CASE STUDY

1) A prisoner sentenced to 10 years for selling illegal drugs develops jaundice, lethargy, and
hepatomegaly. A test for hepatitis B surface antigen is positive, and the patient is placed in the
prison infirmary. When his condition appears to worsen and a low urinary output is observed, the
patient is transferred to a local hospital. Additional testing detects a superinfection with delta
hepatitis virus and decreased renal concentrating ability. Urinalysis results are as follows:

COLOR: Amber CLARITY: Hazy

KETONES: Negative NITRITE : Negative

GLUCOSE : Negative PROTEIN : 2+

BLOOD: Negative LEUKOCYTES : Negative

SP . GRAVITY : 1.011 UROBILINOGEN : 4.0

BILIRUBIN : Large pH : 7.0

Microscopic:
2 to 4 WBCs/hpf 0 to 1 RTE casts/lpf
1 to 2 hyaline casts/lpf 0 to 1 bile-stained waxy casts/lpf
1 to 3 RBCs/hpf
1 to 2 granular casts/lpf
2 to 4 bile-stained RTE cells/hpf

a) Based on the urinalysis results, in what area of the nephron is damage occurring?
b) Is this consistent with the patient’s primary diagnosis?

c) What is causing the RTE cells to be bile stained?

d) Why is the urobilinogen level elevated

e) State a disorder in which the urobilinogen level would be elevated, but the bilirubin result would
be negative

2) Upon arriving at work, a technologist notices that a urine specimen left beside the sink by
personnel on the nightshift has a black color. The initial report describes the specimen as yellow.

a) Should the technologist be concerned about this specimen?

b) If the specimen had an initial pH of 6.0 and now has a pH of 8.0, what is the most probable
cause of the black color?

c) If the specimen has a pH of 6.0 and was sitting uncapped, what is the most probable cause of
the black color?

d) If the original specimen was reported to be red and to contain RBCs, what is a possible cause
of the black color?

3) Cindy, a 20-year old woman, developed a febrile illness 10 days after returning from a weekend
hiking expedition in the New England countryside. She complained of headache, muscle aches,
chills, sweating, and fatigue at the college infirmary. Laboratory studies included Giemsastained
thick and thin blood smears. Ring and Maltese cross forms were detected within the red blood
cells.
a) What is the diagnosis of Cindy’s infection?
b) How is speciation of the organism causing this infection best achieved?
c) How is this infection transmitted?
d) What other disease(s) is (are) transmitted by this vector?

4) Anthony, a 30-year-old Italian man, worked as an archeologist in the Nile Valley. Anthony and
his team recently made an important historical discovery, the Providence Stone. This stone allows
a person’s mind and soul on his or her death to be transferred into another person’s body. To
celebrate this find, the team went out to a local pub for champagne and escargot (snails). The
team members became somewhat rowdy and insisted on ending the evening with a dip in the
Nile.

Approximately 1 month later, Anthony experienced increased urination with spots of

blood. He was also frequently tired and complained of a slight fever. Anthony explained his
symptoms to a local physician and was asked if he had eaten or done anything unusual lately.
Embarrassed, Anthony admitted only to an early morning swim in the Nile. On examination, the
physician ordered a complete blood count (CBC), Chem 6 (a battery of chemistry tests for Na+,
K+, Cl−, CO2, glucose, and BUN-blood urea nitrogen), and urinalysis (UA).
 The samples were sent to a laboratory. The CBC revealed eosinophilia. The Chem 6
results were normal. The UA showed a trace of blood. Microscopic examination of the
concentrated urine showed a yellowish-brown ovoid organism that measured approximately 115
by 50 µm.

a) What parasite, including its morphologic form, is suspected?

b) Name the disease caused by this parasite.

c) What is the first intermediate host associated with the life cycle of this parasite?

d) What is the mode of transmission for this parasite?

5) A 51-year-old, overweight white man visits his family physician with a symptom of “indigestion”
of 5 days’ duration. He has also had bouts of sweating, malaise, and headache. His blood pressure
is 140/105 mm Hg; his family history includes a father with diabetes who died at age 62 of AMI
secondary to diabetes mellitus. An electrocardiogram revealed changes from one performed 6
months earlier. The results of the patient’s blood work are as follows:

CK 129 U/L (30-60)

CK-MB 4% (<6%)
LDH 280 U/L (100-225)
LDH Isoenzymes LDH-1>LDH2
AST 35 U/L (5-30)

a) Can a diagnosis of AMI be ruled out in this patient?

b) What further cardiac markers should be run on this patient?

c) Should this patient be admitted to the hospital?

6) A nurse caring for patients with diabetes performed a fingerstick glucose test on the Accu-Chek
glucose monitor and obtained a value of 200 mg/dL. A plasma sample, collected at the same time
by a phlebotomist and performed by the laboratory, resulted in a glucose value of 225 mg/dL.
 a) Are these two results significantly different?

b) Explain.

7) A 65-year-old man presents to the emergency department after he had abnormally tarry-colored
stool on multiple occasions. He has had gastrointestinal discomfort and has felt increasingly tired
during the past 2 months. Physical examination reveals a guaiac-positive stool. A subsequently
colonoscopy identified a circumferential mass in the sigmoid colon. A biopsy was performed,
which identified the mass as an adenocarcinoma. CEA level was obtained as part of the
presurgery workup.

a) Is the CEA test useful as a screening test for colon carcinoma?

b) What other conditions can result in elevated CEA levels?

c) How is CEA used to monitor patients after surgery for colon cancer?

8) The co-anchor for a local television station newscast comes to a clinic for a blood test. The
phlebotomist recognizes her immediately. They have a pleasant conversation while the
phlebotomist draws the specimen. Later that evening the phlebotomist says to her husband,
“Guess who I drew today?” She then proceeds to tell him the co-anchor’s name, adding, “She is
probably bipolar because I drew a lithium level on her.”

a) What mistake did the phlebotomist make?

b) What law was violated by her actions?

c) What legal action could result?

9) A10-year-old boy became ill a few days after a fourth of July picnic where fried chicken was
served. He complained of diarrhea, abdominal pain, and fever. Symptoms continued over the next
week and he was seen at the local clinic. Blood was found in his stool and cultures were ordered.
He was treated with ampicillin but switched to azithromycin (a macrolide similar to
erythromycin) for 5 days when the cultures results were reported.

a) At 42° C in a microaerophilic environment, water droplet–type colonies were seen that were
oxidasepositive and strongly catalase-positive. A Gram stain showed gram-negative rods with
“seagull” shapes. What rapid test can be done to confirm the identity of this bacterium?

b) What testing is needed if the hippurate is negative?

c) How do you think our patient became infected? 4. Why can’t the nalidixic acid disk be used
in the identification of C. jejuni/coli?
10) Apatient has come to the emergency department at 11:00 pm with an unexplained fever; the
person had just returned from a trip to Africa. Blood is sent to microbiology for malaria smears
and to hematology for routine testing.

a) Should these requests be handled as stat requests or as routine orders?

b) How should the blood films be examined and why is it important to identify any organisms
present to the species level?

c) What are the chances that a malarial infection could be a “mixed infection”?

d) Can malaria parasites be detected using automated hematology instruments?

11) A2-year-old girl presented to her physician with a sore throat and fever. On examination, her
tonsils were enlarged and inflamed. A rapid test was performed for group A streptococci; the test
result was negative. The physician decided to treat with amoxicillin regardless of the test results
and asked that a culture be performed. The next day the laboratory reported that moderate growth
of beta-hemolytic group A streptococcus was present.

a) List the tests that rapidly identify group A streptococcus (Streptococcus pyogenes).

b) Not all group A streptococci are S. pyogenes. How can the nonpathogenic group A streptococci
be differentiated from the pathogenic strains?

c) Not all S. pyogenes are beta-hemolytic. What is the reason for this phenomenon, and how can the
laboratory ensure that it detects the nonhemolytic strains?

d) What is the sensitivity of rapid diagnostic tests to detect group A streptococcal antigen?

12) A 10-month-old Central American child was referred to the laboratory for testing after being seen
by a pediatrician. The phlebotomist noted that the child was very pale and listless. The following
tests were ordered: complete blood count (CBC), platelet count, reticulocyte count, total serum
bilirubin, total serum iron and TIBC, and a stool examination for occult blood, ova, and parasites.
The results were as follows:

Laboratory Data
Hemoglobin 5.6 g/dL
Hct 24%
RBC 3.5
WBC 10.5

The RBC indices were as follows:

MCV 68.6 fL MCH 16 pg MCHC 23 g/dL
 The peripheral blood smear revealed signifi cant anisocytosis, microcytosis, hypochromia, and
poikilocytosis. A normal distribution of platelets was present. Additional laboratory fi ndings
were as follows:

Platelet count 200 ´ 109/L

Reticulocyte count 0.5%
Total serum bilirubin 0.9 mg/dL
Serum iron 40 mg/dL
TIBC 465 mg/dL
Percent saturation of transferrin 8.6%

A stool examination was negative for occult blood, ova, and parasites.

a) What category of anemia is suggested by the morphology of the RBCs on the peripheral
blood smear?
b) What laboratory assays would be of additional value in establishing the diagnosis?
c) What is the most probable cause of the patient’s anemia?

13) An 8-year-old white girl had been complaining of fatigue and had experienced night sweats for
several weeks. Her mother took her to the pediatrician when she noted that the child was
beginning to look pale and had some unexplained large bruises. Physical examination revealed
that the mucous membranes were pale. Hepatomegaly was present, but lymphadenopathy was
absent. The physician ordered a routine complete blood count (CBC) and urinalysis.

Laboratory Data

The erythrocytes and hemoglobin were severely decreased. The total leukocyte count was 110 × 109/L.
The leukocyte distribution on the differential counts was as follows:

Blast cells 53%

Promyelocytes 12%
Myelocytes 8%
Metamyelocytes 6%
Bands 4%
Segmented neutrophils 10%
Lymphocytes 7%

Auer rods were seen in many of the blast cells. The thrombocyte distribution was severely
diminished on the peripheral blood smear. The result of urinalysis was normal.
 Follow-up cytochemical staining demonstrated that the blast cells were positive for Sudan black
B, with a variable number of moderate and coarse black granules. The PAS stain was negative. A bone
marrow aspiration revealed hyperproliferation of the granulocytic precursors.

a) What is the most probable diagnosis in this case?

b) What types of supplementary testing could be done to establish the diagnosis?
c) What is the prognosis in such a case?

14) You are working second shift at a Midwestern suburban hospital. Although you were trained in
school using gel technology, your lab utilizes the conventional tube testing method using LISS as
an enhancement medium, because the medical director refuses to adopt gel as the primary AHG
methodology. About an hour before the end of your shift, the phlebotomist brings you a routine
type and screen for a patient just admitted to the medical surgical floor. Because you are
confident you can finish before your shift ends, you decide to proceed with testing. The patient
types as an A-positive. The antibody screen results were negative in all phases of testing.
Therefore, check cells were added to all tubes and the reactions after centrifuging were also
negative.

a) Can the antibody screen be interpreted as negative?

b) What steps must be taken to resolve the problem?
c) What is the most likely cause for the discrepant results?
d) What are other causes for the results

15) Labor and delivery orders 4 units of packed red blood cells stat on a 32-year-old white female
with the following results: ABO/Rh—A-positive; antibody screen—no unexpected antibodies
detected; history—no unexpected antibodies in two previous deliveries at this facility, and no
previous red cell transfusions recorded.

a) What crossmatch options do you have?

b) Which do you choose and why?