Michael Laposata MD, PhD

Pathologist-in-chief
Vanderbilt University Hospital

:DIAGNOSIS

O~F

CHILD ABUSE

SYMPTOMS THAT SUGGEST CHILD ABUSE AND

NONINFLICTED ENTITIES THAT MIGHT CAUSE THEM
Possible Noninflicted Cause
.

",

v~.J1Willebr~dlddis~ase

Hemophilia A and B
Thrombocytopenia with lymphoblastic leukemia
..... taminK deficiency
Purpura fulminans
. Meningifiswith.disseminafedlntravascular coagulatioJ1
Hemorrhagic disease of the newborn
..

,".

Uenoch-Schonlein purpura
Ruptured subarachnoid vascular formation
Bluesp~ts malform~tion

COMPARI 0
LIDES
OF CHILD ABUSE
VS.
COAGULOPATHY Which case is abuse and
which case is a child with
a bleeding disorder who
experienced a minor injury?

-_Director of Clinjcal Lallo.ratories

1VI~lssachusetts

General

H~ospital

~P-rofessor_Har'laJ"dMedical
/

Scho(ll-

COAGULATION TESTS

o
a

Platelet Specific PLA-l Antigen (526)

Platelet .Factor 4 (504)
.
Protein C
.

Activity (035) 0 Antigen (036)

AntigenIF VII Ratio (067)
,
Protein C Inhibitor (PAf3)" (717)
Protein S
Activity (088)
Antigen Total (038)QAntigenFree,'087j
AntigenIF VII Ratio (059)
Protein C and S
Activity (149) 0 Antigen (142)
. 0 AntigenIF VII Ratio (032)
Activity and Antigen (204)
Proconvertin Prothrombin Assay (084)
ProthrombinConsumption(PF3)(503)
Prothrombin Fragment 1+2 (718)
Prothrombin Time (060)
Prothrombin Time Mixing Study (116)
Reptilase Time (610)
Stypven Time (611)
Thrombin Time (807)
Thrombin Time Mixing Study (813)
Thrombin-ATIU Complex (714)
Thrombus Precusor Protein- (209)
Tissue FactorPathwaylnhibitorAg(147
Tissue Plasminogen Act Antigen (125)
Tissue Thromboplastin Inhibition (804)
von Wlilebrand Factor
Activfty(114) Q Antigen (113)
Q Multimers (117)

o
o

o
o

o
o
o
o
a
o

o
o
o

o
a
o


o
o

F VIII Human (Bethesda) (T01)

F VIII Porcine SCreen (703)
F IX (Bethesda) (704)

Fibrin Monomer (202)

Fibrinogen

Activity (200) Q Antigen (199)

Fibrin(ogen) Degradation Products (201)
Fibrinopeptide A (OSS)
Fletcher Factor
Prek81likrein Assay (121)
Prekallikrein Screen (120)
Heparin Adsorption of Plasma (135)
Heparin AnUXa Assay
Unfractionated (GOO)

o
a

LMWH(602)

Q Heparin Cofactor II- (133)

Heparin-tnduced Antibody
Antibody (522) 0 Antibody Titer" (52fJ)

o
o
o
o

o
o

Q
Q

a
o

Heparin Solution Quantltation (139)

Hexagonal Phospholipid Neut..(144)
High Mol Wt Kininogen Assay (123)
Homocysteine (Serum) (727)
Homocysteine (Urine) (729)
Kaolin Clotting Time (OSS)
Upoprotein(a) (715)
Plasminogen Activator Inhibitor-1 (126)

Plasminogen Activator Inhibitor-2- (140) .

PIVKA-W (726)

Plasminogen

o AclMty (400)

0 Antigen (408)
Platelet Neutralization Procedure (805)

Platelet Antibody

Q Direct (523)

o Screen

(520)

Pistelet SpecfflC (524}

Activated Protein C Resistance (716)

alpha-2-Antiplasmin Assay (039)

AnUcardlollplnAntlbody

IgG. IgM (034) OlgA (164)

Q Antiphosphatldylserine

(153)

Antithrombin

Activity Plasma (030)

AntiQ6n Plasma (033)
Activity Servm (031)

Q
Q APn(040)

Q APTT Mixing Study (800)

Q beta-Thromboglobulln (085)

C4b Binding Protein" (160)

Q Cryofibnnogen (203)
O.otmer
QuantitatNe(405)
Semiquantitative (404)
Q Ollute Russefl's Viper Venom Test (057)
Euglobulin Lysis Time (401)

a
o

Factor Activities

o
o
o
o

o
o

F 1/ (100)
F V (101)
0 F X (105)
F VII (102)
Q F XI (106)
F Vila- (activated Factor VII) (111)
F VIII (103)
F XII (107)
FIX (104)
F ')(1fI* (t08)

Factor AnUgens

a
a

a
a

F VII- (112)
0 F IX (205)
FX(206)
Factor V Mutation (Lelden) (719)
Factor VIII Concentrate Quantitation (056}
Factor InaCHvators
Q Inhibitorlfnaclivalor Screen (lOO)

F V (Bethesda) (706)

F VIIf Porcine (BetheSda) (702)

1 Check in Box forProlonged PTTPanel

Initiates Use of This Test Selection Algorithm

Prolonged PTT Evaluation

Degrade heparin in sample and repeat PTT if the PTT normalizes, heparin is the cause

t
PTT mixing study (1: 1 mix of

patient:normal plasma) ' "

PTT NOralizes
Factor deficiencymeasure factors VIII, IX,
XI, and XII

PTT remains prolonged

~
Inhibitor, most commonly Lupus
coagulant; may be a Factor VIII inhilU' . . . .~J,
if PTT mixing study first normalizesang'
then becofes prolonged
..

Perform tests for specific inhibitors

. . by results ()fPTT' ,,~'., ".po,
& ....

..

c<'f.'iorl.'KT"

MGH experience with detectable errors in test

selection by clinicians

1996 Survey of MGH physician experience with

narrative interpretations of complex laboratory
evaluations in coagulation

TIS I TERP" "" TATION HEL"PED

AVOI:D A :M:IS~DIAG OSlS?

2000 Survey of MGH physician experience with

narrative interpretations of complex laboratory
evaluations in coagulation

Interpretation Impact - Physician Outcomes

90
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80

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40

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30

co
c

20

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CI)
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0
Saved Physician
Time

Impacted Differential
Diagnosis

Reduced Time to
Diagnosis