Casi Clinici

Statins have been recently associated with a necrotizing autoimmune myopathy (NAM) characterized by inflammation, myopathy and muscle necrosis and by the presence of anti 3-hydroxy-3-methylglutaryl-coenzim A reductase antibodies (anti-HMGCR). This case report describes a case of a man who was taking atorvastatin, complaining muscle weakness and creatine kinase (CK) very high levels. The main laboratory and autoimmunity tests (including the major myositis antibodies) were negative, despite a muscle biopsy showed a myopathic process. Because of these results the detection of anti-HMGCR antibody was activated and the positive result confirmed the diagnosis of NAM. The patient stopped the statin therapy and started a steroid therapy with improvement in muscle symptoms and mild decrease of CK. The role of the autoimmunity laboratory in the diagnostic path of this rare autoimmune disease is fundamental. Though statin-associated NAM is a rare entity, it should be considered in patients who continue to have CK elevation and muscle weakness during or after discontinuation of statin therapy.

A male, 54 years old, presented to the emergency department of Bergamo Papa Giovanni XXIII hospital, with confusion and neurological symptoms.
The peripheral blood cells count, performed on the Sysmex XN-20, showed a severe macrocytic anemia: hemoglobin 42 g/L, mean corpuscular volume 107 fL, accompanied by the morphology flag “fragments”. The morphological evaluation on the blood smear, strongly recommended with a blood cell count showing such values, confirmed the presence of erythroblasts, and revealed several morphological alterations (remarkable anisopoikilocytosis, basophilic stippling, hypersegmented neutrophils). The patient was admitted to the hospital and transfused. Further investigations showed a severe deficiency of vitamin B12, an abnormal lactate dehydrogenase activity, and an undetectable haptoglobin concentration. After the transfusions, the patient recovered quickly, and was able to report about a previous gastric resection; the information was missed at admission because of the patients confusional state. The possibility of metal poisoning or cupper deficiency were not investigated.

We report a case of a 75-years-old female with pancytopenia, fever unresponsive to antibiotic therapy and persistent cough, hepatosplenomegaly and lymphadenopathy. Bone marrow shows pathological cells; some of them showed “hand-mirror” morphology and numerous hemophagocytosis. Atypical T lymphocytes with CD3+CD5-CD7-CD2++CD8+CD56- immunophenotype are detected by flow-cytometric analysis. Based on this evidence, Hemophagocytic lymphohistiocytosis (HLH) in lymphoproliferative disease is suspected and confirmed by biopsy. HLH is a rare and life-threatening hematologic disease caused by excessive activation of immune system resulting in a systemic hyperinflammation with tissue destruction and multiorgan failure. According to HLH-2004 diagnostic criteria, HLH can be diagnosed in a patient with mutations in HLH-related genes or with at least 5 out of 8 diagnostic criteria (fever, hemophagocytosis, splenomegaly, high ferritin, elevated soluble-CD25, cytopenia, low natural killer cell activity, and hypertryglyceridemia or hypofibrinogenemia). HLH diagnosis is very challenging and integration of clinical-anamnestic, instrumental and laboratory information are essential for diagnosis and therapeutic strategy.

Hemoglobin variants are abnormal forms of hemoglobin that may cause hematological disorders. The variants can be (or not) associated with normal hematology parameters. We were able to identify a hemoglobin variant in a 56-year-old Italian Caucasian male using a hematology analyzer.
A routine complete blood count was performed on the Sysmex XN-9000 analyzer for a patient presenting at the Emergency Department with dizziness. Unusual morphological alarms were reported by the analyzer. The microscopy observation of the peripheral blood smear showed a significant number of contracted ed cells and target red cells. Differential count cytograms showed changes in the distribution of the cell clusters and a reduction in the fluorescence signal. In the hypothesis that these alterations were caused by a hemoglobin variant, a HPLC test was performed and a variant in the D/E zone was detected. Molecular analysis confirmed the presence of a variant identified as Hb Leiden. We were thus able to demonstrate the importance to correlate instrumental alarms with validation rules to detect variants in cases where clinical evidence was lacking. The introduction of a new validation rule that automatically activates reticulocyte count and peripheral blood smear in case of specific instrumental alarms is highly advisable.

In September 2018 a previously healthy 6-years-old female was admitted for unspecific visual impairment. Physical examination revealed bilateral papilledema with haemorrhage signs, torpid photomotor reflex and slow eye-blink reflex. No other physical abnormalities or alterations in routine laboratory workup were found.
Brain imaging showed alterations in cortical white matter; both optic nerves and cervical spinal cordanti aquaporin-4 antibodies (AQP4-Ab) and myelin oligodendrocyte glycoprotein antibodies (MOG-Ab) testing was then ordered suspecting a neuromyelitis optica spectrum disorder (NMOSD).
MOG-Ab positivity was found at >1:160 and at 1:40 titre in serum and in cerebrospinal fluid respectively. After steroid treatment, the titre in serum was still positive at 1:160, with mild clinical recovery. Clinical and laboratory follow up was maintained for 1 year, highlighting a fluctuating antibody titre related to both the clinical course and the immunosuppressive treatment.
The need of MOG-Ab laboratory follow-up is still debated, nevertheless it might be useful in predicting clinical relapse, as the presentation of this case report illustrates.

Secondary hyperparathyroidism (HPT) is a common issue in dialysis patients; it contributes significantly to their morbidity and mortality. Here we describe the case of a hemodialysis patient with severe secondary HPT, treated with Etelcalcetide, the new intravenous calcimimetic agent, employed after a nephrectomy due to a renal neoplasm to reduce successfully the serum levels of parathyroid hormone (PTH) and bone specific alkaline phosphatase (BAP). No significant change in serum calcium was recorded during treatment, while the already high serum phosphorus concentrations further increased after surgery. By maintaining the calcium mimetic therapy, even if at lower doses, the concentrations of PTH and BAP remained constant over the time.

Chronic lymphoproliferative disorders typically affect elderly patients with a median age at the diagnosis of 71 years. These disorders include a number of conditions characterized by an abnormal proliferation of lymphocytes towards a monoclonal lymphocytosis. The case of an 83-year-old man affected by chronic lymphocytic leukemia is presented; the peripheral blood cells count, performed on the analyzer Sysmex XN-20, showed significant differences between the white nucleated red (WNR) and white differentiation (WDF) channels that did not allow the differential counting of leukocytes. On the opposite, the reflex analysis channel white progenitor cell (WPC), returned the correct white blood cell count. Actually, when the peripheral blood sample was diluted (1:5) and resubmitted to analysis, leukocytes count resulting from WNR and WDF analysis channels corresponded to that obtained in the reflex WPC analysis channel on the undiluted sample. To verify if the instrumental anomaly found in the cell counting could be associated to an elevated plasma concentrations of immunoglobulins, a serum protein electrophoresis was performed, showing the presence of four monoclonal components. These data demonstrate that the WPC channel is an important tool for the clinical laboratory, since it is able to give a correct result even when interferents are present.

A 2-month-old newborn was hospitalized for fever, persistent infections, failure to thrive. Complete differential blood count detected a severe neutropenia and monocytosis, associated to an anomalous scatterplot of the hematology analyzer. Blood film review showed that neutrophils had been misclassified as monocytes, due to hypogranulated cytoplasms and nuclear hyposegmentation. Re-analysis on a different hematology platform agreed with the manual differential count. These clinical-morphological features suggested a possible diagnosis of immune deficiency due to lack of neutrophil specific granules. Indeed, Sanger sequencing allowed the detection of a homozygous mutation in SMARCD2 gene, whose alterations very recently had been associated to a similar syndrome, encompassing both hematological and skeletal anomalies. This case shows that a proper interpretation of routine tests can successfully drive the choice of higher-level analysis and led to a prompt diagnosis of a very rare condition. The diagnosis paved the way to a precocious allogeneic hematopoietic stem-cell transplantation that successfully cured the condition of immune deficiency and the hematology abnormalities of the young patient.

Maturity Onset Diabetes of the Young (MODY), the most frequent form of monogenic diabetes, comprises a group of heterogeneous disorders, characterized by non-autoimmune diabetes due to mutations of at least 14 different genes.
We report a case of a 38-years-old patient with non-autoimmune diabetes, where molecular analysis evidenced a large deletion on chromosome 17q12 including several genes, among them HNF1β associated to MODY5. The analysis allowed us to clarify the complex phenotype of the patient including, in addition to diabetes, intellectual disability, seizures, kidney cysts and facial dimorphisms. This case shows that diabetes when caused by large deletions, can be just one of the symptoms of a “clinical syndrome” that includes other features due to the deletion of neighboring genes and confirms the important role of the molecular test to obtain a correct diagnosis in a patient with a suspicion of monogenic diabetes.

A 72 year-old female was screened before a minor orthopaedic surgery with routine coagulation tests, that resulted highly altered. Prothrombin time and activated partial thromboplastin time (PT and aPTT) could not be calculated because the system registered a biphasic curve, protein C and protein S (PC and PS) levels were not measurable and antiphospholipid antibodies were highly positive. Reviewing previous laboratory findings, a serum protein electrophoresis showing the presence of a monoclonal peak in the gamma region was retrieved. A serum immunofixation was then performed, and an IgM kappa monoclonal component was typed; a cryoglobulin test was positive for cryoglobulin type II. To investigate the possible relationship between these laboratory findings, a pool of normal plasma was spiked with the patient IgM monoclonal component at progressively higher concentrations registering a prolongation of PT and aPTT and a slight reduction of PC and PS. The presence of an IgM paraprotein, although not quantitatively relevant, was therefore functionally able to interfere with the coagulation time calculation system. Although coagulation abnormalities in monoclonal gammopathy of undetermined significance are uncommon, these should be attentively investigated, to guarantee a correct laboratory report.

Identification errors in laboratory medicine are a major issue. Delta checks rules have a fundamental function to identify this type of errors. In the haematology section of the laboratory, the mean corpuscular volume (MCV) is one of the parameters which delta checks rely on. Unfortunately, this approach is sub-optimal since many patients show similar MCV. We present here a case illustrating the problem and the potential drawbacks for patient safety.

A 13 year-old child whit headache, nausea and repeated episodes of vomiting was hospitalized at the Major Hospital of Charity of Novara. A lumbar puncture and biochemical investigations on cerebrospinal fluid (CSF) including oligoclonal bands (OCB) screen were performed. Kappa and Lambda free light chains (kFLC and λFLC) and IgG concentrations were measured in serum and CSF by nephelometry. OCB were evaluated by isoelectric focusing (IEF) followed by immunofixation (IMF). A negative IgG index, no OCB IgG (type I pattern), positive kFLC index with increased levels of kFLC (0.14 mg/dL) and λFLC (0.14 mg/dl in CSF) were found. The FLC data suggested an intrathecal synthesis. A CSF IMF was then performed using anti-IgM peroxidase together with the IgM index using Reiber’s hyperbolyc graphic. The presence of a monoclonal IgM band and 76% of intrathecal IgM synthesis was demonstrated. A subsequent molecular biology investigation was performed on CSF and revealed a clear positivity for enterovirus.

Isocitrate Dehydrogenase 2 (IDH2) mutations are reported in about 20% of Acute Myeloid Leukemia (AML) and they are promising Minimal/Measurable Residual Disease (MRD) molecular markers because of the possible therapy whit the inhibitor Enasidenib. A man with a diagnosis of AML, negative for the common molecular markers, resulted in complete remission (CR) only after three induction cycles. The patient underwent a transplant procedure but after 7 months a relapse was observed. We retrospectively studied the status of IDH2 mutation in this patient which was positive at diagnosis (29%), after two induction cycles and at the allogeneic transplantation (2%). In the next follow-up, both WT1 and IDH2 were normal. After 3 months, when the patient was in CR and WT1 was still normal, IDH2 resulted 0.12%. After further 2 months, the patient clinically relapsed; at that time, WT1 was very high and IDH2 was 7.8%. In this case, IDH2 monitoring by Droplet Digital PCR (ddPCR) predicted relapse two months before WT1 levels and clinical evidence.

This case describes the clinical presentation of a Kawasaki-like syndrome, an inflammatory process that can affect all blood vessels of the body and may cause cardiac complications, such as coronary artery aneurysms. Patients are typically children, the majority of them are below 5-year-old, who initially present high fever and non-specific skin rash. The girl who came to our attention showed typical clinical symptoms and the diagnosis of Kawasaki disease was made based on the clinical evaluation, anamnesis and interpretation of laboratory results. This case came to our observation during the recent Coronavirus pandemic infection in Northeast of Italy, and can be classified as a Kawasaki-like syndrome. The laboratory data recorded at the time of diagnosis and during the follow-up are presented and discussed.

Wilson’s Disease (WD) is an autosomal recessive genetic disease caused by mutations to the copper-transporting gene ATP7B. WD leads to hepatic copper retention with subsequently clinical manifestations in different organs. The biochemical diagnostic approach includes measurement of serum ceruloplasmin levels and 24-hour urinary copper excretion (uCu/24h). WD patients are generally treated with D-penicillamine and cupruria is necessary to confirm the efficacy of maintenance treatment and the patient's adherence to therapy. A 30-year-old man was diagnosed with WD at the age of 5 and, since then, was treated with D-penicillamine. In this patient the uCu/24h values never fell within the range recommended by International Guidelines, but no clinical or subclinical progressions of the disease were found. The information derived from this single WD patient, monitored by serial clinical and laboratory checks for more than twenty years, may be useful for a better long-term management of WD, although we suggest that multicenter studies to re-define cupruria reference and therapeutic intervals are needed.

To date, approximately 1700 hemoglobin (Hb) variants have been identified, many of which are clinically silent. We report a hemoglobin variant visible only with capillary electrophoresis (CE). In a 65-year-old woman, using a high-performance liquid chromatography system (HPLC), HbF and HbA2were 19.3% and 0.7%, respectively, and no abnormal peaks were observed. Subsequent analysis by capillary electrophoresis (CE) showed an atypical profile with a clear presence of an abnormal Hb in the "zone Z14". The molecular investigation of the globin genes confirmed a variation of the alpha1 c.271 A> G gene corresponding to Hb Sudbury. The HPLC analysis initially led to an incorrect interpretation of defects on gamma genes with production of hereditary persistence of HbF (HPFH) and on delta genes, a delta thalassemia. The combination of different technologies (such as CE and HPLC) can certainly be useful to detect new variants of hemoglobin and allowsmore correct diagnostic conclusions.

When arrived to our observation, BS was an African origin newborn of a few days. His hemoglobin concentration and complete blood count were within normal ranges, and he had no jaundice; however, his parents are heterozygous carriers of hemoglobin variant: HbC trait the mother and HbS trait the father. Screening was therefore required for hemoglobin variants. The request is appropriate since the evidence of a double heterozygosis S/C (SCD) would allow timely treatment of these patients. Screening was performed in capillary electrophoresis but was not conclusive because the presence of a small concentration of HbS and of another variant did us not allow to make a diagnosis, although the presence of HbA allowed to exclude the state of SCD. Hemoglobin electrophoresis was then performed, but it was not conclusive. It was necessary resorting to the molecular analysis, that highlights the presence of HbS trait and a mutation in heterozygosis at the charge of the gamma-globin chain consistent with HbF Granada. The recognition of HbF Granada was meaningless from a clinical point of view, but allowed to exclude the presence of a hemoglobin compound, the main clinical question of this clinical case.

Serum monoclonal components, Bence-Jones proteinuria (PBJ) and free light chains (FLC) are clonal biomarkers for diagnosis and response assessment in light chain (AL) amyloidosis. Two clinical reports are presented here toi llustrate the utility of these biomarkers. The first case is a patient with AL κappa renal amyloidosis. Serum and urine immunofixation were negative and the FLC ratio was abnormal. Immunoelectron microscopy on tissue biopsy was negative. Amyloid typing was achieved by mass spectrometry on fat pad aspirate. The second case is a patient with AL cardiac amyloidosis with PBJ lambdaand low concentration of amyloidogenic FLC (32 mg/L). Urine capillary electrophoresis was used to assess response to treatment. The progressive reduction of PBJ after treatment was accompanied by reduction of NT-proBNP and improvement of clinical conditions. Clonal biomarkers are irreplaceable tools in management of AL amyloidosis. There is a need for more sensitive techniques for identification of monoclonal FLC on serum and urine.

We describe the case of a 47 years old male patient who underwent cardiac surgery for valve sparing root replacement (known as David procedure), in September 2018. In the post-operative period and during the rehabilitation stage, the patient was constantly monitored with the measurement of cardiac troponin I (cTnI), performed in different hospital facilities using different cTnI analytical methods. In the rehabilitation clinic, cTnI [measured with Access AccuTnI+3 method (Beckman Coulter)] was found steadily raising, so the patient was readmitted to the hospital to undergo a coronary angiography. The coronary arteries were found free from critical lesions and the cTnI [measured with Advia Centaur cTnI Ultra method, (Siemens Healthcare)] was repeatedly negative. This finding rose the suspect of an analytical interference in the Access AccuTnI+3 method. This was actually the case: heterophile and anti-alkaline phosphatase antibodies were demonstrated in the patient sample; they both were responsible for the elevated values of cTnI.

Solitary plasmacytoma is a rare form of plasma cell dyscrasia characterized by localized proliferation of neoplastic monoclonal plasmacells. The lesion can originate in bone or in soft tissue, with no or minimal evidence of bone marrow plasmacytosis (<10%) and absence of end-organ damage signs such as hypercalcaemia, renal insufficiency, anaemia, or bone lesions (CRAB). We present a case of solitary bone plasmacytoma (SPB) that rapidly evolved to multiple myeloma (MM). A partial response was obtained within few months of chemotherapy but then the disease rapidly progressed with involvement of liver, kidneys and lungs. Salvage therapy (bendamustine-bortezomib-dexamethasone, 1 cycle) had no effect and the patient died shortly after. Biochemical work up plays a central role in the follow up of MM patients, as recommended by international guidelines. In some cases the disease is so aggressive that early diagnosis and treatment fail to improve the outcome.

Monoclonal gammopathy of renal significance (MGRS) is a condition defined by the presence of a small-B cell clone causing a renal disease trough deposition in renal tissues of the monoclonal component (MC) secreted by the B cells. Since MGRS is associated with several types of renal diseases, characterization of renal damage caused by protein deposition is important to define the correct diagnosis as well as the identification of the MC. Adult Fanconi Syndrome (FS) is characterized by the presence of a MC and damage in the proximal tubule with impaired small molecules transport. We report the case of a 32 years old man with moderate kidney failure, normoglycemic glycosuria and hypouricemia. Further investigations revealed hypophosphoremia and phosphaturia; an IgGκ MC was detected by immunofixation. The kidney biopsy confirmed FS suspect. This case underlines that the results of the biochemical analysis carried on for the diagnosis of FS, need to be confirmed by histopathologic analysis.

The human parechoviruses (HPeV) have recently been recognized as emerging pathogenic microorganisms causing a broad pattern of diseases including sepsis and meningitis in children. A born-at-term, 33-day-old child, was admitted to the hospital with fever, irritability, and loss of appetite. Results of physical examination and routine blood chemistry were unremarkable (no lung rales or skin rashes; normal hemoglobin and leukocyte and platelets counts) with the only exception of an elevated procalcitonin serum level. Examination of the patient’s cerebrospinal fluid (CSF) showed pleocytosis, normal glycorrhachia and a mild increase of proteins. Blood and CSF cultures were negative. When tested with a commercial multiplex PCR technology (FILMARRAY®- Biomerieux), CSF turned out positive for the HPeV. Rapid identification of HPeV may contribute to reduce the laboratory turnaround time and improve clinical management. HPeV should be included in the differential diagnosis of young children with central nervous system symptoms and sepsis-like illness.

Growth hormone deficiency (GHD) is a disorder characterized by the inadequate secretion of GH, which results in short stature reflected by the delay in the bone lengthening, that is inappropriate to the chronological age of the child. Laboratory tests are very important to determine whether the growth-delayed child actually has GHD. These tests are intended to stimulate the pituitary gland to secrete GH, allowing the measuring of its levels in blood at timed intervals. In a 7-year-old child arrived at our attention for deceleration of growth rate, laboratory tests excluded other causes of short stature and the GH measurement confirmed the deficit of this hormone. The patient started the therapy using the recombinant human growth hormone (rhGH). Serum insulin-like growth factor-1 (IGF-1) concentration was monitored during the treatment to help with dose adjustment and to determine the adherence to therapy by the child.

Persistent Polyclonal Binucleated B-cell Lymphocytosis (PPBL) is a rare, benign hematological disorder characterized by a chronic polyclonal B-cell lymphocytosis with binucleated lymphocytes. We report the clinical case of a young woman with lymphocytosis who presented binucleate lymphocytes at the morphological examination of the peripheral venous blood smear. Flow cytometry immunophenotyping performed in peripheral blood showed a polyclonal lymphocyte B subpopulation. Serological tests were negative for viral infections. Because of its benign and indolent course, the diagnoses of PPBL is important in order to avoid unnecessary diagnostic procedures and therapies.

Multiple myeloma (MM) represents 10% of all hematologic malignancies; in 15% of MM the monoclonal component consists of only free light chains. A 53 year-old patient performs at the Corelab laboratory (AOU-AUSL Modena) blood tests for bone pain. Serum electrophoresis shows hypogammaglobulinemia (5,5 g/L). The laboratory professional decides to carry on further studies: a serum immunofixation that highlighted the presence of kappa free light chains not traceable to any heavy chain and the measure of the serum free light chains (sFLC) with the following results: FLC-κ 26 777 mg/L (i.r. 3.3-19.4); FLC-λ 6.15 mg/L (i.r. 5.7-26.3); ratio FLC (rFLC), 435.31 (i.r. 0.26-1.65). The light chain MM is a type of MM difficult to recognize. The laboratory professional's own initiative defines a procedure of "personalized medicine" oriented to to the patient's needs. The expertise of the laboratory professional is crucial in assuring the patient the best outcome when carried out on the basis of the available guidelines.

Antinuclear antibodies (ANA) displaying densefine speckled pattern on HEp-2/HEp-2000 cells are frequently observed in clinical laboratory, often associated withanti-DFS70 antibodies. Anti-DFS70 positive patients rarely develop systemic autoimmune rheumatic disease,especially in the absence of clinical evidence or additional antibodies.
A 60-years old woman complaining severe muscle weakness of the legs was tested positive for dense fine speckledANA pattern by indirect immune-fluorescence. Immunoblot analysis revealed the presence of anti-DFS70 antibodies.Positivity for anti-dsDNA antibodies, not revealed by immunoblot, was also found by Crithidia luciliae(CL). All theresults were confirmed by a different laboratory.
This case underlines the complex interpretation of a laboratory scenario where anti-DFS70 possibly coexist with muchmore specific and clinically relevant ANA. The discrepancies (observed in both laboratories) between CL and theother methods is puzzling, and may be due to different reasons, including false positive CL results or interference.

The case reports about a patient who underwenta kidney transplantation for chronic disease of unknown cause. The clinical course showed a delayed graft functionand acute tubular necrosis. Urine microscopy confirmed a tubular disfunction: presence of renal epithelial cells,cylindruria and crystals. The microscopy images showed brownish-colored crystals that, under polarized light,suggested a 2.8-dihydroxyadenine (DHA) urolithiasis, rare and underdiagnosed pathology, due to the deficiency ofadenine-phosphoribosyltransferase (APRT). The specific analysis, i.e. the determination of the enzyme activity onerythrocyte lysate, did not confirm our initial hypothesis, excluding de facto a DHA urolithiasis. Analysis of purine andpyrimidine profile confirmed the presence of a purine dysmetabolism. The patient was treated with allopurinol, whichimproved the clinical picture. This case underlines the need for more extensive studies of crystal and/or metabolicnephropathies before renal transplantation. The microscopy study was however useful to trigger investigations thathave then influenced the therapy and the clinical progress of the patient.

We describe a case of a 32 year old woman visiting to the NeurologyUnit with progressive bi-frontal headache and reduced visual acuity followed by disequilibrium and dysarthria.
Cerebrospinal fluid (CSF) analysis documented pleyocitosis with slight CSF-blood-barrier damage.
Routine laboratory tests that were all negative except for the presence of serum anti-myelin oligodendrocyteglycoprotein (MOG) antibody.
Thanks to the laboratory test results, neurologists could classified the patient as a case of encephalomyelitis anti-MOG antibody related and have treated her with methylprednisolone followed by Rituximab with clinical improvementand reduction of brain lesion.
Anti-MOG antibody associated to encephalomyelitis is currently considerated as a distinct nosologic entityimmunopathogenetically identifiable among the neuromyelitis spectrum disorders.
The case illustrated here underlines the central role of the clinical laboratory for the correct diagnosis of demyelinatingnervous system diseases.

Autoimmune hemolyticanemia (AIHA) is a relatively rare disease where red blood cells are selectively destroyed by auto-antibodies. Ingeneral, direct antiglobulin test (DAT) is the test used for confirmation even if there are other markers to guide thedifferential diagnosis and to evaluate the degree of hemolysis. We present a case of severe warm-type AIHA occurredin a thirty-six year old man with initial symptoms of asthenia and dark urine. The case shows how specialists inlaboratory medicine can play a fundamental role in the diagnostic process through an appropriate use of the tests,speeding up the management of the patient, improving thus the prognosis.

Automated urinalysis instruments image-based for cell analysis can identify non-squamousepithelial cells (NSE). Among these elements, expert pathologists can distinguish the so called Decoy Cells (DC),Polyomavirus BK (BKV)-infected elements primarily seen in immunocompromised patients. Epstein-Barr virus (EBV)infection can induce a transient immunosuppression in immunocompetent patients, and this could lead to areactivation of a latent BKV infection in urothelial cells: this is a rare event in pediatric patients. This study reports thecase of a 4 year-old child with lateral lymphadenopathy, fever and oliguria. Automated urinary sediment analysisevidenced the presence of many NSEs identifed as DC, generating a subsequent virological investigation with a finaldiagnosis of concomitant BKV and EBV infection. The combination of an automated technology, an efficientmiddleware and the expertise of the laboratory professionals , allowed the proper identification of these peculiarreactive elements, which could easily be mistaken for malignant atypical cells.

Methylenetetrahydrofolate Reductase (MTHFR) deficiency, is avery rare congenital defect of folate metabolism, inherited in an autosomal recessive pattern included in newbornscreening (NBS) programs in Italy. It is caused by mutations in the MTHFRgene and is characterized by elevatedplasma homocysteine and borderline-low or normal methionine levels, causing severe neurological signs, recurrentapnoea, microcephaly and convulsions, generally during the neonatal period. An early treatment may prevent theclinical manifestations with a positive impact on patient’s health.
We report a new case of MTHFRdeficiency, identified during NBS that showed hypomethioninemia 4.6 μmol/L (r.i.6-20). The second level-test revealed hyperhomocysteinemia (106.7 μM, r.i. 5-15). The whole sequencing of theMTHFRgene showed two missense mutation: c.176G>C (p.Trp59Ser), reported as disease causing and the novelc.1769T>G (p.Leu590Arg), classified as likely pathogenetic. The baby was immediately treated with vitamin B12,folate and betaine; after 12 months of follow-up he has no signs or symptoms of the disease.
In conclusion, this case report highlights the importance of NBS for inborn errors of metabolism and genetic analysis,that can prevent the establishment of a serious disorder of folate metabolism.

Cerebrospinal fluid (CSF) of a 64 year old malepatient was sent from the hematology unit to laboratory for cell count and morphology and chemical-physicalexamination. CSF was clear, colourless and with increased total protein concentration. Cell count was first performedin Burker camera with a result of 40/μL; some of the cells showed an abnormal morphology. Our laboratory workflowincludes the CSF examination utilizing an automatic cell counter: it showed a few white blood cells (3/μL), but a highnumber of total cells (64/μL). The morphological evaluation, with cytocentrifugation and May-Grunwald Giemsa stain,identified the elements as mature plasma cells; the result was then confirmed by immunophenotyping.
These findings suggest a neurological localization of a multiple myeloma (MM). Actually, the patient had beendiagnosed as IgA lambda MM, with bone involvement that caused progressive loss of walk. Positron EmissionTomography revealed hyperdense areas, but it wasn’t able to distinguish between lymphoproliferative disease andthrombotic phlogosis. In spite of the therapy, patient neurological conditions worsened till irreversible coma. He dieda few days later.

Intraocular hemorrhage in a patient with acquired hemophilia A. Intraocular hemorrhage is frequently encountered by ophthalmologists and by emergency room professionals as well. Although the diagnosis of intraocular hemorrhage is  easy  by fundoscopic examination or ultrasonography, further investigation may be required to determine the underlying etiology. In the literature, several cases of intravascular bleeding caused by the use of warfarin and new oral anticoagulants (NOACs) are described. We report here  a case of intraocular hemorrhage in a patient with acquired hemophilia A (AHA).

A case of lymphadenopathy, hepatosplenomegaly and elevated serum tryptase level. Mastocytosis is a rare clonal disease characterized by neoplastic proliferation of mast cells in one or more organs, frequently skin and bone marrow. Diagnosis and classification of mastocytosis is based on the identification of neoplastic mast cells in according to the morphological, immunophenotypical and/or molecular criteria established by the WHO. For the diagnosis, serum levels of the tryptase which correlate with quantity and activity of mast cells is particulary useful. This case reports about a 60-year-old man with hepatosplenomegaly, modest monoclonal component, reactive lymph node hyperplasia and moderate macrocytic anemia (haemoglobin:129 gr/L). Bone marrow aspiration shows areas of infiltration of atypical mast cells type II and rarely type I with aberrant immunophenotype: CD45++CD117++CD2+CD25+. The tryptase concentration is significantly increased. According to WHO 2008 criteria, diagnosis of systemic mastocytosis is made. Early diagnosis of mastocytosis is pivotal because immunotherapy is often required to reduce the risk of allergic reactions or major bone complications.

Evaluation of response to treatment in a patient with light chain amyloidosis and low free light chain burden. In patients with light chain (AL) amyloidosis, reduction of amyloidogenic circulating free light chain (FLC) concentration translates in improvement of organ dysfunction and is associated with an increase in overall survival. Validated criteria for hematologic response to therapy are based on FLC quantification. However, patients with a difference between involved and uninvolved FLC (dFLC) <50 mg/L are not evaluable for hematologic response. Here we report the case of a 69 year old man with AL (λ) amyloidosis with renal involvement, presenting a low-FLC burden (dFLC 41 mg/L) at diagnosis. After two lines of treatment, a profound reduction of amyloidogenic FLC (dFLC 0 mg/L) was associated with an improvement of organ dysfunction. This case emphasizes the role of FLC assessment in the monitoring also of patients with a low-dFLC burden.

Incidental detection of a new hemoglobin beta variant performing HbA1c measurement. Hemoglobin α and β chain variants can be incidentally detected during the glycated hemoglobin (HbA1c) determination. A 58-year-old female was investigated for HbA1c with Tera 3 Capillarys system (CE, Sebia). Quantification of HbA1c was invalidated by the presence of a double peak in the HbA0 zone. Standard high performance liquid chromatography (HPLC), performed with VARIANT IITM Analyzer (Biorad), did not separate the variant from Hb A0. β-globin gene sequencing showed a heterozygous variation of nucleotide sequence HBB: c.376C>A; beta 125 (H3) Pro>Thr. The new variant, called Hb-Novara, was found also in the daughter of the proband, associated with an alpha-talassemic trait. The hemoglobin stability tests of both subjects were normal. A combination of different technologies (such as HPLC and CE) can be useful in the detection of new hemoglobin variants. Although Hb-Novara seems to be asymptomatic, it could produce relevant hematological phenotypes when associated with α or β chain defects

Laboratory professional and urinary sediment analyzer for the diagnosis of Polyomavirus BK infection. Polyomavirus BK (BKV)-infected cells, (the so called decoy cells) were observed in two solid organ (kidney and lung) transplant recipients. In both patients, serum creatinine and BKV viremia were increased. Pharmacological immunodepression, during the 3-6 month period after transplantation, increases the risk of this viral infection and the related BKV nephropathy. Sedimax (Menarini), the automatic urinary sediment analyzer equipped with instrumental filters to select specific cellular patterns, utilized in our laboratory for urine examination, recognized some elements with enlarged ground glass–like nucleus and flagged them as "non-squamous epithelial cells". By using a phase contrast microscopy, we re-analyzed these specific urinary samples and identified these elements as decoy cells. Serial urinary sediment analysis is strictly required both to search early infection signs and to switch the differential diagnosis from neoplastic to BKV-infected cells. These crucial findings, provided by the laboratory staff expertise, can accelerate clinical decisions improving thus the long term transplantation outcomes.

Three neonates with Down syndrome and hematological abnormalities. We report three cases of neonates with Down syndrome. In the first newborn, the complete blood count (CBC) showed leukocytosis (30x109/L). The presence of rare blasts, with morphological characteristics attributable to megacaryocytic blasts, were appreciated at the review of peripheral blood. In the second case the patient was hospitalized for severe anemia and neutropenia. The visual inspection of the peripheral blood smear showed the presence of rare undifferentiated blasts. The third patient was a premature neonate, with fetal hydrops. The CBC showed 172x109/L leukocytes and anemia. The peripheral blood smear showed erythroblasts and dysplastic platelets, prevalence of blasts, some of them with cytoplasmic blebs. In the all cases the diagnosis was Transient Abnormal Myelopoiesis (TAM), rather frequent in patients with Down syndrome. It is a transient syndrome characterized by the presence of megacaryoblasts in peripheral blood and mutation of the GATA1 gene. The information obtained by the visual inspection of the peripheral smears, could be important for a correct diagnosis, especially when the CBC data are not particularly abnormal

In 2014, the International Myeloma Working Group updated the criteria for the diagnosis of Multiple Myeloma (MM), adding to the classic CRAB features (hypercalcaemia, renal failure, anemia, and bone lesions) a recently validated biomarker and recommended the implementation of this criterium in the routine practice. The biomarker is the ratio of involved to non-involved free light chain ≥100, provided that the involved light chain is ≥100 mg/L. We report the case of a man aged 68, referring to our Hematology Unit in March 2016 who was diagnosed with a monoclonal gammopathy of undetermined significance since 2009. Serum protein electrophoresis and immunofixation were performed, along with serum free light chain (sFLC) quantification. During the follow-up, despite the small peak entity, the sFLC kappa concentration was very high (3684 mg/L; reference interval 3.3-19.40) with an abnormal sFLC ratio (304; reference interval 0.26-1.65). At that stage, the patient did not show any signs of CRAB features, however a drug treatment was started. For months later, a magnetic resonance revealed a numer of lytic lesions. This case underlines the crucial role of sFLC in the management of patients with plasmacell dyscrasias and shows how sFLC ratio can induce early treatment before the development of major organ damage.

Malaria is a major global health problem. The clinical diagnosis must be confirmed by laboratory tests. However, the research of malarial plasmodia is performed only in case of clinical suspicion, while it should be used with greater awareness given the increase of the migratory phenomena towards Europe in recent years. We present a case of Plasmodium falciparum infection with a parasitemia of 1/1500 red blood cells in a young immigrant from Burkina Faso carrier of a HbC variant hemoglobin without any alterations to the blood count. The case shows how microscopic revision is a fundamental diagnostic element; the detection of a hemoglobin variant made possible to understand the dynamic of the infection in order to be able to assure to the patient the best therapeutic treatment.

The case concerns a 82-year-old patient, organ donor, affected by diabetes mellitus, hypertension and reported type A haemophilia, showing a traumatic severe cerebral haemorrhage. The Medical Committee started the donor evaluation process: the liver was compatible for a recipient in life-threatening conditions. Although the first level coagulation tests were within the normal range, the Regional Center for Organ and Tissue Allocation of the Tuscany Region - Italy requested further investigations in order to clarify the reported diagnosis of haemophilia and to exclude the presence of a specific FVIII inhibitor. FVII activity was evaluated to assess the protein synthesis of the liver, and FVIII for suspected haemophilia; both of them were normal. Considering the importance of the diagnosis, the parallelisms of both FVII and FVIII were performed; the tests were negative for the presence of inhibitors. Second-level tests therefore rejected the diagnosis of haemophilia and excluded the presence of a specific inhibitor of FVIII. The absence of coagulative alterations allowed the liver explant, which was successfully transplanted on a 59-year-old male recipient.

A 34 years old woman presented progressive severe thrombocytopenia, without major bleeding. The diagnostic tests for systemic lupus erythematosus, HIV infection and HCV infection, were negative. The platelet count was 9x10⁹/L, with elevated immature platelet fraction (IPF). Bone marrow aspirate was normal; the final diagnosis was immune thrombocytopenia (ITP). ITP is an autoimmune disease characterized by low platelet count in the absence of other causes of thrombocytopenia. IPF is a parameter of Sysmex hematological analyzers that measures young platelets in peripheral blood. It is elevated in peripheral platelet destruction and it is low in hypoproliferative thrombocytopenias, making it useful in differential diagnosis. This case report demonstrates the utility of IPF in diagnosis, management and follow up of ITP.

The detection and quantification of amyloidogenic light-chains (LC) is necessary for diagnosis and evaluation of response in AL amyloidosis. A 69 years old woman was initially diagnosed, in another center, with AL-λ amyloidosis with renal and soft tissue involvement in December 2001. After 4 cycles of therapy with melphalan and dexamethasone serum and urine immunofixation were negative and, after cycle 6, complete remission was confirmed. Free light chain (FLC) ratio was normal until June 2006, when proteinuria increased, and an elevated k-FLC concentration with abnormal k/λ-ratio was documented. We repeated the abdominal fat aspirate for amyloid typing by immune-electron microscopy that revealed k-LC deposits. The diagnosis was AL-k. A relapse was documented and the patient was started on bortezomib and dexamethasone therapy. After 8 cycles, complete remission was obtained. In this case, FLC allowed the identification of the amyloidogenic-LC, enabling the detection of relapse.

Presently, oligoclonal band (OCB) detection is considered the gold standard for Multiple Sclerosis (MS) diagnosis. The technique is however cumbersome and requires interpretative expertise for the evaluation of dubious OCB patterns. Recently, the kappa and lambda free light chains (FLCs) measurement in cerebrospinal fluid (CSF) has been suggested as potential diagnostic tool. We describe here two case reports where the FLCs determination contributed importantly to the diagnosis. A 43 years old female with left homonym hemianopia and frontal headache showed a negative OCBs pattern showing only a single monoclonal band. CSF and serum FLCs were within the reference range while kFLC index was positive. Visual evoked potentials and magnetic resonance investigation (MRI) were suggestive of clinically isolated syndrome. A 55 year old female with visual left homonym hemianopia and mild retroorbital pain showed very similar findings with a negative pattern for OCBs, and a single monoclonal band. CSF FLCs were slightly above the upper value of the reference range and kFLC index was positive. Evoked potentials and MRI were suggestive for MS diagnosis. In conclusion, the FLCs quantification in CSF could be a valid tool to support MS diagnosis especially in the presence of unclear OCB results.

A 52 year old female, born in Ecuador, was admitted to the medical ward because of dizziness, blurred vision, sweating and vomiting started 3 days earlier. Complete blood count showed a severe anemia, while mean corpuscolar volume, mean corpuscolar hemoglobin, white blood cell, differential and platelet count were normal. Biochemical tests revealed a very high LDH and a low haptoglobin value. The blood smear revealed marked anisocytosis, hypocromia, oval erythrocytes, teardrop cells and fragments, with the presence of hypersegmented neuthrophils. These morphological features, together with the information obtained by the hematology analyzers, gave rise to the suspicion of vitamin B12 deficiency. Further investigation confirmed a low level of vitamin B12. Variant hemoglobin was detected by high performance liquid chromatography and capillary electrophoresis; an elevated soluble transferrin receptor value was observed. A diagnosis of sickle cell disorder associated to alpha thalassemia with iron and B12 deficiency was formulated.

A 3-year-old child was admitted to our Emergency Department with neurological multifocal symptoms. Magnetic resonance imaging showed pulvinar and lenticular nucleus involvement. The parents reported an infection from Varicella Zooster Virus (VZV) a few days earlier. After taking lumbar puncture, the patient was hospitalized with a preliminary diagnosis of viral encephalitis. Cerebrospinal fluid (CSF) examination was negative for albumin quotient, quantitative IgG synthesis, isoelectric focusing and Polimerase Chain Reaction (PCR) for Herpes viruses. High CSF intrathecal total IgM fraction (48% r.v. ≤0) was detected as well with highly positive IgM antibody indices specific for VZV. CSF free light chain (FLC) kappa and lambda indices were highly positive: respectively 34.12 (r.v. <6.39) and 17.78 (r.v. <5.51). The diagnosis of VZV encephalitis, was possible only after specific CSF serology and CSF FLC measurement. IgG isoelectric focusing is considered the best screening test to detect immune activation in CNS, however, in this patient we observed mainly an IgM response. Our case indicates that CSF FLC determination is perhaps a better test to screen for an immune activation of the central nervous system, as it becomes positive also in case of IgM intrathecal synthesis.

Systemic Lupus Erythematosus (SLE) is a connective tissue disease characterized by skin erythema-sensitivity to sunlight. It systemically effects almost all organs and systems due to immune complexes and complement deposits.The early diagnosis of SLE is imperative to initiate the correct therapy and limit further damage to the organs. Laboratory auto-immunity tests play a vital role in the diagnosis of this disease, as described in our case study. We have considered the clinical history of a patient who has shown symptoms and laboratory data apparently unrelated, for up to five years. We suggested further and appropriate laboratory tests resulting in the diagnosis of SLE. We believe that this clinical case could be of great interest because it points out the importance of multidisciplinary approach to an early diagnosis of this disease, especially when the clinical symptoms are not specific. Once again, it also highlights the central role of the laboratory in diagnosis of autoimmune disease.

We report a case of interference with electrophoretic (CZE) and immunofixation (IFE) techniques after repeated cycles of a biological anti-cancer drug. A man, with colon neoplasia, underwent a prolonged therapy with Bevacizumab and other chemoterapeutic agents from September 2013 until May 2015. Before therapy, the electrophoretic pattern was normal while, during treatment, it showed a modification suggestive of the presence of a monoclonal component (MC) that was possible to type (IgG k) and to quantify (8 g/L) after 22 cycles of therapy. The cooperation with clinicians and our study about biological drugs, allowed us to recognize this MC as an interference due to the accumulation of Bevacizumab in the serum of the patient. The laboratory report of a MC would have involved the patient in further procedures that are invasive, cost and time expensive. This case emphasizes the importance of a strict collaboration between physicians and the clinical laboratory in the management of patients treated with biological drugs.

IgD multiple myeloma (MM) is a rare disease affecting less than 2% of patients with MM, and it is frequently characterized by an aggressive course. It is usually associated with low monoclonal protein levels, so adequate diagnostic procedures have to be performed in order to identify the involved monoclonal component (MC). We present a case of a 38-year-old man with acute kidney disease caused by an IgD lambda MM. Diagnosis was achieved by serum protein electrophoresis and immunofixation with anti IgD and IgE antisera. After autologous stem cell transplantations (ASCT) the patient developed a MC different from the original isotype, followed by an oligoclonal bands (OB) pattern. Recently, the occurrence of MC and OB unrelated to the original clone has been proven to be an important favorable prognostic factor in patients with MM who undergo ASCT. The role of the protein laboratory at diagnosis and during follow up of MM patients is highlighted.

A 77-year-old patient with a long-lasting stable proteinuria was admitted to the Nephrology Department for the recent onset of nephrotic syndrome and renal failure. The initial laboratory profile was unremarkable, except for a severe hypogammaglobinemia without monoclonal spike on serum protein electrophoresis. Renal biopsy was performed, showing diffuse amyloidosis; however, immunohistochemistry for light chains was negative, leading to the hypothesis of a genetic amyloidosis. To rule out an AL-type amyloidosis, serum immunofixation and FLC measurement were performed, showing a monoclonal component of lambda light chain with a significant impairment of the kappa/lambda ratio. The bone-marrow biopsy led to the final diagnosis of light chain multiple myeloma. A Bortezomib-based chemotherapy regimen was started, however, despite clinical improvement, lambda free light chains showed a marked increase, leading to a Melphalan-based therapeutic strategy. In conclusion, measurement of FLC ratio was crucial for the diagnosis and the therapeutic monitoring in this troublesome myeloma case.

Maturity Onset Diabetes of the young (MODY) is an autosomal dominant disease that includes clinically heterogeneous forms of not autoimmune diabetes that are caused by mutations in different genes. To date at least thirteen subtypes of MODY have been described. Hepatocyte Nuclear Factor-1α (HNF-1α) gene mutations (MODY3) lead to a severe form of diabetes during adolescence, with glycosuria and progressive reduction of insulin secretion. The management of pregnancies in women with familial diseases could be difficult. We reported a case of a 36-year-old woman at the 5th week of a twin, bicorial, biamniotic pregnancy, diagnosed with diabetes at 18 years of age, with negative autoimmunity and diabetes family history. Genetic tests on woman and on her family showed father, sister, first daughter and one of the twins, carriers of c.812G>A HNF-1α mutation. This case of a twin pregnancy, with only one fetus inheriting the disease, allowed us to evaluate the genotype influence in a shared metabolic environment.

Light chain escape (LCE) is a type of relapse where a serum free light chains (FLC) increase is observed, in the absence of a parallel increase of the original monoclonal component; this particular kind of relapse seems to be influenced by new therapeutic regimens. We present a case of a 55-years old man with a IgG kappa multiple myeloma (MM), who underwent double autologous bone marrow transplantation as first line therapy; after relapse, the patient was treated with lenalidomide/dexamethasone (LD). After more than three years of LD treatment, in September 2014, an increase of FLCs was observed, while serum and urine immunofixations remained negative until January and February 2015 respectively, when a LCE was diagnosed. Despite the new treatment, the patient died in June 2016. The FLCs measurement, although not reaching the IMWG criteria, detected relapse earlier than immunofixation. This case indicates that FLCs should be routinely performed during follow up of MM patients to ensure that LCE is not missed.

A 4 years old child from Sry Lanka was admitted in our hospital after several blood transfusions for severe anemia in her country. Very low hemoglobin (65 g/L) and ferritin (<1 ng/mL) concentrations were detected, consistent with iron deficiency anemia. The reticulocyte count and the hemoglobin content (Ret-He) were low (49,20x10⁹/L and 13.7 pg respectively). An important number of causes of iron deficiency anemia were excluded. The patient was treated with iron infusion for two weeks, with good recovery of hemoglobin levels iron stores, Ret-He and reticulocyte number. The patient was then treated with oral iron supplementation, but a considerable decrease of Ret-He and reticulocyte count was observed, so the infusive therapy was reintroduced. Diagnosis and treatment were optimized by the synergy between the clinical laboratory and pediatricians, utilizing these hematological parameters. The blood transfusions could thus be stopped and the bone marrow biopsy could be avoided. This case demonstrates the importance of the reticulocyte count and the Ret-He in the management of iron deficiency anemia.

A 22-year-old male with recurrent bilateral stone disease and positive family history for stones was referred in March 2015 to the Metabolic Stone Clinic of the Policlinico Gemelli Hospital; a metabolic assessment revealed a number of abnormalities including hypercalciuria, hypocitraturia and abnormally high fasting urine pH. The previously expelled urinary calculus was sent to the clinical laboratory for the biochemical analysis by the infrared method. Fourier transform infrared spectroscopy (FT-IR) analysis identifying brushite and carbapatite, together with the finding of high urine pH, raised the suspicion of distal renal tubular acidosis which was subsequently confirmed by the urinary acidification test. The semiquantitative method of stone composition analysis would have yielded a mixture of calcium, ammonium, phosphate and magnesium, thus likely directing the diagnostic work-up, together with the abnormally high urine pH, towards infectious stones (e.g., by urease-producing bacteria). The information obtained by FT-IR analysis allowed clinicians to correctly hypothesize a urinary acidification deficit, which was subsequently treated with potassium citrate supplements.

It is acknowledged that the risk management strategy is cardinal to maintain safety in health care organisations. Clinical risk assessment and management is a continuous and dynamic process aimed to evaluate risks and to develop appropriate plans to reduce them. Internationally, there is an increasing recognition of the need to collect and analyse data on patient safety incidents to facilitate cultural growth and to develop appropriate solutions. The practice of reporting is commonly used, and several countries have established national reporting systems to facilitate large scale monitoring and analysis of data. This activity provides information on the extent, types and causes of errors, adverse events and near misses, supporting healthcare workers in the activity of reporting errors. This case shows how a non-optimal communication between laboratory and clinicians has caused an adverse advent and which corrective actions have been undertaken.

We present a case of a 74-year-old woman with myelofibrosis, hypothyroidism and negative bleeding history, showing a prolonged APTT performed within a pre-intervention screening. The laboratory tests showed a positivity for the presence of lupus anticoagulant antibodies (LA). Further investigations revealed normal intrinsic factor and von Willebrand factor (VWF) antigen concentrations, and normal to only slightly reduced VWF Ristocetin Cofactor (VWF:RCo) by chemiluminescent assay and by platelet agglutination. The VWF:RCo by a latex- immunoturbidimetric method was strongly reduced and the platelet function test was found to be abnormal. The negative bleeding history, the myeloproliferative chronic disease, the LA positivity and the other laboratory findings were consistent with the presence of acquired VWF disease. However, the disproportionate values of VWF:RCo measurements obtained by the latex method and all the other assays, made us to conclude for the presence of an interference (possibly due to autoantibodies) on latex VWF:RCo immunoassay and the patient went successfully to surgery without anti-haemorrhagic prophylaxis.

Gluten hypersensitivity: basophil activation test (BAT) may help in the differential diagnosis? The main forms of gluten-related disorders are wheat allergy (WA), celiac disease (CD) and possibly immune-mediated disease (gluten sensitivity). S-IgE play an essential role in WA. For CD tests available are anti-tissue transglutaminase (tTG) IgA, anti-endomysium (EMA) and deamidated gliadin peptides (DGP) antibodies IgG particular. For other immunemediated diseases there is currently no test available. The usefulness of basophil activation test (BAT) in anaphylactic adverse reactions, late-onset allergy has been demonstrated. We report the case of a woman of 46 years old with disorders of wheat tied overt clinical signs, intestinal and extra-intestinal symptoms, whose tests above were all negative. Only the BAT showed a stimulation of basophils exposed (52.9%) to extract wheat. We diagnosed gluten sensitivity (GS) on the basis of an algorithm for the differential diagnosis of gluten-related disorders, including CD, GS and WA. We believe that the BAT confirms a hypersensitivity reaction to wheat not-IgE-mediated, not CD.

Factor V Leiden (FVL) mutation causes activated protein C (APC) resistance by decreasing the susceptibility of FVa to APC-mediated inactivation. In our Laboratory, the usual approach to the identification of FV deficit includes a combination of genetic and functional tests. The aim of this paper was to highlight the importance to investigate both the genotype and the phenotype in the diagnosis of FVL-APC resistance related thrombophilia. Among a group of 292 subjects examined for thrombophilia, we observed three patients with discordant results of genetic test for the detection of G1691A FV gene mutation and functional APCr assay: the first subject has a mild APC resistance with a wild type genotype; the second one, and her sister, shows a severe APC resistance with a heterozygous genotype. To determine the FV deficit, it is important to associate the molecular analysis of G1691A mutation with the APC resistance test.

This case reports on a 6-year-old child, suffering from phenylketonuria treated with levetiracetam. The complete blood count showed degranulated platelets, confirmed by optical microscopy of the peripheral blood smear. Medical history revealed no bleeding or thrombocytopenia, so a correlation between the phenomenon and the pharmacological treatment was postulated. However, among the adverse effect of this drug, only cases of drug-induced thrombocytopenia are known. From a literature research, we were able to retrieve a description of a "pseudo gray platelet syndrome induced by EDTA". The blood sampling was thus repeated using sodium-citrate as anticoagulant besides EDTA; smears were performed using these samples and directly from a finger stick. The smear from the EDTA sample confirmed the presence of degranulated platelets; while the one from the sodium-citrate sample showed no platelet abnormalities. Platelet morphology was also normal in the smear from the finger stick. Pseudo Gray Syndrome Platelet (PGSP) by EDTA is an “in vitro” phenomenon not associated with bleeding disorders. The observation of different peripheral blood smears (EDTA, sodium-citrate and finger stick) allowed us to correctly identified a harmless condition, distinguishing it from the true gray platelet syndrome, a much more severe disorder.

A 69-year-old female, suffering from myelodysplastic syndrome, is admitted to the hospital because of worsening of anemia and thrombocytopenia. The blood count confirms anemia (hemoglobin 97 g/L) and thrombocytopenia (platelets 43x109/L) At the optical microscopy 87% blast cells are observed; these are characterized by numerous cytoplasmic vacuoles, mimicking an acute lymphoid leukemia. A similar finding is obtained in myeloaspirate smears. By means of 6-color immunophenotyping, blast cells appear to be positive for CD13, CD33, CD34, CD117, CD38, CD45RA, CD71, myeloperoxidase, and partially positive for CD235a. The positivity for myeloperoxidase is confirmed by standard cytochemistry. Acute myeloid leukemia with myelodysplasia-related changes is diagnosed. This case shows that marked vacuolation of blasts, although more frequent in cases of B-cell acute leukemia, may be present in sporadic cases of acute myeloid leukemia.

The National Academy of Clinical Biochemistry states that cancer antigen 15-3 (CA15-3) in combination with imaging and clinical examinations can be used for therapeutic monitoring in patients with advanced breast cancer. In a 62 year old patient with a 2 year history of invasive ductal breast carcinoma and bone metastasis, treated with an aromatase inhibitor, the imaging showed bone marrow infiltration and liver metastasis. The oncologist planned a close monitoring of the disease and the patient has been followed for two years by CA15-3 every month and imaging when necessary. It has been observed that the clinician modified the therapy on the basis of the CA15-3 values during two phases of apparent stability of the disease. This case report shows that the CA15-3 has contributed to a large extent to stop ineffective treatments and has effectively helped the clinician in selecting the most appropriate treatment options. However, it is to be noted that the monthly request of the marker is not appropriate.

Patients with AL amyloidosis often have small monoclonal components (MCs) difficult to quantify by densitometry. IgA are the most problematic, due to anodic migration and possible masking under proteins migrating in β zone. We evaluated the usefulness of the Hevylite assay (Binding Site, Birmingham UK), at diagnosis and during follow-up, in a patient with AL amyloidosis and biclonal gammopathy. At diagnosis serum immunofixation identified an IgGλ and an IgAλ band (the last one not reliably quantifiable in capillary electrophoresis). The κ serum free light chain (FLC) concentration was 4.94 mg/L and λ 26 mg/L (κ/λ ratio 0.19). The Hevylite test showed both IgGλ and IgAλ above the reference limits, with abnormal κ/λ ratios. After treatment, a 27% decrease in IgGλ and a 56% decrease in IgAλ concentration were documented by Hevylite, which was the only mean to quantify the monoclonal components in this patient.

Serum and cerebrospinal fluid immunoglobulins and free light chains measurements in a patient with autoinflammatory disease. We report a case of a patient with chronic meningitis, headache, deafness, leukoencephalopathy, and osteomyelitis who showed a selective interleukin-6 (IL-6) overproduction. An inflammatory pattern was observed in serum; the cerebrospinal fluid (CSF) examination revealed positive oligoclonal IgG bands and IgG, IgA, IgM intrathecal synthesis. CSF free light chains (FLC) indices were very high. Steroids gave modest benefits. IL-6 was persistently increased in CSF and serum; after treatment with Tocilizumab, an anti IL6-receptor monoclonal antibody, the serum inflammatory pattern normalized and FLC decreased. Central neurological symptoms improved to a lesser degree than systemic ones, probably due to Tocilizumab blood-brain barrier restriction. The biochemical CSF parameters showed partial improvement: the albumin ratio decreased, immunoglobulin intrathecal synthesis and oligoclonal bands were no more detectable, but FLC absolute values and indices remained elevated, confirming persisting CSF inflammation. This is the first report on Tocilizumab and steroid treatment effects on FLC concentrations. FLC measurement both in serum and CSF could be useful markers both for diagnosis and evaluation of the response to therapy in the inflammatory and immunological processes of SNC.

POEMS syndrome is a rare paraneoplastic, multisystemic, plasma cell discrasia characterized by Polyneuropathy, Organomegaly, Endocrinopathy, Monoclonal gammopathy and Skin changes. Most patients have high serum free light chains (sFLC) concentrations but a normal sFLC ratio. Hevylite (HLC) is a new method that allows separated quantification of the serum k and l bounded levels of the six isotype specific immunoglobulins. In this study HLC and sFLC were measured in serum samples during the follow up of two patients with POEMS syndrome. The HLC ratio of the involved monoclonal immunoglobulin could provide additional information to assess residual disease, allowing  detection of relapse earlier than clinical symptoms in patients with POEMS syndrome.

We observed a case of superficial siderosis (SS) of the central nervous system caused by an hemorrhagic trauma forty years before. We questioned whether SS was the stabilized effect of a remote bleeding or an evolutionary process indirectly related to the trauma. Moreover, we aimed to evaluate whether an iron chelator can affect the level of iron deposition. Magnetic Resonance (MRI) demonstrated iron accumulation mainly on the surface of the cerebellum and brain stem. Cerebrospinal fluid (CSF) microscopic analysis revealed few siderophages; CSF ferritin level was 76 ng/mL (reference value <12). After treatment with an iron chelator (deferiprone) for three months, MRI was unchanged, but the CSF ferritin was about 20% less. The presence of few siderophages supported the hypothesis of a persistent subarachnoid microbleeding. CSF ferritin, as an iron deposition index, allowed a diagnosis of SS and a
more sensitive evaluation of the efficacy of the treatment than the MRI.

Monoclonal gammopathy of renal significance is defined by the causal relationship between a small B-cell clone and the renal disease. Immunotactoid glomerulopathy is a rare glomerular disease characterized by
highly organized crystalline structure of Congo Red-negative immune deposits in the absence of systemic disease. We describe a 54 years-old man with non-nephrotic proteinuria and chronic renal failure. Laboratory findings revealed a serum monoclonal component. Renal histology showed a morphological pattern of membrano-proliferative glomerulonephritis; electron microscopy evidenced micro tubular structures within the mesangium measuring approximately 20 nm in thickness, similar to cryoglobulins. Renal immunofluorescence demonstrated in the deposits the same monoclonal component observed in serum, leading to a final diagnosis of immunotactoid glomerulopathy.

Adult onset Still’s disease (AOSD) is a rare clinical entity with unknown etiology and pathogenesis, characterized by high spiking fevers, arthritis, typical evanescent, nonpruritic, macular and salmon
coloured rash, and multiorgan involvement. AOSD remains a diagnostic challenge due to the overlapping features with numerous infective, neoplastic and rheumatological conditions. A case of AOSD with atypical cutaneous manifestations in a 50-year-old female is reported. The patient’s symptoms included: remittent fever, widespread urticarial, maculopapular erythema and a sore throat. Hematological investigations showed leukocytosis with neutrophilia. There were markedly elevated levels of serum ferritin (20.920 μg/L) and mild liver dysfunction. A glycosylated ferritin assay was performed because of a severe hyperferritinemia, showing a reduction of the glycosylated fraction (<20%), a newly proposed diagnostic criteria for AOSD. We emphasize the diagnostic value of low glycosylated ferritin concentration for the differential diagnosis of this rare disease, particularly in case of atypical presentation.

Despite several pathological conditions are associated with free light chains (FLC) deposition in human tissues, only few cases of human diseases caused by the specific binding activity of monoclonal FLC are described. A 65-year old male patient, with highly abnormal functional coagulation tests and undetectable functional fibrinogen was admitted to the Hematological Clinic of the University Hospital of Pisa. The same tests were within the reference intervals one year before. After excluding a number of causes for abnormal coagulation tests, we focused on potential causes of acquired dysfibrinogenemia. Due to the presence of abnormal values of FLC, we performed an immunofixation: while serum did not show any detectable monoclonal band, the immunofixation of a plasma sample revealed the presence of monoclonal FLC of kappa type co-migrating with fibrinogen. The serum kappa FLC concentrations were much lower than plasma levels, suggesting that the majority of these FLC were bound to fibrinogen, remaining associated to fibrin after clotting. Bone marrow biopsy showed 4% monoclonal plasma cells producing kappa light chains. The patient was diagnosed as affected by a FLC MGUS. After two courses of dexamethasone, the plasma concentration of kappa FLC decreased substantially and most of the coagulation tests normalized. The nature of the interaction between fibrinogen and kappa FLC is currently under investigation to elucidate the mechanism able to inhibit fibrinogen polymerization.

In November 2013, following a febrile episode lasting for one week, a 51-year-old male reported fatigue and increasing clumsiness and rigidity of lower limbs. Two months after the symptoms onset, neurological examination showed ataxic-spastic gait, diffuse accentuation of deep tendon reflexes with extensor plantar response and abolition of the abdominal reflexes. The clinical suspicion of an autoimmune para-infectious myelo-neuropathy, prompted us to a comprehensive clinical chemistry, hematology and autoimmunity work-up: the only pathological result was an IgG monoclonal gammopathy. Nerve conduction studies showed a very mild sensory neuropathy, while visual evoked potentials were abnormal. Contrast magnetic resonance imaging showed a contrastfree parenchymal C2 spinal cord lesion. Cerebrospinal fluid examination, obtained to rule out multiple sclerosis (MS), demonstrated a moderate barrier disruption without oligoclonal bands reaction. These features rule out MS suggesting Devic's disease (neuromyelitis optica). Additional serological testing to detect aquaporin-4 antibodies (NMO-IgG) was positive, underscoring the paramount importance of laboratory testing in this differential diagnosis.

The newly described 22q11.2 microduplication syndrome is an association of a broad clinical spectrum and up to now more than 50 unrelated cases have been reported. The clinical presentation of patients is extremely variable and shares features with 22q11.2 deletion syndromes (DG/VCFS), including heart defects, urogenital abnormalities, velopharyngeal insufficiency with or without cleft palate; it ranges from multiple defects to mild learning difficulties with some individuals being essentially normal. A high resolution array comparative genomic hybridization (a-CGH) 4x180K was performed on a patient with a congenital heart defect, a pulmonary valve stenosis, in order to identify potential mutations and to characterize the clinical phenotype at molecular level. Using a-CGH analysis, we identified a duplication in 22q11.21 region of approximately 2.5 Mbp containing several genes including TBX1. The obtained results demonstrate the relevance of a-CGH as a screening method to detect genomic rearrangements responsible for congenital heart defects.

Nucleated red blood cells (NRBCs) in adult peripheral blood (PB) are often a signal of severe haemopoietic stress. Refractory anaemia with excess blasts (RAEB) is a myelodysplastic syndrome characterized by ineffective hemopoiesis and diserytropoiesis; two categories of RAEB (1-2) are recognized, defined by the amount of blasts in the bone marrow (BM) and in PB. We describe an unusual onset of RAEB-2 in a patient with asthenia, weigh loss and fatigue. The automated blood cells analysis and optical microscopic PB smear revision showed severe anemia, mild trombocytopenia, blasts, NRBCs and dysplasia. After definitive diagnosis (RAEB-2) and one year of appropriate treatment, the patient shows normalized haematological values with just some optical microscopic hints of dysplasia. NRBCs play a pivotal role to trigger the diagnostic process and are useful in the follow-up. We highlight the role of automated haematology analysers with improved features in NRBCs analysis.

Prekallikrein (PK) is a contact factor of the intrinsic pathway of the coagulation cascade. Patients with PK deficiency usually do not show a bleeding tendency despite a prolonged activated partial thromboplastin time (aPTT) test. Here we report a case of a 72-years-old Caucasian woman manifesting a prolonged aPTT test. The aPTT correction after 1:1 mixing with normal pool plasma (NPP) indicated a coagulation factor deficiency; however factors XII, XI, IX and VIII activities were normal. A 100:1 mixing with NPP was performed, resulting in an aPTT test correction; the aPTT test was then performed increasing the pre-incubation time of the patient’s plasma. This resulted in a significant reduction of the aPTT. The PK deficiency was ultimately confirmed by direct measurement of PK plasma activity. This experience shows that PK deficiency should be considered for asymptomatic patients with prolonged aPTT and that, whenever a PK deficient plasma is not available, the diagnosis can be correctly oriented on the basis of simple aPTT tests.

Immunoglobulin light chain amyloidosis (AL) is characterized by the production of immunoglobulin light chains with conformational abnormalities that cause systemic toxicity with rapid deterioration of the function of vital organs. When the heart is involved, as it is the case in ~3/4 of patients, clinical signs and symptoms often appear when organ damage is already irreversible and the treatment cannot longer change the course of disease. Although in recent years new powerful therapeutic regimens have become available, which are able to significantly improve long-term survival, the mortality rate in the first year after diagnosis has indeed not improved, still being 25-30%. Cardiac involvement is responsible for almost all of these deaths. Early diagnosis based on biochemical markers of the disease rather than on clinical symptoms and signs can allow for early detection of patients with cardiac amyloidosis and to establish an effective therapy. To this end, our group has proposed the introduction of the measurement of natriuretic peptides that can identify the presence of amyloid cardiomyopathy with a sensitivity of 100% in the monitoring of subjects with monoclonal gammopathies of undetermined significance (MGUS) and altered ratio of circulating free light chains (FLC). Individuals with MGUS and altered FLC ratio are at intermediate/high risk of developing a malignant disease (AL amyloidosis in 10-15% of cases) and, according to the guidelines of the International Myeloma Working Group, they should be monitored regularly for their entire life. Here we describe a case where the application of these recent recommendations has allowed the timely recognition of amyloid cardiomyopathy.

Bullous pemhigoid (BP) is an autoimmune subepidermal blistering disease, usually occurring in the elderly. In Europe the incidence of BP has doubled in the last 10 years. The disease has a chronic relapsing course and a relatively benign prognosis. An increasing number of publications report altered expression of a number of cytokines. However, at the present it is not possible to establish a specific role for them in the disease. We report a case of a centenarian woman with a BP occurrence in otherwise optimal health conditions. Besides the usual biochemical investigations, plasma concentrations of a number of cytokines were evaluated during the disease course (relapse and remission). The majority of the measured cytokines were elevated in the active phase of the disease and returned to values similar to those presented by a group of apparently healthy subjects of similar age during the remission. This case could be useful to better understand the role of cytokines in autoimmune skin diseases of the aging.

We present a report about the interference due to factor IIa and factor Xa direct oral inhibitors on activated C protein resistance ratio (APCr), evaluated with a prothrombinase-based assay, in a patient heterozygous for factor V Leiden treated first with dabigatran and then with rivaroxaban. In this patient dabigatran increased the APCr ratio to a degree compatible with values observed in homozygous wild-type carriers, thus causing a potential misdiagnosis. We also found that rivaroxaban therapy was effective in lowering the APCr ratio.

Chronic atrophic gastritis (CAG) and gastric cancer are leading causes of morbidity and mortality worldwide. Serum pepsinogens have been used as biomarkers of gastric mucosa status, including gastric inflammation, so that they might be useful for detection of gastric atrophy or gastric neoplasm at an early stage. Serum pepsinogen 1 and pepsinogen 2 concentrations are known to increase in the presence of Helicobacter pylori-related non-atrophic chronic gastritis, and the eradication of this pathogen is associated with a significant decrease in their values. We describe here the case of an asymptomatic 60 years old man, with a casual serological diagnosis of severe gastric atrophy, macrocytosis and severe complications, culminating in an acute coronary syndrome. This case report raises some important considerations, such as the fact that CAG could not be correctly and early diagnosed and that it may be misleadingly regarded as a rare condition, whereas its prevalence is conversely largely underestimated. This may lead to severe complications that may include gastric malabsorption and vitamin B₁₂ deficiency, along with gastrointestinal, neurologic, psychiatric, cardiovascular, cerebral and peripheral vascular disorders.

Acquired hemophilia A is a rare autoimmune syndrome characterized by the presence of autoantibodies directed to clotting factor VIII. This disorder most commonly occurs in the elderly. Although it may be associated with several underlying pathologies, up to 50% of cases are idiopatic. Typical clinical manifestations are extensive cutaneous purpura and internal hemorrhage. The steps of the diagnostic process include: the presence of a prolonged activated partial thromboplastin time, non corrected by incubation with normal plasma, the absence of lupus anticoagulant, the selective deficiency of factor VIII and, finally, the dosage of the inhibitor anti-factor VIII, using the Bethesda assay or its Nijmegen modification. Here we describe two new cases of acquired hemophilia A. After the diagnosis confirmation, patients were treated with a bypassing agent, the recombinant activated factor VII.
This drug directly activates clotting factor X on the surface of activated platelets, causing the burst of thrombin, which is indispensable for the formation of a stable clot able to stop bleeding.

We describe the case of a 78 year old man admitted to the Nephrology ward with strangury. Laboratory tests showed proteinuria with preserved renal function. Serum and urine immunofixation showed a faint monoclonal l band, while serum free light chain (FLC) assays (Freelite, The Binding Site) resulted in an abnormal k/l ratio, confirming the presence of a lFLC monoclonal component. After bone marrow examination, the diagnosis was stage IIA l light chain multiple myeloma. The patient started bortezomib, melphalan and prednisone treatment. In the following days, l FLC concentrations still remained elevated indicating therapy failure. A week later, the patient became anuric and laboratory tests showed a pattern of acute renal failure and increased serum l FLC concentrations. The patient started a new treatment with bicarbonate, mannitol and dexamethasone, but therapy was not effective again and l FLC concentrations resulted persistently high and associated with anury. Clinicians decided to suspend pharmacological therapy and to dialyze the patient. FLC assay was performed every two hours to monitor FLC removal. After six sessions of hemodialysis, l FLC concentrations decreased, diuresis was restored and renal function improved. Myeloma treatment was re-initiated with steroids and, after kidney recovery, dialysis was suspended. In this case, FLC assays helped to confirm myeloma suspicion, to define the most effective therapy and to assess the response to treatment.

Rhabdomyolysis is a clinicopathological situation of heterogeneous origin, characterized by skeletal muscle damage followed by the release into the circulation of various myocyte components, including myoglobin. This small protein, which plays a pivotal role in the myocyte function, is easily filtered through the glomerulus in the urine, representing a potential factor of tubular toxicity. In this report, we describe three cases in which standard urine samples were analyzed with the integrated system iRICELL 3000 (Beckman Coulter): the observed discrepancy between a strong strip positivity for hemoglobin and an absent hematuria induced to perform an immunoassay measurement of myoglobin, leading to a well grounded suspect of rhabdomyolysis. The management of patients was thus optimized, suggesting to clinicians the elements for a rapid diagnosis.

Mastocytosis is one of the rare causes of unexplained osteoporosis, above all in males. On the other hand, a strict association between severe systemic reactions after hymenoptera sting and mastocytosis was recently demonstrated. Here we report a case of unexplained severe osteoporosis with multiple vertebral fractures in a 48 years old male, which also suffered an anaphylactic reaction after hymenoptera sting. Among laboratory tests performed to clarify the cause of osteoporosis, serum tryptase concentrations were determined. The value of tryptase was 43.6 μg/L, four times higher than the upper reference limit. Skin did not show abnormalities; bone marrow vertebral biopsy was not valuable, but bone marrow aspirate from iliac crest demonstrated the presence of atypical mast cells expressing CD25; D816V mutation of KIT gene was also identified. These findings, in association with an increase of serum tryptase concentrations, fulfil all minor criteria requested for the diagnosis of systemic mastocytosis. Osteoporosis treatment with zolendronate and vitamin D supplementation was started, but later, for the persistence of bone pain, therapy with -interferon was added. This case confirms that an unexplained osteoporosis, especially if associated with hymenoptera sting systemic reaction, requires exclusion of a systemic mastocytosis.

New psychoactive substances that in some cases are not subjected to any legal restriction recently overwhelmed web market. They were historically defined “smart drugs”: substances either natural or synthetic with alleged psychoactive effects as well as effects on sexual performance. We present here two intoxication cases: the first concernes a male subject hospitalized for deep unconsciousness, who took in yohimbine and kawaine, two psychoactive alkaloids present in herbal preparations of Pausinystalia yohimbe and Piper methysticum, sold on the sexy shop websites; the second concernes a female with a previous history of drug poliabuse, hospitalized for dysphoric syndrome/hallucinations, who took in benzydamine, a local anesthetic and analgesic drug, contained in an antibacterial gynecological powder that in oral mis-overdosage acts as a deliriant and central nervous system stimulant.

G6PD deficiency is an X-linked disorder, due to more than 190 mutations that determine ~400 different phenotypes. Herein, we report a case of a symptomatic male newborn affected by severe G6PD deficiency due to a novel “de novo” mutation in the exon 13 of the G6PD gene: c.1465C>T (named “G6PD Buenos Aires”)”. G6PD activity is affected by NADP⁺ amount through at least two mechanisms. On one hand, the activity of the enzyme is directly related to the NADP⁺/NADPH ratio; on the other hand, NADP⁺ is necessary for stabilizing the enzyme in the proper conformation. The c.1465C>T mutation, causing a proline to serine substitution at 489 amino-acid position in the “NADP⁺ structural site”, prevents the NADP⁺ to play the latter function, explaining the severe phenotype of the child.

TEN is a rare disease characterized by the separation of skin and mucous membranes from the derma. The reported clinical case refers to an adult female hospitalized at the Burns Unit after allopurinol prescription. During hospitalization the patient underwent the therapeutic protocol established at the Burns Unit including intravenus immunoglobulin administration and plasmapheresis. At the end of therapy a clinical improvement of both local and global conditions was observed. During the course of disease, we measured plasma concentrations of a number of cytokines. Measurements were performed using commercially available multiplex bead-based sandwich immunoassays (Biorad). We found a marked decrease in concentrations of interleukin (IL)-6, interferon -induced protein (IP)-10 e IL-13 at various stages of apheresis therapy, particularly pronounced for IP-10. We also found a normalization of IL-6 and IP-10 concentrations during the follow-up. In addition, very high concentrations of the same cytokines in the plasma effluent after apheresis were observed. Although obtained in a single case, our results suggest a correlation between plasma concentrations of cytokines and the clinical course of TEN. It can be postulated that this approach could serve as a guide for future research in the development of targeted therapy based on the etiopathogenesis of TEN.

We describe a case of a 63-years old woman affected by Hashimoto’s thyroiditis and multinodular goiter. Her laboratory results showed elevated free triiodothyronine (FT3) concentrations (18.5 ng/L), with free thyroxine (FT4) and thyrotropin (TSH) within the physiologic range. On the basis of these results, she started methimazole therapy, with persistence of inappropriately elevated FT3 concentrations. The therapy was thus stopped and blood examination was repeated after one month in our laboratory: concentrations of thyroid tests were within the physiologic range, including FT3 (2.8 ng/L). The difference between this result and that previously obtained raised the suspicion of the presence of an interference in the first result. In fact, in our laboratory a competitive electrochemiluminescence immunoassay with labeled antibody is used, while the first laboratory employed a competitive chemiluminescence immunoassay with labeled analogue, which has a more important risk of interference. After treating sample by polyethylene glycol, FT3 resulted indeed normal also by the immunoassay used by the first laboratory.

A case of successful pregnancy in a woman with previous episodes of unprovoked deep vein thrombosis treated with vitamin K antagonist (warfarin) therapy is described. As the patient became pregnant, warfarin therapy was immediately stopped and lowmolecular-weight heparin (LMWH) prophylaxis was started. In the second and third trimesters of pregnancy we observed an increase in body weight (from 64 to 80 kg) and in body mass index (from 21 to 26.4). During the pregnancy, we used the heparin-anti factor Xa assay (Anti-FXa) to monitor the LMWH treatment and to adjust the dosage in a increasing way. The Anti-FXa can be very useful in improving safety and efficacy of LMWH treatment in pregnancy.

Paroxysmal nocturnal hemoglobinuria (PNH) is a rare acquired hematological disease of the hematopoietic stem cell. PNH arises as a consequence of non-malignant clonal expansion of hematopoietic stem cells and progeny mature blood cells of both myeloid and monocyte lineage, which are deficient in some surface proteins, including the two complement regulators CD55 and CD59. As a result, PNH erythrocytes are incapable to modulate on their surface physiologic complement activation, leading to complement-mediated intravascular hemolysis, which is the central clinical feature of PNH. We present a case of a 16 years old Ukrainian boy who presented with a diagnosis of myelodysplastic syndrome and who was found to be affected by PNH.

Markedly increased CA 125 and CA 19.9 concentrations in serum are considered specific enough to reliably identify malignant cancers (ovarian and gastrointestinal tumours, respectively), although a consistent body of literature has reported marker elevations in several benign conditions. Here we report the case of a woman in post-menopausal status, with a previous history of hysterectomy, presenting with a 12-cm pelvic mass at sonography and serum CA 125 and CA 19.9 concentrations >400 kU/L. One month after initial presentation, she underwent surgical evaluation for laparoscopy, repeating marker determinations. Concentrations of CA 125 and CA 19.9 were still elevated, but decreased if compared with the previous data (~200 kU/L). Magnetic resonance imaging characterized a multicystic mass in the mesentery, allowing to hypothesize a benign multicystic mesothelioma of the peritoneum (BMMP). The laparoscopy revealed multiple cysts, some of them resulting in colliquation, associated to ascites. Histological examination of biopsy specimens confirmed BMMP as composed of multiple, thin-walled, irregularly spaced cysts lined by flattened and cuboidal mesothelial cells. The cystic colliquation was though as the main cause for decrease in marker concentrations. To our knowledge, this is the first case of BMMP associated with significantly increased concentrations of CA 125 and CA 19.9 and their decrease before any surgical treatment.

We describe the case of a 82 years old female, who has been referred to the emergency department for a gross trauma of the right knee after an accidental fall. Physical examination revealed a palpable mass in the right pelvis, which was then identified as a large intramuscular hematoma of the right iliacus muscle by computerized tomography scan. The most suggestive laboratory findings were anemia and a prolonged activated partial thromboplastin time (APTT) (ratio 1.33), with physiological platelet count and prothrombin time. After ten days of hospitalization, when a spontaneous hematoma developed in the right arm, APTT had steadily increased, up to a value of 3.33. A mixing study and assessment of coagulation factors were rapidly performed. The former test was not effective to normalized the APTT, whereas concentrations of all factors were within the reference interval, except for factor VIII (0.6%). Factor VIII inhibitor titration using Bethesda assay confirmed the diagnosis of acquired hemophilia A, yielding a value of 77 Bethesda units. Acquired hemophilia A, which is caused by autoantibodies against coagulation factor VIII, is a rare condition that can be frequently overlooked or misdiagnosed. The role of laboratory diagnostics is thereby as important as the clinics, wherein serious hemorrhages accompanied by variable APTT prolongations onset in a previously asymptomatic patient. Along with discussion about laboratory and clinical aspects of acquired hemophilia A, we present a diagnostic algorithm for efficiently troubleshooting prolonged APTT values in clinical laboratories.

IgD monoclonal gammopathy is a rare event, but its recognition and management are quite important because the condition is potentially life-threatening. This paper reports a peculiar case of IgD monoclonal gammopathy. The monoclonal protein was rapidly degraded by proteolysis and the usual laboratory tests showed different immunochemical patterns. The study of the proteolitic dynamic of the monoclonal immunoglobulin allowed us to obtain the complete characterization of the monoclonal component.

Markedly elevated CA 19.9 concentrations in serum are regarded as specific enough to reliably identify pancreatic cancer, even if a consistent body of literature shows CA 19.9 concentrations >1000 kU/L in a variety of benign conditions. Scarce data are, however, available on the prevalence and clinical significance of CA 19.9 values >10,000 kU/L. Here we present a case series of 18 consecutive patients admitted to our hospital in a time period of 14 months showing an enormous elevation of CA19.9 concentrations (11,568 to >100,000 kU/L), with the aim to assess the association of such concentrations with the presence of pancreatic cancer and, more in general, with tumours of the gastrointestinal system. We also tried to define whether the exact measurement of CA 19.9 concentrations in this range, which needs serial sample dilutions, is cost-effective. CA 19.9 measurements, including sample dilutions according to a defined laboratory protocol, were performed on Roche Modular EVO system. The yearly prevalence of hospitalized patients tested for CA 19.9 and with marker concentrations >10,000 kU/L was 2.9%. All recruited patients were diagnosed as malignancies: 15 had primary or secondary pancreatic cancer, two had gastric cancer, and one a cholangiocarcinoma. CA 19.9 concentrations ranged between >10,000-30,000 kU/L in 9 cases, >30,000-60,000 kU/L in two, >60,000-100,000 kU/L in three, and >100,000 kU/L in four cases, respectively. A surgical resection of the tumour was performed in five patients, independently of CA 19.9 concentrations. The median patient’s survival was <6 months. In conclusion, CA 19.9 concentrations >10,000 kU/L unequivocally identify a gastrointestinal malignancy, more frequently (~83%) a primary or secondary pancreatic cancer. Exactly measuring CA 19.9 concentrations >10,000 kU/L after multiple sample dilution does not add relevant information for patients’ prognosis and treatment.

Monoclonal gammopathy is a uncommon finding in pediatric age. Only viral infections, bone marrow or solid organ transplantation, and immunosuppressive therapy may induce B-lymphocyte clonal proliferation leading to monoclonal components (MC) in serum. Here we present a case of clinically relevant monoclonal gammopathy in pediatric age. After receiving an unusual request for a serum protein electrophoresis (SPE) test in 12 years-old boy, information on the patient was collected. The boy was affected by Crohn’s disease and treated with prednisone, azathioprine, and antibodies against tumor necrosis factor-V (infliximab and, later, adalimumab). As both disease and treatment made the patient at risk for developing lymphoid/myeloid malignancies (LMM), the search for MC in serum was indeed recommended. On SPE three MC were detected and typed by agarose gel immunofixation (IFE) as IgAk, IgMk, and IgGg. Moreover, a k-type Bence Jones protein was detected by urine IFE. Bone marrow examination was then carried out to exclude LMM, resulting in a negative pattern. It is known that Crohn’s disease in adults, particularly when treated by means of immunosuppresive therapies, can be associated with monoclonal gammopathies and an increased risk of developing leukemia or lymphoma and, rarely, myeloma. However, at our best knowledge, no report of such association has been previously reported in pediatrics. This case illustrates a specific situation in which the request and execution of a SPE in the young is not only appropriate, but even recommended to prevent the risk of silent LMM development.

IgD monoclonal gammopathies represent a rare subset of the universe of monoclonal immunoglobulin abnormalities. They are often characterized by a clinically progressive myelomatous behaviour and by peculiar laboratory aspects. We present here a case of IgD monoclonal gammopathy, detected in a 44-years old woman, which was stable from a clinical and laboratory point of view for 15 years. This case represents a quite unusual figure of a very long lasting IgD monoclonal gammopathy of undetermined significance.

This report presents a case of an incidental detection of very high concentrations of serum copper in an apparently healthy adult male. Clinical and laboratory  investigations for Wilson’s disease were negative. The electrophoresis of serum proteins showed a IgG 􀀀 monoclonal peak of 10 g/L. To clarify the nature of this unusual association (high concentration of copper and monoclonal immunoglobulin), an immunosubtraction experiment was performed: after incubation with an anti-IgG antiserum, the vast majority of serum copper was found in the IgG-anti IgG complex when the patient serum was tested; when other samples with monoclonal IgG and physiological copper concentrations were incubated, the copper remained in surnatants. The experiment allowed us to establish that the monoclonal immunoglobulin showed a high affinity for copper. Similar reports can be found in the literature; the main difference with the present case is that our patient did not show any ocular problems due to the copper deposition in the Descemet’s membrane, while in all the previously reported cases an ocular deposition of copper was observed. It is possible to speculate that in our case the affinity of the protein for copper was very high, while in other cases a lower affinity made possible the intraocular release of copper.

Although the malaria infection is essentially a problem in tropical countries, it has becoming a health issue even in Western countries due to tourism and immigration. The specific diagnostic tests are ordered if a clinical suspicion is raised, but symptoms of malaria infection can be vague and easily attributed to minor febrile affections, particularly in non-endemic regions. The diagnosis of malaria cannot be dismissed to rapidly establish the appropriate treatment, avoiding harmful complications of the disease. Recently, hematological analyzers have been proposed as potentially useful tools to detect in the blood count of affected patients abnormalities that can guide a timely malaria diagnosis. We present here two cases of malaria infection in which the first diagnostic suspicion was posed on the basis of abnormal scattergrams of a hematological analyzer. The aim is to present this relatively new diagnostic opportunity, increasing the awareness of laboratorians on the possibility to raise a suspicion of malaria infection, even if specific diagnostic tests have not been ordered.

The physiological colour of urine is usually yellow. Urine discoloration is a common situation in clinical practice and a variety of colours may be seen. When a patient complains of green or blue urine, there is no confusion with a pathological origin. However, when the urine is red, the first thought is usually hematuria leading to anxiety for patient himself and for physicians too. We present a case of a 54 years old man presenting with asymptomatic apparent gross hematuria ruled out by chemical urinalysis and visual microscopic evaluation of the sediment showing neither hemoglobin nor red blood cells in his urine specimen. Possible causes of red urine not related to presence of blood are critically presented and discussed.

We present here the detection of a lactate dehydrogenase (LDH) macroenzyme in the blood of an apparently healthy female. The finding of an increased LDH activity during routine biochemical investigations led to a number of further laboratory and imaging examinations. When the diagnostic problem was finally posed to the laboratory consultant, a serum treatment with polyethylene glycol and an isoenzyme electrophoretic separation allowed to demonstrate the presence of a circulating macroenzyme. Macroenzymes have been described from almost 50 years, but despite many efforts it was difficult to recognize a pathogenetic role. Their recognition is, however, important in order to avoid expensive and cumbersome procedures to explain elevated enzyme values.

Diabetes mellitus is a worldwide disease and glycated hemoglobin (HbA1c) is the gold standard for the diagnosis and monitoring. Hemoglobin variants can interfere with HbA1c measurement in both preanalytical and analytical phases, and their incidental detection is continuously increasing, due to the recent migration waves. In the Roma 1 HUB Laboratory, HbA1c is measured by capillary electrophoresis (CE). A 51-year-old man from Bangladesh underwent HbA1c analysis and a variant was evident in the electrophoretic pattern. After informed consent for further analysis was given, a hemoglobin electrophoresis by CE was performed. A suspected HbE was found and then confirmed by molecular testing. The patient showed mild microcytosis and hypochromia, but no anemia. The presence of the variant HbE was without influence on HbA1c measurement by CE. This technique offers the advantage to detect hemoglobin variants as well as a reliable measurement of hemoglobin A2 (HbA2). These features allow a correct diagnosis of thalassemia and hemoglobinopathies without interfering with HbA1c measurement.