Professional Documents
Culture Documents
of
Clinical Pathology
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Essentials
of
Clinical Pathology
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Shirish M Kawthalkar
Associate Professor
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Department of Pathology
Government Medical College
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Nagpur, Maharashtra, India
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Published by
Jitendar P Vij
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Jaypee Brothers Medical Publishers (P) Ltd
Corporate Office
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Phone: +91-11-43574357, Fax: +91-11-43574314
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Phones: +91-11-23272143, +91-11-23272703, +91-11-23282021 te
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All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means:
electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the author and the publisher.
This book has been published in good faith that the material provided by author is original. Every effort is made to ensure accuracy of material,
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Preface
The major aims of this book are discussion of (i) use of laboratory tests in the investigation and management of
common diseases, and (ii) basic biochemical and pathological principles underlying the application of laboratory
tests. The book has been written keeping in mind mainly the curricula of undergraduate students of pathology. It
should also prove to be appropriate for postgraduate residents and students of medical laboratory technology. The
laboratory tests that are demonstrated to and performed by medical students in pathology practical class and during
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university examination are given in more detail. To keep pace with new knowledge and advances, principles of
currently performed techniques in clinical laboratory practice have also been outlined. Most of the chapters are
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followed by reference ranges and critical values for ready access. Critical values or action values are those laboratory
results that require immediate attention of the treating clinician. While interpreting results of laboratory tests, it is
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necessary to follow two fundamental rules of laboratory medicine: (i) diagnosis should never be made from a single
abnormal test result (since it is affected by a number of preanalytical and analytical factors), and (ii) try to arrive at
a single diagnosis (rather than multiple diagnoses) from all the abnormal test results obtained.
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Clinical pathology is the second major subdivision of the discipline of pathology after anatomic pathology. It is
concerned with laboratory investigations for screening, diagnosis, and overall management of diseases by analysis
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of blood, urine, body fluids, and other specimens. The specialties included under the discipline of clinical pathology
are clinical chemistry, hematology, blood banking, medical microbiology, cytogenetics, and molecular genetics.
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However, scope of this book does not allow microbiology and genetics to be included in this book.
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I must appreciate and recognize the unstinting support of my parents, my beloved wife Dr Anjali, and my two
children, Ameya and Ashish during preparation of this book. I am thankful to Dr HT Kanade, Dean, Government
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Medical College, Akola, Dr Smt Deepti Dongaonkar, Dean, Government Medical College, Nagpur, Dr BB Sonawane,
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Professor and Head, Department of Pathology, Government Medical College, Akola, and Dr WK Raut, Professor
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and Head, Department of Pathology, Government Medical College, Nagpur, for encouraging me in undertaking
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undertaking to publish this book, being patient with me during the preparation of the manuscript, and bringing it
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Although I have made every effort to avoid any mistakes and errors, some may persist and feedback in this
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Shirish M Kawthalkar
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Contents
Section 1
Chemical Pathology and Related Studies
Section 2
Laboratory Hematology
16. Hematopoiesis ......................................................................................................................................................... 169
17. Collection of Blood ................................................................................................................................................. 179
18. Estimation of Hemoglobin ................................................................................................................................... 183
19. Packed Cell Volume ............................................................................................................................................... 188
20. Total Leukocyte Count .......................................................................................................................................... 192
21. Reticulocyte Count ................................................................................................................................................. 196
22. Blood Smear ............................................................................................................................................................. 200
23. Red Cell Indices ...................................................................................................................................................... 213
24. Erythrocyte Sedimentation Rate .......................................................................................................................... 215
25. Examination of Bone Marrow .............................................................................................................................. 220
26. Diagnosis of Malaria and Other Parasites in Blood ........................................................................................ 229
27. Laboratory Tests in Anemia ................................................................................................................................. 244
28. Laboratory Tests in Hematological Malignancies ........................................................................................... 273
29. Laboratory Tests in Bleeding Disorders ............................................................................................................ 288
30. Laboratory Tests in Thrombophilia .................................................................................................................... 311
31. Laboratory Tests in Porphyrias ............................................................................................................................ 314
32. Automation in Hematology .................................................................................................................................. 319
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viii Essentials of Clinical Pathology
Section 3
Practical Blood Transfusion
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Chemical Pathology and
Related Studies
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1
Examination of Urine
Time of Collection
INDICATIONS FOR URINALYSIS
1. A single specimen: This may be a first morning
1. Suspected renal diseases like glomerulonephritis voiding, a random specimen, or a post-prandial
nephrotic syndrome, pyelonephritis, and renal failure specimen.
2. Detection of urinary tract infection The first voided specimen in the morning is the
most concentrated and has acidic pH in which formed
3. Detection and management of metabolic disorders
elements (cells and casts) are well preserved. This
like diabetes mellitus specimen is used for routine examination, fasting
4. Differential diagnosis of jaundice glucose, proteins, nitrite, microscopic analysis for
5. Detection and management of plasma cell dyscrasias cellular elements, pregnancy test, orthostatic
6. Diagnosis of pregnancy. proteinuria, and bacteriological analysis.
1. Volume 600-2000 ml
2. Specific gravity 1.003-1.030
3. Osmolality 300-900 mOsm/kg
4. pH 4.6-8.0
5. Glucose <0.5 gm
6. Proteins <150 mg
7. Urobilinogen 0.5-4.0 mg
8. Porphobilinogen 0-2 mg
9. Creatinine 14-26 mg/kg (men), 11-20 mg/kg (women)
10. Urea nitrogen 12-20 gm
11. Uric acid 250-750 mg
12. Sodium 40-220 mEq
13. Potassium 25-125 mEq
14. Chloride 110-250 mEq
15. Calcium (low calcium diet) 50-150 mg
16. Formiminoglutamic acid (FIGlu) < 3 mg
17. Red cells, epithelial cells, and white blood cells <1-2/high power field
4 Essentials of Clinical Pathology
Box 1.1: Collection of urine sample Box 1.2: Collection of urine for routine and culture
examination
• First morning, midstream: Preferred for routine urine Collection for routine urinalysis
examination. For routine examination of urine, a wide-mouthed glass bottle
• Random, midstream: Routine urine examination. of 20-30 ml capacity, which is dry, chemically clean, leak-
• First morning, midstream, clean catch: Bacteriological proof, and with a tight fitting stopper is used. About 15 ml
examination. of midstream sample is cleanly collected.
• Postprandial: Estimation of glucose, urobilinogen Collection for bacterial culture
• 24-hour: Quantitative estimation of proteins or hormones. • Use sterile container
• Catheterised: Bacteriological examination in infants, • Collect midstream, clean catch sample
bedridden patients, and in obstruction of urinary tract. • Must be plated within 2 hours of collection
• Plastic bag (e.g. colostomy bag) tied around genitals: • If refrigerated, must be plated within 24 hours of
Infants; incontinent adults. collection
• No preservative should be added.
The random specimen is a single specimen collected 3. Catheter specimen: This is used for bacteriological
at any time of day. It is used for routine urine exami- study or culture in bedridden, ill patients or in
nation. patients with obstruction of urinary tract. It is usually
Post-prandial specimen (collected 2 hours after a avoided in ambulatory patients since it carries the
meal in the afternoon) is sometimes requested for risk of introduction of infection.
estimation of glucose (to monitor insulin therapy in 4. Infants: In infants, a clean plastic bag can be attached
diabetes mellitus) or of urobilinogen. around the baby’s genitalia and left in place for some
2. 24-hour specimen: After getting up in the morning, time. For bacteriologic examination, urine is aspirated
the first urine is discarded. All the urine voided from bladder by passing a needle just above
subsequently during the rest of the day and the night symphysis pubis.
is collected in a large bottle (clean bottle of 2 liter
capacity with a cap). The first urine after getting up Changes which Occur in Standing Urine at
in the morning on the next day is also collected. The Room Temperature
urine should be preserved at 4-6°C during the period
of collection. The container is then immediately If urine is left standing at room temperature for long after
transported to the laboratory. The urine is thoroughly collection, following changes occur:
mixed and an aliquot is used for testing. This method • Increase in pH due to production of ammonia from
is used for quantitative estimation of proteins and urea by urease-producing bacteria.
hormones. • Formation of crystals due to precipitation of phos-
phates and calcium (making the urine turbid)
Collection Methods • Loss of ketone bodies, since they are volatile.
1. Midstream specimen: This is used for all types of • Decrease in glucose due to glycolysis and utilization
examinations. After voiding initial half of urine into of glucose by cells and bacteria.
the toilet, a part of urine is collected in the bottle. First • Oxidation of bilirubin to biliverdin causing false-
half of stream serves to flush out contaminating cells negative test for bilirubin
and microbes from urethra and perineum. Subse- • Oxidation of urobilinogen to urobilin causing false-
quent stream is collected which is from the urinary negative test for urobilinogen
bladder. • Bacterial proliferation
2. Clean-catch specimen: This is recommended for • Disintegration of cellular elements, especially in
bacteriologic culture. In men, glans penis is suffi- alkaline and hypotonic urine.
ciently exposed and cleaned with soap and water. In
women urethral opening should be exposed, washed
Urine sample must be tested in the laboratory within 2
with soapy cotton balls, rinsed with water-saturated
hours of collection to get the correct results.
cotton, and holding the labia apart, the initial urine
is allowed to pass into the toilet and the remaining is
Preservation of Urine Sample
voided into the bottle (amount 20-100 ml). This
method avoids contamination of urine with the The urine sample should ideally be examined within 1-2
vaginal fluids. hours of voiding. If delay in examination is expected,
Examination of Urine 5
then to slow down the above changes, sample can be Box 1.3: Physical examination
kept in the refrigerator for a maximum of 8 hours.
Refrigeration (4-6°C) is the best general method of • Volume • Odor
preservation up to 8 hours. Before analysis, refrigerated • Color • Specific gravity
samples should be warmed to room temperature. For • Appearance • pH
routine urinalysis, preservatives should be avoided, as
they interfere with reagent strip techniques and
chemical test for protein. Following chemical preser-
vatives can be added to the 24-hour urine sample: diabetes insipidus (failure of secretion of antidiuretic
• Hydrochloric acid: It is used for preservation of a 24- hormone), chronic renal failure (loss of concentrating
hour urine sample for adrenaline, noradrenaline, ability of kidneys) or diuretic therapy.
vanillylmandelic acid, and steroids. • Oliguria means urinary volume < 400 ml/24 hours.
• Toluene: It forms a thin layer over the surface and Causes include febrile states, acute glomerulo-
acts as a physical barrier for bacteria and air. It is used nephritis (decreased glomerular filtration), congestive
for measurement of chemicals. cardiac failure or dehydration (decreased renal blood
• Boric acid: A general preservative. flow).
• Thymol: It inhibits bacteria and fungi.
• Anuria means urinary output < 100 ml/24 hours or
• Formalin: It is an excellent chemical for preservation
of formed elements. complete cessation of urine output. It occurs in acute
tubular necrosis (e.g. in shock, hemolytic transfusion
PHYSICAL EXAMINATION reaction), acute glomerulonephritis, and complete
The parameters to be examined on physical examination urinary tract obstruction.
of urine are shown in Box 1.3.
Color
Volume
Volume of only the 24-hr specimen of urine needs to be Normal urine color in a fresh state is pale yellow or amber
measured and reported. The average 24-hr urinary and is due to the presence of various pigments
output in adults is 600-2000 ml. The volume varies collectively called urochrome. Depending on the state
according to fluid intake, diet, and climate. Abnormalities of hydration urine may normally be colorless (over
of urinary volume are as follows: hydration) or dark yellow (dehydration). Some of the
• Polyuria means urinary volume > 2000 ml/24 hours. abnormal colors with associated conditions are listed in
This is seen in diabetes mellitus (osmotic diuresis), Table 1.2.
Colors Conditions
Note: Many drugs cause changes in urine color; drug history should be obtained if there is abnormal coloration of urine
6 Essentials of Clinical Pathology
show SG of 1.000 at the temperature of calibration. If not, 7.0). On standing, urine becomes alkaline because of loss
then the difference needs to be adjusted in test readings of carbon dioxide and production of ammonia from urea.
taken subsequently. Therefore, for correct estimation of pH, fresh urine
The method is as follows: should be examined.
1. Fill a measuring cylinder with 50 ml of urine. There are various methods for determination of
2. Lower urinometer gently into the urine and let it float reaction of urine: litmus paper, pH indicator paper, pH
freely.
meter, and reagent strip tests.
3. Let urinometer settle; it should not touch the sides or
bottom of the cylinder. 1. Litmus paper test: A small strip of litmus paper is
4. Take the reading of SG on the scale (lowest point of dipped in urine and any color change is noted. If blue
meniscus) at the surface of the urine. litmus paper turns red, it indicates acid urine. If red
5. Take out the urinometer and immediately note the paper turns blue, it indicates alkaline urine (Fig. 1.2A).
temperature of urine with a thermometer. 2. pH indicator paper: Reagent area (which is impreg-
Correction for temperature: Density of urine increases at nated with bromothymol blue and methyl red) of
low temperature and decreases at higher temperature. indicator paper strip is dipped in urine sample and
This causes false reading of SG. Therefore, SG is corrected the color change is compared with the color guide
for difference between urine temperature and calibration provided. Approximate pH is obtained.
temperature. Check the temperature of calibration of the
3. pH meter: An electrode of pH meter is dipped in urine
urinometer To get the corrected SG, add 0.001 to the
reading for every 3°C that the urine temperature is above sample and pH is read off directly from the digital
the temperature of calibration. Similarly subtract 0.001 display. It is used if exact pH is required.
from the reading for every 3°C below the calibration 4. Reagent strip test: The test area (Fig. 1.2B) contains
temperature. polyionic polymer bound to H+; on reaction with
Correction for dilution: If quantity of urine is not sufficient cations in urine, H+ is released causing change in color
for measurement of SG, urine can be appropriately of the pH-sensitive dye.
diluted and the last two figures of SG are multiplied by Normal pH range is 4.6 to 8.0 (average 6.0 or slightly
the dilution factor. acidic). Urine pH depends on diet, acid base balance,
Correction for abnormal solute concentration: High SG in the water balance, and renal tubular function.
presence of glycosuria or proteinuria will not reflect true Acidic urine is found in ketosis (diabetes mellitus,
kidney function (concentrating ability). Therefore it is starvation, fever), urinary tract infection by Escherichia
necessary to nullify the effect of glucose or proteins. For coli, and high protein diet. Alkaline urine may result from
this, 0.003 is subtracted from temperature-corrected SG
for each 1 gm of protein/dl urine and 0.004 for every 1
gm of glucose/dl urine.
2. Refractometer method: SG can be precisely deter-
mined by a refractometer, which measures the
refractive index of the total soluble solids. Higher the
concentration of total dissolved solids, higher the
refractive index. Extent of refraction of a beam of light
passed through urine is a measure of solute concen-
tration, and thus of SG. The method is simple and
requires only 1-2 drops of urine. Result is read from
a scale or from digital display.
3. Reagent strip method: Reagent strip (Fig. 1.1B)
measures the concentration of ions in urine, which
correlates with SG. Depending on the ionic strength
of urine, a polyelectrolyte will ionize in proportion.
This causes a change in color of pH indicator
(bromothymol blue).
Reaction and pH
The pH is the scale for measuring acidity or alkalinity Fig. 1.2: Testing pH of urine with litmus paper (A) and
(acid if pH is < 7.0; alkaline if pH is > 7.0; neutral if pH is with reagent strip test (B)
8 Essentials of Clinical Pathology
urinary tract infection by bacteria that split urea to Box 1.5: Causes of proteinuria
ammonia (Proteus or Pseudomonas), severe vomiting,
vegetarian diet, old ammoniacal urine sample and • Glomerular proteinuria
chronic renal failure. • Tubular proteinuria
Determining pH of urine helps in identifying various • Overflow proteinuria
crystals in urine. Altering pH of urine may be useful in • Hemodynamic (functional) proteinuria
treatment of renal calculi (i.e. some stones form only in • Post-renal proteinuria
acid urine e.g. uric acid calculi; in such cases urine is
kept alkaline); urinary tract infection (urine should be
kept acid); and treatment with certain drugs (e.g. disease, there is increased excretion of lower molecular
streptomycin is effective in urinary tract infection if urine weight proteins like albumin and transferrin. When
is kept alkaline). In unexplained metabolic acidosis, glomeruli can retain larger molecular weight proteins
measurement of urine pH is helpful in diagnosing renal but allow passage of comparatively lower molecular
tubular acidosis; in renal tubular acidosis, urine pH is weight proteins, the proteinuria is called as selective.
consistently alkaline despite metabolic acidosis. With further glomerular damage, this selectivity is lost
and larger molecular weight proteins (γ globulins) are
CHEMICAL EXAMINATION also excreted along with albumin; this is called as
nonselective proteinuria.
The chemical examination is carried out for substances
Selective and nonselective proteinuria can be distin-
listed in Box 1.4.
guished by urine protein electrophoresis. In selective
proteinuria, albumin and transferrin bands are seen,
Box 1.4: Chemical examination of urine
while in nonselective type, the pattern resembles that of
• Proteins • Urobilinogen serum (Fig. 1.3).
• Glucose • Blood Causes of glomerular proteinuria are glomerular
• Ketones • Hemoglobin diseases that cause increased permeability of glomerular
• Bilirubin • Myoglobin basement membrane. The degree of glomerular proteinu-
• Bile salts • Nitrite or leukocyte esterase
Proteins
Normally, kidneys excrete scant amount of protein in
urine (up to 150 mg/24 hours). These proteins include
proteins from plasma (albumin) and proteins derived
from urinary tract (Tamm-Horsfall protein, secretory
IgA, and proteins from tubular epithelial cells, leucocytes,
and other desquamated cells); this amount of proteinuria
cannot be detected by routine tests. (Tamm-Horsfall
protein is a normal mucoprotein secreted by ascending
limb of the loop of Henle).
Proteinuria refers to protein excretion in urine
greater than 150 mg/24 hours in adults.
Causes of Proteinuria
Causes of proteinuria can be grouped as shown in Box
1.5.
1. Glomerular proteinuria: Proteinuria due to increased
Fig. 1.3: Glomerular and tubular proteinuria. Upper figure shows
permeability of glomerular capillary wall is called as normal serum protein electrophoresis pattern. Lower part shows
glomerular proteinuria. comparison of serum and urine electrophoresis in (1) selective
There are two types of glomerular proteinuria: proteinuria, (2) non-selective proteinuria, and (3) tubular
selective and nonselective. In early stages of glomerular proteinuria
Examination of Urine 9
Box 1.6: Nephrotic syndrome and is probably due to lordotic posture that causes
inferior venacaval compression between the liver and
• Massive proteinuria (>3.5 gm/24 hr) vertebral column. The condition disappears in adulthood.
• Hypoalbuminemia (<3.0 gm/dl) Amount of proteinuria is <1000 mg/day. First-morning
• Generalised edema urine after rising is negative for proteins, while another
• Hyperlipidemia (serum cholesterol >350 mg/dl) urine sample collected after patient performs normal
• Lipiduria
activities is positive for proteins. In such patients, periodic
testing for proteinuria should be done to rule out renal
disease.
ria correlates with severity of disease and prognosis.
5. Post-renal proteinuria: This is caused by inflamma-
Serial estimations of urinary protein are also helpful in
monitoring response to treatment. Most severe degree tory or neoplastic conditions in renal pelvis, ureter,
of proteinuria occurs in nephrotic syndrome (Box 1.6). bladder, prostate, or urethra.
2. Tubular proteinuria: Normally, glomerular mem-
brane, although impermeable to high molecular Tests for Detection of Proteinuria
weight proteins, allows ready passage to low 1. Heat and acetic acid test (Boiling test): This test is
molecular weight proteins like β2-microglobulin, based on the principle that proteins get precipitated
retinol-binding protein, lysozyme, α1-microglobulin,
when boiled in an acidic solution.
and free immunoglobulin light chains. These low
molecular weight proteins are actively reabsorbed by Method: Urine should be clear; if not, filter or use
proximal renal tubules. In diseases involving mainly supernatant from a centrifuged sample.
tubules, these proteins are excreted in urine while Urine should be just acidic (check with litmus paper);
albumin excretion is minimal. if not, add 10% acetic acid drop by drop until blue litmus
Urine electrophoresis shows prominent α- and β- paper turns red.
bands (where low molecular weight proteins migrate) A test tube is filled 2/3rds with urine. The tube is
and a faint albumin band (Fig. 1.3). inclined at an angle and the upper portion is boiled over
Tubular type of proteinuria is commonly seen in
the flame. (Only the upper portion is heated so that
acute and chronic pyelonephritis, heavy metal
poisoning, tuberculosis of kidney, interstitial convection currents generated by heat do not disturb the
nephritis, cystinosis, Fanconi syndrome and rejection precipitate and the upper portion can be compared with
of kidney transplant. the lower clear portion). Compare the heated part with
Purely tubular proteinuria cannot be detected by the lower part. Cloudiness or turbidity indicates presence
reagent strip test (which is sensitive to albumin), but of either phosphates or proteins (Fig. 1.4). A few drops
heat and acetic acid test and sulphosalicylic acid test of 10% acetic acid are added and the upper portion is
are positive. boiled again. Turbidity due to phosphates disappears
3. Overflow proteinuria: When concentration of a low while that due to proteins does not.
molecular weight protein rises in plasma, it “over-
flows” from plasma into the urine. Such proteins are
immunoglobulin light chains or Bence Jones proteins
(plasma cell dyscrasias), hemoglobin (intravascular
hemolysis), myoglobin (skeletal muscle trauma), and
lysozyme (acute myeloid leukemia type M4 or M5).
4. Hemodynamic proteinuria: Alteration of blood flow
through the glomeruli causes increased filtration of
proteins. Protein excretion, however, is transient. It
is seen in high fever, hypertension, heavy exercise,
congestive cardiac failure, seizures, and exposure to
cold.
Postural (orthostatic) proteinuria occurs when the
subject is standing or ambulatory, but is absent in
recumbent position. It is common in adolescents (3-5%) Fig. 1.4: Principle of heat test for proteins
10 Essentials of Clinical Pathology
Causes of Glycosuria
1. Glycosuria with hyperglycemia:
Fig. 1.7: Urine protein electrophoresis showing heavy Bence • Endocrine diseases: diabetes mellitus, acromegaly,
Jones proteinuria (red arrow) along with loss of albumin and Cushing’s syndrome, hyperthyroidism, pancrea-
other low molecular weight proteins in urine tic disease
• Non-endocrine diseases: central nervous system
diseases, liver disorders
Further evaluation of persistent overt proteinuria is • Drugs: adrenocorticotrophic hormone, cortico-
shown in Figure 1.8. steroids, thiazides
• Alimentary glycosuria (Lag-storage glycosuria):
Glucose After a meal, there is rapid intestinal absorption
of glucose leading to transient elevation of blood
The main indication for testing for glucose in urine is glucose above renal threshold. This can occur in
detection of unsuspected diabetes mellitus or follow-up persons with gastrectomy or gastrojejunostomy
of known diabetic patients. and in hyperthyroidism. Glucose tolerance test
Practically all of the glucose filtered by the glomeruli reveals a peak at 1 hour above renal threshold
is reabsorbed by the proximal renal tubules and returned (which causes glycosuria); the fasting and 2-hour
to circulation. Normally a very small amount of glucose glucose values are normal.
is excreted in urine (< 500 mg/24 hours or <15 mg/dl) 2. Glycosuria without hyperglycemia
that cannot be detected by the routine tests. Presence of • Renal glycosuria: This accounts for 5% of cases of
detectable amounts of glucose in urine is called as glycosuria in general population. Renal threshold
Note: Quantitation of proteins and creatinine clearance are done in all patients with persistent proteinuria
• Urine should be tested for glucose within 2 hours of collection (due to lowering of glucose by glycolysis and by contaminating
bacteria which degrade glucose rapidly)
• Reagent strip test is a rapid, inexpensive, and semi-quantitative test
• In the past this test was used for home-monitoring of glucose; the test is replaced by glucometers.
• Urine glucose cannot be used to monitor control of diabetes since renal threshold is variable amongst individuals, no
information about level of blood glucose below renal threshold is obtained, and urinary glucose value is affected by
concentration of urine.
is the highest glucose level in blood at which Other carbohydrates (like lactose, fructose, galactose,
glucose appears in urine and which is detectable pentoses), certain metabolites (glucuronic acid, homo-
by routine laboratory tests. The normal renal gentisic acid, uric acid, creatinine), and drugs (ascorbic
threshold for glucose is 180 mg/dl. Threshold acid, salicylates, cephalosporins, penicillins, strepto-
substances need a carrier to transport them from mycin, isoniazid, para-aminosalicylic acid, nalidixic acid,
tubular lumen to blood. When the carrier is etc.) also reduce alkaline copper sulphate solution.
saturated, the threshold is reached and the
substance is excreted. Up to this level glucose Method
filtered by the glomeruli is efficiently reabsorbed 1. Take 5 ml of Benedict’s qualitative reagent in a test
by tubules. Renal glycosuria is a benign condition tube (composition of Benedict’s qualitative reagent:
in which renal threshold is set below 180 mgs/dl copper sulphate 17.3 gram, sodium carbonate 100
but glucose tolerance is normal; the disorder is gram, sodium citrate 173 gram, distilled water 1000
transmitted as autosomal dominant. Other ml).
conditions in which glycosuria can occur with 2. Add 0.5 ml (or 8 drops) of urine. Mix well.
blood glucose level remaining below 180 mgs/dl 3. Boil over a flame for 2 minutes.
are renal tubular diseases in which there is 4. Allow to cool at room temperature.
decreased glucose reabsorption like Fanconi’s 5. Note the color change, if any.
syndrome, and toxic renal tubular damage. During Sensitivity of the test is about 200 mg reducing
pregnancy, renal threshold for glucose is substance per dl of urine. Since Benedict’s test gives
decreased. Therefore it is necessary to estimate positive reaction with carbohydrates other than glucose,
blood glucose when glucose is first detected in it is also used as a screening test (for detection of
urine. galactose, lactose, fructose, maltose, and pentoses in
urine) for inborn errors of carbohydrate metabolism in
Tests for Detection of Glucose in Urine infants and children. For testing urine only for glucose,
reagent strips are preferred (see below).
1. Copper reduction methods The result is reported in grades as follows (Fig. 1.10):
A. Benedict’s qualitative test: When urine is boiled in Nil: no change from blue color
Benedict’s qualitative solution, blue alkaline copper Trace: Green without precipitate
sulphate is reduced to red-brown cuprous oxide if a 1+ (approx. 0.5 grams/dl): Green with precipitate
reducing agent is present (Fig. 1.9). The extent of 2+ (approx. 1.0 grams/dl): Brown precipitate
reduction depends on the concentration of the reducing 3+ (approx. 1.5 grams/dl: Yellow-orange precipitate
substance. This test, however, is not specific for glucose. 4+ (> 2.0 grams/dl): Brick- red precipitate.
Fig. 1.9: Principle of Benedict’s qualitative test for sugar in urine. Sensitivity is 200 mg of glucose/dl
14 Essentials of Clinical Pathology
Ketones
Excretion of ketone bodies (acetoacetic acid, β-hydroxy-
butyric acid, and acetone) in urine is called as ketonuria.
Fig. 1.10: Grading of Benedict’s test (above) and reagent Ketones are breakdown products of fatty acids and their
strip test (below) for glucose presence in urine is indicative of excessive fatty acid
metabolism to provide energy.
B. Clinitest tablet method (Copper reduction tablet test): This Causes of Ketonuria
is a modified form of Benedict’s test in which the reagents Normally ketone bodies are not detectable in the urine
are present in a tablet form (copper sulphate, citric acid,
of healthy persons. If energy requirements cannot be met
sodium carbonate, and anhydrous sodium hydroxide).
by metabolism of glucose (due to defective carbohydrate
Sensitivity is 200 mgs/dl of glucose.
metabolism, low carbohydrate intake, or increased
2. Reagent strip method This test is specific for glucose metabolic needs), then energy is derived from break-
and is therefore preferred over Benedict’s and Clinitest down of fats. This leads to the formation of ketone bodies
methods. It is based on glucose oxidase-peroxidase (Fig. 1.12).
reaction. Reagent area of the strips is impregnated with
two enzymes (glucose oxidase and peroxidase) and a 1. Decreased utilization of carbohydrates
chromogen. Glucose is oxidized by glucose oxidase with a. Uncontrolled diabetes mellitus with ketoacidosis: In
the resultant formation of hydrogen peroxide and diabetes, because of poor glucose utilization, there is
gluconic acid. Oxidation of chromogen occurs in the compensatory increased lipolysis. This causes
presence of hydrogen peroxide and the enzyme peroxi- increase in the level of free fatty acids in plasma.
dase with resultant color change (Fig. 1.11). Nature of Degradation of free fatty acids in the liver leads to
chromogen and buffer system differ in different strips. the formation of acetoacetyl CoA which then forms
The strip is dipped into the urine sample and color is ketone bodies. Ketone bodies are strong acids and
observed after a specified time and compared with the produce H+ ions, which are neutralized by bicar-
color chart provided (Fig. 1.10). bonate ions; fall in bicarbonate (i.e. alkali) level
This test is more sensitive than Benedict’s qualitative produces ketoacidosis. Ketone bodies also increase
test and specific only for glucose. Other reducing agents the plasma osmolality and cause cellular dehydration.
give negative reaction. Children and young adults with type 1 diabetes are
Fig. 1.11: Principle of reagent strip test for glucose in urine. Each mole of glucose produces one mole of peroxide,
and each mole of peroxide reduces one mole of oxygen. Sensitivity is 100 mg glucose/100 ml
Examination of Urine 15
• Nonglomerular diseases: Calculus, tumor, infec- cells) as well as myoglobin. Heme proteins in
tion, tuberculosis, pyelonephritis, hydronephrosis, hemoglobin act as peroxidase, which reduces
polycystic kidney disease, trauma, after strenuous hydrogen peroxide to water. This process needs a
physical exercise, diseases of prostate (benign hydrogen donor (benzidine, orthotoluidine, or
hyperplasia of prostate, carcinoma of prostate). guaiac). Oxidation of hydrogen donor leads to
2. Hematological conditions: Coagulation disorders, sickle development of a color (Fig. 1.19). Intensity of color
cell disease produced is proportional to the amount of hemo-
Presence of red cell casts and proteinuria along with
globin present.
hematuria suggests glomerular cause of hematuria.
Chemical tests are positive in hematuria, hemo-
Tests for Detection of Blood in Urine globinuria, and myoglobinuria.
1. Microscopic examination of urinary sediment: • Benzidine test: Make saturated solution of benzidine
Definition of microscopic hematuria is presence of 3 in glacial acetic acid. Mix 1 ml of this solution with 1
or more number of red blood cells per high power ml of hydrogen peroxide in a test tube. Add 2 ml of
field on microscopic examination of urinary sediment urine. If green or blue color develops within 5
in two out of three properly collected samples. A
minutes, the test is positive.
small number of red blood cells in urine of low specific
• Orthotoluidine test: In this test, instead of benzidine,
gravity may undergo lysis, and therefore hematuria
may be missed if only microscopic examination is orthotoluidine is used. It is more sensitive than
done. Therefore, microscopic examination of urine benzidine test.
should be combined with a chemical test. • Reagent strip test: Various reagent strips are
2. Chemical tests: These detect both intracellular and commercially available which use different
extracellular hemoglobin (i.e. intact and lysed red chromogens (o-toluidine, tetramethylbenzidine).
Fig. 1.19: Principle of chemical test for red cells, hemoglobin, or myoglobin in urine
20 Essentials of Clinical Pathology
organized or unorganized. Organized substances examined within 2 hours of voiding because cells and
include red blood cells, white blood cells, epithelial cells, casts degenerate upon standing at room temperature. If
casts, bacteria, and parasites. The unorganized sub- preservative is required, then 1 crystal of thymol or 1
stances are crystalline and amorphous material. These drop of formalin (40%) is added to about 10 ml of urine.
elements are suspended in urine and on standing they
settle down and sediment at the bottom of the container; Method: A well-mixed sample of urine (12 ml) is
therefore they are known as urinary deposits or urinary centrifuged in a centrifuge tube for 5 minutes at 1500
sediments. Examination of urinary deposit is helpful in rpm and supernatant is poured off. The tube is tapped
diagnosis of urinary tract diseases as shown in Table 1.8. at the bottom to resuspend the sediment (in 0.5 ml of
Different types of urinary sediments are shown in urine). A drop of this is placed on a glass slide and
Figure 1.22. The major aim of microscopic examination covered with a cover slip (Fig. 1.23). The slide is examined
of urine is to identify different types of cellular elements immediately under the microscope using first the low
and casts. Most crystals have little clinical significance. power and then the high power objective. The condenser
Specimen: The cellular elements are best preserved in should be lowered to better visualize the elements by
acid, hypertonic urine; they deteriorate rapidly in reducing the illumination.
alkaline, hypotonic solution. A mid-stream, freshly
voided, first morning specimen is preferred since it is Cells
the most concentrated. The specimen should be Cellular elements in urine are shown in Figure 1.24.
HPF: High power field; LPF: Low power field; RBCs: Red blood cells; WBCs: White blood cells.
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Examination of Urine 23
Fig. 1.24: Cells in urine (1) Isomorphic red blood cells, (2) Crenated red cells, (3) Swollen red cells, (4) Dysmorphic red
cells, (5) White blood cells (pus cells), (6) Squamous epithelial cell, (7) Transitional epithelial cells, (8) Renal tubular epithelial
cells, (9) Oval fat bodies, (10) Maltese cross pattern of oval fat bodies, and (11) spermatozoa
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24 Essentials of Clinical Pathology
White Blood Cells (Pus Cells) diamond- or pear-shaped (caudate cells). Large numbers
or sheets of these cells in urine occur after catheterization
White blood cells are spherical, 10-15 μ in size, granular
and in transitional cell carcinoma.
in appearance in which nuclei may be visible. Degene-
rated white cells are distorted, smaller, and have fewer Oval Fat Bodies
granules. Clumps of numerous white cells are seen in These are degenerated renal tubular epithelial cells filled
infections. Presence of many white cells in urine is called with highly refractile lipid (cholesterol) droplets. Under
as pyuria. In hypotonic urine white cells are swollen and polarized light, they show a characteristic “Maltese
the granules are highly refractile and show Brownian cross” pattern. They can be stained with a fat stain such
movement; such cells are called as glitter cells; large as Sudan III or Oil Red O. They are seen in nephrotic
numbers are indicative of injury to urinary tract. syndrome in which there is lipiduria.
Normally 0-2 white cells may be seen per high power
field. Pus cells greater than 10/HPF or presence of Spermatozoa
clumps is suggestive of urinary tract infection. They may sometimes be seen in urine of men.
Increased numbers of white cells occur in fever,
pyelonephritis, lower urinary tract infection, tubulo- Telescoped urinary sediment: This refers to urinary
interstitial nephritis, and renal transplant rejection. sediment consisting of red blood cells, white blood cells,
In urinary tract infection, following are usually seen oval fat bodies, and all types of casts in roughly equal
in combination: proportion. It occurs in lupus nephritis, malignant
• Clumps of pus cells or pus cells >10/HPF hypertension, rapidly proliferative glomerulonephritis,
and diabetic glomerulosclerosis.
• Bacteria
• Albuminuria Organisms
• Positive nitrite test
Organisms detectable in urine are shown in Figure 1.25.
Simultaneous presence of white cells and white cell
casts indicates presence of renal infection (pyelo- Bacteria
nephritis). Bacteria in urine can be detected by microscopic
Eosinophils (>1% of urinary leucocytes) are a examination, reagent strip tests for significant bacteriuria
characteristic feature of acute interstitial nephritis due to (nitrite test, leucocyte esterase test), and culture.
drug reaction (better appreciated with a Wright’s stain). Method of collection for bacteriologic examination
is given earlier in Box 1.2.
Renal Tubular Epithelial Cells
Significant bacteriuria exists when there are >105
Presence of renal tubular epithelial cells is a significant bacterial colony forming units/ml of urine in a clean-
finding. Increased numbers are found in conditions catch midstream sample, >104 colony forming units/ml
causing tubular damage like acute tubular necrosis, of urine in catheterized sample, and >10 3 colony-
pyelonephritis, viral infection of kidney, allograft forming units/ml of urine in a suprapubic aspiration
rejection, and salicylate or heavy metal poisoning. sample.
These cells are small (about the same size or slightly
larger than white blood cell), polyhedral, columnar, or
oval, and have granular cytoplasm. A single, large,
refractile, eccentric nucleus is often seen.
Renal tubular epithelial cells are difficult to distin-
guish from pus cells in unstained preparations.
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Examination of Urine 25
1. Microscopic examination: In a wet preparation, mellitus. Usually pyuria is present if there is infection
presence of bacteria should be reported only when by Candida. Candida may also be a contaminant in the
urine is fresh. Bacteria occur in combination with pus sample and therefore urine sample must be examined in
cells. Gram’s-stained smear of uncentrifuged urine a fresh state.
showing 1 or more bacteria per oil-immersion field
Trichomonas vaginalis
suggests presence of > 105 bacterial colony forming
units/ml of urine. If many squamous cells are present, These are motile organisms with pear shape, undulating
then urine is probably contaminated with vaginal membrane on one side, and four flagellae. They cause
flora. Also, presence of only bacteria without pus cells vaginitis in females and are thus contaminants in urine.
indicates contamination with vaginal or skin flora. They are easily detected in fresh urine due to their
2. Chemical or reagent strip tests for significant motility.
bacteriuria: These are given earlier.
3. Culture: On culture, a colony count of >105/ml is Eggs of Schistosoma haematobium
strongly suggestive of urinary tract infection, even Infection by this organism is prevalent in Egypt.
in asymptomatic females. Positive culture is followed
by sensitivity test. Most infections are due to Gram- Microfilariae
negative enteric bacteria, particularly Escherichia coli. They may be seen in urine in chyluria due to rupture of
If three or more species of bacteria are identified on a urogenital lymphatic vessel.
culture, it almost always indicates contamination by
vaginal flora. Casts
Negative culture in the presence of pyuria (‘sterile’ Urinary casts are cylindrical, cigar-shaped microscopic
pyuria) occurs with prior antibiotic therapy, renal structures that form in distal renal tubules and collecting
tuberculosis, prostatitis, renal calculi, catheterization, ducts. They take the shape and diameter of the lumina
fever in children (irrespective of cause), female genital (molds or ‘casts’) of the renal tubules. They have parallel
tract infection, and non-specific urethritis in males. sides and rounded ends. Their length and width may be
variable. Casts are basically composed of a precipitate of
Yeast Cells (Candida) a protein that is secreted by tubules (Tamm-Horsfall
These are round or oval structures of approximately the protein). Since casts form only in renal tubules their
same size as red blood cells. In contrast to red cells, they presence is indicative of disease of the renal parenchyma.
show budding, are oval and more refractile, and are not Although there are several types of casts, all urine casts
soluble in 2% acetic acid. are basically hyaline; various types of casts are formed
Presence of Candida in urine may suggest immuno- when different elements get deposited on the hyaline
compromised state, vaginal candidiasis, or diabetes material (Fig. 1.26). Casts are best seen under low power
Fig. 1.26: Genesis of casts in urine. All cellular casts degenerate to granular and waxy casts
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26 Essentials of Clinical Pathology
objective (×10) with condenser lowered down to reduce muscle exercise in healthy persons and during fever.
the illumination. Increased numbers are found in conditions causing
Casts are the only elements in the urinary sediment glomerular proteinuria.
that are specifically of renal origin.
Granular casts: Presence of degenerated cellular debris in
Casts (Fig. 1.27) are of two main types:
a cast makes it granular in appearance. These are
• Noncellular: Hyaline, granular, waxy, fatty
cylindrical structures with coarse or fine granules (which
• Cellular: Red blood cell, white blood cell, renal represent degenerated renal tubular epithelial cells)
tubular epithelial cell. embedded in Tamm-Horsfall protein matrix. They are
Hyaline and granular casts may appear in normal or seen after strenuous muscle exercise and in fever, acute
diseased states. All other casts are found in kidney glomerulonephritis, and pyelonephritis.
diseases.
Waxy cast: These are the most easily recognized of all
Non-cellular Casts casts. They form when hyaline casts remain in renal
tubules for long time (prolonged stasis). They have
Hyaline casts: These are the most common type of casts
homogenous, smooth glassy appearance, cracked or
in urine and are homogenous, colorless, transparent, and
serrated margins and irregular broken-off ends. The ends
refractile. They are cylindrical with parallel sides and
are straight and sharp and not rounded as in other casts.
blunt, rounded ends and low refractive index. Presence
They are light yellow in color. They are most commonly
of occasional hyaline cast is considered as normal. Their
seen in end-stage renal failure.
presence in increased numbers (“cylinduria”) is
abnormal. They are composed primarily of Tamm- Fatty casts: These are cylindrical structures filled with
Horsfall protein. They occur transiently after strenuous highly refractile fat globules (triglycerides and cholesterol
Fig. 1.27: Urinary casts: (A) Hyaline cast, (B) Granular cast, (C) Waxy cast, (D) Fatty cast, (E) Red cell cast,
(F) White cell cast, and (G) Epithelial cast
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Examination of Urine 27
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28 Essentials of Clinical Pathology
Fig. 1.28: Crystals in urine. (A) Normal crystals: (1) Calcium oxalate, (2) Triple phosphates, (3) Uric acid, (4) Amorphous
phosphates, (5) Amorphous urates, (6) Ammonium urate. (B) Abnormal crystals: (1) Cysteine, (2) Cholesterol, (3) Bilirubin,
(4) Tyrosine, (5) Sulfonamide, and (6) Leucine
crystals should not be reported on microscopy alone; and appear stacked in a stair-step arrangement. They
additional chemical tests are done for confirmation. are soluble in ether, chloroform, or alcohol. They are
1. Cysteine crystals: These are colorless, clear, hexagonal seen in lipiduria e.g. nephrotic syndrome and hyper-
(having 6 sides), very refractile plates in acid urine. cholesterolemia. They can be positively identified by
polarizing microscope.
They often occur in layers. They are soluble in 30%
3. Bilirubin crystals: These are small (5 μ), brown crystals
hydrochloric acid. They are seen in cysteinuria, an of variable shape (square, bead-like, or fine needles).
inborn error of metabolism. Cysteine crystals are often Their presence can be confirmed by doing reagent
associated with formation of cysteine stones. strip or chemical test for bilirubin. These crystals are
2. Cholesterol crystals: These are colorless, refractile, flat soluble in strong acid or alkali. They are seen in severe
rectangular plates with notched (missing) corners, obstructive liver disease.
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Examination of Urine 29
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2
Kidney is a highly specialized organ that performs Box 2.1: Conditions with increased risk of
following functions: chronic renal disease
• Maintenance of extracellular fluid volume and
• Diabetes mellitus
composition: Kidney regulates water and electrolyte • Hypertension
balance, acid-base balance, and fluid osmotic • Autoimmune diseases like systemic lupus erythematosus
pressure. • Older age (GFR declines with age)
• Excretion of metabolic waste products (blood urea, • Family history of renal disease
creatinine, uric acid) and drugs, but retention of • Systemic infection
essential substances (like glucose and amino acids). • Urinary tract infection
• Lower urinary tract obstruction
• Regulation of blood pressure by renin-angiotensin
mechanism
• Synthesis of erythropoietin, a hormone which 4. Plan renal replacement therapy (dialysis or renal
stimulates erythropoiesis transplantation) in advanced renal disease.
• Production of vit. D3 (active form of vit. D) from vit. 5. Adjust dosage of certain drugs (e.g. chemotherapy)
D2, which stimulates absorption of calcium from according to renal function.
gastrointestinal tract.
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Renal Function Tests 31
Box 2.2: Glomerular filtration rate (GFR) • Stage 3: Moderately reduced GFR (GFR 30-59 ml/
min/1.73 m2)
• Best test for assessment of excretory renal function • Stage 4: Severely reduced GFR (GFR 15-29 ml/min/
• Varies according to age, sex, and body weight of an 1.73 m2)
individual; a normal GFR also depends on normal
• Stage 5: Kidney failure (GFR < 15 ml/min/1.73 m2)
renal blood flow and pressure.
• Normal GFR in young adults is 120-130 ml/min per Kidney damage refers to presence of pathological
1.73 m2. abnormalities or markers of damage like abnormalities
• Creatinine clearance is commonly used as a measure in blood or urine tests or imaging studies. Symptoms
of GFR. Equations can be used to estimate GFR usually develop at or after stage 3. GFR <60 ml/min per
from serum creatinine value. 1.73 m2 indicates loss of ≥ 50% of kidney function. GFR
• GFR declines with age (due to glomerular arteriolo- <15 ml/min per 1.73 m2 is associated with kidney failure
sclerosis) and uremia. Following methods are used to measure
• GFR <60 ml/min per 1.73 m2 indicates loss of ≥50% GFR: (1) Clearance tests and (2) Prediction equations.
of kidney function.
• Fall in GFR leads to accumulation of waste products
of metabolism in blood. GFR <15 ml/min per 1.73 m2 Clearance Tests to Measure Glomerular
is associated with uremia. Filtration Rate (GFR)
Glomerular filtration rate refers to the rate in ml/min at
which a substance is cleared from the circulation by the
Normal GFR in young adults is 120-130 ml/min per 1.73 glomeruli. The ability of the glomeruli to filter a substance
m2 of body surface area. GFR declines progressively with from the blood is assessed by clearance studies. If a
age (due to arteriolosclerosis of glomeruli). After 40 years substance is not bound to protein in plasma, is completely
of age, there is a steady and progressive fall in the GFR filtered by the glomeruli, and is neither secreted nor
at the rate of 1 ml/minute/year because of reduction in reabsorbed by the tubules, then its clearance rate is equal
the number of glomeruli due to arteriolosclerosis. to the glomerular filtration rate (GFR). Clearance of a
GFR is measured to (i) detect suspected incipient substance refers to the volume of plasma, which is
kidney disease (i.e. early detection), (ii) monitor course completely cleared of that substance per minute; it is
of established kidney disease, (iii) plan renal replacement calculated from the following formula:
therapy in advanced renal disease, and (iv) adjust dosage
of certain drugs which are nephrotoxic. UV
Clearance = ——
Based on GFR, chronic kidney disease is divided into P
following stages (US National Kidney Foundation where, U = concentration of a substance in urine in
Kidney Disease Quality Outcomes Initiative Classifi- mg/dl; V = volume of urine excreted in ml/min; and P
cation of Chronic Kidney Disease, 2002): = concentration of the substance in plasma in mg/dl.
• Stage 1: Kidney damage with normal or increased Since U and P are in the same units, they cancel each
GFR (GFR ≥ 90 ml/min/1.73 m2) other and the clearance value is expressed in the same
• Stage 2: Kidney damage with mildly reduced GFR unit as V i.e. ml/min. All clearance values are adjusted
(GFR 60-89 ml/min/1.73 m2) to a standard body surface area i.e. 1.73 m2.
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32 Essentials of Clinical Pathology
The agents used for measurement of GFR are: and is not returned to circulation after filtration. It is a
• Exogenous: Inulin, Radiolabelled ethylenediamine more sensitive and specific marker of impaired renal
tetraacetic acid (51Cr- EDTA), 125I-iothalamate function than plasma creatinine. Its level is not affected
• Endogenous: Creatinine, Urea, Cystatin C by sex, diet, or muscle mass. It is thought that cystatin C
The agent used for measurement of GFR should have is a superior marker for estimation of GFR than creatinine
following properties: (1) It should be physiologically inert clearance. It is measured by immunoassay.
and preferably endogenous, (2) It should be freely filtered
by glomeruli and should be neither reabsorbed nor Creatinine Clearance
secreted by renal tubules, (3) It should not bind to plasma
This is the most commonly used test for measuring GFR.
proteins and should not be metabolized by kidneys, and
Creatinine is being produced constantly from creatine
(4) It should be excreted only by the kidneys. However,
in muscle. It is completely filtered by glomeruli and is
there is no such ideal endogenous agent.
not reabsorbed by tubules; however, a small amount is
Clearance tests are cumbersome to perform,
secreted by tubules.
expensive, and not readily available. One major
problem with clearance studies is incomplete urine A 24-hour urine sample is preferred to overcome the
collection. problem of diurnal variation of creatinine excretion and
Abnormal clearance occurs in: (i) pre-renal factors: to reduce the inaccuracy in urine collection.
reduced blood flow due to shock, dehydration, and After getting up in the morning, the first voided urine
congestive cardiac failure; (ii) renal diseases; and is discarded. Subsequently all the urine passed is
(iii) obstruction to urinary outflow. collected in the container provided. After getting up in
the next morning, the first voided urine is also collected
Inulin Clearance and the container is sent to the laboratory. A blood
sample for estimation of plasma creatinine is obtained
Inulin, an inert plant polysaccharide (a fructose polymer), at midpoint of urine collection. Creatinine clearance is
is filtered by the glomeruli and is neither reabsorbed nor calculated from (1) concentration of creatinine in urine
secreted by the tubules; therefore it is an ideal agent for in mg/ml (U), (2) volume of urine excreted in ml/min
measuring GFR. A bolus dose of inulin (25 ml of 10% (V) (this is calculated by the formula: volume of urine
solution IV) is administered followed by constant collected/collection time in minutes e.g. volume of urine
intravenous infusion (500 ml of 1.5% solution at the rate collected in 24 hours ÷ 1440), and (3) concentration of
of 4 ml/min). Timed urine samples are collected and creatinine in plasma in mg/dl (P). Creatinine clearance
blood samples are obtained at the midpoint of timed in ml/min per 1.73 m2 is then derived from the formula
urine collection. This test is considered as the ‘gold UV/P.
standard’ (or reference method) for estimation of GFR. Because of secretion of creatinine by renal tubules,
However, this test is rarely used because it is time the above formula overestimates GFR by about 10%. In
consuming, expensive, constant intravenous infusion of advanced renal failure, secretion of creatinine by tubules
inulin is needed to maintain steady plasma level, and is increased and thus overestimation of GFR is even more.
difficulties in laboratory analysis. Average inulin Jaffe’s reaction (see later under serum creatinine) used
clearance for males is 125 ml/min/1.73 m2 and for for estimation of creatinine measures creatinine as well
females is 110 ml/min/1.73 m2. In children less than 2 as some other substances (non-creatinine chromogens)
years and in older adults, clearance is low. This test is in blood and thus gives slightly higher result. Thus effect
largely limited to clinical research. of tubular secretion of creatinine is somewhat balanced
by slight overestimation of serum creatinine by Jaffe’s
Clearance of Radiolabeled Agents reaction.
Urinary clearance of radiolabeled iothalamate (125I- To provide values closer to the actual GFR, cimetidine
iothalamate) correlates closely with inulin clearance. (which blocks secretion by renal tubules) can be
However, this method is expensive with risk of exposure administered before commencing urine collection
to radioactive substances. Other radiolabelled substances (cimetidine-enhanced creatinine clearance).
used are 51Cr-EDTA and 99Tc-DTPA. Creatinine clearance is not an ideal test for estimation
of GFR because of following reasons:
Cystatin C Clearance 1. A small amount of creatinine is secreted by renal
This is a cysteine protease inhibitor of MW 13,000, which tubules that increase even further in advanced renal
is produced at a constant rate by all the nucleated cells. failure.
It is not bound to protein, is freely filtered by glomeruli 2. Collection of urine is often incomplete.
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Renal Function Tests 33
3. Creatinine level is affected by intake of meat and It is recommended by National Kidney Foundation
muscle mass. (USA) to calculate creatinine clearance by Cockcroft and
4. Creatinine level is affected by certain drugs like Gault or other equation from serum creatinine value
cimetidine, probenecid, and trimethoprim (which rather than estimating creatinine clearance from a 24-
block tubular secretion of creatinine). hour urine sample. This is because the latter test is
inconvenient, time-consuming, and often inaccurate.
Urea Clearance
Blood Biochemistry
Urea is filtered by the glomeruli, but about 40% of the
filtered amount is reabsorbed by the tubules. The Two biochemical parameters are commonly used to
reabsorption depends on the rate of urine flow. Thus it assess renal function: blood urea nitrogen (BUN) and
underestimates GFR, depends on the urine flow rate, and serum creatinine. Although convenient, they are
is not a sensitive indicator of GFR. insensitive markers of glomerular function.
BUN and serum creatinine, by themselves, are not
Blood Urea Nitrogen (BUN)
sensitive indicators of early renal impairment since
values may be normal e.g. if baseline values of serum Urea is produced in the liver from amino acids (ingested
creatinine is 0.5 mg/dl, then 50% reduction in kidney or tissue-derived). Amino acids are utilized to produce
function would increase it to 1.0 mg/dl. Thus clearance energy, synthesize proteins, and are catabolized to
tests are more helpful in early cases. If biochemical tests ammonia. Urea is produced in the liver from ammonia
are normal and renal function impairment is suspected, in the Krebs urea cycle. Ammonia is toxic and hence is
then creatinine clearance test should be carried out. If converted to urea, which is then excreted in urine
biochemical tests are abnormal, then clearance tests need (Fig. 2.1).
not be done. The concentration of blood urea is usually expressed
as blood urea nitrogen. This is because older methods
Estimation of Creatinine Clearance from Serum estimated only the nitrogen in urea. Molecular weight
Creatinine by Prediction Equations of urea is 60, and 28 grams of nitrogen are present in a
gm mole of urea. As the relationship between urea and
One can estimate GFR from age, sex, body weight, and BUN is 60/28, BUN can be converted to urea by
serum creatinine value of a person from the following multiplying BUN by 2.14, i.e. the real concentration of
formula (Cockcroft and Gault): urea is BUN × (60/28).
Creatinine clearance
Urea is completely filtered by the glomeruli, and
(140 - Age in years) × (Body weight in kg) about 30-40% of the filtered amount is reabsorbed in the
in ml/min =
(72 × Serum creatinine in mg/dl) renal tubules depending on the person’s state of
hydration
In females, the value obtained from above equation Blood level of urea is affected by a number of non-
is multiplied by 0.85 to get the result. renal factors (e.g. high protein diet, upper gastrointestinal
hemorrhage, liver function, etc.) and therefore utility of • It is not reabsorbed, and very little is secreted by
BUN as an indicator of renal function is limited. Also tubules.
considerable destruction of renal parenchyma is required With muscle mass remaining constant, increased
before elevation of blood urea can occur. creatinine level reflects reduction of glomerular filtration
The term azotemia refers to the increase in the blood rate. However, because of significant kidney reserve,
level of urea; uremia is the clinical syndrome resulting increase of serum creatinine level (from 1.0 mg/dl to 2.0
from this increase. If renal function is absent, BUN rises mg/dl) in blood does not occur until about 50% of kidney
by 10-20 mg/dl/day. function is lost. Therefore, serum creatinine is not a
sensitive indicator of early renal impairment. Also,
Causes of increased BUN: laboratory report showing serum creatinine “within
1. Pre-renal azotemia: shock, congestive heart failure, normal range” does not necessarily mean that the level
salt and water depletion is normal; the level should be correlated with body
2. Renal azotemia: impairment of renal function weight, age, and sex of the individual. If renal function
3. Post-renal azotemia: obstruction of urinary tract is absent, serum creatinine rises by 1.0 to 1.5 mg/dl/day
4. Increased rate of production of urea: (Fig. 2.2).
• High protein diet
• Increased protein catabolism (trauma, burns,
fever)
• Absorption of amino acids and peptides from a
large gastrointestinal hemorrhage or tissue
hematoma
a yellow-red color. The color is measured in a Causes of Decreased BUN/Creatinine Ratio (<10:1)
spectrophotometer at 485 nm. Certain substances in
• Acute tubular necrosis
plasma (such as glucose, protein, fructose, ascorbic
• Low protein diet, starvation
acid, acetoacetate, acetone, and cephalosporins) react • Severe liver disease
with picrate in a similar manner; these are called as
non-creatinine chromogens (and can cause false Microalbuminuria and Albuminuria
elevation of serum creatinine level). Thus ‘true’
Normally, a very small amount of albumin is excreted
creatinine is less by 0.2 to 0.4 mg/dl when estimated
in urine. The earliest evidence of glomerular damage in
by Jaffe’s reaction. diabetes mellitus is occurrence of microalbuminuria
2. Enzymatic methods: These methods use enzymes (albuminuria in the range of 30 to 300 mg/24 hours). An
that cleave creatinine; hydrogen peroxide produced albuminuria > 300-mg/24 hour is termed clinical or overt
then reacts with phenol and a dye to produce a and indicates significant glomerular damage. (See
colored product, which is measured in a spectro- “Proteinuria” under Chapter 1 “Examination of Urine”).
photometer.
Tests to Evaluate Tubular Function
Reference range:
Adult males: 0.7-1.3 mg/dl. Tests to Assess Proximal Tubular Function
Adult females: 0.6-1.1 mg/dl. Renal tubules efficiently reabsorb 99% of the glomerular
Serum creatinine alone should not be used to assess filtrate to conserve the essential substances like glucose,
renal function. This is because serum creatinine amino acids, and water.
concentration depends on age, sex, muscle mass, 1. Glycosuria: In renal glycosuria, glucose is excreted in
glomerular filtration and amount of tubular secretion. urine, while blood glucose level is normal. This is
Thus, normal serum creatinine range is wide. Serum because of a specific tubular lesion which leads to
creatinine begins to rise when GFR falls below 50% of impairment of glucose reabsorption. Renal glycosuria
normal. Minor rise of serum creatinine is associated with is a benign condition. Glycosuria can also occur in
significant reduction of GFR (Fig 2.2). Therefore early Fanconi syndrome.
stage of chronic renal impairment cannot be detected by 2. Generalized aminoaciduria: In proximal renal tubular
measurement of serum creatinine alone. dysfunction, many amino acids are excreted in urine
due to defective tubular reabsorption.
BUN/Serum Creatinine Ratio 3. Tubular proteinuria (Low molecular weight proteinuria):
Clinicians commonly calculate BUN/creatinine ratio to Normally, low molecular weight proteins (β 2 –
discriminate pre-renal and post-renal azotemia from microglobulin, retinol-binding protein, lysozyme, and
α1-microglobulin) are freely filtered by glomeruli and
renal azotemia. Normal ratio is 12:1 to 20:1.
are completely reabsorbed by proximal renal tubules.
With tubular damage, these low molecular weight
Causes of Increased BUN/Creatinine Ratio (>20:1): proteins are excreted in urine and can be detected by
1. Increased BUN with normal serum creatinine: urine protein electrophoresis. Increased amounts of
• Pre-renal azotemia (reduced renal perfusion) these proteins in urine are indicative of renal tubular
damage.
• High protein diet
• Increased protein catabolism 4. Urinary concentration of sodium: If both BUN and serum
creatinine are acutely increased, it is necessary to
• Gastrointestinal hemorrhage
distinguish between prerenal azotemia (renal
2. Increase of both BUN and serum creatinine with underperfusion) and acute tubular necrosis. In
disproportionately greater increase of BUN: prerenal azotemia, renal tubules are functioning
• Post-renal azotemia (Obstruction to the outflow normally and reabsorb sodium, while in acute tubular
of urine) necrosis, tubular function is impaired and sodium
Obstruction to the urine outflow causes diffusion absorption is decreased. Therefore, in prerenal
of urinary urea back into the blood from tubules azotemia, urinay sodium concentration is < 20 mEq/
because of backpressure. L while in acute tubular necrosis, it is > 20 mEq/L.
36 Essentials of Clinical Pathology
5. Fractional excretion of sodium (FENa): Measurement of 2. Urine osmolality: The most commonly employed test
urinary sodium concentration is affected by urine to evaluate tubular function is measurement of urine/
volume and can produce misleading results. There- plasma osmolality. This is the most sensitive method for
fore, to avoid this, fractional excretion of sodium is determination of ability of concentration. Osmolality
calculated. This refers to the percentage of filtered measures number of dissolved particles in a solution.
sodium that has been absorbed and percentage that Specific gravity, on the other hand, is the ratio of mass of
has been excreted. Measurement of fractional sodium a solution to the mass of water i.e. it measures total mass
excretion is a better indicator of tubular absorption of solute. Specific gravity depends on both the number
of sodium than quantitation of urine sodium alone. and the nature of dissolved particles while osmolality is
This test is indicated in acute renal failure. In oliguric exact number of solute particles in a solution. Specific
patients, this is the most reliable means of early gravity measurement can be affected by the presence of
distinction between pre-renal failure and renal failure solutes of large molecular weight like proteins and
due to acute tubular necrosis. It is calculated from the glucose, while osmolality is not. Therefore measurement
following formula: of osmolality is preferred.
When solutes are dissolved in a solvent, certain
(Urine sodium × Plasma creatinine)
× 100% changes take place like lowering of freezing point,
(Plasma sodium × Urine creatinine) increase in boiling point, decrease in vapor pressure, or
increase of osmotic pressure of the solvent. These
In pre-renal failure this ratio is less than 1%, and in
properties are made use of in measuring osmolality by
acute tubular necrosis it is more than 1%. In pre-renal
an instrument called as osmometer.
failure (due to reduced renal perfusion), aldosterone
Osmolality is expressed as milliOsmol/kg of water.
secretion is stimulated which causes maximal sodium
Urine/plasma osmolality ratio is helpful in distin-
conservation by the tubules and the ratio is less than 1%.
guishing pre-renal azotemia (in which ratio is higher)
In acute tubular necrosis, maximum sodium reabsorption
from acute renal failure due to acute tubular necrosis (in
is not possible due to tubular cell injury and consequently
which ratio is lower). If urine and plasma osmolality are
the ratio will be more than 1%. Values above 3% are almost similar, then there is defective tubular reabsorp-
strongly suggestive of acute tubular necrosis. tion of water.
Tests to Assess Distal Tubular Function 3. Water deprivation test If the value of baseline osmolality
of urine is inconclusive, then water deprivation test is
1. Urine specific gravity: Normal specific gravity is 1.003 performed. In this test, water intake is restricted for a
to 1.030. It depends on state of hydration and fluid intake. specified period of time followed by measurement of
i. Causes of increased specific gravity: specific gravity or osmolality. Normally, urine osmolality
a. Reduced renal perfusion (with preservation of should rise in response to water deprivation. If it fails to
concentrating ability of tubules), rise, then desmopressin is administered to differentiate
b. Proteinuria, between central diabetes insipidus and nephrogenic
c. Glycosuria, diabetes insipidus. Urinary concentration ability is
d. Glomerulonephritis. corrected after administration of desmopressin in central
e. Urinary tract obstruction. diabetes insipidus, but not in nephrogenic diabetes
ii. Causes of reduced specific gravity: insipidus.
a. Diabetes insipidus If urine osmolality is > 800 mOsm/kg of water or
b. Chronic renal failure specific gravity is ≥1.025 following dehydration,
c. Impaired concentrating ability due to diseases of concentrating ability of renal tubules is normal. However,
tubules. normal result does not rule out presence of renal disease.
As a test of renal function, it gives information about False result will be obtained if the patient is on low-salt,
the ability of renal tubules to concentrate the glomerular low-protein diet or is suffering from major electrolyte
and water disturbance.
filtrate. This concentrating ability is lost in diseases of
renal tubules. 4. Water loading antidiuretic hormone suppression test This
Fixed specific gravity of 1.010, which cannot be test assesses the capacity of the kidney to make urine
lowered or increased by increasing or decreasing the fluid dilute after water loading.
intake respectively, is an indication of chronic renal After overnight fast, patient empties the bladder and
failure. drinks 20 ml/kg of water in 15-30 minutes. The urine is
Renal Function Tests 37
collected at hourly intervals for the next 4 hours for Indications for Renal Biopsy
measurements of urine volume, specific gravity, and
1. Nephrotic syndrome in adults (most common
osmolality. Plasma levels of antidiuretic hormone and
indication)
serum osmolality should be measured at hourly intervals.
2. Nephrotic syndrome not responding to cortico-
Normally, more than 90% of water should be excreted
steroids in children.
in 4 hours. The specific gravity should fall to 1.003 and
3. Acute nephritic syndrome for differential diagnosis
osmolality should fall to < 100 mOsm/kg. Plasma level
4. Unexplained renal insufficiency with near-normal
of antidiuretic hormone should be appropriate for serum
kidney dimensions on ultrasonography
osmolality. In renal function impairment, urine volume
5. Asymptomatic hematuria, when other diagnostic
is reduced (<80% of fluid intake is excreted) and specific
tests fail to identify the source of bleeding
gravity and osmolality fail to decrease. The test is also
6. Isolated non-nephrotic range proteinuria (1-3 gm/
impaired in adrenocortical insufficiency, malabsorption,
24 hours) with renal impairment
obesity, ascites, congestive heart failure, cirrhosis, and
7. Impaired function of renal graft
dehydration.
8. Involvement of kidney in systemic disease like
This test is not advisable in patients with cardiac
systemic lupus erythematosus or amyloidosis
failure or kidney disease. If there is failure to excrete
water load, fatal hyponatremia can occur.
Contraindications
5. Ammonium chloride loading test (Acid load test): Diagnosis
1. Uncontrolled severe hypertension
of renal tubular acidosis is usually considered after
2. Hemorrhagic diathesis
excluding other causes of metabolic acidosis. This test is
3. Solitary kidney
considered as a ‘gold standard’ for the diagnosis of distal
4. Renal neoplasm (to avoid spread of malignant cells
or type 1 renal tubular acidosis. Urine pH and plasma
along the needle track)
bicarbonate are measured after overnight fasting. If pH
5. Large and multiple renal cysts
is less than 5.4, acidifying ability of renal tubules is
6. Small, shrunken kidneys
normal. If pH is greater than 5.4 and plasma bicarbonate
7. Acute urinary tract infection like pyelonephritis
is low, diagnosis of renal tubular acidosis is confirmed.
8. Urinary tract obstruction
In both the above cases, further testing need not be
performed. In all other cases in which neither of above
Complications
results is obtained, further testing is carried out. Patient
is given ammonium chloride orally (0.1 gm/kg) over 1 1. Hemorrhage: As renal cortex is highly vascular, major
hour after overnight fast and urine samples are collected risk is bleeding in the form of hematuria or peri-
hourly for next 6-8 hours. Ammonium ion dissociates nephric hematoma. Severe bleeding may occasionally
into H+ and NH3. Ammonium chloride makes blood necessitate blood transfusion and rarely removal of
acidic. If pH is less than 5.4 in any one of the samples, kidney.
acidifying ability of the distal tubules is normal. 2. Arteriovenous fistula
3. Infection
RENAL BIOPSY 4. Accidental biopsy of another organ or perforation of
viscus (liver, spleen, pancreas, adrenals, intestine, or
Renal biopsy refers to obtaining a small piece of kidney gallbladder)
tissue for microscopic examination. Percutaneous renal 5. Death (rare).
biopsy was first performed by Alwall in 1944. In renal
disease, renal biopsy is helpful to: Procedure
• Establish the diagnosis 1. Patient’s informed consent is obtained.
• Assess severity and activity of disease 2. Ultrasound/CT scan is done to document the
• Assess prognosis by noting the amount of scarring location and size of kidneys.
• To plan treatment and monitor response to therapy 3. Blood pressure should be less than 160/90 mm of
Renal biopsy is associated with the risk of procedure- Hg. Bleeding time, platelet count, prothrombin
related morbidity and rarely mortality. Therefore, before time, and activated partial thromboplastin time
performing renal biopsy, risks of the procedure and should be normal. Blood sample should be drawn
benefits of histologic examination should be evaluated for blood grouping and cross matching, as blood
in each patient. transfusion may be needed.
38 Essentials of Clinical Pathology
Diabetes Mellitus
METABOLIC ACTIONS OF INSULIN Fig. 3.1: Proinsulin, insulin, and C-peptide. The biochemical
cleavage of proinsulin to insulin and C-peptide occurs in Golgi
Insulin is the major hormone regulating blood glucose apparatus of β cell. Secretion of insulin is stimulated by glucose,
level. Insulin is synthesized by β cells of pancreas as mannose, amino acids, and sulfonylureas
preproinsulin, which is rapidly converted to proinsulin.
Proinsulin is a single chain polypeptide. In the Golgi
apparatus, proinsulin is broken down into 2 units- insulin “Stress hormones” like glucagons, glucocorticoids,
(51 amino acids) and C (connecting)-polypeptide (31 growth hormone, and adrenaline oppose action of
amino acids) (Fig. 3.1). Both insulin and C peptide are insulin.
stored in membrane-bound granules in the cytoplasm
of β cells. Upon stimulation (mainly by blood glucose), CLASSIFICATION OF DIABETES MELLITUS
both insulin and C peptide are released in circulation. According to American Diabetes Association (1997), DM
C peptide is often measured as a marker of activity of β is classified into following types:
cells. C peptide has no known function. • Type 1 (Absolute deficiency of insulin due to
Insulin acts on various cells (especially those of liver, destruction of β cells of pancreas)
muscle, and adipose tissue) through receptors. – Immune mediated
Important actions of insulin are shown in Box 3.1. – Idiopathic
40 Essentials of Clinical Pathology
children and adolescents, but can occur at any age. These Other Specific Types
patients are also at risk of other autoimmune disorders
There are several forms of DM associated with under-
like Graves’ disease, Hashimoto’s thyroiditis, vitiligo,
lying conditions:
Addison’s disease, pernicious anemia, etc.
• Genetic defects of β cell function: In these disorders,
Some cases of type 1 DM do not have any known
insulin secretion from β cells is impaired. These are
etiologies or evidence of autoimmunity. These indivi-
duals are of Asian or African origin and their disease is called as maturity onset diabetes of the young
strongly inherited. This form of type 1 DM is called as (MODY). They are inherited in an autosomal
idiopathic DM. dominant manner and they are caused by mutations
in genetic loci such as hepatic nuclear factor,
Type 2 Diabetes Mellitus glucokinase, etc.
• Genetic defects in insulin action: These result from
This is the most common form of DM comprising about mutations in insulin receptor gene.
90-95% of all patients of DM. This was previously called • Diseases of exocrine pancreas: Diseases causing
as non-insulin-dependent DM (NIDDM), maturity-onset generalized pancreatic damage can result in DM.
DM (because onset usually occurs during adult life), These include cystic fibrosis, hemochromatosis,
stable DM, or ketosis-resistant DM. It is characterized chronic pancreatitis, trauma, pancreatectomy, and
by insulin resistance along with relative deficiency of pancreatic cancer.
insulin secretion (i.e. inadequate insulin secretory • Endocrine disorders: Several hormones inhibit the
action of insulin. Excessive secretion of these
response to overcome peripheral insulin resistance).
hormones will cause DM. Hyperglycemia is corrected
(Fig. 3.4). Type 2 DM is not HLA-linked and there is no
following resolution of the primary endocrinopathy.
role of autoimmunity in its pathogenesis. It has a strong Endocrine disorders associated with hyperglycemia
genetic predisposition. Type 2 DM occurs more are:
frequently in individuals with positive family history – Acromegaly: Excess growth hormone.
(parents or siblings with DM), obesity (≥ 20% over ideal – Cushing’s syndrome: Excess cortisol.
body weight or body mass index ≥ 25 kg/m2), hyper- – Glucagonoma: Excess glucagon
tension (>140/90 mm Hg in adults), dyslipidemia, lack – Pheochromocytoma: Excess epinephrine.
of physical activity, pre-diabetes (impaired fasting – Hyperthyroidism: Excess thyroxine
glucose or impaired glucose tolerance), and prior • Drug- or chemical-induced DM: Drugs or chemicals can
gestational DM. impair insulin secretion or insulin action. Destruction
Type 2 diabetes is more common in certain racial of β cells and formation of islet cell antibodies have
also been reported with some drugs. Examples
groups like South Asians and Africans. Rising trend of
include thiazide diuretics, α-interferon, and gluco-
type 2 DM is due to increasing tendency towards obesity
corticoids.
in urban populations coupled with high-calorie diet.
• Infections: Certain viral infections (such as Coxsackie
Differences between type 1 and type 2 DM are listed virus B, congenital rubella, cytomegalovirus) can
in Table 3.1. cause destruction of β cells.
• Other genetic syndromes sometimes associated with DM:
Many genetic syndromes (e.g. Down’s syndrome,
Klinefelter’s syndrome, Turner’s syndrome) are
associated with increased risk of developing DM.
of GDM are essential to prevent perinatal morbidity and acute complications of DM and microangiopathy, but are
mortality. After delivery, GDM can have following at increased risk of cardiovascular disease (1.5 times
course: normal individuals). Development of DM can be delayed
1. Return to normal glucose tolerance (however, many or prevented through modest amount of weight loss, diet
of these patients are likely to develop DM during modification, and regular moderate exercise in patients
subsequent years), or with prediabetes.
2. Persistence of DM or impaired glucose tolerance.
Patient should be reassessed 6 weeks or later METABOLIC SYNDROME (INSULIN
following delivery. RESISTANCE SYNDROME, REAVEN’S
Risk factors for GDM are shown in Box 3.2. SYNDROME, SYNDROME X)
PREDIABETES The metabolic syndrome refers to a constellation of lipid
Prediabetes is a state in which plasma glucose level is and non-lipid risk factors that are of metabolic origin and
higher than normal but not high enough for diagnosis of associated with risk of cardiovascular disease. The Adult
DM. It is also referred to as impaired fasting glucose (IFG) Treatment Panel III (ATP III) 1 of the National Cholesterol
or impaired glucose tolerance (IGT), depending on which Education Program in 2001 proposed criteria for
test is used for its detection. Studies have shown that diagnosing the metabolic syndrome. The metabolic
majority of individuals with prediabetes develop type 2 syndrome is diagnosed when three or more out of
DM within 10 years. Prediabetic persons do not develop following five criteria are present.
• Abdominal obesity
– Men: Waist circumference > 40 inches (102 cm)
– Women: Waist circumference > 35 inches (88 cm)
Box 3.2: Risk factors for gestational DM • Fasting glucose ≥ 110 to < 126 mg/dl (As these criteria
• Past history of GDM were proposed in 2001, the fasting plasma glucose
• Previous high-birth-weight baby
value should be reduced to 100 mg/dl according to
revised criteria proposed by American Diabetes
• Obesity
Association in 2004).
• Family history of diabetes mellitus
• Blood pressure ≥ 130/> 85 mm Hg
• High-risk ethnic group: South Asian or African.
• Triglycerides ≥ 150 mg/dl (> 1.7 mmol/L)
Diabetes Mellitus 43
• Plasma high density lipoprotein (HDL)-cholesterol insulin deficiency). In reaction to this, there are
– Men: < 40 mg/dl (< 1 mmol/L) compensatory glycogenolysis (breakdown of glyco-
– Women: < 50 mg/dl (< 1.3 mmol/L) gen to glucose) and gluconeogenesis (formation of
Metabolic syndrome is common in Asian Indians in glucose from non-carbohydrates like proteins), which
Britain and in Africa. It is said that insulin resistance is contribute to hyperglycemia. Typical clinical features
common to all above risk factors and plays an etiological of hyperglycemia are polyuria, polydipsia, poly-
role. These persons have increased risk of developing phagia, weakness, weight loss, and blurring of vision.
Type 2 DM. • Glycosuria: Glycosuria results when blood glucose
level exceeds renal threshold (180 mg/dl or 10 mmol/
METABOLIC ALTERATIONS IN L in most individuals). Excess glucose increases
DIABETES MELLITUS osmolality of glomerular filtrate with resultant
In DM, there are abnormalities of carbohydrate osmotic diuresis and polyuria. This causes depletion
metabolism (hyperglycemia, glycosuria, impaired of water and electrolytes, cellular dehydration, and
glucose tolerance), protein metabolism (increased protein intense thirst (polydipsia). Insulin deficiency leads to
catabolism with muscle wasting, gluconeogenesis), and catabolism of proteins, and released amino acids are
fat metabolism (increased fatty acid synthesis, ketosis) used for formation of glucose (gluconeogenesis).
(Fig. 3.5). Metabolic alterations in type 2 DM are less Breakdown of lipids also occurs and coupled with
severe than in type 1 DM. proteolysis, lead to negative energy balance and
• Hyperglycemia: Hyperglycemia is due to deficient weight loss. This in turn induces polyphagia
uptake of glucose by muscle and fat cells (due to (increased appetite).
patient presents with (a) hyperglycemia and ketoacidosis, Addition of sodium fluoride is not necessary if plasma
or (b) hyperosmolar hyperglycemia. is separated from whole blood within 1 hour of blood
The tests used for laboratory diagnosis of DM are (1) collection.
estimation of blood glucose and (2) oral glucose tolerance Plasma is preferred for estimation of glucose since
test. whole blood glucose is affected also by concentration of
proteins (especially hemoglobin).
Estimation of Blood Glucose There are various methods for estimation of blood
Measurement of blood glucose level is a simple test to glucose:
assess carbohydrate metabolism in DM (Fig. 3.6). Since • Chemical methods:
– Orthotoluidine method
glucose is rapidly metabolized in the body, measurement
– Blood glucose reduction methods using
of blood glucose is indicative of current state of
neocuproine, ferricyanide, or copper.
carbohydrate metabolism.
Glucose concentration can be estimated in whole Chemical methods are less specific but are cheaper as
blood (capillary or venous blood), plasma or serum. compared to enzymatic methods.
However, concentration of blood glucose differs • Enzymatic methods: These are specific for glucose.
according to nature of the blood specimen. Plasma – Glucose oxidase-peroxidase
glucose is about 15% higher than whole blood glucose – Hexokinase
(the figure is variable with hematocrit). During fasting – Glucose dehydrogenase
state, glucose levels in both capillary and venous blood Chemical methods have now been replaced by
enzymatic methods.
are about the same. However, postprandial or post
glucose load values are higher by 20-70 mg/dl in Terms used for blood glucose specimens: Depending
capillary blood than venous blood. This is because venous on the time of collection, different terms are used for
blood is on a return trip after delivering blood to the blood glucose specimens.
tissues. • Fasting blood glucose: Sample for blood glucose is
When whole blood is left at room temperature after withdrawn after an overnight fast (no caloric intake
collection, glycolysis reduces glucose level at the rate of for at least 8 hours).
about 7 mg/dl/hour. Glycolysis is further increased in • Post meal or postprandial blood glucose: Blood
sample for glucose estimation is collected 2 hours after
the presence of bacterial contamination or leucocytosis.
the subject has taken a normal meal.
Addition of sodium fluoride (2.5 mg/ml of blood)
• Random blood glucose: Blood sample is collected at
maintains stable glucose level by inhibiting glycolysis.
any time of the day, without attention to the time of
Sodium fluoride is commonly used along with an
last food intake.
anticoagulant such as potassium oxalate or EDTA.
Oral Glucose Tolerance Test (OGTT)
Glucose tolerance refers to the ability of the body to
metabolize glucose. In DM, this ability is impaired or
lost and glucose intolerance represents the fundamental
pathophysiological defect in DM. OGTT is a provocative
test to assess response to glucose challenge in an
individual (Fig. 3.7).
American Diabetes Association does not
recommend OGTT for routine diagnosis of type 1 or
type 2 DM. This is because fasting plasma glucose cut-
off value of 126 mg/dl identifies the same prevalence of
abnormal glucose metabolism in the population as
OGTT. World Health Organization (WHO) recommends
OGTT in those cases in which fasting plasma glucose is
in the range of impaired fasting glucose (i.e. 100-125 mg/
Fig. 3.6: Blood glucose values in normal individuals, dl). Both ADA and WHO recommend OGTT for
prediabetes, and diabetes mellitus diagnosis of gestational diabetes mellitus.
46 Essentials of Clinical Pathology
In two-step approach, an initial screening test is done Screening for type 1 DM: Type 1 DM is detected early after
in which patient drinks a 50 g glucose drink irrespective its onset since it has an acute presentation with
of time of last meal and a venous blood sample is characteristic clinical features. Therefore, it is not
collected 1 hour later (O’Sullivan’s test). GDM is excluded necessary to screen for type 1 DM by estimation of blood
if glucose level in venous plasma sample is below 140 glucose. Detection of immunologic markers (mentioned
mg/dl. If level exceeds 140 mg/dl, then the complete earlier) has not been recommended to identify persons
100 g, 3-hour OGTT is carried out. at risk.
In the 3-hour OGTT, blood samples are collected in
Screening for GDM: Given earlier under OGTT in
the morning (after 8-10 hours of overnight fasting), and
gestational diabetes mellitus.
after drinking 100 g glucose, at 1, 2, and 3 hours. For
diagnosis of GDM, glucose concentration should be
Laboratory Tests to Assess Glycemic Control
above the following cut-off values in 2 or more of the
venous plasma samples: There is a direct correlation between the degree of blood
• Fasting: 95 mg/dl glucose control in DM (both type 1 and type 2) and the
• 1 hour: 180 mg/dl development of microangiopathic complications i.e.
• 2 hour: 155 mg/dl nephropathy, retinopathy, and neuropathy. Maintenance
• 3 hour: 140 mg/dl of blood glucose level as close to normal as possible
(referred to as tight glycemic control) reduces the risk of
Laboratory Tests for Screening of microvascular complications. There is also association
Diabetes Mellitus between persistently high blood glucose values in DM
with increased cardiovascular mortality.
Aim of screening is to identify asymptomatic individuals
Following methods can monitor degree of glycemic
who are likely to have DM. Since early detection and
control:
prompt institution of treatment can reduce subsequent
• Periodic measurement of glycated hemoglobin (to
complications of DM, screening may be an appropriate
assess long-term control).
step in some situations.
• Daily self-assessment of blood glucose (to assess day-
Screening for type 2 DM: Type 2 DM is the most common to-day or immediate control).
type of DM and is usually asymptomatic in its initial
stages. Its onset occurs about 5-7 years before clinical Glycated Hemoglobin
diagnosis. Evidence indicates that complications of type (Glycosylated Hemoglobin, HbA1C)
2 DM begin many years before clinical diagnosis.
American Diabetes Association recommends screening Glycated hemoglobin refers to hemoglobin to which
for type 2 DM in all asymptomatic individuals ≥ 45 years glucose is attached nonenzymatically and irreversibly;
of age using fasting plasma glucose. If fasting plasma its amount depends upon blood glucose level and
glucose is normal (i.e. < 100 mg/dl), screening test should lifespan of red cells.
be repeated every three years.
Another approach is selective screening i.e. screening Hemoglobin + Glucose ↔ Aldimine → Glycated hemoglobin
individuals at high risk of developing type 2 DM i.e. if
one or more of the following risk factors are present- Plasma glucose readily moves across the red cell
obesity (body mass index ≥ 25.0 kg/m2), family history membranes and is being continuously combined with
of DM (first degree relative with DM), high-risk ethnic hemoglobin during the lifespan of the red cells (120 days).
group, hypertension, dyslipidemia, impaired fasting Therefore, some hemoglobin in red cells is present
glucose, impaired glucose tolerance, or history of GDM. normally in glycated form. Amount of glycated
In such cases, screening is performed at an earlier age hemoglobin in blood depends on blood glucose
(30 years) and repeated more frequently. concentration and lifespan of red cells. If blood glucose
Recommended screening test for type 2 DM is fasting concentration is high, more hemoglobin is glycated. Once
plasma glucose. If ≥126 mg/dl, it should be repeated on formed, glycated hemoglobin is irreversible. Level of
a subsequent day for confirmation of diagnosis. If <126 glycated hemoglobin is proportional to the average
mg/dl, OGTT is indicated if clinical suspicion is strong. glucose level over preceding 6-8 weeks (about 2 months).
A 2-hour post-glucose load value in OGTT ≥200 mg/dl Glycated hemoglobin is expressed as a percentage of total
is indicative of DM and should be repeated on a different hemoglobin. Normally, less than 5% of hemoglobin is
day for confirmation. glycated.
48 Essentials of Clinical Pathology
Box 3.4: Glycated hemoglobin Semiquantitative urine glucose testing for monitoring
of diabetes mellitus in home setting is not recommen-
• Hemoglobin A1C of 6% corresponds to mean serum glucose ded. This is because (1) even if glucose is absent in
level of 135 mg/dl. With every rise of 1%, serum glucose
increases by 35 mg/dl. Approximations are as follows:
urine, no information about blood glucose concen-
– Hb A1C 7%: 170 mg/dl tration below the renal threshold (which itself is
– Hb A1C 8%: 205 mg/dl variable) is obtained (Normally, renal threshold is
– Hb A1C 9%: 240 mg/dl around 180 mg/dl; it tends to be lower in pregnancy (140
– Hb A1C 10%: 275 mg/dl mg/dl) and higher in old age and in long-standing
– Hb A1C 11%: 310 mg/dl
– Hb A1C 12%: 345 mg/dl
diabetics; in some normal persons it is low), (2) urinary
• Assesses long-term control of DM (thus indirectly glucose testing cannot detect hypoglycemia, and (3)
confirming plasma glucose results or self-testing results). concentration of glucose in urine is affected by urinary
• Assesses whether treatment plan is working concentration. Semiquantitative urine glucose testing
• Measurement of glycated hemoglobin does not replace for monitoring has now been replaced by self-testing
measurement of day-to-day control by glucometer devices. by portable glucose meters.
Diabetes Mellitus 49
Laboratory Tests to Assess Long-term Risks Albumin excretion rate is intermediate between normal
(normal albumin excretion in urine is < 30 mg/24 hours)
Urinary Albumin Excretion and overt albuminuria (> 300 mg/24 hours). Significance
of microalbuminuria in DM is as follows:
Diabetes mellitus is one of the leading causes of renal
• It is the earliest marker of diabetic nephropathy.
failure. Diabetic nephropathy develops in around 20-30%
Early diabetic nephropathy is reversible.
of patients with type 1 or type 2 DM. Diabetic nephro-
• It is a risk factor for cardiovascular disease in both
pathy progresses through different stages as shown in type 1 and type 2 patients.
Figure 3.8. Hypertension also develops along the course • It is associated with higher blood pressure and poor
of nephropathy with increasing albumin excretion. glycemic control.
Evidence indicates that if diabetic nephropathy is Specific therapeutic interventions such as tight
detected early and specific treatment is instituted, further glycemic control, administration of ACE (angiotensin-
progression of nephropathy can be significantly converting enzyme) inhibitors, and aggressive treatment
ameliorated. Early detection of diabetic nephropathy is of hypertension significantly slow down the progression
based on estimation of urinary albumin excretion. In all of diabetic nephropathy.
adult patients with DM, usual reagent strip test for In type 2 DM, screening for microalbuminuria
proteinuria should be carried out periodically. Positive should begin at the time of diagnosis, whereas in type
test means presence of overt proteinuria or clinical 1 DM, it should begin 5 years after diagnosis. At this
proteinuria and may be indicative of overt nephropathy. time, a routine reagent strip test for proteinuria is carried
In all such patients quantitation of albuminuria should out; if negative, testing for microalbuminuria is done.
be carried out to plan appropriate therapy. If the routine Thereafter, in all patients who test negative, screening
dipstick test for proteinuria is negative, test for for microalbuminuria should be repeated every year.
microalbuminuria should be carried out. Screening tests for microalbuminuria include:
The term ‘microalbuminuria’ refers to the urinary • Albumin to creatinine ratio in a random urine sample
excretion of albumin below the level of detection by • Urinary albumin excretion in a 24-hour urine sample.
routine dipstick testing but above normal (30-300 mg/ Reagent strip tests to detect microalbuminuria are
24 hrs, 20-200 μg/min, or 30-300 μg/mg of creatinine). available. Positive results should be confirmed by more
Fig. 3.8: Evolution of diabetic nephropathy. In 80% of patients with type 1 DM, microalbuminuria progresses in 10-15 years
to overt nephropathy that is then followed in majority of cases by progressive fall in GFR and ultimately end-stage renal
disease. Amongst patients with type 2 DM and microalbuminuria, 20-40% of patients progress to overt nephropathy, and
about 20% of patients with overt nephropathy develop end-stage renal disease. Abbreviation: GFR: Glomerular filtration rate
50 Essentials of Clinical Pathology
specific quantitative tests like radioimmunoassay and Laboratory Tests in the Management of Acute
enzyme immunoassay. For diagnosis of microalbumi- Metabolic Complications of Diabetes Mellitus
nuria, tests should be positive in at least two out of three The three most serious acute metabolic complications of
different samples over a 3 to 6 month period. DM are:
• Diabetic ketoacidosis (DKA)
• Hyperosmolar hyperglycemic state (HHS)
Lipid Profile • Hypoglycemia
The typical features of DKA are hyperglycemia,
Abnormalities of lipids are associated with increased risk
ketosis, and acidosis. The common causes of DKA are
of coronary artery disease (CAD) in patients with DM. infection, noncompliance with insulin therapy, alcohol
This risk can be reduced by intensive treatment of lipid abuse and myocardial infarction. Patients with DKA
abnormalities. Lipid parameters which should be present with rapid onset of polyuria, polydipsia,
measured include: polyphagia, weakness, vomiting, and sometimes
abdominal pain. Signs include Kussmaul’s respiration,
• Total cholesterol odour of acetone on breath (fruity), mental clouding, and
• Triglycerides dehydration. Classically, DKA occurs in type 1, while
• Low-density lipoprotein (LDL) cholesterol HHS is more typical of type 2 DM. However, both
• High-density lipoprotein (HDL) cholesterol complications can occur in either types. If untreated, both
events can lead to coma and death.
The usual pattern of lipid abnormalities in type 2
Hyperosmolar hyperglycemic state is characterized by
DM is elevated triglycerides, decreased HDL choleste- very high blood glucose level (> 600 mg/dl), hyper-
rol and higher proportion of small, dense LDL particles. osmolality (>320 mOsmol/kg of water), dehydration, lack
Patients with DM are categorized into high, intermediate of ketoacidosis, and altered mental status. It usually occurs
and low-risk categories depending on lipid levels in in elderly type 2 diabetics. Insulin secretion is adequate to
prevent ketosis but not hyperglycemia. Causes of HHS are
blood (Table 3.3).
illness, dehydration, surgery, and glucocorticoid therapy.
Annual lipid profile is indicated in all adult patients Differences between DKA and HHS are presented in
with DM. Table 3.4.
Table 3.3: Categorization of cardiovascular risk in diabetes mellitus
according to lipid levels (American Diabetes Association)
Category Low density lipoproteins High density lipoproteins Triglycerides
Laboratory evaluation consists of following investiga- Serum Osmolality can also be calculated by the
tions: following formula recommended by American Diabetes
• Blood and urine glucose Association:
• Blood and urine ketone
Effective serum osmolality (mOsm/kg) =
• Arterial pH, Blood gases
(2 × sodium mEq/L) + Plasma glucose (mg/dl)
• Serum electrolytes (sodium, potassium, chloride,
bicarbonate) 18
• Blood osmolality • Anion gap:
• Serum creatinine and blood urea. – Na+ – (Cl– + HCO3–): 8-16 mmol/L (Average 12)
– (Na + + K + ) – (Cl – + HCO3 – ): 10-20 mmol/L
Testing for ketone bodies: Ketone bodies are formed (Average 16)
from metabolism of free fatty acids and include • Serum sodium: 135-145 mEq/L
acetoacetic acid, acetone and β-hydroxybutyric acid. • Serum potassium: 3.5-5.0 mEq/L
Indications for testing for ketone bodies in DM include: • Serum chloride: 100-108 mEq/L
• At diagnosis of diabetes mellitus • Serum bicarbonate: 24-30 mEq/L
• At regular intervals in all known cases of diabetes,
during pregnancy with pre-existing diabetes, and in CRITICAL VALUES
gestational diabetes • Venous plasma glucose: > 450 mg/dl
• In known diabetic patients: during acute illness, • Strongly positive test for glucose and ketones in
persistent hyperglycemia (> 300 mgs/dl), pregnancy, urine
and clinical evidence of diabetic acidosis (nausea, • Arterial pH: < 7.2 or > 7.6
vomiting, abdominal pain). • Serum sodium: < 120 mEq/L or > 160 mEq/L
An increased amount of ketone bodies in patients • Serum potassium: < 2.8 mEq/L or > 6.2 mEq/L
with DM indicate impending or established diabetic • Serum bicarbonate: < 10 mEq/L or > 40 mEq/L
ketoacidosis and is a medical emergency. Method based • Serum chloride: < 80 mEq/L or > 115 mEq/L
on colorimetric reaction between ketone bodies and
BIBLIOGRAPHY
nitroprusside (by dipstick or tablet) is used for detection
of both blood and urine ketones. 1. American Diabetes Association. Diagnosis and
classification of diabetes mellitus. Diabetes Care 2004;
Test for urine ketones alone should not be used for
24:S5-S10.
diagnosis and monitoring of diabetic ketoacidosis. It is 2. American Diabetes Association. Gestational diabetes
recommended to measure β-hydroxybutyric acid (which mellitus. Diabetes Care 2004;27:S88-S90.
accounts for 75% of all ketones in ketoacidosis) for 3. American Diabetes Association. Hyperglycemic crises
diagnosis and monitoring DKA. in diabetes. Diabetes Care 2004;27:S94-S102.
4. American Diabetes Association. Screening for type 2
diabetes. Diabetes Care 2004;27:S11-S14.
REFERENCE RANGES 5. American Diabetes Association. Tests of glycemia in
• Venous plasma glucose: diabetes. Diabetes Care 2004;27:S91-S93.
6. Lernmark A. Type 1 diabetes. Clin Chem 1999;45:
Fasting: 60-100 mg/dl
1331-38.
At 2 hours in OGTT (75 gm glucose): <140 mg/dl 7. Lebovitz HE. Type 2 diabetes: An overview. Clin Chem
• Glycated hemoglobin: 4-6% of total hemoglobin 1999;45:1339-45.
• Lipid profile: 8. Reaven GM. The metabolic syndrome: Requiescat in
– Serum cholesterol: Desirable level: <200 mg/dl pace. Clin Chem 2005;51:931-8.
9. Reinauer H, Home PD, Kanagasabapathy AS, Heuck
– Serum triglycerides: Desirable level: <150 mg/dl
C. Laboratory diagnosis and monitoring of diabetes
– HDL cholesterol: ≥60 mg/dl mellitus. Geneva. World Health Organization, 2002.
– LDL cholesterol: <130 mg/dl 10. Sacks DB, Bruns DE, Goldstein DE, Maclaren NK,
– LDL/HDL ratio: 0.5-3.0 McDonald JM, Parrott M. Guidelines and recommen-
• C-peptide: 0.78-1.89 ng/ml dations for laboratory analysis in the diagnosis and
management of diabetes mellitus. Clin Chem 2002;
• Arterial pH: 7.35-7.45 48:436-72.
• Serum or plasma osmolality: 275-295 mOsm/kg of 11. Trachtenbarg DE. Diabetic ketoacidosis. Am Fam
water. Physician 2005;71:1705-14.
52 Essentials of Clinical Pathology
4
FUNCTIONS OF LIVER
1. Excretory function: Liver cells metabolize and excrete
endogenous as well as exogenous substances. Liver
regulates bilirubin metabolism by secretion and
excretion of bilirubin.
2. Synthetic function: Synthesis of proteins like
albumin, α- and β-globulins, transport proteins and
many coagulation proteins occurs in the liver. Liver
also produces triglycerides, cholesterol, lipoproteins,
and primary bile acids. Albumin maintains osmotic
pressure of plasma, transports various compounds,
and acts as a protein reserve. Liver does not
synthesize immunoglobulins and complement.
3. General metabolic functions: Liver regulates carbo-
hydrate, lipid, and protein metabolism.
Glycogen, derived from monosaccharides, is
stored in the liver. When carbohydrate intake is
reduced, blood glucose level is maintained by
breakdown of stored glycogen (glycogenolysis). If
needed, amino acids and fat are converted to glucose
by the liver (gluconeogenesis).
Synthesis of triglycerides, phospholipids, choles-
terol, and lipoproteins occurs in the liver. Liver also
esterifies cholesterol, and forms bile acids from
cholesterol (Fig. 4.1). Bile acids are essential for fat Fig. 4.1: Formation of bile acids and bile salts
absorption from the intestine. Lipoproteins help in
transport of fats.
Besides synthesis of various proteins and NORMAL BILIRUBIN METABOLISM
enzymes, liver is the site for deamination and
transamination of amino acids. Ammonia is Bilirubin is mostly (85%) produced from breakdown
converted to urea in the urea cycle and detoxified in of hemoglobin of old red cells in reticuloendothelial
the liver. cells (macrophages), mainly in spleen. A smaller
4. Liver is the storage site for iron, glycogen, and amount is derived from premature destruction of red cell
vitamins. precursors in bone marrow, and from myoglobin,
5. During fetal life, hematopoiesis occurs in the liver. It
cytochromes, and peroxidases. Steps in metabolism of
is also a site for destruction of damaged red cells
(immune hemolysis). bilirubin are outlined below (Fig. 4.2).
6. Liver is the major organ for catabolism of steroid 1. Hemoglobin is degraded within macrophages to form
hormones. heme and globin; globin consists of amino acids
Liver Function Tests 53
which are recycled. Heme (iron + protoporphyrin) are necessary for digestion and absorption of fat from
releases iron, which is stored as ferritin. the small intestine.
Protoporphyrin is first converted to biliverdin, which 6. When bilirubin reaches the large intestine, it is
is then reduced to bilirubin. converted by bacterial action to a group of
2. Bilirubin is released from macrophages into the compounds known as urobilinogen by the action of
circulation where it binds with albumin. This is called bacterial enzymes.
as unconjugated bilirubin. It is soluble in lipid but 7. Most of the urobilinogen is excreted in feces as
insoluble in water. urobilin and is responsible for brown coloration of
3. Bilirubin-albumin complex reaches the liver where feces. A part of urobilinogen is absorbed into the
it is taken up by the hepatocytes. Bilirubin is set free circulation from where it reaches the liver, is taken
in the cytoplasm, while albumin is released back into by the hepatocytes, and is again re-excreted in bile
the circulation. (enterohepatic circulation). A small amount of
4. Bilirubin is conjugated with glucuronic acid to form urobilinogen in circulation escapes clearance by the
bilirubin monoglucuronide and diglucuronide liver and is excreted in urine.
(conjugated bilirubin); this process is mediated by the
enzyme glucuronyl transferase. Conjugated bilirubin INDICATIONS AND LIMITATIONS OF
is more soluble in water. LIVER FUNCTION TESTS
5. Conjugated bilirubin is secreted from the hepatocyte
into the biliary canaliculi, from where it passes into Liver function tests (LFT) are the various laboratory tests
the bile duct and gallbladder along with bile (bilirubin that are used to:
monoglucuronide 25% and bilirubin diglucuronide • Screen for liver disease;
75%). Bilirubin reaches the small intestine via the • Identify the nature of liver disease (hepatocellular,
common bile duct. Bile also contains bile salts, which cholestatic, or infiltrative);
54 Essentials of Clinical Pathology
• Assess severity and prognosis of liver disease; and Table 4.1: Commonly performed liver function tests
• Follow up the course of liver disease
Test Hepatic cause of abnormality
Box 4.1: Limitations of liver function tests
1. Serum alanine Hepatocellular injury
• Do not necessarily assess liver function aminotransferase
• Lack sensitivity (i.e. may be normal in some liver
2. Serum aspartate Hepatocellular injury
diseases like cirrhosis)
aminotransferase
• Lack specificity (i.e. may be abnormal in non-liver
disorders e.g. serum albumin is low in nephrotic 3. Serum alkaline Cholestasis
syndrome and in cirrhosis) phosphatase
4. Serum bilirubin Defective conjugation or excretion
5. Serum albumin Decreased synthesis
The term ‘liver function tests’ is a misnomer since
most of these tests are used for identification of liver CLASSIFICATION OF
disease, its severity, and its type and do not necessarily
LIVER FUNCTION TESTS
assess liver function. Generally these tests, which are
performed in combination, are abnormal in liver disease, Liver function tests can be classified as follows:
and the pattern of abnormality is indicative of the nature 1. Tests that assess excretory function of the liver:
of liver disease. Since liver has a large amount of Bilirubin in serum and urine, and urobilinogen in
urine and feces.
anatomical and functional reserve and capacity for rapid
2. Tests that assess synthetic and metabolic functions
regeneration, functional deficiency becomes apparent if
of the liver: Serum proteins, serum albumin, serum
there is an extensive liver damage. Also, these tests are albumin/globulin (A/G) ratio, prothrombin time
not specific for liver disease (except serum bile acids) and (PT), and blood ammonia level.
are abnormal in various non-hepatic conditions (Boxes 3. Tests that assess hepatic injury (liver enzyme
4.1 and 4.2). Therefore, laboratory tests should be studies): Serum alanine aminotransferase (ALT),
selected and interpreted in the context of clinical serum aspartate aminotransferase (AST), serum
features and other investigations. An isolated alkaline phosphatase, serum γ-glutamyl transferase
abnormality of a single liver function test usually means (GGT), and 5’-nucleotidase (5’-NT).
a non-hepatic cause. If several liver function tests are 4. Tests that assess clearance of exogenous substances
simultaneously abnormal, then hepatic etiology is likely. by the liver: Bromosulphthalein excretion test.
Commonly performed liver function tests are listed
in Table 4.1.
Box 4.2: Non-hepatic causes of abnormal liver Tests that Assess Excretory
function tests Function of the Liver
• Increased serum bilirubin: Jaundice
– Hemolysis
– Ineffective erythropoiesis
Jaundice (from French jaune, meaning yellow) or icterus
– Resorption of a large hematoma refers to yellow discoloration of skin, sclera, and mucous
membranes due to increased level of serum bilirubin.
• Increased aminotransferases:
Jaundice becomes clinically evident when serum
– Muscle injury
– Alcohol abuse
bilirubin level exceeds 2.0 mg/dl.
– Myocardial infarction There are various methods for classification of
jaundice as follows:
• Increased serum alkaline phosphatase:
1. According to the main type of bilirubin increased
– Pregnancy
– Bone disease
in plasma:
• Predominantly unconjugated hyperbilirubinemia:
• Low serum albumin: Indirect or unconjugated bilirubin is > 85% of total;
– Poor nutritional status
causes are hemolysis, resorption of a large
– Proteinuria
– Malabsorption
hematoma, ineffective erythropoiesis, Gilbert’s
– Severe illness causing protein catabolism syndrome, physiologic jaundice of newborn, and
Crigler-Najjar syndrome.
Liver Function Tests 55
• Predominantly conjugated hyperbilirubinemia: and feces. Jaundice is usually mild (serum bilirubin
Direct or conjugated bilirubin is >50% of total; <5.0 mg/dl; conjugated bilirubin is <15% of total).
causes are hepatitis, cirrhosis, cholestasis, drugs The cause can usually be identified by examination
(anabolic steroids, oral contraceptives), toxins, of a stained blood smear and hematological
Dubin-Johnson syndrome, and Rotor syndrome. investigations. In jaundiced newborns, rapidly rising
• Mixed (conjugated + unconjugated) hyperbili- unconjugated bilirubin needs careful management to
rubinemia: Conjugated bilirubin is 20-50% of total; prevent kernicterus.
it results from viral or alcoholic hepatitis. 2. Hepatic jaundice: In hepatic disease, unconjugated,
2. According to etiology: conjugated, or both are increased.
• Hemolytic: The increased rate of red cell destruc- a. Unconjugated hyperbilirubinemia:
tion causes increased haemoglobin breakdown to 1. Defective uptake of bilirubin by liver cells from
bilirubin in reticuloendothelial cells; this exceeds blood: Gilbert’s syndrome is the most common
the capacity of conjugation in liver. cause of unconjugated hyperbilirubinemia,
• Hepatocellular: Inability of hepatocytes to conju- affecting 5% of general population. It is a
gate and/or excrete bilirubin. familial, benign disease with autosomal domi-
• Obstructive: Failure of excretion of conjugated nant mode of inheritance. Raised bilirubin is
bilirubin into the intestine, causing its usually noticed during routine laboratory
regurgitation in circulation.
examination. There is defective uptake by
3. According to site of disease:
hepatocytes and mild deficiency of glucuronyl
• Prehepatic
transferase. Jaundice is mild and fluctuating,
• Hepatic
and may go unnoticed for years. Jaundice
• Posthepatic
becomes noticeable during illness or after
A simple classification is division of jaundice into
fasting. Mildly elevated serum bilirubin is the
three main types: prehepatic, hepatic, and
sole abnormality; other LFTs are normal.
posthepatic. This classification is the basis for
identifying the cause of jaundice (Table 4.2). 2. Defective conjugation of bilirubin:
1. Prehepatic jaundice: There is excessive formation of Crigler-Najjar syndrome: This is of two types.
bilirubin exceeding the capacity of the liver to Type I is characterized by autosomal recessive
conjugate it for excretion. The type of bilirubin mode of inheritance, complete absence of
increased in serum is of unconjugated type. Bilirubin glucuronyl transferase, severe unconjugated
is absent in urine since unconjugated bilirubin is hyperbilirubinemia, and kernicterus (deposition
water-insoluble. Urobilinogen is increased in urine of bilirubin in basal ganglia of brain). Type II is a
Prehepatic jaundice
• Hemolytic anemia
• Ineffective erythropoiesis (megaloblastic anemia, thalassemias)
• Resorption of a large hematoma
Hepatic jaundice
• Predominantly unconjugated hyperbilirubinemia
– Gilbert’s syndrome
– Crigler-Najjar syndrome
– Physiologic jaundice of newborn
• Predominantly conjugated hyperbilirubinemia
– Hepatocellular diseases: viral hepatitis, toxic hepatitis, alcoholic hepatitis, active cirrhosis
– Intrahepatic cholestasis: Dubin-Johnson syndrome, drugs, primary biliary cirrhosis, primary sclerosing
cholangitis, biliary atresia
Posthepatic jaundice
• Carcinoma of head of pancreas
• Carcinoma of ampulla of Vater
• Secondaries in porta hepatis
• Gallstones in or stricture of common bile duct
56 Essentials of Clinical Pathology
less severe disease in which some amount of mation and destruction of both intrahepatic
enzyme activity is present. and extra-hepatic bile ducts. Associated
Physiologic jaundice of newborn: This is a tran- inflammatory bowel disease is often present.
sient increase of unconjugated bilirubin which is Serum alkaline phosphatase is elevated and
observed in almost all newborns. It usually many patients have circulating perinuclear
develops during the 2nd to 4th day after birth antineutrophil cytoplasmic antibodies.
with return to normal bilirubin level by 7th to 3. Posthepatic jaundice: This is also called as
10th day. It is because of deficiency of glucuronyl obstructive jaundice, surgical jaundice, or
transferase leading to impaired conjugation extrahepatic cholestasis.
during the first few days of life. Different sites of cholestasis and causative
b. Conjugated hyperbilirubinemia: disorders are shown in Figure 4.3.
1. Hepatocellular disease: Liver enzymes (aspar- Obstruction of extrahepatic biliary tract
tate aminotransferase and alanine amino- prevents flow of bile into the duodenum. This
transferase) are markedly elevated, and serum causes “regurgitation” of conjugated bilirubin
bilirubin is usually in the range of 4.0 to 8.0 into the circulation. (Biliary canaliculi distend
mg/dl. Conjugated bilirubin is 20-50% of total and rupture due to backpressure of bile and
bilirubin. In hepatocellular injury, both conju- conjugated bilirubin escapes into the
gated and unconjugated bilirubins are increa- sinusoids). Conjugated bilirubin is usually
sed. Unconjugated bilirubin is increased due >50% of total in posthepatic jaundice. Urinary
to reduced ability of liver cells to conjugate and fecal urobilinogen are decreased, faeces are
bilirubin. Conjugated bilirubin is raised from clay-colored, and bilirubin (being conjugated
cholestasis due to hepatocyte swelling. and water-soluble) appears in urine.
2. Intrahepatic cholestasis: In intrahepatic choles- Differences between three main types of jaundice are
tasis, there may be (1) impairment of secretion given in Table 4.3.
of bilirubin from hepatocytes into the biliary Investigation of a case of jaundice is shown in Figure 4.4.
canaliculi; (2) obstruction of bile flow in The tests employed to assess excretory function of
canaliculi by swollen hepatocytes;or (3) liver are serum/urine bilirubin and urine/fecal
damage to intrahepatic canaliculi. urobilinogen.
In Dubin-Johnson syndrome, there is a Serum Bilirubin
defect in the excretion of bilirubin by hepato-
Normal serum bilirubin is less than 1 mg/dl. There are two
cytes, and liver is darkly pigmented due to
types of bilirubin in plasma: unconjugated (indirect-
accumulation of polymerized epinephrine
reacting) and conjugated (direct-reacting) (Box 4.3).
metabolites. Bromosulphthalein excretion test
Normally, conjugated bilirubin is 10% or less, while
is abnormal. In Rotor syndrome, there is impai-
red excretion of bilirubin but without pigmen-
tation of liver; bromosulphthalein test is
normal. Alkaline phosphatase is normal in both
conditions.
Drugs commonly associated with choles-
tatic injury are oral contraceptives, anabolic
steroids, oral anti-diabetics, phenothiazines,
and erythromycin.
In primary biliary cirrhosis, there is auto-
immune destruction of intrahepatic bile ducts.
It predominantly occurs in middle-aged
females and is characterized by chronic eleva-
tion of alkaline phosphatase and positive anti-
mitochondrial antibody in serum. There is an
association with other autoimmune disorders.
Primary sclerosing cholangitis is an auto-
immune disorder occurring in young to
middle-aged men in whom there is inflam- Fig. 4.3: Sites of cholestasis
Liver Function Tests 57
1. Basic mechanism of Hemolysis leading to excess Deficient uptake, Deficient excretion due to
raised bilirubin production conjugation, or obstruction of biliary tract
excretion by hepato-
cytes
2. Type of serum bilirubin Mainly unconjugated Unconjugated + Mainly conjugated (>50%)
increased Conjugated
3. Urine bilirubin Absent Present Present
4. Urine urobilinogen Increased Variable Decreased
5. Prototype Hemolytic anemia Viral hepatitis Common duct stone
6. Prothrombin time Normal Abnormal that is not Abnormal that is corrected
corrected with with vit K
vitamin K
7. Additional features Features of haemolysis on Marked rise of serum Marked rise of serum ALP
blood smear (reticulocytosis, ALT and AST (>3 times normal)
low haptoglobin, low hemoglobin)
Fig. 4.4: Investigation of jaundice. ALT: alanine aminotransferase; AST: aspartate aminotransferase;
ALP: alkaline phosphatase
unconjugated bilirubin is 90% or more. This is because very small amount. In cholestasis, proportion of δ-bili-
conjugated bilirubin is rapidly secreted into the bile after rubin increases. Owing to its longer half-life, it is cleared
its formation and removed through the gut. Conjugated slowly from circulation. Conjugated bilirubin is weakly
bilirubin is composed of blirubin glucuronide, bilirubin bound to albumin, is water-soluble, and can be excreted
diglucuronide, and delta (δ) bilirubin. Delta bilirubin in urine. Unconjugated bilirubin is tightly bound to
represents bilirubin covalently bound to albumin in albumin and is water-insoluble. As bilirubin is altered by
circulation. Normally, δ bilirubin is absent or present in exposure to light, sample should be kept in the dark.
58 Essentials of Clinical Pathology
There are two methods for estimation of serum also contain carotene and other pigments, which absorb
bilirubin: diazo method and spectrophotometry. light at the same wavelength. In newborns, other
In diazo method, total and direct-reacting bilirubin pigments are absent.
are measured, and indirect bilirubin is obtained by
subtracting direct from total bilirubin (Fig. 4.5). Urine Bilirubin and Urobilinogen
Estimation of both types of bilirubin is helpful in the See Chapter 1 “Examination of Urine”.
differential diagnosis of jaundice. In post-hepatic type
of jaundice, direct bilirubin is the predominant form (> Tests which Assess Synthetic and Metabolic
50% of the total). In hepatocellular jaundice, direct Functions of Liver
bilirubin is usually between 20-50% of total. Indirect Markers of hepatic synthetic function are serum albumin
bilirubin predominates in hemolysis, Gilbert’s syndrome, and prothrombin time. Hypoalbuminemia and a pro-
and Crigler-Najjar syndrome (direct bilirubin is < 15% longed prothrombin time indicate severe functional
of total). impairment of liver.
Proteins
Box 4.3: Serum bilirubin
Liver is the sole site for the synthesis of most of the plasma
• Direct bilirubin (Conjugated bilirubin): It reacts
proteins, except gamma globulins which are synthesized
directly with diazo reagent. It consists of mono-
conjugated bilirubin, diconjugated bilirubin, and bilirubin
by plasma cells. Concentration of total serum proteins
tightly bound to albumin (delta bilirubin). in adults is about 5.5 to 8.0 gm/dl, while that of serum
albumin is 3.5 to 5.0 gm/dl. Serum albumin comprises
• Indirect bilirubin (Unconjugated bilirubin): It reacts
about 60% of total serum proteins.
with diazo reagent in the presence of alcohol. It consists
of bilirubin bound to albumin. It is calculated as ‘total Tests for proteins in liver disease include total
bilirubin minus direct bilirubin’. serum proteins, serum albumin, calculation of serum
albumin/globulin ratio (normal ratio is >1.5), and serum
protein electrophoresis.
Direct spectroscopic estimation is used for measurement 1. Total serum proteins: These can be estimated by
of total serum bilirubin in newborns and infants (<3 refractometer method or by biuret method.
months of age). Concentration of serum bilirubin is In refractometer method, refractive index of the
directly proportional to its absorbance in a solution (which depends on solute concentration) is
spectrophotometer at 454 nm. This method cannot be measured. Refractive index varies mainly with concen-
used in older children and adults because their sera may tration of proteins and is affected very little by electrolytes
Liver Function Tests 59
and other molecules. Protein concentration is read 1. In cirrhosis, albumin may be reduced and there may
directly from the scale on the refractometer. In biuret be polyclonal increase of IgG and IgA, with β-γ
method, copper ions react with peptide bonds of proteins bridging. (IgA migrates between β and γ regions which
and form a violet-colored compound. Intensity of this obscures the demarcation between β and γ peaks).
color (measured colorimetrically) is proportional to the 2. In primary biliary cirrhosis, there is polyclonal
concentration of proteins. increase of IgM.
Total serum protein level is affected by both albumin 3. In α1-antitrypsin deficiency (associated with cirrhosis)
and gamma globulins. In cirrhosis, decrease in albumin α1- globulin band is reduced.
level is often compensated by increase in the level of 4. In chronic active hepatitis, IgG is elevated.
gamma globulins; therefore, estimation of total serum
proteins is of limited value in cirrhosis. Estimation of Prothrombin Time (PT)
serum albumin and serum protein electrophoresis are Most of the coagulation proteins are synthesized in the
more helpful. liver. Vitamin K is required for the synthesis of factors
II, VII, IX, and X by the hepatocytes; therefore these
2. Serum albumin: Albumin is synthesized exclusively
factors are called as vitamin K-dependent factors.
in liver and constitutes about 60% of total proteins in
Synthesis of these factors is deficient in hepatocellular
serum; therefore its estimation is an important investi-
disease. In obstructive jaundice, vitamin K (a fat-soluble
gation in liver disease. Half-life of albumin is about 20
vitamin) cannot be absorbed due to the absence of bile
days and therefore fall in its level in response to decreased
in the intestine.
synthesis is not immediately apparent. Therefore, in
PT measures three out of four vitamin K-dependent
acute liver disease (e.g. viral hepatitis), there is little
factors (II, VII, and X) and is prolonged in hepatocellular
change in albumin level. Serum albumin level is low in
disease and in obstructive jaundice. Intramuscular
chronic liver disease (cirrhosis) and correlates with
injection of vitamin K corrects prolonged PT in
synthetic capacity of hepatocytes; therefore, it is helpful
obstructive jaundice but not in hepatocellular jaundice.
in following progression of cirrhosis. Also, fall in serum
In acute fulminant liver failure, marked prolongation
albumin level correlates with severity of ascites. In
of PT is an unfavourable prognostic sign.
cirrhosis and in chronic active hepatitis, serum gamma
globulins are increased due to inflammation. Low To distinguish between a prolonged PT due to hepato-
albumin and raised gamma globulins in serum cause cellular disease from that due to cholestasis with fat
reversal of albumin/globulin ratio. malabsorption, PT is repeated after administration of
Serum albumin is estimated by bromocresol green vitamin K. Reduction of prolonged PT occurs in
method. Bromocresol green is an indicator dye, which cholestatic liver disease, but not in hepatocellular
when added to serum, binds selectively and tightly to disease.
albumin and becomes blue in color. Absorbance (in a
spectrophotometer at 632 nm) is directly proportional to Blood Ammonia
concentration of albumin. Blood ammonia is mainly derived from gastrointestinal
Causes of decreased serum albumin: tract. In the intestine, bacterial enzymes act on nitrogen-
• Decreased intake: malnutrition. containing foods to produce ammonia, which is carried
• Decreased absorption: malabsorption syndromes. to the liver via portal vein. In the liver, ammonia is
• Decreased synthesis: liver disease, chronic infections. converted to non-toxic urea in the urea cycle.
• Increased catabolism: thyrotoxicosis, fever, malig- Increased blood ammonia levels are seen in:
nancy, infections. • Fulminant hepatic failure
• Increased loss: nephrotic syndrome, severe burns, • Cirrhosis
protein-losing enteropathies, ascites • Reye’s syndrome
• Increased blood volume: pregnancy, congestive • “Shunting” of portal blood to systemic circulation
cardiac failure. • Gastrointestinal hemorrhage (there is increased
As low serum albumin occurs in diseases other than production of ammonia from blood proteins by
those of liver, serum albumin is a sensitive but non- bacterial enzymes). In hepatic disease, gastro-
specific test for liver disease. intestinal hemorrhage is associated with increased
3. Serum protein electrophoresis: Details of serum risk of hepatic encephalopathy.
protein electrophoresis are given in Chapter 28 • Inherited deficiencies of urea cycle enzymes.
“Laboratory Tests in Hematological Malignancies”. If raised, estimation of blood ammonia is likely to be
In liver disease, following changes may be seen on helpful in patients with coma of unknown origin, since
protein electrophoresis (Fig. 4.6): it is indicative of hepatic encephalopathy.
60 Essentials of Clinical Pathology
Fig. 4.6: Serum protein electrophoresis patterns and densitometer scans in normal individuals and in
cirrhosis of liver and α1-antitrypsin deficiency
Most marked elevations of ALT and AST (>15 times Serum Alkaline Phosphatase (ALP)
normal) are seen in acute viral hepatitis, toxin-induced
Alkaline phosphatase is distributed widely in various
hepatocellular damage (e.g. carbon tetrachloride), and
tissues like liver, bones, intestine, kidney, and placenta.
centrilobular necrosis due to ischemia (congestive
In the liver, ALP, GGT, and 5’-NT are located normally
cardiac failure).
on canalicular surface of hepatocytes (See Fig. 4.7). In
Moderate elevations (5-15 times) occur in chronic
cholestasis, accumulated bile acids dissolve canalicular
hepatitis, autoimmune hepatitis, alcoholic hepatitis, acute side of hepatocyte membrane and enzymes are released
biliary tract obstruction, and drug-induced hepatitis. in blood. Therefore, diseases that affect mainly
Mild elevations (1-3 times) are seen in cirrhosis, non- hepatocyte secretion have elevated levels of ALP.
alcoholic steatosis, and cholestasis. Measurement of ALP is helpful in differentiation of
Determinations of these enzymes are helpful in the hepatocellular jaundice from cholestatic jaundice
differential diagnosis of hepatocellular from cholestatic (See Fig. 4.8).
jaundice. Increase of AST and ALT is much more in
Causes of increased ALP
hepatocellular jaundice (>500 units/ml) than in choles-
1. Hepatobiliary disease: ALP is increased in most cases
tatic jaundice (<200 units/ml) (Fig. 4.8).
of cholestatic type of jaundice. While hepatocellular
Although determination of any one aminotransferase
injury is characterized by marked elevation of ALT
is adequate, measurement of both can be helpful in the and AST, cholestasis is characterized by marked
calculation of AST/ALT ratio. Normal ratio is 0.7 to 1.4. increase (more than 3 times normal) of ALP. Since
Increased ratio (>2.0) is highly suggestive of alcoholic there are many other sources of ALP apart from liver,
hepatitis, while ratio <1.0 is seen in acute viral hepatitis. simultaneous measurement of serum GGT and
ALT and AST are elevated in acute viral hepatitis serum 5’-NT may be used to ascertain whether
even before the appearance of jaundice. Persistence of increase of ALP is of hepatic origin.
elevated ALT and AST beyond 6 months in a case of Hepatobiliary causes of increased alkaline
hepatitis indicates development of chronic hepatitis. phosphatase are:
In massive liver necrosis, aminotransferase levels • Bile duct obstruction (cancer of head of pancreas,
gradually decrease. Therefore, falling levels do not stone in common bile duct, stricture of bile duct,
necessarily indicate recovery from acute hepatitis. biliary atresia)
Fig. 4.7: Locations of enzymes in liver cell. The enzymes are found in specific locations as follows: Alanine aminotransferase
(ALT): cytosol; Aspartate aminotransferase (AST): mitochondria and cytosol; Lactate dehydrogenase (LDH): cytosol; Alkaline
phosphatase (ALP): canalicular surface; Gamma glutamyl transferase (GGT): canalicular surface and microsomes; 5’ NT:
canalicular surface. The pattern of hepatocyte injury determines the enzymes elevated: cytoplasmic damage: elevated AST,
ALT, and LDH; mitochondrial damage: elevated AST; cholestatic damage: elevated ALP and GGT
62 Essentials of Clinical Pathology
Fig. 4.8: (A) Comparative serum alanine transferase (ALT) levels in liver diseases. Red horizontal line represents upper limit
of normal. (B) Comparison of percentage levels of serum alkaline phosphatase (ALP) in hepatocellular disease and cholestasis.
Red horizontal line represents discriminatory level between hepatocellular disease and cholestasis (i.e. 3 times normal), while
black horizontal line represents upper limit of normal
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Liver Function Tests 63
whether increased ALP is due to liver disease or due to impairment of bile flow that may be intrahepatic or
increased osteoblastic activity in growing children. extrahepatic). History and physical examination findings
should be correlated with liver function tests.
Tests that Assess Clearance of Exogenous
Substances from the Liver Box 4.4: Typical LFT profile in hepatocellular disease
Some synthetic dyes, when introduced into the body, are • Marked elevation of AST and ALT (usually >500 IU)
rapidly removed from the blood stream by the liver and • Mild increase of ALP (<3 times normal)
excreted into the bile. Disappearance of these dyes from • Hyperbilirubinemia, if present, is of both conjugated and
the blood is dependent on adequate hepatic circulation, unconjugated type
normal hepatocyte function, and uninterrupted bile flow.
Dye excretion tests are sensitive tests of liver function Hepatocellular injury may be acute (e.g. acute viral
and are usually indicated in those patients in whom liver hepatitis, toxic hepatitis, ischemic hepatitis, alcoholic
disease is suspected but have little or no jaundice. Three hepatitis) or chronic (cirrhosis, chronic active hepatitis,
synthetic dyes are commonly employed to test liver autoimmune hepatitis). Acute hepatocellular injury is
function: bromosulphthalein (BSP), indocyanine green usually associated with marked elevation of ALT and
(used by surgeons before resecting liver for hepato- AST and mild elevation of alkaline phosphatase (Box 4.4).
cellular cancer) , and Rose Bengal. However, because of In chronic hepatocellular injury, aminotransferases are
the risk of adverse reactions and advent of more sensitive moderately elevated, and serum albumin is reduced.
tests for detection of liver disease, dye excretion tests are Cholestasis is characterized by mild elevation of ALT
nowadays rarely used. and AST and marked increase of ALP and GGT (Box
Bromosulphthalein (BSP) excretion test: After adminis- 4.5). With complete obstruction of bile ducts, both serum
tration, BSP is taken up by the hepatocytes, binds to ALP and serum bilirubin are increased, stools are pale,
ligandin and Z protein, conjugated to glutathione, and and urine contains no urobilinogen. The pattern of
then excreted into the bile. In this test, BSP is injected elevated ALP but normal serum bilirubin is seen in
intravenously, a blood specimen is obtained after a infiltrative diseases. Laboratory abnormalities often
specified time, and the percent of dye retained in blood overlap in cholestatic and infiltrative diseases; imaging
is calculated. If the amount of dye retained in blood is studies (such as ultrasound, CT scan, magnetic resonance
more than 50% at 45 minutes, abnormal liver function is imaging, and cholangiography) and liver biopsy are
present. needed for distinction between them.
BSP excretion test will yield falsely abnormal result
if hepatic circulation is impaired. Also, there is a risk of Box 4.5: Typical LFT profile in cholestatic jaundice
adverse reactions including tissue necrosis and anaphy- • Marked elevation of ALP (>3 times normal)
laxis in a small number of patients. • Elevation of GGT and 5’-NT
BSP test remains useful in the diagnosis of Dubin- • Mild or no increase of ALT and AST (usually <200 IU)
Johnson syndrome and its differentiation from Rotor • Elevation of conjugated bilirubin
syndrome. A higher level of BSP in blood at 2 hours with
normal value at 45 minutes is seen in Dubin-Johnson For specific or etiologic diagnosis of liver disease,
syndrome. In Rotor syndrome, value of BSP is higher at further testing is required:
45 minutes and lower at 2 hours. • Hepatocellular disease: In patients with hepato-
cellular pattern of injury, common investigations to
INTERPRETATION OF detect underlying cause include viral serology (viral
LIVER FUNCTION TESTS hepatitis: IgM anti-hepatitis A antibody, hepatitis
A stepwise approach consists of laboratory tests for: surface B antigen (HBsAg), antihepatitis C antibody),
• Presence of liver disease: History, physical findings, search for injurious drugs, toxins or alcohol,
and liver function tests autoantibodies like antinuclear antibodies and anti-
• Nature of liver disease: whether hepatocellular (cell smooth muscle antibodies (autoimmune hepatitis),
injury) or cholestatic and serum ceruloplasmin (Wilson disease). If cause
• Specific cause of liver disease is not detected in the presence of persistent elevation
• Assessment of severity of liver disease of aminotransferases, liver biopsy is performed (that
Liver diseases can be broadly classified into two types: may reveal chronic viral hepatitis, autoimmune
hepatocellular (primary abnormality is liver cell disorders, Wilson disease, haemochromatosis, and
necrosis), and cholestatic (primary abnormality is infiltrative diseases) (Table 4.4 and Figure 4.9).
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64 Essentials of Clinical Pathology
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Liver Function Tests 65
the biopsy, potential risks of the procedure and benefits TYPES OF LIVER BIOPSY
of histological examination should be assessed and the Currently, several methods are available for obtaining
procedure should be performed only when benefits out liver tissue specimen. Choice of the method depends on
weigh the risks. its availability, clinical situation, and preference of the
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66 Essentials of Clinical Pathology
Grade A (excellent prognosis): Score 5 or 6; Grade B (intermediate prognosis): Score 7 to 9; Grade C (very poor prognosis):
Score ≥ 10.
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Liver Function Tests 67
• Tense ascites: Tense ascites is associated with failure real time imaging of the liver (ultrasonography,
to obtain liver tissue (due to increased distance computed tomography, or magnetic resonance imaging).
between abdominal wall and liver) and risk of This approach is suitable for biopsy of focal lesions.
bleeding in ascites. Biopsy can be performed after
removal of ascitic fluid or through transjugular Percutaneous ‘Plugged’ Liver Biopsy
approach.
In this method, after taking the biopsy sample, the outer
• Hydatid cyst of liver: Puncture of hydatid cyst will
sheath of the needle is left in place and the obturator
lead to spread of cysts throughout the abdomen and
holding the liver biopsy tissue is removed. A cannula is
sometimes, anaphylactic reaction.
then introduced through the outer sheath and gel or gel
• Suspected hemangioma or other highly vascular
foam is injected to seal or ‘plug’ the needle track in the
tumor
liver. This method is said to reduce the risk of bleeding
• Amyloidosis is associated with increased risk of
in individuals with impaired coagulation.
bleeding.
Patients with encephalopathy, hepatic failure with
Transvenous (Transjugular) Liver Biopsy
severe jaundice, severe congestive cardiac failure, and
advanced age are at increased risk of complications Liver biopsy is obtained from within the vascular system
following liver biopsy. of liver. A small catheter is inserted through the jugular
vein in the neck and radiologically guided, via right
Pre-requisites:
atrium and inferior vena cava, into the hepatic vein. The
• Prior imaging of liver should be carried out to identify
biopsy needle is then inserted through the catheter,
any abnormality, to define borders, and to determine
advanced into the liver, and biopsy is taken.
relative positions of gallbladder, lungs, and kidneys.
This method is suitable in severe coagulation
• Routine hemogram
disorders and in massive ascites. Due to the risk of cardiac
• Coagulation profile
arrhythmias (as the catheter passes through the atrium),
• Informed consent
close cardiac monitoring is required during this
• Blood grouping and cross matching
procedure.
Method:
1. Patient lies in supine position. Laparoscopic Liver Biopsy
2. After selecting the site for liver biopsy, a local
A laparoscope is introduced through an incision in the
anesthetic is injected.
abdominal wall, and liver biopsy is obtained under direct
3. A small incision is made and the biopsy needle is
visualization. Usually, such a biopsy is taken when a focal
passed into the liver. Patient is asked to hold his/her
lesion is incidentally detected on diagnostic laparoscopy
breath in expiration. Method of obtaining liver tissue
of abdomen.
depends on the type of needle used.
4. After needle is removed, patient lies supine or on the
right side and is closely monitored especially during
REFERENCE RANGES
first 6 hours for early detection of complications. Serum alanine aminotransferase (ALT, SGPT): 5-42 U/L
Complications: Serum aspartate aminotransferase (AST, SGOT): 5-40 U/L
1. Pain Serum alkaline phosphatase (ALP):
2. Intraperitoneal hemorrhage: Patients at particular • Children: 25-350 U/L
risk of bleeding are those with cirrhosis and malig- • Adult males: 25-120 U/L
nancy in liver. These patients should not be biopsied • Adult females: 25-90 U/L
on outpatient basis. AST/ALT ratio: 0.7-1.4
3. Biliary peritonitis due to puncture of gallbladder. Serum bilirubin:
4. Puncture of other organs like kidney, lung, and colon. • Total: 0.3-1.0 mg/dl
Overall mortality following liver biopsy is reported • Direct (Conjugated): 0-0.2 mg/dl
to be 0.1%. Serum proteins, total: 5.5-8.0 gm/dl
Serum albumin: 3.5-5.0 gm/dl
Percutaneous Guided Liver Biopsy
Serum globulins: 1.8-3.5 gm/dl
In percutaneous guided liver biopsy, needle is inserted
into the liver through the abdomen or lower chest during Albumin/Globulin (A/G) ratio: >1.5
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68 Essentials of Clinical Pathology
Serum protein electrophoresis: 6. Dufour DR, Lott JA, Nolte FS, Gretch DR, Koff RS, Seeff
Albumin 52-65% LB. Diagnosis and monitoring of hepatic injury. II.
α1 globulin: 2.5-5% Recommendations for use of laboratory tests in
α2 globulin: 7-13% screening, diagnosis, and monitoring. Clin Chem 2000;
β globulin: 8-14% 46:2050-68.
γ globulin: 12-22% 7. Dufour DR, Lott JA, Nolte FS, Gretch DR, Koff RS, Seeff
LB. Diagnosis and monitoring of hepatic injury. I.
Prothrombin time: 11-15 seconds Performance characteristics of laboratory tests. Clin
Chem 2000;46:2027-49.
Plasma ammonia: 9-33 μmol/L
8. Gaw A, Murphy MJ, Cowan RA, O’Reilly DSJ, Stewart
Serum gammaglutamyl transferase: MJ, Shepherd J. Clinical Biochemistry. An Illustrated
• Males: Up to 40 U/L Colour Text, 3rd Ed. Edinburgh. Churchill Livingstone.
• Females: Up to 25 U/L 2004.
9. Grant A, Neuberger J. Guidelines on the use of liver
CRITICAL VALUES biopsy in clinical practice. Gut 1999; 45 (Suppl IV):
IV1-IV11.
Plasma ammonia: >40 μmol/L 10. Johnston DE. Special considerations in interpreting liver
function tests. Am Fam Physician 1999;59:2223-30.
Serum bilirubin: >15 mg/dl in newborns 11. Limdi JK, Hyde GM. Evaluation of abnormal liver
function tests. Postgrad Med J 2003;79;307-12.
BIBLIOGRAPHY 12. Lucey MR, Brown KA, Everson GT, et al. Minimal
criteria for placement of adults on the liver transplant
1. American Gastroenterological Association Clinical
waiting list; a report of a national conference organized
Practice Committee: AGA technical review on liver
by the American Society of Transplant Physicians and
chemistry tests. Gastroenterology 2002;123:1367-84.
2. American Gastroenterological Association Medical the American Association for the Study of Liver
Position Statement: Evaluation of liver chemistry tests. Disease. Liver Transpl Surg 1997;3:628-37.
Gastroenterology 2002;123:1364-6 13. Pugh RN, Murray-Lyon IM, Dawson JL, et al.
3. Beckingham IJ, Ryder SD. Investigation of liver and Transection of the oesophagus for bleeding oesopha-
biliary disease. BMJ 2001;322:33-6. geal varices. Br J Surg 1973;60:646-9.
4. Black ER. Diagnostic strategies and test algorithms in 14. Roche SP, Kobos R. Jaundice in the adult patient. Am
liver disease. Clin Chem 1997;43:1555-60. Fam Physician 2003;69:299-304.
5. Burke MD. Liver function: test selection and interpreta- 15. Thapa BR, Walia A. Liver function tests and their
tion of results. Clin Lab Med 2002;22:377-90. interpretation. Indian J Pediatr 2007;74:663-71.
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5
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70 Essentials of Clinical Pathology
2. Very low density Triglycerides, Secreted by liver Transport of endogenous triglycerides to adipose
lipoprotein Cholesterol tissue and muscle from liver
3. Low density Cholesterol Formed from modification Transport of cholesterol from liver to peripheral
lipoprotein of VLDL by lipoprotein tissues
lipase in peripheral
tissues
4. High density Cholesterol Secreted from liver “Reverse cholesterol transport”, i.e. from peripheral
lipoprotein tissues to liver
chylomicrons consists mainly of triglycerides, some cholesterol. It carries most of the endogenous
cholesterol and fat-soluble vitamins. Intestinal cells triglyceride from liver to adipose tissue and muscle.
secrete chylomicrons into the lymphatics, which then Triglyceride is removed by the action of lipoprotein lipase
enter the bloodstream via the thoracic duct. In circulation, in the circulation and VLDL particle becomes smaller,
chylomicrons are acted upon by lipoprotein lipase to when it is called as intermediate density lipoprotein
release triglycerides; further hydrolysis of triglycerides (IDL). Further processing of IDL leads to the formation
by lipoprotein lipase causes release of free fatty acids that of low-density lipoprotein (LDL), which is the major
are then taken up by adipose tissue and muscle. Liver
carrier for cholesterol.
takes up the cholesterol-rich chylomicron remnant
particle and cholesterol enters the metabolic pathway. Intermediate density lipoprotein (IDL): This is the
Very low-density lipoproteins (VLDL): VLDL particle remnant of VLDL formed when triglycerides are
is synthesized by the liver. It transports triglycerides and removed from VLDL by lipoprotein lipase in circulation.
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Disorders of Lipids and Biochemical Cardiac Markers 71
About half of IDL is cleared from blood by the liver and cholesterol esters and incorporate them into the core of
the remaining half is further processed to form LDL. the chylomicrons. Chylomicrons are secreted into the
Normally, IDL is not detected in plasma as it is formed lymphatics from where they reach the bloodstream via
transiently. thoracic duct. In the circulation, endothelial-bound
lipoprotein lipase hydrolyzes triglycerides in the
Low-density lipoprotein (LDL): LDL is the major carrier chylomicron core and releases free fatty acids that are
lipoprotein for cholesterol from liver to the peripheral then taken up by the adipose tissue and muscle; in these
tissues. It is formed from VLDL. LDL plays a major role the free fatty acids are converted to triglycerides and
in the genesis of atherosclerosis. stored. The remaining smaller chylomicron is taken by
LDL is taken up by the cells through the LDL receptor, the liver, degraded, and cholesterol contained therein is
a glycoprotein. The LDL receptor is present on the surface then used for the formation of bile acids, incorporated
of all cells and recognizes apolipoprotein B on the surface into cell membranes, secreted in blood as lipoprotein
of LDL particle. After internalization of LDL particle, the cholesterol, or excreted in bile (Fig. 5.3).
lipoprotein is catabolized and the receptor is recycled
back to the cell surface. Intracellularly, LDL is degraded Endogenous pathway: This pathway is divided into:
to free cholesterol that is needed for cellular needs. The • Apo B-100 lipoprotein system
level of LDL in circulation is determined by number and • Apo A-I lipoprotein system
function of LDL receptors. Joseph Goldstein and Michael Apo B-100 lipoprotein system: In the liver, triglycerides and
Brown were awarded the Nobel Prize for Physiology or cholesterol are assembled with apo B-100 and
Medicine in 1985 for characterizing the LDL receptor. phospholipids to produce VLDL. VLDL represents the
Genetic absence of LDL receptors leads to familial hyper- major export pathway for cholesterol from liver. After
cholesterolemia. its secretion from the liver, lipoprotein lipase on capillary
High-density lipoprotein (HDL): HDL binds to endothelium hydrolyzes triglyceride in the core of the
peripheral tissues that have apolipoprotein A receptors VLDL particles resulting in the formation of (cholesterol
and takes up cholesterol. HDL cholesterol is either taken ester-rich) intermediate density lipoproteins (IDL).
by the liver or is incorporated into IDL to form LDL. Further degradation results in the formation of LDL
particles that are rich in cholesterol ester. LDL particles
Lipoprotein (a) or Lp (a): Attachment of apolipoprotein
are taken up by all nucleated cells through LDL receptors
(a) molecule to apolipoprotein B molecule on the surface
(receptor- mediated endocytosis) or by other scavenger
of LDL particle leads to the formation of a new particle
routes (e.g. monocytes or foam cell in atheromatous
called as lipoprotein (a). Excess Lp (a) is associated with plaques).
risk of atherosclerosis.
Apo A-I lipoprotein system: High-density lipoprotein
Lipoprotein Metabolism (HDL) particles are synthesized by liver and intestine
and participate in reverse cholesterol transport. HDL, rich
There are two pathways of lipoprotein metabolism:
in apo A-I, acquires free cholesterol from peripheral
exogenous and endogenous.
tissues, esterifies it, and either transfers it directly to the
Exogenous pathway: Small intestinal cells absorb fatty liver or to other lipoproteins (IDL and LDL), which then
acids and cholesterol, esterify them into triglycerides and transport it to liver (Fig. 5.4).
Fig. 5.3: Exogenous lipid pathway showing route of metabolism of lipid absorbed from the intestine
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72 Essentials of Clinical Pathology
Fig. 5.4: Endogenous lipid pathway showing route of metabolism of endogenously synthesized lipid Abbreviations: VLDL:
very low density lipoprotein; IDL: intermediate density lipoprotein; LDL: Low density lipoprotein; HDL: high density lipoprotein;
LCAT: lecithin-cholesterol acyltransferase
In routine clinical practice lipid abnormalities are identified by standard lipid assays.
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Disorders of Lipids and Biochemical Cardiac Markers 73
Table 5.3: Guidelines of National Cholesterol Education Program Adult treatment Panel III (All values in mg/dl)
Primary Secondary
Primary Secondary
VLDL level can be derived from serum triglyceride measured directly or can be derived from Friedewald’s
level by the formula: equation as follows:
LDL cholesterol = Total cholesterol – (HDL cholesterol – VLDL)
Triglycerides
VLDL = Triglycerides
5 and VLDL =
5
(3) HDL-cholesterol: HDL contains 20-30% of total
Identification of cause of dyslipidemia: After the
serum cholesterol. Low HDL-cholesterol is a significant
risk factor for coronary artery disease even if total presence of dyslipidemia is established, it is necessary
to determine whether it is primary or secondary on the
cholesterol level is normal. HDL is involved in “reverse
basis of clinical features, family history, and laboratory
cholesterol transport” (i.e. from peripheral tissues to the
studies. Initially, the secondary causes should be ruled
liver where it is excreted in bile) and thus decreases
out. Laboratory studies for identification of the secondary
cholesterol accumulated in blood vessel walls. Therefore,
nature of the disorder are blood glucose (diabetes
it is called as cardioprotective cholesterol. Concentration
of HDL-cholesterol is inversely related with the risk of mellitus), liver function tests (biliary cirrhosis), thyroid
function tests, and plasma and urine albumin (nephrotic
atherosclerotic coronary artery disease. HDL-cholesterol
syndrome).
<40 mg/dl is an important risk factor for coronary artery
disease (positive risk factor), while level >60 mg/dl is
BIOCHEMICAL CARDIAC MARKERS
cardioprotective (negative risk factor).
(4) LDL-cholesterol: LDL contains about 60% of total Acute Coronary Syndrome
serum cholesterol. High LDL-cholesterol is a strong risk The term acute coronary syndrome comprises of condi-
factor for atherosclerotic heart disease, and is the major tions characterized by acute myocardial ischemia and
atherogenic lipoprotein. It is the primary lipoprotein that includes (i) unstable angina, (ii) non-ST segment
mediates atherosclerotic heart disease, and is the primary elevation myocardial infarction (NSTEMI) and (iii) ST
target of lipid-lowering therapy. High LDL levels are segment elevation myocardial infarction (STEMI)
associated with obesity, high carbohydrate intake, (Table 5.6). The basic pathogenetic mechanism is
diabetes mellitus, lack of exercise, smoking, and some atherosclerosis of a coronary artery; acute coronary
drugs. Intensive therapy to lower LDL cholesterol slows syndrome results from rupture or erosion of an athero-
the progression of atherosclerosis, reduces coronary matous plaque with subsequent superimposition of
events, and decreases mortality. LDL-cholesterol can be thrombosis (Fig. 5.7). Clinical presentation is decided by
Disorders of Lipids and Biochemical Cardiac Markers 75
1. Clinical features Three main presentations: Similar to UA or STEMI Pain similar to angina but more severe
1. New angina of severe onset, and persistent; not completely relieved
2. Angina at rest, or by rest or nitroglycerin; nausea, sense
3. Recent increase in frequency, of apprehension, and sweating;
duration and severity of angina asymptomatic in 25%
2. ECG ST depression and/or T wave ST depression and/or ST segment elevation followed by
inversion OR Normal T wave inversion OR appearance of Q wave and T
Normal wave inversion
3. Biomarkers of Not raised Raised Raised
myocardial
injury in blood
Fig. 5.7: Pathogenesis and classification of acute coronary syndrome. Acute coronary syndrome
results from acute reduction of myocardial blood supply due to disruption of atheromatous plaque
the degree of ischemia, amount of collateral circulation, The term acute coronary syndrome is coined to
myocardial oxygen demand, and certain other patient- distinguish between chronic stable angina from unstable
specific determinants. As the condition is life-threatening, angina and acute myocardial infarction.
early recognition of acute coronary syndrome is essential Majority of patients with acute coronary syndrome
so that proper and timely treatment can be instituted. have prior history of effort angina or coronary artery
The essential parameters for diagnosis are clinical disease. The usual clinical manifestation of myocardial
features, electrocardiographic changes, and detection of ischemia is chest pain. The pain is typically located in
biochemical markers released in blood from myocardial centre or left side of chest, and variously described as
damage. pressure, squeezing, constriction, crushing, tightness or
76 Essentials of Clinical Pathology
Fig. 5.9: (1) Normal electrocardiogram pattern; (2) to (6): Sequential electrocardiographic changes after acute myocardial
infarction. Initially T wave becomes tall, peaked, and pointed (first few minutes) and there is ST segment elevation. T wave
inversion occurs after a few hours and there is development of an abnormal Q wave. After some duration, ST segment returns
to normal and T wave becomes normal. Q wave changes, however, persist.
Disorders of Lipids and Biochemical Cardiac Markers 77
Table 5.8: Timeline of cardiac markers after acute MB is the most cardiac-specific CK isoenzyme, and it is
myocardial infarction recommended to measure CK-MB mass.
Markers Time for Peak Return to Total serum CK and CK-MB are always elevated
detection normal following MI. However, serum CK and CK-MB can arise
from tissues other than heart. Following MI, CK-MB rises
Myoglobin 1-3 hr 6-9 hr 1 day within 3-6 hours after the onset of symptoms, peaks
CK-MB 3-6 hr 12-24 hr 2-3 days within 12-24 hours, and returns to normal level by 48-72
hours.
Troponin 4-8 hr 12-24 hr 5-10 days
Relative index or RI ([CK-MB/total CK × 100) is used
to distinguish cardiac from skeletal muscle damage; RI
Role of biochemical cardiac markers in acute coronary above 5% is highly suggestive of acute myocardial
syndrome: infarction.
• To confirm or exclude the diagnosis of acute It is recommended to obtain sequential samples (one
myocardial infarction in cases with sudden onset of at presentation and subsequently at 8-hour intervals for
chest pain: In the presence of typical history and ECG 24 hours).
findings consistent with acute MI, measurement of Myoglobin: Myoglobin is the oxygen-binding low
biochemical markers does not provide additional molecular weight protein of cardiac and skeletal muscle
information for initial management. These patients cells. Myoglobin rises early after MI (1-3 hours) and is
need urgent treatment in the form of thrombolytic currently the earliest marker. Myoglobin of cardiac
therapy or angioplasty or both. If diagnosis is muscle cannot be distinguished from that of skeletal
uncertain from clinical features and ECG in an muscle. Myoglobin levels are raised following MI, open
emergency setting, biochemical markers are helpful
heart surgery, muscle injury, muscle dystrophy, renal
in ruling out myocardial infarction.
failure, shock, and trauma. Thus, although myoglobin
Serial determinations (at admission, 6-9 hours, and
rises early following MI, it is not cardiac-specific.
12-24 hours) are recommended to rule in or rule out
diagnosis of acute myocardial infarction. Use of CK-MB However, non-elevation of myoglobin (in two sequential
(mass) and cardiac troponin is recommended for samples 2-4 hours apart) is helpful for exclusion of early
diagnosis. MI in patients presenting with chest pain at emergency
• Detection of old (by some days) myocardial infarction department.
by cardiac troponin
Troponins (Tn): Cardiac troponin T (cTnT) and cardiac
• Diagnosis of reinfarction (CK-MB mass assay)
troponin I (cTnI) are the most sensitive and specific of
• To assess effectiveness of immediate reperfusion
the available markers of myocardial necrosis and are
therapy (thrombolysis or percutaneous coronary
intervention) in STEMI. considered ideal markers for definitive diagnosis (either
• Risk stratification to determine the likelihood of acute cTnT or cTnI). Troponins regulate the interaction of actin
coronary syndrome and myosin filaments during myocardial contraction.
Following MI, troponins appear in blood at about the
Creatine kinase: Highest activity of CK is present in
same time as CK-MB. If troponins are elevated atleast 12
striated muscle, brain, and heart.
or more hours following onset of chest pain, their
Causes of increased CK are as follows: diagnostic sensitivity is 100%. TnI is more cardio-specific
• Disorders of skeletal muscle: Trauma, intramuscular as it is found only in heart muscle. It is not elevated
injection, vigorous exercise, dermatomyositis, mus-
following skeletal muscle injury. Following myocardial
cular dystrophy
damage, TnI rises 4-8 hours the onset of chest pain, peaks
• Disorders of heart: Myocardial infarction, myocarditis
• Disorders of central nervous sytem: Cerebrovascular within 12-24 hours, and remains elevated for 7-10 days.
accident, head injury, generalized convulsions Development of assays for TnI and TnT represent a major
• Disorders of thyroid: Hypothyroidism advance in the diagnosis of MI. As troponins remain
CK-BB, CK-MB, and CK-MM are the isoenzymes of elevated for 7-10 days, they are useful in cases presenting
CK. CK-BB predominates in brain, CK-MB in cardiac late. If onset of chest pain is 9-12 hours before admission,
muscle, while CK-MM in skeletal muscle and heart. CK- only troponin needs to be measured.
Disorders of Lipids and Biochemical Cardiac Markers 79
REFERENCE RANGES 2. Bock JL. Test strategies for the detection of myocardial
damage. Clin Lab Med 2002;22:357-75.
• Lipid profile: 3. Crook MA. Clinical chemistry and metabolic medicine
– Serum cholesterol: Desirable level: <200 mg/dl 7th Ed. London. Edward Arnold (Publishers) Ltd. 2006.
– Serum triglycerides: Desirable level: <150 mg/ 4. Eaton CB. Hyperlipidemia. Prim Care Clin Office Pract
2005;32:1027-55.
dl
5. Executive Summary of The Third Report of The
– HDL cholesterol: >60 mg/dl
National Cholesterol Education Program (NCEP).
– LDL cholesterol: <130 mg/dl Expert Panel on Detection, Evaluation, and Treatment
– LDL/HDL ratio: 0.5-3.0 of High Blood Cholesterol in Adults (Adult Treatment
• Biochemical cardiac markers: Panel III). JAMA 2001;285:2486-97.
– CK-MB: <5% or <10 μg/L 6. Koolman J, Roehm KH. Color Atlas of Biochemistry,
– Cardiac Troponin T: <0.1 μg/L 2nd Ed. Stuttgart. Thieme 2005.
– Myoglobin: < 90 μg/L 7. McDermott MT. Endocrine secrets. 4th Ed.
Philadelphia: Mosby, 2005.
8. Senger AK, Jaffe AS. The use of biomarkers for the
CRITICAL VALUES evaluation and treatment of patients with acute
• CK-MB: >5% or >10 μg/L coronary syndromes. Med Clin N Am 2007;91:657-81.
9. The Joint European Society of Cardiology/American
• Cardiac Troponin T: >0.1 μg/L
College of Cardiology Committee: Myocardial infarc-
• Myoglobin: >110 μg/L tion redefined-A consensus document of The Joint
European Society of Cardiology/American College of
BIBLIOGRAPHY Cardiology Committee for the redefinition of myo-
1. Achar SA, Kundu S, NorcrossWA. Diagnosis of acute cardial infarction. Eur Heart J 2000;21:1502-13.
coronary syndrome. Am Fam Physician 2005;72: 10. Tiyyagura SR, Smith DA. Standard lipid profile. Clin
119-26. Lab Med 2006;26:707-32.
80 Essentials of Clinical Pathology
6
Examination of
Cerebrospinal Fluid
Cerebrospinal fluid (CSF) is a clear, colorless fluid formed • Chloride: 120-130 mEq/L (20 mEq/L more than
in the ventricles of the brain mainly by choroid plexus serum level)
(meshwork of tiny small blood vessels in lateral third • Bilirubin: Absent.
and fourth ventricles). It is mainly an ultrafiltrate of
plasma. CSF is contained within the cerebral ventricles, FUNCTIONS OF CEREBROSPINAL FLUID
the spinal canal and the subarachnoid space (space
between arachnoid externally and pia mater internally) 1. Protection of brain and spinal cord from injury by
surrounding the brain and spinal cord (Fig. 6.1). CSF is acting as a shock absorber.
reabsorbed into the blood through the arachnoid villi of 2. To serve as a medium between blood and brain for
dural venous sinuses. supply of nutrients to and removal of waste products
from brain.
COMPOSITION OF NORMAL COLLECTION OF CEREBROSPINAL FLUID
CEREBROSPINAL FLUID IN ADULTS
Some diseases produce characteristic alterations in
• Total volume: 100-150 ml (10-60 ml in the newborn) composition of CSF, thus providing the basis for
• Opening pressure: 60-180 mm of water (10-100 mm examination of CSF. Lumbar puncture or LP (first
in infants and young children) performed by Quincke in 1891) is the procedure whereby
• Appearance: Clear and colorless with no clots a sample of CSF is obtained. Spinal or LP needle is passed
(viscosity similar to water) between 3rd and 4th or between 4th and 5th lumbar
• Cells: vertebra (L3-L4 or L4-L5) and CSF is obtained from the
– Adults: 0-5 cells/cmm subarachnoid space (Fig. 6.2). LP is carried out at these
– Infants: 0-30 cells/cmm
– 1-4 years: 0-20 cells/cmm
– 5-18 years: 0-10 cells/cmm
• Glucose: 45-80 mg/dl. (Normally CSF glucose is 60%
or 2/3rds of blood glucose)
• Proteins: 15-45 mg/dl. (Normally CSF proteins are
1% of plasma proteins).
• Oligoclonal bands: Negative
it can precipitate herniation of brain. There is a direct tumor, subdural hematoma, epidural abscess): These
correlation between CSF pressure and pressure in patients usually have headache, altered pupillary
jugular vein (because of continuity with dural venous response, absent Doll's eye reflex, abnormal
sinuses in which arachnoid villi project). In
respiratory pattern, papilledema, bradycardia,
Queckenstedt's test, both jugular veins are
hypertension, and decerebrate or decorticate
compressed and then released, and subsequent
changes in CSF pressure are observed. Normally, posturing. Lumbar puncture in such cases can lead
upon compression of jugular veins, CSF pressure to herniation of brain. If a mass lesion is clinically
rapidly rises and with the release of pressure on suspected, cranial computerized tomography (CT) or
jugular veins, CSF pressure rapidly falls. In the magnetic resonance imaging (MRI) should be
presence of a spinal block, there is no rise of CSF obtained first.
pressure with jugular vein compression (or a pressure 2. Cardiorespiratory compromise
rise is low or delayed). This test is positive in about
3. Bleeding diathesis that has not been corrected
80% of patients with cord compression. With the
4. Local infection at the site of lumbar puncture
advent of myelography, Queckenstedt's test is rarely
performed. LABORATORY EXAMINATION OF
Box 6.1: Indications for emergency lumbar puncture CEREBROSPINAL FLUID
• Suspected meningitis After collection, specimen of CSF should be transported
• Suspected subarachnoid hemorrhage immediately to the laboratory and examined without
• Suspected meningeal involvement by leukemia delay. This is because (i) cells disintegrate rapidly, and
(ii) reduction of glucose level occurs due to glycolysis.
COMPLICATIONS OF LUMBAR PUNCTURE At the latest, CSF should be examined within 1 hour of
1. Post-puncture headache: This is the most common collection, and CSF cell counts are always done within
side effect and results from leakage of CSF from 30-60 minutes of collection. Glass tubes should not be
puncture site at a rate faster than the rate of CSF used for collection since cell adherence to glass reduces
production. With the use of a large bore needle, the cell count. Specimen for bacterial culture should not
greater CSF leak occurs. Use of a smaller bore needle be refrigerated as fastidious organisms (Hemophilus
(22 G) for LP and keeping the patient flat after the influenzae, Neisseria meningitidis) do not survive in the cold
procedure for 2-3 hours reduces the risk of headache. temperature.
2. Introduction of infection in spinal canal if aseptic CSF chemical examination results should always be
precautions are not observed, if septicemia is present, compared with those in plasma since any change in
or if infection is present at the site of LP. plasma is reflected in CSF.
3. Subdural hematoma with resultant neurologic deficit
Examination of CSF includes:
in patients with bleeding diathesis.
1. Opening pressure
4. Failure to obtain CSF (dry tap) which may be due to
the incorrect positioning of the patient or spinal block. 2. Appearance
5. Herniation of brain through tentorium (uncus of 3. Total and differential cell counts
temporal lobe) or foramen magnum (cerebellar 4. Chemical examination
tonsils), if intracranial pressure is high. This can 5. Microbiological examination
damage the brainstem. This risk has led to the 6. Special investigations
reduced use of lumbar puncture over the last few
years. 1. Opening Pressure
6. Subarachnoidal epidermal cyst (due to traumatic After attaching the manometer to the hub of the spinal
implantation of a skin plug in subarachnoid space) needle, patient's legs should be gently extended and neck
may develop after a few years if LP is preformed returned to neutral position. The CSF pressure is then
without a stylet. measured. CSF pressure is directly related to jugular and
vertebral venous pressures. Patient should be relaxed
CONTRAINDICATIONS TO LUMBAR PUNCTURE since tension, straining, or breath-holding will increase
1. Raised intracranial pressure due to a space- the CSF pressure, while hyperventilation will lower the
occupying lesion (e.g. brain abscess, posterior fossa opening pressure.
Examination of Cerebrospinal Fluid 83
Table 6.1: Differences between traumatic lumbar puncture and subarachnoid hemorrhage
1. Gross appearance Blood more in initial tubes as Blood uniform in all tubes; Blood does not
compared to later tubes; clot on standing
Blood clots on standing.
2. Supernatant after centrifugation Clear Pink or yellow (xanthochromia); yellow
within 1 hour of collection xanthochromia develops 12 hours after
hemorrhage
3. Microscopy Progressive decrease of red cell Red cell counts uniform in all tubes;
counts in later tubes Hemosiderin-laden macrophages
present
4. Latex agglutination test for Negative Positive
D-dimer*
5. Cerebrospinal fluid pressure Normal Increased
6. Cerebrospinal fluid protein Normal Increased
leucocyte count by 1 WBC per 1000 red cells. This 4. Chemical Examination of Cerebrospinal Fluid
correction factor should be used if patient's hemogram
is normal. If significant anemia or leukocytosis is present, Routine chemical examination of CSF consists of estima-
then leukocyte count in CSF should be corrected as tion of proteins and glucose. CSF from tube 1 is used for
follows: chemical examination.
Corrected WBC count in CSF = (1) Estimation of proteins in CSF: Normal CSF protein
WBC count in blood × level in adults is 15-45 mg/dl. An increase in CSF protein
Red cell count in CSF is a sensitive but non-specific indicator of CNS disease.
WBC count in CSF (cells/cmm) –
Red cell count in blood CSF proteins may be normal during early stages of
(2) Differential leukocyte count: This provides informa- meningitis. Significant elevation (>150 mg/dl) occurs in
tion about relative proportion of various leukocytes. bacterial meningitis.
1. Meningitis: bacterial, 1. Meningitis: viral, tuberculous 1. Tuberculous meningitis 1. Parasitic and fungal
early viral, fungal, 2. Incompletely treated bacterial 2. Fungal meningitis infections
early tuberculous meningitis 3. Chronic bacterial 2. Reaction to foreign
2. Subarachnoid hemorrhage 3. Cysticercosis, toxoplasmosis meningitis material (e.g. shunts)
3. Repeated lumbar punctures 4. Multiple sclerosis
4. Introduction of anticancer 5. Subacute sclerosing
drugs or contrast media in panencephalitis
subarachnoid space
5. Meningeal metastasis
86 Essentials of Clinical Pathology
CSF/Serum albumin ratio CSF/Serum IgG ratio CSF IgG/Albumin index Causes
Fig. 6.9: Gram stained smears of CSF showing (1) Neisseria meningitidis,
(2) Streptococcus pneumoniae, and (3) Haemophilus influenzae
88 Essentials of Clinical Pathology
Note: No single criterion is adequate for differentiation. Test combinations are more sensitive and accurate
Examination of Pleural Fluid • Pleural fluid LDH above 2/3rds of upper limit of
normal for serum LDH.
This consists of:
Exudates have at least one of the above criteria.
• Appearance
Presence of all the three criteria best differentiates an
• Chemical examination exudate from a transudate. Transudates have none of
• Cell counts these criteria. If the fluid is an exudate, further
• Microbiological examination investigations are indicated like cell counts, estimation
• Cytological examination. of glucose, cytological examination, test for tuberculosis,
1. Appearance: Transudates are clear, pale yellow, or Gram smear, and culture. In case of transudates,
straw-colored and do not clot on standing. Exudates are diagnostic considerations include congestive cardiac
opaque or turbid due to increased proteins, leukocytes, failure, cirrhosis, and pulmonary embolism (Fig. 7.2).
or presence of malignant cells, and often clot on standing Low glucose levels are found in empyema,
due to high fibrinogen content. Frank pus with putrid rheumatoid pleurisy, tuberculous pleurisy, and
odor indicates empyema. malignant effusion.
Straw-colored transudative fluid occurs in congestive There is a direct correlation between lactate dehydro-
cardiac failure, pulmonary embolism, and cirrhosis of genase levels in pleural fluid with degree of pleural
liver. inflammation.
Thick exudative fluid occurs in pneumonia and 3. Cell counts: Total leukocyte count should routinely
cancer. be obtained on all fluids. In transudates, leukocytes are
Bloody or hemorrhagic fluid indicates traumatic tap, <1000/ml and are mostly small, mature lymphocytes.
pulmonary infarction, or malignancy. Hemorrhage in Predominance of neutrophils (>50%) indicates an
pleural space is referred to as hemothorax. A traumatic acute process (e.g. parapneumonic effusion, pulmonary
tap progressively becomes less bloodstained during infarct), while predominance of lymphocytes indicates
removal of pleural fluid. a chronic process (e.g. tuberculosis, rheumatoid pleurisy,
Accumulation of a milky or chylous pleural fluid is malignancy).
referred to as chylothorax. True chylous effusion results Very high leukocyte count (>50,000/ml) with
from obstruction of lymphatic duct (due to injury, predominance of neutrophils suggests parapneumonic
effusion (usually empyema). Presence of many small,
carcinoma, or lymphoma). A characteristic feature of
mature lymphocytes with only a few or no mesothelial
chylous effusion is triglyceride level >110 mg/dl.
cells is suggestive of tuberculosis.
Microscopy of such fluid shows lymphocytosis and fat
Blood-tinged pleural fluid is not diagnostic of any
droplets that stain with Sudan III. Following
condition and can occur in a transudate or an exudate.
centrifugation of a chylous fluid, a layer of creamy
Grossly hemorrhagic pleural fluids have red cells above
chylomicrons forms at the top. A pseudochylous effusion 100,000/ml and are seen in pulmonary infarction,
results from long-standing chronic pleural effusion malignancy, or traumatic tap. Traumatic bloody effusion
through breakdown of cellular lipids (tuberculous or is suggested by gradual clearing with aspiration, clotting
rheumatoid effusion). It has a bright, shiny appearance, of fluid after some time, and lack of hemosiderin-laden
and microscopic examination shows mixed cellularity macrophages.
and cholesterol crystals. Triglyceride level is ≤50 mg/dl
4. Microbiological examination: Gram’s smear and
and chylomicrons are absent.
culture should be carried out on exudates, especially on
A foul smelling pleural fluid may indicate a possible
purulent, bloodstained, or cloudy samples. The
anerobic infection, while urinous (ammoniacal) odor
likelihood of isolation of organisms is increased if pleural
indicates possible urinothorax.
fluid is inoculated in blood culture bottles at the bedside.
In mesothelioma, pleural fluid is viscous. Ziehl-Neelsen stained smear is positive in <20% of
2. Chemical examination: If old criteria are used for tuberculous pleural effusions and culture in <40% of
differentiation of exudates and transudates (like protein cases. If tuberculosis is suspected and culture is negative,
level, specific gravity, cell count, and clots in sample), polymerase chain reaction for mycobacterial DNA or
significant cases are misclassified. Therefore, in pleural increased level of adenosine deaminase (released in
fluid, differentiation of exudates from transudates is pleural fluid from activated lymphocytes) can establish
based on following criteria (known as Light’s criteria): the diagnosis.
• Pleural fluid protein/serum protein ratio > 0.5 5. Cytological examination: For cytological examination,
• Pleural fluid LDH/serum LDH ratio > 0.6 pleural fluid is centrifuged, smears are prepared from
94 Essentials of Clinical Pathology
the sediment, and are stained with Papanicolaou stain. Pleural fluid triglyceride ≥ 110 mg/dl indicates chylous
In older age, metastatic malignancy is responsible for effusion.
majority of pleural effusions. The common malignancies
are bronchogenic carcinoma, carcinoma of breast, and Box 7.1: Special studies on pleural fluid to determine the
cause of pleural effusion
lymphoma. Pleural effusion results from lymphatic
obstruction by tumor cells. Typically, effusion is blood • Tuberculous pleural effusion: Adenosine deaminase,
tinged or hemorrhagic. Examination of three separately gamma interferon, polymerase chain reaction
obtained pleural fluid samples increases sensitivity of • Rheumatoid effusion: Rheumatoid factor
detection of cancer cells to 80%.
• Lupus pleuritis: Antinuclear antibodies
6. Other tests: For diagnosis of pulmonary embolism,
• Pancreatic disease, esophageal disease: Amylase
D-dimer test (a breakdown product of fibrin) should be
• Malignancy: Carcinoembryonic antigen
carried out on peripheral blood sample. Flow cytometric
• Chylothorax: Triglycerides
analysis of pleural fluid sample should be done if
lymphoma is suspected. In parapneumonic effusion, if
pleural fluid pH is <7.20, drainage is indicated; if pH is Pleural fluid findings in main causes of pleural
>7.30, complete resolution will occur with medical effusion are shown in Table 7.3. Evaluation of pleural
treatment. In malignant pleural effusion, low pH effusion is shown in Figure 7.2. Special studies on pleural
indicates poor prognosis and poor response to fluid are listed in Box 7.1.
tetracycline pleurodesis. A pleural fluid rheumatoid
factor ≥ 1:320 is suggestive of rheumatoid pleurisy. PLEURAL BIOPSY
Presence of LE cells in pleural fluid makes diagnosis of Percutaneous needle biopsy of the parietal pleura is
lupus nephritis virtually certain. Elevated pleural fluid indicated in patients with exudative pleural effusion if
amylase occur in pancreatitis and esophageal rupture. examination of pleural fluid does not yield a specific
Examination of Pleural and Peritoneal Fluids 95
*Parapneumonic effusion: an exudative pleural effusion that occurs in bacterial pneumonia due to inflammation of pleura
adjacent to the affected lobe; **Empyema: Presence of purulent exudate in pleural cavity; it can result from parapneumonic
effusion, rupture of lung abscess in pleural space, injury, or rupture of subdiaphragmatic or hepatic abscess in pleural space;
*** Common causes of malignant pleural effusion are carcinoma of lung, carcinoma of breast, and lymphoma
diagnosis. It is done especially if tuberculosis or procedure can be combined with aspiration of pleural
malignancy is suspected. For better results, thoracoscopy fluid, pleural biopsy, and pleurodesis. Thorascopy is
(direct visualization of pleural surface by introducing a better than blind pleural biopsy for diagnosis of
thoracoscope through the chest wall into the pleural malignancy.
cavity previously filled with air) can be helpful in Thoracoscopy is contraindicated if pleural space is
localizing the site of biopsy. For diagnosis of tuberculosis, obliterated and in the presence of coagulopathy and
pleural biopsy is more sensitive than pleural fluid severe cardiac disease.
examination and culture. In malignancy, improved Complications include subcutaneous emphysema,
techniques in pleural fluid cytology have increased the empyema, spread of malignant cells along the access
diagnostic yield to 80%; combination of pleural fluid track, and hemorrhage. Reported mortality rate is <0.1%.
cytology and pleural biopsy can increase the detection
PERITONEAL FLUID
rate further.
For pleural biopsy, special needles like Abrams, Cope Peritoneal cavity is a potential space in the abdomen lined
and tru-cut are available. Needle is inserted with its by mesothelial cells and normally containing about 30-
cutting chamber closed into the pleural effusion. It is 50ml of serous fluid. The fluid is an ultrafiltrate of plasma
recommended to obtain at least three biopsy samples and its formation is dependent upon hydrostatic pressure,
(from 3, 6, and 9 ‘O’ clock positions of cutting chamber) plasma oncotic pressure, and capillary permeability.
for histology and culture. Pathological accumulation of fluid in peritoneal cavity is
Risks of hemothorax and pneumothorax are higher called as ascites, and the accumulated fluid is called as
ascitic fluid.
as compared to thoracentesis. Spread of malignant cells
can occur along the needle track. Causes of Ascites
Thoracoscopy: In thoracoscopy, an endoscope is Causes of ascites are listed in Table 7.4. Causes are
introduced into the pleural cavity for direct visualization classified based on whether the fluid is a transudate or
of pleural surfaces. It is indicated if pleural fluid analysis an exudate. Unlike pleural fluid, there are no well-
is non-diagnostic in a case of pleural effusion and to defined criteria for distinction between transudates and
localize the site of biopsy. exudates. Majority of patients with ascites have cirrhosis
Adequate pleural space is created by removing of liver; presence of ascites in a patient with cirrhosis is a
pleural fluid and replacing it with an equal amount of poor prognostic sign.
atmospheric air. Thoracoscope is inserted through a skin
incision via a trocar into the pleural cavity. Indications for Abdominal Paracentesis
It is especially helpful for diagnosis of metastatic Abdominal paracentesis refers to removal of ascitic fluid
cancer and mesothelioma. Appearance of pleura is also through puncture of the peritoneal cavity. Indications
diagnostic in tuberculosis and rheumatoid pleurisy. The for abdominal paracentesis are given in Table 7.5.
96 Essentials of Clinical Pathology
Collection of Sample
Presence of ascites can usually be detected by clinical
examination; if clinical examination is not definitive,
ultrasound can be helpful. Ultrasonography can also be
useful for determining the cause of ascites.
A hollow needle is inserted through the abdominal Fig. 7.3: Sites for paracentesis (blue filled circles)
wall (usually left lower quadrant of abdomen below the
border of shifting dullness) into the peritoneal cavity Box 7.2: Tests commonly done on ascitic fluid
(Fig. 7.3) and fluid (20-50 ml) is removed under aseptic • White cell count: This is the most important test as it
precautions. For cytology, to maximize the yield of rapidly provides information about possible bacterial
malignant cells, 100 ml should be submitted. For cell infection. Neutrophil count >250/cmm is a strong
count sample is collected in EDTA-containing tube. For indication of bacterial infection, whereas lymphocytosis
microbiologic culture, sample is inoculated in blood indicates peritoneal tuberculosis or carcinomatosis.
culture bottles at bedside. • Albumin: Estimation of serum and ascitic fluid albumin
Complications of the procedure include hemorrhage, allows calculation of serum-ascites albumin gradient
perforation of viscus, and introduction of infection. (SAAG) that allows categorization of ascites into low and
high SAAG.
Evidence of fibrinolysis or of disseminated intra-
vascular coagulation in liver disease is a contraindication • Microbiological tests: Gram stain, Ziehl-Neelsen stain,
culture
for paracentesis.
• Cytological examination: For detection of malignant
Examination of Ascitic Fluid cells when peritoneum is involved by cancer.
Laboratory analysis of ascitic fluid helps in the 1. Appearance: Transudates are pale yellow or straw-
differential diagnosis of ascites. A variety of tests can be colored and clear, whereas exudates are opaque or turbid.
carried out; however, the tests should be decided in an Turbid fluid results from leucocytes, malignant cells, or
individual patient according to the clinical presentation. proteins. Bloody or hemorrhagic fluid indicates
The commonly performed tests include estimation of traumatic tap, recent surgery, abdominal trauma, or
total proteins and albumin, cell count, cytological malignancy. A traumatic tap shows gradual clearing of
examination, and bacterial culture (Box 7.2). fluid during aspiration. Milky or chylous fluid results
Examination of Pleural and Peritoneal Fluids 97
Fig. 7.4: Classification of ascites into high and low albumin gradient. This system has replaced test for total protein concentration
in ascitic fluid for classification of ascites into transudate and exudate. Patients with high albumin gradient respond to sodium
restriction and diuretics, while patients with low albumin gradient require specific treatment
from obstruction of lymphatic duct due to inflammation <1.0 gm/dl) from secondary bacterial peritonitis
or malignancy (lymphoma, carcinomatosis), or from (total protein > 1.0 gm/dl).
abdominal injury. ii. Lactate dehydrogenase: Lactate dehydrogenase in
ascitic fluid is elevated in spontaneous bacterial
2. Chemical examination: peritonitis (i.e. there is no obvious source of
i. Proteins: Traditionally, fluid is called as a transudate infection), secondary bacterial peritonitis (i.e.
if protein content is low, and an exudate if its protein identifiable source of infection is present), and in
content is high. However, this criterion alone is not peritoneal carcinomatosis.
always sufficient. In ascitic fluid, distinction Ascitic fluid findings in various diseases are shown
between transudates and exudates cannot be in Table 7.6. Distinction between spontaneous and
secondary bacterial peritonitis is presented in Table
reliably made by estimation of proteins. A better
7.7 and Figure 7.5.
indicator is albumin gradient (calculated as serum
iii. Amylase: Normally, amylase in ascitic fluid is
albumin minus ascitic fluid albumin done on the similar to serum amylase. If ascitic fluid amylase is
same day) (Fig 7.4). three times greater than serum amylase, ascites is
Total protein concentration in ascitic fluid can be most likely to be due to pancreatic disease such as
helpful in differentiating spontaneous (total protein acute pancreatitis.
1. Spontaneous bacterial peritonitis Cloudy or turbid Exudate Neutrophils Single organism isolated
≥250/μl on culture; Proteins
<1.0 gm/dl; Glucose normal
2. Secondary bacterial peritonitis Cloudy or turbid Exudate Neutrophils Multiple organisms isolated
≥1000/μl on culture
3. Cirrhosis of liver Clear, straw- Transudate Lymphocytes Albumin gradient ≥1.1 gm/dl
colored <500/μl
4. Tuberculous peritonitis Serosanguineous Exudate Lymphocytes Ziehl-Neelsen stain; culture;
>500/μl Low albumin gradient;
Total proteins ≥2.5 gm/dl
5. Malignancy Bloody Exudate Lymphocytes, Cytology
malignant cells
98 Essentials of Clinical Pathology
iv. Bilirubin: Ascitic fluid bilirubin greater than 6.0 mg/ 50% of cases. Laparoscopic biopsy is more helpful in
dl and ascitic fluid bilirubin/serum bilirubin ratio diagnosis of tuberculous peritonitis.
greater than 1.0 indicate perforation of biliary tract 5. Cytological examination: Cytological examination of
(biliary peritonitis). Ascitic fluid is bile-stained. peritoneal fluid can detect 40-65% cases of malignant
3. Cell count: Cell count is usually done to distinguish ascites.
cirrhotic ascites from spontaneous bacterial
peritonitis. In ascitic fluid, total leukocyte count > BIBLIOGRAPHY
500/ml and absolute neutrophil count >250/ml 1. Light RW. Pleural effusion. N Engl J Med 2002;346:
constitute the presumptive evidence of spontaneous 1971-77.
bacterial peritonitis. 2. Runyon BA. Care of patients with ascites. N Engl J Med
4. Microbiological examination: Gram smear is positive 1994;330:337-42.
in 25% cases of spontaneous bacterial peritonitis. If 3. Tarn AC and Lapworth R. Biochemical analysis of
ascitic fluid is inoculated in blood-culture bottles pleural fluid; What should we measure? Ann Clin
at bedside, sensitivity of isolation rises to 85% (as Biochem 2001;38:311-22.
compared to conventional method of inoculation in 4. Thomsen TW, DeLaPena J, Setnik GS. Thoracentesis.
broth and agar plates in laboratory). In spontaneous N Engl J Med 2006;355:e16. Downloaded from
bacterial peritonitis, a single organism is isolated, www.nejm. org on January 14, 2007.
while secondary bacterial peritonitis is polymicrobial. 5. Thomsen TW, Shaffer RW, White B, Setnik GS.
In case of tuberculosis, Ziehl-Neelsen stain has Paracentesis. N Engl J Med 2006;355: e21. Downloaded
sensitivity of 25-30%, while culture is positive in about from www.nejm.org on January 14, 2007.
8
Examination of Sputum
Fig. 8.1: Unacceptable sputum sample: Sputum sample Fig. 8.2: Gram stained smear of sputum showing
shows many squamous cells covered with masses of bacteria gram-positive diplococci (Streptococcus pneumoniae)
Examination of Sputum 101
incubation for 18 hours; if growth is not satisfactory, Ziehl-Neelsen stain of sputum smear: This simple,
incubation for further 24 hours is indicated. Antibiotic inexpensive, and rapid technique is mainly useful for:
sensitivity test is carried out only if amount of growth is • Diagnosis of infectious cases of pulmonary tubercu-
significant. losis. (Sputum smear-positive cases are a major source
of spread of infection).
EXAMINATION OF SPUTUM FOR • Assessment of response to anti-tuberculous treat-
MYCOBACTERIUM TUBERCULOSIS ment.
• Determining cure or treatment failure.
Tuberculosis is one of the major public health problems Ziehl-Neelsen-stained sputum smear is positive if at
in India. Early diagnosis of pulmonary tuberculosis will least 5000-10000 tubercle bacilli/ml are present in the
lead to early institution of therapy enabling cure, and sputum. Sensitivity of the technique is reported to be 60-
also prevention of spread of disease to others. Number 80%. Chances of detection of tubercle bacilli are increased
of cases of tuberculosis has increased in recent times, with if multiple sputum samples are examined or if bleach
World Health Organization calling it a global emergency. concentration technique is used. In bleach concentration
Multidrug-resistant tuberculosis is also emerging on a technique, a solution of bleach (concentrated sodium
large scale. hypochlorite) is added to the sputum sample, which
Mycobacterium tuberculosis complex comprises of M. leads to the liquefaction of mucus and killing of
tuberculosis, M. bovis, and M. africanum. These tubercle mycobacteria. After centrifugation (or overnight
bacilli are the aetiologic agents of human tuberculosis. sedimentation), smears are prepared from the sediment,
Other mycobacteria are called as non-tuberculous. stained, and examined.
There are two main approaches for diagnosis of With Ziehl-Neelsen staining, mycobacteria appear as
tuberculosis: bright red straight or slightly curved beaded rods (2-4 μ
• Direct tests: This consists of detection of M. in length and 0.2-0.5 μ in width) against a blue or green
tuberculosis or its components background (Fig. 8.3). Mycobacteria are both acid- and
• Indirect tests: This involves detection of humoral or alcohol-fast and are termed acid-fast bacilli (AFB). If acid-
cellular immune response to tuberculous infection. fast bacilli are seen, their number should be reported. At
These tests have not been considered in this chapter. least 100 fields are examined before reporting the smear
Direct tests for diagnosis of tuberculosis on sputum as negative.
A negative smear does not rule out the diagnosis of
sample are as follows:
tuberculosis since organisms may be few in number,
• Examination of sputum smear
sputum sample may not have been collected satisfac-
1. Ziehl-Neelsen technique torily, or smear may be of poor quality.
2. Fluorescence microscopy
• Culture on conventional media
• Commercial automated culture systems
• Molecular methods.
tahir99 - UnitedVRG
vip.persianss.ir
9
Examination of Feces
Waste products excreted from the digestive tract are stool sample or 48- or 72-hour sample is collected.
composed of water (up to 75%), indigestible residue, Random diarrheal sample can be tested for occult
undigested food, food which is digested but not blood, fat, pH, white blood cells, culture, or micro-
absorbed, bile, epithelial cells, secretions from digestive scopy. A 48- or 72-hour sample is examined for
tract, inorganic material, and bacteria. Normal amount weight, fat content, carbohydrate, osmolality, or
of feces in an adult is 100-200 grams per day. chymotrypsin activity.
Examination of feces is helpful in the investigation • Evaluation of dysentery: Identification of causative
of diseases of the gastrointestinal tract as follows: organism is definitive in differentiating amebic from
• Detection of parasites: Stool examination is done for
bacillary dysentery.
detection of worms (adult worms, segments of
• Bacteriologic examination: Infection by bacteria such
tapeworms, larvae, ova), and protozoa (trophozoites
or cysts). as Salmonella, Shigella, Vibrio, Yersinia, or Clostridium
• Evaluation of chronic diarrhea: Chronic diarrhea difficile can be identified by stool culture. Bacterial
refers to passage of 3 or more loose or liquid stools toxins (such as those released by Clostridium botulinum
per day lasting for more than 4 weeks. Acute diarrhea or Clostridium difficile) can also be identified.
is defined as passage of 3 or more loose or liquid stools • Chemical examination: Chemical tests can be applied
per day for less than 4 weeks. In diarrhea, stool on feces to detect occult blood (in ulcerated lesions of
examination is an important part of laboratory work- gastrointestinal tract, especially occult carcinoma of
up. Causes of chronic and acute diarrhea are listed in colon), excess fat excretion (malabsorption syn-
Table 9.1 and Figure 9.1 respectively. Depending on drome), and presence or absence of urobilinogen
the nature of information sought, either a random (obstructive jaundice).
1. Watery diarrhea
i. Osmotic
• Carbohydrate malabsorption
• Osmotic laxatives
ii. Secretory
• Bacterial toxins
• Bile acid malabsorption
• Laxative abuse
• Hormonal disorders: VIPoma, carcinoid syndrome, gastrinoma, hyperthyroidism
2. Inflammatory diarrhea
i. Invasive bacterial and parasitic infections
ii. Inflammatory bowel disease
iii. Pseudomembranous colitis
iv. Infectious diseases
v. Neoplasia
3. Fatty diarrhea
• Malabsorption syndromes
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Fig. 9.2: Preliminary evaluation of acute diarrhea. Examination of feces for white blood cells is helpful in
narrowing differential diagnosis in intestinal infections in acute diarrhea
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106 Essentials of Clinical Pathology
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Examination of Feces 109
Fig. 9.8: Trophozoite (left) and uninucleate cyst (right) of E. histolytica. Nuclear chromatin is finely beaded and
evenly coats regular nuclear membrane. Karyosome is central. Chromatoid body is long with rounded ends
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110 Essentials of Clinical Pathology
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Examination of Feces 111
Laboratory Diagnosis
1. Examination of stools for demonstration of oocysts
of I. belli, C. parvum, or C. cayetanensis:
Isospora belli: Oocysts of I. belli can usually be found
in direct wet mounts of feces (unstained). Formalin-
ether concentration technique may sometimes be
necessary. Oocysts of I. belli are oval and about 32 ×
16 μ in size. Immature oocysts contain a granular
zygote. Mature oocysts contain two sporocysts, each
Fig. 9.11: Cyst and trophozoite of Giardia lamblia with four sporozoites. With modified Ziehl-Neelsen
stain (on a fecal smear prepared from the sediment
after formalin-ether concentration), oocysts stain
Cysts of G. lamblia are 8-12 μ in diameter, oval, uniform red-pink. Under ultraviolet light, oocysts
and contain 4 nuclei, axonemes, median bodies, and show autofluorescence.
remains of flagella (Fig. 9.11).
2. Detection of antigen of G. lamblia in stool sample: Cryptosporidium parvum: Oocysts of C. parvum are
Antigen of G. lamblia can be demonstrated by enzyme difficult to demonstrate in direct fecal wet mounts.
immunoassay technique with high sensitivity (90- They are demonstrated either by modified Ziehl-
99%) and specificity (95-100%). This test can be used Neelsen staining of concentrated fecal smear or by
as the initial test for diagnosis of giardiasis; however, immunofluorescence technique. They are 4-6 μ in size,
stool examination is still important for detection of round to oval, and stain pink-red.
other concomitant parasite infections. Cyclospora cayetanensis: In direct wet mounts of feces,
3. Direct fluorescent antibody assay: This test is oocysts measure 8-10 μ in diameter, and contain a
available commercially in a kit form and is highly cluster of refractile globules (morula-like appearance).
sensitive and specific. Cysts are labeled with With modified Ziehl-Neelsen stain, they appear
immunofluorescent antibodies and are detected similar to C. parvum, but are larger. Under ultraviolet
under fluorescence microscope. light (365 nm), oocysts show intense blue auto-
fluorescence.
Coccidia 2. Detection of antigen in stool samples: Enzyme
Isospora belli, Cryptosporidium parvum, and Cyclospora immunoassay for detection of specific antigen of C.
cayetanensis are human intestinal coccidia. They have a parvum is available. It is more sensitive and specific
worldwide distribution. Transmission is by fecal-oral than Ziehl-Neelsen staining.
route (ingestion of infective oocysts). These protozoan 3. Direct fluorescent antibody assay: This assay is
organisms cause self-limited, mild diarrheal illness; available for Cryptosporidium parvum and is highly
sensitive and specific. Oocysts of Cryptosporidium
however, in immunocompromised patients (such as
labeled with fluorescent antibody are readily detected
patients with acquired immunodeficiency syndrome)
under fluorescence microscope.
they can induce severe and protracted diarrhea, which
may sometimes be life-threatening. Microsporidia
Life cycle: Ingestion of infective oocysts by humans leads Microsporidia are obligate intracellular protozoa, which
to infection. Release of sporozoites from oocysts occurs cause opportunistic infection in immunocompromised
which infect intestinal epithelial cells. Sporozoites patients leading to persistent diarrhea and weight loss.
multiply within epithelial cells with formation of Common species causing infection in humans are
merozoites (asexual reproduction by fission or schizo- Enterocytozoon bieneusi, Encephalitozoon intestinalis, and
gony), which infect other epithelial cells. Some mero- Encephalitozoon hellem.
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112 Essentials of Clinical Pathology
Transmission of infection is by ingestion of spores. and intestinal perforation. Sometimes worms can
The organisms develop and multiply in intestinal cells invade pancreatic duct or common bile duct and
and form infective spores; rupture of host cells releases cause obstruction; this can lead to pancreatitis or
spores some of which infect newer cells while others are obstructive jaundice respectively. From the bile duct,
excreted in feces. adult worms can reach liver and cause abscess. Adult
Some microsporidia can cause keratoconjunctivitis, worms can migrate to the appendix to cause
hepatitis, peritonitis, respiratory infection, and kidney appendicitis.
disease. Microsporidia cannot be demonstrated on wet • Malabsorption
mounts because of their very small size.
Laboratory Diagnosis
Laboratory Diagnosis
1. Demonstration of eggs of A. lumbricoides: Diagnosis
1. Modified trichrome stain of stool sample: Spores are
of A. lumbricoides infection is made by demonstration
very small (1-5 μ), stain red, and may show a
of eggs on stool examination. Eggs can be demons-
transverse band.
trated in direct wet mount of feces in moderate to
2. Small intestinal biopsy for demonstration of spores
heavy infections. The recommended procedure is
within intestinal cells.
formol-ethyl acetate sedimentation technique for
concentration of eggs. In feces, four types of eggs are
HELMINTHS found: fertilized (double-shelled or decorticated) and
Ascaris lumbricoides (Roundworm) unfertilised (double-shelled or decorticated).
Fertilized eggs: These are oval, yellow-brown, and
This is the most common helminthic infection of humans.
about 70 μ × 50 μ in size. They have outer and inner
Children are more commonly affected than adults. Mode
shells. Outer shell is uneven, brown (due to staining
of transmission is fecal-oral route (ingestion of infective
by bile), and rough (mamillated), while the inner shell
eggs). Adult worms live in the small intestine (duodenum
is thick, smooth , and colorless. The egg contains a
and jejunum) of the host. Eggs are laid by adult female
single central granular mass (fertilized ovum).
worms (about 200,000 per day), which are excreted in
feces. Eggs can remain viable in soil for many years. Unfertilized eggs: Single female worms discharge these
Contamination can occur when untreated human feces eggs. They are slightly larger and more elongated
are used as a fertilizer or by soiling of hands of playing than the fertilized eggs (90 μ in length). Outer shell is
children. Adult worms can live in the intestine for 1-2 dark brown and more irregular, while the inner shell
years. is thinner. This egg is filled with a mass of large
refractile granules (Fig. 9.12).
Life cycle: Infection is acquired by ingestion of infective
Decorticated eggs do not have the outer uneven shell
eggs via contaminated food or hands. Eggs hatch to
and resemble the hookworm eggs.
release larvae in intestine. Larvae penetrate the mucosa
and enter the bloodstream. Larvae circulate, reach lungs
and penetrate alveolar walls to enter the respiratory tree.
Larvae migrate up the trachea to the epiglottis from
where they are swallowed. Maturation of larvae to adult
worms occurs in the small intestine. Female worms lay
down eggs, which are excreted in feces. Eggs become
embryonated (infective) in 4-6 weeks in favorable
environment.
Clinical Features
• Asymptomatic if infection is light.
• Loeffler’s syndrome: Migration of larvae through the
lungs can induce cough, wheezing, eosinophilia, and
bilateral, irregular pulmonary densities.
• Local effects: These include abdominal pain, diarrhea, Fig. 9.12: Fertilized and unfertilized eggs of
intestinal obstruction due to a large mass of worms, Ascaris lumbricoides
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Examination of Feces 113
Hookworms
The hookworms are Ancylostoma duodenale (old world
hookworm) and Necator americanus (new world hook-
worm).
Life cycle: Infection occurs when there is penetration of
skin of foot by filariform larvae present in soil. Larvae Fig. 9.13: Hookworm egg in fresh stools. Egg in oval shape
enter the circulation, and through veins are carried to with a thin shell, has a clear space between wall and developing
the heart and then reach lungs, migrate up the respiratory cleavage, and contains granular cells
tree and are swallowed. Maturation of larvae to the adult
worms occurs in small intestine. Adult worms attach to
the mucosa and suck blood. Adult female worms produce mount of fecal sample can demonstrate eggs in
eggs, which are excreted in feces. Rhabditiform larvae moderate to heavy infections. Eggs of A. duodenale
are released from eggs into the soil and mature into and N. americanus are morphologically similar. They
infective filariform larvae. Both A. duodenale and N. are 50-75 μ in length and 40 μ in width, oval,
americanus infection are acquired when infective colourless, and have a thin shell. In fresh stools, eggs
filariform larvae penetrate the skin. A. duodenale infection show 4-8 gray, granular cells (Fig. 9.13). If stool is
is also acquired by ingestion of infective larvae. more than 12 hours old, eggs will show a rhabditiform
larva folded upon itself. Such egg is called as
Clinical Features
embryonated. If feces are more than 24 hours old, then
Hookworm infection can cause: free rhabditiform larvae will be seen. This should be
• “Ground itch”: This is inflammation and marked differentiated from larvae of Strongyloides stercoralis
itching on the skin at the site of larval penetration. (buccal cavity of hookworm larva is longer).
• Loeffler’s syndrome: This is due to migration of larvae 2. Other laboratory features: Blood examination often
through the lungs. shows eosinophilia. Microcytic hypochromic anemia
• Iron deficiency anemia due to chronic blood loss: This develops due to chronic blood loss. Test for occult
is a well-known and most common complication of blood in stools is positive.
hookworm infection. Adult worms attach themselves
to the small intestinal mucosa by teeth-like structures Trichuris trichiura
or cutting plates, and suck blood. They then change
their sites of attachment (every 4-8 hours) while blood Infection is acquired by ingestion of infective eggs.
continues to ooze from the previous site. One adult Larvae, which are released, develop into adult worms
A. duodenale causes loss of 0.15 ml of blood while one and attach to the mucosa. Released eggs are excreted in
N. americanus causes loss of 0.03 ml per day. feces, and mature in soil to infective stage under suitable
conditions.
• Abdominal pain and diarrhea if worm load is high.
Heavy infection can cause diarrhea with blood and
Laboratory Diagnosis mucus in stools, iron deficiency anaemia, or rectal
prolapse.
1. Demonstration of hookworm eggs: Diagnosis is based Diagnosis depends on identification of typical eggs
on identification of hookworm eggs on stool on stool examination. Eggs measure 50 × 25 μ in size, are
examination. Technique of formol-ethyl acetate yellow-brown and barrel-shaped. A rounded, trans-
sedimentation is preferred; if not available, direct wet parent plug is present at both poles (Fig. 9.14). Eggs
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114 Essentials of Clinical Pathology
Laboratory Diagnosis
Identification of larvae of S. stercoralis: Diagnosis of S.
stercoralis infection depends on demonstration of
rhabditiform larvae in fresh stool specimens. Eggs of S.
stercoralis are rarely seen in stool samples because they
hatch and release rhabditiform larvae in the intestine.
Rhabditiform larvae are 200-300 μ in length and 15 μ in
width and are actively motile. They have two esopha-
geal swellings, a prominent genital primordium and a
Fig. 9.14: Egg of Trichuris trichiura in iodine wet mount
short buccal cavity. Sometimes, in old fecal samples,
rhabditiform larvae of hookworms are seen which
resemble those of S. stercoralis; the differentiating feature
contain central, uniformly granular mass. Eggs are often
is the longer buccal cavity of the former.
quantitated to assess the severity of infection.
Excretion of larvae is often irregular and their number
may be few. Therefore, fecal examination may yield
Strongyloides stercoralis
negative result. In suspected cases, concentration
Life cycle: Life cycle is more complex than that of other technique (formol-ethyl acetate) is helpful.
nematodes. Penetration of skin by infective filariform Duodenal fluid can be aspirated for detection of
larvae in soil causes infection. Larvae enter the circulation larvae or Entero-test (String test) can be performed.
and migrate to the lungs, penetrate the alveolar spaces, (Entero-test: A commercially available gelatin capsule
move up the trachea, and are swallowed. Maturation to consists of a textured string. One end of the string is
adult worms occurs in the small intestine. Female worms attached or taped to the cheek and the capsule is then
lay down eggs (parthenogenesis). Eggs hatch to release swallowed. The end of the string reaches and is exposed
rhabditiform larvae in small intestine, which are excreted in the duodenum after several hours. After removal, the
along with feces (Sometimes, rhabditiform larvae can terminal part of the string should be bile-stained. The
mature into filariform larvae, which penetrate mucosa, mucus from the end of the string is wiped onto a glass
or perianal skin and enter the circulation; this is called slide and examined for larvae). In disseminated infection,
as autoinfection). Maturation of rhabditiform larvae to larvae may be detected in sputum.
infective filariform larvae occurs in soil, which can Enzyme immunoassay test that detects IgG antibodies
penetrate the skin and cause infection. If this does not to S. stercoralis is available and is indicated if organism is
happen, larvae develop into adult male and female not detected in feces, duodenal aspirate, or string test
worms which mate and lay down eggs, from which and clinical suspicion is strong. It cannot differentiate
rhabditiform larvae are released which further mature between recent and past infection.
into infective filariform larvae.
Enterobius vermicularis
Clinical Features
E. vermicularis is also called as pinworm, seatworm, or
1. Redness and itching at the site of penetration of oxyuris. It is distributed worldwide. Infection is common
filariform larva. in children. Mode of transmission is ingestion of food or
2. Loeffler’s syndrome due to migration of larva through water contaminated with infective eggs through fingers.
the lungs.
3. Heavy infection can cause abdominal pain, diarrhea, Life cycle: After ingestion, eggs hatch to release larvae in
and malabsorption. the intestine. Larvae mature to the adult worms in the
4. Chronic infection causes abdominal pain, diarrhea, cecum or appendix. Female worms migrate at night to
and urticaria. perianal skin to deposit up to 15,000 eggs. Marked
Examination of Feces 115
Fig. 9.15: (A) Enterobius eggs, (B) Enterobius eggs collected by transparent tape method
116 Essentials of Clinical Pathology
Clinical Features
1. Intestinal infection: Clinical features are usually
insignificant. The patient may notice passage of a flat
segment of the worm in feces.
2. Cysticercosis: This occurs if man accidentally ingests
food contaminated with T. solium eggs (or if there is
auto infection). Nodules containing cysticercus
develop in skeletal muscle, subcutaneous tissue, Fig. 9.16: Egg of Taenia solium/saginata
heart, liver, brain, etc. Cysticercus (or bladder worm)
is a small cyst (< 1.5 cm) containing clear fluid and
inverted scolex. of T. solium shows 4 suckers and a crown of
Involvement of brain (neurocysticercosis) can cause hooklets.
seizures (neurocysticercosis is a common cause of 2. Diagnosis of cysticercosis: Cysticercosis can be
epilepsy in endemic areas in children), raised intracranial diagnosed by serologic tests, radiologic studies, and
tension (due to obstruction to cerebrospinal fluid flow biopsy of the lesion.
by intraventricular cysts), psychiatric disturbances, and Indirect hemagglutination assay has sensitivity of
localizing signs; sometimes sudden death can occur. about 80%. A titer of ≥ 1:64 indicates cysticercosis. Newer
glycoprotein immunoblot assay is more sensitive and
Laboratory Diagnosis specific for diagnosis of neurocysticercosis. .
1. Examination of feces X-ray is helpful in detecting calcified cysts. Computed
tomography scans are helpful in diagnosing neuro-
i. Identification of eggs: Morphologically, eggs of T. cysticercosis.
solium and T. saginata are identical. Distinction
between the two species requires examination of Taenia saginata
proglottids or scolices. Egg measures 30-40 μ in
diameter, is round to oval, and has a thick, brown T. saginata (beef tapeworm) has worldwide distribution
wall with transverse lines. The egg contains an with particularly high prevalence in the Middle East,
embryo, which is a round granular mass contai- Africa, Asia, and Latin America. Mode of transmission
ning 3 pairs of hooklets and surrounded by a fine is eating raw or undercooked beef (containing infective
membrane (Fig. 9.16). Occasionally, the egg is cysticercus bovis larvae).
enclosed in a clear sac. Eggs are discharged Life cycle is similar to that of T. solium except: (i)
intermittently by the tapeworm and therefore may animal host is cattle, (ii) eggs are not infectious to humans
not be detected easily. Repeated stool exami- and therefore human cysticercosis does not occur after
nations and formol-ether concentration technique ingestion of eggs, and (iii) segments of T. saginata also
are often required for their demonstration. migrate to the perianal skin and deposit eggs.
ii. Identification of gravid segments or proglottids: This
allows identification of species. The segment is Clinical Features
flattened between two glass slides and examined
under a magnifying glass. Gravid segment is 13 These are usually insignificant. Sometimes abdominal
mm × 8 mm in size, translucent, and pale blue. It pain and diarrhea can occur.
has a central uterine stem with 8-13 lateral
Laboratory Diagnosis
branches. (Uterine branches are >13 in T. saginata).
iii. Identification of scolex (head): Scolex of a tapeworm 1. Identification of eggs: Eggs of T. saginata can be
is very small (pinhead size) and is rarely seen. identified in feces and perianal skin. They are
When examined with a magnifying glass, scolex morphologically similar to those of T. solium.
Examination of Feces 117
cancer. Yearly examinations should be carried out after is measured in fecal sample and in simultaneously
the age of 50 years. If the test is positive, endoscopy and collected blood specimen. Radioactivity in feces indicates
barium enema are indicated. gastrointestinal bleeding. Amount of blood loss can be
calculated. Although the test is sensitive, it is not suitable
Tests for detection of occult blood in feces: Many tests are
available which differ in their specificity and sensitivity. for routine screening.
These tests include tests based on peroxidase-like activity Apt test: This test is done to decide whether blood in the
of hemoglobin (benzidine, orthotolidine, aminophena- vomitus or in the feces of a neonate represents swallowed
zone, guaiac), immunochemical tests, and radioisotope maternal blood or is the result of bleeding in the
tests. gastrointestinal tract. The test was devised by Dr. Apt
and hence the name. The baby swallows blood during
Tests Based on Peroxidase-like
delivery or during breastfeeding if nipples are cracked.
Activity of Hemoglobin
Apt test is based on the principle that if blood is of
Principle: Hemoglobin has peroxidase-like activity and neonatal origin it will contain high proportion of
releases oxygen from hydrogen peroxide. Oxygen hemoglobin F (Hb F) that is resistant to alkali denatu-
molecule then oxidizes the chemical reagent (benzidine, ration. On the other hand, maternal blood mostly
orthotolidine, aminophenazone, or guaiac) to produce a contains adult hemoglobin or Hb A that is less resistant.
colored reaction product.
Benzidine and orthotolidine are carcinogenic and are Test for Malabsorption of Fat
no longer used. Benzidine test is also highly sensitive
and false-positive reactions are common. Dietary fat is absorbed in the small intestine with the
Since bleeding from the lesion may be intermittent, help of bile salts and pancreatic lipase. Fecal fat mainly
repeated testing may be required. consists of neutral fats (unsplit fats), fatty acids, and soaps
(fatty acid salts). Normally very little fat is excreted in
Causes of False-positive Tests feces (<7 grams/day in adults). Excess excretion of fecal
fat indicates malabsorption and is known as steatorrhea.
1. Ingestion of peroxidase-containing foods like red It manifests as bulky, frothy, and foul-smelling stools,
meat, fish, poultry, turnips, horseradish, cauliflower, which float on the surface of water.
spinach, or cucumber. Diet should be free from
peroxidase-containing foods for at least 3 days prior Causes of Malabsorption of Fat
to testing.
2. Drugs like aspirin and other anti-inflammatory drugs, i. Deficiency of pancreatic lipase (insufficient
which increase blood loss from gastrointestinal tract lipolysis): chronic pancreatitis, cystic fibrosis.
in normal persons. ii. Deficiency of bile salts (insufficient emulsification
of fat): biliary obstruction, severe liver disease, bile
Causes of False-negative Tests salt deconjugation due to bacterial overgrowth in
1. Foods containing large amounts of vitamin C. the small intestine.
2. Conversion of all hemoglobin to acid hematin (which iii. Diseases of small intestine: tropical sprue, celiac
has no peroxidase-like activity) during passage disease, Whipple’s disease.
through the gastrointestinal tract. Tests for fecal fat are qualitative (i.e. direct micro-
scopic examination after fat staining), and quantitative
Immunochemical Tests (i.e. estimation of fat by gravimetric or titrimetric
These tests specifically detect human hemoglobin. analysis).
Therefore there is no interference from animal hemo- 1. Microscopic stool examination after staining for fat:
globin or myoglobin (e.g. meat) or peroxidase-containing A random specimen of stool is collected after putting
vegetables in the diet. the patient on a diet of >80 gm fat per day. Stool
The test consists of mixing the sample with latex sample is stained with a fat stain (oil red O, Sudan
particles coated with anti-human haemoglobin antibody, III, or Sudan IV) and observed under the microscope
and if agglutination occurs, test is positive. This test can for fat globules (Fig. 9.18). Presence of ≥60 fat
detect 0.6 ml of blood per 100 grams of feces. droplets/HPF indicates steatorrhea. Ingestion of
mineral or castor oil and use of rectal suppositories
51
Radioisotope Test Using Cr can cause problems in interpretation.
In this test, 10 ml of patient’s blood is withdrawn, labeled 2. Quantitative estimation of fecal fat: The definitive
with 51Cr, and re-infused intravenously. Radioactivity test for diagnosis of fat malabsorption is quantitation
Examination of Feces 119
Gastric Analysis
Gastric analysis consists of quantitation of gastric acid into pyloric antrum and pyloric canal. It is lined by
(basal and pentagastrin-stimulated) produced by the mucus-secreting cells and gastrin-secreting neuro-
stomach. Gastric juice is collected by a nasogastric tube endocrine cells (G cells) (Fig. 10.1).
and gastric acid is quantitated by its titration with sodium In the stomach, ingested food is mechanically and
hydroxide solution. chemically broken down to form semi-digested liquid
called chyme. Following relaxation of pyloric sphincter,
NORMAL GASTRIC ANATOMY AND chyme passes into the duodenum.
PHYSIOLOGY There are three phases of gastric acid secretion:
cephalic, gastric, and intestinal.
Anatomically, stomach is divided into four parts: cardia, • Cephalic or neurogenic phase: This phase is initiated
fundus, body, and pyloric part. Cardia is the upper part by the sight, smell, taste, or thought of food that causes
surrounding the entrance of the esophagus and is lined stimulation of vagal nuclei in the brain. Vagus nerve
by the mucus-secreting epithelium. The epithelium of directly stimulates parietal cells to secrete acid; in
the fundus and the body of the stomach is composed of addition, it also stimulates antral G cells to secrete
different cell types including: (i) mucus-secreting cells gastrin in blood (which is also a potent stimulus for
which protect gastric mucosa from self-digestion by gastric acid secretion) (Fig. 10.2). Cephalic phase is
forming an overlying thick layer of mucus, (ii) parietal abolished by vagotomy.
cells which secrete hydrochloric acid and intrinsic factor, • Gastric phase: Entry of swallowed food into the
and (iii) peptic cells or chief cells which secrete the stomach causes gastric distension and induces gastric
proteolytic enzyme pepsinogen. Pyloric part is divided phase. Distension of antrum and increase in pH due
Fig. 10.2: Stimulation of gastric acid secretion. Three receptors on parietal cells stimulate acid secretion: histamine (H2) receptor,
acetylcholine or cholinergic receptor, and gastrin/CCK-B receptor. Histamine is released by enterochromaffin-like cells in lamina
propria. Acetylcholine is released from nerve endings. Gastrin is released from G cells in antrum (in response to amino acids
in food, antral distention, and gastrin-releasing peptide). After binding to receptors, H+ is secreted in exchange for K+ by
proton pump
to neutralization of acid by food stimulate antral G the formation of large polypeptide molecules (optimal
cells to secrete gastrin into the circulation. Gastrin, in function at pH 1.0 to 3.0). Its secretion is enhanced by
turn, causes release of hydrochloric acid from parietal vagal stimulation.
cells. • Mucus
• Intestinal phase: Entry of digested proteins into the • Intrinsic factor (IF): IF is necessary for absorption of
duodenum causes an increase in acid output from vitamin B12 in the terminal ileum. It is secreted by
the stomach. It is thought that certain hormones and parietal cells of stomach.
absorbed amino acids stimulate parietal cells to
secrete acid. INDICATIONS FOR GASTRIC ANALYSIS
The secretion from the stomach is called as gastric juice. In gastric analysis, amount of acid secreted by the
The chief constituents of the gastric juice are: stomach is determined on aspirated gastric juice sample.
• Hydrochloric acid (HCl): This is secreted by the parietal Gastric acid output is estimated before and after
cells of the fundus and the body of the stomach. HCl stimulation of parietal cells (i.e. basal and peak acid
provides the high acidic pH necessary for activation output). This test was introduced in the past mainly for
of pepsinogen to pepsin. Gastric acid secretion is the evaluation of peptic ulcer disease (to assess the need
stimulated by histamine, acetylcholine, and gastrin for operative intervention). However, diminishing
(Fig. 10.2). HCl kills most microorganisms entering frequency of peptic ulcer disease and availability of safe
the stomach and also denatures proteins (breaks and effective medical treatment have markedly reduced
hydrogen bonds making polypeptide chains to the role of surgery.
unfold). Its secretion is inhibited by somatostatin 1. To determine the cause of recurrent peptic ulcer
(secreted by D cells in pancreas and by mucosa of disease:
intestine), gastric inhibitory peptide (secreted by K • To detect Zollinger-Ellison (ZE) syndrome: ZE
cells in duodenum and jejunum), prostaglandin, and syndrome is a rare disorder in which multiple
secretin (secreted by S cells in duodenum). mucosal ulcers develop in the stomach, duode-
• Pepsin: Pepsin is secreted by chief cells in stomach. num, and upper jejunum due to gross hyper-
Pepsin causes partial digestion of proteins leading to secretion of acid in the stomach. The cause of
Gastric Analysis 123
Gastric juice can be aspirated through an oral or that has accumulated overnight is aspirated and
nasogastric tube (polyvinyl chloride, silicone, or discarded. This is followed by aspiration of gastric
polyurethane) or during endoscopy. secretions at 15-minute intervals for 1 hour (i.e. total 4
Oral or nasogastric tube (Fig. 10.3) is commonly used. consecutive samples are collected). All the samples are
It is a flexible tube having a small diameter and a bulbous centrifuged to remove any particulate matter. Each 15-
end that is made heavy by a small weight of lead. The minute sample is analyzed for volume, pH, and acidity.
end is perforated with small holes to allow entry of gastric The acid output in the four samples is totaled and the
juice into the tube. As the end is radiopaque, the tube result is expressed as concentration of acid in milliequi-
can be positioned in the most dependent part of the valents per hour or in mmol per hour.
stomach under fluoroscopic or X-ray guidance. The tube After the collection of gastric juice for determination
is lubricated and can be introduced either through the of BAO, patient is given a subcutaneous or intramuscular
mouth or the nose. The patient is either sitting or reclining injection of pentagastrin (6 μg/kg of body weight), and
on left side. The tube has three or four markings on its immediately afterwards, gastric secretions are aspirated
outer surface that correspond with distance of the tip of at 15-minute intervals for 1 hour (for estimation of MAO
the tube from the teeth, i.e. 40 cm (tip to cardio- or PAO). MAO is calculated from the first four 15-minute
esophageal junction), 50 cm (body of stomach), 57 cm samples after stimulation. PAO is calculated from two
(pyloric antrum), and 65 cm (duodenum). The position consecutive 15-minute samples showing highest acidity.
of the tube can be verified either by fluoroscope or by
‘water recovery test’. In the latter test, 50 ml of water is Titration
introduced through the tube and aspirated again;
Gastric acidity is estimated by titration, with the end
recovery of > 90% of water is indicative of proper
point being determined either by noting the change in
placement. The tube is usually positioned in the antrum.
color of the indicator solution or till the desired pH is
A syringe is attached to the outer end of the tube for the
reached.
aspiration of gastric juice.
For estimation of BAO, sample is collected in the In titration, a solution of alkali (0.1 N sodium
morning after 12-hour overnight fast. Gastric secretion hydroxide) is added from a graduated vessel (burette)
to a known volume of acid (i.e. gastric juice) till the end
point or equivalence point of reaction is reached. The
concentration of acid is then determined from the
concentration and volume of alkali required to neutralize
the particular volume of gastric juice. Concentration of
acid is expressed in terms of milliequivalents per liter or
mmol per liter.
Free acidity refers to the concentration of HCl present
in a free, uncombined form in a solution. The volume of
alkali added to the gastric juice till the Topfer’s reagent
(an indicator added earlier to the gastric juice) changes
color or when the pH (as measured by the pH meter)
reaches 3.5 is a measure of free acidity. A screening test
can be carried out for the presence of free HCl in the
gastric juice. If red color develops after addition of a drop
of Topfer’s reagent to an aliquot of gastric juice, free HCl
is present and the diagnosis of pernicious anaemia
(achlorhydria) can be excluded.
Combined acidity refers to the amount of HCl
combined with proteins and mucin and also includes
Fig. 10.3: Oral or nasogastric Ryle’s tube. The tube is marked small amount of weak acids present in gastric juice.
at 40, 50, 57, and 65 cm with radiopaque lines for accurate
Total acidity is the sum of free and combined acidity.
placement. The tip is bulbous and contains a small weight
of lead to assist the passage during intubation and to know
The amount of alkali added to the gastric juice till
the position under fluoroscopy or X-ray guidance. There are phenolphthalein indicator (added earlier to the gastric
four perforations or eyes to aspirate contents from the stomach juice) changes color is a measure of total acidity
through a syringe attached to the base (Box 10.1).
Gastric Analysis 125
In this test, after determining BAO, insulin is results may be obtained. The test is no longer in use.
administered intravenously (0.15-0.2 units/kg) and 4. Spot check of gastric pH: According to some
acid output is estimated every 15 minutes for 2 hours investigators, spot determination of pH of fasting
(8 post-stimulation samples). Vagotomy is considered gastric juice (obtained by nasogastric intubation) can
as complete if, after insulin-induced hypoglycemia detect the presence of hypochlorhydria (if pH>5.0 in
(blood glucose < 45 mg/dl), no acid output is men or >7.0 in women).
5. Congo red test during esophagogastroduodeno-
observed within 45 minutres.
scopy: This test is done to determine the completeness
The test gives reliable results only if blood glucose
of vagotomy. Congo red dye is sprayed into the
level falls below 50 mg/dl at some time following stomach during esophagogastroduodenoscopy; if it
insulin injection. It is best carried out after 3-6 months turns red, it indicates presence of functional parietal
of vagotomy. cells in stomach with capacity of producing acid.
The test is no longer recommended because of the
risk associated with hypoglycemia. Myocardial REFERENCE RANGES
infarction, shock, and death have also been reported. • Volume of gastric juice: 20-100 ml
2. Fractional test meal: In the past, test meals (e.g. oat • Appearance: Clear
meal gruel, alcohol) were administered orally to • pH: 1.5 to 3.5
stimulate gastric secretion and determine MAO or • Basal acid output: Up to 5 mEq/hour
PAO. Currently, parenteral pentagastrin is the gastric • Peak acid output: 1 to 20 mEq/hour
stimulant of choice. • Ratio of basal acid output to peak acid output: <0.20
3. Tubeless gastric analysis: This is an indirect and or < 20%
rapid method for determining output of free
BIBLIOGRAPHY
hydrochloric acid in gastric juice. In this test, a cation-
exchange resin tagged to a dye (azure A) is orally 1. Burtis CA, Ashwood ER (Eds). Tietz Fundamentals of
Clinical Chemistry, 4th ed. Philadelphia: WB Saunders
administered. In the stomach, the dye is displaced
Co, 1996.
from the resin by the free hydrogen ions of the 2. Drossman DA, Shaheen NJ, Grimm IS (Eds). Handbook
hydrochloric acid. The displaced azure A is absorbed of Gastroenterologic Procedures (4th Ed). Philadelphia:
in the small intestine, enters the bloodstream, and is Lippincott Williams and Wilkins, 2005.
excreted in urine. Urinary concentration of the dye is 3. Rosenfeld L. Gastric tubes, meals, acid, and analysis-
rise and decline. Clin Chem 1997;43:837-42.
measured photometrically or by visual comparison
4. Wallach J. Interpretation of Diagnostic tests (7th Ed).
with known color standards. The quantity of the dye Philadelphia. Lippincott: Williams and Wilkins, 2000.
excreted is proportional to the gastric acid output. 5. Wolfe MM, Soll AH. The physiology of gastric acid
However, if kidney or liver function is impaired, false secretion. N Engl J Med 1988;319:1707-14.
11
Fig. 11.1: Carbohydrate digestion and absorption. Carbohydrate digestion and absorption depend mainly on normal
pancreatic function (amylase) and normal intestinal mucosal cells (disaccharidases)
128 Essentials of Clinical Pathology
Fig. 11.2: Digestion and absorption of fat. This requires presence of normal functioning and
adequate absorptive area of intestinal mucosa, bile salts, and pancreatic enzymes
Impaired digestion
1. Diseases of pancreas: Chronic pancreatitis, cystic fibrosis,
resection of pancreas
2. Deficiency of bile salts: Impaired excretion of bile
(cholestasis), blind loop syndrome (bile salt deconjugation),
intestinal resection (impaired enterohepatic circulation)
Impaired absorption
1. Disorders of mucosa: Tropical sprue, giardiasis, celiac
disease, Crohn’s disease, Whipple’s disease, radiation
enteritis, amyloidosis, disaccharidase deficiency (e.g.
lactase), abetalipoproteinemia
2. Intestinal resection
3. Lymphatic obstruction: Lymphoma
malabsorption. In the beginning, complete blood count stain) is poorly validated and often misses mild forms
(for detecting anemia); iron studies, vitamin B12, and of steatorrhoea (See Chapter 9 “Examination of
folate levels; serum albumin, and serum calcium; Feces”).
erythrocyte sedimentation rate (raised in Crohn’s disease 2. Butter fat test: In this test, a standard amount of fat
and Whipple’s disease), and prothrombin time (for is ingested and if chylomicrons are observed in blood
malabsorption of vitamin K) should be obtained. after the fatty meal, fat digestion and absorption are
considered to be adequate.
Radiological investigations (such as small bowel barium
3. Estimation of fecal fat: Patient should take 70 g per
enema, CT scan of abdomen, plain X-ray film of
day fat diet for at least 6 days. This is followed by
abdomen, etc.) can be helpful in certain cases. collection of feces for atleast 3 days and measurement
Laboratory tests for malabsorption can be classified of fecal mass or volume and fat. Fecal fat excretion >7%
as follows: is considered as abnormal. The test is unpleasant to
• Tests for malabsorption of fat perform and misleading results are often obtained due
• Tests for malabsorption of carbohydrates to incompleteness of collection and poor analytical
• Tests for pancreatic function performance (See Chapter 9 “Examination of feces”).
• Tests for malabsorption of vitamin B12 (See ‘Schilling 4. 14CO2-breath tests: Labeled triglycerides (e.g. 14C-
test’ in Chapter on ‘Approach to Diagnosis of triolein) are administered orally; after hydrolysis by
Anemias’) pancreatic lipase to monoglycerides and free fatty
• Tests for bacterial overgrowth in small intestine acids, micelles are formed with the aid of bile acids
• Tests for laxative abuse. that are then absorbed. Ultimately metabolism leads
Tests for malabsorption of fat These tests include: to their excretion as CO2. Measurement of breath 14CO2
• Microscopic examination of feces for fat should show peak radioactivity at 5 to 7 hours. Result
• Butter fat test depends both on fat digestion and absorption. To
• Estimation of fecal fat distinguish between the two, the test is repeated after
• 14CO2 breath tests, e.g. 14C-triolein breath test. administration of a radiolabeled free fatty acid. This
1. Microscopic examination for fecal fat: This test (that test is indirect and qualitative rather than quantitative.
detects fat globules in feces after staining with a fat Evaluation of steatorrhea is shown in Figure 11.4.
Tests for malabsorption of carbohydrates the large intestine, where hydrogen is produced by
These tests include: bacterial fermentation (Note: Hydrogen cannot be
• Lactose tolerance test produced by mammalian cells and bacterial fermen-
• Breath hydrogen test tation of unabsorbed carbohydrate is responsible for
• D-xylose absorption test. its presence in the expired air). About 20% of such
1. Lactose tolerance test: Lactose is a carbohydrate hydrogen is absorbed by mucosa and excreted
consisting of one molecule of glucose and one through respiration. In lactase deficiency, breath
molecule of galactose. It is also called as milk sugar hydrogen is increased following lactose load.
as it comprises of 2-8% of milk. A 50 g oral dose of Clinically such patients also develop symptoms of
lactose in 400 ml of water is given and blood glucose lactose intolerance such as abdominal distention,
response is measured as in oral glucose tolerance test discomfort, flatulence and diarrhea.
Lactase deficiency may be congenital or acquired.
(at 0, 30, 60, and 120 minutes) and patient is also
Transient deficiency occurs following damage to gut
observed for development of symptoms. Failure of
mucosa, e.g. gastroenteritis, celiac disease, and
expected rise of blood glucose (i.e. peak rise of blood
inflammatory bowel disease.
glucose <20 mg/dl) and provocation of symptoms
3. D-xylose absorption test: This test assesses the
are indicative of lactose intolerance (Fig. 11.5). To
absorptive capacity of small intestinal mucosa. D-
improve specificity, test is repeated following xylose, a plant sugar, is completely absorbed in the
administration of glucose (25 g) and galactose (25 g); small intestine (without prior digestion) after
a normal rise in blood glucose indicates lactose ingestion (5 g dose) and excreted largely unchanged
intolerance. This test is less reliable than breath in urine. If excretion is less than 20% of ingested dose,
hydrogen test. absorption is considered as impaired (small intestinal
2. Breath hydrogen test: An oral dose of lactose is disease). Misleading results are obtained in renal
administered and breath hydrogen is measured. In failure, delayed gastric emptying and incomplete
lactase deficiency, lactose is not absorbed, and reaches urine collection.
Tests for bacterial overgrowth in small intestine Bacterial urine or of faecal water, while magnesium abuse can be
overgrowth in the small intestine occurs if there is stasis identified by measuring fecal osmotic gap and
of small bowel contents (e.g. due to stricture or magnesium concentration in fecal water.
diverticulosis). Bacteria cause deconjugation of bile salts
Other tests for malabsorption Some intestinal disorders
leading to failure of mixed micelle formation and fat
have characteristic radiological abnormalities like
malabsorption. Various tests for detection of small bowel
Crohn’s disease, diverticula, enterocolic fistula, etc. CT
bacterial overgrowth include:
scan can detect changes associated with chronic
• Aspiration and culture of duodenal/jejunal contents
pancreatitis.
• Breath hydrogen tests (e.g. with lactulose)
A definitive diagnosis can be established in certain
• Breath CO2 tests (e.g. with 14C-glycocholic acid or 14C-
malabsorption syndromes by endoscopically-directed
xylose)
biopsy of small intestinal mucosa.
• Measurement of urinary indican
1. Aspiration and culture of duodenal/jejunal contents:
PANCREATIC FUNCTION TESTS
Duodenal or jejunal contents are aspirated at
endoscopy and sent for bacterial culture. This is the The pancreas is a major gland having both exocrine and
most reliable diagnostic test for bacterial overgrowth; endocrine functions. The exocrine component secretes
however, it is invasive and occasionally false-negative its fluid into the pancreatic duct that opens into the
result is obtained. duodenum and is concerned with digestion of food. The
2. Breath hydrogen tests: Lactulose, a non-absorbable endocrine component secretes its hormones directly into
carbohydrate, is administered orally (10 g). In the bloodstream.
bacterial overgrowth, fermentation of unabsorbed
carbohydrate occurs in the small as well as large Anatomy and Physiology of Pancreas
intestine with the production of hydrogen. Breath 1. Exocrine component: Exocrine pancreas is the major
hydrogen is increased early (40 minutes) following component of the gland. It is made up of closely
the oral dose of lactulose. packed secretory acini that drain their secretions via
3. Breath CO 2 tests: In 14C-xylose breath test, 1 g small, highly branched ducts into the main pancreatic
radiolabeled xylose is given orally. In bacterial duct. The main pancreatic duct joins the common bile
overgrowth a large amount of xylose is metabolized duct and opens into the duodenum via the ampulla
by bacteria to 14CO2 that is absorbed and excreted of Vater. A small accessory pancreatic duct is also
through breath. This isotopically labeled CO 2 is present in most individuals and opens into the
measured in expired breath. duodenum separately (Fig. 11.6).
This test is better than 14C-glycocholic acid test. In
the later test, 14C-glycocholic acid (a radiolabeled
conjugated bile acid) is given orally. Normally this
bile acid is absorbed intact. Bacterial overgrowth
causes deconjugation of glycocholic acid with the
release of 14C-glycine which is absorbed in the small
intestine, and metabolized in the liver releasing
labeled carbon dioxide. Excretion of labeled CO2 is
measured in expired breath.
4. Test for urinary indican: Indican is a bacterial
metabolic product of dietary tryptophan.
Tests for laxative abuse Diarrhea due to malabsorption
should be distinguished from that due to laxative abuse.
Laxatives or their metabolites can be detected in urine
or loose fecal sample by thin layer chromatography.
Phenolphthalein can also be detected by alkalization of Fig. 11.6: Gross anatomy of pancreas
132 Essentials of Clinical Pathology
Each acinus is lined by pyramidal secretory cells, duodenum stimulates secretion of secretin that in turn
apices of which are packed with zymogen secretory stimulates release of bicarbonate from the pancreas into
granules (Figs 11.7 and 11.8). These granules contain the small intestine.
inactive forms of enzymes synthesized by acinar cells. Proteolytic enzymes are secreted in an inactive form
Zymogen granules are released into the acinar lumina (trypsinogen and chymotrypsinogen) into the pancreatic
by the process of exocytosis. Secretions in acinar lumina juice to prevent the autodigestion of pancreas. Entero-
initially drain into intercalated ducts, lining cells of which kinase, secreted by duodenal mucosa, activates the
secrete water and bicarbonate ions. High concentration inactive trypsinogen to trypsin in duodenal lumen.
of bicarbonate ions is responsible for alkaline pH of Trypsin converts chymotrypsinogen to the active enzyme
pancreatic juice, which serves to neutralize the acidic pH chymotrypsin. Trypsin and chymotrypsin degrade large
of the chyme entering into the duodenum. polypeptide molecules to smaller ones. Peptidase, an
The pancreatic enzymes entering into the duodenum intestinal enzyme bound to enterocyte cell membrane,
breakdown proteins, carbohydrates, lipids, and nucleic further degrades smaller polypeptides to amino acids.
acids, making them suitable for digestion and absorption. Other proteolytic enzymes elaborated by the pancreas
Pancreatic secretions also neutralize gastric acid entering include elastase, carboxypeptidases, ribonuclease, and
into the small intestine. Gastric acid entering the collagenase (Box 11.1).
Carbohydrates are broken down by amylase in the
pancreatic juice and by intestinal cell membrane-bound
disaccharidases to monosaccharides.
Lipids are emulsified in the duodenum by the action
of bile; they are then broken down by the pancreatic
lipase into free fatty acids, monoglycerides, and glycerol.
Exocrine pancreatic function is regulated by neural
factors and by certain hormones of the gastrointestinal
tract like cholecystokinin-pancreozymin (CCK-PZ),
gastrin, and secretin.
CCK-PZ stimulates contraction of gallbladder and
also secretion of enzyme-rich pancreatic juice. It is a
polypeptide hormone synthesized by duodenal endo-
crine cells in response to contact with partially digested
Fig. 11.7: Major components of exocrine pancreas proteins and gastric hydrochloric acid.
Gastrin is produced mainly by G cells of the antral
mucosa of the stomach and has actions on the pancreas
similar to that of CCK-PZ. Gastrin secretion is promoted
by antral distention and the presence of partially digested mild pancreatic insufficiency (i.e. when imaging studies
proteins. are normal). However, no such non-invasive pancreatic
Secretin is a polypeptide synthesized by duodenal function test is currently available. Also, the results of
endocrine S cells in response to contact with gastric these tests in pancreatic insufficiency often overlap with
hydrochloric acid. It enhances secretion of bicarbonate- normal values.
rich pancreatic fluid into the duodenum.
Normal pancreatic juice is colorless, has alkaline pH, Direct (Invasive or Tube) Tests
and its 24-hour volume is 1000-2500 ml. It consists of In direct tests, duodenum is intubated, a pancreatic
water, sodium, potassium, chloride, bicarbonate, and stimulant (such as secretin-CCK-PZ, secretin-cerulin, or
pancreatic enzymes. Lundh meal) is administered, and pancreatic secretions
2. Endocrine component: Isolated clusters of endocrine entering into the duodenum are aspirated. Quantity of
cells are scattered throughout the exocrine pancreatic bicarbonate and enzyme secretions is measured, which
tissue and are known as islets of Langerhans. correlates with functional mass of pancreas.
Endocrine cells are also present singly in between the 1. Secretin-CCK-PZ or Secretin-Cerulin test: This test
pancreatic acini. Hormones secreted by the endocrine is the ‘gold standard’ for detection of exocrine pancreatic
pancreas include insulin, glucagon, somatostatin, insufficiency.
vasoactive intestinal polypeptide, and pancreatic This test is based on the principle that output of
polypeptide. pancreatic juice, bicarbonate, and enzymes from pancreas
(after maximum stimulation by an exogenously adminis-
Tests of Pancreatic Function tered hormone) is dependent on the amount of functional
pancreatic tissue. The method, in short, is as follows:
Tests for assessing pancreatic function measure the
i. In a fasting patient, duodenum is intubated with a
physiologic function of exocrine component. These tests
radioopaque tube under fluoroscopic guidance and
either determine the functional activity of certain
contents are aspirated until the contents are clear.
pancreatic enzymes, or directly quantitate the products ii. Secretin and cholecystokinin-pancreozymin (or
of pancreatic secretions. secretin-caerulin) are administered intravenously.
Pancreatic function tests are listed in Table 11.2. Secretin stimulates secretion of watery, bicarbonate-
Nowadays, the direct tests have largely been replaced rich fluid, while CCK-PZ or cerulin stimulate
by the indirect (tubeless) tests. secretion of enzymes from the pancreas.
Pancreatic insufficiency can be readily diagnosed in iii. Three samples of duodenal secretions are aspirated:
advanced cases showing steatorrhea, pancreatic basal, following intravenous secretin, and following
calcification, and diabetes mellitus. Clinical features of intravenous CCK-PZ. Total volume of fluid, pH and
pancreatic insufficiency do not appear until about 90% concentrations of bicarbonate and enzymes (amylase,
of the gland is destroyed. If pancreatic insufficiency is trypsin) are measured, and compared with the
detected early, appropriate treatment can be given and normal values.
improved outlook can be expected. Ideally, exocrine In exocrine pancreatic insufficiency, bicarbonate
pancreatic function tests should be simple to perform, secretion is lost earlier than enzyme secretions. Also,
specific, sensitive, and should be able to detect early or enzyme activity and bicarbonate content are reduced
before there is any reduction in volume of pancreatic
juice.
Table 11.2: Pancreatic function tests
The specificity and sensitivity of this test is high
Direct tests (Invasive) (around 90%). However, the test is invasive, laborious,
• Secretin-CCK-PZ test (or secretin-cerulin test)
time-consuming, and expensive. It also requires special
• Lundh test
skills for performance and interpretation.
Indirect tests (Non-invasive) 2. Lundh meal: Lundh meal is a physiologic test meal
• NBT-PABA (Bentiromide) test consisting of protein (15 gm), fat (18 gm), carbohydrates
• Pancreolauryl test (40 gm glucose), and water (300 ml). It induces pancreatic
• Breath tests secretion by stimulating release of endogenous secretin
• Estimation of faecal enzymes
• Estimation of faecal fat and CCK-PZ. Following administration of the meal,
duodenal contents are aspirated and activity of one or
134 Essentials of Clinical Pathology
more enzymes (usually trypsin) and the volume of the ester hydrolase in the presence of bile acids to release
pancreatic juice are measured. The results are usually fluorescein, which is then absorbed in the small intestine,
abnormal in pancreatic insufficiency. As compared to the partially conjugated by the liver, and excreted in urine.
direct hormonal stimulation, this test is more physio- Amount of fluorescein excreted in urine for 10 hours is
logical and cheaper. measured (Alternatively, serum concentrations can also
Disadvantages of this test are: be measured). Test is repeated a day later, but following
i. Lower specificity and sensitivity (70-80%) as ingestion of free fluorescein to correct for individual
compared to the direct secretin-pancreozymin test. variation in intestinal absorption, conjugation in liver,
ii. Abnormal result is also obtained in small bowel and urinary excretion. Ratio of excretion of fluorescein
mucosal disease. dilaurate to excretion of free fluorescein is determined.
If it is less than 0.20, pancreatic insufficiency is present.
Indirect (Non-invasive or Tubeless) Tests
Sensitivity and specificity are similar to NBT-PABA test.
As direct tests are invasive, labor-intensive, and need a 3. Breath tests: Breath tests have been developed which
specialized set-up, various indirect (tubeless) function indirectly assess pancreatic function by measuring 13CO2
tests have been developed. Deficient activity of pancreatic or 14CO2 in breath following ingestion of a substrate such
enzymes is indirectly demonstrated by reduced digestion as 14C-triglyceride, 14C-triolein, mixed triglyceride, 13C-
or increased faecal excretion of fat, low concentration of D-hiolein, or cholesteryl octanoate.
pancreatic enzymes in feces or in blood, or decreased Principle of one such test using 14C-triglyceride is as
hydrolysis of ingested synthetic compounds causing their follows. When 14C-triglyceride is ingested, it is hydro-
reduced urinary excretion. Although simpler, indirect lysed by pancreatic lipase to free fatty acids and
tests have low sensitivity and specificity and cannot monoglycerides. After absorption, metabolism of free
detect mild pancreatic insufficiency. fatty acids ultimately leads to the formation of 14CO2 that
1. NBT-PABA test (Bentiromide test): When a synthetic is excreted in the breath. The amount of 14CO2 formed is
compound N-benzoyl-l tyrosyl-p-aminobenzoic acid proportional to the rate of absorption of fatty acids in
(NBT-PABA, bentiromide) is ingested orally, it is the intestine. Normally there is a peak radioactivity in
hydrolyzed by pancreatic chymotrypsin in duodenum breath after about 6 hours. Low radioactivity in breath
to release p-aminobenzoic acid (PABA). PABA is can be due to deficient fat digestion or deficient fat
absorbed in the small intestine and metabolized in the absorption. To distinguish between the two, the test is
liver. The urinary excretion of metabolites of PABA is repeated after 2 weeks using radiolabeled free fatty acids
measured for 6 hours; if excretion is less than 50% of (instead of radiolabeled triglycerides). If the result is
ingested dose, exocrine pancreatic insufficiency is normal, pancreatic insufficiency is present.
present. Thus, amount of PABA excreted in urine
indirectly reflects activity of pancreatic chymotrypsin and Disadvantages of the test are:
pancreatic function. • Time consuming.
False results are obtained in small bowel disease • Exposure to radioisotopes.
(decreased absorption), liver disease (defective conju- • Inability to detect mild pancreatic insufficiency.
gation), and renal disease (decreased excretion). To guard • False-positive test in respiratory or metabolic disease
against false results, urinary excretion of PABA after in which excretion of CO2 is affected.
administration of bentiromide is compared against 4. Estimation of fecal enzymes: Concentration of
urinary excretion of free radiolabeled PABA given at the enzymes secreted by the pancreatic acinar cells into the
same time. gut is lowered in pancreatic insufficiency and obstruction
2. Pancreolauryl test (Test for pancreatic arylesterase): of pancreatic duct. Output of elastase-1 or chymotrypsin
This test is similar in principle to NBT-PABA test. (both of which remain intact during their passage
Fluorescein dilaurate (Pancreolauryl), a synthetic ester, through the gut) is measured in a fecal sample, which
is ingested along with a standard breakfast. Fluorescein correlates well with their secretion from the pancreas into
dilaurate is hydrolysed by pancreas-specific cholesterol the duodenum.
Tests for Malabsorption and Pancreatic Function 135
Activity of elastase-1 is measured in a random fecal Elevation of serum amylase occurs in:
sample by immunoassay. Its concentration is reduced in • Pancreatic diseases: acute and chronic pancreatitis,
pancreatic insufficiency. The test is sensitive and specific. pseudocyst
Although the test is simple and noninvasive, it is • Parotitis
expensive. • Intestinal diseases: perforation, ischemia, obstruction.
Activity of chymotrypsin is measured by spectro- • Biliary tract disease
photometric assay of 4-nitroaniline in a fecal sample (A • Ectopic pregnancy
synthetic pentapeptide is mixed with fecal extract that is
• Malignant tumors of lung or ovary
hydrolyzed by chymotrypsin in feces to release 4-
• Macroamylasemia.
nitroaniline). Although the test is cheaper, it has low
sensitivity. It is commonly used as a screening test for Binding of normal serum amylase with high mole-
detection of pancreatic insufficiency in cystic fibrosis. cular weight plasma proteins (immunoglobulins) leads
5. Estimation of fecal fat: Quantitation of fecal fat is a to the formation of macroamylase. Because of large size,
definitive test for diagnosis of steatorrhea but not for they cannot be excreted in urine. Macroamylasemia is
identification of its cause. The standard indirect test for not associated with any clinical features, but it must be
pancreatic insufficiency is estimation of 72-hour faecal
distinguished from other causes of elevated serum
fat. (See Chapter 9: Examination of Feces).
amylase. In renal failure, and in macroamylasemia,
Normal fat excretion of fat is <7% of total amount of
fat ingested. In pancreatic insufficiency, fat excretion is urinary amylase is low or absent.
often >20%. 2. Serum lipase: Serum lipase is elevated in pancreatic
Aside from pancreatic insufficiency, excess fecal fat diseases, intestinal diseases, acute cholecystitis, and renal
excretion also occurs in conditions such as biliary failure. Values are normal in parotitis and in macro-
obstruction, small bowel mucosal disease, lymphatic amylasemia.
obstruction, liver disease, abetalipoproteinemia, and In acute pancreatitis, serum amylase begins to rise
small bowel bacterial overgrowth. Apart from its
within 3-6 hours, peaks at 24 hours, and returns to normal
nonspecificity, the test is inconvenient and unpleasant.
levels by 2-3 days. Urinary amylase is also high in acute
It cannot differentiate between malabsorption and
deficient digestion, and the result is normal in mild pancreatitis and remains elevated for 7-10 days. Serum
pancreatic insufficiency. lipase starts to increase within 3-6 hours, reaches
maximum at 24 hours, and remains elevated for 8-14
Pancreatic Enzymes Used as Markers of
days.
Active Pancreatic Disease
Very high levels of both serum amylase and serum
Two enzymes, serum or urinary amylase and serum
lipase (i.e. >5 times the upper limit of normal) are
lipase, are often measured to determine the presence of
observed in acute pancreatitis; in other intra-abdominal
pancreatic disease, especially acute pancreatitis.
1. Amylase: Serum amylase is mainly derived from disorders, elevations are moderate or slight. It has been
pancreas and salivary glands. Amylase is a small recommended to measure both serum amylase and
molecule and is filtered by the glomeruli and excreted in serum lipase if diagnosis of acute pancreatitis is suspected
urine. (Fig. 11.9).
Fig. 12.6: In conditions with altered TBG concentration, total T4 is altered. Therefore measurement of free
T4 is more reliable as a test of thyroid function. TBG: Thyroid-binding globulin
cardiac arrhythmias, heart failure (especially in elderly); Table 12.2: Differences between primary and
and muscle weakness, proximal myopathy, and secondary hyperthyroidism
osteoporosis (especially in elderly). Parameter Primary Secondary
The triad of Graves’ disease consists of hyper- hyperthyroidism hyperthyroidism
thyroidism, ophthalmopathy (exophthalmos, lid
1. Serum TSH Low Normal or high
retraction, lid lag, corneal ulceration, impaired eye
2. Serum free High High
muscle function), and dermopathy (pretibial myxo- thyroxine
edema). 3. TSH receptor May be Negative
antibodies positive
Laboratory Features 4. Causes Graves’ disease,
In most patients, free serum T3 and T4 are elevated. In toxic multinodular
goiter, toxic Pituitary
T3 thyrotoxicosis (5% cases of thyrotoxicosis), serum T4
adenoma adenoma
levels are normal while T3 is elevated. Serum TSH is low
or undetectable (< 0.1 mU/L) (Box 12.2).
Undetectable or low serum TSH along with normal Hypothyroidism
levels of T3 and T4 is called as subclinical hyper- Hypothyroidism is a condition caused by deficiency of
thyroidism; subtle signs and symptoms of thyrotoxicosis thyroid hormones. Causes of hypothyroidism are listed
may or may not be present. Subclinical hyperthyroidism in Table 12.3. Primary hypothyroidism results from
is associated with risk of atrial fibrillation, osteoporosis, deficient thyroid hormone biosynthesis that is not due
and progression to overt thyroid disease. to disorders of hypothalamus or pituitary. Secondary
Features of primary and secondary hyperthyroidism hypothyroidism results from deficient secretion of TSH
are compared in Table 12.2. from pituitary. Deficient or loss of secretion of thyro-
Evaluation of hyperthyroidism is presented in Figure
12.7.
Table 12.3: Causes of hypothyroidism
Box 12.2: Thyroid function tests in hyperthyroidism 1. Primary hypothyroidism (Increased TSH)
• Iodine deficiency
• Thyrotoxicosis: • Hashimoto’s thyroiditis
– Serum TSH low or undetectable • Exogenous goitrogens
– Raised total T4 and free T4. • Iatrogenic: surgery, drugs, radiation
• T3 toxicosis: 2. Secondary hypothyroidism (Low TSH): Diseases of
– Serum TSH undetectable pituitary
– Normal total T4 and free T4 3. Tertiary hypothyroidism (Low TSH, Low TRH):
– Raised T3 Diseases of hypothalamus
Fig. 12.7: Evaluation of hyperthyroidism. TSH: thyroid stimulating hormone; FT4: free T4; FT3: free T3; TRAb: TSH
receptor antibody; TRH: Thyrotropin releasing hormone
Thyroid Function Tests 141
THYROID FUNCTION TESTS Table 12.5: Causes of low and increased TSH
Biochemical tests for diagnosis of a thyroid disorder are Low TSH Increased TSH
called as thyroid function tests. The first-line tests are
Primary hyperthyroidism Primary hypothyroidism
serum TSH, total T4 or free T4, and total T3 and free T3.
A variety of non-thyroidal diseases can alter the T3 toxicosis Secondary hyperthyroidism
(pituitary adenoma secreting
results of thyroid function tests in patients with normal TSH)
thyroid status. These disorders include infections, liver
Secondary and tertiary
disease, malignancy, trauma, surgery, renal failure, and hypothyroidism
cardiac failure. To avoid misinterpretation, thyroid
function tests should not be performed during an acute
non-thyroidal illness. 2. Screening for hypothyroidism in newborn
3. Diagnosis of primary and secondary hypothyroidism,
Thyroid Stimulating Hormone (TSH)
and subclinical hypothyroidism
Currently, the most important single test to assess 4. Diagnosis of clinical and subclinical hyperthyroidism
thyroid function and to monitor thyroid hormone 5. Follow-up of T3 and T4 replacement therapy in
replacement therapy is a sensitive TSH assay. This is hypothyroidism.
because most cases of thyroid dysfunction result from
primary thyroid disease. TSH is a hormone secreted by The best single test for initial assessment of thyroid
anterior pituitary gland. A normal TSH level excludes function is a sensitive (3rd or 4th generations) TSH
thyroid disease. TSH is low in primary hyperthyroidism assay, which is sufficiently sensitive and specific for
and high in primary hypothyroidism. The standard early detection of primary hyper- and hypothyroidism.
method for measurement of TSH is immunoassay. Newer
• In primary hyperfunctioning of thyroid, TSH is low.
sensitive methods can reliably distinguish between
• In primary hypofunction of thyroid, TSH is high.
extremely low or undetectable levels seen in hyper-
• Serum free T4 should be measured in all patients
thyroidism and low normal or below-normal levels seen
with elevated TSH.
in some euthyroid patients.
• Serum free T4 and total T3 or free T3 should be
Normal reference range in adults is 0.5 –5.0 mU/L
measured in all patients with low TSH.
and in newborns < 20 mU/L. In adults, borderline
increase is 5-10 mU/L, while values >10 mU/L are
considered as high. Values less than 0.1 mU/L are low. TOTAL THYROXINE (T4)
Third and fourth generations TSH assays have detection
Total serum thyroxine includes both free and protein-
limits of 0.01 to 0.02 mU/L and 0.001 to 0.002 mU/L,
bound thyroxine and is usually measured by competitive
respectively.
immunoassay. Normal level in adults is 5.0-12.0 μg/dl.
TSH levels are affected by non-thyroidal illness and
Test for total thyroxine or free thyroxine is usually
certain drugs; therefore for confirmation of thyroid
combined with TSH measurement and together they
dysfunction, estimation of free T4 and total T4 should
give the best assessment of thyroid function.
also be done. With the availability of sensitive TSH
assays, TRH stimulation test is usually not required (see
Causes of Increased Total T4
later).
Causes of low and increased TSH are shown in Table 1. Hyperthyroidism: Elevation of both T4 and T3 values
12.5. along with decrease of TSH are indicative of primary
hyperthyroidism.
Uses of TSH Measurement
2. Increased thyroxine-binding globulin: If concentration
1. Screening for euthyroidism: The availability of of TBG increases, free hormone level falls, release of
sensitive TSH assay has made the TSH measurement TSH from pituitary is stimulated, and free hormone
the first-line test for assessment of thyroid function. concentration is restored to normal. Reverse occurs
In most patients a normal TSH test indicates normal if concentration of binding proteins falls. In either
function, and no further testing is required case, level of free hormones remains normal, while
Thyroid Function Tests 143
concentration of total hormone is altered. Therefore, Free T3: Measurement of free T3 gives true values in
estimation of only total T4 concentration can cause patients with altered serum protein levels (like preg-
misinterpretation of results in situations that alter nancy, intake of estrogens or oral contraceptives, and
concentration of TBG. nephrotic syndrome). It represents 0.5% of total T3.
3. Factitious hyperthyroidism
4. Pituitary TSH-secreting tumor. Thyrotropin Releasing Hormone (TRH)
Stimulation Test
Causes of Decreased Total T4
Uses
1. Primary hypothyroidism: The combination of
decreased T4 and elevated TSH are indicative of 1. Confirmation of diagnosis of secondary hypo-
primary hypothyroidism. thyroidism
2. Secondary or pituitary hypothyroidism 2. Evaluation of suspected hypothalamic disease
3. Tertiary or hypothalamic hypothyroidism 3. Suspected hyperthyroidism
4. Hypoproteinaemia, e.g. nephrotic syndrome This test is not much used nowadays due to the
5. Drugs: oestrogen, danazol availability of sensitive TSH assays.
6. Severe non-thyroidal illness.
Procedure
Free Thyroxine (FT4)
• A baseline blood sample is collected for estimation
FT4 comprises of only a small fraction of total T4, is
of basal serum TSH level.
unbound to proteins, and is the metabolically active form
• TRH is injected intravenously (200 or 500 μg) followed
of the hormone. It constitutes about 0.05% of total T4.
by measurement of serum TSH at 20 and 60 minutes.
Normal range is 0.7 to 1.9 ng/dl. Free hormone
concentrations (FT4 and FT3) correlate better with
Interpretation
metabolic state than total hormone levels (since they are
not affected by changes in TBG concentrations). . 1. Normal response: A rise of TSH > 2 mU/L at 20
Measurement of FT4 is helpful in those situations in minutes, and a small decline at 60 minutes.
which total T4 level is likely to be altered due to alteration 2. Exaggerated response: A further significant rise in
in TBG level (e.g. pregnancy, oral contraceptives, already elevated TSH level at 20 minutes followed
nephrotic syndrome). by a slight decrease at 60 minutes; occurs in primary
hypothyroidism.
Total and Free Triiodothyronine (T3) 3. Flat response: There is no response; occurs in
Uses secondary (pituitary) hypothyroidism.
4. Delayed response: TSH is higher at 60 minutes as
1. Diagnosis of T3 thyrotoxicosis: Hyperthyroidism with compared to its level at 20 minutes; seen in tertiary
low TSH and elevated T3, and normal T4/FT4 is
(hypothalamic) hypothyroidism.
termed T3 thyrotoxicosis.
2. Early diagnosis of hyperthyroidism: In early stage of Antithyroid Antibodies
hyperthyroidism, total T4 and free T4 levels are
normal, but T3 is elevated. Various autoantibodies (TSH receptor, antimicrosomal,
A low T3 level is not useful for diagnosis of and antithyroglobulin) are detected in thyroid disorders
hypothyroidism since it is observed in about 25% of like Hashimoto’s thyroiditis and Graves’ disease.
normal individuals. Antimicrosomal (also called as thyroid peroxidase) and
For routine assessment of thyroid function, TSH and anti-thyroglobulin antibodies are observed in almost all
T4 are measured. T3 is not routinely estimated because patients with Hashimoto’s disease. TSH receptor
normal plasma levels are very low. antibodies (TRAb) are mainly tested in Graves’ disease
Normal T3 level is 80-180 ng/dl. to predict the outcome after treatment (Box 12.4).
144 Essentials of Clinical Pathology
• Hyperthyroidism due to Graves’ disease, toxic Thyroid hormone deficiency during neonatal period can
multinodular goiter, toxic adenoma, TSH-secreting cause severe mental retardation (cretinism) that can be
tumor. prevented by early detection and treatment. Estimation
of TSH is done on dry blood spots on filter paper or cord
Causes of Decreased Uptake serum between 3rd to 5th days of life. Elevated TSH is
diagnostic of hypothyroidism. In infants with confirmed
• Hyperthyroidism due to administration of thyroid hypothyroidism, RAIU (123I) scan should be done to
hormone, factitious hyperthyroidism, subacute distinguish between thyroid agenesis and dyshormono-
thyroiditis. genesis.
2. Heuck CC, Kallner A, Kanagasabapathy AS, Riesen W. 5. McDermott MT. Endocrine Secrets (4th Ed).
Diagnosis and monitoring of diseases of thyroid. World Philadelphia. Mosby, 2005.
Health Organization. 2000 WHO/DIL/0.004. 6. US Preventive Services Task Force: Screening for
3. Kaplan MM. Clinical perspectives in the diagnosis of thyroid disease: Recommended statement. Ann Intern
thyroid disease. Clin Chem 1999;45:1377-83. Med 2004;140:125-7.
4. Lazarus JH, Obuobie K. Thyroid disorders—an update. 7. Woeber KA. The year in review: the thyroid. Ann Intern
Postgrad Med J 2000;76:529-36. Med 1999;131:959-62.
13
Pregnancy Tests
Pregnancy tests detect human chorionic gonadotropin CLINICAL APPLICATIONS OF TESTS FOR
(hCG) in serum or urine. Although pregnancy is the most HUMAN CHORIONIC GONADOTROPIN
common reason for ordering the test for hCG, measure-
1. Early diagnosis of pregnancy: Qualitative serum hCG
ment of hCG is also indicated in other conditions as
test becomes positive 3 weeks after last menstrual
shown in Box 13.1.
period (LMP), while urine hCG test becomes positive
Human chorionic gonadotropin is a glycoprotein
5 weeks after LMP.
hormone produced by placenta that circulates in
2. Exclusion of pregnancy before prescribing certain
maternal blood and excreted intact by the kidneys. It
medications (like oral contraceptives, steroids, some
consists of two polypeptide subunits: α (92 amino acids)
antibiotics), and before ordering radiological studies,
and β (145 amino acids) which are non-covalently bound
radiotherapy, or chemotherapy. This is necessary to
to each other. Structurally, hCG is closely related to three
prevent any teratogenic effect on the fetus.
other glycoprotein hormones, namely, luteinizing
3. Early diagnosis of ectopic pregnancy: Trans-vaginal
hormone (LH), follicle-stimulating hormone (FSH), and
ultrasonography (USG) and quantitative estimation
thyroid-stimulating hormone (TSH). The α subunits of
of hCG are helpful in early diagnosis of ectopic
hCG, LH, FSH, and TSH are similar, while β subunits
pregnancy (before rupture).
differ and confer specific biologic and immunologic
4. Evaluation of threatened abortion: Serial quantitative
properties. Immunological tests use antibodies directed
estimation of hCG is helpful in following the course
against β-subunit of hCG to avoid cross-reactivity against
of threatened abortion.
LH, FSH, and TSH.
5. Diagnosis and follow-up of gestational trophoblastic
Syncytiotrophoblastic cells of conceptus and later of
disease (GTD).
placenta synthesize hCG. Human chorionic gonado-
6. Maternal triple test screen: This consists of measure-
tropin supports the corpus luteum of ovary during early
ment of hCG, α-fetoprotein, and unconjugated estriol
pregnancy. Progesterone, produced by corpus luteum,
in maternal serum at 14-19 weeks of gestation. The
prevents ovulation and thus maintains pregnancy. After
maternal triple screen identifies pregnant women
7-10 weeks of gestation, sufficient amounts of proges-
with increased risk of Down syndrome and major
terone are synthesized by placenta, and hCG is no longer
congenital anomalies like neural tube defects.
needed and its level declines.
7. Follow-up of ovarian or testicular germ cell tumors,
which produce hCG.
Box 13.1: Indications for measurement of β human
chorionic gonadotropin Normal Pregnancy
• Early diagnosis of pregnancy In women with normal menstrual cycle, conception
• Diagnosis and management of gestational trophoblastic (fertilization of ovum to form a zygote) occurs on day 14
disease in the fallopian tube. Zygote travels down the fallopian
• As a part of maternal triple test screen
tube into the uterus. Division of zygote produces a
• Follow-up of malignant tumors that produce β human
chorionic gonadotropin. morula. At 50-60-cell stage, morula develops a primitive
yolk sac and is then called as a blastocyst. About 5 days
Pregnancy Tests 147
REFERENCE RANGES
• Serum human chorionic gonadotropin:
– Non-pregnant females: <5.0 mIU/ml
– Pregnancy: 4 weeks after LMP: 5-100 mIU/ml
– 5 weeks after LMP: 200-3000 mIU/ml
– 6 weeks after LMP: 10,000-80,000 mIU/ml
– 7-14 weeks: 90,000-500,000 mIU/ml
Fig. 13.2: Principle of agglutination inhibition test for
– 15-26 weeks: 5000-80000 mIU/ml
diagnosis of pregnancy
– 27-40 weks: 3000-15000 mIU/ml
and are known as ‘heterophil’ antibodies. Fetal death,
abortion, dilute urine, and low sensitivity of a particular BIBLIOGRAPHY
test are causes of false-negative test. Renal failure leads 1. Burtis CA, Ashwood ER. Tietz fundamentals of clinical
to accumulation of interfering substances causing chemistry (5th Ed). Philadelphia: WB Saunders
incorrect results. Company, 2001.
In latex particle agglutination inhibition test 2. Davies S, Byrn F, Cole LA. Human chorionic gonado-
tropin testing for early pregnancy viability and
(Fig. 13.2), anti-hCG antibodies are incubated with complications. Clin Lab Med 2003;23:257-64.
patient’s urine. This is followed by addition of hCG- 3. Tenore JL. Ectopic pregnancy. Am Fam Physician
coated latex particles. If hCG is present in urine, anti- 2000;61:1080-8.
14
Infertility
Males
• Semen analysis
• Blood glucose
• Endocrine tests: Serum FSH, LH, testosterone
Females
• Hemogram, X-ray chest, Mantoux test, erythrocyte
sedimentation rate
• Thyroid hormones, serum prolactin
• Endometrial biopsy
• Laparoscopy with hysteroscopy and/or hysterosalpin-
gography
• Transvaginal ultrsonography
Fig. 14.6: The hypothalamus-pituitary-ovarian axis
obstructive azoospermia is not evident (i.e. normal ovary collapses and fills with blood clot (corpus luteum).
FSH and normal testicular volume). LH converts granulose cells in the follicle to lutein cells
Common initial investigations for diagnosis of cause which begin to secrete progesterone. Progesterone
of infertility are shown in Box 14.1. stimulates secretion from the endometrial glands
(secretory phase) that were earlier under the influence
FEMALE INFERTILITY
of estrogen. Rising progesterone levels inhibit LH
The ovaries are the sites of production of female gametes production from the anterior pituitary. Without LH, the
or ova by the process of oogenesis. The ova are released corpus luteum regresses and becomes functionless
by the process of ovulation in a cyclical manner at regular corpus albicans. After regression of corpus luteum,
intervals. Ovary contains numerous follicles that contain production of estrogen and progesterone stops and
ova in various stages of development. During each
endometrium collapses, causing onset of menstruation.
menstrual cycle, up to 20 primordial follicles are activated
If the ovum is fertilized and implanted in the uterine
for maturation; however, only one follicle becomes fully
wall, human chorionic gonadotropin (hCG) is secreted
mature; this dominant follicle ruptures to release the
by the developing placenta into the maternal circulation.
secondary oocyte from the ovary. Maturation of the
follicle is stimulated by follicle stimulating hormone Human chorionic gonadotropin maintains the corpus
(FSH) secreted by anterior pituitary (Fig. 14.6). Maturing luteum for secetion of estrogen and progesterone till 12th
follicle secretes estrogen that causes proliferation of week of pregnancy. After 12th week, corpus luteum
endometrium of the uterus (proliferative phase). regresses to corpus albicans and the function of synthesis
Follicular cells also secrete inhibin which regulates of estrogen and progesterone is taken over by placenta
release of FSH by the anterior pituitary. Fall in FSH level till parturition.
is followed by secretion of luteinizing hormone (LH) by The average duration of the normal menstrual cycle
the anterior pituitary (LH surge). This causes follicle to is 28 days. Ovulation occurs around 14th day of the cycle.
rupture and the ovum is expelled into the peritoneal The time interval between ovulation and menstruation
cavity near the fimbrial end of the fallopian tube. The is called as luteal phase and is fairly constant (14 days)
fallopian tubes conduct ova from the ovaries to the (Fig. 14.7).
uterus. Fertilization of ovum by the sperm occurs in the
fallopian tube. Causes of Female Infertility
The ovum consists of the secondary oocyte, zona
pellucida and corona radiata. The ruptured follicle in the Causes of female infertility are shown in Table 14.3.
Infertility 155
Fig. 14.8: Evaluation of female infertility. FSH: Follicle stimulating hormone; LH: Luteinizing hormone;
DHEA-S: Dihydroepiandrosterone; TSH: Thyroid stimulating hormone; ↑ : Increased; ↓ : Decreased
ficial squamous cells with pyknotic nuclei to all Increased testosterone: Polycystic ovarian disease
mature squamous cells in a lateral vaginal wall smear. (PCOD), congenital adrenal hyperplasia (To differen-
Usually minimum of 300 cells are evaluated. The peak tiate PCOD from congenital adrenal hyperplasia,
KI usually corresponds with time of ovulation and ultrasound and estimation of dihydroepiandros-
terone or DHEA are done).
may reach upto 50 to 85.
3. Transvaginal ultrasonography: This is done for detection
7. Estimation of progesterone in mid-luteal phase (day 21 or
of PCOD.
7 days before expected menstruation): Progesterone
level > 10 nmol/L is a reliable evidence of ovulation Investigations to Assess Tubal and Uterine Status
if cycles are regular (Fig. 14.10). A mistimed sample 1. Infectious disease: These tests include endometrial
is a common cause of abnormal result. biopsy for tuberculosis and test for chlamydial IgG
antibodies for tubal factor in infertility.
Tests to Determine the Cause of Anovulation
2. Hysterosalpingography (HSG): HSG is a radiological
1. Measurement of LH, FSH, and estradiol during days 2 to contrast study for investigation of the shape of the
6: All values are low in hypogonadotropic hypo- uterine cavity and for blockage of fallopian tubes
gonadism (hypothalamic or pituitary failure). (Fig. 14.11). A catheter is introduced into the cervical
2. Measurement of TSH, prolactin, and testosterone if cycles canal and a radiocontrast dye is injected into the
are irregular or absent: uterine cavity. A real time X-ray imaging is carried
Increased TSH: Hypothyroidism
out to observe the flow of the dye into the uterine
Increased prolactin: Pituitary adenoma cavity, tubes, and spillage into the uterine cavity.
3. Hysterosalpingo-contrast sonography: A catheter is
introduced into the cervical canal and an echocontrast
fluid is introduced into the uterine cavity. Shape of
the uterine cavity, filling of fallopian tubes, and
spillage of contrast fluid are noted. In addition,
ultrasound scan of the pelvis provides information
about any fibroids or polycystic ovarian disease.
4. Laparoscopy and dye hydrotubation test with hysteroscopy:
In this test, a cannula is inserted into the cervix and
methylene blue dye is introduced into the uterine
cavity. If tubes are patent, spillage of the dye is
observed from the ends of both tubes. This technique
also allows visualization of pelvic organs, endo-
metriosis, and pelvic adhesions. If required, endo-
Fig. 14.10: Serum progesterone during metriosis and tubal blockage can be treated during
normal menstrual cycle the procedure.
Possible pregnancy and active pelvic or vaginal • Serum dehydroepiandrosterone sulfate (DHEA-S):
infection are contraindications to tubal patency tests. – Adult males: 59-452 μg/ml
– Adult females: 12-379 μg/ml
REFERENCE RANGES BIBLIOGRAPHY
• Serum follicle stimulating hormone: 1. Brugh III, VM, Lipshultz LI. Male factor infertility: Evaluation
and management. Med Clin N Am 2004;88:367-85.
– Adult males: 1.4-15.4 mIU/ml 2. Burtis CA, Ashwood ER. Tietz fundamentals of clinical
– Adult females: Follicular phase: 1-10 mIU/ml; chemistry. 5th Ed. Philadelphia: WB Saunders
Ovulatory peak: 6-17 mIU/ml; Luteal phase: 1-9 Company, 2001.
mIU/ml 3. Dohle GR, Jungwirth A, Colpi G, Papp G, Pomerol J,
Hargreave TB. Guidelines on male infertility. European
• Serum luteinizing hormone: Association of Urology, 2006.
– Adult males: 1.24-7.8 mU/ml 4. Hirsh A. Male subfertility. BMJ 2003;327:669-72.
– Adult females: Follicular phase: 1.68-15 mIU/ml; 5. Hamilton-Fairley D, Taylor A. Anovulation. BMJ
Ovulatory peak: 21.9-56.6 mIU/ml; Luteal phase: 2003;327:546-9.
6. Jarrow JP. Diagnostic approach to the infertile male
0.61-16.3 mIU/ml
patient. Endocrinol Metab Clin N Am 2007;36:297-311.
• Serum testosterone: 7. Khalaf Y. Tubal subfertility. BMJ 2003;327:610-3.
– Adult males: 280-1100 ng/dl 8. Kolettis PN. Evaluation of the subfertile man. Am Fam
– Adult females: 15-70 ng/dl Physician 2003;67:2165-73.
9. Williams C, Giannopoulos T, Sherriff EA. Investigation
• Serum prolactin:
of infertility with the emphasis on laboratory testing
– Adult males: 3.0-14.7 ng/ml and with reference to radiological imaging. J Clin Pathol
– Adult females: 3.8-23.2 ng/ml 2003;56:261-7.
15
Semen Analysis
Semen (or seminal fluid) is a fluid that is emitted from Normal values for semen analysis are shown in Tables
the male genital tract and contains sperms that are 15.1 and 15.2.
capable of fertilizing female ova. Structures involved in
production of semen are (Box 15.1): INDICATIONS FOR SEMEN ANALYSIS
• Testes: Male gametes or spermatozoa (sperms) are
Availability of semen for examination allows direct
produced by testes; constitute 2-5% of semen volume.
examination of male germ cells that is not possible with
• Epididymis: After emerging from the testes, sperms
female germ cells. Semen analysis requires skill and
are stored in the epididymis where they mature;
should preferably be done in a specialized andrology
potassium, sodium, and glycerylphosphorylcholine
(an energy source for sperms) are secreted by laboratory.
epididymis. 1. Investigation of infertility: Semen analysis is the first
• Vas deferens: Sperms travel through the vas deferens step in the investigation of infertility. About 30% cases
to the ampulla which is another storage area. Ampulla of infertility are due to problem with males.
secretes ergothioneine (a yellowish fluid that reduces 2. To check the effectiveness of vasectomy by confir-
chemicals) and fructose (source of nutrition for ming absence of sperm.
sperms). 3. To support or disprove a denial of paternity on the
• Seminal vesicles: During ejaculation, nutritive and grounds of sterility.
lubricating fluids secreted by seminal vesicles and 4. To examine vaginal secretions or clothing stains for
prostate are added. Fluid secreted by seminal vesicles the presence of semen in medicolegal cases.
consists of fructose (energy source for sperms), amino 5. For selection of donors for artificial insemination.
acids, citric acid, phosphorous, potassium, and 6. For selection of assisted reproductive technology, e.g.
prostaglandins. Seminal vesicles contribute 50% to in vitro fertilization, gamete intrafallopian transfer
semen volume. technique.
• Prostate: Prostatic secretions comprise about 40% of
semen volume and consist of citric acid, acid COLLECTION OF SEMEN FOR
phosphatase, calcium, sodium, zinc, potassium, INVESTIGATION OF INFERTILITY
proteolytic enzymes, and fibrolysin.
Semen specimen is collected after about 3 days of sexual
• Bulbourethral glands of Cowper secrete mucus.
abstinence. Longer period of abstinence reduces motility
of sperms. If the period of abstinence is shorter than 3
Box 15.1: Contributions to semen volume days, sperm count is lower. The sample is obtained by
masturbation, collected in a clean, dry, sterile, and leak-
• Testes and epididymis: 10%
proof wide-mouthed plastic container, and brought to
• Seminal vesicles: 50%
the laboratory within 1 hour of collection. The entire
• Prostate: 40%
• Cowper’s glands: Small volume
ejaculate is collected, as the first portion is the most
concentrated and contains the highest number of sperms.
160 Essentials of Clinical Pathology
Table 15.1: Normal values of semen analysis (World Health Organization, 1999)
Test Result
1. Volume ≥2 ml
2. pH 7.2 to 8.0
3. Sperm concentration ≥20 million/ml
4. Total sperm count per ejaculate ≥40 million
5. Morphology ≥30% sperms with normal morphology
6. Vitality ≥75% live
7. White blood cells <1 million/ml
8. Motility within 1 hour of ejaculation
• Class A ≥25% rapidly progressive
• Class A and B ≥50% progressive
9. Mixed antiglobuiln reaction (MAR) test <50% motile sperms with adherent particles
10. Immunobead test <50% motile sperms with adherent particles
Table 15.2: Biochemical variables of semen analysis (World Helath Organization, 1992)
The tests that can be done on seminal fluid are shown in Box 15.3: Semen analysis for initial
Box 15.2. Tests commonly done in infertility are shown investigation of infertility
in Box 15.3. The usual analysis consists of measurement • Volume
of semen volume, sperm count, sperm motility, and • pH
• Microscopic examination for (i) percentage of motile
sperm morphology.
spermatozoa, (ii) sperm count, and (iii) sperm morphology
Terminology in semen analysis is shown in Box 15.4.
Semen Analysis 161
Method
5. Normal sperm count is ≥ 20 million/ml (i.e. ≥ 20 ×
1. Mix one drop of semen with 1 drop of eosin-nigrosin
10 6/ml). Sperm count < 20 million/ml may be
solution and incubate for 30 seconds.
associated with infertility in males.
2. A smear is made from a drop placed on a glass slide.
3. The smear is air-dried and examined under oil- Sperm Morphology
immersion objective. White sperms are classified as
A smear is prepared by spreading a drop of seminal fluid
live or viable, and red sperms are classified as dead
on a glass slide, stained, and percentages of normal and
or non-viable. At least 200 spermatozoa are examined.
abnormal forms of spermatozoa are counted. The
4. The result is expressed as a proportion of viable
staining techniques used are Papanicolaou, eosin-
sperms against non-viable as an integer percentage.
nigrosin, hematoxylin-eosin, and Rose Bengal-toluidine
Seventy-five percent or more of sperms are normally
blue stain. Atleast 200 spermatozoa should be counted
live or viable.
under oil immersion. Percentages of normal and
Sperm Count abnormal spermatozoa should be recorded.
Normal morphology: A spermatozoon consists of three
Principle: The sperm count is done after liquefaction in a
main components: head, neck, and tail. Tail is further
counting chamber following dilution and the total
subdivided into midpiece, main (principle) piece, and
number of spermatozoa is reported in millions/ml (106/
end piece (Fig. 15.2 and Box 15.5).
ml).
Head is pear-shaped. Most of the head is occupied
Method by the nucleus which has condensed chromatin and few
1. Semen is diluted 1:20 with sodium bicarbonate- areas of dispersed chromatin (called nuclear vacuoles).
formalin diluting fluid (Take 1 ml liquefied semen in The anterior 2/3rds of the nucleus is surrounded by
a graduated tube and fill with diluting fluid to 20 ml acrosomal cap. Acrosomal cap is a flattened membrane-
mark. Mix well). bound vesicle containing glycoproteins and enzymes.
2. A coverslip is placed over the improved Neubauer These enzymes are required for separation of cells of
counting chamber and the counting chamber is filled corona radiata and dissolution of zona pellucida of ovum
with the well-mixed diluted semen sample using a during fertilization.
Semen Analysis 163
Fig. 15.3: Abnormal morphological sperm forms: (1) Normal sperm, (2) Large head, (3) Small head, (4) Tapered head, (5)
Pyriform head, (6) Round head, (7) Amorphous head, (8) Vacuoles in head, (9) Round head without acrosome, (10) Double
head, (11) Pin head, (12) Round head without acrosome and thick midpiece, (13) Coiled tail, and (14) Double tail
Round Cells a. SpermMARTM test: This test can detect IgG and IgA
antibodies against sperm surface in semen sample.
Round cells on microscopic examination may be white
In direct SpermMARTM IgG test, a drop each of semen
blood cells or immature sperm cells. Special stain
(peroxidase or Papanicolaou) is required to differentiate (fresh and unwashed), IgG-coated latex particles, and
anti-human immunoglobulin are mixed together on
between them. White blood cells >1 million/ml indicate
a glass slide. At least 200 motile spermatozoa are
presence of infection. Presence of large number of
examined. If the spermatozoa have antibodies on
immature sperm cells indicates spermatogenesis
their surface, antihuman immunoglobulin will bind
dysfunction at the testicular level.
IgG-coated latex particles to IgG on the surface of the
spermatozoa; this will cause attachment of latex
Immunologic Analysis
particles to spermatozoa, and motile, swimming
Antisperm Antibodies sperms with attached particles will be seen. If the
spermatozoa do not have antibodies on their surface,
The role of antisperm antibodies in causation of male
they will be seen swimming without attached
infertility is controversial. The immunological tests done
particles; the latex particles will show clumping due
on seminal fluid include mixed antiglobulin reaction to binding of their IgG to antihuman immuno-
(MAR test) and immunobead test. globulin.
The antibodies against sperms immobilize or kill In direct SpermMARTM IgA test, a drop each of fresh
them, thus preventing their passage through the cervix unwashed semen and of IgA-coated latex particles,
to the ovum. The antibodies can be tested in the serum, are mixed on a glass slide. The latex particles will
seminal fluid, or cervical mucus. If the antibodies are bind to spermatozoa if spermatozoa are coated with
present bound to the head of the sperm, they will prevent IgA antibodies.
the penetration of the egg by the sperm. If antibodies are In indirect SpermMAR TM tests, fluid without
bound to the tail of the sperm, they will retard motility. spermatozoa (e.g. serum) is tested for the presence of
Semen Analysis 165
Hematopoiesis
lymphoid and all blood cells belong to either of these Blood cells in the bone marrow can be considered to
two lineages. Myeloid cells include erythrocytes or red be in three compartments or pools: stem cell pool
cells, platelets, neutrophils, eosinophils, basophils, and (comprises of pleuripotent and multipotent stem cells,
monocytes. Lymphoid cells are of two main types: B and and commited CFUs), proliferating pool (morpholo-
T lymphocytes. The myeloid stem cell is called as CFU- gically identifiable precursors that are capable of DNA
GEMM (Colony forming unit granulocyte-erythrocyte- synthesis and mitosis), and storage pool (maturing and
monocyte-megakaryocyte). CFU refers to the develop- mature cells that are stored for later release in peripheral
ment of colonies of cells when marrow cells are injected blood).
in a tissue culture medium. CFU-GEMM leads to the Hematopoiesis is regulated by two main factors: (i)
formation of BFU-E (Burst Forming Unit-Erythroid), hematopoietic growth factors (HGFs) or cytokines,
CFU-Meg (Colony Forming Unit-Megakaryocyte), CFU- secreted by various cell types (Table 16.1), and (ii) stromal
GM (Colony Forming Unit-Granulocyte-Monocyte/ cells in the microenvironment of the bone marrow. HGFs
Macrophage), CFU-Eo (Colony Forming Unit- are glycoproteins secreted by various cell types which
Eosinophil), and CFU-Baso (Colony Forming Unit- regulate proliferation and differentiation of progenitor
Basophil). CFU-GM further produces CFU-G (Colony cells and function of mature blood cells. Stromal cells
Forming Unit-Granulocyte) and CFU-M (Colony secrete a variety of HGFs in the bone marrow micro-
Forming Unit-Monocyte/Macrophage) (Fig. 16.2). The environment; secondly hematopoietic progenitor cells
progenitor cells up to these stages are not identifiable adhere to receptors on stromal cells and on the stromal
morphologically; they can however be identified by their matrix that facilitates interaction of progenitor cells with
surface receptors. regulatory cytokines.
Fig. 16.2: Hierarchy of hematopoiesis. Abbreviations: SCF: Stem cell factor; IL: Interleukin; CFU-GEMM: Colony forming unit
granulocyte-erythrocyte-monocyte-megakaryocyte; CFU-GM: Colony forming unit granulocyte-macrophage; TPO: Thrombopoietin;
CFU- G: Colony forming unit granulocyte; CFU-M: Colony forming unit macrophage; CFU-Eo: Colony-forming unit eosinophil;
CFU-Baso: Colony forming unit basophil; CFU-Meg: Colony forming unit megakaryocyte; Epo: Erythropoietin; GM-CSF: granulocyte
macrophage colony stimulating factor; G-CSF: Granulocyte colony stimulating factor; M-CSF: Macrophage Colony stimulating
factor
Hematopoiesis 171
ribosomal RNA). With each stage of development, cell Red Cell Enzymes
size and nuclear size become smaller, chromatin
Energy for various metabolic processes in the red cell
clumping increases, and ultimately nucleus is extruded.
(transport of oxygen and carbon dioxide, membrane
Color of cytoplasm gradually changes from basophilic
pump, prevention of oxidant damage to hemoglobin, and
to pink due to hemoglobinization. A mature red cell or
erythrocyte is a biconcave, non-nucleated disk of 7-8 μ to convert methemoglobin to oxyhemoglobin) is
size. provided by glycolysis or Embden-Meyerhof pathway
and hexose monophosphate (HMP) shunt. A metabolic
Hemoglobin shunt in glycolytic pathway is Rapoport-Luebering shunt
Hemoglobin (average molecular weight 64,000) consists for generation of 2,3-diphosphoglycerate (2,3-DPG), an
of heme (iron and protoporphyrin) and globin (two important determinant for oxygen affinity of hemo-
polypeptide chains). A heme group is attached to each globin. In HMP pathway, NADPH is produced that
polypeptide chain. Normally, different types of hemo- reduces oxidized glutathione; reduced glutathione along
globins are present during embryonic life, fetal life, with glutathione peroxidase detoxifies hydrogen
infancy, and adulthood (Table 16.3). peroxide and prevents oxidant damage to hemoglobin.
Hemoglobin (Hb) Gower I, Hb Gower II, and Hb The enzyme glucose 6 phosphate dehydrogenase (G6PD)
Portland predominate during embryonic life, while Hb is necessary for generation of NADPH (Fig. 16.5).
F predominates during fetal life. HbF starts to decline
after 36 weeks of gestation, and constitutes <1% of total Red Cell Membrane
hemoglobin in adults. HbA becomes the main hemo-
globin after 3-4 months of age. Red cell cytoskeletal proteins lie beneath the lipid bilayer
Steps in the synthesis of β globin chain of hemo- and consist of horizontally oriented spectrin hetero-
globin A are shown in Figure 16.4. dimers (α and β spectrin intertwined together) that link
Biosynthesis of heme is outlined in Chapter 31: with ankyrin, proteins 4.1 and 4.2, and band 3 (vertical
Laboratory Tests in Porphyrias. elements) (Fig. 16.6). Cytoskeletal proteins maintain
The function of red cells is transport of oxygen and shape and allow flexibility permitting red cells to traverse
carbon dioxide. Oxygen binds covalently and reversibly through the capillaries of small diameter.
with hemoglobin, with maximum 4 oxygen molecules The lifespan of red cells is about 120 days, after which
binding to four iron molecules (i.e. one molecule of they are ingested and degraded by mononuclear
oxygen binds to each heme group). Oxygen affinity of phagocytes. Iron and amino acids are recycled for reuse,
hemoglobin is affected by pH, temperature, and oxygen while the remainder of the heme molecule is metabolized
pressure in capillaries. to bilirubin and excreted by liver in bile.
Fig. 16.4: (A) β globin gene cluster on chromosome 11; (B) Steps in the synthesis of β globin
polypeptide chain from β globin gene
Fig. 16.5: Role of glucose-6-phosphate dehydrogenase enzyme in detoxification of toxic peroxide. Abbreviations: HK: Hexokinase;
GSSG: Oxidized glutathione; GSH: Reduced glutathione; H2O2: Hydrogen peroxide; 6PGL: 6 Phosphogluconolaconase; 6PGD:
6 Phosphogluconate dehydrogenase; Ru5PI: Ribulose 5 phosphate isomerase
174 Essentials of Clinical Pathology
1. Myeloblast 15-20 Large, immature, fine dispersed chromatin, 2-5 nucleoli Scanty, light blue
2. Promyelocyte 16-20 Similar to myeloblast, slightly eccentric Azurophil granules
3. Myelocyte 14-18 Chromatin condensed, no nucleoli Specific granules
predominate
4. Metamyelocyte 14-18 Indented or kidney-shaped; peripheral clumping Faint pink; numerous
of chromatin specific granules
5. Band form 14-16 U-shaped or band-like nucleus with heavily Pink; numerous
clumped chromatin specific granules
6. Neutrophil 14-15 2-5 lobes joined by chromatin strands Pink; numerous
specific granules
Hematopoiesis 175
Lymphocytes
There are three main types: B lymphocytes, T lympho-
cytes, and natural killer (NK) cells.
B lymphocytes comprise about 10-20% of lympho-
cytes in peripheral blood. In lymphoid organs they are
located in superficial cortex, germinal centers, and mantle
zone of lymph nodes, follicles in spleen, and mucosa-
associated lymphoid tissue (MALT) in gastrointestinal
and respiratory tracts. On antigen stimulation, B
lymphocytes differentiate into plasma cells that produce
immunoglobulins (antibodies).
T lymphocytes comprise 60-70% of circulating
lymphocytes. In lymphoid organs, they are located in
thymus, paracortex of lymph nodes, and periarteriolar Fig. 16.9: Normal mature white blood cells in
lymphoid sheaths in spleen. T lymphocytes are respon- peripheral blood
176 Essentials of Clinical Pathology
THROMBOPOIESIS
Platelets are produced by cytoplasmic fragmentation of Fig. 16.12: Stages of platelet formation. The morphologically
large cells in bone marrow called as megakaryocytes, recognizable stages are megakaryoblast (high nucleo-
cytoplasmic ratio with basophilic cytoplasm), promegakaryocyte
which in turn are derived from megakaryoblasts. The
(nucleus typically horse-shoe shaped), and megakaryocyte
morphologically identifiable stages in thrombopoiesis (cytoplasm granular, nucleus highly lobular). Megakaryocytes
are: megakaryoblast, promegakaryocyte, megakaryocyte, undergo endomitosis and are the largest cells in the bone
marrow
and platelets (Fig. 16.12). Although nucleus of a mega-
karyocyte divides, cell division does not occur so that a
very large cell with multiple nuclear lobes (increased cytoplasmic processes through the sinusoidal wall in
ploidy) is formed (the process whereby nuclear DNA is marrow and platelets are released directly in bloodstream
duplicated without cell division is called as endomitosis). by fragmentation of cytoplasm. The lifespan of platelets
Megakaryocyte is the largest normally occurring hemato- is about 7-10 days.
poietic cell in the bone marrow. Each megakaryocyte
BIBLIOGRAPHY
produces about 4000 platelets during its lifespan. The
1. Hoffbrand AV, Moss PAH, Pettit JE (Eds). Essential
primary regulator of megakaryocyte differentiation is Hematology (5th Ed). Blackwell Publishing Ltd, 2006.
thrombopoietin (secreted by liver and stromal cells of 2. Kawthalkar SM. Essentials of Hematology. New Delhi:
bone marrow). A mature megakaryocyte extends Jaypee Brothers Medical Publishers (P) Ltd, 2006.
17
Collection of Blood
SKIN PUNCTURE
This method is commonly used in infants and small
children and if the amount of blood required is small. It
is suitable for cell counts, estimation of hemoglobin,
determination of hematocrit by micro method, and
preparation of blood films.
Blood obtained by skin puncture is also called as
capillary blood. However, it is a mixture of blood from
capillaries, venules, and arterioles. It also contains some
tissue fluid.
In adults, blood is obtained from the side of a ring or
middle finger (distal digit) or ear lobe. In infants, it is
collected from the heel (lateral or medial aspect of plantar Fig. 17.1: (A) Blood lancet and sites of (B) finger
surface) or great toe (Fig. 17.1). puncture (cross) and (C) heel puncture (shaded areas)
The puncture site is cleansed with 70% ethanol or
other suitable disinfectant. After drying, a puncture,
VENOUS BLOOD COLLECTION
sufficiently deep to allow free flow of blood, is made with
a sterile, dry, disposable lancet. The first drop of blood is When multiple tests are to be done and larger quantity
wiped away with sterile, dry cotton as it contains tissue of blood is needed, anticoagulated venous blood should
fluid. Next few drops of blood are collected. Excessive be obtained.
squeezing should be avoided, as it will dilute the blood
Method
with tissue fluid. After collection a piece of sterile cotton
is pressed over the puncture site till bleeding ceases. 1. Due to the ease of access, blood is best obtained from
As compared to the venous blood, hemoglobin, the veins of the antecubital fossa (Fig. 17.2). A rubber
hematocrit, and red cell count are slightly higher in blood tourniquet (18 inches long × 3/4 or 1 inch in adults
from skin puncture. As platelets adhere to the puncture and 12 inches × 1/8 inch in children) is applied to
site, platelet count is lower. Because of small sample size, the upper arm. It should not be too tight and should
immediate repeat testing is not possible if the result is not remain in place for more than two minutes.
abnormal. Patient is asked to make a fist so that veins become
Blood should not be collected from cold, cyanosed more prominent and palpable.
skin since false elevation of values of hemoglobin and 2. Venepuncture site is cleansed with 70% ethanol and
red/white cell counts will be obtained. allowed to dry.
180 Essentials of Clinical Pathology
Precautions
1. Blood is never collected from an intravenous line or
from the arm being used for intravenous line (since
it will dilute the blood sample). Blood is not collected
from a sclerosed vein and from an area with hema-
toma.
2. Tourniquet should not be too tight and should not be
Fig. 17.2: Common sites of venepuncture in antecubital applied for more than 2 minutes as it will cause
fossa (red circles) hemoconcentration and alteration of test results.
3. Puncture site should be allowed to dry completely
after cleaning with alcohol (before performing the
3. The selected vein is anchored by compressing and venepuncture).
pulling the soft tissues below the puncture site with 4. Tourniquet should be released before removing the
the left hand.
needle from the vein (to prevent hematoma
4. Sterile, disposable needles and syringes should be
formation).
used for venepuncture. Needle size should be 19- to
5. To avoid hemolysis, blood is withdrawn gradually, a
21-gauge in adults and 23-gauge in children.
Venepuncture is performed with the bevel of the small-bore needle should not be used, and the needle
needle up and along the direction of the vein. Blood is detached from the syringe before dispensing blood
is withdrawn slowly. Pulling the plunger quickly can into the container.
cause hemolysis and collapse of the vein. 6. All blood samples are considered as infectious and
Tourniquet should be released as soon as the blood proper precautions should be observed while
begins to flow into the syringe. collecting blood either from a vein or a skin puncture.
5. When the required amount of blood is withdrawn, Anticoagulated blood sample should be tested within
the patient is asked to open his/her fist. The needle 1-2 hours of collection. If this is not possible, sample can
is withdrawn from the vein. A sterile cotton gauze is be stored in a refrigerator at 4-6°C for maximum of 24
pressed over the puncture site. Patient is asked to hours. After the sample is taken out of refrigerator, it
press the gauze over the site till bleeding stops. should be allowed to return to room temperature, mixed
6. The needle is detached from the syringe and the properly, and then tested.
required amount of blood is carefully delivered into
the tube containing appropriate anticoagulant (see Complications
later). If the blood is forced through the needle 1. Failure to obtain blood: This happens if vein is missed,
without detaching it, hemolysis can occur. Containers or excessive pull is applied to the plunger causing
may be glass bottles or disposable plastic tubes with collapse of the vein.
caps and flat bottom. 2. Occurrence of hematoma, thrombosis, thrombo-
7. Blood is mixed with the anticoagulant in the container phlebitis, abscess, or bleeding.
thoroughly by gently inverting the container several 3. Transmission of infections like hepatitis B or human
times. The container should not be shaken vigorously immunodeficiency virus if reusable needles and
as it can cause frothing and hemolysis. syringes, which are not properly sterilised, are used.
Collection of Blood 181
ANTICOAGULANTS
Anticoagulants used for hematological investigations are
ethylene diamine tetra-acetic acid (EDTA), heparin,
double oxalate, and trisodium citrate (Table 17.1).
Table 17.1: Salient features of three main anticoagulants used in the hematology laboratory
1. EDTA Chelation of calcium 1.5 mg/ml Complete blood Cannot be used for
count, blood smear, coagulation tests; can cause
hemoglobin pseudothrombocytopenia on
electrophoresis, hematology analyzer
sickling test
2. Heparin Inhibition of thrombin 15 U/ml Osmotic fragility test, Causes blue background of
activity immunophenotyping blood smears; expensive
3. Sodium citrate Chelation of calcium 0.109 mg/ml Coagulation studies, Liquid anticoagulant: causes
estimation of ESR by dilution and cannot be used
Westergren method for complete blood counts
182 Essentials of Clinical Pathology
Mix to dissolve. Place 0.04 ml of this solution in a Other Tubes for Collection of Blood
bottle for 2.5 ml of blood. Anticoagulant should be dried Plain tubes (i.e. without any anticoagulant) are used for
on a warm bench or in an incubator at 37°C before use. chemistry studies after separation of serum: liver function
For routine hematological investigations, 2-3 ml of tests (total proteins, albumin, aspartate aminotransferase,
EDTA blood is required. alanine aminotransferase, bilirubin), renal function tests
Heparin (blood urea nitrogen, creatinine), calcium, lipid profile,
electrolytes, hormones, and serum osmolality.
Heparin prevents coagulation by enhancing the activity Fluoride bulb is used for collection of whole blood
of antithrombin III (AT III). AT III inhibits thrombin and for estimation of blood glucose. Addition of sodium
some other coagulation factors. It is used in the fluoride (2.5 mg/ml of blood) maintains stable glucose
proportion of 15-20 IU/ ml of blood. Sodium, lithium, or level by inhibiting glycolysis. Sodium fluoride is
ammonium salt of heparin is used. commonly used along with an anticoagulant such as
Heparin should not be used for total leukocyte count potassium oxalate or EDTA.
(since it causes leukocyte clumping) and for making of
blood films (since it imparts a blue background). SEQUENCE OF FILLING OF TUBES
It is used for osmotic fragility test (since it does not Following order of filling of tubes should be followed
alter the size of cells) and for immunophenotyping. after withdrawal of blood from the patient if multiple
Double Oxalate (Wintrobe Mixture) investigations are ordered:
1. First tube: Blood culture.
This consists of ammonium oxalate and potassium 2. Second tube: Plain tube (serum).
oxalate in 3:2 proportion. This combination is used to 3. Third tube: Tube containing anticoagulant (EDTA,
balance the swelling of red cells caused by ammonium citrate, or heparin).
oxalate and shrinkage caused by potassium oxalate. 4. Fourth tube: Tube containing additional stabilizing
Mechanism of anticoagulant action is removal of calcium. agent like fluoride.
It is used for routine hematological tests and for
estimation of erythrocyte sedimentation rate by Wintrobe USE OF PLASMA VS. SERUM
method. Plasma is the supernatant liquid obtained after centrifu-
As it causes crenation of red cells and morphologic gation of anticoagulated whole blood. Serum is the liquid
alteration in white blood cells, it cannot be used for obtained after clotting of whole blood sample collected
making of blood films. in a plain tube. Some of the differences between the two
are as follows:
Preparation
1. Plasma contains fibrinogen as well as all the other
Ammonium oxalate 1.2 gm proteins, while serum does not contain fibrinogen.
Potassium oxalate 0.8 gm 2. Plasma can be obtained immediately after sample
Distilled water upto 100 ml collection by centrifugation, while minimum of 30
Place 0.5 ml of this solution in a bottle for 5 ml of minutes are required for separation of serum from
blood. Anticoagulant should be dried in an incubator at the clotted blood.
37°C or on a warm bench before use. 3. Amount of sample is greater with plasma than with
serum for a given amount of blood.
Trisodium Citrate (3.2%) 4. Use of anticoagulant may alter the concentration of
This is the anticoagulant of choice for coagulation studies some constituents if they are to be measured like
and for estimation of erythrocyte sedimentation rate by sodium, potassium, lithium, etc.
Westergren method.
BIBLIOGRAPHY
Preparation
1. Lewis SM, Bain BJ, Bates I. Dacie and Lewis Practical
Trisodium citrate 3.2 gm Hematology. 9th Ed. London: Churchill Livingstone,
Distilled water upto 100 ml 2001.
Mix well to dissolve. Store in a refrigerator at 2-8°C. 2. World Health Organization. Manual of Basic Techni-
Use 1:9 (anticoagulant: blood) proportion for coagu- ques for a Health Laboratory. 2nd Ed. Geneva: World
lation studies; for ESR, 1:4 proportion is recommended. Health Organization, 2003.
ESR should be measured within 4 hours of collection 3. World Health Organization. Use of anticoagulants in
of blood, while coagulation studies should be performed diagnostic laboratory investigations. 2002. WHO/DIL/
within 2 hours. LAB/99.1 Rev.2
18
Estimation of Hemoglobin
• Development of color is slow and acid hematin World Health Organization after extensive field trials. It
solution is not stable. is mainly intended for detection and management of
• Source of light (daylight or artificial) will influence anemia in under-resourced countries. It is especially
the visual comparison of colors. useful for screening of blood donors, for screening
• Personal error in matching brown glass standard children and women in health programs, monitoring iron
with test solution is 10%. therapy, decision- making regarding referral to a hospital,
• Color of brown glass standard fades with time. and as a point of care device.
Equipment
1. Photoelectric colorimeter or spectrophotometer
2. Sahli’s pipette marked at 20 μl (20 cmm).
3. Pipette 5 ml.
Reagents
1. Drabkin’s solution (pH 7.0-7.4):
Potassium ferricyanide 200 mg
Potassium cyanide 50 mg
Potassium dihydrogen phosphate 140 mg
Non-ionic detergent 1 ml
Distilled water to 1000 ml.
2. Cyanmethemoglobin standard solution with known
Fig. 18.2: Hemoglobin color scale hemoglobin value
186 Essentials of Clinical Pathology
Method
1. In a test tube, take 5 ml of Drabkin’s solution and to
it add 20 μl of blood (1:251 dilution). Stopper the tube,
mix by inverting several times, and allow to stand
for atleast 5 minutes. This time is adequate for
conversion of hemoglobin to cyanmethemoglobin.
2. Transfer the test sample to a cuvette. Read the
absorbance in a spectrophotometer at 540 nm or in a
photoelectric colorimeter using a yellow-green filter.
Also take the absorbance of the standard solution.
Absorbance should be read against reagent blank
(Drabkin’s solution).
3. Hemoglobin value is derived from the formula given
below or from the previously prepared graph or table.
Dilution factor
Concentration of standard × Oxyhemoglobin Method
100
In this method, blood sample is mixed with a weak
Preparation of graph and table: If a graph or a table is ammonia solution. Absorbance of this solution is
prepared which correlates absorbance with hemoglobin measured in a spectrophotometer at 540 nm or in a
photometer using a yellow-green filter. Absorbance of
concentration, result can be obtained quickly. This is
the test sample is compared with that of the standard
particularly suitable when a large number of samples
solution.
are regularly processed on the same instrument.
This method is rapid and simple. However, no stable
Diluted cyanmethemoglobin standards are available
standard solution is available, color of oxyhemoglobin
commercially for preparation of a calibration graph.
solution rapidly fades, and hemoglobin derivatives other
Alternatively, standard cyanmethemoglobin solution is
than oxyhemoglobin are not measured.
diluted serially with Drabkin’s solution. On a linear
graph paper, hemoglobin concentration (horizontal axis) Specific Gravity Method
in each dilution is plotted against the absorbance (vertical
This is a rapid and simple method, which gives approxi-
axis). A straight line joining the points and passing
mate hemoglobin value. It is commonly used for selection
through the origin is obtained. From this graph, a table
of blood donors in blood banks.
can be prepared relating absorbance to hemoglobin A drop of blood is allowed to fall in copper sulphate
concentration (Fig. 18.3). solution of specific gravity 1.053 from a height of 1 cm.
Notes: Specific gravity of 1.053 is equivalent to hemoglobin
concentration of 12.5 grams/dl. The drop of blood gets
1. Lipemic blood (hypertriglyceridemia), high total
covered with copper proteinate and remains discrete for
leukocyte count (> 25,000/μl), or abnormal plasma
15-20 seconds. If the drop sinks within this time, its
proteins (e.g. in multiple myeloma, Waldenström’s specific gravity is higher than that of copper sulphate
macroglobulinemia) can cause erroneous results. solution (i.e. hemoglobin is >12.5 grams/dl) and
2. Cyanmethemoglobin solution is stable so that delay hemoglobin level is acceptable for donation. If it floats,
in taking the reading of absorbance does not affect hemoglobin level is unacceptable. However, specific
the result. gravity of whole blood is also affected by total leukocyte
Estimation of Hemoglobin 187
count and concentration of plasma proteins. In the • Anemia is graded as mild (hemoglobin value from
presence of leukocytosis (e.g. as in chronic myeloid lower limit of normal range to 10.0 grams/dl),
leukemia) or hypergammaglobulinemia (e.g. multiple moderate (7.0-10.0 grams/dl), and severe (< 7.0
myeloma), hemoglobin value will be misleadingly high. grams/dl).
GENERAL REMARKS
REFERENCE RANGES (WORLD HEALTH
• The cyanmethemoglobin method is the most accurate ORGANIZATION)
method for estimation of hemoglobin.
• If anemia is suspected, it is prudent to measure • Adult males: 13.0 - 17.0 gm/dl.
packed cell volume and red cell count along with • Adult females (non-pregnant): 12.0 – 15.0 gm/dl.
hemoglobin concentration. This will be useful in • Adult females (pregnant): 11.0 - 14.0 gm/dl.
assessing the correctness of hemoglobin value and in • Children, 6-12 years: 11.5 - 15.5 gm/dl.
calculation of red cell indices (for morphological • Children, 6 months to 6 years: 11.0 – 14.0 gm/dl.
classification of anemia). Packed cell volume is • Children, 2 – 6 months: 9.5 – 14.0 gm/dl.
roughly three-times the hemoglobin value. This rule, • At birth (full term): 13.6 – 19.6 gm/dl.
however, does not apply to hypochromic anemia
since red cells contain lower hemoglobin for their size. CRITICAL VALUES
• Hemoglobin level is decreased in anemia, recumbent
position (by 5-6%), excess squeezing during finger • < 7 gm/dl (severe anemia)
puncture, presence of clots in the sample, inadequate • > 20 gm/dl (hyperviscosity)
mixing of blood with anticoagulant, and “spurious”
anemia. Causes of “spurious” or “pseudo” anemia BIBLIOGRAPHY
are increased plasma volume in third trimester of 1. Cheesbrough M. District Laboratory Practice in Tropical
pregnancy, pooling of red cells in splenomegaly, fluid Countries. Part 2. Cambridge: Cambridge University
retention in congestive cardiac failure, and rise in Press, 1998.
plasma proteins in paraproteinemias. Hemoglobin 2. Lewis SM, Bain BJ, Bates I. Dacie and Lewis Practical
level is increased following strenuous exercise, at high Hematology (9th Ed). London: Churchill Livingstone,
2001.
altitude, in hemoconcentration (e.g. dehydration),
3. Wallach J. Interpretation of Diagnostic Tests (7th Ed).
prolonged application of tourniquet during vene- Philadelphia: Lippincott Williams & Wilkins, 2000.
puncture, and in polycythemia. 4. World Health Organization. Manual of Basic Techni-
• On most automated hematology analyzers, hemo- ques for a Health Laboratory (2nd Ed). Geneva: World
globin is measured as cyanmethemoglobin. Health Organization, 2003.
19
Packed cell volume (PCV) is the volume occupied by the Internal diameter is 3 mm. It can hold about 3 ml of
red cells when a sample of anticoagulated blood is blood.
centrifuged. It indicates relative proportion of red cells 2. Pasteur pipette with a rubber bulb and a sufficient
to plasma. PCV is also called as hematocrit or erythrocyte length of capillary to reach the bottom of the Wintrobe
volume fraction. It is expressed either as a percentage of tube.
original volume of blood or as a decimal fraction. 3. Centrifuge with a speed of 2300 g.
• Detection of presence or absence of anemia or Venous blood collected in EDTA (1.5 mg EDTA for 1 ml
polycythemia of blood) or in double oxalate. Test should be performed
• Estimation of red cell indices (mean cell volume and within 6 hours of collection.
mean corpuscular hemoglobin concentration)
• Checking accuracy of hemoglobin value (Hemoglobin Method
in grams/dl × 3 = PCV). 1. Mix the anticoagulated blood sample thoroughly.
There are two methods for estimation of PCV: macro 2. Draw the blood sample in a Pasteur pipette and
method (Wintrobe method) and micro method (micro- introduce the pipette up to the bottom of the Wintrobe
hematocrit method). Micro method is preferred because tube. Fill the tube from the bottom exactly up to the
it is rapid, convenient, requires only a small amount of 100 mark. During filling, tip of the pipette is raised,
blood, capillary blood from skin puncture can be used, but should remain under the rising meniscus to avoid
and a large number of samples can be tested at one time. foaming.
This method is also more accurate as plasma trapping in 3. Centrifuge the sample at 2300 g for 30 min (To
red cell column is less. counterbalance a second Wintrobe tube filled with
blood from another patient or water should be placed
MACRO METHOD (WINTROBE METHOD) in the centrifuge).
4. Take the reading of the length of the column of red
Principle
cells. Hematocrit can be expressed either as a
Anticoagulated whole blood is centrifuged in a Wintrobe percentage or as a fraction of the total volume of blood
tube to completely pack the red cells. The volume of sample.
packed red cells is read directly from the tube.
An advantage with this method is that before Significance
performing PCV, test for erythrocyte sedimentation rate In anemia, PCV is below the lower level of normal range.
can be set up. PCV is raised in dehydration, shock, burns, and
polycythemia.
Equipment
After centrifugation of anticoagulated whole blood,
1. Wintrobe tube: This tube is about 110 mm in length three zones can be distinguished in the Wintrobe tube
and has 100 markings, each at the interval of 1 mm. from above downwards- plasma, buffy coat layer (a small
Packed Cell Volume 189
Fig. 19.1: Anticoagulated blood-filled Wintrobe hematocrit tubes Fig. 19.2: Preparation of smear from buffy coat
after centrifugation, showing normal PCV, low PCV (anemia),
and thick buffy coat layer
MICRO METHOD Fig. 19.3: Lupus erythematosus or LE cell (red arrow) in buffy
coat smear. LE cell is a neutrophil with a homogeneous red
Principle purple inclusion distending the cytoplasm. It is seen in collagen
disorders, drug reactions, chronic hepatitis, and serum sickness
Anticoagulated whole blood is centrifuged in a capillary
tube of uniform bore to pack the red cells. Centrifugation
is done in a special microhematocrit centrifuge till
packing of red cells is as complete as possible. The
reading (length of packed red cells and total length of
the column) is taken using a microhematocrit reader, a
ruler, or arithmetic graph paper (Fig. 19.4).
Equipment
1. Microhematocrit centrifuge: It should provide relative
centrifugal force of 12000 g for 5 minutes.
2. Capillary hematocrit tubes: These are disposable glass Fig. 19.4: Microhematocrit capillary tubes following
tubes 75 mm in length and 1 mm in internal diameter. centrifugation in a microhematocrit centrifuge
190 Essentials of Clinical Pathology
Principle
0.1 ml. In the improved Neubauer chamber, the
A sample of whole blood is mixed with a diluent, which
central large square is divided into 25 squares, each
lyses red cells and stains nuclei of white blood cells. White
of which is further subdivided into 16 small squares.
blood cells are counted in a hemocytometer counting
A group of 16 small squares is separated by closely
chamber under the microscope and the result is
ruled triple lines (Figs 20.2 and 20.3). Metallized
expressed as total number of leukocytes per μl of blood
surface makes background rulings and cells easily
or per liter of blood.
visible. The 4 large corner squares are used for
Equipment counting leukocytes, while the central large square
is used for counting platelets and red blood cells.
1. Hemocytometer or counting chamber with coverglass: The Only special coverglass, which is intended for
recommended hemocytometer is one with improved use with hemocytometer, should be used. It should
Neubauer rulings and metallized surface. There are be thick and optically flat. When the special
two ruled areas on the surface of the chamber coverglass is placed on the surface of the chamber, a
(Fig. 20.1). Each ruled area is 3 mm × 3 mm in size volumetric chamber with constant depth and volume
and consists of 9 large squares with each large square throughout its entire area is formed. Ordinary cover
measuring 1 mm × 1 mm. When the special thick slips should never be employed since they do not
coverglass is placed over the ruled area, the volume provide constant depth to the underlying chamber
occupied by the diluted blood in each large square is due to bowing.
Total Leukocyte Count 193
Fig. 20.2: Neubauer counting chamber showing areas for Fig. 20.4: (A) WBC pipette and (B) Sahli’s pipette
counting WBCs (W) and red blood cells and platelets (R) calibrated to deliver 20 μl
Reagent
WBC diluting fluid (Turk’s fluid) consists of a weak acid
solution (which hemolyzes red cells) and gentian violet
(which stains leucocyte nuclei deep violet). Diluting fluid
also suspends and disperses the cells and facilitates
counting. Its composition is as follows:
• Acetic acid, glacial 2 ml
Fig. 20.3: (A) Counting area for WBCs and (B) counting • Gentian violet, 1% aqueous 1 ml
area for RBCs and platelets in Neubauer counting chamber • Distilled water to make 100 ml
Specimen
When the special cover glass is placed over the
ruled area of the chamber and pressed, Newton’s EDTA anticoagulated venous blood or blood obtained
rings (colored refraction or rainbow colored rings) by skin puncture is used. (Heparin should not be used
appear between the two glass surfaces; their since it causes leukocyte clumping). While collecting
formation indicates the correct placement of the cover capillary blood from the finger, excess squeezing should
be avoided so as not to dilute blood with tissue fluid.
glass.
2. Pipette calibrated to deliver 20 μl (0.02 ml, 20 cmm): WBC
Method
bulb pipettes (Fig. 20.4), which have a bulb for
dilution and mixing (Thoma pipettes) are no longer 1. Dilution of blood: Take 0.38 ml of diluting fluid in a
recommended. This is because blood and diluting test tube. To this, add exactly 20 μl of blood and mix.
fluid cannot be mixed adequately inside the bulb of This produces 1:20 dilution. Alternatively, 0.1 ml of
the pipette. Bulb pipettes are also difficult to calibrate, blood can be added to 1.9 ml of diluting fluid to get
costly, and charging of counting chamber is difficult. the same dilution.
Tips of pipettes often chip easily and unnecessarily 2. Charging the counting chamber: Place a coverglass
small volume of blood needs to be used. over the hemocytometer. Draw some of the diluted
194 Essentials of Clinical Pathology
blood in a Pasteur pipette. Holding the Pasteur pipette conventional to SI units is 0.001 and SI to conventional
at an angle of 45° and placing its tip between the units is 1000.
coverglass and the chamber, fill one of the ruled areas
Correction of TLC for nucleated red cells: The diluting
of the hemocytometer with the sample. The sample
fluid does not lyse nucleated red cells or erythroblasts.
should cover the entire ruled area, should not contain
Therefore, they are counted as leukocytes in hemo-
air bubbles, and should not flow into the side
cytometer. If erythroblasts are markedly increased in the
channels. Allow 2 minutes for settling of cells.
blood sample, overestimation of TLC can occur. To avoid
3. Counting the cells: Place the charged hemocytometer
this if erythroblasts are greater than 10 per 100 leukocytes
on the microscope stage. With the illumination
as seen on blood film, TLC should be corrected for
reduced to give sufficient contrast, bring the rulings
nucleated red cells by the following formula:
and the white cells under the focus of the low power
objective (× 10). White cells appear as small black dots.
Count the number of white cells in four large corner TLC/μl × 100
squares. (To reduce the error of distribution, counting Corrected TLC/μl = ————————————
Nucleated red cells per
of cells in all the nine squares is preferable). To correct 100 WBCs + 100
for the random distribution of cells lying on the
margins of the square, cells which are touching the
Sources of error in manual blood cell count: There are
left hand lines or upper lines of the square are
two main errors: technical and inherent.
included in the count, while cells touching the lower
and right margins are excluded. Technical Errors
Reticulocyte Count
Reticulocytes are young or juvenile red cells released 4. To assess response to erythropoietin therapy in
from the bone marrow into the bloodstream and that anemia of chronic renal failure.
contain remnants of ribonucleic acid (RNA) and 5. To follow the course of bone marrow transplantation
ribosomes but no nucleus. After staining with a for engraftment
supravital dye such as new methylene blue, RNA 6. To assess recovery from myelosuppressive therapy
appears as blue precipitating granules or filaments within 7. To assess anemia in neonate
the red cells. Following supravital staining, any non-
nucleated red cell containing 2 or more granules of blue- PRINCIPLE
stained material is considered as a reticulocyte (The
A few drops of blood (collected in EDTA) are incubated
College of American Pathology). Supravital staining
with new methylene blue solution which stains granules
refers to staining of cells in a living state before they are
of RNA in red cells. A thin smear is prepared on a glass
killed by fixation or drying or with passage of time.
slide from the mixture and reticulocytes are counted
Reticulocyte count is performed by manual method.
under the microscope. Number of reticulocytes is
Recently methods based on flow cytometry have been
expressed as a percentage of red cells.
introduced which are rapid and more precise.
REAGENT
Reticulocyte count is performed to assess erythropoietic
activity of the bone marrow New methylene blue solution is prepared as follows:
New methylene blue 1.0 gm
USES Sodium citrate 0.6 gm
Sodium chloride 0.7 gm
1. As one of the baseline studies in anemia with no Distilled water 100 ml
obvious cause Reagent should be kept stored in a refrigerator at
2. To diagnose anemia due to ineffective erythropoiesis 2-6°C and filtered before use.
(premature destruction of red cell precursors in bone Suitable alternatives to new methylene blue are
marrow seen in megaloblastic anemia and thalasse- brilliant cresyl blue and azure B.
mia) or due to decreased production of red cells: In
hypoplastic anemia or in ineffective erythropoiesis, SPECIMEN
reticulocyte count is low as compared to the degree Capillary blood or EDTA-anticoagulated venous blood
of anemia. Increased erythropoiesis (e.g. in hemolytic can be used.
anemia, blood loss, or specific treatment of nutritional
anemia) is associated with increased reticulocyte METHOD
count. Thus reticulocyte count is used to differentiate 1. Take 2-3 drops of filtered new methylene blue
hypoproliferative anemia from hyperproliferative solution in a 12 × 75 mm test tube.
anemia. 2. Add equal amount of blood and mix well.
3. To assess response to specific therapy in iron 3. Keep the mixture at room temperature or at 37°C for
deficiency and megaloblastic anemias. 15 minutes.
Reticulocyte Count 197
• Normocytic normochromic anemia with low • HbH inclusions: These are round, golf ball like
reticulocyte count: inclusion bodies seen in α-thalassemias. They are
– Aplastic anemia seen in most of the red cells while reticulocytes
– Chronic renal failure are seen in only a few cells.
– Anemia of chronic disease
• Granules of new methylene blue superimposed on
– Anemia due to ineffective erythropoiesis
red cells, if stain is not filtered before use.
7. Reticulocytes should be distinguished from (Fig. 21.4):
• Heinz bodies: These are precipitated globin chains • Howell-Jolly bodies: These are nuclear remnants in
attached to the red cell membrane. They stain light red cells seen in certain anemias and following
blue and are seen in glucose-6-phosphate dehy- splenectomy. As supravital dyes stain both DNA
drogenase deficiency following exposure to and RNA, these structures are also stained.
oxidant stress. 8. The polychromatic red cells on Romanowsky-stained
• Pappenheimer bodies: These are iron-containing blood smears represent reticulocytes. However, only
granules which appear as one or more small dots stages 1, 2, and 3 cause polychromasia, while stage 4
in red cells. They give positive Prussian blue reticulocytes having small amount of RNA do not
reaction. They are confused with reticulocytes in
cause polychromasia. Therefore, counting polychro-
Romanowsky-counterstained preparations.
matic cells cannot be used as a substitute for
reticulocyte count.
REFERENCE RANGES
BIBLIOGRAPHY
Blood Smear
A blood smear or film is a specimen for microscopic blood is used, smear should be prepared and stained
examination prepared by spreading a drop of blood within 2 hours of blood collection. If venous blood
across a glass slide followed by staining with one of the collected in a syringe is used, the last drop of blood
Romanowsky's stains. in the needle after withdrawing (or first drop while
dispensing) should be used.
USES 2. A 'spreader' slide is placed at an angle of 30° in front
of the drop and then drawn back to touch the drop of
1. Blood smear is helpful in suggesting the cause of
blood. Blood spreads across the line of contact of two
anemia or thrombocytopenia, identifying and typing
slides.
of leukemia, and in diagnosing hemoparasitic
3. Smear is made by smooth, forward movement of the
infections (malaria, filaria, and trypanosomiasis). It
'spreader' along the slide. The whole drop should be
is also helpful in the management of these conditions.
used up 1 cm before the end of the slide. The length
2. To monitor the effect of chemotherapy and radio-
of the smear should be about 3 cm (Fig. 22.1). The
therapy on bone marrow.
'spreader' should not be raised above the slide surface
3. To provide direction for further investigations that
till whole drop of blood is spread out.
will help in arriving at the correct diagnosis (e.g. in
infections, drug toxicity, etc.).
Blood smear examination is therefore indicated in
clinically suspected cases of anemia, thrombocytopenia,
hematological malignancies (leukemia, lymphoma,
multiple myeloma), disseminated intravascular coagu-
lation, parasitic infections (like malaria or filaria),
infectious mononucleosis, and various inflammatory, or
malignant diseases.
EXAMINATION OF BLOOD SMEAR Fig. 22.4: Area for examination of blood cells and for
A blood smear is examined for: differential cell count in blood smear
• Red cells: Morphology, immature forms, inclusion
bodies, arrangement of cells.
cell distribution, and to select an area for examination of
• White cells: Differential count, abnormal or immature
blood cells. Best morphologic details are seen in the area
forms. where red cells are just touching one another. Low power
• Platelets: Adequacy, abnormal forms.
view is also helpful for the identification of Rouleaux
• Parasites: Malaria, filaria.
formation, autoagglutination of red cells, and micro-
A peripheral blood smear has three parts: Head, body,
filaria. High power objective (45×) is suitable for
and tail (Fig. 22.4). A blood smear should be examined
examination of red cell morphology and for differential
in an orderly manner. Initially, blood smear should be leukocyte count. A rough estimate of total leukocyte
observed under low power objective (10×) to assess count can be obtained which also serves to crosscheck
whether the film is properly spread and stained, to assess the total leukocyte count done by manual counting or
automated method. Oil-immersion objective (100×) is
used for more detailed examination of any abnormal
cells.
Red Cells
Red cells are best examined in an area where they are
just touching one another (towards the tail of the film).
Normal red cells are 7-8 µm in size, round with smooth
contours, and stain deep pink at the periphery and paler
in the center. Area of central pallor is about 1/3rd the
diameter of the red cell. Size of a normal red cell
corresponds roughly with the size of the nucleus of a
small lymphocyte. Normal red cells are described as
normocytic (of normal size) and normochromic (with
normal staining intensity i.e. hemoglobin content).
Morphologic abnormalities of red cells in peripheral
blood smear can be grouped as follows:
Fig. 22.3: Normal blood smear showing red cells (R), a
• Red cells with abnormal size (Fig. 22.5)
neutrophil (N), a lymphocyte (L), eosinophil (E), basophil (B), • Red cells with abnormal staining
monocyte (M), and platelets (P) • Red cells with abnormal shape (Fig. 22.5)
204 Essentials of Clinical Pathology
Fig. 22.5: Variations in size and shape of red cells: (A) Microcytic hypochromic red cells in iron deficiency anemia; (B) Oval
macrocytes and a hypersegmented neutrophil in megaloblastic anemia; (C) Sickle cells in sickle cell anemia; (D) Spherocytes
in hereditary spherocytosis; (E) Fragmented red cells or schistocytes in microangiopathic hemolytic anemia; (F) Target cells
in hemoglobinopathy; (G) Burr cells in chronic renal failure; (H) Tear drop red cells in myelofibrosis; (I) Bite cells and
(J) Blister cell in glucose-6-phosphate dehydrogenase deficiency
Pappenheimer bodies are basophilic, small, iron- Box 22.2: Role of blood smear in anemias
containing granules in red cells. They give positive Perl's
Prussian blue reaction. Unlike basophilic stippling, • Macrocytic anemia: Differential diagnosis between
Pappenheimer bodies are few in number and are not megaloblastic anemia (oval macrocytosis and hyper-
distributed throughout the red cell. They are seen segmented neutrophils), liver disease (round macrocytosis
following splenectomy and in thalassemias and and target cells), hemolytic anemia (numerous poly-
chromatic cells), and myelodysplastic syndrome (dimor-
sideroblastic anemia.
phic red cells, pseudo-Pelger-Huet neutrophils, giant
Cabot's rings are fine, reddish-purple or red, ring-like platelets, occasional blast cell).
structures. They appear like loops or figure of eight • Microcytic anemias: Differential diagnosis between iron
structures. They indicate impaired erythropoiesis and are deficiency anemia (microcytic hypochromic red cells,
seen in megaloblastic anemia and lead poisoning. pencil cells), thalassemia minor (microcytic hypochromic
5. Immature red cells: red cells, basophilic stippling), and sideroblastic anemia
Polychromatic cells are young red cells containing (dimorphic anemia).
remnants of ribonucleic acid. These cells are slightly • Sickle cell disease: Differentaition between sickle cell trait
larger than normal red cells and have a diffuse bluish- (target cells with no sickle cells), sickle cell anemia (sickle
cells), and sickle cell β-thalassemia (microcytic hypo-
grey tint. (They represent reticulocytes when stained with
chromic red cells, sickle cells).
a supravital stain like new methylene blue). Poly-
• Hemolytic anemias: Spherocytosis (hereditary sphero-
chromasia is due to the uptake of acid stain by cytosis, autoimmune hemolytic anemia), fragmented cells
hemoglobin and basic stain by ribonucleic acid. Presence (microangiopathic haemolytic anemia), bite cells or blister
of polychromatic cells is indicative of active erythro- cells (Glucose-6-phosphate dehydrogenase deficiency),
poiesis and are increased in hemolytic anemia, acute and autoagglutination of red cells (cold hemagglutinin
blood loss, and following specific therapy for nutritional disease).
anemia.
Nucleated red cells are red cell precursors (erythro-
blasts), which are released prematurely in peripheral
blood from the bone marrow. They are a normal finding
in cord blood of newborns. Large number of nucleated
red cells in blood smear is seen in hemolytic disease of
newborn, hemolytic anemia, leukemias, myelophthisic
anemia, and myelofibrosis.
6. Abnormal red cell arrangement:
Rouleaux formation refers to alignment of red cells on top
of each other like a stack of coins. It occurs in multiple
myeloma, Waldenström's macroglobulinemia, hyper-
gammaglobulinemia, and hyperfibrinogenemia.
Autoagglutination refers to the clumping of red cells
in large, irregular groups on blood smear. It is seen in
cold agglutinin disease.
Role of blood smear in anemia is shown in Box 22.2
and Figures 22.9 to 22.11.
White Cells
Approximate idea about total leukocyte count can be
gained from the examination of the smear under high Fig. 22.9: Differential diagnosis of macrocytic anemia on blood
power objective (40× or 45×). A differential leukocyte smear: (A) Megaloblastic anemia; (B) Hemolytic anemia;
count should be carried out. Abnormal appearing white (C) Liver disease; (D) Myelodysplastic syndrome
Blood Smear 207
Fig. 22.13: Comparison of blood smears in (A) acute myeloid leukemia and (B) acute lymphoblastic leukemia
Blood Smear 209
Neutrophilia
An absolute neutrophil count greater than 7500/µl is
termed as neutrophilia or neutrophilic leukocytosis.
Causes
1. Acute bacterial infections: Abscess, pneumonia,
meningitis, septicemia, acute rheumatic fever, urinary
tract infection.
2. Tissue necrosis: Burns, injury, myocardial infarction.
3. Acute blood loss
4. Acute hemorrhage
5. Myeloproliferative disorders
6. Metabolic disorders: Uremia, acidosis, gout
7. Poisoning Fig. 22.15: Leukemoid reaction in blood smear
210 Essentials of Clinical Pathology
Monocytosis
Box 22.4: Differential diagnosis of lymphocytosis
This is an increase in the absolute monocyte count above
1000/µl. • Mature lymphocytosis: Viral infections, whooping
cough, tuberculosis, infectious lymphocytosis, chronic
Causes lymphocytic leukemia
1. Infections: Tuberculosis, subacute bacterial endocar- • Atypical lymphocytosis: Infectious mononucleosis,
ditis, malaria, kala azar. cytomegalovirus, toxoplasmosis, infectious hepatitis
2. Recovery from neutropenia. • Lymphoblasts: Acute lymphoblastic leukemia
3. Autoimmune disorders.
4. Hematologic diseases: Myeloproliferative disorders,
fingerstick), they occur in clumps. If platelet count is done
monocytic leukemia, Hodgkin's disease.
on automated blood cell counters using EDTA-anticoagu-
5. Others: Chronic ulcerative colitis, Crohn's disease,
lated blood sample, about 1% of persons show falsely
sarcoidosis.
low count due to the presence in them of EDTA-
Lymphocytosis dependent antiplatelet antibody.
Examination of a parallel blood film is useful in
This is an increase in absolute lymphocyte count above
avoiding the false diagnosis of thrombocytopenia in such
upper limit of normal for age (4000/µl in adults, >7200/
µl in adolescents, >9000/µl in children and infants) (Box cases. Occasionally, platelets show rosetting around
neutrophils (platelet satellitism) (Fig. 22.16). This is seen
22.4).
in patients with platelet antibodies and in apparently
Causes normal persons.
1. Infections: Blood smear examination can be helpful in deter-
• Viral: Acute infectious lymphocytosis, infective mining underlying cause of thrombocytopenia such as
hepatitis, cytomegalovirus, mumps, rubella, leukemia, lymphoma, or microangiopathic hemolytic
varicella anemia (Box 22.5).
• Bacterial: Pertussis, tuberculosis
• Protozoal: Toxoplasmosis Organisms
2. Hematological disorders: Acute lymphoblastic Common parasites seen in blood are malaria parasites
leukemia, chronic lymphocytic leukemia, multiple and microfilaria (See Chapter 26: Diagnosis of Malaria
myeloma, lymphoma. and Other Parasites in Blood). Other parasites that can
3. Other: Serum sickness, post-vaccination, drug
reactions. Box 22.5: Role of blood smear in thrombocytopenia
Red cell indices are mean cell volume (MCV), mean cell MCV is expressed in femtoliters or fl (10–15 of a liter).
hemoglobin (MCH), and mean cell hemoglobin concen- It corresponds with red cell diameter on blood smear.
tration (MCHC). They are also called as “absolute Normal MCV is 80-100 fl.
values”. They are derived from the values of hemoglobin,
packed cell volume (PCV or hematocrit), and red cell Causes of Increased MCV
count. Red cell indices are accurately measured by • Megaloblastic anemia
automated hematology analyzers. Recently, a new • Non-megaloblastic macrocytosis: Chronic alcoholism,
parameter called red cell distribution width (RDW) has liver disease, hypothyroidism, normal pregnancy,
been introduced. reticulocytosis
• Newborns.
USES OF RED CELL INDICES
Causes of Low MCV
1. Morphological classification of anemia: Based on
values of red cell indices, anemia is classified into • Microcytic hypochromic anemia
threee main types: normocytic normochromic, MCV is normal in normocytic normochromic anemia
microcytic hypochromic, and macrocytic normo- (acute blood loss, hemolysis, aplastic anemia).
chromic (See Chapter 27: Laboratory Tests in In the presence of large number of abnormal red cells
Anemia). Calculation of red cell indices is especially like sickle cells, and in dimorphic anemia (e.g. mixed
helpful in mild or moderate anemia when red cell normocytic and microcytic), MCV may be normal (since
changes are subtle and often difficult to appreciate it is an average value) and thus unreliable for morpho-
on stained blood smear. logical classification.
2. Differentiation of iron deficiency anemia from Mentzer index is derived by dividing MCV with red
thalassemia trait: In iron deficiency, MCV, MCH, and cell count. Ratio of less than 13 is seen in thalassemia
MCHC are low, while in thalassemia trait, MCV and while ratio is more than 13 in iron deficiency anemia.
MCH are low and MCHC is normal.
MEAN CELL HEMOGLOBIN (MCH)
MEAN CELL VOLUME
MCH is the average amount of hemoglobin in a single
MCV is a measure of average size of the red cells. It is
red cell. It is obtained by dividing hemoglobin value by
measured directly by automated instruments from the
red cell count.
measurement of volume of each red cell. With semi-
automated instruments and by manual method, it is
obtained by dividing PCV by red cell count. Hemoglobin in grams/dl
MCH = ——————————————— × 10
Red cell count in millions/cmm
PCV in% MCH is expressed in picograms or pg (10–12 gram).
MCV = —————————————— × 10
Red cell count in million/cmm Reference range is 27-32 pg.
214 Essentials of Clinical Pathology
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24
Erythrocyte
Sedimentation Rate
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216 Essentials of Clinical Pathology
Table 24.1: Causes of increased erythrocyte (≥100 mm at 1 hour) is seen in infections, parapro-
sedimentation rate teinemias, metastatic malignancy, polymyalgia rheu-
1. Infections • Acute rheumatic fever matica, temporal arteritis, and rheumatoid arthritis.
• Osteomyelitis ESR is decreased in polycythemia, congestive cardiac
• Bacterial endocarditis failure, dehydration, sickle cell anemia, hereditary
• Pyogenic arthritis spherocytosis, and hypofibrinogenemia.
• Pelvic inflammatory disease
In patients with chronic inflammatory conditions like
• Tuberculosis
• Acute hepatitis rheumatoid arthritis, ESR can be helpful in distinguishing
iron deficiency anemia from anemia of chronic disease.
2. Inflammatory diseases • Rheumatoid arthritis
In inflammatory conditions, ESR rises more than 24
• Systemic lupus
erythematosus hours after onset and returns to normal about 4 weeks
• Temporal arteritis following resolution.
• Polymyalgia rheumatica There is no role of ESR in the evaluation of asympto-
3. Acute myocardial matic patients.
infarction
4. Malignancy
INDICATIONS FOR MEASUREMENT OF
ERYTHROCYTE SEDIMENTATION RATE
5. Paraproteinemias • Multiple myeloma
• Waldenström’s It is recommended to measure ESR (i) when infectious,
macroglobulinemia inflammatory, or a neoplastic disease is suspected in
• Cryoglobulinemia symptomatic individuals in whom a specific diagnosis
6. Technical problems • Increased temperature has not been established, (ii) to monitor disease activity
• Tilted ESR tube in tuberculosis, inflammatory arthritis, rheumatic fever,
7. Others • Ruptured ectopic pregnancy Hodgkin’s disease, giant cell arteritis, and polymyalgia
• Anemia rheumatica, and (iii) as a diagnostic criterion for temporal
• Renal disease with arteritis and polymyalgia rheumatica. ESR can also be
azotemia helpful in distinguishing iron deficiency anemia from
• Administration of dextran or anemia of chronic disease in patients known to have
oral contraceptives inflammatory disease.
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Erythrocyte Sedimentation Rate 217
Method
1. Mix anticoagulated blood sample thoroughly. The
Westergren tube is filled with the blood sample up
to the “0” mark. A rubber bulb or a mechanical device
should be used for filling. There should be no air
bubbles in the blood.
2. The tube is placed in a strictly vertical position in the
Fig. 24.2: Westergren ESR stand with ESR tubes ESR stand and left undisturbed for 1 hour. It should
not be kept in direct sunlight and should not be
subjected to vibrations.
2. Westergren stand: This holds the tube in a motionless, 3. After exactly 1 hour, read the height of the column of
vertical position (Fig. 24.2). plasma above the red cell column in mm.
3. Anticoagulant-diluent solution: Trisodium citrate 4. Express the result as:
dihydrate is the anticoagulant of choice. Its compo-
sition is as follows:
Erythrocyte sedimentation rate = ——— mm in 1 hour.
Trisodium citrate dihydrate 32.08 gm
Distilled water upto 1000 ml Precautions
It is filtered through a sterile membrane (0.22 μm)
into a sterile container and stored in a refrigerator at 4°C. 1. Use the correct proportion of blood and anticoagulant.
It keeps for several months, but if it becomes turbid (due Mix blood and anticoagulant thoroughly. There
to the growth of moulds), it should be discarded. should be no clots and air bubbles in blood.
Alternate anticoagulant is EDTA (1.5 mg/ml); 2. The reference range relates to test performed at room
however, such anticoagulated blood sample should be temperature of 18-25°C. If temperature is higher, ESR
diluted with trisodium citrate just before the test will increase and different reference range will have
(1 volume of trisodium citrate to 4 volumes of blood). to be derived.
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218 Essentials of Clinical Pathology
Other Methods
Wintrobe Method
Wintrobe tube (Fig. 24.1) can be used for estimation of
both ESR and packed cell volume (PCV). After obtaining
ESR in the first hour, the tube can be spun in a centrifuge
to get PCV. Wintrobe’s method is more reliable when
ESR is low, while Westergren’s method is more sensitive
for high ESR. EDTA or double oxalate is used as an
anticoagulant. Length of Wintrobe tube is shorter (110
mm) and internal diameter is about 3 mm.
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Erythrocyte Sedimentation Rate 219
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25
Examination of
Bone Marrow
NORMAL BONE MARROW development, mature blood cells leave the bone marrow
and enter the circulation by passing through or in
Bone marrow is the site of hematopoiesis in postnatal
between the endothelial cells of the sinusoids.
life. Bone marrow is one of the largest organs in the body,
Marrow fibroblasts (reticular cells) are highly
and although distributed widely in the skeleton,
branched cells, which form reticulin fibers and form a
functions as a single unit. It is located within the cavities
supporting framework for the hematopoietic cells.
of the bones and mainly consists of hematopoietic cells,
Accumulation of lipid in reticular cells is said to produce
vascular sinusoids, fibroblasts, fat cells, and macro-
fat cells of the bone marrow.
phages. There are no lymphatic channels in the bone
Amount of fatty tissue depends on activity of
marrow. There are two types of marrow: red and yellow.
hematopoietic cells. The proportion of fat cells increases
Red marrow refers to the active hematopoietic tissue
with advancing age with corresponding decrease in
while fatty tissue comprises the yellow (inactive)
hematopoietic tissue. On demand, fatty tissue (yellow
marrow. Red coloration is due to presence of large
marrow) can be rapidly replaced by hematopoietic tissue
amounts of developing red cells. The average volume of
(red marrow). In children and adolescents, fat cells
bone marrow (red and yellow) in an adult is 3000-4000
occupy about 20-30% of the bone marrow volume, in
ml. Red or active marrow constitutes 1500 ml.
The hematopoietic cells are present as cords between adults about 50%, while in the elderly about 70%.
vascular sinusoids and are supported by a framework of Macrophages in bone marrow serve various functions
branching processes of fibroblasts and reticulin fibers. like synthesis of hematopoietic growth factors and
Erythroid precursors are present as clusters (islands) and inhibitory substances, phagocytosis of senescent red cells,
are closely associated with centrally placed sinusoids. and transport of iron to the erythroblasts.
An erythroid island consists of a centrally placed The stromal cells of the bone marrow (fibroblasts, fat
macrophage around which erythroid precursors are cells, macrophages, and endothelial cells) and vascular
concentrically arranged. Early granulocyte precursors are sinusoids constitute the bone marrow microenvironment,
located close to the bony trabecule, while more mature which is essential for normal hematopoiesis.
granulocytes are located more centrally, between During infancy and early childhood, hematopoiesis
adjacent trabeculae. Megakaryocytes, the largest of the is occurring in almost all the bones of the body. By late
hematopoietic cells, are closely apposed to the walls of childhood, hematopoiesis becomes mainly restricted to
the sinusoids. Lymphocytes and plasma cells are mostly flat bones like sternum, ribs, iliac bones, and vertebre,
present around capillaries and arterial vessels. In contrast and proximal ends of long bones; other sites of red
to other blood cells, lymphocytes also divide and mature marrow are transformed into yellow marrow. However,
outside the bone marrow. when there is increased demand for blood cells, blood
Hematopoiesis occurs extravascularly in between cell production can resume in the yellow marrow. In
interconnecting marrow sinusoids. The marrow sinu- extremely severe cases (e.g. chronic hemolytic anemia),
soids are lined by endothelial cells and are covered resumption of hematopoiesis in other organs like liver
partially by cytoplasmic processes of fibroblasts. After and spleen (extramedullary hematopoiesis) can occur.
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Examination of Bone Marrow 221
Apart from its major function of hematopoiesis, bone 2. Suspected acute leukemia: In majority of cases, acute
marrow also plays a role in the removal of senile and leukemia can be diagnosed from examination of a
defective red cells (via macrophages) and immunity blood smear and cell counts. Bone marrow exami-
(processing of antigen by macrophages and synthesis of nation is carried out in acute leukemia for:
antibodies by plasma cells). • Detection of subleukemic or aleukemic leukemia
There are two techniques for sampling of bone • Comparison of baseline marrow smear with
marrow: aspiration and biopsy. In aspiration, bone follow-up marrow aspiration smears during
marrow fluid is obtained by a special needle and syringe. treatment
Smears from this material are prepared on glass slides, • Diagnosis of acute myeloid leukemia with
stained, and examined under the microscope. In bone trilineage dysplasia
marrow trephine biopsy (core biopsy), a small tissue • Cytogenetic analysis.
piece of bone marrow is removed with a special needle, • Detection of remission
processed to obtain histological sections, and examined. 3. Suspected myelodysplastic syndrome.
4. Suspected myeloproliferative disorders including
INDICATIONS FOR BONE MARROW chronic myeloid leukemia, polycythemia vera,
essential thrombocythemia, and myelofibrosis.
EXAMINATION
5. Suspected plasma cell dyscrasia: Bone marrow
Before performing bone marrow aspiration/biopsy, one aspiration is indicated if multiple myeloma is
should assess clinical features, treatment received, and suspected from clinical and radiologic features.
relevant laboratory test results (especially basic blood 6. Suspected chronic lymphoid leukemias like chronic
studies and peripheral blood smear). Based on above lymphocytic leukemia, prolymphocytic leukemia,
data, if appropriate indication exists, then examination hairy cell leukemia, etc.
of bone marrow is carried out and findings are correlated 7. Investigation of pyrexia of unknown origin:
to arrive at the final diagnosis. Sometimes, bone marrow aspiration smears are
helpful in detecting Histoplasma capsulatum and
INDICATIONS FOR BONE MARROW Leishmania donovani organisms in macrophages of
ASPIRATION bone marrow. Aspirated material can also be cultured
1. Unexplained cytopenia: If the cause of cytopenia to isolate above organisms or mycobacteria.
8. Suspected storage disorder like Gaucher’s disease or
(anemia, leukopenia, or thrombocytopenia) is not
Neimann-Pick disease.
apparent from blood investigations and clinical
9. Suspected infections like kala azar, miliary tuber-
details, bone marrow examination is indicated.
culosis, or histoplasmosis.
(A) To distinguish amongst causes of microcytic hypo-
chromic anemia (e.g. iron deficiency from chronic
INDICATIONS FOR BONE MARROW BIOPSY
disease), bone marrow examination can be done to
assess storage iron. Identification of ringed sidero- 1. Repeated failure of aspiration (dry tap) which may
blasts is helpful in diagnosis of sideroblastic anemia be due to faulty technique, myelofibrosis or leuke-
or myelodysplastic syndrome. In macrocytic anemia, mia.
in the absence of vitamin assays and typical features 2. Suspected aplastic anemia
of megaloblastic anemia on blood smear, marrow 3. Suspected myelofibrosis.
aspiration is carried out to distinguish megaloblastic 4. Suspected focal lesions like granuloma, metastatic
macrocytosis from non-megaloblastic one. (B) In deposit, or infiltrate of lymphoma.
leukopenia or thrombocytopenia, bone marrow 5. Suspected hairy cell leukemia.
examination is helpful in distinguishing peripheral 6. Suspected bone disorder, e.g. osteopetrosis.
destruction from deficient production. (C) In the 7. Staging of lymphoma.
presence of isolated thrombocytopenia, if idiopathic
thrombocytopenic purpura (ITP) is suspected, CONTRAINDICATIONS
marrow examination is done for ruling out under-
lying hematologic disorder or deficient platelet Bone marrow aspiration or biopsy is contraindicated in
production. hemophilia and other coagulation disorders; however,
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222 Essentials of Clinical Pathology
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Examination of Bone Marrow 223
Fig. 25.4: (A) Bone marrow smear and (B) Bone marrow
biopsy sample
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224 Essentials of Clinical Pathology
Jamshidi or Islam needles are commonly used. Often, bone is longer than that for blood films. On smears, marrow
marrow aspiration and biopsy are combined together; particles are dragged towards the tail end of the smear
aspiration is carried out first followed by biopsy. If both and after staining appear as dark blue-violet irregular
aspiration and biopsy are combined, then, after aspiration, granules. Rest of the film stains even pink. Routinely,
either (i) the needle is advanced a little further (1-3 cm) one marrow smear (containing one or more marrow
into the bone, or (ii) the needle is withdrawn and reinserted particles) should also be stained with Perl’s stain for
through the same skin incision but placed at a different assessment of bone marrow storage iron.
site in the bone (about 1 cm away). For biopsy, the needle
Bone marrow aspiration provides following information:
should be advanced through the bone rotating it clockwise
• Assessment of morphology of bone marrow cells.
10 times. The needle should be removed by anticlockwise
• Assessment of nature of hematopoiesis (normal,
rotation. The biopsy should be removed gently from the
dyshematopoiesis)
hub end of the needle by inserting the stylet through the
point of the needle. For adequate assessment, biopsy • Cytogenetic analysis
should measure at least 1.6 cm in length (Fig. 25.4). Biopsy • Immunophenotyping of abnormal cells in leukemias.
should be placed in a fixative solution (either 10% formalin • Cytochemistry for typing of leukemia
or preferably Helly’s fluid). Dressing should be applied to • Iron stain for assessing iron stores and sideroblasts
the site similar to aspiration. • Microbial culture, e.g. for tuberculosis
Along with bone marrow aspiration/biopsy, peri- With marrow aspiration, marrow architecture and
pheral blood smears should be prepared from finger cellular relations cannot be studied.
prick and venous blood should be collected in EDTA
anticoagulant for cell counts. Bone Marrow Trephine Biopsy
If prior marrow aspiration is not satisfactory, imprint
COMPLICATIONS OF BONE MARROW smears should be prepared by gently rolling the marrow
ASPIRATION AND/OR BIOPSY biopsy specimen on a glass slide. These smears are
1. Local infection: This complication, which is more stained with one of the Romanowsky stains for
likely to occur in neutropenic patients, can be cytological evaluation. Biopsy specimen is then fixed in
prevented if strict aseptic precautions are observed. either 10% formalin or Helly’s fluid. (Helly’s fluid
2. Hemorrhage: Serious hemorrhage can occur if (i) consists of potassium dichromate 2.5 gm; mercuric
marrow biopsy is done without adequate replace- chloride 5 gm; 40% formalin 5 ml; and water 100 ml).
ment cover in coagulation disorders, and (ii) great The biopsy is processed (by decalcification, dehydration,
vessels or heart is injured during sternal aspiration. clearing, and embedding) to obtain paraffin wax blocks.
3. Cardiac tamponade or mediastinitis: This is likely if Less than 4 μm thick sections are cut and stained with
posterior sternal plate is penetrated during sternal hematoxylin and eosin stain and reticulin. It is
aspiration. recommended to mount 5 stepwise serial sections on one
slide to increase the chance of detecting small focal
PROCESSING OF MARROW SPECIMENS lesions. In addition, Giemsa stain is also recommended
for easier differentiation between blood and marrow cells
Bone Marrow Aspiration and mast cells. Iron stain is less informative on biopsy
A drop of aspirated marrow sample is put on each of the since iron is usually lost during decalcification.
several glass slides, excess blood is removed by sucking Bone marrow biopsy provides following information:
with a Pasteur pipette, and smears are prepared with a • Cellularity of bone marrow
‘spreader’. The marrow particles are carried just behind • Bone marrow architecture
the spreader and cellular trails are produced while • Bone structure
spreading. The smears are allowed to dry in the air and • Marrow fibrosis
are labeled. They are stained with one of the • Focal lesions (granulomas, metastatic deposits,
Romanowsky stains. The staining time for marrow films infiltration by lymphoma).
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Examination of Bone Marrow 225
1. Site Iliac spine, sternum, tibia, spinous Iliac spine (posterior superior)
process of vertebra
2. Information obtained Morphology, cytochemistry, iron stain, Cellularity, architecture, fibrosis,
immunophenotyping, culture focal lesions, bone structure
3. Main indications Unexplained cytopenia, suspected Repeated dry tap, aplastic anemia,
hematological malignancy myelofibrosis, focal lesions, hairy cell
leukemia, staging of lymphoma
4. Needle used Salah, Klima Jamshidi
commonly
5. Studies done Romanowsky stain, Iron stain, H and E stain, reticulin stain,
cytochemistry, cytogenetic or immunohistochemistry
molecular genetic analysis,
immunophenotyping, culture
6. Time for routine Same day Up to 7 days
examination report
cellular trails of particles. Normal differential count in necrotic cells, or metastatic cells should be carried out.
bone marrow in adults is shown at the end of this chapter Parasites like Leishmania donovani and Histoplasma
under “Reference Ranges”. capsulatum are detected in macrophages.
Usually a 5-finger differential count is sufficient Routinely, Perl’s stain for iron is done on a marrow
which consists of counting relative percentages of smear (containing at least one marrow particle) to assess
erythroid cells, myeloid cells, lymphoid cells, plasma storage iron and number and types of sideroblasts.
cells, and blast cells. In acute leukemia, myelodysplastic In acute leukemia, cytochemical stains like myelo-
syndrome, lymphoma infiltration, and plasma cell peroxidase, nonspecific esterase, and periodic acid shiff
dyscrasias, a more detailed differential count is essential. are done for typing of acute leukemia.
Myeloid:erythroid (M:E) ratio is the ratio of all
granulocytes and their precursors to all erythroid Iron Staining of Bone Marrow Aspiration Smears
precursor cells. Normal M:E ratio ranges from 2:1 to 4:1. Presence of iron in marrow aspiration smears can be
On an average, there are 3 myeloid precursors for every demonstrated by Perls’ Prussian blue reaction. In this
erythroid precursor. Since M:E ratio is relative it should method, ionic iron reacts with acid ferrrocyanide solution
be interpreted carefully. Increased M:E ratio is observed to form blue-colored ferric ferrocyanide. Iron appears as
when myeloid series is hyperplastic as in infections and bright blue granular aggregates. Perls’ stain does not
myeloproliferative disorders (chronic or acute myeloid detect heme iron of hemoglobin.
leukemia) or when erythroid series is suppressed as in Iron staining is a valuable test for detection of iron
aplastic crisis of hemolytic anemia. Reduced M:E ratio is deficiency and must be carried out as a routine on all
observed when myeloid series is depressed and in aspiration smears (Fig. 25.5). Bone marrow aspiration
erythroid hyperplasia (e.g. hemolytic anemia). smears containing at least one marrow particle are
Maturation of erythroid and myeloid series should required for demonstration of storage iron in macro-
be assessed. Nature of erythroid maturation may be phages. Bone marrow biopsy sections are not suitable
normoblastic, micronormoblastic, or megaloblastic. for evaluation of iron stores since some iron is lost during
Dyshematopoietic features may be suggestive of processing (decalcification step) of tissue.
myelodysplastic syndrome or congenital dyserythro- On marrow smears, stainable iron can be demons-
poietic anemia. trated in siderocytes, sideroblasts, and macrophages of
Detailed cytological evaluation of abnormal cells like reticuloendothelial system. Siderocytes are immature,
blast cells, lymphoma cells, myeloma cells, storage cells, non-nucleated red cells, which contain 1-2 granules of
non-heme iron. On Romanowsky-stained smears, these Cellularity (Fig. 25.6) varies with the age of the patient.
are called as Pappenheimer bodies. Erythroblasts There is a gradual reduction in red marrow (hematopoietic
containing aggregates of iron are called as sideroblasts. tissue) and proportionate increase in fat cells as age
They are of three types—I, II, and III. In type I sideroblasts advances. A rough estimate of normal cellularity is
(which are seen normally), iron granules are small and obtained by deducting 1 for each year of age from 100 and
few (1-4) in number. Normally, about 25-50% of expressing it as a percentage; expected normal cellularity
erythroblasts contain 1-4, small iron granules. Types II is ±10% of this value. For example, if age of the patient is
and III sideroblasts are abnormal. In type II sideroblasts, 25 years, then expected normal cellularity is 65% to 85%.
iron granules are large and numerous. Type II sidero- The cellularity in the first decade of life is about 80% while
blasts are seen in hemolytic anemia and iron overload. in adults it is about 50%. In older age (>70 years), cellularity
In type III sideroblasts, iron granules are distributed in decreases to about 30%. Also, normally, the cellularity
the form of a ring around the nucleus. The ‘ringed’ immediately beneath the subcortical area is low as
sideroblasts are seen in sideroblastic anemias. compared to the deeper medullary areas.
Iron granules in macrophages of reticuloendothelial Normally bone marrow biopsy shows bony trabecule
system represent storage form of iron. Normally, a few,
(lamellar bone) separated by interconnecting spaces
small granules are seen. In iron deficiency anemia, there
is complete lack of stainable iron in the erythroblasts and containing bone marrow. The bony trabecule are thin,
macrophages. Lack of stainable iron in erythroblasts and irregular, and show osteocytes within lacune. The
increased amount of iron in macrophages is a feature of trabecule show lining of endosteum (osteoblasts and
anemia of chronic disease. Marked increase of storage iron osteocytes). In a disease called osteopetrosis, bony
in macrophages occurs in thalassemias and iron overload. trabecule are markedly thick with severe reduction in
marrow space; there are cartilaginous plates in trabecular
Bone Marrow Trephine Biopsy
bone; and numerous osteoclasts are present along the
Hematoxylin and eosin-stained sections of marrow endosteal surface.
trephine biopsy are initially examined under low power High power examination is carried out to assess relative
objective to assess cellularity, to identify focal lesions like
proportion of myeloid and erythroid cells, location of
granuloma, lymphoma infiltrates and clumps of metastatic
malignancy, and to assess bone structure and number of hematopoietic precursors, pattern of infiltration of
megakaryocytes. Because of variable cellularity between lymphoma cells, morphology of abnormal cells, and
particles and dilution with peripheral blood in marrow parasites.
aspiration smears, assessment of cellularity is more Normally, erythroid precursors are located in clusters
reliably performed on biopsy sections. in the center of marrow spaces, while granulocyte
Fig. 25.6: Cellularity of bone marrow on biopsy: (A) Normocellular; (B) Hypercellular; and (C) Hypocellular
228 Essentials of Clinical Pathology
a. Pre-erythrocytic schizogony (Hepatic schizogony): P. vivax, P. ovale, and P. malariae complete the
Inoculated sporozoites rapidly leave the circulation erythrocyte schizogony in general circulation.
to enter the liver cells where they develop into Schizonts of P. falciparum induce membrane
hepatic (pre-erythrocytic) schizonts (Schizonts are changes in red cells, which causes them to adhere
cells undergoing schizogony). One sporozoite to the capillary endothelial cells (cytoadherence).
produces one tissue form. Hepatic schizonts Therefore, in P. falciparum infection, erythrocyte
rupture to release numerous merozoites in schizogony is completed in capillaries of internal
circulation (Merozoites are daughter cells organs and usually only ring forms are seen in
produced after schizogony). Up to 40,000 merozoi- circulation.
tes are produced in the hepatic schizont. c. Gametogony: After several cycles of erythrocytic
In P. falciparum infection, all of the hepatic schizogony, some merozoites, instead of develo-
schizonts mature and rupture simultaneously; ping into trophozoites and schizonts, transform
dormant forms do not persist in hepatocytes. In into male and female gametocytes. These sexual
contrast, some of the sporozoites of P. vivax and forms are infective to mosquito and the person
P. ovale remain dormant after entering liver cells harboring them is called as a “carrier”. Gameto-
and develop into schizonts after some delay. Such cytes are not pathogenic for humans.
persistent forms are called as hypnozoites; they d. Exoerythrocytic schizogony: In P. vivax and P.
develop into schizonts at a later date and are a ovale infections, some of the sporozoites in liver
cause of relapse. cells persist and remain dormant. These dormant
b. Erythrocytic schizogony: Merozoites released forms in liver cells are called as hypnozoites. They
from rupture of hepatic schizonts enter the red become active and develop into schizonts a few
days, months, or even years later. These schizonts
blood cells via specific surface receptors. These
rupture, release merozoites, and cause relapse.
merozoites become trophozoites that utilize red
Exoerythrocytic schizogony is absent in P.
cell contents for their metabolism. A brown-black
falciparum infection and therefore relapse does not
granular pigment (malaria pigment or hemozoin)
occur. Hence, P. vivax and P. ovale are called as
is produced due to breakdown of hemoglobin by
relapsing plasmodia while P. falciparum and
malaria parasites. The fully formed trophozoite
P. malariae are known as non-relapsing plasmodia.
develops into a schizont by multiple nuclear and
2. Sexual cycle (mosquito cycle, sporogony): The sexual
cytoplasmic divisions. Mature schizonts rupture
cycle begins when a female Anopheles mosquito
to release merozoites, red cell contents, malarial
ingests mature male and female gametocytes during
toxins, and malarial pigment. (This pigment is
a blood meal. First, 4-8 microgametes are produced
taken up by monocytes in peripheral blood and from one male gametocyte (microgametocyte) in the
by macrophages of reticulo-endothelial system. In stomach of the mosquito; this is called as ex-
severe cases, organs which are rich in macro- flagellation. The female gametocyte (macrogameto-
phages like spleen, liver, lymph nodes, and bone cyte) undergoes maturation to produce one macro-
marrow become slate-gray or black in color due gamete. By chemotaxis, microgametes are attracted
to hemozoin pigment). Rupture of red cell toward the macrogamete; one of the microgametes
schizonts corresponds with clinical attack of fertilizes the macrogamete to produce a zygote. The
malaria. Released merozoites infect new red cells zygote becomes motile and is called as ookinete.
and enter another erythrocytic schizogony cycle. Ookinete penetrates the lining of the stomach and
This leads to rapid amplification of plasmodia in comes to lie on the outer surface of the stomach where
the red cells of the human host. In P. falciparum, it develops into an oocyst. On further growth and
P. vivax, and P. ovale infections, cycle of schizogony maturation, multiple sporozoites are formed within
lasts for 48 hours, while in P. malarie infection it the oocyst. After complete maturation, oocyst
lasts for 72 hours. Merozoites of P. vivax and P. ruptures to release sporozoites into the body cavity
ovale preferentially invade young red cells or of the mosquito. Most of the sporozoites migrate to
reticulocytes while those of P. falciparum infect red the salivary glands. Infection is transmitted to the
cells of all ages. Senescent red cells are preferred humans by the bite of the mosquito through saliva
by P. malariae. when it takes a blood meal.
Diagnosis of Malaria and Other Parasites in Blood 231
species of malaria parasites can be distinguished graphic tests. Also, in some cases of falciparum malaria,
morphologically by microscopic examination of thin parasites get sequestered in the capillaries of internal
blood smear. organs and are not detectable on blood smears (but can
Microscopic examination of blood smears for be detected by immunochromatographic tests).
diagnosis of malaria is a sensitive test; it can detect about If P. falciparum is identified, it is necessary to estimate
50 parasites/μl in experienced hands. parasite density. Since gametocytes are non-pathogenic,
Morphological features of malaria parasites are they should be excluded while counting parasites. Two
summarized and compared in Table 26.1. Stages of P. methods for estimation of parasite density are given
vivax and P.falciparum are shown in Figures 26.3 and 26.5. below.
Blood smears in P. vivax and P. falciparum are shown in 1. In a thick smear, number of parasites is counted till
Figures 26.4 and 26.6 respectively. 200 white blood cells are observed. Number of
As compared to the recently available rapid immuno- parasites present per μl of blood is calculated from
chromatographic tests (see below), microscopic examina- the following formula:
tion of the blood smear is relatively inexpensive.
Number of parasites
However, it needs good quality control, is labor- Total leukocyte count/µl × ———————————
intensive, and takes more time than immunochromato- 200
Plasmodium falciparum
Often only ring forms and gametocytes are seen; multiple rings in a single cell common; red cell size normal; high
parasite density.
Plasmodium vivax
Often all stages are seen; single parasite in a red cell; red cell enlarged and shows Schuffner’s dots (fine, pink
granules); medium parasite density.
Blue cytoplasmic ring Irregularly thick 12-24 merozoites Large and spherical
1/3rd the diameter of the cytoplasmic ring arranged rosette-like
red cell; one side of ring (ameboid); large granular yellow-brown
thicker; red chromatin at red chromatin dot pigment in center
thinner part of ring
Plasmodium ovale
Often all stages are seen; single parasite in a red cell; red cell slightly enlarged, oval, and with fimbriated margins;
prominent Schuffner’s dots.
Thick, dense blue ring Compact ring; slightly 8-12 irregularly placed Oval; prominent
with a large red amoeboid merozoites Schuffner’s dots
chromatin dot
Plasmodium malariae
Often all stages are seen; single parasite in a red cell; red cell normal in size; no Schuffner’s dots; low parasite
density.
Similar to P. vivax Compact band-like ring 6-12 merozoites in a Round or oval
across the red cell “daisy-head” pattern
•••••••••••••••••
• Diagnosis of P. falciparum in endemic remote Acridine orange stains all the cells that contain
peripheral areas where properly trained technicians nucleic acids. Therefore, considerable experience
and facilities for microscopic diagnosis are not is required to distinguish fluorescing parasites
available. Local health workers with little training can from other cells containing nucleic acids. This
perform rapid diagnostic tests. method also needs expensive apparatus and
• Rapid, self-diagnosis of malaria by tourists traveling materials. Howell-Jolly bodies (nuclear remnants
to endemic countries. Some manufacturers have in red cells in certain anemias) give a false positive
developed self-help diagnostic kits for travelers. reaction. Schizonts and gametocytes get localized
Positive rapid diagnostic tests (for HRP-2) persist for in the buffy layer and are missed. Specific
several days following successful treatment of P. identification of species is difficult and it is
falciparum infection (due to persistence of antigens in necessary to use Romanowsky-stained smears for
blood). Therefore these tests are not useful in following this purpose. Despite these disadvantages, this
response to treatment. Also these tests are not able to technique is a more rapid alternative to blood
estimate parasite density. Distinction between non- smears.
pathogenic gametocyte stage and other pathogenic stages b. Kawamoto technique: Blood smears are prepared,
is not possible. stained with a fluorescent dye (acridine orange),
Comparison between blood smear and rapid diag- and examined by fluorescence microscopy. An
nostic tests is given in Table 26.2. interference filter designed for acridine orange is
4. Fluorescence microscopy: There are two fluorescence placed in the pathway of transmitted light beam
microscopy techniques employed for diagnosis of and a barrier filter is placed in the eyepiece. Nuclei
malaria: quantitative buffy coat (QBC) system (Becton of malaria parasites fluoresce bright green and
Dickinson), and Kawamoto technique. cytoplasm red. Nuclei of white cells also fluoresce
a. Quantitative Buffy Coat (QBC) system (Becton bright green. Definitive species identification is
Dickinson): Blood is centrifuged in a special difficult; therefore Romanowsky-stained smears
capillary tube which contains a float and which is are required for species diagnosis. Kawamoto
coated with acridine orange (a fluorescent dye) technique is less expensive than QBC system.
and an anticoagulant. Following centrifugation, 5. Detection of nucleic acid sequences of malaria
malaria parasites get concentrated in the upper parasites: Malaria parasites can be detected by
layer of red cells just below the buffy coat and are identification of specific nucleic acid sequences in
stained with the fluorescent dye. When the their DNA. Methods based on polymerase chain
capillary tube is viewed using a special objective reaction (PCR) have been developed for identification
(paralens) attached to the fluorescence micro- of DNA of malaria parasite. Species diagnosis is also
scope, malaria parasites fluoresce green yellow possible. PCR-based methods can detect very low
against a dark red-black background. Nuclei of levels of parasites in blood (< 5 parasites/μl of blood)
trophozoites fluoresce bright green. with very high sensitivity and specificity.
Table 26.2: Comparison of blood smear and commercial rapid diagnostic tests for malaria diagnosis
Parameter Blood smear Rapid diagnostic tests
1. Sensitivity 5-10 parasites/μl 40-100 parasites/μl
2. Species identified All Depends on test kit
3. Parasite density Can be estimated Cannot be estimated
4. Performance Laborious Easy
5. Time required 1 hour 15-20 minutes
6. Detection of sequestered P. falciparum No Yes
7.Distinction between gametocytes and other stages Yes No
8. Cost Low High
Diagnosis of Malaria and Other Parasites in Blood 237
external genitals, or breasts) with coarse thickening and prepared from capillary blood collected at the appropriate
fissuring of skin. Local bacterial and fungal infections time, and if clinical suspicion is strong, concentration
are common. Microfilariae are usually not found in blood techniques are employed. This is because circulating
of patients with hydrocele and elephantiasis. microfilariae are often scanty and sensitivity of
In some cases, there is passage of milky-white chyle microfilarial detection increases when volume of blood
in urine (chyluria). This is due to rupture of distended sampled is increased.
urogenital lymphatics, which are connected to the
intestinal lymphatic vessels carrying chyle. Microscopic Concentration techniques
examination of such urine shows microfilariae. Membrane filtration: This is a sensitive method but is
expensive for routine use in endemic areas. Anticoa-
gulated venous blood (10 ml) is passed through a
LABORATORY DIAGNOSIS
polycarbonate membrane filter of 3 μm or 5 μm pore size.
Diagnostic methods in lymphatic filariasis include: Following this 10 ml of methylene blue saline solution is
• Microscopic examination of blood for demonstration passed through the filter for staining the microfilariae.
of microfilaria Microfilariae are trapped and retained on the filter, which
• Detection of filarial antigen in blood by rapid is placed on a glass slide and examined under the
immunochromatographic test microscope.
• Demonstration of microfilariae in hydrocele fluid or Microhematocrit tube or capillary tube method: Two
chylous urine heparinised capillary tubes are filled with blood from
• Demonstration of adult worms in lymph node biopsy skin punctures (or two plain capillary tubes are filled
• Detection of parasite DNA by polymerase chain with anticoagulated venous blood). After sealing the dry
reaction. ends with a suitable sealant, tubes are centrifuged in a
microhematocrit centrifuge for about 5 minutes. The
Microscopic Examination of Blood for capillary tubes are placed on a glass slide and fixed with
Demonstration of Microfilaria adhesive tape. Plasma just above the buffy coat layer is
examined for motile microfilariae under the microscope
Since some species exhibit periodicity (i.e. circulation of
(Fig. 26.9).
microfilariae in increased numbers at certain times of the
day), blood should be collected at the correct time to Lysed venous blood method: 10 ml of venous blood is lysed
improve the chances of detection. For Wuchereria bancrofti by saponin-saline solution. The hemolysate is centri-
and Brugia malayi showing nocturnal periodicity, blood fuged, supernatant is discarded, and the sediment is
should be collected at night between 10 p.m. to 4 a.m. placed on glass slide. After adding a drop of methylene
Microfilariae are present in greater numbers in capillary blue solution, a coverslip is placed, and the preparation
blood than in venous blood; therefore, skin puncture is is examined under the microscope for microfilariae.
preferred. Usually microfilariae are scanty in peripheral
blood so that concentration techniques may be necessary Lysed capillary blood method: 0.1 ml of blood obtained by
for their demonstration. skin puncture is added to 1 ml of saponin-saline solution
Following microscopic methods can be used for to cause lysis of red cells. After centrifugation, super-
detection of microfilariae in peripheral blood: natant is discarded and sediment is placed on a glass
• Thick blood smear slide. A drop of methylene blue solution is added and a
• Concentration techniques: membrane filtration, coverslip is placed over it. The entire preparation is
microhematocrit centrifugation, lysed venous blood examined under the microscope for motile microfilariae.
technique, lysed capillary blood technique.
Morphology of Microfilariae on
Thick Blood Smear Romanowsky-stained Blood Smears
A thick blood smear is spread from 20 μl of capillary blood Wuchereria bancrofti: Microfilariae measure about 300 μ in
on a glass slide, air-dried, and stained with a Romanowsky length and 8 μ in breadth. They have a hyaline sheath,
stain. If microfilariae are not detected in thick smears which stains pink. There are distinct nuclei in the central
Diagnosis of Malaria and Other Parasites in Blood 239
Detection of Filarial DNA by Polymerase along Brahmaputra and Ganges, Bihar, Orissa, and
Chain Reaction Andhra Pradesh.
L. infantum is endemic in the Mediterranean basin and
Filarial DNA can be detected in circulating blood by
infection is zoonotic (i.e. transmitted to humans from
polymerase chain reaction. Although this test is highly
animals like dogs through sandfly vector).
sensitive and species-specific for diagnosis, it is laborious
L. chagasi occurs in Latin America with domestic dog
and expensive for routine use in developing countries.
as the primary reservoir of infection.
VISCERAL LEISHMANIASIS Typical manifestations of VL include fever, enlarge-
Leishmaniases are a group of parasitic diseases caused ment of spleen, enlargement of liver, severe cachexia,
by obligate intracellular protozoa of the genus Leishmania pancytopenia (anemia, leukopenia, and thrombo-
and transmitted by the bite of an infected female sandfly cytopenia), and hypergammaglobulinemia. Secondary
of the genus Phlebotomus (Africa, Asia, and Europe) or infections are frequent. The name “ Kala-azar” is derived
Lutzomyia (South and Central America). from the grayish coloration of skin that often develops
Leishmaniases are endemic in tropical and sub- during the course of disease. If untreated, death often
tropical regions of 88 countries on five continents. There follows.
are about 12 million cases of leishmaniases worldwide Post kala azar dermal leishmaniasis (PKDL) is a
and 1.5 to 2 million cases occur annually. Rising cutaneous form of leishmaniasis occurring after
prevalence of leishmaniases is attributed to massive rural resolution of visceral leishmaniasis. It is observed in India
to urban migration, deforestation with development of and East Africa. It manifests as hypopigmented and
newer dwelling sites, and newer irrigation projects. In raised erythematous lesions most prominently on the
addition, leishmania/human immunodeficiency virus face. The lesions contain amastigote forms of L. donovani.
coinfection is rapidly emerging as a new, severe disease. Since Leishmania are present in large numbers in
Leishmaniases occur in three different clinical forms: peripheral blood, they can be transmitted via sharing of
visceral, cutaneous, and mucocutaneous. Only visceral needles among intravenous drug abusers.
leishmaniasis is considered below. The typical clinical features of visceral leishmaniasis
In Asia, visceral leishmaniasis (VL) is also called as are not always seen and atypical presentations make
kala azar or black sickness. This is the most severe form of diagnosis difficult. Response to treatment is poor and
leishmaniases and is caused by Leishmania donovani relapses are common.
complex (which includes L. donovani, L. infantum, and L.
chagasi species). Majority of cases of VL occur in Life Cycle of Leishmania donovani
Bangladesh, northeastern Brazil, northeast India, Nepal,
and Sudan. Leishmania donovani (LD) exists in two stages: promasti-
In India, the causative organism is L. donovani and gote (flagellated form found in sandfly vector) and
infection is anthroponotic (i.e. transmitted from one amastigote (non-flagellated tissue-form found in
human to another through sandfly vector Phlebotomus). In mammalian host) (Fig. 26.11). Infection is transmitted to
India, leishmaniasis is prevalent in Assam and Bengal man when the infected female sandfly takes a blood meal
Parasite Culture
Cultures are usually made on Novy-McNeal Nicolle
(NNN) medium. After inoculation with 1-2 drops of
splenic or bone marrow aspirate, the culture is incubated
at 22 to 28°C, and examined weekly for promastigote
forms for upto 4 weeks.
In vitro culture of infected tissue is not required for
diagnosis in clinical practice. Parasite culture is necessary
if other methods of diagnosis are negative in the presence
Fig. 26.13: Formol gel test for visceral leishmaniasis
of strong clinical suspicion, and to obtain sufficient
quantity of antigen for direct agglutination test.
6. Moody A. Rapid diagnostic tests for malaria parasites. 11. Weil GJ, Lammie PJ, and Weiss N. The ICT Filariasis
Clin Microbiol Reviews 2002;15:66-78. Test: A rapid-format antigen test for diagnosis of
7. Palmer CJ, et al. Evaluation of the OptiMal test for rapid bancroftian filariasis. Parasitology Today 1997;13:
diagnosis of P. vivax and P. falciparum malaria. J Clin 401-4.
microbial 1998;36:203-6. 12. WHO information Fact sheets: The Leishmaniases and
8. Sundar S, Rai M. Laboratory diagnosis of visceral Leishmania/HIV co-infections. Fact sheet no. 116.
Leishmaniasis. Clinical and Diagnostic Laboratory Revised May 2000. Geneva. World Health Organization.
13. World Health Organization. New perspectives in
Immunology 2002; 9:951-8.
malaria diagnosis. World Health Organization. 2000.
9. Warhurst DC, Williams JE. Laboratory diagnosis of
Geneva, Switzerland. WHO/MAL/2000.1091.
malaria. J Clin Pathol 1996;49:533-98. 14. World health Organization. Basic laboratory methods
10. Warrell DA, Gilles HM (Eds): Essential Malariology. (4th in medical parasitology. 1991. Geneva. World Health
Ed). 2002. London. Arnold. Organization.
27
Anemia is defined as a reduction in hemoglobin circulation causes palpitations and heart murmurs, and
concentration below the level, which is expected for in severe cases congestive cardiac failure can develop,
healthy persons of same age and sex, and in the same particularly in elderly. Anginal pain can result from
environment. Adequate oxygen cannot be delivered to myocardial hypoxia.
various organs and tissues due to low oxygen carrying Anemia is an objective sign of disease and needs
capacity of blood. further evaluation to determine the underlying cause and
The normal hemoglobin ranges, as proposed by appropriate treatment.
World Health Organization (WHO), are given at the end
of this chapter under “Reference Ranges”. CLASSIFICATION OF ANEMIAS
Anemia may occur without symptoms and may be
detected incidentally during medical examination. When There are two ways of classifying anemia:
severe enough, clinical features due to anemia result from • Etiological classification
hypoxia such as fatigue, weakness, dizziness, fainting, • Morphological classification
and mental confusion. Pallor of skin, mucous mem- 1. Etiological classification: Anemia can result from a
branes, and conjunctiva is present. Hyperdynamic variety of causes (Table 27.1).
saturation is <10% in iron deficiency anemia. Free 8. Response to oral iron therapy: Increased reticulocyte
erythrocyte protoporphyrin is increased. count beginning around 3rd day and reaching
6. Increased soluble transferrin receptor (sTfR) in serum: This maximum on 5th-10th day after starting oral iron
assay is useful in cases with associated inflammation. therapy indicates optimal response. Hemoglobin rises
The transferrin receptor is a specific receptor for at the rate of 0.5-1.0 gm/dl/week.
transferrin-iron complex and is located on cell Iron deficiency anemia should be differentiated from
membranes. A soluble form also exists in circulation, other causes of microcytic hypochromic anemia such as
which is derived from proteolysis of cell membrane anemia of chronic disease, thalassemia, and sideroblastic
during erythrocyte maturation. Concentration of anemia (Table 27.3).
serum transferrin receptors correlates with the Diagnosis of iron deficiency anemia is straight
number of cellular receptors and varies with the rate forward. It is more important to determine the cause of
of erythropoiesis. In iron deficiency, its level increases iron deficiency, especially in adults since a serious
due to increased expression on cell membranes. underlying disorder (like carcinoma of gastrointestinal
However, increased levels are also found in any tract) may be present. To uncover the causative factor,
condition associated with increased erythropoietic apart from complete clinical examination, it may be
activity like hemolytic anemias and myeloprolife- necessary to perform stool examination for parasites and
rative disorders. for occult blood, urine examination for occult hematuria,
7. Bone marrow iron stain: This is the gold standard for radiologic and endoscopic workup of gastrointestinal
diagnosis of iron deficiency and shows lack of tract, and in females, pelvic ultrasonography.
stainable iron in the bone marrow. The test assesses
storage iron in bone marrow (confined mainly within Megaloblastic Anemia
macrophages; small amount in erythroblasts). This Megaloblastic anemia results from deficiency of either
test is expensive, and not required for routine folate or vitamin B12 (Table 27.4). Folate and vitamin B12
diagnosis. are essential for synthesis of deoxyribonucleic acid
*Autoimmune disorder characterized by gastric atrophy and loss of production of intrinsic factor in stomach that is
necessary for absorption of vitamin B12
Fig. 27.4 Evaluation of suspected megaloblastic anemia. (*: Measurement of serum methylmalonic acid is said to be
more sensitive than measurement of vitamin B12 and an earlier marker for detection of vitamin B12 deficiency)
(Table 27.5, and Fig. 27.4). Treatment only with folate in Anemia of Chronic Disease
vitamin B12 deficiency can worsen the neurological Anemia of chronic disease is the most common form of
abnormalities. anemia amongst hospitalized patients. The three disease
In vitamin B 12 deficiency, test for vitamin B 12 categories associated with anemia of chronic disease are
absorption (Schilling test) can be carried out. In this test, chronic infection, inflammation, and malignancy
(Table 27.6). There is a block in release of storage iron
urinary excretion of oral dose of radio-labeled vitamin
from macrophages for erythropoiesis that is mediated
B 12 is compared with the excretion of oral dose of by inflammatory cytokines.
radiolabeled vitamin B12 bound to intrinsic factor. In Anemia is mild (9-10 gm/dl) and non-progressive.
pernicious anemia, deficient absorption is corrected with Clinical features reflect underlying disease. The main
addition of intrinsic factor. differential diagnosis is iron deficiency anemia.
Laboratory Tests in Anemia 249
Acquired
Idiopathic
Drugs:
Idiosyncratic: antibacterials (chloramphenicol,
sulfonamides), nonsteroidal anti-inflammatory drugs
(phenylbutazone, indomethacin, piroxicam, diclofenac),
antithyroid drugs, furosemide, phenothiazines, allopurinol,
oral antidiabetics, Dose-related: Cytotoxic drugs
Chemicals (e.g. benzene) or radiation
Infections: Hepatitis; Epstain Barr virus, Mycobacteria
Paroxysmal nocturnal hemoglobinuria
Systemic lupus erythematosus
Graft vs. host disease
Fig. 27.5: Blood smear (on left) in sideroblastic anemia showing Inherited
dimorphic red cells, basophilic stippling, and a polychromatic
Fanconi’s anemia, Dyskeratosis congenita
red cell. Bone marrow smear stained with iron stain (on right)
shows ringed sideroblasts
250 Essentials of Clinical Pathology
• Tests for diagnosis of underlying cause: Viral studies polypeptide chain with abnormal structure (Table 27.8).
(hepatitis A antibody, hepatitis B surface antigen, The inherited disorders of hemoglobin have achieved a
hepatitis C antibody), Ham’s test and/or flow high frequency due to the selective advantage afforded
cytometry for lack of CD55 and CD59 (for paroxysmal to the heterozygotes of these genetic variations against
nocturnal hemoglobinuria), detailed drug history, infection by Plasmodium falciparum.
antinuclear antibody test (for systemic lupus
erythematosus), and cytogenetic analysis (for Fanconi Thalassemias
anemia). Etiology remains unknown in 50% cases of
The thalassemias are inherited disorders characterized
aplastic anemia.
by reduced or absent synthesis of α or β globin
Severity of Aplastic Anemia polypeptide chains.
Note: β0 indicates no production of β globin chain; β+ indicates diminished but some production of β globin chain;
β indicates normal β chain production
Laboratory Tests in Anemia 253
shows marked variation in size and shape of red cells, Mode of inheritance is autosomal recessive. If both the
microcytosis, hypochromia, and nucleated red cells. parents have sickle cell trait, sickle cell anemia will develop
Hemoglobin electrophoresis reveals predominance of Hb in the offspring (1:4 chance). Clinical features of sickle cell
Bart’s and absence of Hb A. anemia are highly variable, and range from infrequent
Patients with HbH disease have moderate anemia and mild to frequent and severe. Manifestations include
(hemoglobin 7-10 gm/dl), jaundice, and hepato- chronic hemolytic anemia, vaso-occlusive crises (acute
splenomegaly. Typical laboratory features are microcytic episodes of severe pain in chest, abdomen, back, or
hypochromic red cells, Hb H inclusions in red cells, and extremities), aplastic crisis (sudden aggravation of anemia
variable amount of HbH on electrophoresis. due to infection by parvovirus), hemolytic crisis
α thalassemia carriers are asymptomatic. Microcytic (exacerbation of hemolysis due to infection or associated
hypochromic red cells may or may not be present. glucose-6-phosphate dehydrogenase deficiency), splenic
Hemoglobin electrophoresis is normal. Determining sequestration crisis (sudden enlargement of spleen due to
ethnic origin, family studies, globin chain analysis, or pooling of blood leading to circulatory failure), risk of
genetic analysis may be needed for definitive diagnosis. infections (especially Streptococcus pneumonia, Hemophilus
influenzae, Neisseria meningitidis, Escherichia coli) and
Sickle Cell Disorders retarded growth and development.
In sickle cell anemia, blood smear shows sickled red
Sickle cell disorders are characterized by the presence of cells and target cells (Fig. 27.9), solubility test is positive,
hemoglobin S (HbS) in red cells due to a point mutation and hemoglobin electrophoresis shows mostly HbS with
A→T in the 6th codon of β globin gene, which results in no HbA. In sickle cell trait, blood smear is normal or
substitution of valine for glutamic acid at position 6 of β shows target cells, solubility test is positive, and
polypeptide chain (β6glu→val). Upon deoxygenation, HbS hemoglobin electrophoresis shows HbA (60%) and HbS
polymerizes in red cells leading to the formation of sickle- (40%).
shaped red cells; such red cells are rigid, occlude the Although blood smear shows sickle cells in sickle cell
microvasculature, and cause painful vaso-occlusive anemia, and both slide test and solubility test are positive
crises. Sickle cells adhere to vascular endothelium due in sickle cell disorders, hemoglobin electrophoresis is
to increased expression of adhesion molecules. Deformed
red cells are removed from the circulation and destroyed
prematurely, leading to chronic hemolytic anemia.
Disease manifests in individuals with homozygous sickle
cell disease; heterozygotes are usually asymptomatic.
Sickling disorders (Table 27.10) are prevalent in
Africa, Middle East, Mediterranean region, and central
and southern parts of India. It is thought that the disease
has achieved high frequency due to evolutionary
selection for resistance against falciparum malaria.
Disorder Genotype
Hemoglobin D
In India, hemoglobin D is observed in Punjab. Hetero-
zygotes (A/D) are asymptomatic, while homozygotes
(D/D) have mild anemia. Blood smear shows hypo-
chromia, microcytosis, and target cells. On hemoglobin
electrophoresis at alkaline pH, hemoglobin D co-migrates
with HbS. Slide test for sickling, however, is negative in
Hb D disease.
HEREDITARY SPHEROCYTOSIS
Fig. 27.10: Blood smear in hereditary spherocytosis showing
This is the most common type of hereditary hemolytic spherocytes, a polychromatic cell, and a nucleated red cell
anemia in North Europeans. Hereditary spherocytosis
(HS) is characterized by an inherited defect in the red
cell cytoskeleton leading to the formation of spherocytes. Anemia, reticulocytosis, and microspherocytes on
Normally, the lipid bilayer is anchored to the underlying blood smear are the usual findings (Fig. 27.10). Micro-
cytoskeleton by interactions of (i) spectrin, protein 4.1, spherocytes are small and dense red cells lacking central
actin, and glycophorin C, and (ii) spectrin, ankyrin, and area of pallor. (They are also observed in autoimmune
band 3. In most cases of HS, there is a deficiency of hemolytic anemia, ABO hemolytic disease of newborn,
ankyrin so that membrane becomes unstable with burns, microangiopathic hemolytic anemia, and
fragmentation of part of membrane, loss of surface area, hemolytic transfusion reaction).
and spherocyte formation. Spherocytic red cells are rigid, The usual screening test for HS is osmotic fragility
less deformable than normal red cells, and are destroyed (OF) test (Figs 27.31 and 27.32, later). This test assesses
prematurely in spleen. Mode of transmission is usually the ability of the red cells to withstand osmotic stress
autosomal dominant. when they are suspended in decreasing concentrations
Usual clinical manifestations are presentation in of hypotonic saline solutions. Spherocytes have reduced
childhood with mild to moderate anemia, intermittent surface area to volume ratio and are osmotically fragile.
jaundice, and splenomegaly. Pigment gallstones are Incubated variant of OF test is more sensitive. Auto-
frequent. Similar history is obtained in a close relative. hemolysis test shows markedly increased hemolysis that is
Clinical presentation, however, is markedly variable. partially corrected by addition of glucose (Fig. 27.33, later).
Laboratory Tests in Anemia 255
GLUCOSE-6-PHOSPHATE
DEHYDROGENASE DEFICIENCY
Fig. 27.12: Blood smear in warm antibody type autoimmune Fig. 27.13: Blood smear in cold agglutinin disease
hemolytic anemia showing spherocytes, polychromasia, and showing large clusters of red cells (autoagglutination)
late normoblast
warming of blood sample causes disappearance of case of anti-D, mother is Rh D-negative and father is Rh
autoagglutination. Direct antiglobulin test is positive due D-positive. Rh HDN develops during second or
to the presence of complement on red cells. subsequent pregnancies if the fetus is Rh D-positive.
Clinical presentation is variable. Rh HDN may
HEMOLYTIC DISEASE OF NEWBORN manifest with (i) mild anemia and jaundice, (ii) icterus
Hemolytic disease of newborn (HDN) is characterized gravis neonatorum with kernicterus, or (iii) hydrops
by destruction of red cells of the fetus or neonate due to fetalis with intrauterine fetal death.
antibodies produced by the mother. Allo-antibodies The usual clinical presentation of ABO HDN is mild
develop in the mother against foreign red cell antigens anemia and jaundice.
of the fetus inherited from the father. Leakage of fetal Antenatal investigations consist of:
red cells during pregnancy or delivery into the maternal 1. Maternal: These are ABO and Rh grouping, antibody
circulation stimulates formation of antibodies. Passage screening, antibody identification, and antibody
of IgG maternal antibodies across placenta into the fetal titration: If antibody is clinically significant, titer is
circulation causes hemolysis of fetal red cells. determined. Titer >1:32 or a rising titer showing
The two main red cell antigens responsible for HDN increase of 2 dilutions or more is significant and
are Rh and ABO. In Rh HDN, antibodies develop against amniocentesis should be performed to determine
anti-D and less commonly against anti-C or anti-E. In severity of disease (Fig. 27.14).
Laboratory Tests in Anemia 257
Fig. 27.16: Use of Kleihauer-Betke test to determine the dose of anti-D following delivery by a Rh D-negative woman
of a Rh D-positive baby. The maternal sample should be taken within 2 hours of delivery or any other sensitizing event
PAROXYSMAL NOCTURNAL
HEMOGLOBINURIA
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare,
acquired clonal stem cell disorder in which red cells are
abnormally sensitive to the hemolytic action of the
complement. PNH red cells are deficient in several cell
membrane proteins including CD 55 (decay accelerating
factor) and CD 59 (membrane inhibitor of reactive lysis or
MIRL). Normally, small amount of complement is being
continuously generated via alternate complement
pathway. CD 55 inactivates C3 convertase while CD 59
inhibits the formation of membrane attack complex and
protects the red cells against complement-mediated attack.
Fig. 27.17: Blood smear in Rh hemolytic disease of
In a typical case of PNH, red cell destruction occurs newborn showing erythroblasts and polychromatic cells
at night so that hemoglobinuria (passage of reddish-
brown urine) is noticed after getting up in the morning.
However, presentation is often variable and may be in • Demonstration of increased sensitivity of red cells to
the form of pancytopenia, aplastic anemia, chronic complement: Sucrose hemolysis test, Ham’s test.
intravascular hemolysis, or recurrent venous thromboses. • Flow cytometric analysis of blood cells for lack of
Some cases of PNH evolve to acute myeloid leukemia. CD55 or CD59.
Laboratory diagnosis of PNH is based on:
• Evidence of intravascular hemolysis: Hemoglo- MICROANGIOPATHIC HEMOLYTIC ANEMIA
binuria, hemosiderinuria, methemalbuminemia, and This is a form of mechanical hemolytic anemia resulting
increased indirect serum bilirubin. from intravascular fragmentation and lysis of red cells
Laboratory Tests in Anemia 259
Estimation of Hemoglobin
Cyanmethemoglobin method is the method of choice.
Recently introduced WHO hemoglobin color scale is a
simple and inexpensive method and well suited for
under-resourced laboratories (see Chapter 18: Estimation
of Hemoglobin).
Depending on hemoglobin concentration, anemia is
graded as mild (hemoglobin less than lower limit of
normal but above 10.0 gm/dl), moderate (hemoglobin
7-10 gm/dl), and severe (hemoglobin < 7 gm/dl).
Measured hemoglobin level depends on amount of
hemoglobin in red blood cells and blood volume.
Fig. 27.18: Blood smear in microangiopathic hemolytic Pseudoanemia or spurious anemia results from relative
anemia showing many fragmented red cells increase in plasma volume in pregnancy, splenomegaly,
congestive cardiac failure, and paraproteinemias.
Therefore, hemoglobin level should be interpreted in the
due to vascular endothelial abnormalities. Common
light of clinical features.
causes include thrombotic thrombocytopenic purpura,
hemolytic uremic syndrome, disseminated intravascular Estimation of Packed Cell Volume (PCV)
coagulation, eclampsia, disseminated malignancy, and
PCV is the volume of packed red cells obtained after
generalized vasculitis. Blood film shows numerous
centrifugation of a sample of anticoagulated blood in a
fragmented red cells (schistocytes) (Fig. 27.18).
Wintrobe tube or a capillary tube (see Chapter 19 : Packed
APPROACH TO DIAGNOSIS OF ANEMIA Cell Volume). Hematocrit is the equivalent measurement
derived on automated blood cell analyzer from the red
Evaluation of a case of anemia consists of: cell indices. Although not entirely synonymous, the terms
• Establishing the presence and severity of anemia, and PCV and hematocrit are used interchangeably in clinical
• Determining the cause of anemia. practice.
PCV is about three times the value of hemoglobin
Establishing the Presence and concentration and thus can be used to cross-check the
Severity of Anemia
hemoglobin value.
Clinical features of anemia are non-specific and their Sometimes, additional information can be gained
assessment is often subjective. Laboratory methods for from the observation of color of plasma and thickness of
260 Essentials of Clinical Pathology
probable cause of anemia. Apart from morphological type Red cell indices: Among the red cell indices, mean cell
of anemia and abnormality of red cells, blood smear also volume is the most useful for classification of anemia
provides information regarding disorders of white cells into normocytic, microcytic, and macrocytic types
(e.g. leukemias), and platelets (thrombocytopenia). (See (Table 27.16). Red cell distribution width is used to
Chapter 22: Blood Smear). distinguish between iron deficiency anemia and
thalassemia (see Chapter 23: Red Cell Indices).
Reticulocyte count: It is a measure of the capacity of the
bone marrow to produce red cells. Reticulocyte count is
Microcytic Hypochromic Anemia
mainly useful for diagnosis of anemia due to decreased
red cell production or ineffective erythropoiesis (in which An approach for evaluation for microcytic hypochromic
reticulocyte count is low). Increased reticulocyte count anemia is shown in Figure 27.20. The distinction between
appropriate for degree of anemia indicates effective red different causes of microcytic anemia is shown in Table
cell production. Causes of low reticulocyte count are 27.3 earlier.
megaloblastic anemia, aplastic anemia, bone marrow
infiltration, and alcoholism. Causes of increased Macrocytic Anemias
reticulocyte count are response to hematinic therapy in Evaluation of macrocytic anemia is presented in Figure
nutritional anemia, hemolysis, and bleeding (see Chapter 27.21.
21: Reticulocyte Count). If reticulocyte count is increased,
then tests for hypoproliferative anemias are generally not Normocytic Normochromic Anemia
required (such as iron studies, vitamin B12 and folate Evaluation of normocytic anemia is shown in Figure
assays, bone marrow examination). 27.22.
*Another way of classification of macrocytic anemia: (1) Round macrocytosis: alcoholism, liver disease, hypothyroidism;
and (2) oval macrocytosis: folate or vitamin B12 deficiency, myelodysplastic syndrome. Abbreviations: MCV: mean cell
volume; MCHC: mean cell hemoglobin concentration
262 Essentials of Clinical Pathology
The three typical laboratory features indicative of In extravascular hemolysis, unconjugated bilirubin in
hemolytic anemia are low hemoglobin, increased serum and urobilinogen in urine are increased. However,
reticulocyte count, and raised indirect serum bilirubin. hemoglobinemia, hemoglobinuria, hemosiderinuria, and
2. Whether hemolysis is intravascular or extravascular: In methemalbuminemia are absent.
intravascular hemolysis, red cell destruction occurs 3. Defining cause of hemolysis: Usually, clinical features
within circulation (Fig. 27.23), while in extravascular and morphology of red cells on blood smear suggest
hemolysis, red cells are destroyed by macrophages the probable cause of hemolytic anemia (Fig. 27.25).
of the reticuloendothelial system in spleen and liver Specific laboratory tests are then carried out for
(Fig. 27.24). definitive diagnosis.
Main causes of intravascular hemolysis are hemolytic Specific laboratory studies to establish the cause of
transfusion reaction, glucose-6-phosphate dehydro- hemolytic anemia are:
genase deficiency, blackwater fever in falciparum
malaria, septicemia, autoimmune hemolytic anemia a. Tests in hereditary hemolytic anemias:
(some types), and paroxysmal nocturnal hemoglobinuria. • Hemoglobin disorders: sickling test, hemoglobin
Laboratory features of intravascular hemolysis are: electrophoresis, high performance liquid
• Hemoglobinemia chromatography, estimation of hemoglobin A2,
• Decreased or absent plasma haptoglobin estimation of hemoglobin F, red cell inclusions.
• Hemosiderinuria • Red cell enzyme defects: test for glucose-6-
• Methemalbuminemia: Methemalbumin has a phosphate dehydrogenase deficiency
characteristic absorption band at 558 nm (Schumm’s • Red cell membrane disorders: osmotic fragility
test). test, autohemolysis test
Iron Studies
Causes of false-negative test are old or outdated Cellulose acetate electrophoresis at alkaline pH is the
reagent, low concentration of Hb S (e.g. infants <6 first-line test in the investigation of hemoglobinopathies.
months, severe anemia), and recent blood transfusion. The procedure in short is as follows:
If the test is positive, hemoglobin electrophoresis 1. Hemolysates are prepared from EDTA antico-
should be performed for confirmation of Hb S, and to agulated blood (both control and patient’s samples)
distinguish between various sickle cell disorders. to obtain hemoglobin solutions. The control consists
of hemoglobins A, F, S, and C.
Hemoglobin Electrophoresis 2. Samples are applied near one end of the cellulose
There are different forms of normal (e.g. HbA, Hb F, Hb acetate strip (point of origin) in separate lanes.
A 2 ) and abnormal (e.g. Hb S, Hb C, Hb D, Hb G) 3. Cellulose acetate strips are placed in the electro-
hemoglobins. The proportions of different hemoglobins phoresis chamber containing the Tris-EDTA-borate
in common disorders of hemoglobin are shown in Table buffer (pH 8.5) with point of origin towards the
27.17. Various hemoglobins differ in their amino acid cathode.
composition, and hence in their charge when placed in 4. The chamber is connected to the power supply and
an electric field and migrate at different rates. Electro- electric current is applied till adequate separation of
phoresis can detect only those abnormalities of hemo- hemoglobins is obtained.
globin that alter the charge. These hemoglobins are 5. The strips are removed from the chamber and results
identified by positions they occupy when they migrate are read visually. If a permanent record is required,
from their point of origin. A control sample consisting strips are stained with a protein stain.
of known normal and abnormal hemoglobins is also run
Relative mobilities of some hemoglobins after
along with the test sample so as to compare and identify
electrophoresis at alkaline pH are shown in Figure 27.28.
locations of hemoglobins in the test sample.
Hemoglobin electrophoresis is used for: At alkaline pH, some hemoglobins have the same net
• Detection of abnormal hemoglobins like Hb S, Hb C, charge so that they migrate to the same position, e.g.
Hb D, Hb G, etc. and determining the phenotype by hemoglobins S, D, and G occupy the same position, and
assessing relative proportions of Hb A, Hb F, and the A2 , C, E, and O run together. To differentiate these
abnormal hemoglobin. hemoglobins from each other, citrate agar electrophoresis
• Detection of elevated HbF or Hb A2 in thalassemias. should next be carried out at acid pH (see Fig. 27.28).
• Quantitation of Hb A2 for diagnosis of β thalassemia Citrate agar electrophoresis at acid pH (6.0) provides
trait. separation of hemoglobins that migrate to the same
Two types of hemoglobin electrophoresis are commonly position on cellulose acetate at pH 8.5. In addition, it is
used: also well-suited for neonatal screening of sickle cell
• Cellulose acetate electrophoresis at alkaline pH anemia since clear separation between hemoglobins A,
• Citrate agar electrophoresis at acid pH. F, and S is obtained.
Table 27.17: Proportions of different hemoglobins in normal individuals and in hemoglobin disorders
Condition HbA HbF HbA2 HbS
This test may be negative if only a few spherocytes are Antiglobulin (Coombs’) Test
present in peripheral blood. Sensitivity of the test can be
Antiglobulin or Coomb’s test is of two types: direct
increased by incubating the red cells at 37°C for 24 hours
(Fig. 27.34) and indirect (Fig. 27.35).
before performing the test (osmotic fragility test after
incubation). Direct antiglobulin test (DAT): This test detects antibodies
or complement or both attached to red cells. DAT is used
Autohemolysis Test
in the investigation of acquired immune hemolytic
In autohemolysis test, blood is incubated at 370 C for 48
hours and the amount of spontaneous hemolysis is noted.
The test is carried out with and without addition of
glucose. In hereditary spherocytosis, autohemolysis is
markedly increased, which is corrected partially
following addition of glucose (Fig. 27.33).
Fig. 27.36: Ham’s acidified serum lysis test for paroxysmal nocturnal hemoglobinuria. Tube 1: Fresh normal serum + Patient’s
red cells; Tube 2: Fresh normal serum + Hydrochloric acid + Patient’s red cells; Tube 3: Patient’s serum + Hydrochloric acid
+ Patient’s red cells; Tube 4: Heat-inactivated normal serum + Hydrochloric acid + Patient’s red cells; Tube 5: Fresh normal
serum + Normal red cells; Tube 6: Fresh normal serum + Hydrochloric acid + Normal red cells; Tube 7: Heat-inactivated
normal serum + Hydrochloric acid + Normal red cells. Tube 1 is showing trace hemolysis, tube 2: marked hemolysis;
tube 3: slight hemolysis; tubes 4 to 7: No hemolysis
272 Essentials of Clinical Pathology
3. Flow cytometric analysis: This can detect deficiency of Vitamin B12 and Folate Studies
CD 55 or CD 59 proteins by using monoclonal • Serum vitamin B12: 150-700 ng/L
antibodies. • Serum folate: 3-20 µg/L
• Red cell folate: 150-700 µg/L
REFERENCE RANGES
Hemoglobin Serum Haptoglobin
Recently, World Health Organization (WHO) classifi- for diagnosis of AML (Earlier FAB recommendation was
cation of hematopoietic and lymphoid neoplasms has 30%). The term ‘blast’ includes myeloblasts, promyelo-
been proposed (2001). WHO classification (2001) of acute cytes (for acute promyelocytic leukemia), monoblasts and
myeloid leukemias is shown in Table 28.2. This promonocytes (for acute myelomonocytic and acute
classification integrates clinical, morphologic, genetic, and monocytic leukemia), and megakaryoblasts (for acute
immunophenotypic features to define specific disease megakaryocytic leukemia).
categories. Myeloid cell lines are erythroid, granulocytic,
In WHO classification, acute lymphoblastic leukemias monocytic, and megakaryocytic. Myeloid nature of blasts
are placed under lymphoid neoplasms. ALL and is established by morphology (Auer rods), cytochemistry
lymphoblastic lymphoma or Burkitt’s lymphoma are
(myeloperoxidase, nonspecific esterase), and immuno-
considered as biologically the same disease with different
phenotyping (myeloid related antigens like CD 117, CD
clinical presentations. The term ALL is used for leukemic
13, CD 33).
phase of precursor neoplasms of B or T cell type. Burkitt
In contrast to FAB classification, WHO classification
cell leukemia is the counterpart of Burkitt lymphoma and
recognizes AML with recurrent cytogenetic abnormalities,
corresponds with FAB L3 subtype of ALL. ALL includes
following categories in WHO classification: AML with multilineage dysplasia, and therapy-related
• Precursor B cell ALL AML as distinct entities.
• Precursor T cell ALL Patients with clonal, recurrent cytogenetic abnor-
• Burkitt cell leukemia malities listed in Table 28.2 are considered to have AML
Salient features of WHO classification are outlined in irrespective of the percentage of blasts in blood or bone
Table 28.2. marrow. These patients have characteristic clinical and
According to WHO criteria, blast count should be 20% morphological features and a favorable response to
or more in either peripheral blood smear or bone marrow therapy.
Diagnosis of AML with multilineage dysplasia 1. Morphology: Initial step in the diagnosis of acute
requires either (i) prior history of myelodysplastic leukemias is examination of Romanowsky-stained
syndrome for atleast 6 months before the onset of overt smears of peripheral blood and marrow aspirate.
AML, or (ii) ≥ 50% of dysplastic cells in two or more In a typical case, bone marrow suppression leads
myeloid lineages. This category of AML is associated to normocytic normochromic anemia, thrombo-
with poor outcome. cytopenia, and neutropenia. Total leukocyte count is
Features of alkylating therapy related AML are (i) usually elevated; however, it may be normal or low.
development 4-7 years following therapy, (ii) charac- In subleukemic leukemia, leukocyte count is normal or
teristic cytogenetic abnormalities involving chromo- decreased, but blasts are demonstrable in peripheral
somes 5 or 7, (iii) associated and preceding multilineage blood. In aleukemic leukemia, blasts are not demonst-
dysplasia, and (iv) adverse prognosis. rable in peripheral blood, but present in bone marrow.
Topoisomerase II inhibitor therapy-related AML In AML (M0, M1), leukemic hiatus occurs, i.e.
develops 6 months to 5 years after starting therapy, and peripheral blood shows blast cells and mature cells,
is also associated with characteristic cytogenetic while intermediate cells (like promyelocytes,
alterations affecting 11q23. There is no preceding myelocytes, and metamyelocytes) are not seen.
myelodysplasia. This form of therapy can also cause acute Bone marrow is usually hypercellular due to
lymphoblastic leukemia. infiltration by monomorphic population of leukemic
Cases of AML which do not fit into any of the above cells; normal hematopoietic cells are reduced.
three major categories are placed under the category of Blast percentage should be derived from 200-cell
AML, not otherwise categorized. differential leukocyte count on a blood smear or 500-
According to WHO classification, FAB terms L1, L2, cell differential count on a marrow aspirate smear.
and L3 are not distinct disease categories since they do Presence of Auer rods (needle- or rod-shaped
not have clinical, immunophenotypic, or genetic inclusion in cytoplasm composed of azurophil
correlates, and therefore these terms should no longer granules) in blast cells is diagnostic of AML.
be used. L3 subtype of ALL, however, correlates with However, they are seen in only 10-20% cases of AML.
Burkitt’s lymphoma. Morphological features of ALL and AML are shown
In WHO classification, the term ALL corresponds in Tables 28.3 and 28.4 and Figures 28.1 and 28.2.
with leukemic phase of precursor neoplasms of B or T Features of AML and ALL are compared in Table 28.5.
lymphocytic lineage. For diagnosis of ALL, blast count 2. Cytochemistry: Cytochemistry comprises of techni-
in marrow should be greater than 25%. ques for identification of enzymes, fats, or certain
other substances in the cytoplasm of blood cells. In
Laboratory Diagnosis of Acute Leukemias acute leukemia, cytochemistry is mainly useful for
Currently, diagnosis of leukemias is based on combi- identifying various subtypes of AML. In lymphoid
nation of clinical features, microscopic examination of leukemias, cytochemistry has been replaced by
peripheral blood and bone marrow, cytochemistry, immunophenotyping for characterization of different
immunophenotyping by flow cytometry, cytogenetics, subtypes. The results of cytochemistry should always
and molecular analysis. be interpreted along with conventional morphology
MPO: Myeloperoxidase; EM: Electron microscopy; Type I blasts: No azurophil granules in cytoplasm; Type II blasts: Few
azurophil granules; NSE: Non-specific esterase; PAS: Periodic Acid Schiff; TLC: Total leucocyte count
and immunophenotyping. The important cyto- • MPO stain is positive in AML M1, AML M2, AML M3,
chemical studies in acute leukemias are (Fig. 28.3): and AML M4 (only in myeloblasts). In AML M0, MPO
• Myeloperoxidase (identifies an enzyme present activity is visible only by electron microscopy.
in primary granules of granulocytic cells) • Lymphoblasts are negative for MPO.
• Non-specific esterase (identifies an enzyme
present in large amounts in monocytic cells)
• Periodic acid Schiff (identifies intracellular Nonspecific Esterase (NSE)
glycogen).
NSE activity is strongly positive in monocytic series
Myeloperoxidase (MPO) (monoblasts, promonocytes, and monocytes). It allows
• MPO enzyme is located in primary (azurophil) and diagnosis of AML M4 and AML M5 (Fig. 28.5).
secondary granules in all stages of neutrophil series Sodium fluoride may be added that renders monocytic
(Fig. 28.4). cells negative.
Laboratory Tests in Hematological Malignancies 277
Fig. 28.1: (A) AML M0; (B) AML M1; (C) AML M2; (D) AML M3; (E) AML M4; (F) AML M5; (G) AML M6; (H) AML M7
Fig. 28.2: (A) ALL L1; (B) ALL L2; (C) ALL L3
278 Essentials of Clinical Pathology
Table 28.5: Differences between acute lymphoblastic leukemia and acute myeloid leukemia
Parameter Acute lymphoblastic leukemia Acute myeloid leukemia
1. Predominant age Children (peak 3-4 years) Adults
2. Morphology of blasts
• Size of blasts Small Large
• Cytoplasm Scanty Moderate
• Granules in cytoplasm Absent May be present
• Nuclear chromatin Coarse Fine
• Nucleoli 0-2 >3
• Auer rods Absent Pathognomonic, if present
3. Cytochemistry
• Myeloperoxidase Negative Positive
• Periodic acid Schiff Block-like Diffuse
4. Immunophenotyping B or T lymphoid markers Myeloid markers
5. Prognosis Curable in majority of children Curable in minority of adults
monocytic component (AML M4 and M5). In acute • Detection of minimal residual disease: Relapse
erythroleukemia (AML M6), glycophorin A and in acute following therapy is due to the persistence of viable
megakaryocytic leukemia (AML M7), platelet glyco- leukemic cells following cytotoxic chemotherapy.
protein antigens (CD41, CD42, and CD61) are demons- Leukemic cells on the background of normal cells can
trated. be detected by morphology, cytogenetics, immuno-
Immunophenotyping is also used for detection of phenotyping, and molecular methods.
minimal residual disease. Detection of minimal residual • To establish clonality i.e. determining whether a cell
disease (MRD) consists of identification of a small population is derived from a single cell (monoclonal)
population of leukemic cells among a large population or from multiple cells (polyclonal); it is helpful mainly
of normal cells after therapy to determine whether in B or T cell lymphomas.
residual disease is present that may later cause a relapse. • To detect chromosomal disorders which predispose
MRD can also be detected by morphology, cytogenetic to acute leukemia, e.g. trisomy 21.
analysis, and molecular analysis. 5. Molecular genetic analysis: This is used for:
4. Cytogenetic analysis: Structural or numerical • Detection of clonality by gene rearrangement
abnormalities of chromosomes are detected by studies (by polymerase chain reaction or Southern
cytogenetic analysis or karyotyping (Table 28.6). With blot analysis).
cytogenetic analysis, a variety of gross alterations can • Detection of minimal residual disease: Molecular
be detected such as translocations, deletions, and methods like polymerase chain reaction can be
duplications. In contrast to molecular methods, helpful in detecting a small submicroscopic
cytogenetic analysis is more widely available. In acute population of residual leukemic cells when
leukemias, cytogenetic abnormalities are linked to the peripheral blood and bone marrow examinations
pathogenesis of the disease. appear normal.
Applications of cytogenetic analysis in acute leukemia are • Diagnosis of specific types of acute leukemias by
• Diagnosis of specific types of AML: WHO classi- specific molecular probes: Molecular methods are
fication of AML recognizes distinct entities, which used for detection of chromosomal translocations
have clonal, recurrent cytogenetic abnormalities. that generate fusion transcripts and chimeric
Their identification is necessary as they have a proteins. The commonly used methods are reverse
correlation with response to therapy. transcription-polymerase chain reaction (RT-PCR)
• Prediction of prognosis: Certain cytogenetic abnor- and fluorescent in situ hybridization (FISH). The
malities are associated with poor prognosis and their technique detects t(15;17) in acute promyelocytic
detection may affect treatment strategies. leukemia that generates PML/RARα fusion gene,
and t(9;22) in B-ALL that generates bcr/abl fusion
Table 28.6: Chromosomal abnormalities in gene. Detection of these translocations is also
acute leukemias helpful for determining prognosis and response
Chromosomal abnormality Prognosis to treatment.
• Detection of opportunistic pathogens in immuno-
Acute lymphoblastic leukemia compromised patients.
1. t(9;22)(q34;q11.2) Poor
2. t(4;11)(q21;q23) Poor
CHRONIC LEUKEMIAS
3. t(1;19)(q23;p13.3) Average
4. t(12;21)(p13;q22) Good
Chronic leukemias are heterogeneous disorders
5. Hyperdiploidy>50 Good
6. Hypodiploidy Poor characterized by neoplastic proliferation of mature-
looking cells of myeloid or lymphoid lineage. General
Acute myeloid leukemia differences between acute and chronic leukemias are
1. t(8;21)(q22;q22) Good outlined in Table 28.7.
2. t(15;17)(q22;q12) Good Chronic leukemias are of two main types:
3. inv(16) Good
• Chronic myeloid leukemia
4. Monosomy 7 Poor
• Chronic lymphoid leukemias (Table 28.8).
Laboratory Tests in Hematological Malignancies 281
Chronic Myeloid Leukemia 22. The chimeric gene bcr-abl codes a tyrosine kinase that
affects cell proliferation.
Chronic myeloid leukemia (CML) is a chronic myelo-
proliferative neoplasm originating from a pleuripotent Chronic phase: The average age at diagnosis is 45 years. In
hematopoietic stem cell and characterized by predomi- chronic phase, the usual presenting features include
nant proliferation of granulocytic cells. weakness, weight loss, abdominal fullness, easy
There are three phases of CML: chronic phase (3-5 bruisability, and splenomegaly.
years), accelerated phase (6-12 months), and blast crisis Blood smear in chronic phase of CML shows marked
(2-4 months). leukocytosis, immature white blood cells, basophilia,
CML is associated with a characteristic cytogenetic eosinophilia, anemia, and thrombocytosis (Fig. 28.8).
abnormality called Philadelphia chromosome that results
from t(9;22)(q34;q11) (Fig. 28.7). This leads to juxtaposition
of c-abl gene from chromosome 9 to bcr gene on chromosome
LAP score in an individual smear is the sum of the surface membrane immunoglobulin, single light chain,
scores of 100 consecutive neutrophils. Normal range is CD19, CD20, and T-associated antigen CD5). The
40-100. neoplastic lymphocytes are more fragile than normal cells
Chronic phase of CML should be differentiated from and are often disrupted while spreading blood smear
leukemoid reaction in which myeloid cells increase in producing smudge (or basket) cells (Fig. 28.11).
number in peripheral blood secondary to infections, Complications include infections, autoimmune
inflammation, and other disorders (See Table 22.1 in
hemolytic anemia, and transformation to prolymphocytic
Chapter 22: Blood Smear).
leukemia or large cell lymphoma (Richter’s syndrome).
Accelerated phase: During accelerated phase, basophils
and blast cells increase in number and patient increa- PLASMA CELL DYSCRASIAS
singly becomes resistant to therapy.
Plasma cell dyscrasias are a group of disorders
Blast crisis: Blast crisis results when blast cells become (Table 28.9) characterized by clonal proliferation of
> 20% in blood or bone marrow. Additional cytogenetic plasma cells or plasmacytoid lymphocytes and mono-
abnormalities develop in accelerated and blast phases. clonal production of immunoglobulins.
Features of plasma cell dyscrasias are summarized
Chronic Lymphocytic Leukemia in Table 28.10.
Chronic lymphocytic leukemia (CLL) is a neoplastic Laboratory investigations in plasma cell dyscrasias
disorder characterized by monoclonal proliferation of are shown in Box 28.2.
immunologically incompetent, slowly dividing, mature The laboratory findings that are suspicious of a
B lymphocytes. Most patients are adults >60 years. plasma cell dyscrasia are raised erythrocyte sedimen-
Clinical features include insidious onset of weakness, tation rate, rouleaux formation on blood smear, increased
weight loss, susceptibility to infections, lymphadeno- plasma cells in bone marrow (Fig. 28.12), renal impair-
pathy, and splenomegaly. About 25% of patients are ment with bland urinary sediment, unexplained lytic bone
asymptomatic. lesions, anemia associated with renal failure and bone
Laboratory features include absolute lymphocytosis
(> 5000/cmm) consisting of small mature lymphocytes, Table 28.9: Plasma cell dyscrasias
smudge cells, and typical immunophenotype (weak 1. Multiple myeloma
2. Plasmacytoma
3. Waldenström macroglobulinemia
4. Amyloidosis
5. Heavy chain disease
6. Monoclonal gammopathy of undetermined
significance (MGUS)
Fig. 28.13: Principle of serum protein electrophoresis. (A) On agar gel electrophoresis, serum proteins get separated into
5 regions or bands. Each region or band contains 1 or more proteins, knowledge of which aids in interpretation. (B) Densitometric
scan of serum protein electrophoresis reveals 5 peaks; elevation or depression of the peak(s) can reflect concentrations
of constituent proteins. If abnormal pattern is identified (e.g. M protein), further testing is done to identify the nature of M
protein and quantification of M protein
pain, Bence Jones proteinuria, and hypergamma- on the supporting medium (like agar gel, cellulose,
globulinemia with immune deficiency. etc.) which is then placed in an electrophoresis
1. Serum protein electrophoresis: The most common chamber and exposed to the electric current. Serum
indication for serum protein electrophoresis is proteins get separated into five components: albumin,
suspected plasma cell dyscrasia (especially multiple α1-globulins, α2-globulins, β-globulins, and
myeloma). In this technique, patient’s serum is placed γ-globulins (Fig. 28.13). The last four zones are
Laboratory Tests in Hematological Malignancies 285
composed of a mixture of proteins (Table 28.11). If plasma cell dysrasia is strongly suspected and
Majority of plasma proteins are synthesized in the liver, serum protein electrophoresis is normal, immuno-
except immunoglobulins that are produced by plasma fixation should be performed as it is more sensitive
cells. for detection of small amounts of monoclonal protein.
The bands are inspected visually for any The amount of M protein corresponds directly with
qualitative abnormality. For quantitation, membrane tumour burden.
is then run through an instrument called as densito- Comparison of polyclonal vs. monoclonal
meter. This records absorbance of each protein band, gammaglobulinemia is presented in Table 28.12.
generates a tracing, and quantitates percentage 2. Immunoelectrophoresis: This technique combines
fraction of each band. If total serum proteins have been separation by electrophoresis and identification by
measured earlier, concentration of each protein band double immunodiffusion. Antigenic mixture (placed
can be obtained from the percentage fraction. in a well cut in agar gel) is separated by electro-
286 Essentials of Clinical Pathology
phoresis. A trough is cut parallel to the electrophoretic ponding immunoglobulin protein to form a complex
migration, filled with antibody, and then kept for that becomes fixed in the gel. The gel is washed to
immunodiffusion in a moist chamber for 24 hours. remove the unbound proteins, leaving only the fixed
The resulting immunoprecipitates form arcs that protein that is then visualized with staining (Fig.
assume different shapes and varying mobilities 28.16). The test is sensitive and can detect small
(Figs 28.14 and 28.15). amounts of M protein.
This technique is most useful for recognition of 4. Single radial immunodiffusion (SRID): This is a
abnormal immunoglobulins in paraproteinemias. quantitative method used for measuring concen-
3. Immunofixation electrophoresis: This technique is tration of serum proteins (M protein in parapro-
used on serum or urine to identify the nature of M teinemias). In this technique, antibody is incorporated
protein. In this type of electrophoresis, monospecific into the gel. A soluble antigen is placed in the well
antibodies are used to identify specific types of cut in the agar gel. Following the radial diffusion of
immunoglobulins and light chains. the antigen into the antibody-incorporated gel,
Patient’s serum sample is subjected to agarose gel circular precipitates develop. The diameter of the
electrophoresis in 5 different lanes. Different circular precipitates is directly proportional to the
monospecific antibodies (IgG, IgM, IgA, κ light chain, antigenic concentration, provided that the mono-
λ light chain) are then applied directly over the specific antibody is evenly distributed in the uniformly
surface of gel. The antibody reacts with the corres- thick gel, and the well size and the volume of the
PHYSIOLOGY OF HEMOSTASIS cells synthesize von Willebrand factor (vWF), tissue factor,
and platelet activating factor, which promote hemostasis.
Hemostasis is the normal physiologic mechanism for
Also, following injury, subendothelial collagen is exposed
keeping the blood in fluid state in vascular system and for
which provides site for attachment of platelets (adhesion).
prevention of hemorrhage by complex interaction of blood
Endothelial cells synthesize prostacycline (inhibits platelet
vessel walls, platelets, and plasma proteins. Following
aggregation), protein S (a cofactor for protein C, which is
injury, initially vessel wall and platelets interact to control
an inhibitor of coagulation), and tissue plasminogen
hemorrhage by forming a platelet plug at the site of injury;
activator (activates fibrinolysis).
this is called as primary hemostasis. This is followed by
activation of coagulation factors by a series of enzymatic
Platelets
reactions to form a stable fibrin clot (platelet plug
enmeshed by fibrin); this is secondary hemostasis. Platelets are produced by cytoplasmic fragmentation of
Dissolution of the clot will eventually occur by fibrinolysis megakaryocytes in bone marrow. Life-span of platelets is
when healing is complete. Hemostatic equilibrium about 7-10 days. Normal platelet count in peripheral blood
requires normal blood vessels, normal platelets, normal is 1.5-4.0 lac/µl. About 2/3rd of platelets in the body are
coagulation factors, normal fibrinolysis, and normal circulating in peripheral blood, while 1/3rd are pooled in
coagulation inhibitor system.
spleen.
Role of the three main components of hemostasis is
Main functions of platelets in hemostasis are adhesion,
outlined below.
release reaction, and aggregation (Fig. 29.1).
Blood Vessel Wall Platelets attach to exposed subendothelium following
Transient constriction of blood vessels occurs at the site injury; this adhesion is mediated by vWF, which binds
of injury which helps to control blood loss. Endothelial to GpIb receptor on platelets. This initiates activation of
platelets, which change shape from a disc to a sphere and Coagulation System
release their contents to the exterior (release reaction). Normally, coagulation factors (Table 29.1) are circulating
These are mainly adenosine diphosphate (ADP), in an inactive form. Except for thromboplastin and
serotonin, and thromboxane A 2 (TxA 2 ). Platelet calcium, all the coagulation factors are proteins.
aggregation refers to sticking of platelets to each other; Coagulation factors have been divided into thee groups
platelet agonists such as collagen, ADP, thrombin, and depending on similarities in structural and functional
TxA2 mediate aggregation. Binding of ADP to platelets properties: (1) Fibrinogen group: I, V, VIII, XIII; (2)
causes exposure of GpIIb/IIIa receptors which bind Vitamin-K dependent: II, VII, IX, X; and (3) Contact
fibrinogen. Fibrinogen binding to multiple platelets group: XI, XII, high molecular weight kininogen,
causes formation of large platelet aggregates. prekallikrein. When activated, coagulation factors
Activated platelets also provide phospholipid surface interact with each other in a sequential manner to
for certain coagulation reactions (platelet factor 3 or ultimately form a fibrin clot and arrest bleeding. Blood
platelet procoagulant activity). coagulation occurring in vitro is divided into three
pathways: extrinsic, intrinsic, and common (Fig. 29.2).
Plasma Proteins This division is helpful in understanding the principles
Plasma proteins, which regulate hemostasis, are of common screening tests of coagulation.
coagulation factors, coagulation inhibitors, and proteins Extrinsic pathway: The extrinsic pathway is initiated when
of fibrinolytic system. F VII combines with tissue factor (released after tissue
Table 29.1: Coagulation factors
Aged plasma: Stored plasma that is deficienct in factors V and VIII. Adsorbed plasma: Plasma adsorbed with ammo-
nium hydroxide that is deficient in factors II, VII, IX, and X (vitamin K-dependent factors)
290 Essentials of Clinical Pathology
Fig. 29.2: Normal coagulation mechanism. HMWK = high molecular weight kininogen; PL = phospholipid; Ca = calcium;
TF: tissue factor; solid arrow: conversion; Dotted arrow: action; subscript a: activated form of the coagulation factor
Fig. 29.3: Natural inhibitors of coagulation and their actions. – indicates inhibition. Antithrombin III mainly inhibits F Xa and
thrombin, activated protein C degrades activated forms of FV and F VIII, while tissue factor pathway inhibitor inhibits F VII-
tissue factor complex
network. Endothelial cells secrete tissue plasminogen Fibrinolysis is inhibited by plasminogen activator
activator, which activates plasminogen to plasmin. inhibitor (PAI) type 1, α2-antiplasmin and α2-macro-
Plasmin cleaves fibrin strands to release fibrin globulin.
degradation products. Plasmin also digests fibrinogen BLEEDING DISORDERS
(Fig. 29.4). Fibrinogen/fibrin degradation products Bleeding disorders are the result of a generalized defect in
interfere with action of thrombin and with platelet hemostasis due to abnormalities of blood vessels, platelets,
aggregation. FDPs are cleared from the circulation by or coagulation factors. Common bleeding disorders are
macrophages. listed in Table 29.2.
292 Essentials of Clinical Pathology
Complete remission is usual. Chronic ITP has a gradual seen in children. It is characterized by a triad of acute
onset, occurs usually in adults (especially young females), renal failure, thrombocytopenia, and microangiopathic
and platelet count is moderately decreased. Cause is hemoloytic anemia.
unknown. It is characterized by remissions and
exacerbations over a long duration. Bone marrow Post-Transfusion Purpura
examination in ITP shows increased number of mega- This is allo-antibody induced thrombocytopenia. There is
karyocytes. Diagnosis of ITP requires exclusion of all a sudden onset of severe thrombocytopenia in some adult
other causes of thrombocytopenia. maltiparous women 1-10 days following blood
transfusion. It is due to sensitization to platelet antigen
Thrombotic Thrombocytopenic Purpura HPA-1a (platelet antigen A1 or PlA1) during previous
pregnancy by foetal platelets.
There is formation of hyaline microthrombi in micro-
circulation due to systemic clumping of platelets because Disorders of Platelet Function
of unusually large multimers of von Willebrand factor.
This causes thrombocytopenia. The characteristic pentad Disorders of platelet function are characterized by
of signs includes: bleeding secondary to severe thrombo- prolonged bleeding time and normal platelet count. They
cytopenia, microangiopathic hemolytic anemia (with may be inherited or acquired. Acquired disorders are
production of schistocytes), fever, neurological signs, and more common. Sites of defects in platelet function
renal abnormalities. disorders are shown in Figure 29.5.
adhesion of platelets to subendothelium via von gene. It is an X-linked recessive disorder primarily affecting
Willebrand factor. Blood smear shows giant platelets. males; females are carriers but do not manifest the disease
Platelet aggregation studies reveal impaired aggregation (Fig. 29.6). Hemophilia A is classified into three types
with ristocetin and normal aggregation with other based on the level of F VIII level in plasma: mild, moderate,
agonists. and severe (Table 29.4).
Glanzmann’s thrombasthenia: In this very rare autosomal In severe hemophilia, hemarthroses lead to crippling
recessive disorder, platelet aggregation is defective due deformities; intramuscular hematomas can compress
to congenital absence of platelet membrane glycoproteins vital structures; intracranial hemorrhage can occur
GpIIb/IIIa on platelet surface. Laboratory features following minor trauma; operative and post-traumatic
include discrete, small platelets on blood smear, poor clot bleeding can be life-threatening; infections like hepatitis
retraction, and defective platelet aggregation with ADP, and acquired immunodeficiency syndrome can be
epinephrine, and collagen, and normal aggregation with transmitted through blood products. Screening tests for
ristocetin. hemostasis show normal bleeding time, platelet count,
and prothrombin time. Activated partial thromboplastin
Aspirin inhibits the enzyme cyclo-oxygenase leading to
time is prolonged. Diagnosis is made by one-stage F VIII
failure of synthesis of thromboxane A2 that is required
assay.
for platelet aggregation. The inhibitory effect of aspirin
on platelets lasts for 7-10 days (i.e. lifespan of platelets).
Hemophilia B (Christmas Disease, F IX Deficiency)
Inherited Disorders of Coagulation
This is clinically indistinguishable from hemophilia A.
Deficiencies of all the coagulation factors have been
reported. Out of these, the three relatively common Diagnosis requires F IX assay.
disorders are hemophilia A (F VIII deficiency), hemo-
philia B (F IX deficiency), and von Willebrand disease von Willebrand Disease (VWD)
(Table 29.3).
vWD is a markedly heterogeneous congenital bleeding
Hemophilia A disorder characterized by deficiency or functional defect
(Classical Hemophilia, F VIII Deficiency) of von Willebrand factor (vWF). Mode of inheritance is
It is caused by hereditary deficiency or dysfunction of F autosomal dominant or recessive, with overall prevalence
VIII due mainly to point mutations or deletions of F VIII in the general population being 1%. There are three main
Fig. 29.6: Typical pedigree in X-linked recessive trait (hemophilia A or B). Females are
heterozygous (carriers) and only males are affected
AD: Autosomal dominant; AR: Autosomal recessive; XR: X-linked recessive; BT: Bleeding time; PC: Platelet count;
PT: Prothrombin time; APTT: Activated partial thromboplastin time
types: I, II, and III. Type I (partial deficiency of vWF) is the Screening tests for hemostasis reveal prolonged bleeding
most common in which all types of vWF multimers (small, time and activated partial thromboplastin time. Platelet
intermediate, and large) are mildly deficient; bleeding count and prothrombin time are normal. Ristocetin-
manifestations are slight. In type II vWD (qualitative
induced platelet aggregation is deficient. One stage F VIII
defects in vWF) there is a qualitative abnormality of vWF
assay shows reduced F VIII activity.
with absence of large vWF multimers. Type III (complete
vWF deficiency) is a rare severe bleeding disorder in which The three main inherited bleeding disorders are
there is a severe deficiency of all forms of vWF multimers. compared in Table 29.5.
296 Essentials of Clinical Pathology
• Red cell abnormalities (especially fragmented red 2. Charge the improved Neubauer counting chamber as
cells which may indicate disseminated intra- described for total leukocyte count.
vascular coagulation) 3. Place the mounted counting chamber inside a moist
• White cell abnormalities (like abnormal cells in chamber (which consists of a covered Petri dish with
leukemias) a dampened filter paper at the bottom) and leave it
• Abnormalities of platelets: thrombocytopenia undisturbed for 20 minutes. This allows platelets to
(normally there is 1 platelets per 500-1000 red settle and prevents drying of fluid.
cells), giant platelets (seen in myeloproliferative
4. Place the charged counting chamber on the stage of
disorders and Bernard-Soulier syndrome), and
the microscope. With the illumination reduced to give
isolated discrete platelets without clumping in
sufficient contrast, bring the central large square
finger-prick smear (seen in uremia, Glanzmann’s
under the focus of the low power (×10) objective.
thrombasthenia).
Changing to ×40 objectives, count the total number
of platelets in five smaller squares (Fig. 29.9). Platelets
Platelet Count
appear as bluish, round or oval, small, brightly
Platelets can be counted manually under a microscope refractile fragments with one or more fine dendritic
or by means of an automated hematology analyzer. processes.
Platelets are difficult to count by manual method since
5. Calculation:
they are small in size (2-4 μm) and difficult to distinguish
from dirt particles and cell debris. Platelet count/μl of blood =
Number of platelets counted × Correction for dilution × Correction
Manual Method for volume
Platelet count/L of blood = Number of platelets counted × 109
Principle: Whole blood sample is mixed with a diluent
(1% ammonium oxalate) in which red cells are lysed. An Note:
improved Neubauer counting chamber is filled with the 1. For counting platelets, phase-contrast microscope is
mixture, and platelets are counted under the microscope. preferable to ordinary light microscope. This is
Result is expressed as number platelets per μl or per liter. because platelets are easily distinguished from dirt
Equipment: Similar to that required for total leukocyte
count (see Chapter 20: Total Leukocyte Count).
Reagent: This is 1% ammonium oxalate. It is prepared by
dissolving 1.0 gm of ammonium oxalate in 100 ml of
distilled water. It should be stored in a refrigerator. Since
small particles can be mistaken for platelets, reagent
should be filtered immediately before use.
Specimen: Venous blood anticoagulated with EDTA is
preferable. Capillary blood should be avoided since
platelets adhere to the skin puncture site resulting in a
erroneously lower platelet count. Platelet count from skin
puncture blood is also not reproducible.
Method
1. Take 0.38 ml of 1% ammonium oxalate in a test tube.
To this add 20 µl of well-mixed anticoagulated
venous blood and mix thoroughly. Dilution of blood Fig. 29.9: Area (P) for counting platelets in
is 1:20. Neubauer chamber
300 Essentials of Clinical Pathology
particles or debris using phase-contrast. A flat-bottom, Clinical significance: Platelet count is usually obtained if
thin, phase-contrast hemocytometer with Neubauer there is a suspicion of a bleeding disorder. Thrombo-
ruling is preferable. cytopenia between 1,50,000-50,000/μl is generally not
2. Platelet count done on blood obtained by skin associated with bleeding. Platelet count between 50,000-
puncture is significantly lower due to adhesion of 20,000/μl causes excess bleeding following surgery or
platelets to the puncture site. Therefore, anticoagu- mild degree of spontaneous bleeding. Platelet count
below 20,000/μl is usually associated with spontaneous,
lated venous blood should be used (If capillary blood
severe hemorrhage. Bleeding is often serious if platelets
is used, a free flowing blood drop should be obtained
are below 5,000/μl. Thrombocytosis (platelet count
after wiping away the first drop of blood). > 4,00,000/μl) in chronic myeloproliferative disorders is
3. Blood and the anticoagulant should be mixed sometimes associated with thrombosis and bleeding
thoroughly by inverting the tube for 20 times. Venous manifestations.
blood sample anticoagulated with EDTA should not Causes of thrombocytopenia: Thrombocytopenia is defined
contain any clots. as platelet count below 1,50,000/μl. Causes of thrombo-
4. All the glassware must be scrupulously clean and the cytopenia are listed earlier in Table 29.2. Evaluation of
diluent fluid must be filtered just before use. This is thrombocytopenia is shown in Figure 29.10.
to prevent erroneous counting of dirt particles as Causes of thrombocytosis: Thrombocytosis is defined as
platelets. platelet count greater than 4,00,000/μl. Its causes are (i)
5. A well-spread blood smear should always be primary: chronic myeloproliferative disorders like
examined simultaneously to check the direct platelet chronic myeloid leukemia, essential thrombocythemia,
count on hemocytometer. Normally there is one idiopathic myelofibrosis, and polycythemia vera; (ii)
platelet per 500-1000 red cells on a blood smear. A secondary (reactive): disseminated malignancy,
rough estimate about number of platelets (adequate, hemorrhage, splenectomy, chronic inflammation, and
low, or increased) thus can be obtained. iron deficiency anemia with bleeding.
2. Disorders of platelet function time is prolonged. Also, in the presence of a strong clinical
3. von Willebrand disease suspicion of a platelet function defect and normal PFA-
4. Disorders of blood vessels 100 result, further testing is still necessary.
Evaluation of prolonged bleeding time is shown in
Clotting Time
Figure 29.11.
This is a crude test and is now replaced by activated
Platelet Function Analyzer (PFA-100) partial thromboplastin time. Clotting time measures the
This is a newly introduced screening test for platelet time required for the blood to clot in a glass test tube
function that assesses both platelet adhesion and kept at 37°C. Prolongation of clotting time only occurs
aggregation. This method uses an instrument called as in severe deficiency of a clotting factor and is normal in
PFA-100 in which anticoagulated whole blood is passed mild or moderate deficiency.
at a high shear rate through small membranes that have
Prothrombin Time (PT)
been coated with either collagen and epinephrine or
collagen and ADP. Platelets adhere to each membrane PT assesses coagulation factors in extrinsic pathway (F
VII) and common pathway (F X, F V, prothrombin, and
and gradually occlude an aperture at the centre of the
fibrinogen) (Fig. 29.12).
membrane. The time required for complete occlusion of
the aperture is called as closure time. Normal closure Principle: Tissue thromboplastin and calcium are added
time is 1-3 minutes. The PFA-100 test is performed to plasma and clotting time is determined. The test
initially with the collagen/epinephrine membrane; if determines the overall efficiency of extrinsic and
closure time is normal, there is no significant platelet common pathways.
function defect. If closure time with collagen/epine- Equipment
phrine is prolonged, test with collagen/ADP is carried 1. Water bath at 37°C
out; if normal, aspirin-induced platelet dysfunction is the 2. Test tubes (75 × 12 mm)
probable cause; if prolonged, other platelet function 3. Stopwatch
defect (acquired or inherited) is likely. Reagents
This test is more sensitive than bleeding time to assess 1. Thromboplastin reagent: This contains tissue factor
primary hemostasis, sensitive for detection of von and phospholipids and is available commercially.
Willebrand disease and easy to perform. However, in 2. Calcium chloride 0.025 mol/liter.
the presence of thrombocytopenia and anemia, closure Specimen: Platelet-poor citrated plasma (Box 29.2).
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Laboratory Tests in Bleeding Disorders 303
Uses of PT
1. To monitor patients who are on oral anticoagulant therapy:
PT is the standard test for monitoring treatment with
oral anticoagulants. Oral anticoagulants inhibit
carboxylation of vitamin K-dependent factors
(Factors II, VII, IX, and X) and make these factors
inactive.
In patients receiving oral anticoagulants, PT
should be reported as a ratio of PT of patient to PT of
control; it should not be reported as percentage.
Various types of thromboplastin reagents obtained
from different sources (like ox brain, rabbit brain, or
rabbit lung) are available for PT test. These differ in
Fig. 29.12: Principle of prothrombin time their responsiveness to deficiency of vit. K-dependent
factors. Technique of PT is also different in different
laboratories. For standardization and to obtain
Box 29.2: Collection of blood for coagulation studies comparable results, it is recommended to report PT
(in persons on oral anticoagulants) in the form of an
Venous blood is collected from antecubital fossa with a
plastic, siliconized glass, or polypropylene syringe and a International Normalized Ratio (INR).
large bore needle (20 or 21 G in adults, 22 or 23 G in infants).
ISI
Blood should never be collected from indwelling intravenous PT of patient
lines, as these often contain heparin. Glass syringe should INR =
PT of control
not be used for collection since it activates coagulation. The
blood is drawn gently but quickly after a single, smooth
venepuncture. The needle is detached from the syringe, and International Sensitivity Index (ISI) of a particular
the sample is passed gently into the plastic container. After tissue thromboplastin is derived (by its manufacturer)
capping the container, the blood and the anticoagulant are by comparing it with a reference thromboplastin of
mixed immediately by gentle inversion 5 times. The known ISI.
anticoagulant used for coagulation studies is trisodium citrate
INR should be maintained in the therapeutic range
(3.2%), with anticoagulant to blood proportion being 1:9.
Most coagulation studies require platelet poor plasma (PPP). for the particular indication (INR of 2.0-3.0 for
To obtain PPP, blood sample is centrifuged at 3000-4000 prophylaxis and treatment of deep venous throm-
revolutions per minute for 15-30 minutes. Coagulation studies bosis; INR of 2.5-3.5 for mechanical heart valves).
are carried out within 2 hours of collection of sample. Therapeutic range provides adequate anticoagulation
for prevention of thrombosis and also checks excess
dosage, which will cause bleeding.
Method
2. To assess liver function: Liver is the site of synthesis of
1. Deliver 0.1 ml of plasma in a glass test tube kept in
water bath at 37°C. various coagulation factors, including vitamin K-
2. Add 0.1 ml of thromboplastin reagent and mix. dependent proteins. Therefore PT is a sensitive test
3. After 1 minute, add 0.1 ml of calcium chloride for assessment of liver function.
solution. Immediately start the stopwatch and record 3. Detection of vitamin K deficiency: PT measures three of
the time required for clot formation. the four vitamin K-dependent factors (i.e. II, VII, and
X).
Normal range: 11-16 seconds.
4. To screen for hereditary deficiency of coagulation factors
Causes of prolongation of PT VII, X, V, prothrombin, and fibrinogen.
1. Treatment with oral anticoagulants
2. Liver disease Activated Partial Thromboplastin Time (APTT)
3. Vitamin K deficiency APTT is a measure of coagulation factors in intrinsic
4. Disseminated intravascular coagulation pathway (F XII, F XI, high molecular weight kininogen,
5. Inherited deficiency of factors in extrinsic and prekallikrein, F IX, and F VIII) and common pathway (F
common pathways. X, F V, prothrombin, and fibrinogen) (Fig. 29.13).
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304 Essentials of Clinical Pathology
Principle: Plasma is incubated with an activator (which Normal range: 30-40 seconds.
initiates intrinsic pathway of coagulation by contact
Causes of prolongation of APTT
activation). Phospholipid (also called as partial thrombo-
1. Hemophilia A or B.
plastin) and calcium are then added and clotting time is 2. Deficiencies of other coagulation factors in intrinsic
measured. and common pathways.
Equipment: This is same as for PT. 3. Presence of coagulation inhibitors
4. Heparin therapy
Reagents 5. Disseminated intravascular coagulation
1. Kaolin 5 gm/liter: This is a contact activator. 6. Liver disease
2. Phospholipid: Various APTT reagents are available
Uses of APTT
commercially, which contain phospholipids.
1. Screening for hereditary disorders of coagulation: Since
3. Calcium chloride 0.025 mol/liter.
deficiencies of F VIII (hemophilia A) and F IX
Specimen: Citrated platelet poor plasma (Box 29.2).
(hemophilia B) are relatively common, APTT is the
Method most important screening test for inherited coagu-
1. Mix equal volumes of phospholipid reagent and lation disorders. APTT detects deficiencies of all
calcium chloride solution in a glass test tube and keep coagulation factors except F VII and F XIII.
in a waterbath at 37°C. PT is also performed along with APTT. Prolongation
2. Deliver 0.1 ml of plasma in another test tube and add of both PT and APTT is indicative of deficiency of
0.1 ml of kaolin solution. Incubate at 37°C in the coagulation factors in common pathway. Normal PT
waterbath for 10 minutes. with prolongation of APTT is indicative of intrinsic
3. After exactly 10 minutes, add 0.2 ml of phospholipid- pathway deficiency (particularly of F VIII or IX).
calcium chloride mixture, start the stopwatch, and 2. To monitor heparin therapy: Heparin potentiates the
note the clotting time. action of natural anticoagulant antithrombin III which
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Laboratory Tests in Bleeding Disorders 305
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306 Essentials of Clinical Pathology
Fig. 29.16: Evaluation of a suspected bleeding disorder. BT: bleeding time; PC: platelet count;
PT: prothrombin time; APTT: activated partial thromboplastin time
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Laboratory Tests in Bleeding Disorders 307
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308 Essentials of Clinical Pathology
Fig. 29.18: Platelet aggregation curves in von Willebrand disease and Bernard-Soulier syndrome (absent aggregation
with ristocetin, normal aggregation with ADP, epinephrine, and arachidonic acid)
Fig. 29.19: Platelet aggregation curves in storage pool defect (absent second wave of aggregation with ADP and
epinephrine, absent or greatly diminished aggregation with collagen, and normal ristocetin aggregation)
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Laboratory Tests in Bleeding Disorders 309
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310 Essentials of Clinical Pathology
period or following trauma. D-dimer test is commonly • Factors II, V, VII, VIII, IX, X, XI, XII: 50-150%
used for exclusion of thrombosis and thrombotic • vWF:Ag: 50-150%
tendencies.
5. Estimation of fibrinogen: Fibrinogen is commonly CRITICAL VALUES
measured by Clauss method that consists of modifi- • Prothrombin time: > 30 seconds or > 3 times control
cation of thrombin time by diluting plasma; thrombin value
time of diluted plasma is inversely proportional to
• Activated partial thromboplastin time: ≥ 75 seconds
concentration of fibrinogen. Fibrinogen can also be
• Platelet count < 20,000/cmm or > 1 million/cmm
estimated by immunological method; in dysfibrino-
genemia, fibrinogen estimated by functional assay • D-dimer: Positive
(Clauss method) is abnormal while immunological • Plasma fibrinogen: < 100 mg/dl
assay is normal.
6. Platelet glycoprotein analysis: This is done by flow BIBLIOGRAPHY
cytometric analysis for detection of lack of GpIb/IX 1. Evatt BL, Gibbs WN, Lewis SM, McArthur JR.
in Bernanrd Soulier syndrome (deficiency of CD42), Fundamental Diagnostic Hematology: The Bleeding
and lack of GpIIb/IIIa in Glanzmann’s thromb- and Clotting Disorders (2nd ed), 1992. US Dept. of
asthenia (deficiency of CD41, CD61). health and Human Services, Atlanta, Georgia and
World Health Organization, Geneva, Switzerland.
REFERENCE RANGES 2. Kawthalkar SM. Essentials of Hematology. New Delhi:
Jaypee Brothers Medical Publishers (P) Ltd, 2006.
• Bleeding time: Ivy method: 2-7 minutes; Template 3. Lewis SM, Bain BJ, bates I (Eds). Dacie and Lewis
method: 2.5-9.5 minutes Practical Hematology (9th ed). London: Churchill
• Prothrombin time: 11-16 seconds Livingstone, 2002.
4. Provan D, Krentz A. Oxford Handbook of Clinical and
• Activate partial thromboplastin time: 30-40 seconds Laboratory Investigations (2002). Oxford university
• Thrombint time: ±3 seconds of control Press. Oxford.
• Plasma fibrinogen: 200-400 mg/dl 5. Shrikhande AV, Warhadpande MS, Kawthalkar SM.
• Fibrinogen/fibrin degradation products: < 10 μg/ml A laboratory manual of coagulation (1994). Dept. of
Pathology. Govt. Medical College, Nagpur.
• D-dimer: Qualitiative: Negative; Quantitative: < 200 6. Wallach J. Interpretation of Diagnostic Tests (7th ed).
mg/L Philadelphia: Lippincott Williams and Wilkins, 2000.
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30
Laboratory Tests in
Thrombophilia
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312 Essentials of Clinical Pathology
activated protein C. If the screening test is positive for increased synthesis of coagulation factors in liver and
activated protein C resistance, genetic testing is decreased synthesis of antithrombin III.
performed. Genetic analysis by polymerase chain 2. Antiphospholipid syndrome: Antiphospholipid
reaction can detect heterozygous and homozygous antibodies are autoantibodies directed against
states. antigens composed of phospholipids. They are of two
2. Prothrombin gene G20210A mutation: A G→A types: lupus anticoagulant (so named because it was
mutation at position 20210 of prothrombin gene is first detected in a patient with systemic lupus
the second most common cause of inherited thrombo- erythematosus) and anticardiolipin antibodies. Lupus
philia. This mutation, by some unknown mechanism, anticoagulant is detected by prolongation of phos-
leads to a rise in the concentration of prothrombin, pholipid-dependent coagulation tests such as
thus making available large amounts of prothrombin activated partial thromboplastin time (APTT) and
for conversion to thrombin. It is implicated in dilute Russell’s viper venom time. If APTT is
prolonged, the test is repeated after mixing the sample
causation of both arterial and venous thrombosis and
50:50 with normal plasma. If not corrected, it suggest
pregnancy-associated thrombosis. Diagnosis is based
presence of lupus anticoagulant (Box 30.1). Anti-
on genetic analysis.
cardiolipin antibodies are detected by enzyme linked
3. Deficiency of protein C and S: Protein C, when
immunosorbent assay (ELISA). Antiphospholipid
activated by thrombin, inactivates factors V and VIII.
antibodies are associated with arterial and venous
Protein S serves as a cofactor in this reaction. In thrombosis, spontaneous, recurrent abortions, and
protein C and S deficiency, thrombin generation is thrombocytopenia. Antiphospholipid syndrome is
increased, producing hypercoagulability. Both present if antiphospholipid antibodies (lupus
protein C and protein S deficiencies primarily cause anticoagulant or anticardiolipin antibodies or both)
venous thrombosis. Diagnosis of protein C deficiency are present along with an episode of arterial or venous
requires quantification of protein C concentration. thrombosis, thrombocytopenia, or frequent second
Distinction between deficiency and dysfunction of trimester abortions. Antiphospholipid antibodies
protein C is based on functional assay for protein C. may occur without any underlying disorder
Protein S deficiency is detected by quantification of (primary) or in association with systemic lupus
protein S (both free and bound forms). erythematosus, Sjogren’s syndrome, rheumatoid
4. Deficiency of antithrombin III: Antithrombin III is arthritis, human immunodeficiency virus infection or
the natural inhibitor of thrombin, F Xa, IXa, XIa, and malignancy (secondary).
XIIa. Deficiency state is associated with venous 3. Heparin-induced thrombocytopenia: This compli-
thrombosis. Homozygous state is incompatible with cation occurs in 1-3% of patients receiving any type
life. of heparin. Platelet count should be checked every
5. Hyperhomocysteinemia: Increased levels of the alternate day in patients receiving heparin. The
amino acid homocysteine can occur in various condition should be suspected when patient is not
inherited disorders like homocystinuria, cystathione
synthase deficiency, and C677T gene polymorphism
Box 30.1: Criteria for diagnosis of lupus anticoagulant
in the methyl tetrahydrofolate reductase (MTHFR) gene. (International Society of Thrombosis and Hemostasis)
Acquired causes of hyperhomocysteinemia are vitamin
B12 deficiency, folate deficiency, and vitamin B6 • Prolongation of a phospholipid-dependent screening test
deficiency. Hyperhomocysteinemia is associated with for coagulation like activated partial thromboplastin time
(APTT) or dilute Russell’s viper venom time
increased risk of both arterial and venous thrombosis.
• Mixing study with APTT using 50:50 mixture of patient’s
Laboratory tests are assay for homocyseine or genetic
and normal plasma shows no correction, indicating that
analysis of MTHFR gene. prolongation is due to an inhibitor.
• Demonstration of antiphospholipid nature of antibodies
ACQUIRED THROMBOPHILIA by neutralizing them with high concentration of platelets
(platelet neutralization test)
1. Oral contraceptive therapy and pregnancy: Increa- • No other cause for thrombosis
sed predisposition to thrombosis results from
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Laboratory Tests in Thrombophilia 313
Porphyrias (from Greek porphura meaning purple various steps as shown in Figure 31.1. Each of the steps is
pigment; the name is probably derived from purple catalyzed by a separate enzyme; if any of these steps fails
discoloration of some body fluids during the attack) are (due to hereditary or acquired cause), precursors of heme
a heterogeneous group of rare disorders resulting from (porphyrin intermediates) accumulate in blood, get
disturbance in the heme biosynthetic pathway leading deposited in skin and other organs, and excreted in urine
to the abnormal accumulations of red and purple and feces. Depending on the site of defect, different types
pigments called as porphyrins in the body. Heme, a of porphyrias are described with varying clinical features,
component of hemoglobin, is synthesized through severity, and the nature of accumulated porphyrin.
Fig. 31.1: Figure on left shows steps in the biosynthesis of heme. Some steps (first and last three) occur in mitochondria,
while some occur in cytosol. Figure on right shows deficiency state associated with each enzyme. Deficiency of ALA synthase
is associated with sideroblastic anemia, and deficiencies of other enzymes cause porphyria
Laboratory Tests in Porphyrias 315
Porphyria has been offered as a possible explanation precursors up to the point of enzyme defect. Increased
for the medieval tales of vampires and werewolves; this levels of heme precursors cause symptoms of acute
is because of the number of similarities between the porphyria. When the heme level returns back to normal,
behavior of persons suffering from porphyria and the symptoms subside.
folklore (avoiding sunlight, mutilation of skin on Accumulation of porphyrin precursors can occur in
exposure to sunlight, red teeth, psychiatric disturbance, lead poisoning due to inhibition of enzyme aminolevulinic
and drinking of blood to obtain heme). acid dehydratase in heme biosynthetic pathway. This can
Porphyrias are often missed or wrongly diagnosed mimick acute intermittent porphyria.
as many of them are not associated with definite physical
findings, screening tests may yield false-negative results,
CLINICAL FEATURES
diagnostic criteria are poorly defined and mild disorders
produce an enzyme assay result within ‘normal’ range. Clinical features of porphyrias are variable and depend
Heme is mainly required in bone marrow (for hemo- on type. Acute porphyrias present with symptoms like
globin synthesis) and in liver (for cytochromes). acute and severe abdominal pain/vomiting/consti-
Therefore, porphyrias are divided into erythropoietic and pation, chest pain, emotional and mental disorders,
hepatic types, depending on the site of expression of seizures, hypertension, tachycardia, sensory loss, and
disease. Hepatic porphyrias mainly affect the nervous muscle weakness. Cutaneous porphyrias present with
system, while erythropoietic porphyrias primarily affect photosensitivity (redness and blistering of skin on
the skin. Porphyrias are also classified into acute and non- exposure to sunlight), itching, necrosis of skin and gums,
acute (or cutaneous) types depending on clinical and increased hair growth over the temples (Table 31.2).
presentation (Table 31.1). Symptoms can be triggered by drugs (barbiturates,
Inheritance of porphyrias may be autosomal domi- oral contraceptives, diazepam, phenytoin, carbama-
nant or recessive. Most acute porphyrias are inherited in zepine, methyldopa, sulfonamides, chloramphenicol,
an autosomal dominant manner (i.e. inheritance of one and antihistamines), emotional or physical stress,
abnormal copy of gene). Therefore, the activity of the infection, dieting, fasting, substance abuse, premenstrual
deficient enzyme is 50%. When the level of heme falls in period, smoking, and alcohol.
the liver due to some cause, activity of ALA synthase is Autosomal dominant porphyrias include acute
stimulated leading to increase in the levels of heme intermittent porphyria, variegate porphyria, porphyria
Disorders marked with * are the three most common porphyrias. PBG: Porphobilinogen
cutanea tarda, erythropoietic protoporphyria (most cases), be submitted for detection of excessive urinary excretion
and hereditary coproporphyria. Autosomal recessive of porphobilinogen (PBG) (Fig. 31.2). In AIP, urine becomes
porphyrias include: congenital erythropoietic porphyria, red or brown on standing (Fig. 31.3). In suspected cases of
erythropoietic protoporphyria (few cases), and ALA- cutaneous porphyrias (acute photosensitivity without skin
dehydratase porphyria (plumboporphyria). fragility), free erythrocyte protporphyrin or FEP in EDTA
blood (for diagnosis of erythrocytic protoporphyria) and
LABORATORY DIAGNOSIS for all other cutaneous porphyrias (skin fragility and
Porphyria can be diagnosed through tests done on blood, bullae), examination of fresh, random urine (10-20 ml)
urine, and feces during symptomatic period. Timely and and either feces (5-10 g) or plasma for excess porphyrins
accurate diagnosis is required for effective management are necessary (Fig. 31.4 and Table 31.2).
of porphyrias. Due to the variability and a broad range of Apart from diagnosis, the detection of excretion of a
clinical features, porphyrias are included under particular heme intermediate in urine or feces can help
differential diagnosis of many conditions. All routine in detecting site of defect in porphyria. Heme precursors
hospital laboratories usually have facilities for initial up to coproporphyrinogen III are water-soluble and thus
investigations in suspected cases of porphyrias; laboratory can be detected in urine. Protoporphyrinogen and
tests for identification of specific type of porphyrias are Protoporphyrin are insoluble in water and are excreted
available in specialized laboratories. in bile and can be detected in feces.
All samples should be protected from light. Samples
Initial Studies
required are (i) 10-20 ml of fresh random urine sample
In suspected acute porphyrias (acute neurovisceral attack), without any preservative; (ii) 5-10 g wet weight of fecal
a fresh randomly collected urine sample (10-20 ml) should sample, and (iii) blood anticoagulated with EDTA.
Laboratory Tests in Porphyrias 317
Test for Porphobilinogen in Urine Tests for Porphyrins in Erythrocytes and Plasma
Ehrlich’s aldehyde test is done for detection of PBG. Visual examination for porphyrin fluorescence, and
Ehrlich’s reagent (p-dimethylaminobenzaldehyde) reacts solvent fractionation and spectrophotometry have now
with PBG in urine to produce a red color. The red product been replaced by fluorometric methods.
has an absorption spectrum with a peak at 553 nm and a Further Testing
shoulder at 540 nm. Since both urobilinogen and
If the initial testing for porphyria is positive, then
porphobilinogen produce similar reaction, further testing
concentrations of porphyrins should be estimated in
is required to distinguish between the two. Urobilinogen
urine, feces, and blood to arrive at specific diagnosis
can be removed by solvent extraction. (See Watson- (Tables 31.3 and 31.4)
Schwartz test in Chapter 1: Examination of Urine). In latent porphyrias and in patients during remission,
Levels of PBG may be normal or near normal in porphyrin levels may be normal; in such cases, enzymatic
between attacks. Therefore, samples should be tested and DNA testing is necessary for diagnosis.
during an attack to avoid false-negative results. If porphyria is diagnosed, then it is necessary to
investigate close family members for the disorder.
Test for Total Porphyrins in Urine
Positive family members should be counseled regarding
Total porphyrins can be detected in acidified urine triggering factors.
sample by spectrophotometry (Porphyrins have an
intense absorbance peak around 400 nm). Semi- BIBLIOGRAPHY
quantitative estimation of porphyrins is possible. 1. Deacon AC, Elder GH: Frontline tests for the investi-
Test for Total Porphyrins in Feces gation of suspected porphyria. J Clin Pathol 2001; 54;
500-7.
Total porphyrins in feces can be determined in acidic 2. Crook MA: Clinical chemistry and metabolic medicine.
extract of fecal sample by spectrophotometry; it is Seventh edition. London. Edward Arnold, 2006.
necessary to first remove dietary chlorophyll (that also 3. Thadani H, Deacon A, Peters T: Diagnosis and
absorbs light around 400 nm) by diethyl ether extraction. management of porphyria. BMJ 2000; 320; 1647-51.
32
Automation in Hematology
AUTOMATED HEMATOLOGY ANALYZER Automated hematology analyzers are of two main types:
• Semi-automated: Some steps like dilution of blood
Automation is a process of replacement of tasks hitherto
sample are performed by the technologist; can
performed by humans by computerized methods.
measure only a few parameters
Until recently, hematological tests were performed
• Fully automated: Require only anticoagulated blood
only by manual methods. These methods, though still
sample; measure multiple parameters.
performed in many peripheral laboratories, are labor-
intensive, and involve use of hemocytometers (counting
chambers), centrifuges, Wintrobe tubes, photometers, PRINCIPLES OF WORKING
and stained blood smears. Hematology cell analyzers can Automated hematology analyzers work on different
generate the blood test results rapidly and also perform principles:
additional tests not possible by manual technology. • Electrical impedance
Both manual and automated laboratory techniques • Light scatter
have advantages and disadvantages, and it is unlikely • Fluorescence
that one will completely replace the other. • Light absorption
• Electrical conductivity.
Advantages of Automated Hematology Analyzer
Most analyzers are based on a combination of
• Speed with efficient handling of a large number of different principles.
samples 1. Electrical impedance: This is the classic and time-
• Accuracy and precision in quantitative blood tests tested technology for counting cellular elements of
• Ability to perform multiple tests on a single platform blood. As this method of cell counting was first
• Significant reduction of labor requirements developed by Coulter Electronics, it is also called as
• Invaluable for accurate determination of red cell Coulter principle (Fig. 32.1). Two electrodes placed
indices. in isotonic solutions are separated by a glass tube
having a small aperture. A vacuum is applied and as
Disadvantages of Automated a cell passes through the aperture, flow of current is
Hematology Analyzer
impeded and a voltage pulse is generated.
• Flags: Flagging of a laboratory test result demands The requisite condition for cell counting by this
labour-intensive manual examination of a blood method is high dilution of sample so that minimal
smear numbers of cells pass through the aperture at one
• Comments on red cell morphology cannot be point of time. There are two electrodes on either side
generated. Abnormal red cell shapes (such as of the aperture; as the solution in which the cells are
fragmented cells) cannot be recognized. suspended is an electrolyte solution, an electric
• Erroneously increased or decreased results due to current is generated between the two electrodes.
interfering factors When a cell passes through this narrow aperture
• Expensive with high running costs. across which a current is flowing, change in electrical
320 Essentials of Clinical Pathology
Estimation of Hemoglobin
Hemoglobin is measured directly by a modification of
cyanmethemoglobin method (all hemoglobins are
converted to cyanmethemoglobin by potassium
ferricyanide; cyanmethemoglobin has a broad absor-
bance peak at 540 nm). Some analyzers use a non-
hazardous reagent such as sodium lauryl sulphate. A
non-ionic detergent is added for rapid red cell lysis and
to minimize turbidity caused by cell membranes and
plasma lipids.
Fig. 32.2: Diagrammatic representation of red cell histogram
Estimation of Red Blood Cell Count and obtained by aperture impedance. The analyzer counts cells
Mean Cell Volume (MCV) between 36 fl and 360 fl as red cells. Although leukocytes
are present and counted along with red cells in the diluting
Red cell count and cell volume are directly measured by fluid, their number is not statistically significant. Only if
aperture impedance or light scatter analysis. In a red cell leukocyte count is markedly elevated (>50,000/μl), histogram
histogram, cell numbers are plotted on Y-axis, while cell and the red cell count will be affected. Area of the peak
volume is indicated on X-axis (Fig. 32.2). The analyzer between 60 fl and 125 fl is used for calculation of mean
counts those cells as red cells volume of which ranges cell volume and red cell distribution width. Abnormalities in
between 36 fl and 360 fl. red cell histogram include: (1) Left shift of the curve in
MCV is used for morphological classification of microcytosis, (2) Right shift of the curve in macrocytosis, and
anemia into microcytic, macrocytic, and normocytic (3) Bimodal peak of the curve in double (dimorphic)
types. population of red cells
in iron deficiency anemia, but not in β-thalassemia minor Instruments measuring a 5-part differential work on a
and anemia of chronic disease (other causes of microcytic combination of different principles, e.g. light scatter,
anemia). However, this distinction is not absolute and impedance, and electrical conductivity, a combination
there is a significant overlap between values among of light scatter, peroxidase staining, and resistance of
patients. Raised RDW requires examination of blood basophils to lysis in acid buffer, etc.
smear.
Among the red cell values generated by the analyzer Platelet Count
(red cell count, hemoglobin, hematocrit, MCV, MCH, Platelets are difficult to count because of their small size,
MCHC, and RDW), most important for decision- marked variation in size, tendency to aggregation, and
making are hemoglobin, hematocrit, and MCV. overlapping of size with microcytic red cells, cellular
fragments, and other debris. In hematology analyzers,
WBC Differential
this difficulty is addressed by mathematical analysis of
Hematology analyzers can either generate a 3-part platelet volume distribution so that it corresponds to log-
differential (differential count reported as lymphocytes, normal distribution. Platelets are counted by electrical
monocytes, and granulocytes) or a 5-part differential impedance method in the RBC aperture, and a histogram
(lymphocytes, monocytes, neutrophils, eosinophils, and is generated with platelet volume on X-axis and relative
basophils). The 3-part differential counting is based on cell frequency on Y-axis (Fig. 32.4). Normal platelet
electrical impedance volume measurement of leukocytes. histogram consists of a right-skewed single peak.
In volume histogram for WBCs, approximate numbers Particles greater than 2 fl and less than 20 fl are classified
of cells are plotted on Y-axis and cell size on X-axis. Those as platelets by the analyzer.
cells with volume 35-90 fl are designated as lymphocytes, Two other platelet parameters can be obtained from
cells with volume 90-160 fl as mononuclear cells, and platelet histogram using computer technology: mean
cells with volume 160-450 fl as neutrophils (Fig. 32.3). platelet volume (MPV) and platelet distribution width
Any deviation from the expected histogram is flagged (PDW). Some analyzers can generate another parameter
by the analyzer, mandating review of blood smear. A called as reticulated platelets.
large proportion of 3-part differential counts are ‘flagged’ MPV refers to the average size of platelets and is
to avoid missing abnormal cells. obtained from mathematical calculation. Normal MPV
Fig. 32.3: Diagrammatic representation of WBC histogram. WBC histogram analysis shows relative numbers of cells on
Y-axis and cell size on X-axis. The lytic agent lyses the cytoplasm that collapses around the nucleus causing differential
shrinkage. The analyzer sorts the WBCs according to the nuclear size into 3 main groups (3-part differential): Cells with
35-90 fl volume are designated as lymphocytes, cells with 90-160 fl volume are designated as monocytes, and cells with
160-450 fl volume are designated as neutrophils. Abnormalities in WBC histogram include: (1) Peak to the left of lymphocyte
peak: Nucleated red cells, (2) Peak between lymphocytes and monocytes: Blast cells, eosinophilia, basophilia, plasma
cells, and atypical lymphocytes, and (3) Peak between monocytes and neutrophils: Left shift
Automation in Hematology 323
TERMINOLOGY IN FLOW CYTOMETRY When a cell passes through laser beam, side scatter
and fluorescent signals that are emitted by the cell are
Fluorescence
directed to photomultiplier tubes, while the forward scatter
A fluorochrome absorbs light energy and emits excess signals are directed to a photodiode. Photomultiplier tubes
energy in the form of photon light (fluorescence). and photodiodes are called as detectors. Optical filters
Fluorescence is the property of molecules to absorb light are placed before the detectors that allow only a narrow
at one wavelength and emit light at a longer wavelength. range of wavelengths to reach the detectors (Fig. 32.5).
The fluorescent dyes commonly used in flow cytometry
are fluorescein isothiocyanate (FITC) and phycoerythrin Data Analysis
(PE). The fluorochrome-labeled antibodies are used for
detection of antigenic markers on the surface of cells. A The data collected and stored in the computer can be
particular cell type can be identified on the basis of the displayed in various formats. A parameter means forward
antigenic profile expressed. Multiple fluorochromes can scatter, or side scatter, or emitted fluorescence from a
be used to identify different cell types in a mixed particle as it passes through a laser beam. A histogram is
population of cells. a data plot of a single parameter, with the parameter’s
signal value in channel numbers or relative fluorescence
Light Scatter intensity on X-axis (horizontal axis) and number of events
Light is scattered when the incident light is deflected by a on the Y-axis. A dot plot is a two parameter data graph in
particle traversing through a beam of light. This depends which each dot represents one event that the flow
on the physical properties of the cell. Two forms of light cytometer analyzed; one parameter is displayed on the X-
scatter are used to identify different cell types: forward axis and the other on the Y-axis. A 3-D plot represents one
scatter and side scatter. Forward scatter (light scattered in parameter on X-axis, another parameter on Y-axis, and
the same direction as the laser beam) is related to cell size. number of events per channel on Z-axis.
Side scatter (light scattered at a 90° angle to the laser beam)
Gating
is related to internal granularity of the cell. Main
subpopulations of leukocytes are identified on the A gate is a boundary that can be set to restrict the analysis
basis of correlated measurements of forward and side to a specific population within the sample. For example, a
scatters. gate boundary can be drawn on a dot plot or histogram to
restrict the analysis only to cells with the size of 2. Paroxysmal nocturnal hemoglobinuria: Deficiency of
lymphocytes. Gates can be inclusive (selection of events CD 55 and CD 59.
that fall within the boundary) or exclusive (selection of 3. Hematopoietic stem cell transplantation: Enumeration
events that fall outside the boundary). Data selected by
of CD34+ stem cells.
the gate is then displayed in subsequent plots.
4. Feto-maternal hemorrhage: Detection and quantitation
Sorting of foetal hemoglobin in maternal blood sample.
5. Anemias: Reticulocyte count.
Usually, when a cell passes through the laser beam, it is
6. Human immunodeficiency virus infection: For
sent to waste. Sorting consists of collecting cells of interest
(defined through criteria of size and fluorescence) for enumeration of CD4+ lymphocytes.
further analysis (such as microscopy or functional or 7. Histocompatibility cross matching.
chemical analysis). Sorting feature is available only in
some flow cytometers. BIBLIOGRAPHY
COMMON APPLICATIONS OF FLOW 1. Henry JB. Clinical Diagnosis and Management by
CYTOMETRY IN HEMATOLOGY Laboratory Methods (20th Ed). Philadelphia: WB
Saunders Company, 2001.
1. Leukemias and lympomas: Immunophenotyping 2. Houwen B. The differential count. Laboratory Hema-
(evaluation of cell surface markers), diagnosis, tology 2001;7:89-100.
detection of minimal residual disease, and to identify 3. Ward PJ. The CBC at the turn of the millennium: an
prognostically important subgroups. overview. Clin Chem 2000;46:1215-20.
Practical Blood Transfusion
33
International Society of Blood Transfusion (ISBT) Table 33.1: Blood group systems
Working Party has organized red cell antigens into 25 ABO Dombrock
blood group systems (Table 33.1). Red cell antigens that MNS Colton
are produced by alleles (alternative forms of a specified P Landseiner-Weiner
gene) at a single gene locus or very closely linked loci Rh Chido/Rogers
constitute a blood group system. Lutheran Hh
Kell Kx
Blood group genes are inherited in a Mendelian
Lewis Gerbich
manner and are mostly located on autosomes. Most of Duffy Cromer
the blood group genes are expressed in a co dominant Kidd Knops
manner (i.e. the two allelic forms are expressed equally Diego Indian
if inherited in a heterozygous state, and no gene or Yt Ok
allele is dominant over another). The particular alleles Xg Raph
Scianna
at a specified gene locus in an individual constitute the
genotype. Phenotype is the outward expression of the
genotype. ABO SYSTEM
In blood transfusion practice, most important blood In ABO system, there are four main types of blood groups:
group systems are ABO and Rh. This is because, A, B, A, B, AB, and O. Identification of these four blood groups
and Rh D antigens are the most immunogenic (i.e. is based on presence or absence of A and/or B antigens
capable of eliciting a strong antibody response on on red cells. According to Landsteiner’s law, anti-A and/
stimulation) and their alloantibodies can cause destruc- or anti-B antibodies are always present in plasma of
tion of transfused red cells or induce hemolytic disease individuals who lack corresponding antigen(s) on their
of newborn (HDN). ABO antigens are also important in red cells (Table 33.2). ABO is the only blood group system,
organ transplantation. in which if an antigen is absent in an individual,
Note: A and B genes are dominant while O gene is recessive. Individuals with AA, BB, and OO are homozygous
respectively for A, B, and O, while AO, BO, and AB are heterozygous.
330 Essentials of Clinical Pathology
Box 33.2: Identification of Bombay phenotype not match with the ABO blood group of the accused).
Inhibitor tests are used to detect the presence of soluble
• Blood group: O blood group antigens in body secretions. If saliva contains
• Cross-matching: Serum incompatible with O cells a soluble antigen, and if corresponding antibody is
• Red cells yield negative reaction with anti-H lectin
added, the activity of the antibody is neutralized. When
red cells carrying the appropriate antigens are subse-
on presence of a dominant secretor gene (Se) on quently added to the mixture, there will be inhibition of
chromosome 19. About 80% of individuals are secretors agglutination (i.e. the person is a secretor). If aggluti-
(genotype Sese or SeSe) and remaining are non-secretors nation occurs, then the individual is a non-secretor.
(genotype sese). Both secretors and non-secretors express Example:
ABO antigens on red cells. 1. Blood group: B
Antigens secreted by different ABO blood groups are: Saliva + anti-B; Add B cells: No agglutination
• Group A: A, H Interpretation: Secretor
• Group B: B, H 2. Blood group: O
• Group AB: A, B, H Saliva + Anti-A; Add A cells: Agglutination; Saliva +
• Group O: H Anti-B; Add B cells: Agglutination; Saliva + Anti-H;
Antigens secreted into body fluids are called as ABH Add O cells: No agglutination.
substances. Testing for ABH substances in saliva may be Interpretation: Secretor
helpful when red cell grouping yields uncertain results. 3. In non-secretors, no soluble antigens are present in
Determining secretor status in saliva and semen can be secretions. Thus antibodies in the reagent are free to
helpful in resolving ABO blood group discrepancies and bind to red cells of respective group. There will be
in forensic studies (e.g. semen sample collected from a agglutination reaction.
rape victim revealing a soluble ABH antigen that does
332 Essentials of Clinical Pathology
Antibodies of the ABO System B antibodies. Therefore, group O persons are traditionally
considered as universal donors.Group AB persons are
The most important antibodies in transfusion practice are
considered as universal recipients. This, however, is an
anti-A and anti-B. They are also called as naturally
occurring antibodies because they arise without immune oversimplification because only the reaction between
recipient’s plasma (antibodies) and the donor’s red cells
stimulation by red cells by relevant blood group antigens.
is considered; a small amount of antibodies in donor’s
They are regularly-occurring, i.e. if an antigen is absent
plasma can cause destruction of recipient’s red cells. In
the corresponding antibody is always present. They are
addition, antigens other than A, B, or RhD can bind to
not detectable in the blood of newborn infants due to
corresponding antibodies or immunize the recipient.
their underdeveloped immune system and appear
around 3-6 months of life. It is thought that they are
THE Rh SYSTEM
produced in response to A- and B-like antigens of
bacteria, which are present in the intestine and certain When Rhesus monkey red cells were injected into rabbits
foods. If anti-A and/or anti-B are present at birth, they and guinea pigs (by Landsteiner and Weiner in 1940),
are of maternal origin (IgG). Anti-A and anti-B antibodies antibody, which was raised, was found to react with
are usually of IgM class. Immune or IgG antibodies (anti- Rhesus monkey red cells as well as with 85% of human
A or anti-B) can be stimulated by exposure to red cells, red cells (White residents of New York city). The antigen
white cells, or platelets. involved was called as Rh factor. Subsequently it was
IgM antibodies are large molecules and can bind up shown that the original antibody was different from anti-
to ten antigens; therefore they can cause direct D antibody discovered later. The name of the antigen,
agglutination of red cells and cause visible agglutination. however, has remained as Rhesus. Apart from
IgM antibodies can efficiently fix the complement. Landsteiner and Weiner, credit for discovery of Rh
Naturally occurring ABO antibodies can cause: system also goes to Levine and Stetson who discovered
• Hemolytic transfusion reaction in a case of ABO- in 1939 the antibody (actually anti-D) that caused
mismatched blood transfusion, hemolytic disease of newborn.
• Acute graft rejection in case of ABO-incompatible The Rh system is only next in importance to ABO
solid organ transplantation, and system in transfusion practice. The importance of this
• Hemolysis of donor red cells following ABO- system lies in the high immunogenicity of Rh D antigen,
incompatible bone marrow transplantation. which readily induces formation of anti-D antibodies in
Less commonly, some individuals have large 50-70% of Rh D-negative individuals. Anti-D antibodies
amounts of ABO antibodies of immune nature. Usually, can cause hemolytic transfusion reaction or, in pregnant
group O individuals following immune stimulation by women, Rh hemolytic disease of newborn.
transfusion, pregnancy, or injection of certain vaccines
or toxoids (that contain bacterial A- and B-like antigens) The Rh system was discovered independently by:
produce them in large amounts. These antibodies are of (1) Stetson and Levine in 1939 and (2) by Landsteiner
IgG class, of high titer, and cannot be neutralized by and Weiner in 1940.
soluble blood group antigens. If blood of such group O
individuals (called dangerous universal group O donors)
is transfused to group A or B individuals, serious Antigens of the Rh System
hemolysis of recipient’s red cells can occur. Therefore Rh system is highly complex and consists of about 40
group O donors should not be employed as universal antigens. The important antigens of the Rh system are
donors. In addition to causing hemolytic transfusion C, D, E, c, and e. Antigen d does not exist. D antigen is
reaction, these IgG antibodies can cross the placenta and the most immunogenic. There are various nomenclature
induce hemolytic disease of newborn. systems for Rh antigens. Fisher-Race or CDE nomen-
clature system and Weiner system are popular.
Concepts of Universal Donor and Recipient
According to Fisher and Race, three closely linked
Red cells of group O donors are devoid of A and B genes are inherited together on one chromosome
antigens and cannot be agglutinated by anti-A and anti- (haplotype) from each parent. Allelic forms of these genes
Blood Group Systems 333
are C and c, D and d, and E and e with eight possible In Rh negative persons, deletions, point mutations, or
haplotypes: Cde, cde, cDE, cDe, cdE, Cde, CDE, and CdE. partial mutations of D gene have been found. Rh antigens
As an individual inherits one haplotype from each are expressed only on red cells and not on any other
parent, 36 genotypes are possible such as Cde/cde, Cde/ tissues. They are also not secreted in body fluids. In
cDe, CDE/cde, etc (Fig. 33.2). The presence of D in either contrast to ABO antigens, Rh antigens are fully expressed
homozygous (D/D) or heterozygous (D/d) state makes on red cells before birth and also on red cells of early
that individual Rh positive, while Rh negative persons fetuses.
are homozygous for d (d/d). It was thought that d gene Depending on the presence or absence of antigen D
was an amorph. on red cells, a person is grouped either as Rh positive
According to the theory by Dr. Alexander Weiner, a (when red cells express antigen D) or Rh negative (when
single Rh gene is inherited from each parent; this single D antigen is absent on red cells). Frequency of D antigen
Rh gene, however, has multiple alleles (Fig. 33.3). The varies in different populations. In India, approx. 95% of
Weiner system uses Rh-Hr nomenclature. The major the people express D antigen on their red cells (Rh D
difference between Fisher-Race and Weiner systems is positive), while 5% are Rh D negative. The frequency
that according to Fisher-Race, there are three closely in Caucasians is 85% Rh positive and 15% Rh negative.
linked genes that are inherited from each parent, while Other forms of D antigen are weak D and partial D
according to Weiner, a single gene with multiple alleles (Fig. 33.5). Red cells having weak D antigen were
is inherited from each parent. formerly called as Du cells which react weakly with anti-
Results of current genetic studies suggest that both D reagent. There is a quantitative reduction in the
Fisher-Race and Weiner systems are partially correct. It number of D antigen sites on such red cells. Du recipients
has been found that the RH locus is located on do not make anti-D antibodies following stimulation by
chromosome 1 and consists of two closely linked genes- D antigen (e.g. following D positive blood transfusion).
RHD and RHCE (Fig. 33.4). The alleles of RHCE are CE, Du donors should be considered as Rh positive and their
Ce, ce, and cE. blood should not be transfused to Rh negative donors.
Fig. 33.4: According to current genetic studies, there are two genes on
short arm of chromosome 1: RHCE and RHD
Fig. 33.5: Diagrammatic representation of Fig. 33.6: Relative immunogenicity of Rh antigens. D antigen
variations of Rh antigen is the most immunogenic while e antigen is the weakest
Blood Group Systems 335
1. Lewis Lea, Leb Natural, IgM Lewis antigens are passively absorbed from plasma on red cells;
Lewis antibodies are rarely of clinical significance
2. Kell About 20 IgG Anti-K antibodies can cause hemolytic transfusion reaction and
(KEL1, hemolytic disease of newborn; Some individuals do not have
KEL2, etc) precursor substance on their red cells from which K antigens are
produced; such red cells have short life, acanthocytic features, and
express Kell antigens weakly (MacLeod phenotype).
3. Duffy Fya, Fyb IgG Antibodies can cause hemolytic transfusion reaction. Plasmodium
vivax enters the red cells at the Duffy antigen site. The Fy(a-b-)
phenotype in blacks confers resistance against Plasmodium vivax
infection
4. Kidd JKa, JKb IgG Antibodies cause delayed transfusion reaction and mild hemolytic
disease of newborn
5. MNSs M, N, S, s M and N antigens are important in paternity testing
k
6. P P, P1, P IgM, IgG Auto-anti-P occurs in paroxysmal cold hemoglobinuria
In red cells having partial D antigen, parts of D antigen be transfused only with Rh-negative blood. During
are missing. Variants of partial D antigen exist. pregnancy, IgG anti-D can cross the placenta and induce
Individuals with DVI variant are able to produce anti-D hemolytic disease of newborn by causing immune
antibody against the missing part of the antigen. Such hemolysis of fetal red cells. Rh hemolytic disease of
recipients should be considered as Rh negative, while newborn can be prevented by prophylactic adminis-
donors should be regarded as Rh positive. However, in
tration of Rh immune globulin to all Rh-negative women
practice, individuals with partial D antigen are typed as
during mid pregnancy and within 72 hours of delivery.
D negative and are identified only after they have
Anti-D and anti-c can cause severe HDN. Anti-C, anti-
produced anti-D antibodies.
Complete absence of all Rh antigens on red cells E, and anti-e usually do not cause HDN or cause mild
(Rh null cells) is associated with stomatocytosis and HDN. Relative immunogenicity of Rh antigens is shown
compensated hemolysis. in Figure 33.6.
Blood Grouping
ABO GROUPING
Box 34.1: ABO antisera
There are two methods for ABO grouping:
• Three types: Anti-A, anti-B, anti-A, B.
• Cell grouping (forward grouping): Red cells are tested
• Anti-A: Blue-colored;
for the presence of A and B antigens employing
• Anti-B: Yellow-colored.
known specific anti-A and anti-B (and sometimes
• Anti-A, B: Colorless.
anti-A, B) sera.
• Serum grouping (reverse grouping): Serum is tested for • Sodium azide is added to prevent the growth of bacteria
the presence of anti-A and anti-B antibodies by • Antisera are kept stored at 4-6°C to preserve their potency
employing known group A and group B reagent red • Routinely, anti-A and anti-B are used for blood grouping.
cells. • Indications for using anti-A, B: (1) for confirmation of cell
grouping in newborns, and (2) to resolve ABO group
Both cell and serum grouping should be done since
discrepancies.
each test acts as a check on the other.
• Antisera may be polyclonal or monoclonal. Monoclonal
There are three methods for blood grouping: tube, antisera are specific, avid, and can detect weak antigens.
microplate, and slide. Slide test is described below. Tube Monoclonal antisera are commonly used.
and microplate methods are better and are employed in
blood banks; they are outlined in short following slide
test.
SLIDE TEST
Principle
Red cells from the specimen are reacted with reagent
antisera (anti-A and anti-B). Agglutination of red cells
indicates presence of corresponding antigen (aggluti-
nogen) on red cells.
Specimen
Capillary blood from finger prick, or venous blood
collected in EDTA anticoagulant.
Reagents
ABO antisera: See box 34.1 and Figure 34.1. Fig. 34.1: Anti-A and anti-B sera used for cell grouping
Method 2. Place one drop of anti-A serum and one drop of anti-
1. A clean and dry glass slide is divided into two sections B serum in the center of the corresponding section of
with a glass marking pencil. The sections are labeled the slide. Antiserum must be taken first to ensure that
as anti-A and anti-B to identify the antisera (Fig. 34.2). no reagents are missed.
Blood Grouping 337
Negative (–): Red cells are floating homogeneously in a Positive (+) Test
uniform suspension. Clumps of red cells suspended in a clear fluid. Aggluti-
7. Interpretation: Interpret the result as shown in the nation in tube test is graded from 1+ to 4+ and read
Table 34.1 and Figure 34.2. macroscopically (Fig. 34.3).
MICROPLATE METHOD
Microplate is a polystyrene plate consisting of 96 micro
wells of either U- or V-shape. Grouping is carried out in
micro wells. This method is sensitive and ideal for large
number of samples (Fig. 34.4).
Fig. 34.4: Microplate (96 well) method for blood grouping. Numbers 1 to 12 represent patient identification numbers. Reagents
added to the patient sample are written on left, while interpretation (blood group of patient) is written at the bottom. For understanding,
reaction patterns of the 8 possible blood groups are shown, while the last 4 columns have been kept empty. Red compact
button indicates agglutination, while uniform suspension indicates no agglutination
*In dosage effect, antibody reacts stronger with homozygous cells than with heterozygous cells
red cells and cause hemolytic disease of newborn. In other Rh typing is done at the same time as ABO grouping.
sensitized individuals, re-exposure to D antigen can Method of Rh D grouping is similar in principle to ABO
cause hemolytic transfusion reaction. grouping. Since serum or reverse grouping is not possible,
In Rh D grouping, patient’s red cells are mixed with each sample is tested in duplicate. Dosage effect (stronger
anti-D reagent. Serum or reverse grouping is not carried antigen-antibody reaction in homozygous cells i.e.
out because most Rh-negative persons do not have anti- stronger reaction with DD) is observed with antigens of
D antibodies; anti-D develops in Rh-negative individuals the Rh system. Autocontrol (patient’s red cell + patient’s
only following exposure to Rh-positive red cells. serum) and positive and negative controls are included
340 Essentials of Clinical Pathology
In India, collection of blood, processing, storage, and blood donation. General steps for collection of donor blood
preparation of blood components and derivatives are are shown in Figure 35.1. The safe transfusion practice
regulated by Food and Drugs Administration (FDA). starts with proper selection of blood donors; if donors are
Blood is regarded as a “drug” (under section 3(b) of the not properly screened, blood can become a medium of
Drugs and Cosmetics Act, 1940) by the FDA and all the transmission of infections like human immunodeficiency
blood banks have to obtain a license from the FDA and virus, hepatitis B and C virus, syphilis, and malaria.
follow the FDA guidelines. Blood donations are of three main types: whole blood
donation (collection of one unit or 350 ml of whole blood
TYPES OF BLOOD DONORS in an anticoagulant solution), autologous donation
(donation for subsequent transfusion to self), and
Blood donation is a process through which a blood donor apheresis donation (removal of whole blood from a
has a specified amount of blood drawn for the purpose donor, separation and retention of the desired portion,
of storage in a blood bank and for subsequent blood and returning the remaining portion to the donor).
transfusion. Blood donation may be done in a blood bank There are three main types of whole blood donors:
or in blood donation camps. The process of blood • Voluntary
donation involves selection of blood donors by screening, • Professional
actual donation of blood, and a brief recovery period after • Replacement.
A blood bank should function only on voluntary blood Box 35.1: Typical questions in the
donations. A voluntary blood donor donates blood out of questionnaire asked to the prospective donor
his/her own free will and on humanitarian grounds or
out of sense of duty or responsibility towards the • Have you donated blood previously? If yes, date of last
community. A voluntary donor is issued a voluntary donor donation and discomfort during or after donation if any.
• Were you deferred as a donor?
card which can be presented for free blood unit if blood is
• Did you receive any blood or blood products in the last
required for himself or a close family member. 6 months?
Paid or professional donors donate blood for money. • Do you currently suffer from or were suffering from any
As payment encourages concealment of a significant of the following conditions: Heart disease, lung disease,
illness, high-risk behavior, or medical history, such form liver disease, kidney disease, cancer, diabetes, epilepsy,
of donations should be completely discouraged. tuberculosis, bleeding disorder, hepatitis, allergy, jaundice,
sexually transmitted disease, malaria (last 6 months),
A replacement blood donor is a friend or a relative
typhoid (last 1 year)?
of the recipient whose donated blood unit is credited to • Have you had recent weight loss, swollen glands, low
the patient (predeposit donation). Blood unit that has grade fever, persistent cough, or repeated diarrhea?
been donated replaces the blood unit used for the patient. • Individuals with multiple sexual partners, homosexuals,
Directed donor donates blood for a specific, named and intravenous drug abusers are likely to be infected
patient and is a friend or a relative of the patient. Patient with AIDS virus. Do you practice any of these?
• Have you taken aspirin in last 3 days? Are you taking
selects his or her own blood donor. Directed donations
any other medications?
can be less safe as the donor may hide significant medical • Have you been vaccinated recently?
information due to pressure of donation. Graft vs. host • Have you had any major surgery or received blood
disease is possible after blood transfusion from a relative. transfusion in the last 6 months?
• Did you have any accidental needle stick (health care
CRITERIA FOR SELECTION OF workers), tattooing, or ear piercing in the last 6 months?
BLOOD DONORS • For women donors: Are you pregnant? Are you breast-
feeding a child? Did you have an abortion in the last 6
Careful selection of blood donors is an essential months?
requirement for safe transfusion practice. It is necessary
to ensure safety of both the donor and the recipient. It is
essential to identify potential health problems for the Box 35.2: Reasons for permanent deferral of a
donor and to prevent transmission of infections through blood donor
transfusion to the recepient. Selection process consists
of obtaining medical history, and performing physical • Positive test for HBV, HCV, HIV
examination and certain laboratory tests. Selection of • Known case of angina pectoris or myocardial infarction
blood donors should be carried out by a qualified • Recipient of clotting factor concentrate
physician or by a person working under his supervision. • High risk behavior for HIV infection
A blood donor questionnaire and consent form needs • Gay or bisexual male
to be filled by the prospective donor before blood • History of viral hepatitis in adult life
• Intravenous drug abuse
donation. Typical questions asked to the prospective
• Recipients of human pituitary-derived growth hormone
donor are shown in Box 35.1. The prospective donor
• Any malignancy, endocrine disease, chronic renal disease,
should be assured that the personal information revealed
chronic liver disease, bleeding disorder, diabetes mellitus
shall be kept confidential. dependent on insulin, asthma
Criteria for selection of blood donors are given below
in short. Reasons for permanent and 1 year deferral are
shown in Boxes 35.2 and 35.3. Donation Interval
To protect the donor from iron deficiency, interval
Age
between two successive donations should be atleast 3
Blood donor should be between 18 and 60 years of age. months.
Collection of Donor Blood, Processing and Storage 343
• History of tattooing, ear-piercing, accidental needle Many donors who are taking drugs are excluded because
stick in health workers of their clinical condition. Other donors are not accepted
• Rabies vaccine or hepatitis B immunoglobulin because the drug they are taking can be potentially
• Rape victims harmful to the recipient, e.g. aspirin (which inhibits
• Sexual contact with a person with hepatitis, AIDS, or platelet function), and drugs with teratogenic action like
with an intravenous drug abuser finasteride, isotretinoin, acitretin, and etretinate, or
• Recipient of blood transfusion or organ transplant
cytotoxic drugs (like cyclophosphamide). Recipients of
human pituitary-derived growth hormone are perma-
Volume of Donation nently debarred due to the risk of Creutzfeldt-Jakob
disease.
A donor weighing 45 kg or more can give 350 ml of blood
along with pilot samples for processing. Dental Treatment
Needle is removed from the vein and pressure is legs are elevated above the level of the head. Cold
applied over the puncture site with sterile cotton gauze. compresses are placed on the neck and forehead. This
The needle is discarded in a special “sharps” container. reaction should be distinguished from hypotensive
Blood remaining in the tubing is non-anticoagulated shock (tachycardia, hypotension, and loss of con-
and is forced back into the blood bag. Bag is inverted sciousness). A severe vasovagal reaction is a contra-
gently several times to mix the blood and the anticoagu- indication for future donations.
lant. Anticoagulated blood is then allowed to run back 2. Hyperventilation: This is seen in first-time donors
into the tubing. The blood bag is placed in the refrigerator who are highly excited. Hyperventilation causes loss
at 4-6°C immediately following collection. If platelet of carbon dioxide. This may result in facial twitching
concentrate is to be prepared, the bag should be kept at or muscular spasms. Relief can be obtained by
room temperature till platelets are separated (within 4 breathing in a paper bag.
hours of collection). 3. Nausea and vomiting
After cessation of bleeding, the venepuncture site is 4. Hematoma at the site of venepuncture
covered with sterile gauze and an adhesive tape. After 5. Infection at venepuncture site or thrombophlebitis
8-10 minutes, the donor is allowed to sit up and guided 6. Inadvertent arterial puncture.
to the refreshment area. The donor is issued a donation Any donor reactions should be recorded on the card
card and is given information about need to drink more issued to the donor.
fluids, activities permissible, and care of venepuncture General procedure after collection of donor blood is
site. outlined in Figure 35.2.
Table 35.1: Tests done on donor blood after collection increases oxygen affinity of haemoglobin and reduces
and before cross-matching
release of oxygen to the tissues. 2,3-DPG in red cells
• ABO and Rh grouping tends to return to normal levels within 24 hours of
• Screening and identification of unexpected antibodies transfusion.
• Screening tests for infections transmissible by transfusion 4. Loss of granulocyte function (phagocytic and
– Hepatitis B surface antigen
– Test for antibodies to hepatitis C virus
bactericidal property) occurs within 24 hours and
– Test for antibodies to human immunodeficiency virus loss of platelet function occurs within 48 hours of
– Venereal disease research laboratory (VDRL) test for blood collection. F VIII level declines to 50% by 24
syphilis hours and F V declines to 50% by 10-14 days.
– Blood smear for malaria parasite
5. Decrease in pH of blood
6. Formation of microaggregates: In stored blood,
circulation after transfusion. There is progressive loss
aggregates of aged platelets, leucocytes, and cold
of viability with increasing durtion of storage. Storage
insoluble globulin form. Their number and size
conditions should be such that, after transfusion, at
least 75% of transfused red cells should survive at 24 increase with increasing length of storage.
hours in the recipient’s circulation. Shelf life of the
stored whole blood is based on this criterion. For BIBLIOGRAPHY
whole blood stored in CPDA-1 and maintained at 2°
1. Cheesbrough M. District Laboratory Practice in Tropical
to 6°C, shelf life is 35 days.
Countries. Part 1 and Part 2. Cambridge: Cambridge
2. Depletion of ATP: Progressive loss of ATP with
University Press, 1998.
increasing length of storage causes decreased 2. Henry JB. Clinical Diagnosis and Management by
deformability of red cells and impairment of Na+/ Laboratory Methods. 20th Ed. Philadelphia: WB
K+-ATPase pump. Saunders Company, 2001.
3. Reduction of 2, 3-diphosphoglycerate (2,3-DPG): 3. Kawthalkar SM. Essentials of Haematology. New Delhi:
Progressive depletion of 2, 3-DPG with storage Jaypee Brothers Medical Publishers (P) Ltd, 2006.
36
Screening Tests for Infections
Transmissible by Transfusion
The organisms likely to be transmitted by transfusion • Concealment of relevant medical history by pros-
are usually those, which are prevalent in a particular pective donors
geographic area or population. Organisms transmissible • Specificity and sensitivity of screening tests for
by transfusion are listed in Table 36.1. infections may be poor
According to studies conducted in India, prevalence • Non-implementation of National Transfusion Policy
of transmission of infections through transfusions is • Repeat donor system is non-existent
significantly higher as compared to developed nations. • Collection of donor blood during window period
Some of the reasons include: In India, pre-transfusion testing of donor blood for
• Proportion of replacement and professional dona- agents listed in Table 36.2 is currently mandatory.
tions is high The importance of mandatory testing for infectious
organisms transmissible by transfusion is: (i) some
carriers of disease are often asymptomatic, (ii) some viral
Table 36.1: Microorganisms transmissible by transfusion
infections have long incubation periods, and (iii) it is
• Hepatitis viruses essential to safeguard the health of the recipient.
– Hepatitis A virus (rare) Infections by hepatitis B and C viruses and HIV-1 and
– Hepatitis B virus
HIV-2 are characterized by:
– Hepatitis C virus
• Human immunodeficiency virus (HIV) • Persistence of organisms in circulation for prolonged
– HIV-1 duration without necessarily causing clinical
– HIV-2 manifestations
• Human parvovirus B 19 • Persistence in high titers
• Cytomegalovirus
• Long incubation period
• Epstein Barr virus (rare)
• Human T cell leukemia virus (HTLV) • Ability to cause chronic carrier state
– HTLV-1 • Viability of organisms in blood stored at 4°-6°C.
– HTLV-2
Following principal measures can prevent trans-
Prions mission of infection through transfusion:
• Creutzfeldt-Jakob disease (CJD) and variant CJD • Blood should be collected only from voluntary, non-
Bacteria remunerated donors. All high risk persons (intra-
• Treponema pallidum (syphilis) venous drug abusers, homosexuals, prostitutes, and
• Bacterial contamination of donor unit sexual partners of such persons) and professional
• Brucellosis
donors should be excluded. Standard criteria for
Parasites selection of blood donors should be followed.
• Malaria parasites • All blood donations should be tested for infectious
• Trypanosoma cruzi
agents by screening tests; addition of further
• Toxoplasma gondii
• Babesia microti screening tests like HIV RNA and HCV RNA will
• Leishmania donovani further reduce the risk.
• Universal hepatitis B virus vaccination
348 Essentials of Clinical Pathology
Table 36.2: Mandatory infectious disease testing in blood transfusion practice in India
Disease Test
1. Syphilis Serologic test like Venereal Disease Research Laboratory (VDRL) test
2. Hepatitis B Hepatitis B surface antigen (HBsAg)
3. Human immunodeficiency Anti-HIV 1 and anti-HIV 2 antibodies*
virus (HIV) infection
4. Hepatitis C Anti-HCV antibodies•
5. Malaria Blood smear
* Window periods for HIV and HCV infections are further reduced if tests for HIV RNA and HCV RNA (nucleic acid testing or
NAT) are added. NAT, however, is not currently mandatory in India
• Observation of universal precautions in blood fusion was 6.7%; this was much higher in multi-transfused
collection, processing, storage, and transfusion patients like patients with thalassemia and hemophilia.
• Leukofiltration of blood products Infected hepatocytes release large amounts of hepatitis
• Stringent quality control measures. B surface antigen (HbsAg) into the bloodstream. Presence
of HbsAg indicates active infection. The serological marker
VIRUSES first to appear in HBV infection is HBsAg (as early as 5
days after infection).
Hepatitis B Virus (HBV)
Screening of all blood donations for HbsAg has
HBV is a partially double-stranded DNA virus of 42 nm greatly reduced the risk of transmission of HBV through
diameter (Fig. 36.1). It can cause acute hepatitis, chronic transfusion.
hepatitis, asymptomatic carrier state, cirrhosis, or Tests for screening donor blood for HbsAg are:
hepatocellular carcinoma. • Reverse passive hemagglutination assay (RPHA)
In India, prevalence of HBsAg carriers is reported to • Enzyme linked immunosorbent assay (ELISA)
be 1.5 to 4%. HBV is highly infectious and is transmitted • Radioimmunoassay (RIA).
through all blood components and most of the blood Commercial test kits for detection of HbsAg are
derivatives. According to one study in India, incidence available and the exact test procedure is provided with
of post-transfusion hepatitis following a single trans- each kit. General principles of these tests are outlined
below.
Fig. 36.1: Diagrammatic representation of Serum sample to be tested is incubated with anti-HbsAg
hepatitis B virus antibody which has been coated to microtitre plate. The
Screening Tests for Infections Transmissible by Transfusion 349
immunodeficiency in infected persons. The cells most ELISA, and (ii) HIV-1 nucleic acid amplification testing
susceptible to HIV infection are CD4+ T lymphocytes. (NAT). NAT testing is based on polymerase chain reaction.
Destruction of CD4+ T lymphocytes results in slowly
progressive impairment of the immune system. The
BACTERIA
infected individual becomes susceptible to a range of Treponema pallidum
opportunistic infections and malignancies. The most Blood transfusion can transmit Treponema pallidum, the
advanced stage of HIV disease is acquired immune causative agent for syphilis. It is a spirochete that can be
deficiency syndrome or AIDS. visualized by dark ground illumination (Fig. 36.6). T.
According to the estimates of India’s National AIDS pallidum is destroyed by storage of blood at 2-8°C for 48-
Control Organization (NACO), adult prevalence of HIV 72 hours. However, fresh blood or platelet concentrates
infection is 0.7% with approximately 4 million HIV can transmit these organisms. Transfusion-transmission
infections, 90% of which are in the age group of 15-45 of syphilis is, therefore, rare. The main value of testing
years. donor blood for T pallidum is to identify and exclude
donors with high-risk behavior and thus who are at risk
Following HIV infection, viremia becomes detectable
of having sexually transmitted infections.
after a few days and lasts for several weeks. Anti-HIV
antibodies appear 6-12 weeks after infection (called as
seroconversion). Principle of ELISA test for detection of
anti-HIV antibodies is shown in Figure 36.5. Window
period is the period between the onset of HIV infection
and appearance of detectable anti-HIV antibodies in
serum; it is the infectious but seronegative period (i.e.
the test for anti-HIV antibodies is yet to become positive).
Transfusion of donor blood collected during the window
period will transmit HIV to the recipient.
According to American Association of Blood Bank
standards, HIV screening tests necessary for whole blood Fig. 36.6: Treponema pallidum observed under dark
donors are (i) Anti-HIV antibodies (HIV-1 and HIV-2) by ground illumination
Screening Tests for Infections Transmissible by Transfusion 351
PARASITES
Plasmodium Species
Malaria parasite can be transmitted through all blood
components. For detection of malaria parasite, commonly
blood smears are examined by light microscopy.
However, the test is positive only when parasites are
> 100/μl in blood.
BIBLIOGRAPHY
1. Chatterjee K, Sen A. Step by Step Blood Transfusion
Services. A Practical Manual on the Technical and
Clinical Aspects. New Delhi: Jaypee Brothers and
Medical Publishers (P) Ltd, 2006.
Fig. 36.7: Principle of Venereal Disease Research 2. Kawthalkar SM. Essentials of Haematology. New Delhi:
Laboratory (VDRL) slide test for syphilis Jaypee Brothers Medical Publishers (P) Ltd, 2006.
37
Compatibility Test
(Cross-match)
EMERGENCY CROSS-MATCH
If blood is required urgently, ABO and Rh grouping are
carried out by rapid slide test and immediate spin cross
match (i.e. the first stage of cross match) is performed
(to exclude ABO incompatibility). If the blood unit is
compatible, then after issuing it, remaining stage of the
cross-match is completed. If any incompatibility is
detected, the concerned physician is immediately
informed about the incompatibility detected.
Adverse Effects of
Transfusion
Blood transfusion is a life saving procedure in an the recipient. It results from transfusion of ABO-
appropriate setting and there are no side-effects in mismatched blood to the recipient due most commonly
majority of cases. However, it is a potentially harmful to a clerical error. Most severe reaction occurs if group A
procedure and every recipient of transfusion is at risk of blood is transfused to a group O recipient.
an adverse reaction. It should be prescribed only if there Pathophysiology consists of antigen-antibody
is a definite clinical indication. This is because even with reaction that leads to complement activation and
best possible blood banking standards, transmission of intravascular hemolysis. This causes hypotension, shock,
infections or other complications can occur. acute renal failure, and disseminated intravascular
Adverse effects of transfusion are listed in Table 38.1. coagulation (Fig. 38.1). Signs and symptoms (that appear
Main causes of transfusion-related deaths are: within minutes of starting transfusion) include fever,
• Immediate acute hemolytic transfusion reaction (ABO pain at the infusion site, loin pain, tachycardia,
incompatibility) hemoglobinuria, and hypotension. In anesthetized
• Pulmonary edema and congestive heart failure patients, bleeding and hypotension are the only
(circulatory overload) indications.
• Bacterial contamination of blood unit
• Transfusion of physically damaged red cells (e.g. by
heat, cold)
• Transfusion-associated graft vs. host disease
Laboratory features are: Gram staining and culture of blood from the blood bag
• Hemoglobinemia (pink coloration of plasma after and from the recipient. Direct antiglobuin test is negative.
centrifugation of post-transfusion sample)
• Positive direct antiglobulin test TRANSFUSION-ASSOCIATED LUNG INJURY
• Hemoglobinuria This is an acute respiratory disorder that manifests with
• Schistocytes (fragmented red cells) and spherocytes fever, chills, dyspnea, and dry cough. X-ray shows diffuse
on blood smear pulmonary infiltrates. One probable mechanism is
• Elevated indirect serum bilirubin reaction of anti-HLA or anti-neutrophil antibodies in
donor blood with leukocytes of the recipient leading to
FEBRILE NON-HEMOLYTIC the formation of leukocyte aggregates; these aggregates
TRANSFUSION REACTION deposit in pulmonary vasculature and cause increased
This is the most common transfusion reaction. It occurs vascular permeability and pulmonary edema.
in about 1% of all transfusions and is defined as an
unexplained rise of temperature of atleast 1°C during or DELAYED HEMOLYTIC
shortly after transfusion. It is caused by the release of TRANSFUSION REACTION
pyrogenic cytokines from white cells (during storage of This is a hemolytic transfusion reaction occurring several
blood unit or following transfusion due to reaction of days or weeks after transfusion. This occurs in indi-
alloantibodies with white cells of donor). This reaction viduals who have been sensitized to a red cell antigen
is common in multiply-transfused patients. Signs and by a previous transfusion or pregnancy so that the
symptoms include fever, chills, and tachycardia. antibody is present in a low titer. On re-exposure, there
Diagnosis depends on exclusion of other causes of febrile is a secondary IgG immune response and mainly
transfusion reaction. exravascular hemolysis. This reaction is typically
Transfusion reactions presenting with fever are associated with Kidd antibodies.
shown in Figure 38.2. Signs and symptoms include fever, mild jaundice,
and mild anemia. Laboratory features include raised
BACTERIAL CONTAMINATION OF indirect serum bilirubin, spherocytes on blood smear,
DONOR UNIT anemia, and positive direct antiglobulin test.
Transfusion of an infected blood product is more Acute and delayed hemolytic transfusion reactions
common with platelet concentrates since platelets are are compared in Table 38.2.
stored at a higher temperature (20-24°C) that promotes
multiplication of contaminating bacteria. Organisms ANAPHYLACTIC REACTION
depend on the nature of blood product. Platelets are This rare reaction occurs in IgA-deficient recipients in
usually contaminated with gram-positive cocci, while red whom anti-IgA antibodies react with IgA in donor
cells are contaminated with Yersinia enterocolitica, plasma, leading to activation of complement and
Escherichia coli, or Pseudomonas species. formation of anaphylatoxins (C3a and C5a). Signs and
Signs and symptoms include high grade fever with symptoms include development of acute hypotension,
rigors, hypotension, and shock. Laboratory studies shock, and dyspnoea after transfusion of a few drops of
include inspection of blood bag for discoloration, and blood.
reduce the window period from infection to appea- form gradually in stored blood. Rapid transfusion of large
rance of antibodies from about 22 days to 10 days, volumes of stored blood leads to:
nucleic acid testing (NAT) for HIV RNA is • Dilution of platelets and coagulation factors
recommended. • Hyperkalemia (due to release of potassium from
5. Treponema pallidum: Trasfusion-transmission of stored red cells)
syphilis is rare since T. pallidum does not survive in • Hypocalcemia (due to binding of calcium by citrate)
refrigerated storage and is inactivated at 4°C after 4 • Hypothermia (due to rapid infusion of large amount
days; however, fresh blood and platelet concentrates of cold blood)
can transmit the organism. The main value of • Adult respiratory distress syndrome due to migration
screening test is as a marker of high-risk behavior. of microaggregates to lungs.
6. Malaria parasites: Malaria parasites are readily RECOGNITION AND INVESTIGATION OF A
transmitted by transfusion. In endemic areas, it is not TRANSFUSION REACTION
practical to reject all potential donors with history of
All reactions following blood transfusion should be
malaria in the past. In endemic areas, the only safe
considered as hemolytic in nature and should be
prevention is administration of preventive anti-
investigated accordingly (Fig. 38.3).
malarial drugs to all recipients of transfusion.
1. Transfusion should be immediately stopped, leaving
open intravenous line with normal saline.
COMPLICATIONS ASSOCIATED WITH 2. All paperwork and blood bag should be checked for
MASSIVE TRANSFUSION clerical error. More than 90% of hemolytic trans-
fusions result from a clerical error (i.e. a wrong unit
Massive transfusion refers to transfusion of stored blood of blood is given to the wrong recipient).
equivalent to patient’s blood volume in 24 hours. 3. Blood bank is informed immediately and the blood
Morbidity and mortality is due to rapid blood loss bag, administration set, and post-transfusion blood
coupled with transfusion of stored blood. and urine samples should be sent to the blood bank.
Storage of blood is associated with loss of 2,3- 4. Evidence of hemolysis: Obtain a post-transfusion
diphosphoglycerate, lowering of pH, loss of ATP, loss of blood sample from the recipient, centrifuge, and
platelet function, and depletion of coagulation factors. observe for pink discoloration of overlying plasma
Microaggregates composed of leukocytes and platelets (hemoglobinemia); this is the most rapid way of
Fig. 38.3: Immediate management of a suspected transfusion reaction. All reactions should be assumed to be
hemolytic and investigated accordingly
358 Essentials of Clinical Pathology
Blood Components
A single whole blood donation can be separated into gation due to differences in their specific gravities. After
different components to provide treatment to more than their separation, various components can be
one patient. One unit of whole blood can be broken down transferred from one bag to another in a closed circuit
into one unit of packed red cells, one unit of platelets, thus avoiding exposure to external environment and
and one unit of fresh frozen plasma/cryoprecipitate. This maintaining the sterility. Blood should be processed
practice avoids wastage of collected whole blood (each for component separation within 6 hours of collection
component is stored at a temperature that is optimal for (Figs 39.1 and 39.2).
that component), allows administration of specific 2. Apheresis: This is a procedure in which a suitable donor
replacement therapy, and also avoids transfusion of is connected to an automated cell separator machine
unnecessary blood elements that are not required by the (that is essentially designed as a centrifuge) through
which whole blood is withdrawn, the desired blood
patient.
component is retained, and the remainder of the
Terms used in transfusion therapy are shown in Table
blood is returned back to the donor. Depending on
39.1.
the component that is separated and removed, the
There are two methods for collection of blood for
procedure is called as plateletpheresis, leukapheresis,
preparation of blood components:
or plasmapheresis.
1. Single whole blood donation: Preparation of blood
components has been greatly facilitated by the
WHOLE BLOOD
introduction of double and triple bags having closed
integral tubing. After collection of a unit of whole Whole blood is one unit of donor blood collected in a
blood in the primary bag, blood components can be suitable anticoagulant-preservative solution (citrate
separated from one another by differential centrifu- phosphate dextrose adenine or CPDA-1). Its total volume
Blood product
A therapeutic substance prepared from human blood
Whole blood
One unit of non-separated donor blood collected in an appropriate container containing anticoagulant-preservative
solution
Blood component
A constituent separated from whole blood by differential centrifugation or that is obtained directly from donor by apheresis
Plasma derivative
Human plasma proteins obtained from multiple donor units of plasma under pharmaceutical manufacturing conditions.
These products are heat-treated or chemical-treated to inactivate lipid-enveloped viruses.
Plasma derivatives like factor concentrates and immunoglobulins can also be prepared by recombinant DNA technology
360 Essentials of Clinical Pathology
Fig. 39.1: Blood components are prepared from a unit of whole blood within 6 hours of collection. Initial light centrifugation
separates red cells from platelets and plasma. Heavy centrifugation of platelet-rich plasma separates platelets and plasma
Fig. 39.2: Principle of preparation of blood components from one unit of whole blood
is about 400 ml (350 ml of blood + 49 ml of anticoagulant). F VIII). Transfusion of whole blood should commence
It consists of cellular elements and plasma. Whole blood within 30 minutes of removal from the refrigerator, and
is stored in an approved blood bank refrigerator at should be complete within 4 hours of starting. Trans-
fusion of one unit raises hemoglobin by 1 gm/dl or
4°-6°C. Shelf life of such blood (collected in CPDA hematocrit by 3%.
anticoagulant) is 35 days. It does not contain functionally Indications and contraindications for whole blood
effective platelets and labile coagulation factors (F V and transfusion are given in Table 39.2.
Blood Components 361
Table 39.2: Indications and contraindications for whole Table 39.4: Indications for packed red cell transfusion
blood transfusion
• Anemia: Chronic severe anemia, severe anemia with
Indications congestive cardiac failure, anemia in elderly
• Acute blood loss with hypovolemia • Acute blood loss (transfused along with a crystalloid
• Exchange transfusion in neonates or a colloid solution)
• Non-availability of red cell concentrate or suspension
(PRP). PRP is then transferred to the attached satellite Table 39.6: Indications for fresh frozen plasma
bag and spun (high spin) to get platelets at the bottom • Multiple coagulation factor deficiencies: liver disease,
and supernatant plasma. Most of the supernatant is warfarin overdose, massive blood transfusion
returned back to the primary collection bag or to • Disseminated intravascular coagulation
another satellite bag, leaving behind 50-60 ml of • Inherited deficiency of a coagulation factor for which
plasma with the platelets. no specific replacement therapy is available
Platelets are stored at 20°-24°C with continuous • Thrombotic thrombocytopenic purpura
agitation (in a storage device called platelet agitator).
Maximum period of storage is 5 days. separated from whole blood by centrifugation,
One unit of platelet concentrate contains > 45 × expressed into the attached satellite bag, and rapidly
109 platelets. Transfusion of one unit will raise the frozen at –20°C or at lower temperature. FFP contains
platelet count in the recipient by about 5000/μl. all the coagulation factors.
The usual adult dose is 4-6 units of platelet FFP can be stored for 1 year if temperature is
concentrate (or 1 unit/10 kg of body weight). These maintained below –25°C. When required for transfusion,
units (which are from different donors) are pooled FFP is thawed between 30-37°C and then stored in the
into one bag before transfusion. This dose will raise refrigerator at 2-6°C. Since labile coagulation factors
the platelet count by 20,000 to 40,000/μl. rapidly deteriorate, FFP should be transfused within 2
2. Plateletpheresis (Single donor platelets): In platelet hours of thawing.
pheresis, a donor is connected to a blood cell separator Indications for FFP are shown in Table 39.6.
machine in which whole blood is collected in an 2. Cryoprecipitate: Cryoprecipitate is prepared from
anticoagulant solution, platelets are separated and plasma that has been freshly separated (within 6
retained, and remaining components are returned hours of collection) by rapidly freezing it at -20°C or
back to the donor. With this method, a large number lower and thawing it slowly at 4-6°C. A white
of platelets can be obtained from a single donor flocculent precipitate and plasma are obtained. The
(equivalent to 6 units of platelet concentrate). This mixture is centrifuged and supernatant plasma is
method is especially suitable if HLA-matched removed leaving behind sediment of cryoprecipitate
platelets are required (i.e. if patient has developed suspended in 10-20 ml of plasma. The unit is then
refractoriness to platelet transfusion due to the refrozen (-20°C or colder) and can be stored at this
formation of alloantibodies against HLA antigens). temperature for 1 year. When needed, cryoprecipitate
The usual indications and contraindications for is thawed at 30-37°C, required donations are pooled
administering platelets are shown in Table 39.5. and transfused to the patient. Cryoprecipitate
contains F VIII, von Willebrand factor, fibrinogen, F
PLASMA COMPONENTS
XIII, and fibronectin. Indications for cryoprecipitate
The main plasma components are fresh frozen plasma are F VIII deficiency (if F VIII concentrate is not
and cryoprecipitate. available), von Willebrand disease, and deficiency of
1. Fresh frozen plasma (FFP): FFP is prepared from fibrinogen.
whole blood within 6 hours of collection because after
this time labile coagulation factors are lost. Plasma is
PLASMA DERIVATIVES
Table 39.5: Indications and contraindications to Plasma derivatives are manufactured by fractionation of
platelet transfusions large volumes of pooled human plasma. Important
Indications plasma derivatives are listed in Table 39.7.
• Bleeding due to decreased platelet production 1. Human albumin solutions: Albumin is prepared by
• Bleeding in hereditary disorders of platelet function cold ethanol fractionation of pooled plasma and is
• Massive blood transfusion
sterilized during manufacture to destroy viruses and
Contraindications bacteria. Albumin is used as a replacement fluid in
• Thrombotic thrombocytopenic purpura therapeutic plasma exchange, and for treatment of
• Hemolytic uremic syndrome
diuretic-resistant edema of hypoproteinemia.
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Blood Components 363
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General References
1. Cheesbrough M. District laboratory practice in tropical countries. Part 1 and Part 2. Cambridge. Cambridge University
Press, 1998.
2. Crook MA. Clinical chemistry and metabolic medicine (7th Ed). London: Edward Arnold (Publishers) Ltd, 2006.
3. Wallach J. Interpretation of diagnostic tests (7th Ed). Philadelphia: Lippincott Williams and Wilkins, 2000.
4. Mitchell RN, Kumar V, Abbas AK, Fausto N. Robbins and Cotran pathologic basis of disease (7th Ed). Philadelphia:
Saunders, 2006.
5. Henry JB. Clinical diagnosis and management by laboratory methods (20th Ed). Philadelphia: WB Saunders Company,
2001.
6. Burtis CA, Ashwood ER. Tietz fundamentals of clinical chemistry (5th Ed). Philadelphia: WB Saunders Company,. 2001.
7. World Health Organization. Manual of basic techniques for a health laboratory (2nd Ed). Geneva: World Health
Organization, 2003.
8. Provan D, Krentz A. Oxford Handbook of Clinical and Laboratory Investigation. Oxford. Oxford University Press, 2002.
9. Lewis SM, Bain BJ, Bates I. Dacie and Lewis Practical Haematology (9th Ed). London: Churchill Livingstone, 2001.
10. Provan D, Singer CRJ, Baglin T, Lilleyman J. Oxford Handbook of Clinical Haematology (2nd Ed). Oxford: Oxford
University Press, 2004.
11. King M. A medical laboratory for developing countries. London: Oxford University Press, 1973.
12. Kawthalkar SM. Essentials of Haematology. New Delhi: Jaypee Brothers Medical Publishers (P) Ltd, 2006.
13. Gaw A, Murphy MJ, Cowan RA, O’Reilly DSJ, Stewart MJ, Shepherd J. Clinical biochemistry. An illustrated colour test.
3rd Ed. Edinburgh: Churchill Livingstone, 2004.
14. Hoffbrand AV, Pettit JE, Moss PAH. Essential Haematology (4th Ed). Oxford. Blackwell Science Ltd, 2001.
15. Chatterjee K, Sen A. Step by step blood transfusion services. A practical manual on the technical and clinical aspects.
New Delhi: Jaypee Brothers and Medical Publishers (P) Ltd, 2006.
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Index
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Index 369
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370 Essentials of Clinical Pathology
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Index 371
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372 Essentials of Clinical Pathology
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Index 373
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374 Essentials of Clinical Pathology
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Index 375
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376 Essentials of Clinical Pathology
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