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Introduction
BASIC LABORATORY & RADIOLOGIC SUPPORT
Daniel Ansong Child Health

Laboratory and radiological services offer great deal of support to clinicians in establishing diagnosis & in monitoring disease progression Lab services include body fluid and tissue sampling whilst radiological services involve the use of X-rays (plain or with contrast), ultrasound scan, CT scan, and MRI

Urine
Two broad tests are routinely performed;
Urine chemistry Urine microscopy

Urine chemistry
May be done using modern dipstick Tests performed include: 1. Protein :-graded as mild-mod (1+ 2+) [30mg/l 100mg/l] or heavy (3+4+) [500mg/l >1g/l] 1+ proteinuria may occur in simple febrile states or during ambulation Otherwise proteinuria esp albuminuria is abnormal and indicate glomerular disease

Urine culture

Urine chemistry
2. Blood: This test detects reaction by the haem group A +ve blood test in urine may thus indicate the presence of haem containing substance like Haemoglobin or Myoglobin A +ve blood test in the presence of red cells on microscopy confirms haematuria whilst a +ve test with absent red cells on microscopy may indicate myoglobinuria

Urine chemistry
3.Bilirubin Bilirubin in the urine is always abnormal and indicates conjugated hyperbilirubinaemia or choiestasis 4.Urobilinogen Urobilinogen is the metabolic end-product of bilirubin and is absorbed from the gut There is always some level of urobilinogen in the urine levels occur in haemolysis whilst absence indicate total biliary obstruction

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Urine chemistry
5. Urine pH: Normal value is 6. High urine ph (8) may occur in the presence of urea-splitting organisms like proteusliberation of NH3 High urine pH in the presence of low serum pH (acidosis) indicate renal tubular acidosis

Urine chemistry
7. Nitrite Occurs in the presence of bacterial enzyme called nitrate reductase which converts nitrate, a normal urinary constituent, to nitrite. Urine nitrite indicate significant bacteriuria and thus UTI

Urine Microscopy
Formed elements in urine Samples for urine microscopy should be sent to lab within 2 hrs of collection to prevent disintegration of formed elements

Urine Microscopy
Pus Cells:
Pus cells > 10/HPF is defined as pyuria Pyuria may indicate UTI Other causes of Pyuria:
TB of kidney Interstitial nephritis Glomerulonephritis dehydration

Urine Microscopy
Haematuria
Presence of > 5RBCs/HPF Haematuria may indicate glomerulonephritis Other causes of haematuria include:
UTI Nephrolithiasis Schistosomiasis

Urine Microscopy
Casturia Represents proteinacious substances transformed into cylindrical forms via its journey thro the renal tubules Granular cast:
Usually occurs in GN Granular cast also occurs in other ischaemic conditions of the kidney as in Acute Tubular Necrosis & Dehydration

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Urine Microscopy
Cellular cast: May be red cell or white cell cast
Indicate cells originating from the glomerulus e.g.: Red cell cast invariably indicates GN WBC cast indicate Pyelonepritis or GN

Urine Microscopy
Epithelial cells Represent normal exfoliated cells of the lining of the urinary tract Excessive amount of epithelial cells may indicate injury to the urinary tract like infection

Urine Microscopy
Crystalluria Represents precipitation of various salts in the urine may occur as a result of concentration of salt in urine or alteration of urine pH Ca2+ crystals may occur in hypercalcaemic states Tripple PO4- crystals are always abnormal and indicate cystinuria

Urine Culture
Gold standard test for diagnosis of UTI
Diagnosis of UTI is based on culture of a single bacterial species of appropriate colony count from appropriately collected urine Sample for urine culture should be plated within 2 hrs of collection to prevent overgrowth of contaminants

Stool investigations
Two common tests performed on stool are microscopy and culture Stool microscopy/RE:
Looks for ova, larvae, trophozoites, or cyst of intestinal worms Stool microscopy also detects pus cells and red cells whose presence in stool are always abnormal and indicate invasive process like dysentery

Stool investigations
Stool culture Indicated in bacillary dysentery or enteric fever

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Stool investigations
Other tests on stool include: Stool pH in galactose intolerance Stool occult blood in occult GI bleeding as may occur in GI cancers Estimation of fat content of stool may be done in malabsorption syndrome Radioactive imaging studies may also be performed in Protein Losing Enteropathy

Blood
Countless number of tests may be performed on blood These include haematological tests, biochemical tests, serological tests, microbiological tests etc

Haematological tests -FBC

A) FBC/CBC: Involves estimation of Hb content, Platelet count, and WBC count Hb < 11g/dl but > 8g/dl is graded mild anaemia Hb between 5g/dl and 8g/dl is graded moderate anaemia Hb < 5g/dl is graded severe anaemia

Haematological tests -FBC

Platelet count: Normal 150 400 x 109/L (150,000/cmm) Low platelet count is called thrombocytopenia (Causes: - - - - ?) High platelet count is called thrombocytosis (causes: iron def., acute haemorrhage, some leukaemias, vit E def., Kawasarki dx, e.t.c.)

Haematological tests -FBC

WBC Normal count: 4.5 11.0 x 109/L or 4500 11,000/cmm Lower count may occur in marrow failure states and in some infectious conditions e.g. enteric Higher counts, esp with neutrophilia, may indicate bacteria infections

Haematological tests -FBC

Absolute neutrophil count (ANC) Defined as % of neutrophils x WBC total in mm3 Normal ANC > 1,000/cmm Neutropenia < 500/cmm in presence of fever is called Neutropenic fever and is a medical emergency

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Haematological tests -FBC

Total Lymphocyte Count (TLC) Defined as % of lymphocytes x WBC total in mm3 TLC < 1,500/cmm in children > 5yrs & adults indicate severe immunosuppresion

Haematological tests -FBC

Pancytopenia Low blood cell count affecting all cell lines is called Pancythopenia Pancytopenia may occur in:
Bone marrow failure Peripheral destruction of all cell lines as in Evans syndrome Sequestration of blood in organs like the spleen

Low cell count affecting specific cell lines may also occur e.g. isolated anaemia, isolated thrombocytopenia, and isolated leucopenia

Haematological tests -FBC

Polycythaemia Refers to excessive number of red cells or increased HB levels Excessive number of all 3 blood cell lines is called Polycythaemia vera

Haematological tests -others

B) Reticulocyte count Measures the % of reticulocyte out of total red cell population Normal ret. Count is > 2% Lower ret count < 1% may indicate bone marrow failure states (aplastic anaemia) Higher ret count (>5%) may indicate hyperactive marrow usually as a response to peripheral red cell destruction

Haematological tests -others

C) Coagulation test Done to evaluate bleeding disorder Four tests are usually done as 10 screening tests for most bleeding disorders namely: platelet count, bleeding time, PT, & PTT.

Haematological tests -others

Bleeding time: (N=1-6 mins)
Asseses platelet function and vascular intergrity

Platelet count: (N=150 -400 x 109/L) PT: (N= 14 sec)

Assesses intergrity of extrinsic pathway of coagulation

PTT: (N=35 sec)

Assesses intergrity of intrinsic pathway of coagulation

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Haematological tests -others

D) Blood film comment Not the same as test for malarial parasites Blood film comment looks at the morphology of the cell lines i.e. size, shape, colour e.t.c. RBCs Abnormality in size:
MCV < 80 fl is called microcytosis and may indicate iron deficiency or thalasemia MCV > 100 fl is called macrocytosis and may occur in folate or vit B 12 deficiency

Blood film comment

RBCs - Abnormality in colour: Is a measure of Hb content Low colour is called hypochromasia and may indicate iron deficiency Other red cell abnormalities seen on film comment include fragmented red cell in microangiopathic states like vasculitic syndromes e.g. HUS

Blood film comment

WBCs Abnormality on film comment may occur with maturity & shape Large immature cells are called blast cells and indicate leukaemia Other abnormalities are hypersegmented and large sized neutrophils in acute bacterial infections

Blood film comment

Platelets Abnormality may occur with size and maturity Immature platelets are large in size and are called megakaryocytes Presence of megakaryocytes on blood film indicate high marrow output of platelets in response to peripheral destruction of platelets

Haematological tests -others

E) Blood film for Parasites E.g. malaria Here, 2 film types are requested;
Thick film which identifies the presence of malarial parasite Thin film which identifies the particular Plasmodium species

Haematological tests -others

F) Other haematological tests include; Sickling Hb electrophoresis G6PD activity ESR e.t.c.

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Blood Chemistry
Common biochemical tests done on blood include: 1. BUN (N= 3 8 mmol/l) Assesses kidney function esp perfusion Raised levels occur in kidney failure and hypoperfusion states of the kidney Low levels may occur in liver failure.

Blood Chemistry
2. Serum Creatinine Assesses kidney function more accurately than BUN. Serum levels affected by muscle bulk Values are thus lower in children and in females Normal values:
Males = 60 130 mol/l Females = 40 110 mol/l

Note: serum creatinine begins to rise only after ~ of kidney function is lost

Blood Chemistry
3. Serum Electrolytes This measures Na+, K+ & Cl Levels may be deranged in conditions like dehydration, renal failure Normal values:
Na+: 135 mmol/l K+: 4.5 5.5 mmol/L Cl-: 90 mmol/L

Blood Chemistry
4. serum Ca2+ Normal level Ca2+ : 2.1 2.6 mmol/L Levels may be deranged in impaired renal function and bony disorders including rickets

Blood Chemistry
5. Blood Sugar Normal values: FBS: 3.6 6.4 mmol/l RBS: Commonly done in hypo- or hyperglycemic states Hypoglycemia may occur in sepsis, severe malaria, PEM, liver failure, pancreatic tumour e. g. nesidioblastosis Hyperglycemia may occur in DM.

Blood Chemistry
6. LFTs This involves Liver enzymes
Tranaminases; ALT & AST Alkaline Phosphatase GGT

Bilirubin Albumin & Globulin

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LFTs
Transaminases are in acute damage to hepatocytes whilst ALP levels are in biliary obstruction ALP levels are normally higer in childen than adults Direct bilirubin levels are in cholestasis (biliary obstruction) as in acute hepatitis Indirect bilirubin levels are in haemolyti processes Albumin levels reflect synthetic function of the liver and becomes impaired in chronic liver disease (also in albumin losing conditions) ? Normal levels Serum NH3 Levels are useful in acute liver failure as detoxification of NH3 by liver becomes impaired

Other serum chemistry

Amylase: done to assess pancreatic function LDH: higher levels occur in high grade malignancies and in haemolysis Thyroid function test. Involves:
TSH, T4, T3

Blood Culture
Done in bacteraemia/septicaemia In some disease conditions e.g. severe immunosuppression, both aerobic and anaerobic cultures as well as fungal cultures may be done

Serological tests
Hundreds of tests can be performed including test for auto-antibodies in auto immune diseases like rheumatoid arthritis Commonly done serological tests in KATH include HBsAg & HIV

Other body fluid analysis

CSF Obtained by LP or cisternal puncture Indications: inflammatory condition of the meninges e.g. meningitis Normal CSF:
Naked eye appearance clear CSF flow - not under pressure Cell count -0 -5 lymphocytes/cmm

CSF
In disease state, CSF becomes:
Cloudy or turbid ( due to cells pleocytocis) Xanthochromic ( due to protein or bilirubin as in SAH)

Two tests are routinely performed on CSF: Biochemistry for

protein content (N=0.15-0.40g/L) glucose content (N=2/3 of blood sugar; 2.3 -3.9 mmol/L)

Microbiology for
Gram stain Cell count & type Culture & sensitivity

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Abnormal CSF condition

1. Bacterial menigitis key CSF findings: cell count Cell type: PML Gram stain: pus cells, G+ diplo, G-diplo, G- coccobacillus (pleomorphic) CSF protein CSF glucose

Abnormal CSF condition

2. Viral meningitis Key findings: Slightly raised proteins; 0.5 -1.0 g/L Normal CSF glucose Few cells (pleocytosis); 100s /cmm Cell type lymphocytes Gram; nil organisms seen CSF culture; nil isolate

Abnormal CSF condition

3. TB meningitis Key findings: cells (not in 1000s) Cell type; lymphocytes or mixed CSF protein CSF glucose, sometimes 0.0 mmol/l Gram; nil organisms seen CSF culture; no isolate NB: Z/N stain may be + for AFBs

Abnormal CSF condition

4. Guillain Barre syndrome History of acute flaccid paralysis Key findings: Gram; nil seen Cell count few cells <100/cmm CSF protein (may be> 10g/L) Few cells in context of CSF protein is called cytoclastic dissociation and is hallmark of diagnosis

Pleural, Ascitic & Pericardial fluid

Both microbial & biochemical tests may be performed Biochemical tests differentiates inflammatory conditions (exudate) from non-inflammatory ones (transudate) In exudate:
Protein content of fluid usually > 30g/l (3g/dl) Ratio of fluid protein : serum protein > 0.5 Fluid LDH: serum LDH > 0.5

Imaging in clinical practice

Commom imaging studies include; X-rays, USS, CT scan, MRI X-rays : In plain X-rays, air appears black (radioluscent) whilst fluid, including blood, appears white (radio-opaque)

The reverse is true for transudate

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Imaging in clinical practice

Common X-rays: CXR: Assesses lung fields, mediastinum, pleural space, ribs, heart size & contour Common CXR abnormalities: Pneumonia:
Uniform or discrete opacities in lung fields

Common CXR abnormalities

Pleural effusion:
Appears as uniformly white shadow with loss of costophrenic angle fluid level/meniscus

Pneumothorax:
Appears as very dark shadow (hyperluscent) with loss of vascular lung markings

Mediastinal lymadenopathy:
Appear as widened mediastinum ( may be due to thymic shadow in very young children)

Common CXR abnormalities

Cardiomegaly: CTR > 0.6 Globular heart shadow on CXR indicates either Pericardial effusion or dilated cardiomyopathy

Abdominal X-rays
Abdominal X-ray: Common abnormalities: Intestinal obstruction; multiple air-fluid levels & absence of gas in rectum Duodenal atresia appears as double bubble gas shadow Perforated hollow viscus: free air under diaphragm

X-ray of long bones

Common abnormalities: Osteomyelitis which appears as periosteal reaction Fractures which appears as break in continuity

Skull X-ray
Looks for fractures in head trauma, widened suture lines in raised ICP, intracranial calcifications which occur in some brain tumour, and in certain congenital infections like congenital toxoplasmosis Copper-beaten appearance occurs in advanced cases of ICP esp tumours

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Assignment
1.What are the indication of Ultrasound in pediatric practice-List 10 2. What specific investigation will you conduct in a following pediatric patients and WHY.
Nephritics syndrome Renal Failure Cardiac Failure Hepatic Failure Patient with recurrent pyogenic infections

Submit assignment to Class president Monday Only Student Index Numbers Maximum of three pages Typed or Hand written is acceptable Font size 12 Times New Roman OR Arial.

Thank you

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