CONTENTS
School of Immunity & Infection
College of Medical & Dental Sciences
Introduction
3
Contact address / telephone numbers / web addresses
3-4
Routine/Urgent assay processing
4
Specimen collection requirements:
Clinical Immunology Service
Laboratory Handbook
and price list
A brief guide for clinical and laboratory staff
General
Surface markers
Cell Function
4–5
39 – 40
45
Guide to appropriate use of immunology assays
6–7
Details of available assays/normal adult ranges
8 – 34
Assay turnaround times/costs
35 – 44
Cell function assays
45
APRIL 2010
2
INTRODUCTION
The Clinical Immunology Service (CIS), in the School of Immunity and
Infection, provides a comprehensive range of laboratory services. In particular
the CIS is a major testing centre for multiple myeloma, leukaemia/lymphoma,
immunodeficiency, autoimmunity and rheumatic diseases. The CIS laboratory
liaises closely with other on site laboratories, particularly pathology,
cytogenetics, haematology and chemistry.
This handbook provides information about turnaround times for assays,
together with test costs and other information about the laboratory staff,
working hours, results and their interpretation.
Normal working hours are 8:00am to 5:30pm from Monday to Friday. Clinical
advice is available from 8:00am to 8:00pm Mon – Fri via mobile telephone
numbers listed below. If you are unable to reach a clinician on their mobile,
please leave a voice mail and someone will contact you as soon as possible.
There is no on call service but clinically urgent requests may be arranged
through a clinician, clinical scientist or senior BMS by telephone.
Most analytes and autoantibodies are carried out on the same day, or the day
following receipt of the specimen. However many tests are expensive when
dealt with in small numbers and in order to maintain an economic cost and
acceptable turn around time such assays are ‘batched’ on certain days of the
week. (See page 4). If in doubt, please phone for advice.
Postal delays are notorious. Frequently we have despatched the results but the
report has not reached its destination. We are now able to offer an automated
email reporting system. Please contact the Laboratory Manager for information
and implementation (0121 414 3092). Address: Clinical Immunology Service,
School of Immunity and Infection, The Medical School, University of
Birmingham, Vincent Drive, Edgbaston, Birmingham, B15 2TT
Telephone numbers: (University switchboard prefix 7600 from UHB Trust)
Results: (0121) 414 3824/4069
Clinical enquiries:
(Mobile) 07831 681955 General clinical enquiries (Prof PJL Lane)
Email: P.J.L.Lane@bham.ac.uk
(Mobile) 07798 585319 Myeloma/Lymphoma/Leukaemia enq. (Dr MT Drayson)
Departmental Website:
Services: http://www.ii.bham.ac.uk/clinicalimmunology/
Image library: http://www.ii.bham.ac.uk/clinicalimmunology/CISimagelibrary/
Neuroimmunology: http://www.ii.bham.ac.uk/clinicalimmunology/Neuroimmunology/
Daily assays:
As a guide most immunochemistry, indirect
immunofluorescence, electrophoresis, cell markers and some neuroimmunology
assays are carried out daily. Radial immunodiffusion (RIDs) though carried out
on a daily basis take three days to completion.
Batched assays: Non urgent, expensive or labour intensive assays which are
batched on a weekly basis are: Cardiolipin abs (Wednesday); dsDNA abs
(Tuesday and Friday); ENA abs (Thursday); Intrinsic factor abs
(Wednesday); GBM abs (Wednesday and Friday); Functional C1Inh (Friday);
tTG/Gliadin abs (Monday); Organ specific abs (Friday); IgG subclasses
(Tuesdays); MPO/PR3 EIA (Tuesday & Thursday).
Urgent assays: Certain assays are available with a rapid turnaround time.
These include ANA, ANCA, dsDNA abs, glomerular basement membrane
(GBM) abs, myeloperoxidase and proteinase 3 abs (ANCA). Specimens
should be sent, or preferably brought, to the laboratory with the request form
clearly marked “Urgent”. Prior warning for urgent requests is essential. It
should be noted that urgent requests will incur an additional charge and where a
qualitative result is provided (GBM, MPO and PR3) these will be followed up
with quantitative assays when the next batch is processed.
General specimen collection:
When sending specimens to the laboratory the following should be noted:
•
Some complement components are labile. For these assays send 10ml of
whole blood (for C3d use EDTA blood) immediately after venepuncture.
For distant clinics the serum or plasma should be separated within the hour,
frozen and sent to the laboratory to arrive frozen.
•
For cryoglobulins whole blood to be taken into a warm syringe, transferred
to a warm tube and brought to the laboratory whilst being maintained at not
less than 37°C (and up to 45°C). Prior warning that this test is required is
appreciated.
•
For Von Willebrand factor (FVIII Rag) use citrated tubes (4ml).
Email: M.T.Drayson@bham.ac.uk
(Mobile) 07884 310528 Myeloma/Lymphoma/Leukaemia enq. (Dr SD Freeman)
Email: S.Freeman@bham.ac.uk
3
4
GUIDE TO THE APPROPRIATE USE OF IMMUNOLOGICAL
ASSAYS.
•
•
•
Urinary free light chains (BJP). A 25ml aliquot of a random urine in a
universal container (NO preservative) sent together with 10ml clotted
blood.
T cell antigen receptor & Immunoglobulin gene rearrangement
studies: Please supply blood or bone marrow samples drawn into an EDTA
bottle (N.B. Heparinised material may interfere with PCR process).
T-SPOT TB: A Li Heparin specimen is required for this assay. Samples
must arrive in the laboratory before 2pm on the same day as they are
drawn. This assay must be booked with laboratory staff before sending.
Testing is carried out on Tuesdays and Thursdays
Arthritis screen:
Anti-nuclear antibodies (ANA); C Reactive protein (CRP): Rheumatoid factor
(RF) and Cyclic citrulinated peptide (CCP) antibodies.
Autoantibody screen:
Anti-nuclear antibodies (ANA); Gastric parietal cell (GPC) antibodies; Liver
kidney microsomal (LKM) antibodies; Mitochondrial (MT) antibodies and
Smooth muscle (SM) antibodies.
Autoimmune thyroid disease:
For all cell markers and cell functional assays please see the notes at the back of
this book under ‘Cell Marker Tests’ (p39 – 40) and ‘Investigation of immune
deficiencies’ (p45).
Request thyroid peroxidise (TPO) antibodies
All high-risk specimens and accompanying form must be clearly labelled.
Anti-nuclear antibodies (ANA); Anti neutrophil cytoplasmic antibodies
(ANCA) and C Reactive protein (CRP)
Please also note special requirements for cell work and neuroimmunology
requests both of which have separate request forms.
Investigation of allergy:
Vasculitis screen:
Request total IgE in conjunction with specific IgE RAST tests to individual
allergens indicated by clinical history
Diagnosis of SLE:
Request: Anti-nuclear antibodies (ANA); dsDNA antibodies; Extractable
Nuclear Antigen (ENA) antibodies; Complement C3 and C4; anti cardiolipin
(ACL) antibodies; Immunoglobulins (IgG, A, M) and C Reactive protein
(CRP).
Follow up of SLE:
Request dsDNA abs; C3/C4, and CRP. (IgG, A, M and ENA at no less than 12
monthly intervals)
5
6
SLE in pregnancy or with planned pregnancy.
These patients should also have their anti-cardiolipin (ACL) antibodies assayed.
List of assays available through the department:
TEST:
(Preferred sample: normal range)
Monitoring Infections:
Alternate day samples for CRP will give adequate information regarding
response to antibacterial therapy. CRP, an acute phase protein, has a half-life
of 4-6 hrs.
Acetylcholine receptor abs
(Serum: 0 – 5 x 10-10 moles/l)
Test for Myasthenia Gravis.
Adrenal cortical abs
(Serum: Negative)
Test for autoimmune adrenal disease.
Adverse Anaesthetic reactions
In suspected cases where a patient has had
symptoms of an adverse reaction we
recommend the following: A clotted blood
sample should be taken immediately and at
24 hrs post reaction and sent to the clinical
immunology laboratory for measurement of
serum tryptase. Please indicate time/date of
adverse reaction and time/date of samples.
Raised levels of this enzyme indicate
systemic mast cell degranulation and
substantiate
clinical
suspicions
of
anaphylactic reactions. To identify which
drug precipitated the reaction and to find
safe alternatives we recommend skin prick
and intradermal testing.
Diagnosis of Myeloma: Full characterisation (Blood and Urine)
IgG, IgA and IgM; electrophoresis; total protein; albumin; densitometry;
immunofixation; B2Microglobulin (B2M); cryoglobulin; viscosity; kappa and
lambda light chains and creatinine.
Monitoring Myeloma: Follow up (Blood and Urine).
IgG, IgA and IgM; electrophoresis; total protein; albumin; densitometry; B2M;
kappa and lambda light chains and creatinine.
Mast cell tryptase
(Serum: 0 – 13.5 µg/l)
In conjunction with Heartlands Hospital, the
University of Birmingham’s Clinical
Immunology Service runs an outpatient
clinic for patients with allergy at the Chest
Clinic in Great Charles Street, Birmingham
B3 3HX. All patients should be referred to
Prof Peter Lane at the above address (phone
07831 681955). Please indicate all drugs
administered to the patient prior to the
allergic reaction.
7
8
Antinuclear abs
(Serum: Titre <1:40)
ANA titres of 1/40 are generally
not significant in adults, but can
be in children.
Antibodies against ENA usually
give a low titre ANA result but
to exclude ENA abs an ENA
screen should be performed
rather than relying upon a
negative ANA result.
Anti-C1q autoantibodies
(Serum: 0 – 15 units/ml)
ANA’s are associated with a variety of
conditions other than SLE including
rheumatoid diseases, chronic active hepatitis,
fibrosing alveolitis, viral infections and drug
ingestion. Patterns of ANA are said to be
significant: Nucleolar associated with
scleroderma, centromere with CREST
syndrome, and speckled pattern with MCTD,
Sjögrens, SLE and Polymyositis. Rim or
homogeneous has been associated with SLE
but there is a considerable amount of pattern
overlap.
Aquaporin 4 antibodies
Autoantibodies against C1q are a major
criterion
in
the
diagnosis
of
hypocomplementaemic urticarial vasculitis.
They are also found in up to 50% of SLE
patients and 95% of patients with lupus
nephritis. C1q antibodies may be useful for
assessing the risk of renal flares, and also for
monitoring
the
effectiveness
of
immunosuppressive treatment in active lupus
nephritis.
See NMO antibodies
Aspergillus - specific IgG abs
(Serum: Negative)
Specific IgG antibodies directed against
aspergillus fumigatus are currently available.
Basal ganglia antibodies
(BGA) (Serum: Negative)
Anti-BGA antibodies are reported in patients
with post-streptococcal infection(s) and
movement disorders associated with basal
ganglia. This is a useful diagnostic marker of
neurological disorders such as Sydenham’s
chorea, tic and an encephalitis lethargica-like
syndrome. This assay is currently sent to
Immunology, Churchill Hospital, Oxford.
Bence Jones Protein
Please see urinary free light chains
B2 microglobulin (B2M)
(Serum: 0 – 4.0 mg/l)
Useful for monitoring lymphocyte activation
and turnover in myeloma and HIV related
diseases. Because B2M is metabolised in the
renal tubules high levels are seen in patients
with renal dysfunction.
B2GP1 antibodies
(Serum: IgG: 0 – 20 U/ml)
B2GP1 is a 50kD plasma protein
(apolipoprotein H) that inhibits the intrinsic
coagulation pathway, ADP mediated platelet
aggregation and the prothrombinase activity
of activated platelets. “Anti cardiolipin abs”
bind to an altered form of B2GP1 which may
be reproduced by binding B2GP1 directly to
an ‘ELISA’ plate. The detection of antiB2GP1 abs is said to have enhanced
specificity for APS and related coagulation
disorders over the traditional anti-cardiolipin
assay, which may display some false positive
results due to cross reactivity of these abs
with some infectious disease related
antigens. This is currently a quantitative IgG
antibody assay.
[Also see cardiolipin antibodies]
Also see fungal antigens
Avian antigens - specific IgG
abs (Serum: Negative)
Specific IgG antibodies directed against
budgerigar and pigeon antigens are currently
available.
Caeruloplasmin
(Serum: 0.15 – 0.60 g/l)
9
Copper binding serum protein, levels of
which are reduced in Wilson’s disease,
nephrotic syndrome and Menkes’ kinky hair
syndrome. Raised levels are found in chronic
active liver disease, pregnancy, leukaemia,
post trauma, infectious diseases and after
myocardial infarction.
10
Cardiac abs
(Serum: Negative)
Though the diagnostic value is low these abs
are found in some patients with Dressler’s
syndrome, following myocardial infarction,
after cardiac surgery and in some
cardiomyopathies.
Cardiolipin/Phospholipid abs
(Serum: IgG: 0 – 12 GPLU/ml
IgM: 0 – 10 MPLU/ml)
Antibodies have been associated with SLE,
recurrent miscarriages and arterial and
venous thrombosis. Slightly elevated levels
may be found in some infections and so only
positive results at two time points at least 6
weeks apart are considered significant. IgG
and IgM antibodies are assayed separately.
Significant levels of abs do not necessarily
correlate with the severity of the disease.
Please note that lupus anticoagulant is
performed in haematology.
[Also see B2GP1 abs]
C-Reactive Protein
(Serum: 0 – 10 mg/l)
Viral infection/AI disease:
11 – 49mg/l
Bacterial infection:
50 – 100mg /l
As CRP has a short serum half-life this acute
phase protein is useful in distinguishing
bacterial
infections,
inflammatory
conditions, activity of rheumatoid arthritis
and monitoring response to therapy. It is not
affected
directly
by
steroids
or
immunosuppressives.
Major bacterial infection:
>100mg/l
11
CSF pigments (scan)
xanthochromia
(Red cell free CSF:
Normal Spectroscopy no
pigments detected)
Important in the evaluation of the 14% of
subarachnoid haemorrhage patients who are
both orientated and CAT scan negative with
absence of xanthochromia by visual
inspection
of
CSF.
Spectroscopic
xanthochromia is defined by the presence of
bilirubin peak at 478 nm in the supernatant
after centrifugation of freshly obtained CSF.
NB: A traumatic tap leading to blood
stained CSF will obfuscate interpretation of
xanthochromia. Pseudo- xanthochromia can
result from in vitro haemolysis of as little as
1,000x103 red cells per ml if CSF is left for
12 hrs or more at room temperature.
CSF Tau protein:
asialo-transferrin
Present only in CSF
Cerebrospinal rhinorrhoea is potentially
serious due to risk from infection. In patients
presenting with a nasal discharge of clear
fluid it is important to identify the nature of
the fluid. CSF is readily identified by the
presence of asialo-transferrin (Tau protein).
This laboratory offers a reliable, sensitive
and simple electrophoretic method for the
rapid identification of Tau protein.
Please send whole blood/serum
sample for control purposes.
Complement C3 and C4
(Serum: C3: 0.75 – 1.75 g/l)
C4: 0.14 – 0.54 g/l)
Measurement of C3 and C4 is of value in
monitoring activity of SLE and in immune
complex disease. C4 is of particular value in
SLE and angioedema when levels are well
below normal. When taking blood care
should be taken to avoid unnecessary in vitro
activation of complement.
C1q complement component
(Fresh serum: 0.08 – 0.15 g/l)
IgG antibodies to the collagen-like region of
C1q have been described in patients with
SLE and are said to be present in 30% of
patients with active disease. Serum C1q is
found to be lowered due to activation of
immune complexes, which are deposited on
capillary walls.
12
C1 (esterase) Inhibitor
Immunochemical levels:
(Fresh serum: 0.18 – 0.30 g/l)
Functional activity
(Fresh serum: 70 – 130%)
Hereditary
Angioedema:
Autosomal
dominant. Most cases have reduced serum
C1Inh levels. In 10% of cases there are
normal or elevated levels of C1Inh but this is
functionally
inactive.
In
hereditary
angioedema C4 levels are almost always
reduced and C1q levels are normal.
Please see page 4 for collection
procedure
Acquired angioedema: Have reduced
C1Inh levels and usually reduced levels of
both C4 and C1q. Associated with B cell
neoplasia.
C3d complement component
(EDTA plasma : 0 – 3 mg/l)
C3d is a 35kD product derived from
protease activity on native C3b and may be
detected in fresh plasma indicating in vivo
activation of the complement cascade. It is
essential that blood is collected in EDTA
bottles and the sample transported to the
laboratory without delay. This assay is
currently sent to Immunology PRU,
Northern General Hospital, Sheffield
C3 Nephritic factor
(Fresh Serum: Negative)
C3 nephritic factor is an IgG antibody,
which stabilises the alternative pathway C3
convertase leading to continuous C3
breakdown. It is associated with type II
MPGN and also with partial lipodystrophy.
Please note: C3 nephritic factor will not be
carried out in the presence of normal levels
of C3. This assay is currently sent to
Immunology PRU, Northern General
Hospital, Sheffield
13
Complement function
Classical pathway (CH50)
(Fresh serum: Normal)
Currently referred to Immunology at
Birmingham Heartlands Hospital, this assay
tests the integrity of the classical pathway of
complement. Low levels are found when any
one component is absent or non-functional.
Assays for the individual complement
components are available as follow up.
Please see full list on page 37. Refer to
important notes regarding collection of
blood and its despatch to the laboratory
(page 4).
Complement function
Alternative pathway
(Fresh serum: Normal)
Currently referred to Immunology at
Birmingham Heartlands Hospital, this assay
tests the integrity of the alternative pathway
of complement and the terminal sequence
(C3-C9) components. Low levels are found
when any one component is absent or nonfunctional. Assays for the individual
complement components are available as
follow up. Refer to important notes
regarding collection of blood and its
despatch to the laboratory (page 4).
Cryoglobulins
(Serum: Negative)
When cryoglobulins are associated with
Waldenströms
macroglobulinaemia,
myeloma or lymphoma they consist of one
immunoglobulin isotype but may be mixed
or polyclonal in other diseases such as
connective tissue diseases. Patients with
renal disease and a low C4 level or patients
with unexplained cutaneous vasculitis should
be screened for presence of circulating
cryoglobulin.
Please refer to special
conditions of collection and despatch to
laboratory (page 4).
Positives may be typed:
monoclonal, polyclonal or
mixed (IgG/A/M).
14
Cyclic citrullinated
(CCP) antibodies
(Serum: 0 – 7)
peptide
Anti-CCP
antibodies
are
potentially
important surrogate markers for diagnosis
and prognosis in rheumatoid arthritis (RA),
because they:
Extractable Nuclear Antigen
(ENA) antibodies
(Serum: 0 – 10 ELISA units)
ENA antibodies recognise saline extracted
nuclear antigens. There are many
specificities recognised of which this
laboratory currently offers six:
Sm (a
marker for SLE); RNP (said to be present in
>95% MCTD); SSA [Ro] (associated with
SLE, cutaneous lupus, neonatal lupus and
congenital heart block); SSB [La] (SLE,
Sjögrens syndrome); Jo1 (30% of
polymyositis cases) and Scl70 (associated
with systemic sclerosis). Patients with SLE
or Sjögrens should be screened for ENA abs
especially females considering pregnancy.
Functional antibodies
(Serum)
Pneumococcal ab protective
level is 0.35 ug/ml for each
serotype. 7/12 serotypes tested
(4, 6B, 9V, 14, 18C, 19F, 23F)
are present in both pneumovax
II and Prevnar whilst a further
5 are present only in pneumovax
II (1, 3, 5, 7f, 19a). A normal
adult response to Pneumovax II
is >0.35 ug/ml in 8/12 serotypes
(6/12 in children aged 2 to 5
years).
Meningococcal ab protective
level is 2.0 ug/ml for each
serotype.
Hib ab protective levels - 1.0
ug/ml (long-term) and
0.15ug/ml (short-term).
Tetanus and Diphtheria ab
protective levels are 0.1 IU/ml
(long-term) and 0.01 IU/ml
(short-term).
Specific
antibody
production
is
recommended for first line investigation of
B-cell function. In patients with recurrent
infections, functional antibody responses can
be abnormal even if immunoglobulin and Ig
subclass levels are normal. T-cell dependent
protein antigens (e.g. Tetanus and Diphtheria
toxins)
and
protein
conjugated
polysaccharides eg. Meningococcal C
conjugate vaccine, Prevnar conjugate
vaccine and Haemophilus influenzae
conjugate vaccine produce an IgG1 response
whilst pure polysaccharide antigens (e.g.
Pneumovax II and meningococcal ACWY
unconjugated polysaccharide vaccines) elicit
an IgG2 response. Antibody responses are
normally assessed 4 – 6 weeks after
vaccination.
•
are as sensitive as, and more
specific than, IgM rheumatoid factors (RF)
in early and fully established disease
•
may
predict
the
eventual
development into RA when found in
undifferentiated arthritis
•
RA
are a marker of erosive disease in
•
may be detected in healthy
individuals years before onset of clinical RA
dsDNA abs
(Serum:
Crithidia IIF: Negative
EIA: 0 – 75 IU/ml)
Assay of abs to native, double stranded DNA
(dsDNA abs), is carried out on all patients
with SLE, as a qualitative test by IIF on the
kinetoplast of crithidia lucillae which is then
followed up with a quantitative assay by
EIA. dsDNA antibodies may be detected in
the absence of ANA and are extremely
useful in monitoring the activity of the
disease.
Endomysial abs
(Serum: Negative)
IgA abs directed against the endomysium are
detected in 70% of patients with dermatitis
herpetiformis and >90% of patients with
untreated coeliac disease but are rarely
present in normal individuals or in patients
with other enteropathies.
Decreasing
antibody titres correlate well with adherence
to gluten free diet. See also gliadin abs.
[Also see Transglutaminase]
15
16
Fungal antigens – Specific IgG
(Serum: Negative)
Specific IgG antibodies directed against
candida albicans, aspergillus fumigatus and
micropolyspora faeni are currently available.
Note: most adult women will have low levels
of candida antibodies.
Ganglioside abs GD1b
(Serum: IgG <1:500
IgM <1:500)
Antibody to the ganglioside GD1b has been
associated with motor or sensorimotor
neuropathies. High titres of anti GM1 are
most typical of multifocal motor neuropathy
but abs to other gangliosides such as GD1b
and asialoGM1 may also be detected. Low
titres of abs directed against GD1b, GM1
and asialoGM1 may also be detected in
amyotrophic lateral sclerosis and Guillain Barré syndrome. These abs are currently
screened in house and positives are sent to
Neurology, Southern General Hospital,
Glasgow, for quantitation.
Ganglioside abs GM1
(Serum: IgG <1:500
IgM <1:500)
The presence of abs directed against GM1
(monosialoganglioside GM) has been
associated with motor and sensorimotor
neuropathies and in particular with multifocal motor neuropathies. Lower titre of
GM1 abs may also be found in amyotrophic
lateral sclerosis and Guillain - Barré
syndrome. a’GM1 abs may occur as either
polyclonal or IgM monoclonal abs. The
carbohydrate moiety of GM1, in particular
the galactose and sialic acid residues, is the
site of antibody binding to gangliosides.
Due to the presence of similar moieties on
other gangliosides low levels of antibody
cross-reaction may be experienced in tests
for gangliosides other than GM1. These abs
are currently screened in house and positives
are sent to Neurology, Southern General
Hospital, Glasgow, for quantitation.
17
Ganglioside abs GQ1b
(Miller Fisher syndrome)
(Serum: <1:500 IgG & IgM)
These abs are currently screened by this
department and positives are sent to
specialist centres for confirmation. Please
see price list for full details of assays done.
These abs are currently screened in house
and positives are sent to Neurology,
Southern General Hospital, Glasgow, for
quantitation.
Ganglioside abs sulphatide
(Sensory neuropathy)
(Serum: <1:10000 (IgG & IgM)
These abs are currently screened by this
department and positives are sent to
specialist centres for confirmation. Please
see price list for full details of assays done.
These abs are currently screened in house
and positives are sent to Neurology,
Southern General Hospital, Glasgow, for
quantitation.
Gastric parietal cell abs
(Serum: Negative)
These antibodies are present in up to 90% of
patients with atrophic gastritis and
pernicious anaemia. Also present in gastritis
without anaemia (12%), autoimmune thyroid
disease (30%), Addison’s disease (25%) and
iron deficiency anaemia (20%).
Intrinsic factor Abs should be
carried out in conjunction with
GPC Abs
18
Gliadin abs
(Serum: IgA <10 mg/ml
IgG <70 mg/ml)
Gliadin Abs are often seen in
patients with inflammatory
bowel and liver disease and they
do not necessarily indicate
underlying coeliac disease.
Endomysial, tissue trans glutaminase (TTG), antibodies
are much more specific tests for
Coeliac Disease, but are
negative in patients with IgA
deficiency where gliadin abs are
most clinically useful.
Glomerular basement
membrane abs
(Serum: 0 – 3 EU/ml)
A rapid qualitative test is now
available
In susceptible individuals alpha gliadins are
known to activate Coeliac Disease a gastrointestinal disorder characterised by the
flattening of the jejunal mucosa. The
laboratory offers a quantitative enzyme
immunoassay, which allows monitoring of
the patient for both IgG and IgA abs. The
titre of IgA abs decreases with gluten free
diet, as does the level of endomysial abs and
TTG antibodies.
IgA Gliadin abs are more specific for
Coeliacs than IgG (~95% compared to
~60%) but IgG abs are more sensitive (~8090% c.f. ~50%). It has been reported that
IgA deficient patients have a ten to fifteen
fold increased incidence of Coeliac Disease.
It is suggested that gliadin abs are carried out
in all IgA deficient individuals.
Test for Goodpastures syndrome. Abs to the
non collagenous portion of type IV collagen
are detected by EIA as indirect
immunofluorescence is both less sensitive
and less specific being positive in only 75%,
or less, of proven cases. Urgent requests for
GBM abs (as with ANA, ANCA and dsDNA
abs) must be arranged with the laboratory.
Glutamic acid decarboxylase:
Stiff Man syndrome
(Serum: 0 - 10 IU/ml)
Glutamic acid decarboxylase (GAD) is an
enzyme concentrated in neurons, which
control muscle tone and exteroreceptive
spinal reflexes. High levels of abs to GAD
are found in ~60% of patients with Stiff man
syndrome; in IDDM the titres are much
lower. The contribution of GAD abs to
IDDM has not been proved.
IgA antibodies
(Serum: zero titre (negative))
IgA abs occur in IgA deficient patients in
receipt of blood products containing IgA.
Their presence is indicative of risk of
adverse transfusion reactions. This assay is
currently sent to the National Blood Service,
Bristol.
19
IgA Subclasses
(Serum: IgA1 0.64 – 3.40 g/l
adult
IgA2 0.11 – 0.60 g/l)
The clinical significance of IgA
subclass deficiency is unknown.
It may be a marker for
underlying impaired antibody
responses to bacterial
polysaccharide antigens.
Immunoglobulins (IgG/A/M)
(Serum IgG: 6.00 – 16.00 g/l
(adult): IgA: 0.80 – 4.00 g/l
IgM: 0.50 – 2.00 g/l)
IgA comprises two subclasses of which, in
serum,
IgA1
predominates
(85%).
Consequently deficiencies or even complete
absence of IgA2 may go undetected with
normal or near normal levels of total serum
IgA. The functions of the two subclasses of
IgA are comparable to IgG1 and IgG2 but
their activity is on mucosal surfaces whereas
IgG is intravascular. The immunology
laboratory offers RID assays of IgA1 and
IgA2 with a turnaround of up to 28 days.
Immunoglobulins are an essential request in
recurrent infections, lymphoproliferative
diseases including myeloma and all cases of
‘failure to thrive’. IgA deficiency occurs in
1:500 individuals but, transfusion reactions
apart, may not be associated with disease.
Polyclonal increases of IgG occur in chronic
infection and inflammation, chronic liver
disease and connective tissue diseases.
Raised levels of IgM are found in acute
inflammation and in primary biliary
cirrhosis. (Markedly elevated IgM in the
presence of mitochondrial abs is virtually
diagnostic of PBC) Low levels of IgG and
IgA may be due to loss (protein losing
enteropathy or nephrotic syndrome) reduced
synthesis (lympho - proliferative disorders
or primary immunodeficiency) or excessive
catabolism. Low levels of immunoglobulins
always indicate further investigation. Where
appropriate details are supplied age and sex
related normal levels are printed on the
report. See also sub-classes (IgG and IgA)
and functional abs.
20
IgG Subclasses
(Serum IgG1: 2.75 – 9.50 g/l
adult: IgG2: 1.20 – 4.50 g/l
IgG3: 0.17 – 1.79 g/l
IgG4: 0.00 – 1.30 g/l)
Generally functional antibodies
to tetanus (a T-cell dependent
antigen), and Pneumovax (a T
cell independent antigen) give a
much better picture of the
capacity to mount protective
antibody responses than total
subclass assays.
IgG subclass deficiency is mainly related to
IgG1 and IgG2 where individuals suffer
recurrent infections because they are unable
to mount an antibody response against
organisms. (This may be ascertained
employing functional antibody assays using
Tetanus toxoid requiring the presence of
IgG1 and pneumococcus requiring IgG2)
Detected in 70% of patients with pernicious
anaemia. Assayed by enzyme immunoassay
this test should be carried out together with
gastric parietal cell abs.
Isoelectric focusing
(Oligobanding) IgG
(Paired serum and CSF:
Clinical comment is supplied
with each report)
Oligobanding refers to discrete populations
of immunoglobulin detected by electrophoresis in CSF, which are NOT paralleled
in serum from the same patient. Oligo
banding is seen in ~85-95% of patients with
clinically proven multiple sclerosis. The
assay is useful as a confirmatory test in
multiple sclerosis but bands are not specific
for this disease as they also occur in
cerebrovascular accidents, in infections of
the CNS and in pathological processes
involving an immune response e.g.:
encephalitis, neurosarcoid and SLE. Please
note that paired samples of CSF and serum
are essential for this assay.
Please enclose CSF protein
value with each request
Immunoglobulin D (IgD)
(Serum: 2 – 100 mg/l)
There is no known clinical significance for
the measurement of serum IgD except in the
case of IgD myeloma and periodic fever.
Immunoglobulin E (IgE)
(Serum: 0 – 90 IU/ml, adult)
Serum IgE may be helpful in diagnosing
atopic diseases however the normal range is
very wide and levels do not always correlate
well with symptoms. A high level of specific
IgE to a single allergen may be seen with a
normal level of IgE. Very high levels of IgE
are seen both in atopic eczema and in
parasitic infestations (especially S Mansoni).
Please note that paediatric values are
quoted on all reports provided that the age
of the patient is given.
N.B. Our normal range is given
for Caucasians. Due to
environmental factors, and an
inherited capacity to produce
higher quantities of Igs, other
ethnic groups, notably Black
Africans, may have higher
normal levels compared to
Europeans.
Intrinsic factor abs
(Serum: Negative)
21
Liver antigen abs (blot)
LKM abs
(Serum: Negative)
Detection and confirmation of antigen
specific antibodies associated with primary
biliary cirrhosis and autoimmune hepatitis.
These include M2, LKM-1, LC-1 and
SLA/LP.
These abs, which stain the cytoplasm of
hepatocytes and proximal renal tubules, and
hence, to the untrained eye are difficult to
distinguish from mitochondrial abs by IIF,
are found in a subgroup of patients with
ANA negative, autoimmune chronic active
hepatitis (CAH). LKM1 abs are positive in
CAH type 2, which is the most common
autoimmune liver disease of childhood and
has a relatively unfavourable prognosis.
22
Lymphocyte cell markers
A wide range of lymphocyte markers for
assessment of immunodeficiency and
lymphoproliferative diseases are available to
the West Midland Region. A separate
request form is in use for cell markers.
Lymphocyte function tests
Special sample requirements. Please discuss
with Consultant Immunologist.
Mitochondrial abs
(Serum: Negative)
Present in >95% of cases of primary biliary
cirrhosis usually in high titre (>1:200). Also
occasionally present in chronic active
hepatitis and halothane induced hepatitis
patients but with titres of <1:100. Serum
IgM levels are invariably increased.
Mitochondrial (M2) abs
(Serum: 0 – 10 EU/ml)
For those wishing to confirm the presence of
mitochondrial abs or to monitor patients with
a quantitative assay an EIA method is
available which distinguishes three separate
mitochondrial abs (enzymes) and affords a
quantitative assay in EU’s/ml.
Currently abs to the major enzyme pyruvate
dehydrogenase complex (M2) are assayed
routinely.
MuSK antibodies
(Serum: Negative)
Muscle specific tyrosine kinase (MuSK) is a
surface membrane enzyme that is thought to
be essential in aggregating AChR during the
development of the neuromuscular junction.
Anti-MuSK antibodies assist in confirming
the diagnosis in seronegative myasthenia
gravis (MG). These are particularly useful
when clinical features are not typical for
MG.
This assay is currently sent to
Immunology, Churchill Hospital, Oxford.
23
Myeloperoxidase (MPO) abs
(Serum: 0 – 8 EU/ml)
A rapid qualitative test is now
available.
Antibody to myeloperoxidase is associated
with organ-limited vasculitis including
necrotising and crescentic glomerulonephritis. The assay is useful in confirming
MPO specific abs in sera which are positive
for anti neutrophil cytoplasmic abs of the
perinuclear type (pANCA). Typically the
level of MPO abs parallel disease state with
increasing levels when vasculitis is active.
Urgent requests must be arranged with
the laboratory.
Neutrophil cytoplasmic abs
(ANCA)
(Serum: Negative)
Pattern and titre reported on
positives
c-ANCA is a test for Wegener’s granulomatosis and for microscopic polyarteritis
(see also test for proteinase 3). pANCA may
occur in other vasculitic disorders as well as
some forms of glomerulonephritis (see also
test for myeloperoxidase).
[See MPO & PR3 antibodies]
Neutrophil function test
Special samples required. Please discuss
with Consultant Immunologist.
NMO antibodies
(Serum: Negative)
Anti-NMO antibodies are associated with
neuromyelitis optica (NMO) also known as
Devic’s disease and optic-spinal multiple
sclerosis. It is a severe inflammatory
demyelinating disease that affects optic
nerves and spinal cord without affecting the
brain. Aquaporin 4 has been identified a
major NMO antigen and the test offer is
against this antigen. This test is used to
distinguish NMO from multiple sclerosis.
This assay is currently sent to Immunology,
Churchill Hospital, Oxford.
24
Pancreatic islet cell abs
(Serum: Negative)
At the time of diagnosis 75% of type I
diabetics have detectable levels of
circulating islet cell abs.
Such abs
decrease and eventually disappear with
duration of disease. Some studies have
indicated persistent levels of abs in
association with polyendocrine disease (type
Ib). There have been no reports of abs to
pancreatic islet cells in type II diabetics.
Paraprotein (M-protein)
quantitation
Reported in g/l.
Levels of monoclonal IgG, IgA, IgM, IgD
and in some instances IgE are measured
immunochemically and in all cases of follow
up the previous specimen is run in parallel to
confirm
the
change
in
M-protein
(paraprotein) level. Immunofixation of
presentation sample defines both the isotype
and light chain type. Follow up specimens
will be subjected only to electrophoresis
unless immunofixation is required to confirm
complete response. (See ‘guide to
appropriate use of tests at the front of this
booklet). The presence of an M-protein
(paraprotein) should prompt investigation of
B cell malignancy, particularly myeloma,
(IgG, IgA) and lymphoplasmacytoid
lymphoma (IgM). Monoclonal gammopathy
of uncertain significance (MGUS) is found
in one or more percent of the general
population over the age of 50 years.
25
Paraprotein neuropathies
MAG abs
(Serum: Negative)
Myelin associated glycoprotein (MAG) is a
glycoprotein component of the myelin of
central and peripheral nervous systems
present in the periaxonal region, SchmidtLantermans incisures, lateral loops and outer
mesaxon of the myelin sheath. A member of
the immunoglobulin super- family MAG
probably functions as an adhesion molecule
and
mediates
cell-cell
interactions.
Monoclonal reactivities against MAG are
detected in about 50-75% of patients with
IgM paraproteinaemia and peripheral
neuropathy.
Sera from patients with
neuropathy that are negative for MAG
antibodies often exhibit reactivity against
various gangliosides.
Proteinase 3 (PR3) abs
(Serum: 0 – 3 EU/ml)
PR3 antibody is a marker for Wegener’s
granulomatosis and is occasionally detected
in microscopic polyarteritis. The quantity of
PR3 antibody generally parallels disease
activity with higher levels in the active state
of the disease. EIA affords a quantitative
assay which is useful when monitoring the
disease. Abs to PR3, an elastinolytic neural
serine protease, are responsible for the
characteristic granular cytoplasmic pattern of
the neutrophils when stained by IIF.
A rapid qualitative test is now
available.
Urgent requests must be arranged with
the laboratory.
26
Paraneoplastic neurological antibodies:
Paraneoplastic pemphigus abs
(Serum: Negative)
Paraneoplastic pemphigus is a severely
debilitating blistering disease affecting skin
and mucous membranes in patients with
malignancy,
such
as
haematologic
(lymphoma and leukaemia), sarcomas,
thymomas and Castleman syndrome. As in
other types of pemphigus, IgG is deposited
on the cell surfaces of epidermal and
epithelial cells in and around affected areas.
IgG antibodies to basement membrane zone
may also be present.
RAST (allergen specific IgE)
(Serum: 0 – 0.35 kU/l)
Assays for the detection of circulating IgE
antibodies directed against specific antigens
in sensitised patients are available to a wide
range of allergens. Common substrates
include animal fur or dander, house dust
mite, tree and grass pollens, moulds, feathers
and an extensive range of food substances
including a variety of nuts. Tests against
allergens in stock have a turnaround time of
seven days.
Paraneoplastic neurological antibodies are associated with paraneoplastic
neurological syndrome and systemic malignancies
Antibody
Yo (PCA-1)
Ma (Ma1)
Ta (Ma2)
Hu
(ANNA1)
Ri (ANNA2)
GAD
CV2/CRMP5
Amphiphysin
Tr
Neurological disorder(s)
paraneoplastic cerebellar
degeneration
paraneoplastic neurological
disorder, brainstem
encephalomyelitis
brainstem encephalomyelitis,
limbic encephalomyelitis
paraneoplastic cerebellar
degeneration, paraneoplastic
encephalomyelitis, sensory
neuropathy
opsoclonus/myclonus,
paraneoplastic cerebellar
degeneration, brainstem
encephalomyelitis
Stiff person syndrome
paraneoplastic encephalomyelitis /
sensory neuropathy
Stiff person syndrome,
paraneoplastic
encephalomyelitis
paraneoplastic cerebellar
degeneration
Most frequent
tumour(s)
Ovary, breast
Various, lung cancer
Testicular cancer
small cell lung
carcinoma
Breast, small cell lung
carcinoma,
gynaecological
Breast, colon, small
cell lung carcinoma
small cell lung
carcinoma, thymoma
Breast cancer, small
cell lung carcinoma
For clinical advice regarding
allergic diseases and reactions
phone
07831-681955.
A
regional allergy clinic now
operates from the Chest Clinic
in the centre of Birmingham
where skin prick and patch
testing is available.
N.B. Total IgE will be carried
out on all RAST requests
unless an IgE level is stated at
the time of request.
It is essential to supply as much information
as possible with RAST tests, including
clinical details and total IgE, if available. If
in any doubt it is advisable to discuss the
patient with the Consultant Immunologist
(07831 681955).
Hodgkin’s lymphoma
The presence of Yo, Hu (ANNA1) and Ri (ANNA2), Ma/Ta, CV2/CRMP5 and
amphiphysin antibodies are confirmed by Western blot.
27
28
Rheumatoid factor
(Serum: Negative)
Also see Cyclic citrullinated
peptide (CCP) antibodies
Salivary Duct abs
Salivary IgA and secretory
piece.
(Saliva: Clinical comment will
accompany each report)
Rheumatoid factors are antibodies which are
directed against other immunoglobulins. A
latex enhanced turbidimetric assay is used to
detect these. Approximately 70% of patients
with rheumatoid arthritis are sero positive
and antibodies may occur in other conditions
including many infections, myeloma,
lymphomas,
cryoglobulinaemia
and
connective tissue diseases. Antibodies (RF)
may also be found in allegedly normal
individuals aged over 75. Titre of
rheumatoid factor is less sensitive
than
sequential assay of CRP when monitoring
activity of rheumatoids.
No longer offered by this laboratory –
Suggest testing for ENA antibodies.
This assay may be inaccurate at levels
<0.9mg/l. In <1% of patients with high
levels of serum FLC these are missed by
this assay because of antigen excess.
Any anomaly between the serum FLC
results and other laboratory tests and/or
clinical evidence should be reported to
the laboratory for re-testing the serum
FLC.
Sera
are
screened
for
qualitative
abnormalities in proteins especially of the
immunoglobulins. Scans demonstrating a
monoclonal band are automatically followed
up using immunofixation to determine both
the isotype and the light chain of the
monoclonal protein. Other typical patterns
seen on electrophoresis may indicate
evidence of acute phase responses,
immunodeficiency, etc.
Where myeloma is suspected urine and
serum should be sent together.
29
Normal
plasma
cells
make
more
immunoglobulin light than heavy chains and
secrete free light chains in amounts
detectable in serum (estimated to be
0.5g/day). Serum free light chains are
removed by glomerular filtration with a halflife of a few hours. They are not easily
detectable in urine until the threshold for
tubular reabsorption is exceeded (10 – 20g /
day). Serum flc measurements are
recommended in diagnosis and management
of light chain amyloid, plasmacytoma, nonsecretory myeloma and light chain only
myeloma.
Skin abs.
(Serum: Negative)
Abs are found in (i) intercellular substance
of the epidermis (desmosome), which
strongly suggest a diagnosis of pemphigus
though these abs may also be found in
patients with severe burns or a trichophyton
infection. (ii) dermal-epidermal basement
membrane which is highly specific for
bullous pemphigoid and is present in 80% of
these patients. A titre is useful in monitoring
the disease.
Smooth muscle abs.
(Serum: Negative)
Present in high titre in up to 70% of patients
with autoimmune hepatitis who may also be
positive for mitochondrial, nuclear and
dsDNA abs (25%)
Striated muscle abs
(Serum: Negative)
In patients with Myasthenia Gravis with
thymoma these abs are invariably positive
but in such patients without thymoma the abs
occur in only 60% of cases. This assay is
usually carried out with a test for acetyl
choline receptor abs but as this latter test is
sent away to Oxford for quantitative assay it
will not be carried out as a routine unless
specifically requested.
This is a quantitative test for the presence of
mucosal, saliva antibody (secretory IgA,
sIgA) used in the work up of suspected cases
of immunodeficiency.
Serum levels of
immunoglobulins should be carried out in
parallel.
Normal age related levels will be shown on
the form and will be accompanied by a
clinical comment.
Serum electrophoresis.
(Serum: Clinical comment will
accompany each report)
Serum immunoglobulin free
light chains
Kappa 3.30 – 19.40 mg/l
Lambda 5.71 – 26.30 mg/l
Kappa / Lambda ratio 0.26 –
1.65)
30
Thyroid peroxidise abs.
(microsomal [TPO])
(Serum: <35 IU/ml)
Present at high levels in 95% of patients with
Hashimotos thyroiditis, 20% of patients with
Graves disease and 90% of patients with
primary myxoedema. Abs may also be
present at low levels in colloidal goitre,
thyroid carcinoma, De Quervains thyroiditis,
other organ specific auto-immunities and in
allegedly normal people. If persistent in
euthyroid individuals it may indicate
autoimmune thyroiditis and predisposition to
future thyroid failure.
Thyroglobulin abs
(Serum: Negative)
Thyroglobulin antibodies will be assayed for
specific patients if requested. For example,
where thyroglobulin levels are used as a
tumour marker. This assay is currently sent
to Immunology PRU, Northern General
Hospital, Sheffield.
TSH receptor abs
(Serum: Negative)
Hyperthyroidism in Grave’s disease is due to
autoantibodies to the TSH receptor and
measurement of these autoantibodies can be
useful in disease diagnosis and management.
This assay is currently sent to Immunology
PRU, Northern General Hospital, Sheffield.
Tissue Transglutaminase abs
(Serum: 0 – 20 ELISA Units)
Positive tTG abs will be tested
for endomysial abs by IIF
[Also see anti-Gliadin abs]
The endomysial autoantigen has been
identified as the protein cross-linking
enzyme tissue transglutaminase (tTG).
Antigen specific EIA assays provide an
alternative to the conventional indirect
immunofluorescence assay based on primate
oesophagus. The EIA assay provides a
quantitative measurement of IgG and IgA
anti-tTG antibodies and is not adversely
influenced by the presence of other
autoantibodies such as ANA or ASMA.
31
Tryptase
[See Adverse Anaesthetic reactions]
T-SPOT TB
(Non-reactive)
In vitro diagnostic test that measures T cells
specific to Mycobacterium tuberculosis
antigens. This aids diagnosis of both latent
TB infection and TB disease. The test can be
performed on all individuals including those
who have had BCG vaccination and the
immunocompromised. Refer to important
notes regarding collection of blood and its
despatch to the laboratory (page 4-5).
Urinary free light chains.
(Urine: Kappa or Lambda
0 – 0.04 g/g of creatinine)
As a National centre for myeloma trials this
laboratory quantitates the level of free light
chains in urine. Expressed in terms of g/g of
creatinine it is an accurate method for the
assessment of light chain output in the
presence
of
circulating
M-protein
(paraprotein); 24hr urine collections are not
required.
See serum immunoglobulin
free light chains
Polyclonal free light chains may occur in
healthy individuals particularly following
strenuous exercise and also in patients with
chronic infections or inflammatory diseases
such as rheumatoid arthritis. Unlike
laboratories where concentration of urine is
carried out before assay, thereby introducing
a source of error, this laboratory measures
free light chain directly on urine using a
multiplexed bead array assay.
Vasculitis screen
(ANA/ANCA and CRP)
Several laboratory tests may be useful in the
diagnosis of clinical disorders involving
inflammation of vessel walls. These include
ANA, anti-neutrophil cytoplasmic antibody
and measurement of Von Willebrand factor
(FVIII Rag) and CRP. The laboratory offers
a vasculitis screen of the three most
commonly requested tests as first line
investigation of this condition.
32
Vasculitis screen (Urgent)
A vasculitis screen is available as an urgent
request with a turnaround time of just two
hours. However, as this disrupts the normal
planned laboratory work there will be an
extra charge for this service.
The
laboratory must be telephoned to arrange
urgent processing.
Viscosity
(Serum: 1.25 – 1.70 (c.f. to
water)
Plasma: 1.40 – 1.90 (c.f. to
water))
Serum or plasma viscosity is an essential test
when monitoring Waldenstroms’ macroglobulinaemia and also when investigating
an unexplained retinal or cerebrovascular
occlusion. In such patients a cryoglobulin
may also be present. It is therefore essential
that
the
precautions
outlined
for
cryoglobulins are observed and blood
collected and transported to the laboratory at
body temperature.
Volt gated Ca++ channel abs
(Serum: 0 – 45 pM)
The Lambert Eaton myasthenic syndrome
(LEMS) is a form of myasthenia often
associated with small cell lung carcinoma.
In ~50% of cases there is IgG mediated
reduction in presynaptic voltage gated
calcium channels. This assay is currently
sent to Immunology, Churchill Hospital,
Oxford.
Volt gated K+ channel abs
(Serum: 0 – 100 pM)
Antibodies to voltage gated potassium
channel are found in ~40% of patients with
acquired neuromyotonia. This assay is
currently sent to Immunology, Churchill
Hospital, Oxford.
33
Test
Turn around time
Cost
Autoantibodies
Autoantibody Screen
up to 4d
(ANA [Hep 2]; GPC; AMA; SMA; LKM)
Adrenal antibodies
Anti-C1q antibodies
B2GP1 antibodies (IgG)
Cardiolipin antibodies (IgG and IgM)
Centromere antibodies
CCP antibodies
Endomysial antibodies
Epidermal antibodies
Gastric parietal cell antibodies
Gliadin antibodies (IgG and IgA)
Glomerular basement membrane abs (quantitative)
GBM - rapid test for urgent samples
Intrinsic factor antibodies
Islet cell antibodies
LKM/Mitochondrial/Smooth muscle antibodies
Liver antibody blot (M2, LC1, LKM, SLA, etc)
Mitochondrial M2 antibodies (quantitative)
Myocardial antibodies
Skeletal muscle antibodies
Thyroid microsomal antibodies (TPO)
Tissue transglutaminase antibodies (tTG)
up to 14d
up to 28d
up to 7d
up to 7d
up to 4d
up to 14d
up to 7d
up to 14d
up to 4d
up to 7d
up to 4d
2 hours, from receipt
up to 7d
up to 14d
up to 4d
up to 28d
up to 7d
up to 14d
up to 14d
up to 4d
up to 7d
Arthritis screen (RF/ANA/CRP)
up to 4d
ANA (Hep2 cells; includes titre/pattern on
positives) Centromere antibodies
ds(native)DNA antibodies (Crithidia + EIA
quantitation)
ENA antibodies Screen
ENA
" Type: (SSA,SSB,Sm,RNP,Jo-1,Scl70)
up to 4d
up to 4d
up to 7d
£8.00
£8.00
£14.70
up to 7d
up to 7d
£9.65
£30.65
Rheumatoid factor by turbidimetry (RALX)
CCP antibodies
up to 4d
up to 14d
£7.05
£8.60
34
£10.15
£16.80
£9.70
£14.80
£8.00
£8.60
£8.00
£8.00
£8.00
£14.80
£18.70
£17.95
£12.75
£10.15
£8.01
£37.60
£12.75
£10.15
£10.15
£8.35
£12.75
Test
Turn around time
Cost
Allergy Assays
Test
Turn around time
Cost
up to 14d
up to 14d
up to 14d
up to 14d
£11.15
£18.85
£11.15
£11.15
up to 14d
£30.50
up to 14d
£109.90
up to 14d
£67.80
up to 4d
up to 4d
up to 7d
up to 14d
up to 7d
up to 4d
up to 7d
up to 7d
up to 4d
up to 14d
up to 4d
up to 4d
£5.60
£4.75
£3.85
£23.45
£3.88
£4.85
£19.55
£7.35
£13.75
£9.90
£5.85
£9.25
up to 14d
up to 14d
up to 4d
£12.85
£26.20
£26.20
Precipitin Assays
up to 7d
up to 28d
up to 7d
£12.75
£14.60
£14.60
up to 7d
up to 7d
up to 7d
up to 7d
up to 28d
£36.90
£36.90
£24.60
£15.45
£14.60
£33.20
£14.20
Tau protein (blood must be provided with CSF)
up to 14d
same day (if rec’d
before 3.00pm)
up to 4d
Blood Samples
Caeruloplasmin
up to 14d
Total IgE
Mast cell tryptase
Specific IgE antibodies (RAST) per allergen
Common allergies:
Cat/House dust mite/grass
Egg/Milk/Wheat
Aspergillus/Cladosporium
Mixed allergens (eg trees, nuts)
Other specific allergens (Many available)
Neuroimmunology Assays
CSF Samples
Oligoclonal IgG bands (paired blood and CSF)
Spectrophotometric scan/xanthochromia
Autoimmune diseases (Serum Samples)
Acetylcholine receptor (Myasthenia gravis)
MuSK antibodies
NMO (aquaporin 4) abs
Paraneoplastic epidermal abs
Paraneoplastic syndromes: PCA1 (Yo), ANNA1 (Hu),
ANNA2 (Ri), CV2/CRMP5, Ma/Ta, & amphiphysin
Brain antibody western blot (Yo, Hu, Ri,
CV2/CRMP5, Ma/Ta, and amphiphysin)
Paraprotein neuropathies: MAG abs
Miller-Fisher syndrome GQ1b, GT1a abs
Sensory motor neuropathies (e.g. Guillan-Barré syn)
GM1, Asialo-GM1, GD1a+b abs
Sensory neuropathies. Sulphatide abs
Stiff-man syndrome. Glut. Decarboxylase (GAD) abs
Volt. gated Ca+ channel (Lambert-Eaton syndrome)
Volt. gated K+ channel (Acquired neuromyotonia)
35
£30.75
£8.60
Approx. 28d
Approx. 28d
Approx. 28d
Approx. 28d
up to 7d
£24.95
£41.85
£55.95
£10.15
£19.30
up to 28d
£37.60
7-10d
Done as a panel of
assays taking approx.
28 days and
charged at £44.00
up to 14d
Approx. 28d
Approx. 28d
£12.75
£44.75
£24.95
£43.10
£43.10
Aspergillus fumigatus
Avian (Pigeon & budgerigar)
Candida albicans
Mycopolyspora faeni
Immunochemistry
M-protein (paraprotein)/Myeloma Screen
(IgG,A,M; Elec; Urine immunofixation)
M-protein (paraprotein)/Myeloma (full
characterisation, blood and urine)
(IgG,A and M; Imfix; B2M; Cryo; Visc; Ser + Ur
K/L light chains)
M-protein (paraprotein)/Myeloma (follow up,
blood and urine)
(IgG,A,M, M-protein; Elec; B2M; Ser + Ur - K/L
light chains)
B2Microglobulin
CRP (C reactive protein)
Cryoglobulin
(qualitative screen)
(type and quantitation)
Cryofibrinogen
Serum protein electrophoresis
Immunofixation (serum)
Immunofixation (urine – kappa/lambda)
Immunoglobulins (IgG,A and M)
IgD
Plasma/serum viscosity
M-protein (paraprotein) quantitation
Urinary free light chain: Kappa or Lambda
quantitation:
as part of the myeloma workup*
as an individual quantitative assay*
Serum free kappa/lambda & ratio
36
Test
Turn around time
Cost
Antibody Deficiency
Test
Turn around time
Cost
up to 4d
up to 4d
Approx. 28d
up to 4d
up to 7d
up to 7d
2 hours (from receipt
2 hours of specimen)
8.00
8.00
4.75
12.75
12.75
17.95
17.95
Vasculitis
up to 4d
up to 14d
up to 28d
£13.75
£25.45
£18.50
Approx. 28d
Approx. 28d
Approx. 28d
£31.20
£15.45
£15.45
C1q
C1r
C1s
C2
C3/C4
C3d
C5
C6
C7
C8
C9
Factor-B
Factor-D
Factor H(ß1H)
Factor I (KAF)
up to 14d
Approx. 28d
Approx. 28d
Approx. 28d
up to 4d
Approx. 28d
Approx. 28d
Approx. 28d
Approx. 28d
Approx. 28d
Approx. 28d
Approx. 28d
Approx. 28d
Approx. 28d
Approx. 28d
£9.90
£9.90
£9.90
£9.90
£9.70
£9.90
£9.90
£9.90
£9.90
£9.90
£9.90
£9.90
£9.90
£9.90
£9.90
C1 esterase inhibitor
(Immunochemical and functional assays)
C3 Nephritic factor (C3 Nef)
Functional complement: Classical/Alternate pathway
up to 28d
Approx. 28d
Approx 28d
£19.25
£22.30
£18.50
Immunoglobulins (IgG, A and M)
IgG subclasses (IgG1,2,3 and 4)
IgA
"
(IgA1 and 2)
Functional antibodies:
(Tetanus toxoid, Pneumococcus and H.Influenza b)
Free Secretory component
Secretory IgA
Vasculitis screen (ANA/ANCA/CRP)
Neutrophil cytoplasmic antibodies (ANCA)
Von Willebrand factor (FVIII Rag)
CRP
ANCA (EIA)
Myeloperoxidase (Quantitative)
Proteinase III
(Quantitative)
Myeloperoxidase (urgent screen)
Proteinase III (urgent screen)
Complement Assays
Complement
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Cell marker tests performed by the
Clinical Immunology Service
All queries and requests for urgent investigations to be addressed to Mr Peter
Richardson in the Clinical Immunology laboratory (0121 414 4069)
Specimen collection for Cell Marker Work
All samples must arrive in the laboratory by 5.00 p.m. on the day of sampling
accompanied by clinical details. Samples received day 1 will normally be
processed day 2 and reported day 3 (except samples received on a Friday).
Immunodeficiency studies: please telephone for clinical discussion and advice
regarding appropriate tests and samples required (07831 681 955 or 0121 414 4069)
Bone marrow
2ml bone marrow in EDTA and an
unfixed marrow smear
Blood *
Immunodeficiency marker studies
5mls blood in EDTA
Effusions
At least 20mls in EDTA
C.S.F.
As much as possible in a
universal bottle containing
tissue culture medium
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Tissue biopsy
Freshly excised and put in cold
tissue culture medium or saline.
NB no preservative
T cell antigen receptor &
immunoglobulin gene
Rearrangement studies
Blood or bone marrow drawn
into EDTA bottle (Heparinised
material is unsuitable for the PCR
process)
Immunodeficiency studies (inc HIV+)** 5ml EDTA blood
* When taking blood for marker studies a sample must also be sent to the local
haematology department for a white cell count and differential. A clotted blood
sample and urine may be needed for assessment of immunoglobulin concentrations
and M-protein (paraprotein) analysis.
** For paediatric and adult cases of congenital immunodeficiency please discuss with
a clinician in order to ensure the most appropriate assays are booked in and performed.
Haematological Malignancies
Panels currently available (all 3 to 7 colour analysis).
All include morphological appraisal and a written report
Myeloid markers - 7 colour panel – Appropriate for MDS, MPD and
most AML
Kappa, lambda, CD3, CD4, CD7, CD11b, CD13, CD14, CD16, CD19,
CD33, CD34, CD38, CD45, CD45RA, CD47, CD56, CD71, CD117,
CD123,CD235a, HLA-DR
In addition to the above, if a megakaryocytic leukaemia (M7) is
suspected, CD41a may be also be used.
In the event of an Acute Promyelocytic leukaemia (M3), direct
immunofluorescent stain of a cytospin preparation for PML-RAR fusion
protein may be performed
Cytoplasmic staining for myeloperoxidase, CD3, CD79a and TdT may
also be performed if deemed appropriate.
£91.10
Acute leukaemia rapid screen 4 colour panel
This panel may be used to determine the lineage of a presenting
malignancy for the purpose of providing an urgent, telephoned report to
the requesting clinician. The information thus derived will be used to
select a more appropriate secondary panel.
CD1a, CD3, CD7, CD10, CD13, CD14, CD19, CD33, CD34, CD79a,
CD117
£49.25
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AML (CSF) 4 colour panel
CD13/CD33/CD34/CD117, CD4/CD8/CD45/CD3
B-ALL 4 colour panel
Appropriate for the diagnosis and follow-up of precursor B lineage
neoplasms
CD20/CD10/CD34/CD19, CD22/CD10/CD34/CD19,
CD34/CD10/CD45/CD19, CD38/CD10/CD34/CD19
CD13/CD33/CD10/CD34/CD19, skappa/slambda/CD45/CD19
At diagnosis, Tdt and cytoplasmic IgM are also included
£100.95
B-ALL (CSF) 4 colour panel
CD79b/CD10/CD34/CD19, CD4/CD8/CD45/CD3
T-ALL 4 colour panel
Appropriate for the diagnosis and follow-up of precursor T lineage
neoplasms
CD4/CD8/CD45/CD3, CD7/CD2/CD3/CD5, CD7/CD38/CD34/CD3,
CD7/CD117/CD3,CD5
At diagnosis : Tdt, MPO and cytoplasmic CD3 are also included
£91.10
T-ALL (CSF) 4 colour panel
CD7/CD2/CD34/CD5, CD4/CD8/CD45/CD3
PNH screen
Appropriate for the investigation of suspected or known PNH cases.
N.B. This assay is best performed on freshly drawn EDTA blood. Bone
marrow samples are not suited as interpretation is too difficult.
The following surface markers are analysed on leukocytes:
CD16, CD15, CD24, CD14, CD64, CD45
And on red cells:
CD55, CD59
£80.75
Lymphoproliferative diseasesGeneral panel (LPD) 7 colour
Appropriate for the investigation of unexplained lympocytosis, mature B
cell neoplasms and mature T cell neoplasms.
kappa, lambda, CD2, CD3, CD4, CD5, CD7, CD8, CD10, CD11c,
CD16, CD19, CD20, CD23, CD25, CD27, CD30, CD34, CD38, CD45,
CD49d, CD56, CD57, CD103, TCR-gamma/delta.
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£80.75
LPD (CSF) panel
kappa/lambda/CD19/CD45, CD4/CD8/CD45/CD3
Investigation of Immunodeficiency
Hodgkins (CSF) 4 colour panel
CD15/CD30/CD45/CD19, CD4/CD8/CD45/CD3
Myeloma 3 colour (7-8 colour in the near future)
Appropriate for the investigation of known or suspected cases of
myeloma, MGUS and paraproteinaemia.
skappa/slambda/CD19, CD20/CD5/CD19, CD22/CD23/CD19,
CD10/CDCD19/CD34, CD138/CD45/CD38, CD56/CD19/CD38
cytoplasmic kappa/lambda/CD38
£80.75
ZAP-70
Appropriate for known cases of B-CLL. At the time of compilation it is
not clear whether or not flow cytometry is useful in the detection of Zap70. The assay will be performed if specifically requested.
ZAP70/CD19/CD3
£26.65
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B/NK cell markers
Expressed as percentile and absolute values: CD19, CD16, CD56
£26.65
Full Immunodeficiency surface markers panel
Similar panel as for T/NK lymphoproliferative Disease
£113.95
Leukocyte adhesion deficiency surface markers
CD11a, CD11b, CD11c, CD15, CD18
£62.85
HIV monitoring
Expressed as percentile and absolute values: CD3, CD4, CD8
£26.65
Immunoglobulin/T cell receptor gene studies
£218.40
Lymphocyte proliferation studies
This assay can only be run on Tuesdays.
Please contact the department before sending samples.
£61.55 –
£154.55
Neutrophil function studies (respiratory burst)
£49.25
Full type 1 cytokine studies
Full type 1 cytokine studies can take up to 2 months
from sample receipt to a report being issued
£390.00
Cytokine measurement Available cytokines include: IL-1b, IL-2, IL-4, IL-5, IL-6, IL-7, IL-8, IL-10, TNF-a, IL-12p70,
IL-13, IL-17, IFN-g, G-CSF, GM-CSF, MCP-1, MIP-1b, Eotaxin,
FGF basic, IL-1ra, IL-9, IL-15, IP-10, MIP-1a, PDGFbb, Rantes,
VEGF
£11.15/
cytokine
Interferon gamma receptor antibodies
£25.35
Anti-cytokine antibodies and antibodies to biological therapeutics
By arrangement with the laboratory
POA
T-SPOT TB
This assay is only run on Tuesdays and Thursdays.
Samples must be received in the laboratory by 2.00pm on the day that
they are taken. Please contact the department prior to sending
samples.
£60.00
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Neutrophil/lymphocyte functional studies
NOTES
We perform a number of basic investigations to test defects in neutrophil function
including oxidative burst and phagocytosis, and lymphocyte proliferation and
function including cytokine production. These investigations are labour intensive
and technically demanding. To identify which tests are most appropriate please
discuss with one of the clinicians on the mobile telephone numbers listed below.
Specialist staff and facilities are booked to carry out detailed functional
assessments of neutrophils and lymphocytes. Only a limited number of
appointments can be made. It is essential that the blood arrives in the laboratory in
good condition and with sufficient time to carry out the assays. We cannot
guarantee to carry out investigations if samples are received after 10am.
Functional studies must be booked in advance. To obtain advice please contact:
Prof P.J.L.Lane (0121) 414 4078
(mobile 07831 681955)
Dr M.T.Drayson (0121) 414 4069/4074
(mobile 07798 585319)
Please carefully follow the guidelines below:
1.
The following samples should be taken and sent by taxi without delay
to arrive by 10am
10ml blood in Lithium heparin (50ml for type I cytokine studies)
10ml clotted blood
5ml blood in EDTA.
In the case of children the minimum blood volume required should be
confirmed with the laboratory.
2.
A full blood count and white cell differential should be done on the
same day at your hospital. (We will telephone your laboratory for the
results).
3.
A concise clinical summary including results of preliminary tests
should be sent with the specimen.
4.
Samples should be addressed to:
Clinical Immunology Service, Medical School, Birmingham.
and labelled “URGENT!!” contact 44069 on arrival.
5.
Include the telephone number, or bleep, of the doctor to be contacted in
case of any query.
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