Describe about the Clinical Serology / Immunology and Urinalysis Case 1 - Tammy R.
Case 1 - Tammy R
What are the abnormal laboratory results?
Ans. Abnormal laboratory results for this patient are WBC count (14.5 X 109 /L), slight increase in RBC count (5.35 X 1012 /L), atypical lymphocytes (25 %), AST (89 AU/L), ALT AST (80 AU/L)and positive monotest.
Based on Tammy’s history (symptoms) and laboratory results, what is the probable diagnosis?
Ans. There is positive monotest and symptoms like fever, sore throat and swollen lymph glands are evident in Tammy. Probable diagnosis for Tammy is Infectious mononucleosis. Infectious mononucleosis is caused by infection of Epstein–Barr virus (EBV).
What age group is associated with this disease? Why it is known as the “kissing disease”?
Ans. 18-24 age group people are associated with this disease. Infectious mononucleosis occurs in the around 90 % cases due to Epstein–Barr virus. This virus can only be transferred to other person through saliva of infected person. In kissing saliva is transferred from one person to other person, hence this disease is called as kissing disease.
If the monotest were negative, would you change your answer to question 2? Explain why or why not.
Ans. Even if monotest is negative, answer to the question 2 remains same. It is because if monotest performed in the initial weeks of infection with Epstein–Barr virus gives false negative results due to less number of antibody titer but symptoms are evident.
What antibodies react in the monotest?
Ans. Heterophile antobody react in monotest.
List and briefly describe three classes of antibodies making up this group of antibodies.
Ans. Heterophile antibody contains IgM, IgM and Anti-EBNA.
IgM appear in the initial phase of the this disease. IgG appear in the late phase of this disease. Anti-EBNA appears at 14-18 weeks after onset of symptoms and remains throughout the life.
Briefly explain the Davidohn differential test.
Ans. In Davidsohn Differtial test two types of sheep agglutinins can diffentiated by reacting them with prior to later absorption with guinea pig kidney and ox cells. I first test IgM antibodies are added to the guinea pig kidney cells. These are no absorption of these antibodies through kidney cells and upon reaction with ox cells these cells causes agglutination which is positive for IgM. Second test Forssman antibodies are added to the guinea pig kidney cells. These antibodies get absorbed through kidney cells and upon reaction with ox cells these cells doesn’t cause agglutination which is positive for Forssman antigens.
Briefly describe the monotest.
Ans. Serum or plasma of the patient is placed on the microscopic slide. It is then mixed with Guinea Pig Kidney Antigen and Preserved Hose Erythrocytes. Mix the reagents thoroughly and incubate the slide for 1 minute. If agglutination is there this test is positive.
What virus is usually associated with this disease? What other disease are also associated with this virus?
Ans. Epstein–Barr virus is associated with Infectious mononucleosis. Other diseases associated with Epstein–Barr virus are Burkitt's lymphoma,] Hodgkin's lymphoma, gastric cancer, nasopharyngeal carcinoma, multiple sclerosis, and lymphomatoid granulomatosis. Gianotti–Crosti syndrome, erythema multiforme, acute genital ulcers, oral hairy leukoplakia.
What would the physician do next?
Ans. Infectious mononucleosis is self-limiting, hence physician will suggest for rest. Physician will ask to take plenty of water. Physician will advise for salt water gargle for throat. Physician wil advice for avoiding heavy physical activity for around 1-2 months. Also physician will prescribe NSAID to reduce fever and pain, also physician will prescribe anti-inflammatory drugs for tonsils.
If it is still negative, what test(s) can be ordered to confirm the diagnosis?
Ans.Test for presence of cytomegalovirus infection and Toxoplasma gondii infections can be performed.
What viral antibodies or antigens are commonly available?
Ans. Commonly available viral antibodies are IgG and IgM
At what stage of the disease are they found?
Ans. These antibodies appear at the different stages of the disease. IgM appears at the start of the infection and IgG appears at the time of recovering from the infection.
What other viruses are also associated with this disease?
Ans. Other viruses associated with disease are Cytomegalovirus , human herpesvirus 6 , HIV, toxoplasmosis, and hepatitis virus.
What other more serious, life life-threatening diseases must be ruled out?
Ans. Following are the life-threatening diseases must be ruled out : Fulminant hepatitis, Burkitt's lymphoma, Hodgkin lymphoma, gastric carcinoma, pyothorax-associated lymphoma
What organ system is associated with the abnormal chemistry test?
Ans. As there is the increase in the ALT, AST and Bilirubin, Liver is associated with abnormal chemistry test.
Is this consistent with your original diagnosis?
Ans. Earlier diagnosis is infectious mononucleosis. In more than 90 % patients with infectious mononucleosis, there is the abnormal liver function test.
What is the usual course of this disease: incubation period and time to recover?
Ans. Infectious mononucleosis has incubation period of 1-2 months. Fever can resolve in one month and fatigue can resolve in 6 months.
What is the normal treatment of this disease?
Ans. As common symptoms of this disease are fever and swelling following treatment is suggested. Normal treatment for this disease includes antiviral like acyclovir, NSAID for fever and pain and anti-inflammatory drugs like prednisolone.
Case 2- Bonnie J
Circle or highlight the abnormal value(s) or discrepant urinalysis result (s).
Ans. Yellow color of urine, cloudy or frothy appearance, increased protein, decreased albumin, increased creatinine, increased BUN and cholesterol.
What type of disease/ condition would be characterized by this urinalysis?
Ans. Nephrotic syndrome
What is the primary problem/defect found in this condition?
Ans. Primary defect found is kidney problem.
What urinalysis result(s) led to your probable diagnosis?
Ans. Yellow color, cloudy/frothy appearance of urine, protein level, and occasional oval fat bodies.
A.What confirmatory test could be performed to identify the oval fat bodies?
Ans.Microscopic test can be performed to identify oval fat bodies.
What is the source of oval fat bodies?
Ans. Fat is accumulated in the epithelial cells and fat bodies formed. Fat is the source of oval fat bodies.
Explain the reason for frothy urine.
Ans. In nephritic condition more urine is excreted in the urine. Frothy urine is due to high amount of protein in urine.
List five conditions that may progress to this disease (primary or secondary causes of this disease).
Ans. Following are the disease which leads to the nephrotic syndrome. Minimal change disease, Focal segmental glomerulosclerosis, Membranous glomerulonephritis, Membranoproliferative glomerulonephritis and rapidly progressive glomerulonephritis.
List five risk factors of this disease.
Following are the risk factors for nephrotic syndrome.
Other disease condition like diabetes, lupus, amyloidosis.
Infections like HIV, hepatitis B, hepatitis C and malaria.
Age over 65.
Are the abnormal chemistry tests consistent with the probable diagnosis? Explain why or why not.
Ans.Abnormal chemistry test are consistent with nephritis syndrome diagnosis. Total protein and cholesterol increase is there like nephrotic syndrome. Albumin is decreased like nephrotic syndrome. Also there is increase in creatinine and BUN like nephrotic syndrome.
What other renal function tests could be performed on a 24-hour urine? Would you expect the results to be decreased, normal or elevated?
Ans. In 24 hr urine test like protein and creatinine can be performed.
In 24 hr sample protein and creatinine levels are higher as compared to the spot test.
Discuss the physiological cause of the edema.
Ans. Damage of blood vessels causes nephrotic syndrome. In nephrotic syndrome there is the decreased level of protein in blood i.e. hypoalbuminia. This decreased level of albumin causes reduced effective colloid osmotic pressure gradient, which results in the increased transcapillary fluid flux. Finally it results in fluid accumulation and edema.
Describe what you would expect to see in Bonnie’s protein electrophoresis.
Ans. In Bonnie’s protein electrophoresis very thin protein bands are evident. α2 globulin is more as compared to the α1 because of its larger size it cannot be excreted. Albumin moves towards the anode and globulin moves towards cathode.
What is the protein selectivity index? What can it tell the physician about the type of renal damage?
Ans. Protein selectivity index is ratio of IgG and albumin multiplied by 100. If protein selectivity is less than 15, there is high selectivity of albumin for excretion. If protein selectivity is more than 30, there is less selectivity of albumin for excretion.
What are some of the possible consequences (complications) of this condition-what could it lead to?
Ans. Acute kidney failure, Pulmonary edema, Hypothyroidism, Hypocalcaemia, Vitamin D deficiency, Protein malnutrition, Growth retardation and Microcytic hypochromic anaemia