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Requisition for Immunology Testing Client (Organization): ________________________________________________________ Suspect or known diagnosis: __________ Patient Information: _____________________________________________________________ Name: ______________ ___ ClinicalImmunology – Birthdate: (YYYY/MM/DD): ___Sex: Male Female Referring Physician Information: Date Drawn (YYYY/MM/DD): ___ Name: _______ Email: __ ____ Lab Reference Specimen #: ___ Phone: ______________ Test Request Autoimmune Encephalitis Panel IIFA Vasculitis NMDAR, LGI1, CASPR2, AMPAR1/R2, GABARB1/B2, DPPX, GAD65 and IgLON5 ANCA (anti-MPO/anti-PR3) (ANCA) ELISA Current WBC count for specimen collected: Serum (AEPS) CSF (AEPCSF) Anti-GBM (AGBM) ELISA Please fill out the Clinical Questionnaire and submit it with the patient’s sample. Clinical Anti-Cyclic presentaiton: Citrullinated Peptide (ACCP) ELISA Paraneoplastic Antibody Panel Anti-ds DNA by dsDNA-NcX Elisa (DNA) ELISA Hu, Yo, Ri, Ma2/Ta, Amphiphysin, CV2, recoverin, SOX1, titin, zic4, GAD65 and Tr (DNER) Anti-GM1, IgM (AGM1) ELISA store and ship frozen Serum (PNAS) IIFA, Immunoblot CSF (PNACSF) IFFA Anti-Histone Group (HIST) ELISA For serum samples titin and recoverin only done by Immunoblot testing. Immune Complexes (CIC) ELISA LondonHealth Sciences Centre For CSF samples titin and recoverin are not available. Anti-Tissue Transglutaminase, IgA (TTGAB) Chemiluminescence Neuromyelitis Spectrum Profile IIFA Store & ship frozen Anti-Myelin Oligodendrocyte Glycoprotein and Aquaporin4 (MOG/AQP4) C1 Inhibitor Protein (C1IN) ELISA Serum (NMOSD) CSF (NMOSDCSF) CH50 (TCOMP) Turbidimetric Anti-Gangliosides Profile, IgG and IgM (GAN) Immunoblot Complement C2 (C2) RID Anti GM1, GM2, GM3, GD1a, GD1b, GT1b, GQ1b IgG Subclasses (IGGSUB) IgG1, IgG2, IgG3 and IgG4 Turbidimetric Chromosome Profile (ANACP) Immunoblot Serum Free Light Chains (FLC) Turbidimetric dsDNA, Nucleosomes, Histones, DFS70, Scl-70, CENP A, CENP B Galactomannan Aspergillus Antigen ELISA ENA Profile (ANAEPP) Immunoblot Galactomannan Aspergillus Antigen Serum (GALACTOM) nRNP/Sm, Sm, SS-A, BB-B, Ro-52, Scl-70 and Jo-1 Galactomannan Aspergillus Antigen BAL Fluid GALACTOMF) Liver Profile (ANALP) Immunoblot Anti-Nuclear Antibodies (ANA) IIFA M2, M2-3E, Sp100, PML, gp210, LKM-1, LC-1, SLA/LP and Ro-52 For certain patterns immunoblot follow up with either or: Myositis Antibodies Profile (.MYOAP) Immunoblot Chromosome profile, ENA profile for titres ≥1:160 Anti-Mi-2α, Mi-2β, TIF1γ, MDA5, NXP2, SAE1, Ku, PM-Scl 100, PM-Scl 75, Jo-1, Autoimmune Liver Disease Profile (AILDP) IIFA SRP PL-7, PL-12, EJ, OJ and Ro-52 AMA, ASMA, LKM and ANA Systemic Sclerosis Profile (.ANANP) Immunoblot For certain patterns immunoblot(s) follow up with either or: Scl 70, CENP A, CENP B, RP11, RP 155, Fibrillarin, NOR90, Th/To, PM-Scl75 Chromosome profile, ENA profile for titres ≥1:160 PM-Scl 100, Ku, PDGFR, Ro-52 Liver Profile for titres ≥1:80 SPECIMEN REQUIREMENTS AND SHIPPING INSTRUCTIONS Sample: Ship to: CSF or Serum, 1 mL: Send in a small 12x75 or 13x75 mm polystyrene tube. LHSC, Victoria Hospital Samples should arrive before Friday 3 pm. Do not send samples to arrive on weekends or holidays. Sample Reception, Room D1-206 Ship Anti-GM1 and TTGAB frozen with dry ice. All other samples can be shipped with ice packs. 800 Commissioners Rd East London, ON N6A 5W9 For individual test pricing go to REQUEST FOR SERVICES - CLINICAL LABORATORIES and fill out the form to get a quote. LHSC, Victoria Hospital Clinical Immunology Laboratory, B10-236 800 Commissioners Rd East London, ON, N6A 5W9 Phone: 519-685-8500 ext. 33097 │ Fax: 519-663-3704 .

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Supplement 1 Overview of Dystonia Genes
Supplement 1 Overview of genes that may cause dystonia in children and adolescents Gene (OMIM) Disease name/phenotype Mode of inheritance 1: (Formerly called) Primary dystonias (DYTs): TOR1A (605204) DYT1: Early-onset generalized AD primary torsion dystonia (PTD) TUBB4A (602662) DYT4: Whispering dystonia AD GCH1 (600225) DYT5: GTP-cyclohydrolase 1 AD deficiency THAP1 (609520) DYT6: Adolescent onset torsion AD dystonia, mixed type PNKD/MR1 (609023) DYT8: Paroxysmal non- AD kinesigenic dyskinesia SLC2A1 (138140) DYT9/18: Paroxysmal choreoathetosis with episodic AD ataxia and spasticity/GLUT1 deficiency syndrome-1 PRRT2 (614386) DYT10: Paroxysmal kinesigenic AD dyskinesia SGCE (604149) DYT11: Myoclonus-dystonia AD ATP1A3 (182350) DYT12: Rapid-onset dystonia AD parkinsonism PRKRA (603424) DYT16: Young-onset dystonia AR parkinsonism ANO3 (610110) DYT24: Primary focal dystonia AD GNAL (139312) DYT25: Primary torsion dystonia AD 2: Inborn errors of metabolism: GCDH (608801) Glutaric aciduria type 1 AR PCCA (232000) Propionic aciduria AR PCCB (232050) Propionic aciduria AR MUT (609058) Methylmalonic aciduria AR MMAA (607481) Cobalamin A deficiency AR MMAB (607568) Cobalamin B deficiency AR MMACHC (609831) Cobalamin C deficiency AR C2orf25 (611935) Cobalamin D deficiency AR MTRR (602568) Cobalamin E deficiency AR LMBRD1 (612625) Cobalamin F deficiency AR MTR (156570) Cobalamin G deficiency AR CBS (613381) Homocysteinuria AR PCBD (126090) Hyperphelaninemia variant D AR TH (191290) Tyrosine hydroxylase deficiency AR SPR (182125) Sepiaterine reductase
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