Ampath Desk Reference: Guide to Laboratory Tests

Ampath Guide to Lab Tests front cover final repro outlines 15 March 2016.indd 1 2016/03/15 11:43 AM

Ampath Desk Reference: Guide to laboratory tests

Edition 2 AUTHORS Biochemistry: Dr Marita du Plessis Dr Helene Rossouw Dr Leentjie van Niekerk Dr René van der Watt

Haematology: Dr Bettie Oberholster Dr Nico Lategan Dr Piet Wessels

Immunology: Dr Sylvia van den Berg Dr Cathy van Rooyen Dr Mark Cruz da Silva

Virology: Dr Terry Marshall Dr Craig Corcoran

Tel: 012 678 0700

© Copyright reserved Publication date: March 2016 Edition 2 CONTENTS Abbreviations and Symbols key �� xii General notes �� xviii BIOCHEMISTRY �� 1 Electrolytes and renal function �� 1 Diagnosis of chronic kidney disease (CKD) �� 3 Classification of CKD using the CGA system �� 3 Assignment of the cause of CKD �� 3 Recommendations regarding GFR estimation �� 4 Albuminuria as a marker of kidney damage �� 7 Areas of controversy �� 8 Calcium, magnesium, phosphate, vitamin D and PTH �� 9 Liver function tests �� 10 Interpretation of unconjugated hyperbilirubinaemia �� 13 Interpretation of liver profiles �� 13 Evaluation of isolated mild chronic elevation of serum ALT and AST �� 14 Pancreas �� 15 Inflammatory markers �� 16 C-reactive protein (CRP) �� 16 Procalcitonin �� 16 Cardiac and skeletal muscle markers �� 17 Homocysteine interpretation �� 19 NT-ProBNP interpretation �� 19 Diagnosis and classification of Acute Coronary Syndrome in the emergency department setting �� 20 List of contemporary sensitive troponin assays with relevant cut-off values (ng/l) �� 22 Proposed algorithm for work-up of suspected acute coronary syndrome (ACS) for hsTroponin T �� 23 Proposed algorithm for work-up of suspected acute coronary syndrome (ACS) for Troponin I �� 24 Causes of cardiac troponin elevation (other than acute coronary syndrome) �� 25 Carbohydrate metabolism �� 26 Criteria for diagnosing diabetes and categories of intermediate hyperglycaemia �� 27 WHO recommendations (2013 update) for classification of hyperglycaemia during pregnancy �� 28 Factors influencing HbA1c measurement �� 29 HbA1C targets for glycaemic control �� 29 Diagnostic criteria for insulin resistance syndrome / metabolic syndrome �� 30 Lipid metabolism �� 31 CVD Risk Stratification and Cholesterol Targets �� 31 Framingham 10 year risk assessment score �� 33 Laboratory tests for dyslipidaemia �� 37 Interpretation of abnormal lipid profiles �� 39 Effects of secondary causes of dyslipidaemia on the lipogram �� 43 Iron studies �� 45 Interpretation of Iron profile �� 45 Folate and vitamin B12 �� 46 ENDOCRINOLOGY �� 47 Thyroid function tests �� 47 Interpretation of thyroid function tests �� 48 Goals for thyroid hormone replacement �� 49 Other endocrinology tests �� 50 Ovarian profile �� 60 Anti-Müllerian Hormone (AMH) �� 61 Use of AMH in males �� 61 Use of AMH in female patients �� 61 Use of AMH for IVF treatment �� 62 Use of AMH as tumour marker for granulosa cell tumours of the ovaries �� 62 Pregnancy �� 63 Interpretation of BHCG results �� 63 Screening for fetal anomalies in the first and second trimesters of pregnancy �� 63 TUMOUR MARKERS �� 64 Tumour marker reference ranges �� 64 Intended clinical use of HE4 and ROMA Index �� 67 Interpretation of PSA Ratio (Free PSA:Total PSA) �� 68 Appropriate tumour markers for specific tumours �� 69 THERAPEUTIC DRUGS �� 71 CLINICAL TOXICOLOGY �� 77 Paracetamol overdose/toxicity �� 77 Salicylate overdose/toxicity �� 78 Organophosphate toxicity �� 79 DRUGS OF ABUSE �� 79 ALCOHOL ABUSE �� 81 LABORATORY INVESTIGATIONS FOR SPECIFIC CLINICAL DISORDERS �� 83 Screening tests for endocrine disorders �� 83 Addison’s disease �� 83 Carcinoid syndrome �� 83 Cushing’s syndrome �� 84 Diabetes insipidus �� 84 Hypercalcaemia and hypocalcaemia �� 84 Phaeochromocytoma �� 84 Primary hyperaldosteronism �� 85 Diagnosis of Porphyria �� 86 Causes and investigation of Gynaecomastia �� 87 Investigation of Female Hirsutism �� 89 Secondary Causes and Investigation of Osteoporosis �� 89 Osteoporosis in men �� 91 Work-up for Hypertension �� 91 Late onset male Hypogonadism �� 92 HAEMATOLOGY �� 96 Full blood count (FBC) �� 96 ESR (erythrocyte sedimentation rate) �� 101 Investigation of a bleeding disorder �� 106 Basic coagulation screen �� 102 Laboratory assessment for Von Willebrand disease (VWD) �� 109 Platelet aggregation studies �� 110 PFA-200 (for evaluating platelet function) �� 110 Thromboelastogram (TEG) �� 112 Other specialised coagulation tests (D-dimer and FDP) �� 105 Disseminated intravascular coagulation (DIC) screen �� 113 Tests used in the investigation of a thrombotic tendency �� 115 Testing for the presence of a lupus anticoagulant �� 119 Monitoring of anticoagulation therapy �� 120 Antifactor Xa activity (IU/ml) �� 121 Direct thrombin inhibitor (DTI) �� 121 Bone marrow investigation �� 122 Flow cytometry �� 123 Tests used in the investigation of a haemolytic process �� 123 Direct Coombs test �� 124 Osmotic fragility �� 124 Testing for haemosiderin in the urine �� 125 PNH screen (paroxysmal nocturnal haemoglobinuria) �� 126 Testing for inherited enzyme abnormalities �� 126 Malaria testing �� 126 JAK2 V617F PCR �� 127 IMMUNOLOGY �� 128 Autoimmune disorders �� 128 Autoimmunity and the endocrine system �� 128 Autoimmunity and the central nervous system �� 130 Autoimmunity and renal disease �� 131 Autoimmunity in gastrointestinal disease �� 131 Autoimmunity in liver disease �� 133 Autoimmune skin disorders �� 134 Autoimmune ear disease �� 134 Interpretation of Anti-nuclear Antibodies �� 134 Connective tissue disease �� 136 Basic spectrum �� 136 Rheumatoid arthritis (RA) �� 137 Systemic lupus erythematosus (SLE) �� 137 Sjögren’s syndrome �� 138 Polymyositis and dermatomyositis �� 138 Systemic sclerosis (localized and systemic forms) �� 139 Ankylosing spondylitis �� 139 Anti-phospholipid syndrome �� 139 Vasculitis �� 140 Allergic diseases �� 141 Allergic disorders (Attachments A - D) �� 141 Immediate type hypersensitivity �� 141 Basophil mediated hypersensitivity �� 141 Delayed type hypersensitivity �� 142 Allergy diagnostic tests (Attachment E) �� 142 Urticaria �� 142 Microbiology and Microbial Serology �� 142 Antenatal screening �� 142 Chronic fatigue �� 143 CNS (meningitis/encephalitis) �� 143 Congenital screening �� 144 Diarrhoea - Stool Investigations �� 144 Genital Ulcer �� 145 Haematuria �� 145 Hepatitis �� 146 Respiratory Infections �� 150 Primary Immunodeficiencies: A Diagnostic Approach �� 152 Antibody (Humoral) Deficiencies �� 154 T-Cell Defects �� 155 Tests to Determine Neutrophil Function �� 156 Tests to Determine Complement Function �� 156 Natural Killer Cells �� 157 Tests for Causes of Secondary Immunodeficiency �� 157 VIROLOGY �� 158 HIV Diagnosis and Monitoring �� 158 Possible diagnostic algorithms �� 158 HIV monitoring �� 160 Indications for starting ARV therapy �� 160 HIV and HBV �� 161 HIV and TB �� 161 HIV and pregnancy �� 161 HIV in serodiscordant couples �� 162 HIV prophylaxis after unprotected sex, rape survivors, needle sharing and occupational post exposure 162 Hepatitis Diagnosis and Monitoring �� 163 Hepatitis A virus (HAV) �� 163 Hepatitis B virus (HBV) �� 165 Hepatitis C virus (HCV) �� 172 Hepatitis D virus (HDV) �� 178 Hepatitis E virus (HEV) �� 179 Viral Infections in Pregnancy �� 180 Rubella �� 180 CMV �� 181 HSV �� 183 Parvovirus B19 �� 185 HBV �� 185 HCV �� 186 VZV �� 186 Measles �� 188 Enterovirus infections �� 188 Viral Respiratory Tract infections �� 189 Influenza �� 189 Other respiratory viruses �� 191 Infections in the Immunocompromised Patient �� 193 CMV �� 193 EBV �� 193 HSV �� 194 VZV �� 194 BK �� 194 Bacterial and fungus infections �� 195 Pneumocystis jiroveci �� 195 Tuberculosis �� 195 Viral Central Nervous System Infections (including Rabies) �� 196 Diagnosis �� 196 Prevention �� 197 Treatment �� 199 Infection control �� 200 xii | Ampath Desk Reference ABBREVIATIONS AND SYMBOLS KEY Symbol/Abbreviation Interpretation ↑ Increased / High ↓ Decreased / Low ↔ No Change ↑↑ Very High ↑↑↑ Extremely High ACE Angiotensin-converting Enzyme ACTH Adrenocorticotropic Hormone ADH Antidiuretic Hormone ADP Adenosine Diphosphate AFP Alpha-fetoprotein AIDS Acquired Immune Deficiency Syndrome ALP Alkaline Phosphatase ALT Alanine Aminotransferase APC-R Activated Protein C Resistance APTT Activated Partial Thromboplastin Time ARB Angiotensin Receptor Blocker ARR Aldosterone:Renin Ratio ART Antiretroviral Therapy AST Aspartate Aminotransferase AVS Adrenal Venous Sampling AZT Zidovudine BP Blood Pressure CDC Center for Disease Control CDT Carbohydrate Deficient Transferrin Guide to laboratory tests | xiii

Symbol/Abbreviation Interpretation CEA Carcinoembryonic Antigen CETP Cholesteryl Ester Transfer Protein CHD Coronary Heart Disease CHF Congestive Heart Failure CK Creatine Kinase CKD Chronic Kidney Disease CLL Chronic Lymphocytic Leukaemia CMML Chronic Myelomonocytic Leukaemia CMV Cytomegalovirus CNS Central Nervous System CrCl Creatinine Clearance CRP C-Reactive Protein CSF Cerebrospinal Fluid CT Computed Tomography CVD Coronary Vascular Disease DHEA Dehydroepiandrosterone DHP Dihydropyridine DIC Disseminated Intravascular Coagulation DM Diabetes Mellitus EBV Epstein-Barr virus EBNA IgG Epstein-Barr Virus Nuclear Antigen IgG EBV VCA IgM Epstein-Barr Virus Viral Capsid Antigen IgM EBV VCA IgG Epstein-Barr Virus Viral Capsid Antigen IgG ECG Electrocardiography xiv | Ampath Desk Reference Symbol/Abbreviation Interpretation EDTA Ethylenediaminetetraacetate eGFR Estimated (calculated) Glomerular Filtration Rate ESR Erythrocyte Sedimentation Rate F Female FBC Full Blood Count FDP Fibrinogen Degradation Products FH Familial Hypercholesterolaemia FISH Fluorescent In Situ Hybridization FN False Negative FP False Positive FSH Follicle-stimulating Hormone GGT Gamma Glutamyltransferase GFR Glomerular Filtration Rate H High HAART Highly Active Antiretroviral Therapy Hb Haemoglobin HBcAb Hepatitis B Core Total (IgM & IgG) Antibody HBcIgM Hepatitis B Core IgM HBeAb Hepatitis B e-Antibody HBeAg Hepatitis B e-Antigen HBIG Hepatitis B Immune Globulin HBsAb Hepatitis B Surface Antibodies HBsAg Hepatitis B Surface Antigen HBV Hepatitis B Virus HC Hypercholesterolaemia Guide to laboratory tests | xv Symbol/Abbreviation Interpretation HCG Human Chorionic Gonadotropin HCV Hepatitis C Virus HDL High-Density Lipoprotein HDLC High-Density Lipoprotein Cholesterol HHV-7 Human Herpes virus-7 HHV-6 Human Herpes virus-6 HIAA 5-Hydroxyindoleacetic acid HIV Human Immunodeficiency Virus HNIG Human Normal Immune Globulin HPLC High-performance Liquid Chromatography HRP-2 Histidine-rich Protein 2 HSV Herpes Simplex Virus HT Hypertension HTLV-1 Human T-cell Lymphotrophic Virus-1 HVA Homovanillic Acid IM Infectious Mononucleosis ITP Idiopathic Thrombocytopenic Purpura L Low LCAT Lecithin-cholesterol Acyltransferase LD Lactate Dehydrogenase LDLC Low-Density Lipoprotein Cholesterol LH Luteinizing Hormone LMWH Low Molecular Weight Heparin M Male MA Maximum Amplitude xvi | Ampath Desk Reference Symbol/Abbreviation Interpretation MAOI Monoamine Oxidase Inhibitors MCS Microscopy, Culture, Sensitivity MCV Mean Cell Volume MDRD Modification of Diet in Renal Disease MELISA Memory Lymphocyte Immuno Stimulation Assay MRI Magnetic Resonance Image N Normal NA Nuclear Antigen NCEP National Cholesterol Education Program NNRTI Non-nucleoside Reverse Transcriptase Inhibitors NRTI Nucleoside Reverse Transcriptase Inhibitors NSAID’s Nonsteroidal Anti-inflammatory Drugs NSE Neuron-specific Enolase NSTEMI Non-ST Elevation Acute Myocardial Infarction NVP Nevirapine PA Primary Aldosteronism PAI Plasminogen activator inhibitor PBC Primary Biliary Cirrhosis PCNSL Primary Central Nervous System Lymphoma PCR Polymerase Chain Reaction PCT Procalcitonin PEP Post Exposure Prophylaxis PHA-2 Pseudohypoaldosteronism Type 2 PML Progressive Multifocal Leukoencephalopathy PNH Paroxysmal Nocturnal Haemoglobinuria Guide to laboratory tests | xvii Symbol/Abbreviation Interpretation PSA Prostate-specific Antigen PT Prothrombin Time RA Rheumatoid Arthritis RF Rheumatoid Factor RIG Rabies Immune Globulin RNA Ribonucleic Acid RPR Rapid Plasma Reagin RSV Respiratory Syncytial Virus SCC Squamous Cell Carcinoma SHBG Sex Hormone-Binding Globulin SLE Systemic Lupus Erythematosus STEMI ST-elevation Acute Myocardial Infarction T3 Triiodothyronine T4 Thyroxine TAD Tricyclic Antidepressants TB Tuberculosis TC Total Cholesterol TEG Thromboelastogram TG Triglyceride TK Thymidine Kinase TPA Tissue Plasminogen Activator TSH Thyroid-stimulating Hormone TT Thrombin Time TTP Thrombotic Thrombocytopenic Purpura UFH Unfractionated Heparin xviii | Ampath Desk Reference Symbol/Abbreviation Interpretation UTI Urinary Tract Infections VAR Variable VCA Viral Capsid Antigen VMA Vanillylmandelic Acid VZV Varicella Zoster Virus WHO World Health Organization ZIG Zoster Immune Globulin General notes: 1. The reference ranges provided are applicable to adults only. 2. The reference ranges provided may vary according to instrument and methodology. 3. Only the most common causes are listed in the interpretation of analytes.

1 | Ampath Desk Reference BIOCHEMISTRY Electrolytes and renal function

Analyte Ref. Range Units Interpretation Sodium 136 – 145 mmol/l ↑: Diabetes insipidus, dehydration (water loss in excess of salt loss). ↓: Medication (e.g. diuretics, indapamide, ACE inhibitors), vomiting, diarrhoea, acute renal failure, congestive heart failure, Addison’s disease, syndrome of inappropriate ADH secretion, falsely decreased (due to ↑ protein, ↑ triglycerides). Potassium 3.5 – 5.1 mmol/l ↑: Acute renal failure, falsely elevated (haemolysed blood, aged blood, contamination with FBC tube anticoagulant), medication (e.g. ACE inhibitors, angiotensin receptor blockers, spironolactone, amiloride), Addison’s disease, acidosis, untreated diabetic ketoacidosis. ↓: Vomiting, diarrhoea, drugs (e.g. diuretics, indapamide, laxatives). Chloride 98 – 107 mmol/l ↑: Diarrhoea, dehydration. ↓: Diuretics, vomiting. Bicarbonate 22 – 29 mmol/l ↑: Potassium depletion, vomiting, diuretics, emphysema. ↓: Acute renal failure, diabetic ketoacidosis, diabetic hyperosmolar coma, diarrhoea, renal tubular acidosis, lactic acidosis, toxins. Urea 1.7 – 8.3 mmol/l ↑: Acute or chronic renal failure, dehydration (due to vomiting, diarrhoea, sweating), intestinal bleeding, shock. ↓: Hepatic failure, pregnancy, cachexia. Creatinine M 64 – 104 µmol/l ↑: Acute or chronic renal failure, acromegaly, meat meals, F 49 – 90 hyperthyroidism. ↓: Pregnancy, chronic muscle wasting, immobilisation. Guide to laboratory tests | 2

Analyte Ref. Range Units Interpretation Urate M 0.21 – 0.43 mmol/l ↑: Gout, renal failure, insulin resistance syndrome, alcoholism, F 0.16 – 0.36 malignancies (e.g. leukaemia, lymphoma, multiple myeloma), psoriasis, medication (e.g. diuretics, salicylates, etc). ↓: Syndrome of inappropriate ADH secretion, pregnancy. eGFR ≥90 ml/min/ eGFR = estimated (calculated) Glomerular Filtration Rate 1.73m² ↓: Renal impairment (see table for classification of chronic kidney disease). Osmolality 275 – 295 mOsm/kg ↑: Hyperglycaemia, water depletion, uraemia, ethanol intoxication, hypernatraemia, diabetes insipidus, cerebral lesions. ↓: Addison’s disease, water intoxication, syndrome of inappropriate ADH secretion. Creatinine M 105 – 157 ml/min/ ↑: Pregnancy, high protein diet, urine collected for Clearance F 81 – 123 1.73 m² >24 hours (false ↑). (24 hour urine ↓: Prerenal (shock, haemorrhage, dehydration, congestive and blood) heart failure), intrinsic renal disease, acute tubular dysfunction, post-renal obstruction, urine collected for <24 hours (false ↓). Although a moderate decrease in GFR is expected with age, a major decrease (<60 ml/min/1.73 m2) is uncommon in the absence of disease (e.g. diabetes) or co-morbid cardiovascular conditions (including HT, heart failure and atherosclerosis). Urine protein <150 mg/24 h ↑: Cystitis, pyelonephritis, glomerular disease, renal tubular (24 hour urine) disease, nephrotic syndrome, diabetes mellitus, fever, strenuous exercise, orthostatic changes. 3 | Ampath Desk Reference Diagnosis of Chronic Kidney Disease (CKD) Chronic kidney disease (CKD) is defined as abnormalities of kidney structure or function, present for longer than 3 months, with implications for health. The most recent Kidney Disease Improving Global Outcomes (KDIGO) Clinical Practice Guidelines (2012) recommended that CKD should be classified using the CGA staging system. This includes Cause, Glomerular filtration rate (GFR) category and Albuminuria category (as marker for kidney damage), as the combination of these factors relates to risks of adverse outcomes. Criteria for CKD: Either of the following present for more than 3 months 1. Decreased GFR (<60 ml/min/1.73 m2) (GFR categories G3a-G5) 2. Markers of kidney damage (one or more): a. Albuminuria: Albumin excretion rate (AER) ≥30 mg/day or albumin-to-creatinine ratio (ACR) ≥3 mg/mmol. b. Urine sediment abnormalities (e.g. haematuria, red cell / white cell / granular casts, etc). c. Electrolyte and other abnormalities due to tubular disorders. d. Abnormalities detected by histology. e. Structural abnormalities detected by imaging. f. History of kidney transplantation. Classification of CKD using the CGA system Previous CKD guidelines included only the level of GFR for staging. By using the CGA system, the cause and albuminuria category are also used. CKD is not a disease in itself, and the assignment of cause is important for determination of prognosis and to guide treatment decisions. 1. Assignment of the cause of CKD The cause of CKD is assigned based on the presence or absence of systemic disease and the location of observed or assumed pathology within the kidney. In developed countries, hypertension and diabetes are the most frequent causes of CKD. Examples are supplied in Table 1. Guide to laboratory tests | 4 Table 1: Classification of CKD based on systemic disease and location of pathology within kidney Examples of systemic diseases Examples of primary kidney diseases affecting the kidney (absence of systemic diseases) Glomerular Diabetes mellitus, systemic Diffuse, focal or concentric proliferative diseases autoimmune diseases, systemic glomerulonephritis, focal and segmental infections, drugs, neoplasia glomerulosclerosis, membranous (including amyloidosis) nephropathy, minimal change disease Tubulointerstitial Systemic infections, autoimmune, Urinary-tract infections, stones, diseases sarcoidosis, drugs, urate, obstruction environmental toxins (lead, aristolochic acid found in Chinese herbal medicine), neoplasia (myeloma) Vascular diseases Atherosclerosis, hypertension, ANCA-associated renal limited vasculitis, ischaemia, cholesterol emboli, fibromuscular dysplasia systemic vasculitis, thrombotic microangiopathy, systemic sclerosis Cystic and Polycystic kidney disease, Alport Renal dysplasia, medullary cystic congenital diseases syndrome, Fabry disease disease, podocytopathies ANCA: Antineutrophil cytoplasmic antibody Kidney International Supplements 2013: 3:19-62 2. Recommendations regarding GFR estimation • Since November 2014 Ampath is using the 2009 CKD – EPI creatinine equation. • The main advantages of using the Chronic Kidney Disease Epidemiology Collaboration (CKD – EPI) equation are the following: • More accurate at GFR >60 ml/min/1.73 m² and GFR >90 ml/min/1.73 m² is reportable using CKD – EPI equation. • Less influenced by ethnic origin and reasonable to use without correction for race and ethnicity. 5 | Ampath Desk Reference • Significant reclassification from stage 3a (GFR 45 – 59) to stage 2 (GFR 60 – 89). • CKD – EPI classification shows better accuracy compared to gold standard methods of GFR estimation than MDRD, especially at high GFRs, in younger people and women. • Validated in older people. • Limitations of serum creatinine (SCr) as a marker are still applicable – see Table 2.

Table 2: Sources of error in GFR estimation using creatinine

Source of error Example Non-steady state • Acute kidney injury (AKI) Non-GFR determinants of SCr that differ from study populations in which equations were developed • Factors affecting creatinine generation • Race / ethnicity other than US / European black and white • Extremes of muscle mass or body size • Diet and nutritional status (high protein diet / creatine supplements / ingestion of cooked meats) • Muscle wasting diseases

• Factors affecting tubular secretion of creatinine • Decreased by drug-induced inhibition: trimethoprim, cimetidine, fenofibrate

• Factors affecting extra-renal elimination of • Dialysis creatinine • Decreased by inhibition of gut creatininase by antibiotics • Increased by large volume losses of extracellular fluids Guide to laboratory tests | 6

Source of error Example Higher GFR • Higher measurement error in low SCr and high GFR Interference with creatinine assay • Spectral interferences (e.g. bilirubin, some drugs) • Chemical interferences (e.g. glucose, ketones, bilirubin, some drugs) • GFR categories in CKD: Please take note that the previously used Stage 3 has been subdivided into stages 3a and 3b, based on data supporting different risks and outcomes. Although some decline in GFR is expected with aging, a value below 60 ml/min/1.73 m2 is also regarded as decreased.

Table 3: GFR categories in CKD

GFR GFR Terms category (ml/min/1.73 m2) G1 ≥90 Normal or high G2 60 – 89 Mildly decreased* G3a 45 – 59 Mildly to moderately decreased G3b 30 – 44 Moderately to severely decreased G4 15 – 29 Severely decreased G5 <15 Kidney failure *Relative to young adult level Kidney International Supplements 2013: 3:19-62 • In the absence of evidence of kidney damage, neither GFR category G1 nor G2 fulfil the criteria for CKD. • eGFR from 60 to 89 is mildly decreased and not regarded as CKD unless present for longer than 3 months in the presence of moderate albuminuria (>3.0 mg/mmol). Associated risk factors 7 | Ampath Desk Reference for cardiovascular disease, including hypertension, dyslipidaemia, smoking and other lifestyle factors, should be addressed. The following additional investigations are recommended: • Creatinine: repeat within 14 days for confirmation (after 12 hours of no meat consumption), and then annually. • Annual urine albumin-to-creatinine ratio. 3. Albuminuria as a marker of kidney damage: • Albuminuria is the preferred marker for assessment of kidney damage, and should be used in preference to proteinuria, as it is the earliest marker of glomerular diseases. There is a graded increase in risk for all-cause and cardiovascular mortality, kidney failure, acute kidney injury (AKI) and CKD progression for higher albuminuria categories across all GFR categories. • For screening purposes, an early-morning urine sample (first pass) for determination of the albumin-to-creatinine ratio (ACR) is preferred. • The term microalbuminuria used for an ACR of 3 – 30 mg/mmol (category A2) should no longer be used and has been replaced by the term “moderately increased” albuminuria. • An abnormal screening test should be confirmed by an ACR on an early-morning urine sample or an albumin excretion rate (AER) in a timed urine collection. • The use of reagent test strips are discouraged due to poor sensitivity at lower concentrations and because the values are not adjusted for urinary concentration. • If non-albuminuric proteinuria is suspected, use assays for specific proteins, e.g. determination of Bence Jones proteins in myeloma patients. Guide to laboratory tests | 8 Table 4: Albuminuria categories in CKD and relationship with proteinuria

Categories Measure Normal (A1) Moderately Severely increased (A2) increased (A3) Albumin-to-creatinine ratio (ACR) (mg/mmol) <3 3 – 30 >30 Albumin excretion rate (AER) (mg/24h) <30 30 – 300 >300 Protein-to-creatinine ratio (PCR) (mg/mmol) <15 15 – 50 >50 Protein excretion rate (PER) (mg/24h) <150 150 – 500 >500 Protein reagent strip Negative to Trace to + + or greater trace Nephrotic syndrome: ACR >220 mg/mmol, AER >2200 mg/24h, PCR >350 mg/mmol, PER >3500 mg/24h

Areas of controversy or confusion CKD with isolated GFR decrease without markers of kidney damage may be seen with heart failure, liver cirrhosis, hypothyroidism, malnutrition and in kidney donors. CKD with isolated persistent albuminuria without decreased GFR is seen in obesity and the metabolic syndrome. CKD should be excluded in patients with orthostatic (postural) proteinuria with PER >1000 mg/24h. 9 | Ampath Desk Reference Calcium, magnesium, phosphate, vitamin D and PTH

Analyte Ref. Range Units Interpretation Calcium 2.15 – 2.50 mmol/l ↑: Primary hyperparathyroidism, malignancy, sarcoidosis, immobilisation, Addison’s disease, thyrotoxicosis, medication, e.g. lithium, thiazides. ↓: Renal failure, falsely ↓ due to contamination with FBC tube anticoagulant, hypoparathyroidism, hypomagnesaemia, vitamin D deficiency, blood transfusion, major surgery, trauma, sepsis, burns, pancreatitis, multiple organ failure, haemodialysis, advanced osteomalacia. Magnesium 0.66 – 1.07 mmol/l ↑: Acute and chronic renal failure, untreated diabetic ketoacidosis. ↓: Malabsorption, chronic alcoholism, diarrhoea, drugs (e.g. diuretics, laxatives), treatment of diabetic ketoacidosis. Phosphate 0.78 – 1.42 mmol/l ↑: Renal failure, untreated diabetic ketoacidosis. ↓: Acute alcoholism, primary hyperparathyroidism, drugs (e.g. diuretics, insulin), severe diarrhoea, vomiting, treatment of diabetic ketoacidosis, severe malnutrition, malabsorption, hypokalaemia, vitamin D deficiency. 25(OH) <20 ng/ml Severe deficiency. Vitamin D 20 – 29 Moderate to mild deficiency. 30 – 100 Optimum level. ↑: Vitamin D intoxication, excessive exposure to sunlight. ↓: Malabsorption, dietary osteomalacia, steatorrhea, biliary and portal cirrhosis, anticonvulsants, renal osteodystrophy, osteïtis fibrosis cystica, thyrotoxicosis, pancreatic insufficiency, coeliac disease, inflammatory bowel disease, bowel resection, rickets, hypoparathyroidism, chronic renal failure, underexposure to sunlight. Often no specific pathological cause is found, except for inadequate sunlight exposure combined with a vitamin D deficient diet (our normal diet does not contain adequate vitamin D). Guide to laboratory tests | 10

Analyte Ref. Range Units Interpretation Parathyroid 15 – 65 pmol/l ↑: Primary hyperparathyroidism (calcium ↑), medication e.g. lithium, hormone (Roche) thiazides. ↑: Secondary hyperparathyroidism (calcium normal or ↓) due to e.g. renal disease, vitamin D deficiency, anticonvulsant therapy. ↓: With ↑ calcium – due to malignancy, sarcoidosis, immobilisation, Addison’s disease. ↓: With ↓ calcium – due to hypoparathyroidism, hypomagnesaemia. Liver function tests

Analyte Ref. Range Units Interpretation Total protein 60 – 83 g/l ↑: Multiple myeloma, autoimmune disease, chronic liver disease, chronic infection (e.g. AIDS, TB). ↓: Nephrotic syndrome, chronic liver failure, malnutrition, pregnancy. Albumin 35 – 52 g/l ↑: Dehydration, prolonged tourniquet application during venipuncture. ↓: Acute and chronic liver disease, malnutrition, malabsorption, nephrotic syndrome, acute and chronic inflammation, systemic infections, autoimmune disease, congestive cardiac failure, pregnancy. Prealbumin 200 – 400 mg/l Used for monitoring of nutritional status due to short (Transthyretin) half-life (1 – 2 days) ↓: Protein – caloric malnutrition, inflammation, malignancy, liver cirrhosis. 11 | Ampath Desk Reference

Analyte Ref. Range Units Interpretation Serum M y 5320 – 12920 U/l ↓: Organophosphorus insecticide poisoning, hepatitis, Cholinesterase F 18 – 39y 4260 – 11250 cirrhosis, hepatic metastases, hepatic congestion ≥40y 5320 – 12920 due to heart failure, hepatic amebiasis, malnutrition, anaemias, acute infections, burns, myocardial infarction, pulmonary embolism, after surgery, chronic renal disease, late pregnancy, conditions with low serum albumin (e.g. malabsorption), genetic cholinesterase variants. Ammonia M 15 – 55 µmol/l ↑: Liver failure, liver cirrhosis, gastrointestinal bleeding, F 11 – 48 portal – systemic shunting of blood. Total Bilirubin 5 – 21 µmol/l ↑: Hepatocellular damage (e.g. hepatitis, toxic damage due to drugs or toxins), intrahepatic biliary tree obstruction (e.g. primary biliary cirrhosis), extrahepatic biliary tree obstruction (e.g. gallstones, carcinoma of the head of the pancreas), haemolytic diseases, Gilbert’s disease. Conjugated 0 – 5 µmol/l ↑: Hepatocellular damage (e.g. hepatitis, toxic Bilirubin damage due to drugs or toxins), intrahepatic biliary tree obstruction (e.g. primary biliary cirrhosis), extrahepatic biliary tree obstruction (e.g. gallstones, carcinoma of the head of the pancreas). Unconjugated 0 – 18 µmol/l ↑: Mainly unconjugated bilirubin increase: Bilirubin - Gilbert’s disease, haemolytic diseases. Combined increase of unconjugated and conjugated bilirubin: - Hepatocellular damage, intrahepatic and extrahepatic biliary tree obstruction. Guide to laboratory tests | 12

Analyte Ref. Range Units Interpretation Alkaline M 40 – 130 U/l ↑: Primary and secondary hyperparathyroidism, Phosphatase F 35 – 105 extrahepatic biliary tree obstruction (e.g. gallstones, (ALP) carcinoma of the head of the pancreas), intrahepatic biliary tree obstruction (e.g. primary biliary cirrhosis), hepatocellular disease (e.g. hepatitis), space occupying lesions in the liver (e.g. liver metastases), bone metastases, Paget’s disease of bone, uraemic osteodystrophy, thyrotoxicosis, during healing of a fracture, pregnancy. Gamma M <60 U/l ↑: Extrahepatic biliary tree obstruction (e.g. gallstones, Glutamyl- F <40 carcinoma of the head of the pancreas), transferase intrahepatic biliary tree obstruction (e.g. primary (GGT) biliary cirrhosis), hepatocellular disease (e.g. hepatitis), fatty liver, space occupying lesions in the liver (e.g. liver metastases), induction by alcohol or medication. Alanine M <50 U/l ↑: Acute hepatitis, chronic hepatitis, liver cirrhosis, liver amino- F <35 cell necrosis (e.g. hypoxic shock, paracetamol transferase overdosage), viraemia, chronic alcohol abuse, (ALT) liver cirrhosis, fatty liver. Aspartate M <38 U/l ↑: Acute hepatitis, acute liver cell necrosis amino- F <32 (e.g. hypoxic shock, paracetamol overdose), transferase chronic hepatitis, liver cirrhosis, chronic alcohol (AST) abuse (AST:ALT ratio >2), intrahepatic neoplasms, viraemia, fatty liver, haemolytic anemia, megaloblastic anaemia, rhabdomyolysis, vigorous exercise, muscular dystrophy. 13 | Ampath Desk Reference

Analyte Ref. Range Units Interpretation Lactate 100 – 250 U/l ↑: Megaloblastic anaemia, haemolytic anaemia, dehydro- leukaemia, acute hepatitis, acute liver cell genase necrosis, liver cirrhosis, musculoskeletal disease, (LD) vigorous exercise, rhabdomyolysis, neoplastic disease, myocardial infarction.

Interpretation of unconjugated hyperbilirubinaemia

Gilbert’s disease Haemolysis Megaloblastic anaemia Total Bilirubin ↑ ↑ ↑ Unconjugated Bilirubin ↑ ↑ ↑ ALP N N N GGT N N N ALT N N N AST N N / ↑ ↑ LD N ↑ ↑ / ↑↑

Interpretation of liver profiles

Extrahepatic Space occupying Hepatitis Alcohol obstruction lesion Total Bilirubin N / ↑ ↑↑↑ N N Conjugated Bilirubin N / ↑ ↑↑↑ N N Unconjugated Bilirubin N / ↑ ↑↑↑ N N ALP N / ↑ ↑↑↑ N / ↑ N Guide to laboratory tests | 14 Interpretation of liver profiles (continued)

Extrahepatic Space occupying Hepatitis Alcohol obstruction lesion GGT N / ↑ ↑↑↑ ↑ ↑ ALT ↑ to ↑↑↑ N / ↑ N N AST ↑ to ↑↑↑ N / ↑ N / ↑ ↑ LD N / ↑↑ N / ↑ N / ↑ N

Evaluation of isolated mild chronic elevation of serum ALT and AST

Definition: Mild (<4 times upper limit of normal), chronic (≥6 months) elevation of one or both aminotransferases.

Disease Tests Step 1 History Medication, herbal remedies, recreational drugs Alcohol abuse AST: ALT >2:1, GGT ↑, CDT Hepatitis B and C Hepatitis B and C studies Haemochromatosis Iron profile (fasting), Haemochromatosis PCR Fatty Liver AST: ALT <2:1, GGT sometimes ↑, Ultrasound, CT, MRI, Liver Biopsy Step 2 – If the above are unrevealing, exclude extra-hepatic source Hyperthyroidism and TSH, FT4 Hypothyroidism Coeliac Disease Anti-endomysial IgA, anti-tissue transglutaminase IgA antibodies Adrenal insufficiency 8 – 10 am ACTH and Cortisol 15 | Ampath Desk Reference

Disease Tests Step 3 Serum protein electrophoresis, antinuclear antibodies, anti-smooth Auto immune hepatitis muscle antibodies, liver-kidney microsomal antibodies, liver biopsy Wilson’s Disease Serum caeruloplasmin, 24-hour urine copper, Kayser Fleischer rings Alpha-1-antitrypsin Deficiency Alpha-1-antitrypsin level, alpha-1-antitrypsin PCR Pancreas

Analyte Ref. Range Units Interpretation Amylase <110 U/l ↑: Pancreatitis, intestinal obstruction or infarction, strangulated bowel, ectopic pregnancy, perforated hollow viscus, biliary tract disease of all types, diabetic ketoacidosis, pancreatic cyst or pseudocyst, peritonitis, macroamylasemia, renal failure, abdominal trauma, viral infections, postoperative patients, alcohol, parotitis, mumps. Lipase 22 – 51 U/l ↑: Pancreatitis, gallstone colic, perforated hollow viscus, (Beckman) strangulated or infarcted bowel, pancreatic cyst or pseudocyst, peritonitis. 13 – 60 (Roche) Stool elastase >200 µg/g stool ↓: Chronic pancreatitis. Guide to laboratory tests | 16 Inflammatory markers CRP (C-Reactive Protein)

Marker Ref. Range Units Interpretation ↑: Inflammatory conditions including trauma, burns, surgery, CRP 0.0 – 4.9 mg/l autoimmune disease, neoplastic disease and infection. Procalcitonin

Analyte Range Units Interpretation Procalcitonin (PCT) 0.0 – 0.05 ng/ml Normal range. 0.06 – 0.49 ng/ml May indicate: - no or minor systemic inflammatory response. - local inflammation. - chronic inflammatory processes. - autoimmune diseases. - viral infections. - mild to moderate localised bacterial infections. 0.5 – 1.99 ng/ml Possible bacterial infection. Non bacterial causes (such as invasive fungal infections, viral infections, severe trauma, major surgery, burns, cardiogenic shock, small cell lung cancer, Plasmodium falciparum malaria, etc.) have to be excluded. 2 – 10 ng/ml Systemic bacterial, fungal or parasitic infection is likely. Also compatible with severe polytrauma or burns. >10 ng/ml Sepsis, severe sepsis or septic shock (almost exclusively bacterial) or multi organ failure most likely. 17 | Ampath Desk Reference It is important to note that PCT levels below 0.5 ng/ml do not always indicate the absence of bacterial infection. Falsely low PCT levels may occur in the presence of bacterial infections e.g.: • in the early course of localised infections and sub-acute infective endocarditis • if PCT done very early following onset of a systemic bacterial infection (usually <6 hours) In the above cases, PCT should be re-assessed 6 – 24 hours later. Cardiac and skeletal muscle markers

Marker Ref. Range Units Interpretation CK M 39 – 308 U/l ↑: Myocardial infarction, myocarditis, muscular dystrophies, (Creatine F 26 – 192 polymyositis, seizures, muscle trauma, exercise, IM injection, kinase) rhabdomyolysis, surgery, hypothyroidism, congestive heart failure, tachycardia, pulmonary emboli, hypoxic shock, tetanus, extensive brain infarction, head injury. CK-MB (mass) M 0 – 6.4 ng/ml ↑: Myocardial infarction, myocarditis, muscular dystrophies, F 0 – 6.4 polymyositis, seizures, muscle trauma, exercise, IM injection, (Abbott) post-operative. M 0 – 7.6 F 0 – 5.2 (Beckman) M 0 – 7.5 F 0 – 3.9 (Minividas) M 0.9 – 11.0 F 0.6 – 6.9 (Radiometer) M 0 – 7.6 F 0 – 4.7 (Roche) Guide to laboratory tests | 18

Marker Ref. Range Units Interpretation Troponin I M/F 0 – 26.2 ng/l ↑: See diagnosis of acute coronary syndrome and table for (Abbott) causes of troponin elevation. M/F 0 – 40 (Beckman Accu TnI) Troponin T M/F 0 – 14 (high sensitive) (hsTnT-Roche) M/F 0 – 17 (Radiometer AQT) Myoglobin M 0 – 154 µg/l ↑: Myocardial infarction, rhabdomyolysis, seizures, IM injection, F 0 – 105 exercise. (Abbott) M 17 – 106 F 14 – 66 (Beckman) M 28 – 72 F 25 – 58 (Roche) M 21 – 98 F 19 – 56 (Stratus) Homocysteine Adults <15 µmol/l ↑: Homocystinuria, heterozygous cystathionine-β-synthase Elderly <20 defect, vitamin B12 deficiency, folate deficiency, vitamin B6 See table for deficiency, cigarette smoking, coffee consumption, renal interpretation failure, hypothyroidism, diabetes mellitus, psychiatric disorders. ↓: Pregnancy, hyperthyroidism, early diabetes mellitus. NT-ProBNP <125 pg/ml See NT-ProBNP interpretation below. 19 | Ampath Desk Reference Homocysteine Interpretation

Classification of risk for atherosclerotic vascular disease Homocysteine concentration (µmol/l) Moderate 15 – 30 in adults 20 – 30 in elderly Intermediate 31 – 100 Severe >100 A follow up homocysteine level one month post initiation of treatment is indicated.

NT-ProBNP interpretation NT-proBNP <300 pg/ml NT-proBNP values below 300 pg/ml virtually excludes ACUTE heart failure. However, an NT-proBNP result >125 pg/ml may be compatible with symptomatic heart failure in an out-patient setting. ProBNP may be decreased by: • Hypothyroidism • Treatment with diuretics • ACE-inhibitors / Angiotensin II antagonists (ARB’s) • Obesity • Vasodilators • Left atrial failure Guide to laboratory tests | 20 ProBNP cut-off points for patients with clinical evidence of acute (decompensated) cardiac failure

Patient age (years) NT-proBNP values (pg/ml) <50 300 – 450 >450 50 – 75 300 – 900 >900 >75 300 – 1800 >1800 Acute Congestive Heart Failure Acute Congestive Heart Failure (CHF) less likely (CHF) likely Consider possible: Stable left ventricular failure (LVF), Right ventricular failure (RVF), Myocardial infarction (MI), Acute pulmonary embolism (PE), Kidney failure Elevated proBNP levels also occur in stable CHF (no clinical evidence of acute decompensation). Diagnosis and classification of Acute Coronary Syndrome (ACS) in the emergency department setting • A sensitive cardiac troponin (TnT / TnI) is the preferred biochemical marker for diagnosis of AMI, replacing previously used biomarkers such as myoglobin and CK-MB. • CK-MB is an acceptable alternative only when troponin is not available. • The 99th percentile of a reference population is used as upper limit of normal for troponin testing. • The diagnosis of ST-elevation myocardial infarction (STEMI) is made by typical ECG findings in patients with a suggestive clinical presentation, and not by elevation of troponins. Treatment must be initiated immediately and not delayed until Troponin results are available. • Non-ST elevation myocardial infarction (NSTEMI) is confirmed by a troponin above the rule-in level (>100 ng/l for hsTnT). 21 | Ampath Desk Reference • Troponin results above the 99th percentile but below the MI-rule in level, should be repeated after 3 hours to show a significant change for diagnosis of acute mycardial damage / AMI in a setting of ischaemia (recent onset chest pain / ECG-changes). • A significant change for hsTnT is regarded as a 50% increase for values from 15 – 52 ng/l or 20% increase for values from 53 – 100 ng/l in a follow up sample. A 50% change should be regarded as significant in the case of Troponin I. • NSTEMI is excluded after 2 measurements taken at least 3 hours apart that remain negative or show an insignificant change or if a value reliably 6 hours following the onset of chest pain is negative. • A stable increase in troponin level (hsTnT 15 – 100 with insignificant % change) could be due to congestive cardiac failure (CCF), severe hypertension, haemodynamic shock, pulmonary embolism, myocarditis, cardiac trauma and sepsis.

ST elevation acute myocardial infarction (STEMI) A clinical scenario suggestive of evolving ischaemia and One of the following ECG changes: 1. ST segment elevation (which is not transient). 2. New (or presumably new) onset left bundle branch block. 3. New onset Q waves. Biomarkers of myocardial necrosis should still be requested but the diagnosis and treatment should not be delayed by pending results. Non-ST elevation acute myocardial infarction (NSTEMI) A rising (or falling) troponin I or troponin T concentration where at least one of the values is positive and one of the following: Guide to laboratory tests | 22 1. A clinical scenario suggestive of evolving ischaemia. 2. ECG findings of ischaemia excluding those associated with STEMI. This includes: a. ST segment depression. b. T wave inversion. c. Transient ST segment elevation. 3. A recent coronary artery intervention. Unstable angina A troponin I or T concentration that does not follow a rising (or falling) pattern, but A clinical scenario suggestive of evolving ischaemia at rest or that is evoked through stress testing. The ECG may be normal or may show signs of ischaemia similar to that of a NSTEMI.

List of contemporary sensitive troponin assays with relevant cut-off values (ng/l)

99th percentile MI rule-in Assay (upper limit of normal) (using WHO-criteria) Troponin I Abbott Architect TnI 26.2 300 Beckman AccuTnI 40 500 Siemens Stratus CS TnI 70 600 Troponin T Radiometer AQT90 TnT 17 100 Roche hsTnT 14 100 23 | Ampath Desk Reference Proposed algorithm for work-up of suspected acute coronary syndrome (ACS) For hsTroponin T:

First sample

hsTnT <15 ng/l hsTnT >100 hsTnT 15 – 52 ng/l hsTnT 53 – 100 ng/l (99th percentile) (MI cutoff)

Pain duration Pain duration Admit >6 hours <6 hours Follow-up sample after 3 hours

<50% change >50% change <20% change >20% change Discharge

Discharge Admit Discharge Admit Guide to laboratory tests | 24 Proposed algorithm for work-up of suspected acute coronary syndrome (ACS) For Troponin I:

First sample

Tnl Tnl value between 99th percentile and MI-cutoff TnI above MI cutoff <99th percentile

Pain duration Pain duration Admit >6 hours <6 hours Follow-up sample after 3 hours

<50% change >50% change Discharge

Discharge Admit

Admit = Admit and treat for ACS. Discharge = Discharge after symptomatic treatment / stress test / investigations for other causes of chest pain. 25 | Ampath Desk Reference Causes of cardiac troponin elevation (other than acute coronary syndrome) ACUTE Ischaemic mechanisms Acute heart failure Hypotension / shock Pulmonary embolism Sepsis Tachy-arrhythmias Acute respiratory distress syndrome (ARDS) Brady-arrhythmias Aortic dissection Accelerated hypertension Carbon monoxide poisoning

Other mechanisms Cardiac contusion Myo-pericarditis Procedural trauma: Endocarditis Cardiac sugery Stroke Uncomplicated Percutaneous Coronary Tako-tsubo cardiomyopathy Intervention (PCI) Atrial septal defect (ASD) closure Rhabdomyolysis Endomyocardial biopsy Acute renal failure Pacing Burns >30% Implantable cardioverter defibrillator (ICD) Snake venoms shocks Radiofrequency (RF) ablation / cryo ablation Chemotherapy: Adriamycin, 5-fluoro-uracil, herceptin External cardiac massage Sympathomimetic drugs External cardioversion / defibrillation Strenuous exertion After non-cardiac surgery Chronic obstructive pulmonary disease (COPD) exacerbation Guide to laboratory tests | 26 Causes of cardiac troponin elevation (other than acute coronary syndrome) (continued) CHRONIC Stable atherosclerotic coronary artery disease Hypertension / Left ventricular (LV) hypertrophy Other coronary disease e.g. SLE, scleroderma, Pulmonary arterial hypertension Kawasaki’s disease, transplant vasculopathy Atrial fibrillation Aortic valve disease Chronic heart failure Hypertrophic cardiomyopathy Chronic renal failure Infiltration: amyloidosis, haemochromatosis, sarcoidosis Hypothyroidism Peri-partum cardiomyopathy Diabetes mellitus Carbohydrate metabolism Analyte Ref. Range Units Interpretation Glucose fasting 3.9 − 6.0 mmol/l ↑: Impaired fasting glucose, diabetes mellitus type 1 and type 2, strenuous excercise, stress, severe illness, hyperthyroidism, Cushing’s syndrome, acromegaly, phaeochromocytoma, corticosteroid therapy, acute and chronic pancreatitis. ↓: Insulinoma, Addison’s disease, poisoning (e.g. alcohol, salicylates), medication (sulfonylureas), hepatic failure, postprandial (reactive hypoglycaemia, postgastrectomy, gastroenterostomy). Insulin fasting 0 − 10 µIU/ml ↑: Insulin resistance syndrome, obesity, diabetes mellitus type 2, (Abbott) insulinoma. 2.1 − 10.4 ↓: Diabetes mellitus type 1. (Beckman) 0.2 − 9.4 (Roche) Quick index ≥0.36 <0.36 indicative of insulin resistance. 27 | Ampath Desk Reference

Analyte Ref. Range Units Interpretation HbA1c 4.3 − 6.1 % Reflects the mean blood glucose concentration over the past (Biorad) 4 – 8 weeks. 4.0 – 6.0 Target for diabetic glycaemic control: Ideal <7%; (Roche) Poor >8%. Fructosamine 205 − 285 µmol/l Reflects the mean blood glucose concentration over the past (Roche) 2 – 3 weeks. Useful in patients with Hb variants and gestational diabetes mellitus.

Criteria for diagnosing diabetes and categories of intermediate hyperglycaemia

Interpretation Plasma glucose HbA1c (mmol/l) (%) Fasting OGTT (2 hr) or random Normal <6.1 And <7.8 Impaired fasting glycaemia (IFG) 6.1 – 6.9 And <7.8 N/A Impaired glucose tolerance (IGT) <7.0 And 7.8 – 11.0 N/A Diabetes Mellitus (DM) (two abnormal ≥7.0 And / or ≥11.1 And / or ≥6.5 values confirm diagnosis)

• An HbA1c of 6.5% is recommended as the cut point for diagnosing diabetes. An HbA1c value less than 6.5% does not exclude diabetes if glucose values are within the diabetic range. • In an asymptomatic person the diagnosis should not be based on a single abnormal glucose or HbA1c result, but should be confirmed by at least one additional HbA1c or plasma glucose in the diabetic range, either fasting, random or 2 hours following an oral 75 g glucose load (OGTT). Guide to laboratory tests | 28 • Important conditions to adhere to before performing the OGTT are ingestion of at least 150 g of dietary carbohydrate per day for 3 days prior to the test, a 10 to 16 hour fast, and commencement of the test between 7 am and 9 am. • The use of blood glucose monitoring meters and non-laboratory HbA1c methods for diagnosis of diabetes is discouraged. WHO recommendations (2013 update) for classification of hyperglycaemia during pregnancy:

Interpretation Plasma glucose Plasma glucose (mmol/l) (mmol/l) Fasting OGTT 75 g Random with diabetes symptoms 1 hour 2 hour DM in pregnancy (If either / both ≥7.0 ≥11.1 ≥11.1 values are abnormal, confirm by a repeat test on another day)

Gestational Diabetes Mellitus 5.1 – 6.9 ≥10.0 8.5 – 11.0 (one abnormal value confirms the diagnosis at any gestation)

Hyperglycaemia detected at any time during pregnancy should be classified as either: • Diabetes mellitus in pregnancy • Gestational DM in pregnancy NB: The use of the 50 g and 100 g OGTT tests have been abandoned in favour of the 75 g OGTT. Guidelines for use of HbA1c levels to diagnose DM in pregnancy are not yet established. 29 | Ampath Desk Reference Factors influencing HbA1c measurement (consider when HbA1c and glucose results are discrepant)

Increased HbA1c Decreased HbA1c Erythropoiesis Iron deficiency, vitamin Administration of iron, B12 or erythropoietin, B12 deficiency, decreased reticulocytosis, chronic liver disease erythropoiesis Altered Haemoglobin variants do not directly cross- haemoglobin react with assays used, but lead to decreased erythrocyte lifespan, HbF is often measured as part of total Hb Erythrocyte Increased erythrocyte lifespan: Decreased erythrocyte life span: destruction Splenectomy Haemoglobinopathies, haemolytic anaemia or other causes of haemolysis e.g.splenomegaly or malaria, RA or drugs (antiretrovirals, ribavirin and dapsone) Glycation Alcoholism, chronic renal Aspirin, vitamin C and E, certain failure haemoglobinopathies, increased intra- erythrocyte pH

HbA1c targets for glycaemic control: • The optimal HbA1c target for the majority of diabetic patients is 7.0% tested at 6 monthly intervals. • A lower HbA1c target of 6.5% is advocated for younger, newly diagnosed patients at low risk for CVD. • A higher HbA1c target of 7.5% is applicable to the elderly, patients at high risk for CVD, those with poor short-term prognosis or hypoglycaemic unawareness. • Although HbA1c may not be used for diagnosis of Gestational Diabetes Mellitus, it can be used for monitoring treatment with a lower target level of 6%. Guide to laboratory tests | 30 Diagnostic criteria for insulin resistance syndrome / metabolic syndrome The diagnosis of the metabolic syndrome requires increased waist circumference plus any 2 of the other criteria according to the International Diabetes Federation (IDF) definition.

Parameter Categorical cut points Elevated waist circumference ≥ 94 cm in men ≥ 80 cm women Elevated Triglycerides ≥1.7 mmol/l or Drug treatment for elevated TG Reduced HDL – Cholesterol <1.0 mmol/l men <1.3 mmol/l women Elevated blood pressure ≥130 mm Hg systolic BP or ≥85 mm Hg diastolic BP or Drug treatment for hypertension Elevated fasting glucose ≥5.6 mmol/l or Previously diagnosed type 2 diabetes mellitus 31 | Ampath Desk Reference Lipid metabolism CVD Risk Stratification and Cholesterol Targets (SA Dyslipidaemia Guidelines 2012)

Fasting lipogram required

Exclude secondary causes: • Diabetes • Hypothyroidism • Liver / renal disease • Alcohol excess • Medication e.g. progestins, steroids, antiretrovirals, retinoids

• Institute lifestyle changes Category 1: Very high risk (DO NOT score) • Start statin immediately • Established atherosclerotic disease (coronary artery, cerebrovascular or peripheral artery disease) Treatment goal: • Type 2 diabetes (>40y age, >10y duration) • Type 1 diabetes with micro-albuminuria / • LDL-C <1.8 mmol/l proteinuria • And / or >50% reduction Guide to laboratory tests | 32

Category 2: Score using updated Framingham scores (Use correct gender table and score for age, T-Chol, smoking status, HDL-C, systolic BP – see scoring table)

CVD risk <3% CVD risk 3 – <15% CVD risk 15 – 30% CVD risk >30% (low risk) (moderate risk) (high risk) (very high risk) • Institute lifestyle • Institute lifestyle • Institute lifestyle • Institute lifestyle changes changes changes changes • Consider statin if • Consider statin if • Start statin • Start statin LDL-C persistently LDL-C persistently immediately if immediately >4.9 mmol/l >3.0 mmol/l LDL-C >2.5 mmol/l

Treatment goal: Treatment goal: Treatment goal: T-Chol <5.0 mmol/l T-Chol <4.5 mmol/l T-Chol <4.0 mmol/l LDL-C: <3.0 mmol/l LDL-C: <2.5 mmol/l LDL-C: <1.8 mmol/l (Non-HDL Chol <3.8 mmol/l) (Non-HDL Chol <3.3 mmol/l) (Non-HDL Chol <2.6 mmol/l)

Reference: South African Dyslipidaemia Guideline Consensus Statement. SAMJ 2012 March; 102(3): 178-188. http://www.samj.org.za/index.php/samj/article/view/5502 33 | Ampath Desk Reference Framingham 10-year risk assessment chart for patients without diabetes Risk of CVD: coronary heart disease, stroke, peripheral artery disease or heart failure

Estimate of 10-year risk of CVD for men Estimate of 10-year risk of CVD for women Age (years) Points Age (years) Points 30 – 34 0 30 – 34 0 35 – 39 2 35 – 39 2 40 – 44 5 40 – 44 4 45 – 49 6 45 – 49 5 50 – 54 8 50 – 54 7 55 – 59 10 55 – 59 8 60 – 64 11 60 – 64 9 65 – 69 12 65 – 69 10 70 – 74 14 70 – 74 11 75 years or older 15 75 years or older 12 Total cholesterol Total cholesterol Points Points (mmol/l) (mmol/l) <4.10 0 <4.10 0 4.10 – 5.19 1 4.10 – 5.19 1 5.20 – 6.19 2 5.20 – 6.19 3 6.20 – 7.20 3 6.20 – 7.20 4 >7.20 4 >7.20 5 HDL – cholesterol HDL – cholesterol Points Points (mmol/l) (mmol/l) ≥1.50 -2 ≥1.50 -2 1.30 – 1.49 -1 1.30 – 1.49 -1 Guide to laboratory tests | 34

Estimate of 10-year risk of CVD for men Estimate of 10-year risk of CVD for women HDL – cholesterol HDL – cholesterol Points Points (mmol/l) (mmol/l) 1.20 – 1.29 0 1.20 – 1.29 0 0.90 – 1.19 1 0.90 – 1.19 1 <0.90 2 <0.90 2 Systolic BP – untreated Systolic BP – untreated Points Points (mmHg) (mmHg) <120 -2 <120 -3 120 –129 0 120 –129 0 130 – 139 1 130 – 139 1 140 – 159 2 140 – 149 2 ≥160 3 150 – 159 4 ≥160 5 Systolic BP – on Systolic BP – on antihypertensive Points antihypertensive Points treatment (mmHg) treatment (mmHg) <120 0 <120 -1 120 –129 2 120 –129 2 130 – 139 3 130 – 139 3 140 – 159 4 140 – 149 5 ≥160 5 150 – 159 6 ≥160 7 Smoker Points Smoker Points No 0 No 0 Yes 4 Yes 3 35 | Ampath Desk Reference

Points total for men Points total for women Points total 10-year risk (%) Points total 10-year risk (%) -3 or less <1 -2 or less <1 -2 1.1 -1 1.0 -1 1.4 0 1.1 0 1.6 1 1.5 1 1.9 2 1.8 2 2.3 3 2.1 3 2.8 4 2.5 4 3.3 5 2.9 5 3.9 6 3.4 6 4.7 7 3.9 7 5.6 8 4.6 8 6.7 9 5.4 9 7.9 10 6.3 10 9.4 11 7.4 11 11.2 12 8.6 12 13.2 13 10.0 13 15.6 14 11.6 14 18.4 15 13.5 15 21.6 16 15.6 16 25.3 17 18.1 17 29.4 18 20.9 18 or more >30 19 24.0 20 27.5 20 or more >30 Guide to laboratory tests | 36

Point totals indicate the 10-year risk of cardiovascular disease (coronary, cerebrovascular and peripheral)

Low risk High risk

Moderate risk Very high risk

Adapted from D’Agostino RB, et al., General cardiovascular risk profile for use in primary care: The Framingham Heart Study. Circulation 2008;117:743-753 and Mosca L, et al., Effectiveness-based guidelines for the prevention of cardiovascular disease in women 2011 update: A guideline from the American Heart Association. Circulation 2011;123:1243-1262. 37 | Ampath Desk Reference Laboratory tests for dyslipidaemia Screening

Analyte Indications Random total cholesterol Asymptomatic patient without known secondary causes for dyslipidaemia. Fasting lipogram Random total cholesterol >5 mmol/l. Secondary causes of dyslipidaemia. Existing cardiovascular disease. Family history of premature cardiovascular disease (men <55 years, women <65 years). Signs of dyslipidaemia.

Conditions for fasting lipogram

Condition Time period No eating, drinking (except water), smoking 12 hours before test Usual diet, weight and activity level At least 2 weeks No major illness or surgery At least 3 months No pregnancy At least 6 weeks

Additional testing which might be indicated if lipogram is abnormal 1. Urine dipstick 2. Serum creatinine and eGFR 3. TSH 4. Fasting glucose and / or HbA1c Guide to laboratory tests | 38

Additional testing which might be indicated if lipogram is abnormal (continued) 5. Liver function tests 6. CK 7. Apo B especially in diabetes mellitus and metabolic syndrome

Other lipid parameters

Analyte Ref.Range Units Interpretation Non-HDL Refer to risk mmol/l Non-HDL cholesterol provides an estimate of the total cholesterol groups for number of atherogenic particles in plasma including therapeutic LDL, VLDL, IDL and Lipo(a). Non-HDL cholesterol is targets (p.32) recommended as secondary target for treatment especially in patients with diabetes mellitus, metabolic syndrome and chronic kidney disease, where hypertriglyceridaemia / mixed hyperlipidaemia is commonly found. Therapeutic targets are 0.8 mmol/l above LDL targets. Lipoprotein (a) <75 nmol/l ↑: Genetic. Secondary causes include uncontrolled diabetes mellitus, hypothyroidism, chronic renal failure, nephrotic syndrome. Apolipoprotein A-I >1.2 g/l ↓: Familial causes, hepatocellular disorders, cholestasis, nephrotic syndrome, chronic renal failure, malignancy. Apolipoprotein B <1.2 g/l ↑: Familial hypercholesterolaemia, familial combined hyperlipidaemia, polygenic (sporadic) hypercholesterolaemia, and other secondary causes of hypercholesterolaemia. 39 | Ampath Desk Reference Interpretation of abnormal lipid profiles

TG TC HDLC LDLC Causes Extreme hyper- <2.5 >15 N >13 Primary: LDL-receptor defect, Autosomal recessive cholesterolaemia hypercholesterolaemia. Secondary: Nephrotic syndrome, cholestatic liver disease. Severe hyper- <2.5 >7.5 N >5 Primary: LDL-receptor defect, Apo B defect, PCSK9 cholesterolaemia defect, familial combined hyperlipidaemia (FCH). Secondary: Hypothyroidism, nephrotic syndrome, chronic renal failure, diabetes mellitus type 2, pregnancy, cholestatic liver disease, primary biliary cirrhosis, acute intermittent porphyria, SLE, Cushing’s syndrome. Medication: Amiodarone, corticosteroids, immunosuppressants (e.g. cyclosporine), protease inhibitors, retinoids. Moderate hyper- <2.5 >5 N >3 Primary: Polygenic. cholesterolaemia Secondary: Obesity, metabolic syndrome, hypothyroidism, nephrotic syndrome, chronic renal failure, diabetes mellitus type 2, pregnancy, obstructive liver disease, primary biliary cirrhosis, acute intermittent porphyria, SLE , Cushing’s syndrome. Medication: Amiodarone, corticosteroids, immunosuppressants (e.g. cyclosporine), loop diuretics, protease inhibitors, retinoids, thiazide diuretics, unopposed progestogens. Guide to laboratory tests | 40

TG TC HDLC LDLC Causes Hyper-alpha- <2.5 >5 >2 N Primary: Familial hyper-alpha-lipoproteinaemia. lipoproteinaemia* Secondary: Oestrogens, alcohol, chronic hepatitis, primary biliary cirrhosis. Mixed hyper- Primary: lipidaemia 1.7 – 5 >5 L H FCH. 1.7 – 5 >5 L L Dysbetalipoproteinaemia. 1.7 – 5 >5 L N Metabolic syndrome. 1.7 – 5 >5 L H, N Secondary: Obesity, hypothyroidism, diabetes mellitus type 2, poorly controlled diabetes mellitus type 1, nephrotic syndrome, pregnancy, SLE, chronic renal failure. Medication: Combined oral contraceptives with second generation progestogens, immunosuppressants, loop diuretics, thiazide diuretics, protease inhibitors, retinoids. Moderate hyper- 5 – 15 >5 L VAR Primary: Familial combined hyperlipidaemia, triglyceridaemia hereditary hypertriglyceridaemia. Secondary: Obesity, diet, metabolic syndrome, diabetes mellitus type 2, poorly controlled diabetes mellitus type 1, chronic renal failure, hypothyroidism, alcohol abuse, nephrotic syndrome, pregnancy, viral hepatitis, biliary cirrhosis, extrahepatic biliary obstruction, infection, inflammation, HIV not on HAART. Medication: Beta-blockers, clozapine, immunosuppressive drugs especially when combined with corticosteroids, loop diuretics, olanzapine, oral contraceptives, protease inhibitors, retinoids, tamoxifen, thiazide diuretics, unopposed oestrogens. 41 | Ampath Desk Reference

TG TC HDLC LDLC Causes Severe hyper- >15** >5*** L VAR Primary: Familial combined hyperlipidaemia, triglyceridaemia lipoprotein lipase deficiency, Apo C2 deficiency. Secondary: Obesity, diet, diabetes mellitus type 2, poorly controlled diabetes mellitus type 1, metabolic syndrome, chronic renal failure, hypothyroidism, alcohol abuse, nephrotic syndrome, pregnancy, viral hepatitis, biliary cirrhosis, extrahepatic biliary obstruction, infection, inflammation, HIV not on HAART. Medication: Protease inhibitors, retinoids. Severe hypo- VAR <2.5 VAR <1.5 Primary: Abetalipoproteinaemia, cholesterolaemia hypobetalipoproteinaemia. (low LDLC) Secondary: Severe acute illness, infection, inflammation, malnutrition, malabsorption, malignancy, hyperthyroidism, hepatocellular necrosis, HIV not on HAART. * HDLC >2.5 mmol/l may be associated with increased risk for atherosclerosis. ** Triglyceride >15 mmol/l may trigger acute pancreatitis and is a medical emergency. *** The most common cause of cholesterol >15 mmol/l is extreme hypertriglyceridaemia, i.e. the cholesterol is increased secondary to the increased triglycerides and often normalises when the triglycerides have normalised. VAR Varies depending on cause Guide to laboratory tests | 42

TG TC HDLC LDLC Causes Hypoalphalipo- VAR VAR <0.9 VAR Primary: Tangier disease, fish eye disease, familial proteinaemia LCAT deficiency, familial CETP deficiency, familial Apo (low HDLC) A1 deficiency. Secondary: Obesity, metabolic syndrome, cigarette smoking, diabetes mellitus type 2, poorly controlled diabetes mellitus type 1, hepatocellular disorders, cholestasis, chronic renal failure, nephrotic syndrome, hypothyroidism, hyperthyroidism, malignancy, Cushing’s syndrome, chronic illnesses, severe illnesses, Crohn’s disease, coeliac disease, SLE, HIV not on HAART. Medication: Beta-blockers, unopposed progestogens, anabolic steroids. VAR Varies depending on cause 43 | Ampath Desk Reference Effects of secondary causes of dyslipidaemia on the lipogram TC LDLC HDLC TG LIFESTYLE Alcohol ↔ ↔ ↑ ↑ Cigarette smoking ↔ ↔ ↓ ↔ Diet (high saturated fats and cholesterol) ↑ ↑ ↔ ↑ Diet (high caloric intake, rapid weight gain, obesity) ↑ ↑ ↓ ↑ Physical stress ↓ ↓ ↔ ↑ ENDOCRINOPATHIES Diabetes mellitus type 1 (poor control) ↑ ↑ ↓ ↑ Diabetes mellitus type 2 ↑ ↑ ↓ ↑ Hypothyroidism ↑ ↑ ↑ ↔ ↓ ↔ ↑ Hyperthyroidism ↓ ↓ ↓ ↓ Metabolic syndrome ↑ ↑ ↓ ↑ Obesity ↑ ↑ ↓ ↑ GASTROINTESTINAL AND HEPATIC DISEASE Acute Intermittent Porphyria ↑ ↑ ↔ ↔ Cholestatic liver disease ↑ ↑ ↔ ↑ ↑ Coeliac disease ↓ ↓ ↓ ↔ Crohn’s disease ↓ ↓ ↓ ↔ RENAL DISEASE Chronic renal failure ↔ ↔ ↓ ↑ Nephrotic syndrome ↑ ↑ ↔ ↓ ↔ ↑ Guide to laboratory tests | 44

TC LDLC HDLC TG MISCELLANEOUS HIV (untreated) ↓ ↓ ↓ ↑ Pregnancy ↑ ↑ ↑ ↑ SLE ↑ ↑ ↓ ↑ Severe illness ↓ ↓ ↔↓ ↑ DRUGS a-Blockers ↓ ↓ ↑ ↓ Amiodarone ↑ ↑ ↔ ↔ β-Blockers ↔ ↔ ↓ ↑ Clozapine ↔ ↔ ↔ ↑ Loop diuretics ↑ ↑ ↔ ↑ Protease inhibitors ↑ N/A ↓ ↑ Retinoids ↑ ↑ ↔ ↓ ↑ Thiazide diuretics ↑ ↑ ↔ ↑ Steroids ↑ ↑ N/A ↑ Immunosuppressants ↑ ↑ ↑ ↑ Combined oral contraceptives with: Second-generation progestogens N/A ↑ ↓ ↑ Third-generation progestogens N/A ↓ ↑ ↑ Hormone replacement therapy ↓ ↓ ↑ / ↔ / ↓ ↑ / ↔ / ↓ Unopposed oestrogens ↓ ↓ ↑ ↑ Unopposed progestogens N/A ↑ ↓ ↓ Raloxifene ↓ ↓ ↔ ↔ Tamoxifen ↓ ↓ ↔ ↑ 45 | Ampath Desk Reference Iron studies Analyte Ref. Range Unit Interpretation Iron M 11.6 – 31.3 µmol/l ↑: Pernicious and haemolytic anaemia, haemochromatosis, F 9.0 – 30.4 acute hepatitis, iron therapy, repeated blood transfusions. ↓: Iron deficiency anaemia, acute and chronic infections. Transferrin M 2.2 – 3.7 g/l ↑: Iron deficiency anaemia, exogenous oestrogen intake, F 2.5 – 3.8 pregnancy. ↓: Haemochromatosis, inflammation, hepatocellular disease, iron supplements. Percentage M 20 – 50 % ↑: Haemochromatosis, secondary iron overload (liver disease, transferrin F 15 – 50 untreated pernicious anaemia, >50 blood transfusions). saturation ↓: Iron deficiency anaemia, iron depletion, acute and chronic Infections, some chronic disorders, rheumatoid arthritis. Ferritin M 20 – 250 ng/ml ↑↑:Haemochromatosis, HIV, non-HIV chronic infection, liver F 10 – 120 disease, malignancy, renal disease, chronic transfusions. (Beckman) ↑: Infection, chronic inflammation, autoimmune disease M 30 – 400 (RA, SLE), megaloblastic anaemia. F 13 – 150 ↓: Iron deficiency. (Roche) Interpretation of iron profile Condition S-Iron S-Transferrin % Transferrin S-Ferritin saturation Iron deficiency anaemia ↓ / ↔ ↑ / ↔ * ↓ / ↔ ↓ / ↔ * Iron overload e.g. ↑ ↓ / ↔ ↑ ↑ ↑ Haemochromatosis Chronic disease ↓ / ↔ ↓ / ↔ ↔ / ↓ VAR Acute disease ↓ ↔ ↓ ↑ *Concomitant infection/inflammation Guide to laboratory tests | 46

Condition S-Iron S-Transferrin % Transferrin S-Ferritin saturation Liver disease ↑ VAR VAR ↑ Pernicious anaemia ↑ ↔ / ↓ ↑ ↑ VAR – varies according to cause A fasting morning specimen is preferred. • In the earlier stages of haemochromatosis, the percentage transferrin saturation may be increased with a normal ferritin. • Haemochromatosis PCR is available if haemochromatosis is suspected. • Ferritin is a positive acute-phase protein. • In the presence of an acute-phase response a ferritin level below 50 ng/ml is regarded as an indication of depleted iron stores, whereas a level >100 ng/ml excludes iron deficiency. • A soluble transferrin receptor determination is recommended for ferritin levels between 50 ng/ml and 100 ng/ml to help distinguish between iron deficiency (increased) and an iron transfer block due to inflammation / chronic disease (normal). Folate and vitamin B12

Analyte Ref. Range Units Interpretation Serum Folate 10.0 – 45.1 nmol/l Serum folate is the test of choice for assessment of folate status. (Beckman) Red blood cell folate is only indicated in dialysis patients and where the serum folate is normal in the presence of clinical findings suggestive of deficiency. ↑: Excess daily intake, vitamin B12 deficiency. 10.4 – 42.4 ↓: Alcoholism, malnutrition, liver disease, adult coeliac disease, (Roche) Crohn’s disease, malabsorption, haemolytic anaemia, carcinoma, pregnancy. 47 | Ampath Desk Reference

Analyte Ref. Range Units Interpretation Red blood 317 – 1894 nmol/l ↑: Excess daily intake. cell folate (Beckman) ↓: Alcoholism, malnutrition, liver disease, vitamin B12 deficiency, 1133 – 3413 adult coeliac disease, Crohn’s disease, malabsorption, (Roche) haemolytic anaemia, carcinoma, pregnancy. Vitamin B12 M 107 – 418 pmol/l ↑: Chronic renal failure, severe congestive heart failure, diabetes F 107 – 443 mellitus, liver disease, certain leukaemias, certain carcinomas. (Beckman) ↓: Lack of intrinsic factor (pernicious anaemia, total or partial M/F 156 – 698 gastrectomy, atrophic gastritis, intrinsic factor antibody); (Roche) malabsorption (pancreatic insufficiency, regional ileitis, coeliac disease); dietary deficiency (vegetarians). ENDOCRINOLOGY Thyroid function tests

Reference ranges Manufacturer FT4 (pmol/l) FT3 (pmol/l) TSH (mIU/l)

Abbott 10 – 20 2.6 – 5.7 0.35 – 4.2 Beckman 7.6 – 16.1 3.5 – 5.4 0.35 – 3.5 Roche 12 – 22 3.1 – 6.8 0.27 – 4.2 Guide to laboratory tests | 48 Interpretation of thyroid function tests

Combination of results Clinical condition FT4 (pmol/l) FT3 (pmol/l) TSH (mIU/l) Subclinical hypothyroidism N N ↑ (Treat if >10) Primary hypothyroidism ↓↓ N / ↓ ↑ Secondary hypothyroidism ↓↓ N /↓ N / ↓ Subclinical hyperthyroidism N N ↓↓ (Suppressed) Primary hyperthyroidism / excessive ↑ ↑ ↑ ↓↓ (Suppressed) thyroid hormone replacement Secondary hyperthyroidism / thyroid ↑ ↑ ↑ N / ↑ hormone resistance (both very rare) ↓/ N / Euthyroid sick syndrome ↓ / N / ↑ ↓↓ ↑ (Recovery) Amiodarone, salicylate, heparin, ↑↑ ↑ N NSAID’s Phenytoin / glucocorticoids N N ↓↓ (Suppressed) Lithium ↓ ↓↓ ↑ Phenytoin, Carbamazepine, Rifampicin, ↓ N N Tertroxin 49 | Ampath Desk Reference

Analyte Ref. Range Units Interpretation Thyroid <10 IU/ml ↑: Autoimmune thyroid disease (Hashimoto’s thyroiditis, peroxidase (Beckman) Graves’ disease, idiopathic myxedoema), increased levels antibodies <35 can occur in 8 – 27% of individuals with no symptoms of (Roche) disease. Thyroglobulin <116 IU/ml ↑: Hashimoto’s thyroiditis, thyroid carcinoma, some cases antibodies (Roche) of thyrotoxicosis, pernicious anaemia, SLE, De Quervain’s subacute thyroiditis, 10% of the normal population may have a moderate increase. TSH receptor <1.75 IU/l ↑: Graves’ disease antibodies (Roche) Thyroglobulin 3.5 – 77.0 ng/ml ↑: Hashimoto’s thyroiditis, Graves’ disease, thyroid adenoma, (Roche) subacute thyroiditis. Also used as a tumour marker for monitoring recurrence of thyroid cancer.

Goals for thyroid hormone replacement: Ideal TSH: 0.50 – 2.00 mIU/l (1.50 – 3.00 mIU/l with underlying CVD / elderly). Eltroxin: FT4: high normal – mildly increased. Tertroxin: FT3: high normal – mildly increased. Guide to laboratory tests | 50 Other endocrinology tests

Analyte Ref. Range Units Interpretation 17-hydroxy – M 1.9 – 6.52 nmol/l ↑: Congenital adrenal hyperplasia, some cases Progesterone F Follicular phase 0.97 – 4.45 of adrenal or ovarian neoplasms. Luteal phase 0.76 – 8.79 Oral contraceptive 0.60 – 5.75 Post menopausal 0.56 – 2.15 (Beckman RIA) Acetylcholine 0 – 0.24 nmol/l >0.41: Myasthenia gravis receptor (IBL RIA) 0.25 – 0.40: Autoimmune diseases other than antibodies Myasthenia Gravis. ACTH 1.6 – 13.9 pmol/l ↑: Adrenal insufficiency, Cushing’s disease, (Roche) ectopic ACTH-producing tumour. ↓: Pituitary insufficiency, adrenal Cushing’s syndrome. Active ≤80 Ratio >80 is suggestive of primary aldosterone: hyperaldosteronism (Conn’s syndrome). renin ratio 51 | Ampath Desk Reference

Analyte Ref. Range Units Interpretation Aldosterone Resting 49 – 644 pmol/l ↑: Primary hyperaldosteronism / Conn’s syndrome Active 70 – 1087 (renin ↓). (DiaSorin Liaison) ↑: Secondary hyperaldosteronism (renin ↑) With hypertension: Renal artery stenosis, unilateral renal disease with severe hypertension, high-renin forms of hypertension, renal parenchymal disease, oral contraceptive-induced hypertension, phaeochromocytoma. Without hypertension: Congestive heart failure, liver cirrhosis, nephrotic syndrome ↓: Addison’s disease, diabetic nephropathy, renal failure, drugs (e.g. ACE inhibitors). Androstene- M 2.1 – 10.8 nmol/l ↑: Polycystic ovarian syndrome, congenital dione F 1.0 – 11.5 adrenal hyperplasia, Cushing’s syndrome, (Siemens Immulite) hyperplasia of ovarian stroma, ovarian tumour, cyproterone acetate therapy. Bone alkaline M 3.7 – 20.9 μg/l ↑: Postmenopausal, Paget’s disease, phosphatase F Premenopausal 2.9 – 14.5 hyperthyroidism, hyperparathyroidism, Postmenopausal 3.8 – 22.6 acromegaly, bone malignancies (bone forming), bone fractures (recovery phase), (Beckman) osteoporosis (sometimes, especially high turnover type). Increased S-BALP normalises 3 – 6 months after successful therapy. Guide to laboratory tests | 52

Analyte Ref. Range Units Interpretation Cortisol M / F ≤9.7 nmol/l ↑: Cushing’s syndrome – useful for screening. midnight Samples should not be collected when any (saliva) (IBL) oral disease or inflammation is present (blood contamination) or when taking any exogenous corticosteroids (including oral, nasal, aerosol or topical preparations). Cortisol 08h00 – 10h00: 101 – 535 nmol/l ↑: Cushing’s syndrome, ↑ oestrogen (serum) After 17h00: 79 – 477 (oral contraceptives, oestrogen 24h00: <50 administration, pregnancy), depression (Abbott) and other psychiatric conditions, alcohol 08h00 – 10h00: 185 – 624 dependence, morbid obesity, poorly 16h00 – 20h00: <276 controlled diabetes mellitus, physical stress 24h00: <50 (hospitalisation, surgery, pain), malnutrition, (Beckman) anorexia nervosa, intense chronic exercise, 08h00 – 10h00: 142 – 651 exogenous hydrocortisone administration 16h00 – 20h00: 51 – 424 (usually intravenous) due to cross-reactivity 24h00: <50 with the method. (Roche) ↓: Addison’s disease, congenital adrenal hyperplasia, exogenous corticosteroids [oral (e.g. Celestamine, Meticorten); local injections with betamethasone (e.g. Celestone, Betanoid, Lenasone, Diprosone), methylprednisolone (Depo-Medrol), dexamethasone (Decasone, Dexona); inhalation]. 53 | Ampath Desk Reference

Analyte Ref. Range Units Interpretation Cortisol M 11.6 – 165.6 nmol/ ↑: Cushing’s syndrome, other causes as listed (24-hour urine) F 8.3 – 118.7 24h under ↑ serum cortisol except ↑ oestrogen. (LC-MS) DHEA-S M 21 – 30 years 2.3 – 13.9 µmol/l ↑: Polycystic ovarian syndrome, congenital 31 – 40 years 2.9 – 12.6 adrenal hyperplasia, adrenal cortex 41 – 50 years 1.9 – 13.4 adenomas and carcinomas, Cushing’s 51 – 54 years 1.0 – 8.5 disease, ectopic ACTH-producing tumors. 55 – 60 years 1.1 – 8.6 ↓: Primary and secondary adrenal insufficiency. 61 – 70 years 0.7 – 6.6 ≥71 years 0.1 – 6.9 F 21 – 30 years 0.5 – 10.6 31 – 40 years 0.6 – 7.2 41 – 50 years 0.5 – 6.3 51 – 54 years 0.2 – 5.1 55 – 60 years 0.4 – 6.0 61 – 70 years 0.3 – 3.6 ≥71 years 0.2 – 4.8 (Beckman) Guide to laboratory tests | 54

Analyte Ref. Range Units Interpretation DHEA-S M 15 – 19 years 1.4 – 14.2 µmol/l 20 – 24 years 5.1 – 13.5 25 – 44 years 1.8 – 13.9 45 – 54 years 1.0 – 9.9 55 – 64 years 1.1 – 8.6 65 – 74 years 0.9 – 6.9 ≥ 75 0.4 – 5.6

F 15 – 19 years 1.5 – 11.4 20 – 24 years 3.9 – 11.5 25 – 44 years 1.5 – 10.8 45 – 54 years 0.8 – 8.7 55 – 74 years 0.4 – 6.0 ≥ 75 0.2 – 4.5 (Roche) FSH M 1.0 – 12.0 IU/l ↑: Testicular absence or failure, ovarian absence (Abbott) or premature failure, menopause. : Anterior pituitary hypofunction, hypothalamic M 1.3 – 19.3 ↓ disorders, hyperprolactinaemia, polycystic (Beckman) ovarian syndrome, severe illness, pregnancy, M 1.2 – 15.8 oral contraceptives. (Roche) F See ovarian profile table 55 | Ampath Desk Reference

Analyte Ref. Range Units Interpretation Growth M 0 – 0.97 µg/l ↑: Gigantism, acromegaly, exercise, stress, hormone F 0.01 – 3.61 prolonged fasting, uncontrolled diabetes (Ultrasensitive Beckman) mellitus, hypoglycaemia, renal failure, liver cirrhosis, malnutrition, anorexia nervosa. ↓: Pituitary dwarfism, hypopituitarism. IGF-1 M / F 18 years 163 – 584 µg/l ↑: Acromegaly. (Somatomedin) 19 years 141 – 483 ↓: Growth hormone deficiency, hypopituitarism, 20 years 127 – 424 malnutrition, anorexia, hepatocellular disease, 21 years 116 – 358 hypothyroidism. 26 years 117 – 329 31 years 115 – 307 36 years 109 – 284 41 years 101 – 267 46 years 94 – 252 51 years 87 – 238 56 years 81 – 225 61 years 75 – 212 66 years 69 – 200 71 years 64 – 188 76 years 59 – 177 81 years 55 – 166 (Siemens) Guide to laboratory tests | 56

Analyte Ref. Range Units Interpretation LH M 0.6 – 12.1 IU/l ↑: Testicular absence or failure, ovulation, ovarian (Abbott) absence or premature failure, polycystic ovarian syndrome, menopause. M 1.2 – 8.6 : Anterior pituitary hypofunction, hypothalamic (Beckman) ↓ disorders, severe stress, severe illness, M 1.3 – 9.6 hyperprolactinaemia, pregnancy, oral (Roche) contraceptives. F See ovarian profile table Oestradiol M 40 – 161 pmol/l ↑: Exogenous oestradiol, fertility treatment, (Abbott) perimenopausal, liver cirrhosis, hyperthyroidism, pregnancy. M 95-223 : Anovulation, primary and secondary (Roche) ↓ hypogonadism, postmenopausal, oral F See ovarian profile table contraceptives. Progesterone M 0.7 – 4.7 nmol/l ↑: Pregnancy. (Abbott) ↓: Threatened abortion, primary or secondary hypogonadism, short luteal phase syndrome, M 0.4 – 6.6 oral contraceptives, postmenopausal. (Beckman) M 0.7 – 4.7 (Roche) F See ovarian profile table 57 | Ampath Desk Reference

Analyte Ref. Range Units Interpretation Prolactin M ≥18 years 3 – 13 µg/l ↑: Prolactin-secreting pituitary tumours, F 18 – 49 years 3 – 27 hypothalamic-pituitary disease ≥50 years 3 – 20 (e.g. craniopharyngioma), stress, primary (Beckman) hypothyroidism, polycystic ovarian disease, M ≥18 years 4 – 15 renal failure, adrenal insufficiency, anorexia F ≥18 years 5 – 23 nervosa, chest wall injury, medication (Roche) (e.g. antipsychotics, monoamine oxidase inhibitors, opiates, tricyclic antidepressants), macroprolactinaemia. ↓: Pituitary apoplexy (Sheehan’s syndrome). Guide to laboratory tests | 58

Analyte Ref. Range Units Interpretation Renin Resting 2.2 – 45.4 mU/l ↑: With secondary hyperaldosteronism and Active 3.5 – 56 hypertension: Renal artery stenosis, unilateral renal disease with severe hypertension, (DiaSorin Liaison) high-renin forms of hypertension, renal parenchymal disease, oral contraceptive- induced hypertension, phaeochromocytoma. ↑: With secondary hyperaldosteronism, oedema and normal BP: congestive heart failure, liver cirrhosis, nephrotic syndrome. ↑: Without secondary hyperaldosteronism – Addison’s disease, potassium depletion, ACE inhibitors, angiotensin receptor antagonist. ↑: With secondary hyperaldosteronism and hypovolemia: Vomiting, diarrhoea, blood loss, diuretics, etc. ↓: With hypertension: primary hyperaldosteronism, low-renin essential hypertension, sometimes with renal parencymal disease. Serotonin M / F 70 – 270 ng/ml ↑: Carcinoid syndrome, dumping syndrome, acute intestinal obstruction, cystic fibrosis, (Fast Track RIA) nontropical sprue. ↓: Severe depression, Parkinson’s disease 59 | Ampath Desk Reference

Analyte Ref. Range Units Interpretation SHBG M 18 – 19 years 13.0 – 88.0 nmol/l ↑: Pregnancy, exogenous oestrogen, ≥20 years 13.3 – 89.5 hyperthyroidism, liver cirrhosis, advancing age. F 18 – 46 years 18.2 – 135.5 ↓: Hypothyroidism, excess testosterone, obesity, ≥47 years 16.8 – 125.2 polycystic ovarian syndrome. (Beckman) M i≥18 years 11.4 – 52.3 F 18 – 49 years 19.8 – 122 ≥50 years 14.1 – 68.9 (Roche) Testosterone M 18 – 30 years 9.0 – 28.3 nmol/l Total 31 – 49 years 6.9 – 23.6 i ≥50 years 6.1 – 18.7 F ≥18 years <2.7 (Beckman) M 17 – 49 years 8.0 – 27.1 ≥50 years 8.0 – 18.7 F ≥17 years <1.9 (Roche) Testosterone M 18 – 49 years 170 – 660 pmol/l ↑: Polycystic ovarian syndrome, idiopathic Free ≥50 years 170 – 419 hirsutism, virilising adrenal tumours, virilising (Calculated) F i18 – 46 years 6.0 – 55.0 ovarian tumours, Cushing’s syndrome, ≥47 years 2.0 – 33.0 congenital adrenal hyperplasia, exogenous (Beckman) testosterone administration, obesity. M 17 – 49 years 180 – 536 ↓: Primary (LH / FSH ↑) and secondary ≥50 years 180 – 419 hypogonadism (LH / FSH ↓). F 17 – 50 years 1.0 – 34.0 >50 years 1.0 – 22.0 (Roche) Guide to laboratory tests | 60 Ovarian profile These tests should be evaluated in conjunction with the clinical picture (pre-pubertal, phase of the menstrual cycle in menstruating women, menopause, etc). To confirm ovulation progesterone determination should be done on day 21 of the menstrual cycle.

Ref. Ranges (Abbott) FSH LH Oestradiol Progesterone Follicular 3.0 – 8.1 1.8 – 11.8 77 – 921 <9.3 Midcycle 2.6 – 16.7 7.6 – 89.1 139 – 2382 2.4 – 9.4 Luteal 1.4 – 5.5 0.6 – 14.0 77 – 1145 4.5 – 111 Oral contraceptive <5.7 <104 Post menopausal 26.7 – 133.4 5.2 – 62.0 <104 <2.7 Pregnancy first trimester <0.1 <0.1 33 – 140 Prepubertal 0.7 – 6.7 <4.0 <100 <1.8

Ref. Ranges (Beckman) FSH LH Oestradiol Progesterone Follicular 3.9 – 8.8 2.1 – 10.9 99 – 448 1.0 – 4.8 Midcycle 4.5 – 22.5 19.2 – 103 180 – 1068 Luteal 1.8 – 5.1 1.2 – 12.9 349 – 1589 16.4 – 59 Oral contraceptive <5.7 <145 Post menopausal 16.7 – 113.6 10.9 – 58.6 <148 <2.5 Pregnancy first trimester 3670 – >13216 15 – 161 Prepubertal 0.7 – 6.7 <4.0 <100 <1.8 61 | Ampath Desk Reference

Ref. Ranges (Roche) FSH LH Oestradiol Progesterone Follicular 2.9 – 14.6 1.9 – 14.6 45 – 854 <9.3 Midcycle 4.7 – 23.2 12 – 118 151 – 1461 2.4 – 9.4 Luteal 1.4 – 8.9 0.7 – 12.9 82 – 1251 4.5 – 111 Oral contraceptive <5.7 <140 Post menopausal 16 – 157 5.3 – 65.4 <184 <2.7 Pregnancy first trimester <0.1 <0.1 563 – 11902 33 – 140 Prepubertal 0.7 – 6.7 <4.0 <150 <1.8 Anti-Müllerian Hormone Use of AMH in males A measurable value in a boy or adult male with bilateral cryptorchidism is predictive of undescended testes, whereas an undetectable level is highly suggestive of anorchia. Use of AMH in female patients Since AMH is produced continuously in the granulosa cells of small follicles, the AMH level can be used to assess the ovarian reserve. Although there are slight fluctuations of AMH during the menstrual cycle, it is not considered clinically significant enough to recommend sampling during a specific phase. Although oral or vaginal oestrogen- or progestin-based contraceptives show minimal effect, it is preferable to determine AMH levels after discontinuation of the medication for at least 4 weeks. After puberty, AMH concentration declines slowly over the reproductive lifespan as the size of the pool of follicles decrease and frequently reach undetectable levels after natural or premature menopause. Guide to laboratory tests | 62 Use of AMH for IVF treatment Fertility studies have shown that females with higher AMH concentrations (indicating better ovarian reserve) have a better response to ovarian stimulation and tend to produce more retrievable oocytes than those with low or undetectable levels. Significantly elevated AMH levels can be used to identify females at risk of ovarian hyperstimulation syndrome following gonadotropin administration. The following values can be used to predict the response following ovarian stimulation, but should be used in combination with clinical and ultrasound findings (antral follicular count). These values have been adjusted for the new automated method (Beckman Coulter DXI) implemented by Ampath during March 2015.

Suggested cut-off values ng/ml pmol/l Response to ovarian stimulation treatment <0.17 <1.2 Negligible / non-responders 0.17 – 1.21 1.2 – 8.6 Reduced / poor response (≤2 eggs at oocyte retrieval) 1.22 – 2.30 8.7 – 16.4 Normal response (3 – 20 eggs at oocyte retrieval) >2.30 >16.4 High / excessive response (>20 eggs at oocyte retrieval)

In patients with polycystic ovarian syndrome (PCOS), serum AMH levels may be elevated due to large numbers of small follicles. AMH levels have subsequently also been shown to be affected by differences in body mass index and insulin levels. Use of AMH as tumour marker for granulosa cell tumours of the ovaries Serum AMH concentrations may be increased in patients with ovarian granulosa cell tumours which comprise approximately 10% of all ovarian tumours. AMH combined with CA 125 may be useful for monitoring response to treatment and follow up of patients with these tumours. 63 | Ampath Desk Reference Pregnancy Interpretation of βHCG results Analyte Ref. Range Units Interpretation βHCG 0 – 4.9 Negative mIU/ml Positive 8 – 11 days after conception. 5 – 25 Equivocal βHCG reaches 25 IU/l in 50% of >25 Positive pregnant women on the first day of their missed period. Screening for foetal anomalies in the first and second trimesters of pregnancy • For all tests listed below, a completed Ampath Down’s screening request form should be submitted, as calculated risks are dependent on the accuracy of information provided by the referring clinician. • Calculated risks are screening tests and NOT diagnostic. First-trimester screening (FTDS) • Has better sensitivity than second-trimester screening • Combined risk (with Nuchal Translucency (NT) measurement) has better sensitivity than biochemistry risk (without NT measurement) • Biochemistry risk can be done 8w 0d – 13w 6d • Combined risk can be done 10w 6d – 13w 6d • Includes Trisomy 21 (Down’s syndrome) and Trisomy 18 (Edward’s syndrome) • Does not include neural tube defects. Second-trimester screening (STDS) • Should not be done if FTDS has already been done (integrated first- and second-trimester screening is not available at Ampath yet) • Can be done 15w 0d – 20w 6d • Includes Trisomy 21, Trisomy 18 and neural tube defects Guide to laboratory tests | 64 Neural tube defect (NTD) screening • Should be done if FTDS has been done • Can be done 15w 0d – 20w 6d

Optimal step wise approach for best sensitivity: • Step 1: 8w 0d – 9w 6d: Blood collection for Biochemistry Risk (request FTDS) • Step 2: 10w 6d – 13w 6d: Sonar to measure NT for Combined Risk, no blood collection, no cost (request FTDS2) • Step 3: 15w 0d – 20w 6d: Blood collection for NTD

TUMOUR MARKERS Please note: Tumour markers should not be used for screening for malignancy. An increased marker does not necessarily indicate the presence of a tumour, whilst a normal marker does not indicate the absence of a tumour. Tumour marker reference ranges

Marker Ref. Range Units Specimen AFP 0 – 10 µg/l Blood b-2-microglobulin 1.1 – 2.5 mg/l Blood CA 125 0 – 35 U/ml Blood CA 15–3 (Abbott) 0 – 31 U/ml Blood CA 15–3 (Beckman) 0 – 23 U/ml Blood CA 15–3 (Roche) 0 – 34 U/ml Blood 65 | Ampath Desk Reference

Marker Ref. Range Units Specimen CA 19–9 0 – 37 U/ml Blood CA 72–4 0 – 6.9 U/ml Blood Calcitonin M 0 – 8.4 ng/l Blood F 0 – 5.0 Catecholamines Adrenaline 0 – 109 nmol/d 24-hour urine Noradrenaline 89 – 473 Dopamine 424 – 2612 CEA 0 – 5 ng/ml Blood Chromogranin A 0 – 85 ng/ml Blood Ferritin M 20 – 250 ng/ml Blood F 10 – 120 (Beckman) M 30 – 400 F 13 – 150 (Roche) Gastrin 0 – 115 ng/l Blood (>500 diagnostic of gastrinoma) HCG 0 – 5 IU/ml Blood (Values up to 11.6 may be seen in post-menopausal females) HIAA 10.4 – 41.6 μmol/d Random or 24-hour urine 0 – 7.2 μmol/mmol (with HCl as preservative) Guide to laboratory tests | 66

Marker Ref. Range Units Specimen HE4 (Human Epididymal 18-39 y <60.5 pmol/l Blood protein 4) 40-49 y <76.2 50-59 y <74.3 60-69 <82.9 >70 <104 ROMA-index Premenopausal % < 11.4 Postmenopausal <29.9 (see below) HVA 8 – 48 μmol/d Random or 24-hour urine 2 – 6.4 μmol/mmol (with HCl as preservative) Metanephrines 160 – 2478 nmol/d 24-hour urine 26 – 176 nmol/mmol (with HCl as preservative) Normetanephrines 241 – 3418 nmol/d 24-hour urine 21 – 312 nmol/mmol (with HCl as preservative) NSE 0 – 16 µg/l Blood PSA 0 – 4 ng/ml Blood Free PSA:PSA ratio See table below Blood S100-B 0.005 – 0.105 µg/l Blood SCC 0.3 – 2.0 ng/ml Blood Serotonin 70 – 270 ng/ml Blood 67 | Ampath Desk Reference

Marker Ref. Range Units Specimen Serum free light chains: Blood Kappa 3.3 – 19.4 mg/l Lambda 5.71 – 26.3 mg/l Ratio 0.26 – 1.65 Thyroglobulin 1.4 – 78 ng/ml Blood TPA 0 – 75 U/l Blood Urine light chains: Urine Kappa 0 – 7.1 mg/l Lambda 0 – 3.9 mg/l Ratio 0.75 – 4.5 VMA 11.5 – 34.6 μmol/d 24-hour urine (with HCl as 0.7 – 4.3 μmol/mmol preservative) Intended clinical use of HE4 and ROMA Index • Risk assessment for ovarian cancer in patients with a pelvic mass (in conjunction with CA 125) • Monitoring the treatment of patients with epithelial ovarian cancer (EOC) Risk assessment of ovarian cancer in patients with a pelvic mass • When compared to CA 125, HE4 has better sensitivity in the early stages of EOC and better sensitivity to discriminate malignant from benign disease. When combined, the ability of these markers to discriminate benign from malignant disease is further enhanced by the Risk of Ovarian Malignancy Algorithm (ROMA). The algorithm takes into account the HE4 and CA 125 values as well as menopausal status of the patient. The algorithm calculates the predictive probability of finding EOC on surgery in patients with pelvic masses. A ROMA value of ≥11.4% in pre-menopausal women and a value of ≥29.9% in post-menopausal women are consistent with an increased risk to find malignancy on surgery. Guide to laboratory tests | 68

Sensitivity at 95% specificity to discriminate benign Biomarker from malignant disease CA 125 43.3% HE4 72.9% CA 125 + HE4 76.4% Distribution of patients in low- and high-risk groups Benign disease vs EOC and low-malignant potential tumours Menopausal status Sensitivity Specificity Negative predictive value Combined 88.7% 74.7% 93.9% Pre-menopausal 76.5% 74.8% 95% Post-menopausal 92.3% 74.7% 92.6%

Interpretation of PSA Ratio (Free PSA:Total PSA) 1. PSA Ratio is useful with total PSA values of 2.5 – 10 ng/ml. 2. PSA Ratio is generally lower in carcinoma and higher in benign hyperplasia. PSA ratio: >0.25 Probability for prostate cancer <10%. <0.10 Probability for prostate cancer >80%. 3. Probability of finding prostate cancer on needle biopsy increases with increasing age and decreasing PSA ratios. 69 | Ampath Desk Reference Probability of finding prostate cancer on needle biopsy: Beckman method: % FPSA 50 – 64 years 65 – 75 years 0 – 10 % 56% 55% >10 – 15% 24% 35% >15 – 20% 17% 23% >20 – 25% 10% 20% >25% 5% 9% Abbott & Roche method: % FPSA 50 – 59 years 60 – 69 years ≥70 years <11% 49% 58% 65% 11 – 18% 27% 34% 41% 19 – 25% 18% 24% 30% >25 % 9% 12% 16%

Appropriate tumour markers for specific tumours

Tumour Tumour marker Breast CEA, CA 15-3 Bladder CEA, TPA Biliary tract CA 19-9 Colon Stool occult blood, CEA, CA 19-9 Cervix SCC, CEA Choriocarcinoma HCG Carcinoid 24-hour urine 5-HIAA, Chromogranin A, Serotonin, NSE Guide to laboratory tests | 70

Tumour Tumour marker Germ cell AFP, HCG Head and neck SCC Liver AFP, CEA Lung – small-cell lung cancer NSE, TPA Lung – non-small-cell lung cancer TPA, CEA Lymphoma, leukaemia Ferritin, b-2-microglobulin Melanoma S-100B Serum protein electrophoresis, urine Bence Jones protein, Myeloma serum free light chains Neuroblastoma Urine HVA, NSE, Chromogranin A Oesophagus SCC CA 125 and HE4 with ROMA-value (most common). Ovary Others CA 72-4, CEA, CA 19-9, CA 15-3 Pancreas CA 19-9, CEA, CA 72-4 (less common) Prostate PSA, free PSA Urine meta- and normetanephrines, plasma meta- and Phaeochromocytoma normetanephrines, Chromogranin A Stomach CA 72-4 Testis AFP, HCG, LDH, NSE Thyroid Thyroglobulin, CEA Thyroid C-cell carcinoma Calcitonin Uterus SCC, CA 125 The tumour marker list above is not a complete list and includes only the markers which occur most commonly in these tumours. 71 | Ampath Desk Reference THERAPEUTIC DRUGS Drug Ref. Range Units Time of sampling ANTIDEPRESSANTS Amitryptyline / Trough: 100 – 250 μg/l Prior to next dose or minimum 12 hours Tryptanol Toxic: >500 post dose. Fluoxetine / Trough: 30 – 500 μg/l Prior to next dose. Prozac Toxic: >1000 Imipramine / Trough: 150 – 250 μg/l Prior to next dose or minimum 12 hours Tofranil Toxic: >500 post dose. ANTI-EPILEPTICS Carbamazepine / Therapeutic: 17 – 51 μmol/l Prior to next dose (to assess efficacy). Tegretol Toxic: >63 For monitoring of possible toxicity a peak level is recommended (4 – 8 hours after oral dose). Clonazepam / Therapeutic: 20 – 80 μg/l Prior to next dose after time to steady state Rivotril Toxic: >80 (7 days) has been reached.

Gabapentin / Therapeutic: 2 – 20 mg/l Prior to next dose after time to steady state Neurontin Toxic: >25 (1 – 2 days) has been reached. Lamotrigine / Therapeutic: 2.5 – 15 mg/l Trough (prior to next dose) after time to Lamictin Toxic: >20 steady state has been reached: 3 – 6 days or 5 – 15 days with valproic acid comedication. Levetiracetam / Peak: 10 – 63 mg/l Peak: 1 hour post dose. Keppra Trough: 3 – 34 Trough: Prior to next dose. Guide to laboratory tests | 72

Drug Ref. Range Units Time of sampling Phenobarbitone / Therapeutic: 65 – 172 μmol/l Prior to next dose (to assess efficacy). For Lethyl monitoring of possible toxicity a PEAK level Toxic: is recommended (4 – 10 hours after oral Slowness, >172 dose). Levels often increase after addition ataxia, of valproic acid to the treatment regime, nystagmus usually requiring an adjustment in dosage. Coma >280 Phenytoin / Therapeutic: 40 – 79 μmol/l Prior to next dose (to assess efficacy). Epanutin For monitoring of possible toxicity a peak Toxic: level is recommended (4 – 8 hours after Lateral >79 oral dose). nystagmus Depressed >158 mental capacity Topiramate / Trough: 5 – 20 mg/l Prior to next dose, preferably after steady Topamax Toxic: not state has been reached. Time to steady established state: 4 – 5 days. Valproic acid / Therapeutic: 346 – 693 μmol/l Prior to next dose (to assess efficacy). Epilim Toxic: >693 For monitoring of possible toxicity a peak level is recommended (1– 4 hours after oral dose). 73 | Ampath Desk Reference

Drug Ref. Range Units Time of sampling ANTI-INFECTIVES Antibacterials: Amikacin PEAK Level: μg/ml PEAK: Intermittent dosing: 15 – 30 60 minutes after bolus IV / IM dose or Single daily (pulse) dosing: 56 – 64 60 minutes after start of a 30-minute IV infusion. TROUGH Level: TROUGH: Intermittent dosing: 5 – 10 Immediately prior to next dose. Single daily (pulse) dosing: <1 Gentamycin PEAK Level: μg/ml PEAK: Intermittent dosing: 4 – 10 60 minutes after bolus IV / IM dose or Single daily (pulse) dosing: 16 – 24 60 minutes after start of a 30-minute IV infusion. TROUGH Level: TROUGH: Intermittent dosing: 1 – 2 Immediately prior to next dose. Single daily (pulse) dosing: <1 Tobramycin PEAK Level: μg/ml PEAK: Intermittent dosing: 4 – 10 60 minutes after bolus IV / IM dose or Single daily (pulse) dosing: 16 – 24 60 minutes after start of a 30-minute IV infusion.

TROUGH Level: TROUGH: Intermittent dosing: 1 – 2 Immediately prior to next dose. Single daily (pulse) dosing: <1 Guide to laboratory tests | 74

Drug Ref. Range Units Time of sampling Vancomycin PEAK Level: μg/ml PEAK: Intermittent dosing: 20 – 50 60 minutes after bolus IV / IM dose or 60 minutes after start of a 30 minutes TROUGH Level: IV infusion. Non-serious infections : 5 – 10 Serious infections: 10 – 15 TROUGH: Cloxacillin-resistant Immediately prior to next dose. S.aureus (MRSA) pneumonia: 15 – 20 CONTINUOUS INFUSION: Target Plateau level: 20 – 25 Antimycotics: Voriconazole Trough: 1 – 6 mg/l Prior to next dose. Antiparasitic: Quinine Therapeutic: 15.4 – 30.8 umol/l Toxic: >30.8 Antiretrovirals: Atazanavir / Minimum target trough Reyataz concentration: 150 ng/ml Prior to next dose. Efavirenz / Minimum target trough Stocrin concentration: 1000 ng/ml Prior to next dose. Indinavir / Minimum target trough Crixivan concentration: 100 ng/ml Prior to next dose. Lopinavir / Minimum target trough Kaletra / Aluvia concentration: 1000 ng/ml Prior to next dose. 75 | Ampath Desk Reference

Drug Ref. Range Units Time of sampling Nelfinavir / Minimum target trough Viracept concentration: 800 ng/ml Prior to next dose. Nevirapine / Minimum target trough Viramune concentration: 3400 ng/ml Prior to next dose. Ritonavir / Norvir Minimum target trough concentration: 2100 ng/ml Prior to next dose. Saquinavir / Minimum target trough Invirase concentration: 100 ng/ml Prior to next dose. Tipranavir / Minimum target trough Aptivus concentration: 20500 ng/ml Prior to next dose. BRONCHODILATORS Theophylline Therapeutic: μmol/l Immediately prior to next dose. 0 – 30 Days 33 – 72 After dosage adjustment, repeat ≥1 Month 44 – 111 sampling is recommended after Toxic: >111 48 – 72 hours for oral dosing. CARDIAC Digoxin Therapeutic: 1 – 2.6 nmol/l Prior to next dose ideally, but at least Toxic: >3.2 8 – 12 hours after previous dose. PSYCHOLEPTICS Antipsychotics: Clozapine / Trough: 250 – 750 μg/l Prior to next dose. Leponex Guide to laboratory tests | 76

Drug Ref. Range Units Time of sampling Lithium Therapeutic: 0.4 – 1.2 mmol/l 24 hours after dose ideally, but at Target concentrations: least 12 hours after previous dose. Acute mania 0.8 – 1.2 Prophylaxis 0.4 – 0.8 Toxic: >1.5 Benzodiazepines: Chlordiazepoxide Trough: 400 – 3000 μg/l Prior to next dose. / Librium Toxic: >3500 Clonazepam / Therapeutic: 20 – 80 μg/l Trough or peak after time to steady Rivotril Toxic: >80 state (7 days) has been reached Trough: prior to next dose. Peak: 1 – 4 hours post dose. Diazepam / Therapeutic: 200 – 1500 μg/l Trough levels (prior to next dose) are Valium Toxic: >3000 most reproducible. Flunitrazepam / Peak: 5 –15 μg/l 1 – 2 hours post dose. Rohypnol Toxic: >50 Lorazepam / Therapeutic: 50 – 240 μg/l Trough levels (prior to next dose) are Ativan Toxic: >300 most reproducible. Midazolam / Therapeutic: 40 – 150 μg/l Trough or peak after time to steady Dormicum Toxic: >1000 state (app. 6.5 – 12.5 hours) has been reached. Trough: prior to next dose Peak: 0.22 – 1.12 hours post oral dose. Nitrazepam / Therapeutic: 30 – 100 μg/l Trough levels (prior to next dose) are Mogadon Toxic: >299 most reproducible. 77 | Ampath Desk Reference

Drug Ref. Range Units Time of sampling Oxazepam / Peak: 200 – 1400 μg/l 2 – 4 hours post dose. Serepax Toxic: >2000 Zolpidem / Therapeutic: <251 μg/l Random. Expected concentration Stillnox when taking therapeutic daily dose. CLINICAL TOXICOLOGY Paracetamol overdose / toxicity: • The first specimen should not be taken earlier than 4 hours after paracetamol ingestion to ensure complete absorption. Serial sampling (2 – 3 samples, at 2 – 3 hour intervals) is recommended if the time of ingestion is uncertain or unreliable or if extended-release medication has been taken and may be used to estimate the paracetamol elimination half-life (probable hepatotoxicity risk if half-life more than 4 hours, hepatic coma risk if half-life more than 12 hours).

Serum paracetamol levels (μmol/l) Hours after ingestion Toxic concentration 4 >993 6 >695 8 >497 10 >347 12 >248 • Acetylcysteine should be instituted if the patient’s serum paracetamol concentration is above or near the toxic level for the time after ingestion. • In substantial overdose (≥7.5 g or ≥125 mg/kg) and in patients where the time of intake is doubtful, treatment should be started before paracetamol levels are available. The antidote may subsequently be discontinued if levels are below the toxic range. Guide to laboratory tests | 78 • Patients presenting more than 24 hours after ingestion with detectable paracetamol levels should also be treated and hepatotoxicity ruled out. • For patients on hepatic enzyme inducers (e.g. barbiturates, phenytoin, carbamazepine, rifampicin, meprobamate, alcohol abusers) or those with depleted glutathione (e.g. malnutrition and HIV) antidote therapy may be started at levels 25% lower than the above. • The following additional investigations are recommended daily in toxic patients: Potassium (hypokalaemia), urea, creatinine, LFT, glucose and INR. Salicylate overdose / toxicity: • Salicylate absorption may be delayed when overdose quantities are consumed, therefore serum salicylate values should be interpreted with care, especially if obtained earlier than 6 hours after ingestion. • Repeat testing within 2 – 3 hours to ensure that absorption is complete. Correlation of serum salicylate levels with level of toxicity after acute ingestion (should not be used for chronic toxicity) Serum salicylate levels (mmol/l) Hours after ingestion Asymptomatic Severe toxic 6 <3.26 >6.52 8 <3.04 >6.19 10 <2.79 >5.79 12 <2.59 >5.18 24 <1.74 >3.48 36 <1.21 >2.27 48 <0.78 >1.45 60 0 >0.83 Intermediate values are associated with mild to moderate toxicity. 79 | Ampath Desk Reference Organophosphate Toxicity Acute exposure Serum cholinesterase ↓: Organophosphates days to weeks, (pseudocholinesterase) carbamates up to 48 hours. See other causes of decreased serum cholinesterase on page 11. Chronic exposure RBC cholinesterase ↓: 1-3 months (RBC lifespan) DRUGS OF ABUSE Drug of abuse Street Name(s) Type of Approximate duration of specimen detectability Amphetamine Speed, Crystal, Ice, Uppers, Ecstacy, Urine 1 – 4 days Ephedrine, Pseudoephedrine Barbiturates Blue Heavens, Velvet, Devil, Red devils, Urine Short acting: 1 day Pink lady, Purple Hearts Long acting: up to 14 days Benzodiazepines Benzos, Mellow, Downers, Ativan, Blood 3 hours to 3 days Rohypnol, Valium, Serepax Urine Average 1 – 9 days, up to 30 days Cannabinoids / THC Dagga, Marijuana, Pot, Weed Urine 2 – 5 days (infrequent use) 3 – 4 weeks (chronic use) 6.5 – 11 weeks (heavy use) CAT (Methcathinone) CAT Urine At least 24 hours Guide to laboratory tests | 80

Drug of abuse Street Name(s) Type of Approximate duration of specimen detectability Cocaine Crack, Coke, Rock, Snow, Flake, Blow Urine Average: 2 – 3 days, up to 7 – 9 days Ecstacy “X” Urine At least 24 hours Lysergic Acid Acid Urine 0 – 48 hours Diethylamide (LSD) Metamphetamine Tik-Tik Urine At least 24 hours Methadone Meth, Methadose Urine 1 – 3 days Methaqualone and Mandrax, Soaps, Love Pill Urine 90 – 225 hours Diphenhydramine 2 weeks after a therapeutic dose Opiates (codeine, Morphine: Junk, White Stuff, “M” Urine Occasional use: 7 – 54 heroin, morphine) hours Heroin: Horse, White Lady, “H” Chronic use: up to 11 – 12 days on confirmation method *Opiate immunoassays do not cross-react with synthetic opioids (eg. Buprenorphine) or some commonly used opioid analgesics (eg. Fentanyl, meperidine (pethidine) and methadone). Phencyclidine Angel dust, PCP Urine Average 1 – 14 days, up to 30 days Propoxyphene PPX, Doloxene Urine 1 – 2 days 81 | Ampath Desk Reference ALCOHOL ABUSE Ethanol • Cut-off: 0.05 g/dl (SA legal limit when driving) • Use: - Detect acute alcohol use - Detect tolerance (>0.15 g/dl without intoxication or >0.3 g/dl at any time) • Ingestion of >2 beers by a person weighing 70 kg, would cause blood alcohol to be >0.05 g/dl, 1 hour after ingestion • Time to normalize with abstinence is hours, depending on the dose • Short detection time limits the use

%CDT (Carbohydrate deficient transferrin) • Cut-off: 2.47% (N-Latex INA method) • Sensitivity 93%, Specificity 97% • Use: - Most useful to monitor abstinence in alcoholics - Detect at least 1 week of heavy drinking in alcoholics • Ingestion of 50 – 80 g/d (4 – 6 beers/d) for at least 1 week would cause an abnormal result • Time to normalize with abstinence: 2 – 4 weeks Guide to laboratory tests | 82 • Notes on %CDT: • Normal transferrin has 4 carbohydrate chains. With excessive alcohol use, forms of transferrin that contain no, one or two carbohydrate chains, collectively known as CDT, increase. • In alcoholics that relapse, lower alcohol use can lead to rapid re-elevation. • %CDT is the most accurate single serum marker for chronic alcohol use and recent heavy drinking, which is readily available. • The main strength of %CDT is specificity. • Single episodes of acute alcohol intoxication do not elevate CDT. • %CDT is less sensitive to detect alcohol abuse in females. • False positive results may occur due to non alcoholic liver disease (primary billiary cirrhosis, chronic active hepatitis, chronic Hepatitis C, hepatocellular carcinoma), carbohydrate deficient glycoprotein syndrome (rare), cystic fibrosis, pregnancy, untreated galactosaemia, rectal carcinoma, senile dementia, depression, pregnancy and solvent abuse. False positive results do not occur with genetic transferrin variants or high transferrin concentrations with the N-Latex INA (immuno-nephelometric assay) currently in use. • %CDT methods include immunoassays, capillary electrophoresis and HPLC. Results and cut-off values from different methods cannot be used interchangeably. 83 | Ampath Desk Reference LABORATORY INVESTIGATIONS FOR SPECIFIC CLINICAL DISORDERS Screening tests for endocrine disorders

Disease Screening tests Addison’s disease 8 – 10 am ACTH and cortisol Carcinoid syndrome LABORATORY TESTS: 24-hour urine 5-hydroxyindoleacetic acid (5-HIAA), serum serotonin, plasma chromogranin A. Preparation for 24-hour urine collection for 5-HIAA determination: 48 hours before and during collection: No tea and coffee, nicotine, avocados, dates, eggplant, butternut, fruit, nuts, tomatoes and tomato products. Medication: Avoid for 7 days if possible False positive: paracetamol, cough syrups containing guaifenesin or antihistamines, mephenesin (e.g Spasmend), methocarbamol (Robaxin, Flexeril), reserpine, diazepam, phenobarbital. False negative: L-dopa (Sinemet), methyldopa (Aldomet), MAOIs, isoniazid, TAD, methenamine (e.g. Hipramine), phenothiazines, salicylates, heparin, chlorpromazine (Largactil), hydrazine, prochlorperazine (Stemetil), promazine, promethazine (Phenergan). Serum serotonin: Medication: Discontinue for 7 days False positive: MAOI, methyldopa, lithium, reserpine, morphine. False negative: SSRI – escitalopram, citalopram, fluvoxamine, paroxetine, sertraline. Medication: Discontinue for 10 weeks False negative: SSRI – fluoxetine. Chromogranin A (CgA): Medication: Proton Pump Inhibitors: discontinue for 2 weeks H2-receptor antagonists: discontinue for 3 days Corticosteroids: discontinue for 2 weeks Guide to laboratory tests | 84

Disease Screening tests Cushing’s syndrome First line screening: midnight salivary cortisol, 24-hour urinary cortisol excretion or overnight dexamethasone suppression test. Any oestrogen intake should be discontinued for 2 months before the dexamethasone suppression test. Confirmation: midnight salivary cortisol (24 – 48 hours apart), 24-hour urinary cortisol excretion (at least 1 week apart) or dexamethasone suppression test. Diabetes insipidus Serum electrolytes, urea, creatinine and osmolality, 24 hour urine volume and random urine osmolality after an 8 hour overnight fast. Hypercalcaemia and PTH, phosphate, magnesium. hypocalcaemia Phaeochromocytoma LABORATORY TESTS: Urine meta- and normetanephrines, plasma meta- and normetanephrines, plasma chromogranin A. Urine meta- and normetanephrines: Patient preparation Discontinue 1 week prior to specimen collection, if possible: TAD’s, beta blockers, MAOI, phenothiazines, phenoxybenzamine, L-Dopa. Allowable drugs: hydralazine, ACE inhibitors, ARB’s, diuretics (small effect). Plasma meta- and normetanephrines: Patient preparation Discontinue for at least 5 days prior to specimen collection, if possible: Caffeine, decaffeinated coffee, nicotine, cocaine, TAD, phenoxybenzamine, MAOI Allowable drugs: diuretics, vasodilators e.g. hydralazine and minoxidil, and calcium channel blockers. Collection of the specimen after the patient has rested for 15 minutes in a supine position is recommended. 85 | Ampath Desk Reference

Disease Screening tests Primary Active aldosterone: renin ratio (ARR) hyperaldosteronism Preparation for ARR measurement: 1. Hypokalaemia must be corrected. 2. Sodium intake should not be restricted, rather liberalise. 3. Stop medication that markedly affect ARR for at least 4 weeks: • Spironolactone, eplerenone, amiloride, triamterene. • Potassium-wasting diuretics. • Products derived from licorice root (chewing tobacco, licorice).

If the ARR is not diagnostic and hypertension can be controlled with relatively non-interfering medications: Withdraw other medications that may affect ARR for at least 2 weeks: 1. False positive ARR: β-Adrenergic blockers, central α-2 agonists (e.g. clonidine and α-methyldopa), nonsteroidal anti-inflammatory drugs, oestrogen. 2. False negative ARR: Angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, renin inhibitors, dihydropyridine calcium channel blockers. Medication that can be used include verapamil slow-release, hydralazine (with verapamil slow release, to avoid reflex tachycardia), prazosin, doxazosin, terazosin. Guide to laboratory tests | 86 Diagnosis of Porphyria • The 3 most common forms of Porphyria in South Africa are: • Porphyria Variegata (VP, acute porphyria, neurovisceral and / or skin presentation) • Porphyria Cutanea Tarda (PCT, skin presentation) • Acute Intermittent Porphyria (AIP, acute porphyria, neurovisceral presentation) A. Acute neurovisceral symptoms (abdominal pain, nausea, vomiting, constipation, bladder dysfunction, hypertension, tachycardia, hyponatraemia, seizures, peripheral neuropathy) • Request a STAT Porphyria Screen Urine on a random urine specimen protected from light • Urine porphobilinogen (PBG) and total free porphyrins are 10-fold increased with an acute porphyria attack • Failure to diagnose an acute porphyria attack may cause: • Death, as life-saving Rx will not be given • Administration of porphyrinogenic drugs • Unnecessary surgery • Only the diagnosis is important in this setting as the initial treatment of all types of acute porphyria is the same 87 | Ampath Desk Reference B. Skin lesions OR to determine the type of porphyria • Request a Porphyria Study • Submit urine, faeces and EDTA blood specimens protected from light, ideally while symptomatic. • The tests may be negative between acute attacks or when skin lesions are not present at the time of testing, therefore specimen collection should proceed if symptoms are present and not be delayed for 3 days to follow the diet below. Negative test results do not rule out a diagnosis of porphyria and follow up testing may be necessary. • The patient should refrain from taking the following for 3 days prior to and on the collection day: red meat, pork, biltong, meat extracts (Marmite, Oxo, soup, gravy etc.), aspirin and laxatives. OR • Request a Porphyria Variegata PCR on an EDTA blood specimen if Porphria Variegata is suspected clinically C. Family of a porphyria patient (siblings and children) • First diagnose the type of porphyria in the index patient. • Request a Porphyria Study (see above) if the index patient was diagnosed with a type of Porphyria other than Porphyria Variegata. The tests may be negative in the absence of symptoms and in children. Negative results in children should be repeated when clinically indicated until 20 years of age before porphyria can be excluded. OR • Request a Porphyria Variegata PCR (see above) if the index patient was diagnosed with Porphyria Variegata. Guide to laboratory tests | 88 Causes and investigation of Gynaecomastia Physiological causes 1. Neonatal 2. Pubertal (25%) 3. Involutional (mostly 50 – 80 year-old men) Pathological Causes Test 1. Neoplasms HCG, oestradiol. Testicular (3%) – germ cell, Sertoli cell, Leydig cell Adrenal (adenoma or carcinoma) Ectopic production of HCG (especially lung, liver and kidney cancer) 2. Primary gonadal failure (8%) Testosterone, LH, FSH. 3. Secondary hypogonadism (2%) Testosterone, LH, FSH, prolactin. 4. Liver disease Liver function tests. 5. Renal disease and dialysis (1%) Urea and creatinine. 6. Hyperthyroidism (2%) TSH, free T4, free T3. 7. Hyperprolactinaemia Prolactin, testosterone, oestradiol, LH, FSH. 8. Starvation especially during the recovery phase 9. Medication (10 – 20%): Amiodarone, androgens and anabolic steroids, anti-retroviral therapy (some), captopril, cimetidine, cyproterone, diazepam, digitoxin, enalapril, oestrogen and oestrogen agonists, flutamide, haloperidol, isoniazid, ketoconazole, methyldopa, metronidazole, nifedipine, omeprazole, penicillamine, phenothiazines, phenytoin, ranitidine, reserpine, verapamil, tricyclic antidepressants 10. Drugs of abuse: Alcohol, amphetamines, cannabis, heroin 11. Idiopathic (25%) 89 | Ampath Desk Reference Investigation of Female Hirsutism

Differential diagnosis 1. Polycystic Ovarian Syndrome 2. Non-classic congenital adrenal hyperplasia (e.g. 21-hydroxylase deficiency) 3. Cushing’s Syndrome 4. Hyperprolactinaemia 5. Adrenal tumour First line investigations Serum free testosterone, androstenedione, DHEAS, 17-OH progesterone during days 3 – 7 of the menstrual cycle, prolactin and midnight salivary cortisol / 24-hour urinary cortisol excretion / overnight dexamethasone suppression test.

Secondary causes and investigation of osteoporosis

Cause Tests A. Endocrine 1. Hyperparathyroidism Calcium, phosphate, PTH. 2. Cushing’s syndrome See screening tests for endocrine disorders. 3. Hypogonadism Oestradiol, LH, FSH (females). Testosterone, LH, FSH (males). 4. Hyperthyroidism TSH, free T4, free T3. 5. Prolactinoma Prolactin. 6. Type 1 diabetes mellitus Plasma glucose, oral glucose tolerance test, HbA1c. 7. Pregnancy and lactation Guide to laboratory tests | 90

B. Gastro-intestinal and liver disease 1. Subtotal gastrectomy Clinical history. 2. Malabsorption Serum total protein, albumin, oral fat loading test, xylose absorption test, faecal elastase, stool α-1-antitrypsin. 3. Hepatobiliary disease Liver function tests. C. Bone marrow disorders 1. Multiple myeloma Serum protein electrophoresis, urine Bence Jones protein. 2. Disseminated carcinomatosis Clinically appropriate tumour markers. 3. Leukaemia Full blood count. 4. Lymphoma Clinically, full blood count, ESR, β-2-microglobulin. D. Miscellaneous 1. Smoking History. 2. Chronic alcoholism Liver function tests, CDT, MCV. 3. Immobilisation History. 4. Rheumatoid arthritis Rheumatoid Factor. 5. Chronic obstructive pulmonary disease X-rays lungs, lung function tests. 6. Chronic renal failure Urea, creatinine, eGFR. E. Medications 1. Corticosteroids 2. Heparin 3. Anticonvulsants 4. Lithium 5. Excess thyroid hormone therapy TSH, Free T4, Free T3. 91 | Ampath Desk Reference Osteoporosis in men Common causes of osteoporosis in men are hypogonadism, alcohol abuse and glucocorticoid excess. In 50% of men, a secondary cause is present and in the other 50% no cause may be found (idiopathic osteoporosis). Work-up for hypertension Laboratory tests indicated following initial diagnosis of hypertension Serum urea, creatinine, glucose and total cholesterol. Random urine sample for albumin-to-creatinine ratio (ACR). Follow up visits • Creatinine (with eGFR), serum electrolytes, fasting glucose and fasting lipogram are recommended after the introduction of a new antihypertensive agent and then annually or more frequently if clinically indicated. • Annual urine albumin-to-creatinine ratio if eGFR is 60-89 When should secondary hypertension be considered? • Onset of hypertension before age 20 or after age 50 years. • Very high blood pressure (>200 / 120 mm Hg). • Organ damage: Fundoscopy: grade 2 or more retinopathy. Serum creatinine >150 µmol/l. Cardiomegaly. Features of secondary hypertension: • Spontaneous hypokalaemia (primary hyperaldosteronism, Cushing’s syndrome, renal artery stenosis). • Abdominal systolic bruit (renal artery stenosis). • Episodic hypertension, tachycardia, sweat, tremor (phaeochromocytoma). Guide to laboratory tests | 92 • Family history of renal or endocrine disease. • Haematuria, palpable kidneys. • Poor femoral pulse (coarctation of the aorta). • Poor response to actually effective antihypertensive therapy. Late-onset male hypogonadism Flow diagram for diagnosis of late onset male hypogonadism

Patient presents with one or more symptoms

Erectile dysfunction, loss of libido, fatigue, reduced feeling of well-being, depression, loss of concentration, sweats / hot flushes, unexplained anaemia, reduced muscle mass, reduced body hair.

General history: Past medical history: Drug history: Physical examination: Duration of Previous testicular injury. Prescription drugs. Physical exam. symptoms. Previous head injury. “Alternative” BMI / waist Social history Headache ±. remedies circumference. (relationships, alcohol, Visual disturbance. Drug abuse. Testicular size / smoking). Any chronic illnesses1. consistency. Metabolic syndrome. Secondary sexual hair. Haemochromatosis. Visual fields.

1: DM, COLS, inflammatory arthritis, renal or HIV-related diseases. 93 | Ampath Desk Reference Flow diagram for diagnosis of late onset hypogonadism (continued)

Measure serum testosterone levels between 7 to 11 am

TTesto >10 nmol/l and cFT >210 pmol/l TTesto ≤10 nmol/l or cFT ≤210 (Beckman) (Beckman) ≤12 nmol/l or cFT ≤250 (Roche) TTesto >12 nmol/l and cFT >250 pmol/l Repeat 7 to 11 am testosterone level. (Roche) Luteinizing hormone (LH). Consider other diagnoses including Follicle stimulating hormone (FSH). psychosexual dysfunction. • TTesto: Total testosterone • cFT: Calculated free testosterone

Beckman: Beckman: Beckman: Beckman: TTesto >10 nmol/l TTesto 6.1 – 10 nmol/l TTesto 6.1 – 10 nmol/l TTesto <6.1 nmol/l AND cFT >210 pmol/l OR cFT 170 – 210 pmol/l OR cFT 170 – 210 pmol/l OR cFT <170 pmol/l Roche: Roche: Roche: Roche: TTesto >12 nmol/l TTesto 8 – 12 nmol/l TTesto 8 – 12 nmol/l TTesto <8 nmol/l AND cFT >250 pmol/l OR cFT 180 – 250 pmol/l OR cFT 180 – 250 pmol/l OR cFT <180 pmol/l FSH / LH Normal FSH / LH Normal ↑↓ FSH / LH

Consider other diagnosis. Consider treatment. Follow up after 6 to 12 Refer to specialist. months. See next page. Guide to laboratory tests | 94 All patients with erectile dysfunction must be examined for coronary heart disease. Contra-indications for treatment with testosterone: • Prostate cancer. • Breast cancer. • A palpable prostate nodule or induration of the prostate. • PSA >3 ng/ml without further urological evaluation. • Erythrocytosis (haematocrit >54%). • Hyperviscosity. • Untreated obstructive sleep apnoea. • Class 3 or 4 heart failure. • Severe lower urinary tract symptoms associated with benign prostatic hypertrophy, International Prostate Symptom Score (IPSS) >21. The following should be performed prior to initiating treatment, after 3 months, after 12 months and annually thereafter: • Digital rectal examination: if abnormal refer to urologist. • PSA: If PSA >4 ng/ml, PSA increase >1.4 ng/ml within any 12 month period of testosterone treatment, PSA velocity >0.4 ng/ml/year using the level after 6 months of testosterone administration as the reference (only applicable if PSA data is available for a period exceeding 2 years) → refer to urologist. • Haematocrit: If haematocrit is >54%, stop therapy until it normalises and re-evaluate the patient for hypoxia and sleep apnoea, reinitiate therapy with a reduced dose. 95 | Ampath Desk Reference Monitoring of testosterone levels: Monitor testosterone levels 2 – 3 months after onset of therapy. Therapy should aim to raise serum testosterone levels into the mid-normal range, supraphysiological levels should be avoided. Adjust dose or frequency if testosterone is >20 nmol/l or <10 nmol/l for Beckman method OR >24 nmol/l or <12 nmol/l for Roche method. • Injectable testosterone undecanoate: Measure testosterone level prior to each subsequent injection and adjust the dosing interval to maintain testosterone in mid-normal range. • Injectable testosterone cypionate or combined testosterone esters: Measure serum testosterone midway between injections. • Oral testosterone undecanoate: Measure serum testosterone level 3 – 5 hours after ingestion. Guide to laboratory tests | 96 HAEMATOLOGY Full blood count (FBC)

Analyte Ref. Range Units Interpretation Haemoglobin Inland: M 14.3 − 18.3 g/dl ↑: Polycythaemia. Sea level: M 13.0 − 17.0 ↓: Anaemia (bleeding, nutritional deficiencies, Inland: F 12.1 − 16.3 g/dl malabsorption, chronic illness, haemolysis and Sea level: F 12.0 − 15.0 bone marrow failure (inherited or acquired). Red cell count Inland: M 4.89 − 6.11 1012/l ↑: Polycythaemia, thalassaemia. Sea level: M 4.50 − 5.50 ↓: Anaemia. Inland: F 4.13 − 5.67 1012/l Sea level: F 3.80 − 4.80 Haematocrit Inland: M 43.0 − 55.0 % ↑: Polycythaemia. Sea level: M 40.0 − 50.0 ↓: Anaemia. Inland: F 37.0 − 49.0 % Sea level: F 36.0 − 46.0 MCV 79.1 – 98.9 fl ↑: Macrocytic red cells. (mean Check peripheral blood smear for round or oval corpuscular macrocytes. volume) Oval macrocytes are associated with megaloblastic anaemia (e.g. vit B12 / folate deficiency). Round macrocytes are associated with liver disease, hypothyroidism, antiretroviral therapy, alcohol, chemotherapy, reticulocytosis and myelodysplasia. 97 | Ampath Desk Reference

Analyte Ref. Range Units Interpretation ↓: Microcytic red cells Iron deficiency, thalassaemia, other haemoglobin defects, anaemia of chronic disease, lead poisoning, sideroblastic anaemia. MCH (mean 27.0 – 32.0 pg ↑: Hyperchromatic red cells e.g. spherocytes. corpuscular ↓: Hypochromic (pale) red cells haemoglobin) (Causes as for microcytic cells). MCHC (mean 31 – 37 g/dl ↑: Spherocytes, bilirubinaemia, auto- corpuscular agglutination, lipaemic sample. haemoglobin concentration) Red cell M 10 – 16.3 % If raised it means there are red cells of distribution F 10 – 17.3 different sizes. width (RDW) Often the earliest sign of a nutritional deficiency. Guide to laboratory tests | 98

Analyte Ref. Range Units Interpretation Platelet count 150 – 450 109/l ↑: Thrombocytosis Reactive causes should firstly be excluded e.g. iron deficiency, trauma, infection, and malignancy. If no reason is found and platelets remain increased, a chronic myeloproliferative disorder should be excluded. Platelet anisocytosis will be important to evaluate. ↓: Thrombocytopenia

Production defect – bone marrow infiltration or failure Peripheral loss mechanism e.g. peripheral destruction (ITP) Pooling / sequestration (hypersplenism) or usage ( e.g. DIC,TTP). White cell count 3.92 – 9.88 109/l If abnormal, evaluate the differential white cell count. 99 | Ampath Desk Reference

Analyte Ref. Range Units Interpretation Lymphocytes 1.0 – 4.0 109/l ↑: Lymphocytosis Primary causes: Lymphoproliferative disorders e.g. CLL, lymphoma overspill into the blood Reactive causes e.g. viral infections, Bordetella pertussis, stress lymphocytosis (e.g. myocardial infarction, surgery, trauma), smoking, post splenectomy and autoimmune disorders. ↓: Lymphopenia Inherited: congenital immunodeficiencies. Acquired: e.g. viral infections, TB, lymphoma, aplastic anaemia, immunosuppressive therapy, radiation, renal failure, autoimmune diseases and negative acute-phase response. Neutrophils 2.0 – 7.5 109/l ↑: Neutrophil leucocytosis Bacterial infection, inflammation, trauma / surgery, neoplasia, haemorrhage, haemolysis, pregnancy, metabolic e.g. diabetic ketoacidosis, drugs e.g. steroids, growth factor therapy e.g. G-CSF. ↓: Neutropenia Decreased production: • General bone marrow failure e.g. aplastic anaemia, acute leukaemia. • Specific failure of neutrophil production e.g. congenital, cyclical, drug induced Guide to laboratory tests | 100

Analyte Ref. Range Units Interpretation Peripheral loss: e.g. hypersplenism, autoimmune destruction, severe infection. Monocytes 0.18 – 1.00 109/l ↑: Monocytosis Infections e.g. TB, CMV, subacute bacterial endocarditis, syphilis Inflammatory and immune disorders e.g. SLE, RA,ulcerative colitis, sarcoidosis. Haematological malignancies e.g. CMML, AML. Non-haematological malignancies. Chronic neutropenias. ↓: Monocytopenia Haematological disorders e.g. Aplasia, hairy cell leukaemia, autoimmune e.g. RA, SLE, HIV. Eosinophils 0.0 − 0.45 109/l ↑: Eosinophilia Allergy e.g. asthma, parasites, skin disease, drug sensitivity, connective tissue disease, Hodgkin lymphoma, chronic myeloproliferative disorders, hypereosinophilic syndrome. Basophils 0.0 − 0.2 109/l Usually increased in chronic myeloproliferative disorders e.g. chronic myeloid leukaemia. 101 | Ampath Desk Reference ESR (erythrocyte sedimentation rate) It measures the rate of fall of a column of red cells in plasma during one hour. Largely determined by the concentration of plasma proteins e.g. fibrinogen, other acute-phase proteins and immunoglobulins. Raised ESR is a non-specific indicator of an acute-phase response and is of value in monitoring disease activity e.g. rheumatoid arthritis. Normal value: Male 1 – 15 mm / hour and female 1 – 20 mm / hour (Wintrobe or Westergren method). Causes of an elevated ESR include: • Inflammatory disorders e.g. rheumatoid arthritis, temporal arthritis, polymyalgia rheumatica, SLE. • Infections e.g. TB, HIV. • Malignancy. • Myeloma. • Anaemia. • Pregnancy.

Causes of a decreased ESR: • Polycythaemia. • Hypofibrinogenaemia. • Congestive heart failure. • Spherocytosis. • Sickle cells. Guide to laboratory tests | 102 Investigation of a bleeding disorder Clinical evaluation is important prior to requesting lab tests. Five important questions should be asked, if all negative, no tests may be required. The questions are: • Is it real? Did the patient bleed with previous surgery, tooth extraction, during menstruation, circumcision, child birth, etc; keeping in mind that this may be a new cause of bleeding tendency. • Is it a primary or secondary haemostatic dysfunction, with epistaxis, petechiae, mucosal bleeding indicating a primary (platelet / endothelial type) defect and muscle / joint bleeds pointing to a secondary (clotting factor defect). • Is there a family history? Often this helps in requesting the correct tests. • Does the patient have any systemic disorder that influences haemostatic function, e.g. haematological, renal or hepatic disorders. • Which medication, including over-the-counter drugs is the patient taking that may be the cause of bleeding? Start with the basic coagulation screen (PT, APTT, fibrinogen, thrombin time, platelet count and bleeding time). See table for interpretation of results. Normal screening values may be found with minor factor deficiencies and factor levels may then rather be done. 103 | Ampath Desk Reference Basic coagulation screen

Analyte What is tested Ref. Range Units Interpretation Prothrombin Efficiency of the 9.0 – 11.2 seconds Prolonged: time (PT) extrinsic clotting Warfarin therapy pathway. Rivaroxaban (Xeralto) therapy (neoplastin) Liver disease. Vit K deficiency. DIC. Clotting factor deficiency or defect (I, II, V, VII, X). Activated partial Efficiency of the 22.0 – 30.7 seconds Prolonged: thromboplastin intrinsic clotting Heparin therapy (esp. unfractionated) or time (APTT) pathway. heparin contamination. Dabigatran (Pradaxa) therapy DIC. Liver disease. Massive transfusion. Lupus anticoagulant. Clotting factor defects (other than FVII). Also moderately prolonged in patients on warfarin and in vit K deficiency. Guide to laboratory tests | 104

Analyte What is tested Ref. Range Units Interpretation Thrombin time Fibrinogen to 14.0 − 21.0 seconds Prolonged: (TT) fibrin stage. Very sensitive to unfractionated heparin (LMWH can slightly prolong it at therapeutic levels). Dabigatran (Pradaxa) therapy Hypofibrinogenaemia – as with DIC or congenital defect / deficiency. Dysfibrinogenaemia – inherited or acquired (in liver disease) or physiologically in neonates. Raised concentrations of FDP as with DIC or liver disease. Hypoalbuminaemia. Grossly elevated fibrinogen. Fibrinogen Plasma level. 1.8 – 3.5 g/l ↑: Acute-phase. ↓: DIC, liver disease, fibrinogen deficiency or dysfibrinogenaemia. Platelet count Number of 150 − 450 109/l ↓: Production defect – bone marrow platelets in the infiltration / failure. blood. Peripheral loss mechanism e.g. immune (ITP), hypersplenism, DIC, TTP, etc. 105 | Ampath Desk Reference

Analyte What is tested Ref. Range Units Interpretation Bleeding Platelet function and 3 − 9 minutes Increased: time capillary integrity. Platelet dysfunction: (Ivy method) • Acquired e.g. aspirin, plavix, uraemia, Time measured for myeloproliferative neoplasms, bleeding to stop after myelodysplasia and the presence of an incision is made a paraprotein. on the forearm of the • Congenital e.g. Von Willebrand’s patient in standardised disease, storage pool defect, Bernard- manner. Soulier syndrome etc.

NB: platelet count Vascular disorders e.g. Ehlers-Danlos’s should be normal. syndrome.

Important: a normal bleeding time does not imply normal haemostasis and it does not correlate well with bleeding at other sites or with intra- operative bleeding. Guide to laboratory tests | 106 Interpretation of basic coagulation screen

Platelet PT APTT TT Fibrinogen Conditions count Prolonged Normal Normal Normal Normal Factor VII deficiency. Early oral anticoagulation. Mild factor II, V or X deficiency. Lupus anticoagulant with some reagents. Normal Prolonged Normal Normal Normal Factor VIII, IX, XI, XII, prekallikrein, HMWK deficiency / defect. Von Willebrand’s disease. Lupus anticoagulant. Mild II, V or X deficiency. Unfractionated heparin Prolonged Prolonged Normal Normal Normal Vit K deficiency. Warfarin therapy. Factor II, V or X deficiency. Multiple factor deficiency e.g. liver failure. Combined V & VIII deficiency. Prolonged Prolonged Prolonged Normal or Normal Heparin in large amount. low Liver disease. Fibrinogen deficiency / disorder. Hyperfibrinolysis. Inhibition of fibrin polymerization. 107 | Ampath Desk Reference

Platelet PT APTT TT Fibrinogen Conditions count Prolonged Prolonged Prolonged Low Low DIC. Acute liver disease. Prolonged Prolonged Normal Normal or Low Massive transfusion. low Liver disease. Normal Normal Normal Normal Low Thrombocytopenia. Consider causes for thrombocytopenia. Normal Normal Normal Normal Normal Platelet dysfunction. Factor XIII deficiency. Mild Von Willebrand’s disease. Vascular disorder. Disorder of fibrinolysis. Mild or masked coagulation factor deficiency. Normal haemostasis. Reference: Dacie and Lewis: Practical Haematology • If PT, APTT, thrombin time, fibrinogen and platelet count are normal and the patient has a significant bleeding history, further investigation is needed to exclude a platelet function disorder and other rarer disorders e.g. fibrinolytic defects (tPa, PAI, antiplasmin), Von Willebrand disease and FXIII deficiency. Guide to laboratory tests | 108 Laboratory assessment for Von Willebrand disease (VWD) Initial tests: • Von Willebrand antigen (VWF: Ag) • Von Willebrand activity (Ristocetin cofactor activity) • Factor VIII Additional tests: • Von Willebrand multimeric analysis if antigen and / or activity is decreased. • Platelet aggregation study with ristocetin (RIPA). • VWF collagen-binding assay.

Based on the results of these tests, the diagnosis can be made of: • Type 1 Von Willebrand disease (mild quantitative defect). • Type 2 Von Willebrand disease (subclassified as type 2A, 2B, 2M or 2N) (qualitative / functional defect). • Type 3 Von Willebrand disease (severe quantitative defect).

NB: Testing for Von Willebrand disease should be done in the absence of any acute-phase responses (VWF is an acute-phase protein). Systemic inflammation, infection, pregnancy, oestrogen / oral contraceptives, stress e.g. surgery can cause an increase in levels of VWF and mask lower baseline levels. Individuals with bloodgroup O have plasma VWF levels that are 25 – 30% lower than those with bloodgroup A, B or AB. In patients with borderline results, it is often helpful to repeat the diagnostic test on two or 3 occasions and to study available family members. 109 | Ampath Desk Reference Platelet aggregation studies Platelet aggregation responses to different agonists are measured. It detects congenital and acquired abnormalities of platelet function.

Agonist Ref. Range Units Interpretation/causes ADP (10 μM/ml) 50 − 100 % ↓: Drugs e.g. clopidogrel and aspirin; storage pool defect. Collagen (10 μg/ml) 50 − 100 % ↓: Storage pool defect; aspirin; cyclo-oxygenase and thromboxane synthetase deficiency. Arachidonic acid (1.5 mM/ml) 50 − 100 % ↓: Aspirin; storage pool defect; cyclo-oxygenase and thromboxane synthetase deficiency. Ristocetin high concentration 50 − 100 % ↓: Bernard-Soulier syndrome – confirm with flow (1.25 mg/ml) cytometry for Gp Ib Von Willebrand disease. Ristocetin low concentration <10 % ↑: Von Willebrand disease type 2 b (functional (0.5 mg/ml) defect). If ↓ with ADP, Collagen and Glanzman thrombasthenia. Arachidonic acid; and often Confirm with flow cytometry for Gp IIbIIIa primary wave only with Ristocetin PFA-200 (for evaluating platelet function) (Special acknowledgement – Dr Rita Govender; Pathchat Edition no. 23) This test may be seen as a cross between bleeding time and quick aggregation testing. Availability: Testing on the PFA 200 requires a sample <4 hours old. Request for the test must take into account the sample's transit time to the laboratory that hosts the instrument. Guide to laboratory tests | 110 Principle: • Citrated whole blood is aspirated at high shear rates through disposable cartridges. • The cartridge contains an aperture within a membrane coated with either collagen and epinephrine (Col / EPI) or collagen and ADP (Col / ADP). • The agonists induce platelet adhesion, activation and aggregation, resulting in occlusion of the aperture and hence cessation of blood flow. Parameter is reported as closure time. Variables affecting results: • Test must be performed within 4 hours of blood collection. • HCT <35% and platelet count <150 may affect closure times. • Samples with HCT >50% and platelet count >500 have not been evaluated. • Fatty acids, lipaemia. • Haemolysis of sample. Advantages: • Small volume of citrated venous blood (therefore suitable for paediatric samples as well) • Insensitive to clotting factor deficiency (not dependent on plasma fibrinogen of fibrin generation) • Better standardisation • No influence on result from oedema, loss of connective tissue, presence of fragile vessels (as in bleeding time performed in elderly patients) Interpretation:

Von Willebrand Glanzmann Normal Aspirin Disease thrombasthenia Col / EPI Normal (82 − 150 s) Prolonged Prolonged Prolonged Col / ADP Normal (62 − 100 s) Normal Prolonged Prolonged 111 | Ampath Desk Reference In the event of abnormal results, further testing is indicated, especially if history supports a bleeding diathesis. Consultation with a clinical haematologist or haematopathologist is strongly recommended. Please keep in mind: The test may be normal despite abnormal platelet function e.g. in: • Storage Pool Disease • Primary secretion defects • Mild VWDx The need for further testing must be guided by history and clinical features supportive of platelet disorder. References: Bain, B.J., Bates, I., Laffan, M.A. & Lewis, S.M. 2012. Dacie and Lewis Practical Haematology, 11th edition, Churchill Livingstone. British Committee for Standards in Haematology. 2011. Postgraduate haematology: guidelines for laboratory investigation of inheritable platelet disorders Aug 2011 Thromboelastogram (TEG) What is tested: The rate of clot formation, the kinetics of clot formation, the strength and stability of the clot. Indication: Investigation of patients with abnormal bleeding during and after surgery. It can guide in the specific treatment needed. It is also requested by some physicians as part of pre-operative work-up. Its usefulness to predict bleeding or thrombosis is however debatable. Guide to laboratory tests | 112

Different aspects of TEG Ref. Range Units Interpretation R-time (reaction time) 3 − 8 min If prolonged, it indicates a longer time for Measures the time between the fibrin to form and may be due to a clotting start of the test until the first sign of factor defect or anticoagulant therapy. fibrin formation K-time 1 − 3 min Dependent on the availability of fibrinogen Measures the speed to reach a and FXIII and to a lesser extent platelets. certain level of clot strength. Alpha angle 55 − 78 min Dependent on the availability of fibrinogen Measures the rapidity of fibrin and FXIII and, to a lesser extent, platelets. build-up and cross-linking (clot strengthening) Different aspects of TEG Ref. Range Interpretation Maximum amplitude (MA) 51 − 69 Affected by platelet function and to a lesser extent by Direct function of the maximum fibrinogen concentration. dynamic properties of fibrin and A small MA usually indicates a thrombocytopenia or platelet bonding via GPIIb / IIIa and platelet dysfunction. represents the ultimate strength / stability of the fibrin clot. Thromboelastogram index -3 – +3 <-3: hypocoagulable (mathematic product of the netto >3+: hypercoagulable, especially if >5. effect of the R-time, K-time, alpha angle and MA measurements). 113 | Ampath Desk Reference Other specialised coagulation tests (D-dimer and FDP)

Analyte What is tested Normal Units Interpretation values D-dimer (XDP) Measures 0 – 0.50 mg/l ↑: Causes: cross- DIC. linked fibrin DVT/Pulmonary embolism. degradation Recent surgery. products Trauma. Pregnancy. Infection. Cancer. Elderly patients (approximately 0.age for cut-off) Acute coronary syndromes. Cardiac or renal failure. Acute non-lacunar stroke. Circulatory half-life of D-dimer is about 12 hours. Elevated D-dimer can therefore persist for some time after the active process has ceased. D-dimer should always be interpreted in the clinical context and not on its own. Fibrin and Semi- <5 μg/ml ↑: Acute venous thromboembolism. fibrinogen quantitative Myocardial infarction. degradation detection of Severe pneumonia. products (FDP) FDP in plasma After major surgery. Systemic fibrinolysis associated with DIC. Thrombolytic therapy with streptokinase. Guide to laboratory tests | 114 Disseminated intravascular coagulation (DIC) screen There is no single laboratory test that can establish or rule out the diagnosis of DIC. The diagnosis should be made based on an appropriate clinical suspicion supported by relevant laboratory tests. If clinically indicated, repeat testing should be done if initial results are negative. Tests used in the diagnosis and evaluation of patients with possible DIC: Prothrombin time (PT) ↑ Activated partial thromboplastin time (APTT) ↑ Thrombin time (TT) ↑ Fibrinogen normal or ↓ XDP (D-dimer) ↑ FDP ↑ Platelets ↓ Blood smear: red cell fragments ISTH diagnostic scoring system for DIC (International Society of Thrombosis and Haemostasis): Scoring system for overt DIC: Risk assessment: Does the patient have an underlying disorder known to be associated with overt DIC? If yes: proceed. If not: do not use this algorithm. Score Platelet count (>100 x 109/l = 0, <100 x 109/l = 1, <50 x 109/l = 2). Elevated fibrin marker (e.g. D-dimer, fibrin degradation products). (no increase = 0, moderate increase = 2, strong increase = 3). Prolonged PT (<3 s = 0, >3 s BUT <6 s = 1, >6 s =2). Fibrinogen level (>1 g/l = 0, <1 g/l = 1). 115 | Ampath Desk Reference Calculate score: ≥5 compatible with overt DIC: repeat score daily. <5 suggestive of non-overt DIC: repeat within 1 – 2 days.

Tests used in the investigation of a thrombotic tendency Testing should be done prior to starting anticoagulation or 7 − 10 days after completion of anticoagulation therapy. Analyte What is tested Ref. Range Units Interpretation Protein S Free Prot S level. M 60 − 140 % ↓:Congenital deficiency. F 70 − 140 Acquired deficiencies: Prot S is a vit K • Warfarin therapy. dependent natural • Oestrogen-containing oral anticoagulant that contraceptives. potentiates the • Pregnancy. function of protein C. • Hormone replacement therapy. • Acute-phase reaction. • Liver disease. • Nephrotic syndrome. • L-asparaginase chemotherapy. • DIC. • Some patients with antiphospholipids. Guide to laboratory tests | 116

Analyte What is tested Ref. Range Units Interpretation Protein C Prot C function 70 − 140 % ↓:Congenital deficiency. Acquired deficiencies: Prot C is a vit • Warfarin therapy. K dependent • Liver disease. anticoagulant. • DIC. After activation by • Early post-operative period. thrombin, it forms complexes with prot The presence of aprotinin may result in S and phospholipids an underestimation of protein C level. to degrade factors Va and VIIIa. Antithrombin Antithrombin function. 80 − 120 % ↓:Congenital deficiency. Acquired deficiency: It is an inhibitor of • DIC thrombin and its • Nephrotic syndrome. action is enhanced by • Liver disease. heparin. • L-asparaginase chemotherapy. It also inhibits factor Xa • Current massive thrombosis. and, to a lesser extent, • Inflammatory bowel disease . IXa, XIa,XIIa, plasmin Some test procedures may be affected and kallikrein. by heparin therapy. (The current method used by our lab is not affected by therapeutic doses of heparin). Thrombin inhibitors may lead to an over- estimation of antithrombin level. 117 | Ampath Desk Reference

Analyte What is tested Ref. Range Interpretation Activated Resistance against ≥ 120 seconds Congenital: protein C activated protein C. • Factor V Leiden If < 120 seconds resistance (mutation in factor V). sample is regarded (APC-R). Acquired: as APC-R positive • Lupus anticoagulant. In these cases, PCR • Increased factor VIII levels. for factor V Leiden is • Oestrogen-containing oral important. contraceptives. • Hormonal replacement therapy. • Pregnancy. The presence of thrombin inhibitors may lead to false negative results and aprotinin may lead to false positive results. Insensitive to heparin (UFH and LMWH up to 1 IU/ml). Factor V Leiden Detect a mutation Detects heterozygotes and PCR Arg 506Glu in factor V. homozygotes for Factor V Leiden with This mutation destroys a higher risk of thrombosis. the cleavage site of FVa by activated protein C and results in a slower inactivation of factor Va by activated prot C. Guide to laboratory tests | 118

Analyte What is tested Ref. Range Interpretation Prothrombin Detect a mutation Detects heterozygotes and gene mutation G20210A in the 3’ homozygotes for this mutation with a PCR untranslated region of higher risk of thrombosis. the prothrombin gene. This mutation is associated with elevated levels of prothrombin. Plasminogen Fibrinolytic activity. 75 − 150% ↓: DIC. Liver cirrhosis. During and after fibrinolytic therapy, Newborn. ↑: Acute-phase and malignant disease. Lupus See separate table. anticoagulant 119 | Ampath Desk Reference Testing for the presence of a lupus anticoagulant

Test What is tested Ref. Range Interpretation Dilute Russell’s The venom activates <1.2 ratio Increased: viper venom FX directly and triggers • Lupus anticoagulant. If >1.2, a test the coagulation • Factor deficiency (X,V, II and fibrinogen). confirmatory pathway downstream. • Other clotting factor inhibitor. test based on The presence of a lupus anticoagulant is the addition of confirmed if the patient time is shortened by phospholipids the addition of phospholipids. is done. (screen test ratio / confirmed ratio > 1.15). If a clotting factor deficiency or oral anticoagulation, correction will be obtained with addition of normal plasma and not with phospholipids. If other clotting factor inhibitor, no correction will be obtained with either normal plasma or phospholipids. Kaolin clotting Modified aPTT test <1.2 ratio Increased: time without added • Lupus anticoagulant. phospholipid. • Other clotting factor defects. If correction with platelet neutralization procedure, it supports the presence of a lupus anticoagulant. Guide to laboratory tests | 120

Test What is tested Ref. Range Interpretation Lupus sensitive The reagent has been 31.6 – 44 Prolonged: PTT sensitized to aid the seconds • Lupus anticoagulant. detection of lupus • Intrinsic pathway factor deficiencies or anticoagulants. inhibitors. • Dysfibrinogenaemia. • Presence of heparin and warfarin. • Treatment with thrombin inhibitors. • DIC. If correction is obtained with platelet neutralization procedure it confirms the presence of a lupus anticoagulant, while correction with normal plasma supports a clotting factor deficiency. Monitoring of anticoagulation therapy INR (International normalised ratio) Standardised way of reporting the Prothrombin time (To compensate for different laboratories using different reagents and instruments). Developed for the standardisation of oral anticoagulant treatment. Using the INR system, the patient’s INR should be approximately the same in any laboratory worldwide. Used for monitoring of warfarin therapy. Therapeutic target varies according to the indication for warfarin, but generally aimed at 2 – 3.5 INR >4 – usually over anticoagulated INR <2 – usually under anticoagulated 121 | Ampath Desk Reference Antifactor Xa activity (IU/ml) Used for monitoring of low molecular weight heparin therapy. The medication type (pharmaceutical name) and the time of the last dose should always be supplied. Sample should be taken 3 hours after the last dose on Day 2 of treatment, especially if renal dysfunction is present. Expected Anti-Xa activity levels for patients on therapy are as follows: Prophylaxis: 0.3 – 0.5 IU/ml Therapeutic: 0.5 – 1.2 IU/ml Valve replacement: 1.0 – 1.2 IU/ml Direct thrombin inhibitor (DTI): Haemoclot: For the measurement of Dabigatran (Pradaxa) levels. Haemoclot Thrombin Inhibitors is an in vitro diagnostic test intended to be used for the quantitative measurement of direct thrombin inhibitors, such as dabigatran, in human citrated plasma. It is a clotting method based on the inhibition of a constant and defined concentration of thrombin. It is intended for prescriptive use. Measuring DTI concentrations in patient’s plasma may be used as an aid in the management of patients receiving DTIs who are suspected of having excess anticoagulant activity. Pradaxa is a direct thrombin inhibitor with a mean half-life of 12 – 17 hours. It is eliminated unchanged primarily in the urine (85%). The rate of elimination by the kidney depends on the individual patient’s kidney function; the half-life of Pradaxa is prolonged in cases of renal impairment. The Haemoclot direct inhibitor assay determines dabigatran plasma concentration: Guide to laboratory tests | 122 Expected plasma levels Two hours after dosing ng/ml 10 - 16 hours after dosing ng/ml 150 mg bd 175 (117 – 275) 91 (61 – 143) 110 mg bd 126 (85 – 200) 65 (43 – 102) Bone marrow investigation Bone marrow aspirate and trephine biopsy can be done to assess the bone marrow status. It is usually done under local anaesthetic or under conscious sedation from the posterior iliac crest of the pelvic bone. Aspirated cells and bone marrow particles are spread onto slides, which allow evaluation of cytological detail, and iron stores can be assessed. The trephine biopsy is fixed and processed for histology assessment. Indications for bone marrow investigation • Unexplained cytopenias e.g. anaemia, thrombocytopenia, neutropenia and pancytopenia. • Suspected bone marrow disorders or infiltration e.g. leukaemia, chronic myeloproliferative neoplasm, myeloma, storage disease, metastatic disease, myelodysplasia, aplastic anaemia. • As part of a staging procedure in lymphoma. • Suspected infection e.g. TB, fungi. Special investigations that can be done on bone marrow aspirate • Chromosome analysis (cytogenetics), FISH (fluorescent in situ hybridization) for specific molecular abnormalities and PCR analysis. • Immunophenotyping of abnormal populations of cells with flow cytometry. • These tests are used to aid in the diagnosis, sub-classification and prognostification of haematological malignancies. Also used to detect evidence of residual disease after treatment. • Microbiological cultures e.g. tuberculosis, MCS and fungus culture. 123 | Ampath Desk Reference Flow cytometry Automated technique where cells are incubated with different monoclonal antibodies that are conjugated to different fluorochromes. The labelled cells are then passed in a fluid stream past a laser light source, which allows quantification of antigen expression on the population of interest. Depending on the underlying pathology, various panels of antibodies can be used to identify the immunophenotype of an abnormal population of cells. The technique is very important in the diagnosis and classification of acute and chronic leukaemias and lymphomas, to detect minimal residual disease during disease follow-up and may provide valuable prognostic information. It is also used in the diagnosis of PNH (paroxysmal nocturnal hemoglobinuria). Flow cytometry can be performed on blood samples, bone marrow aspirate, FNA samples and body fluids e.g. pleural effusions, ascites fluid and CSF. Sample needed: EDTA (purple top) or heparin (green top). At our laboratory, flow cytometry testing and data analysis are being performed in accordance with EuroFlow protocols. The EuroFlow protocol is a standardised method of flow cytometric testing for the diagnosis and classification of haematological malignancies. It is currently the only available protocol that is completely validated and standardised at every stage of flow cytometry testing. The adoption of this protocol ensures that our laboratory is able to maintain an international standard in haematological flow cytometry. Tests used in the investigation of a haemolytic process Reticulocyte count Reticulocytes are young red cells, which contain remnants of RNA. Normal range: 0.5 – 2.5 % (absolute count 50 – 100 x 109/l) Guide to laboratory tests | 124 Increase with increased erythropoietic activity e.g. blood loss, haemolysis and response on haematinic replacement therapy. Decreased: red cell production defect e.g. bone marrow disorders and dietary deficiencies. Reticulocyte production index (RPI) The reticulocyte production index (RPI) can be calculated to assess whether the reticulocyte response is appropriate for the degree of the anaemia. RPI: 1 – when Hb is normal and marrow activity normal RPI >2.5 – when anaemia is due to haemolysis, bleeding or hyposplenism and bone marrow response is normal RPI <2 − when anaemia is due to marrow failure for any reason e.g. iron deficiency, vit B12 / folate deficiency or bone marrow infiltration Direct Coombs test Detect the coating of red cells by immunoglobulins and / or complement. Causes for a positive Direct Coombs include: Autoimmune haemolytic anaemia (warm type and cold type). Alloimmune haemolytic anaemia (mismatched transfusion, haemolytic disease of the newborn and following solid organ or bone marrow transplantation). Drug induced immune haemolytic anaemia. False adsorption of antibodies to the surface of the red cells (occurs in some cases of HIV). Osmotic fragility Red cells are suspended in different concentrations of saline and the degree of haemolysis is assessed by spectophotometry. Spherocytes have an increased volume / surface area ratio and are therefore more susceptible to lysis than normal red blood cells. 125 | Ampath Desk Reference If the blood smear shows a picture of spherocytic haemolysis, it is usual practice to start with a Direct Coombs test. If negative, an osmotic fragility could be done and if that is increased, a sample should be sent for red cell membrane protein electrophoresis to confirm a possible congenital spherocytosis. Hb electrophoresis / Abnormal haemoglobin screen A lysate of red cells is applied to a gel and an electronic current is applied at an acid and alkaline pH. Different haemoglobins show different migration patterns. Indication: to detect the presence of inherited haemoglobin defects e.g. Hb S (sickle cell disorders), Hb E, Hb C, Hb D, Hb H and thalassaemia. Our laboratory has changed to a new method of using ion-exchange high-performance liquid chromatography (HPLC) to detect abnormal haemoglobin in whole blood and to determine the percentages of Hb A2 and HbF. Testing for haemosiderin in the urine It can be used as a marker of intravascular haemolysis. With intravascular haemolysis, haemoglobin is released from the red blood cells into the bloodstream in excess of the binding capacity of haptoglobin. The excess haemoglobin is then filtered by the kidney and reabsorbed in the proximal tubule. The iron portion then gets stored as ferritin or haemosiderin. When the tubule cells get sloughed off, the haemosiderin gets excreted into the urine. It can remain in the urine for several weeks. Haptoglobin assay can also be used as a more reliable marker for intravascular haemolysis. A decreased level of haptoglobin will support the presence of intravascular haemolysis. Guide to laboratory tests | 126 PNH screen (paroxysmal nocturnal haemoglobinuria) Haemosiderin in the urine – confirms the presence of intravascular haemolysis. Flow cytometry: at our laboratory, we perform immunophenotyping of the neutrophils for the expression of FLAER and CD24 and monocytes for the expression of CD14 and FLAER. In PNH, there is a decreased expression of these antigens. Sample needed: peripheral blood (EDTA or heparin). Testing for inherited enzyme abnormalities • Glucose-6-phosphate dehydrogenase defiency (G6PD). A screening test is done and if positive, a quantitative test should be done for confirmation. Reticulocytes have higher G6PDH levels and therefore false negative results may be obtained if testing is done during a reticulocytosis. • Pyruvate kinase deficiency screen. Malaria testing • Thin smear – used for species identification and quantification of parasite load. • Thick smear – higher detection rate, but cannot be used for species identification or quantification. • Fluorescent microscopy/Quantitative Buffy Coat method (malaria parasites fluorescent after staining with acridine orange). Fairly sensitive, but false positives may occur in the presence of Howell Jolly bodies and reticulocytes. May be used as an additional screening test. Increases the detection rate and is more sensitive than the thick smear. • Malaria antigen testing based on the presence of certain malaria antigens (pLDH and HRP-2). It aids in the detection and identification of malaria and is usually used in conjunction with the thin smear. • Malaria PCR – parasite nucleic acids are detected. Not suitable for routine diagnostic use, but may be useful in selected cases – most useful for species identification. • If malaria profile is negative, but clinical suspicion is high, repeat testing is advised. 127 | Ampath Desk Reference JAK2 V617F PCR Principle: A real-time polymerase chain reaction assay which is used to identify the JAK2 V617F mutation. Indication: It is usually requested where a chronic myeloproliferative neoplasm is suspected from the clinical picture, peripheral blood and / or bone marrow findings. Sample type: Blood or bone marrow collected in EDTA (purple top). Clinical use and interpretation: The presence of the Jak-2 V617F mutation will support the diagnosis of an underlying chronic myeloproliferative neoplasm. A bone marrow investigation will usually be performed to confirm the diagnosis and to identify which type of myeloproliferative disorder is present. The highest incidence of the JAK2 V617F mutation is found in polycythaemia vera (65-97% of cases will be positive). The mutation may also be present in approximately 50% of cases of essential thrombocythaemia and primary myelofibrosis. It is negative in CML (Chronic myelocytic leukaemia). If polycythaemia vera is suspected clinically and the Jak-2 V617F PCR is negative, further screening for JAK2 exon 12 mutations can be arranged. Please take note that a negative JAK2 screen does not exclude the presence of a chronic myeloproliferative disorder. Guide to laboratory tests | 128 IMMUNOLOGY AUTOIMMUNE DISORDERS Autoimmunity and the endocrine system Diabetes Mellitus:

Antibodies May be increased in the following conditions: Islet cell antibodies: • Type 1 diabetes mellitus. Can be detectable several years before the onset of disease • Latent autoimmune diabetes in adults (LADA) • Close relatives of affected patients • Autoimmune gestational diabetes • Normally not detectable in other forms of diabetes such as maturity onset diabetes of the young (MODY) Glutamic acid decarboxylase (GAD)- • Newly diagnosed type 1 DM 65 antibodies • First degree relatives of patients with type 1 DM • Stiffman syndrome • LADA • Gestational DM • Organ-specific autoimmune diseases • Autoimmune polyendocrine syndrome type II • A small percentage of non-insulin dependent diabetic patients: A positive titre is also predictive of insulin requirement within 2 – 3 years in elderly type II diabetics 129 | Ampath Desk Reference

Diabetes Mellitus:

Antibodies May be increased in the following conditions: Islet antigen 2 (IA-2) antibodies • Newly diagnosed type 1 DM • LADA • First degree relatives • There is an overall risk in IA2 antibody positive relatives in developing IDDM within 5 years. Insulin receptor antibodies • Antibodies against the insulin receptor can have an inhibitory or stimulatory influence and can therefore cause hyper- or hypoglycaemia • Paraneoplastic hypoglycaemia has been described in patients with Hodgkin’s lymphoma Thyroid disease – refer to interpretation of thyroid antibodies (page 49) Addison’s disease • Adrenocortical auto-antibodies: found in two thirds of patients. • 21-Hydroxylase antibodies • 17 α-Hydroxylase antibodies • TPO antibodies, Parietal cell antibodies: Monitor for development of associated endocrinopathies and B12 deficiency Poly-endocrinopathy • Adrenal cortex antibodies • 21-Hydroxylase antibodies • Ovarian antibodies • Testis antibodies Guide to laboratory tests | 130 • Steroid hormone-producing cell antibodies • Parathyroid gland antibodies • Islet cell antibodies • TPO antibodies • Parietal cell antibodies • Intrinsic factor antibodies Infertility • Anti-phospholipid antibodies • Ovarian antibodies • Testis antibodies • Spermatozoa antibodies • Pituitary gland antibodies • Placenta antibodies • Prostate antibodies

Chronic atrophic gastritis (autoimmune gastritis) / Pernicious anaemia (PA) • Parietal cell antibodies • Intrinsic factor antibodies

Autoimmunity and the central nervous system Syndrome Antibodies Autoimmune polyneuropathy Ganglioside antibodies Neuronal antibodies, including anti-amphiphysin, anti-CV2, anti-Hu, Paraneoplastic syndromes anti-Ma2, anti-Ri, anti-VGCC, anti-Yo, anti-NMDA receptor antibodies etc. Neuromyelitis optica Anti-Aquaporin 4 Antibodies (NMO IgG) 131 | Ampath Desk Reference

Autoimmune encephalitis NMDA antibody profile Demyelinating neuropathy Myelin associated glycoprotein (MAG) antibodies Myasthenia Gravis Acetylcholine receptor antibodies, MuSK antibodies, Titin antibodies Autoimmunity and renal disease • Initial laboratory assessment of auto-antibodies should include tests for ANCA, ANA and dsDNA- antibodies since GBM disease, systemic vasculitis and SLE may produce similar clinical features. • Glomerular basement membrane (GBM) antibodies. • PLA2R antibodies. Autoimmunity in gastrointestinal disease Inflammatory bowel diseases Faecal calprotectin Elevated in organic bowel disease with bowel inflammation, eg: Colitis, Crohn’s, ulcerative colitis, ulcers, diverticulitis, polyps, adenomas, malignancies or infections. Crohn’s disease ANCA Anti-saccharomyces cerevisiae antibodies (ASCA) Pancreas acinar cell antibodies Ulcerative colitis ANCA DNA-bound lactoferrin (pANCA) Goblet cell antibodies Guide to laboratory tests | 132 Coeliac disease The definitive diagnosis is usually identification of villous atrophy by examination of small intestinal biopsy followed by a clear improvement once the patient is on a gluten-free diet. • Total IgA • Endomysial IgA • Tissue Transglutaminase IgA • Gliadin IgA • If total IgA <0.3 g/l do: • Endomysial IgG • Tissue Transglutaminase IgG • Gliadin IgG • HLA DQ2 / HLA DQ8 Positive anti-tissue transglutaminase (TTG) antibodies and endomysial antibodies (EMA) are associated with a high probability for Coeliac Disease. HLA DQ2 / DQ8 typing is a useful tool to determine if the patient is genetically susceptible to Coeliac Disease (CD). If HLA DQ2 / DQ8 testing is negative, CD is excluded or highly unlikely. The HLA DQ2 allele is found in 90 – 95% of individuals with CD and the remaining 5 –10% possess the HLA DQ8 allele. In symptomatic patients with high anti-TTG IgA levels (> 10x ULN), verified by EMA positivity and who are HLA DQ2 and / or HLA DQ8 positive, histological assessment may be omitted. If a diagnosis of CD has been made, a gluten-free diet (GFD) should be instituted. Follow up regularly for symptom improvement and normalisation of CD-specific antibodies – in general this is achieved within 12 months of starting a GFD. 133 | Ampath Desk Reference Autoimmunity in liver disease Screening auto-antibodies in suspected autoimmune liver disease: • Smooth muscle antibodies • Mitochondrial antibodies • Liver kidney microsome (LKM) antibodies Primary biliary cirrhosis (PBC) Liver western blot: • Anti-mitochondrial M2 (AMA-M2) antibodies • AMA-M4 and AMA-M8 • SP100, PML: These antibodies can occur in AMA-negative PBC • Gp210 Autoimmune hepatitis (AIH) Liver western blot: • Soluble liver antigen / liver pancreas (SLA/LP) antibodies • Liver cytosol (LC) antibodies • Liver kidney microsome (LKM) antibodies Primary sclerosing cholangitis (PSC) • pANCA • Liver western blot • Biopsy Guide to laboratory tests | 134 Autoimmune skin disorders Tests for diagnosis • Skin biopsy (H&E, direct immunofluorescence, EM) • Skin antibodies: Indirect immunofluorescence detect antibodies against desmosomes and basal membrane • IgA EMA / tTG (dermatitis herpetiforme) • Vitiligo: strong association with other autoimmune diseases, including autoimmune endocrinopathies, pernicious anaemia, autoimmune hepatitis, alopecia, psoriasis, SLE, RA, myasthenia gravis Autoimmune ear disease Heat shock protein (hsp)-70 antibodies: autoimmune sensorineural hearing loss Interpretation of anti-nuclear antibodies Antibody Disease association ANA pattern Homogenous SLE, exclude mixed connective tissue disease (MCTD), Drug- induced Lupus, RA, Systemic Sclerosis, Juvenile chronic arthritis. Speckled Sjögren’s syndrome, Scleroderma with or without Polymyositis overlap, MCTD, Raynaud’s phenomenon, Psoriasis. Nucleolar Scleroderma, Polymiositis-Schleroderma overlap, SLE. Centromere CREST syndrome, also other auto-immune disorders. Rim SLE. Multiple nuclear dots Various autoimmune diseases, especially Sjögren’s syndrome, SLE and Primary Biliary Cirrhosis (PBC). Few nuclear dots Autoimmune and viral liver disease. 135 | Ampath Desk Reference

Golgi SLE, Sjögren’s syndrome, other undefined rheumatic diseases. Lysosomal SLE. Centriole Viral infection, Raynaud’s, Scleroderma, hyperthyroidism, non- specific rheumatic disease, Sjögrens Syndrome. Midbody Scleroderma, Raynaud’s. Mitotic spindle Unknown significance, associated with respiratory tract tumours. PCNA (Proliferating cell nuclear SLE. antigen) High avidity dsDNA-antibodies Highly specific for SLE, associated with renal involvement. ENA (extractable nuclear antigens) Sm SLE. RNP Mixed connective tissue disease, SLE. SSA Sjögren's, SLE, Scleroderma, RA, Polymyositis. SSB Sjögren's, SLE. Scl-70 Scleroderma, SLE, Raynaud’s phenomenon. PM-Scl Polymyositis, dermatomyositis and Scleroderma overlap syndrome, Scleroderma, dermatomyositis and Polymyositis. Jo-1 Polymyositis, often associated with interstitial lung fibrosis. Nucleosome SLE. Histone Drug-induced SLE, SLE, Rheumatoid arthritis. Ribosomal-P SLE. Anti-mitochondrial M2 Primary Biliary Cirrhosis, RA, Scleroderma. Guide to laboratory tests | 136

CENP B CREST syndrome, mild variant of progressive systemic sclerosis, primary biliary cirrhosis, Raynaud’s phenomenon and infrequently in Sjögren’s syndrome. PCNA SLE. Mi-2 Steroid responsive dermatomyositis, rarely polymyositis. Ku SLE, MCTD, Sjögren’s syndrome, scleroderma (often with myositis). Fibrillarin Fibrillarin antibodies occur in 5 – 10% of patients with systemic sclerosis, occurring in the diffuse or limited cutaneous forms. The clinical phenotype associated with this antibody include pulmonary arterial hypertension, cardiac and skeletal muscle involvement. CONNECTIVE TISSUE DISEASE Basic spectrum • FBC • Platelet Count • ESR • CRP • Anti-nuclear antibodies • Double stranded DNA antibodies • ENA Screening Test: If positive: • ENA profile: Include antibodies to RNP, Sm, SSA, SSB, Scl70, PM-Scl, Mi-2, Fibrillarin, Jo-1, CENP-B, PCNA, ribosomal P-protein OR • ENA Western blot: Include antibodies to double-stranded DNA, RNP, Sm, SSA, SSB, Scl70, PM- Scl, Jo-1, CENP-B, PCNA, ribosomal P-protein, Histone, Nucleosome, AMA M2 • RF • AMA (anti-mitochondrial antibodies) 137 | Ampath Desk Reference • ASMA (anti-smooth muscle antibodies) • ANCA Rheumatoid arthritis (RA) • FBC and platelets • ESR • CRP • Anti-nuclear antibodies (ANA) • ENA Screening Test: If positive: • ENA profile / Western blot • Rheumatoid factor (RF) • Anti-cyclic citrullinated peptide (CCP) antibodies • ANCA may be found in RA vasculitis • CRP most sensitive marker of disease activity • Immunoglobulins: Hypergammaglobulinaemia often present Systemic Lupus Erythematosus (SLE) • FBC and platelets • ESR: Raised in active disease • CRP: Normal or slightly elevated. Increased levels associated with intercurrent infections • ANA • dsDNA-antibodies • ENA screen – if positive: • ENA profile / ENA Western blot: Sm (SLE specific), SSA (Ro), Ro-52, SSB (La), Ribosomal P-proteins (SLE specific), U1-nRNP, histones, nucleosome (SLE specific), PCNA • ANCA • Complement 4: C4 reduction is common and does not relate to disease activity reliably • Complement 3: Active disease: levels are reduced, but owing to increased levels within an acute- phase response, levels may not drop below normal range Guide to laboratory tests | 138 • Immunoglobulins: Polyclonal increase, IgA deficiency may occur • Regular monitoring of UKE, LFT, TFT and urine • Monitoring of established disease: FBC, UKE, LFT, TFT, Urine, ESR / CRP, C3 / C4, anti-dsDNA / Sm • Recheck full serology every 6 – 12 months: patterns may change, half life of antibodies is 3 weeks, do not repeat more frequently than monthly Sjögren’s syndrome • ANA • dsDNA • ENA screen – if positive: • ENA profile / ENA Western blot : SS-A (Ro) – Antibodies to SSA are found in approximately 50 − 75% of patients with primary Sjögren’s syndrome, SSB – SSB antibodies are primarily found in patients with Sjögren’s syndrome (40 – 80%) but may also occur in patients with SLE (6 – 21%) • RF • Thyroid antibodies: Strong association with thyroid disease • Mitochondrial antibodies: May be found in those going on to develop PBC • C3 / C4 • Serum protein electrophoresis and Cryoglobulins • IgG subclasses: May have an increase in IgG1 with reduced IgG2, IgG3 and IgG4 • β2-microglobulin: should be monitored as marker of lymphoproliferation Polymyositis and dermatomyositis • ANA • ENA screen − if positive: • ENA profile / ENA Western blot: Jo-1, PM-Scl75 • Myositis profile: Mi-2, Jo-1, PL-7, PL-12, PM-Scl, RO-52, Ku 139 | Ampath Desk Reference Systemic sclerosis (localised and systemic forms) • ANA: Anti-centromere antibodies (very specific for CREST) • ENA screen – if positive: • ENA profile / ENA Western blot: CENP B, Scl-70, Pm-Scl • Systemic sclerosis profile: Scl-70, CENP A, CENP B, RP11, RP155, Fibrillarin, NOR90, Th/To, PM-Scl100, PM- Scl175, KU, PDGFR, Ro-52 • FBC • U&E and creatinine: Systemic sclerosis may lead to major renal and lung involvement • TFT: association with thyroid disease • LFT • Anti-mitochondrial antibodies: association with PBC • Cryoglobulins: All patients with Raynaud’s phenomenon • CRP, ESR

Ankylosing spondylitis: • HLA B27

Anti-phospholipid syndrome • Anti-cardiolipin antibodies • β2-glycoprotein antibodies • Prothrombin antibodies • Clotting studies • Lupus anticoagulant • Thrombophilia screen (exclude other thrombophilic disorders) Guide to laboratory tests | 140 Vasculitis • Biopsy • Imaging • Immunological tests • Immunoglobulin levels: may be non-specifically raised • Serum protein electrophoresis: to look for paraproteins, albumin will be reduced (negative acute-phase protein) with elevated a2 band • Consider possibility of cryoglobulins • ANA • ENA • dsDNA-antibodies • Anti-neutrophil cytoplasmic antibodies (ANCA) • Acute-phase markers: mostly high, regular monitoring provides useful information on response to treatment • CRP • ESR • C3, C4: levels will be elevated • Caeruloplasmin: often significantly elevated in some vasculitides • Ferritin: levels may be very high (> 1000 ng/ml) in adult Still’s disease • FBC: often anaemia of chronic disease with thrombocytosis and often a lymphopaenia 141 | Ampath Desk Reference ALLERGIC DISEASES Allergic disorders (also refer to Ampath’s "An approach to the diagnosis of an Allergy)" – **refer to attachments A - D Immediate type hypersensitivity Total IgE Phadiatop inhalant screen • Breakdown into individual allergens if positive Food mix screen (FX5) • Breakdown into individual allergens if positive • Individual food allergen component IgE if positive Allergen specific IgE (Immunocap®) ; eg latex, bee venom, individual allergens ISAC: 112 Allergen component IgE testing Skin Prick Testing Nasal mucus examination for eosinophils Basophil mediated hypersenstitivity (can present like immediate type hypersensitivity or with delayed type onset of up to 48 hours after exposure) CAST inhalant screen CAST food screen CAST colourants and preservatives Allergen-specific CAST Drug-specific CAST Guide to laboratory tests | 142 Delayed type hypersensitivity reaction Allergen-specific MELISA testing Metal MELISA testing Drug-specific MELISA **For a complete list of allergy diagnostic tests available at Ampath, refer to attachment E Urticaria FBC + diff ESR ANA, ENA Total IgE CAST colourants and preservatives or medication Allergy tests dependent on history Complement (C3, C4) Helicobacter pylori antibodies Thyroid antibodies LFT + protein electrophoresis Mast cell tryptase Urine for PGD2 (elevated in mast cell activation syndrome) Urine for Methyl Histamine (elevated in mast cell activation syndrome – this is sent away to the Mayo clinic) MICROBIOLOGY AND MICROBIAL SEROLOGY Antenatal screening FBC Indirect Coombs ABO Group 143 | Ampath Desk Reference Rh type HBs Ag HIV Rubella IgG Ab Syphilis serology including RPR, Treponema pallidum screen Chronic fatigue FBC Glucose LFT TSH U & E Coxsackie B Ab EBV Ab Brucella Ab Enterovirus PCR (CSF) Lyme serology (Borrelia ELISA) Q-fever serology Immunoglobulins Total IgE and allergic work-up if clinically indicated CNS (meningitis / encephalitis) Autoimmune encephalitis antibodies including: • NMDA • Aquaporin 4 antibodies ANA Bacterial antigens Blood culture Guide to laboratory tests | 144 CMV PCR Cryptococcus antigen CSF MCS Enterovirus PCR HSV PCR HIV serology Lyme serology Mumps PCR Syphilis serology on CSF (including VDRL, Treponema pallidum IgM and IgG) and serum (including RPR, Treponema pallidum antibody screen) TB culture and PCR Toxoplasma PCR Varicella zoster PCR Viral Meningitis Multiplex PCR Congenital screening CMV Ab HSV 1 & 2 Ab Rubella Ab Syphilis serology including RPR, Treponema pallidum IgM and IgG Toxoplasma Ab Rubella PCR CMV PCR Diarrhoea – stool investigations Microscopy including parasites Culture for pathogens Clostridium difficile PCR 145 | Ampath Desk Reference • Bacterial gastroenteritis multiplex PCR panel for detection of: • Campylobacter spp. (jejuni and coli) • Salmonella spp • Shigella spp • Enteroinvasive E. coli (EIEC) • Shiga toxins (stx1 and stx 2) found in Shiga toxin-producing E. Coli (STEC) and Shigella dysenteriae • Viral gastroenteritis multiplex PCR panel for detection of: • Rotavirus • Norovirus genogroup 1 and 2 • Adenovirus • Astrovirus • Sapovirus

• Parasite gastroenteritis multiplex PCR panel for detection of: • Entamoeba histolytica • Cryptosporidium spp • Giardia spp Rotavirus and adenovirus rapid antigen test Genital ulcer MCS HSV PCR Syphilis serology including RPR, Treponema pallidum antibody screen Haematuria Urine MCS Urine microscopy for parasites Guide to laboratory tests | 146 Bilharzia Ag + Ab HBsAg ANA, ENA ASOT Complement (C3, C4) ALT Glucose Protein electrophoresis U & E FBC PNH flow cytometry HEPATITIS Hepatitis A, B, C Acute disease Hep A IgM Hep B acute profile (HBsAg, cAb, sAB) HCV PCR Immunity / post vaccination Hep B sAb Hep A IgG Other hepatitides Amoebic Ab Brucella Ab/PCR CMV Ab 147 | Ampath Desk Reference EBV Ab Hep E Ab HSV Ab / PCR Hydatid Ab Leptospira Ab/PCR Q-fever Ab Syphilis serology RPR, Treponema pallidum antibody screen Mitochondrial Ab Smooth muscle Ab LKM Ab Autoimmune hepatitis western blot Alpha-1 antitrypsin Iron studies Serum Caeruloplasmin 24-hour urine copper Lymphadenopathy / mononucleosis syndrome serology Cytomegalovirus Ab HIV ELISA TB spot test / Mantoux Bartonella Ab Brucella Ab EBV Ab Mumps Ab Rubella Ab Syphilis serology including RPR, Treponema pallidum antibody screen Toxoplasma Ab Guide to laboratory tests | 148 Other: Bone marrow Lymph node biopsy • Histology • TB culture • TB PCR ANA, ENA Serum ACE Proteinuria Urine MCS Urine protein / creatinine ratio 24-hour urine protein FBC Albumin Complement (C3, C4) ANA, ENA ASOT HIV ELISA Hep B sAg Glucose Protein electrophoresis Urine for Bence Jones proteins Pyrexia of Unknown Origin (PUO) Blood cultures (Large vol – 60 ml) Culture of any suspected source e.g. sputum Malaria films / QBC / PCR 149 | Ampath Desk Reference Mantoux skin test Urine micro and culture Serology: • EBV Ab • CMV Ab • Arbovirus Ab • Bartonella Ab • Brucella Ab • Brucella PCR • Dengue Ab • Leptospira Ab • Q-fever Ab • Rickettsia Ab • Toxoplasma Ab ANA, ENA Bone marrow if indicated Rash − vesicular MCS Serology: • Bartonella Ab • CMV Ab • Coxsackie B Ab • Dengue and other arbovirus Ab • EBV Ab • HIV Ab • Human herpes virus 6 Ab • Human herpes virus 7 Ab Guide to laboratory tests | 150 • Measles Ab • Mycoplasma pneumonia Ab • Mycoplasma pneumonia PCR • Parvovirus B19 Ab • Rickettsia Ab • Rickettsia PCR • Rubella Ab • Syphilis serology including RPR, Treponema pallidum antibody screen ANA, ENA Respiratory infections Upper Culture (throat swab) Bordetella pertussis PCR (throat Swab / NPA) Multiplex Respiratory Virus PCR Respiratory virus DFA Serology: • Bordetella pertussis toxin IgA and IgG • ASOT / Anti DNase B Lower (acute) Blood cultures x 2 Sputum MCS Legionella PCR (sputum) Mycoplasma pneumoniae PCR (sputum) Chlamydophila pneumoniae PCR (sputum) Influenza PCR Bordetella pertussis PCR 151 | Ampath Desk Reference Multiplex Respiratory Virus PCR Multiplex Bacterial Pneumonia PCR Serology: • Bordetella pertussis toxin IgA, IgG • Chlamydophila pneumoniae Ab • Chlamydophila psittaci Ab • Legionella Ab • Mycoplasma pneumoniae Ab • Q-fever Ab Lower (non-resolving): Sputum and / or BAL • MCS • Fungal culture x 3 • MTB micro and culture x 3 • MTB PCR T Spot TB Test / Quantiferon Gold / Mantoux Skin Test Total IgE Serology: • Bordetella pertussis toxin IgA, IgG • Aspergillus precipitins / IgG • Aspergillus IgE / skin prick test • HIV Ab • Legionella Ab • Mycoplasma pneumoniae Ab Sweat test ANCA Pneumocystis jiroveci PCR Guide to laboratory tests | 152 Urethral discharge MCS Chlamydia trachomatis PCR Neisseria gonorrhoea PCR Urinary tract infection Urine MCS Blood cultures x 2 (systemic symptoms) Serology: ASOT / Anti DNAse B (Nephritis) PRIMARY IMMUNODEFICIENCIES: A DIAGNOSTIC APPROACH Features suggestive of a primary immunodeficiency (First three features most predictive) • Family history of immunodeficiency or unexplained early death (< 30 years) • Failure to thrive • Need for IV antibiotics and / or hospitalisation to clear infection • Six or more new infections in one year • Two or more sinus infections or pneumonia in one year • Four or more new ear infections in one year • Two or more episodes of sepsis or meningitis in a lifetime • Two or more months of antibiotics without an effect • Recurrent or resistant Candida infections • Recurrent tissue or organ abscesses • Infection with an opportunistic pathogen • Structural damage due to infections 153 | Ampath Desk Reference • Complications from a live vaccine • Chronic diarrhoea • Non-healing wounds • Extensive skin lesions • Persistent lymphopaenia • Unexplained fever or autoimmunity Additional features in infants include: • Delayed umbilical separation (> 30 days) • Congenital heart defects • Hypocalcaemia • Absent thymic shadow on CXR Most children referred for recurrent infections do not have an underlying immunodeficiency. The majority of children will have increased exposure, allergy (~30%), other chronic diseases (~10%) or an anatomic defect. Only about 10% will have an immunodeficiency. Laboratory investigations Abnormal results need to be verified at a later stage, as external factors like infections and medication may have a transient influence on the test results. • Test for HIV, CMV, EBV, TB, disseminated BCGosis, PCP and other infections where relevant • FBC and differential count • Quantitative immunoglobulins PRIOR to administration of immunoglobulins: IgG, M, A & E • CRP and ESR • Screen for Cystic Fibrosis where indicated Guide to laboratory tests | 154 1. ANTIBODY (HUMORAL) DEFICIENCIES – these accounts for about 70% of primary immunodeficiencies Patients suffering from antibody deficiencies have a problem with recurrent, severe upper (recurrent pneumonia), and lower respiratory tract infections (i.e. recurrent otitis media, sinusitis) especially with pyogenic organisms such as S. pneumoniae and H. influenzae. Appropriate screening tests would be: • Full blood count and differential • IgG, IgA, IgM • IgG subclasses IF any abnormality is detected, additional tests should be done: • Lymphocyte immunophenotype: To determine total B-cell numbers • Specific antibody titres to S. pneumoniae, H. influenzae, Tetanus and Diphtheria • If specific antibody levels are low, booster immunisations should be administered and titres measured again 3 – 4 weeks later • B-cell function testing for B-cell activation markers • Memory B-cells: Flow cytometric assay to assess germinal B-cell function in a patient with a humoral immunodeficiency. • B-cells are associated with more serious / frequent infections, autoimmune disease • KREC PCR • Diagnostic tests: a. Bruton’s Tyrosine Kinase: Flow cytometric assay in patients with suspected X-linked agammaglobulinaemia b. CD 40 Ligand: Flow cytometric assay in patients with suspected hyper-IgM syndrome 155 | Ampath Desk Reference 2. T-CELL DEFECTS – these account for about 15% of primary immunodeficiencies T-cell defects usually present at a very young age with life-threatening infections due to a wide range of different pathogens, often opportunistic infections. Infections are persistent and severe and viruses, fungi and intracellular bacteria are often involved. A family history of unexplained, especially infective deaths should prompt further investigation. HIV ELISA or PCR in babies: Performed on all patients suspected of having a T-cell deficiency. • FBC and differential: Patients are usually lymphopaenic with persistent absolute lymphocyte counts < 1.5 X109/l in older children and • < 2.5 X 109/l in younger children • Lymphocyte immunophenotyping to enumerate the lymphocyte subtypes (B- and T-cells and NK cells) • TREC PCR • Lymphocyte proliferation tests to mitogens a. PHA b. PMA c. PMA + ionophore d. CD3 e. CD3 + IL-2 f. CON A g. PWM • Lymphocyte proliferation tests to recall antigens: a. Varicella zoster b. Candida c. Tetanus Guide to laboratory tests | 156 • Specialised immunophenotyping: a. Naïve and memory CD4 and CD8 cells, recent thymic emigrants b. Alpha / beta, gamma / delta T-cells c. Common gamma chain / IL–7RA d. CD3+ CD25+ Fox P3 e. Th17 • Genetic testing (contact genetic councellor Sarah Walters, 012 678 1362) For infants and young children, all of the lymphocyte proliferation tests to mitogens should be ordered, whereas only LPT to candida, varicella zoster and PHA should be ordered in adults. 3. TESTS TO DETERMINE NEUTROPHIL FUNCTION These tests should be requested in patients with recurrent skin, soft tissue or deep abscesses, or recurrent infections with S.aureus, coagulase negative staphylococci, Serratia marcescens, P. aeruginosa, Chromobacterium violaceum or Aspergillus spp • FBC with differential count • Neutrophil oxidative burst, phagocytosis and chemotaxis • Leukocyte adhesion studies: CD11 and CD18: in babies with delayed umbilical cord separation (> 30 days) and patients with recurrent bacterial infections, mainly involving the skin and mucous membranes, periodontitis, absent pus formation, impaired wound healing • Neutrophil antibodies for suspected autoimmune neutropaenia 4. TESTS TO DETERMINE COMPLEMENT FUNCTION The total Haemolytic Complement activity should be requested in patients with recurrent Neisserial and pyogenic infections. It is therefore important that symptomatic patients with normal antibody and neutrophil tests be further evaluated by complement function testing. • Classic and alternate pathways (CH100 and ACH100) • Complement 3 and 4 levels • Mannan Binding Lectin (MBL) 157 | Ampath Desk Reference 5. NATURAL KILLER CELLS NK cells play a crucial role in the host defence against herpes virus infections, especially Herpes simplex virus and Varicella zoster virus reactivation and latency. • Total NK cell numbers • NK cell function. 6. TESTS FOR CAUSES OF SECONDARY IMMUNODEFICIENCY Secondary causes for immunodeficiencies should always be excluded. Includes HIV, UKE, LFT, glucose, albumin, urinalysis, serum protein electrophoresis, stool α1-antitrypsin levels etc. Guide to laboratory tests | 158 VIROLOGY HIV (Human immunodeficiency virus) diagnosis and monitoring: HIV infection is usually diagnosed by means of serology testing. This includes the 4th generation ELISA based technology, which detects both p24 antigen and HIV antibody; 3rd Generation ELISA- based technology, which detects only antibodies, and the p24 antigen testing ELISA, which is useful in the diagnosis of acute infection with HIV. Serological diagnosis includes the use of western blot tests which may be used to confirm positive ELISA results, or to differentiate HIV-1 from HIV-2. HIV infection in infants <18 months of age is normally diagnosed using HIV PCR testing where viral DNA is detected, as persistent maternal HIV antibodies in the baby may be detected with HIV ELISAs up until 18 months of age. Over the age of 18 months, routine diagnostic algorithms may be used. Possible diagnostic algorithms include:

Algorithm Interpretation • Screening assay (usually 4th generation HIV ELISA Patient not infected with HIV, or in early infection or HIV rapid test) non-reactive pre-seroconversion. If the latter is suspected, HIV nucleic acid testing should be requested. This is likely to be positive approximately 5 days prior to p24 antigen becoming detectable. • 4th-generation HIV ELISA reactive Confirmed HIV infection. A second sample should • HIV western blot positive be tested to ensure that there have been no sample misidentification problems.

• 4th-generation HIV ELISA reactive Confirmed HIV infection. A second sample should • 3rd-generation HIV ELISA reactive be tested to ensure that there have been no sample misidentification problems. 159 | Ampath Desk Reference

Algorithm Interpretation • 4th-generation HIV ELISA reactive Confirmed HIV infection. A second sample should • HIV viral load detectable (HIV VL should be be tested to ensure that there have been no above 5000 copies/ml). Bear in mind that the sample misidentification problems. use of HIV VL assays to confirm HIV infection is off-label use of these assays, as they are only licensed for use in monitoring HIV infection once diagnosis has been made. • 4th-generation HIV ELISA reactive Acute infection with HIV. This infection may be • HIV western blot or 3rd-generation ELISA confirmed with the use of HIV VL (viral load) testing indeterminate or non-reactive as the HIV VL is usually high in these circumstances. • HIV p24 antigen positive One may also confirm infection simply by monitoring the course of seroconversion with repeat serology at a later stage. • 4th-generation HIV ELISA (Enzyme Linked This result combination may be due to false Immunosorbent Assay) reactive reactivity in the 4th-generation ELISA assay. • HIV western blot or 3rd -generation ELISA Molecular testing such as HIV viral load or PCR indeterminate or non-reactive (Polymerase chain reaction) may be useful in • HIV p24 antigen non-reactive determining whether or not infection is present. HIV -2 should also be considered. • 4th-generation HIV ELISA reactive Ensure that there are no laboratory / specimen • HIV Wwestern blot indeterminate or negative errors. • HIV p24 antigen non-reactive Exclude HIV-2 infection. • HIV VL/PCR negative or undetectable or Check CD4 count. If high, consider that the patient unexpectedly low (<5000 copies/ml). may be an elite or viraemic controller of HIV. Consult with a pathologist. Guide to laboratory tests | 160 HIV monitoring: Once a diagnosis of HIV has been confirmed in a patient, it is then necessary to commence with staging the infection and making treatment and prophylaxis decisions with the patient. The staging is clinical, as well as laboratory based, with the use of CD4 (cluster of differentiation 4) and viral load testing. In general, antiretroviral treatment should be commenced in any patient with confirmed HIV infection regardless of CD4 count. SMX / TMP (Bactrim) prophylaxis should be used in any patient with a CD4 of less than 200 cells/µl in order to reduce the risk of pneumocystis pneumonia developing in the patient. In addition, all patients with CD4 counts <100 cells/µl should be tested for cryptococcal antigenaemia by means of a serum cryptocococcal antigen test (CRAG) and positive asymptomatic antigenaemic patients must be given fluconazole 800 mg daily for 2 weeks, then 400 mg daily for 8 weeks followed by fluconazole 200 mg daily for at least 10 months (or until the CD4+ T-cell count rises to >200 cells/µl, twice, 6 months apart) to prevent the development of cryptococcal meningitis. Indications for starting ARV therapy 1. Symptomatic patients (irrespective of CD4 count) • WHO clinical stage 3 and 4 • Any severe HIV-related disorder should be considered an indication for ART such as: –– Immune thrombocytopaenia –– Thrombotic thrombocytopaenia –– Polymyositis –– Lymphocytic interstitial pneumonitis • Non-HIV-related disorders, e.g.: –– Malignancies –– Hepatitis B 161 | Ampath Desk Reference –– Hepatitis C –– Symptomatic vascular disease or diabetes mellitus –– Any condition that requires long term immunosuppressive therapy 2. Asymptomatic patients • Start ART regardless of CD4 count HIV and HBV (Hepatitis B virus): Screening for HBV should occur at the time of diagnosis of HIV with the use of HBsAg (hepatitis B surface antigen) testing. If the patient is HBsAg negative and not immune, HBV vaccine should be offered. If HBsAg positive, ARV (antiretroviral) therapy should be commenced irrespective of CD4 count. First and second line ARV regimens should contain Tenofovir and Emtricitabine, or Tenofovir and Lamivudine for the treatment of both the HBV and HIV infections, together with a third drug active against HIV. HIV and TB: WHO recommends that all patients are started on ARV as soon as possible after starting TB treatment, regardless of CD4 count (within 8 weeks of starting TB treatment). • CD4 <50 cells/mm3: Start ARV 2 weeks after starting TB treatment • CD4 >50 cells/mm3 but with severe clinical disease (low Karnofsky score, low BMI, low Hb, low albumin, organ system dysfunction): start ARV within 2 – 4 weeks of starting TB treatment • CD4 >50 cells/mm3 without severe disease clinically: start ARV within 8 weeks of TB treatment. HIV and pregnancy: All pregnant women should start triple drug ARV treatment regardless of CD4 count or viral load. This treatment should be started with a view to lifelong therapy. Guide to laboratory tests | 162 HIV in serodiscordant couples: The HIV-infected partner should start ARV treatment regardless of CD4 count and WHO stage in order to prevent transmission to the non-infected partner. HIV prophylaxis after unprotected sex, rape and needle sharing, and occupational post exposure prophylaxis HIV PEP is of critical importance in a high prevalence setting such as South Africa. PEP has proven efficacy if taken correctly and without interruption and for the full 28 days. PEP should be started as soon as possible following exposure. The longer the delay in starting PEP, the less likely it is to be effective. Beyond 7 days, PEP is no longer given. In South Africa, we recommend a triple drug regimen, although this should never be at the expense of adherence. HIV, HBV and HCV testing should be performed at baseline, at 6 weeks, and at 3 months following exposure. HCV testing should be repeated at 6 months. Some sources also recommend repeat HIV ELISA at 6 months post exposure. • In high prevalence regions such as South Africa, a 3 drug regimen is usually recommended: • The backbone NRTI regimen can include either of the following combinations: • Truvada (Emtricitabine 200 mg and Tenofovir 300 mg) taken once daily • AZT (Azithromicin) 300 mg and Lamivudine 150 mg (Combivir) taken twice a day

• The third drug can include one of the following: • Lopinavir 400 mg boosted with Ritonavir 100 mg (Aluvia) twice daily • Lopinavir 800 mg boosted with Ritonavir 200 mg (Aluvia) once daily • Raltegravir (Isentress) 400 mg twice daily • Atazanavir (Reyataz) 300 mg boosted with Ritonavir 100 mg daily. It is very important to use Ritonavir boosted Atazanavir if using it in combination with Tenofovir. 163 | Ampath Desk Reference A good “go to” PEP regimen is Truvada once daily and Raltegravir 400 mg BID for 28 days. The side effect profile is favourable, and these drugs work early in the life cycle of HIV. HIV PCR or viral load testing is NOT recommended following exposure to determine possible early HIV infection. This is because the time points following exposure when HIV PCR and viral loads become positive, should infection occur, are not well defined. In addition, PEP can delay infection, and a negative PCR or viral load performed early after exposure does not exclude the possibility of HIV infection. Routine HIV ELISA testing at 6 weeks and 3 months are the only HIV tests that should be performed. For detailed information on the management of HIV in South Africa, check the latest guidelines on the website of the SA HIV clinician’s society http://www.sahivsoc.org Hepatitis diagnosis and monitoring Hepatitis A virus (HAV) Diagnosis: HAV IgG positive, IgM negative: immune to HAV HAV IgG negative, IgM positive: acute infection with HAV. HAV IgG positive, IgM positive: acute infection with HAV. IgM persists for 3 – 6 months, while IgG persists lifelong. Management for HAV-infected patients is largely supportive. A small percentage of patients may develop fulminant hepatitis, but this is not a common manifestation of infection with this virus. Some laboratory HAV IgG assays have been replaced by total antibody assays that detect both IgG and IgM antibodies. Total antibody assays may be a more sensitive marker of acute HAV infection even in the absence of a positive HAV IgM result. If acute HAV infection is suspected and HAV total antibodies are positive, repeat the HAV IgM after 3 – 5 days. If the IgM is then positive, a diagnosis of acute HAV is confirmed. Guide to laboratory tests | 164 Post exposure prophylaxis for HAV can be achieved in 2 ways HAV is oral-faecal transmitted. Rare cases of transmission in blood products have been described. Sexual transmission may occur, but is also rare. • Hepatitis A vaccine alone is favoured unless >2 weeks since contact or if the contact is immunocompromised or has pre-existing liver disease where vaccine plus immune globulin should be given. The efficacy of vaccine alone in persons over 40 years is not well established and HNIG (human immunoglobulin) should be given in addition to vaccine. • People who may need PEP after contact with an infected patient include: • Household and sexual contacts • Children in day-care centres • Cases in institutions where hygiene is likely to be poor e.g. with physically or mentally disabled people, and where incontinence and nappy use is likely to be encountered. • Workers who may have been exposed to faecal material without use of adequate protective equipment. • Dose • Vaccine (Havrix ®, Avaxim®) – 2 doses a month apart • Human normal immune globulin (HNIG) (Beriglobin®, Intragam®) – 0.02 – 0.04 ml/kg. • Vaccine and immune globulin should be given at different sites. Pre-exposure prophylaxis: • HAV inactivated vaccine is the method of choice for pre-exposure prophylaxis for HAV. It is highly immunogenic and almost 100% of adults will develop immunity within 4 weeks of vaccination. A booster provided within 6 – 12 months provides long lasting, and probably lifelong, immunity to HAV. • Should travel to a highly endemic area be anticipated and there is insufficient time available for immunity to the vaccine to develop, normal human immunoglobulin may be administered at a dose of 0.02ml/kg IM. It is important to note that this only provides immunity for 3 months and so the vaccine 165 | Ampath Desk Reference should be administered at the same time (administered into the opposite Deltoid muscle to the one used for immunoglobulin). It takes approximately 2 – 4 weeks for immunity to develop to the vaccine. Immunity provided by the immunoglobulin is almost immediate. Infection control • Standard and contact precautions are adequate • Strict hand hygiene • Proper and careful disposal of faecal waste For detailed information on HAV, refer to the guidelines on “Guidelines for the control of hepatitis A in South Africa” on the NICD website: http://www.nicd.ac.za. Click on the publications tab, and then on guidelines. Treatment Management is mainly supportive. Hepatitis B Virus: Diagnosis

Anti Anti HBsAg HBeAg Anti HBc Anti HBs Interpretation HBcIgM HBe Pos Neg Neg Neg Neg Neg Incubation, Early disease Pos Pos Pos Pos Neg Neg Acute disease Pos Neg Pos Pos Pos Neg Acute disease Neg Neg Pos Pos/Neg Neg Neg Diagnostic window Pos Pos Pos/Neg Pos Neg Neg Super carrier Pos Neg Neg Pos Pos Neg Simple carrier Guide to laboratory tests | 166

Anti Anti HBsAg HBeAg Anti HBc Anti HBs Interpretation HBcIgM HBe Neg Neg Neg Pos Pos Pos Convalescence Neg Neg Neg Pos Neg Pos Immune following wild virus infection Immune due to vaccine or Neg Neg Neg Neg Neg Pos immunoglobulin Neg Neg Pos Neg Neg Pos/Neg Fulminant HBV infection • In general, HBsAg should clear within 6 months following an acute infection. If this does not occur, the patient is classified as a chronically infected or a carrier of HBV and remains potentially infectious. The rate of chronic infection varies depending on the age at which infection is acquired. An adult infected with HBV generally has a risk of chronicity of around 10%. A child infected in the perinatal period has a risk of 80 – 90% if no PEP (post exposure prophylaxis) is available. Post exposure prophylaxis HBV is transmitted parenterally. Contamination with infected blood or blood products, IVDU (intravenous drug use), and vertical transmission usually during the birth from an infected mother to the baby are the common routes of transmission. HBV is not transmitted in breast milk. Sexual transmission also occurs. Transmission has been described in some contact sports where blood contamination may occur. • A previously vaccinated healthy individual with proven seroconversion requires no PEP • Contacts are infectious if they are hepatitis B surface antigen (HBsAg) positive • Mucocutaneous exposure to blood and body fluids requires PEP with hepatitis B immune globulin (HBIG) and vaccine • Institutional or household contacts (no defined exposure) require vaccine only • Newborns of HBsAg-positive mothers • If mother eAg-positive: HBIG and vaccine (first dose at birth) 167 | Ampath Desk Reference • If mother eAg negative: vaccine only (first dose at birth). Then continue with the normal EPI schedule. • Dose (vaccine and immunoglobulin to be given at different sites) • HBIG (200 IU/2ml) (Hebagam®) • Newborn – <5 years: 200 IU • 5 – 9 years: 300 IU • 10 years: 500 IU • Vaccine (Engerix-B®, H-B-Vax II® Heberbiovac HB®): 3 doses at 0, 1 and 2 months with a booster at 12 months. Pre-exposure prophylaxis HB vaccine is administered now as part of our EPI programme in South Africa. In addition to the children vaccinated in the EPI schedule, the following people should also be vaccinated against HBV: • Healthcare workers at risk of exposure to blood or blood contaminated fluids • Patients in renal failure in need of chronic dialysis • Patients with underlying liver disease or HCV (hepatitis C virus) infection • HIV-infected people who are not immune to HBV • People who present to medical care with a sexually transmitted infection • Men who have sex with men • Sexual partners of those with a chronic HBV infection • Household members of a person chronically infected with HBV • Residents and staff of institutions for developmentally disabled people • Non-immune travellers Higher doses of vaccine may be required in immunocompromised people and people on dialysis. People requiring post vaccine serological testing for immunity (anti-HBs – hepatitis B surface antibody): Guide to laboratory tests | 168 • Healthcare workers • Infants born to HBsAg-positive mothers • Immunocompromised and dialysis patients • Sexual partners of people with chronic hepatitis B. People who require booster vaccine: • Immunocompromised patients should be monitored annually, and when their HBsAb (hepatitis B surface antibody) levels drop below 10mIU/mL, booster dose of vaccine should be administered. • Otherwise healthy individuals with recorded seroconversion to vaccine do not need ongoing monitoring or boosters. HBV treatment • Treatment of acute infection is largely supportive. However, Lamivudine may be used in severe infection as it reduces viral load and therefore reduces the risk of recurrent infection should liver transplantation be necessary. It may also be used in patients with prolonged severe acute infection (jaundice >4 weeks and INR >1.5). The elderly, immunocompromised patients, and patients coinfected with HCV should also be treated if they acquire acute HBV disease, as they are more likely to follow a fulminant or sub-fulminant course. Treatment for chronic HBV infection Assessment and monitoring • Assessment of liver disease • Full LFTs • FBC • PTT 169 | Ampath Desk Reference • Liver ultrasound • Declining trend in albumin, increase in globulins, prolonged PTT and declining platelet counts are often seen as cirrhosis develops • Hepatitis VB viral load • Essential for diagnosis and decision to treat and subsequent monitoring • Exclude other causes of liver disease • HCV, HIV, HDV, HAV IgG (if negative, vaccinate against HAV) • Alcoholic, autoimmune, and metabolic liver disease • Liver biopsy • Determines degree of fibrosis and necroinflammatory disease and can assist in the decision to start treatment. Usually not required in patients with other evidence of cirrhosis, or in those in whom treatment is indicated irrespective of what histology would show End goals of therapy The goal of therapy is to achieve sufficient viral suppression so that biochemical and histological improvement occurs and complications are prevented. Ideally one would like to achieve sustained loss of HBsAg, but this is not often reached with current treatment options. The aim presently therefore is sustained biochemical and virological remission. • In HBeAg (hepatitis B e antigen) positive and negative patients sustained off therapy loss of HBsAg even without serological evidence of seroconversion to HBsAb. This is associated with complete remission of chronic hepatitis B and improved long-term outcome. • Sustained off therapy virological and biochemical response in HBeAg-negative patients. This has been associated with improved prognosis. • A maintained virological remission with undetectable HBV DNA under long-term antiviral therapy in HBeAg-positive patients who do not achieve HBeAg seroconversion and in also in HBeAg-negative patients who do not necessarily achieve the above end points. Guide to laboratory tests | 170 Indications for therapy Factors to consider: • HBV DNA levels >2000IU/mL • Serum ALT levels above the upper limit of normal • Severity of liver disease indicating moderate to severe necroinflammatory disease, or moderate fibrosis on the liver biopsy. If there is evidence of severe liver disease and elevated HBV DNA levels, treatment is indicated even if ALT is normal • HBeAg-positive patients, <30 years of age, normal ALT levels, high HBV VL ( HBV viral load) levels, no evidence of liver disease or family history of HCC or cirrhosis: • No need for immediate therapy or biopsy • Follow up 3 – 6 monthly • HBeAg-positive patients >30 years of age, and/or family history of HCC (hepatocellular carcinoma) or cirrhosis: • Consider biopsy • Consider therapy even if biopsy not available • HBeAg-negative patients, normal ALT levels (determined 3 monthly for at least 1 year), HBV VL >2000IU/ml but <20 000IU/ml, no evidence of liver disease: • No need for immediate liver biopsy or therapy • ALT 3 monthly for first year • HBV VL 6 monthly for first 3 years • Thereafter, follow up as for all inactive chronic HBV carriers • HBeAg-positive and -negative patients with obvious chronic active Hepatitis, • ALT > 2 times upper limit of normal, HBV VL >20 000 IU/ml: • Start treatment even without liver biopsy. Biopsy or a non-invasive method to determine presence of cirrhosis would be useful, but would probably not change the decision to treat. 171 | Ampath Desk Reference • Detectable HBV DNA and compensated cirrhosis: • Treat even if ALT levels are normal • Detectable HBV VL and decompensated cirrhosis: • Urgent treatment with nucleot(s)ide analogues • Liver transplantation may be necessary, although some patients are rescued by use of urgent antiviral intervention Available drugs (adefovir and telbivudine not yet available in South Africa): • Interferon (IFN) and pegylated interferon (PEG-IFN) • Nucleoside analogues (lamivudine, entecavir, emtricitabine, telbivudine) • Nucleotide analogues (tenofovir, adefovir) Treatment strategies • Finite duration treatment: • IFN, PEG IFN, or a nucleoside/nucleotide analogue (NA): This treatment is designed to achieve a sustained off-therapy virological response. • IFN/PEG IFN (latter is preferred) for 48 weeks has several advantages including finite duration of therapy, absence of resistance, and immune mediated control of the virus allowing the chance of achieving a sustained virological response with HBsAg loss once treatment is concluded. However, the use of IFN demands subcutaneous injections and has a high rate of side effects and is contraindicated in patients with decompensated cirrhosis, autoimmune disease, pregnancy, and severe depression or psychotic conditions. Combination with a NA is currently not recommended. IFN works best on genotypes A and B HBV. • Entecavir or Tenofovir are the only NA recommended for first line monotherapy as they both have a high barrier to resistance. The other 3 drugs should be avoided unless the above 2 are not available or contraindicated. Treatment duration is unpredictable, and close virological monitoring of patients is required after Guide to laboratory tests | 172 treatment is stopped, as relapses are common. Once HBeAg seroconversion occurs, treatment should be continued for at least another 12 months. If HBeAg seroconversion persists during these 12 months, a durable off-treatment response will be found in 40 – 80% of such patients. • Long-term treatment with a nucleoside/nucleotide analogue: • This strategy is necessary in patients who fail finite therapy or who are not expected to achieve a sustained off-treatment response (e.g. patients who fail to achieve HBeAg seroconversion or who are HBeAg negative at the start of therapy). This strategy is also recommended for patients with cirrhosis regardless of HBeAg status or seroconversion. Tenofovir or Entecavir are recommended as first line monotherapies in this situation. Treatment for >3 years is associated with maintained virological remission in the majority of patients.

Before treatment is considered, all patients with chronic HBV infection should be screened for HIV. If HIV is found, treatment using 2 active NA’s against HIV and HBV should be used, together with a third ARV drug for HIV. HBV should never be treated in isolation in this situation as HIV will develop resistance to the NA used for HBV. Similarly, HIV should never be treated without using drugs active against HBV, as immune reconstitution will be associated with severe flare ups of HBV disease. For complete guidelines on the management of HBV infection, please refer to EASL clinical practice guidelines: Management of hepatitis B virus infection. Journal of Hepatology 2012; vol 57:167-185. South African Guideline for the Management of Chronic Hepatitis B:2013 S Afr Med J 2013;103(5):335-349. DOI:10.7196/SAMJ.6452 Hepatitis C virus Diagnosis If the HCV ELISA (combined IgG and IgM) is negative then the patient is unlikely to be infected with HCV. The seroconversion window period may however be prolonged, anything from 6 weeks to 3 173 | Ampath Desk Reference months, and testing should be repeated to exclude later seroconversion. Alternatively, PCR is helpful in that window period to determine an acute HCV infection. In HIV infected persons with chronic HCV, the ELISA may be negative and a PCR should be requested should a person have risk factors for HCV or if it is suspected on clinical grounds. HCV ELISA serology: positive. The patient is seropositive for HCV. This result should be confirmed on an alternative technology as we have a low prevalence of HCV in South Africa and the positive predictive value of a single ELISA result is poor. The seropositive result may be confirmed with the use a recombinant blot (RIBA) assay, or PCR. Most patients infected with HCV will become chronic carriers of the virus and therefore PCR confirmation is more useful than additional serological assays, and a positive result will indicate the need for further monitoring and treatment.

HCV ELISA HCV PCR Interpretation Positive Negative Seroconversion and cleared infection, OR early infection with low-level viraemia. Positive Positive Seroconversion and chronically infected. May also be a recent infection depending on clinical context. Negative Positive Early acute infection prior to seroconversion. Negative Negative Unlikely to be infected. Pre- and post exposure prophylaxis At this stage there is no vaccine available for HCV. Prevention includes avoiding exposure to the virus by preventing percutaneous injury or mucosal exposure and contamination with infected blood. The use of gloves and PPE (personal protection equipment), proper and safe use and disposal of sharps, Guide to laboratory tests | 174 appropriate testing of the blood supply, and use of clean needles/needle exchange in IVDU are the best methods of preventing infection. Sexual transmission of HCV does occur particularly in receptive MSM (men who have sex with men) and can be prevented with condom use. Similarly there is no proven post-exposure prophylaxis for HCV exposure. Should an exposure occur with a known HCV infected source then a baseline ALT and anti-HCV should be performed on the exposed person. Follow-up testing at 6, 12 and 24 weeks is advised and if the ALT is elevated then request a HCV PCR to determine an early infection in the exposed person. Management of acute HCV infection Identification of acute HCV infections is not common as most acute infections are asymptomatic. Acute infections may be confirmed in patients who are symptomatic or when there has been laboratory monitoring for HCV infection following an exposure to an infected source such as from a needle stick injury. There is growing evidence that interferon alpha therapy given during the acute-phase will reduce the rate of chronicity to 10% or less. Thus, all patients with acute HCV infections, where detected, should be considered for interferon- based therapy. The excellent responses seen in clinical trials of antivirals for acute HCV were with standard interferon monotherapy, however, because of the ease of administration Pegylated interferon is preferred. Treatment should be delayed for 8 – 12 weeks to allow for spontaneous resolution first. No definite recommendations can be made regarding the optimal duration of therapy but most guidelines recommend treating for up to 24 weeks. In addition no recommendations can be made at this stage for or against the addition of Ribavirin given the high rates of a sustained virological response with interferon, and the decision to add Ribavirin is made on a case by case basis. 175 | Ampath Desk Reference Dose: Standard interferon alpha 2b- 5 MU subcutaneously daily for 4 weeks then 5 MU subcutaneously 3 times a week for 20 weeks. Pegylated interferon alpha 2b- 1.5 µg/kg subcutaneously given weekly for 12 – 24 weeks. Management of chronic HCV infection Workup prior to starting therapy • HCV VL as a baseline for future monitoring once on treatment • HCV genotyping as this determines duration of treatment and likelihood of virological response • Liver biopsy if information is needed on fibrosis stage for prognostic reasons, or to detect the presence of liver disease in the subset of patients in whom ALT levels are normal Indications for therapy • All adults with confirmed chronic HCV infection. • Particular consideration should be given to those most likely to progress to fibrosis and other complications of HCV infection: patients with HIV infection, male gender, older people with HCV infection, obese individuals, and the use of more than 50 g of alcohol daily all predict quicker progression to fibrotic liver disease. Obesity also adversely affects treatment outcomes and patients with BMI >25 should be encouraged to lose weight before commencing treatment. Excessive alcohol use also increases the rate of fibrosis, and while not an absolute contraindication to antiviral therapy, should be stopped before treatment is considered. • Patients with advanced fibrosis should be considered for treatment although this is not an absolute indicator for antiviral treatment. • Symptomatic cryoglobulinaemia. • Occupations in which transmission to others is likely. Guide to laboratory tests | 176 Predictors of good response to treatment • Female gender; age <40; genotype 2 or 3 infections; HCV VL <600 000 IU/ml; body weight <75 kg; ALT >3 times upper limit of normal; absence of bridging fibrosis or cirrhosis; absence of insulin resistance Treatment • PEG IFN in combination with ribavirin. • Genotype 2 and 3 infections: • PEG IFN α2a 180 ug per week subcutaneously + Ribavirin 800 mg daily OR • PEG IFN α2b 1.5 ug/kg/week subcutaneously + Ribavirin 800 mg daily • Duration of treatment: 24 weeks • Genotype 1 and 4 infections: • PEG IFN α2a 180 ug per week subcutaneously + Ribavirin 15 mg/kg daily OR • PEG IFN α2b 1.5 ug/kg/week subcutaneously + Ribavirin 15 mg daily • Duration of treatment: 48 weeks. This may be extended to 72 weeks if RNA clearance is delayed. • Genotype 5 and 6 infections: • There is little data on treatment of these 2 genotypes, and while some evidence is emerging to show a good response to treatment in Genotype 5, the recommendation is rather to treat as per Genotype 1 and 4 infections until more definitive data is available. • The newer antiviral treatments for HCV, while not yet easily obtained in South Africa, are extremely successful in curing HCV across various genotypes. An example likely to be available shortly is Gilead Science's Harvoni® (Sofosbuvir and Ledipasvir). A 12 week course of one dose a day has demonstrated cure rates of up to 98%. Even at special public sector prices though, this drug is likely to cost around R17 000 for the full treatment course. 177 | Ampath Desk Reference Types of response to therapy encountered RVR (rapid virological response): Negative HCV RNA at Week 4 of treatment. RVR may allow shortening of treatment period for Genotypes 2 and 3 cEVR (complete early virological response: Negative HCV RNA at week 12 of treatment pEVR (partial early virological response): >2log reduction in VL from baseline ETR (end of treatment response): HCV RNA negative at end of treatment (week 24 or 48) SVR (sustained virological response): HCV RNA negative at 24 weeks after treatment is stopped. SVR is the best predictor of a sustained response to HCV treatment Breakthrough: Reappearance of HCV RNA while still on therapy Relapse: Reappearance of HCV RNA once therapy has been stopped Non responder: failure to clear HCV RNA after 24 weeks of therapy Null responder: failure to decrease HCV RNA by > 2 logs by week 24 of therapy Partial responder: >2 log decrease in HCV RNA level by week 24, but failure to clear infection Contraindications to therapy • Major uncontrolled depressive illness • Solid organ transplant • Autoimmune disease which may be exacerbated by IFN (interferon) • Untreated thyroid disease • Pregnancy or not on adequate contraception • Severe concurrent medical disease e.g. hypertension, COPD (chronic obstructive airway disease), uncontrolled diabetes, CAD (coronary artery disease) • Age less than 2 years • Known hypersensitivity to the drugs for treatment of HCV Guide to laboratory tests | 178 For full guidelines of the management of HCV, please refer to the guidelines below: AASDL guidelines: Hepatology 2009; April:1335–1373 EASL clinical practice guidelines: management of hepatitis C virus infection. Journal of Hepatology 2011; vol 55: 245–264 South African Hepatitis C management guidelines: The South African Gastroenterology Review April 2010. Hepatitis D virus HDV is a defective viral particle that cannot cause infection in the absence of HBV. Therefore, infection with HDV either occurs simultaneously with HBV infection (co-infection), or is superimposed on existing chronic HBV infection (superinfection). Severe/fulminant hepatitis is seen more frequently in HBV-HDV coinfection than in HBV infection alone, while chronic HDV infection is more commonly encountered when HDV superinfects an existing HBV chronically infected patient. HDV is found mainly in the Mediterranean countries and in South America. It is infrequently encountered in South Africa except in patients of Mediterranean extraction and occasionally from the former Portuguese colonies (Mozambique and Angola). Diagnosis Diagnostic assays are not commonly available for HDV infection, so please contact the laboratory should you wish to test for this virus. Assays that can be used to make a diagnosis: HDV IgM serology HDV RNA PCR (none are standardised at this stage) 179 | Ampath Desk Reference Prevention • Infection control • HBV vaccine Treatment • Treatment of the underlying HBV infection. • HDV does not respond to the NA, and only responds to PEG-IFN or IFN. Not much is known about the efficacy, or how long to treat, or how long to monitor post treatment, but more than a year of treatment may be necessary. Hepatitis E virus HEV is mainly faecal orally transmitted, and is associated with contaminated water sources. HEV is commonly encountered in India and parts of Africa. We do not often see disease due to HEV in South Africa except in travellers, but there is evidence that the virus is present in this country. It causes clinical illness similar to that encountered in HAV infection and most people will recover with supportive management. Patients particularly vulnerable to severe infection with a mortality rate of 20% include pregnant women. Diagnosis Diagnostic assays are not freely available in South Africa, so please contact the laboratory should you wish to test for HEV. HEV serology HEV PCR Guide to laboratory tests | 180 Prevention and PEP • None known or proven to work • Ensure that only clean water is consumed, particularly when travelling • Contact precautions and careful disposal of faecal material in the hospital setting. Treatment Mainly supportive Other viral causes of Hepatitis • HSV which can cause a rapidly fulminant hepatitis and needs to be treated with IV acyclovir as a matter of urgency. A HSV PCR must be requested on a blood sample in any patient with an unexplained hepatitis where an acute hepatitis A and B has been excluded. • VZV frequently causes a low grade hepatitis that is seldom severe. • CMV may cause hepatitis particularly in immune-compromised patients. This may occasionally be encountered in otherwise healthy patients too during a primary CMV infection. • EBV may cause fulminant hepatitis. This is a well-described complication in people with X-linked lymphoproliferative disorder and certain other primary immunodeficiency conditions. It can occur in otherwise healthy people during a primary EBV infection. • Arboviral infection and Viral Haemorrhagic Fevers.

Viral infections in pregnancy Rubella Rubella in the first 4 months of pregnancy carries a severe risk to the foetus of Congenital Rubella Syndrome. Diagnosis of Rubella in pregnancy is predominantly serological. 181 | Ampath Desk Reference Interpretation of serology Maternal IgM Maternal IgG Avidity Interpretation % Risk to the foetus - + Maternal immunity 0 + (always confirm - Primary infection in the >80% on a second mother different assay) + + >70% Pre-existing immunity with 3 – 8% re-exposure to rubella + + <30% Recent primary infection >80% - - No evidence of infection 0, but recheck in 2 serologically, but monitor for weeks. Immunize seroconversion mother once baby is delivered! CMV: Serological interpretation Maternal IgM Maternal IgG Avidity Interpretation - + Previous maternal infection 30% mortality + (always confirm on a - Primary infection in the mother second different assay) + + >50% Prior infection with CMV and most likely reactivation of CMV or second infection with a different genotype of CMV + + <50% Recent primary infection - - No evidence of infection serologically, but monitor for seroconversion Guide to laboratory tests | 182 Risks to the foetus in primary maternal infection

50 – 85% baby uninfected

Primary maternal infection

15 – 50% baby infected

8 – 18% symptomatic at birth

30% mortality 70% survival

90% hearing loss, poor psychomotor development, optic atrophy 183 | Ampath Desk Reference It is important to note that CMV may cause foetal infection in primary infection of the mother, which is the highest risk situation, but also with reactivation or secondary CMV infection. Additional tests that may be performed include looking for evidence of maternal viraemia, and examining the CMV VL in amniotic fluid after 21 weeks gestation. If a primary CMV infection is detected antenatally then mother needs to be treated with CMV hyper immune globulin to reduce the possibility of CMV damage to the foetus. Infected babies can be treated with Ganciclovir 6mg/kg 12 hourly IVI for 6 weeks. Evidence accumulating in the literature suggests that this treatment limits the damage caused by CMV in the neonate. HSV Diagnosis In the infant: • HSV PCR performed on lesions or CSF (cerebrospinal fluid). May be positive also in blood in babies with disseminated infection. In the mother: • Serology can be confusing for diagnosis of HSV disease. • IgG negative, IgM positive: most likely primary infection with HSV. • IgG positive, IgM negative: most likely prior exposure to HSV. • IgG positive, IgM positive: this could be due to late primary infection or reactivation disease or a false positive IgM result. • IgG negative, IgM negative: IgM responses can be significantly delayed in some people. So in general this result may indicate no prior infection with HSV, but should not suggest that HSV is not present at the time serology is performed. • PCR of lesion fluid. Guide to laboratory tests | 184 Primary genital infection with HSV poses a 30% risk of HSV transmission to the neonate. The risk is considerably lower in reactivation disease being closer to 3%. The risk to the baby occurs in being delivered through an infected genital tract, or with HSV ascending into the uterus (which is rare). Maternal treatment with acyclovir does not seem to be protective for the infant. Disease manifestations in the infant • True congenital infection following in-utero transmission is rare • Presents within 48 hours. • Triad of skin vesicles or scarring, eye disease, and microcephaly or hydrancephaly. • Disseminated disease • Multi-organ involvement in which 80% have skin vesicles (IMPORTANT -20% have no skin lesions) and 75% will have encephalitis as part of the dissemination. • Presents at 9 to 11 days of life. • Encephalitis • Found in 30% of babies with neonatal HSV infection. • May not have evidence of rash . • Presents within 9 to 11 days if part of disseminated disease, or 16 to 17 days if part of retrograde axonal spread to the brain. • It is important to note that the CSF may be cytologically and biochemically normal in these babies! A high index of clinical suspicion is required, and treatment should be started empirically and not wait on laboratory results. • Skin, eye and mouth disease • Presents with typical HSV lesions within 10 to 11 days of birth. • Should be treated because there is a high rate of subsequent neurological delay in these children if they are not managed with acyclovir. Treatment • Acyclovir 20mg/kg slow IVI 8 hourly for 21 days. 185 | Ampath Desk Reference Parvovirus B19 Parvovirus infection occurs in approximately 5% of pregnant women exposed to this virus, and about 8% of these pregnancies will show an adverse outcome. In general, infection with this virus is not an indication for TOP, as many babies will recover before delivery. Parvovirus can cause anaemia in the foetus with subsequent cardiac failure and the development of hydrops foetalis. This frequently recovers spontaneously in utero. There are accounts of successful treatment with the use of foetal blood transfusion. Diagnosis Serology: • IgG positive, IgM negative: previous infection with parvovirus, foetus not at risk. • IgG negative, IgM negative: no previous infection with parvovirus. Check serology again in 2 weeks. • IgG negative, IgM positive: primary infection with parvovirus, monitor foetus. • IgG positive, IgM positive: may be primary infection or repeated exposure on a background of maternal immunity. Monitor foetus. Parvovirus PCR on maternal blood. HBV infection in pregnancy This is generally encountered in countries with high or intermediate endemicity where chronic infection rates with HBV are high. Diagnosis in the mother is usually serological as in the earlier section on HBV diagnosis. Risks to the infant • HBeAg positive mother: the risk of the baby acquiring the infection during the birth is 70 – 90%. • HBeAg negative mother: the risk of the baby acquiring infection during the birth is 10 – 40%. • If the baby becomes infected, the risk of becoming chronically infected is 80 – 98% with risk of early manifestation of progressive disease such as cirrhosis and hepatocellular carcinoma. Guide to laboratory tests | 186 Management of the exposed infant • HBIG administered within 24 hours of birth AND • Vaccine administered within 24 hours of birth. After this initial dose, the normal EPI schedule is followed. • 85 – 90% of babies will be protected if this combination is used. • In some countries, HBIG is not easily obtained and vaccine alone is used. This is efficacious, but carries a slightly increased risk of infection of the baby.

HBV is not transmitted in breast milk, so babies born to infected mothers can be safely breast fed in the absence of other contraindications. HCV infection in pregnancy South Africa has a relatively low prevalence of HCV (<2%) in the general population. Transmission from the mother to the foetus/newborn is relatively rare. No immunopropylaxis is available. However, it seems that babies tend to clear the HCV at a higher rate than adults, so monitoring of an exposed baby is usually sufficient. Treatment is usually not indicated until the child reaches 2 years of age if infection persists. HCV transmission is not associated with breast feeding. Diagnosis is as described in the previous section on HCV infection. A higher risk of infant infection is associated with dual HCV/HIV infection of the mother, and higher HCV VL in the mother (>106 IU/ml). VZV (varicella zoster virus) infection in pregnancy Most in utero infections occur with primary rather than reactivation disease in the mother. The highest risk to the foetus is in the first 4 months of pregnancy. In utero injury to the baby is rare in this infection, and the overall risk to the foetus is around 2% in primary maternal infection (chicken pox). Infection with this virus is therefore usually not regarded as an indication for TOP (termination of pregnancy). 187 | Ampath Desk Reference Diagnosis Serology: • IgG positive, IgM negative: prior exposure with immunity to VZV. • IgG negative, IgM positive: primary infection with VZV. • IgG positive, IgM positive: either recent primary infection or reactivation of VZV – correlate clinically. • IgG negative, IgM negative: no prior immunity to VZV. Monitor for serological conversion.

PCR on blister fluid if lesions are present. If chicken pox occurs in the mother in the last 5 days of pregnancy or first 2 days following delivery, the baby is unprotected (maternal IgG has not had time to form, cross the placenta and protect the baby). Such infants are very vulnerable to severe chicken pox with a 30% associated mortality rate. These babies should receive varicella-zoster immune globulin (VZIG) administered as close to delivery as possible, and acyclovir should be used at the first sign of break-through disease. Chicken pox in pregnancy is also far more dangerous for the mother than in adults generally. Any pregnant woman or woman in the perinatal period who develops chicken pox should be treated with acyclovir (800 mg orally 5 times daily for 7 days, or 10mg/kg 8 hourly IVI for 7 to 14 days). This increased risk is present during the pregnancy and for up to 2 months following delivery of the baby. Acyclovir has not been associated with foetal abnormalities when used in pregnancy, although consent for its use should be obtained from the mother. Strict infection control and isolation of the mother and baby is required to protect other susceptible patients/staff in the hospital. Guide to laboratory tests | 188 Measles in pregnancy Diagnosis: Serology: • Measles IgG positive, IgM negative: immune to measles. • IgG positive, IgM positive: could be either late primary infection or re-exposure in an immune individual. Correlate clinically. • IgG negative, IgM positive: primary infection with measles. Notify the local authorities and hospital infection control. • IgG negative, IgM negative: non-immune and no evidence of acute infection. Repeat if suspect acute disease, although usually IgM is present when the patient presents.

Measles infection in pregnancy is not associated with foetal abnormalities. If the mother develops measles in the last week of pregnancy though, disease in the infant can be severe. The mortality rate associated with neonatal measles approaches 30%. Immunoglobulin prophylaxis should be administered to the infant as close to delivery as possible. Exposed contacts should be offered measles vaccine within 72 hours of exposure. This measure is an excellent PEP in most cases. Measles vaccine is often not effective in young babies due the presence of maternal antibody. Strict infection control and isolation must be practiced in the ward/ ICU in which the mother and baby are nursed. Enterovirus infections in pregnancy There is no consensus at this stage regarding the development of foetal abnormalities if enteroviral infections occur during pregnancy. However, if the mother is infected with an enterovirus in the last part of the pregnancy and does not have time to develop antibodies that can cross the placenta and protect the infant before delivery, infection in the neonate can be severe. The disease is usually multi-system and resembles gram-negative septicaemia. Diagnosis may be made with the use of 189 | Ampath Desk Reference PCR testing on throat swabs, stool, blood, CSF etc. Treatment is supportive. Some reports indicate that the use of high titre immunoglobulin against the specific enterovirus is useful therapeutically. Serological diagnosis of enteroviral infections is seldom helpful. Viral respiratory tract infections Acute respiratory disease accounts for an estimated 75% of all morbidity in developed countries, and 80% of these are due to viral infections. Up to 8 URTI (upper respiratory tract infections) will be encountered in young children per year and up to 5 in adults, making URTI the commonest disease encounter human beings experience! Influenza Influenza virus is a member of the Orthomyxoviridae family. Annual epidemics in temperate climates generally lasting 3 – 8 weeks are encountered in the winter months. Influenza has pandemic potential when novel viruses emerge into the human population either from a zoonotic source, or from genetic reassortment resulting in a major antigenic change and the emergence of a virus to which there is little or no population immunity. Further genetic changes may then accumulate which render the virus more suitable to human transmission and disease. Many respiratory infections are indistinguishable clinically, and influenza is an important pathogen to diagnose accurately as treatment is available in severe cases and in persons at risk of developing a severe infection, and infection control a priority in institutional or hospital settings. Available diagnostic tests include the following: DFA (direct immunoflourescence assay): The sensitivity of this assay is 70 – 100%, and the specificity 80 – 100% (compared with culture) PCR for influenza virus is the gold standard of diagnosis. The sensitivity is 91 – 100% for influenza B, and 96% – 100% influenza A. The specificity 96% for both influenza A and influenza B. Guide to laboratory tests | 190 Influenza prevention • Annual vaccination with WHO (World Health Organization) recommended strains for that season. • Infection control in hospital settings. • Antiviral agents such as Oseltamivir are no longer recommended as PEP. Use of these drugs as PEP has been associated with the development of antiviral resistance in influenza. Influenza treatment Treatment decisions should be based on clinical presentation and NOT delayed pending laboratory confirmation. • Oseltamivir (Tamiflu): • Standard adult treatment: 75 mg bd for 5 days. Longer duration of therapy may be considered in critically ill patients. In these patients, higher dosages (150 mg 12 hourly) have no proven efficacy, and the side effect profile is increased at these dosages. • In critically ill ventilated patients, the tablets can be crushed and given via the nasogastric (NG) tube. The NG tube must be flushed initially with saline and then flushed again after the oseltamivir is given with 50 mL saline. • Renal adjustment is required depending on GFR. • Children: • Premature infants; 1 mg/kg 12 hourly for 5 days • 0 – 12 months: 3 mg/kg 12 hourly for 5 days • ≤15 kg body weight: 30mg/kg 12 hourly for 5 days • 15 – 23 kg: 45 mg/kg 12 hourly for 5 days • 24 – 40 kg: 60 mg/kg 12 hourly for 5 days • >40 kg: adult doses. • Dosing should be adjusted in children with renal impairment. 191 | Ampath Desk Reference • Zanamivir (Relenza): • Two inhalations (5 mg per inhalation) bd for 5 days • Poorly suited for treatment in children due to difficulty in coordination of inhalational drugs. • Should not be used in patients on mechanical ventilation as it damages the ventilator, and also must not be administered via nebulisation. Other respiratory viruses These include parainfluenza viruses, respiratory syncytial virus, human metapneumovirus, adenovirus, rhinoviruses, entero and parechoviruses, bocavirus and coronaviruses. These are generally best diagnosed by means of PCR assays.PCR technologies are generally more sensitive assays for respiratory pathogen detection and permit more frequent and accurate diagnoses of RTI. This is particularly important in the case where shedding of virus may be low in respiratory specimens. The advantages of PCR: • Appropriate drugs may be prescribed to manage the viral condition. • Assists infection control in the hospital. • Prevents unnecessary investigations. • Provides accurate epidemiological information. • Can be multiplexed, thus testing for a range of pathogens. • Allows for the detection of pathogens that are not easily cultured or for which mAb (monoclonal antibodies) are not easily available for the performance of DFA. • Generally more sensitive than other detection technologies. • Allows the documentation of multiple viral aetiologies, which may account for an average of 3 – 30% of positive samples. There is also some evidence that mixed viral infections may contribute to more severe disease in the patient. Guide to laboratory tests | 192 Disadvantages: • Increased costs associated with PCR. • These costs may well be offset by the benefit to the patient, the hospital and epidemiologically.

Infection control for most viral RTI • Standard precautions. • Droplet precautions. • Isolation/cohort isolation. • Be aware that many of these viruses can be transmitted via fomites. 193 | Ampath Desk Reference Infections in the immunocompromised patient Infections encountered in this population depend on the degree and type of immunosuppression, and the use of prophylactic agents such as TMP/SMX, and antivirals. The more commonly encountered pathogens include: CMV (cytomegalovirus) • Initial screening can be serological. In transplant patients this will allow some determination of the risk of acquiring or reactivating CMV infection. For example, if the recipient is found to be CMV seronegative and the donor seropositive, a significant risk exists for CMV infection developing in the post-transplant period in the immunocompromised recipient. • Thereafter, CMV is best diagnosed using molecular technology. PCR is useful in terms of qualitative positive/negative results, but quantitative viral load offers more information in terms of the significance of a positive result. In addition, VL trends may be monitored over time and either therapeutic or pre- emptive management strategies followed when CMV is seen to be increasing or reaching a pre- determined threshold. • Treatment usually includes the use of Ganciclovir 5 mg/kg 12 hourly IVI. Oral management and maintenance with Valganciclovir 900 mg 12 hourly may be used under certain circumstances.

EBV (Epstein-Barr virus) • In certain patients, particularly transplant patients, EBV is associated with the development of post- transplant lymphoproliferative disorder. This presents as pyrexia, a mononucleosis type of illness, GIT bleeding/obstruction/perforation, hepatocellular/splenic infiltrative disease, CNS disease. If allowed to continue unchecked, there is a high chance of malignant disease occurring in these patients. • EBV VL monitoring is helpful in following trends in these patients. Diagnosis is aided with the use of flow cytometry and histology including staining for EBV RNA. • Management includes decreasing the level of immunosuppression, chemotherapy, Anti-CD20 antibody. Some research indicates that adoptive immunotherapy may be useful. Guide to laboratory tests | 194 HSV (Herpes simplex virus) • Systemic disease due to HSV or local reactivations can be dangerous and troublesome in immunosuppressed patients. • Diagnosis is usually easily achieved with PCR testing of lesion fluid, or of other appropriate samples such as CSF if encephalitis is suspected, or blood in the case of hepatitis. • Treatment: acyclovir 10 mg/kg 8 hourly IVI for 14 – 21 days for severe systemic illness. Oral treatment (acyclovir 200 mg 5 times daily or 400 mg 8 hourly) may be considered for localised disease. Valacyclovir 1000 mg 12 hourly may also be used. VZV (Varicella zoster virus) • Primary infection with VZV can be extremely dangerous in patients who are immunocompromised, and should always be treated with IVI acyclovir 10 mg/kg 8 hourly IVI for 7 – 14 days. • Reactivation or zoster should be treated with valacyclovir 1000 mg 8 hourly for 7 days or acyclovir 800 mg 5 times daily for 7 days. If the zoster is disseminated, then IVI treatment is recommended with acyclovir 10 mg/kg 8 hourly for 7 days IVI. • Diagnosis may be serological if primary infection is found. The VZV IgG will ideally be negative and IgM positive. Otherwise PCR of lesion fluid will provide a quick and sensitive result. BK virus • Diagnosis by PCR/VL on either urine and blood. Although there is no precise viral load level fully predictive of disease, useful cut off values seem to be 107copies/ml in urine, and 104copies/ml in plasma. A diagnosis of BK nephropathy should always be confirmed with a renal biopsy. • Associated with BK nephropathy and ureteric stricture in renal transplant patients • Associated with haemorrhagic cystitis in HSCT transplant patients. • Management includes decreasing the level of immunosuppression. At times, it may be necessary to allow the renal graft to be lost and then to consider re-transplantation once the BK viraemia is under control. 195 | Ampath Desk Reference Bacterial and fungal infections • Usually MCS serves for diagnosis • Antigen testing such as for Cryptococcus is useful for some pathogens Pneumocystis jiroveci • Diagnosis is most usefully achieved with PCR in correlation with clinical findings. Tuberculosis • The gold standard of diagnosis is still the use of culture. • Molecular PCR methods are useful, but of limited sensitivity on smear negative samples. They average around 70% sensitivity when compared with culture on smear negative TB samples at this stage. • Genotypic methods may also be used to determine drug resistance in Mycobacterium tuberculosis. Guide to laboratory tests | 196 Viral central nervous system infections (including rabies) Viral infections may cause injury to the CNS either due to the infection itself, or following post- infectious phenomena. Commonly encountered CNS viral infections responsible for meningitis / encephalitis include the following: • Enteroviruses (EV) • Mumps • HSV 1 and 2 • VZV Rarer cases are caused by arbovirus infections (arthropod borne) such as West Nile virus, and rabies transmitted from infected animals. Diagnosis • PCR on CSF is the most sensitive and specific method. As these viruses often cause clinically indistinguishable signs and symptoms, multiplex viral PCRs are most useful in excluding at least the EV, mumps, HSV and VZV as causes of the infection. • Arbovirus infection can also be diagnosed by means of PCR on CSF. These requests are sent to the NICD, as most diagnostic laboratories lack the facilities to safely handle these pathogens. • Blood serology may be requested for mumps diagnosis, but is not helpful for the other viral causes of meningo-encephalitis. • Arbovirus serology may be useful, but one often has to look for a 4-fold rise in titre over a period of 2 weeks, so it does not always allow the quickest diagnosis. • Rabies may be diagnosed by means of PCR on CSF, on 3 saliva samples collected at different times, and on nuchal skin biopsy samples. Fluorescent antibody testing may also be performed on corneal impression slides or nuchal skin biopsies, but PCR is the most reliable ante-mortem diagnostic testing available. Serology is not helpful, as antibodies are only detectable in blood approximately 5 days after the onset of clinical disease. If rabies vaccine or immunoglobulin has been given, the serology 197 | Ampath Desk Reference will be positive and is not predictive of disease. Post-mortem sampling of the brain is mandatory in rabies cases, particularly those in whom diagnosis was not confirmed ante-mortem. Ideally, the entire brain should be removed, half preserved in 50% glycerol saline, and half in 10% neutral buffered formaldehyde solution. If post-mortem sampling of the brain is strongly opposed by the surviving relatives, a Tru-Cut biopsy taken by inserting a Tru-Cut needle through the superior orbital fissure into the cranial cavity may be taken. This has the added advantage of minimalizing exposure of healthcare workers to the virus. It should be noted that consent is NOT required to perform a post-mortem examination of a possible rabies patient. Brain samples should be packaged in screw-top secure plastic containers, packaged in secure secondary containers with lots of absorbant material to cushion the specimens and absorb any spills, carefully labelled and sent to the NICD via secure courier. The NICD should be notified in advance that a sample is en route. Prevention of viral CNS infections • Vaccination against measles and mumps and chicken pox. • PEP. • VZIG (Varicella-zoster immunoglobulin) under appropriate conditions for exposure to VZV. The live attenuated VZV vaccine is also a reasonably good PEP measure if administered within 72 hours to non-immunocompromised exposed people. • Immunoglobulin or live attenuated measles vaccine administered within 72 hours of exposure provides good protection against measles infection. • There is little PEP available for enteroviruses, mumps, HSV and arboviruses. • Rabies following contact with an infected or suspected animal: • Determine category of exposure and treat accordingly. Guide to laboratory tests | 198

Risk category Type of exposure Recommended action 1 • Handling or feeding the None if the history is reliable. animal If the history is not reliable, • Licking of intact skin manage as for Category 2. 2 • Nibbling of uncovered skin • Quarantine animal. If well • Superficial scratch with no after 10 days, can stop PEP. bleeding • Wound care. • No need for RIG (rabies immunoglobulin). • Administer rabies vaccine. 3 • Licking of mucous • Wound care membranes • Administer RIG 20IU/kg as • Licking of broken skin much as possible into the • Bites or scratches that wound, and the remainder penetrate skin and cause into the deltoid muscle. bleeding • Administer rabies vaccine into the opposite deltoid muscle on day 0, 3, 7, 14. • Special categories: • Previously immunized people: • No need for RIG. • Administer a single dose of vaccine on day 0 and day 3. • Immunocompromised people: • Administer full course of RIG and vaccine for category 2 and 3 exposures. • Bat exposure: 199 | Ampath Desk Reference • Any close contact with bats is regarded as Category 3 exposure. Bites can be inapparent and should not be treated lightly. • Late presentation: • Treat as if the exposure was recent and according to category of exposure. RIG and vaccine should be used when appropriate and the schedule should be adhered to rigidly. • If RIG is not immediately available in Category 3 exposures, start the vaccine. RIG can still be administered within 7 days of starting the vaccine. Treatment of viral CNS infections • HSV: acyclovir 10 mg/kg IVI 8 hourly for 14 to 21 days (neonates 20 mg/kg IVI 8 hourly for 21 days) • VZV: acyclovir 10 mg/kg IVI 8 hourly for 14 days • Enteroviral infection: supportive. In severe cases, high titre virus-specific immunoglobulin may be effective. • Mumps: supportive • Arbovirus infection: mainly supportive • Rabies virus: No curative treatment is available. Rabies is fatal once clinical disease starts. • Honestly counsel relatives and prepare them for the course of the disease. • High-level supportive care • Sedation. • Pain relief. • Anxiolytics. • Hydration and nutrition. • Prevent bedsores and bacterial complications. • Antiviral medications, corticosteroids, rabies vaccines and RIG have no proven efficacy in management of rabies once clinical disease is established. Guide to laboratory tests | 200 Infection control This depends on the virus: • Enterovirus: • Standard precautions. • Contact precautions when handling children in nappies or incontinent adults. • Careful disposal of faecal waste. • Strict hand hygiene/washing. Alcohol disinfectants are not sufficient for enteroviruses. • HSV: • Standard precautions. • Contact precautions. • VZV: • Contact precautions. • Airborne precautions. • Measles • Airborne precautions. • Mumps: • Droplet precautions. • Arbovirus • Mostly standard precautions depending on the virus concerned. • Rabies • Standard precautions. • Respiratory precautions. • If significant exposure occurs in a staff member, e.g. saliva contamination of mucous membranes, copious washing with water, and rabies vaccine should be administered. 201 | Ampath Desk Reference

ImmunoCap® IgE LIST OF ALLERGY TESTS ImmunoCap® IgE LIST OF ALLERGY TESTS CHAPTER 10 LIST OF ALLERGY TESTSCHAPTER 10 INHALANT ALLERGENS INHALANT ALLERGENS INHALANT ALLERGENS INSECT ALLERGENS DRUG ALLERGENS GRASS WEED POLLENS • Horse serum protein • American Cockroach • Amoxycillin LIST OF ALLERGY TESTS • GrassINHALANT mix ALLERGENS • WeedINHALANT Mix ALLERGENS • MouseINHALANT epithelium ALLERGENS • GermanINSECT Cockroach ALLERGENS • AmpicillinDRUG ALLERGENS • BahiaGRASS Grass • CommonWEED POLLENS Pigweed • Mouse• Horse serum serum protein protein • Oriental• American Cockroach Cockroach • Penicillin• Amoxycillin G IgE • Bermuda• Grass mixGrass • Dandelion• Weed Mix • Mouse• Mouse urine epithelium protein • Mosquito• German Cockroach • Penicillin• Ampicillin V IgE • Brome• Bahia Grass Grass • Lambs• Common Quarters Pigweed • Parrot• Mouse droppings serum protein • Honey• Oriental Bee Cockroach • Cefaclor• Penicillin G IgE • Cocksfoot• Bermuda Grass Grass • Marguerite• Dandelion • Parrot• Mouse feathers urine protein • Common• Mosquito Wasp • Insulin• Penicillin Bovine V IgE • Golden• Brome Rod Grass Grass – Johnson • Mugwort • Lambs Quarters • Pigeon• Parrot droppings droppings • European• Honey HornetBee • Insulin• Cefaclor Human Grass• Cocksfoot Grass MITES• Marguerite • Pigeon• Parrot feathers feathers • Hornet• Common (White Wasp faced) • Insulin• Insulin Porcine Bovine • Maize• Golden Pollen Rod Grass – Johnson • House• Mugwort dust mix • Pigeon• Pigeon serum droppings protein • Hornet• European (Yellow) Hornet • Tetanus• Insulin Toxoid Human • Cultivated Grass wheat • A.siroMITES • Rabbit• Pigeon epithelium feathers • Paper• Hornet Wasp (White faced) • Insulin Porcine Grass• Maize Allergen Pollen components • B.• House tropicalis dust mix • Rabbit• Pigeon serum serum protein protein Bee• Hornet and Wasp (Yellow) components • Tetanus Toxoid • Grass• Cultivated group 1 wheat Bermuda • B.• A.siro spicifera • Rabbit• Rabbit urine epithelium protein • Api• Paper m 1, bee Wasp Phospholipase • GrassGrass group Allergen 1 Timothy components • D.• B. farinae tropicalis • Rat• Rabbit epithelium serum protein A2,Bee and Wasp components • Grass• Grass group group 5 Timothy 1 Bermuda • D• B. pteronyssinus spicifera • Rat• Rabbit serum urineprotein protein • Ves• Api v 1, m Common 1, bee Phospholipase wasp CROSS• Grass - REACTIVE group 1 Timothy • E.• D. maynei farinae • Rat• Rat urine epithelium protein Phopholipase A2, A1; COMPONENTS• Grass group 5 Timothy • Glycyphagus• D pteronyssinus domesticus • Sheep• Rat epitheliumserum protein • Ves• Ves v 5, v Common 1, Common Wasp wasp • ProfilinCROSS - REACTIVE • Lepidoglyphus• E. maynei destructor • Swine• Rat epitheliumurine protein Allergen Phopholipase 5 A1; • CCDCOMPONENTS • Tyrophagus• Glycyphagus putrescentiae domesticus • Turkey• Sheep feathers epithelium • Pol• Ves d 5, v European 5, Common Paper Wasp • PR-10• Profilin House• Lepidoglyphus dust mite components destructor Animal• Swine Allergen epithelium components Wasp Allergen Allergen 5 5 • LTP• CCD • Der• Tyrophagus p 1 cystein putrescentiaeprotease • Can• Turkey f 1 dog feathers lipocalin • CCD• Pol Marker d 5, European Paper TREE• PR-10 POLLENS • DerHouse p 2 NPC2dust mite protein components • CanAnimal f 2 dog Allergen lipocalin components OCCUPATIONAL Wasp Allergen 5 • Tree• LTP mix 1 (Olive, Willow, pine, • Der• Der p 10 p tropomyosin1 cystein protease • Can• Can f 3 dogf 1 dog serum lipocalin albumin • Ethylene• CCD MarkerOxide Acacia,TREE POLLENSEucalyptus, Cajeput) EPIDERMALS• Der p 2 NPC2 AND protein ANIMAL • Can• Can f 5 dogf 2 dog arginine lipocalin kinase • FormaldehydeOCCUPATIONAL • Tree• Tree mix mix 2 (Oak, 1 (Olive, Elm, Willow, Plane, pine, PROTEINS• Der p 10 tropomyosin • Cat• Can fel d f 13 uteroglobindog serum albumin • Isocyanate• Ethylene HDI Oxide Willow, Acacia, Cottonwood) Eucalyptus, Cajeput) • AnimalEPIDERMALS dander mix AND ANIMAL • Cat• Can fel d f 25 serumdog arginine albumin kinase • Isocyanate• Formaldehyde MDI • Acacia• Tree mix 2 (Oak, Elm, Plane, • CagedPROTEINS birds feather mix • Cat• Cat fel dfel 4 d lipocalin 1 uteroglobin • Isocyanate• Isocyanate TDI HDI • Birch Willow, Cottonwood) • Feather• Animal mix dander mix • Equ• Cat c1 felHorse d 2 serumlipocalin albumin • Latex• Isocyanate MDI • Cajeput• Acacia • Budgie• Caged droppings birds feather mix • Bos• Cat d 6 fel Cow d 4 serumlipocalin albumin • Maleic• Isocyanate Anhydride TDI • Cypress• Birch • Budgie• Feather feathers mix MOULDS• Equ c1 Horse lipocalin • Phthalic• Latex Anhydride • Elm• Cajeput • Budgie• Budgie serum droppings protein • Mould• Bos mix d 6 Cow serum albumin • Trimellitic• Maleic Anhydride Anhydride • Eucalyptus• Cypress Tree • Canary• Budgie feathers feathers • AlternariaMOULDS tenuis • Silk• Phthalic Natural Anhydride • Italian• Elm Cypress • Cat• Budgie dander serum protein • Aspergillus• Mould mix fumigatus • Untreated• Trimellitic cotton Anhydride • Japanese• Eucalyptus Cedar Tree • Chicken• Canary feathers feathers • Botrytis• Alternaria cinerea tenuis • Silk Natural • London• Italian Plane Cypress Tree • Cow• Cat dander dander • Candida• Aspergillus albicans fumigatus • Untreated cotton • Oak• Japanese Cedar • Dog• Chicken Dander feathers • C• Botrytis herbarum cinerea • Olive• London Tree Plane Tree • Duck• Cow feathers dander • Epicoccum• Candida albicans Please note that this is not a comprehensive list of tests • Pecan• Oak Tree • Finch• Dog feathers Dander • Helminthos• C herbarum halodes but only represents the most common allergens.Please • Pepper• Olive Tree Tree • Goat• Duck epithelium feathers • Penicillin• Epicoccum notatum phonePlease the note laboratory that this at is not(012) a comprehensive678 08614 to listenquire of tests • Pine• Pecan Tree Tree • Goose• Finch feathers feathers • Phoma• Helminthos betae halodes aboutbut theonly availability represents of the other most allergens. common allergens.Please • Walnut• Pepper Tree Tree • Guinea• Goat pig epithelium Mould• Penicillin components: notatum phone the laboratory at (012) 678 08614 to enquire • Willow• Pine Tree Tree • Hamster• Goose epithelium feathers • Alt• Phoma a 1 Alternaria betae about the availability of other allergens. Tree• Walnut mix 1 consists Tree of: • Horse• Guinea dander pig • AspMould f 6 Aspergillus components: (ABPA) Tree• Willow mix 2 consists Tree of: • Hamster epithelium • Alt a 1 Alternaria Tree mix 1 consists of: • Horse dander • Asp f 6 Aspergillus (ABPA) Tree mix 2 consists of:

ImmunoCap® IgE LIST OF ALLERGY TESTS Cast Tests (CAST) LIST OF ALLERGY TESTS ImmunoCap® IgE LIST OF ALLERGY TESTS Cast Tests (CAST) LIST OF ALLERGY TESTS

SCREENING TESTS LEGUMES FISH ALLERGENS CONT FRUIT VEG ALLERGENS CONT DIVERSE SCREENING TESTS: FOOD ADDITIVES CONT: FOOD ALLERGENS CONT: DRUGS GENERAL ANAESTHETICS CONT: • Fx5 food mix • Chick pea • Mackerel • Tropical fruit mix • Onion • Ascaris Food mix • Sodium Benzoate • Arah 2 storage protein ANTIBIOTICS Propofol • PhadiatopSCREENING inhalant TESTS mix • GreenLEGUMES beans • SalmonFISH ALLERGENS CONT• AppleFRUIT • PotatoVEG ALLERGENS CONT • BakersDIVERSE yeast ConsistsSCREENING of: TESTS: • SodiumFOOD NitritesADDITIVES CONT: • ArahFOOD 6 storage ALLERGENS protein CONT: AmoxycillinDRUGS LOCALGENERAL ANAESTHETICS ANAESTHETICS CONT: • IgE• Fx5 food mix • Lentils• Chick pea • Sardine• Mackerel • Apricot• Tropical fruit mix • Pumpkin• Onion & Ssquash • Bilharzia• Ascaris • EggFood White mix • MSG• Sodium Benzoate FRUITS• Arah AND 2 storage VEGETABLES protein AmpicillinANTIBIOTICS LidocainePropofol / Lignocaine (Xylotox) FOOD• Phadiatop ALLERGENS inhalant mix• Lupin• Green seed beans • Snoek• Salmon • Banana• Apple • Spinach• Potato • Canola• Bakers oil yeast • EggConsists yolk of: • Potassium• Sodium SorbateNitrites Carrot• Arah 6 storage protein PenicillinAmoxycillin G ArticaineLOCAL (Ubistesin) ANAESTHETICS GRAIN• IgE • Peas• Lentils • Sole• Sardine • Blackberry• Apricot • Sweet• Pumpkin potato & Ssquash • Cocoa• Bilharzia (Chocolate) • Milk • Egg White CAST• MSG FOODS CeleryFRUITS AND VEGETABLES PenicillinAmpicillin V MepivacaineLidocaine (Carbocaine)/ Lignocaine (Xylotox) • GrainFOOD mix ALLERGENS • Red• Lupin kidney seed bean • Swordfish• Snoek • Blueberry• Banana • Tomato• Spinach • Coffee• Canola oil • Codfish • Egg yolk MILK• Potassium AND DAIRY Sorbate OrangeCarrot BenzylpenicilloylPenicillin G (PPL) BupivacaineArticaine (Ubistesin)(Marcaine) • BarleyGRAIN • Soya• Peas bean • Tuna• Sole • Cherry• Blackberry HERBS• Sweet AND potato SPICES • Cotton• Cocoa (Chocolate) • Wheat • Milk EggCAST White FOODS PeachCelery MinorPenicillin determinant V Mix RADIOMepivacaine CONTRAST (Carbocaine) MEDIA • Buckwheat• Grain mix • White• Red beans kidney bean • Trout• Swordfish • Cranberry• Blueberry • Spice• Tomato mix • Gelatin• Coffee • Soya • Codfish EggMILK Yolk AND DAIRY TomatoOrange ClavulanicBenzylpenicilloyl acid + Amoxycillin (PPL) IobitridolBupivacaine (Marcaine) • Maize• Barley Soya• Soya Components: bean Fish• Tuna Components: • Dates• Cherry • AniseHERBS AND SPICES • Formaldehyde• Cotton • Peanut • Wheat MilkEgg White INHALANTSPeach CephalosporinMinor determinant C Mix IohexolRADIO (Omnipaque) CONTRAST MEDIA • Malt• Buckwheat • Gly• White m 4 PR-10 beans • Parvalbumin• Trout carp • Grape• Cranberry • Basil• Spice mix • Honey• Gelatin • Hazelnut • Soya MilkEgg components: Yolk ANIMALTomato DANDER CefazolinClavulanic acid + Amoxycillin IomeprolIobitridol • Oats• Maize • GlySoya m 5 Components: storage • ParvalbuminFish Components: cod • Grapefruit• Dates • Black• Anise pepper • Hops• Formaldehyde • Shrimp • Peanut • α Milk- Lactalbumin CatINHALANTS epithelium CeftriaxoneCephalosporin C IopamidolIohexol (Omnipaque) • Rice• Malt protein• Gly m 4 PR-10 SHELLFISH• Parvalbumin carp • Guava• Grape • Cardamon• Basil • P.• Honey notatum Inhalant • Hazelnut mix • β Milk- Lactoglobulin components: DogANIMAL epithelium DANDER CefuroximeCefazolin IopromideIomeprol • Rye• Oats • Gly• Gly m 6 m storage 5 storage • Shellfish• Parvalbumin mix cod • Jackfruit• Grapefruit • Carraway• Black pepper • Seminal• Hops (semen) fluid Consists • Shrimp of: • Casein• α - Lactalbumin POLLENSCat epithelium ClarithromycinCeftriaxone IoxaglateIopamidol • Wheat• Rice protein protein • AbeloneSHELLFISH • Kiwi• Guava • Chilli• Cardamon pepper • Tea• P. notatum • GrassInhalant mix mix CEREALS• β - Lactoglobulin AND GRAINS 6 grassDog mixepithelium TetracyclineCefuroxime IoxitalamateIopromide Wheat• Rye allergen DAIRY• Gly m 6 storage • Blue• Shellfish mussel mix • Lemon• Jackfruit • Cinnamon• Carraway • Tobacco• Seminal leaf (semen) fluid • CultivatedConsists of: rye grass Baker’s• Casein yeast BermudaPOLLENS grass TrimethoprimClarithromycin ANTISEPTICSIoxaglate components:• Wheat • Diary protein mix • Clam• Abelone • Litchi• Kiwi • Clove• Chilli pepper • Tea • Common • Grass mixbirch BarleyCEREALS flour AND GRAINS Cultivated6 grass rye mix grass SulfamethoxazoleTetracycline ChlorhexidineIoxitalamate • OmegaWheat 5 allergen Gliadin • MilkDAIRY (Cow) • Crab• Blue mussel • Mango• Lemon • Coriander• Cinnamon • Tobacco leaf • Hazel • Cultivated tree rye grass MaizeBaker’s yeast CommonBermuda birch grass LevofloxacinTrimethoprim DIVERSEANTISEPTICS DRUG ALLERGY • Glutencomponents: IgE • Milk• Diary (Goats) mix • Crayfish• Clam • Melon• Litchi • Curry• Clove • Mugwort • Common birch OatsBarley flour HazelCultivated tree rye grass CiprofloxacinSulfamethoxazole TESTINGChlorhexidine • Tri• Omega a 14 LT P, 5 WheatGliadin • Cheddar• Milk (Cow) cheese • Langoustine• Crab • Naartjie• Mango • Dill• Coriander • Ribwort/ • Hazel plantaintree RiceMaize MugwortCommon birch CefaclorLevofloxacin DiverseDIVERSE CAST DRUG ALLERGY NUTS• Gluten AND IgESEEDS • Mould• Milk cheese (Goats) • Lobster• Crayfish • Orange• Melon • Garlic• Curry • Altenaria • Mugwort tenuis RyeOats flour RibwortHazel tree CefamandoleCiprofloxacin TESTING • Nut• Tri mix a 14 LT P, Wheat Milk• Cheddar components cheese • Octopus• Langoustine • Passion• Naartjie fruit • Ginger• Dill • D. • Ribwort/ pteronyssinus plantain SoyaRice P officinalisMugwort RifampicinCefaclor PleaseDiverse contact CAST the laboratory for • Garlic • AlmondNUTS AND SEEDS • α • MouldLactalbumin cheese • Oyster• Lobster • Pawpaw• Orange • Mint • D. • Altenaria farinae tenuis WheatRye flour MOULDSRibwort ANALGESIC/Cefamandole ANTI- details (012) 678 0627 • Ginger • Brazil• Nut nut mix • β MilkLactaglobulin components • Scallop• Octopus • Peach• Passion fruit • Mustard • Cat • D. pteronyssinus AllergenSoya components: PenicilliumP officinalis notatum INFLAMMATORIESRifampicin Please contact the laboratory for • Cashew• Almond nut • Casein• α Lactalbumin • Shrimp• Oyster • Pear• Pawpaw • Nutmeg• Mint • Dog • D. farinae • MaizeWheat profilin AspergillusMOULDS fumigatus ParacetamolANALGESIC/ ANTI- Senddetails tablets/ (012) medication 678 0627 with • Coconut• Brazil nut • Lactoferrin• β Lactaglobulin • Snail• Scallop • Pineapple• Peach • Oregano• Mustard CAST • Cat FOOD ADDITIVES • WheatAllergen profilin components: CandidaPenicillium albicans notatum IndomethacinINFLAMMATORIES patient Heparin specimens, clearly • Hazelnut• Cashew nut • Bovine• Casein serum albumin • Squid• Shrimp • Plum• Pear • Paprika• Nutmeg Food • DogColourants Mix 1 • CCD• Maize profilin AlternariaAspergillus tenuis fumigatus MefenamicParacetamol acid marked.Send tablets/ medication with • Linseed• Coconut EGG• Lactoferrin AND POULTRY Shellfish• Snail components • Strawberry• Pineapple • Parsley• Oregano consistsCAST of: FOOD ADDITIVES SEAFOOD• Wheat profilin CladosporiumCandida albicans herbarum NaproxenIndomethacin patient Heparin specimens, clearly • Macadamia• Hazelnut nut • Chicken• Bovine serum albumin• Tropomyosin• Squid Shrimp VEGETABLES• Plum • Saffron• Paprika • QuinolineFood Colourants Yellow Mix 1 Anisakis• CCD MITESAlternaria tenuis DiclofenacMefenamic acid Collectmarked. specimens Mondays to • Pecan• Linseed nut • TurkeyEGG AND POULTRY MEATShellfish components • Asparagus• Strawberry • Tarragon• Parsley • Sunsetconsists Yellow of: FCF CodSEAFOOD StorageCladosporium mite mix herbarum IbuprofenNaproxen Thursdays, and not on the day • Pistachio• Macadamia nut nut • Egg• Chicken yolk • Meat• Tropomyosin mix Shrimp• AvocadoVEGETABLES • Thyme• Saffron • Chromotrope • Quinoline Yellow B CrabAnisakis D pteronyssinusMITES AspirinDiclofenac beforeCollect a Public specimens Holiday. Mondays to • Peanuts• Pecan nut Egg• Turkey white components • BeefMEAT • Bamboo• Asparagus shoot • Tarragon • Amaranth • Sunset Yellow FCF OysterCod D farinaeStorage mite mix Dipyrone/MetamizoleIbuprofen Thursdays, and not on the day • Pine• Pistachio Nut nut • Ovomucoid• Egg yolk • Gelatin• Meat mix • Beetroot• Avocado • Thyme • New • Chromotrope Coccine B ShrimpCrab AcarusD pteronyssinus siro PhenylbutazoneAspirin Discontinuebefore a Publicparenteral Holiday. • Poppy• Peanuts seed • OvalbuminEgg white components• Mutton/Lamb• Beef • Brinjal• Bamboo shoot Food • AmaranthColourants Mix 2 SquidOyster OCCUPATIONALD farinae GENERALDipyrone/Metamizole ANESTHETICS corticossteroids two weeks prior • Sesame• Pine Nutseed • Conalbumin• Ovomucoid • Pork• Gelatin • Brussel• Beetroot sprouts consists • New of: Coccine MEATShrimp CarboxymethylcelluloseAcarus siro GeneralPhenylbutazone anaesthetic mix, to testing.Discontinue Idealy parenteral wait two weeks • Sunflower• Poppy seed • Lysozyme• Ovalbumin Beef• Mutton/Lamb components: • Cabbage• Brinjal • ErythrosineFood Colourants Mix 2 PorkSquid LatexOCCUPATIONAL (breakdownGENERAL if positive)ANESTHETICS aftercorticossteroids an acute allergic two reaction weeks orprior • Walnut• Sesame seed FISH• Conalbumin ALLERGENS • Alpha• Pork 1,3-Gal • Carrot• Brussel sprouts • Patentconsists Blue of: V BeefMEAT FormaldehydeCarboxymethylcellulose MuscleGeneral Relaxants anaesthetic mix, illnessto testing. before testing.Idealy wait two weeks Peanut• Sunflower components seed • Fish• Lysozyme mixture • BovineBeef components: serum • Celery• Cabbage • Indigo • Erythrosine Carmine NUTSPork AND SEEDS ChlorhexidineLatex • (breakdownVecuronium if positive) after an acute allergic reaction or • Ara• Walnut h 1 storage protein • AnchovyFISH ALLERGENS albumin• Alpha 1,3-Gal • Cucumber• Carrot • Brilliant • Patent Black Blue BN V HazelnutBeef AlphaFormaldehyde amylase • MuscleSuxamethonium Relaxants illness before testing. • AraPeanut h 2 storage components protein • Anisakis• Fish mixture (fish parasite) • Bovine serum • Green• Celery pepper • Methylene • Indigo Carmine Blue AlmondNUTS AND SEEDS INSECTChlorhexidine VENOMS • •Rocuronium Vecuronium • Ara• Ara h 3 hstorage 1 storage protein protein• Cod• Anchovy fish albumin • Lettuce• Cucumber Preservative • Brilliant group, Black includes:BN CashewHazelnut nut HoneyAlpha Bee amylase • •Mivacurium Suxamethonium • Ara h 2 storage protein • Anisakis (fish parasite) • Green pepper • Methylene Blue SesameAlmond seed CulicoidesINSECT Antigen VENOMS • Rocuronium • Ara h 8 profilin • Hake • Mushrooms • Potassium Metabisulphite PeanutCashew nut • Atracurium • Ara• Ara h 9 h LTP 3 storage protein • Cod fish • Olive• Lettuce • TartrazinePreservative group, includes: YellowHoney jacket Bee hornet • Mivacurium • Herring PeanutSesame components seed PaperCulicoides wasp Antigen • Pancuronium • Ara h 8 profilin • Hake • Mushrooms • Sodium • Potassium Salycilate Metabisulphite • ArahPeanut 1 storage protein • •Cisatracurium Atracurium • Ara h 9 LTP • Herring • Olive • Tartrazine EuropeanYellow jackethornet hornet Peanut components Paper wasp • Pancuronium • Sodium Salycilate • Arah 1 storage protein European hornet • Cisatracurium ImmunoCap® IgE LIST OF ALLERGY TESTS CHAPTER 10 ImmunoCap® IgE LIST OF ALLERGY TESTS LIST OF ALLERGY TESTS INHALANT ALLERGENS INHALANT ALLERGENS INHALANT ALLERGENS INSECT ALLERGENS DRUG ALLERGENS GRASS WEED POLLENS • Horse serum protein • American Cockroach • Amoxycillin CHAPTER 10 • Grass mix • Weed Mix • Mouse epithelium • German Cockroach • Ampicillin • Bahia Grass • Common Pigweed • Mouse serum protein • Oriental Cockroach • Penicillin G IgE • Bermuda Grass • Dandelion • Mouse urine protein • Mosquito • Penicillin V IgE LIST OF ALLERGY TESTS INHALANT ALLERGENS INHALANT ALLERGENS INHALANT ALLERGENS INSECT ALLERGENS DRUG ALLERGENS • Brome Grass • Lambs Quarters • Parrot droppings • Cefaclor GRASS WEED POLLENS • Horse serum protein • Honey• American Bee Cockroach • Amoxycillin • Cocksfoot • GrassGrass mix • Marguerite• Weed Mix • Parrot• Mouse feathers epithelium • Common• German Wasp Cockroach • Insulin• Ampicillin Bovine • Golden Rod• Bahia Grass Grass – Johnson • Mugwort • Common Pigweed • Pigeon• Mouse droppings serum protein • European• Oriental Hornet Cockroach • Insulin• Penicillin Human G IgE Grass • Bermuda Grass MITES • Dandelion • Pigeon• Mouse feathers urine protein • Hornet• Mosquito (White faced) • Insulin• Penicillin Porcine V IgE • Maize Pollen• Brome Grass • House dust• Lambs mix Quarters • Pigeon• Parrot serum droppingsprotein • Hornet• Honey (Yellow) Bee • Tetanus• Cefaclor Toxoid • Cultivated • Cocksfootwheat Grass • A.siro • Marguerite • Rabbit• Parrot epithelium feathers • Paper• Common Wasp Wasp • Insulin Bovine Grass Allergen• Golden components Rod Grass – Johnson• B. tropicalis • Mugwort • Rabbit• Pigeon serum protein droppings Bee and• European Wasp components Hornet • Insulin Human • Grass group Grass 1 Bermuda • B. spiciferaMITES • Rabbit• Pigeon urine protein feathers • Api • Hornetm 1, bee (White Phospholipase faced) • Insulin Porcine • Grass group• Maize 1 Timothy Pollen • D. farinae• House dust mix • Rat epithelium• Pigeon serum protein A2, • Hornet (Yellow) • Tetanus Toxoid • Grass group• Cultivated 5 Timothy wheat • D pteronyssinus• A.siro • Rat serum• Rabbit protein epithelium • Ves• Paper v 1, Common Wasp wasp CROSS - REACTIVEGrass Allergen components• E. maynei• B. tropicalis • Rat urine• Rabbit protein serum protein PhopholipaseBee and Wasp A1; components COMPONENTS• Grass group 1 Bermuda• Glycyphagus• B. spicifera domesticus • Sheep• Rabbit epithelium urine protein • Ves• Api v 5, Commonm 1, bee PhospholipaseWasp • Profilin • Grass group 1 Timothy • Lepidoglyphus• D. farinae destructor • Swine• Rat epithelium epithelium Allergen A2, 5 • CCD • Grass group 5 Timothy • Tyrophagus• D pteronyssinusputrescentiae • Turkey• Rat feathers serum protein • Pol • Vesd 5, European v 1, Common Paper wasp • PR-10 CROSS - REACTIVE House dust• E. mite maynei components Animal Allergen• Rat urine components protein Wasp Phopholipase Allergen 5 A1; COMPONENTS • Glycyphagus domesticus • Sheep epithelium • Ves v 5, Common Wasp • LTP • Der p 1 cystein protease • Can f 1 dog lipocalin • CCD Marker • Profilin • Lepidoglyphus destructor • Swine epithelium Allergen 5 TREE POLLENS• CCD • Der p 2 NPC2• Tyrophagus protein putrescentiae • Can f • Turkey2 dog lipocalin feathers OCCUPATIONAL• Pol d 5, European Paper • Tree mix 1 • PR-10(Olive, Willow, pine, • Der p 10House tropomyosin dust mite components• Can f Animal3 dog serumAllergen albumin components • Ethylene Wasp Oxide Allergen 5 Acacia, Eucalyptus,• LTP Cajeput) EPIDERMALS• Der ANDp 1 cystein ANIMAL protease • Can f • Can5 dog farginine 1 dog lipocalin kinase • Formaldehyde• CCD Marker • Tree mix 2 TREE(Oak, POLLENSElm, Plane, PROTEINS• Der p 2 NPC2 protein • Cat fel• Can d 1 uteroglobin f 2 dog lipocalin • IsocyanateOCCUPATIONAL HDI Willow, Cottonwood)• Tree mix 1 (Olive, Willow,• Animal pine, dander• Der p mix 10 tropomyosin • Cat fel• Can d 2 serum f 3 dog albumin serum albumin • Isocyanate• Ethylene MDI Oxide • Acacia Acacia, Eucalyptus, Cajeput)• Caged birdsEPIDERMALS feather mix AND ANIMAL• Cat fel• Can d 4 lipocalin f 5 dog arginine kinase • Isocyanate• Formaldehyde TDI • Birch • Tree mix 2 (Oak, Elm, Plane,• Feather PROTEINSmix • Equ c1• Cat Horse fel dlipocalin 1 uteroglobin • Latex• Isocyanate HDI • Cajeput Willow, Cottonwood) • Budgie droppings• Animal dander mix • Bos d• Cat 6 Cow fel serumd 2 serum albumin albumin • Maleic• Isocyanate Anhydride MDI • Cypress • Acacia • Budgie feathers• Caged birds feather mix MOULDS• Cat fel d 4 lipocalin • Phthalic• Isocyanate Anhydride TDI • Elm • Birch • Budgie serum• Feather protein mix • Mould• Equ mix c1 Horse lipocalin • Trimellitic• Latex Anhydride • Eucalyptus• Cajeput Tree • Canary feathers• Budgie droppings • Alternaria• Bos tenuis d 6 Cow serum albumin • Silk • MaleicNatural Anhydride • Italian Cypress• Cypress • Cat dander• Budgie feathers • AspergillusMOULDS fumigatus • Untreated• Phthalic cotton Anhydride • Japanese Cedar• Elm • Chicken • Budgiefeathers serum protein • Botrytis• Mould cinerea mix • Trimellitic Anhydride • London Plane• Eucalyptus Tree Tree • Cow dander• Canary feathers • Candida• Alternaria albicans tenuis • Silk Natural • Italian Cypress • Aspergillus fumigatus • Untreated cotton • Oak • Dog Dander• Cat dander • C herbarum • Japanese Cedar • Chicken feathers • Botrytis cinerea • Olive Tree • London Plane Tree • Duck feathers• Cow dander • Epicoccum• Candida albicans Please note that this is not a comprehensive list of tests • Pecan Tree• Oak • Finch feathers• Dog Dander • Helminthos• C herbarum halodes but only represents the most common allergens.Please • Pepper Tree• Olive Tree • Goat epithelium• Duck feathers • Penicillin• Epicoccum notatum phone the laboratory at (012) 678 08614 to enquire • Pine Tree • Goose feathers • Phoma betae Please note that this is not a comprehensive list of tests • Pecan Tree • Finch feathers • Helminthos halodes aboutbut the only availability represents of theother most allergens. common allergens.Please • Walnut Tree• Pepper Tree • Guinea pig• Goat epithelium Mould components:• Penicillin notatum • Willow Tree • Hamster epithelium • Alt a 1 Alternaria phone the laboratory at (012) 678 08614 to enquire • Pine Tree • Goose feathers • Phoma betae about the availability of other allergens. Tree mix 1 consists• Walnut of: Tree • Horse dander• Guinea pig • Asp f 6Mould Aspergillus components: (ABPA) Tree mix 2 consists• Willow of: Tree • Hamster epithelium • Alt a 1 Alternaria Tree mix 1 consists of: • Horse dander • Asp f 6 Aspergillus (ABPA) Tree mix 2 consists of: Guide to laboratory tests | 202

ImmunoCap® IgE LIST OF ALLERGY TESTS Cast Tests (CAST) LIST OF ALLERGY TESTS ImmunoCap® IgE LIST OF ALLERGY TESTS Cast Tests (CAST) LIST OF ALLERGY TESTS

SCREENING TESTS LEGUMES FISH ALLERGENS CONT FRUIT VEG ALLERGENS CONT DIVERSE SCREENING TESTS: FOOD ADDITIVES CONT: FOOD ALLERGENS CONT: DRUGS GENERAL ANAESTHETICS CONT: • Fx5 food mixSCREENING TESTS• Chick peaLEGUMES • MackerelFISH ALLERGENS CONT• TropicalFRUIT fruit mix • OnionVEG ALLERGENS CONT • AscarisDIVERSE FoodSCREENING mix TESTS: FOOD• Sodium ADDITIVES Benzoate CONT: FOOD• Arah ALLERGENS 2 storage CONT: protein DRUGSANTIBIOTICS GENERALPropofol ANAESTHETICS CONT: • Phadiatop• Fx5 inhalant food mix mix• Green beans• Chick pea • Salmon• Mackerel • Apple• Tropical fruit mix • Potato• Onion • Bakers• Ascaris yeast ConsistsFood mix of: • Sodium• Sodium Benzoate Nitrites • Arah• Arah 2 storage 6 storage protein protein ANTIBIOTICSAmoxycillin Propofol LOCAL ANAESTHETICS • IgE • Phadiatop inhalant• Lentils mix • Green beans • Sardine• Salmon • Apricot• Apple • Pumpkin• Potato & Ssquash • Bilharzia• Bakers yeast Consists • Egg White of: • Sodium• MSG Nitrites • ArahFRUITS 6 storage AND protein VEGETABLESAmoxycillinAmpicillin LOCAL ANAESTHETICSLidocaine / Lignocaine (Xylotox) FOOD ALLERGENS• IgE • Lupin seed• Lentils • Snoek• Sardine • Banana• Apricot • Spinach• Pumpkin & Ssquash • Canola• Bilharzia oil • Egg Whiteyolk • MSG• Potassium Sorbate FRUITSCarrot AND VEGETABLES AmpicillinPenicillin G LidocaineArticaine / Lignocaine (Ubistesin) (Xylotox) GRAIN FOOD ALLERGENS• Peas • Lupin seed • Sole • Snoek • Blackberry• Banana • Sweet• Spinach potato • Cocoa• Canola (Chocolate) oil • Egg• Milk yolk • PotassiumCAST FOODS Sorbate CarrotCelery PenicillinPenicillin G V Articaine (Ubistesin)Mepivacaine (Carbocaine) • Grain mix GRAIN • Red kidney• Peas bean • Swordfish• Sole • Blueberry• Blackberry • Tomato• Sweet potato • Coffee• Cocoa (Chocolate) • Milk• Codfish CASTMILK FOODS AND DAIRY CeleryOrange PenicillinBenzylpenicilloyl V (PPL) MepivacaineBupivacaine (Carbocaine) (Marcaine) • Barley • Grain mix • Soya bean• Red kidney bean• Tuna • Swordfish • Cherry• Blueberry HERBS• Tomato AND SPICES • Cotton• Coffee • Codfish• Wheat MILKEgg AND White DAIRY OrangePeach BenzylpenicilloylMinor determinant (PPL) Mix BupivacaineRADIO (Marcaine) CONTRAST MEDIA • Buckwheat• Barley • White beans• Soya bean • Trout • Tuna • Cranberry• Cherry • SpiceHERBS mix AND SPICES • Gelatin• Cotton • Wheat• Soya EggEgg White Yolk PeachTomato Minor determinant Mix RADIO CONTRASTIobitridol MEDIA • Cranberry • Spice mix Clavulanic acid + Amoxycillin • Maize • Buckwheat Soya Components:• White beans Fish Components:• Trout • Dates • Anise • Formaldehyde• Gelatin • Soya• Peanut EggMilk Yolk TomatoINHALANTS Clavulanic acid + Amoxycillin Iobitridol Iohexol (Omnipaque) Soya Components: • Dates • Anise • Peanut Cephalosporin C • Maize Fish Components:• Grape • Basil • Formaldehyde • Hazelnut Milk INHALANTS Cephalosporin C Iohexol (Omnipaque) • Malt • Gly m 4 • GlyPR-10 m 4 PR-10• Parvalbumin carp • Grape • Basil • Honey• Honey • Hazelnut Milk components: ANIMALANIMAL DANDER DANDER Cefazolin Iomeprol • Malt • Parvalbumin carp• Grapefruit • Black pepper Milk components: Cefazolin Iomeprol • Oats • Oats • Gly m 5 • Glystorage m 5 storage• Parvalbumin • Parvalbumin cod cod • Grapefruit • Black pepper • Hops• Hops • Shrimp • • α- Lactalbumin - Lactalbumin Cat epitheliumCat epithelium CeftriaxoneCeftriaxone IopamidolIopamidol • Guava • Cardamon α • Rice • Rice protein protein SHELLFISHSHELLFISH • Guava • Cardamon • P. •notatum P. notatum Inhalant mixmix • β• -β Lactoglobulin - Lactoglobulin Dog Dogepithelium epithelium CefuroximeCefuroxime IopromideIopromide • Rye • Rye • Gly m 6 • Glystorage m 6 storage• Shellfish • Shellfish mix mix • Jackfruit• Jackfruit • Carraway• Carraway • Seminal• Seminal (semen) (semen) fluid fluid Consists of:of: • Casein• Casein POLLENSPOLLENS ClarithromycinClarithromycin Ioxaglate Ioxaglate • Wheat • Wheat protein protein • Abelone• Abelone • Kiwi • Kiwi • Chilli• Chilli pepper pepper • Tea• Tea • Grass mixmix CEREALSCEREALS AND AND GRAINS GRAINS 6 grass6 grass mix mix TetracyclineTetracycline IoxitalamateIoxitalamate Wheat allergenWheat allergenDAIRY DAIRY • Blue mussel• Blue mussel • Lemon• Lemon • Cinnamon• Cinnamon • Tobacco• Tobacco leaf leaf • Cultivated rye rye grass grass Baker’sBaker’s yeast yeast BermudaBermuda grass grass TrimethoprimTrimethoprim ANTISEPTICSANTISEPTICS components:components: • Diary mix• Diary mix • Clam • Clam • Litchi• Litchi • Clove• Clove • Common birch birch BarleyBarley flour flour CultivatedCultivated rye grass rye grass SulfamethoxazoleSulfamethoxazole ChlorhexidineChlorhexidine • Omega 5 • OmegaGliadin 5 Gliadin• Milk (Cow)• Milk (Cow) • Crab • Crab • Mango• Mango • Coriander• Coriander • Hazel treetree MaizeMaize CommonCommon birch birch LevofloxacinLevofloxacin DIVERSEDIVERSE DRUG ALLERGY DRUG ALLERGY • Gluten IgE• Gluten IgE • Milk (Goats)• Milk (Goats) • Crayfish• Crayfish • Melon• Melon • Curry• Curry • Mugwort OatsOats HazelHazel tree tree CiprofloxacinCiprofloxacin TESTINGTESTING • Tri a 14 LT• Tri P, Wheat a 14 LT P, Wheat• Cheddar • Cheddar cheese cheese• Langoustine• Langoustine • Naartjie• Naartjie • Dill • Dill • Ribwort/ plantain plantain RiceRice MugwortMugwort CefaclorCefaclor Diverse CASTDiverse CAST NUTS AND NUTSSEEDS AND SEEDS• Mould cheese• Mould cheese • Lobster• Lobster • Orange• Orange • Garlic• Garlic • Altenaria tenuis tenuis RyeRye flour flour RibwortRibwort CefamandoleCefamandole • Nut mix • Nut mix Milk componentsMilk components• Octopus• Octopus • Passion• Passion fruit fruit • Ginger• Ginger • D. pteronyssinuspteronyssinus SoyaSoya P officinalisP officinalis RifampicinRifampicin Please contactPlease the contact laboratory the laboratoryfor for • Pawpaw • Mint • Almond • Almond • α Lactalbumin• α Lactalbumin • Oyster• Oyster • Pawpaw • Mint • D. farinaefarinae WheatWheat MOULDSMOULDS ANALGESIC/ANALGESIC/ ANTI- ANTI- details (012)details 678 (012)0627 678 0627 • Peach • Mustard • Cat Penicillium notatum • Brazil nut • Brazil nut • β Lactaglobulin• β Lactaglobulin• Scallop• Scallop • Peach • Mustard • Cat AllergenAllergen components: components: Penicillium notatum INFLAMMATORIESINFLAMMATORIES • Pear • Nutmeg • Dog • Maize profilin Aspergillus fumigatus • Cashew nut• Cashew nut • Casein • Casein • Shrimp• Shrimp • Pear • Nutmeg • Dog • Maize profilin Aspergillus fumigatus ParacetamolParacetamol Send tablets/Send medication tablets/ medication with with • Coconut • Pineapple • Oregano CAST FOOD ADDITIVES • Wheat profilin Candida albicans patient Heparin specimens, clearly • Coconut • Lactoferrin• Lactoferrin • Snail • Snail • Pineapple • Oregano CAST FOOD ADDITIVES • Wheat profilin Candida albicans Indomethacin patient Heparin specimens, clearly • Hazelnut • Bovine serum albumin • Squid • Plum • Paprika Food Colourants Mix 1 • CCD Alternaria tenuis Indomethacin marked. • Plum • Paprika Food Colourants Mix 1 Mefenamic acid • Hazelnut • Linseed • Bovine serumEGG AND albumin POULTRY• Squid Shellfish components • Strawberry • Parsley consists of: SEAFOOD• CCD CladosporiumAlternaria herbarum tenuis NaproxenMefenamic acid marked. • Strawberry • Parsley • Linseed • Macadamia nutEGG AND• Chicken POULTRY Shellfish• Tropomyosin components Shrimp VEGETABLES • Saffron consists • Quinoline of: Yellow AnisakisSEAFOOD MITESCladosporium herbarum DiclofenacNaproxen Collect specimens Mondays to • Macadamia• Pecan nut nut • Chicken• Turkey • TropomyosinMEAT Shrimp VEGETABLES• Asparagus • Saffron• Tarragon • Sunset• Quinoline Yellow Yellow FCF CodAnisakis StorageMITES mite mix IbuprofenDiclofenac Thursdays,Collect and not specimens on the day Mondays to • Pecan nut• Pistachio nut • Turkey • Egg yolk MEAT • Meat mix • Asparagus• Avocado • Tarragon• Thyme • Chromotrope• Sunset Yellow B FCF CrabCod D pteronyssinusStorage mite mix Aspirin Ibuprofen before a PublicThursdays, Holiday. and not on the day • Pistachio nut• Peanuts • Egg yolkEgg white components• Meat mix• Beef • Avocado• Bamboo shoot • Thyme • Amaranth• Chromotrope B OysterCrab D farinaeD pteronyssinus Dipyrone/MetamizoleAspirin before a Public Holiday. • Peanuts • Pine Nut Egg white• Ovomucoid components • Beef • Gelatin • Bamboo• Beetroot shoot • New• Amaranth Coccine ShrimpOyster AcarusD farinaesiro PhenylbutazoneDipyrone/Metamizole Discontinue parenteral • Pine Nut • Poppy seed • Ovomucoid• Ovalbumin • Gelatin• Mutton/Lamb • Beetroot• Brinjal Food • New Colourants Coccine Mix 2 SquidShrimp OCCUPATIONALAcarus siro GENERALPhenylbutazone ANESTHETICS corticossteroidsDiscontinue two weeks parenteral prior • Poppy seed• Sesame seed• Ovalbumin• Conalbumin • Mutton/Lamb• Pork • Brinjal• Brussel sprouts Foodconsists Colourants of: Mix 2 MEATSquid CarboxymethylcelluloseOCCUPATIONAL GeneralGENERAL anaesthetic ANESTHETICS mix, to testing.corticossteroids Idealy wait two weeks two weeks prior • Sesame seed• Sunflower seed• Conalbumin• Lysozyme • Pork Beef components:• Brussel• Cabbage sprouts consists • Erythrosine of: PorkMEAT LatexCarboxymethylcellulose (breakdownGeneral if positive) anaesthetic mix, after an acuteto testing. allergic Idealy reaction wait or two weeks • Sunflower• Walnut seed • LysozymeFISH ALLERGENSBeef components:• Alpha 1,3-Gal • Cabbage• Carrot • Patent• Erythrosine Blue V BeefPork FormaldehydeLatex Muscle(breakdown Relaxants if positive) illness beforeafter testing. an acute allergic reaction or • Walnut Peanut componentsFISH ALLERGENS• Fish mixture • Alpha 1,3-Gal• Bovine serum • Carrot• Celery • Indigo• Patent Carmine Blue V NUTSBeef AND SEEDS ChlorhexidineFormaldehyde • VecuroniumMuscle Relaxants illness before testing. Peanut components• Ara h 1 storage• Fish protein mixture• Anchovy • Bovine serum albumin • Celery• Cucumber • Brilliant• Indigo BlackCarmine BN HazelnutNUTS AND SEEDS AlphaChlorhexidine amylase • Suxamethonium • Vecuronium • Green pepper Almond • Ara h 1 storage• Ara proteinh 2 storage• Anchovy protein • Anisakis (fish parasite) albumin • Cucumber • Methylene• Brilliant Black Blue BN Hazelnut INSECTAlpha VENOMS amylase • Rocuronium • Suxamethonium • Ara h 3 storage protein • Lettuce Preservative group, includes: Cashew nut Honey Bee • Ara h 2 storage protein • Anisakis • Cod(fish parasite) fish • Green pepper • Methylene Blue SesameAlmond seed INSECT VENOMS • Mivacurium • Mushrooms • Potassium Metabisulphite Culicoides Antigen • Rocuronium • Ara h 3 storage• Ara proteinh 8 profilin• Cod fish• Hake • Lettuce Preservative group, includes: PeanutCashew nut Honey Bee • Atracurium • Ara h 9 LTP • Herring • Olive • Tartrazine Sesame seed Yellow jacket hornet • Pancuronium • Mivacurium • Ara h 8 profilin • Hake • Mushrooms • Potassium Metabisulphite Peanut components PaperCulicoides wasp Antigen • Sodium Salycilate • ArahPeanut 1 storage protein • Cisatracurium • Atracurium • Olive • Tartrazine EuropeanYellow hornet jacket hornet • Ara h 9 LTP • Herring Peanut components Paper wasp • Pancuronium • Sodium Salycilate • Arah 1 storage protein European hornet • Cisatracurium ImmunoCap® IgE LIST OF ALLERGY TESTS ImmunoCap® IgE LIST OF ALLERGY TESTS CHAPTER 10 LIST OF ALLERGY TESTSCHAPTER 10 INHALANT ALLERGENS INHALANT ALLERGENS INHALANT ALLERGENS INSECT ALLERGENS DRUG ALLERGENS LIST OF ALLERGY TESTS GRASSINHALANT ALLERGENS WEEDINHALANT POLLENS ALLERGENS • HorseINHALANT serum ALLERGENSprotein • AmericanINSECT ALLERGENS Cockroach • AmoxycillinDRUG ALLERGENS • GrassGRASS mix • WeedWEED Mix POLLENS • Mouse• Horse epithelium serum protein • German• American Cockroach Cockroach • Ampicillin• Amoxycillin • Bahia• Grass Grass mix • Common• Weed MixPigweed • Mouse• Mouse serum epithelium protein • Oriental• German Cockroach Cockroach • Penicillin• Ampicillin G IgE • Bermuda• Bahia Grass • Dandelion• Common Pigweed • Mouse• Mouse urine serum protein protein • Mosquito• Oriental Cockroach • Penicillin• Penicillin V GIgE IgE • Brome• Bermuda Grass Grass • Lambs• Dandelion Quarters • Parrot• Mouse droppings urine protein • Honey• Mosquito Bee • Cefaclor• Penicillin V IgE • Cocksfoot• Brome Grass • Marguerite• Lambs Quarters • Parrot• Parrot feathers droppings • Common• Honey BeeWasp • Insulin• Cefaclor Bovine • Golden• Cocksfoot Rod Grass Grass – Johnson • Mugwort • Marguerite • Pigeon• Parrot droppings feathers • European• Common Hornet Wasp • Insulin• Insulin Human Bovine Grass• Golden Rod Grass – Johnson MITES• Mugwort • Pigeon• Pigeon feathers droppings • Hornet• European (White Hornet faced) • Insulin• Insulin Porcine Human • Maize Grass Pollen • HouseMITES dust mix • Pigeon• Pigeon serum feathers protein • Hornet• Hornet (Yellow) (White faced) • Tetanus• Insulin ToxoidPorcine • Cultivated• Maize Pollenwheat • A.siro• House dust mix • Rabbit• Pigeon epithelium serum protein • Paper• Hornet Wasp (Yellow) • Tetanus Toxoid Grass• Cultivated Allergen componentswheat • B.• A.siro tropicalis • Rabbit• Rabbit serum epithelium protein Bee• Paper and Wasp Wasp components • GrassGrass group Allergen 1 Bermuda components • B.• B. spicifera tropicalis • Rabbit• Rabbit urine serum protein protein • ApiBee m and 1, bee Wasp Phospholipase components • Grass• Grass group group 1 Timothy 1 Bermuda • D.• B. farinae spicifera • Rat• Rabbit epithelium urine protein A2,• Api m 1, bee Phospholipase • Grass• Grass group group 5 Timothy 1 Timothy • D• D. pteronyssinus farinae • Rat• Rat serum epithelium protein • Ves A2, v 1, Common wasp CROSS• Grass - REACTIVE group 5 Timothy • E.• D maynei pteronyssinus • Rat• Rat urine serum protein protein Phopholipase• Ves v 1, Common A1; wasp COMPONENTSCROSS - REACTIVE • Glycyphagus• E. maynei domesticus • Sheep• Rat urineepithelium protein • Ves Phopholipase v 5, Common A1; Wasp • ProfilinCOMPONENTS • Lepidoglyphus• Glycyphagus destructor domesticus • Swine• Sheep epithelium epithelium Allergen• Ves v 5,5 Common Wasp • CCD• Profilin • Tyrophagus• Lepidoglyphus putrescentiae destructor • Turkey• Swine feathers epithelium • Pol Allergen d 5, European 5 Paper • PR-10• CCD House• Tyrophagus dust mite putrescentiaecomponents Animal• Turkey Allergen feathers components Wasp• Pol dAllergen 5, European 5 Paper • LTP• PR-10 • DerHouse p 1 cysteindust mite protease components • CanAnimal f 1 dog Allergen lipocalin components • CCD Wasp Marker Allergen 5 TREE• LTP POLLENS • Der• Der p 2 p NPC2 1 cystein protein protease • Can• Can f 2 fdog 1 dog lipocalin lipocalin OCCUPATIONAL• CCD Marker • TreeTREE mix POLLENS 1 (Olive, Willow, pine, • Der• Der p 10 p 2tropomyosin NPC2 protein • Can• Can f 3 fdog 2 dog serum lipocalin albumin • EthyleneOCCUPATIONAL Oxide Acacia,• Tree Eucalyptus,mix 1 (Olive, Cajeput) Willow, pine, EPIDERMALS• Der p 10 tropomyosin AND ANIMAL • Can• Can f 5 fdog 3 dog arginine serum kinase albumin • Formaldehyde• Ethylene Oxide • Tree Acacia, mix 2 (Oak,Eucalyptus, Elm, Plane, Cajeput) PROTEINSEPIDERMALS AND ANIMAL • Cat• Can fel df 51 doguteroglobin arginine kinase • Isocyanate• Formaldehyde HDI Willow,• Tree Cottonwood) mix 2 (Oak, Elm, Plane, • AnimalPROTEINS dander mix • Cat• Cat fel feld 2 d serum 1 uteroglobin albumin • Isocyanate• Isocyanate MDI HDI • Acacia Willow, Cottonwood) • Caged• Animal birds dander feather mix mix • Cat• Cat fel feld 4 d lipocalin 2 serum albumin • Isocyanate• Isocyanate TDI MDI • Birch• Acacia • Feather• Caged mix birds feather mix • Equ• Cat c1 fel Horse d 4 lipocalin lipocalin • Latex• Isocyanate TDI • Cajeput• Birch • Budgie• Feather droppings mix • Bos• Equ d 6 c1 Cow Horse serum lipocalin albumin • Maleic• Latex Anhydride • Cypress• Cajeput • Budgie• Budgie feathers droppings MOULDS• Bos d 6 Cow serum albumin • Phthalic• Maleic Anhydride Anhydride • Elm• Cypress • Budgie• Budgie serum feathers protein • MouldMOULDS mix • Trimellitic• Phthalic Anhydride Anhydride • Eucalyptus• Elm Tree • Canary• Budgie feathers serum protein • Alternaria• Mould mixtenuis • Silk• Trimellitic Natural Anhydride • Italian• Eucalyptus Cypress Tree • Cat• Canary dander feathers • Aspergillus• Alternaria fumigatus tenuis • Untreated• Silk Natural cotton • Japanese• Italian CypressCedar • Chicken• Cat dander feathers • Botrytis• Aspergillus cinerea fumigatus • Untreated cotton • London• Japanese Plane Cedar Tree • Cow• Chicken dander feathers • Candida• Botrytis albicans cinerea • Oak• London Plane Tree • Dog• Cow Dander dander • C• Candida herbarum albicans • Olive• Oak Tree • Dog Dander • Epicoccum• C herbarum • Duck feathers Please note that this is not a comprehensive list of tests • Pecan• Olive Tree Tree • Duck feathers • Helminthos• Epicoccum halodes • Finch feathers butPlease only represents note that this the is most not acommon comprehensive allergens.Please list of tests • Pepper• Pecan Tree Tree • Goat• Finch epithelium feathers • Penicillin• Helminthos notatum halodes phonebut only the representslaboratory theat most(012) common678 08614 allergens.Please to enquire • Pine• Pepper Tree Tree • Goat epithelium • Phoma• Penicillin betae notatum • Goose feathers aboutphone the theavailability laboratory of other at (012) allergens. 678 08614 to enquire • Walnut• Pine Tree Tree • Guinea• Goose pig feathers Mould• Phoma components: betae about the availability of other allergens. • Willow• Walnut Tree Tree • Hamster• Guinea epithelium pig • AltMould a 1 Alternaria components: Tree• Willow mix 1 consists Tree of: • Horse• Hamster dander epithelium • Asp• Alt f 6a Aspergillus1 Alternaria (ABPA) TreeTree mix mix 2 consists 1 consists of: of: • Horse dander • Asp f 6 Aspergillus (ABPA) Tree mix 2 consists of: 203 | Ampath Desk Reference

ImmunoCap®ImmunoCap® IgE IgE LISTLIST OF OF ALLERGY ALLERGY TESTS TESTS CastCast Tests Tests (CAST) (CAST) LISTLIST OFOF ALLERGYALLERGY TESTS

SCREENING TESTS LEGUMES FISH ALLERGENS CONT FRUIT VEG ALLERGENS CONT DIVERSE SCREENING TESTS: FOOD ADDITIVES CONT: FOOD ALLERGENS CONT: DRUGS GENERAL ANAESTHETICS CONT: SCREENING TESTS LEGUMES FISH ALLERGENS CONT FRUIT VEG ALLERGENS CONT DIVERSE SCREENING TESTS: FOOD ADDITIVES CONT: FOOD ALLERGENS CONT: DRUGS GENERAL ANAESTHETICS CONT: • Fx5 food mix • Chick pea • Mackerel • Tropical fruit mix • Onion • Ascaris Food mix • Sodium Benzoate • Arah 2 storage protein ANTIBIOTICS Propofol • Fx5 food mix • Chick pea • Mackerel • Tropical fruit mix • Onion • Ascaris Food mix • Sodium Benzoate • Arah 2 storage protein ANTIBIOTICS Propofol • Phadiatop inhalant mix • Green beans • Salmon • Apple • Potato • Bakers yeast Consists of: • Sodium Nitrites • Arah 6 storage protein Amoxycillin LOCAL ANAESTHETICS • Phadiatop inhalant mix • Green beans • Salmon • Apple • Potato • Bakers yeast Consists of: • Sodium Nitrites • Arah 6 storage protein Amoxycillin LOCAL ANAESTHETICS • IgE • Lentils • Sardine • Apricot • Pumpkin & Ssquash • Bilharzia • Egg White • MSG FRUITS AND VEGETABLES Ampicillin Lidocaine / Lignocaine (Xylotox) • IgE • Lentils • Sardine • Apricot • Pumpkin & Ssquash • Bilharzia • Egg White • MSG FRUITS AND VEGETABLES Ampicillin Lidocaine / Lignocaine (Xylotox) FOOD ALLERGENS • Lupin seed • Snoek • Banana • Spinach • Canola oil • Egg yolk • Potassium Sorbate Carrot Penicillin G Articaine (Ubistesin) FOOD ALLERGENS • Lupin seed • Snoek • Banana • Spinach • Canola oil • Egg yolk • Potassium Sorbate Carrot Penicillin G Articaine (Ubistesin) GRAIN • Peas • Sole • Blackberry • Sweet potato • Cocoa (Chocolate) • Milk CAST FOODS Celery Penicillin V Mepivacaine (Carbocaine) GRAIN • Peas • Sole • Blackberry • Sweet potato • Cocoa (Chocolate) • Milk CAST FOODS Celery Penicillin V Mepivacaine (Carbocaine) • Grain mix • Red kidney bean • Swordfish • Blueberry • Tomato • Coffee • Codfish MILK AND DAIRY Orange Benzylpenicilloyl (PPL) Bupivacaine (Marcaine) • Grain mix • Red kidney bean • Swordfish • Blueberry • Tomato • Coffee • Codfish MILK AND DAIRY Orange Benzylpenicilloyl (PPL) Bupivacaine (Marcaine) • Barley • Soya bean • Tuna • Cherry HERBS AND SPICES • Cotton • Wheat Egg White Peach RADIO CONTRAST MEDIA • Barley • Soya bean • Tuna • Cherry HERBS AND SPICES • Cotton • Wheat Egg White Peach MinorMinor determinantdeterminant MixMix RADIO CONTRAST MEDIA • Buckwheat • White beans • Trout • Cranberry • Spice mix • Gelatin • Soya Egg Yolk Tomato Iobitridol • Buckwheat • White beans • Trout • Cranberry • Spice mix • Gelatin • Soya Egg Yolk Tomato ClavulanicClavulanic acidacid ++ AmoxycillinAmoxycillin Iobitridol • Maize Soya Components: Fish Components: • Dates • Anise • Formaldehyde • Peanut Milk INHALANTS Iohexol (Omnipaque) • Maize Soya Components: Fish Components: • Dates • Anise • Formaldehyde • Peanut Milk INHALANTS CephalosporinCephalosporin CC Iohexol (Omnipaque) • Malt • Gly m 4 PR-10 • Parvalbumin carp • Grape• Grape • Basil• Basil • Honey • Hazelnut Milk components: ANIMAL DANDER Cefazolin Iomeprol • Malt • Gly m 4 PR-10 • Parvalbumin carp • Grapefruit • Black pepper • Honey • Hazelnut Milk components: ANIMAL DANDER Cefazolin Iomeprol • Oats • Gly m 5 storage • Parvalbumin cod • Grapefruit • Black pepper • Hops• Hops • Shrimp • α - Lactalbumin CatCat epithelium epithelium Ceftriaxone Iopamidol • Oats • Gly m 5 storage • Parvalbumin cod • Guava • Cardamon • Shrimp • α - Lactalbumin Ceftriaxone Iopamidol • Rice protein protein SHELLFISH • Guava • Cardamon • P.• P.notatum notatum InhalantInhalant mix mix • β - Lactoglobulin DogDog epithelium epithelium Cefuroxime Iopromide • Rice SHELLFISH • Jackfruit • Carraway • β - Lactoglobulin Cefuroxime Iopromide • Rye• Rye • Gly• Gly m 6m storage 6 storage • Shellfish mix • Jackfruit • Carraway • Seminal• Seminal (semen) (semen) fluid fluid ConsistsConsists of: of: • Casein• Casein POLLENSPOLLENS Clarithromycin IoxaglateIoxaglate • Shellfish mix • Kiwi • Chilli pepper Clarithromycin • Wheat• Wheat protein protein • Abelone• Abelone • Kiwi • Chilli pepper • Tea• Tea • Grass • Grass mix mix CEREALSCEREALS AND AND GRAINS GRAINS 66 grass grass mix mix Tetracycline IoxitalamateIoxitalamate • Lemon • Cinnamon Tetracycline WheatWheat allergen allergen DAIRYDAIRY • Blue• Blue mussel mussel • Lemon • Cinnamon • Tobacco• Tobacco leaf leaf • Cultivated • Cultivated rye rye grass grass Baker’sBaker’s yeast yeast BermudaBermuda grass grass Trimethoprim ANTISEPTICSANTISEPTICS • Litchi • Clove Trimethoprim components:components: • Diary• Diary mix mix • Clam• Clam • Litchi • Clove • Common • Common birch birch BarleyBarley flour flour CultivatedCultivated rye rye grass grass Sulfamethoxazole ChlorhexidineChlorhexidine • Mango • Coriander Sulfamethoxazole • Omega• Omega 5 Gliadin 5 Gliadin • Milk• Milk (Cow) (Cow) • Crab• Crab • Mango • Coriander • Hazel • Hazel tree tree MaizeMaize CommonCommon birch birch LevofloxacinLevofloxacin DIVERSEDIVERSE DRUG ALLERGY • Melon • Curry • Gluten• Gluten IgE IgE • Milk• Milk (Goats) (Goats) • Crayfish• Crayfish • Melon • Curry • Mugwort • Mugwort OatsOats HazelHazel tree tree CiprofloxacinCiprofloxacin TESTINGTESTING • Naartjie • Dill • Tri• Tri a 14 a LT14 P, LT Wheat P, Wheat • Cheddar• Cheddar cheese cheese • Langoustine• Langoustine • Naartjie • Dill • Ribwort/ • Ribwort/ plantain plantain RiceRice MugwortMugwort CefaclorCefaclor DiverseDiverse CAST • Orange • Garlic NUTSNUTS AND AND SEEDS SEEDS • Mould• Mould cheese cheese • Lobster• Lobster • Orange • Garlic • Altenaria • Altenaria tenuis tenuis RyeRye flour flour RibwortRibwort CefamandoleCefamandole • Passion fruit • Ginger • Nut• Nut mix mix MilkMilk components components • Octopus• Octopus • Passion fruit • Ginger • D. • D. pteronyssinus pteronyssinus SoyaSoya PP officinalis officinalis RifampicinRifampicin PleasePlease contact the laboratory for • Pawpaw • Mint • Almond• Almond • α• Lactalbumin Lactalbumin • Oyster• Oyster • Pawpaw • Mint • D. • D. farinae farinae WheatWheat MOULDSMOULDS ANALGESIC/ANALGESIC/ ANTI-ANTI- detailsdetails (012)(012) 678678 06270627 α • Peach • Mustard • Brazil• Brazil nut nut • β• Lactaglobulinβ Lactaglobulin • Scallop• Scallop • Peach • Mustard • Cat • Cat AllergenAllergen components: components: PenicilliumPenicillium notatum notatum INFLAMMATORIESINFLAMMATORIES • Cashew• Cashew nut nut • Casein• Casein • Shrimp• Shrimp • Pear• Pear • Nutmeg• Nutmeg • Dog • Dog • Maize• Maize profilin profilin AspergillusAspergillus fumigatus fumigatus ParacetamolParacetamol SendSend tablets/ medication with • Coconut• Coconut • Lactoferrin• Lactoferrin • Snail• Snail • Pineapple• Pineapple • Oregano• Oregano CASTCAST FOOD FOOD ADDITIVES ADDITIVES • Wheat• Wheat profilin profilin CandidaCandida albicans albicans IndomethacinIndomethacin patientpatient Heparin specimens, clearly • Hazelnut• Hazelnut • Bovine• Bovine serum serum albumin albumin• Squid• Squid • Plum• Plum • Paprika• Paprika FoodFood Colourants Colourants Mix Mix 1 1 • CCD• CCD AlternariaAlternaria tenuis tenuis MefenamicMefenamic acidacid marked. • Linseed• Linseed EGGEGG AND AND POULTRY POULTRY ShellfishShellfish components components • Strawberry• Strawberry • Parsley• Parsley consistsconsists of: of: SEAFOODSEAFOOD CladosporiumCladosporium herbarum herbarum NaproxenNaproxen • Macadamia• Macadamia nut nut • Chicken• Chicken • Tropomyosin• Tropomyosin Shrimp Shrimp VEGETABLESVEGETABLES • Saffron• Saffron • Quinoline • Quinoline Yellow Yellow AnisakisAnisakis MITESMITES DiclofenacDiclofenac CollectCollect specimens Mondays to • Pecan• Pecan nut nut • Turkey• Turkey MEATMEAT • Asparagus• Asparagus • Tarragon• Tarragon • Sunset • Sunset Yellow Yellow FCF FCF CodCod StorageStorage mite mite mix mix IbuprofenIbuprofen Thursdays,Thursdays, and not on the day • Pistachio• Pistachio nut nut • Egg• Egg yolk yolk • Meat• Meat mix mix • Avocado• Avocado • Thyme• Thyme • Chromotrope • Chromotrope B B CrabCrab DD pteronyssinus pteronyssinus AspirinAspirin beforebefore a Public Holiday. • Peanuts• Peanuts EggEgg white white components components• Beef• Beef • Bamboo• Bamboo shoot shoot • Amaranth • Amaranth OysterOyster DD farinae farinae Dipyrone/MetamizoleDipyrone/Metamizole • Pine• Pine Nut Nut • Ovomucoid• Ovomucoid • Gelatin• Gelatin • Beetroot• Beetroot • New • New Coccine Coccine ShrimpShrimp AcarusAcarus siro siro PhenylbutazonePhenylbutazone DiscontinueDiscontinue parenteral • Poppy• Poppy seed seed • Ovalbumin• Ovalbumin • Mutton/Lamb• Mutton/Lamb • Brinjal• Brinjal FoodFood Colourants Colourants Mix Mix 2 2 SquidSquid OCCUPATIONALOCCUPATIONAL GENERALGENERAL ANESTHETICSANESTHETICS corticossteroidscorticossteroids twotwo weeks prior • Sesame• Sesame seed seed • Conalbumin• Conalbumin • Pork• Pork • Brussel• Brussel sprouts sprouts consistsconsists of: of: MEATMEAT CarboxymethylcelluloseCarboxymethylcellulose GeneralGeneral anaestheticanaesthetic mix,mix, toto testing.testing. IdealyIdealy wait two weeks • Sunflower• Sunflower seed seed • Lysozyme• Lysozyme BeefBeef components: components: • Cabbage• Cabbage • Erythrosine • Erythrosine PorkPork LatexLatex (breakdown(breakdown ifif positive)positive) afterafter anan acuteacute allergic reaction or • Walnut• Walnut FISHFISH ALLERGENS ALLERGENS • Alpha• Alpha 1,3-Gal 1,3-Gal • Carrot• Carrot • Patent • Patent Blue Blue V V BeefBeef FormaldehydeFormaldehyde MuscleMuscle RelaxantsRelaxants illnessillness before testing.testing. PeanutPeanut components components • Fish• Fish mixture mixture • Bovine• Bovine serum serum • Celery• Celery • Indigo • Indigo Carmine Carmine NUTSNUTS AND AND SEEDS SEEDS ChlorhexidineChlorhexidine • • VecuroniumVecuronium • Ara• Ara h 1 hstorage 1 storage protein protein• Anchovy• Anchovy albumin albumin • Cucumber• Cucumber • Brilliant • Brilliant Black Black BN BN HazelnutHazelnut AlphaAlpha amylase amylase • • SuxamethoniumSuxamethonium Almond • Ara• Ara h 2 hstorage 2 storage protein protein• Anisakis• Anisakis (fish (fish parasite) parasite) • Green• Green pepper pepper • Methylene • Methylene Blue Blue Almond INSECTINSECT VENOMS VENOMS • • RocuroniumRocuronium • Ara h 3 storage protein • Lettuce Preservative group, includes: CashewCashew nut nut Honey Bee • Ara h 3 storage protein• Cod• Cod fish fish • Lettuce Preservative group, includes: Sesame seed Honey Bee • • MivacuriumMivacurium • Ara h 8 profilin • Hake • Mushrooms • Potassium Metabisulphite Sesame seed CulicoidesCulicoides Antigen Antigen • Ara h 8 profilin • Hake • Mushrooms • Potassium Metabisulphite PeanutPeanut • • AtracuriumAtracurium • Ara h 9 LTP • Olive • Tartrazine YellowYellow jacket jacket hornet hornet • Ara h 9 LTP • Herring• Herring • Olive • Tartrazine PeanutPeanut components components Paper wasp • • PancuroniumPancuronium • Sodium Salycilate Paper wasp • Sodium Salycilate • Arah• Arah 1 1 storage storage protein protein EuropeanEuropean hornet hornet • • CisatracuriumCisatracurium Guide to laboratory tests | 204

MELISA,MELISA, Skin Skin Prick Prick Test Test and and Patch Patch Test Test LISTLIST OF OFALLERGY ALLERGY TESTS TESTS ISACISAC Tests Tests Continued... Continued... LISTLIST OF OFALLERGY ALLERGY TESTS TESTS

HEAVYHEAVY METALS METALS SKIN SKINPRICK PRICK TEST TESTALLERGENS ALLERGENS MITESMITES • Aluminium• Aluminium ONE COLLECTIVEONE COLLECTIVE TEST TESTTHAT THATINCLUDES INCLUDES 112 FOOD 112 FOOD AND INHALANTAND INHALANT ALLERGEN ALLERGEN COMPONENTS. COMPONENTS. ISAC ISACALLERGEN ALLERGEN COMPONENTS COMPONENTS • Arsenic• Arsenic INHALANTSINHALANTS HouseHouse dust mite dust mix mite mix • Barium• Barium ANIMALANIMAL ALLERGENS ALLERGENS B.tropicalisB.tropicalis ALLERGENALLERGEN COMPONENT COMPONENT ALLERGENALLERGEN SOURCE SOURCE PROTEIN PROTEIN GROUP GROUP • Beryllium• Beryllium Cat Cat CockroachCockroach COMMON COMMON NAME NAME • Chromium• Chromium (A shortened(A shortened profile profile is also is available) also available) • Cobalt• Cobalt Dog Dog NUTSNUTS AND LEGUMESAND LEGUMES • Copper• Copper MOULDSMOULDS FOODSFOODS Ana o Ana2 Cashew o 2 Cashew nut Storage nut Storage protien protien 11 S globulin11 S globulin • Ethyl• Ethyl Mercury Mercury AlternariaAlternaria alternata alternata Cow’sCow’s milk milk Ara h Ara1 Peanut Storage h 1 Peanut Storage protein, protein, 7 S globulin 7 S globulin • Galium• Galium CladosporiumCladosporium Egg Egg Ara h Ara2 Peanut Storage h 2 Peanut Storage protein, protein, conglutin conglutin Cod fishCod fish • Gold• Gold AspergillusAspergillus Ara h Ara3 Peanut Storage h 3 Peanut Storage protein, protein, 11 S globulin11 S globulin • Iridium• Iridium ShellfishShellfish Ara h Ara8 Peanut PR-10 h 8 Peanut PR-10 protein protein • Indium• Indium FEATHERSFEATHERS Soya Soya Ara h Ara6 Peanut Storage h 6 Peanut Storage protein, protein, conglutin conglutin • Iron • Iron FeatherFeather mix mix WheatWheat Ara h Ara9 Peanut Lipid h 9 Peanut Lipid transfer transfer protein protein (LTP) (LTP) • Inorganic• Inorganic Mercury Mercury GRASSESGRASSES PeanutPeanut Ber e1 Brazil Ber e1 Brazil nut Storage nut Storage protein, protein, 2S albumin 2S albumin • Lanthanum• Lanthanum BermudaBermuda Grass Grass Maize/CornMaize/Corn Cor a Cor1.0401 Hazelnut PR-10 a 1.0401 Hazelnut PR-10 protein protein PotatoPotato • Lead• Lead 6-grass6-grass mix mix Cor a Cor8 Hazelnut Lipid a 8 Hazelnut Lipid transfer transfer protein protein (LTP) (LTP) • Manganese• Manganese TomatoTomato Cor a Cor9 Hazelnut Storage a 9 Hazelnut Storage protein, protein, 11 S globulin11 S globulin • Methyl• Methyl mercury mercury POLLENSPOLLENS OrangeOrange Jug r 1 Walnut Storage Jug r 1 Walnut Storage protein, protein, 2S albumin 2S albumin • Molybdenum• Molybdenum Maize Maizepollen pollen AppleApple Jug r 2 Walnut Storage Jug r 2 Walnut Storage protein, protein, 7S globulin 7S globulin • Nickel• Nickel Weed Weedmix mix BananaBanana Jug r 3 Walnut Lipid Jug r 3 Walnut Lipid transfer transfer protein protein (LTP) (LTP) • Platinum• Platinum Plane Planetree pollen tree pollen BakersBakers yeast yeast Gly m Gly4 Soybean Pr-10 m 4 Soybean Pr-10 protein protein (A Shortened(A Shortened profile profile is available) is available) • Phenyl• Phenyl Mercury Mercury Oak pollenOak pollen Gly m Gly5 Soybean Storage m 5 Soybean Storage protein, protein, B-conglycinin B-conglycinin • Palladium• Palladium PATCHPATCH TESTS: TESTS: Gly m Gly6 Soybean Storage m 6 Soybean Storage protein, protein, Glycinin Glycinin • Platinum• Platinum Olive pollenOlive pollen Ses i 1 Ses Sesame i 1 Sesame seed Storage seed Storage protein, protein, 2S albumin 2S albumin EuropeanEuropean baseline, baseline, sunscreen, sunscreen, • Ruthenium• Ruthenium CypressCypress pollen pollen GRAINSGRAINS • Silver• Silver AcaciaAcacia pollen pollen cosmeticcosmetic and hairdressing and hairdressing series. series. Fag e Fag2 Buckwheat Storage e 2 Buckwheat Storage Protein, Protein, 2S albumin 2S albumin • Tin • Tin EucalyptusEucalyptus Tri Tri a 14 Wheat a 14 Wheat Crude Crude gliadin gliadin (LTP) (LTP) • Titanium• Titanium SPECIMENSPECIMEN REQUIREMENTS: REQUIREMENTS: Tria a Tria19.0101 Wheat a 19.0101 Wheat Omega-5 Omega-5 gliadin gliadin • Thimerosal• Thimerosal mercury mercury TEST TEST SPECIMEN SPECIMEN SPECIAL SPECIAL INSTRUCTIONS INSTRUCTIONS Tria a TriaaA_TI Wheat a aA_TI Wheat • Vanadium• Vanadium IgE IgE SST/Clotted SST/Clotted Tube/1ml Tube/1ml OCCUPATIONALOCCUPATIONAL • Zinc• Zinc RAST RAST SST/Clotted SST/Clotted Tube/5ml Tube/5ml - - Hev b Hev 1 Latex b 1 Latex • Zirconium• Zirconium depending depending on the on number the number of allergens of allergens requested requested Hev b Hev 3 Latex b 3 Latex ANTISEPTICSANTISEPTICS ECP ECP SST/Clotted SST/Clotted Tube/1ml Blood Tube/1ml Blood must bemust taken be takenin a SST in a SST Hev b Hev 8 Latex Profilin b 8 Latex Profilin Hev b Hev 5 Latex b 5 Latex • Mercurochrome• Mercurochrome tube tube and serum and serum must bemust be • Iodine• Iodine Hev b Hev 6.01 Latex b 6.01 Latex separated separated within within1 hour. 1 hour. • Clorhexidine• Clorhexidine Bos d Bos 4 Cow’s d 4 Cow’s milk milk a-lactalbumina-lactalbumin Mast Cell Mast Cell SST/Clotted SST/Clotted Tube/1ml Tube/1ml Bos d Bos 5 Cow’s d 5 Cow’s milk milk B-lactoglobulin B-lactoglobulin TryptaseTryptase Bos d Bos 6 Cow’s d 6 Cow’s milk and milk meat Serum and meat Serum albumin albumin See listSee of listCAST of CAST allergens: allergens: ISAC ISAC SST/Clotted SST/Clotted Tube/1ml Tube/1ml or less or less Bos d Bos 8 Cow’s d 8 Cow’s milk Casein milk Casein all allergensall allergens available available on CAST on CAST CAST CAST Heparin Heparin Tube/5ml Must Tube/5ml Must reach reachthe lab the within lab within24 24 Bos d Bos lactoferrin d lactoferrin Cow’s Cow’s milk Transferrin milk Transferrin is alsois available also available for MELISA for MELISA hours hours on week on weekdays anddays before and before EGG EGG testing,testing, including including diverse diverse drug drug 12:00 12:00 on Fridays. on Fridays. Gal d Gal1 Egg d 1 Egg white Ovomucoid white Ovomucoid allergyallergy testing. testing. MELISA MELISA Citrate Citrate Tube/5ml Tube/5ml (4-6 depending (4-6 depending on the on number the number Must reach Must reachthe lab the within lab within24 24 Gal d Gal2 Egg d 2 Egg white Ovalbumin white Ovalbumin of of allergens allergens requested) requested) hours hourson week on weekdays anddays before and before Gal d Gal3 Egg d 3 Egg white Conalbumin white Conalbumin 12:00 12:00 on Fridays. on Fridays. Gal d Gal5 Egg d 5 Egg yolk Serum yolk Serum albumin albumin FISH FISH Gad c Gad 1 Cod Parvalbumin c 1 Cod Parvalbumin Ani s 3 Anisakis Ani s 3 Anisakis (Fish parasite)(Fish parasite) Tropomyosin Tropomyosin Ani s 1 Anisakis Ani s 1 Anisakis (Fish parasite) (Fish parasite) Pen m Pen 2 Shrimp Arginine m 2 Shrimp Arginine kinase kinase ISACISAC Tests Tests LISTLIST OF OFALLERGY ALLERGY TESTS TESTS Pen m Pen 4 Shrimp Sarcoplasmic m 4 Shrimp Sarcoplasmic Ca-binding Ca-binding protein protein Pen m Pen 1 Shrimp Tropomyosin m 1 Shrimp Tropomyosin MITESMITES Der f 1 House Der f 1 House dust mite dust (D.farinae) mite (D.farinae) Der f 2 House Der f 2 House dust mite dust (D.farinae) mite (D.farinae) ONE COLLECTIVEONE COLLECTIVE TEST TESTTHAT THATINCLUDES INCLUDES 112 FOOD 112 FOOD AND INHALANTAND INHALANT ALLERGEN ALLERGEN COMPONENTS. COMPONENTS. ISAC ISACALLERGEN ALLERGEN COMPONENTS COMPONENTS Der p Der1 House p 1 House dust mite dust (D.pteronyssinus) mite (D.pteronyssinus) ALLERGEN ALLERGEN COMPONENT COMPONENT ALLERGENALLERGEN SOURCE SOURCE PROTEIN PROTEIN GROUP GROUP Der p Der2 House p 2 House dust mite dust (D.pteronyssinus) mite (D.pteronyssinus) COMMON COMMON NAME NAME Der p Der10 House p 10 House dust mite dust (D.pteronyssinus) mite (D.pteronyssinus) Tropomyosin Tropomyosin Blo t 5 House Blo t 5 House dust mite dust (B.tropicalis) mite (B.tropicalis) GRASSGRASS POLLEN POLLEN Lep d Lep2 Storage d 2 Storage mite mite Cyn d Cyn 1 Bermuda d 1 Bermuda Grass Grass Grass Grass group group1 1 MOULDSMOULDS Phl p 1 Timothy Phl p 1 Timothy Grass Grass Grass Grass group group1 1 Alt a 1 Alternaria Alt a 1 Alternaria Phl p 2 Timothy Phl p 2 Timothy Grass Grass Grass Grass group group2 2 Alt a 6 Alternaria Alt a 6 Alternaria Enolase Enolase Phl p 4 Timothy Phl p 4 Timothy Grass Grass Asp f 1 Aspergillus Asp f 1 Aspergillus Phl p 5 Timothy Phl p 5 Timothy Grass Grass Grass Grass group group5 5 Asp f 3 Aspergillus Asp f 3 Aspergillus Phl p Phl6 Timothy p 6 Timothy Grass Grass Asp f 6 Aspergillus Mn Asp f 6 Aspergillus Mn Superoxide Superoxide dismutase dismutase Phl p 7 Timothy Phl p 7 Timothy Grass Polcalcin Grass Polcalcin Cla h 8 Cladosporium Cla h 8 Cladosporium Phl p 11 Timothy Phl p 11 Timothy Grass Grass INSECTSINSECTS AND PARASITESAND PARASITES Phl p 12 Timothy Phl p 12 Timothy Grass Grass Proflin Proflin Api m Api1 Honey m 1 Honey bee venom bee venom Phospholipase Phospholipase A2 A2 TREE TREEPOLLEN POLLEN Api m Api4 Honey m 4 Honey bee venom bee venom Melittin Melittin Aln g 1 Alde Aln g 1 Alde Tree PR-10 Tree PR-10 protein protein Pol d 5 Paper Pol d 5 Paper wasp waspvenom Venom, venom Venom, Antigen Antigen 5 5 Bet v 1 Birch Tree PR-10 Bet v 1 Birch Tree PR-10 protein protein Ves Ves v 5 Common v 5 Common wasp waspvenom venom Venom, Venom, Antigen Antigen 5 5 Bet v 2 Birch Tree Profilin Bet v 2 Birch Tree Profilin Ani s 1 Anisakis Ani s 1 Anisakis Bet v 4 Birch Tree Polcalcin Bet v 4 Birch Tree Polcalcin Ani s 3 Anisakis Tropomyosin Ani s 3 Anisakis Tropomyosin Cor a Cor1.0101 Hazel a 1.0101 Hazel pollen PR-10 pollen PR-10 protein protein Bla g 1 Bla Cockroach g 1 Cockroach Cry j 1 Japanese Cry j 1 Japanese ceder ceder Bla g 2 Bla Cockroach g 2 Cockroach Cup a Cup 1 Cypress a 1 Cypress Tree Tree Bla g 7 Cockroach Tropomyosin Bla g 7 Cockroach Tropomyosin Ole e 1 Olive Ole e 1 Olive Tr e e Tr e e Bla g 5 Bla Cockroach g 5 Cockroach Ole e 7 Olive Tree Lipid Ole e 7 Olive Tree Lipid transfer transfer protein protein (LTP) (LTP) ANIMALSANIMALS Ole e 9 Olive Tree Ole e 9 Olive Tree Can f Can1 Dog Lipocalin f 1 Dog Lipocalin Pla a1 Plane Pla a1 Plane Tree Tree Can f Can2 Dog Lipocalin f 2 Dog Lipocalin Pla a 2 Plane Pla a 2 Plane Tree Tree Can f Can3 Dog Serum f 3 Dog Serum albumin albumin Pla a 3 Plane Pla a 3 Plane Tree Lipid Tree Lipid transfer transfer protein protein (LTP) (LTP) Can f Can5 Dog Arginine f 5 Dog Arginine esterase esterase WEEDWEED POLLEN POLLEN Equ c Equ3 Horse Serum c 3 Horse Serum albumin albumin Che a Che 1 Goosefoot a 1 Goosefoot Equ c Equ1 Horse Lipocalin c 1 Horse Lipocalin Amb a Amb 1 Ragweed a 1 Ragweed Fel d 1 Cat Fel d 1 Cat Uteroglobin Uteroglobin Pla l 1 Plantain Pla l 1 Plantain (English) (English) Fel d 2 Cat Fel d 2 Cat Serum Serum albumin albumin Art v 1 Art Mugwort v 1 Mugwort Fel d 4 Cat Fel d 4 Cat Lipocalin Lipocalin Art v 3 Mugwort Lipid Art v 3 Mugwort Lipid transfer transfer protein protein (LTP) (LTP) Mus m Mus 1 Mouse Lipocalin m 1 Mouse Lipocalin Mer a Mer1 Annual a 1 Annual mercury Profilin mercury Profilin CROSS-REACTIVECROSS-REACTIVE PLANTS PLANTS Par j 2 Wall Par j 2 Wall pellitory Lipid pellitory Lipid transfer transfer protein protein (LTP) (LTP) Bet v 4 Birch Polcalcin Bet v 4 Birch Polcalcin Sal k 1 Saltwort Sal k 1 Saltwort Phl p 7 Timothy Polcalcin Phl p 7 Timothy Polcalcin FRUITFRUIT Bet v 2 Birch Profilin Bet v 2 Birch Profilin Act d Act1 Kiwi d 1 Kiwi Hev b Hev 8 Latex Profilin b 8 Latex Profilin Act d Act2 Kiwi Thaumatine-like d 2 Kiwi Thaumatine-like protein protein Mer a Mer1 Annual a 1 Annual mercury Profilin mercury Profilin Act d Act5 Kiwi d 5 Kiwi Ole e 7 Olive Lipid Ole e 7 Olive Lipid transfer transfer protein protein (LTP) (LTP) Act d Act8 Kiwi PR-10 d 8 Kiwi PR-10 protein protein Phl p 12 Timothy Profilin Phl p 12 Timothy Profilin Api g 1 Celery PR-10 Api g 1 Celery PR-10 protein protein MUXF MUXF 3 Sugar 3 Sugar epitope epitope from Bromelain from Bromelain CCD-marker CCD-marker Mal d Mal1 Apple PR-10 d 1 Apple PR-10 protein protein Pru p Pru1 Peach PR-10 p 1 Peach PR-10 protein protein Pru p Pru3 Peach Lipid p 3 Peach Lipid transfer transfer protein protein (LTP) (LTP) MELISA,MELISA, SkinMELISA, Skin Prick Prick Test Skin Test and Prick and Patch Test Patch Test and Test Patch Test LISTLIST OF OFALLERGY LISTALLERGY OF TESTS ALLERGY TESTS TESTS ISACISAC Tests Tests ISACContinued... Continued... Tests Continued... LISTLIST OF OFALLERGY LISTALLERGY OF TESTS ALLERGY TESTS TESTS

HEAVYHEAVY METALS METALS HEAVY METALS SKIN SKINPRICK PRICK TEST TESTALLERGENS ALLERGENS MITESMITES SKIN PRICK TEST ALLERGENS MITES ONE COLLECTIVEONE COLLECTIVE TEST TESTTHAT THATINCLUDES INCLUDES 112 FOOD 112 FOOD AND INHALANTAND INHALANT ALLERGEN ALLERGEN COMPONENTS. COMPONENTS. ISAC ALLERGENISAC ALLERGEN COMPONENTS COMPONENTS • Aluminium• Aluminium • Aluminium ONE COLLECTIVE TEST THAT INCLUDES 112 FOOD AND INHALANT ALLERGEN COMPONENTS. ISAC ALLERGEN COMPONENTS • Arsenic• Arsenic INHALANTSINHALANTS • Arsenic INHALANTS HouseHouse dust mite dust mix miteHouse mix dust mite mix • Barium• Barium ANIMALANIMAL ALLERGENS ALLERGENS tropicalistropicalis ALLERGENALLERGEN COMPONENT COMPONENT ALLERGENALLERGEN SOURCE SOURCE PROTEIN PROTEIN GROUP GROUP • Barium ANIMAL ALLERGENS B. B. B.tropicalis ALLERGEN COMPONENT ALLERGEN SOURCE PROTEIN GROUP • Beryllium• Beryllium CockroachCockroach COMMON COMMON NAME NAME • Beryllium Cat Cat Cat Cockroach COMMON NAME • Chromium• Chromium • Chromium (A shortened(A shortened profile profile is also is available) also available) Dog Dog (A shortened profile is also available) NUTSNUTS AND LEGUMESAND LEGUMES • Cobalt• Cobalt • Cobalt Dog NUTS AND LEGUMES MOULDSMOULDS FOODSFOODS Ana o Ana2 Cashew o 2 Cashew nut Storage nut Storage protien protien 11 S globulin11 S globulin • Copper• Copper • Copper MOULDS FOODS Ana o 2 Cashew nut Storage protien 11 S globulin Alternaria alternata Cow’sCow’s milk milk Ara h 1 Peanut Storage Ara h 1 Peanut Storage protein, protein, 7 S globulin 7 S globulin • Ethyl• Ethyl Mercury Mercury • Ethyl Mercury Alternaria alternataAlternaria alternata Cow’s milk Ara h 1 Peanut Storage protein, 7 S globulin Egg Egg Ara h 2 Peanut Storage Ara h 2 Peanut Storage protein, protein, conglutin conglutin • Galium• Galium • Galium CladosporiumCladosporium Egg Ara h 2 Peanut Storage protein, conglutin Cladosporium Cod fishCod fish Ara h 3 Peanut Storage Ara h 3 Peanut Storage protein, protein, 11 S globulin11 S globulin • Gold• Gold • Gold AspergillusAspergillus Cod fish Ara h 3 Peanut Storage protein, 11 S globulin Aspergillus ShellfishShellfish Ara h 8 Peanut PR-10 Ara h 8 Peanut PR-10 protein protein • Iridium• Iridium • Iridium Shellfish Ara h 8 Peanut PR-10 protein FEATHERSFEATHERS Soya Soya Ara h 6 Peanut Storage Ara h 6 Peanut Storage protein, protein, conglutin conglutin • Indium• Indium • Indium FEATHERS Soya Ara h 6 Peanut Storage protein, conglutin FeatherFeather mix mix WheatWheat Ara h 9 Peanut Lipid Ara h 9 Peanut Lipid transfer transfer protein protein (LTP) (LTP) • Iron • Iron • Iron Feather mix Wheat Ara h 9 Peanut Lipid transfer protein (LTP) GRASSES PeanutPeanut Ber e1 Brazil Ber e1 Brazil nut Storage nut Storage protein, protein, 2S albumin 2S albumin • Inorganic• Inorganic Mercury Mercury• Inorganic Mercury GRASSES GRASSES Peanut Ber e1 Brazil nut Storage protein, 2S albumin Maize/CornMaize/Corn Cor a Cor1.0401 Hazelnut PR-10 a 1.0401 Hazelnut PR-10 protein protein • Lanthanum• Lanthanum • Lanthanum BermudaBermuda Grass Grass Maize/Corn Cor a 1.0401 Hazelnut PR-10 protein Bermuda Grass PotatoPotato Cor a Cor8 Hazelnut Lipid a 8 Hazelnut Lipid transfer transfer protein protein (LTP) (LTP) • Lead• Lead • Lead 6-grass6-grass mix mix Potato Cor a 8 Hazelnut Lipid transfer protein (LTP) 6-grass mix TomatoTomato Cor a Cor9 Hazelnut Storage a 9 Hazelnut Storage protein, protein, 11 S globulin11 S globulin • Manganese• Manganese • Manganese Tomato Cor a 9 Hazelnut Storage protein, 11 S globulin POLLENSPOLLENS OrangeOrange Jug r 1 Walnut Storage Jug r 1 Walnut Storage protein, protein, 2S albumin 2S albumin • Methyl• Methyl mercury mercury• Methyl mercury POLLENS Orange Jug r 1 Walnut Storage protein, 2S albumin Maize Maizepollen pollen AppleApple Jug r 2 Walnut Storage Jug r 2 Walnut Storage protein, protein, 7S globulin 7S globulin • Molybdenum• Molybdenum • Molybdenum Maize pollen Apple Jug r 2 Walnut Storage protein, 7S globulin Weed mix BananaBanana Jug r 3 Walnut Lipid Jug r 3 Walnut Lipid transfer transfer protein protein (LTP) (LTP) • Nickel• Nickel • Nickel Weed mix Weed mix Banana Jug r 3 Walnut Lipid transfer protein (LTP) BakersBakers yeast yeast Gly m Gly4 Soybean Pr-10 m 4 Soybean Pr-10 protein protein • Platinum• Platinum • Platinum Plane Planetree pollen tree pollen Bakers yeast Gly m 4 Soybean Pr-10 protein Plane tree pollen (A Shortened(A Shortened profile profile is available) is available) Gly m Gly5 Soybean Storage m 5 Soybean Storage protein, protein, B-conglycinin B-conglycinin • Phenyl• Phenyl Mercury Mercury• Phenyl Mercury Oak pollenOak pollen (A Shortened profile is available) Gly m 5 Soybean Storage protein, B-conglycinin Oak pollen Gly m Gly6 Soybean Storage m 6 Soybean Storage protein, protein, Glycinin Glycinin • Palladium• Palladium • Palladium PATCHPATCH TESTS: TESTS: Gly m 6 Soybean Storage protein, Glycinin • Platinum Olive pollenOlive pollen PATCH TESTS: Ses i 1 Ses Sesame i 1 Sesame seed Storage seed Storage protein, protein, 2S albumin 2S albumin • Platinum • Platinum Olive pollen European baseline, sunscreen, Ses i 1 Sesame seed Storage protein, 2S albumin CypressCypress pollen pollen European baseline,European sunscreen, baseline, sunscreen, GRAINSGRAINS • Ruthenium• Ruthenium • Ruthenium Cypress pollen GRAINS Acacia pollen cosmeticcosmetic and hairdressing and hairdressing series. series. Fag e Fag2 Buckwheat Storage e 2 Buckwheat Storage Protein, Protein, 2S albumin 2S albumin • Silver• Silver • Silver Acacia pollen Acacia pollen cosmetic and hairdressing series. Fag e 2 Buckwheat Storage Protein, 2S albumin Tri Tri a 14 Wheat a 14 Wheat Crude Crude gliadin gliadin (LTP) (LTP) • Tin • Tin • Tin EucalyptusEucalyptus Tri a 14 Wheat Crude gliadin (LTP) Eucalyptus Tria a 19.0101 Wheat Tria a 19.0101 Wheat Omega-5 Omega-5 gliadin gliadin • Titanium• Titanium • Titanium SPECIMENSPECIMEN REQUIREMENTS: REQUIREMENTS: Tria a 19.0101 Wheat Omega-5 gliadin SPECIMEN REQUIREMENTS: Tria a aA_TI Wheat Tria a aA_TI Wheat • Thimerosal• Thimerosal mercury mercury• Thimerosal mercuryTEST TEST SPECIMEN SPECIMEN SPECIAL SPECIAL INSTRUCTIONS INSTRUCTIONS Tria a aA_TI Wheat TEST SPECIMEN SPECIAL INSTRUCTIONS OCCUPATIONALOCCUPATIONAL • Vanadium• Vanadium • Vanadium IgE IgE SST/Clotted SST/Clotted Tube/1ml Tube/1ml OCCUPATIONAL IgE SST/Clotted Tube/1ml Hev b Hev1 Latex b 1 Latex • Zinc• Zinc • Zinc RAST RAST SST/Clotted SST/Clotted Tube/5ml Tube/5ml - - Hev b 1 Latex RAST SST/Clotted Tube/5ml - Hev b Hev3 Latex b 3 Latex • Zirconium• Zirconium • Zirconium depending depending on the on number the number of allergens of allergens requested requested Hev b 3 Latex depending on the number of allergens requested Hev b Hev8 Latex Profilin b 8 Latex Profilin ANTISEPTICSANTISEPTICS ANTISEPTICS ECP ECP SST/Clotted SST/Clotted Tube/1ml Blood Tube/1ml Blood must bemust taken be takenin a SST in a SST Hev b 8 Latex Profilin • Mercurochrome ECP SST/Clotted Tube/1ml Blood must be taken in a SST Hev b Hev5 Latex b 5 Latex • Mercurochrome• Mercurochrome tube tube and serum and serum must bemust be Hev b 5 Latex • Iodine tube and serum must be Hev b Hev6.01 Latex b 6.01 Latex • Iodine • Iodine separated within 1 hour. Hev b 6.01 Latex • Clorhexidine separated separated within 1 hour. within 1 hour. Bos d Bos4 Cow’s d 4 Cow’s milk milk lactalbuminlactalbumin • Clorhexidine • Clorhexidine Bos d 4 Cow’s milk a- a- a-lactalbumin Mast Cell Mast Cell SST/Clotted Mast SST/Clotted Cell Tube/1ml Tube/1ml SST/Clotted Tube/1ml Bos d Bos5 Cow’s d 5 Cow’s milk milk B-lactoglobulin B-lactoglobulin TryptaseTryptase Bos d 5 Cow’s milk B-lactoglobulin Tryptase Bos d Bos6 Cow’s d 6 Cow’s Bos d 6 Cow’s milk and milk meat Serum and meat Serum milk and meat Serum albumin albumin albumin ISAC ISAC SST/Clotted SST/Clotted Tube/1ml Tube/1ml or less or less Bos d Bos8 Cow’s d 8 Cow’s milk Casein milk Casein See listSee of listCAST of CAST allergens:See allergens: list of CAST allergens: ISAC SST/Clotted Tube/1ml or less Bos d 8 Cow’s milk Casein CAST CAST Heparin Heparin Tube/5ml Must Tube/5ml Must reach reachthe lab the within lab within24 24 Bos d Boslactoferrin d lactoferrin Cow’s Cow’s milk Transferrin milk Transferrin all allergensall allergens available availableall on allergens CAST on CAST available on CAST CAST Heparin Tube/5ml Must reach the lab within 24 Bos d lactoferrin Cow’s milk Transferrin hours hours on week on daysweek anddays before and before EGG EGG is alsois available also available for MELISAis for also MELISA available for MELISA hours on week days and before EGG 12:00 12:00 on Fridays. on Fridays. Gal d Gal1 Egg d 1 Egg white Ovomucoid white Ovomucoid testing,testing, including including diversetesting, diverse drug including drug diverse drug 12:00 on Fridays. Gal d 1 Egg white Ovomucoid MELISA Citrate Tube/5ml (4-6 depending on the number Must reach the lab within 24 Gal d Gal2 Egg d 2 Egg white Ovalbumin white Ovalbumin allergyallergy testing. testing. allergy testing. MELISA MELISA Citrate Tube/5ml Citrate (4-6 depending Tube/5ml (4-6on the depending number on the Must number reach the lab Must within reach 24 the lab within 24 Gal d 2 Egg white Ovalbumin Gal d Gal3 Egg d 3 Egg white Conalbumin white Conalbumin of of allergens of allergens requested) requested) allergens requested) hours hourson week on daysweek anddayshours before and on beforeweek days and before Gal d 3 Egg white Conalbumin Gal d Gal5 Egg d 5 Egg yolk Serum yolk Serum albumin albumin 205 | Ampath Desk Reference 12:00 12:00 12:00 on Fridays. on Fridays. on Fridays. Gal d 5 Egg yolk Serum albumin FISH FISH FISH Gad c Gad 1 Cod Parvalbumin c 1 Cod Parvalbumin Gad c 1 Cod Parvalbumin Ani s 3 Anisakis Ani s 3 Anisakis Ani s 3 Anisakis (Fish parasite) (Fish parasite) Tropomyosin Tropomyosin (Fish parasite) Tropomyosin Ani s 1 Anisakis Ani s 1 Anisakis Ani s 1 Anisakis (Fish parasite) (Fish parasite) (Fish parasite) Pen m Pen 2 Shrimp Arginine m 2 Shrimp Arginine Pen m 2 Shrimp Arginine kinase kinase kinase ISACISAC Tests TestsISAC Tests LISTLIST OF OFALLERGY LISTALLERGY OF TESTS ALLERGY TESTS TESTS Pen m Pen 4 Shrimp Sarcoplasmic m 4 Shrimp Sarcoplasmic Pen m 4 Shrimp Sarcoplasmic Ca-binding Ca-binding protein protein Ca-binding protein Pen m Pen 1 Shrimp Tropomyosin m 1 Shrimp Tropomyosin Pen m 1 Shrimp Tropomyosin MITESMITES MITES Der f 1 House Der f 1 House Der f 1 House dust mite dust (D.farinae) mite (D.farinae) dust mite (D.farinae) Der f 2 House Der f 2 House Der f 2 House dust mite dust (D.farinae) mite (D.farinae) dust mite (D.farinae) ONE COLLECTIVEONE COLLECTIVE TESTONE TESTTHAT COLLECTIVE THATINCLUDES INCLUDES TEST 112 THAT FOOD 112 INCLUDES FOOD AND INHALANTAND 112 INHALANT FOOD ALLERGEN AND ALLERGEN INHALANT COMPONENTS. COMPONENTS. ALLERGEN ISAC COMPONENTS. ALLERGENISAC ALLERGEN COMPONENTS ISAC COMPONENTS ALLERGEN COMPONENTS Der p Der1 House p 1 House Der p 1 House dust mite dust (D.pteronyssinus) mite (D.pteronyssinus) dust mite (D.pteronyssinus) Der p Der2 House p 2 House dust mite dust (D.pteronyssinus) mite (D.pteronyssinus) ALLERGEN ALLERGEN COMPONENT COMPONENT ALLERGEN COMPONENTALLERGEN ALLERGEN SOURCE SOURCEALLERGEN SOURCE PROTEIN PROTEIN GROUP GROUP PROTEIN GROUP Der p 2 House dust mite (D.pteronyssinus) Der p Der10 House p 10 House dust mite dust (D.pteronyssinus) mite (D.pteronyssinus) Tropomyosin Tropomyosin COMMON COMMON NAME NAME COMMON NAME Der p 10 House dust mite (D.pteronyssinus) Tropomyosin Blo t 5 House Blo t 5 House dust mite dust (B.tropicalis) mite (B.tropicalis) GRASSGRASS POLLEN POLLEN Blo t 5 House dust mite (B.tropicalis) GRASS POLLEN Lep d Lep2 Storage d 2 Storage Lep d 2 Storage mite mite mite Cyn d Cyn1 Bermuda d 1 Bermuda Cyn d 1 Bermuda Grass Grass Grass Grass Grass Grass group group1 1 group 1 MOULDSMOULDS Phl p 1 Timothy Phl p 1 Timothy Grass Grass Grass Grass group group1 1 MOULDS Phl p 1 Timothy Grass Grass group 1 Alt a 1 Alternaria Alt a 1 Alternaria Alt a 1 Alternaria Phl p 2 Timothy Phl p 2 Timothy Phl p 2 Timothy Grass Grass Grass Grass Grass Grass group group2 2 group 2 Alt a 6 Alternaria Alt a 6 Alternaria Enolase Enolase Phl p 4 Timothy Phl p 4 Timothy Grass Grass Alt a 6 Alternaria Enolase Phl p 4 Timothy Grass Asp f 1 Aspergillus Asp f 1 Aspergillus Asp f 1 Aspergillus Phl p 5 Timothy Phl p 5 Timothy Phl p 5 Timothy Grass Grass Grass Grass Grass Grass group group5 5 group 5 Asp f 3 Aspergillus Asp f 3 Aspergillus Phl p Phl6 Timothy p 6 Timothy Grass Grass Asp f 3 Aspergillus Phl p 6 Timothy Grass Asp f 6 Aspergillus Mn Asp f 6 Aspergillus Mn Asp f 6 Aspergillus Mn Superoxide Superoxide dismutase dismutase Superoxide dismutase Phl p 7 Timothy Phl p 7 Timothy Phl p 7 Timothy Grass Polcalcin Grass Polcalcin Grass Polcalcin Cla h 8 Cladosporium Cla h 8 Cladosporium Phl p 11 Timothy Phl p 11 Timothy Grass Grass Cla h 8 Cladosporium Phl p 11 Timothy Grass INSECTSINSECTS AND PARASITESAND INSECTSPARASITES AND PARASITES Phl p 12 Timothy Phl p 12 Timothy Phl p 12 Timothy Grass Grass Grass Proflin Proflin Proflin Api m Api1 Honey m 1 Honey bee venom bee venom Phospholipase Phospholipase A2 A2 TREE TREEPOLLEN POLLEN Api m 1 Honey bee venom Phospholipase A2 TREE POLLEN Api m Api4 Honey m 4 Honey Api m 4 Honey bee venom bee venom bee venom Melittin Melittin Melittin Aln g 1 Alde Aln g 1 Alde Aln g 1 Alde Tree PR-10 Tree PR-10 Tree PR-10 protein protein protein Pol d 5 Paper Pol d 5 Paper wasp waspvenom Venom, venom Venom, Antigen Antigen 5 5 Bet v 1 Birch Tree PR-10 Bet v 1 Birch Tree PR-10 protein protein Pol d 5 Paper wasp venom Venom, Antigen 5 Bet v 1 Birch Tree PR-10 protein Ves Ves v 5 Common v 5 Common Ves v 5 Common wasp waspvenom venom wasp venom Venom, Venom, Antigen Antigen 5 Venom, 5 Antigen 5 Bet v 2 Birch Tree Profilin Bet v 2 Birch Tree Profilin Bet v 2 Birch Tree Profilin Ani s 1 Anisakis Ani s 1 Anisakis Bet v 4 Birch Tree Polcalcin Bet v 4 Birch Tree Polcalcin Ani s 1 Anisakis Bet v 4 Birch Tree Polcalcin Ani s 3 Anisakis Tropomyosin Ani s 3 Anisakis Tropomyosin Ani s 3 Anisakis Tropomyosin Cor a Cor1.0101 Hazel a 1.0101 Hazel Cor a 1.0101 Hazel pollen PR-10 pollen PR-10 pollen PR-10 protein protein protein Bla g 1 Bla Cockroach g 1 Cockroach Cry j 1 Japanese Cry j 1 Japanese ceder ceder Bla g 1 Cockroach Cry j 1 Japanese ceder Bla g 2 Bla Cockroach g 2 Cockroach Bla g 2 Cockroach Cup a Cup 1 Cypress a 1 Cypress Cup a 1 Cypress Tree Tree Tree Bla g 7 Cockroach Tropomyosin Bla g 7 Cockroach Tropomyosin Ole e 1 Olive Ole e 1 Olive Tr e e Tr e e Bla g 7 Cockroach Tropomyosin Ole e 1 Olive Tr e e Bla g 5 Bla Cockroach g 5 Cockroach Bla g 5 Cockroach Ole e 7 Olive Tree Lipid Ole e 7 Olive Tree Lipid Ole e 7 Olive Tree Lipid transfer transfer protein protein (LTP) (LTP)transfer protein (LTP) ANIMALSANIMALS Ole e 9 Olive Tree Ole e 9 Olive Tree ANIMALS Ole e 9 Olive Tree Can f Can1 Dog Lipocalin f 1 Dog Lipocalin Can f 1 Dog Lipocalin Pla a1 Plane Pla a1 Plane Pla a1 Plane Tree Tree Tree Can f Can2 Dog Lipocalin f 2 Dog Lipocalin Pla a 2 Plane Pla a 2 Plane Tree Tree Can f 2 Dog Lipocalin Pla a 2 Plane Tree Can f Can3 Dog Serum f 3 Dog Serum Can f 3 Dog Serum albumin albumin albumin Pla a 3 Plane Pla a 3 Plane Pla a 3 Plane Tree Lipid Tree Lipid Tree Lipid transfer transfer protein protein (LTP) (LTP)transfer protein (LTP) Can f Can5 Dog Arginine f 5 Dog Arginine esterase esterase WEEDWEED POLLEN POLLEN Can f 5 Dog Arginine esterase WEED POLLEN Equ c Equ3 Horse Serum c 3 Horse Serum Equ c 3 Horse Serum albumin albumin albumin Che a Che1 Goosefoot a 1 Goosefoot Che a 1 Goosefoot Equ c Equ1 Horse Lipocalin c 1 Horse Lipocalin Amb a Amb 1 Ragweed a 1 Ragweed Equ c 1 Horse Lipocalin Amb a 1 Ragweed Fel d 1 Cat Fel d 1 Cat Fel d 1 Cat Uteroglobin Uteroglobin Uteroglobin Pla l 1 Plantain Pla l 1 Plantain Pla l 1 Plantain (English) (English) (English) Fel d 2 Cat Fel d 2 Cat Serum Serum albumin albumin Art v 1 Art Mugwort v 1 Mugwort Fel d 2 Cat Serum albumin Art v 1 Mugwort Fel d 4 Cat Fel d 4 Cat Fel d 4 Cat Lipocalin Lipocalin Lipocalin Art v 3 Mugwort Lipid Art v 3 Mugwort Lipid Art v 3 Mugwort Lipid transfer transfer protein protein (LTP) (LTP)transfer protein (LTP) Mus m Mus 1 Mouse Lipocalin m 1 Mouse Lipocalin Mer a Mer1 Annual a 1 Annual mercury Profilin mercury Profilin Mus m 1 Mouse Lipocalin Mer a 1 Annual mercury Profilin CROSS-REACTIVECROSS-REACTIVE PLANTSCROSS-REACTIVE PLANTS PLANTS Par j 2 Wall Par j 2 Wall Par j 2 Wall pellitory Lipid pellitory Lipid pellitory Lipid transfer transfer protein protein (LTP) (LTP)transfer protein (LTP) Bet v 4 Birch Polcalcin Bet v 4 Birch Polcalcin Sal k 1 Saltwort Sal k 1 Saltwort Bet v 4 Birch Polcalcin Sal k 1 Saltwort Phl p 7 Timothy Polcalcin Phl p 7 Timothy Polcalcin Phl p 7 Timothy Polcalcin FRUITFRUIT FRUIT Bet v 2 Birch Profilin Bet v 2 Birch Profilin Act d Act1 Kiwi d 1 Kiwi Bet v 2 Birch Profilin Act d 1 Kiwi Hev b Hev8 Latex Profilin b 8 Latex Profilin Hev b 8 Latex Profilin Act d Act2 Kiwi Thaumatine-like d 2 Kiwi Thaumatine-like Act d 2 Kiwi Thaumatine-like protein protein protein Mer a Mer1 Annual a 1 Annual mercury Profilin mercury Profilin Act d Act5 Kiwi d 5 Kiwi Mer a 1 Annual mercury Profilin Act d 5 Kiwi Ole e 7 Olive Lipid Ole e 7 Olive Lipid Ole e 7 Olive Lipid transfer transfer protein protein (LTP) (LTP)transfer protein (LTP) Act d Act8 Kiwi PR-10 d 8 Kiwi PR-10 Act d 8 Kiwi PR-10 protein protein protein Phl p 12 Timothy Profilin Phl p 12 Timothy Profilin Api g 1 Celery PR-10 Api g 1 Celery PR-10 protein protein Phl p 12 Timothy Profilin Api g 1 Celery PR-10 protein MUXF MUXF 3 Sugar 3 Sugar MUXF 3 Sugar epitope epitope from Bromelain from Bromelain epitope from CCD-markerBromelain CCD-marker CCD-marker Mal d Mal1 Apple PR-10 d 1 Apple PR-10 Mal d 1 Apple PR-10 protein protein protein Pru p Pru1 Peach PR-10 p 1 Peach PR-10 Pru p 1 Peach PR-10 protein protein protein Pru p Pru3 Peach Lipid p 3 Peach Lipid Pru p 3 Peach Lipid transfer transfer protein protein (LTP) (LTP)transfer protein (LTP) Guide to laboratory tests | 206 MELISA, Skin Prick Test and Patch Test LIST OF ALLERGY TESTS ISAC Tests Continued... LIST OF ALLERGY TESTS

MELISA, Skin Prick Test and Patch Test LIST OF ALLERGY TESTS ISAC Tests Continued... LIST OF ALLERGY TESTS HEAVY METALS SKIN PRICK TEST ALLERGENS MITES • Aluminium ONE COLLECTIVE TEST THAT INCLUDES 112 FOOD AND INHALANT ALLERGEN COMPONENTS. ISAC ALLERGEN COMPONENTS • Arsenic INHALANTS House dust mite mix • Barium ANIMAL ALLERGENS B.tropicalis ALLERGEN COMPONENT ALLERGEN SOURCE PROTEIN GROUP • Beryllium HEAVY METALS Cat SKIN PRICK TEST ALLERGENSCockroach MITES COMMON NAME • Chromium • Aluminium ONE COLLECTIVE TEST THAT INCLUDES 112 FOOD AND INHALANT ALLERGEN COMPONENTS. ISAC ALLERGEN COMPONENTS Dog (A shortened profile is also available) • Cobalt • Arsenic INHALANTS House dust mite mix NUTS AND LEGUMES MOULDS FOODS Ana o 2 Cashew nut Storage protien 11 S globulin • Copper • Barium ANIMAL ALLERGENS B.tropicalis ALLERGEN COMPONENT ALLERGEN SOURCE PROTEIN GROUP Cow’s milk • Ethyl Mercury • Beryllium Alternaria alternata Cat Cockroach Ara h 1 Peanut Storage COMMON NAME protein, 7 S globulin • Galium • Chromium Cladosporium Egg (A shortened profile is also available) Ara h 2 Peanut Storage protein, conglutin Dog Cod fish • Gold • Cobalt Aspergillus Ara h 3 Peanut StorageNUTS AND LEGUMES protein, 11 S globulin • Iridium • Copper MOULDS Shellfish FOODS Ara h 8 Peanut PR-10 Ana o 2 Cashew nut Storage protein protien 11 S globulin • Indium • Ethyl Mercury FEATHERS Alternaria alternata Soya Cow’s milk Ara h 6 Peanut Storage Ara h 1 Peanut Storage protein, conglutin protein, 7 S globulin • Iron • Galium Feather mix Cladosporium Wheat Egg Ara h 9 Peanut Lipid Ara h 2 Peanut Storage transfer protein (LTP) protein, conglutin Peanut Cod fish • Inorganic Mercury • Gold GRASSES Aspergillus Ber e1 Brazil Ara h 3 Peanut Storage nut Storage protein, 2S albumin protein, 11 S globulin • Lanthanum • Iridium Bermuda Grass Maize/Corn Shellfish Cor a 1.0401 Hazelnut PR-10 Ara h 8 Peanut PR-10 protein protein FEATHERS Potato • Lead • Indium 6-grass mix Soya Cor a 8 Hazelnut Lipid Ara h 6 Peanut Storage transfer protein (LTP) protein, conglutin • Manganese • Iron Feather mix Tomato Wheat Cor a 9 Hazelnut Storage Ara h 9 Peanut Lipid protein, 11 S globulin transfer protein (LTP) • Methyl mercury • Inorganic Mercury POLLENS GRASSES Orange Peanut Jug r 1 Walnut Storage Ber e1 Brazil nut Storage protein, 2S albumin protein, 2S albumin • Molybdenum • Lanthanum Maize pollen Bermuda Grass Apple Maize/Corn Jug r 2 Walnut Storage Cor a 1.0401 Hazelnut PR-10 protein, 7S globulin protein Banana Potato • Nickel • Lead Weed mix 6-grass mix Jug r 3 Walnut Lipid Cor a 8 Hazelnut Lipid transfer protein (LTP) transfer protein (LTP) • Platinum • Manganese Plane tree pollen Bakers yeast Tomato Gly m 4 Soybean Pr-10 Cor a 9 Hazelnut Storage protein protein, 11 S globulin • Phenyl Mercury • Methyl mercury POLLENS (A Shortened profile isOrange available) Gly m 5 Soybean Storage Jug r 1 Walnut Storage protein, B-conglycinin protein, 2S albumin Oak pollen Maize pollen • Palladium • Molybdenum PATCH TESTS: Apple Gly m 6 Soybean Storage Jug r 2 Walnut Storage protein, Glycinin protein, 7S globulin • Platinum • Nickel Olive pollen Weed mix Banana Ses i 1 Sesame Jug r 3 Walnut Lipid seed Storage protein, 2S albumin transfer protein (LTP) European baseline, sunscreen, • Ruthenium • Platinum Cypress pollen Plane tree pollen Bakers yeast GRAINS Gly m 4 Soybean Pr-10 protein cosmetic and hairdressing(A Shortened series. profile is available) • Silver • Phenyl Mercury Acacia pollen Oak pollen Fag e 2 Buckwheat Storage Gly m 5 Soybean Storage Protein, 2S albumin protein, B-conglycinin • Tin • Palladium Eucalyptus PATCH TESTS: Tri a 14 Wheat Gly m 6 Soybean Storage Crude gliadin (LTP) protein, Glycinin • Titanium • Platinum Olive pollen Tria a 19.0101 Wheat Ses i 1 Sesame Omega-5 seed Storage gliadin protein, 2S albumin SPECIMEN REQUIREMENTS:European baseline, sunscreen, • Thimerosal mercury• Ruthenium TEST SPECIMEN Cypress pollen SPECIAL INSTRUCTIONS Tria a aA_TI WheatGRAINS cosmetic and hairdressing series. • Vanadium • Silver IgE SST/Clotted Tube/1mlAcacia pollen OCCUPATIONAL Fag e 2 Buckwheat Storage Protein, 2S albumin • Zinc • Tin RAST SST/Clotted Tube/5mlEucalyptus - Hev b 1 Latex Tri a 14 Wheat Crude gliadin (LTP) • Zirconium • Titanium depending on the number of allergens requested SPECIMEN REQUIREMENTS: Hev b 3 Latex Tria a 19.0101 Wheat Omega-5 gliadin ANTISEPTICS • Thimerosal mercuryECP SST/ClottedTEST Tube/1ml Blood SPECIMEN must be taken SPECIALin a SST INSTRUCTIONS Hev b 8 Latex Profilin Tria a aA_TI Wheat Hev b 5 Latex OCCUPATIONAL • Mercurochrome • Vanadium tubeIgE SST/Clotted Tube/1ml and serum must be • Iodine • Zinc Hev b 6.01 Latex Hev b 1 Latex separatedRAST SST/Clotted Tube/5ml - within 1 hour. • Clorhexidine • Zirconium Bos d 4 Cow’s Hev b 3 Latex milk a-lactalbumin Mast Cell SST/Clotted depending Tube/1ml on the number of allergens requested ANTISEPTICS ECP SST/Clotted Tube/1ml Blood must be taken in a SST Bos d 5 Cow’s Hev b 8 Latex Profilin milk B-lactoglobulin Tryptase Bos d 6 Cow’s Hev b 5 Latex milk and meat Serum albumin • Mercurochrome tube and serum must be See list of CAST allergens:• Iodine ISAC SST/Clotted Tube/1ml or less Bos d 8 Cow’s Hev b 6.01 Latex milk Casein separated within 1 hour. all allergens available• Clorhexidine on CAST CAST Heparin Tube/5ml Must reach the lab within 24 Bos d lactoferrin Bos d 4 Cow’s Cow’s milk Transferrin milk a-lactalbumin is also available for MELISA hoursMast Cell SST/Clotted Tube/1ml on week days and before EGG Bos d 5 Cow’s milk B-lactoglobulin testing, including diverse drug 12:00Tryptase on Fridays. Gal d 1 Egg Bos d 6 Cow’s white Ovomucoid milk and meat Serum albumin allergy testing. See list of CAST allergens:MELISA CitrateISAC Tube/5ml (4-6 SST/Clotteddepending on Tube/1ml the number or less Must reach the lab within 24 Gal d 2 Egg Bos d 8 Cow’s white Ovalbumin milk Casein all allergens available of on CAST allergensCAST requested) Heparin Tube/5ml Musthours on week days and before reach the lab within 24 Gal d 3 Egg Bos d lactoferrin white Conalbumin Cow’s milk Transferrin is also available for MELISA 12:00 hours on Fridays. on week days and before Gal d 5 EggEGG yolk Serum albumin testing, including diverse drug 12:00 on Fridays. FISH Gal d 1 Egg white Ovomucoid allergy testing. MELISA Citrate Tube/5ml (4-6 depending on the number Must reach the lab within 24 Gad c 1 Cod Parvalbumin Gal d 2 Egg white Ovalbumin of allergens requested) hours on week days and before Ani s 3 Anisakis Gal d 3 Egg (Fish parasite) Tropomyosin white Conalbumin 12:00 on Fridays. Ani s 1 Anisakis Gal d 5 Egg (Fish parasite) yolk Serum albumin Pen m 2 Shrimp ArginineFISH kinase ISAC Tests LIST OF ALLERGY TESTS Pen m 4 Shrimp Sarcoplasmic Gad c 1 Cod Parvalbumin Ca-binding protein Pen m 1 Shrimp Tropomyosin Ani s 3 Anisakis (Fish parasite) Tropomyosin MITES Ani s 1 Anisakis (Fish parasite) Der f 1 House Pen m 2 Shrimp Arginine dust mite (D.farinae) kinase Der f 2 House Pen m 4 Shrimp Sarcoplasmic dust mite (D.farinae) Ca-binding protein ONE COLLECTIVEISAC Tests TEST THAT INCLUDES 112 FOOD AND INHALANT ALLERGEN COMPONENTS. ISAC ALLERGENLIST COMPONENTS OF ALLERGY TESTS Der p 1 House Pen m 1 Shrimp Tropomyosin dust mite (D.pteronyssinus) ALLERGEN COMPONENT ALLERGEN SOURCE PROTEIN GROUP Der p 2 HouseMITES dust mite (D.pteronyssinus) COMMON NAME Der p 10 House Der f 1 House dust mite (D.pteronyssinus) dust mite (D.farinae) Tropomyosin Blo t 5 House Der f 2 House dust mite (B.tropicalis) dust mite (D.farinae) ONE COLLECTIVE TEST THAT INCLUDES 112 FOOD AND INHALANT ALLERGEN COMPONENTS. ISAC ALLERGEN COMPONENTS GRASS POLLEN Lep d 2 Storage Der p 1 House mite dust mite (D.pteronyssinus) Cyn d 1 Bermuda ALLERGEN COMPONENT Grass GrassALLERGEN SOURCE group 1 PROTEIN GROUP MOULDS Der p 2 House dust mite (D.pteronyssinus) Phl p 1 Timothy Grass Grass COMMON NAME group 1 Alt a 1 Alternaria Der p 10 House dust mite (D.pteronyssinus) Tropomyosin Phl p 2 Timothy Grass Grass group 2 Alt a 6 Alternaria Blo t 5 House Enolase dust mite (B.tropicalis) Phl p 4 TimothyGRASS POLLEN Grass Asp f 1 Aspergillus Lep d 2 Storage mite Phl p 5 Timothy Cyn d 1 Bermuda Grass Grass Grass Grass group 5 group 1 Asp f 3 Aspergillus MOULDS Phl p 6 Timothy Phl p 1 Timothy Grass Grass Grass group 1 Asp f 6 Aspergillus Mn Alt a 1 Alternaria Superoxide dismutase Phl p 7 Timothy Phl p 2 Timothy Grass Polcalcin Grass Grass group 2 Cla h 8 Cladosporium Alt a 6 Alternaria Enolase Phl p 11 Timothy Phl p 4 Timothy Grass Grass INSECTS AND PARASITES Asp f 1 Aspergillus Phl p 12 Timothy Phl p 5 Timothy Grass Grass Grass Proflin group 5 Api m 1 Honey Asp f 3 Aspergillus bee venom Phospholipase A2 TREE POLLEN Phl p 6 Timothy Grass Api m 4 Honey Asp f 6 Aspergillus Mn bee venom Melittin Superoxide dismutase Aln g 1 Alde Phl p 7 Timothy Tree PR-10 Grass Polcalcin protein Pol d 5 Paper Cla h 8 Cladosporium wasp venom Venom, Antigen 5 Bet v 1 Birch Tree PR-10 Phl p 11 Timothy Grass protein Ves v 5 CommonINSECTS AND PARASITES wasp venom Venom, Antigen 5 Bet v 2 Birch Tree Profilin Phl p 12 Timothy Grass Proflin Ani s 1 Anisakis Api m 1 Honey bee venom Phospholipase A2 Bet v 4 Birch Tree PolcalcinTREE POLLEN Ani s 3 Anisakis Tropomyosin Api m 4 Honey bee venom Melittin Cor a 1.0101 Hazel Aln g 1 Alde pollen PR-10 Tree PR-10 protein protein Bla g 1 Cockroach Pol d 5 Paper wasp venom Venom, Antigen 5 Cry j 1 Japanese Bet v 1 Birch Tree PR-10 ceder protein Bla g 2 Cockroach Ves v 5 Common wasp venom Venom, Antigen 5 Cup a 1 Cypress Bet v 2 Birch Tree Profilin Tree Bla g 7 Cockroach Tropomyosin Ani s 1 Anisakis Ole e 1 Olive Bet v 4 Birch Tree Polcalcin Tr e e Bla g 5 Cockroach Ani s 3 Anisakis Tropomyosin Ole e 7 Olive Tree Lipid Cor a 1.0101 Hazel pollen PR-10 transfer protein (LTP) protein ANIMALS Bla g 1 Cockroach Ole e 9 Olive Tree Cry j 1 Japanese ceder Can f 1 Dog Lipocalin Bla g 2 Cockroach Pla a1 Plane Cup a 1 Cypress Tree Tree Can f 2 Dog Lipocalin Bla g 7 Cockroach Tropomyosin Pla a 2 Plane Ole e 1 Olive Tree Tr e e Can f 3 Dog Serum Bla g 5 Cockroach albumin Pla a 3 Plane Ole e 7 Olive Tree Lipid Tree Lipid transfer protein (LTP) transfer protein (LTP) Can f 5 Dog ArginineANIMALS esterase WEED POLLEN Ole e 9 Olive Tree Equ c 3 Horse Serum Can f 1 Dog Lipocalin albumin Che a 1 Goosefoot Pla a1 Plane Tree Equ c 1 Horse Lipocalin Can f 2 Dog Lipocalin Amb a 1 Ragweed Pla a 2 Plane Tree Fel d 1 Cat Can f 3 Dog Serum Uteroglobin albumin Pla l 1 Plantain Pla a 3 Plane (English) Tree Lipid transfer protein (LTP) Fel d 2 Cat Can f 5 Dog Arginine Serum albumin esterase Art v 1 Mugwort WEED POLLEN Fel d 4 Cat Equ c 3 Horse Serum Lipocalin albumin Art v 3 Mugwort Lipid Che a 1 Goosefoot transfer protein (LTP) Mus m 1 Mouse Lipocalin Equ c 1 Horse Lipocalin Mer a 1 Annual Amb a 1 Ragweed mercury Profilin CROSS-REACTIVE PLANTS Fel d 1 Cat Uteroglobin Par j 2 Wall Pla l 1 Plantain pellitory Lipid (English) transfer protein (LTP) Bet v 4 Birch Polcalcin Fel d 2 Cat Serum albumin Sal k 1 Saltwort Art v 1 Mugwort Phl p 7 Timothy Polcalcin Fel d 4 Cat Lipocalin FRUIT Art v 3 Mugwort Lipid transfer protein (LTP) Bet v 2 Birch Profilin Mus m 1 Mouse Lipocalin Act d 1 Kiwi Mer a 1 Annual mercury Profilin Hev b 8 Latex ProfilinCROSS-REACTIVE PLANTS Act d 2 Kiwi Thaumatine-like Par j 2 Wall pellitory Lipid protein transfer protein (LTP) Mer a 1 Annual Bet v 4 Birch Polcalcin mercury Profilin Act d 5 Kiwi Sal k 1 Saltwort Ole e 7 Olive Lipid Phl p 7 Timothy Polcalcin transfer protein (LTP) Act d 8 Kiwi PR-10FRUIT protein Phl p 12 Timothy Profilin Bet v 2 Birch Profilin Api g 1 Celery PR-10 Act d 1 Kiwi protein MUXF 3 Sugar Hev b 8 Latex Profilin epitope from Bromelain CCD-marker Mal d 1 Apple PR-10 Act d 2 Kiwi Thaumatine-like protein protein Mer a 1 Annual mercury Profilin Pru p 1 Peach PR-10 Act d 5 Kiwi protein Ole e 7 Olive Lipid transfer protein (LTP) Pru p 3 Peach Lipid Act d 8 Kiwi PR-10 transfer protein (LTP) protein Phl p 12 Timothy Profilin Api g 1 Celery PR-10 protein MUXF 3 Sugar epitope from Bromelain CCD-marker Mal d 1 Apple PR-10 protein Pru p 1 Peach PR-10 protein Pru p 3 Peach Lipid transfer protein (LTP) MELISA, Skin Prick Test and Patch Test LIST OF ALLERGY TESTS ISAC Tests Continued... LIST OF ALLERGY TESTS

HEAVY METALS SKIN PRICK TEST ALLERGENS MITES • Aluminium ONE COLLECTIVE TEST THAT INCLUDES 112 FOOD AND INHALANT ALLERGEN COMPONENTS. ISAC ALLERGEN COMPONENTS • Arsenic INHALANTS House dust mite mix • Barium ANIMAL ALLERGENS B.tropicalis ALLERGEN COMPONENT ALLERGEN SOURCE PROTEIN GROUP • Beryllium Cat Cockroach COMMON NAME • Chromium (A shortened profile is also available) • Cobalt Dog NUTS AND LEGUMES • Copper MOULDS FOODS Ana o 2 Cashew nut Storage protien 11 S globulin • Ethyl Mercury Alternaria alternata Cow’s milk Ara h 1 Peanut Storage protein, 7 S globulin • Galium Cladosporium Egg Ara h 2 Peanut Storage protein, conglutin Cod fish • Gold Aspergillus Ara h 3 Peanut Storage protein, 11 S globulin • Iridium Shellfish Ara h 8 Peanut PR-10 protein • Indium FEATHERS Soya Ara h 6 Peanut Storage protein, conglutin • Iron Feather mix Wheat Ara h 9 Peanut Lipid transfer protein (LTP) • Inorganic Mercury GRASSES Peanut Ber e1 Brazil nut Storage protein, 2S albumin • Lanthanum Bermuda Grass Maize/Corn Cor a 1.0401 Hazelnut PR-10 protein Potato • Lead 6-grass mix Cor a 8 Hazelnut Lipid transfer protein (LTP) • Manganese Tomato Cor a 9 Hazelnut Storage protein, 11 S globulin • Methyl mercury POLLENS Orange Jug r 1 Walnut Storage protein, 2S albumin • Molybdenum Maize pollen Apple Jug r 2 Walnut Storage protein, 7S globulin • Nickel Weed mix Banana Jug r 3 Walnut Lipid transfer protein (LTP) • Platinum Plane tree pollen Bakers yeast Gly m 4 Soybean Pr-10 protein (A Shortened profile is available) • Phenyl Mercury Oak pollen Gly m 5 Soybean Storage protein, B-conglycinin • Palladium PATCH TESTS: Gly m 6 Soybean Storage protein, Glycinin • Platinum Olive pollen Ses i 1 Sesame seed Storage protein, 2S albumin European baseline, sunscreen, • Ruthenium Cypress pollen GRAINS • Silver Acacia pollen cosmetic and hairdressing series. Fag e 2 Buckwheat Storage Protein, 2S albumin • Tin Eucalyptus Tri a 14 Wheat Crude gliadin (LTP) • Titanium SPECIMEN REQUIREMENTS: Tria a 19.0101 Wheat Omega-5 gliadin • Thimerosal mercury TEST SPECIMEN SPECIAL INSTRUCTIONS Tria a aA_TI Wheat • Vanadium IgE SST/Clotted Tube/1ml OCCUPATIONAL • Zinc RAST SST/Clotted Tube/5ml - Hev b 1 Latex • Zirconium depending on the number of allergens requested Hev b 3 Latex ANTISEPTICS ECP SST/Clotted Tube/1ml Blood must be taken in a SST Hev b 8 Latex Profilin Hev b 5 Latex • Mercurochrome tube and serum must be • Iodine Hev b 6.01 Latex separated within 1 hour. • Clorhexidine Bos d 4 Cow’s milk a-lactalbumin Mast Cell SST/Clotted Tube/1ml Bos d 5 Cow’s milk B-lactoglobulin Tryptase Bos d 6 Cow’s milk and meat Serum albumin See list of CAST allergens: ISAC SST/Clotted Tube/1ml or less Bos d 8 Cow’s milk Casein all allergens available on CAST CAST Heparin Tube/5ml Must reach the lab within 24 Bos d lactoferrin Cow’s milk Transferrin is also available for MELISA hours on week days and before EGG testing, including diverse drug 12:00 on Fridays. 207 Gal| Ampathd 1 Egg Desk Reference white Ovomucoid allergy testing. MELISA Citrate Tube/5ml (4-6 depending on the number Must reach the lab within 24 Gal d 2 Egg white Ovalbumin of allergens requested) hours on week days and before Gal d 3 Egg white Conalbumin 12:00 on Fridays. Gal d 5 Egg yolk Serum albumin FISH MELISA, Skin Prick Test and Patch Test LIST OF ALLERGY TESTS ISAC Gad cTests 1 Cod Parvalbumin Continued... LIST OF ALLERGY TESTS Ani s 3 Anisakis (Fish parasite) Tropomyosin Ani s 1 Anisakis (Fish parasite) Pen m 2 Shrimp Arginine kinase ISAC Tests LIST OF ALLERGY TESTS Pen m 4 Shrimp Sarcoplasmic Ca-binding protein HEAVY METALS SKIN PRICK TEST ALLERGENS MITES Pen m 1 Shrimp Tropomyosin • Aluminium MITES ONE COLLECTIVE TEST THAT INCLUDES 112 FOOD AND INHALANT ALLERGEN COMPONENTS. ISAC ALLERGEN COMPONENTS • Arsenic INHALANTS House dust mite mix Der f 1 House dust mite (D.farinae) Der f 2 House dust mite (D.farinae) ONE COLLECTIVE• Barium TEST THAT INCLUDES 112 FOOD AND INHALANT ANIMALALLERGEN ALLERGENS COMPONENTS. ISAC ALLERGEN COMPONENTSB.tropicalis ALLERGEN COMPONENT ALLERGEN SOURCE PROTEIN GROUP • Beryllium Cat Cockroach Der p 1 House dust mite (D.pteronyssinus) COMMON NAME ALLERGEN• Chromium COMPONENT ALLERGEN SOURCE PROTEIN GROUP(A shortened profile is also available) Der p 2 House dust mite (D.pteronyssinus) • Cobalt COMMON NAMEDog Der p 10 HouseNUTS AND LEGUMES dust mite (D.pteronyssinus) Tropomyosin • Copper MOULDS FOODS Blo t 5 House Ana o 2 Cashew dust mite (B.tropicalis) nut Storage protien 11 S globulin GRASS• Ethyl POLLEN Mercury Alternaria alternata Cow’s milk Lep d 2 Storage Ara h 1 Peanut Storage mite protein, 7 S globulin Cyn d 1 Bermuda Grass Grass group 1 • Galium Cladosporium Egg MOULDS Ara h 2 Peanut Storage protein, conglutin Phl p 1 Timothy Grass Grass group 1 Cod fish Alt a 1 Alternaria • Gold Aspergillus Ara h 3 Peanut Storage protein, 11 S globulin Phl p• Iridium 2 Timothy Grass Grass group 2 Shellfish Alt a 6 Alternaria Ara h 8 Peanut PR-10 Enolase protein Phl p• Indium 4 Timothy Grass FEATHERS Soya Asp f 1 Aspergillus Ara h 6 Peanut Storage protein, conglutin Phl p• Iron 5 Timothy Grass GrassFeather mix group 5 Wheat Asp f 3 Aspergillus Ara h 9 Peanut Lipid transfer protein (LTP) Phl • Inorganicp 6 Timothy Mercury Grass GRASSES Peanut Asp f 6 Aspergillus Mn Ber e1 Brazil nut Storage Superoxide dismutase protein, 2S albumin Phl p 7 Timothy Grass Polcalcin • Lanthanum Bermuda Grass Maize/Corn Cla h 8 Cladosporium Cor a 1.0401 Hazelnut PR-10 protein Phl p 11 Timothy Grass Potato INSECTS AND PARASITES • Lead 6-grass mix Cor a 8 Hazelnut Lipid transfer protein (LTP) Phl p• Manganese 12 Timothy Grass Proflin Tomato Api m 1 Honey Cor a 9 Hazelnut Storage bee venom Phospholipase A2 protein, 11 S globulin TREE POLLEN• Methyl mercury POLLENS Orange Api m 4 Honey Jug r 1 Walnut Storage bee venom Melittin protein, 2S albumin Aln g• Molybdenum 1 Alde Tree PR-10Maize pollen protein Apple Pol d 5 Paper Jug r 2 Walnut Storage wasp venom Venom, Antigen 5 protein, 7S globulin Bet • Nickelv 1 Birch Tree PR-10Weed mix protein Banana Ves v 5 Common Jug r 3 Walnut Lipid wasp venom Venom, Antigen 5 transfer protein (LTP) Bet v 2 Birch Tree Profilin • Platinum Plane tree pollen Bakers yeast Ani s 1 Anisakis Gly m 4 Soybean Pr-10 protein Bet • Phenylv 4 Birch Tree Polcalcin Mercury (A Shortened profile is available) Ani s 3 Anisakis Tropomyosin Gly m 5 Soybean Storage protein, B-conglycinin Cor a 1.0101 Hazel pollen PR-10Oak pollen protein • Palladium PATCH TESTS: Bla g 1 Cockroach Gly m 6 Soybean Storage protein, Glycinin Cry • Platinumj 1 Japanese ceder Olive pollen Bla g 2 Cockroach Ses i 1 Sesame seed Storage protein, 2S albumin European baseline, sunscreen, Cup• Ruthenium a 1 Cypress Tree Cypress pollen Bla g 7 Cockroach TropomyosinGRAINS Ole • Silvere 1 Olive Tr e e Acacia pollen cosmetic and hairdressing series. Bla g 5 Cockroach Fag e 2 Buckwheat Storage Protein, 2S albumin Ole e 7 Olive Tree Lipid transfer protein (LTP) • Tin Eucalyptus ANIMALS Tri a 14 Wheat Crude gliadin (LTP) Ole • Titaniume 9 Olive Tree SPECIMEN REQUIREMENTS: Can f 1 Dog Lipocalin Tria a 19.0101 Wheat Omega-5 gliadin Pla a1 Plane• Thimerosal mercury TEST Tree SPECIMEN SPECIAL INSTRUCTIONS Can f 2 Dog Lipocalin Tria a aA_TI Wheat Pla a 2 Plane Tree • Vanadium IgE SST/Clotted Tube/1ml Can f 3 Dog SerumOCCUPATIONAL albumin Pla a• Zinc 3 Plane Tree Lipid transfer protein (LTP) Can f 5 Dog Arginine Hev b 1 Latex esterase WEED POLLEN RAST SST/Clotted Tube/5ml - • Zirconium depending on the number of allergens requested Equ c 3 Horse Serum Hev b 3 Latex albumin Che a 1 Goosefoot Equ c 1 Horse Lipocalin ANTISEPTICS ECP SST/Clotted Tube/1ml Blood must be taken in a SST Hev b 8 Latex Profilin Amb a 1 Ragweed Fel d 1 Cat Hev b 5 Latex Uteroglobin • Mercurochrome tube and serum must be Pla l• 1 Plantain Iodine (English) Fel d 2 Cat Hev b 6.01 Latex Serum albumin separated within 1 hour. Art v• Clorhexidine 1 Mugwort Fel d 4 Cat Bos d 4 Cow’s Lipocalin milk a-lactalbumin Art v 3 Mugwort LipidMast Cell SST/Clotted Tube/1ml transfer protein (LTP) Mus m 1 Mouse Lipocalin Bos d 5 Cow’s milk B-lactoglobulin Mer a 1 AnnualTryptase mercury Profilin CROSS-REACTIVE PLANTS Bos d 6 Cow’s milk and meat Serum albumin Par Seej 2 Wall list of CAST allergens: ISAC pellitory Lipid SST/Clotted Tube/1ml or less transfer protein (LTP) Bet v 4 Birch Polcalcin Bos d 8 Cow’s milk Casein Sal kall 1 Saltwort allergens available on CAST CAST Heparin Tube/5ml Must reach the lab within 24 Phl p 7 Timothy Polcalcin Bos d lactoferrin Cow’s milk Transferrin FRUIT is also available for MELISA hours on week days and before Bet v 2 Birch ProfilinEGG Act d testing,1 Kiwi including diverse drug 12:00 on Fridays. Hev b 8 Latex Profilin Gal d 1 Egg white Ovomucoid Act d allergy2 Kiwi Thaumatine-like testing. MELISA Citrate Tube/5ml (4-6 depending on the proteinnumber Must reach the lab within 24 Mer a 1 Annual Gal d 2 Egg mercury Profilin white Ovalbumin Act d 5 Kiwi of allergens requested) hours on week days and before Ole e 7 Olive Lipid Gal d 3 Egg white Conalbumin transfer protein (LTP) Act d 8 Kiwi PR-10 12:00 protein on Fridays. Phl p 12 Timothy Profilin Gal d 5 Egg yolk Serum albumin Api g 1 Celery PR-10 protein MUXF 3 SugarFISH epitope from Bromelain CCD-marker Mal d 1 Apple PR-10 protein Gad c 1 Cod Parvalbumin Pru p 1 Peach PR-10 protein Ani s 3 Anisakis (Fish parasite) Tropomyosin Pru p 3 Peach Lipid transfer protein (LTP) Ani s 1 Anisakis (Fish parasite) Pen m 2 Shrimp Arginine kinase ISAC Tests LIST OF ALLERGY TESTS Pen m 4 Shrimp Sarcoplasmic Ca-binding protein Pen m 1 Shrimp Tropomyosin MITES Der f 1 House dust mite (D.farinae) Der f 2 House dust mite (D.farinae) ONE COLLECTIVE TEST THAT INCLUDES 112 FOOD AND INHALANT ALLERGEN COMPONENTS. ISAC ALLERGEN COMPONENTS Der p 1 House dust mite (D.pteronyssinus) ALLERGEN COMPONENT ALLERGEN SOURCE PROTEIN GROUP Der p 2 House dust mite (D.pteronyssinus) COMMON NAME Der p 10 House dust mite (D.pteronyssinus) Tropomyosin Blo t 5 House dust mite (B.tropicalis) GRASS POLLEN Lep d 2 Storage mite Cyn d 1 Bermuda Grass Grass group 1 MOULDS Phl p 1 Timothy Grass Grass group 1 Alt a 1 Alternaria Phl p 2 Timothy Grass Grass group 2 Alt a 6 Alternaria Enolase Phl p 4 Timothy Grass Asp f 1 Aspergillus Phl p 5 Timothy Grass Grass group 5 Asp f 3 Aspergillus Phl p 6 Timothy Grass Asp f 6 Aspergillus Mn Superoxide dismutase Phl p 7 Timothy Grass Polcalcin Cla h 8 Cladosporium Phl p 11 Timothy Grass INSECTS AND PARASITES Phl p 12 Timothy Grass Proflin Api m 1 Honey bee venom Phospholipase A2 TREE POLLEN Api m 4 Honey bee venom Melittin Aln g 1 Alde Tree PR-10 protein Pol d 5 Paper wasp venom Venom, Antigen 5 Bet v 1 Birch Tree PR-10 protein Ves v 5 Common wasp venom Venom, Antigen 5 Bet v 2 Birch Tree Profilin Ani s 1 Anisakis Bet v 4 Birch Tree Polcalcin Ani s 3 Anisakis Tropomyosin Cor a 1.0101 Hazel pollen PR-10 protein Bla g 1 Cockroach Cry j 1 Japanese ceder Bla g 2 Cockroach Cup a 1 Cypress Tree Bla g 7 Cockroach Tropomyosin Ole e 1 Olive Tr e e Bla g 5 Cockroach Ole e 7 Olive Tree Lipid transfer protein (LTP) ANIMALS Ole e 9 Olive Tree Can f 1 Dog Lipocalin Pla a1 Plane Tree Can f 2 Dog Lipocalin Pla a 2 Plane Tree Can f 3 Dog Serum albumin Pla a 3 Plane Tree Lipid transfer protein (LTP) Can f 5 Dog Arginine esterase WEED POLLEN Equ c 3 Horse Serum albumin Che a 1 Goosefoot Equ c 1 Horse Lipocalin Amb a 1 Ragweed Fel d 1 Cat Uteroglobin Pla l 1 Plantain (English) Fel d 2 Cat Serum albumin Art v 1 Mugwort Fel d 4 Cat Lipocalin Art v 3 Mugwort Lipid transfer protein (LTP) Mus m 1 Mouse Lipocalin Mer a 1 Annual mercury Profilin CROSS-REACTIVE PLANTS Par j 2 Wall pellitory Lipid transfer protein (LTP) Bet v 4 Birch Polcalcin Sal k 1 Saltwort Phl p 7 Timothy Polcalcin FRUIT Bet v 2 Birch Profilin Act d 1 Kiwi Hev b 8 Latex Profilin Act d 2 Kiwi Thaumatine-like protein Mer a 1 Annual mercury Profilin Act d 5 Kiwi Ole e 7 Olive Lipid transfer protein (LTP) Act d 8 Kiwi PR-10 protein Phl p 12 Timothy Profilin Api g 1 Celery PR-10 protein MUXF 3 Sugar epitope from Bromelain CCD-marker Mal d 1 Apple PR-10 protein Pru p 1 Peach PR-10 protein Pru p 3 Peach Lipid transfer protein (LTP) Guide to laboratory tests | 208

AN INTRODUCTION TO ALLERGY DIAGNOSIS

AN APPROACH TO ALLERGY DIAGNOSIS – MADE EASY WITH FLOW-DIAGRAMS: AN APPROACH TO ALLERGY DIAGNOSIS – MADE EASY WITH FLOW-DIAGRAMS: IN VIVO TESTING: TAKE A GOOD HISTORY: SKIN-PRICK TESTINGLOW SUSPICION OF ALLERGY HIGH SUSPICION OF ALLERGY • DecideTAKE A GOODwhether HISTORY: you have a HIGH SUSPICION OF ALLERGY SPTs with allergenLOW extracts SUSPICION are an in vivo OF method ALLERGY to test for IgE-mediated sensitivity. The quality of extracts and test technique is important for reliable HISTORY • Decidelow or high whether suspicion you h ofave allergy a HISTORY results. Standardised commercial extracts are currently available• Can for you most identify common a specific inhalant allergens and for some food allergens. Some patients HISTORY low or high suspicion of allergy HISTORY with a documented food allergy on history fail to react to these• Can aextracts,llergen? you identify but may a s pecificreact to fresh extracts of the food (prick-prick testing), e.g. fruits, fish LOW SUSPICION OF ALLERGY HIGH SUSPICION OF ALLERGY and shellfish. Results are influenced by certain medications• What likeallergen? antihistamines,mechanism of allergytherefore do patients will need to stop certain medications before skin prick testing. SPTs mustLOW SUSPICIONbe performed OF ALLERGYin a setting where personnel• Whatyou suspect? mandechanism equipment of allergy are davailableo for resuscitation,HIGH SUSPICION as there OFis a ALLERGY small but definite risk SCREENING TESTS TO EXCLUDE ALLERGY of anaphylaxis. Please see table below for a comparison of they ouadvantages suspect? and disadvantages of SPTAllergen vs specific specific IgE screening (RAST): tests or allergen SCREENING TESTS TO EXCLUDESPT ALLERGY SPECIFICtargeted IgE testing, e.g. foods, inhalants or both Allergen specific screening tests or allergen Screen for• IgEInexpensive as well as non-IgE mediated • Not affected by concurrent drugstargeted e.g. antihistamines testing, e.g. foods, inhalants or both allergy. May screen for IgE mediated first and if Screen for• IgEImmediate as well asresults non-IgE mediated • Not influenced by skin disease negative, proceed with non-IgE mediated testing DECIDE ON MECHANISM allergy. May• Extracts screen forare IgE difficult mediated to standardise first and if • Completely safe negative, • Dependantproceed with non-IgEon technique mediated testing • Tests for wider range of possible allergensDECIDE ON MECHANISM AND / OR • Risk of systemic reactions / anaphylaxis • Allergen component testing available IgE mediated Non IgE mediated IgE mediated Non IgE mediated • Screening tests available, making it more cost-effectiveAND / OR IgE mediated Non IgE mediated • Quantitative reporting, reproducibleIgE mediated Non IgE mediated Skin prick• Total testing IgE and intradermal testing• Nasal for drug eosinophils allergies, including penicillin skin prick testing,• Phadiatop/specific can also be performed inhalant using a• Inhalant variety of m differentix CAST/specific drugs • Phadiatop/Inhalant SPTs (rhinitis symptoms) IgE/inhalant SPTs inhalant CASTS • Total IgE • Nasal eosinophils • Phadiatop/specific inhalant • Inhalant mix CAST/specific • Food mix IgE/food SPTs •CAST inhalant mix AND/OR AND/OR PATCH• Phadiatop/Inhalant TESTING: SPTs (rhinitis symptoms) IgE/inhalant SPTs inhalant CASTS •CAST food mix • Food mix IgE/ specific food • Food mix CAST/specific food • Food mix IgE/food SPTs •CAST inhalant mix AND/OR AND/OR •CAST colorants + preservatives IgE/food SPTs CAST/CAST colorants and Patch testing is used for the diagnosis•CAST of contact food mix allergies and contact dermatitis. There •areFood general mix IgE/ screening specific food panels available,• Food e.g. mix CtheAST/specific European food preservatives baseline series (most common contact•CAST allergens), colorants cosmetic + preservatives series, sunscreen series, hairdressingIgE/food SPTs series, etc. These tests measureCAST/CAST delayed colorants type and hypersensitivity reactions on the skin of sensitised subjects. The patient’s skin is exposed to the occluded allergens for 48-72 hourspreservatives and reactions are interpreted at 72 hours. This type of testing may sometimes be used for other allergens like food allergens (atopy patch test) in specialised settings. If negative, consider other diseases If positive, consider Continue search if results are negative: DIAGNOSTIC TESTS OF UNPROVEN VALUE component testing: If positive, consider • Other allergen If negative, consider other diseases • ISAC testing for Continue search if results are negative: component testing: • Other mechanism Unfortunately there are many techniques available that have not been validatedcomplex scientificallyallergies or that• Other canno tallergen identify allergy by means of a known Correlation with clinical findings and history • ISAC testing for (consider T-cell mediated allergy testing) • Specific IgE • Other mechanism immunological mechanism. These tests include the following: complex allergies • Other disease Correlation with clinical findings and history components on (consider T-cell mediated allergy testing) • Specific IgE ImmunoCap® • Other disease • Neutralisation provocation (Miller) tests (based on multiple skin tests; environmentalcomponents on allergens includeCorrelation smoke, with petrol, clinical tobacco, findings etc.) and history • Leukocytotoxic tests ImmunoCap® Correlation with clinical findings and history 10 • Hair analysis • Vega testing (a ‘black box’ electrical test). The test is based on the addition of food extracts to a chamber contained within an electrical circuit 10 completed by the patient • Applied kinesiology (based on muscle weakness) • Auricular cardiac reflex testing (based on pulse rate) • ALCAT • IgG measurements / ImmuPro allergy tests offered at some Pharmacies and Laboratories. 9 209 | Ampath Desk Reference

AN APPROACH TO INHALANT ALLERGY

FIGURE 2: APPROACH TO THE DIAGNOSIS OF INHALANT ALLERGIES. FIGURE 2: APPROACH TO THE DIAGNOSIS OF INHALANT ALLERGIES.

POLLEN CROSS-REACTIVITY: HISTORY SUGGESTIVE OF HISTORYINHALANT SUGGESTIVE ALLERGY OF Please note that patients with pollen allergies are often sensitized to cross-reactiveINHALANT components ALLERGY that occur in pollens as well as foods of plant origin. The most common cross-reactive components are cross-reactive carbohydrate determinants (CCD), profilins, Proteinase-10 (PR-10) and lipid transfer proteins (LTP). The implicationSymptoms of this all is year that round patients may test positive to multiple allergen-specificSymptoms IgE tests, worse including in Spring other pollens and foods of plant origin. IgE to CCD,Symptoms profilin, all PR-10year round and LTP should be requested in these patients toSymptoms determine worse the inlikelihood Spring that they have a relevant allergy or whether tests are positive due to cross-reactivity. This has important implications to advise on allergen avoidance and selecting patients for allergen immunotherapy.Phadiatop Immunotherapy Inhalant Screen is discussed in moreOr SPT detail panel in chapter 8. Phadlatop Inhalant Screen Phadiatop Inhalant Screen Or SPT panel Phadlatop Inhalant Screen FIGURE 1: SAMPLE REQUEST FORM FOR INHALANT ALLERGIES Positive Negative if negative Negative Positive Positive Negative if negative Negative Positive HISTORY SUGGESTED PANEL Break down in Break down in ? OTHER MECHANISM Asthma/Rhinitis BreakALLSA/NPG down in • Phadiatop inhalant screen BreakALLSA/NPG down in CAST inhalant mix ** (all year round) ALLSA/NPGpanel* • Breakdown? OTHER if positive:MECHANISM ALLSA/NPGpanel*AND Nasal eosinophils panel* BermudaCAST inhalant grass mix ** panel*ANDallergy tree RyeNasal grass eosinophils allergymix/individual tree Altenaria (mould) mix/individualtrees trees WHERE Cladosporium DOES THE (mould) PATIENT LIVE? WHERE Aspergillus DOES (mould)THE PATIENT LIVE? D. pteronyssinus (mite) B. tropicalis (mite) Highveld, Free State, Western Cape Cat KZN Highveld,Northwest Free State, Western Cape Dog KZN Northwest Asthma/Rhinitis Add: (with seasonal aggravation in ConsiderSpring) adding: • Tree mix 1Consider adding: Consider adding: Consider• Epicoccum adding: (mould) (olive, willow,Consider• Cockroach pine, adding: eucalyptus, (Oriental) acacia, maleleuca)Consider• Maize Pollen adding: • EpicoccumCockroach (German)(mould) • Tree mix 2• Cockroach (Oriental) • MaizeEucalyptus Pollen • Cockroach (German) (oak, elm, plane, willow, cottonwood) • EucalyptusWeed Mix (Cosmos, • Other trees (specify) • WeedKakhibos) Mix (Cosmos, * ALLSA/NPG panel: Bermuda grass, Rye grass, Alternaria (mould), Cladosporium (mould), Kakhibos) Where does the patientAspergillus* ALLSA/NPG live? (mould), panel: D.pteronyssinus Bermuda grass, (mite), Rye Consider:B.tropicalis grass, Alternaria (mite), (mould),cat, dog Cladosporium (mould), ** Request specific allergen breakdown if CAST inhalant mix is positive and phadiatop is negative. - Western Cape Aspergillus (mould), D.pteronyssinus (mite), B.tropicalis • Epicoccum (mite), cat,(mould), dog Cockroach (German) ** Request specific allergen breakdown if CAST inhalant mix is positive and phadiatop is negative. 14 - Highveld, Free state, Northwest • Weed mix (cosmos/ khakibos), Maize pollen, 14 Eucalyptus pollen - Kwazulu Natal • Cockroach (oriental)

13 Guide to laboratory tests | 210

AN APPROACH TO FOOD ALLERGY

THETHE FOLLOWING FOLLOWING DIAGNOSTIC DIAGNOSTIC TOOLS TOOLS ARE ARE KEY KEY ININ THETHE ASSESSMENTASSESSMENT OF A POSSIBLE FOODFOOD ALLERGY:ALLERGY: Food intolerance comprises most of the adverse reactions to foods and may be due to toxic contaminants in food (i.e. histamine in scombroid fish HISTORYHISTORY SUGGESTIVESUGGESTIVE poisoning, bacterial toxins), pharmacologic agents in food, including caffeine, theobromineOFOF FOODFOOD in chocolate ALLERGYALLERGY and tea, histamine-like compounds (fish, wine etc.), tryptamine (tomato, plum), tyramine (aged cheese, pickled fish), serotonin (banana, tomato), phenylethylamine (chocolate), glycosidal alkaloid solanine (potatoes) and alcohol. Other nonallergicSpecificSpecific food reactions food food allergensallergens include notnot lactose intolerance, fructose intolerance, gastroesophagealClear history indicatesindicates reflux, aa anatomic and neurologic abnormalities, enzyme deficiencies,implicatedimplicated metabolic disorders, gastrointestinal infections and food additivespecific intolerance. foodfood

When a patient has a confirmed allergy to oneFoodFood food, allergen allergen evaluation screen screen on ofon related foods may be indicated to determine if theseFood foods allergen are IgEIgE also oror SPTSPT problematic. It should always be kept in mind that a “positive”ImmunoCap® ImmunoCap®allergy test toor or SPTa SPT related food food panelfood panel may simply represent immunologic cross-reactivity due to the presence of a homologous protein that does not have clinical significance. This is more common than true clinical cross-reactivity. A patient with a peanut allergy Positive NegativeNegative can therefore have “positive” serum immunoglobulinNegativeNegative E (IgE) tests or skinPositivePositive prick tests to multiple legumes that are clinically tolerated. It is often difficult to decide what is clinically relevant. ?? OtherOther allergenallergen Breakdown in Breakdown in •• OtherOther foodfood Tree nuts, fish, and shellfish are more commonly clinically cross-reactive.••EggEgg white white Caution and possible allergy testing (including oral foodIgE/SPT’sIgE/SPT’s challenges) are • Milk warranted if ingestion of related foods is being considered. Grains, fruits,• Milk vegetables, and legumes are clinically less cross-reactive and elimination diets/ ••WheatWheat ? Other mechanism ? Other mechanism chalenges with food diaries are generally? Otherrecommended mechanism to expand •the•SoyaSoya diet. Component testing is also valuable, for knowledge of? certain Other mechanism components CAST test CAST test CAST test ••PeanutPeanut CAST test may predict the clinical relevance of the reaction.• Food mix Please refer to table 2 on cross-reactive pollen and plant food components. • Food mix • Food mix ••CodfishCodfish • Food mix • Colourants • Colourants ORAL ALLERGY SYNDROME • Colourants • Colourants • •PreservativesPreservatives If food IgE is positive do component testing to indicate •• PreservativesPreservatives MELISA/patch test If food IgE is positive do component testing to indicate MELISA/patch test risk, severity and for dietary advice MELISA/patch test test The oral allergy syndrome (OAS), also known as the food-pollen syndrome,risk, severity describesand for dietary an IgE-mediatedadvice reaction, usually limited to the oropharynx, Egg: ovomucoid ? Other disease, e.g. Egg: ovomucoid ? Other disease, e.g. which occurs upon ingestion of certain? Other fresh disease, fruits e.g.and nuts or vegetablesMilk: in pollen-sensitizedcasein individuals. The cross reactive? Othercomponents disease, e.g.typically Coelliacs disease Milk: casein Coelliacs disease involved in the OAS include CCD, profilin,Coelliacs PR-10, disease and LTP. The symptomsWheat: result fromΩ 5 gliadin contact allergy of the oropharynx. OAS isCoelliacs caused disease by ubiquitous • HLADQ2+8 Wheat: Ω 5 gliadin • HLADQ2+8 • HLADQ2+8 Soy: gly m 5, 6 storage proteins • HLADQ2+8 plant allergens present in fruit, vegetables,• lgA nuts and pollen. Symptoms areSoy: usually glyconfined m 5, 6 storage to the prmouth,oteins but in rare circumstances,• lgA systemic reactions • lgA Peanut: Arah 1, 2, 3 storage proteins • lgA • TTG lgA Peanut: Arah 1, 2, 3 storage proteins • TTG lgA can occur. The responsible allergens are• TTG usually lgA destroyed by cooking/peelingCodfish: of food, parvalbumin but rarely, symptoms do occur in a small proportion• TTG lgA of patients, • Endomysial lgA Codfish: parvalbumin • Endomysial lgA with cooked food as well. • •Endomysial Deamidated lgA Gliadin lgA •• DeamidatedEndomysial lgAGliadin lgA • Deamidated Gliadin lgA NB! If soy, wheat and peanuts are • Deamidated Gliadin lgA NB!positive, If soy ,consider wheat and food-pollen peanuts syndromeare positive, consider food-pollen syndrome ? Non Immunological Mechanism Add: ? Non Immunological Mechanism ? Non Immunological Mechanism Add: • Grass mix IgE • CCD ? Non Immunological Mechanism i.e. lactase deficiency • Grass mix IgE • CCD i.e. lactase deficiency i.e. lactase deficiency • Proflin • LTP i.e. lactase deficiency • H-breath test • Proflin • PR-10 • LTP • H-breath test • H-breath• Stool reducing test substances • PR-10 • StoolH-breath reducing test substances • Stool reducing substances • Stool reducing substances 30 30

19 211 | Ampath Desk Reference Notes

Ampath Guide to Lab Tests front cover final repro outlines 15 March 2016.indd 1 2016/03/15 11:43 AM