TOPICS. Continuing Education April 2014 Volume 16 Number 2. Journal of. Inside This Issue. Official publication of the American Medical Technologists

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1 Journal of TOPICS & ISSUES Official publication of the American Medical Technologists Continuing Education April 2014 Volume 16 Number 2 Inside This Issue Back to the Future with Urinalysis: Part 2 A Confusing, Unexpected and Mistaken Case of Bacteremia Quality Management for the Analytical Phase of Sample Processing: Part 4 Troubleshooting Determination of Trace Elements, Biochemical Tests and Epidemiological Aspects of Women Infected with Toxoplasma gondii

2 Journal of Continuing Education April 2014 Volume 16 Number 2 Contents 50 Cases in Clinical Microbiology 56 Article 409 Back to the Future with Urinalysis: Part 2 Leslie Williams and David Plaut 59 Questions for Article Article 410 Case Twenty Eight: A Confusing, Unexpected and Mistaken Case of Bacteremia Sreeharsha Masineni, Barbara DeBurger, and Joel Mortensen 63 Crossword Puzzle 64 Questions for Article 410 CENTER PULLOUT SECTION TOPICS &ISSUES Chicago Convention Preliminary Program 66 Article 411 Quality Management for the Analytical Phase of Sample Processing: Part 4 Troubleshooting David Plaut and Deena Davis 68 Questions for Article Article 412 Determination of Trace Elements, Biochemical Tests and Epidemiological Aspects of Women Infected with Toxoplasma gondii Yahya Jirjees Salman Editor Gerard P. Boe, PhD 77 Questions for Article AMT Directory Associate Editor Diane Powell Business Office American Medical Technologists W. Higgins Rd., Suite 150 Rosemont, IL address: mail@americanmedtech.org Web Site: Journal of Continuing Education Topics & Issues (ISSN ) is published in January, April, and August under the sponsorship of the American Medical Technologists, W. Higgins Rd., Suite 150, Rosemont, Illinois Copyright 2014 by American Medical Technologists. Subscriptions include three issues of Journal of CE Topics & Issues and three issues of AMT Events: $50.00/year + $10 postage for foreign countries. Members may not deduct subscription price from dues. Postmaster: Please send change of address to AMT, W. Higgins Rd., Suite 150, Rosemont, Illinois Moving? Be sure AMT publications move with you. Send your new address and old mailing label from an AMT publication to AMT six weeks before you move. Cover photo: Cefotaxime photomicrograph, Eric Clark, National High Magnetic Field, Florida State University, Tallahassee.

3 Cases in Clinical Microbiology The case description on this page and its follow-up discussion presented elsewhere in this issue is the 28th in a series of articles presenting clinical microbiology cases that will appear in this journal. Readers should study the case description below and formulate their own answers to the questions posed. After coming up with a solution to the problem, turn to page 60 in this issue and read the Case Follow-up and Discussion. This is followed by Questions for STEP Participants on page 64. Joel E. Mortensen, PhD, MLT(AMT), Series Editor Case Description: A 21-year-old male with cystic fibrosis and prior history of Pseudomonas aeruginosa bronchopneumonia (diagnosed and treated in July) presented to the pulmonary clinic in August, with increasing cough, dyspnea and chest discomfort. He also complained of purulent discharge from the site of his Medi-port that had been placed in July. Chest X-ray revealed possible bronchopneumonia, and the patient was admitted for treatment of bronchopneumonia and suspected catheter related infection. A respiratory culture (epiglottis swab) was taken at admission and submitted to the laboratory. His Medi-port was replaced. The respiratory culture grew two colony types of Pseudomonas aeruginosa, a common finding from the respiratory tract of patients with cystic fibrosis. A course of IV tobramycin and ceftazidime was administered. During the hospital stay he developed fever, joint pain, edema, and lower extremity blotchy erythema. Peripheral bacterial and fungal blood cultures, as well as follow-up respiratory cultures were collected. Initially, the blood cultures did not grow. The patient was discharged home on oral azithromycin and nebulized tobramycin. After one week of incubation, the peripheral fungal blood culture grew a smooth white colony on Sabouraud heart infusion agar (SABHI). Gram stained smears showed beaded Gram-positive bacilli (figure 1). The organism was subcultured to 5% sheep blood agar and Lowenstein-Jensen agar (figures 2). A Kinyoun stain from a colony on the Lowenstein-Jensen agar was performed and interpreted as negative (figure 3). Therefore, a modified Kinyoun stain was done. The modified Kinyoun stain was reported as positive (figure 4). Based upon the information available, the laboratory identified the organism as probable Nocardia species. Is this a reasonable assessment of the identification of this organism? 50 April 2014 Continuing Education Topics & Issues

4 Article Clock Hour CASES IN CLINICAL MICROBIOLOGY Case Twenty Eight: A Confusing, Unexpected and Mistaken Case of Bacteremia Sreeharsha Masineni, Barbara DeBurger, and Joel Mortensen Sreeharsha Masineni, MD, is a pathologist in the University of Cincinnati School of Medicine. Barbara DeBurger, MT(ASCP), is a technical consultant in Diagnostic Infectious Diseases Testing, Cincinnati Children s Hospital. Joel Mortensen Ph.D., is the Director of the Diagnostic Infectious Diseases Testing, Cincinnati Children s Hospital, Cincinnati, Ohio EDITOR S NOTE: BEFORE reading the Case Follow-up and Discussion below, study the Case Description on page 50 of this issue, and formulate your own answers to the questions posed. Case Follow up The isolate was sent to The Mycobacterial/Nocardia Research Lab, University of Texas Health Center at Tyler, Texas. Based on the preliminary blood culture results, the infectious disease physicians, concerned about infection with Nocardia species or Actinomyces species, initiated a follow-up visit for the patient. During the follow-up visit, blood cultures were collected through the Medi-port and from peripherial venipuncture. A sputum specimen for culture was also collected. Respiratory cultures again grew Pseudomonas aeruginosa. Again, a beadedbranching Gram-positive bacilli was isolated from the blood cultures collected from the Medi-port. The Medi-port was removed and the patient was started on intravenous ampicillin and trimethoprim/sulfamethoxazole. Using polymerase chain reaction of the hsp65 gene followed by restriction enzyme analysis, the reference laboratory identified the organism as Mycobacterium mucogenicum. Susceptibility testing was done using broth microdilution. See Table 1 for susceptibility results. The patient was continued on trimethoprim/sulfamethoxazole, the ampicillin was discontinued, and ciprofloxacin and clarithromycin were added for a total duration of three months. Cystic fibrosis is a genetic disease resulting from mutations in the gene encoding cystic fibrosis transmembrane conductance regulator protein that is involved in the transport of chloride and thiocyanates across cell membranes. It is an inherited autosomal recessive disorder and causes thick viscous secretions with resulting dysfunction of many organ systems. It is associated with increased respiratory infections as a result of compromised clearance of pulmonary secretions. Many organisms have been associated with respiratory infections, including Pseudomonas aeruginosa, Haemophilus influenzae, Staphylococcus aureus, Burkholderia cepacia, Alcaligenes xylosoxidans, Burkholderia gladioli, Proteus spp., Escherichia coli, Klebsiella spp. and Aspergillus fumigatus. Respiratory infections caused by nontuberculous mycobacteria have also been seen in patients with cystic fibrosis. The most com- Table 1: MIC values for Mycobacterium mucogenicum isolate Antimicrobial Agent MIC (µg/ml) S I R Doxycycline 0.12 Minocycline 1.0 Tigecycline 0.12 Ciprofloxacin 0.25 Moxifloxacin 0.25 Linezolid 1 Imipenem 2 Trimethoprim/ sulfamethoxazole 0.25/4.75 Clarithromycin 0.12 Amikacin 1.0 Cefoxitin 8 S= susceptible, I= intermediate, R= resistant. 60 April 2014 Continuing Education Topics & Issues

5 Article Clock Hour Quality Management for the Analytical Phase of Sample Processing: Part 4 Troubleshooting David Plaut and Deena Davis David Plaut, Plano, TX, Consultant, AMT s Book Reviewer, and frequent speaker at AMT national conventions and regional meetings Deena Davis, MLS, Point of Care Coordinator for Bozeman Deaconess Hospital, Bozeman, MT In this installment, we discuss in general terms how to begin trouble shooting a run that has been rejected due to a rule (or rules) being broken. [Remember that a single value outside 2SD is not a reject signal. Only the 1 3SD, the 2 2SD or the R 4SD rule, when using 2 controls, is a reject signal.] We assume that your instrument is a multi-channel instrument, so for our discussion we will imagine that it measures 5 different analytes concurrently: A, B, C, D, and E. Here is the way we view a run with 2 controls for each of the 5 tests, with all tests in control, a.k.a. acceptable: B IN IN REPORT C IN IN REPORT As you see all the controls are in [no rules were broken], and thus all the patients data are reported and the control data included in the monthly report. Let s look at the next example: B IN >2SD <3 SD REPORT C IN IN REPORT In this run, Level II for Test B was outside - 2 SD (>) but within 3 SD (<). The run should be reported. In the following example, what do you see? B IN IN REPORT C >2SD >2SD HOLD [PONDER] Here there is a 2 2SD rule failure within the run (both controls in the same run are greater than the same 2SD either both < 2SD or both > 2 SD). As we learned in the last installment, a 2 2SD rule failure suggests a bias or systematic error. For the time being we must hold the results for Test C and begin looking for the problem. One way to begin trouble shooting is to look at the control values on the other tests in this case all of them are acceptable. Does that tell us anything that will help solve the question? Indeed it does. First may we not assume that 1) the controls were not switched Level I put in level II s slot and vice versa? The answer is yes, because the other tests for both level I and level II were in 2) May we assume the control materials are OK? Yes, again because all the other tests were in and they all run on the same control material as the analyte that is currently out. If the controls on the other tests are in we now consider the instrument. [Ask yourself how long did your examination of the situation take?] In thinking about a possible instrument problem, can we get any help from looking at all 5 sets of data? Yes, note that all 5 tests were run at the same time on the same instrument, but only one 66 April 2014 Continuing Education Topics & Issues