Professional Documents
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Staphylococcus Gram-stain: gram-positive cocci arranged in Bound coagulase (clumping factor): positive
aureus clusters Free coagulase: positive
Medium to large, raised colonies on blood agar MSA: growth and fermentation
and CNA with cream to golden yellow DNAse: positive
pigmentation Thermostable nuclease: positive
Beta haemolytic or nonhemolytic on sheep
blood agar
Staphylococcus Gram-positive cocci in clusters To differentiate from S. aureus: S. epidermidis
epidermidis White, creamy, raised growth on blood agar is coagulase negative, DNase negative and
Nonhemolytic on blood agar cannot ferment mannitol.
Growth, but lack of fermentation on MSA To differentiate from S. saprophyticus: S.
Coagulase negative epidermidis is susceptibe to novobiocin; S.
DNase negative saprophyticus is resistant to novobiocin.
Susceptible to novobiocin
2. Streptococci
Streptococcus species Gram-positive cocci occurring in pairs or Some species show enhanced growth
chains under increased CO2
Nonmotile Requires supportive or enriched media
Non-sporeforming such as blood agar
Facultative anaerobes Susceptible to vancomycin
Catalase negative
3. In the CAMP reaction, an arrowhead zone of hemolysis forms when group B Streptococus ( S. agalactiae) is streaked
perpendicularly to a beta-hemolytic strain of S. aureus. The CAMP factor is an extracellular, thermostable antigenic
protein produced by group B Streptococcus.
4. Occasionally, nonbeta-hemolytic strains of S. agalactiae may be encountered, but identification of such isolates can
be accomplished using the serologic agglutination approach. (Bailey and Scott’s)
5. Neisseria
Neisseria Gram-negative diplococcic resembling tiny N. gonorrhoeae requires CAP and N.
species coffee beans or kidney beans except N. meningitidis and M. catarrhalis require BAP
elongate that is rod-shaped as the minimal growth standard. The
Obligate aerobes pathogenic Neisseria grow optimally between
Capnophilic 35o and 37oC.
Cytochrome oxidase positive The Neisseria organisms establish disease
through attachment to mucous membranes of
the host through pili. Pili also participate in
conjugation and transfer of genetic material.
6. Enterobacteriaceae
TSI Reactions
TSI Reactions Typical Organisms
A/AG H2S – Glucose with acid and gas Escherichia
Lactose and/or sucrose with acid and Klebsiella
gas Enterobacter
K/AG H2S + Glucose with acid and gas Salmonella
Lactose or sucrose not fermented Proteus
Citrobacter
K/A H2S – Glucose with acid; no gas Shigella
Lactose or sucrose not fermented Providencia
Serratia
Anaerogenic Escherichia coli
K/K H2S – Glucose not fermented Pseudomonas
Lactose or sucrose not fermented Alcaligenes
Differentiation of Proteeae
Reaction P. vulgaris P. mirabilis M. morganii Prov. rettgeri Prov. stuartii
TSI K/AG K/AG K/AG K/A K/A
H2S + + - - -
Gas + + + - -
MR + + + + +
VP - V - - -
Indole + - + + +
Citrate - V - + +
Deaminase + + + + +
(phenylalanine)
Urease + + + + -*
Motility swarms/+ swarms/+ + + +
LDC - - - - -
ADH - - - - -
ODC - + + - -
*Most strains negative
7. Salmonella are positive for lysine decarboxylase and most are negative for KCN. Citrobacter are negative for lysine
decarboxylase and positive for growth in KCN. (BOR)
8. Citrobacter organisms resemble Salmonella but are ONPG positive and LDC negative. (Delost)
9. Morganella is indole positive, VP and citrate negative. PDA and TDA positive. (Ciulla)
10. Providencia species are PDA, TDA, indole and citrate positive and VP negative. (Ciulla)
11. MUG test: Escherichia coli produces the enzyme beta-D-glucuronidase which hydrolyzes beta-D-
glucopyranosid-uronic derivatives to aglycons and D-glucuronic acid. the substrate 4-methylumbelliferyl-
beta-D-glucuronide is impregnated in the disk ang is hydrolyzed by the enzyme to yield the 4-
methylumbelliferyl moiety, which fluoresces blue under long wavelength ultraviolet light.
EXPECTED RESULTS QUALITY CONTROL
Positive Electric blue fluorescence Positive : E. coli
Negative Lack of fluorescence Negative: P. aeruginosa
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13. A mucoid strain of Pseudomonas aeruginosa has been found to cause severe pneumonia in patients with cystic
fibrosis. Patients with cystic fibrosis activate the alginate gene resulting in the production of alginate, which surrounds
the bacterial cell wall and protects it from phagocytosis. (Delost)
14. Burkholderia cepacia causes nosocomial infections and is also an important respiratory tract pathogen in patients
with cystic fibrosis; second most common cause to P. aeruginosa. (Ciulla)
16. Among the vibrios, Vibrio vulnificus causes the most severe disease. Wound infections and septicemia with this
organism are often fatal. Disease is usually associated with consumption of raw oysters or oyster-related injury.
(Henry)
17. HACEK bacteria: Five small gram-negative coccobacilli are part of the normal oral flora and are associated
occasionally with bacterial endocarditis and rarely with other infections. They are opportunists that enter the
bloodstream, settle on damaged heart valves, and cause a relatively slowly progressive, indolent form of endocarditis.
They typically require an additional 1–2 days before they are isolated from blood cultures, and they are uniformly
susceptible to many antimicrobial agents. The word HACEK is an acronym for the bacteria responsible for this
disease: Haemophilus spp. (influenzae, parainfluenzae), Aggregatibacter (Haemophilus) aphrophilus (most
commonly, Aggregatibacter [Actinobacillus] actinomycetemcomitans), Cardiobacterium hominis, Eikenella corrodens,
and Kingella spp. Some taxonomic changes have been noted more recently, and some of the HACEK members have
been reassigned to the genus Aggregatibacter. (Henry)
MacConkey sorbitol A modification of MacConkey agar in which lactose has For the selection and
agar been replaced with d-sorbitol as the primary carbohydrate differentiation of E. coli O157:H7
in stool specimens
Mannitol salt agar Peptone base, mannitol, and phenol red indicator. Salt Selective isolation of
concentration of 7.5% inhibits most bacteria staphylococci
New York City (NVC) Peptone agar base with cornstarch, supplemented with Selective for N.gonorrhoeae
agar yeast dialysate, 3% hemoglobin, and horse plasma.
Antibiotic supplement includes vancomycin (2µg/mL),
colistin (5.5µg/mL), amphotericin B (1.2 µg/mL), and
trimethoprim (3 µg/mL)
Phenylethyl alcohol Nutrient agar base. Phenylethanol inhibits growth of gram- Selective isolation of gram-
(PEA) agar negative organisms positive cocci and anaerobic
gram-negative bacilli
Regan Lowe Charcoal agar supplemented with horse blood, cephalexin, Enrichment and selective
and amphotericin B medium for isolation of B.
pertussis
Salmonella-Shigella Peptone base with lactose, ferric citrate, and sodium citrate. Selective for Salmonella and
(SS) agar Neutral red as indicator; inhibition of coliforms by brilliant Shigella spp.
green and bile salts
Schaedler agar Peptone and soy protein base agar with yeast extract, Nonselective medium for the
dextrose, and buffers. Addition of hemin, l-cystine, and 5% recovery of anaerobes and
blood enriches for anerobes aerobes
Selenite broth Peptone base broth. Sodium selenite toxic for most Enrichment of isolation of
Enterobacteriaceae Salmonella spp.
Skirrow agar Peptone and soy protein base agar with lysed horse blood. Selective for Campylobacter spp.
Vancomycin inhibits gram-positive organisms; polymyxin B
and trimethoprim inhibit most gram-negative organisms
Streptococcal Contains crystal violet, colistin, and trimethoprim Selective for S. pyogenes and S.
selective agar (SSA) sulfamethoxazole in 5% sheep blood agar base agalactiae
Tetrathionate broth Peptone base broth. Bile salts and sodium thiosulfate inhibit Selective for Salmonella and
gram-positive organisms and Enterobacteriaceae Shigella spp.
Thayer-Martin agar Blood agar base enriched with hemoglobin and supplement Selective for N. gonorrhoeae and
b; contaminating organisms are inhibited by colistin, N. meningitides
nystatin, vancomycin and trimethorprim
Thioglycollate broth Pancreatic digest of casein, soy broth, glucose enrich Supports growth of anaerobes,
growth of most microorganisms aerobes, microaerophilic and
fastidious microorganisms
Thiosulfate citrate- Peptone base agar with yeast extract, bile salts, citrate, Selective and differential for
bile salt sucrose sucrose, ferric citrate, and sodium thiosulfate. Bromthymol Vibrio spp.
(TCBS) agar blue acts as indicator
Todd-Hewitt broth An enrichment broth for streptococci, supplemented with Selective and enrichment for S.
supplemented with nalidixic acid and gentamicin or colistin for greater agalactiae in female genital
antibiotics selectivity thioglycollate and agar reduce redox potential specimens
Trypticase soy broth All-purpose enrichment broth that can support the growth of Enrichment broth used for
many fastidious and nonfastidious bacteria subculturing various bacteria
from primary agar plates
Xylose lysine Yeast extract agar with lysine, xylose, lactose, sucrose, and Isolation and differentiation of
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Cell Wall Synthesis Protein Synthesis Nuclei Acid Synthesis Cell Membrane Function
Beta-lactams: penicillins, Aminoglycosides: Sulfonamides Polymyxins: colistin
cephalosporins, gentamicin, tobramycin, Trimethoprim
carbapenems, kanamycin Quinolones
monobactams Tetracyclines Rifampicin
Glycopeptides: Chloramphenicol
vancomycin, teicoplanin Erythromycin
Cycloserine Fusidic acid
Bacitracin
20. C. TRACHOMATIS: Cell culture is the reference method for diagnosis of chlamydial infections and should be
performed when the diagnosis is disputed and in cases of suspected sexual assault or abuse. Cell lines most
commonly used are McCoy or buffalo green monkey cells. (Henry)
21. Direct Fluorescent Antibody Tests. The DFA test allows direct visualization of C. trachomatis elementary
bodies in smears of clinical specimens. (Henry)
22. Enzyme immunoassays: EIAs detect chlamydial LPS with monoclonal or polyclonal antibodies labeled with an
enzyme that converts a colorless substrate into a colored product. (Henry)
23. Nucleic Acid Hybridization Tests. A commercially available acridinium-ester–labeled DNA probe
complementary to C. trachomatis ribosomal RNA allows direct detection of C. trachomatis in urogenital and
conjunctival specimens. (Henry)
24. Nucleic Acid Amplification. Several nucleic acid amplification tests for direct detection of C. trachomatis in
endocervical swab specimens, male urethral swab specimens, and male and female urine samples are commercially
available. (Henry)
25. The “gold standard” serologic test for rickettsioses is the indirect immunofluorescent antibody (IFA) assay (Kaplan,
1986). The indirect immunoperoxidase antibody test yields similar results. For spotted fever and typhus-group
rickettsial infections in the United States, IFA titers of 1 : 64 or greater are considered to be diagnostic in a compatible
clinicoepidemiologic situation. (Henry)
26. Confirmation with a more specific method, such as microimmunofluorescence, is necessary to detect serum
antibodies to rickettsia. In this procedure, antigenic dots for rickettsial diseases are fixed on a microscope slide, and
the patient’s serum is added. A fluorescein-conjugated antihuman globulin is added, which binds to the antigen-
antibody complex in a positive reaction. (Delost)
27. Zygomycetes
Coarse, woolly, fluffy, white to gray to brown mycelium with black or brown sporangium. Hyphae grow within 1 - 3
days and rapidly cover agar surface.
Rhizopus Absidia Mucor
Large, broad, nonseptate hyphae that Similar to Rhizopus; however, No rhizoids.
produce horizontal runners, or stolons, sporangiophores arise between nodes
which attach at rhizoids. from which rhizoids are formed.
Sporangiophores arise in clusters at
rhizoids and terminate sporangia.
28. Morphologically, Geotrichum candidum, exhibits round, oval or rectangular yeast cells that are paired or in chains.
Fragmented hyphae with rectangular arthroconidia with rounded ends when grown on cornmeal agar.
29. Alternaria
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30. The greatest hazard for laboratory personnel comes from handling mould cultures of the dimorphic
pathogens, Coccidioides spp. and H. capsulatum. These isolates are classified as risk group 3 pathogens,
requiring biosafety level 3 practices and facilities for propagating and manipulating cultures, as well as for processing
soil or other environmental materials known or likely to contain infectious conidia from these agents. (Henry)
32. Rubella (German measles) is highly communicable and produces mild fever and a transient rash in children and
adults. All infections are viremic, and transplacental spread during the first trimester produces devastating
teratogenic cardiac, ocular, and brain malformations. Routine prenatal screening for maternal rubella IgG as proof of
immunity is standard practice. When acute rubella is suspected in a pregnant woman, the most straightforward
diagnostic method is assay of maternal serum for rubella IgM by EIA or IFA. Culture of rubella is technically complex
and is not routinely available. The congenitally infected newborn is IgM positive and excretes rubella in urine for
months to years. (Henry)
33. ROTAVIRUS
EIA is used to detect rotavirus antibody and for serotyping
EIA and latex agglutination can be used for detection of group A rotavirus antigen in fecal samples
RT-PCR can detect rotavirus RNA
34. Acanthamoeba keratitis is an increasingly recognized painful infection of the cornea that is most likely to occur in
persons who use daily-wear or extended-wear soft contact lenses or who have experienced trauma to the cornea.
Incomplete or infrequent disinfection and use of homemade saline and multipurpose solutions are known risk factors
for acquiring the infection. (Henry)
Stages in All stages are present All stages are present Ring forms and All stages are present
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36. DNA stores human genetic information and dictates the amino acid sequence of peptides and proteins. The purine
bases (adenine and guanine) and the pyrimidine bases (cytosine and thymine). Adenine pairs with thymine with two
hydrogen bonds and cytosine pairs with guanine with three hydrogen bonds. The strands are complementary due to
the fixed manner by which the base pairs bond.
37. PCR is a simple in vitro chemical reaction that permits the synthesis of essentially limitless quantities of a targeted
nucleic acid sequence. This is accomplished through the action of a deoxyribonucleic acid (DNA) polymerase that,
under the right conditions, can copy a strand of DNA. At its simplest, a PCR consists of target DNA, a molar excess of
two oligonucleotide primers, a heat-stable DNA polymerase, an equimolar mixture of deoxyribonucleotide
triphosphates (dATP, dCTP, dGTP, and dTTP), MgCl2, KCl, and a Tris-HCl buffer. The two primers flank the
sequence to be amplified, are typically 18–30 bases long, and are complementary to opposite strands of the target.
To initiate a PCR, the reaction mixture is heated to separate the two strands of target DNA (denaturation) and then
cooled to permit the primers to anneal to the target DNA in a sequence-specific manner (annealing). The DNA
polymerase then initiates extension of each primer at its 3′ end (extension). The primer extension products are
dissociated from the target DNA by heating. Each extension product, as well as the original target, can serve as a
template for subsequent rounds of primer annealing and extension.
A PCR cycle consists of three steps: denaturation, annealing, and extension. At the end of each cycle, the
PCR products are theoretically doubled.
38. PCR is a licensed technology, and other methods of nucleic acid amplification have since been developed. In
branched DNA (bDNA) signal amplification, the target DNA is denatured and added to a well containing immobilized
probes. One end of each probe hybridizes with the target DNA, capturing it, and the other contains multiple branches
that hybridizes with the target DNA, capturing it, and the other contains multiple branches that hybridize with alkaline
phosphatase-labeled probes. After washing to remove the unbound labelled probes, dioxetane is added, and
chemiluminescence is measured. A thermocycler is not used and the target DNA is not amplified. Other nucleic acid
amplification methods include nucleic acid sequence-based amplification (NASBA), transcription-mediated
amplification (TMA), hybrid capture, and rolling circe; amplification (RCA). HARR: the target DNA is bound by
multiple probes, and those are amplified instead of the target DNA.
39. No genomic or plasmid DNA, RNA, or patient specimens should be introduced into the dead air box where reagent
preparation takes place. This dead air box should be furnished with an ultraviolet (UV) light connected to a timer. The
surface areas of the dead air boxes should be treated with UV light, then wiped with freshly made 10% sodium
hypochlorite solution and finally with 75% ethanol solution before and after working in this area. (Henry)
CLINICAL CHEMISTRY
40. WAVELENGTH SELECTORS: A critical component of all spectrometers is the device used to select the appropriate
wavelength. Several types of wavelength selectors are available, including filters, prisms, grating monochromators,
and, recently, holographic gratings. (Henry)
41. Monochromator disperses the light into wavelengths. Glass filters and interference filters are used in photometers.
Diffraction gratings and prisms are used in spectrophotometers. (Ciulla)
42. Fluoresecence is a process where atoms absorb energy at a particular wavelength (excitation), electrons are raised
to higher-energy orbitals, and the electrons release energy as they return to ground state by emitting light energy if a
longer wavelength and lower energy than the exciting wavelength. (Ciulla)
44. Malloy and Evelyn developed the first clinically useful methodology for the quantitation of bilirubin in serum samples
using the classic diazo reaction with a 50% methanol solution as an accelerator. The Jendrassik and Grof described a
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method using the diazo reaction with caffeine-benzoate-acetate as an accelerator. Today, all commonly used
methods for measuring bilirubin and its fractions are modifications of the technique described by Malloy and Evelyn.
Total bilirubin and conjugated bilirubin are measured and unconjugated bilirubin is determined by subtracting
conjugated bilirubin from total bilirubin. (Bishop)
46. Glycosylated hemoglobin assays vary in reliability in the presence of a variety of factors. Interference by carbamylated
hemoglobin can occur with uremia, hypertriglyceridemia, and hyperbilirubinemia, and salicylates can cause
interference by acetylated species. Hemoglobinopathies (HbSS, HbSC, HbCC) associated with high red blood cell
turnover and the need for transfusions will adversely affect accuracy, as will chronic alcohol or opiate use, iron
deficiency, and lead poisoning. Vitamins C and E can falsely lower levels by inhibiting glycosylation, but vitamin C can
also increase levels for some assays. Sample storage effects may occur. Any condition associated with
shortened red blood cell survival or lower mean red blood cell age, such as hemolysis, recovery from acute
blood loss, transfusions, or splenectomy, will lower the HbA1c level as the result of reduced exposure to
plasma glucose. Hyperglycemia has been associated with a decrease in erythrocyte survival, suggesting that HbA1c
levels in poorly controlled patients may underestimate their mean plasma glucose concentration. (Henry)
47. Several analytic approaches have been used to assay for urea. Enzymatic methods are used most frequently in
clinical laboratories. The enzyme urease (urea amidohydrolase) hydrolyzes urea in the sample and the ammonium ion
(NH4+) produced in the reaction is quantified.The most common method couples the urease reaction with glutamate
dehydrogenase (GLDH) and the rate of disappearance of nicotinamide adenine dinucleotide (reduced, NADH) at 340
nm is measured. (Bishop)
48. Total Iron Content (Serum Iron). Measurement of serum iron concentration refers specifically to the Fe +3 bound to
transferrin and not to the iron circulating as free hemoglobin in serum. Spectrophotometric determinations have been
adapted to automated analysis. These procedures generally have the following steps: Fe +3 is released from binding
proteins by acidification, reduced to Fe_2 by ascorbate or a similar reducing agent, and complexed with a color
reagent such as ferrozine, ferene, or bathophenanthroline. (Bishop)
49. Serum (Total) Iron-Binding Capacity. The reference interval for adults is 250–400 μg/dL (45–72 μmol/L). In iron
deficiency anemia, the serum TIBC is increased. It is normal or decreased in the anemia of chronic disease. (Henry)
51. CRYOGLOBULINEMIA: Cryoglobulins are Igs that reversibly precipitate at cold temperature. Three categories
of cryoglobulins exist. Type I cryoglobulin consists of a single monoclonal protein and is usually seen in multiple
myeloma, Waldenström’s macroglobulinemia, or other lymphoproliferative disorders. Usually, the immunoglobulin is
IgG or IgM. Type II cryoglobulin consists of a mixture of polyclonal immunoglobulins with a monoclonal protein,
usually IgM, directed toward polyclonal IgG. Type II cryoglobulinemia is associated with chronic hepatitis C infection,
autoimmune disorders, and IgM-producing malignancies. Finally, Type III cryoglobulin consists of polyclonal
immunoglobulins, usually IgM, that have activity toward polyclonal IgG. They are associated with autoimmune
conditions, as well as infections. Cryoglobulins produce symptoms by precipitating in areas of low temperature, such
as the skin or extremities, resulting in vascular occlusion. This produces a wide variety of symptoms, including
acrocyanosis, Raynaud’s phenomenon, skin ulcers, skin purpura, and glomerulonephritis (Henry)
52. The role of magnesium in the body is widespread. It is an essential cofactor of more than 300 enzymes, including
those important in glycolysis, transcellular ion transport, neuromuscular transmission, synthesis of carbohydrates,
proteins, lipids, and nucleic acids, and release of and response to certain hormones. (Bishop)
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53. The main biochemical role of zinc is its influence on the activity of more than 300 enzymes (from the classes of
oxidoreductases, transferases, hydrolases, lyases, isomerases, and ligases). (Bishop)
58. Methods used for measurement of CK isoenzymes include electrophoresis; ion-exchange chromatography and
several immunoassays, including radioimmunoassay (RIA) and immunoinhibition methods. Although mass methods
are more sensitive and preferred for quantitation of CK-MB, electrophoresis has been the reference method. (Bishop)
59. Immunoassays detect CK-MB reliably with minimal cross-reactivity. Immunoassays measure the concentration of
enzyme protein rather than enzymatic activity and can, therefore, detect enzymatically inactive CK-MB. This leads to
the possibility of permitting detection of infarction earlier than other methods. A double-antibody immunoinhibition
assay is also available. This technique allows differentiation of MB activity due to adenylate kinase and the atypical
isoenzymes, resulting in a more specific analytic procedure for CK-MB. Point-of-care assay systems for CM-MB are
available but not as widely used as those for troponins. (Bishop)
60. In the immunoinhibition technique for CKMB determination, antibodies are directed against the M and B units of the
enzymes. Anti-M inhibits all M activity but not B activity. CK activity is measured before and after inhibition. The
activity remaining after inhibition is a result of the B subunit for BB and MB activity. (BOR)
61. Cardiac troponin T or cardiac troponin I is used as an acute myocardial infarction indicator because of specificity and
early rise in serum concentration following AMI. In cases of AMI, cTnT increases 3 to 4 hours following infarction,
peaks in 10 to 24 hours, and returns to normal in 10 to 14 days. cTnI increases in 3 to 6 hours following infarctions,
peaks in 14 to 20 hours, and returns to normal in 5 to 10 days. (Ciulla)
62. Laboratory diagnosis of acute pancreatitis includes elevation of serum and urine amylase and serum lipase. Serum
AMS levels generally become elevated within 2 hours to 12 hours of an attack, reach peak levels at 24 hours, and
return to normal within 3 to 5 days. Serum LPS peak levels occur at 12 to 24 hours, and levels remain elevated longer
than AMS.
63. Routine measurement of electrolytes usually involves only Na+, K+, Cl-, and HCO3- (as total CO2). These values may
be used to approximate the anion gap (AG), which is the difference between unmeasured anions and unmeasured
cations. (Bishop)
There are two commonly used methods for calculating the anion gap.
The first equation is
AG = Na+ - (Cl- + HCO3-)
The reference range for the AG using this calculation is 7–16 mmol/L.
An elevated anion gap may be caused by uremia/renal failure, which leads to PO 4- and SO42- retention; ketoacidosis,
as seen in cases of starvation or diabetes; methanol, ethanol, ethylene glycol poisoning, or salicylate; lactic acidosis;
hypernatremia; and instrument error. Low anion gap values are rare but may be seen with hypoalbuminemia
(decrease in unmeasured anions) or severe hypercalcemia (increase in unmeasured cations). (Bishop)
64. All sodium ions must be neutralized by counter-ions, most of which, in blood, are constituted by chloride and
bicarbonate ions, and, to a lesser degree, by phosphate, sulfate, and protein carboxylate groups. Normal serum
sodium is about 140 mEq/L, chloride is usually around 100 mEq/L, and bicarbonate around 2 mEq/L. The anion gap
is then defined as Na+ − (Cl− + HCO3−), which for normal individuals is around 16. This 16 mEq/L really accounts
for the other counter-ions that neutralize sodium but are not measured in serum.
65. DETERMINATION OF LACTATE: Special care should be practiced when collecting and handling specimens for
lactate analysis. Ideally, a tourniquet should be not be used because venous stasis will increase lactate levels. If a
tourniquet is used, blood should be collected immediately and the patient should not exercise the hand before or
during collection.14 After sample collection, glucose is converted to lactose by way of anaerobic glycolysis and should
be prevented. Heparinized blood may be used but must be delivered on ice and the plasma must be quickly
separated. Iodoacetate or fluoride, which inhibit glycolysis without affecting coagulation, are usually satisfactory
additives, but the specific method directions must be consulted. (Bishop)
pH increased pH normal
71. PROCAINAMIDE: Like quinidine, procainamide is used to treat cardiac arrhythmia. Oral administration is the most
common. Gastrointestinal absorption is rapid and complete. Peak plasma concentrations occur at about 1 hour.
Absorbed procainamide is about 20% bound to plasma proteins. It is eliminated by a combination of renal filtration
and hepatic metabolism. N-Acetyl procainamide (NAPA) is a hepatic metabolite of the parent drug, with
antiarrhythmic activity similar to procainamide. The total antiarrhythmic potential of this drug must take into
consideration the parent drug and this metabolite. Alteration in either renal or hepatic function may lead to increased
serum concentration of the parent drug and its metabolites. Increased concentration results in myocardial
depression and arrhythmia. Both procainamide and its active metabolite can be measured by immunoassay.
(Bishop)
72. Cocaine’s short half-life is a result of rapid hepatic hydrolysis to inactive metabolites. This is the major route of
elimination. Only a small portion of the parent drug can be found in urine after an administered dose. The primary
product of hepatic metabolism is benzoylecgonine, which is primarily eliminated in urine. The half-life of
benzoylecgonine is 4–7 hours. The presence of this metabolite in urine is a sensitive and specific indicator of
cocaine use. It can be detected in urine for up to 3 days after a single use. In chronic heavy abusers, it can be
P a g e | 17
detected in urine for up to 20 days after the last dose. The primary screening procedure for identification of cocaine
use is detection of benzoylecgonine in urine by immunoassay.
Confirmation testing is done by GC/MS. (Bishop)
73. Serum HER2/neu is used as marker of prognosis and monitoring therapy for breast cancer. HER2/neu is
cancerspecific but not tissue-specific and is found to be increased in breast cancers, as well as lung and other
epithelial cell tumors. (Henry)
HEMATOLOGY
75. Red blood cells that resist lysis, such as sickle cells, can produce falsely elevated WBC counts and falsely increase
the number of lymphocytes. (Steininger)
76. The electrophoretic mobility of hemoglobin D is the same as hemoglobin S, although red blood cells containing
hemoglobin D show no sickling at a reduced oxygen concentration. (Brown)
78. Spherocytic red blood cells are almost spherical in shape. They are not biconcave like a normal red blood cells
and do not have the central area of pallor which a normal red cell shows. These cells are associated with hemolytic
anemia, ABO haemolytic disease of the newborn, and hereditary spherocytosis. (Brown)
79. Stomatocytes show a slit-like area of central pallor. These red blood cells have lost the indentation on one side and
may be found un liver disease, alcoholism, electrolyte imbalance, and hereditary stomatocytosis. (Brown)
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80. Teardrop red blood cells or dacrocytes are found most notably in myelofibrosis, pernicious anemia, myeloid
metaplasia, thalassemia and some hemolytic anemias.
84. An alpha thalassemia of varying severity results from reduced of absent alpha chain synthesis affecting the two
pairs of alpha globin genes (one pair in each chromosome. As the capacity to produce α chains decreases, this
results in an accumulation of excess γ chains in fetal life to form hemoglobin Bart’s (γ4) and an excess of β chains to
form hemoglobin H (β4) later on. (Brown)
85. The presence of Heinz bodies in freshly drawn blood indicates that (1) an oxidizing drug or chemical (e.g.,
phenylhydrazine, chlorate, naphthalene, dapsone) has been ingested in sufficient amount to overwhelm the normal
protective mechanisms of the red cell and denature Hb; (2) a drug such as primaquine has been ingested by an
individual with G6PD deficiency (or another defect resulting in a deficiency of reduced glutathione), so that Hb is not
protected from oxidative denaturation; or (3) the subject has an unstable Hb. (Henry)
86. Acquired or pseudo-Pelger-Huet anomaly is most often seen in chronic myelogenous leukemia and myeloid
metaplasia but may also be seen in patients receiving chemotherapy. Most of these pseudo-Pelger-Huet cells have
a round, centrally located nucleus. The acquired form can also be differentiated from the inherited form by the
presence of more than 10% of normal three lobed neutrophils. (Brown)
88. Leukocyte alkaline phosphatase: Segmented neutrophils, neutrophil bands, neutrophil metamyelocytes, as well
as myelocytes may show ALP activity. Only segmented neutrphils are counted. Eosinophils do not stain and must
be recognized by their nuclear structure and by the presence of refractile droplets (cytoplasmic granules) so they
are not included in the count and mistakenly scored as 0. (Steininger)
89. In essential thrombocythemia, the most striking feature is the marked increase in platelets (≥450 × 109/L; usually
>1000 × 109/L), often with abnormal and giant forms, and usually accompanied by fragments of megakaryocytes.
Platelet function defects in thrombocythemia are frequently demonstrable. (Henry)
CLINICAL MICROSCOPY
91. The pH of freshly excreted urine does not reach 9 in normal or abnormal conditions. A pH of 9 is associated with an
improperly preserved specimen and indicates that a fresh specimen should be obtained to ensure the validity of the
analysis. (Strasinger)
92. Urine specimens containing porphyrins also may appear red resulting from the oxidation of porphobilinogen to
porphyrins. They are often referred to as having the color of port wine. (Strasinger)
93. COMPARISON OF GLUCOSE OXIDASE AND CLINITEST: There are several explanations for the finding of
conflicting results between the two glucose tests. As stated, the Clinitest is not as sensitive as the glucose oxidase
test, so the finding of a 1+ reagent strip reading and a negative Clinitest should not be surprising. A strongly positive
reagent strip and a negative Clinitest, however, should cause concern about possible contamination by strong
oxidizing agents. The most significant discrepancy is the negative reagent strip with a positive Clinitest. Although
interfering substances affecting either test may cause this problem, the most frequent cause is the presence of
other reducing sugars in the urine. (Strasinger)
94. Glycosuria occurs in the absence of hyperglycemia when the reabsorption of glucose by the renal tubules is
compromised. This is frequently referred to as “renal glycosuria” and is seen in end-stage renal disease, cystinosis,
and Fanconi syndrome. (Strasinger)
95. When RBCs are present, the urine is red and cloudy; however, if hemoglobin or myoglobin is present, the
specimen is red and clear. (Strasinger)
96. Hemoglobinuria may result from the lysis of red blood cells produced in the urinary tract, particularly in dilute, alkaline
urine. It also may result from intravascular hemolysis and the subsequent filtering of hemoglobin through the
glomerulus. Lysis of red blood cells in the urine usually shows a mixture of hemoglobinuria and hematuria, whereas
no red blood cells are seen in cases of intravascular hemolysis. Under normal conditions, the formation of large
hemoglobin-haptoglobin complexes in the circulation prevents the glomerular filtration of hemoglobin. When the
amount of free hemoglobin present exceeds the haptoglobin content—as occurs in hemolytic anemias, transfusion
reactions, severe burns, brown recluse spider bites, infections, and strenuous exercise—hemoglobin is available for
glomerular filtration. Reabsorption of filtered hemoglobin also results in the appearance of large yellow-brown
granules of denatured ferritin called hemosiderin in the renal tubular epithelial cells and in the urine sediment.
(Strasinger)
97. MYOGLOBINURIA: The presence of myoglobin rather than hemoglobin should be suspected in patients with
conditions associated with muscle destruction (rhabdomyolysis). Examples of these conditions include trauma,
crush syndromes, prolonged coma, convulsions, muscle-wasting diseases, alcoholism, heroin abuse, and extensive
exertion. The development of rhabdomylosis has been found to be a side effect in certain patients taking the
cholesterol-lowering statin medications. (Strasinger)
98. URINE BILIRUBIN: Questionable results can be repeated using the Ictotest. The Ictotest is less subject to
interference and is sensitive to 0.05 to 0.10 mg/dL of bilirubin, whereas the reagent strips have a lower sensitivity
level of 0.40 mg/dL. Because of its higher sensitivity, an Ictotest may be requested to detect early stages of liver
disease. (Strasinger)
99. Nephrotic syndrome is marked by massive proteinuria (greater than 3.5 g/d), low levels of serum albumin, high
levels of serum lipids, and pronounced edema. Urinalysis observations include marked proteinuria; urinary fat
droplets; oval fat bodies; renal tubular epithelial (RTE) cells; epithelial, fatty, and waxy casts; and microscopic
hematuria. Absorption of the lipid-containing proteins by the RTE cells followed by cellular sloughing produces the
characteristic oval fat bodies seen in the sediment examination. (Strasinger)
100. Xanthochromia is a term used to describe CSF supernatant that is pink, orange, or yellow. A variety of factors can
cause the appearance of xanthochromia, with the most common being the presence of RBC degradation products.
Depending on the amount of blood and the length of time it has been present, the color will vary from pink (very
slight amount of oxyhemoglobin) to orange (heavy hemolysis) to yellow (conversion of oxyhemoglobin to
unconjugated bilirubin). Other causes of xanthochromia include elevated serum bilirubin, presence of the pigment
carotene, markedly increased protein concentrations, and melanoma pigment. Xanthochromia that is caused by
bilirubin due to immature liver function is also commonly seen in infants, particularly in those who are premature.
(Strasinger)
101. In general, the CSF contains protein fractions similar to those found in serum. As in serum, albumin makes up the
majority of CSF protein. But in contrast to serum, prealbumin is the second most prevalent fraction in CSF. The
alpha globulins include primarily haptoglobin and ceruloplasmin. Transferrin is the major beta globulin present; also,
a separate carbohydrate deficient transferrin fraction, referred to as “tau,” is seen in CSF and not in serum. gamma
globulin is primarily immunoglobulin G (IgG), with only a small amount of IgA. Immunoglobulin M (IgM), fibrinogen,
and beta lipoprotein are not found in normal CSF. (Strasinger)
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102. A fresh semen specimen is clotted and should liquefy within 30 to 60 minutes after collection; therefore, recording
the time of collection is essential for evaluation of semen liquefaction. Analysis of the specimen cannot begin until
after liquefaction has occurred. (Strasinger)
103. Measurement of the amount of hyaluronate polymerization can be performed using Ropes, or mucin clot, test.
When added to a solution of 2% to 5% acetic acid, normal synovial fluid forms a solid clot surrounded by clear fluid.
As the ability of the hyaluronate to polymerize decreases, the clot becomes less firm, and the surrounding fluid
increases in turbidity. The mucin clot test is reported in terms of good (solid clot), fair (soft clot), low (friable clot),
and poor (no clot).
104. SYNOVIAL FLUID: Clear fluids can usually be counted undiluted, but dilutions are necessary when fluids are turbid
or bloody. Traditional WBC diluting fluid cannot be used because it contains acetic acid that causes the
formation of mucin clots. Normal saline can be used as a diluent. If it is necessary to lyse the RBCs, hypotonic
saline (0.3%) or saline that contains saponin is a suitable diluent. Methylene blue added to the normal saline stains
the WBC nuclei, permitting separation of the RBCs and WBCs during counts performed on mixed specimens.
(Strasinger)
106. AMNIOSTAT-FLM: The presence of another lung surface lipid, phosphatidyl glycerol, is also essential for adequate
lung maturity. The production of phosphatidylglycerol normally parallels that of lecithin, but its production is delayed
in cases of maternal diabetes. (Strasinger)
107. ACCURACY: Closeness of the measured result to the true value. (Strasinger)
109. EXTERNAL QUALITY CONTROL: Commercial controls used to verify accuracy and reliability of patient test
results. (Strasinger)
110. INTERNAL QUALITY CONTROL: Electronic, internal, and procedural controls contained within the test system
that ensures the reliability of the test system. (Strasinger)