9 f s id e ro b la s tic , 2 1 4

W a rfa rin (c o u m a d in ), 2 88 A n ti-c y c lic c itru lin a te d p e p tid e a n tib o d ie s , 311 A n tid iu re tic h o rm o n e , 39

w a rm a u to im m u n e h e m o ly tic , 2 0 8

A n ti-E G F R a g e m ts , 376

A n g e lm a n s y n d ro m e , 3 5 6 1 A n g io im m u n o b la s tic T ce ll ly m p h o m a , 2 4 0 -2 4 1 ,2 4 1 / A n g io te n s in c o n v e rtin g e n z y m e , 3 0 9

A n ti-e n d o m y s iu m , 311 A n tifu n g a l a g e n ts , 1 46 -14 7 A n tig e n d e p e n d e n t c e llu la r c y to to x ic ity , 2 97

A n io n g a p , 1 4 -1 5 , 21

A n tig e n ic a s s a y s , 301

A n irid ia /W A G R s y n d ro m e , 3 7 9

A n tig e n ic d rift, 114

A n is a k ia s is , 127

A n tig e n ic sh ift, 114

A N K 1, 200

A n tig e n p re s e n tin g ce lls, 2 98 , 2 99

A n th ra x

A n tig e n s , 8 0 -8 3 , 81 f, 8 2 f, 2 6 1 -2 6 3

c u ta n e o u s , 158

pub lic, 301

g a s tro in te s tin a l, 158

A n tig e n te s t v ia la te x a g g lu tin a tio n , 130, 1 51 -15 2

p u lm o n a ry , 158

A n ti-g lia d in , 311

A n tib io tic a s s o c ia te d d ia rrh e a , 96

A n ti-l a n tib o d ie s, 82

A n tib o d ie s

A n ti-id io to p e a n tib o d ie s , 2 96

A B O , 82

A n tik ic k b a c k law , 4 0 0

a n ti-c e n tro m e re , 308

A n tim e ta b o lite s , 146

a n ti-c itru llin a te d p ro te in , 3 0 9

A n ti-m ito c h o n d ria l a n tib o d ie s , 309, 3 0 9 1

a n ti-c y c lic c itru lin a te d p e p tid e , 311

A n ti-n e u tro p h il c y to p la s m ic a n tib o d ie s , 3 09 , 3 0 9 f

a n ti-l, 8 2

A n ti-n u c le a r a n tib o d ie s , 3 0 7 -3 0 9 , 3 07 f, 308/Y

a n ti-id io to p e , 2 9 6

A n ti-p h o s p h o lip id s y n d ro m e , 2 87

a n ti-m ito c h o n d ria l, 3 0 9 , 3 0 9 1 a n ti-n e u tro p h il c y to p la s m ic , 3 0 9 , 3 0 9 1

416

L u th e ra n , 87

S o p p o ro c la s s ific a tio n of, 2 8 7 f

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

Index

Antiplatelet— Autoimmune A n ti-p la te le t a ge n ts, 289

A s p e rg illu s te rre u s, 142

A n ti-re ticulin, 311

A spirin, 283, 2 89

A n ti-S c 1 -7 0 , 308

A S T :A L T ratio, 2

A n ti-s m o o th m uscle antib o dies, 309, 3 0 9 f

A s tro c y to m a , o lig o d e n d ro d ro g lio m a v e rs u s , 3 7 4 f

A n tith ro m b in d eficien cy, 286

A stro virid a e , 113

A n ti-th yro id a n tib o d ie s by im m u n o flu o re s c e n c e , 309, 31 Of

A ta x ia te la n g ie c ta s ia , 3 05

A n ti-tis s u e tra n s g lu ta m in a s e a ntib o dies, 311

A th e ro s c le ro s is , p re m a tu re , 25

a 1-A n titryp sin (A A T), 7, I t

A typ ica l h e m o ly tic u re m ic sy n d ro m e (a H U S ), 64 A typ ica l te ra to id /rh a b d o id tu m or, 375

d e fic ie n c y of, 8, 8 f A P C a sso cia te d sp o ra d ic and inh erited tu m ors, 3 56 -35 8 , 357/

A u sb a c h m y e n te ric p le xu s, 343

A p h e re s is

A u to a d s o rp tio n , 64 A u to a n tib o d ie s

ca te g o rica l ind ica tio ns for, 7 1 1

in blood bank, 6 7-6 8, 6 7 f b lo o d b a n kin g c o n s id e ra tio n s w ith co ld a u to a n tib o d y , 68

th e ra p e u tic, 70-72, 7 0 f A p h e re s is d o n o r re qu ire m en ts, 57

cold re actin g a u to a n tib o d ie s, 67 m e c h a n is m s o f d ru g induced p ositive, 68 m ixed ty p e a u to a n tib o d ie s, 67 p a ro xysm a l cold h e m o g lo b in u ria (P C H ), 68 w a rm re actin g a u to a n tib o d ie s, 67

p la sm a p h e re sis, 57 p la te le tp h ere sis, 57 R B C a p h e re sis and m u ltic o m p o n e n t d on a tio n s, 57 A p h e re s is g ran u lo cyte s, 7 5 1 A p h e re s is p latelets, 75f, 76

im m u n o flu o re s c e n c e in d ete ctio n of, 3 07

A p ix a b a n , 288

A u to h e m o ly s is test, 202

A p la s tic ane m ia , 2 16 -21 7 , 216f, 2 1 7 f

A u to im m u n e d estru ctio n , 38

A p la s tic crisis, 202

A u to im m u n e d ise a se s, 19, 3 09 -31 6 , 31 Of

A rc a n o b a c te riu m h a e m o lyticu m , 161-162

a u to im m u n e h epatitis, 312

A re n a virid a e , 115

B e hp e t d ise a se , 314

A rh ru s reaction, 316

B u e rg e r d ise a se , 314

A rrh y th m o g e n ic right v e n tric u la r d ysplasia , 338

c e lia c d ise a se , 311

A rs e n ic p oison ing , 23-2 4

C h u rrg -S tra u s s syn dro m e , 3 13

A rte rh e p a tic d ysplasia , 345/, 3 4 5 -34 6

fa m ilia l M e d ite rra n e a n fever, 3 1 5 -3 1 6

A rte ria l blood g a s a na lyze r, 261

g ia n t cell a rteritis, 314, 315/

A rth ra lg ia s, 11

lg G 4 related scle ro s in g d ise ase , 3 12 , 3 1 2 /

A rth ritis

Ig va scu littis, 3 15

reactive, 311

in fla m m a to ry m yop a th ie s, 3 15

rh eu m atoid, 45, 310-311

K a w a sa ki d ise a se , 314 -31 5

septic, 46

m ic ro s c o p ic p olya n g iitis, 313

A rth ro p a th y, reactive, 97

m y a sth e n ia g ravis, 315, 31 5 f

A rtifa ctu al x a n th o ch ro m ia , 44

p olyartritis n od o sa, 313, 313/

A s b e s to s e xp o su re , 45

p rim a ry b ilia ry cirrh o sis, 312

A s c a ris lu m b rico id e s, 126

p rim a ry scle ro sin g ch olan g itis, 3 12

A s e p tic m en ing itis, 99

p ro g re s s iv e s y s te m ic scle ro sis, 3 1 1 -3 1 2

A s p a rta te a m in o tra n s fe ra s e and a la n in e a m in o tra n sfe ra se , 2

rh e u m a to id arthritis, 310-311

A S P E N syn d ro m e , 69

se ro n e g a tiv e s p n d y lo a rrth ro p a th ie s , 311

A sp e rg illu s, 140, 141/, 141-144, 142/, 143/, 144/

S jog ren syn d ro m e , 312

A s p e rg illu s flavus, 142

s y s te m ic lup u s e ryth e m a to su s, 3 0 9 -3 1 0 , 311 f

A s p e rg illu s fu m ig a tu s, 142

T a k a y a s u arteritis, 3 14

A s p e rg illu s niger, 142

va scu litis, 312, 3 1 3 f W e g e n e r g ra n u lo m a to sis, 313

© A S C P 2018

ISBN 9 7 8 -0 8 9 1 8 9 -6 6 7 8

417

Index

A utoim m une— B cell A u to im m u n e h e m o ly tic a n e m ia , 3 0 7

B a c te ro id e s , 179

A u to im m u n e h e p a titis , 3 1 2

B a c u te ly m p h o b la s tic le u k e m ia , 2 37 , 2 3 8 1

A u to im m u n e n e u tro p e n ia , 2 1 6

B a irn e s d a le u lce r, 192

A u to im m u n ity a n d rh e u m a to lo g ic d is e a s e , 3 0 6 -3 1 6 a n tib o d ie s to c y to p la s m ic c o n s titu e n ts , 3 0 9 , 3 0 9 /

B a la m u th ia m a n d rilla ris , 123

a n ti-n u c le a r a n tib o d ie s , 3 0 7 -3 0 9 , 3 0 7 /, 3 0 8 / a u to a n tib o d y d e te c tio n b y im m u n o flu o re s c e n c e , 3 0 7 a u to im m u n e d is e a s e s in w o m e n o f re p ro d u c tiv e a g e , 3 0 6 la b o ra to ry te s tin g in, 3 0 7 p a th o p h y s io lo g y , 3 0 6 -3 0 9 , 3 0 6 /, 307/. 308/', 3 0 7 /, 3 0 8 f, 309/ te s ts fo r a u to im m u n e d is e a s e s , 3 0 9 trig g e rin g a g e n ts in, 3 0 7

B a la n tid iu m coli, 118, 118/ B a lle le , 80 B a n n a y a n -R ile y -R u v a lc a b a s y n d ro m e , 380 B a rb itu ra te s , 20 B a rte r8 sy n d ro m e , 12 B a rto n e lla , 185 B a rto n e lla h e n s e la e , 185 B a rto n e lla q u in ta n a , 185

A u to lo g o u s d o n o r re q u ire m e n ts , 57

B a s o p h ilic stip p lin g , 22

A u to s o m a l d o m in a n t d is o rd e rs , 3 2 5 d ila te d c a rd io m y o p a th y , 339

B a so p h ils , 2 98 B c e ll(s ), 2 9 6 -2 9 7 , 2 9 6 ft, 304

p o ly c y s tic k id n e y d is e a s e , 336/, 3 3 6 -3 3 7 A u to s o m a l re c e s s iv e d is o rd e rs , 3 2 5 p o ly c y s tic k id n e y d is e a s e , 3 36

d e fe c ts in, 3 00 B ruton a g a m m a g lo b u lin e m ia , 3 0 3 -3 0 4 c o m m o n v a ria b le im m u n o d e fic ie n c y , 3 04 h y p e r IgE s y n d ro m e , 3 04

A z o le s , 146 A z o te m ia , 15 p re re n a l, 16

s e le c tiv e IgA d e fic ie n c y , 3 04 m atu re , 2 96 s p e c ific te s tin g o f fu n c tio n , 3 00 B cell n e o p la s m s , 2 2 3 -2 3 6

B

A L K + larg e B ly m p h o m a , 2 33 , 2 3 4 1

B a b e s ia , 119, 119/

B u rk itt ly m p h o m a /le u k e m ia , 2 36 , 2 3 6 /

B a b e s io s is , 92

d iffu s e la rg e B cell ly m p h o m a , 2 3 1 -2 3 2 , 2 3 2 fi

B a c illa ry a n g io m a to s is , 1 8 4 -1 8 5

EBV+ D LBCL, NO S, 235

B a c illu s a n th ra c is , 156/', 1 5 6 -1 5 7 , 157/

fo llic u la r ly m p h o m a , 2 2 6 -2 2 8 , 2 2 7 /

B a c illu s c e re u s , 158

g e n e ra l c lin ic a l c o n s id e ra tio n s , 2 23 , 2 2 3 /

B a c te re m ic p n e u m o n ia , 169

h a iry cell le u k e m ia , 230/', 2 3 0 -2 3 1 ,2 3 1 /

B a c te ria l c o n ta m in a tio n , 90

h e a v y c h a in d is e a s e , 231

B a c te rio lo g y , 1 4 8 -1 8 6 a n a e ro b e s , 1 7 6 -1 7 9

h ig h g ra d e B cell ly m p h o m a , 2 3 5 im m u n o d e fic ie n c y a s s o c ia te d ly m p h o p ro life ra tiv e d is o rd e rs , 2 35

A n a p la s m a , 1 8 4 -1 8 5 B a rto n e lla , 1 85

in tra v a s c u la r la rg e B cell ly m p h o m a , 2 34 , 2 3 5 /

C h la m y d ia , 183 C o x ie lla b u rn e tii, 1 8 4 -1 8 5

ly m p h o m a to id g ra n u lo m a to s is , 235, 2 3 5 / ly m p h o p la s m a c y tic ly m p h o m a , 231

E h rlic h ia , 185

M a n tle cell ly m p h o m a , 225/', 2 2 5 -2 2 6

g ra m n e g a tiv e c o c c i, 1 6 2 -1 6 4 , 1 6 3 it

m a rg in a l z o n e le u k e m ia , 227/', 2 2 8 -2 3 0 , 2 2 8 it

g ra m n e g a tiv e ro d s , 1 6 4 -1 7 5 g ra m p o s itiv e c o c c i, 1 5 0 -1 5 6 , 152/', 153/', 154/', 155/', 1 5 6 t g ra m p o s itiv e ro d s, 156/', 1 5 6 -1 6 2 , 157/', 159/', 160/', 161/', 162/', 163/', 164/ M y c o p la s m a , 185

p la s m a b la s tic ly m p h o m a , 2 34 , 2 3 4 / p rim a ry c u ta n e o u s D L B C L , leg typ e , 234 p rim a ry D L B C L o f th e C N S , 2 33 , 2 3 3 / p rim a ry m e d ia s tin a l la rg e B cell ly m p h o m a , 234

R ic k e tts ia , 1 8 4 -1 8 5 , 1 8 4 1

p ro ly m p h o c y tic le u k e m ia , 2 31 , 2 3 1 /

s p e c im e n p ro c e s s in g , 1 4 6 -1 5 0

s m a ll ly m p h o c y tic ly m p h o m a , 2 2 3 -2 2 5 , 224/', 2 2 5 ft

s p iro c h e te s , 1 8 0 -1 8 2

T c e ll/h is tio c y te rich la rg e B cell ly m p h o m a , 2 34

418

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

Index

Becker— Blood B e ck e r m u s c u la r d y s tro p h y , 3 39 , 3 53

B loo d a lco h o l

B e c k w ith -W ie d e m a n n s y n d ro m e , 3 79

c lin ic a l e ffe c ts of, 2 1 1

B e hg e t d is e a s e , 314

leve l of, 20

B e n ce J o n e s p ro te in u ria , 10

B loo d a n d tis s u e p ro to z o a , 1 1 9 -1 2 3

B e n e d ic t re a ctio n , 41

B a b e s ia , 1 1 9 -1 2 0 , 119/

B e n ig n fa m ilia l h y p e rc a lc e m ia , 3 42

flu k e s , 1 2 5 -1 2 6 , 125/

B e n ig n p h y s io lo g ic ja u n d ic e , 5

fre e living a m e b a e , 123, 1 23 /

B e rn a rd -S o u lie r s y n d ro m e , 2 21 , 2 22 f, 2 80

L e is h m a n ia , 122/, 1 22 -12 3 , 1 2 2 t, 1 2 3 /

P th a la s s e m ia , 207, 2 60

P la s m o d iu m , 10f, 1 19 -12 1 , 1 21 /

B e th e s d a a s s a y , 2 7 7 -2 7 8 B ica rb o n a te w a s tin g , 3 36 B iclo n a l g a m m o p a th y , 9 B ila te ra l a c o u s tic n e u ro m a s y n d ro m e , 378 B ila te ra l re na l a g e n e s is , 3 37 B ile d uct, s y n d ro m ic p a u c ity of, 345/, 3 4 5 -3 4 6 B ilia ry fib ro c y s tic d is e a s e s , 3 45 B ilirub in , 3-4, 4f, 2 0 0 co n ju g a te d , 3 co n ju g a tio n d is o rd e rs , 348 se cre tio n d is o rd e rs , 348 u n c o n ju g a te d , 3, 4 u rin a ry, 41 u ro b ilin o g e n and, 4 1 -4 2 , 41 f

ro u n d w o rm s , 126/, 126 -12 8 ta p e w o rm s , 1 24 -12 5 , 125/ T o x o p la s m a g o n d ii, 122, 1 2 2 / T ric h o m o n a s h o m in is , 123 T ry p a n o s o m a , 121, 121/ B loo d b a n k in g , 5 9 -6 8 a p h e re s is d o n o r re q u ire m e n ts , 57 p la s m a p h e re s is , 57 p la te le tp h e re s is , 57 R B C a p h e re s is and m u ltic o m p o n e n t d o n a tio n s , 57 a u to lo g o u s d o n o r re q u ire m e n ts , 57 b lo o d c o m p o n e n ts , 74-8 0 c ry o p re c ip ita te d a n tih e m o p h ilic fa c to r, 7 8 -7 9 g ra n u lo c y te c o n c e n tra te s , 7 7 -7 8 m a n ip u la te d p ro d u cts, 7 9 -8 0

5 -B iliru b in , 4

p la s m a , 78

B io te rro ris m , c la s s ific a tio n o f a g e n ts of, 1 1 0 t

p la s m a d e riv a tiv e s , 79

B irt-H o g g -D u b e s y n d ro m e , 366, 3 6 7 /

p la te le ts , 7 6 -7 7

B isa lb u m in e m ia , 6, 8 B itte r a lm o n d o d o r, 21 f B K v iru s , 109 -11 0 B la c k fa n -D ia m o n d sy n d ro m e , 81, 3 50 , 3 5 0 / B la ck p ie d ra , 133 B la d d e r tu m o r a n tig e n , 32 B la s tic p la s m a c y to id d e n d ritic cell n e o p la s m , 2 57 B la s to m y c e s , 135/, 135 B la s to m y c e s d e rm a titid is , 135, 135/ B le e d in g , e x c e s s iv e , 2 7 8 -2 8 5 , 2 7 9 1, 2 8 0 t, 2 8 3 f co a g u la tio n d e fe c ts, 2 8 3 -2 8 5 , 2 8 3 1 la b o ra to ry e v a lu a tio n of, 2 7 8 -2 8 0 , 2 7 9 f n o n h e m o s ta tic c a u s e s of, 2 8 5 p la te le t d is o rd e rs , 2 8 0 -2 8 3 , 2 8 0 f B le e d in g tim e, 2 75 B lood

red b lo o d ce ll c o m p o n e n ts , 7 4 -7 6 b lo o d d o n a tio n , 56-5 9 d o n o r h is to ry a nd p h ysica l e x a m in a tio n , 5 6 -5 7 , 5 6 1, b i t b lo o d g ro u p a n tig e n s , 80-8 8 A B O a nd c a rb o h y d ra te a n tig e n s , 8 0 -8 8 D u ffy, 86 h u m a n le u k o c y te a ntig e n, 8 7 -8 8 K ell a n tig e n s , 8 6 -8 7 , 8 6 1 K idd b lo o d g ro u p syste m , 85, 8 5 1 L u th e ra n , 87 M N S s y s te m , 86 P /G L O B b lo o d g ro u p , 8 3 -8 4 Rh, 8 4 -8 5 , 8 4 f b lo o d o b ta in e d fro m th e ra p e u tic p h le b o to m y , 57 co ld a u to a n tib o d ie s a nd , 68 c o lle c tin g b lo o d fro m d o n o r, 5 7 -5 8 , 5 8 f

blood d e v ic e s a nd , 399 fro m th e ra p e u tic p h le b o to m y , 57 v isu a l in s p e c tio n of, 62 © A S C P 2018

ISBN 9 7 8 -0 8 9 1 8 9 -6 6 7 8

419

Index

B lood— BRCA1 L u th e ra n , 87

B lo o d b a n k in g (c o n tin u e d ) la b o ra to ry te s tin g o f d o n o r b lo o d , 5 8 -5 9 A B O a n d R h te s tin g , 5 8 -5 9 , 5 8 1 a n tib o d y s c re e n , 59

P /G L O B b lo o d g ro u p , 8 3 -8 4 R h, 8 4 -8 5 , 8 4 f

in fe c tio u s d is e a s e s c re e n in g , 5 9, 5 9 t n e o n a ta l a n d in tra u te rin e tra n s fu s io n , 7 2 -7 4 h e m o ly tic d is e a s e o f fe tu s a n d n e w b o rn , 7 3 -7 4 , 7 3 f m a te rn a l im m u n e th ro m b o c y to p e n ic p u rp u ra , 72 n e o n a ta l a llo im m u n e th ro m b o c y to p e n ia , 7 2 -7 3 s p e c ia l b lo o d re q u ire m e n ts fo r n e o n a ta l a n d in tra u te rin e tra n s fu s io n , 7 2 p re tra n s fu s io n p ro c e d u re s , 59 a u to a n tib o d ie s in b lo o d b a n k , 6 7 -6 8 , 6 7 f b lo o d b a n k in g c o n s id e ra tio n s w ith c o ld a u to a n tib o d y ,

68 c o ld re a c tin g a u to a n tib o d ie s , 67 m e c h a n is m s o f d ru g in d u c e d p o s itiv e , 68 m ix e d ty p e a u to a n tib o d ie s , 67 p a ro x y s m a l c o ld h e m o g lo b in u ria , 68 w a rm re a c tin g a u to a n tib o d ie s , 67 n o n ro u tin e p re tra n s fu s io n p ro c e d u re s , p o s itiv e a n tib o d y s c re e n o r c ro s s m a tc h , 6 2 -6 8 , 637, 6 47 657, 6 6 f, 677, 6 8 f ro u tin e p re tra n s fu s io n p ro c e d u re s , 5 97 6 0 -6 2 , 607, 6 1 1 th e ra p e u tic a p h e re s is , 7 0 -7 2 , 7 07 717 tra n s fu s io n c o m p lic a tio n s , 8 8 -9 4 , 8 8 7 8 9 7 9 1 7 9 3 f b lo o d b a n k re g u la to ry a u th o rity , 94 re c o rd s re te n tio n , 93, 9 3 f

B lo o d lakes, 2 30 B lo o d loss, s h o c k c a u s e d b y a c u te , 6 9, 6 9 f B lo o d urea n itro g e n , in renal fu n c tio n , 15 B lo o m s y n d ro m e , 352 B lo ttin g , 327 B o d y flu id s, 4 0 -4 6 c e re b ro s p in a l flu id , 4 4, 4 5 f p e rito n e a l flu id (a s c ite s flu id ), 46 p le u ra l flu id , 4 5 e x u d a te v e rs u s tra n s u d a te , 4 5 -4 6 , 4 5 f sy n o v ia l flu id , 4 6, 4 6 ft u rin e , 4 0 -4 4 b iliru b in a nd u ro b ilin o g e n , 4 1 -4 2 , 417 g lu co se , 40-41 h e m o g lo b in , 41 ke to ne s, 41 le u k o c y te e s te ra s e , 4 2 nitrite, 42 pH , 4 2 prote in, 41 s p e c ific g ra v ity , 42 u rin e m ic ro s c o p y , 4 3 -4 4

s u s p e c te d tra n s fu s io n re a c tio n , 88

B o n e m a rro w b io p sy , 2 6 5 -2 6 6

ty p e s o f c o m p lic a tio n s , 89 tra n s fu s io n in s p e c ia l c lin ic a l c irc u m s ta n c e s , 6 9 -7 0 B lo o d b o rn e p a th o g e n s , 4 0 0

b o n e m a rro w a s p ira te a nd to u c h im p rin ts , 2 6 5 -2 6 6 b o n e m a rro w b io p s y a nd c lo t s e c tio n , 2 66 p e rip h e ra l b lo o d, 2 65

B lo o d c o m p o n e n ts , 7 4 -8 0 c ry o p re c ip ita te d a n tih e m o p h ilic fa c to r, 7 8 -7 9 g ra n u lo c y te c o n c e n tra te s , 7 7 -7 8 m a n ip u la te d p ro d u c ts , 7 9 -8 0

s ite s o f h e m a to p o ie s is , 2 65 B o n e m a rro w s u p p re s s io n , tra n s fu s io n a s s o c ia te d g ra ft vs h o s t d is e a s e a nd , 90 B o rd e te lla b ro n c h is e p tic a , 171

p la s m a , 7 8

B o rd e te lla p a ra p e rtu s s is , 171

p la s m a d e riv a tiv e s , 79

B o rd e te lla p e rtu s s is , 147, 171

p la te le ts , 7 6 -7 7

B o rre lia b u rg d o rfe ri, 6, 182

red b lo o d ce ll c o m p o n e n ts , 7 4 -7 6

B o rre lia h erm sii, 182

B lo o d d o n a tio n , 5 6 -5 9 d o n o r h is to ry a n d p h y s ic a l e x a m in a tio n , 5 6 -5 7 , 5 67 5 7 f B lo o d g ro u p a n tig e n s , 8 0 -8 8 A B O a n d c a rb o h y d ra te a n tig e n s , 8 0 -8 8 D u ffy , 86

M N S syste m , 86

B o rre lia re cu rre n tis , 182 B o u n d a u to a n tib o d ie s , 307 B o u rn e v ille s y n d ro m e B o w e l isch e m ia , 5

h u m a n le u k o c y te a n tig e n , 8 7 -8 8

B o w e n o id p a p u lo s is , 109

K e ll a n tig e n s , 8 6 -8 7 , 8 6 1

B R A F m uta tio n s, te s tin g fo r, 360

K id d b lo o d g ro u p s y s te m , 85, 8 5 f

B R C A 1 m utatio n , 3 76

420

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

Index

BRCA2—Carney B R C A 2 m u ta tio n , 3 76

C a lifo rn ia e n c e p h a litis , 99

B R C A a s s o c ia te d tu m o rs , 365, 3 6 5 i

C a lin o s is , 311

B re a k a p a rt p ro b e s, 3 28

C a m p y lo b a c te r, 9 6

B re a k b o n e fe ve r, 110

C a m p y lo b a c te r je ju n i, 96, 1 7 2 -17 3

B re a k e v e n p oint, 401

C a N a -E D T A , 22

B re a s t ca n c e r, 3 6 4 -3 6 6

C a n a v a n s y n d ro m e , 352

B R C A a s s o c ia te d tu m o rs , 365, 3 6 5 i

C a n c e r a n tig e n , 30

H E R 2, 3 6 4 -3 6 6

C a n c e r a n tig e n 125, 30

m o le c u la r c la s s ific a tio n , 3 66 , 3 6 6 f

C a n d id a , 96, 130, 130/, 131/

s te ro id re ce p to rs , 3 65

C a n d id a a lb ica n s , 130

T P 5 3 tu m o r s u p p re s o r g e n e , 3 4 4 -3 4 5

C a n d id a d u b lin ie n s is , 130

B re a th a lco h o l te s tin g , 2 1 ,2 1 f

C a n d id a g la b ra ta , 1 30 -13 1 , 1 3 1 /

B ru c e lla , 1 74 -17 5

C a n d id a k ru se i, 131

B ru g a d a sy n d ro m e , 338

C a n d id a lu s ita n ia e , 130-131

B ru g ia m ala yi, 127

C a p illa ry z o n e e le c tro p h o re s is , 11

B ru g ia tim ori, 127

C a p ita l b u d g e ts, 401

B ruton a g a m m a g lo b u lin e m ia , 3 0 3 -3 0 4 , 3 0 4 1

C a p n o c y to p h a g a , 174

B ruton ty ro s in e kina se, 3 04

C a p n o c y to p h a g a ca n im o rs u s , 174

B ty p e n a triu re tic p e p tid e , 6

C a p n o c y to p h a g a o c h ra c e u s , 174

B u b o n ic p la g u e , 176

C a rb a m a te s o v e rd o s e , 24

B u d d -C h ia ri s y n d ro m e , 4 6, 283, 385

C a rb o h y d ra te a n tig e n s , 80

B u dg e ts, 401

C a rb o h y d ra te s , 2 6 -2 8

a llo ca tio n , 401

m e th o d s fo r m e a s u rin g , 26, 2 6 1

ca p ita l, 401

C a rb o n m o n o x id e p o iso n in g , 2 2 -2 3 , 2 3 1

o p e ra tin g , 401

C a rb o x y h e m o g lo b in , 2 06 , 2 0 6 1

p e rso n n e l, 401

C a rc in o e m b ry o n ic a n tig e n (C E A ), 29

B u e rg e r d is e a s e , 3 14

C a rc in o id tu m o rs , 31

B U N and c re a tin e , 40

C a rc in o m a

B U N c re a tin in e ra tio in re na l fu n c tio n , 16

c o lo n ic , 221

B u n y a v irid a e , 1 13 -11 4

c o lo re c ta l, 29, 360

B u rk h o ld e ria , 170

h e p a to c e llu la r, 363

B u rk h o ld e ria c e p a c ia , 170

m e d u lla ry th y ro id , 3 1-3 2

B u rk h o ld e ria m allei, 170

p a p illa ry th y ro id , 3 7 2 -3 7 3

B u rk itt ly m p h o m a /le u k e m ia , 2 36 , 2 36 /

s p o ra d ic renal ce ll, 367, 367/

B u ru li u lcer, 192

s q u a m o u s cell, 371 u ro th e lia l, 32, 3 6 7 -3 6 8 v e rru c o u s , 109

c

C a rd ia c e n z y m e s , 5-6, 5 /

C1 e s te ra s e in h ib ito r d e fic ie n c y , 306

C a rd ia c re p o la riza tio n , 338

C A 1 9 -9 , 30

C a rd io b a c te riu m h o rn inis, 175

C A 2 7 .2 9 and 15-3, 30

C a rd io p u lm o n a ry b yp a ss, 283

C a lciu m o x a la te s to n e s, 42

C a rd io v a s c u la r d is e a s e , 3 3 8 -3 4 0

C a lciu m p h o s p h a te s to n e s , 42

c h a n n e l c o n d u ctio n , 3 2 8 -3 3 9

C a lciu m p y ro p h o s p h a te c ry s ta ls , 46

m y o c a rd ia l, 3 39

C a lib ra tio n , 4 0 5 © A S C P 2018

C a rn e y c o m p le x , 3 80 ISBN 9 7 8 -0 8 9 1 8 9 -6 6 7 8

421

Index

Caroli— Clinical C a ro li d is e a s e , 3 4 5 , 3 45 /, 3 6 4

C h ild re n , re a c tiv e ly m p h o c y to s is in, 2 2 0

C a s p o fu n g in , 146

C h im e ris m , 333

C a s ts , 4 3

C h is tm a s d is e a s e , 2 84

fa tty , 4 3

C h la m y d ia , 182

g ra n u la r, 4 3

C h la m y d ia p n e u m o n ia e , 97

h y a lin e , 4 3

C h la m y d ia tra c h o m a tis , 183

re d ce ll, 4 3

C h la m y d o p h ila p n e u m o n ia e , 184

tu b u la r, 4 3

C h la m y d o p h ila p s itta c i, 183

w axy, 43

C h lo n o rc h is s in e n s is , 125, 125/

w h ite ce ll (n e u tro p h il), 4 3

C h lo rid e , 4 0, 4 0 f

C a tc h 2 2 s y n d ro m e , 3 5 6 1

C h o la n g io c a rc in o m a , 364

C a t s c ra tc h d is e a s e , 184/, 1 8 4 -1 8 5

C h ro m o b la s to m y c o s is , 1 3 8 -1 3 9

C a v ita ry d is e a s e , 9 8, 191

C h ro m o g ra n in A, 31

C D C c ro s s m a tc h , 3 0 2

C h ro m o m y c o s is , 1 38 -13 9

C e lia c d is e a s e , 311

C h ro m o s o m a l b re a k a g e s y n d ro m e s , 3 7 9 -3 8 0

C e ll c y c le , 3 2 4

C h ro m o s o m e e n u m e ra tio n p ro b e s , 327

C e ll s ig n a lin g , 321

C h ro m o s o m e s tru c tu re a nd n o m e n c la tu re , 321

C e n te rs fo r M e d ic a re a n d M e d ic a id S e rv ic e s (C M S ), 3 9 6

C h ro n ic d is e a s e , a n e m ia of, 2 1 3 -2 1 4 , 2 1 3 f

” 14 d a y ru le ” of, 3 9 9

C h ro n ic e o s in o p h ilic le u k e m ia , 251

” 3 d a y ru le ” of, 3 9 9

C h ro n ic g ra n u lo m a to u s d is e a s e , 87, 3 00 , 3 05

C e n tra l n e rv o u s s y s te m tu m o rs , 3 7 3 -3 7 5 e m b ry o n a l tu m o rs , 3 7 5

C h ro n ic k id n e y s c re e n in g , la b o ra to ry s c re e n in g for, 16

m e n in g io m a , 3 7 5

C h ro n ic ly m p h o c y tic le u k e m ia , 9, 2 2 3 -2 2 5 , 224/, 2 2 5 ft

p ilo c y tic a s tro c y to m a , 3 7 4

C h ro n ic ly m p h o p ro life ra tiv e d is o rd e r o f N K ce lls, 242

re tin o b la s to m a , 3 7 4 -3 7 5 C e n tra l n e u ro d e g e n e ra tiv e d is e a s e , 3 5 0 -3 5 2 , 3 5 1 / C e re b ra l a m y lo id a n g io p a th y , 3 3 9 C e re b ra l a u to s o m a l d o m in a n t a rte rio p a th y w ith s u b c o rtic a l in fa rc tio n s a n d le u k o e n c e p h a lo p a th y , 351 C e re b ro s p in a l flu id , 4 4, 4 5 f C e re b ro s p in a l flu id p ro te in e le c tro p h o re s is , 10, 10 f C e ru lo p la s m in , 7, 7 t, 3 4 7 C e rv ic itis , 184 C e rv ix , tu m o rs of, 3 7 6 -3 7 7 C H 5 0 te s t, 301 C h a g a s d is e a s e , 1 0 1 -1 0 2 , 1 0 2 t, 121 C h a n n e l c o n d u c tio n d is o rd e rs , 3 2 8 -3 3 9 B ru g a d a s y n d ro m e , 3 3 8 C h a rc o t-L e y d e n c ry s ta ls , 2 9 8 C h a rc o t-M a rie -T o o th d is o rd e r, 3 5 2 C h a rg a ff, E rw in , 3 1 9 C H A R G E se qu e nce , 304, 3 5 6 t C h e d ia k -H ig a s h i s y n d ro m e , 2 8 0 , 3 0 5 C h e m ic a ls , h a z a rd o u s , 4 0 0 C h ic k e n p ox, 106

422

C h ro n ic h e p a tic C v iru s h e p a titis , 2

C h ro n ic m u c o c u ta n e o u s c a n d id ia s is , 3 05 C h ro n ic m yelo id le u k e m ia , 2 4 6 -2 5 0 C h ro n ic m y lo m o n o c y tic le u k e m ia , 247/, 2 4 7 -2 4 8 C h ro n ic p u lm o n a ry h is to p la s m o s is , 134 C h ro n ic re je ction , 302 C h u rg -S tra u s s s y n d ro m e , 2 21 , 313 C h y lo th o ra x , 4 5 C h y lo u s e ffu sio n , 4 5, 4 5 f C irc u la tin g a u to a n tib o d ie s , 3 07 C irrh o s is , 2, 12 p rim a ry b ilia ry, 312 C itra te to xicity, 5 8 f C itro b a c te r, 167 C K B B , 5, 5 f C K M B , 5f, 6 C K M M , 5f, 6 C la s s ic H o d gkin ly m p h o m a , 2 4 3 -2 4 5 , 2 4 5 it, 2 4 6 / C la u s s assay, 278 C le a v a s e te c h n iq u e , 331 C lin ic a l L a b o ra to ry A c t (1 9 6 7 ), 396

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

Index

Clinical—Corynebacterium C lin ica l L a b o ra to ry Im p ro v e m e n t A m e n d m e n t (C L IA ) (1 9 8 8 ), 3 9 6 -3 9 8 , 397f, 4 0 4

C o c c id io id e s im m itis , 135, 135/ C o c c id io id e s p o s a d a s ii, 135

c e rtific a tio n a nd a c c re d ita tio n u n d e r, 3 9 6 -3 9 8

C o ld a u to a g g lu tin in s , 2 0 8 -2 0 9 , 2 0 8 f, 2 0 9 /

la b o ra to ry re p o rts u nd e r, 4 12

C o ld re a c tin g a u to a n tib o d ie s , 67

m e d ic a l d ire c to rs u n d e r, 3 9 6 -3 9 8

C o lo n ic c a rc in o m a , 221

o th e r p ro v is io n s of, 3 9 7 -3 9 8 p ro fic ie n c y te s tin g and, 4 1 0

C o lo re c ta l a d e n o c a rc in o m a , 3 5 6 -3 6 2 , 357/, 3 5 8 f, 3 5 9 it, 360/', 3 61 ft, 3 62 /

te s t c o m p le x ity u nd e r, 396, 3 9 7 1

C o lo re c ta l c a rc in o m a

C lin ica l L a b o ra to ry Im p ro v e m e n t A m e n d m e n t (C L IA ) (2 00 3), 334 C lin ica l re p o rta b le ra ng e, 4 06

s c re e n in g fo r, 29 ta rg e te d th e ra p y in, 3 60 C o m m o n v a ria b le im m u n o d e fic ie n c y , 3 04 , 3 0 4 /

C lin ica l staff, e d u c a tio n of, 4 07 , 4 0 8 f

C o m p a ra tiv e g e n o m ic h y b rid iz a tio n , 3 28

C lin ica l s y n d ro m e s and c a u s a tiv e a g e n ts , 1 0 0 -1 0 1 1

C o m p a tib le b lo o d, fin d in g , 65

in fe c tio u s d ia rrh e a , 97, 9 6 f

C o m p a tib le p ro d u c ts , s e le c tio n of, 61, 6 1 1

in fe c tiv e e n d o c a rd itis , 9 8 -9 9

C o m p le m e n t d e p e n d e n t c y to to x ic ity a s s a y , 301

m e n in g itis, 99

C o m p le m e n ts , 2 9 8 -2 9 9 , 2 9 8 f

p n e u m o n ia , 9 7-9 8

d e fic ie n c ie s of, 306

p ro s th e tic jo in t in fe c tio n s , 99

te s tin g , 301

u rin a ry tra c t in fe c tio n s , 96

C o m p le x a c id -b a s e d iso rd e r, 14

v e c to rs , 1 0 2 f

C o n g e n ita l a d re n a l h y p e rp la s ia , 12, 3 7 -3 8 , 37f, 3 4 0 -34 1

C lin ica l v a lu e s re p o rtin g , 4 12

C o n g e n ita l a m e g a k a ry o c y tic th ro m b o c y to p e n ia , 2 1 5 , 2 2 2 ,

C lo n a lity a s s e s s m e n t in ly m p h o id n e o p la s m s , 3 33

316f

C lo p id o g re l (P la vix), 2 89

C o n g e n ita l ce n tra l h y p o v e n tila tio n s y n d ro m e , 3 4 4

C lo s trid iu m b o tu lin u m , 177

C o n g e n ita l d y s e ry th ro p o ie tic a n e m ia , 81

C lo s trid iu m d ifficile, 96, 97, 150f, 178

C o n g e n ita l h e a rin g loss, 3 5 4 -3 5 5

C lo s trid iu m p e rfrin g e n s , 96, 1 77 -17 8

C o n g e n ita l h e p a tic fib ro s is , 3 45 , 3 4 5 /

C lo s trid iu m s e p tic u m , 178

C o n g e n ita l n e p h ro tic s y n d ro m e o f th e F in n is h ty p e , 3 3 5 , 3 3 5 f

C lo s trid iu m so rd e llii, 178

C o n g e n ita l n e u tro p e n ia a nd c y lic n e u tro p e n ia , 2 1 6 , 2 1 6 1

C lo s trid iu m te ta n i, 177

C o n g e n ita l s y p h ilis , 181

C o a g u la s e n e g a tive S ta p h y lo c o c c u s , 151

C o n g e s tiv e h e a rt fa ilu re , 12

C o a g u la tio n , 2 7 4 -2 8 9

C o n ju g a te d b iliru b in , 3

d e fe c ts of, 2 8 3 -2 8 5 , 2 8 3 1 in h e rite d fa c to r d e fic ie n c ie s , 2 8 3 -2 8 4 , 2 8 3 f

C o n ju g a te d h y p e rb iliru b in e m ia , 3, 4, At C o n ta c t fa c to r d e fic ie n c y , 284

h e m o s ta s is , 2 7 4 -2 7 5 , 2 7 4 f, 2 1 5 ft fib rin o ly s is , 2 7 5

C o n tin u o u s Q u a lity Im p ro v e m e n t (C Q I), 4 0 7 C o o m b s te st, 2 08

la b o ra to ry e v a lu a tio n of, 2 7 5 -2 7 8 , 2 7 6 f, 2 1 1 ft p la sm a c o a g u la tio n (fibrin fo rm a tio n ), 2 74 , 21 A ft

C o -o x im e te r, 14, 261

p la te le t a c tiva tio n in, 2 74 , 3 7 At

C o p p e r s to ra g e d e fe c ts, 352

p rim a ry, 274

C o p p e r s u lfa te m e th o d , 41

la b o ra to ry e v a lu a tio n of, 2 7 6 -2 7 8 , 2 1 1 ft

C o rn e lia de L a n g e s y n d ro m e , 3 44

p la sm a, 274, 21 A ft

C o ro n a ry a rte ry d is e a s e , lipids in a s s e s s m e n t o f ris k of, 26, 261

C o a g u la tio n fa c to r in h ib ito r a s s a y , 2 7 7 -2 7 8 C o a g u la tio n ty p e b le e d in g , 2 79 C o c a in e , 20 C o c c id ia , 1 18 -11 9 C o c cid io id e s, 1 35 -13 6 , 135/ © A S C P 2018

C o ro n a v irid a e , 110 C o rtis o l re le a s in g h o rm o n e (C R H ), 35 C o ry n e b a c te riu m d ip h th e ria e , 149, 159, 159/ C o ry n e b a c te riu m je ik e iu m , 159 ISBN 9 7 8 -0 8 9 1 8 9 -6 6 7 8

423

Index

C orynebacterium — Diabetes C o ry n e b a c te riu m u re a ly tic u m , 159

C y s tin e s to n e s , 42

C o s y n tro p in , 35

C y s tin o sis , 3 36

C o w d e n s y n d ro m e , 3 66 , 3 80

C y s to is o s p o ra b e lli, 119, 1 28 /

C o x ie lla b u rn e tii, 1 7 6 -1 7 7 , 185

C y to c h e m ic a l s ta in s , 2 6 1 ,2 6 1 /

C o x s a c k ie B, 6

C y to c h ro m e P 4 50 , 3 3 3

C o x s a c k ie v iru s , 1 1 1 -1 1 2

C y to m e g a lo v iru s ,7 1 0 7 , 107/

C ra n io p h a ry n g io m a s , 38

C y to p la s m ic A N C A , 309, 3 0 9 /

C -re a c tiv e p ro te in , 7/, 8

C y to p la s m ic c o n s titu e n ts , a n tib o d ie s to, 3 09 , 3 0 9 /

C re a tin e k in a s e

C y to s in e (C ), 3 18 , 3 19 C y to s k e le ta l d is o rd e rs , 200-201

a s c a rd ia c e n z y m e , 5 -6, 5 f m a c ro , 6

h e re d ita ry e llip to c y to s is /h e re d ity o v a lo c y to s is , 200

m ito c h o n d ria l, 6

h e re d ita ry s p h e ro c y to s is , 2 0 0 , 2 0 0 / h e re d ita ry s to m a to c y to s is , 2 00 , 201/, 2 03

C re a tin in e a n d g lo m e ru la r filtra tio n ra te c a lc u la tio n s , in re na l fu n c tio n , 1 5 -1 6 C R E S T s y n d ro m e , 311 C re u tz fe ld t-J a k o b d is e a s e , 3 5 2

D

C ri d u c h a t, 3 5 6 1

D a n a p a ro id , 2 89

C rig le r-N a jja r s y n d ro m e , 4, 3 4 8

D a n e p article, 104 D -d im e rs, 278

ty p e 2, 4

D e g ra n u la tio n , 2 74

C ro s s m a tc h , 61

D e la y e d h e m o ly tic tra n s fu s io n re a c tio n s , 90

p o s itiv e , 65 C ro s s re a c tiv e a n tig e n g ro u p s , 301

D e la y e d s e ro lo g ic tra n s fu s io n re a c tio n s (D S T R ), 90

C ry o g lo b u lin e m ia , 10, 2 0 9 -2 1 0 , 2 1 0 /

D e la y e d ty p e h y p e rs e n s itiv ity , 300

c ry o g lo b u lin s , 10-11

D e le tio n m u ta tio n , 324

m ix e d c ry o g lo b u lin e m ia (ty p e s II & III), 11

D e lte rio u s m u ta tio n s , 3 2 5

C ry o g lo b u lin s , 10-11

D e n d ritic re tic u lu m ce lls, 2 9 8

C ry o p re c ip ita te d A H F , 7 5 1

D e n g u e virus, 110

C ry o p re c ip ita te d a n tih e m o p h ilic fa c to r, 7 8 -7 9

D e n s e g ra n u le d is o rd e rs , 2 8 0

C ry p to c o c c u s , 1 3 1 -1 3 2 , 132/

D e n t d ise a se , 3 36

C ry p to c o c c u s g a ttii, 131

D e n y s -D ra s h s y n d ro m e , 335, 3 3 5 /

C ry p to c o c c u s n e o fo rm a n s , 9 8, 1 3 1 -1 3 2 , 132/

D e o x y rib o s e , 318

C ry p to s p o rid iu m p a rv u m , 118

d e Q u e rv a in th y ro id itis , 34

C ry s ta ls (c ry s ta llu ria ), 4 3 -4 4 , 4 3 f

D e R itis ratio, 2

C u n n in g h a m e lla , 1 4 3 -1 4 4

D e rm a titis s e b o rrh e ic, 133

C u s h in g s y n d ro m e , 12, 35, 36

tra n s fu s io n a s s o c ia te d g ra ft vs h o s t d is e a s e a nd , 90

ia tro g e n ic , 36 C u ta n e o u s a n th ra x , 158

D e rm a to fib ro s a rc o m a p ro tu b ra n s , 373

C u ta n e o u s T ce ll ly m p h o m a , 2 4 3

D e rm a to m y o s itis , 3 15

C y a n id e p o is o n in g , 23

D e rm a to p h y te s and o th e r s u p e rfic ia l m y c o s e s , 137 -13 8

C y c lic n e u tro p e n ia , 2 1 6

D e x a m e th a s o n e , 35

C y c lo s p o ra c a y e ta n e n s is , 119, 1 2 8 /

D ia b e te s insip id u s, 12, 39

C Y P 2C 9, 288

D ia b e te s m ellitu s, 3 43

C y s ta tin C in re n a l fu n c tio n , 16

d ia g n o s is and m o n ito rin g , 2 7 -2 8

C y s tic fib ro s is , 170, 3 1 1 ,3 4 8 -3 5 0 , 349/, 3 4 9 /

g e s ta tio n a l, 27

Cystic renal dysplasia, 337

types of, 27

424

ASCP Quick Compendium of Clinical Pathology 4e

©ASCP2018

Index

Diabetic— Electrolyes D o n or, c o lle c tin g b lo o d fro m , 5 7 -5 8 , 5 8 1

D ia b e tic k e to a c id o s is , 5, 28 ke to n e s in, 2 8

D o n o r a d v e rs e re a c tio n s , 58, 587

p o ta s s iu m in, 28

D o t b lo t a n a lys is , 3 29

D ia m o n d B la ckfa n s y n d ro m e , 2 15 , 2 18 , 3 1 6 f

D o u b le s tra n d e d D N A , 319, 3197, 3207

D ia p h o re s is , 2 1 1

D o w n s y n d ro m e , 3 11 , 3167, 3 40 , 3 4 4

D ia rrh e a

a c u te le u k e m ia in, 2 5 7

a n tib io tic a s s o c ia te d , 97

D -p e n ic illa m in e , 22

in fe c tio u s , 9 6 -9 7 , 9 6f, 97

D ra c u n c u lu s m e d in e s is, 127

in fla m m a to ry , 96

D re s s ie r s y n d ro m e , 4 5

n o n in fla m m a to ry , 96

D ru g in d u ce d lup u s, 3 07 , 310

D iffe re n tia tio n , 321

D u b in -J o h n s o n s y n d ro m e , 348

D iffu se g lio m a s , 3 7 3 -3 7 4 , 3 7 4 it

D u c h e n n e m u s c u la r d y s tro p h y , 3 3 9 , 3 5 3

D iffu se la rg e B cell ly m p h o m a , 2 3 1 -2 3 2 , 2 3 2 ft

D u cta l a d e n o c a rc in o m a , 363

D iG e o rg e s y n d ro m e , 13, 3 0 4 -3 0 5 , 340, 3 5 6 1

D u ffy a n tib o d ie s , 86

D ig oxin , 24, 4 0, 4 0 f

D u ffy a n tig e n s , 86

D ilated pup ils, 2 1 1

D u n ca n d is e a s e , 3 05

D im e rc a p ro l, 22

D w a rfis m , 38

D im e rc a p to s u c c in ic a cid, 22

D -x y lo s e te st, 5

D im o rp h ic fu n g i, 129, 1 33 -13 7 , 134/', 134f, 135/, 136/

D y s e ry th ro p o ie s is , 2 6 6

D ip h y llo b o th riu m la tu m , 124, 124/

D y s fib rin o g e n e m iia , 2 84

D ip s tick m eth o d , 4 0 - 4 1 ,4 2

D y s k e ra to s is co n g e n ita , 215, 3167

D ip y lid iu m , 124, 124/

D y sto n ia , 217

D ip y rid a m o le , 2 8 9

D y s tro p h in o p a th ie s , 353

D ire ct b illin g law , 4 0 0 D ire ct im m u n o flu o re s c e n c e , 3 07 D ire ct th ro m b in in h ib ito rs , 2 89

E

D iro fila ria im m itis , 127

E a g le -B a rre tt s y n d ro m e , 337

D is s e m in a te d h is to p la s m o s is , 134

E B V + D L B C L , N O S , 2 35

D is s e m in a te d in tra v a s c u la r c o a g u la tio n , 278, 2 8 4 -2 8 5 , 2 8 5 1

E c h in o c o c c u s sp p (h y d a tid o s is ), 124

D L B C L a s s o c ia te d w ith c h ro n ic in fla m m a tio n , 2 35

E c h in o c y te s , 2 0 1 ,2 0 2 /

D N A (d e o x y rib o n u c le ic a cid ), 318, 319

E c h o v iru s , 99t, 112

d o u b le s tra n d e d , 318, 3197, 3 2 0 f

E c to p ic a d re n o c o rtic o tro p h ic h o rm o n e , 36

m ic ro a rra y s , 3 29

E c to p ic p re g n a n c y , 5

m ito c h o n d ria l, 320-321

E ffu sio n s

re p lica tio n , 323, 3 2 3 f

p a ra p n e u m o n ic , 4 5

s e q u e n c in g , 332

tu b e rc u lo s is , 4 5

D N A a s sa ys, 301

E G F R m u ta tio n s , 3 75

D N A v iru se s, 1 03 -11 0 , 104f, 105ft, 106/, 107/, 108ftf

E h lo rs -D a n lo s s y n d ro m e , 274, 2 7 5 , 3 6 6

a d e n o v irid a e , 1 03 -10 4

E h rlic h ia , 184i, 185

h e p a d n a virid a e , 1 04 -10 5

E h rlic h ia c h a ffe e n s is , 185

h e rp e s v irid a e , 1 05 -10 6 , 1 0 5 f

E IA , 309

p a p o v a v irid a e , 1 09 -11 0

E ike n e lla c o rro d e n s , 165t, 174

p a rv o v irid a e , 109

E le c tro lye s . S e e A c id -b a s e a n d e le c tro ly te s

p o x v irid a e , 110 D o h le b o d ie s, 2 80 © A S C P 2018

ISBN 9 7 8 -0 8 9 1 8 9 -6 6 7 8

425

Index

Electrophoresis— Expressivity E o sin o p h ilia , 221

E le c tro p h o re s is , 2

E o s in o p h ilic ce llu litis , 221

1 1 -h y d ro x y la s e d e fic ie n c y , 341 E lu tio n , 64

E o s in o p h ilic fa s c iitis , 221

E m b ry o g e n e s is , 3 2 5

E o s in o p h ilic p n e u m o n ia , 221

E m b ry o n a l tu m o rs , 3 7 5

E o s in o p h ilic v a s cu litis , 221

E n c e p h a litis , 9 8 (s e e a ls o s p e c ific a g e n ts )

E o sin o p h ils , 46, 2 98

E n d e m ic re la p s in g fe v e r, 183

E p id e m ic re la p s in g fe v e r, 182

E n d o c a rd itis , 170

E p id e m ic ty p h u s , 184

E n d o c rin e d is o rd e rs , 19, 3 2 -3 9 , 3 4 0 -3 4 2

E p id e rm o d y s p la s ia v e rru c ifo rm is , 109

a d re n a l c o rte x , 3 5 -3 8 , 3 4 0 -3 4 2 A d d is o n d is e a s e , 3 6 -3 7 c o n g e n ita l a d re n a l h y p e rp la s ia , 3 7 -3 8 , 3 7 1

E p id e rm o p h y to n flo c c o s u m , 138 E p ig e n e tic re g u la tio n , 322 E p in e p h rin e , 32

C u s h in g s y n d ro m e , 36

E p s te in -B a rr v iru s (E B V ), 1 07 -10 8 , 1 0 8 f

p rim a ry a ld o s te ro n is m , 37

E p s te in sy n d ro m e , 2 80

s e c o n d a ry a d re n a l in s u ffic ie n c y , 37

E ru p tiv e x a n th o m a s , 25

te s ts , 3 5 -3 6

E ry s ip e lo th rix rh u s io p a th ia e , 161

d ia b e te s m e llitu s , 3 4 3

E ry th e m a , 130

p a ra th y ro id g la n d , 3 4 2

E ry th e m a in fe c tio s u m , 109

p itu ita ry g la n d , 3 42

E ry th ro b la s to s is fe ta lis , 316

th y ro id c h e m is try , 3 2 -3 5 e x o g e n o u s e s tro g e n s , 34

E ry th ro c y to p e n ia , tra n s ie n t, o f c h ild h o o d , 215 E ry th ro c y to s is , 2 19 , 2 1 9 f

h y p e rth y ro id is m , 3 3 -3 4

E ry th ro p h a g o c y to s is , 44, 118

h y p o th y ro id is m , 34

E s c h e ric h ia coli, 96, 98, 1 65 -16 6

m e d ic a tio n s , 3 4 -3 5 n e o n a ta l h y p o th y ro id is m , 34

E s o p h a g e a l a tre s ia , 344

n o n th y ro id a l illn e s s s y n d ro m e , 34

E s o p h a g e a l p e rfo ra tio n , 45

th y ro id fu n c tio n te s ts , 3 2 -3 3 , 3 2 f

E s o p h a g e a l s c le ro s is , 311 E s s e n tia l th ro m b o c y th e m ia , 250, 2 5 0 f

th y ro id g la n d , 3 4 3 E n ta m o e b a h is to ly tic a , 9 7, 117/, 1 1 7 -1 1 8

E s tro g e n s , e x o g e n o u s , 34

E n te ro b a c te ria c e a e , 1 6 4 -1 6 7 , 1 6 6 f

E s tro g e n th e ra p y , 3

E n te ro b a c te r s p p , 97

E th a n o l, 20-21

E n te ro b iu s v e rm ic u la ris , 116i, 126, 1 2 6 /

E th y le n e glycol p o is o n in g , 22 tre a tm e n t of, 22

E n te ro c o c c u s , 9 6, 1 5 2 -1 5 3 , 9 9 8 E n te ro c o c c u s fa e c a lis , 97

E u m y c o tic m y c e to m a , 138

E n te ro c o litis , 167, 178

E u th y ro id s ic k s y n d ro m e , 33

tra n s fu s io n a s s o c ia te d g ra ft vs h o s t d is e a s e a nd , 90

E u v o le m ic :d ia b e te s insip id u s, 12

E n te ro h e m o rrh a g ic E s c h e ric h ia c o li, 1 6 5 -1 6 6

E w in g s a rc o m a fa m ily o f tu m o rs , 3 6 8 -3 6 9 , 3 6 9 /

E n te ro p a th y a s s o c ia te d T ce ll ly m p h o m a , 2 4 2

E x c e s s iv e b le e d in g , 2 7 8 -2 8 5

E n te ro v iru s e s , 98, 1 1 1 -1 1 2

c o a g u la tio n d e fe c ts, 2 8 3 -2 8 5 , 2 8 3 f

E n z y m e d is o rd e rs , 2 0 1 -2 0 2

la b o ra to ry e v a lu a tio n of, 2 7 8 -2 8 0 , 2 7 9 1

g lu c o s e -6 -p h o s p h a te d e h y d ro g e n a s e d e fic ie n c y , 2 0 1 ,2 0 1 /

n o n h e m o s ta tic c a u s e s of, 285

p y im id in e 5 ’ n u c le o tid a s e d e fic ie n c y , 2 0 2

p la te le t d is o rd e rs , 2 8 0 -2 8 3 , 2 8 0 1

p y ru v a te k in a s e d e fic ie n c y , 2 0 1 -2 0 2

E x o g e n o u s e s tro g e n s , 34

E n z y m e s , h e p a tic , 2

E x o g e n o u s th y ro x in e , 34

E o s in 5 m a le im id e , 2 0 0

E x p re s s iv ity , 325

426

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

Index

Extensive— Forensic E x te n s iv e g ra n u lo m a , 3 05

F e to m a te rn a l h e m o rrh a g e , te s ts fo r, 74

E x tra c ta b le n u c le a r a n tig e n s , 308, 309

a -fe to p ro te in , 30-31

E x tra n o d a l m a rg in a l z o n e B cell ly m p h o m a , 2 28

F ibrin fo rm a tio n , 2 74 , 2 7 4 ft

E x tra o s s e o u s p la s m a c y to m a , 2 39

F ib rin o g e n , 7 f, 8

E x tra s k e le ta l m yxo id c h o n d ro s a rc o m a , 3 69

F ib rin o g e n a s s a y , 2 7 8

E ye o f th e tig e r sign , 352

F ib rin o g e n d e fe c ts , 2 8 4 a c q u ire d , 2 8 4 F ib ro s in g (s c le ro s in g ) m e d ia s tin itis , 134

F

F icin, 64

F a c to r IX c o n c e n tra te , 79

Fifth d is e a s e , 109

F a c to r V II c o n c e n tra te , 79

F ila ria s is , s u b c u ta n e o u s , 127

F a c to r V III c o n c e n tra te , 79

F ilo v irid a e , 115

F a c to r V L e id e n , 2 8 5 -2 8 6

F in a n c ia l c o n s id e ra tio n s in th e la b o ra to ry , 401

F a c to r X III, 278

b u d g e tin g in, 401

F a m ilia l a p o C -ll d e fic ie n c y , 2 5 f

c o s ts in, 4 0 1 , 401 ft

F a m ilia l a u to s o m a l d o m in a n t fo ca l s e g m e n ta l g lo m e ru lo s c le ro s is , 335, 3 3 5 f

F irst trim e s te r te s t, 17

F a m ilia l a u to s o m a l re c e s s iv e c o rtic o s te ro id re s is ta n t n e p h ro tic s y n d ro m e , 335, 3 3 5 f F a m ilia l c le a r cell R C C , 366 F a m ilia l c o m b in e d h y p e rlip id e m ia , 2 5 f F a m ilia l d y s a u to n o m ia s y n d ro m e , 344, 3 5 2 -3 5 3 F a m ilia l d y s b e ta lip o p ro te in e m ia , 2 5 1 F a m ilia l h e m a tu ria , 3 34 F a m ilia l h y p e rc h o le s te ro le m ia , 2 5 1 F a m ilia l h y p e rtrig ly c e rid e m ia , 2 5 f F a m ilia l h y p o c a lc u ric h y p e rc a lc e m ia , 342 F a m ilia l iso la te d c a rd ia c a m y lo id o sis , 339 F a m ilia l lip o p ro te in lip a se d e fic ie n c y , 2 5 f F a m ilia l M e d ite rra n e a n fe ve r, 3 1 5 -3 1 6 F a m ilia l P ick d is e a s e , 350-351 F a m ilia l prion d is e a s e , 352 F a m ilia l th y ro id c a rc in o m a , 3 7 1 -3 7 2 , 372/ F a m ilia l th y ro id d y s h o rm o n o g e n e s is , 34 F a n co n i a n e m ia , 2 1 4 -2 1 5 , 3 1 6 f F a n co n i sy n d ro m e , 2 18 F a s c io la h e p a tic a , 125, 125/ F a s c io lo p s is b uski, 125/, 126 F a s c io s c a p u lo h u m e ra l m u s c u la r d y s tro p h y , 354 Fatal fa m ilia l in so m n ia , 352 F a tty ca sts, 43 F e brile, n o n h e m o ly tic tra n s fu s io n re a ctio n s, 89 F e c h tn e r sy n d ro m e , 280 F e lty s y n d ro m e Fetal lung m a tu rity, d e te rm in a tio n of, 18 ©ASCP 2018

5 ’ n u c le o tid a s e , 3 F la v iv irid a e , 110-111 F leas, 102 f, 124 Flies, 1 0 2 f F lip p e d LD ratio, 2 F lo w c y to m e tric c ro s s m a tc h , 3 02 F lo w c y to m e try , 301 F lu c o n a z o le , 131, 146 F luid re s u s c ita tio n , p rin c ip le s of, 6 9 -7 0 F lu ke s, 1 25 -12 6 , 125/ F lu o re s c e n c e in situ h y b rid iz a tio n , 3 2 7 -3 2 8 , 3 2 8 / F lu o re s c e n t s p o t te st, 2 02 F M T C s y n d ro m e , 372 F o la te , d e fic ie n c y of, 2 1 2 -2 1 3 , 2 1 2 f, 2 1 3 / F o llic le -s tim u la tin g h o rm o n e (F S H ), 39 F o llic u la r ly m p h o m a , 2 2 6 -2 2 8 , 2 2 7 / F o n d a p a rin u x (a rix tra ), 289 F o od and D ru g A d m in is tra tio n (F D A ) C e n te r fo r B io lo g ie s E v a lu a tio n a n d R e s e a rc h , 94 m e d ic a l d e v ic e s and, 398 te s t c o m p le x ity a nd , 396 F o re n s ic to x ic o lo g y , 19-21 a m p h e ta m in e s , 20 b a rb itu ra te s , 20 c o c a in e , 20 e th a n o l, 20-21 m e th a m p h e ta m in e , 20 o p ia te s, 20 p h e n c y c lid in e , 20

ISBN 9 7 8 -0 8 9 1 8 9 -6 6 7 8

427

Index

Frameshift— Global F ra m e s h ift m u ta tio n , 3 2 5

p y lo ric s te n o s is , 3 44

F ra n c is e lla tu la re n s is , 1 75

s y n d ro m ic p a u c ity o f b ile d u c ts, 345/, 3 4 5 -3 4 6

F ra n k lin , R o s a lin d , 3 1 9

W ils o n d is e a s e , 347, 3 4 7 f

F ra s ie r s y n d ro m e , 3 3 5 , 3 3 5 f

G a s tro in te s tin a l a n th ra x , 158

F re e e ry th ro c y te p ro to p o rp h y rin (F E P ), 2 2

G a s tro in te s tin a l s tro m a l tu m o rs , 3 6 2 -3 6 3 , 3 6 2 f

F re e liv in g a m e b a e , 123, 123/

G a s tro in te s tin a l tra c t tu m o rs , 3 5 6 -3 6 3

F re s h fro z e n p la s m a , 7 5 t F ro n to te m p o ra l d e m e n tia w ith P a rk in s o n is m , 3 50 -35 1 F ro z e n red b lo o d ce ll, 7 5 1, 76

c o lo re c ta l a d e n o c a rc in o m a , 3 5 6 -3 6 2 , 357/', 3 5 8 f, 359/7, 360/, 361 ft, 3 62 / g a s tro in te s tin a l s tro m a l tu m o rs , 3 6 2 -3 6 3 , 3 6 2 f G a s tro s c h is is , 3 4 4 -3 4 5

F u n c tio n a l s e n s itiv ity , 4 0 6

G e l e le c tro p h o re s is , 327

F u n c tio n te s ts , 3 2 -3 3 , 3 2 f

G e n e e x p re s s io n , 3 2 1 -3 2 3 , 3 2 3 f, 329

F u n g ite ll, 143

ce ll s ig n a lin g in, 321

F u s a riu m , 142, 143/

c h ro m o s o m e s tru c tu re a nd n o m e n c la tu re in, 321

F u s o b a c te riu m , 179, 179/

g e n e s in, 321

F u s o b a c te riu m n e c ro p h o ru m , 180

tra n s c rip tio n in, 3 2 1 -3 2 2

F u s o b a c te riu m n u c le a tu m , 180

tra n s la tio n in, 3 2 2 -3 2 3 , 3 2 3 f G e n e s , 321

G

G e n e tic a n o m a lie s , c la s s ific a tio n of, 3 2 4 -3 2 5

G a is b o c k s y n d ro m e , 2 1 9

G e n e tic c o u n s e lin g , 334

G a la c to m a n n a n , 142

G e n e tic e x c e p tio n a lis m , 334

G a la c to s e m ia , 3 3 6

G e n e tic In fo rm a tio n a l N o n d is c rim in a tio n A c t (2 0 0 8 ), 334

G a lls to n e s , 2 0 0

G e n e tic p o ly m o rp h is m , 3 33

G a m m a g lo b u lin s , a s m a rk e r o f im p a ire d h e p a tic fu n c tio n , 4

G e n ita l w a rts, 109

y -g lu ta m y l tra n s fe ra s e , 3

G e n ito u rin a ry d is e a s e s , 19

G a rd n e re lla v a g in a lis , 174

G e n ito u rin a ry tu m o rs , 3 6 6 -3 6 8 , 3 6 7 f, 3 6 8 1 re n a l cell c a rd in o m a s y n d ro m e s , 3 6 6 -3 6 7

G a rlic o d o r, 2 1 1 G a s c h ro m a to g ra p h y /m a s s s p e c tro m e try (G C /M S ), 20

s p o ra d ic renal ce ll c a rd in o m a , 367, 3 67 /

G a s tric a d e n o c a rc in o m a , 66

te s tic u la r tu m o rs , 3 68

G a s tric a n d g a s tro e s o p h a g e a l ju n c tio n c a n c e r, ta rg e te d th e ra p y in, 3 6 0 -3 6 1 , 361 f

u ro th e lia l c a rc in o m a , 3 6 7 -3 6 8 W ilm s tu m o r, 367

G a s tro e n te ritis , v ira l, 9 7

G e o tric h u m ca n d id u m , 133

G a s tro in te s tin a l, h e p a to b ilia ry a n d p a n c re a tic d is e a s e s , 3 4 3 -3 5 0

G e rm a n m e a sle s, 113

a b d o m in a l w a ll d e fe c ts , 3 4 4 -3 4 5 a1 a n titry p s in d e fic ie n c y , 3 4 7 -3 4 8 , 3 4 7 / b ilia ry fib ro c y s tic d is e a s e s , 3 4 5

G ia rd ia lam b lia , 117/', 118, 118/

e s o p h a g e a l a tre s ia , 3 44 h e re d ita ry h e m o c h ro m a to s is , 3 4 6 -3 4 7 , 3 4 7 /

in te s tin a l a rre s ia , 3 4 4 m ic ro v illu s in c lu s io n d is e a s e , 3 4 4 O s le r-W e b e r-R e n d u s y n d ro m e , 3 4 4 428

G e s ta tio n a l tro p h o b la s tic d is e a s e , 377 G ia n t cell m y o c a rd itis , 6

b iliru b in s e c re tio n d is o rd e rs , 3 4 8

in h e rite d p a n c re a titis , 3 4 8 -3 5 0 , 3 4 9 /f

G e s ta tio n a l d ia b e te s , 27 G ia n t cell a rte ritis , 314, 315/

b iliru b in c o n ju g a tio n d is o rd e rs , 3 4 8

H irs c h s p ru n g d is e a s e , 3 4 3 -3 4 4

G e rs tm a n n -S tra u s s le r-S c h e in k e r s y n d ro m e , 3 52

G ilb e rt sy n d ro m e , 4 , 348 G ite lm a n s y n d ro m e , 12 G J B 2 g en e , m u ta tio n s of, 3 5 4 -3 5 5 G la n z m a n n th o m b a s th e n ia , 276 G lio m a s , d iffu se , 3 7 3 -3 7 4 , 3 7 4 it G lo b a l te sts o f im m u n e s y s te m , 300

A S C P Q uick Com pendium o f Clinical Pathology 4e

©ASCP 2018

Index

Glomerular— Hematoma G lo m e ru la r h e m a tu ria , 4 3

H

G lo m e ru lo c y s tic k id n e y d is e a s e , 337, 3 37 /

H A C E K o rg a n is m s , 97, 174

G lo m e ru lo n e p h ritis , 153, 334

H a d d a d s y n d ro m e , 344

G lu ca n s y n th e s is in h ib ito rs, 146

H a e m o p h ilu s , 173, 1 7 3 f

G lu co s e , 40-41

H a e m o p h ilu s d u c re y i, 173

G lu c o s e -6 -p h o s p h a te d e h y d ro g e n a s e (G 6 P D ) d e fic ie n c y ,

H a e m o p h ilu s in flu e n z a e , 173

201 , 201/

H a e m o p h ilu s p a ra in flu e n z a e , 173

G ly c o s u ria , 336

H a iry cell le u k e m ia , 230/, 2 3 0 -2 3 1 , 2 3 1 1

G ly c o s y la te d h e m o g lo b in (H b A 1 c), 2 6 -2 7

H a lle rv o rd e n -S p a tz s y n d ro m e , 3 5 1 -3 5 2

G o o d p a s tu re s y n d ro m e , 316

H a n s e n d is e a s e , 192

G o rlin G o ltz sy n d ro m e , 3 78

H a n ta v iru s , 1 1 3 -11 4

G o rlin s y n d ro m e , 3 75

H a n ta v iru s p u lm o n a ry sy n d ro m e , 2 2 0

G P ilb /llla re c e p to r a n ta g o n is ts , 2 89

H a n tig e n , 80-81

G ra ft vs h o s t d is e a s e , 3 0 2 -3 0 3

H a p to g lo b in , 7-8, I t

a cute, 3 0 2 -3 0 3

H a s h im o to th y ro id itis , 34

c h ro n ic , 3 03

H a z a rd o u s c h e m ic a ls , 4 0 0

tra n s fu s io n a s s o c ia te d , 90, 303

H D F /H D N , la b o ra to ry te stin g fo r, 74

G ra m n e g a tive co cci, 1 62 -16 4 , 1 63 it

H e a d a nd n e c k tu m o rs , 3 7 1 -3 7 3 , 3 7 2 /

G ra m n e g a tive rods, 1 64 -17 6

fa m ilia l th y ro id c a rc in o m a , 3 7 1 -3 7 2 , 3 7 2 /

w ith a n im a l h osts, 1 74 -17 6

p a p illa ry th y ro id c a rc in o m a , 3 7 2 -3 7 3

G ra m p o s itiv e co cci, 1 50 -15 6 , 150f, 153/, 154/, 155/7 G ra m p o s itiv e rods, 156/, 1 55 -16 2 , 159/, 160/, 161/, 162/, 163/, G ra n u la r ca sts, 43 G ra n u lo c y te c o n c e n tra te s , 7 7 -7 8 G ra n u lo c y te m a c ro p h a g e c o lo n y s tim u la tin g fa c to r, 2 20 G ra n u lo c y te s , 2 98 G ra n u lo c y te s p h e re s is , 7 5 1

s a liv a ry g la n d tu m o rs , 371 s q u a m o u s cell c a rc in o m a , 371 H e a lth C a re P ro c e d u ra l C o d in g S y s te m (H C P C S ) s y s te m , 399 H e a lth In s u ra n c e P o rta b ility a n d A c c o u n ta b ility A c t, 3 34 H eart, 5-6 a c u te c o ro n a ry s y n d ro m e /a c u te m y o c a rd ia l in fa rc tio n , 6

G ra n u lo m a , e x te n s iv e , 305

m y o c a rd ia l m a rke rs, 5 -6 B ty p e n a triu re tic p ep tid e, 6

G ra n u lo m a in g u in a le , 167

c a rd ia c e n z y m e s , 5-6, 5 f

G ra n u lo m a to s is in fa n tis e p tic a , 160-161

m y o g lo b in , 6

G ra n u lo m a to u s th y ro id itis , 34

tro p o n in , 6

G ra v e s d is e a s e , 34

m y o c a rd itis , 6

G ra y p la te le t s y n d ro m e , 2 80

H e a rt fa ilu re , 6

G ro u p B s tre p to c o c c i, 97

H e a v y ch a in d is e a s e , 231

G ro u p D s tre p to c o c c i, 97

H e a v y c h a in s , 2 9 6

G ro w th h o rm o n e , 38

H e lic o b a c te r, 172/, 173

G u a n in e (G ), 3 18 , 3 19

H e lic o b a c te r h e ilm a n n ii, 173

G u illa in -B a rre s y n d ro m e (G B S ), 114, 173

H e lic o b a c te r p y lo ri, 173

G y n e c o lo g ic tu m o rs , 3 7 6 -3 7 7

H e m a g g lu tin a tio n , 64

c e rv ic a l tu m o rs , 3 7 6 -3 7 7

H e m a g g lu tin a tio n in h ib itio n , 64

g e s ta tio n a l tro p h o b la s tic d is e a s e , 377

H e m a to lo g ic m a lig n a n c y , 412

in h e rite d g y n e c o lo g ic tu m o r s y n d ro m e , 376

H e m a to ly m p h o id n e o p la s m s , 66 H e m a to m a , 5 8 f

© A S C P 2018

ISBN 9 7 8 -0 8 9 1 8 9 -6 6 7 8

429

Index

Hem atopathology— Hem oglobin H e m a to p a th o lo g y , 1 9 9 -2 6 6 . S e e a ls o N e o p la s tic h e m a to p a th o lo g y m a rro w p ro d u c tio n d is o rd e rs , 2 1 0 -2 2 3 a n e m ia o f c h ro n ic d is e a s e , 2 1 3 -2 1 4 , 2 1 3 / a p la s tic a n e m ia , 2 1 6 -2 1 7 , 2 1 6 f, 2 1 7 f a u to im m u n e n e u tro p e n ia , 2 1 6 c o n g e n ita l a m e g a k a ry o c y tic th ro m b o c y to p e n ia , 2 1 5 c o n g e n ita l n e u tro p e n ia a n d c y lic n e u tro p e n ia , 2 1 6 , 2 1 6 f d ia g n o s is o f q u a n tita tiv e a b n o rm a litie s , 2 1 7 -2 2 3 a n e m ia , 2 1 7 -2 1 9 , 2 1 7 ft, 2187, 219/7 e o s in o p h ilia , 221 ly m p h o c y to s is , 2 2 0 , 2 2 2 / ly m p h o p e n ia , 221 m o n o c y to p e n ia , 221 m o n o c y to s is , 221 n e u tro p e n ia , 221 n e u tro p h ilia , 2 2 0 th ro m b o c y to p e n ia , 2 2 1 -2 2 3 , 2 2 2 /f, 2237 d y s k e ra to s is c o n g e n ita , 2 1 5 F a n c o n i a n e m ia , 2 1 4 -2 1 5 fo la te a n d v ita m in B 1 2 , 2 1 2 -2 1 3 , 2127, 2 1 3 / iro n d e fic ie n c y , 2 1 0 , 2 1 2 -2 1 3 , 2127 m y e lo k a th e x is , 2 1 6 p u re red ce ll a p la s ia , 2 1 5 S h w a c h m a n -D ia m o n d s y n d ro m e , 2 1 6 s id e ro b la s tic a n e m ia , 2 1 4 , 2 1 4 / th ro m b o c y to p e n ia w ith a b s e n t ra d ii s y n d ro m e , 2 1 5 m e th o d s in b o n e m a rro w b io p s y , 2 6 5 -2 6 6 c o n v e n tio n a l c y to g e n e tic s a n d m o le c u la r te c h n iq u e s , 2 6 4 -2 6 5 , 2657

red blood ce ll d is e a s e s , 2 0 0 -2 1 0 c y to s k e le ta l d is o rd e rs , 200-201 h e re d ita ry e llip to c y to s is /h e rre d ity o v a lo c y to s is , 2 00 h e re d ita ry s p h e ro c y to s is , 2 00 , 2 0 0 / h e re d ita ry s to m a to c y to s is , 200, 201/, 2 03 e n z y m e d is o rd e rs , 2 0 1 -2 0 2 g lu c o s e -6 -p h o s p h a te d e h y d ro g e n a s e (G 6 P D ) d e fic ie n c y , 2 01 , 2 0 1 / p y im id in e 5 ’ n u c le o tid a s e d e fic ie n c y , 2 02 p y ru v a te k in a s e d e fic ie n c y , 2 0 1 -2 0 2 s tru c tu ra lly a b n o rm a l h e m o g lo b in v a ria n ts , 2 0 2 -2 0 6 , 2021 a lte re d o x y g e n a ffin ity h e m o g lo b in s , 2 05 , 2057 c a rb o x y h e m o g lo b in , 2 06 , 2 0 6 1 h e m o g lo b in C, 2 04 , 2047 h e m o g lo b in C & G , 2 04 h e m o g lo b in c o n s ta n t s p rin g , 2 0 5 h e m o g lo b in E, 2 04 h e m o g lo b in L e p o re , 2 0 4 -2 0 5 h e m o g lo b in S, 2 0 2 -2 0 4 , 203/7 m e th e m o g lo b in , 2 0 5 -2 0 6 s u lfh e m o g lo b in , 2 0 6 u n s ta b le h e m o g lo b in s , 2 05 th a la s s e m ia , 2 0 6 -2 0 8 , 2 0 6 / a th a la s s e m ia s y n d ro m e s , 2 03 , 2 0 7 (3 th a la s s e m ia s y n d ro m e s , 2 03 , 2 0 7 h e m o g lo b in A 2 p rim e , 2 08 h e re d ita ry p e rs is te n c e o f fe ta l h e m o g lo b in , 2 08 im m u n e h e m o ly tic d is o rd e rs , 2 0 8 -2 1 0 , 2087, 209/7, 210/, 211/7 H e m a to p o ie s is in tra s in u s o id a l, 2 66 s ite s of, 2 6 5

d e te c tio n o f n o rm a l a n d v a ria n t h e m o g lo b in s , 259/, 2 5 9 -2 6 1 , 2 60 /, 261 f, 2 6 2 /

H e m a tu ria , 4 0, 41

h is to c h e m is try a n d c y to c h e m is try , 2 6 1 , 2 6 1 1

H e m e s y n th e s is , 22

im m u n o p h e n o ty p in g , 2 6 1 -2 6 4

H e m o c h ro m a to s is , 38, 57

le u k o c y te in d ic e s , 2 5 8 -2 5 9 , 2597

H e m o g lo b in , 4 1, 2 58

p la te le t in d ic e s , 2 5 9

H e m o g lo b in A 2 p rim e , 208

red b lo o d ce ll in d ic e s , 2 5 8 , 258/7

H e m o g lo b in C, 2 04 , 2047 H e m o g lo b in C & G , 2 04 H e m o g lo b in c o n s ta n t s p rin g , 2 05 H e m o g lo b in E, 2 0 4 H e m o g lo b in e le c tro p h o re s is , 2 5 9 -2 6 0 , 2 6 0 / H e m o g lo b in F, d e te c tio n of, 2 59 H e m o g lo b in L ep o re , 2 0 4 -2 0 5 H e m o g lo b in o x y g e n s a tu ra tio n , 261 H e m o g lo b in S, 2 0 2 -2 0 4 , 203/7 ra p id d e te c tio n of, 2 5 9 H e m o g lo b in S C d is e a s e , 2047

430

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

Index

Hemoglobin— Homocystinuria h e p a to c e llu la r c a rc in o m a , 3 6 3

H e m o g lo b in s o lu b ility te st, 2 5 9 H e m o g lo b in u ria , 4 0, 41

H e p a to c e llu la r c a rc in o m a , 363

H e m o ly s is , 3, 63

H e p a to le n tic u la r d e g e n e ra tio n , 3 4 7 , 3 4 7 /

in tra v a s c u la r, 2 18 v e rs u s e x tra v a s c u la r, 2 1 9 /

H e p a to s p le n ic T ce ll ly m p h o m a , 2 4 2

s c re e n in g te s ts fo r, 217, 2 1 9 /

H e p c id in , 346

H e p a to s p le n o m e g a ly , 11

H e m o ly tic d is e a s e o f fe tu s a n d n e w b o rn , 5, 7 3 -7 4 , 7 3 /

H e p e v irid a e , 113

H e m o p h a g o c y to s is , 2 42

H E R 2 , 3 6 4 -3 6 6

H e m o p h ilia A, 2 79 , 2 8 3 -2 8 4

H e re d ita ry a n g io e d e m a , 306

H e m o p h ilia B, 2 79 , 284

H e re d ita ry e llip to c y to s is , 200

H e m o rrh a g ic cystitis, 96

H e re d ita ry h e m o c h ro m a to s is , 3 4 6 -3 4 7 , 3 4 7 /

H e m o rrh a g ic d is e a s e o f th e n e w b o rn , 2 84

H e re d ita ry h e m o rrh a g ic te la n g ie c ta s ia , 2 7 4 , 2 7 8 , 344

H e m o sid e rin la d e n m a c ro p h a g e s , 44

H e re d ita ry h y p o p a ra th y ro id is m , 13

H e m o sta s is , 2 7 4 -2 7 5 , 2 74 f, 2 7 5 ft

H e re d ita ry m e th e m o g lo b in e m ia , 2 0 5

fib rin o ly s is , 2 75

H e re d ita ry o v a lo c y to s is , 200

la b o ra to ry e v a lu a tio n of, 2 7 5 -2 7 8 , 2 7 6 f, 2 7 7 ft

H e re d ita ry p e rs is te n c e o f fe ta l h e m o g lo b in , 2 0 8

p la s m a c o a g u la tio n in, 2 74 , 2 7 4 ft

H e re d ita ry p y ro p o ik ilo c y to s is , 2 0 0

p la te le t a c tiva tio n in, 2 74 , 3 7 4 f

H e re d ita ry s p h e ro c y to s is , 200, 2 0 0 /

p rim a ry, 2 74

H e re d ita ry s to m a to c y to s is , 200, 2 01 /, 2 0 3

H e n d e rs o n -H a s s e lb a lc h e q u a tio n , 14

H e rm a n s k y -P u d la k s y n d ro m e , 2 8 0

H e n o c h -S c h o n le in p u rp u ra , 315, 3 16

H e rp e s s im p le x v iru s , 105-106

H e p arin

H e rp e s v irid a e , 105 -10 6 , 106/

lo w m o le c u la r w e ig h t, 2 89

H e rre d ity o v a lo c y to s is , 2 0 0

u n fra c tio n e d , 2 8 8 -2 8 9

H e te ro c h ro m a tin , 321

H e p a rin a ssay, 2 77

H e te ro p la s m y , 3 2 0

H e p a rin in d u ce d th ro m b o c y to p e n ia , 2 8 7 -2 8 8

H e tro p h ile a n tib o d y in te rfe re n c e , 4 0 5

H e p a tic d is e a s e , 19

H (F U T 1 ) g e n e , 81

H e p a tic e n z y m e s , 2

H ig h -d e n s ity lip o p ro te in , 24, 26

H e p a tic fa ilu re , d e c re a s e d c e ru lo p la s m in in, 7, 7 1 H e p a tic ve in th ro m b o s is , 283

H igh g ra d e B cell ly m p h o m a w ith M Y C a n d B C L 2 a n d /o r B C L 6 re a rra n g e m e n ts , 235

H e p a tic v e n o -o c c lu s iv e d is e a s e , 46

H igh p re s s u re liquid c h ro m a to g ra p h y , 2 6 0

H e p a tic y -g lu ta m y l tra n s fe ra s e , 3

H irs c h s p ru n g d is e a s e , 3 4 3 -3 4 4

H e p a titis

H is tio cy to s is X, 38

a u to im m u n e , 312

H is to n e a c e tyla tio n , 322

c h ro n ic h e p a titis C v iru s , 2

H is to p la s m a , 122/, 122/, 1 33 -13 4 , 134/, 1 35 /

tra n s fu s io n a s s o c ia te d g ra ft vs h o s t d is e a s e and, 90

H is to p la s m a c a p s u la tu m , 1 33 -13 4 , 1 3 4 /

H e p a titis A viru s, 92, 112

H L A te s tin g , 3 0 1 -3 0 2

H e p a titis B viru s, 92, 1 04 -10 5 , 307

H o d g e te st, 165, 165/

H e p a titis C v iru s , 92, 111, 1 1 1 1

H o d g kin ly m p h o m a , 2 2 1 ,2 4 3 -2 4 5

H e p a titis D v iru s , 116

c la s s ic , 2 4 3 -2 4 5 , 2 45 //, 2 4 6 /

H e p a titis E viru s, 92, 113

n o d u la r ly m p h o c y te p re d o m in a n t H o d g k in ly m p h o m a , 2 4 3 , 243/, 2 4 4 /

H e p a titis G viru s, 111 H e p a to b ilia ry tu m o rs . S ee a ls o G a s tro in te s tin a l, h e p a to b ilia ry and p a n c re a tic d is e a s e c h o la n g io c a rc in o m a , 3 64 © A S C P 2018

H o ffa u e r ce lls, 2 98 H o lt-O ra m s y n d ro m e , 340 H o m o cy s tin u ria , 2 86

ISBN 9 7 8 -0 8 9 1 8 9 -6 6 7 8

431

Index

Homocystinuria— Hypoxanthine H o m o p la s m y , 3 2 0

H y p e rco rtis o l ism , 36 b io c h e m ic a l e ffe c ts of, 36

H o o k e ffe c t, 28 H P V in fe c tio n , 3 7 6 -3 7 7

H y p e rg ly c e m ia , 12

H T L A a n tib o d ie s , 63

H y p e rh e m o ly tic crisis, 2 02

H T L V : h u m a n T ly m p h o tro p ic v iru s , 113

H y p e rh o m o c y s te in e m ia , 2 8 6

H T L V l/ll, 113

H y p e r IgE s y n d ro m e , 304, 3 0 4 /

H u m a n a n tis e ra , 301

H y p e rk a le m ia , 12-13, 93

H u m a n c h o rio n ic g o n a d o tro p in , 17, 31

H y p e rn a tre m ia , 12

H u m a n h e rp e s v iru s 6, 99, 108

H y p e ro s m o la r h y p e rg ly c e m ia sta te , 28

H u m a n h e rp e s v iru s 8, 108/, 1 0 8 -1 0 9

H y p e rp a ra th y ro id is m

H u m a n im m u n o d e fic ie n c y v iru s , 6, 9 2, 1 1 2 -1 1 3 , 1 1 3 /

p rim a ry, 13

H u m a n ita ria n u s e d e v ic e s , 3 9 8

s e c o n d a ry , 13

H u m a n le u k o c y te a n tig e n s , 8 7 -8 8 , 2 9 9

te rtia ry , 13

H u m a n m e ta p n e u m o v iru s , 115

H y p e rp ro la c tin e m ia , 39

H u m a n p a p illo m a v iru s , 109

H y p e rre n in is m , 12

H u m a n p o ly o m a v iru s , 1 0 9 -1 1 0

H y p e rth e rm ia , m a lig n a n t, 354

H u n tin g to n d is e a s e , 3 3 3 , 351

H y p e rth y ro id is m , 3 3 -3 4

H y a lin e c a s ts , 4 3

H y p e rtrig ly c e rid e m ia , p re d o m in a n t, 25

H y a lin e m o ld s , 1 4 0 -1 4 3

H y p e rtro p h ic c a rd io m y o p a th y , 3 39

A s p e rg illu s , 1 4 0 -1 4 4 , 141/, 142/, 143/, 1 4 4 /

H y p e rv e n tila tio n , 5 8 1

F u s a riu m , 142, 1 4 3 /

H y p e rv ita m in o s is D, 13

S c e d o s p o riu m a p io s p e rm u m /P s e u d a lle s c h e ria b o y d ii, 143

H y p o c a lc e m ia , 13, 14f, 93

H y b rid c a p tu re , 3 3 1 -3 3 2

H y p o c h ro m ia , 217

H y b rid iz a tio n te c h n iq u e s

H y p o fib rin o g e n e m ia , 284

a lle le s p e c ific o lig o n u c le o tid e p ro b e s , 3 2 9

H y p o g ly c e m ia , 27, 2 7 f

c o m p a ra tiv e g e n o m ic h y b rid iz a tio n , 3 2 8

H y p o g ly c o rrh a c h ia , 44

D N A m ic ro a rra y s a n d g e n e e x p re s s io n p ro filin g , 3 2 9

H y p o k a le m ia , 12, 93, 3 36

flu o re s c e n c e in situ h y b rid iz a tio n , 3 2 7 -3 2 8 , 3 2 8 /

H y p o m a g n e s e m ia , 13

s p e c tra l k a ry o ty p e im a g in g , 3 28

H y p o n a tre m ia , 11-12

H y d ra lin iz in g s p in d le tu m o r w ith g ia n t ro s e tte s , 3 7 0 , 3 7 1 / H y d ra q la z in e , 3 0 7

s p u rio u s , 11 H y p o p a ra th y ro id is m

5 -H y d ro x y try p to p h a n , 31

h e re d ita ry , 13

H y m e n o le p is n a n a , 124, 1 2 4 /

p rim a ry, 13

H y p e ra c u te re je c tio n , 3 0 2

H y p o p h o s p h a ta s ia , 3

H y p e ra m m o n e m ia , 3

H y p o p itu ita ris m , 34

c a u s e s of, 3 1

H y p o th a la m ic g o n a d o tro p in -re le a s in g h o rm o n e , 39

H y p e rb iliru b in e m ia

H y p o th e rm ia , 93

c o n ju g a te d , 3, 4, 4 1

H y p o th y ro id is m , 19, 34

d iffe re n tia l d ia g n o s is o f c o n ju g a te d , 4 1

n e o n a ta l, 34

p a th o p h y s io lo g ic d iffe re n tia l d ia g n o s is of, At

s u b c lin ic a l, 34

H y p e rc a lc e m ia , 13, 1 3 f d iffe re n tia l d ia g n o s is of, 1 3 f

H y p o v o le m a , 5 8 1 H y p o x a n th in e g u a n in e p h o s p h o rib o s y l tra n s fe ra s e , 333

H y p e rc h o le s te ro le m ia m ix e d h y p e rtrig ly c e rid e m ia a n d , 26 p re d o m in a n t, 25

432

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

Index

I— Immunology

/

m ic ro s c o p ic p o ly a n g iitis , 3 1 3 m y a s th e n ia g ra v is , 315, 3 1 5 f

Ia tro g e n ic C u s h in g s y n d ro m e , 36

p o ly a rtritis n o d o s a , 313, 3 1 3 /

Id io p a th ic h y p e rtro p ic s u b a c u te s te n o s is , 339

p rim a ry b ilia ry c irrh o sis , 3 1 2

Id io p a th ic th ro m b o c y to p e n ic p u rp u ra , 19

p rim a ry s c le ro s in g c h o la n g itis , 3 1 2

Id io to p e , 2 96

p ro g re s s iv e s y s te m ic s c le ro s is , 3 1 1 -3 1 2

IgA, 2 97 , 2 9 7 f

rh e u m a to id a rth ritis , 3 10 -31 1

d e fic ie n c y of, 300, 311

s e ro n e g a tiv e s p o n d y lo a rrth ro p a th ie s , 311

IgD , 2 97 , 2 9 7 1

S jo g re n s y n d ro m e , 312

IgE, 2 97 , 2 9 7 f

s y s te m ic lu p u s e ry th e m a to s u s , 3 0 9 -3 1 0 , 3 1 1 f

igG , 2 97 , 2 9 7 1

T a k a y a s u a rte ritis , 314

lg G 4 re la te d s c le ro s in g d is e a s e , 312, 3 12 /

v a s c u litis , 3 12 , 3 1 3 f

IgM , 2 97 , 2 9 7 f

W e g e n e r g ra n u lo m a to s is , 3 13

Ig v a s cu littis, 3 15

a u to im m u n ity a n d rh e u m a to lo g ic d is e a s e , 3 0 6 -3 1 6 a n tib o d ie s to c y to p la s m ic c o n s titu e n ts , 3 0 9 , 3 0 9 f

Im m u n e h e m o ly ic d is o rd e rs cold a u to a g g lu tin in s , 2 0 8 -2 0 9 , 2 0 8 f, 2 0 9 /

a n ti-$ 2 a n tib o d ie s , 3 0 7 -3 0 9 , 3 0 7 f, 3 0 8 /f

c ry o g lo b u lin e m ia , 2 0 9 -2 1 0 , 2 10 /

a u to a n tib o d y d e te c tio n b y im m u n o flu o re s c e n c e , 3 0 7

p a ro x y s m a l c o ld h e m o g lo o b in u ria , 2 09 , 2 0 9 it

a u to im m u n e d is e a s e s in w o m e n o f re p ro d u c tiv e a ge , 306

p a ro x y s m a l n o c tu rn a l h e m o g lo b in u ria , 2 10 , 211 f

la b o ra to ry te s tin g in, 307

w a rm a u to im m u n e h e m o ly tic a n e m ia , 2 08 im m u n e h e m o ly s is , 316 Im m u n e h e m o ly tic d is o rd e rs , 2 0 8 -2 1 0 , 2 0 8 f, 209/f, 210/, 21 I f f Im m u n e th ro m b o c y to p e n ia , 222

p a th o p h y s io lo g y , 3 0 6 -3 0 9 , 3 0 6 f, 307/'. 308/, 3 0 7 f, 3 0 8 f, 309f te s ts fo r a u to im m u n e d is e a s e s , 309 trig g e rin g a g e n ts in, 307

Im m u n e th ro m b o c y to p e n ic p u rp o s a (U P ), 221

e v a lu a tio n o f im m u n e fu n c tio n , 3 0 0 -3 0 3 g lo b a l te s ts , 3 00

Im m u n o a ss a y , 20 Im m u n o d e fic ie n c y , in fe c tio u s d ia rrh e a in, 97

H L A te s tin g , 3 0 1 -3 0 3

Im m u n o d e fic ie n c y a s s o c ia te d B u rk itt ly m p h o m a , 2 36

s c re e n in g te s ts , 3 00

Im m u n o d e fic ie n c y a s s o c ia te d ly m p h o p ro life ra tiv e d is o rd e rs , 2 35

s p e c ific te s tin g o f B cell fu n c tio n , 3 0 0

Im m u n o fix a tio n and im m u n o ty p in g , 11, 11 f

te s tin g c o m p le m e n t, 301

Im m u n o flu o re s c e n c e , a u to a n tib o d y d e te c tio n by, 3 07

te s tin g n e u tro p h il fu n c tio n , 3 0 0 -30 1

Im m u n o g lo b u lin , 2 96

te s tin g N K cell fu n c tio n , 3 0 0

Im m u n o lo g y , 2 9 4 -3 1 6 a u to im m u n e d is e a s e s , 3 0 9 -3 1 6 , 31 Of a u to im m u n e h e p a titis, 312

s p e c ific te s tin g o f T cell fu n c tio n , 3 00

h y p e rs e n s itiv ity re a ctio n s, 3 16 im m u n e s y s te m in, 2 9 6 -2 9 9 a n tig e n p re s e n tin g ce lls in, 2 9 8

B e hg e t d is e a s e , 314

B c e lls in, 2 9 6 -2 9 7 , 2 9 6 ff

B u e rg e r d is e a s e , 3 14

c o m p le m e n t in, 2 9 8 -2 9 9 , 2 9 8 f

c e lia c d is e a s e , 311

g ra n u lo c y te s in, 298

C h u rg -S tra u s s s y n d ro m e , 3 13

h u m a n le u k o c y te a n tig e n s in, 2 9 9

fa m ilia l M e d ite rra n e a n fe ve r, 3 1 5 -3 1 6

N K c e lls in, 2 9 7

g ia n t cell a rte ritis, 3 14 , 315/

T c e lls in, 2 9 6 ft, 2 97

lg G 4 re la te d s c le ro s in g d is e a s e , 312, 3 12 / Ig v a s cu littis, 315

p rim a ry im m u n o d e fic ie n c y d is o rd e rs , 3 0 3 -3 0 6 B cell d e fe c ts, 3 0 3 -3 0 4 , 3 0 4 f

in fla m m a to ry m y o p a th ie s , 3 15

c o m p le m e n t d e fic ie n c ie s , 3 0 6

K a w a s a k i d is e a s e , 3 1 4 -3 1 5

n e u tro p h il/p h a g o c y tic d e fe cts, 3 0 5 -3 0 6 T ce ll d e fe c ts, 3 0 4 -3 0 5

© A S C P 2018

ISBN 9 7 8 -0 8 9 1 8 9 -6 6 7 8

433

Index

Immunophenotypic—Klebsiella Im m u n o p h e n o ty p ic e v o lu tio n in h e m a to ly m p h o id cell, 2 6 3 -2 6 4

Is o n ia z id , 307

Im m u n o p h e n o ty p in g , 2 6 1 -2 6 4

Is o p ro p y l a lco ho l (is o p ro p a n o l), 22

Im p a ire d g lu c o s e to le ra n c e , 27

Itra c o n a z o le , 146

In c lu s io n b o d y m y o s itis , 3 1 5 , 3 5 4 In c re a s e d fa s tin g g lu c o s e , 2 7

J

In d ire c t im m u n o flu o re s c e n c e , 3 0 7

Ja ffe re a ctio n , 15

In fe c tio u s d ia rrh e a , 9 6 -9 7 , 9 6 1

J A K 2 m u ta tio n , 2 50 , 2 8 6 -2 8 7

In fe c tio u s d is e a s e s c re e n in g , 59, 5 9 / In fe c tio u s m o n o n u c le o s is , 107

J a k /S ta t p a th w a y, 321

In fe c tiv e e n d o c a rd itis , 9 7 -9 8

J a n u s k in a s e (Ja k) re ce p to r, 321

In fla m m a to ry b o w e l d is e a s e , 9 7, 221

J a ris c h -H e rx h e im e r re a c tio n , 181

In fla m m a to ry d ia rrh e a , 96

J a u n d ic e , 2 0 0 n e o n a ta l, 2 00

In fla m m a to ry m y o p a th ie s , 3 1 5

JC v iru s , 109

In fo rm a tio n s y s te m s , 4 0 6

J e rv e ll L a n g e -N ie ls e n s y n d ro m e , 338, 3 55

In h e rita n c e , p a tte rn s of, 3 2 5 In h e rite d c o m b in e d fa c to r d e fic ie n c y , 2 8 4 In h e rite d fa c to r d e fic ie n c ie s , 2 8 3 -2 8 4 In h e rite d g y n e c o lo g ic tu m o r s y n d ro m e , 3 7 6 In h e rite d n e p h ritic s y n d ro m e , 3 3 4 -3 3 5 , 3 3 5 / In h e rite d p a n c re a titis , 3 4 8 -3 5 0 , 3 4 9 it

Jo b sy n d ro m e , 3 0 4 , 3 0 4 / J o h a n s o n -B liz z a rd s y n d ro m e s , 3 50 , 3 5 0 / J o n e s criteria, 1 5 3 / J o rd a n a n o m a ly , 306 J u v e n ile m y e lo m o n o c y tic le u k e m ia , 2 4 8 J u v e n ile n e p h ro n o p h th is is , 337

In h e rite d p la te le t d is o rd e rs , 2 8 0 In h e rite d tu b u la r d is o rd e rs , 3 3 5 -3 3 6 , 3 3 6 f

J u v e n ile p o ly p o s is , 361

In s e rtio n m u ta tio n , 3 2 4 In s u lin , 2 6

K

In s u lin to le ra n c e te s t, 35

K a llm a n n s y n d ro m e , 3 42 , 3 5 6 f

In ta c t v irio n , 104

K a n tig e n , 86

In te rfe ro n y re le a s e a s s a y s , 189

K a p o s i sa rc o m a , 108, 108/

In te rle u k in 5, 221 In te rn a tio n a l C o d in g o f D is e a s e s y s te m , 399 In te s tin a l a tre s ia , 3 4 4

K a w a s a k i d is e a s e , 3 1 4 -3 1 5 K a y s e r-F le is c h e r rings, 3 47

In te s tin a l o b s tru c tio n , 5

K e a rn s -S a y re s y n d ro m e , 3 55

In tra c ra n ia l in s u lts , 6 In tra h e p a tic c h o le s ta s is o f p re g n a n c y , 19 In tra s in u s o id a l h e m a to p o ie s is , 2 6 6

K ell a n tib o d ie s , 87 K ell a n tig e n s , 8 6 -8 7 , 8 6 f K ell null p h e n o ty p e , 86

In tra v a s c u la r h e m o ly s is , 2 1 8 in tra v a s c u la r la rg e B ce ll ly m p h o m a , 2 3 4 , 2 3 5 / In v itro h a ir p e rfo ra tio n te s t, 137

K e to ne s, 41 in d ia b e tic k e to a c id o s is , 28 K id d a n tib o d ie s, 85

Iron a b s o rp tio n , 3 4 6 Iro n d e fic ie n c y , 2 1 0 , 2 1 2 -2 1 3 , 2 1 2 f, 2 1 3 / Iro n o v e rlo a d , 93

K idd a ntig e n, 85, 8 5 / K id d blood g ro u p s y s te m , 85, 8 5 / K id n e y s to n e s, 42

Irra d ia te d p ro d u c ts , 7 9 -8 0

K in g e lla k in g a e , 174

Irra d ia te d red b lo o d ce ll, 7 5 /

K le b s ie lla g ra n u lo m a tis , 167

Irra d ia tio n , 38 Is o la te d g ro w th h o rm o n e d e fic ie n c y , 3 42

434

K a ry o g ra m s , 326, 3 2 6 f

K le b s ie lla p n e u m o n ia e , 98, 1 66 -16 8 , 168/ K le b s ie lla rh in o s c le ro m a tis , 167, 1 66 /

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

Index

Kligler— Liver K lig le r iron a ga r, 1 66 -16 7 , 1 6 6 f

L e g io n e lla p n e u m o p h ila , 150, 174

K o stm a n n sy n d ro m e , 2 16 , 3 1 6 f

L e ig h s y n d ro m e , 3 56

K R A S m u ta tio n s , 376

L e is h m a n ia , 122/, 1 22 -12 3 , 122f, 1 2 3 /

K u p p fe r ce lls, 2 98

L e p ro m a to u s le p ro s y , 192

K uru, 116, 352

L e p ro s y , 192 le p ro m a to u s , 192 tu b e rc u lo id , 192

L

L e p to s p ira , 1 8 1 -1 8 2

L a b o ra to ry d e v e lo p e d te s ts , 398

L e u k o c y te a lk a lin e p h o s p h a ta s e s c o re , 261

L a b o ra to ry e v a lu a tio n

L e u k o c y te d iffe re n tia l, 259

o f c o a g u la tio n , 2 7 6 -2 7 8 , 2 7 7 ft

L e u k o c y te e s te ra s e , 42

o f d o n o r b lo o d, 5 8-5 9 A B O a nd Rh te s tin g , 5 8 -5 9 , 5 8 1

L e u k o c y te in d ice s , 2 5 8 , 2 5 8 f L e u k o c y to c la s tic v a s cu litis , 11

a n tib o d y scre e n , 59

L e u k o re d u c e d p la te le ts , 76

in fe c tio u s d is e a s e s c re e n in g , 59, 5 9 f

L e u k o re d u c e d p ro d u c ts , 80

o f h e m o s ta s is , 2 7 5 -2 7 8 , 2 7 6 ft 2 7 7 ft

L e w e y -J e n n in g s c h a rts , 4 08

o f vo n W ille b ra n d ’s d is e a s e , 2 82 , 2 8 2 ft

L e w is a n tib o d ie s , 82

L a b o ra to ry m e d ic in e

L e w is p h e n o ty p e s , 82, 8 2 1

e d u c a tio n o f staff, 4 0 7 , 4 0 8 f

L e w y b o d y d is e a s e , 351

fin a n c ia l c o n s id e ra tio n s in, 4 0 1 ,4 0 1 ft im p le m e n ta tio n o f n e w m e th o d s, 4 0 4 -4 0 7 , 4 0 4 ft 4 0 5 ft 4 0 6 ft 407f

L h e rm itte -D u c lo s lesion , 3 78 / L ice, 1 0 2 f L ic o ric e c o n s u m p tio n , 12

n o n a n a ly tic v a ria b le s in p o s ta n a ly tic v a ria b le s , 4 1 2

L id d le s y n d ro m e , 12

p re a n a ly tic v a ria b le s , 4 1 1 -4 1 2 , 4 1 1 ft 4 1 2 f

L i-F ra u m e n i s y n d ro m e , 366, 3 74 , 3 7 5 , 3 7 8 -3 7 9

p ro c e d u re s in, 4 0 7

L ig a se , 320

e le m e n ts of, 4 0 7 , 4 0 7 f

L ig a tio n a m p lific a tio n , 331

q u a lity m a n a g e m e n t in, 4 0 7 -4 1 0 , 4 0 8 ft 4 0 9 ft

L ig h t c h a in s , 2 9 6

s ta tis tic a l c o n s id e ra tio n s in, 402/, 4 0 2 -4 0 4 , 403ft

L im b -g ird le m u s c u la d y s tro p h ie s , 3 5 4

L a b o ra to ry te s t p a n e ls, 3 9 9 -4 0 0

L im it o f b la n k, 4 0 6

L a c a z ia lob o i, 140

L im it o f d e te c tio n , 4 0 6

L a c ta te d e h y d ro g e n a s e , 2, 2 00

L im it o f q u a n tific a tio n , 4 0 6

L a c to b a c illu s , 179

L in e a r re g re s s io n a n a lys is , 4 05

L a c to s e n e g a tive E n te ro b a c te ria c e a e , 1 67 -16 9

L ip a se , 5

L a c to s e p o sitive E n te ro b a c te ria c e a e , 1 65 -16 7 , 166/

L ip ids, 2 4 -2 6

L A M B sy n d ro m e , 380

b rie f re v ie w of, 24, 2 5 1

L a n g e rh a n s cell h is tio c y to s is , 366

d is o rd e rs , 2 5 -2 6 , 2 5 1

L a n g e rh a n s ce lls, 298

m e th o d s , 2 4 -2 5

L a rg e B cell ly m p h o m a w ith IR F 4 re a rra n g e m e n t, 231

L iq u id c h ro m a to g ra p h y /m a s s s p e c tro m e try , 20

L ea d p o iso n in g , 22

L is te ria m o n o c y to g e n e s , 160/, 160-161

Lead tim e, 28

L is te rio ly s in O, 160

L ecith in , 18

L iver, 2-5

L e c ith in :s p h in g o m y e lin (L :S ) ratio, 18 Le (F U T 3 ) g e n e , 82 © A S C P 2018

n e o n a ta l ja u n d ic e a nd , 4 -5, 4 f L iv e r d is e a s e , 2 84 ISBN 9 7 8 -0 8 9 1 8 9 -6 6 7 8

435

Index

Liver— Marrow L y m p h o m a to id g ra n u lo m a to s is , 2 35 , 2 35 /

L iv e r fu n c tio n te s ts 5 ’ n u c le o tid a s e , 3

L y m p h o p e n ia , 221

a lk a lin e p h o s p h a ta s e , 2 -3 , 2 t

a b s o lu te , 3 00

a m m o n ia , 3

L y m p h o p la s m a c y tic ly m p h o m a , 9, 231

a s p a rta te a m in o tra n s fe ra s e a n d a la n in e a m in o tra n s fe ra s e , 2

L y n c h sy n d ro m e , 3 33 , 3 59 , 376

b iliru b in , 3 -4 , 4 f la c ta te d e h y d ro g e n a s e , 2

M

p ro th ro m b in tim e , 4

M a c ro a m y la s e m ia , 5

y -g lu ta m y l tra n s fe ra s e , 3

M a c ro C K , 6

L o a lo a , 127

a 2 -M a c ro g lo b u lin , 7, 7 f

L o b o m y c o s is , 140

M a d u ra foot, 138

L o e ffle r s y n d ro m e , 221

M a d u re lla g rise a , 138

L o m e n to s p o ra p ro lific a n s , 140, 140/

M a d u re lla m y c e to m a tis , 138

L o n g Q T s y n d ro m e , 3 3 8 -3 3 9 , 3 3 9 1

M a jo r s e ru m p ro te in s , 6 -8, I t

L o o p m e d ia te d is o th e rm a l a m p lific a tio n , 3 2 9

a lb u m in , 6-8, 7 1

L o u is -B a r s y n d ro m e , 3 0 5

a 1 -a n titry p s in , 7, 7 1

L o w -d e n s ity lip o p ro te in (L D L ), 2 4

c e ru lo p la s m in , 7, I t

L o w g ra d e fib ro m y x o id s a rc o m a , 3 7 0 , 3 7 1 /

C -re a c tiv e p ro te in , I t , 8

L o w m o le c u la r w e ig h t h e p a rin , 2 8 9

fib rin o g e n , I t , 8

L -p h e n y la la n in e , 2, 2 1

h a p to g lo b in , 7-8, 7 f

L u m in e x te c h n o lo g y , 3 0 2

a 2 -m a c ro g lo b u lin , 7, I t

L u p u s e ry th e m a o s u s c e lls , 3 0 7

p re a lb u m in , 7, 7 1

L u te in iz in g h o rm o n e , 39

tra n s fe rrin , I t , 8

L u te in iz in g h o rm o n e re le a s in g h o rm o n e , 39

M a la s s e z ia , 133

L u th e ra n a n tib o d ie s , 87

M A L D I-T O F M S , 150

L u th e ra n a n tig e n s , 87

M a lig n a n t h y p rth e rm ia , 354

L y m e d is e a s e , 6, 182

M a ln u tritio n , 3 d e c re a s e d c e ru lo p la s m in in, 7, 7 1

L y m p h a d e n o p a th y , 11 L y m p h a n g io m y o m a to s is , 3 66

M A L T ly m p h o m a , 228

L y m p h a tic fila ria s is , 127

M a n n a n b in d in g lectin p a th w a y , 299

Lym ph nodes, 300

M a n n o s e b in d in g lectin , 2 99

L y m p h o b la s tic ly m p h o m a , 2 3 7 , 2 3 7 f, 2 3 8 1

M a n tle cell ly m p h o m a , 225/, 2 2 5 -2 2 6

L y m p h o c y tic c h o rio m e n in g itis v iru s , 115

M a rg a n s y n d ro m e , 3 66

L y m p h o c y tic p le u ra l e ffu s io n s , 4 5

M a rg in a l z o n e le u k e m ia , 227/, 2 2 8 -2 3 0 , 2 2 8 it

L y m p h o c y to s is , 2 2 4

M a rk e rs o f n e u ro e n d o c rin e tu m o rs , 3 1-3 2

a b s o lu te , in a d u lts o v e r 4 0 y e a rs , 2 2 0 c a u s e s of, 2 2 0

M a rro w p ro d u c tio n d is o rd e rs , 2 1 0 -2 2 3 a n e m ia o f c h ro n ic d is e a s e , 2 1 3 -2 1 4 , 2 1 3 f

m o le c u la r e x a m in a tio n of, 2 6 4

a p la s tic a n e m ia , 2 1 6 -2 1 7 , 2 16 f, 2 1 7 1

p o ly c lo n a l B, 2 2 0

a u to im m u n e n e u tro p e n ia , 216

re a c tiv e , in c h ild re n , 2 2 0

co n g e n ita l a m e g a k a ry o c y tic th ro m b o c y to p e n ia , 2 15

tra n s ie n t s tre s s , 2 2 0

co n g e n ita l n e u tro p e n ia a nd c y lic n e u tro p e n ia , 2 16 , 2 1 6 1

L y m p h o g ra n u lo m a v e n e re u m , 184 L y m p h o id n e o p la s m s , 2 5 1 -2 5 2 , 2 5 3 1 c lo n a lity a s s e s s m e n t in, 3 3 3

436

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© A S C P 2018

Index

Marrow— Melanoma im p le m e n ta tio n o f n e w m e th o d s , 4 0 4 -4 0 7 , 4 0 4 f, 4057, 4067 a c c u ra c y a nd , 4 0 5 , 4057

d ia g n o s is o f q u a n tita tiv e a b n o rm a litie s , 2 1 7 -2 2 3 a n e m ia , 2 1 7 -2 1 9 , 2 1 7 ft, 2187, 219/7 ly m p h o c y to s is , 2 20 , 2 2 2 /

a n a ly tic a l s e n s itiv ity and, 4 0 6

ly m p h o p e n ia , 221

a n a ly tic s p e c ific ity and, 4 0 5 -4 0 6 , 4067

m o n o c y to p e n ia , 221

c a lib ra tio n a nd c a lib ra tio n v e rific a tio n , 4 0 5

m o n o c y to s is , 221

e d u c a tio n o f s ta ff in, 4 0 7 , 4087

n e u tro p e n ia , 221

in fo rm a tio n s y s te m s and, 4 0 6

n e u tro p h ilia , 2 2 0

p re c is io n a nd q u a lity c o n tro l in, 4 0 5

th ro m b o c y to p e n ia , 2 2 1 -2 2 3 , 2 2 2 it, 2237

s p e c im e n s ta b ility , 4 06 w ritte n p ro c e d u re s in, 4 0 7

d y s k e ra to s is co n g e n ita , 2 15

le g isla tio n a nd re g u la tio n of, 3 9 6 -4 0 0 , 3 9 7 ft b illin g a nd re im b u rs e m e n t a n d , 3 9 9 -4 0 0

F a n co n i a n e m ia , 2 1 4 -2 1 5 fo la te a nd v ita m in B 12, 2 1 2 -2 1 3 , 2 1 2f, 2 13 /

C lin ic a l L a b o ra to ry Im p ro v e m e n t A m e n d m e n t, 3 9 6 -3 9 8 , 3977, 4 0 4

iron d e fic ie n c y , 2 10 , 2 1 2 -2 1 3 , 2 1 2 f m y e lo k a th e x is , 2 16

d ire c t b illin g la w in, 400

p u re red cell a p la sia , 2 1 5

M e d ic a id , 399

S h w a c h m a n -D ia m o n d sy n d ro m e , 216

m e d ic a l d e v ic e s and b io lo g ie s a n d , 3 9 8 -3 9 9

s id e ro b la s tic a n e m ia , 2 14 , 2 1 4 / th ro m b o c y to p e n ia w ith a b s e n t radii sy n d ro m e , 215

M e d ic a re , 399

M a s s iv e tra n s fu s io n , 70

O c c u p a tio n a l S a fe ty and H e a lth A d m in is tra tio n A c t a nd , 400

M a s t cell n e o p la s m s , 2 57

p riv a c y a nd , 4 0 0

M a s t ce lls, 2 98

S ta rk la w a nd , 4 0 0

M a te rn a l im m u n e th ro m b o c y to p e n ic p u rp u ra , 72

n o n a n a ly tic v a ria b le s in p o s ta n a ly tic , 4 1 2

M a te rn a l in h e rita n c e , 321

p re a n a ly tic , 4 1 1 -4 1 2 , 4117, 4127

M a trix a s s o c ia te d la s e r d e s o rp tio n io n iza tio n tim e o f flig h t m a s s s p e c tro m e try , 150

p ro fic ie n c y te s tin g and, 4 10 , 4117

M a tu re B ce lls, 2 96

q u a lific a tio n s o f d ire c to r, 3 9 6

M a tu rity o n s e t d ia b e te s o f th e y o u n g , 343

q u a lity m a n a g e m e n t and, 4 0 7 -4 1 0 , 4097

M a x im u m d ilu tio n /c o n c e n tra tio n , 4 0 6

re s p o n s ib ilitie s o f d ire cto r, 3 96 , 4 0 4 , 4047

M a y -H e g g lin a n o m a ly , 2 21 , 2 22 , 2227, 2 80 , 306, 3 0 6 /

s ta tis tic a l c o n s id e ra tio n s in th e la b o ra to ry , 4 02 /, 4 0 2 -4 0 4 re fe re n c e in te rv a ls and, 4 0 3 -4 0 4

M c C u n e -A lb rig h t sy n d ro m e , 342

M e d ic a re , 3 99

M cL e o d p h e n o ty p e , 86, 86f, 87 M e a sle s, 114

P a rt A, 3 99

M e c h a n is m s o f d ru g in d u ce d p o sitive , 68

P a rt B, 3 99

M e c k e l-G ru b e r sy n d ro m e , 337

M e d ic a tio n s, 3 4 -3 5

M e d ica id , 399

M e d ite rra n e a n ly m p h o m a , 231

M ed ical d e vice s, 398

M e d ite rra n e a n m a c ro th ro m b o c y to p e n ia , 2 2 2

M ed ical d ire c to rsh ip , 3 9 6 -4 1 2

M e d u lla ry s p o n g e kidn ey, 337

c e rtific a tio n a nd a c c re d ita tio n o f d ire c to r, 3 9 6 -3 9 8

M e d u lla ry th y ro id c a rc in o m a , 3 1 -3 2

fin a n c ia l c o n s id e ra tio n s in th e la b o ra to ry a nd , 4 0 1 ,4 0 1 ft b u d g e tin g in, 401

M e d u llo b la s to m a , 357, 375

co s ts in, 4 0 1 , 401 ft

M e g a k a ry o c y te s , 2 66 M e ig s s y n d ro m e , 4 5 M e io sis, 324 M e is s n e r s u b m u c o s a l plexus, 3 4 3 M e la n o c y te -s tim u la tin g h o rm o n e , 39 M e la n o m a , 373

© A S C P 2018

ISBN 9 7 8 -0 8 9 1 8 9 -6 6 7 8

437

Index

Melting— Molecular M e ltin g p o in t a n a ly s is , 3 3 0 -3 3 1 , 3 3 1 f

M ilk a lka li s y n d ro m e , 13

M e m b ra n o p ro life ra tiv e g lo m e ru lo n e p h ritis ty p e II, 11

M ille r-D ie k e r s y n d ro m e , 3 5 6 f

M e m b ra n o u s g lo m e ru lo n e p h ritis , 3 1 6

M in im a l re sid ua l d is e a s e , 2 5 0

M E N 2 A s y n d ro m e , 3 4 4 , 3 72 M E N 2 B s y n d ro m e , 3 7 2

M is m a tc h re p a ir a s s o c ia te d s p o ra d ic a nd in h e rite d tu m o rs , 3 5 6 -3 6 0 , 3 5 8 f

M e n in g io m a , 3 7 5

M is s e n s e m u ta tio n , 3 2 4 -3 2 5

M e n in g itis , 9 8, 166

M ito c h o n d ria d is o rd e rs , 3 5 5 -3 5 6

a s e p tic , 98

M ito c h o n d ria l C K , 6

c e re b ro s p in a l flu id d iffe re n tia l c o u n ts in, 4 5 f

M ito c h o n d ria l e n c e p h a lo p a th y , 3 5 5 -3 5 6

M o lla re t, 106

M ito c h o n d ria l g n o m e , 3 20

M e n in g o e n c e p h a litis , 162

M ito c h o n d ria l in h e rita n c e , 355

M e n k e s d is e a s e , 3 5 2

M ito c h o n d ria l n e u ro g a s tro in te s tin a l e n c e p h a lo m y o p a th y , 356

M e n k e s s y n d ro m e , 7, I t

M ito s is , 324

M e rc u ry p o is o n in g , 2 4

M itra l v a lv e p ro la p s e , 336

M e rk e l c e ll p o ly o m a v iru s , 1 0 9 -1 1 0

M ix e d c o n n e c tiv e tis s u e d is e a s e , 3 08

M e rlin , 3 7 5

M ix e d c ry o g lo b u lin e m ia , 11

M e ta b o lic a c id o s is , 14, 15f, 3 3 6

M ix e d h y p e rtrig ly c e rid e m ia , h y p e rc h o le s te ro le m ia a nd , 26

M e ta b o lic a lk a lo s is , 14, 15, 1 5 f

M ix e d ly m p h y o c y te cu ltu re , 301

M e ta p h a s e , 3 2 4

M ix e d typ e a u to a n tib o d ie s , 67

M e th a m p h e ta m in e , 2 0

M N S a n tib o d ie s , 86

M e th a n o l, 22

M N S a n tig e n s , 86 M o d ific a tio n o f D ie t in R e n a l D is e a s e S tu d y, 15-16

tre a tm e n t of, 2 2

M o le c u la r b io lo g y, 3 1 8 -3 2 5

M e th e m o g lo b in , 2 0 5 -2 0 6

c la s s ific a tio n o f g e n e tic a n o m a lie s , 3 2 4 -3 2 5

M e th e m o g lo b in e m ia a c q u ire d , 2 0 5 -2 0 6

D N A re p lica tio n a nd cell d iv is io n , 3 23 , 3 2 3 f

h e re d ita ry , 2 0 5

g e n e e x p re s s io n , 3 2 1 -3 2 3 , 3 2 3 f

M e th ic illin -re s is ta n t S ta p h y lo c o c c u s a u re u s (M R S A ), 151

m ito c h o n d ria l D N A , 320-321

M e th y la tio n , 322

n u c le i acid m o d ify in g e n z y m e s , 3 20

M e th y la tio n s p e c ific p o ly m e ra s e c h a in re a c tio n , 3 30

n u c le ic a c id s a nd , 3 1 8 -3 2 0 , 3187, 3197 n u c le o tid e s , 3 18 , 3187

M e ty ra p o n e s tim u la tio n te s t, 35

p h o s p h o d ie s te r bond, 318, 3197

M ic o R N A s , 3 2 0

ty p e s of, 3 1 9 -3 2 0

M ic ro c o c c u s , 152, 1 5 2 /

p a tte rn s o f in h e rita n c e a nd , 3 25

M ic ro c y tic , h y p o c h ro m ic a n e m ia , 22

M o le c u la r c la s s ific a tio n fo r b re a s t ca n c e r, 3 66 , 3 6 6 f

M ic ro d e le tio n s , 3 0 5

M o le c u la r p a th o lo g y , 3 1 8 -3 8 0

d is o rd e rs of, 3 4 0 , 3 5 6 1

a p p lic a tio n s in, 3 3 3 -3 3 4 c h im e ris m , 333

R>2 m ic ro g lo b u lin , 31 M ic ro s a te llite s , 3 3 3 , 3 5 8

c lo n a lity a s s e s s m e n t, 333

M ic ro s c o p ic p o ly a n g iitis , 3 1 3

g e n e tic c o u n s e lin g , 334

M ic ro s p o ru m , 1 3 7 -1 3 8

le g isla tio n a n d o v e rs ig h t, 334

M ic ro s p o ru m c a n is , 137

p h a rm a c o g e n o m ic s , 3 3 3 -3 3 4

M ic ro s p o ru m g y p s e u m , 138

c y to g e n e tic s in, 3 2 5 -3 2 6

M ic ro v e s ic u la r s te a to s is , 19

k a ry o ty p in g in, 3 2 5 -3 2 6

M ic ro v illu s in c lu s io n d is e a s e , 3 4 4 M iito c h o n d ria l n e u ro g a s tro in te s tin a l e n c e p h a lo m y o p a th y , 3 5 6

438

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

Index

Molecular— Myelodysplastic M y c o b a c te ria , 1 85 -19 2 , 185/, 186i, 187i, 1 88 i

m o le c u la r te c h n iq u e s a m p lific a tio n , 3 2 9 -3 3 2 , 3 2 9 f, 3 30 f, 331 f

la b o ra to ry d ia g n o s is , 1 86 -18 8 , 188/

b lo ttin g, 3 27

M y c o b a c te riu m tu b e rc u lo s is c o m p le x , 1 8 8 -1 9 0 , 187f, 188/

D N A s e q u e n c in g , 332, 3 3 2 f

n o n tu b e rc u lo u s M y c o b a c te ria , 190/, 1 9 0 -1 9 2 , 1 9 1 /

gel e le c tro p h o re s is , 327

M y c o b a c te riu m a b s c e s s u s , 192

h y b rid iz a tio n , 3 2 7 -3 2 9 , 328/

M y c o b a c te riu m a v iu m c o m p le x , 191, 190/

is o la tio n o f n u c le ic a cid , 326

M y c o b a c te riu m b o v is , 188

re stric tio n e n z y m e s , 3 2 6 -3 2 7

M y c o b a c te riu m c h e io n a e , 192

n e o p la s tic d is e a s e s (S e e N e o p la s tic d is e a s e s ) n o n n e o p la s tic d is e a s e (S e e N o n n e o p la s tic d is e a s e ) M o lla re t m e n in g itis, 106

M y c o b a c te riu m h a e m o p h ilu m , 191

M o n o c lo n a l B cell ly m p h o c y to s is , 2 24

M y c o b a c te riu m k a n s a s ii, 190, 189/

M o n o c lo n a l g a m m o p a th y , 9 -10 , 9 f, 10 f

M y c o b a c te riu m le p ra e , 191, 191/

o f u n k n o w n s ig n ific a n c e , 2 39 , 2 3 9 f

M y c o b a c te riu m m a rin u m , 190

M o n o c y to p e n ia , 221

M y c o b a c te riu m s c ro fu ia c e u m , 191

M o n o c y to s is , 221

M y c o b a c te riu m s z u lg a i, 192

M o n o n u c le o s is , in fe c tio u s , 107

M y c o b a c te riu m tu b e rc u lo s is c o m p le x , 1 8 8 -1 9 0 , 1 8 8 f, 189/

M o n o s o d iu m u ra te c rysta ls, 46

M y c o b a c te riu m u ic e ra n s , 192

M o n o s o m y X, 3 25

M y c o b a c te riu m x e n o p i, 191

M o ra x e lla ca ta rrh a lis , 98, 165

M y c o lo g y , 1 28 -14 6

M o s q u ito e s , 1 0 2 f

d e m a tia c e o u s m o ld s and o th e r s u b c u ta n e o u s in fe c tio n s , 1 3 8 -1 4 0

M o th b a ll o d o r, 2 1 t M prote in, 9 M T H F R g e n e m u ta tio n a n d h y p e rh o m o c y s te in e m ia , 2 8 6 M u c o m y s t, 23

M y c o b a c te riu m g e n a v e n s e , 191 M y c o b a c te riu m g o rd o n a e , 191

M o llu s c u m c o n ta g io s u m , 110, 110/

M u c o c u ta n e o u s lym p h n o d e s y n d ro m e , 3 1 4 -3 1 5

M y c o b a c te riu m fo rtu itu m g ro u p , 192

d e rm a to p h y te s a nd o th e r s u p e rfic ia l m y c o s e s M ic ro s p o ru m , 137 -13 8 T ric h o p h yto n , 138, 138/ d ia g n o s tic te c h n iq u e s , 129/, 1 2 9 -1 3 0

M u co r, 144, 144/

d im o rp h ic fu n g i, 1 33-138, 13 4 /-1 37/, 1 3 4 1

M u ir-T o rre sy n d ro m e , 359

fu n g a l s tru c tu re , 128

M u ltic o m p o n e n t d o n a tio n s , R B C a p h e re s is and, 57

h y a lin e m old s, 1 40 -14 3 A s p e rg illu s , 1 40 -14 3 , 141/-144/'

M u ltic y s tic d y s p la s tic k id n e y , 337 M u ltip le g e n e tic d e fe c ts, 27 M u ltip le m ye lo m a , 2 3 7 -2 3 9 , 2 38 f, 2 3 9 ft M u ltip le s c le ro sis, 44 M u m p s virus, 98, 114 M u rin e ty p h u s , 184 M u ta tio n s, 324 d e le tio n , 324 d e lte rio u s , 325 fra m e s h ift, 325 in s e rtio n , 324 m is s e n se , 3 2 4 -3 2 5 n o n s e n s e , 324 p oint, 324, 325 M y a s th e n ia g ravis, 315, 3 1 5f, 3 16 © A S C P 2018

F u s a riu m , 142, 143/ S c e d o s p o riu m a p io s p e rm u m /P s e u d a lle s c h e ria b o y d ii, 143 P n e u m o c y s tis jiro v e c i, 1 46 -14 7 , 1 4 7 / P ro to th e c a , 147 y e a s ts , 130/, 1 30 -13 3 , 131/, 1 3 2 i C a n d id a , 130, 130/, 131/ C ry p to c o c c u s , 1 31-132, 132/ z y g o m y c e te s , 143, 143/ M y c o p la s m a , 185 M y c o p la s m a h o m in is , 185 M y c o p la s m a p n e u m o n ia e , 82, 97, 98, 186 M y c o s is fu n g o id e s , 243 M y e lo d y s p la s tic /m y e lo p ro life ra tiv e n e o p la s m s , 247/, 2 4 7 -2 4 8 , 248f ISBN 9 7 8 -0 8 9 1 8 9 -6 6 7 8

439

Index

Myelodysplastic— Neoplastic M y e lo d y s p la s tic s y n d ro m e s , 2 46 /, 2 4 6 -2 4 7 , 2 4 7 /

N e c a to r a m e ric a n u s , 126

M y e lo id n e o p la s m s , 2 4 6 -2 5 7 , 2 4 6 f, 2 5 3 /

N e c k tu m o rs . S e e H e a d a nd n e c k tu m o rs

a c u te le u k e m ia in D o w n s y n d ro m e , 2 5 7

N e c ro tiz in g e n te ro c o litis (N E C ), 64

a c u te m e g a k a ry o b la s tic le u k e m ia , 2 5 6 -2 5 7

N e is s e ria , 1 6 2 -16 4

a c u te m o n o c y tic /m o n o b la s tic le u k e m ia , 2 5 6

N e is s e ria g o n o rrh o e a e , 163/7, 1 63 -16 4

a c u te m y e lo g e n o u s le u k e m ia , 2 5 1 -2 5 6 , 2 52 /, 2 5 3 t, 254/, 2 5 5 ft, 2 5 6 /

N e is s e ria m e n in g itid e s , 163, 1 6 3 /

a c u te m y e lo m o n o c y tic le u k e m ia , 2 5 6 a c u te p a n m y e lo s is w ith m y e lo fib ro s is , 2 5 7 b la s tic p la s m a c y to id d e n d ritic c e ll n e o p la s m , 2 5 7 w ith g e rm lin e p re d is p o s itio n , 2 5 7 m y e lo d y s p la s tic /m y e lo p ro life ra tiv e n e o p la s m s , 247/, 2 4 7 -2 4 8 , 2 4 8 1 m y e lo d y s p la s tic s y n d ro m e s , 2 46 /, 2 4 6 -2 4 7 , 2 4 7 1 m y e lo id n e o p la s m s w ith g e rm lin e p re d is p o s itio n , 2 5 7 m y e o p ro life ra tiv e n e o p la s m s , 2 4 8 -2 5 1 , 2 49 /, 2 5 0 /, 2 5 1 / p u re e ry th ro id le u k e m ia , 2 5 6 , 2 5 6 /

N e o n a ta l a llo im m u n e th ro m b o c y to p e n ia , 7 2 -7 3 , 2 22 N e o n a ta l a n d in tra u te rin e tra n s fu s io n , 7 2 -7 4 h e m o ly tic d is e a s e o f fe tu s a nd n e w b o rn , 7 3 -7 4 , 7 3 / m a te rn a l im m u n e th ro m b o c y to p e n ic p u rp u ra , 72 n e o n a ta l a llo im m u n e th ro m b o c y to p e n ia , 7 2 -7 3 s p e c ia l b lo o d re q u ire m e n ts fo r, 72 N e o n a ta l a n e m ia , 2 1 8 -2 1 9 N e o n a ta l h y p e rb iliru b in e m ia , 4 / N e o n a ta l h y p o th y ro id is m , 34 N e o n a ta l ja u n d ic e , 4 -5, 4/, 2 00 N e o n a ta l tra n s fu s io n s , 62

M y e lo id to e ry th ro id (M :E ) ra tio , 2 6 6

N e o p la s tic d is e a s e s , 3 5 6 -3 8 0

M y e lo k a th e x is , 2 1 6 M y e lo p ro life ra tiv e n e o p la s m s , 2 4 8 -2 5 1 ,2 4 9 /, 2 5 0 f, 2 5 1 / M y e lo p ro life ra tiv e s ta in in g , 301

b re a s t ca n c e r, 3 6 4 -3 6 6 B R C A a s s o c ia te d tu m o rs , 365, 3 6 5 / H E R 2, 3 6 4 -3 6 6

M y e lo p ro life ra tiv e th ro m b o c y to s is , 2 2 3

m o le c u la r c la s s ific a tio n , 3 66 , 3 6 6 /

M y o c a rd ia l d is o rd e rs , 3 3 9

ste ro id re ce p to rs, 3 65

d ila te d (c o n g e s tiv e ) c a rd io m y o p a th y ), 3 3 9 M y o c a rd ia l m a rk e rs , 5 -6

T P 5 3 tu m o r s u p p re s o r g e n e , 3 4 4 -3 4 5 c e n tra l n e rv o u s s y s te m tu m o rs , 3 7 3 -3 7 5 d iffu se g lio m a s , 3 7 3 -3 7 4 , 374/7

B ty p e n a triu re tic p e p tid e , 6 c a rd ia c e n z y m e s , 5 -6 , 5 f

e m b ry o n a l tu m o rs , 3 7 5

m y o g lo b in , 6

m e n in g io m a , 3 75

tro p o n in , 6

p ilo c y tic a s tro c y to m a , 374 re tin o b la s to m a , 3 7 4 -3 7 5

M y o c a rd itis , 6 M y o c lo n ic e p ile p s y w ith ra g g e d red fib e rs , 3 5 6 M y o g lo b in , 6 M y o g lo b in u ria , 4 0 , 41

g a s tro in te s tin a l tra c t tu m o rs , 3 5 6 -3 6 3 c o lo re c ta l a d e n o c a rc in o m a , 3 5 6 -3 6 2 , 357/, 358/, 359/7, 360/, 361 ft, 3 6 2 / g a s tro in te s tin a l s tro m a l tu m o rs , 3 6 2 -3 6 3 , 3 6 2 f

M y o to n ic m u s c u la r d y s tro p h y , 3 5 3 -3 5 4

g e n ito u rin a ry tu m o rs , 3 6 6 -3 6 8 , 367/, 3 6 8 / renal cell c a rd in o m a s y n d ro m e s , 3 6 6 -3 6 7

M yxedem a, 46

s p o ra d ic re na l cell c a rd in o m a , 3 67 , 3 6 7 / te s tic u la r tu m o rs , 368

N

u ro th e lia l c a rc in o m a , 3 6 7 -3 6 8

/V -a c e ty lc y s te in e , 2 3

W ilm s tu m o r, 367

N -a c e ty ltra n s fe ra s e , 3 3 3

g y n e c o lo g ic tu m o rs , 3 7 6 -3 7 7 ce rvix, 3 7 6 -3 7 7

N a e g le ria fo w le ri, 123, 1 2 3 / N a il-p a te lla s y n d ro m e , 3 3 5 , 3 3 5 /

g e s ta tio n a l tro p h o b la s tic d is e a s e , 377

N A M E s y n d ro m e , 3 8 0

in h e rite d g y n e c o lo g ic tu m o r s y n d ro m e , 376

N a s a l ty p e n a tu ra l k ille r/T ce ll ly m p h o m a s , 2 4 2 N a tio n a l A c a d e m y o f C lin ic a l B io c h e m is try , 21, 2 2 /

440

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

Index

Neoplastic—Neoplastic H o d g k in ly m p h o m a , 2 4 3 -2 4 5 c la s s ic , 2 4 3 -2 4 5 , 245//, 2 4 6 /

head a nd n e c k tu m o rs , 3 7 1 -3 7 3 , 3 72 / fa m ilia l th y ro id c a rc in o m a , 3 7 1 -3 7 2 , 3 72 /

n o d u la r ly m p h o c y te p re d o m in a n t H o d g k in ly m p h o m a , 2 43 , 243/, 2 4 4 f

p a p illa ry th y ro id c a rc in o m a , 3 7 2 -3 7 3 s a liv a ry g la n d tu m o rs , 371

m y e lo id n e o p la s m s , 2 4 6 -2 5 7 , 2 4 6 / a c u te le u k e m ia in D o w n s y n d ro m e , 2 5 7

s q u a m o u s cell c a rc in o m a , 371 h e p a to b ilia ry tu m o rs c h o la n g io c a rc in o m a , 3 64

a c u te m e g a k a ry o b la s tic le u k e m ia , 2 5 6 -2 5 7 a c u te m o n o c y tic /m o n o b la s tic le u k e m ia , 2 5 6

h e p a to c e llu la r c a rc in o m a , 363

a c u te m y e lo g e n o u s le u k e m ia , 2 5 1 -2 5 6 , 252/', 2 5 3 /, 254/', 2 5 5 ft, 2 5 6 /

p a n c re a tic tu m o rs , 3 63 d u cta l a d e n o c a rc in o m a , 3 63

a c u te m y e lo m o n o c y tic le u k e m ia , 2 5 6

p u lm o n a ry tu m o rs , 3 7 5 -3 7 6

a c u te p a n m y e lo s is w ith m y e lo fib ro s is , 2 5 7

skin tu m o rs , 3 73 d e rm a to fib ro s a rc o m a p ro tu b ra n s , 373

b la s tic p la s m a c y to id d e n d ritic ce ll n e o p la s m , 2 5 7

m e la n o m a , 373 s o ft tis s u e a nd b o n e tu m o rs , 3 6 8 -3 7 1 , 3 6 8 / E w in g s a rc o m a fa m ily o f tu m o rs , 3 6 8 -3 6 9 lo w g ra d e fib ro m y x o id s a rc o m a /h y a lin iz in g s p in d le tu m o r w ith g ia n t ro se tte s, 3 70 n e u ro b la s to m a , 3 6 9 -3 7 0 , 3 70 /

m y e lo d y s p la s tic /m y e lo p ro life ra tiv e n e o p la s m s , 247/', 2 4 7 -2 4 8 , 2 4 8 / m y e lo d y s p la s tic s y n d ro m e s , 246/, 2 4 6 -2 4 7 , 2 4 7 / m y e lo id n e o p la s m s w ith g e rm lin e p re d is p o s itio n , 2 5 7 m y e o p ro life ra tiv e n e o p la s m s , 2 4 8 -2 5 1 , 249/', 2 5 0 f, 2 5 1 / p u re e ryth ro id le u k e m ia , 2 5 6 , 2 5 6 / p la s m a cell n e o p la s m s m o n o c lo n a l g a m m o p a th y o f u n k n o w n s ig n ific a n c e , 2 3 9 , 239f o s te o s c le ro tic m ye lo m a , 2 4 0

rh a b d o m y o s a rc o m a , 3 70 s y n o v ia l s a rc o m a , 370, 370/ tu m o rs o f a d ip o c y te s , 370-371 N e o p la s tic h e m a to p a th o lo g y , 2 2 3 -2 5 7

p la s m a cell le u ke m ia , 2 3 9

B cell n e o p la s m s , 2 2 3 -2 3 6 A L K + larg e B ly m p h o m a , 2 33 , 2 3 4 /

p la s m a cell m y e lo m a /m u ltip le m y e lo m a , 2 3 7 -2 3 9 , 2 3 8 /, 2 3 9 ft

B u rk itt ly m p h o m a /le u k e m ia , 2 36 , 2 3 6 /

s o lita ry p la s m a c y to m a , 2 3 9

d iffu se la rg e B cell ly m p h o m a , 2 3 1 -2 3 2 , 2 3 2 fi

p re c u s o r n e o p la s m s , 2 3 6 -2 3 7 , 2 3 7 // a c u te le u k e m ia w ith m ixed lin e a g e , 2 3 7

EBV+ D LBCL, NO S, 235 fo llic u la r ly m p h o m a , 2 2 6 -2 2 8 , 2 27 / g e n e ra l c lin ic a l c o n s id e ra tio n s , 2 23 , 2 2 3 / h a iry cell le u ke m ia , 230/, 2 3 0 -2 3 1 , 2 3 1 / h e a v y ch ain d is e a s e , 231 high g ra d e B cell ly m p h o m a , 2 35 im m u n o d e fic ie n c y a s s o c ia te d ly m p h o p ro life ra tiv e d is o rd e rs , 2 35 in tra v a s c u la r la rg e B cell ly m p h o m a , 2 34 , 2 35 /

B a c u te ly m p h o b la s tic le u k e m ia /ly m p h o b la s tic ly m p h o m a w ith re c u rre n t g e n e tic a b n o rm a litie s , 2 3 7 , 238/ p re c u s o r B a c u te lo y m p h o b la s tic le u k e m ia /ly m p h o b la s tic ly m p h o m a , N O S , 237, 2 3 7 / T a c u te ly m p h o b la s tic le u k e m ia , 2 3 7 T cell n e o p la s m s a d u lt T cell le u k e m ia /ly m p h o m a , 2 4 0

ly m p h o m a to id g ra n u lo m a to s is , 2 35 , 2 35 /

a g g re s s iv e N K cell le u k e m ia , 2 4 2

ly m p h o p la s m a c y tic ly m p h o m a , 231

a n a p la s tic la rg e cell ly m p h o m a , A L K + , 2 4 1 , 2 4 1 /

M a n tle cell ly m p h o m a , 225/, 2 2 5 -2 2 6

a n g io im m u n o b la s tic T ce ll ly m p h o m a , 2 4 0 - 2 4 1 ,2 4 1 /

m a rg in a l z o n e le u k e m ia , 227/', 2 2 8 -2 3 0 , 2 2 8 it

c h ro n ic ly m p h o p ro life ra tiv e d is o rd e r o f N K c e lls , 2 4 2

p la s m a b la s tic ly m p h o m a , 2 34 , 2 3 4 / p rim a ry c u ta n e o u s D L B C L , leg typ e , 2 34

c u ta n e o u s T ce ll ly m p h o m a , m y c o s is fu n g o id e s , and S e z a ry s y n d ro m e , 243

p rim a ry D L B C L o f th e C N S , 2 33 , 2 3 3 /

e n te ro p a th y a s s o c ia te d T ce ll ly m p h o m a , 2 4 2

p rim a ry m e d ia s tin a l la rg e B ce ll ly m p h o m a , 2 3 4

h e p a to s p le n ic T ce ll ly m p h o m a , 2 4 2

p ro ly m p h o c y tic le u ke m ia , 2 31 , 2 3 1 /

n asa l ty p e n a tu ra l k ille r/T cell ly m p h o m a s , 2 4 2

sm all ly m p h o c y tic ly m p h o m a /c h ro n ic ly m p h o c y tic le u k e m ia , 2 2 3 -2 2 5 , 224/, 2 2 5 ft

s u b c u ta n e o u s p a n n ic u litic T ce ll ly m p h o m a , 2 4 2 -2 4 3

T c e ll/h is tio c y te rich la rg e B cell ly m p h o m a , 234

T ce ll la rg e g ra n u la r ly m p h o c y tic le u k e m ia , 2 4 2 , 2 4 2 /

© A S C P 2018

p e rip h e ra l T cell ly m p h o m a , N O S , 2 4 0 , 2 4 0 /

ISBN 9 7 8 -0 8 9 1 8 9 -6 6 7 8

441

Index

Nephrin— Nonneoplastic N e p h rin , 3 3 5

N o n d is ju n c tio n , 324

N e p h ro lith ia s is , 4 2

N o n fe rm e n ta tiv e b acilli, 1 69 -17 0

N e p h ro n o p h th is is , 3 3 7

N o n in fla m m a to ry d ia rrh e a , 96

N e p h ro p a th ie s , s ic k le ce ll, 2 0 3

N o n n e o p la s tic d is e a s e , g e n e tic s o f

N e p h ro tic s y n d ro m e , 8, 12

c a rd io v a s c u la r, 3 3 8 -3 4 0 c h a n n e l c o n d u c tio n , 3 2 8 -3 3 9

N e u o b la s to m a , 3 6 9 -3 7 0 , 3 7 0 /

m y o c a rd ia l, 3 39

N e u ra lg ia , p o s th e rp e tic , 1 0 6 -1 0 7 N e u ra l tu b e d e fe c ts , p re n a ta l s c re e n in g fo r, 1 7 -1 8 N e u ro b la s to m a , 32

e n d o c rin e , 3 4 0 -3 4 2 a d re n a l c o rte x , 3 4 0 -3 4 2 d ia b e te s m e llitu s , 3 43

N e u ro e n d o c rin e tu m o rs , 3 1 -3 2

p a ra th y ro id g la n d , 342

N e u ro fib ro m a to s is

p itu ita ry g la n d , 342

ty p e 1, 3 4 4 , 3 7 8

th y ro id g la n d , 343

ty p e 2, 3 7 8

g a s tro in te s tin a l, h e p a to b ilia ry a nd p a n c re a tic , 3 4 3 -3 5 0 a b d o m in a l w a ll d e fe c ts, 3 4 4 -3 4 5

N e u ro h y p o p h y s is , 38 N e u ro lo g ic a l s y n d ro m e s , 107

b ilia ry fib ro c y s tic d is e a s e s , 3 45

N e u ro m u s c u la r d is o rd e rs c e n tra l n e u ro d e g e n e ra tiv e d is e a s e , 3 5 0 -3 5 2 p e rip h e ra l n e u ro p a th y , 3 5 2 -3 5 3

b iliru b in c o n ju g a tio n d is o rd e rs , 348 b iliru b in s e c re tio n d is o rd e rs , 348 e s o p h a g e a l a tre s ia , 344

s k e le ta l m u s c le d is e a s e s , 3 5 3 -3 5 4 N e u ro p e p tid e K, 31

h e re d ita ry h e m o c h ro m a to s is , 3 4 6 -3 4 7 , 3 4 7 / H irs c h s p ru n g d is e a s e , 3 4 3 -3 4 4

N e u tro p e n ia , 221

in h e rite d p a n c re a titis , 3 4 8 -3 5 0 , 3 4 9 /f

a b s o lu te , 3 0 0

in te stin a l a rre s ia , 344

a u to im m u n e , 2 1 6

m ic ro v illu s in c lu s io n d is e a s e , 344

c o n g e n ita l, 2 1 6 , 2 1 6 f

O s le r-W e b e r-R e n d u s y n d ro m e , 344

c y c lic , 2 1 6 , 2 1 6 1

p y lo ric s te n o s is , 344 s y n d ro m ic p a u c ity o f b ile d u c ts, 345/, 3 4 5 -3 4 6 W ils o n d is e a s e , 347, 3 4 7 f

N e u tro p h ilia , 2 2 0 re a c tiv e , 2 2 0

a1 a n titryp sin d e fic ie n c y , 3 4 7 -3 4 8 , 3 4 7 1

N e u tro p h il/p h a g o c y tic d e fe c ts , 3 0 5 -3 0 6 A ld e r-R e illy a n o m a ly , 3 0 6

M ic ro d e le tio n d is o rd e rs , 3 5 6 f

C h e d ia k -H ig a s h i s y n d ro m e , 3 0 5

M ito c h o n d ria d is o rd e rs , 3 5 5 -3 5 6 K e a m s -S a y re s y n d ro m e , 3 55 Leigh s y n d ro m e

c h ro n ic g ra n u lo m a to u s d is e a s e , 3 0 5 J o rd a n a n o m a ly , 306

m ito c h o n d ria l e n c e p h a lo p a th y w ith la c tic a c id o s is and s tro k e like e p is o d e s , 3 5 5 -3 5 6

M a y -H e g g lin a n o m a ly , 3 0 6 , 3 0 6 / P e lg e r-H u e t a n o m a ly , 3 0 6

m ito c h o n d ria l n e u ro g a s tro in te s tin a l e n c e p h a lo m y o p a th y , 356

N e u tro p h ils , 4 5 , 2 9 8 s p e c ific te s tin g o f fu n c tio n , 3 0 0 -30 1 N e v o id b a s a l ce ll c a rc in o m a s y n d ro m e , 3 7 8 N e w b o rn , h e m o rrh a g ic d is e a s e o f th e , 2 8 4

m y o c lo n ic e p ile p s y w ith ra g g e d red fib e rs , 356 P e a rso n s y n d ro m e , 355 n e u ro m u s c u la r, 3 5 0 -3 5 5

N e x t g e n e ra tio n s e q u e n c in g , 332

ce n tra l n e u ro d e g e n e ra tiv e d is e a s e , 3 5 0 -3 5 2 , 3 5 1 /

N itrite , 4 2

c o n g e n ita l h e a rin g loss, 3 5 4 -3 5 5

N K c e lls , 2 9 7

p e rip h e ra l n e u ro p a th y , 3 5 2 -3 5 3 ske le ta l m u s c le d is e a s e s , 3 5 3 -3 5 4

s p e c ific te s tin g o f fu n c tio n , 3 0 0 N o c a rd ia , 147, 1 6 1 -1 6 2 , 161/ N o d u la r ly m p h o c y te p re d o m in a n t H o d g k in ly m p h o m a , 2 43 , 243/', 2 4 4 1

442

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

Index

Nonneoplastic—Paraganglioma renal, 3 3 4 -3 3 6 in h e rite d n e p h ritic s y n d ro m e , 3 3 4 -3 3 5 , 3 3 5 /

O s e lta m iv ir, 114

in h e rite d n e p h ro tic s y n d ro m e , 335, 3 3 5 t

O s m o la l g ap , 14

O s le r-W e b e r-R e n d u s y n d ro m e , 2 7 4 , 2 7 5 , 2 7 8 , 3 44

in h e rite d tu b u la r d is o rd e rs , 3 3 5 -3 3 6 , 3 3 6 f

to x ic a lc o h o l p o is o n in g a n d , 22

p o ly c y s tic k id n e y d is e a s e , 336/, 3 3 6 -3 3 7

O s m o tic fra g ility te s t, 2 0 0

s p o ra d ic a nd m u ltifa c to ria l c o n g e n ita l d is o rd e rs , 3 3 7 -3 3 8

O s te o m a la ia , 3 3 6

N o n s e n s e m u ta tio n , 324

O s te o s c le ro tic m y e lo m a , 240

N o n th y ro id a l illn e s s sy n d ro m e , 33, 34

O v a ria n fib ro m a s , 4 5

N o n tu b e rc u lo u s M y c o b a c te ria , 190/', 1 90 -19 2 , 191/

O v e rd o s e , 2 1 -2 4

N o o n a n sy n d ro m e , 340

g e n e ra l a s p e c ts o f la b o ra to ry e v a lu a tio n , 2 1 -2 2 , 21 f, 2 2 1

N o re p in e p h rin e , 32

O v e rflo w p ro te in u ria p atte rn , 10

N o rm al s e ru m , 8, 8 f

O x a la te , 22

N o rw a lk like v iru s , 96

O x y g e n s a tu ra tio n g ap , 2 1 -2 2

N o rw a lk viru s, 96, 113 N S A ID s, 2 83 N u c le a r m a trix p ro te in 22, 32

P

N u c le a s e , 320

P a cke d red b lo o d ce lls, 74

N u c le ic acid

P a g e t d is e a s e , 3 P a n c re a s , 5

is o la tio n of, 326

enzym es, 5 a m y la s e , 5

stru c tu re of, 3 1 8 -3 2 0 , 3 1 8f, 3 1 9 f ty p e s of, 3 1 9 -3 2 0

lip a se , 5

N u c le ic a cid m o d ify in g e n z y m e s

te s ts o f p a n c re a tic e x o c rin e fu n c tio n , 5 n o n in v a s iv e te sts, 5 s e c re tin c h o le c y s to k in in te s t, 5

lig a se , 320 n u cle a se , 3 20 p o ly m e ra s e , 320 N u c le ic a cid s e q u e n c e b a se d a m p lific a tio n , 329, 331, 331 f

P a n c re a tic cyst, la b o ra to ry e v a lu a tio n of, 5, 5 f

N u c le o tid e s , 318, 3187

P a n c re a tic e n z y m e s , 5 a m y la s e , 5 lip a se , 5

o

P a n c re a tic e x o c rin e fu n c tio n , te s ts of, 5

O a lle le , 80

P a n c re a tic lip o m a to s is s y n d ro m e s , 3 5 0 , 3 5 0 /

O c c u p a tio n a l S a fe ty a nd H e a lth A c t (1 9 7 0 ), 4 0 0

P a n c re a tic p o ly p e p tid e , 31

O c c u p a tio n a l S a fe ty a nd H e a lth A d m in is tra tio n (O S H A ), 4 0 0

P a n c re a tic tu m o rs , 3 63

O c u la r Lisch n o d u le s, 3 78

d u c ta l a d e n o c a rc in o m a , 3 63

O k a z a k i fra g m e n ts , 323

P a n c re a titis , 45

O le c ra n o n b ursitis, 145

a cu te , 25

O lig o d e n d ro g lio m a , v e rs u s a tro c y to m a , 3 7 4 f

in h e rite d , 3 4 8 -3 5 0 , 3 4 9 /f

O m p h a lo c e le , 3 4 4 -3 4 5

P a ne l re a c tiv e a n tib o d y te sts, 3 0 1 -3 0 2

O n y c h o m y c o s is , 137

P a n h y p o p itu ita ris m , 38

O o g e n e sis , 325

P a n to th e n a te k in a s e a s s o c ia te d n e u ro d e g e n e ra tio n , 3 5 1 -3 5 2

O p e ra tin g b u d g e ts, 401

P a p a in , 64

O p ia te s , 20

P a p illa ry th y ro id c a rc in o m a , 3 7 2 -3 7 3

O rg a n o p h o s p h a te o v e rd o s e , 24

P a p o v a v irid a e , 1 0 9 -1 1 0

O rie n tia ts u ts u g a m u sh i, 102

P a ra c o c c id io id e s b ra s ilie n s is , 136, 137/

O rth o m yx o v irid a e , 114

P a ra g a n g lio m a , 32

© A S C P 2018

ISBN 9 7 8 -0 8 9 1 8 9 -6 6 7 8

443

Index

Paragonim us— Pinpoint P a ra g o n im u s w e s te rm a n i, 125, 125/

P e lg e r-H u e t a n o m a ly , 2 65 , 3 06

P a ra in flu e n z a : c ro u p , 114

P e n d re d sy n d ro m e , 355

P a ra m y x o v irid a e , 1 1 4 -1 1 5

P e n e tra n c e , 3 25

P a ra p n e u m o n ic e ffu s io n s , 4 5

P e n ic illin -E a g le e ffe c t, 153

P a ra p ro te in e m ia , 2 8 3

P e n ic illin G, 181

P a ra s itic in fe c tio n s

P e n ic illiu m m a rn e ffe i, 1 3 6 -1 3 7

b y b o d y site , 1 1 6 /

P e p tic u lce r d is e a s e , 5

in im m u n o d e fic ie n t p a tie n ts , 1 2 8 /

P e ria rte rio la r ly m p h a tic s h e a th s , 3 05

o c u lo c u ta n e o u s , 1 2 8 /

P e ric a rd itis , 6

p e rs o n to p e rs o n s p re a d of, 1 2 8 /

P e rin u c le a r A N C A , 3 09 , 3 0 9 /

P a ra s ito lo g y , 1 1 6 -1 2 8

P e rip h e ra l h o rm o n e re sis ta n c e , 34

b lo o d a n d tis s u e p ro to z o a , 1 1 9 -1 2 4 B a b e s ia , 119, 119/

P e rip h e ra l n e u ro p a th y , 3 5 2 -3 5 3 P e rip h e ra l T cell ly m p h o m a , N O S , 2 40 , 2 4 0 /

flu k e s (tre m a to d e s ), 1 2 5 -1 2 6 , 125/

P e rito n e a l flu id (a s c ite s flu id ), 46

fre e liv in g a m e b a e , 123, 123/ L e is h m a n ia , 122/, 1 2 2 -1 2 3 , 122/, 1 23 /

P e rs o n n e l b u d g e ts , 401

P la s m o d iu m , 1 0 1, 1 1 7 -1 2 0 , 1 2 1 /

P e rtu s s is , 171

ro u n d w o rm s (n e m a to d e s ), 126/, 127/, 1 2 6 -1 2 8

P e te ch ia e , 3 00

ta p e w o rm s (c e s to d e s ), 1 2 4 -1 2 5 , 1 24 /

P e u tz -J e g h e rs s y n d ro m e , 362, 3 6 2 /

T o x o p la s m a g o n d ii, 122, 122/

P F A 1 0 0 , 275

T ric h o m o n a s h o m in is , 123

P /G L O B blood g ro u p , 8 3 -8 4

T ry p a n o s o m a , 121, 1 22 /

P H , 42

g a s tro in te s tin a l p ro to z o a , 117/, 1 1 7 -1 1 9 la b o ra to ry m e th o d s , 1 1 6 -1 1 7 c u ltu re , 117

P h a e o h y p h o m y c o s is , 1 3 9 -1 4 0 P h a g o cy te s , d e fe c ts in, 300 P h a rm a c o k in e tic s , 19

d ire c t e x a m in a tio n , 1 1 6 -1 1 7 , 1 1 6 /

fre e v e rs u s b o u n d , 19

m o le c u la r m e th o d s , 117

half-life, 19

s e ro lo g y , 117 P a ra th y ro id g la n d , d is o rd e rs in v o lv in g , 3 4 2 P a ra th y ro id h o rm o n e , fo rm s of, 1 3 / P a ra tra b e c u la r ly m p h o id a g g re g ra te s , 2 6 6 P a rk in s o n d is e a s e , 351

v o lu m e o f d is trib u tio n (V d), 19 P h a ry n g itis , 163, 165 P h e n c y c lid in e , 20 P h e n o l o x id a s e te st, 132 P h e o c h ro m o c y to m a , 32

P a ro v iu s B 1 9 , 2 1 5 P a ro x y s m a l c o ld h e m o g lo b in u ria , 6 8, 2 0 9 , 2 0 9 it P a ro x y s m a l n o c tu rn a l h e m o g lo b in u ria , 2 8 6

P h le b o to m y , b lo o d o b ta in e d fro m th e ra p e u tic , 57 P h o s p h a ta s e , 3

P a rth y ro id g la n d , 3 4 2

P h o s p h a tu ria , 336

P a rtia l D iG e o rg e s y n d ro m e , 3 0 4

P h o s p h o d ie s te r b on d , 318, 3 1 9 /

P a rv o v irid a e , 109

P h ys ic ia n F e e S c h e d u le (P F S ), 3 99

P a rv o v iru s B 1 9 , 6

P ick b od ies, 351

P a s m in , 2 7 5

P ic k cells, 351

P a s te u re lla m u lto c id a , 175

P ic o rn a v irid a e , 1 11 -11 2

P a th o lo g y . S e e M o le c u la r p a th o lo g y

P ie rs o n s y n d ro m e , 335, 3 3 5 /

P D L i (p ro g ra m m e d d e a th lig a n d 1), 3 7 6

P ilo c y tic a s tro c y to m a , 374

P e a rs o n s y n d ro m e , 3 5 5

P in k x a n th o c h ro m ia , 44

P e d ic u iu s h u m a n u s , 182, 185

P in p o in t pupils, 2 1 1

444

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

Index

Pituitary— Pontiac la b o ra to ry e v a lu a tio n of, 2 7 5 -2 7 6

P itu ita ry, 3 8 -3 9 a d re n o c o rtic o tro p h ic h o rm o n e , 39

le u k o re d u c e d , 76

a n tid iu re tic h o rm o n e , 39

m o rp h o lo g ic e x a m in a tio n of, 2 7 9 -2 8 0 , 2 8 0 1

d is o rd e rs in v o lv in g , 342

re fra c to rin e s s , 9 1 -9 2

fo llic le stim u la tin g , 39

P la te le ts p h e re s is , 7 5 1

g ro w th h o rm o n e , 38

P la te le t tra n s m itte d in fe c tio n , p re v e n tio n of, 77

lu te in iz in g h o rm o n e , 39

P la te le t ty p e b le e d in g , 2 7 8 -2 7 9

p ro la c tin , 39

P le o m o rp h ic a d e n o m a , 371

P itu ita ry a d e n o m a , 34

P le s io m o n a s s h ig e llo id e s , 173

P ity ria s is v e rs ic o lo r, 133

P le u ra l flu id , 45 e x u d a te v e rs u s tra n s u d a te , 4 5 -4 6 , 4 5 1

P la g u e b u b o n ic , 176

P lu m b is m , 22

p n e u m a tic , 176

P lu m m e r s y n d ro m e , 34

s e p tic e m ic , 176

P n e u m a tic p la g u e , 176

P la sm a , 78

P n e u m o c y s tis jiro v e c i, 98, 1 4 4 -1 4 5 , 1 45 /

P la s m a b la s tic ly m p h o m a , 2 34 , 2 3 4 1

P n e u m o n ia , 97, 146

P la sm a c a lc ito n in , 3 1 -3 2

b a c te re m ic , 169

P la sm a cell le u k e m ia , 239

ris k fa c to rs fo r a g e n ts of, 9 7 1

P la sm a cell m y e lo m a , 2 3 7 -2 3 9 , 2 38 f, 2 3 9 ft

vira l, 100 P O E M S s y n d ro m e , 2 4 0

P la s m a cell n e o p la s m s m o n o c lo n a l g a m m o p a th y o f u n k n o w n s ig n ific a n c e , 239, 2391

P o in t m u ta tio n , 3 24 , 325 P o is o n in g

o s te o s c le ro tic m y e lo m a , 2 40

a c e ta m in io p h e n , 23

p la sm a cell le u k e m ia , 2 39

a rse n ic , 2 3 -2 4

p la s m a cell m y e lo m a , 2 3 7 -2 3 9 , 238f, 2 3 9 ft s o lita ry p la s m a c y to m a , 2 39

ca rb o n m o n o x id e , 2 2-2 3, 2 3 f cy a n a te , 23

P la sm a c o a g u la tio n , 274, 2 7 4 ft

e th y le n e g ly c o l, 2 2

P la s m a p h e re s is, 57

lead, 22

P la sm in , 2 76

m e rc u ry , 24

P la s m o d iu m , 10f, 1 19 -12 1 , 120f, 1 21 /

to x ic a lc o h o l, 22, 2 2 t

P la te le tp h e re s is , 57

P o lio v iru s , 1 11 -11 2

P la te le ts, 7 5 f, 7 6 -7 7

P o ly a g g lu tin a tio n , 63

a c tiva tio n of, 2 74 , 2 7 4 f

P o ly a rtritis n o d o s a , 313, 3 13 /

a g g re g a tio n , 2 46 , 2 80

P o ly c lo n a l B ly m p h o c y to s is , 2 2 0

a g g re g o m e try , 2 7 5 -2 7 6

P o ly c y s tic k id n e y d is e a s e , 336/, 3 3 6 -3 3 7

a p h e re s is , 76

P o ly c y th e rm ia ve ra , 250-251

cell s u rfa c e s of, 2 7 4 f

P o lye n e , 1 4 7 -14 8

d e fe c ts in m y e lo p ro life ra tiv e a nd m y e lo d y s p la s ttic d is o rd e rs , 2 83 d is o rd e rs o f a c q u ire d , 2 83 G la n z m a n n th o m b a s th e n ia , 281

P o ly m e ra s e , 320 P o ly m e ra s e c h a in re a c tio n , 2 6 4 -2 6 5 , 3 26 , 3 2 9 -3 3 0 , 3297 P o ly m e riz a tio n , 318 P o ly m o rp h is m , 3 2 4 -3 2 5 g e n e tic, 333

in h e rite d , 2 8 0 s to ra g e pool d is o rd e rs , 280-281

P o ly m y o s itis , 3 15

vo n W ille b ra n d d is e a s e , 2 8 1 -2 8 2 , 2 8 1 1

P o ly s a c c h a rid e v a c cin e , 165

ind ice s, 259 © A S C P 2018

P o n tia c fe v e r, 98 ISBN 9 7 8 -0 8 9 1 8 9 -6 6 7 8

445

Index

Porphyrom onas— Procainam ide P o rp h y ro m o n a s g in g iv a lis , 180

la b o ra to ry te s ts in, 17-1 9 a m n io tic flu id b iliru b in , 17

P o rta l v e in th ro m b o s is , 4 6 P o s a c o n a z o le , 146

a s s e s s in g risk o f p re te rm birth , 18

P o s itiv e c ro s s m a tc h , 65

e v a lu a tio n o f d is e a s e s , 1 8-1 9, 1 8f a u to im m u n e d is e a s e s , 19 e n d o c rin e d is o rd e rs , 19 g e n ito u rin a ry d is e a s e s , 19 h e p a tic d is e a s e , 19 fe ta l lung m a tu rity , d e te rm in a tio n of, 18

P o s ta n a ly tic v a ria b le s , 4 1 2 P o s te rio r u re th ra l v a lv e s , 3 3 8 P o s th e rp e tic n e u ra lg ia , 106 P o s tm o rte m c h e m is trie s , 3 9 -4 0 a n a ly te s B U N a n d c re a tin e , 4 0

h u m a n c h o rio n ic g o n a d o tro p in , 17 p re n a ta l s c re e n in g fo r tris o m y a n d n e u ra l tu b e d e fe cts, 17-18

c h lo rid e , 4 0 , 4 0 f d ig o x in , 4 0, 4 0 1

tra n s m is s io n o f v iru s e s , 116

g lu c o s e , 4 0

P re m a tu re a th e ro s c le ro s is , 25

p o ta s s iu m , 4 0, 4 0 f

P re n a ta l s c re e n in g fo r tris o m y and n e u ra l tu b e d e fe c ts, 17-18

s o d iu m , 4 0 , 4 0 1 try p ta s e a n d p o s tm o rte m d ia g n o s is o f a n a p h y la x is , 4 0 s a m p le s , 39

P re re n a l a z o te m ia , 16 P re te rm birth, a s s e s s in g risk of, 18 P re tra n s fu s io n p ro c e d u re s , 59

P o s tm y o c a rd ia l in fa rc tio n , 4 5 P o s ts tre p to c o c a lo g lo m e ru lo n e p h ritis , 316

a u to a n tib o d ie s in b lo o d b an k, 6 7 -6 8 , 6 I t

P o s ttra n s fu s io n p u rp u ra , 91, 2 2 2

b lo o d b a n k in g c o n s id e ra tio n s w ith co ld a u to a n tib o d y , 68 co ld re a c tin g a u to a n tib o d ie s , 67

P o ta s s iu m , 4 0 , 4 0 f

m e c h a n is m s o f d ru g in d u ce d p o s itiv e , 68

in d ia b e tic k e to a c id o s is , 28

m ixed ty p e a u to a n tib o d ie s , 67

P o tte r s e q u e n c e , 3 3 7

p a ro x y s m a l co ld h e m o g lo b in u ria (P C H ), 68

P o x v irid a e , 110

w a rm re a c tin g a u to a n tib o d ie s , 67 n o n ro u tin e , p o s itiv e a n tib o d y s c re e n o r c ro s s m a tc h , 6 2-6 8, 6 3 f, 6 4 1, 6 5 f, 66f, 6 7 1, 6 8 1

P ra d e r-W illi s y n d ro m e , 3 5 6 f P ra s u g re l, 2 8 9

ro u tin e , 59f, 6 0 -6 2 , 6 0 f, 6 1 1

P re a lb u m in , 7, 7 1 P re a n a ly tic v a ria b le s , 4 1 1 -4 1 2 , 4 1 1f, 4 1 2 1 P re c is io n , 4 0 5 P re c u s o r B a c u te lo y m p h o b la s tic le u k e m ia , 2 3 7 , 2 3 7 1 P re c u s o r n e o p la s m s , 2 3 6 -2 3 7 , 2 3 7 it a c u te le u k e m ia w ith m ix e d lin e a g e , 2 3 7 B a c u te ly m p h o b la s tic le u k e m ia /ly m p h o b la s tic ly m p h o m a w ith re c u rre n t g e n e tic a b n o rm a litie s , 2 3 7 , 2 3 8 1

P re v o te lla , 179 P rim a ry a d re n a l h y p e rc o rtis o lis m , 36 P rim a ry a d re n a l in s u ffic ie n c y , 3 6 -3 7 P rim a ry a ld o ste ro n is m , 37 P rim a ry b ilia ry cirrh o sis , 312 P rim a ry c u ta n e o u s D L B C L , leg typ e , 2 34 P rim a ry D L B C L o f th e C N S , 2 3 3 , 2 3 3 /

p re c u s o r B a c u te lo y m p h o b la s tic le u k e m ia /ly m p h o b la s tic ly m p h o m a , N O S , 2 3 7 , 2 3 7 f

P rim a ry e ffu sio n ly m p h o m a , 1 08 -10 9 , 2 34 , 2 3 5 /

T a c u te ly m p h o b la s tic le u k e m ia , 2 3 7

P rim a ry h y p e rp a ra th y ro id is m , 13

P re d o m in a n t h y p e rc h o le s te ro le m ia , 25

P rim a ry h e m o s ta s is , 2 74 P rim a ry h y p o p a ra th y ro id is m , 13

P re d o m in a n t h y p e rtrig ly c e rid e m ia , 25

P rim a ry m e d ia s tin a l la rg e B ce ll ly m p h o m a , 2 34

P re g n a n c y

P rim a ry m u e lo fib ro s is , 251

la b o ra to ry e v a lu a tio n o f d is e a s e s in, 1 8 -1 9 , 187

P rim a ry s c le ro s in g c h o la n g itis , 3 12 P rio n s, 116 P riv a c y A c t (1 9 7 4 ), 4 0 0 P riv a c y R ule (1 9 9 6 ), 4 0 0 P ro c a in a m id e , 24, 3 07

446

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

Index

Proficiency— Quality P ro te in u ria , b e n ig n ty p e s of, 41

P ro fic ie n c y te stin g , 334, 4 1 0 C e m b ro w s k i ru le rs fo r e v a lu a tio n o f d ata, 4 1 0 , 411 f

P ro te u s m ira b ilis , 169

P ro g re s siv e h y d ro ly s is , 24

P ro te u s s y n d ro m e , 380

P ro g re s siv e s y s te m ic s c le ro s is , 3 1 1 -3 1 2

P ro te u s v u lg a ris, 169

P rola ctin, 39

P ro th ro m b in tim e , 4, 2 78

P ro life ra tio n a s sa ys, 3 00

P ro th ro m b in va ria n t, 2 86

P ro ly m p h o c y tic le u k e m ia , 2 31 , 2 3 1 1

P ro to n p u m p in h ib ito r th e ra p y , 9 7

P ro o p io m e la n o c o rtin , 39

P ro to th e c a , 145

P ro p h a se , 324

P ro to th e c a w ic k e rh a m ii, 145

P ro p io n ib a c te riu m a cn e s, 98, 179

P ro to th e c o s is , 145

P ro s ta te c a n c e r s c re e n in g , 29

P ru n e b e lly s y n d ro m e , 337

P ro s ta te s p e c ific a n tig e n , 29

P s e u d a lle s c h e ria b oyd ii, 1 4 3 -14 4

P ro s th e tic jo in t in fe c tio n s , 98

P s e u d o c h y lo u s e ffu s io n , 45

P ro te c te d h ea lth in fo rm a tio n , 4 0 0

P s e u d o h y p e rk a le m ia , 12

P ro te in (s), 6 -11 , 41

P s e u d o h y p o n a tre m ia , 12

c ry o g lo b u lin e m ia , 10 c ry o g lo b u lin s , 10-11 m ixe d c ry o g lo b u lin e m ia , 11

P s e u d o h y p o p a ra h y ro id is m , 3 42 P s e u d o m e m b ra n o u s colitis, 178, 1 78 / P s e u d o m o n a s a e ru g in o s a , 170

C S F p ro te in e le c tro p h o re s is , 10, 10 f

P s e u d o th ro m b o c y to p e n ia , 221

la b o ra to ry m e th o d s im m u n o fix a tio n and im m u n o ty p in g , 11, 11 f

P T E N re la te d d is o rd e rs , 380

p ro te in e le c tro p h o re s is , 11 m a jo r s e ru m p ro te in s , 6 -8, 7 f a lb u m in , 6-8, 7 1 a 1 -a n titry p s in , 7, 7t c e ru lo p la s m in , 7, 7 1 C -re a c tiv e p ro te in , 7f, 8

P u b lic a n tig e n s , 301 P u lm o n a ry a n th ra x , 158 P u lm o n a ry e m b o lis m , 6 P u lm o n a ry h y p o p la s ia , 336 P u lm o n a ry tu m o rs , 3 7 5 -3 7 6 P u lse o x im e try , 14, 261

fib rin o g e n , 7f, 8

P u re e ry th ro id le u k e m ia , 256, 2 5 6 /

h a p to g lo b in , 7 -8, I t

P u re red cell a p la sia , 215

a 2 -m a c ro g lo b u lin , 7, I t

a c q u ire d , 2 1 5

p re a lb u m in , 7, I t

P y im id in e 5 ’ n u c le o tid a s e d e fic ie n c y , 2 02

tra n s fe rrin , 7f, 8

P y lo ric s te n o s is , 344

p a tte rn s in se ru m p ro te in e le c tro p h o re s is , 8 -10 a c u te in fla m m a tio n , 8, 9 f a 1 -a n titry p s in d e fic ie n c y , 8, 8 f

P y ro p o ik ilo c y to s is , h e re d ita ry, 2 0 0 P y ro s e q u e n c in g , 3 32 , 3 3 2 f P y ru v a te k in a s e d e fic ie n c y , 2 0 1 -2 0 2

b is a lb u m in e m ia , 8 m o n o c lo n a l g a m m o p a th y , 9 -10 , 9 f, 10 f n e p h ro tic s y n d ro m e , 8 n orm a l s e ru m , 8, 8 f

Q Q b a n d in g , 3 25

li- y b rid g in g , 9

Q fe v e r, 184

u rin e p rote in e le c tro p h o re s is , 10, 10f o v e rflo w p ro te in u ria p atte rn , 10 tu b u la r p ro te in u ria p a tte rn , 10

Q u a d sc re e n , 17 Q u a lity a s s u ra n c e , 396, 407 Q u a lity c o n tro l, 4 0 8

P rotein C d e fic ie n c y , 2 86

a lte rn a tiv e s to tra d itio n a l, 4 1 0

P ro te in e le c tro p h o re s is , 11

in d iv id u a liz e d pla n s, 410

P rotein S d e fic ie n c y , 286

tra d itio n a l, 4 0 8 -4 1 0

© A S C P 2018

ISBN 9 7 8 -0 8 9 1 8 9 -6 6 7 8

447

Index

Quality— Rhabdomyolysis Q u a lity im p ro v e m e n t, 4 0 7

th a la s s e m ia , 2 0 6 -2 0 8 , 2 0 6 / a th a la s s e m ia s y n d ro m e s , 2 0 7 P th a la s s e m ia s y n d ro m e s , 2 07 h e m o g lo b in A 2 p rim e , 2 08 h e re d ita ry p e rs is te n c e o f fe ta l h e m o g lo b in , 2 08 im m u n e h e m o ly tic d is o rd e rs , 2 0 8 -2 1 0 , 2 0 8 /, 2 0 9 it,

Q u a lity m a n a g e m e n t, 4 0 7 -4 1 0 Q u a n tita tiv e P C R , 3 3 0 , 3 3 0 f Q u e b e c p la te le t s y n d ro m e , 2 8 0

210/, 21 Iff

R

in d ice s, 2 58

R a d io a c tiv e io d in e u p ta k e (R A IU ), 33

m o rp h o lo g ic fin d in g s in, 2187

R a m s a y H u n t s y n d ro m e , 106

R ed ce ll A C P , 2

R A S T (ra d io a lle rg o s o rb e n t te s t), 3 0 0

R e d ce ll casts, 4 3

R a t b ite fe v e r, 175, 182

R ed skin , 2 1 /

R a y n a u d p h e n o m e n o n , 311

R e fe re n c e in te rv a ls , 4 0 3 -4 0 4

R b a n d in g , 3 2 5

R e g a n iso e n zym e , 2

R e a c tiv e a rth ritis , 311

R e la p s in g fe v e r, 182

R e a c tiv e a rth ro p a th y , 97

R e la tiv e th ro m b o c y th e m ia , 2 5 0

R e a c tiv e ly m p h o c y to s is , 2 2 0

R e la tiv e va lu e u n its (R V U s), 3 99

R e a c tiv e n e u tro p h ilia , 2 2 0

R e n a l a rte ry s te n o s is , 38

R e a g e n t red ce ll p a n e l, 6 2 -6 3

R e n a l cell c a rd in o m a , 3 36 , 3 6 6 -3 6 7

R e a g e n ts , 3 9 9 R e c ip ie n t b lo o d , A B O a n d R h te s tin g of, 60

R e n a l F a n co n i s y n d ro m e , 3 3 5 -3 3 6 R e n a l fu n c tio n

R e d b lo o d ce ll a p h e re s is , m u ltic o m p o n e n t d o n a tio n s a n d , 57

b lo o d urea n itro g e n , 15

R e d b lo o d c e lls , 4 3, 7 5 f

B U N c re a tin in e ratio, 16

c o m p o n e n ts of, 7 4 -7 6 , 7 5 f d is e a s e s of, 2 0 0 -2 1 0 c y to s k e le ta l d is o rd e rs , 2 0 0 -2 0 1 h e re d ita ry e llip to c y to s is /h e rre d ity o v a lo c y to s is , 2 0 0 h e re d ita ry s p h e ro c y to s is , 2 0 0 , 2 0 0 / h e re d ita ry s to m a to c y to s is , 2 0 0 , 2 01 /, 2 0 3 e n z y m e d is o rd e rs , 2 0 1 -2 0 2 g lu c o s e -6 -p h o s p h a te d e h y d ro g e n a s e (G 6 P D ) d e fic ie n c y , 2 0 1 , 2 0 1 / p y im id in e 5 ’ n u c le o tid a s e d e fic ie n c y , 2 0 2 p y ru v a te k in a s e (P K ) d e fic ie n c y , 2 0 1 -2 0 2 s tru c tu ra lly a b n o rm a l h e m o g lo b in v a ria n ts , 2 0 2 -2 0 6 , 202/ a lte re d o x y g e n a ffin ity h e m o g lo b in s , 2 0 5 , 2 0 5 / c a rb o x y h e m o g lo b in , 2 0 6 , 2 0 6 / h e m o g lo b in C , 2 0 4 , 2 0 4 / h e m o g lo b in C & G , 2 0 4 h e m o g lo b in c o n s ta n t s p rin g , 2 0 5 h e m o g lo b in E, 2 0 4 h e m o g lo b in L e p o re , 2 0 4 -2 0 5 h e m o g lo b in S, 2 0 2 -2 0 4 , 2 0 3 it m e th e m o g lo b in , 2 0 5 -2 0 6 s u lfh e m o g lo b in , 2 0 6 u n s ta b le h e m o g lo b in s , 2 0 5

c re a tin in e and g lo m e ru la r filtra tio n ra te c a lc u la tio n s , 15-16 c y s ta tin C , 16 te s ts of, 15 u rin e p rote in a n d u rin e a lb u m in , 16 R e n a l in s u ffic ie n c y , 5, 6 R e n a l tra n s p la n ta tio n , 3 02 R e p lic a tio n fo rk , 323, 3 2 3 f R e s p ira to ry a c id o s is , 14, 15 R e s p ira to ry a lk a lo s is , 14, 15 R e s p ira to ry s y n cy tia l v iru s, 1 14 -11 5 , 115/ R e s tric tio n e n z y m e s , 3 2 6 -3 2 7 R e s tric tiv e c a rd io m y o p a th y , 3 39 R e tic u la tio n co un t, 2 17 , 258, 2 5 8 / R e tic u lo c y te h e m o g lo b in c o n c e n tra tio n , 2 58 R e tic u lo c y to s is , 2 00 R e tin itis , 107 R e tin o b la s to m a , 3 7 4 -3 7 5 R F L P , 327 R h, 8 4-8 5, 8 4 / te s tin g , 5 8 -6 0 , 5 8 / R h a b d o m y o ly s is , 2, 6 c a u s e s of, 4 1 /

448

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

Index

Rhabdomyosarcoma— Serum R h a b d o m y o s a rc o m a , 370

s

R h a b d o v irid a e , 115, 115/

St. L o u is e n c e p h a litis , 98, 1 10 -11 1

R h e u m a tic fe v e r, 153

S a lic y la te (a s p irin ), 23

R h e u m a to id a rth ritis , 4 5, 310-311

S a liv a , 20

R h e u m a to id fa c to r, 3 09

S a liv a ry g la n d tu m o rs , 371

Rh H D F N , p re v e n tio n of, 7 3 1

S a lm o n e lla , 96, 148, 167

Rh im m u n e g lo b u lin (R h lg), 79

S a lm o n e llo s is , 167

Rh in c o m p a tib le b lo o d p ro d u cts, 70, 7 0 1

S a lp in g itis , 5

R h in o s p o rid iu m s e e b e ri, 140

S a n g e r d id e o x y s e q u e n c in g , 3 3 2 , 3 3 2 f

R h in o v iru s , 112

S a rc o id o s is , 13, 38

R h iz o p u s , 144, 144/

S a te llito s is , 2 8 0

R hlg, 7 3 1

S c a rle t fe v e r, 153

c a lc u la tin g d o s e of, 7 3 t

S c e d o s p o riu m a p io s p e rm u m , 1 43

R h o d o c o c cu s , 162, 162/

S c h illin g te s t, 2 1 3

Rh te s tin g o f re c ip ie n t b lo o d, 5 8 -6 0 , 5 8 f

S c h is to c y te s , 2 5 8 , 2 8 0

Rh typ e , 5 8 -5 9

S c h is to s o m e s , 125, 1 2 5 /

R ib o s o m a l R N A , 319

S c h w a c h m a n -B o d ia n -D ia m o n d s y n d ro m e , 3 5 0 , 3 5 0 /

R ic h te r sy n d ro m e , 224, 2 2 5 f (see a lso C o xie lla )

S c h w a c h m a n -D ia m o n d s y n d ro m e , 3 5 0 , 3 5 0 /

R ic k e tts ia , 1 83 -18 4 , 1 8 4 f

S c le rd e rm a , 311

R ic k e tts ia a k a ri (ric k e tts ia lp o x ), 184

S c le ro d a ty ly , 311

R ic k e tts ia p ro w a z e k ii, 184

S c ru b ty p h u s , 184

R ic k e tts ia ric k e tts ii (O rie n tia ts u ts u g a m u sh i), 184 R ic k e tts ia typhi, 184 R ig h t h e a rt d is e a s e , 46 R ile y -D a y sy n d ro m e , 344, 3 5 2 -3 5 3 R iv a ro x a b a n , 2 88 R N A (R ib o n u c le ic a cid ), 318, 3 1 9 -3 2 0 rib o so m a l, 319 tra n s fe r, 320 R o c k y M o u n ta in sp o tte d fe ve r, 185 R o m a n a sign, 121 R o m a n o -W a rd sy n d ro m e , 3 38 , 339 ro se b u d , 4 4 9 R o se ola , 1 08 -10 9 R o th ia , 152 R o to r sy n d ro m e , 348 R o u gh e n d o p la s m ic re ticu lu m , 323 R o u n d w o rm s , 126/, 1 26 -12 8 R u b e o la , 1 14 -11 5 R u b iviru s: ru be lla , 113 R u m a c k -M a tth e w n o m o g ra m , 23, 2 3 f

S e b o rrh e ic d e rm a titis , 133 S e c o n d a ry a d re n a l in s u ffic ie n c y , 37 S e c o n d a ry h y p e rp a ra th y ro id is m , 13 S e c o n d a ry p o ly c y th e m ia , 2 50 S e c re tin c h o le c y s to k in in te st, 5 S e (F U T 2 ) g e n e , 8 1 -8 2 S e le c tiv e Ig A d e fic ie n c y , 304, 3 0 4 / S e lf re fe rra l law , 4 0 0 S e n ile c a rd ia c a m y lo id o s is , 3 3 9 S e n s o rin e u ra l d e fic its , 11 S e p s is , 6 tra n s fu s io n tra n s m itte d , 90 S e p tic a rth ritis , 4 6 S e p tic e m ia , 167 S e p tic e m ic p la g u e , 176 S e ro lo g ic c ro s s re a c tiv ity , 301 S e ro lo g ic m a rk e rs , 311 S e ro n e g a tiv e s p n d y lo a rrth ro p a th ie s , 311 S e ro to n in , 31 S e rra tia s p p , 97 S e ru m e le c tro p h o re s is , p a tte rn s in, 8 -1 0 S e ru m in te g ra te d sc re e n , 17

© A S C P 2018

ISBN 9 7 8 -0 8 9 1 8 9 -6 6 7 8

449

Index

Serum— Statistical S e ru m p ro te in e le c tro p h o re s is , p a tte rn s in, 8 -1 0

S o ft tis s u e a nd b o n e tu m o rs , 3 6 8 -3 7 1 , 3 6 8 f

a c u te in fla m m a tio n , 8, 9 f

E w in g s a rc o m a fa m ily o f tu m o rs , 3 6 8 -3 6 9

c q -a n titry p s in (A A T ) d e fic ie n c y , 8, 8 f b is a lb u m in e m ia , 8

lo w g ra d e fib ro m y x o id s a rc o m a /h y a lin iz in g s p in d le tu m o r w ith g ia n t ro se tte s , 3 70

m o n o c lo n a l g a m m o p a th y , 9 -1 0 , 9 f, 1 0 f

n e u ro b la s to m a , 3 6 9 -3 7 0 , 3 70 / rh a b d o m y o s a rc o m a , 370

n e p h ro tic s y n d ro m e , 8

s y n o v ia l s a rc o m a , 370, 3 70 /

n o rm a l, 8, 8 f

tu m o rs o f a d ip o c y te s , 370-371

ft-y b rid g in g , 9

S o lita ry p la s m a c y to m a , 2 39

S e ru m s ic k n e s s , 3 1 6

S o lv e n t e x c lu s io n e ffe ct, 4 0 5 -4 0 6

S e z a ry s y n d ro m e , 2 4 3

S o m a tic cells, 2 9 9

S h e e h a n s y n d ro m e , 19, 38

S o p p o ro c la s s ific a tio n o f a n tip h o s p h o lip id s y n d ro m e , 2 8 7 t

S h e w h a rt, W a lte r, 4 0 8

S o u th A m e ric a n b la s to m y c o s is , 136

S h e w h a rt c o n tro l c h a rts , 4 0 8

S o u th e a s t A s ia n o v a lo c y to s is , 2 0 0

S h ig e lla , 9 6 1, 9 7, 1 6 7 -1 6 8

S o u th e rn b lo ttin g, 327

S hock, 6 a c u te b lo o d lo s s a s c a u s e of, 6 9, 6 9 1 S h o rt ta n d e m re p e a ts , 3 3 3

S p e c ific g ravity, 42 S p e c im e n s ta b ility, 406 S p e c tra l k a ry o ty p e im a g in g , 3 28

S h u lm a n s y n d ro m e , 221 S h w a c h m a n -D ia m o n d s y n d ro m e , 2 1 6 , 3 1 6 1 S ic k le c e ll a n e m ia , 38

S p e rm a to g e n e s is , 3 25 S p e rm a to g e n ic m e io s is , 3 24 S p h e ro c y te s , 200

S ic k le c e ll d is e a s e

S p h e ro c y to s is , h e re d ita ry , 2 00 , 2 00 /

c lin ic a l c o u rs e of, 2 0 2 -2 0 3

S p in a l m u s c u la r a tro p h ie s , 352

tra n s fu s io n in, 69

S p ire llu m m in u s, 182

S ic k le ce ll n e p h ro p a th ie s , 2 0 3

S p iro c h e te s , 1 80 -18 1 , 180/

S ic k le c e ll tra it, 2 0 3 . 2 0 3 it

S p le n d o re -H o e p p li p h e n o m e n o n , 136

S ic k lin g te s t, 2 5 9

S p le n ic s e q u e stra tio n crisis, 2 02

S id e ro b la s tic a n e m ia , 2 1 4 , 2 1 4 /

S p le n o m e g a ly , 2 0 0 , 2 46

S ig n a l a m p lific a tio n , 3 3 1 -3 3 2

S p lic in g , 322

S ig n a l re c o g n itio n p a rtic le s , 3 0 8 , 3 0 9

S p o ra d ic and m u ltifa c to ria l c o n g e n ita l d is o rd e rs , 3 3 7 -3 3 8

S in g le fu s io n p ro b e s , 3 2 8

S p o ra d ic renal cell c a rc in o m a , 3 67 , 3 67 /

S in g le n u c le o tid e p o ly m o rp h is m s , 3 2 4

S p o ro th rix , 136

S ip p le s y n d ro m e , 3 72

S p o ro tric h o s is , 136

6 S ig m a , 4 0 8

S P T B , 200

S jo g re n s y n d ro m e , 3 0 6 , 3 1 2

S p u rio u s h y p o n a tre m ia , 11

S k e le ta l m u s c le d is e a s e s , 3 5 3 -3 5 4

S q u a m o u s cell c a rc in o m a , 371

S k in tu m o rs , 3 7 3

S ta lk e ffect, 39

d e rm a to fib ro s a rc o m a p ro tu b ra n s , 3 7 3

S ta p h y lo c o c c u s a u re u s , 98, 1 50 -15 1 , 150f, 151 f

m e la n o m a , 3 7 3

S ta p h y lo c o c c u s e p id e rm id is , 151, 151 f

S L A M a s s o c ia te d p ro te in , 3 0 5

S ta p h y lo c o c c u s h a e m o ly tic u s , 152

S le e p d e a th , 3 3 8

S ta p h y lo c o c c u s lu g d u n e n s is , 151

S m a ll ly m p h o c y tic ly m p h o m a , 9, 2 2 3 -2 2 5 , 2 2 4 /, 2 2 5 ft

S ta p h y lo c o c c u s s a p ro p h y tic u s , 96, 1 51 -15 2 , 151 f

S m a llp o x , 110

S ta rk law , 4 0 0

S m ith -L e m il-O p itz s y n d ro m e , 3 4 4

S ta tis tic a l c o n s id e ra tio n s in th e la b o ra to ry , 402/, 4 0 2 -4 0 4

S m ith -M a g e n is s y n d ro m e , 3 5 6 1

d ia g n o s tic a c c u ra c y and, 4 0 3 , 4 0 3 f

S o d iu m , 4 0 , 4 0 f

re fe re n c e in te rv a ls in, 4 0 3 -4 0 4

450

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

Index

Statistical—Telophasee S ta tis tic a l q u a lity c o n tro l, 4 0 8 -4 1 0 , 4 0 9 f

S y n o v ia l s a rc o m a , 3 70

S te a to sis , m ic ro v e s ic u la r, 19

S y p h ilis , 92, 1 80 -18 1 , 180it c o n g e n ita l, 181

S te n o tro p h o m o n a s m a lto p h ilia , 170-171 S te ro id re ce p to rs , 3 6 5

S y s te m ic lu p u s e ry th e m a to s u s , 11, 19, 3 07 , 3 0 9 -3 1 0 , 3117

S te roid s u lfa ta s e d e fic ie n c y , 342

S y s te m ic v a s cu litis , 307

S to m a to c y to s is , 201 h e re d ita ry , 2 00 , 201/, 2 03

T

S tra n d d is p la c e m e n t a m p lific a tio n , 3 29

T 3 re sin u p ta k e , 33

S tre p to b a c illu s , 1 75 -17 6

T a c u te ly m p h o b la s tic le u k e m ia , 2 3 7

S tre p to c o c c u s a g a la c tia e , 152 f, 154

T a en ia s a g in a ta , 124

S tre p to c o c c u s a n g in o s u s g ro u p , 154

T a en ia s o liu m , 124, 124/

S tre p to c o c c u s b o vis, 156

T a k a y a s u a rte ritis , 314

S tre p to c o c c u s p n e u m o n ia e , 97, 1527, 1 54 -15 5 , 155/

T a m m -H o rs fa ll (tu b u la r) prote in, 16, 41

S tre p to c o c c u s p y o g e n e s , 152 f, 1 52 -15 3

T a p e w o rm s , 124, 124/

S tre p to c o c c u s re la te d o rg a n is m s , 158

T a rtra te re s is ta n t A C P (T R A P ), 2

S tre p to c o c c u s s a n g u is, 97

T A T A box, 322

S tre p to c o c c u s virid an s, 1 52 f S tro n g y lo id e s s te rc o ra lis (th re a d w o rm ), 1 26 -12 7 , 127/ S tru c tu ra l c a rd ia c d is o rd e rs , 340, 3 4 0 1 S tru c tu ra lly a b n o rm a l h e m o g lo b in v a ria n ts , 2 0 2 -2 0 6 , 2 0 2 f a lte re d o x y g e n a ffin ity h e m o g lo b in s , 2 05 , 2057

T c e ll/h is tio c y te rich la rg e B ce ll ly m p h o m a , 2 3 4 T cell la rg e g ra n u la r ly m p h o c y tic le u k e m ia , 2 4 2 , 2427 T cell n e o p la s m s , 221 a d u lt T cell le u k e m ia /ly m p h o m a , 2 4 0 a g g re s s iv e N K cell le u ke m ia , 2 4 2

c a rb o x y h e m o g lo b in , 2 06 , 2 0 6 f

a n a p la s tic la rg e ce ll ly m p h o m a , A L K + , 2 4 1 , 2 4 1 /

h e m o g lo b in C, 2 04 , 2047

a n g io im m u n o b la s tic T cell ly m p h o m a , 2 4 0 -2 4 1 , 2 4 1 /

h e m o g lo b in C & G, 2 04

c h ro n ic ly m p h o p ro life ra tiv e d is o rd e r o f N K ce lls, 2 4 2

h e m o g lo b in c o n s ta n t s p rin g , 205

c u ta n e o u s T cell ly m p h o m a , m y c o s is fu n g o id e s , a nd S e z a ry s y n d ro m e , 2 43

h e m o g lo b in E, 204 h e m o g lo b in L ep o re , 2 0 4 -2 0 5

e n te ro p a th y a s s o c ia te d T ce ll ly m p h o m a , 2 42

h e m o g lo b in S, 2 0 2 -2 0 4 , 2 0 3 it

h e p a to s p le n ic T cell ly m p h o m a , 2 4 2

m e th e m o g lo b in , 2 0 5 -2 0 6

n asa l ty p e n a tu ra l k ille r/T ce ll ly m p h o m a s , 2 4 2

s u lfh e m o g lo b in , 206

p e rip h e ra l T cell ly m p h o m a , N O S , 2 4 0 , 2407

u n s ta b le h e m o g lo b in s, 2 0 5

s u b c u ta n e o u s p a n n ic u litic T cell ly m p h o m a , 2 4 2 -2 4 3

S tru v ite sto n es, 42

T cell la rg e g ra n u la r ly m p h o c y tic le u k e m ia , 2 4 2 , 2 4 2 f

S u b a c u te s p o n g ifo rm e n c e p h a lo p a th ie s , 116

T ce ll re ce p to r, 2 97 , 2977

S u b c lin ic a l h y p o th y ro id is m , 34

T ce lls, 2967, 2 97

S u b c u ta n e o u s fila ria s is , 127

d e fe c ts in, 300 a ta x ia te la n g ie c ta s ia , 305

S u b c u ta n e o u s p a n n ic u litic T cell ly m p h o m a , 2 4 2 -2 4 3 S u lfh e m o g lo b in , 2 06

c h ro n ic m u c o c u ta n e o u s c a n d id ia s is , 3 0 5

S y n a p to p h y s in , 31

D iG e o rg e sy n d ro m e , 3 0 4 -3 0 5

S y n d ro m e o f in a p p ro p ria te a n tid iu re tic h o rm o n e , 39

D u n c a n d is e a s e , 3 05

S y n d ro m e o f tra n s ie n t h y p e rth y ro id is m o f h y p e re m e s is g ra v id a ru m , 19

h y p e r IgM sy n d ro m e , 305

S y n d ro m ic h ea rin g loss, 355 S y n d ro m ic p a u c ity o f th e bile d uct, 345/', 3 4 5 -3 4 6 S y n o v ia l flu id , 46, 4 6 ft a n a lys is of, 307, 311 © ASCP2018

s e v e re c o m b in e d im m u n o d e fic ie n t, 3 0 5 W is k io tt-A ld ric h s y n d ro m e , 3 0 5 s p e c ific te s tin g o f fu n ctio n , 3 0 0 T e la n g ie c ta s ia , 3 1 1 ,3 4 4 T e lo p h a s e e , 324

ISBN 9 7 8 -0 8 9 1 8 9 -6 6 7 8

451

Index

Temporal—Toxicology T e m p o ra l a rte ritis , 3 1 4 , 3 1 5 /

T h y ro g lo b u lin , 2 9-3 0

T e n d in o u s x a n th o m a s , 2 5

T h y ro id c h e m is try , 3 2 -3 5

T e rm in a l c o m p le m e n t, e ffic ie n c ie s in, 3 0 0

e x o g e n o u s e s tro g e n s , 34

T e rtia ry h y p e rp a ra th y ro id is m , 13

fu n c tio n te s ts , 3 2 -3 3 , 3 2 1

T e s tic u la r tu m o rs , 3 6 8

h y p e rth y ro id is m , 3 3 -3 4

T h a la s s e m ia , 2 0 6 -2 0 8 , 2 0 6 1

h y p o th y ro id is m , 34

a th a la s s e m ia s y n d ro m e s , 2 0 7

m e d ic a tio n s, 3 4 -3 5

P th a la s s e m ia s y n d ro m e s , 2 0 7

n e o n a ta l h y p o th y ro id is m , 34

c o in h e rita n c e o f, 2 0 3

n o n th y ro id a l illn e s s s y n d ro m e , 34

h e m o g lo b in A 2 p rim e , 2 0 8

th y ro id fu n c tio n te s ts , 3 2 -3 3 , 3 2 1

h e re d ita ry p e rs is te n c e o f fe ta l h e m o g lo b in , 2 0 8 im m u n e h e m o ly tic d is o rd e rs , 2 0 8 -2 1 0 , 2 0 8 f, 2 0 9 it, 21 (

21 Iff

T h y ro id g la n d, 343 d is o rd e rs in v o lv in g , 3 43 tu m o rs of, 3 7 1 -3 7 2 , 3 72 /

T h e o p h y llin e th e ra p y , 3

T h y ro id itis , 34

T h e ra p e u tic a g e n ts

T h y ro id -re le a s in g h o rm o n e , 33

d ire c t th ro m b in in h ib ito rs , 2 8 9

T h y ro tro p in , 33

fo n d a p a rin u x (a rix tra ), 2 8 9

T h y ro x in e b in d in g p re a lb u m in , 7

lo w m o le c u la r w e ig h t h e p a rin , 2 8 9

T ic k s , 1 02 1

o ra l, 2 8 8

T ic lo p id in e (T iclid), 2 89

u n fra c tio n e d h e p a rin , 2 8 8 -2 8 9

T in e a ca pitis, 137

W a rfa rin (c o u m a d in ), 2 8 8

T in e a co rp o ris, 137

T h e ra p e u tic a p h e re s is , 7 0 -7 2 , 7 0 t, 7 1 1

T in e a cruris, 137

T h e ra p e u tic d ru g m o n ito rin g

T in e a p e d is, 137

a m in o g ly c o s id e s , 24

T ine a u ng u iu m , 137

d ig o x in , 2 4

T is s u e n e m a to d e s , 127

p ro c a in a m id e , 2 4

T is s u e p la s m in o g e n a c tiv a to r (tP A ), 275

T h ie n o p y rid in e s , 2 8 9

T o g a v irid a e , 102 f, 113

T h in b a s e m e n t m e m b ra n e d is e a s e , 3 3 4

T o rs a d e de p o in te s, 338

T h io p u rin e m e th y ltra n s fe ra s e , 3 3 3

T o ta l le u k o c y te c o u n t, 2 58

T h io p u rin e s , 3 3 3

T o ta l Q u a lity M a n a g e m e n t, 4 0 8

T h ro m b in tim e , 2 7 8

T o x ic a d e n o m a , 34

T h ro m b o a n g itis o b lite ra n s , 314

T o x ic a ge n ts, s ig n s o r s y m p to m s a s s o c ia te d w ith , 2 1 1

T h ro m b o c y th e m ia , e s s e n tia l, 2 5 0 , 2 5 0 1

T o x ic a lco ho l p o is o n in g , 22, 2 2 1

T h ro m b o c y to p e n ia , 2 2 1 -2 2 3 , 3 0 0

T o x ic m u ltin o d u la r g o ite r, 34

w ith a b s e n t ra d ii s y n d ro m e , 2 1 5

T o x ic o lo g y , 19-24

c o n g e n ita l a m e g a k a ry o c y tic , 2 1 5

fo re n s ic , 19-21 a m p h e ta m in e s , 20

h e p a rin in d u c e d , 2 8 7 -2 8 8 T h ro m b o c y to p e n ia p u rp u ra , 2 2 2 , 2 8 8

b a rb itu ra te s , 20

T h ro m b o c y to p e n ia w ith a b s e n t ra d ii s y n d ro m e , 2 15 , 2 2 2

co caine , 20

T h ro m b o p h ilia , 2 8 5 -2 8 8 , 2 8 5 t, 2 8 7 f

e th an o l, 20-21

s p e c ific c a u s e s of, 2 8 5 -2 8 8

m e th a m p h e ta m in e , 20

T h ro m b o s is , 2 8 5 -2 8 8 , 2 8 5 t, 2 8 7 1

o pia te s, 20

T h ro m o c y to s is , 2 2 3

p h e n c yc lid in e , 20

T h ru s h , 130 T h y m in e (T), 3 1 8 , 3 1 9

452

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

Index

Toxicology— Tumorigenesis o v e rd o s e , 2 1 -2 4

T ra n s fu s io n tra n s m itte d s e p s is , 90

a c e ta m in o p h e n p o is o n in g , 2 3

T ra n s ie n t e ry th ro c y to p e n ia o f c h ild h o o d , 2 1 5

a rse n ic , 2 3 -2 4

T ra n s ie n t n e o n a ta l h y p o th y ro id is m , 34

ca rb o n m o n o x id e p o is o n in g , 2 2 -2 3 , 2 3 f

T ra n s ie n t n e o n a ta l p o ly c th e m ia , 2 1 9

c y a n id e p o is o n in g , 2 3 g e n e ra l a s p e c ts o f la b o ra to ry e v a lu a tio n , 2 1 -2 2 , 21 f, 2 2 t lea d p o is o n in g (p lu m b is m ), 22

T ra n s ie n t s tre s s ly m p h o c y to s is , 2 2 0 T ra n s la tio n 3 2 2 -3 2 3 3237

m e rcu ry, 24

T ra n s p la n ta tio n te stin g , 3 0 1 -3 0 2 T ra n s th y re tin , 7

o rg a n o p h o s p h a te s a nd c a rb a m a te s , 24

T ra n s th y re tin a m y lo id o s is , 3 3 9

s a lic y la te (a sp irin ), 23

T re m o r, 2 1 1

to x ic a lc o h o l p o is o n in g , 22, 2 2 f

T re n c h fe v e r, 185

tric y c lic a n tid e p re s s a n ts , 2 4

T re p o n e m a , 180

p h a rm a c o k in e tic s , 19

n o n v e n e re a l d is e a s e s c a u s e d by, 181

fre e v e rs u s b o u n d , 19 h a lf-life , 19

T re p o n e m a p a llid u m , 180, 180/

v o lu m e o f d is trib u tio n (V d), 19

T ric h in e lla s p ira lis , 127 T ric h o m o n a s h o m in is , 123

th e ra p e u tic d ru g m o n ito rin g a m in o g ly c o s id e s , 24

T ric h o p h y to n , 1 3 8 -1 3 9

d ig o xin , 24

T ric h o p h y to n m e n ta g ro p h y te s , 138

p ro c a in a m id e , 24

T ric h o p h y to n ru b ru m , 138

T o x ic s h o c k s y n d ro m e , 154

T ric h o p h y to n to n s u ra n s , 138

T o x id ro m e s , 21

T ric h o s p o ro n , 133

c o m m o n , 21 f

T ric h u ris tric h iu ra , 126

T o xo ca ra c a n is , 127

T ric y c lic a n tid e p re s s a n ts o v e rd o s e , 24

T o x o p la s m a g o n d ii, 122, 122/

T ris o m y , p re n a ta l s c re e n in g fo r, 17-1 8

T P 5 3 tu m o r s u p p re s s o r g e n e , 3 4 4 -3 4 5

T ris o m y 13, 221

T ra c h o m a , 183

T ris o m y 16, 221

T ra n s c rip tio n , 321

T ris o m y 18, 344

T ra n s c rip tio n m e d ic a te d a m p lific a tio n , 329, 3 31 , 3 3 1 f

T ris o m y 21, 221

T ra n s fe rrin , I t , 8

T ro p h e rym a w h ip p e lii, 162

T ra n s fe r R N A , 320

T ro p o n in , 6

T ra n s fu s io n (s ), 62

T ry p a n o s o m a , 1 2 1 -1 2 2 , 121/

m a ssive , 70

T ry p a n o s o m a b ru c e i, 1 2 1 ,1 2 2 it

n e o n a ta l, 62

T ry p a n o s o m a cruzi, 6, 121, 121 it

in sick le cell d is e a s e , 69

T ry p s in , 64

in sp e cia l clin ica l c irc u m s ta n c e s , 6 9 -7 0

T ry p ta s e a n d p o s tm o rte m d ia g n o s is o f a n a p h y la x is , 4 0

T ra n s fu s io n a s s o c ia te d a c u te lung inju ry, 91, 91 f

T u b e rc u lin skin te st, 189, 3 16

T ra n s fu s io n a s s o c ia te d c irc u la to ry o v e rlo a d , 93

T u b e rc u lo id le p ro sy, 192

T ra n s fu s io n a s s o c ia te d g ra ft vs h ost d is e a s e , 90, 303

T u b e rc u lo s is e ffu s io n s , 4 5

T ra n s fu s io n c o m p lic a tio n s , 8 8 -9 4 , 88f, 8 9f, 9 1 1, 9 3 f

T u b e ro u s s c le ro s is co m p le x , 3 7 7 -3 7 8

b lo o d b a n k re g u la to ry a u th o rity, 94

T u b u la r ca s ts , 43

re co rd s re te n tio n , 93, 9 3 1

T u b u la r p ro te in u ria p a tte rn , 10

s u s p e c te d tra n s fu s io n re a ctio n , 88 ty p e s o f c o m p lic a tio n s , 89 T ra n s fu s io n re la te d im m u n o m o d u la tio n , 93 © ASCP2018

T u la re m ia , 175 T u m o rig e n e s is , 3 7 3 -3 7 4 ISBN 9 7 8 -0 8 9 1 8 9 -6 6 7 8

453

Index

Tumor— Vectors T u m o r m a rk e rs , 2 8 -3 2

U ra te s to n e s , 42

a lk a lin e p h o s p h a ta s e , 31

U re a , in re n a l fu n c tio n , 15

C A 1 9 -9 , 30

U re a p la s m a u re a ly tic u m , 96, 186

C A 2 7 .2 9 a n d 1 5-3 , 30

U re m ia , 4 5, 2 83

c a n c e r a n tig e n 125, 3 0

U re th ritis , 184

c o lo re c ta l c a rc in o m a s c re e n in g , 2 9

U rin a ry b iliru b in , 41

a -fe to p ro te in , 30-31

U rin a ry tra c t in fe ctio n s, 96

h u m a n c h o rio n ic g o n a d o tro p in (h C G ), 31

U rin a ry u ro b ilin o g e n , 41

m a rk e rs o f n e u ro e n d o c rin e tu m o rs , 3 1 -3 2

U rin e, 4 0 -4 4

(12 m ic ro g lo b u lin , 31

b iliru b in a nd u ro b ilin o g e n , 4 1 -4 2 , 4 1 f

o f n e u ro e n d o c rin e tu m o rs , 3 1 -3 2

g lu c o s e , 40-41

p ro s ta te s p e c ific a n tig e n , 29

h e m o g lo b in , 41

th y ro g lo b u lin , 2 9 -3 0

k e to n e s , 41

T u m o r s y n d ro m e s , 3 7 7 -3 8 0

le u k o c y te e s te ra s e , 42

a n irid ia /W A G R s y n d ro m e , 3 7 9

n itrite , 42

B e c k w ith -W ie d e m a n n s y n d ro m e , 3 7 9

pH , 42

C a rn e y c o m p le x , 3 8 0

p ro te in , 41

c h ro m o s o m a l b re a k a g e s y n d ro m e s , 3 7 9 -3 8 0

s p e c ific g ravity, 42

L i-F ra u m e n i s y n d ro m e , 3 7 8 -3 7 9

u rin e m ic ro s c o p y , 4 3 -4 4

n e u ro fib ro m a to s is ty p e 1, 3 44 , 3 7 8

U rin e a lb u m in in re n a l fu n c tio n , 16

n e u ro fib ro m a to s is ty p e 2, 3 7 8 n e v o id b a s a l c e ll c a rc in o m a s y n d ro m e , 3 7 8 P T E N re la te d d is o rd e rs , 3 8 0

U rin e m a rk e rs fo r u ro th e lia l c a rc in o m a , 32 U rin e m ic ro s c o p y , 4 3 -4 4 U rin e p rote in e le c tro p h o re s is , 10, 10 f

tu b e ro u s s c le ro s is c o m p le x , 3 7 7 -3 7 8

o v e rflo w p ro te in u ria p a tte rn , 10

T u rc o t s y n d ro m e , 3 5 7 , 3 5 9 , 3 7 5 T u rn e r s y n d ro m e , 2 2 1 , 3 1 1 , 3 25 , 3 4 0 , 3 4 4 2 1 -h y d ro x y la s e d e fic ie n c y , 341 T y le n o l p o is o n in g , 23 T y p e 1 d ia b e te s m e llitu s , 3 4 3 T y p e 2 d ia b e te s m e llitu s , 27 T y p h u s , e p id e m ic , 184 T y ro s in e k in e a s e in h ib ito r th e ra p y , 2 4 9 T y ro s in e m ia , 3 3 6

u U hl a n o m a ly , 3 3 8 U n b u n d lin g , 3 9 9 U n c o n ju g a te d b iliru b in , 3, 4 U n c o n ju g a te d h y p e rb iliru b in e m ia , 3 U n fra c tio n e d h e p a rin , 2 8 8 -2 8 9 U n it c o s ts , 401 U n s ta b le h e m o g lo b in s , 2 0 5 U p s h a w -S c h u lo m a n s y n d ro m e , 2 8 8 U ra c il (U ), 3 1 8

454

tu b u la r p ro te in u ria p a tte rn , 10 U rin e p rote in in re n a l fu n c tio n , 16 U ro b ilin o g e n , 41 urin ary, 41 U ro k in a s e , 2 75 U ro th e lia l c a rc in o m a , 3 6 7 -3 6 8 u rin e m a rk e rs fo r, 32 U ro V y s io n a s s a y , 3 68 U s h e r s y n d ro m e , 355

V V a cc in ia , 110 V a g in itis , 130 V a n illy lm a n d e lic a cid, 32 V a ria b ility , 4 08 V a ric e lla -z o s te r viru s, 98, 106/, 1 0 6 -10 7 V a rio la , 110 V a sc u litis , 2 78 , 312, 3 1 3 1 V a so v a g a l, 5 8 1 V e cto rs , 1 0 2 1 ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018

Index

V e lo a rd io fa c ia l— X a n th o c h ro m ia

V e lo a rd io fa c ia l sy n d ro m e , 3 5 6 f

vo n R e c k lin g h a u s e n d ise a se , 378

V e n o u s th ro m b o e m b o lis m , D -d im e rs in th e d ia g n o s is of, 2 7 8

vo n W ille b ra n d ’s d is e a s e , 275 la b o ra to ry d ia g n o s is of, 282, 2 8 2 f

V e n tric u la r a rrh y th m ia s , 3 38

ty p e s of, 2 8 1 -2 8 2 , 2 8 1 1

V e rru c o u s ca rc in o m a , 109

V o ric o n a z o le , 146

V e ry lo w -d e n s ity lip o p ro te in (V LD ), 24 Vibrio, 96, 171 -17 2

w

V ibrio a lg in o ly tic u s , 172 V ibrio c h o le ra e , 97, 171, 172

W a a rd e n b u rg s y n d ro m e , 344, 3 5 5

V ibrio p a ra h a e m o ly tic u s , 171, 172

W A G R s y n d ro m e , 367, 379

V ibrio vu ln ificu s, 171, 172

W a iv e d te s ts , 396

V ire m ia , 92

W a ld e n s tro m m a c ro g lo b u lin e m ia , 9, 231

V irid a n s s tre p to c o c c i g ro u p , 155

W a rfa rin , 2 8 8 , 3 33

V iro lo g y , 1 02 -11 6 D N A v iru s e s , 1 03 -11 0 , 104f, 105ft, 106/, 107/', 1 08 fff a d e n o v irid a e : a d e n o v iru s , 1 03 -10 4

W a rm a u to im m u n e h e m o ly tic a n e m ia , 2 0 8 W a rm re a c tin g a u to a n tib o d ie s , 67

h e p a d n a v irid a e : h e p a titis B v iru s , 1 04 -10 5

W a rts , g e n ita l, 109

h e rp e s v irid a e , 1 05 -10 6 , 1 0 5 f

W a s h e d p ro d u c ts , 80

p a p o v a v irid a e , 1 0 9 -1 1 0

W a te rh o u s e -F rid e ric h s e n s y n d ro m e , 36, 163

p a rv o v irid a e , 109

W a te ry /b lo o d y d ia rrh e a , 168

p o x v irid a e , 110

W a x y ca s ts , 43

im p lic a te d v iru s e s by d is e a s e sta te s, 116

W e g e n e r g ra n u lo m a to s is , 313, 3 1 4 /

la b o ra to ry d ia g n o s is , 103

W e ll s y n d ro m e , 221

n e g a tive s e n s e R N A v iru s e s , 1 1 3 -1 1 5 b u n y a virid a e , 1 13 -11 4

W e s te rn B u rk itt ly m p h o m a /le u k e m ia , 2 3 6 W e s t N ile v iru s , 92, 98, 111

o rth o m y x o v irid a e , 114

W H IM s y n d ro m e , 2 16

p a ra m y x o v irid a e , 1 1 4 -1 1 5

W h ip p le d is e a s e , 162, 162/

rh a b d o v irid a e , 115, 115/

W h ite ce ll (n e u tro p h il) casts, 4 3

p o s itiv e s e n s e R N A v iru s e s , 1 1 0 -1 1 3 a s tro v irid a e , 113 c a lic iv irid a e , 113 c o ro n a v irid a e , 110 fla v iv irid a e , 110-111 h e p e v irid a e , 113

W h ite p ie d ra , 133 W h ite p la te le t sy n d ro m e , 280 W h o le b lo o d , 7 5 1, 76 W h o le g e n o m e te c h n iq u e , 332 W illia m s s y n d ro m e , 340, 3 5 6 f

p ic o rn a v irid a e , 1 11 -11 2

W ilm s tu m o r, 367

re tro v irid a e , 1 12 -11 3

W ils o n d is e a s e , 2, 3, 347, 347f, 3 52 d e c re a s e d c e ru lo p la s m in in, 7, 7 f

to g a v irid a e , 113 re o v irid a e , 1 15 -11 6

W is k o tt-A ld ric h s y n d ro m e , 280, 2 8 1 , 3 00

v a c cin e s , 116

W o lf s y n d ro m e , 3 5 6 f

vira l stru c tu re a nd c la s s ific a tio n , 1 02 -10 3 , 1 0 2 1

W rig h t sta in, 261

V isu a l in s p e c tio n , o f b lo o d, 62

W u c h e re ria b a n cro fti, 127

V ita m in B12, d e fic ie n c y of, 2 1 2 -2 1 3 , 2 1 2 1, 2 1 3 / V ita m in K d e fic ie n c y , 284 V ita m in K e p o x id e re d u c ta s e , 3 33 V K O R C 1 , 2 88 vo n H ip p e l-L in d a u s y n d ro m e , 3 66 ©ASCP 2018

X X a n th e la s m a , 25 X a n th o c h ro m ia , 44 ISBN 9 7 8 -0 8 9 1 8 9 -6 6 7 8

455

Index

X a n th o m a s — Z o o n o tic

X a n th o m a s e ru p tiv e , 2 5 te n d in o u s , 2 5 X e ro d e rm a p ig m e n to s a , 3 7 9 X -lin k e d c a rd io m y o p a th y , 3 5 3 X -lin k e d ic h th y o s is , 3 42 X lin k e d im m u n o p ro life ra tiv e d is e a s e , 107 X lin k e d ly m p h o p ro life ra tiv e d is e a s e , 3 0 5 X -lin k e d re c e s s iv e d is o rd e rs , 3 2 5 X ra y c ry a ta llo g ra p h y , 3 1 9

Y (b-y b rid g in g , 9 Y e a s ts , 128, 130/, 1 3 0 -1 3 3 , 1 3 1 / C a n d id a , 130, 130/, 1 3 1 / C ry p to c o c c u s , 1 3 1 -1 3 2 , 1 3 2 / Y e llo w fe v e r v iru s , 111 Y e llo w x a n th o c h ro m ia , 4 4 Y e rs in ia , 9 6, 168 Y e rs in ia e n te ro c o litic a , 9 7, 168 Y e rs in ia p e s tis , 1 7 5 -1 7 6 Y e rs in ia p s e u d o tu b e rc u lo s is , 176

z Z a lle le , 3 4 7 -3 4 8 Z a n a m iv ir, 114 Z ie h l-N e e ls e n s ta in , 147 Z in c p ro to p o rp h y rin , 22 Z in s s e r-E n g m a n -C o le s y n d ro m e , 2 1 5 Z o o n o s is , 182 Z o o n o tic n e m a to d e s , 127

456

ASCP Quick Compendium of Clinical Pathology 4e

© A S C P 2018