Page Thread

3 Anti-Saccharomyces Cerevisiae Antibody (ASCA)

4 Blood Gases
6 Cardiac Markers
7 Cyclic Citrullinated Peptide (CCP), IgG
8 Estimated GFR
9 Factor V Leiden mutation and Prothrombin-mutation G20210A
10 FibroTest and ActiTest

11 A rapid immunochromatographic test

12 Glycated Protein Testing for Diabetes Management

13 HBsAg Quantitative Assay

14 Diagnosis & Monitoring of HBV patients
16 Helicobacter Pylori Stool Antigen Test (HpSA)
17 Homocysteine : as important as cholesterol
20 Lipoprotein (a)
21 Neonatal screening for inborn errors of metabolism
22 Neuron-specific enolase (NSE)
23 Rapid detection of Streptococcal Pneumoniae Antigen
35 Application of Transcription-Mediated Amplification (TMA)
36
The Double test
37 FibroMax
40 Familial Mediterranean Fever
42 Water is essential for life
44 Flowcytometry Crossmatch
46 Cystatin-C
47 NEW JAK2 MUTATION TEST FOR Myeloproliferative Disorders (MPD)
48 Gastrin hormone
49 Serum inhibin B
50 Serum Amyloid A (SAA)
51 Crossmatching by Flowcytometry (FCXM)
52 Fragile X syndrome
 53 Y-chromosome microdeletion
54 HCV RNA Viral Load by the Only FDA Approved Real-Time PCR

56 HCV RNA Viral Load by the Only FDA Approved Real-Time PCR
57 HBV DNA by TaqMan Real Time PCR
58 Quantiferon T.B. – gold
59 HBsAg Quantitative Test
60 Automated HCV Ag Assay

Anti-Saccharomyces Cerevisiae Antibody (ASCA)

(A new commercially available test for diagnosis of Inflammatory Bowel Disease)

Inflammatory bowel disease (IBD) can be subdivided into ulcerative colitis and Crohn's disease, both
of which present with symptoms of diarrhea and abdominal pain. The definitive diagnosis can usually
be established by a combination of radiographic, endoscopic and histologic criteria, although in 10%
to 15% of patients the distinction between ulcerative colitis and Crohn's disease cannot be made with
certainty.
Two serological markers, perinuclear anti-neutrophilic cytoplasmic antibody (pANCA) and anti-
saccharomyces cerevisiae antibody (ASCA) have been proposed as tools to assist in diagnosing
inflammatory bowel disease, in differentiating ulcerative colitis (UC) from Crohn’s disease (CD) in
patients with indeterminate colitis, and in determining therapy and monitoring response to treatment.

1 Anti-Saccharomyces Cerevisiae Antibody (ASCA) is an antibody that reacts to a

component of yeast commonly found in food. ASCA has been detected in the serum of a
majority of Crohn’s disease patients (60%), and in only 10% or less of Ulcerative Colitis
patients.

2 Perinuclear Anti-Neutrophilic Cytoplasmic Antibody (pANCA) is an antibody directed against

the cytoplasmic components of neutrophils with a perinuclear staining pattern. pANCA has
been detected in the serum of a majority of Ulcerative Colitis patients (70%), but in fewer
patients with Crohn’s disease (10%).
ASCA and pANCA testing has been proposed as a method to reach a
definitive diagnosis of CD or UC in patients with indeterminate
colitis. They have also been proposed as a tool to assist in determining
therapy and monitor response to treatment.
 Blood Gases
Blood gases are emergency investigations.
 H+ Concentration activity of hydrogen ions in plasma
cHCO3- Bicarbonate Concentration in plasma
ctCO2[P] Total concentration of CO2 in plasma
BE The base deviation of the blood results from a calculation to determine the titrable
base of the blood, which in principle is measured by titration of the blood with a
strong acid or base to a pH 7.4 with PCO2 = 40 mmhg at 37o C
BEecf The base deviation of extracellular fluid, is a quantity that reflects only the non-
respiratory components of acid-base balance.
BB The buffer base is the concentration of buffering anions which is available in whole
blood to buffer strong acids and consist mainly of protein anions and bicarbonate of
the protein anions. Hb is the most significant
SO2( c ) Functional oxygen saturation uses blood gas
P50 The oxygen partial pressure at half saturation
ctCO3-st Standard bicarbonate of the blood the plasma bicarbonate concentration in blood
which has been equilibrated at 37°C with a gas mixture having a PCO 2= 40 mmhg

PAO2 The Alveolar oxygen tension

AaDO2 The alveolar to arterial oxygen tension gradient
A/AO2 Arterial – Alveolar Oxygen partial pressure ratio

ctO2 Oxygen content is the sum of oxygen bound to Hb and the amount Of oxygen
dissolved in plasma

ctCO2 Total concentration of CO2 in the blood, the sum of the total CO2 in plasma and the red
blood cells

pHst Standard pH value of the blood is defined as the pH value of blood sample which has
been equilibrated at 37°C with a gas mixture having a PCO2 = 40 mmhg

avDO2 The arterial – Venous oxygen tension ratio

RI The respiratory index is calculated as the ratio of the alveolar arterial oxygen tension
gradient to the arterial oxygen tension
AG The anion gap, the Difference In concentration of major cations And anions in the
blood specimen

Cardiac Markers

The traditional clinical approach used to focus solely on the presence or absence of Acute Myocardial
Infarction (AMI).
This now has been modified to recognize a single clinical entity termed Acute Coronary Syndrome
(ACS) to represent the entire clinical spectrum from AMI with ST- elevation to new-onset angina.
This new clinical approach focuses on risk stratification.
Cardiac Markers have assumed a central role.

A. Creatine Kinase-MB isoenzyme :

The biochemical indicator of choice for the diagnosis of AMI is an elevated CK-MB isoenzyme.
The skeletal and cardiac CK-MB are differentiated by calculating the ratio (relative index) between CK-
MB and CK total. The relative index is only useful when both the total CK and the CK-MB levels are
elevated.

B. Myoglobin:

Myoglobin is an early marker of myocardial infarction.

It typically rises 2-4 hours after onset of infarction, peaks at 6-12 hours and returns to normal within
24-36 hours.

C. Cardiac Troponins: (TnI, TnT)

They appear in serum within 4-8 hours after symptom onset, similar in timing to the release of CK-MB.
However, they remain elevated for as long as 7-10 days
post-myocardial infarction.
The skeletal and cardiac subforms for TnI and TnT are distinct, and specific immunoassays have been
designed to differentiate between them.
Studies have shown patients with rest unstable angina in whom CK-MB levels were normal but who
had elevated Toponin levels.
The Cardiac Troponins are sensitive, cardiospecific and provide prognostic information for patients
with Acute Coronary Syndrome.

Cyclic Citrullinated Peptide (CCP), IgG

Rheumatoid Arthritis (RA) is characterized by chronic low-grade inflammation of multiple joints with
periodic flare-ups of great intensity that lead to severe and irreversible cartilage, bone and joint
destruction. Diagnosis is problematic because there is currently no laboratory test or single symptom
of RA that can lead to a definitive diagnosis, and disease presentation is highly variable from patient to
patient. Early confirmation of RA is important, because aggressive therapy during the earliest stages of
disease can lead to decreased activity and reduced joint damage. Because medications used in the
management of RA lead to progressive toxicity, it is important to limit their use to those patients that
require them.

Cyclic Citrullinated Peptide (CCP) IgG Antibody, a highly specific marker for RA that is
detected in 70%of RA patients in the early stages of disease. Unlike Rheumatoid Factor (RF), CCP is
found almost exclusively in those with RA.

Clinic Utility:
Increased specificity:
Cyclic Citrullinated Peptide IgG antibody (CCP-IgG) has a 98% specificity for RA.

Earlier marker of RA:

High CCP-IgG concentrations are present within year of disease onset in the majority of RA patients.

Helps diagnose RA missed by RF:

High concentrations of CCP-IgG have been detected in 35% of RF IgM-negative patients.

Prognsis:
In RA-diagnosed patients, increased CCP-IgG is predictive of erosive disease; the absence of CCP-IgG
indicates a very low probability of progression
RA patients with increased CCP-IgG my progress to a more severe stage of disease than those who do
not have CCP-IgG
 Estimated GFR

Estimation of glomerular filtration rate ( eGFR ) is most widely used test of renal function, reflecting
the relative mass of functional tissue and thus the number of functioning nephrons. eGFR is usually
accepted as the best overall index of kidney function in health and disease. Normal eGFR varies
according to age, sex and body size, in young adult it is approximately 120-130 ml/min/17.3 m 2 and
decline with age. A decreased in eGFR precedes the onset of kidney failure, therefore a persistently
reduced eGFR is a specific indication of CKD. Below 60 ml/min/1.73 m 2 the prevalence of
complications of CKD increases, as does the risk of cardiovascular disease. ( 1 )
Methods based on measurement of exogenous substances as inulin and 51 Cr - EDTA are accurate but
too complex and laborious for routine clinical use, thus measurement of endogenous blood
substances is common practice. Serum creatinine and its clearance are the approaches most
commonly used.
Measurement of creatinine clearance requires collection of timed urine sample, which is inconvenient
and frequently inaccurate varies with drugs and fluid intake.
Also measurement of serum creatinine alone is affected by many factors such as tubular secretion,
generation, extra renal secretion, diet, body habitues and drugs. ( 2 )
The National Kidney Disease Program of the National Institute of Diabetes and Diseases of the Kidney,
National Kidney Foundation and American Society of Nephrology recommend eGFR which is
expressed in ml/min/1.73m2 which is more accurate than measured creatinine clearance from 24-hour
urine collection. ( 3 )

Uses of eGFR:

 As an index of kidney function in health and disease.

 In chronic kidney disease to avoid development of cardiovascular complications and kidney
failure.
 In diabetic nephropathy.
 In kidney transplant recipients.

The table below shows the average estimated values of eGFR by decade. (4)
Age ( years ) Average
20 – 29 >116 ml/min/1.73 m2
30 – 39 107 – 116 ml/min/1.73 m2
40 – 49 99 – 107 ml/min/1.73 m2
50 – 59 93 – 99 ml/min/1.73 m2
60 – 69 85 – 93 ml/min/1.73 m2
70 + > 75 ml/min/1.73 m2
 Factor V Leiden mutation and Prothrombin-mutation G20210A
Also Known As
Activated Protein C(APC) Resistance
Factor V R506Q
PT G20210A

Factor V Leiden (FVL) mutation and prothrombin 20210 (PT 20210) mutation tests are two tests often
used together to help diagnose the cause of inappropriate blood clot (thrombus) formation, including
deep vein thrombosis (DVT) and/or venous thromboembolism (VTE).

Factor V and prothrombin are two coagulation factors essential for proper blood clot formation. People
who have a mutation in one of the genes that code for these factors have an increased risk of blood
clots. (See "What is being tested?" for more on this.)

Testing for Factor V Leiden and PT 20120 mutations is used to help determine if an individual has
inherited a disorder associated with blot clots and can determine whether the person has one copy or
two copies of the mutation (heterozygous or homozygous.)

If genetic testing indicates that an individual has one Factor V Leiden or PT 20210 gene copy, then the
person is heterozygous; if there are two copies, then the person is homozygous for the mutation.

People with two copies of the Factor V Leiden mutation (homozygous) may have up to 80 times the
risk of developing a blood clot while those with one copy have 4 to 8 times the risk.

Venous thrombosis is a multifactorial disorder, involving one or a combination of genetic and

acquired risk factors. Known genetic causes are present in approximately 25% of unselected venous
thrombosis cases and up to 63% of familial cases. Factor V Leiden mutation is the most common
genetic risk factor for venous thrombosis.

Factor V Leiden (rs6025) is a variant (mutated form) of human factor V (one of several substances
that helps blood clot), which causes an increase in blood clotting (hypercoagulability). With this
mutation, the anticoagulant protein secreted (which normally inhibits the pro-clotting activity of
factor V) is not able to bind normally to Factor V, leading to a hypercoagulable state, i.e., an
increased tendency for the patient to form abnormal and potentially harmful blood clots

In the normal person, factor V functions as a cofactor to allow factor Xa to activate prothrombin,
resulting in the enzyme thrombin. Thrombin in turn cleaves fibrinogen to form fibrin, which
polymerizes to form the dense meshwork that makes up the majority of a clot. Activated protein C
(aPC) is a natural anticoagulant that acts to limit the extent of clotting by cleaving and degrading
factor V.

The condition results in a factor V variant that cannot be as easily degraded by aPC (activated
Protein C).

Two types of tests can be done:

  Activated protein C resistance test. Your blood sample may be tested to determine whether
your blood is resistant to activated protein C, one of the anti-clotting proteins that help control
factor V. This is known as an activated protein C (APC) resistance assay. If your blood is
resistant to activated protein C, you likely have a mutation in the factor V gene.
 Genetic test. A genetic test is done to determine whether you have a factor V gene mutation. It
may also be used to confirm the results of the APC resistance test or to determine whether
you've inherited one or two copies of the gene mutation.
 Sometimes, evaluation for the presence of a Factor V Leiden mutation can begin with a test for
activated protein C (APC) resistance, though it is not commonly performed. About 90% of the
time, APC resistance is due to a Factor V Leiden mutation. If resistance is present, then a test
for the Factor V Leiden gene mutation is performed on the affected person's DNA, both to
confirm the diagnosis and to determine whether the person has one or two copies of the
mutation

If you're taking blood-thinning medications (anticoagulants), you may have only the genetic
test. Anticoagulants interfere with the activated protein C resistance test.

 Who should be tested for Factor V Leiden mutation?

1. Age <50, any venous thrombosis.

2. Venous thrombosis in unusual sites (such as hepatic, mesenteric, and cerebral veins).
3. Recurrent venous thrombosis.
4. Venous thrombosis and a strong family history of thrombotic disease.
5. Venous thrombosis in pregnant women or women taking oral contraceptives.
6. Relatives of individuals with venous thrombosis under age 50.
7. Myocardial infarction in female smokers under age 50.
8. Women with recurrent pregnancy loss or unexplained severe preeclampsia, placental
abruption, intrauterine fetal growth retardation, or stillbirth. Knowledge of factor V
Leiden carrier status may influence management of future pregnancies.

9. myocardial infarction in young female smokers.

 Should patients found to be positive for factor V Leiden mutation be tested for any of the
other heritable thrombophilic risk factors?Venous thrombosis is multifactorial, and the
presence of more than one genetic risk factor is not uncommon. After factor V Leiden, the
most common are the prothrombin -mutation G20210Aand hyperhomocysteinemia.

Hyperhomocysteinemia should be tested in most cases by measuring plasma homocysteine levels

and methylenetetrahydrofolate reductase (MTHFR) gene mutation which accounts for certain
cases of hyperhomocysteinemia.
Hyperhomocysteinemia interacts synergistically with coexisting factor V Leiden to increase the
relative risk of venous thrombosis to 20-fold greater than in individuals without either risk
factor.
Activated Protein C Resistance (APCR)
Activated protein C (aPC), in a complex with protein S, inactivates procoagulant factors Va and VIIIa
by proteolytic cleavage at specific arginine residues.7,10,11 This serves to control coagulation and
limit the extent of thrombus formation.

More than 95% of cases of aPC resistance are caused by a specific polymorphism in the factor V gene
that is referred to as factor V Leiden

Methylenetetrahydrofolate Reductase (MTHFR)

Thermolabile Variant, DNA Analysis
Synonyms

 Hyperhomocysteinemia, C677T and A1298C Mutations

 MTHFR DNA Testing

Use

Follow-up evaluation in individuals with hyperhomocysteinemia; evaluation of patients with venous

thrombosis

The methylenetetrahydrofolate reductase (MTHFR) gene contains the DNA code to produce the
MTHFR enzyme

The methylenetetrahydrofolate reductase (MTHFR) mutation test is used to detect two relatively
common mutations in the MTHFR gene that are associated with elevated levels of homocysteine in the
blood. It is not routinely ordered.

This test is sometimes ordered as a follow-up to an elevated homocysteine test and may be occasionally
ordered along with other cardiac risk tests if a person has a personal or family history of premature
cardiovascular disease (CVD) or inappropriate blood clots (thrombosis). However, its utility for
assessing risk of CVD has not been established and some expert guidelines do not recommended it for
thrombosis screening.

The MTHFR mutation test may sometimes be ordered when a person has elevated homocysteine levels,
especially when the person has a personal or family history of premature cardiovascular disease or
thrombosis.

Limitations

This assay detects only the C677T and A1298C mutations in the MTHFR gene. The diagnosis of
hyperhomocysteinemia cannot rely on DNA testing alone but should take into consideration clinical
findings and other studies, such as serum homocysteine levels.
Hyperhomocysteinemia (high blood levels of homocysteine) is a risk factor for cerebrovascular
disease, cerebral vein thrombosis, coronary artery disease, myocardial infarction, and venous
thrombosis. The levels of homocysteine in the serum are influenced by both genetic and environmental
factors. One of the genetic factors involves point mutations in the methylenetetrahydrofolate reductase
(MTHFR) gene (OMIM 607093)

FibroTest and ActiTest

Liver cirrhosis is a major complication of chronic viral hepatitis. Liver biopsy was the only method for
diagnosis of the degree of liver fibrosis and cirrhosis. However, liver biopsy is invasive, prone to
complications, including pain, hemorrhage and a high risk of sampling error. In addition to the inability
to do it in patients having coagulation defects.

The FibroTest and ActiTest are noninvasive biochemical markers of liver injury that are intended for
use as alternatives to liver biopsy in patients with viral hepatitis.
These markers combine five components (α2-macroglobulin, haptoglobin, Apolipoprotein A1, γ-
glutamyl transpeptidase (GGT), and total bilirubin) for FibroTest and the same parameters plus alanine
aminotransferase (ALT) for ActiTest.
When liver biopsy and biochemical markers are done simultaneously for the same patients and the
results are discordant, biopsy failure is >7 times more common than diagnostic failure of marker
A rapid immunochromatographic test
For
Qualitative detection of Wuchereria bancrofti antigen in blood

Lymphatic filariasis (due to Wuchereria bancrofti) is distributed throughout the tropical regions of Asia
and Africa with reported cases in Egypt.
Diagnosis of Wuchereria bancrofti conventionally depends on detection of microfilariae in nocturnal
blood sample. This requires collection of blood sample during night hours (12 p.m. to 2 a.m.).
Clinical manifestations often develop late in the course of infection, when some people have already
reached amicrofilaraemic stage. Hence, there is a need for a more reliable method of diagnosis than
blood film examination for microfilariae.
Wuchereria bancrofti antigen test detects circulating filarial antigen and therefore blood sample can
be collected at anytime during day. Moreover, this rapid antigen detection test is more sensitive and
can detect infection when microfilariae are not circulating but adult worms are present in the
lymphatics.
 Glycated Protein Testing for Diabetes Management

Glycated protein testing provides a quantitative measure of the average glycemia over an extended
period of time (weeks or months).

Elevated values indicate risk for chronic complications associated with diabetes and a need for
improved glycemic control.

1. HbA1c (glycated haemoglobin):

recommended testing frequency is 2 to 4 times per year.
Method of testing: affinity chromatography; this method is traceable to the Diabetes Control
Complications trial (DCCT) method.
Use: routine diabetes management.

2. Fructosamine (Glycated Albumin):

recommended testing frequency is once each month.
Method of testing: Colorimetric.
Use: patients with gestational diabetes and abnormal Hbs; post major therapeutic changes.

Aggressive control of blood glucose levels can delay the onset or slow the progression
of diabetic retinopathy, nephropathy, and neuropathy.
 HBsAg Quantitative Assay
HBsAg is routinely used to aid in the diagnosis of suspected hepatitis B viral infection, to monitor the
status of infected individuals i.e., whether the patient's infection has resolved or the patient has
become a chronic carrier of the virus and to monitor the response to therapy with antiviral drugs.
HBsAg quantitative assay has the ability to detect the most prevalent HBsAg mutant,
the Gly →Arg 145 mutant with a sensitivity equivalent to detection of wild type of HBsAg.
It was positively correlated with and similar in magnitude to changes in intrahepatic cccDNA in
following the patient with chronic HBV under antiviral therapy. (1)
It was found that in cases that develop drug resistance, the increase in HBsAg preceeded the increase
in HBV DNA, so monitoring the HBsAg concentrations is helpful for evaluating the response to
treatment and for the early detection of drug-resistant strains. (2)

HBsAg quantitative assay has the capacity to detect seroconversion of HBsAg earlier by
3-5 days than other assays in 33% of cases.

The overall sensitivity of the assay is estimated to be 99.87 with a specificity of 99.52%.

Diagnosis & Monitoring of HBV patients

Hepatitis B virus (HBV) is a major cause of acute & chronic hepatitis.
It may lead to cirrhosis and hepatocellular carcinoma.
Egypt is classified

as highly endemic for hepatitis B virus infection.1

Monitoring of hepatitis B virus (HBV) DNA in serum has become the standard method for assessing

the replicative activity of HBV which is crucial in the assessment, management and antiviral treatment

of patients with chronic HBV infection.

Most PCR-based assays have a high rate of false positivity. These assays lack standardization &
reproducibility.
The standardized quantitative Amplicor HBV Monitor test is a PCR-based assay with a lower detection
limit of 102 to 103 HBV DNA copies/ml, thus making the assay 1,000 to 10,000 times more sensitive
than most widely used commercial kits.
The Amplicor HBV Monitor test is an automated system with highly stringent quality controls.
This highly sensitive test enables us to distinguish between inactive carriers of HBV & chronic hepatitis
B patients.
Diagnosis & Monitoring of HCV Patients

Hepatitis C virus (HCV) is highly endemic in Egypt. Unlike HBV, there are no vaccines for hepatitis C
virus (HCV). Approximately 75 percent to 85 percent of individuals infected with HCV will develop
chronic HCV infection; of these 15 percent to 20 percent may develop serious conditions, including
cirrhosis and hepatic carcinomas resulting in death if a liver transplant is not performed.
Proper diagnosis and treatment is highly indicated for HCV patients.

Following the primary infection, there is a 40-day to 80-day time lag for a detectable antibody
response. The enzyme immunoassay and recombinant immunosorbent assay (RIBA) are used for the
detection of HCV antibodies.

Approximately 15 percent of infections resolve without treatment, active viral infection needs to be
differentiated from resolved infection. This can only be done by a highly sensitive test, Qualitative
HCV PCR.

Hepatitis C virus (HCV) is classified into six major genetic groups (1,2,3,4,5 and 6) and several
quasispecies. Both the duration of treatment and odds of successful therapy are related to the
genotype of HCV virus. Patients with genotypes 2 or 3 need to treated for only 24 weeks of
combination treatment of PEG-interferon plus ribavirin, in contrast to genotypes 1 and 4 which both
require 48 weeks of treatment.
HCV genotype is most reliably determined by Hybridization (Inno-LiPA method).

Measurement of HCV RNA circulating in the serum of the patient is referred to as determination of
viral load. Quantitative HCV is important to monitor the success of therapy. Failure to achieve a 2-log
drop in viral load after 12 weeks of treatment is predictive of therapeutic failure.
Routine laboratory tests for patients infected with hepatitis C virus include: liver function tests,
Complete blood picture and α-fetoprotein.

Helicobacter Pylori Stool Antigen Test (HpSA)

Helicobacter Pylori has been associated with duodenal and gastric ulcers and chronic persistent, and
atrophic gastritis in adults and children.Infected persons have a 2 to 6 fold increased risk of
developing gastric cancer and mucosal-associated- lymphoid type (MALT) lymphoma.
Seventy to 90% of infected individuals respond to a multiple drug regimen over 1 to 2 week period.

Helicobacter Pylori Stool Antigen Test (HpSA) is the first totally non-invasive test for accurately
diagnosing Helicobacter pylori infections.
HpSA is an enzyme immunoassay for the detection of helicobacter pylori antigens in human stool. The
test is cleared by the FDA and is CE-marked.
Studies have shown more than 90% sensitivity and specificity for HpSA in diagnosing Helicobacter
Pylori infection and for confirming the eradication after the therapy.

The uncertainty of patients’ compliance and the increasing rate of antibiotic resistance are strongly
supporting the need for confirming the eradication for all treated patients, given the availability of a
simple and accurate non-invasive test.
 Homocysteine : as important as cholesterol

Clinical use:
 Diagnose homocystinuria, vitamin B12 deficiency, and folate deficiency.
 Assess the risk of cardiovascular disease (CVD), stroke, and dementia (including Alzheimer
disease).
 Monitor therapy in patients with elevated homocysteine levels.

Clinical Background:
Severe homocysteinemia (>100 µmol/L) is generally caused by homocystinuria, an autosomal
recessive inborn error of homocysteine metabolism.

Mild to moderate homocysteine elevation can be caused by deficiencies of cobalamin (vitamin B12),
folate, and vitamin B6. Vitamin B12 deficiency can lead to irreversible neurologic damage, folate
deficiency may cause neural tube defects, and either can cause megaloblastic anemia.
Although folate and vitamin B12 can be measured directly, homocysteine is a more accurate indicator
of deficiency at the tissue level.

Modest elevation in plasma homocysteine is a strong & independent risk factor for atherosclerotic &
occlusive

arterial diseases and for venous thrombosis & thromboembolic events .

Supplementation of patients with folate alone or in combination with cobalamin & vitamin B6 are
efficient means to reduce plasma homocysteine levels, even in subjects without overt vitamin
deficiencies.

Individuals Suitable for Testing

 Individuals with clinical evidence of homocystinuria.
 Elderly individuals with clinical evidence of reduced cobalamin and folate intake.
 Individuals with early (< 50 years of age) evidence of CVD.
 Individuals with a family history of premature CVD.
Method of Testing
 Fluorescence polarization immunoassay (FPIA)
 Measures total homocysteine (ie, protein-bound, oxidized, and free reduced homocysteine)
 Analytical sensitivity (limit of quantitation) =
0.8 µmol/L

Accurate estimation of homocysteine is routinely done in AL Mokhtabar (Moamena Kamel

Laboratories).
 Immunophenotyping By Flowcytometry

 Immunophenotyping of Acute Myeloid Leukemia (AML).

Sample Type: EDTA blood or bone marrow.

ㄱ MPO
ㄴ CD 13
ㄷ CD 14
ㄹ CD 33
ㅁ CD 41
ㅂ HLA-DR
ㅅ Glycophorin A

 Immunophenotyping of Acute Lymphoblastic Leukemia (ALL).

Sample Type : EDTA blood or bone marrow.

ㄱ Tdt
ㄴ CD 3
ㄷ CD 5
ㄹ CD 7
ㅁ CD 10
ㅂ CD 19
ㅅ CD 20
ㅇ CD 79
ㅈ SIg.
Immunophenotyping of Undifferentiated Acute Leukemia (UAL).
Sample Type: EDTA blood or bone marrow.
Profile 3-1: Primary Panel for Lineage assignment:
ㄱ MPO
ㄴ Tdt
ㄷ CD3
ㄹ CD 79a

Profile 3-2 : Secondary Panel Accordingly, AML or ALL panels

:
 Immunophenotyping for Chronic lymphatic leukemia (CLL).
Immunophenotyping for Lymphoma
Immunophenotyping for Hairy cell leukemia
Immunophenotyping for Chronic lymphoproliferative
Disorder

Sample Type : EDTA blood or bone marrow.

ㄱ CD 3
ㄴ CD 5
ㄷ CD 7
ㄹ CD 10
ㅁ CD 19
ㅂ CD 20
ㅅ CD 23
ㅇ CD 103
ㅈ Kappa/Lambda
ㅊ SIg
 Lipoprotein (a)
Lipoprotein (a) or Lp(a) is an established risk predictor for heart attack. It not only has a cholesterol
component, like LDL, but a pro-thrombotic (blood clotting) component.
High Lp(a) levels increase the risk for developing coronary artery disease as well as cerebral vascular
disease.
Lowering Lp(a), particularly in patients with high LDL levels, would reduce cardiovascular risks.

Individuals suitable for testing:

 Individuals with suspected premature CHD or cerebrovascular disease.
 Individuals with strong family history of premature CHD.
 Family members of a patient with increased Lp(a).
 Individuals with CHD without established risk factors.

Lp(a) plasma concentrations are controlled by the apo(a) gene. This may be a major source of
genetically linked coronary artery disease.

The oxidized Lp(a) and the glycated Lp(a) have a much more potent effect than native Lp(a) in
promoting the development of atherosclerotic disease. Oxidation happens to lipids from poor nutrition
and chemicals. Glycation is a change to lipids from elevated blood sugar.

Method of Testing:
 Turbidimetric
 Analytical sensitivity: 3 mg/dl
 Neonatal screening for inborn errors of metabolism
Neonatal screening for inborn errors of metabolism is done routinely in U.S.A and Europe aiming for
early identification & treatment of the most common disorders that can lead to catastrophic health
problems.

The most common neonatal disorders are:

1. Congenital hypothyroidism:
Can lead to severe mental retardation, variable degrees of growth failure, deafness &
neurological abnormalities as well as classical symptoms of hypothyroidism.
Treatment in time allows the affected child to grow normally.

2. Phenylketonuria:
Can lead to mental retardation yet prompt treatment with phenylalanine restricted diet allows
normal development.

3. Galactosemia :
The untreated disorder will lead to failure to thrive, vomiting, liver disease, cataract, and
mental retardation .It is lethal in most cases.
Treatment with galactose free diet will allow remission of the symptoms.

4. Congenital adrenal hyperplasia:

Is a group of disorders which may produce ambiguous genitalia in females and salt losing crisis.
Early treatment with glucocorticoides and surgical correction will be beneficial.

Neonatal screening of these disorder is routinely done in ALMokhtabar (Moamena Kamel

Laboratories), taking a blood spot on a filter paper from the heel of the neonate from 3 rd to 7th day
of life.

Screening for other congenital disorder as: Hemoglobinopathies, Fatty acid oxidation disorders,
Biotinidase deficiency& Cystic fibrosis is also available.
 Neuron-specific enolase (NSE)
Enolase is glycolytic enzyme also known as phosphopyruvate hydratase. NSE is the form of
enolase found in the neuronal tissue and in the cells of the diffuse neuroendocrine system.

NSE is found in tumors associated with a neuroendocrine origin, including small cell lung cancer
(SCLC), neuroblastoma, pheochromocytoma, carcinoid, medullary carcinoma of the thyroid,
melanoma, and pancreatic endocrine tumors.

The upper reference limit of serum NSE is 13.0 ug/L. The NSE levels are low in healthy subjects
and in subjects with benign diseases.

In individuals with SCLC the sensitivity is reportedly 80%. The specificity is at least 80% to 90%.
Among children with advanced neuroblastoma, more than 90% have been reported to have elevated
serum levels of NSE are associated with poor prognosis. The levels seem to correlate with the stage of
the disease.
Uses of NSE:
* Confirm the diagnosis of malignant tumors with neuroendocine differentiation in patients with
elevated levels of NSE.

* The NSE level appears to correlate with stages of the malignant disease and provides a useful
prognosis for disease progression.

 NSE is useful in monitoring treatment and detection of recurrent diseases.

Test, NSE: Neuron-specific enolase (NSE) is a substance that has been detected in patients with certain
tumors, namely: neuroblastoma, small cell lung cancer, medullary thyroid cancer, carcinoid tumors,
endocrine tumors of the pancreas, and melanoma.

Studies of NSE as a tumor marker have concentrated primarily on patients with neuroblastoma and
small cell lung cancer. Measurement of NSE levels in patients with these two diseases can provide
information about the extent of the disease and the patient's prognosis (outlook), as well as about the
patient's response to treatment.

NSE is a useful adjunct in the monitoring of patients with small cell lung cancer (SCLC).

It is present in neurons, neuroendocrine cells

 Rapid detection of Streptococcal Pneumoniae Antigen

Streptococcus pneumoniae are gram positive capsulated diplococci. They can cause severe
pneumonia and meningitis. Streptococcus pneumoniae is the most important agent in community
acquired pneumonia with a mortality rate up to 30%, if not properly treated in time. It can also
cause bacteraemia which extends to cause meningitis, pericarditis, endocarditic, empyema and
arthritis.
Pneumococcal meningitis affects persons of all ages, but is most common in children under 5 years,
teenagers and elderly people.
Progression from mild illness to coma can occur within hours, making immediate diagnosis and
antimicrobial treatment critical. Pneumococcal meningitis has a mortality rate between 20-30%
especially in the very young and the very old.
Detection of Streptococcus Pneumoniae Antigen in urine can diagnose pneumonia within minutes. It
also overcomes the difficulties of getting a sputum sample from young patients.
Detection of Streptococcal Pneumoniae Antigen in the CSF in case of meningitis within minutes, can
make a difference between life and death of the patient.
 Thyroid Profile (1)

 They are the tests used to establish the presence of thyroid dysfunction.

The profile includes : T3, T4, TSH, FT3 and FT4

A] Different patterns of thyroid function tests are seen with primary thyroid disease

Condition T3 T4 TSH FT3 FT4

Hyperthyroid   Very low  
Hypothyroid ¯¯ ¯¯ ¯¯ ¯¯
Subclinical
N N ¯ N N
hyperthyroid
Subclinical
N N N N
hypothyroid
T3 toxicosis N N¯ N

B] Thyroid profile in abnormal pituitary-thyroid-axis

Condition T3 T4 TSH FT3 FT4

2ry hyperthyroid
2ry hypothyroid ¯ ¯ ¯ ¯ ¯

C] The profile in other causes of abnormal thyroid function tests

Condition T3 T4 TSH FT3 FT4
Non thyroidal
¯ N N ¯ N
illness
TBG excess N N N
TBG deficient ¯ ¯ N N N
D] Profile For Autoimmune Thyroid Disease (2)

 Free T4 and TSH are reliable tests in screening for autoimmune thyroid disease.
1-Anti thyroglobulin Ab:
-High titre is observed in > 85% of hashimoto’s thyroiditis and in > 30% of Grave’s disease.

2-Antithyroid microsomal Ab: [Antithyroid peroxidase Ab (anti-TPO)]

a-It is more sensitive than antithyroglobulin in Hashimoto’s thyroiditis.
b-The titre is very high in > 95% of cases.
c-It’s presence indicates risk for later development of hypothyroidism
d-Risk factor for post partum thyroiditis.
e-Risk factor for IVF failure.

3-TSH receptor antibody : [Thyroid stimulating Immunoglobulin (TSI)]

a-Diagnosis and therapy control of Grave’s disease (>90% of cases).
b-In assessing the risk of fetal thyroid problems of Grave’s disease mother.

E] Markers of Thyroid Tumours

1-Thyroglobulin (TG):
-Increases with untreated differentiated thyroid follicular and papillary carcinoma.
-Not correlated with T4.
-Falls to normal with successful therapy of cancer.
-Increases again with metastasis.

2-Calcitonin :
-It is a periffolicular cell producing hormone.
-Antagonises PTH effect on calcium.
-Increases markedly with medullary thyroid carcinoma with strong family history.
-Useful for monitoring response to therapy and predicting the recurrence.
 Infertility Profile (Female) (3)

FSH LH E2 Prolactin Testosterone DHEA-S

1ry ovarian failure ¯¯ N N N
Poly cystic ovary syndrome ¯N ¯N N
2nd hypogonadism ¯ ¯ ¯ N N N
Galactorhea / Ammenorhea
¯ ¯ ¯ N N
syndrome

Infertility Profile (Male)

FSH LH Testosterone Prolactin E2
1ry gonadal failure (Klinefelter syndrome) ¯¯ N N
2nd hypogonadism (Kallmann’s syndrome) ¯¯ ¯¯ ¯ N N
Testicular feminization syndrome N N N N
Gynecomastia N N N¯ N
Prolactinoma ¯ ¯ ¯ N
 Adrenogenital Syndrome (4)

 It occurs most commonly with a defect in 21-hydroxylase activity which leads to :

-¯¯ cortisol synthesis
-¯¯ 11-deoxycortisol
-Compensatory  in ACTH secretion with overproduction of the precursors :
  17 OH progesterone
  Androstendione
  DHEA-S
  Testosterone
 N¯ Aldosterone

Profile for hirsutism in female

Test PSO-Cushing’s Ovarian T.

Idiopathic
late CAH Adrenal T.
Serum testosterone
<1.0 1.0-2.0 > 2.2
(N 0.6-1.2ng/ml)
DHEA-S
< 400 400-650 > 700
(N 40-400 ug/dl)
 Parathyroid Gland Disease (5)

Parathormone (PTH) is the calcium regulating hormone and antagonizing the effect of calcitonin
hormone used mainly to differentiate hypercalcaemia of malignancy
Primary Secondary Tertiary 1ry hypoparathyroid
Findings
hyperparathyroid hyperparathyroid hyperparathyroid

Cause : Parathyroid 2nd to any cause of Persistent 2nd Very rare :

adenoma low serum Ca+ e.g. : hyperpara- イsurgical
CRF thyroidism removal
or malabsorption ロfamilial
syndrome ハAuto-
immuno
PTH
¯¯ (< 8.0)
N:(12-72pg/m)
Calcium
N:(8.8- ¯¯ ¯¯
10.5mg/dl)
Ca ionized ¯¯ ¯¯
Phosphorus ¯¯
Alkaline
Phosphatase
Urea N (N ) N
Creat N (N) N

Osteoporosis Profile (6)

 Osteoporosis is a metabolic disorder in which the reduction of bone mass makes the patients
susceptible to fractures.
 There is imbalance between osteoblastic and osteoclastic activity resulting in resorption of bone.
The serum profile includes :
1-Osteocalcin :
i-Major non collagen bone protein.
ii-Marker of bone turn over.
iii-Initially classifies osteoporotic to high, low and normal losers.
iv-So, determines the efficiency of treatment i.e. patients with initial increase in osteocalcin
give good response to E2 and calcitonin treatment.
2-Urinary Deoxypyridinoline (DPD):
i-Stabilizing factors to type I bone collagen.
ii-It is a sensitive and specific marker of bone resorption.
iii-Used to monitor the effect of treatment.
iv-It is expressed as (nM DPD/mM cr.).
3-Serum Calcium, Phosphorus and Alkaline Phosphatase.

S.Ca : N ¯
S. Ph : N
Alk.Ph : N
 Adrenal Cortex Disorders (7)

Hormonal Profile For Adrenal Cortex Hyperfunction

Test Cushing’s Cushing’s Cushing’s
disease syndrome syndrome
Ectopic ACTH
(pituitary (hyperptas (adrenal
) ia) tumour)
Serum cortisol (am)

Serum cortisol (pm)

Circadian rhythm Lost Lost Lost Lost
Urinary cortisol
Urinary (17-OHCS) (metabolite)
Plasma ACTH ¯¯ ¯¯¯ (ND)
Dexamethazone supp. Incomplete Not
Overnight (1-4mg) Suppressed suppressio Not suppressed suppress
N (cortisol < 50% of baseline) n ed
Dexamethazone supp. Low dose Not
(0.5mg x 4x 3ds) Suppressed Suppressed Not suppressed suppress
N (cortisol < 5.0ug/dl) ed
Dexamethazone supp. High-dose Not
(2.0mg x 4 x6ds) Suppressed Suppressed Not suppressed suppress
N (cortisol < 3.0ug/dl) ed

Hormonal Profile in Adrenal Cortex Hypofunction

Test 1ry hypocorticism = ¯ (Addison’s

2nd hypocorticism (pituitary)
disease)
Serum cortisol (am) ¯¯ ¯¯
Serum cortisol (pm) ¯¯ ¯¯
Circadian rhythm Lost Lost
Plasma ACTH ¯¯(N)
ACTH stimulation test (250ug Respond with S. cortisol peak
No response
synacthen IM or IV) >20 ug/dl
 Adrenal Medulla (8)

Hormonal profile of pheochromocytoma tumour :

イTumour arises from chromaffin cells (90% in adrenal medulla)

ロSecrete excessive amount of noradrenaline or adrenaline or both (catecholamines) in plasma

ハExcessive amount of catecholamines, VMA, metanephrine and nor-metanephrine are excreted

in urine.

ニWe must select the time of sampling to coinside with hypertensive episodes (headache, pallar,

palpitation and sweating) .

ホSo, we recommend the measurement of at least 2 of the followings :

1. Plasma catecholamines : adrenaline + noradrenaline

2. Urinary catecholamines : adrenaline + noradrenaline

3. Metanephrine and normetanephrine in urine (metabolites)

4. VMA (vanilly mandelic acid)

5. HMMA (Hydroxy methyl mandilic acid)

6. Urinary sample must be collected for 24hrs on HCl and avoid dietary vanilia and drugs
releasing catecholamines.
 Posterior Pituitary Disorders (9)

Post pituitary produces at least 2 hormones

1- Vassopressin (ADH) 2-Oxytocin

Post pituitary disorders occurs mainly due to affection of ADH out put

Deficient secretion
Excessive secretion
diabetes insipidus (DI)
Causes Head injury – trauma Central nephrogenic
Tumour – cerebral abscess
ADH level ¯¯ N

ECF + ICF ¯¯ ¯
Blood volume ¯¯ ¯
Sodium in serum ¯¯
Serum osmolality ¯¯
Urinary volume ¯¯
Urine osmolality ¯ ¯
ADH administration No value Corrected Not corrected
 Diabetes Mellitus (10)

Juvenile onset DM Adult onset DM

IDDM (type I) NIDDM (type II)
Acute < 30 years with
Incidence Above 40 years more with obese
non-obese
Mechanism Decreased availability of insulin Decreased effectiveness (insulin
with resistance)
¯¯ Its secretion
Anti-Islet cell Abs
Present
Absent
May be associated with HLA
Blood glucose (F-2hrs) > 140 mg/dl > 140 mg/dl
Insulin (F-2hrs) ¯¯ -¯¯ N or
C-peptide (F – 2hrs) ¯¯ - ¯¯ N or
Anti insulin Abs Present Absent
Fructosamine – Normal if 19ds ago control
HBA1C – normal if 3ms ago control
Microalbuminuria if +ve (> 30mg/day) indicate diabetic nephropathy
Follow up for treatment is highly recommend
 Growth Disorders (11)

Hormonal Profile With Short Stature

Test With thyroid disorder With pituitary disorder

TSH N
FT4 ¯¯ N
Basal GH Normal Not detectable
GH stimulation test (with
Peak at 30` No response
clonidine)
> 10 ng/ml Peak < 5.0 ng/ml
-5 samples
GH stimulation test (with insulin) Peak at 40` No response
-5 samples > 10 ng/ml Peak < 5.0 ng/ml

Hormonal Profile With Tall Stature

Test Gigantism Acromegaly

Basal GH Very high before closure of
N: (ND-10 ng/ml) Very high after closure of
epiphysis epiphysis

GH suppression test (75gm

glucose) No. Suppression No. Suppression
N: (supp < 2.0ng/ml)

Application of Transcription-Mediated Amplification (TMA) for the

Ultrasensitive Detection of HCV RNA
TMA, an isothermal, autocatalytic target amplification method, is a tool that can identify HCV
infection earlier, identify clearance of virus earlier, and better identify respsonders vs. non-
responders.
responders

Clinical Use:
 Confirm positive antibody (EIA) results and chronic infection with a lower limit of detection
(LOD) of 5-10 IU/mL.
 Immune-compromised patients with false-negative EIA results require HCV RNA testing for
diagnosis of chronic infection.
 Confirm end of treatment viral clearance with confidence:
TMA detected HCV virus in 36% of "relapsers" that were determined to be
virus-negative by PCR methods.1

Current recommendations for early discontinuation of virologic non-responders at week 12 of

antiviral therapy is based on the 2 log decline.
However, on the basis of the 12 week stopping rule only 50-60% of patients without SVR are
discontinued from therapy.2
Thus, the week 24 stopping rule is needed for discontinuation of further patients with lack of
SVR.
Detection of HCV RNA by TMA, the highly sensitive assay, at week 24 was associated in all
patients with a lack of SVR following a 48 week course of (pegylated) interferon- ribavirin
combination therapy.3

The Double test

Down syndrome, Trisomy 18 and trisomy 13 are chromosomal abnormalities that can occur
sporadically with no family history to women of all ages, and always cause mental retardation in
affected individuals.

Chromosomal abnormalities cannot be cured, so screening and diagnostic testing for these conditions
by the double test is crucial.

The DOUBLE-TEST
 It is a noninvasive and early test that can be between the 11 and the 14 weeks.
 This test comprises of free Beta-hCG and PAPP-A(pregnancy- associated plasma protein-A)

 Down's syndrome is associated with high maternal serum concentrations of the free beta
subunit of human chorionic gonadotropin, and low serum concentrations of pregnancy-
associated plasma protein A..

Double test discovers the risks of 3 groups of syndromes which are Down, Trisomy 13 or Trisomy 18.

Trisomy 18 is a group of risks due to abnormalities in chromosome 18 with limb deformity, cardiovascular
malformations, urinary malformations and gastrointestinalmalformations.

Trisomy 13 can lead to defects in head and face such as harelip, palate, eyes…, cardiovascular, gastrointestinal,
urine malfunctions or defects.

Advantage of the Double test:

First Trimester Screening can detect a higher percentage of babies with Down syndrome
(trisomy 21), trisomy 18 and trisomy 13 than the currently available tests.*

Triple marker screen test?

The triple marker screen test is also known as the triple test, multiple marker test, multiple marker
screening, and AFP Plus. It analyzes how likely an unborn baby is to have certain genetic disorders.
The exam measures the levels of three important substances in the placenta:

 alpha-fetoprotein (AFP)
 human chorionic gonadotropin (HCG)
 estriol

Triple marker screening is administered as a blood test. It’s used for women who are between 15 and 20
weeks pregnant

What does a triple marker screen test do?

A triple marker screen test takes a sample of blood and detects the levels of AFP, HCG, and estriol in it.

AFP: A protein produced by the fetus. High levels of this protein can indicate certain potential defects,
such as neural tube defects or failure of the fetus’s abdomen to close.

HGC: A hormone produced by the placenta. Low levels may indicate potential problems with the
pregnancy, including possible miscarriage or ectopic pregnancy. High levels of HGC can indicate a
molar pregnancy, or a multiple pregnancy with two or more children.

Estriol: An estrogen that comes from both the fetus and the placenta. Low estriol levels may indicate
risk of having a baby with Down syndrome, especially when paired with low AFP levels and high HGC
levels.

FibroMax
 The FibroMAX is a « super biomarker » offering the FibroTest and the
:SteatoTest with, according to risk factors
.The ActiTest for patients with chronic hepatitis C and B*
.The NashTest for patients with metabolic steatosis *
.The AshTest for patients with alcoholic steatosis*

The FibroMAX combines alpha2-macroglobulin, haptoglobin, apolipoprotein

A1, total bilirubin, GGT, fasting glucose, triglycerides, cholesterol, AST and
.ALT

FibroTest and ActiTest are surrogate markers of histological features in

.patients with chronic hepatitis B or C

The SteatoTest measures hepatic steatosis (triglyceride deposits in the liver)

in patients with chronic hepatitis C or B, alcoholic liver disease and
.metabolic steatosis (overweight, diabetes, hyperlipidemia)

The NashTest is diagnostic for non alcoholic steato hepatitis (NASH) in

.patients with metabolic steatosis (overweight, diabetes, hyperlipidemia)

The AshTest measures alcoholic steato hepatitis (ASH) in patients with

.alcoholic liver disease
 Homocysteine: as important as cholesterol

Clinical use:
 Diagnose homocystinuria, vitamin B12 deficiency, and folate deficiency.
 Assess the risk of cardiovascular disease (CVD), stroke, and dementia (including Alzheimer
disease).
 Monitor therapy in patients with elevated homocysteine levels.

Clinical Background:

Severe homocysteinemia (>100 µmol/L) is generally caused by homocystinuria, an autosomal recessive inborn error of
homocysteine metabolism.

Mild to moderate homocysteine elevation can be caused by deficiencies of cobalamin (vitamin B12), folate, and
vitamin B6. Vitamin B12 deficiency can lead to irreversible neurologic damage, folate deficiency may cause neural
tube defects, and either can cause megaloblastic anemia.
Although folate and vitamin B12 can be measured directly, homocysteine is a more accurate indicator of deficiency at
the tissue level.

Modest elevation in plasma homocysteine is a strong & independent risk factor for atherosclerotic & occlusive arterial
diseases and for venous thrombosis & thromboembolic events .
Supplementation of patients with folate alone or in combination with cobalamin & vitamin B6 are efficient means to
reduce plasma homocysteine levels, even in subjects without overt vitamin deficiencies.

Individuals Suitable for Testing:

 Individuals with clinical evidence of homocystinuria.

 Elderly individuals with clinical evidence of reduced cobalamin and folate intake.
 Individuals with early (< 50 years of age) evidence of CVD.
 Individuals with a family history of premature CVD.

Method of Testing:

 Fluorescence polarization immunoassay (FPIA)

 Measures total homocysteine (ie, protein-bound, oxidized, and free reduced
homocysteine)
 Analytical sensitivity (limit of quantitation) = 0.8 µmol/L

Accurate estimation of homocysteine is routinely done in AL Mokhtabar (Moamena Kamel Laboratories).

Complex PSA (cPSA)

It has been recognized initially by Scandinavian investigators and confirmed throughout the world, that PSA
 complexed with alpha-1-antichymotrypsin (cPSA) occurs to a greater proportion of the total PSA in men with cancer.
Conversely, the free form of PSA occurs to a greater extent in men without malignancy (Micheal. 1999).

Numerous efforts have been made to improve the effectiveness of diagnosis of early prostate concer. The use of free-
to-total PSA ratio has become common in an effort to improve the specificity of this test. Scientists have shown that
the use of complex-PSA is a more specific marker for prostate concer detection. It was found that the single test for
complex PSA provides a statistically significant improvement in specificity by 7.4% as compared with the free-to-total
PSA ratio (Mitchell et al.,2001).

Hence complex-PSA is a very valuable protein marker in human blood for the diagnosis of prostate carcinomas (Cap)
and differentiating it from benign prostatic hyperplasia (BPH).

PSA exists in serum in multiple forms: complexed to alpha-1-anti-chymotrypsin (PSA-ACT complex),

unbound (free PSA)
Higher total PSA levels and lower percentages of free PSA are associated with higher risks of prostate
cancer
 Familial Mediterranean Fever
Familial Mediterranean fever (FMF) type 1 is characterized by recurrent
short episodes of inflammation and serositis including fever, peritonitis,
synovitis, pleuritis, and, rarely, pericarditis and meningitis. The symptoms
vary among patients, sometimes even among members of the same family.
Amyloidosis, which can lead to renal failure, is the most severe complication.
FMF type 2 is characterized by amyloidosis as the first clinical manifestation
of FMF in an otherwise asymptomatic individual.

Diagnosis: Blood tests reveal a high erythrocyte sedimentation rate,

leukocytosis, and a high fibrinogen level.
Molecular genetic testing of the MEFV gene (chromosomal locus 16p13.3)
usually confirms the diagnosis.
Molecular genetic testing is also used for carrier detection.

Management: Colchicine prevents both the inflammatory attacks and the

deposition of amyloid.
 HOMA – IR INDEX
As an index of insulin resistance in metabolic syndrome

Insulin resistance (IR) is a pathological situation characterized by a lack of physiological

response of peripheral tissues to insulin action, leading to metabolic & hemodynamic
disturbances known as metabolic syndrome.
The main features of this condition include dyslipidemia (high TG & low HDL-C),
hypertension, glucose intolerance or type 2 diabetes, abdominal obesity, hyperuricemia,
hypercoagulability and an increased incidence of CHD.

The interest of insulin resistance & metabolic syndrome lies in their high prevalence in
the population and the high death rate through CHD. The connection between insulin
resistance, hyperinsulinemia & CHD has been established.

Homeostasis Model Assessment of IR (HOMA-IR) is a simple, and non- invasive, method

used for epidemiological & clinical quantification of insulin resistance.

Results of HOMA test help the clinicians to achieve excellent glycemic control through
several oral hypoglycemic agents (OHAs) that improve insulin resistance & prevents both
microangiopathy & CHD.
 Water is essential for life
Every one is against water pollution, but how does it happen and how can it be
prevented?

Water covers 71% of the earth’s surface and makes up 65% of our bodies.
Everyone wants clean water to drink, for recreation and just to enjoy looking at. If
water becomes polluted, it loses its value to us and becomes a threat to our health.

Water analysis includes physio chemical parameters and undesirable

substances, which when increased may lead to many health problems as :

 Ammonia: A product of microbiological activity, when found in water is

regarded as indication of sanitary pollution.

 Nitrates: Occur in water as the end product in the biological breakdown of

organic nitrogen. Excess nitrates are used as indicator of poor water quality.

 Nitrites: Occur as intermediates product in the biological breakdown of organic

nitrogen. Large quantities are indicative of waste water pollution.

 Phosphate: If high phosphate level persists, algae and other life will flourish.
  Silicate: Often contributes to pond water turbidity and helps diatoms and algae
to proliferate.

 Iron: If it increases, it will impact a foul taste to the water.

Manganese: Is required by aquatic species, Excess manganese produces taste changes.

 Copper: Increase copper level leads to nausea, vomiting and diarrhea and its
toxicity level may lead to liver cirrhosis.

 Zinc: high zinc level may lead to hepatosplenonegaly, anemia and delay in wound
healing.
 Chlorine: Because of its strong oxidizing properties, chlorine acts as a Biocide. Its
increasing leads to taste changes.
 Cyanide: A high Toxic substance used in many chemical and refining processes. It
is prescience is an indication of factories pollution.

 Lead: Lead is a poison whose effects are cumulative.

Flowcytometry Crossmatch
An accredited Histocompatibility laboratory is essential to support a living donor
kidney transplant programme.

The crossmatch test should be performed at an early stage in the assessment of a

prospective donor and the final crossmatch should be performed on serum sample
collected within one week of the planned date for transplantation to confirm that it is
safe to proceed.
A number of techniques are used in the laboratory for the definition of
sensitization including the complement dependent cytotoxicity assay and
Flowcytometry based systems*. As no single technique can provide complete
information, it is recommended that a combination of methods is used to establish a
patient’s antibody profile.
The technique used for the crossmatch test should be sensitive and clinically relevant.
The use of a flowcytometric technique is recommended, particularly for sensitized
patients and re-transplantation, as the conventional cytotoxic crossmatch is not
sufficiently sensitive to detect all clinically relevant antibodies. Low-level preformed
alloantibodies detected by flowcytometry represent a risk of rejection even for patients
purposely selected for having no additional immunological risk factors. The risk seems
to be due to donor-specific memory rather than to a direct effect of the antibodies. The
results indicate that flow cytometry provides useful information to assess donor-
recipient compatibility.
Moreover, the computer printouts represent a permanent record for retrospective
review.

Flowcytometric crossmatch has been shown 30 to 250 times more

sensitive than the serological method.

Anti-Müllerian Hormone (AMH)

Anti-Müllerian hormone (AMH) is a dimeric glycoprotein, a member of the transforming growth

factor (TGF) superfamily. It is produced exclusively in the gonads and is involved in the regulation of
follicular growth and development. In the ovary AMH is produced by the granulosa cells of early
developing follicles and seems to be able to inhibit the initiation of primordial follicle growth and FSH-
induced follicle growth. As AMH is largely expressed throughout folliculogenesis, from the primary
follicular stage towards the antral stage, serum levels of AMH may represent both the quantity and
quality of the ovarian follicle pool.

 Compared to other ovarian tests (FSH, LH, E2), AMH seems to be the best marker reflecting
the decline of reproductive age. AMH measurement could be useful in the prediction of the
menopausal transition.
  It could also be used to predict poor ovarian response and the prognosis of in vitro fertilization
(IVF) cycles. Several studies have shown that AMH is an excellent marker to determine ovarian
responsiveness in an IVF program.
 AMH has been shown to be a good surrogate marker for polycystic ovary syndrome (PCOS).
There is a positive correlation between serum AMH levels and number of antral follicles in
women with PCOS.
 Finally, its use as a marker for granulosa cell tumours has been proposed.

Cystatin-C
A new marker for GFR
-Cystatin-C is a single chain, non-glycosylated basic protein which is synthesized in the
body by all nucleated cells. it is an inhibitor of cysteine proteinase
-It is cleared from the blood by glomerular filtration, and is then reabsorbed and rapidly
broken down by the proximal tubular cells without reentering the circulation.
-Because of its small size (small for a protein) and a positive net charge, it is freely
filtered at the glomerulus at the same concentration as in the plasma. The filtered
peptide is completely reabsorbed by the proximal tubule, but then is destroyed
rather than reentering the circulation
Thus, Cystatin-C has the characteristics of an ideal marker of glomerular filtration rate
(GFR).
-Serum Cystatin-C values increase as GFR decreases.
Cystatin-C measurement indicates early stage of renal impairement, when creatinine is
still in the blind range.
It must be noted that cystatin C renal clearance cannot be measured because
normally it is completely reabsorbed, and none is excreted in the urine. For this
reason, changes in serum concentration of cystatin C are used as indirect estimates
of GFR.
A complex equation to estimate GFR using the exponential functions and plasma
cystatin C concentrations has been developed, and the results were found to be better
than those achieved by the MDRD equation.
Unlike serum creatinine, Cystatin-C values are independent of gender, age and body
mass.

NEW JAK2 MUTATION TEST FOR Myeloproliferative Disorders

(MPD)
 Polycythemia vera, essential thrombocythemia, and idiopathic myelofibrosis are clonal
myeloproliferative disorders arising from a multipotent progenitor.

In 2005, Dr. William Vainchenker (Institute Gustave Roussy) identified the recurrent V617F
mutation in the JAK2 gene encoding a cytoplasmic Tyrosine Kinase in most common
Myeloproliferative Disorders (MPD). This was a major breakthrough in the understanding,
classification and diagnosis of these diseases.

The somatic single point mutation (G1849T), which occurs within exon14 of the Tyrosine
Kinase JAK2 gene, causes the substitution of a Valine to a phenylalanine at position 617 (V617F). The
substitution results in constitutive Kinase activity of the JAK2 protein and thereby in constitutive
activation of tyrosine kinase signalling.

The JAK2V617F mutation is detected in most patients with Polycythaemia Vera (PV) and in
about half of patients with essential thrombocythaemia (ET) or primary myelofibrosis (PMF).

The clinical utility of direct diagnostic test for the V617F JAK2 mutation is to:
o Confirm a diagnosis of Polycythaemia Vera (PV), essential thrombocythaemia (ET) and
primary myelofibrosis (PMF).
o Confirm a clonal hematopoietic stem cell disorder
o Confirm Myeloproliferative Disorders (MPD) in cases with high erythrocyte, leukocyte,
or platelet counts.
 Gastrin hormone
Gastrin is a major gastrointestinal hormone. It is produced by
special cells in the stomach (G cells). Small amounts of gastrin may
also be produced by the pancreas and possibly the intestines.
Food in the stomach stimulates gastrin release into the blood, which
serves to stimulate gastric acid secretion. As stomach and intestinal
acidity rises, gastrin production normally decreases in a case of
negative feed back mechanism.

Excessive secretion of gastrin is a well recognized cause of a severe

disease known as Zollinger – Ellison syndrome (gastrinomas) which
is seen in men. The hallmark of the disease is gastric and duodenal
ulceration due to excessive and unregulated secretion of gastric
acid.
Most Zollinger – Ellison patients have fasting gastrin levels more
than 500 Pg/ml and high basal gastric acid secretion.

Elevated levels of serum gastrin are also encountered in other

conditions with impaired gastric acid secretion, for example in
pernicious anemia, in pyloric obstruction with antrum distension,
after vagotomy without gastric resection and in chronic atrophic
gastritis.
 Serum inhibin B

Inhibins are heterodimeric polypeptide hormones, they selectively

supresss the secretion of pituitary FSH and also have local paracrine
actions of the gonads.
In women, FSH stimulates the secretion of inhibin from granulose
cells of the ovarian follicles in the ovary, in turn inhibin suppresses
FSH production via negative feed back mechanism.

Inhibin B levels offer a new measure for ovarian reserve, which is of

special importance in women of advanced maternal age when
ovarian functions and follicle development subside, yet pregnancy is
desperately desired. Ovarian reserve describes the woman's
capacity to respond to the ovulation induction in producing a
reasonable number of good quality eggs.
So, serum inhibin levels measured early during FSH administration
for IVF may be of value in predicting the number of oocytes to be
retrieved in normal and low responders.

What Is Inhibin B?

Inhibin B is a hormone that is produced by certain cells in the ovarian follicles. When produced, it
helps to suppress another hormone called FSH, or follicle stimulating hormone.

As a woman ages, not only does the number of follicles on the ovaries decrease but so does the
hormones produced by those follicles, like inhibin B.

Inhibin B is a protein hormone produced

by your ovaries. It works to inhibit FSH, which is responsible for
helping your follicles to develop. Levels of Inhibin B decrease with
age.

Inhibin B is actually secreted directly by small, developing

follicles in your ovaries. During the follicular phase of ovulation,
small follicles eventually develop into mature eggs, ready for
fertilization. Inhibin B has a sister hormone called Inhibin A, which is
also produced by the ovaries.

This makes it an effective test of a woman’s ovarian reserve or function.

usually done on day three of your period.

How Does Inhibin B Affect Fertility?

If the result is within the normal range, you have an excellent chance of getting pregnant.

the AMH (anti-mullerian hormone) and inhibin-B hormone test to evaluate a woman’s ovarian reserve,
or how well her ovaries are working.These tests are usually performed as part of an infertility
evaluation
Inhibin B levels may be a better marker for evaluating male factor fertility than FSH and LH. In
patients with infertility, measuring inhibin B levels may provide useful information on
spermatogenesis

Low levels of Inhibin B are associated with:

 impaired ovulation
 decreased success with IVF
 lower pregnancy rates
 increased risk of miscarriage

in males
It is secreted from the Sertoli cells,[18] located in the seminiferous tubules inside the testes. Androgens
stimulate inhibin production; this protein may also help to locally regulate spermatogenesis.

The mean serum inhibin B level is significantly higher among fertile men (approximately 140
pg/mL) than in infertile men (approximately 80 pg/mL).[30]

In men with azoospermia, a positive test for inhibin B slightly raises the chances for successfully
achieving pregnancy through testicular sperm extraction (TESE),
 Serum Amyloid A (SAA)
Acute-phase serum amyloid A proteins (A-SAAs) are secreted during the acute phase of inflammation.
These proteins have several roles, including the transport of cholesterol to the liver for secretion into
the bile, the recruitment of immune cells to inflammatory sites, and the induction of enzymes that
degrade extracellular matrix.
The liver synthesizes SAA stimulated by immune system modulators
as IL1, IL2, TNF and cytokines.

Circulating SAA concentration may increase up to 1000 fold

following tissues injury and cell necrosis.
SAA is a better early predictor of severity than CRP in acute
inflammation.
SAA is also implicated in several chronic inflammatory diseases such
as amyloidosis.
SAA is a great diagnostic function in rheumatoid arthritis. It is an
index of disease activity, it can be high when serum CRP and ESR are
suppressed.
SAA is used as marker of response of rheumatoid arthritis to
treatment with gold or penicillamin.

SAA protein is also present in patients following myocardial

infarction in concentrations proportional to the degree of tissues
injury and correlated very well with cardiac troponin T.

Acute-phase proteins
The acute phase proteins are plasma proteins synthesized in liver that undergo change in concentration in
response to infection, tissue injury, and inflammation (Table 24.2). Acute phase proteins are synthesized by liver
following stimulation by cytokines like interleukin-1, interleukin-6, and tumor necrosis factor-synthesized
by monocytes and macrophages (Fig. 24.3). Acute phase reactants play a role in the defensive process of
inflammation. They help in opsonization, neutralization of proteolytic enzymes released from neutrophils
(thereby limiting tissue damage), clearance of cell debris, and healing of wounds

CRP:
When it was first described in 1930, it was found to bind to C-polysaccharide in the cell wall of Streptococcus
pneumonie; hence the name C-reactive protein. Test for CRP is helpful in determining the presence and extent
of inflammation and in monitoring response to therapy. Among the acute phase reactants, CRP is earliest to rise
during inflammation and to return rapidly to normal level following successful therapy. Also, CRP rises to a
more significantly higher level than other acute phase reactants. Therefore among acute phase proteins,
measurement of CRP is preferred. In acute disease, CRP level correlates well with ESR. As compared to ESR,
CRP is (i) earlier to rise in inflammation and earlier to return to normal following resolution, (ii) more sensitive,
and (iii) more specific since it is not affected by anemia, polycythemia, alteration of red cell shape, and
paraproteinemia (Table 24.3).
Ceruloplasmin (or caeruloplasmin) is a ferroxidase enzyme that in humans is encoded by the CP
gene.[5][6][7]

Ceruloplasmin is the major copper-carrying protein in the blood, and in addition plays a role in iron
metabolism.

Like any other plasma protein, levels drop in patients with hepatic disease due to reduced synthesizing
capabilities.

Lower-than-normal ceruloplasmin levels may indicate the following:

 Wilson disease (a rare (UK incidence 2/100,000) copper storage disease).[14] This disease causes
very high levels of copper in the liver, brain and other organs and has symptoms including
nausea, fatigue, yellowing of the skin and eyes

Greater-than-normal ceruloplasmin levels may indicate or be noticed in:

 copper toxicity / zinc deficiency

 acute and chronic inflammation (it is an acute-phase reactant)


Ceruloplasmin levels are not diagnostic of a specific condition and are usually evaluated along with
copper tests.
 Decreased levels of ceruloplasmin are found in Wilson's Disease, fulminant liver failure, intestinal
malabsorption, renal failure resulting in proteinuria, chronic active hepatitis and malnutrition. Elevated
levels are found in primary biliary cirrhosis, pregnancy (first trimester), oral contraceptive use and in
acute inflammatory conditions since ceruloplasmin is an acute phase reactant.

Crossmatching by Flowcytometry (FCXM):

Crossmatching by flowcytometry has been shown to be more

sensitive than the traditional cytotoxic crossmatching (Koktathong et
al., 2005).
The higher sensitivity of FCXM is due to its ability to identify
complement-fixing and non-fixing antibodies and to simultaneously
define the class of the detected immunoglobulin (IgG and/or IgM)
and the different types of target cells (T and/or B lymphocytes)
(Piazza et al., 2001).
 The patients with a positive flowcytometry crossmatch (FCXM)
are categorized as a high-risk group causing hyperacute or
accelerated acute rejection after kidney transplantation (Takeda et
al., 2000). Furthermore, graft survival is improved among patients
whose final flowcytometric crossmatches were negative compared to
patients with positive flowcytometric crossmatches (Gebel and Bray,
2000).
Low-level of preformed alloantibodies detected by
flowcytometry represent a risk of rejection even for patients
purposely selected for having no additional immunological risk
factors. The risk seems to be due to donor-specific memory rather
than to a direct effect of the antibodies.

Fragile X syndrome

Fragile X syndrome is the most common form of inherited mental retardation. It affects
approximately 1 in 1200 males and 1 in 2500 females.
As suggested by the name, it is associated with a fragile site under specific cytogenetic
laboratory conditions at position Xq27.3.
The inheritance pattern of fragile X puzzled geneticists, as it did not follow a clear X
linked pattern. Approximately 20% of males who are carriers based on pedigree analysis
do not manifest any clinical symptoms and are thus termed as Normal Transmitting
Males (NTM). Approximately 35% of female carriers have some mental impairment.
Based on the above, it has been proposed that there are two states of the mutation,
one mutation range in which there is no clinical expression (premutation), and one
mutation leading to the disease causing state (full mutation).
The peculiar genetic mode of transmission was established and a new class of mutation
came into existence- Triple repeat amplification. This explained the clinical state of
‘premutation’ and ‘full mutation’. The fragile X syndrome is caused by the amplification
of CGG repeats that is located in the 5’ region of the cDNA. The most common allele in
the normal population consists of 29 repeats, the range varying from 6 to 54 repeats.
Premutations in fragile X families showing no phenotypic effect range in size from 52 to
over 200 repeats. In general repeats up to 45 are considered normal; repeats above 50
to 200 are considered as premutation and above 200 as full mutation.

Y-chromosome microdeletion
Nearly 10% of all married couples go childless. Nearly 50% of these are accountable to
the male partner. A large proportion of male infertility cases are associated either with
systemic defects such as diabetes, obesity, varicocele,.. or with infections as mumps,
herpes or else with imbalance in levels of gonadal steroids and trophic hormones.

However, in nearly 15% cases of male infertility no organic cause is identified (idiopathic
infertility). Since infertility is largely due to impairment of gametogenesis, in which a
number of genes participate, it is logical that mutations in spermatogenic genes would
result in impaired spermatogenesis, leading to infertility.

Molecular studies on Y-chromosome microdeletion have led to the identification of an

azoospermia factor (AZF) region in Yq112 (Vogt et al 1996). Most deletions occur de
novo and fall in three nonoverlapping regions, designated AZFa, AZFb and AZFc, the last
of these being the most frequently deleted (Kobayashi et al 1994).

A global estimate places about 10% cases of idiopathic azoo/oligospermia due to

deletion in AZF region. Therefore it is the most common molecularly diagnosable cause
of spermatogenic failure in man (Reijo et al 1995), and is highly recommended in cases
where intracytoplasmic sperm injection (ICSI) is to be adopted for assisted
reproduction.

HCV RNA Viral Load by the

Only FDA Approved Real-Time PCR

The presence of Anti-HCV antibodies is a measure of prior exposure to HCV infection, but cannot be
considered a marker for current infection.

Hepatitis C virus (HCV) RNA is the most important parameter for diagnosis, management of antiviral
therapy and determination of virologic response to therapy in HCV infection. Highly sensitive HCV RNA
detection is also important to accurately determine virologic response at the end-of-treatment and
during follow-up 1.
ALMOKHTABAR LABORATORIES NOW offer the next generation of the first fully automated, FDA
approved, real-time PCR platform: The COBAS AmpliPrep / COBAS TaqMan (CAP/CTM) viral load test
designed by Roche Molecular Diagnostics, providing sample-in/results-out capability 2. The CAP/CTM is
a nucleic acid amplification test for the quantification of Hepatitis C Virus (HCV) RNA in human serum
or plasma with the following benefits:

 The increased limit of detection at 18 HCV RNA IU/ml allows for an optimal monitoring
of treatment success and early detection of treatment failure.
 Increased accuracy throughout 6 logs of viral load titers.
 The high specificity reduces the number of assay related false positive results,
minimizing expensive retesting and patient anxiety.
 Accurate design of primers and probes ensures an optimal quantification for HCV
genotypes 1 to 6.
 The closed sample tube reduces the risk of contamination.

To ensure accurate quantification, the test has been calibrated to the World Health Organization
(WHO) traceable standards and can detect down to 18 IU/ml with 100% certainty. 2

A study published in the Journal of Clinical Virology in June 2008 confirmed that "The CAP/CTM assay
is a reliable and robust assay for highly sensitive detection and quantification of HCV RNA within a
broad linear range". 1

The COBAS AmpliPrep / COBAS TaqMan test is now routinely done at almokhtabar
(Moamena Kamel) Laboratories.

References

1. JOURNAL OF CLINICAL VIROLOGY: Evaluation of an automated, highly sensitive, real-time PCR-based

assay (COBAS AmpliPrep/COBAS TaqMan) for quantification of HCV RNA by Christoph Sarrazin, Anette
Dragan, Barbara C. Gartner, Michael S. Forman, Stella Traver, Stefan Zeuzem, Alexandra Valsamakis.
2. Hepatitis C Information Central: www.hepatitis-central.com
 HBV DNA by TaqMan Real Time PCR

Hepatitis B virus (HBV) infection continues to be a leading cause of chronic

liver disease, With more than 350 million people chronically infected
worldwide. Chronic HBV carriers are at increased risk for the development
of cirrhosis and hepatocellular carcinoma1.

The measurement of HBV DNA levels has become the most direct and
reliable method used for accurate diagnosis and Prognosis of acute and
chronic HBV infection.

The novel COBAS AmpliPrep/COBAS TaqMan HBV test, combines

automated extraction of HBV DNA on the COBAS Ampliprep instrument
,coupled with real-time PCR on the COBAS TaqMan analyzer, that greatly
reducing hands-on time during sample preparation and
amplification/detection.

The assay fullfils the current requirements: a highly sensitive HBV DNA
detection (12 IU/ml) which is calibrated to the International WHO St handard
to reliably quantify HBV genotypes A-G in plasma, with a very broad
measuring range nearly 7-log dynamic range2 .

HBV DNA by TaqMan real time PCR is routinely

done in Almokhtabar (Moamena Kamel
Laboratories)
Reference:
Journal of Clinical Microbiology, April 2006, P.1490-1494, Vol. 44, No.4
Journal of Clinical Virology. 2006 Apr ;35 (4):373-80.Epub 2006 Feb 7
 Quantiferon T.B. – gold

Quantiferon T.B. – gold is a new test that measures interferon gamma

released from sensitized T Lymphocytes when stimulated by antigen from
Mycobacterium Tuberculosis.
It has a role in diagnosis of both pulmonary and extra-pulmonary T.B and
also in children.
This test is done on a blood sample that is incubated with the antigen
overnight, then after centrifugation, interferon gamma is measured by an
ELISA assay.
The result is available after 24 h. and it has many advantages over
environmental mycobacterium: only one visit from the patient is needed, the
reading is objective not like tuberculin skin test, and does not cause boosting.

Quantiferon T.B. – gold. done in Almokhtabar

Laboratories (Moamena Kamel)

HBsAg Quantitative Test

Infection with hepatitis B virus is the leading cause of chronic hepatitis
worldwide and people with chronic hepatitis B infection are at increased risk for
developing hepatocellular carcinoma. In addition, hepatitis B virus is the leading
cause of cirrhosis in the world. About 2 billion people worldwide have been
infected with the virus and about 350 million live with chronic infection.

HBsAg quantitation measurement by automated chemiluminescent microparticle

immunoassay revealed a significant correlation with corresponding HBV DNA
levels(3).
So, it can be considered that HBsAg quantitation is a surrogate marker for viral
load during management of chronic HBV infection as reduction of HBsAg has a
good correlation with the reduction in intrahepatic convalently closed circular
DNA (cccDNA) and the reduction in logarithmic DNA(3).
In addition, the most common method for measuring cccDNA levels is invasive
and requires liver biopsy. In contrast, quantitative HBsAg testing requires only a
serum sample.

Now Architect HBsAg Quantitative Test is used for quantitative determination

of hepatitis B surface antigen (HBsAg) in human serum or plasma. It has the
highest sensitivity of ≤ 0.05 IU/ml.
The patient's result less than this limit is negative for hepatitis B virus. The
Architect QT assay is fully automated and standardized

HBsAg Quantitative Test by ARCHITECT is routinely done

in Almokhtabar (Moamena Kamel Laboratories).

Automated HCV Ag Assay

Egypt leads the world in hepatitis C infection cases (half of all cases in Africa). 1 HCV
infections are characterized by two features which are a high rate of asymptomatic infections
in the acute phase, with current estimates up to 75% and a high chronicity rate. More than
50% of infected patients become chronic and estimates are between 60 and 90%. Over time,
chronic HCV infections may lead to cirrhosis and liver carcinoma. 2

HCV antibodies are useful as an indicator of past HCV infection and do not indicate current
viraemia or elimination of virus from the patient. Active HCV infection, acute or chronic, is
characterized by the presence of HCV antigen. HCV Ag is detectable well before the
occurance of antibodies against HCV. The serodiagnostic window, the time when the virus is
present but antibodies are not, may last as long as 70 days. A negative antibody test does not
rule out an HCV infection in the early incubation phase. 2

The new ARCHITECT HCV Ag assay is a Chemiluminescent Microparticle

Immunoassay (CMIA) for the quantitative determination of core antigen to Hepatitis C virus
(HCV) in human serum and plasma. Hepatitis C virus core Antigen (HCV Ag) is a direct
marker for the diagnosis of HCV infection and can be used as confirmation of active disease,
screening of patients at high risk for HCV infection (e.g dialysis patients, IV drug users) and
therapy monitoring.2

The automated HCV Ag assay showed results comparable to those of the HCV RNA viral
load assay, and it has the advantages of easy testing and rapid reporting. This assay would
be useful to monitor HCV infection and to discriminate active viral replication states from
stable infections and could be an alternative to the quantitation of HCV RNA levels using
quantitative Real Time-PCR.3

HCV Ag Assay Test by ARCHITECT is routinely done in Almokhtabar

(Moamena Kamel Laboratories).
References
1. Hepatitis C in Egypt. http://www.slideshare.net/ahmedicine/hepatitis-c-in-egypt
2. http://southasia.abbottdiagnostics.com
3. Park Y, Lee JH, Kim BS, Kim do Y, Han KH, Kim HS. New automated hepatitis C virus
(HCV) core antigen assay as an alternative to real-time PCR for HCV RNA quantification. J
Clin Microbiol. 2010 June; 48(6): 2253–2256.

Human Papilloma Virus (HPV)

HPV is a small, non-enveloped, double-stranded DNA virus commonly causes epithelial

proliferations at cutaneous and mucosal surfaces. There are more than 100 different
genotypes of HPV, and approximately 40 different HPV genotypes can infect the human
genital mucosa. These types can be divided into 2 groups:
 High Risk HPV genotypes; which are associated with high-grade cervical dysplasia and
cervical cancer, common types are 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68, and
82.
 Low Risk HPV genotypes; which are often associated with benign low-grade intraepithelial
lesions or condylomas, common types are 6, 11, 40, 42, 43, 44, 54, 61, 72, 73, and 81.
The majority of HPV infections clear spontaneously, but persistence of a high risk HPV is a
significant risk factor for the development of cervical cancer.

 Most people with HPV do not have symptoms and do not know they are infected.
 Early detection and treatment of pre-cancerous lesions can prevent development of
cervical cancer.

Testing Human Papilloma Virus:

The Pap smear is primarily used for cervical cancer screening. It requires interpretation by
highly trained cytopathologists and is a relatively inaccurate test with a high rate of false
negatives. Cytological abnormalities observed in the Pap smear are primarily due to infection
with HPV; however, various inflammatory or sampling variations can result in false positive
Pap results.

Nucleic acid DNA testing by PCR is a sensitive and noninvasive method for determining the
presence of an active cervical HPV infection.

The LINEAR ARRAY HPV Genotyping Test is used to qualitatively detect the Human
Papilloma Virus in clinical specimens. The test is based on the amplification of target DNA by
the Polymerase Chain Reaction (PCR), nucleic acid hybridization of the amplified products to
oligonucleotide probes; and detection of the probe-bound amplified products by colorimetric
determination. The test can detect thirty seven anogenital HPV DNA.

Specimen Collection and Storage:

Cervical cell specimens are collected in special medium and then they may be stored at room
temperature for up to 21 days or at 2-8ºC for up to 12 weeks.

Human Papilloma Virus Genotype detection is routinely done in

ALMokhtabar (Moamena Kamel Laboratories).

FEVER OF UNKNOWN ORIGIN

Fever of unknown origin (FUO) is defined as continuous fever of at least 3 weeks duration with
daily temperature elevation above 101 F (38 C) and remaining undiagnosed after one week of
intensive study
In the hospital ,or as Temperature greater than (38 C) persisting for at least for 3 weeks in
patients whom the history, physical examination, blood count , urine analysis, and chest films fail to
indicate the diagnosis . Regardless of which of these criteria is employed, the diagnostic approach to
FUO must be individualized for each patient .The requirement of fever of 3 weeks duration for the
diagnosis of FUO is most important because it eliminates from consideration most viral and bacterial
infections as well as other self- limited diseases associated with fever.

Causes of fever of unknown origin

Most patients with FUO do not have a rare disease but usually suffer from common disorders
that are difficult to diagnose because they present atypically. In approximately 5 % to 10 % of the
cases, the cause is unknown.

Malignant Disease Diseases of connective tissue

* Lymphoma * Giant cell arteritis
* leukemia * Still s disease
* Solid tumors * Lupus erythromatosis
* Hypernephroma * Systemic vasculitis
* Temporal arteritis

Infections Other causes

* Tuberculosis ( esp. lymph node ) * Drug fever
* Endocarditis * Factitious fever ( self induced)
* Rheumatic fever * Thrombophlebitis
* Abscesses ( liver, pelvic ) * Granulomatous diseases
* Malaria * Inflammatory diseases of the bowel
* Visceral leishmaniasis * Sarcoidosis
* Typhoid and paratyphoid fever * Pulmonary emboli
* Urinary tract infection * Brucellosis
* Osteomyelitis
Laboratory tests:
- CBC - HIV
- ESR - Film for Malaria
- CRP - EBV Ab. (IgM - IgG)
- Widal & Brucella - SGPT
- Urine examination & C/S - ASOT
- Stool examination & C/S -ANA
- Blood Culture - Throat swab C/S
- CMV (IgG - IgM) - T3 - T4 - TSH

SICKLE CELL ANEMIA AND ß-THALASSEMIA: MOLECULAR DIAGNOSIS AND CARRIER SCREENING FOR
FREQUENT β-GLOBIN MUTATIONS

Mutations in the β -globin gene lead to the inherited disorders of hemoglobin which are
known as hemoglobinopathies. The β -globin gene cluster is found on chromosome 11. More than 150
different molecular defects have been characterized to date. The altered β -globin structures either
cause structural abnormalities, such as hemoglobin S (sickle cell anaemia) or hemoglobin C, or may
lead to synthesis dysfunctions (β -thalassemia). The globinopathies are common autosomal recessive
disorders especially amongst mediterraneans, Asians, Africans, and Indians. However, some of these
genetic defects are now widespread and also occur in Continental Europe, North and South America
and Australia. In Africans the mutation leading to sickle cell anemia has a frequency of 1 in 500.
Approximately 240 million people worldwide are heterozygote for β -thalassemia and at least 200.000
affected homozygotes are born annually representing a major health problem (table la: Bulletin World
Health Organization 1983).

Sickle cell anemia causes considerable mortality and morbidity in Africa and in populations of
African descent. The variant hemoglobin is due to a single AT substitution (valin for glutamic acid) at
codon 6 of the β -globin chain. The homozygous condition is associated with a complex severe
pathophysiology including increased propensity to infection, vasoocclusive episodes and chronic
hemolytic anemia. Sickle cell anemia usually present during the first or second year of life and is
accompanied with a shortened survival. In the heterozygous state only few clinical effects are
observed. However, often the heterozygous state is seen in association with other
β -globin chain variants such as HbC (resulting from a different nucleotide exchange in the same
codon) or β -thalassemia (compound heterozygosity).

β -thalassemia is heterogeneous at the molecular level. Each population at risk has its own
specific spectrum of common mutations (see table 1b). Three clinical - hematological conditions are
recognized: the β -thalassemia carrier state (heterozygous β -thalassemia), thalassemia intermedia,
and thalassemia major, the last two resulting from homozygosity or compound heterozygosity for β-
thalassemia alleles. The heterozygote carrier state is clinically asymptomatic and can be characterized
hematologically. Homozygosity or compound heterozygosity for β -thalassemia alleles usually
results in transfusion – dependent thalassemia major. The disease manifests at 6 to 12 months of age
with severe anemia, failure to thrive and enlargement of the spleen and liver. Without treatment
patients with thalassemia major die from anaemia & related complications within the first six years of
life. Blood transfusions extent life expectancy into the third decade.

For the large majority of affected individuals with mutations of the β -globin gene there in only
supportive management but no definitive cure. Therefore, emphasis is given to prevention programs
based on heterozygous carrier screening and prenatal diagnosis. Advances in carrier diagnosis using
hematologic analysis followed by mutation analysis in combination with genetic counseling has
resulted in a consistent decline of birth of affected homozygotes in several Mediterranean at- risk
populations.

Table la: Carrier frequencies of β-thalassemia in different populations

Population % carrier
The Mediterranean North and Central Italy 2 - 5
Southern Italy, Dardenia 5 - 20
Greece 5 - 20
Cyprus 10 - 17
Arab and Middle East Jordan 3 - 4
Lebanon 2 - 6
Saudi Arabia (central, north western) 3 - 6
Saudi Arabia (eastern) 13 - 18
Turkey 0.2 - 6
North Africa Libya 3 - 11
Algeria 2 - 3

Table 1b: Most common β- thalassemia mutations in at – risk populations (%)

Mutation Italy Greece Turkey Algeria Jordan Egypt Lebanon

Cd 8-AA - - 6 4 - 3 6
Cd 39C>T 40 17 - 26 10 1 4
IVSI-1G>A 10 13 - 17 17 13 -
IVSI –6 T>C 10 7 18 16 6 13 8
IVSI-110 G>A 23 42 39 27 27 41 62
IVSII-1 G>A - - 12 - 6 3 4
IVSII-745 C>G - - - - - 3 4
Total 83 79 75 90 66 77 88

The DNA- test covers nine of the most common Mediterranean β - globin mutations (-87, HbC, HbS,
IVSI-1, IVSI-6,IVSI-110,cd39,IVSII-1, IVSII-745) representing between 65 and 90% of β -thalassemia
mutation and more than 90% of β -globin mutation present in the Mediterranean region and Middle
East.
 Requirement: 5- 10 ml EDTA blood (in monovette).
If prenatal analysis required, send 10 - 15 mg chorionic villi in sterile
NaCl solution or cultivated fetal cells (one flask 25ml) and blood from
both parents.
Please always quote weeks of pregnancy and send all relevant clinical data as well as the
hemoglobin differentiation results.

Bilharzial Antigen
Definite diagnosis of human schistosomiasis is based on microscopic detection of parasite eggs
in faeces or urine. This is a labor intensive and occasionally insensitive (35%) especially in cases with
very mild infection or intense fibrosis in chronic infection. Biopsy technique gives better result but is
invasive and needs experienced physicians rather than technicians. Serological detection of anti-
schistosomal antibodies dose not discriminate between past and current infection. Recently, detection
of circulating schistosomal antigen secreted by living schistosomes, S. mansoni or S. haematobium, in
body fluids using monoclonal antibodies generated against these antigens has been shown to be a
promising approach to detect active infection and to asses treatment efficacy and effectiveness of
future vaccines.
* Sample required
- Random urine sample or
- Human serum
* Statistical data
- Sensitivity : 93%
- Specificity : 89%
- Accuracy : 91% (in compose with standard rectal biopsy).

Hyaluronic acid test

An enzyme-linked binding protein assay for the determination of hyaluronic acid (HA) in
human serum or plasma. The measurement of HA may be used to assess the degree of liver fibrosis
and cirrhosis in chronic liver disease.(normal range = 0 - 75 ng/ml).
SUMMARY AND EXPLANATION OF THE HYALURONIC ACID TEST:
 Hyaluronic acid (HA), also known as hyaluronate or hyaluronan, is a glycosaminoglycan.
Hyaluronic acid is mainly produced by fibroblasts and other specialized connective tissue cells. It plays
a structural role in the connective tissue matrix (Proteoglycan) and participates in various cell -to-cell
interactions. HA levels are maintained by an efficient receptor dependent removal mechanism present
in sinusoidal endothelial cells (SEC) of the liver and by the enzymatic action of hyaluronidase.
Serum HA levels can be elevated in various liver diseases characterized by liver fibrosis and
cirrhosis, due to decreased hepatic removal and/or increased hepatic production of HA during liver
inflammation. Increased HA levels have shown a better correlation with the degree of
histopathological damage to the liver than conventional liver function tests including ALT/AST, alkaline
phosphatase and billirubin.
It has also been shown that HA levels reflect the extent of hepatic fibrosis in patient with
chronic hepatitis C and may be useful in monitoring the response to interferon alpha treatment.
Similar correlation has been found in patient with alcoholic cirrhosis and primary biliary cirrhosis. HA
levels have been shown to be an early marker of liver damage from toxic agents such as ethanol,
acetaminophen, and bacterial lipopolysaccharide, as pathological changes of the SEC in response to
these agents precede pathological changes of the hepatocytes.
Clinical Sensitivity
Serum samples obtained from 62 patients followed up in a Hepatic Disease clinic USA were
tested with the HA kit to determine the clinical sensitivity of the assay. Forty-nine patients were
diagnosed as liver cirrhosis. And 13 patients were undergoing detoxification (detox) treatment for
alcohol abuse with no clinical or laboratory evidence of liver disease. The percentage of samples with
HA levels >100 ng/mL for the two groups compared to the healthy controls tested at the same time
are shown in the table below:

patients (62) n Mean HA value % positive

Cirrhosis 49 371.6 ng/mL 38/49 = 77.6%
detox 13 51.4 ng/mL 2/13 = 15.4%
healthy 100 19.8 ng/mL 0/100 = 0%
Cut off level 100 ng/ml

N.B: detoxification of alcohol: detox

The mean HA values for the cirrhosis and detox groups were found to be statistically
significantly high when compared to the healthy group (p<0.001).

High Sensitive CRP (ULTRASENSITIVE)

C- Reaction Protein (CRP), which is synthesized in the liver, is one of the most sensitive acute
phase reactants. After tissue damage or inflammation CRP activates the classical complement pathway
as a response to the inflammatory reaction.
CRP levels in serum can rise dramatically after myocardial infarction, stress trauma, infection
inflammation, surgery or neoplastic proliferation.
 The increase occurs within 24 to 48 hours and the level may be up to 2000 times normal. An
elevation can be expected in virtually all diseases involving tissue damages, so the finding is
nonspecific.
Elevations of CRP levels within the conventional reference range have been reported in several
studies. These studies have shown that high sensitivity CRP (HsCRP) is of interest in predicting the risk
for future cardiovascular events and peripheral vascular diseases. Concentrations greater than 10
mg/L generally have a significant other inflammatory process occurring.
.Clinical diagnosis should not be made on the findings of a single test result, but should
integrate both clinical and laboratory data.
REQUIREMENT: 1 ml serum
REF.RANGE: < 5 mg/L
Relative risk of myocardial infarct (after exclusion of an inflammatory process):
CRP ( mg /L) risk
</= 0.55 : 1.0
0.56-1.14 : 1.1-2.9
1.15-2.10 : 1.6-4.3
>/=2.11 : 1.8-4.6

'''

Pregnancy Associated Plasma

Protein –A (PAPP-A)
 First Trimester Screening for Trisomy 21 & 18

PAPP-A was first described in 1974 as a high molecular weight component of serum obtained
from individuals in late pregnancy.
The biological function of PAPP-A is still unclear. It has been shown to bind heparin which has
led to the postulation that it may have a role in modulating the maternal immune response and be
associated with implantation and growth of the placenta.
Much of the initial work of PAPP-A in the early 1980s was based on the finding that low levels
of PAPP-A were associated with poor fetal viability, miscarriage, pregnancy induced hypertension and
growth retardation.
The recent observation of PAPP-A in unstable atherosclerotic plaques, along with increased
circulating levels, may suggest a new role for PAPP-A as a marker of acute coronary syndromes. To
date, however, its major clinical usefulness appears to be limited to a marker of chromosomal
aneuploidy, and as an indicator of early pregnancy failure and pregnancy complications.
The most common chromosomal abnormality is trisomy 21 (Down syndrome), its risk is
increasing dramatically with maternal age. The second trimester incidence of trisomy 21 is now 1:500.
Other common chromosomal aneuploidies include trisomy 18 and trisomy 13.
Since the early 1990s, prenatal screening, initially instituted for detection of trisomy 21, has
become a standard part of obstetric practice through measurement of maternal serum biochemical
markers in the 2nd trimester (15 to 20 weeks gestation). These markers include: AFP- total HCG, free B-
HCG and unconjugated estriol. Using a combination of maternal age & these markers, detection rate
of 65 to 70% can be achieved with 5 - 6% false positive rate.
Most of the research in the past decade has been focused on screening earlier in pregnancy
(10 to 14 weeks). PAPP-A is a good first trimester marker, while total HCG is a second trimester marker.
Free B-HCG is relatively stable from 10-18 weeks and the best clinical use for PAPP-A may be as early
as 8 weeks. Therefore, the best time to measure both PAPP-A & free B-HCG is in the first trimester
between 10 and 13 weeks.
When used in conjunction with free B-HCG, PAPP-A can detect 90% of trisomy 13 and trisomy
18 cases at a 1% false positive rate.
 How to Assess Liver Cirrhosis…?
(1) Acti Test Fibro Test
The major hepatological consequence of hepatitis C infection is the progression of fibrosis
(scars) to cirrhosis.
Activity and fibrosis are two major histological features of chronic hepatitis C.
One of the few validated scoring systems is called METAVIR scoring system. This system
assesses histological lesions in chronic hepatitis C using two separate scores, one for necro-
inflammatory grade (A for activity) and another for the stage of fibrosis (F for Fibrosis).
Liver Fibrosis Progression occurs in two thirds of patients.
Stages of fibrosis (F) are:
FO= no fibrosis,
F1= Portal fibrosis without septa,
F2= Portal fibrosis with rare septa,
F3= numerous septa without cirrhosis,
F4= Cirrhosis.
Liver Activity Grade activity (A) are
A0=no histological activity,
A1=Minimal activity,
A2= Moderate by integration of the severity of the intensity of both piecemeal (periportal) and lobular
necrosis.

(2) Hyaluronic Acid Test

Serum HA levels can be elevated in various liver diseases characterized by liver fibrosis and
cirrhosis, due to decreased hepatic removal and/or increased hepatic production of HA during liver
inflammation. Increased HA levels have shown a better correlation with the degree of
histopathological damage to the liver than conventional liver function tests including ALT/AST, alkaline
phosphatase and billirubin.
It has also been shown that HA levels reflect the extent of hepatic fibrosis in patients with
chronic hepatitis C and may be useful in monitoring the response to interferon alpha treatment.
Similar correlation has been found in patients with alcoholic cirrhosis and primary biliary cirrhosis. HA
levels have been shown to be an early marker of liver damage from toxic agents such as ethanol,
acetaminophen, and bacterial lipopolysaccharide, as pathological changes of the sinusoidal
endothelial cells in response to these agents precede pathological changes of the hepatocytes.
 DIABETES
The new guidelines issued by the American Diabetes Association changed the definition of diabetes
into:
Anyone with fasting glucose >125 mg/dL now qualifies as diabetic
(the old threshold was 140) –and any reading over110 is considered impaired glucose tolerance.

PREDICTION OF DIABETES
Type 1 Diabetes mellitus (lDDM) is a chronic progressive autoimmune disease. It is now
possible to predict (lDDM) in individuals before the onset of clinical manifestations. In fact testing can
begin as early as 1 - 2 years of age.

The criteria for prediction includes:

1) Positive family history of diabetes
However, you must keep in mind that 80% of individuals who develop (lDDM) do not have a
first degree relative with diabetes.
2) HLA typing
More than 90% of (lDDM) patients are DR4-DQ8 or DR3 - DQ2 or both.
3) Presence of more than one Autoantibody
Namely anti insulin, ICA (islet cell antibody) or anti GAD (glutamic acid decarboxylase). Anti
insulin is usually the first to appear in children, while anti GAD is the first to appear in adults.
Screening for prediction of type 1 diabetes in children and adults is now recommended with
the aim of halting or delaying onset of the disease and its complications.
 If the screening tests are positive nonimmune therapy is now suggested in the form of
nicotinamide, antioxidants and small doses of insulin under supervision of the clinician.
MONITORING & FOLLOW UP OF DIABETIC PATIENTS

Monthly  Blood & Urine glucose + Fructosamine

3 Months  Glycosylated Hemoglobin + Microalbuminuria
Yearly  Liver & Kindly functions + Lipid profile.
FRUCTOSAMINE:
Fructosamine is formed by glucose linkage to albumin or other proteins.
It has the advantage over (HBA1C) of having a shorter half life hence is more useful in monitoring over
a one month period.
GLYCOSYLATED HEMOGLOBIN (HBA1C):
(HBA1C) is formed by addition of a glucose molecule to the beta chain of hemoglobin. This
process is formed progressively and irreversible inside the red cells and is directly dependent on the
blood glucose concentration.
(HBA1C) is probably the best single measure for monitoring diabetes over a three month
period especially if the physician plans to alter therapy.
However this test does not give information about same day variations in blood glucose.
MICROALBUMINURIA:
Microalbuminuria is the key parameter in marking the onset of clinical diabetic or hypertensive
nephropathy. Strict glycaemic control and normalization of blood pressure can reverse
Microalbuminuria.
LIPID PROFILES:
Hyperlipidemia is suggested if:
Triglycerides >180mg%
Total Cholesterol > 200mg%
The risk of cardiac and vascular complications are increased if
HDL Cholesterol <35mg%
LDL Cholesterol >160mg%
All patients who perform these tests should be fasting for 12-14hours.
 TUBERCULOSIS (TB)

Successful diagnosis of TB is directly related to obtaining a good sample. If sputum or urine is being
examined, three to six successive samples should be collected to overcome;
Poor expectoration by a patient trying to give a sputum sample.
Intermittent production of bacilli in urine

Diagnosis of TB is also dependent on the technique used:

1) Direct microscopy:
Films are only positive if more than 5,000 Acid Fast Bacilli (AFB) are present in one ml of sputum.
Scoring of a positive result should be reported by the lab in the following manner
1-2AFB/300 fields  (+/-)
1-9AFB/100 fields  (1+)
1-9AFB/ 10 fields  (2+)
1-9AFB/ 1fields  (3+)
>9AFB/ 1fields (4+)
2) Cultures:
a) Conventional cultures: This methodology involves the whole sample then culturing, the deposit-
after adding a cocktail of antibiotics - on several media both liquid and solid. Cultures are positive if
more than 10 AFB are present in the sample. Provisional results can be given before 10 days if the
organisms are fast growers, and after 15 days in slow growers but final results will be handed out in 30
days to allow for identification of the very slow growers.
b) Rapid cultures: by using the BACTEC radio labeled procedure or the MGIT fluorescing labeled
method. Rapid growers can be detected in 3-5 days and slow growers in 7-10 days. However species
identification has to be done by conventional culture.
2) TB-DNA by PCR:
This technique is capable of detecting one AFB/ml. It involves selectively amplifying a single
molecule of DNA several million fold in a few hours followed by coupling of the DNA to its
complementary primer and finally gel electrophoresis for identification. Primers are directed to
Mycobacterium tuberculosis bacilli only.
3)Adenosine Deaminase Activity (ADA):
This test is useful to diagnose TB in body fluids such as CSF, Pleural & Peritoneal effusions. The
sensitivity of the test is 100% and the specificity is 90%.
-ADA activity in pleural & peritoneal effusions
< 40 U/L is negative for TB
> 70 U/L is positive for TB
Between 40-70 U/L is suggestive, to be confirmed by report testing in 2 weeks.
-ADA activity in CSF
 6 U/L is positive for TB.
 T.B Antibody For Active T.B
The Saridar Laboratory has introduced a new assay into the laboratory as a result of receiving
requests for testing for active TB. There is no one single diagnostic method which can detect all TB
cases. Clinicians typically reply on a battery of methods which as x-ray, smear and/or culture, PCR,
clinical signs and symptoms. Diagnosis can take from several days to many weeks and involve
expensive, invasive and complex procedures.
The test being offered is a rapid immunochromatographic test for the qualitative detection of
human IgG antibodies to Mycobacterium tuberculosis in whole blood, plasma, serum, CSF, pleural, or
peritoneal fluids.
The test utilizes multiple antigens, which are secreted by M.tuberculosis during active
infection. This test is designed to indicate the presence, or absence, of IgG antibodies to
M.tuberculosis. Final diagnosis should not be based on this test alone. Other clinical and laboratory
findings should be used to confirm diagnosis.
Detection of M.tuberculosis -reactive IgG antibodies by this method has a sensitivity of 60-70%
and specificity of at least 97% in low-Prevalence areas.
This test is not appropriate for testing for immunity to TB. Reactive antibodies of IgM and IgA
isotopes are less useful.
The IgG synthesis rate for patients with tuberculous meningitis is significantly higher than in
patients with aseptic meningitis and patients with pulmonary tuberculosis only. Therefore, increased
CFS IgG synthesis rates helps differentiate tuberculous meningitis from aseptic meningitis (sensitivity
=100%, specificity =83%).
The BCG vaccine (an attenuated Mycobacterium bovis strain) has been used for more than 60
years and is able to confer delayed cutaneous hypersensitivity but no clear-cut cellular immunity.
Serum antibodies play no role in immunity to mycobacterial disease. Sensitized T-lymphocytes and
activated macrophages are the critical factors in immunity.
In summary, this assay is specific to IgG antibodies which are produced when a patient has an
active infection. The assay does not test for immunity.
Serum Sample. Result is available within 24 hours of receipt of sample.

PLASMA HOMOCYSTEINE
 An amino acid called homocysteine may be as closely linked
to heart disease- and easier to treat

Ordinarily, homocysteine is used by the body to help manufacture proteins and carry out
cellular metabolism. Too much of it, however, appears to cause blood platelets to clump together and
vascular walls begin to break down.

No one knows for certain what it is that causes some individuals and not others to
overproduce homocysteine. However, evidence points to a shortage of vitamins B6, B12 and folic acid
-all of which work to convert the amino acid into a molecular form the body can use. The influence of
the B-group vitamins on plasma homocysteine raises the possibility of prevention or reversal of
cardiovascular disease. It seems that supplementation, whether through vitamin supplements or
vitamin- rich food ranges, does offer a simple way of risk reduction. This is currently the subject of
various prospective studies.

Homocysteine may well be behind some cases of heart disease but it is unlikely to be behind
all. But even the most sceptical will estimate cardiac cases attributable to high homocysteine levels to
be 20%.

Fibro-Max
(Super Biomarker)

The goal of Saridar Lab is the development of non-invasive diagnostic tests which aim to
improve the management of liver disease. That can achieve a 50% reduction in number of required
liver biopsies.
Fibro Max is actually five tests all in one.
1) Fibro Test
Non invasive alternative to measure fibrosis in patients with chronic hepatitis C or B, alcoholic liver
disease and metabolic steatosis (overweight, diabetes, hyperlipidemia).
F0 : No Fibrosis
F1 : Portal Fibrosis
F2 : Bridging fibrosis with few septa
F3 : Bridging fibrosis with many septa
F4 : Cirrhosis
2) Acti Test
 The Acti test offers a non invasive alternative to measure necro inflammatory activity in patients with
chronic hepatitis C or B.
A0 : No activity
A1 : Minimal activity
A2 : Moderate activity
A3 : Severe activity
3) Steato Test
The Steato Test offers a non invasive alternative to measure hepatic steatosis
(triglyceride deposits in the liver) in patients with chronic hepatitis C or B, alcoholic liver disease and
metabolic steatosis (overweight, diabetes, hyperlipidemia).
S0 : No steatosis
S1 : Minimal steatosis, less than 5% of hepatocytes with steatosis.
S2 : Moderate steatosis, between 6-32% of hepatocytes with steatosis.
S3 : Severe steatosis, between 33-100% of hepatocytes with steatosis.
4) Nash Test
The Nash Test offers a non invasive alternative to diagnose non alcoholic steato hepatitis (NASH) in
patients with metabolic steatosis (overweight, diabetes and hyperlipidemia).
N0 : No Nash
N1 : Borderline
N2 : Nash
5) Ash Test
The Ash test offers a non invasive alternative to measure alcoholic steato hepatitis (ASH) in patients
with alcoholic liver disease.
H0 : No Ash
H1 : Minimal Ash
H2 : Moderate Ash
H3 : Severe Ash
What are the most frequent causes of false positive results for Fibro test & Acti Test?
0 Haemolysis, which decreases haptoglobin as observed with ribavirin treatment, or cardiac
prosthesis
ㄱ Gilbert syndrome, which increases total bilirubin.
ㄱ Extra-hepatic cholestasis, which increases GGT and total bilirubin.
ㄱ Drugs which increase total bilirubin as atazanavir.

DYNAMIC TESTING

CLONIDINE - DYNAMIC TEST (Growth hormone stimulation)

Reason for test Investigation of somatotropic function
Protocol Subject fasting for 12H;
Subject resting for 30 min;
- Draw blood at T0 (Basal)
- In adults: orally administer one tablet of clonidine (0.150mg) per m 2 of
body surface area;
 - Draw blood at T+30, T+45, T+60 and T+120 min.
Products Clonidine
Sample requirements Frozen serum samples
Assays GH
Precaution Measure blood pressure every 1/2 hour throughout the test.
DEXAMETHASONE- OVERNIGHT DEXAMETHASONE
Reason for test Diagnosis of Cushing's disease
Protocol Draw blood on d0 at 8 a.m.
-Administer 1mg of dexamethasone at midnight
-Draw blood on d+1 at 8 a.m.
Products Decadron 0.5 mg tablets
Sample requirements Frozen serum and plasma samples
Assays Cortisol and/or ACT

(1)
D-XYLOSE- DYNAMIC TEST
Reason for test Simultaneous blood and urine Xylose assays, performed after oral intake of a
loading dose of D-xylose, allow for intestinal malabsorption screening. D-Xylose,
a 150 molecular -weight pentose, is normally absorbed by the duodenum and
the initial segment of jejunum without undergoing
Protocol Subject fasting for 12 H; subject at rest;
-Adults: oral administration of 25g of D-Xylose in 500 ml of water;
- Draw blood at T+120 min into a fluoridated tube.
-Children: Oral administration of 5g of D-Xylose in 200 ml of water;
-Draw blood at T+60 min into a fluoridated tube
Products D-XYLOSE
Sample requirements Frozen plasma samples, collect urines within 5H after start of test; specify total
urine output
Assays Plasma D-Xylose
Precaution Do not perform this test in case of diarrhea, or if the patient has been sick or
has had food
during the dynamic test.
LH-RH STIMU-LH-DYNAMIC TEST
Reason for test To estimate pituitary gonadotropin reserves (Stimu-LH test)
Protocol Subject fasting for 12 hours.
-Take samples at T0 minutes (Basal).
In adults:
-Inject 100 μg of LH-RH / IV between 8 and 10 a.m.
In Children:
-Inject 100 μg of LH-RH per m2 of body surface area.
- Draw blood at T+30,T+60,T+90 and T+120 minutes.
Products LH-RH Stimulation
Sample requirements Serum samples at +4 C
Assays FSH and LH and /or the Alpha Sub-unit
Precaution This test should not be performed in pregnant women.

(2)

HLA-B27 by PCR

I. INTENDED USE
HLA-B27 Gene Detection Assay provides materials for the isolation of DNA from human whole
blood, the in vitro amplification of HLA-B gene sequences, and the subsequent detection of HLA-B27
by group -specific hybridization in microwells.
II. INTRODUCTION
Human Leukocyte Antigen (HLA) class I specificity B27 represents a family of several closely
related alleles (designated B*2701,B*2702, . . .), differing only by a limited number of nucleotide
substitutions within exons 2 and 3. The various subtypes also differ in their ethnic distributions, with
B*2705 being the most widespread form.
A group of inflammatory rheumatic disorders (collectively termed seronegative spondylo-
arthropathies), among them ankylosing spondilitis (Morbus Becherew), Morbus Reiter, and psoriatic
arthritis, is known to be highly associated with the presence of the HLA-B27 antigen. Although the
exact mechanism determining disease susceptibility is still unknown, testing for HLA-B27 provides a
valuable aid for the definite diagnosis of these rheumatic disorders.

III. PRINCIPLES OF THE ASSAY

The HLA-B27 Gene Detection Assay is based on the reverse- hybridization principle, and
includes three successive steps: DNA is isolated from anticoagulated blood by a rapid and convenient
procedure. Then, HLA-B gene (exon 2) sequences are in vitro amplified and terminally labeled with a
reporter molecule. Finally, the amplification product is hybridized to a group -specific HLA-B27 (B27)
and a generic control (CTL) oligonucleotide probe in two separate cavities of a microwell plate. Bound
sequences are detected using a horseradish peroxidase -labeled antibody to the reporter molecule
and color substrates.
*Run out time: 48 hours.

Leukaemia
Philadelphia Chromosome by RQ-PCR

The lpsogen Fusion Quanttm M-bcr and m-bcr Kits are unique molecular kits providing
standardization and accurate quantification of fusion gene transcripts in leukaemia.
Introduction
The BCR-ABL fusion gene is associated with formation of the Philadelphia chromosome (Ph)
and is one of the most common genetic abnormalities detected in leukaemias. In Acute
Lymphoblastic Leukaemia (ALL), Ph is detected in 25-30% of adult and 2-5% of childhood cases. Less
frequently, it is associated with Acute Myeloid Leukaemia. In the ALL subset, this genetic lesion is
known to confer a very poor prognosis, and consequently, its detection is important in planning
aggressive therapies, including allogenic bone marrow transplant. In addition, the Ph chromosome is
found in more than 95% of Chronic Myeloid Leukaemia (CML) cases and is the hallmark of this
disease. At the molecular level, the Ph chromosome or t(9;22) results in the juxtaposition of the 5 , part
of the BCR gene (chromosome 22) to the 3, part of the ABL gene (chromosome 9). In the vast majority
of patients, the breakpoints in the BCR gene are clustered within three well defined regions (i) a 55 Kb
sequence of the first intron, called the minor breakpoint cluster region (m-bcr), (ii) a 5.8 Kb region
spanning exons 12 to 16, called the major breakpoint cluster region (M-bcr), and (iii) finally intron
19,called μ-bcr (very rare). In the case of m-bcr breakpoints, the first exon of the BCR gene (e1) is
juxtaposed to the second exon of the ABL gene (a2). The resultant fusion transcript (e1-a2) encodes a
190 KDa chimeric protein (p190). This type of BCR -ABL fusion gene is found in 65% of adults and 80%
of children with Ph positive ALL. Only in sporadic cases is the p190 encoding BCR-ABL gene found in
CML.
The quantification of BCR -ABL transcripts is useful in monitoring minimal residual disease and
genetic recurrence in patients known to harbour the translocation. By quantifying the transcript levels,
successive patient samples nay be monitored for changes in copy number.
Two separate assays are available, one for the major breakpoint M-bcr, typically seen in CML,
and one for the minor breakpoint m-bcr, typically seen in ALL.
*Run out time: 48 hours.

Laboratory Diagnosis of Secondary Amenorrhea

1. HCG - if positive: follow up for

pregnancy
(Serum HCG and
Progesterone)
- If negative

2.
 serum E2 low normal serum E2

gonadotropins normal or gonadotropins gonadotropins androgen normal

marginal androgen
(testo,andro,DHEAS)
excess (testo, andro)

Pituitary or
Hypo-
thalamic
lesion

Prolactin Prolactin Prolactin normal

Prolactin DHEAS DHEAS
normal
normal
Ovarian failure
*add -karyotype
evaluate functional physical -Ovarian *End organ evaluate
pituitary evaluate evaluate
hypo- cause cause biopsy failure hypo- tumor
ovary advenel
thalamo- -Anti ovarian *mechanical thalamo
gland
pituitary antibodies obstruction
pituitary
axis genital tract unit
weight loss iatrogenic exclude normal
PCOD
dieting PCOD pituitary
exercise hypo- tumor &
stress thyroidism hypo-
thalamic
tumor
Idiopathic

Abnormal Semen Analysis

 Check serum
FSH / LH / Testosterone

All Normal FSH: increased FSH: increased FSH: normal or low

FSH: normal
LH : normal LH : increased LH : normal or low
LH : increased
T : normal T : decreased T : decreased
T : increased

Non-endocrine Isolated Primary testicular Hypogonadism of

Partial androgen
disorder Spermatogenic failure failure central origin
resistance

*Check presence of testicular biopsy Karyotype PRL

Vas deferens
*Check varicocoele
*Assess ejaculatory
Process
*Check duct patency Germ Cell Arrest 47XXY normal increased
normal
47YYY (>600 IU/L)
46XX
Idio- CT SCAN
pathic if anti- NMR
-Congenital dopaminergic
absence of vas drug use is
deferens excluded TUMOR
normal
-Varicocoele
-Retrograde Micro serum iron, iron-
binding
ejaculation prolactinoma capacity, ferritin
-Obstruction or Macro
prolactinoma
increased
normal
if absent Hemochromatosis

+ANOSMIA
IDIOPATHIC
-Idiopathic Congenital
Hypo-
Oligoazospermia deficiency
gonadotropic
Kallman's
hypo
Syndrome
gonadism