City Medicare Lab & City Diagnostic Center

City Medicare Lab & City Diagnostic Center

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Typhoid / Enteric fever Diagnosis, Widal test and Its Procedure
Lab TestsMicrobiology
Sample
It is done on the serum of the patient.
A random sample can be taken.
Purpose Of The Test (Indication)
This test is done to diagnose enteric fever (Typhoid and paratyphoid fever).
Pathophysiology
History of widal test:
In 1896 widal test was discovered by George-Fernand Widal for the diagnosis of enteric fever.
Enteric fever includes typhoid and paratyphoid fever.
Paratyphoid fever is milder than typhoid fever.
Enteric fever also called as typhoid fever.
Typhoid fever is caused by the bacterium Salmonella Typhi.
Salmonella typhi has an incubation period of 14 to 21 days. Sometimes may even longer.
30% of the cases become chronic carriers due to persistent infection of the gallbladder.
This has flagellar antigen H antigen and Lipopolysaccharides antigen is somatic or O antigen.
Typhoid bacilli structure
Typhoid bacilli structure

The incubation period is 7 to 14 days.
Typhoid fever is common in the developing world, where it affects about 21.5 million persons each year.
Salmonella Typhi lives in humans and also found in chickens and eggs.
It is present in the blood and intestinal tract.
The carrier can harbor bacilli in the gallbladder.
Both patients and carriers shed Salmonella Typhi in their f***s (stool).
Mode Of Spread
Food: if food or drinks are contaminated.
Spread from the carrier, who is shedding Salmonella Typhi.
Contaminated drinking water: If sewage water is contaminated with Salmonella Typhi.
Typhoid fever is more common in areas of the world where handwashing is less frequent.
Once Salmonella Typhi bacteria are eaten or drunk, they multiply and spread into the bloodstream.
Enteric fever pathogenesis
Enteric fever pathogenesis

Signs And Symptoms
The patient has a fever and the pattern of the fever is typical.
Fever is persistent and does not touch normally. This may be as high as 103 to 104 F.
The patient may feel weak.
May have stomach pains, headaches, or loss of appetite.
In some cases, patients have a rash of flat type and rose-colored spots.
Typhoid fever presentation and signs and symptoms
Typhoid fever presentation and signs and symptoms

The procedure of the Widal test

Serial dilution of the patient serum is taken 1:40 to 1:320
Now add an equal volume of Salmonella antigen.
This can be done as a Slide method or as a Tube method.
When running in the tube then incubate tubes for 12 hours or overnight.
Prepare the serial dilution as shown in the diagram.
Widal test procedure and dilution
Widal test procedure and dilution

Widal test is done as follows and can read the result where there is the start of the agglutination, as shown in the following diagram.

widal test result and interpretation
widal test result and interpretation

Drawback: This test will be positive after 7 to 10 days of Enteric fever.

Serologically salmonella has 5 serogroups are A, B, C, D, E on the basis of O somatic antigen.
On the basis of H-antigen are 1200 serotypes.
7 to 10 days antibody to D-somatic antigen appears.
These antibodies against O antigens reach their peak by 3 to 5 weeks.
H-flagellar antibodies appear later on.
Widal test will be positive after 7 to 10 days of infection.
The titer of O-antibodies 1:80 is suspicious in unvaccinated patients.
The titer of 1:160 is strongly suggestive of infection in unvaccinated individuals.
The titer of 1:40 for Antibody to flagellar-antigen (H) are suspicious in unvaccinated individual.
While 1:160 are strongly suggestive.
Titers are much higher in the vaccinated individual.
Vi antigen for S.typhi is used to screen the carrier. antibodies to Vi-antigen are positive in
Reading of the test

The highest dilution of the serum is noted where there is agglutination.
If it ends at 1:320 then that is the titer.
The Widal test is positive
if “O” antigen titer is >1:160 = active infection.
If “H” antigen titer is >1:160, indicate past infection or in immunized persons.
A fourfold increase in the titer (e.g., from 1:40 to 1:160) is diagnostic.
O Antigen
In the acute stage, Antigen O will be positive and titer will be more than 1:160.
O antigen appears early and also disappear early.
H Antigen
H antigen rises late and disappears late.
This will be positive in the recovery stage.
Vi Antigen
This is an indicator of the carrier stage.
The false-positive test may be seen due to cross-reacting infections, including malaria.

Other diagnostic tests for the diagnosis of Typhoid (Enteric) fever are:

Blood culture, which will be positive in the first week when the Widal test is negative.
Stool culture.
60 to 70% cases are negative during the first week and more cases positive in the third week of infection.
Stool 90% of the cases are cleared of the bacteria by the 8th weeks of infection.
Urine culture.
Bone marrow culture. This is a very sensitive test.
Bone marrow 90% of the cases are positive despite antibiotic therapy if these are ≤5 days.
Another serological test is Typhidot.
The gold standard is the blood culture where 90% of cases are positive in the first week.
50% of cases are positive by the third week.
For better yield centrifuge the blood and take a buffy coat for culture.
Other samples are stool, urine, Rose spot, bone marrow, and gastric or intestinal secretions.
When culture is done simultaneously on blood, bone marrow, and intestinal secretions then positivity is >90%.
Small % become the carrier and their stool culture remains positive for at least one year.
Enteric fever diagnostic tests
Enteric fever diagnostic tests

Culture in Enteric fever patients from a different site:

Time period Clinical S/S Blood Stool Urine Bone marrow
During I.P 0 to 1 week diarrhea or constipation negative ± negative negative
1 to 2 weeks fever, headache, myalgia, cough 80 to 90% positive negative negative negative
2 to 4 weeks systemic toxemia 80 to 90% positive 80% positive 25% positive 90% positive
4 to 5 weeks recovering negative except in complications 50% positive 10% positive ±
>5 weeks Cholecystitis, osteomyelitis negative except in complications ± ± negative
Treatment
The drug of choice is chloramphenicol but it has many side-effects.
Ciprofloxacin is now a drug of choice.
Ampicillin, amoxicillin, 3rd generation cephalosporins, and fluoroquinolones can be used.
C0-trimoxazole is better than chloramphenicol with less side-effect.
Carriers:

It is difficult to treat carriers because of gall bladder involvement.
Ampicillin is the most useful drugs but it is to be given in larger doses and for a longer period of time.
Chloramphenicol is less effective than ampicillin.
Ciprofloxacin can also be tried.
The ultimate end is cholecystectomy.
For Nonmedical person explanation of Widal test (Enteric fever):

Please advise the Widal test if the fever persists more than 5 days at least.
Just see the O antigen titer if it is 1:160, indicate Enteric fever.
If O antigen is 1:80 then repeat the test after 5 to 7 days and now the titer is 1:160, rising titer again indicates acute infection.
While H antigen does not indicate acute infection or acute enteric fever.
iabetes Mellitus – Part 6 – Diabetes Mellitus Complications and Work Up
Chemical pathologyLab Tests
Diabetic patients need follow-up and proper control to prevent diabetic complications.
The Complication Of Diabetes Mellitus:
There may be hypoglycemia.
In patients with hyperglycemia of Type I, left uncontrolled may develop life-threatening complications like diabetic Ketoacidosis.
Without treatment, the patient may become acidotic and dehydrated and may lose consciousness.
Type II may develop hyperosmolar coma.
Peripheral neuropathy.
Diabetic retinopathy and cataract formation, it may lead to blindness.
Cardiovascular microangiopathy.
Coronary atherosclerosis.
Myocardial infarction is 3 to 5 times more common in diabetic patients.
AMI is the leading cause of death in patients with diabetes mellitus type 2.
Peripheral vascular diseases like ischemia of lower extremities, erectile dysfunction, and intestinal ischemia.
Gangrene of the foot.
Diabetic kidney diseases, diabetic nephropathy.
It may lead to renal failure.
Chronic pyogenic skin infection.
Candidal infection of the skin.
Bone and joints show contracture.
In the end, maybe result in stroke, gangrene, and coronary artery diseases.

Diabetes mellitus complications
Diabetes mellitus complications

Diagnosis Fasting glucose level Random glucose level 2-hour glucose level (in OGTT) HbA1c
Prediabetics 100 to 125 mg/dL 140 to 199 mg/dL 40 to 199 mg/dL 5.7 to 6.4%
Diabetes mellitus > 126 mg/dL >200 mg/dL >200 mg/dL >6.5%
The Complication Of Diabetes Mellitus:
Acute complications are:

There may be hypoglycemia.
In patients with hyperglycemia of Type I left uncontrolled, they may develop life-threatening complications like diabetic Ketoacidosis.
Without treatment, the patient may become acidotic and dehydrated and may lose consciousness.
Type II may develop hyperosmolar coma.
Chronic complications are:

Peripheral neuropathy.
Diabetic retinopathy and cataract formation.
Cardiovascular microangiopathy.
Coronary atherosclerosis.
Myocardial infarction is 3 to 5 times more common in diabetic patients.
AMI is the leading cause of death in patients with diabetes mellitus type 2.
Peripheral vascular diseases like ischemia of lower extremities, erectile dysfunction, and intestinal ischemia.
Gangrene of the foot.
Diabetic kidney diseases (diabetic nephropathy), and may lead to end-stage renal disease.
Chronic pyogenic skin infection.
Candidal infection of the skin.
Bone and joints show contracture.
Work Up Of Diabetic Patients To Prevent The Complications:
Basic metabolic panel :
Fasting glucose level.
Postprandial glucose level
Microalbuminuria.
BUN (urea).
Creatinine.
Electrolytes.
Anion gap = (Sodium + potassium) — (Chloride + bicarbonate)
HbA1c.
Lipid profile:
Cholesterol.
Triglycerides.
HDL.
LDL.

CITY DIAGNOSTIC CENTER CDC

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20/10/2020

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[10/14/20]   Semen – Part 1 – Semen analysis, Semen Examination, and Semen Counting Procedure
Fluid analysisLab Tests
Sample
This is preferred if the patient in the lab collects the sample.
Masturbation is preferred, and the entire collected semen should be submitted.
The accepted volume is 2 to 5 mL.
Collect the sample when the doctor or the technician should be available to evaluate the motility immediately.
2 to 3 days of sexual abstinence is preferred.
Prolonged abstinence should be discouraged because of the sperm cells’ quality, and especially their motility will decrease.
The proper container is also important.
To evaluate the vasectomy, the patient needs to ejaculate once or twice before the days of semen specimen collection. This process will clear the distal portion of the vas deference.
Samples are unsatisfactory If the sample is obtained at the house by coitus interruptus or masturbation.
In the house sample, instruct the patient to deliver it within one hour of collection.
Instruct the patient to avoid cold and heat during transportation. The best is to keep the sample in the closed hands (in the fist).
Precautions
Don’t use condoms, particularly with spermicide.
The specimen should be maintained at 37 °C during transport if brought from home and should be examined within 3 hours of collection.
A sterile container is needed, and the sample should be collected at room temperature of 37 °C.
Plastic containers are not recommended.
Avoid extreme temperatures.
The analysis should be done immediately when the semen is liquefied.
Should be examined within 4 hours,
The sample should be kept at 37 °C.
Wait till liquefaction is complete for the examination.
Drugs that may decrease the count are:
Antineoplastic agents (nitrogen mustard, procarbazine, vincristine, and methotrexate).
Direct the patient to avoid alcohol intake for several days before the semen collection.
Purpose Of The Test (Indications)
This is the workup of the infertile couple.
This is done to evaluate the quality of sperms.
To confirm the efficacy of vasectomy (postvasectomy).
Done for the forensic studies.
To get semen for artificial insemination.
Pathophysiology
Definition of semen:
Seminal fluid is the secretion of prostate glands, two seminal vesicles, two Cowper glands, and testes serve as the vehicle for sperms transport and create the alkaline medium. It also provides nutrition. This serves as the medium which promotes the sperm’s motility and survival.
Semen (seminal fluid) consists of a combination of products of various male reproductive organs like testes, epididymis, seminal vesicle, prostate, bulbourethral, and urethral glands.
The ejaculated semen is a viscous, yellow-grey fluid, which forms a firm gel-like clot immediately after the ejaculation.
This clotted semen liquefies at room temperature (37 °C) within 5 to 60 minutes. If it requires more than one hour, that semen is considered abnormal.
Semen analysis includes:
Volume.
Sperm count.
Evaluation of the normal sperm.
Evaluation of the sperm motility.
The pH of the semen.
Spermatogenesis occurs in the seminiferous tubules of the testes. These are matured in the epididymis.
Semen production is dependant upon the function of testes.
These are stimulated by testosterone.
The concentration of the testosterone in the testes is 100 times more than the peripheral blood.
This high concentration of testosterone is needed for spermatogenesis.
LH stimulates the Leydig’s cells to produce testosterone.
These are lined with 46 chromosome germ cells called spermatogonia.
These cells undergo mitotic division and ultimately give rise to primary spermatocytes.
Secondary spermatocytes give rise to spermatids, and these will differentiate into sperm or spermatozoa containing 23 chromosomes.
Spermatogenesis and various forms of spermatocytes
Spermatogenesis and various forms of spermatocytes

Semen production depends upon the function of the testis.
Hypothalamus producing a gonadotropin-releasing hormone (GRH) in response to low testosterone levels.
GRH stimulates the pituitary gland to produce the follicular stimulating hormone.
Now the FSH stimulates the Sertoli cell, which is the location of sperm production.
FSH stimulates the Sertoli cells to secrete activin, which stimulates spermatogenesis.
Besides, the Sertoli cells secrete inhibin, which inhibits FSH secretion from the pituitary gland.
LH stimulates the Leydig cells, which produce testosterone. Testosterone then stimulates the seminiferous tubules to produce sperm.
Spermatogenesis (in the seminiferous tubules) takes approximately 3 months.
Maturation of the spermatogonia to mature spermatocytes takes approximately 75 days, through the epididymis.
In the epididymis, the motility is acquired; it takes another 14 days.
Spermatogenesis and the role of Hormones
Spermatogenesis and the role of Hormones

Spermatocytes develop from the Sertoli cells in the seminiferous tubules. They get matured in the epididymis and are ready for fertilization.
Spermatogenesis and Sperm can move in a female genital tract
Spermatogenesis and Sperm can move in a female genital tract.

Spermatogenesis process
Spermatogenesis process

In primary gonadal failure:
FSH is raised.
LH is raised.
In secondary gonadal failure:
FSH is decreased.
LH is decreased.
Classification of spermatocytes dependant upon the sperm count:
Aspermia (azoospermia) When there is no sperm.
Oligospermia when the count is < 20 million/mL.
Asthenospermia is low sperm motility.
Necrospermia Normal count of the sperm but are non-motile.
Hemospermia when there are abundant RBCs.
Various forms of the sperms
Various forms of the sperms

Semen Analysis Includes:
Volume. Check when the sample is fresh.
Sperm count. This can be done when the semen is completely liquified.
Motility. This should be checked when the sample is fresh and repeat when it is liquefied.
Morphology. This can be better appreciated if the smear is stained.
Normal
The volume is 2 to 6 ml.
Color is gray to white or opalescent.
Liquefaction time normally 10 to 30 minutes at 37 °C.
The volume normally is 1.5 to 5 mL.
pH varies between 7.7 to 8. Below, 7.0 usually has prostatic secretion.
Sperm count is 20 to 250 million/mL.
Normally a total count of more than 80 million/ml. But now it is considered as > 20 million /mL as fertile semen.
Live spermatozoa of more than 50%.
>65% of the sperm does not take stain, and these are alive.
Sperm motility >50% at one hour. This is moderate to the strong forward motion.
Place the semen drop on the prewarmed slide at 37 °C.
Examine under the 40x and find the motile sperm.
Evaluate the sperm actively motile and sluggish one.
Normally >70% of sperms are motile after one hour when the sperms are kept at 37 °C.
The progressive motility score is 3 to 4.
Sperm morphology should be >30%. Normally normal forms are >70%, and immature forms are 75 µg/ml.
Magnesium = >70 µg/ml.
Inositol = >1 mg/ml.
Glucosidase = >20 mU/ ejaculate.
Carnitine = >250 µg/ml.
Source 2 Normal semen

Volume = 2 to 5 mL
Liquefaction time = 20 to 30 minutes afte the collection.
pH = 7.12 to 8.0
Sperm count = 50 to 200 million/mL
Sperm motility = 60 to 80% actively motile.
Sperm morphology = 70 to 90% normal shaped
Structure of the normal Sperm
Structure of the normal Sperm

Pathological Semen:
The color is brown to red. Or maybe yellow and turbid.
Liquefaction time is >60 minutes.
Suppose the volume is

26/08/2020

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[07/04/20]   Blood banking – part 2 – Definition of blood banking, Donor selection, Blood Cross Matching Procedure, Compatibility test

Blood bankingLab Tests

Platelets concentratePlatelets are separated from a single unit of blood, suspended in40 to 60 mL of plasma. Stored at 20 to 24 °C. Indicated in thrombocytopenia due to any cause, and prevents bleeding in low platelets count Granulocytes collected by apheresis granulocytes are collected by apheresis.In neutropenia, and infection. It is more effective in infants than adults.Platelets collected by apheresisplatelets collected by apheresis and volume is 200 to 300 mLUsed as platelets concentrateLeucocyte poor bloodBlood where leucocytes are removedFor patients with leucocytes antibodiesFactor IX concentrateContains factor IXIn factor IX deficiencyII, VII, X, IX concentrateconcentrate of factorsCorrection of vitamin K-dependant factors deficiencyGamma globulinsContains gamma globulinsIn hypogammaglobulinemiaSerum albuminContains albuminIn burns, protein depletion, and blood volume restorerSample
Patient (recipient) venous blood in the disposable syringe is taken.
Take the blood sample from the donor.
Definition Of Blood Banking
This is the collection, storage, and testing of the blood components and derivatives.
There is a therapeutic use of blood components, plasma derivates, and apheresis technology.
It includes the collection, storage, and use of hematopoietic and other blood-derived cells.

Whole blood may be fractionated into:Packed RBCs.
Platelets.
Plasma products.

Plasma after processing provides:Albumin.
blood coagulation factors concentrate.
immunoglobulins preparation.
Precautions For The Donor (Rejection Of The Donor):

Do not take blood from the donor if:Blood donated in less than 8 weeks.
Poor health like cancer, cardiopulmonary disease, and bleeding disorder.
Pregnancy during and after 6 weeks of delivery.
Blood pressure more than 180/100.
Pulse when 50/min or more than 100/min. The only exception in the athlete where the pulse is usually slow.
Hemoglobin is less than 12.5 g/dL or hematocrit less than 38%.
The donor with a history of viral hepatitis like HBV, HCV, HIV, etc.
The donor with leukemia or lymphoma.
The donor with Malaria or coming from the malarial area should avoid giving blood for three years.
A person with the venereal disease should not give blood at least for one year (Syphilis or Gonorrhoea).
A person with rubella or varicella vaccination should not give blood for 4 weeks.
Donor if running fever > 99.5 °C.

History of recent surgery or illness needs to be considered unfit. In case of illness, after the recovery at least there should a period of 2 to 3 weeks interval free of any signs/symptoms.After the surgery, it depends upon the type of surgery and if he is under the supervision of a physician should be deferred.
If the donor has a cold, influenza or tooth extraction should be deferred at least for one week.
Donors with a history of allergies and allergy to drugs should be rejected.
Donors on drugs medication like antihypertensive drugs, antibiotics, and corticosteroids should be rejected.
Donors who have recent vaccination should be deferred at least for one week.
Criteria For The Selection Of The Blood Donor:

History of the donor:There is no history of viral hepatitis in the last 6 months.
No history of blood transfusion in the last 6 months.
There should be no contact with the patient of viral hepatitis.
Avoid drug addicts.
No history of tattooing in the last 6 months.
Blood positive for HBV or HCV or HIV.
Hemoglobin should be at least 12.5 G/dL. This should be checked before taking the blood.
Age: Ideal age between 18 to 65 years.
Bodyweight: The donor should weigh at least 50 kg (110 lbs).
History of recent immunization: Defer this donor for at least one week till they have no sign and symptom.
History of malaria: Such donors with a history of malaria should be deferred for at least three years. The people who have traveled to the malarial area should also be deferred for three years.

History of donation: Avoid professional donors because they have always low hemoglobin.The donor should not donate blood more than 4 times a year.
Male should donate more than females.
Donors should not donate the blood more than 4 times a year.
Females should donate less as compared to males because of the menstrual cycle where she may loose one point of blood donation per year.
Purpose Of Cross-Matching (Indication):
The primary purpose of the crossmatch is to prevent a transfusion reaction.
Crossmatch is done before the major surgery.
Crossmatch is also done before operation where there is usually no need for blood, e.g. hysterectomy, and cholecystectomy.

packed RBCs transfusion:Anemia when the hemoglobin is

Location

Products

Complete Dx service
1. CT SCAN
2. DR & XRAY
3. Ultrasound /Color Doppler
4. Complete Lab Services
5. Blood Bank
6. Consultant Clinics

Telephone

Address


Satellite Town
Rawalpindi
45000
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