Syzygy - Sullivan Nicolaides Pathology

syzygy
December 2015
Syphilis — The great masquerader is back with a vengeance
Dr Jenny Robson, Head of the Microbiology Department, Sullivan Nicolaides Pathology
Syphilis, caused by the spirochaete Treponema pallidum, is an old disease. Many notable figures throughout history are thought to
have suffered from this scourge. It remains exquisitely sensitive to penicillin so, in theory, should be easily treatable.
Over the past two years, the number of notified cases of infectious syphilis – syphilis
of less than two years' duration (Figure 1) — has continued to grow.
In the Northern Territory and Queensland, the emerging risk groups are young
Aboriginal and Torres Strait Islanders (ATSI), particularly people from the north of the
State. In this group, in which young females are infected, there is now a real risk of
new cases of congenital syphilis (Figures 2 and 3). In other geographical areas, gay
and bisexual males form the major risk group.
Co-infections with other sexually transmitted infections (STIs) are common and
should always be tested for simultaneously. Similarly, all STI screens should include
a test for syphilis. At-risk patients require screening for co-existing chlamydia,
gonorrhoea and/or and trichomonas if the patient belongs to the ATSI group.
Screening for HIV, hepatitis A, B and C should also occur, with hepatitis A and B
vaccination in those who are non-immune. The recommended regular screening
for asymptomatic gay and bisexual males is outlined in the now renamed STIGMA
guidelines (http://stipu.nsw.gov.au/wp-content/uploads/STIGMA_Testing_
Guidelines_Final_v5.pdf).
Presentation
Early or infectious syphilis (less than two years' duration) includes primary,
secondary and early latent syphilis (Algorithms 1 and 2).
‚‚Primary syphilis usually manifests as a chancre (an anogenital or, less commonly, extragenital painless, but also sometimes painful, ulcer with indurated edges).
‚‚Progression to secondary syphilis occurs over the following months and presents as an acute systemic illness with rash, which is usually truncal, but also involving palms and soles (Figure 4), condylomata lata (clusters of soft, moist lumps in skin folds of the anogenital area), mucosal lesions, alopecia, lymphadenopathy, hepatitis, or meningitis.
‚‚Early latent syphilis is infection of less than two years' duration where the patient is asymptomatic.
Late latent syphilis is defined as latent
(asymptomatic) syphilis of longer than two
years' duration, or of unknown duration. Tertiary
syphilis refers to syphilis of longer than two
years' duration, or of unknown duration, with
cardiovascular, central nervous system or skin and
bone (gummatous syphilis) involvement.
Figure 4: Secondary syphilitic rash involving
palm of hand
Risk of transmission of syphilis from a pregnant
mother to her fetus depends on the stage of
syphilis during pregnancy. Management is clearly
outlined in the ASID Management of Perinatal
Infections Guidelines (https://www.asid.net.au/
documents/item/368)
Syphilis — The great masquerader is back with a vengeance (cont.)
Testing strategies for syphilis
Whilst serology remains the mainstay of diagnosis
(Algorithm 1), syphilis PCR examination using
a dry, black topped swab of primary chancre
lesions targeting T. pallidum DNA allows for early
diagnosis, sometimes even before the development
of antibodies. This molecular assay replaces the
classical Dark Ground Illumination (DGI) which
has been used in the past to detect corkscrew
spirochaetes with characteristic rotatory flexion and
back and forth motion (Figure 5).
Figure 5: Dark Ground Illumination (DGI) of T. pallidum spiroocaetes
For high-risk patients with genital ulcers, it is
advisable to test and treat for syphilis on the
day of presentation without waiting for a positive
test result. Sexual partners of people who have
infectious syphilis should also be tested and treated
simultaneously without waiting for the results of
tests.
Contact tracing of partners is outlined in Algorithm 2.
References
1. Bollet, A.J. 2004. The major infectious epidemic diseases of civil war
soldiers. Infect. Dis. Clin. N. Am. 18:293-309.
Historical figures with syphilis
Desiderius Erasmus
Paul Gaugin
Al Capone
Ferdinand Magellan
Florence Nightingale
Giovanni Casanova
Gustave Flaubert
John Keats
King Henry VIII of England
Ludwig van Beethoven
Napoleon Bonaparte
Vincent van Gogh
NEW TEST ANNOUNCEMENT
TNF drug (Infliximab and adalimumab) serum levels
TNF drug levels are useful in determining the therapeutic strategy in IBD and in
rheumatoid arthritis. When combined with anti-drug antibodies, the levels help decide
between increasing the dose or frequency, changing the TNF drug, or changing to a
different class of drugs.
Testing is indicated if therapeutic failure is being investigated, or if down, titration of
medication is being considered.
If therapeutic failure is being assessed, a trough level (for instance, taken 1 to 2 days
prior to the next infusion/injection) is necessary for adequate assessment.
A serum sample is taken and tested for TNF drug level and, if needed, for anti-drug
antibodies. Infliximab and adalimumab levels and antibodies are available at present.
They are reported weekly.
For further information please contact:
Dr Daman Langguth P: (07) 3377 8698 E: daman_langguth@snp.com.au
What to request: Infliximab levels or Adalimumab levels
Collection:
Any SNP collection centre
Sample: Serum
Transportation:
No special conditions
(ambient temp)
Out of pocket costs:
Drug levels: $60
Antibody levels if indicated: $60
Both tests are eligible for Medicare Safety Net Inclusion
24-hour turnaround with new PCR test for BCR-ABL
Sullivan Nicolaides Pathology is pleased to advise that our Molecular Pathology Department is now NATA accredited for testing for
BCR-ABL by PCR using the Cepheid XPert BCR-ABL test cartridge platform.
Results will be available to our referring clinicians in one working
day after receipt of the specimen in the lab. Previously, there was an
average of almost seven working days between collection and reporting
of results.
The new test detects transcripts at the p210 breakpoint that represent
>95% of BCR-ABL rearrangements in adult patients.
The XPert BCR-ABL CML p210 assay is also capable of detecting to
the level of MR4.5 (</= 0.0032% IS); however, accurate quantification
at these low transcript levels is not possible. Quantification is accurate
to the level of MR4 (0.01% IS) with this system.
The next generation of the XPert cartridge for BCR-ABL, the ‘Ultra’,
will be implemented from December 2015.This system is capable of
accurate quantification to the low transcript level of MR4.5. The newer
cartridge will deliver 100% sensitivity at the level of MR4.5 and 71.4%
sensitivity at the level of MR5 (manufacturer data).
Specimen
It is important to note that EDTA peripheral blood is the specimen of
choice for molecular detection and monitoring for BCR-ABL.
Bone marrow samples are no longer suitable for BCR-ABL testing
using this system.
Requesting the test
There will be no changes to test ordering for BCR-ABL. Please continue
to order this test as you do at present. In the diagnostic setting, if there
is strong clinical suspicion of a BCR-ABL rearrangement despite a prior
negative Gene Xpert result, alternative testing such as FISH should
be considered as a follow-up request. Alternative testing will also be
necessary for monitoring patients with known rare transcripts
(e.g. p190).
Cumulative test results
All patient results from prior testing are available and will continue to
be included in reports in the cumulative reporting format and graphical
plots (when requested).
Collection and transport
As this test measures the levels of RNA transcribed from the BCRABL gene fusion responsible for CML, and RNA degrades over time,
speed of sample transport and testing within 24 hours of collection is
essential.
If a patient requires testing on a weekend, this will require co-ordination
with the laboratory to receive the sample and process the test. To do
so, please phone SNP (07) 3377 8666.
For further information please contact:
Dr Helen Wordsworth P: (07) 3377 8639 E: helen_wordsworth@snp.com.au Dr James Harraway P: (07) 3377 8396 E: james_harraway@snp.com.au
Changed collection protocol for plasma free metanephrines
Dr David Kanowski, Biochemistry Department, Sullivan Nicolaides Pathology
Optimal biochemical testing for PPGLs (phaeochromocytomas and
paragangliomas) involves the measurement of plasma free metanephrines.
To further improve the diagnostic accuracy of this test, it is now
recognised that blood should be collected from patients who have been
resting in the supine position for 30 minutes beforehand (Clinical Practice
Guideline, JCEM 99: 1915-1942, 2014).
Normally, plasma catecholamines and their metabolites (metanephrines)
rise with upright posture due to strong sympathetic activation. Patients
with PPGLs do not show this response. Therefore, if higher reference
intervals are chosen to suit an upright posture, there is a significant
decrease in diagnostic sensitivity for PPGLs.
In addition, the accuracy of the test has been improved by the
incorporation of age-related reference intervals for normetanephrine.
This is because levels rise significantly with increasing age. Age-related
intervals result in significantly improved sensitivity for PPGLs in younger
patients and improved specificity in older patients, compared with a fixed
reference interval.
Fasting is important for the 3-methoxytyramine reference interval (the
metabolite of dopamine), since many foods, particularly certain fruits
and nuts, contain biogenic amines. Dietary influences are minimal for
normetanephrine and metanephrine.
Sullivan Nicolaides Pathology has recently implemented this new
collection procedure. Patients need to phone their local collection centre
to check whether collection for plasma free metanephrines is available.
The facilities for patients to lie down for 30 minutes are not available in
every collection room.
For further information please contact:
Dr David Kanowski P: (07) 3377 8779 E: david_kanowski@snp.com.au
Recent change to therapeutic range for APTT for unfractionated heparin
Our therapeutic range for APTT for unfractionated intravenous heparin has been changed from 60–80 seconds to 65–90 seconds.
This change is in response to the latest batch of test reagent. Every batch of APTT reagent supplied to SNP undergoes rigorous pre-release testing
by the manufacturer. A number of factors are assessed to ensure batch-to-batch stability of the reagent, and hence, test results.
Assessments are conducted for heparin sensitivity, factor sensitivity (particularly to reduced levels of factor VIIIc), sensitivity to the presence of lupus
anticoagulants, and to determine the normal range. A shift in APTT sensitivity to heparin, detected during the most recent reagent assessment
process, was confirmed by the manufacturer.
To ensure effective and safe management of patients receiving UFH anticoagulation, all hospitals using our services have been notified of the new
UFH therapeutic range to enable them to update heparin dosing protocols to reflect the change in therapeutic range. Comments are also being
included in all APTT results reports.
Clinicians should note that APTT results are specific to the reagent and to the instrument used to generate the result. Also APTT results are NOT
interchangeable between different pathology providers.
For further information please contact:
Sullivan Nicolaides Pathology – Haematologist P: (07) 3377 8670
Seasons greetings
from the Doctors,
Management and
Staff of
Sullivan Nicolaides
Pathology
Changes to services for
Christmas and the New Year
Assisting you with categorising your
patients for Diabetes PIP – Webster
Custom View
With the introduction of the diagnostic item number for HbA1c, correct
classification of patients either as diabetic monitoring or diagnostic testing
is an important step in your Diabetes PIP system.
We are pleased to advise that our online results application, Webster, can
now provide you with a new, easy-to-use report—the HbA1c Screen/
Monitor Report–which gives you real-time information about how your
patients have been classified.
Webster is available with a personal account for medical practitioners, or a
clinic account for your diabetes care plan manager. Application forms are
available at www.snp.com.au.
Your Medical Liaison Manager is available to assist you and your diabetes
care plan manager with your applications if you are not already using
Webster, and can provide an update on using the diabetes e-health reports
in Webster.
Telephone 1300 SNPATH (1300 767 284)
Screen shot of report list

Please visit our website www.snp.com.au for information regarding
Collection Centre closures.
Warfarin Care
To ensure the safe and complete enrolment of patients into our Warfarin
Care program, enrolments will be closed on the following dates:
Community patients: closing 5 pm Friday 11 December 2015 and
re-opening 8 am Monday 4 January 2016
Hospital patients: closing 5 pm Tuesday 15 December 2015 and
re-opening 8 am Monday 4 January 2016
Cardiology services: ECG, Holter and ABP
To ensure all patient results are reported prior to Christmas, please be
advised that the final date for appointments will be:
48-hour Holter monitoring: Wednesday 9 December 2015
24-hour Holter monitoring: Monday 14 December 2015
24-hour ABP monitoring: Thursday 17 December 2015
ECGs:
Tuesday 22 December 2015
All bookings will resume from Monday 4 January 2016.
Paediatric ECG & Holter services
Please be advised that paediatric ECGs and Holters will be unavailable
from Monday 07 December to Monday 11 January 2016 because the
reporting paediatric cardiologist will be on leave. Services will resume after
Monday 11 January 2016. Any paediatric patients (12 years and younger)
requiring urgent assessment during this time should be directed to the local
Children's hospital.
Screen shot of patient list
Found

Patients classified as
diagnostic at SNP are
listed as "Found"
SULLIVAN NICOLAIDES PTY LTD • ABN 38 078 202 196 • A subsidiary of Sonic Healthcare Limited • ABN 24 004 196 909
134 WHITMORE STREET • TARINGA • QLD 4068 • AUSTRALIA •TEL (07) 3377 8666 • FAX (07) 3870 0549
PO BOX 344 • INDOOROOPILLY • QLD 4068 • AUSTRALIA
www.snp.com.au
Syzygy—now on 100% recycled paper.
Meridio 153750 December 2015
Correct at time of publication
© Sullivan Nicolaides Pty Ltd 2015