The Medical Laboratory Science (MLS) Review has been designed to provide

a challenging
personal assessment of practical and theoretical knowledge needed by medical lab
oratory
scientists and technicians. The MLS Review will help you identify strengths, wea
knesses, and gaps
in your knowledge base. Because taxonomy level is a part of the assessment, you
will also be able
to concentrate on the type of question that causes the most difficulty. The sugg
ested approach to
maximizing use of the MLS Review is to read the explanation that follows each qu
estion
thoroughly, regardless of whether you answered it correctly or not. High- light
the content you
did not know, and study it until com- mitted to memory. This MLS Review was deve
loped as a tool
to facilitate both self-assessment and new learning. The units are arrang
ed in a
logical sequence corresponding to the organization of a textbook, and f
ollow the
pattern of presentation used in laboratory science lectures. The question
s within a unit
are related, and can be used by students as they progress through their courses
in order to
improve understanding. The sections are comprehen- sive, and suitable for all ce
rtification
levels although some questions may be more appropriate for one certification lev
el than another.
The MLS Reviewis intended to supple- ment courses in the curriculum and assist t
echnologists and
technicians who are re-entering the laboratory. In addition, it is desi
gned to improve
performance on generalist, categorical, and specialist certification exams. De
sign of Questions
Test questions used in certification examinations are mul- tiple choice. Each co
nsists of a
question, incomplete state- ment, or problem to be solved called the stem and fo
ur alternative
responses. One of the alternatives is the correct response and the remaining thr
ee are incorrect
(these may be wrong, incomplete, partially correct, or less correct than
the most
appropriate response). Incorrect alternatives that appear plausible are called d
istractors. The
difficulty of a question is determined by how close the distractors are to the c
orrect response.
Some questions were written for assessment of your knowledge, and others for lea
rning. For
pedagogic reasons, the latter may contain an all of these options alternative. Thi
s makes such
questions into three true or false statements that are related by the subject (s
tem) of the
question. If you are reasonably sure that two of the responses are true, then th
e correct
response must be all of these options. For this reason, such questions are not use
d on
certification exams. Questions involving combinations of statements (multiple, m
ultiple choice)
are not used on certification examinations or in this book. All of the questions

in this book are

multiple choice. Each question is followed by the test item classification. Alon
gside each
question is the correct answer and an explanation. The test item classific
ation consists of
the subject category, task, and taxonomy level of the question. A question in Bl
ood Banking, for
example, that asks for an interpretation of an ABO problem, may have a test item
classification,
Blood Bank/Evaluate laboratory data to recognize problems/ABO discrepancy/3. The t
est item
classification places the question in the major category of blood banking; the
question asks
for an evaluation of data; the subcategory is ABO discrepancy; and the
taxonomy level
classifies the question as problem solving. Taxonomy level 1 questions address r
ecall of
information. Taxonomy 2 questions require calculation, correlation, comprehensio
n, or relation.
Taxonomy 3 questions require problem solving, interpretation, or decision making
. This question
design allows you to compute a score, which helps you to identify strengths and
weaknesses in
various content areas and tasks. You may then focus study time on a particular c
ontent area or on
practicing with questions of a specific taxonomy level. For example, if you answ
er several
mycology questions incorrectly, then you should devote extra time to studying th
is content area.
If, xiii 2828_FM_i-xvi 21/08/12 2:32 PM Page xiii however, you miss severa
l recall
questions (taxonomy 1 level) over several different content areas such as hematology,
chemistry, and immunology, then repetitive review is indicated for all of t
hese sections.
Poor perfor - mance with questions that require mathematical solutions (taxonom
y 2 level)
requires you to review formulas used for lab calculations, and to practice using
them. If interpretation or problem solving (taxonomy 3 level) is iden- tified as a weakness, t
hen the best
approach is to study the explanation that follows each question in order to unde
r- stand the
logic or reasoning behind the answer. Because the answers and explanations appea
r on the same
page as the questions, it is recommended that you tear off the perforated flap a
nd use it as a
blocker to cover the answers while answering the questions. When you have
answered a
question, slide the blocker down the page to reveal the answer and explanat
ion. The
blocker is printed with a compilation of reference ranges for com- mon analyte
s that will
assist you with answering some questions. Prepare for Your Certi cation Examin
ation Ideally,
an examination score should reflect your knowl- edge of the content without
the influence
of other variables. However, variables such as stress, wellness, self- confiden
ce, emotional
state, and alertness all influence performance. In addition, examination skills

often factor into

exam scores and can be decisive. A single question answered correctly can make t
he difference
between pass- ing or failing, the only two meaningful scores for a certi- ficati
on exam.
Certification exams are usually delivered by computer. There are two types of co
mputer-based
examinations, tra- ditional and adaptive. Traditional exams are of fixed
length and
content. Therefore, everyone taking the exam does so at the same time and receiv
es the same set
of ques- tions. Computer adaptive exams may be fixed or variable in length, but
every exam is
different because the difficulty of the next question is determined by whether y
ou answer the
current question correctly. Since the difficulty of the questions answered corre
ctlynot the
number answered correctlydetermines passing or failing, you should always gi
ve your best
answer the first time. Although every examinees question set is different, all qu
estions come
from a common database, and therefore there is some overlap between the
questions used.
The examination is constructed so that the number of questions in each c
ategory (e.g.,
hematology) is within the specifications published for the exam; however, the di
stribution of
ques- tions and the order of questions will vary significantly. Certification ex
ams are criterion
referenced. This means that examination performance is scored passing or failing
independently
of the performance of other candidates taking the examination. The minimum
passing score for
certification examinations is normalized in order to min- imize the variance bet
ween
examinations. However, the xiv Introduction minimum passing score usually falls
within the range
of 65%70% correct responses. A score below 65% on any content area in the MLS Rev
iew is a strong
indicator that you have not mastered the material in this area, and that further
study is
required. Preparation for a certification exam requires a study plan. Begin with
a review of the
exam content outline that is made available by the certification agency. For exa
mple, if 20% of
the exam is Microbiology but only 2% of the exam is Laboratory Management, you s
hould spend significantly more time studying the former. Within each content area will be s
ubcategories
(e.g., Bacteriology and Parasitology under Microbiology). If 60% of the
Microbiology
content is Bacteriology and only 10% is Parasitology, then devote significa
ntly more time to
studying the former. Allow yourself sufficient time prior to the exam to re- vie
w each content
area no less than three times. Begin studying your strongest subject, then
progress to
your weakest. Study your class notes first, then use this review book to test
your knowledge
of the respective content area. Devote time to reading the explanation

for each
question, regardless of whether you answered it correctly or not. Highlight info
rmation you did
not know and re- view it before answering the questions in this book a
second time.
Rarely, will you encounter any of the same questions on your certification exam;
however, you are
likely to encounter variants of the questions, and the explanations will
help prepare you
to answer these cor- rectly. When finished with the second round, take the compr
ehensive exam
included with this book. Evaluate your performance by both subject and taxonomy.
If you score
lower in Clinical Chemistry, devote more time to it in your third round of
study. If you
are weakest in recall-type questions, make note cards with charts and tables,
and study them
regularly until the information on them is committed to memory. Note your progre
ss from the first
to the second round. If your progress is signifi- cant, use the same approac
h on the third
round. If not, devote more time to studying your weakest content areas. Plan y
our third round
of study so that you end with your weakest subject. Then, repeat each chapter in
the MLS Review a
final time. Finish by taking the exam- inations on the CD included with this boo
k. These questions are all different than those in the book, and will give you exposure to ma
ny more based on
interpreting photomicrographs. Test-Taking Skills Before the Exam First, make a
study plan such
as the one suggested earlier. You cannot expect to review all of this material i
n only a few
days. Allow yourself at least 1 month to study all areas completely and carefull
y. Set aside an
allotted time period of at least 1 hour each day when you are alert and can stay
focused.
2828_FM_i-xvi 21/08/12 2:32 PM Page xiv Assemble all of your study materials
before you begin
your review. Searching for old notes or textbooks may become time consuming and
frustrating. You
may have a tendency to give up looking for needed materials, if you do not have th
em readily
available. Therefore, you may neglect or not study a major content area. Provide
a study
environment. Choose a quiet, comfort- able area for your study. Find a place whe
re you will not
be distracted or disturbed. Simulate test conditions. Re- gardless of your study
plan, you should
take some portion of the review process, for example, the mock examination, unde
r simulated
test conditions. These examinations should be timed, uninterrupted, and desig
ned to observe
realistic testing practices. For example, you should take the mock examination w
ith only a sheet
of scratch paper, pencil, and a basic calculator at your disposal. A few days
before the
exam, be sure to again read through the instructions sent to you by the cer
tification
agency. Some types of calculators (e.g., graphing or pro- grammable calculators)

may be
prohibited and you should know what you can and cannot bring with you. Make your
travel
arrangements and familiarize yourself with directions to the site. Finally,
go to sleep early
the night before the exam, and leave yourself extra time if you have to travel a
long distance to
the examination site. On Exam Day Eat properly and, if possible, engage in some
light physical
activity such as walking prior to leaving for the exam. Dress comfortab
ly with layered
clothing that you may re- move, if the examination room is too warm. Make sure y
ou bring two
forms of signed identification including 1 photo identification card (drivers lic
ense or state
issued ID card). These must not be expired, and the name on them must match the
name on your
letter of admission to the exam that you should also have with you. Wear a watch
so that you can
keep track of time. Do not take notes or books with you. If you have not pre- pa
red prior to the
examination day, you will not succeed by trying to cram last-minute facts. If yo
u become anxious before or during the exam, close your eyes and breathe deeply fo
r a few
seconds. Perhaps focus on a Introduction xv special activity that you may
have planned as a
reward for yourself after the examination. Have confidence in your abilities. At
this point, you
have successfully completed a rigorous course of classroom and clinical traini
ng and the
examination represents merely the last step in this long process. Tell
yourself that
you have adequately practiced and prepared for the examination and that you are
ready. During the
Exam Read all directions. Make sure you understand how to take the examination.
Read the
questions carefully and note key words. Accept the question as you first read it
; do not read
your own thoughts into the question and do not look for hidden meanings. Quickly
look at all of
the answers. Next, carefully read all choices. You may wish to mentally p
lace a T for
true or an F for false beside each alternative, or to reject outright obviously
wrong choices.
Select your first choice and do not change your answer. Answer all of the questions. There is
no penalty for guessing on certification examinations. Always answer to the best
of your ability
the first time. A computer-adapted exam selects the next question based upon you
r previous
answer. Apply a few simple rules to those questions you cannot answer. Consiste
ntly choose the
same letter on those questions. B is the most common correct answer. Choose on
e of the
longest answers. Pick items that are more specific or detailed than the ot
hers. Do not
overlook words such as not, never, always, most, least, best, worst, except. Sta
tements that
contain unquali- fied absolutes (always, never) are usually incorrect. In con- t

rast,
alternatives that are worded to contain exceptions (usually, generally) are ofte
n true. Do not
panic if you do not know an answer. Continue the test and do not allow anxiety t
o make you forget
items that you know. Work steadily and do not spend too much time on qu
estions you do
not know; keep an eye on the time. Try to pace yourself so that sufficient time
remains after
com- pleting the test to review all of your answers. Do not change you
r original answer
unless you are certain that you made a mistake when you answered the question in
itially.
2828_FM_i-xvi 21/08/12 2:32 PM Page xv 2828_FM_i-xvi 21/08/12 2:32 PM Page
xvi 1.1 Basic
Hematology Concepts and Laboratory Procedures 1.2 Normocytic and Normochromic An
emias 1.3
Hypochromic and Microcytic Anemias 1.4 Macrocytic and Normochromic Anemias 1.5 Q
ualitative and
Quantitative White Blood Cell Disorders 1.6 Acute Leukemias 1.7 Lymphoproliferat
ive and
Myeloproliferative Disorders 1.8 Hematology Problem Solving CHAPTER 1 Hematology
1
2828_Ch01_001-040 09/08/12 4:10 PM Page 1 2828_Ch01_001-040 09/08/12 4:10 P
M Page 2 3 1.1
Basic Hematology Concepts and Laboratory Procedures 1. Insu cient centrifugation w
ill result in:
A. A false increase in hematocrit (Hct) value B. A false decrease in Hct value C
. No e ect on Hct
value D. All of these options, depending on the patient Hematology/Apply princip
les of basic
laboratory procedures/Microscopic morphology/Di erential/2 2. Variation in red cel
l size observed
on the peripheral smear is described as: A. Anisocytosis B. Hypochromia C. Poiki
locytosis D.
Pleocytosis Hematology/Apply knowledge of fundamental biological characteristics
/Microscopic
morphology/RBCs/1 3. Which of the following is the preferable site for bone marr
ow aspiration and
biopsy in an adult? A. Iliac crest B. Sternum C. Tibia D. Spinous processes of a
vertebra
Hematology/Apply knowledge of fundamental biological characteristics/Bone marrow
/1 4. Mean cell
volume (MCV) is calculated using the following formula: A. (Hgb RBC) 10 B. (Hct
RBC) 10
C. (Hct Hgb) 100 D. (Hgb RBC) 100 Hematology/Calculate/RBC indices/2 5. What ter
m
describes the change in shape of erythrocytes seen on a Wrights-stained periphera
l blood smear?
A. Poikilocytosis B. Anisocytosis C. Hypochromia D. Polychromasia Hematology/App
ly knowledge of
fundamental biological characteristics/Microscopic morphology/ RBCs/1 Answers to
Questions 15 1.
A Insu cient centrifugation does not pack down the red blood cells; therefore, the
Hct, which is
the volume of packed cells, will increase. 2. A A mature erythrocyte is approxim
ately 78 m in
diameter. Variation in normal size is denoted by the term anisocytosis. Hypochro
mia is a term
that indicates increased central pallor in erythrocytes, and poikilocytosis deno

tes variation in
red cell shape. 3. A The iliac crest is the most frequently used site for bone m
arrow aspiration
and biopsy. This site is the safest and most easily accessible, with the bone ju
st beneath the
skin, and neither blood vessels nor nerves are in the vicinity. 4. B MCV is the
average volume
of the red cells. This is obtained by dividing the Hct or packed cell volume (PC
V) by the red
blood cell (RBC) count in millions per microliter of blood and multiplying by 10
. The MCV is
expressed in cubic microns (m 3 ) or femtoliters (fL). 5. A Variation in shape of
the
erythrocytes on a peripheral blood smear is poikilocytosis. Anisocytosis refers
to a change in
size. Hypochromia is an increase in central pallor in erythrocytes. Polychromasi
a describes the
bluish tinge of the immature erythrocytes (reticulocytes) circulating in the per
ipheral blood.
2828_Ch01_001-040 09/08/12 4:10 PM Page 3 6. Calculate the mean cell hemoglob
in concentration
(MCHC) using the following values: Hgb: 15 g/dL (150 g/L) Hct: 47 mL/dL (0.47) R
BC: 4.50 10 6
/
L (4.50 10
12
/
L)
A. 9.5% (.095) B. 10.4% (.104) C. 31.9% (.319) D. 33.3% (.333) Hematolog
y/Calculate/RBC
indices/2 7. A manual white blood cell (WBC) count was performed. A total of 36
cells were
counted in all 9-mm 2 squares of a Neubauer-ruled hemacytometer. A 1:10 dilution
was used. What
is the WBC count? A. 0.4 10 9
/L
B. 2.5 10 9
/L
C. 4.0 10 9
/L
D. 8.0 10 9
/L
Hematology/Calculate/Manual WBCs/2 8. When an erythrocyte containing iro
n granules is stained
with Prussian blue, the cell is called a: A. Spherocyte B. Leptocyte C. Schistoc
yte D. Siderocyte
Hematology/Apply knowledge of fundamental biological characteristics/RBCs micros
copic
morphology/Stain/1 9. A 7.0-mL ethylenediaminetetraacetic acid (EDTA) tube is re
ceived in the
laboratory containing only 2.0 mL of blood. If the laboratory is using manual te
chniques, which
of the following tests will most likely be erroneous? A. RBC count B. Hemoglobin
(Hgb) C. Hct D.
WBC count Hematology/Apply knowledge to identify sources of error/Specimen colle
ction and
handling/CBCs/2 10. A 1:200 dilution of a patients sample was made and 336 red ce
lls were
counted in an area of 0.2 mm 2 . What is the RBC count? A. 1.68 10 12
/L
B. 3.36 10 12
/L

C. 4.47 10 12
/L
D. 6.66 10 12
/L
Hematology/Calculate/Manual RBCs/2 Answers to Questions 611 6. C MCHC is
the average
concentration of Hgb in red cells expressed as a percentage. It expresses the ra
tio of the weight
of Hgb to the volume of erythrocytes and is calculated by dividing Hgb by the Hc
t, and then
multiplying by 100. A decreased MCHC indicates that cells are hypochromic. In th
is example, (15
47) 100 = 31.9%. The reference range for MCHC is 32%36%. 7. A The formula used fo
r calculating
manual cell counts using a hemacytometer is: Number of cells counted dilution fa
ctor depth
factor (10) divided by the area. In this example, 36 10 10 = 3600 9 = 400/mm 3 o
r 0.4 10 9
/
L.
8. D Siderocytes are red cells containing iron granules and are visible
when stained with
Prussian blue. 9. C Excessive anticoagulant causes shrinkage of cells; thus, the
Hct will be
a ected. RBC and WBC counts remain the same, as does the Hgb content. 10. B RBC co
unt = number of
cells counted dilution factor depth factor (10), divided by the area. In this ex
ample, 336
200 10 = 672,000 0.2 = 3.36 10 6
/
mm
3 = 3.36 10 12
/
L.
11. D Neutrophils are highly phagocytic and release lysozymes, peroxidas
e, and pyrogenic
proteins. Eosinophils migrate to sites where there is an allergic reaction or pa
rasitic
infestation, releasing peroxidase, pyrogens, and other enzymes, including an oxi
dase that
neutralizes histamine. They are poorly phagocytic and do not release lysozyme. 4
Chapter 1 |
Hematology 11. What phagocytic cells produce lysozymes that are bacteriocidal? A
. Eosinophils B.
Lymphocytes C. Platelets D. Neutrophils Hematology/Apply knowledge of fundamenta
l biological
characteristics/Leukocytes/1 2828_Ch01_001-040 09/08/12 4:10 PM Page 4 12. If
a patient has a
reticulocyte count of 7% and an Hct of 20%, what is the corrected reticulocyte c
ount? A. 1.4% B.
3.1% C. 3.5% D. 14% Hematology/Apply principles of basic laboratory
procedures/Calculate/Reticulocytes/2 13. A decreased osmotic fragility test woul
d be associated
with which of the following conditions? A. Sickle cell anemia B. Hereditary sphe
rocytosis C.
Hemolytic disease of the newborn D. Acquired hemolytic anemia Hematology/Apply p
rinciples of
basic laboratory procedures/RBCs/Osmotic fragility/2 14. What e ect would using a
bu er at pH 6.0
have on a Wrights-stained smear? A. Red cells would be stained too pink B. White
cell cytoplasm
would be stained too blue C. Red cells would be stained too blue D. Red cells wo
uld lyse on the

slide Hematology/Evaluate laboratory data to recognize problems/Microscopic morp

hology/Stains/2
15. Which of the following erythrocyte inclusions can be visualized with supravi
tal stain but
cannot be detected on a Wrights-stained blood smear? A. Basophilic stippling B. H
einz bodies C.
HowellJolly bodies D. Siderotic granules Hematology/Apply principles of basic lab
oratory
procedures/Microscopic morphology/RBC inclusions/2 16. A falsely elevated Hct is
obtained. Which
of the following calculated values will not be a ected? A. MCV B. MCH C. MCHC D. R
ed cell
distribution width (RDW) Hematology/Evaluate sources of error/Microhematocrit/2
17. A Miller disk
is an ocular device used to facilitate counting of: A. Platelets B. Reticulocyte
s C. Sickle cells
D. Nucleated red blood cells (NRBCs) Hematology/Apply knowledge of standard oper
ating
procedures/Manual counts/1 Answers to Questions 1217 12. B In anemic states, the
reticulocyte
percentage is not a true measure of reticulocyte production. The following formu
la must be
applied to calculate the corrected (for anemia) reticulocyte count. Corrected re
ticulocyte count
= reticulocytes (%) Hct 45, the average normal Hct. In this case, 7 (20 45) = 3.
1. 13. A
Osmotic fragility is decreased when numerous sickle cells and target cells are p
resent and is
increased in the presence of spherocytes. Spherocytes are a prominent feature of
hereditary
spherocytosis (HS), hemolytic disease of the newborn, and acquired hemolytic ane
mia. The osmotic
fragility test is increased in the presence of spherocytes, whereas this test is
decreased when
sickle cells, target cells, and other poikilocytes are present. 14. A The pH of
the bu er is
critical in Romanowsky stains. When the pH is too low (<6.4), the red cells take
up more acid dye
(eosin), becoming too pink. Leukocytes also show poor nuclear detail when the pH
is decreased.
15. B Heinz bodies are irregular, refractile, purple inclusions that are not vis
ible with
Wrights stain but show up with supravital staining. The other three inclusions ca
n be detected
with Wrights stain. 16. B The MCH = Hgb 10/RBC count and is not a ected by the Hct.
The MCV =
Hct 10/RBC count, and MCHC = Hgb 100/Hct; therefore, an erroneous Hct will a ect t
hese
parameters. Centrifugal force for microhematocrit determination should be 12,000
g for 5 min in
order to avoid error caused by trapped plasma. The red cell distribution width (
RDW) is
calculated by electronic cell counters and re ects the variance in the size of the
red cell
population. Electronic cell counters calculate Hct from the MCV and RBC count. T
herefore, the RDW
would be a ected by an erroneous MCV. 17. B The manual reticulocyte count involves
the counting
of 1,000 RBCs. The Miller disk is a reticle (grid) that is placed in the eyepiec
e of the

microscope and divides the eld into two squares, one being nine times larger in s
ize than the
other. Reticulocytes are enumerated in both the squares. Mature red cells are co
unted in the
smaller one. 1.1 | Basic Hematology Concepts and Laboratory Procedures 5 2828_
Ch01_001-040
09/08/12 4:10 PM Page 5 6 Chapter 1 | Hematology Answers to Questions 1823 18.
C The MCV, MCH,
and MCHC are all within the reference interval (normal range); hence, the erythr
ocytes should be
of normal size and should re ect normal concentrations of Hgb. Therefore, the anem
ia is
normocytic normochromic. 19. A EDTA and sodium citrate can be used without any e e
ct on the ESR.
Anisocytosis and poikilocytosis may impede rouleaux formation, thus causing a lo
w ESR. Plasma
proteins, especially brinogen and immunoglobulins, enhance rouleaux, increasing t
he ESR.
Reference ranges must be established for di erent caliber tubes. 20. B The reticul
um within the
reticulocytes consists of ribonucleic acid (RNA), which cannot be stained with W
rights stain.
Supravital staining with new methylene blue is used to identify the reticulocyte
s. 21. A
Electronic cell (Coulter) counters use the principle of electrical impedance. Tw
o electrodes
suspended in isotonic solutions are separated by a glass tube having a small ape
rture. A vacuum
is applied, and as a cell passes through the aperture it impedes the ow of curren
t and generates
a voltage pulse. 22. C The automated hematology analyzers enumerate all nucleate
d cells. NRBCs
are counted along with WBCs, falsely elevating the WBC count. To correct the WBC
count, determine
the number of NRBCs per 100 WBCs. Corrected WBC count = (uncorrected WBC count [
NRBCs + 100])
100. 23. B The RDW parameter correlates with the degree of anisocytosis seen on
the
morphological examination. The reference range is 11.5%14.5%. 18. SITUATION: RBC
indices
obtained on an anemic patient are as follows: MCV 88 m 3 (fL); MCH 30 pg; MCHC 34
% (.340). Te
RBCs on the peripheral smear would appear: A. Microcytic, hypochromic B. Microcy
tic, normochromic
C. Normocytic, normochromic D. Normocytic, hypochromic Hematology/Evaluate labor
atory data to
recognize health and disease states/RBC indices/2 19. All of the following facto
rs may in uence
the erythrocyte sedimentation rate (ESR) except: A. Blood drawn into a sodium ci
trate tube B.
Anisocytosis, poikilocytosis C. Plasma proteins D. Caliber of the tube Hematolog
y/Apply
principles of basic laboratory procedures/ESRs/2 20. What staining method is use
d most frequently
to stain and manually count reticulocytes? A. Immuno uorescence B. Supravital stai
ning C.
Romanowsky staining D. Cytochemical staining Hematology/Apply knowledge of stand
ard operating
procedures/Reticulocytes/1 21. Te Coulter principle for counting of cells is bas
ed upon the fact

that: A. Isotonic solutions conduct electricity better than cells do B. Conducti

vity varies
proportionally to the number of cells C. Cells conduct electricity better than s
aline does D.
Isotonic solutions cannot conduct electricity Hematology/Apply principles of bas
ic laboratory
procedures/Instrumentation/Cell counters/2 22. A correction is necessary for WBC
counts when
nucleated RBCs are seen on the peripheral smear because: A. Te WBC count would b
e falsely lower
B. Te RBC count is too low C. Nucleated RBCs are counted as leukocytes D. Nuclea
ted RBCs are
confused with giant platelets Hematology/Evaluate laboratory data to take correc
tive action
according to predetermined criteria/Leukocytes/2 23. Using an electronic cell co
unter analyzer,
an increased RDW should correlate with: A. Spherocytosis B. Anisocytosis C. Leuk
ocytosis D.
Presence of NRBCs Hematology/Correlate laboratory data with other laboratory dat
a to assess test
results/RBC microscopic morphology/2 2828_Ch01_001-040 09/08/12 4:10 PM Page
6 1.1 | Basic
Hematology Concepts and Laboratory Procedures 7 Answers to Questions 2429 24. C
Spherocytes
have a decreased cell diameter and volume, which results in loss of central pall
or and discoid
shape. The index most a ected is the MCHC, usually being in excess of 36%. 25. C S
tandard
deviation(s) describes the distribution of a sample of observations. It depends
upon both the
mean (average value) and dispersion of results and is most in uenced by reproducib
ility or
precision. Because s is in uenced by the mean and expressed as a percentage of the
mean, the
coe cient of variation ([s mean] 100) can be used to compare precision of tests wi
th di erent
means (e.g., WBC and RBC counts or low vs. high controls). 26. D Deoxyhemoglobin
is the
physiological Hgb that results from the unloading of oxygen by Hgb. This is acco
mpanied by the
widening of the space between chains and the inding of 2,3-diphosphoglycerate (2,
3-DPG) on a
mole-for-mole asis. 27. A Acidosis is associated with a shift to the right of t
he oxyhemoglo in
dissociation curve and, therefore, increased oxygen release (decreased a nity of H
g for oxygen).
Alkalosis does the opposite. Multiple lood transfusions shift the curve to the
left ecause the
transfused lood is low in 2,3-DPG. Hg S and Hg C do not change the a nity of ox
ygen for
hemoglo in; however, many hemoglo inopathies do. For example, Hg Kansas causes
a right shift and
Hg Chesapeake causes a left shift of the oxyhemoglo in dissociation curve. 28.
B Lymphocytes
constitute the majority of the nucleated cells seen. The one marrow in aplastic
anemia is spotty
with patches of normal cellularity. A solute granulocytopenia is usually present
; however,
lymphocyte production is less a ected. 29. C The normal adult percentage of lympho
cytes in a

white cell di erential is etween 20% and 44%, although normal ranges vary y inst
itution,
patient population, and testing methodology. This range is higher in the pediatr
ic population.
24. Given the following values, which set of red lood cell indices suggests sph
erocytosis? A.
MCV 76 m 3 MCH 19.9 pg MCHC 28.5% B. MCV 90 m 3 MCH 30.5 pg MCHC 32.5% C. MCV 80 m
3 MCH 36.5
pg MCHC 39.0% D. MCV 81 m 3 MCH 29.0 pg MCHC 34.8% Hematology/Evaluate la oratory
data to
recognize health and disease states/RBC indices/3 25. Which of the following sta
tistical terms
re ects the est index of precision when comparing two CBC parameters? A. Mean B.
Median C.
Coe cient of variation D. Standard deviation Hematology/Correlate la oratory data
with other
la oratory data to assess test results/QC/Statistics/2 26. Which of the followin
g is considered a
normal hemoglo in? A. Car oxyhemoglo in B. Methemoglo in C. Sulfhemoglo in D. De
oxyhemoglo in
Hematology/Apply knowledge of fundamental iological characteristics/Hemoglo in/
1 27. Which
condition will shift the oxyhemoglo in dissociation curve to the right? A. Acido
sis B. Alkalosis
C. Multiple lood transfusions D. Increased quantities of hemoglo in S or C Hema
tology/Correlate
la oratory data with other la oratory data to assess test results/RBCs/ Meta oli
sm/2 28. What is
the major type of leukocyte seen in the peripheral smear of a patient with aplas
tic anemia? A.
Segmented neutrophil B. Lymphocyte C. Monocyte D. Eosinophil Hematology/Correlat
e clinical and
la oratory data/ Leukocytes/Aplastic anemia/1 29. What is the normal WBC di erenti
al lymphocyte
percentage (range) in the adult population? A. 5%10% B. 10%20% C. 20%44% D. 50%70%
Hematology/Correlate asic la oratory values/ Di erentials/1 2828_Ch01_001-040 09
/08/12 4:10 PM
Page 7 30. In which age group would 60% lymphocytes e a normal nding? A. 6 mont
hs2 years B.
46 years C. 1115 years D. 4060 years Hematology/Evaluate la oratory data/Di erentials
/2 31.
Which of the following results on an automated di erential suggests that a periphe
ral smear
should e reviewed manually? A. Segs = 70% B. Band = 6% C. Mono = 15% D. Eos = 2
%
Hematology/Correlate la oratory data/Instrumentation/2 32. Which is the rst stage
of
erythrocytic maturation in which the cytoplasm is pink due to the formation of h
emoglo in? A.
Reticulocyte B. Pronormo last C. Basophilic normo last D. Polychromatic normo la
st
Hematology/Apply knowledge of fundamental iological characteristics/Microscopic
morphology/1 33.
Which of the following can shift the hemoglo in oxygen dissociation curve to the
right? A.
Increases in 2,3 DPG B. Acidosis C. Hypoxia D. All of these options Hematology/E
valuate
la oratory data to recognize health and disease states/O 2 dissociation curves/2
34. Which of the
following Hg con gurations is characteristic of Hg H? A. 4 B. 2 - 2 C. 4 D. 2 - 2

Hem
toloy/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics/Hemolo in/

2 35.
Auto
lutin
tion of red cells
t room temper
ture c
n c
use which of the follow
in
norm
l test
results? A. Low RBC count B. Hih MCV C. Low hem
tocrit D. All of these options
Hem
toloy/Correl
te l
or
tory d
t
with other l
or
tory d
t
to
ssess test r
esults/CBCs/3
Answers to Questions 3035 30. A There is
rel
tive neutropeni
in children from

es 4 months
to 4 ye
rs. Bec
use of this, the percent
e of lymphocytes is incre
sed in this
popul
tion. This
is commonly referred to
s
revers
l in the norm
l di erenti
l percent
e (or inv
erted
di erenti
l). 31. C A rel
tive monocyte count of 15% is
norm
l, iven th
t the

seline
monocyte count in
norm
l di erenti
l is etween 1%
nd 8%. An incre
sed monocyte
count m
y
sin
l
myeloprolifer
tive process such
s chronic myelomonocytic leukemi
,
n
in
mm
tory
response, or
norm
l lymphocytes th
t m
y h
ve een counted
s monocytes y
n

utom
ted cell
counter. 32. D In norm
l erythrocytic m
tur
tion, H form
tion in the l
te poly
chrom
tic
normo l
st st
e ives the cytopl
sm
prominent pink color
tion. The red cell c
ontinues to
produce H throuhout the reticulocyte st
e of development. 33. D Incre
ses in
2,3-DPG,

cidosis, hypoxi
,
nd
rise in ody temper
ture
ll shift the hemolo in-oxye
n dissoci
tion
curve to the riht. In
nemi
,
lthouh the num er of RBCs is reduced, the cells

re more e cient

t oxyen delivery ec
use there is
n incre
se in red cell 2,3-DPG. This c
uses
the
oxyhemolo in dissoci
tion curve to shift to the riht,
llowin more oxyen to
e rele
sed to
the tissues. 34. C The structure of H H is 4 . H H dise
se is
severe clini
c
l expression
of th
l
ssemi
in which only one ene out of four is functionin. 35. D Auto
lutin

tion
t
room temper
ture m
y c
use
low RBC count
nd hih MCV from
n electronic count
er. The Hct will
e low ec
use it is c
lcul
ted from the RBC count. Low RBC count
nd low Hct c

use f
lsely hih
c
lcul
tions of MCH
nd MCHC, respectively. 8 Ch
pter 1 | Hem
toloy 2828_Ch01_0
01-040 09/08/12
4:10 PM P
e 8 Answers to Questions 16 1. C Hypersplenic conditions
re ener
ll
y descri ed y
the followin four criteri
: (1) cytopeni
s of one or more peripher
l cell lines
, (2)
splenome
ly, (3) one m
rrow hyperpl
si
,
nd (4) resolution of cytopeni
y sp
lenectomy. 2. B
The spleen is the supreme lter of the ody, pittin imperfections from the erythr
ocyte without
destroyin the interity of the mem r
ne. 3. D Spherocytes lose their deform
il
ity owin to the
defect in spectrin,
mem r
ne protein,
nd
re therefore prone to splenic seque
str
tion
nd
hemolysis. 4. C Cl
ssic fe
tures of intr
v
scul
r hemolysis such
s hemolo inem
i
,
hemolo inuri
, or hemosiderinuri
do not occur in heredit
ry spherocytosis. The

hemolysis seen
in heredit
ry spherocytosis is
n extr
v
scul
r r
ther th
n
n intr
v
scul
r pro
cess. 5. D
Spherocytic cells h
ve decre
sed toler
nce to swellin
nd, therefore, hemolyze

t
hiher
concentr
tion of sodium s
lt comp
red with norm
l red cells. 6. C Sickle cell di
se
se is

chronic hemolytic
nemi
cl
ssi ed
s
normocytic, normochromic
nemi
. 6. Te
ne
mi
seen in
sickle cell dise
se is usu
lly: A. Microcytic, normochromic B. Microcytic, hypoc
hromic C.
Normocytic, normochromic D. Normocytic, hypochromic Hem
toloy/Apply knowlede o
f fund
ment
l
ioloic
l ch
r
cteristics/RBC microscopic morpholoy/ Hemolo inop
thy/1 1. Hyp
ersplenism is
ch
r
cterized y: A. Polycythemi
B. P
ncytosis C. Leukopeni
D. Myelodyspl
si

Hem
toloy/Correl
te clinic
l
nd l
or
tory d
t
/ WBCs/Hypersplenism/2 2. Which
of the followin
or
ns is responsi le for the pittin process for RBCs? A. Liver B. Spleen C. Kidn
ey D. Lymph
nodes Hem
toloy/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics/Physi
oloy/1 3.
Spherocytes di er from norm
l red cells in
ll of the followin except: A. Decre
s
ed surf
ce to
volume B. No centr
l p
llor C. Decre
sed resist
nce to hypotonic s
line D. Incre

sed
deform
ility Hem
toloy/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristi
cs/RBC
microscopic morpholoy/2 4. Which of the followin is not
ssoci
ted with heredi
t
ry
spherocytosis? A. Incre
sed osmotic fr
ility B. An MCHC re
ter th
n 36% C. Int
r
v
scul
r
hemolysis D. Extr
v
scul
r hemolysis Hem
toloy/Correl
te clinic
l
nd l
or
tor
y d
t
/
Heredit
ry spherocytosis/2 5. Which of the followin disorders h
s
n incre
se i
n osmotic
fr
ility? A. Iron de ciency
nemi
B. Heredit
ry elliptocytosis C. Heredit
ry sto
m
tocytosis D.
Heredit
ry spherocytosis Hem
toloy/Ev
lu
te l
or
tory d
t
to reconize he
lth

nd dise
se
st
tes/Speci
l tests/Osmotic fr
ility/2 1.2 Normocytic
nd Normochromic Anemi
s
9
2828_Ch01_001-040 09/08/12 4:10 PM P
e 9 Answers to Questions 713 7. D The m

jor hemolo in
in sickle cell tr
it is H A, which constitutes 50%70% of the tot
l. H S compr
ises 20%40%,

nd H A 2
nd H F
re present in norm
l
mounts. 8. B The structur
l mut
tio
n for H S is
the su stitution of v
line for lut
mic
cid
t the sixth position of the -ch
in.
Bec
use
lut
mic
cid is ne
tively ch
red, this decre
ses its r
te of mir
tion tow
rd
the
node
t pH
8.6. 9. D Su stitution of
positively ch
red
mino
cid for
ne
tively ch
r
ed
mino
cid in
H C dise
se results in
slow electrophoretic mo ility
t pH 8.6. 10. C At pH
8.6, sever
l
hemolo ins mir
te toether. These include H A 2 , H C, H E, H 0 Ar
,

nd H C H
rlem
. These
re loc
ted ne
rest the c
thode
t pH 8.6. 11. B Electrophoresis
t
lk

line pH usu
lly

shows 50% 70% H A, 20%40% H S,
nd norm
l levels of H A 2 in
p
tient with

the sickle
cell tr
it. 12. D Autosplenectomy occurs in sickle cell
nemi

s
result of re
pe
ted inf
rcts
to the spleen c
used y the overwhelmin sicklin phenomenon. 13. A PNH is
r
r
e
cquired stem
cell disorder th
t results in
norm
lities of the red cell mem r
ne. This c
use
s the red cells
to e hihly sensitive to complement-medi
ted hemolysis. Bec
use this is
stem
cell disorder,

norm
lities
re seen in leukocytes
nd pl
telets,
s well
s in red cells. PNH
is ch
r
cterized
y recurrent, episodic intr
v
scul
r hemolysis, hemolo inuri
,
nd venous throm
osis. 13. Which
of the followin is most true of p
roxysm
l nocturn
l hemolo inuri
(PNH)? A. I
t is
r
re

cquired stem cell disorder th
t results in hemolysis B. It is inherited
s
se
x-linked tr
it C.
It is inherited
s
n
utosom
l domin
nt tr
it D. It is inherited
s
n
utosom

l recessive tr
it
Hem
toloy/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics/PNH/1 10 Ch

pter 1 |
Hem
toloy 7. Which is the m
jor H found in the RBCs of p
tients with sickle c
ell tr
it? A. H
S B. H F C. H A 2 D. H A Hem
toloy/Apply knowlede of fund
ment
l ioloi
c
l
ch
r
cteristics/Anemi
/Hemolo inop
thy/1 8. Select the
mino
cid su stitution
th
t is
responsi le for sickle cell
nemi
. A. Lysine is su stituted for lut
mic
cid

t the sixth
position of the -ch
in B. V
line is su stituted for lut
mic
cid
t the sixth po
sition of the
-ch
in C. V
line is su stituted for lut
mic
cid
t the sixth position of the -ch

in D.
Glut
mine is su stituted for lut
mic
cid
t the sixth position of the -ch
in He
m
toloy/Apply
knowlede of fund
ment
l ioloic
l ch
r
cteristics/Hemolo inop
thy/1 9. All of
the followin

re usu
lly found in H C dise
se except: A. H C cryst
ls B. T
ret cells C.
Lysine
su stituted for lut
mic
cid
t the sixth position of the ch
in D. F
st mo ility
of H C
t
pH 8.6 Hem
toloy/Apply knowlede of fund
ment
l ioloic
l
ch
r
cteristics/Anemi
/Hemolo inop
thy/1 10. Which of the followin hemolo ins
mir
tes to the
s
me position
s H A 2
t pH 8.6? A. H H B. H F C. H C D. H S Hem
tolo
y/Correl
te
clinic
l
nd l
or
tory d
t
/ Hemolo in electrophoresis/1 11. Which of the foll
owin
electrophoretic results is consistent with
di
nosis of sickle cell tr
it? A.
H A: 40% H S:
35% H F: 5% B. H A: 60% H S: 40% H A 2
:
2%
C. H A: 0% H A 2
:
5% H F: 95%
D. H A: 80% H S: 10% H A2: 10% Hem
toloy/Ev
lu
te l
or
tory d
t

to reconize he
lth

nd dise
se/Speci
l tests/Electrophoresis/2 12. In which of the followin condit
ions will

utosplenectomy most likely occur? A. T
l
ssemi
m
jor B. H C dise
se C. H S

C dise
se D.
Sickle cell dise
se Hem
toloy/Apply knowlede of fund
ment
l ioloic
l
ch
r
cteristics/Anemi
/Hemolo inop
thy/1 2828_Ch01_001-040 09/08/12 4:10 PM
P
e 10 1.2 |
Normocytic
nd Normochromic Anemi
s 11 14. Hemolytic uremic syndrome (HUS) is
ch
r
cterized y

ll of the followin except: A. Hemorrh
e B. Trom ocytopeni
C. Hemolo inuri

D.
Reticulocytopeni
Hem
toloy/Correl
te clinic
l
nd l
or
tory d
t
/ HUS/2 15. A
n
utohemolysis
test is positive in
ll the followin conditions except: A. Glucose-6-phosph
te
dehydroen
se
(G6PD) de ciency B. Heredit
ry spherocytosis (HS) C. Pyruv
te kin
se (PK) de ciency
D. P
roxysm
l
nocturn
l hemolo inuri
(PNH) Hem
toloy/Correl
te clinic
l
nd l
or
tory test
s/ Speci
l
tests/2 16. Which
nti ody is
ssoci
ted with p
roxysm
l cold hemolo inuri
(PC
H)? A. Anti-I B.
Anti-i C. Anti-M D. Anti-P Hem
toloy/Apply knowlede of fund
ment
l ioloic
l
ch
r
cteristics/Anemi
/PCH/1 17. All of the followin
re
ssoci
ted with intr
v

scul
r hemolysis
except: A. Methemolo inemi
B. Hemolo inuri
C. Hemolo inemi
D. Decre
sed h

ptolo in
Hem
toloy/Correl
te clinic
l
nd l
or
tory d
t
/ Anemi
/Hemolytic/2 18. Autoim
mune hemolytic

nemi
is est ch
r
cterized y which of the followin? A. Incre
sed levels of p
l
sm
C3 B.
Spherocytic red cells C. Decre
sed osmotic fr
ility D. Decre
sed unconju
ted
iliru in
Hem
toloy/Correl
te clinic
l
nd l
or
tory d
t
/ Anemi
/Hemolytic/2 19. Bite ce
lls
re
usu
lly seen in p
tients with: A. Rh null tr
it B. Chronic r
nulom
tous dise
se
C. G6PD
de ciency D. PK de ciency Hem
toloy/Correl
te clinic
l
nd l
or
tory d
t
/RBC micr
oscopic
morpholoy/1 Answers to Questions 1419 14. D The hemolytic
nemi
of HUS is
ssoc
i
ted with
reticulocytosis. The
nemi
seen in HUS is multif
ctori
l, with ch
r
cteristic s
chistocytes
nd
polychrom
si
commensur
te with the
nemi
. 15. D The
utohemolysis test is posi
tive in G6PD
nd
PK de ciencies
nd in HS, ut is norm
l in PNH ec
use lysis in PNH requires sucro
se to enh
nce
complement indin. The
ddition of lucose, sucrose, or
denosine triphosph
te
(ATP) corrects
the
utohemolysis of HS. Autohemolysis of PK c
n e corrected y ATP. 16. D PCH
is c
used y the

nti-P
nti ody,
cold
uto
nti ody th
t inds to the p
tients RBCs
t low tempe
r
tures
nd
xes complement. In the cl
ssic Don
thL
ndsteiner test, hemolysis is demonstr
ted i
n
s
mple
pl
ced
t 4C th
t is then w
rmed to 37C. 17. A Methemolo in occurs when iron is o
xidized to
the ferric st
te. Norm
lly, iron is predomin
ntly in the ferrous st
te in the he
molo in th
t
circul
tes. Durin intr
v
scul
r hemolysis, the red cells rupture, rele
sin hem
olo in directly
into the loodstre
m. H
ptolo in is
protein th
t inds to free H . The incre

sed free H in
intr
v
scul
r hemolysis c
uses depletion of h
ptolo in. As h
ptolo in is deple

ted, un ound
hemolo in dimers
ppe
r in the pl
sm
(hemolo inemi
)
nd
re ltered throuh th
e kidneys
nd
re
sor ed y the ren
l tu ul
r cells. The ren
l tu ul
r upt
ke c
p
city is
ppr
oxim
tely 5  per
d
y of ltered hemolo in. Beyond this level, free hemolo in
ppe
rs in the urine
(hemolo inuri
). Hemolo inuri
is
ssoci
ted with hemolo inemi
. 18. B Sphero
cytes
re
ch
r
cteristic of
utoimmune hemolytic
nemi

nd result in
n incre
sed osmotic
fr
ility. In

utoimmune hemolytic
nemi
s (AIHAs), production of
uto
nti odies

inst ones o
wn red cells
c
uses hemolysis or ph
ocytic destruction of RBCs. A positive direct
ntilo ul
in (DAT or
Coom s) test identi es in vivo
nti ody-co
ted
nd complement-co
ted red cells. A p
ositive DAT
distinuishes AIHA from other types of hemolytic
nemi
th
t produce spherocytes
. 19. C In
p
tients with G6PD de ciency, the red cells
re un
le to reduce nicotin
mide
den
ine
dinucleotide phosph
te (NADP) to NADPH; consequently, H is den
tured
nd Heinz
odies
re
formed. Bite cells
ppe
r in the peripher
l circul
tion
s
result of splenic pit
tin of Heinz
odies. 2828_Ch01_001-040 09/08/12 4:10 PM P
e 11 12 Ch
pter 1 | Hem
toloy
Answers to
Questions 2025 20. C RBC indices cl
ssify the
nemi
morpholoic
lly. Anemi
s c
n
e cl
ssi ed
morpholoic
lly y the use of l
or
tory d
t
; physioloic
lly,
sed upon the m
ech
nism;
nd
clinic
lly,
sed upon
n
ssessment of symptoms. 21. C Apl
stic
nemi
h
s m
ny
c
uses, such
s
chemic
l, dru, or r
di
tion poisonin; conenit
l
pl
si
;
nd F
nconis syndrome
. All result in
depletion of hem
topoietic precursors of
ll cell lines, le
din to peripher
l
lood
p
ncytopeni
. 22. A There
re four cl
ssi c
tions of CDAs, e
ch ch
r
cterized y i
ne ective
erythropoiesis, incre
sed unconju
ted iliru in,
nd iz
rre multinucle
ted ery
throid
precursors. 23. D Micro
niop
thic hemolytic
nemi
is
condition resultin fro
m she
r stress to
the erythrocytes. Fi rin str
nds
re l
id down within the microcircul
tion,
nd
red cells ecome
fr
mented
s they cont
ct
rin throuh the circul
tion process, formin schistoc
ytes. 24. D
Chlor
mphenicol is the dru most often implic
ted in
cquired
pl
stic
nemi
. A
out h
lf of the
c
ses occur within 30 d
ys
fter ther
py
nd
out h
lf of the c
ses
re reversi
le. Penicillin,
tetr
cycline,
nd sulfon
mides h
ve een implic
ted in
sm
ll num er of c
ses.
25. A Sickle cell
disorders
re intr
corpuscul
r red cell defects th
t
re heredit
ry
nd result i
n defective H s
ein produced. The ene for sickle cell c
n e inherited either homozyously or
heterozyously.
20. Te morpholoic
l cl
ssi c
tion of
nemi
s is
sed on which of the followin?
A. M:E
(myeloid:erythroid) r
tio B. Prussi
n lue st
in C. RBC indices D. Reticulocyte
count

Hem
toloy/Correl
te clinic
l
nd l
or
tory dise
ses/ RBC microscopic morpholo

y/1 21. Which of
the followin is
common ndin in
pl
stic
nemi
? A. A monoclon
l disorder B. T
umor
in ltr
tion C. Peripher
l lood p
ncytopeni
D. Defective DNA synthesis Hem
toloy
/Apply
knowlede of fund
ment
l ioloic
l ch
r
cteristics/Apl
stic
nemi
/1 22. Conen
it
l
dyserythropoietic
nemi
s (CDAs)
re ch
r
cterized y: A. Biz
rre multinucle
ted
erythro l
sts B.
Cytoenetic disorders C. Me
lo l
stic erythropoiesis D. An elev
ted M:E r
tio H
em
toloy/Apply
knowlede of fund
ment
l ioloic
l ch
r
cteristics/Anemi
/Ch
r
cteristics/2 23.
Micro
niop
thic
hemolytic
nemi
is ch
r
cterized y: A. T
ret cells
nd C
ot rins B. Toxic 
r
nul
tion
nd
Dhle odies C. P
ppenheimer odies
nd
sophilic stipplin D. Schistocytes
nd n
ucle
ted RBCs
Hem
toloy/Correl
te clinic
l
nd l
or
tory d
t
/ RBC microscopic morpholoy/An
emi
/2 24. Which

nti iotic(s) is (
re) most often implic
ted in the development of
pl
stic
nem
i
? A.
Sulfon
mides B. Penicillin C. Tetr
cycline D. Chlor
mphenicol Hem
toloy/Correl

te clinic
l
nd
l
or
tory d
t
/ Apl
stic
nemi
/1 25. Sickle cell disorders
re: A. Heredit
ry,
intr
corpuscul
r
RBC defects B. Heredit
ry, extr
corpuscul
r RBC defects C. Acquired, intr
corpus
cul
r RBC defects
D. Acquired, extr
corpuscul
r RBC defects Hem
toloy/Apply knowlede of fund
men
t
l ioloic
l
concepts/2 2828_Ch01_001-040 09/08/12 4:10 PM P
e 12 1.2 | Normocytic
nd No
rmochromic
Anemi
s 13 Answers to Questions 2630 26. C Spherocytes
re produced in
utoimmu
ne hemolytic

nemi
. Spherocytes m
y e produced y one of three mech
nisms. First, they
re

n
tur
l
morpholoic
l ph
se of norm
l red cell senescence. Second, they
re produced whe
n the cell
surf
ce-to-volume r
tio is decre
sed,
s seen in heredit
ry spherocytosis. And t
hird, they m
y e
produced
s
result of
nti ody co
tin of the red cells. As the
nti ody-co
te
d red cells
tr
vel throuh the spleen, the
nti odies
nd portions of the red cell mem r
ne

re removed y
m
croph
es. The mem r
ne rep
irs itself; hence, the red cells morpholoy ch
nes
from

iconc
ve disk to
spherocyte. 27. C This p
tients
norm
l peripher
l sme
r ind
ic
tes m
rked
red cell reener
tion, c
usin m
ny reticulocytes to e rele
sed from the m
rrow
. Bec
use
reticulocytes
re l
rer th
n m
ture RBCs, the MCV will e slihtly elev
ted. 28
. B As
result
of splenectomy, HowellJolly odies m
y e seen in re
t num ers. One of the m
in
functions of
the spleen is the pittin function, which
llows inclusions to e removed from t
he red cell
without destroyin the cell mem r
ne. 29. D Reticulocytes
re polychrom
tophilic
m
crocytes,
nd
the presence of reticulocytes indic
tes red cell reener
tion. The one m
rrows

ppropri
te

response to
nemi
is to deliver red cells prem
turely to the peripher
l circul

tion. In this
w
y, reticulocytes
nd possi ly nucle
ted red cells m
y e seen in the peripher

l sme
r. 30. C HP
is
mem r
ne defect ch
r
cterized y
spectrin
norm
lity
nd therm
l inst
i
lity. The MCV is
decre
sed
nd the red cells
ppe
r to e uddin
nd fr
mented. 26. Which of th
e followin
conditions m
y produce spherocytes in
peripher
l sme
r? A. PelerHut
nom
ly B.
Pernicious

nemi
C. Autoimmune hemolytic
nemi
D. Sidero l
stic
nemi
Hem
toloy/Ev
lu
t
e l
or
tory d
t

to reconize he
lth
nd dise
se st
tes/Morpholoy/2 27. A p
tients peripher
l sme

r reve
ls
numerous NRBCs, m
rked v
ri
tion of red cell morpholoy,
nd pronounced polychro
m
si
. In

ddition to
decre
sed H
nd decre
sed Hct v
lues, wh
t other CBC p
r
meters
m
y e

nticip
ted? A. Reduced pl
telets B. Incre
sed MCHC C. Incre
sed MCV D. Decre
se
d red-cell
distri ution width (RDW) Hem
toloy/Correl
te l
d
t
with clinic
l picture/ Co
mplete lood
counts/3 28. Wh
t red cell inclusion m
y e seen in the peripher
l lood sme
r o
f
p
tient
postsplenectomy? A. Toxic r
nul
tion B. HowellJolly odies C. M
l
ri
l p
r
sites
D. Siderotic
r
nules Hem
toloy/Correl
te clinic
l l
or
tory d
t
/ Inclusions/1 29. Reticul
ocytosis usu
lly
indic
tes: A. Response to in
mm
tion B. Neopl
stic process C. Apl
stic
nemi
D.
Red cell
reener
tion Hem
toloy/Correl
te l
or
tory d
t
for clinic
l conditions/Morpho
loy/2 30.
Heredit
ry pyropoikilocytosis (HP) is
red cell mem r
ne defect ch
r
cterized
y: A. Incre
sed
pencil-sh
ped cells B. Incre
sed ov
l m
crocytes C. Missh
pen uddin fr
mented
cells D. Bite
cells Hem
toloy/Ev
lu
te l
or
tory d
t
to reconize he
lth
nd dise
se st
tes
/Red cell
mem r
ne/2 2828_Ch01_001-040 09/08/12 4:10 PM P
e 13 1. Te osmotic fr
ility
test result in

p
tient with th
l
ssemi
m
jor would most likely e: A. Incre
sed B. Decre
sed C
. Norm
l D.
Decre
sed
fter incu
tion
t 37C Hem
toloy/Correl
te clinic
l
nd l
or
tory d

t
/ Microscopic
morpholoy/Osmotic fr
ility/1 2. All of the followin
re ch
r
cteristic ndins
in
p
tient
with iron de ciency
nemi
except: A. Microcytic, hypochromic red cell morpholoy
B. Decre
sed
serum iron
nd ferritin levels C. Decre
sed tot
l iron- indin c
p
city (TIBC) D
. Incre
sed RBC
protoporphyrin Hem
toloy/Correl
te clinic
l
nd l
or
tory d
t
/ Anemi
/Iron de c
iency/2 3. Iron
de ciency
nemi
m
y e distinuished from
nemi
of chronic infection y: A. Seru
m iron level B.
Red cell morpholoy C. Red cell indices D. Tot
l iron- indin c
p
city Hem
tolo
y/Ev
lu
te
l
or
tory d
t
to reconize he
lth
nd dise
se st
tes/Anemi
/3 4. Which
nemi

h
s red cell
morpholoy simil
r to th
t seen in iron de ciency
nemi
? A. Sickle cell
nemi
B.
T
l
ssemi

syndrome C. Pernicious
nemi
D. Heredit
ry spherocytosis Hem
toloy/Correl
te l

or
tory d
t

with other l
or
tory d
t
to
ssess test results/Anemi
/RBC microscopic morphol
oy/2 5. Iron
de ciency
nemi
is ch
r
cterized y: A. Decre
sed pl
sm
iron, decre
sed % s
tur

tion, incre
sed
tot
l iron- indin c
p
city (TIBC) B. Decre
sed pl
sm
iron, decre
sed pl
sm
fe
rritin, norm
l
RBC porphyrin C. Decre
sed pl
sm
iron, decre
sed % s
tur
tion, decre
sed TIBC D
. Decre
sed
pl
sm
iron, incre
sed % s
tur
tion, decre
sed TIBC Hem
toloy/Ev
lu
te l
or
to
ry d
t
to
reconize he
lth
nd dise
se st
tes/Anemi
/Iron de ciency/2 1.3 Hypochromic
nd Mi
crocytic
Anemi
s 14 Answers to Questions 16 1. B The osmotic fr
ility is decre
sed ec
us
e numerous
t
ret cells
re present
nd h
ve incre
sed surf
ce volume in th
l
ssemi
m
jor
p
tients. 2. C In
iron de ciency
nemi
(IDA), there is
n incre
se in TIBC
nd in RBC protoporphyri
n. The serum
iron
nd ferritin levels
re decre
sed. IDA is ch
r
cterized y
microcytic hyp
ochromic
nemi
.
3. D In iron de ciency
nemi
, the serum iron
nd ferritin levels
re decre
sed
n
d the tot
l
iron- indin c
p
city
nd RBC protoporphyrin
re incre
sed. In chronic dise
se,
serum iron
nd
TIBC
re oth decre
sed ec
use the iron is tr
pped in reticuloendotheli
l (RE)
cells,
nd is
un
v
il
le to the red cells for hemolo in production. 4. B Iron de ciency
nemi


nd
th
l
ssemi

re oth cl
ssi ed
s microcytic, hypochromic
nemi
s. Iron de ciency
n
emi
is
c
used y defective heme synthesis; where
s th
l
ssemi
is c
used y decre
sed 
lo in ch
in
synthesis. 5. A Iron de ciency
nemi
is ch
r
cterized y decre
sed pl
sm
iron, i
ncre
sed TIBC,
decre
sed % s
tur
tion,
nd microcytic, hypochromic
nemi
. Iron de ciency occurs
in three
ph
ses: iron depletion, iron-de cient erythropoiesis,
nd iron de ciency
nemi
. 6.
D Ferritin
enters the serum from
ll ferritin-producin tissues,
nd therefore is considere
d to e
ood
indic
tor of ody stor
e iron. Bec
use iron stores must e depleted efore
nem
i
develops, low
serum ferritin levels precede the f
ll in serum iron
ssoci
ted with iron de cienc
y
nemi
. 6.
Stor
e iron is usu
lly est determined y: A. Serum tr
nsferrin levels B. H v

lues C.
Myolo in v
lues D. Serum ferritin levels Hem
toloy/Apply knowlede of
sic l

or
tory
procedures/Iron/1 2828_Ch01_001-040 09/08/12 4:10 PM P
e 14 1.3 | Hypochromi
c
nd Microcytic
Anemi
s 15 7. All of the followin
re
ssoci
ted with sidero l
stic
nemi
ex
cept: A.
Incre
sed serum iron B. Rined sidero l
sts C. Dimorphic lood picture D. Incre

sed RBC
protoporphyrin Hem
toloy/Ev
lu
te l
or
tory d
t
to reconize he
lth
nd dise

se
st
tes/Anemi
/Sidero l
stic/3 8. Wh
t is the
sic hem
toloic
l defect seen in
p
tients with

th
l
ssemi
m
jor? A. DNA synthetic defect B. H structure C. -Ch
in synthesis D

. H
phosphoryl
tion Hem
toloy/Apply knowlede of fund
ment
l ioloic
l
ch
r
cteristics/Hemolo inop
thy/1 9. Which of the followin is the prim
ry H
in p
tients with
th
l
ssemi
m
jor? A. H D B. H A C. H C D. H F Hem
toloy/Correl
te clin
ic
l
nd
l
or
tory dise
ses/ Hemolo in/Hemolo inop
thy/2 10. A p
tient h
s
n Hct of 3
0%,
hemolo in
of 8 /dL,
nd
n RBC count of 4.0 10 12
/
L. Wh
t
is the morpholoic
l cl
ssi c
tion of this
nemi
? A. Normocytic normochro
mic B. M
crocytic
hypochromic C. Microcytic hypochromic D. Normocytic hyperchromic Hem
toloy/Ev
l
u
te l
or
tory
d
t
to reconize he
lth
nd dise
se st
tes/Hemolo inop
thy/ Ch
r
cteristics/3
11. In which of
the followin conditions is H A 2 elev
ted? A. H H B. H SC dise
se C. -T
l

ssemi
minor D.
H S tr
it Hem
toloy/Correl
te l
or
tory results with dise
se st
tes/2 12. Wh
ich of the
followin p
r
meters m
y e simil
r for the
nemi
of in
mm
tion
nd iron de ciency

nemi
? A.
Normocytic indices B. Decre
sed serum iron concentr
tion C. Rined sidero l
sts
D. P
ppenheimer
odies Hem
toloy/Correl
te l
or
tory d
t
to reconize he
lth
nd dise
se st
t
es/2 Answers to
Questions 712 7. D Sidero l
stic
nemi
h
s
decre
sed red cell protoporphyrin.
The defect in
sidero l
stic
nemi
involves ine ective erythropoiesis. The f
ilure to produce RB
C
protoporphyrin occurs ec
use the nonheme iron is tr
pped in the mitochondri

n
d is un
v
il
le
to e recycled. 8. C In th
l
ssemi
m
jor, there is little or no production of t
he -ch
in,
resultin in severely depressed or no synthesis of H A. Severe
nemi
is seen,

lon with
skelet
l
norm
lities
nd m
rked splenome
ly. The p
tient is usu
lly supported
with tr
nsfusion
ther
py. 9. D P
tients with th
l
ssemi
m
jor
re un
le to synthesize the -ch
in
; hence, little
or no H A is produced. However, -ch
ins continue to e synthesized
nd le
d to
v
ri
le
elev
tions of H F in these p
tients. 10. C The indices will provide
morpholo
ic
l
cl
ssific
tion of this
nemi
. The MCV is 75 fL (reference r
ne 80100 fL), the M
CH is 20.0 p
(reference r
ne 2731 p),
nd the MCHC is 26.6% (reference r
ne 32%36%). Therefo
re, the

nemi
is microcytic hypochromic. 11. C H A 2 is p
rt of the norm
l complement
of
dult H .
This H is elev
ted in -th
l
ssemi
minor ec
use the individu
l with this condi
tion h
s only
one norm
l -ene; consequently, there is
sliht elev
tion of H A 2
nd H F.
12. B Thirty
to fty percent of the individu
ls with the
nemi
of chronic in
mm
tion demonstr
t
e

microcytic hypochromic lood picture with decre
sed serum iron. Serum iron is de
cre
sed ec
use
it is un
le to esc
pe from the RE cells to e delivered to the nucle
ted red ce

lls in the one

m
rrow. 2828_Ch01_001-040 09/08/12 4:10 PM P
e 15 Answers to Questions 15 1.
D Me
lo l
stic
m
crocytic
nemi
is normochromic ec
use there is no defect in the H synthesi
s. These
nemi
s
comprise
roup of
synchronized
nemi
s ch
r
cterized y defective nucle
r m
t
ur
tion due to
defective deoxyri onucleic
cid (DNA) synthesis. This
norm
lity
ccounts for t
he me
lo l
stic
fe
tures in the one m
rrow
nd the m
crocytosis in the peripher
l lood. 2. D P
ernicious
nemi

is c
used y
l
ck of intrinsic f
ctor, which prevents vit
min B 12
sorption.
3. B
Me
lo l
stic
nemi
s
re
ssoci
ted with
n ine ective erythropoiesis
nd therefo
re
decre
se
in the reticulocyte count. 4. B Administr
tion of folic
cid to
p
tient with v
it
min B 12
de ciency will improve the hem
toloic
l
norm
lities; however, the neuroloic
l
pro lems will
continue. This helps to con rm the correct di
nosis of vit
min B 12 de ciency. 5. D
Ine ective
erythropoiesis is c
used y destruction of erythroid precursor cells prior to th
eir rele
se from
the one m
rrow. Pernicious
nemi
results from defective DNA synthesis; it is s
uested th
t the

synchronous development of red cells renders them more li
le to intr
medull
ry
destruction. 16
1.4 M
crocytic
nd Normochromic Anemi
s 1. Which morpholoic
l cl
ssi c
tion is ch

r
cteristic of
me
lo l
stic
nemi
? A. Normocytic, normochromic B. Microcytic, normochromic C.
M
crocytic,
hypochromic D. M
crocytic, normochromic Hem
toloy/Correl
te clinic
l
nd l
or

tory
d
t
/Microscopic morpholoy/RBCs/2 2. Which
nemi
is ch
r
cterized y
l
ck of
intrinsic f
ctor
th
t prevents B 12
sorption? A. Tropic
l sprue B. Tr
nsco
l
min de ciency C. Bl
ind loop
syndrome D. Pernicious
nemi
Hem
toloy/Ev
lu
te l
or
tory d
t
to reconize h
e
lth
nd dise
se
st
tes/2 3. All of the followin
re ch
r
cteristics of me
lo l
stic
nemi
exc
ept: A.
P
ncytopeni
B. Elev
ted reticulocyte count C. Hypersemented neutrophils D. M
c
rocytic
erythrocyte indices Hem
toloy/Correl
te clinic
l
nd l
or
tory d
t
/ Anemi
/Me

lo l
stic/2 4.
A p
tient with
vit
min B 12
nemi
is iven
hih dos
e of fol
te. Which of
the followin is
expected
s
result of this tre
tment? A. An improvement in neuroloic
l pro le
ms B. An
improvement in hem
toloic
l
norm
lities C. No expected improvement D. Toxicit
y of the liver

nd kidneys Hem
toloy/Select course of
ction/Anemi
/Ter
py/3 5. Which of the f
ollowin
disorders is
ssoci
ted with ine ective erythropoiesis? A. G6PD de ciency B. Liver d
ise
se C. H
C dise
se D. Me
lo l
stic
nemi
Hem
toloy/Ev
lu
te l
or
tory d
t
to reconi
ze he
lth
nd
dise
se st
tes/RBC physioloy/2 2828_Ch01_001-040 09/08/12 4:10 PM P
e 16 6.
A 50-ye
r-old
p
tient is su erin from pernicious
nemi
. Which of the followin l
or
tory d
t


re most
likely for this p
tient? A. RBC = 2.5 10 12
/
L; WBC =12,500/L (12.5
10 9
/
L); PLT = 250,000/L (250 10
9
/
L)
B. RBC = 4.5 10 12
/
L; WBC = 6,500/L (6.5
10 9
/
L); PLT = 150,000/L (150 10
9
/
L)
C. RBC = 3.0 10 12
/
L; WBC = 5,000/L (5.0
10 9
/
L); PLT = 750,000/L (750 10
9
/
L)
D. RBC = 2.5 10 12
/
L; WBC = 2,500/L (2.5
10 9
/
L); PLT = 50,000/L (50 10
9
/
L)
Hem
toloy/Correl
te clinic
l
nd l
or
tory d
t
/ Anemi
s/2 7. Which of
the followin m
y e
seen in the peripher
l lood sme
r of
p
tient with o structive liver dise
se?
A. Schistocytes
B. M
crocytes C. HowellJolly odies D. Microcytes Hem
toloy/Apply principles of

sic
l
or
tory procedures/Microscopic morpholoy/2 8. Te m
crocytes typic
lly seen i
n me
lo l
stic
processes
re: A. Crescent-sh
ped B. Te
rdrop-sh
ped C. Ov
locytic D. Pencil-sh

ped
Hem
toloy/Apply principles of
sic l
or
tory procedures/Microscopic morpholo
y/Di erenti
ls/2
9. Which of the followin
re most ch
r
cteristic of the red cell indices
ssoci

ted with
me
lo l
stic
nemi
s? A. MCV 99 , MCH 28 p, MCHC 31% B. MCV 62 fL, MCH 27 p, M
CHC 30% C. MCV
125 fL, MCH 36 p, MCHC 34% D. MCV 78 fL, MCH 23 p, MCHC 30% Hem
toloy/Correl

te clinic
l
nd
l
or
tory d
t
/ Me
lo l
stic
nemi
/2 10. A p
tient h
s 80 nucle
ted red lood
cells per 100
leukocytes. In
ddition to incre
sed polychrom
si
on the peripher
l sme
r, wh
t
other ndin m
y
e present on the CBC? A. Incre
sed pl
telets B. Incre
sed MCV C. Incre
sed Hct
D. Incre
sed red
lood cell count Hem
toloy/Correl
te clinic
l
nd l
or
tory d
t
/ Me
lo l
sti
c
nemi
/2 1.4 |
M
crocytic
nd Normochromic Anemi
s 17 Answers to Questions 610 6. D P
tients w
ith pernicious

nemi
demonstr
te
p
ncytopeni
with low WBC, PLT,
nd RBC counts. Bec
use thi
s is

me
lo l
stic process
nd
DNA m
tur
tion defect,
ll cell lines
re
ected. In
the one
m
rrow, this results in
norm
lly l
re precursor cells, m
tur
tion
synchrony,
hyperpl
si
of

ll cell lines,
nd
low M:E r
tio. 7. B P
tients with o structive liver dise
s

e m
y h
ve red

lood cells th
t h
ve
n incre
sed tendency tow
rd the deposition of lipid on th
e surf
ce of the
red cell. Consequently, the red cells
re l
rer or more m
crocytic th
n norm
l
red cells. 8. C
M
crocytes in true me
lo l
stic conditions
re ov
l m
crocytes
s opposed to th
e round
m
crocytes th
t
re usu
lly seen in
lcoholism
nd o structive liver dise
se. 9.
C The red cell
indices in
p
tient with me
lo l
stic
nemi

re m
crocytic
nd normochromic.
The m
crocytosis
is prominent, with
n MCV r
nin from 100 to 130 fL. 10. B The p
tient will h
v
e
n incre
sed
MCV. One of the c
uses of
m
crocytic
nemi
th
t is not me
lo l
stic is
n in
cre
sed
reticulocyte count, here noted
s incre
sed polychrom
si
. Reticulocytes
re pol
ychrom
tic
m
crocytes; therefore, the MCV is slihtly incre
sed. 2828_Ch01_001-040 09/08/1
2 4:10 PM P
e
17 18 1.5 Qu
lit
tive
nd Qu
ntit
tive White Blood Cell Disorders 1. Which of th
e followin is
n
unusu
l complic
tion th
t m
y occur in infectious mononucleosis? A. Splenic inf

rctions B.
D
ctylitis C. Hemolytic
nemi
D. Gi
nt pl
telets Hem
toloy/Ev
lu
te l
or
tory
d
t
to
reconize he
lth
nd dise
se st
tes/Infectious mononucleosis/2 2. In
p
tient w
ith hum
n
immunode ciency virus (HIV) infection, one should expect to see: A. Shift to the l
eft in WBCs B.
T
ret cells C. Re
ctive lymphocytes D. Peleroid cells Hem
toloy/Ev
lu
te l
o
r
tory d
t
to
reconize he
lth
nd dise
se st
tes/AIDS/Microscopic morpholoy/1 3. Which inclu
sions m
y e seen
in leukocytes? A. Dhle odies B. B
sophilic stipplin C. M
l
ri
l p
r
sites D. Ho
wellJolly
odies Hem
toloy/Apply knowlede of fund
ment
l ch
r
cteristics/WBC inclusions/
1 4. Which of the
followin is cont
ined in the prim
ry r
nules of the neutrophil? A. L
ctoferrin
B.
Myeloperoxid
se C. Hist
mine D. Alk
line phosph
t
se Hem
toloy/Apply knowlede
of fund
ment
l
ioloic
l ch
r
cteristics/WBC kinetics/2 5. Wh
t is the typic
l r
ne of rel
ti
ve lymphocyte
percent
e in the peripher
l lood sme
r of
1-ye
r-old child? A. 1%6% B. 27%33%
C. 35%58% D.
50%70% Hem
toloy/Ev
lu
te l
or
tory d
t
to reconize he
lth
nd dise
se st
tes
/Di erenti
l
norm
l v
lues/2 Answers to Questions 15 1. C Occ
sion
lly p
tients with infectiou
s mononucleosis
develop
potent cold
lutinin with
nti-I speci city. This cold
uto
nti ody c

n c
use stron
hemolysis
nd
hemolytic
nemi
. 2. C HIV infection rins
out sever
l hem
to
loic
l

norm
lities seen on peripher
l sme
r ex
min
tion; most p
tients demonstr
te re

ctive
lymphocytes
nd h
ve r
nulocytopeni
. 3. A Dhle odies
re RNA-rich
re
s within
polymorphonucle
r neutrophils (PMNs) th
t
re ov
l
nd liht lue in color. Alth
ouh often

ssoci
ted with infectious st
tes, they
re seen in
wide r
ne of conditions

nd toxic

re
ctions, includin hemolytic
nd pernicious
nemi
s, chronic r
nulocytic leuk

emi
,
nd ther
py
with
ntineopl
stic drus. The other inclusions
re
ssoci
ted with erythrocytes
. 4. B
Myeloperoxid
se, lysozyme,
nd
cid phosph
t
se
re enzymes th
t
re cont
ined i
n the prim
ry
r
nules of neutrophils. The contents of second
ry
nd terti
ry r
nules include
l
ctoferrin,
coll
en
se, NADPH oxid
se,
nd
lk
line phosph
t
se. 5. D The me
n rel
tive lym
phocyte
percent
e for
1-ye
r-old child is 61% comp
red to the me
n lymphocyte percent

e of 35% for
n

dult. 2828_Ch01_001-040 09/08/12 4:10 PM P
e 18 6. Qu
lit
tive
nd qu
ntit

tive neutrophil
ch
nes noted in response to infection include
ll of the followin except: A. N
eutrophili
B.
Peleroid hyposement
tion C. Toxic r
nul
tion D. V
cuoliz
tion Hem
toloy/Appl
y knowlede of
fund
ment
l ioloic
l ch
r
cteristics/WBC microscopic morpholoy/2 7. Neutropen
i
is present in
p
tients with which
solute neutrophil counts? A. <1.5 10 9
/L
B. <5.0 10 9
/L
C. <10.0 10 9
/L
D. <15.0 10 9
/L
Hem
toloy/Ev
lu
te l
or
tory d
t
to reconize he
lth
nd dise
se st
t
es/Di erenti
l norm
l
v
lues/2 8. Te morpholoic
l ch
r
cteristic(s)
ssoci
ted with the Chdi
kHi
shi s
yndrome is
(
re): A. P
le lue cytopl
smic inclusions B. Gi
nt lysosom
l r
nules C. Sm
ll,
d
rk-st
inin
r
nules
nd condensed nuclei D. Nucle
r hyposement
tion Hem
toloy/Reconize m
orpholoic
l
ch
nes
ssoci
ted with dise
ses/WBC inclusions/2 9. Te f
mili
l condition of Pe
lerHut
nom
ly
is import
nt to reconize ec
use this disorder must e di erenti
ted from: A. Inf
ectious
mononucleosis B. M
yHelin
nom
ly C. A shift-to-the-left incre
se in imm
ture 
r
nulocytes D.
G6PD de ciency Hem
toloy/Reconize morpholoic
l ch
nes
ssoci
ted with dise
ses
/WBC
inclusions/2 10. SITUATION: A di erenti
l shows re
ctive lymphocytes,
nd the phys
ici
n suspects

vir
l infection is the c
use. Wh
t is the expected l
or
tory ndin in
p
tien
t with

cytome
lovirus (CMV) infection? A. Heterophile
nti ody: positive B. EpsteinB
rr
virus
(EBV)immunolo ulin (IM): positive C. Direct
ntilo ulin test (DAT): positive D
. CMVIM:
positive Hem
toloy/Ev
lu
te l
or
tory d
t
to reconize he
lth
nd dise
se
st
tes/Di erenti
ls/2 1.5 | Qu
lit
tive
nd Qu
ntit
tive White Blood Cell Disorder
s 19 Answers
to Questions 610 6. B Neutrophil ch
nes
ssoci
ted with infection m
y include ne
utrophili
,
shift to the left, toxic r
nul
tion, Dhle odies,
nd v
cuoliz
tion. Peleroid h
yposement
tion
is noted in neutrophils from individu
ls with the conenit
l PelerHut
nom
ly
nd


s
n

cquired
nom
ly induced y dru inestion or second
ry to conditions such
s le
ukemi
. 7. A
Neutropeni
is de ned
s
n
solute decre
se in the num er of circul
tin neutrop
hils. This
condition is present in p
tients h
vin neutrophil counts of less th
n 1.5 10 9
/
L.
8. B Chdi
kHi
shi syndrome is
disorder of neutrophil ph
ocytic dysfunc
tion c
used y
depressed chemot
xis
nd del
yed der
nul
tion. The der
nul
tion distur
nce is

ttri uted to
interference from the i
nt lysosom
l r
nules ch
r
cteristic of this disorder.
9. C PelerHut

nom
ly is
enin f
mili
l condition reported in 1 out of 6,000 individu
ls. C

re must e t
ken
to di erenti
te PelerHut cells from the numerous
nd neutrophils
nd met
myelocyte
s th
t m
y
e o served durin severe infection or
shift-to-the-left of imm
turity in r
n
ulocyte st
es.
10. D If oth the heterophile
nti ody test
nd the EBV-IM tests
re ne
tive i
n
p
tient with
re
ctive lymphocytosis
nd
suspected vir
l infection, the serum should e
n
l
yzed for IM

nti odies to CMV. CMV elons to the herpes virus f
mily
nd is endemic worldwi
de. CMV infection
is the most common c
use of heterophile-ne
tive infectious mononucleosis. 2828_
Ch01_001-040
09/08/12 4:10 PM P
e 19 11. Neutrophil ph
ocytosis
nd p
rticle inestion
r
e
ssoci
ted with

n incre
se in oxyen utiliz
tion c
lled respir
tory urst. Wh
t
re the two mos
t import
nt
products of this iochemic
l re
ction? A. Hydroen peroxide
nd superoxide
nion
B. L
ctoferrin

nd NADPH oxid
se C. Cytochrome

nd coll
en
se D. Alk
line phosph
t
se
nd
s
cor ic
cid
Hem
toloy/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics/WBC kinetic
s/3 12. Which of
the morpholoic
l ndins
re ch
r
cteristic of re
ctive lymphocytes? A. Hih nucl
e
r:cytopl
smic
r
tio B. Prominent nucleoli C. B
sophilic cytopl
sm D. All of these options Hem

toloy/Reconize
morpholoic
l ch
nes
ssoci
ted with dise
ses/WBC morpholoy/2 20 Ch
pter 1 | H
em
toloy Answers
to Questions 1112 11. A The iochemic
l products of the respir
tory urst th
t
r
e involved with
neutrophil p
rticle inestion durin ph
ocytosis
re hydroen peroxide
nd supe
roxide
nion. The

ctiv
ted neutrophil disch
res the enzyme NADPH oxid
se into the ph
olysosome,
where it
converts O 2 to superoxide
nion (O 2 ), which is then reduced to hydroen perox
ide (H 2 O 2 ).
12. D Both re
ctive lymphocytes
nd l
sts m
y h
ve
sophilic cytopl
sm,
hih
N:C r
tio,
nd
the presence of prominent nucleoli. Bl
sts, however, h
ve
n extremely ne nucle
r
chrom
tin
st
inin p
ttern
s viewed on
WrihtsGiems
sst
ined sme
r. 2828_Ch01_001-040 09/0
8/12
4:10 PM P
e 20 1. Auer rods m
y e seen in
ll of the followin except: A. Acu
te myelomonocytic
leukemi
(M4) B. Acute lympho l
stic leukemi
C. Acute myeloid leukemi
without

m
tur
tion (M1)
D. Acute promyelocytic leukemi
(M3) Hem
toloy/Apply knowlede of fund
ment
l
ioloic
l
ch
r
cteristics/Acute leukemi
/1 2. Which type of
nemi
is usu
lly present in

p
tient with

cute leukemi
? A. Microcytic, hyperchromic B. Microcytic, hypochromic C. Normoc
ytic,
normochromic D. M
crocytic, normochromic Hem
toloy/Correl
te clinic
l
nd l
or

tory d
t
/RBC
microscopic morpholoy/Anemi
/2 3. In leukemi
, which term descri es
peripher

l lood ndin of
leukocytosis with
shift to the left,
ccomp
nied y nucle
ted red cells? A. My
elophthisis B.
Dyspl
si
C. Leukoerythro l
stosis D. Me
lo l
stosis Hem
toloy/Apply knowlede
of fund
ment
l
ioloic
l ch
r
cteristics/WBC di erenti
ls/2 4. Te
sic p
thophysioloic
l mech

nisms
responsi le for producin sins
nd symptoms in leukemi
include
ll of the foll
owin except: A.
Repl
cement of norm
l m
rrow precursors y leukemic cells c
usin
nemi
B. Decr
e
se in
function
l leukocytes c
usin infection C. Hemorrh
e second
ry to throm ocytope
ni
D. Decre
sed
erythropoietin production Hem
toloy/Correl
te clinic
l
nd l
or
tory d
t
/ Leu
kemi
/2 1.6 Acute
Leukemi
s 21 Answers to Questions 14 1. B Auer rods
re not seen ch
r
cteristic
l
ly in
lympho l
sts. They m
y e seen in myelo l
sts, promyelocytes,
nd mono l
sts. 2.
C Acute leukemi

is usu
lly
ssoci
ted with
normocytic normochromic
nemi
. Anemi
in
cute leu
kemi
is usu
lly
present from the onset
nd m
y e severe; however, there is no inherent nutritio
n
l de ciency
le
din to either
microcytic, hypochromic, or me
lo l
stic process. 3. C The
presence of
imm
ture leukocytes
nd nucle
ted red cells is c
lled leukoerythro l
stosis
nd
frequently
denotes
m
lin
nt or myeloprolifer
tive process. Myelophthisis refers to repl

cement of one
m
rrow y
dise
se process such
s
neopl
sm. The development of
norm
l tiss
ue is c
lled
dyspl
si
. 4. D A norm
l physioloic
l response to
nemi
would e
n incre
se i
n the kidneys
production of erythropoietin. The
ccumul
tion of leukemic cells in the one m
r
row le
ds to
m
rrow f
ilure, which is m
nifested y
nemi
, throm ocytopeni
,
nd r
nulocyto
peni
.
2828_Ch01_001-040 09/08/12 4:10 PM P
e 21 Answers to Questions 59 5. D Acute
monocytic
leukemi
h
s
n incidence of etween 1%8% of
ll
cute leukemi
s. It h
s
distin
ctive clinic
l
m
nifest
tion of monocytic involvement resultin in skin
nd um hyperpl
si
. Th
e WBC count is
m
rkedly elev
ted,
nd pronosis is poor. 6. A Acute lympho l
stic leukemi
(ALL
) usu
lly
ects
children from
es 115
nd is the most common type of
cute leukemi
in this
e
roup. In

ddition, ALL constitutes the sinle most prev
lent m
lin
ncy in pedi
tric p
ti
ents. 7. B The

zurophilic r
nules in the leukemic promyelocytes in p
tients with
cute promye

locytic leukemi

cont
in throm opl
stic su st
nces. These
ctiv
te solu le co
ul
tion f
ctors, w
hich when
rele
sed into the lood, c
use DIC. 8. B A disproportion
te incre
se in the myel
oid component of
the one m
rrow is usu
lly the result of
leukemic st
te. The norm
l M:E r
tio
is
pproxim
tely
4:1 in
dults with norm
l cellul
rity. 9. A Auer rods
re
line
r projection of
prim
ry

zurophilic r
nules,
nd
re present in the cytopl
sm of myelo l
sts
nd mono l

sts in p
tients
with
cute leukemi
. 22 Ch
pter 1 | Hem
toloy 5. Which type of
cute myeloid le
ukemi
is c
lled
the true monocytic leukemi

nd follows
n
cute or su
cute course ch
r
cterize
d y mono l
sts,
promonocytes,
nd monocytes? A. Acute myeloid leukemi
, minim
lly di erenti
ted B.
Acute myeloid
leukemi
without m
tur
tion C. Acute myelomonocytic leukemi
D. Acute monocytic
leukemi

Hem
toloy/Ev
lu
te l
or
tory d
t
to m
ke identi c
tions/Leukemi
/2 6. In which

e roup does

cute lympho l
stic leukemi
occur with the hihest frequency? A. 115 ye
rs B. 203
5 ye
rs C.
4560 ye
rs D. 6075 ye
rs Hem
toloy/Correl
te clinic
l
nd l
or
tory d
t
/ Leukem
i
/1 7.
Dissemin
ted intr
v
scul
r co
ul
tion (DIC) is most often
ssoci
ted with which
of the followin
types of
cute leukemi
? A. Acute myeloid leukemi
without m
tur
tion B. Acute p
romyelocytic
leukemi
C. Acute myelomonocytic leukemi
D. Acute monocytic leukemi
Hem
toloy
/Ev
lu
te
l
or
tory d
t
to reconize he
lth
nd dise
se st
tes/Leukemi
/DIC/2 8. An M:E
r
tio of 10:1 is
most often seen in: A. T
l
ssemi
B. Leukemi
C. Polycythemi
ver
D. Myelo rosis
Hem
toloy/Ev
lu
te l
or
tory d
t
to reconize he
lth
nd dise
se st
tes/Bone
m
rrow/M:E/2 9.
Which of the followin is
ch
r
cteristic of Auer rods? A. Tey
re composed of

zurophilic
r
nules B. Tey st
in periodic
cidSchi (PAS) positive C. Tey
re predomin
ntly se
en in chronic
myeloenous leukemi
(CML) D. Tey
re nonspeci c ester
se positive Hem
toloy/Appl
y knowlede of
fund
ment
l ioloic
l ch
r
cteristics/Leukocytes/Auer rods/1 2828_Ch01_001-040
09/08/12 4:10
PM P
e 22 1.6 | Acute Leukemi
s 23 Answers to Questions 1014 10. C In
cute e
rythroid
leukemi
, more th
n 50% of nucle
ted one m
rrow cells
re erythroid
nd more th

n 30%
nonerythroid cells
re l
sts. Pernicious
nemi
results in p
ncytopeni

nd low
vit
min B 12
concentr
tions. 11. D Common sins of
cute lymphocytic leukemi

re hep
tosplen
ome
ly (65%),
lymph
denop
thy (50%),
nd fever (60%). Anemi

nd throm ocytopeni

re usu
lly
present
nd the
WBC count is v
ri
le. The numerous lympho l
sts
re ener
lly PAS positive. 12.
A AML l
sts
st
in positive for Sud
n Bl
ck B
nd peroxid
se. Usu
lly, fewer th
n 10% l
sts

re found in the
peripher
l sme
r of p
tients with CML, unless there h
s een
tr
nsition to l

st crisis. The

or
nelles in the cells of AUL
re not m
ture enouh to st
in positive for SBB o
r peroxid
se.
Bl
sts in ALL
re ch
r
cteristic
lly ne
tive with these st
ins. 13. C Phospholi
pids, neutr
l
f
ts,
nd sterols
re st
ined y Sud
n Bl
ck B. The PAS re
ction st
ins intr
cel
lul
r lycoen.
Myeloperoxid
se is
n enzyme present in the prim
ry r
nules of myeloid cells
n
d to
lesser
deree in monocytic cells. Termin
l deoxynucleotidyl tr
nsfer
se is
DNA polyme
r
se found in
thymus- derived
nd some one m
rrow-derived lymphocytes. 14. B NASDA st
ins mon
ocytes (
nd
mono l
sts)
nd r
nulocytes (
nd myelo l
sts). The
ddition of uoride renders th
e monocytic
cells (
nd l
sts) ne
tive, thus
llowin for di erenti
tion from the r
nulocyti
c cells, which
rem
in positive. WBC Differenti
l Bone M
rrow 6% PMNs 40% myelo l
sts 40% lymph
ocytes 60%
prome
lo l
sts 4% monocytes 40 me
lo l
stoid NRBCs/100 WBCs 50% l
sts 10. SIT
UATION: Te
followin l
or
tory v
lues
re seen: WBCs = 6.0 10 9
/
L H = 6.0 /dL
RBCs = 1.90 10 12
/
L Hct = 18.5%
Pl
telets = 130 10 9
/L
Serum vit
min B 12
nd folic
cid: norm
l Tese results
re most ch
r
cte
ristic of: A.
Pernicious
nemi
B. Acute myeloid leukemi
without m
tur
tion C. Acute erythroi
d leukemi
D.
Acute myelomonocytic leukemi
Hem
toloy/Ev
lu
te l
or
tory d
t
to m
ke
identi c
tions/Leukemi
/3 11. A 24-ye
r-old m
n with Down syndrome presents with

fever, p
llor,
lymph
denop
thy,
nd hep
tosplenome
ly. His CBC results
re
s follows: WBCs =
10.8 10 9
/
L RBCs = 1.56 10
12
/L
8% PMNs H = 3.3 /dL 25% lymphocytes Hct = 11% 67% PAS-positive l
sts
Pl
telets = 2.5 10
9
/L
Tese ndins
re suestive of: A. Hodkins lymphom
B. Myeloprolifer
tive
disorder C.
Leukemoid re
ction D. Acute lymphocytic leukemi
Hem
toloy/Ev
lu
te l
or
tory
d
t
to reconize
he
lth
nd dise
se st
tes/Leukemi
/3 12. SITUATION: A peripher
l sme
r shows 75%
l
sts. Tese
st
in positive for oth Sud
n Bl
ck B (SBB)
nd peroxid
se. Given these v
lues,
which of the
followin disorders is most likely? A. Acute myelocytic leukemi
(AML) B. CML C.
Acute
undi erenti
ted leukemi
(AUL) D. Acute lymphocytic leukemi
(ALL) Hem
toloy/Ev
l
u
te l
or
tory
d
t
to reconize he
lth
nd dise
se st
tes/Leukemi
/Cytochemic
l st
ins/3 13. I
n myeloid cells,
the st
in th
t selectively identi es phospholipid in the mem r
nes of oth prim
ry

nd second
ry
r
nules is: A. PAS B. Myeloperoxid
se C. Sud
n Bl
ck B st
in D. Termin
l deoxyn
ucleotidyl

tr
nsfer
se (TdT) Hem
toloy/Apply principles of speci
l procedures/ Leukemi
/Cy

tochemic
l
st
ins/3 14. Sodium uoride m
y e
dded to the n
phthyl ASD
cet
te (NASDA) ester

se re
ction.
Te uoride is
dded to inhi it
positive re
ction with: A. Me
k
ryocytes B. Mono
cytes C.
Erythrocytes D. Gr
nulocytes Hem
toloy/Apply principles of speci
l procedures/
Leukocytes/Cytochemic
l st
ins/2 2828_Ch01_001-040 09/08/12 4:10 PM P
e 23 1
5. Leukemic
lympho l
sts re
ctin with
nti-CALLA
re ch
r
cteristic
lly seen in: A. B-cell
ALL B. T-cell ALL
C. Null-cell ALL D. Common ALL Hem
toloy/Ev
lu
te l
or
tory d
t
to reconize
he
lth
nd
dise
se st
tes/Leukemi
/Immunochemic
l re
ctions/2 16. Which of the followin re

ctions
re often
positive in ALL ut
re ne
tive in AML? A. Termin
l deoxynucleotidyl tr
nsfer
s
e
nd PAS B.
Chloro
cet
te ester
se
nd nonspeci c ester
se C. Sud
n Bl
ck B
nd peroxid
se D.
New methylene
lue
nd
cid phosph
t
se Hem
toloy/Apply principles of speci
l procedures/ Leu
kemi
/Speci
l
tests/2 17. A p
tients peripher
l lood sme
r
nd one m
rrow oth show 70% l
st
s. Tese cells

re ne
tive for Sud
n Bl
ck B st
in. Given these d
t
, which of the followin i
s the most likely
di
nosis? A. Acute myeloid leukemi
B. Chronic lymphocytic leukemi
C. Acute pr
omyelocytic
leukemi
D. Acute lymphocytic leukemi
Hem
toloy/Apply principles of speci
l pr
ocedures/
Leukemi
/Cytochemic
l st
ins/2 18. Which of the followin leukemi
s
re included
in the 2008
World He
lth Or
niz
tion cl
ssi c
tion of myeloprolifer
tive neopl
sms? A. Chroni
c myeloenous
leukemi
(CML) B. Chronic neutrophilic leukemi
(CNL) C. Chronic eosinophilic le
ukemi
(CEL) D.
All of these options
re cl
ssi ed
s myeloprolifer
tive neopl
sms (MPN)
Hem
toloy/Leukemi
s/Apply knowlede of speci
l procedures/Cl
ssi c
tions/2 19. In

ddition to
morpholoy, cytochemistry,
nd immunophenotypin, the WHO cl
ssi c
tion of myelo
nd
lymphoprolifer
tive disorders is
sed upon which ch
r
cteristic? A. Proteomics
B. Cytoenetic

norm
lities C. C
r ohydr
te-
ssoci
ted tumor
ntien production D. Cell sin
l
in
nd
dhesion
m
rkers Hem
toloy/Leukemi
s/Apply knowlede of speci
l procedures/Cl
ssi c
tions/
1 24 Ch
pter 1
| Hem
toloy Answers to Questions 1520 15. D The m
jority of non-T, non-B ALL l

st cells
displ
y the common ALL
ntien (CALLA) m
rker. Lympho l
sts of common ALL
re Td
T positive
nd
CALLA positive ut do not h
ve surf
ce mem r
ne IM or chains and are pre-B lymp
hoblasts.
Common ALL has a lower relapse rate and better prognosis than other immunologic
subtypes of
B-cell ALL. 16. A PAS is positive in about 50% of ALL with L1 and L2 morphology
but is negative
in ALL with L3 morphology (B-cell ALL). Terminal deoxynucleotidyl transferase is
positive in all
types of ALL except L3. Both terminal deoxynucleotidyl transferase and PAS are n
egative in AML.

17. D Sudan Black B stains phospholipids and other neutral fats. It is the most
sensitive stain
for granulocytic precursors. Lymphoid cells rarely stain positive for it. Becaus
e 70%
lymphoblasts would never be seen in CLL, the correct response is ALL. 18. D The
2008 WHO
classification system includes the following disorders under the myeloproliferat
ive neoplasms
(MPN): chronic myelogenous leukemia (CML), chronic neutrophilic leukemia (CNL),
chronic
eosinophilic leukemia (CEL), essential thrombocythemia (ET), polycythemia vera (
PV), primary
(idiopathetic) myelofibrosis, hypereosinophilic syndrome, mast cell disease, and
MPNs
unclassified. 19. B In addition to morphology, cytochemical stains, and ow cytome
try, the WHO
classi cation relies heavily on chromosomal and molecular abnormalities. 20. B The
WHO
classi cation of AML requires that 20% of nucleated bone marrow cells be blasts, wh
ile the FAB
classi cation generally requires 30%. WHO classi es AML into ve subgroups: These are a
cute
myeloid leukemias with recurrent genetic disorders; acute myeloid leukemia with
multilineage
dysplasia; acute myeloid leukemia and myelodysplastic syndromes, therapy related
; acute myeloid
leukemia not otherwise categorized; and acute leukemia of ambiguous lineage. 20.
Te WHO
classi cation requires what percentage for the blast count in the blood or bone ma
rrow for the
diagnosis of AML? A. At least 30% B. At least 20% C. At least 10% D. Any percent
age
Hematology/Apply knowledge of special procedures/ Leukemias/Classi cations/2 2828_
Ch01_001-040
09/08/12 4:10 PM Page 24 21. What would be the most likely designation by the
WHO for the FAB
AML M2 by the FrenchAmericanBritish classi cation? A. AML with t(15;17) B. AML with
mixed
lineage C. AML with t(8;21) D. AML with inv(16) Hematology/Apply knowledge of sp
ecial procedures/
Leukemias/Classi cations/3 22. What would be the most likely designation by the WH
O for the FAB
AML M3 by the FrenchAmericanBritish classi cation? A. AML with t(15;17) B. AML with
mixed
lineage C. AML with t(8;21) D. AML with inv(16) Hematology/Apply knowledge of sp
ecial procedures/
Leukemias/Classi cations/3 23. Which AML cytogenetic abnormality is associated wit
h acute
myelomonocytic leukemia with marrow eosinophilia under the WHO classi cation of AM
L with
recurrent genetic abnormalities? A. AML with t(15;17) B. AML with mixed lineage
C. AML with
t(8;21) D. AML with inv(16) Hematology/Apply knowledge of special procedures/
Leukemias/Classi cations/3 24. What would be the most likely classi cation by the WH
O for the FAB
AML M7 by the FrenchAmericanBritish classi cation? A. Acute myeloid leukemias with r
ecurrent
genetic abnormalities B. Acute myeloid leukemia with multilineage dysplasia C. A
cute myeloid
leukemia not otherwise categorized D. Acute leukemias of ambiguous lineage Hemat

ology/Apply
knowledge of special procedures/ Leukemias/Classi cations/3 1.6 | Acute Leukemias
25 Answers to
Questions 2124 21. C AML with t(8;21) is classi ed under the category of AML with R
ecurrent
Genetic Abnormalities by the WHO. This translocation occurs in up to 15% of case
s of AML and may
be the most common translocation. The AML1ETO translocation occurs chie y in younge
r patients
and often in cases of acute myeloblastic leukemia with maturation, FAB M2. The t
ranslocation
involves the fusion of the AML1 gene on chromosome 21 with the ETO gene on chrom
osome 8. 22. A
AML with t(15;17) is classi ed under the category of AML with Recurrent Genetic Ab
normalities by
the WHO. Acute promyelocytic leukemia (PML; known as M3 under the FAB system) is
composed of
abnormal promyelocytes with heavy granulation, sometimes obscuring the nucleus,
and abundant
cytoplasm. Acute promyelocytic leukemia (APL) contains a translocation that resu
lts in the fusion
of a transcription factor called PML on chromosome 15 with the alpha ()-retinoic

cid receptor
ene (RAR) on chromosome 17. 23. D AML with inv(16) h
s pericentric inversion of
chromosome 16,

nd is
ssoci
ted with
cute myelomonocytic leukemi
with m
rrow eosinophili
, M
4eo under the FAB
system. The inv(16) results in the fusion of the CBF ene on 16q22 with the MYH11
ene on 16p13.
24. C Acute me
k
ryo l
stic leukemi
, which is equiv
lent to FAB M7, is
rel
t
ively uncommon
form of leukemi
ch
r
cterized y neopl
stic prolifer
tion of me
k
ryo l
sts
n
d
typic
l
me
k
ryocytes. Reconition of this entity w
s
ided y the use of pl
telet pero
xid
se (PPO)
ultr
structur
l studies. PPO, which is distinct from myeloperoxid
se, is speci c f
or the
me
k
ryocytic cell line. Acute me
k
ryo l
stic leukemi
is de ned
s
n
cute le
ukemi
in which
re
ter th
n or equ
l to 50% of the l
sts
re of me
k
ryocytic line
e. 2828_C
h01_001-040
09/08/12 4:10 PM P
e 25 Answers to Questions 15 1. C The most common tre
tment
mod
lity
utilized in PV is phle otomy. Reduction of lood volume (usu
lly 1 unit of whole
lood450 cc),
c
n e performed weekly or even twice weekly in youner p
tients to control symp
toms. The Hct
t
ret r
ne is less th
n 45% for men, less th
n 42% for women. Iron de ciency
ne
mi
is

predict
le complic
tion of ther
peutic phle otomy ec
use
pproxim
tely 250 m
of iron is
removed with e
ch unit of lood. 2. A In essenti
l throm ocythemi
, the pl
telet
count is
extremely elev
ted. These pl
telets
re
norm
l in function, le
din to oth l
eedin
nd
throm otic di
thesis. 3. D The morpholoic
l common denomin
tor in Hodkins lymph
om
is the
ReedStern er (RS) cell. It is
l
re, inucle
ted cell with
dense nucleolus s
urrounded y
cle
r sp
ce. These ch
r
cteristics ive the RS cell
n owls eye
ppe
r
nce. Niem
nnP

ick cells
(fo
m cells)
re histiocytes cont
inin ph
ocytized sphinolipids th
t st
in p

le lue
nd
imp
rt
fo
mlike texture to the cytopl
sm. Fl
me cells
re pl
sm
cells with di
stinctive red
cytopl
sm. They
re sometimes seen in the one m
rrow of p
tients with multiple
myelom
. 4. C The
m
rked
mount of rosis, oth medull
ry
nd extr
medull
ry,
ccounts for the irre
versi le red
cell morpholoic
l ch
ne to
te
rdrop sh
pe. The red cells
re te
red
s they
t
tempt to p
ss
throuh the rotic tissue. 5. D The di
nosis of PV requires the demonstr
tion of

n incre
se in
red cell m
ss. P
ncytosis m
y
lso e seen in
out two thirds of PV c
ses. The
pl
sm
volume is
norm
l or slihtly reduced,
nd the
rteri
l oxyen s
tur
tion is usu
lly norm
l
. 1. Repe
ted
phle otomy in p
tients with polycythemi
ver
(PV) m
y le
d to the development o
f: A. Folic
cid
de ciency B. Sidero l
stic
nemi
C. Iron de ciency
nemi
D. Hemolytic
nemi

Hem
toloy/Ev
lu
te l
or
tory d
t
to reconize he
lth
nd dise
se st
tes/Anemi

/2 2. In
essenti
l throm ocythemi
, the pl
telets
re: A. Incre
sed in num er
nd functio
n
lly
norm
l B.
Norm
l in num er
nd function
lly
norm
l C. Decre
sed in num er
nd function
l
D. Decre
sed in
num er
nd function
lly
norm
l Hem
toloy/Ev
lu
te l
or
tory d
t
to reconiz
e he
lth
nd
dise
se st
tes/CBCs/Pl
telets/2 3. Which of the followin cells is considered p

thonomonic for
Hodkins dise
se? A. Niem
nnPick cells B. Re
ctive lymphocytes C. Fl
me cells D. R
eedStern er
cells Hem
toloy/Ev
lu
te l
or
tory d
t
to reconize he
lth
nd dise
se st
tes
/Lymphom
/1 4. In
myelo rosis, the ch
r
cteristic
norm
l red lood cell morpholoy is th
t of: A.
T
ret cells
B. Schistocytes C. Te
rdrop cells D. Ov
locytes Hem
toloy/Correl
te clinic
l
n
d l
or
tory
d
t
/RBC microscopic morpholoy/1 5. PV is ch
r
cterized y: A. Incre
sed pl
sm

volume B.
P
ncytopeni
C. Decre
sed oxyen s
tur
tion D. A solute incre
se in tot
l red ce
ll m
ss
Hem
toloy/Ev
lu
te l
or
tory d
t
to reconize he
lth
nd dise
se st
tes/RBCs/
Leukemi
s/2 1.7
Lymphoprolifer
tive
nd Myeloprolifer
tive Disorders 26 2828_Ch01_001-040 09/08
/12 4:10 PM
P
e 26 Answers to Questions 611 6. A Splenome
ly is
fe
ture of PV ut not ch

r
cteristic of
second
ry polycythemi
. The red cell m
ss is incre
sed in oth prim
ry polycythe
mi
(PV)
nd
second
ry polycythemi
. Erythropoietin is incre
sed
nd oxyen s
tur
tion is dec
re
sed in
second
ry polycythemi
. 7. B Rel
tive polycythemi
is c
used y
reduction of p
l
sm
r
ther th
n

n incre
se in red lood cell volume or m
ss. Red cell m
ss is incre
sed in oth
PV
nd second
ry
polycythemi
, ut erythropoietin levels
re hih only in second
ry polycythemi
.
8. B PV is

myeloprolifer
tive disorder ch
r
cterized y uncontrolled prolifer
tion of eryth
roid precursors.

However, production of
ll cell lines is usu
lly incre
sed. P
nhyperpl
si
is

term used to
descri e the cellul
rity of the one m
rrow in PV. 9. C One hundred m
ture neutr
ophils
re
counted
nd scored. The LAP score is c
lcul
ted
s: (the num er of 1+ cells 1) +
(2+ cells 2)
+ (3+ cells 3) + (4+ cells 4). Th
t is, 48 + 76 + 9 + 4 = 137. The reference r
n
e is

pproxim
tely 20130. 10. A CML c
uses
low LAP score, where
s
n elev
ted or nor
m
l score
occurs in
leukemoid re
ction. CML c
nnot e distinuished y WBC count ec
use
oth CML
nd
leukemoid re
ction h
ve
hih count. 11. D Anemi
,
rosis, myeloid met
pl
si
, t
hrom ocytosis,

nd leukoerythro l
stosis occur in idiop
thic myelo rosis. 1.7 | Lymphoprolifer
t
ive
nd
Myeloprolifer
tive Disorders 27 6. Fe
tures of second
ry polycythemi
include

ll of the
followin except: A. Splenome
ly B. Decre
sed oxyen s
tur
tion C. Incre
sed re
d cell m
ss D.
Incre
sed erythropoietin Hem
toloy/Ev
lu
te l
or
tory d
t
to reconize he
lth

nd dise
se
st
tes/RBC disorders/2 7. Te erythrocytosis seen in rel
tive polycythemi
occurs
ec
use of: A.
Decre
sed
rteri
l oxyen s
tur
tion B. Decre
sed pl
sm
volume of circul
tin
lood C. Incre
sed
erythropoietin levels D. Incre
sed erythropoiesis in the one m
rrow Hem
toloy/
Correl
te
clinic
l
nd l
or
tory d
t
/RBC disorders/2 8. In PV, wh
t is ch
r
cteristic
ll
y seen in the
peripher
l lood? A. P
nmyelosis B. P
ncytosis C. P
ncytopeni
D. P
nhyperpl
si

Hem
toloy/Apply
knowlede of fund
ment
l ioloic
l ch
r
cteristics/Polycythemi
/1 9. Te leukocy
te
lk
line
phosph
t
se (LAP) st
in on
p
tient ives the followin results 10(0) 48(1+) 38
(2+) 3(3+) 1(4+)
C
lcul
te the LAP score. A. 100 B. 117 C. 137 D. 252 Hem
toloy/C
lcul
te/LAP sc
ore/2 10. CML is
distinuished from leukemoid re
ction y which of the followin? A. CML: low LAP
; leukemoid: hih
LAP B. CML: hih LAP; leukemoid: low LAP C. CML: hih WBC; leukemoid: norm
l WBC
D. CML: hih
WBC; leukemoid: hiher WBC Hem
toloy/Ev
lu
te l
or
tory
nd clinic
l d
t
to s
pecify
ddition
l
tests/Leukemi
s/2 11. Which of the followin occurs in idiop
thic myelo rosis (IM
F)? A. Myeloid
met
pl
si
B. Leukoerythro l
stosis C. Fi rosis of the one m
rrow D. All of the
se options
Hem
toloy/Ev
lu
te l
or
tory d
t
to reconize he
lth
nd dise
se st
tes/Myelo
prolifer
tive
neopl
sms/3 2828_Ch01_001-040 09/08/12 4:10 PM P
e 27 12. Wh
t in uence does t
he Phil
delphi

(Ph 1 ) chromosome h
ve on the pronosis of p
tients with chronic myelocytic leu
kemi
? A. It is
not predictive B. Te pronosis is etter if Ph 1 is present C. Te pronosis is w
orse if Ph 1 is
present D. Te dise
se usu
lly tr
nsforms into AML when Ph 1 is present Hem
tolo
y/Ev
lu
te
l
or
tory d
t
to reconize he
lth
nd dise
se st
tes/Genetic theory
nd princi
ples/CML/2 13.

Which of the followin is (
re) commonly found in CML? A. M
ny te
rdrop-sh
ped c

ells B. Intense
LAP st
inin C. A decre
se in r
nulocytes D. An incre
se in
sophils Hem
tolo
y/Ev
lu
te
l
or
tory d
t
to reconize he
lth
nd dise
se st
tes/CML/3 14. In which of the
followin
conditions does LAP show the le
st
ctivity? A. Leukemoid re
ctions B. Idiop
thi
c myelo rosis C.
PV D. CML Hem
toloy/Correl
te clinic
l
nd l
or
tory d
t
/LAP score/1 15. A st
rikin fe
ture of
the peripher
l lood of
p
tient with CML is
: A. Profusion of iz
rre l
st c
ells B. Norm
l
num er of typic
l r
nulocytes C. Presence of r
nulocytes
t di erent st
es of d
evelopment D.
P
ncytopeni
Hem
toloy/Ev
lu
te l
or
tory d
t
to reconize he
lth
nd dise
se
st
tes/WBCs/CML/2 16. Which of the followin is often
ssoci
ted with CML ut no
t with AML? A.
Infections B. WBCs re
ter th
n 20.0 10 9
/L
C. Hemorrh
e D. Splenome
ly Hem
toloy/Correl
te clinic
l
nd l
or
to
ry d
t
/
CML/Ch
r
cteristics/2 17. Multiple myelom

nd W
ldenstrms m
crolo ulinemi
h
ve

ll the
followin in common except: A. Monoclon
l 
mmop
thy B. Hyperviscosity of the l
ood C.
BenceJones protein in the urine D. Osteolytic lesions Hem
toloy/Ev
lu
te l
or
t
ory d
t
to
reconize he
lth
nd dise
se st
tes/Myelom
/Ch
r
cteristics/2 28 Ch
pter 1 | Hem

toloy Answers
to Questions 1217 12. B Ninety percent of p
tients with CML h
ve the Phil
delphi

chromosome.
This
ppe
rs
s
lon
rm deletion of chromosome 22, ut is
ctu
lly
tr
nsloc

tion etween the
lon
rms of chromosomes 22
nd 9. The ABL oncoene from chromosome 9 forms
hy
rid ene with
the cr reion of chromosome 22. This results in production of
chimeric protei
n with tyrosine
kin
se
ctivity th
t
ctiv
tes the cell cycle. The pronosis for CML is etter i
f the
Phil
delphi
chromosome is present. Often,
second chromosom
l
norm
lity occu
rs in CML efore
l
st crisis. 13. D CML is m
rked y
n elev
ted WBC count demonstr
tin v
rious
st
es of
m
tur
tion, hypermet
olism,
nd
minim
l LAP st
inin. An incre
se in
sophil
s
nd eosinophils
is
common ndin. PseudoPeler-Hut cells
nd throm ocytosis m
y e present. The m

rrow is
hypercellul
r with
hih M:E r
tio (e.., 10:1). 14. D Chronic myeloenous leuk
emi
shows the
le
st LAP
ctivity, where
s the LAP score is slihtly to m
rkedly incre
sed in e

ch of the other
st
tes. 15. C The WBC count in CML is often hiher th
n 100 10 9
/
L,
nd the peripher
l sme
r shows
r
nulocyte
proression from myelo l
st to semented neutrophil. 16. D Splenome
ly
is seen in more th
n
90% of CML p
tients, ut it is not
ch
r
cteristic ndin in AML. Infections, hem
orrh
e,
nd
elev
ted WBC counts m
y e seen in oth CML
nd AML. 17. D Osteolytic lesions in
dic
tin
destruction of the one
s evidenced y r
dior
phy
re seen in multiple myelom

ut not in
W
ldenstrms m
crolo ulinemi
. In
ddition, W
ldenstrms ives rise to
lymphocytosi
s th
t
does not occur in multiple myelom

nd di ers in the morpholoy of the m
lin
nt c
ells.
2828_Ch01_001-040 09/08/12 4:10 PM P
e 28 18. Wh
t is the ch
r
cteristic ndin
 seen in the
peripher
l sme
r of
p
tient with multiple myelom
? A. Microcytic hypochromic c
ells B.
Intr
cellul
r inclusion odies C. Roule
ux D. Hypersemented neutrophils Hem
tol
oy/Apply
knowlede of fund
ment
l ioloic
l ch
r
cteristics/Myelom
/Microscopic morpholo
y/1 19. All of
the followin
re
ssoci
ted with the di
nosis of multiple myelom
except: A. M

rrow
pl
sm
cytosis B. Lytic one lesions C. Serum
nd/or urine M component (monoclon

l protein) D.
Phil
delphi
chromosome Hem
toloy/Correl
te clinic
l
nd l
or
tory d
t
/ Myelo
m
/2 20. Multiple
myelom
is most di cult to distinuish from: A. Chronic lymphocytic leukemi
B. Ac
ute myeloenous
leukemi
C. Benin monoclon
l 
mmop
thy D. Benin
denom
Hem
toloy/Apply know
lede of
fund
ment
l ioloic
l ch
r
cteristics/Myelom
/2 21. Te p
tholoy of multiple my
elom
includes
which of the followin? A. Exp
ndin pl
sm
cell m
ss B. Overproduction of monoc
lon
l
immunolo ulins C. Production of osteocl
st
ctiv
tin f
ctor (OAF)
nd other cy
tokines D. All of
these options Hem
toloy/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristi
cs/Immunoloic
m
nifest
tion of dise
se/Immunolo ulins/2 22. W
ldenstrms m
crolo ulinemi
is

m
lin
ncy of
the: A. Lymphopl
sm
cytoid cells B. Adren
l cortex C. Myelo l
stic cell lines D.
Erythroid cell
precursors Hem
toloy/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics/
Immunoloic
m
nifest
tion of dise
se/2 1.7 | Lymphoprolifer
tive
nd Myeloprolifer
tive Diso
rders 29
Answers to Questions 1822 18. C Roule
ux is o served in multiple myelom
p
tients

s
result of
incre
sed viscosity
nd decre
sed
l umin/lo ulin r
tio. Multiple myelom
is

pl
sm
cell
dyscr
si
th
t is ch
r
cterized y
n overproduction of monoclon
l immunolo uli
n. 19. D The Ph 1
chromosome is
di
nostic m
rker for CML. Osteolytic lesions, monoclon
l 
mmop

thy,
nd one
m
rrow in ltr
tion y pl
sm
cells constitute the tri
d of di
nostic m
rkers for
multiple
myelom
. 20. C Benin monoclon
l 
mmop
thies h
ve peripher
l lood ndins simil

r to those in
myelom
. However,
lower concentr
tion of monoclon
l protein is usu
lly seen. T
here
re no
osteolytic lesions,
nd the pl
sm
cells comprise less th
n 10% of nucle
ted cel
ls in the one
m
rrow. A out 30% ecome m
lin
nt,
nd therefore the term monoclon
l 
mmop
thy
of undetermined
sini c
nce (MGUS) is the desin
tion used to descri e this condition. 21. D Mut
t
ed pl
sm
l
sts
in the one m
rrow undero clon
l replic
tion
nd exp
nd the pl
sm
cell m
ss. N

orm
l one m
rrow

is r
du
lly repl
ced y the m
lin
nt pl
sm
cells le
din to p
ncytopeni
. Mos
t m
lin
nt
pl
sm
cells
ctively produce immunolo ulins. In multiple myelom
, the norm
lly
controlled
nd
purposeful production of
nti odies is repl
ced y the in
ppropri
te production
of even l
rer

mounts of useless immunolo ulin molecules. The norm
lly equ
l production of li
ht ch
ins
nd
he
vy ch
ins m
y e im
l
nced. The result is the rele
se of excess free liht c
h
ins or free
he
vy ch
ins. The immunolo ulins produced y
clone of myelom
cells
re ident
ic
l. Any

norm
l production of identic
l
nti odies is referred to y the ener
l n
me o
f monoclon
l

mmop
thy. Osteocl
sts
re one cells
ctive in loc
lly resor in one
nd rele

sin c
lcium
into the lood. Ne
r y osteo l
sts
re equ
lly
ctive in utilizin c
lcium in th
e lood to form
new one. Multiple myelom
interrupts this
l
nce y the secretion of
t le
st
two su st
nces.
These
re interleukin-6 (IL-6)
nd osteocl
st-
ctiv
tin f
ctor (OAF). As its n

me implies, OAF
stimul
tes osteocl
sts to incre
se one resorption
nd rele
se of c
lcium, which
le
ds to lytic
lesions of the one. 22. A W
ldenstrms m
crolo ulinemi
is
m
lin
ncy of the
lymphopl
sm
cytoid cells, which m
nuf
cture IM. Althouh the cells secrete immu
nolo ulin, they

re not fully di erenti
ted into pl
sm
cells
nd l
ck the ch
r
cteristic perinucl
e
r h
lo, deep

sophili
,
nd eccentric nucleus ch
r
cteristic of cl
ssic pl
sm
cells. 2828_C
h01_001-040
09/08/12 4:10 PM P
e 29 23. Cells th
t exhi it
positive st
in with
cid pho
sph
t
se
nd
re
not inhi ited with t
rt
ric
cid
re ch
r
cteristic
lly seen in: A. Infectious m
ononucleosis B.
Infectious lymphocytosis C. H
iry cell leukemi
D. T-cell
cute lympho l
stic le
ukemi

Hem
toloy/Apply principles of speci
l procedures/Cytochemic
l st
ins/2 24. Te J
AK2(V617F)
mut
tion m
y e positive in
ll of the followin chronic myeloprolifer
tive diso
rders except: A.
Essenti
l throm ocythemi
B. Idiop
thic myelo rosis C. PV D. CML Hem
toloy/Corre
l
te clinic
l

nd l
or
tory d
t
/ CML/Ch
r
cteristics/3 25. All of the followin
re m
jor cr
iteri
for the
2008 WHO di
nostic criteri
for essenti
l throm ocythemi
except: A. Pl
telet c
ount >450 10 9
/L
B. Me
k
ryocyte prolifer
tion with l
re
nd m
ture morpholoy,
nd no
or little r
nulocyte
or erythroid prolifer
tion C. Demonstr
tion of JAK2(V617F) or other clon
l m
rke
r D. Sust
ined
pl
telet count >600 10 9
/L
Hem
toloy/Apply knowlede of speci
l procedures/ Myeloprolifer
tive
dise
ses/Cl
ssi c
tions/3 30 Ch
pter 1 | Hem
toloy Answers to Questions 2325 23. C
A v
ri
le
num er of m
lin
nt cells in h
iry cell leukemi
(HCL) will st
in positive with
t
rtr
te-

resist
nt
cid phosph
t
se (TRAP+). Althouh this cytochemic
l re
ction is f
irl

y speci c for
HCL, TRAP
ctivity h
s occ
sion
lly een reported in B-cell
nd r
rely T-cell le
ukemi
. 24. D The
JAK2(V617F) mut
tion is ne
tive in p
tients with CML. It m
y e positive in p
t
ients with
idiop
thic myelo rosis (35%57%), polycythemi
ver
(65%97%),
nd essenti
l throm oc
ythemi

(23%57%). 25. D The criterion for the 2001 WHO di
nosis of essenti
l throm ocyth
emi
(ET) w
s

pl
telet count 600 x 10 9
/
L. This w
s ch
ned in the 2008 WHO
criteri
to 450 x 10 9
/
L. Di
nosis of essenti
l
throm ocythemi
requires meetin
ll four m
jor 2008 WHO di
nostic crit
eri
, which
lso
includes: me
k
ryocyte prolifer
tion with l
re
nd m
ture morpholoy
nd no or
little
r
nulocyte or erythroid prolifer
tion; not meetin WHO criteri
for CML, PV, IM
F, MDS, or other
myeloid neopl
sm;
nd demonstr
tion of JAK2(V617F) mut
tion or other clon
l m
rk
er, or no
evidence of re
ctive throm ocytosis. 2828_Ch01_001-040 09/08/12 4:10 PM P
e
30 Answers to
Questions 13 1. B The formul
for correctin the WBC count for the presence of NR
BCs is: Tot
l
WBC 100 or (21.0 100) 126 = 16.7 10 9
/L
where tot
l WBC = WBCs 10 9
/
L, 100 is the
num er of WBCs counted in the di erenti
l,
nd 126 is the sum of NRBCs plu
s WBCs counted in
the di erenti
l. 2. C The formul
for c
lcul
tin m
nu
l cell counts usin
hem
c
ytometer is:
#
cells counted 10 (depth f
ctor)
dilution f
ctor divided y the
re
counted in mm 2 , or (80 10 100) 4 =
20,000/L or
20.0 10 9
/L
3. D Regardless of the cell or uid type, the formula for calculating manu
al cell counts
using a hemacytometer is:
#
cells counted 10 (depth factor)
dilution factor divided by the area counted in mm 2 , or (125 10 200) 1
= 250,000/L or
250.0 10 9
/L
1. A 19-year-old man came to the emergency department with severe joint
pain, fatigue, cough,
and fever. Review the following laboratory results: WBCs 21.0 10 9
/L
RBCs 3.23 10 12
/L
Hgb 9.6 g/dL PLT 252 10 9
/L
Di erential: 17 band neutrophils; 75 segmented neutrophils; 5 lymphocytes;
2 monocytes; 1
eosinophil; 26 NRBCs What is the corrected WBC count? A. 8.1 10 9
/L
B. 16.7 10 9

/L
C. 21.0 10 9
/L
D. 80.8 10 9
/L
Hematology/Calculate/WBCs corrected for NRBCs/2 2. A manual WBC count is
performed. Eighty
WBCs are counted in the four large corner squares of a Neubauer hemacytometer. T
e dilution is
1:100. What is the total WBC count? A. 4.0 10 9
/L
B. 8.0 10 9
/L
C. 20.0 10 9
/L
D. 200.0 10 9
/L
Hematology/Calculate/Cell count/2 3. A manual RBC count is performed on
a pleural uid. Te
RBC count in the large center square of the Neubauer hemacytometer is 125, and t
he dilution is
1:200. What is the total RBC count? A. 27.8 10 9
/L
B. 62.5 10 9
/L
C. 125.0 10 9
/L
D. 250.0 10 9
/L
Hematology/Calculate/Cell count/2 1.8 Hematology Problem Solving 31 2828
_Ch01_001-040
09/08/12 4:10 PM Page 31 4. Review the scatterplot of white blood cells shown.
Which section of
the scatterplot denotes the number of monocytes? 32 Chapter 1 | Hematology Answe
rs to Questions
45 4. A White blood cell identi cation is facilitated by analysis of the impedance,
conductance,
and light-scattering properties of the WBCs. The scatterplot represents the rela
tionship between
volume (x axis) and light scatter (y axis). Monocytes account for the dots in se
ction A,
neutrophils are represented in section B, eosinophils in section C, and lymphocy
tes are denoted
in section D. 5. C When an automated WBC count is performed using a hematology a
nalyzer, the RBCs
are lysed to allow enumeration of the WBCs. Sickle cells are often resistant to
lysis within the
limited time frame (less than 1 minute), during which the RBCs are exposed to th
e lysing reagent
and the WBCs are subsequently counted. As a result, the nonlysed RBCs are counte
d along with the
WBCs, thus falsely increasing the WBC count. When an automated cell counting ana
lyzer indicates a
review ag for the WBC count, and sickle cells are noted on peripheral smear analy
sis, a manual
WBC count must be performed. The manual method allows optimal time for sickle ce
ll lysis and
accurate enumeration of the WBCs. W BC V O L U M E DF 1 A D B C A. A B. B C. C
D. D
Hematology/Apply basic principles to interpret results/ Automated cell counting/

2 5. Review the
following automated CBC values. WBCs = 17.5 10 9
/
L ( agged) MCV = 86.8 fL
RBCs = 2.89 10 12
/
L MCH = 28.0 pg
Hgb = 8.1 g/dL MCHC = 32.3% Hct = 25.2% PLT = 217 10 9
/L
Many sickle cells were observed upon review of the peripheral blood smea
r. Based on this
nding and the results provided, what automated parameter of this patient is most
likely
inaccurate and what follow-up test should be done to accurately assess this para
meter? A.
MCV/perform reticulocyte count B. Hct/perform manual Hct C. WBC/perform manual W
BC count D.
Hgb/perform serum:saline replacement Hematology/Apply knowledge to identify sour
ces of
error/Instrumentation/3 2828_Ch01_001-040 09/08/12 4:10 PM Page 32 6. Review
the following CBC
results on a 2-day-old infant: WBCs = 15.2 10 9
/
L MCV = 105 fL
RBCs = 5.30 10 12
/
L MCH = 34.0 pg
Hgb = 18.5 g/dL MCHC = 33.5% Hct = 57.9% PLT = 213 10 9
/L
Tese results indicate: A. Macrocytic anemia B. Microcytic anemia C. Live
r disease D. Normal
values for a 2-day-old infant Hematology/Apply knowledge of fundamental biologic
al
characteristics/Normal values/2 7. Review the following scatterplot, histograms,
and automated
values on a 21-year-old college student. 1.8 | Hematology Problem Solving 33 A
nswers to
Questions 67 6. D During the rst week of life, an infant has an average Hct of 55
mL/dL. This
value drops to a mean of 43 mL/dL by the rst month of life. The mean MCV of the rs
t week is 108
fL; after 2 months, the average MCV is 96 fL. The mean WBC count during the rst w
eek is
approximately 18 10 9
/
L, and this drops to
an average of 10.8 10 9
/
L after the rst month. The
platelet count of newborns falls within the same normal range as adults.
7. A Lymphocytosis
with numerous atypical lymphocytes is a hallmark nding consistent with the diagno
sis of
infectious mononucleosis. The automated results demonstrated abnormal WBC subpop
ulations,
speci cally lymphocytosis as well as monocytosis. However, on peripheral smear exa
mination, 60
atypical lymphocytes and only 6 monocytes were noted. Atypical lymphocytes are o
ften misclassi ed
by automated cell counters as monocytes. Therefore, the automated analyzer di eren
tial must not
be released and the manual di erential count must be relied upon for diagnostic in
terpretation.
WBC di erential: 5 band neutrophils; 27 segmented neutrophils; 60 atypical lymphoc
ytes; 6
monocytes; 1 eosinophil; 1 basophil What is the presumptive diagnosis? A. Infect

ious
mononucleosis B. Monocytosis C. Chronic lymphocytic leukemia D. -T
l
ssemi
Hem
t
oloy/Apply
knowlede to identify sources of error/Instrument
tion/3 2828_Ch01_001-040 09/0
8/12 4:10 PM
P
e 33 WBC di erenti
l: 14
nd neutrophils; 50 semented neutrophils; 7 lymphocy
tes; 4
monocytes; 10 met
myelocytes; 8 myelocytes; 1 promyelocyte; 3 eosinophils; 3
s
ophils; 2
NRBCs/100 WBCs Wh
t is the presumptive di
nosis? A. Leukemoid re
ction B. Chron
ic myelocytic
leukemi
C. Acute myelocytic leukemi
D. Me
lo l
stic leukemi
Hem
toloy/Ev
lu

te l
or
tory
d
t
to reconize he
lth
nd dise
se st
tes/Instrument
tion/3 9. Review the
uto
m
ted results
from the previous question. Which p
r
meters c
n e rele
sed without further fol
low-up
veri c
tion procedures? A. WBC
nd rel
tive percent
es of WBC popul
tions B. RBCs

nd PLTs C.
H
nd Hct D. None of the
utom
ted counts c
n e rele
sed without follow-up ve
ri c
tion
Hem
toloy/Apply knowlede to identify sources of error/Instrument
tion/3 Answer
s to Questions
89 8. B The +++++ on the printout indic
tes th
t the WBC count exceeds the upper
line
rity of
the
n
lyzer (>99.9 10 9
/
L). This m
rkedly elev
ted WBC count,
com ined with the spectrum of imm
ture r
nulocytic cells seen on periph
er
l sme
r
ex
min
tion, indic
tes the di
nosis of chronic myelocytic leukemi
. 9. D All of
the
utom
ted
results h
ve R or review
s indic
ted; none c
n e rele
sed without veri c
tion pr
ocedures. The
specimen must e diluted to rin the WBC count within the line
rity r
ne of th
e
n
lyzer. When
enumer
tin the RBC count, the
n
lyzer does not lyse the WBCs
nd
ctu
lly coun
ts them in with
the RBC count. As such, the RBC count is f
lsely elev
ted ec
use of the incre
s
ed num er of
WBCs. Therefore,
fter
n
ccur
te WBC count h
s een o t
ined, this v
lue c
n
e su tr
cted from
the RBC count to o t
in
true RBC count. For ex
mple, usin the v
lues for this
p
tient: Step 1:
O t
in
n
ccur
te WBC count y dilutin the s
mple 1:10. WBC = 41.0 10 (dilutio
n) = 410 10 9
/L
Step 2: Convert this v
lue to cells per 10 12 in order to su tr
ct from
the RBC count. 410
10 9
/
L = 0.41 10
12
/L
Step 3: Su tr
ct the WBC count from the RBC count to et
n
ccur
te RBC
count. 3.28
(oriin
l RBC) 0.41 (true WBC) = 2.87 10 12
/
L =
ccur
te RBC
The Hct m
y e o t
ined y microhem
tocrit centrifu
tion. The true MCV
m
y e o t
ined usin
the st
nd
rd formul
. MCV = (Hct RBC) 10 where RBC = RBC count in millions per m
icroliter

Addition
lly, the pl
telet count must e veri ed y sme
r estim
te or performed m

nu
lly. 34
Ch
pter 1 | Hem
toloy 8. Review the followin sc
tterplot, histor
ms,
nd
uto
m
ted v
lues on

61-ye
r-old wom
n. 2828_Ch01_001-040 09/08/12 4:10 PM P
e 34 A. Redr
w lood
s
mple usin

sodium citr
te tu e; multiply PLTs 1.11 B. Dilute the WBCs 1:10; multiply 10 C.
Perform
pl
sm
l
nk H to correct for lipemi
D. W
rm specimen
t 37C for 15 minutes; r
erun specimen
Hem
toloy/Apply knowlede to identify sources of error/Instrument
tion/3 Answer
to Question 10
10. A The pl
telet clumpin phenomenon is often induced in vitro y the
ntico

ul
nt EDTA.
Redr
win
s
mple from the p
tient usin
sodium citr
te tu e usu
lly corrects
this phenomenon

nd
llows
ccur
te pl
telet enumer
tion. The pl
telet count must e multiplied
y 1.11 to
djust
for the
mount of sodium citr
te. Pl
telet clumps c
use
spurious decre
se in t
he pl
telet count
y
utom
ted methods. The WBC v
lue h
s
n R (review)
 ec
use the pl
telet clu
mps h
ve een
f
lsely counted
s WBCs; therefore,
m
nu
l WBC count is indic
ted. 1.8 | Hem
t
oloy Pro lem
Solvin
35 10. Refer to the followin sc
tterplot, histor
ms,
nd
utom
ted v

lues on

45-ye
r-old m
n. Wh
t follow-up veri c
tion procedure is indic
ted efore rele
sin
 these
results? 2828_Ch01_001-040 09/08/12 4:10 PM P
e 35 A. Redr
w specimen usin

sodium citr
te
tu e; multiply PLT 1.11 B. Dilute the WBCs 1:10; multiply 10 C. Perform pl
sm

l
nk H to
correct for lipemi
D. W
rm the specimen
t 37C for 15 minutes; rerun the specime
n
Hem
toloy/Apply knowlede to identify sources of error/Instrument
tion/3 Answer
to Question 11
11. D The presence of
hih titer cold
lutinin in
p
tient with cold
utoim
mune hemolytic

nemi
will interfere with
utom
ted cell countin. The most rem
rk
le ndins
r
e
f
lsely
elev
ted MCV, MCH,
nd MCHC
s well
s
f
lsely decre
sed RBC count. The p
tien
ts red lood
cells will quickly
lutin
te in vitro when exposed to
m ient temper
tures el
ow ody
temper
ture. To correct this phenomenon, incu
te the EDTA tu e
t 37C for 1530 mi
nutes
nd
then rerun the specimen. 36 Ch
pter 1 | Hem
toloy 11. Refer to the followin sc

tterplot,
histor
ms,
nd
utom
ted v
lues on
52-ye
r-old wom
n. Wh
t follow-up veri c
tio
n procedure is
indic
ted efore rele
sin these results? 2828_Ch01_001-040 09/08/12 4:10 PM
P
e 36 A.
Perform
m
nu
l hem
tocrit
nd redr
w the s
mple usin
sodium citr
te tu e; m
ultiply PLT
1.11 B. Dilute the WBC 1:10; multiply 10 C. Perform pl
sm
l
nk H to correct
for lipemi
D.
W
rm the specimen
t 37C for 15 minutes; rerun the specimen Hem
toloy/Apply know
lede to
identify sources of error/Instrument
tion/3 Answer to Question 12 12. C The rule
of thum

re
rdin the H /Hct correl
tion dict
tes th
t H 3 Hct ( 3). This rule is viol

ted in
this p
tient; therefore,
follow-up veri c
tion procedure is indic
ted. Addition

lly, the MCHC
is m
rkedly elev
ted in these results,
nd
n expl
n
tion for
f
lsely incre
se
d H should e
investi
ted. Lipemi
c
n e visu
lized y centrifuin the EDTA tu e
nd o serv
in for
milky
white pl
sm
. To correct for the presence of lipemi
,
pl
sm
H v
lue (
seli
ne H ) should e

scert
ined usin the p
tients pl
sm

nd su sequently su tr
cted from the oriin

l f
lsely
elev
ted H v
lue. The followin formul
c
n e used to correct for lipemi
. Wh
ole lood H
[(Pl
sm
H ) (1 Hct/100)] = Corrected H 1.8 | Hem
toloy Pro lem Solvin
37
12. Refer to
the followin sc
tterplot, histor
ms,
nd
utom
ted v
lues on
33-ye
r-old wom

n. Wh
t
follow-up veri c
tion procedure is indic
ted efore rele
sin these results? 2828_
Ch01_001-040
09/08/12 4:10 PM P
e 37 A. Dilute WBCs 1:10; multiply 10 B. Redr
w the s
mple
usin
sodium
citr
te tu e; multiply WBC 1.11 C. Prep
re u y co
t peripher
l lood sme
rs
nd p
erform

m
nu
l di erenti
l D. W
rm specimen
t 37C for 15 minutes; rerun specimen Hem
tolo
y/Select
course of
ction/Instrument
tion/3 14. Review the followin CBC results on
70ye
r-old m
n:
WBCs = 58.2 10 9
/
L MCV = 98 fL
RBCs = 2.68 10 12
/
L MCH = 31.7 p
H = 8.5 /dL MCHC = 32.6% Hct = 26.5 mL/dL% PLT = 132 10 9
/L
Di erenti
l: 96 lymphocytes; 2
nd neutrophils; 2 semented neutrophils;
25 smude cells/100
WBCs Wh
t is the most likely di
nosis
sed on these v
lues? A. Acute lymphocyt
ic leukemi
B.
Chronic lymphocytic leukemi
(CLL) C. Infectious mononucleosis D. Myelodyspl
sti
c syndrome
Hem
toloy/Ev
lu
te l
or
tory d
t
to reconize he
lth
nd dise
se st
tes/2 Ans
wers to Questions
1314 13. C The m
rkedly decre
sed WBC count (0.2 10 9
/
L)
indic
tes th
t
m
nu
l di erenti
l is necess
ry
nd very few leukocytes w
ill e
v
il
le
for di erenti
l cell countin. To incre
se the yield
nd there y f
cilit
te counti
n, di erenti
l
sme
rs should e prep
red usin the u y co
t technique. 14. B CLL is
dise
se of
the elderly,
cl
ssic
lly
ssoci
ted with
n elev
ted WBC count
nd rel
tive
nd
solute lymp
hocytosis. CLL is
twice
s common in men,
nd smude cells (WBCs with little or no surroundin cyt
opl
sm)
re
usu
lly present in the peripher
l lood sme
r. CLL m
y occur with or without
ne
mi
or
throm ocytopeni
. The p
tients
e
nd l
ck of l
sts rule out
cute lymphocytic
leukemi
.
Simil
rly, the p
tients
e
nd the l
ck of
typic
l lymphocytes m
ke infectious
mononucleosis

unlikely. Myelodyspl
stic syndromes m
y involve the erythroid, r
nulocytic, or

me
k
ryocytic
cell lines ut not the lymphoid cells. 38 Ch
pter 1 | Hem
toloy 13. Refer to th
e followin
sc
tterplot, histor
ms,
nd
utom
ted v
lues on
48-ye
r-old m
n. Wh
t followup veri c
tion
procedure is indic
ted efore rele
sin the ve-p
rt WBC di erenti
l results? 2828_C
h01_001-040
09/08/12 4:10 PM P
e 38 A. Dissemin
ted intr
v
scul
r co
ul
tion (DIC) B. He
redit
ry
elliptocytosis (ov
locytosis) C. Cirrhosis D. H C dise
se Hem
toloy/Ev
lu
te
l
or
tory d
t

to reconize he
lth
nd dise
se st
tes/2 1.8 | Hem
toloy Pro lem Solvin
39 1
5. Refer to the
followin sc
tterplot, histor
ms,
nd
utom
ted v
lues on
28-ye
r-old wom
n w
ho h
d
preoper
tive l
or
tory testin. A m
nu
l WBC di erenti
l w
s requested y her phy
sici
n. Te WBC
di erenti
l w
s not sini c
ntly di erent from the
utom
ted ve-p
rt di erenti
l; however
, the
technoloist noted 3+ elliptocytes/ov
locytes while reviewin the RBC morpholoy
. Wh
t is the
most likely di
nosis for this p
tient? Answers to Questions 1516 15. B The ndin
of ov
locytes

s the predomin
nt RBC morpholoy in peripher
l lood is consistent with the di

nosis of
heredit
ry elliptocytosis (HE), or ov
locytosis. This disorder is rel
tively com
mon
nd c
n r
ne
in severity from
n
symptom
tic c
rrier to homozyous HE with severe hemolysis.
The most common
clinic
l su type is
ssoci
ted with no or minim
l hemolysis. Therefore, HE is us
u
lly
ssoci
ted
with
norm
l RBC histor
m
nd cell indices
nd will o unnoticed without micro
scopic ev
lu
tion
of the peripher
l sme
r. 16. A The osmotic fr
ility test is indic
ted
s
con rm

tory test for
the presence of numerous spherocytes,
nd individu
ls with heredit
ry spherocyto
sis (HS) h
ve
n
incre
sed osmotic fr
ility. The MCHC is elev
ted in more th
n 50% of p
tients w
ith
spherocytosis,
nd this p
r
meter c
n e used
s
clue to the presence of HS. S
pherocytes h
ve

decre
sed surf
ce-to-volume r
tio, pro
ly resultin from mild cellul
r dehydr

tion. 16. A
25-ye
r-old wom
n s
w her physici
n with symptoms of j
undice,
cute cholecystit
is,
nd
n
enl
red spleen. On investi
tion, numerous 
llstones were discovered. Review t
he followin CBC
results: WBCs = 11.1 10 9
/
L MCV = 100 fL
RBCs = 3.33 10 12
/
L MCH = 34.5 p
H = 11.5 /dL MCHC = 37.5% Hct = 31.6 mL/dL PLT = 448 10 9
/L
WBC di erenti
l: 13
nd neutrophils; 65 semented neutrophils; 15 lymphoc
ytes; 6 monocytes;
1 eosinophil RBC morpholoy: 3+ spherocytes, 1+ polychrom
si
Wh
t follow-up l

or
tory test
would provide v
lu
le inform
tion for this p
tient? A. Osmotic fr
ility B. H
electrophoresis

C. G6PD
ss
y D. Methemolo in reduction test Hem
toloy/Ev
lu
te l
or
tory d
t

to reconize
he
lth
nd dise
se st
tes/2 2828_Ch01_001-040 09/08/12 4:10 PM P
e 39 A. Iro
n de ciency

nemi
(IDA) B. Polycythemi
ver
(PV) C. Sidero l
stic
nemi
D. -T
l
ssemi
min
or
Hem
toloy/Ev
lu
te l
or
tory d
t
to reconize he
lth
nd dise
se st
tes/2 18.
Review the
followin CBC results: WBCs = 11.0 10 9
/
L MCV = 85.0 fL
RBCs = 3.52 10 12
/
L MCH = 28.4 p
H = 10.0 /dL MCHC = 33.4% Hct = 29.9 mL/dL PLT = 155 10 9
/L
12 NRBCs/100 WBCs RBC morpholoy: Moder
te polychrom
si
, 3+ t
ret cell
s, few schistocytes
Which of the followin
ddition
l l
or
tory tests would yield inform
tive di
n
ostic inform
tion
for this p
tient? A. Osmotic fr
ility B. H electrophoresis C. Su
r w
ter tes
t D. Bone m
rrow
ex
min
tion Hem
toloy/Correl
te l
or
tory d
t
with other l
or
tory d
t
to

ssess test
results/3 Answers to Questions 1718 17. D -Th
l
ssemi
minor c
n e
sily e detecte
d y notin

n
norm
lly elev
ted RBC count,
n Hct th
t does not correl
te with the elev
t
ed RBC count, in
conjunction with
decre
sed MCV. Althouh th
l
ssemi

nd IDA
re oth microcyt
ic, hypochromic
processes, th
l
ssemi
c
n e di erenti
ted from IDA ec
use in IDA the RBC count,
H ,
nd Hct
v
lues
re usu
lly decre
sed
lon with the MCV. Althouh the RBC count is incre

sed in PV, the
Hct must
lso e hiher th
n 50% to consider
di
nosis of PV. 18. B The ndins
of
moder
te

nemi
, numerous t
ret cells seen on
peripher
l lood sme
r,
s well
s the p
resence of NRBCs,

re often
ssoci
ted with hemolo inop
thies. Hemolo in electrophoresis
t
lk

line pH is

commonly performed test to correctly di
nose the type of hemolo inop
thy. 40 C
h
pter 1 |
Hem
toloy 17. Refer to the followin sc
tterplot, histor
ms,
nd
utom
ted v
l
ues on

53-ye
r-old m
n who h
d preoper
tive l
or
tory testin. Wh
t is the most likely
di
nosis for
this p
tient? BI BL I OGRAPHY 1. Greer J, Foerster J, Roders GM, P
r
skev
s F,
Gl
der B, Ar er
DA,
nd Me
ns RT Jr. Wintro es Clinic
l Hem
toloy. 12th edition, 2009. Lippincot
t Willi
ms &
Wilkins, Phil
delphi
. 2. H
rmenin D. Clinic
l Hem
toloy
nd Fund
ment
ls of H
emost
sis. 5th
edition, 2009. F.A. D
vis, Phil
delphi
. 3. Hillm
n R, Ault K, Leporrier M, Rind
er HM,
nd Rinder
H. Hem
toloy in Clinic
l Pr
ctice. 5th edition, 2011. McGr
w-Hill, New York. 4.
Ho m
n R,
Sil erstein LE, Sh
ttil SJ, Furie B,
nd McGl
ve P. Hem
toloy: B
sic Principles

nd Pr
ctices,
Expert Consult. 5th edition, 2009. Churchhill Livinstone Elsevier, Phil
delphi

. 5. K
ush
nsky
K, Lichtm
n M, Beutler E, Kipps T, Prch
l J,
nd Selisohn U. Willi
ms Hem
tolo
y. 8th edition,

2010. McGr
w-Hill, New York. 6. Roders GP
nd Youn NS. Te Bethesd
H
nd ook of
Clinic
l
Hem
toloy. 2010. Lippincott Willi
ms & Wilkins, Phil
delphi
. 7. S

HI
nd Mu
fti G. Adv
nces
in M
lin
nt Hem
toloy. 2011. Wiley-Bl
ckwell, Chichester, West Sussex, UK. 282
8_Ch01_001-040
09/08/12 4:10 PM P
e 40 2.1 Co
ul
tion
nd Fi rinolytic Systems/ Re
ents
n
d Methods 2.2
Pl
telet
nd V
scul
r Disorders 2.3 Co
ul
tion System Disorders 2.4 Inhi itors,
Trom otic
Disorders,
nd Antico
ul
nt Drus 2.5 Hemost
sis Pro lem Solvin CHAPTER 2 41 H
emost
sis
2828_Ch02_041-074 06/08/12 11:09 AM P
e 41 2828_Ch02_041-074 06/08/12 11:0
9 AM P
e 42 43
2.1 Co
ul
tion
nd Fi rinolytic Systems/Re
ents
nd Methods 1. Which of the fo
llowin initi
tes
in vivo co
ul
tion y
ctiv
tion of f
ctor VII? A. Protein C B. Tissue f
ctor C
. Pl
smin

ctiv
tor D. Trom omodulin Hemost
sis/Apply knowlede of fund
ment
l ioloic
l
ch
r
cteristics/Co
ul
tion/2 Answer to Question 1 1. B In vivo,
ctiv
tion of c
o
ul
tion occurs
on the surf
ce of
ctiv
ted pl
telets or cells th
t h
ve tissue f
ctor. Tissue f

ctor is found on
the surf
ce of m
ny cells outside the v
scul
r system (extrinsic). Upon v
scul
r
injury, TF is
exposed to the v
scul
r system. TF h
s hih
nity for f
ctors VII
nd VII
. TF
c
tiv
tes f
ctor
VII to VII

nd forms TF-VII
complex. TF-VII
complex in the presence of C
+2

nd pl
telet
phospholipid
ctiv
tes f
ctors IX to IX

nd X to X
. F
ctor X
forms
complex
with cof
ctor V

(X
-V
) on the surf
ce of the
ctiv
ted pl
telets. F
ctor X
-V
complex in the p
resence of C
+2

nd pl
telet phospholipid converts prothrom in (f
ctor II) to throm in (II
). Th
rom in
cts on
solu le pl
sm
rinoen to form

rin clot, which is st
ilized y
ctiv
ted f
ct
or XIII
(XIII
). In
ddition,
ctiv
ted f
ctor IX (IX
) forms
complex with
ctiv
ted c
of
ctor VIII
(VIII
) on the surf
ce of the
ctiv
ted pl
telets. F
ctor IX
VIII
complex in the
presence of C

+2
nd pl
telet phospholipid converts f
ctor X to X
with the end products of th
rom in
nd rin
clot
s discussed previously. The cl
ssic
l description of intrinsic, extrinsic,

nd common
p
thw
ys does not t
ke pl
ce in vivo. The concept of these three p
thw
ys is use
d to expl
in clot
form
tion in l
or
tory tests. The
ctiv
ted throm opl
stin time (APTT) is deter
mined y the
intrinsic
nd common p
thw
ys, while the prothrom in time (PT) is determined y
the extrinsic
nd
common p
thw
ys. The extrinsic p
thw
y is so n
med ec
use the tissue f
ctor is
derived from
extr
v
scul
r cells. 2828_Ch02_041-074 06/08/12 11:09 AM P
e 43 2. Which of
the followin
clottin f
ctors pl
ys
role in clot form
tion in vitro, ut not in vivo? in vi
tro clot
form
tion
nd not in vivo co
ul
tion? A. VII
B. II
C. XII
D. X
Hemost
sis/A
pply knowlede of
fund
ment
l ioloic
l ch
r
cteristics/Co
ul
tion/2 3. Te
ntico
ul
nt of choi

ce for most
routine co
ul
tion studies is: A. Sodium ox
l
te B. Sodium citr
te C. Hep
rin D
.
Ethylenedi
minetetr

cetic
cid (EDTA) Hemost
sis/Select methods/Re
ents/Specim
en collection
nd
h
ndlin/Specimen/1 4. Which r
tio of
ntico
ul
nt-to- lood is correct for co

ul
tion
procedures? A. 1:4 B. 1:5 C. 1:9 D. 1:10 Hemost
sis/Select methods/Re
ents/Spec
imen collection

nd h
ndlin/Specimen/1 5. Which results would e expected for the prothrom in t
ime (PT)
nd

ctiv
ted p
rti
l throm opl
stin time (APTT) in
p
tient with polycythemi
? A.
Both proloned B.
Both shortened C. Norm
l PT, proloned APTT D. Both norm
l Hemost
sis/Correl
te
clinic
l
nd
l
or
tory d
t
/Co
ul
tion tests/3 6. Wh
t re
ents
re used in the PT test? A.
Trom opl
stin

nd sodium chloride B. Trom opl
stin
nd pot
ssium chloride C. Trom opl
stin
nd
c
lcium D. Actin

nd c
lcium chloride Hemost
sis/Select methods/Re
ents/Co
ul
tion tests/1 7. W
hich test would
e
norm
l in
p
tient with f
ctor X de ciency? A. PT only B. APTT only C. PT
n
d APTT D.
Trom in time Hemost
sis/Correl
te clinic
l
nd l
or
tory d
t
/ Co
ul
tion test
s/2 44 Ch
pter 2
| Hemost
sis Answers to Questions 27 2. C F
ctor XII
does not pl
y
role in co

ul
tion in
vivo; however, in vitro, the de ciency of this f
ctor c
uses
proloned APTT resu
lt. In vitro,
f
ctor XII is
ctiv
ted y su st
nces such
s l
ss, K
olin,
nd ell
ic
cid,

nd in vivo it m
y
e
ctiv
ted y exposure to
ne
tively ch
red cell surf
ce mem r
ne such coll

en
s well
s
k
llikrein (
n
ctiv
ted form of prek
llikrein)
nd hih molecul
r weiht kinino
en (HMWK). In
vivo, f
ctor XII
pl
ys
n import
nt role in the rinolytic system y
ctiv
tin
pl
sminoen to
pl
smin. Pl
smin der
des the
rin clot
t the site of injury. De ciency of f
ctor
XII is

ssoci
ted with throm osis
nd not leedin. F
ctors VII
, X
,
nd II
pl
y
ro
le in vivo
nd in
vitro. 3. B The
ntico
ul
nt of choice for most co
ul
tion procedures is sodiu
m citr
te (3.2%).
Bec
use f
ctors V
nd VIII
re more l
ile in sodium ox
l
te, hep
rin neutr
lize
s throm in,
nd
EDTA inhi its throm ins
ction on rinoen, these
ntico
ul
nts
re not used for
routine
co
ul
tion studies. 4. C The optimum r
tio of
ntico
ul
nt to lood is one p
r
t
ntico
ul
nt
to nine p
rts of lood. The
ntico
ul
nt supplied in this
mount is su cient to
ind
ll the

v
il
le c
lcium, there y preventin clottin. 5. A The volume of lood in
po
lycythemic
p
tient cont
ins so little pl
sm
th
t excess
ntico
ul
nt rem
ins
nd is
v
il

le to ind to
re
ent c
lcium, there y resultin in prolon
tion of the PT
nd APTT. For more

ccur
te results,
the pl
sm
:
ntico
ul
nt r
tio c
n e modi ed y decre
sin the
mount of
ntico

ul
nt in the
collection tu e usin the followin formul
: (0.00185)(V)(100H) = C, where V = l

ood volume in
mL; H = p
tients Hct;
nd C = volume (mL) of
ntico
ul
nt. A new s
mple should
e dr
wn to
rerun the PT
nd APTT. 6. C Throm opl
stin
nd c
lcium (com ined into
sinle r
e
ent) repl
ce
the tissue throm opl
stin
nd c
lcium necess
ry in vivo to
ctiv
te f
ctor VII t
o f
ctor VII
.
This ultim
tely ener
tes throm in from prothrom in vi
the co
ul
tion c
sc
de.
7. C F
ctor X is
involved in the common p
thw
y of the co
ul
tion c
sc
de; therefore, its de cienc
y prolons oth
the PT
nd APTT. Activ
ted f
ctor X
lon with f
ctor V in the presence of c
lci
um
nd pl
telet
f
ctor III (PF3) converts prothrom in (f
ctor II) to the
ctive enzyme throm in
(f
ctor II
).
2828_Ch02_041-074 06/08/12 11:09 AM P
e 44 8. Which clottin f
ctor is not m
e
sured y PT
nd
APTT tests? A. F
ctor VIII B. F
ctor IX C. F
ctor V D. F
ctor XIII Hemost
sis/Ap
ply principles of

sic l
or
tory procedures/Co
ul
tion tests/1 9. A modi c
tion of which procedur
e c
n e used
to me
sure rinoen? A. PT B. APTT C. Trom in time D. Fi rin der
d
tion products
Hemost
sis/Apply principles of
sic l
or
tory procedures/Co
ul
tion tests/2 1
0. Which of the
followin ch
r
cterizes vit
min K? A. It is required for ioloic
l
ctivity of
rinolysis B.
Its
ctivity is enh
nced y hep
rin ther
py C. It is required for c
r oxyl
tion
of lut
m
te
residues of some co
ul
tion f
ctors D. It is m
de y the endotheli
l cells Hemo
st
sis/Apply
knowlede of fund
ment
l ioloic
l ch
r
cteristics/Vit
min K/2 11. Which st
tem
ent
out the
rinoen/ rin der
d
tion product test is correct? A. It detects e
rly der
d
tion
products (X

nd Y) B. It is decre
sed in dissemin
ted intr
v
scul
r co
ul
tion (DIC) C. It
ev
lu
tes the
co
ul
tion system D. It detects l
te der
d
tion products (D
nd E) Hemost
sis/
Apply principles
of
sic l
or
tory procedures/FDPs/2 12. Which of the followin clottin f
ctor
s
re me
sured y
the APTT test? A. II, VII, IX, X B. VII, X, V, II, I C. XII, XI, IX, VIII, X, V,
II, I D. XII,
VII, X, V, II, I Hemost
sis/Correl
te clinic
l
nd l
or
tory d
t
/ Co
ul
tion
tests/2 13. Which
co
ul
tion test(s) would e
norm
l in
vit
min Kde cient p
tient? A. PT only B.
PT
nd APTT
C. Fi rinoen level D. Trom in time Hemost
sis/Correl
te clinic
l
nd l
or
tory
d
t
/
Co
ul
tion tests/2 2.1 | Co
ul
tion
nd Fi rinolytic Systems/Re
ents
nd Meth
ods 45 Answers
to Questions 814 8. D F
ctor XIII is not me
sured y the PT or APTT. F
ctor XIII
( rin
st
ilizin f
ctor) is
tr
ns
mid
se. It cre
tes cov
lent onds etween rin mon
omers formed
durin the co
ul
tion process to produce
st
le rin clot. In the
sence of f

ctor XIII, the
hydroen onded
rin polymers
re solu le in 5M ure
or in 1% monochloro
cetic
c
id. 9. C
Fi rinoen c
n e qu
ntit
tively me
sured y
modi c
tion of the throm in time y
dilutin the

pl
sm
, ec
use the throm in clottin time of diluted pl
sm
is inversely propor
tion
l to the
concentr
tion of
rinoen (principle of Cl
uss method). 10. C Vit
min K is necess

ry for

ctiv
tion of vit
min K dependent clottin f
ctors (II, VII, IX,
nd X). This
ct
iv
tion is

ccomplished y c
r oxyl
tion of lut
mic
cid residues of the in
ctive clottin
f
ctors. The

ctivity of vit
min K is not enh
nced y hep
rin ther
py. Vit
min K is present i
n
v
riety of
foods
nd is
lso the only vit
min m
de y the or
nisms livin in the intestine
. 11. D The
rin
der
d
tion product (FDP) test detects the l
te der
d
tion products (fr
ments
D
nd E)
nd not
the e
rly ones (fr
ments X
nd Y). 12. C The APTT test ev
lu
tes the clottin f

ctors in the
intrinsic p
thw
y (XII, XI, IX,
nd VIII)
s well
s the common p
thw
y (X, V, I
I,
nd I). 13. B
P
tients with vit
min K de ciency exhi it decre
sed production of function
l proth
rom in proteins
(f
ctors II, VII, IX,
nd X). Decre
sed levels of these f
ctors prolon oth the
PT
nd APTT. 14.
B INR is used to st
nd
rdize PT results to
djust for the di erence in throm opl
s
tin re
ents
m
de y di erent m
nuf
cturers
nd used y v
rious institutions. The INR c
lcul
ti
on uses the
Intern
tion
l Sensitivity Index (ISI) v
lue,
nd is used to monitor
n or
l
nti
co
ul
nt such
s
w
rf
rin. INR is not used to st
nd
rdize APTT testin. 14. Which of the followin
 is correct
re
rdin the intern
tion
l norm
lized r
tio (INR)? A. It uses the Intern
tion
l
Sensitivity
R
tio (ISR) B. It st
nd
rdizes PT results C. It st
nd
rdizes APTT results D. It
is used to
monitor hep
rin ther
py Hemost
sis/Apply knowlede of fund
ment
l ioloic
l
ch
r
cteristics/INR/2 2828_Ch02_041-074 06/08/12 11:09 AM P
e 45 15. Which o
f the followin
is referred to
s
n endoenous
ctiv
tor of pl
sminoen? A. Streptokin
se B. Tr

ns
mid
se C.
Tissue pl
sminoen
ctiv
tor D. Tissue pl
sminoen
ctiv
tor inhi itor Hemost
si
s/Apply knowlede
of fund
ment
l ioloic
l ch
r
cteristics/Pl
sminoen/2 16. Which protein is the
prim
ry
inhi itor of the rinolytic system? A. Protein C B. Protein S C. 2 -Antipl
smin D
. 2
-M
crolo ulin Hemost
sis/Apply knowlede of fund
ment
l ioloic
l ch
r
cterist
ics/Pl
smin/1 17.
Which of the followin st
tements is correct re
rdin the D-dimer test? A. Leve
ls
re decre
sed
in DIC B. Test detects polypeptides A
nd B C. Test detects fr
ments D
nd E D.
Test h
s

ne
tive predictive v
lue Hemost
sis/Apply principles of
sic l
or
tory proced
ures/D-dimer/2
18. A protein th
t pl
ys
role in oth co
ul
tion
nd pl
telet
re
tion is:
A. F
ctor I B.
F
ctor VIII C. F
ctor IX D. F
ctor XI Hemost
sis/Apply knowlede of fund
ment
l
ioloic
l
ch
r
cteristics/Clottin f
ctors/2 19. A st
nd
rd 4.5-mL lue-top tu e lled with
3.0 mL of lood
w
s su mitted to the l
or
tory for PT
nd APTT tests. Te s
mple is from
p
tie

nt underoin
surery the followin mornin for
tonsillectomy. Which of the followin is the
necess
ry course
of
ction y the technoloist? A. Run oth tests in duplic
te
nd report the
ve
r
e result B.
Reject the s
mple
nd request
new s
mple C. Report the PT result D. Report the
APTT result
Hemost
sis/Select methods/Re
ents/Specimen collection
nd h
ndlin/Specimens/3
20. Which
st
tement is correct re
rdin s
mple stor
e for the prothrom in time test? A.
St
le for 24
hours if the s
mple is c
pped B. St
le for 24 hours if the s
mple is refrier
t
ed
t 4C C.
St
le for 4 hours if the s
mple is stored
t 4C D. Should e run within 8 hours
Hemost
sis/Select methods/Re
ents/Specimen collection
nd h
ndlin/Specimens/2
46 Ch
pter 2 |
Hemost
sis Answers to Questions 1520 15. C Tissue pl
sminoen
ctiv
tor (tPA) is

n endoenous
(produced in the ody)
ctiv
tor of pl
sminoen. It is rele
sed from the endothe
li
l cells y the

ction of protein C. It converts pl
sminoen to pl
smin. Streptokin
se is
n exo
enous (not m
de
in the ody)
ctiv
tor of pl
sminoen. 16. C 2 -Antipl
smin is the m
in inhi ito
r of pl
smin.
It inhi its pl
smin y formin
1:1 stoichiometric complex with
ny free pl
smi
n in the pl
sm


nd, therefore, prevents the indin of pl
smin to rin
nd rinoen. 17. D The Ddimer
ss
y
ev
lu
tes rin der
d
tion. It is
nonspeci c screenin test th
t is incre
sed in
m
ny
conditions in which
rinolysis is incre
sed, such
s DIC
nd rinolytic ther
py. T
he D-dimer
test is widely used to rule out throm osis
nd throm otic
ctivities. The ne
ti
ve predictive
v
lue of
test is the pro
ility th
t
person with
ne
tive result is free
of the dise
se
the test is me
nt to detect. Therefore,
ne
tive D-dimer test rules out throm
osis
nd hence
further l
or
tory investi
tions
re not required. 18. A F
ctor I ( rinoen) is
necess
ry for
pl
telet
re
tion
lon with the lycoprotein II /III
complex. F
ctor I is

lso
su str
te
in the common p
thw
y of co
ul
tion. Throm in
cts on rinoen to form
rin clots
. 19. B A
4.5-mL lue-top tu e cont
ins 4.5 mL lood + 0.5 mL sodium citr
te. The tu e sho
uld e 90% full.
A tu e with 3.0 mL lood should e rejected
s qu
ntity not sufficient (QNS). QN
S s
mples
lter
the necess
ry lood to
n
ntico
ul
nt r
tio of 9:1. The excess
ntico
ul
nt i
n
QNS s
mple
inds to the re
ent c
lcium, there y resultin in prolon
tion of the PT
nd AP
TT. 20. A
Accordin to Clinic
l L
or
tory St
nd
rds Institute (CLSI, formerly NCCLS) uid
elines, pl
sm

s
mples for PT testin
re st
le for 24 hours
t room temper
ture if c
pped. Re
frier
tin the
s
mple c
uses cold
ctiv
tion of f
ctor VII
nd, therefore, shortened PT results
. The APTT
s
mples
re st
le for 4 hours if stored
t 4C. 2828_Ch02_041-074 06/08/12 11:0
9 AM P
e 46

21. In prim
ry rinolysis, the rinolytic
ctivity results in response to: A. Incr
e
sed rin
form
tion B. Spont
neous
ctiv
tion of
rinolysis C. Incre
sed rin monomers D. DI
C
Hemost
sis/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics/Fi rinolysi
s/2 22.
Pl
sminoen de ciency is
ssoci
ted with: A. Bleedin B. Trom osis C. Incre
sed
ri
nolysis D.
Incre
sed co
ul
tion Hemost
sis/Correl
te clinic
l
nd l
or
tory d
t
/Pl
smino
en/2 23. Which
of the followin clottin f
ctors
re
ctiv
ted y throm in th
t is ener
ted y
tissue p
thw
y
(TF-VII
)? A. XII, XI B. XII, I C. I, II D. V, VIII Hemost
sis/Apply knowlede o
f fund
ment
l
ioloic
l ch
r
cteristics/Trom in/2 24. Wh
t su str
te is used in
chromoenic
f
ctor
ss
y? A.
p-nitro
n
line B. Chloropheonol red C. Prussi
n lue D. Ferricy
nide Hemost
sis/
Selected
methods/Re
ents/Chromoenic
ss
ys/1 25. Which of the followin
nti odies is u
sed in the
D-dimer
ss
y? A. Polyclon
l directed

inst X
nd Y fr
ments B. Polyclon
l di
rected

inst
D-dimer C. Monoclon
l

inst D
nd E fr
ments D. Monoclon
l

inst D-dimer He
most
sis/Selected
methods/Re
ents/D-dimer
ss
y/2 2.1 | Co
ul
tion
nd Fi rinolytic Systems/Re

ents
nd Methods
47 Answers to Questions 2125 21. B Prim
ry rinolysis is
r
re p
tholoic
l cond
ition in
which
spont
neous systemic rinolysis occurs. Pl
smin is formed in the
sence
of co
ul
tion

ctiv
tion
nd clot form
tion. Prim
ry rinolysis is
ssoci
ted with incre
sed pr
oduction of
pl
sminoen
nd pl
smin, decre
sed pl
smin remov
l from the circul
tion,
nd spo
nt
neous
leedin. 22. B Pl
sminoen de ciency is
ssoci
ted with throm osis. Pl
sminoen i
s
n import
nt
component of the rinolytic system. Pl
sminoen is
ctiv
ted to pl
smin, which is
necess
ry for
der
d
tion of
rin clots to prevent throm osis. When pl
sminoen is de cient, pl
s
min is not
formed, c
usin
defect in the clot lysin processes. 23. D F
ctors V
nd VIII

re
ctiv
ted y
the throm in th
t is ener
ted y the
ction of TF-VII
on f
ctor X to form f
ct
or X
. F
ctor X

forms
complex with f
ctor V
on the pl
telet surf
ces. FX
V
complex in the pr
esence of
phospholipid
nd C
+2 tr
nsform more prothrom in to throm in. 24. A The chromo
enic, or

midolytic,
ss
ys use
color-producin su st
nce known
s
chromophore. The c
hromophore used
for the co
ul
tion l
or
tory is p-nitro
niline (pN
). The pN
is ound to
sy
nthetic
oliopeptide su str
te. The prote
se cle
ves the chromoenic su str
te
t the si
te indin the
oliopeptide to the pNA, which results in rele
se of pNA. Free pNA h
s
yellow
color; the color
intensity of the solution is proportion
l to the prote
se
ctivity
nd is me
sur
ed y

photodetector
t 405 nm. 25. D The D-dimer is the rin der
d
tion product ener

ted y the


ction of pl
smin on cross-linked rin formed y XIII
. The p
tient pl
sm
is mix
ed with l
tex
p
rticles co
ted with monoclon
l
nti odies

inst D-dom
ins. The test c
n e

utom
ted or
performed m
nu
lly on
l
ss slide, lookin m
croscopic
lly for
lutin
tion.
ELISA methods
re

lso
v
il
le. Norm
l D-dimer in pl
sm
is less th
n 2 n/mL. Incre
sed levels
of D-dimer
re

ssoci
ted with DIC, throm olytic ther
py, venous throm osis,
nd throm oem olic
disorders. The
D-dimer
ss
y h
s
90%95% ne
tive predictive v
lue,
nd h
s een used to rule o
ut throm osis

nd throm oem olic disorders. 2828_Ch02_041-074 06/08/12 11:09 AM P
e 47 48
2.2 Pl
telet
nd
V
scul
r Disorders 1. Trom otic throm ocytopenic purpur
(TTP) is ch
r
cterized
y: A. Proloned
PT B. Incre
sed pl
telet
re
tion C. Trom ocytosis D. Proloned APTT Hemost
s
is/Correl
te
clinic
l
nd l
or
tory d
t
/ Pl
telets/2 2. Trom ocytopeni
m
y e
ssoci
ted w
ith: A.
Postsplenectomy B. Hypersplenism C. Acute lood loss D. Incre
sed prolifer
tion
of pluripotenti
l
stem cells Hemost
sis/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics/
Pl
telets/2 3.
Aspirin prevents pl
telet
re
tion y inhi itin the
ction of which enzyme?
A. Phospholip
se
B. Cyclo-oxyen
se C. Trom ox
ne A 2 synthet
se D. Prost
cyclin synthet
se Hemos
t
sis/Apply
knowlede of fund
ment
l ioloic
l ch
r
cteristics/Pl
telets/1 4. Norm
l pl
tel
et
dhesion
depends upon: A. Fi rinoen B. Glycoprotein I C. Glycoprotein II , III
complex
D. C
lcium
Hemost
sis/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics/Pl
telets/1
5. Which of the
followin test results is norm
l in
p
tient with cl
ssic von Wille r
nds dise
s
e? A. Bleedin
time B. Activ
ted p
rti
l throm opl
stin time C. Pl
telet count D. F
ctor VIII:C

nd von
Wille r
nds f
ctor (VWF) levels Hemost
sis/Correl
te clinic
l
nd l
or
tory d
t

/ Pl
telet
disorders/3 Answers to Questions 16 1. B Throm otic throm ocytopenic purpur
(TTP
) is

qu
ntit
tive pl
telet disorder
ssoci
ted with incre
sed intr
v
scul
r pl
telet

ctiv
tion
nd

re
tion resultin in throm ocytopeni
. The PT
nd APTT results
re norm
l in
TTP. 2. B
Hypersplenism is
ssoci
ted with throm ocytopeni
. In this condition, up to 90%
of pl
telets c
n
e sequestered in the spleen, c
usin decre
ses in circul
tory pl
telets. Postsp
lenectomy,
cute
lood loss,
nd incre
sed prolifer
tion of pluripotenti
l stem cells
re
ssoci

ted with
throm ocytosis. 3. B Aspirin prevents pl
telet
re
tion y inhi itin the
ct
ivity of the
enzyme cyclo-oxyen
se. This inhi ition prevents the form
tion of throm ox
ne A
2 (TXA2), which
serves
s
potent pl
telet
re
tor. 4. B Glycoprotein I is
pl
telet recep
tor for VWF.
Glycoprotein I
nd VWF
re oth necess
ry for
norm
l pl
telet
dhesion. Other
proteins th
t

pl
y
role in pl
telet
dhesion
re lycoproteins V
nd IX. 5. C Von Wille r
nds
dise
se is
n
inherited, qu
lit
tive pl
telet disorder resultin in incre
sed leedin, prolon
ed APTT,
nd
decre
sed f
ctor VIII:C
nd VWF levels. The pl
telet count
nd morpholoy
re e
ner
lly norm
l in
von Wille r
nds dise
se, ut
re
tion in the pl
telet function
ss
y is
norm

l. 6. C
Bern
rdSoulier syndrome is
ssoci
ted with throm ocytopeni

nd i
nt pl
telets.
It is

qu
lit
tive pl
telet disorder c
used y the deficiency of lycoprotein I . In Be
rn
rdSoulier
syndrome, pl
telet
re
tion to ADP is norm
l. Are
tion in the pl
telet fun
ction
ss
y is

norm
l. F
ctor VIII
ss
y is not indic
ted for this di
nosis. 6. Bern
rdSoulie
r syndrome is

ssoci
ted with: A. Decre
sed leedin time B. Decre
sed f
ctor VIII
ss
y C. Tr
om ocytopeni

nd
i
nt pl
telets D. A norm
l pl
telet
re
tion to ADP Hemost
sis/Correl
te cli
nic
l
nd
l
or
tory d
t
/Pl
telet disorders/3 2828_Ch02_041-074 06/08/12 11:09 AM P
e
48 7. When
performin pl
telet
re
tion studies, which set of pl
telet
re
tion resul
ts would most
likely e
ssoci
ted with Bern
rdSoulier syndrome? A. Norm
l pl
telet
re
tion
to coll
en,
ADP,
nd ristocetin B. Norm
l pl
telet
re
tion to coll
en, ADP,
nd epineph
rine; decre
sed

re
tion to ristocetin C. Norm
l pl
telet
re
tion to epinephrine
nd rist
ocetin; decre
sed

re
tion to coll
en
nd ADP D. Norm
l pl
telet
re
tion to epinephrine, r
istocetin,
nd
coll
en; decre
sed
re
tion to ADP Hemost
sis/Correl
te clinic
l
nd l
or
t
ory d
t
/
Pl
telet disorders/3 8. Which set of pl
telet responses would e most likely
ss
oci
ted with
Gl
nzm
nns throm
stheni
? A. Norm
l pl
telet
re
tion to ADP
nd ristocetin;
decre
sed

re
tion to coll
en B. Norm
l pl
telet
re
tion to coll
en; decre
sed

re
tion to ADP

nd ristocetin C. Norm
l pl
telet
re
tion to ristocetin; decre
sed
re
ti
on to coll
en,
ADP,
nd epinephrine D. Norm
l pl
telet
re
tion to ADP; decre
sed
re
tio
n to coll
en
nd
ristocetin Hemost
sis/Correl
te clinic
l
nd l
or
tory d
t
/ Pl
telet disorders
/3 9. Which of
the followin is
ch
r
cteristic of
cute immune throm ocytopenic purpur
? A. S
pont
neous
remission within
few weeks B. Predomin
ntly seen in
dults C. Nonimmune pl
tel
et destruction D.
Insidious onset Hemost
sis/Apply knowlede of fund
ment
l ioloic
l ch
r
cteris
tics/Pl
telet
disorders/2 10. TTP di ers from DIC in th
t: A. APTT is norm
l in TTP ut prolone
d in DIC B.
Schistocytes
re not present in TTP ut
re present in DIC C. Pl
telet count is
decre
sed in TTP
ut norm
l in DIC D. PT is proloned in TTP ut decre
sed in DIC Hemost
sis/Corr
el
te clinic
l

nd l
or
tory d
t
/ Pl
telet disorders/3 2.2 | Pl
telet
nd V
scul
r Disorders
49 Answers to

Questions 711 7. B Bern
rdSoulier syndrome is
disorder of pl
telet
dhesion c
us

ed y
de ciency of lycoprotein I . Pl
telet
re
tion is norm
l in response to coll

en, ADP,
nd
epinephrine ut
norm
l in response to ristocetin. 8. C Gl
nzm
nns throm
stheni

is
disorder
of pl
telet
re
tion. Pl
telet
re
tion is norm
l in response to ristoceti
n, ut
norm
l
in response to coll
en, ADP,
nd epinephrine. 9. A Acute immune throm ocytopeni
c purpur
is
n
immune-medi
ted disorder found predomin
ntly in children. It is commonly
ssoci

ted with
infection (prim
rily vir
l). It is ch
r
cterized y
rupt onset,
nd spont
neou
s remission
usu
lly occurs within sever
l weeks. 10. A Throm otic throm ocytopenic purpur
i
s
pl
telet
disorder in which pl
telet
re
tion incre
ses, resultin in throm ocytopeni
.
Schistocytes
re
present in TTP
s
result of micro
niop
thic hemolytic
nemi
; however, the PT

nd APTT
re
oth norm
l. In DIC, the PT
nd APTT
re oth proloned, the pl
telet count is d
ecre
sed,
nd
schistocytes
re seen in the peripher
l sme
r. 11. C Neon
t
l
lloimmune throm o
cytopeni
is
simil
r to the hemolytic dise
se of the fetus
nd new orn. It results from immun
iz
tion of the
mother y fet
l pl
telet
ntiens. The o endin
nti odies
re commonly
nti HPA-1



llo
nti odies th
t
re directed

inst lycoproteins II /III
, I /IX, I
/II ,

nd CD 109. The
m
tern
l
nti odies cross the pl
cent
, resultin in throm ocytopeni
in the fet
us. 11. Sever
l
hours
fter irth,

y oy develops petechi
e
nd purpur

nd
hemorrh
ic d
i
thesis. Te
pl
telet count is 18 10 9
/
L. Wh
t is
the most likely expl
n
tion for the low pl
telet count? A. Dru-induced
throm ocytopeni
B.
Second
ry throm ocytopeni
C. Neon
t
l
lloimmune throm ocytopeni
D. Neon
t
l D
IC
Hemost
sis/Correl
te clinic
l
nd l
or
tory d
t
/Pl
telet disorders/3 2828_Ch02
_041-074
06/08/12 11:09 AM P
e 49 12. Which of the followin is
ssoci
ted with post-t
r
nsfusion
purpur
(PTP)? A. Nonimmune throm ocytopeni
/
llo
nti odies B. Immune-medi
ted t
hrom ocytopeni
/

llo
nti odies C. Immune-medi
ted throm ocytopeni
/
uto
nti odies D. Nonimmunemedi
ted
throm ocytopeni
/
uto
nti odies Hemost
sis/Apply knowlede of fund
ment
l iolo
ic
l
ch
r
cteristics/Pl
telet disorders/2 13. Hemolytic uremic syndrome (HUS) is
sso
ci
ted with: A.
Fever, throm ocytosis,
nemi
,
nd ren
l f
ilure B. Fever, r
nulocytosis,
nd t
hrom ocytosis C.
Escherichi
coli 0157:H7 D. Leukocytosis
nd throm ocytosis Hemost
sis/Apply kno
wlede of
fund
ment
l ioloic
l ch
r
cteristics/Pl
telet disorders/2 14. Stor
e pool de ci
encies
re
defects of: A. Pl
telet
dhesion B. Pl
telet
re
tion C. Pl
telet r
nules D.
Pl
telet

production Hemost
sis/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics/

Pl
telet
disorders/1 15. Lumi-
re
tion me
sures: A. Pl
telet
re
tion only B. Pl
te
let
re
tion

nd ATP rele
se C. Pl
telet
dhesion D. Pl
telet lycoprotein I Hemost
sis/Sele
ct
methods/Re
ents/Specimen collection
nd h
ndlin/Areometry/1 16. Neuroloic

l ndins m
y e
commonly
ssoci
ted with which of the followin disorders? A. HUS B. TTP C. ITP
D. PTP
Hemost
sis/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics/Pl
telet fu
nction/1 17.
Which of the followin is correct re
rdin
cquired throm otic throm ocytopenic
purpur
? A.
Autoimmune dise
se B. Decre
sed VWF C. Decre
sed pl
telet
re
tion D. Decre
s
ed pl
telet

dhesion Hemost
sis/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics/Pl

telet
disorders/2 50 Ch
pter 2 | Hemost
sis Answers to Questions 1218 12. B Post-tr
nsf
usion purpur

is
r
re form of
lloimmune throm ocytopeni
ch
r
cterized y severe throm ocyt
openi
followin
tr
nsfusion of lood or lood products. PTP is c
used y
nti ody-rel
ted pl
tel
et destruction in
previously immunized p
tients. In the m
jority of c
ses, the
llo
nti ody produc
ed is

inst
pl
telet
ntien A 1 (Pl A1 ),
lso referred to
s HPA-1
. 13. C HUS is c
used
y E. coli
0157:H7. It is
ssoci
ted with inestion of E. colicont
min
ted foods
nd is comm
only seen in
children. The clinic
l m
nifest
tions in HUS
re fever, di
rrhe
, throm ocytopen
i
,
micro
niop
thic hemolytic
nemi
,
nd ren
l f
ilure. 14. C Stor
e pool de cienci
es
re defects
of pl
telet r
nules. Most commonly,
decre
se in pl
telet-dense r
nules is pr
esent with
decre
sed rele
se of ADP, ATP, c
lcium,
nd serotonin from pl
telet-dense r
nul
es. 15. B
Lumi-
re
tion me
sures pl
telet
re
tion
nd ATP rele
se. It is performed
on whole lood
diluted with s
line. Pl
telet
re
tion is me
sured y imped
nce, where
s ATP
rele
se is
me
sured y
ddition of luciferin to
lood s
mple. There is no ATP rele
se in
stor
e pool
de ciencies. 16. B TTP is ch
r
cterized y neuroloic
l pro lems, fever, throm ocy
topeni
,
micro
niop
thic hemolytic
nemi
,
nd ren
l f
ilure. 17. A Acquired TTP is
n

utoimmune dise
se

ssoci
ted with
uto
nti odies produced

inst VWF cle
vin enzyme (ADAMTS-13).
This de ciency
results in
n incre
se in pl
sm
VWF
nd consequently incre
sed pl
telet
re

tion
nd
throm ocytopeni
. 18. D Heredit
ry hemorrh
ic tel
niect
si
(Osler-We er-Rendu
syndrome) is

connective tissue disorder
ssoci
ted with tel
niect
ses (dil
ted c
pill
ries)
of the mucous
mem r
nes
nd skin. Lesions m
y develop on the tonue, lips, p
l
te, f
ce, h
nds
, n
s
l mucos
,

nd throuhout the 
strointestin
l tr
ct. This disorder is
n
utosom
l domin
n
t condition th
t

usu
lly m
nifests in
dolescence or e
rly
dulthood. 18. Heredit
ry hemorrh
ic

tel
niect
si
is

disorder of: A. Pl
telets B. Clottin proteins C. Fi rinolysis D. Connective t
issue
Hemost
sis/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics/2 2828_Ch02
_041-074
06/08/12 11:09 AM P
e 50 19. Which of the followin prevents pl
telet
re

tion? A.
Trom ox
ne A 2 B. Trom ox
ne B 2 C. Prost
cyclin D. Antithrom in Hemost
sis/Appl
y knowlede of
fund
ment
l ioloic
l ch
r
cteristics/Pl
telets/2 20. Which defect ch
r
cterize
s Gr
ys
syndrome? A. Pl
telet
dhesion defect B. Dense r
nule defect C. Alph
r
nule d
efect D.
Co
ul
tion defect Hemost
sis/Apply knowlede of fund
ment
l ioloic
l ch
r
cte
ristics/Pl
telet
disorders/2 21. Te P2Y12 ADP receptor
onist
ss
y m
y e used to monitor pl
te
let
re
tion
inhi ition to which of the followin drus? A. W
rf
rin B. Hep
rin C. LMWH D. Cl
opidorel
(Pl
vix) Hemost
sis/Selected methods/Re
ents/Speci
l tests/2 2.2 | Pl
telet
nd
V
scul
r
Disorders 51 Answers to Questions 1921 19. C Prost
cyclin is rele
sed from the
endothelium
nd
is
n inhi itor of pl
telet
re
tion. Throm ox
ne A 2 promotes pl
telet
re

tion.
Throm ox
ne B 2 is
n oxidized form of throm ox
ne A 2
nd is excreted in the ur
ine. Antithrom in
is
physioloic
l
ntico
ul
nt. 20. C Gr
ys syndrome is
pl
telet r
nule defe
ct
ssoci
ted
with
decre
se in
lph
r
nules resultin in decre
sed production of
lph
r

nule proteins
such
s pl
telet f
ctor 4
nd et
throm olo ulin. Alph
r
nule de ciency result
s in the

ppe
r
nce of
r
nul
r pl
telets when viewed on
Wrihts- st
ined lood sme
r.
21. D The
VerifyNow P2Y12 test is used to
ssess
p
tients response to
ntipl
telet drus
such
s
clopidorel (Pl
vix)
nd pr
surel (E ent). These drus
re iven or
lly for preve
ntion of
throm osis
lon with
spirin, or
s
ltern
tive
ntipl
telet drus for p
tients
who c
nnot
toler
te or
re not sensitive to
spirin. Clopidorel
nd pr
surel prevent pl
t
elet
re
tion
y irreversi ly indin to P2Y12, which is
pl
telet mem r
ne receptor for ADP.
The VerifyNow
P2Y12 test is
whole lood test
nd uses ADP
s
n
re
tin
ent to me
sure
the level of
pl
telet
re
tion imp
ired y these medic
tions. The
seline pl
telet
re

tion is
est
lished. The percent (%) ch
ne from
seline
re
tion is c
lcul
ted
nd
reported
s %
P2Y12 inhi ition. 2828_Ch02_041-074 06/08/12 11:09 AM P
e 51 22. Which of th
e followin
instruments c
n e used to ev
lu
te pl
telet function? A. Pl
telet
reometer
B. VerifyNow C.
PFA-100 D. All of the
ove Hemost
sis/Selected methods/Re
ents/Speci
l tests/2
23. Which of the
followin pl
telet
re
tin
ents demonstr
tes
monoph
sic
re
tion curv
e when used in

optim
l concentr
tion? A. Trom in B. Coll
en C. Adenosine diphosph
te (ADP) D.

Epinephrine
Hemost
sis/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics/Are
tin

ents/1 52
Ch
pter 2 | Hemost
sis Answers to Questions 2223 22. D All of the instruments lis
ted c
n e used
to ev
lu
te pl
telet function. Pl
telet function testin is done to either deter
mine the c
use of
leedin in
p
tient with norm
l pl
telet count
nd norm
l co
ul
tion tests, o
r to
ssess the
e c
cy of
ntipl
telet drus. Pl
telet
reometry is used for the di
nosis of i
nherited
pl
telet disorders. A pl
telet
reometer uses pl
telet-rich pl
sm
to me
sure
pl
telet

re
tion in response to di erent pl
telet
re
tin
ents y me
surin the l
iht
tr
nsmission. A Lumi-
reometer uses whole lood,
nd h
s the
ility to me
su
re dense-r
nule
secretion (usin
luminescent m
rker) in
ddition to pl
telet
re
tion. The
VerifyNow
me
sures
p
tients response to multiple
ntipl
telet drus includin
spirin, P2
Y12 inhi itors,

nd lycoprotein II /III
inhi itors. The PFA-100 (Pl
telet Function
n
nlyzer-1
00) is used
s

pl
telet function screen in pl
ce of the leedin time. It uses citr
ted whole
lood. A drop of
venous lood is put into
test c
rtride. V
cuum is used to move the lood thro
uh
very thin
l
ss tu e th
t h
s een co
ted with
mem r
ne cont
inin coll
en
nd either e
pinephrine (EPI)
or ADP. This co
tin
ctiv
tes the pl
telets in the movin s
mple,
nd promotes
pl
telet
dhesion

nd
re
tion. The time it t
kes for the clot to form inside the l
ss tu e
n
d prevent further
ow is me
sured
s the closure time (CT). An initi
l screen is done with coll
en/
EPI. If the CT
is norm
l, it is unlikely th
t pl
telet dysfunction exists. The coll
en/ADP mem
r
ne is used to
con rm
n
norm
l coll
en/EPI test. If oth tests
re
norm
l, it is likely th

t the p
tient
h
s
pl
telet dysfunction,
nd further testin for inherited
nd
cquired leed
in disorders is
indic
ted. If coll
en/ADP is norm
l, then the
norm
l coll
en/EPI test is lik
ely due to

spirin sensitivity. 23. B Coll
en is the only commonly used
ent th
t demonst
r
tes

sinle-w
ve (monoph
sic) response preceded y
l
 time. 2828_Ch02_041-074 06/
08/12 11:09 AM
P
e 52 53 2.3 Co
ul
tion System Disorders 1. Te APTT is sensitive to
de ciency
of which
clottin f
ctor? A. F
ctor VII B. F
ctor X C. PF3 D. C
lcium Hemost
sis/Ev
lu
te
l
or
tory d
t

to reconize he
lth
nd dise
se st
tes/F
ctor de ciency/2 2. Which test result wou
ld e norm
l in

p
tient with dys rinoenemi
? A. Trom in time B. APTT C. PT D. Immunoloic rino
en level
Hemost
sis/Correl
te clinic
l
nd l
or
tory d
t
/ F
ctor de ciency/3 3. A p
tient
with

proloned PT is iven intr
venous vit
min K. Te PT corrects to norm
l
fter 24 h
ours. Wh
t

clinic
l condition most likely c
used these results? A. Necrotic liver dise
se B
. F
ctor X
de ciency C. Fi rinoen de ciency D. O structive j
undice Hemost
sis/Correl
te clini
c
l
nd
l
or
tory d
t
/ Vit
min K de ciency/3 4. Which f
ctor de ciency is
ssoci
ted with

proloned
PT
nd APTT? A. X B. VIII C. IX D. XI Hemost
sis/Ev
lu
te l
or
tory d
t
to rec
onize he
lth
nd
dise
se st
tes/F
ctor de ciency/2 5. A proloned APTT is corrected with f
ctor VII
I de cient
pl
sm
ut not with f
ctor IXde cient pl
sm
. Which f
ctor is de cient? A. V B. VIII
C. IX D. X
Hemost
sis/Ev
lu
te l
or
tory d
t
to reconize he
lth
nd dise
se st
tes/F
cto
r de ciency/3
Answers to Questions 16 1. B The APTT is sensitive to the de ciency of co
ul
tion
f
ctors in
the intrinsic p
thw
y (f
ctors XII, XI, IX,
nd VIII)
nd the common p
thw
y (f

ctors X, V, II,

nd I). 2. D The level of pl
sm
rinoen determined immunoloic
lly is norm
l. I
n
p
tient
with dys rinoenemi
,
rinoen is not polymerized properly, c
usin
norm
l
rinoen-dependent co
ul
tion tests. 3. D O structive j
undice contri utes to co

ul
tion
disorders y preventin vit
min K
sorption. Vit
min K is f
t solu le
nd requi
res ile s
lts
for
sorption. P
renter
l
dministr
tion of vit
min K yp
sses the owel; hence
the need for
ile s
lts. 4. A F
ctor X,
common p
thw
y f
ctor de ciency, is most likely suspe
cted, ec
use
oth PT
nd APTT
re proloned. Other c
uses m
y include liver dise
se, vit
min
K de ciency,
nd

ntico
ul
nt drus such
s Coum
din
nd hep
rin. 5. C Bec
use the proloned APT
T is not
corrected with
f
ctor IXde cient pl
sm
, f
ctor IX is suspected to e de cient in t
he test
pl
sm
. 6. C Hemophili
A (f
ctor VIII de ciency) is ch
r
cterized y mild to seve
re leedin
episodes, dependin upon the concentr
tion of f
ctor VIII:C. Hemophili
A is inh
erited
s

sex-linked dise
se. Bleedin time
nd prothrom in time
re oth norm
l in hemoph
ili
A. 6. Which
of the followin is
ch
r
cteristic of cl
ssic hemophili
A? A. Proloned leed
in time B.
Autosom
l recessive inherit
nce C. Mild to severe leedin episodes D. Proloned
PT
Hemost
sis/Correl
te clinic
l
nd l
or
tory d
t
/ Hemost
sis/Hemophili
/2 2828_
Ch02_041-074
06/08/12 11:09 AM P
e 53 7. Refer to the followin results: PT = proloned AP
TT = proloned
Pl
telet count = decre
sed Which disorder m
y e indic
ted? A. F
ctor VIII de cien
cy B. von
Wille r
nds dise
se C. DIC D. F
ctor IX de ciency Hemost
sis/Correl
te clinic
l
nd
l
or
tory
d
t
/ Co
ul
tion disorders/3 8. Which of the followin is
predisposin condit
ion for the
development of DIC? A. Adenoc
rcinom
B. Idiop
thic throm ocytopenic purpur
(IT
P) C.
Post-tr
nsfusion purpur
(PTP) D. Hep
rin-induced throm ocytopeni
(HIT) Hemost

sis/Correl
te
clinic
l
nd l
or
tory d
t
/DIC/1 9. F
ctor XII de ciency is
ssoci
ted with: A.

Bleedin
episodes B. Epist
xis C. Decre
sed risk of throm osis D. Incre
sed risk of throm
osis
Hemost
sis/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics/F
ctor de cie
ncy/2 10. Te
followin results were o t
ined on
p
tient: norm
l pl
telet count
nd function
, norm
l PT,
nd
proloned APTT. Which of the followin disorders is most consistent with these r
esults? A.
Hemophili
A B. Bern
rdSoulier syndrome C. von Wille r
nds dise
se D. Gl
nzm
nns
throm
stheni
Hemost
sis/Correl
te clinic
l
nd l
or
tory d
t
/ Co
ul
tion di
sorders/3 11. Te
followin l
or
tory results were o t
ined from
40-ye
r-old wom
n: PT = 20 sec
; APTT = 50 sec;
throm in time = 18 sec. Wh
t is the most pro
le di
nosis? A. F
ctor VII de cien
cy B. F
ctor
VIII de ciency C. F
ctor X de ciency D. Hypo rinoenemi
Hemost
sis/Correl
te clinic

l
nd
l
or
tory d
t
/ F
ctor de ciency/3 12. When performin
f
ctor VIII
ctivity
ss

y,
p
tients
pl
sm
is mixed with: A. Norm
l p
tients pl
sm
B. F
ctor VIII de cient pl
sm
C. P
l
sm
with

hih concentr
tion of f
ctor VIII D. Norm
l control pl
sm
Hemost
sis/Apply prin
ciples of
sic
l
or
tory procedures/Co
ul
tion tests/2 54 Ch
pter 2 | Hemost
sis Answers to Q
uestions 712 7.
C In DIC, there is
di use intr
v
scul
r ener
tion of throm in
nd rin. As
res
ult,
co
ul
tion f
ctors
nd pl
telets
re consumed, resultin in decre
sed pl
telet
count
nd
incre
sed PT
nd APTT. 8. A Adenoc
rcinom
c
n li er
te proco
ul
nt (throm opl

stic) su st
nces
th
t c
n
ctiv
te prothrom in intr
v
scul
rly. ITP is
throm ocytopeni
c
used
y
n

uto
nti ody; PTP is
n
lloimmune throm ocytopeni
c
used y tr
nsfusion of lo
od or lood
products; HIT results from
n
nti ody to hep
rin-PF4 complex c
usin throm ocyt
openi
in 1%5%
of p
tients who
re on hep
rin ther
py. In some
ected persons, throm osis m
y
l
so occur. 9. D
F
ctor XIIde cient p
tients commonly h
ve throm otic episodes. F
ctor XII is the co
nt
ct

ctiv
tor of the intrinsic p
thw
y of co
ul
tion. It
lso pl
ys
m
jor role in
the rinolytic
system y
ctiv
tin pl
sminoen to form pl
smin. Hemorrh
ic m
nifest
tions
re
not
ssoci
ted
with f
ctor XII de ciency ec
use throm in ener
ted y the extrinsic p
thw
y c
n

ctiv
te f
ctor
XI to XI
,
nd f
ctor VII
/TF c
n
ctiv
te f
ctor IX to IX
. 10. A Hemophili
A
is
ssoci
ted
with the de ciency of f
ctor VIII resultin in leedin
nd
n
norm
l APTT. The
pl
telet num er

nd function
re norm
l in this disorder. Von Wille r
nds dise
se is
disorder o
f pl
telet

dhesion
ssoci
ted with decre
sed VWF
nd f
ctor VIII, c
usin
n
norm
l pl
t
elet function
test
nd
n
norm
l APTT test. Both Gl
nzm
nns throm
stheni

nd Bern
rdSoulier
syndrome
c
use de cient pl
telet
re
tion, ut do not c
use
n
norm
l APTT. 11. D Fi r
inoen (f
ctor

I) is
clottin protein of the common p
thw
y
nd is ev
lu
ted y the throm in

time. In
hypo rinoenemi
( rinoen concentr
tion <100 m/dL), the PT, APTT,
nd TT
re pro
loned. In
f
ctor VII de ciency, the APTT is norm
l; in f
ctor VIII de ciency, the PT is norm
l
;
nd in
f
ctor X de ciency, the TT is norm
l. 12. B Co
ul
tion f
ctor
ss
ys
re
sed up
on the
ility
of the p
tients pl
sm
to correct
ny speci c f
ctor-de cient pl
sm
. To me
sure for
f
ctor VIII

ctivity in
p
tients pl
sm
, diluted p
tient pl
sm
is mixed with
f
ctor VIIId
e cient
pl
sm
. An APTT test is performed on the mixture. E
ch l
or
tory should c
lcul

te its own norm
l
r
nes
sed on p
tient popul
tion, re
ents,
nd the instrument used. An
pprox
im
te r
ne of
50%150% is considered norm
l. 2828_Ch02_041-074 06/08/12 11:09 AM P
e 54 13.
Te most
suit
le product for tre
tment of f
ctor VIII de ciency is: A. Fresh frozen pl
sm

B. F
ctor VIII
concentr
te C. Prothrom in complex concentr
te D. F
ctor V Leiden Hemost
sis/Cor
rel
te clinic
l

nd l
or
tory d
t
/Tre
tment/2 14. Which of the followin is
ssoci
ted with
n

norm
l
pl
telet
re
tion test? A. F
ctor VIII de ciency B. F
ctor VIII inhi itor C. Lu
pus

ntico
ul
nt D. A rinoenemi
Hemost
sis/Correl
te clinic
l
nd l
or
tory d
t
/
F
ctor
de ciency/2 15. Refer to the followin results: PT = norm
l APTT = proloned Bleed
in time=
incre
sed Pl
telet count = norm
l Pl
telet
re
tion to ristocetin =
norm
l
Which of the
followin disorders m
y e indic
ted? A. F
ctor VIII de ciency B. DIC C. von Wille
r
nds dise
se
D. F
ctor IX de ciency Hemost
sis/Correl
te clinic
l
nd l
or
tory d
t
/ Co
ul
t
ion disorders/3
16. Which results
re
ssoci
ted with hemophili
A? A. Proloned APTT, norm
l PT
B. Proloned PT

nd APTT C. Proloned PT, norm
l APTT D. Norm
l PT
nd APTT Hemost
sis/Correl
te
clinic
l
nd
l
or
tory d
t
/ Hemophili
/2 17. Fi rin monomers
re incre
sed in which of the
followin
conditions? A. Prim
ry rinolysis B. DIC C. F
ctor VIII de ciency D. Fi rinoen de ci
ency
Hemost
sis/Correl
te clinic
l
nd l
or
tory d
t
/2 18. Which of the followin i
s
ssoci
ted with
multiple f
ctor de ciencies? A. An inherited disorder of co
ul
tion B. Severe liv
er dise
se C.
Dys rinoenemi
D. Lupus
ntico
ul
nt Hemost
sis/Correl
te clinic
l
nd l
or
to
ry d
t
/ F
ctor
de ciency/2 2.3 | Co
ul
tion System Disorders 55 Answers to Questions 1319 13. B
F
ctor VIII
concentr
te (hum
n or recom in
nt) is the tre
tment of choice for p
tients with
f
ctor VIII
de ciency. Fresh frozen pl
sm
cont
ins f
ctor VIII; however, it is no loner used

s the prim
ry
tre
tment for f
ctor VIII de ciency. Prothrom in complex concentr
te is used to tr
e
t p
tients
with f
ctor VIII inhi itor. 14. D Fi rinoen is
pl
sm
protein th
t is essenti

l for pl
telet


re
tion
nd rin form
tion. In
rinoenemi
, pl
telet
re
tion is
norm
l

. 15. C VWF
is involved in oth pl
telet
dhesion
nd co
ul
tion vi
complexin with f
ctor
VIII. Therefore,
in von Wille r
nds dise
se (de ciency or function
l
norm
lity of VWF) f
ctor VIII
is
lso
decre
sed, c
usin
n
norm
l APTT
s well
s
norm
l pl
telet
re
tion to
ristocetin. The
pl
telet count
nd the PT
re not
ected in VWF de ciency. 16. A Hemophili
A is
s
soci
ted with
f
ctor VIII de ciency. F
ctor VIII is
f
ctor in the intrinsic co
ul
tion p
thw

y th
t is
ev
lu
ted y the APTT
nd not the PT test. The PT test ev
lu
tes the extrinsic

nd common
p
thw
ys. 17. B Incre
sed rin monomers result from co
ul
tion
ctiv
tion. DIC i
s
n
cquired
condition
ssoci
ted with spont
neous
ctiv
tion of co
ul
tion
nd rinolysis. I
n prim
ry
rinolysis, the rinolytic system is
ctiv
ted
nd rin monomers
re norm
l. 18. B
Most of the
clottin f
ctors
re m
de in the liver. Therefore, severe liver dise
se results
in multiple
f
ctor de ciencies. An inherited disorder of co
ul
tion is commonly
ssoci
ted wi
th
sinle
f
ctor de ciency. Lupus
ntico
ul
nt is directed

inst the phospholipid-depende
nt co
ul
tion
f
ctors. Dys rinoenemi
results from
n
norm
l
rinoen molecule. 19. D F
ctor
XIII
de ciency c
n le
d to imp
ired wound he
lin
nd m
y c
use severe leedin pro lem
s. F
ctor XIII
is

rin st
ilizin f
ctor th
t ch
nes the
rinoen onds in
rin polymers to st

le
cov
lent onds. F
ctor XIII is not involved in the process of rin form
tion
nd,
therefore, the
PT
nd APTT
re oth norm
l. 19. Norm
l PT
nd APTT results in
p
tient with

poor wound
he
lin m
y e
ssoci
ted with: A. F
ctor VII de ciency B. F
ctor VIII de ciency C.
F
ctor XII
de ciency D. F
ctor XIII de ciency Hemost
sis/Correl
te clinic
l
nd l
or
tory d
t

/ F
ctor
de ciency/2 2828_Ch02_041-074 06/08/12 11:09 AM P
e 55 20. Fletcher f
ctor (pr
ek
llikrein)
de ciency m
y e
ssoci
ted with: A. Bleedin B. Trom osis C. Trom ocytopeni
D. T
rom ocytosis
Hemost
sis/Correl
te clinic
l
nd l
or
tory d
t
/ F
ctor de ciency/2 21. One of t
he
complic
tions
ssoci
ted with
severe hemophili
A is: A. Hem
rthrosis B. Mucou
s mem r
ne
leedin C. Mild leedin durin surery D. Immune-medi
ted throm ocytopeni
Hem
ost
sis/Apply
knowlede of fund
ment
l ioloic
l ch
r
cteristics/Hemophili
/1 22. Te most com
mon su type of
cl
ssic von Wille r
nds dise
se is: A. Type 1 B. Type 2A C. Type 2B D. Type 3 Hem
ost
sis/Apply
knowlede of fund
ment
l ioloic
l ch
r
cteristics/von Wille r
nds dise
se/2 23.
A proloned
APTT
nd PT
re corrected when mixed with norm
l pl
sm
. Which f
ctor is most li
kely de cient? A.
VIII B. V C. XI D. IX Hemost
sis/Ev
lu
te l
or
tory d
t
to reconize he
lth
n
d dise
se

st
tes/F
ctor de ciency/3 56 Ch
pter 2 | Hemost
sis Answers to Questions 2023 20. B

Fletcher
f
ctor (prek
llikrein) is
cont
ct f
ctor. Activ
ted prek
llikrein is n
med k
l
likrein
nd is
involved in
ctiv
tion of f
ctor XII to XII
. Like f
ctor XII de ciency, Fletcher
f
ctor
de ciency m
y e
ssoci
ted with throm osis. 21. A In severe hemophili
A, f
ctor
VIII
ctivity
is less th
n 1%, resultin in
severe leedin di
thesis such
s hem
rthrosis (
leedin into the
joints). 22. A VWF is
multimeric pl
sm
lycoprotein th
t results in di erent su
types of von
Wille r
nds dise
se with v
ried severity. The most common su type is su type 1,

nd 70%80% of
these c
ses
re
ssoci
ted with mild leedin. Su type 3 involves the tot
l
se
nce of the von
Wille r
nds molecule
nd is
ssoci
ted with severe leedin. Su types 2A
nd 2B r
esult in
de ciency of intermedi
te
nd/or hih molecul
r weiht portions of the von Wille r

nd molecule

nd
re
ssoci
ted with 10%12%
nd 3%6% of c
ses of von Wille r
nds dise
se, respec
tively. 23.
B F
ctor V (common p
thw
y f
ctor) de ciency is most likely suspected, ec
use ot
h the PT
nd
APTT
re proloned,
nd oth
re corrected when mixed with norm
l pl
sm
. 2828_C
h02_041-074
06/08/12 11:09 AM P
e 56 57 2.4 Inhi itors, Trom otic Disorders,
nd Antico

ul
nt Drus 1.
Which ch
r
cteristic descri es
ntithrom in (AT)? A. It is synthesized in me
k

ryocytes B. It is

ctiv
ted y protein C C. It is
cof
ctor of hep
rin D. It is
p
tholoic
l in
hi itor of
co
ul
tion Hemost
sis/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics
/AT/1 2. Which
l
or
tory test is
ected y hep
rin ther
py? A. Trom in time B. Fi rinoen
ss
y
C. Protein C

ss
y D. Protein S
ss
y Hem
toloy/Apply knowlede of fund
ment
l ioloic
l
ch
r
cteristics/Hemost
sis/Hep
rin/2 3. An
norm
l APTT c
used y
p
tholoic

l circul
tin

ntico
ul
nt is: A. Corrected with f
ctor VIIIde cient pl
sm
B. Corrected with f

ctor
IXde cient pl
sm
C. Corrected with norm
l pl
sm
D. Not corrected with norm
l pl
s
m

Hemost
sis/Correl
te clinic
l
nd l
or
tory d
t
/ Speci
l tests/2 4. Te lupus

ntico
ul
nt

ects which of the followin tests? A. F
ctor VIII
ss
y B. F
ctor IX
ss
y C. VW
F
ss
y D.
Phospholipid-dependent
ss
ys Hemost
sis/Apply knowlede of fund
ment
l ioloic

l
ch
r
cteristics/Lupus
ntico
ul
nt/2 5. Which st
tement
out Coum
din (w
rf
ri
n) is
ccur
te?
A. It is
vit
min B
nt
onist B. It is not recommended for pren
nt
nd l
ct
t
in women C. It
needs
ntithrom in
s
cof
ctor D. APTT test is used to monitor its dos
e Hemo
st
sis/Apply
knowlede of fund
ment
l ioloic
l ch
r
cteristics/W
rf
rin/2 Answers to Questi
ons 15 1. C
Antithrom in is hep
rin cof
ctor
nd it is the most import
nt n
tur
lly occurrin
 physioloic
l
inhi itor of lood co
ul
tion. It represents
out 75% of
ntithrom otic
ctivi

ty
nd is
n 2lo ulin m
de y the liver. 2. A Hep
rin is
n
ntithrom in dru,
nd therefore
incre
ses the
throm in time test
lon with the APTT
nd PT. Hep
rin ther
py h
s no e ect on rin
oen, protein
C, or protein S
ss
ys. APTT is the test of choice for monitorin hep
rin ther
p
y. 3. D In the
presence of
p
tholoic
l circul
tin
ntico
ul
nt,
mixin test usin norm
l
pl
sm
does not
correct the
norm
l APTT. These
ntico
ul
nts
re p
tholoic
l su st
nces
nd

re endoenously
produced. They
re either directed

inst
speci c clottin f
ctor or

inst

roup of
f
ctors. A proloned APTT due to
f
ctor de ciency is corrected when mixed with

norm
l pl
sm
.
F
ctors VIII
nd IX de cient pl
sm
s
re used for
ss
yin f
ctor VIII
nd IX
cti
vities,
respectively. 4. D The lupus
ntico
ul
nt interferes with phospholipid-dependen
t co
ul
tion

ss
ys such
s the PT
nd APTT tests. The lupus
ntico
ul
nt does not inhi it c
lottin f
ctor

ss
ys,
nd does not inhi it in vivo co
ul
tion. 5. B Coum
din (w
rf
rin) cross
es the pl
cent


nd is present in hum
n milk; it is not recommended for pren
nt
nd l
ct
tin w
omen. W
rf
rin is

vit
min K
nt
onist dru th
t ret
rds synthesis of the
ctive form of vit
min
Kdependent
f
ctors (II, VII, IX,
nd X). Antithrom in is
hep
rin (not w
rf
rin) cof
ctor.
The
Intern
tion
l Norm
lized R
tio (INR) is used to monitor w
rf
rin dos
e. 2828_Ch
02_041-074
06/08/12 11:09 AM P
e 57 6. Which st
tement re
rdin protein C is correct? A
. It is
vit
min
Kindependent zymoen B. It is
ctiv
ted y
rinoen C. It
ctiv
tes cof
ctors V
n
d VIII D. Its

ctivity is enh
nced y protein S Hemost
sis/Apply knowlede of fund
ment
l iol
oic
l
ch
r
cteristics/Protein C/1 7. Which of the followin is
n
ppropri
te screenin
 test for the
di
nosis of lupus
ntico
ul
nt? A. Trom in time test B. Diluted Russells viper
venom test
(DRVVT) C. D-dimer test D. FDP test Hemost
sis/Correl
te clinic
l
nd l
or
tory
d
t
/Lupus

ntico
ul
nt/2 8. Which of the followin is most commonly
ssoci
ted with
ctiv

ted protein C
resist
nce (APCR)? A. Bleedin B. Trom osis C. Epist
xis D. Menorrh
i
Hemost
s
is/Correl
te
clinic
l
nd l
or
tory d
t
/ APCR/2 9. A 50-ye
r-old m
n h
s een on hep
rin fo
r the p
st 7
d
ys. Which com in
tion of the tests is expected to e
norm
l? A. PT
nd APTT
only B. APTT, TT
only C. APTT, TT, rinoen
ss
y D. PT, APTT, TT Hemost
sis/Correl
te clinic
l
n
d l
or
tory
d
t
/ Hep
rin ther
py/3 10. Which of the followin drus inhi its ADP medi
ted p
l
telet

re
tion? A. Hep
rin B. W
rf
rin C. Aspirin D. Pr
surel Hemost
sis/Correl
te
clinic
l
nd
l
or
tory d
t
/ Pl
telet
re
tion/2 11. Trom in-throm omodulin complex is ne
cess
ry for

ctiv
tion of: A. Protein C B. Antithrom in C. Protein S D. F
ctors V
nd VIII H

emost
sis/Apply
knowlede of fund
ment
l ioloic
l ch
r
cteristics/Trom omodulin/2 58 Ch
pter 2
| Hemost
sis
Answers to Questions 611 6. D Protein S functions
s
cof
ctor of protein C
nd

s such
enh
nces its
ctivity. Activ
ted protein C in
ctiv
tes f
ctors V

nd VIII
. 7.
B Russells viper
venom (RVV) re
ent cont
ins f
ctors X
nd V,
ctiv
tin enzymes th
t
re stron
ly phospholipid
dependent. The re
ent
lso cont
ins RVV, c
lcium ions,
nd phospholipid. In the
presence of
phospholipid
uto
nti odies such
s lupus
ntico
ul
nt, the re
ent phospholipi
d is p
rti
lly
neutr
lized c
usin prolon
tion of the clottin time. Throm in time ev
lu
tes
r
inoen. FDP
nd
D-dimer tests ev
lu
te rinoen
nd rin der
d
tion products. 8. B Activ
ted prot
ein C
resist
nce is the sinle most common c
use of inherited throm osis. In 90% of in
dividu
ls, the
c
use is ene mut
tion of f
ctor V (f
ctor V Leiden). A ected individu
ls
re pred
isposed to
throm osis, m
inly
fter
e 40. Heterozyous individu
ls m
y not m
nifest throm
osis unless
other clinic
l conditions coexist. 9. D Hep
rin is
ther
peutic
ntico
ul
nt w
ith
n

ntithrom in
ctivity. Hep
rin
lso inhi its f
ctors XII
, XI
, X
,
nd IX
. In
p
tients
receivin hep
rin ther
py, the PT, APTT,
nd TT
re
ll proloned. Qu
ntit
tive
rinoen
ss
y,
however, is not
ected y hep
rin ther
py. 10. D Pr
surel (E ent) is
n
ntipl
tel
et dru th
t
reduces pl
telet
re
tion y irreversi ly lockin the P2Y12 receptors on the
pl
telet surf
ce
mem r
ne, there y inhi itin pl
telet
re
tion to ADP. Aspirin is
nother
nt
ipl
telet dru
th
t inhi its pl
telet
re
tion y lockin the
ction of the enzyme cyclo-ox
yen
se. W
rf
rin

nd hep
rin
re
ntico
ul
nt drus th
t
ct

inst clottin f
ctors. 11. A Pro
tein C is

ctiv
ted y throm inthrom omodulin complex. Throm omodulin (TM) is
tr
nsmem r

ne protein th
t

cceler
tes protein C
ctiv
tion 1,000-fold y formin
complex with throm in.
When throm in
inds to TM, it loses its clottin function, includin
ctiv
tion of f
ctors V

nd VIII.
Activ
ted protein C de
ctiv
tes f
ctors V

nd VIII
. Protein S is
cof
ctor ne
cess
ry for the

ctiv
tion of protein C. 2828_Ch02_041-074 06/08/12 11:09 AM P
e 58 12. Wh
t
test is used to
monitor hep
rin ther
py? A. INR B. APTT C. TT D. PT Hemost
sis/Correl
te clinic

l
nd l
or
tory
d
t
/ Hep
rin ther
py/2 13. Wh
t test is commonly used to monitor w
rf
rin ther

py? A. INR B.
APTT C. TT D. Ec
rin time Hemost
sis/Correl
te clinic
l
nd l
or
tory d
t
/ W
r
f
rin ther
py/2
14. Wh
t clottin f
ctors (cof
ctors)
re inhi ited y protein S? A. V
nd X B.
V

nd VIII
C.
VIII
nd IX D. VIII
nd X Hemost
sis/Correl
te clinic
l
nd l
or
tory d
t
/ Clo
ttin f
ctors/2
15. Which dru promotes rinolysis? A. W
rf
rin B. Hep
rin C. Urokin
se D. Aspiri

n
Hemost
sis/Correl
te clinic
l
nd l
or
tory d
t
/ Ter
pies/2 16. Di
nosis of l
upus

ntico
ul
nt is con rmed y which of the followin criteri
? A. Decre
sed APTT B.
Correction of
the APPT y mixin studies C. Neutr
liz
tion of the
nti ody y hih concentr
ti
on of pl
telets
D. Con rm
tion th
t
norm
l co
ul
tion tests
re time
nd temper
ture dependent
Hemost
sis/Correl
te clinic
l
nd l
or
tory d
t
/ LA/3 17. Which of the followi
n
norm
lities
is consistent with the presence of lupus
ntico
ul
nt? A. Decre
sed APTT/ leedi
n complic
tions
B. Proloned APTT/throm osis C. Proloned APTT/throm ocytosis D. Trom ocytosis/t
hrom osis
Hemost
sis/Correl
te clinic
l
nd l
or
tory d
t
/ LA/3 2.4 | Inhi itors, Trom o
tic Disorders,

nd Antico
ul
nt Drus 59 Answers to Questions 1217 12. B Hep
rin dos
e m
y
e monitored y
the APTT test. Hep
rin dose is
djusted to
n APTT of 1.52.5 times the me
n of th
e l
or
tory
reference r
nes. This level of APTT is equiv
lent to pl
sm
hep
rin levels of 0
.30.7 U/mL. The
PT would e proloned in hep
rin ther
py, ut the test is not
s sensitive
s th
e APTT. Hep
rin
inhi its throm in,
nd therefore, c
uses
proloned TT. The TT test, however, i
s not used to
monitor hep
rin ther
py. 13. A W
rf
rin is
vit
min K
nt
onist dru. It inhi
its vit
min
Kdependent f
ctors (II, VII, IX,
nd X)
nd other vit
min Kdependent proteins such

s proteins
C
nd S. W
rf
rin ther
py is monitored y the INR. An INR of 2.03.0 is used
s th
e t
ret when
monitorin w
rf
rin ther
py for prophyl
xis
nd tre
tment of DVT. A hiher dose
of w
rf
rin
(ivin
n INR of 2.5 3.5) is required for p
tients with mech
nic
l he
rt v
lves.
14. B F
ctors
V

nd VIII

re de
ctiv
ted y protein S
nd
ctiv
ted protein C. 15. C Urokin

se is

throm olytic dru commonly used to tre
t
cute
rteri
l throm osis. Urokin
se c

n
lso e used
for the tre
tment of venous throm oem olism, myoc
rdi
l inf
rction,
nd clotted
c
theters.
W
rf
rin
nd hep
rin
re
ntico
ul
nt drus, where
s
spirin prevents pl
telet

re
tion y
inhi itin cyclo-oxyen
se. 16. C The Intern
tion
l Society of Hemost
sis
nd Th
rom osis h
s
recommended four criteri
for the di
nosis of lupus
ntico
ul
nt: (1)
prolon

tion of one or
more of the phospholipid-dependent clottin tests such
s APTT or DRVVT; (2) the
presence of
n
inhi itor con rmed y mixin studies (not corrected); (3) evidence th
t the inhi i
tor is directed


inst phospholipids y neutr
lizin the
nti odies with
hih concentr
tion o
f pl
telets
(pl
telet neutr
liz
tion test or DRVVT with pl
telet-rich pl
sm
); (4) l
ck of

ny other c
uses
for throm osis. Lupus inhi itor is not commonly time or temper
ture dependent. 1
7. B Lupus

ntico
ul
nt interferes with phospholipids in the APTT re
ent, resultin in pr
olon
tion of

APTT. However, in vivo, lupus
ntico
ul
nt decre
ses

rinolytic
ctivity, c
usin

n incre
sed
risk of throm osis. Lupus
ntico
ul
nt does not result in
leedin tendency u
nless there is

coexistin throm ocytopeni
or other co
ul
tion
norm
lity. 2828_Ch02_041-074
06/08/12 11:09
AM P
e 59 18. Which of the followin is
ch
r
cteristic of low molecul
r wei
ht hep
rin
(LMWH)? A. Gener
lly requires monitorin B. Speci c
lly
cts on f
ctor V
C. H
s

loner
h
lf-life th
n unfr
ction
ted hep
rin D. C
n e used
s
rinolytic
ent Hemost

sis/Apply
knowlede of fund
ment
l ioloic
l ch
r
cteristics/LMWH/1 19. Which of the foll
owin tests is
most likely to e
norm
l in p
tients t
kin
spirin? A. Pl
telet morpholoy B.
Pl
telet count
C. Bleedin time D. Prothrom in time Hemost
sis/Correl
te clinic
l
nd l
or
tor
y d
t
/ Aspirin
ther
py/2 20. Which of the followin is
ssoci
ted with
ntithrom in de ciency? A.
Trom ocytosis
B. Trom osis C. Trom ocytopeni
D. Bleedin Hemost
sis/Correl
te clinic
l
nd l

or
tory d
t
/
Inhi itors/2 21. Which of the followin m
y e
ssoci
ted with throm otic events
? A. Decre
sed
protein C B. Incre
sed
rinolysis C. A rinoenemi
D. ITP Hemost
sis/Correl
te cli
nic
l
nd
l
or
tory d
t
/ Protein C/2 22. Aspirin resist
nce m
y e
ssoci
ted with: A. B
leedin B. F
ctor
VIII de ciency C. Trom osis D. Trom ocytosis Hemost
sis/Correl
te clinic
l
nd l

or
tory d
t
/
Aspirin resist
nce/2 23. A proloned throm in time is indic
tive of which of the
followin

ntithrom otic ther
pies? A. Pr
surel B. Clopidorel C. Aspirin D. Hep
rin Hemo
st
sis/Correl
te
clinic
l
nd l
or
tory d
t
/ Antithrom otic ther
py/2 60 Ch
pter 2 | Hemost
sis
Answers to
Questions 1824 18. C Low molecul
r weiht hep
rin (LMWH) is
sm
ll lycos
minol
yc
n th
t is
derived from unfr
ction
ted hep
rin (UFH). The LMWH h
s
low
nity for pl
sm
pr
oteins
nd
endotheli
l cells
nd therefore h
s
loner h
lf-life. The h
lf-life of the dru
 does not depend
on the dos
e. LMWH h
s
n inhi itory e ect on f
ctors X

nd II
. It does not req
uire routine
monitorin except in p
tients with ren
l f
ilure, o ese p
tients, pedi
tric p
ti
ents,
nd
pren
nt p
tients. 19. C Aspirin is
n
ntipl
telet dru. It prevents pl
telet

re
tion y
inhi ition of cyclo-oxyen
se. Aspirin h
s no e ect on the pl
telet count, pl
tele
t morpholoy,
or prothrom in time. 20. B Antithrom in is
physioloic
l
ntico
ul
nt. It inh
i its f
ctors
II
, X
, IX
, XI
,
nd XII
. De ciency of
ntithrom in is
ssoci
ted with throm os
is. Throm otic
events m
y e prim
ry (in the
sence of
trierin f
ctor) or m
y e
ssoci

ted with
nother
risk f
ctor such
s pren
ncy or surery. 21. A Protein C is
physioloic
l inh
i itor of
co
ul
tion. It is
ctiv
ted y throm inthrom omodulin complex. Activ
ted protein
C inhi its

cof
ctors V

nd VIII
. The de ciency of protein C is
ssoci
ted with throm osis.
Incre
sed
rinolysis,
rinoenemi
,
nd ITP
re
ssoci
ted with leedin. 22. C Up to 22% o
f p
tients
t
kin
spirin ecome resist
nt to
spirins
ntipl
telet e ect. P
tients who
re
s
pirin
resist
nt h
ve
hiher risk of throm osis (he
rt
tt
cks
nd strokes). 23. D He
p
rin is
n

ntithrom in dru c
usin proloned TT in p
tients who
re on hep
rin ther
py. P
r
surel,
clopidorel,
nd
spirin
re
ntipl
telet drus c
usin inhi ition of pl
telet

re
tion. 24. C
L
or
tory tests for ev
lu
tion of throm ophili

re justi ed in youn p
tients wi
th throm otic
events, in p
tients with
positive f
mily history
fter
sinle throm otic eve
nt, in those with
recurrent spont
neous throm osis,
nd in pren
ncies
ssoci
ted with throm osis.
24. Screenin
tests for throm ophili
should e performed on: A. All pren
nt women ec
use of
the throm otic
risk B. P
tients with
ne
tive f
mily history C. P
tients with throm otic even
ts occurrin
t

youn
e D. P
tients who
re receivin
ntico
ul
nt ther
py Hemost
sis/Correl

te clinic
l
nd
l
or
tory d
t
/Trom ophili
/2 2828_Ch02_041-074 06/08/12 11:09 AM P
e 60 25
. Prothrom in
G20210A is ch
r
cterized y which of the followin c
uses
nd conditions? A. Sin
le mut
tion of
prothrom in molecule/ leedin B. Sinle mut
tion of prothrom in molecule/ throm
osis C.
Decre
sed levels of prothrom in in pl
sm
/ throm osis D. Incre
sed levels of pro
throm in in
pl
sm
/ leedin Hemost
sis/Correl
te clinic
l
nd l
or
tory d
t
/ Prothrom in/
3 26. F
ctor V
Leiden promotes throm osis y preventin: A. De
ctiv
tion of f
ctor V
B. Activ

tion of f
ctor V
C. Activ
tion of protein C D. Activ
tion of protein S Hemost
sis/Correl
te clini
c
l
nd
l
or
tory d
t
/ F
ctor V Leiden/3 27. Wh
t is the
pproxim
te incidence of
nti
phospholipid

nti odies in the ener
l popul
tion? A. <1% B. 2% C. 10% D. 20% Hemost
sis/Appl
y knowlede of
fund
ment
l ioloic
l ch
r
cteristics/LA/1 28. Which of the followin l
or
tor
y tests is
helpful in the di
nosis of
spirin resist
nce? A. APTT B. PT C. Pl
telet count

nd morpholoy D.
Pl
telet
re
tion Hemost
sis/Correl
te clinic
l
nd l
or
tory d
t
/ Aspirin
resist
nce/3 29.
Which of the followin complic
tions m
y occur
s
result of decre
sed tissue f

ctor p
thw
y
inhi itor (TFPI)? A. Incre
sed hemorrh
ic episodes B. Incre
sed throm otic risk
C. Imp
ired
pl
telet plu form
tion D. Immune throm ocytopeni
Hemost
sis/Apply knowlede of
fund
ment
l
ioloic
l ch
r
cteristics/ TFPI/2 2.4 | Inhi itors, Trom otic Disorders,
nd An
tico
ul
nt Drus
61 Answers to Questions 2530 25. B Prothrom in G20210A is de ned
s
sinle-poin
t mut
tion of
the prothrom in ene, resultin in incre
sed concentr
tion of pl
sm
prothrom in

nd there y

risk f
ctor for throm osis. Prothrom in G20210A is the second most common c
use
of inherited
hyperco
ul
ility ( ehind f
ctor V Leiden). It h
s the hihest incidence in whi
tes from southern
Europe. The throm otic episodes ener
lly occur efore
e 40. 26. A F
ctor V Le
iden is

sinle-point mut
tion in the f
ctor V ene th
t inhi its f
ctor V
in
ctiv
tion
y protein C.
Activ
ted protein C enh
nces de
ctiv
tion of f
ctors V

nd VIII
. 27. B The inc
idence of

ntiphospholipid
nti odies in the ener
l popul
tion is
out 2%. 28. D Current
ly, the pl
telet

re
tion test is considered the old st
nd
rd for ev
lu
tion of
spirin resis
t
nce. In
spirin
resist
nce, pl
telet
re
tion is not inhi ited y
spirin inestion. Aspirin
resist
nce h
s no
e ect on pl
telet count
nd morpholoy. 29. B Tissue f
ctor p
thw
y inhi itor (TFP
I) is rele
sed
from the v
scul
ture
nd is the most import
nt inhi itor of the extrinsic p
thw

y. TFPI inhi its
f
ctors X

nd VII
-TF complex. Therefore, the de ciency of TFPI is
ssoci
ted wit
h throm osis.
30. D F
ctor VIII inhi itors (
nti odies) occur in 10%20% of p
tients with f
ctor
VIII de ciency
receivin f
ctor VIII repl
cement. 30. F
ctor VIII inhi itors occur in _________
___ of p
tients
with f
ctor VIII de ciency? A. 40%50% B. 30%40% C. 25%30% D. 10%20% Hemost
sis/Apply
knowlede of fund
ment
l ioloic
l ch
r
cteristics/Inhi itors/1 2828_Ch02_041-0
74 06/08/12
11:09 AM P
e 61 31. Which ther
py
nd resultin mode of
ction
re
ppropri
te
for the
tre
tment of
p
tient with
hih titer of f
ctor VIII inhi itors? A. F
ctor VI
II concentr
te to
neutr
lize the
nti odies B. Recom in
nt f
ctor VII
(rVII
) to
ctiv
te f
ctor
X C. F
ctor X
concentr
te to
ctiv
te the common p
thw
y D. Fresh frozen pl
sm
to repl
ce f
c
tor VIII
Hemost
sis/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics/Inhi itors/
2 32. Te Bethesd


ss
y is used for which determin
tion? A. Lupus
ntico
ul
nt titer B. F
ctor VI
II inhi itor
titer C. F
ctor V Leiden titer D. Protein S de ciency Hemost
sis/Select methods/Re

ents/Speci
l
tests/2 33. Hyperhomocysteinemi
m
y e
risk f
ctor for: A. Bleedin B. Trom o
cythemi
C.
Trom osis D. Trom ocytopeni
Hemost
sis/Correl
te clinic
l
nd l
or
tory d
t
/H
omocysteine/2 34.
Which dru m
y e
ssoci
ted with deep venous throm osis (DVT)? A. Aspirin B. tP
A C. Or
l
contr
ceptives D. Pl
vix (clopidorel) Hemost
sis/Apply knowlede of fund
ment
l
ioloic
l
ch
r
cteristics/Trom ophili
/2 35. Ar
tro
n m
y e used
s
n
ntico
ul
nt dr
u in p
tients
with: A. DVT B. Hemorrh
e C. TTP D. Trom ocytosis Hemost
sis/Apply knowlede of
fund
ment
l
ioloic
l ch
r
cteristics/Ter
pies/2 36. Hep
rin-induced throm ocytopeni
(HIT)
results from: A.
Anti odies to hep
rin B. Anti odies to pl
telets C. Anti odies to PF4 D. Anti od
ies to
hep
rin-PF4 complex Hemost
sis/Apply knowlede of fund
ment
l ioloic
l ch
r
ct

eristics/HIT/2 62
Ch
pter 2 | Hemost
sis Answers to Questions 3136 31. B Recom in
nt f
ctor VII (rV
II
) is
e ective for the tre
tment of
hih titer f
ctor VIII inhi itor. F
ctor VII
c
n
directly

ctiv
te f
ctor X to X
in the
sence of f
ctors VIII
nd IX. Recom in
nt f
cto
r VII
does not
stimul
te
n
mnestic responses in p
tients with f
ctor VIII inhi itor. F
ctor VI
II concentr
te is
used for
low titer f
ctor VIII inhi itor. F
ctor X concentr
te
nd FFP
re not
the tre
tments
of choice for f
ctor VIII inhi itor. 32. B The Bethesd

ss
y is
qu
ntit
tive

ss
y for f
ctor
VIII inhi itor. In this
ss
y, norm
l pl
sm
is incu
ted with di erent dilutions
of the
p
tients pl
sm
or
norm
l control. The inhi itor in
ctiv
tes f
ctor VIII presen
t in norm
l
pl
sm
followin incu
tion for 2 hours
t 37C. The residu
l
ctivities in the s

mple
re
determined,
nd the inhi itor titer is c
lcul
ted. 33. C Elev
ted pl
sm
homocys
teine is
risk
f
ctor for the development of venous throm osis. Homocystinemi
m
y e inherited
or
cquired.
Acquired homocystinemi
is c
used y the diet
ry de ciencies of vit
mins B 6 , B 1
2 ,
nd folic

cid. 34. C Or
l contr
ceptive drus
re
cquired risk f
ctors for throm osis. A
spirin
nd Pl
vix

re
ntipl
telet drus
nd tPA is
rinolytic dru used for the tre
tment of thr
om osis. 35. A
Ar
tro
n is
throm in inhi itor dru
nd m
y e used
s
n
ntico
ul
nt in p

tients with
hep
rin-induced throm ocytopeni
(HIT) to prevent throm osis. Ar
tro
n is
sm

ll synthetic
molecule th
t inds to free
nd clot- ound throm in. Ar
tro
n
ffects TT, PT,
APTT,
nd ACT
tests. The APTT test is recommended for monitorin the dos
e with the t
ret th
er
peutic r
ne
of 1.5 to 3.0 times the me
n of the l
or
tory reference r
ne. In p
tients with
lupus

ntico
ul
nt or f
ctor deficiencies, the
seline APTT is proloned; in these c
onditions, the
Ec
rin time c
n e used
s
n
ltern
tive
ss
y. 36. D Hep
rin-induced throm ocy
topeni
is
n
immune process c
used y the production of
nti odies to hep
rin-PF4 complex. Th
is immune complex
inds to pl
telet Fc receptors, c
usin pl
telet
ctiv
tion
nd form
tion of pl

telet
microp
rticles th
t in turn induce hyperco
ul
ility
nd throm ocytopeni
. 2828
_Ch02_041-074
06/08/12 11:09 AM P
e 62 37. Which l
or
tory test is used to screen for
cti
v
ted protein C
resist
nce? A. Mixin studies with norm
l pl
sm
B. Mixin studies with f
ctor-d
e cient pl
sm
C.
Modi ed APTT with
nd without
ctiv
ted protein C D. Modi ed PT with
nd without
ct
iv
ted
protein C Hemost
sis/Select methods/Re
ents/Speci
l tests/2 38. Ec
rin clottin
time m
y e used
to monitor: A. Hep
rin ther
py B. W
rf
rin ther
py C. Fi rinolytic ther
py D. Hi
rudin ther
py
Hemost
sis/Select methods/Re
ents/Speci
l tests/2 39. Which of the followin m

y interfere with
the
ctiv
ted protein C resist
nce (APCR) screenin test? A. Lupus
ntico
ul
nt
B. Protein C
de ciency C. Antithrom in de ciency D. Protein S de ciency Hemost
sis/Correl
te clinic

l
nd
l
or
tory/Speci
l tests/2 40. Trom ophili
m
y e
ssoci
ted with which of the
followin
disorders? A. A rinoenemi
B. Hypo rinoenemi
C. F
ctor VIII inhi itor D. Hyper r
inoenemi

Hemost
sis/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics/Fi rinoen/
2 41. Which of
the followin
ntico
ul
nt drus c
n e used in p
tients with HIT? A. W
rf
rin
B. Hep
rin C.
Aspirin D. Lepirudin Hemost
sis/Apply knowlede of fund
ment
l ioloic
l
ch
r
cteristics/Ter
pies/2 2.4 | Inhi itors, Trom otic Disorders,
nd Antico
ul

nt Drus 63
Answers to Questions 3741 37. C Activ
ted protein C resist
nce c
n e ev
lu
ted
y
two-p
rt
APTT test. The APTT is me
sured on the p
tients pl
sm
with
nd without the
ddit
ion of

ctiv
ted protein C (APC). The result is expressed
s the r
tio of the APTT with
APC to the APTT
without APC. The norm
l r
tio is 2:5. P
tients with APCR h
ve
lower r
tio th
n
the reference
r
ne. A positive screenin test should e followed y
con rm
tory test such
s
polymer
se
ch
in re
ction (PCR) for f
ctor V Leiden. 38. D Ec
rin clottin time,
sn
ke ve
nom
sed
clottin
ss
y, m
y e used to monitor hirudin ther
py in inst
nces when the
s
eline APTT is
proloned due to lupus
ntico
ul
nt or f
ctor de ciencies. The APTT is insensitiv
e to hirudin
levels
ove 0.6 m/L,
nd this insensitivity m
y result in
dru overdose desp
ite
monitorin
protocol. Hep
rin ther
py is monitored y the APTT; w
rf
rin ther
py is monitore
d y the INR.
Fi rinolytic ther
py m
y e monitored y D-dimer. 39. A The lupus
ntico
ul
nt
interferes with
the APCR screenin
ss
y
sed on the APTT r
tio with
nd without APC
ddition.
Persons with the
lupus
ntico
ul
nt h
ve
proloned APTT th
t renders the test inv
lid for APCR
screenin. 40. D
Hyper rinoenemi
is
risk f
ctor for throm ophili
. Fi rinoen is
n
cute ph
s
e re
ct
nt
nd
m
y e incre
sed in in
mm
tion, stress, o esity, smokin,
nd medic
tions such
s
or
l
contr
ceptives. Hypo rinoenemi
,
rinoenemi
,
nd f
ctor VIII inhi itors
re
s
soci
ted with
leedin. 41. D Lepirudin is
recom in
nt
n
loue of hirudin. It is
n
ltern

tive

ntico
ul
nt dru used in p
tients with HIT who c
nnot toler
te hep
rin or LMWH
ther
py.
W
rf
rin should not e used to
ntico
ul
te persons with HIT ec
use it c
uses

f
ll in protein
C concentr
tion prior to inducin
decre
se in co
ul
tion f
ctors derived from
vit
min K. The
lower protein C predisposes HIT p
tients to le throm osis. 2828_Ch02_041-074 0
6/08/12 11:09 AM
P
e 63 42. Which of the followin is the preferred method to monitor hep
rin t
her
py
t the

point of c
re durin c
rdi
c surery? A. APTT B. Activ
ted clottin time test (A
CT) C. PT D. TT
Hemost
sis/Correl
te clinic
l
nd l
or
tory/Speci
l tests/2 43. Mrs. Smith h
s
the followin
l
or
tory results,
nd no leedin history: APTT: proloned APTT results on
1
:1 mixture of the
p
tients pl
sm
with norm
l pl
sm
: Preincu
tion: proloned APTT 2-hour incu
ti
on: proloned
APTT Tese results
re consistent with: A. F
ctor VIII de ciency B. F
ctor VIII inh
i itor C. Lupus

ntico
ul
nt D. Protein C de ciency Hemost
sis/Correl
te clinic
l
nd l
or
tory
d
t
/ Speci
l
tests/3 44. Which test m
y e used to monitor LMWH ther
py? A. APTT B. INR C. An
ti-X
hep
rin

ss
y D. Activ
ted clottin time Hemost
sis/Correl
te clinic
l
nd l
or
tory d

t
/ LMWH
ther
py/3 64 Ch
pter 2 | Hemost
sis Answers to Questions 4244 42. B The
ctiv
ted
clottin time
(ACT) is
point-of-c
re co
ul
tion test used to monitor hih-dose hep
rin ther

py durin
c
rdi
c surery, c
rdi
c
niopl
sty, hemodi
lysis,
nd other m
jor sureries. I
t is the
preferred method to determine if su cient hep
rin w
s
dministered to prevent clot
tin durin
surery ec
use it is more r
pid th
n the APTT test. The test uses
clot
ctiv

tor such
s
K
olin or Celite to stimul
te co
ul
tion,
nd the time in seconds is line
rly r
el
ted to the
dose of hep
rin
dministered. The ACT test is
v
il
le in di erent form
ts,
nd t
he reference
r
ne v
ries dependin on the method used. At low to moder
te hep
rin doses, the
ACT test does
not correl
te well with the APTT or the
nti- f
ctor X

ss
y. 43. C Mixin stud
ies di erenti
te
f
ctor de ciencies from f
ctor inhi itors. Lupus
ntico
ul
nt is
ssoci
ted with
throm osis,
nd
it is directed

inst phospholipid-dependent co
ul
tion tests such
s the APTT
. In p
tients
with lupus
ntico
ul
nt, the APTT
fter mixin p
tients pl
sm
with norm
l pl
sm

rem
ins
proloned immedi
tely
fter mixin
nd followin 2-hours incu
tion. F
ctor VIII
de ciency
nd
f
ctor VIII inhi itor
re
ssoci
ted with leedin. F
ctor VIII inhi itor is tim
e
nd temper
ture
dependent. The proloned APTT m
y e corrected immedi
tely
fter mixin,
nd ec
omes proloned
followin incu
tion. In f
ctor VIII de ciency, the proloned APTT would e correc
ted
fter
mixin the p
tients pl
sm
with norm
l pl
sm
. 44. C The
nti-f
ctor X
hep
rin

ss
y is used to
monitor LMWH ther
py when required ec
use the APTT test is insensitive to LMWH.
The
ss
y c
n e
performed y chromoenic end-point detection used on
utom
ted
n
lyzers. The pr
inciple of the
test is to me
sure the inhi ition of X
y hep
rin. The re
ent is
mixture of

xed
concentr
tion of f
ctor X
,
su str
te which is speci c for f
ctor X
,
nd
xed c
oncentr
tion
of
ntithrom in (AT). Some kits rely on the
ntithrom in in p
tients pl
sm
. Hep

rin forms

complex with AT
nd f
ctor X
(AT-hep
rin-X
). Excess free f
ctor X
cle
ves the
chromoenic
su str
te
nd rele
ses
yellow product. The color intensity of the product is i
nversely
proportion
l to pl
sm
hep
rin concentr
tion,
nd is me
sured y
photodetector

t 405 nm. LMWH
ther
py does not usu
lly require monitorin; however, exceptions include pedi
tr
ic, o ese,
nd
pren
nt p
tients
nd those with ren
l f
ilure. 2828_Ch02_041-074 06/08/12 11:
09 AM P
e 64 65
2.5 Hemost
sis Pro lem Solvin 1. P
tient History A 3-ye
r-old m
le w
s
dmitted
to
hospit
l
with sc
ttered petechi
e
nd epist
xis. Te p
tient h
d norm
l rowth
nd h
d no
other medic
l
pro lems except for chickenpox 3 weeks e
rlier. His f
mily history w
s unrem
rk

le. Answer to
Question 1 1. C These clinic
l m
nifest
tions
nd l
or
tory results
re consist
ent with ITP. ITP
is
n
utoimmune throm ocytopeni
. In children,
cute ITP throm ocytopeni
occur
s followin

vir
l infection,
s is the c
se in this 3-ye
r-old p
tient. Clinic
l m
nifest
ti
ons
re

ssoci
ted with petechi
e, purpur
,
nd mucous mem r
ne leedins such
s epist

xis
nd iniv
l
leedin. A norm
l l
or
tory tests include
very low pl
telet count
nd
prol
oned leedin
time. Other c
uses of throm ocytopeni
should e ruled out in p
tients with ITP.
L
or
tory
Results P
tient Reference R
ne PT: 11 sec 1013 sec APTT: 32 sec 2837 sec Pl
tele
t count: 18
10 3
/
L 150450 10
3
/
L
Tese clinic
l m
nifest
tions
nd l
or
tory results
re consistent with
which condition? A.
TTP B. DIC C. ITP D. HUS Hemost
sis/Ev
lu
te l
or
tory d
t
to reconize he
lth

nd dise
se
st
tes/Pl
telet disorders/3 2828_Ch02_041-074 06/08/12 11:09 AM P
e 65 2. P

tient History A
12-ye
r-old white m
le h
s the followin symptoms: visi le ruisin on
rms
nd
les, ruisin

fter sports
ctivities,
nd excessive postoper
tive hemorrh
e followin tonsil
lectomy 3 months

o. His f
mily history reve
led th
t his mother su ers from he
vy menstru
l leed
in,
nd his
m
tern
l r
ndf
ther h
d recurrent nose leeds
nd ruisin. 66 Ch
pter 2 | Hemos
t
sis Answers to
Questions 24 2. B These clinic
l m
nifest
tions
nd l
or
tory results
re consis
tent with von
Wille r
nds dise
se. Von Wille r
nds dise
se is
n inherited leedin disorder c
u
sed y

norm
l pl
telet
dhesion. Pl
telet
dhesion depends on VWF
nd lycoprotein I
. In von
Wille r
nds dise
se, VWF is de cient or dysfunction
l. VWF promotes second
ry hemos
t
sis y

ctin
s
c
rrier for f
ctor VIII. De cient or dysfunction
l VWF results in decr
e
sed f
ctor
VIII
nd therefore
norm
l second
ry hemost
sis. The clinic
l m
nifest
tions
s
soci
ted with von

Wille r
nds dise
se
re e
sy ruisin, epist
xis,
nd leedin
fter surery. A n
orm
l
l
or
tory test results
re incre
sed leedin time
nd
norm
l pl
telet
re

tion to
ristocetin, which is corrected on
ddition of norm
l pl
sm
cont
inin VWF. Acti
v
ted p
rti
l
throm opl
stin time (APTT) is proloned
s
result of the de ciency of f
ctor VII
I. F
ctor VIII

ctivity (VIII:C), VWF ristocetin cof
ctor
ctivity (VWF:Rco),
nd VWF:
ntienic

ctivity
(VWF:
ntien)
re
ll
norm
l. The pl
telet count
nd prothrom in time
re norm

l in von
Wille r
nds dise
se. 3. D Cryoprecipit
te cont
ins
rinoen, f
ctor VIII,
nd VWF.
Fresh frozen
pl
sm
h
s
ll of the clottin f
ctors; however, it is not the est choice if cr
yoprecipit
te is

v
il
le. 4. C The pl
telet count should e checked every other d
y in p
tients
receivin
hep
rin ther
py. Hep
rin-induced throm ocytopeni
(HIT) should e suspected in p

tients who
re
not respondin to hep
rin ther
py
nd/or
re developin throm ocytopeni
(50% e
low the
seline
v
lue)
nd throm otic complic
tions while on hep
rin ther
py. Incre
se in hep
ri
n dose should e

voided in p
tients with the clinic
l symptoms of throm osis while they
re rece
ivin hep
rin.
Fi rinoen
ss
y
nd PT
re not the
ppropri
te
ss
ys for monitorin hep
rin th
er
py, nor
re
they used to test for HIT. L
or
tory Results Reference P
tient R
ne Pl
telet
Count: 350 10
3
/
L 200450 10
3
/
L
PT: 11.0 sec 1012 sec APTT: 70 sec 2837 sec TT: 13 sec 1015 sec Pl
telet A
re
tion
Norm
l
re
tion with coll
en, epinephrine, ADP A norm
l
re
tion with ris
tocetin
Confirm
tory Reference Tests P
tient R
ne VWF:Rco 25% 45%140% VIII:C 20% 5
0%150%
WWF:
ntien 10% 45%185% Tese clinic
l m
nifest
tions
nd l
or
tory results
re c
onsistent with
which di
nosis? A. F
ctor VIII de ciency B. von Wille r
nds dise
se C. Gl
nzm
nns
throm
stheni
D. Bern
rdSoulier syndrome Hemost
sis/Ev
lu
te l
or
tory d
t
to
reconize
he
lth
nd dise
se st
tes/Pl
telet disorders/3 3. Te followin results
re o t
i
ned from

p
tient who developed severe leedin: Proloned PT
nd APTT Pl
telet count = 10
0 10 9
/L
Fi rinoen = 40 m/dL Which of the followin lood products should e re
commended for
tr
nsfusion? A. F
ctor VIII concentr
te B. Pl
telets C. Fresh frozen pl
sm
D. C
ryoprecipit
te
Hemost
sis/Correl
te clinic
l
nd l
or
tory d
t
/ Ter
pies/2 4. A 30-ye
r-old w
om
n develops
sins
nd symptoms of throm osis in her left lower le followin 5 d
ys of hep
r
in ther
py. Te
p
tient h
d open-he
rt surery 3 d
ys previously
nd h
s een on hep
rin ever si
nce. Which of the

followin would e the most helpful in m
kin the di
nosis? A. Fi rinoen
ss
y
B. Prothrom in
time C. Pl
telet counts D. Incre
sed hep
rin dose Hemost
sis/Correl
te clinic
l

nd l
or
tory
d
t
/Hep
rin ther
py/3 2828_Ch02_041-074 06/08/12 11:09 AM P
e 66 5. Te foll
owin l
or
tory
results were o t
ined on
25-ye
r-old wom
n with menorrh
i

fter delivery of
her second son.
Te p
tient h
s no previous leedin history. Norm
l pl
telet count; norm
l leed
in time; norm
l
PT; proloned APTT Mixin of the p
tients pl
sm
with norm
l pl
sm
corrected the
proloned APTT
on immedi
te testin. However, mixin followed y 2-hour incu
tion
t 37C c
used

proloned
APTT. Wh
t is the most pro
le c
use of these l
or
tory results? A. Lupus
nti
co
ul
nt B.
F
ctor VIII de ciency C. F
ctor IX de ciency D. F
ctor VIII inhi itor Hemost
sis/Cor
rel
te
clinic
l
nd l
or
tory d
t
/ Speci
l tests/3 6. A 62-ye
r-old fem
le presents w
ith j
undice
nd
the followin l
or
tory d
t
: Peripher
l lood sme
r: m
crocytosis, t
ret cell
s Pl
telet count:
355 10 9
/L
PT: 25 sec (reference r
ne =1014) APTT: 65 sec (reference r
ne = 2836) T
r
ns
min
ses:
elev
ted (AST:ALT>1) Tot
l
nd direct iliru in: elev
ted Tese clinic
l present

tions
nd
l
or
tory results
re consistent with: A. Inherited f
ctor VII de ciency B. DIC C
. Cirrhosis of
the liver D. von Wille r
nds dise
se Hemost
sis/Correl
te clinic
l
nd l
or
tory
d
t
/Co
ul
tion disorders/3 7. When performin
mixin study, the p
tients APTT
is corrected
to 12% of norm
l. Wh
t is the most
ppropri
te interpret
tion of these ndins? A.
Te APTT is
considered corrected B. Te APTT is considered uncorrected C. Te mixin study nee
ds to e repe
ted
D. A circul
tin
ntico
ul
nt c
n e ruled out Hemost
sis/Correl
te clinic
l
n
d l
or
tory
d
t
/ Mixin studies/3 2.5 | Hemost
sis Pro lem Solvin
67 Answers to Question
s 57 5. D F
ctor
VIII inhi itor is found in 10%20% of hemophili
p
tients receivin repl
cement th
er
py. It m
y

lso develop in p
tients with immunoloic pro lems, women
fter child irth,
nd
p
tients with
lymphoprolifer
tive
nd pl
sm
cell disorders, or it m
y develop in response to
medic
tions.
F
ctor VIII inhi itor is
n IG immunolo ulin with
n inhi itory e ect th
t is ti
me
nd
temper
ture dependent. The presence of f
ctor VIII inhi itor c
uses
n elev
ted
APTT in the f
ce
of
norm
l prothrom in time. Mixin studies in f
ctors VIII
nd IX de ciencies wi
ll correct the
proloned APTT oth
t the immedi
te mixin st
e
nd
fter incu
tion for 2 hou
rs. The APTT
would not e corrected y mixin studies if lupus
ntico
ul
nt w
s present. In

ddition, lupus

ntico
ul
nt is not
ssoci
ted with leedin unless it coexists with throm ocyt
openi
. 6. C The
clinic
l present
tion
nd l
or
tory results in this p
tient
re indic
tive of c

irrhosis of the
liver. Most of the clottin f
ctors
re m
de in the liver. A decre
se in multipl
e clottin
f
ctors is
ssoci
ted with
proloned PT
nd APTT. M
crocytosis
nd t
ret cell
s
re present in
liver dise
se. The liver ch
nes the unconju
ted iliru in to conju
ted iliru
in. Conju
ted
iliru in is excreted into the intestines, where the iliru in is then converted
to uro ilinoen

nd excreted into the stool. In cirrhosis of the liver, oth necrosis
nd o stru
ction c
used y
sc
rrin produce
n incre
se in unconju
ted
nd conju
ted iliru in, respectiv
ely. In
ddition,
the liver enzymes
re elev
ted (the AST:ALT r
tio is <1 in necrotic liver dise
s
es such
s
hep
titis ut not in cirrhosis). 7. C In mixin studies, correction occurs if

proloned APTT
result drops to within 10% of the result of norm
l hum
n pl
sm
. Only 50% f
ctor

ctivity is
required for
norm
l PT or APTT. Clottin results
>
15%
re not considered corrected,
nd results
etween 10%15% should e repe
ted. A circul
tin
ntico
ul
nt typic
lly
results in f
ilure
to correct the APTT with norm
l pl
sm
. 2828_Ch02_041-074 06/08/12 11:09 AM P

e 67 8. A
st
nd
rd lue-top tu e lled
ppropri
tely (with 4.5 mL lood) w
s su mitted to th
e l
or
tory
for preoper
tive PT
nd APTT testin. Te results of oth tests were elev
ted. Te
p
tients PT
nd
APTT from the previous d
y were within norm
l limits,
nd he is not on hep
rin t
her
py. Which is
the most
ppropri
te rst step to investi
te the
norm
l results? A. Report the
result
s
o t
ined B. Perform
mixin study C. Check the s
mple for
clot D. Report the
APTT only
Hemost
sis/Apply knowlede to identify sources of errors/Specimens/3 9. A pl
sm

s
mple su mitted
to the l
for PT testin h
s een stored for 25 hours
t 4C. Te PT result is sho
rtened. Wh
t is
the most pro
le c
use? A. F
ctor VII de ciency B. Activ
tion of f
ctor VII due t
o exposure to
cold temper
ture C. Lupus inhi itor D. F
ctor X inhi itor Hemost
sis/Apply knowl
ede to identify
sources of errors/Specimen stor
e/3 10. Te APTT results
re not elev
ted in
p

tient receivin
hep
rin. Which of the followin f
ctors m
y e
ssoci
ted with the l
ck of respo
nse to hep
rin
ther
py in this p
tient? A. Protein C de ciency B. Antithrom in de ciency C. Protein
S de ciency
D. F
ctor VIII de ciency Hemost
sis/Correl
te clinic
l
nd l
or
tory d
t
/ Inhi i
tors/3 11. A
50-ye
r-old p
tient w
s
dmitted to the emerency dep
rtment compl
inin of p
in
in her riht
le. Her le w
s red, swollen,
nd w
rm to the touch. Deep venous throm osis w
s
suspected,
nd
the p
tient w
s st
rted on hep
rin ther
py. Which of the followin is (
re) the
proper protocol
to ev
lu
te p
tients receivin hep
rin ther
py? A. A
seline APTT
nd pl
telet
count; APTT
testin every 6 hours until the t
ret is re
ched B. Repe
t APTT
fter 5 d
ys po

sthep
rin ther
py
to
djust the ther
peutic dose C. Monitor the pl
telet count d
ily
nd every oth
er d
y
fter
hep
rin ther
py is completed D. Monitor PT d
ily to
djust the ther
peutic dose
Hemost
sis/Correl
te clinic
l
nd l
or
tory d
t
/ Hep
rin ther
py/2 68 Ch
pter
2 | Hemost
sis
Answers to Questions 811 8. C A clot c
n form ec
use of in
dequ
te mixin of the
s
mple
fter
venipuncture, if the lood lls the ev
cu
ted tu e
t
slow r
te, or with tr
um
t
ic
venipuncture. In vitro, lood clots result in consumption of the clottin f
ctor
s
nd therefore
prolon
tion of PT, APTT,
nd other clot-
sed
ss
ys. If the clottin f
ctors h

ve een

ctiv
ted ut the clot form
tion is incomplete, it m
y result in shortenin of t
he PT
nd APTT.
Checkin the s
mple for
clot is the most re
son
le step in this c
se. 9. B S

mples for
ev
lu
tion of PT
re st
le for 24 hours if kept
t room temper
ture. Proloned
exposure to cold
will
ctiv
te f
ctor VII, resultin in decre
sed PT results. 10. B Antithrom in
de ciency in
p
tients receivin hep
rin ther
py m
y le
d to hep
rin resist
nce,
nd therefore
, l
ck of
prolon
tion of APTT results. Antithrom in is
hep
rin cof
ctor
nd
s such inc
re
ses hep
rin

ctivity y 1,000-fold. The de ciency of AT is
ssoci
ted with
poor response to
hep
rin
ther
py. 11. A The
seline pl
telet count
nd APTT should e performed on
ll p

tients prior to

dministr
tion of hep
rin. The response to hep
rin ther
py v
ries
mon di erent p

tients for the
followin re
sons: Hep
rin h
lf-life is decre
sed in extended throm osis,
nd th
e
ntico
ul
nt

ctivities of hep
rin ch
ne
sed upon nonspeci c indin of hep
rin to pl
sm
pr
oteins.
Therefore, hep
rin ther
py should e closely monitored. Hep
rin dos
e c
n e mo
nitored y
n
APTT or
ctiv
ted clottin time (ACT) test ut not y the PT. In
ddition, the p
l
telet count
should e monitored reul
rly durin hep
rin ther
py, ec
use
decre
se of the
pl
telet count to
50% elow the
seline v
lue is sini c
nt
nd m
y e
ssoci
ted with HIT. 2828_Ch
02_041-074
06/08/12 11:09 AM P
e 68 12. P
tient History: A 46-ye
r-old fem
le w
s
dmitt
ed to the
emerency dep
rtment with compl
ints of he
d
che, dizziness, leth
ry, n
use
, v
omitin,
nd
we
kness. Te p
tient h
d

strectomy procedure 4 months e
rlier to remove
den
oc
rcinom
of the
stom
ch. She w
s pl
ced on mitomycin ther
py. Di
nostic procedures indic
ted re
currence of the
c
rcinom
. 2.5 | Hemost
sis Pro lem Solvin
69 Answer to Question 12 12. C The
clinic
l
m
nifest
tions
nd l
or
tory results in this p
tient
re consistent with TTP. T
he clinic
l
m
nifest
tions of TTP include micro
niop
thic hemolytic
nemi
(MAHA), throm oc
ytopeni
, fever,
ren
l f
ilure,
nd neuroloic
l symptoms. The neuroloic
l symptoms in this p
ti
ent
re

m
nifested y he
d
che, dizziness, n
use
,
nd vomitin. We
kness
nd leth
ry

re sins
nd
symptoms of
nemi
. Low hemolo in
nd hem
tocrit with norm
l MCV
nd MCHC indic

te

normocytic/normochromic
nemi
. The presence of schistocytes on the peripher
l
lood with low
pl
telet counts
nd low h
ptolo in
re consistent with micro
niop
thic hemolyt
ic
nemi
. The
hih lood ure
nitroen
nd cre
tinine levels
re ch
r
cteristic of ren
l f
ilu
re. The pl
telet
count, performed on
dmission, w
s done on
hem
toloy
n
lyzer
nd w
s f
lsely
elev
ted ec
use
of the presence of microcytes or fr
mented red cells. The m
nu
l pl
telet count
w
s much lower.
The co
ul
tion tests
re norm
l in TTP. In von Wille r
nds dise
se, the pl
telet
count is
norm
l
nd the APTT is usu
lly
norm
l. ITP is ch
r
cterized y throm ocytopeni

ut not HA.
Althouh DIC is
ssoci
ted with
low pl
telet count
nd HA, it is ch
r
cterized
y
norm
l
co
ul
tion studies. The
cute onset of symptoms m
y e rel
ted to mitomycin use
d for the
tre
tment of 
stric c
rcinom
in this p
tient. Admission CBC Results Reference
P
tient R
ne
WBC 17.1 10 9
/
L 4.810.8 10
9
/L
RBC 2.29 10 12
/
L 3.805.50 10
12
/L
H
8.1 /dL 12.015.2 /dL Hct 23% 37%46% MCV 95.7 fL 79101 fL MCH 35.4 p
 2733 p MCHC
35.0 /dL 3134 /dL RDW 18.5 11.514.5 PLT 48.0 10 9
/
L 140450 10
9
/L
MPV 11.2 7.49.4 DIFFERENTIAL COUNTS % Semented 79 30%70% neutrophils B
nd
neutrophils 3
0%10% Lymphocytes 11 20%50% Monocytes 6 2%12% B
sophils 1 0%2% NRBCs (/100 WBCs) 3 0
M
nu
l
pl
telet 18 10 9
/
L 140450 10
9
/L
count: M
rked
nisocytosis none M
rked RBC none fr
ment
tion PT, APTT,

nd TT: Norm
l
ADDITIONAL LABORATORY DATA Reference Urin
lysis P
tient R
ne pH 5.0 57 Prote
in 30.0 m/dL
015 m/dL RBC 60100/L 05/L C
sts 10/hpf Not detect
le r
nul
r/ hy
line Cre
tinine
3.1
m/dL 0.71.3 m/dL BUN 39 m/dL 822 m/dL H
ptolo in 5.0 m/dL 50150 m/dL Tese
clinic
l
m
nifest
tions
nd l
or
tory results
re consistent with: A. ITP B. von Wille r

nds dise
se C.
TTP D. DIC Hemost
sis/Correl
te clinic
l
nd l
or
tory d
t
/ Pl
telet disorders
/3
2828_Ch02_041-074 06/08/12 11:09 AM P
e 69 13. P
tient History A 1-ye
r-old
inf
nt w
s


dmitted to the hospit
l with recurrent epist
xis for the p
st 5 d
ys. Te p
st m
edic
l history
reve
led e
sy ruisin
nd
severe nose leed
t 3 months of
e, necessit
tin
tr
nsfusion
ther
py. Te mother h
d h
d
severe nose leed 8 ye
rs
o. Te f
ther w
s reporte
d to leed e
sily

fter l
cer
tions. Te p
tient w
s tr
nsfused with 2 units of p
cked red cells up
on
dmission. 70
Ch
pter 2 | Hemost
sis Answer to Question 13 13. C These clinic
l m
nifest
tions

nd l
or
tory
results
re consistent with Gl
nzm
nns throm
stheni
. Epist
xis
nd e
sy ruisin

re
ch
r
cteristics of pl
telet disorders. The positive f
mily history is indic
tive
of
n inherited
leedin disorder. L
or
tory tests reve
l
low hemolo in level due to epist
x
is. The norm
l
pl
telet count rules out
ny qu
ntit
tive pl
telet disorder. The pl
telet count
is typic
lly low
in Bern
rdSoulier syndrome. The leedin time test ev
lu
tes in vivo pl
telet fun
ction
nd
num er. Norm
l PT
nd APTT com ined with
norm
l f
ctor VIII
ss
y rule out co

ul
tion
disorders. The l
or
tory tests th
t con rm
n inherited pl
telet disorder
re pl

telet

re
tion studies. Pl
telet
re
tion is norm
l to ristocetin
nd
norm
l t
o ADP,
epinephrine,
nd throm in. These results
re consistent with Gl
nzm
nns throm
st
heni
. Pl
telet

re
tion is
norm
l to ristocetin in von Wille r
nds dise
se
nd Bern
rdSoulie
r syndrome.
Admission L
or
tory Results Reference P
tient R
ne H : 4.5 /dL 1315 /dL Pl

telet count:
249 10 9
/
L 150450 10
9
/L
PT: 11.2 sec 1113 sec APTT: 34 sec 2837 sec ADDITIONAL LABORATORY TESTS F

ctor VIII
ss
y
70% 50%150% Pl
telet A norm
l to
re
tion: ADP, epinephrine,
nd throm in; no
rm
l to
ristocetin Tese clinic
l m
nifest
tions
nd l
or
tory results
re consistent wi
th which
condition? A. von Wille r
nds dise
se B. Bern
rdSoulier syndrome C. Gl
nzm
nns thro
m
stheni

D. F
ctor VIII de ciency Hemost
sis/Correl
te clinic
l
nd l
or
tory d
t
/ Pl
tel
et disorders/3
2828_Ch02_041-074 06/08/12 11:09 AM P
e 70 14. P
tient History: A 30-ye
r-ol
d fem
le w
s
referred to the hospit
l for ev
lu
tion for multiple spont
neous
ortions
nd c
urrent compl
int
of p
in
nd swellin in her riht le. Her f
mily history is unrem
rk
le. 2.5 |
Hemost
sis
Pro lem Solvin
71 Answers to Questions 1415 14. D These clinic
l m
nifest
tion
s
nd
l
or
tory results
re consistent with lupus
ntico
ul
nt. P
in
nd swellin in
her riht le
m
y e indic
tive of throm osis. As m
ny
s 48% of women with repe
ted spont
neo
us
ortions h
ve
lupus
ntico
ul
nt or/
nd
nti ody to phospholipid such
s
ntic
rdiolipin
nti
odies. The

unrem
rk
le f
mily history in this p
tient rules out
n inherited throm otic di
sorder. A norm
l
TT rules out rinoen disorders. A proloned PT
nd APTT in the
sence of leedi
n history
elimin
te the di
nosis of f
ctor de ciency, includin f
ctor VIII de ciency. The AP
TT performed
on
mixture of p
tient pl
sm

nd norm
l pl
sm
did not correct. This result is
indic
tive of
n
inhi itor. However, ec
use the p
tient is not leedin, f
ctor VIII inhi itor i
s not indic
ted.
A ne
tive
ntic
rdiolipin
nti ody result rules out the possi ility of
ntic
rd
iolipin

nti odies ein responsi le for the p
tients clinic
l symptoms. The l
or
tory t
est th
t
con rms the presence of
lupus
ntico
ul
nt is
proloned APTT th
t is not corr
ected when
mixed with norm
l pl
sm

nd th
t is neutr
lized y preincu
tion with pl
telets
(
n excess of
pl
telet phospholipid neutr
lizes the
nti ody, resultin in
norm
l APTT). 15.
C Liver iopsy
in
p
tient with
proloned PT
nd
hih INR could e life thre
tenin. In th
is p
tient, the
proloned PT is likely c
used y liver dise
se. Vit
min K is stored in the liver

nd is essenti
l
for
ctiv
tion of f
ctors II, VII, IX,
nd X. Vit
min K needs ile (secreted y
the liver) for
its
sorption. In liver dise
se ch
r
cterized y o struction, ile is not secre
ted into the GI
tr
ct,
nd therefore, vit
min K is poorly
sor ed. The most loic
l course of

ction is to
recommend the followin: St
rt the p
tient on vit
min K ther
py, repe
t the PT t
est 4 d
ys
fter
st
rtin vit
min K
dministr
tion,
nd c
ncel the iopsy until the p
tients PT re
turns to
norm
l. L
or
tory Reference Tests P
tient R
ne PT: 14.5 sec 1113 sec APTT:
63.0 sec 2837
sec Throm in time: 12.0 sec 1015 sec Mixin Study APTT: Preincu
tion
nd 57.0 s
ec
fter 2-hour
incu
tion
t 37C Pl
telet Neutr
liz
tion Procedure: P
tient pl
sm
+ APTT: 35.0
sec
freeze-th
wed pl
telets P
tient pl
sm
+ APTT: 59.0 sec s
line Antic
rdiolipin
Ne
tive

nti odies done y ELISA: Tese clinic
l m
nifest
tions
nd l
or
tory results
r
e consistent
with: A. F
ctor VIII inhi itor B. F
ctor VIII de ciency C. Antic
rdiolipin
nti od
ies D. Lupus

ntico
ul
nt Hemost
sis/Correl
te clinic
l
nd l
or
tory d
t
/ Co
ulop
thies/
3 15. A
60-ye
r-old p
tient w
s
dmitted to
hospit
l for
liver iopsy. Te iopsy w
s
scheduled for
11:00
.m. Te co
ul
tion results performed
t the time of
dmission reve
led

proloned PT with

n INR of 4.5. Wh
t is the physici
ns most
ppropri
te course of
ction? A. Proce
ed with iopsy,
ec
use
proloned PT is expected in liver dise
se B. Postpone the procedure fo
r
couple of
d
ys C. C
ncel the procedure
nd st
rt the p
tient on vit
min K ther
py D. Put p

tient on vit
min
K
nd proceed with the procedure immedi
tely Hemost
sis/Correl
te clinic
l
nd l

or
tory d
t
/

INR/3 2828_Ch02_041-074 06/08/12 11:09 AM P
e 71 16. A fresh lood s
mple w

s sent to the
l
or
tory
t 8:00
.m. for
PT test. At 4:00 p.m., the doctor requested
n APT
T test to e done
on the s
me s
mple. Wh
t should the technoloist do? A. Rerun APTT on the 8:00

.m. s
mple
nd
report the result B. Request
new s
mple for APTT C. Run APTT in duplic
te
nd
report the

ver
e D. Mix the p
tient pl
sm
with norm
l pl
sm

nd run the APTT Hemost
sis
/Select
methods/Re
ents/Specimen collection
nd h
ndlin/Specimens/3 17. An APTT test i
s performed on

p
tient
nd the result is 50 sec (reference r
ne 2737 sec). Te instrument
s the
result owin
to f
ilure of the delt
check. Te p
tient h
d
n APTT of 35 sec the previous d
y
. Te technoloist
c
lls the nursin unit to check whether the p
tient is on hep
rin ther
py. Te p

tient is not
receivin hep
rin. Wh
t is the next
ppropri
te step? A. Check the f
mily histor
y for
n
inherited f
ctor VIII de ciency B. Check to see if the p
tient h
s received
ny ot
her

ntico
ul
nt medic
tions C. Perform mixin studies D. Perform
f
ctor VIII
ss

y
Hemost
sis/Select course of
ction/3 18. A p
tient w
s put on hep
rin ther
py po
stoper
tively for
prevention of throm osis. Te p
tient h
d the followin l
or
tory results on
dm
ission: Pl
telet
count = 350 10 9
/
L; PT =
12 sec (reference: 1013 sec); APTT = 35 sec (reference: 2837). After 6 d
y
s of hep
rin
ther
py, the p
tient compl
ined of p
in
nd swellin in her left le. Her pl
tel
et count dropped
to 85 10 9
/
L
nd her APTT result w
s 36 sec.
Te physici
n suspected hep
rin-induced throm ocytopeni
(HIT)
nd ordere
d
pl
telet

re
tion test to e performed immedi
tely. Te hep
rin-induced pl
telet
re

tion test result
w
s ne
tive. Hep
rin ther
py w
s continued. Sever
l d
ys l
ter, the p
tient dev
eloped
m
ssive
clot in her left le th
t necessit
ted
mput
tion. Which of the followin should
h
ve een
reconized or initi
ted? A. Te p
tient should h
ve een pl
ced on LMWH B. Te hep

rin dose should
h
ve een incre
sed C. Te ne
tive pl
telet
re
tion does not rule out HIT D.
Te p
tient
should h
ve een pl
ced on w
rf
rin ther
py Hemost
sis/Correl
te clinic
l
nd l

or
tory d
t
/
HIT/3 72 Ch
pter 2 | Hemost
sis Answers to Questions 1618 16. B Accordin to Clin
ic
l L
or
tory
St
nd
rds Institute (CLSI) uidelines, s
mples for APTT should e centrifued
n
d tested within 2
hours
fter collection. However, the s
mple is st
le for 4 hours if stored
t 4
o C. APTT
ev
lu
tes the clottin f
ctors in the intrinsic
nd common co
ul
tion p
thw
ys,
includin f
ctor
VIII (intrinsic)
nd f
ctor V (common). F
ctors VIII
nd V
re cof
ctors necess

ry for rin

form
tion. However, they
re oth l
ile. Stor
e eyond 4 hours c
uses f
lsely
elev
ted APTT
results. The technoloist should request
new s
mple for the APTT. 17. B Tr
dit
ion
l

ntico
ul
nt drus such
s hep
rin
nd w
rf
rin
re well known. There
re new

ntico
ul
nt
drus
v
il
le for the tre
tment
nd prevention of throm osis. Some of these ne
w drus h
ve

ntithrom in e ects
nd therefore incre
se PT, APTT,
nd TT results. Ex
mples of t
hese drus
re
hirudin, which inhi its throm in;
nd d
n
p
roid, which inhi its f
ctor X
. 18.
C Hep
rin ther
py
should e stopped immedi
tely when clinic
l symptoms indic
te HIT. The lood s
m
ple should e
tested
t le
st 4 hours
fter hep
rin ther
py is discontinued. E
rly s
mplin fo
r HIT testin m
y
ive
f
lse-ne
tive result due to the neutr
liz
tion of
nti ody y hep
rin. L
MWH should not e
used in p
tients who develop HIT, ec
use LMWH drus c
n
lso c
use HIT. W
rf
ri
n ther
py c
n e
st
rted in p
tients who respond to hep
rin ther
py
s soon
s the APTT is incre

sed to 1.5 times
the
seline APTT. Hep
rin ther
py must overl
p w
rf
rin ther
py until the INR r
e
ches
st
le
ther
peutic r
ne (2.03.0). W
rf
rin ther
py could not e used in this p
tient e
c
use she did
not respond to hep
rin ther
py. The rst step in the tre
tment of HIT is discontin
u
tion of
hep
rin, includin intr
venous c
theter ushes, hep
rin- co
ted indwellin c
thete
rs,
unfr
ction
ted hep
rin,
nd LMWH. 2828_Ch02_041-074 06/08/12 11:09 AM P
e 72
19. A
50-ye
r-old fem
le w
s
dmitted to
hospit
l for hip repl
cement surery. Te pr
eoper
tive tests
were performed
nd the results showed
n H of 13.5 /dL; Hct = 42%; PT = 12 se
c; APTT = 36 sec.
Te p
tient w
s leedin durin surery
nd the postoper
tive test results reve
l
ed
n H = 5.0
/dL; Hct = 16%; PT = 8 sec;
nd APTT = 25 sec. Wh
t steps should e t
ken efor
e rele
sin these
results? A. No follow-up steps
re needed; report the results
s o t
ined B. Rep
ort H
nd Hct
results,
djust the
ntico
ul
nt volume,
nd redr
w
new s
mple for PT
nd APT
T C. C
ll the
nurse
nd
sk if the p
tient is receivin hep
rin D. Bec
use the p
tient is seve
rely
nemic,
multiply the PT
nd APTT results y two
nd report the results Hemost
sis/Select
course of

ction/3 20. P
tient
nd F
mily History A 45-ye
r-old wom
n visited her doctor c
ompl
inin of
e
sy ruisin
nd menorrh
i
occurrin for the p
st few weeks. Te p
tient h
d n
o history of
excessive leedin durin child irth sever
l ye
rs e
rlier nor durin
tonsille
ctomy in
childhood. Her f
mily history w
s unrem
rk
le. 2.5 | Hemost
sis Pro lem Solvin
73 Answers to
Questions 1920 19. B The
ntico
ul
nt-to- lood r
tio should e
djusted for PT

nd APTT tests
in p
tients with
severe
nemi
. The st
nd
rd
ntico
ul
nt volume (0.5 mL) is
not su cient for

the l
re qu
ntity of pl
sm
in these p
tients, c
usin unreli
le PT
nd APTT r
esults. The low
H
nd Hct in this p
tient were due to severe leedin durin surery. To et

ccur
te PT
nd
APTT results, the
mount of
ntico
ul
nt is
djusted
ccordin to the followin
formul
:
(0.00185)(V)(100H) = C, where V = lood volume in mL; H = p
tients Hct;
nd C = vo
lume of

ntico
ul
nt in mL. A new s
mple should e dr
wn to rerun the PT
nd APTT. Ther
e
re other
c
uses for decre
sed PT
nd APTT, such
s incre
sed
rinoen
nd incre
sed f
ctor
VIII; however,
the pre
n
lytic
l v
ri
les
ectin unreli
le results should e ruled out rst. He
p
rin ther
py
would incre
se PT
nd APTT. 20. B The l
ck of
positive f
mily history in this
p
tient indic
tes
the presence of
n
cquired co
ulop
thy. Bec
use oth PT
nd APTT tests
re
n
orm
l, the
clottin f
ctor involved is most pro
ly in the common p
thw
y. The l
ck of cor
rection y mixin
studies suests the presence of
n inhi itor. F
ctor V
nti odies
re the most
common
nti odies

mon the clottin f
ctors of the common p
thw
y (I, II, V,
nd X). F
ctor V
nt
i odies
re
reported to e
ssoci
ted with surery, some
nti iotics such
s streptomycin, p

tients who
re
exposed to lood products, or the ovine form of rin lue. P
tients with
nti odie
s to f
ctor
V m
y require lon-term ther
py with immunosuppressive drus. Acute leedin epi
sodes m
y e
tre
ted y pl
telet tr
nsfusions. The PT test is norm
l in p
tients with f
ctor
VIII de ciency

nd f
ctor VIII inhi itor. Lupus
ntico
ul
nt is not present with leedin unle
ss
ssoci
ted
with coexistin throm ocytopeni
. L
or
tory Reference Tests P
tient R
ne
PT 45 sec 1113
sec APTT 125 sec 2837 sec Throm in Time 14.0 sec 1015 sec Mixin studies (p
tient
pl
sm
+
norm
l pl
sm
): PT = 40 sec; APTT = 90 sec Pl
telet count
nd morpholoy = norm

l Liver function
tests = norm
l Tese clinic
l m
nifest
tions
nd l
or
tory results
re consisten
t with: A. F
ctor
VIII inhi itor B. F
ctor V inhi itor C. F
ctor VIII de ciency D. Lupus
ntico
ul

nt
Hemost
sis/Correl
te clinic
l
nd l
or
tory d
t
/ Inhi itors/3 BI BL I OGRAPHY
1. Bick RL.
Disorders of Trom osis
nd Hemost
sis. 3rd edition, 2002. Lippincott Willi
ms
n
d Wilkins,
Phil
delphi
. 2. Colem
n RW, Hirsh J, M
rder VJ, et
l. Hemost
sis
nd Trom osi
s, B
sic
Principles
nd Clinic
l Pr
ctice. 5th edition, 2006. Lippincott Willi
ms
nd Wil
kins,
Phil
delphi
. 3. Greer JP, Foester J, Roders GM, et
l. Wintro es Clinic
l Hem
t
oloy. 12th
edition, Vol. 2, 2009. Lippincott Willi
ms
nd Wilkins, Phil
delphi
. 4. K
ush
n
sky K, Lichtm
n
MA, Beutler E, et
l. Willi
ms Hem
toloy. 8th edition, 2010. McGr
w-Hill, New Y
ork. 5. N
th
n
DG, Orkin SH, Gins ur D, et
l. Hem
toloy of Inf
ncy
nd Childhood. 7th editio
n, Vol. 2, 2008.

W.B.S
unders, Phil
delphi
. 6. Rod
k BF, Fritsm
GA,
nd Doi K. Hem
toloy, Cli
nic
l
nd
Applic
tion. 3rd edition, 2007. W.B. S
unders, Phil
delphi
. 2828_Ch02_041-074
06/08/12 11:09
AM P
e 73 2828_Ch02_041-074 06/08/12 11:09 AM P
e 74 75 3.1 B
sic Principl
es of Immunoloy
3.2 Immunoloic Procedures 3.3 Infectious Dise
ses 3.4 Autoimmune Dise
ses 3.5 H
ypersensitivity
3.6 Immunolo ulins, Complement,
nd Cellul
r Testin 3.7 Tumor Testin
nd Tr
n
spl
nt
tion 3.8
Immunoloy Pro lem Solvin CHAPTER 3 Immunoloy 2828_Ch03_075-120 06/08/12 11:
10 AM P
e 75
2828_Ch03_075-120 06/08/12 11:10 AM P
e 76 77 3.1 B
sic Principles of Immuno
loy 1. From the
followin, identify
speci c component of the
d
ptive immune system th
t is form
ed in response
to
ntienic stimul
tion: A. Lysozyme B. Complement C. Commens
l or
nisms D. Im
munolo ulin
Immunoloy/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics/Immune syst
em/1 2. Which two
or
ns
re considered the prim
ry lymphoid or
ns in which immunocompetent cells
oriin
te
nd
m
ture? A. Tyroid
nd Peyers p
tches B. Tymus
nd one m
rrow C. Spleen
nd mucos

l-
ssoci
ted
lymphoid tissue (MALT) D. Lymph nodes
nd thor
cic duct Immunoloy/Apply knowled
e of fund
ment
l
ioloic
l ch
r
cteristics/Immune system/Or
ns/1 3. Wh
t type of B cells
re fo
rmed
fter

ntien stimul
tion? A. Pl
sm
cells
nd memory B cells B. M
ture B cells C. Ant
ien-dependent B
cells D. Receptor-
ctiv
ted B cells Immunoloy/Apply knowlede of fund
ment
l i
oloic
l
ch
r
cteristics/Immune system/Cells/1 4. T cells tr
vel from the one m
rrow to
the thymus for
m
tur
tion. Wh
t is the correct order of the m
tur
tion sequence for T cells in
the thymus? A.
Bone m
rrow to the cortex;
fter thymic educ
tion, rele
sed
ck to peripher
l c
ircul
tion B.
M
tur
tion
nd selection occur in the cortex; mir
tion to the medull
; rele
se
of m
ture T cells
to second
ry lymphoid or
ns C. Stor
e in either the cortex or medull
; rele
se
of T cells into
the peripher
l circul
tion D. Activ
tion
nd selection occur in the medull
; m
t
ure T cells
re
stored in the cortex until
ctiv
ted y
ntien Immunoloy/Apply knowlede of fu
nd
ment
l
ioloic
l ch
r
cteristics/Immune system/Cells/1 Answers to Questions 14 1. D Imm
unolo ulin is

speci c p
rt of the
d
ptive immune system
nd is formed only in response to
s
peci c

ntienic stimul
tion. Complement, lysozyme,
nd commens
l or
nisms
ll
ct non
speci c
lly
s

p
rt of the
d
ptive immune system. These three components do not require
ny ty
pe of speci c

ntienic stimul
tion. 2. B The one m
rrow
nd thymus
re considered prim
ry ly
mphoid or
ns
ec
use immunocompetent cells either oriin
te or m
ture in them. Some immunocom
petent cells
m
ture or reside in the one m
rrow (the source of
ll hem
topoietic cells) unti
l tr
nsported to

the thymus, spleen, or Peyers p
tches, where they process
ntien or m
nuf
cture

nti ody. T
lymphocytes,
fter oriin
tin in the one m
rrow, tr
vel to the thymus to m
tur
e
nd
di erenti
te. 3. A M
ture B cells exhi it surf
ce immunolo ulin th
t m
y cross li
nk
forein

ntien, thus formin the
ctiv
ted B cell
nd le
din to c
ppin
nd intern
liz

tion of
ntien.
The
ctiv
ted B cell ives rise to pl
sm
cells th
t produce
nd secrete immuno
lo ulins
nd
memory cells th
t reside in lymphoid or
ns. 4. B Imm
ture T cells tr
vel from t
he one m
rrow to
the thymus to m
ture into function
l T cells. Once in the thymus, T cells under
o
selection
nd
m
tur
tion sequence th
t eins in the cortex
nd moves to the medull
of the th
ymus. Thymic
f
ctors such
s thymosin
nd thymopoietin
nd cells within the thymus such
s m

croph
es
nd
dendritic cells
ssist in this sequence. After completion of the m
tur
tion cycl
e, T cells
re
rele
sed to second
ry lymphoid or
ns to
w
it
ntien reconition
nd
ctiv
tio
n.
2828_Ch03_075-120 06/08/12 11:10 AM P
e 77 5. Which cluster of di erenti
tion
(CD) m
rker

ppe
rs durin the rst st
e of T-cell development
nd rem
ins present
s
n iden
tifyin m
rker
for T cells? A. CD1 B. CD2 C. CD3 D. CD4 or CD8 Immunoloy/Apply principles of

sic l
or
tory
procedures/T cells/M
rkers/1 6. Which m
rkers
re found on m
ture, peripher
l he
lper T cells? A.
CD1, CD2, CD4 B. CD2, CD3, CD8 C. CD1, CD3, CD4 D. CD2, CD3, CD4 Immunoloy/Appl
y knowlede of
fund
ment
l ioloic
l ch
r
cteristics/T cells/M
rkers/1 7. Which T cell express
es the CD8 m
rker

nd
cts speci c
lly to kill tumors or vir
lly infected cells? A. Helper T B. T su
ppressor C. T
cytotoxic D. T inducer/suppressor Immunoloy/Apply knowlede of fund
ment
l iol
oic
l
ch
r
cteristics/T cells/Cytokines/1 8. How
re cytotoxic T cells (T C cells)
nd
n
tur
l killer
(NK) cells simil
r? A. Require
nti ody to e present B. E ective

inst vir
lly
infected cells
C. Reconize
ntien in
ssoci
tion with HLA cl
ss II m
rkers D. Do not ind to
infected cells
Immunoloy/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics/Lymphocytes
/Functions/1 9.
Wh
t is the n
me of the process y which ph
ocytic cells
re
ttr
cted to
su
st
nce such
s


cteri
l peptide? A. Di
pedesis B. Der
nul
tion C. Chemot
xis D. Ph
ot
xis Im
munoloy/Apply
knowlede of fund
ment
l ioloic
l ch
r
cteristics/Immune system/Cells/1 10. Al
l of the
followin
re immunoloic functions of complement except: A. Induction of
n
nt
ivir
l st
te B.
Opsoniz
tion C. Chemot
xis D. An
phyl
toxin form
tion Immunoloy/Apply knowlede
of fund
ment
l
ioloic
l ch
r
cteristics/Complement/Functions/1 78 Ch
pter 3 | Immunoloy Answ
ers to Questions
511 5. B The CD2 m
rker
ppe
rs durin the rst st
e of T-cell development
nd c
n
e used to

di erenti
te T cells from other lymphocytes. This T-lymphocyte receptor inds shee
p red lood
cells (RBCs). This peculi
r ch
r
cteristic w
s the
sis for the cl
ssic E roset
te test once used
to enumer
te T cells in peripher
l lood. CD2 is not speci c for T cells, however,

nd is
lso
found on l
re r
nul
r lymphocytes (LGL or n
tur
l killer [NK] cells). 6. D M
t
ure, peripher
l
helper T cells h
ve the CD2 (E rosette), CD3 (m
ture T cell),
nd CD4 (helper) m

rkers. 7. C T
cytotoxic cells reconize
ntien in
ssoci
tion with m
jor histocomp
ti ility c
omplex (MHC)
cl
ss I complexes
nd
ct

inst t
ret cells th
t express forein
ntiens. Th
ese include vir
l

ntiens
nd the hum
n leukocyte
ntiens (HLA) th
t
re the t
ret of r
ft rej
ection. 8. B Both
T C
nd NK cells
re e ective

inst vir
lly infected cells,
nd neither requires

nti ody to e
present to ind to infected cells. NK cells do not exhi it MHC cl
ss restriction
, where
s

ctiv
tion of T C cells requires the presence of MHC cl
ss I molecules in
ssoci

tion with the
vir
l
ntien. 9. C Chemot
xis is the process y which ph
ocytic cells
re
ttr

cted tow
rd
n

re
where they detect
distur
nce in the norm
l functions of ody tissues. Pr
oducts from

cteri

nd viruses, complement components, co
ul
tion proteins,
nd cytokines
from other
immune cells m
y
ll
ct
s chemot
ctic f
ctors. 10. A Complement components
re
serum proteins
th
t function in opsoniz
tion, chemot
xis,
nd
n
phyl
toxin form
tion ut do no
t induce
n

ntivir
l st
te in t
ret cells. This function is performed y interferons. 11.
D C3 is found in
oth the cl
ssic
nd
ltern
tive (
ltern
te) p
thw
ys of the complement system.
In the cl
ssic
p
thw
y, C3 forms
complex on the cell with C4 2
th
t enzym
tic
lly cle
ves C
5. In the

ltern
tive p
thw
y, C3 inds to
n
ctiv
tor on the cell surf
ce. It forms
c
omplex with
f
ctor B c
lled C3 B which, like C4 2
3 , c
n split C5. 11. Which complement co
mponent is found
in oth the cl
ssic
nd
ltern
tive p
thw
ys? A. C1 B. C4 C. F
ctor D D. C3 Immu
noloy/Apply
knowlede of fund
ment
l ioloic
l ch
r
cteristics/Complement/Components/1 2828
_Ch03_075-120
06/08/12 11:10 AM P
e 78 12. Which immunolo ulin(s) help(s) initi
te the cl

ssic complement
p
thw
y? A. IA
nd ID B. IM only C. IG
nd IM D. IG only Immunoloy/Apply
knowlede of
fund
ment
l ioloic
l ch
r
cteristics/Complement/Activ
tion/1 13. How is comple
ment
ctivity
destroyed in vitro? A. He
tin serum
t 56C for 30 min B. Keepin serum
t room t
emper
ture of
22C for 1 hour C. He
tin serum
t 37C for 45 min D. Freezin serum
t 0C for 24 ho
urs
Immunoloy/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics/Complement/
Activ
tion/1 14.
Wh
t is the purpose of C3
, C4
,
nd C5
, the split products of the complement c

sc
de? A. To

ind with speci c mem r
ne receptors of lymphocytes
nd c
use rele
se of cytotoxic
su st
nces B.
To c
use incre
sed v
scul
r perme
ility, contr
ction of smooth muscle,
nd rele

se of hist
mine
from
sophils C. To ind with mem r
ne receptors of m
croph
es to f
cilit
te p
h
ocytosis
nd
the remov
l of de ris
nd forein su st
nces D. To reul
te
nd der
de mem r
ne
cof
ctor protein

fter
ctiv
tion y C3 convert
se Immunoloy/Apply knowlede of fund
ment
l iol
oic
l
ch
r
cteristics/Complement/An
phyl
toxins/1 15. Which reion of the immunolo ul
in molecule c
n
ind
ntien? A. F
B. Fc C. C L D. C H Immunoloy/Apply knowlede of fund
ment

l ioloic
l
ch
r
cteristics/Immunolo ulins/ Structures/1 16. Which reion determines whethe
r
n
immunolo ulin molecule c
n x complement? A. V H B. C H C. V L D. C L Immunoloy/
Apply knowlede
of fund
ment
l ioloic
l ch
r
cteristics/Immunolo ulins/Structures/1 3.1 | B
s
ic Principles of
Immunoloy 79 Answers to Questions 1217 12. C Both IG
nd IM
re the immunol
o ulins th
t
help to initi
te the
ctiv
tion of the cl
ssic complement p
thw
y. IM is
more
potent
complement
ctiv
tor, however. 13. A Complement
ctivity in serum in vitro is de
stroyed y
he
tin the serum
t 56C for 30 min. In test procedures where complement m
y inte
rfere with the
test system, it m
y e necess
ry to destroy complement
ctivity in the test s
mp
le y he
t
in
ctiv
tion. 14. B C3
, C4
,
nd C5

re split products of the complement c
sc

de th
t
p
rticip
te in v
rious ioloic
l functions such
s v
sodil
tion
nd smooth musc
le contr
ction.
These sm
ll peptides
ct
s
n
phyl
toxins, e.., e ector molecules th
t p
rticip

te in the
in
mm
tory response to
ssist in the destruction
nd cle
r
nce of forein
ntien
s. 15. A The
F
(fr
ment
ntien indin) is the reion of the immunolo ulin molecule th
t
c
n ind

ntien. Two F
fr
ments
re formed from hydrolysis of the immunolo ulin mole
cule y p
p
in.
E
ch consists of
liht ch
in
nd the V H
nd C H1 reions of the he
vy ch
in.
The v
ri
le
reions of the liht
nd he
vy ch
ins inter
ct, formin
speci c
ntien-com inin
 site. 16. B
The composition
nd structure of the const
nt reion of the he
vy ch
in determin
e whether th
t
immunolo ulin will x complement. The Fc fr
ment (fr
ment cryst
lliz
le) is fo
rmed y p
rti
l
immunolo ulin diestion with p
p
in
nd includes the C H2
nd C H3 dom
ins of
oth he
vy ch
ins.
The complement component C1q molecule will ind to the C H2 reion of
n IG or
IM molecule. 17.
C Both IM
nd secretory IA h
ve
J ch
in joinin individu
l molecules toethe
r; the J ch
in in
IM joins ve molecules
nd the J ch
in in sIA joins two molecules. 17. Which imm
unolo ulin
cl
ss(es) h
s (h
ve)
J ch
in? A. IM B. IE
nd ID C. IM
nd sIA D. IG3
n
d IA

Immunoloy/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics/Immunolo u

lins/Structures/1
2828_Ch03_075-120 06/08/12 11:10 AM P
e 79 18. Which immunolo ulin
ppe
rs r
st in the
prim
ry immune response? A. IG B. IM C. IA D. IE Immunoloy/Apply knowlede
of fund
ment
l
ioloic
l ch
r
cteristics/Immunolo ulins/Functions/1 19. Which immunolo ulin

ppe
rs in
hihest titer in the second
ry response? A. IG B. IM C. IA D. IE Immunoloy/
Apply knowlede
of fund
ment
l ioloic
l ch
r
cteristics/Immunolo ulin/Function/1 20. Which im
munolo ulin c
n
cross the pl
cent
? A. IG B. IM C. IA D. IE Immunoloy/Apply knowlede of fu
nd
ment
l
ioloic
l ch
r
cteristics/Immunolo ulins/Functions/1 21. Which immunolo ulin
cross links m
st
cells to rele
se hist
mine? A. IG B. IM C. IA D. IE Immunoloy/Apply knowled
e of fund
ment
l
ioloic
l ch
r
cteristics/Immunolo ulins/Functions/1 22. All of the followin

re functions of
immunolo ulins except: A. Neutr
lizin toxic su st
nces B. F
cilit
tin ph
ocy
tosis throuh
opsoniz
tion C. Inter
ctin with T C cells to lyse viruses D. Com inin with com
plement to
destroy cellul
r
ntiens Immunoloy/Apply knowlede of fund
ment
l ioloic
l
ch
r
cteristics/Immunolo ulins/Functions/1 23. Which of the followin cell surf

ce molecules is
cl
ssi ed
s
n MHC cl
ss II
ntien? A. HLA-A B. HLA-B C. HLA-C D. HLA-DR Immunol
oy/Apply
knowlede of fund
ment
l ioloic
l ch
r
cteristics/MHC/HLA
ntiens/1 80 Ch
pte
r 3 | Immunoloy
Answers to Questions 1823 18. B The rst
nti ody to
ppe
r in the prim
ry immune r
esponse to
n

ntien is IM. The titer of
ntivir
l IM (e.., IM
nti ody to cytome
loviru
s [
nti-CMV]) is
more speci c for
cute or
ctive vir
l infection th
n IG
nd m
y e me
sured to h
elp
di erenti
te
ctive from prior infection. 19. A A hih titer of IG ch
r
cterizes
the second
ry
immune response. Consequently, IG
nti odies comprise
out 80% of the tot
l im
munolo ulin
concentr
tion in norm
l serum. 20. A IG is the only immunolo ulin cl
ss th
t c

n cross the
pl
cent
. All su cl
sses of IG c
n cross the pl
cent
, ut IG2 crosses more sl
owly. This
process requires reconition of the Fc reion of the IG y pl
cent
l cells. The
se cells t
ke up
the IG from the m
tern
l lood
nd secrete it into the fet
l lood, providin h
umor
l immunity
to the neon
te for the rst few months
fter delivery. 21. D IE is the immunolo
ulin th
t cross
links with
sophils
nd m
st cells. IE c
uses the rele
se of such immune respo
nse modi ers
s
hist
mine
nd medi
tes
n
lleric immune response. 22. C Cytotoxic T cells lyse
vir
lly infected
cells directly, without requirement for speci c
nti ody. The T C cell is
ctiv
te
d y vir
l

ntien th
t is
ssoci
ted with MHC cl
ss I molecules on the surf
ce of the infe
cted cell. The

ctiv
ted T C cell secretes sever
l toxins, such
s tumor necrosis f
ctor, which

destroy the
infected cell
nd virions. 23. D The MHC reion is loc
ted on the short
rm of c
hromosome 6
nd
codes for
ntiens expressed on the surf
ce of leukocytes
nd tissues. The MHC r
eion enes
control immune reconition; their products include the
ntiens th
t determine t
r
nspl
nt
tion
rejection. HLA-DR
ntiens
re expressed on B cells. HLA-DR2, DR3, DR4,
nd DR5

ntiens show
link
e with
wide r
ne of
utoimmune dise
ses. 2828_Ch03_075-120 06/08/12 1
1:10 AM P
e 80
24. Which MHC cl
ss of molecule is necess
ry for
ntien reconition y CD4-posi
tive T cells? A.
Cl
ss I B. Cl
ss II C. Cl
ss III D. No MHC molecule is necess
ry for
ntien rec
onition
Immunoloy/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics/MHC/Functio
ns/1 25. Which of
the followin
re products of HLA cl
ss III enes? A. T-cell immune receptors B.
HLA-D
ntiens
on immune cells C. Complement proteins C2, C4,
nd F
ctor B D. Immunolo ulin V
L reions
Immunoloy/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics/MHC/Functio
ns/1 26. Wh
t
molecule on the surf
ce of most T cells reconizes
ntien? A. IT,
four-ch
in
molecule th
t
includes the t
u he
vy ch
in B. MHC protein,
two-ch
in molecule encoded y the
HLA reion C.
CD3, consistin of six di erent ch
ins D. TcR, consistin of two ch
ins,
lph

nd
et

Immunoloy/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics/Functions/1
27. Te T-cell

ntien receptor is simil
r to immunolo ulin molecules in th
t it: A. Rem
ins
ound to the cell
surf
ce
nd is never secreted B. Cont
ins V
nd C reions on e
ch of its ch
ins
C. Binds
complement D. C
n cross the pl
cent

nd provide protection to
fetus Immunolo
y/Apply knowlede
of fund
ment
l ioloic
l ch
r
cteristics/TcR/Functions/2 28. Toll-like receptor
s
re found on
which cells? A. T cells B. Dendritic cells C. B cells D. L
re r
nul
r lymphocy
tes
Immunoloy/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics/Inn
te immu
ne system/
Toll-like receptors/1 3.1 | B
sic Principles of Immunoloy 81 Answers to Quest
ions 2428 24. B
Helper T lymphocytes (CD4-positive T cells) reconize
ntiens only in the conte
xt of
cl
ss II
molecule. Bec
use cl
ss II
ntiens
re expressed on m
croph
es, monocytes,
nd
B cells, the
helper T-cell response is medi
ted y inter
ction with processed
ntien on the
surf
ce of these
cells. 25. C Complement components C2
nd C4 of the cl
ssic p
thw
y
nd F
ctor B
of the

ltern
tive p
thw
y
re cl
ss III molecules. HLA-A, HLA-B,
nd HLA-C
ntiens
r
e cl
ssi ed
s
cl
ss I
ntiens,
nd HLA-D, HLA-DR, HLA-DQ,
nd HLA-DP
ntiens
s cl
ss II
nt
iens. 26. D T
cells h
ve
mem r
ne ound receptor (T-cell receptor or TcR) th
t is
ntien sp
eci c. This twoch
in molecule consists of
sinle -ch
in, simil
r to
n immunolo ulin liht ch


in,
nd

sinle -ch
in, simil
r to
n immunolo ulin he
vy ch
in. Some T cells m
y express

- receptor
instea of the - molecule. There is no heavy chain. MHC and CD3 molecules are pres
en on T
cells, bu hey are no he molecules ha give anigen speci ciy o he cell. 27
. B The anigen
binding regions of boh he -
nd -ch
ins of the T-cell receptor
re encoded y V
enes th
t
undero re
rr
nement simil
r to th
t o served in immunolo ulin enes. The -ch
i
n ene consists
of V
nd J sements, simil
r to
n immunolo ulin liht ch
in. The -ch
in consist
s of V, D,
nd
J sements, simil
r to
n immunolo ulin he
vy ch
in. The -
nd -ch
ins e
ch h
ve

sinle
C-reion ene encodin the const
nt reion of the molecule. While
nswer A is tr
ue for T-cell
receptors, it is not true for immunolo ulins th
t c
n e cell ound or secreted
. Answers C
nd D

re true for cert
in immunolo ulin he
vy-ch
in isotypes ut
re not true for th
e T-cell
receptor. 28. B Toll-like receptors (TLR)
re the prim
ry
ntien reconition pr
otein of the
inn
te immune system. They
re found on
ntien-presentin cells such
s dendrit
ic cells
nd
m
croph
es. Eleven TLRs h
ve een descri ed. TLRs reconize cert
in structur
l
motifs common to
infectin or
nisms. TLR 4, for ex
mple, reconizes
cteri
l lipopolys
cch
ride
(LPS). The n
me
comes from their simil
rity to the Toll protein in Drosophil
. 2828_Ch03_075-120
06/08/12 11:10
AM P
e 81 29. M
croph
es produce which of the followin proteins durin
nti
en processin? A.
IL-1
nd IL-6 B. -Interferon C. IL-4, IL-5,
nd IL-10 D. Complement components C1

nd C3
Immunoloy/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics/Inn
te immu
ne system/Toll
cytokines/2 30. A super
ntien, such
s toxic shock syndrome toxin-1 (TSST-1),
yp
sses the
norm
l
ntien processin st
e y indin to
nd cross linkin: A. A portion of

n
immunolo ulin molecule
nd complement component C1 B. Toll-like receptors
nd

n MHC cl
ss 1
molecule C. A portion of
n immunolo ulin
nd
portion of
T-cell receptor D.
A portion of

T-cell receptor
nd
n MHC cl
ss II molecule Immunoloy/Apply knowlede of fund

ment
l ioloic
l
ch
r
cteristics/Antien processin/ Super
ntiens/2 31. T reul
tor cells, respo
nsi le for
controllin
utoimmune
nti ody production, express which of the followin pheno
types? A. CD3,
CD4, CD8 B. CD3, CD8, CD25 C. CD3, CD4, CD25 D. CD8, CD25, CD56 Immunoloy/Apply
knowlede of
fund
ment
l ioloic
l ch
r
cteristics/T cells/M
rkers/1 82 Ch
pter 3 | Immunolo
y Answers to
Questions 2931 29. A Interleukin-1 (IL-1)
nd IL-6
re proin
mm
tory m
croph
e-pr
oduced
cytokines. In
ddition to their in
mm
tory properties, they
ctiv
te T-helper cel
ls durin

ntien present
tion. -Interferon, IL-4, 5,
nd 10
re
ll produced y T cells. C

omplement
components
re produced y
v
riety of cells ut
re not p
rt of the m
croph
e

ntien
present
tion process. 30. D A super
ntien inds to the V portion of the T-cell
receptor
nd
n
MHC cl
ss II molecule. This indin c
n
ctiv
te T cells without the involvement
of
n

ntien-presentin cell. In some individu
ls,
sinle V protein th
t reconizes
TSST-1 is
expressed on up to 10%20% of T cells. The simult
neous
ctiv
tion of this
mount
of T cells
c
uses
he
vy cytokine rele
se, resultin in the v
scul
r coll
pse
nd p
tholo
y of toxic shock
syndrome. 31. C T reul
tor cells
re elieved to e the prim
ry immune suppress
or cells
nd
express CD3, CD4,
nd CD25. CD25 is the interleukin 2 receptor. CD25 m
y e expr
essed y

ctiv
ted T cells, ut is constitutively expressed y the T-reul
tor cells. CD2
5 expression on
T-reul
tor cells occurs in the thymus
nd is reul
ted y the FOXP3 protein. 28
28_Ch03_075-120
06/08/12 11:10 AM P
e 82 83 3.2 Immunoloic Procedures 1. Te inter
ction etw
een
n individu
l

ntien
nd
nti ody molecule depends upon sever
l types of onds such
s ionic
onds, hydroen
onds, hydropho ic onds,
nd v
n der W

ls forces. How is the strenth of this

ttr
ction
ch
r
cterized? A. Avidity B. A nity C. Re
ctivity D. V
lency Immunoloy/Apply prin
ciples of
sic
l
or
tory procedures/1 2. A l
or
tory is ev
lu
tin
n enzyme-linked immunosor
ent
ss
y
(ELISA) for detectin
n
nti ody to cyclic citrullin
ted peptide (CCP), which i
s
m
rker for
rheum
toid
rthritis. Te l
or
tory includes serum from he
lthy volunteers
nd p

tients with
other connective tissue dise
ses in the ev
lu
tion. Tese specimens determine whi
ch f
ctor of the

ss
y? A. Sensitivity B. Precision C. Bi
s D. Speci city Immunoloy/Apply principl
es of
sic
l
or
tory procedures/RA/2 3. Te detection of precipit
tion re
ctions depends on
the presence of
optim
l proportions of
ntien
nd
nti ody. A p
tients s
mple cont
ins
l
re

mount of

nti ody, ut the re
ction in
test system cont
inin
ntien is ne
tive. Wh
t
h
s h
ppened? A.
Perform
nce error B. Low speci city C. A shift in the zone of equiv
lence D. Prozo
ne phenomenon
Immunoloy/Apply principles of
sic l
or
tory procedures/3 4. Which p
rt of th
e r
di
l
immunodi usion (RID) test system cont
ins the
ntiser
? A. Center well B. Outer we
lls C. Gel D.
Antiser
m
y e
dded to
ny well Immunoloy/Apply principles of
sic l
or
tor
y
procedures/RID/Principles/1 Answers to Questions 14 1. B Affinity refers to the s
trenth of

sinle
nti ody
ntien inter
ction. Avidity is the strenth of inter
ctions etw
een m
ny
different
nti odies in
serum

inst
p
rticul
r
ntien (i.e., the sum of m

ny
ffinities).
2. D Specificity is defined
s
ne
tive result in the
sence of the dise
se.

The
nonrheum
toid
rthritis specimens would e expected to test ne
tive if the
ss
y
h
s hih
specificity. Precision is the
ility of the
ss
y to repe
tedly yield the s
me
results on

sinle specimen. Both i
s
nd sensitivity c
lcul
tions would include specimens
from rheum
toid

rthritis specimens. Althouh those specimens would e included in the ev
lu
tio
n, they
re not
listed in the question. 3. D Althouh perform
nce error
nd low specificity shou
ld e considered,
if
test system f
ils to yield the expected re
ction, excessive
nti ody preven
tin

precipit
tion re
ction is usu
lly the c
use. Prozone occurs when
nti ody molecu
les s
tur
te the

ntien sites, preventin cross linkin of the
ntien
nti ody complexes y other

nti ody
molecules. Bec
use the
ntien
nd
nti ody do not re
ct
t equiv
lence,
visi
le product is not
formed, le
din to
f
lse-ne
tive result. 4. C In
n RID test system, for ex
m
ple, one
me
surin hemopexin concentr
tion, the el would cont
in the
ntihemopexin. A st

nd
rdized volume
of serum cont
inin the
ntien is
dded to e
ch well. Antien di uses from the we
ll into the el

nd forms
precipitin rin y re
ction with
nti ody. At equiv
lence, the
re

of the rin is
proportion
l to
ntien concentr
tion. 2828_Ch03_075-120 06/08/12 11:10 AM P

e 83 5. Wh
t is
the interpret
tion when
n Ouchterlony pl
te shows crossed lines etween wells 1

nd 2 (
ntien
is pl
ced in the center well
nd
ntiser
in wells 1
nd 2)? A. No re
ction etw
een wells 1
nd 2
B. P
rti
l identity etween wells 1
nd 2 C. Nonidentity etween wells 1
nd 2 D
. Identity
etween wells 1
nd 2 Immunoloy/Apply principles of
sic l
or
tory procedures
/Ouchterlony
techniques/Interpret
tion/2 6. Why is
chemiluminescent immuno
ss
y (CIA) or en
zyme immuno
ss
y
(EIA) the method of choice for detection of cert
in
n
lytes, such
s hormones,
norm
lly found in
low concentr
tions? A. Bec
use of low cross re
ctivity B. Bec
use of hih speci ci
ty C. Bec
use
of hih sensitivity D. Bec
use test systems m
y e desined
s oth competitive

nd
noncompetitive
ss
ys Immunoloy/Apply principles of
sic l
or
tory procedures
/Immuno
ss
ys/1
7. Wh
t comprises the indic
tor system in
n indirect ELISA for detectin
nti o
dy? A.
Enzyme-conju
ted
nti ody + chromoenic su str
te B. Enzyme conju
ted
ntien
+ chromoenic
su str
te C. Enzyme +
ntien D. Su str
te +
ntien Immunoloy/Apply principles
of
sic
l
or
tory procedures/ELISA/1 8. Wh
t outcome results from improper w
shin of

tu e or well

fter
ddin the enzyme
nti ody conju
te in
n ELISA system? A. Result will e f

lsely
decre
sed B. Result will e f
lsely incre
sed C. Result will e un
ected D. Resul
t is impossi le
to determine Immunoloy/Apply knowlede to identify sources of error/ELISA/3 9.

Wh
t would h
ppen

if the color re
ction ph
se is proloned in one tu e or well of
n ELISA test? A
. Result will e
f
lsely decre
sed B. Result will e f
lsely incre
sed C. Result will e un
ected
D. Impossi le
to determine Immunoloy/Apply knowlede to identify sources of error/ELISA/3 84
Ch
pter 3 |
Immunoloy Answers to Questions 510 5. C Crossed lines indic
te nonidentity etwe
en wells 1
nd
2. The
nti ody from well 1 reconizes
different
ntienic determin
nt th
n th
e
nti ody from
well 2. 6. C The sensitivity of EIA methods producin visi le color ch
ne,
nd u
orescent
nd
chemiluminescent products
ppro
ches n
nor
m levels of
nti ody. These methods

re e
sily

utom
ted. 7. A The ELISA test me
sures
nti ody usin immo ilized re
ent
nti
en. The
ntien
is xed to the w
lls of
tu e or ottom of
microtiter well. Serum is
dded (
nd
incu
ted)
nd
the
nti ody inds, if present. After w
shin, the
ntien
nti ody complexes
re
detected y

ddin
n enzyme l
eled
nti-immunolo ulin. The un ound enzyme l
el is remove
d y w
shin,
nd
the ound enzyme l
el is detected y
ddin chromoenic su str
te. The enzyme c

t
lyzes the
conversion of su str
te to colored product. 8. B If un ound enzyme-conju
ted
n
ti-immunolo ulin
is not w
shed
w
y, it will c
t
lyze conversion of su str
te to colored product,
yieldin

f
lsely elev
ted result. 9. B If the color re
ction is not stopped within the ti
me limits
speci ed y the procedure, the enzyme will continue to
ct on the su str
te, produ
cin
f
lsely
elev
ted test result. 10. D Usu
lly when
test s
mple re
ds
t
v
lue
ove th
e hihest
st
nd
rd in
n ELISA test, it is diluted
nd me
sured

in. In those inst
nces
where no

ddition
l clinic
l v
lue c
n e o t
ined y dilution, the result m
y e reporte
d
s re
ter th
n
the hihest st
nd
rd (citin the upper report
le limit of the
ss
y). 10. Te

sor
nce of

s
mple me
sured y ELISA is re
ter th
n the hihest st
nd
rd. Wh
t corrective

ction should e
t
ken? A. Extr
pol
te
n estim
ted v
lue from the hihest re
din B. Repe
t the
test usin

st
nd
rd of hiher concentr
tion C. Repe
t the
ss
y usin one h
lf the volume o
f the s
mple D.
Dilute the test s
mple Immunoloy/Ev
lu
te l
or
tory d
t
to t
ke corrective
c
tion
ccordin to
predetermined criteri
/ELISA/3 2828_Ch03_075-120 06/08/12 11:10 AM P
e 84 11
. A p
tient w
s
suspected of h
vin
lymphoprolifer
tive disorder. After sever
l l
or
tory tes
ts were
completed, the p
tient w
s found to h
ve
n IM paraproein. In wha sequence sho
uld he
laboraory ess leading o his diagnosis have been performed? A. Serum proein
elecrophoresis
(SPE) followed by immuno xaion elecrophoresis (IFE) B. Immunoglobulin levels fol
lowed by SPE C.
Toal lymphocye coun followed by immunoglobulin levels D. Immunoglobulin level

s followed by
urine proein elecrophoresis Immunology/Evaluae laboraory daa o reach concl
usions/IFE/3 12.
An IFE performed on a serum sample showed a narrow dar band in he lanes conai
ning ani- an
anti-. How shou this resut be interprete? A. Abnormay ecrease IG concent
ration B.
Abnorma test resut emonstratin monocona IG C. Norma test resut D. Imposs
ibe to
etermine without ensitometric quantitation Immunooy/Evauate aboratory ata
to make
ienti cations/IFE/2 13. Which type of nepheometry is use to measure immune comp
ex formation
amost immeiatey after reaent has been ae? A. Rate B. Enpoint C. Continuo
us D. One
imensiona Immunooy/Appy principes of basic aboratory proceures/Nepheome
try/1 14. An
immuno uorescence microscopy assay (IFA) was performe, an a sini cant antiboy ti
ter was
reporte. Positive an neative contros performe as expecte. However, the ci
nica evauation
of the patient was not consistent with a positive nin. What is the most ikey
expanation of
this situation? A. Te cinica conition of the patient chane since the sampe
was teste B. Te
pattern of uorescence was misinterprete C. Te contro resuts were misinterprete
 D. Te wron
ce ine was use for the test Immunooy/Appy principes of basic aboratory
proceures/IFA/3
3.2 | Immunooic Proceures 85 Answers to Questions 1114 11. A Serum protein e
ectrophoresis
shou be performe initiay to etect the presence of an abnorma immunoobu
in that
emonstrates restricte eectrophoretic mobiity. A patient proucin ony monoc
ona iht
chains may not show any abnorma serum nin because the iht chains may be excr
ete in the
urine. A positive nin for either serum or urine shou be foowe by IFE on th
e positive
specimen. This is require to con rm the presence of monocona immunoobuin an
to ientify
the heavy an iht chain type. 12. B A narrow ark ban forme in both the ane
containin
anti- an anti- inicates the presence of a monocona IG immunoobuin. A iffu
se ark
ban wou inicate a poycona increase in IG that often accompanies chronic
infammatory
isorers such as systemic upus erythematosus (SLE). 13. A Rate nepheometry is
use to measure
formation of sma immune compexes as they are forme uner conitions of antib
oy excess. The
rate of increase in photoetector output is measure within secons or minutes a
n increases with
increasin antien concentration. Antien concentration is etermine by compari
n the rate for
the sampe to that for stanars usin an aorithm that compensates for nonine
arity. In
enpoint nepheometry, reactions are rea after equivaence. Immune compexes ar
e of maxima size
but may have a tenency to sette out of soution, thereby ecreasin the amount

of scatter. 14.
B In an IFA, for exampe, an antinucear antiboy (ANA) test, the fuorescence p
attern must be
correate correcty with the specificity of the antiboies. Both pathooica a
n
nonpathooica antiboies can occur, an antiboies may be etecte at a sinif
icant titer in a
patient whose isease is inactive. Faiure to correcty ientify subceuar str
uctures may
resut in misinterpretation of the antiboy specificity, or a fase positive cau
se by
nonspecific fuorescence. 2828_Ch03_075-120 06/08/12 11:10 AM Pae 85 15. Wha
t corrective
action shou be taken when an ineterminate pattern occurs in an inirect IFA?
A. Repeat the
test usin a arer voume of sampe B. Ca the physician C. Have another meic
a aboratory
scientist rea the sie D. Diute the sampe an retest Immunooy/Evauate ab
oratory ata to
take corrective action accorin to preetermine criteria/IFA/3 16. Which state
ment best
escribes passive autination reactions use for seroianosis? A. Such aut
ination reactions
are more rapi because they are a sine-step process B. Reactions require the a
ition of a
secon antiboy C. Passive autination reactions require biphasic incubation D
. Carrier
partices for antien such as atex partices are use Immunooy/Appy princip
es of basic
aboratory proceures/Autination/1 17. What has happene in a titer, if tube
Nos. 57 show a
stroner reaction than tube Nos.14? A. Prozone reaction B. Postzone reaction C. E
quivaence
reaction D. Poor technique Immunooy/Evauate ata to etermine possibe incons
istent
resuts/Serooica titration/3 18. What is the titer in tube No. 8 if tube No.
1 is uniute
an iutions are oube? A. 64 B. 128 C. 256 D. 512 Immunooy/Cacuate/Sero
oica
titration/2 19. Te irections for a sie autination test instruct that after
mixin the
patients serum an atex partices, the sie must be rotate for 2 minutes. What
wou happen
if the sie were rotate for 10 minutes? A. Possibe fase-positive resut B. P
ossibe
fase-neative resut C. No e ect D. Depens on the amount of antiboy present in
the sampe
Immunooy/Appy principes of basic aboratory proceures/Autination/3 86 Ch
apter 3 |
Immunooy Answers to Questions 1520 15. D An unexpecte pattern may inicate the
presence of
more than one antiboy. Diutin the sampe may hep to ceary show the antibo
y speci cities,
if they are foun in i erent titers. If the pattern is sti atypica, a new samp
e shou be
coecte an the test repeate. 16. D Most autination tests use in serooy
empoy passive
or inirect autination where carrier partices are coate with the antien. T
he carrier
moecue is of su cient size so that the reaction of the antien with antiboy res

uts in
formation of a compex that is more easiy visibe. 17. A In tubes Nos.14, insu cie
nt antien is
present to ive a visibe reaction because excess antiboy has saturate a ava
iabe antien
sites. After iution of antiboy, tubes Nos.14 have the equivaent concentration
s of antien
an antiboy to aow formation of visibe compexes. 18. B The antiboy titer i
s reciproca of
the hihest iution of serum ivin a positive reaction. For oubin iutions
, each tube has
one haf the amount of serum as the previous tube. Because the rst tube was uni
ute (neat),
the iution in tube No. 8 is (1/2) 7 an the titer equas 2 7 or 128. 19. A Fai
ure to foow
irections, as in this case where the reaction was aowe to procee beyon the
recommene
time, may resut in a fase-positive reain. Dryin on the sie may ea to a
possibe
erroneous positive reain. 20. C In compement xation, hemoysis inicates a ne
ative test
resut. The absence of hemoysis inicates that compement was xe in an antienan
tiboy
reaction an, therefore, that the speci c compement binin antiboy was present
in the
patients serum. Consequenty, it was not avaiabe to react in the inicator syst
em. 20. Which
outcome inicates a neative resut in a compement xation test? A. Hemautinat
ion B. Absence
of hemautination C. Hemoysis D. Absence of hemoysis Immunooy/Appy princi
pes of basic
aboratory proceures/Compement xation/1 2828_Ch03_075-120 06/08/12 11:10 AM
Pae 86 21.
What e ect oes seectin the wron ate have on the resuts when ces are counte
 by ow
cytometry? A. No e ect B. Faiure to count the esire ce popuation C. Fasey
eevate
resuts D. Impossibe to etermine Immunooy/Appy principes of basic aborato
ry
proceures/Fow cytometry/3 22. Which statement best escribes immunophenotypin
? A. Lineae
etermination by etectin antiens on the surface of the ate ces usin uores
cent antiboies
B. Ienti cation of ce maturity usin antiboies to etect antiens within the n
uceus C.
Ienti cation an sortin of ces by front an sie-scatter of iht from a aser
D. Anaysis of
ces coecte by ow cytometry usin traitiona autination reactions Immuno
oy/Appy
principes of basic aboratory proceures/Fow cytometry/1 23. A ow cytometry sca
tterram of a
bone marrow sampe shows a ense popuation of ces ocate in-between norma 
ymphoi an
norma myeoi ces. What is the most ikey expanation? A. Te sampe was impr
opery coecte
B. An abnorma ce popuation is present C. Te aser optics are out of ainmen
t D. Te ces are
most ikey not eukocytes Immunooy/Appy principes of basic aboratory proce
ures/Fow
cytometry/3 3.2 | Immunooic Proceures 87 Answers to Questions 2123 21. B Gat

in is the step

performe to seect the proper ces to be counte. Faiure to propery perform
this proceure
wi resut in probems in isoatin an countin the esire ces. It is impos
sibe to
etermine if the na resut wou be fasey eevate or fasey owere by prob
ems with
atin. 22. A Immunophenotypin refers to cassi cation of ces (ineae an ma
turity
assinment) usin a pane of uorescent-abee antiboies irecte aainst speci c
surface
antiens on the ces. Antiboies are referre to by their CD (custer of i erent
iation) number.
Monocona antiboies havin a common CD number o not necessariy bin to the s
ame epitope but
reconize the same antien on the ce surface. Reactivity of the seecte ces
with a pane of
antiboies i erentiates ymphoi from myeoi ces an ienti es the stae of ce
maturation.
23. B Lymphoi ces an myeoi ces ispay in preictabe reions of the sca
tterpot because
of their characteristic size an ensity. Lymphoi ces cause ess forwar an
sie scatter from
the aser than o myeoi ces. A ense zone of ces in between those reions
is cause by the
presence of a are number of abnorma ces, usuay basts. The ineae of the
ces can be
etermine by immunophenotypin with a pane of uorescent-abee antiboies. 282
8_Ch03_075-120
06/08/12 11:10 AM Pae 87 88 3.3 Infectious Diseases 1. Which serum antiboy r
esponse usuay
characterizes the primary (eary) stae of syphiis? A. Antiboies aainst syphi
is are
unetectabe B. Detecte 13 weeks after appearance of the primary chancre C. Dete
cte in 50% of
cases before the primary chancre isappears D. Detecte within 2 weeks after inf
ection
Immunooy/Correate aboratory ata with physiooica processes/Syphiis/Testi
n/1 2. What
substance is etecte by the rapi pasma reain (RPR) an Venerea Disease Rese
arch Laboratory
(VDRL) tests for syphiis? A. Carioipin B. Anticarioipin antiboy C. Anti-T.
paium
antiboy D. Treponema paium Immunooy/Appy knowee of funamenta biooi
ca
characteristics/Syphiis/Testin/1 3. What type of antien is use in the RPR ca
r test? A. Live
treponema oranisms B. Kie suspension of treponema oranisms C. Carioipin
D. Tanne sheep
ces Immunooy/Appy principes of basic aboratory proceures/Syphiis/Testin
/1 4. Which of
the foowin is the most sensitive test to etect conenita syphiis? A. VDRL
B. RPR C.
Microhemautinin test for T. paium (MHA-TP) D. Poymerase chain reaction (P
CR)
Immunooy/Appy principes of basic aboratory proceures/Syphiis/Testin/1 An
swers to
Questions 15 1. B Durin the primary stae of syphiis, about 90% of patients ev
eop antiboies
between 1 an 3 weeks after the appearance of the primary chancre. 2. B Reain

is the name for

a nontreponema antiboy that appears in the serum of syphiis-infecte persons
an is etecte
by the RPR an VDRL assays. Reain reacts with carioipin, a ipi-rich extract
of beef heart
an other anima tissues. 3. C Carioipin is extracte from anima tissues, suc
h as beef hearts,
an attache to carbon partices. In the presence of reain, the partices wi
autinate. 4. D
The PCR wi ampify a very sma amount of DNA from T. paiuman aow for e
tection of the
oranism in the infant. Antiboy tests such as VDRL an RPR may etect materna
antiboy ony,
not inicatin if the infant has been infecte. 5. B The FTA-ABS test is more sp
eci c for T.
paium than nontreponema tests such as the VDRL an RPR an wou be east i
key to etect a
biooica fase-positive resut. The FTA-ABS test uses heat-inactivate serum t
hat has been
absorbe with the Reiter strain of T. paiumto remove nonspeci c antiboies. Non
treponema
tests have a biooica fase-positive rate of 1%10%, epenin upon the patient
popuation
teste. Fase-positive nins are cause commony by infectious mononuceosis (IM
), SLE, vira
hepatitis, an human immunoe ciency virus (HIV) infection. 5. A biooica fasepositive
reaction is east ikey with which test for syphiis? A. VDRL B. Fuorescent T.
paium
antiboy absorption test (FTA-ABS) C. RPR D. A are equay ikey to etect a
fase-positive
resut Immunooy/Appy principes of basic aboratory proceures/Syphiis/Testi
n/1
2828_Ch03_075-120 06/08/12 11:10 AM Pae 88 6. A 12-year o ir has symptom
s of fatiue an
a ocaize ymphaenopathy. Laboratory tests revea a periphera boo ymphocy
tosis, a positive
RPR, an a positive spot test for IM. What test shou be performe next? A. HIV
test by ELISA B.
VDRL C. EpsteinBarr virus (EBV) speci c antien test D. Treponema paium partice
autination (TP-PA) test Immunooy/Correate aboratory ata with physiooic
a
processes/Syphiis/Testin/3 7. Which test is most ikey to be positive in the
tertiary stae of
syphiis? A. FTA-ABS B. RPR C. VDRL D. Reain screen test (RST) Immunooy/Corre
ate aboratory
ata with physiooica processes/Syphiis/Testin/3 8. What is the most ikey
interpretation of
the foowin syphiis serooica resuts? RPR: reactive; VDRL: reactive; MHA-T
P: nonreactive A.
Neurosyphiis B. Seconary syphiis C. Syphiis that has been successfuy treat
e D. Biooica
fase positive Immunooy/Correate aboratory ata with physiooica
processes/Syphiis/Testin/2 9. Which specimen is the sampe of choice to evaua
te atent or
tertiary syphiis? A. Serum sampe B. Chancre ui C. CSF D. Joint ui Immunooy/C
orreate
aboratory ata with physiooica processes/Syphiis/Testin/1 10. Interpret th
e foowin
quantitative RPR test resuts. RPR titer: weaky reactive 1:8; reactive 1:81:64 A

. Excess
antiboy, prozone e ect B. Excess antien, postzone e ect C. Equivaence of antien
an antiboy
D. Impossibe to interpret; testin error Immunooy/Correate aboratory ata w
ith physiooica
processes/Syphiis/Testin/2 3.3 | Infectious Diseases 89 Answers to Questions
610 6. D The
patients symptoms are nonspeci c an cou be attribute to many potentia causes.
However, the
patients ae, ymphocytosis, an serooica resuts point to infectious mononuc
eosis (IM). The
rapi spot test for antiboies seen in IM is hihy speci c. The EBV-speci c antien
test is more
sensitive but is unnecessary when the spot test is positive. HIV infection is un
common at this
ae an is often associate with eneraize ymphaenopathy an a norma or re
uce tota
ymphocyte count. IM antiboies are commony impicate as a cause of biooica
fase-positive
nontreponema tests for syphiis. Therefore, a treponema test for syphiis shou
 be performe
to ocument this phenomenon in this case. 7. A The FTA-ABS or one of the trepone
ma tests is more
ikey to be positive than a nontreponema test in the tertiary stae of syphii
s. In some cases,
systemic esions have subsie by the tertiary stae an the nontreponema tests
become
seroneative. Athouh the FTA-ABS is the most sensitive test for tertiary syphi
is, it wi be
positive in both treate an untreate cases. 8. D A positive reaction with nont
reponema antien
an a neative reaction with a treponema antien is most ikey cause by a bio
oica
fase-positive nontreponema test. 9. C Latent syphiis usuay beins after the
secon year of
untreate infection. In some cases, the serooica tests become neative. Howev
er, if
neurosyphiis is present, cerebrospina ui serooy wi be positive an the CSF
wi ispay
increase protein an peocytosis characteristic of centra nervous system infec
tion. 10. A This
patient may be in the seconary stae of syphiis an is proucin are amounts
of antiboy to
T. paium su cient to cause antiboy excess in the test. The test became stron
y reactive ony
after the antiboy was iute. 2828_Ch03_075-120 06/08/12 11:10 AM Pae 89 1
1. Tests to
ientify infection with HIV fa into which three enera cassi cation types of t
ests? A. Tissue
cuture, antien, an antiboy tests B. Tests for antiens, antiboies, an nuc
eic aci C. DNA
probe, DNA ampi cation, an Western bot tests D. ELISA, Western bot, an Southe
rn bot tests
Immunooy/Appy principes of basic aboratory proceures/HIV/Testin/1 12. Whi
ch tests are
consiere screenin tests for HIV? A. ELISA, 4th eneration, an rapi antiboy
tests B.
Immuno uorescence, Western bot, raioimmuno-precipitation assay C. Cuture, anti
en capture
assay, DNA ampi cation D. Reverse transcriptase an messener RNA (mRNA) assay Im

munooy/Appy
principes of basic aboratory proceures/HIV/Testin/1 13. Which tests are cons
iere
con rmatory tests for HIV? A. ELISA an rapi antiboy tests B. Western bot test,
HIC-1,2
i erentiation assays, an poymerase chain reaction C. Cuture, antien capture a
ssay,
poymerase chain reaction D. Reverse transcriptase an mRNA assay Immunooy/App
y principes of
basic aboratory proceures/HIV/Testin/1 14. Which is most ikey a positive We
stern bot resut
for infection with HIV? A. Ban at p24 B. Ban at p60 C. Bans at p24 an p31 D
. Bans at p24
an p120 Immunooy/Evauate aboratory ata to reconize heath an isease st
ates/HIV/Western
bot/2 15. A woman who has ha ve prenancies subsequenty tests positive for HIV
by Western
bot. What is the most ikey reason for this resut? A. Possibe cross-reaction
with herpes or
EBV antiboies B. Interference from meication C. Cross-reaction with HLA antie
ns in the antien
preparation D. Possibe technica error Immunooy/Evauate aboratory ata to r
econize heath
an isease states/HIV/Western bot/3 90 Chapter 3 | Immunooy Answers to Quest
ions 1116 11. B
Two common methos for etectin antiboies to HIV are the ELISA an Western bo
t tests. Two
common methos for etectin HIV antiens are ELISA an immuno uorescence. Two com
mon methos for
etectin HIV enes are the Southern bot test an DNA ampi cation usin the poy
merase chain
reaction to etect vira nuceic aci in infecte ymphocytes. 12. A ELISA, rapi
 antiboy tests,
as we as the 4th eneration automate antien/antiboy combination assays are
screenin tests
for HIV. The 4th eneration assays etect both antien an antiboy. 13. B Weste
rn bot, an PCR
tests are eneray use as con rmatory tests for HIV. An HIV-1,2 i erentiation ass
ay is
recommene as the con rmin proceure foowin a reactive 4th eneration HIV ass
ay. PCR,
however, is more often use for eary etection of HIV infection, for ocumentin
 infant HIV
infection, an for foowin antivira therapy. 14. D To be consiere positive
by Western bot
testin, bans must be foun for at east two of the foowin three HIV protein
s: p41, p24, an
p120 or 160. The p24 ban enotes antiboy to a a protein. The p160 is the p
recursor protein
from which p120 an p41 are mae; these are env proteins. 15. C Mutiparous wo
men often have
HLA antiboies. The Western bot antiens are erive from HIV rown in human ce
 ines havin
HLA antiens. A cross reaction with HLA antien(s) in the Western bot cou hav
e occurre. 16. B
These resuts are not inicative of an HIV infection an may be ue to a testin
error in the
rst ELISA assay. Known fase-positive ELISA reactions occur in autoimmune isease
s, syphiis,
acohoism, an ymphoproiferative iseases. A sampe is consiere positive fo

r HIV if it is
repeatey positive by ELISA or other screenin metho an positive by a con rmato
ry metho. 16.
Interpret the foowin resuts for HIV infection. ELISA: positive; repeat ELISA
: neative;
Western bot: no bans A. Positive for HIV B. Neative for HIV C. Ineterminate
D. Further
testin neee Immunooy/Evauate aboratory ata to reconize heath an isea
se
states/HIV/Testin/2 2828_Ch03_075-120 06/08/12 11:10 AM Pae 90 17. Interpre
t the foowin
resuts for HIV infection. HIV 1,2 ELISA: positive; HIV-1 Western bot: ineterm
inate; HIV-1 p24
antien: neative A. Positive for antiboies to human immunoe ciency virus, HIV-1
B. Positive
for antiboies to human immunoe ciency virus, HIV-2 C. Cross reaction; biooica
fase-positive
resut D. Aitiona testin require Immunooy/Evauate aboratory ata to rec
onize heath an
isease states/HIV/Testin/3 18. What is the most ikey expanation when antibo
y tests for HIV
are neative but a poymerase chain reaction test performe 1 week ater is posi
tive? A. Probaby
not HIV infection B. Patient is in the winow phase before antiboy prouction C.
Tests were
performe incorrecty D. Cinica sins may be misinterprete Immunooy/Correa
te aboratory
ata with physiooica processes/HIV/Testin/3 19. What criteria constitute the
cassi cation
system for HIV infection? A. CD4-positive T-ce count an cinica symptoms B.
Cinica
symptoms, conition, uration, an number of positive bans on Western bot C. P
resence or
absence of ymphaenopathy D. Positive bans on Western bot an CD8-positive Tce count
Immunooy/Appy knowee of funamenta biooica characteristics/HIV/2 20. W
hat is the main
i cuty associate with the eveopment of an HIV vaccine? A. Te virus has been 
i cut to
cuture; antien extraction an concentration are extremey aborious B. Human t
rias cannot be
performe C. Di erent strains of the virus are eneticay iverse D. Anti-iiotyp
e antiboies
cannot be eveope Immunooy/Appy principes of basic immunooy/ HIV/Vaccine
s/2 21. Which
CD4:CD8 ratio is most ikey in a patient with acquire immunoe ciency synrome (
AIDS)? A. 2:1
B. 3:1 C. 2:3 D. 1:2 Immunooy/Correate aboratory ata with physiooica
processes/HIV/Testin/2 3.3 | Infectious Diseases 91 Answers to Questions 1721
17. D The
ineterminate Western bot an neative p24 antien assay inicate that HIV-1 in
fection is
unikey, However, aitiona testin is require to etermine if the patient ha
s antiboies to
HIV-2 or if this cou be a fase-positive ELISA assay. 18. B In eary seroconve
rsion, patients
may not be makin enouh antiboies to be etecte by antiboy tests. The perio
between
infection with HIV an the appearance of etectabe antiboies is cae the win
ow phase.

Athouh this perio has been reuce to a few weeks by sensitive enzyme immunoa
ssays, patients
at hih risk or ispayin cinica conitions associate with HIV isease shou
 be teste aain
after waitin severa more weeks. 19. A The cassification system for HIV infect
ion is base upon
a combination of CD4-positive T-ce count (heper T ces) an various cateori
es of cinica
symptoms. Cassification is important in eterminin treatment options an the p
roression of the
isease. 20. C Vaccine eveopment has been i cut primariy because of the enet
ic iversity
amon i erent strains of the virus, an new strains are constanty emerin. HIV1 can be
ivie into two main subtypes esinate M (for main) an O (for outier). The
M roup is
further ivie into 9 subroups, esinate AJ (there is no E subroup), base u
pon i erences
in the nuceotie sequence of the a ene. Two remainin subtypes are esine
N (non M an non
O) an P (a subtype reate to SIVor). A vaccine has yet to be eveope that i
s e ective for
a of the subroups of HIV-1. 21. D An inverte CD4:CD8 ratio (ess than 1.0) i
s a common nin
in an AIDS patient. The Centers for Disease Contro an Prevention requires a CD
4-positive
(heper T) ce count of ess than 200/L or 14% in the absence of an AIDS-de ning i
llness (e.g.,
Pneumocystis carinii pneumonia) in the case surveillance de nition of AIDS. 2828_C
h03_075-120
06/08/12 11:10 AM Page 91 22. What is the advantage of 4th-generation rapid HI
V tests over
earlier rapid HIV tests? A. Tey use recombinant antigens B. Tey detect multiple
strains of HIV C.
Tey detect p24 antigen D. Tey are quantitative Immunology/Apply principles of ba
sic laboratory
procedures/HIV/Testing/2 23. Which method is used to test for HIV infection in i
nfants who are
born to HIV-positive mothers? A. ELISA B. Western blot test C. Polymerase chain
reaction D. Viral
culture Immunology/Apply principles of special procedures/ HIV/1 24. What is the
most likely
cause when a Western blot or ELISA is positive for all controls and samples? A.
Improper
pipetting B. Improper washing C. Improper addition of sample D. Improper reading
Immunology/Evaluate laboratory data to recognize problems/HIV/Testing/3 25. What
constitutes a
diagnosis of viral hepatitis? A. Abnormal test results for liver enzymes B. Clin
ical signs and
symptoms C. Positive results for hepatitis markers D. All of these options Immun
ology/Evaluate
laboratory data to recognize health and disease states/Hepatitis/Testing/2 26. W
hich of the
following statements regarding infection with hepatitis D virus is true? A. Occu
rs in patients
with HIV infection B. Does not progress to chronic hepatitis C. Occurs in patien
ts with hepatitis
B D. Is not spread through blood or sexual contact Immunology/Apply knowledge of
fundamental
biological characteristics/Hepatitis/1 27. All of the following hepatitis viruse

s are spread
through blood or blood products except: A. Hepatitis A B. Hepatitis B C. Hepatit
is C D. Hepatitis
D Immunology/Apply knowledge of fundamental biological characteristics/Hepatitis
/1 92 Chapter 3 |
Immunology Answers to Questions 2227 22. C Both 3rd-generation and 4th-generation
rapid tests
for HIV use recombinant and synthetic HIV antigens conjugated to a solid phase.
The multivalent
nature of these tests allows for detection of less common subgroups of HIV-1 and
simultaneous
detection of both HIV-1 and HIV-2. However, the 4th-generation assays also use s
olid-phase
antibodies to p24 antigen to detect its presence. Because p24 antigen appears be
fore antibodies
to HIV, 4th-generation tests can detect infection 47 days earlier than tests base
d on antibody
detection alone. 23. C ELISA and Western blot primarily re ect the presence of mat
ernal antibody.
The PCR uses small amounts of blood and does not rely on the antibody response.
PCR ampli es
small amounts of viral nucleic acid and can detect less than 200 copies of viral
RNA per
milliliter of plasma. These qualities make PCR ideal for the testing of infants.
Nucleic acid
methods for HIV RNA include the Roche Amplicor reverse- transcriptase assay, the
branched DNA
(bDNA) signal ampli cation method, and the nucleic acid sequence-based ampli cation
(NASBA)
method. 24. B Improper washing may not remove unbound enzyme conjugated anti-hum
an globulin, and
every sample may appear positive. 25. D To diagnose a case of hepatitis, the phy
sician must
consider clinical signs as well as laboratory tests that measure liver enzymes a
nd hepatitis
markers. 26. C Hepatitis D virus is an RNA virus that requires the surface antig
en or envelope of
the hepatitis B virus for entry into the hepatocyte. Consequently, hepatitis D v
irus can infect
only patients who are coinfected with hepatitis B. 27. A Hepatitis A is spread t
hrough the
fecaloral route and is the cause of infectious hepatitis. Hepatitis A virus has a
shorter
incubation period (27 weeks) than hepatitis B virus (16 months). Epidemics of hepa
titis A virus
can occur, especially when food and water become contaminated with raw sewage. H
epatitis E virus
is also spread via the oralfecal route and, like hepatitis A virus, has a short i
ncubation
period. 2828_Ch03_075-120 06/08/12 11:10 AM Page 92 28. Which hepatitis B mar
ker is the best
indicator of early acute infection? A. HBsAg B. HBeAg C. Anti-HBc D. Anti-HBs
Immunology/Correlate laboratory data with physiological processes/Hepatitis/Test
ing/2 29. Which
is the rst antibody detected in serum after infection with hepatitis B virus (HBV
)? A. Anti-HBs
B. Anti-HBc IgM C. Anti-HBe D. All are detectable at the same time Immunology/Co
rrelate
laboratory data with physiological processes/Hepatitis/Testing/2 30. Which antib
ody persists in

low-level carriers of hepatitis B virus? A. IgM anti-HBc B. IgG anti-HBc C. IgM

anti-HBe D. IgG
anti-HBs Immunology/Correlate laboratory data with physiological processes/Hepat
itis/Testing/2
31. What is the most likely explanation when a patient has clinical signs of vir
al hepatitis but
tests negative for hepatitis A IgM, hepatitis B surface antigen, and hepatitis C
Ab? A. Tests
were performed improperly B. Te patient does not have hepatitis C. Te patient ma
y be in the core
window D. Clinical evaluation was performed improperly Immunology/Correlate labor
atory data with
physiological processes/Hepatitis/Testing/3 32. Which hepatitis B markers should
be performed on
blood products? A. HBsAg and anti-HBc B. Anti-HBs and anti-HBc C. HBeAg and HBcA
g D. Anti-HBs and
HBeAg Immunology/Apply principles of laboratory operations/ Hepatitis/Testing/1
33. Which
hepatitis antibody confers immunity against reinfection with hepatitis B virus?
A. Anti-HBc IgM
B. Anti-HBc IgG C. Anti-HBe D. Anti-HBs Immunology/Correlate laboratory data wit
h physiological
processes/Hepatitis/Testing/1 3.3 | Infectious Diseases 93 Answers to Question
s 2833 28. A
Hepatitis B surface antigen (HBsAg) is the first marker to appear in hepatitis B
virus infection.
It is usually detected within 4 weeks of exposure (prior to the rise in transami
nases) and
persists for about 3 months after serum enzyme levels return to normal. 29. B An
tibody to the
hepatitis B core antigen (anti-HBc) is the rst detectable hepatitis B antibody. I
t persists in
the serum for 12 years postinfection and is found in the serum of asymptomatic ca
rriers of HBV.
Because levels of total anti-HBc are high after recovery, IgM anti-HBc is a more
useful marker
for acute infection. Both anti-HBc and anti-HBs can persist for life, but only a
nti-HBs is
considered protective. 30. B IgG antibodies to the hepatitis B core antigen (ant
i-HBc) can be
detected in carriers who are HBsAg and anti-HBs negative. These persons are pres
umed infective
even though the level of HBsAg is too low to detect. No specific B core IgG test
is available,
however. This patient would be positive in the anti-B core total antibody assay
and negative in
the anti-HB core IgM test. 31. C The patient may be in the core window, the period
of hepatitis
B infection when both the surface antigen and surface antibody are undetectable.
The IgM
anti-hepatitis B core and the anti-hepatitis B core total antibody assays would
be the only
detectable markers in the serum of a patient in the core window phase of hepatit
is B infection.
32. A Blood products are tested for HBsAg, an early indicator of infection, and
anti-HBc, a
marker that may persist for life. Following recovery from HBV infection, some pa
tients
demonstrate negative serology for HBsAg and anti-HBs but are positive for anti-H
Bc. Such patients

are considered infective. 33. D Anti-HBs appears later in infection than anti-HB
c and is used as
a marker for immunity following infection or vaccination rather than for diagnos
is of current
infection. 2828_Ch03_075-120 06/08/12 11:10 AM Page 93 34. Which test, other
than serological
markers, is most consistently elevated in viral hepatitis? A. Antinuclear antibo
dies B. Alanine
aminotransferase (ALT) C. Absolute lymphocyte count D. Lactate dehydrogenase Imm
unology/Correlate
laboratory data with physiological processes/Hepatitis/Testing/1 35. If only ant
i-HBs is
positive, which of the following can be ruled out? A. Hepatitis B virus vaccinat
ion B. Distant
past infection with hepatitis B virus C. Hepatitis B immune globulin (HBIG) inje
ction D. Chronic
hepatitis B virus infection Immunology/Correlate laboratory data with physiologi
cal
processes/Hepatitis/Testing/2 36. Interpret the following results for EBV infect
ion: IgG and IgM
antibodies to viral capsid antigen (VCA) are positive. A. Infection in the past
B. Infection with
a mutual enhancer virus such as HIV C. Current infection D. Impossible to interp
ret; need more
information Immunology/Correlate laboratory data with physiological processes/EB
V/Testing/3 37.
Which statement concerning non-Forssman heterophile antibody is true? A. It is n
ot absorbed by
guinea pig antigen B. It is absorbed by guinea pig antigen C. It does not agglut
inate horse RBCs
D. It does not agglutinate sheep RBCs Immunology/Apply principles of basic labor
atory
procedures/IM/Testing/1 38. Given a heterophile antibody titer of 224, which of
the following
results indicate IM? A. B. C. D. Immunology/Evaluate laboratory data to recogniz
e health and
disease states/IM/Testing/2 94 Chapter 3 | Immunology Answers to Questions 3439 3
4. B ALT is a
liver enzyme and may be increased in hepatic disease. Highest levels occur in ac
ute viral
hepatitis, reaching 2050 times the upper limit of normal. 35. D Persons with chro
nic HBV
infection show a positive test result for anti-HBc (IgG or total) and HBsAg but
not anti-HBs.
Patients with active chronic hepatitis have not become immune to the virus. 36.
C Antibodies to
both IgG and IgM VCA are found in a current infection with EBV. The IgG antibody
may persist for
life, but the IgM anti-VCA disappears within 4 months after the infection resolv
es. 37. A
Non-Forssman antibody is not absorbed by guinea pig antigen. This is one of the
principles of the
Davidsohn di erential test for antibodies to IM. These antibodies are non-Forssman
; they are
absorbed by sheep, horse, or beef RBCs but not by guinea pig kidney. Therefore,
a heterophile
titer remaining higher after absorption with guinea pig kidney than with beef RB
Cs indicates IM.
38. A Antibodies to infectious mononucleosis (non- Forssman antibodies) are not
neutralized or

absorbed by guinea pig antigen (but are absorbed by beef cell antigen). A positi
ve test is
indicated by at least a four-tube reduction in the heterophile titer after absor
ption with beef
cells and no more than a three-tube reduction in titer after absorption with gui
nea pig kidney.
39. C In serum sickness, antibodies are neutralized by both guinea pig kidney an
d beef cell
antigens, and at least a three-tube (eightfold) reduction in titer should occur
after absorption
with both. Absorption with Absorption with Beef Guinea Pig Kidney Cells Two-t
ube titer
reduction Five-tube titer reduction No titer reduction No titer reduction Five-t
ube titer
reduction Five-tube titer reduction Five-tube titer reduction No titer reduction
Absorption with
Absorption with Beef Guinea Pig Kidney Cells Two-tube titer reduction Five-tub
e titer reduction
No titer reduction No titer reduction Five-tube titer reduction Five-tube titer
reduction
Five-tube titer reduction No titer reduction 39. Given a heterophile antibody ti
ter of 224, which
of the following results indicate serum sickness? A. B. C. D. Immunology/Evaluat
e laboratory data
to recognize health and disease states/Serum sickness/Testing/2 2828_Ch03_075-12
0 06/08/12
11:10 AM Page 94 40. Given a heterophile antibody titer of 224, which of the fo
llowing results
indicate an error in testing? A. B. C. D. Immunology/Evaluate laboratory data to
determine
possible inconsistent results/IM/Testing/2 41. Blood products are tested for whi
ch virus before
being transfused to newborns? A. EBV B. Human T-lymphotropic virus II (HTLV-II)
C.
Cytomegalovirus (CMV) D. Hepatitis D virus Immunology/Apply principles of labora
tory
operations/Virus testing/1 42. What is the endpoint for the antistreptolysin O (
ASO) latex
agglutination assay? A. Highest serum dilution that shows no agglutination B. Hi
ghest serum
dilution that shows agglutination C. Lowest serum dilution that shows agglutinat
ion D. Lowest
serum dilution that shows no agglutination Immunology/Apply principles of basic
laboratory
procedures/ASO/Interpretation/1 43. Interpret the following ASO results: Tube No
s. 14 (Todd unit
125): no hemolysis; Tube No. 5 (Todd unit 166): hemolysis A. Positive Todd unit
125 B. Positive
Todd unit 166 C. No antistreptolysin O present D. Impossible to interpret Immuno
logy/Evaluate
laboratory data to make identi cations/ASO/Interpretation/2 44. Which control show
s the correct
result for a valid ASO test? A. SLO control, no hemolysis B. Red cell control, n
o hemolysis C.
Positive control, hemolysis in all tubes D. Hemolysis in both SLO and red cell c
ontrol
Immunology/Apply principles of basic laboratory procedures/ASO/Controls/1 3.3 |
Infectious
Diseases 95 Answers to Questions 4044 40. B An individual with a 56 or higher t
iter in the

presumptive test (signi cant heterophile antibodies) has either Forssman antibodie
s, non-Forssman
antibodies, or both. A testing error has occurred if no reduction in the titer o
f antibody
against sheep RBCs is observed after absorption because absorption should remove
one or both
types of sheep RBC agglutinins. 41. C CMV can be life threatening if transmitted
to a newborn
through a blood product. HTLV-II is a rare virus, which like HIV, is a T-cell tr
opic RNA
retrovirus. The virus has been associated with hairy cell leukemia, but this is
not a consistent
nding. 42. B The latex test for ASO includes latex particles coated with streptol
ysin O. Serial
dilutions are prepared and the highest dilution showing agglutination is the end
point. 43. A An
ASO titer is expressed in Todd units as the last tube that neutralizes (no visib
le hemolysis) the
streptolysin O (SLO). Most laboratories consider an ASO titer signi cant if it is
166 Todd units
or higher. However, people with a recent history of streptococcal infection may
demonstrate an
ASO titer of 166 or higher; demonstration of a rise in titer from acute to conva
lescent serum is
required to con rm a current streptococcal infection. ASO is commonly measured usi
ng a rapid
latex agglutination assay. These tests show agglutination when the ASO concentra
tion is 200 IU/mL
or higher. 44. B The red cell control contains no SLO and should show no hemolys
is. The SLO
control contains no serum and should show complete hemolysis. An ASO titer canno
t be determined
unless both the RBC and SLO controls demonstrate the expected results. Absorptio
n with
Absorption with Beef Guinea Pig Kidney Cells Two-tube titer reduction Five-tub
e titer reduction
No titer reduction No titer reduction Five-tube titer reduction Five-tube titer
reduction
Five-tube titer reduction No titer reduction 2828_Ch03_075-120 06/08/12 11:10
AM Page 95 45. A
streptozyme test was performed, but the result was negative, even though the pat
ient showed
clinical signs of a streptococcal throat infection. What should be done next? A.
Either ASO or
anti-deoxyribonuclease B (anti-DNase B) testing B. Another streptozyme test usin
g diluted serum
C. Antihyaluronidase testing D. Wait for 35 days and repeat the streptozyme test
Immunology/Evaluate laboratory data to recognize health and disease states/ASO/T
esting/3 46.
Rapid assays for in uenza that utilize specimens obtained from nasopharyngeal swab
s detect: A.
IgM anti-in uenza B. IgA anti-in uenza C. IgA-in uenza Ag immune complexes D. In uenza a
ntigen
Immunology/Apply principles of basic laboratory procedures/Virus testing/2 47. H
ow can
interfering cold agglutinins be removed from a test sample? A. Centrifuge the se
rum and remove
the top layer B. Incubate the clot at 1C4C for several hours, then remove serum C.
Incubate
the serum at 56C in a water bath for 30 minutes D. Use an anticoagulated sample I

mmunology/Apply
principles of special procedures/ Cold agglutinins/Testing/2 48. All tubes (dilu
tions) except the
negative control are positive for cold agglutinins. Tis indicates: A. Contaminat
ed red cells B. A
rare antibody against red cell antigens C. Te sample was stored at 4C prior to se
parating serum
and cells D. Further serial dilution is necessary Immunology/Select course of ac
tion/Cold
agglutinins/ Testing/3 49. All positive cold agglutinin tubes remain positive af
ter 37C
incubation except the positive control. What is the most likely explanation for
this situation?
A. High titer cold agglutinins B. Contamination of the test system C. Antibody o
ther than cold
agglutinins D. Faulty water bath Immunology/Evaluate laboratory data to determin
e possible
inconsistent results/Cold agglutinins/Testing/3 96 Chapter 3 | Immunology Answer
s to Questions
4550 45. A A streptozyme test is used for screening and contains several of the a
ntigens
associated with streptococcal products. Because some patients produce an antibod
y response to a
limited number of streptococcal products, no single test is su ciently sensitive t
o rule out
infection. Clinical sensitivity is increased by performing additional tests when
initial results
are negative. The streptozyme test generally shows more false positives and fals
e negatives than
ASO and anti-DNase. A positive test for antihyaluronidase occurs in a smaller nu
mber of patients
with recent streptococcal infections than ASO and anti-DNase. 46. D The rapid in u
enza assays are
antigen detection methods. They are designed to detect early infection, before a
ntibody is
produced. 47. B Cold agglutinins will attach to autologous red cells if incubate
d at 1C4C. The
absorbed serum will be free of cold agglutinins. 48. D Cold agglutinins may be m
easured in
patients who have cold agglutinin disease, a cold autoimmune hemolytic anemia. I
n such cases,
titers can be as high as 10 6 . If all tubes (dilutions) for cold agglutinins ar
e positive,
except the negative control, then a high titer of cold agglutinins is present in
the sample.
Further serial dilutions should be performed. 49. C Cold agglutinins do not rema
in reactive above
30C, and agglutination must disperse following incubation at 37C. The most likely
explanation
when agglutination remains after 37C incubation is that a warm alloantibody or au
toantibody is
present. 50. C A fourfold (2 tube) or greater increase in antibody titer is usua
lly indicative of
an acute infection. Although answers A and B show a fourfold rise in titer, answ
er C shows a
16-fold rise in titer and is the most de nitive. In most serological tests, a sing
le high titer
is insu cient evidence of acute infection unless speci c IgM antibodies are measured
because age,
individual variation, immunologic status, and history of previous exposure (or v

accination) cause
a wide variation in normal serum antibody titers. 50. Which increase in antibody
titer (dilution)
best indicates an acute infection? A. From 1:2 to 1:8 B. From 1:4 to 1:16 C. Fro
m 1:16 to 1:256
D. From 1:64 to 1:128 Immunology/Correlate laboratory data with physiological pr
ocesses/Antibody
titers/1 2828_Ch03_075-120 06/08/12 11:10 AM Page 96 51. Which of the followi
ng positive
antibody tests may be an indication of recent vaccination or early primary infec
tion for rubella
in a patient with no clinical symptoms? A. Only IgG antibodies positive B. Only
IgM antibodies
positive C. Both IgG and IgM antibodies positive D. Fourfold rise in titer for I
gG antibodies
Immunology/Apply principles of basic laboratory procedures/Rubella/Testing/2 52.
Why is
laboratory diagnosis di cult in cases of Lyme disease? A. Clinical response may no
t be apparent
upon initial infection; IgM antibody may not be detected until 36 weeks after the
infection B.
Laboratory tests may be designed to detect whole Borrelia burgdorferi, not agella
r antigen found
early in infection C. Most laboratory tests are technically demanding and lack s
peci city D.
Antibodies formed initially to B. burgdorferi may cross react in antigen tests f
or autoimmune
diseases Immunology/Correlate clinical signs with laboratory procedures/Lyme dis
ease/Testing/2
53. Serological tests for which disease may give a false- positive result if the
patient has Lyme
disease? A. AIDS B. Syphilis C. Cold agglutinins D. Hepatitis C Immunology/Evalu
ate laboratory
data to determine possible inconsistent results/Lyme disease/Testing/3 54. In mo
nitoring an
HIV-infected patient, which parameter may be expected to be the most sensitive i
ndicator of the
e ectiveness of antiretroviral treatment? A. HIV antibody titer B. CD4:CD8 ratio C
. HIV viral
load D. Absolute total T-cell count Immunology/Correlate clinical and laboratory
data/ HIV/2 55.
A renal transplant recipient is found to have a rising creatinine level and redu
ced urine output.
Te physician orders a Urine PCR assay. When you call to nd out what organism the ph
ysician
wants to identify, you are told: A. Hepatitis C virus B. Legionella pneumophila
C. EBV D. BK
virus Immunology/Apply knowledge of fundamental biological characteristics/Trans
plant/Virus/2 3.3
| Infectious Diseases 97 Answers to Questions 5156 51. B If only IgM antibodies
are positive,
this result indicates a recent vaccination or an early primary infection. 52. A
Lyme disease is
caused by B. burgdorferi, a spirochete, and typical clinical symptoms such as ra
sh or erythema
chronicum migrans may be lacking in some infected individuals. Additionally, IgM
antibody is not
detectable by laboratory tests until 36 weeks after a tick bite, and IgG antibody
develops
later. 53. B Lyme disease is caused by a spirochete and may give positive result

s with some
speci c treponemal antibody tests for syphilis. 54. C The HIV viral load will rise
or fall in
response to treatment more quickly than any of the other listed parameters. The
absolute CD4
count is also an indicator of treatment e ectiveness and is used in resource-poor
areas that
might not have facilities for molecular testing available. Note that the absolut
e CD4 count is
not one of the choices, however. 55. D BK virus is a polyoma virus that can caus
e renal and
urinary tract infections. The virus is an opportunistic pathogen and has become
a well-recognized
cause of poor renal function in kidney transplant recipients. Antibody testing i
s not practical
or useful for this infection. The principal diagnostic assays are urinary cytolo
gy, and speci c
BK virus PCR testing in urine and serum. Although Legionella pneumophila can be
diagnosed through
a urinary antigen assay, that organism is not a primary cause of renal insu ciency
in transplant
patients. 56. A Neonatal HIV diagnosis is performed by screening for the presenc
e of the virus.
The current antibody tests are either IgG-speci c or an IgG/IgM combination assay.
Thus an infant
whose mother is HIV positive will also be positive in the HIV antibody assay. Al
though the CD4
count may be a useful assay to determine disease activity, there are many causes
of reduced CD4
numbers and this assay should not be used to diagnose HIV infection. 56. A newbo
rn is to be
tested for a vertically transmitted HIV infection. Which of the following tests
is most useful?
A. HIV PCR B. CD4 count C. Rapid HIV antibody test D. HIV IgM antibody test Immu
nology/Select
test/Neonatal HIV/2 2828_Ch03_075-120 06/08/12 11:10 AM Page 97 57. Which of
the following
methods used for HIV identi cation is considered a signal ampli cation technique? A.
Branched
chain DNA analysis B. DNA PCR C. Reverse transcriptase PCR D. Nucleic acid seque
nce based assay
(NASBA) Immunology/Apply knowledge of special procedures/ Molecular/HIV/1 58. Wh
ich of the
following fungal organisms is best diagnosed by an antibody detection test as op
posed to an
antibody detection assay? A. Histoplasma B. Cryptococcus C. Candida D. Aspergill
us
Immunology/Apply knowledge of special procedures/ Fungal testing/2 59. Your cyto
logy laboratory
refers a Papanicolaou smear specimen to you for an assay designed to detect the
presence of a
virus associated with cervical cancer. You perform: A. An ELISA assay for anti-H
SV-2 antibodies
B. A molecular assay for HSV-2 C. An ELISA assay for HPV antibodies D. A molecul
ar assay for HPV
Immunology/Select course of action/Virus testing/ Methods/3 60. An immunosuppres
sed patient has
an unexplained anemia. Te physician suspects a parvovirus B19 infection. A parvo
virus IgM test is
negative. Te next course of action is to tell the physician: A. Te patient does

not have
parvovirus B. A convalescent specimen is recommended in 4 weeks to determine if
a fourfold rise
in titer has occurred C. A parvovirus PCR is recommended D. Tat a recent transfu
sion for the
patients anemia may have resulted in a false-negative assay and the patient shoul
d be retested
in 4 weeks Immunology/Select course of action/Virus testing/ Parvovirus/3 98 Cha
pter 3 |
Immunology Answers to Questions 5760 57. A Branched chain DNA is a signal ampli cat
ion
technique, i.e., if you start with one copy of the gene you nish with one copy. T
he detection
reagent is ampli ed, increasing the sensitivity of the assay. 58. B The Cryptococc
us antibody
response is not a reliable indicator of a current infection; thus, an antigen as
say is normally
used to monitor the disease. The antigen assay may be used for serum or spinal ui
d and will
decline in response to treatment much faster than a traditional antibody test. A
urinary antigen
test is avail - able for histoplasmosis, and a serum galactomannan assay is avai
lable for
Aspergillus. Those two assays preform better than antibody detection. No antige
n test is
available for Candida, thus antibody is the best serologic procedure for this or
ganism. 59. D
Cervical cell atypia and cervical cancer are associated with speci c high-risk ser
otypes of human
papilloma virus (HPV) infections. Although HPV antibody assays are available, th
ey are not
serotype speci c, nor do they relate to disease activity. Thus molecular probe ass
ays are the
tests of choice to detect high-risk HPV infection. Although HSV-2 is associated
with genital
herpesvirus, that virus has not been shown to cause cervical cancer. 60. C A neg
ative IgM assay
rarely rules out an infection. While a convalescent specimen may be useful in ma
ny cases, in an
immunosuppressed patient the convalescent specimen may remain negative in the pr
esence of an
infection. Thus a parvovirus PCR test is the preferred choice in this case. A fa
lse-negative
result could conceivably be caused by multiple whole blood or plasma transfusion
s, but retesting
for antibody a month later would not be bene cial to the patient. 2828_Ch03_075-12
0 06/08/12
11:10 AM Page 98 99 3.4 Autoimmune Diseases 1. What is a general de nition for au
toimmunity? A.
Increase of tolerance to self-antigens B. Loss of tolerance to self-antigens C.
Increase in
clonal deletion of mutant cells D. Manifestation of immunosuppression Immunology
/Apply knowledge
of fundamental biological characteristics/Autoimmunity/De nitions/1 2. An antinucl
ear antibody
test is performed on a specimen from a 55-year-old woman who has unexplained joi
nt pain. Te IFA
result is a titer of 40 and a homogeneous pattern. Te appropriate follow-up for
this patient is:
A. Anti-DNA assay B. Extractable nuclear antigen (ENA) testing C. Retest ANA in

36 months D.
CH50 complement assay Immunology/Correlate laboratory data with physiological pr
ocesses/IF/2 3.
Which disease is likely to show a rim (peripheral) pattern in an immuno uorescence
(IF)
microscopy test for ANA? A. Mixed connective tissue disease (MCTD) B. Rheumatoid
arthritis C.
Systemic lupus erythematosus D. Scleroderma Immunology/Correlate laboratory data
with
physiological processes/IF/2 4. A patients specimen is strongly positive in an AN
A ELISA. Which
of the following would not be an appropriate follow up to this result? A. Immuno u
orescence test
on HEp-2 cells B. Speci c ENA ELISA tests C. Speci c anti-DNA ELISA D. Rheumatoid fa
ctor assay
Immunology/Select tests/ANA Con rmation/2 5. What type of antibodies is represente
d by the solid
or homogeneous pattern in the immuno uorescence test for antinuclear antibodies? A
. Antihistone
antibodies B. Anticentromere antibodies C. Anti-ENA (anti-Sm and anti-RNP) antib
odies D. Anti-RNA
antibodies Immunology/Correlate laboratory data with physiological processes/IF/
1 Answers to
Questions 16 1. B Autoimmunity is a loss of tolerance to self-antigens and the su
bsequent
formation of autoantibodies. 2. C Approximately 25% of women in this age range m
ay have low
titer-positive ANA assays with no demonstrable connective tissue disease. A pati
ent with
anti-DNApositive SLE would be expected to have a much higher titer (> 160) in an
IFA assay. A
similar titer would be expected for an ENA positive specimen, although the patte
rn would be
speckled. Complement testing would not be indicated with this low titer in a 55year-old female.
3. C The rim or peripheral pattern seen in indirect immunofluorescence technique
s is most
commonly found in cases of active SLE. The responsible autoantibody is highly co
rrelated to
antidouble-stranded DNA (anti-dsDNA). 4. D The ANA ELISA is a screening assay. A
positive result
may be followed up by more speci c antibody ELISA tests or an ANA immuno uorescence
test to
determine pattern and titer. The ANA ELISA does not screen for rheumatoid factor
. 5. A
Antihistone antibodies (and also anti-DNA antibodies) cause the solid or homogen
eous pattern,
which is commonly found in patients with SLE, RA, mixed connective tissue diseas
e, and Sjgrens
syndrome. Antibodies to the centromere of chromosomes is a marker for the CREST
(calcinosis,
Raynauds phenomenon, esophageal dysfunction, sclerodactyly, and telangiectasia) f
orm of systemic
sclerosis. 6. C High titer anti-Sm is indicative of SLE. Anti-Sm is one of two a
ntibodies against
saline extractable nuclear antigens, the other being anti-RNP. These antibodies
cause a speckled
pattern of immuno uorescence. 6. What disease is indicated by a high titer of anti
-Sm
(anti-Smith) antibody? A. Mixed connective tissue disease (MCTD) B. RA C. SLE D.

Scleroderma
Immunology/Correlate laboratory data with physiological processes/IF/2 2828_Ch03
_075-120
06/08/12 11:10 AM Page 99 7. Which disease is least likely when a nucleolar pa
ttern occurs in
an immuno uorescence test for antinuclear antibodies? A. MCTD B. Sjgrens syndrome C.
SLE D.
Scleroderma Immunology/Correlate laboratory data with physiological processes/IF
/2 8. What
antibodies are represented by the nucleolar pattern in the immuno uorescence test
for antinuclear
antibodies? A. Antihistone antibodies B. Anti-dsDNA antibodies C. Anti-ENA (anti
-Sm and anti-RNP)
antibodies D. Anti-RNA antibodies Immunology/Correlate laboratory data with phys
iological
processes/IF/1 9. Which test would best distinguish between SLE and MCTD? A. Mul
tiplex or ELISA
test for anti-SM and anti-RNP B. Immuno uorescence testing using Crithidia as subs
trate C. Slide
agglutination testing D. Laboratory tests cannot distinguish between these disor
ders
Immunology/Evaluate laboratory data to recognize and report the need for additio
nal testing/
Autoimmune/Testing/3 10. An ANA test on HEp-2 cells shows nucleolar staining in
interphase cells
and dense chromatin staining in mitotic cells. Te most likely cause of this stai
ning pattern is:
A. Anti brillarin antibody B. Antiribosomal p antibody C. A serum with nucleolar a
nd homogeneous
patterns D. Technical artifact Immunology/Correlate laboratory data with physiol
ogical
processes/IF/1 11. Which immuno uorescence pattern indicates the need for ENA test
ing by
Ouchterlony immunodi usion, Multiplex, or ELISA assays? A. Homogeneous or solid B.
Peripheral or
rim C. Speckled D. Nucleolar Immunology/Evaluate laboratory data to recognize an
d report the need
for additional testing/ Autoimmune/Testing/3 100 Chapter 3 | Immunology Answers
to Questions 712
7. A All of the diseases except MCTD may cause a nucleolar pattern of immuno uores
cence.
Nucleolar uorescence is caused by anti-RNA antibodies and is seen in about 50% of
patients with
scleroderma. 8. D Anti-RNA antibodies are represented by the nucleolar pattern.
This pattern may
be seen in most systemic autoimmune diseases and is especially common in patient
s with
scleroderma. Anti-RNA and anti-Sm are not usually found in patients with mixed c
onnective tissue
disease. This is a syndrome involving aspects of SLE, RA, scleroderma, and polym
yositis. The
immuno uorescence pattern most often seen in MCTD is the speckled pattern caused b
y anti-RNP. 9.
A The Ouchterlony (double) immunodi usion assay may be used to identify and di erent
iate anti-Sm
from anti-RNP. Multiplex and ELISA assays, using puri ed or recombinant antigens,
are also
available for this testing. Anti-Sm with or without anti-RNP is found in approxi
mately one third
of SLE patients. Anti-RNP in the absence of anti-Sm is found in over 95% of MCTD

patients. 10. A
Anti brillarin antibody has this appearance. Ribosomal p antibody has nucleolar st
aining and a
background homogeneous and cytoplasmic stain. A combination nucleolar/homogeneou
s specimen will
also show homogeneous staining in the interphase cells. This pattern is not seen
in typical
technical artifacts. 11. C A speckled pattern is often due to the presence of an
tibodies against
the extractable nuclear antigens, such as Sm, RNP, SSA, and SSB. Homogenous and
rim patterns
suggest antibodies to double-stranded DNA. The homogeneous pattern may also be s
een with
antibodies to deoxyribonuclear protein, which is not an ENA. Nucleolar patterns
often indicate
antibodies to RNA or brillarin. 12. B Rheumatoid factors react with the Fc portio
n of the IgG
molecule and are usually IgM. This is the basis of rapid agglutination tests for
RA. Particles of
latex or cells are coated with IgG. Addition of serum containing rheumatoid fact
or results in
visible agglutination. 12. Which of the following is used in rapid slide tests f
or detection of
rheumatoid factors? A. Whole IgM molecules B. Fc portion of the IgG molecule C.
Fab portion of
the IgG molecule D. Fc portion of the IgM molecule Immunology/Apply knowledge of
fundamental
biological characteristics/RA/Testing/1 2828_Ch03_075-120 06/08/12 11:10 AM P
age 100 13. Which
of the following methods is least likely to give a de nitive result for the diagno
sis of RA? A.
Nephelometric measurement of anti-IgG B. Agglutination testing for rheumatoid fa
ctor C. Anti CCP
D. Immuno uorescence testing for antinuclear antibodies Immunology/Select routine
laboratory
procedures/ Autoimmune/RA/Testing/1 14. Which disease might be indicated by anti
bodies to smooth
muscle? A. Atrophic gastritis B. Autoimmune hepatitis C. Myasthenia gravis D. Sjg
rens syndrome
Immunology/Apply knowledge of fundamental biological characteristics/Autoimmune/
Testing/1 15.
Antibodies to thyroid peroxidase can be detected by using agglutination assays.
Which of the
following diseases may show positive results with this type of assay? A. Graves d
isease and
Hashimotos thyroiditis B. Myasthenia gravis C. Granulomatous thyroid disease D. A
ddisons
disease Immunology/Select routine laboratory procedures/ Autoimmune/Testing/1 16
. What is the
main use of laboratory tests to detect antibodies to islet cells and insulin in
cases of
insulin-dependent diabetes mellitus (IDDM)? A. To regulate levels of injected in
sulin B. To
diagnose IDDM C. To rule out the presence of other autoimmune diseases D. To scr
een susceptible
individuals prior to destruction of cells Immunoloy/Select routine l
or
tory p
rocedures/
Autoimmune/IDDM/Testin/1 17. A p
tient presents with clinic
l symptoms of celi

c dise
se. Tests
for
nti-tissue tr
nslut
min
se
nd
ntili
din
nti odies
re ne
tive. Which

of the followin
tests should e ordered? A. IG level B. HLA DQ typin C. HLA DR typin D. IM l
evel
Immunoloy/Select routine l
or
tory procedures/ Autoimmune/Celi
c dise
se/Testi
n/2 3.4 |
Autoimmune Dise
ses 101 Answers to Questions 1317 13. D P
tients with RA often
show

homoeneous p
ttern of uorescence in tests for
ntinucle
r
nti odies. However, t
his p
ttern is
seen in
wide r
ne of systemic
utoimmune dise
ses
nd in m
ny norm
l persons

t
titer elow
10. The rst two methods listed m
y e used to identify
nti-IG, which is require
d to est
lish

di
nosis of RA Anti CCP is
speci c
ss
y for rheum
toid
rthritis. 14. B Anti
odies to
smooth muscle
re found in the serum of up to 70% of p
tients with
ctive chroni
c hep
titis
nd
up to 50% of p
tients with prim
ry ili
ry cirrhosis. 15. A Anti odies to thyroi
d peroxid
se m
y
e detected in oth Gr
ves dise
se (hyperthyroidism)
nd H
shimotos thyroiditis
(hypothyroidism). If
positive result is found to thyroid peroxid
se, thyroxine
levels c
n e
me
sured to distinuish etween the two dise
ses. 16. D F
stin hyperlycemi
is
the prim
ry
ndin used to di
nose IDDM. For individu
ls with
n inherited suscepti ility to
the development
of IDDM, l
or
tory tests for the detection of
nti odies to islet cells
nd ins
ulin m
y help to
initi
te e
rly tre
tment efore complete destruction of cells. 17. B While
nti
odies to tissue
tr
nslut
min
se
nd li
din
re often found in celi
c dise
se, their com ined s
ensitivity is
less th
n 100%. Celi
c dise
se is
lmost exclusively
ssoci
ted with the presenc
e of HLA DQ2

nd/or HLA DQ8. These HLA enes
re not di
nostic of celi
c dise
se, ut provid
e
testin

ltern
tive in
nti ody-ne
tive individu
ls who meet the clinic
l di
nostic cr
iteri
for celi
c
dise
se. 2828_Ch03_075-120 06/08/12 11:10 AM P
e 101 18. A specimen
ppe
rs
to h
ve

perinucle
r st
inin p
ttern in
n
ntineutrophil cytopl
smic
nti ody (ANCA) im
muno uorescent

ss
y usin eth
nol- xed neutrophils, suestin the possi ility of
pANCA. On w
hich of the
followin su str
tes would this specimen displ
y cytopl
smic specklin? A. Form

lin- xed
neutrophils B. Un xed neutrophils C. HEp-2 cells D. R
it kidney tissue Immunolo
y/Select
routine l
or
tory procedures/ Autoimmune/ANCA/Testin/2 102 Ch
pter 3 | Immunol
oy Answer to
Question 18 18. A Anti odies to neutrophil cytopl
smic
ntien demonstr
tin
p
erinucle
r
p
ttern of uorescence indic
te
di
nosis of v
sculitis. However,
typic
l ANCAs

nd ANAs
lso
demonstr
te
perinucle
r st
inin p
ttern on eth
nol- xed neutrophils. To di erenti

te these
from pANCA, specimens
ppe
rin
s
pANCA on eth
nol- xed cells
re tested on for
m
lin- xed
neutrophils. The myeloperoxid
se cont
inin r
nules th
t co
lesce
round the nu
cle
r mem r
ne

durin eth
nol x
tion will rem
in in the cytopl
sm durin form
lin x
tion. Thus, p
ANCA will
h
ve
cytopl
smic (cANCA) p
ttern on
form
lin- xed slide, ut ANAs will ret
in

perinucle
r
p
ttern
nd the uorescence will e diminished. 2828_Ch03_075-120 06/08/12 11:10
AM P
e 102
103 3.5 Hypersensitivity 1. Which of the followin is
description of
type I
hypersensitivity
re
ction? A. R
weed
ntien cross links with IE on the surf
ce of m
st cells,
c
usin rele
se
of preformed medi
tors
nd resultin in symptoms of
n
lleric re
ction B. Anti
-Fy
from

pren
nt wom
n crosses the pl
cent

nd
tt
ches to the Fy

ntien-positive re
d cells of the
fetus, destroyin the red cells C. Immune complex deposition occurs on the lome
rul
r
sement
mem r
ne of the kidney, le
din to ren
l f
ilure D. Exposure to poison ivy c
use
s sensitized T
cells to rele
se lymphokines th
t c
use
loc
lized in
mm
tory re
ction Immunolo
y/Apply
knowlede of fund
ment
l ioloic
l ch
r
cteristics/Hypersensitivity/2 2. Why is
skin testin the
most widely used method to test for
type I hypersensitivity re
ction? A. It c

uses less tr
um


nd is more cost e ective th
n other methods B. It h
s re
ter sensitivity th
n in
vitro
me
surements C. It is more likely to e positive for IE-speci c
llerens th
n ot
her methods D.
It m
y e used to predict the development of further
lleren sensitivity Immuno
loy/Apply
principles of
sic l
or
tory procedures/Hypersensitivity/Testin/1 3. Which in
vitro test
me
sures IE levels

inst
speci c
lleren? A. Hist
mine rele
se
ss
y B. R
di
oimmunosor ent
test (RIST) C. Fluorescent
llerosor ent test (FAST) D. Precipitin r
dioimmunos
or ent test
(PRIST) Immunoloy/Apply principles of
sic l
or
tory procedures/Hypersensitiv
ity/IE testin/1
4. A p
tient who is lood roup O is
ccident
lly tr
nsfused with roup A lood

nd develops

re
ction durin the tr
nsfusion. Wh
t
nti ody is involved in this type II re
ct
ion? A. IM B.
IE C. IG
nd IE D. IG Immunoloy/Apply principles of
sic l
or
tory
procedures/Hypersensitivity/Testin/1 Answers to Questions 14 1. A Type I immedi

te
hypersensitivity (
n
phyl
ctic) responses
re ch
r
cterized y IE molecules in
din to m
st
cells vi
the Fc receptor. Cross linkin of surf
ce IE c
used y indin of
ll
erens c
uses the
m
st cell to der
nul
te, rele
sin hist
mine
nd other chemic
l medi
tors of
l
lery. Answer B
descri es
type II re
ction; C descri es
type III re
ction;
nd D descri es

type IV
re
ction. 2. B Skin testin is considered much more sensitive th
n in vitro test
s th
t me
sure
either tot
l or
ntien-speci c IE. 3. C The FAST is
uorescent
ss
y th
t me
sur
es speci c
IE; the RIST
nd PRIST tests
re r
dioimmuno
ss
ys th
t me
sure tot
l IE. The
FAST procedure
h
s repl
ced the RAST, or r
dio
llerosor ent
ss
y. The hist
mine rele
se
ss
y

me
sures the

mount of hist
mine. Alleren-speci c IE
ss
ys
re
v
il
le
sed upon solid-ph

se enzyme
immuno
ss
y. The
lleren is cov
lently ound to
cellulose solid ph
se
nd re

cts with speci c
IE in the serum. After w
shin, enzyme (-
l
ctosid
se)-l
eled monoclon
l
ntiIE is
dded.
The un ound
nti ody conju
te is w
shed
w
y
nd uoroenic su str
te
(4-methylum elliferyl--D-
l
ctose) is
dded. Fluorescence is directly proportion

l to speci c
IE. 4. A IG
nd IM
re the
nti odies involved in
type II cytotoxic re
ctio
n. N
tur
lly
occurrin
nti-A in the form of IM is present in the lood of
roup O individ
u
l
nd would
c
use
n immedi
te tr
nsfusion re
ction. Cell destruction occurs when
nti odies
ind to cells
c
usin destruction vi
complement
ctiv
tion, there y trierin intr
v
scul
r
hemolysis.
2828_Ch03_075-120 06/08/12 11:10 AM P
e 103 5. Which test would me
sure the
co
tin of red
cells y
nti ody
s occurs in hemolytic tr
nsfusion re
ctions? A. Indirect
nti
lo ulin test
(IAT) B. Direct
ntilo ulin test (DAT) C. ELISA D. Hem
lutin
tion Immunoloy/
Apply principles
of
sic l
or
tory procedures/Hemolytic re
ction/1 6. Which test detects
nti o
dies th
t h
ve

tt
ched to tissues, resultin in
type-II cytotoxic re
ction? A. Mir
tion inh
i ition f
ctor

ss
y (MIF) B. Direct immuno uorescence (IF) C. Immuno x
tion electrophoresis (IFE)
D.
Hem
lutin
tion Immunoloy/Apply principles of
sic l
or
tory procedures/Hemo
lytic re
ctions/1
7. Which of the followin conditions will most likely result in
f
lse-ne
tive
DAT test? A.
Insu cient w
shin of RBCs B. Use of he
vy ch
inspeci c polyclon
l
nti-hum
n I C. U
se of
excessive centrifu
l force D. Use of
s
mple o t
ined y ner puncture Immunolo
y/Apply
knowlede to identify sources of error/Hemolytic re
ctions/3 8. Which of the fol
lowin tests is
used to detect circul
tin immune complexes in the serum of some p
tients with s
ystemic

utoimmune dise
ses such
s rheum
toid
rthritis? A. Direct immuno uorescence B. E
nzyme
immuno
ss
y C. Ass
y of cryolo ulins D. Indirect
ntilo ulin test Immunoloy/A
pply knowlede of
fund
ment
l ioloic
l ch
r
cteristics/Hypersensitivity/1 9. All of the followin
 tests m
y e

norm
l in
type III immune complex re
ction except: A. C1q- indin
ss
y y E
LISA B. R
ji cell

ss
y C. CH 50 level D. Mitoen response Immunoloy/Apply principles of speci
l
l
or
tory
procedures/Hypersensitivity/Testin/1 10. Wh
t immune elements
re involved in

positive skin
test for tu erculosis? A. IE
nti odies B. T cells
nd m
croph
es C. NK cells

nd IG
nti ody
D. B cells
nd IM
nti ody Immunoloy/Apply knowlede of fund
ment
l ioloic
l
ch
r
cteristics/Hypersensitivity/1 104 Ch
pter 3 | Immunoloy Answers to Questio
ns 510 5. B The
DAT test me
sures
nti ody th
t h
s
lre
dy co
ted RBCs in vivo. Direct
ntilo

ulin
nd direct

immuno uorescence tests use
nti-immunolo ulin to detect
nti ody-sensitized cell
s. 6. B The
direct IF test detects the presence of
nti ody th
t m
y c
use
type II cytotox
ic re
ction. For
ex
mple, ren
l iopsies from p
tients with Goodp
stures syndrome exhi it
smooth
p
ttern of
uorescence
lon the
sement mem r
ne
fter re
ction with uorescein isothiocy
n
t
e (FITC)
conju
ted
nti-immunolo ulin. The re
ction detects
nti odies

inst the
se
ment mem r
ne of
the lomeruli. 7. A Insu cient w
shin c
n c
use incomplete remov
l of excess or u
n ound
immunolo ulins
nd other proteins, which m
y neutr
lize the
ntilo ulin re
en
t. 8. C Most

utoimmune dise
ses involve the form
tion of
ntien
nti ody complexes th
t depos
it in the
tissues, c
usin loc
l in
mm
tion
nd necrosis induced y complement
ctiv
tion,
ph
ocytosis,
WBC in ltr
tion,
nd lysosom
l d
m
e. Some p
tients m
ke monoclon
l or polyclon
l

nti odies
with rheum
toid f
ctor
ctivity th
t ind to serum immunolo ulins, formin
r
e
tes th
t
re
insolu le
t 4C. These circul
tin immune complexes
re detected y
llowin
l
ood s
mple to
clot
t 37C, tr
nsferrin the serum to
sediment
tion r
te tu e,
nd then incu

tin the serum

t 4C for 3 d
ys. 9. D Mitoen stimul
tion is used to me
sure T-cell, B-cell,
nd
null-cell
responsiveness, which is import
nt in p
tients displ
yin
nery
nd other sins
of
immunode ciency. The C1q
ss
y
nd the R
ji cell
ss
ys detect circul
tin immune
complexes th
t

re present durin
type III re
ction. The CH 50 level is usu
lly decre
sed owi
n to complement

ctiv
tion y the immune complexes. R
ji cells
re derived from
m
lin
nt B-ce
ll line th
t
demonstr
tes C3 receptors ut no surf
ce mem r
ne immunolo ulin. Immune complex
es th
t h
ve xed
complement will ind to R
ji cells
nd c
n e identi ed usin r
diol
eled or enzy
me l
eled

nti-immunolo ulin. More recently,
C3 indin ELISA
ss
y h
s repl
ced the R

ji cell
procedure. 10. B T cells
nd m
croph
es
re the immune elements prim
rily respo
nsi le for the
clinic
l m
nifest
tions of
positive tu erculosis test. Re
ctions usu
lly t
ke
72 hours to re
ch
pe
k development
nd
re ch
r
cteristic of loc
lized type IV cell-medi
ted hyper
sensitivity. The
skin re
ction is ch
r
cterized y
lesion cont
inin
mononucle
r cell in ltr
te
.
2828_Ch03_075-120 06/08/12 11:10 AM P
e 104 11. A p
tient receives
tr
nsfu
sion of p
cked
red cells
nd fresh frozen pl
sm

nd develops
n
n
phyl
ctic, nonhemolytic re

ction. She
reports receivin
tr
nsfusion 20 ye
rs e
rlier. She h
d no re
ction to the pre
vious
tr
nsfusion, ut she did feel poorly
few weeks l
ter. Which of the followin tr

nsfused
su st
nces most likely elicited the re
ction? A. IA B. Group A
ntien C. Rho (

D)
ntien D. An

ntien elonin to the Du y system Immunoloy/Apply knowlede of fund
ment
l io
loic
l
ch
r
cteristics/Immune de ciency/Hypersensitivity/3 12. A p
tient de cient in the C3
complement
component would e expected to mount
norm
l: A. Type I
nd IV hypersensitivity
response B. Type
II
nd IV hypersensitivity response C. Type I
nd III hypersensitivity response
D. Type II
nd
III hypersensitivity response Immunoloy/Apply knowlede of fund
ment
l ioloic

l
ch
r
cteristics/Immune de ciency/ Hypersensitivity/2 3.5 | Hypersensitivity 105
Answers to
Questions 1112 11. A The f
ct th
t this is
nonhemolytic re
ction suests th
t

nonred cell

ntien m
y e involved. Selective IA deficiency occurs in
pproxim
tely 1 in 7
00 individu
ls

nd is often
symptom
tic. Individu
ls deficient in IA m
y m
ke
n
nti ody


inst the he
vy
ch
in if they
re exposed to IA vi

tr
nsfusion. This
nti ody m
y le
d to

serum sickness
re
ction if the IA is still present
fter
nti ody form
tion. This could expl
i
n the poor
feelin the p
tient h
d
fter the initi
l tr
nsfusion. A su sequent tr
nsfusion m

y le
d to
n
Arthus re
ction if IG
nti-IA is present or
n
n
phyl
ctic re
ction if IE
n
ti-IA is
present. 12. A Complement is involved in types II
nd III hypersensitivity; thus

n individu
l
deficient in C3 will e deficient in those responses. The complement deficiency
should h
ve no
effect on IE (type I) or cell-medi
ted (type IV) hypersensitivities. 2828_Ch03_
075-120 06/08/12
11:10 AM P
e 105 106 3.6 Immunolo ulins, Complement,
nd Cellul
r Testin 1.
Which of the
followin symptoms in
youn child m
y indic
te
n immunode ciency syndrome? A. A
n
phyl
ctic
re
ctions B. Severe r
shes
nd my
li
C. Recurrent
cteri
l, fun
l,
nd vir
l
infections D.
Weiht loss, r
pid he
rt e
t, re
thlessness Immunoloy/Apply knowlede of fund

ment
l ioloic
l
ch
r
cteristics/T cell/Testin/1 2. Wh
t screenin test should e performed rst i
n
youn
p
tient suspected of h
vin
n immune dysfunction disorder? A. Complete lood co
unt (CBC)
nd
white cell di erenti
l B. Chemot
xis
ss
y C. Complement levels D. Bone m
rrow io
psy
Immunoloy/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics/Select test
s/3 3. Which test
should e performed when
p
tient h
s
re
ction to tr
nsfused pl
sm
products?
A.
Immunolo ulin levels B. T-cell count C. Hemolo in levels D. Red cell enzymes
Immunoloy/Ev
lu
te l
or
tory
nd clinic
l d
t
to specify
ddition
l tests/Sel
ect tests/3 4.
Wh
t is the M component in monoclon
l 
mmop
thies? A. IM produced in excess B. H
e
vy ch
in
produced in excess C. M
lin
nt prolifer
tion of B cells D. Monoclon
l
nti ody
or cell line
Immunoloy/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics/Immunolo u
lins/Testin/1

Answers to Questions 14 1. C An immunode ciency syndrome should e considered in

youn child
who h
s
history of recurrent
cteri
l, fun
l,
nd vir
l infections m
nifeste
d
fter the
dis
ppe
r
nce of m
tern
l IG. Immunode ciency disorders m
y involve de ciencies in
production

nd/or function of lymphocytes
nd ph
ocytic cells or
de ciency in production o
f
complement
f
ctor. Choice of l
or
tory tests is
sed upon the p
tients clinic
l present
ti
on,
e,
nd
history. 2. A The rst screenin tests performed in the initi
l ev
lu
tion of
yo
un p
tient who
is suspected of h
vin
n immune dysfunction
re the CBC
nd di erenti
l. White l
ood cells th
t

re decre
sed in num er or
norm
l in
ppe
r
nce m
y indic
te further testin.
3. A A re
ction
to pl
sm
products m
y e found in
n IA-deficient person who h
s formed
nti-I
A
nti odies.
Immunolo ulin levels would
id in this determin
tion. Selective IA deficiency
is the most
common immunodeficiency dise
se
nd is ch
r
cterized y serum IA levels elow 5
m/dL. IA is
usu
lly
sent from secretions, ut the B-cell count is usu
lly norm
l. 4. D The
M component
refers to
ny monoclon
l protein or cell line produced in
monoclon
l 
mmop
th
y such
s
multiple myelom
. 2828_Ch03_075-120 06/08/12 11:10 AM P
e 106 5. A child sus
pected of h
vin

n inherited humor
l immunode ciency dise
se is iven diphtheri
/ tet
nus v
ccine.
Two weeks

fter the immuniz
tion, his level of
nti ody to the speci c
ntiens is me
sured.
Which result
is expected for this p
tient if he/she indeed h
s
humor
l de ciency? A. Incre
se
d levels of
speci c
nti ody B. No ch
ne in the level of speci c
nti ody C. An incre
se in IG
-speci c

nti ody ut not IM-speci c
nti ody D. Incre
sed levels of nonspeci c
nti ody
Immunoloy/Ev
lu
te l
or
tory d
t
/ Immunolo ulins/Testin/2 6. Which dise
se
m
y e expected
to show
n IM spike on
n electrophoretic p
ttern? A. Hypo
mm
lo ulinemi
B.
Multicystic
kidney dise
se C. W
ldenstrms m
crolo ulinemi
D. WiskottAldrich syndrome Immunolo
y/Ev
lu
te
l
or
tory d
t
to m
ke identi c
tions/Immunolo ulins/Testin/2 7. In testin for
DiGeores
syndrome, wh
t type of l
or
tory
n
lysis would e most helpful in determinin
the num er of
m
ture T cells? A. Complete lood count B. Nitro lue tetr
zolium (NBT) test C. T
-cell enzyme

ss
ys D. Flow cytometry Immunoloy/Ev
lu
te l
or
tory d
t
to m
ke identi c
tion
s/T
cells/Testin/2 8. Interpret the followin description of
n immuno x
tion electro
phoresis
ss
y
of urine. Dense wide
nds in oth the and anes. No bans present in the heavychain anes.
A. Norma B. Liht chain isease C. Increase poycona Fab framents D. Mutip
e myeoma
Immunooy/Evauate aboratory ata to make ienti cations/Immunoobuins/Testin
/2 9. Free
monocona iht chains are often present in the serum of mutipe myeoma patie

nts, an may be

usefu for isease monitorin. Which of the foowin assays wou be recommene
 to etect the
presence of serum-free iht chains? A. Serum protein eectrophoresis B. Urine i
mmuno xation C.
Nepheometry D. ELISA Immunooy/Evauate aboratory an cinica ata to specif
y aitiona
tests/Testin/2 3.6 | Immunoobuins, Compement, an Ceuar Testin
107 An
swers to
Questions 59 5. B In an immunoeficient patient, the expecte eves of specific
antiboy to the
antiens in the vaccine wou be ecrease or not present. This response provie
s evience of
eficient antiboy prouction. 6. C Waenstrms macroobuinemia is a mainancy
of
pasmacytoi ymphocytes invovin both the bone marrow an ymph noes. The ma
inant ces
secrete monocona IM an are in transition from B ces to pasma ces. In co
ntrast to
mutipe myeoma, osteoytic bone esions are not foun. 7. D DiGeores synrome
is cause by a
eveopmenta faiure or hypopasia of the thymus, an resuts in a e ciency of T
ymphocytes
an ce-meiate immune function. The T-ce count is ow, but the eve of imm
unoobuins is
usuay norma. Fow cytometry is most hepfu in eterminin numbers an subpop
uations of T
ces. 8. C Heavy wie bans seen with both anti- and ani- antisera inicate exce
ssive
iht-chain excretion. Liht-chain isease wou show a heavy restricte ban fo
r one of the
iht-chain reactions, but not both. The nin of excess an chains indicaes a p
olyclonal
gammopahy wih increased immunoglobulin urnover and excreion of he ligh cha
ins as Fab
fragmens. 9. C Serum-free ligh chains are a sensiive indicaor of a monoclona
l gammopahy.
They are ofen no presen in sufficien quaniy o show a band on a proein el
ecrophoresis
gel. Deecing ligh chains in he urine is no an indicaor of wha he serum l
evels may be.
Serum immunoglobulin heavy and ligh chains are mos commonly measured by rae o
r endpoin
nephelomery. ELISA assays are mos ofen used o measure specific anibody leve
ls, no o
quaniae immunoglobulin heavy- or ligh-chain isoypes. 2828_Ch03_075-120 06/
08/12 11:10 AM
Page 107 10. Wha is measured in he CH 50 assay? A. RBC quaniy needed o aggl
uinae 50% of
anibody B. Complemen needed o lyse 50% of RBCs C. Complemen needed o lyse 5
0% of anibodysensiized RBCs D. Anibody and complemen needed o sensiize 50% of RBCs Immun
ology/Apply
principles of basic laboraory procedures/Complemen/Tesing/1 11. Wha ype of
disorders would
show a decrease in C3, C4, and CH 50 ? A. Auoimmune disorders such as SLE and R
A B.
Immunode ciency disorders such as common variable immunode ciency C. Tumors D. Bace
rial, viral,
fungal, or parasiic infecions Immunology/Evaluae laboraory daa o mae

ideni caions/Complemen/Tesing/2 12. All of he following ess measure phagocy

e funcion
excep: A. Leuocye adhesion molecule analysis B. Di Hydro rhodamine reducion
assay C. NBT es
D. IL-2 (inerleuin-2) assay Immunology/Apply principles of basic laboraory
procedures/Phagocyes/Tesing/1 108 Chaper 3 | Immunology Answers o Quesions
1012 10. C The
CH 50 is he amoun of complemen needed o lyse 50% of sandardized hemolysin-s
ensiized sheep
RBCs. I is expressed as he reciprocal of he serum diluion resuling in 50% h
emolysis. Low
levels are associaed wih de ciency of some complemen componens and acive sys
emic auoimmune
diseases in which complemen is being consumed. 11. A The paern of decreased C
3, C4, and CH 50
indicaes classic pahway acivaion. This resuls in consumpion of complemen
and is associaed
wih SLE, serum sicness, subacue bacerial endocardiis, and oher immune comp
lex diseases. The
in ammaory response seen in malignancy and acue infecions gives rise o an incr
ease in
complemen componens. Immunode ciency caused by an inheried de ciency in complemen
 consiues
only abou 1% of immunode ciency diseases. Such disorders reduce he CH 50 bu inv
olve a de cien
serum level of only one complemen facor. 12. D The Di-hydro rhodamine reducio
n assay and NBT
ess are used o diagnose chronic granulomaous disease, an inheried disorder
in which
phagocyic cells fail o ill microorganisms owing o a defec in peroxide produ
cion
(respiraory burs). Leuocye adhesion de ciency is associaed wih a defec in 
he producion
of inegrin molecules on he surface of WBCs and heir granules. IL-2 is a cyo
ine produced by
acivaed T h and B cells. I causes B-cell proliferaion and increased produci
on of anibody,
inerferon, and oher cyoines. IL-2 can be measured by EIA and is used o dee
c ransplan
rejecion, which is associaed wih an increase in he serum and urine levels. 2
828_Ch03_075-120
06/08/12 11:10 AM Page 108 109 3.7 Tumor Tesing and Transplanaion 1. A pai
en had surgery
for colorecal cancer, afer which he received chemoherapy for 6 monhs. Te es
 for
carcinoembryonic anigen (CEA) was normal a his ime. One year laer, he bimo
nhly CEA was
elevaed (above 10 ng/mL). An examinaion and biopsy revealed he recurrence of
a small umor.
Wha was he value of he resuls provided by he CEA es in his clinical siu
aion? A.
Diagnosic informaion B. Informaion for furher reamen C. Informaion on h
e immunologic
response of he paien D. No useful clinical informaion in his case Immunolog
y/Apply
principles of basic laboraory procedures/Tumors/Tesing/1 2. A carbohydrae an
igen 125 assay
(CA-125) was performed on a woman wih ovarian cancer. Afer reamen, he leve
ls fell
signi canly. An examinaion performed laer revealed he recurrence of he umor,

bu he CA 125

levels remained low. How can his nding be explained? A. Tes error B. CA-125 was
he wrong
laboraory es; -fetoprotein (AFP) is
etter test to monitor ov
ri
n c
ncer C.
CA-125 m
y not
e sensitive enouh when used
lone to monitor tumor development D. CA-125 is no
t speci c enouh
to detect only one type of tumor Immunoloy/Apply principles of
sic l
or
tory
procedures/Tumors/Testin/3 3. Wh
t is the correct procedure upon receipt of
t
est request for
hum
n chorionic on
dotropin (hCG) on the serum from
60-ye
r-old m
n? A. Retur
n the request;
hCG is not performed on men B. Perform
qu
lit
tive hCG test to see if hCG is p
resent C. Perform
the test; hCG m
y e incre
sed in testicul
r tumors D. Perform the test ut use
di erent
st
nd
rds
nd controls Immunoloy/Correl
te l
or
tory d
t
with physioloic
l
processes/Tumors/HCG/3 Answers to Questions 13 1. B CEA is
lycoprotein th
t is
elev
ted in

out 60% of p
tients with colorect
l c
ncer
nd one third or more p
tients with
pulmon
ry,

stric,
nd p
ncre
tic c
ncers. CEA m
y e positive in smokers, p
tients with c
irrhosis, Crohns
dise
se,
nd other nonm
lin
nt conditions. Bec
use sensitivity for m
lin
nt di
se
se is low, CEA
is not recommended for use
s
di
nostic test. However,
n elev
ted CEA
fter
tre
tment is
evidence of tumor recurrence
nd the need for second-look surery. 2. C CA-125 i
s
tumor

ssoci
ted c
r ohydr
te
ntien th
t is elev
ted in 70%80% of p
tients with ov
ri

n c
ncer
nd

out 20% of p
tients with p
ncre
tic c
ncer. While
n incre
se in CA-125 m
y in
dic
te recurrent
or proressive dise
se, f
ilure to do so does not necess
rily indic
te the
sen
ce of tumor
rowth. 3. C hCG is norm
lly tested for in pren
ncy; it is incre
sed in
pproxi
m
tely 60% of
p
tients with testicul
r tumors
nd
lower percent
e of those with ov
ri
n, GI
, re
st,
nd
pulmon
ry tumors. M
lin
nt cells secretin hCG m
y produce only the -su unit; th
erefore,
qu
lit
tive
nd qu
ntit
tive tests th
t detect only int
ct hormone m
y not e
p
propri
te.
2828_Ch03_075-120 06/08/12 11:10 AM P
e 109 4. Would
n hCG test usin
mon
oclon
l
nti ody


inst the -su unit of hCG likely e
ected y
n incre
sed level of follicle-sti
mul
tin
hormone (FSH)? A. Yes, the -su unit of FSH is identic
l to th
t of hCG B. No, the
test would e
speci c for the -su unit of hCG C. Yes,
cross re
ction would occur ec
use of str
uctur
l
simil
rities D. No, the structure of FSH
nd hCG
re not
t
ll simil
r Immunolo
y/Ev
lu
te
l
or
tory d
t
to check for sources of error/hCG/Testin/3 5. Which of the foll
owin su st
nces,
sometimes used
s
tumor m
rker, is incre
sed two- or threefold in
norm
l pre
n
ncy? A.
Alk
line phosph
t
se (ALP) B. C
lcitonin C. Adrenocortocotropic hormone (ACTH) D
. Neuron-speci c
enol
se Immunoloy/Tumor m
rkers/Testin/1 6. Wh
t is
n
dv
nt
e of performin


prost
tespeci c
ntien (PSA) test for prost
te c
ncer? A. PSA is st
le in serum
nd not

ected y

diit
l-rect
l ex
min
tion B. PSA is incre
sed only in prost
tic m
lin
ncy C. A
norm
l serum
level rules out m
lin
nt prost
tic dise
se D. Te percent
e of free PSA is elev

ted in persons
with m
lin
nt dise
se Immunoloy/Correl
te l
or
tory d
t
with physioloic
l
processes/Tumors/PSA/1 7. Which method is the most sensitive for qu
ntit
tion of
AFP? A. Dou le
immunodi usion B. Electrophoresis C. Enzyme immuno
ss
y D. P
rticle
lutin
tion
Immunoloy/Select
ppropri
te method/AFP/1 110 Ch
pter 3 | Immunoloy Answers to
Questions 47 4.
B Luteinizin hormone, FSH,
nd hCG sh
re
common -su unit ut h
ve di erent su un
its. A test
for hCG usin
monoclon
l
nti ody would e speci c for hCG provided th
t the
nt
i ody w
s
directed

inst
n
ntienic determin
nt on the c
r oxy termin
l end of the su
unit. 5. A
Isoenzymes of ALP
re sometimes used
s tumor m
rkers ut h
ve
low speci city e
c
use they
re

lso incre
sed in nonm
lin
nt dise
ses. These include the pl
cent
l-like (he
tst
le) ALP
isoenzymes, which
re found (infrequently) in some m
lin
ncies such
s c
ncer o
f the lun; onederived ALP, which is
m
rker for met
st
tic one c
ncer;
nd the f
st-mir
tin
 liver
isoenzyme, which is
m
rker for met
st
tic liver c
ncer. ACTH is secreted
s
n
ectopic hormone
in some p
tients with c
ncer of the lun. C
lcitonin is
hormone produced y th
e medull
of the
thyroid
nd is incre
sed in the serum of p
tients with medull
ry thyroid c
rcino
m
.
Neuron-speci c enol
se is
n enzyme th
t is used
s
tumor m
rker prim
rily for n
euro l
stom
.
6. A PSA is
lycoprotein with prote
se
ctivity th
t is speci c for the prost
te
l
nd. Hih
levels m
y e c
used y prost
te m
lin
ncy, enin prost
tic hypertrophy, or pr
ost
titis, ut
PSA is not incre
sed y physic
l ex
min
tion of the prost
te. PSA h
s
sensitiv
ity of 80%
nd

speci city of
out 75% for prost
te c
ncer. The sensitivity is su ciently hih to w

rr
nt its
use
s
screenin test, ut sensitivity for st
e A c
ncer is elow 60%. Most o
f the serum PSA
is ound to prote
se inhi itors such
s 1 -
ntitrypsin
nd 1 -
ntichymotrypsin.
P
tients with
orderline PSA levels (410 n/mL)
nd
low percent
e of free PSA
re more likel
y to h
ve
c
ncer of the prost
te th
n p
tients with
norm
l percent
e of free PSA. 7. C
AFP is

lycoprotein th
t is produced in
out 80% 90% of p
tients with hep
tom

nd in

lower
percent
e of p
tients with other tumors, includin retino l
stom
, re
st, uter
ine,
nd
p
ncre
tic c
ncer. The upper reference limit for serum is only 10 n/mL, which r
equires

sensitive method of
ss
y such
s EIA. The hih
n
lytic
l sensitivity of immuno

ss
ys permits
detection of reduced AFP levels in m
tern
l serum
ssoci
ted with Down syndrome,


s well
s
elev
ted levels
ssoci
ted with spin
i d
. 2828_Ch03_075-120 06/08/12 11:10 AM
P
e 110 8.
How is HLA typin used in the investi
tion of enetic dise
ses? A. For predicti
on of the
severity of the dise
se B. For enetic link
e studies C. For direct di
nosis o
f dise
se D. Is
not useful in this situ
tion Immunoloy/Correl
te clinic
l
nd l
or
tory d
t
/H
LA typin/1 9.
Select the est donor for
m
n, lood type AB, in need of
kidney tr
nspl
nt.
A. His rother,
type AB, HLA m
tched for cl
ss II
ntiens B. His mother, type B, HLA m
tched fo
r cl
ss I

ntiens C. His cousin, type O, HLA m
tched for m
jor cl
ss II
ntiens D. C
d
v
er donor, type O,
HLA m
tched for some cl
ss I
nd II
ntiens Immunoloy/Correl
te d
t
with othe
r l
or
tory d
t

to
ssess test results/Tr
nspl
nt
tion/Testin/3 10. Interpret the followin mic
rocytotoxicity
results: A9
nd B12 cells d
m
ed; A1
nd Aw19 cells int
ct. A. Positive for A1

nd Aw19;
ne
tive for A9
nd B12 B. Ne
tive for A1
nd Aw19; positive for A9
nd B12 C.
Error in test
system; retest D. Impossi le to determine Immunoloy/Ev
lu
te l
or
tory d
t
to
m
ke
identi c
tions/Tr
nspl
nt
tion/Testin/2 11. Which method, cl
ssic
lly used for HL
A-D typin, is
often used to determine the comp
ti ility etween
livin or
n donor
nd recip
ient? A. Flow
cytometry B. Mixed lymphocyte culture (MLC) C. Primed lymphocyte test (PLT) D. R
estriction
fr
ment lenth polymorphism (RFLP) Immunoloy/Apply principles of speci
l proce
dures/
Tr
nspl
nt
tion/HLA typin/1 12. SITUATION: Cells type ne
tive for
ll HLA
nti
ens in

complement-dependent cytotoxicity
ss
y. Wh
t is the most likely c
use? A. Too m
uch supr
vit
l
dye w
s
dded B. R
it complement is in
ctiv
ted C. All leukocytes
re de
d D.
Antiser
is too
concentr
ted Immunoloy/Ev
lu
te l
or
tory d
t
to check for sources of error/H
LA typin/3 3.7 |
Tumor Testin
nd Tr
nspl
nt
tion 111 Answers to Questions 812 8. B HLA typin
is useful in
predictin some enetic dise
ses
nd for enetic counselin ec
use cert
in HLA
types show stron
link
e to some dise
ses. HLA typin is not speci c
lly used to di
nose
dise
se
or
ssess its
severity. In link
e studies,
dise
se ene c
n e predicted ec
use it is loc

ted next to the
locus of
norm
l ene with which it sere
tes. For ex
mple, the rel
tive risk
of developin

nkylosin spondylitis is 87% in persons who
re positive for HLA-B27. An
lysis
of f
mily
pedirees for the link
e m
rker
nd dise
se c
n e used to determine the pro

ility th
t

f
mily mem er will inherit the dise
se ene. 9. A A twin or si lin donor of the
s
me lood type

nd HLA m
tched for cl
ss II
ntiens is the est donor in this situ
tion. Cl
ss
II
ntiens
(HLA-D, HLA-DR, DQ,
nd DP) determine the
ility of the tr
nspl
nt recipient to

reconize the
r
ft. The HLA enes
re loc
ted close toether on chromosome 6,
nd crossover
etween HLA enes
is r
re. Si lins with closely m
tched cl
ss II
ntiens most likely inherited t
he s
me cl
ss I
enes. The pro
ility of si lins inheritin the s
me HLA h
plotypes from oth
p
rents is 1:4.
10. B The microcytotoxicity test is
sed upon the re
ction of speci c
ntiser

n
d HLA
ntiens
on test cells. Cells d
m
ed y the indin of
nti ody
nd complement
re detec
ted with

supr
vit
l dye such
s eosin. 11. B Flow cytometry c
n e used in tr
nspl
nt
tio
n to type
seroloic
lly de ned HLA
ntiens. The one-w
y mixed lymphocyte re
ction is used t
o identify
HLA-D
ntiens on the donors lymphocytes
nd is used for cross m
tchin livin do
nors with
tr
nspl
nt recipients. The
ss
y is time consumin
nd would not e used
s p
rt
of
workup for

c
d
ver donor tr
nspl
nt. HLA-D incomp
ti ility is
ssoci
ted with the reconi
tion ph
se of

llor
ft rejection. The primed lymphocyte test is used to identify HLA-DP
nti
ens. 12. B
In
ctive r
it complement m
y not ecome xed to
nti odies th
t h
ve ound test
leukocytes;
therefore, no lysis of cells will occur. When the supr
vit
l dye is
dded,
ll c
ells will
ppe
r
ne
tive (exclude the dye) for
ll HLAs. 2828_Ch03_075-120 06/08/12 11:11 AM
P
e 111 13. Wh
t
method m
y e used for tissue typin inste
d of seroloic
l HLA typin? A. PCR B
. Southern
lottin C. RFLP D. All of these options Immunoloy/Apply principles of speci
l
procedures/
Tr
nspl
nt
tion/HLA typin/1 112 Ch
pter 3 | Immunoloy Answer to Question 13 13
. D PCR, Southern
lottin,
nd testin for RFLPs m
y
ll e used to identify HLA enes. M
ny l
o
r
tories use PCR
technoloy for the routine determin
tion of HLA type. 2828_Ch03_075-120 06/08/1
2 11:11 AM P
e
112 113 3.8 Immunoloy Pro lem Solvin 1. Which of the followin seri
l dilution
s cont
ins
n
incorrect f
ctor? A. 1:4, 1:8, 1:16 B. 1:1, 1:2, 1:4 C. 1:5, 1:15, 1:45 D. 1:2,
1:6, 1:12
Immunoloy/Apply knowlede to reconize sources of error/Seroloic
l dilutions/3
2. A p
tient w
s
tested for syphilis y the RPR method
nd w
s re
ctive. An FTA-ABS test w
s perf
ormed
nd the
result w
s ne
tive. Su sequent testin showed the p
tient to h
ve
hih titer
of

ntic
rdiolipin
nti odies (ACAs) y the ELISA method. Which routine l
or
tory
test is most
likely to e
norm
l for this p
tient? A. Activ
ted p
rti
l throm opl
stin time
(APTT) B.
Antismooth muscle
nti odies C. Asp
rt
te
minotr
nsfer
se (AST) D. C3
ss
y y
immunonephelometry Immunoloy/Apply knowlede to reconize sources of error/Anti
c
rdiolipin/3 3.
In
mm
tion involves
v
riety of iochemic
l
nd cellul
r medi
tors. Which of the
followin m
y
e incre
sed within 72 hours
fter
n initi
l infection? A. Neutrophils, m
croph

es,
nti ody,

complement, 1 -
ntitrypsin B. M
croph
es, T cells,
nti ody, h
ptolo in,

rino
en C.
Neutrophils, m
croph
es, complement, rinoen, C-re
ctive protein D. M
croph
es
, T cells, B
cells, cerulopl
smin, complement Immunoloy/Apply principles of
sic immunoloi
c
responses/In
mm
tion/2 Answers to Questions 13 1. D All the dilutions
re multipli
ed y the
s
me f
ctor in
proression except the l
st one: 1:2 to 1:6 is 3, where
s 1:6 t
o 1:12 is 2.
Threefold dilutions of
1:2 dilution would result in
1:6 followed y
1:18.
2. A
Approxim
tely 50%70% of p
tients with ACA
lso h
ve the lupus
ntico
ul
nt (LAC)
in their
serum. The LAC is
n immunolo ulin th
t interferes with in vitro co
ul
tion te
sts: prothrom in
time (PT), APTT,
nd dilute Russells viper venom (DRVV) time. These tests require
phospholipid
for the
ctiv
tion of f
ctor X. A out 30% of p
tients with
nti odies to c
rdiol
ipin or
phospholipids h
ve
ioloic
l f
lse- positive RPR result. Antismooth muscle is
most commonly

ssoci
ted with chronic
ctive hep
titis,
nd incre
sed AST with necrotic liver
dise
ses.
Althouh ACA
nd LAC m
y e
ssoci
ted with SLE, the m
jority of p
tients with t
hese
nti odies
do not h
ve lupus
nd would h
ve
norm
l C3 level. 3. C The correct list, in wh
ich
ll medi
tors

re involved in
n in
mm
tory response within 72 hours
fter initi
l infection, i
s neutrophils,
m
croph
es, complement,
rinoen,
nd C-re
ctive protein. Ph
ocytic cells,
cut
e ph
se
re
ct
nts,
nd rinolytic f
ctors enter the site of in
mm
tion. Anti ody
nd lymph
ocytes do not
enter until l
ter. 2828_Ch03_075-120 06/08/12 11:11 AM P
e 113 4. An 18-mont
h-old oy h
s
recurrent sinopulmon
ry infections
nd septicemi
. Brutons X-linked immunode ciency
syndrome is
suspected. Which test result would e m
rkedly decre
sed? A. Serum IG, IA,
nd
IM B. Tot
l
T-cell count C. Both B-
nd T-cell counts D. Lymphocyte prolifer
tion with phyto
hem
lutinin
stimul
tion Immunoloy/Correl
te l
or
tory d
t
with physioloic
l
processes/Immunode ciency/Testin/2 5. A p
tient received 5 units of fresh frozen
pl
sm
(FFP)

nd developed
severe
n
phyl
ctic re
ction. He h
s
history of respir
tory
n
d

strointestin
l infections. Post-tr
nsfusion studies showed
ll 5 units to e A
BO-comp
ti le.
Wh
t immunoloic test would help to determine the c
use of this tr
nsfusion re
c
tion? A.
Complement levels, p
rticul
rly C3
nd C4 B. Flow cytometry for T-cell counts C.
Me
surement of
immunolo ulins D. NBT test for ph
ocytic function Immunoloy/Determine l
or
t
ory tests/
Immunode ciency/Testin/3 6. An IFE reve
led excessive
mounts of polyclon
l IM

nd low
concentr
tions of IG
nd IA. Wh
t is the most likely expl
n
tion of these ndin
s
nd the est
course of
ction? A. Proper
mounts of
ntiser
were not
dded; repe
t oth test

s B. Test
specimen w
s not
dded properly; repe
t oth procedures C. P
tient h
s common v

ri
le
immunode ciency; perform B-cell count D. P
tient h
s immunode ciency with hyper-M; p
erform
immunolo ulin levels Immunoloy/Correl
te l
or
tory d
t
with physioloic
l
processes/Immunode ciency/Testin/3 7. SITUATION: A 54-ye
r-old m
n w
s
dmitted t
o the hospit
l

fter h
vin
seizure. M
ny l
or
tory tests were performed, includin
n RPR,
ut none of the
results were positive. Te physici
n suspects
c
se of l
te (terti
ry) syphilis.
Which test
should e performed next? A. Repe
t RPR, then perform VDRL B. Treponem
l test su
ch
s MHA-TP on
serum C. VDRL on CSF D. No l
or
tory test is positive for l
te (terti
ry) syphi
lis
Immunoloy/Correl
te l
or
tory d
t
with physioloic
l processes/Syphilis/Testi
n/3 114 Ch
pter
3 | Immunoloy Answers to Questions 47 4. A A p
tient with Brutons X-linked

mm

lo ulinemi

presents with clinic
l symptoms rel
ted to recurrent infections, demonstr
ted in
the l
or
tory
y decre
sed or
sent immunolo ulins. Peripher
l lood B cells
re
sent or m

rkedly reduced,
ut T cells
re norm
l in num er
nd function. Bec
use phytohem
lutinin is
T
-cell mitoen,
the lymphocyte prolifer
tion test usin PHA would e norm
l for this p
tient. 5.
C The p
tient
h
d
n
n
phyl
ctic re
ction to
pl
sm
product. This, com ined with the histor
y of respir
tory

nd 
strointestin
l infections, suests
selective IA de ciency. Me
surement o
f
immunolo ulins would e helpful in this c
se. A low serum IA
nd norm
l IG su
st
nti
te the
di
nosis of selective IA de ciency. Such p
tients frequently produce
nti-IA, w
hich is often
responsi le for
severe tr
nsfusion re
ction when ABO-comp
ti le pl
sm
is
dmi
nistered. 6. D
Low pl
sm
concentr
tions of IG
nd IA
nd
n
und
nce of IM is consistent w
ith hyper-IM
syndrome. Most c
ses
re X-linked
nd result from
mut
tion of the ene TNFSF5
th
t encodes

receptor needed for switchin immunolo ulin production. P
tients with common v

ri
le
immunode ciency h
ve low serum IG, IA,
nd IM. 7. B Serum
nti ody tests such

s RPR
nd VDRL

re often ne
tive in c
ses of l
te syphilis. However, treponem
l tests rem
in p
ositive in over
95% of c
ses. The VDRL test on CSF is the most speci c test for di
nosis of neuro
syphilis
ec
use treponem
l tests rem
in positive
fter tre
tment. It should e used
s t
he con rm
tory
test when the serum treponem
l test is positive. However, the CSF VDRL is limite
d in sensitivity

nd would not e positive if the serum MHA-TP or FTA-ABS w
s ne
tive. 2828_Ch03
_075-120
06/08/12 11:11 AM P
e 114 8. A p
tient c
me to his physici
n compl
inin of

r
sh, severe
he
d
ches, sti neck,
nd sleep pro lems. L
or
tory tests of sini c
nce were
n el
ev
ted

sediment
tion r
te (ESR)
nd slihtly incre
sed liver enzymes. Further questioni
n of the p
tient
reve
led th
t he h
d returned from
huntin trip in upst
te New York 4 weeks

o. His physici
n
ordered
seroloic
l test for Lyme dise
se,
nd the
ss
y w
s ne
tive. Wh
t is
the most likely
expl
n
tion of these results? A. Te
nti ody response is not su cient to e detect
ed
t this
st
e B. Te clinic
l symptoms
nd l
or
tory results
re not ch
r
cteristic of L
yme dise
se C. Te
p
tient likely h
s
n e
rly infection with hep
titis B virus D. L
or
tory error
h
s c
used

f
lse-ne
tive result Immunoloy/Correl
te l
or
tory d
t
with physioloic
l pr
ocesses/Lyme
testin/Testin/3 9. A 19-ye
r-old irl c
me to her physici
n compl
inin of
s
ore thro
t
nd
f
tiue. Upon physic
l ex
min
tion, lymph
denop
thy w
s noted. Re
ctive lymphocy
tes were noted on
the differenti
l, ut
r
pid test for IM
nti odies w
s ne
tive. Liver enzymes
were only
slihtly elev
ted. Wh
t test(s) should e ordered next? A. Hep
titis testin B.
EBV seroloic
l
p
nel C. HIV con rm
tory testin D. Bone m
rrow iopsy Immunoloy/Correl
te l
or

tory d
t
with
physioloic
l processes/Testin/3 10. A p
tient received 2 units of RBCs followi
n surery. Two
weeks
fter the surery, the p
tient w
s seen y his physici
n
nd exhi ited mil
d j
undice
nd
slihtly elev
ted liver enzymes. Hep
titis testin, however, w
s ne
tive. Wh
t
should e done
next? A. Nothin until more severe or de nitive clinic
l sins develop B. Repe
t h
ep
titis
testin immedi
tely C. Repe
t hep
titis testin in
few weeks D. Check lood

nk donor records

nd cont
ct donor(s) of tr
nsfused units Immunoloy/Correl
te l
or
tory d
t
wi
th physioloic
l
processes/Hep
titis/Testin/3 3.8 | Immunoloy Pro lem Solvin
115 Answers to
Questions 811 8.
A The
nti ody response to B. urdorferi m
y not develop until sever
l weeks
f
ter initi
l
infection. The
nti ody test should e followed y
test such
s PCR to detect
the DNA of the
or
nism. Re
rdless of the test outcome, if the physici
n suspects Lyme dise
se
, tre
tment
should ein immedi
tely. 9. B An EBV seroloic
l p
nel would ive
more
ccur

te
ssessment
th
n
r
pid slide IM test. The time of
ppe
r
nce of the v
rious
nti odies to
the vir
l

ntiens di ers
ccordin to the clinic
l course of the infection. 10. C The level
of HBsA m
y
not h
ve re
ched detect
le levels,
nd
nti odies to HBc
nd HCV would not h
ve
yet developed.
W
itin 1 or 2 weeks
nd repe
tin the tests m
y reve
l evidence of hep
titis vi
rus infection.
11. D She m
y don
te if she is symptom free. The response to hep
titis B v
ccine
would include

positive result for
nti-HBs,
test not norm
lly
p
rt of routine donor testin
. She will e
ne
tive for HBsA
nd
nti-HBc. 11. A hospit
l employee received the n
l dose of
the hep
titis

B v
ccine 3 weeks
o. She w
nts to don
te lood. Which of the followin results

re expected
from the hep
titis screen,
nd will she e
llowed to don
te lood? A. HBsA, po
sitive;
nti-HBc,
ne
tiveshe m
y don
te B. HBsA, ne
tive;
nti-HBc, positiveshe m
y not don
te C.
HBsA,
positive;
nti-HBc, positiveshe m
y not don
te D. HBsA, ne
tive;
nti-HBc, ne

tiveshe m
y
don
te Immunoloy/Correl
te l
or
tory d
t
with physioloic
l processes/Hep
tit
is/Testin/3
2828_Ch03_075-120 06/08/12 11:11 AM P
e 115 12. A pren
nt wom
n c
me to her
physici
n with

m
culop
pul
r r
sh on her f
ce
nd neck. Her temper
ture w
s 37.7C (100F). Ru ell

tests for
oth IG
nd IM
nti ody were positive. Wh
t positive test(s) would reve
l
di

nosis of
conenit
l ru ell
syndrome in her
y
fter irth? A. Positive ru ell
tests f
or oth IG
nd
IM
nti ody B. Positive ru ell
test for IM C. Positive ru ell
test for IG D
. No positive
test is reve
led in conenit
l ru ell
syndrome Immunoloy/Correl
te l
or
tory
d
t
with
physioloic
l processes/Ru ell
/Testin/3 13. SITUATION: A p
tient with RA h
s

cute pneumoni

ut
ne
tive thro
t culture. Te physici
n suspects
n infection with Mycopl
sm

pneumoni
e
nd
requests
n IM-speci c
nti ody test. Te test is performed directly on seri
l dil
utions of serum
less th
n 4 hours old. Te result is positive, ivin
titer of 1:32. However, t
he test is
repe
ted 3 weeks l
ter,
nd the titer rem
ins
t 1:32. Wh
t est expl
ins these
results? A.
IM-speci c
nti odies do not incre
se fourfold etween
cute
nd conv
lescent ser
um B. Te
results
re not sini c
nt ec
use the initi
l titer w
s not
ccomp
nied y
posi
tive test for
cold
lutinins C. Rheum
toid f
ctor c
used
f
lse-positive test result D. Ins
u cient time h
d
el
psed etween me
surement of
cute
nd conv
lescent s
mples Immunoloy/Apply k
nowlede to
reconize sources of error/IM testin/3 14. A p
tient h
s
prost
te-speci c
nti
en level of 60
n/mL the d
y efore surery to remove
loc
lized prost
te tumor. One week foll
owin surery,
the serum PSA w
s determined to e 8 n/mL y the s
me method. Wh
t is the most
likely c
use of
these results? A. Incomplete remov
l of the m
lin
ncy B. Cross re
ctivity of th
e
nti ody with

nother tumor
ntien C. Testin too soon
fter surery D. Hook e ect with the PSA

ss
y
Immunoloy/Apply knowlede to reconize inconsistent results/Tumor m
rkers/3 116
Ch
pter 3 |
Immunoloy Answers to Questions 1214 12. B A ndin of IG is not de nitive for cone
nit
l
ru ell
syndrome ec
use IG crosses the pl
cent
from the mother; however, demo
nstr
tion of IM,
even in
sinle neon
t
l s
mple, is di
nostic. 13. C The IM-speci c
nti ody te
st for M.
pneumoni
e detects
nti odies to mycopl
sm
l mem r
ne
ntiens
nd, unlike cold

lutinins, is

speci c for M. pneumoni
e. A positive result (titer of 1:32 or hiher) occurs duri
n the
cute
ph
se in
out 87% of M. pneumoni
e infections
nd does not need to e con rmed y

ss
y of
conv
lescent serum. However, p
tients with RA m
y show
f
lse-positive re
ction
ec
use
rheum
toid f
ctor in their serum c
n re
ct with the conju
ted
nti-IM used in
the test. For
this re
son, serum from p
tients known or suspected to h
ve rheum
toid f
ctor (R
F) must e
pretre
ted. The serum is he
ted to 56C to
re
te the RF,
nd the
re
ted im
munolo ulin is
removed y
chrom
tor
phy minicolumn. 14. C When monitorin the level of
tum
or m
rker for
tre
tment e c
cy or recurrence, the h
lf-life of the protein must e considered wh
en determinin
the testin interv
l. PSA h
s
h
lf-life of
lmost 4 d
ys
nd would not re
ch n
orm
l levels

fter surery for
pproxim
tely 34 weeks. The hook e ect is the result of very hih

ntien
levels ivin
lower th
n expected result in
dou le
nti ody s
ndwich
ss
y w
hen oth

nti odies
nd s
mple
re
dded
t the s
me time. 2828_Ch03_075-120 06/08/12 1
1:11 AM P
e 116
15. A p
tient with symptoms
ssoci
ted with SLE
nd scleroderm
w
s ev
lu
ted y
immuno uorescence microscopy for ANAs usin the HEp-2 cell line
s su str
te. Te c
ell line
displ
yed
mixed p
ttern of uorescence th
t could not e sep
r
ted y seri
l dil
utions of the
serum. Which procedure would e most helpful in determinin the
nti ody pro le of
this p
tient?
A. Use of
di erent tissue su str
te B. A sorption of the serum usin the
ppropr
i
te tissue
extr
ct C. Ouchterlony technique D. ELISA tests for speci c
nti odies Immunoloy/
Apply knowlede
to identify l
or
tory tests/ANA/Testin/3 16. A p
tient with joint swellin
nd
p
in tested
ne
tive for serum RF y oth l
tex
lutin
tion
nd ELISA methods. Wh
t other
test would help
est
lish
di
nosis of RA in this p
tient? A. Anti CCP B. ANA testin C. Flow
cytometry D.
Complement levels Immunoloy/Correl
te l
or
tory d
t
with physioloic
l proces
ses/RA/Testin/3
17. Wh
t is the m
in
dv
nt
e of the recovery
nd reinfusion of
utoloous stem
cells? A. It
slows the r
te of rejection of tr
nspl
nted cells B. It prevents r
ft-versus-ho
st dise
se C. No
HLA testin is required D. Enr
ftment occurs in
more e cient sequence Immunolo
y/Apply
knowlede of fund
ment
l ioloic
l ch
r
cteristics/Tr
nspl
nt
tion/2 18. A tr
n
spl
nt p
tient
e
n to show sins of rejection 8 d
ys
fter receipt of the tr
nspl
nted or
n,

nd the or
n
w
s removed. Wh
t immune elements miht e found in the rejected or
n? A. Anti
ody
nd
complement B. Prim
rily
nti ody C. M
croph
es D. T cells Immunoloy/Correl
te
l
or
tory d
t


nd
sic immune response/Tr
nspl
nt
tion/Rejection/3 3.8 | Immunoloy Pro lem S
olvin
117
Answers to Questions 1518 15. D M
ny p
tients with multior
n
utoimmune dise
se

displ
y
symptoms th
t overl
p two or more dise
ses
nd h
ve complex mixtures of serum
u
to
nti odies. The
HEp-2 su str
te is the most sensitive cell line for immuno uorescent microscopy e
c
use it
cont
ins cells in v
rious mitotic st
es, which exposes the serum to more
ntie
ns. Use of

nonhum
n su str
te such
s Crithidi
m
y help to identify dsDNA
nti odies ut w
ould not
id in
di erenti
tin
ll of the
nti odies in
complex mixture. Ouchterlony immunodi usio
n helps to
identify speci c ANAs ut h
s limited sensitivity. The est method is ELISA ec
us
e it is more
sensitive th
n immuno uorescence microscopy
nd c
n qu
ntit
te
nti odies to speci c

ntiens.
ELISA is often used to me
sure
nti odies to extr
ct
le nucle
r
ntiens, which
m
y e p
rti
lly
or completely lost durin x
tion of cells used for immuno uorescent microscopy. The
se
nti odies
c
use
speckled p
ttern
nd
re seen in
wide r
ne of
utoimmune dise
ses. Id
enti c
tion of
the
nti ENA speci cities is helpful in di erenti
tin these dise
ses. 16. A Anti od
ies to cyclic
citruillin
ted peptide
re often found in RF-ne
tive p
tients with rheum
toid

rthritis. The

sence of rheum
toid f
ctors from serum does not rule out
di
nosis of RA,
n
d more th
n h
lf
of p
tients who
re di
nosed with RA present initi
lly with
ne
tive serum re
sult. The serum
RF test will eventu
lly e positive in 80%90% of p
tients who meet the clinic
l c
riteri
for RA.
17. B The m
in
dv
nt
e to the p
tient from the reinfusion of
utoloous stem c
ells is th
t the
procedure prevents r
ft-versus-host dise
se, especi
lly in the immunocompromise
d p
tient.
Althouh HLA testin is not required, this is not the prim
ry
dv
nt
e for p
ti
ent c
re. 18. D
Acute rejection occurs within 3 weeks of tr
nspl
nt
tion. The immune element mos
t likely to e
involved in
n
cute rejection is the T cell in
type IV, del
yed hypersensitiv
ity
(cell-medi
ted) re
ction. Preformed
nti ody,
nd possi ly complement, is usu
ll
y involved in
hyper
cute (immedi
te) rejection
nd chronic rejection. 2828_Ch03_075-120 06/08
/12 11:11 AM
P
e 117 19. A p
tient with ov
ri
n c
ncer who h
s een tre
ted with chemother
p
y is ein
monitored for recurrence usin serum CA-125, CA-50,
nd CA 153. Six months
fter
tre
tment the
CA 153 is elev
ted, ut the CA-125
nd CA-50 rem
in low. Wh
t is the most likely
expl
n
tion of
these ndins? A. Ov
ri
n m
lin
ncy h
s recurred B. CA 153 is speci c for re
st c
n
cer
nd
indic
tes met
st
tic re
st c
ncer C. Testin error occurred in the me
surement
of CA 153 c
used
y poor
n
lytic
l speci city D. Te CA 153 elev
tion is spurious
nd pro
ly eni
n
Immunoloy/Correl
te l
or
tory d
t
with physioloic
l processes/Tumor m
rkers/
Testin/3 20. An
initi
l
nd repe
t ELISA test for
nti odies to HIV-1
re oth positive. A Weste

rn lot shows

sinle
nd
t p160. Te p
tient shows no clinic
l sins of HIV infection,
nd t
he p
tients CD4
T-cell count is norm
l. B
sed upon these results, which conclusion is correct? A
. P
tient is
di
nosed
s HIV-1-positive B. P
tient is di
nosed
s HIV-2-positive C. Results

re inconclusive
D. P
tient is di
nosed
s HIV-1-ne
tive Immunoloy/Apply knowlede to reconiz
e inconsistent
results/HIV/3 21. A wom
n who h
s een pren
nt for 12 weeks is tested for toxop
l
smosis. Her IM
ELISA titer is 2.6 (reference r
ne < 1.6),
nd her IG ELISA v
lue is 66 (refer
ence r
ne < 8).
Te physici
n
sks you if these results indic
ted
n infection durin the p
st 12
weeks. Which of
the followin tests would you recommend to determine if the wom
n w
s infected d
urin her
pren
ncy? A. Toxo PCR on
mniotic uid B. Toxo IM on
mniotic uid C. Toxo IG
vi
dity D.
Amniotic uid culture Immunoloy/Correl
te l
or
tory d
t
with physioloic
l proc
esses/Time
course of immune response/Toxopl
smosis/Testin/3 118 Ch
pter 3 | Immunoloy Ans
wers to Questions
1921 19. A Althouh CA-125 is the most commonly used tumor m
rker for ov
ri
n c
n
cer, not
ll
ov
ri
n tumors produce CA-125. Gre
test sensitivity in monitorin for recurrence
is
chieved when
sever
l m
rkers known to e incre
sed in the m
lin
nt tissue type
re me
sured
simult
neously

nd when the m
rkers
re elev
ted ( y m
lin
ncy) prior to tre
tment. In
dditio
n to limited
sensitivity, no sinle tumor m
rker is entirely speci c. C
r ohydr
te
nd other on
cofet
l

ntiens
re produced y sever
l m
lin
nt
nd enin conditions. Althouh testi
n errors m
y
occur in
ny situ
tion, me
surements of c
r ohydr
te
ntiens use puri ed monoclon

l
nti odies
with very low cross re
ctivities. 20. C The Western lot test is used
s
con rm

tory test for
HIV, ut it is not
s sensitive
s enzyme immuno
ss
y tests usin polyv
lent HIV

ntiens derived
from cloned HIV enes. The Western lot test is considered positive only if
nti
odies to
t
le
st two of three vir
l
ntiensp24, p41,
nd p160/120
re detected. The presenc
e of
sinle

nd is indetermin
te. Over the course of the next 3 months, two or more
nti od
ies will e
detected if the p
tient is HIV positive; however,
nti odies to
sinle vir
l p
rotein m
y e
c
used y
cross re
ction,
nd this p
tient m
y f
il to seroconvert. This resul
t should e
reported
s indetermin
te,
nd the p
tient should e retested in 3 months. Alter
n
tively,
more
sensitive con rm
tory test such
s PCR or immuno uorescence m
y e performed. 21. C
Althouh IM
is positive, in toxopl
smosis, speci c IM m
y rem
in detect
le for
ye
r or mor
e followin
infection. IG
vidity, or the strenth of indin of
serum to the
ntien of
interest, is

useful method to determine if
n infection is recent or in the dist
nt p
st. IG


vidity will
incre
se with time followin
n infection. Amniotic uid testin is not useful for
determinin
when the mother miht h
ve een infected. 2828_Ch03_075-120 06/08/12 11:11 AM
P
e 118 22. On
J
nu
ry 4,
serum protein electrophoresis on
specimen o t
ined
t your hospit

l in North
D
kot
from
58-ye
r-old p
tient shows

nd
t the - junction. The specimen w
s

lso
positive for rheum
toid f
ctor. You recommend th
t
n immunofix
tion test e per
formed to
determine if the
nd represents
monoclon
l immunolo ulin. Another specimen i
s o t
ined 2
weeks l
ter y the physici
n in his office 30 miles
w
y,
nd the whole lood is
su mitted to you
for the IFE. The courier pl
ced the whole lood specimen in
n ice chest for tr

nsport. In this
specimen, no -
nd is seen in the serum protein l
ne,
nd the IM l
ne is very f

int. The
rheum
toid f
ctor on this specimen w
s ne
tive. The physici
n w
nts to know wh

ts wron with
your l
or
tory. Your response is: A. Nothins wron with our l
or
tory; the p
t
ient h
d
n
infection 2 weeks
o th
t h
s cle
red up B. Somethins wron with our l
or
toryw
e likely
misl
eled one of the specimens; ple
se resu mit
new specimen
nd we will test
it
t no ch
re
C. You will run
second specimen usin
2-merc
ptoeth
nol tre
tment th
t will
elimin
te IM

re
tes
nd
llow for more sensitive monoclon
l IM detection D. Te physici
n
should redr
w

nother specimen from the p
tient
nd this time sep
r
te the serum from the clot
in his o ce
efore sendin the specimen in y courier Immunoloy/Correl
te l
or
tory d
t
w
ith physioloic
l
processes/Specimen interity/3 23. A di
lysis p
tient is positive for oth hep
t
itis B surf
ce

ntien
nd hep
titis B surf
ce
nti ody. Te physici
n suspects
l
or
tory err
or. Do you
ree?
A. Yes; the p
tient should not test positive for oth HBsA
nd HBsA B. No; inc
omplete di
lysis
of
p
tient in the core window ph
se of hep
titis B infection will yield this r
esult C. No; it
is likely the p
tient h
s recently received
hep
titis B ooster v
ccin
tion
n
d could h
ve
these results D. Perh
ps;
new specimen should e su mitted to cle
r up the con
fusion
Immunoloy/Correl
te l
or
tory d
t
with physioloic
l processes/Hep
titis/Test
in/3 3.8 |
Immunoloy Pro lem Solvin
119 Answers to Questions 2224 22. D The most likely
c
use of the
discrep
nt results is the presence of
type II cryolo ulin. This is
monoclon

l rheum
toid
f
ctor. The protein likely precipit
ted durin the courier ride
nd w
s thus in
the clot when the
l
or
tory sep
r
ted the serum. 23. C Hep
titis B surf
ce
ntien will rem
in de
tect
le
t low
levels followin
v
ccin
tion for up to 12 weeks. Thus, p
tients who h
ve receiv
ed
second
injection of hep
titis B v
ccine m
y h
ve
nti-hep
titis B surf
ce
ntien
nd d

etect
le
ntien
for
rief period of time. This h
s een reported more frequently in di
lysis

nd pedi
tric
popul
tions. 24. D In this situ
tion, you h
ve
lre
dy tested the specimens in d
uplic
te. Testin

n
ddition
l 50 specimens will not ch
ne the f
ct th
t you h
ve 20 discrep
nt
specimens. The
est course of
ction is to determine wh
t
nti odies
re
ctu
lly present in th
ese specimens.
Then, you c
n determine whether the ELISA or IFA is
etter procedure for detec
tin the most
clinic
lly relev
nt
nti odies. You could perform clinic
l ch
rt reviews
s
n

ltern
tive, ut
o t
inin th
t d
t
would e difficult
nd much of it m
y e su jective. 24. You

re ev
lu
tin

n ELISA
ss
y
s
repl
cement for your immuno uorescent
ntinucle
r
nti ody tes
t. You test 50
specimens in duplic
te on e
ch
ss
y. Te ELISA
ss
y uses
HEp-2 extr
ct
s its

ntien source.
Te correl
tion etween the ELISA
nd the IFA tests is only 60% (30 of 50 specime
ns
ree). Which
of the followin is the next est course of
ction? A. Test
nother 50 specimens
B. Perform

competency check on the technoloists who performed the tests C. Order
new lot
of oth kits
nd
then retest on the new lots D. Refer the discrep
nt specimens for testin y
no
ther method
Immunoloy/M
n
ement principles/Method comp
rison/3 2828_Ch03_075-120 06/08/12
11:11 AM P
e
119 BI BL I OGRAPHY 1. Detrick B, H
milton RG,
nd Folds J. M
nu
l of Molecul
r

nd Clinic
l
L
or
tory Immunoloy. 7th edition, 2006. ASM Press, W
shinton, DC. 2. Folds J,

nd Norm
nsell
D. Pocket Guide to Clinic
l Immunoloy. 1999. ASM Press, W
shinton, DC. 3. Kind
t TJ, Os orne BA,

nd Golds y RA. Ku y Immunoloy. 6th edition, 2006. WH Freem
n, New York. 4. M
h
on C
nd Tice D.
Clinic
l L
or
tory Immunoloy. 2006. Prentice-H
ll, Upper S
ddle River, NJ. 120
Ch
pter 3 |
Immunoloy 5. N
k
mur
R, Burek L, Cook L, et
l. Clinic
l Di
nostic Immunoloy
: Protocols in
Qu
lity Assur
nce
nd St
nd
rdiz
tion. 1998. Bl
ckwell Pu lishin, M
lden, MA. 6
. Pl
yf
ir H.
Immunoloy
t
Gl
nce. 2005. Bl
ckwell Pu lishin, M
lden, MA. 7. Rosen F
nd G
eh
R. C
se
Studies in Immunoloy. A Clinic
l Comp
nion. 4th edition, 2004. G
rl
nd Science,
New York. 8.
Stevens CD. Clinic
l Immunoloy
nd Seroloy,
L
or
tory Perspective. 2010. F.
A. D
vis,
Phil
delphi
. 2828_Ch03_075-120 06/08/12 11:11 AM P
e 120 121 Immunohem
tolo
y CHAPTER 4 4.1
Genetics
nd Immunoloy of Blood Groups 4.2 ABO Blood Group System 4.3 Rh Blood
Group System 4.4
Testin for Anti odies 4.5 Comp
ti ility Testin 4.6 Tr
nsfusion Re
ctions 4.7 C
omponents 4.8
Donors 4.9 Hemolytic Dise
se of the New orn (HDN) 4.10 Seroloic
l Testin of Bl
ood Products 4.11
Immunohem
toloy Pro lem Solvin 2828_Ch04_121-170 06/08/12 11:16 AM P
e 121
2828_Ch04_121-170 06/08/12 11:16 AM P
e 122 Answers to Questions 15 1. B Ph
enotypin, or

the physic
l expression of
enotype, is the type of testin routinely performe

d in the lood

nk. An individu
l, for ex
mple, m
y h
ve the AO enotype ut phenotypes
s ro
up A. 2. A
Dos
e is de ned
s
n
nti ody re
ctin stroner with homozyous cells (such
s K
K) th
n with
heterozyous cells (such
s Kk). In
ddition to Kell, dos
e e ect is seen commonl
y with
ntiens
M, N, S, s, Fy
, Fy , Jk
, Jk ,
nd the
ntiens of the Rh system. 3.
C The frequency
of Du y
ntiens Fy

nd Fy v
ries with r
ce. The Fy(
b) phenotype occurs in almo
st 70% of
African Americans and is very rare in whites. The Xg a antigen is Xlinked and,
therefore,
expressed more frequently in women (who may inherit the antigen from either pare
nt) than in men.
4. B An individual having the BB genotype has inherited the B gene from both p
arents and,
therefore, is homozygous for B antigen. 5. A The genotype DCe/dce contains one
C and one c gene
and is heterozygous for C and c antigens. 5. Which genotype is heterozygous for
C? A. DCe/dce B.
DCE/DCE C. Dce/dce D. DCE/dCe Blood bank/Apply knowledge of fundamental biologic
al
characteristics/Genetics/Rh/2 1. What type of serological testing does the blood
bank
technologist perform when determining the blood group of a patient? A. Genotypin
g B. Phenotyping
C. Both genotyping and phenotyping D. Polymerase chain reaction Blood bank/Apply
knowledge of
laboratory operations/Genetics/1 2. If antiK reacts 3+ with a donor cell with a
genotype KK and
2+ with a Kk cell, the antibody is demonstrating: A. Dosage B. Linkage disequili
brium C.
Homozygosity D. Heterozygosity Blood bank/Apply knowledge of fundamental biologi
cal
characteristics/Genetics/Kell/3 3. Carla expresses the blood group antigens Fy a
, Fy b , and Xg
a . James shows expressions of none of these antigens. What factor(s) may accoun
t for the absence
of these antigens in James? A. Gender B. Race C. Gender and race D. Medication B
lood bank/Apply
knowledge of fundamental biological characteristics/Genetics/2 4. Which of the f
ollowing
statements is true? A. An individual with the BO genotype is homozygous for B an
tigen B. An
individual with the BB genotype is homozygous for B antigen C. An individual wit
h the OO genotype
is heterozygous for O antigen D. An individual with the AB phenotype is homozygo
us for A and B
antigens Blood bank/Apply knowledge of fundamental biological characteristics/Ge
netics/ABO/1 4.1
Genetics and Immunology of Blood Groups 123 2828_Ch04_121170 06/08/12 11:16 A
M Page 123 6.
Which genotype(s) will give rise to the Bombay phenotype? A. HH only B. HH and H
h C. Hh and hh D.
hh only Blood bank/Apply knowledge of fundamental biological characteristics/ABO
/Bombay/1 7.
Meiosis in cell division is limited to the ova and sperm producing four gametes
containing what

complement of DNA? A. 1N B. 2N C. 3N D. 4N Blood bank/Apply knowledge of fundame

ntal biological
characteristics/Genetics/1 8. A cell that is not actively dividing is said to be
in: A.
Interphase B. Prophase C. Anaphase D. Telophase Blood bank/Apply knowledge of fu
ndamental
biological characteristics/Genetics/1 9. Which of the following describes the ex
pression of most
blood group antigens? A. Dominant B. Recessive C. Codominant D. Corecessive Bloo
d bank/Apply
knowledge of fundamental biological characteristics/Genetics/1 10. What blood ty
pe is not
possible for an o spring of an AO and BO mating? A. AB B. A or B C. O D. All are p
ossible Blood
bank/Apply knowledge of fundamental biological characteristics/Genetics/ABO/2 11
. Te alleged
father of a child in a disputed case of paternity is blood group AB. Te mother i
s group O and the
child is group O. What type of exclusion is this? A. Direct/primary/ rst order B.
Probability C.
Random D. Indirect/secondary/second order Blood bank/Evaluate laboratory data to
verify test
results/Genotype/Paternity testing/2 124 Chapter 4 | Immunohematology Answers to
Questions 612
6. D The Bombay phenotype will be expressed only when no H substance is presen
t. The O h type
is expressed by the genotype hh. Bombays produce naturally occurring antiH, and
their serum
agglutinates group O red cells in addition to red cells from groups A, B, and AB
persons. 7. A
Meiosis involves two nuclear divisions in succession resulting in four gametocyt
es each
containing half the number of chromosomes found in somatic cells or 1N. 8. A I
nterphase is the
stage in between cell divisions. The cell is engaged in metabolic activity. Chro
mosomes are not
clearly discerned; however, nucleoli may be visible. 9. C The inheritance of m
ost blood group
genes is codominant, meaning that no gene or allele is dominant over another. Fo
r example, a
person who is group AB expresses both the A and B antigen on his or her red cell
s. 10. D A
mating between AO and BO persons can result in an o spring with a blood type of A,
B, AB, or O.
11. D An indirect/secondary/second order exclusion occurs when a genetic marke
r is absent in
the child but should have been transmitted by the alleged father. In this case,
either A or B
should be present in the child. 12. B Linkage disequilibrium is a phenomenon i
n which alleles
situated in close proximity on a chromosome associate with one another more than
would be
expected from individual allelic frequencies. 12. If the frequency of gene Y is
0.4 and the
frequency of gene Z is 0.5, one would expect that they should occur together 0.2
(20%) of the
time. In actuality, they are found together 32% of the time. Tis is an example o
f: A. Crossing
over B. Linkage disequilibrium C. Polymorphism D. Chimerism Blood bank/Apply pri
nciples of

genetics/3 2828_Ch04_121170 06/08/12 11:16 AM Page 124 13. In the HardyWeinbe

rg formula, p 2
represents: A. Te heterozygous population of one allele B. Te homozygous populat
ion of one allele
C. Te recessive allele D. Te dominant allele Blood bank/Apply knowledge of funda
mental biological
characteristics/Genetics/1 14. In this type of inheritance, the father carries t
he trait on his X
chromosome. He has no sons with the trait because he passed his Y chromosome to
his sons;
however, all his daughters will express the trait. A. Autosomal dominant B. Auto
somal recessive
C. Xlinked dominant D. Xlinked recessive Blood bank/Apply knowledge of fundame
ntal biological
characteristics/Genetics/1 15. Why do IgM antibodies, such as those formed again
st the ABO
antigens, have the ability to directly agglutinate red blood cells (RBCs) and ca
use visible
agglutination? A. IgM antibodies are larger molecules and have the ability to bi
nd more antigen
B. IgM antibodies tend to clump together more readily to bind more antigen C. Ig
M antibodies are
found in greater concentrations than IgG antibodies D. IgM antibodies are not li
mited by subclass
speci city Blood bank/Apply knowledge of fundamental biological characteristics/An
tibodies/1 16.
Which of the following enhancement mediums decreases the zeta potential, allowin
g antibody and
antigen to come closer together? A. LISS B. Polyethylene glycol C. Polybrene D.
ZZAP Blood
bank/Apply knowledge of fundamental biological characteristics/Antigens/1 17. Ti
s type of
antibody response is analogous to an anamnestic antibody reaction. A. Primary B.
Secondary C.
Tertiary D. Anaphylactic Blood bank/Apply knowledge of fundamental biological
characteristics/Antibodies/1 4.1 | Genetics and Immunology of Blood Groups 125
Answers to
Questions 1318 13. B In the HardyWeinberg formula p 2 + 2pq + q 2 , p 2 and q 2
represent
homozygous expressions and 2pq represents heterozygous expression. This formula
is used in
population genetics to determine the frequency of di erent alleles. 14. C In Xl
inked dominant
inheritance, there is absence of maletomale transmission because a male passes
his Y chromosome
to all of his sons and his single X chromosome to all his daughters. All daughte
rs who inherit
the a ected gene will express the trait. An example of this type of inheritance is
the Xg a blood
group. 15. A An IgM molecule has the potential to bind up to 10 antigens, as c
ompared to a
molecule of IgG, which can bind only two. 16. A LISS contains a reduced concen
tration of NaCl
(0.2%) and results in a reduction in charged ions within the ionic cloud, decrea
sing the zeta
potential and facilitating antigen and antibody interaction. 17. B An anamnest
ic response is a
secondary immune response in which memory lymphocytes respond rapidly to foreign
antigen in
producing speci c antibody. The antibodies are IgG and are produced at lower doses

of antigen
than in the primary response. 18. B In the DAT (direct antiglobulin test), rab
bit polyspeci c
antisera contains both an antihuman IgG component and an antibody against the C
3d component of
complement. 18. Which antibodies to a component of complement are contained in t
he rabbit
polyspeci c antihuman globulin reagent for detection of in vivo sensitization? A.
AntiIgG and
antiC3a B. AntiIgG and antiC3d C. AntiIgG and antiIgM D. All of these optio
ns Blood
bank/Apply knowledge of fundamental biological characteristics/AHG/2 2828_Ch04_1
21170 06/08/12
11:16 AM Page 125 Answers to Questions 15 1. B The group A 1 comprises both A
1 and A
antigens. AntiA will react with both A 1  and A 2 positive RBCs. A person who
is group A 2 may
form antiA 1 , but an A 1 person will not form antiA 1 (which would cause auto
agglutination).
2. C Bombay is the only ABO phenotype incompatible with O cells. The red cells
of a Bombay show
a negative reaction to antiH because the cells contain no H substance. 3. D A
Bombay
individual does not express A, B, or H antigens; therefore antiA, B, and H are
formed. Because a
Bombay individual has three antibodies, the only compatible blood must be from a
nother Bombay
donor. 4. D The acquired B phenomenon is only seen in group A persons. 5. C
The patient is
likely an A 2 with antiA 1 which is causing reactivity in the crossmatch. A neg
ative antibody
screen rules out the possibility of an antibody to a highfrequency antigen, and
two donor units
incompatible rules out an antibody to a lowfrequency antigen. 5. Blood is cross
matched on an A
positive person with a negative antibody screen. Te patient received a transfusi
on of A positive
RBCs 3 years ago. Te donors chosen for crossmatch were A positive. Te crossmatch
was run on the
Ortho Provue and yielded 3+ incompatibility. How can these results be explained?
A. Te patient
has an antibody to a lowfrequency antigen B. Te patient has an antibody to a hi
ghfrequency
antigen C. Te patient is an A 2 with antiA 1 D. Te patient is an A 1 with anti
A 2 Blood
bank/Apply principles of special procedures/ ABO/3 1. Which of the following dis
tinguishes A 1
from A 2 blood groups? A. A 2 antigen will not react with antiA, A 1 will react
strongly (4+) B.
An A 2 person may form antiA 1 ; an A 1 person will not form antiA 1 C. An A 1
person may form
antiA 2 , an A 2 person will not form antiA 1 D. A 2 antigen will not react wi
th antiA from a
nonimmunized donor; A 1 will react with any antiA Blood bank/Apply knowledge of
fundamental
biological characteristics/ABO blood group/2 2. A patients serum is incompatible
with O cells.
Te patient RBCs give a negative reaction to antiH lectin. What is the most like
ly cause of these
results? A. Te patient may be a subgroup of A B. Te patient may have an immunode c

iency C. Te
patient may be a Bombay D. Te patient may have developed alloantibodies Blood ba
nk/Apply
principles of special procedures/ABO blood group/3 3. What antibodies are formed
by a Bombay
individual? A. AntiA and antiB B. AntiH C. AntiA,B D. AntiA, B, and H Blood
bank/Apply
knowledge of fundamental biological characteristics/ABO blood group/Bombay/1 4.
Acquired B
antigens have been found in: A. Bombay individuals B. Group O persons C. All blo
od groups D.
Group A persons Blood bank/Apply knowledge of fundamental characteristics/ABO/1
4.2 ABO Blood
Group System 126 2828_Ch04_121170 06/08/12 11:16 AM Page 126 Answers to Ques
tions 611 6. C
The strong 4+ reaction in reverse grouping suggests the discrepancy is in forwar
d grouping.
Incubating washed red cells at room temperature with antiA and antiA,B will en
hance reactions.
7. C In forward typing, a 1+ reaction with antiB is suspicious because of the
weak reaction
and the normal reverse grouping that appears to be group A. This may be indicati
ve of an acquired
antigen. In the case of an acquired B, the reverse grouping is the same for a gr
oup A person.
Choice A is indicative of group AB; choice B is indicative of a group A who may
be
immunocompromised. Choice D may be caused by a mistyping or an antibody against
antigens on
reverse cells. 8. A The A 1 B blood group has the least amount of H antigen. T
his is due to
both A and B epitopes present on red cells compromising the availability of H ep
itopes. A 1 B
cells will yield weak reactions with antiH lectin. 9. B A person in need of a
n RBC transfusion
who is an A 2 with antiA 1 can be transfused A or O cells because the antiA 1
is typically only
reactive at room temperature. 10. A These results point to a cold autoantibody
. Washing the
cells with warm saline may elute the autoantibody, allowing a valid forward type
to be performed.
The serum should be adsorbed using washed cells until the autocontrol is negativ
e. Then the
adsorbed serum should be used for reverse typing. 11. B All negative results m
ay be due to
weakened antigens or antibodies. Room temperature or lower incubation temperatur
e may enhance
expression of weakened antigens or antibodies. 11. What should be done if all fo
rward and reverse
ABO results are negative? A. Perform additional testing such as typing with anti
A 1 lectin and
antiA,B B. Incubate at 22C or 4C to enhance weak expression C. Repeat the test wi
th new
reagents D. Run an antibody identi cation panel Blood bank/Evaluate laboratory and
clinical data
to specify additional tests/RBCs/ABO discrepancy/3 4.2 | ABO Blood Group System
127 6. A
patients red cells forward as group O, serum agglutinates B cells (4+) only. Your
next step
would be: A. Extend reverse typing for 15 minutes B. Perform an antibody screen

including a room
temperature incubation C. Incubate washed red cells with antiA 1 and antiA,B f
or 30 minutes at
room temperature D. Test patients red cells with Dolichos bi orus Blood bank/Apply
principles of
special procedures/ RBCs/ABO discrepancy/3 7. Which typing results are most like
ly to occur when
a patient has an acquired B antigen? A. AntiA 4+, antiB3+, A 1 cells neg, B c
ells neg B.
AntiA 3+, antiB neg, A 1 cells neg, B cells neg C. AntiA 4+, antiB 1+, A 1 c
ells neg, B cells
4+ D. AntiA 4+, antiB 4+, A 1 cells 2+, B cells neg Blood bank/Evaluate labora
tory data to
recognize problems/ABO discrepancy/2 8. Which blood group has the least amount o
f H antigen? A. A
1 B B. A 2 C. B D. A 1 Blood bank/Apply knowledge of fundamental biological prin
ciples/ABO/1 9.
What type RBCs can be transfused to an A 2 person with antiA 1 ? A. A only B. A
or O C. B D. AB
Blood bank/Apply knowledge of fundamental biological principles/ABO/3 10. What s
hould be done if
all forward and reverse ABO results as well as the autocontrol are positive? A.
Wash the cells
with warm saline, autoadsorb the serum at 4C B. Retype the sample using a di erent
lot number of
reagents C. Use polyclonal typing reagents D. Report the sample as group AB Bloo
d bank/Evaluate
laboratory and clinical data to specify additional tests/RBCs/ABO discrepancy/3
2828_Ch04_121170
06/08/12 11:16 AM Page 127 Answers to Questions 1217 12. C The immunodominan
t sugar
Nacetylgalactosamine confers A antigen speci city when present at the terminus o
f the type 2
precursor chain on the RBC membrane. Therefore, its presence would cause RBCs to
react with
antiA 1 lectin, Dolichos bi orus. 13. C A transplant patient is probably taking
immunosuppressive medication to increase graft survival. This can contribute to
the loss of
normal blood group antibodies as well as other types of antibodies. 14. D Anti
A,B should react
positively with group A or B and any subgroup of A or B (with exception of A m )
. An A 1 (not A 2
) would react with antiA 1 lectin; only an A 2 person with antiA 1 would give
a positive
reaction with A 1 cells; an A 2 would react more strongly with antiH than A 1.
15. B The
patient is most likely an AB person who has formed a coldreacting alloantibody
reacting with B
cells and O cells. An identi cation panel should be performed. An acquired B perso
n or someone
with hypogammaglobulinemia should not make antibody that would agglutinate O cel
ls. 16. C
Excessive A substance, such as may be found in some types of tumors, may be neut
ralizing the
antiA. Weak A subgroups may fail to react with antiA and require additional te
sting techniques
(e.g., roomtemperature incubation) before their expression is apparent. 17. C
The reverse
typing should agree with the forward typing in this result. The 4+ reaction with
antiB indicates

group B. A positive reaction is expected with A 1 cells in the reverse group. 17

. Which of the
following results is most likely discrepant? AntiA, neg AntiB, 4+ A 1 cells,
neg B cells,
neg A. Negative B cells B. Positive reaction with antiB C. Negative A 1 cells D
. No problem with
this typing Blood bank/Evaluate laboratory data to make identi cations/ABO discrep
ancy/3 128
Chapter 4 | Immunohematology 12. NacetylDgalactosamine is the immunodominant
carbohydrate that
reacts with: A. Arachis hypogaea B. Salvia sclarea C. Dolichos bi orus D. Ulex eur
opeaus Blood
bank/Apply knowledge of fundamental biological principles/ABO/2 13. A stem cell
transplant
patient was retyped when she was transferred from another hospital. What is the
most likely cause
of the following results? Patient cells: AntiA, neg AntiB, 4+ Patient serum
: A 1 cells, neg
B cells, neg A. Viral infection B. Alloantibodies C. Immunode ciency D. Autoimmu
ne hemolytic
anemia Blood bank/Evaluate laboratory data to recognize health and disease state
s/ABO
discrepancy/3 14. What reaction would be the same for an A 1 and an A 2 person?
A. Positive
reaction with antiA 1 lectin B. Positive reaction with A 1 cells C. Equal react
ion with antiH
D. Positive reaction with antiA,B Blood bank/Evaluate laboratory data to make i
denti cations/ABO
discrepancy/2 15. A female patient at 28 weeks gestation yields the following res
ults: Patient
cells: AntiA, 3+ AntiB, 4+ Patient serum: A 1 cells, neg B cells, 1+
O cells, 1+
Which of the following could be causing the ABO discrepancy? A. Hypogammaglobuli
nemia B.
Alloantibody in patient serum C. Acquired B D. Weak subgroup Blood bank/Evaluate
laboratory data
to make identi cations/ABO discrepancy/3 16. Which condition would most likely be
responsible for
the following typing results? Patient cells: AntiA, neg AntiB, neg Patient
serum: A 1
cells, neg B cells, 4+ A. Immunode ciency B. Masking of antigens by the presence
of massive
amounts of antibody C. Weak or excessive antigen(s) D. Impossible to determine B
lood bank/Apply
principles of basic laboratory procedures/ABO discrepancy/3 2828_Ch04_121170 0
6/08/12 11:16 AM
Page 128 Answer to Question 18 18. D In a transplant scenario, there are no m
ethods to employ
to solve the discrepancy. The technologist must rely on the patient history of d
onor type and
recipient type, and the present serological picture. A Bpositive recipient give
n an Opositive
transplant constitutes a minor ABO mismatch. The forward type resembles the dono
r. The reverse
type still resembles the recipient. The ABO type reported out does not t a patter
n resulting in
an undetermined type. 4.2 | ABO Blood Group System 129 18. A 61yearold male
with a history of
multiple myeloma had a stem cell transplant 3 years ago. Te donor was O positive
and the

recipient was B positive. He is admitted to a community hospital for fatigue and

nausea. Typing
results reveal the following: AntiA = 0 AntiB =0 AntiA,B = 0 AntiD = 4+ A 1
cells = 4+ B
cells = 0 How would you report this type? A. O positive B. B positive C. A posit
ive D.
Undetermined Blood bank/Evaluate laboratory data to recognize problems/ABO discr
epancy/3
2828_Ch04_121170 06/08/12 11:16 AM Page 129 130 4.3 Rh Blood Group System 1.
A complete Rh
typing for antigens C, c, D, E, and e revealed negative results for C, D, and E.
How is the
individual designated? A. Rh positive B. Rh negative C. Positive for c and e D.
Impossible to
determine Blood bank/Apply knowledge of fundamental biological characteristics/R
h typing/1 2. How
is an individual with genotype Dce/dce classi ed? A. Rh positive B. Rh negative C.
Rh null D.
Total Rh Blood bank/Apply knowledge of fundamental biological characteristics/Rh
typing/2 3. If a
patient has a positive direct antiglobulin test, should you perform a weak D tes
t on the cells?
A. No, the cells are already coated with antibody B. No, the cells are Rh null C
. Yes, the
immunoglobulin will not interfere with the test D. Yes, Rh reagents are enhanced
in protein media
Blood bank/Apply knowledge of fundamental biological characteristics/Rh typing/3
4. Which donor
unit is selected for a recipient with antic? A. rr B. R 0 R 1 C. R 2 r D. rr y Blo
od
bank/Apply knowledge of fundamental biological characteristics/Rh typing/3 5. Wh
ich genotype
usually shows the strongest reaction with antiD? A. DCE/DCE B. Dce/dCe C. D/D D.
CE/ce Blood
bank/Apply knowledge of fundamental biological characteristics/Rh typing/1 Answe
rs to Questions
15 1. B Rh positive refers to the presence of D antigen; Rh negative refers to
the absence of
the D antigen. These designations are for D antigen only and do not involve othe
r Rh antigens. 2.
A This individual has the D antigen and is classi ed as Rh positive. Any genotyp
e containing
the D antigen will be considered Rh positive. 3. A If a person has a positive
DAT, the red
cells are coated with immunoglobulin (antiIgG and anti C3d, or both). If a tes
t for weak D were
performed, the test would yield positive results independent of the presence or
absence of the D
antigen on the red cells. 4. D The designation r is dCe and r y is dCE, neither
of which
contains the c antigen. The other three Rh types contain the c antigen and could
not be used in
transfusion for a person with antic. 5. C The phenotype that results from D/D i
s classi ed
as enhanced D because it shows a stronger reaction than expected with antiD. Su
ch cells have a
greater amount of D antigen than normal. This is thought to result from a larger
quantity of
precursors being available to the D genes because there is no competition from o
ther Rh genes.

2828_Ch04_121170 06/08/12 11:16 AM Page 130 6. Why is testing for Rh antigen

s and antibodies
di erent from ABO testing? A. ABO reactions are primarily due to IgM antibodies an
d usually occur
at room temperature; Rh antibodies are IgG and agglutination usually requires a
37C incubation
and enhancement media B. ABO antigens are attached to receptors on the outside o
f the red cell
and do not require any special enhancement for testing; Rh antigens are loosely
attached to the
red cell membrane and require enhancement for detection C. Both ABO and Rh antig
ens and
antibodies have similar structures, but Rh antibodies are con gured so that specia
l techniques
are needed to facilitate binding to Rh antigens D. Tere is no di erence in ABO and
Rh testing;
both may be conducted at room temperature with no special enhancement needed for
reaction Blood
bank/Apply knowledge of fundamental biological characteristics/Rh system/1 7. Te
sting reveals a
weak D that reacts 1+ after indirect antiglobulin testing (IAT). How is this res
ult classi ed? A.
Rhpositive B. Rhnegative, Du positive C. Rhnegative D. Rhpositive, Du positi
ve Blood
bank/Apply knowledge of standard operating procedures/Components/Rh label/2 8. W
hat is one
possible genotype for a patient who develops antiC antibody? A. R1r B. R 1 R 1
C. rr D. rr
Blood bank/Apply knowledge of fundamental biological characteristics/Rh typing/2
9. A patient
developed a combination of Rh antibodies: antiC, antiE, and antiD. Can compat
ible blood be
found for this patient? A. It is almost impossible to nd blood lacking the C, E,
and D antigens
B. rr blood could be used without causing a problem C. R 0 R 0 may be used becau
se it lacks all
three antigens D. Although rare, r y r blood may be obtained from close relative
s of the patient
Blood bank/Apply knowledge of fundamental biological characteristics/Rh antibodi
es/1 4.3 | Rh
Blood Group System 131 Answers to Questions 611 6. A Detection of ABO and Rh
antigens and
antibodies requires di erent reaction conditions. ABO antibodies are naturally occ
urring IgM
molecules and react best at room temperature. Rh antibodies are generally immune
IgG molecules
that result from transfusion or pregnancy. Detection may require 37C incubation a
nd/or
enhancement techniques. 7. A Blood tested for weak D that shows 1+ reaction af
ter IAT is
classi ed as Rh positive. The weak D designation is not noted in the reporting of
the result. 8.
D Only rr (dce/dce) does not contain C antigen. A person will form alloantibodi
es only to the
antigens he or she lacks. 9. B The genotype rr (dce/dce) lacks D, C, and E ant
igens and would
be suitable for an individual who has developed antibodies to all three antigens
. This is the
most common Rhnegative genotype and is found in nearly 14% of White blood donor
s. 10. D The D

antigen is comprised of di erent parts designated as a mosaic. If an individual la

cks parts of
the antigen, he or she may make antibodies to the missing parts if exposed to th
e whole D
antigen. 11. A DcE/DcE (R 2 R 2 ) is not possible because R 2 can be inherit
ed only from the
mother and is not present in the father. 10. A patient tests positive for weak D
but also appears
to have antiD in his serum. What may be the problem? A. Mixup of samples or tes
ting error B.
Most weak D individuals make antiD C. Te problem could be due to a disease stat
e D. A D mosaic
may make antibodies to missing antigen parts Blood bank/Apply knowledge to ident
ify sources of
error/Rh antibodies/2 11. Which o spring is not possible from a mother who is R 1
R 2 and a
father who is R 1 r? A. DcE/DcE B. Dce/DCe C. DcE/DCe D. Dce/dce Blood bank/Eval
uate laboratory
data to verify test results/Rh system/Paternity testing/2 2828_Ch04_121170 06/
08/12 11:16 AM
Page 131 18. Te Wiener nomenclature for the E antigen is: A. hr B. hrv C. rh D. Rh
0 Blood
bank/Apply knowledge of fundamental biological principles/Rh typing/1 132 Chapte
r 4 |
Immunohematology 12. Why is testing a pregnant woman for weak D not required? A.
An Rhnegative
fetus may yield false positive results in a fetal maternal bleed B. An Rhpositi
ve fetus may
yield false positive results in a fetal maternal bleed C. D antigen strength dec
reases during
pregnancy D. D antigen strength increases during pregnancy Blood bank/Apply know
ledge of
biological characteristics/Rh testing/3 13. What antibodies could an R 1 R 1 mak
e if exposed to R
2 R 2 blood? A. Antie and antiC B. AntiE and antic C. AntiE and antiC D. A
ntie and antic
Blood bank/Apply knowledge of fundamental biological characteristics/Rh antibodi
es/2 14. What
does the genotype /represent in the Rh system? A. Rh negative B. D mosaic C. Rh nu
ll D. Total
Rh Blood bank/Evaluate laboratory data to make identi cations/Rh system/Rh antigen
s/2 15. What
techniques are necessary for weak D testing? A. Saline + 22C incubation B. Albumi
n or LISS +
37C incubation C. Saline + 37C incubation D. 37C incubation + IAT Blood bank/Apply
knowledge
of basic laboratory procedures/Rh system/2 16. A patient types as AB and appears
to be Rh
positive on slide typing. What additional tests should be performed for tube typ
ing? A. Rh
negative control B. Direct antiglobulin test (DAT) C. Lowprotein Rh antisera D.
No additional
testing is needed Blood bank/Evaluate laboratory data to verify test results/Rh
system/2 17.
According to the Wiener nomenclature and/or genetic theory of Rh inheritance: A.
Tere are three
closely linked loci, each with a primary set of allelic genes B. Te alleles are
named R 1 , R 2 ,
R 0 , r, r, r, R z , and r y C. Tere are multiple alleles at a single complex locu
s that

determine each Rh antigen D. Te antigens are named D, C, E, c, and e Blood bank/

Apply knowledge
of fundamental biological principles/Rh system/2 Answers to Questions 1218 12.
B If a weak D
test is performed on a pregnant woman with no previous history, a falsepositive
weak D test may
result from the presence of fetal blood if the fetus is Rh positive. A pregnant
woman with weak D
may be given Rh immune globulin without any harmful consequences. Therefore, wea
k D testing of
pregnant women is not necessary. 13. B The R 1 R 1 (DCe/DCe) individual does n
ot have the E or
c antigen, and could make antiE and antic antibodies when exposed to R 2 R 2 c
ells (DcE/DcE).
14. C A person who is Rh null shows no Rh antigens on his or her RBCs. Loss of
Rh antigens is
very unlikely to happen because Rh antigens are integral parts of the RBC membra
ne. The Rh null
phenotype can result from either genetic suppression of the Rh genes or inherita
nce of amorphic
genes at the Rh locus. 15. D Weak D testing requires both 37C incubation and th
e IAT
procedure. AntiD is an IgG antibody, and attachment of the D antigen is optimiz
ed at warmer
temperatures. Antihuman globulin in the IAT phase facilitates lattice formation
by binding to the
antigenantibody complexes. 16. A An Rhnegative control (patient cells in salin
e or 6%
albumin) should be run if a sample appears to be AB positive. The ABO test serve
s as the Rh
control for other ABO types. 17. C Wiener proposed a singlelocus theory for R
h, with multiple
alleles determining surface molecules that embody numerous antigens. 18. C The
Wiener
designation for the E antigen is rh. The Wiener designation hr denotes c, hr denote
s e, and Rh
0 is D. 2828_Ch04_121170 06/08/12 11:16 AM Page 132 4.3 | Rh Blood Group Sys
tem 133 19. A
physician orders 2 units of leukocytereduced red blood cells. Te patient is a 5
5yearold male
with anemia. He types as an AB negative, and his antibody screen is negative. Te
re is only 1 unit
of AB negative in inventory. What is the next blood type that should be given? A
. AB positive
(patient is male) B. A negative C. B negative D. O negative Blood bank/Evaluate
sources of
errors/Rh systems/3 20. Which technology may report an Rhweak D positive as Rh
negative? A. Gel
System B. Solid Phase C. Tube Testing D. None of these options Blood bank/Apply
knowledge of
laboratory procedures/ Rh system/2 Answers to Questions 1920 19. B While giving
Rhpositive
RBCs to an Rhnegative patient would not harm the patient in this case, because
he is male,
giving A negative would be the rst choice. You should not expose a patient to the
D antigen, if
possible, and the residual antiB in a unit of Anegative packed cells is less i
mmunogenic than
giving B or O red cells. 20. A The Gel system cannot detect a weak D phenotype
because there is

no 37C or AHG phase with the ABD card. 2828_Ch04_121170 06/08/12 11:16 AM Pag
e 133 1. A
patient has the Lewis phenotype Le(ab). An antibody panel reveals the presence of
antiLe a .
Another patient with the phenotype Le(ab+) has a positive antibody screen; howeve
r, a panel
reveals no conclusive antibody. Should antiLe a be considered as a possibility
for the patient
with the Le(ab+) phenotype? A. AntiLe a should be considered as a possible antib
ody B. AntiLe
a may be a possible antibody, but further studies are needed C. AntiLe a is not
a likely
antibody because even Le b individuals secrete some Le a D. AntiLe a may be fou
nd in saliva but
not detectable in serum Blood bank/Apply knowledge of fundamental biological
characteristics/Blood groups/2 2. A technologist is having great di culty resolvin
g an antibody
mixture. One of the antibodies is anti Le a . Tis antibody is not clinically si
gni cant in this
situation, but it needs to be removed to reveal the possible presence of an unde
rlying antibody
of clinical signi cance. What can be done? A. Perform an enzyme panel B. Neutraliz
e the serum
with saliva C. Neutralize the serum with hydatid cyst uid D. Use DTT (dithiothrei
tol) to treat
the panel cells Blood bank/Apply knowledge of fundamental biological characteris
tics/Blood
groups/3 3. What type of blood should be given to an individual who has an anti
Le b that reacts
1+ at the IAT phase? A. Blood that is negative for the Le b antigen B. Blood tha
t is negative for
both the Le a and Le b antigens C. Blood that is positive for the Le b antigen D
. Lewis
antibodies are not clinically signi cant, so any type of blood may be given Blood
bank/Apply
knowledge of fundamental biological characteristics/Blood group antibodies/3 4.4
Testing for
Antibodies 134 4. Which of the following statements is true concerning the MN ge
notype? A.
Antigens are destroyed using bleachtreated cells B. Dosage e ect may be seen for
both M and N
antigens C. Both M and N antigens are impossible to detect because of crossinte
rference D. MN is
a rare phenotype seldom found in routine antigen typing Blood bank/Apply knowled
ge of fundamental
biological characteristics/Blood groups/2 Answers to Questions 14 1. C AntiLe
a is produced
primarily by persons with the Le(ab) phenotype because Le(ab+) persons still have s
ome Le a
antigen present in saliva. Although Le a is not present on their red cells, Le(ab
+) persons do
not form antiLe a . 2. B Saliva from an individual with the Le gene contains
the Le a antigen.
This combines with antiLe a , neutralizing the antibody. Panel cells treated wi
th DTT (0.2M)
lose reactivity with antiK and other antibodies, but not antiLe a . Hydatid cy
st uid
neutralizes antiP 1. 3. A Lewis antibodies are generally not considered clini
cally signi cant
unless they react at 37C or at the IAT phase. The antibody must be honored in thi

s scenario. 4.
B Dosage e ect is the term used to describe the phenomenon of an antibody that
reacts more
strongly with homozygous cells than with heterozygous cells. Dosage e ect is a cha
racteristic of
the genotype MN because the M and N antigens are both present on the same cell.
This causes a
weaker reaction than seen with RBCs of either the MMor NN genotype, which carry
a greater amount
of the corresponding antigen. 2828_Ch04_121170 06/08/12 11:16 AM Page 134 10
. Which group of
antibodies is commonly found as cold agglutinins? A. AntiK, antik, antiJs b B
. AntiD, antie,
antiC C. AntiM, antiN D. AntiFy a , antiFy b Blood bank/Apply knowledge of
fundamental
biological characteristics/Blood group antibodies/1 11. Which of the following a
ntibodies
characteristically gives a refractile mixed eld appearance? A. AntiK B. AntiDi
a C. AntiSd a
D. Antis Blood bank/Apply knowledge of fundamental biological characteristics/B
lood group
antibodies/1 4.4 | Testing for Antibodies 135 5. AntiM is sometimes found wit
h reactivity
detected at the immediate spin (IS) phase that persists in strength to the IAT p
hase. What is the
main testing problem with a strong antiM? A. AntiM may not allow detection of
a clinically
signi cant antibody B. Compatible blood may not be found for the patient with a st
rongly reacting
antiM C. Te antiM cannot be removed from the serum D. Te antiM may react with
the patients
own cells, causing a positive autocontrol Blood bank/Apply knowledge of fundamen
tal biological
characteristics/Blood groups/2 6. A patient is suspected of having paroxysmal co
ld hemoglobinuria
(PCH). Which pattern of reactivity is characteristic of the Donath Landsteiner an
tibody, which
causes this condition? A. Te antibody attaches to RBCs at 4C and causes hemolysis
at 37C B. Te
antibody attaches to RBCs at 37C and causes agglutination at the IAT phase C. Te
antibody
attaches to RBCs at 22C and causes hemolysis at 37C D. Te antibody attaches to RBC
s and causes
agglutination at the IAT phase Blood bank/Apply knowledge of fundamental biologi
cal
characteristics/Blood group antibodies/1 7. How can interfering antiP 1 antibod
y be removed from
a mixture of antibodies? A. Neutralization with saliva B. Agglutination with hum
an milk C.
Combination with urine D. Neutralization with hydatid cyst uid Blood bank/Apply p
rinciples of
special procedures/ Blood group antibodies/1 8. Which antibody is frequently see
n in patients
with warm autoimmune hemolytic anemia? A. AntiJk a B. Antie C. AntiK D. Anti
Fy b Blood
bank/Apply knowledge of fundamental biological characteristics/Blood group antib
odies/1 9. An
antibody shows strong reactions in all test phases. All screen and panel cells a
re positive. Te
serum is then tested with a cord cell and the reaction is negative. What antibod

y is suspected?
A. AntiI B. Antii C. AntiH D. Antip Blood bank/Apply principles of special p
rocedures/
Antibody ID/2 Answers to Questions 511 5. A While antiM may not be clinically
signi cant, a
strongly reacting antiM that persists through to the IAT phase may interfere wi
th detection of a
clinically signi cant antibody that reacts only at IAT. 6. A The DonathLandsteine
r antibody
has antiP speci city with biphasic activity. The antibody attaches to RBCs at 4C a
nd then
causes the red cells to hemolyze when warmed to 37C. 7. D Hydatid cyst uid conta
ins P 1
substance, which can neutralize antiP 1 antibody. 8. B Antie is frequently i
mplicated in
cases of warm autoimmune hemolytic anemia. The corresponding antigen is characte
rized as high
frequency in the Rh system and can mask the presence of other alloantibodies. 9.
A Adult cells
contain mostly I antigen, and antiI would react with all adult cells found on s
creen or panel
cells. Cord cells, however, contain mostly i antigen and would test negative or
only weakly
positive with antiI. 10. C Antibodies to the M and N antigens are IgM antibod
ies commonly
found as cold agglutinins. 11. C AntiSd a characteristically gives a refracti
le mixed eld
agglutination reaction in the IAT phase. The refractile characteristic is more e
vident under the
microscope. 2828_Ch04_121170 06/08/12 11:16 AM Page 135 16. A patient is adm
itted to the
hospital. Medical records indicate that the patient has a history of antiJk a .
When you
performed the type and screen, the type was O positive and screen was negative.
You should: A.
Crossmatch using units negative for Jk a antigen B. Crossmatch random units, sin
ce the antibody
is not demonstrating C. Request a new sample D. Repeat the screen with enzymetr
eated screening
cells Blood bank/Apply principles of basic laboratory procedures/Antibody ID/3 1
36 Chapter 4 |
Immunohematology 12. What does the 3+3 rule ascertain? A. An antibody is ruled i
n B. An antibody
is ruled out C. 95% con dence that the correct antibody has been identi ed D. 95% co
n dence that
the correct antibody has not been identi ed Blood bank/Apply principles of basic l
aboratory
procedures/Antibody ID/1 13. Te k (Cellano) antigen is a highfrequency antigen
and is found on
most red cells. How often would one expect to nd the corresponding antibody? A. O
ften, because
it is a high frequency antibody B. Rarely, because most individuals have the ant
igen and
therefore would not develop the antibody C. It depends upon the population, beca
use certain
racial and ethnic groups show a higher frequency of antik D. Impossible to dete
rmine without
consulting regional blood group antigen charts Blood bank/Calculate/Hemotherapy/
1 14. Which
procedure would help to distinguish between an antie and antiFy a in an antibo

dy mixture? A.
Lower the pH of test serum B. Run an enzyme panel C. Use a thiol reagent D. Run
a LISS panel
Blood bank/Apply principles of special procedures/ Antibody ID/2 15. Which chara
cteristics are
true of all three of the following antibodies: antiFy a , antiJk a , and anti
K? A. Detected at
the IAT phase; may cause hemolytic disease of the newborn and hemolytic transfus
ion reactions B.
Not detected with enzymetreated cells C. Requires the IAT technique for detecti
on; usually not
associated with HDN D. Enhanced reactivity with enzymetreated cells; may cause
severe hemolytic
transfusion reactions Blood bank/Apply principles of special procedures/ Antibod
y ID/2 Answers to
Questions 1216 12. C The 3+3 rule ascertains correct identi cation of antibody at
a con dence
level of 95%. For this level to be met, reagent red cells are found containing t
arget antigen to
suspected antibody that react in test phase; likewise, reagent red cells devoid
of antigen will
not react in test phase. 13. B The k antigen is found with a frequency of 99.8
%; therefore, the
knegative person is rare. Because knegative individuals are very rare, the occ
urrence of antik
is also rare. 14. B Enzymetreated cells will not react with Du y antibodies. Rh
antibodies
react more strongly with enzymetreated red cells. An enzyme panel, therefore, w
ould enhance
reactivity of antie and destroy reactivity to antiFy a . 15. A AntiFy a , a
ntiJk a , and
antiK are usually detected at IAT and all may cause HDN and transfusion reactio
ns that may be
hemolytic. Reactivity with antiFy a is lost with enzymetreated red cells, but
reactivity with
anti Jk a is enhanced with enzymetreated cells. Reactivity with antiK is una ec
ted by
enzymetreated cells. 16. A The Kidd antibodies are notorious for disappearing
from serum,
yielding a negative result for the antibody screen. If a patient has a history o
f a Kidd
antibody, blood must be crossmatched using antigennegative units. If the patien
t is transfused
with the corresponding antigen, an anamnestic response may occur with a subseque
nt hemolytic
transfusion reaction. 2828_Ch04_121170 06/08/12 11:16 AM Page 136 4.4 | Test
ing for
Antibodies 137 17. A technologist performs an antibody study and nds 1+ and wea
k positive
reactions for several of the panel cells. Te reactions do not t a pattern. Severa
l selected
panels and a patient phenotype do not reveal any additional information. Te seru
m is diluted and
retested, but the same reactions persist. What type of antibody may be causing t
hese results? A.
Antibody to a highfrequency antigen B. Antibody to a lowfrequency antigen C. H
igh titer low
avidity (HTLA) D. AntiHLA Blood bank/Evaluate laboratory data to make identi cati
ons/Antibody
ID/3 18. An antibody is detected in a pregnant woman and is suspected of being t

he cause of fetal
distress. Te antibody reacts at the IAT phase but does not react with DTTtreate
d cells. Tis
antibody causes in vitro hemolysis. What is the most likely antibody speci city? A
. AntiLe a B.
AntiLu a C. AntiLu b D. AntiXg a Blood bank/Evaluate laboratory data to make
identi cations/Antibody ID/3 19. What sample is best for detecting complement dep
endent
antibodies? A. Plasma stored at 4C for no longer than 24 hours B. Serum stored at
4C for no
longer than 48 hours C. Either serum or plasma stored at 20C24C no longer than 6 ho
urs D.
Serum heated at 56C for 30 minutes Blood bank/Apply principles of basic laborator
y
procedures/Antibody ID/2 Answers to Questions 1721 17. C HTLA antibodies may pe
rsist in
reaction strength, even when diluted. These antibodies are directed against high
frequency
antigens (such as Ch a ). They are not clinically signi cant but, when present, ar
e responsible
for a high incidence of incompatible crossmatches. 18. C Of the antibodies lis
ted, only Lu b is
detected in the IAT phase, causes in vitro hemolysis, may cause HDN, and does no
t react with
DTTtreated cells. 19. B Serum stored at 4C for no longer than 48 hours preserv
es complement
activity. Plasma is inappropriate because most anticoagulants chelate calcium ne
eded for
activation of complement. Heating the serum to 56C destroys complement. 20. B A
BO antibodies
are not detected by group O screening cells, because O cells contain no A or B a
ntigens. 21. B
The pattern clearly ts that of antiJk b , an antibody that usually reacts best a
t IAT. The
weaker reactions are due to dosage e ect found on cells that are heterozygous for
the Jk b
antigen. Panel 1 Cell D C E c e K k Kp a Kp b Js a Js b Fy a Fy
b Jk a Jk b Xg a
Le a Le b S s M N P 1 Lu a Lu b 37 IAT 1 + + O O + O + O
+ O + O
+ O + + + O O + O + O O + O 2+ 2 + + O O
+ + + O
+ O + + + + + + O + + + O + + O + O 1+ 3 +
O + + O
O + O + O + + O + + O O + + + + + + O +
O 1+ 4 O +
O + + O + O + O + + + + + + O + O + + +
O O + O
 5 O O + + + + + O + O + + + + O O O + O
+ + + +
O + O O 6 O O O O + O + O + O + + + + + +
+ O + +
+ O + O + O  7 O O O + + + + O + O + O O
+ O + O
+ + O + O + O + O O 8 O O O + + O + O + O
+ O + O
+ + O O + + + O + O + O 2+ 9 + + O O + O +
O + O +
+ + + + + + O O + + + + O + O 1+ 10 + O O
+ + O +

O + O + O O + + + O O O O + O + O + O 1+ 2
0. Which antibody
would not be detected by group O screening cells? A. AntiN B. AntiA 1 C. Anti
Di a D. Antik
Blood bank/Apply principles of special procedures/ Antibody ID/1 21. Refer to Pa
nel 1. Which
antibody is most likely implicated? A. AntiFy b B. AntiJk b C. Antie D. Anti
c and antiK
Blood bank/Apply principles of special procedures/ Antibody ID/2 2828_Ch04_1211
70 06/08/12
11:16 AM Page 137 138 Chapter 4 | Immunohematology Answers to Questions 2224 22.
D The
pattern ts antiC at 37C, which becomes stronger at the IAT phase. The additional
antibody is
antiK, which appears only at the IAT phase. 23. B To rule out an antibody, th
ere should be a
homozygous cell with the corresponding antigen that fails to react with the seru
m. Of the
choices, antiC was not ruled out on Panel 2. To rule this antibody out, a cell
that is
homozygous for C and negative for K (the other probable antibody) would be run a
gainst patient
serum. A positive reaction supports the presence of antiC, whereas a negative r
eaction would
rule out antiC. 24. B On panel cells 1, 2, and 9, the C antigen is present an
d the c antigen
is absent, rendering the cells homozygous for C. 22. Refer to Panel 2. Which ant
ibody speci city
is most likely present? A. AntiS and antiE B. AntiE and antiK C. AntiLe a a
nd antiFy b D.
AntiC and antiK Blood bank/Apply principles of special procedures/ Antibody ID
/3 23. On Panel
2, which of the following antibodies could not be ruled out? A. AntiJk b B. Ant
iC C. AntiM D.
AntiFy b Blood bank/Apply principles of special procedures/ Antibody ID/3 24. O
n Panel 2, which
cells are homozygous for C? A. 1, 2, 3 B. 1, 2, 9 C. 3, 4, 7 D. 7, 8, 10 Blood b
ank/Apply
principles of special procedures/ Antibody ID/2 Panel 2 Cell D C E c e
K k Kp a
Kp b Js a Js b Fy a Fy b Jk a Jk b Xg a Le a Le b S s M N P 1 Lu a Lu b
37 IAT 1 + +
O O + O + O + O + O + O + + + O O + O +
O O + 1+
2+ 2 + + O O + + + O + O + + + + + + O +
+ + O + +
O + 1+ 2+ 3 + O + + O O + O + O + + O + +
O O + +
+ + + + O + O O 4 O + O + + O + O + O + +
+ + + +
O + O + + + O O + 
+ 5 O O + + + + + O +
O + + +
+ O O O + O + + + + O + O 2+ 6 O O O O + O
+ O + O
+ + + + + + + O + + + O + O + O O 7 O O O
+ + + +
O + O + O O + O + O + + O + O + O + O 2+
8 O O O +
+ O + O + O + O + O + + O O + + + O + O
+ O O 9 +

+
+

O O + O + O + O + + + + + + + O O + +
+ O +
1+ 1+ 10 + O O + + O + O + O + O O + + + O
O O O +
O + O + O O 2828_Ch04_121170 06/08/12 11:16 AM Page 138 25. A 77y
earold female is
admitted to a community hospital after a cardiac arrest. History includes an abd
ominal aortic
aneurysm 2 years ago in which she received 6 units of packed cells. Her blood ty
pe is A positive
and antibody screen is positive at AHG phase in screening cells II and III. A pa
nel is performed
using LISS. Referring to panel 3, which antibodies are likely implicated? A. C a
nd K B. Jk a and
c C. E and c D. Fy a and M Blood bank/Apply principles of special procedures/ An
tibody ID/3 26.
What observation is apparent with one of the antibodies present on Panel 3? A. O
ne antibody is
only reacting with heterozygous cells B. Both antibodies are only reacting with
homozygous cells
C. One antibody is only reacting with homozygous cells D. Both antibodies are ex
hibiting dosage
Blood bank/Apply principles of special procedures/ Antibody ID/3 4.4 | Testing f
or Antibodies
139 Answers to Questions 2526 25. C The antibodies evident in the panel are E a
nd c. Every
positive reaction at 37C and IAT phases are positive for either the E antigen and
/or for cells
homozygous for c antigen. 26. C Antic is only reacting with homozygous cells.
Panel 3 Cell D
C E c e K k Kp a Kp b Js a Js b Fy a Fy b Jk a Jk b Xg a Le a Le b
S s M N
P 1 Lu b 37 IAT 1 0 + 0 + + 0 + 0 + 0 + + + + 0
+ 0 + +
+ + + 0 + 0 0 2 + 0 0 + + + + 0 + 0 + 0 +
0 + + +
0 0 + 0 0 0 + + + 3 + + + 0 0 0 + 0 + 0 +
0 0 + +
0 0 + + + + + 0 + + + 4 + + 0 0 + + + 0 +
0 + + +
+ + + + + 0 0 + + + + 0 0 5 + + 0 + + 0 +
0 + 0 +
0 + 0 + 0 0 + + + + + + + 0 0 6 0 + + + +
0 + 0 +
0 + + 0 0 + + + + + + + + 0 + + + 7 0 + 0
0 + + +
0 + 0 + + + + + + + 0 0 + 0 + + + 0 0 8 0
+ + 0 +
0 + 0 + 0 + 0 + 0 + + + + + + + + + + +
+ 9 0 0 0
+ + 0 + 0 + 0 + + + + + + + 0 0 + + + +
+ + + 10 +
+ 0 + + + + 0 + 0 + + + 0 + + 0 + + + +
+ + + 0
0 2828_Ch04_121170 06/08/12 11:16 AM Page 139 140 4.5 Compatibility Testing
1. SITUATION: An
emergency trauma patient requires transfusion. Six units of blood are ordered st
at. Tere is no
time to draw a patient sample. Onegative blood is released. When will compatibi
lity testing be

performed? A. Compatibility testing must be performed before blood is issued B.

Compatibility
testing will be performed when a patient sample is available C. Compatibility te
sting may be
performed immediately using donor serum D. Compatibility testing is not necessar
y when blood is
released in emergency situations Blood bank/Apply knowledge of laboratory operat
ions/Crossmatch/3
2. How would autoantibodies a ect compatibility testing? A. No e ect B. Te DAT would
be positive
C. ABO, Rh, antibody screen, and crossmatch may show abnormal results D. Results
would depend on
the speci city of autoantibody Blood bank/Evaluate laboratory data to make
identi cations/Antibody ID/3 3. An antibody screen is reactive at IAT phase of tes
ting using a
threecell screen and the autocontrol is negative. What is a possible explanatio
n for these
results? A. A cold alloantibody B. Highfrequency alloantibody or a mixture of a
lloantibodies C.
A warm autoantibody D. A cold and warm alloantibody Blood bank/Evaluate laborato
ry data to make
identi cations/Antibody ID/3 4. What does a minor crossmatch consist of? A. Recipi
ent plasma and
recipient red cells B. Recipient plasma and donor red cells C. Recipient red cel
ls and donor
plasma D. Donor plasma and donor red cells Blood bank/Apply knowledge of laborat
ory operations/
Crossmatch/1 Answers to Questions 15 1. B When patient serum is available, it w
ill be
crossmatched with donor cells. Patient serum might contain antibodies against an
tigens on donor
cells that may destroy donor cells. If an incompatibility is discovered, the pro
blem will be
reported immediately to the patients physician. 2. C Autoantibodies may cause p
ositive
reactions with screening cells, panel cells, donor cells, and patient cells. The
DAT will be
positive; however, the DAT is not included in compatibility testing. 3. B High
frequency
alloantibodies or a mixture of alloantibodies may cause all three screening cell
s to be positive.
A negative autocontrol would rule out autoantibodies. 4. C A minor crossmatch
consists of
recipient red cells and donor serum or plasma. 5. A Compatibility testing may
be performed on a
patient sample within 3 days of the scheduled transfusion; however, if the patie
nt is pregnant or
was transfused within 3 months, the sample must be less than 3 days old. 5. Can
crossmatching be
performed on October 14th using a patient sample drawn on October 12th? A. Yes,
a new sample
would not be needed B. Yes, but only if the previous sample has no alloantibodie
s C. No, a new
sample is needed because the 2day limit has expired D. No, a new sample is need
ed for each
testing Blood bank/Apply knowledge of standard operating procedures/Crossmatch/2
2828_Ch04_121170 06/08/12 11:16 AM Page 140 4.5 | Compatibility Testing 14
1 6. A type and
screen was performed on a 32yearold woman, and the patient was typed as AB neg
ative. Tere are

no ABnegative units in the blood bank. What should be done? A. Order ABnegativ
e units from a
blood supplier B. Check inventory of A, B, and Onegative units C. Ask the pat
ient to make a
preoperative autologous donation D. Nothingthe blood will probably not be used Bl
ood bank/Apply
principles of basic laboratory procedures/Crossmatch/2 7. What ABO types may don
ate to any other
ABO type? A. A negative, B negative, AB negative, O negative B. O negative C. AB
negative D. AB
negative, A negative, B negative Blood bank/Apply knowledge of fundamental biolo
gical
characteristics/Crossmatch/2 8. What type(s) of red cells is (are) acceptable to
transfuse to an
Onegative patient? A. A negative, B negative, AB negative, or O negative B. O n
egative C. AB
negative D. AB negative, A negative, B negative Blood bank/Apply knowledge of fu
ndamental
biological characteristics/Crossmatch/2 9. A technologist removed 4 units of blo
od from the blood
bank refrigerator and placed them on the counter. A clerk was waiting to take th
e units for
transfusion. As she checked the paperwork, she noticed that one of the units was
leaking onto the
counter. What should she do? A. Issue the unit if the red cells appear normal B.
Reseal the unit
C. Discard the unit D. Call the medical director and ask for an opinion Blood ba
nk/Apply
knowledge of standard operating procedures/Crossmatch/3 10. A donor was found to
contain antiK
using pilot tubes from the collection procedure. How would this a ect the compatib
ility test? A.
Te AHG major crossmatch would be positive B. Te IS (immediate spin) major crossm
atch would be
positive C. Te recipients antibody screen would be positive for antiK D. Compati
bility testing
would not be a ected Blood bank/Apply principles of basic laboratory procedures/Cr
ossmatch/2 11.
Which of the following is not a requirement for the electronic crossmatch? A. Te
computer system
contains logic to prevent assignment and release of ABO incompatible blood B. Te
re are concordant
results of at least two determinations of the recipients ABO type on record, one
of which is
from the current sample C. Critical elements of the system have been validated o
n site D. Tere
are concordant results of at least one determination of the recipients ABO type o
n le Blood
bank/Apply principles of basic laboratory procedures/Crossmatch/1 12. A patient
showed positive
results with screening cells and 4 donor units. Te patient autocontrol was negat
ive. What is the
most likely antibody? A. AntiH B. AntiS C. AntiKp a D. Antik Blood bank/Eval
uate laboratory
data to make identi cations/Incompatible crossmatch/3 Answers to Questions 612 6.
B An AB
person is the universal recipient and may receive any blood type; because only a
type and screen
were ordered and blood may not be used, check inventory for A, B, and Onegati
ve units. 7. B

An Onegative individual has no A or B antigens and may donate red cells to any
other ABO type.
8. B An Onegative individual has both antiA and antiB and may receive only
Onegative red
cells. 9. C Leaking may indicate a broken seal or a puncture, which indicates
possible
contamination of the unit, even if the red cells appear normal. The unit should
be discarded. 10.
D Compatibility testing would not be a ected if the donor has antiK in his or h
er serum. This
is because the major crossmatch uses recipient serum and not donor serum. Other
tests such as
ABO, Rh, and antibody screen on the recipient also would not be a ected. 11. D A
BO
determinations must be concordant on at least two occasions, including the curre
nt sample. 12.
D Antik (cellano) is a highfrequency alloantibody that would react with screen
ing cells and
most donor units. The negative autocontrol rules out autoantibodies. AntiH and
antiS are cold
antibodies and antiKp a is a lowfrequency alloantibody. 2828_Ch04_121170 06/
08/12 11:16 AM
Page 141 Answers to Questions 1319 13. A A cold alloantibody would show a react
ion with
screening cells and donor units only at IS phase. The negative autocontrol rules
out
autoantibodies and abnormal protein. 14. C The incompatible donor unit may hav
e an antibody
coating the red cells, or the patient may have an alloantibody to a lowfrequenc
y antigen. An
alloantibody to a highfrequency antigen would agglutinate all units and screeni
ng cells. 15. A
The incompatible unit may have red cells coated with antibody and/or complement.
If red cells are
sensitized, then some problem exists with the donor. Discard the unit. 16. C A
n abnormal
protein or nonspeci c autoantibody would cause antibody screen, crossmatch, and pa
tient
autocontrol to be positive. Alloantibodies would not cause a positive patient au
tocontrol. 17.
B Antigen typing or phenotyping of the patients cells con rms the antibody identi cat
ion;
antigen typing of donor cells helps ensure the crossmatch of compatible donor un
its. 18. D The
unit may be used in the general blood inventory, if it is properly labeled and o
nly cellular
elements are used. 19. C A positive DAT using antiIgG indicates that antibodi
es are coating
the patient cells. An eluate would be helpful to remove the antibody, followed b
y a cell panel in
order to identify it. 13. Screening cells and major crossmatch are positive on I
S only, and the
autocontrol is negative. Identify the problem. A. Cold alloantibody B. Cold auto
antibody C.
Abnormal protein D. Antibody mixture Blood bank/Evaluate laboratory data to make
identi cations/Incompatible crossmatch/3 14. Six units are crossmatched. Five unit
s are
compatible, one unit is incompatible, and the recipients antibody screen is negat
ive. Identify
the problem: A. Patient may have an alloantibody to a highfrequency antigen B.

Patient may have

an abnormal protein C. Donor unit may have a positive DAT D. Donor may have a hi
ghfrequency
antigen Blood bank/Evaluate laboratory data to make identi cations/Incompatible cr
ossmatch/3 15.
An incompatible donor unit is found to have a positive DAT. What should be done
with the donor
unit? A. Discard the unit B. Antigen type the unit for highfrequency antigens C
. Wash the donor
cells and use the washed cells for testing D. Perform a panel on the incompatibl
e unit Blood
bank/Apply principles of special procedures/ Incompatible crossmatch/3 16. Scree
ning cells, major
crossmatch, and patient autocontrol are positive in all phases. Identify the pro
blem. A. Speci c
cold alloantibody B. Speci c cold autoantibody C. Abnormal protein or nonspeci c aut
oantibody D.
Cold and warm alloantibody mixture Blood bank/Evaluate laboratory data to make
identi cations/Incompatible crossmatch/3 17. A panel study has revealed the presen
ce of patient
alloantibodies. What is the rst step in a major crossmatch? A. Perform a DAT on p
atient cells
and donor units B. Antigen type patient cells and any donor cells to be crossmat
ched C. Adsorb
any antibodies from the patient serum D. Obtain a di erent enhancement medium for
testing Blood
bank/Apply principles of special procedures/ Incompatible crossmatch/2 18. What
is the
disposition of a donor red blood cell unit that contains an antibody? A. Te unit
must be
discarded B. Only the plasma may be used to make components C. Te antibody must
be adsorbed from
the unit D. Te unit may be labeled indicating it contains antibody and released
into inventory
Blood bank/Apply knowledge of laboratory operations/ Hemotherapy/Blood component
s/1 19. Given a
situation where screening cells, major crossmatch, autocontrol, and DAT (antiIg
G) are all
positive, what procedure should be performed next? A. Adsorption using rabbit st
roma B. Antigen
typing of patient cells C. Elution followed by a cell panel on the eluate D. Sel
ected cell panel
Blood bank/Apply principles of special procedures/ Incompatible crossmatch/3 142
Chapter 4 |
Immunohematology 2828_Ch04_121170 06/08/12 11:16 AM Page 142 4.5 | Compatibi
lity Testing
143 Answers to Questions 2027 20. B The reaction pattern ts that of a cold antib
ody reacting
at the IS phase and of su cient titer to persist at 37C incubation. The reactions d
isappear in
the IAT phase. 21. A Rouleaux may be dispersed or lessened by using the saline
replacement
technique. This involves recentrifuging the tube, then withdrawing serum and rep
lacing it with 2
drops of saline. The tube is respun and examined for hemolysis. 22. D Antibodi
es causing a
positive DAT would be coating red cells and would require an elution, not an ads
orption, to
identify them. 23. C According to AABB standards, the recipient sample must be
kept for 7 days

following compatibility testing. 24. B For transfusion of platelets and plasma

, there is no
required protocol for crossmatching. 25. A The only requirement for transfusin
g an autologous
unit is a check of the ABO and Rh type. 26. A The type chosen should be Aposi
tive red cell
units. Although all choices would be compatible, the rst choice should be Aposit
ive because
this unit will contain residual plasma antiB. AntiB is less immunogenic than a
ntiA, which
would be present, albeit in small amounts, in Bpositive and Opositive units. 2
7. B The
abbreviated crossmatch usually consists of a type and screen and an immediate sp
in crossmatch.
20. A major crossmatch and screening cells are 2+ at IS, 1+ at 37C, and negative
at the IAT
phase. Identify the most likely problem. A. Combination of antibodies B. Cold al
loantibody C.
Rouleaux D. Test error Blood bank/Evaluate laboratory data to make identi cations/
Incompatible
crossmatch/3 21. What corrective action should be taken when rouleaux causes pos
itive test
results? A. Perform a saline replacement technique B. Perform an autoabsorption
C. Run a panel D.
Perform an elution Blood bank/Apply principles of special procedures/ Testing pr
oblems/3 22. All
of the following are reasons for performing an adsorption, except: A. Separation
of mixtures of
antibodies B. Removal of interfering substances C. Con rmation of weak antigens on
red cells D.
Identi cation of antibodies causing a positive DAT Blood bank/Apply principles of
special
procedures/ Antibody identi cation/2 23. How long must a recipient sample be kept
in the blood
bank following compatibility testing? A. 3 days B. 5 days C. 7 days D. 10 days B
lood bank/Apply
principles of basic laboratory procedures/Compatibility/1 24. What is the crossm
atching protocol
for platelets and/or plasma? A. Perform a reverse grouping on donor plasma B. No
testing is
required C. Perform a reverse grouping on recipient plasma D. Platelets must be
HLA compatible
Blood bank/Apply principles of basic laboratory procedures/Compatibility/2 25. W
hat are the
compatibility requirements for an autologous unit? A. ABO and Rh typing B. Type
and screen C.
Major crossmatch D. All of these options Blood bank/Apply principles of basic la
boratory
procedures/Compatibility/1 26. A patient types as AB positive. Two units of bloo
d have been
ordered by the physician. Currently, the inventory shows no AB units, 10 Aposit
ive units, 1
Anegative unit, 5 Bpositive units, and 20 Opositive units. Which should be se
t up for the
major crossmatch? A. Apositive units B. Opositive units C. Bpositive units D.
Call another
blood supplier for typespeci c blood Blood bank/Apply principles of basic laborat
ory
procedures/Compatibility/2 27. Which of the following comprises an abbreviated c
rossmatch? A.

ABO, Rh, and antibody screen B. ABO, Rh, antibody screen, IS crossmatch C. Type
and screen D.
ABO, Rh, IS crossmatch Blood bank/Apply principles of basic laboratory procedure
s/Crossmatch/2
2828_Ch04_121170 06/08/12 11:16 AM Page 143 28. When may an IS crossmatch be
performed? A.
When a patient is being massively transfused B. When there is no history of anti
bodies and the
current antibody screen is negative C. When blood is being emergency released D.
When a patient
has not been transfused in the past 3 months Blood bank/Apply principles of basi
c laboratory
procedures/Crossmatch/1 Answer to Question 28 28. B The IS crossmatch may be p
erformed when the
patient has no history of antibodies and the current antibody screen is negative
. 144 Chapter 4 |
Immunohematology 2828_Ch04_121170 06/08/12 11:16 AM Page 144 145 4.6 Transfu
sion Reactions 1.
A patient had a transfusion reaction to packed red blood cells. Te medical labor
atory scientist
began the laboratory investigation of the transfusion reaction by assembling pre
 and
posttransfusion specimens and all paperwork and computer printouts. What should
he do next? A.
Perform a DAT on the posttransfusion sample B. Check for a clerical error(s) C.
Repeat ABO and
Rh typing of patient and donor unit D. Perform an antibody screen on the post t
ransfusion sample
Blood bank/Apply knowledge of standard operating procedures/Transfusion reaction
s/2 2. What is
the pathophysiological cause surrounding anaphylactic and anaphylactoid reaction
s? A. Antibody in
patient serum is detected 37 days after transfusion, and is attached to donor red
blood cells B.
Donor plasma has reagins (IgE or IgA) that combine with allergens in patient pla
sma C. Patient is
de cient in IgE and develops IgE antibodies via sensitization from transfusion or
pregnancy D.
Patient is de cient in IgA and develops IgA antibodies via sensitization from tran
sfusion or
pregnancy Blood bank/Apply knowledge of fundamental biological principles/Transf
usion reactions/1
3. A patient has a hemolytic reaction to blood transfused 8 days ago. What is th
e most likely
cause? A. Immediate, nonimmunologic probably due to volume overload B. Delayed i
mmunologic,
probably due to an antibody such as antiJk a C. Delayed nonimmunologic, probabl
y due to iron
overload D. Immediate, immunologic, probably due to clerical error, ABO incompat
ibility Blood
bank/Apply knowledge of fundamental biological characteristics/Transfusion react
ions/2 Answers to
Questions 14 1. B Over 90% of transfusion reactions are due to some type of cle
rical error.
The most timesaving approach would be to check all paperwork before performing
any laboratory
testing. 2. D Anaphylactic or anaphylactoid reactions are the most severe form
of allergic
transfusion reaction and are associated with de cient or absent IgA in the patient
s, allowing

them the capability to form anti IgA. These patients must be transfused with wa
shed cellular
products where the plasma has been removed. 3. B A transfusion reaction that o
ccurs several
days after a transfusion of blood products is probably a delayed immunologic rea
ction due to an
antibody formed against donor antigens. This is a classic example of a reaction
caused by an
antibody such as antiJk a . 4. C TRALI is associated with antibodies to human
leukocyte
antigens or neutrophil antigens, which react with patient granulocytes and cause
acute
respiratory insu ciency. 4. What may be found in the serum of a person who is exhi
biting signs of
TRALI (transfusionrelated acute lung injury)? A. Red blood cell alloantibody B.
IgA antibody C.
Antileukocyte antibody D. Allergen Blood bank/Apply knowledge of fundamental bio
logical
characteristics/Transfusion reactions/1 2828_Ch04_121170 06/08/12 11:16 AM P
age 145 146
Chapter 4 | Immunohematology 5. Which type of transfusion reaction occurs in abo
ut 1% of all
transfusions, results in a temperature rise of 1C or higher, is associated with b
lood component
transfusion, and is not related to the patients medical condition? A. Immediate h
emolytic B.
Delayed hemolytic C. Febrile nonhemolytic reaction D. Transfusionrelated acute
lung injury Blood
bank/Apply knowledge of fundamental biological characteristics/Transfusion react
ions/1 6. What
would be the result of group A blood given to an O patient? A. Nonimmune transfu
sion reaction B.
Immediate hemolytic transfusion reaction C. Delayed hemolytic transfusion reacti
on D. Febrile
nonhemolytic transfusion reaction Blood bank/Apply knowledge of fundamental biol
ogical
characteristics/Transfusion reactions/2 7. Patient DB received 2 units of group
Apositive red
cells 2 days ago. Two days later, he developed a fever and appeared jaundiced. H
is blood type was
A positive. A transfusion reaction workup was ordered. Tere were no clerical err
ors detected. A
posttransfusion specimen was collected and a DAT performed. Te DAT was positive
with monospeci c
antiIgG. Te plasma was also hemolyzed. An antibody screen and panel studies rev
ealed the
presence of antiJk b (postspecimen). Te antibody screen on the pretransfusion s
pecimen was
negative. Which of the following explain the positive DAT? A. Te donor cells had
a positive DAT
B. Te donor cells were polyagglutinable C. Te donor cells were likely positive f
or the Jk b
antigen D. Te recipient cells were likely positive for the Jk b antigen Blood ba
nk/Apply
knowledge of fundamental biological characteristics/Transfusion reactions/3 8. A
ll of the
following are part of the preliminary evaluation of a transfusion reaction, exce
pt: A. Check pre
and posttransfusion samples for color of serum B. Perform ABO and Rh recheck C.
DAT on the

posttransfusion sample D. Panel on pre and posttransfusion samples Blood bank

/Apply knowledge
of standard operating procedures/Transfusion reactions/1 Answers to Questions 59
5. C A
febrile nonhemolytic transfusion reaction (FNHTR) is de ned by a rise in temperatu
re of 1C or
higher within 24 hours posttransfusion, and unexplained by other causes. The pa
tient has formed
antibodies to HLA, which react with donor cells and result in release of pyrogen
s. 6. B Group A
blood given to a group O patient would cause an immediate hemolytic transfusion
reaction because
a group O patient has antiA and antiB antibodies and would destroy A cells. 7.
C This is an
example of an anamnestic reaction where the patient was most likely exposed to t
he Jk b antigen
at some point in his life, and upon reexposure to the antigen, the antibody tit
er rose to
detectable levels. This resulted in a positive DAT and posttransfusion antibody
screen. 8. D
The preliminary evaluation of a transfusion reaction includes checking the color
of serum, and
performing ABO and Rh checks and a DAT on the posttransfusion sample. A panel w
ould not be part
of the preliminary workup. 9. C The temperature rose from 37.1C to 38.1C. The DA
T was
negative, and while blood was found on the urinalysis, microscopic red cells wer
e also found.
Since intact RBCs are not caused by a transfusion reaction, the cause of hematur
ia was not likely
transfusion related. A febrile nonhemolytic reaction is highly consistent with b
oth symptoms and
post transfusion test results. 9. A 68yearold female diagnosed with neutropen
ia and
in ammation of the left hand was typed as A positive, and received 1 packed red bl
ood cell unit.
Te antibody screen was negative and crossmatch was compatible. During the transf
usion, her pulse
was 94, and blood pressure rose from 114/59 to 132/64. Her temperature rose from
37.1C
pretransfusion to 37.8C 60 minutes after starting transfusion, then to 38.1C upon
completion. A
posttransfusion specimen yielded plasma that was neither hemolyzed nor icteric,
and a negative
DAT. Posttransfusion urinalysis gave a 1+ blood and protein with 10 RBCs/hpf mi
croscopically. Te
clerical check was acceptable. What type of reaction most likely occurred as a r
esult of
transfusion? A. Allergic B. Circulatory overload C. Febrile nonhemolytic D. Dela
yed hemolytic
Blood bank/Correlation of laboratory and clinical data/Transfusion reactions/3 2
828_Ch04_121170
06/08/12 11:16 AM Page 146 4.6 | Transfusion Reactions 147 10. A 92yearold
male diagnosed
with anemia and episodes of frequent falling was typed as B negative and transfu
sed 1 unit of
packed red blood cells, also B negative. He was not recently transfused, and the
antibody screen
was negative. During the transfusion, his temperature rose from 36.2C to 36.4C, hi
s pulse rose

from 96 to 124, respirations from 18 to 20, and BP from 127/81 to 174/83. He was
transfused with
205 mL before a reaction was called by the transfusionist. Te postspecimen DAT w
as negative and
clerical check acceptable. Urinalysis yielded 1+ blood with 5 RBCs microscopical
ly. Other
symptoms included tachycardia and ushing. What reaction had most likely taken pla
ce? A. Febrile
nonhemolytic B. Acute hemolytic C. Anaphylactic D. Volume overload Blood bank/Co
rrelation of
laboratory and clinical data/Transfusion reaction/3 11. A 76yearold female dia
gnosed with
urosepsis was transfused 2 units of packed red blood cells. Her type was AB posi
tive with a
negative antibody screen. Te units transfused were AB positive. Upon receiving t
he second unit,
the patient became hypoxic with tachypnea. Te clerical check was acceptable and
DAT negative. She
received 269 mL from the second unit before a reaction was called. Her temperatu
re fell from 38C
to 36.4C, her pulse increased from 72 to 90, and respirations rose from 35 to 41.
Her BP was
110/70. Te patient expired approximately 12 hours from the time the reaction was
called. What
type of reaction was most likely present? A. Febrile B. Symptoms not related to
transfusion C.
Allergic D. TRALI Blood bank/Correlate laboratory and clinical data/ Transfusion
reactions/3
Answers to Questions 1012 10. D The tachycardia, increased pulse, and volume tr
ansfused before
a reaction was called are consistent with volume overload. The temperature chang
e did not meet
criteria for a febrile reaction, and evidence for a hemolytic reaction is lackin
g. 11. B This
case emphasizes the statistic that not all causes of death are related to transf
usion. The
temperature dropped ruling out a febrile reaction; there was no evidence of pulm
onary edema or
hypotension seen with TRALI (and plasma products are more associated with TRALI
than red cells);
and there was no sign of hives or itching, which are often associated with an al
lergic reaction.
12. A This case represents an acute hemolytic reaction where the patient had p
revious
sensitization to E and c antigens. Given the history of antiFy a , an assumptio
n was made that
antiFy a was the cause of the positive reverse type with A 1 cells, even though
this antibody
does not react at IS. This brings to light the importance of running a panel whe
never the patient
has a positive antibody screen regardless of previous results. Hemoglobinuria, p
ositive DAT, and
the hemolyzed postspecimen all are consistent with an acute hemolytic reaction.
12. A 52yearold
male received 2 units of packed red blood cells as an outpatient in the IV thera
py unit. He had a
20year history of head trauma and was quadriplegic. He had recurrent pneumonia
and hematuria due
to removal of a Foley catheter. His blood type was A positive with a previously
identi ed antiFy

a . Tere was an ABO discrepancy in that the A 1 cells were positive. Te technolo
gist attributed
the reaction to the Fy a antigen being present on the A 1 cells. Te patient also
had a cold
autoantibody. Two units of Apositive packed cells were crossmatched that were F
y a negative, and
were compatible. One unit was transfused at 11:30 a.m. without incident. Te seco
nd unit was
transfused at 2:16 p.m., and stopped at 3:55 p.m. due to reddish browntinged urin
e discovered in
his collection bag. A posttransfusion specimen yielded a positive DAT, and plas
ma that was
grossly hemolyzed. A prewarm crossmatch was incompatible in both the pre and po
stspecimen.
AntiE and c were present in the postspecimen. What reaction was most likely pre
sent? A. Acute
hemolytic B. Febrile C. Allergic D. TRALI Blood bank/Correlate laboratory and cl
inical data/
Transfusion reactions/3 2828_Ch04_121170 06/08/12 11:16 AM Page 147 148 Chap
ter 4 |
Immunohematology 13. An 82yearold male was admitted for renal failure. His typ
e was B positive,
and his antibody screen was negative. Two units of red cells were ordered. Te rst
unit was
transfused at 1:00 p.m. without incident. Te second was started at 4:15 p.m. an
d stopped at 5:12
p.m., after the nurse observed the patient had expired. Vital signs were taken a
t 4:30 p.m. with
no abnormalities. A transfusion reaction was called and the blood unit, tubing,
and paperwork
sent to the blood bank. Tere were no clinical manifestations noted on the paperw
ork and no
posttransfusion specimen was sent to the blood bank. What type of reaction most
likely occurred?
A. Symptoms not related to transfusion B. Acute hemolytic reaction C. Anaphylact
ic reaction D.
Volume overload Blood bank/Correlate clinical and laboratory data/ Transfusion r
eactions/3 Answer
to Question 13 13. A This example represents a situation where the pathologist
was not provided
with all information needed to interpret the reaction. There were no patient sym
ptoms, the
patient had received another unit of red cells hours previously with no problems
, and a
postreaction specimen was not collected. Therefore, any serological abnormalitie
s could not be
identi ed. The FDA recommends collecting a specimen postmortem if a reaction is ca
lled, so that
the transfusion reaction investigation can be completed. In this case, the patho
logist
interpreted the reaction as symptoms not related to transfusion because no sympt
oms were
documented. 2828_Ch04_121170 06/08/12 11:16 AM Page 148 149 4.7 Components 1
. A male cancer
patient with a hemoglobin of 6 g/dL was admitted to the hospital with acute abdo
minal pain. Small
bowel resection was indicated, but the attending physician wanted to raise the p
atients
hemoglobin to 12 g/dL before surgery. How many units of RBCs would most likely b
e required to

accomplish this? A. 2 B. 3 C. 6 D. 8 Blood bank/Apply knowledge of fundamental b

iological
characteristics/Blood components/RBCs/2 2. Which of the following is not a viabl
e method for
removing leukocytes from red blood cells? A. Prestorage ltration B. Bedside ltrati
on C.
Poststorage ltration D. Bu y coat removal Blood bank/Apply knowledge of fundamental
biological
characteristics/Blood components/RBCs/1 3. Four units of packed RBCs were brough
t to the nurses
station at 10:20 a.m. Two units were transfused immediately, and 1 unit was tran
sfused at 10:40
a.m. Te remaining unit was returned to the blood bank at 11:00 a.m. Te units wer
e not
refrigerated after leaving the blood bank. What problem(s) is (are) present in t
his situation? A.
Te only problem is with the returned unit; the 30minute limit has expired and t
he unit cannot be
used B. Te unit should not have been transfused at 10:40 a.m. because the time l
imit had expired;
this unit and the remaining unit should have been returned to the blood bank C.
Te returned unit
may be held for this patient for 48 hours but cannot be used for another patient
D. No problems;
all actions were performed within the allowable time limits Blood bank/Select co
urse of
action/Blood components/ RBCs/3 Answers to Questions 14 1. C One unit of RBCs w
ill raise the
hemoglobin level by approximately 1 to 1.5 g/dL, and the hematocrit by 3%4%. Resu
lts vary
depending upon the age of the blood, and the patients blood volume and hydration
status. Six
units will raise the hemoglobin to at least 12 g/dL. 2. D Removal of the bu y co
at, which
contains both platelets and WBCs, is not an approved method for leukoreduction o
f red blood
cells. The other methods can be employed to achieve a leukoreduction of <5x10 6.
3. A There is
a 30minute time limit for a unit of RBCs that is not kept under proper storage
conditions
(1C6C). 4. B Platelets preparation from whole blood must be done within 8 hours o
f
collection. 4. A unit of whole blood is collected at 10:00 a.m. and stored at 20C2
4C. What is
the last hour platelet concentrates may be made from this unit? A. 4:00 p.m. B.
6:00 p.m. C. 7:00
p.m. D. 8:00 p.m. Blood bank/Apply knowledge of standard operating procedures/Bl
ood components/3
2828_Ch04_121170 06/08/12 11:16 AM Page 149 150 Chapter 4 | Immunohematology
5. Which of the
following is acceptable according to AABB standards? A. Rejuvenated RBCs may be
made within 3
days of outdate and transfused or frozen within 24 hours of rejuvenation B. Froz
en RBCs must be
prepared within 30 minutes of collection and may be used within 10 years C. Irra
diated RBCs must
be treated within 8 hours of collection and transfused within 6 hours D. Leukocy
tereduced RBCs
must be prepared within 6 hours of collection and transfused within 6 hours of p
reparation Blood

bank/Apply knowledge of laboratory operations/ Blood components/RBCs/2 6. Which

of the following
is true regarding apheresis platelets? A. Te minimum platelet count must be 3.0
10 11 , pH must
be 6.0 B. Te minimum platelet count must be 3.0 10 10 , pH must be 6.2 C. Te minim
um platelet
count must be 3.0 10 11 , pH must be 6.2 D. Te minimum platelet count must be 5.5
10 10 , pH
must be 6.0 Blood bank/Apply knowledge of laboratory operations/ Blood components
/Platelets/1 7.
What is the component of choice for a patient with chronic granulomatous disease
(CGD)? A. FFP B.
Granulocytes C. Cryoprecipitate D. RBCs Blood bank/Apply knowledge of laboratory
operations/
Blood components/3 8. What method can be employed to detect bacteria in random d
onor platelets?
A. pH B. Glucose C. Pan genera detection (PGD) assay D. Gram stain Blood bank/Ap
ply knowledge of
laboratory operations/ Blood components/Preparation of components/1 9. All of th
e following
statements regarding FFP are true, except: A. FFP must be prepared within 24 hou
rs of collection
B. After thawing, FFP must be transfused within 24 hours C. Storage temperature
for FFP with a
1year shelf life is 18C D. When thawed, FFP must be stored between 1C6C Blood bank/Ap
ply
knowledge of standard operating procedures/Blood components/RBCs/1 Answers to Qu
estions 510 5.
A Rejuvenated RBCs may be prepared within 3 days of the outdate of the unit and
washed and
transfused or frozen within 24 hours. A unit of RBCs may be frozen within 6 days
of collection.
An RBC unit can be irradiated any time prior to expiration date; once irradiated
, the unit must
be transfused within 28 days of irradiation or the original outdate, whichever c
omes rst.
Leukocytereduced RBCs should be prepared within 6 hours of collection, but must
be given within
24 hours, if prepared using an open system. Leukocytereduced RBCs prepared usin
g a closed system
may be kept until the original outdate. 6. C Singledonor platelets prepared b
y apheresis must
contain a minimum of 3.0 10 11 platelets and the pH must be 6.2 or higher throug
hout the shelf
life of the product. 7. B Patients with CGD cannot ght bacterial infections due
to
dysfunctional phagocytic enzymes; granulocyte concentrates are the product of ch
oice for these
patients. 8. C The FDA has mandated that pH and glucose can no longer be used
as a screening
test for platelets. The Verax PGD assay has been FDA approved for both singledo
nor platelets and
randomdonor platelets for bacteria screening. 9. A FFP must be prepared withi
n 8 hours after
collection if the anticoagulant is citrate phosphate dextrose (CPD), citrate pho
sphate double
dextrose (CP2D), or citrate phosphate dextrose adenine (CPDA1); or within 6 hou
rs if the
anticoagulant is ACD. 10. C A patient having cold agglutinins might have a rea
ction to a cold

blood product. The product should be warmed to 37C before transfusion. 10. What m
ay be done to
RBCs before transfusion to a patient with cold agglutinin disease in order to re
duce the
possibility of a transfusion reaction? A. Irradiate to prevent graftversushost
disease (GVHD)
B. Wash with 0.9% percent saline C. Warm to 37C with a blood warmer D. Transport
so that
temperature is maintained at 20C24C Blood bank/Apply knowledge of standard operatin
g
procedures/Hemotherapy/RBCs/2 2828_Ch04_121170 06/08/12 11:16 AM Page 150 4.
7 | Components
151 11. A unit of packed RBCs is split using the open system. One of the half un
its is used. What
may be done with the second half unit? A. Must be issued within 24 hours B. Must
be issued within
48 hours C. Must be irradiated D. Must retain the original expiration date Blood
bank/Apply
knowledge of laboratory operations/ Blood components/RBCs/2 12. What should be d
one if a
noticeable clot is found in an RBC unit? A. Issue the unit; the blood will be lte
red B. Issue
the unit; note the presence of a clot on the release form C. Filter the unit in
the blood bank
before issue D. Do not issue the unit Blood bank/Select course of action/Hemothe
rapy/ RBCs/2 13.
Cryoprecipitate may be used to treat all of the following, except: A. von Willeb
rands disease B.
Hypo brinogenemia C. Idiopathic thrombocytopenic purpura (ITP) D. Factor XIII de cie
ncy Blood
bank/Select best course of action/Hemotherapy/ Cryo/3 14. SITUATION: A transplan
t patient may
receive only type A or AB platelets. Tere are only type O apheresis platelets av
ailable. What
devices may be used to deplete the incompatible plasma and replace with sterile
saline? A.
Cytospin/irradiator B. Water bath/centrifuge C. Centrifuge/sterile connecting de
vice D. Cell
washer/heat sealer Blood bank/Apply knowledge of standard operating procedures/B
lood
components/Platelets/2 15. What component(s) is (are) indicated for patients who
have antiIgA
antibodies? A. Whole blood B. Packed RBCs C. Washed or deglycerolized RBCs D. Gr
anulocytes Blood
bank/Select course of action/Hemotherapy/2 16. FFP can be transfused without reg
ard for: A. ABO
type B. Rh type C. Antibody in product D. All of these options Blood bank/Apply
knowledge of
standard operating procedures/Blood components/FFP/1 Answers to Questions 1118 11
. A The other
half unit must be issued within 24 hours, if an open system is used to split the
unit. 12. D A
unit having a noticeable clot should not be issued for transfusion to a patient.
The clot may be
an indication of contamination or bacterial growth. 13. C Cryoprecipitate may
be used to treat
von Willebrands disease, hypo brinogenemia, and factor XIII de ciency, but is not ind
icated in
ITP. IVIG is the product of choice for ITP. 14. C In the event of an ABO misma
tched stem cell

transplant, special attention must be paid to the choice of transfused blood pro
ducts. Type A or
AB platelets may be given to a transplant in which the donor is A and the recipi
ent is O; once
the stem cells engraft, platelets/plasma must be compatible with type A cells. I
f only type O
singledonor platelets are available, the product can be spun down using a centr
ifuge and plasma
can be removed. Then, a sterile connecting device can be used to aseptically tra
nsfer sterile
isotonic saline to the platelet product, replacing the incompatible plasma. 15.
C Patients with
antiIgA antibodies should not receive components containing plasma. Washed or d
eglycerolized red
cells can be issued. 16. B FFP can be transfused without regard for Rh type be
cause FFP is not
a cellular product. 17. C Washed RBCs renders the system open and shortens the e
xpiration
time to 24 hours. 18. D Platelets require constant agitation and are stored be
tween 20C24C.
17. All of the following are true regarding washed RBCs, except: A. RBCs are was
hed with 12 L of
normal saline B. Volume is 180 mL C. Shelf life is extended D. Leukocytes are re
moved Blood
bank/Apply knowledge of standard operating procedures/Blood components/Processin
g/1 18. What is a
special condition for the storage of platelets? A. Room temperature, 20C24C B. No o
ther
components may be stored with platelets C. Platelets must be stored upright in s
eparate
containers D. Platelets require constant agitation at 20C24C Blood bank/Apply knowl
edge of
standard operating procedures/Blood components/Processing/1 2828_Ch04_121170 0
6/08/12 11:16 AM
Page 151 152 Chapter 4 | Immunohematology 19. Transfusion of an irradiated prod
uct is indicated
in all of the following conditions except: A. Exchange transfusion B. Bone marro
w transplant C.
Severe combined immunode ciency syndrome (SCIDS) D. Warm autoimmune hemolytic anem
ia (WAIHA)
Blood bank/Select course of action/Hemotherapy/ Irradiation/2 20. What percentag
e of red cells
must be retained in leukocytereduced red cells? A. 75% B. 80% C. 85% D. 100% Bl
ood bank/Apply
knowledge of standard operating procedures/Blood components/1 21. Which of the f
ollowing is true
regarding granulocyte concentrates? A. Te product must contain a maximum of 1.0
10 10
granulocytes B. Te pH must be 6.0 C. Te product must be crossmatched D. Te produ
ct must be
irradiated Blood bank/Apply knowledge of standard operating procedures/Blood com
ponents/2 22.
What course of action should be taken if a medical laboratory scientist inadvert
ently irradiates
a unit of red cells twice? A. Issue the unit B. Discard the unit C. Change the e
xpiration date;
then issue the unit D. Note on the irradiation sticker that the unit was irradia
ted twice and
issue Blood bank/Apply knowledge of standard operating procedures/Irradiation/2
23. What

components(s) may be shipped together with FFP? A. Frozen RBCs and cryoprecipita
te B. Platelets
C. Packed RBCs and granulocytes D. Double red cell Blood bank/Apply knowledge of
standard
operating procedures/Blood components/FFP/1 24. A blood supplier ships 3 units o
f pooled
cryoprecipitate. Each pool consists of 5 units of cryoprecipitate. If one unit i
s thawed at 5:00
p.m., when must it be dispensed from the blood bank? A. Before 9:00 p.m. B. Befo
re 11:00 p.m. C.
Before 12:00 a.m. D. Before 5:00 p.m. the next day Blood bank/Apply knowledge of
standard
operating procedures/Blood components/FFP/1 Answers to Questions 1926 19. D WAI
HA would not
require irradiation unless the patient had an underlying immunosuppressive disor
der. 20. C A
red cell unit that has been leukocyte reduced must retain 85% of original red ce
lls. 21. C
Granulocyte concentrates contain a large amount of red cells and must be crossma
tched with the
recipients serum. 22. B If a technologist mistakenly irradiates a unit of red c
ells more than
once, the unit must be discarded due to subsequent potassium accumulation. This
does not apply to
platelets. 23. A FFP requires dry ice for shipment. Frozen RBCs and cryoprecip
itate also
require dry ice. 24. A Pooled cryoprecipitate is a closed system; however, it
has an outdate of
4 hours once thawed. 25. A Gamma rays or xrays have the ability to prohibit a
lymphocytes
ability to divide, preventing TAGVHD. 26. C Frozen RBCs may be kept for up to
10 years. FFP
and Cryo stored at 18C or lower expire in 1 year. If FFP is kept at 65C or lower
, the
expiration time is 7 years. Platelet concentrates expire in 5 days. 25. How does
irradiation
prevent transfusion associated graftversushost disease (TAGVHD)? A. Gamma ray
s and xrays
destroy the lymphocytes ability to divide B. Xrays cause lysis of the lymphocyte
s C. Gamma rays
enhance lymphocyte reactivity D. Ultraviolet radiation induces apoptosis of lymp
hocytes Blood
bank/Apply knowledge of standard operating procedures/Blood components/Stem cell
s/1 26. Which
component has the longest expiration date? A. Cryoprecipitate B. FFP C. Frozen R
BCs D. Platelet
concentrates Blood bank/Apply knowledge of standard operating procedures/Blood b
ank/Expiration
date/1 2828_Ch04_121170 06/08/12 11:16 AM Page 152 4.7 | Components 153 27
. All of the
following are advantages of using single donor platelets as opposed to random d
onor platelets,
except: A. Less preparation time B. Less antigen exposure for patients C. May be
HLA matched D.
No pooling is required Blood bank/Apply principles of special procedures/ Blood
components/Platelets/1 28. What is the expiration of cryoprecipitate once pooled
? A. 4 hours B. 6
hours C. 8 hours D. 24 hours Blood bank/Apply knowledge of standard operating pr
ocedures/Blood
components/Expiration date/1 29. What is the number of white blood cells permitt

ed in a unit of
leukoreduced red cells? A. <5 10 10 B. <5 10 6 C. <8.3 10 5 D. <8.3 10 6 Blood b
ank/Apply
knowledge of standard operating procedures/Blood components/1 30. SITUATION: A c
ancer patient
recently developed a severe infection. Te patients hemoglobin is 8 g/dL owing to
chemotherapy
with a drug known to cause bone marrow depression and immunode ciency. Which blood
products are
indicated for this patient? A. Liquid plasma and cryoprecipitate B. Crossmatched
platelets and
washed RBCs C. Factor IX concentrates and FFP D. Irradiated RBCs, platelets, and
granulocytes
Blood bank/Correlate clinical and laboratory data/Blood and components/3 Answers
to Questions
2730 27. A Singledonor platelets require more preparation time than randomdon
or platelets
because they are prepared by apheresis, which may require 13 hours depending on t
he
instrumentation used. Pooling random donor platelets in equivalent amounts may r
equire only a few
minutes. 28. A When individual Cryo units are pooled in an open system, the ex
piration time is
4 hours; if Cryo is pooled using a sterile connecting device, the expiration tim
e is 6 hours. 29.
B Red cells that have been leukoreduced must have fewer than 5 10 6 white cell
s per unit. 30.
D This cancer patient may be immunocompromised from the medication but needs t
o receive RBCs
for anemia; therefore, irradiated RBCs are indicated. Platelets may be needed to
control
bleeding, and granulocytes may be indicated for shortterm control of severe inf
ection.
2828_Ch04_121170 06/08/12 11:16 AM Page 153 154 4.8 Donors 1. Which of the f
ollowing
individuals is acceptable as a blood donor? A. A 29yearold man who received th
e hepatitis B
vaccine last week B. A 21yearold woman who had her nose pierced last week C. A
30yearold man
who lived in Zambia for 3 years and returned last month D. A 54yearold man who
tested positive
for hepatitis C last year, but has no active symptoms of disease Blood bank/Appl
y knowledge of
standard operating procedures/Donor requirements/2 2. SITUATION: A 53yearold w
oman donates
blood at her place of employment. She weighs 150 lb and has a hemoglobin of 13 g
/dL. She is
currently on warfarin and vitamin B 12 . Is she an acceptable donor? A. Yes B. N
o, she is on
warfarin C. Yes, for red cells only D. No, her hemoglobin is too low Blood bank/
Apply knowledge
of standard operating procedures/Donor requirements/2 3. Which immunization has
the longest
deferral period? A. HBIG B. Rubella vaccine C. In uenza vaccine D. Yellow fever va
ccine Blood
bank/Apply knowledge of standard operating procedures/Donor requirements/1 4. Te
following whole
blood donors regularly give blood. Which donor may donate on September 10th? A.
A 40yearold
woman who last donated on July 23rd B. A 28yearold man who had plateletpheresi

s on August 24th
C. A 52yearold man who made an autologous donation 2 days ago D. A 23yearold
woman who
donated blood for her aunt on August 14th Blood bank/Apply knowledge of standard
operating
procedures/Donor requirements/2 Answers to Questions 15 1. A If the donor is sy
mptom free,
there is no deferral period for the hepatitis B vaccine. Persons who have had bo
dy piercing are
given a 12month deferral. Persons who lived in an area endemic for malaria or w
ho received
antimalarial drugs are deferred for 3 years. A positive test for the HCV is caus
e for permanent
deferral. 2. C Her age and hemoglobin meet donor criteria. However, because sh
e is currently on
warfarin, only red cells can be prepared from her donation. 3. A Deferral for
HBIG injection is
12 months. Deferral for rubella vaccine is 4 weeks. The deferral period for in uen
za and yellow
fever vaccines is 2 weeks. 4. B A plateletpheresis donor must wait at least 48
hours between
donations. The waiting period following an autologous donation is at least 3 day
s. An 8week
interval must pass between all other types of donations. 5. A To be eligible f
or
plateletpheresis, the platelet count should be >150 10 9 for a frequent platelet
donor. Plasma
loss exceeding 1,000 mL would be cause for rejection, 800 mL would not. A donor
may donate 24
times a year, but not as frequent as once every 2 days in a 7day period. A dono
r cannot ingest
aspirin within 36 hours of platelet donation. 5. Which of the following preclude
s acceptance of a
plateletpheresis donor? A. Platelet count of 75 10 9
/
L in a donor who is a
frequent platelet donor B. Plasma loss of 800 mL from plasmapheresis 1 w
eek ago C.
Plateletpheresis performed 4 days ago D. Aspirin ingested 7 days ago Blood bank/
Apply knowledge
of standard operating procedures/Donor requirements/1 2828_Ch04_121170 06/08/1
2 11:16 AM Page
154 4.8 | Donors 155 6. Which of the following donors could be accepted for wh
oleblood
donation? A. A construction worker who was incarcerated for opiate abuse B. A tr
iathlete with a
pulse of 45 C. A man who is currently taking nasteride (Propecia) D. A woman in h
er 14th week of
pregnancy Blood bank/Apply knowledge of standard operating procedures/Donor requ
irements/2 7.
Which physical examination result is cause for rejecting a wholeblood donor? A.
Weight of 105 lb
B. Pulse of 75 C. Temperature of 99.3 F D. Diastolic pressure of 110 mm Hg Blood
bank/Apply
knowledge of standard operating procedures/Donor requirements/1 8. Which situati
on is not a cause
for inde nite deferral of a donor? A. Male currently on dutasteride (Avodart) B. D
onation of a
unit of blood that transmitted hepatitis B virus to a recipient C. History of Cr
eutzfeldtJacob
disease D. Accidental needle stick 1 year ago; negative for infectious disease B

lood bank/Apply
knowledge of standard operating procedures/Donor requirements/1 9. A wholeblood
donor currently
on clopidogrel (Plavix) is precluded from donating which product? A. Platelets B
. Red blood cells
C. FFP D. Cryoprecipitate Blood bank/Select course of action/Donor processing/ U
nacceptable
donors/3 10. How much anticoagulant would have to be removed from the collection
bag given a
donor who weighs 90 lb? A. 12 mL B. 15 mL C. 20 mL D. 23 mL Blood bank/Apply kno
wledge of
standard operating procedures/Donor collection/3 Answers to Questions 611 6. B
Athletes may
have a pulse below 50 and may still be acceptable as blood donors. Drug addictio
n is cause for
permanent deferral, as is a major illness. The deferral period following treatme
nt for syphilis
or gonorrhea is 12 months. 7. D Diastolic pressure must not be higher than 100
mm Hg. Donors
weighing less than 110 lb may donate up to 12% of their blood volume (volume = w
eight in kg/50
450 mL). Oral temperature must not be greater than 99.5 F. Blood pressure limits
for donation
are 180 mmHg for systolic and 100 mmHg for diastolic pressure. The limit for hem
oglobin is 12.5
g/dL, and for hematocrit 38%. 8. D An accidental needle stick would not be a c
ause for
inde nite deferral of a donor. The deferral period is 1 year. 9. A Clopidogrel r
enders
platelets nonfunctional and therefore potential donors on this medication cannot
donate
platelets. 10. A To determine the amount of anticoagulant to remove when the d
onor is less than
110 lb, divide weight by 110 lb and multiply by 450 mL; divide that number by 10
0 and multiply by
14 (this gives the anticoagulant volume needed); then subtract this from 63 mL,
which is the
standard volume of anticoagulant in a 450 mL bag. The result is the amount of an
ticoagulant to
remove. 11. C This woman is hyperventilating; therefore, the donation should b
e discontinued. A
paper bag should be provided for the donor to breathe into in order to increase
the carbon
dioxide in the donors air. 11. A woman begins to breathe rapidly while donating b
lood. Choose
the correct course of action. A. Continue the donation; rapid breathing is not a
reason to
discontinue a donation B. Withdraw the needle, raise her feet, and administer am
monia C.
Discontinue the donation and provide a paper bag D. Tell her to sit upright and
apply a cold
compress to her forehead Blood bank/Select course of action/Donor processing/ Do
nor adverse
reactions/3 2828_Ch04_121170 06/08/12 11:16 AM Page 155 156 Chapter 4 | Immu
nohematology 12.
A donor bag is half lled during donation when the blood ow stops. Select the corre
ct course of
action. A. Closely observe the bag for at least 3 minutes; if blood ow does not r
esume, withdraw
the needle B. Remove the needle immediately and discontinue the donation C. Chec

k and reposition
the needle if necessary; if blood ow does not resume, withdraw the needle D. With
draw the needle
and perform a second venipuncture in the other arm Blood bank/Select course of
action/Collection/3 13. Who is the best candidate for a predeposit autologous do
nation? A. A
45yearold man who is having elective surgery in 2 weeks; he has alloantik B.
A 23yearold
female leukemia patient with a hemoglobin of 10 g/dL C. A 12yearold boy who ha
s hemophilia D. A
53yearold woman who has septicemia Blood bank/Select course of action/Donor pr
ocessing/
Autologous donation/2 14. Can an autologous donor donate blood on Monday, if he
is having surgery
on Friday? A. Yes, he or she can donate up to 72 hours before surgery B. No, he
or she cannot
donate within 7 days of surgery C. Yes, he or she can donate, but only a half a
unit D. No, he or
she cannot donate within 5 days of surgery Blood bank/Apply knowledge of standar
d operating
procedures/Autologous donation/2 15. Which of the following is an acceptable tim
e in which a unit
of whole blood is collected? A. 33 minutes B. 25 minutes C. 20 minutes D. 13 min
utes Blood
bank/Apply knowledge of standard operating procedures/Collection/1 16. Which of
the following is
true regarding acute normovolemic hemodilution? A. One or more units of blood ar
e withdrawn from
the patient and replaced with FFP B. Units removed may be stored in the operatin
g room at room
temperature for 8 hours C. Units removed may be stored in the operating room at
room temperature
for 24 hours D. Unused units can be added to the general donor blood inventory B
lood bank/Apply
knowledge of standard operating procedures/Autologous donation/2 Answers to Ques
tions 1217 12.
C If blood ow has stopped, check the needle rst. If blood ow does not resume after
repositioning, then withdraw the needle and discontinue the donation. Do not per
form a second
venipuncture on the donor. 13. A The 45yearold man with alloantik is the be
st candidate for
predeposit autologous donation because compatible blood will be hard to nd if he
needs blood
after surgery. The other candidates may not be good choices for donation because
the process may
prove harmful to them. 14. A An autologous donor can donate up to 72 hours bef
ore expected
surgery. 15. D A unit of whole blood should be collected within 15 minutes. 16
. B In acute
normovolemic hemodilution, one or more units of blood are removed from the donor
and replaced
with crystalloid or colloid. Blood may be stored at room temp for up to 8 hours
or at 1C6C for
up to 24 hours. Bleeding during surgery results in less RBC loss after hemodilut
ion, and the
autologous red cells are infused after bleeding stops. Such units are for autolo
gous transfusion
only. 17. A The minimum hematocrit for a double red cell donation is 40%. 17.
All of the
following apply to a double red cell unit apheresis collection except: A. Te hem

atocrit must be
at least 38% B. Te weight for a female is at least 150 lb C. Te height for a mal
e is at least 5
ft 1 in. D. Te deferral period following collection is 16 weeks Blood bank/Apply
knowledge of
standard operating procedures/Apheresis/1 2828_Ch04_121170 06/08/12 11:16 AM
Page 156 4.8 |
Donors 157 18. An autologous unit of whole blood was collected on a 33yearol
d woman in
preparation for a knee replacement procedure in 3 weeks. Te whole blood unit had
her hyphenated
last name, rst name, and last four digits of her social security number for ident
i cation. Te
lab computer system, however, only had her married name and rst name, medical rec
ord number, and
social security number. What should be done with this blood product? A. Discard
the unit B. Make
the unit available for transfusion C. Confirm the name with donor and have admis
sions make the
correction in the computer system, then make the unit available for transfusion
D. Ensure that
social security numbers match, con rm the name with donor and have admissions make
the correction
in the computer system with the medical directors approval, then make the unit av
ailable for
transfusion Blood bank/Standard operating procedures/Autologous donation/3 19. W
hat is the
youngest age a person can make an allogeneic wholeblood donation? A. 14 B. 15 C
. 16 D. 17 Blood
bank/Apply knowledge of standard operating procedures/Donation/1 20. Which of th
e following
vaccinations carries no deferral period? A. Rubella B. Varicella zoster C. Recom
binant HPV D.
Smallpox Blood bank/Apply knowledge of standard operating procedures/Donors/1 An
swers to
Questions 1820 18. D This is a common scenario with women who have recently mar
ried, and have
not changed their license or other form of identi cation given to the collection f
acility.
Checking that other demographic information matches is su cient if approved by the
medical
director, because an autologous unit is very di cult to replace in time for surger
y. 19. C In
most states, the youngest age a person can donate is 16 with parental permission
. 20. C
Vaccines developed by recombinant technology carry no deferral period. 2828_Ch04
_121170
06/08/12 11:16 AM Page 157 158 4.9 Hemolytic Disease of the Newborn (HDN) 1. A
ll of the
following are reasons for a positive DAT on cord blood cells of a newborn except
: A. High
concentrations of Whartons jelly on cord cells B. Immune antiA from an O mother
on the cells of
an A baby C. Immune antiD from an Rh negative mother on the cells of an Rhposi
tive baby D.
Immune antiK from an Knegative mother on the cells of a Knegative baby Blood
bank/Correlate
clinical and laboratory data/ Hemolytic disease of the newborn/DAT/2 2. A fetal
screen yielded
negative results on a mother who is O negative and infant who is O positive. Wha

t course of
action should be taken? A. Perform a KleihauerBetke test B. Issue one full dose o
f RhIg C.
Perform a DAT on the infant D. Perform an antibody screen on the mother Blood ba
nk/Select course
of action/Hemolytic disease of the newborn/Rosette test/3 3. What should be done
when a woman who
is 24 weeks pregnant has a positive antibody screen? A. Perform an antibody iden
ti cation panel;
titer if necessary B. No need to do anything until 30 weeks gestation C. Adminis
ter Rh immune
globulin (RhIg) D. Adsorb the antibody onto antigenpositive cells Blood bank/Ap
ply knowledge of
standard operating procedures/Hemolytic disease of the newborn/Antibody testing/
2 4. All of the
following are interventions for fetal distress caused by maternal antibodies att
acking fetal
cells except: A. Intrauterine transfusion B. Plasmapheresis on the mother C. Tra
nsfusion of
antigenpositive cells to the mother D. Early induction of labor Blood bank/Appl
y knowledge of
standard operating procedures/Hemolytic disease of the newborn/Clinical interven
tions/2 Answers
to Questions 15 1. D Immune antiK from the mother would not coat the babys red
cells if they
did not contain the K antigen; therefore, the DAT would be negative. 2. B If t
he fetal screen
or rosette test is negative, indicating the fetal maternal blood is negligible i
n a possible RhIg
candidate, standard practice is to issue one dose of RhIg. 3. A The identi catio
n of the
antibody is very important at this stage of the pregnancy. If the antibody is de
termined to be
clinically signi cant, then a titer may determine the strength of the antibody and
the need for
clinical intervention. 4. C Transfusion of antigenpositive cells to the mothe
r who already has
an antibody might cause a transfusion reaction and/or evoke an even stronger ant
ibody response,
possibly causing more harm to the fetus. 5. A If the cord cells contain excess
ive Whartons
jelly, then further washing or obtaining another cord sample will not solve the
problem. A
heelstick sample will not contain Whartons jelly and should give a valid DAT resu
lt. 5. Cord
cells are washed six times with saline and the DAT and negative control are stil
l positive. What
should be done next? A. Obtain a heelstick sample B. Record the DAT as positive
C. Obtain another
cord sample D. Perform an elution on the cord cells Blood bank/Select course of
action/Hemolytic
disease of the newborn/DAT/3 2828_Ch04_121170 06/08/12 11:16 AM Page 158 4.9
| Hemolytic
Disease of the Newborn (HDN) 159 6. What can be done if HDN is caused by mater
nal antiK? A.
Give Kell immune globulin B. Monitor the mothers antibody level C. Prevent format
ion of
Kpositive cells in the fetus D. Not a problem; antiK is not known to cause HDN
Blood bank/Apply
principles of special procedures/ Hemolytic disease of the newborn/Antibody form

ation/2 7. Should
an Onegative mother receive RhIg if a positive DAT on the newborn is caused by
immune antiA? A.
No, the mother is not a candidate for RhIg because of the positive DAT B. Yes, i
f the babys type
is Rh negative C. Yes, if the babys type is Rh positive D. No, the babys problem i
s unrelated
to Rh blood group antibodies Blood bank/Correlate clinical and laboratory data/
Hemolytic disease
of the newborn/RhIg/3 8. Should an Anegative woman who has just had a miscarria
ge receive RhIg?
A. Yes, but only if she does not have evidence of active AntiD B. No, the type
of the baby is
unknown C. Yes, but only a minidose regardless of trimester D. No, RhIg is given
for term
pregnancies only Blood bank/Apply knowledge of standard operating procedures/Hem
otherapy/RhIg/3
9. SITUATION: The Ortho Provue reports a type on a woman who is 6 weeks pregnant
with vaginal
bleeding as O negative. The woman tells the emergency department physician she i
s O positive and
presents a blood donor card. The medical laboratory scientist performs a test fo
r weak D and
observes a 1+ reaction in AHG phase. A KleihauerBetke test is negative. Is this w
oman a
candidate for RhIg? A. No, she is Rh positive B. Yes, she is a genetic weak D C.
No, there is no
evidence of a fetal bleed D. Yes, based upon the Provue results Blood bank/Corre
late clinical and
laboratory results/ Hemolytic disease of the newborn/RhIg/3 Answers to Questions
610 6. B
AntiD is the only antibody for which prevention of HDN is possible. If a pregna
nt woman develops
antiK, she will be monitored to determine if the antibody level and signs of fe
tal distress
necessitate clinical intervention. 7. C RhIg is immune antiD and is given to
Rhnegative
mothers who give birth to Rhpositive babies and who do not have antiD already
formed from
previous pregnancies or transfusion. 8. A When the fetus is Rh positive or the
Rh status of the
fetus is unknown, termination of a pregnancy from any cause presents a situation
in which an
Rhnegative patient should receive RhIg. A minidose is used if the pregnancy is
terminated in the
rst trimester. 9. A The negative KleihauerBetke test con rms that the positive rea
ction of
the womans RBCs with antiD at IAT is not the result of a fetalmaternal bleed. T
he woman is
weak D positive, and, therefore, is not a candidate for RhIg. Typically, a test
for weak D is not
done as part of the obstetric workup. In such cases, if the rosette test is posi
tive, the mother
is given RhIg. 10. B An Onegative mother who gives birth to an Apositive bab
y and has no
antiD formed from a previous pregnancy would be a candidate for RhIg. A mother
who already has
active antiD or a mother who gives birth to an Rhnegative baby is not a candid
ate for RhIg.
AntiD formation via active immunization typically has a titer >4, compared with

passive
administration of antiD, which has a titer <4. 10. Which of the following patie
nts would be a
candidate for RhIg? A. Bpositive mother; Bnegative baby; rst pregnancy; no anti
D in mother B.
Onegative mother; Apositive baby; second pregnancy; no antiD in mother C. An
egative mother;
Onegative baby; fourth pregnancy; antiD in mother D. ABnegative mother; Bpos
itive baby;
second pregnancy; antiD in mother Blood bank/Correlate clinical and laboratory
data/ Hemolytic
disease of the newborn/RhIg/2 2828_Ch04_121170 06/08/12 11:16 AM Page 159 16
0 Chapter 4 |
Immunohematology 11. A KleihauerBetke acid elution test identi es 40 fetal cells in
2,000
maternal red cells. How many full doses of RhIg are indicated? A. 1 B. 2 C. 3 D.
4 Blood
bank/Calculate/Hemolytic disease of the newborn/RhIg/2 12. Kernicterus is caused
by the e ects
of: A. Anemia B. Unconjugated bilirubin C. Antibody speci city D. Antibody titer B
lood bank/Apply
knowledge of biological principles/ Hemolytic disease of the newborn/1 13. Anti
E is detected in
the serum of a woman in the rst trimester of pregnancy. Te rst titer for antiE is
32. Two
weeks later, the antibody titer is 64 and then 128 after another 2 weeks. Clinic
ally, there are
beginning signs of fetal distress. What may be done? A. Induce labor for early d
elivery B.
Perform plasmapheresis to remove antiE from the mother C. Administer RhIg to th
e mother D.
Perform an intrauterine transfusion using Enegative cells Blood bank/Correlate
clinical and
laboratory data/ Hemolytic disease of the newborn/3 14. What testing is done for
exchange
transfusion when the mothers serum contains an alloantibody? A. Crossmatch and an
tibody screen
B. ABO, Rh, antibody screen, and crossmatch C. ABO, Rh, antibody screen D. ABO a
nd Rh only Blood
bank/Apply knowledge of standard operating procedures/Hemolytic disease of the n
ewborn/
Hemotherapy/1 15. Which blood type may be transfused to an ABpositive baby who
has HDN caused by
antiD? A. AB negative, CMV negative, Hgb S negative; irradiated or O negative,
CMV negative, Hgb
S negative B. AB positive, CMV negative; irradiated or O positive, CMV negative
C. AB negative
only D. O negative only Blood bank/Select course of action/Hemolytic disease of
the
newborn/Hemotherapy/2 Answers to Questions 1116 11. D To calculate the number o
f vials of RhIg
to infuse, divide 40 by 2,000 and multiply by 5,000, which is the estimated tota
l blood volume of
the mother in milliliters. Divide this number by 30 to arrive at the number of d
oses. When the
number to the right of the decimal point is less than 5, round down and add one
dose of RhIg.
Conversely, when the number to the right of the decimal point is 5 or greater, r
ound up and add
one dose of RhIg. In this example, the number of doses is 3.3. Rounding down and

adding 1 vial
gives an answer of 4 vials. 12. B Kernicterus occurs because of high levels of
unconjugated
bilirubin. High levels of this pigment cross into the central nervous system, ca
using brain
damage to the infant. 13. B Plasmapheresis removes excess antiE from the moth
er and provides a
temporary solution to the problem until the fetus is mature enough to be deliver
ed. The procedure
may need to be performed several times, depending upon how quickly and how high
the levels of
antiE rise. Administration of RhIg would not contribute to solving this problem
caused by
antiE. Intrauterine transfusion would not be performed before week 20, and woul
d be considered
only if there is evidence of severe hemolytic disease. 14. B ABO (forward) and
Rh are required.
An antibody screen using either the neonatal serum or maternal serum is required
. A crossmatch is
necessary as long as maternal antibody persists in the infants blood. 15. A Eit
her ABnegative
or Onegative RBCs may be given to an ABpositive baby because both types are AB
O compatible and
lack the D antigen. 16. B An antibody screen is not performed routinely on a c
ord blood sample
because a baby does not make antibodies until about 6 months of age. Any antibod
ies detected in a
cord blood sample come from the mother. 16. All of the following are routinely p
erformed on a
cord blood sample except: A. Forward ABO typing B. Antibody screen C. Rh typing
D. DAT Blood
bank/Apply knowledge of laboratory operations/ Hemolytic disease of the newborn/
Cord blood/1
2828_Ch04_121170 06/08/12 11:16 AM Page 160 4.9 | Hemolytic Disease of the N
ewborn (HDN)
161 17. Why do Rhnegative women tend to have a positive antibody screen compare
d to Rhpositive
women of childbearing age? A. Tey have formed active antiD B. Tey have received
RhIg C. Tey have
formed antiK D. Tey have a higher rate of transfusion Blood bank/Apply knowledg
e of biological
principles/ Hemolytic disease of the newborn/3 18. SITUATION: An Onegative moth
er gave birth to
a Bpositive infant. Te mother had no history of antibodies or transfusion. Tis
was her rst
child. Te baby was mildly jaundiced and the DAT weakly positive with polyspeci c a
ntisera. What
could have caused the positive DAT? A. AntiD from the mother coating the infant
red cells B. An
alloantibody, such as antiK, coating the infant red cells C. Maternal antiB co
ating the infant
cells D. Maternal antiA, B coating the infant cells Blood bank/Correlate clinic
al and laboratory
data/ Hemolytic disease of the newborn/3 19. SITUATION: RhIg is requested on a 2
8yearold woman
with suspected abortion. When the nurse arrives in the blood bank to pick up the
RhIg, she asks
the medical laboratory scientist (MLS) if it is a minidose. Te MLS replies that
it is a full
dose, not a minidose. Te nurse then requests to take 50 mcg from the 300 mcg syr

inge to satisfy
the physicians orders. What course of action should the MLS take? A. Let the nurs
e take the
syringe of RhIg, so that she may withdraw 50 mcg B. Call a supervisor or patholo
gist C. Instruct
the nurse that the blood bank does not stock minidoses of RhIg and manipulating
the full dose
will compromise the purity of the product D. Instruct the nurse that the blood b
ank does not
stock minidoses of RhIg, and relay this information to the patients physician Blo
od bank/Select
course of action/Hemolytic disease of the newborn/RhIg/3 Answers to Questions 171
9 17. B The
most common reason an Rhnegative woman has a positive antibody screen is becaus
e of previously
receiving RhIg or passive antiD. 18. D AntiA,B is an IgG antibody and can cr
oss the placenta
and attach to infant cells. It is known as a single entity as opposed to separat
e antibodies.
AntiD would not be the cause because this is the rst pregnancy. AntiK is not th
e cause because
there is no history of alloantibodies or past transfusions. 19. D Blood banks
operate by strict
standard operating procedures. These include which products are supplied from th
e blood bank.
While B may also be a solution, D is the best answer because the patients physici
an can
communicate with the pathologist once he or she receives this information from t
he nurse.
2828_Ch04_121170 06/08/12 11:16 AM Page 161 162 4.10 Serological Testing of
Blood Products 1.
What protocol is followed when screening whole blood donors for HIV1 RNA? A. Po
ols of 10 are
tested; if the pool is nonreactive, donors are accepted B. Pools of 20 are teste
d; if the pool is
reactive, samples are tested individually C. Pools of up to 16 donors are tested
; if pool is
reactive, individual samples are screened D. All donors are screened individuall
y; if samples are
reactive, blood is discarded Blood bank/Standard operating procedures/Processing
/3 2. Currently,
nucleic acid ampli cation testing (NAT) testing is performed to detect which virus
es? A. HIV and
HTLV1 B. HTLV I/II C. HIV, HCV, and WNV D. HIV, HBV, and WNV Blood bank/Apply k
nowledge of
standard operating procedures/Processing/1 3. John comes in to donate a unit of
whole blood at
the collection center of the community blood supplier. Te EIA screen is reactive
for
antiHIV1/2. Te test is repeated in duplicate and is nonreactive. John is: A. C
leared for
donation B. Deferred for 6 months C. Status is dependent on con rmatory test D. De
ferred for 12
months Blood bank/Select course of action/Processing/3 4. What marker is the rst
to appear in
hepatitis B infection? A. AntiHBc (IgM) B. HbsAg C. AntiHBs D. AntiHBc (IgG)
Blood bank/Apply
knowledge of biological principles/ Processing/1 Answers to Questions 15 1. C P
ools of up to
16 donors are tested by nucleic acid ampli cation technology. If the pool is react

ive, samples
from each individual donor are tested. 2. C According to AABB standards, NAT t
esting is
required for viruses HIV1, HCV, and WNV. 3. A If the initial EIA screen for a
ntiHIV is
reactive, and the test is repeated in duplicate and found to be nonreactive, the
blood components
may be used. 4. B The rst viral marker of hepatitis B to appear in the serum on
ce exposed is
the HBSAg, which appears in as few as 5 days (528 days postexposure). 5. C Anti
HBs is
indicative of immunity or vaccination to hepatitis B. AntiHBc (IgM) occurs in t
he early stage of
infection; antiHBc (IgG) follows and may persist for years following infection.
HBsAg is a
marker of HBV infection, not immunity. 5. What marker indicates immunity to hepa
titis B
infection? A. AntiHBc (IgM) B. HBsAg C. AntiHBs D. AntiHBc (IgG) Blood bank/A
pply knowledge of
standard operating procedures/Processing/1 2828_Ch04_121170 06/08/12 11:16 AM
Page 162 4.10 |
Serological Testing of Blood Products 163 6. An EIA screening test for HTLV I/
II was performed
on a wholeblood donor. Te results of the EIA were repeatedly reactive but the c
on rmatory test
was negative. On the next donation, the screening test was negative by two di eren
t EIA tests. Te
donor should be: A. Accepted B. Deferred C. Told that only plasma can be made fr
om his donation
D. Told to come back in 6 months Blood bank/Select best course of action/Process
ing/3 7. A unit
tests positive for syphilis using the rapid plasma reagin test (RPR). Te microhe
magglutinin
assayTreponema pallidum (MHATP) on the same unit is negative. What is the disp
osition of the
unit? A. Te unit may be used to prepare components B. Te donor must be contacted
and questioned
further; if the RPR result is most likely a false positive, then the unit may be
used C. Te unit
must be discarded D. Cellular components may be prepared but must be irradiated
before issue
Blood bank/Apply knowledge of standard operating procedures/Processing/2 8. SITU
ATION: John Smith
donated a unit of whole blood in May. Red blood cells made from the whole blood
were transfused
to a recipient of a community hospital in June with no apparent complications. T
e blood supplier
noti ed the medical director of the hospital that the donor reported highrisk beh
avior with
another male in April, although viral tests remain negative and the donor is hea
lthy. What course
of action should be taken? A. No action should be taken B. Te recipients physicia
n should be
noti ed C. Te recipients physician and the recipient should be noti ed D. Te recipien
t should be
noti ed Blood bank/Apply knowledge of biological principles/ Market withdrawal/3 9
. All of the
following are required tests on donor blood, except: A. HBsAg B. AntiCMV C. HIV
1 D. AntiHTLV
I/II Blood bank/Apply knowledge of standard operating procedures/Processing/1 An

swers to
Questions 610 6. A If screening results are repeatedly reactive and the con rmato
ry test is
negative for antiHTLV and upon the next donation the EIA is negative by two di er
ent methods,
the donor may be accepted. 7. A This is a case of a falsepositive screening t
est (RPR). The
con rmatory test for treponemal antibodies was negative. The donor unit is accepta
ble and may be
used to prepare blood components. 8. B The recipients physician should be noti ed
by the
medical director to ascertain the current health status of the recipient, if kno
wn, and determine
what treatment, if any, the recipient should receive. 9. B Testing of donor bl
ood for
antibodies to CMV is not required. However, testing may be done on units intende
d for transfusion
to low birth weight infants born to seronegative mothers or units used for intra
uterine
transfusion; units intended for immunocompromised patients who are seronegative;
prospective
transplant recipients who are seronegative; or transplant recipients who have re
ceived a
seronegative organ. Leukoreduced RBCs carry a reduced risk of transmitting CMV a
nd are
recommended for such patients when CMV testing has not been performed on donor u
nits. The
prevalence of antiCMV in the population ranges from 40%90%. 10. A According to
current FDA
and CDC criteria, a sample is de ned as antiHIV positive if at least two of the f
ollowing bands
are present on a Western Blot: p24, gp41, and/or GP120/160. 10. Which of the fol
lowing bands
would constitute a positive Western Blot for HIV? A. p24, gp41, p17 B. p55, gp12
0, p51 C. gp160,
p31, p56 D. p24, p30, p55 Blood bank/Apply knowledge of standard operating
procedures/Processing/1 2828_Ch04_121170 06/08/12 11:16 AM Page 163 1. Is th
ere a discrepancy
between the following blood typing and secretor study results? Blood typing resu
lts: AntiA
AntiB A 1 cells B cells 4+ 0 0 4+ Secretor results: AntiA + saliva
+ A 1 cells = 0
AntiB + saliva + B cells = 4+ AntiH + saliva + O cells = 0 A. No problem, the
sample is from a
group A secretor B. Blood types as A and saliva types as B C. Blood types as A,
but the secretor
study is inconclusive D. No problem, the sample is from a group A nonsecretor Bl
ood bank/Evaluate
laboratory data to make identi cations/Saliva neutralization/3 2. What is the best
course of
action given the following test result? (Assume the patient has not been transfu
sed recently.)
AntiA AntiB A 1 cells B cells Mixed eld 0 1+ 4+ A. Nothing, typing
is normal B.
Type patient cells with antiA 1 lectin and type serum with A 2 cells C. Retype
patient cells;
type with antiH and antiA,B; use screen cells or A 2 cells on patient serum; r
un patient
autocontrol D. Wash patient cells four times with saline, then repeat the forwar
d type Blood

bank/Apply principles of special procedures/ RBCs/ABO discrepancy/3 Answers to Q

uestions 13 1.
A The blood typing result demonstrates A antigen on the red cells and antiB in
the serum. The
secretor result reveals the A antigen in the saliva. The A antigen neutralized t
he antiA,
preventing agglutination when A 1 cells were added. Each blood type (except a Bo
mbay) contains
some H antigen; therefore, the H antigen in the saliva would be bound by antiH
reagent. No
agglutination would occur when the O cells are added. 2. C The mixed eld reacti
on with antiA
suggests a subgroup of A, most likely A 3. The reverse grouping shows weak agglu
tination with A 1
cells, indicating antiA 1. A positive reaction with antiA,B would help to di ere
ntiate an A
subgroup from group O. If A 2 cells are not agglutinated by patient serum, the r
esult would
indicate the presence of antiA 1. If the patients serum agglutinates A 2 cells,
then an
alloantibody or autoantibody should be considered. 3. B The scenario showed an
antibody in the
patient serum directed toward the M antigen, and the M antigen happened to be on
the A 1 cells in
reverse grouping. To solve this problem, nd A 1 cells negative for the M antigen
or enzyme treat
the A 1 cells to resolve the ABO discrepancy. 3. Te following results were obtai
ned on a
41yearold female: AntiA AntiB A 1 cells B cells O cells 4+ 0 3+
4+ 3+ Due to
the discrepant reverse grouping, a panel was performed on patient serum revealin
g the presence of
antiM. How can the reverse grouping be resolved? A. Repeat the reverse grouping
with a 10minute
incubation at room temperature B. Repeat the reverse grouping using A 1 cells th
at are negative
for M antigen C. Repeat the reverse grouping using A 1 cells that are positive f
or M antigen D.
No further work is necessary Blood bank/Evaluate laboratory data to recognize pr
oblems/ABO
discrepancy/3 164 4.11 Immunohematology Problem Solving 2828_Ch04_121170 06/08
/12 11:16 AM
Page 164 4.11 | Immunohematology Problem Solving 165 4. A 59yearold male cam
e through the
emergency department of a community hospital complaining of dizziness and fatigu
e. History
included no transfusions and a positive rheumatoid factor 1 year ago. His CBC co
n rmed anemia. A
sample was sent to the blood bank for a type and crossmatch. Upon receipt of the
sample in the
blood bank, the MLS noticed the EDTA sample appeared very viscous. Fearing the s
ample would clog
the ProVue, testing was performed using the tube method. Initial results reveale
d the following:
AntiA AntiB AntiD Rh Control A 1 cells B cells 0 0 4+ 2+ 4+
4+ Te patients
red cells were washed eight times with saline, and testing was repeated giving t
he following
results: AntiA AntiB AntiD Rh Control A 1 cells B cells 0 0 4+
0 4+ 4+ Te

antibody screen was negative at IS, 37C, and AHG phases; check cells were positiv
e. Crossmatch
testing using two Opositive donor units revealed a 1+ at immediate spin, and ne
gative results at
37C and AHG phases. Te check cells were positive. In light of the crossmatch resu
lts, what is
the next course of action? A. Use other donor cells for the crossmatch B. Perfor
m a saline
replacement for the crossmatch C. Run the crossmatch using the Gel system D. Res
ult the
crossmatch as incompatible Blood bank/Correlate clinical and laboratory data/Rh
discrepancy/3 5.
Te following results were obtained on a 51yearold male with hepatitis C: Anti
A AntiB
AntiD A 1 cells B cells 4+ 4+ 3+ 0 0 What should be done next? A. R
etype the
patients sample to con rm group AB positive B. Repeat the Rh typing C. Run a saline
control in
forward grouping D. Report the patient as group AB, Rh positive Blood bank/Apply
knowledge of
routine laboratory procedures/ABO/2 Answers to Questions 47 4. B The history of
the patient
correlates with abnormal plasma proteins causing a positive result with the Rh c
ontrol. Perform a
saline replacement technique to rectify the incompatible crossmatches at immedia
te spin. 5. C
In the case of an ABpositive person, a saline control must be run in forward gr
ouping to obtain
a negative reaction; this will ensure agglutination is speci c in the other reacti
ons. 6. C The
most likely genotype is R 1 R 1 . The possibilities are DCe/DCe or DCe/dCe, whic
h translates to R
1 R 1 or R 1 r. The former is more common. 7. C Because the patient has never b
een transfused
or pregnant, she probably has not formed any atypical antibodies. Because she is
Rh negative she
would have received a dose of RhIg at 28 weeks (antenatal dose) if her prenatal
antibody screen
had been negative. Although technical error cannot be ruled out, it is far less
likely than RhIg
administration. 6. An Rh phenotyping shows the following results: AntiD Anti
C AntiE
Antic Antie 4+ 2+ 0 0 3+ What is the most likely Rh genotype? A. R 1
r B. R 0 r C. R
1 R 1 D. R 1 r Blood bank/Apply knowledge of fundamental biological characterist
ics/Rh typing/3
7. An obstetric patient, 34 weeks pregnant, shows a positive antibody screen at
the indirect
antiglobulin phase of testing. She is group B, Rh negative. Tis is her rst pregna
ncy. She has no
prior history of transfusion. What is the most likely explanation for the positi
ve antibody
screen? A. She has developed an antibody to fetal red cells B. She probably does
not have
antibodies because this is her rst pregnancy, and she has not been transfused; ch
eck for
technical error C. She received an antenatal dose of RhIg D. Impossible to deter
mine without
further testing Blood bank/Correlate clinical and laboratory data/ Hemolytic dis
ease of the

newborn/3 2828_Ch04_121170 06/08/12 11:16 AM Page 165 166 Chapter 4 | Immuno

hematology 8. A
patients serum contains a mixture of antibodies. One of the antibodies is identi ed
as antiD.
AntiJk a or antiFy a and possibly another antibody are present. What technique
(s) may be
helpful to identify the other antibody(s)? A. Enzyme panel; select cell panel B.
Tio reagents C.
Lowering the pH and increasing the incubation time D. Using albumin as an enhanc
ement media in
combination with selective adsorption Blood bank/Apply principles of special pro
cedures/ Antibody
ID/3 9. An antiM reacts strongly through all phases of testing. Which of the fo
llowing
techniques would not contribute to removing this reactivity so that more clinica
lly signi cant
antibodies may be revealed? A. Acidifying the serum B. Prewarmed technique C. Ad
sorption with
homozygous cells D. Testing with enzymetreated red cells Blood bank/Apply princ
iples of special
procedures/ Antibody ID/3 10. Te reactivity of an unknown antibody could be anti
Jk a , but the
antibody identi cation panel does not t this pattern conclusively. Which of the fol
lowing would
not be e ective in determining if the speci city is antiJk a ? A. Testing with enzy
metreated
cells B. Select panel of homozygous cells C. Testing with AETtreated cells D. I
ncreased
incubation time Blood bank/Apply principles of special procedures/ Antibody ID/3
11. A
coldreacting antibody is found in the serum of a recently transfused patient an
d is suspected to
be antiI. Te antibody identi cation panel shows reactions with all cells at room
temperature,
including the autocontrol. Te reaction strength varies from 2+ to 4+. What proce
dure would help
to distinguish this antibody from other coldreacting antibodies? A. Autoadsorpt
ion technique B.
Neutralization using saliva C. Autocontrol using ZZAP reagenttreated cells D. R
eaction with cord
cells Blood bank/Apply principles of special procedures/ Antibody ID/3 Answers t
o Questions 811
8. A An enzyme panel would help to distinguish between antiJk a (reaction enh
anced) and
antiFy a (destroyed). AntiD, however, would also be enhanced and may mask reac
tions that may
distinguish another antibody. A select panel of cells negative for D may help to
reveal an
additional antibody or antibodies. 9. A Lowering the pH will actually enhance
reactivity of
antiM. Prewarming (antiM is a coldreacting antibody), cold adsorption with ho
mozygous M cells,
and testing the serum with enzymetreated red cells (destroys M antigens) are al
l techniques to
remove reactivity of antiM. 10. C AET denatures Kell antigens and has no e ect
on Kidd
antibodies. Because the detection of Kidd antibodies is subject to dosage e ect, s
election of
cells homozygous for the Jk a antigen (and longer incubation) would help to dete
ct the presence

of the corresponding antibody. Enzymetreated red cells would also react more st
rongly in the
presence of Kidd antibodies. 11. D Because RBCs contain variable amounts of I
antigen,
reactions with antiI often vary in agglutination strength. However, because thi
s patient was
recently transfused, the variation in reaction strength may be the result of an
antibody mixture.
Although autoadsorption would remove antiI, this procedure does not con rm the an
tibody
speci city and can result in removal of other antibodies, as well. Cord cells expr
ess primarily i
antigen with very little I antigen. AntiI would react weakly or negatively with
cord RBCs. ZZAP
removes IgG antibodies from red cells. Because antiI is IgM, the use of ZZAP wo
uld not be of
value. 2828_Ch04_121170 06/08/12 11:16 AM Page 166 4.11 | Immunohematology P
roblem Solving
167 12. An antibody identi cation panel reveals the presence of antiLe b and a po
ssible second
speci city. Saliva from which person would best neutralize the Le b antibody? A. B
. C. D. Blood
bank/Apply principles of special procedures/ Antibody ID/3 13. Te Ortho Provue d
oes not detect
weak forms of the D antigen. Why would running type and screens on the Provue pr
event a patient
with a weak D phenotype from forming antiD? A. Weak D persons cannot form anti
D B. Te Provue
would result the sample as Rh negative; the patient would receive Rhnegative bl
ood C. Te Provue
would result the sample as Rh positive; the patient would receive Rhpositive bl
ood D. A and C
Blood bank/Correlate clinical and laboratory data/ Blood group antigens/2 14. A
cord blood workup
was ordered on Baby Boy Jones. Te mother is O negative. Results on the baby are
as follows:
AntiA AntiB AntiA, B AntiD DAT (poly) 4+ 0 4+ 0 2+ Te test f
or weak D was
positive at AHG. Is the mother an RhIg candidate? A. No, the baby is Rh positive
B. Yes, the
babys Rh type cannot be determined due to the positive DAT C. No, the baby is Rh
negative D.
Yes, the mother is Rh negative Blood bank/Evaluate laboratory data/Rh type/3 15.
Red cells from a
recently transfused patient were DAT positive when tested with antiIgG. Screen
cells and a panel
performed on a patients serum showed very weak reactions with inconclusive result
s. What
procedure could help to identify the antibody? A. Elution followed by a panel on
the eluate B.
Adsorption followed by a panel on the adsorbed serum C. Enzyme panel D. Antigen
typing the
patients red cells Blood bank/Apply principles of special procedures/ Antibody id
enti cation/3
Answers to Questions 1215 12. C Lewis antibodies are usually not clinically sig
ni cant but may
interfere with testing for clinically signi cant antibodies. Lewis antibodies are
most easily
removed by neutralizing them with soluble Lewis substance. The Lewis antigens ar
e secreted into

saliva and plasma and are adsorbed onto the red cells. Le b substance is made by
adding an
Lfucose to both the terminal and next to last sugar residue on the type 1 precu
rsor chain. This
requires the Le, H, and Se genes. Since some examples of antiLe b react only wi
th group O or A 2
RBCs, neutralization is best achieved if the saliva comes from a person who is g
roup O. 13. B
The Ortho Provue would result the patient with a weak D phenotype as Rh negative
, and if blood
were needed, the patient would receive Rhnegative blood. 14. B The baby forwa
rd types as an A
and the mother is O negative. It is possible that antiA,B from the mother is at
taching to the
babys red cells, causing a positive DAT. In the presence of a positive DAT, a wea
k test for D is
not valid. Therefore, the babys Rh type is unknown and the mother would be a cand
idate for RhIg.
15. A If the red cells show a positive DAT, then IgG antibody has coated incom
patible,
antigenpositive red cells. If screening cells and panel cells show missing or w
eak reactions,
most of the antibody is on the red cells and would need to be eluted before it c
an be detected.
An elution procedure followed by a panel performed on the eluate would help to i
dentify the
antibody. Genes Lewis ABO Secretor Le H sese Le hh Se Le H Se le
le hh sese
2828_Ch04_121170 06/08/12 11:16 AM Page 167 168 Chapter 4 | Immunohematology
16. A patient
types as O positive. All three screen and red cells from two Opositive donor un
its show
agglutination after incubation at 37C, and increase in reactivity at the IAT phas
e of testing.
What action should be taken next? A. Perform an autocontrol and direct antiglobu
lin test on the
patient B. Perform an enzyme panel C. Perform an elution D. Choose another 2 uni
ts and repeat the
crossmatch Blood bank/Select course of action/Incompatible crossmatch/3 17. Four
units of blood
are ordered for a patient. Blood bank records are checked and indicate that 5 ye
ars ago this
patient had an antiJk b . What is the next course of action? A. Antigen type un
its for the Jk b
antigen and only crossmatch units positive for Jk b B. Antigen type units for th
e Jk b antigen
and only crossmatch units negative for Jk b C. Randomly pull 4 units of blood th
at are ABO
compatible and crossmatch D. Perform an immediate spin crossmatch on 4 Jk b neg
ative units Blood
bank/Apply principles of laboratory operations/ Compatibility testing/3 18. A 56
yearold patient
diagnosed with colon cancer demonstrates a positive antibody screen in all three
screen cells at
the antiglobulin phase. A panel study is done and shows 10 cells positive as wel
l as the
autocontrol at the antiglobulin phase. Te reactions varied from 1+ to 3+. Tis pa
tient had a
history of receiving 2 units of blood approximately 1 month ago. What should be
done next? A.

Perform a DAT on the patient cells B. Perform an autoadsorption C. Perform an al

loadsorption D.
Issue Onegative cells Blood bank/Evaluate laboratory data to determine best cou
rse of
action/Panel study/3 Answers to Questions 1619 16. A All screening cells and al
l units are
positive at both 37C and the IAT phase. This indicates the possibility of a high
frequency
alloantibody or a warm autoantibody. An autocontrol would help to make this dist
inction. A
positive autocontrol indicates an autoantibody is present; a negative autocontro
l and positive
screen cells indicates an alloantibody. A DAT would be performed to determine if
an antibody has
coated the patients red cells, and is directed against screening cells and donor
cells. 17. B
A patient with a history of a signi cant antibody like antiJk b must receive bloo
d that has been
completely crossmatched and negative for the corresponding antigen; otherwise, a
n anamnestic
reaction may occur with subsequent lysis of donor cells. 18. C In this situati
on, an allogeneic
adsorption must be performed to adsorb out the autoantibody and leave potential
alloantibodies in
the patients serum that will need to be identi ed before transfusion of blood to th
e patient. An
autoadsorption cannot be performed due to the fact that any alloantibodies would
be absorbed by
circulating donor cells from a month prior. 19. C AntiP 1 is a coldreacting
antibody. Warming
the plasma at 37C will dissipate the antibody, preventing its reactivity with P 1
antigen on the
A 1 cells. 19. A 33yearold maternity patient is drawn for a type and screen at
36 weeks
gestation. Te following results are found on the Ortho Provue: AntiA AntiB
AntiA, B
AntiD A 1 cells B cells 3+ 0 4+ 4+ 2+ 4+ SCI SCII SCIII A 1
lectin 0 0 0
3+ Te reference lab identi ed antiP 1 in the patient plasma using enzyme techni
ques. How could
the ABO discrepancy be solved? A. Wash the patients red cells and repeat the forw
ard grouping B.
Test the patients plasma against A 2 cells C. Warm the patient plasma at 37C for 1
0 minutes and
repeat the reverse grouping D. Treat the A 1 cells with dithiothreitol and repea
t the reverse
grouping Blood bank/Evaluate laboratory data to determine possible inconsistent
results/ABO/3
2828_Ch04_121170 06/08/12 11:16 AM Page 168 4.11 | Immunohematology Problem
Solving 169 20.
An Onegative mother with no record of any previous pregnancies gives birth to h
er rst child, a
Bpositive baby. Te babys DAT is weakly positive and the negative control is nega
tive. Te
antibody screen is also negative. Te baby appears healthy but develops mild jaun
dice after 2
days, which is treated with phototherapy. Te baby goes home after 4 days in the
hospital without
complications. What is the most likely explanation for the weakly positive DAT?
A. Technical

error B. A low titer antiD C. Immune antiB from the mother D. A maternal antib
ody against a
lowincidence antigen Blood bank/Correlate clinical and laboratory data/ Hemolyt
ic disease of the
newborn/2 Answer to Question 20 20. C In this case, the maternal antiA,B is p
robably coating
the infants B cells, causing a positive DAT and jaundice. AntiA,B from an O pers
on is a single
entity that cannot be separated. It is IgG and can cross the placenta. This anti
body may attach
to A, B, or AB red cells. BI BL I OGRAPHY 1. American Association of Blood Banks
. Standards for
Blood Banks and Transfusion Services. 27th edition, 2011. Bethesda, MD. 2. Harme
ning D. Modern
Blood Banking and Transfusion Practices. 5th edition, 2005. F.A. Davis, Philadel
phia. 3. Issitt
PD. Applied Blood Group Serology. 1998. Montgomery Scienti c Publications, Miami.
4. Quinley E.
Immunohematology: Principles and Practice. 3rd edi tion, 2010. Lippincott Willi
ams & Wilkins,
Philadelphia. 5. Roback JD. American Association of Blood Banks Technical Man u
al. 17th edition,
2011. American Association of Blood Banks, Bethesda, MD. 6. Rudmann SV. Textbook
of Blood Banking
and Transfusion Medi cine. 2nd edition, 2005. W.B. Saunders, Philadelphia. 7. T
urgeon ML.
Fundamentals of Immunohematology. 2nd edition, 1995. Lippincott Williams & Wilki
ns, Philadelphia.
2828_Ch04_121170 06/08/12 11:16 AM Page 169 2828_Ch04_121170 06/08/12 11:
16 AM Page 170
CHAPTER 5 5.1 Instrumentation 5.2 Blood Gases, pH, and Electrolytes 5.3 Glucose,
Hemoglobin,
Iron, and Bilirubin 5.4 Calculations, Quality Control, and Statistics 5.5 Creati
nine, Uric Acid,
Bun, and Ammonia 5.6 Proteins, Electrophoresis, and Lipids 5.7 Enzymes and Cardi
ac Markers 5.8
Clinical Endocrinology 5.9 Toxicology and Terapeutic Drug Monitoring 5.10 Tumor
Markers 5.11
Clinical Chemistry Problem Solving 171 Clinical Chemistry 2828_Ch05_171326 06/
08/12 5:14 PM
Page 171 2828_Ch05_171326 06/08/12 5:14 PM Page 172 Answers to Questions 15 1
. D Absorbance
is proportional to the inverse log of transmittance. A = log T = log 1/T Multiply
ing the
numerator and denominator by 100 gives: A = log (100/100 X T) 100 X T = %T, subs
tituting %T for
100 X T gives: A = log 100/%T A = log 100 log %T A = 2.0 log %T For example, if
%T = 10.0,
then: A = 2.0 log 10.0 log 10.0 = 1.0 A = 2.01.0 = 1.0 2. B A = 2.0 log %T A = 2.
0 log 1.0
The log of 1.0 = 0 A = 2.0 3. D Beers law states that A = a b c, where a is the a
bsorptivity
coe cient (a constant), b is the path length, and c is concentration. Absorbance i
s directly
proportional to both b and c. Doubling the path length results in incident light
contacting twice
the number of molecules in solution. This causes absorbance to double, the same
e ect as doubling
the concentration of molecules. 4. A A solution transmits light corresponding in
wavelength to

its color, and usually absorbs light of wavelengths complementary to its color.
A red solution
transmits light of 600650 nm and strongly absorbs 400500 nm light. 5. B Green ligh
t consists of
wavelengths from 500550 nm. A greencolored solution with a transmittance maximum
of 525 nm and
a 50nm bandpass transmits light of 525 nm and absorbs light below 475 nm and ab
ove 575 nm. A
solution that is green would be quantitated using a wavelength that it absorbs s
trongly, such as
450 nm. 1. Which formula correctly describes the relationship between absorbance
and %T ? A. A =
2 log %T B. A = log 1/T C. A = log T D. All of these options Chemistry/Identify b
asic
principle(s)/Instrumentation/2 2. A solution that has a transmittance of 1.0 %T
would have an
absorbance of: A. 1.0 B. 2.0 C. 1% D. 99% Chemistry/Calculate/Beers law/2 3. In a
bsorption
spectrophotometry: A. Absorbance is directly proportional to transmittance B. Pe
rcent
transmittance is directly proportional to concentration C. Percent transmittance
is directly
proportional to the light path length D. Absorbance is directly proportional to
concentration
Chemistry/De ne fundamental characteristics/ Beers law/1 4. Which wavelength would
be absorbed
strongly by a redcolored solution? A. 450 nm B. 585 nm C. 600 nm D. 650 nm Chem
istry/De ne
fundamental characteristics/ Spectrophotometry/2 5. A greencolored solution wou
ld show highest
transmittance at: A. 475 nm B. 525 nm C. 585 nm D. 620 nm Chemistry/De ne fundamen
tal
characteristics/ Spectrophotometry/2 5.1 Instrumentation 173 2828_Ch05_171326
06/08/12 5:14 PM
Page 173 6. SITUATION: A technologist is performing an enzyme assay at 340 nm u
sing a
visiblerange spectrophotometer. After setting the wavelength and adjusting the
readout to zero
%T with the light path blocked, a cuvette with deionized water is inserted. With
the light path
fully open and the 100%T control at maximum, the instrument readout will not ris
e above 90%T.
What is the most appropriate rst course of action? A. Replace the source lamp B.
Insert a wider
cuvette into the light path C. Measure the voltage across the lamp terminals D.
Replace the
instrument fuse Chemistry/Select course of action/Spectrophotometry/3 7. Which t
ype of
monochromator produces the purest monochromatic light in the UV range? A. A di rac
tion grating
and a xed exit slit B. A sharp cuto
lter and a variable exit slit C. Interference lt
ers and a
variable exit slit D. A prism and a variable exit slit Chemistry/Select
component/Spectrophotometry/2 8. Which monochromator speci cation is required in o
rder to measure
the true absorbance of a compound having a natural absorption bandwidth of 30 nm
? A. 50nm
bandpass B. 25nm bandpass C. 15nm bandpass D. 5nm bandpass Chemistry/Select
component/Spectrophotometry/2 9. Which photodetector is most sensitive to low le
vels of light? A.

Barrier layer cell B. Photodiode C. Diode array D. Photomultiplier tube Chemistr

y/De ne
fundamental characteristics/ Instrumentation/1 10. Which condition is a common c
ause of stray
light? A. Unstable source lamp voltage B. Improper wavelength calibration C. Dis
persion from
secondorder spectra D. Misaligned source lamp Chemistry/Identify sources of
error/Spectrophotometry/2 174 Chapter 5 | Clinical Chemistry Answers to Question
s 610 6. A
Visible spectrophotometers are usually supplied with a tungsten or quartz haloge
n source lamp.
Tungsten lamps produce a continuous range of wavelengths from about 3202,000 nm.
Output
increases as wavelength becomes longer peaking at around 1,000 nm, and is poor b
elow 400 nm. As
the lamp envelope darkens with age, the amount of light reaching the photodetect
or at 340 nm
becomes insufficient to set the blank reading to 100%T. Quartz halogen lamps pro
duce light from
300 nm through the infrared region. Deuterium or hydrogen lamps produce ultravio
letrich spectra
optimal for ultraviolet (UV) work. Mercury vapor lamps produce a discontinuous s
pectrum that
includes a high output at around 365 nm that is useful for fluorescent applicati
ons. Xenon lamps
generate a continuous spectrum of fairly uniform intensity from 3002,000 nm, maki
ng them useful
for both visible and UV applications. 7. D Diffraction gratings and prisms both
produce a
continuous range of wavelengths. A diffraction grating produces a uniform separa
tion of
wavelengths. A prism produces much better separation of highfrequency light bec
ause refraction
is greater for higherenergy wavelengths. Instruments using a prism and a variab
le exit slit can
produce UV light of a very narrow bandpass. The adjustable slit is required in o
rder to allow
sufficient light to reach the detector to set 100%T. 8. D Bandpass refers to the
range of
wavelengths passing through the sample. The narrower the bandpass, the greater t
he photometric
resolution. Bandpass can be made smaller by reducing the width of the exit slit.
Accurate
absorbance measurements require a bandpass less than one fth the natural bandpass
of the
chromophore. 9. D The photomultiplier tube uses dynodes of increasing voltage to
amplify the
current produced by the photosensitive cathode. It is 10,000 times as sensitive
as a barrier
layer cell, which has no ampli cation. A photomultiplier tube requires a DCregula
ted lamp
because it responds to light uctuations caused by the AC cycle. 10. C Stray light
is caused by
the presence of any light other than the wavelength of measurement reaching the
detector. It is
most often caused by secondorder spectra, deteriorated optics, light dispersed
by a darkened
lamp envelope, and extraneous room light. 2828_Ch05_171326 06/08/12 5:14 PM
Page 174 11. A
linearity study is performed on a visible spectrophotometer at 650 nm and the fo

llowing
absorbance readings are obtained: Te study was repeated using freshly prepared s
tandards and
reagents, but results were identical to those shown. What is the most likely cau
se of these
results? A. Wrong wavelength used B. Insu cient chromophore concentration C. Matri
x interference
D. Stray light Chemistry/Identify sources of error/Spectrophotometry/3 12. Which
type of lter is
best for measuring stray light? A. Wratten B. Didymium C. Sharp cuto D. Neutral d
ensity
Chemistry/Select methods/Reagents/Media/ Spectrophotometry/2 13. Which of the fo
llowing materials
is best suited for verifying the wavelength calibration of a spectrophotometer?
A. Neutral
density lters B. Potassium dichromate solutions traceable to the National Bureau
of Standards
reference C. Wratten lters D. Holmium oxide glass Chemistry/Identify standard ope
rating
procedure/ Spectrophotometry/2 14. Why do many optical systems in chemistry anal
yzers utilize a
reference light path? A. To increase the sensitivity of the measurement B. To mi
nimize error
caused by source lamp uctuation C. To obviate the need for wavelength adjustment
D. To reduce
stray light e ects Chemistry/De ne fundamental characteristics/ Spectrophotometry/2
5.1 |
Instrumentation 175 Answers to Questions 1114 11. D Stray light is the most com
mon cause of
loss of linearity at highanalyte concentrations. Light transmitted through the
cuvette is lowest
when absorption is highest. Therefore, stray light is a greater percentage of th
e detector
response when sample concentration is high. Stray light is usually most signi cant
when
measurements are made at the extremes of the visible spectrum because lamp outpu
t and detector
response are low. 12. C Sharp cutoff filters transmit almost all incident light
until the cutoff
wavelength is reached. At that point, they cease to transmit light. Because they
give an all or
none effect, only stray light reaches the detector when the selected wavelength i
s beyond the
cutoff. 13. D Wavelength accuracy is verified by determining the wavelength read
ing that gives
the highest absorbance (or transmittance) when a substance with a narrow natural
bandpass (sharp
absorbance or transmittance peak) is scanned. For example, didymium glass has a
sharp absorbance
peak at 585 nm. Therefore, an instrument should give its highest absorbance read
ing when the
wavelength dial is set at 585 nm. Holmium oxide produces a very narrow absorbanc
e peak at 361 nm;
likewise, the hydrogen lamp of a UV spectrophotometer produces a 656nm emission
line that can be
used to verify wavelength. Neutral density filters and dichromate solutions are
used to verify
absorbance accuracy or linearity. A Wratten filter is a wide bandpass filter ma
de by placing a
thin layer of colored gelatin between two glass plates and is unsuitable for spe

ctrophotometric
calibration. 14. B A reference beam is used to produce an electrical signal at t
he detector to
which the measurement of light absorption by the sample is compared. This safegu
ards against
measurement errors caused power fluctuations that change the source lamp intensi
ty. Although
reference beams increase the accuracy of measurements, they do so at the expense
of optical
sensitivity since some of the incident light must be used to produce the referen
ce beam.
Concentration of Standard Absorbance 10.0 mg/dL 0.20 20.0 mg/dL 0.41 30.0 mg/d
L 0.62 40.0 mg/dL
0.79 50.0 mg/dL 0.92 2828_Ch05_171326 06/08/12 5:14 PM Page 175 15. Which co
mponent is
required in a spectrophotometer in order to produce a spectral absorbance curve?
A. Multiple
monochromators B. A reference optical beam C. Photodiode array D. Laser light so
urce
Chemistry/De ne fundamental characteristics/ Spectrophotometry/1 16. Te halfband
width of a
monochromator is de ned by: A. Te range of wavelengths passed at 50% maximum trans
mittance B.
Onehalf the lowest wavelength of optical purity C. Te wavelength of peak transm
ittance D.
Onehalf the wavelength of peak absorbance Chemistry/De ne fundamental characteris
tics/
Spectrophotometry/1 17. Te reagent blank corrects for absorbance caused by: A. T
e color of
reagents B. Sample turbidity C. Bilirubin and hemolysis D. All of these options
Chemistry/Identify basic principle(s)/Spectrophotometry/2 18. A plasma sample is
hemolyzed and
turbid. What is required to perform a sample blank in order to correct the measu
rement for the
intrinsic absorbance of the sample when performing a spectrophotometric assay? A
. Substitute
deionized water for the sample B. Dilute the sample 1:2 with a standard of known
concentration C.
Substitute saline for the reagent D. Use a larger volume of the sample Chemistry
/Identify basic
principle(s)/Spectrophotometry/2 19. Which instrument requires a highly regulate
d DC power
supply? A. A spectrophotometer with a barrier layer cell B. A colorimeter with m
ultilayer
interference lters C. A spectrophotometer with a photomultiplier tube D. A densit
ometer with a
photodiode detector Chemistry/Select component/Spectrophotometry/2 176 Chapter 5
| Clinical
Chemistry Answers to Questions 1519 15. C There are two ways to perform spectral
scanning for
compound identi cation. One is to use a stepping motor that continuously turns the
monochromator
so that the wavelength aligned with the exit slit changes at a constant rate. A
more practical
method is to use a diode array detector. This consists of a chip embedded with a
s many as several
hundred photodiodes. Each photodiode is aligned with a narrow part of the spectr
um produced by a
di raction grating, and produces current proportional to the intensity of the band
of light

striking it (usually 12 nm in range). The diode signals are processed by a comput

er to create a
spectral absorbance or transmittance curve. 16. A Halfband width is a measure o
f bandpass made
using a solution or lter having a narrow natural bandpass (transmittance peak). T
he wavelength
giving maximum transmittance is set to 100%T (or 0 A). Then, the wavelength dial
is adjusted
downward, until a readout of 50%T (0.301 A) is obtained. Next, the wavelength is
adjusted upward
until 50%T is obtained. The wavelength di erence is the halfband width. The narro
wer the
halfband width, the better the photometric resolution of the instrument. 17. A
When a
spectrophotometer is set to 100%T with the reagent blank instead of water, the a
bsorbance of
reagents is automatically subtracted from each unknown reading. The reagent blan
k does not
correct for absorbance caused by interfering chromogens in the sample such as bi
lirubin,
hemolysis, or turbidity. 18. C A sample blank is used to subtract the intrinsic
absorbance of the
sample usually caused by hemolysis, icterus, turbidity, or drug interference. On
automated
analyzers, this is accomplished by measuring the absorbance after the addition o
f sample and a
rst reagent, usually a diluent. For tests using a single reagent, sample blanking
can be done
prior to the incubation phase before any color develops. Substituting deionized
water for sample
is done to subtract the absorbance of the reagent (reagent blanking). Diluting t
he sample with a
standard (standard addition) may be done when the absorbance is below the minimu
m detection limit
for the assay. Using a larger volume of sample will make the interference worse.
19. C When AC
voltage regulators are used to isolate source lamp power, light output uctuates a
s the voltage
changes. Because this occurs at 60 Hz, it is not detected by eyesight or slowre
sponding
detectors. Photomultiplier tubes are sensitive enough to respond to the AC frequ
ency and require
a DCregulated power supply. 2828_Ch05_171326 06/08/12 5:14 PM Page 176 20.
Which statement
regarding re ectometry is true? A. Te relation between re ectance density and concen
tration is
linear B. Singlepoint calibration can be used to determine concentration C. 100
% re ectance is
set with an opaque lm called a white reference D. Te diode array is the photodete
ctor of choice
Chemistry/Apply principles of special procedures/ Instrumentation/2 21. Bichroma
tic measurement
of absorbance can correct for interfering substances if: A. Te contribution of t
he interferent to
absorbance is the same at both wavelengths B. Both wavelengths pass through the
sample
simultaneously C. Te side band is a harmonic of the primary wavelength D. Te chr
omogen has the
same absorbance at both wavelengths Chemistry/Apply principles of special proced
ures/

Instrumentation/2 22. Which instrument requires a primary and secondary monochro

mator? A.
Spectrophotometer B. Atomic absorption spectrophotometer C. Fluorometer D. Nephe
lometer
Chemistry/Apply principles of special procedures/ Instrumentation/1 23. Which of
the following
statements about uorometry is accurate? A. Fluorometry is less sensitive than spe
ctrophotometry
B. Fluorometry is less speci c than spectrophotometry C. Unsaturated cyclic molecu
les are often
uorescent D. Fluorescence is directly proportional to temperature Chemistry/Apply
principles of
special procedures/ Instrumentation/2 24. Which of the following components is n
ot needed in a
chemiluminescent immunoassay analyzer? A. Source lamp B. Monochromator C. Photod
etector D. Wash
station Chemistry/De ne fundamental characteristics/ Instrumentation/1 5.1 | Instr
umentation
177 Answers to Questions 2024 20. C Re ectometry does not follow Beers law, but the
relationship between concentration and re ectance can be described by a logistic f
ormula or
algorithm that can be solved for concentration. For example, K/S = (1 R) 2
/
2R, where K = KubelkaMunk absorptivity
constant, S = scattering coe cient, R = re ectance density. K/S is proportio
nal to
concentration. The white reference is analogous to the 100%T setting in spectrop
hotometry and
serves as a reference signal. D r = log R 0
/R
1 , where D r is the re ectance density, R 0 is the white reference signal
, and R 1 is the
photodetector signal for the test sample. 21. A In bichromatic photometry, the a
bsorbance of
sample is measured at two di erent wavelengths. The primary wavelength is at or ne
ar the
absorbance maximum. An interfering substance having the same absorbance at both
primary and
secondary (side band) wavelengths does not a ect the absorbance di erence (Ad). 22.
C A
uorometer uses a primary monochromator to isolate the wavelength for excitation,
and a secondary
monochromator to isolate the wavelength emitted by the uorochrome. 23. C Increasi
ng temperature
results in more random collision between molecules by increasing their motion. T
his causes energy
to be dissipated as heat instead of uorescence. Temperature is inversely proporti
onal to
uorescence. Fluorescence is more sensitive than spectrophotometry because the det
ector signal
can be ampli ed when dilute solutions are measured. It is also more speci c than
spectrophotometry because both the excitation and emission wavelengths are chara
cteristics of the
compound being measured. 24. A Chemiluminescence is the production of light foll
owing a chemical
reaction. Immunoassays based upon chemiluminescence generate light when the chem
iluminescent
molecule becomes excited; therefore, a light source is not used. In immunoassay
platforms,
chemiluminescent molecules such as acridinium can be used to label antigens or a
ntibodies.

Alternatively, chemiluminescent substrates such as luminol or dioxetane phosphat

e may be used.
Light will be emitted when the enzymelabeled molecule reacts with the substrate
. In such assays,
free and bound antigen separation is required and is usually accomplished using
paramagnetic
particles bound to either antibody or reagent antigen. 2828_Ch05_171326 06/08/
12 5:14 PM Page
177 25. Which substance is used to generate the light signal in electrochemilumi
nescence? A.
Acridinium B. Luminol C. Dioxetane phosphate D. Ruthenium Chemistry/Apply princi
ples of special
procedures/Instrumentation/2 26. Light scattering when the wavelength is greater
than 10 times
the particle diameter is described by: A. Rayleighs law B. Te BeerLambert law C. M
ies law D.
Te RayleighDebye law Chemistry/Apply principles of special procedures/ Instrument
ation/2 27.
Which statement regarding nephelometry is true? A. Nephelometry is less sensitiv
e than absorption
spectrophotometry B. Nephelometry follows Beers law C. Te optical design is ident
ical to a
turbidimeter except that a HeNe laser light source is used D. Te detector respon
se is directly
proportional to concentration Chemistry/Apply principles of special procedures/
Instrumentation/2
28. Te purpose of the nebulizer in an atomic absorption spectrophotometer that u
ses a ame is to:
A. Convert ions to atoms B. Cause ejection of an outer shell electron C. Reduce
evaporation of
the sample D. Burn o organic impurities Chemistry/Apply principles of basic proce
dures/
Instrumentation/2 29. A ameless atomic absorption spectrophotometer dehydrates an
d atomizes a
sample using: A. A graphite capillary furnace B. An electron gun C. A thermoelec
tric
semiconductor D. A thermospray platform Chemistry/Apply principles of special pr
ocedures/
Instrumentation/1 178 Chapter 5 | Clinical Chemistry Answers to Questions 2529 25
. D All of
these substances are chemiluminescent. Dioxetane phosphate is excited by alkalin
e phosphatase.
Acridinium and luminol are excited by hydrogen peroxide. In electrochemiluminese
nce, ruthenium is
used to label antibody or antigen. Antigenantibody complexes containing the ruthe
nium label are
bound to paramagnetic particles via a strepavidinbiotin reaction. The paramagneti
c particles are
attracted to an electrode surface. The owcell is washed with a solution containin
g
tripropylamine (TPA) to remove unbound ruthenium label. At the electrode surface
, the TPA is
oxidized and the electrons excite the ruthenium, causing production of 620nm li
ght. 26. A
Rayleighs law states that when the incident wavelength is much longer than the pa
rticle
diameter, there is maximum backscatter and minimum rightangle scatter. The Rayl
eighDebye law
predicts maximum rightangle scatter when wavelength and particle diameter appro
ach equality. In

nephelometry, the relationship between wavelength and diameter determines the an

gle at which the
detector is located. 27. D In nephelometry, the detector output is proportional
to concentration
(as opposed to turbidimetry where the detector is behind the cuvette). The detec
tor(s) is (are)
usually placed at an angle between 25 and 90 to the incident light, depending upon
the
application. Nephelometers, like uorometers, are calibrated to read zero with the
light path
blocked, and sensitivity can be increased up to 1,000 times by ampli cation of the
detector
output or increasing the photomultiplier tube dynode voltage. 28. A The atomizer
of the atomic
absorption spectrophotometer consists of either a nebulizer and flame or a graph
ite furnace. The
nebulizer disperses the sample into a fine aerosol, distributing it evenly into
the flame. Heat
from the flame is used to evaporate water and break the ionic bonds of salts, fo
rming ground
state atoms. The flame also excites a small percentage of the atoms, which relea
se a
characteristic emission line. 29. A Flameless atomic absorption uses a hollow tu
be of graphite
with quartz ends. The tube is heated in stages by an electric current to success
ively dry, ash,
and atomize the sample. During the ash and atomization steps, argon is injected
into the tube to
distribute the atoms. The furnace is more sensitive than a ame atomizer and more
e cient in
atomizing thermostable salts. However, it is prone to greater matrix interferenc
e and is slower
than the ame atomizer because it must cool down before introduction of the next s
ample.
2828_Ch05_171326 06/08/12 5:14 PM Page 178 30. When measuring lead in whole
blood using
atomic absorption spectrophotometry, what reagent is required to obtain the need
ed sensitivity
and precision? A. Lanthanum B. Lithium C. Triton X100 D. Chloride Chemistry/App
ly principles of
special procedures/ Instrumentation/1 31. Interference in atomic absorption spec
trophotometry
caused by di erences in viscosity is called: A. Absorption interference B. Matrix
e ect C.
Ionization interference D. Quenching Chemistry/Evaluate sources of error/Instrum
entation/2 32.
All of the following are required when measuring magnesium by atomic absorption
spectrophotometry
except: A. A hollow cathode lamp with a magnesium cathode B. A chopper to preven
t optical
interference from magnesium emission C. A monochromator to isolate the magnesium
emission line at
285 nm D. A 285nm reference beam to correct for background absorption Chemistry
/Select
methods/Reagents/Media/ Electrolytes/2 33. When measuring calcium by atomic abso
rption
spectrophotometry, which is required? A. An organic extraction reagent to deconj
ugate calcium
from protein B. An internal standard C. A magnesium chelator D. Lanthanum oxide
to chelate

phosphates Chemistry/Select methods/Reagents/Media/ Electrolytes/2 34. Ion selec

tive analyzers
using undiluted samples have what advantage over analyzers that use a diluted sa
mple? A. Can
measure over a wider range of concentration B. Are not subject to pseudohyponatr
emia caused by
high lipids C. Do not require temperature equilibration D. Require less maintena
nce
Chemistry/Apply knowledge to identify sources of error/Electrolytes/2 5.1 | Inst
rumentation 179
Answers to Questions 3034 30. C A graphite furnace is preferred over a ame for mea
suring lead
because it is su ciently sensitive to detect levels below 5 g/dL, the cuto needed fo
r lead
screening of children. The matrix modi er consists of Triton X -100, ammonium phos
phate and
nitric acid. This allows for release of Pb from the RBCs, and solubilization of
cell stroma. The
matrix modi er also prevents loss of Pb caused by formation of lead halides and pr
omotes
interaction between Pb and the tube wall, preventing its loss during the ashing
cycle. 31. B
Signi cant di erences in aspiration and atomization result when the matrix of sample
and unknowns
di er. Di erences in viscosity and protein content are major causes of matrix error.
Matrix
e ects can be reduced by using protein-based calibrators and diluting both standar
ds and samples
prior to assay. 32. D Atomic absorption requires a lamp with a cathode made from
the metal to be
assayed. The lamp emits the line spectrum of the metal, providing the wavelength
that the atoms
can absorb. The chopper pulses the source light, allowing it to be discriminated
from light
emitted by excited atoms. A monochromator eliminates light emitted by the ideal
gas in the lamp.
Deuterium (wide bandpass light) or Zeeman correction (splitting the incident lig
ht into side
bands by a magnetic field) may be used to correct for background absorption. 33.
D An acidic
diluent such as hydrochloric acid (HCl) will displace calcium bound to albumin.
However, calcium
forms a thermostable bond with phosphate that causes chemical interference in at
omic absorption.
Lanthanum displaces calcium, forming lanthanum phosphate, and eliminates interfe
rence from
phosphates. Unlike in some colorimetric methods for calcium (e.g., o-cresolphtha
lein complexone),
magnesium does not interfere because it does not absorb the 422.7 nm emission li
ne from the
calcium-hollow cathode lamp. 34. B Ion-selective analyzers measure the electroly
te dissolved in
the uid phase of the sample in millimoles per liter of plasma water. When undilut
ed blood is
assayed, the measurement is independent of colloids such as protein and lipid. H
yperlipemic
samples cause falsely low sodium measurements when assayed by ame photometry and
ion-selective
analyzers requiring dilution because lipids displace plasma water containing the
electrolytes.

One drawback to undiluted or direct measuring systems is that the electrodes req
uire more
frequent deproteinization and usually have a shorter duty cycle. 2828_Ch05_171-3
26 06/08/12
5:14 PM Page 179 35. Select the equation describing the potential that develops
at the surface
of an ion-selective electrode. A. van Deemter equation B. van Slyke equation C.
Nernst equation
D. HendersonHasselbalch equation Chemistry/De ne fundamental characteristics/ Instr
umentation/1
36. Te reference potential of a silversilver chloride electrode is determined by
the: A.
Concentration of the potassium chloride lling solution B. Surface area of the ele
ctrode C.
Activity of total anion in the paste covering the electrode D. Te concentration
of silver in the
paste covering the electrode Chemistry/De ne fundamental characteristics/ Instrume
ntation/1 37.
Te term RT/nF in the Nernst equation de nes the: A. Potential at the ion-selective
membrane B.
Slope of the electrode C. Decomposition potential D. Isopotential point of the e
lectrode
Chemistry/De ne fundamental characteristics/ Instrumentation/1 38. Te ion-selectiv
e membrane used
to measure potassium is made of: A. High-borosilicate glass membrane B. Polyviny
l chloride
dioctylphenyl phosphonate ion exchanger C. Valinomycin gel D. Calomel Chemistry/
Apply principles
of basic laboratory procedures/Electrolytes/1 39. Te response of a sodium electr
ode to a 10-fold
increase in sodium concentration should be: A. A 10-fold drop in potential B. An
increase in
potential of approximately 60 mV C. An increase in potential of approximately 10
mV D. A decrease
in potential of approximately 10 mV Chemistry/Calculate/Electrolytes/2 180 Chapt
er 5 | Clinical
Chemistry Answers to Questions 3539 35. C The van Deemter equation describes the
relation
between the velocity of mobile phase to column efficiency in gas chromatography.
The
HendersonHasselbalch equation is used to determine the pH of a solution containin
g a weak acid
and its salt. van Slyke developed an apparatus to measure CO 2 and O 2 content u
sing a manometer.
36. A The activity of any solid or ion in a saturated solution is unity. For a s
ilver electrode
covered with silver chloride paste, the Nernst equation is E = E RT/nF 2.3 log 10
[Ag Cl
]/
[AgCl]. Because silver and silver
chloride have an activity of 1.0, and all components except chloride are
constants, the
potential of the reference electrode is determined by the chloride concentration
of the lling
solution. E = E o RT/nF 2.3 log 10 [Cl
]
= E 59.2 mV
log[Cl
]
(at room temperature)
37. B In the term RT/nF, R = the molar gas constant, T = temperature in
degrees Kelvin, F =
Faradays constant, and n = the number of electrons donated per atom of reductant.

The slope
depends upon the temperature of the solution and the valence of the reductant. A
t room
temperature, the slope is 59.2 mV for a univalent ion and 29.6 mV for a divalent
ion. 38. C
Valinomycin is an antibiotic with a highly selective reversible-binding a nity for
potassium
ions. Sodium electrodes are usually composed of a glass membrane with a high con
tent of aluminum
silicate. Calcium and lithium ion-selective electrodes are made from organic liq
uid ion
exchangers called neutral carrier ionophores. Calomel is made of mercury covered
with a paste of
mercurous chloride (Hg/Hg 2 Cl 2 ) and is used as a reference electrode for pH. 3
9. B The Nernst
equation predicts an increase of approximately 60 mV per 10-fold increase in sod
ium activity. For
sodium: E = E + RT/nF 2.3 log 10 [Na +
]
RT/nF 2.3 = 60 mV at 37C. Therefore: E = E + 60 mV log 10 [Na +
].
If sodium concentration is 10 mmol/L, then: E = E + 60 mV log 10 [10] = E
+ 60 mV. If
sodium concentration increases from 10 mmol/L to 100 mmol/L, then: E = E + 60 mV
log 10 [100]
= E + 60 mV 2 = E + 120 mV. 2828_Ch05_171-326 06/08/12 5:14 PM Page 180 40. Whi
ch of the
electrodes below is a current- producing (amperometric) rather than a voltage-pr
oducing
(potentiometric) electrode? A. Clark electrode B. Severinghaus electrode C. pH e
lectrode D.
Ionized calcium electrode Chemistry/De ne fundamental characteristics/ Instrumenta
tion/1 41.
Which of the following would cause a response error from an ion-selective electrod
e for sodium
when measuring serum but not the calibrator? A. Interference from other electrol
ytes B. Protein
coating the ion-selective membrane C. An overrange in sodium concentration D. Pr
otein binding to
sodium ions Chemistry/Identify sources of error/Electrolytes/2 42. In polarograp
hy, the voltage
needed to cause depolarization of the cathode is called the: A. Half-wave potent
ial B.
Isopotential point C. Decomposition potential D. Polarization potential Chemistr
y/De ne
fundamental characteristics/ Instrumentation/1 43. Persistent noise from an ionselective
electrode is most often caused by: A. Contamination of sample B. Blocked junctio
n at the salt
bridge C. Overrange from high concentration D. Improper calibration Chemistry/Id
entify sources of
error/Electrolytes/2 44. Which element is reduced at the cathode of a Clark pola
rographic
electrode? A. Silver B. Oxygen C. Chloride D. Potassium Chemistry/De ne fundamenta
l
characteristics/ Instrumentation/1 45. Which of the following statements accurat
ely characterizes
the coulometric titration of chloride? A. Te indicator electrodes generate volta
ge B. Constant
current must be present across the generator electrodes C. Silver ions are forme

d at the
generator cathode D. Chloride concentration is inversely proportional to titrati
on time
Chemistry/De ne fundamental characteristics/ Instrumentation/2 5.1 | Instrumentati
on 181
Answers to Questions 4045 40. A The Clark electrode is composed of two half cells
that generate
current, not voltage. It is used to measure partial pressure of oxygen (PO 2 ),
and is based upon
an amperometric method called polarography. When 0.8 V is applied to the cathode,
O 2 is
reduced, causing current to ow. Current is proportional to the PO 2 of the sample
. 41. B
Response is the time required for an electrode to reach maximum potential. Ion-s
elective
analyzers use a microprocessor to monitor electrode response, slope, drift, and
noise. When an
electrode gives an acceptable response time when measuring an aqueous calibrator
, but not when
measuring serum, the cause is often protein buildup on the membrane. 42. C In po
larography, a
minimum negative voltage must be applied to the cathode to cause reduction of me
tal ions (or O 2
) in solution. This is called the decomposition potential. It is concentration d
ependent (dilute
solutions require greater negative voltage), and can be determined using the Ner
nst equation. 43.
B Electrode noise most often results from an unstable junction potential. Most r
eference
electrodes contain a high concentration of KCl internal solution used to produce
the reference
potential. This forms a salt bridge with the measuring half cell by contacting s
ample, but is
kept from equilibrating via a barrier called a junction. When this junction beco
mes blocked by
salt crystals, the reference potential will be unstable, resulting in uctuation i
n the analyzer
readout. 44. B The Clark electrode is designed to measure oxygen. O 2 di uses thro
ugh a
gas-permeable membrane covering the electrode. It is reduced at the cathode, whi
ch is made of
platinum or other inert metal. Electrons are supplied by the anode, which is mad
e of silver. The
net reaction is: 4 KCl + 2 H 2 O + O 2 + 4 Ag 4 AgCl + 4 KOH 45. B The Cotlove chl
oridometer is
based upon the principle of coulometric titration with amperometric detection. C
harge in the form
of silver ions is generated by oxidation of silver wire at the generator anode.
Silver ions react
with chloride ions, forming insoluble silver chloride (AgCl). When all of the ch
loride is
titrated, free silver ions are detected by reduction back to elemental silver, w
hich causes an
increase in current across the indicator electrodes (a pair of silver electrodes
with a voltage
di erence of about 1.0 V DC). Charge or titration time is directly proportional to
chloride
concentration as long as the rate of oxidation remains constant at the generator
anode.
2828_Ch05_171-326 06/08/12 5:14 PM Page 181 46. In the coulometric chloride t

itration: A.
Acetic acid in the titrating solution furnishes the counter ion for reduction B.
Te endpoint is
detected by amperometry C. Te titrating reagent contains a phosphate bu er to keep
pH constant D.
Nitric acid (HNO 3 ) is used to lower the solubility of AgCl Chemistry/Apply pri
nciples of
special procedures/ Electrolytes/2 47. Which of the following compounds can inte
rfere with the
coulometric chloride assay? A. Bromide B. Ascorbate C. Acetoacetate D. Nitrate C
hemistry/Apply
knowledge to identify sources of error/Electrolytes/2 48. All of the following c
ompounds
contribute to the osmolality of plasma except: A. Lipids B. Creatinine C. Drug m
etabolites D.
Glucose Chemistry/Apply knowledge of fundamental biological characteristics/Osmo
lality/2 49. One
mole per kilogram H 2 O of any solute will cause all of the following except: A.
Lower the
freezing point by 1.86C B. Raise vapor pressure by 0.3 mm Hg C. Raise the boiling
point by
0.52C D. Raise osmotic pressure by 22.4 atm Chemistry/Apply knowledge of fundamen
tal biological
characteristics/Osmolality/2 50. What component of a freezing point osmometer me
asures the sample
temperature? A. Termistor B. Termocouple C. Capacitor D. Electrode Chemistry/App
ly principles of
special procedures/ Osmometry/1 51. What type of measuring circuit is used in a
freezing point
osmometer? A. Electrometer B. Potentiometer C. Wheatstone bridge D. Termal condu
ctivity bridge
Chemistry/Apply principles of special procedures/ Osmometry/1 182 Chapter 5 | Cl
inical Chemistry
Answers to Questions 4651 46. B Reduction of Ag + back to Ag generates the current
, which
signals the endpoint. The titrating reagent contains HNO 3 , acetic acid, H 2 O,
and either
gelatin or polyvinyl alcohol. The HNO 3 furnishes nitrate, which is reduced at t
he generator
cathode, forming ammonium ions. The ammonium becomes oxidized back to nitrate at
the indicator
anode. Gelatin or polyvinyl alcohol is needed to prevent pitting of the generato
r anode. Acetic
acid lowers the solubility of AgCl, preventing dissociation back to Ag + . 47. A
Chloride assays
based upon either coulometric or chemical titration are subject to positive inte
rference from
other anions and electronegative radicals that may be titrated instead of chlori
de ions. These
include other halogens such as bromide, cyanide, and cysteine. 48. A Osmolality
is the
concentration (in moles) of dissolved solute per kilogram solvent. Proteins and
lipids are not in
solution, and do not contribute to osmolality. The nonionized solutes such as gl
ucose and urea
contribute 1 osmole per mole per kilogram water, whereas dissociated salts contr
ibute 1 osmole
per mole of each dissociated ion or radical. 49. B Both freezing point and vapor
pressure are
lowered by increasing solute concentration. Boiling point and osmotic pressure a

re raised.
Increasing solute concentration of a solution opposes a change in its physical s
tate and lowers
the concentration of H 2 O molecules. 50. A A thermistor is a temperature-sensit
ive resistor. The
resistance to current ow increases as temperature falls. The temperature at which
a solution
freezes can be determined by measuring the resistance of the thermistor. Resista
nce is directly
proportional to the osmolality of the sample. 51. C The resistance of the thermi
stor is measured
using a network of resistors called a Wheatstone bridge. When the sample is froz
en, the bridge is
balanced using a calibrated variable resistor, so that no current ows to the read
out. The
resistance required to balance the meter is equal to the resistance of the therm
istor.
2828_Ch05_171-326 06/08/12 5:14 PM Page 182 52. Which measurement principle i
s employed in a
vapor pressure osmometer? A. Seebeck B. Peltier C. Hayden D. Darlington Chemistr
y/Apply
principles of special procedures/ Osmometry/1 53. Te freezing point osmometer di e
rs from the
vapor pressure osmometer in that only the freezing point osmometer: A. Cools the
sample B. Is
sensitive to ethanol C. Requires a thermoelectric module D. Requires calibration
with aqueous
standards Chemistry/Apply principles of special procedures/ Osmometry/2 54. Te m
ethod for
measuring iron or lead by plating the metal and then oxidizing it is called: A.
Polarography B.
Coulometry C. Anodic stripping voltometry D. Amperometry Chemistry/Apply princip
les of special
procedures/ Instrumentation/1 55. Te term isocratic is used in high-performance
liquid
chromatography (HPLC) to mean the: A. Mobile phase is at constant temperature B.
Stationary phase
is equilibrated with the mobile phase C. Mobile phase consists of a constant sol
vent composition
D. Flow rate of the mobile phase is regulated Chemistry/Apply principles of spec
ial procedures/
High-performance liquid chromatography/1 56. Te term reverse phase is used in HP
LC to indicate
that the mobile phase is: A. More polar than the stationary phase B. Liquid and
the stationary
phase is solid C. Organic and the stationary phase is aqueous D. A stronger solv
ent than the
stationary phase Chemistry/Apply principles of special procedures/ High-performa
nce liquid
chromatography/1 57. What is the primary means of solute separation in HPLC usin
g a C18 column?
A. Anion exchange B. Size exclusion C. Partitioning D. Cation exchange Chemistry
/Apply principles
of special procedures/ High-performance liquid chromatography/1 5.1 | Instrument
ation 183
Answers to Questions 5257 52. A The Seebeck e ect refers to the increase in voltage
across the
two junctions of a thermocouple caused by a di erence in the temperature at the ju
nctions.
Increasing osmolality lowers the dew point of a sample. When sample is cooled to

its dew point,

the voltage change across the thermocouple is directly proportional to osmolalit
y. 53. B Alcohol
enters the vapor phase so rapidly that it evaporates before the dew point of the
sample is
reached. Therefore, ethanol does not contribute to osmolality as measured using
the vapor
pressure osmometer. Freezing-point osmometers measure alcohol and can be used in
emergency
department settings to estimate ethanol toxicity. 54. C Anodic stripping voltome
try is used to
measure lead and iron. The cation of the metal is plated onto a mercury cathode
by applying a
negative charge. The voltage of this electrode is reversed until the plated meta
l is oxidized
back to a cation. Current produced by oxidation of the metal is proportional to
concentration.
55. C An isocratic separation uses a single mobile phase of constant composition
, pH, and
polarity, and requires a single pump. Some HPLC separations use a gradient mobil
e phase to
increase distance between peaks. Gradients are made by mixing two or more solven
ts using a
controller to change the proportions of solvent components. 56. A In reverse-pha
se HPLC, the
separation takes place using a nonpolar sorbent (stationary phase) such as octad
ecylsilane (C18).
Solutes that are nonpolar are retained longer than polar solutes. Most clinical
separations of
drugs, hormones, and metabolites use reverse phase because aqueous mobile phases
are far less
toxic and ammable. 57. C Stationary phases (column packings) used in HPLC separat
e solutes by
multiple means, but in reverse-phase HPLC the relative solubility between the mo
bile phase and
stationary phase is most important and depends upon solvent polarity, pH, and io
nic strength.
2828_Ch05_171-326 06/08/12 5:14 PM Page 183 58. Te most commonly used detecto
r for clinical
gasliquid chromatography (GLC) is based upon: A. Ultraviolet light absorbance at
254 nm B. Flame
ionization C. Refractive index D. Termal conductance Chemistry/Apply principles
of special
procedures/ Gas chromatography/1 59. What type of detector is used in high-perfo
rmance liquid
chromatography with electrochemical detection (HPLCECD)? A. Calomel electrode B.
Conductivity
electrode C. Glassy carbon electrode D. Polarographic electrode Chemistry/Apply
principles of
special procedures/ High-performance liquid chromatography/1 60. In gas chromato
graphy, the
elution order of volatiles is usually based upon the: A. Boiling point B. Molecu
lar size C.
Carbon content D. Polarity Chemistry/Apply principles of special procedures/ Gas
chromatography/2
61. Select the chemical that is used in most HPLC procedures to decrease solvent
polarity. A.
Hexane B. Nonane C. Chloroform D. Acetonitrile Chemistry/Apply principles of spe
cial procedures/
Biochemical/2 62. In thin-layer chromatography (TLC), the distance the solute mi

grates divided by
the distance the solvent migrates is the: A. t R B. K d C. R f D. pK Chemistry/A
pply principles
of special procedures/ High-performance liquid chromatography/1 63. Which reagen
t is used in
thin-layer chromatography (TLC) to extract cocaine metabolites from urine? A. Ac
id and sodium
chloride B. Alkali and organic solvent C. Chloroform and sodium acetate D. Neutr
al solution of
ethyl acetate Chemistry/Apply principles of special procedures/ Biochemical/2 18
4 Chapter 5 |
Clinical Chemistry Answers to Questions 5863 58. B Volatile solutes can be detect
ed in GLC using
ame ionization, thermal conductivity, electron capture, and mass spectroscopy. In
ame
ionization, energy from a ame is used to excite the analytes as they elute from t
he column. The
ame is made by igniting a mixture of hydrogen, carrier gas, and air. Current is p
roduced when an
outer shell electron is ejected from the excited analyte. 59. C HPLCECD uses a gl
assy carbon
measuring electrode and a silversilver chloride reference. The analyte is oxidize
d or reduced by
holding the glassy carbon electrode at a positive voltage (oxidization) or negat
ive voltage
(reduction). The resulting current ow is directly proportional to concentration.
Phenolic groups
such as catecholamines can be measured by HPLCECD. 60. A The order of elution is
dependent upon
the velocity of the analyte. Usually, the lower the boiling point of the compoun
d, the greater
its velocity or solubility in carrier gas. 61. D All of the compounds mentioned
have nonpolar
properties. Because most HPLC is reverse phase (a polar solvent is used), hexane
and nonane are
too nonpolar. Acetonitrile is more polar and less toxic than chloroform and alon
g with methanol
is a common polarity modi er for HPLC. 62. C R f is the distance migrated by the s
olute divided
by the distance migrated by the solvent. The t R refers to the retention time of
the solute in
HPLC or gas chromatography (GC). The K d is the partition coe cient, and is a meas
ure of the
relative a nity of solutes for the stationary phase. The solute with the greater K
d will be
retained longer. The pK is the negative logarithm of K, the ionization constant,
and is a measure
of ionization. 63. B Alkaline drugs such as cocaine, amphetamine, and morphine a
re extracted at
alkaline pH. Ideally, the pH for extracting alkaline drugs into an organic solve
nt should be 2 pH
units greater than the negative log of dissociation constant (pK a ) of the drug
. More than 90%
of the drug will be nonionized and will extract in ethyl acetate or another orga
nic solvent.
2828_Ch05_171-326 06/08/12 5:14 PM Page 184 64. What is the purpose of an int
ernal standard in
HPLC and GC methods? A. To compensate for variation in extraction and injection
B. To correct for
background absorbance C. To compensate for changes in ow rate D. To correct for c

oelution of
solutes Chemistry/Apply principles of special procedures/ Chromatography/2 65. W
hat is the
con rmatory method for measuring drugs of abuse? A. HPLC B. Enzyme-multiplied immu
noassay
technique (EMIT) C. Gas chromatography with mass spectroscopy (GC-MS) D. TLC Che
mistry/Select
instruments to perform test/Drugs of abuse/2 66. Te fragments typically produced
and analyzed in
methods employing mass spectroscopy are typically: A. Of low molecular size rang
ing from 10100
daltons B. Cations caused by electron loss or proton attachment C. Anions caused
by bombarding
the molecule with an electron source D. Neutral species formed after excited mol
ecules form a
stable resonance structure Chemistry/Identify basic principle(s)/Mass spectrosco
py/1 67. What
component is used in a GC-MS but not used in an LC-MS? A. Electron source B. Mas
s lter C.
Detector D. Vacuum Chemistry/De ne fundamental characteristics/ Instrumentation/1
5.1 |
Instrumentation 185 Answers to Questions 6467 64. A Internal standards should h
ave the same
a nity as the analyte for the extraction reagents. Dividing peak height (or area)
of all samples
(standards and unknowns) by the peak height (or area) of the internal standard r
educes error
caused by variation in extraction recovery and injection volume. 65. C GC-MS det
ermines the mass
spectrum of the compounds eluting from the analytic column. Each substance has a
unique and
characteristic spectrum of mass fragments. This spectrum is compared to spectra
in a library of
standards to determine the percent match. A match of greater than 95% is conside
red con rmatory.
66. B In almost all MS applications, cations of the molecule are measured. Catio
ns can be formed
by various methods, the most common of which is electron bombardment (electron i
onization). The
energy transferred to the molecule causes ejection of an outer shell electron. M
S can analyze
sizes from trace metals through macromolecules. Proteins are measured following
conversion to
cations by ionization procedures such as matrix-assisted laser desorption ioniza
tion (MALDI) in
which energy from a nitrogen laser causes transfer of a proton from the matrix (
an acid) to the
protein. 67. A The mass spectrometer requires a sample that is suspended in a ga
s phase, and
therefore, the sample from a GC can be directly injected into the mass spectrome
ter. While
chemical ionization of the sample is possible, most GC-MS instruments utilize el
ectron
ionization. Electrons are produced by applying 70 electron volts to a lament of t
ungsten or
rhenium under vacuum. The electrons collide with the neutral molecules coming fr
om the GC,
splitting them into fragments. The array of fragments is a unique identi er of eac
h molecule.
2828_Ch05_171-326 06/08/12 5:14 PM Page 185 68. What process is most often us

ed in LC-MS to
introduce the sample into the mass lter? A. Electrospray ionization B. Chemical i
onization C.
Electron impact ionization D. Fast atom bombardment Chemistry/Identify basic pri
nciple(s)/Mass
spectroscopy/1 69. In mass spectroscopy, the term base peak typically refers to:
A. Te peak with
the lowest mass B. Te peak with the most abundance C. A natural isotope of the m
olecular ion D.
Te rst peak to reach the mass detector Chemistry/De ne fundamental characteristics/
Instrumentation/1 70. Which method is the most useful when screening for errors
of amino and
organic acid metabolism? A. Two-dimensional thin-layer chromatography B. Gas chr
omatography C.
Electrospray ionization tandem-mass spectroscopy D. Inductively charged coupledmass spectroscopy
Chemistry/Select instruments to perform test/Newborn screening/2 186 Chapter 5 |
Clinical
Chemistry Answers to Questions 6870 68. A HPLC instruments use solvent rather tha
n gas to
separate molecules. The sample is converted into a gaseous state by electrospray
ionization
before it enters the mass lter. Electrospray ionization uses a small-bore tube th
at forms a 14
nozzle at the mass lter inlet and which is charged by several kilovolts. The samp
le enters the
tube along with inert drying gas. The tube is heated to help evaporate solvent,
but unlike
electron impact used in GC-MS, the ionizer is not under vacuum. When a droplet o
f the sample
reaches the nozzle, it becomes highly charged. The size of the droplet is decrea
sed owing to
evaporation. This causes the charge density to become excessive, and the droplet
s break apart.
The tiny charged droplets repel each other and break apart again, forming a plum
e. These
particles are drawn into the mass lter by ion optics (a system of repeller plates,
counter
electrode, and magnets). ESI does not result in extensive fragmentation, produci
ng mostly the
parent or molecular ion, a process called soft ionization. 69. B The base peak is
typically the
molecular ion or parent ion, meaning that it is the initial fragment made by relea
sing an
electron. The cation thus formed has a charge of +1, and therefore, its m/z rati
o is equal to its
mass. The base peak is used for selective ion monitoring (SIM). It is the most a
bundant and most
stable ion, and gives the best sensitivity for quantitative analysis. 70. C Whil
e two-dimensional
thin-layer chromatography can separate both amino and organic acids, it is not s
u ciently
sensitive for newborn screening. Electrospray ionization allows a small alcoholextracted
whole-blood sample to be analyzed by two mass spectrometers without prior separa
tion by liquid or
gas chromatography. Disorders of both organic and fatty acid metabolism are iden
ti ed by the
speci c pattern of acylcarnitine ions produced. Amino acids are detected as amino
species that

have lost a carboxyl group during ionization, a process called neutral loss. 282
8_Ch05_171-326
06/08/12 5:14 PM Page 186 71. In tandem-mass spectroscopy, the rst mass lter per
forms the
same function as: A. Te ion source B. Te chromatography column C. Extraction D.
Te vacuum system
Chemistry/Apply principles of special procedures/ Instrumentation/1 72. SITUATIO
N: A GC-MS
analysis using nitrogen as the carrier gas shows an extensively noisy baseline.
A sample of the
solvent used for the extraction procedure, ethyl acetate, was injected and showe
d the same noise.
Results of an Autotune test showed the appearance of a base peak at 16 with two
smaller peaks at
17 and 18. Tese results indicate: A. Te solvent is contaminated B. Te carrier ga
s is contaminated
C. Tere is electrical noise in the detector D. Te ion source is dirty Chemistry/
Evaluate sources
of error/GC-MS/3 73. Why is vacuum necessary in the mass lter of a mass spectrome
ter? A.
Ionization does not occur at atmospheric pressure B. It prevents collision betwe
en fragments C.
It removes electrons from the ion source D. It prevents contamination Chemistry/
Identify basic
principle(s)/Mass spectroscopy/2 5.1 | Instrumentation 187 Answers to Question
s 7173 71. B A
tandem mass spectrometer uses two or more mass lters in sequence. The rst lter func
tions as an
ion trap. Once the sample is ionized, the lter selects molecular or parent ions o
f interest by
excluding ions outside a speci ed size range. Therefore, it e ectively separates the
analyte(s)
of interest from unwanted compounds. Tandem MS uses ESI to introduce the sample
into the rst
mass lter, usually a quadrapole. The RF and DC voltages of the quadrapole are set
to optimize
the trajectory of the parent ions of interest and cause ejection of unwanted ion
s. The parent
ions are drawn into a second mass lter where they are bombarded by argon atoms. T
he collisions
result in the formation of mass fragments called daughter ions. This process is
called
collision-induced dissociation and the second lter is called a collision chamber.
The process
can be repeated in a third mass lter that generates granddaughter ions. A total-i
on chromatogram
is produced from these, enabling the compound of interest to be identi ed and quan
ti ed. Tandem
MS is used to screen for inborn errors of fatty acid, amino acid, and organic ac
id metabolism.
72. B All of these situations are sources of baseline noise in GC-MS. However, t
he peak at 16
indicates the presence of oxygen in the carrier gas. Oxygen in the atmosphere al
so contains small
quantities of two isotopes with molecular weights of 17 and 18 owing to one and
two extra
neutrons, respectively. 73. B Vacuum is needed in the mass lter of the MS to prev
ent random
collisions between ions that would alter their trajectory or time of ight. It is
also needed in

CG-MS instruments that use electron ionization. The vacuum prevents collision be
tween the carrier
gas molecules and the ions. In spectrometers that use electrospray ionization, c
hemical
ionization, and laser desorption ionization (MALDI and SELDI TOF), the ion sourc
e is not under
vacuum. 2828_Ch05_171-326 06/08/12 5:14 PM Page 187 74. What method is used t
o introduce the
sample into a mass spectrometer for analysis of a trace element? A. Electrospray
ionization B.
Laser desorption C. Inductively charged plasma (ICP) ionization D. Direct inject
ion
Chemistry/Apply principles of special procedures/ Instrumentation/2 75. Which co
mponent is needed
for a thermal cycler to amplify DNA? A. Programmable heating and cooling unit B.
Vacuum chamber
with zero head space C. Sealed airtight constant-temperature chamber D. Temperat
ure-controlled
ionization chamber Chemistry/De ne fundamental characteristics/ Instrumentation/1
76. In
real-time PCR, what value is needed in order to determine the threshold? A. Back
ground signal B.
Melt temperature C. Maximum uorescence D. Treshold cycle Chemistry/Apply principl
es of special
procedures/ Instrumentation/1 188 Chapter 5 | Clinical Chemistry Answers to Ques
tions 7476 74. C
Mass spectrometers can be used to measure trace metals, but the atoms need to be
vaporized and
ionized like molecules before they enter the mass lter. This is done by introduci
ng the sample
into a very hot plasma (6,00010,000K) called a torch. The torch is made by circula
ting argon
through inner and outer quartz tubes. The tubes are wrapped with a coil of wire
that receives a
radio frequency. This creates current ow through the wire and a magnetic eld at th
e torch end.
Argon atoms are excited by the current and magnetic eld and ionize. When the argo
n is ignited by
a spark, it forms the plasma. The sample is mixed with argon at the other end to
create an
aerosol. When it reaches the torch, the solvent is evaporated and the energy fro
m the torch and
collisions with argon ions cause ejection of outer- shell electrons, forming cat
ions of the
element. ICP-MS is used to measure any trace element that readily forms cations.
75. A The
polymerase chain reaction for DNA ampli cation consists of three phases. Denaturat
ion requires a
temperature of 90C94C and separates the double-stranded DNA. Annealing requires a t
emperature
between 40C65C and allows the primers to bind to the target base sequence. Extensio
n requires
a temperature of 72C and allows the heat-stable polymerase to add complementary b
ases to the
primer in the 5 to 3 direction. A cycle consists of each temperature stage for a s
peci c number
of minutes and most procedures require 30 or more cycles to generate a detectabl
e quantity of
target DNA. Rapid heating and cooling is usually achieved using a thermoelectric
block that is

cooled by forced air ow. 76. A In real-time PCR, the uorescence of the reporter pr
obe is
proportional to the concentration of PCR products. For quantitation of PCR produ
cts, a well
factor and background uorescence must be determined. Well-factor values are analo
gous to cuvette
blanks. They are used to correct the measurements from each well so that the sam
e concentration
of uorescent dye gives the same signal intensity regardless of the well. The thre
shold is the
lowest signal that indicates the presence of product. It can be calculated manua
lly from a
real-time ampli cation curve by nding the average standard deviation of the uorescen
t signal
(RFU) from cycles 210. This is multiplied by 10 to give the threshold value in RF
Us.
2828_Ch05_171-326 06/08/12 5:14 PM Page 188 77. Given the following real-time
PCR ampli cation
curve, what is the threshold cycle? 5.1 | Instrumentation 189 Answers to Quest
ions 7780 77. C
The maximum curvature of the plot approximates the threshold cycle. A line is dr
awn from the
threshold value on the y-axis through the curve, and a perpendicular dropped to
the x-axis. The
Ct is determined by the intersection point on the x-axis. The threshold is usual
ly determined by
an algorithm but can be calculated manually as 10 times the average standard dev
iation of the
RFUs for cycles 210. 78. A The relative centrifugal force (number times the force
of gravity) is
proportional to the square of the rotor speed in revolutions per minute and the
radius in
centimeters of the head (distance from the shaft to the end of the tube). RCF =
s 2 x r x 1.118 x
10 5 where s is the speed in RPM, r is the radius in cM, and 1.118 x 10 5 is a con
version
constant. 79. B Electronic balances do not use substitution weights or knife edg
es to balance the
weight on the pan. Instead, they measure the displacement of the pan by the weig
ht on it using
electromagnetic force to return it to its reference position. Regardless of the
type of balance
used, all need to be located on a rm weighing table free of vibration. Doors must
be closed to
prevent air currents from in uencing the weighing, and the pan and platform must b
e clean and
free of dust and chemical residue. 80. D Gravimetric and spectrophotometric anal
ysis are the two
methods used to verify pipet volume accuracy and precision. Since spectrophotome
tric analysis
involves dilution, gravimetric analysis is associated with greater certainty. At
20C, the
density of pure water is 0.99821 g/mL. Therefore, each microliter weighs almost
exactly 1.0 mg.
A. 15 B. 20 C. 25 D. 30 Chemistry/Apply principles of special procedures/PCR/2 7
8. In addition to
velocity, what variable is also needed to calculate the relative centrifugal for
ce (g force) of a
centrifuge? A. Head radius B. Angular velocity coe cient C. Diameter of the centri
fuge tube D.

Ambient temperature in degrees Centigrade Chemistry/De ne fundamental characterist

ics/
Instrumentation/1 79. Which of the following situations is likely to cause an er
ror when weighing
with an electronic analytical balance? A. Failure to keep the knife edge clean B
. Failure to
close the doors of the balance before reading the weight C. Oxidation on the sur
face of the
substitution weights D. Using the balance without allowing it to warm up for at
least 10 minutes
Chemistry/Identify sources of error/Balances/3 80. When calibrating a semiautoma
tic pipet that
has a xed delivery of 10.0 L using a gravimetric method, what should be the averag
e weight of
deionized water transferred? A. 10.0 g B. 100.0 g C. 1.0 mg D. 10.0 mg Chemistry/D
e ne
fundamental characteristics/ Instrumentation/1 2828_Ch05_171-326 06/08/12 5:14
PM Page 189 190
5.2 Blood Gases, pH, and Electrolytes 1. Which of the following represents the
HendersonHasselbalch equation as applied to blood pH? A. pH = 6.1 + log HCO 3
/
PCO
2 B. pH = 6.1 + log HCO 3
/
(0.03 PCO
2 ) C. pH = 6.1 + log dCO 2
/
HCO
3 D. pH = 6.1 + log (0.03 PCO 2 )/HCO 3 Chemistry/Calculate/Acidbase/1 2.
What is the
PO 2 of calibration gas containing 20.0% O 2 , when the barometric pressure is 3
0 in.? A. 60 mm
Hg B. 86 mm Hg C. 143 mm Hg D. 152 mm Hg Chemistry/Calculate/Blood gas/2 3. What
is the blood pH
when the partial pressure of carbon dioxide (PCO 2 ) is 60 mm Hg and the bicarbo
nate
concentration is 18 mmol/L? A. 6.89 B. 7.00 C. 7.10 D. 7.30 Chemistry/Calculate/
Acidbase/2 4.
Which of the following best represents the reference (normal) range for arterial
pH? A. 7.357.45
B. 7.427.52 C. 7.387.68 D. 6.857.56 Chemistry/Apply knowledge of fundamental biolog
ical
characteristics/Acidbase/1 5. What is the normal ratio of bicarbonate to dissolve
d carbon
dioxide (HCO 3
:
dCO
2 ) in arterial blood? A. 1:10 B. 10:1 C. 20:1 D. 30:1 Chemistry/Apply k
nowledge of
fundamental biological characteristics/Acidbase/1 Answers to Questions 15 1. B The
HendersonHasselbalch equation describes the pH of a bu er comprised of a weak acid
and its salt.
pH = pK a + log salt/acid, where pK a is the negative logarithm of the dissociat
ion constant of
the acid. In this case, the salt is sodium bicarbonate and the acid is the disso
lved CO 2 , which
is equal to 0.03 (mmol/L per mm Hg) x PCO 2 . The pK a includes both the hydrati
on and
dissociation constant for dissolved CO 2 in blood, 6.1 and is termed pK. 2. C Con
vert barometric
pressure in inches to mm Hg by multiplying by 25.4 (mm/in.). Next, subtract the
vapor pressure of
H 2 O at 37C, 47 mm Hg, to give dry gas pressure. Multiply dry gas pressure by th
e %O 2

:
25.4 mm/in. 30 in. = 762 mm Hg 762 mm Hg 47 mm Hg (vapor pressure) = 715
mm Hg (dry gas
pressure) 0.20 715 mm Hg = 143 mm Hg PO 2 3. C Solve using the HendersonHasselbal
ch equation.
pH = pK + log HCO 3
/
(0.03 PCO
2 ), where pK, the negative logarithm of the combined hydration and disso
ciation constants
for dissolved CO 2 and carbonic acid, is 6.1 and 0.03 is the solubility coe cient
for CO 2 gas.
pH = 6.1 + log 18/(0.03 60) = 6.1 + log 18/1.8 pH = 6.1 + log 10. Because log 10
= 1, pH = 7.10
4. A The reference range for arterial blood pH is 7.357.45 and is only 0.03 pH un
its lower for
venous blood owing to the bu ering e ects of hemoglobin (Hgb) known as the chloride
isohydric
shift. Most laboratories consider less than 7.20 and greater than 7.60 the criti
cal values for
pH. 5. C When the ratio of HCO 3
:
dCO
2 is 20:1, the log of salt/acid becomes 1.3. Substituting this in the He
ndersonHasselbalch
equation and solving for pH gives pH = 6.1 + log 20; pH = 6.1 + 1.3 = 7.4. Acido
sis results when
this ratio is decreased, and alkalosis when it is increased. 2828_Ch05_171-326
06/08/12 5:14 PM
Page 190 6. What is the PCO 2 if the dCO 2 is 1.8 mmol/L? A. 24 mm Hg B. 35 mm
Hg C. 60 mm Hg D.
72 mm Hg Chemistry/Calculate/Blood gas/2 7. In the HendersonHasselbalch expressio
n pH = 6.1 +
log HCO 3
/
dCO
2 , the 6.1 represents: A. Te combined hydration and dissociation consta
nts for CO 2 in blood
at 37C B. Te solubility constant for CO 2 gas C. Te dissociation constant of H 2
O D. Te
ionization constant of sodium bicarbonate (NaHCO 3 ) Chemistry/Apply knowledge o
f fundamental
biological characteristics/Acidbase/1 8. Which of the following contributes the m
ost to the
serum total CO 2 ? A. PCO 2 B. dCO 2 C. HCO 3 D. Carbonium ion Chemistry/Apply k
nowledge of
fundamental biological characteristics/Acidbase/2 9. In addition to sodium bicarb
onate, what
other substance contributes most to the amount of base in the blood? A. Hemoglob
in concentration
B. Dissolved O 2 concentration C. Inorganic phosphorus D. Organic phosphate Chem
istry/Apply
knowledge of fundamental biological characteristics/Acidbase/2 10. Which of the f
ollowing e ects
results from exposure of a normal arterial blood sample to room air? A. PO 2 inc
reased PCO 2
decreased pH increased B. PO 2 decreased PCO 2 increased pH decreased C. PO 2 in
creased PCO 2
decreased pH decreased D. PO 2 decreased PCO 2 decreased pH decreased Chemistry/
Evaluate
laboratory data to recognize problems/Blood gas/3 5.2 | Blood Gases, pH, and Ele
ctrolytes 191
Answers to Questions 610 6. C Dissolved CO 2 is calculated from the measured PCO

2 0.0306, the
solubility coe cient for CO 2 gas in blood at 37C. dCO 2 = PCO 2 0.03 Therefore, PC
O 2 = dCO 2
/
0.03
PCO 2 = 1.8 mmol/L 0.03 mmol/ L per mm Hg = 60 mm Hg 7. A The equilibriu
m constant, K h ,
for the hydration of CO 2 (dCO 2 + H 2 O H 2 CO 3 ) is only about 2.3 10 3 M, maki
ng dCO 2
far more prevalent than carbonic acid. The dissociation constant, K d , for the
reaction H 2 CO 3
H + + HCO 3 is about 2 10 4 M. The product of these constants is the combined equi
librium
constant, K. The negative logarithm of K is the pK, which is 6.103 in blood at 37C.
8. C The
total CO 2 is the sum of the dCO 2 , H 2 CO 3 (carbonic acid or hydrated CO 2 ),
and bicarbonate
(as mainly NaHCO 3 ). When serum is used to measure total CO 2 , the dCO 2 is in
signi cant
because all the CO 2 gas has escaped into the air. Therefore, serum total CO 2 i
s equivalent to
the bicarbonate concentration. Total CO 2 is commonly measured by potentiometry.
An organic acid
is used to release CO 2 gas from bicarbonate and pCO 2 is measured with a Severi
nghaus electrode.
Alternately, bicarbonate can be measured by an enzymatic reaction using phosphoe
nol pyruvate
carboxylase. The enzyme forms oxaloacetate and phosphate from phosphoenol pyruva
te and
bicarbonate. The oxaloacetate is reduced to malate by malate dehydrogenase and N
ADH is oxidized
to NAD + . The negative reaction rate is proportional to plasma bicarbonate conc
entration. 9. A
The primary blood bu er bases preventing acidosis in order of concentration are bi
carbonate,
deoxyhemoglobin, albumin, and monohydrogen phosphate. At physiological pH, there
is signi cantly
more H 2 PO 4 1 than HPO 4 2 , and phosphate is a more e cient bu er system at prevent
ing
alkalosis than acidosis. Since all of the blood bu er systems are in equilibrium,
the pH can be
calculated accurately from the concentration of bicarbonate and dissolved CO 2 u
sing the
HendersonHasselbalch equation. 10. A The PO 2 of air at sea level (21% O 2 ) is a
bout 150 mm Hg.
The PCO 2 of air is only about 0.3 mm Hg. Consequently, blood releases CO 2 gas
and gains O 2
when exposed to air. Loss of CO 2 shifts the equilibrium of the bicarbonate bu er
system to the
right, decreasing hydrogen ion concentration and blood becomes more alkaline. 28
28_Ch05_171-326
06/08/12 5:14 PM Page 191 11. Which of the following formulas for O 2 content
is correct? A. O
2 content = %O 2 saturation/100 Hgb g/dL 1.39 mL/g + (0.0031 PO 2 ) B. O 2 conte
nt = PO 2
0.0306 mmol/L/mm C. O 2 content = O 2 saturation Hgb g/dL 0.003 mL/g D. O 2 cont
ent = O 2
capacity 0.003 mL/g Chemistry/Calculate/Blood gas/1 12. Te normal di erence betwee
n alveolar
and arterial PO 2 (PAO 2 PaO 2 di erence) is: A. 3 mm Hg B. 10 mm Hg C. 40 mm Hg D.
50 mm Hg

Chemistry/Apply knowledge of fundamental biological characteristics/Blood gas/2

13. A decreased
PAO 2 PaO 2 di erence is found in: A. A/V (arteriovenous) shunting B. V/Q
(ventilation/perfusion) inequality C. Ventilation defects D. All of these option
s
Chemistry/Evaluate laboratory data to recognize health and disease states/Blood
gas/2 14. Te
determination of the oxygen saturation of hemoglobin is best accomplished by: A.
Polychromatic
absorbance measurements of a whole-blood hemolysate B. Near infrared transcutane
ous absorbance
measurement C. Treatment of whole blood with alkaline dithionite prior to measur
ing absorbance D.
Calculation using PO 2 and total hemoglobin by direct spectrophotometry Chemistr
y/Apply
principles of special procedures/ Oxyhemoglobin/1 15. Correction of pH for a pat
ient with a body
temperature of 38C would require: A. Subtraction of 0.015 B. Subtraction of 0.01%
C. Addition of
0.020 D. Subtraction of 0.020 Chemistry/Calculate/Acidbase/2 16. Select the antic
oagulant of
choice for blood gas studies. A. Sodium citrate 3.2% B. Lithium heparin 100 U/mL
blood C. Sodium
citrate 3.8% D. Ammonium oxalate 5.0% Chemistry/Apply knowledge of standard oper
ating
procedures/Specimen collection and handling/1 192 Chapter 5 | Clinical Chemistry
Answers to
Questions 1116 11. A Oxygen content is the sum of O 2 bound to Hgb and O 2 dissol
ved in the
plasma. It is dependent upon the Hgb concentration and the percentage of Hgb bou
nd to O 2 (O 2
saturation). Each gram of Hgb binds 1.39 mL of O 2 . The dissolved O 2 is determ
ined from the
solubility coe cient of O 2 (0.0031 mL per dL/mm Hg) and the PO 2 . O 2 content =
% Sat/100 Hgb
in g/dL 1.39 mL/g + (0.0031 PO 2 ). 12. B The PAO 2 PaO 2 di erence results from th
e low
ratio of ventilation to perfusion in the base of the lungs. The hemoglobin in th
e blood coming
from the base of the lung has a lower O 2 saturation. This blood will take up O
2 from the plasma
of blood leaving well-ventilated areas of the lung, thus lowering the mixed arte
rial PO 2 . 13. C
Patients with A/V shunts, V/Q inequalities, and cardiac failure will have an inc
reased PAO 2 PaO
2 di erence. However, patients with ventilation problems have low alveolar PO 2 ow
ing to
retention of CO 2 in the airway. This reduces the PAO 2 PaO 2 di erence. 14. A Meas
urement of
oxyhemoglobin, deoxyhemoglobin (reduced hemoglobin), carboxyhemoglobin, methemog
lobin, and
sulfhemoglobin can be accomplished by direct spectrophotometry at multiple wavel
engths and
analysis of the absorptivity coe cients of each pigment at various wavelengths. Th
e O 2
saturation is determined by dividing the fraction of oxyhemoglobin by the sum of
all pigments.
This eliminates much of the error that occurs in the other methods when the quan
tity of an
abnormal hemoglobin pigment is increased. 15. A The pH decreases by 0.015 for ea

ch degree Celsius
above the 37C. Because the blood gas analyzer measures pH at 37C, the in vivo pH w
ould be 0.015
pH units below the measured pH. 16. B Heparin is the only anticoagulant that doe
s not alter the
pH of blood; heparin salts must be used for pH and blood gases. Solutions of hep
arin are air
equilibrated and must be used sparingly to prevent contamination of the sample b
y gas in the
solution. 2828_Ch05_171-326 06/08/12 5:14 PM Page 192 17. What is the maximum
recommended
storage time and temperature for an arterial blood gas sample drawn in a plastic
syringe? A. B.
C. D. Chemistry/Apply knowledge of standard operating procedures/Specimen collec
tion and
handling/Blood gas/1 18. A patients blood gas results are as follows: pH = 7.26 d
CO 2 = 2.0
mmol/L HCO 3 = 29 mmol/L Tese results would be classi ed as: A. Metabolic acidosis
B. Metabolic
alkalosis C. Respiratory acidosis D. Respiratory alkalosis Chemistry/Evaluate la
boratory data to
recognize health and disease states/Acidbase/3 19. A patients blood gas results ar
e: pH = 7.50
PCO 2 = 55 mm Hg HCO 3 = 40 mmol/L Tese results indicate: A. Respiratory acidosi
s B. Metabolic
alkalosis C. Respiratory alkalosis D. Metabolic acidosis Chemistry/Evaluate labo
ratory data to
recognize health and disease states/Acidbase/3 20. Which set of results is consis
tent with
uncompensated respiratory alkalosis? A. pH 7.70 HCO 3 30 mmol/L PCO 2 25 mm Hg B
. pH 7.66 HCO 3
22 mmol/L PCO 2 20 mm Hg C. pH 7.46 HCO 3 38 mmol/L PCO 2 55 mm Hg D. pH 7.36 HC
O 3 22 mmol/L PCO
2 38 mm Hg Chemistry/Evaluate laboratory data to recognize health and disease st
ates/Acidbase/3
21. Which of the following will shift the O 2 dissociation curve to the left? A.
Anemia B.
Hyperthermia C. Hypercapnia D. Alkalosis Chemistry/Calculate clinical and labora
tory data/ Blood
gas/2 5.2 | Blood Gases, pH, and Electrolytes 193 Answers to Questions 1721 17.
D Arterial
blood gas samples collected in plastic syringes should be stored at room tempera
ture because
cooling the sample allows oxygen to enter the syringe. Storage time should be no
more than 30
minutes because longer storage results in a signi cant drop in pH and PO 2 and inc
reased PCO 2 .
18. C Imbalances are classi ed as respiratory when the primary disturbance is with
PCO 2 because
PCO 2 is regulated by ventilation. PCO 2 = dCO 2
/
0.03 or
60 mm Hg (normal 3545 mm Hg). Increased dCO 2 will increase hydrogen ion
concentration,
causing acidosis. Bicarbonate is moderately increased, but a primary increase in
NaHCO 3 causes
alkalosis. Thus, the cause of this acidosis is CO 2 retention (respiratory acido
sis), and it is
partially compensated by renal retention of bicarbonate. 19. B A pH above 7.45 c
orresponds with
alkalosis. Both bicarbonate and PCO 2 are elevated. Bicarbonate is the conjugate

base and is
under metabolic (renal) control, while PCO 2 is an acid and is under respiratory
control.
Increased bicarbonate (but not increased CO 2 ) results in alkalosis; therefore,
the
classi cation is metabolic alkalosis, partially compensated by increased PCO 2 . 2
0. B
Respiratory alkalosis is caused by hyperventilation, inducing low PCO 2 . Very o
ften, in the
early phase of an acute respiratory disturbance, the kidneys have not had time t
o compensate, and
the bicarbonate is within normal limits. In answer A, the bicarbonate is high an
d PCO 2 low;
thus, both are contributing to alkalosis and this would be classi ed as a combined
acidbase
disturbance. In answer C, the pH is almost normal, and both bicarbonate and PCO
2 are increased.
This can occur in the early stage of a metabolic acid base disturbance when full
respiratory
compensation occurs or in a combined acidbase disorder. In answer D, both bicarbo
nate and PCO 2
are within normal limits (2226 mmol/L, 3545 mm Hg, respectively) as is the pH. 21.
D A left
shift in the oxyhemoglobin dissociation curve signi es an increase in the a nity of
Hgb for O 2 .
This occurs in alkalosis, hypothermia, and in those hemoglobinopathies such as H
gb Chesapeake
that increase the binding of O 2 to heme. A right shift in the oxyhemoglobin dis
sociation curve
lowers the a nity of Hgb for O 2 . This occurs in anemia due to increased 2,3-diph
osphoglycerate
(2,3-DPG), with increased body temperature, increased hydrogen ion concentration
, hypercapnia
(increased PCO 2 ), and in some hemoglobinopathies, such as Hgb Kansas. Storage
Time
Temperature 10 min 2C8C 20 min 2C8C 30 min 2C8C 30 min 22C 2828_Ch05_171-326 06/08
5:14 PM Page 193 22. In which circumstance will the reporting of calculated oxy
gen saturation of
hemoglobin based on PO 2 , PCO 2 , pH, temperature, and hemoglobin be in error?
A. Carbon
monoxide poisoning B. Diabetic ketoacidosis C. Patient receiving oxygen therapy
D. Assisted
ventilation for respiratory failure Chemistry/Identify sources of error/Blood ga
s/3 23. Which
would be consistent with partially compensated respiratory acidosis? A. pH PCO
2 Bicarbonate
increased increased increased B. pH PCO 2 Bicarbonate increased decreased decre
ased C. pH PCO 2
Bicarbonate decreased decreased decreased D. pH PCO 2 Bicarbonate decreased inc
reased increased
Chemistry/Evaluate laboratory data to recognize health and disease states/3 24.
Which condition
results in metabolic acidosis with severe hypokalemia and chronic alkaline urine
? A. Diabetic
ketoacidosis B. Phenformin-induced acidosis C. Renal tubular acidosis D. Acidosi
s caused by
starvation Chemistry/Correlate clinical and laboratory data/ Acidbase and electro
lytes/2 25.
Which of the following mechanisms is responsible for metabolic acidosis? A. Bica
rbonate de ciency

B. Excessive retention of dissolved CO 2 C. Accumulation of volatile acids D. Hy

peraldosteronism
Chemistry/Apply knowledge of fundamental biological characteristics/Acidbase/1 26
. Which of the
following disorders is associated with lactate acidosis? A. Diarrhea B. Renal tu
bular acidosis C.
Hypoaldosteronism D. Alcoholism Chemistry/Correlate clinical and laboratory data
/ Acidbase/2 27.
Which of the following is the primary mechanism of compensation for metabolic ac
idosis? A.
Hyperventilation B. Release of epinephrine C. Aldosterone release D. Bicarbonate
excretion
Chemistry/Apply knowledge of fundamental biological characteristics/Acidbase/2 19
4 Chapter 5 |
Clinical Chemistry Answers to Questions 2227 22. A CO has about 200 times the a nit
y as O 2 for
hemoglobin and will displace O 2 from hemoglobin at concentrations that have no
signi cant e ect
on the PAO 2 . Consequently, calculated oxygen saturation will be erroneously hi
gh. Other cases
in which the calculated O 2 Sat should not be used include any hemoglobinopathy
that a ects
oxygen a nity and methemoglobinemia. The other situations above a ect the O 2 satura
tion of
hemoglobin in a manner that can be predicted by the e ect of pH, PO 2 , and PCO 2
on the
oxyhemoglobin dissociation curve. 23. D Acidosis = low pH; respiratory = disturb
ance of PCO 2 ; a
low pH is caused by increased PCO 2 . In partially compensated respiratory acido
sis, the
metabolic component of the bu er system, bicarbonate, is retained. This helps to c
ompensate for
retention of PCO 2 by titrating hydrogen ions. The compensatory component always
moves in the
same direction as the cause of the acidbase disturbance. 24. C Metabolic acidosis
can be caused
by any condition that lowers bicarbonate. In nonrenal causes, the kidneys will a
ttempt to
compensate by increased acid excretion. However, in renal tubular acidosis (RTA)
, an intrinsic
defect in the tubules prevents bicarbonate reabsorption. This causes alkaline in
stead of acidic
urine. Excretion of bicarbonate as potassium bicarbonate (KHCO 3 ) results in se
vere hypokalemia.
25. A Metabolic acidosis is caused by bicarbonate de ciency and metabolic alkalosi
s by
bicarbonate excess. Respiratory acidosis is caused by PCO 2 retention (defective
ventilation),
and respiratory alkalosis is caused by PCO 2 loss (hyperventilation). Important
causes of
metabolic acidosis include renal failure, diabetic ketoacidosis, lactate acidosi
s, and diarrhea.
26. D Lactate acidosis often results from hypoxia, which causes a de cit of nicoti
namide adenine
dinucleotide, the oxidized form (NAD + ). This promotes the reduction of pyruvat
e to lactate,
regenerating NAD + needed for glycolysis. In alcoholic acidosis, oxidation of et
hanol to
acetaldehyde consumes the NAD + . In diabetes, lactate acidosis can result from
depletion of

Krebs cycle intermediates. Diarrhea and renal tubular acidosis result in metabol
ic acidosis via
bicarbonate loss. Hypoaldosteronism causes metabolic acidosis via hydrogen and p
otassium ion
retention. 27. A In metabolic acidosis, the respiratory center is stimulated by
chemoreceptors in
the carotid sinus, causing hyperventilation. This results in increased release o
f CO 2 .
Respiratory compensation begins almost immediately unless blocked by pulmonary d
isease or
respiratory therapy. Hyperventilation can bring the PCO 2 down to approximately
1015 mm Hg.
2828_Ch05_171-326 06/08/12 5:14 PM Page 194 28. Te following conditions are a
ll causes of
alkalosis. Which condition is associated with respiratory (rather than metabolic
) alkalosis? A.
Anxiety B. Hypovolemia C. Hyperaldosteronism D. Hypoparathyroidism Chemistry/Cor
relate clinical
and laboratory data/ Acidbase/2 29. Which of the following conditions is associat
ed with both
metabolic and respiratory alkalosis? A. Hyperchloremia B. Hypernatremia C. Hyper
phosphatemia D.
Hypokalemia Chemistry/Correlate clinical and laboratory data/ Acidbase/2 30. In u
ncompensated
metabolic acidosis, which of the following will be normal? A. Plasma bicarbonate
B. PCO 2 C. p50
D. Total CO 2 Chemistry/Correlate clinical and laboratory data/ Acidbase/2 31. Wh
ich of the
following conditions is classi ed as normochloremic acidosis? A. Diabetic ketoacid
osis B. Chronic
pulmonary obstruction C. Uremic acidosis D. Diarrhea Chemistry/Correlate clinica
l and laboratory
data/ Acidbase/2 32. Which PCO 2 value would be seen in maximally compensated met
abolic
acidosis? A. 15 mm Hg B. 30 mm Hg C. 40 mm Hg D. 60 mm Hg Chemistry/Evaluate lab
oratory data to
recognize health and disease states/Blood gas/3 33. A patient has the following
arterial blood
gas results: pH = 7.56 PCO 2 = 25 mm Hg PO 2 = 100 mm Hg HCO 3 = 22 mmol/L Tese
results are
most likely the result of which condition? A. Improper specimen collection B. Pr
olonged storage
C. Hyperventilation D. Hypokalemia Chemistry/Evaluate laboratory data to recogni
ze health and
disease states/Acidbase/3 5.2 | Blood Gases, pH, and Electrolytes 195 Answers t
o Questions
2833 28. A Respiratory alkalosis is caused by hyperventilation, which leads to de
creased PCO 2 .
Anxiety and drugs such as epinephrine that stimulate the respiratory center are
common causes of
respiratory alkalosis. Excess aldosterone increases net acid excretion by the ki
dneys. Low
parathyroid hormone causes increased bicarbonate reabsorption, resulting in alka
losis.
Hypovolemia increases the relative concentration of bicarbonate. This is common
and is called
dehydrational alkalosis, chloride responsive alkalosis, or alkalosis of sodium d
e cit. 29. D
Hypokalemia is both a cause and result of alkalosis. In alkalosis, hydrogen ions
may move from

the cells into the extracellular uid and potassium into the cells. In hypokalemia
caused by
overproduction of aldosterone, hydrogen ions are secreted by the renal tubules.
This increase in
net acid excretion results in metabolic alkalosis. 30. B The normal compensatory
mechanism for
metabolic acidosis is respiratory hyperventilation. In uncompensated cases, the
PCO 2 is not
reduced, indicating a concomitant problem in respiratory control. 31. A Bicarbon
ate de cit will
lead to hyperchloremia unless the bicarbonate is replaced by an unmeasured anion
. In diabetic
ketoacidosis, acetoacetate and other ketoacids replace bicarbonate. The chloride
remains normal
or low and there is an increased anion gap. 32. A In metabolic acidosis, hyperve
ntilation
increases the ratio of bicarbonate to dissolved CO 2 . The extent of compensatio
n is limited by
the rate of both gas di usion and diaphragm contraction. The lower limit is betwee
n 10 and 15 mm
Hg PCO 2 , which is the maximum compensatory e ect. 33. C The pH is alkaline (refe
rence range
7.357.45) and this can be caused by either low PCO 2 or increased bicarbonate. Th
is patient has
a normal bicarbonate (reference range 2226 mmol/L) and a low PCO 2 (reference ran
ge 3545 mm
Hg). Low PCO 2 is always caused by hyperventilation, and therefore, this is a ca
se of
uncompensated respiratory alkalosis. The acute stages of respiratory disorders a
re often
uncompensated. Prolonged storage would cause the pH and PO 2 to fall, and the PC
O 2 to rise.
Hypokalemia causes alkalosis, but usually is associated with the retention of CO
2 as
compensation. 2828_Ch05_171-326 06/08/12 5:14 PM Page 195 34. Why are three l
evels used for
quality control of pH and blood gases? A. Systematic errors can be detected earl
ier than with two
controls B. Analytical accuracy needs to be greater than for other analytes C. H
igh, normal, and
low ranges must always be evaluated D. A di erent level is needed for pH, PCO 2 ,
and PO 2
Chemistry/Select appropriate controls/Acidbase/2 35. A single-point calibration i
s performed
between each blood gas sample in order to: A. Correct the electrode slope B. Cor
rect electrode
and instrument drift C. Compensate for temperature variance D. Prevent contamina
tion by the
previous sample Chemistry/Apply knowledge of standard operating procedures/Blood
gas/2 36. In
which condition would hypochloremia be expected? A. Respiratory alkalosis B. Met
abolic acidosis
C. Metabolic alkalosis D. All of these options Chemistry/Correlate clinical and
laboratory data/
Blood gas electrolytes/2 37. Given the following serum electrolyte data, determi
ne the anion gap.
Na = 132 mmol/L Cl = 90 mmol/L HCO 3 = 22 mmol/L A. 12 mmol/L B. 20 mmol/L C. 64
mmol/L D.
Cannot be determined from the information provided Chemistry/Calculate/Electroly
tes/2 38. Which

of the following conditions will cause an increased anion gap? A. Diarrhea B. Hy

poaldosteronism
C. Hyperkalemia D. Renal failure Chemistry/Correlate clinical and laboratory dat
a/ Electrolytes/2
39. Alcoholism, liver failure, and hypoxia induce acidosis by causing: A. Deplet
ion of cellular
NAD + B. Increased excretion of bicarbonate C. Increased retention of PCO 2 D. L
oss of carbonic
anhydrase Chemistry/Apply knowledge of fundamental biological characteristics/Ac
idbase/2 196
Chapter 5 | Clinical Chemistry Answers to Questions 3439 34. A Error detection oc
curs sooner
when more controls are used. Some errors, such as those resulting from temperatu
re error and
protein coating of electrodes, are not as pronounced near the calibration point,
as in the
acidosis and alkalosis range. The minimum requirement for blood gas QC is one sa
mple every 8
hours and three levels (acidosis, normal, alkalosis) every 24 hours. Three level
s of control are
also used commonly for therapeutic drug monitoring and hormone assays because pr
ecision di ers
signi cantly in the high and low ranges. 35. B Calibration using a single standard
corrects the
instrument for error at the labeled value of the calibrator but does not correct
for analytic
errors away from the set point. A two-point calibration adjusts the slope respon
se of the
electrode, eliminating proportional error caused by poor electrode performance.
36. C Chloride is
the major extracellular anion and is retained or lost to preserve electroneutral
ity. Low chloride
will occur in metabolic alkalosis because excess bicarbonate is present. Low chl
oride also will
occur in partially compensated respiratory acidosis because the kidneys compensa
te by increased
retention of bicarbonate. 37. B The anion gap is de ned as unmeasured anions minus
unmeasured
cations. It is calculated by subtracting the measured anions (bicarbonate and ch
loride) from the
serum sodium (or sodium plus potassium). A normal anion gap is approximately 816
mmol/L (1220
mmol/L when potassium is used). Anion gap = Na (HCO3 + Cl) Anion gap = 132 (90 +
22) = 20
mmol/L 38. D An increased anion gap occurs when there is production or retention
of anions other
than bicarbonate or chloride (measured anions). For example, in renal failure, r
etention of
phosphates and sulfates (as sodium salts) increases the anion gap. Other common
causes of
metabolic acidosis with an increased anion gap are diabetic ketoacidosis and lac
tate acidosis.
The anion gap may also be increased in the absence of an acidbase disorder. Commo
n causes
include hypocalcemia, drug overdose, and laboratory error when measuring electro
lytes. 39. A
Oxygen debt and liver failure block oxidative phosphorylation, preventing NADH
from being
oxidized back to NAD + . Oxidation of ethanol to acetate results in accumulation
of NADH. When

NAD + is depleted, glycolysis cannot proceed. It is regenerated by reduction of

pyruvate to
lactate, causing lactate acidosis. 2828_Ch05_171-326 06/08/12 5:14 PM Page 19
6 40. Which of
the following is the primary mechanism causing respiratory alkalosis? A. Hyperve
ntilation B.
De cient alveolar di usion C. De cient pulmonary perfusion D. Parasympathetic inhibiti
on
Chemistry/Apply knowledge of fundamental biological characteristics/Acidbase/2 41
. Which
condition can result in acidosis? A. Cystic brosis B. Vomiting C. Hyperaldosteron
ism D.
Excessive O 2 therapy Chemistry/Correlate clinical and laboratory data/ Blood ga
s/2 42. Which of
the following conditions is associated with an increase in ionized calcium (Ca i
) in the blood?
A. Alkalosis B. Hypoparathyroidism C. Hyperalbuminemia D. Malignancy Chemistry/C
orrelate clinical
and laboratory data/ Electrolytes/2 43. Which of the following laboratory result
s is consistent
with primary hypoparathyroidism? A. Low calcium; high inorganic phosphorus P i B
. Low calcium;
low P i C. High calcium; high P i D. High calcium; low P i Chemistry/Correlate c
linical and
laboratory data/ Electrolytes/2 44. Which of the following conditions is associa
ted with
hypophosphatemia? A. Rickets B. Multiple myeloma C. Renal failure D. Hypervitami
nosis D
Chemistry/Correlate laboratory data with physiological processes/Electrolytes/2
5.2 | Blood
Gases, pH, and Electrolytes 197 Answers to Questions 4044 40. A Hyperventilatio
n via
stimulation of the respiratory center (or induced by a respirator) is the mechan
ism of
respiratory alkalosis. Causes include low PO 2 , anxiety, fever, and drugs that
stimulate the
respiratory center. Acute respiratory alkalosis is often uncompensated because r
enal compensation
is not rapid. Uncompensated respiratory alkalosis is characterized by an elevate
d pH and a low
PCO 2 with normal bicarbonate. 41. D When O 2 saturation of venous blood is grea
tly elevated, Hgb
cannot release O 2 . Oxyhemoglobin cannot bind CO 2 or hydrogen ions and acidosi
s results. Pure O
2 may cause neurological damage, leading to convulsion and blindness, especially
in infants. It
can induce respiratory failure by causing pulmonary hemorrhage, edema, and hyali
nization. The
other three conditions cause alkalosis. Vomiting and cystic brosis cause loss of
chloride,
resulting in hypovolemia and intestinal bicarbonate absorption. Hyperaldosteroni
sm causes
hypokalemia; this results in increased renal H + excretion and a shift of H + in
to cells in
exchange for K + . 42. D Increased Ca i occurs in hyperparathyroidism, malignanc
y, and acidosis.
Ca i is elevated in primary hyperparathyroidism due to resorption of calcium fro
m bone. Many
nonparathyroid malignancies create products called parathyroid hormone-related p
roteins that

stimulate the parathyroid receptors of cells. Acidosis alters the equilibrium be

tween bound and
free calcium, favoring ionization. Hyperalbuminemia increases the total calcium
by increasing the
protein- bound fraction, but does not a ect the Ca i . 43. A Parathyroid hormone d
e ciency causes
reduced resorption of calcium from bone, increased renal excretion of calcium, a
nd decreased
renal excretion of phosphorus. It is distinguished from other causes of hypocalc
emia by Ca i ,
which is reduced only by primary hypoparathyroidism and alkalosis. 44. A Rickets
can result from
dietary phosphate de ciency, vitamin D de ciency, or an inherited disorder of either
vitamin D or
phosphorus metabolism. Vitamin Ddependent rickets (VDDR) can be reversed by megad
oses of vitamin
D. Type 1 is caused by a de ciency in renal cells of 1--hydroxyl
se,
n enzyme th
t
converts 25
hydroxyvit
min D to the
ctive form, 1,25 hydroxyvit
min D. Type 2 is c
used y

de ciency in
the vit
min D receptor of one tissue. Vit
min Dresist
nt rickets (VDRR) is c
use
d y

de ciency in the ren
l re
sorption of phosph
te. Consequently,
ected persons (usu

lly men
ec
use it is most commonly X-linked) h
ve
norm
l serum c
lcium
nd
low P i
.
2828_Ch05_171-326 06/08/12 5:14 PM P
e 197 45. Which of the followin tests
is consistently

norm
l in osteoporosis? A. Hih urin
ry c
lcium B. Hih serum P i C. Low serum
c
lcium D. Hih
urine or serum N-telopeptide of type 1 coll
en Chemistry/Correl
te l
or
tory d

t
with
physioloic
l processes/Electrolytes/2 46. Which of the followin is
m
rker fo
r one form
tion?
A. Osteoc
lcin B. T
rtr
te resist
nt
cid phosph
t
se (TRAP) C. Urin
ry pyridino
line
nd
deoxypyridinoline D. Urin
ry C-telopeptide
nd N-telopeptide crosslinks (CTx
nd
NTx)
Chemistry/Select tests/Bone disorders/2 47. Wh
t role do CTx
nd NTx pl
y in the
m
n
ement of
osteoporosis? A. Incre
sed urin
ry excretion is di
nostic of e
rly st
e dise
s
e B. Incre
sed
levels indic
te
low risk of developin osteoporosis C. Decre
sed urin
ry excre
tion indic
tes

positive response to tre
tment D. Te r
te of urin
ry excretion correl
tes with t
he st
e of the
dise
se Chemistry/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics/Bone
disorders/2 198
Ch
pter 5 | Clinic
l Chemistry Answers to Questions 4547 45. D Commonly used m
rk
ers for other
one dise
ses such
s serum or urin
ry c
lcium, inor
nic phosphorus, tot
l
lk

line phosph
t
se
(ALP),
nd vit
min D
re neither sensitive nor specific for osteoporosis. C
lciu
m
nd phosphorus

re usu
lly within norm
l limits. Althouh estroen deficiency reduces form
tion
of 1,25
hydroxyvit
min D (1,25 hydroxycholec
lciferol), promotin postmenop
us
l osteopo
rosis, the 1,25
hydroxyvit
min D is low in only 30%35% of c
ses,
nd low levels m
y e c
used y
other one

disorders. Serum m
rkers for osteoporosis include oth N-telopeptide of type 1 c

oll
en (NTx)
nd
C-telopeptide of type 1 coll
en (CTx). These c
n e used to follow tre
tment wi
th resorption

nt
onists ( isphosphon
tes) ec
use they decre
se sinific
ntly when ther
py i
s successful. 46.
A Biochemic
l m
rkers for osteoporosis
re cl
ssi ed
s either m
rkers for one fo
rm
tion or
resorption. Osteoc
lcin is
protein hormone th
t stimul
tes osteo l
sts
nd inc
re
ses one
miner
liz
tion. Pyridinoline is formed when hydroxylysine roups on
dj
cent ril
s
re joined
toether,
nd deoxypyridinoline when hydroxylysine
nd lysine roups
re joined.
These form
crosslinks etween the C
nd N termin
l ends of one ril (which
re nonhelic
l)

nd the helic
l
portion of
n
dj
cent ril. The resultin products
re c
lled C-
nd N-telopepti
de crosslinks
of type 1 coll
en. Osteocl
sts c
use cle
v
e of these onds, resultin in loss
of oth
telopeptidesdeoxypyridinoline
nd pyridinolinein the urine. TRAP is
n enzyme (pro
duced y
osteocl
sts) th
t hydrolyzes phosph
te in the hydroxy
p
tite m
trix of the one.
47. C M
rkers
for oth one form
tion
nd resorption
re used to monitor tre
tment for osteopo
rosis. Serum
nd
urin
ry me
surements of CTx
nd NTx
nd urin
ry deoxypyridinoline
re used to mo
nitor medic
tions
such
s iphosphon
tes th
t inhi it one resorption. Levels f
ll with successful
tre
tment. DEXA
sc
n,
n x-r
y procedure
sed on su tr
ction of surroundin tissue, is the most
sensitive
di
nostic test for osteoporosis
nd c
n show one loss
s sm
ll
s 1%. However,
it t
kes months
efore
DEXA sc
n shows incre
sed one remodelin followin tre
tment. 2828_Ch0
5_171-326
06/08/12 5:14 PM P
e 198 48. Wh
t role does vit
min D me
surement pl
y in the
m
n
ement of
osteoporosis? A. Vit
min D de ciency must e demonstr
ted to est
lish the di
nos
is B. Vit
min D
is consistently elev
ted in osteoporosis C. A norm
l vit
min D level rules out o
steoporosis D.
Vit
min D de ciency is
risk f
ctor for developin osteoporosis Chemistry/Apply k
nowlede of
fund
ment
l ioloic
l ch
r
cteristics/Bone disorders/2 49. Which st
tement est
descri es
testin recommend
tions for vit
min D? A. Vit
min D testin should e reserved o
nly for those
persons who demonstr
te hyperc
lcemi
of
n undetermined c
use B. Vit
min D test
in should e
speci c for the 1,25(OH)D3 form C. Testin should e for tot
l vit
min D when scre
enin for
de ciency D. Vit
min D testin should not e performed if the p
tient is receivin

vit
min D
supplement Chemistry/Correl
te l
or
tory d
t
with physioloic
l processes/Elec
trolytes/2 50. Te
serum level of which of the followin l
or
tory tests is decre
sed in oth VDDR

nd VDRR? A.
Vit
min D B. C
lcium C. P i D. P
r
thyroid hormone Chemistry/Correl
te l
or
tor
y d
t
with

physioloic
l processes/Bone dise
se/2 5.2 | Blood G
ses, pH,
nd Electrolytes

199 Answers to
Questions 4850 48. D Vit
min D
ss
y is not used to di
nose osteoporosis. Vit
mi
n D de ciency
is
c
use of second
ry osteoporosis,
nd toether with low PTH, c
lcium,
nd es
troen
re
import
nt risk f
ctors. If one or more of these is
norm
l, then one resorptio
n or remodelin
m
y e
norm
l, predisposin one to osteoporosis. De ciency of vit
min D
lso c
u
ses rickets
(c
lled osteom
l
ci
in
dults),
condition in which ones ecome soft owin to
reduced
deposition of hydroxy
p
tite. 49. C Vit
min D de ciency is f
r more common th
n vi
t
min D excess,

nd screenin for vit
min D de ciency is
dvoc
ted especi
lly for d
rk-skinned per
sons
nd people
who do not et
dequ
te sunliht. Provit
min D is
steroid,
nd vit
min D is no
w considered

hormone r
ther th
n
vit
min. The hormone reul
tes tr
nscription of over 200 
enes
nd h
s
pronounced e ects on oth dendritic cells
nd T lymphocytes. De ciency is
ssoci
ted
with m
ny
chronic dise
ses includin
utoimmune dise
ses, c
ncers, hypertension,
nd he
rt
dise
se. There

re two forms of the vit
min, eroc
lciferol (D 2 )
nd cholec
lciferol (D 3 ).
Active D 2
nd D
3
re formed when two hydroxyl roups
re
dded, the rst ein
t the 25 position
y the liver

nd the second
t the -1 position y the kidney. The m
jority of the circul
tin
vit
min D is in
the 25-hydroxyl
ted form of D 2
nd D 3 , c
lled 25(OH)D. The pl
sm
25(OH)D con
centr
tion is
n
expression of oth diet
ry
nd endoenous vit
min D
nd is the most
ppropri
te
test for
detectin nutrition
l vit
min D de ciency. Since the e ect on c
lcium is derived fro
m the
ctive
1,25 form of the vit
min, pl
sm
1,25(OH)D concentr
tion is
more speci c test fo
r
hypervit
minosis D. 50. C Persons with VDDR
nd VDRR h
ve
low P i . However, p
ersons with VDDR
h
ve decre
sed serum c
lcium,
s well. P
r
thyroid hormone (PTH) is incre
sed in
persons with
VDDR ec
use c
lcium is the prim
ry stimulus for PTH rele
se, ut not in persons
with VDRR.
Vit
min D levels v
ry dependin upon the type of rickets
nd the vit
min D met

olite th
t is
me
sured. 1,25(OH)D, the
ctive form of vit
min D, is low in type 1 ut hih in
type 2 VDDR. It
m
y e either norm
l or low in VDRR. 2828_Ch05_171-326 06/08/12 5:14 PM P
e
199 51. Which of
the followin is the most
ccur
te me
surement of P i in serum? A. R
te of unred
uced
phosphomoly d
te form
tion
t 340 nm B. Me
surement of phosphomoly denum lue
t
680 nm C. Use of

minon
ptholsulfonic
cid to reduce phosphomoly d
te D. Form
tion of
complex w
ith m
l
chite
reen dye Chemistry/Apply principles of
sic l
or
tory procedures/Biochemic
l/
2 52. Wh
t is the
percent
e of serum c
lcium th
t is ionized (C
i )? A. 30% B. 45% C. 60% D. 80%
Chemistry/Apply

knowlede of fund
ment
l ioloic
l ch
r
cteristics/Electrolytes/1 53. Which of

the followin
conditions will c
use erroneous C
i results? Assume th
t the s
mples
re collec
ted
nd stored

n
ero ic
lly, kept
t 4C until me
surement,
nd stored for no loner th
n 1 hour
. A. Sliht
hemolysis durin venipuncture B. Ass
y of whole lood collected in sodium ox
l
t
e C. An
lysis of
serum in

rrier el tu e stored
t 4C until the clot h
s formed D. An
lysis of
whole lood
collected in sodium hep
rin, 20 U/mL (low-hep
rin tu e) Chemistry/Apply knowled
e to reconize
sources of error/Specimen collection
nd h
ndlin/3 54. Which of the followin c
onditions is

ssoci
ted with
low serum m
nesium? A. Addisons dise
se B. Hemolytic
nemi
C.
Hyperp
r
thyroidism D. P
ncre
titis Chemistry/Correl
te clinic
l
nd l
or
tory
d
t
/
Electrolytes/2 55. When me
surin c
lcium with the complexometric dye o-cresolph
th
lein
complexone, m
nesium is kept from interferin y: A. Usin
n
lk
line pH B. Ad
din
8-hydroxyquinoline C. Me
surin
t 450 nm D. Complexin to EDTA Chemistry/Apply
principles of

sic l
or
tory procedures/Biochemic
l/1 200 Ch
pter 5 | Clinic
l Chemistry Ans
wers to Questions
5155 51. A The colorimetric method (Fiske
nd Su
Row) used previously for P i r
e
cted
mmonium
moly d
te with P i , formin
mmonium phosphomoly d
te (NH 4 ) 3 [PO 4 (MoO 3 )
12
]
. A
reducin
ent,
minon
ptholsulfonic
cid (ANS), w
s
dded, formin phos
phomoly denum lue.
The product w
s unst
le
nd required sulfuric
cid, m
kin precipit
tion of pro
tein
potenti
l
source of error. These pro lems
re
voided y me
surin the r
te of form
tion o
f unreduced
phosphomoly d
te
t 340 nm. 52. B C
lcium exists in serum in three forms: protei
n ound, ionized,

nd complexed (
s undissoci
ted s
lts). Only C
i is physioloic
lly
ctive. Pro
tein ound
nd C

i e
ch
ccount for
pproxim
tely 45% of tot
l c
lcium,
nd the rem
inin 10% is
complexed. 53. B
Unlike P i , the intr
cellul
r c
lcium level is not sini c
ntly di erent from pl
sm

c
lcium,

nd c
lcium is not re
tly
ected y diet. Whole lood collected with 520 U/mL hep

rin
nd
stored on ice no loner th
n 2 hours is the s
mple of choice for C
i . Blood 

s syrines
pre lled with 100 U/mL hep
rin should not e used ec
use the hih hep
rin concent
r
tion will
c
use low results. Citr
te, ox
l
te,
nd ethylenedi
minetetr

cetic
cid (EDTA)
must not e used
ec
use they chel
te c
lcium. Serum m
y e used provided th
t the s
mple is iced
, kept c
pped
while clottin,
nd
ss
yed within 2 hours (
rrier el tu es m
y e stored lon
er). 54. D Low
m
nesium c
n e c
used y 
strointestin
l loss,
s occurs in di
rrhe

nd p
nc
re
titis (loss of
M
nd C

s so
ps). Hyperp
r
thyroidism c
uses incre
sed rele
se of oth c
lciu
m
nd m
nesium

from one. Addisons dise
se (
drenocorticosteroid de ciency) m
y e
ssoci
ted with

incre
sed
m
nesium
ccomp
nyin hyperk
lemi
. Hemolytic
nemi
c
uses incre
sed rele
se o
f m
nesium
s
well
s pot
ssium from d
m
ed red lood cells (RBCs). 55. B o-Cresolphth
lein c
omplexone c
n e
used to me
sure either m
nesium or c
lcium. Interference in c
lcium
ss
ys is p
revented y

ddition of 8-hydroxyquinoline, which chel
tes m
nesium. When m
nesium is me
s
ured,
ethylenelycol istetr

cetic
cid (EGTA) or EDTA is used to chel
te c
lcium. Tw
o other dyes th
t
c
n e used for oth m
nesium
nd c
lcium
ss
ys
re c
lm
ite
nd methylthymol
lue. Arsen
zo
III dye is commonly used to me
sure c
lcium. It is more speci c for C
+2 th
n the
others,
nd
does not require
ddition of
M +2 chel
tor. 2828_Ch05_171-326 06/08/12 5:14
PM P
e 200 56.
Which electrolyte me
surement is le
st
ected y hemolysis? A. Pot
ssium B. C
lci
um C. P i D.
M
nesium Chemistry/Apply knowlede to reconize sources of error/Specimen colle
ction
nd
h
ndlin/2 57. Which of the followin conditions is
ssoci
ted with hypok
lemi
?
A. Addisons
dise
se B. Hemolytic
nemi
C. Dioxin intoxic
tion D. Alk
losis Chemistry/Corre
l
te clinic
l
nd
l
or
tory d
t
/ Electrolytes/2 58. Which of the followin conditions is most li
kely to produce

n elev
ted pl
sm
pot
ssium? A. Hypop
r
thyroidism B. Cushins syndrome C. Di
rr
he
D.
Diit
lis overdose Chemistry/Correl
te clinic
l
nd l
or
tory d
t
/Electrolytes
/2 59. Which of
the followin v
lues is the threshold critic
l v
lue (
lert or
ction level) for
low pl
sm

pot
ssium? A. 1.5 mmol/L B. 2.0 mmol/L C. 2.5 mmol/L D. 3.5 mmol/L Chemistry/App
ly knowlede of
fund
ment
l ioloic
l ch
r
cteristics/Electrolytes/1 60. Which electrolyte is l
e
st likely to e
elev
ted in ren
l f
ilure? A. Pot
ssium B. M
nesium C. Inor
nic phosphorus D.
Sodium
Chemistry/Correl
te clinic
l
nd l
or
tory d
t
/ Electrolytes/2 5.2 | Blood G
s
es, pH,
nd
Electrolytes 201 Answers to Questions 5660 56. B Pot
ssium, phosphorus,
nd m

nesium
re the
m
jor intr
cellul
r ions,
nd even sliht hemolysis will c
use f
lsely elev
ted
results. Serum
s
mples with visi le hemolysis (20 m/dL free H ) should e redr
wn. 57. D Addi
sons dise
se
(
drenocortic
l insu ciency) results in low levels of
dren
l corticosteroid hormo
nes, includin

ldosterone
nd cortisol. Bec
use these hormones promote re
sorption of sodium

nd secretion of
pot
ssium y the collectin tu ules, p
tients with Addisons dise
se displ
y hyper
k
lemi

nd
hypon
tremi
. Hemolytic
nemi

nd dioxin intoxic
tion c
use rele
se of intr
ce
llul
r pot
ssium.
Alk
losis c
uses pot
ssium to move from the extr
cellul
r uid into the cells
s h
ydroen ions
move from the cells into the extr
cellul
r uid to compens
te for
lk
losis. 58. D
Diit
lis

toxicity c
uses pot
ssium to le
ve the cells
nd enter the extr
cellul
r uid, res
ultin in
hyperk
lemi
. Ren
l f
ilure, hemolytic
nemi

nd Addisons dise
se
re other freq
uent c
uses of
hyperk
lemi
. Hypop
r
thyroidism indirectly c
uses hypok
lemi
y inducin
lk
l
osis vi

incre
sed ren
l retention of phosph
te
nd ic
r on
te. Cushins syndrome (
dren

l cortic
l
hyperfunction) results in low pot
ssium
nd elev
ted sodium. Di
rrhe
c
uses los
s of sodium
nd
pot
ssium. 59. C The reference r
ne for pot
ssium is 3.65.4 mmol/L. However, v
l
ues elow 2.5
mmol/L require immedi
te intervention ec
use elow th
t level there is
r
ve
risk of c
rdi
c

rrhythmi
, which c
n le
d to c
rdi
c
rrest. The upper
lert level for pot
ssiu
m is usu
lly 6.5
mmol/L, except for neon
t
l
nd hemolyzed s
mples. A ove this level, there is d

ner of c
rdi
c
f
ilure. 60. D Reduced lomerul
r ltr
tion coupled with decre
sed tu ul
r secreti
on c
uses

ccumul
tion of pot
ssium, m
nesium,
nd inor
nic phosphorus. Poor tu ul
r re

sorption of
sodium o sets reduced lomerul
r ltr
tion. Un ltered sodium dr
ws oth chloride
nd w

ter,
c
usin osmotic equili r
tion etween ltr
te, serum,
nd the tissues. In ren
l di
se
se, serum
sodium is often norm
l,
lthouh tot
l ody sodium is incre
sed owin to uid
nd
s
lt retention.
2828_Ch05_171-326 06/08/12 5:14 PM P
e 201 61. Which of the followin is the
prim
ry
mech
nism for v
sopressin (ADH) rele
se? A. Hypovolemi
B. Hyperosmol
r pl
sm
C
. Renin rele
se
D. Reduced ren
l lood ow Chemistry/Apply knowlede of fund
ment
l ioloic
l
ch
r
cteristics/Osmol
lity/2 62. Which of the followin conditions is
ssoci
ted
with
hypern
tremi
? A. Di
etes insipidus B. Hypo
ldosteronism C. Burns D. Di
rrhe

Chemistry/Correl
te clinic
l
nd l
or
tory d
t
/ Electrolytes/2 63. Which of th
e followin
v
lues is the threshold critic
l v
lue (
lert or
ction level) for hih pl
sm
s
odium? A. 150
mmol/L B. 160 mmol/L C. 170 mmol/L D. 180 mmol/L Chemistry/Apply knowlede of fu
nd
ment
l
ioloic
l ch
r
cteristics/Electrolytes/1 64. Which of the followin conditions
is
ssoci
ted
with tot
l ody sodium excess? A. Ren
l f
ilure B. Hyperthyroidism C. Hypop
r
th
yroidism D.
Di
etic keto
cidosis Chemistry/Correl
te clinic
l
nd l
or
tory d
t
/ Electrol
ytes/2 202
Ch
pter 5 | Clinic
l Chemistry Answers to Questions 6164 61. B ADH is rele
sed y
the posterior
pituit
ry in response to incre
sed pl
sm
osmol
lity. Norm
lly, this is triere
d y rele
se of

ldosterone c
used y ine ective
rteri
l pressure in the kidney. Aldosterone c
us
es sodium
re
sorption, which r
ises pl
sm
osmol
lity; rele
se of ADH c
uses re
sorption
of w
ter, which
incre
ses lood volume
nd restores norm
l osmol
lity. A de ciency of ADH (di
ete
s insipidus)
results in dehydr
tion
nd hypern
tremi
. An excess of ADH (syndrome of in
pprop
ri
te ADH rele
se

[SIADH]) results in dilution
l hypon
tremi
. This m
y e c
used y reion
l hypo

volemi
,
hypothyroidism, centr
l nervous system injury, drus,
nd m
lin
ncy. 62. A Di

etes insipidus
results from f
ilure to produce ADH. Bec
use the collectin tu ules
re imperme

le to w
ter in
the
sence of ADH, severe hypovolemi

nd dehydr
tion result. Hypovolemi
stimu
l
tes
ldosterone
rele
se, c
usin sodium re
sorption, which worsens the hypern
tremi
. Burns, hy
po
ldosteronism,
di
rrhe
,
nd diuretic ther
py
re common c
uses of hypon
tremi
. 63. B The
dul
t reference r
ne
for pl
sm
sodium is
pproxim
tely 135145 mmol/L. Levels in excess of 160 mmol/L

re
ssoci
ted
with severe dehydr
tion, hypovolemi
,
nd circul
tory
nd he
rt f
ilure. The thr
eshold for the
low critic
l v
lue for sodium is 120 mmol/L. This is
ssoci
ted with edem
, hype
rvolemi
,
nd
circul
tory overlo
d. Alert levels must
lso e est
lished for pot
ssium, ic
r
on
te, c
lcium,
pH, PO 2 , lucose, iliru in, hemolo in, pl
telet count,
nd prothrom in time.
When
s
mple
result is elow or
ove the low or hih
lert level, respectively, the physici

n must e noti ed
immedi
tely. 64. A Tot
l ody sodium excess often occurs in persons with ren
l f

ilure,
conestive he
rt f
ilure,
nd cirrhosis of the liver. When w
ter is ret
ined
lo
n with sodium,
tot
l ody sodium excess results r
ther th
n hypern
tremi
. He
rt f
ilure c
uses
sodium
nd w
ter
retention y reducin lood ow to the kidneys. Cirrhosis c
uses o struction of he
p
tic
lymph
tics
nd port
l veins, le
din to loc
l hypertension
nd
ccumul
tion of

scites uid.
Ren
l f
ilure results in poor lomerul
r ltr
tion
nd isosmotic equili r
tion of
s
lt
nd w
ter.
2828_Ch05_171-326 06/08/12 5:14 PM P
e 202 65. Which of the followin condit
ions is

ssoci
ted with hypon
tremi
? A. Diuretic ther
py B. Cushins syndrome C. Di
ete
s insipidus D.
Nephrotic syndrome Chemistry/Correl
te clinic
l
nd l
or
tory d
t
/ Electrolyte
s/2 66. Which of
the followin conditions involvin electrolytes is descri ed correctly? A. Pseud
ohypon
tremi

occurs only when undiluted s
mples
re me
sured B. Pot
ssium levels
re slihtly
hiher in
hep
rinized pl
sm
th
n in serum C. Hypo
l uminemi
c
uses low tot
l c
lcium ut
does not
ect
C
i D. Hyperc
lcemi
m
y e induced y low serum m
nesium Chemistry/Correl
te
clinic
l
nd
l
or
tory d
t
/ Electrolytes/2 67. Which of the followin l
or
tory results is
usu
lly

ssoci
ted with cystic rosis? A. Swe
t chloride re
ter th
n 60 mmol/L B. Elev
t
ed serum sodium

nd chloride C. Elev
ted fec
l trypsin
ctivity D. Low lucose Chemistry/Ev
lu
t
e l
or
tory d
t

to reconize he
lth
nd dise
se st
tes/Electrolytes/2 5.2 | Blood G
ses, pH,
nd
Electrolytes
203 Answers to Questions 6567 65. A Diuretics lower lood pressure y promotin w

ter loss. This

is
ccomplished y c
usin sodium loss from the proxim
l tu ule
nd/or loop. Add
isons dise
se,
syndrome of in
ppropri
te ADH rele
se, urns, di
etic keto
cidosis, hypopituit

rism, vomitin,
di
rrhe
,
nd cystic
rosis
lso c
use hypon
tremi
. Cushins syndrome c
uses hype
rn
tremi
y
promotin sodium re
sorption in the collectin tu ule in exch
ne for pot
ssium
. Di
etes
insipidus
nd nephrotic syndrome promote hypern
tremi
y c
usin w
ter loss. 66
. C When serum

l umin is low, the equili rium etween ound
nd C
i is shifted, producin inc
re
sed C
i .
This inhi its rele
se of PTH y ne
tive feed
ck until the C
i level returns t
o norm
l.
Pot
ssium is rele
sed from pl
telets
nd leukocytes durin co
ul
tion, c
usin
serum levels to
e hiher th
n pl
sm
. Pseudohypon
tremi
is
me
surement error c
used y dilut
in s
mples
cont
inin excessive f
t or protein. The colloids displ
ce pl
sm
w
ter, resulti
n in less
electrolytes ein delivered into the diluent. Only ion-selective electrodes th

t me
sure whole
lood or undiluted serum
re un
ected. M
nesium is needed for rele
se of PTH,
n
d PTH c
uses
rele
se of c
lcium
nd m
nesium from one. Therefore, hypoc
lcemi
c
n e
ssoc
i
ted with either
m
nesium de ciency or m
nesium excess. 67. A Cystic
rosis c
uses o struction of
the exocrine
l
nds includin the swe
t l
nds, mucus l
nds,
nd p
ncre
s. New orns with p
n
cre
tic
involvement demonstr
te fec
l trypsin de ciency, which m
y e detected y
low fe
c
l
chymotrypsin or immunore
ctive trypsin result. However, these tests require con rm

tion. Serum
sodium
nd chloride levels
re low. More th
n 98% of
ected inf
nts h
ve elev
ted
swe
t sodium

nd chloride
nd low serum levels. Swe
t chloride in excess of 60 mmol/L con rms t
he clinic
l
di
nosis. Some persons with the dise
se h
ve insulin de ciency
nd elev
ted lood
lucose.
Genetic tests
re
v
il
le to detect sever
l mut
tions th
t occur
t the cystic
rosis
tr
nsmem r
ne conduct
nce reul
tor (CFTR) locus on chromosome 7. 2828_Ch05_171326 06/08/12
5:14 PM P
e 203 68. When performin
swe
t chloride collection, which of the
followin steps
will result in
n
lytic
l error? A. Usin unweihed 
uze so
ked in piloc
rpine
nitr
te on the
inner surf
ce of the fore
rm to stimul
te swe
tin B. Collectin more th
n 75 m
of swe
t in 30
minutes C. Le
vin the preweihed 
uze on the inside of the
rm exposed to
ir
durin collection
D. Rinsin the collected swe
t from the 
uze p
d usin chloride titr
tin solut
ion
Chemistry/Apply knowlede to reconize sources of error/Specimen collection
nd
h
ndlin/3 69.
Which electrolyte level est correl
tes with pl
sm
osmol
lity? A. Sodium B. Chl
oride C.
Bic
r on
te D. C
lcium Chemistry/Apply knowlede of fund
ment
l ioloic
l
ch
r
cteristics/Electrolytes/2 70. Which formul
is most
ccur
te in predictin

pl
sm

osmol
lity? A. N
+ 2(Cl) + BUN + lucose B. 2(N
) + 2(Cl) + lucose + ure
C. 2
(N
) + (lucose
18) + (BUN 2.8) D. N
+ Cl + K + HCO 3 Chemistry/C
lcul
te/Osmol
lity/2 204 Ch
p
ter 5 |
Clinic
l Chemistry Answers to Questions 6870 68. C The swe
t chloride procedure r
equires the

pplic
tion of piloc
rpine to stimul
te swe
tin,
nd the use of iontophoresis (

pplic
tion of
0.16-mA current for 5 minutes) to rin the swe
t to the surf
ce. After iontopho
resis, the skin
on the inner surf
ce of the fore
rm is w
shed with deionized w
ter
nd dried,
n
d
preweihed
p
ir of 2-in. 2 p
ds is t
ped to the skin. Durin the 30-minute collection of sw
e
t, the 
uze
must e completely covered to prevent cont
min
tion
nd loss of swe
t y ev
por

tion. The
Gi sonCooke reference method for swe
t chloride uses the Sch
les
nd Sch
les meth
od (titr
tion
y H[NO 3
]
2 with diphenylc
r
zone indic
tor) to
ss
y 1.0 mL of swe
t eluted from
the 
uze with 5 mL
of w
ter. A Cotlove chloridometer is often used to me
sure swe
t chloride. The s
we
t is eluted
from the 
uze with the titr
tin solution to f
cilit
te me
surement. Altern
tiv
ely,
m
croduct
collection system m
y e used th
t does not require weihin. A minimum m
ss of
75 m swe
t is
required for collection in 
uze
nd 15 L sweat for collection in macroduct tubin
g. 69. A Sodium
and chloride are the major extracellular ions. Chloride passively follows sodium
, making sodium
the principal determinant of plasma osmolality. 70. C Calculated plasma osmolali
ty is based upon
measurement of sodium, glucose, and urea. Because sodium associates with a count
er ion, two times
the sodium estimates the millimoles per liter of electrolytes. Some laboratories
multiply by 1.86
instead of 2 to correct for undissociated salts. Dividing glucose by 18 converts
from milligrams
per deciliter to millimoles per liter. Dividing blood urea nitrogen (BUN) by 2.8
converts from
milligrams per deciliter BUN to millimoles per liter urea. 2828_Ch05_171-326 06
/08/12 5:14 PM
Page 204 205 5.3 Glucose, Hemoglobin, Iron, and Bilirubin 1. Which of the follow
ing biochemical
processes is promoted by insulin? A. Glycogenolysis B. Gluconeogenesis C. Lipoly
sis D. Uptake of
glucose by cells Chemistry/Apply knowledge of fundamental biological
characteristics/Carbohydrates/1 2. Which of the following hormones promotes hype
rglycemia? A.
Calcitonin B. Growth hormone C. Aldosterone D. Renin Chemistry/Apply knowledge o
f fundamental
biological characteristics/Carbohydrates/1 3. Which of the following is characte
ristic of type 1
diabetes mellitus? A. Requires an oral glucose tolerance test for diagnosis B. I
s the most common
form of diabetes mellitus C. Usually occurs after age 40 D. Requires insulin rep
lacement to

prevent ketosis Chemistry/Correlate clinical and laboratory data/ Biological man

ifestation of
disease/2 Answers to Questions 13 1. D Insulin reduces blood glucose levels by in
creasing
glucose uptake by cells. It promotes lipid and glycogen production, induces synt
hesis of
glycolytic enzymes, and inhibits formation of glucose from pyruvate and Krebs cy
cle
intermediates. 2. B Growth hormone and cortisol promote gluconeogenesis and epin
ephrine
stimulates glycogenolysis. Excess thyroid hormone causes hyperglycemia by increa
sing glucagon and
inactivation of insulin, thereby promoting both gluconeogenesis and glycogenolys
is. An increase
in any of these hormones can cause hyperglycemia. Calcitonin opposes the action
of parathyroid
hormone. Aldosterone is the primary mineralocorticoid hormone and stimulates sod
ium reabsorption
and potassium secretion by the kidneys. Renin is released from the kidney due to
ine ective
arterial pressure and promotes activation of angiotensinogen and aldosterone sec
retion. 3. D Type
1, or juvenile, diabetes is also called insulin- dependent diabetes because pati
ents must be
given insulin to prevent ketosis. Type 1 accounts for only about 10%20% of cases
of diabetes
mellitus, and is usually diagnosed by a fasting plasma glucose. Two consecutive
results 126
mg/dL is diagnostic. Approximately 95% of patients produce autoantibodies agains
t the beta cells
of the pancreatic islets. Other autoantibodies may be produced against insulin,
glutamate
decarboxylase, and tyrosine phosphorylase IA2. There is genetic association betw
een type 1
diabetes and human leukocyte antigens (HLA) DR3 and DR4. 2828_Ch05_171-326 06/0
8/12 5:14 PM
Page 205 4. Which of the following is characteristic of type 2 diabetes mellitus
? A. Insulin
levels are consistently low B. Most cases require a 3-hour oral glucose toleranc
e test to
diagnose C. Hyperglycemia is often controlled without insulin replacement D. Te
condition is
associated with unexplained weight loss Chemistry/Correlate clinical and laborat
ory data/
Biological manifestation of disease/2 5. Which of the following results falls wi
thin the
diagnostic criteria for diabetes mellitus? A. Fasting plasma glucose of 120 mg/d
L B. Two-hour
postprandial plasma glucose of 160 mg/dL C. Two-hour plasma glucose of 180 mg/dL
following a 75 g
oral glucose challenge D. Random plasma glucose of 250 mg/dL and presence of sym
ptoms
Chemistry/Evaluate laboratory data to recognize health and disease states/Carboh
ydrates/2 6.
Select the most appropriate adult reference range for fasting blood glucose. A.
40105 mg/dL
(2.225.82 mmol/L) B. 60140 mg/dL (3.337.77 mmol/L) C. 6599 mg/dL (3.615.50 mmol/L) D.
75150
mg/dL (4.168.32 mmol/L) Chemistry/Apply knowledge of fundamental biological
characteristics/Carbohydrates/1 7. When preparing a patient for an oral glucose

tolerance test
(OGTT), which of the following conditions will lead to erroneous results? A. Te
patient remains
ambulatory for 3 days prior to the test B. Carbohydrate intake is restricted to
below 150 g/day
for 3 days prior to test C. No food, co ee, tea, or smoking is allowed 8 hours bef
ore and during
the test D. Administration of 75 g of glucose is given to an adult patient follo
wing a 1012-hour
fast Chemistry/Apply knowledge to recognize sources of error/Glucose tolerance t
est/3 206 Chapter
5 | Clinical Chemistry Answers to Questions 47 4. C Type 2, or late-onset diabete
s, is
associated with a defect in the receptor site for insulin. Insulin levels may be
low, normal, or
high. Patients are usually obese and over 40 years of age, although the incidenc
e is increasing
in both children and young adults. The American Diabetes Association (ADA) recom
mends screening
all adults for diabetes who are overweight and have one additional risk factor a
nd all adults
over age 45, and to retest them every 3 years, if negative. Patients do not requ
ire insulin to
prevent ketosis and hyperglycemia can be controlled in most patients by diet and
drugs that
promote insulin release. Type 2 accounts for 80%90% of all diabetes mellitus. 5.
D The American
Diabetes Association recommends the following criteria for diagnosing diabetes m
ellitus: fasting
glucose 126 mg/dL, casual (random) glucose 200 mg/dL in the presence of symptoms
(polyuria,
increased thirst, weight loss), glucose 200 mg/dL at 2 hours after an oral dose
of 75 g of
glucose, and hemoglobin A 1c 6.5%. A diagnosis of diabetes mellitus is indicated
if any one or
combination of these four criteria is met on more than a single testing event. T
he fasting plasma
glucose test requires at least 8 hours with no food or drink except water. The 2
-hour postloading
test should be conducted according to the oral glucose tolerance guidelines curr
ently recommended
by the World Health Organization. 6. C Reference ranges vary slightly depending
upon method and
specimen type. Enzymatic methods speci c for glucose have an upper limit of normal
no greater
than 99 mg/dL. This is the cuto value for impaired fasting plasma glucose (predia
betes)
recommended by the American Diabetes Association. Although 65 mg/dL is considere
d the 2.5
percentile, a fasting level below 50 mg/dL is often seen without associated clin
ical
hypoglycemia, and neonates have a lower limit of approximately 40 mg/dL owing to
maternal
insulin. 7. B Standardized OGTTs require that patients receive at least 150 gram
s of carbohydrate
per day for 3 days prior to the test in order to stabilize the synthesis of indu
cible glycolytic
enzymes. The 2-hour OGTT test is no longer recommended for screening and should
be reserved for
con rmation of diabetes in cases that are di cult to diagnose, such as persons who l

ack symptoms
and signs of fasting hyperglycemia. 2828_Ch05_171-326 06/08/12 5:14 PM Page 2
06 8. Which of
the following 2-hour glucose challenge results would be classi ed as impaired gluc
ose tolerance
(IGT)? Two-hour serum glucose: A. 130 mg/dL B. 135 mg/dL C. 150 mg/dL D. 204 mg/
dL
Chemistry/Evaluate laboratory data to recognize health and disease states/Glucos
e tolerance/2 9.
Which statement regarding gestational diabetes mellitus (GDM) is correct? A. Is
diagnosed using
the same oral glucose tolerance criteria as in nonpregnancy B. Converts to diabe
tes mellitus
after pregnancy in 60%75% of cases C. Presents no increased health risk to the fe
tus D. Is
de ned as glucose intolerance originating during pregnancy Chemistry/Evaluate labo
ratory data to
recognize health and disease states/Glucose tolerance test/2 10. Which of the fo
llowing ndings
is characteristic of all forms of clinical hypoglycemia? A. A fasting blood gluc
ose value below
55 mg/dL B. High fasting insulin levels C. Neuroglycopenic symptoms at the time
of low blood
sugar D. Decreased serum C peptide Chemistry/Correlate clinical and laboratory d
ata/
Carbohydrates/2 5.3 | Glucose, Hemoglobin, Iron, and Bilirubin 207 Answers to
Questions 810 8.
C With the exception of pregnant females, impaired glucose tolerance is de ned by
the ADA as a
serum or plasma glucose at 2 hours following a 75-g oral glucose load of 140 mg/d
L and < 200
mg/dL. Persons who have a fasting plasma glucose of 100 but < 126 mg/dL are class
i ed as having
impaired fasting glucose (IFG). Both IGT and IFG are risk factors for developing
diabetes later
in life. Such persons are classi ed as having prediabetes and should be tested ann
ually. 9. D
Control of GDM reduces perinatal complications such as respiratory distress synd
rome, high birth
weight, and neonatal jaundice. Women at risk are usually screened between 24 and
28 weeks
gestation. The screening test can be performed nonfasting and consists of an ora
l 50-g glucose
challenge followed by serum or plasma glucose measurement at 1 hour. A result 14
0 mg/dL is
followed by a 2-hour or 3-hour oral glucose tolerance test to confirm gestationa
l diabetes. For
the 3-hour test, a 100-g dose of glucose is used and at least two of the followi
ng cutoffs must
be exceeded: fasting, 95 mg/dL or higher; 1 hour, 180 mg/dL or higher; 2 hour 15
5 mg/dL or
higher; 3 hour, 140 mg/dL or higher. The same cutpoints are used for the 2-hour
test except
that a 75-g dose is used. GDM converts to diabetes mellitus within 10 years in 3
0%40% of cases.
ADA recommends testing persons with GDM for diabetes 612 weeks after delivery. 10
. C Clinical
hypoglycemia can be caused by insulinoma, drugs, alcoholism, and reactive hypogl
ycemia. Reactive
hypoglycemia is characterized by delayed or excessive insulin output after eatin

g and is very
rare. Fasting insulin is normal but postprandial levels are increased. High fast
ing insulin
levels (usually > 6 g/L) are seen in insulinoma, and patients with insulinoma alm
ost always
display fasting hypoglycemia, especially when the fast is extended to 4872 hours.
C peptide is a
subunit of proinsulin that is hydrolyzed when insulin is released. In hypoglycem
ia, low levels
indicate an exogenous insulin source, whereas high levels indicate overproductio
n of insulin.
2828_Ch05_171-326 06/08/12 5:14 PM Page 207 11. Which statement regarding gly
cated
(glycosylated) Hgb (G-Hgb) is true? A. Has a sugar attached to the C-terminal en
d of the ch
in
B. Is
hihly reversi le
minolyc
n C. Re ects the extent of lucose reul
tion
in the 8- to
12-week interv
l prior to s
mplin D. Will e
norm
l within 4 d
ys followin

n episode of
hyperlycemi
Chemistry/Correl
te l
or
tory d
t
with physioloic
l processes/G
lyc
ted
hemolo in/2 12. Wh
t is the Americ
n Di
etes Associ
tion recommended cuto v
lue
for
dequ
te
control of lood lucose in di
etics
s me
sured y lyc
ted hemolo in? A. 5%
B. 6.5% C. 9.5%
D. 11% Chemistry/Ev
lu
te l
or
tory d
t
to reconize he
lth
nd dise
se st
tes
/Glucose/2 13.
Which st
tement re
rdin me
surement of H A 1c is true? A. Levels do not need
to e done
f
stin B. Both the l
ile
nd st
le H A 1c fr
ctions
re me
sured C. S
mples
should e
me
sured within 2 hours of collection D. Te
ss
y must e done y chrom
tor
phy
Chemistry/Apply
knowlede to reconize sources of error/Glyc
ted hemolo in/2 14. Which st
tion

ry ph
se is used
for the me
surement of hemolo in A 1c y hih perform
nce liquid chrom
tor
phy
? A.
Oct
decylsil
ne (C18) B. C
tion exch
ner C. Anion exch
ner D. Polystyrene divi
nyl enzene
Chemistry/Apply principles of speci
l procedures/ Glyc
ted hemolo in/2 208 Ch
p
ter 5 | Clinic
l
Chemistry Answers to Questions 1114 11. C G-H results from the nonenzym
tic
tt

chment of

su
r such
s lucose to the N-termin
l v
line of the ch
in. The re
ction is non
reversi le
nd
is rel
ted to the time-
ver
ed lood lucose concentr
tion over the life sp
n o
f the RBCs. There

re three G-H fr
ctions desin
ted A 1
, A 1 ,
nd A lc . Hemolo in A 1c m

kes up
out 80%
of lyc
ted hemolo in,
nd is used to determine the
dequ
cy of insulin ther
py
. The
time-
ver
ed lood lucose is
pproxim
ted y the formul
(G-H 33.3) 86 m/dL
,
nd insulin

djustments c
n e m
de to rin this level to within reference limits. Also, l
yc
ted protein

ss
y (c
lled fructos
mine) provides simil
r d
t
for the period etween 2
nd 4
weeks efore
s
mplin. 12. B The ADA recommends th
t 6.5% e used
s the cuto for determinin
the
dequ
cy of
tre
tment for di
etes. A lyc
ted hemolo in test should e performed
t the ti

me of di
nosis

nd every 6 months there
fter if the result is < 6.5%. If the result is 6.5% or
more, the
tre
tment pl
n should e
djusted to
chieve
lower level,
nd the test perform
ed every 3 months
until control is improved. 13. A Since H A 1C represents the
ver
e lood lu
cose 23 months
prior to lood collection, the diet
ry st
tus of the p
tient on the d
y of the t
est h
s no e ect
upon the results. Refrier
ted whole- lood s
mples
re st
le for up to 1 week.
H A 1C is

ss
yed y c
tion exch
ne hih-perform
nce liquid chrom
tor
phy or immuno
ss
y
(immunotur idimetric inhi ition) ec
use oth methods
re speci c for st
le H A
1C ,
nd do
not demonstr
te errors c
used y
norm
l hemolo ins, temper
ture of re
ents,
or fr
ctions
other th
n A 1c . 14. B HPLC methods for me
surin H A 1c
re performed y dil
utin whole lood
with
n
cid u er th
t hemolyzes the s
mple. Norm
l hemolo in A h
s
we
k posit
ive ch
re
t

n
cidic pH
nd inds we
kly to the resin. Glyc
ted hemolo in h
s
n even we
k
er positive
ch
re
nd is eluted efore hemolo in A. A norm
l hemolo in molecules S, D, E,

nd C h
ve

hiher positive ch
re th
n hemolo in A
nd
re ret
ined loner on the column.
Elution is

ccomplished y incre
sin the ionic strenth of the mo ile ph
se. C
tions in th
e u er displ
ce
the hemolo in piments from the column. 2828_Ch05_171-326 06/08/12 5:14 PM P

e 208 15.
Ev
lu
te the followin chrom
tor
m of
whole- lood hemolys
te,
nd identify th
e c
use
nd est
course of
ction. A. Result is not report
le ec
use hemolo in F is present
n
d interferes B.
Te result is not report
le ec
use hemolo in C is present
nd interferes C. Te
result is not
report
le ec
use l
ile hemolo in A 1c is present D. Te result is report
le;
neither
hemolo in F or C interfere Chemistry/Ev
lu
te l
or
tory d
t
to reconize pro
lems/Glyc
ted
hemolo in/3 16. Which st
tement est descri es the use of the H A 1C test? 5.
3 | Glucose,
Hemolo in, Iron,
nd Biliru in 209 Answers to Questions 1517 15. D The chrom
t
or
m is from

person with hemolo in AC; however, hemolo in C is completely sep
r
ted from H
A 1c
nd does
not interfere. H F is
lso present, ut does not interfere unless its concentr

tion is > 30%.
L
ile hemolo in is formed initi
lly when the
ldehyde of lucose re
cts with t
he N-termin
l
v
line of the lo in ch
in. This Shi
se is reversi le ut is converted to H A
1c y
re
rr
nement to
keto
mine. It is c
lled l
ile A 1c
nd produces
pe
k (LA 1
c )
fter HF
nd
efore H A 1c . Therefore, it does not interfere. 16. B The ADA now recommends
th
t the
hemolo in A 1c test e used for oth di
nosis
nd monitorin lood lucose lev
els. The cutpoint
for di
etes is
n A 1c of 6.5. Persons with
n A 1c of 5.7%6.4%
re cl
ssi ed
s
ein
t hih

risk for di
etes within 5 ye
rs. An A 1c etween 4.0%5.5% is de ned
s within norm

l limits.
17. B Imp
ired f
stin lucose is de ned
s
pl
sm
lucose 100 ut <126 m/dL. A
f
stin
lucose of 126 or hiher on two consecutive occ
sions indic
tes di
etes. A f
st
in lucose of 99
m/dL is considered norm
l. Pe
k C
li r
ted Retention Pe
k
%
Are

% Are
Time Are

Al 0.60 0.25 12500 F 0.50 0.50 11300 LA 1c 0.75 0.70 15545 A 1c 6.2 0.9
0 45112 P 3 2.6 1.60
57489 Ao 48.0 1.8 994813 C 43.0 2.00 926745 17. Accordin to Americ
n Di
etes A
ssoci
tion
criteri
, which result is consistent with
di
nosis of imp
ired f
stin lucos
e? A. 99 m/dL B.
117 m/dL C. 126 m/dL D. 135 m/dL Chemistry/Ev
lu
te l
or
tory d
t
to recon
ize he
lth
nd
dise
se st
tes/Glucose/2 A. Should e used for monitorin lucose control only B
. M
y e used for
oth di
nosis
nd monitorin C. Should e used only to monitor persons with typ
e 1 di
etes D.
M
y e used only to monitor persons with type 2 di
etes Chemistry/Correl
te cli
nic
l
nd
l
or
tory d
t
/ Glyc
ted hemolo in/2 2828_Ch05_171-326 06/08/12 5:14 PM P

e 209 18. Wh
t is
the recommended cuto for the e
rly detection of chronic kidney dise
se in di
eti
cs usin the
test for micro
l uminuri
? A. >30 m/ cre
tinine B. >80 m/ cre
tinine C. >200
m/ cre
tinine
D. >80 m/L Chemistry/Ev
lu
te l
or
tory d
t
to reconize he
lth
nd dise
se s
t
tes/Glucose/2
19. In
ddition to me
surin lood lucose, H A 1c ,
nd micro
l umin, which t
est should e
done on di
etic persons once per ye
r? A. Urine lucose B. Urine ketones C. Pl

sm
fructos
mines
D. Estim
ted lomerul
r ltr
tion r
te Chemistry/Select method/C
r ohydr
tes/2 20.
Which testin
situ
tion is
ppropri
te for the use of point-of-c
re whole- lood lucose method
s? A. Screenin
for type 2 di
etes mellitus B. Di
nosis of di
etes mellitus C. Monitorin of
lood lucose
control in type 1
nd type 2 di
etics D. Monitorin di
etics for hyperlycemic
episodes only
Chemistry/Select method/C
r ohydr
tes/2 21. Which of the followin is the refere
nce method for
me
surin serum lucose? A. SomoyiNelson B. Hexokin
se C. Glucose oxid
se D. Glu
cose
dehydroen
se Chemistry/Select method/C
r ohydr
tes/2 210 Ch
pter 5 | Clinic
l C
hemistry Answers
to Questions 1821 18. A Micro
l uminuri
is the excretion of sm
ll qu
ntities of

l umin in the
urine. In di
etics, excretion of
l umin th
t is within
llow
le limits for he

lthy persons m
y
sin
l the onset of chronic kidney dise
se. The term micro
l uminuri
is defined

s
l umin
excretion 30 m/ cre
tinine ut 300 m/ cre
tinine. The use of the
l umin to
cre
tinine
r
tio is preferred to me
sures of
l umin excretory r
te (g/min) because the latt
er is subject
to error associated with timed specimen collection. ADA recommends the test be d
one annually for

all type 2 diabetics and type 1 diabetics who have had the disease for > 5 years
. 19. D While
urinary glucose can identify persons who may have diabetes, it is not sensitive
enough to manage
glucose control on a daily basis, and has been replaced by whole-blood glucose m
onitoring or
continuous glucose monitoring. While the urinary ketone test is a useful screeni
ng test for
diabetic and other forms of ketosis, the plasma hydroxy utyr
te test should e u
sed to identify

nd monitor ketosis in di
etic persons. Fructos
mine is
useful
djunct to H
A 1c to identify
poor control of lood lucose in the p
st 24 weeks, ut h
s not een recommended
for routine use
in
ll di
etic p
tients. 20. C The ADA does not recommend the use of whole- loo
d lucose
monitors for est
lishin
di
nosis of di
etes or screenin persons for di
e
tes. The

n
lytic
l me
surement r
ne of these devices v
ries re
tly,
nd whole lood l
ucose is

pproxim
tely 10% lower th
n serum or pl
sm
lucose. In
ddition,
n
lytic
l v

ri
nce is re
ter

nd
ccur
cy less th
n for l
or
tory instruments. Whole lood lucose meters sh
ould e used y
di
etics
nd c
reivers to monitor lucose control
nd c
n detect oth hyper-

nd hypolycemic
st
tes th
t result from too little or too much insulin repl
cement. Therefore, p
ostpr
ndi
l
monitorin with such
device is recommended for
ll persons who receive insulin
ther
py. 21. B
The hexokin
se method is considered more
ccur
te th
n lucose oxid
se methods
ec
use the
couplin re
ction usin lucose-6-phosph
te dehydroen
se (G-6-PD) is hihly spe
ci c. The
hexokin
se method m
y e done on serum or pl
sm
collected usin hep
rin, EDTA, u
oride, ox
l
te,
or citr
te. The method c
n
lso e used for urine, cere rospin
l uid,
nd serous u
ids.
2828_Ch05_171-326 06/08/12 5:14 PM P
e 210 22. Pol
ror
phic methods for lu
cose
n
lysis
re

sed upon which principle of me
surement? A. Nonenzym
tic oxid
tion of lucose
B. Te r
te of O 2
depletion C. Chemiluminescence c
used y form
tion of
denosine triphosph
te (AT
P) D. Te ch
ne
in electric
l potenti
l
s lucose is oxidized Chemistry/Apply principles of
s
ic l
or
tory
procedures/C
r ohydr
tes/2 23. In
ddition to pol
ror
phy, wh
t other electroch
emic
l method c
n
e used to me
sure lucose in pl
sm
? A. Conductivity B. Potentiometry C. Anodic
strippin
volt
mmetry D. Amperometry Chemistry/Apply principles of
sic l
or
tory
procedures/C
r ohydr
tes/2 24. Select the enzyme th
t is most speci c for -D-lucos
e. A.
Hexokin
se B. G-6-PD C. Phosphohexisomer
se D. Glucose oxid
se Chemistry/Apply k
nowlede of
fund
ment
l ioloic
l ch
r
cteristics/Biochemic
l/1 25. Select the couplin enz
yme used in the
hexokin
se method for lucose. A. Glucose-6-phosph
te dehydroen
se B. Peroxid
s
e C. Glucose
dehydroen
se D. Glucose-6-phosph
t
se Chemistry/Apply knowlede of
sic l
or

tory
procedures/C
r ohydr
tes/1 26. Which lucose method is su ject to f
lsely low re
sults c
used y

scor
te? A. Hexokin
se B. Glucose dehydroen
se C. Trinder lucose oxid
se D.
Pol
ror
phy
Chemistry/Apply knowlede to reconize sources of error/C
r ohydr
tes/2 5.3 | Gl
ucose,
Hemolo in, Iron,
nd Biliru in 211 Answers to Questions 2226 22. B Pol
ror
ph
ic lucose
electrodes me
sure the consumption of O 2
s lucose is oxidized. Glucose oxid
s
e in the re
ent
c
t
lyzes the oxid
tion of lucose y O 2 under rst-order conditions, formin hyd
roen peroxide
(H 2 O 2 ). As the dissolved O 2 decre
ses, less is reduced
t the c
thode, resu
ltin in

decre
se in current proportion
l to lucose concentr
tion. It is import
nt th
t
the H 2 O 2 not
re
kdown to re-form O 2 . This is prevented y
ddin moly d
te
nd iodide th
t
re
ct with H 2 O
2 , formin iodine
nd w
ter,
nd y
ddin c
t
l
se
nd eth
nol th
t re
ct with
H 2 O 2 ,
formin
cet
ldehyde
nd w
ter. 23. D In some critic
l c
re
n
lyzers,
mperomet
ric me
surement
of lucose is used. The lucose oxid
se is impren
ted into the mem r
ne coverin
 the electrode.
It re
cts with lucose in the s
mple, formin H 2 O 2. This di uses
cross the mem
r
ne to the

node of the electrode, where it is oxidized to O 2 . The electrons produced
re
used to reduce
oxyen
t the c
thode, completin the current p
th. At the
node (usu
lly pl
tin
um), 2H 2 O 2 4e
+ 2O 2 + 4H + . At the c
thode(usu
lly silver), O 2 + 4H + + 4e 2H 2 O. The net e
qu
tion is
2H 2 O 2 O 2 + 2H 2 O. 24. D Glucose oxid
se is the most speci c enzyme re
ctin wi
th only
-D-lucose. However, the peroxid
se couplin re
ction used in the lucose oxid
se
method is
su ject to positive
nd ne
tive interference. Therefore, hexokin
se is used in
the reference
method. 25. A The hexokin
se reference method uses
protein-free ltr
te prep
red
with
rium
hydroxide (B
OH)
nd zinc sulf
te (ZnSO 4 ). Hexokin
se c
t
lyzes the phosphoryl

tion of lucose
in the ltr
te usin ATP
s the phosph
te donor. Glucose-6-phosph
te (lucose-6-PO
4 ) is
oxidized to 6-phospholucon
te
nd NAD + is reduced to NADH usin G-6-PD. The in
cre
se in

sor
nce
t 340 nm is proportion
l to lucose concentr
tion. Althouh hexokin

se will
phosphoryl
te some other hexoses includin m
nnose, fructose,
nd lucos
mine, t
he couplin
re
ction is entirely speci c for lucose-6-PO 4 elimin
tin interference from othe
r su
rs. 26. C
Althouh lucose oxid
se is speci c for -D-lucose, the couplin (indic
tor) re
cti
on is prone
to ne
tive interference from
scor
te, uric
cid,
ceto
cetic
cid,
nd other
reducin
ents.
These compete with the chromoen (e.., o-di
nisidine) for peroxide, resultin i
n less dye ein
oxidized to chromophore. The choice of chromoen determines the speci city
nd lin

e
rity.
4-
minophen
zone
nd phenol is more resist
nt to interference from
zo compounds

nd proteins
th
n is o-di
nisidine. 2828_Ch05_171-326 06/08/12 5:14 PM P
e 211 27. Which
of the followin
is
potenti
l source of error in the hexokin
se method? A. G
l
ctosemi
B. Hemo
lysis C. S
mple
collected in uoride D. Ascor ic
cid Chemistry/Apply knowlede to reconize sourc
es of
error/C
r ohydr
tes/2 28. Which st
tement
out lucose in cere rospin
l uid (CSF
) is correct?
A. Levels elow 40 m/dL occur in septic meninitis, c
ncer,
nd multiple sclero
sis B. CSF
lucose is norm
lly the s
me
s the pl
sm
lucose level C. Hyperlycorrh
chi
i
s c
used y
dehydr
tion D. In some clinic
l conditions, the CSF lucose c
n e re
ter th
n
the pl
sm

lucose Chemistry/Correl
te l
or
tory d
t
with physioloic
l processes/Cere ro
spin
l uid/2 29.
In peroxid
se-coupled lucose methods, which re
ent complexes with the chromoe
n? A.
Nitroprusside B. Phenol C. T
rtr
te D. Hydroxide Chemistry/Apply knowlede of

sic l
or
tory
procedures/C
r ohydr
tes/1 30. Point-of-c
re-tests (POCTs) for whole- lood luco
se monitorin
re

sed m
inly on the use of: A. Glucose oxid
se
s the enzyme B. Amperometric det
ection C.
Immunochrom
tor
phy D. Peroxid
se couplin re
ctions Chemistry/Apply knowlede
of
sic
l
or
tory procedures/C
r ohydr
tes/1 31. Wh
t e ect does hem
tocrit h
ve on POCT
tests for
whole- lood lucose monitorin? A. Low hem
tocrit decre
ses lucose re
dins on

ll devices B.
Hih hem
tocrit r
ises lucose re
dins on
ll devices C. Te e ect is v
ri
le
nd
dependent on
the enzyme/coenzyme system D. Low hem
tocrit r
ises re
dins
nd hih hem
tocrit
lowers re
dins
unless corrected Chemistry/Apply knowlede to reconize sources of error/C
r ohy
dr
tes/3 212
Ch
pter 5 | Clinic
l Chemistry Answers to Questions 2731 27. B The hexokin
se met
hod c
n e
performed on serum or pl
sm
usin hep
rin, EDTA, citr
te, or ox
l
te. RBCs cont

in lucose-6-PO
4
nd intr
cellul
r enzymes th
t ener
te NADH, c
usin positive interference. T
herefore,
hemolyzed s
mples require
serum l
nk correction (su tr
ction of the re
ction
r
te with
hexokin
se omitted from the re
ent). 28. A Hih lucose in CSF is
re ection of
hyperlycemi


nd not centr
l nervous system dise
se. The CSF lucose is usu
lly 50%65% of the
pl
sm
lucose.
Low levels
re sini c
nt
nd
re most often
ssoci
ted with
cteri
l or fun
l m
eninitis,
m
lin
ncy in the centr
l nervous system,
nd some c
ses of su
r
chnoid hemorrh

e, rheum
toid

rthritis,
nd multiple sclerosis. 29. B The couplin step in the Trinder lucos
e oxid
se method
uses peroxid
se to c
t
lyze the oxid
tion of
dye y H 2 O 2 . Dyes such
s 4-

minophenozone or
4-
mino
ntipyrine
re coupled to phenol to form
quinoneimine dye th
t is red

nd is me
sured
t

out 500 nm. 30. B All POCT devices for monitorin lood lucose use either lu
cose
dehydroen
se (GDH) or lucose oxid
se
nd
re
mperometric. For lucose oxid
se
methods, the
electrons derive from the oxid
tion of hydroen peroxide. For GDH, the electrons

re tr
nsferred
from one of sever
l coenzymes th
t
re reduced when lucose is oxidized, FAD + ,
NAD + , or PQQ
(pyrroloquinoline quinone). Interferences depend upon which enzyme/coenzyme p
ir

re used. For
ex
mple, m
ltose
nd xylose interference c
n e pronounced with GDH/PQQ-
sed st
rips, ut not
with other GDH or lucose oxid
se strips. Uric
cid depresses lucose oxid
se re

ctions ut h
s
no e ect on GDH re
ctions. 31. D Hem
tocrit
ects POCT lucose me
surements. Hih h
em
tocrit
lowers the lucose ec
use RBC lucose concentr
tion is lower th
n pl
sm
concen
tr
tion. Other
f
ctors include indin of oxyen to hemolo in
nd the slower di usion of lucose
onto the solid
ph
se oth of which occur when the hem
tocrit is hih. Bi
s due to
n
norm
l hem

tocrit c
n e

voided y simult
neously me
surin the conductivity of the s
mple. The hem
tocr
it is c
lcul
ted

nd used to m
them
tic
lly correct the lucose me
surement. 2828_Ch05_171-326 0
6/08/12 5:14 PM
P
e 212 32. Which of the followin is cl
ssi ed
s
mucopolys
cch
ride stor
e d
ise
se? A.
Pompes dise
se B. von Gierke dise
se C. Hers dise
se D. Hurlers syndrome Chemistry/
Correl
te
clinic
l
nd l
or
tory d
t
/ C
r ohydr
tes/1 33. Identify the enzyme de ciency re
sponsi le for
type 1 lycoen stor
e dise
se (von Gierkes dise
se). A. Glucose-6-phosph
t
se B
. Glycoen
phosphoryl
se C. Glycoen synthet
se D. -Glucosid
se Chemistry/Correl
te clinic
l

nd l
or
tory
d
t
/ C
r ohydr
tes/2 34. Which of the followin
norm
l l
or
tory results is
found in von
Gierkes dise
se? A. Hyperlycemi
B. Incre
sed lucose response to epinephrine
d
ministr
tion C.
Met
olic
lk
losis D. Hyperlipidemi
Chemistry/Correl
te clinic
l
nd l
or
tor
y d
t
/
C
r ohydr
tes/2 35. Te D-xylose
sorption test is used for the di erenti
l di
no
sis of which
two dise
ses? A. P
ncre
tic insu ciency from m
l
sorption B. Prim
ry from second

ry disorders of
lycoen synthesis C. Type 1
nd type 2 di
etes mellitus D. Gener
lized from sp
eci c
c
r ohydr
te intoler
nce Chemistry/Correl
te clinic
l
nd l
or
tory d
t
/ D-xyl
ose
sorption/2
5.3 | Glucose, Hemolo in, Iron,
nd Biliru in 213 Answers to Questions 3235 32
. D Hurlers
syndrome is
n
utosom
l recessive dise
se resultin from
de ciency of iduronid

se.
Glycos
minolyc
ns (mucopolys
cch
rides)
ccumul
te in the lysosomes. Multiple o
r
n f
ilure
nd
ment
l ret
rd
tion occur, resultin in e
rly mort
lity. Excess derm
t
n
nd hep

rin sulf
te
re
excreted in urine. Other mucopolys
cch
ridoses (MPS stor
e dise
ses)
re Hunters

, Scheies,
S
n lippos,
nd Morquios syndromes. 33. A Type 1 lycoen stor
e dise
se (von Gierk
es
dise
se) is
n
utosom
l recessive de ciency of lucose-6-phosph
t
se. Glycoen
c
cumul
tes in
tissues, c
usin hypolycemi
, ketosis,
nd f
tty liver. There
re seven types o
f lycoen
stor
e dise
se, desin
ted type 1 throuh type 7, involvin de ciency of
n enzym
e th
t
cts on
lycoen. Types 1, 4,
nd 6 c
use de cient lycoen re
kdown in the liver. Types
2, 5,
nd 7
involve skelet
l muscle
nd
re less severe. Type 3 usu
lly involves oth liver

nd muscle,

lthouh
n uncommon su type (3B) involves only the liver. 34. D Von Gierkes dise

se (type 1
lycoen stor
e dise
se) results from
de ciency of lucose-6-phosph
t
se. This
locks the
hydrolysis of lucose-6-PO 4 to lucose
nd P i , preventin der
d
tion of lyc
oen to lucose.
The dise
se is
ssoci
ted with incre
sed trilyceride levels ec
use f
ts
re mo
ilized for
enery
nd l
ct
te
cidosis c
used y incre
sed lycolysis. A presumptive di
no
sis is m
de when
intr
venous 
l
ctose
dministr
tion f
ils to incre
se serum lucose,
nd c
n e
con rmed y
demonstr
tin lucose-6-phosph
t
se de ciency or decre
sed lucose production in r
esponse to
epinephrine. 35. A Xylose is
pentose th
t is
sor ed without the help of p
nc
re
tic enzymes

nd is not met
olized. In norm
l
dults, more th
n 25% of the dose is excreted
into the urine

fter 5 hours. Low lood or urine levels
re seen in m
l
sorption syndrome, spr
ue, Crohns
dise
se,
nd other intestin
l disorders, ut not p
ncre
titis. 2828_Ch05_171-326
06/08/12 5:14
PM P
e 213 36. Which of the followin st
tements
out c
r ohydr
te intoler
nc
e is true? A.
G
l
ctosemi
results from de ciency of 
l
ctose-1-phosph
te (
l
ctose-1-PO 4 ) u
ridine
diphosph
te tr
nsfer
se B. G
l
ctosemi
results in
positive lucose oxid
se te
st for lucose in
urine C. Urin
ry 
l
ctose is seen in oth 
l
ctosemi

nd l
ct
se de ciency D. A

l
ctose
toler
nce test is used to con rm
di
nosis of 
l
ctosemi
Chemistry/Correl
te c
linic
l
nd
l
or
tory d
t
/ C
r ohydr
tes/2 37. Which of the followin st
tements re
rdin
iron met
olism
is correct? A. Iron
sorption is decre
sed y
lcohol inestion B. Norm
lly, 40
%50% of inested
iron is
sor ed C. Te d
ily requirement is hiher for pren
nt
nd menstru
tin
women D.
A sorption incre
ses with the
mount of iron in the ody stores Chemistry/Apply
knowlede of
fund
ment
l ioloic
l ch
r
cteristics/Iron/1 38. Which of the followin process
es occurs when
iron is in the oxidized (Fe 3+ ) st
te? A. A sorption y intestin
l epithelium B
. Bindin to
tr
nsferrin
nd incorpor
tion into ferritin C. Incorpor
tion into protoporphyrin
IX to form
function
l heme D. Re
ction with chromoens in colorimetric
ss
ys Chemistry/App

ly knowlede of
fund
ment
l ioloic
l ch
r
cteristics/Iron/1 39. Which of the followin is
sso
ci
ted with low
serum iron
nd hih tot
l iron- indin c
p
city (TIBC)? A. Iron de ciency
nemi
B
. Hep
titis C.
Nephrosis D. Noniron de ciency
nemi
s Chemistry/Correl
te clinic
l
nd l
or
tory
d
t
/ Iron/2
214 Ch
pter 5 | Clinic
l Chemistry Answers to Questions 3639 36. A G
l
ctose is m
et
olized to

l
ctose-1-PO 4 y the
ction of 
l
ctokin
se. G
l
ctose-1-PO 4 uridine diphos
ph
te (UDP)
tr
nsfer
se converts 
l
ctose-1-PO 4 to lucose. De ciency of either enzyme c
use
s elev
ted
lood
nd urine 
l
ctose. L
ct
se de ciency results in the presence of urin
ry l

ctose ec
use
it is not roken down to lucose
nd 
l
ctose. Tests for reducin su
rs employ
in copper
sulf
te
re used to screen for 
l
ctose, l
ctose,
nd fructose in urine. Nonlu
cose-reducin
su
rs
re not detected y the lucose oxid
se re
ction. A positive test is foll
owed y TLC to
identify the su
r,
nd demonstr
tion of the enzyme de ciency in RBCs. The 
l
cto
se toler
nce
test is used (r
rely) to ev
lu
te the extent of liver f
ilure since the liver is
the site of

l
ctose met
olism. 37. C For
dult men
nd nonmenstru
tin women,
pproxim
te
ly 12 m/d
y of
iron is needed to repl
ce the sm
ll
mount lost m
inly y exfoli
tion of cells.
Bec
use 5%10% of
diet
ry iron is
sor ed norm
lly, the d
ily diet
ry requirement in this roup i
s 1020 m/d
y.
Menstru
tin women h
ve
n
ddition
l requirement of 1 m/d
y
nd pren
nt women
2 m/d
y.
A sorption e ciency will incre
se in iron de ciency
nd decre
se in iron overlo
d. I
ron

sorption is enh
nced y low 
stric pH
nd is incre
sed y
lcohol inestion.
38. B Intestin
l

sorption occurs only if the iron is in the reduced (Fe +2 ) st
te. After
sor
ption, Fe +2 is
oxidized to Fe +3 y ut mucos
l cells. Tr
nsferrin
nd ferritin ind iron e cient
ly only when in
the oxidized st
te. Iron within H
inds to O 2 y coordin
te ondin, which oc
curs only if the
iron is in the reduced st
te. Likewise, in colorimetric methods, Fe +2 forms coo
rdin
te onds
with c
r on
nd nitroen
toms of the chromoen. 39. A Iron-de ciency
nemi
is th
e princip
l
c
use of low serum iron
nd hih TIBC ec
use it promotes incre
sed tr
nsferrin.
Pren
ncy
without iron supplement
tion depletes m
tern
l iron stores
nd
lso results in l
ow serum iron
nd
hih TIBC. Iron-supplemented pren
ncy
nd use of contr
ceptives incre
se oth i
ron
nd TIBC.
Nephrosis c
uses low iron
nd TIBC due to loss of oth iron
nd tr
nsferrin y t
he kidneys.
Hep
titis c
uses incre
sed rele
se of stor
e iron, resultin in hih levels of
iron
nd
tr
nsferrin. Noniron de ciency
nemi
s m
y c
use hih iron
nd usu
lly show low TI
BC
nd norm
l
or hih ferritin. 2828_Ch05_171-326 06/08/12 5:14 PM P
e 214 40. Which condi

tion is

ssoci
ted with the lowest percent s
tur
tion of tr
nsferrin? A. Hemochrom
tosis
B. Anemi
of
chronic infection C. Iron de ciency
nemi
D. Noniron de ciency
nemi
Chemistry/Cor
rel
te
clinic
l
nd l
or
tory d
t
/ Iron/2 41. Which condition is most often
ssoci
te
d with
hih
serum iron level? A. Nephrosis B. Chronic infection or in
mm
tion C. Polycythemi

ver
D.
Noniron de ciency
nemi
s Chemistry/Correl
te clinic
l
nd l
or
tory d
t
/Iron/2
42. Which of
the followin is likely to occur rst in iron de ciency
nemi
? A. Decre
sed serum i
ron B.
Incre
sed TIBC C. Decre
sed serum ferritin D. Incre
sed tr
nsferrin Chemistry/Co
rrel
te clinic
l

nd l
or
tory d
t
/ Iron/2 43. Which formul
provides the est estim
te of seru
m TIBC? A. Serum
tr
nsferrin in m/dL 0.70 = TIBC (/dL) B. Serum tr
nsferrin in m/dL 1.43 = TIBC
(/dL) C.
Serum iron (/dL)/1.2 + 0.06 = TIBC (/dL) D. Serum Fe (/dL) 1.25 = TIBC (/dL)
Chemistry/C
lcul
te/Iron/2 44. Which st
tement re
rdin the di
nosis of iron d
e ciency is
correct? A. Serum iron levels
re
lw
ys hiher
t niht th
n durin the d
y B.
Serum iron levels
ein to f
ll efore the ody stores ecome depleted C. A norm
l level of serum
ferritin rules
out iron de ciency D. A low serum ferritin is di
nostic of iron de ciency Chemistry
/Correl
te
clinic
l
nd l
or
tory d
t
/ Iron/2 5.3 | Glucose, Hemolo in, Iron,
nd Biliru
in 215 Answers
to Questions 4044 40. C Percent s
tur
tion = Serum Fe 100/TIBC. Norm
lly, tr
nsfe
rrin is
one-third s
tur
ted with iron. In iron de ciency st
tes, the serum iron f
lls ut
tr
nsferrin
rises. This c
uses the numer
tor
nd denomin
tor to move in opposite directions,
resultin in
very low percent s
tur
tion (
out 10%). The opposite occurs in hemochrom
tosis

nd sidero l
stic

nemi
, resultin in
n incre
sed percent s
tur
tion. 41. D Anemi

ssoci
ted wi
th chronic
infection c
uses
low serum iron, ut unlike iron de ciency, c
uses
low (or nor
m
l) TIBC
nd
does not c
use low ferritin. Noniron de ciency
nemi
s such
s pernicious
nemi


nd
sidero l
stic
nemi
produce hih serum iron
nd low TIBC. Nephrosis c
uses iron
loss y the
kidneys. Polycythemi
is
ssoci
ted with incre
sed iron within the RBCs
nd depl
etion of iron
stores. 42. C Body stores must e depleted of iron efore serum iron f
lls. Thus
, serum ferritin
f
lls in the e
rly st
es of iron de ciency, m
kin it
more sensitive test th
n
serum iron in
uncomplic
ted c
ses. Ferritin levels
re low only in iron de ciency. However, conc
urrent illness
such
s m
lin
ncy, infection,
nd in
mm
tion m
y promote ferritin rele
se from t
he tissues,
c
usin the serum ferritin to e norm
l in iron de ciency. 43. B Tr
nsferrin,
-l
o ulin, h
s

molecul
r size of
out 77,000. Tr
nsferrin is the princip
l iron tr
nsport prot
ein,
nd TIBC is

determined y the serum tr
nsferrin concentr
tion. One mole of tr
nsferrin inds

two moles of Fe
+3 , so the tr
nsferrin concentr
tion c
n e used to predict the TIBC. Since the
direct
me
surement of TIBC requires m
nu
l pretre
tment to remove the excess iron
dded

nd is prone to
overestim
tion if
ll of the un ound iron is not removed, some l
s prefer to me

sure tr
nsferrin
immunochemic
lly
nd c
lcul
te TIBC. This formul
m
y underestim
te TIBC ec
use

l umin
nd
other proteins will ind iron when the percent iron s
tur
tion of tr
nsferrin is

norm
lly hih.
44. D Serum iron levels
re f
lsely elev
ted y hemolysis
nd su ject to diurn
l
v
ri
tion.
Levels
re hihest in the mornin
nd lowest
t niht, ut this p
ttern is rever
sed in persons
who work
t niht. A low ferritin is speci c for iron de ciency. However, only
out
1% of
ferritin is in the v
scul
r system. Any dise
se th
t incre
ses ferritin rele
se
m
y m
sk iron
de ciency. 2828_Ch05_171-326 06/08/12 5:14 PM P
e 215 45. Which st
tement
ou
t iron methods
is true? A. Interference from H c
n e corrected y
serum l
nk B. Colorimet
ric methods
me
sure indin of Fe 2+ to
li
nd such
s ferrozine C. Atomic
sorption is t
he method of
choice for me
surement of serum iron D. Serum iron c
n e me
sured y potentiome
try
Chemistry/Apply principles of speci
l procedures/Iron/2 46. Which of the followi
n st
tements
re
rdin the TIBC
ss
y is correct? A. All TIBC methods require
ddition of exc
ess iron to
s
tur
te tr
nsferrin B. All methods require the remov
l of un ound iron C. Me
su
rement of TIBC is
speci c for tr
nsferrin- ound iron D. Te chromoen used must e di erent from the o
ne used for
me
surin serum iron Chemistry/Apply principles of speci
l procedures/Iron/2 47.
Which of the
followin st
tements re
rdin the met
olism of iliru in is true? A. It is for
med y hydrolysis
of the methene ride of uro ilinoen B. It is reduced to iliverdin prior to ex
cretion C. It
is
y-product of porphyrin production D. It is produced from the destruction o
f RBCs
Chemistry/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics/Biliru in/1
48. Biliru in is
tr
nsported from reticuloendotheli
l cells to the liver y: A. Al umin B. Biliru
in- indin
lo ulin C. H
ptolo in D. Tr
nsferrin Chemistry/Apply knowlede of fund
ment
l
ioloic
l
ch
r
cteristics/Biliru in/1 49. In the liver, iliru in is conju
ted y
dditio
n of: A. Vinyl
roups B. Methyl roups C. Hydroxyl roups D. Glucuronyl roups Chemistry/Apply
knowlede of
fund
ment
l ioloic
l ch
r
cteristics/Biliru in/1 50. Which enzyme is responsi
le for the
conju
tion of iliru in? A. -Glucuronid
se B. UDP-lucuronyl tr
nsfer
se C. Bili
ru in oxid
se
D. Biliverdin reduct
se Chemistry/Apply knowlede of fund
ment
l ioloic
l
ch
r
cteristics/Biliru in/1 216 Ch
pter 5 | Clinic
l Chemistry Answers to Questi

ons 4550 45. B

Atomic
sorption is not the method of choice for serum iron ec
use m
trix erro
r
nd v
ri
tion
of iron recovered y extr
ction c
use i
s
nd poor precision. Most methods use
HCl to
deconju
te Fe 3+ from tr
nsferrin followed y reduction to Fe 2+ . This re
cts
with
neutr
l
li
nd such
s ferrozine, tripyridyltri
zine (TPTZ), or
thophen
nthroline to 
ive
lue
complex. Anodic strippin volt
mmetry c
n
lso e used to me
sure serum iron. He
molysis must e

voided ec
use RBCs cont
in
much hiher concentr
tion of iron th
n does pl
sm

. 46. A All TIBC
methods require
ddition of excess iron to s
tur
te tr
nsferrin. Excess iron is
removed y ion
exch
ne or
lumin
el columns or precipit
tion with MCO 3
nd the ound iron
is me
sured y
the s
me procedure
s is used for serum iron. Altern
tively, excess iron in the
reduced st
te c
n
e
dded
t
n
lk
line pH. Under these conditions, tr
nsferrin will ind Fe 2+

nd the un ound
Fe 2+ c
n e me
sured directly. 47. D Synthesis of porphyrins results in product
ion of heme
nd
met
olism of porphyrins other th
n protoporphyrin IX yields uroporphyrins
nd c
oproporphyrins,
not iliru in. Reticuloendotheli
l cells in the spleen diest H
nd rele
se th
e iron from heme.
The tetr
pyrrole rin is opened
t the methene ride y heme oxyen
se, formin
iliverdin.
Biliru in is formed y reduction of iliverdin
t the methene ride. It is comp
lexed to

l umin
nd tr
nsported to the liver. 48. A Al umin tr
nsports iliru in, h
pto
lo in tr
nsports
free H ,
nd tr
nsferrin tr
nsports ferric iron. When
l umin indin is exceed
ed, un ound
iliru in, c
lled free iliru in, incre
ses. This m
y cross the lood r
in
rrie
r, resultin in
kernicterus. 49. D The esteri c
tion of lucuronic
cid to the propionyl side ch
i
ns of the inner
pyrrole rins (I
nd II) m
kes iliru in w
ter solu le. Conju
tion is required
efore iliru in
c
n e excreted vi
the ile. 50. B UDP-lucuronyl tr
nsfer
se esteri es lucuroni
c
cid to
unconju
ted iliru in, m
kin it w
ter solu le. Most conju
ted iliru in is di
lucuronide;
however, the liver m
kes
sm
ll
mount of monolucuronide
nd other lycosides.
-Glucuronid
se
hydrolyzes lucuronide from iliru in, hormones, or drus. It is used prior to o
r
nic extr
ction
to deconju
te urin
ry met
olites (e.., tot
l cortisol). Biliverdin reduct
se
forms iliru in
from iliverdin (
nd heme oxyen
se forms iliverdin from heme). Biliru in oxid

se is used in
n
enzym
tic iliru in
ss
y in which iliru in is oxidized
ck to iliverdin
nd
the r
te of
iliverdin form
tion is me
sured
t 410 nm. 2828_Ch05_171-326 06/08/12 5:14 PM
P
e 216 51. Te
term -biirubin refers to: A. Water-soube biirubin B. Free unconjuate biiru
bin C.
Biirubin tihty boun to abumin D. Direct-reactin biirubin Chemistry/Appy

knowee of
funamenta biooica characteristics/Biirubin/1 52. Which of the foowin pr
ocesses is part
of the norma metaboism of biirubin? A. Both conjuate an unconjuate biir
ubin are excrete
into the bie B. Methene bries of biirubin are reuce by intestina bacteria
formin
urobiinoens C. Most of the biirubin eivere into the intestine is reabsorbe
 D. Biirubin
an urobiinoen reabsorbe from the intestine are mainy excrete by the kiney
s Chemistry/Appy
knowee of funamenta biooica characteristics/Biirubin/1 53. Which of the
foowin is a
characteristic of conjuate biirubin? A. It is water soube B. It reacts more
sowy than
unconjuate biirubin C. It is more stabe than unconjuate biirubin D. It ha
s the same
absorbance properties as unconjuate biirubin Chemistry/Appy knowee of fun
amenta
biooica characteristics/Biirubin/1 54. Which of the foowin statements re
arin
urobiinoen is true? A. It is forme in the intestines by bacteria reuction o
f biirubin B. It
consists of a sine water-soube bie piment C. It is measure by its reactio
n with
p-aminosaicyate D. In hemoytic anemia, it is ecrease in urine an feces Che
mistry/Appy
knowee of funamenta biooica characteristics/Biirubin/1 55. Which statem
ent rearin
biirubin metaboism is true? A. Biirubin uneroes rapi photo-oxiation when
expose to
ayiht B. Biirubin excretion is inhibite by barbiturates C. Biirubin excret
ion is increase
by chorpromazine D. Biirubin is excrete ony as the iucuronie Chemistry/E
vauate
aboratory ata to reconize probems/Biirubin/2 5.3 | Gucose, Hemoobin, Iro
n, an Biirubin
217 Answers to Questions 5155 51. C HPLC separates biirubin into four fractions
: =
unconju
ted, = monolucuronide, = dilucuronide,
nd = irreversiby abumin bou
n.
Biirubin is a separate fraction from the unconjuate biirubin, which is boun
oosey to
abumin. Biirubin an conjuate biirubin react with iazo reaent in the ire
ct biirubin
assay. 52. B Most of the conjuate biirubin eivere into the intestine is e
conjuate by
-lucuronid
se
nd then reduced y intestin
l or
to form three di erent reduction p
roducts
collectively c
lled uro ilinoens. The m
jority of iliru in
nd uro ilinoen in
the intestine

re not re
sor ed. Most of th
t which is re
sor ed is re-excreted y the liver
. The port
l vein
delivers lood from the owel to the sinusoids. Hep
tocytes t
ke up
out 90% of
the returned
ile piments
nd secrete them

in into the ile. This process is c
lled the e
nterohep
tic
circul
tion. 53. A Conju
ted iliru in refers to iliru in mono-
nd dilucuron
ides. Conju
ted
iliru in re
cts
lmost immedi
tely with the
queous di
zo re
ent without need

for
nonpol
r
solvent. Historic
lly, conju
ted iliru in h
s een used synonymously with dire
ct-re
ctin
iliru in,
lthouh the l
tter includes the -biirubin fraction when measure by
the
JenrassikGrof metho. Conjuate biirubin is excrete in both bie an urine. I
t is easiy
photo-oxiize an has very imite stabiity. For this reason, biirubin stana
rs are usuay
prepare from unconjuate biirubin stabiize by the aition of akai an a
bumin. 54. A
Urobiinoen is a coective term iven to the reuction proucts of biirubin f
orme by the
action of enteric bacteria. Urobiinoen excretion is increase in extravascuar
hemoytic
anemias an ecrease in obstructive jaunice (choestatic isease). Urobiinoe
n is measure
usin Ehrichs reaent, an aci soution of p-imethyaminobenzaehye. 55. A Sa
mpes for
biirubin anaysis must be protecte from irect suniht. Drus may have a sin
i cant in vivo
e ect on biirubin eves. Barbiturates ower serum biirubin by increasin excret
ion. Other
rus that cause choestasis, such as chorpromazine, increase the serum biirub
in. Athouh most
conjuate biirubin is in the form of iucuronie, some monoucuronie an o
ther ycosies
are excrete. In ucurony transferase e ciency, some biirubin is excrete as s
ufaties.
2828_Ch05_171-326 06/08/12 5:14 PM Pae 217 56. Which conition is cause by
e cient
secretion of biirubin into the bie canaicui? A. Giberts isease B. Neonata
hyperbiirubinemia C. DubinJohnson synrome D. CrierNajjar synrome Chemistry/Co
rreate
aboratory ata with physiooica processes/Biirubin/2 57. In hepatitis, the r
ise in serum
conjuate biirubin can be cause by: A. Seconary rena insu ciency B. Faiure o
f the
enterohepatic circuation C. Enzymatic conversion of urobiinoen to biirubin D
. Extrahepatic
conjuation Chemistry/Correate aboratory ata with physiooica processes/Bi
irubin/2 58.
Which of the foowin is a characteristic of obstructive jaunice? A. Te ratio
of irect to
tota biirubin is reater than 1:2 B. Conjuate biirubin is eevate, but unc
onjuate
biirubin is norma C. Urinary urobiinoen is increase D. Urinary biirubin is
norma
Chemistry/Correate cinica an aboratory ata/ Biirubin/2 59. Which of the f
oowin wou
cause an increase in ony the unconjuate biirubin? A. Hemoytic anemia B. Obs
tructive jaunice
C. Hepatitis D. Hepatic cirrhosis Chemistry/Correate cinica an aboratory a
ta/ Biirubin/2
218 Chapter 5 | Cinica Chemistry Answers to Questions 5659 56. C DubinJohnson sy
nrome is an
autosoma recessive conition arisin from mutation of an ABC transporter ene.
It prouces mi
jaunice from accumuation of conjuate biirubin that is not secrete into the
bie canaicui.

Tota an irect biirubin are eevate, but other iver function is norma. Rot
or synrome is an
autosoma recessive conition that aso resuts in retention of conjuate biir
ubin. The
mechanism in Rotor synrome is unknown, an ike DubinJohnson synrome it is comm
ony
asymptomatic. It can be i erentiate from DubinJohnson synrome by the pattern of
urinary
coproporphyrin excretion an because it prouces no back pimentation in the i
ver. 57. B
Conjuate biirubin is increase in hepatitis an other causes of hepatic necro
sis ue to
faiure to re-excrete conjuate biirubin reabsorbe from the intestine. Increa
se irect
biirubin can aso be attribute to accompanyin intrahepatic obstruction, which
bocks the ow
of bie. 58. A Obstruction prevents conjuate biirubin from reachin the intes
tine, resutin
in ecrease prouction, excretion, an absorption of urobiinoen. Conjuate b
iirubin
reuritates into sinusoia boo an enters the enera circuation via the he
patic vein. The
eve of serum irect (conjuate) biirubin becomes reater than unconjuate b
iirubin. The
unconjuate form is aso increase because of accompanyin necrosis, econjuat
ion, an
inhibition of UDP-ucurony transferase 59. A Conjuate biirubin increases as
a resut of
obstructive processes within the iver or biiary system or from faiure of the
enterohepatic
circuation. Hemoytic anemia (prehepatic jaunice) presents a reater biirubin
oa to a norma
iver, resutin in increase biirubin excretion. When the rate of biirubin fo
rmation excees
the rate of excretion, the unconjuate biirubin rises. 2828_Ch05_171-326 06/0
8/12 5:14 PM
Pae 218 60. Which form of hyperbiirubinemia is cause by an inherite absence
of UDP-ucurony
transferase? A. Giberts synrome B. Rotor synrome C. CrierNajjar synrome D. D
ubinJohnson
synrome Chemistry/Appy knowee of funamenta biooica characteristics/Bi
irubin/1 61.
Which statement rearin tota an irect biirubin eves is true? A. Tota bi
irubin eve is
a ess sensitive an speci c marker of iver isease than the irect eve B. Dire
ct biirubin
excees 3.5 m/L in most cases of hemoytic anemia C. Direct biirubin is norma
 in choestatic
iver isease D. Te ratio of irect to tota biirubin excees 0.40 in hemoytic
anemia
Chemistry/Correate cinica an aboratory ata/Biirubin/2 62. Which statement
best
characterizes serum biirubin eves in the rst week foowin eivery? A. Serum
biirubin 24
hours after eivery shou not excee the upper reference imit for auts B. J
aunice is
usuay rst seen 4872 hours postpartum in neonata hyperbiirubinemia C. Serum bi
irubin above
5.0 m/L occurrin 25 ays after eivery inicates hemoytic or hepatic isease
D. Conjuate

biirubin accounts for about 50% of the tota biirubin in neonates Chemistry/Co
rreate cinica
an aboratory ata/ Biirubin/2 63. Which form of jaunice occurs within ays o
f eivery an
usuay asts 13 weeks, but is not ue to norma neonata hyperbiirubinemia or h
emoytic
isease of the newborn? A. Gibert synrome B. Lucey Drisco synrome C. Rotor s
ynrome D.
DubinJohnson synrome Chemistry/Correate cinica an aboratory ata/ Biirubin
/2 5.3 |
Gucose, Hemoobin, Iron, an Biirubin 219 Answers to Questions 6063 60. C Cr
ierNajjar
synrome is a rare conition that occurs in two forms. Type 1 is inherite as an
autosoma
recessive trait an causes a tota e ciency of UDP-ucurony transferase. Life e
xpectancy is
ess than 1 year. Type 2 is an autosoma ominant trait an is characterize by
esser jaunice
an usuay the absence of kernicterus. Biirubin eves can be controe with
phenobarbita,
which promotes biirubin excretion. Giberts synrome is an autosoma recessive c
onition
characterize by ecrease biirubin uptake an ecrease formation of biirubin
iucuronie.
It is the most common form of inherite jaunice. UDP ucurony transferase act
ivity is reuce
owin to an increase in the number of AT repeats in the promoter reion of the 
ene.
DubinJohnson an Rotor synromes are autosoma recessive isorers associate wit
h efective
eivery of biirubin into the biiary system. 61. A Direct biirubin measuremen
t is a sensitive
an speci c marker for hepatic an posthepatic jaunice because it is not eevate
by hemoytic
anemia. In hemoytic anemia, the tota biirubin oes not excee 3.5 m/L, an
the ratio of
irect to tota is ess than 0.20. Unconjuate biirubin is the major fraction
in necrotic iver
isease because microsoma enzymes are ost. Unconjuate biirubin is eevate
aon with irect
biirubin in choestasis because some necrosis takes pace an some conjuate b
iirubin is
hyroyze back to unconjuate biirubin. 62. B Biirubin eves may reach as h
ih as 23 m/L
in the rst 24 hours after birth owin to the trauma of eivery, such as resorpti
on of a
subura hematoma. Neonata hyperbiirubinemia occurs 23 ays after birth ue to
increase
hemoysis at birth an transient e ciency of the microsoma enzyme, UDP-ucurony
 transferase.
Normay, eves rise to about 510 m/L but may be reater than 15 m/L, requir
in therapy
with UV iht to photo-oxiize the biirubin. Neonata jaunice can ast up to 1
week in a mature
neonate an up to 2 weeks in prematures babies. Neonata biirubin is amost exc
usivey
unconjuate. 63. B LuceyDrisco synrome is a rare form of jaunice cause by u
nconjuate
biirubin that presents within 24 ays of birth an can ast severa weeks. It is
cause by an

inhibitor of UDP-ucurony transferase in materna pasma that crosses the pac

enta. Jaunice is
usuay severe enouh to require treatment. 2828_Ch05_171-326 06/08/12 5:14 PM
Pae 219 64. A
ab measures tota biirubin by the JenrassikGrof biirubin metho with sampe b
ankin. What
wou be the e ect of moerate hemoysis on the test resut? A. Fasey increase
ue to optica
interference B. Fasey increase ue to reease of biirubin from RBCs C. Fase
y ow ue to
inhibition of the iazo reaction by hemoobin D. No e ect ue to correction of po
sitive
interference by sampe bankin Chemistry/Appy knowee to reconize sources o
f
error/Biirubin/2 65. Which reaent is use in the JenrassikGrof metho to soub
iize
unconjuate biirubin? A. 50% methano B. N-butano C. Ca eine D. Acetic aci Che
mistry/Appy
principes of basic aboratory proceures/Biirubin/1 66. Which statement about
coorimetric
biirubin methos is true? A. Direct biirubin must react with iazo reaent un
er akaine
conitions B. Most methos are base upon reaction with iazotize sufaniic ac
i C. Ascorbic
aci can be use to eiminate interference cause by Hb D. Te coor of the azob
iirubin prouct
is inepenent of pH Chemistry/Appy principes of basic aboratory proceures/B
iirubin/1 67.
Which statement rearin the measurement of biirubin by the JenrassikGrof meth
o is correct?
A. Te same iuent is use for both tota an irect assays to minimize i erences
in reactivity
B. Positive interference by Hb is prevente by the aition of HC after the i
azo reaction C.
Te coor of the azobiirubin prouct is intensi e by the aition of ascorbic aci
 D. Fehins
reaent is ae after the iazo reaction to reuce optica interference by hemo
obin
Chemistry/Appy principes of basic aboratory proceures/Biirubin/2 220 Chapte
r 5 | Cinica
Chemistry Answers to Questions 6467 64. C The sampe bank measures the absorbanc
e of the sampe
an reaent in the absence of azobiirubin formation an corrects the measuremen
t for optica
interference cause by hemoobin absorbin the waveenth of measurement. Howev
er, hemoobin is
an inhibitor of the iazo reaction an wi cause fasey ow resuts in a bank
correcte
sampe. For this reason, irect bichromatic spectrophotometric methos are prefe
rre when
measurin biirubin in neonata sampes, which are often hemoyze. 65. C A poa
rity moi er is
require to make unconjuate biirubin soube in iazo reaent. The MaoyEvey
n metho uses
50% methano to reuce the poarity of the iazo reaent. Ca eine is use in the J
enrassikGrof
metho. This metho is recommene because it is not fasey eevate by hemoys
is an ives
quantitative recovery of both conjuate an unconjuate biirubin. 66. B Uncon
juate biirubin

is poory soube in aci, an therefore, irect biirubin is assaye usin iaz
otize sufaniic
aci iute in weak HC. The irect iazo reaction shou be measure after no
oner than 3
minutes to prevent reaction of unconjuate biirubin, or the iazo roup can be
reuce usin
ascorbate or hyroxyamine preventin any further reaction. 67. D The JenrassikG
rof metho uses
HC as the iuent for the measurement of irect biirubin because unconjuate
biirubin is
poory soube at ow pH. Tota biirubin is measure usin an acetate bu er with
ca eine ae
to increase the soubiity of the unconjuate biirubin. After aition of iaz
otize sufaniic
aci an incubatiion, the iazo roup is reuce by ascorbic aci, an Fehins r
eaent is ae
to akainize the iuent. At an akaine pH the prouct chanes from pink to b
ue, shiftin the
absorbance maximum to 600 nm where Hb oes not contribute sini canty to absorba
nce.
2828_Ch05_171-326 06/08/12 5:14 PM Pae 220 68. A neonata biirubin assay pe
rforme at the
nursery by bichromatic irect spectrophotometry is 4.0 m/L. Four hours ater,
a secon sampe
assaye for tota biirubin by the JenrassikGrof metho ives a resut of 3.0 m
/L. Both
sampes are reporte to be hemoyze. What is the most ikey expanation of the
se resuts? A.
Hb interference in the secon assay B. -Biirubin contributin to the resut of
the rst assay
C. Fasey hih resuts from the rst assay cause by irect biirubin D. Physioo
ica variation
owin to premature hepatic microsoma enzymes Chemistry/Appy knowee to reco
nize sources of
error/Biirubin/3 69. In the enzymatic assay of biirubin, how is measurement of
both tota an
irect biirubin accompishe? A. Usin i erent pH for tota an irect assays B.
Usin UDP
ucurony transferase an biirubin reuctase C. Usin i erent poarity moi ers D
. Measurin
the rate of absorbance ecrease at i erent time intervas Chemistry/Appy princip
es of basic
aboratory proceures/Biirubin/2 70. What is the principe of the transcutaneou
s biirubin
assay? A. Conuctivity B. Amperometric inhibition C. Mutiwaveenth re ectance ph
otometry D.
Infrare spectroscopy Chemistry/Appy principes of specia proceures/ Biirubi
n/1 5.3 |
Gucose, Hemoobin, Iron, an Biirubin 221 Answers to Questions 6870 68. A Th
e
JenrassikGrof metho is base upon a iazo reaction that may be suppresse by H
b. Because
serum bankin an measurement at 600 nm correct for positive interference from
Hb, the resuts
may be fasey ow when sini cant hemoysis is present. Direct spectrophometric b
iirubin
methos empoyin bichromatic optics correct for the presence of Hb. These are
often cae
neonata biirubin tests. A commony use approach is to measure absorbance at 454
nm an 540

nm. The absorbance contribute by Hb at 540 nm is equa to the absorbance contr
ibute by Hb at
454 nm. Therefore, the absorbance i erence wi correct for free Hb. Neonata sa
mpes contain
itte or no irect -biirubin. They aso ack carotene piments that cou inter
fere with the
irect spectrophotometric measurement of biirubin. 69. A Enzymatic methos use
biirubin oxiase
to convert biirubin back to biiverin, an measure the ecrease in absorbance
that resuts. At
pH 8, both conjuate, unconjuate, an eta biirubin react with the enzyme,
but at pH 4 ony
the conjuate form reacts. 70. C Measurement of biirubin concentration throuh
the skin
requires the use of mutipe waveenths to correct for absorbance by meanin an
 other
iht-absorbin constituents of skin an boo. More than 100 waveenths an mu
tipe re ectance
measurements at various sites may be use to erive the venous biirubin concent
ration in m/L.
Such evices have been shown to have a hih speci city. They can be use to ienti
fy neonates
with hyperbiirubinemia, an to monitor treatment. 2828_Ch05_171-326 06/08/12
5:14 PM Pae 221
222 5.4 Cacuations, Quaity Contro, an Statistics 1. How many rams of soiu
m hyroxie
(NaOH) are require to prepare 150.0 mL of a 5.0% w/v soution? A. 1.5  B. 4.0
 C. 7.5  D.
15.0  Cinica chemistry/Cacuate/Soutions/2 2. How many miiiters of aci
a acetic aci
are neee to prepare 2.0 L of 10.0% v/v acetic aci? A. 10.0 mL B. 20.0 mL C. 1
00.0 mL D. 200.0
mL Cinica chemistry/Cacuate/Soutions/2 3. A biuret reaent requires prepara
tion of a stock
soution containin 9.6  of copper II sufate (CuSO 4 ) per iter. How many ra
ms of CuSO 4 5H
2 O are neee to prepare 1.0 L of the stock soution? Atomic weihts: H = 1.0;
Cu = 63.6; O =
16.0; S = 32.1 A. 5.4  B. 6.1  C. 15.0  D. 17.0  Cinica chemistry/Cacuat
e/Reaent
preparation/2 Answers to Questions 13 1. C A percent soution expresse in w/v (w
eiht/voume)
refers to rams of soute per 100.0 mL of soution. To cacuate, mutipy the p
ercentae (as
rams) by the voume neee (mL), then ivie by 100.0 (mL). (5.0  150.0 mL) 10
0.0 mL = 7.5
 To prepare the soution, weih 7.5  of NaOH peets an a to a 150.0-mL vo
umetric ask. A
su cient eionize H 2 O to issove the NaOH. After the soution coos, a eion
ize H 2 O to
the 150.0-mL ine on the ask an mix aain. 2. D The expression percent v/v refer
s to the voume
of one iqui in mL present in 100.0 mL of soution. To cacuate, mutipy the
percentae (as
mL) by the voume require (mL), then ivie by 100 (mL). (10.0 mL 2000.0 mL) 10
0.0 mL =
200.0 mL To prepare 2.0 L of a 10.0% v/v soution of acetic aci, a approximat
ey 1.0 L of
eionize H 2 O to a 2.0-L voumetric ask. A 200.0 mL of acia acetic aci an
 mix. Then,

a su cient eionize H 2 O to brin the meniscus to the 2.0-L ine an mix aain
. 3. C
Determine the mass of CuSO 4 5H 2 O containin 9.6  of anhyrous CuSO 4 . First
, cacuate the
percentae of CuSO 4 in the hyrate, then ivie the amount neee (9.6 ) by th
e percentae.
%
CuSO
4 = moecuar weiht CuSO 4 moecuar weiht CuSO 4 5H 2 O 100 = (159.7
249.7) 100
= 63.96% Grams CuSO 4 5H 2 O = 9.6  0.6396 = 15.0  A convenient formua to use
is: 
hyrate = (MW hyrate MW anhyrous sat)  anhyrous sat 2828_Ch05_171-326 06/
08/12 5:14
PM Pae 222 4. How many miiiters of HNO 3 (purity 68.0%, speci c ravity 1.42)
are neee to
prepare 1.0 L of a 2.0 N soution? Atomic weihts: H = 1.0; N = 14.0; O = 16.0 A
. 89.5 mL B.
126.0 mL C. 130.5 mL D. 180.0 mL Cinica chemistry/Cacuate/Reaent preparatio
n/2 5. Convert
10.0 m/L cacium (atomic weiht = 40.1) to Internationa System of Units (SI).
A. 0.25 B. 0.40
C. 2.5 D. 0.4 Cinica chemistry/Cacuate/SI unit conversion/2 6. Convert 2.0 m
Eq/L manesium
(atomic weiht = 24.3) to miirams per eciiter. A. 0.8 m/L B. 1.2 m/L C.
2.4 m/L D. 4.9
m/L Cinica chemistry/Cacuate/Unit conversion/2 7. How many miiiters of
a 2,000.0 m/L
ucose stock soution are neee to prepare 100.0 mL of a 150.0 m/L ucose w
orkin stanar?
A. 1.5 mL B. 7.5 mL C. 15.0 mL D. 25.0 mL Cinica chemistry/Cacuate/Soutions
/2 5.4 |
Cacuations, Quaity Contro, an Statistics 223 Answers to Questions 47 4. C
The moecuar
weiht of HNO 3 is 63.0 . Because the vaance of the aci is 1 (1 mo of hyro
en is prouce
per moe of aci), the equivaent weiht is aso 63.0 . The mass is cacuate
by mutipyin
the normaity (2.0 N) by the equivaent weiht (63.0 ) an voume (1.0 L); ther
efore, 126.0  of
aci are require. Because the purity is 68.0% an the speci c ravity 1.42, the a
mount of HNO 3
in rams per miiiter is 0.68 1.42 /mL or 0.9656 /mL. The voume require to
ive 126.0 
is cacuate by iviin the mass neee (rams) by the rams per miiiter. m
L HNO 3 = 126.0 
0.9656 /mL = 126.0  1.0 mL/0.9656  = 130.5 mL 5. C The SI unit is the recomme
ne metho
of reportin cinica aboratory resuts. The SI unit for a eectroytes is mi
imoe per
iter. To convert from miirams per eciiter to miimoes per iter, mutip
y by 10 to
convert to miirams per iter, then ivie by the atomic mass expresse in mi
irams. 10.0
m/L 10.0 L/1.0 L = 100.0 m/L 100.0 m/L 1.0 mmo/40.1 m = 2.5 mmo/L 6. C T
o convert
from miiequivaent per iter to miirams per eciiter, rst cacuate the mi
iequivaent
weiht (equivaent weiht expresse in miirams), which is the atomic mass iv
ie by the
vaence. Because manesium is ivaent, each moe has the chare equivaent of 2

mo of hyroen.
Then, mutipy the miiequivaent per iter by the miiequivaent weiht to co
nvert to
miirams per iter. Next, ivie by 10 to convert miirams per iter to mi
irams per
eciiter. Miiequivaent weiht M = 24.3 2 = 12.15 m/mEq 2.0 mEq/L 12.15 m/
mEq = 24.3
m/L 24.3 m/L 1.0 L/10.0 L = 2.4 m/L 7. B To cacuate the voume of stock s
oution neee,
ivie the concentration of workin stanar by the concentration of stock stan
ar, then
mutipy by the voume of workin stanar that is neee. C 1 V 1 = C 2 V 2 , w
here C 1 =
concentration of stock stanar V 1 = voume of stock stanar C 2 = concentrati
on of workin
stanar V 2 = voume of workin stanar 2000.0 m/L V 1 = 150.0 m/L 100.0 m
L V 1 =
(150.0 2000.0) 100.0 mL V 1 = 7.5 mL 2828_Ch05_171-326 06/08/12 5:14 PM Pae
223 8. What
is the pH of a soution of HNO 3 , if the hyroen ion concentration is 2.5 10 2
M? A. 1.0 B.
1.6 C. 2.5 D. 2.8 Cinica chemistry/Cacuate/pH/2 9. Cacuate the pH of a so
ution of 1.5 10
5 M NH 4 OH. A. 4.2 B. 7.2 C. 9.2 D. 11.2 Cinica chemistry/Cacuate/pH/2 10. H
ow many
sini cant ures shou be reporte when the pH of a 0.060 M soution of nitric aci
 is
cacuate? A. 1 B. 2 C. 3 D. 4 Cinica chemistry/Cacuate/Sini cant ures/2 11.
What is the
pH of a 0.05 M soution of acetic aci? K a = 1.75 10 5 , pK a = 4.76 A. 1.7 B. 3
.0 C. 4.3 D.
4.6 Cinica chemistry/Cacuate/pH/2 12. What is the pH of a bu er containin 40.
0 mmo/L NaHC 2
O 4 an 4.0 mmo/L H 2 C 2 O 4 ? (pK a = 1.25) A. 1.35 B. 2.25 C. 5.75 D. 6.12 C
inica
chemistry/Cacuate/pH/2 224 Chapter 5 | Cinica Chemistry Answers to Questions
812 8. B For a
stron aci, the pH is equa to the neative oarithm of the hyroen ion conce
ntration. pH =
-Lo H + pH = -Lo 0.025 pH = 1.6 9. C First, cacuate the pOH of the soution.
pOH = -Lo [OH
]
pOH = - Lo 1.5 x 10 5 = 4.82 pH = 14 - pOH pH = 14 - 4.8 = 9.2 10. B Whe
n zeros appear by
themseves to the eft of the ecima point, they are not sinificant. When they
are to the eft
of the ecima point an are precee by a number, they are sinificant. Zeros a
fter the ecima
point precein a number are not sinificant. However, they are sinificant if t
hey foow
another number or are between two numbers. Therefore, 0.060 M has ony two sini
ficant fiures
(the unerine iits). In aboratory practice, most anaytes are reporte with
two sinificant
fiures. Routine anaytes that are exceptions are pH, which incues three sini
ficant fiures,
an anaytes with whoe numbers above 100 such as soium, choestero, triycer
ies, an
ucose. 11. B Weak acis are not competey ionize, an pH must be cacuate
from the

issociation constant of the aci (in this case 1.75 10 5 ). K a = [H +

]
[Ac

]
[HAc] 1.75 x 10 5 = [H +
]
[Ac

]
5.0 x 10 2 Since [H +
]
= [Ac

]
X 2 = (1.75 10 5 ) (5.0 10 2 ) = 8.75 10 7 x = 8.75 10 7 = [H +
]
= 9.35 10
4 M pH = Lo 9.35 10 4 M = 3.0 Aternativey, pH = 1
/
2 (pK
a Lo HA) pH = 1
/
2 (4.76 Lo 5.0 10
2 ) = 1
/
2 (4.76 + 1.30)
= 3.0 12. B The HenersonHassebach equation can be use to etermine th
e pH of a bu er
containin a weak aci an a sat of the aci. pH = pK a + o sat Aci = 1.25
+ o 40.0 mmo/L
4.0 mmo/L = 1.25 + o 10 = 2.25 2828_Ch05_171-326 06/08/12 5:14 PM Pae 224
13. A sovent
neee for HPLC requires a 20.0 mmo/L phosphoric aci bu er, pH 3.50, mae by mix
in KH 2 PO 4
an H 3 PO 4 . How many rams of KH 2 PO 4 are require to make 1.0 L of this bu e
r? Formua
weihts: KH 2 PO 4 = 136.1; H 3 PO 4 = 98.0; pK a H 3 PO 4 = 2.12 A. 1.96  B. 2
.61  C. 2.72 
D. 19.2  Cinica chemistry/Cacuate/Bu ers/2 14. A proceure for choestero is
caibrate
with a serum-base choestero stanar that was etermine by the AbeKena m
etho to be
200.0 m/L. Assumin the same voume of sampe an reaent are use, cacuate
the choestero
concentration in the patients sampe from the foowin resuts. 5.4 | Cacuatio
ns, Quaity
Contro, an Statistics 225 Answers to Questions 1315 13. B The HenersonHasseb
ach equation
is use to cacuate the ratio of sat to aci neee to ive a pH of 3.50. pH =
pK a +
o(sat/aci) 3.50 = 2.12 + o(KH 2 PO 4
/H
3 PO 4 ) 1.38 = o(KH 2 PO 4
/H
3 PO 4 ) antio 1.38 = KH 2 PO 4
/H
3 PO 4 KH 2 PO 4
/H
3 PO 4 = 23.99 Rearranin ives KH 2 PO 4 = 23.99 H 3 PO 4 . Because th
e phosphate in the
bu er is 20.0 mmo/L, then H 3 PO 4 + KH 2 PO 4 must equa 20. Because KH 2 PO 4 =
23.99 H 3 PO
4 then: H 3 PO 4 + (23.99 H 3 PO 4 ) = 20.0 mmo/L 24.99 H 3 PO 4 = 20.0 mmo/L
H 3 PO 4 =
20.0/24.99 = 0.800 mmo/L KH 2 PO 4 = 20.00.800 = 19.2 mmo/L (0.0192 M) To eter
mine the rams

require, mutipy the moes of KH 2 PO 4 by the formua weiht. 0.0192 mo/L 13

6.1 /mo =
2.613  14. B C u = A u
/A
s C s where C u = concentration of unknown, A u = absorbance of unknown,
A s = absorbance
of stanar, an C s = concentration of stanar. C u = 0.740/0.860 200 m/L =
172 m/L 15. B
The serum bank absorbance is subtracte from the resut for the patients serum b
efore appyin
the ratiometric formua to cacuate concentration. C u = [(A u A SB )/A s
]
C
s where A SB = absorbance of serum bank = (0.7500.100)/0.620 125 m/L =
131 m/L
Stanar Absorbance Absorbance Concen- of Reaent Absorbance of Patient
tration Bank
of Stanar
Serum 200 m/L 0.00 0.860 0.740 Stanar Absorbance of Absorba
nce of
Absorbance of Absorbance of Concentration Reaent Bank Stanar
Patient
Serum Serum
Bank 125 m/L 0.000 0.62 0.750 0.100 A. 123 m/L B. 172 m/L C. 232 m/L D.
314 m/L
Cinica chemistry/Cacuate/Beers aw/2 15. A ycero kinase metho for triyc
erie cas for
a serum bank in which norma saine is substitute for ipase in orer to measu
re enoenous
ycero. Given the foowin resuts, an assumin the same voume of sampe an
 reaent are
use for each test, cacuate the triycerie concentration in the patients samp
e. A. 119
m/L B. 131 m/L C. 156 m/L D. 180 m/L Cinica chemistry/Cacuate/Beers 
aw/2
2828_Ch05_171-326 06/08/12 5:14 PM Pae 225 16. A proceure for aspartate ami
notransferase
(AST) is performe manuay because of a repeatin error coe for noninearity o
btaine on the
aboratorys automate chemistry anayzer; 0.05 mL of serum an 1.0 mL of substrat
e are use. Te
reaction rate is measure at 30C at 340 nm usin a 1.0 cM iht path, an the e
ta absorbance
(-A) per minute is etermine to be 0.382. Base upon a moar absorptivity coe cien
t for NADH at
340 nm of 6.22 X 10 3 M 1 cM 1 L 1 , cacuate the enzyme activity in internationa
units
(IUs) per iter. A. 26 IU/L B. 326 IU/L C. 1228 IU/L D. 1290 IU/L Cinica
chemistry/Cacuate/Internationa units/2 17. When referrin to quaity contro
(QC) resuts,
what parameter usuay etermines the acceptabe rane? A. Te 95% con ence interv
a for the mean
B. Te rane that incues 50% of the resuts C. Te centra 68% of resuts D. Te
rane encompasse
by 2.5 stanar eviations Chemistry/Evauate aboratory ata to assess vaiity/
Accuracy of
proceures/Quaity contro/1 18. Which of the foowin quaity contro (QC) ru
es wou be
broken 1 out of 20 times by chance aone? A. 1 2s B. 2 2s C. 1 3s D. 1 4s Chemis
try/Evauate
aboratory ata to assess vaiity/ Accuracy of proceures/Quaity contro/1 19.
Which of the
foowin conitions is cause for rejectin an anaytica run? A. Two consecutiv

e contros
reater than 2 s above or beow the mean B. Tree consecutive contros reater th
an 1 s above the
mean C. Four contros steaiy increasin in vaue but ess than 1 s from the mea
n D. One
contro above +1 s an the other beow 1 s from the mean Chemistry/Seect course
of
action/Quaity contro/3 226 Chapter 5 | Cinica Chemistry Answers to Questions
1619 16. D An
IU is e ne as 1 mol of substrate consumed or product produced per minute. The mic
romoles of
NADH consumed in this reaction are determined by dividing the change in absorban
ce per minute by
the absorbance of 1 mol of NADH. Because 1 mol/L/cm would have an absorbance of 6
.22 X 10 3
absorbance units, then 1 mol/mL/cm would produce an absorbance of 6.22. Therefore
, dividing the
A per minute by 6.22 ives the micromoes of NADH consume in the reaction. This
is mutipie
by the iution of serum to etermine the micromoes per miiiter, an mutip
ie by 1,000 to
convert to micromoes per iter. IU/L = A/min x TV(mL) 1,000 mL/L 6.22(A/mol/mL/cM
) x 1 cm x
SV(mL) = A/min 1.05 x 1,000 6.22 X 0.05 = A/min 1,050 0.311 = A/min 3,376 = 0.382
376
= 1,290 IU/L 17. A The acceptabe rane for quaity contro resuts is usuay s
et at the 95%
con ence interva. This is e ne as the rane between 1.96s an +1.96s. This means
that we can
expect a QC resut to fa within this rane 95 out of 100 times. For practica
purposes, this is
the same as 2 s (95.4 out of 100 resuts shou fa within 2 s of the mean on the
basis of
chance). 18. A The notation 1 2S means that one contro is outsie 2 stanar ev
iation units.
QC resuts foow the be- shape curve cae the Gaussian (norma) istributi
on. If a contro
is assaye 100 times, 68 out of 100 resuts wou fa within +1 s an 1 s of the
mean. Ninetyve (95.4) out of 100 resuts wou fa within +2 s an 2 s. This eaves ony 5 ou
t of 100
resuts (1:20) that fa outsie the 2 s imit. Aso, 99.7 out of 100 resuts fa
 within 3 s
of the mean. 19. A Rejectin a run when three consecutive contros fa between
1 an 2 s or when
a tren of four increasin or ecreasin contro resuts occurs wou ea to fr
equent rejection
of vai anaytica runs. Appropriate contro imits are four consecutive contro
s above or beow
1 s (4 1s ) to etect a sini cant shift, an a cusum resut exceein the 2.7 s i
mit to etect
a sini cant shift or tren. When contros eviate in opposite irections, the i er
ence shou
excee 4s before the run is rejecte. 2828_Ch05_171-326 06/08/12 5:14 PM Pae
226 20. One of
two contros within a run is above +2s an the other contro is beow 2s from the
mean. What o
these resuts inicate? A. Poor precision has e to ranom error (RE) B. A syst
ematic error (SE)
is present C. Proportiona error is present D. QC materia is contaminate Chemi

stry/Evauate
aboratory ata to reconize probems/Quaity contro/2 21. Two consecutive cont
ros are both
beyon 2s from the mean. How frequenty wou this occur on the basis of chance a
one? A. 1:100
B. 5:100 C. 1:400 D. 1:1,600 Chemistry/Evauate aboratory ata to assess vaii
ty/ Accuracy of
proceures/Quaity contro/2 22. Te term R 4S means that: A. Four consecutive co
ntros are
reater than 1 stanar eviation from the mean B. Two contros in the same run a
re reater than
4s units apart C. Two consecutive contros in the same run are each reater than
4s from the
mean D. Tere is a shift above the mean for four consecutive contros Chemistry/E
vauate
aboratory ata to assess vaiity/Accuracy of proceures/Quaity contro/2 23.
A tren in QC
resuts is most ikey cause by: A. Deterioration of the reaent B. Miscaibrat
ion of the
instrument C. Improper iution of stanars D. Eectronic noise Chemistry/Evau
ate aboratory
ata to assess vaiity/ Accuracy of proceures/Quaity contro/2 24. In most ci
rcumstances, when
two contros within a run are both reater than 2s from the mean, what action sho
u be taken
rst? A. Recaibrate, then repeat contros foowe by seecte patient sampes if
quaity
contro is acceptabe B. Repeat the contros before takin any corrective action
C. Chane the
reaent ot, then recaibrate D. Prepare fresh stanars an recaibrate Chemist
ry/Evauate
aboratory ata to take corrective action accorin to preetermine criteria/Qu
aity contro/3
5.4 | Cacuations, Quaity Contro, an Statistics 227 Answers to Questions 2
024 20. A When
contro resuts eviate from the mean in opposite irections, the run is a ecte b
y RE, which
resuts from imprecision. An anaytica run is rejecte when two contros within
the same run
have an aebraic i erence in excess of 4s (R 4s ). The R 4S rue is appie ony
to contros
within a run (Leve 1 Leve 2), never across runs or ays. 21. D QC resuts fo
ow a Gaussian
or norma istribution. Ninety- ve percent of the resuts fa within 2s of the mea
n; therefore,
2.5 out of 100 (1:40) are above +2s an 2.5 out of 100 are beow 2s. The probabi
ity of two
consecutive contros bein beyon 2s is the prouct of their iniviua probabii
ties. 1/40
1/40 = 1/1,600 trias by chance. 22. B The R 4s rue is appie to two contro 
eves within the
same run. The rue is vioate when the aebraic ifference between them (eve
1 eve 2)
excees 4s. The rue is never appie across ifferent runs. The R 4s rue etec
ts ranom error
(error ue to poor precision). 23. A A tren occurs when six or more consecutive
quaity contro
resuts either increase or ecrease in the same irection; however, this is not
cause for
rejection unti a mutirue is broken. Trens are systematic errors (a ectin accu

racy) inke to
an unstabe reaent, caibrator, or instrument conition. For exampe, oss of v
oatie aci from
a reaent causes a steay pH increase, preventin separation of anayte from pro
tein. This
resuts in ower QC resuts each ay. 24. A When a 2 2s rue is broken an SE is
present an
corrective action is require (repeatin just the QC wi not correct the probe
m). If
recaibration yies acceptabe QC resuts, both sets of QC resuts an the corr
ective action
taken are ocumente in the QC o. If the manitue of the error is are enou
h to be meicay
sini cant, then a patient sampes since the ast previousy acceptabe QC shou
 be repeate.
If in question, the manitue of the error can be evauate by repeatin abnorma
 patient
sampes. If the averae i erence between resuts before an after recaibration i
s > 2s, then
a sampes shou be repeate since the ast acceptabe QC. 2828_Ch05_171-326
06/08/12 5:14 PM
Pae 227 25. When estabishin QC imits, which of the foowin practices is i
nappropriate? A.
Usin ast months QC ata to etermine current taret imits B. Excusion of any
QC resuts
reater than 2s from the mean C. Usin contro resuts from a shifts on which t
he assay is
performe D. Usin imits etermine by reference aboratories usin the same me
tho
Chemistry/Appy principes of aboratory operations/Quaity contro/2 26. Which
of the foowin
assays has the poorest precision? A. B. C. D. Chemistry/Cacuate/Coe cient of var
iation/3 27.
Given the foowin ata, cacuate the coe cient of variation for ucose. A. 3.0
% B. 4.6% C.
7.6% D. 33.0% Cinica chemistry/Cacuate/Statistics/2 28. Which of the foowi
n pots is best
for etectin a types of QC errors? A. LevyJennins B. TonksYouen C. Cusum D. L
inear
reression Chemistry/Evauate aboratory ata to reconize probems/Quaity cont
ro/2 29. Which
of the foowin pots is best for comparison of precision an accuracy amon a
boratories? A.
LevyJennins B. TonksYouen C. Cusum D. Linear reression Chemistry/Evauate abor
atory ata to
reconize probems/Quaity contro/2 228 Chapter 5 | Cinica Chemistry Answers
to Questions
2529 25. B Data between 2 an 3s must be incue in cacuations of the next months
acceptabe rane. Eimination of these vaues wou continuousy reuce the ist
ribution of QC
resuts, makin out-of-contro situations a frequent occurrence. Generay, QC res
uts reater
than 3s are not use to cacuate next months mean. 26. A Athouh cacium has th
e owest s, it
represents the assay with poorest precision. Reative precision between i erent a
naytes or
i erent eves of the same anayte must be evauate by the coe cient of variation
(CV) because
stanar eviation is epenent upon the mean. CV = s 100/Mean. This normaizes
stanar

eviation to a mean of 100. The CV for cacium in the exampe is 12.0%. 27. A Th
e coe cient of
variation is cacuate by iviin the stanar eviation by the mean an muti
pyin by 100.
%
CV =
s x 100 = 2.3 100 = 3.0% 76 The CV is the most appropriate statistic to
use when
comparin the precision of sampes that have i erent means. For exampe, when com
parin the
precision of the eve 1 contro to the eve 2 contro, the coe cient of variatio
n normaizes
the variance to be inepenent of the mean. The contro with the ower CV is the
one for which
the anaysis is more precise. 28. A The LevyJennins pot is a raph of a QC re
suts with
concentration potte on the y axis an run number on the x axis. The mean is at
the center of
the y axis, an concentrations corresponin to 2 an +2s are hihihte. Resut
s are evauate
for mutirue vioations across both eves an runs. Corrective action for shif
ts an trens can
be taken before QC rues are broken. 29. B The TonksYouen pot is use for inter
aboratory
comparison of monthy means. The metho mean for eve 1 is at the center of the
y axis an mean
for eve 2 at the center of the x axis. Lines are rawn from the means of both
eves across the
raph, iviin it into four equa quarants. If a aboratorys monthy means both
pot in the
ower eft or upper riht, then systematic error (SE) exists in its metho. Mean
Stanar
Anayte (mmo/L) Deviation Ca 2.5 0.3 K 4.0 0.4 Na 140 4.0 C 100 2.5 Anayt
e Mean
Stanar Deviation Gucose 76 m/L 2.3 2828_Ch05_171-326 06/08/12 5:14 PM Pa
e 228 30. Which
pot wi ive the eariest inication of a shift or tren? A. LevyJennins B. To
nksYouen C.
Cusum D. Historam Chemistry/Evauate aboratory ata to reconize probems/Qua
ity contro/2 31.
A of the foowin are requirements for a QC materia except: A. Lon-term sta
biity B. Te
matrix is simiar to the specimens bein teste C. Te concentration of anaytes
re ects the
cinica rane D. Anayte concentration must be inepenent of the metho of ass
ay
Chemistry/Appy principes of basic aboratory proceures/Quaity contro/2 5.4
| Cacuations,
Quaity Contro, an Statistics 229 Answers to Questions 3031 30. C Cusum point
s are the
aebraic sum of the i erence between each QC resut an the mean. The y axis is
the sum of
i erences an the x axis is the run number. The center of the y axis is 0. Becaus
e QC resuts
foow a ranom istribution, the points shou istribute about the zero ine.
Resuts are out
of contro when the sope excees 45 or a ecision imit (e.., 2.7s) is exceee.
31. D
Quaity contro materias are stabe, mae of the same components as the specime
n, cover the
ynamic inear rane of the assay, an can be use for mutipe anaytes. The ta

ret mean for QC

sampes is etermine from repicate assays by the users metho, not the true conce
ntration of
the anayte. Out-of-contro resuts are inke to anaytic performance rather th
an to the
inherent accuracy of the metho. 1 2 3 4 5 6 7 8 9 10
11121314151617181920212223242526 2728293031 1 2 3 4 5 6 7 8 9 10
11121314151617181920212223242526 2728293031 8.8 8.5 8.2 7.9 7.6 12.8 12.5 12.2 1
1.9 11.6 Leve 1
Contro: Cacium Mean 8.2 m/L s = 0.31 Leve 2 Contro: Cacium Mean 12.2
m/L s = 0.30
+2s +1s -2s -1s +2s +1s -2s -1s x x 2828_Ch05_171-326 06/08/12 5:14 PM Pae 2
29 Questions
3235 refer to the precein LevyJennins chart. 32. Examine the LevyJennins chart
at the
bottom of the previous pae an ientify the QC probem that occurre urin the
rst haf of the
month. A. Shift B. Tren C. Ranom error D. Kurtosis Chemistry/Evauate aborato
ry ata to
reconize probems/Quaity contro/3 33. Referrin to the LevyJennins chart, wha
t is the rst
ay in the month when the run shou be rejecte an patient resuts shou be r
epeate? A. Day 6
B. Day 7 C. Day 8 D. Day 9 Chemistry/Evauate aboratory ata to reconize prob
ems/Quaity
contro/3 34. Referrin to the LevyJennins chart, what anaytica error is prese
nt urin the
secon haf of the month? A. Shift B. Tren C. Ranom error D. Kurtosis Chemistr
y/Evauate
aboratory ata to reconize probems/Quaity contro/3 35. What is the rst ay i
n the secon
haf of the month that patient resuts wou be rejecte? A. Day 16 B. Day 17 C.
Day 18 D. Day 19
Chemistry/Evauate aboratory ata to reconize probems/Quaity contro/3 230 C
hapter 5 |
Cinica Chemistry Answers to Questions 3235 32. B A tren is characterize by si
x consecutive
ecreasin or increasin contro resuts. The vaue for both contros becomes pr
oressivey
hiher from ay 4 to ay 9. Trens are cause by chanes to the test system that
increase over
time, such as eterioration of reaents or caibrators, proressive chanes in t
emperature,
evaporation, iht exposure, an bacteria contamination. A tren is a type of S
E because a
resuts are a ecte. Conversey, RE a ects some resuts (but not others) in an unpre
ictabe
manner. Contro rues a ecte by RE are 1 3s an R 4s . 33. C Athouh the tren i
s apparent
across QC eves by ay 7, the patient resuts wou not be rejecte unti ay 8
when the 4 1s
rue is broken. An avantae to pottin contro ata is that trens can be ien
ti e before
resuts are out of contro an patient ata must be rejecte. In this case, corr
ective steps
shou have been impemente by ay 7 to avoi the eay an expense associate
with havin to
repeat the anaysis of patient sampes. 34. A A shift is characterize by six co
nsecutive points
yin on the same sie of the mean. This occurs from ay 15 to ay 20. Shifts ar

e cause by a
chane in the assay conitions that a ect the accuracy of a resuts, such as a c
hane in the
concentration of the caibrator; chane in reaent; a new ot of reaent that i e
rs in
composition; or improper temperature settin, waveenth, or sampe voume. The
term kurtosis
refers to the eree of atness or sharpness in the peak of a set of vaues havin
a Gaussian
istribution. 35. B The 4 1s rue is broken across QC eves on ay 17. This mea
ns that four
consecutive contros are reater than 1s from the mean. QC rues that are sensiti
ve to SE are
appie across both runs an eves to increase the probabiity of error etecti
on. These are 2
2s , 4 1s , an 10. 2828_Ch05_171-326 06/08/12 5:14 PM Pae 230 36. Given the
foowin QC
chart, ientify the ay in which a vioation of the R 4s QC rue occurs. 5.4 | C
acuations,
Quaity Contro, an Statistics 231 Answers to Questions 3638 36. D An R 4s err
or is e ne as
the aebraic i erence between two contros within the same run. In this LevyJenni
ns pot, on
ay 15, Leve 1 is above the +2s imit (approximatey +2.5s) an Leve 2 is beo
w the 2s imit
(approximatey 2.5s). These contros are approximatey 5s apart (+2.5s minus 2.5s
= +5s). 37. C
The minimum requirement for frequency of quaity contro for a enera chemistry
anayte (base
upon the Cinica Laboratory Improvement Act, 1988) is two eves of contro ass
aye every 24
hours. Some aboratories prefer to assay two contro eves every 8 hours to inc
rease the
opportunity for error etection. Two contros every 8 hours are require for bo
o ases,
automate hematooy, an point-of-care ucose testin to compy with Coee o
f American
Pathooy requirements. Anaytes that ispay ifferent CVs at the ow, norma,
an hih ranes
require 3 eves of contro in 24 hours. These incue boo ases, therapeutic
rus, an
hormones. 38. A Stuents t test is the ratio of mean ifference to the stanar e
rror of the
mean ifference (bias/ranom error) an tests for a sinificant ifference in me
ans. The F test
is the ratio of variances an etermines if one metho is sinificanty ess pre
cise. The
correation coefficient is a measure of the association between two variabes an
 shou be hih
in any metho comparison. An r vaue ess than 0.90 in metho comparisons usua
y occurs when the
rane of resuts is too narrow. +2s Mean -2s +2s Mean -2s QC1 QC2 1 16 15 14 1
3 12 11 10 9 8 7
6 5 4 3 2 A. Day 3 B. Day 8 C. Day 10 D. Day 15 Chemistry/Evauate aboratory a
ta to reconize
probems/Quaity contro/ 3 37. What is the minimum requirement for performin Q
C for a tota
protein assay? A. One eve assaye every 8 hours B. Two eves assaye within 8
hours C. Two
eves assaye within 24 hours D. Tree eves assaye within 24 hours Chemistry/

Appy principes
of basic aboratory proceures/Quaity contro/2 38. Which of the foowin stat
istica tests is
use to compare the means of two methos? A. Stuents t test B. F istribution C.
Correation
coe cient (r) D. Linear reression anaysis Chemistry/Evauate aboratory ata to
assess the
vaiity/Accuracy of proceures/Statistics/2 2828_Ch05_171-326 06/08/12 5:14 P
M Pae 231 39.
Two freezin point osmometers are compare by runnin 40 paire patient sampes
one time on each
instrument, an the foowin resuts are obtaine: 232 Chapter 5 | Cinica Che
mistry Answers to
Questions 3941 39. A The F test etermines whether there is a statisticay sini c
ant i erence
in the variance of the two sampin istributions. Assumin the sampes are co
ecte an store
in the same way an the anaysis is one by a technooist who is famiiar with
the instrument,
then i erences in variance can be attribute to a i erence in instrument precision
. The F test
is cacuate by iviin the variance (s 1 ) 2 of the instrument havin the hi
her stanar
eviation by the variance (s 2 ) 2 of the instrument havin the smaer stanar
eviation. F =
(s 1 ) 2 (s 2 ) 2 = (3.1) 2 (2.8) 2 = 9.61 7.84 = 1.22 If the vaue of F is sma
er than the
critica vaue at the 0.10 eve of sini cance, then the hypothesis (there is no
sini cant
i erence in the variance of the two instruments) is accepte. 40. D The bias is 
efine as the
ifference between the means of the two methos an is cacuate usin the form
ua: bias = y
. The bias is an estimate of SE. The stuents t test is use to etermine if bias
is
statisticay sinificant. The t statistic is the ratio of bias to the stanar
error of the mean
ifference. The reater the bias, the hiher the t score. 41. B Proportiona err
or (sope or
percent error) resuts in reater absoute error (eviation from the taret vau
e) at hiher
sampe concentration. Constant error refers to a ifference between the taret v
aue an the
resut, which is inepenent of sampe concentration. For exampe, if both eve
1 an eve 2
contros for aboratory A averae 5 m/L beow the cumuative mean reporte by
a other
aboratories usin the same metho, then aboratory A has a constant error of 5 m
/L for that
metho. Stanar Instrument Mean Deviation Osmometer A 280 mOsm/k 3.1 Osmom
eter B 294
mOsm/k 2.8 Stanar Instrument Mean Deviation Metho x (reference 235 m/
L 3.8 metho)
Metho y (caniate 246 m/L 3.4 metho) If the critica vaue for F = 2.8, th
en what
concusion can be rawn rearin the precision of the two instruments? A. Tere
is no
statisticay sini cant i erence in precision B. Osmometer A emonstrates better p
recision that
is statisticay sini cant C. Osmometer B emonstrates better precision that is s

tatisticay
sini cant D. Precision cannot be evauate statisticay when sine measurements
are mae on
sampes Chemistry/Evauate aboratory ata to assess the vaiity/Accuracy of
proceures/Statistics/3 40. Two methos for tota choestero are compare by ru
nnin 40 paire
patient sampes in upicate on each instrument. Te foowin resuts are obtain
e: Assumin the
sampes are coecte an store in the same way an the anaysis one by a tech
nooist who is
famiiar with both methos, what is the bias of metho y? A. 0.4 B. 7.2 C. 10.6
D. 11.0
Chemistry/Evauate aboratory ata to assess the vaiity/Accuracy of proceures
/Statistics/2 41.
When the manitue of error increases with increasin sampe concentration, it i
s cae: A.
Constant error B. Proportiona error C. Ranom error D. Bias Chemistry/Evauate
aboratory ata
to assess vaiity/ Accuracy of proceures/Statistics/2 2828_Ch05_171-326 06/08
/12 5:14 PM
Pae 232 42. Which expanation is the best interpretation of the foowin BUN b
ias pot? 5.4 |
Cacuations, Quaity Contro, an Statistics 233 Answers to Questions 4243 42.
D A bias pot
compares the bias (caniate metho minus reference metho) to the resut of the
reference
metho. Ieay, points shou be scattere equay on both sies of the zero i
ne. When the
majority of points is beow the zero ine, the caniate metho is neativey bi
ase (ower than
the reference). In this case, the ifference between the methos increases in pr
oportion to the
BUN concentration. This type of pot occurs when the sope of the inear reress
ion ine is ow.
43. A The inear reression anaysis is the most usefu statistic to compare pai
re patient
resuts because it estimates the manitue of specific errors. The y intercept o
f the reression
ine is a measure of constant error, an the sope is a measure of proportiona
error. Toether,
these represent the bias or SE of the new metho. The correation coefficient is
infuence by
the rane of the sampe an the RE. Two methos that measure the same anayte wi
 have a hih
correation coefficient, provie the concentrations are measure over a wie ra
ne, an this
statistic shou not be use to jue the acceptabiity of the new metho. The s
tanar error of
estimate is a measure of the coseness of ata points to the reression ine an
is an expression
of RE. Linear Correation Stanar Error of Reression Coefficient (r) Est
imate (s y/x )
= 2.10 + 1.01x 0.984 0.23 Which statement best characterizes the reationship be
tween the
methos? A. Tere is a sini cant bias cause by constant error B. Tere is a sini ca
nt
proportiona error C. Tere is no isareement between the methos because the co
rreation
coe cient approaches 1.0 D. Tere is no systematic error, but the ranom error of t
he new metho

is unacceptabe Chemistry/Evauate aboratory ata to assess the vaiity/Accura

cy of
proceures/Statistics/2 5 0 -5 -10 -15 B i a s
( y x ) BUN (Ref) BUN Bias Pot 0 20 40 60 80 100 120 A. Te
new metho
consistenty overestimates the BUN by a constant concentration B. Te new metho
is reater than
the reference metho but not by a statisticay sini cant marin C. Te new metho
is ower than
the reference metho by 5 m/L D. Te new metho is ower than the reference an
the manitue is
concentration epenent Chemistry/Evauate aboratory ata to assess the vaiit
y/Accuracy of
proceures/Statistics/ 3 43. Serum sampes coecte from hospitaize patients
over a 2-week
perio are spit into two aiquots an anayze for prostate speci c antien (PSA)
by two
methos. Each sampe was assaye by both methos within 30 minutes of coection
by a
technooist famiiar with both methos. Te reference metho is metho (upper re
ference imit =
4.0 /L). Linear reression anaysis was performe by the east-squares metho, a
n resuts are
as foows: 2828_Ch05_171-326 06/08/12 5:14 PM Pae 233 44. Which statement b
est summarizes
the reationship between the new BUN metho an reference metho base upon the
foowin inear
reression scatterpot? 234 Chapter 5 | Cinica Chemistry Answers to Questions
4446 44. B The
scatterpot shows that each sampe prouces a coorinate (x correspons to the r
eference resut
an y to the caniate metho resut) that is very cose to the reression ine.
This means that
the variance of reression is ow an there is a hih eree of certainty that t
he preicte
vaue of y wi be cose to its measure vaue. Near-zero concentration there is
oo areement
between methos; however, the hiher the resut, the reater the i erence between
x an y. The
reression equation for this scatterpot is y = 0.01 + 0.90 x, inicatin a propo
rtiona error
of 10%. 45. C Linear reression anaysis ives an estimate of SE, which is equa
to ( x c )
where x c is the expecte concentration, an is the vaue preicte by the inea
r reression
equation. SE = [0.3 + (0.9 50 m/L)] 50.0 m/L = 44.750.0 = 5.3 m/L The stanar

eviation of the new metho for the hih contro is use to estimate the RE beca
use the mean of
this contro is nearest to the expecte concentration of 50 m/L. RE is estimat
e by 1.96 s.
RE = 1.96 1.12 =  2.2 m/L Tota anaytica error (TE) is equa to the sum of SE
an RE. TE =
SE + RE = 5.3 m/L + (2.2 m/L) = 7.5 m/L 46. D The cinica speci city of a abo
ratory
test is e ne as the true neatives ivie by the sum of true neatives an fas
e positives
(FP).
%
Speci city =

TN 100 TN + FP Speci city is e ne as the percentae of isease-free peope

who have a
neative test resut. The probabiity of fase positives is cacuate from the
speci city as: 1
(
%
speci city
) 100 100 80 60 40 20 0 B U N
C a n  i  a t e BUN Reference BUN Metho Com parison 0 20 40 60
80 100 120 A.
Te methos aree very we but show a hih stanar error of estimate B. Tere is
itte or no
constant error, but some proportiona error C. Tere wi be a sini cant eree of
uncertainty in
the reression equation D. Tere is sini cant constant an proportiona error but
itte ranom
error Chemistry/Evauate aboratory ata to assess the vaiity/Accuracy of
proceures/Statistics/3 45. A new metho for BUN is evauate by comparin the r
esuts of 40
paire patient sampes to the urease-UV metho. Norma an hih contros were ru
n on each shift
for 5 ays, ve times per ay. Te resuts are as foows: Linear Reression Low
Contro
Hih
Contro = 0.3 + 0.90x x = 14.2 m/L; x = 48.6 m/L; s = 1.24 s = 1.12 What is t
he tota
anaytica error estimate for a sampe havin a concentration of 50 m/L? A. 2.2
m/L B. 2.8
m/L C. 7.5 m/L D. 10.0 m/L Chemistry/Cacuate/Metho comparison statistics/
3 46. In
aition to the number of true neatives (TN), which of the foowin measuremen
ts is neee to
cacuate speci city? A. True positives B. Prevaence C. Fase neatives D. Fase
positives
Chemistry/Cacuation/Speci city/2 2828_Ch05_171-326 06/08/12 5:14 PM Pae 234
47. A new tumor
marker for ovarian cancer is evauate for sensitivity by testin serum sampes
from patients who
have been ianose by stain biopsy as havin mainant or benin esions. Te
foowin resuts
were obtaine: Number of mainant patients who are positive for CA 125 = 21 out
of 24 Number of
benin patients who are neative for CA 125 = 61 out of 62 What is the sensitivi
ty of the new CA
125 test? A. 98.4% B. 95.3% C. 87.5% D. 85.0% Cinica chemistry/Cacuate/Sensi
tivity/2 48. A
new test for prostate cancer is foun to have a sensitivity of 80.0% an a speci c
ity of 84.0%.
If the prevaence of prostate cancer is 4.0% in men over 42 years o, what is t
he preictive
vaue of a positive test resut (PV+) in this roup? A. 96.0% B. 86.0% C. 32.4%
D. 17.2%
Chemistry/Cacuate/Preictive vaue/2 49. What measurement in aition to true
neatives an
prevaence is require to cacuate the preictive vaue of a neative test resu
t (PV)? A.
Fase neatives B. Variance C. True positives D. Fase positives Chemistry/Cacu
ate/Preictive
vaue/2 50. A aboratory is estabishin a reference rane for a new anayte an
wants the rane
to be etermine by the reiona popuation of auts ae 18 an oer. Te anay

te concentration
is known to be inepenent of race an ener. Which is the most appropriate pro
cess to foow?
A. Determine the mean an stanar eviation of the anayte from 40 heathy au
ts an cacuate
the 2s imit B. Measure the anayte in 120 heathy auts an cacuate the centr
a 95th
percentie C. Measure the anayte in 120 heathy auts an use the owest an h
ihest as the
reference rane imits D. Measure the anayte in 60 heathy auts an 60 auts
with conitions
that a ect the anayte concentration; cacuate the concentration of east overap
Chemistry/Seect methos/Statistics/2 5.4 | Cacuations, Quaity Contro, an S
tatistics 235
Answers to Questions 4750 47. C Sensitivity is e ne as the percentae of persons
with the
isease who have a positive test resut. It is cacuate as true positives (TP)
ivie by the
sum of TP an fase neatives (FN).
%
Sensitivity =
TP 100 TP + FN Sensitivity = (21 100) (21 + 3) = 87.5% 48. D The preict
ive vaue of a
positive test (PV+) is e ne as the percentae of persons with a positive test re
sut who wi
have the isease or conition. It is epenent upon the sensitivity of the test
an the
prevaence of the isease in the popuation teste. PV+ is cacuate by mutip
yin the true
positives by 100, then iviin by the sum of true positives an fase positives
.
%
PV+ =
TP 100 (TP + FP) where TP equas (sensitivity prevaence) an FP equas
(1 speci city)
(1 prevaence) = 0.80 0.04 100 (0.80 0.04) + [(1 0.84) (1 0.04)] = 0.032 10
0.032 + (0.96 0.16) = 17.2% 49. A The PV is e ne as the probabiity that a person
with a
neative test resut is free of isease. A hih PV is a characteristic of a oo
screenin test.
The preictive vaue of a neative test is cacuate by mutipyin the true ne
atives by 100,
then iviin by the sum of the true neatives an fase neatives.
%
PV =
TN 100 TN + FN 50. B Since the concentration of an anayte may not be no
rmay istribute
in a popuation, the reference rane shou not be etermine from the stanar
eviation. It is
more appropriate to etermine the centra 95th percentie (the rane that encomp
asses 95% of the
resuts). A minimum of 120 sampes is neee for statistica sinificance. Resu
ts are rank
orere from owest to hihest. The 3r resut is the owest vaue an the 118th
is the hihest
vaue in the reference rane. The aboratory can verify a preexistin reference
rane (e.., as
etermine by the manufacturers stuy) by testin 20 heathy persons. If no more
than 10% fa
outsie the rane, it can be consiere vai for the patient popuation. 2828_C
h05_171-326
06/08/12 5:14 PM Pae 235 51. When comparin the aboratorys monthy mean to it
s peer roup to

etermine if bias is present, what statistic is most appropriate? A. F test B. L

inear reression
anaysis C. Correation coe cient D. Stanar eviation inex Chemistry/Appy prin
cipes of
aboratory operations/ Quaity manaement/2 52. Which of the foowin methos i
s most usefu in
orer to etect sampe misienti cation? A. Cumuative summation B. Critica imit
C. Deta imit
D. Sini cant chane imit Chemistry/Appy knowee to ientify sources of error/
Statistics/2
53. Which of the foowin tota quaity manaement toos can be use to cacua
te the anaytica
error rate for an anayte in the cinica aboratory? A. LEAN B. Six sima C. IS
O 9000 D.
Laboratory information system Chemistry/Appy principes of aboratory operation
s/ Quaity
manaement/2 236 Chapter 5 | Cinica Chemistry Answers to Questions 5153 51. D T
he stanar
eviation inex (SDI) compares the abs mean to the peer roups mean in terms of s
tanar
eviations instea of concentration. This normaizes the vaue so that it is in
epenent of mean,
an aows performance comparisons for any anayte. The SDI equas the abs mean
minus the peer
roups mean ivie by the peer roups stanar eviation. It has a simiar probab
iity
istribution to a t test an a vaue reater than 2.0 is consiere sini cant. 52
. C Cumuative
summation is a statistica metho use in quaity assurance to etect a tren in
QC resuts.
Critica imits are use to efine when meica intervention is ikey neee to
prevent injury
or eath. The sinificant chane imit is the ifference in test resuts that is
meicay
sinificant, or that which cannot be attribute to the sum of norma physiooic
a an anaytica
variation. The eta imit (eta check) etermines whether the ifference betwe
en two
measurements usuay 2448 hours apart excees the expecte. Athouh this can res
ut from an
abrupt chane in the patients status, other causes are sampe misientification,
contamination,
an ranom error. Deta imits are expresse in percent an vary epenin on an
ayte stabiity.
53. B A four of the answer choices are tota quaity manaement (TQM) toos us
e in the
cinica aboratory to improve performance. Six sima is a measurement of the fr
equency of
prouct efects. In cinica aboratories, it refers to the frequency of an erro
neous resut. At
the six-sima eve, the anaytica process has such sma variance that an erro
r of six times
the stanar eviation wou sti be within acceptabe imits for tota aowab
e error. For
exampe, a six-sima process for an anayte prouces a sini cant error in test re
sut ony 3.4
out of 1 miion times the test is performe. Conversey, a metho performin at
the three-sima
eve wou ive 66,807 errors per miion. The sima of a metho is cacuate
by subtractin

its bias from the tota metho error an iviin by its stanar eviation. It
is the methos
ranom error ivie by its stanar eviation. 2828_Ch05_171-326 06/08/12 5:1
4 PM Pae 236
54. In which circumstances is a vaiation stuy (versus performin routine qua
ity contro)
require? A. Instrument recaibration B. Source amp or ion seective eectroe
chane C. Chane
in reaent ot D. Chane in caibrator ot Chemistry/Appy principes of aborat
ory operations/
Quaity manaement/2 55. Te foowin pot represents a stuy of a screenin tes
t for mainant
prostate cancer usin pasma PSA (n/mL). Te outcome measure was positive cyto
oy resuts
obtaine by biopsy. What concentration ives the hihest sensitivity with the e
ast number of
unnecessary biopsies? 5.4 | Cacuations, Quaity Contro, an Statistics 237
Answers to
Questions 5455 54. C A of the iste conitions except a chane in the reaent
ot number can
be vaiate by assayin two eves of contro materia foowin the proceure.
A chane in
reaent ot number may ater the test system more ramaticay, especiay when
the reaent was
subjecte to storae an shippin conitions that ater its performance. Therefo
re, both contros
an patient sampes shou be anayze an the resuts compare to the reaent i
n current use
usin criteria etermine by the tota aowabe error for the anayte. 55. B A
receiver
operatin characteristic (ROC) curve is use to ientify the test resut, ivin
the hihest
sensitivity with the east number of fase-positive resuts. Sensitivity (true p
ositives) is
potte aainst fase positives. The number in the uppermost eft corner represe
nts the hihest
etection with the owest number of fase positives. In this case, a resut of 3
.6 n/mL etects
72% of mainancies with 1 in 10 (10%) fase positives. 0.0 0.1 0.2
0.4
0.5 0.6 0.7 0.8 0.50 0.55 0.60 0.65 0.70 0.75 2.6 2.8 3.0 3.2 3.4 3.6

3.8 4.0 4.2 4.4 4.6 4.8 5.0 5.2 S E N S I T I V I T Y 1-SPECIFICITY Receiver Op
eratin
Characteristic Curve:PSA A. 2.6 B. 3.6 C. 3.8 D. 5.2 Chemistry/Evauate aborato
ry ata to assess
vaiity/ Accuracy of proceures/Laboratory operations/3 2828_Ch05_171-326 06/0
8/12 5:14 PM
Pae 237 238 5.5 Creatinine, Uric Aci, BUN, an Ammonia 1. Creatinine is forme
from the: A.
Oxiation of creatine B. Oxiation of protein C. Deamination of ibasic amino ac
is D. Metaboism
of purines Chemistry/Appy knowee of funamenta biooica characteristics/B
iochemica/1 2.
Creatinine is consiere the substance of choice to measure enoenous rena ce
arance because:
A. Te rate of formation per ay is inepenent of boy size B. It is competey 
tere by the
omerui C. Pasma eves are hihy epenent upon iet D. Cearance is the sa
me for both men

0.3

an women Chemistry/Appy knowee of funamenta biooica characteristics/Bi

ochemica/1 3.
Which statement rearin creatinine is true? A. Serum eves are eevate in ea
ry rena isease
B. Hih serum eves resut from reuce omeruar tration C. Serum creatine ha
s the same
ianostic utiity as serum creatinine D. Serum creatinine is a more sensitive m
easure of rena
function than creatinine cearance Chemistry/Cacuate aboratory ata with phys
iooica
processes/Biochemica/2 4. Which of the foowin formuas is the correct expres
sion for
creatinine cearance? A. Creatinine cearance = U/P X V X 1.73/A B. Creatinine c
earance = P/V X
U X A/1.73 C. Creatinine cearance = P/V X U X 1.73/A D. Creatinine cearance =
U/V X P X 1.73/A
Chemistry/Cacuate/Creatinine cearance/1 Answers to Questions 14 1. A Creatinin
e is prouce
at a rate of approximatey 2% aiy from the oxiation of creatine mainy in ske
eta musce.
Creatine can be converte to creatinine by aition of stron aci or akai or
by the enzyme
creatine hyroxyase. 2. B Creatinine concentration is epenent upon musce mas
s, but varies by
ess than 15% per ay. Creatinine is not metaboize by the iver, or epenent
on iet, an is
100% tere by the omerui. It is not reabsorbe sini canty but is secrete si
hty,
especiay when trate ow is sow. Pasma creatinine an cystatin C are the two su
bstances of
choice for evauatin the omeruar tration rate (GFR). 3. B Serum creatinine i
s a specific
but not a sensitive measure of omeruar function. About 60% of the fitration
capacity of the
kineys is ost when serum creatinine becomes eevate. Because urine creatinine
iminishes as
serum creatinine increases in rena isease, the creatinine cearance is more se
nsitive than
serum creatinine in etectin omeruar isease. A creatinine cearance beow 6
0 mL/min
inicates oss of about 50% functiona nephron capacity an is cassifie as mo
erate (stae 3)
chronic kiney isease. 4. A Cearance is the voume of pasma that contains the
same quantity of
substance that is excrete in the urine in 1 minute. Creatinine cearance is ca
cuate as the
ratio of urine creatinine to pasma creatinine in miirams per eciiter. This
is mutipie by
the voume of urine prouce per minute an correcte for ean boy mass by mut
ipyin by
1.73/A, where A is the patients boy surface area in square meters. Separate refe
rence ranes
are neee for maes, femaes, an chiren because each has a i erent percentae
of ean musce
mass. 2828_Ch05_171-326 06/08/12 5:14 PM Pae 238 5. Which of the foowin c
onitions is most
ikey to cause a fasey hih creatinine cearance resut? A. Te patient uses t
he mistream voi
proceure when coectin his or her urine B. Te patient as tap water to the u
rine container

because he or she forets to save one of the urine sampes C. Te patient oes no
t empty his or
her baer at the concusion of the test D. Te patient empties his or her ba
er at the start
of the test an as the urine to the coection Chemistry/Ientify sources of e
rror/Creatinine
cearance/3 6. Te moi cation of iet in rena isease (MDRD) formua for cacuat
in eGFR
requires which four parameters? A. Urine creatinine, serum creatinine, heiht, w
eiht B. Serum
creatinine, ae, ener, race C. Serum creatinine, heiht, weiht, ae D. Urine
creatinine,
ener, weiht, ae Chemistry/Appy principes of specia proceures/Creatinine
cearance/1 7.
What substance may be measure as an aternative to creatinine for evauatin GF
R? A. Pasma urea
B. Cystatin C C. Uric aci D. Potassium Chemistry/Appy knowee of funamenta
biooica
characteristics/Biochemica/1 8. Which of the foowin enzymes aows creatinin
e to be measure
by coupin the creatinine amiohyroase (creatininase) reaction to the peroxi
ase reaction? A.
Gucose-6-phosphate ehyroenase B. Creatinine iminohyroase C. Sarcosine oxi
ase D. Creatine
kinase Chemistry/Appy principes of enera aboratory proceures/Biochemica/1
5.5 |
Creatinine, Uric Aci, BUN, an Ammonia 239 Answers to Questions 58 5. D Urine
in the baer
shou be eiminate an not save at the start of the test because it represent
s urine forme
prior to the test perio. The other conitions (choices AC) wi resut in fase
y ow urine
creatinine or voume an, therefore, fasey ower cearance resuts. Error is i
ntrouce by
incompete emptyin of the baer when short times are use to measure cearanc
e. A 24-hour
time urine is the specimen of choice. When trate ow fas beow 2 mL/min, error
is introuce
because tubuar secretion of creatinine occurs. The patient must be kept we hy
rate urin the
test to prevent this. 6. B The Nationa Kiney Founation recommens screenin f
or chronic kiney
isease usin the estimate omeruar tration rate (eGFR) because of the hih f
requency of
sampe coection errors associate with measurin creatinine cearance. The eGF
R shou be
cacuate accorin to the MDRD formua, an reporte aon with the serum or p
asma creatinine.
eGFR (mL/min/1.73m 2 ) = 186 x Pasma Cr 1.154 x Ae 0.203 x 0.742 (if femae) x 1
.21 (if
Back) 7. B Athouh a of the anaytes iste are increase in chronic kiney
isease as a
resut of ow GFR, potassium, urea, an uric aci may be increase by other mech
anisms an
therefore, they are not speci c for omeruar function. Cystatin C is an inhibito
r of cysteine
proteases. Bein ony 13 kioatons, it is competey tere by the omeruus t
hen reabsorbe
by the tubues. The pasma eve is hihy correate to GFR because itte is e
iminate by

nonrena routes. Pasma eves are not in uence by iet, ae, ener, or nutritio
na status. Low
GFR causes retention of cystatin C in pasma an eves become abnormay hih a
t cearance rates
beow 90 mL/min, makin the test more sensitive than creatinine. 8. C The peroxi
ase-coupe
enzymatic assay of creatinine is base upon the conversion of creatinine to crea
tine by
creatinine amiohyroase (creatininase). The enzyme creatinine amiinohyroase
(creatinase)
then hyroyzes creatine to prouce sarcosine an urea. The enzyme sarcosine oxi
ase converts
sarcosine to ycine proucin formaehye an hyroen peroxie. Peroxiase th
en catayzes the
oxiation of a ye (4-aminophenazone an pheno) by the peroxie formin a re-c
oore prouct.
This metho is more speci c than the Ja e reaction, which tens to overestimate crea
tinine by
about 5% in persons with norma rena function. 2828_Ch05_171-326 06/08/12 5:1
4 PM Pae 239 9.
Seect the primary reaent use in the Ja e metho for creatinine. A. Akaine cop
per II sufate
B. Saturate picric aci an NaOH C. Soium nitroprussie an pheno D. Phosphot
unstic aci
Chemistry/Appy principes of enera aboratory proceures/Biochemica/1 10. In
terference from
other reucin substances can be partiay eiminate in the Ja e reaction by: A.
Measurin the
prouct at 340 nm B. Measurin the prouct with an eectroe C. Measurin the ti
me rate of
prouct formation D. Performin a sampe bank Chemistry/Ientify sources of err
or/Biochemica/2
11. Which of the foowin statements is true? A. Cystatin C is measure immunoc
hemicay B. Te
caibrator use for cystatin C is traceabe to the Nationa Bureau of Stanars
caibrator C.
Cystatin C assays have a ower coe cient of variation than pasma creatinine D. En
zymatic an
rate Ja e reactions for creatinine ive comparabe resuts Chemistry/Ientify sour
ces of
error/Biochemica/3 12. In which case wou eGFR erive from the pasma creatin
ine ikey ive a
more accurate measure of GFR than measurement of pasma cystatin C? A. Diabetic
patient B.
Chronic rena faiure C. Postrena transpant D. Chronic hepatitis Chemistry/Ien
tify sources of
error/Biochemica/ 3 240 Chapter 5 | Cinica Chemistry Answers to Questions 912
9. B The Ja e
metho uses saturate picric aci, which oxiizes creatinine in akai, formin
creatinine
picrate. The reaction is nonspeci c; ketones, ascorbate, proteins, an other reuc
in aents
contribute to the na coor. Akaine CuSO 4 is use in the biuret metho for pro
tein. 10. C The
Ja e reaction is nonspeci c; proteins an other reucin substances such as pyruvate
, protein,
an ascorbate cause positive interference. Much of this interference is reuce
by usin a time
rate reaction. Ketoacis react with akaine picrate amost immeiatey, an pro
teins react

sowy. Therefore, reain the absorbance at 20 an 80 secons an usin the abs
orbance i erence
minimizes the e ects of those compouns. Creatinine can be measure usin an amper
ometric
eectroe. However, this requires the enzymes creatininase, creatinase, an sarc
osine oxiase.
The ast enzyme prouces hyroen peroxie from sarcosine, which is oxiize. Th
is prouces
current in proportion to creatinine concentration. Performin a sampe bank oe
s not correct for
interferin substances that react with akaine picrate. 11. A Cystatin C can be
measure by
enzyme immunoassay, immunonepheometry, an immunoturbiimetry. However, there i
s no stanarize
caibrator as for creatinine, an therefore, resuts vary consieraby from ab
to ab. The
coe cient of variation for these methos tens to be sihty hiher than for crea
tinine. Since
the enzymatic methos are speci c, they ive ower pasma creatinine resuts than
the Ja e metho
in persons with norma rena function. However, they ten to ive hiher cearan
ce resuts than
for inuin or iohexo cearance because some creatinine is secrete by the rena
tubues. 12. C
Cystatin C is eiminate amost excusivey by the kineys an pasma eves are
not epenent on
ae, sex, or nutritiona status. However, pasma eves are a ecte by some rus,
incuin
those use to prevent rena transpant rejection. Increase pasma eves have b
een reporte in
chronic in ammatory iseases an cancer. Formuas are avaiabe to cacuate eGFR
from pasma
cystatin C, but unike for creatinine, the formuas must be matche to the metho
 of assay. The
eGFR erive from cystatin C can etect a fa in GFR sooner an may be more sen
sitive for
iabetic an other popuations at risk for chronic kiney isease. As a screenin
 test for eGFR,
it has about the same preictive vaue as eGFR erive from creatinine. 2828_Ch0
5_171-326
06/08/12 5:14 PM Pae 240 13. A sampe of amniotic ui coecte for feta un
maturity
stuies from a woman with a prenancy compromise by hemoytic isease of the ne
wborn (HDN) has a
creatinine of 88 m/L. What is the most ikey cause of this resut? A. Te spec
imen is
contaminate with boo B. Biirubin has interfere with the measurement of crea
tinine C. A
ranom error occurre when the absorbance sina was bein processe by the ana
yzer D. Te ui
is urine from accienta puncture of the urinary baer Chemistry/Ientify sour
ces of
error/Biochemica/3 14. Which anayte shou be reporte as a ratio usin creati
nine
concentration as a reference? A. Urinary microabumin B. Urinary estrio C. Urin
ary soium D.
Urinary urea Chemistry/Appy principes of enera aboratory proceures/Creatin
ine/1 15. Urea is
prouce from: A. Te cataboism of proteins an amino acis B. Oxiation of puri
nes C. Oxiation

of pyrimiines D. Te breakown of compex carbohyrates Chemistry/Appy knowe

e of funamenta
biooica characteristics/Biochemica/1 16. Urea concentration is cacuate fr
om the BUN by
mutipyin by a factor of: A. 0.5 B. 2.14 C. 6.45 D. 14 Chemistry/Cacuate/Bio
chemica/2 17.
Which of the statements beow about serum urea is true? A. Leves are inepenen
t of iet B. Urea
is not reabsorbe by the rena tubues C. Hih BUN eves can resut from necrot
ic iver isease
D. BUN is eevate in prerena as we as rena faiure Chemistry/Correate abo
ratory ata with
physiooica processes/Biochemica/2 5.5 | Creatinine, Uric Aci, BUN, an Ammo
nia 241 Answers
to Questions 1317 13. D Creatinine eves in this rane are foun ony in urine s
pecimens.
Auts usuay excrete between 1.2 an 1.5  of creatinine per ay. For this rea
son, creatinine
is routiney measure in 24-hour urine sampes to etermine the competeness of
coection. A
24-hour urine with ess than 0.8 /ay inicates that some of the urine was prob
aby iscare.
Creatinine is aso use to evauate feta maturity. As estation proresses, mor
e creatinine is
excrete into the amniotic ui by the fetus. Athouh a eve above 2 m/L is no
t a speci c
inicator of maturity, a eve beow 2 m/L inicates immaturity. 14. A Measure
ment of urinary
microabumin concentration shou be reporte as a ratio of abumin to creatinin
e (e.., m
abumin per  creatinine). This eiminates the nee for 24-hour coection in or
er to avoi
variation cause by i erences in ui intake. A ry reaent strip test for creatini
ne is
avaiabe that measures the abiity of a creatininecopper compex to break own H
2 O 2 ,
formin a coore compex. The strip uses bu ere copper II sufate, tetramethybe
nziine, an
anhyrous peroxie. Binin of creatinine in urine to copper forms a peroxiaseike compex that
resuts in oxiation of the benziine compoun. Aso, 24-hour urinary metanephri
nes,
vaniymaneic aci, an homovaniic aci are reporte per ram creatinine wh
en measure in
infants an chiren in orer to compensate for i erences in boy size. 15. A Ure
a is enerate
by eamination of amino acis. Most is erive from the hepatic cataboism of pr
oteins. Uric aci
is prouce by the cataboism of purines. Oxiation of pyrimiines prouces orot
ic aci. 16. B
BUN is mutipie by 2.14 to ive the urea concentration in m/L. BUN (m/L) =
urea (% N in
urea 100) Urea = BUN 1/(% N in urea 100) Urea = BUN (1/0.467) = 2.14 17. D Urea i
s
competey tere by the omerui but reabsorbe by the rena tubues at a rate
epenent upon
trate ow an tubuar status. Urea eves are a sensitive inicator of rena isea
se, becomin
eevate by omeruar injury, tubuar amae, or poor boo ow to the kineys (p
rerena

faiure). Serum urea (an BUN) eves are in uence by iet an are ow in necroti
c iver
isease. 2828_Ch05_171-326 06/08/12 5:14 PM Pae 241 18. A patients BUN is 60
m/L an serum
creatinine is 3.0 m/L. Tese resuts suest: A. Laboratory error measurin BUN
B. Rena faiure
C. Prerena faiure D. Patient was not fastin Chemistry/Evauate aboratory at
a to etermine
possibe inconsistent resuts/Biochemica/3 19. Urinary urea measurements may be
use for
cacuation of: A. Gomeruar tration B. Rena boo ow C. Nitroen baance D. A
 of these
options Chemistry/Correate aboratory ata with physiooica processes/Biochem
ica/2 20. BUN is
etermine eectrochemicay by coupin the urease reaction to measurement of:
A. Potentia with
a urea-seective eectroe B. Te time rate of increase in conuctivity C. Te ox
iation of
ammonia D. Carbon ioxie Chemistry/Appy principes of specia proceures/ Bioc
hemica/1 21. In
the utravioet enzymatic metho for BUN, the urease reaction is coupe to a se
con enzymatic
reaction usin: A. AST B. Gutamate ehyroenase C. Gutamine synthetase D. Aa
nine
aminotransferase (ALT) Chemistry/Appy principes of basic aboratory proceures
/Biochemica/1
22. Which prouct is measure in the coupin step of the urease-UV metho for B
UN? A. CO 2 B.
Dinitrophenyhyrazine C. Diphenycarbazone D. NAD + Chemistry/Appy principes
of basic
aboratory proceures/Biochemica/1 242 Chapter 5 | Cinica Chemistry Answers t
o Questions 1822
18. C BUN is a ecte by rena boo ow as we as by omeruar an tubuar functio
n. When boo
ow to the kineys is iminishe by circuatory insu ciency (prerena faiure), om
eruar
tration ecreases an tubuar reabsorption increases ue to sower trate ow. Beca
use urea is
reabsorbe, BUN eves rise hiher than creatinine. This causes the BUN:creatini
ne ratio to be
reater than 10:1 in prerena faiure. 19. C Because BUN is hane by the tubu
es, serum eves
are not speci c for omeruar tration rate. Urea cearance is in uence by iet an
iver
function as we as rena function. Protein intake minus excretion etermines ni
troen baance. A
neative baance (excretion excees intake) occurs in stress, starvation, fever,
cachexia, an
chronic iness. Nitroen baance = (Protein intake in rams per ay 6.25) (Urin
e urea
nitroen in rams per ay + 4), where 4 estimates the protein nitroen ost in t
he feces per ay
an iviin by 6.25 converts protein to protein nitroen. 20. B A conuctivity
eectroe is use
to measure the increase in conuctance of the soution as urea is hyroyze by
urease in the
presence of soium carbonate. Urea + H 2 O 2NH 3 + CO 2 2NH 3 + 2H 2 O + Na 2 CO
3 2NH 4 + +
CO 3 2 + 2NaOH Ammonium ions increase the conuctance of the soution. The time
rate of current

increase is proportiona to the BUN concentration. Aternativey, the ammonium i

ons prouce can
be measure usin an ion-seective eectroe. 21. B BUN is most frequenty measu
re by the
urease-UV metho in which the urease reaction is coupe to the utamate ehyr
oenase reaction,
eneratin NAD + . Urea + H 2 O Urease 2NH 3 + CO 2 2-Oxoutarate + NH 3 + NADH
+ H + GLD
Gutamate + NAD + + H 2 O When the urease reaction is performe uner rst-orer c
onitions, the
ecrease in absorbance at 340 nm is proportiona to the urea concentration. 22.
D In the
urease-UV metho, urease is use to hyroyze urea, formin CO 2 an ammonia. G
utamate
ehyroenase catayzes the oxiation of NADH, formin utamate from 2-oxouta
rate an ammonia.
The utamate ehyroenase reaction is use for measurin both BUN an ammonia.
2828_Ch05_171-326 06/08/12 5:14 PM Pae 242 23. Which enzyme e ciency is respo
nsibe for
phenyketonuria (PKU)? A. Phenyaanine hyroxyase B. Tyrosine transaminase C.
p-Hyroxyphenypyruvic aci oxiase D. Homoentisic aci oxiase Chemistry/Appy
knowee of
funamenta biooica characteristics/Aminoaciuria/1 24. Which of the foowin
 conitions is
cassi e as a rena-type aminoaciuria? A. Fanconi synrome B. Wisons isease C.
Hepatitis D.
Homocystinuria Chemistry/Correate cinica an aboratory ata/ Aminoaciuria/2
25. Which
aminoaciuria resuts in the over ow of branche chain amino acis? A. Hartnups is
ease B.
Akaptonuria C. Homocystinuria D. Mape syrup urine isease Chemistry/Appy know
ee of
funamenta biooica characteristics/Aminoaciuria/1 26. In aition to pheny
ketonuria, mape
syrup urine isease, an homocystinuria, what other aminoaciuria can be etecte
 by tanem MS?
A. Akaptonuria B. Hartnup isease C. Citruinemia D. Cystinuria Chemistry/App
y principes of
specia proceures/ Aminoaciuria/2 27. Of the methos use to measure amino aci
s, which is
capabe of measurin fatty acis simutaneousy? A. Tanem-mass spectroscopy B.
Hih-performance
iqui chromatoraphy C. Capiary eectrophoresis D. Two-imensiona thin-ayer
chromatoraphy
Chemistry/Appy principes of specia proceures/Amino acis/1 5.5 | Creatinine,
Uric Aci, BUN,
an Ammonia 243 Answers to Questions 2327 23. A PKU is an over ow aminoaciuria r
esutin from
the accumuation of phenyaanine. It is cause by a e ciency of phenyaanine hy
roxyase,
which converts phenyaanine to tyrosine. Excess phenyaanine accumuates in b
oo. This is
transaminate, formin phenypyruvic aci, which is excrete in the urine. 24. A
Fanconi
synrome is an inherite isorer characterize by anemia, menta retaration, r
ickets, an
aminoaciuria. Because the aminoaciuria resuts from a efect in the rena tubu
e, it is
cassifie as a (seconary-inherite) rena-type aminoaciuria. Wisons isease
(inherite

ceruopasmin eficiency) causes hepatic faiure. It is cassifie as a seconar

y-inherite
overfow-type aminoaciuria because the aminoaciuria resuts from urea cyce fa
iure. Hepatitis
is cassifie as a seconary-acquire overfow-type aminoaciuria. Homocystinuri
a is a
primary-inherite overfow-type aminoaciuria, an is cause by a eficiency of
cystathionine
synthase. 25. D Vaine, eucine, an isoeucine accumuate ue to branche-chain
ecarboxyase
e ciency in mape syrup urine isease. These are transaminate to ketoacis that
are excrete,
ivin urine a mape suar oor. Akaptonuria is cause by homoentisic aci oxi
ase e ciency,
causin homoentisic aciuria. Homocystinuria is a no-thresho-type aminoaciur
ia that usuay
resuts from cystathionine synthase e ciency. 26. C Most states use eectrospray
ionization
tanem-mass spectroscopy (MS/MS), which can etect over 20 inborn errors of meta
boism from a
sine boo spot. Typicay, this incues phenyketonuria, tyrosinemia, mape
syrup urine
isease, homocystinuria, citruinemia, an arininosuccinate aciemia. The att
er two are errors
of the urea cyce. 27. A A four methos are abe to separate each amino aci (
up to 40
species); however, tanem-mass spectroscopy with eectrospray ionization can mea
sure amino acis,
oranic acis such as methymaonic aci, an fatty acis. The acis are eute
from the rie
boo spot with methano after aition of interna stanars an then erivatiz
e with
butanohyrochoric aci. Soft ionization of the buty esters of the amino acis
an buty
acycarnitines of oranic an fatty acis yies parent ions, an these are fra
mente by
coision with aron in the secon mass ter to prouce auhter ions. A process
cae mutipe
reaction monitorin ienti es both parent ions an neutra framents that ientify
the acis.
Carnitines are quarternary ammonium compouns that carry the acis across the mi
tochonria
membrane. 2828_Ch05_171-326 06/08/12 5:14 PM Pae 243 28. Boo ammonia eve
s are usuay
measure in orer to evauate: A. Rena faiure B. Acibase status C. Hepatic com
a D.
Gastrointestina maabsorption Chemistry/Correate cinica an aboratory ata/
Biochemica/2
29. Enzymatic measurement of ammonia requires which of the foowin substrates
an coenzymes? A.
B. C. D. Chemistry/Appy principes of basic aboratory proceures/Biochemica/1
30. Which
statement about ammonia is true? A. Normay, most of the pasma ammonia is eri
ve from
periphera boo eamination of amino acis B. Ammonia-inuce coma can resut f
rom saicyate
poisonin C. Hepatic coma can resut from Reyes synrome D. Hih pasma ammonia i
s usuay
cause by respiratory akaosis Chemistry/Correate cinica an aboratory ata
/Biochemica/2

31. SITUATION: A sampe for ammonia assay is taken from an IV ine that ha been
cappe an
injecte with ithium heparin (cae a heparin ock). The sampe is rawn in a
syrine
containin ithium heparin, an immeiatey cappe an ice. The pasma is separ
ate an anayze
within 20 minutes of coection, an the resut is 50 /L hiher than one measur
e 4 hours
before. What is the most ikey expanation of these resuts? A. Sini canty rea
ter
physiooica variation is seen with patients havin systemic, hepatic, an ast
rointestina
iseases B. Te syrine was contaminate with ammonia C. One of the two sampes w
as coecte from
the wron patient D. Stasis of boo in the ine cause increase ammonia Chemis
try/Evauate
sources of error/Specimen coection an hanin/3 244 Chapter 5 | Cinica Che
mistry Answers to
Questions 2831 28. C Hepatic coma is cause by accumuation of ammonia in the bra
in as a resut
of iver faiure. The ammonia increases centra nervous system pH an is coupe
to utamate, a
centra nervous system neurotransmitter, formin utamine. Boo an cerebrospi
na ui ammonia
eves are use to istinuish encephaopathy cause by cirrhosis or other iver
isease from
nonhepatic causes an to monitor patients with hepatic coma. 29. A Enzymatic ass
ays of ammonia
utiize utamate ehyroenase (GLD). This enzyme forms utamate from ketolut
r

te
(2oxolut
r
te)
nd
mmoni
, resultin in oxid
tion of NADH. The r
te of
sor
n
ce decre
se
t
340 nm is proportion
l to
mmoni
concentr
tion when the re
ction r
te is m
int

ined under
first-order conditions. 30. C Ammoni
produced in the intestines from the re
kd
own of proteins
y
cteri
l enzymes is the prim
ry source of pl
sm

mmoni
. Most of the
mmoni


sor ed from
the intestines is tr
nsported to the liver vi
the port
l vein
nd converted to
ure
. Blood

mmoni
levels will rise in
ny necrotic liver dise
se includin hep
titis, Reyes
syndrome,
nd
dru-induced injury such
s
cet
minophen poisonin. In hep
tic cirrhosis, shunt
in of port
l
lood to the ener
l circul
tion c
uses lood
mmoni
levels to rise. Ammoni
cr
osses the lood
r
in
rrier, which
ccounts for the frequency of centr
l nervous system compli
c
tions
nd, if
severe, hep
tic com
. 31. D F
lsely elev
ted lood
mmoni
levels
re commonly c

used y improper
specimen collection. Venous st
sis
nd proloned stor
e c
use peripher
l de
min

tion of
mino

cids, c
usin
f
lsely hih
mmoni
level. Pl
sm
is the s
mple of choice sinc
e
mmoni
levels
incre
se with stor
e. Lithium hep
rin
nd EDTA
re
ccept
le
ntico
ul
nts; t
he
ntico
ul
nt
used should e tested to m
ke sure it is free of
mmoni
. A v
cuum tu e c
n e u
sed if lled
completely. Serum m
y e used provided the tu e is iced immedi
tely,
nd the ser
um is sep
r
ted


s soon
s the s
mple clots. The p
tient should e f
stin
nd must not h
ve smo
ked for 8 hours
ec
use to
cco smoke c
n dou le the pl
sm

mmoni
level. Su str
te Coenzyme Ke
tolut
r
te
NADH Glut
m
te NADH Glut
mine ATP Glut
mine NAD + 2828_Ch05_171-326 06/08/12 5
:14 PM P
e 244
32. Uric
cid is derived from the: A. Oxid
tion of proteins B. C
t
olism of pur
ines C. Oxid
tion
of pyrimidines D. Reduction of c
techol
mines Chemistry/Apply knowlede of fund

ment
l ioloic
l
ch
r
cteristics/Biochemic
l/1 33. Which of the followin conditions is
ssoci
te
d with
hyperuricemi
? A. Ren
l f
ilure B. Chronic liver dise
se C. X
nthine oxid
se de ci
ency D. P
ets
dise
se of the one Chemistry/Correl
te clinic
l
nd l
or
tory d
t
/ Biochemic

l/2 34. Orders
for uric
cid
re leitim
te st
t requests ec
use: A. Levels
ove 10 m/dL c
u
se urin
ry tr
ct
c
lculi B. Uric
cid is hep
totoxic C. Hih levels induce
pl
stic
nemi
D. Hi
h levels c
use
joint p
in Chemistry/Correl
te clinic
l
nd l
or
tory d
t
/Biochemic
l/2 35. Wh
ich uric
cid
method is
ssoci
ted with ne
tive i
s c
used y reducin
ents? A. Uric
se co
upled to the
Trinder re
ction B. Ultr
violet uric
se re
ction coupled to c
t
l
se
nd
lcohol
dehydroen
se
re
ctions C. Me
surement of the r
te of
sor
nce decre
se
t 290 nm
fter
ddi
tion of uric
se
D. Phosphotunstic
cid usin
protein-free ltr
te Chemistry/Ev
lu
te sources of
error/Biochemic
l/2 5.5 | Cre
tinine, Uric Acid, BUN,
nd Ammoni
245 Answers
to Questions
3235 32. B Uric
cid is the princip
l product of purine (
denosine
nd u
nosine)
met
olism.
Oxid
tion of proteins yields ure

lon with CO 2 , H 2 O,
nd inor
nic
cids.
C
techol
mines

re oxidized, formin v
nillylm
ndelic
cid (VMA)
nd homov
nillic
cid (HVA). 3
3. A Excessive
retention of uric
cid results from ren
l f
ilure
nd diuretics (or other drus)
th
t lock uric

cid excretion. Hyperuricemi
m
y result from overproduction of uric
cid in pri
m
ry essenti
l
out or excessive cell turnover
ssoci
ted with m
lin
ncy
nd chemother
py. Ove
rproduction m
y

lso result from
n enzyme deficiency in the p
thw
y formin u
nosine triphosph

te (GTP) or

denosine monophosph
te (AMP) (purine s
lv
e). Hyperuricemi
is
lso
ssoci
ted
with
keto
cidosis
nd l
ct
te
cidosis, hypertension,
nd hyperlipidemi
. X
nthine ox
id
se converts
x
nthine to uric
cid; therefore,
deficiency of this enzyme results in low ser
um levels of uric

cid. P
ets dise
se of one c
uses cyclic episodes of one deener
tion
nd ree
ner
tion
nd is

ssoci
ted with very hih serum ALP
nd urin
ry c
lcium levels. 34. A Uric
cid
c
lculi form
quickly when the serum uric
cid level re
ches 10 m/dL. They
re tr
nslucent co
mp
ct stones th
t
often lode in the ureters, c
usin postren
l f
ilure. 35. A The peroxid
se-coup
led uric
se
re
ction is the most common method for me
surin uric
cid in serum or pl
sm
. U

ric
se methods
form
ll
ntoin, c
r on dioxide,
nd hydroen peroxide from the oxid
tion of uric

cid. When
peroxide is used to oxidize
Trinder dye (e..,
phenol deriv
tive
nd 4-
mino

ntipyrine), some
ne
tive i
s m
y occur when hih levels of
scor
te or other reducin
ents

re present. R
te
UV methods
re free from this interference. Reduction of phosphotunstic
cid y
uric
cid forms
tunsten lue. This colorimetric re
ction is nonspeci c, resultin in f
lsely elev

ted uric
cid
c
used y proteins
nd m
ny other reducin su st
nces. 2828_Ch05_171-326 06/08/
12 5:14 PM P
e
245 246 5.6 Proteins, Electrophoresis,
nd Lipids 1. Kjeld
hls procedure for tot

l protein is

sed upon the premise th
t: A. Proteins
re ne
tively ch
red B. Te pK
of pr
oteins is the
s
me C. Te nitroen content of proteins is const
nt D. Proteins h
ve simil
r tyr
osine
nd
tryptoph
n content Chemistry/Apply principles of speci
l procedures/ Proteins
n
d enzymes/1 2.
Upon which principle is the iuret method
sed? A. Te re
ction of phenolic rou
ps with CuIISO 4
B. Coordin
te onds etween Cu +2
nd c
r onyl
nd imine roups of peptide onds
. C. Te protein
error of indic
tor e ect producin color when dyes ind protein D. Te re
ction of
phosphomoly dic

cid with protein Chemistry/Apply principles of
sic l
or
tory procedures/Prot
eins
nd
enzymes/1 3. Which st
tement
out the iuret re
ction for tot
l protein is true
? A. It is
sensitive to protein levels elow 0.1 m/dL B. It is suit
le for urine, exud
te
s,
nd
tr
nsud
tes C. Polypeptides
nd compounds with repe
tin imine roups re
ct D. H
emolysis will not
interfere Chemistry/Apply knowlede to identify sources of error/Proteins
nd en
zymes/2 4. Which
of the followin protein methods h
s the hihest
n
lytic
l sensitivity? A. Refr

ctometry B.
FolinLowry C. Tur idimetry D. Direct ultr
violet
sorption Chemistry/Apply knowl
ede of speci
l
procedures/ Proteins
nd enzymes/2 Answers to Questions 14 1. C Kjeld
hls method m
e
sures the
nitroen content of proteins
s
mmonium ion y
ck titr
tion followin oxid
ti
on of proteins y
sulfuric
cid
nd he
t. It
ssumes th
t proteins
ver
e 16% nitroen y weiht.
Protein in r
ms
per deciliter is c
lcul
ted y multiplyin protein nitroen y 6.25. The Kjeld
h
l method is

reference method for tot
l protein th
t is used to
ssin
protein
ss
y v
lue
to c
li r
tors.
2. B Biuret is
compound with two c
r onyl roups
nd three
mino roups
nd fo
rms coordin
te
onds with Cu +2 in the s
me m
nner
s does protein. Therefore, proteins
nd pep
tides
re oth
me
sured in the iuret re
ction. The iuret re
ent consists of
n
lk
line solu
tion of copper II
sulf
te. T
rtr
te s
lts
re
dded to keep the copper in solution
nd prevent tur
idity. Pot
ssium
iodide prevents
utoreduction of Cu +2 . 3. C The iuret re
ction is not sensiti

ve to protein
levels elow 0.1 /dL
nd, therefore, is not sensitive enouh for
ss
ys of tot

l protein in CSF,
urine, or tr
nsud
tes. Sliht hemolysis does not c
use f
lsely hih results, if
the
sor
nce of
the Cu +2 -protein complexes is me
sured ichrom
tic
lly. However, fr
nkly hemol
yzed s
mples
cont
in su cient lo in to c
use positive interference. The re
ent re
cts with pe
ptides
cont
inin
t le
st two peptide onds, ut due to the hih concentr
tion of prot
eins in pl
sm

rel
tive to peptides present this re
ctivity c
uses insini c
nt i
s. 4. B The Fo
linLowry
(Lowrys) method uses oth iuret re
ent
nd phosphotunstic
nd moly dic
cids t
o oxidize the

rom
tic side roups on proteins. The
cids oxidize the phenolic rins of tyrosi
ne
nd
tryptoph
n. These, in turn, reduce the Cu +2 in the iuret re
ent, incre
sin s
ensitivity
out
100-fold. 2828_Ch05_171-326 06/08/12 5:14 PM P
e 246 5. Which of the followi
n st
tements
re
rdin proteins is true? A. Tot
l protein
nd
l umin
re
out 10% hiher in

m ul
tory
p
tients B. Pl
sm
tot
l protein is
out 20% hiher th
n serum levels C. Al umi
n norm
lly

ccounts for
out one-third of the cere rospin
l uid tot
l protein D. Tr
nsud
ti
ve serous uid
protein is
out two-thirds of the serum tot
l protein Chemistry/Ev
lu
te l
or

tory d
t
to
reconize he
lth
nd dise
se st
tes/Proteins
nd enzymes/2 6. Hyper
l uminemi
i
s c
used y: A.
Dehydr
tion syndromes B. Liver dise
se C. Burns D. G
stroenterop
thy Chemistry/C
orrel
te clinic
l

nd l
or
tory d
t
/ Proteins
nd enzymes/2 7. Hih serum tot
l protein ut low

l umin is
usu
lly seen in: A. Multiple myelom
B. Hep
tic cirrhosis C. Glomerulonephritis
D. Nephrotic
syndrome Chemistry/Correl
te clinic
l
nd l
or
tory d
t
/ Proteins
nd enzymes/
2 8. Which of the
followin conditions is most commonly
ssoci
ted with
n elev
ted level of tot
l
protein? A.
Glomerul
r dise
se B. St
rv
tion C. Liver f
ilure D. M
lin
ncy Chemistry/Correl

te clinic
l
nd
l
or
tory d
t
/ Proteins
nd enzymes/2 9. Which of the followin dyes is the mo
st speci c for
me
surement of
l umin? A. Bromcresol reen (BCG) B. Bromcresol purple (BCP) C.
Tetr
romosulfophth
lein D. Tetr
romphenol lue Chemistry/Apply principles of

sic l
or
tory
procedures/Proteins
nd enzymes/1 5.6 | Proteins, Electrophoresis,
nd Lipids
247 Answers to
Questions 59 5. A W
ter pools in the v
scul
r ed in non
m ul
tory p
tients, lowe
rin the tot
l
protein,
l umin, hem
tocrit,
nd c
lcium. Pl
sm
levels of tot
l protein
re 0.
20.4 /dL hiher
th
n serum (
out 5%) owin to
rinoen. Cere rospin
l uid
l umin levels
re norm

lly 1030
m/dL, which is
pproxim
tely two-thirds of the CSF tot
l protein. Tr
nsud
tes h

ve
tot
l
protein elow 3.0 /dL
nd less th
n 50% of the serum tot
l protein. 6. A A hih
serum
l umin

level is c
used only y dehydr
tion or
dministr
tion of
l umin. Liver dise
se,

urns,

stroenterop
thy, nephrosis, st
rv
tion,
nd m
lin
ncy c
use hypo
l uminemi
.
7. A In multiple
myelom
, synthesis of l
re qu
ntities of monoclon
l immunolo ulin y pl
sm
ce
lls often results
in decre
sed synthesis of
l umin. In lomerulonephritis
nd nephrotic syndrome,
oth tot
l
protein
nd
l umin
re low owin to loss of proteins throuh the lomeruli. In
hep
tic
cirrhosis, decre
sed hep
tic production of protein results in low tot
l protein

nd
l umin. 8. D
M
lin
nt dise
se is usu
lly
ssoci
ted with incre
sed immunolo ulin
nd
cuteph
se protein
production. However, nutrients required for protein synthesis
re consumed, c
us
in reduced
hep
tic
l umin production. Glomerul
r d
m
e c
uses
l umin
nd other low molec
ul
r weiht
proteins to e lost throuh the kidneys. Liver f
ilure
nd st
rv
tion result in
decre
sed protein
synthesis. 9. B Tetr
romphenol lue
nd tetr
romosulfophth
lein
re dyes th
t
ch
ne pK
in
the presence of protein. Althouh they h
ve re
ter
nity for
l umin th
n lo ul
ins, they
re
not su ciently speci c to
pply to me
surement of serum
l umin. BCG
nd BCP
re
ni
onic dyes
th
t undero
spectr
l shift when they ind
l umin
t
cid pH. BCP is more spe
ci c for
l umin
th
n BCG. Re
ction of oth dyes with lo ulins requires
loner incu
tion time
th
n with

l umin,
nd re
ction times
re kept
t 30 seconds or less to incre
se speci city.
Both dyes
re
free of interference from iliru in. However, BCG is the method used most often.
One re
son for
this is th
t ren
l di
lysis p
tients produce
n or
nic
cid th
t competes with
BCP for the
indin site on
l umin, c
usin
f
lsely low result. 2828_Ch05_171-326 06/08/
12 5:14 PM P
e
247 10. Which of the followin f
ctors is most likely to c
use
f
lsely low res
ult when usin
the BCG dye- indin
ss
y for
l umin? A. Te presence of penicillin B. An incu

tion time of 120
seconds C. Te presence of iliru in D. Lipemi
Chemistry/Apply knowlede to reco
nize sources of
error/Proteins
nd enzymes/2 11. At pH 8.6, proteins
re _________ ch
red
nd m
ir
te tow
rd the
_________. A. Ne
tively,
node B. Positively, c
thode C. Positively,
node D. N
e
tively,
c
thode Chemistry/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics/Elec
trophoresis/1 12.
Electrophoretic movement of proteins tow
rd the
node will decre
se y incre
sin
 the: A. Bu er
pH B. Ionic strenth of the u er C. Current D. Volt
e Chemistry/Apply principles
of
sic
l
or
tory procedures/Electrophoresis/2 13. At pH 8.6, the c
thod
l movement of
lo ulins is
c
used y: A. Electroendosmosis B. Wick ow C. A net positive ch
re D. C
thod
l s

mple

pplic
tion Chemistry/Apply principles of
sic l
or
tory procedures/Electropho
resis/2 14. Which

of the followin conditions will prevent
ny mir
tion of proteins
cross
n ele
ctrophoretic
support medium such
s

rose? A. Usin too hih
volt
e B. Excessive current
durin the
procedure C. Loss of cont
ct etween
u er ch
m er
nd the medium D. Ev
por
tion
of solvent
from the surf
ce of the medium Chemistry/Apply principles of
sic l
or
tory
procedures/Electrophoresis/3 15. Which of the followin proteins h
s the hihest
pI? A. Al umin
B. Tr
nsferrin C. Cerulopl
smin D. IG Chemistry/Apply knowlede of fund
ment
l
ioloic
l
ch
r
cteristics/Electrophoresis/1 248 Ch
pter 5 | Clinic
l Chemistry Answers to
Questions 1015
10. A BCG
nd BCP
re not sini c
ntly
ected y iliru in or hemolysis,
lthouh n
e
tive
interference c
used y free H h
s een reported with some BCG methods. Lipemic
s
mples m
y
c
use positive interference, which c
n e elimin
ted y serum l
nkin. Incu
ti
on times
s lon

s 2 minutes result in positive interference from lo ulins, which re
ct with th
e dye. Penicillin

nd some other
nionic drus ind to
l umin
t the s
me site
s the dye, c
usin
 f
lsely low
results. 11. A Proteins
re
mphoteric owin to ioniz
tion of
cidic
nd
sic s
ide ch
ins of

mino
cids. When the pH of the solution equ
ls the isoelectric point ( pI ), th
e protein will
h
ve no net ch
re
nd is insolu le. When the pH of the solution is
ove the pI
, the protein
will h
ve
net ne
tive ch
re. Anions mir
te tow
rd the
node (positive elect
rode). 12. B
Electrophoresis is the mir
tion of ch
red molecules in
n electric eld. Incre
s
in the
strenth of the eld y incre
sin volt
e (or current) incre
ses mir
tion. Howev
er, incre
sin
ionic strenth decre
ses the mir
tion of proteins. Counterions (c
tions) in the
u er move with
the proteins, reducin their electrom
netic
ttr
ction for the
node. 13. A A

rose
nd
cellulose
cet
te cont
in xed
nions (e..,
cet
te) th
t
ttr
ct counterions whe
n hydr
ted with
u er. When volt
e is
pplied the c
tions mir
te to the c
thode, cre
tin
n osm
otic force th
t
dr
ws H 2 O with them. This force, c
lled electroendosmosis, opposes protein mi
r
tion tow
rd the

node
nd m
y c
use some lo ulins to e displ
ced tow
rd the c
thode. 14. C Movem
ent of
proteins is dependent upon the presence of
s
lt ride th
t
llows current to o
w vi
tr
nsport
of ions to the electrodes
cross the support medium. If the s
lt ride is not i
nt
ct, there will
e no mir
tion, even if volt
e is m
int
ined
cross the electrodes. For

ros
e
nd cellulose

cet
te, he
t c
uses ev
por
tion of solvent from the u er. This incre
ses the ion
ic strenth,
c
usin current to rise durin the run. Excessive he
t c
n d
m
e the support me
dium
nd den
ture
proteins. Power = E (volt
e) I (current) t (time); since E = I R (resist
nce),
he
t is
proportion
l to the squ
re of current (P = I 2 R t). Const
nt current or power m

ode is used
for lon runs to prevent he
t d
m
e. 15. D Al umin is the f
stest mir
tin pro
tein tow
rd the

node
t pH 8.6 followed y 1 -, 2 -, -,
nd -lo ulins. Bec
use
l umin is f
stes
t, it h
s
the re
test net ne
tive ch
re
nd lowest pI (
out 4.6). -Glo ulins
re predom
in
ntly
immunolo ulins
nd h
ve the hihest pI (
out 7.2). 2828_Ch05_171-326 06/08/12
5:14 PM P
e
248 16. Which of the followin proteins mir
tes in the reion
t pH 8.6? A. H
p
tolo in B.
Orosomucoprotein C. Antichymotrypsin D. Tr
nsferrin Chemistry/Apply knowlede of
fund
ment
l
ioloic
l ch
r
cteristics/Electrophoresis/1 17. Which of the followin is one

dv
nt
e of
hih-resolution (HR)

rose electrophoresis over lower-current electrophoresis?
A.
Hih-resolution procedures detect monoclon
l
nd olioclon
l
nds
t
lower co
ncentr
tion B. A
sm
ller s
mple volume is used C. Results
re o t
ined more r
pidly D. Densitomet
ric sc
nnin of
HR els is more
ccur
te Chemistry/Apply principles of speci
l procedures/ Elect
rophoresis/2 18.
Which of the followin conditions is
ssoci
ted with - ridin? A. Multiple myelom

B.
M
lin
ncy C. Hep
tic cirrhosis D. Rheum
toid
rthritis Chemistry/Correl
te clin
ic
l
nd
l
or
tory d
t
/ Electrophoresis/2 19. Which support medium c
n e used to deter
mine the
molecul
r weiht of
protein? A. Cellulose
cet
te B. Poly
cryl
mide el C. A

r el D. A
rose
el Chemistry/Apply principles of speci
l procedures/ Electrophoresis/2 20. Whic
h of the
followin st
ins is used for lipoprotein electrophoresis? A. Oil Red O B. Coom
s
sie Brilli
nt
Blue C. Amido Bl
ck D. Ponce
u S Chemistry/Select re
ents/Medi
/Blood products/
Electrophoresis/1 5.6 | Proteins, Electrophoresis,
nd Lipids 249 Answers to Q
uestions 1620
16. D Tr
nsferrin, lipoprotein, C3,
nd C4
re the domin
nt proteins in the -lo
ulin reion.
H
ptolo in
nd 2 - m
crolo ulin
re the princip
l proteins in the 2 -fr
ction.
1
-Antitrypsin, 1 -lipoprotein,
nd 1 -
cid lycoprotein (orosomucoprotein) m
ke u
p most of the
1 -fr
ction. Immunolo ulins domin
te the reion. Pl
sm
is not used for protein
electrophoresis ec
use
rinoen will produce

nd resem lin
sm
ll monoclon

l protein in
the et
reion. 17. A HR

rose procedures use hiher current
nd
coolin de
vice to resolve
12 or more
nds. Adv
nt
es include phenotypin of 1 -
ntitrypsin (detection of
Z
nd S
v
ri
nts), detection of 2 microlo ulin in urine indic
tin tu ul
r proteinuri

(often

ssoci
ted with dru-induced nephrosis),
nd re
ter sensitivity detectin monoc
lon
l

mmop
thies, immune complexes,
nd olioclon
l
nds in CSF
ssoci
ted with mul
tiple sclerosis.
Its dis
dv
nt
e is th
t densitometric sc
ns of HR els usu
lly underestim
te
l
umin. 18. C
Hep
tic cirrhosis produces
polyclon
l 
mmop
thy
ssoci
ted with
hih IA le

vel. This
o liter
tes the v
lley etween
nd zones. M
lin
ncy
nd rheum
toid
rthritis pr
oduce
polyclon
l 
mmop
thies cl
ssi ed
s chronic in
mm
tory or del
yed response p
ttern
s. Multiple
myelom
produces
zone of restricted mo ility usu
lly in the , ut sometimes in
the - or 2
-reion. 19. B Poly
cryl
mide els sep
r
te y molecul
r sievin
s well
s ch
r
e. Sodium
dodecyl sulf
te (SDS) is
nonionic deterent th
t inds to proteins, neutr
lizi
n their ch
re.
Poly
cryl
mide el electrophoresis (PAGE)
fter tre
tin with SDS sep
r
tes prot
eins on the
sis
of molecul
r size. The sm
ller proteins ecome tr
pped in the pores of the el

nd mir
te more
slowly. 20. A Oil Red O
nd Sud
n Bl
ck B st
in neutr
l f
ts
nd
re used to st

in lipoproteins

s well
s f
t in urine or stool. The other st
ins
re used for proteins. Coom
s
sie Brilli
nt
Blue is more sensitive th
n Ponce
u S or Amido Bl
ck,
nd
ll three st
ins h
ve
slihtly re
ter

nity for
l umin th
n lo ulins. In
ddition, silver nitr
te m
y e used to st
i
n CSF proteins
ec
use it h
s re
ter sensitivity th
n the other st
ins. 2828_Ch05_171-326 06/
08/12 5:14 PM
P
e 249 21. Which of the followin serum protein electrophoresis results sues
ts
n
cute
in
mm
tory process? A. B. C. D. Chemistry/Correl
te clinic
l
nd l
or
tory d
t
/
Electrophoresis/2 22. Which of the followin conditions is usu
lly
ssoci
ted wi
th
n
cute
in
mm
tory p
ttern? A. Myoc
rdi
l inf
rction (MI) B. M
lin
ncy C. Rheum
toid
rt
hritis D.
Hep
titis Chemistry/Correl
te clinic
l
nd l
or
tory d
t
/ Electrophoresis/2 23
. Te
electrophoretic p
ttern shown in the followin densitometric tr
cin most likely
indic
tes: A.
1 -Antitrypsin de ciency B. Infection C. Nephrosis D. Systemic sclerosis 250 Ch
pt
er 5 | Clinic
l
Chemistry Answers to Questions 2124 21. C Acute infl
mm
tion is ch
r
cterized y
incre
sed
production of
cute ph
se proteins. These include 1 -
ntitrypsin, 1 -
cid lycop
rotein, 1
-
ntichymotrypsin,
nd h
ptolo in. Al umin is slihtly decre
sed. -
nd -fr
ction
s
re norm
l.
22. A MI produces
p
ttern of
cute in
mm
tion usu
lly
ssoci
ted with tissue in
jury. This
p
ttern results from production of
cute ph
se proteins includin 1 -
ntitrypsin
, 1
-
ntichymotrypsin,
nd h
ptolo in. It is
lso seen in e
rly infection, pren
nc
y,
nd e
rly
nephritis. M
lin
ncy, rheum
toid
rthritis,
nd hep
titis
re
ssoci
ted with

chronic
in
mm
tory p
ttern. This di ers from the
cute p
ttern y the
ddition of
polyclo
n
l

mmop
thy. 23. A This p
ttern shows
m
rked decre
se in the 1 -lo ulin (slih
tly less th
n
one- fth of the expected pe
k
re
). St
inin of the 1 -lo ulin fr
ction is predo
min
tely
determined y the 1 -
ntitrypsin level. A v
lue of less th
n 20% of norm
l (0.20.
4 /dL) is

usu
lly c
used y homozyous 1 -
ntitrypsin de ciency. There is
sliht decre
se

in
l umin

nd incre
se in the 2 -fr
ction. P
tients with 1 -
ntitrypsin de ciency often disp
l
y
elev
tions in the 2 -lo ulin
nd -lo ulin fr
ction ec
use the condition is
ss
oci
ted with
chronic emphysem

nd hep
tic cirrhosis. 24. C Pre
l umin (
lso c
lled tr
nsthyr
etin) is
sm
ll
protein with
h
lf-life of only 2 d
ys. Serum levels f
ll r
pidly in p
tients w
ith de cient
protein nutrition. As
result, pre
l umin is used to detect m
lnutrition
nd to
me
sure the
p
tients response to diet
ry supplement
tion. The cutpoint used to identify nutri
tion
l
de ciency in elderly p
tients is usu
lly 11 m/dL. Pre
l umin is usu
lly me
sured
y
immunonephelometry. Al umin 1 2 Decre
sed Incre
sed Decre
sed Norm
l Norm
l
Norm
l
Incre
sed Norm
l Incre
sed Incre
sed Decre
sed Incre
sed Incre
sed Norm
l Norm
l
I ncre
sed
Incre
sed Incre
sed Incre
sed Incre
sed + - Chemistry/Ev
lu
te l
or
tory d
t
t
o reconize
he
lth
nd dise
se st
tes/Proteins
nd enzymes/2 24. Wh
t is the clinic
l utilit
y of testin for
serum pre
l umin? A. Low levels
re
ssoci
ted with incre
sed free cortisol B. H
ih levels
re
n
indic
tor of
cute in
mm
tion C. Seri
l low levels indic
te compromised nutrition

l st
tus D.
Levels correl
te with lomerul
r injury in p
tients with di
etes mellitus Chemi
stry/Apply
knowlede of fund
ment
l ioloic
l ch
r
cteristics/Nutrition m
rkers/1 2828_Ch0
5_171-326
06/08/12 5:14 PM P
e 250 25. Which serum protein should e me
sured in
p
ti
ent suspected of
h
vin Wilsons dise
se? A. Hemopexin B. Alph
-1
ntitrypsin C. H
ptolo in D. Cer
ulopl
smin
Chemistry/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics/Proteins/2 2
6. A p
tient with
hemolytic-uremic syndrome
ssoci
ted with septicemi
h
s
h
ptolo in level th

t is norm
l,

lthouh the pl
sm
free hemolo in is elev
ted
nd hemolo inuri
is present. W
hich test would
e more
ppropri
te th
n h
ptolo in to me
sure this p
tients hemolytic episode?
A. Hemopexin B.
Alph
-1
ntitrypsin C. C-re
ctive protein D. Tr
nsferrin Chemistry/Apply knowled
e to reconize
inconsistent l
or
tory results/Proteins/3 27. Qu
ntit
tive determin
tion of H
A 2
nd H F

re est performed y: A. Hih-perform
nce liquid chrom
tor
phy B. Alk
li den
t
ur
tion C.
Electrophoresis D. Direct ichrom
tic spectrophotometry Chemistry/Apply principl
es of speci
l
procedures/ Hemolo in/1 28. Select the correct order of H mir
tion on

ros
e or cellulose

cet
te
t pH 8.6. A. CFSA + B. SCAF + C. CSFA + D. SFAC + Chemistry/Appl
principles of speci
l procedures/ Electrophoresis/2 29. Which of the followin

norm
l types of
H mir
tes to the s
me position
s H S on

rose or cellulose
cet
te
t pH
8.6? A. H C B.
H D Punj
C. H O Ar
D. H E Chemistry/Apply principles of speci
l proced

ures/
Electrophoresis/2 5.6 | Proteins, Electrophoresis,
nd Lipids 251 Answers to Q
uestions 2529
25. D -1
ntitrypsin, h
ptolo in,
nd cerulopl
smin
re
cute ph
se proteins
nd
will e
incre
sed in infl
mm
tory dise
ses. Cerulopl
smin is
n -2 lo ulin th
t inds th
e m
jority of
the serum copper. Levels
re low in
lmost
ll p
tients with Wilsons dise
se,
n

utosom
l
recessive disorder c
used y
ccumul
tion of copper in liver, r
in, kidney,
nd
other tissues.
Low cerulopl
smin m
y occur in p
tients with nephrosis, m
lnutrition,
nd hep
to
ili
ry dise
se.
Therefore, the di
nosis of Wilsons dise
se is m
de y demonstr
tin decre
sed pl

sm

cerulopl
smin, incre
sed urin
ry copper,
nd the presence of K
yserFleischer rin
s ( rown
deposits
t the ede of the corne
). 26. A Hemopexin is
sm
ll lo ulin th
t i
nds to free
heme. H
ptolo in is
n -2 lo ulin th
t inds to free hemolo in
nd dis
ppe
rs
from the serum
when intr
v
scul
r hemolysis produces more th
n 3 r
ms of free pl
sm
hemolo i
n. However,
h
ptolo in is
n
cute ph
se protein,
nd hep
tic production
nd rele
se
re in
cre
sed in
response to
cute infections. The norm
l serum h
ptolo in is most likely the re
sult of incre
sed
synthesis
nd would not
ccur
tely estim
te the hemolytic episode in this p
tien
t. 27. A H A 2

nd H F
re often qu
ntit
ted to di
nose persons with th
l
ssemi
. The method
of choice is
HPLC usin c
tion exch
ne chrom
tor
phy. Hemolo ins
re eluted from the colum
n in order of
incre
sin positive ch
re usin
sodium phosph
te u er to produce
r
dient of
incre
sin
ionic strenth. Hemolo in F elutes from the column e
rlier th
n H A 2 ec
use
it is less
positively ch
red. 28. C H A 2 is the slowest of the norm
l H s,
nd H A i
s the f
stest.
H F mir
tes just ehind H A. H S mir
tes midw
y etween H A 2
nd H
A. H s C, C
H
rlem (Georetown), O,
nd E mir
te with H A 2 . H s G
nd D Punj

nd H
O Ar
mir
te
with H S. 29. B H D Punj
mir
tes with H S on cellulose
cet
te or

ro
se
t pH 8.69.2.
H C, E, O Ar
,
nd C H
rlem mir
te to the s
me position
s H A 2 on cellu
lose
cet
te or


rose
t pH 8.69.2. H S m
y e di erenti
ted from H D Punj
usin citr
te (

cid)

r
t
pH 6.2. Usin this technique, H S mir
tes further tow
rd the
node th
n H D
Punj
.
2828_Ch05_171-326 06/08/12 5:14 PM P
e 251 30. Which H is
- chain hybri a
n mirates
to the same position as Hb S at pH 8.6? A. Hb C Harem B. Hb Lepore C. Hb G
Phiaephia D.
Hb D Punjab Chemistry/Appy principes of specia proceures/ Eectrophoresis/2
31. Seect the
correct orer of Hb miration on citrate aar at pH 6.2. A. FSCA + B. FASC + C.
ASFC + D. ACSF + Chemistry/Appy principes of specia proceures/ Eectrophoresis/2
2.

Which Hb separates from Hb S on citrate (aci) aar, but not aarose or ceu
ose acetate? A.
Hb D Punjab B. Hb E C. Hb C Harem (Georetown) D. Hb O Arab Chemistry/Evau
ate aboratory
ata to verify test resuts/Eectrophoresis/2 33. Which statement best escribes
immuno xation
eectrophoresis (IEF)? A. Proteins are separate by eectrophoresis foowe by
overay of
monospeci c anti-immunoobuins B. Proteins react with monospeci c antisera foowe
 by
eectrophoresis C. Antisera are eectrophorese, then i use aainst patients seru
m D. Serum is
eectrophorese; the separate immunoobuins i use aainst speci c antisera pace
 into
trouhs Chemistry/Appy knowee of specia proceures/ Immuno xation/2 34. In o
ube
immunoi usion reactions, the precipitin ban is: A. Invisibe before the equivae
nce point is
reache B. Concave to the protein of reatest moecuar weiht C. Cosest to the
we containin
the hihest eve of antien D. Locate in an area of antiboy excess Chemistry/
Appy knowee
of specia proceures/ Immunoi usion/1 252 Chapter 5 | Cinica Chemistry Answers
to Questions
3034 30. B Hb Lepore resuts from transocation of
nd obin enes, resutin i
n a
poypeptie chain that mirates miway between Hb A 2 an Hb A. The chain is t
ranscribe more
sowy than the polypeptide ch
in, c
usin the qu
ntity of H Lepore to e less
th
n 15%. H
Lepore is suspected when H mir
tin in the S zone comprises less th
n 20% of th
e tot
l H .
In H S tr
it, the AS phenotype produces 20%40% H S. 31. B In
n
cid u er, the
hemolo ins

re expected to mir
te to the c
thode, with hemolo in A ein the slowest ec

use it h
s the
we
kest net positive ch
re. However, H C
nd H S ind to sulf
ted pectins i
n the

r el,
formin
complex th
t is ne
tively ch
red c
usin them to mir
te tow
rd the

node. H C
mir
tes furthest tow
rd the
node, followed y H S. H F mir
tes furthest t
ow
rd the
c
thode. H s A, A 2 , D Punj
, E, G,
nd H Lepore mir
te slihtly tow
rd t
he c
thode. 32. A
H s O Ar
, E,
nd C H
rlem mir
te to the s
me position
s H s A 2
nd C on


rose or
cellulose
cet
te)
t pH 8.6. H D Punj
mir
tes to the s
me position
s H
S on

rose, ut
moves with H A on citr
te

r. A
rose is
puri ed form of

r; it l
cks the
sulf
ted
pectins required to sep
r
te H s D Punj

nd G from H S,
nd H s E, C H
rle
m ,
nd O Ar

from H C. H C H
rlem is
sicklin H
nd it mir
tes to the s
me position

s H S on
citr
te (
cid)

r. 33. A Immuno x
tion electrophoresis (IFE) is used to identify
monoclon
l

nds in serum or urine. Electrophoresis is performed on the serum or urine s
mp
le in the s
me
m
nner
s for protein electrophoresis, except th
t six l
nes
re used for the s

me s
mple. After

the proteins
re sep
r
ted,
di erent monospeci c
ntiserum is
pplied
cross the s
urf
ce of
e
ch l
ne. After incu
tin, the el is w
shed
nd lotted to remove uncomplexed
proteins
nd
s
lts. The immune complexes th
t rem
in
re st
ined. Monoclon
l
nds will e se
en only in those
l
nes where the monoclon
l immunolo ulins were reconized y the correspondin

ntiserum. 34. B
In dou le immunodi usion (Ouchterlony), the molecules of lower molecul
r weiht mo
ve f
stest
throuh the el, c
usin
visi le precipitin
rc when
ntien
nd
nti ody
ppr
o
ch equiv
lence.
At equiv
lence the precipitin
rc rem
ins st
tion
ry. If the concentr
tion of
n
tiser
is
const
nt, the dist
nce of the precipitin
rc from the
ntien well is proportion

l to
ntien
concentr
tion. 2828_Ch05_171-326 06/08/12 5:14 PM P
e 252 35. Which of the f
ollowin
st
tements re
rdin the identi c
tion of monoclon
l proteins y IFE is true? A. T
e monoclon
l

nd must e present in the reion B. When testin for
monoclon
l 
mmop
thy,
oth serum
nd
urine must e ex
mined C. A di
nosis of monoclon
l 
mmop
thy is
sed upon qu

ntit
tion of IG,
IA,
nd IM D. A monoclon
l
nd
lw
ys indic
tes
m
lin
nt disorder Chemistr
y/Correl
te
clinic
l
nd l
or
tory d
t
/ Immuno x
tion/2 36. Which of the followin st
tement
s re
rdin
p
r
proteins is true? A. Olioclon
l
ndin is seen in the CSF of re
ter th
n
90% of multiple
sclerosis c
ses B. Te BenceJones protein he
t test is con rm
tory for monoclon
l li
ht ch
ins C.
Liht ch
ins found in urine
re
lw
ys derived from monoclon
l protein D. Te IA

nd is usu
lly
c
thod
l to the IG precipitin
nd Chemistry/Correl
te clinic
l
nd l
or
tory
d
t
/
Immuno x
tion/2 37. Which st
tement re
rdin IFE is true? A. Serum cont
inin
m
onoclon
l
protein should h
ve
: ratio of 0.5 B. A monocona ban seen with monospeci c anti
serum
shou not be visibe in the ane where poyvaent antiserum or sufosaicyic a
ci was ae C.
CSF shou be concentrate 50- to100-fo before performin IFE D. When oioco
na bans are
seen in the CSF, they must aso be present in serum to inicate mutipe sceros
is
Chemistry/Appy knowee of specia proceures/ Immuno xation/2 5.6 | Proteins, E
ectrophoresis,
an Lipis 253 Answers to Questions 3537 35. B Quantitation of IG, IA, IM, o
r ID inicates
the concentration of each cass of immunoobuin but oes not istinuish monoc
ona from
poycona ammopathies. Monocona characteristics are etermine by emonstrat
in restricte
eectrophoretic mobiity, inicatin that a immunoobuins in the ban are of
the same amino
aci sequence. Monocona iht chains can be emonstrate in about 60% of monoc
ona
ammopathies. In up to 25% of mutipe myeoma patients, a heavy chain ene ee
tion resuts in

prouction of monocona iht chains ony. Because these are fitere by the 
omeruus, the
proceure must be performe on urine as we as serum. Some patients with a mono
cona protein
fai to eveop mainant pasma ce proiferation. This state is cae a mono
cona ammopathy
of unetermine sinificance (MGUS). Within 1015 years, 15%20% of persons with MGU
S eveop
some form of ymphoproiferative isease. 36. A The he
vy ch
in is more
cidic t
h
n or
chains, giving IgA a greater net negative charge at alkaline pH. The IgA precipi
tin band is
anodal to the IgG or IgM band. In hepatic cirrhosis, the - ridin o served on se
rum protein
electrophoresis results from incre
sed IA. Liht ch
ins in the form of F
fr

ments
re often
found in incre
sed
mounts in the urine of p
tients with polyclon
l 
mmop
thies
, especi
lly from
p
tients with
n
utoimmune dise
se. These c
n c
use
positive BenceJones test

nd will produce

polyclon
l (spre
d-out)
ppe
r
nce on IFE els. 37. C Any monoclon
l precipiti
n
nd formed
when he
vy- or liht-ch
inspecific
ntiserum re
cts with
s
mple should
lso e
found in the
s
me position when s
mple is fixed with sulfos
licylic
cid or re
cted with poly
v
lent
ntihum
n
I. The norm
l free : ratio can vary between 0.26 an 1.65. In a monocona ammop
athy, this
ratio aways heaviy favors the iht chain type of M protein. A ianosis of mu
tipe scerosis
is usuay confirme by emonstration of oiocona banin in the CSF, which i
s not present in
the serum. CSF is usuay concentrate 50100 times to increase sensitivity. 2828_
Ch05_171-326
06/08/12 5:14 PM Pae 253 38. Which test is the most sensitive in etectin ea
ry monocona
ammopathies? A. Hih-resoution serum protein eectrophoresis B. Urinary eectr
ophoresis for
monocona iht chains C. Capiary eectrophoresis of serum an urine D. Serum
-free iht chain
immunoassay Chemistry/Seect tests/Immunoobuins/2 39. Which test is the most
usefu way to
evauate the response to treatment for mutipe myeoma? A. Measure of tota imm
unoobuin B.
Measurement of 24-hour urinary iht chain concentration (BenceJones protein) C.
Capiary
eectrophoresis of M-protein recurrence D. Measurement of serum-free iht chain
s Chemistry/Appy
knowee of specia proceures/ Immunoobuins/2 40. Which of the foowin is
more commony
associate with a nonmainant form of monocona ammopathy (MGUS)? A. Bone mar
row pasma ces
comprise 20% of nuceate ces B. Monocona protein (M-protein) concentration
is 3.5 /L C.
M-protein is IG D. Ae reater than 60 at the time of monocona protein iscov
ery
Chemistry/Correate cinica an aboratory ata/ Immunoobuins/2 254 Chapter
5 | Cinica
Chemistry Answers to Questions 3840 38. D Immunonepheometric free iht chain as
says can etect

monocona protein prouction before the mass is su cient to cause a monocona sp

ike on protein
eectrophoresis or capiary eectrophoresis, but wi be positive ony in cases
where monocona
iht chain prouction occurs. Therefore, measurement of free iht chains is re
commene aon
with protein eectrophoresis when testin for myeoma. Free iht chains are nor
may present in
serum because L chains are mae at a faster rate than H chains. However, in case
s where free L
chains are the resut of monocona pasma ce proiferation, the kappa:amba
ratio wi be
abnorma in aition to one of the L chain types bein eevate. 39. D Unike e
ectrophoresis
methos, serum free iht chain assays are quantitative an an increase in free
iht chain
prouction with an abnorma kappa:amba ratio occurs eariest in recurrence of
myeoma. Liht
chains have a shorter pasma haf ife than intact I an therefore, the reucti
on in free iht
chain concentration is an earier inicator of treatment e ect than measurement of
intact I. It
is not subject to the variation in 24-hour urinary iht chain measurement cause
 by sampe
coection error an abnorma rena function. A 50% or more reuction in serum f
ree iht chain
concentration is consiere a partia response to treatment. A fu response is
inicate by
reuction to within norma imits an a return of the kappa:amba ratio to norm
a. An abnorma
free iht chain ratio has a 3.5-fo hiher risk of proression to myeoma in p
ersons with
monocona ammopathy of unetermine sini cance (MGUS). 40. D MGUS is the most c
ommon cause of
monocona ammopathy. About 3% of the U.S. popuation at ae 50 an 5% at ae 7
0 have MGUS. The
absence of bone esions an oran amae, pasma ces beow 10% of nuceate bo
ne marrow ces,
an M-protein beow 3.0 /L are characteristic of MGUS as oppose to myeoma or
other mainant
ammopathy. About 50% of persons with MGUS have IH ene transocations or chrom
osome 13 eetion
associate with mutipe myeoma. The risk of transformation of MGUS to mainan
t isease is
about 1% per year. 2828_Ch05_171-326 06/08/12 5:14 PM Pae 254 41. Capiary
eectrophoresis
i ers from aarose e eectrophoresis in which respect? A. A stationary support
is not use B.
An aciic bu er is use C. A ow votae is use D. Eectroenosmosis oes not occ
ur
Chemistry/Appy principes of specia proceures/ Eectrophoresis/1 42. Seect t
he orer of
mobiity of ipoproteins eectrophorese on ceuose acetate or aarose at pH 8
.6. A.
Chyomicronspre- + B. pre-chylomicrons + C. Chylomicrons pre- + D.
pre-chylomicrons + Chemistry/Apply principles of speci
l procedures/ Electrophoresis/1
43.
Followin ultr
centrifu
tion of pl
sm
, which fr
ction correl
tes with pre- lipo
protein? A.
Very low-density lipoprotein (VLDL) B. Low-density lipoprotein (LDL) C. Hih-den

sity lipoprotein
(HDL) D. Chylomicrons Chemistry/Apply principles of speci
l procedures/ Lipoprot
eins/2 44. Select
the lipoprotein fr
ction th
t c
rries most of the endoenous trilycerides. A. V
LDL B. LDL C. HDL
D. Chylomicrons Chemistry/Correl
te l
or
tory d
t
with physioloic
l processes
/Lipoproteins/2
45. Te protein composition of HDL is wh
t percent
e y weiht? A. Less th
n 2%
B. 25% C. 50% D.
90% Chemistry/Correl
te l
or
tory d
t
with physioloic
l processes/Lipoprotein
s/1 5.6 |
Proteins, Electrophoresis,
nd Lipids 255 Answers to Questions 4145 41. A C
pil
l
ry
electrophoresis is
r
pid
utom
ted procedure for sep
r
tin serum or ody uid p
roteins.
Inste
d of
st
tion
ry support, the proteins mir
te
sed upon their ch
re/m

ss r
tio inside

sm
ll- ore silic
c
pill
ry tu e (20200 m). The cations in the bu er are attracted t
o the
negatively charged silicates and migrate to the cathode rapidly when voltage is
applied. The
electroendosmotic force created moves the proteins toward the cathode and they a
re detected by an
in-line UV photometer that measures their absorbance. High voltage (e.g., 9,000
volts) is used to
e ect separation of serum proteins in an 810 minute run, giving resolution equal to
or greater
than HR agarose gel electrophoresis. 42. C Although pre- lipoprotein is lower in
density th
n
lipoprotein, it mir
tes f
ster on

rose or cellulose
cet
te owin to its mor
e ne
tive

poprotein composition. When lipoproteins
re sep
r
ted on poly
cryl
mide el, p
re- moves slower
th
n lipoprotein. Molecul
r sievin c
uses mir
tion to correl
te with lipoprote
in density when
PAGE is used. 43. A The VLDL (very low-density lipoprotein) mir
tes in the pre-
zone. The VLDL
is
out 50% trilyceride, where
s LDL is only 10% trilyceride y weiht. LDL i
s formed from
VLDL in the circul
tion. The process is initi
ted y
poC-II on VLDL
ctiv
tin
peripher
l
lipoprotein lip
se. Hydrolysis of trilycerides
nd tr
nsfer of
poproteins from
VLDL to HDL
result in form
tion of IDL. L
rer IDLs
re returned to the liver
s remn
nt lip
oproteins.
Further hydrolysis of trilycerides, tr
nsfer cholesterol esters from HDL,
nd t
r
nsfer of

poproteins to HDL convert IDL to LDL. 44. A The VLDL is formed in the liver l
r
ely from
chylomicron remn
nts
nd hep
tic-derived trilycerides. Therefore, the VLDL tr
n
sports the
m
jority of endoenous trilycerides, while the trilycerides of chylomicrons
r
e derived
entirely from diet
ry
sorption. 45. C A out 50% of the weiht of HDL is protei
n, l
rely
po
A-I
nd
po A-II. The HDL is
out 30% phospholipid
nd 20% cholesterol y weih
t. The HDL inds

nd esteri es free cholesterol from cells
nd tr
nsports it to the liver, where it
c
n e
elimin
ted in the ile. 2828_Ch05_171-326 06/08/12 5:14 PM P
e 255 46. Which


poprotein is
inversely rel
ted to risk of coron
ry he
rt dise
se? A. Apoprotein A-I B. Apopro
tein B100 C.
Apoprotein C-II D. Apoprotein E 4 Chemistry/Correl
te clinic
l
nd l
or
tory d

t
/
Lipoproteins/2 47. In f
mili
l dyslipoproteinemi
(formerly type III hyperlipopr
oteinemi
),
which lipoprotein
ccumul
tes? A. Chylomicrons B. VLDL C. IDL D. VLDL Chemistry/
Correl
te
clinic
l
nd l
or
tory d
t
/ Lipoproteins/2 48. Which of the followin mech
nis
ms
ccounts for
the elev
ted pl
sm
level of lipoproteins seen in f
mili
l hypercholesterolemi

(formerly type
II hyperlipoproteinemi
)? A. Hyperinsulinemi
B. ApoB-100 receptor defect C. Apo
C-II
ctiv
ted
lip
se de ciency D. ApoE 3 de ciency Chemistry/Apply knowlede of fund
ment
l iolo
ic
l
ch
r
cteristics/Lipoproteins/2 256 Ch
pter 5 | Clinic
l Chemistry Answers to Que
stions 4648 46.
A Apoprotein A-I
nd
po A-II
re the princip
l
poproteins of HDL,
nd low
po
A-I h
s
hih
correl
tion with
therosclerosis. Conversely,
po-B100 is the princip
l
poprote
in of LDL,
nd
n
elev
ted level is
m
jor risk f
ctor in developin coron
ry he
rt dise
se. Apop
rotein
ss
ys
re
not recommended
s screenin tests ec
use they
re not
s well st
nd
rdized
s
LDL cholesterol

ss
ys. However,
po-B100
ss
y is more sensitive th
n LDL cholesterol in predic
tin coron
ry

rtery dise
se risk. Apo-B100 m
y e
norm
l in persons with incre
sed sm
ll de
nse LDL. Sm
ll
dense LDL is more
theroenic th
n l
re LDL molecules. In
ddition, persons wit
h
hyper
po et
lipoproteinemi
overproduce
po-B100 without h
vin sini c
ntly elev

ted LDL
cholesterol. 47. C IDLs h
ve rouhly equ
l
mounts of cholesterol
nd trilyceri
de. The IDL h
s

density of
out 1.0061.020, c
usin it to o
t on the 1.063 density pot
ssium rom
ide solution
used to recover LDL y ultr
centrifu
tion. IDL h
s f
ster electrophoretic mo il
ity on

rose
th
n et
lipoprotein. These o serv
tions 
ve rise to the terms o
tin et

nd ro

d et
,
respectively. F
mili
l dys et
lipoproteinemi
is in p
rt c
used y
polymorphis
m of
poE (
po-E
2 ) th
t h
s poor
nity for the
po-E receptor on hep
tocytes. Not
ll persons wi
th the
homozyous polymorphism develop the dise
se; thus, other f
ctors
re necess
ry f
or the

ccumul
tion of IDL. 48. B The production of excess insulin le
ds to hypertrily
ceridemi

nd is
one mech
nism responsi le for f
mili
l endoenous hypertrilyceridemi
. ApoC-II
is
n
ctiv
tor
of lipoprotein lip
se,
nd
homozyous de ciency results in hih pl
sm
chylomicr
ons
nd VLDL.
ApoE 3 de ciency is synonymous with inherit
nce of two
po-E 2
lleles th
t le
d t
o
dyslipoproteinemi
. F
mili
l hypercholesterolemi
is inherited
s
n
utosom
l d
omin
nt tr
it.
The cl
ssic
l form results from one of m
ny mut
tions
ectin the LDL receptor th


t c
use it to
h
ve
lower
nity for LDL. A rel
ted hypercholesterolemi
common in people of Eu
rope
n
ncestry
results from
mut
tion of the
po-B100 ene th
t c
uses LDL to h
ve
lower
nit
y for the LDL
receptor. Toether, they m
ke f
mili
l hypercholesterolemi
the most common inhe
rited
hyperlipoproteinemi
with
frequency over 1:500. 2828_Ch05_171-326 06/08/12 5
:14 PM P
e 256
49. Which enzyme de ciency is most commonly
ssoci
ted with f
mili
l hypertrilyce
ridemi


ssoci
ted with f
stin pl
sm
cholomicrons (formerly type I hyperlipoproteinemi

)? A.
Glucocere rosid
se de ciency B. Posthep
rin-
ctiv
ted lipoprotein lip
se de ciency C.
Apo-B
de ciency D. Apo-C-III de ciency Chemistry/Correl
te clinic
l
nd l
or
tory d
t
/ L
ipoproteins/2
50. Which of the followin conditions is most consistently
ssoci
ted with secon
d
ry
hypercholesterolemi
? A. Hypothyroidism B. P
ncre
titis C. Or
l contr
ceptive th
er
py D. Di
etes
mellitus Chemistry/Correl
te clinic
l
nd l
or
tory d
t
/Lipoproteins/2 51. Whi
ch of the
followin is
ssoci
ted with T
nier dise
se? A. Apoprotein C-II de ciency B. Homo
zyous
po-B100
de ciency C. Apoprotein C-II
ctiv
ted lip
se D. Apoprotein A-I de ciency Chemistry/
Correl
te
clinic
l
nd l
or
tory d
t
/ Lipoproteins/2 52. Which of the followin st
temen
ts is correct? A.
Both HDL
nd LDL
re homoenous B. Tere
re sever
l su fr
ctions of LDL ut not
HDL C. Tere
re
sever
l su fr
ctions of HDL ut not LDL D. Tere
re sever
l su fr
ctions of oth
HDL
nd LDL
Chemistry/C
lcul
te/Lipoproteins/1 5.6 | Proteins, Electrophoresis,
nd Lipids
257 Answers to
Questions 4952 49. B Deficiency of c
pill
ry endotheli
l lip
se is the most commo
n c
use of
f
stin chylomicronemi
. This lip
se is
lso known
s posthep
rin-
ctiv
ted lip

se
nd
po
C-II
ctiv
ted lip
se. Glucocere rosid
se deficiency results in
ccumul
tion of
lucocere rosides
nd is the c
use of G
uchers dise
se. ApoC-II deficiency result
s in decre
sed

ctivity of peripher
l
nd hep
tic lip
ses
nd is
ssoci
ted with hypertrilycer
idemi
. Apo-B
deficiency resultin from
point mut
tion in the
po-B ene, is responsi le for
hypo et
lipoproteinemi
,
nd is inherited
s
n
utosom
l domin
nt tr
it. LDL le
vels
re
out
h
lf norm
l in heterozyotes,
nd this reduces their risk of coron
ry
rtery dis
e
se. 50. A The
conditions listed
re very commonly encountered c
uses of second
ry hyperlipopro
teinemi
. Or
l
contr
ceptives, pren
ncy,
nd estroens m
y c
use second
ry hypertrilyceridemi

owin to
incre
sed VLDL
nd endoenous trilycerides. Hypothyroidism
nd o structive hep

to ili
ry
dise
ses
re usu
lly
ssoci
ted with second
ry hypercholesterolemi
owin to hi
h LDL. Di
etes
mellitus
nd chronic p
ncre
titis m
y produce hypertrilyceridemi
, chylomicrone
mi
, or mixed
hyperlipidemi
. 51. D Deficiency of
po A-I is seen in T
nier dise
se,
f
mili


l
hypocholesterolemi
. Heterozyotes h
ve
out h
lf of the norm
l level of HDL (f

mili
l
hypo
lph
lipoproteinemi
)
nd homozyotes h
ve
lmost no detect
le HDL. T
nier
dise
se is
c
used y
mut
tion of the ATP- indin c
ssette ene. The deficient ene preven
ts
po A-I from
indin lipids,
nd it is r
pidly c
t
olized. A et
lipoproteinemi
results from
defective
hep
tic tr
nsport of
po-B100,
nd is
lso inherited
s
n
utosom
l recessive c
ondition. LDL is

sent,
nd the condition is
ssoci
ted with hemolytic
nemi

nd centr
l nervou
s system d
m
e.
52. D There
re 7 su fr
ctions of LDL
nd 10 su fr
ctions of HDL. These
re rou
ped into
su cl
sses de ned y their molecul
r sizes. In ener
l, the sm
ll, dense LDL su cl

sses cont
in
more oxidized LDL
nd
re more
theroenic th
n the l
rer LDL molecules. The l

rer HDL
su fr
ctions comprisin the HDL-3 su cl
ss
re
ssoci
ted with
lower risk of c
oron
ry
rtery
dise
se. 2828_Ch05_171-326 06/08/12 5:14 PM P
e 257 53. Wh
t is the lipid te
stin protocol
for
dults recommended y the N
tion
l Cholesterol Educ
tion Pror
m (NCEP) to e
v
lu
te risk for

therosclerosis einnin
t
e 20? A. Tot
l cholesterol, f
stin or nonf
stin
every ye
r B.
Tot
l cholesterol, f
stin, every 2 ye
rs C. Lipid pro le, f
stin, every 5 ye
rs
D. LDL
cholesterol, f
stin, every 2 ye
rs Chemistry/Apply knowlede of
sic l
or
tor
y
procedures/Lipids/1 54. Wh
t is the most
ppropri
te f
stin procedure when
li
pid study of
trilyceride, tot
l cholesterol, HDL cholesterol,
nd LDL cholesterol tests
re
ordered? A. 8
hours; nothin ut w
ter
llowed B. 10 hours; w
ter, smokin, co ee, te
(no su
r
or cre
m)

llowed C. 12 hours; nothin ut w
ter
llowed D. 16 hours; w
ter, smokin, co ee,
te
(no su
r
or cre
m)
llowed Chemistry/Apply knowlede of
sic l
or
tory procedures/Lipid
s/1 55. Tre
tment
recommend
tions for p
tients with coron
ry he
rt dise
se
re
sed upon me
surem
ent of which

n
lyte? A. HDL cholesterol B. Apo-B100 C. LDL cholesterol D. Tot
l cholesterol
Chemistry/Ev
lu
te l
or
tory d
t
to reconize he
lth
nd dise
se st
tes/Lipids
/1 56. Wh
t is
the HDL cholesterol cutpoint recommend y NCEP? A. <30 m/dL B. <40 m/dL C. <30
m/dL for m
les

nd < 40 m/dL for fem
les D. <45 m/dL for m
les
nd < 50 m/dL for fem
les Che
mistry/Ev
lu
te
l
or
tory d
t
to reconize he
lth
nd dise
se st
tes/Lipids/1 258 Ch
pter 5 |
Clinic
l
Chemistry Answers to Questions 5356 53. C Bec
use LDL cholesterol, HDL cholestero
l, VLDL
cholesterol,
nd trilycerides
re
ll risk f
ctors for coron
ry
rtery dise
se,
NCEP recommends

f
stin lipid pro le to include trilycerides, tot
l cholesterol, HDL cholestero
l,
nd LDL
cholesterol e performed every 5 ye
rs einnin
t
e 20. However, ec
use LDL
cholesterol is

the t
ret of tre
tment, ther
peutic o
ls
re
sed on the LDL cholesterol. New
uidelines
recommend
n LDL cholesterol o
l elow 70 m/dL for the hihest-risk persons. 5
4. C Lipid orders
th
t include trilyceride
nd LDL cholesterol should
lw
ys e performed usin

pl
sm
or serum
specimen collected
fter
1214 hour f
st. The p
tient should e instructed to dr
ink nothin ut
w
ter durin this period. F
stin specimens
re preferred for tot
l
nd HDL chol
esterol
s well,
ut nonf
stin specimens m
y e used for initi
l screenin purposes. 55. C NECP
h
s identi ed LDL
cholesterol
s the t
ret of ther
py for reducin the risk of he
rt
tt
ck ec
u
se lowerin LDL
cholesterol h
s proven to e
n e ective intervention. The re
ter the risk of cor
on
ry he
rt
dise
se, the lower the cutpoint for intervention. For persons
t hih risk (
10
-ye
r risk of
he
rt
tt
ck
>
20%) the cutpoint is 100 m/dL for initi
tion of
st
tin ther
py. For hihest-risk persons (those th
t h
ve
cute coron
ry
syndrome,
nd
multiple or uncontrolled risk f
ctors) the tre
tment o
l is LDL cholesterol el
ow 70 m/dL. 56.
B The HDL cholesterol cutpoint recommended y NCEP is < 40 m/dL re
rdless of s
ex. A result
elow 40 m/dL counts
s
risk f
ctor for coron
ry
rtery dise
se. Conversely,
if the HDL
cholesterol is 60 m/dL, then one risk f
ctor is su tr
cted from the tot
l num e
r. The
ther
peutic o
l for someone with low HDL cholesterol is still reduction of LDL
cholesterol (if
elev
ted), weiht loss,
nd incre
sed exercise. 2828_Ch05_171-326 06/08/12 5:1
4 PM P
e 258
57. An EDTA lood s
mple is collected from
nonf
stin person for
CBC. Te phy
sici
n collected
the s
mple from the femor
l vein ec
use venipuncture from the
rm w
s unsuccess
ful. He c
lled
the l
15 minutes
fter the s
mple
rrived
nd requested
lipid study includin
 trilyceride,
tot
l cholesterol, HDL cholesterol,
nd LDL cholesterol. Which test results shou
ld e used to
ev
lu
te the p
tients risk for coron
ry
rtery dise
se? A. Tot
l cholesterol
nd
LDL cholesterol
B. LDL cholesterol
nd trilyceride C. Tot
l cholesterol
nd HDL cholesterol D.
Tot
l cholesterol

nd trilyceride Chemistry/Apply knowlede of
sic l
or
tory procedures/Lipids
/3 58. Which of
the followin dise
ses is c
used y
de ciency of sphinomyelin
se? A. G
ucher di
se
se B. F
ry
dise
se C. Niem
nnPick dise
se D. T
yS
chs dise
se Chemistry/Correl
te clinic
l
n
d l
or
tory
d
t
/ Lipids/2 59. Which method is considered the c
ndid
te reference method for
trilyceride
me
surement? A. Glycerol kin
se-ultr
violet B. CDC modi c
tion of v
n H
ndel
nd Z
ilversmit C.
H
ntzsch condens
tion D. Glycerol kin
se coupled to peroxid
se Chemistry/Apply p
rinciples of

sic l
or
tory procedures/Lipids/1 60. Which of the followin enzymes is commo
n to
ll

enzym
tic methods for trilyceride me
surement? A. Glycerol phosph
te oxid
se B.

Glycerol
phosph
te dehydroen
se C. Glycerol kin
se D. Pyruv
te kin
se Chemistry/Apply pr
inciples of
sic
l
or
tory procedures/Lipids/2 5.6 | Proteins, Electrophoresis,
nd Lipids 259
Answers to
Questions 5760 57. C NCEP recommends
12-hour f
stin s
mple when screenin pers
ons for risk of
coron
ry
rtery dise
se. However, if
f
stin s
mple is un
v
il
le, NCEP recom
mends performin
the tot
l cholesterol
nd HDL cholesterol ec
use these tests
re le
st
ffected
y recent
inestion of food. If the tot
l cholesterol is 200 m/dL or the HDL cholesterol
is < 40 m/dL,
then testin for LDL cholesterol
nd trilycerides should e performed when
f

stin s
mple c
n
e o t
ined. An EDTA pl
sm
s
mple is
ccept
le for most enzym
tic cholesterol

nd trilyceride

ss
ys. 58. C The dise
ses mentioned result from in orn errors of lipid met
oli
sm (lipidoses)
c
used y de ciency of
n enzyme needed for lipid der
d
tion. Speci c lipids
ccumu
l
te in the
lysosomes. Niem
nnPick dise
se results from
de ciency of sphinomyelin
se; G
uche
r dise
se
from -lucocere rosid
se; F
ry dise
se (sex linked) from -
l
ctosid
se A;
nd T

yS
chs from
N
cetyllucos
minid
se A. 59. B Enzym
tic methods for trilyceride me
surement

re widely used
ec
use they elimin
te the need for extr
ction
nd s
ponific
tion. However, they

re su ject to
positive interference from endoenous lycerol
nd v
ri
tions in the efficiency
of lip
se, which
c
n result in under- or overestim
tion of trilycerides. The most
ccur
te metho
d for
trilyceride
ss
y is the nonenzym
tic method
sed upon re
ction of form
ldehyd
e with
chromotropic
cid. In this method, extr
ction with silicic
cid
nd chloroform s
ep
r
tes
trilycerides from lipoproteins, phospholipids,
nd lycerol. S
ponific
tion wit
h
lcoholic
pot
ssium hydroxide (KOH) produces lycerol, which is oxidized to form
ldehyde
y period
te. The
form
ldehyde re
cts with chromotropic
cid to form
pink product. 60. C All enz
ym
tic
trilyceride methods require lip
se to hydrolyze trilycerides,
nd lycerol kin

se to
phosphoryl
te lycerol, formin lycerol-3-phosph
te. The most common method cou
ples lycerol
kin
se with lycerol phosph
te oxid
se
nd peroxid
se. 1. Trilyceride + H 2 O L
ip
se lycerol +
f
tty
cids 2. Glycerol + ATP GK lycerol-3-phosph
te + ADP 3. Glycerol-3-phosph

te + O 2 GPO
dihydroxy
cetone phosph
te + H 2 O 2 H 2 O 2 + phenol + 4-
minophen
zone Px quin
oneimine dye + H
2 O GK = lycerol kin
se; GPO = lycerol phosph
te oxid
se; Px = peroxid
se 2828
_Ch05_171-326
06/08/12 5:14 PM P
e 259 61. Select the re
ent needed in the couplin enzyme
re
ction used to
ener
te
colored product in the cholesterol oxid
se method for cholesterol. A.
Cholest
hex
ene

B. H 2 O 2 C. 4-Amino
ntipyrine D. Cholest-4-ene-3-one Chemistry/Apply knowlede

of
sic
l
or
tory procedures/Lipids/2 62. Wh
t is the purpose of the s
poni c
tion step u
sed in the
A ellKend
ll method for cholesterol me
surement? A. Remove phospholipids B. Reduc
e sterol
molecules structur
lly simil
r to cholesterol C. Convert cholesterol esters to f
ree cholesterol
D. Remove proteins th
t c
n interfere with color form
tion Chemistry/Apply knowl
ede of
sic
l
or
tory procedures/Lipids/2 63. Which of the followin methods for HDL choles
terol is the
reference method? A. M
n
nesehep
rin B. M
nesiumphosphotunst
te C. M
nesiumdext
r
n D.
Ultr
centrifu
tion Chemistry/Apply knowlede of
sic l
or
tory procedures/Lip
ids/1 64.
Cholesterol ester
se is used in enzym
tic
ss
ys to: A. Oxidize cholesterol to f
orm peroxide B.
Hydrolyze f
tty
cids ound to the third c
r on
tom of cholesterol C. Sep
r
te
cholesterol from

poproteins A-I
nd A-II y hydrolysis D. Reduce NAD + to NADH Chemistry/Apply k
nowlede of
sic
l
or
tory procedures/Lipids/2 65. Which of the followin re
ents is used in th
e direct HDL
cholesterol method? A. Sulf
ted cyclodextrin B. M
nesium sulf
te
nd dextr
n su
lf
te C.
Anti-
poA-I D. M
n
nese hep
rin Chemistry/Apply knowlede of
sic l
or
tory
procedures/Lipids/2 260 Ch
pter 5 | Clinic
l Chemistry Answers to Questions 6165
61. C In the
cholesterol oxid
se method, cholesterol ester hydrol
se converts cholesterol est
ers to free
cholesterol y hydrolyzin the f
tty
cid from the C3-OH roup. Cholesterol oxid

se c
t
lyzes the
oxid
tion of free cholesterol
t the C3-OH roup formin cholest-4-ene-3-one
nd
hydroen
peroxide. The peroxide is used in
peroxid
se re
ction to oxidize
dye (e..,
4-
mino
ntipyrine), which couples to phenol, formin
red quinoneimine complex.
62. C The
A ellKend
ll method is the reference method for cholesterol
ss
y ec
use di erence
s in ester
se

ctivity
nd interference in the peroxid
se step
re potenti
l sources of error
in enzym
tic

ss
ys. S
poni c
tion is performed to hydrolyze the f
tty
cid esters of cholester
ol, formin
free cholesterol. This is required ec
use the re
ents re
ct more intensely wit
h cholesterol
esters th
n with free cholesterol. S
poni c
tion is followed y extr
ction of chol
esterol in
petroleum ether to sep
r
te it from proteins
nd interferin su st
nces. The ext
r
ct is re
cted
with sulfuric
cid,
cetic
nhydride,
nd
cetic
cid (Lie erm
nnBurch
rd re
ent
), which
oxidizes the cholesterol
nd forms
colored product. 63. D Ultr
centrifu
tion
of pl
sm
in

pot
ssium romide solution with
density of 1.063 is used to sep
r
te HDL from
LDL
nd VLDL. The
HDL fr
ction is tr
nsferred from the ottom of the tu e
nd
ss
yed for choleste
rol content y
the A ellKend
ll method. The rem
inin three methods rely upon selective precipit

tion of

lipoproteins cont
inin
poprotein B usin
poly
nionic solution. All of these

methods
re
su ject to interference y very hih trilycerides
nd v
ry somewh
t in speci city
dependin on
the e ciency of precipit
tion. 64. B Approxim
tely two-thirds of the serum cholest
erol h
s

f
tty
cid esteri ed to the hydroxyl roup of the third c
r on
tom of the cholest
erol molecule.
Cholesterol ester
se hydrolyzes f
tty
cids
nd is required ec
use cholesterol
oxid
se c
nnot
utilize esteri ed cholesterol
s
su str
te. 65. A The direct HDL cholesterol met
hod most
commonly employed uses cholesterol ester
se
nd oxid
se enzymes conju
ted to po
lyethylene
lycol. In the presence of sulf
ted cyclodextrin, the enzymes do not re
ct with
non-HDL
cholesterol molecules. Anti-
poA-I inds to HDL
nd is not used in HDL
ss
ys. 2
828_Ch05_171-326
06/08/12 5:14 PM P
e 260 66. Wh
t do direct or homoenous methods for LDL chole
sterol
ss
y
h
ve in common? A. Tey
re in
ccur
te when pl
sm
trilyceride is
ove 250 m/d
L B. All use

deterent to f
cilit
te selective re
ctivity with re
ent enzymes C. All use mon
oclon
l

nti odies to
po A1
nd C D. All
re free of interference from
norm
l lipopro
teins
Chemistry/Apply knowlede of
sic l
or
tory procedures/Lipids/2 67. Lipoprotei
n (
), or Lp(
),
is sini c
nt when elev
ted in serum ec
use it: A. Is
n independent risk f
ctor
for

therosclerosis B. Blocks the cle
r
nce of VLDLs C. Displ
ces
po-AI from HDLs D
. Is linked
closely to
ene for o esity Chemistry/Apply knowlede of fund
ment
l ioloic

l
ch
r
cteristics/Lipoproteins/1 68. Which type of diet
ry f
tty
cid is not
ssoc
i
ted with
n
incre
se in serum LDL cholesterol production? A. Monouns
tur
ted tr
ns f
tty
ci
ds B. S
tur
ted
f
tty
cids C. Monouns
tur
ted cis f
tty
cids D. Monouns
tur
ted tr
ns -9 f
tty

cids
Chemistry/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics/F
tty
cids/
1 69. SITUATION:
A lipemic specimen collected from
n
dult
fter
12-hour f
st w
s
ss
yed for
tot
l
cholesterol, trilycerides,
nd HDL cholesterol usin
direct HDL method. Follo
win
re the
results: Tot
l cholesterol = 220 m/dL HDL cholesterol = 40 m/dL Trilyceride =
420 m/dL Te
physici
n requests
n LDL cholesterol
ss
y
fter receivin the results. How sho
uld the LDL
cholesterol e determined? A. Dilute the specimen 1:10
nd repe
t
ll tests; c
l
cul
te LDL
cholesterol usin the Friedew
ld equ
tion B. Perform
direct LDL cholesterol
s
s
y C.
Ultr
centrifue the s
mple
nd repe
t the HDL cholesterol on the infr
n
te. Use
the new result to
c
lcul
te the LDL cholesterol D. Repe
t the HDL cholesterol usin the m
n
nese
hep
rin
precipit
tion method. Use the new result to c
lcul
te the LDL cholesterol Chemis
try/Apply

knowlede to reconize sources of error/Lipids/3 5.6 | Proteins, Electrophoresis

,
nd Lipids
261 Answers to Questions 6669 66. B The direct LDL cholesterol
ss
ys
re
ll det
erent
sed
methods. One commonly used method employs
poly
nionic deterent to rele
se cho
lesterol from
HDL, chylomicrons,
nd VLDL. The deterent inds to LDL
nd locks its re
ction
with the ester
se

nd oxid
se enzymes in the re
ent. Cholesterol oxid
se oxidizes the non-LDL cho
lesterol, formin
H 2 O 2,
nd peroxid
se c
t
lyzes the oxid
tion of
n electron donor y the H 2
O 2 ,which does
not result in color form
tion. A second nonionic deterent
nd chromoen is
dde
d. The second
deterent removes the rst from the LDL,
llowin it to re
ct with the enzymes. Th
e resultin H 2
O 2 re
cts with the chromoen, formin
colored product. 67. A Lp(
) is
compl
ex of
po-B100

nd protein (
) formed y
disul de ride. The complex is structur
lly simil
r t
o pl
sminoen

nd is thouht to promote coron
ry he
rt dise
se y interferin with the norm
l
rinolytic
process. Lp(
) is me
sured y immuno
ss
y; however, the me
surement will v
ry de
pendin on the
type of
nti odies used
nd their epitope speci city. 68. C Polyuns
tur
ted
nd ci
s
monouns
tur
ted f
tty
cids
re not
ssoci
ted with incre
sed production of LDL
cholesterol. On
the other h
nd, s
tur
ted
nd tr
ns monouns
tur
ted f
tty
cids
re oth
ssoci

ted with
incre
sed LDL. Cis f
tty
cids
re those in which the H
toms elonin to the d
ou le- onded
c
r ons
re on the s
me side of the molecule. -9 (n-9) f
tty
cids
re those with

dou le ond
loc
ted 9 c
r ons from the termin
l methyl roup. F
tty
cids
re
ssoci
ted wit
h incre
sed
cholesterol, if the hydroens
tt
ched to the dou le- onded c
r ons
re in the t
r
ns position.
69. B An
ccur
te LDL cholesterol c
n e reported, if the direct (deterent) met
hod for LDL
cholesterol is employed. These methods
re not su ject to interference y trily
cerides
t

concentr
tion elow 700 m/dL. 2828_Ch05_171-326 06/08/12 5:14 PM P
e 261 70
. A person h
s

f
stin trilyceride level of 240 m/dL. Te physici
n wishes to know the p
tients
non-HDL
cholesterol level. Wh
t cholesterol fr
ctions should e me
sured? A. Tot
l chole
sterol
nd HDL
cholesterol B. Tot
l cholesterol
nd LDL cholesterol C. HDL cholesterol
nd LDL
cholesterol D.
Tot
l cholesterol
nd chylomicrons Chemistry/Apply knowlede of speci
l procedur
es/ Lipids/3 262
Ch
pter 5 | Clinic
l Chemistry Answer to Question 70 70. A When the HDL choleste
rol is su tr
cted
from the tot
l cholesterol, the result is c
lled the non-HDL cholesterol. This r
esult, the sum of
LDL cholesterol
nd VLDL cholesterol, represents the fr
ction with
theroenic r
emn
nt
lipoproteins
s well
s LDL cholesterol. People who h
ve
f
stin trilyceride
200 m/dL
re


t incre
sed risk for coron
ry
rtery dise
se ownin to
theroenic VLDL remn
nt
s,
nd the
tre
tment o
l is to h
ve
non-HDL cholesterol no more th
n 30 m/dL re
ter th

n the LDL
cholesterol. 2828_Ch05_171-326 06/08/12 5:14 PM P
e 262 263 5.7 Enzymes
nd
C
rdi
c M
rkers
1. An intern
tion
l unit (IU) of enzyme
ctivity is the qu
ntity of enzyme th
t:
A. Converts 1
mol of su str
te to product per liter B. Forms 1 m of product per deciliter C. C
onverts 1 mol
of su str
te to product per minute D. Forms 1 mol of product per liter Chemistry/
Apply
principles of
sic l
or
tory procedures/Enzymes/1 2. Which of the followin st

tements
descri es
nonkinetic enzyme
ss
y? A. Initi
l
sor
nce is me
sured followed
y
second
re
din
fter 5 minutes B. A sor
nce is me
sured
t 10-second interv
ls for 100
seconds C.
A sor
nce is monitored continuously for 1 minute usin
ch
rt recorder D. Re ect

nce is
me
sured from
xenon source l
mp pulsin
t 60 Hz Chemistry/Apply principles of

sic l
or
tory
procedures/Enzymes/2 3. Which of the followin st
tements re
rdin enzym
tic re

ctions is true?
A. Te enzyme shifts the equili rium of the re
ction to the riht B. Te enzyme
l
ters the
equili rium const
nt of the re
ction C. Te enzyme incre
ses the r
te of the re
c
tion D. Te enzyme

lters the enery di erence etween re
ct
nts
nd products Chemistry/Apply knowled
e of
fund
ment
l ioloic
l ch
r
cteristics/Enzymes/1 4. Which st
tement
out enzyme
s is true? A. An
enzyme
lters the Gi s free enery of the re
ction B. Enzymes c
use
re
ction w
ith
positive
free enery to occur spont
neously C. An enzymes n
tur
l su str
te h
s the hihes
t K m D. A
competitive inhi itor will
lter the
pp
rent K m of the re
ction Chemistry/Appl
y knowlede of
fund
ment
l ioloic
l ch
r
cteristics/Enzymes/2 Answers to Questions 15 1. C The
IU is
r
te
expressed in micromoles per minute. Activity is reported
s IUs per liter (IU/L)
or mIU/mL. The
SI unit for enzyme
ctivity is the k
t
l (1 k
t
l converts 1 mol of su str
te to
product in 1
second). 2. A A kinetic
ss
y uses sever
l evenly sp
ced
sor
nce me
surements
to c
lcul
te the
ch
ne in
sor
nce per unit time. A const
nt ch
ne in
sor
nce per unit of
time occurs only
when the r
te of the re
ction is zero order (independent of su str
te concentr
t
ion). Enzyme

ctivity is proportion
l to r
te only under zero-order conditions. 3. C An enzym
e will
cceler
te
the r
te of
re
ction, reducin the time required to re
ch equili rium. The con
centr
tion of
re
ct
nts
nd products
t equili rium will e the s
me with or without the enzym
e. 4. D Enzymes

lter the enery of
ctiv
tion y formin
met
st
le intermedi
te, the enzyme
su str
te
complex. Enzymes do not
lter the free enery or direction of
re
ction. Compet
itive inhi itors

ind to the
ctive site where the enzyme inds su str
te
nd
re overcome y inc
re
sin the
su str
te concentr
tion. 5. A A zero-order re
ction r
te is independent of su st
r
te
concentr
tion ec
use there is su cient su str
te to s
tur
te the enzyme. V = V m

x [S]/K m +
[S] where V = velocity, V m
x = m
ximum velocity, [S] = su str
te concentr
tion,

nd K m =
su str
te concentr
tion required to ive 1/2 V m
x . If [S] >>> K m , then the K
m c
n e
inored. V = V m
x [S]/[S] = V m
x [S] or velocity
ppro
ches m
ximum
nd is inde
pendent of
su str
te concentr
tion. 5. Which su str
te concentr
tion is needed to
chieve z
ero-order
conditions? A. Gre
ter th
n 99 K m B. [S] = K m C. Less th
n 10 K m D. [S] = 0
Chemistry/Select re
ents/Enzymes/3 2828_Ch05_171-326 06/08/12 5:14 PM P
e 2
63 6. Which of
the followin st
tements is true? A. Apoenzyme + prosthetic roup = holoenzyme B
. A coenzyme is

n inor
nic molecule required for
ctivity C. Cof
ctors
re
s tihtly ound to
the enzyme
s
prosthetic roups D. All enzymes h
ve optim
l
ctivity
t pH 7.00 Chemistry/Appl
y fund
ment
l
ioloic
l ch
r
cteristics/Enzymes/2 7. Which of the followin st
tements
out
enzym
tic
re
ctions is true? A. NADH h
s
sor
nce m
xim
s
t 340
nd 366 nm B. Enzyme co
ncentr
tion must
e in excess to
chieve zero-order kinetics C. R
te is proportion
l to su str
te
concentr
tion in

zero-order re
ction D. Accumul
tion of the product incre
ses the re
ction r
te
Chemistry/Apply
principles of
sic l
or
tory procedures/Enzymes/2 8. Te incre
se in the level
of serum enzymes
used to detect cholest
tic liver dise
se is c
used m
inly y: A. Enzyme rele
se
from de
d cells
B. Le
k
e from cells with
ltered mem r
ne perme
ility C. Decre
sed perfusion
of the tissue D.
Incre
sed production
nd secretion y cells Chemistry/Correl
te l
or
tory d
t

with
physioloic
l processes/Enzymes/2 9. Which of the followin enzymes is considere
d most tissue
speci c? A. Cre
tine kin
se (CK) B. Amyl
se C. Alk
line phosph
t
se (ALP) D. Alcoh
ol
dehydroen
se (ADH) Chemistry/Correl
te clinic
l
nd l
or
tory d
t
/ Enzymes/2
10. Which of the
followin enzymes is
ctiv
ted y c
lcium ions? A. CK B. Amyl
se C. ALP D. LD Ch
emistry/Apply
knowlede of fund
ment
l ioloic
l ch
r
cteristics/Enzymes/2 11. Which of the f
ollowin enzymes
is
tr
nsfer
se? A. ALP B. CK C. Amyl
se D. LD Chemistry/Apply knowlede of fun
d
ment
l
ioloic
l ch
r
cteristics/Enzymes/2 264 Ch
pter 5 | Clinic
l Chemistry Answers
to Questions 611
6. A A coenzyme is
n or
nic molecule required for full enzyme
ctivity. A pros
thetic roup is

coenzyme th
t is tihtly ound to the
poenzyme
nd is required for
ctivity. Co
f
ctors
re
inor
nic
toms or molecules needed for full c
t
lytic
ctivity. Pyridoxyl- 5-pho
sph
te is

prosthetic roup for ALT
nd AST. Consequently, p
tients with low levels of pyri

dox
l5-phosph
te (P-5-P) (vit
min B 6 de ciency) m
y h
ve reduced tr
ns
min
se
ctivity i

n vitro.
Enzymes c
n h
ve diverse pH (
nd temper
ture) optim
s. 7. A Most enzymes
re me

sured y
monitorin the r
te of
sor
nce ch
ne
t 340 nm
s NADH is produced or consum
ed. This r
te
will e proportion
l to enzyme
ctivity when su str
te is in excess. When the en
zyme is present
in excess, the initi
l re
ction r
te will e proportion
l to su str
te concentr

tion. This
condition, c
lled
rst-order re
ction, is needed when the enzyme is used
s
re

ent to
me
sure
speci c
n
lyte. 8. D The
mount of enzyme in the serum c
n e incre
sed
y necrosis,

ltered perme
ility, secretion, or synthesis. It is
lso dependent upon tissue
perfusion, enzyme
h
lf-life, molecul
r size,
nd loc
tion of the enzyme within the cell. Most enzy
mes
re li er
ted
y necrosis, ut
few, such
s ALP
nd -lut
myltr
nsfer
se,
re produced
nd se
creted
t

re
ter r
te in o structive liver dise
se. 9. D No enzyme is truly tissue speci c

nd di
nostic

ccur
cy depends upon reconizin ch
nes in pl
sm
levels th
t ch
r
cterize di er
ent dise
ses.
This includes the m
ss or
ctivity of enzyme rele
sed, its rise, pe
k,
nd retur
n to norm
l, the
isoenzyme(s) rele
sed,
nd the concomit
nt ch
nes of other enzymes. Al
nine
mi
notr
nsfer
se
nd

lcohol dehydroen
se
re prim
rily incre
sed in necrotic liver dise
se. 10. B M
ost enzymes
require met
ls
s
ctiv
tors or cof
ctors. CK
nd ALP require M +2 for full
ct
ivity,
nd

myl
se requires C
+2 . Met
ls required for
ctivity should e components of th
e su str
te used
for enzyme
n
lysis. The su str
te must
lso cont
in
nions required (e.., Cl f
or
myl
se)
nd
should not cont
in inhi itin c
tions or
nions (e.., Zn +2
nd Mn +2 for CK).
11. B Enzymes
re
identi ed y
numeric system c
lled the EC (Enzyme Commission) num er. The rst num
er refers to
the cl
ss of the enzyme. There
re six cl
sses; in order, these
re oxidoreduct

ses,
tr
nsfer
ses, hydrol
ses, ly
ses, isomer
ses,
nd li
ses. Dehydroen
ses
re ox
idoreduct
ses,
where
s kin
ses
nd tr
ns
min
ses
re tr
nsfer
ses. CK is EC num er 2.7.3.2, whi
ch distinuishes
it from other kin
ses. 2828_Ch05_171-326 06/08/12 5:14 PM P
e 264 12. Which
st
tement
out
methods for me
surin LD is true? A. Te form
tion of pyruv
te from l
ct
te (forw

rd re
ction)
ener
tes NAD + B. Te pyruv
te-to-l
ct
te re
ction proceeds
t
out twice the r

te
s the
forw
rd re
ction C. Te l
ct
te-to-pyruv
te re
ction is optimized
t pH 7.4 D. Te
ne
tive-r
te
re
ction is preferred Chemistry/Apply principles of
sic l
or
tory procedures/
L
ct
te
dehydroen
se/2 13. Which condition produces the hihest elev
tion of serum l
ct

te
dehydroen
se? A. Pernicious
nemi
B. Myoc
rdi
l inf
rction C. Acute hep
titis

D. Muscul
r
dystrophy Chemistry/Correl
te clinic
l
nd l
or
tory d
t
/L
ct
te dehydroen
se
/2 14. In which
condition is the LD most likely to e within norm
l limits? A. Hep
tic c
rcinom

B. Pulmon
ry
inf
rction C. Acute
ppendicitis D. Crush injury Chemistry/Correl
te clinic
l
n
d l
or
tory
d
t
/ L
ct
te dehydroen
se/2 15. Te LD pleur
l uid:serum r
tio for
tr
nsud
tiv
e uid is
usu
lly: A. 3:1 or hiher B. 2:1 C. 1:1 D. 1:2 or less Chemistry/Correl
te clini
c
l
nd
l
or
tory d
t
/ L
ct
te dehydroen
se/2 16. In which type of liver dise
se woul
d you expect the
re
test elev
tion of LD? A. Toxic hep
titis B. Alcoholic hep
titis C. Cirrhosis
D. Acute vir
l
hep
titis Chemistry/Correl
te clinic
l
nd l
or
tory d
t
/ L
ct
te dehydroen
s
e/2 17. Which of
the followin conditions will interfere with the me
surement of LD? A. Sliht he
molysis durin
s
mple collection B. Stor
e
t 4C for 3 d
ys C. Stor
e
t room temper
ture for
16 hours D. Use
of pl
sm
collected in hep
rin Chemistry/Apply knowlede to reconize sources of
error/L
ct
te
dehydroen
se/3 5.7 | Enzymes
nd C
rdi
c M
rkers 265 Answers to Questions 1217
12. B Althouh
the r
te of the reverse re
ction (P L) is f
ster, the L P re
ction is more popul
r
ec
use it
produces
positive r
te (ener
tes NADH), is not su ject to product inhi ition,

nd is hihly
line
r. The pH optimum for the forw
rd re
ction is
pproxim
tely 8.8. 13. A Seru
m LD levels
re
hihest in pernicious
nemi
, re
chin 1050 times the upper reference limit (URL)

s
result of
intr
medull
ry hemolysis. Moder
te elev
tions (510 URL) usu
lly
re seen in
cute
myoc
rdi
l
inf
rction, necrotic liver dise
se,
nd muscul
r dystrophy. Sliht incre
ses (23
URL)
re
sometimes seen in o structive liver dise
se. 14. C LD is incre
sed slihtly to m
oder
tely in most
c
uses of liver dise
se. Sm
llest elev
tions
re seen in o structive j
undice
n
d hihest in
hep
tic c
rcinom

nd toxic hep
titis, where levels c
n re
ch 10-fold the upper
reference limit.
LD is
lso incre
sed in crush injury
nd muscul
r dystrophies due to skelet
l mu
scle d
m
e,
nd
in pulmon
ry inf
rction owin to em olism form
tion. Amyl
se is incre
sed in
m

jority of
persons with
cute
ppendicitis, ut LD is not. 15. D The l
ct
te dehydroen
se

ctivity of ody
uids is norm
lly less th
n serum,
nd
uid to serum LD r
tio re
ter th
n 1:2 is
hihly
suestive of
n exud
tive process. Elev
ted l
ct
te dehydroen
se in chest uid i
s often c
used
y lun m
lin
ncy, met
st
tic c
rcinom
, Hodkins dise
se,
nd leukemi
. 16. A L
iver dise
se
produces
n elev
ted LD-4
nd LD-5. Levels m
y re
ch up to 10 times the URL in t
oxic hep
titis

nd in hep
tom
. However, LD levels
re lower in vir
l hep
titis (25 URL), only s
lihtly
elev
ted in cirrhosis (23 URL)
nd not sini c
ntly elev
ted in
lcoholic liver dis

e
se. 17. A
RBCs
re rich in LD-1
nd LD-2,
nd even sliht hemolysis will f
lsely elev
te r
esults.
Hemolytic, me
lo l
stic,
nd pernicious
nemi
s
re
ssoci
ted with LD levels o
f 1050 times the
URL. LD is st
le for 2 d
ys
t room temper
ture or 1 week
t 4C; however, freezi
n c
uses
deterior
tion of LD-5. The
ctivity of LD is inhi ited y EDTA, which inds div

lent c
tions;
serum or hep
rinized pl
sm
should e used. 2828_Ch05_171-326 06/08/12 5:14 PM
P
e 265 18. In
the OliverRos
lki method, the reverse re
ction is used to me
sure CK
ctivity. Te
enzyme(s) used
in the couplin re
ctions is (
re): A. Hexokin
se
nd G-6-PD B. Pyruv
te kin
se

nd LD C.
Lucifer
se D. Adenyl
te kin
se Chemistry/Apply knowlede of
sic l
or
tory pro
cedures/Cre
tine
kin
se/2 19. In the OliverRos
lki method for CK,
denosine monophosph
te (AMP) is

dded to the
su str
te in order to: A. Inhi it
denyl
te kin
se B. Block the oxid
tion of lu
t
thione C.
Incre
se the
mount of ADP th
t is
v
il
le D. Block the
ction of di
denosine
pent
phosph
te
Chemistry/Apply principles of
sic l
or
tory procedures/Cre
tine kin
se/2 20.
Which su st
nce
is used in the CK
ss
y to
ctiv
te the enzyme? A. Fl
vin
denine dinucleotide (
FAD) B. Imid
zole
C. N-
cetylcysteine D. Pyridoxyl-5-phosph
te Chemistry/Apply principles of
sic
l
or
tory
procedures/Cre
tine kin
se/2 21. SITUATION: A specimen for CK performed on
n
u
tom
ted
n
lyzer
usin
n optimized OliverRos
lki method ives
n error
 indic
tin su str
te dep
letion. Te
s
mple is diluted 1:2
nd 1:4 y the seri
l dilution technique
nd re
ss
yed. Af
ter correctin
for the dilution, the results
re
s follows: 1:2 Dilution = 3,000 IU/L 1:4 Dilu
tion = 3,600 IU/L
Dilutions
re m
de
second time
nd
ss
yed

in ut ive identic
l results. W
h
t is the most
likely expl
n
tion? A. Te serum ec
me cont
min
ted prior to m
kin the 1:4 dilu
tion B. Te wron
pipet w
s used to m
ke one of the dilutions C. An endoenous competitive inhi it
or is present in
the serum D. An error h
s een m
de in c
lcul
tin the enzyme
ctivity of one of
the two
dilutions Chemistry/Apply knowlede to reconize sources of error/Cre
tine kin
s
e/3 266 Ch
pter 5
| Clinic
l Chemistry Answers to Questions 1821 18. A The OliverRos
lki method for
CK is
sed
upon the form
tion of ATP from cre
tine phosph
te. Hexokin
se c
t
lyzes the phos
phoryl
tion of
lucose y ATP. This produces lucose-6-PO 4
nd
denosine diphosph
te (ADP). Th
e lucose-6-PO 4
is oxidized to 6-phospholucon
te
s NADP + is reduced to NADPH. ATP + lucose H
exokin
se ADP +
lucose-6-PO 4 lucose-6-PO 4 + NADP + G6PD 6-phospholucon
te + NADPH + H + 19. A
Positive
interference in the OliverRos
lki method c
n occur when
denyl
te kin
se is prese
nt in the serum
from hemolysis or d
m
ed tissue. Adenyl
te kin
se hydrolyzes ADP, formin AMP

nd ATP (2 ADP AK
AMP + ATP). This re
ction is inhi ited y
ddin AMP
nd di
denosine pent
phosph

te (Ap 5 A) to
the su str
te. 20. C In
ddition to M +2 , CK requires
thiol compound to redu
ce interch
in
disul de rides
nd ind he
vy met
ls th
t in
ctiv
te the enzyme. N-
cetylcystein
e is
n

ctiv
tor of CK used for this purpose in the IFCC recommended method. Pyridoxyl5-phosph
te is

prosthetic roup of AST
nd ALT. FAD is
prosthetic roup of lucose oxid
se. I
mid
zole is used
to u er the CK re
ent. 21. C When
competitive inhi itor is present in the seru
m,
dilution
of the s
mple will c
use
n incre
se in the re
ction r
te y reducin the concen
tr
tion of the
inhi itor. Dilution of serum frequently incre
ses the
ctivity of CK
nd
myl
se
. The s
me e ect
will occur when
sm
ller volume of serum is used in the
ss
y ec
use less inhi
itor will e
present in the re
ction mixture. 2828_Ch05_171-326 06/08/12 5:14 PM P
e 266
22. SITUATION: A
physici
n c
lls to request
CK on
s
mple
lre
dy sent to the l
or
tory for c
o
ul
tion
studies. Te s
mple is 2-hour-old citr
ted lood
nd h
s een stored
t 4C. Te pl

sm
shows very
sliht hemolysis. Wh
t is the est course of
ction
nd the re
son for it? A. Pe
rform the CK

ss
y on the s
mple ec
use no interferent is present B. Reject the s
mple ec
u
se it is slihtly
hemolyzed C. Reject the s
mple ec
use it h
s een stored too lon D. Reject the
s
mple ec
use
the citr
te will interfere Chemistry/Apply knowlede to reconize sources of err
or/Cre
tine
kin
se/3 23. Which of the followin st
tements re
rdin tot
l CK is true? A. Le
vels
re
un
ected y strenuous exercise B. Levels
re un
ected y repe
ted intr
muscul
r in
jections C.
Hihest levels
re seen in Duchennes muscul
r dystrophy D. Te enzyme is hihly sp
eci c for he
rt
injury Chemistry/Ev
lu
te l
or
tory d
t
to reconize he
lth
nd dise
se st
tes
/Cre
tine
kin
se/2 24. Which of the followin st
tements re
rdin the clinic
l use of CKMB (CK-2) is
true? A. CK-MB ecomes elev
ted efore myolo in
fter
n AMI B. CK-MB levels
r
e usu
lly
incre
sed in c
ses of c
rdi
c ischemi
C. CK-MB is more speci c th
n myolo in D.
An elev
ted
CK-MB is
lw
ys
ccomp
nied y
n elev
ted tot
l CK Chemistry/Correl
te clinic
l

nd l
or
tory
d
t
/ Cre
tine kin
se/2 25. A p
tients CK-MB is reported
s 18 /L
nd the tot
l C
K
s 560
IU/L. Wh
t is the CK rel
tive index (CKI)? A. 0.10% B. 3.2% C. 10.0% D. 30.0% Ch
emistry/Correl
te
clinic
l
nd l
or
tory d
t
/ Cre
tine kin
se/2 5.7 | Enzymes
nd C
rdi
c M
rker
s 267 Answers
to Questions 2225 22. D CK
ctivity is lost with excessive stor
e, the most l
i
le isoenzyme
ein CK-1. However, CK in serum is st
le
t room temper
ture for
out 4 hours

nd up to 1 week

t 4C provided th
t
n optimized method is used. Sliht hemolysis does not interf

ere ec
use CK
is
sent from RBCs. More sini c
nt hemolysis m
y c
use positive interference y
contri utin
ATP, lucose-6-PO 4 ,
nd
denyl
te kin
se to the serum. C
lcium chel
tors remov
e m
nesium
s
well
s c
lcium
nd should not e used. 23. C Tot
l CK is neither sensitive nor
speci c for AMI.
An inf
rct c
n occur without c
usin
n elev
ted tot
l CK. Exercise
nd intr
mus
cul
r injections
c
use
sini c
nt incre
se in tot
l CK. Crush injuries
nd muscul
r dystrophy c
n
incre
se the
tot
l CK up to 50 times the URL. 24. C Serum myolo in ecomes
norm
l within 12
hours
fter
n

cute myoc
rdi
l inf
rction (AMI) efore troponin
nd CK-MB. CK-MB ecomes
nor
m
l shortly
fter
troponin I (TnI) or troponin T (TnT) when
URL of 4 g/L is used, and peaks at ar
ound the same
time following AMI. However, cardiac troponins remain elevated significantly lon
ger than CK-MB
after AMI, are not increased in crush injuries. There is less than 5 g/L CK-MB in
the serum of
healthy adults, while the total CK ranges from 10110 U/L. Consequently, an abnorm
al CK-MB can
occur in the absence of an elevated total CK. 25. B The CKI is an expression of
the percentage of
the total CK that is attributed to CK-MB. CKI = CK-MB in g/L 100 Total CK in IU/L
The
reference range is 0%2.5%. Values above 2.5% point to an increase in CK-MB from c
ardiac muscle.
2828_Ch05_171-326 06/08/12 5:14 PM Page 267 26. In a nonmyocardial as opposed
to a myocardial
cause of an increased serum or plasma CK-MB, which would be expected? A. An incr
ease in CK-MB
that is persistent B. An increase in the percent CK-MB as well as concentration
C. Te presence of
increased TnI D. A more modest increase in total CK than CK-MB Chemistry/Evaluat
e laboratory data
to recognize health and disease states/Creatine kinase/2 27. Which statement bes
t describes the
clinical utility of plasma or serum myoglobin? A. Levels greater than 100 g/L are
diagnostic of
AMI B. Levels below 100 g/L on admission and 24 hours postadmission help to exclud
e a diagnosis
of AMI C. Myoglobin peaks after the cardiac troponins but is more sensitive D. T
e persistence of
myoglobin > 110 g/L for 3 days following chest pain favors a diagnosis of AMI Che
mistry/Evaluate
laboratory data to recognize health and disease states/Cardiac markers/2 28. Wha
t is the typical
time course for plasma myoglobin following an AMI? A. Abnormal before 1 hour; pe
aks within 3
hours; returns to normal in 8 hours B. Abnormal within 3 hours; peaks within 6 h
ours; returns to
normal in 18 hours C. Abnormal within 2 hours; peaks within 12 hours; returns to
normal in 36
hours D. Abnormal within 6 hours; peaks within 24 hours; returns to normal in 72
hours
Chemistry/Evaluate laboratory data to recognize health and disease states/Cardia
c markers/2 29.
What is the typical time course for plasma TnI or TnT following an AMI? A. Abnor

mal within 3
hours; peaks within 12 hours; returns to normal in 24 hours B. Abnormal within 4
hours; peaks
within 18 hours; returns to normal in 48 hours C. Abnormal within 4 hours; peaks
within 24 hours;
returns to normal in 1 week D. Abnormal within 6 hours; peaks within 36 hours; r
eturns to normal
in 5 days Chemistry/Evaluate laboratory data to recognize health and disease sta
tes/Cardiac
markers/2 268 Chapter 5 | Clinical Chemistry Answers to Questions 2629 26. A Plas
ma CK-MB
becomes abnormal 4 hours postinfarction, peaks in 1620 hours, and usually returns
to normal
within 48 hours. In some noncardiac causes of elevated plasma CK-MB such as musc
ular dystrophy,
there is a persistent elevation of both total CK and CK-MB. TnI and TnT are card
iac-speci c
markers. They become elevated slightly before CK-MB when a CK-MB URL of 4 g/L is
used, remain
elevated for 710 days following an AMI, and are not increased in muscular dystrop
hy, malignant
hyperthermia, or crush injuries that are associated with an increase in the conc
entration of
CK-MB. Absolute CK-MB increases are evaluated cautiously, when CK-MB is less tha
n 2.5% of total
enzyme because noncardiac sources may be responsible. 27. B Myoglobin is a hemecontaining
pigment in both skeletal and cardiac muscle cells. The upper limit of normal is
approximately 90
g/L for males and 75 g/L for females. The plasma myoglobin is a sensitive marker f
or AMI. Over
95% of a ected persons have a value higher than the cuto (typically >110 g/L). Howev
er,
speci city is approximately 75%85% owing to skeletal muscle injury or renal insu cien
cy. For
this reason, a plasma myoglobin below the cuto on admission, and within the rst 3
hours
following chest pain helps to rule out AMI. A value above the cuto must be con rmed
using a
cardiac speci c assay such as TnI or TnT. 28. C After AMI, myoglobin usually rises
above the
cuto within 12 hours, peaks within 812 hours and returns to normal within 36 hours.
Typically,
levels reach a peak concentration that is 10-fold the upper reference limit. Sin
ce myoglobin is
the rst marker to become abnormal after an AMI, it should be measured on admissio
n and if
negative, again 2 hours later. If both samples are below the cuto , the probabilit
y of an AMI
having occurred is low. If the myoglobin is above the cuto , a cardiac speci c marke
r such as
TnI, or TnT must be performed at some point to con rm the diagnosis. 29. C Troponi
n is a complex
of three polypeptides that function as a regulator of actin and tropomyosin. The
three subunits
are designated TnC, TnI, and TnT. All are present in both cardiac and some skele
tal muscles, but
cardiac and skeletal isoforms of TnI and TnT can be di erentiated by speci c antiser
as. TnI and
TnT cardiac isoforms in plasma will at least double within 46 hours after MI, pea

k within 24
hours and usually remain elevated for 710 days. TnT and TnI have the same sensiti
vity, but TnT
is more commonly elevated in renal failure patients. Both are increased slightly
in unstable
angina (chest pain while at rest) and cardiac ischemia. 2828_Ch05_171-326 06/08
/12 5:14 PM
Page 268 30. Which of the following is the most e ective serial sampling time for
ruling out AMI
using both myoglobin and a cardiac speci c marker in an emergency department envir
onment? A.
Admission and every hour for the next 3 hours or until positive B. Admission, 2
hours, 4 hours,
and 6 hours or until positive C. Admission, 3 hours, 6 hours, and a nal sample wi
thin 12 hours
D. Admission and one sample every 8 hours for 48 hours Chemistry/Apply knowledge
of basic
laboratory procedures/Cardiac markers/2 31. What is the recommended troponin T a
nd I cuto (upper
limit of normal) for detecting myocardial infarction? A. Te cuto varies with the
method of assay
but should be no lower than 0.2 ng/mL B. Te upper 99th percentile or lowest leve
l that can be
measured with 10% CV C. Te concentration corresponding to the lowest level of ca
librator used D.
Te highest value tting under the area of the curve for the 95% con dence interval
Chemistry/Apply knowledge of basic laboratory procedures/Cardiac markers/2 32. W
hich of the
following cardiac markers is consistently increased in persons who exhibit unsta
ble angina? A.
Troponin C B. Troponin T C. CK-MB D. Myoglobin Chemistry/Evaluate laboratory dat
a to recognize
health and disease states/Cardiac markers/2 33. A patient has a plasma myoglobin
of 10 g/L at
admission. Tree hours later, the myoglobin is 14 g/L and the troponin I is 0.02 g/
L (reference
range 00.03 g/L). Tese results are consistent with which condition? A. Skeletal mu
scle injury
B. Acute myocardial infarction C. Unstable angina D. No evidence of myocardial o
r skeletal muscle
injury Chemistry/Evaluate laboratory data to recognize health and disease states
/Cardiac
markers/2 5.7 | Enzymes and Cardiac Markers 269 Answers to Questions 3033 30. C
Since the time
between the onset of symptoms and arrival in the emergency department is often s
peculative,
serial measurement of cardiac markers is required in order to rule out AMI. Sinc
e myoglobin is
the rst marker to rise after AMI, if used it should be measured on admission. Sin
ce TnI, TnT,
and CK-MB are more cardiac speci c, at least one should be measured starting at 3
hours
postadmission, and again at 6 hours postadmission. If all results are negative t
o this point, a
nal assay should be performed 612 hours postadmission to conclusively rule out the
possibility
of AMI and evaluate the short-term risk of AMI. 31. B The American College of Ca
rdiology
recommends the cuto for an abnormal troponin test be set at the 99th percentile o
f the normal

population, 0.013 ng/mL, or if the assay precision at this level is >10% then th
e cuto should be
the lowest value measurable with a CV of 10% (typically 0.03 ng/mL). An abnormal
result (0.04
ng/mL or higher) in a patient with other evidence of ischemic changes indicates
cardiac damage.
This typically occurs when a pattern of increasing troponin concentration is see
n over the rst 6
hours after initial testing. 32. B Persons with unstable angina (angina at rest)
who have an
elevated TnT or TnI are at eight times greater risk of having an MI within the n
ext 6 months.
This property is being used to identify short-term risk patients who should be c
onsidered for
coronary angioplasty. The reference range for troponin is very low (00.03 ng/mL);
persons with
unstable angina usually have values between 0.04 and 0.1 ng/mL without clinical
evidence of AMI.
CK-MB and myoglobin have not been useful in identifying persons with unstable an
gina. 33. D This
person displays very low plasma myoglobin (reference range for females is approx
imately 1775
g/L). The TnI result is also within normal limits. These results are consistent w
ith baseline
levels and no evidence of cardiac or skeletal muscle injury. TnI cutpoints for d
iagnosis of AMI
are dependent upon the method, and may be higher than the upper limit of normal.
Troponin results
above the upper reference limit but below the cutpoint for AMI indicate myocardi
al injury and
increased risk for AMI. 2828_Ch05_171-326 06/08/12 5:14 PM Page 269 34. A pat
ient has a plasma
CK-MB of 14 g/L at admission and a total CK of 170 IU/L. Serum myoglobin is 130 g/
L and TnI is
1.6 g/L. Tree hours later, the TnI is 3.0 g/L. Which statement best describes this
situation?
A. Tis patient has had an AMI and further testing is unnecessary B. A second CKMB and myoglobin
test should have been performed at 3 hours postadmission to con rm AMI C. Tese res
ults are
consistent with skeletal muscle damage associated with a crush injury that eleva
ted the CK-MB D.
Further testing 612 hours postadmission is required to establish a diagnosis of A
MI
Chemistry/Evaluate laboratory data to recognize health and disease states/Cardia
c markers/2 35.
SITUATION: An EDTA sample for TnI assay gives a result of 0.04 ng/mL (reference
range 00.03
ng/mL). The test is repeated 3 hours later on a new specimen and the result is 0
.06 ng/mL. A
third sample collected 6 hours later gives a result of 0.07 ng/mL. The EKG showe
d no evidence of
ST segment elevation (STEMI). What is the most likely explanation? A. A false-po
sitive result
occurred due to matrix interference B. Heparin should have been used instead of
EDTA, which
causes false positives C. Te patient has su ered cardiac injury D. Te patient has
had an ischemic
episode without cardiac injury Chemistry/Evaluate laboratory data to recognize h
ealth and disease

states/Cardiac markers/3 36. Which of the following laboratory tests is a marker

for ischemic
heart disease? A. CK-MB isoforms B. Myosin light chain 1 C. Albumin cobalt bindi
ng D. Free fatty
acid binding protein Chemistry/Correlate clinical and laboratory data/ Cardiac m
arkers/1 270
Chapter 5 | Clinical Chemistry Answers to Questions 3436 34. A Results on admissi
on indicate
strongly that the patient has su ered an MI. The 3-hour TnI con rms this and rules o
ut the
possibility of a sample collection or transcription error for the admission samp
le. Repeat
testing of other cardiac markers at 3 hours was not necessary because admission
results were
signi cantly increased for all three markers. Skeletal muscle damage or crush inju
ry does not
cause an increase in cardiac TnI. 35. C EDTA is the additive of choice for tropo
nin assays
because it avoids microclots that can lead to false positive results when serum
or heparinized
plasma is used. Spurious false positives caused by matrix e ects usually revert to
normal when
the test is repeated on a new sample. An AMI will cause the TnI to increase in s
ubsequent tests.
Results between 0.040.10 ng/mL are the result of cardiac injury, and indicate eit
her AMI or an
increased short-term risk of AMI. 36. C When heart muscle suffers reversible dam
age as a result
of oxygen deprivation, free radicals are released from the cells and bind to cir
culating albumin.
The albumin is modified at the N-terminus, causing a reduced ability to bind cer
tain metals. This
ischemia-modified albumin can be measured by its inability to bind cobalt. An ex
cess of cobalt is
incubated with plasma followed by addition of dithiothreitol. The sulfhydryl com
pound complexes
with the free cobalt, forming a colored complex. The absorbance of the reaction
mixture is
directly proportional to the ischemia-modified albumin concentration. In additio
n to
ischemia-modified albumin, glycogen phosphorylase-BB is a marker for ischemia be
cause it is
released from heart muscle during an ischemic episode. Myosin light chains and f
atty acidbinding
protein are released from necrotic heart tissue in the early stages of AMI. 2828
_Ch05_171-326
06/08/12 5:14 PM Page 270 37. Which test becomes abnormal in the earliest stag
e of the acute
coronary syndrome? A. Myosin light chain 1 B. CK-MB isoforms C. Myoglobin D. Hig
h-sensitivity
C-reactive protein Chemistry/Correlate laboratory data with physiological proces
ses/Enzymes/2 38.
Which statement best describes the clinical utility of B-type natriuretic peptid
e (BNP)? A.
Abnormal levels may be caused by obstructive lung disease B. A positive test ind
icates prior
myocardial damage caused by AMI that occurred within the last 3 months C. A norm
al test result
(<100 pg/mL) helps rule out congestive heart failure in persons with symptoms as
sociated with

coronary insu ciency D. A level above 100 pg/mL is not signi cant if evidence of con
gestive heart
failure is absent Chemistry/Correlate clinical and laboratory data/ Cardiac mark
ers/2 5.7 |
Enzymes and Cardiac Markers 271 Answers to Questions 3738 37. D The acute coron
ary syndrome
(ACS) refers to the evolution of coronary artery events that lead up to AMI. Cor
onary artery
disease (CAD) begins with formation of a plaque comprised of lipid from dead end
othelium that
proliferates into the artery lumen. The plaque becomes disrupted and the vessel
wall in amed in
the asymptomatic stage of CAD. If platelet activation occurs and results in thro
mbosis, blood ow
becomes signi cantly reduced, resulting in angina. This signals the transition to
more advanced
disease in which ischemia to heart muscle occurs and eventually to AMI. Myoglobi
n and CK-MB
isoforms are not increased until the end stage of ACS. High-sensitivity C-reacti
ve protein
(hs-CRP) is an ultrasensitive CRP assay that accurately measures CRP below 1 mg/
L. CRP is an
acute-phase protein increased in in ammation. Levels of CRP between 3.210 mg/L sign
al low-grade
in ammation, which occurs in the asymptomatic phase of ACS. Such in ammation occurs
when coronary
artery plaques become disrupted, and therefore, persons with CAD who have a mild
ly increased CRP
are at high risk of disease progression. Glycogen phosphorylase-BB and albumin c
obalt binding are
increased by ischemia. Troponins are increased when there is unstable angina and
ischemic injury,
and indicate an increased risk for AMI. 38. C B-type natriuretic peptide is a ho
rmone produced by
the ventricles in response to increased intracardiac blood volume and hydrostati
c pressure. It is
formed in the heart from a precursor peptide (preproBNP) by enzymatic hydrolysis
, rst forming
proBNP followed by BNP and NT (N-terminal) proBNP which is not physiologically a
ctive. Both BNP
and NT-proBNP are increased in persons with congestive heart failure (CHF). Leve
ls are not
increased in pulmonary obstruction, hypertension, edema associated with renal in
su ciency, and
other conditions that cause physical limitation and symptoms that overlap CHF. A
t a cuto of <100
pg/mL the BNP test is e ective in ruling out CHF. Diagnostic accuracy in distingui
shing CHF from
nonCHF ranges from 83%95%. In addition, persons with ischemia who have an increas
ed BNP are at
greater risk for MI. The NTpro-BNP assay is similar in clinical value, and can b
e used for
persons being treated with nesiritide, a recombinant form of BNP used to treat C
HF.
2828_Ch05_171-326 06/08/12 5:14 PM Page 271 39. Which statement best describe
s the clinical
utility of plasma homocysteine? A. Levels are directly related to the quantity o
f LDL cholesterol
in plasma B. High plasma levels are associated with atherosclerosis and increase
d risk of

thrombosis C. Persons who have an elevated plasma homocysteine will also have an
increased plasma
Lp(a) D. Plasma levels are increased only when there is an inborn error of amino
acid metabolism
Chemistry/Correlate clinical and laboratory data/ Cardiac markers/2 40. Which of
the following
cardiac markers derived from neutrophils predicts an increased risk for myocardi
al infarction? A.
Phospholipase A 2 (PLA 2 ) B. Glycogen phosphorylase BB (GPBB) C. Soluble CD40 l
igand (sCD40l) D.
Myeloperoxidase (MPO) Chemistry/Correlate clinical and laboratory data/ Cardiac
markers/2 41.
Which of the following statements about the aminotransferases (AST and ALT) is t
rue? A.
Isoenzymes of AST and ALT are not found in humans B. Both transfer an amino grou
p to
ketolut
r
te C. Both require NADP+
s
coenzyme D. Both utilize four c
r on
min
o
cids
s
su str
tes Chemistry/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics/A
minotr
nsfer
se/2
42. Select the products formed from the forw
rd re
ction of AST. A. Al
nine
nd ke
tolut
r
te
B. Ox
lo
cet
te
nd lut
m
te C. Asp
rt
te
nd lut
mine D. Glut
m
te
nd NADH C
hemistry/Apply
knowlede of fund
ment
l ioloic
l ch
r
cteristics/Aminotr
nsfer
se/1 43. Selec
t the products
formed from the forw
rd re
ction of ALT. A. Asp
rt
te
nd
l
nine B. Al
nine
nd
ketolut
r
te
C. Pyruv
te
nd lut
m
te D. Glut
mine
nd NAD + Chemistry/Apply knowlede of fu
nd
ment
l
ioloic
l ch
r
cteristics/Aminotr
nsfer
se/1 272 Ch
pter 5 | Clinic
l Chemistry
Answers to
Questions 3943 39. B Homocysteine includes the monomeric
mino
cid
s well
s th
e dimers such

s homocystine th
t cont
in homocysteine. Pl
sm
levels
re me
sured
s
n indep
endent risk
f
ctor for coron
ry
rtery dise
se. Hih levels of homocysteine
re toxic to v
s
cul
r endothelium

nd promote in
mm
tion
nd pl
que form
tion. Pl
sm
levels
re independent of LDL

nd other
cholesterol fr
ctions
nd help expl
in why
pproxim
tely 35% of people with rst-t
ime AMI h
ve
LDL cholesterol levels < 130 m/dL. 40. D All of the
nswer choices
re m
rkers
for
cute
coron
ry syndrome
nd incre
sed risk of AMI. MPO is rele
sed from neutrophils
n
d is thouht to
dest
ilize the
rteri
l pl
que y oxidizin oth LDL
nd HDL
nd reducin nitri
c oxide levels in
the coron
ry
rteries. Levels in the upper third qu
rtile predict
n incre
sed r
isk of
coron
ry
event even when troponin is norm
l. GPBB is rele
sed from myocytes e
rly in
n i
schemic episode

nd ecomes
norm
l
out 2 hours
fter
n AMI. sCD40l is rele
sed from
ctiv
t
ed pl
telets
nd
indic
tes
n unst
le pl
que. PLA 2 is produced y the
rteri
l w
ll. It removes

f
tty
cid
from phospholipids
nd incre
ses the
mount of oxidized LDL, le
din to fo
m cel
l form
tion. Like
hs-CRP, it is
m
rker for
n in
med pl
que. 41. B ALT c
t
lyzes the tr
nsfer of

n
mino roup

from
l
nine,
three-c
r on
mino
cid, to ketolut
r
te (2oxolut
r
te), formin

pyruv
te.
AST c
t
lyzes the tr
nsfer of
n
mino roup from
sp
rt
te (four c
r ons) to keto
lut
r
te,
formin ox
lo
cet
te. The re
ctions
re hihly reversi le
nd reul
te the ow of

sp
rt
te into
the ure
cycle. Both tr
ns
min
ses require P-5-P
s
n intermedi
te
mino
ccepto
r (coenzyme).
Cytopl
smic
nd mitochondri
l isoenzymes
re produced ut
re not di erenti
ted in
clinic
l
pr
ctice. 42. B AST forms ox
lo
cet
te
nd lut
m
te from
sp
rt
te
nd ketolut
r

te
(2oxolut
r
te). Both tr
ns
min
ses use ketolut
r
te
nd lut
m
te
s
common su
str
te
nd
product p
ir. Both
sp
rt
te
nd
l
nine c
n e used to ener
te lut
m
te in th
e centr
l nervous
system, where it
cts
s
neurotr
nsmitter. 43. C Bec
use lut
m
te is
common
product for
tr
ns
min
ses, pyruv
te (
three-c
r on keto
cid)
nd lut
m
te would e ener
t
ed from the
tr
ns
min
tion re
ction etween
l
nine
nd ketolut
r
te. 2828_Ch05_171-326 06/0
8/12 5:14 PM
P
e 272 44. Which of the st
tements elow re
rdin the methods of Henry for A
ST
nd ALT is
correct? A. Hemolysis will c
use positive interference in oth AST
nd ALT
ss
y
s B. Loss of

ctivity occurs if s
mples
re frozen
t 20C C. Te
sor
nce
t the st
rt of the
re
ction
should not exceed 1.0 A D. Re
ction r
tes
re un
ected y
ddition of P-5-P to the
su str
te
Chemistry/Apply principles of
sic l
or
tory procedures/Aminotr
nsfer
se/2 45.
Select the
couplin enzyme used in the kinetic AST re
ction of Henry. A. LD B. M
l
te dehyd
roen
se C.
Glut
m
te dehydroen
se D. G-6-PD Chemistry/Apply principles of
sic l
or
tory
procedures/Aminotr
nsfer
se/1 46. Wh
t is the purpose of LD in the kinetic metho
d of Henry for
AST? A. Forms NADH, en
lin the re
ction to e monitored
t 340 nm B. R
pidly e
xh
usts
endoenous pyruv
te in the l
 ph
se C. Reduces ox
lo
cet
te, preventin product
inhi ition D.
Gener
tes l
ct
te, which
ctiv
tes AST Chemistry/Select re
ents/Aminotr
nsfer
s
e/2 47. Which of
the followin st
tements re
rdin the n
min of tr
ns
min
ses is true? A. Serum
lut
mic
ox
lo
cetic tr
ns
min
se (SGOT) is the older
revi
tion for ALT B. Serum lut

mic pyruvic
tr
ns
min
se (SGPT) is the older
revi
tion for AST C. SGPT is the older
re
vi
tion for ALT
D. SGOT is the newer
revi
tion for AST Chemistry/Apply knowlede of fund
ment

l ioloic
l
ch
r
cteristics/Aminotr
nsfer
se/1 48. Which st
tement
ccur
tely descri es seru
m tr
ns
min
se
levels in AMI? A. ALT is incre
sed 5- to 10-fold
fter
n AMI B. AST pe
ks 2448 h
ours
fter
n
AMI
nd returns to norm
l within 46 d
ys C. AST levels
re usu
lly 2050 times the
upper limit
of norm
l
fter
n AMI D. Isoenzymes of AST
re of re
ter di
nostic utility th

n the tot
l
enzyme level Chemistry/Correl
te clinic
l
nd l
or
tory d
t
/ Aminotr
ns
min
se

s/2 5.7 | Enzymes

nd C
rdi
c M
rkers 273 Answers to Questions 4448 44. A RBCs
re rich in AST
n
d to
lesser
extent in ALT. Hemolysis c
uses positive interference in oth
ss
ys,
lthouh t
he e ect on AST
is re
ter. S
mples
re st
le for up to 24 hours
t room temper
ture
nd up to
3 d
ys
t 4C,

nd should e frozen if kept loner. The st
rtin
sor
nce should e
t le
st
1.5 A for oth

ss
ys. Su str
tes with lower concentr
tions of NADH
re su ject to NADH depleti
on durin the l

ph
se due to side re
ctions or hih tr
ns
min
se
ctivity. When P-5-P is
dded,

sini c
nt
incre
se in
ctivity sometimes occurs ec
use some of the enzyme in the serum is
in the in
ctive

poenzyme form. 45. B The method of Henry for AST uses m
l
te dehydroen
se (MD)
to reduce
ox
lo
cet
te to m
l
te. The electrons come from NADH formin NAD + . Asp
rt
te +
ketolut
r
te
AST Ox
lo
cet
te + Glut
m
te Ox
lo
cet
te + NADH + H + MD M
l
te + NAD + 46. B P

tients with
liver dise
se often h
ve hih levels of pyruv
te
nd LD. The LD c
n c
t
lyze the
re
ction of
pyruv
te with NADH in the su str
te, formin NAD +
nd l
ct
te. This would ive

f
lsely hih
r
te for AST ec
use NAD + is the product me
sured. Addin LD to the su str
te c

uses pyruv
te to
e depleted in the rst 30 seconds, efore AST
nd MD re
ctions re
ch ste
dy st
te
. 47. C SGOT
refers to the products me
sured in the in vitro re
ction,
nd is more correctly
n
med AST for the
four-c
r on
mino
cid su str
te
sp
rt
te. SGPT is the older n
me referrin to
the products of
the re
ction for ALT. SGPT is more correctly n
med ALT for the three-c
r on
min
o
cid su str
te

l
nine. 48. B ALT m
y e slihtly elev
ted
fter
n AMI. AST levels c
n e up t
o 510 times the
URL
fter AMI, ut elev
tions of this r
ne
re
lso seen in p
tients with muscu
l
r dystrophy,
crush injury, pulmon
ry em olism, infectious mononucleosis,
nd c
ncer of the l
iver.
2828_Ch05_171-326 06/08/12 5:14 PM P
e 273 49. Which condition ives rise to
the hihest
serum level of tr
ns
min
ses? A. Acute hep
titis B. Alcoholic cirrhosis C. O str
uctive ili
ry
dise
se D. Di use intr
hep
tic cholest
sis Chemistry/Correl
te clinic
l
nd l
or

tory d
t
/
Aminotr
nsfer
se/2 50. In which liver dise
se is the DeRitis r
tio (ALT:AST) usu

lly re
ter th
n
1.0? A. Acute hep
titis B. Chronic hep
titis C. Hep
tic cirrhosis D. Hep
tic c
r
cinom

Chemistry/Ev
lu
te l
or
tory d
t
to reconize he
lth
nd dise
se st
tes/Aminot
r
nsfer
se/2 51.
Which of the followin liver dise
ses produces the hihest levels of tr
ns
min
s
es? A. Hep
tic
cirrhosis B. O structive j
undice C. Hep
tic c
ncer D. Alcoholic hep
titis Chemi
stry/Correl
te
clinic
l
nd l
or
tory d
t
/ Aminotr
nsfer
se/2 52. Which of the followin st
t
ements re
rdin
tr
ns
min
ses is true? A. ALT is often incre
sed in muscul
r dise
se, p
ncre
tit

is,
nd lymphom

B. ALT is incre
sed in infectious mononucleosis, ut AST is usu
lly norm
l C. AL
T is f
r more
speci c for liver dise
ses th
n is AST D. Su str
te depletion seldom occurs in
ss

ys of serum
from hep
titis c
ses Chemistry/Correl
te clinic
l
nd l
or
tory d
t
/ Aminotr
n
s
min
ses/2 53.
Select the most sensitive m
rker for
lcoholic liver dise
se. A. GLD B. ALT C. A
ST D.
-Glut
myltr
nsfer
se (GGT) Chemistry/Correl
te clinic
l
nd l
or
tory d
t
/ Enzy
mes/2 54. Which
enzyme is le
st useful in di erenti
tin necrotic from o structive j
undice? A. GG
T B. ALT C. 5
Nucleotid
se D. LD Chemistry/Correl
te clinic
l
nd l
or
tory d
t
/ Enzymes/2 2
74 Ch
pter 5 |
Clinic
l Chemistry Answers to Questions 4954 49. A The tr
ns
min
ses usu
lly re
c
h 2050 times
the URL in
cute vir
l
nd toxic hep
titis. Both tr
ns
min
ses
re moder
tely in
cre
sed (510
URL) in infectious mononucleosis, toxic hep
titis, di use intr
hep
tic o struction
, lymphom
,
nd
c
ncer of the liver,
nd slihtly incre
sed (25 URL) in cirrhosis
nd extr
hep
ti
c
o struction. 50. A ALT prev
ils over AST in hep
titis; however, AST is re
ter t
h
n ALT in
c
rcinom
,
lcoholic liver dise
se,
nd cirrhosis of the liver. 51. C Elev
tion
of tr
ns
min
ses
is re
test in
cute hep
titis (2050 URL). Levels
re moder
tely elev
ted (510 URL
) in
hep
tic c
ncer. They
re slihtly elev
ted (25 URL) in chronic hep
titis, hep
tic
cirrhosis,

lcoholic hep
titis,
nd o structive j
undice. 52. C ALT is f
r more speci c for l
iver dise
se
th
n AST. Hih ALT m
y result from nonhep
tic c
uses such
s AMI, muscle injury
or dise
se,
nd
severe hemolysis, ut nonhep
tic sources c
n e ruled out y
hih direct ilir
u in. Elev
ted
ALT (e.., >65 IU/L) is used
lon with immunoloic tests for hep
titis to disqu

lify lood
donors. AST is incre
sed in muscle dise
se, MI, p
ncre
titis,
nd lymphom
. Both
tr
ns
min
ses

re moder
tely incre
sed in infectious mononucleosis. 53. D Althouh AST
nd ALT

re elev
ted in

lcoholic hep
titis, GGT is
more sensitive indic
tor of
lcoholic liver dise
s
e. Levels of GGT
c
n re
ch in excess of 25 times the URL in
lcoholic hep
titis. It is
lso m
rke
dly elev
ted in
o structive j
undice;
hih GGT supports the inference th
t liver is the tissue
source of
n
elev
ted ALP. 54. D GGT
nd 5 nucleotid
se
re m
rkedly elev
ted in oth intr
-

nd posthep
tic
o struction. ALT is slihtly elev
ted in o structive j
undice ut is m
rkedly el
ev
ted in
necrotic j
undice. Althouh LD is usu
lly re
ter in necrotic j
undice th
n in o
structive
j
undice, elev
tions in these conditions overl
p frequently
nd result from m
ny
other c
uses.
2828_Ch05_171-326 06/08/12 5:14 PM P
e 274 55. Which of the followin st
tem
ents
out the
phosph
t
ses is true? A. Tey hydrolyze
denosine triphosph
te
nd rel
ted compou

nds B. Tey
re

divided into two cl
sses
sed upon pH needed for
ctivity C. Tey exhi it
hih
speci city for
su str
te D. Tey
re
ctiv
ted y P i Chemistry/Apply knowlede of fund
ment
l
ioloic
l
ch
r
cteristics/Phosph
t
ses/1 56. Which of the followin st
tements re
rdin A
LP is true? A. In
norm
l
dults, the prim
ry tissue source is f
st-twitch skelet
l muscle B. Geri

tric p
tients
h
ve
lower serum ALP th
n other
dults C. Serum ALP levels
re lower in childr
en th
n in
dults
D. Pren
nt women h
ve
hiher level of serum ALP th
n other
dults Chemistry/C
orrel
te clinic
l

nd l
or
tory d
t
/ Phosph
t
ses/2 57. Which isoenzyme of ALP is most he
t st

le? A. Bone B.
Liver C. Intestin
l D. Pl
cent
l Chemistry/Apply knowlede of fund
ment
l iolo
ic
l
ch
r
cteristics/Phosph
t
ses/1 58. Which isoenzyme of ALP mir
tes f
rthest tow

rd the
node when
electrophoresed
t pH 8.6? A. Pl
cent
l B. Bone C. Liver D. Intestin
l Chemistry
/Apply principles
of speci
l procedures/ Phosph
t
ses/1 59. Which st
tement re
rdin one-speci c A
LP is true? A.
Te one isoenzyme c
n e me
sured immunochemic
lly B. Bone ALP is incre
sed in
one resorption C.
Bone ALP is used for the di
nosis of osteoporosis D. Tere
re two distinct one
isoenzymes
Chemistry/Apply principles of speci
l procedures/ Phosph
t
ses/1 5.7 | Enzymes

nd C
rdi
c
M
rkers 275 Answers to Questions 5559 55. B Phosph
t
ses
re cl
ssi ed
s either

lk
line or

cid dependin upon the pH needed for optimum
ctivity. The phosph
t
ses hydroly
ze
wide r
ne
of monophosphoric
cid esters. ALP is inhi ited y phosphorus (product inhi itio
n). The
Intern
tion
l Feder
tion of Clinic
l Chemistry (IFCC) recommended method employs
2-
mino-2-methyl-1-prop
nol,
u er th
t inds P i . 56. D ALP is hiher in child
ren th
n in

dults due to one rowth. Children
nd eri
tric p
tients h
ve hiher serum ALP
due to incre
sed
one isoenzyme. Serum ALP levels
re often two- or threefold hiher th
n the URL
in the third
term of pren
ncy. In nonpren
nt norm
l
dults, serum ALP is derived from liver

nd one. Liver,
one, pl
cent
l, ren
l,
nd intestin
l isoenzymes of ALP c
n e sep
r
ted y ele
ctrophoresis,
nd
m
ny other ALP isoenzymes h
ve een identified y isofocusin. 57. D Pl
cent
l A
LP
nd
tumor-
ssoci
ted isoenzymes such
s the Re
n isoenzyme
ssoci
ted with lun c
n
cer
re the only
isoenzymes th
t ret
in
ctivity when serum is he
ted to 65 C for 10 minutes. He
t
in
ctiv
tion
is used prim
rily to distinuish liver ALP from one ALP. If less th
n 20%
ctiv
ity rem
ins
fter
he
tin serum to 56C for 10 minutes, then one ALP is most likely present. 58. C
Liver ALP
isoenzymes mir
te f
rthest tow
rd the
node, ut f
st
nd slow v
ri
nts occur.
The slow liver
ALP
nd is di cult to distinuish from pl
cent
l
nd one ALP. The order from c
t
hode to
node

is: Ren
lIntestin
lBonePl
cent
lLiver + Improved sep
r
tion of one
nd liver isoenz

ymes
c
n e
chieved y incu
tin the serum with neur
minid
se prior to electrophore
sis. The enzyme
reduces the si
lic content of the one isoenzyme, c
usin it to mir
te
t
slo
wer r
te. 59. A
Bone ALP
ss
ys (Ost
se
nd Alkph
se-B) use monoclon
l
nti odies to me
sure the
one isoenzyme
in m
ss units. The
ss
ys m
y e used to monitor one remodelin y osteo l
sts
in osteoporosis,

nd thus,
re useful for followin tre
tment. Bone speci c ALP is not su ciently sen
sitive to
di
nose osteoporosis,
nd
nti odies m
y cross-re
ct with other ALP isoenzymes,
dependin on
their source. 2828_Ch05_171-326 06/08/12 5:14 PM P
e 275 60. Which of the fo
llowin
st
tements re
rdin ALP is true? A. All isoenzymes of ALP
re
ntienic
lly dis
tinct
nd c
n e
identi ed y speci c
nti odies B. Hihest serum levels
re seen in intr
hep
tic o s
truction C.
Elev
ted serum ALP seen with elev
ted GGT suests
hep
tic source D. When j
un
dice is present,

n elev
ted ALP suests
cute hep
titis Chemistry/Correl
te clinic
l
nd l
or

tory d
t
/
Phosph
t
ses/2 61. In which condition would
n elev
ted serum
lk
line phosph
t

se e likely to
occur? A. Sm
ll cell lun c
rcinom
B. Hemolytic
nemi
C. Prost
te c
ncer D. Ac
ute myoc
rdi
l
inf
rction Chemistry/Correl
te clinic
l
nd l
or
tory d
t
/ Phosph
t
ses/2 62.
Which condition
is le
st likely to e
ssoci
ted with incre
sed serum ALP? A. Osteom
l
ci
B. Bi
li
ry o struction
C. Hyperp
r
thyroidism
nd hyperthyroidism D. Osteoporosis Chemistry/Correl
te c
linic
l
nd
l
or
tory d
t
/ Phosph
t
ses/2 63. Which su str
te is used in the BowersMcCom m
ethod for ALP?
A. p-Nitrophenyl phosph
te B. -Glycerophosph
te C. Phenylphosph
te D. -N
phthylpho
sph
te
Chemistry/Apply principles of
sic l
or
tory procedures/Phosph
t
ses/2 64. Whi
ch of the
followin u ers is used in the IFCC recommended method for ALP? A. Glycine B. Pho
sph
te C.
2-Amino-2-methyl-1-prop
nol D. Citr
te Chemistry/Apply principles of
sic l
or

tory
procedures/Phosph
t
ses/2 276 Ch
pter 5 | Clinic
l Chemistry Answers to Question
s 6064 60. C ALP
isoenzymes c
n result from di erent enes or from modi c
tion of
common ene produ
ct in the
tissues. Some di er m
inly in c
r ohydr
te content
nd c
nnot e identi ed y immuno
loic
methods. Hihest levels of ALP
re seen in P
ets dise
se of one, where ALP c
n
e
s hih
s
25 times the URL. GGT in serum is derived from the hep
to ili
ry system
nd is i
ncre
sed in

lcoholic hep
titis
nd hep
to ili
ry o struction. It is not incre
sed in dise
s
es of one or in
pren
ncy. When the incre
se in GGT is twofold hiher th
n the incre
se in ALP,
the liver is

ssumed to e the source of the elev
ted ALP. Serum ALP is
sensitive m
rker fo
r extr
hep
tic

o struction, which c
uses
n incre
se of
pproxim
tely 10 times the URL. A lesse

r incre
se is
seen in intr
hep
tic o struction. ALP is only mildly elev
ted in
cute hep
titis

s
result of

ccomp
nyin o struction. 61. A The prim
ry di
nostic utility of ALP is to help
di erenti
te
necrotic j
undice (ALT) from o structive j
undice ( ALP). ALP is
lso incre
sed in
sever
l one
dise
ses. L
re incre
ses
re seen in P
ets dise
se, moder
te incre
ses in one
c
ncer,
nd
sliht incre
ses in rickets. Tot
l ALP m
y e slihtly incre
sed in osteoporosis
ut often it is
not. In
ddition to o structive j
undice
nd one dise
ses,
lk
line phosph
t
se
is
tumor
m
rker. In most c
ses, the
lk
line phosph
t
se is the product of fet
l ene
ct
iv
tion,
nd
resem les pl
cent
l ALP (e.., hep
tom
, sm
ll cell c
rcinom
of the lun, ov
ri

n c
ncer).
Leukemi

nd Hodkins dise
se m
y c
use
n elev
ted leukocyte or one-derived ALP
. 62. D ALP is
elev
ted in osteom
l
ci
(rickets), one c
ncer,
nd one dise
se second
ry to h
yperthyroidism

nd hyperp
r
thyroidism, ut tot
l ALP it is hih in less th
n 30% of osteoporos
is p
tients.
P
ncre
tic dise
se
ssoci
ted with ili
ry o struction, such
s c
ncer
t the he

d of the
p
ncre
s, is
ssoci
ted with elev
ted ALP. 63. A The method of BowersMcCom (Sz
s
z modi c
tion)
is the IFCC-recommended method for ALP. This method uses 2-
mino-2-methyl-1-prop

nol, pH 10.15,

nd me
sures the incre
se in
sor
nce
t 405 nm
s p-nitrophenyl phosph
te is
hydrolyzed to
p-nitrophenol. 64. C The Sz
sz modific
tion of the BowersMcCom method me
sures t
he hydrolysis
of p-nitrophenyl phosph
te,
nd continuously monitors the form
tion of p-nitroph
enol
t 405 nm.
AMP uffer chel
tes phosphorus, preventin product inhi ition; Zn +2
nd M +2

re
dded to the
su str
te to
ctiv
te ALP. HEDTA is used to chel
te the excess Zn +2 , which is
inhi itory
t
hih concentr
tions. 2828_Ch05_171-326 06/08/12 5:14 PM P
e 276 65. A serum
ALP level re
ter
th
n twice the elev
tion of GGT suests: A. Misidenti c
tion of the specimen B. F
oc
l
intr
hep
tic o struction C. Acute
lcoholic hep
titis D. Bone dise
se or m
lin

ncy
Chemistry/Ev
lu
te l
or
tory d
t
to reconize he
lth
nd dise
se st
tes/Enzyme
s/2 66. In which
condition is the me
surement of
cid phosph
t
se clinic
lly useful? A. Me
surin
the prost
tic
isoenzyme to screen for prost
te c
ncer B. Me
surin the enzyme in
v
in
l sw

extr
ct C. Te
di
nosis of hemolytic
nemi
D. As
m
rker for one reener
tion Chemistry/App
ly knowlede to
identify sources of error/Phosph
t
ses/3 67. Which de nition est descri es the c

t
lytic

ctivity of
myl
se? A. Hydrolyzes second 14 lycosidic link
es of st
rch, lyco
en,
nd
other polyluc
ns B. Hydrolyzes
ll polyluc
ns completely to produce lucose C.
Oxid
tively

der
des polys
cch
rides cont
inin lucose D. Splits polys
cch
rides
nd dis
cc

h
rides y

ddition of w
ter Chemistry/Apply knowlede of fund
ment
l ioloic
l ch
r
cteri
stics/Enzymes/1
68. Which of the followin
myl
se su str
tes is recommended y the IFCC? A. St

rch B.
M
ltodextrose C. M
ltotetrose D. Blocked m
ltohep
toside Chemistry/Apply knowled
e of
sic
l
or
tory procedures/Enzymes/1 69. How soon followin
cute
domin
l p
in due
to p
ncre
titis
is the serum
myl
se expected to rise? A. 12 hours B. 212 hours C. 34 d
ys D. 56 d
y
s
Chemistry/Correl
te clinic
l
nd l
or
tory d
t
/ Enzymes/2 5.7 | Enzymes
nd C

rdi
c M
rkers
277 Answers to Questions 6569 65. D In o structive j
undice, GGT is elev
ted more
th
n ALP. A
disproportion
te incre
se in ALP points to
nonhep
tic source of ALP, often on
e dise
se. GGT is
the most sensitive m
rker of
cute
lcoholic hep
titis, risin
out vefold hihe
r th
n ALP or
tr
ns
min
ses. 66. B The PSA test is clinic
lly more sensitive th
n prost
tic
c
id phosph
t
se in
detectin prost
tic c
ncer. The clinic
l use of prost
tic
cid phosph
t
se is co
n ned to the
investi
tion of sexu
l
ss
ult. Acid phosph
t
se
ctivity > 50 IU/L est
lishes
the presence of
semin
l uid in the v
in
l s
mple. T
rtr
te-resist
nt
cid phosph
t
se is used
s

cytochemic
l
m
rker for h
iry-cell leukemi
,
nd m
y e me
sured in serum to identify dise
se
s with incre
sed
osteocl
st
ctivity, p
rticul
rly m
lin
ncies involvin one. 67. A Amyl
se in
hum
ns is

hydrol
se th
t splits the second 1-4 lycosidic onds of polyluc
ns formin m
l
tose. There
re
two m
jor types of
myl
se: P-type derived from the p
ncre
s
nd S-type derived
from the s
liv
ry
l
nds. These c
n e differenti
ted y oth electrophoresis
nd immuno
ss
y. In
he
lthy persons,
the princip
l form in pl
sm
is the s
liv
ry isoenzyme. There
re sever
l eneti
c v
ri
nts of the
s
liv
ry isoenzyme, which in p
rt
ccounts for the ro
d reference r
ne. 68. D
Amyl
se is
commonly me
sured usin synthetic su str
tes. In the IFCC-recommended method, pnitrophenyl
m
ltohep
tiside is used. One end of the polymer is cov
lently linked to p-nitrop
henol
nd the
other is linked to 4,6 ethylidine to prevent its hydrolysis y -lucosid
se. Amyl

se hydrolyzes
the su str
te from oth ends producin fr
ments of 2, 3,
nd 4 lucose su units
. -Glucosid
se
hydrolyzes the su units cont
inin p-nitrophenyl roups, formin lucose
nd p-n
itrophenol. The
incre
se
sor
nce
t 405 nm is proportion
l to
myl
se
ctivity. 69. B Serum

myl
se usu
lly
pe
ks 212 hours followin
cute
domin
l p
in resultin from p
ncre
titis. Level
s re
ch 26
times the URL
nd return to norm
l within 34 d
ys. Urin
ry
myl
se pe
ks concurre
ntly with serum
ut rises hiher
nd rem
ins elev
ted for up to 1 week. 2828_Ch05_171-326 06/08
/12 5:14 PM

P
e 277 70. Which of the followin st
tements re
rdin the di
nosis of p
ncre

titis is
correct? A. Amyl
se
nd lip
se
re
s predictive in chronic
s in
cute p
ncre
t
itis B.
Di
nostic sensitivity is incre
sed y
ss
yin oth
myl
se
nd lip
se C. Me
su
rin the urin
ry

myl
se:cre
tinine r
tio is useful only when p
tients h
ve ren
l f
ilure D. Seru
m lip
se pe
ks
sever
l hours efore
myl
se
fter
n episode of
cute p
ncre
titis Chemistry/Co
rrel
te clinic
l

nd l
or
tory d
t
/ Enzymes/2 71. Which of the followin conditions is
ssoci
t
ed with
hih
level of S-type
myl
se? A. Mumps B. Intestin
l o struction C. Alcoholic liver d
ise
se D. Peptic
ulcers Chemistry/Correl
te clinic
l
nd l
or
tory d
t
/ Enzymes/2 72. Which of
the followin
st
tements re
rdin
myl
se methods is true? A. Requires sulfhydryl compounds f
or full
ctivity
B. Activity will v
ry dependin on the method used C. Amylocl
stic methods me
su
re the production
of lucose D. Overr
ne s
mples
re diluted in deionized w
ter Chemistry/Apply k
nowlede of
sic
l
or
tory procedures/Enzymes/2 278 Ch
pter 5 | Clinic
l Chemistry Answers to Qu
estions 7072 70.
B Amyl
se is not incre
sed in
ll persons with p
ncre
titis
nd c
n e incre
sed
in sever
l
nonp
ncre
tic conditions. Lip
se
dds oth sensitivity
nd speci city to the di
n
osis of
cute
p
ncre
titis. Pl
sm
or serum lip
se ecomes
norm
l within 6 hours, pe
ks
t

pproxim
tely 24
hours,
nd rem
ins
norm
l for
out 1 week followin
n episode of
cute p
ncr
e
titis. In
cute
p
ncre
titis, the r
te of urin
ry
myl
se excretion incre
ses,
nd the
myl
se:c
re
tinine
cle
r
nce r
tio is helpful in di
nosin some c
ses of p
ncre
titis. The norm
l
A:C cle
r
nce
r
tio is 1%4%. In
cute p
ncre
titis, the r
tio is usu
lly
ove 4%
nd c
n e
s
hih
s 15%.
In chronic p
ncre
titis,
cin
r cell deener
tion often occurs, resultin in los
s of
myl
se
nd
lip
se production. This lowers the sensitivity of
myl
se
nd lip
se in detectin
 chronic dise
se
to elow 50%. P
tients with chronic dise
se h
ve p
ncre
tic insu ciency ivin ris
e to incre
sed
fec
l f
t,
nd decre
sed p
ncre
tic diestive enzymes such
s trypsin, chymotryp
sin,
nd el
stin.
71. A Both s
liv
ry
nd p
ncre
tic
myl
ses desin
ted S-type
nd P-type, respec
tively,
re
present in norm
l serum. Hih
myl
se occurs in mumps, ectopic pren
ncy, ili
r
y o struction,
peptic ulcers,
lcoholism, m
lin
ncies,
nd other nonp
ncre
tic dise
ses. Isoen
zymes c
n e
sep
r
ted y electrophoresis (S-type is f
ster th
n P-type), ut more commonly i
mmunoinhi ition
of S-type
myl
se is used to rule out mumps, m
lin
ncy,
nd ectopic pren
ncy,
which ive rise
to hih S-type
myl
se. 72. B Chloride
nd C
2+ ions
re required for
myl
se

ctivity. S
mples
with hih
ctivity should e diluted with N
Cl to prevent in
ctiv
tion. Lip
se

nd CK require

sulfhydryl
ctiv
tors. S
cch
roenic methods me
sure the production of lucose,

while

mylocl
stic methods me
sure the der
d
tion of st
rch. St
rch is
polymer of -D
lucose
su units linked toether y oth 1-4
nd 1-6 lycosidic onds. Different lots m

y h
ve more
or less r
nchin owin to the num er of 1-6 onds. Since
myl
se hydrolyzes
t
the 1-4 sites
only, the
mount of product me
sured is influenced y the extent of r
nchin. 2
828_Ch05_171-326
06/08/12 5:14 PM P
e 278 73. Which of the followin st
tements re
rdin
myl

se methods is
true? A. Dilution of serum m
y result in lower th
n expected
ctivity B. Methods
ener
tin NADH

re preferred ec
use they h
ve hiher sensitivity C. Synthetic su str
tes c
n
e conju
ted to
p-nitrophenol (PNP) for
kinetic
ss
y D. Te reference r
ne is consistent from
method to method
Chemistry/Apply knowlede to identify sources of error/Enzymes/2 74. Te referenc
e method for
lip
se uses olive oil
s the su str
te ec
use: A. Other ester
ses c
n hydrolyze
trilyceride
nd
synthetic dilycerides B. Te re
ction product c
n e coupled to NADH ener
tin
re
ctions C.
Synthetic su str
tes
re less solu le th
n olive oil in
queous re
ents D. Tri
lyceride
su str
tes c
use product inhi ition Chemistry/Apply knowlede of
sic l
or
tor
y
procedures/Enzymes/2 75. Which st
tement
out the clinic
l utility of pl
sm
or
serum lip
se is
true? A. Lip
se is not incre
sed in mumps, m
lin
ncy, or ectopic pren
ncy B. L
ip
se is not
incre
sed
s dr
m
tic
lly
s
myl
se in
cute p
ncre
titis C. Incre
sed pl
sm
o
r serum lip
se is
speci c for p
ncre
titis D. Lip
se levels
re elev
ted in oth
cute
nd chronic p

ncre
titis
Chemistry/Correl
te clinic
l
nd l
or
tory d
t
/ Enzymes/2 76. Te reference met
hod for serum
lip
se is
sed upon: A. Ass
y of trilycerides followin incu
tion of serum wi
th olive oil B.
R
te tur idimetry C. Titr
tion of f
tty
cids with dilute N
OH followin control
led incu
tion of
serum with olive oil D. Immunochemic
l
ss
y Chemistry/Apply principles of
sic
l
or
tory
procedures/Enzymes/1 5.7 | Enzymes
nd C
rdi
c M
rkers 279 Answers to Question
s 7376 73. C
M
ny endoenous inhi itors of
myl
se, such
s whe
t erm,
re found in serum. D
iluted s
mples
often show hiher th
n expected
ctivity c
used y dilution of the inhi itor. Un
its of
myl
se

ctivity v
ry widely dependin upon the method of
ss
y
nd c
li r
tion. Synthet
ic su str
tes
such
s m
ltotetrose or 4-nitrophenyl m
ltohep
toside c
n e used for kinetic
s
s
ys.
M
ltotetrose is hydrolyzed to m
ltose y
myl
se,
nd the m
ltose hydrolyzed y lucosid
se or
m
ltose phosphoryl
se, formin lucose or lucose-1-phosph
te, respectively. The
se c
n e
me
sured y couplin to NADH-ener
tin re
ctions. Anti odies to the s
liv
ry is
oenzyme c
n e


dded to synthetic su str
te
ss
ys to inhi it S-type
myl
se. 74. A Trilycerid

es m
y e
hydrolyzed y nonspeci c ester
ses in serum
s well
s lip
se. Lip
se
cts only
t

n interf
ce
of oil
nd H 2 O
nd requires ile s
lts
nd colip
se for
ctivity. Colip
se is

protein
secreted y the p
ncre
s. 75. A Lip
se elev
tion is of re
ter m
nitude (2-50 N
)
nd dur
tion
th
n
myl
se in
cute p
ncre
titis. When the lip
se method is optimized y inclu
sion of colip
se

nd ile s
lts, the test is more sensitive
nd speci c th
n serum
myl
se for dete
ction of
cute
p
ncre
titis. However, lip
se is
lso incre
sed in peptic ulcers, ren
l insu cienc
y,
nd
intestin
l o struction. Lip
se levels
re often low in chronic p
ncre
titis,
nd

re low in
cystic rosis. 76. C The reference method of Cherry
nd Cr
nd
ll is
sed upon th
e titr
tion of
f
tty
cids formed y the hydrolysis of
n emulsion of olive oil
fter incu
tio
n for 24 hours
t
37C. Bec
use most of the
ctivity occurs within the rst 3 hours, the incu
tion ti
me m
y e
shortened to
s little
s 1 hour without loss of clinic
l utility. 2828_Ch05_171
-326 06/08/12
5:14 PM P
e 279 77. Te most commonly employed method of
ss
y for pl
sm
or se
rum lip
se is

sed on: A. Hydrolysis of olive oil B. R
te tur idimetry C. Immuno
ss
y D. Pero
xid
se couplin
Chemistry/Apply principles of
sic l
or
tory procedures/Enzymes/1 78. Which of
the followin
enzymes is usu
lly depressed in liver dise
se? A. El
st
se-1 B. GLD C. Pseudocho
linester
se D.
Aldol
se Chemistry/Correl
te clinic
l
nd l
or
tory d
t
/Enzymes/2 79. Which en
zyme is most
likely to e elev
ted in the pl
sm
of
person su erin from
muscle w
stin dis
order? A.
5-Nucleotid
se B. Pseudocholinester
se C. Aldol
se D. Glut
m
te dehydroen
se
Chemistry/Correl
te clinic
l
nd l
or
tory d
t
/Enzymes/2 280 Ch
pter 5 | Clini
c
l Chemistry
Answers to Questions 7779 77. D Althouh
ll of the methods cited
re
v
il
le,
the most
commonly used method for lip
se
ss
y is
sed upon the hydrolysis of
syntheti
c dilyceride
su str
te yieldin 2-monolyceride. This is hydrolyzed
nd forms lycerol, which
is
phosphoryl
ted
nd forms lycerol-3-phosph
te. This is oxidized y lycerophosph

te oxid
se,
yieldin hydroen peroxide. 1,2 dilyceride + H 2 O Lip
se 2-monolyceride + f
t
ty
cid 2monolyceride + H 2 O Monolyceride ester
se lycerol + f
tty
cid lycerol + AT
P Glycerol kin
se
lycerol-3-phosph
te + ADP lycerol-3-PO 4 + O 2 Glycerophosph
te oxid
se dihydr
oxy
cetone
phosph
te + H 2 O 2 H 2 O 2 + 4-
mino
ntipyrene + TOOS Peroxid
se quinoneimine d
ye + H 2 O 78. C
Pseudocholinester
se is found m
inly in the liver
nd functions to hydrolyze
ce
tylcholine. It is
depressed y or
nophosph
te insecticides
nd drus th
t function
s cholinester

se inhi itors

nd the serum
ss
y is used to presumptively identify c
ses of insecticide poiso

nin. Levels of
pseudocholinester
se
re decre
sed in p
tients with liver dise
se
s
result of
depressed
synthesis. In cirrhosis
nd hep
tom
, there is
50%70% reduction in serum level

nd
30%50%
reduction in hep
titis. El
st
se-1 is
p
ncre
tic diestive enzyme th
t re
ks
down connective
tissue protein. Its level in feces is reduced in persons with p
ncre
tic insuffi
ciency. GLD is
incre
sed in necrotic j
undice,
nd
ldol
se in necrotic j
undice
nd muscle dis
e
se. 79. C
5-Nucleotid
se is incre
sed prim
rily in o structive liver dise
se
nd liver c
nc
er. When
elev
ted
lon with ALP, it identi es the liver
s the source of ALP. Glut
m
te de
hydroen
se is
incre
sed in necrotic liver dise
ses
lon with tr
ns
min
ses, ut ec
use of it
s distri ution it
is elev
ted to
re
ter extent in toxic hep
titis
nd therefore is useful
s

m
rker for
h
loth
ne (
nesthesi
) toxicity. Aldol
se is found in
ll tissues
nd is incre
s
ed in m
ny
conditions includin myoc
rdi
l inf
rction, vir
l hep
titis,
nd myelocytic leuk
emi
. However,
like CK, the re
test incre
se is seen in skelet
l muscle-w
stin dise
se such

s muscul
r
dystrophies. 2828_Ch05_171-326 06/08/12 5:14 PM P
e 280 80. Which enzyme is
me
sured in whole
lood? A. Chymotrypsin B. Glucose-6-phosph
te dehydroen
se C. Glycoen phosphor
yl
se D. Lip
se
Chemistry/Apply principles of speci
l l
or
tory procedures/Enzymes/1 5.7 | Enzy
mes
nd C
rdi
c
M
rkers 281 Answer to Question 80 80. B Glucose-6-phosph
te dehydroen
se de cie
ncy is the most
common inherited RBC enzyme de ciency
nd is X linked. The enzyme is me
sured on

whole- lood
hemolys
te usin lucose-6-phosph
te
s the su str
te,
nd forms 6-phospholucon

te
s NADP+ is
converted to NADPH. Persons with the de ciency
re prone to
hemolytic episode up
on exposure to
cert
in oxid
tive drus
nd f
v
e
ns
nd
s
result of infections. Heinz odi
es form in the
RBCs, ite cells
re seen in the circul
tion,
nd pl
sm
h
ptolo in is reduced
in severe c
ses.
2828_Ch05_171-326 06/08/12 5:14 PM P
e 281 282 5.8 Clinic
l Endocrinoloy 1.
Which of the
followin hormones is often decre
sed y
pproxim
tely 25% in the serum of pren

nt women who
h
ve
fetus with Down syndrome? A. Estriol (E 3 ) B. Hum
n chorionic on
dotrop
in (hCG) C.
Proesterone D. Estr
diol (E 2 ) Chemistry/Correl
te l
or
tory d
t
with physio
loic
l
processes/Endocrine/2 2. Te syndrome of in
ppropri
te
ntidiuretic hormone secre
tion (SIADH)
c
uses: A. Low serum v
sopressin B. Hypern
tremi
C. Urine osmol
lity to e lowe
r th
n pl
sm
D.
Low serum electrolytes Chemistry/Correl
te clinic
l
nd l
or
tory d
t
/ Endocri
ne/2 3. Select
the hormone which when elev
ted is
ssoci
ted with 
l
ctorrhe
, pituit
ry
deno
m
,
nd

menorrhe
. A. E 2 B. Proesterone C. Follicle-stimul
tin hormone (FSH) D. Prol


ctin
Chemistry/Correl
te clinic
l
nd l
or
tory d
t
/Endocrine/2 4. ZollinerEllison
(ZE) syndrome
is ch
r
cterized y re
t (e.., 20-fold) elev
tion of: A. G
strin B. Cholecysto
kinin C. Pepsin
D. Gluc
on Chemistry/Correl
te clinic
l
nd l
or
tory d
t
/ G
stric/2 Answers
to Questions 14
1. A E 3 is produced in the pl
cent

nd fet
l liver from dehydroepi
ndrosterone
derived from the
mother
nd fet
l liver. E 3 is the m
jor estroen produced durin pren
ncy,
nd
levels rise
throuhout est
tion. Serum free E 3 is often lower th
n expected for the est
t
ion
l
e in

pren
ncy
ssoci
ted with Down syndrome. The com in
tion of low serum free estri
ol, low-
fetoprotein, hih hCG,
nd hih- inhi in A is used
s
screenin test to detect
Down syndrome.
When one of the four m
rkers is
norm
l,
mniocentesis should e performed for
the di
nosis of
Down syndrome y k
ryotypin or FISH. The four m
rkers h
ve
com ined sensitivi
ty (detection
r
te) of
pproxim
tely 75%. 2. D SIADH results in excessive secretion of v
sopre
ssin (ADH) from
the posterior pituit
ry, c
usin uid retention
nd low pl
sm
osmol
lity, sodium,
pot
ssium,
nd
other electrolytes y hemodilution. It is suspected when urine osmol
lity is hi
her th
n pl
sm
,
ut urine sodium concentr
tion is norm
l or incre
sed. P
tients with sodium depl
etion h
ve

urine osmol
lity hiher th
n pl
sm
, ut low urine sodium. 3. D Serum prol
ctin
m
y e incre
sed
from hypoth
l
mic dysfunction or pituit
ry
denom
. When levels
re re
ter th
n
ve times the
URL,
pituit
ry tumor is suspected. Prol
ctin is me
sured y enzyme immuno
ss
y
(EIA). 4. A ZE
syndrome is c
used y
p
ncre
tic or intestin
l tumor secretin 
strin (
stri
nom
),
nd
results in re
tly incre
sed 
stric
cid production. A serum 
strin level 10-f
old re
ter th
n
the URL in
person with hyper
cidity
nd stom
ch or duoden
l ulcers is di
nost
ic. Con rm
tion
of 
stric hyper
cidity is demonstr
ted usin the
s
l
cid output (BAO) test.
2828_Ch05_171-326
06/08/12 5:14 PM P
e 282 5. Which st
tement
out multiple endocrine neopl
s
i
(MEN) is true?
A. It is
ssoci
ted with hyperpl
si
or neopl
si
of
t le
st two endocrine or

ns B. Insulinom

is
lw
ys present when the pituit
ry is involved C. It is inherited
s
n
utoso
m
l recessive
disorder D. Pl
sm
hormone levels from
ected or
ns
re elev
ted
t le
st 10-fol
d
Chemistry/Correl
te clinic
l
nd l
or
tory d
t
/ Endocrine/2 6. Select the m
in
estroen
produced y the ov
ries
nd used to ev
lu
te ov
ri
n function. A. Estriol (E 3 )
B. Estr
diol (E
2 ) C. Epiestriol D. Hydroxyestrone Chemistry/Apply knowlede of fund
ment
l io
loic
l
ch
r
cteristics/Estroen/1 7. Which st
tement est descri es the rel
tionship e
tween luteinizin
hormone (LH)
nd follicle- stimul
tin hormone (FSH) in c
ses of dysmenorrhe
? A

. Both
re
usu
lly incre
sed when there is pituit
ry
denom
B. Incre
ses in oth hormones

nd
decre
se in
estroen sin
l
pituit
ry c
use of ov
ri
n f
ilure C. Both hormones norm
lly p
e
k 12 d
ys
efore ovul
tion D. In menop
use, the LH level
t the midcycle pe
k is hiher th

n the level of
FSH Chemistry/Correl
te clinic
l
nd l
or
tory d
t
/ Endocrine/2 8. When pituit

ry
denom
is
the c
use of decre
sed estroen production,
n incre
se of which hormone is most
frequently
responsi le? A. Prol
ctin B. FSH C. LH D. Tyroid-stimul
tin hormone (TSH) Chemi
stry/Correl
te
clinic
l
nd l
or
tory d
t
/ Endocrine/2 9. Which set of results is most likely
in
n
dult m
le
with prim
ry testicul
r f
ilure? A. Incre
sed LH, FSH,
nd decre
sed testosteron
e B. Decre
sed
LH, FSH,
nd testosterone C. Decre
sed testosterone,
ndrostenedione,
nd FSH D.
Incre
sed

ndrostenedione, decre
sed testosterone,
nd norm
l FSH Chemistry/Correl
te clin
ic
l
nd
l
or
tory d
t
/ Endocrine/2 5.8 | Clinic
l Endocrinoloy 283 Answers to Quest
ions 59 5. A
Multiple-endocrine neopl
si
syndrome is inherited
s
n
utosom
l domin
nt dise

se involvin
excess production of hormones from sever
l endocrine l
nds. MEN I results from

denom
s (usu
lly
enin) of
t le
st two l
nds, includin the pituit
ry,
dren
l cortex, p
r
thy
roid,
nd
p
ncre
s. The p
r
thyroid l
nd is the or
n most commonly involved,
nd in thos
e p
tients
n
elev
ted C
i is
n e
rly sin. The p
ncre
s is the next most frequently involve
d or
n, ut the
hormone most commonly oversecreted is 
strin (not insulin). MEN II is ch
r
cter
ized y
pheochromocytom

nd thyroid c
rcinom
. MEN II-B is
v
ri
nt of MEN II showin
the
ddition of
neuro rom
. 6. B E 2 is the m
jor estroen produced y the ov
ries
nd ives rise
to oth
estrone (E 1 )
nd E 3 . E 2 is used to ev
lu
te oth ov
ri
n function
nd menst
ru
l cycle
dysfunction. 7. C In women, serum or urine LH
nd FSH
re me
sured
lon with es
troen
nd
proesterone to ev
lu
te the c
use of menstru
l cycle
norm
lities
nd
novul
t
ion. Both
hormones show
pronounced serum pe
k 12 d
ys prior to ovul
tion
nd urine pe
k 2
044 hours
efore ovul
tion. Norm
lly, the LH pe
k is sh
rper
nd re
ter th
n the FSH pe
k
; however, in
menop
use, the FSH usu
lly ecomes hiher th
n LH. In p
tients with prim
ry ov
r
i
n f
ilure, the
LH
nd FSH
re elev
ted ec
use low estroen levels stimul
te rele
se of luteini
zin
hormone-rele
sin hormone (LHRH) from the hypoth
l
mus. Conversely, in pituit
ry
f
ilure, levels
of FSH
nd LH
re reduced,
nd this reduction c
uses
de ciency of estroen produ
ction y the
ov
ries. 8. A Prol
ctinom
c
n result in
novul
tion ec
use hih levels of prol

ctin suppress
rele
se of LHRH (on
dotropin-rele
sin hormone), c
usin suppression of rowth

hormone (GH),
FSH,
nd estroen. Prol
ctinom
is the most commonly occurrin pituit
ry tumor

ccountin for
40%60%. Adenom
s producin FSH h
ve
frequency of
out 20%, while those pituit

ry tumors
secretin LH
nd TSH
re r
re. 9. A Prim
ry testicul
r f
ilure produces
pictur
e th
t is
hyperon
dotropic. The LH
nd FSH
re incre
sed ec
use the pituit
ry l
nd is n
orm
l
nd
responds to decre
sed free testosterone. Androstenedione is
n
dren
l
ndroen

nd is
un
ffected. In testicul
r f
ilure second
ry to pituit
ry deficiency (hypoon
dot
ropic testicul
r
f
ilure), the LH, FSH,
nd testosterone
re low. 2828_Ch05_171-326 06/08/12 5:
14 PM P
e 283
10. When should proesterone e me
sured when ev
lu
tin
n
dult fem
le for
no
vul
tion? A. At
the onset of menses B. Durin the rst 7 d
ys of the menstru
l cycle C. At the mid
cycle just

fter LH pe
ks D. At the end of the menstru
l cycle Chemistry/Apply knowlede to
identify sources
of error/Fertility testin/2 11. A fem
le with severe excessive pu ic
nd f
ci
l
h
ir rowth
(hirsutism) should e tested for which of the followin hormones? A. Estroen
n
d proesterone B.
Chorionic on
dotropin C. Growth hormone D. Testosterone
nd dehydroepi
ndroster
one sulf
te
Chemistry/Correl
te l
or
tory
nd clinic
l d
t
/ Fertility testin/2 12. Which
set of results is
most likely in
fem
le with hypoon
dotropic ov
ri
n f
ilure? A. Incre
sed LH,
FSH,
nd estroen
B. Decre
sed LH, FSH,
nd estroen C. Decre
sed prol
ctin
nd estroen D. Incre

sed LH
nd FSH,

nd decre
sed estroen Chemistry/Correl
te l
or
tory
nd clinic
l d
t
/ Fertili
ty testin/2 13.
Te onset of menop
use is usu
lly
ssoci
ted with wh
t hormone ch
nes? A. Decre

sed estroen,
testosterone,
nd
ndroens B. Decre
sed estroen, FSH, LH,
nd proesterone C.
Decre
sed
estroen
nd proesterone,
nd incre
sed LH
nd FSH D. Decre
sed estroen
nd pr
oesterone,
norm
l LH
nd FSH Chemistry/Correl
te l
or
tory
nd clinic
l d
t
/Fertility tes
tin/2 14. Which
of the followin st
tements is correct in
ssessin GH de ciency? A. Pituit
ry f
i
lure m
y
involve one, sever
l, or
ll
denohypophyse
l hormones; ut GH de ciency is usu
ll
y found B. A
norm
l r
ndom serum level of GH in
child under 6 ye
rs old rules out GH de cienc
y C.
Administr
tion of
rinine, insulin, or luc
on will suppress GH rele
se D. GH
levels in the
lood show little v
ri
tion within
24-hour period Chemistry/Apply knowlede of
fund
ment
l
ioloic
l ch
r
cteristics/Endocrine/2 284 Ch
pter 5 | Clinic
l Chemistry Answer
s to Questions
1114 10. C Proesterone is often me
sured
lon with LH, FSH, estroen,
nd prol

ctin to
ev
lu
te fem
le infertility
nd dysmenorrhe
. Proesterone is produced y the co
rpus luteum
nd
levels
re very low durin the e
rly follicul
r ph
se of the cycle. Proesterone

is rele
sed y
the corpus luteum followin the LH sure th
t occurs 12 d
ys prior to ovul
tion

nd is
n
indic
tion th
t ovul
tion occurred. Low proesterone
t midcycle indic
tes th
t
ovul
tion did not
occur. This is often the c
se in polyov
ri
n cyst syndrome. 11. D Excessive h
ir
rown in fem
les
results from excessive
ndroen production,
nd is most commonly seen in polycys
tic ov
ri
n
syndrome, which produces hih levels of ov
ri
n-derived testosterone. It will
l
so occur
s

consequence of Cushins syndrome
nd mild conenit
l
dren
l hyperpl
si
. Therefo
re, cortisol

nd 17 -hydroxyproesterone c
n help identify those c
uses. R
pid onset of hirsut
ism c
n result
from
n ov
ri
n or
dren
l tumor. Dehydroepi
ndrosterone sulf
te is produced onl
y y the
dren
ls

nd would e useful in identifyin those r
re c
ses where the c
use is
n
ndro
en-secretin

dren
l tumor. 12. B Hypoon
dotropic ov
ri
n f
ilure is the result of pituit
ry
dysfunction. It
m
y e c
used y low levels of oth LH
nd FSH, or it m
y e c
used y hih leve
ls of prol
ctin

s in prol
ctinom
, since prol
ctin will inhi it LHRH
nd result in low LH
nd F
SH. 13. C In
menop
use, estroen production decre
ses to where the menstru
l cycle
nd ov
ri

n follicle
m
tur
tion stop. The decre
sed estroen c
uses the pituit
ry rele
se of LH
nd F
SH. In menop
use,
the FSH
t midcycle is hiher th
n LH. The incre
sed LH c
uses the ov
ries to se
crete
testosterone
nd
ndroens. 14. A Bec
use GH is the most
und
nt pituit
ry horm
one, it m
y e
used
s
screenin test for pituit
ry f
ilure in
dults. Pituit
ry hormone de cie
ncies
re r
re

nd
re ev
lu
ted y me
surin those hormones
ssoci
ted with the speci c type of
t
ret or
n
dysfunction. GH secretion pe
ks durin sleep,
nd pulsed incre
ses
re seen foll
owin exercise

nd me
ls. In
dults,
de ciency of GH c
n e ruled out y demonstr
tin norm
l o
r hih levels
on two successive tests. In children, there is extensive overl
p etween norm
l

nd low GH
levels,
nd
stimul
tion (provoc
tive) test is usu
lly needed to est
lish
di

nosis of
de ciency. Exercise is often used to stimul
te GH rele
se. If GH levels
re re
te
r th
n 6 g/L
after vigorous exercise, then de ciency is ruled out. In addition to exercise, dru
gs such as
arginine, insulin, propranolol, and glucagon can be used to stimulate GH release
. De ciency is
documented by registering a subnormal response to two stimulating agents. 2828_C
h05_171-326
06/08/12 5:14 PM Page 284 15. Which statement best describes the level of GH i
n patients with
pituitary adenoma associated with acromegaly? A. Te fasting GH level is always e
levated at least
twofold B. Some patients will require a glucose suppression test to establish a
diagnosis C. A
normal fasting GH level rules out acromegaly D. Patients produce a lower concent

ration of
insulin-like growth factor I (IGF-1) than expected from their GH level Chemistry
/Correlate
clinical and laboratory data/ Endocrine/2 16. Hyperparathyroidism is most consis
tently associated
with: A. Hypocalcemia B. Hypocalciuria C. Hypophosphatemia D. Metabolic alkalosi
s
Chemistry/Correlate clinical and laboratory data/ Endocrine/2 17. Which statemen
t regarding the
use of PTH is true? A. Determination of serum PTH level is the best screening te
st for disorders
of calcium metabolism B. PTH levels di erentiate primary and secondary causes of
hypoparathyroidism C. PTH levels di erentiate primary and secondary causes of hypo
calcemia D. PTH
levels are low in patients with pseudohypoparathyroidism Chemistry/Correlate cli
nical and
laboratory data/Endocrine/2 18. Te best method of analysis for serum PTH involve
s using
antibodies that detect: A. Te amino-terminal fragment of PTH B. Te carboxy-termi
nal end of PTH C.
Both the amino-terminal fragment and intact PTH D. All fragments of PTH as well
as intact hormone
Chemistry/Apply principles of special procedures/ Hormone assays/1 5.8 | Clinica
l Endocrinology
285 Answers to Questions 1518 15. B Approximately 90% of patients with acromegaly
will have an
elevated fasting GH level, but 10% will not. In addition, a single measurement i
s not su cient to
establish a diagnosis of acromegaly because various metabolic and nutritional fa
ctors can cause
an elevated serum GH in the absence of pituitary disease. The glucose suppressio
n test is used to
diagnose acromegaly. An oral dose of 100 g of glucose will suppress the serum GH
level at 1 hour
(postadministration) to below 1 g/L in normal patients, but not in patients with
acromegaly.
Patients with acromegaly also have high levels of IGF-1, also called somatomedin
C, which is
overproduced by the liver in response to excess release of GH. 16. C Hyperparath
yroidism causes
increased resorption of calcium and decreased renal retention of phosphate. Incr
eased serum
calcium leads to increased urinary excretion. The distal collecting tubule of th
e nephron
reabsorbs less bicarbonate as well as phosphate, resulting in acidosis. 17. C Se
rum Ca i is the
best screening test to determine if a disorder of calcium metabolism is present,
and will
distinguish primary hyperparathyroidism (high Ca i ) and secondary hyperparathyr
oidism (low Ca i
). PTH levels are used to distinguish primary and secondary causes of hypocalcem
ia. Serum PTH is
low in primary hypocalcemia (which results from parathyroid gland disease), but
is high in
secondary hypocalcemia (e.g., renal failure). Serum PTH is also used for the ear
ly diagnosis of
secondary hypocalcemia because PTH levels rise prior to a decrease in the serum
Ca i . Serum PTH
is used to help distinguish primary hyperparathyroidism (high PTH) and hypercalc
emia of

malignancy (usually low PTH), and pseudohypoparathyroidism from primary hypopara

thyroidism.
Pseudohypoparathyroidism results from a de cient response to PTH and is associated
with normal or
elevated serum PTH. 18. C PTH is a polypeptide comprised of 84 amino acids. The
biological
activity of the hormone resides in the N-terminal portion of the polypeptide, bu
t the hormone is
rapidly degraded and produces N-terminal, middle, and C-terminal fragments. Frag
ments lacking the
N-terminal portion are inactive. Immunoassays for PTH using antibodies to differ
ent portions of
the polypeptide will give different results. The assay of choice is a two-site d
ouble-antibody
sandwich method that measures only intact PTH and active fragments. Methods that
use single
antibodies may detect inactive as well as active PTH fragments and are not as sp
ecific for
parathyroid disease. 2828_Ch05_171-326 06/08/12 5:14 PM Page 285 19. Which of
the following is
most often elevated in hypercalcemia associated with malignancy? A. Parathyroidderived PTH B.
Ectopic PTH C. Parathyroid hormonerelated protein (PTHRP) D. Calcitonin Chemistry
/Apply
principles of special procedures/ Hormone assays/1 20. Which is normally the mos
t abundant
corticosteroid hormone secreted by the adrenal cortex? A. Cortisol B. Dehydroepi
androsterone C.
Aldosterone D. Corticosterone Chemistry/Apply knowledge of fundamental biologica
l
characteristics/Adrenal/1 21. Which of the following statements regarding adrena
l cortical
dysfunction is true? A. Patients with Cushings syndrome usually have hyperkalemia
B. Cushings
syndrome is associated with glucose intolerance C. Addisons disease is associated
with
hypernatremia D. Addisons disease is caused by elevated levels of cortisol Chemis
try/Correlate
clinical and laboratory data/ Adrenal/2 286 Chapter 5 | Clinical Chemistry Answe
rs to Questions
1921 19. C PTHRP is a peptide produced by many tissues and normally present in th
e blood at a
very low level. The peptide has an N-terminal sequence of eight amino acids that
are the same as
found in PTH and that will stimulate the PTH receptors of bone. Some malignancie
s (e.g.,
squamous, renal, bladder, and ovarian cancers) secrete PTHRP, causing hypercalce
mia-associated
malignancy. Because the region shared with PTH is small and poorly immunoreactiv
e, the peptide
does not cross-react in most assays for PTH. For this reason, and because tumors
producing
ectopic PTH are rare, almost all patients who have an elevated Ca i and elevated
PTH have primary
hyperparathyroidism. The immunoassay for PTHRP will frequently be elevated in pa
tients who have
not yet been diagnosed with malignancy but have an elevated Ca i , without an el
evated serum PTH.
Calcitonin is a hormone produced in the medulla of the thyroid that opposes the
action of PTH.

However, calcitonin levels do not greatly in uence the serum calcium. Assay of cal
citonin is used
exclusively to diagnose medullary thyroid cancer, which produces very high serum
levels. 20. A
Cortisol is the most abundant adrenal hormone, and abnormal levels have pronounc
ed e ects on
carbohydrate and lipid metabolism. Cortisol is a 21-carbon steroid with a dihydr
oxyacetone group
at C17 and hydroxyl group at C11 that account for its glucocorticoid potency. Pl
asma and urinary
cortisol measurements are used to diagnose most types of adrenocortical dysfunct
ion.
Dehydroepiandrosterone (DHEA), an adrenal androgen, is the next most abundant ad
renal hormone.
Aldosterone is the principal mineral corticoid made by the adrenals, and cortico
sterone is the
immediate precursor to aldosterone. Both regulate salt balance. 21. B Patients w
ith Cushings
syndrome have elevated levels of cortisol and other adrenal corticosteroids. Thi
s causes the
characteristic cushingoid appearance that includes obesity, acne, and humpback p
osture.
Osteoporosis, hypertension, hypokalemia, and glycosuria are characteristics. Add
isons disease
results from adrenal hypoplasia and produces the opposite symptoms including hyp
otension,
hyperkalemia, and hypoglycemia. 2828_Ch05_171-326 06/08/12 5:14 PM Page 286 2
2. Which of the
following statements about cortisol in Cushings syndrome is true? A. Twenty-fourho
ur urinary
free cortisol is a more sensitive test than plasma total cortisol B. Patients wi
th Cushings
disease show pronounced diurnal variation in serum cortisol C. Free cortisol is
increased by a
high-serum cortisol-binding protein concentration D. An elevated serum total cor
tisol level is
diagnostic of Cushings syndrome Chemistry/Apply knowledge to identify sources of
error/Cortisol/2 23. Which of the following conditions is characterized by prima
ry
hyperaldosteronism caused by adrenal adenoma, carcinoma, or hyperplasia? A. Cush
ings syndrome B.
Addisons disease C. Conns syndrome D. Pheochromocytoma Chemistry/Correlate clinica
l and
laboratory data/ Endocrine/2 24. Which of the following is the most common cause
of Cushings
syndrome? A. Pituitary adenoma B. Adrenal hyperplasia C. Overuse of corticostero
ids D. Ectopic
adrenocorticotropic hormone (ACTH) production by tumors Chemistry/Correlate clin
ical and
laboratory data/ Adrenal/2 25. Which of the following is the mechanism causing C
ushings disease?
A. Excess secretion of pituitary ACTH B. Adrenal adenoma C. Treatment with corti
costeroids D.
Ectopic ACTH production by tumors Chemistry/Apply knowledge of fundamental biolo
gical
characteristics/Adrenal/2 26. In which situation is the plasma or 24-hour urinar
y cortisol not
consistent with the clinical picture? A. In pregnant patients B. In patients wit
h a positive
overnight dexamethasone suppression test C. In congenital adrenal hyperplasia D.

In Cushings
syndrome caused by ectopic ACTH producing tumors Chemistry/Apply knowledge to re
cognize
inconsistent results/Adrenal/2 5.8 | Clinical Endocrinology 287 Answers to Que
stions 2226 22.
A Serum cortisol can be increased by factors such as stress, medications, and co
rtisol-binding
protein, and the cortisol level of normal patients will overlap those seen in Cu
shings syndrome
because of pulse variation. When cortisol levels become elevated, cortisol-bindi
ng protein
becomes saturated, and free (unbound) cortisol is ltered by the glomeruli. Most i
s reabsorbed,
but a signi cant amount reaches the urine as free cortisol. Twenty-fourhour urinary
free
cortisol avoids the diurnal variation that may a ect plasma free cortisol levels a
nd is a more
sensitive test than serum total or free cortisol. 23. C Conns syndrome is charact
erized by
hypertension, hypokalemia, and hypernatremia with increased plasma and urine ald
osterone and
decreased renin. Cushings syndrome results from excessive production of cortisol,
and Addisons
disease from de cient production of adrenal corticosteroids. Pheochromocytoma is a
tumor of
chroma n cells (usually adrenal) that produces catecholamines. 24. C The most comm
on cause of
Cushings syndrome is the administration of medications with cortisol or glucocort
icoid activity.
Excluding iatrogenic causes, approximately 60%70% of Cushings syndrome results fro
m
hypothalamicpituitary misregulation and is called Cushings disease. Adrenal adenom
a or
carcinoma (non-ACTH-mediated Cushings syndrome) comprise about 20% of cases, and
ectopic ACTH
production accounts for 10%20%. 25. A Cushings disease refers to adrenal hyperplas
ia resulting
from misregulation of the hypothalamicpituitary axis. It is usually caused by sma
ll pituitary
adenomas. Cushings syndrome may be caused by Cushings disease, adrenal adenoma or
carcinoma,
ectopic ACTH-producing tumors, or excessive corticosteroid administration. The c
ause of Cushings
syndrome can be di erentiated using the ACTH and dexamethasone suppression tests.
26. C
Congenital adrenal hyperplasia (adrenogenital syndrome) results from a de ciency o
f an enzyme
required for synthesis of cortisol. Approximately 90% of cases are caused by a d
e ciency of
21-hydroxylase blocking conversion of 17- hydroxyproesterone to 11-deoxycortisol
. Most other
c
ses
re c
used y 11-hydroxyl
se de ciency, which locks conversion of 11-deoxyc
ortisol to
cortisol. Precursors of cortisol, usu
lly either 17- hydroxyproesterone or 11-de
oxycortisol
re
incre
sed. This results in low serum cortisol levels, ut hih levels of these i
ntermedi
tes
(m
inly 17-ketoenic steroids). The two most common fe
tures of CAH
re s
lt w
s
tin c
used y
incre
sed miner
l corticoid
ctivity
nd viriliz
tion due to incre
sed
ndroens

.
2828_Ch05_171-326 06/08/12 5:14 PM P
e 287 27. Which test is used to distin
uish Cushins
dise
se (pituit
ry Cushins) from Cushins syndrome c
used y
dren
l tumors? A. L
ow-dose
overniht dex
meth
sone suppression B. Petros
l sinus s
mplin C. Serum ACTH D.
Twenty-fourhour
urin
ry free cortisol Chemistry/Select course of
ction/Adren
l/2 28. Which is t
he most widely
used screenin test for Cushins syndrome? A. Overniht low-dose dex
meth
sone su
ppression test
B. Corticotropin-rele
sin hormone stimul
tion test C. Petros
l sinus s
mplin D
. Metyr
pone
stimul
tion test Chemistry/Select course of
ction/Adren
l/2 29. Which test is t
he most speci c
for est
lishin
di
nosis of Cushins dise
se (pituit
ry Cushins)? A. Low-dose
dex
meth
sone suppression B. Hih-dose dex
meth
sone suppression C. Twenty-fourho
ur urin
ry free
cortisol D. Petros
l sinus s
mplin followin corticotropin-rele
sin hormone st
imul
tion
Chemistry/Correl
te clinic
l
nd l
or
tory d
t
/ Adren
l/2 288 Ch
pter 5 | Clin
ic
l Chemistry
Answers to Questions 2729 27. C Serum ACTH
ss
ys
re very helpful in distinuish
in the c
use
of Cushins syndrome. P
tients with
dren
l tumors h
ve v
lues
ppro
chin zero.
P
tients with
ectopic ACTH tumors h
ve v
lues re
ter th
n 200 p/dL. Fifty percent of p
tient
s with Cushins
dise
se h
ve hih 8
.m. ACTH levels ( etween 100200 p/dL). The hih-dose dex
me
th
sone
suppression test is
lso used. P
tients with Cushins dise
se show more th
n 50%
suppression of
cortisol rele
se
fter receivin
n 8-m dose of dex
meth
sone, ut p
tients wit
h
dren
l tumors
or ACTH producin tumors do not. Inferior petros
l sinus s
mplin (the petros
l
sinuses dr
in the
pituit
ry) is used to determine if
hih ACTH is from the pituit
ry l
nds, or
from
n ectopic
source. 28. A Dex
meth
sone is
synthetic corticosteroid th
t exhi its 30-fold
re
ter ne
tive
feed
ck on the hypoth
l
mus th
n cortisol. When
n or
l dose of 1 m of the dru
 is iven to

p
tient
t 11 p.m., the 8
.m. serum tot
l cortisol level should e elow 5.0 g/d
L. Patients
with Cushings syndrome almost always exceed this cuto . Therefore, a normal respons
e to
dexamethasone excludes Cushings syndrome with a sensitivity of about 98%. CRH sti
mulation and
petrosal sinus sampling are con rmatory tests for Cushings disease, and are used wh
en the
high-dose dexamethasone suppression test is inconclusive. The metyrapone stimula
tion test
measures the patients ACTH reserve. Metyrapone blocks cortisol formation by inhib
iting 11-
hydroxyl
se. This c
uses
n incre
se in ACTH output in norm
ls. A su norm
l ACTH
response is seen
in persons with Addisons dise
se c
used y pituit
ry f
ilure. 29. D Althouh dex

meth
sone
suppression tests h
ve
hih sensitivity, some p
tients without Cushins syndrom
e h
ve

indetermin
te results (e.., v
lues etween 5
nd 10 g/dL) or abnormal results ow

ing to
medications or other conditions. When corticotropin-releasing hormone is given i
ntravenously,
patients with Cushings disease have an exaggerated ACTH response. Samples are dra
wn from the
sinuses draining the pituitary gland and from the peripheral blood. In patients
with pituitary
tumors, the ACTH will be several times higher in the sinus samples than in the p
eripheral blood
samples. 2828_Ch05_171-326 06/08/12 5:14 PM Page 288 30. Which of the followi
ng statements
about the diagnosis of Addisons disease is true? A. Patients with primary Addisons
disease show
a normal response to ACTH stimulation B. Primary and secondary Addisons disease c
an often be
di erentiated by plasma ACTH C. Twenty-fourhour urinary free cortisol is normal in
Addisons
disease D. Pituitary ACTH reserves are normal in secondary Addisons disease Chemi
stry/Correlate
clinical and laboratory data/ Adrenal/2 31. Which of the following statements re
garding the
catecholamines is true? A. Tey are derived from tryptophan B. Tey are produced b
y the zona
glomerulosa of the adrenal cortex C. Plasma levels show both diurnal and pulsed
variation D. Tey
are excreted in urine primarily as free catecholamines Chemistry/Apply knowledge
of fundamental
biological characteristics/Catecholamines/2 32. Which assay using 24-hour urine
is considered the
best single screening test for pheochromocytoma? A. Total urinary catecholamines
B. VMA C.
Homovanillic acid (HVA) D. Metanephrines Chemistry/Correlate clinical and labora
tory data/
Catecholamines/2 33. Which metabolite is most often increased in carcinoid tumor
s of the
intestine? A. 5-Hydroxyindolacetic acid (5-HIAA) B. 3-Methoxy-4-hydroxyphenylgly
col (MHPG) C.
3-Methoxydopamine D. HVA Chemistry/Correlate clinical and laboratory data/ Endoc
rine/1 5.8 |
Clinical Endocrinology 289 Answers to Questions 3033 30. B ACTH (Cortrosyn) sti
mulation is
used as a screening test for Addisons disease. A 250-g dose of Cortrosyn is given
intravenously. Normal patients show a 25 times increase in serum cortisol. A subn
ormal response
occurs in both primary and secondary Addisons disease. Plasma ACTH is high in pri
mary but is low
in secondary Addisons disease. Patients with secondary Addisons disease (pituitary
failure) do
not respond to metyrapone because their ACTH reserve is diminished. 31. C
Catecholaminesepinephrine, norepinephrine, and dopamineare produced from the amino
acid
tyrosine by the chroma n cells of the adrenal medulla. Plasma and urinary catechol
amines are
measured in order to diagnose pheochromocytoma. Symptoms include hypertension, h
eadache,
sweating, and other endocrine involvement. Plasma catecholamines are oxidized ra
pidly to
metanephrines and VMA; only about 2% is excreted as free catecholamines. The zon
a glomerulosa is

the outermost portion of the adrenal cortex, where aldosterone is mainly produce
d. 32. D
Catecholamines are metabolized to metanephrines and VMA. Urinary catecholamines
are increased by
exercise and dietary ingestion. Measurement of 24-hour urinary metanephrine is a
bout 95%
sensitive for pheochromocytoma, and is the best single test. Speci city and sensit
ivity for
detecting pheochromocytoma approach 100% when both VMA and metanephrines are mea
sured. 33. A
5-HIAA is a product of serotonin catabolism. Excess levels are found in urine of
patients with
carcinoid tumors composed of argenta n cells. Carcinoid tumors are usually found i
n the intestine
or lung, and produce serotonin and 5-hydroxytryptophan, a serotonin precursor. S
erotonin is
deaminated by monamine oxidase, forming 5-HIAA, and the 5-HIAA is excreted in th
e urine. Some
carcinoid tumors produce mainly 5-hydroxytryptophan because they lack an enzyme
needed to convert
it to serotonin. The 5-hydroxytryptophan is converted by the kidneys to serotoni
n resulting in
high urinary serotonin. Both 5-HIAA and serotonin are usually measured by HPLC w
ith EDC.
2828_Ch05_171-326 06/08/12 5:14 PM Page 289 34. Which statement regarding the
measurement of
urinary catecholamines is true? A. An increased excretion of total urinary catec
holamines is
speci c for pheochromocytoma B. Twenty-fourhour urinary catecholamine assay avoids
pulse
variations associated with measurement of plasma catecholamines C. Total urinary
catecholamine
measurement provides greater speci city than measurement of urinary free catechola
mines D. Total
urinary catecholamines are not a ected by exercise Chemistry/Apply knowledge to id
entify sources
of error/Catecholamines/2 35. Which method is most often used to measure fractio
nated
catecholamines (epinephrine, norepinephrine, and dopamine)? A. Measurement of uor
escence
following oxidation by potassium ferricyanide B. Measurement by HPLC with electr
ochemical
detection C. Measure of radioactivity after conversion by catechol-O-methyltrans
ferase (COMT) to
tritiated metanephrines D. Measurement by HPLC with uorescence detection Chemistr
y/Apply
principles of special procedures/Catecholamines/2 36. Which statement about samp
le collection for
catecholamines and metabolites is true? A. Blood for catecholamines is collected
in the usual
manner following a 12-hour fast B. Twenty-fourhour urine for vanillylmandelic aci
d,
catecholamines, or metanephrines is collected in 1 mL of boric acid C. Twenty-fo
urhour urine
creatinine should be measured with vanillylmandelic acid, homovanillic acid, or
metanephrines D.
Tere is no need to discontinue medications if a 24-hour urine collection is used
Chemistry/Apply
principles of special procedures/Specimen collection and handling/2 290 Chapter
5 | Clinical

Chemistry Answers to Questions 3436 34. B Measurement of total urinary catecholam

ines is not a
speci c test for pheochromocytoma. Urine levels may be increased by exercise and i
n muscular
diseases. Catecholamines in urine may also be derived from dietary sources rathe
r than endogenous
production. Most catecholamines are excreted as the glucuronide, and the urinary
free
catecholamines increase only when there is increased secretion. Measurement of f
ree hormone in
urine is equal in clinical sensitivity and speci city to measurement of metanephri
nes.
Twenty-fourhour urine is the sample of choice because plasma levels are subject t
o pulse
variation and a ected by the patients psychological and metabolic condition at the
time of
sampling. 35. B HPLCECD separates catecholamines by reverse- phase chromatography
, then detects
them by oxidizing the aromatic ring at +0.8 V to a quinone ring. Current is prop
ortional to
epinephrine and norepinephrine concentration. Fluorescent methods employing ferr
icyanide
(trihydroxyindole method) or ethylenediamine (EDA method) show interference by A
ldomet and
several other drugs and are obsolete. The radioenzymatic assay of catecholamines
is a speci c
alternative to HPLC but requires a liquid scintillation counter. The method uses
the enzyme COMT
to transfer a tritiated methyl group from S-adenosyl methionine to the catechola
mines. This
results in formation of radiolabeled metanephrines that are measured. HPLC with u
orescence
detection is not as sensitive as HPLCECD. Electrospray ionization tandem-mass spe
ctroscopy is an
alternative to HPLCEDC for measurement of fractionated catecholamines and metanep
hrines. 36. C
Stress, exercise, and an upright position induce catecholamine elevation, and th
erefore, patients
must be resting supine for at least 30 minutes prior to blood collection. The pr
eferred method of
collection is catheterization, so that the anxiety of venipuncture is not a fact
or. A 4-hour fast
is also recommended. Many drugs contain epinephrine, which may falsely elevate c
atecholamine
measurements. In addition, many drugs inhibit monoamine oxidase, which is needed
to convert
metanephrines to VMA. Therefore, medications should be removed prior to testing
whenever
possible. Twenty-fourhour urine samples for catecholamines are usually preserved
with 10 mL of
6N HCl because some degradation occurs during storage when pH is greater than 3.
Renal clearance
a ects excretion of catecholamine metabolites; it is preferable to report VMA, HVA
, and
metanephrines, in g/mg creatinine. The urinary creatinine measurement should be a
t least 0.8
g/day, to validate the completeness of the 24-hour urine sample. 2828_Ch05_171-3
26 06/08/12
5:14 PM Page 290 37. Which of the following statements applies to both measurem
ent of VMA and

metanephrines in urine? A. Both can be oxidized to vanillin and measured at 360

nm without
interference from dietary compounds B. Both can be measured immunochemically aft
er hydrolysis and
derivatization C. Both require acid hydrolysis prior to measurement D. Both can
be measured by
speci c HPLC and MS assays Chemistry/Apply principles of special procedures/ Catec
holamines/2 38.
Urinary HVA is most often assayed to detect: A. Pheochromocytoma B. Neuroblastom
a C. Adrenal
medullary carcinoma D. Psychiatric disorders such as manic depression Chemistry/
Correlate
laboratory and clinical data/ Catecholamines/1 39. Tyroid hormones are derived f
rom the amino
acid: A. Phenylalanine B. Methionine C. Tyrosine D. Histidine Chemistry/Apply kn
owledge of
fundamental biological characteristics/Tyroid/1 40. Which statement regarding th
yroid hormones is
true? A. Circulating levels of T 3 and T 4 are about equal B. T 3 is about 10-fo
ld more active
than T 4 C. Te rate of formation of monoiodotyrosine and diiodotyrosine is about
equal D. Most of
the T 3 present in plasma is from its direct release from thyroid storage sites
Chemistry/Apply
knowledge of fundamental biological characteristics/Tyroid/2 41. Which of the fo
llowing
statements regarding thyroid hormones is true? A. Both protein-bound and free T
3 and T 4 are
physiologically active B. Total T 3 and T 4 are in uenced by the level of thyroxin
e-binding
globulin C. Variation in thyroxine-binding protein levels a ects both free T 3 and
T 4 D. An
elevated serum total T 4 and T 3 is diagnostic of hyperthyroidism Chemistry/Appl
y knowledge of
fundamental biological characteristics/Tyroid/2 5.8 | Clinical Endocrinology 2
91 Answers to
Questions 3742 37. D VMA and metanephrines can both be measured as vanillin after
oxidation with
periodate. However, these methods are a ected by dietary sources of vanillin; co ee,
chocolate,
bananas, and vanilla must be excluded from the diet. Metanephrines, VMA, and HVA
are most often
measured by HPLCEDC. 38. B HVA is the major metabolite of dopa, and urinary HVA i
s elevated in
more than 75% of neuroblastoma patients. Neuroblastomas also usually produce VMA
from
norepinephrine. Thus, HVA and VMA are assayed together and this increases the se
nsitivity of
detection to around 90%. 39. C Thyroid hormones are derived from the enzymatic m
odification of
tyrosine residues on thyroglobulin. Tyrosine is halogenated enzymatically with i
odine, forming
monoiodotyrosine (MIT) and diiodotyrosine (DIT). Enzymatic coupling of these res
idues form T 3
(3,5,3-triiodothyronine) and T 4 (3,5,3,5-tetraiodothyronine). These are hydrolyzed
from
thyroglobulin, forming active hormones. 40. B The rate of DIT synthesis is twice
that of MIT and
the rate of coupling favors formation of T 4 . Levels of T 4 are about 50 times
those of T 3 ,

but T 3 is approximately 10 times more active physiologically. Eighty percent of

circulating T 3
is derived from enzymatic conversion of T 4 by T 4 5-deiodinase. 41. B Total seru
m T 4 and T 3
are dependent upon both thyroid function and the amount of thyroxine-binding pro
teins such as
thyroxine-binding globulin (TBG). Total T 4 or T 3 may be abnormal in a patient
with normal
thyroid function, if the TBG level is abnormal. For this reason, free T 3 and T
4 are more
speci c indicators of thyroid function than are measurements of total hormone. Onl
y free hormone
is physiologically active. 42. D Pregnancy and estrogens are the most common cau
se of increased
TBG. Other causes include hepatitis, morphine, and clo brate therapy. Acute illnes
s, anabolic
steroids, and nephrotic syndrome decrease the level of TBG. Normal pregnancy cau
ses an elevated
serum total T 4 . Suitable assays are available that estimate free T 4 and T 3 a
nd these should
be used instead of total hormone assays. 42. Which of the following conditions w
ill increase
total T 4 by increasing TBG? A. Acute illness B. Anabolic steroid use C. Nephrot
ic syndrome D.
Pregnancy or estrogens Chemistry/Correlate clinical and laboratory data/ Tyroid/
2
2828_Ch05_171-326 06/08/12 5:14 PM Page 291 43. Select the most appropriate s
ingle screening
test for thyroid disease. A. Free thyroxine index B. Total T 3 assay C. Total T
4 D. TSH assay
Chemistry/Correlate clinical and laboratory data/ Tyroid/2 44. Te serum TSH leve
l is almost
absent in: A. Primary hyperthyroidism B. Primary hypothyroidism C. Secondary hyp
erthyroidism D.
Euthyroid sick syndrome Chemistry/Correlate clinical and laboratory data/ Tyroid
/1 45. Which
assay is used to con rm di cult cases of hypothyroidism? A. Free T 3 assay B. Free t
hyroxine
index C. Tyrotropin-releasing hormone (TRH) stimulation test D. TBG assay Chemis
try/Correlate
clinical and laboratory data/ Tyroid/2 46. Which of the following statements is
true regarding
reverse T 3 (rT 3 )? A. Formed in the blood by degradation of T 4 B. Physiologic
ally active, but
less than T 3 C. Decreased in euthyroid sick syndrome D. Interferes with the mea
surement of serum
T 3 Chemistry/Apply knowledge of fundamental biological characteristics/Tyroid/2
47. A patient
has an elevated serum T 3 and free T 4 and undetectable TSH. What is the most li
kely cause of
these results? A. Primary hyperthyroidism B. Secondary hyperthyroidism C. Euthyr
oid with
increased thyroxine-binding proteins D. Euthyroid sick syndrome Chemistry/Correl
ate clinical and
laboratory data/ Tyroid/3 48. A serum thyroid panel reveals an increase in total
T 4 , normal
TSH, and normal free T 4 . What is the most likely cause of these results? A. Pr
imary
hyperthyroidism B. Secondary hyperthyroidism C. Euthyroid with increased thyroxi
ne-binding

protein D. Subclinical hypothyroidism Chemistry/Correlate clinical and laborator

y data/ Tyroid/3
292 Chapter 5 | Clinical Chemistry Answers to Questions 4348 43. D TSH is produce
d by the
anterior pituitary in response to low levels of free T 4 or T 3 . A normal TSH r
ules out thyroid
disease. TSH is low in primary hyperthyroidism and high in primary hypothyroidis
m. 44. A Low TSH
and a high T 3 (and usually T 4 ) occur in primary hyperthyroidism, but may also
occur in
systemic nonthyroid illnesses where T 4 has been converted to T 3 . A 2-fold inc
rease in free
hormone can produce a 100-fold decrease in TSH. In primary hyperthyroidism, the
TSH will be
within a range of 00.02 mU/mL, while in nonthyroid illnesses it will be 0.03 mU/m
L or higher. A
high TSH and low T 4 occur in primary hypothyroidism but can also occur in an ac
utely ill patient
without thyroid disease, the euthyroid sick syndrome. Secondary hyperthyroidism
is caused by
pituitary hyperfunction, resulting in increased serum TSH. 45. C The TRH stimula
tion test is used
to con rm borderline cases of abnormal thyroid function. In normal patients, intra
venous
injection of 500 g of TRH causes a peak TSH response within 30 minutes. In patien
ts with primary
hypothyroidism, there is an exaggerated response (>30 mU/L). Patients with hyper
thyroidism do not
show the expected rise in TSH after TRH stimulation. 46. A Reverse T 3 is formed
from the
deiodination of T 4 in the blood. It is an inactive isomer of T 3 , (3,3,5-triiodo
thyronine).
Reverse T 3 is increased in acute and chronic illness and is used to identify pa
tients with
euthyroid sick syndrome. 47. A An undetectable TSH with increased T 3 is caused
by primary
hyperthyroidism (suppression via high free thyroid hormone). In secondary hypert
hyroidism, the
TSH will be elevated in addition to at least the T 3 . Patients with an increase
d
thyroxine-binding protein level will have an increase in total T 3 but not free
T 4 or TSH.
Patients with euthyroid sick syndrome usually have a low total T 3 due to de cient
conversion of
T 4 to T 3 , normal free T 4 , and a normal or slightly elevated TSH. 48. C Pati
ents with a
normal TSH are euthyroid, and most commonly an increase in total T 4 in these pa
tients is caused
by an increase in TBG. An increase in TBG causes an increase in total T 4 but no
t free T 4 .
Subclinical hypothyroidism is usually associated with a high TSH, but normal fre
e T 3 and free T
4 . When TSH is indeterminate, the diagnosis is made by demonstrating an exagger
ated response to
the TRH stimulation test. 2828_Ch05_171-326 06/08/12 5:14 PM Page 292 49. Whi
ch statement
about TSH and T 4 in early pregnancy is correct? A. TSH and thyroid hormones fal
l B. TSH falls
and thyroid hormones rise C. TSH and thyroid hormones both rise D. TSH rises and
thyroid hormones

fall Chemistry/Correlate clinical and laboratory data/ Tyroid/3 50. In which cas
e might a very
low plasma TSH result not correlate with thyroid status? A. Euthyroid sick syndr
ome B. Congenital
hypothyroidism C. When TBG is elevated D. After high-dose corticosteroid treatme
nt
Chemistry/Correlate clinical and laboratory data/ Tyroid/3 5.8 | Clinical Endocr
inology 293
Answers to Questions 4950 49. B Estrogens released in pregnancy cause an increase
in TBG, which
causes an increase in total T 4 and T 3 . In early pregnancy, the hCG produced b
y the placenta
stimulates the thyroid, causing an increase in free thyroid hormones. This supp
resses TSH
production. In the second trimester, as hCG diminishes, free T 4 levels fall, an
d may be lower
than 0.8 ng/dL, the lower limit of the adult reference range due to expansion of
the blood
volume. Therefore, both TSH and free T 4 should be evaluated during pregnancy us
ing
trimester-speci c reference ranges. In early pregnancy, a TSH above the rst- trimes
ter reference
range should be followed up with free T 4 and thyroid peroxidase antibody levels
to assess the
need for thyroid treatment. 50. D In persons with severe chronic diseases or who
have
hCG-secreting tumors, TSH production may be suppressed. Some drugs, especially h
igh doses of
corticosteroids, will suppress TSH production. Low TSH levels not matching thyro
id status can
also be seen in patients who have recently been treated for hyperthyroidism beca
use there is a
delay in the pituitary response. High-sensitivity TSH assays that can measure as
little as 0.01
mIU/L and free T 4 and T 3 can help di erentiate these conditions from clinical hy
perthyroidism.
If the TSH is below .03 mIU/L and the free hormone levels are increased, this po
ints to
hyperthyroidism. Lab values in euthyroid sick syndrome may mimic mild hypothyroi
dism. In
euthyroid sick syndrome, thyroid function will be normal, but TSH may be slightl
y increased owing
to lower levels of free T 3 . In euthyroid sick syndrome, the rT 3 will be incre
ased.
2828_Ch05_171-326 06/08/12 5:14 PM Page 293 294 5.9 Toxicology and Terapeutic
Drug Monitoring
1. In which of the following cases is qualitative analysis of the drug usually a
dequate? A. To
determine whether the dose of a drug with a low therapeutic index is likely to b
e toxic B. To
determine whether a patient is complying with the physicians instructions C. To a
djust dose if
individual di erences or disease alter expected response D. To determine whether t
he patient has
been taking amphetamines Chemistry/Apply knowledge of fundamental biological
characteristics/Terapeutic drug monitoring/1 2. Te term pharmacokinetics refers
to the: A.
Relationship between drug dose and the drug blood level B. Concentration of drug
at its sites of
action C. Relationship between blood concentration and therapeutic response D. T

e relationship
between blood and tissue drug levels Chemistry/Apply knowledge of fundamental bi
ological
characteristics/Terapeutic drug monitoring/1 3. Te term pharmacodynamics is an e
xpression of the
relationship between: A. Dose and physiological e ect B. Drug concentration at tar
get sites and
physiological e ect C. Time and serum drug concentration D. Blood and tissue drug
levels
Chemistry/Apply knowledge of fundamental biological characteristics/Terapeutic d
rug monitoring/1
4. Te study of pharmacogenomics involves which type of testing? A. Family studie
s to determine
the inheritance of drug resistance B. Testing drugs with cell cultures to determ
ine the minimum
toxic dosage C. Testing for single nucleotide polymorphisms known to a ect drug me
tabolism D.
Comparison of dose-response curves between family members Chemistry/Apply knowle
dge of
fundamental biological characteristics/Terapeutic drug monitoring/1 Answers to Q
uestions 14 1. D
The purpose of therapeutic drug monitoring is to achieve a therapeutic blood dru
g level rapidly
and minimize the risk of drug toxicity caused by overdose. Therapeutic drug moni
toring is a
quantitative procedure performed for drugs with a narrow therapeutic index (rati
o of the
concentration producing the desired e ect to the concentration producing toxicity)
. Drug groups
that require monitoring because of high risk of toxicity include aminoglycoside
antibiotics,
anticonvulsants, antiarrhythmics, antiasthmatics, immunosuppressive agents used
for transplant
rejection, and psychoactive drugs. When testing for abuse substances, the goal i
s usually to
determine whether the drug is present or absent. The most common approach is to
compare the
result to a cuto determined by measuring a standard containing the lowest level o
f drug that is
considered signi cant. 2. A Pharmacokinetics is the mathematical expression of the
relationship
between drug dose and drug blood level. When the appropriate formula is applied
to quantitative
measures of drug dose, absorption, distribution, and elimination, the blood conc
entration can be
accurately determined. 3. B Pharmacodynamics is the relationship between the dru
g concentration
at the receptor site (tissue concentration) and the response of the tissue to th
at drug. For
example, the relationship between lidocaine concentration in the heart muscle an
d the duration of
the action potential of Purkinje bers. 4. C Pharmacogenomics refers to the study
of genes that
a ect the performance of a drug in an individual. One method is to test for single
nucleotide
polymorphisms (SNPs) using DNA microarrays in genes such as those that code for
the cytochrome
P450 enzymes involved in the metabolism of many drugs. Genetic variations of one
such enzyme may
account for individual pharmacokinetic di erences and can be used to predict the e c

acy of the
drug. 2828_Ch05_171-326 06/08/12 5:14 PM Page 294 5. Select the ve pharmacolog
ical parameters
that determine serum drug concentration. A. Absorption, anabolism, perfusion, bi
oactivation,
excretion B. Liberation, equilibration, biotransformation, reabsorption, elimina
tion C.
Liberation, absorption, distribution, metabolism, excretion D. Ingestion, conjug
ation,
integration, metabolism, elimination Chemistry/Apply knowledge of fundamental bi
ological
characteristics/Terapeutic drug monitoring/1 6. Which route of administration is
associated with
100% bioavailability? A. Sublingual B. Intramuscular C. Oral D. Intravenous Chem
istry/Apply
knowledge of fundamental biological characteristics/Terapeutic drug monitoring/2
7. Te phrase
rst-pass hepatic metabolism means that: A. One hundred percent of a drug is excrete
d by the
liver B. All drug is inactivated by hepatic enzymes after one pass through the l
iver C. Some drug
is metabolized from the portal circulation, reducing bioavailability D. Te drug
must be
metabolized in the liver to an active form Chemistry/Apply knowledge of fundamen
tal biological
characteristics/Terapeutic drug monitoring/2 8. Which formula can be used to est
imate dosage
needed to give a desired steady-state blood level? A. Dose per hour = clearance
(milligrams per
hour) average concentration at steady state f B. Dose per day = fraction absorbe
d fraction
excreted C. Dose = fraction absorbed (1/protein-bound fraction) D. Dose per day
= half-life
log V d (volume distribution) Chemistry/Calculate/Terapeutic drug monitoring/2 5
.9 | Toxicology
and Terapeutic Drug Monitoring 295 Answers to Questions 58 5. C Liberation is t
he release of
the drug and absorption is the transport of drug from the site of administration
to the blood.
The percent of drug absorption and the rate of absorption determine the bioavail
able fraction, f.
This is the fraction of the dose that reaches the blood. Distribution refers to
the delivery of
the drug to the tissues. It involves dilution and equilibration of the drug in v
arious fluid
compartments including the blood, and is influenced by binding to proteins and b
lood cells.
Metabolism is the process of chemical modification of the drug by cells. This re
sults in
production of metabolites with altered activity and solubility. Excretion is the
process by which
the drug and its metabolites are removed from the body. 6. D When a drug is admi
nistered
intravenously, all the drug enters the bloodstream, and therefore, the bioavaila
ble fraction is
1.0. All other routes of administration require absorption through cells, and th
is process
reduces the bioavailable fraction. The bioavailable fraction for a drug given or
ally can be
calculated by dividing the peak blood concentration after oral administration by

the peak drug

concentration after IV administration. A value of 0.7 or higher is desired for d
rugs given
orally. 7. C Drugs given orally enter the blood via the portal circulation and a
re transported
directly to the liver. Some drugs are excreted by the liver, and a fraction will
be lost by
hepatic excretion before the drug reaches the general circulation. An example is
propranolol, a
- locker th
t reduces he
rt r
te
nd hypertension. The io
v
il
le fr
ction is 0
.20.4 when
iven or
lly ec
use much of the dru is removed y first-p
ss hep
tic met
olis
m. 8. A After

p
tient receives
lo
din dose to r
pidly rin the dru level up to the desire
d ther
peutic
r
ne,
m
inten
nce dose must e iven
t consistent interv
ls to m
int
in the
lood dru level

t the desired concentr
tion. The dose per hour is determined y multiplyin the
cle
r
nce per
hour y the desired
ver
e ste
dy-st
te concentr
tion, then dividin y f ( io

v
il
le
fr
ction). 2828_Ch05_171-326 06/08/12 5:14 PM P
e 295 9. Which st
tement is
true re
rdin
the volume distri ution (V d ) of
dru? A. V d is equ
l to the pe
k lood conc
entr
tion divided
y the dose iven B. V d is the theoretic
l volume in liters into which the dru
distri utes C.
Te hiher the V d , the lower the dose needed to re
ch the desired lood level o
f dru D. Te V d
is the princip
l determin
nt of the dosin interv
l Chemistry/Apply knowlede of
fund
ment
l
ioloic
l ch
r
cteristics/Ter
peutic dru monitorin/2 10. For drus with rst-or
der
elimin
tion, which st
tement
out dru cle
r
nce is true? A. Cle
r
nce = elimin

tion r
te
serum level B. It is most often performed y the liver C. It is directly rel
ted
to h
lf-life D.
Cle
r
nce r
te is independent of dose Chemistry/Apply knowlede of fund
ment
l
ioloic
l
ch
r
cteristics/Ter
peutic dru monitorin/2 11. Which st
tement
out ste
dy-st

te dru levels
is true? A. Te
sor ed dru must e re
ter th
n the
mount excreted B. Ste
dy
st
te c
n e
me
sured
fter two elimin
tion h
lf-lives C. Const
nt intr
venous infusion will
ive the s
me
minim

nd m
xim

s
n or
l dose D. Or
l dosin interv
ls ive pe
ks
nd trouh
s in the
dose-response curve Chemistry/Apply knowlede of fund
ment
l ioloic
l
ch
r
cteristics/Ter
peutic dru monitorin/2 12. If too sm
ll
pe
ktrouh di erenc
e is seen for

dru iven or
lly, then: A. Te dose should e decre
sed B. Time etween doses
should e
decre
sed C. Dose interv
l should e incre
sed D. Dose per d
y
nd time etween
doses should e
decre
sed Chemistry/Select course of
ction/Ter
peutic dru monitorin/3 13. If
the pe
k level is

ppropri
te ut the trouh level too low
t ste
dy st
te, then the dose interv
l
should: A. Be
lenthened without ch
nin the dose per d
y B. Be lenthened
nd dose r
te decr
e
sed C. Not e

ch
ned, ut dose per d
y incre
sed D. Be shortened, ut dose per d
y not ch
ne
d
Chemistry/Select source of
ction/Ter
peutic dru monitorin/3 296 Ch
pter 5 | C
linic
l Chemistry
Answers to Questions 913 9. B The V d of
dru represents the dilution of the dr
u
fter it h
s
een distri uted in the ody. The V d is used to estim
te the pe
k dru lood le
vel expected

fter
lo
din dose is iven. The pe
k lood level equ
ls the dose multiplied
y f V d . The V
d c
n e c
lcul
ted y dividin the dose, X o , y the initi
l pl
sm
dru conce
ntr
tion, C o ,
(V d = X o
/C
o ) or y dividin the cle
r
nce r
te y K, the elimin
tion r
te const
n
t (K = 0.693 divided
y dru h
lf-life). The re
ter the V d , the hiher the dose th
t will e neede
d to
chieve the
desired lood concentr
tion of dru. The V d is the princip
l determin
nt of the
dose,
nd the
cle
r
nce r
te is the princip
l determin
nt of the dosin interv
l. 10. A Firstorder elimin
tion
represents
line
r rel
tionship etween the
mount of dru elimin
ted per hour

nd the lood
level of dru. For drus followin line
r kinetics, cle
r
nce equ
ls the elimin

tion r
te divided
y the dru concentr
tion in lood. When cle
r
nce (in millir
ms per hour)
nd
f
re known, the
dose per hour needed to ive
desired
ver
e dru level
t ste
dy st
te c
n e
c
lcul
ted.
Cle
r
nce is inversely rel
ted to the drus h
lf-life
nd is
ccomplished m
inly
y the kidneys.
11. D When drus
re infused intr
venously, oth the distri ution
nd elimin
tio
n r
tes
re
const
nt. This elimin
tes the pe
ks
nd trouhs seen in the dose-response curve.
Pe
k
nd trouh
levels
re ch
r
cteristics of intermittent dosin reimens. The ste
dy st
te is
re
ched when dru
in the next dose is su cient only to repl
ce the dru elimin
ted since the l
st do
se. Ste
dy
st
te c
n e me
sured
fter ve dru h
lf-lives ec
use lood levels will h
ve re

ched 97% of
ste
dy st
te. 12. C Incre
sin the dosin interv
l will reduce the trouh concen
tr
tion of the
dru,
nd incre
sin the dose will incre
se the pe
k concentr
tion of the dru,
resultin in

re
ter pe
ktrouh di erence. The pe
ktrouh r
tio is usu
lly
djusted to 2 with the
dose
interv
l set to equ
l the dru h
lf-life. Under these conditions, oth pe
k
nd
trouh levels
often f
ll within the ther
peutic r
ne. 13. D Incre
sin the dose r
te m
y resu
lt in pe
k dru
levels in the toxic r
ne. Decre
sin the dosin interv
l will r
ise the trouh
level so th
t it
is m
int
ined in the ther
peutic r
ne. The trouh level is
ected y the dru cl
e
r
nce r
te.
If cle
r
nce incre
ses, then trouh level decre
ses. 2828_Ch05_171-326 06/08/12
5:14 PM P
e
296 14. If the ste
dy-st
te dru level is too hih, the est course of
ction is
to: A. Decre
se

the dose B. Decre
se the dose interv
l C. Decre
se the dose
nd decre
se the dos
e interv
l D.
Ch
ne the route of
dministr
tion Chemistry/Select course of
ction/Ter
peutic
dru monitorin/3
15. When should lood s
mples for trouh dru levels e collected? A. 30 minutes

fter pe
k
levels B. 45 minutes efore the next dose C. 12 hours
fter the l
st dose D. Imme
di
tely efore
the next dose is iven Chemistry/Apply knowlede to reconize sources of error/S

mple collection

nd h
ndlin/1 16. Blood s
mple collection time for pe
k dru levels: A. V
ries
with the dru,
dependin on its r
te of
sorption B. Is independent of dru formul
tion C. Is
independent of
the route of
dministr
tion D. Is 30 minutes
fter
olus intr
venous injection
is completed
Chemistry/Apply knowlede to reconize sources of error/S
mple collection
nd h

ndlin/2 17.
Which could
ccount for dru toxicity followin
norm
lly prescri ed dose? A. D
ecre
sed ren
l
cle
r
nce c
used y kidney dise
se B. Discontinu
nce or
dministr
tion of
nothe
r dru C. Altered
serum protein indin c
used y dise
se D. All of these options Chemistry/Apply
knowlede of
fund
ment
l ioloic
l ch
r
cteristics/Ter
peutic dru monitorin/2 18. Select t
he elimin
tion
model th
t est descri es most or
l drus. A. One comp
rtment, line
r rst-order e
limin
tion B.
Mich
elisMenton or concentr
tion-dependent elimin
tion C. Two comp
rtment with

iph
sic
elimin
tion curve D. Lo
rithmic elimin
tion Chemistry/Apply knowlede of fund
m
ent
l ioloic
l
ch
r
cteristics/Ter
peutic dru monitorin/2 19. Drus r
pidly infused intr
veno
usly usu
lly
follow which elimin
tion model? A. One comp
rtment, rst order B. One comp
rtment,
lo
rithmic C.
Biph
sic or two comp
rtment with serum level r
pidly f
llin in the rst ph
se D.
Mich
elisMenton or concentr
tion-dependent elimin
tion Chemistry/Apply knowlede
of fund
ment
l
ioloic
l ch
r
cteristics/Ter
peutic dru monitorin/2 5.9 | Toxicoloy
nd Ter

peutic Dru
Monitorin
297 Answers to Questions 1419 14. A Decre
sin oth dose
nd dosin
interv
l will
h
ve o settin e ects on pe
k
nd trouh lood levels. The
ppropri
te dose c
n e c

lcul
ted if
the cle
r
nce or V d
nd f
re known. For ex
mple, the initi
l dose is c
lcul
te
d y multiplyin
the desired pe
k lood dru concentr
tion y the V d . 15. D The trouh concentr

tion of
dru
is the lowest concentr
tion o t
ined in the dosin interv
l. This occurs immedi

tely efore the

sorption of the next dose iven. Trouh levels
re usu
lly collected just efo
re the next dose
is iven. 16. A The pe
k concentr
tion of
dru is the hihest concentr
tion o
t
ined in the
dosin interv
l. For or
l drus, the time of pe
k concentr
tion is dependent upo
n their r
tes of

sorption
nd elimin
tion
nd is determined y seri
l lood me
surements. Pe
k
levels for or
l
drus
re usu
lly dr
wn 12 hours
fter
dministr
tion of the dose. For drus ive

n
intr
venously, pe
k levels
re me
sured immedi
tely
fter the infusion is comple
ted. 17. D
Ther
peutic dru monitorin is necess
ry for drus th
t h
ve
n
rrow ther
peuti
c index.
Individu
l di erences
lter ph
rm
cokinetics, c
usin l
ck of correl
tion etween
dose
nd dru
lood level. These include
e, diet, inestion with or without food, enetic f

ctors, exercise,
smokin, pren
ncy, met
olism of other drus, protein indin,
nd dise
se st
t
es. 18. A Most
drus iven or
lly distri ute uniformly throuh the tissues re
chin r
pid equil
i rium, so oth
lood
nd tissues c
n e viewed
s
sinle comp
rtment. Elimin
tion
ccordin t
o
Mich
elisMenton kinetics is nonline
r ec
use
t hih concentr
tions, the hep
tic
enzyme system
ecomes s
tur
ted, reducin the elimin
tion e ciency. 19. C Drus r
pidly infused
intr
venously
follow
two-comp
rtment model of elimin
tion. The centr
l comp
rtment is the l
ood
nd tissues
th
t
re well perfused. The second consists of tissues for which distri ution of
dru is time
dependent. In determinin the lo
din dose, the desired serum concentr
tion shou
ld e multiplied
y the volume of the centr
l comp
rtment to
void toxic levels. 2828_Ch05_171-32
6 06/08/12 5:14
PM P
e 297 20. Which f
ct must e considered when ev
lu
tin
p
tient who dis
pl
ys sins of
dru toxicity? A. Dru met
olites (e.., N-
cetylproc
in
mide) m
y need to e m
e
sured
s well

s p
rent dru B. If the concentr
tion of tot
l dru is within ther
peutic limit
s, the
concentr
tion of free dru c
nnot e toxic C. If the dru h
s
wide ther
peutic
index, then it
will not e toxic D. A dru level c
nnot e toxic if the trouh is within the pu
lished
ther
peutic r
ne Chemistry/Apply knowlede of fund
ment
l ioloic
l ch
r
cteri
stics/Ter
peutic
dru monitorin/2 21. When
ther
peutic dru is suspected of c
usin toxicity,
which specimen is
the most
ppropri
te for
n initi
l investi
tion? A. Trouh lood s
mple B. Pe

k lood s
mple C.
Urine
t the time of symptoms D. G
stric uid
t the time of symptoms Chemistry/Se
lect course of

ction/Ter
peutic dru monitorin/3 22. For
dru th
t follows rst-order ph
rm
c
okinetics,

djustment of dos
e to
chieve the desired lood level c
n e m
de usin which
formul
? A. New
dose = current dose desired concentr
tion concentr
tion
t ste
dy st
te B. New d
ose = current
dose concentr
tion
t ste
dy st
te desired concentr
tion C. New dose = concentr

tion
t ste
dy
st
te h
lf-life desired concentr
tion D. New dose = concentr
tion
t ste
dy st
t
e desired
current dose concentr
tion Chemistry/Apply knowlede of fund
ment
l ioloic
l
ch
r
cteristics/Ter
peutic dru monitorin/2 23. For which dru roup
re oth p
e
k
nd trouh
me
surements usu
lly required? A. Anti
rrhythmics B. An
lesics C. Tricyclic
nt
idepress
nts D.

Aminolycoside
nti iotics Chemistry/Select course of
ction/Ter
peutic dru mon

itorin/2 298
Ch
pter 5 | Clinic
l Chemistry Answers to Questions 2023 20. A Altered dru ph
rm

cokinetics m
y
result in toxicity even when the dose of dru is within the
ccepted ther
peutic
r
ne. Two
common c
uses of this
re the presence of unme
sured met
olites th
t
re physio
loic
lly
ctive,

nd the presence of
hiher th
n expected concentr
tion of free dru. Bec
use o
nly free dru is
physioloic
lly
ctive, decre
sed indin protein or f
ctors th
t shift the equi
li rium f
vorin
more un ound dru c
n result in toxicity when the tot
l dru concentr
tion is wi
thin the
ther
peutic r
ne. Some drus with
wide ther
peutic index
re potenti
lly toxi
c ec
use they
m
y e inested in re
t excess with little or no initi
l toxicity. For ex
mple,

cet
minophen
overdose does not usu
lly ecome
pp
rent until 35 d
ys
fter the overdose. This
cre
tes the
potenti
l for hep
tic d
m
e to occur from continued use, especi
lly in p
tients
who h
ve
decre
sed hep
tic or ren
l function ec
use the dru h
lf-life is extended. 21.
B When
dru is
suspected of toxicity, the pe
k lood s
mple (s
mple
fter
sorption
nd distri
ution
re
complete) should e o t
ined ec
use it is most likely to exceed the ther
peutic
limit. If the
pe
k level is
ove the upper ther
peutic limit, then toxicity is con rmed,
nd th
e dru dose is
lowered. If the pe
k dru concentr
tion is within the ther
peutic r
ne, toxicit
y is less likely,
ut c
nnot e ruled out. A hih concentr
tion of free dru, the presence of
cti
ve met
olites,

nd
norm
l response to the dru
re c
uses of dru toxicity th
t m
y occur whe
n the lood dru
level is within the pu lished ther
peutic r
ne. 22. A Most drus follow rst-orde
r
ph
rm
cokinetics, me
nin the cle
r
nce of dru is line
rly rel
ted to the dru
dose. The dose of
such drus c
n e
djusted y multiplyin the r
tio of the current dose to lood
concentr
tion y
the desired dru concentr
tion, provided the lood concentr
tion is me
sured
t
ste
dy st
te. 23.
D Aminolycoside
nti iotics c
use d
m
e to the eihth cr
ni
l nerve
t toxic l
evels, resultin
in he
rin loss. When iven
t su ther
peutic doses, they f
il to resolve infect
ion. Most drus
f
llin in the other cl
sses h
ve
n
rrow pe
ktrouh di erence ut
re hihly toxi
c when lood
levels exceed the ther
peutic r
ne. Usu
lly, these c
n e s
fely monitored y m
e
surin trouh
levels. 2828_Ch05_171-326 06/08/12 5:14 PM P
e 298 24. Which of the followin
 st
tements

out TLC for dru screenin is true? A. Acidic drus
re extr
cted in
n
lk
li
ne nonpol
r
solvent B. A dru is identi ed y comp
rin its R f v
lue
nd st
inin to st
nd
rd
s C. Testin
must e performed usin
urine s
mple D. Opi
tes
nd other
lk
loids
re extr
c
ted
t
n
cid pH

Chemistry/Apply principles of speci
l procedures/ Chrom
tor
phy/2 25. Te EMIT f

or drus of
use
uses
n: A. Anti ody conju
ted to
dru B. Enzyme conju
ted to
n
nti ody C.
Enzyme
conju
ted to
dru D. Anti ody ound to
solid ph
se Chemistry/Apply principl
es of speci
l
procedures/ Biochemic
l theory
nd principles/2 26. Which st
tement
out EMIT i
s true? A. Enzyme

ctivity is inversely proportion
l to dru level B. Form
tion of NADH is monitor
ed
t 340 nm C.
ALP is the commonly used conju
te D. Ass
y use is restricted to serum Chemistry
/Apply principles
of speci
l procedures/ Biochemic
l theory
nd principles/2 27. Which st
tement r
e
rdin cloned
enzyme donor immuno
ss
y (CEDIA) is true? A. Te enzyme used is lucose-6-phosph

te dehydroen
se
B. Te enzyme donor
nd
cceptor molecules
re fr
ments of -
l
ctosid
se C. Dru
concentr
tion
is inversely rel
ted to uorescence D. Te
nti ody is cov
lently linked to the enz
yme donor
Chemistry/Apply principles of speci
l procedures/ Biochemic
l theory
nd princip
les/2 5.9 |
Toxicoloy
nd Ter
peutic Dru Monitorin
299 Answers to Questions 2427 24. B T
LC c
n e
performed on urine, serum, or 
stric uid
nd qu
lit
tively identi es most drus. E

ch h
s

ch
r
cteristic R f , which is the r
tio of the dist
nce mir
ted y the dru to
the solvent. The
R f of the s
mple must m
tch the R f of the dru st
nd
rd. Extr
ction of drus f
or TLC is hihly
pH dependent. The pH must e
djusted to reduce the solu ility (ioniz
tion) of t
he dru in the

queous ph
se. Usu
lly,
lk
line drus (e.., opi
tes)
re extr
cted
t pH 9.0

nd
cidic drus
(e..,
r itur
tes)
t pH 4.5. 25. C In EMIT, enzyme-l
eled dru competes with
dru in the
s
mple for
limited
mount of re
ent
nti odies. When
nti ody inds to the en
zymedru
conju
te, it locks the c
t
lytic site of the enzyme. Enzyme
ctivity is direct
ly proportion
l
to s
mple dru concentr
tion ec
use the qu
ntity of un ound druenzyme conju
te
will e
hihest when dru is present in the s
mple. 26. B EMIT is
homoenous immuno
ss

y, me
nin th
t
free
ntien does not h
ve to e sep
r
ted from ound
ntien. Most EMIT
ss
ys
use
two-re
ent
system. Re
ent A cont
ins su str
te (usu
lly lucose-6-PO 4 ), coenzyme (NAD +
),
nd
nti ody
to the dru. Re
ent B cont
ins enzyme-l
eled dru (usu
lly G-6-PD-dru)
nd u e
r. The r
te of
NADH production is proportion
l to the dru concentr
tion. EMIT
ss
ys
re commo
nly used to test
for drus of
use in urine. In such c
ses, the enzyme
ctivity of the low c
li
r
tor (dru
concentr
tion equ
l to U.S. Su st
nce A use
nd Ment
l He
lth Services Administr

tion minimum for

positive test) is used
s the cuto . 27. B CEDIA is
homoenous enzyme immuno
s
s
y th
t is
commonly used to me
sure drus of
use. Dru conju
ted to
fr
ment of -
l
ct
osid
se th
t is

c
t
lytic
lly in
ctive competes with dru in the s
mple for
limited num er of

nti odies to the
dru. The fr
ment, c
lled the enzyme donor (ED),
nd su str
te (chlorophenol
red--D-
l
ctopyr
nose)
re mixed with the s
mple. A second re
ent cont
inin mo
noclon
l

nti ody
nd
second fr
ment of -
l
ctosid
se c
lled the enzyme
cceptor (EA)
is
dded. If
the
nti ody is neutr
lized y dru from the s
mple, the ED
nd EA com ine formi
n
n
ctive
enzyme. The concentr
tion of dru in the s
mple is directly proportion
l to the

mount of
chlorophenol red formed. 2828_Ch05_171-326 06/08/12 5:14 PM P
e 299 28. Whic
h st
tement is
true re
rdin p
rticle-enh
nced tur idimetric inhi ition immuno
ss
y methods fo
r ther
peutic
drus? A. Dru concentr
tion is proportion
l to liht sc
tter B. M
netic sep
r

tion is needed to
remove un ound conju
te C. When p
rticle- ound dru inds to
nti ody, liht sc

tterin is
incre
sed D. Two
nti odies to the dru
re needed Chemistry/Apply principles of
speci
l
procedures/ Biochemic
l theory
nd principles/2 29. Qu
ntit
tion of
dru y 

s
chrom
tor
phym
ss spectroscopy (GC-MS) is usu
lly performed in which mode? A. To
t
l ion
chrom
tor
phy B. Selective ion monitorin C. Ion su tr
ction D. Selective re
ct
ion monitorin
Chemistry/Apply principles of speci
l procedures/ Chrom
tor
phy/1 30. SITUATION
: A urine s
mple
is received in the l
or
tory with the
ppropri
te custody control form,
nd
r
equest for dru
of
use screenin. Which test result would e c
use for rejectin the s
mple? A
. Temper
ture

fter collection 95F B. pH 5.0 C. Speci c r
vity 1.005 D. Cre
tinine 5 m/dL Chemi
stry/Ev
lu
te
l
or
tory d
t
to detect sources of error/Toxicoloy/3 300 Ch
pter 5 | Clinic
l
Chemistry
Answers to Questions 2830 28. C P
rticle-enh
nced tur idimetric inhi ition immuno

ss
ys
re
homoenous immuno
ss
ys frequently used to me
sure proteins
nd ther
peutic dru
s in serum or
pl
sm
. Polystyrene-modi ed l
tex p
rticles conju
ted to the dru (p
rticle- ound
dru) compete
with dru in the s
mple for
limited num er of
nti odies. If dru concentr
tio
n is low, more of
the
nti ody inds to the p
rticle- ound dru, incre
sin the tur idity of the r
e
ction.
Therefore, liht sc
tterin is inversely proportion
l to the dru concentr
tion.
29. B Most GC-MS
instruments use
n electron e
m to split the dru emerin from the column into
its component
ions. These
re dr
wn into the m
ss
n
lyzer, usu
lly
v
cuum ch
m er cont
inin
 two p
irs of
ch
red rods (
positive p
ir
nd
ne
tive p
ir) c
lled
qu
drupole
n
lyzer.
By ch
nin the
potenti
l
nd r
dio frequency
pplied to the rods, the tr
vel of ions will v
ry
dependin upon
their m
ss to ch
re (m/z) r
tio. As ions emere from the m
ss lter, they
re det
ected y
n
electron multiplier tu e. CG-MS instruments c
n e oper
ted in two modes, tot
l

ion
chrom
tor
phy
nd selective ion monitorin. A tot
l ion chrom
tor
ph displ
ys
the retention
time of
ll ions detected
nd their
und
nce. It is prim
rily used for identi c
t
ion of unknown
compounds. SIM mode me
sures the
und
nce of one or more princip
l ions th
t pr
ovides su cient
speci city to elimin
te potenti
l interferin su st
nces
nd re
ter qu
ntit
tive
sensitivity.
For ex
mple, tetr
hydroc
nn
inol (THC) c
n e identi ed y ions m/z 371.3, 372.3,

nd 473.3. 30.
D Approxim
tely 5 per 1,000 urine s
mples received for DAU testin h
ve een
du
lter
ted y
either dilution, su stitution, or
ddition of su st
nces such
s lut
r
ldehyde
th
t interfere
with testin. The m
jority of these situ
tions c
n e detected y determinin te
mper
ture
(90F100F) pH (4.58.0), speci c r
vity (1.0031.019),
nd cre
tinine (20 m/dL). All of
he
v
lues listed
re within the limits of
n
ccept
le s
mple with the exception o
f cre
tinine. Dry
re
ent strips
re
v
il
le th
t test for pH, speci c r
vity, cre
tinine, nitrit
e, peroxide,
pyridinium,
nd lut
r
ldehyde. 2828_Ch05_171-326 06/08/12 5:14 PM P
e 300 3
1. Which
su st
nce h
s the lonest detection time? A. Amphet
mines B. Coc
ine C. Benzodi

zepines D.
M
riju
n
Chemistry/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics/Dr
us of
use/1
32. Which st
tement
out the me
surement of c
r oxyhemolo in is true? A. Tre
t
ment with

lk
line dithionite is used to convert c
r oxyhemolo in to oxyhemolo in B. Oxy
hemolo in h
s no

sor
nce
t 540 nm, ut c
r oxyhemolo in does C. Bichrom
tic
n
lysis is requ
ired in order to
elimin
te interference y oxyhemolo in D. C
r oxyhemolo in c
n e me
sured y
potentiometry
Chemistry/Apply principles of speci
l procedures/ C
r oxyhemolo in/2 33. Which
of the followin
st
tements
out lood
lcohol me
surement is correct? A. Symptoms of intoxic
ti
on usu
lly ein
when the level exceeds 0.05% w/v B. Te skin puncture site should e disinfected
with isoprop
nol
C. Te reference method is
sed upon enzym
tic oxid
tion of eth
nol y
lcohol d
ehydroen
se D.
G
s chrom
tor
phy methods require extr
ction of eth
nol from serum Chemistry/Ap
ply principles of
speci
l procedures/ Eth
nol/2 5.9 | Toxicoloy
nd Ter
peutic Dru Monitorin
301 Answers to
Questions 3133 31. D Some drus h
ve
lon h
lf-life,
nd c
n e detected for lo
ner periods

fter use, ut the detection window
lso depends on other v
ri
les such
s dos

e, frequency of
use,
nd method sensitivity. M
riju
n
is stored in f
tty tissue
nd is met
oli
zed slowly. In
persons who use m
riju
n
sever
l times per week, c
nn
inoids c
n e detected s
ever
l weeks

fter l
st use. For chronic d
ily users, this extends to months
fter discontinu

tion. Other
drus with detection windows of
week or more include lon-
ctin
r itur
tes,

LSD,
n
olic

steroids,
nd phencyclidine (PCP). 32. C The
sor
nce spectr
s of oxy-
nd c
r
oxyhemolo in
piments overl
p,
nd ichrom
tic or multichrom
tic
n
lysis is required in orde
r to
ccur
tely
me
sure c
r oxyhemolo in. In ichrom
tic
n
lysis, oxyhemolo in
nd methemolo
in
re converted
to deoxyhemolo in y the
ddition of
lk
line sodium dithionite. The r
tio of

sor
nce
t
541:555 nm is directly proportion
l to c
r oxyhemolo in concentr
tion. Percent
c
r oxyhemolo in
is commonly determined from simult
neous
sor
nce me
surements
t 548, 568,
n
d 578 nm, or
other w
velenth com in
tions,
process c
lled oximetry. 33. A Alcohol dehydro
en
se is not
speci c for eth
nol,
nd in vitro interference c
n occur with some ADH methods whe
n skin is
disinfected with other
lcohols. For this re
son,
nd to
void interference with
the
interpret
tion of chrom
tor
ms for vol
tiles, lood s
mples
re collected
fter
disinfectin the
skin site with enz
lkonium chloride or other non
lcohol
ntiseptic. GLC is the
le
lly
ccepted
method of eth
nol
n
lysis. The low oilin point of eth
nol permits direct
n
l
ysis on lood or
pl
sm
diluted with w
ter cont
inin 1-prop
nol or other suit
le intern
l st
nd

rd.
2828_Ch05_171-326 06/08/12 5:14 PM P
e 301 34. Which specimen is the s
mple
of choice for
le
d screenin? A. Whole lood B. H
ir C. Serum D. Urine Chemistry/Apply princip
les of speci
l
procedures/ Le
d/1 35. Which of the followin enzymes c
n e used to me
sure pl

sm
or serum
s
licyl
te? A. Peroxid
se B. S
licyl
te ester
se C. S
licyl
te hydroxyl
se D. pAminos
licyl
te
oxid
se Chemistry/Apply principles of speci
l procedures/ Toxicoloy/1 36. Which
of the followin
tests is le
st essenti
l to the oper
tion of
n emerency dep
rtment
t
ener

l hospit
l? A.
C
r oxyhemolo in B. Osmol
lity C. S
licyl
te D. Le
d Chemistry/Select tests/Tox
icoloy/2 302
Ch
pter 5 | Clinic
l Chemistry Answers to Questions 3436 34. A Le
d
ccumul
tes i
n RBCs, ones,

nd neur
l tissues,
nd whole lood, h
ir,
nd urine
re suit
le for demonstr
t
in le
d
toxicity. Gre
test sensitivity is o t
ined y usin whole lood, which c
n detec
t exposure over
time. Bec
use le
d is r
pidly elimin
ted from pl
sm
, serum or pl
sm
should not
e used to test
for le
d exposure. Le
d inds to sulfhydryl roups of proteins such
s delt
-
mi
nolevulinic
cid
(-ALA) ehyratase an ferrocheatase an interferes with heme synthesis. This re
suts in
increase free erythrocyte protoporphyrin, erythrocyte zinc protoporphyrin, urin
ary
coproporphyrin III, an aminoevuinic aci, which are aso usefu markers for 
ea poisonin.
When screenin for ea poisonin in chiren, the metho of choice is raphite
furnace atomic
absorption spectrophotometry or inuctivey coupe pasma mass spectroscopy bec

ause they o er
the best anaytica sensitivity. The CDC cuto for norma ea in chiren is ess
than 5.0
g/dL. 35. C The enzymatic assay of salicylate uses salicylate hydroxylase, which
reduces
salicylate with NADH and forms catechol and NAD + . Salicylate can also be measu
red by HPLC and
various immunoassays including EMIT. Salicylate toxicity causes an initial respi
ratory alkalosis
because the drug stimulates the respiratory center. However, this is followed by
metabolic
acidosis as the drug is metabolized. Therefore, it is imperative to identify sal
icylate as the
cause of toxicity before treatment of an acidbase imbalance caused by aspirin ove
rdose. 36. D
The vast majority of acute toxicology situations seen in the emergency departmen
t (ED) involve
poisoning with alcohol, acetaminophen, salicylate, abuse substances, or carbon m
onoxide.
Emergency departments should o er a minimum of these tests. In the absence of spec
i c tests for
abuse substances or a comprehensive drug screen, the serum osmolality measured b
y freezing point
depression is a sensitive surrogate test for drug and alcohol overdose. In the E
D environment, a
di erence between measured and calculated osmolality greater than 10 mOsm/Kg almos
t always
indicates drug or alcohol poisoning. Toxicity from lead poisoning and most other
trace metals is
usually a chronic condition that does not often require immediate access to labo
ratory testing.
2828_Ch05_171-326 06/08/12 5:14 PM Page 302 37. Which of the following trace
elements is
considered an essential micronutrient? A. Tallium B. Aluminum C. Mercury D. Sele
nium
Chemistry/Apply knowledge of fundamental biological characteristics/Trace metals
/1 38. When
measuring trace metals in blood other than lead, what type of tube should be use
d? A. Navy blue
top B. Green top C. Purple top D. Red top Chemistry/Identify standard operating
procedures/
Specimen collection and handling/1 39. Which whole-blood level is suggestive of
excessive
exposure to lead in children but not adults? A. 4 g/dL B. 14 g/dL C. 28 g/dL D. 32 g
/dL
Chemistry/Evaluate data to recognize health and disease states/Lead/2 40. What a
re the likely
laboratory ndings in a person suspected of having Wilsons disease? A. Blood copper
and
ceruloplasmin low, urinary copper excretion high B. Blood and urine copper conce
ntration high,
ceruloplasmin low C. Blood and urine copper concentration high, ceruloplasmin hi
gh D. Blood and
urine copper concentration low, ceruloplasmin low Chemistry/Correlate laboratory
results/Metals/2
5.9 | Toxicology and Terapeutic Drug Monitoring 303 Answers to Questions 3740 3
7. D Trace
elements can be divided into two categories, those that have no known biological
purpose and
those that do. The former include thallium, mercury, lead, cadmium, and aluminum

. All others can

be considered essential, including arsenic that has been shown necessary for nor
mal methionine
metabolism. Most trace elements are of medical importance because excessive leve
ls lead to
toxicity. However, a de ciency of trace elements such as selenium, zinc, and coppe
r are commonly
caused by total parenteral nutrition and are medically important. 38. A In order
to avoid trace
contamination by metals present in the stopper lubricants, a tube with a navy bl
ue top is used
for measuring trace metals. These tubes are validated for most but not all trace
metals. Such
tubes are available with or without EDTA for serum or whole-blood analysis, resp
ectively. Tubes
with tan stoppers containing EDTA are used for lead assay because they are certi e
d to contain no
more than 0.25 g/dL lead. In addition, type 1 purity water (10 Mohm, 10 or less C
FU/mL) and
analytical reagent grade chemicals are always used to prepare reagents such as m
atrix modi ers.
Although most trace metals are measured in whole blood or serum, arsenic is usua
lly measured in
urine because it is metabolized and excreted within hours of ingestion. 39. B Be
cause lead
exposure in children leads to learning impairment, the cuto for exposure recommen
ded by the
Centers for Disease Control is 5 g/dL in venous whole blood. Values of 5 g/dL or m
ore should be
monitored closely with follow-up testing, and if they increase, steps should be
taken to remove
lead contamination from the home and environment. For adults the recommended cut
o is 25 g/dL.
Because lead readily enters the red blood cells, and passes from plasma to urine
quickly, whole
blood is a more sensitive measure of exposure than plasma. Because lead from the
ngers may
contaminate the specimen, a venous sample is preferred over a capillary sample c
ollected by nger
stick. 40. A Wilsons disease is an autosomal recessive disease in which copper tr
ansport is
abnormal. The gene causing the disease codes for an ATPase (called Wilsons protei
n or ATP7B)
that is needed to excrete copper into bile and incorporate copper into cerulopla
smin. There are
over 200 reported mutations of this gene. The absence of Wilsons protein results
in failure to
load ceruloplasmin with copper, dramatically reducing its half-life in blood. Th
erefore, blood
levels of ceruloplasmin are low, and blood levels of copper are usually low beca
use there is
little ceruloplasmin to bind it. Copper deposits in tissues, particularly the li
ver and brain,
causing necrosis, and excess is excreted in the urine. 2828_Ch05_171-326 06/08/
12 5:14 PM Page
303 304 5.10 Tumor Markers 1. Which of the following tumor markers is classi ed as
a tumor
suppressor gene? A. BRCA-1 B. Carcinoembryonic antigen (CEA) C. Human chorionic
gonadotropin
(hCG) D. Nuclear matrix protein Chemistry/Apply knowledge of fundamental biologi

cal
characteristics/Tumor markers/1 2. In general, in which of the following situati
ons is the
analysis of a tumor marker most useful? A. Testing for recurrence B. Prognosis C
. Screening D.
Diagnosis Chemistry/Correlate clinical and laboratory data/ Tumor markers/1 3. W
hich of the
following enzymes is increased in persons with prostate and small-cell lung canc
er? A. Creatine
kinase-1 (CK-1) B. Gamma glutamyl transferase (GGT) C. Amylase D. Lactate dehydr
ogenase
Chemistry/Correlate clinical and laboratory data/ Tumor markers/2 Answers to Que
stions 13 1. A
Tumor markers may be enzymes, hormones, receptors, oncofetal (glycoprotein) anti
gens, or
oncogenes. BRCA-1 is located on the long arm of chromosome 17 and carries an 85%
lifetime risk of
breast or ovarian cancer when present. Its product functions in DNA repair and s
lows cell
proliferation. 2. A Most tumor markers are expressed at very low levels so that
the concentration
in early malignancy overlaps that seen in normal individuals. This makes them in
e ective for
screening. Three exceptions are hCG in males for testicular cancer, calcitonin f
or thyroid
medullary cancer, and prostate-speci c antigen (PSA) for prostate cancer. Most tum
or markers are
increased in nonmalignant disease, and this nonspeci city reduces their usefulness
for diagnosis
of malignancy. In addition to the three markers mentioned, the hormones insulin
(insulinoma),
gastrin (gastrinoma), and prolactin (prolactinoma), and the catecholamines (pheo
chromocytoma)
have some diagnostic utility. Some tumor markers are useful predictors of diseas
e progression and
response to treatment. These include BRCA-1, estrogen and progesterone receptors
, cathepsin-D,
and the Philadelphia chromosome. The major use of tumor markers is to monitor re
currence and
therapy. Successful treatment reduces the concentration of the marker signi cantly
or results in
an undetectable level. A rise in level following treatment signals recurrence. 3
. A CK-1 (CK-BB)
is not normally found in plasma or serum except in neonates. It may be present i
n persons with
central nervous system damage and some other disorders but its presence is often
associated with
various malignancies, especially prostate cancer and small-cell carcinoma of the
lung. Several
other commonly measured enzymes are elevated by malignancy. ALP and LD are assoc
iated with
various tumors. GGT levels are very high in hepatoma, and amylase is elevated in
pancreatic
cancer. 2828_Ch05_171-326 06/08/12 5:14 PM Page 304 4. Which of the following
is the best
analyte to monitor for recurrence of ovarian cancer? A. CA-15-3 B. CA-19-9 C. CA
-125 D. CEA
Chemistry/Correlate clinical and laboratory data/ Tumor markers/2 5. Which tumor
marker is
associated with cancer of the urinary bladder? A. CA-19-9 B. CA-72-4 C. Nuclear

matrix protein D.
Cathepsin-D Chemistry/Correlate clinical and laboratory data/ Tumor markers/2 6.
A person
presents with a cushingoid appearance and an elevated 24-hour urinary cortisol l
evel. Te plasma
adrenocotropic hormone (ACTH) is very elevated, and the physician suspects the c
ause is ectopic
ACTH production. Which test would be most useful in substantiating this diagnosi
s? A. Plasma
cortisol B. CA-50 C. Alkaline phosphatase isoenzymes D. AFP Chemistry/Evaluate l
aboratory and
clinical data to specify additional tests/Tumor markers/3 5.10 | Tumor Markers
305 Answers to
Questions 46 4. C CA-125 is an oncofetal antigen, meaning that it is produced by
genes that are
active during fetal development but minimally active after birth except in malig
nant tissues.
This group includes -fetoprotein (AFP), CEA, PSA,
nd the c
r ohydr
te-
ssoci
ted

ntiens (CA).
CA-15-3 (which sh
res the s
me
ntienic determin
nt
s CA-27.29) is used m
inly
to monitor
re
st c
ncer tre
tment
nd recurrence. CA-19-9 (which sh
res the s
me
ntienic
determin
nt
s
CA-50) is
lycoprotein shed from the surf
ce of 
stric, p
ncre
tic,
nd color
ect
l c
ncer
cells. 5. C Nucle
r m
trix proteins (NMPs)
re RNA-protein complexes. NMP-22 is
shed into the
urine in persons with l
dder c
rcinom

nd is
out 25-fold hiher th
n norm
l
in this
condition. It h
s
clinic
l sensitivity of
out 70% ut is likely to e ne
ti
ve when the tumor
is low r
de. Other m
rkers used for detection of l
dder c
ncer include l
dder
tumor
ssoci
ted

n
lytes (BTAs),
v
ri
nt of the complement f
ctor H protein; cytoker
tin-20,

v
ri
nt
cytoker
tin ( rous protein) in the cytopl
sm of m
lin
nt l
dder epithelium;
nd
telomer
se,
n
enzyme th
t
dds nucleotides to the ends of chromosomes, preventin telomere de
r
d
tion. The
speci city of these tests v
ries from
pproxim
tely 75%80%. Bl
dder c
ncer c
n
lso
e detected
y FISH ec
use it is
ssoci
ted with
hih incidence of ploidy
nd other chrom
osom
l

norm
lities th
t c
n e detected y uorescent-l
eled DNA pro es. FISH speci city
is over 94%,

nd like the immuno
ss
ys its sensitivity is hiher for hih-r
de tumors (
ppro
xim
tely 78% for
r
de 2
nd 94% for r
de 3 c
ncers). 6. C Most often, ectopic ACTH production o
ccurs in lun
c
ncer. Tumors of the lun
re often
ssoci
ted with the production of pl
cent
l
-like
lk
line
phosph
t
se,
nd
positive ndin would support the di
nosis of
n ectopic (nonp
ituit
ry)
source of ACTH. M
ny other tumor m
rkers, includin neuron-speci c enol
se
nd p
r

thyroid
hormone-rel
ted protein,
re
lso incre
sed in lun c
ncers. CA-50 (
lon with C
A-19-9) sh
res
the s
me
ntienic determin
nt
s Lewis A
nd is
m
rker for recurrence
nd tre

tment of

strointestin
l
nd p
ncre
tic c
ncers. AFP is the predomin
nt protein produced

y the fetus,

nd pl
sm
levels
re incre
sed prim
rily in yolk s
c, liver,
nd testicul
r tum
ors.
2828_Ch05_171-326 06/08/12 5:14 PM P
e 305 7. Which of the followin tumor m

rkers is used to
monitor persons with re
st c
ncer for recurrence of dise
se? A. C
thepsin-D B.
CA-15-3 C.
Retino l
stom
ene D. Estroen receptor (ER) Chemistry/Correl
te clinic
l
nd l

or
tory d
t
/
Tumor m
rkers/2 8. Which of the followin st
tements re
rdin the Phil
delphi

chromosome is
true? A. It is seen exclusively in chronic myeloenous leukemi
B. It results fr
om

tr
nsloc
tion C. It
ppe
rs
s
short-
rm deletion of chromosome 21 D. It is
s
soci
ted with

poor pronosis Chemistry/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristi
cs/Tumor
m
rkers/1 9. Wh
t is the prim
ry clinic
l utility of me
surin CEA? A. Di
nosis
of liver c
ncer
B. Di
nosis of colorect
l c
ncer C. Screenin for c
ncers of endoderm
l oriin
D. Monitorin for
recurrence of c
ncer Chemistry/Apply knowlede of fund
ment
l ioloic
l ch
r
ct
eristics/Tumor
m
rkers/1 306 Ch
pter 5 | Clinic
l Chemistry Answers to Questions 79 7. B CA-15-3
sh
res the
s
me
ntienic determin
nt
s CA-27.29. Both
re present on MUC1,
mucinous pro
tein on the cell
mem r
ne of v
rious tissues. The m
rkers
re used to monitor tre
tment
nd recur
rence of re
st
c
ncer. However,
norm
l pl
sm
levels
re seen in m
ny nonm
lin
nt conditions
,
nd the test is
not used for di
nostic purposes. CA-125 is
lycoprotein
ntien shed y
ppro
xim
tely 75% of
ov
ri
n c
ncers. It is
n FDA-
pproved tumor m
rker for monitorin recurrence of
ov
ri
n c
ncer

nd ev
lu
tin the e ectiveness of chemother
py. C
thepsin-D
nd ER
ss
ys
re per
formed to
determine the pronosis of persons with re
st c
ncer. Overexpression of c
theps
in-D is

ssoci
ted with
hiher rel
pse r
te. Bre
st tissue th
t is ne
tive for ER is
poorly responsive
to hormone suppression (t
moxifen) ther
py. The retino l
stom
ene (RB) is
tu
mor-suppressor
ene found to e missin in persons with retino l
stom
. V
rious mut
tions of th
e ene h
ve een
reported in re
st, lun, l
dder,
nd other c
ncers. 8. B The Phil
delphi
chro
mosome (Ph 1 ) is
formed y tr
nsloc
tion of the lon
rms of chromosomes 9
nd 22. The result is
th
t p
rt of the
ABL ene of chromosome 9 ecomes inserted into the BCR ene of chromosome 22. Th
e ABL ene is
n
oncoene
nd the product of the hy rid ene is
tyrosine kin
se th
t sin
ls ce
ll prolifer
tion.
The Ph 1 chromosome
ppe
rs on k
ryotypin
s
lon-
rm deletion of chromosome
22 ec
use only
the termin
l end of the lon
rm of chromosome 9 is exch
ned for most of the lo
n
rm of
chromosome 22. The BCR/ABL tr
nsloc
tion c
n e detected usin FISH hy ridiz
tio
n pro es.
Approxim
tely 95% of persons with chronic myeloenous leukemi
h
ve the Ph 1 chr

omosome. Those
p
tients who do not demonstr
te Ph 1 h
ve
poorer pronosis. It is
lso present
in the
lymphocytes of up to 25% of
dults with
cute lymphocytic leukemi
(ALL)
nd in

sm
ll num er of
children with ALL
nd persons with
cute myeloenous leukemi
. 9. D CEA is
ly
coprotein th
t is
secreted into pl
sm
y v
rious c
ncers of endoderm
l oriin, includin re
st,
lun, colorect
l,

nd stom
ch c
ncer. However, it is present in only 40%60% of such c
ncers, is pre
sent
t low
levels (<3.0 n/mL) in norm
l
dults,
nd is incre
sed y c
uses other th
n c
nc
er (e..,
smokin). Its clinic
l use is to detect recurrence
nd the need for second-look
surery in
persons who h
ve een tre
ted
nd to ev
lu
te the response to tre
tment. 2828_Ch
05_171-326
06/08/12 5:14 PM P
e 306 10. Which tumor m
rker is used to determine the usef
ulness of
tr
stuzum
(Herceptin) ther
py for re
st c
ncer? A. PR B. CEA C. HER-2/neu D.
Myc
Chemistry/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics/Tumor m
rker
s/1 11. A person
is suspected of h
vin testicul
r c
ncer. Which type of hCG test would e most u
seful? A. Pl
sm

immuno
ss
y for int
ct hCG only B. Pl
sm
immuno
ss
y for int
ct hCG
nd the -hCG
su unit C.
Pl
sm
immuno
ss
y for the free
lph

nd -hCG su units D. Urine
ss
y for hCG co
re
Chemistry/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics/Tumor m
rker
s/2 12. A p
tient
tre
ted for
erm cell tumor h
s
tot
l
nd free -hCG
ss
y performed prior to
surery. Te
result is 40,000 mIU/mL. One week followin surery, the hCG is 5,000 mIU/mL. Ch
emother
py is
st
rted,
nd the hCG is me
sured 1 week l
ter
nd found to e 10,000 mIU/mL. Wh

t does this
indic
te? A. Recurrence of the tumor B. F
lsely incre
sed hCG owin to dru inte
rference with the

ss
y C. An
lytic
l error with the test reported
s 5,000 mIU/mL D. Tr
nsient hC
G incre
se c
used
y chemother
py Chemistry/Ev
lu
te l
or
tory d
t
to expl
in inconsistent resul
ts/Tumor
m
rkers/3 13. Which set of results for ER
nd PR is
ssoci
ted with the hihest
likelihood of

f
vor
le response to tre
tment with estroen-suppression ther
py (t
moxifen)? A
. ER positive, PR
positive B. ER positive, PR ne
tive C. ER ne
tive, PR positive D. ER ne
tive,
PR ne
tive
Chemistry/Correl
te clinic
l
nd l
or
tory d
t
/ Tumor m
rkers/2 5.10 | Tumor M

rkers 307
Answers to Questions 1013 10. C Tr
stuzum
is
n
nti ody to the HER-2/neu ene
product,

tyrosine kin
se receptor protein. HER- 2/neu is
n oncoene th
t is overexpresse
d in some re
st
c
ncers. Overexpression is
ssoci
ted with
more
ressive clinic
l course ut
responds to
tre
tment with tr
stuzum
, which locks the
tt
chment of rowth f
ctor to the
receptor. The
proesterone receptor, like the ER, is used to identify persons with re
st c
nc

er who
re more

likely to respond to estroen-suppression ther
py. Myc is
roup of oncoenes t
h
t
re
ctiv
ted
in v
rious c
ncers, includin lun, re
st, colon, stom
ch, leukemi
,
nd lympho
m
. HER-2/neu is
me
sured in pl
sm
y immuno
ss
y. ER, PR,
nd myc
re me
sured in tissue
nd no
t pl
sm
usin
immunohistoloic
l st
ins or FISH. 11. B In
ddition to testicul
r c
ncer, hCG i
s produced y
tropho l
stic tumors
nd chorioc
rcinom
s. Some of these tumors secrete the -su u
nit without
int
ct hCG. This is especi
lly true
fter tre
tment when hCG is used to monitor
for recurrence.
The use of
n immuno
ss
y th
t me
sures oth the int
ct
nd free hCG will h
ve 
re
ter
sensitivity th
n
n
ss
y for int
ct hCG or
n
ss
y for only free su units. Fre
e hCG su units
m
y e produced in persons with testicul
r
nd urin
ry l
dder (urotheli
l) c
nc
er, ut the
incidence of hCG su unit secretion only is rel
tively low. Urin
ry core (urin
ry
on
dotropin
peptide) is
met
olic product of the su unit
nd h
s een used to monitor for
persistence of
tropho l
stic dise
se
nd recurrence of some hCG-producin tumors. 12. D Tre
tme
nt of tumors with
chemother
py often c
uses
tr
nsient incre
se in the production of tumor m
rker
s
s the drus
destroy tumor cells. The h
lf-life of hCG is 2436 hours; therefore, the expected
decline 1 week
postsurery w
s consistent with the result of 5,000 mIU/mL. Initi
tion of chemot
her
py pro
ly
c
used the hCG to dou le in the followin week. The hCG
ss
y should e monitore
d
t reul
r
interv
ls for sever
l months, since
f
ilure for it to decline or
n incre
sed
level would
suest recurrence. 13. A Both ER
nd PR receptor
ss
ys
re performed on re
st
tissue iopsies
to determine the pro
ility of response to t
moxifen. The PR receptor is produc
ed from the ER
receptor
nd expression of oth predicts
positive response to the dru. Less t
h
n 15% of
persons who
re ER ne
tive
nd PR ne
tive h
ve
f
vor
le response, where
s o
ver 75% of those
who
re positive for oth receptors h
ve
f
vor
le response to t
moxifen. 2828
_Ch05_171-326
06/08/12 5:14 PM P
e 307 14. Which type of c
ncer is
ssoci
ted with the hih
est level of AFP?
A. Hep
tom
B. Ov
ri
n c
ncer C. Testicul
r c
ncer D. Bre
st c
ncer Chemistry/Co
rrel
te clinic
l

nd l
or
tory d
t
/ Tumor m
rkers/1 15. Which of the followin
ss
ys is recomm
ended
s

screenin test for colorect
l c
ncer in persons over 50 ye
rs old? A. CEA B. AFP
C. Occult lood
D. Fec
l trypsin Chemistry/Correl
te clinic
l
nd l
or
tory d
t
/ Tumor m
rkers
/2 16. Which of
the followin
ss
ys is used to determine the risk of developin c
ncer? A. Epid
erm
l rowth
f
ctor receptor (EGF-R) B. Squ
mous cell c
rcinom

ntien (SCC) C. c-er B-2 e
ne expression D.
p53 ene mut
tion Chemistry/Apply knowlede of fund
ment
l ioloic
l ch
r
cteri

stics/Tumor
m
rkers/1 17. A person h
s
n elev
ted 24-hour urin
ry homov
nillic
cid (HVA)

nd
v
nillym
ndelic
cid (VMA). Urin
ry met
nephrines, chromor
nin A,
nd neuron-sp
ecific enol
se

re
lso elev
ted ut 5-hydroxyindole
cetic
cid is within the reference r
ne.
Wh
t is the most
likely di
nosis? A. C
rcinoid tumors of the intestine B. Pheochromocytom
C. Ne
uro l
stom
D.
P
ncre
tic c
ncer Chemistry/Correl
te clinic
l
nd l
or
tory d
t
/ Tumor m
rker
s/2 308 Ch
pter 5
| Clinic
l Chemistry Answers to Questions 1417 14. A AFP is incre
sed in
ll pers
ons with yolk
s
c tumors
nd over 80% of those with hep
tom
. Levels
ove 1000 n/mL
re di

nostic of
hep
tom
. Ectopic AFP-secretin tumors
re produced y ov
ri
n, testicul
r, re

st, GI,
nd
l
dder c
ncers,
nd these sources should e considered when 10-fold or hiher e
lev
tions
re
seen in the
sence of
norm
l liver function. AFP is used
lon with hCG to in
cre
se the
di
nostic sensitivity of nonseminom
testicul
r tumors
nd to st
e the dise
se
. Approxim
tely
42% of persons with nonseminom
testicul
r c
ncer
re positive for hCG ut over
70%
re positive
for hCG or AFP. 15. C Bleedin in the 
strointestin
l tr
ct occurs durin the e

rly st
es of
colorect
l c
ncer when tre
tment c
n e most e ective. Althouh occult lood c
n
e c
used y
m
ny other GI pro lems, it is not
ssoci
ted with enin polyps
nd h
s
sensit
ivity of over 80%
for detection of colorect
l c
ncer. CEA is elev
ted in less th
n 60% of such c
s
es. AFP is
elev
ted in only
out 5% of colon c
ncers. Fec
l trypsin is not
m
rker for co
lorect
l c
ncer,
ut 1 -
ntitrypsin is present in the stool in
m
jority of m
lin
nt colon tumo
rs owin to
intestin
l protein loss. 16. D The p53 ene (tumor suppressor ene) is loc
ted o
n chromosome 17

nd produces
protein th
t down-reul
tes the cell cycle. A mut
tion of p53 is

ssoci
ted with

n incre
sed incidence of m
ny c
ncers. The c-er B-2 ene is the s
me
s HER-2/
neu; it codes for

rowth f
ctor receptor with tyrosine kin
se
ctivity on the cell mem r
ne. EGF
-R is
receptor
for epiderm
l rowth f
ctor
nd its overexpression in re
st tissue is
ssoci
te
d with
poorer
pronosis. SCC is
lycoprotein
ntien found in the cytopl
sm of tumors of squ

mous oriin
nd
is secreted in the pl
sm
of persons with uterine c
ncer. 17. C Neuron-speci c eno
l
se is
n
isoenzyme cont
inin two 
mm
polypeptides th
t
re speci c for nervous tissue
n
d
re found in
neuroendocrine cells. Pl
sm
levels
re incre
sed in neuro l
stom
s, c
rcinoid t
umors, thyroid
medull
ry c
rcinom
s,
nd in some lun c
ncers
nd seminom
s. Urin
ry VMA, c
tec
hol
mines,
nd
met
nephrines
re incre
sed in oth pheochromocytom
(
tumor of chrom
n cells)

nd
neuro l
stom
(
lso
tumor of neuroectoderm
l cells derived from the neur
l cre

st neuro l
sts of
the symp
thetic 
nli
). Urin
ry HVA is incre
sed in
out 75% of persons with
neuro l
stom
ut
is not usu
lly incre
sed in pheochromocytom
. Chromor
nin A is
protein th
t i
nhi its rele
se
of c
techol
mines
nd is incre
sed in pheochromocytom
, neuro l
stom
,
nd c
rci
noid tumors.
Urin
ry 5-hydroxyindole
cetic
cid is incre
sed in c
rcinoid tumors (enterochrom

n tumors).
2828_Ch05_171-326 06/08/12 5:14 PM P
e 308 18. In which of the followin con
ditions is PSA
le
st likely to e incre
sed? A. Prec
ncerous lesions of the prost
te B. Postpro
st
te iopsy C.
Benin prost
tic hypertrophy D. Postdiit
l rect
l ex
min
tion Chemistry/Apply kn
owlede to
reconize sources of error/Tumor m
rkers/1 19. Which of the followin st
tements
re
rdin PSA is
true? A. Complexed PSA in pl
sm
is norm
lly less th
n free PSA B. Free PSA elo
w 25% is

ssoci
ted with m
lin
nt dise
se C. A tot
l PSA elow 4 n/mL rules out m
lin

nt dise
se D. A
tot
l PSA
ove 10 n/mL is di
nostic of m
lin
nt dise
se Chemistry/Correl
te
clinic
l
nd
l
or
tory d
t
/ Tumor m
rkers/2 20. A 55-ye
r-old m
le with e
rly st
e prost
t
e c
ncer
di
nosed y iopsy h
d his prost
te l
nd removed (simple prost
tectomy). His P
SA prior to
surery w
s 10.0 n/mL. If the surery w
s successful in completely removin the
tumor cells,
wh
t would the PSA result e 1 month
fter surery? A. Undetect
le B. 13 n/mL C
. Less th
n 4
n/mL D. Less th
n 10 n/mL Chemistry/Correl
te clinic
l
nd l
or
tory d
t
/ Tu
mor m
rkers/3
5.10 | Tumor M
rkers 309 Answers to Questions 1820 18. D PSA is
serine prote

se responsi le
for liquef
ction of the semin
l uid. PSA h
s een used successfully to monitor fo
r recurrence

nd follow the response of p
tients to
ndroen-suppression ther
py. Currently,
it is one of the
few FDA-
pproved tumor m
rkers for c
ncer screenin. Althouh diit
l rect
l ex

min
tion r
ises
the prost
tic
cid phosph
t
se level, it does not incre
se the concentr
tion of
PSA in the
pl
sm
. In
ddition to prost
te c
ncer, PSA m
y e incre
sed in
cute or chronic
prost
te
in
mm
tion, enin prost
te hypertrophy,
nd
fter tr
nsurethr
l prost
te resecti
on or prost
te
iopsy. As
result, the speci city of PSA is
pproxim
tely 60%
nd the predictive
v
lue of

positive result
pproxim
tely 30%. 19. B In norm
l pl
sm
, 55%95% of the PSA is
ound to
prote
se inhi itors, prim
rily 1 -
ntichymotrypsin,
nd the rem
inder is c
lled
free PSA. At

cuto of 4 n/mL commonly used for the upper reference limit, tot
l PSA h
s
sens
itivity of

pproxim
tely 60%,
nd 22% of men with
PSA elow 4 n/mL h
ve evidence of e
rl
y prost
te c
ncer
on iopsy. For this re
son, some l
or
tories prefer
cuto of 2.5 n/mL for tot

l PSA. However,

sed upon this cuto
lone, the num er of f
lse-positive ndins (unnecess
ry iops

ies) would e
extremely hih. A PSA of 2.6 n/mL th
t w
s 2.6 n/mL the previous ye
r would no
t likely e
sini c
nt; however,
PSA of 2.6 n/mL th
t w
s only 1.6 n/mL the previous ye
r
would w
rr
nt
further testin. In persons with
tot
l PSA etween 2.6
nd 10.0 n/mL,
low r

tio of free
PSA:tot
l PSA (<25% fPSA) or
hih level of complexed PSA incre
ses the di
nos
tic sensitivity

nd speci city. Persons with
PSA etween 2.6
nd 10.0 n/mL
re selected for io
psy if either
the fPSA is low or the cPSA is hih. Initi
l studies
lso indic
te th
t the inco
mplete cle
v
e
of the proenzyme of PSA (proPSA) in persons with c
ncer results in
hih r
tio
of proPSA to
fPSA. This r
tio w
s reported to h
ve etter di
nostic sensitivity
nd speci city
th
n the
percent
e of fPSA
lone. The pro
ility of c
ncer when the tot
l PSA is hiher
th
n 10 n/mL is

pproxim
tely 50%,
nd this necessit
tes
iopsy to determine if the prost
te i
s m
lin
nt. 20.
A If the tumor were con ned to the prost
te, the PSA would e undetect
le 1 month
followin
successful surery, since there is no other tissue source of PSA. The h
lf-life
of PSA is 2.23.2
d
ys,
nd the minimum detection limit of most
ss
ys is 0.2 n/mL or lower. Ther
efore, it would
require
t le
st 2 weeks efore the PSA level would e undetect
le. The low min
imum detection
limit of the PSA
ss
y, com ined with the hih tissue speci city of PSA, m
kes the
test very
sensitive in detectin recurrence. 2828_Ch05_171-326 06/08/12 5:14 PM P
e 30
9 310 5.11
Clinic
l Chemistry Pro lem Solvin 1. Which of the followin procedures c
n e u
sed to detect
proportion
l error in
new method for lucose? A. Comp
re the st
nd
rd devi
tio
n of 40 p
tient
s
mples to the hexokin
se method B. Me
sure
mixture m
de from equ
l p
rts of n
orm
l
nd hih-QC
ser
C. Add 5.0 m of lucose to 1.0 mL of
serum of known concentr
tion
nd me

sure D. Comp
re
the me
n of 40 norm
l s
mples to the hexokin
se method Chemistry/Select course o
f
ction/Method
ev
lu
tion/3 2. Which of two instruments c
n e
ssumed to h
ve the n
rrower
n
dp
ss? Assume
th
t w
velenth is
ccur
tely c
li r
ted. A. Te instrument ivin the hihest

sor
nce for

solution of 0.1 mmol/L NADH
t 340 nm B. Te instrument ivin the lowest %T for

solution of
nickel sulf
te
t 700 nm C. Te instrument ivin the hihest %T re
din for 1.0%
v/v HCl
t 350
nm D. Te instrument ivin the most line
r plot of
sor
nce versus concentr
ti
on
Chemistry/Select course of
ction/Spectrophotometry/3 3. A lipemic s
mple ives

sodium of 130
mmol/L on
n
n
lyzer th
t uses
1:50 dilution of serum or pl
sm
efore introd
ucin it to the
ion selective electrodes. Te s
me s
mple ives
sodium of 142 mmol/L usin
di
rect (undiluted)
ion selective electrode. Assumin
ccept
le qu
lity control, which of the follo

win is the most

ppropri
te course of
ction? A. Report
sodium result of 136 mmol/L B. Ultr
ce
ntrifue the
s
mple
nd repe
t y ISE C. Dilute the s
mple 1:4
nd repe
t y ISE D. Report th
e undiluted ion
selective electrode result Chemistry/Select course of
ction/Electrolytes/3 Answ
ers to Questions
13 1. C Proportion
l error is percent
e devi
tion from the expected result,
nd

ects the
slope of the c
li r
tion curve. It c
uses
re
ter
solute error (loss of
ccu
r
cy)
s
concentr
tion incre
ses. It is me
sured y
recovery study in which
s
mple is
spiked with
known
mounts of
n
lyte. In the ex
mple, the concentr
tion should incre
se y 5
00 m/dL. 2. A
B
ndp
ss is de ned y the r
ne of w
velenths p
ssed throuh the s
mple
t the sp
eci ed
w
velenth settin. It c
n e me
sured usin
ny solution h
vin
n
rrow
sor

nce pe
k (e..,
NADH
t 340 nm). The instrument producin the purest monochrom
tic liht will h

ve the hihest

sor
nce re
din. 3. D Lipemic s
mples ive lower results for sodium (pseudohy
pon
tremi
) when
diluted prior to me
surement ec
use the H 2 O ph
se is mostly diluent
nd
si
ni c
nt component
of the s
mple volume is displ
ced y lipid. Direct ISEs me
sure sodium in the pl

sm
w
ter, more

ccur
tely re ectin p
tient st
tus. 2828_Ch05_171-326 06/08/12 5:14 PM P
e 31
0 4. SITUATION:
A 2 2S QC error occurs for serum c
lcium y
tomic
sorption. Fresh st
nd
rds p
rep
red in 5.0%
w/v
l umin
re found to e line
r, ut repe
tin the controls with fresh m
teri

l does not
improve the QC results. Select the most likely c
use of this pro lem. A. M
trix
e ect c
used y

viscosity di erence etween the st
nd
rds
nd QC ser
B. Chemic
l interference c
u
sed incomplete

tomiz
tion C. Incomplete deconju
tion of protein- ound c
lcium D. Ioniz
tion i
nterference
c
used y excessive he
t Chemistry/Ev
lu
te l
or
tory d
t
to reconize pro lem
s/Atomic

sorption/3 5. SITUATION: A serum osmol
lity me
sured in the emerency dep
rtme
nt is 326
mOsm/k. Two hours l
ter, chemistry results
re: N
= 135 mmol/L BUN = 18 m/dL
lucose = 72
m/dL me
sured osmol
lity = 318 mOsm/k Wh
t do these results suest? A. L
or

tory error in
electrolyte or lucose me
surement B. Dru or
lcohol intoxic
tion C. Specimen m
isidenti c
tion
D. Successful rehydr
tion of the p
tient Chemistry/Ev
lu
te l
or
tory d
t
to d
etermine possi le
inconsistent results/Osmol
lity/3 6. When c
li r
tin
pH meter, unst
le re
di
ns occur for
oth pH 7.00
nd 4.00 c
li r
tors,
lthouh oth c
n e set to within 0.1 pH uni
t. Select the
most
ppropri
te course of
ction. A. Me
sure the pH of the s
mple
nd report to
the ne
rest 0.1
pH B. Repl
ce oth c
li r
tors with unopened u ers
nd rec
li r
te C. Ex
mine the
reference
electrode junction for s
lt cryst
ls D. Move the electrodes to
nother pH meter


nd c
li r
te

Chemistry/Select course of
ction/pH/3 7. A method c
lls for extr
ctin
n
cidi
c dru from urine
with
n
nion exch
ne column. Te pK
of the dru is 6.5. Extr
ction is enh
nce
d y
djustin
the s
mple pH to: A. 8.5 B. 6.5 C. 5.5 D. 4.5 Chemistry/Select course of
ction/
Chrom
tor
phy/3
5.11 | Clinic
l Chemistry Pro lem Solvin
311 Answers to Questions 47 4. B Poor
recovery of
c
lcium y
tomic
sorption is often c
used y f
ilure to re
k thermost
le o
nds etween
c
lcium
nd phosph
te (
form of chemic
l interference). This m
y e c
used y f

ilure to
dd
l
nth
num to the diluent or y low
tomizer temper
ture. The use of 5.0 % w/v
l
umin in the
c
li r
tor produces viscosity
nd protein- indin ch
r
cteristics simil
r to pl

sm
, helpin to
elimin
te m
trix interference. 5. B The osmol
l 
p is the di erence etween c
lcu
l
ted
nd
me
sured osmol
lity. Here, the osmol
l 
p is 38 mOsm/k. When the osmol
l 
p i
s re
ter th
n 10
mOsm/k,
n unme
sured solute is present or
n
n
lytic
l error occurred when me

surin the
osmol
lity, electrolytes, ure
, or lucose. The reference r
ne for serum osmol

lity is 280295
mOsm/k. Both osmol
lity me
surements
re
ove the URL. These results point to
the presence of

n unme
sured solute. A sini c
nt osmol
l 
p in s
mples from emerency dep
rtmen
t p
tients
usu
lly results from
lcohol or dru consumption. The di erence in osmol
lity etw
een the two
s
mples is 8 mOsm/k
nd c
n e expl
ined y
lcohol met
olism durin the 2 hou
rs etween
s
mples. 6. C Noise in pH me
surements often results from
locked junction et
ween the
reservoir of the reference electrode
nd test solution. This occurs when s
lt cr
yst
ls collect
t
the junction or when KCl concentr
tion in the reservoir incre
ses due to ev
por

tion of w
ter.
The uid in the reference electrode should e repl
ced with w
rm deionized w
ter.
After the
cryst
ls h
ve dissolved, the w
ter is repl
ced with fresh reference electrolyte
solution. 7. A
Extr
ction of
ne
tively ch
red dru onto
n
nion exch
ne (positively ch
r
ed) column is
optim
l when more th
n 99% of the dru is in the form of
nion. The extr
ction p
H should e 2 pH
units
ove the pK
of
n
cidic dru. When pH = pK
the dru will e 50% ioni
zed,
nd when pH
is re
ter th
n pK
the m
jority of dru is
nionic. 2828_Ch05_171-326 06/08/1
2 5:14 PM P
e
311 8. SITUATION: A p
tient who h
s
positive urin
lysis for lucose
nd ketone
s h
s
lyc
ted
H of 4.0%. A f
stin lucose performed the previous d
y w
s 180 m/dL. Assumin

ccept
le QC,
you would: A. Report the lycosyl
ted H B. Request
new specimen
nd repe
t t
he lycosyl
ted
H C. Perform
H electrophoresis on the s
mple D. Perform
lucose me
surem
ent on the s
mple
Chemistry/Ev
lu
te l
or
tory d
t
to determine possi le inconsistent results/Gl

ycosyl
ted
hemolo in/3 9. Qu
lity control results for uric
cid
re
s follows: 312 Ch
pte
r 5 | Clinic
l
Chemistry Answers to Questions 812 8. B The lyc
ted H is
t the lowest norm
l
limit
(4%5.5%), ut the f
stin lucose indic
tes fr
nk di
etes mellitus. Althouh the
lycosyl
ted
H re ects the
ver
e lood lucose 23 months e
rlier, the v
lue reported is inco
nsistent with
the other l
or
tory results. A hih pro
ility of s
mple misidenti c
tion or
n

lytic
l error
necessit
tes th
t the test e repe
ted. 9. C Althouh no sinle result exceeds t
he 2s limit, the
4 1s rule is roken on Run 4. This me
ns th
t oth QC1
nd QC2 exceeded +1s on R
un 3
nd Run 4.
10. C S
mple collection time is critic
l for
ccur
te ther
peutic dru monitorin
. Blood for
trouh levels must e collected immedi
tely efore the next dose. Blood collecti
on time for pe
k
levels must not occur prior to complete
sorption
nd distri ution of dru. Thi
s usu
lly
requires 12 hours for or
lly
dministered drus. The ther
peutic r
ne for theoph
ylline is 820
m/L. These results
re most consistent with
pe
k s
mple h
vin een dr
wn pri
or to complete

sorption of the dru. 11. D A p
tient re
thin room
ir c
nnot h
ve
n
rteri

l PO 2 re
ter
th
n 105 mm H ec
use
lveol
r PO 2 is 110 mm H when re
thin 20% O 2 . Expos
ure to
ir c
used
loss of CO 2 
s
nd incre
sed pH. 12. D The pH, pCO 2 ,
nd ic
r on
te
re nor
m
l,
nd
therefore,
ree. The electrolytes
re norm
l
lso, ut the TCO 2 is incre
sed s
ini c
ntly. The
reference r
ne for venous TCO 2 is 2228 mmol/L. Althouh TCO 2 is the sum of ic

r on
te
nd
dissolved CO 2 , the venous TCO 2 is determined
lmost entirely y the ic
r on

te, since dCO 2
is lost
s CO 2 
s when the venous lood is exposed to
ir durin processin. A
TCO 2 v
lue of
32 mmol/L would e expected in
person with met
olic
lk
losis. Run 1 Run 2
Run 3 Run 4
Me
n s QC1 3.5 3.8 4.1 4.2 m/dL 3.6 m/dL 0.40 QC2 6.8 7.2 7.4 7.5 m/dL 7.0
m/dL 0.25
Results should e reported from: A. Run 1 only B. Runs 1
nd 2 C. Runs 1, 2,
nd
3 D. Runs 1, 2,
3,
nd 4 Chemistry/Select course of
ction/Qu
lity control/3 10. SITUATION: A pe

k lood level
for or
lly
dministered theophylline (ther
peutic r
ne 820 m/L) me
sured
t 8

.m. is 5.0
m/L. The precedin trouh level w
s 4.6 m/L. Wh
t is the most likely expl
n
ti
on of these
results? A. L
or
tory error m
de on pe
k me
surement B. Specimen for pe
k level
w
s collected
from wron p
tient C. Blood for pe
k level w
s dr
wn too soon D. Elimin
tion r
t
e h
s re
ched
m
ximum Chemistry/Apply knowlede to reconize sources of error/Ter
peutic dru
monitorin/3 11.
SITUATION: A p
tient re
thin room
ir h
s the followin
rteri
l lood 
s
nd
electrolyte
results: pH = 7.54 PCO 2 = 18.5 mm H PO 2 = 145 mm H HCO 3 = N
= 135 mmol/L

K = 4.6 mmol/L 18
mmol/L Cl = 98 mmol/L TCO 2 = 20 mmol/L Te est expl
n
tion for these results is
: A. Blood for
electrolytes w
s dr
wn
ove
n IV B. Serum s
mple w
s hemolyzed C. Venous lood
w
s s
mpled for

rteri
l lood 
ses D. Blood 
s s
mple w
s exposed to
ir Chemistry/Ev
lu
te l

or
tory d
t
to
determine possi le inconsistent results/Blood 
ses/3 12. SITUATION: Te followin
 l
results
re
reported. Which result is most likely to e erroneous? Arteri
l lood 
ses: pH
= 7.42 pO 2 = 90
mm H pCO 2 = 38.0 mm H ic
r on
te = 24 mmol/L. Pl
sm
electrolytes: N
= 135
mmol/L Cl = 98
mmol/L K = 4.6 mmol/L TCO 2 = 33 mmol/L A. pH B. N
C. K D. TCO 2 Chemistry/Ev
l
u
te l
or
tory
d
t
to determine possi le inconsistent results/Blood 
ses/ 3 2828_Ch05_171-326
06/08/12 5:14
PM P
e 312 13. SITUATION: L
or
tory results on
p
tient from the emerency d
ep
rtment
re:
lucose = N
= 155 mmol/L K = 1.2 mmol/L 1,100 m/dL Cl = 115 mmol/L TCO 2 = 3.
0 mmol/L Wh
t is
the most likely expl
n
tion of these results? A. S
mple dr
wn
ove
n IV B. Met

olic
cidosis
with incre
sed
nion 
p C. Di
etic keto
cidosis D. L
or
tory error me
surin
electrolytes
c
used y hyperlycemi
Chemistry/Ev
lu
te l
or
tory d
t
to reconize pro lems
/Specimen
collection/3 14. SITUATION: A pl
sm
s
mple from
person in
com

s
result
of
n
utomo ile

ccident 
ve the followin results: Tot
l CK 480 IU/L CK-MB 8 /L Myolo in 800 
/L Troponin I
0.02 /L Wh
t is the est interpret
tion of these results? A. Te person h
d
he

rt
tt
ck th
t
c
used the
ccident B. Te
ccident c
used tr
um
tic injury, ut no he
rt
tt
ck
occurred C. A
he
rt
tt
ck occurred in
ddition to
stroke D. It is not possi le to tell whet
her
he
rt

tt
ck occurred ec
use of the extensive tr
um
Chemistry/Ev
lu
te l
or
tory d

t
to
ssess
v
lidity/ Accur
cy of procedures/C
rdi
c m
rkers/3 15. SITUATION: A p
tient h
s
the followin
electrolyte results: N
= 130 mmol/L K = 4.8 mmol/L Cl = 105 mmol/L TCO 2 = 26 m
mol/L Assumin

ccept
le QC, select the est course of
ction. A. Report these results B. Chec
k the
l umin,
tot
l protein, C
, P,
nd M results; if norm
l, repe
t the sodium test C. Reque
st
new s
mple
D. Rec
li r
te
nd repe
t the pot
ssium test Chemistry/Ev
lu
te l
or
tory d
t

to check for
sources of error/Anion 
p/3 16. A st
t pl
sm
lithium determined usin
n ion-s
elective
electrode is me
sured
t 14.0 mmol/L. Select the most
ppropri
te course of
cti
on. A.
Immedi
tely report this result B. Check s
mple for hemolysis C. C
ll for
new s
pecimen D. Rerun
the lithium c
li r
tors Chemistry/Select course of
ction/Ter
peutic dru monito
rin/3 5.11 |
Clinic
l Chemistry Pro lem Solvin
313 Answers to Questions 1317 13. A These re
sults
re
consistent with dilution of venous lood y intr
venous uid cont
inin 5% dextros

e
nd norm
l
s
line. The intr
venous uid is free of pot
ssium
nd ic
r on
te,
ccountin for
the low level
of these electrolytes (incomp
ti le with life). 14. B The
utomo ile
ccident c

used oth r
in
d
m
e (com
)
nd muscle d
m
e (myolo in). The s
ndwich
ss
y for MB uses
nti
odies to oth
the M
nd B su units of CK-MB
nd therefore, is not su ject to interference from
CK-BB th
t could
h
ve resulted from r
in injury. The CK rel
tive index is 1.6, which is lower th

n would e
expected if the CK-MB were derived from he
rt d
m
e. Since the TnI is within no
rm
l limits, the
sliht incre
se in CK-MB is due to the ross rele
se of CK from skelet
l muscle.
15. B The
nion

p of this s
mple is < 4 mmol/L. This m
y result from l
or
tory error, retenti
on of
n
unme
sured c
tion (e.., c
lcium), or low level of unme
sured
nion such
s phos
phorus or

l umin. The sodium is in
ppropri
tely low for the chloride
nd ic
r on
te
nd
should e
repe
ted if no iochemic
l c
use is
pp
rent. 16. C Lithium in excess of 2.0 mmo
l/L is toxic (in
some l
or
tories 1.5 mmol/L is the upper ther
peutic limit). A level of 14 mmol
/L would not
occur unless the s
mple were cont
min
ted with lithium. This would most likely r
esult from
collection in
reen-stoppered tu e cont
inin the lithium s
lt of hep
rin. 17.
B Incre
sed oven
temper
ture or 
s ow r
te will shorten retention times
nd decre
se pe
k widths.
Syrine
cont
min
tion m
y c
use the
ppe
r
nce of host pe
ks. W
ter in
PEG column suc
h
s C
r ow
x
used for me
surin vol
tiles c
uses loner retention times
nd loss of resolutio
n. 17. A
chrom
tor
m for lood
lcohol (GC) ives ro
d tr
ilin pe
ks
nd incre
sed ret
ention times for
eth
nol
nd intern
l st
nd
rd. Tis is most likely c
used y: A. A cont
min
ted i
njection syrine
B. W
ter cont
min
tion of the column p
ckin C. C
rrier 
s ow r
te th
t is too f

st D. Oven
temper
ture th
t is too hih Chemistry/Ev
lu
te l
or
tory d
t
to reconize pro
lems/G
s
chrom
tor
phy/3 2828_Ch05_171-326 06/08/12 5:14 PM P
e 313 18. SITUATION: A
n
myl
se result
is 550 U/L. A 1:4 dilution of the specimen in N
Cl ives 180 U/L ( efore m
them

tic
l correction
for dilution). Te dilution is repe
ted with the s
me results. Te technoloist sh
ould: A. Report
the
myl
se
s 550 U/L B. Report the
myl
se
s 720 U/L C. Report the
myl
se
s
900 U/L D.
Dilute the s
mple 1:10 in distilled w
ter
nd repe
t Chemistry/Select course of

ction/Amyl
se/3
19. SITUATION: A p
tients iochemistry results
re: ALT = 55 IU/L AST = 165 IU/L
lucose = 87
m/dL LD = 340 IU/L N
= 142 mmol/L K = 6.8 mmol/L C
= 8.4 m/dL P i = 7.2 m/d
L Select the est
course of
ction. A. Report results
lon with
n estim
te of the deree of hemo
lysis B. Repe
t
LD ut report
ll other results C. Request
new s
mple D. Dilute the serum 1:2


nd repe
t AST

nd LD Chemistry/Select course of
ction/Hemolysis/3 20. A lood s
mple is left
on
phle otomy
tr
y for 4.5 hours efore it is delivered to the l
or
tory. Which roup of test
s could e
performed? A. Glucose, N
, K, Cl, TCO 2 B. Uric
cid, BUN, cre
tinine C. Tot
l

nd direct
iliru in D. CK, ALT, ALP, AST Chemistry/Apply knowlede of fund
ment
l ioloic

l
ch
r
cteristics/S
mple collections
nd h
ndlin/3 21. An HPLC
ss
y for proc
in

mide ives
n
intern
l st
nd
rd pe
k th
t is 15% re
ter in
re

nd heiht for s
mple 1 th
n
s
mple 2. Te
technoloist should suspect th
t: A. Te column pressure incre
sed while s
mple 2
w
s ein

n
lyzed B. Less recovery from s
mple 2 occurred in the extr
ction step C. Te pH
of the mo ile
ph
se incre
sed durin chrom
tor
phy of s
mple 2 D. Tere w
s more proc
in
mide
in s
mple 1 th
n
s
mple 2 Chemistry/Apply principles of speci
l procedures/Liquid chrom
tor
phy/
3 314 Ch
pter 5 |
Clinic
l Chemistry Answers to Questions 1822 18. B A 1:4 dilution refers to 1 p
r
t serum
nd 3
p
rts diluent; the result is multiplied y 4 to determine the serum concentr
tio
n. Serum m
y
cont
in whe
t erm luten or other n
tur
l
myl
se inhi itors th
t, when diluted
, result in
incre
sed enzyme
ctivity. Serum for
myl
se should
lw
ys e diluted with norm

l s
line ec
use
chloride ions
re needed for
myl
se
ctivity. 19. A Results indic
te
moder
te
ly hemolyzed
s
mple. Bec
use sodium, c
lcium,
nd lucose
re not sini c
ntly
ected, results s
hould e
reported
lon with
n estim
te of visi le hemolysis. The physici
n m
y reorder

ected tests of
interest. 20. B Glucose in serum is met
olized y cells
t
r
te of
out 7% p
er hour.
Biliru in levels will f
ll if the s
mple is exposed to sunliht. Tr
ns
min
ses s
hould e me
sured
within 4 hours
nd ALP within 2 hours if the s
mple is stored
t room temper
tur
e. Uric
cid,
BUN,
nd cre
tinine
re le
st likely to e
ected. 21. B The intern
l st
nd
rd co
mpens
tes for
v
ri
tion in extr
ction, ev
por
tion, reconstitution,
nd injection volume. The
s
me
mount of
intern
l st
nd
rd is
dded to
ll s
mples
nd st
nd
rds prior to
ss
y. Incre
se
d column pH or
pressure usu
lly
lters retention time,
nd m
y not
ect pe
k qu
ntit
tion. 22. C
TLC pl
tes
mir
te in solvent until the front comes to 1 cm of the top of the pl
te. Sep
r

tion of lipids on
silic
el is
sed upon
dsorption. Hiher R f v
lues indic
te re
ter solu ili
ty of lipids in
the developin solvent. This m
y e c
used y ev
por
tion of H 2 O, lowerin the
pol
rity of the
solvent. 22. After st
inin
silic
el pl
te to determine the L/S r
tio, the t
echnoloist notes
th
t the lipid st
nd
rds oth mir
ted 1 cm f
ster th
n usu
l. Te technoloist s
hould: A. Repe
t
the sep
r
tion on
new silic
el pl
te B. Check the pH of the developin solve

nt C. Prep
re
fresh developin solvent
nd repe
t the
ss
y D. Reduce solvent mir
tion time f
or
ll su sequent
runs Chemistry/Select course of
ction/Tin-l
yer chrom
tor
phy/3 2828_Ch05_171326 06/08/12
5:14 PM P
e 314 23. A qu
ntit
tive urine lucose w
s determined to e 160 m/d
L y the Trinder
lucose oxid
se method. Te s
mple w
s refrier
ted overniht. Te next d
y, the 
lucose is
repe
ted
nd found to e 240 m/dL usin
pol
ror
phic method. Wh
t is the mos
t likely c
use of
this discrep
ncy? A. Poor precision when performin one of the methods B. Cont
m
in
tion resultin
from overniht stor
e C. Hih levels of reducin su st
nces interferin with th
e Trinder
re
ction D. Positive interference in the pol
ror
phic method c
used y hem
turi


Chemistry/Ev
lu
te l
or
tory d
t
to determine possi le inconsistent results/Gl
ucose/3 24.
SITUATION: Results of
n iron pro le
re: serum Fe = 40 /dL TIBC = 400 /dL ferriti
n = 40/L
tr
nsferrin = 300 m/dL (reference r
ne 15200) Tese results indic
te: A. Error i
n c
lcul
tion
of TIBC B. Serum iron f
lls efore ferritin in iron de ciency C. A defect in iron
tr
nsport
nd
not Fe de ciency D. Excess rele
se of ferritin c
used y injury Chemistry/Ev
lu
te
l
or
tory
d
t
to determine possi le inconsistent results/Iron de ciency/3 25. SITUATION: Re
sults of
n
iron pro le
re: Serum Fe = TIBC = ferritin = 40 /dL 400 /dL 50 /L All of the fo
llowin
tests
re useful in est
lishin
di
nosis of Fe de ciency except: A. Protein el
ectrophoresis
B. Erythrocyte zinc protoporphyrin C. Serum tr
nsferrin D. H electrophoresis C
hemistry/Ev
lu
te
l
or
tory
nd clinic
l d
t
to specify
ddition
l tests/Iron de ciency/3 26. Seru
m protein
nd
immuno x
tion electrophoresis
re ordered on
p
tient. Te former is performed, u
t there is no
evidence of
monoclon
l protein. Select the est course of
ction. A. Perform q
u
ntit
tive I G,
A, M B. Perform the IFE on the serum C. Report the result; request
urine s
mpl
e for protein
electrophoresis D. Perform IFE on the serum
nd request
urine s
mple for IFE C
hemistry/Ev
lu
te
l
or
tory d
t
to reconize
nd report the need for
ddition
l tests/Immuno x
tio
n
electrophoresis/3 5.11 | Clinic
l Chemistry Pro lem Solvin
315 Answers to Que
stions 2327 23.
C Urine often cont
ins hih levels of
scor
te
nd other reducin su st
nces. T
hese m
y c
use
sini c
nt ne
tive i
s when me
surin lucose usin
peroxid
se-coupled method.
The reduct
nts
compete with chromoen for H 2 O 2 . 24. D Serum ferritin levels f
ll efore iro
n or TIBC in iron
de ciency,
nd
low level of serum ferritin is di
nostic. However, low tissue le
vels of
ferritin m
y e m
sked y incre
sed rele
se into the lood in liver dise
se, inf
ection,
nd
cute
in
mm
tion. Althouh this p
tients serum ferritin is within reference limits, seru

m iron is low

nd percent s
tur
tion is only 10%. Note th
t the TIBC
nd tr
nsferrin results

re oth elev
ted

nd
ree. TIBC c
n e estim
ted y multiplyin the serum tr
nsferrin y 1.4. Th
ese results point
to iron de ciency. 25. D Electrophoresis m
y show
n elev
ted -lo ulin (tr
nsferri
n)
ch
r
cteristic of iron de ciency, or in
mm
tion th
t would help expl
in
norm
l fe
rritin. Zinc
protoporphyrin is elev
ted in iron de ciency
nd in le
d poisonin. Hemolo inop
t
hies
nd
th
l
ssemi
s
re not
ssoci
ted with iron de ciency. 26. C An
re
of restricted m
o ility should
e identi ed on serum protein electrophoresis efore IFE is performed. A out one o
ut of four
p
tients with multiple myelom
h
ve monoclon
l free or chains in urine only, and
herefore,
urine elecrophoresis should be included in iniial esing. 27. C Increased mob
iliy, decreased
resoluion, and low curren resul from low ionic srengh. Reducing volage wil
l slow migraion
bu will no improve resoluion. Diluing he bu er will reduce he curren, resul
ing in poorer
resoluion. 27. SITUATION: Hgb elecrophoresis is performed and all of he Hgbs
have greaer
anodal mobiliy han usual. A fas Hgb (Hgb H) is a he edge of he gel and ban
ds are blurred.
Te volage is se correcly, bu he curren reading on he ammeer is oo low.
Selec he course
of acion ha would correc his problem. A. Reduce he volage B. Dilue he b
u er and adjus
he pH C. Prepare fresh bu er and repea he es D. Reduce he running ime Chemi
sry/Selec
course of acion/Elecrophoresis/3 2828_Ch05_171-326 06/08/12 5:14 PM Page 31
5 28. A
echnologis is ased o use he serum from a clo ube lef over from a chemis
ry pro le run a
8 a.m. for a sa ionized calcium (Ca i ) a 11 a.m. Te echnologis should: A.
Perform he assay
on he 8 a.m. sample B. Perform he es only if he serum conainer was ighly
capped C.
Perform he assay on he 8 a.m. sample only if i was refrigeraed D. Reques a
new sample
Chemisry/Selec course of acion/Ionized calcium/3 29. SITUATION: A paiens bio
chemisry
resuls are: Na = 125 mmol/L Cl = 106 mmol/L K = 4.5 mmol/L TCO 2 = 19 mmol/L ch
ol = 240 mg/dL
riglyceride = 640 mg/dL glucose = 107 mg/dL AST = 16 IU/L ALT = 11 IU/L amylase
= 200 U/L Selec
he mos liely cause of hese resuls. A. Te sample is hemolyzed B. Serum was n
o separaed from
cells in su cien ime C. Lipemia is causing in viro inerference D. Te specimen
is conaminaed
Chemisry/Evaluae laboraory daa o recognize problems/Lipemia/3 30. A gasric
uid from a
paien suspeced of having aen an overdose of ampheamine is sen o he labo
raory for
analysis. Te echnologis should: A. Perform an EMIT assay for ampheamine B. Re
fuse he sample
and reques serum or urine C. Dilue 1:10 wih H 2 O and ler; perform TLC for am

pheamines D.
Tirae o pH 7.0, hen follow procedure for measuring ampheamine in urine Chem
isry/Selec
course of acion/Toxicology/3 31. SITUATION: Resuls of biochemisry ess are:
Na = 138 mmol/L K
= 4.2 mmol/L Cl = 94 mmol/L TCO 2 = 20 mmol/L glucose = 100 mg/dL T bili = 1.2 m
g/dL BUN = 6.8
mg/dL crea = 1.0 mg/dL albumin = 4.8 g/dL T proein = 5.1 g/dL Wha should be d
one nex? A.
Reques a new specimen B. Repea he oal proein C. Repea all ess D. Perfor
m a proein
elecrophoresis Chemisry/Evaluae laboraory daa o deermine possible inconsi
sen
resuls/Toal proein/3 316 Chaper 5 | Clinical Chemisry Answers o Quesions
2831 28. D Ca i
is pH dependen. Heparinized blood is preferred because i can be assayed immedi
aely. Serum may
be used, bu he specimen mus remain ighly capped while cloing and cenrifu
ging, and
analyzed as soon as possible. 29. C The riglyceride level is abou ve imes norm
al, causing he
sample o be lipemic. This will cause pseudohyponaremia (unbalanced elecrolye
s). Lipemia may
cause a falsely high rae reacion when amylase is measured by urbidimery; how
ever, he high
amylase may be associaed wih pancreaiis, which resuls in hyperlipidemia. 30
. C The gasric
sample can be measured by TLC, bu such a sample should no be used in place of
serum or urine
wihou documenaion of accepabiliy by he reagen manufacurer or laboraory
. A posiive
ampheamine resul by a screening es such as TLC or immunoassay may be caused
by a relaed drug
which inerferes, and herefore, he resul should be con rmed by GC-MS if here i
s a medicolegal
implicaion. 31. B All resuls are normal excep oal proein. The albumin leve
l canno be 94%
of he oal proein, and a random error in oal proein measuremen should be
assumed.
2828_Ch05_171-326 06/08/12 5:14 PM Page 316 32. Te following char compares 
he monhly oal
bilirubin mean of Laboraory A o he monhly mean of Laboraory B, which uses 
he same conrol
maerials, analyzer, and mehod. 5.11 | Clinical Chemisry Problem Solving 317
Answers o
Quesions 3233 32. B Inerlaboraory variaion in bilirubin resuls is ofen caus
ed by
di erences in he assigned value of he calibraor used. Bilirubin calibraors are
eiher
serum-based maerial ha have been reference assayed or unconjugaed bilirubin
sabilized by
addiion of alali and albumin. Calibraor di erences resul in bias and should be
suspeced when
he laboraory s mean di ers signi canly from he peer group s mean. The bias in h
is example is
due o consan raher han proporional error. When bilirubin calibraor error
is suspeced, he
molar absorpiviy of he calibraor should be measured and he bilirubin concen
raion
calculaed. Phoodegradaion generally resuls in a greaer loss of bilirubin a

higher
concenraion and also conribues o random error. 33. D Carryover errors are u
sually aribued
o inerference caused by a sample wih a very high concenraion of analye pre
ceding a normal
sample. However, reagen carryover may also occur on auomaed sysems ha use
common reagen
delivery lines or reusable cuvees. In he case of lipase mehods, riglyceride
s used in he
reagen may coa he reagen lines or cuvees inerfering wih he riglyceride
measuremens
ha direcly follow. Boh laboraories performed conrols a he beginning of e
ach shif using
commercially prepared liquid QC serum sored a 20C. Which of he following condi
ions would
explain hese di erences? A. Improper handling of he conrol maerial by Laborao
ry A resuled
in loss of bilirubin due o phoodegradaion B. Te laboraories used a di eren so
urce of
bilirubin calibraor C. Laboraory B obained higher resuls because is precisi
on was poorer D.
Carryover from anoher reagen falsely elevaed he resuls of Laboraory B Chem
isry/Evaluae
daa o deermine possible sources of error/Qualiy conrol/3 33. Afer insalli
ng a new analyzer
and reviewing he resuls of paiens for 1 monh, he lead echnologis noices
a greaer
frequency of paiens wih abnormally high riglyceride resuls. Analysis of all
chemisry
pro les run he nex day indicaed ha riglyceride resuls are abnormal whenever
he es is
run immediaely afer any sample ha is measured for lipase. Tese observaions
poin o which
ype of error? A. Speci ciy of he riglyceride reagens B. Precision in pipein
g of lipemic
samples C. Bias caused by sequence of analysis D. Reagen carryover Chemisry/Ev
aluae daa o
deermine possible sources of error/Auomaion/3 Level 1 Conrol Level 2 Conr
ol Mean CV
Mean CV Lab A 1.1 mg/dL 2.1% 6.7 mg/dL 3.2% Lab B 1.4 mg/dL 2.2% 7.0 mg/dL 3.6
%
2828_Ch05_171-326 06/08/12 5:14 PM Page 317 34. SITUATION: A digoxin resul f
rom a sable
paien wih a normal elecrocardiogram (EKG) is repored as 7.4 ng/mL (URL 2.6
ng/mL) using an
immuno uorescen mehod. Renal funcion ess were normal and he paien was no
aing any
oher medicaions. Te assay was repeaed and resuls were he same. Te sample wa
s frozen and sen
o a reference laboraory for con rmaion. Te resul was 1.6 ng/mL measured by a c
ompeiive
chemiluminescen procedure. Which bes explains he discrepancy in resuls? A. T
e uorescen
immunoassay was performed improperly B. Digoxin was lower by he chemiluminescen
 mehod because
i is less sensiive C. An inerfering subsance was presen ha cross-reaced
wih he anibody
in he uorescen immunoassay D. Freezing he specimen caused lower resuls by con
vering he
digoxin o an inacive meabolie Chemisry/Evaluae daa o deermine possible

sources of
error/Terapeuic drug monioring/3 35. Te following resuls are repored on an a
dul male paien
being evaluaed for ches pain: 318 Chaper 5 | Clinical Chemisry Answers o Qu
esions 3435 34.
C An error was suspeced because here was a discrepancy beween he es resul
and he
paiens clinical saus (i.e., signs of digoxin oxiciy such as venricular arr
hyhmia were
no presen.) Some subsances called DLIFs (digoxin-lie immunologic facors) ca
n cross-reac
wih anibodies used o measure digoxin. The exen of inerference varies wih
he source of
ani-digoxin used. In addiion, falsely elevaed digoxin resuls may resul from
accidenal
ingesion of plan poisons such as oleandrin and from adminisraion of Digibind
, a Fab fragmen
agains digoxin ha is used o reverse digoxin oxiciy. 35. A Myoglobin is he
rs cardiac
marer o rise ouside he URL following an MI (23 hours) followed by TnI (46 hour
s) and CK-MB
(48 hours). The admission TnI and CK-MB are boh elevaed, and hey coninue o r
ise in all
hree samples. Because TnI and CK-MB pea before 24 hours pos-AMI, he infarci
on liely
occurred wihin he las 1224 hours. The myoglobin can remain elevaed for up o
36 hours
pos-AMI and should have been elevaed in he admission sample. Myoglobin Tropo
nin I CK-MB
(Cuoff = (Cuoff = (Cuoff = 100 g/L) 0.03 g/L) 4 g/L) Admission 12 g/L 1.1 g/
L 18
g/L 3 hours 360 g/L 1.8 g/L 26 g/L posadmission 6 hours 300 g/L 2.4 g/L 40 g/L
posadmission Wha is he mos liely cause of hese resuls? A. Te wrong sample
was assayed for
he rs myoglobin B. Te paien did no su er an MI unil afer admission C. Hemoly
sis caused
inerference wih he 3-hour and 6-hour myoglobin resul D. Te paien is experi
encing unsable
angina Chemisry/Evaluae daa o deermine possible sources of error/Cardiac ma
rers/3
2828_Ch05_171-326 06/08/12 5:14 PM Page 318 36. Analysis of normal and abnorm
al QCs performed
a he beginning of he evening shif revealed a 2 2s error across levels for r
iglyceride. Boh
conrols were wihin he 3s limi. Te conrols were assayed again, and one conr
ol was wihin he
accepable range and he oher was slighly above he 2s limi. No furher acio
n was aen and
he paien resuls ha were par of he run were repored. Which saemen bes
 describes his
siuaion? A. Appropriae operaing procedures were followed B. Remedial evalua
ion should have
been aen, bu oherwise, he acions were appropriae C. Correcive acion sho
uld have been
aen before he conrols were repeaed D. Te conrols should have been run wic
e before
reporing resuls Chemisry/Evaluae daa o deermine possible sources of error
/Qualiy
conrol/3 37. A biochemical pro le rouinely performed bimonhly on a renal dialys
is paien

showed a decreased serum calcium and decreased PTH level. Such a lab resul may
be explained by
which of he following circumsances? A. Malignancy B. Aluminum oxiciy C. Hype
rviaminosis D D.
Acidosis Chemisry/Evaluae laboraory daa o deermine possible inconsisen r
esuls/3 38.
Which se of he following laboraory resuls is mos liely from a paien who
has su ered an
AMI? Reference inervals are in parenhesis. A. B. C. D. Chemisry/Evaluae labo
raory daa o
explain inconsisen resuls/Enzymes/3 5.11 | Clinical Chemisry Problem Solving
319 Answers o
Quesions 3638 36. C Qualiy conrol limis are chosen o achieve a low probabili
y of false
rejecion. For example, a 2 2s error occurs only once in 1,600 occurrences by ch
ance. Therefore,
such an error can be assumed o be signi can. However, his does no mean he err
or will occur
if he conrols are repeaed again. The error deecion rae (power funcion) of
he 2 2s rule is
only abou 30% for a single run. This means ha here is a greaer chance he r
epeaed conrols
will be wihin range han ouside accepable limis. Therefore, conrols should
never be repeaed
unil he es sysem is evaluaed for poenial sources of error. Calibraion s
hould have been
performed prior o repeaing he conrols, and paien samples should have been
evaluaed o
deermine he magniude of he error before reporing. 37. B Aluminum presen in
medicaions and
dialysis bah uid can cause aluminum oxiciy in paiens receiving dialysis. Ren
al failure
paiens ofen display high PTH levels owing o poor reenion of calcium, and a
re a ris of
developing oseiis brosa (sof bones) as a resul. Excess aluminum causes oseom
alacia by
inhibiing release of parahyroid hormone. The nding of low PTH would no be expe
ced wih low
serum calcium unless aluminum poisoning was presen. Malignancy, hyperviaminosi
s D, and acidosis
are associaed wih high serum calcium. 38. B Resuls shown in C and D can be ex
cluded because
he CK-MB is no increased. Resuls shown in A and B have CK-MB levels above he
URL. However,
paien A has a CK index under 2.5% and a 5- o 10-fold elevaion of oal CK. T
hese resuls
indicae release of a small of amoun of CK-MB from seleal muscle raher han
from cardiac
muscle. To maximize he sensiiviy of CK-MB, laboraories use an URL of 4 or 5 g
/L. This cuto
can detect about two-thirds of AMI cases within 3 hours of the infarct, but requ
ires the use of a
conservative CK index and other cardiac markers to avoid a high number of false
positives. Total
CK CK-MB CK index (10110 U/L) (14 g/L) (1%2.5%) 760 U/L 16 g/L 2.1% 170 U/L 14 g
/L
8.2% 160 U/L 4 g/L 2.5% 80 U/L 2 g/L 2.5% 2828_Ch05_171-326 06/08/12 5:14 PM Pa
ge 319 39.
Hemoglobin electrophoresis performed on agarose at pH 8.8 gives the following re
sults: 320

Chapter 5 | Clinical Chemistry Answers to Questions 3940 39. C Hemoglobin Lepore

results from a
hybridization of the
nd enes an prouces a pattern that is simiar to Hb S t
rait (AS),
except that the quantity of Hb Lepore at the Hb S position is beow 20%. Hemo
obin
S--th
l
ssemi
minor results in
n incre
se in H A 2 (
nd possi ly H F) ec
u
se there is
reduced tr
nscription of the structur
lly norm
l ch
in. However, the H S shoul
d e re
ter
th
n the H A,
nd the
mount
t the H A 2 is f
r too hih. The concentr
tion
of H
t the A
2 position is too hih to result from cont
min
tion or to e considered
s H A
2 . This p
ttern

ppe
rs to express two
norm
l H s (H S
nd C)
s well
s the norm
l
dult H
 A. Bec
use
inherit
nce of two
norm
l enes prohi its form
tion of norm
l H A, this p
tt
ern would occur
only if the p
tient h
s een tr
nsfused with norm
l RBCs. Hemolo in SC dise
se
usu
lly produces

lmost equ
l
mounts of H C
nd S (
nd usu
lly
sliht incre
se in H F),
n
d is the most
likely c
use of these results. This could e con rmed y
cid

r electrophoresis
or isofocusin
to identify the
norm
l H s,
nd review of the p
tients medic
l record for evid
ence of recent
lood tr
nsfusion. 40. C Electrolyte results for oth p
tients
re within the ph
ysioloic
l r
ne
ut
re distinctly di erent. The rst results indic
te
hih pot
ssium
nd incre
se
d
nion 
p,

nd one would expect the BUN, uric
cid,
nd cre
tinine to e elev
ted. However,
the results for
BUN
nd lucose
re unlikely for
ny p
tient,
nd the cre
tinine
nd uric
cid s
in
ls
re elow
the detection limit of the
n
lyzer, indic
tin th
t little or no s
mple w
s
dd
ed. This could e
c
used y
p
rti
lly o structed s
mple pro e, or insu cient s
mple volume. The re
sults for the
second s
mple
re elow detection limits for
ll spectrophotometric tests, which
m
y e the
result of complete pro e o struction or the in
ility to ener
te
detect
le s
in
l with the
tr
ce qu
ntity of serum th
t w
s
dded. Bec
use
ll of the low or undetect
le s
in
ls
re for
tests s
mpled y the rst pro e, the only expl
n
tion is th
t the pro e is o struc
ted or
m
lfunctionin. A 2 Position S Position F Position A Position 35% 30% 5% 3
0% N
K Cl
HCO 3 BUN Glucose Cre
tinine Uric Acid 140 mmol/L 5.8 mmol/L 102 mmol/L 18
mmol/L 2.6 m/dL
20 m/dL DL DL 132 mmol/L 4.8 mmol/L 98 mmol/L 24 mmol/L DL DL DL DL DL = Detect
ion limit

(
sor
nce elow detect
le limit) All components of the H C, S, F, A control
hemolys
te were
within the
ccept
le r
ne. Wh
t is the most likely c
use of this p
tients resul
t? A. H
Lepore B. H S--th
l
ssemi
(H S/ + ) C. H SC dise
se post-tr
nsfusion D. Spe
cimen
cont
min
tion Chemistry/Ev
lu
te l
or
tory d
t
to expl
in inconsistent results
/Enzymes/3 40.

Two consecutive serum s
mples ive the results shown in the t
le
ove (
t the
top of this p
e)
for
met
olic function pro le. Te instrument is
r
ndom
ccess
n
lyzer th
t us
es two s
mple
pro es. Te rst pro e
spir
tes
v
ri
le
mount of serum for the spectrophotomet
ric chemistry
tests,
nd the second pro e m
kes
1:50 dilution of serum for electrolyte me
su
rements. Wh
t is
the most likely c
use of these results? A. Both p
tients h
ve ren
l f
ilure B. T
ere is
n
insu cient
mount of s
mple in oth serum tu es C. Tere is

rin str
nd in the pro
e used for
the spectrophotometric chemistry tests D. Te s
me p
tients s
mple w
s
ccident
ll
y run twice
Chemistry/Ev
lu
te d
t
to determine possi le sources of error/Autom
tion/3 2828
_Ch05_171-326
06/08/12 5:15 PM P
e 320 41. SITUATION: A lood s
mple in
red-stoppered tu
e is delivered to
the l
or
tory for electrolytes, c
lcium,
nd phosphorus. Te tu e is
pproxim
te
ly h
lf full
nd
is
ccomp
nied y
purple-stoppered tu e for
complete lood count th
t is
pp
roxim
tely
three-qu
rters full. Te chemistry results
re
s follows: 5.11 | Clinic
l Chemis
try Pro lem
Solvin
321 Answers to Questions 4143 41. D The pot
ssium
nd the c
lcium resul
ts
re
ove

nd elow physioloic
l limit v
lues, respectively. Althouh hemolysis could exp
l
in the hih
pot
ssium, hemolysis does not c
use
sini c
nt ch
ne in serum c
lcium. The wron
 order of dr
w
could result in the f
lsely low c
lcium v
lue ut would not e su cient to c
use

result th
t is
incomp
ti le with life (
nd does not expl
in
rossly elev
ted pot
ssium). The
results
nd the
condition of the tu es indic
te th
t lood from
full tu e collected in K 3 EDT
A w
s
dded to
the clot tu e, chel
tin the c
lcium
nd incre
sin the pot
ssium. 42. D Results
of thyroid tests
(especi
lly in hospit
lized p
tients) m
y sometimes
ppe
r discrep
nt ec
use me
dic
tions
nd
nonthyroid illnesses c
n
ect test results. The pituit
ry is slow to respond to t
hyroxine
repl
cement,
nd 68 weeks
re usu
lly required efore TSH levels f
ll
ck to nor
m
l. In the
e
rly st
e of ther
py, the p
tient should e monitored y the free T 4 result.
This p
tients
free T 4 is norm
l, indic
tin th
t repl
cement ther
py is
dequ
te. The hih TS
H sometimes seen
in tre
ted p
tients is c
lled pituit
ry l
. 43. C Phenytoin levels must e moni
tored closely
ec
use toxic dru levels c
n occur unexpectedly due to ch
nin ph
rm
cokinetic
s. Phenytoin
follows
nonline
r r
te of elimin
tion, which me
ns th
t cle
r
nce decre
ses
s
lood levels
incre
se. At hih lood levels, s
tur
tion of the hep
tic hydroxyl
tin enzymes
c
n occur,
c
usin
n
rupt incre
se in the lood level from
sm
ll incre
se in dose. The
dru h
lf-life
estim
ted from the two dru levels is
pproxim
tely 15 hours, which is within th
e r
ne expected

for children, so decre
sed cle
r
nce is not likely the pro lem. V
lproic
cid co
mpetes with
phenytoin for indin sites on
l umin. Free phenytoin is the physioloic
lly
c
tive fr
ction
nd
is norm
lly very low, so sm
ll ch
nes in protein indin c
n c
use
l
re ch
n
e in free dru.
For ex
mple,
5% f
ll in protein indin c
used y v
lproic
cid c
n incre
se t
he free phenytoin
level y 50%. This p
tients free phenytoin level should e me
sured,
nd the dose
of phenytoin
reduced to produce
free dru level th
t is within the ther
peutic r
ne. N

K Cl HCO 3 C

InP 135 11.2 103 14 2.6 3.8 mmol/L mmol/L mmol/L mmol/L m/dL m/dL Wh
t i
s the most likely
expl
n
tion of these serum c
lcium results? A. Severe hemolysis durin s
mple co
llection B.
L
or
tory error in the c
lcium me
surement C. Te wron order of dr
w w
s used f
or v
cuum tu e
collection D. Some
ntico
ul
ted lood w
s
dded to the red-stoppered tu e Chem
istry/Ev
lu
te
d
t
to determine possi le sources of error/Electrolytes/3 42. SITUATION: A p
ti
ent previously
di
nosed with prim
ry hypothyroidism
nd st
rted on thyroxine repl
cement ther

py is seen for
follow-up testin
fter 2 weeks. Te serum-free T 4 is norm
l ut the TSH is stil
l elev
ted. Wh
t
is the most likely expl
n
tion for these results? A. L
or
tory error in me
sure
ment of free T 4
B. L
or
tory error in me
surement of TSH C. In vitro dru interference with the
free T 4
ss
y
D. Results
re consistent with
euthyroid p
tient in the e
rly ph
se of ther
py
Chemistry/Ev
lu
te l
or
tory d
t
to expl
in inconsistent results/Endocrinoloy
/3 43. SITUATION:
A 6-ye
r-old child ein tre
ted with phenytoin w
s recently pl
ced on v
lproic

cid for etter
control of seizures. After displ
yin sins of phenytoin toxicity includin
t
x
i
,
st
t
phenytoin is determined to e 15.0 m/L (reference r
ne 1020 m/L). A pe
k lood
level dr
wn 5
hours
fter the l
st dose is 18.0 m/L. Te v
lproic
cid me
sured
t the s
me ti
me is within
ther
peutic limits. Qu
lity control is within
ccept
le limits for
ll tests,
ut the physici
n
questions the
ccur
cy of the results. Wh
t is the most
ppropri
te next course
of
ction? A.
Repe
t the v
lproic
cid level usin the l
st specimen B. Repe
t the phenytoin o
n oth trouh
nd
pe
k s
mples usin
di erent method C. Recommend me
surement of free phenytoin us
in the l
st
specimen D. Recommend
second trouh level e me
sured Chemistry/Ev
lu
te l
or

tory d
t
to
expl
in inconsistent results/TDM/3 2828_Ch05_171-326 06/08/12 5:15 PM P
e 32
1 322 Ch
pter 5 |
Clinic
l Chemistry Answers to Questions 4445 44. D BUN is elev
ted 5- to 10-fold
for three
consecutive p
tients in the
sence of
ny other l
or
tory evidence of ren
l di
se
se. The
lucose results show conclusively th
t the s
mples
re not from the s
me p
tient
. Therefore, the
BUN results must e c
used y
system
tic error,
nd should not e reported. Fu

rther testin for

BUN should ce
se until the
n
lytic
l components of the BUN
ss
y
re completely
ev
lu
ted
nd
the c
use of these results identi ed
nd corrected. This is demonstr
ted y succes
sful
rec
li r
tion
nd perform
nce of controls within
ccept
le limits. Followin th
is, the BUN
ss
y
should e repe
ted on the three s
mples
lon with
ll other specimens with
sp
urious BUN result
th
t h
ve occurred since the st
rt of the shift. 45. A The
n
lytic
l sensitivit
y of
immunochemic
l AFP tests is
pproxim
tely 5 n/mL. The m
tern
l serum AFP
t 12
weeks est
tion
is
rely
ove the
n
lytic
l detection limit. Therefore, to
chieve the needed
sensitivity, the
test should e repe
ted
t 14 weeks. If the result is still equ
l to or re
ter
th
n 2.5 MOM,
then ultr
sound should e performed to verify l
st menstru
l period d
tin. AFP
norm
lly rst
ecomes detect
le in m
tern
l serum
t week 12
nd incre
ses y 15% per week th
rouh the 26th
week. Levels of 2.5 MOM or re
ter
re
ssoci
ted with spin
i d
ut
lso occur
in ventr
l w
ll

nd
domin
l w
ll defects, fet
l de
th, Turners syndrome, trisomy 13, conenit
l
hypothyroidism, tyrosinemi
,
nd sever
l other fet
l conditions. A positive seru
m test should

lw
ys e repe
ted,
nd if positive

in, followed y ultr
sound. If ultr
sound
does not expl
in
the elev
tion,
mniotic uid testin includin AFP
nd
cetylcholinester
se is usu

lly
recommended. N

K Cl HCO 3 BUN Glucose Cre
tinine Uric Acid 140 mmol
/L 3.6 mmol/L 100
mmol/L 28 mmol/L 130 m/dL 110 m/dL 1.2 m/dL 4.8 m/dL 148 mmol/L 4.2 mmol/L 1
10 mmol/L 24
mmol/L 135 m/dL 86 m/dL 0.8 m/dL 3.9 m/dL 138 mmol/L 4.0 mmol/L 105 mmol/L 2
2 mmol/L 142
m/dL 190 m/dL 1.0 m/dL 4.6 m/dL 44. The results shown in the t
le
ove
re
o t
ined from
three consecutive serum s
mples usin
n
utom
ted r
ndom
ccess
n
lyzer th
t s

mples directly
from

r-coded tu e. C
li r
tion
nd QC performed
t the st
rt of the shift
r
e within the

ccept
le r
ne,
nd no error codes
re reported y the
n
lyzer for
ny tests
on the three
s
mples. Upon results verific
tion, wh
t is the most
ppropri
te course of
ctio
n? A. Report the
results
nd proceed with other tests since no
n
lytic
l pro lems
re noted B. R
epe
t the
controls efore continuin with further testin, ut report the results C. Check
s
mple
identi c
tion prior to reportin D. Do not report BUN results for these p
tients o
r continue BUN
testin Chemistry/Ev
lu
te l
or
tory d
t
to expl
in inconsistent results/Autom

tion/3 45. An
AFP me
sured on
30-ye
r-old pren
nt wom
n
t
pproxim
tely 12 weeks est
tion
is 2.5 multiples
of the medi
n (MOM). Wh
t course of
ction is most
ppropri
te? A. Repe
t the se
rum AFP in 2
weeks B. Recommend AFP
ss
y on
mniotic uid C. Repe
t the AFP usin the s
me s
m
ple y
nother

method D. Repe
t the AFP usin the s
mple y the s
me method Chemistry/Select co
urse of

ction/AFP/3 2828_Ch05_171-326 06/08/12 5:15 PM P
e 322 46. SITUATION: Bioch
emistry tests
re
performed 24 hours
p
rt on
p
tient
nd delt
-check
 is reported for inor
ni
c phosphorus y
the l
or
tory inform
tion system. Given the results shown in the t
le
ove, i
dentify the most
likely c
use. A. Results suest
ltered met
olic st
tus c
used y poor insulin
control B. Te
p
tient w
s not f
stin when the s
mple w
s collected on d
y 2 C. Te s
mples wer
e dr
wn from two
di erent p
tients D. Te delt
-check limit is inv
lid when s
mples
re collected 24
or more hours

p
rt Chemistry/Ev
lu
te d
t
to determine possi le sources of error/Autom
tion/
3 47. A
qu
ntit
tive s
ndwich enzyme immuno
ss
y for int
ct serum hCG w
s performed on w
eek 4
nd the
result w
s 40,000 mIU/mL (reference r
ne 10,00080,000 mIU/mL). Te physici
n susp
ected
mol
r
pren
ncy
nd requested th
t the l
or
tory repe
t the test checkin for the hoo
k e ect. Which
process would identify this pro lem? A. O t
in
new pl
sm
specimen
nd he
t in

ctiv
te efore
testin B. O t
in
urine specimen
nd perform the
ss
y C. Perform
qu
lit
tiv
e pren
ncy test
D. Perform
seri
l dilution of the s
mple
nd repe
t the test Chemistry/Identif
y sources of
error/Immuno
ss
y/2 5.11 | Clinic
l Chemistry Pro lem Solvin
323 Answers to Q
uestions 4647
46. B The delt
check comp
res the di erence of the p
tients two most recent l
or

tory results
within
3-d
y period to
delt
limit usu
lly determined
s
percent
e di erenc
e. The purpose
of the delt
check is to detect s
mple identi c
tion errors. A delt
-check
 c
n

lso e c
used
y r
ndom
n
lytic
l errors
nd interferin su st
nces such
s hemolysis, icteru
s,
nd lipemi
,

nd y met
olic ch
nes
ssoci
ted with dise
se or tre
tment. Therefore, result
s should e
c
refully considered efore determinin the c
use. In this c
se, hemolysis
nd i
cterus c
n e
ruled out ec
use enzymes sensitive to hemolysis interference (AST, ALT,
nd LD)

nd iliru in

re within norm
l limits. Tests showin
sini c
nt di erence
re inor
nic phospho
rus, ALP,
trilycerides,
nd lucose. These four tests
re elev
ted y diet (the ALP from
postpr
ndi
l
secretion of intestin
l ALP). All other tests show
hih level of
reement et
ween d
ys,
nd
the di erences
re
ttri ut
le to norm
l physioloic
l
nd
n
lytic
l v
ri
tion.
47. D The hook
e ect is the result of excessive
ntien concentr
tion
nd results in
dose respo
nse
(c
li r
tion) curve th
t reverses direction
t very hih
ntien concentr
tions.
It occurs in
two-site dou le
nti ody s
ndwich
ss
ys when oth the c
pture
nti ody
nd the
enzyme-conju
ted

nti ody
re incu
ted with the
ntien
t the s
me time. The excess
ntien s
t
ur
tes oth


nti odies preventin form
tion of
dou le
nti ody s
ndwich. The hook e ect c
n
c
use results
to e su ciently low to c
use misdi
nosis. It c
n e detected y dilutin the s
m
ple (
ntien)
in which c
se the
ss
y result will e re
ter th
n in the undiluted s
mple. An

ltern
tive
solution is to perform the test usin
competitive indin
ss
y or
s
ndwich

ss
y in which
the enzyme-l
eled
nti ody is not
dded until
fter sep
r
tion of free
nd oun
d
ntien. AST
ALT ALP LD CK GGT TP ALB TBIL GLU TG CA InP BUN U/L U/L U/L
U/L U/L U/L
/dL /dL m/dL m/dL m/dL m/dL m/dL m/dL D
y 1 20 15 40 100 1
5 40 8.2 3.6 0.8
84 140 8.7 4.2 16 D
y 2 22 14 65 90 20 36 8.3 3.8 1.0 128 190 8.8 5.2 26 2828_Ch
05_171-326
06/08/12 5:15 PM P
e 323 48. A p
tient presents to the emerency dep
rtment w
ith symptoms of
intoxic
tion includin imp
ired speech
nd movement. Te pl
sm
osmol
lity w
s me

sured
nd found
to e 330 mOs/k. Te osmol
l 
p w
s 40 mOsm/K. A lood
lcohol w
s me
sured y
the
lcohol
dehydroen
se method
nd found to e 0.15% w/v (150 m/dL). Electrolyte results
showed
n
incre
sed
nion 
p. Ethylene lycol intoxic
tion w
s suspected ec
use the osmo
l
l 
p w
s
re
ter th
n could e expl
ined y eth
nol
lone, ut 
s chrom
tor
phy w
s not

v
il
le. Which
of the followin would e
norm
l if this suspicion proved correct? A. Arteri
l
lood 
ses B.
L
ctic
cid C. Urin
ry ketones D. Glucose Chemistry/Select course of
ction/Toxi
coloy/3 49.
Given the serum protein electrophoresis p
ttern shown, which tr
ns
min
se result
s would you
expect? 324 Ch
pter 5 | Clinic
l Chemistry Answers to Questions 4850 48. A Ethyle
ne lycol is
sometimes used
s
su stitute for eth
nol y
lcoholics. It is met
olized to f
ormic
cid
nd
lycolic
cid y the liver, resultin in met
olic
cidosis
nd
n incre
sed
ni
on 
p. L
ctic

cid, lucose,
nd urin
ry ketones would e useful in rulin out other c
uses of
met
olic

cidosis, ut would not e
norm
l
s
result of ethylene lycol intoxic
tion.
49. C The
protein electrophoresis
nd densitometric sc
n show
sini c
ntly reduced
l umin

nd polyclon
l

mmop
thy. The densitometric sc
n shows et
-
mm
ridin th
t supports
di

nosis of hep
tic
cirrhosis. In this condition one would expect two- to vefold incre
ses of oth tr

ns
min
ses
with
n ALT:AST r
tio elow 1. 50. D Troponin
ss
ys produce very little fluores
cence or
chemiluminescence when pl
sm
levels
re within the reference r
ne
nd ne
r the
minimum
detection limit of the
ss
y. Fi rin, tu e
dditives,
nd heterophile
nti odies
h
ve een known
to c
use spurious elev
tions,
nd this result should e tre
ted
s
r
ndom erro
r ec
use the
result efore
nd
fter
re oth norm
l. Al
1 2 A. Within norm
l limits for
oth B.

M
rked elev
tion of oth (2050-fold norm
l) C. Mild elev
tions of oth (25-fold no

rm
l) D.
M
rked elev
tion of AST ut norm
l ALT Chemistry/Correl
te l
or
tory results/Li
ver dise
se/2 50.
Seri
l TnI
ss
ys
re ordered on
p
tient
t
dmission, 3 hours,
nd 6 hours
f
terw
rds. Te
s
mples were collected in hep
rinized pl
sm
sep
r
tor tu es. Followin
re the
results
(reference r
ne 00.03 /L) Admission = 3 hours = 6 hours = 0.03 /L 0.07 /L 0.02
/L
Tese results indic
te: A. A positive test for
cute myoc
rdi
l inf
rction B. Uns
t
le
nin
C.
C
rdi
c injury of severity less th
n myoc
rdi
l inf
rction D. R
ndom error with
the 3-hour s
mple
Chemistry/Identify sources of error/Immuno
ss
y/2 2828_Ch05_171-326 06/08/12 5
:15 PM P
e 324
BI BL I OGRAPHY 1. Anderson SC
nd Cock
yne S. Clinic
l Chemistry Concepts
nd A
pplic
tions. 2nd
edition, 2007. McGr
w Hill, New York. 2. Bishop ML, Fody EP,
nd Schoe LE. Clinic

l Chemistry
Principles, Procedures,
nd Correl
tions. 6th edition, 2010. Lippincott Willi
ms

nd Wilkins,
Phil
delphi
. 3. Burtis CA, Ashwood ER,
nd Burns DE. Tietz Fund
ment
ls of Clin
ic
l Chemistry.
6th edition, 2008. W.B. S
unders, Phil
delphi
. 5.11 | Clinic
l Chemistry Pro le
m Solvin
325
4. Burtis CA, Ashwood ER,
nd Burns DE. Tietz Text ook of Clinic
l Chemistry
nd
Molecul
r
Di
nostics. 4th edition, 2006. Elsevier S
unders, St. Louis. 5. K
pl
n LA
nd P
esce AJ. Clinic
l
Chemistry Teory An
lysis, Correl
tion. 5th edition, 2009. Mos y, St. Louis. 6. M
cPherson RA
nd
Pinccus MR. Henrys Clinic
l Di
nosis
nd M
n
ement y L
or
tory Methods. 22nd
edition, 2011.
W.B. S
unders, Phil
delphi
. 2828_Ch05_171-326 06/08/12 5:15 PM P
e 325 2828
_Ch05_171-326
06/08/12 5:15 PM P
e 326 CHAPTER 6 6.1 Routine Physic
l
nd Biochemic
l Urine
Tests 6.2 Urine
Microscopy
nd Clinic
l Correl
tions 6.3 Cere rospin
l, Serous,
nd Synovi
l Flu
ids 6.4 Amniotic,
G
strointestin
l,
nd Semin
l Fluids 6.5 Urin
lysis
nd Body Fluids Pro lem Solv
in 327
Urin
lysis
nd Body Fluids 2828_Ch06_327-380 06/08/12 11:23 AM P
e 327 2828_
Ch06_327-380
06/08/12 11:23 AM P
e 328 Answers to Questions 13 1. A The form
tion of pl
sm

ultr
ltr
te
depends upon hih hydrost
tic pressure
nd perme
ility of the lomeruli. Aldost
erone is rele
sed
when
erent
rteri
l pressure f
lls,
nd ADH is rele
sed when pl
sm
osmol
lity
ecomes too
hih. The collectin tu ule re
sor s sodium
nd secretes pot
ssium in response
to
ldosterone,

nd is perme
le to H 2 O only in the presence of ADH. The thick
scendin lim
is perme
le to
s
lt, ut not to H 2 O or ure
. 2. A The tu ules
re
le to concentr
te the ltr

te ec
use the
descendin lim is hihly perme
le to H 2 O
nd ure
ut not to s
lt,
nd the

scendin lim is
perme
le to s
lt. S
lt le
vin the
scendin lim cre
tes
hypertonic intersti
tium th
t forces

H 2 O from the descendin lim . Renin is rele
sed in response to low hydrost
tic

pressure in the

erent
rteriole, which stimul
tes the juxt
lomerul
r cells. ADH is rele
sed y
the posterior
pituit
ry in response to hih pl
sm
osmol
lity. 3. A Sodium is
threshold su s
t
nce, me
nin
th
t no sodium will e excreted in the urine until the ren
l threshold (
pl
sm

sodium
concentr
tion of
pproxim
tely 120 mmol/L) is exceeded. Pot
ssium is not
thres
hold su st
nce

nd will e secreted y the tu ules even when pl
sm
pot
ssium levels
re low. P

tients on
diuretics or who h
ve hypovolemi
ecome hypok
lemic for this re
son. Some su st

nces (e..,
penicillin) c
n e excreted
t
r
te exceedin lomerul
r ltr
tion ec
use the t
u ules secrete
them. The tu ules
re responsi le for concentr
tin the ltr
te in conditions of w

ter
depriv
tion
nd dilutin it in conditions of w
ter excess. When tu ul
r function
is lost, s
lt

nd w
ter equili r
te y p
ssive di usion
nd the speci c r
vity of the urine ecom
es the s
me

s the pl
sm
,
pproxim
tely 1.010. 1. Which st
tement re
rdin ren
l function
is true? A.
Glomeruli
re f
r more perme
le to H 2 O
nd s
lt th
n other c
pill
ries B. Te
collectin tu ule
re
sor s sodium
nd secretes pot
ssium in response to
ntidiuretic hormone (ADH
) C. Te
collectin tu ule is perme
le to H 2 O only in the presence of
ldosterone D. T
e thick
scendin
lim is hihly perme
le to H 2 O
nd ure
Body uids/Apply knowlede of fund
ment

l ioloic
l
ch
r
cteristics/Urine/1 2. Which st
tement re
rdin norm
l s
lt
nd H 2 O h
ndl
in y the
nephron is correct? A. Te
scendin lim of the tu ule is hihly perme
le to s

lt ut not H 2 O
B. Te stimulus for ADH rele
se is low
rteri
l pressure in the
erent
rteriole C
. Te descendin
lim of the tu ule is imperme
le to ure
ut hihly perme
le to s
lt D. Renin
is rele
sed in
response to hih pl
sm
osmol
lity Body uids/Apply knowlede of fund
ment
l iolo
ic
l
ch
r
cteristics/Urine/1 3. Which st
tement concernin ren
l tu ul
r function is
true? A. In s
lt
depriv
tion, the kidneys will conserve sodium
t the expense of pot
ssium B. Pot

ssium is not
excreted when serum concentr
tion is elow 3.5 mmol/L C. No su st
nce c
n e exc
reted into urine

t
r
te th
t exceeds the lomerul
r ltr
tion r
te D. When tu ul
r function is l
ost, the
speci c r
vity of urine will e elow 1.005 Body uids/Correl
te l
or
tory d
t
wi
th
physioloic
l processes/Urine electrolytes/2 6.1 Routine Physic
l
nd Biochemic

l Urine Tests 329
2828_Ch06_327-380 06/08/12 11:23 AM P
e 329 4. Which of the followin is in

ppropri
te when
collectin urine for routine
cterioloic culture? A. Te cont
iner must e ster
ile B. Te
midstre
m void technique must e used C. Te collected s
mple must e pl
ted with
in 2 hours unless

refrier
ted D. Te s
mple m
y e held
t 2C8C for up to 48 hours prior to pl
tin B

ody
uids/Apply knowlede to identify sources of error/Specimen collectin
nd h
ndlin
/2 5. Which
st
tement
out s
mple collection for routine urin
lysis is true? A. Preserv
tiv
e t
lets should
e used for collectin r
ndom urine specimens B. Cont
iners m
y e w
shed
nd re
used if rinsed in
deionized H 2 O C. S
mples m
y e stored
t room temper
ture for up to 2 hours D
. First mornin
voided s
mples
re not
ccept
le when ren
l dise
se is suspected Body uids/Apply
knowlede to
identify sources of error/Specimen collection
nd h
ndlin/2 6. Which urine colo
r is correl
ted
correctly with the piment-producin su st
nce? A. Smoky red urine with homoent
isic
cid B. D
rk

m er urine with myolo in C. Deep yellow urine
nd yellow fo
m with iliru in D
. Red- rown urine
with iliverdin Body uids/Correl
te l
or
tory d
t
with physioloic
l processes/
Urine color/2
7. Which of the followin su st
nces will c
use urine to produce red uorescence w
hen ex
mined
with
n ultr
violet l
mp (360 nm)? A. Myolo in B. Porpho ilinoen (PBG) C. Uro
ilin D.
Coproporphyrin Body uids/Correl
te clinic
l
nd l
or
tory d
t
/ Urine porphyrins
/2 8. Which of
the followin conditions is
ssoci
ted with norm
l urine color ut produces red u
orescence when
urine is ex
mined with
n ultr
violet (Woods) l
mp? A. Acute intermittent porphyr
i
B. Le
d
poisonin C. Erythropoietic porphyri
D. Porphyri
cut
ne
t
rd
Body uids/Correl

te clinic
l

nd l
or
tory d
t
/ Urine color/2 330 Ch
pter 6 | Urin
lysis
nd Body Fluids An
swers to
Questions 48 4. D Urine specimens should e pl
ted
nd incu
ted within 2 hours o
f collection
(some l
s use
1-hour time limit),
nd within 24 hours if the s
mple is refri
er
ted
t 2C8C
immedi
tely followin collection. No
dditives
re permitted when urine is colle
cted for culture.
5. C The rst mornin voided s
mple is the most sensitive for screenin purposes
ec
use formed
elements
re concentr
ted, ut r
ndom s
mples
re s
tisf
ctory ec
use lomerul

r leedin,

l uminuri
,
nd c
st form
tion m
y occur
t
ny time. Preserv
tive t
lets shou
ld e
voided
ec
use they m
y c
use chemic
l interference with some dry re
ent strip
nd tur
idimetric
protein tests. Ch
nes in lucose, iliru in,
nd uro ilinoen c
n occur within
30 minutes of
collection. Therefore, s
mples should e refrier
ted if not tested within 2 hou
rs. 6. C
Homoentisic
cid c
uses d
rk rown or l
ck-colored urine. Myolo in c
uses
r
ed to red- rown
color in urine,
nd iliverdin c
uses
reen or yellow-reen color. In
ddition
to met
olic
dise
ses
nd ren
l dise
se,
norm
l color c
n e c
used y drus (e.., G
ntris
in), dyes
excreted y the kidneys (e.., PSP),
nd n
tur
l or
rtifici
l food colorin (e.
., eets). 7. D

Myolo in c
uses
positive test for lood ut does not c
use urine to fluoresce
. PBG c
uses
urine to ecome d
rk (or
ne to or
ne- rown) on st
ndin ut does not fluoresce
. Uroporphyrin

nd coproporphyrin produce red or or
ne-red fluorescence. Unlike hemolo in, po
rphyrins l
ck
peroxid
se
ctivity. Uro ilin is
n oxid
tion product of uro ilinoen. It turns
the urine or
ne
to or
ne- rown ut does not produce fluorescence. 8. B Le
d poisonin locks th
e synthesis of
heme, c
usin
ccumul
tion of PBG
nd coproporphyrin III in urine. However, urop
orphyrin levels

re not su ciently elev
ted to c
use red piment
tion of the urine. There is su cien
t
coproporphyrin to c
use
positive test for uorescence. Acute intermittent porphy
ri
produces
incre
sed urin
ry delt
-
minolevulinic
cid (-ALA), an PBG. The PBG turns the ur
ine orane to
orane-brown upon stanin. Erythropoietic porphyria an porphyria cutanea tara
prouce are
amounts of uroporphyrin, causin the urine to be re or port wine coore. 2828_
Ch06_327-380
06/08/12 11:23 AM Pae 330 9. Which statement rearin porphyria is accurate?
A. Porphyria is
excusivey inherite B. A types cause an increase in urinary porphyrins C. A
 types are
associate with anemia D. Serum, urine, an feca tests may be neee for iano
sis Boy
uis/Appy principes of specia proceures/ Porphyrins/2 10. Which is the most c
ommon form of
porphyria? A. Erythropoietic porphyria B. Acute intermittent porphyria C. Varie
ate porphyria D.
Porphyria cutanea tara Boy uis/Appy knowee isease states/Porphyria/2 11.
Which of the
foowin methos is the east sensitive an speci c for measurin PBG in urine? A
.
WatsonSchwartz test B. LCMS C. Ion exchane chromatoraphyEhrichs reaction D. Isoto
pe
iutionMS Boy uis/Appy principes of specia proceures/ Urine PBG/2 12. A bro
wn or back
piment in urine can be cause by: A. Gantrisin (Pyriium) B. Phenosufonphtha
ein C. Rifampin
D. Meanin Boy uis/Correate cinica an aboratory ata/ Urine coor/2 13. Ur
ine that is
ark re or port wine in coor may be cause by: A. Lea poisonin B. Porphyria
cutanea tara C.
Akaptonuria D. Hemoytic anemia Boy uis/Correate cinica an aboratory ata
/ Urine coor/2
6.1 | Routine Physica an Biochemica Urine Tests 331 Answers to Questions 913
9. D Porphyria
may be inherite as a resut of an enzyme efect in heme synthesis or may be acq
uire as a resut
of ea poisonin, iver faiure, or ru toxicity. The inherite porphyrias con
sist of eiht
subroups base on which enzyme is e cient. They are ivie cinicay into thre
e roups:
neuropsychiatric, cutaneous, or mixe. The neurooica porphyrias are not assoc
iate with
anemia, but erythropoietic porphyria, a type of cutaneous porphyria, is. In ene
ra, neurooica

porphyrias are associate with increases in porphobiinoen an -aminoevuinic a

ci, whie
cutaneous porphyrias are associate with increase urinary porphyrins. No one sa
mpe type can be
use to ientify a subroups an sometimes a three are neee. 10. D Porphyr
ia is a rare
conition, athouh most of the inherite forms are autosoma ominant. Porphyri
a cutanea tara
resuts from a e ciency of uroporphyrinoen ecarboxyase, an hence, the carboxy
ate forms of
uroporphyrin accumuate in pasma an spi into the urine. The enzyme in hepato
cytes is
susceptibe to rus, acoho, an hepatitis that trier the isease. The isea
se usuay
appears in mie-ae auts, the majority of whom have hepatitis C infection.
The uroporphyrins
are hihy uorescent an may cause port-wine coore urine. A ecte persons present
with skin
bisters an skin burns if expose to suniht. 11. A The WatsonSchwartz test is
a quaitative
screenin test for PBG an is base upon the principe that ietary inoe compo
uns an
urobiinoen can be separate from PBG by extraction. PBG is extracte in n-buta
no, whie
urobiinoen an ietary inoes are extracte into choroform. However, the sen
sitivity an
speci city of the test are poor in comparison to chromatoraphic an mass spectros
copic methos
that better separate PBG from interferin substances. PBG is eevate in neuroo
ica porphyrias,
the most common of which is acute intermittent porphyria. 12. D Excretion of me
anin in mainant
meanoma an homoentisic aci in akaptonuria cause the urine to turn back on
stanin. Other
substances that may cause brown or back-coore urine are methemoobin, PBG, p
orphobiin, an
urobiin. Gantrisin, PSP ye, an rifampin are three exampes of rus that caus
e a re or
orane-re coor in urine. 13. B Porphyria cutanea tara an erythropoietic porp
hyria prouce
su cient uroporphyrins to cause ark re urine. Acute intermittent porphyria prou
ces are
amounts of PBG, which may be oxiize to porphobiin, turnin the urine orane t
o orane-brown.
2828_Ch06_327-380 06/08/12 11:23 AM Pae 331 14. Which of the foowin tests
is a ecte east
by stanin or impropery store urine? A. Gucose B. Protein C. pH D. Biirubin
Boy uis/Appy
knowee to ientify sources of error/Urine/Specimen coection an hanin/2
15. Which type of
urine sampe is neee for a D-xyose absorption test on an aut patient? A. 24
-hour urine
sampe coecte with 20 mL of 6 N HC B. 2-hour time postprania urine preser
ve with boric
aci C. 5-hour time urine kept uner refrieration D. Ranom urine preserve wi
th formain Boy
uis/Appy principes of basic aboratory proceures/Urine/Specimen coection an
 hanin/2
16. Which of the foowin is inappropriate when coectin a 24-hour urine samp
e for

catechoamines? A. Urine in the baer is voie an iscare at the start of

the test B. At 24
hours, any urine in the baer is voie an ae to the coection C. A uri
ne shou be
coecte in a sine container that is kept refrierate D. Ten mL of 1N soium
hyroxie shou
be ae to the container before coection Boy uis/Appy knowee to ientify
sources of
error/Urinary catechoamines/2 17. Urine prouction of ess than 400 mL/ay is:
A. Consistent
with norma rena function an H 2 O baance B. Terme isosthenuria C. De ne as o
iuria D.
Associate with iabetes meitus Boy uis/Correate cinica an aboratory at
a/Urine
voume/2 18. Which of the foowin contributes to SG, but not to osmoaity? A.
Protein B. Sat
C. Urea D. Gucose Boy uis/Evauate aboratory ata to etermine possibe incon
sistent
resuts/Speci c ravity/2 332 Chapter 6 | Urinaysis an Boy Fuis Answers to Qu
estions 1418
14. B Stanin urine may become akaine ue to oss of voatie acis an ammon
ia prouction.
Biirubin ucuronies may become hyroyze to unconjuate biirubin or oxiiz
e to biiverin,
resutin in a fase-neative ry reaent strip test. Gucose can be consume by
ycoysis or
oxiation by ces. 15. C The D-xyose absorption test is use to istinuish pa
ncreatic
insu ciency from intestina maabsorption. The test requires a boo sampe taken
2 hours after
ora aministration of 25  of D-xyose, an a 5-hour time urine sampe. D-xyo
se is absorbe
without the ai of pancreatic enzymes, an is not metaboize by the iver. Ther
efore, e cient
absorption (enote by a pasma eve < 25 m/L an urine excretion of < 4/5ho
urs) points to
maabsorption synrome. Tests requirin a 24-hour urine sampe incue catechoa
mines,
vaniymaneic aci (VMA), metanephrines, cortiso, an estrio. 16. D When co
ectin a
24-hour urine sampe, the baer must be emptie of urine at the start of the t
est an
iscare. The baer must be emptie at the concusion of the test an the uri
ne ae to the
coection. In orer to prevent eraation of catechoamines VMA, metanephrines
, an cortiso,
the urine must be refrierate urin storae an kept at 2C8C unti anaysis or fr
ozen. If
the pH of the specimen excees 3.0, eraation of catechoamines can occur. Pre
servation of the
urine with aci is no oner require for VMA, metanephrines an cortiso. 17.
C Norma aiy
urine excretion is usuay 6001,600 mL/ay. Isosthenuria refers to urine of const
ant specific
ravity (SG) of 1.010, which is the SG of the omeruar fitrate. Gycosuria ca
uses retention of
H 2 O within the tubue, resutin in ehyration an poyuria rather than oiu
ria. 18. A A
substances that issove in the urine contribute to osmotic pressure or osmoai
ty. This incues

nonionize soutes such as urea, uric aci, an ucose as we as sats, but no
t coois such
as protein an ipis. 2828_Ch06_327-380 06/08/12 11:23 AM Pae 332 19. Urine
with an SG
consistenty between 1.002 an 1.003 inicates: A. Acute omeruonephritis B. R
ena tubuar
faiure C. Diabetes insipius D. Aisons isease Boy uis/Evauate aboratory a
ta to
reconize heath an isease states/Speci c ravity/2 20. In which of the foowin
 conitions is
the urine SG ikey to be beow 1.025? A. Diabetes meitus B. Dru overose C.
Chronic rena
faiure D. Prerena faiure Boy uis/Evauate ata to reconize heath an isea
se
states/Speci c ravity/2 21. Which statement rearin methos for measurin SG i
s true? A. To
correct a urinometer, subtract 0.001 per each 3C beow 15.5C B. Coorimetric SG te
sts are
fasey eevate when a are quantity of ucose is present C. Coorimetric SG
reains are
fasey eevate when pH is akaine D. Refractometry shou be performe before
the urine is
centrifue Boy uis/Appy knowee to ientify sources of error/Speci c ravity/
2 22. What is
the principe of the coorimetric reaent strip etermination of SG in urine? A.
Ionic strenth
aters the pK a of a poyeectroyte B. Soium an other cations are cheate by
a ian that
chanes coor C. Anions ispace a pH inicator from a morant, makin it water
soube D.
Ionize soutes catayze oxiation of an azo ye Boy uis/Appy principes of ba
sic aboratory
proceures/Speci c ravity/1 23. Which statement rearin urine pH is true? A. Hi
h-protein
iets promote an akaine urine pH B. pH tens to ecrease as urine is store C.
Contamination
shou be suspecte if urine pH is ess than 4.5 D. Bacteriuria is most often as
sociate with a
ow urine pH Boy uis/Correate cinica an aboratory ata/ Urine pH/2 6.1 | R
outine Physica
an Biochemica Urine Tests 333 Answers to Questions 1923 19. C In severe rena
iseases, the
tubues fai to concentrate the trate. Sat an H 2 O equiibrate by i usion, cau
sin an SG of
about 1.010. If the SG of urine is beow that of pasma, free H 2 O is ost. Thi
s resuts from
faiure to prouce ADH (inherite iabetes insipius) or from faiure of the tub
ues to respon
to ADH (nephroenic iabetes insipius, which can be cause by rus, poycystic
kiney isease,
an hypercacemia). 20. C Gucose an ru metaboites increase the SG of urine.
In prerena
faiure, the tubues are unamae. Ine ective arteria pressure stimuates aost
erone reease.
This increases soium reabsorption, which stimuates ADH reease. Water an sat
are retaine,
an the urine:pasma osmoar ratio (U:P) excees 2:1. Chronic rena faiure is a
ssociate with
nocturia, poyuria, an ow SG cause by scarrin of the coectin tubues. 21.
A The ensity of

urine increases at ow temperature, causin ess ui to be ispace by the urino
meter. This
causes the speci c ravity to be fasey eevate uness correcte for the i erence
between the
urine temperature an the caibration temperature (15.5C). Ces an unissove
soutes refract
iht an wi cause a fasey hih speci c ravity reain by refractometry if ur
ine is not
centrifue. Coorimetric speci c ravity tests are ess sensitive to nonionize c
ompouns such
as urea an ucose, an are neativey biase when are quantities of noneect
roytes are
present. Coorimetric speci c ravity reains are etermine by a pH chane on th
e test pa an
are approximatey 0.005 ower when pH is 6.5 or hiher. 22. A A poyeectroyte
with maic aci
resiues wi ionize in proportion to the ionic strenth of urine. This causes t
he pH inicator,
bromthymo bue, to react as if it were in a more aciic soution. The inicator
wi be bue at
ow SG an reen at hiher SG. 23. C Bacteriuria is usuay associate with an a
kaine pH cause
by the prouction of ammonia from urea. Extene storae may resut in oss of v
oatie acis,
causin increase pH. A hih-protein iet promotes excretion of inoranic acis.
The tubuar
maximum for H + secretion occurs when urine pH reaches 4.5, the owest urinary p
H that the
kineys can prouce. 2828_Ch06_327-380 06/08/12 11:23 AM Pae 333 24. In rena
 tubuar
aciosis, the pH of urine is: A. Consistenty aci B. Consistenty akaine C. N
eutra D.
Variabe, epenin upon iet Boy uis/Correate cinica an aboratory ata/ U
rine pH/2 25.
Te norma aiy urine output for an aut is approximatey: A. 0.20.5 L B. 0.61.6
L C. 2.73.0
L D. 3.23.5 L Boy uis/Appy knowee of funamenta biooica characteristics/
Urine/1 26.
Te SG of the trate in Bowmans space is approximatey: A. 1.0001.002 B. 1.0041.006 C
.
1.0081.010 D. 1.0121.014 Boy uis/Appy knowee of funamenta biooica
characteristics/Urine/1 27. A patient with partiay compensate respiratory ak
aosis wou have
a urine pH of: A. 4.55.5 B. 5.56.5 C. 6.57.5 D. 7.58.5 Boy uis/Correate cinica a
n
aboratory ata/ Urine pH/2 28. Which of the foowin is most ikey to cause a
fase-positive
ry reaent strip test for urinary protein? A. Urine of hih SG B. Hihy bu ere
akaine urine
C. BenceJones protein D. Saicyates Boy uis/Appy knowee to ientify sources
of
error/Urinary protein/2 29. When testin for urinary protein with sufosaicyic
aci (SSA),
which conition may prouce a fase-positive resut? A. Hihy bu ere akaine ur
ine B. Te
presence of x-ray contrast meia C. Increase urinary SG D. Te presence of re b
oo ces (RBCs)
Boy uis/Appy knowee to ientify sources of error/Urinary protein/2 334 Chap
ter 6 |
Urinaysis an Boy Fuis Answers to Questions 2429 24. B Rena tubuar aciosis

resuts from a
efect in the rena tubuar reabsorption of bicarbonate. Hyroen ions are not s
ecrete when
bicarbonate ions are not reabsorbe. Wastin of soium bicarbonate (NaHCO 3 ) an
 potassium
bicarbonate (KHCO 3 ) resuts in akaine urine an hypokaemia in association w
ith aciosis. 25.
B Uner conitions of norma ui intake, the reference rane for urine voume is
0.61.6 L per
ay. Urine output wi vary wiey with ui intake. In cases of ui eprivation, a
most a
trate wi be reabsorbe, resutin in aiy excretion as ow as 500 mL. When ui
intake is
excessive, up to 2.0 L of urine may be voie. Urine output beyon these extreme
s is consiere
abnorma. 26. C The SG of the trate in Bowmans space approximates the SG of the p
asma because
soium, chorie, ucose, urea, an other main soutes are competey tere by
the omerui.
This correspons to an osmoaity of approximatey 280 mOsm/k. 27. D Urine pH i
s etermine by
iet, acibase baance, water baance, an rena function. In partiay compensat
e respiratory
akaosis, the kineys reabsorb ess bicarbonate, which resuts in ower net aci
 excretion. The
oss of bicarbonate heps to compensate for akaosis an causes urine pH to be
akaine. 28. B
In aition to hihy bu ere akaine urine, a fase-positive ry reaent test ma
y be cause by
quaternary ammonium compouns, which increase urine pH. Because the ry reaent
strip tests are
insensitive to obuins, a fase neative is ikey in the case of BenceJones pr
oteinuria.
Positive interference by rus is uncommon for ry reaent strip protein tests b
ut is common for
turbiimetric tests. Hih urinary SG wi suppress the coor reaction of the str
ip protein tests.
29. B Turbiimetric assays are use to test urine suspecte of ivin a fase-po
sitive ry
reaent strip test for abumin because the urine is hihy akaine (pH 8.0) or
contains
pimentation that interferes with reain the protein test pa. In aition, SSA
tests are use
when screenin urine for an increase concentration of obuins because ry rea
ent strip tests
are far ess sensitive to obuins. Sufosaicyic aci is ess speci c but more
sensitive for
abuminuria than ry reaent strip tests. Ioinate yes, peniciin, saicyate
, an tobutamie
may resut in fase positives. Trace turbiity is i cut to etermine when urine
is couy ue
to bacteriuria, mucus, or crystas. Akaine urine may titrate SSA, reucin its
sensitivity.
2828_Ch06_327-380 06/08/12 11:23 AM Pae 334 30. A iscrepancy between the ur
ine SG etermine
by measurin refractive inex an urine osmoaity wou be most ikey to occur
: A. After
catheterization of the urinary tract B. In iabetes meitus C. After an intrave
nous pyeoram
(IVP) D. In uremia Boy uis/Evauate ata to etermine possibe inconsistent res

uts/Speci c
ravity/2 31. Which of the foowin is ikey to resut in a fase-neative ry
reaent strip
test for proteinuria? A. Peniciin B. Aspirin C. Amorphous phosphates D. BenceJo
nes protein
Boy uis/Appy knowee to ientify sources of error/Urinary protein/1 32. Dai
y oss of
protein in urine normay oes not excee: A. 30 m B. 50 m C. 100 m D. 150 m
Boy uis/Appy
knowee of funamenta biooica characteristics/Urinary protein/1 33. Which
of the foowin
is east ikey to cause a fase-positive resut with turbiimetric protein test
s? A. Tobutamie
B. X-ray contrast meia C. Peniciin or sufa antibiotics D. Ascorbic aci Boy
uis/Appy
knowee to ientify sources of error/Urinary protein/2 34. Which statement bes
t escribes the
cinica utiity of tests for microabuminuria? A. Testin may etect eary rena
 invovement in
iabetes meitus B. Microabuminuria refers to a speci c subfraction of abumin f
oun ony in
persons with iabetic nephropathy C. A positive test resut inicates the presen
ce of orthostatic
abuminuria D. Testin shou be part of the routine urinaysis Boy uis/Correa
te cinica an
aboratory ata/Urinary protein/2 6.1 | Routine Physica an Biochemica Urine T
ests 335
Answers to Questions 3034 30. C The IVP ye contains ioine an is hihy refract
ie. This
increases the refractive inex of urine, causin fasey hih measurement of so
ute
concentration. The refractive inex is a ecte by the size an shape of soutes an
 unissove
sois such as protein. Osmoaity is the most speci c measure of tota soute con
centration
because it is a ecte ony by the number of issove soutes. 31. D Dry reaent s
trip tests
usin tetrabromopheno bue or tetrachoropheno tetrabromosufophthaein are po
ory sensitive to
obuins an may not etect immunoobuin iht chains. Turbiimetric methos
such as 3% SSA
wi often etect BenceJones protein but may ive a fase-positive reaction with
peniciin,
tobutamie, saicyates, an x-ray contrast yes containin ioine. Amorphous p
hosphates may
precipitate in refrierate urine, makin interpretation of turbiimetric tests
i cut. 32. D
Sma amounts of abumin an other ow moecuar weiht proteins such as amyase
,
-microlo ulins,
nd immunolo ulin fr
ments
re excreted in the urine. Proteinu
ri
does not
norm
lly exceed 30 m/dL or 150 m/d
y. The detection limit of the SSA test to

l umin is

pproxim
tely 1.52.0 m/dL,
nd for dry re
ent strip tests is
pproxim
tely 15
m/dL.
Therefore, tr
ce positives y either method m
y occur in the
sence of ren
l di
se
se. 33. D
Ascor ic
cid m
y reduce di
zo s
lts used in the iliru in
nd nitrite tests,
n
d re
ct with
hydroen peroxide in peroxid
se re
ctions. Therefore, persons t
kin me
doses o

f
scor ic
cid
(vit
min C) m
y show ne
tive interference with tests for lucose, lood, iliru
in,
nd nitrite.
Ascor
te does not c
use either
f
lse-ne
tive or positive re
ction for protei
n. 34. A The
micro
l umin test is
n
ss
y for me
surin urin
ry
l umin concentr
tion th
t h

s
n incre
sed
sensitivity (detection limit elow 15 m/dL),
nd is recommended for persons who

re
t risk for
chronic ren
l dise
se, especi
lly persons with di
etes mellitus. In di
etes,

n e
rly sin of
ren
l involvement is
n incre
sed r
te of
l umin excretion in the r
ne of 20200
g/mL or in
excess of 30 mg albumin per gram creatinine. Results in this range are signi cant
in the at-risk
population even though the dry reagent strip test for protein may be negative. C
onsequently, dry
reagent strip tests for microalbuminuria are too sensitive for use in routine ur
inalysis, but are
useful in screening persons with diabetes and hypertension for increased urinary
albumin
excretion. 2828_Ch06_327-380 06/08/12 11:23 AM Page 335 35. Dry reagent strip
tests for
microalbuminuria that compare albumin to creatinine determine the creatinine con
centration based
upon which principle? A. Formation of a Cu +2 -creatinine complex B. Enzymatic a
ssay using
sarcosine oxidase and peroxidase C. Reaction of creatinine with alkaline sodium
picrate D. Change
in pH as creatinine is converted to creatine Body uids/Apply principles of specia
l laboratory
procedures/Urine protein/ 2 36. Which of the following conditions is least likel
y to be detected
by dry reagent strip tests for proteinuria? A. Orthostatic albuminuria B. Chroni
c renal failure
C. Pyelonephritis D. Renal tubular proteinuria Body uids/Apply principles of basi
c laboratory
procedures/Urine protein/2 37. Te normal renal threshold for glucose is: A. 7085
mg/dL B.
100115 mg/dL C. 130145 mg/dL D. 165180 mg/dL Body uids/Apply knowledge of fundamenta
l
biological characteristics/Urine glucose/1 38. In which of the following conditi
ons is glycosuria
most likely? A. Addisons disease B. Hypothyroidism C. Pregnancy D. Hypopituitaris
m Body
uids/Correlate clinical and laboratory data/ Urine glucose/2 39. In addition to a
scorbate, the
glucose oxidase reaction may be inhibited by which substance? A. Acetoacetic aci
d (AAA) B.
-Aminocaproic acid C. Cr
atinin
D. Azopyridium Body uids/Apply knowl
dg
to id
nt
ify sourc
s
of
rror/Urin
glucos
/1 336 Chapt
r 6 | Urinalysis and Body Fluids Answ
rs to Q
u
stions 3539
35. A Th
dry r
ag
nt strip t
st for cr
atinin
contains anhydrous bu
r
d CuIISO
4 , alcoholic
t
tram
thylb
nzidin
, and diisopropyl b
nz
n
dihydrop
roxid
. In th
pr
s
nc
o
f cr
atinin
, a
copp
rcr
atinin
compl
x forms. This catalyz
s th
oxidation of a b
nzidin
d
riv
ativ
by an
alcoholic p
roxid
, forming a blu
color on th
t
st pad. Color int
nsity is pro

portional to
cr
atinin
conc
ntration. N
gativ
int
rf
r
nc
occurs from ascorbat
and EDTA (
which ch
lat
s
th
copp
r). Positiv
int
rf
r
nc
occurs from h
moglobin and som
drugs (
.g.,
nitrofurantoin
antibiotics). Th
microalbumin conc
ntration is d
t
rmin
d by th
prot
in
rror
of indicator

ct using a dy
with incr
as
d s
nsitivity, bis-t
trabromosulfon
phthal
in. 36.
D Th
d
t
ction
limit (s
nsitivity) of dry r
ag
nt strip prot
in t
sts is approximat
ly 15 mg/dL
albumin and is
su ci
nt to d
t
ct urinary albumin l
v
ls found in orthostatic albuminuria and r
n
al dis
as
s,
with th

xc
ption of tubular prot
inuria. R
nal tubular prot
inuria r
sults fro
m failur
of
damag
d tubul
s to r
absorb -microlo ulin. Dry re
ent strip tests for proteinur
i

re poorly
sensitive to lo ulins
nd do not detect sm
ll qu
ntities of hemolo in, myolo
in, or
microlo ulins. Protein electrophoresis is used to detect 2 -microlo ulinuri
.
37. D The ren
l
threshold is the concentr
tion of
su st
nce (e.., lucose) in lood th
t must
e exceeded
efore it c
n e detected in the urine. Threshold su st
nces require
c
rrier t
o tr
nsport them
from the tu ul
r lumen to the v
s
rect
. When the c
rrier ecomes s
tur
ted, th
e tu ul
r m
ximum
is re
ched, c
usin the su st
nce to e excreted in the urine. 38. C In
ddition
to di
etes
mellitus, lycosuri
m
y occur in other endocrine dise
ses, pren
ncy, in respon
se to drus th
t

ect lucose toler
nce or ren
l threshold,
nd sever
l other conditions, especi
l
ly those
involvin the liver or centr
l nervous system (CNS). Cushins dise
se
nd hyperth
yroidism c
use
imp
ired lucose toler
nce
nd hyperlycemi
. Incre
sed estroens produced in pr
en
ncy lower the
ren
l threshold for lucose
nd m
y imp
ir lucose toler
nce. Hyperpituit
rism c

uses
hyperlycemi
medi
ted y incre
sed rele
se of rowth hormone. 39. A AAA
nd s
l
icyl
tes m
y
inhi it the lucose oxid
se re
ction y the s
me mech
nism
s
scor
te. These r
educin
ents
compete with the chromoen for hydroen peroxide. Low SG m
y incre
se
nd hih S
G decre
se the
color re
ction for lucose in urine. 2828_Ch06_327-380 06/08/12 11:23 AM P
e
336 40. A
positive lucose oxid
se test
nd
ne
tive test for reducin su
rs indic
tes:
A. True
lycosuri
B. F
lse-positive re
ent strip test C. F
lse-ne
tive reducin test
c
used y

scor
te D. G
l
ctosuri
Body uids/Ev
lu
te l
or
tory d
t
to determine possi l
e inconsistent
results/Urine lucose/2 41. A ne
tive lucose oxid
se test
nd
positive test
for reducin
su
rs in urine indic
tes: A. True lycosuri
B. A f
lse-ne
tive lucose oxid
s
e re
ction C. Te
presence of
nonlucose reducin su
r such
s 
l
ctose D. A tr
ce qu
ntity of
lucose Body
uids/Ev
lu
te l
or
tory d
t
to determine possi le inconsistent results/Urine l

ucose/2 42. In
wh
t condition m
y urin
ry ketone tests underestim
te ketosis? A. Acidosis B. He
molytic
nemi
C.
Ren
l f
ilure D. Excessive use of vit
min C Body uids/Apply knowlede to identify
sources of
error/Urin
ry ketones/2 43. AAA is detected in urine y re
ction with: A. Sodium
nitroprusside B.
o-Toluidine C. m-Dinitro enzene D. m-Dinitrophenylhydr
zine Body uids/Apply princ
iples of
sic
l
or
tory procedures/Urin
ry ketones/1 44. Nondi
etic ketonuri
c
n occur in

ll of the
followin except: A. Pren
ncy B. Ren
l f
ilure C. St
rv
tion D. L
ct
te
cidosi
s Body
uids/Correl
te clinic
l
nd l
or
tory d
t
/ Urin
ry ketones/2 6.1 | Routine Phys
ic
l
nd
Biochemic
l Urine Tests 337 Answers to Questions 4044 40. A Glucose oxid
se is
speci c for
-D-lucose. Therefore,
positive re
ction is
lw
ys considered sini c
nt unless c
ont
min
tion
is evident. A reducin test should not e used to con rm
positive lucose oxid
s
e test ec
use
it is not
s speci c or
s sensitive. Reducin su
r tests
re used to screen inf

nts for in orn
errors of c
r ohydr
te met
olism such
s 
l
ctosuri
ut
re not used to scree
n for lycosuri
.
41. C Reducin tests utilize
lk
line copper sulf
te
nd he
t to oxidize lucose
. Other reducin
su st
nces, includin sever
l su
rs
nd
nti iotics, m
y re
ct, m
kin the test
in
ppropri
te
s

screenin test for lucose. A positive test for reducin su
rs seen with
ne

tive lucose
oxid
se test m
y occur in l
ctose, 
l
ctose,
nd fructosuri

nd other disorder
s of c
r ohydr
te
met
olism. 42. A Tests for urin
ry ketone odies
re sensitive to AAA. They re

ct we
kly with

cetone
nd do not re
ct with -hydroxy utyric
cid. Acidosis f
vors form
tion of
-hydroxy utyric
cid
nd m
y c
use
f
lsely low estim
te of serum or urine keton
es in di
etic
keto
cidosis. Ketonuri
h
s m
ny c
uses other th
n di
etic keto
cidosis such
s
pren
ncy,
fever, protein c
lorie m
lnutrition,
nd diet
ry c
r ohydr
te restriction. Tr
ce
ketones tend to
e more clinic
lly sini c
nt when seen in urine with
low speci c r
vity. 43. A U
rin
ry
ketones
re detected usin
lk
line sodium nitroprusside (nitroferricy
nide). Me
sn

nd other
sulfhydryl compounds m
y c
use
f
lse positive with dry re
ent strip tests
nd
phenylpyruvic

cid (PKU)
nd some
nti iotics with the cl
ssic
l tu e test. 44. B Ketonuri
re
sults from
excessive oxid
tion of f
ts formin
cetyl coenzyme A (CoA). In
ddition to di

etes mellitus,
ketonuri
occurs in st
rv
tion, c
r ohydr
te restriction,
lk
losis, l
ct
te
ci
dosis,
nd von
Gierke dise
se (lycoen stores c
nnot e utilized). Ketonuri

lso occurs in pr
en
ncy,

ssoci
ted with incre
sed vomitin
nd cyclic fever. 2828_Ch06_327-380 06/08/12
11:23 AM P
e
337 45. Which of the followin st
tements re
rdin the cl
ssic
l nitroprusside
re
ction for

ketones is true? A. Te re
ction is most sensitive to
cetone B. Nitroprusside re

cts with

cetone, AAA,
nd -hydroxy utyric
cid C. It m
y e f
lsely positive in phenylket
onuri
D. Te
re
ction is recommended for di
nosin keto
cidosis Body uids/Apply knowlede to
identify
sources of error/Urin
ry ketones/2 46. Hemolo in in urine c
n e di erenti
ted fr
om myolo in
usin: A. 80%
mmonium sulf
te to precipit
te hemolo in B. Sodium dithionite to
reduce
hemolo in C. o-Di
nisidine inste
d of enzidine
s the color indic
tor D. Te dr
y re
ent strip
lood test Body uids/Select methods/Hemolo inuri
/2 47. Which of the followin c
onditions is

ssoci
ted with
ne
tive lood test
nd
n incre
se in urine uro ilinoen? A.
C
lculi of the
kidney or l
dder B. M
lin
ncy of the kidney or urin
ry system C. Crush injury
D. Extr
v
scul
r
hemolytic
nemi
Body uids/Correl
te clinic
l
nd l
or
tory d
t
/ Hem
turi
/2 48
. Which
st
tement
out the dry re
ent strip lood test is true? A. Te test is
sed on
the re
ction of
hemolo in with peroxid
se B. A norm
l color m
y e
sent from the urine when t
he re
ction is
positive C. A nonhemolyzed tr
ce is present when there
re 12 RBCs per hih-power
eld D.
S
licyl
tes c
use
f
lse-positive re
ction Body uids/Apply principles of
sic l

or
tory
procedures/Hem
turi
/2 49. A moder
te-positive lood test
nd tr
ce protein test

re seen on the
dry re
ent strip,
nd 1120 red lood cells per hih-power field
re seen in the
microscopic
ex
m. These results
re most likely c
used y which of the followin? A. Tr
nsfu
sion re
ction B.
Myolo inuri
C. Intr
v
scul
r hemolytic
nemi
D. Recent urin
ry tr
ct c
theter
iz
tion Body
uids/Correl
te clinic
l
nd l
or
tory d
t
/ Hem
turi
/3 338 Ch
pter 6 | Urin
lys
is
nd Body
Fluids Answers to Questions 4549 45. C Tests for ketones
re less sensitive to
c
etone th
n AAA

nd do not detect -hydroxy utyric
cid. Hih levels of phenylpyruvic
cid (phenyl
ketonuri
) will
c
use
f
lse-positive re
ction in the cl
ssic
l nitroprusside re
ction ut do n
ot usu
lly
interfere with the dry re
ent strip test for ketones. Serum ketones c
n e me
s
ured y 
s
chrom
tor
phy,
nd -hydroxy utyric
cid c
n e me
sured enzym
tic
lly. The enzym

tic
ss
y for
-hydroxy utyr
te in pl
sm
is the recommended test for di
nosin keto
cidosis si
nce
cidosis
f
vors its form
tion. 46. A Both hemolo in
nd myolo in h
ve peroxid
se
ctivi
ty
nd c
use

positive lood test. However, myolo in is solu le in 80% w/v
mmonium sulf
te i
n urine, ut
hemolo in precipit
tes. A positive lood re
ction with supern
t
nt
fter
dditi
on of
mmonium
sulf
te
nd sodium hydroxide (N
OH) con rms the presence of myolo in. The presenc
e of RBCs
indic
tes th
t hemolo in r
ther th
n myolo in is present; however, the
sence
of RBCs does not

rule out hemolo in
s the c
use of
positive lood test. 47. D A positive test
for lood c
n
occur from ren
l or lower urin
ry tr
ct leedin, intr
v
scul
r hemolytic
nemi

,
nd tr
nsfusion
re
ction. Extr
v
scul
r hemolysis results in incre
sed iliru in production r
th
er th
n pl
sm

hemolo in. This m
y c
use incre
sed uro ilinoen in urine ut not
positive l
ood re
ction. 48.
B The lood re
ction uses
nhydrous peroxide
nd tetr
methyl enzidine. Hemolo i
n h
s peroxid
se

ctivity
nd c
t
lyzes the oxid
tion of tetr
methyl enzidine y peroxide. The re

ction is
sensitive to su millir
m levels of free hemolo in, where
s visi le hemolysis d
oes not occur
unless free hemolo in exceeds 20 m/dL. The test detects
pproxim
tely 45 int
ct
RBCs per
hih-power field
s
nonhemolyzed tr
ce. Gre
ter th
n 3 RBCs/HPF is
norm
l. 4
9. D The lood
test detects int
ct RBCs, hemolo inuri
,
nd myolo inuri
. C
uses of hemolo i
nuri
include
intr
v
scul
r hemolytic
nemi
s, tr
nsfusion re
ctions,
nd lysis of RBCs in the
ltr
te or urine
c
used y
lk
line or hypotonic conditions. C
uses of hem
turi
include
cute
n
d chronic
lomerulonephritis, pyelonephritis, polycystic kidney dise
se, ren
l c
lculi, l

dder
nd ren
l
c
ncer,
nd postc
theteriz
tion of the urin
ry tr
ct. 2828_Ch06_327-380 06/08/1
2 11:23 AM P
e
338 50. Which of the followin results
re discrep
nt? A. Sm
ll
mount of lood
ut ne
tive
protein B. Moder
te
mount of lood ut no RBCs in microscopic ex
m C. Ne
tive
lood ut 610
RBCs/hih-power eld (HPF) D. Ne
tive lood, positive protein Body uids/Apply know
lede to
reconize sources of error/Hem
turi
/3 51. Which of the followin st
tements re

rdin the dry
re
ent strip test for iliru in is true? A. A positive test is seen in prehep
t
ic, hep
tic,
nd
posthep
tic j
undice B. Te test detects only conju
ted iliru in C. St
ndin ur
ine m
y ecome
f
lsely positive due to
cteri
l cont
min
tion D. Hih levels of
scor
te will
c
use positive
interference Body uids/Apply knowlede to reconize sources of error/Urine iliru
in/2 52. Which
of the followin re
ents is used to detect uro ilinoen in urine? A. p-Dinitro
enzene B.
p-Aminos
licyl
te C. p-Dimethyl
mino enz
ldehyde D. p-Dichloro
niline Body uids/A
pply principles
of
sic l
or
tory procedures/Urine uro ilinoen/1 6.1 | Routine Physic
l
nd B
iochemic
l Urine
Tests 339 Answers to Questions 5052 50. C The lood test detects
s little
s 0
.015 m/dL free
hemolo in
nd 45 RBCs/L. The protein test detects 15 mg/dL albumin but substantia
lly more
hemoglobin is required to give a positive test. Therefore, a small blood reactio
n (nonhemolyzed
or moderately hemolyzed trace, trace, or small) usually occurs in the absence of
a positive
protein. A positive blood test often occurs in the absence of RBCs in the micros
copic exam. This

can result from intravascular hemolysis, myoglobinuria, or lysis of RBCs caused

by alkaline or
hypotonic urine. A positive test for protein and a negative blood test occurs co
mmonly in
conditions such as orthostatic albuminuria, urinary tract infection, and diabete
s mellitus.
However, a negative blood test should not occur if more than 34 RBCs per HPF are
seen in the
microscopic. Either the blood test is falsely negative (a missed nonhemolyzed tr
ace) or yeast
have been mistaken for RBCs. 51. B Only the conjugated form of bilirubin is excr
eted into the
urine. Urinary bilirubin is positive in necrotic and obstructive jaundice but no
t in prehepatic
jaundice, which results in a high level of serum unconjugated bilirubin. The hig
hest levels of
urinary bilirubin occur in obstructive jaundice, which causes decreased urinary
urobilinogen.
Very few drugs have been reported to interfere with urine bilirubin tests, which
are based upon
formation of azobilirubin by reaction with a diazonium salt. Positive interferen
ce by rifampin
and chlorpromazine have been reported. Urine must be fresh because sunlight dest
roys bilirubin.
Bacteria may cause hydrolysis of glucuronides, forming unconjugated bilirubin, w
hich does not
react with the diazonium reagent. Ascorbate inhibits the reaction by reducing th
e diazo reagent.
52. C Urobilinogen reacts with Ehrlichs aldehyde reagent (p-dimethylaminobenzalde
hyde in HCl) to
form a pink color. Dry reagent strips use either p-dimethylaminobenzaldehyde or
4-methoxybenzene
diazonium tetrafluoroborate to detect urobilinogen. The former reagent may react
with PBG,
salicylate, and sulfonamides giving falsely high results. False-positive results
may occur in the
presence of Pyridium and Gantrisin, which color the urine orange-red. Formalin m
ay cause a
false-negative reaction. 2828_Ch06_327-380 06/08/12 11:23 AM Page 339 53. Whi
ch of the
following statements regarding urinary urobilinogen is true? A. Diurnal variatio
n occurs with
highest levels seen in the early morning B. High levels occurring with a positiv
e bilirubin test
indicate obstructive jaundice C. Dry reagent strip tests do not detect decreased
levels D.
False-positive results may occur if urine is stored for more than 2 hours Body ui
ds/Apply
principles of basic laboratory procedures/Urine urobilinogen/2 54. Which of the
following
statements regarding the test for nitrite in urine is true? A. It detects more t
han 95% of
clinically signi cant bacteriuria B. Formation of nitrite is una ected by the urine
pH C. Te test
is dependent upon an adequate dietary nitrate content D. A positive test di erenti
ates
bacteriuria from in vitro bacterial contamination Body uids/Apply knowledge to re
cognize sources
of error/Nitrite/2 55. Which statement about the dry reagent strip test for leuk
ocytes is true?

A. Te test detects only intact white blood cells (WBCs) B. Te reaction is based
upon the
hydrolysis of substrate by WBC esterases C. Several antibiotics may give a false
-positive
reaction D. Te test is sensitive to 23 WBCs per HPF Body uids/Apply principles of
basic
laboratory procedures/Leukocytes/2 56. Which of the following statements about c
reatinine
clearance is correct? A. Dietary restrictions are required during the 24 hours p
receding the test
B. Fluid intake must be restricted to below 600 mL in the 6 hours preceding the
test C.
Creatinine clearance is mainly determined by renal tubular function D. Creatinin
e clearance is
dependent upon lean body mass Body uids/Apply knowledge of fundamental biological
characteristics/Creatinine clearance/1 340 Chapter 6 | Urinalysis and Body Fluid
s Answers to
Questions 5356 53. C Urobilinogen exhibits diurnal variation, and highest levels
are seen in the
afternoon. A 2-hour postprandial afternoon sample is the sample of choice for de
tecting increased
urine urobilinogen. Urobilinogen is formed by bacterial reduction of conjugated
bilirubin in the
bowel. In obstructive jaundice, delivery of bilirubin into the intestine is bloc
ked, resulting in
decreased fecal, serum, and urine urobilinogen. However, the dry reagent strip t
ests are not
sensitive enough to detect abnormally low levels. Urobilinogen is rapidly oxidiz
ed to urobilin,
which does not react with dry reagent strip tests. 54. C The nitrite test is dep
endent upon the
activity of bacterial reductase, and false negatives have been reported when uri
ne is highly
acidic. Nitrite is formed by reduction of diet-derived nitrates and reacts with
p-arsanilic acid
or sulfanilamide to form a diazonium compound. This reacts with benzoquinoline t
o form a pink azo
dye. False negatives also occur in the presence of ascorbate, which reduces the
diazonium
product. Nitrite is positive in about 70% of clinically signi cant bacterial infec
tions of the
urinary tract. Sensitivity is limited by the requirements for dietary nitrate an
d 34 hour
storage time in the bladder. In addition, the causative bacteria must be able to
reduce nitrate.
55. B PMNs in urine are detected by the presence of esterases that hydrolyze an
ester such as
indoxylcarbonic acid. The product reacts with a diazonium salt to give a purple
color. The test
detects esterases in urine as well as intact WBCs but is not sensitive to less t
han 510 WBCs per
HPF. Several antibiotics, high protein, and high SG inhibit the esterase reactio
n. Formalin may
cause a false-positive result. 56. D Although some creatinine is derived from th
e diet, it is
rapidly ltered by the glomeruli, and time variations are reduced by collection of
urine for at
least 4 hours. Creatinine is produced from oxidation of creatine at a constant r
ate of about 2%
per day. It is ltered completely and not signi cantly reabsorbed. However, creatini

ne secretion
by the tubules is increased when ltrate ow is slow, and patients must be given at
least 600 mL
of H 2 O at the start of the test and kept well hydrated throughout. Body size d
etermines how
much creatinine is produced, and clearance must be normalized to eliminate this
variable. Due to
the di culty in collecting a valid 24-hour urine sample, the eGFR is recommended a
s the screening
test for low GFR. Creatinine clearance should be used in situations where lean b
ody mass may not
be accurately represented by the patients age and gender as used in the MDRD form
ula for eGFR.
2828_Ch06_327-380 06/08/12 11:23 AM Page 340 57. A male patients eGFR is 75 mL
/min. Tis
indicates: A. Normal glomerular ltration rate B. Te patient is uremic and will be
hyperkalemic
C. Renal tubular dysfunction D. Reduced glomerular ltration without uremia Body ui
ds/Correlate
clinical and laboratory data/Creatinine clearance/2 58. Which of the following t
ests is a speci c
measure of glomerular ltration? A. p-Aminohippuric acid (PAH) clearance B. Fishbe
rg
concentration test C. Mosenthal dilution test D. Cystatin C Body uids/Correlate l
aboratory data
with physiological processes/Renal function/1 59. Which statement regarding urea
is true? A. Urea
is 100% ltered by the glomeruli B. Blood urea levels are independent of diet C. U
rea is not
signi cantly reabsorbed by the tubules D. Urea excretion is a speci c measure of glo
merular
function Body uids/Correlate laboratory data with physiological processes/Urea/1
60. Given the
following data, calculate the creatinine clearance. Serum creatinine = 1.2 mg/dL
; urine
creatinine = 100 mg/dL; urine volume = 1.4 L/day; body surface area = 1.80 m 2 A
. 47 mL/min B. 78
mL/min C. 100 mL/min D. 116 mL/min Body uids/Calculate/Creatinine clearance/2 6.1
| Routine
Physical and Biochemical Urine Tests 341 Answers to Questions 5760 57. D Normal
eGFR is 90120
mL/min. Values below the lower reference limit, but above 60 mL/min, indicate gl
omerular damage
but not of severity su cient to cause symptoms or uremia. 58. D Cystatin C is a sm
all protease
inhibitor that is produced at a constant rate, eliminated exclusively by glomeru
lar filtration,
and is not dependent on age, sex, or nutritional status. Plasma cystatin C is in
creased when the
glomerular filtration rate is decreased, and levels can be used to give an eGFR
in a similar
manner to plasma creatinine. PAH is a substance that is completely filtered by t
he glomerulus and
also secreted by the tubules. PAH clearance has been used rarely to measure rena
l blood flow. The
other two tests are measures of tubular function, but are used infrequently beca
use they are
associated with significant health risks. The Fishberg concentration test measur
es the ability to
concentrate urine after deprivation of water. The Mosenthal test measures the ab

ility to excrete
free water after excessive water intake. 59. A BUN is a sensitive indicator of r
enal disease, but
is not speci c for glomerular function. BUN levels are a ected by diet, hepatic func
tion, tubular
function, and ltrate ow as well as the glomerular ltration rate. Although urea is c
ompletely
ltered by the glomerulus, the tubules reabsorb 30%40% of the ltered urea, and this
is why BUN
concentration is higher than plasma creatinine. In prerenal failure, up to 70% o
f the ltered
urea can be reabsorbed owing to the slow movement of ltrate through the tubules.
This causes BUN
to rise much more than plasma creatinine in this condition. A BUN:creatinine rat
io of 20:1 is
highly suggestive of prerenal failure. 60. B The clearance formula is U P V 1.73
/A, where U
= urine creatinine (mg/dL), P = plasma creatinine (mg/dL), V = urine volume (mL/
min), and 1.73 =
mean body surface area (m 2 ): 100 mg/dL 1.2 mg/dL 1.4L/day 1,000 mL/L 1 day/1,4
40 min
(1.73 m 2 1.8 m 2 ) = 78 mL/min Note that the creatinine clearance is low (lower
reference
limit approximately 95 mL/min for males and 85 mL/min for females), although the
serum creatinine
is still within normal limits (0.51.2 mg/dL). The clearance test is more sensitiv
e if done
properly, since as serum creatinine goes up, the urine creatinine goes down. 282
8_Ch06_327-380
06/08/12 11:23 AM Page 341 342 6.2 Urine Microscopy and Clinical Correlations
1. Which of the
following dyes are used in SternheimerMalbin stain? A. Hematoxylin and eosin B. C
rystal violet
and safranin C. Methylene blue and eosin D. Methylene blue and safranin Body uids
/Apply
principles of basic laboratory procedures/Staining/1 2. Which of the following s
tatements
regarding WBCs in urinary sediment is true? A. Glitter cells seen in the urinary s
ediment are a
sign of renal disease B. Bacteriuria in the absence of WBCs indicates lower urin
ary tract
infection (UTI) C. WBCs other than PMNs are not found in urinary sediment D. WBC
casts indicate
that pyuria is of renal, rather than lower urinary, origin Body uids/Correlate cl
inical and
laboratory data/Urinary sediment/2 3. Which description of sediment with Sternhe
imerMalbin stain
is correct? A. Transitional epithelium: cytoplasm pale blue, nucleus dark blue B
. Renal
epithelium: cytoplasm light blue, nucleus dark purple C. Glitter cells: cytoplas
m dark blue,
nucleus dark purple D. Squamous epithelium: cytoplasm pink, nucleus pale blue Bo
dy uids/Apply
knowledge of fundamental biological characteristics/Staining/2 Answers to Questi
ons 13 1. B
SternheimerMalbin stain is a supravital stain used to help di erentiate renal tubul
ar epithelium
from transitional cells and PMNs. The mononuclear cells are clearly distinguishe
d from both live
and dead PMNs. Transitional cells have pale blue cytoplasm, but renal cells take

up both dyes,
resulting in an azurophilic appearance (orange-purple cytoplasm and dark purple
nucleus). 2. D
The majority of WBCs in the urinary sediment will be PMNs. Eosinophils and monon
uclear WBCs will
occasionally be seen. High numbers of eosinophils often indicate an allergic dru
g reaction,
causing in ammation in the medullary interstitium and tubules. Mononuclear cells a
re especially
likely in patients with chronic in ammatory diseases and in renal transplant rejec
tion, where
they may account for as many as 30% of the WBCs. Glitter cells are PMNs with hig
hly refractile
granules exhibiting Brownian movement. They are seen only when urine SG is below
1.020. These
cells resist staining with SternheimerMalbin stain and are considered to be livin
g (fresh) WBCs.
When seen in large numbers, they indicate urinary tract injury (with pseudopod e
xtensions, they
point to infection). The presence of bacteria in urine in the absence of PMNs us
ually results
from contamination by vaginal or skin ora that multiply in vitro, especially in u
nrefrigerated
specimens. The presence of WBC casts is always signi cant, and when associated wit
h pyuria and
bacteriuria, indicates renal involvement in the infection. 3. A After staining w
ith
SternheimerMalbin stain, transitional epithelium are readily di erentiated from ren
al tubular
cells and WBCs because their cytoplasm is pale blue. Live WBCs exclude Sternheim
erMalbin stain,
while dead cells stain with a deeply blue-purple nucleus and pale orange-blue cy
toplasm. Renal
epithelium have an orange-purple cytoplasm and dark purple nucleus. Squamous epi
thelium have a
blue or purple cytoplasm and an orange-purple nucleus. Red cells stain very pale
pink or not at
all and hyaline casts stain faintly pink. 2828_Ch06_327-380 06/08/12 11:23 AM
Page 342 4.
SITUATION: A 5-mL urine specimen is submitted for routine urinalysis and analyze
d immediately. Te
SG of the sample is 1.012 and the pH is 6.5. Te dry reagent strip test for blood
is a large
positive (3+) and the microscopic examination shows 1120 RBCs per HPF. Te leukocy
te esterase
reaction is a small positive (1+), and the microscopic examination shows 05 WBCs
per HPF. What
is the most likely cause of these results? A. Myoglobin is present in the sample
B. Free
hemoglobin is present C. Insu cient volume is causing microscopic results to be un
derestimated D.
Some WBCs have been misidenti ed as RBCs Body uids/Apply knowledge to identify sour
ces of
error/Urinalysis/3 5. Which of the following statements regarding epithelial cel
ls in the urinary
system is correct? A. Caudate epithelial cells originate from the upper urethra
B. Transitional
cells originate from the upper urethra, ureters, bladder, or renal pelvis C. Cel
ls from the
proximal renal tubule are usually round in shape D. Squamous epithelium line the

vagina, urethra,
and wall of the urinary bladder Body uids/Apply knowledge of fundamental biologic
al
characteristics/Urine sediment/2 6. Which of the statements regarding examinatio
n of unstained
sediment is true? A. Renal cells can be di erentiated reliably from WBCs B. Large
numbers of
transitional cells are often seen after catheterization C. Neoplastic cells from
the bladder are
not found in urinary sediment D. RBCs are easily di erentiated from nonbudding yea
st Body
uids/Correlate clinical and laboratory data/ Urine sediment/2 6.2 | Urine Microsc
opy and
Clinical Correlations 343 Answers to Questions 46 4. C Given the SG and pH, mos
t RBCs and WBCs
will be intact. Both the RBC and WBC counts are lower than expected from the dry
reagent strip
results. Myoglobin or free hemoglobin may account for the poor correlation betwe
en the blood
reaction and the RBC count, but this does not explain the lower than expected WB
C count.
Microscopic reference ranges are based upon concentrating a uniform volume of se
diment from 12 mL
of urine. When less urine is used, falsely low results will be obtained unless c
orrective action
is taken. The specimen should be diluted with normal saline to 12 mL, then centr
ifuged at 450 g
for 5 minutes. Sediment should be prepared according to the established procedur
e and the results
multiplied by the dilution factor (in this case, 12 5, or 2.4). 5. B Caudate cel
ls are
transitional epithelium that have a sawtooth-shaped tail and are found in the ur
inary bladder and
the pelvis of the kidney. Transitional epithelia line the upper two-thirds of th
e urethra and the
ureters as well as the urinary bladder and renal pelvis. Renal tubular cells may
be columnar,
polyhedral, or oval, depending upon the portion of the tubule from which they or
iginate. Cells
from the proximal tubule are columnar and have a distinctive brush border. Squam
ous epithelia
line the vagina and lower third of the urethra. 6. B Renal cells and PMNs are ab
out the same size
and can be confused in unstained sediment. Catheterization often releases large
clumps or sheets
of transitional and squamous cells. These should be distinguished from neoplasti
c cells derived
from the urinary bladder. When cells appear atypical (e.g., large cells in metap
hase), they
should be referred to a pathologist for cytological examination. Nonbudding yeas
t cells are
approximately the same in size and appearance as RBCs. When RBCs are seen in the
absence of a
positive blood test, the probability of an error in microscopy is high. The micr
oscopic
examination should be reviewed for the presence of yeast. 2828_Ch06_327-380 06/
08/12 11:23 AM
Page 343 7. Which of the following statements regarding cells found in urinary s
ediment is true?
A. Transitional cells resist swelling in hypotonic urine B. Renal tubular cells

are often
polyhedral and have an eccentric round nucleus C. Trichomonads have an oval shap
e with a
prominent nucleus and a single anterior agellum D. Clumps of bacteria are frequen
tly mistaken
for blood casts Body uids/Apply knowledge of fundamental biological characteristi
cs/Urine
sediment/2 8. Which of the following statements regarding RBCs in the urinary se
diment is true?
A. Yeast cells will lyse in dilute acetic acid but RBCs will not B. RBCs are oft
en swollen in
hypertonic urine C. RBCs of glomerular origin often appear dysmorphic D. Yeast c
ells will tumble
when the cover glass is touched but RBCs will not Body uids/Apply knowledge of fu
ndamental
biological characteristics/Urine sediment/2 9. Renal tubular epithelial cells ar
e shed into the
urine in largest numbers in which condition? A. Malignant renal disease B. Acute
glomerulonephritis C. Nephrotic syndrome D. Cytomegalovirus (CMV) infection of t
he kidney Body
uids/Evaluate laboratory data to recognize health and disease states/Urinary sedi
ment/2 10. Te
ova of which parasite may be found in the urinary sediment? A. T. vaginalis B. E
ntamoeba
histolytica C. Schistosoma hematobium D. Trichuris trichiura Body uids/Apply know
ledge of
fundamental biological characteristics/Urinary sediment/1 11. Oval fat bodies ar
e often seen in:
A. Chronic glomerulonephritis B. Nephrotic syndrome C. Acute tubular nephrosis D
. Renal failure
of any cause Body uids/Correlate clinical and laboratory data/ Urine sediment/2 3
44 Chapter 6 |
Urinalysis and Body Fluids Answers to Questions 711 7. B Transitional epithelial
cells readily
take up H 2 O and appear much larger than renal cells or WBCs when urine is hypo
tonic.
Transitional cells are considered a normal component of the sediment unless pres
ent in large
numbers and associated with signs of in ammation such as mucus and PMNs, or presen
ting features
of malignant cells. In contrast, renal cells are signi cant when seen conclusively
in the
sediment. They are often teardrop, polyhedral, or elongated cells with a round e
ccentric nucleus.
Conclusive identi cation requires staining. Trichomonas vaginalis displays an indi
stinct nucleus
and two pairs of prominent anterior agella. Amorphous urate crystals deposited on
the slide may
be mistaken for granular or blood casts. 8. C RBCs are di cult to distinguish from
nonbudding
yeast in unstained sediment. RBCs tumble when the cover glass is touched and wil
l lyse when the
sediment is reconstituted in normal saline containing 2% v/v acetic acid. A nonh
emolyzed trace
blood reaction con rms the presence of RBCs. RBCs have a granular appearance in hy
pertonic urine
due to crenation. The RBC membrane becomes distorted when passing through the gl
omerulus, often
appearing scalloped, serrated, or invaginated. Such cells are called dysmorphic
RBCs and are

associated with glomerulonephritis. 9. D Although seen in glomerulonephritis and

pyelonephritis,
the largest numbers of renal tubular cells appear in urine in association with v
iral infections
of the kidney. Renal epithelium may show characteristic viral inclusions associa
ted with CMV and
rubella. High numbers of renal epithelium are also found in the sediment of pati
ents with
drug-induced tubular nephrosis and some cases of heavy metal poisoning. Renal tu
mors do not
usually shed cells into the urine. 10. C Ova of S. hematobiumare most often reco
vered from urine
because the adult trematodes colonize the blood vessels of the urinary bladder.
The eggs are
approximately 150 60 m and are nonoperculated. They are yellowish and have a prom
inent
terminal spine. 11. B Oval fat bodies are degenerated renal tubular epithelia th
at have
reabsorbed cholesterol from the ltrate. Although they can occur in any in ammatory
disease of
the tubules, they are commonly seen in the nephrotic syndrome, which is characte
rized by marked
proteinuria and hyperlipidemia. 2828_Ch06_327-380 06/08/12 11:23 AM Page 344
12. All of the
following statements regarding urinary casts are true except: A. Many hyaline ca
sts may appear in
sediment after jogging or exercise B. An occasional granular cast may be seen in
a normal
sediment C. Casts can be seen in signi cant numbers even when protein tests are ne
gative D.
Hyaline casts will dissolve readily in alkaline urine Body uids/Apply knowledge t
o recognize
sources of error/Urine casts/2 13. Which condition promotes the formation of cas
ts in the urine?
A. Chronic production of alkaline urine B. Polyuria C. Reduced ltrate formation D
. Low urine SG
Body uids/Apply knowledge of fundamental characteristics/Urine casts/2 14. Te muc
oprotein that
forms the matrix of a hyaline cast is called: A. BenceJones protein B. -Microlo u
lin C.
T
mmHorsf
ll protein D. Arinine-rich lycoprotein Body uids/Apply knowlede of fu
nd
ment
l
ioloic
l ch
r
cteristics/Urine c
sts/1 15. Pseudoc
sts
re often c
used y: A. A
dirty cover
l
ss or slide B. B
cteri
l cont
min
tion C. Amorphous ur
tes D. Mucus in the ur
ine Body
uids/Apply knowlede to identify sources of error/Urine c
sts/2 16. Which of the
followin
st
tements re
rdin urin
ry c
sts is correct? A. Fine r
nul
r c
sts
re more s
ini c
nt th
n
co
rse r
nul
r c
sts B. Cylindruri
is
lw
ys clinic
lly sini c
nt C. Te
ppe
r

nce of
cylindroids sin
ls the onset of end-st
e ren
l dise
se D. Bro
d c
sts
re
sso
ci
ted with
severe ren
l tu ul
r o struction Body uids/Apply knowlede of fund
ment
l ioloi
c
l
ch
r
cteristics/Urine c
sts/2 17. A sediment with moder
te hem
turi

nd RBC c
s
ts most likely
results from: A. Chronic pyelonephritis B. Nephrotic syndrome C. Acute lomerulo
nephritis D.

Lower urin
ry tr
ct o struction Body uids/Correl
te clinic
l
nd l
or
tory d
t
/
Urine
sediment/2 6.2 | Urine Microscopy
nd Clinic
l Correl
tions 345 Answers to Que
stions 1217 12.
C Proteinuri

ccomp
nies cylindruri
ec
use protein is the principle component
of c
sts. After
strenuous exercise, hy
line c
sts m
y e present in the sediment in sini c
nt num
ers ut will
dis
ppe
r
fter restin for
t le
st 24 hours. 13. C C
st form
tion is promoted
y
n
cid
ltr
te, hih solute concentr
tion, slow movement of ltr
te,
nd reduced ltr
te form

tion. The

ppe
r
nce of
c
st is dependent upon the loc
tion
nd time spent in the tu ule
,
s well
s the
chemic
l
nd cellul
r composition of the ltr
te. 14. C Hy
line c
sts
re composed
of

mucoprotein c
lled T
mmHorsf
ll protein. In
ddition, c
sts m
y cont
in cells, im
munolo ulins,
liht ch
ins, cellul
r proteins, f
t,
cteri
,
nd cryst
lloids. 15. C Pseudoc

sts
re formed y

morphous ur
tes th
t m
y deposit in uniform cylindric
l sh
pes
s the sediment
settles under the
cover l
ss. They m
y e mist
ken for r
nul
r or lood c
sts. However, they
re
hihly
refr
ctile
nd l
ck the well-de ned orders of true c
sts. 16. D There is no clini
c
l di erence
etween ne
nd co
rse r
nul
r c
sts. Gr
nul
r c
sts m
y form y deener
tion of
cellul
r c
sts,
ut some show no evidence of cellul
r oriin. Gr
nul
r c
sts m
y form from inclu
sion of urin
ry
c
lculi, ut some
re of unknown etioloy. Cylindruri
refers to the presence of
c
sts in the
urine. Hy
line c
sts m
y e seen in sm
ll num ers in norm
l p
tients
nd in l
r
e num ers
followin strenuous exercise
nd lon-dist
nce runnin. Hy
line c
sts m
y
lso
e incre
sed in
p
tients t
kin cert
in drus such
s diuretics. Bro
d c
sts form in dil
ted or
dist
l tu ules

nd indic
te severe tu ul
r o struction seen in chronic ren
l f
ilure. W
xy c
st
s form when there
is proloned st
sis in the tu ules
nd sin
l end-st
e ren
l f
ilure. Cylindroi
ds
re c
sts with
t
ils
nd h
ve no speci
l clinic
l sini c
nce. 17. C Red-cell c
sts indic
te the
ren
l oriin of
hem
turi
. Urin
ry tr
ct o struction m
y e
ssoci
ted with hem
turi
from ruptu
red vessels, ut
not c
sts. WBCs
nd WBC c
sts predomin
te in pyelonephritis. Sediment in chronic
lomerulonephritis is v
ri
le, ut usu
lly exhi its moder
te to severe intermit
tent hem
turi
.
In
ddition, pyuri

nd cylindruri
(with r
nul
r, lood, ro
d, w
xy,
nd epit
heli
l c
sts)
re
frequent. In nephrotic syndrome, the sediment m
y e unrem
rk
le except for the
presence of ov
l
f
t odies
nd hy
line c
sts. In some c
ses, f
tty, w
xy,
nd epitheli
l cell c

sts m
y
lso e
found. 2828_Ch06_327-380 06/08/12 11:23 AM P
e 345 18. Urine sediment ch
r
c
terized y pyuri

with
cteri
l
nd WBC c
sts indic
tes: A. Nephrotic syndrome B. Pyelonephritis
C. Polycystic
kidney dise
se D. Cystitis Body uids/Correl
te clinic
l
nd l
or
tory d
t
/ Urin

e sediment/2
19. Which type of c
sts sin
ls the presence of chronic ren
l f
ilure? A. Blood
c
sts B. Fine
r
nul
r c
sts C. W
xy c
sts D. F
tty c
sts Body uids/Apply knowlede of fund
men
t
l ioloic
l
ch
r
cteristics/Urine c
sts/2 20. SITUATION: Urin
lysis of
s
mple from
p
tie
nt suspected of
h
vin
tr
nsfusion re
ction reve
ls sm
ll yellow- rown cryst
ls in the microsc
opic ex
min
tion.
Dry re
ent strip tests
re norm
l with the exception of
positive lood re
cti
on (moder
te)
nd
tr
ce positive protein. Te pH of the urine is 6.5. Wh
t test should e performed
to positively
identify the cryst
ls? A. Con rm
tory test for iliru in B. Cy
nidenitroprusside te
st C.
Pol
rizin microscopy D. Prussi
n lue st
in Body uids/Select course of
ction/Ur
ine sediment/3
21. When ex
minin urin
ry sediment, which of the followin is considered
n
n
orm
l ndin? A.
02 RBCs per HPF B. 01 hy
line c
sts per low-power eld (LPF) C. 01 ren
l cell c
sts p
er LPF D.
25 WBCs per HPF Body uids/Ev
lu
te l
or
tory d
t
to reconize he
lth
nd dise
se
st
tes/Urin
ry sediment/2 22. SITUATION: A urine s
mple with
pH of 6.0 produce
s
n
und
nce of
pink sediment
fter centrifu
tion th
t
ppe
rs
s densely p
cked yellow- to red
dish- rown
r
nules under the microscope. Te cryst
ls
re so dense th
t no other formed ele
ments c
n e
ev
lu
ted. Wh
t is the est course of
ction? A. Request
new urine specimen B.
Suspend the
sediment in prew
rmed s
line, then repe
t centrifu
tion C. Acidify
12-mL
liq
uot with three
drops of l
ci
l
cetic
cid
nd he
t to 56C for 5 minutes efore centrifuin D.
Add ve drops
of 1N HCl to the sediment
nd ex
mine Body uids/Select course of
ction/Urine sed
iment/3 346
Ch
pter 6 | Urin
lysis
nd Body Fluids Answers to Questions 1822 18. B Pyelonephr
itis results
from
cteri
l infection of the ren
l pelvis
nd interstitium. It is ch
r
cteriz
ed y polyuri

resultin from f
ilure of the tu ules to re
sor uid. O struction of tu ules
nd
compression y
WBCs m
y reduce lomerul
r ltr
tion
s well
s H 2 O re
sorption. The ndin of WB
C c
sts helps
to di erenti
te pyelonephritis from urin
ry tr
ct infection. 19. C W
xy c
sts form
from the
deener
tion of cellul
r c
sts. Bec
use the c
sts must rem
in loded in the tu u
le lon enouh
for the r
nul
r protein m
trix to w
xify, they
re
ssoci
ted with chronic
nd
end-st
e ren
l
f
ilure. Both w
xy
nd ro
d c
sts form in chronic ren
l f
ilure when there is s
evere st
sis,
nd
they
re
ssoci
ted with
poor pronosis. 20. D A positive lood test
nd tr
ce
protein
occurrin with
norm
l test for uro ilinoen
nd
n
sence of RBCs
re consist
ent with
n
intr
v
scul
r tr
nsfusion re
ction. Sm
ll yellow- rown r
nul
r cryst
ls
t
n

cid pH m
y e
uric
cid, iliru in, or hemosiderin. Biliru in cryst
ls
re ruled out y the ne

tive dry

re
ent strip test for iliru in. Pot
ssium ferrocy
nide is used in the Prussi
n
lue st
inin
re
ction to detect hemosiderin deposits in urin
ry sediment. Hemosiderin is
sso
ci
ted with
hemochrom
tosis
nd incre
sed RBC destruction. C
uses of urin
ry hemosiderin inc
lude tr
nsfusion
re
ction, hemolytic
nemi
,
nd pernicious
nemi
. 21. C Epitheli
l c
sts
re r

rely seen ut
indic
te
dise
se process
ectin the ren
l tu ules. They
re
ssoci
ted with di
se
ses c
usin
necrosis of the tu ules such
s hep
titis, CMV,
nd other vir
l infections,
nd
mercury
nd
ethylene lycol toxicity. Even occ
sion
l cellul
r c
sts
re considered clinic
l
ly sini c
nt.
22. B Ur
tes
re yellow- or reddish- rown r
nules
nd form in
cid or neutr
l u
rine. They often
form followin refrier
tion of urine
nd c
n e dissolved y
ddition of w
rm s

line or dilute
N
OH. Amorphous phosph
tes
re colorless
nd form in neutr
l or
lk
line urine.
They dissolve in
dilute
cetic
cid ut precipit
te if he
ted. 2828_Ch06_327-380 06/08/12 11:23
AM P
e 346 23.
How c
n hex
on
l uric
cid cryst
ls e distinuished from cystine cryst
ls? A.
Cystine is
insolu le in hydrochloric
cid ut uric
cid is solu le B. Cystine ives
posit
ive nitroprusside
test
fter reduction with sodium cy
nide C. Cystine cryst
ls
re more hihly pi
mented D. Cystine
cryst
ls form
t neutr
l or
lk
line pH, uric
cid forms
t neutr
l to
cidic pH
Body uids/Apply
principles of speci
l procedures/ Urine cryst
ls/2 24. Te presence of tyrosine

nd leucine
cryst
ls toether in
urine sediment usu
lly indic
tes: A. Ren
l f
ilure B. Chr
onic liver
dise
se C. Hemolytic
nemi
D. H
rtnup dise
se Body uids/Correl
te clinic
l
nd l

or
tory d
t
/
Urine cryst
ls/2 25. Which of the followin cryst
ls is considered nonp
tholoic

l? A.
Hemosiderin B. Biliru in C. Ammonium iur
te D. Cholesterol Body uids/Ev
lu
te l

or
tory d
t

to reconize he
lth
nd dise
se st
tes/Urine cryst
ls/2 26. At which pH
re
mmo
nium iur
te
cryst
ls usu
lly found in urine? A. Acid urine only B. Acid or neutr
l urine C.
Neutr
l or

lk
line urine D. Alk
line urine only Body uids/Correl
te l
or
tory d
t
with ph
ysioloic
l
processes/Urine cryst
ls/2 27. Which of the followin cryst
ls is seen commonly
in
lk
line
nd
neutr
l urine? A. C
lcium ox
l
te B. Uric
cid C. M
nesium
mmonium phosph
te D
. Cholesterol
Body uids/Correl
te l
or
tory d
t
with physioloic
l processes/Urine cryst
ls/1
28. Which
cryst
l
ppe
rs in urine
s
lon, thin hex
on
l pl
te,
nd is linked to ines
tion of l
re

mounts of enzoic
cid? A. Cystine B. Hippuric
cid C. Ox
lic
cid D. Uric
cid
Body
uids/Correl
te l
or
tory d
t
with physioloic
l processes/Urine cryst
ls/2 6.2
| Urine
Microscopy
nd Clinic
l Correl
tions 347 Answers to Questions 2328 23. B Fl
t s
ix-sided uric


cid cryst
ls m
y e mist
ken for cystine cryst
ls. Both cryst
ls form
t
n
ci
d to neutr
l pH.
Cystine cryst
ls
re colorless, while uric
cid cryst
ls
re pimented (yellow,
reddish rown).
Cystine tr
nsmits pol
rized liht
nd is solu le in dilute HCl. Uric
cid is ins
olu le in HCl
nd
is less
nisotropic. Cystine is reduced y N
CN formin cysteine. The SH roup of
cysteine
re
cts with nitroprusside to form
red color. 24. B Tyrosine cryst
ls m
y occur
in tyrosinemi
,

n in orn error of tyrosine met
olism c
used y
deficiency of fum
ryl
ceto
ce
t
te hydrol
se,
p-hydroxyphenylpyruvic
cid oxid
se, or tyrosine
minotr
nsfer
se (c
uses of tyr
osinuri
).
However, when seen
lon with leucine cryst
ls, the c
use is chronic liver dise

se, usu
lly
cirrhosis of the liver. Tyrosine usu
lly forms fine rown or yellow needles,
nd
leucine forms
yellow spheres with concentric rins. 25. C A norm
l cryst
ls
re those th
t res
ult from

p
tholoic
l process. Hemosiderin cryst
ls result from intr
v
scul
r RBC destruc
tion. Biliru in
cryst
ls
re found in severe necrotic
nd o structive liver dise
ses,
nd choles
terol cryst
ls in
nephrotic syndrome, di
etes mellitus,
nd hypercholesterolemi
. 26. D Ammonium
iur
te is often
c
lled
thorn
pple cryst
l ec
use it forms
d
rk rown spiny sphere. C
lcium c

r on
te is

nother common cryst
l th
t is seen only in
lk
line urine. Sodium ur
te
nd uri
c
cid form in

cid or neutr
l urine. 27. C M
nesium
mmonium phosph
te,
lso c
lled triple ph
osph
te, m
y e
present in neutr
l or
lk
line urine. Most commonly, triple phosph
te cryst
ls

re six-sided
pl
tes th
t resem le
co n lid. Cryst
ls cont
inin phosph
tes do not occur in
c
id urine. 28. B
Hippuric
cid forms lon, colorless,
t six-sided pl
tes. It results from the met

olism of
enzoic
cid
nd resem les the co n lid
ppe
r
nce of triple phosph
te. It m
y occur
norm
lly

s
result of inestion of veet
les preserved with enzoic
cid. 2828_Ch06_32
7-380 06/08/12
11:23 AM P
e 347 29. Sm
ll yellow needles
re seen in the sediment of
urine
s
mple with
pH
of 6.0. Which of the followin cryst
ls c
n e ruled out? A. Sulf
cryst
ls B. B
iliru in cryst
ls
C. Uric
cid cryst
ls D. Cholesterol cryst
ls Body uids/Apply knowlede of fund
m
ent
l
ioloic
l ch
r
cteristics/Urine cryst
ls/2 30. Ov
l f
t odies
re derived from
: A. Ren
l
tu ul
r epithelium B. Tr
nsition
l epithelium C. Deener
ted WBCs D. Mucoprotein
m
trix Body
uids/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics/Urine sediment/1 3
1. Ov
l f
t
odies
re often
ssoci
ted with: A. Lipoid nephrosis B. Acute lomerulonephriti
s C.
Amino
ciduri
D. Pyelonephritis Body uids/Correl
te clinic
l
nd l
or
tory d
t
/
Urine
sediment/2 32. Urine of const
nt SG r
nin from 1.008 to 1.010 most likely indi
c
tes: A.

Addisons dise
se B. Ren
l tu ul
r f
ilure C. Preren
l f
ilure D. Di
etes insipid
us Body
uids/Ev
lu
te l
or
tory d
t
to reconize he
lth
nd dise
se st
tes/Speci c r
vit
y/2 33. Which
of the followin ch
r
cterizes preren
l f
ilure,
nd helps to di erenti
te it from

cute ren
l
f
ilure c
used y ren
l dise
se? A. BUN:cre
tinine r
tio of 20:1 or hiher B. Ur
ine:pl
sm

osmol
l r
tio less th
n 2:1 C. Excess loss of sodium in the urine D. Dehydr
tion
Body
uids/Correl
te clinic
l
nd l
or
tory d
t
/ Ren
l dise
se/2 34. Which of the fol
lowin
conditions ch
r
cterizes chronic lomerulonephritis
nd helps to di erenti
te it f
rom
cute
lomerulonephritis? A. Hem
turi
B. Polyuri
C. Hypertension D. Azotemi
Body uid
s/Correl
te
clinic
l
nd l
or
tory d
t
/ Ren
l dise
se/2 348 Ch
pter 6 | Urin
lysis
nd Bod
y Fluids Answers
to Questions 2934 29. D Cholesterol cryst
ls
re colorless rect
nul
r pl
tes th

t often h
ve

notched corner
nd
ppe
r st
cked in
st
ir-step
rr
nement. Cholesterol cryst

ls
re hihly

nisotropic
nd c
n e positively identified usin
pol
rizin microscope. Bili
ru in, sulf
, or
uric
cid cryst
ls m
y occur
s sm
ll yellow or yellow- rown needles or rods in
neutr
l or
cid
urine. Biliru in cryst
ls should e suspected when the dry re
ent strip test fo
r iliru in is
positive
nd cells in the sediment
re d
rk yellow ( ile st
ined). Sulf
cryst
l
s
re solu le in

cetone, concentr
ted HCl,
nd N
OH. They c
n e confirmed y the linin test in
which one drop
of sediment
nd one drop of 10% HCl re
ct with newsprint to produce
yellow-or

ne color. 30. A
Ov
l f
t odies form from deener
ted ren
l epitheli
l cells th
t h
ve re
sor e
d cholesterol
from the ltr
te. They st
in with Oil Red O or Sud
n III. The f
t lo ules within
the cells ive

M
ltese cross e ect when ex
mined under pol
rized liht. 31. A The term lipoid n
ephrosis is

synonym for idiop
thic (prim
ry) nephrotic syndrome. Like other forms of nephrot
ic syndrome, it
is
ssoci
ted with ross proteinuri
, edem
,
nd hyperlipidemi
; however, the id
iop
thic form is

lso
ssoci
ted with hem
turi
. It is common in children,
nd often
ssoci
ted w
ith mut
tions
th
t
ect podocyte structure. 32. B The SG of the ltr
te in Bowm
ns sp
ce is
pprox
im
tely
1.010. Urine produced consistently with
SG of 1.010 h
s the s
me osmol
lity of
the pl
sm

nd
results from f
ilure of the tu ules to modify the ltr
te. 33. A Preren
l f
ilure
is c
used y
de cient ren
l lood ow. The tu ules
re und
m
ed
nd will re
sor more BUN th
n
norm
l
ec
use ltr
te ow is slow. Under the in uence of
ldosterone, they re
sor sodium

nd
concentr
te the urine. The BUN:cre
tinine r
tio
nd U:P osmol
l r
tio
re very h
ih
nd sodium
output low. In ren
l dise
se, the BUN:cre
tinine r
tio is 10 or less, the U:P os
mol
l r
tio


ppro
ches 1.0,
nd the d
ily sodium excretion is hih. 34. B Acute lomerulonep
hritis results in
severe compression of the lomerul
r vessels. This reduces ltr
tion, c
usin
pr
oression from
oliuri
to
nuri
. In contr
st, polyuri
is
ssoci
ted with chronic lomerulone
phritis, which
c
uses sc
rrin of the collectin tu ules. Both
cute
nd chronic lomerulonephr
itis c
use low
urine osmol
lity,
zotemi
,
cidosis, hypertension, proteinuri
,
nd hem
turi
.
2828_Ch06_327-380
06/08/12 11:23 AM P
e 348 35. Which of the followin conditions is seen in

cute ren
l
f
ilure
nd helps to di erenti
te it from preren
l f
ilure? A. Hyperk
lemi

nd ur
emi
B.
Oliuri

nd edem
C. Low cre
tinine cle
r
nce D. A norm
l urin
ry sediment Body
uids/Correl
te
clinic
l
nd l
or
tory d
t
/ Ren
l dise
se/2 36. Which of the followin conditi
ons ch
r
cterizes

cute ren
l f
ilure
nd helps to di erenti
te it from chronic ren
l f
ilure? A. Hy
perk
lemi
B.
Hem
turi
C. Cylindruri
D. Proteinuri
Body uids/Correl
te clinic
l
nd l
or
to
ry d
t
/ Ren
l
dise
se/2 37. Te serum concentr
tion of which
n
lyte is likely to e decre
sed
in untre
ted
c
ses of
cute ren
l f
ilure? A. Hydroen ions B. Inor
nic phosphorus C. C
lciu
m D. Uric
cid
Body uids/Correl
te clinic
l
nd l
or
tory d
t
/ Ren
l dise
se/2 38. Which of th
e followin
conditions is
ssoci
ted with the re
test proteinuri
? A. Acute lomerulonephri
tis B. Chronic
lomerulonephritis C. Nephrotic syndrome D. Acute pyelonephritis Body uids/Correl

te clinic
l

nd l
or
tory d
t
/ Ren
l dise
se/2 39. Which of the followin conditions is of
ten
c
use of
lomerulonephritis? A. Hypertension B. Cytome
lovirus infection C. Systemic lup
us erythem
tosus
D. He
vy met
l poisonin Body uids/Apply knowlede of fund
ment
l ioloic
l
ch
r
cteristics/Ren
l dise
se/2 6.2 | Urine Microscopy
nd Clinic
l Correl
tions
349 Answers to
Questions 3539 35. D Reduced lomerul
r ltr
tion
s evidenced y low cre
tinine cl
e
r
nce
ch
r
cterizes oth preren
l
nd
cute ren
l f
ilure. This results in retention o
f uid, c
usin
edem
, reduced urine volume, hypertension, uremi
,
nd hyperk
lemi
in oth prer
en
l
nd
cute
ren
l f
ilure. The kidneys
re not d
m
ed in preren
l f
ilure
nd, therefore, t
he microscopic
ex
min
tion is usu
lly norm
l. 36. A In
cute ren
l f
ilure, reduced lomerul
r l
tr
tion coupled
with decre
sed tu ul
r secretion results in hyperk
lemi
. In chronic ren
l f
ilu
re, sc
rrin of
the collectin tu ules prevents s
lt
nd H 2 O re
sorption. This c
n result in
norm
l or low
serum pot
ssium despite reduced lomerul
r ltr
tion. The sediment in chronic ren

l f
ilure is
ch
r
cterized y intermittent he
vy hem
turi

nd proteinuri
. 37. C Decre
sed 
lomerul
r
ltr
tion in ren
l f
ilure results in hih serum cre
tinine, BUN,
nd uric
cid. F

ilure of the
tu ules results in retention of hydroen ions
nd phosph
tes, c
usin
cidosis

nd
n incre
sed

nion 
p. The tu ules f
il to respond to p
r
thyroid hormone, resultin in exce
ssive loss of
c
lcium in urine. Serum sodium is usu
lly norm
l or slihtly incre
sed, while hy
perk
lemi
is

const
nt ndin in
cute ren
l f
ilure. 38. C Althouh
ll four conditions
re
ss
oci
ted with
proteinuri
, it is re
test in the nephrotic syndrome. Urin
ry
l umin loss is t
ypic
lly in
excess of 4 /d
y or 3 m per m cre
tinine, c
usin dry re
ent strip protein t
ests to ive 3+
to 4+ re
ctions. In contr
st to lomerulonephritis
nd pyelonephritis, the urin

ry sediment in
nephrotic syndrome in
dults is not usu
lly ch
r
cterized y either hem
turi
or
pyuri
. V
rious
c
sts, lipid l
den ren
l epitheli
l cells,
nd ov
l f
t odies
re usu
lly found
. 39. C
Autoimmune dise
ses, di
etes mellitus,
nd nephrotoxic drus
re common c
uses
of
cute
lomerulonephritis. Autoimmune d
m
e m
y result from the deposition of
ntien
n
ti ody
complexes
nd complement-medi
ted d
m
e such
s occurs in poststreptococc
l lo
merulonephritis,
or from the production of
uto
nti odies th
t
tt
ck the
sement mem r
ne
s in
Goodp
stures
syndrome. Acute lomerulonephritis is often cl
ssi ed y the p
ttern of injury r
t
her th
n the
c
use. For ex
mple, insulin de ciency produces sclerotic v
scul
r d
m
e to the l
omeruli, often
resultin in crescentic lomerulonephritis. Group A strep
nd SLE result in immu
noloic
lly
medi
ted d
m
e to the lomeruli usu
lly c
usin mem r
nous or mem r
noprolifer

tive
lomerulonephritis. Cytome
lovirus infections
nd he
vy met
l poisonin c
use d

m
e to the
tu ules, resultin in nephrosis. 2828_Ch06_327-380 06/08/12 11:23 AM P
e 349
40. Acute
pyelonephritis is commonly c
used y: A. B
cteri
l infection of medull
ry inters
titium B.
Circul
tory f
ilure C. Ren
l c
lculi D. Antien
nti ody re
ctions within the lom
eruli Body
uids/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics/Ren
l dise
se/2 41
. All of the
followin
re common ch
r
cteristics of the nephrotic syndrome except: A. Hyperl
ipidemi
B.
Hypo
l uminemi
C. Hem
turi

nd pyuri
D. Severe edem
Body uids/Correl
te clini
c
l
nd
l
or
tory d
t
/ Ren
l dise
se/2 42. Which of the followin conditions is
ch
r

cteristic ndin
in p
tients with o structive ren
l dise
se? A. Polyuri
B. Azotemi
C. Dehydr
ti
on D. Alk
losis
Body uids/Correl
te l
or
tory d
t
with physioloic
l processes/Ren
l dise
se/2
43. Whewellite

nd weddellite kidney stones
re composed of: A. M
nesium
mmonium phosph
te B.
C
lcium ox
l
te
C. C
lcium phosph
te D. C
lcium c
r on
te Body uids/Apply knowlede of fund
ment

l ioloic
l
ch
r
cteristics/Ren
l c
lculi/1 350 Ch
pter 6 | Urin
lysis
nd Body Fluids Answe
rs to Questions
4043 40. A Acute pyelonephritis is c
used y infection of the medull
ry interstit

ium, usu
lly y
coliforms th
t enter from the lower urin
ry tr
ct. Escherichi
coli is the most
commonly
implic
ted
cterium. Since it is focused in the medull
, the dise
se involves m

inly the
tu ules. As opposed to
cute lomerulonephritis, pyelonephritis is not
ssoci
te
d with reduced
cre
tinine cle
r
nce,
zotemi
, or oliuri
. Re
sorption of s
lt
nd w
ter
re
locked,
resultin in hyperk
lemi
,
cidosis,
nd polyuri
. 41. C Althouh c
sts m
y e p
resent, the
urin
ry sediment in nephrotic syndrome is not ch
r
cterized y RBCs
nd WBCs or
y RBC, lood,

nd WBC c
sts. In nephrotic syndrome, unlike ren
l f
ilure (nephritic syndrome),
the cre
tinine
cle
r
nce
nd serum pot
ssium
re usu
lly norm
l. Nephrotic syndrome c
n e seco
nd
ry to other
ren
l dise
ses, infections,
nd dru tre
tment. In such c
ses, it is often tr
ns
ient. When it
follows the
nuric ph
se of
cute lomerulonephritis, it sin
ls
revers
l in t
he course of the
dise
se. 42. B O structive ren
l dise
se m
y result from ren
l or urin
ry tr
ct
c
lculi, enin
prost
tic hypertrophy, chronic urin
ry tr
ct infection, or uroenit
l m
lin
ncy
. O struction
c
uses the hydrost
tic pressure in Bowm
ns sp
ce to incre
se. This pressure oppos
es lomerul
r
filtr
tion. If the hydrost
tic pressure in Bowm
ns sp
ce equ
ls the hydrost
tic p
ressure in the
lomeruli, then filtr
te will not e produced, resultin in
nuri
. Postren
l f

ilure produces
m
ny of the s
me serum
norm
lities
s
cute ren
l f
ilure, includin hyperk
le
mi
,
cidosis,
edem
,
nd
zotemi
. The urin
ry sediment will often e
norm
l,
s well. B
cte
riuri

nd pyuri


re common,
nd hem
turi
m
y result from rupture of the v
s
rect
or other lo
od vessels. 43. B
Over three-fourths of urin
ry tr
ct stones
re composed of c
lcium s
lts,
nd hy
perp
r
thyroidism
is commonly
ssoci
ted with c
lcium stones. Stones composed of m
nesium
mmoniu
m phosph
te
re
c
lled struvite
nd lode in the ren
l pelvis, c
usin
ch
r
cteristic st
horn

ppe
r
nce on
r
dior
phic ex
min
tion. Stones m
inly composed of c
lcium phosph
te
re c
lled
hydroxy
p
tite
or ushite, dependin upon the c
lcium composition. Stones of C
CO 3
re c
lled
c
r on
te

p
tite. 2828_Ch06_327-380 06/08/12 11:23 AM P
e 350 44. Which of the follow
in
norm
l
cryst
ls is often
ssoci
ted with form
tion of ren
l c
lculi? A. Cystine B. Ampi
cillin C.
Tyrosine D. Leucine Body uids/Correl
te clinic
l
nd l
or
tory d
t
/ Ren
l c
lcu
li/2 45. Which
st
tement
out ren
l c
lculi is true? A. C
lcium ox
l
te
nd c
lcium phosph
te

ccount for
out
three-fourths of
ll stones B. Uric
cid stones c
n e seen y x-r
y C. Triple p
hosph
te stones

re found princip
lly in the ureters D. Stones
re usu
lly comprised of sinle s

lts Body
uids/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics/Ren
l c
lculi/2 6.

2 | Urine
Microscopy
nd Clinic
l Correl
tions 351 Answers to Questions 4445 44. A Cystin
uri
is c
used
y
n
utosom
l recessive defect in the tu ul
r re
sorption of di
sic
mino
c
ids (
ren
l-type

mino
ciduri
). Cystine cryst
ls
re hihly insolu le
nd form kidney stones. Ty
rosine cryst
ls
form ne d
rk she
ves or needles
nd m
y result from liver dise
se or tyrosinosis,

n over ow

mino
ciduri
. Leucine cryst
ls form yellow spheres with concentric rins
nd
r
e seen in chronic
liver dise
se. Ampicillin (r
rely) forms lon colorless prisms in she
ves in som
e p
tients ein
tre
ted with hih doses. 45. A Three-fourths of
ll stones cont
in c
lcium
nd t
hree-fourths of
these cont
in c
lcium ox
l
te. Stones
re usu
lly composed of sever
l inor
nic
s
lts, ut
c
lcium ox
l
te is the most common component of urin
ry stones. Ox
l
tes
re h
r
d, d
rk,
nd
co
rse stones. Uric
cid stones
re
lw
ys pimented yellow to reddish rown. Th
ey
re sm
ll
tr
nslucent stones not
pp
rent on x-r
y. Stones m
de of prim
rily c
lcium phosp
h
te (
s
hydroxy
p
tite)
re liht
nd crum le e
sily. Stones m
de of struvite (
mmonium
m
nesium
phosph
te)
re r
diodense
nd lode in the ren
l pelvis, formin
n outline of t
he structures
resem lin the
ntlers of
deer (st
horn c
lculi). 2828_Ch06_327-380 06/08/12
11:23 AM P
e
351 352 6.3 Cere rospin
l, Serous,
nd Synovi
l Fluids 1. Cere rospin
l uid (CSF)
is formed y
ultr
ltr
tion of pl
sm
throuh the: A. Choroid plexus B. S
itt
l sinus C. Anter
ior cere r
l
lymph
tics D. Ar
chnoid mem r
ne Body uids/Apply knowlede of fund
ment
l ioloi
c
l
ch
r
cteristics/Cere rospin
l uid/1 2. Which st
tement re
rdin CSF is true? A.
Norm
l v
lues
for mononucle
r cells
re hiher for inf
nts th
n
dults B. A solute neutrophili

is not
sini c
nt if the tot
l WBC count is less th
n 25/L C. Te rst
liquot of CSF should
e sent to
the micro ioloy l
or
tory D. Neutrophils compose the m
jority of WBCs in norm

l CSF Body
uids/Apply principles of
sic l
or
tory procedures/Cere rospin
l uid/2 3. When c
ollectin
CSF,
di erence etween openin
nd closin uid pressure re
ter th
n 100 mm H 2 O
indic
tes:
A. Low CSF volume B. Su
r
chnoid hemorrh
e C. Meninitis D. Hydroceph
lus Body
uids/Correl
te
l
or
tory d
t
with physioloic
l processes/Cere rospin
l uid/2 Answers to Quest
ions 13 1. A
CSF is formed y ultr
filtr
tion of pl
sm
throuh the choroid plexus,
tuft of
c
pill
ries in
the pi
m
ter loc
ted in the third
nd fourth ventricles. Endotheli
of the chor
oid plexus
vessels
nd ependym
l cells linin the ventricles
ct
s

rrier to the p
ss

e of proteins,
drus,
nd met
olites. Glucose in CSF is
out 60% of the pl
sm
lucose. Tot
l
protein in CSF
is only 1545 m/dL, while chloride levels
re 10%15% hiher th
n pl
sm
. Approxim

tely 500 mL
of ultr
filtr
te
re produced per d
y, the ulk of which is returned to the circ
ul
tion vi
the
s
itt
l sinus. The norm
l volume of CSF in
dults is 100160 mL (1060 mL for sm
ll
children).
2. A Lymphocytes
ccount for 40%80% of WBCs in
dults; monocytes
nd m
croph
es
for 20%50%.
Neutrophils should e less th
n 10% of the WBCs. The reference r
ne for WBCs in

dults is
05/L. Disease may be present when the WBC count is normal, if the majority of WBCs
are PMNs. In
infants, monocytes account for 50%90% of WBCs, and the upper limit for WBCs is 30
/L. The first
aliquot is sent to the chemistry department because it may be contaminated with
blood or skin
flora. 3. A Normal CSF volume in adults is 100160 mL. When volume is low, an abno
rmally high
di erence is observed between the opening and closing pressure. The di erence is nor
mally 1030
mm H 2 0, after removal of 1520 mL. Low opening pressure is caused by reduced vol
ume or block
above the puncture site. High opening pressure may result from high CSF volume,
CNS hemorrhage,
or malignancy. 2828_Ch06_327-380 06/08/12 11:23 AM Page 352 4. Which of the f
ollowing ndings
is consistent with a subarachnoid hemorrhage rather than a traumatic tap? A. Cle
aring of the uid
as it is aspirated B. A clear supernatant after centrifugation C. Xanthochromia
D. Presence of a
clot in the sample Body uids/Evaluate laboratory data to recognize health and dis
ease
states/Cerebrospinal uid/2 5. Te term used to denote a high WBC count in the CSF
is: A. Empyema
B. Neutrophilia C. Pleocytosis D. Hyperglycorrhachia Body uids/Apply knowledge of
fundamental
biological characteristics/Cerebrospinal uid/1 6.3 | Cerebrospinal, Serous, and S
ynovial Fluids
353 Answers to Questions 45 4. C Xanthochromia is pigmentation of CSF caused by
subarachnoid
hemorrhage, high CSF protein, free hemoglobin, or bilirubin. The bilirubin may b
e caused by
hepatic disease, CNS hemorrhage, or prior traumatic tap. In subarachnoid hemorrh
age, the uid
will be pink if the RBC count is greater than 500/L. It will turn orange as RBCs
lyse in the
rst few hours, and will turn yellow after about 12 hours. Granulocyte in ltration o
ccurs
immediately after a subarachnoid hemorrhage, and disappears after 24 hours. It i
s followed by an
increase in macrophages, showing evidence of erythrophagocytosis that remains fo
r up to 2 weeks.
After subarachnoid hemorrhage, D-dimer is present in CSF, and can be used to dis
tinguish between
a traumatic tap and subarachnoid hemorrhage. 5. C Pleocytosis refers to an incre
ase in WBCs
within the CSF. Bacterial meningitis causes a neutrophilic pleocytosis, viral me
ningitis a
lymphocytic pleocytosis, and tuberculous and fungal meningitis a mixed-cell pleo
cytosis. Other
causes of pleocytosis include multiple sclerosis, cerebral hemorrhage or infarct

ion, and
leukemia. 2828_Ch06_327-380 06/08/12 11:23 AM Page 353 6. Which of the adult
CSF values in the
following table are consistent with bacterial meningitis? A. B. C. D. Body uids/E
valuate
laboratory data to recognize health and disease states/Cerebrospinal uid/2 7. Giv
en the
following data, determine the corrected CSF WBC count. 354 Chapter 6 | Urinalysi
s and Body Fluids
Answers to Questions 69 6. C Normal WBC counts for CSF are 05/L for adults and 030/L
for
children. Neutrophils predominate the di erential in bacterial meningitis, while l
ymphocytes
predominate in viral meningitis. Hemorrhage and traumatic tap will also cause in
creased PMNs, and
WBC counts should be corrected using the CSF RBC count. 7. B Corrected WBC count
= WBCs in CSF
[(Blood WBCs CSF RBCs) Blood RBCs] Corrected WBC count = 150/L [(5,000/L WBCs 6,00
0/L
RBCs) 4,000,000/L RBCs] Corrected WBC count = 150/L 7.5/L Corrected WBC count = 142
/L 8.
D Acute bacterial meningitis causes increased production of immunoglobulins in C
SF. Glucose
levels are below normal (<40 mg/dL) due to consumption by PMNs and bacteria. Lac
tate levels rise
due to increased pressure and hypoxia (>35 mg/dL being correlated with bacterial
meningitis).
When associated with increased PMNs and LD, these ndings point to bacterial menin
gitis. 9. D In
viral (aseptic) meningitis, the CSF glucose is usually above 40 mg/dL and the to
tal protein is
normal or slightly increased. Some types of viral meningitis can cause a low glu
cose, which makes
the di erentiation of bacterial and viral meningitis di cult. Low CSF glucose and el
evated total
protein are also seen in malignancy, subarachnoid hemorrhage, and some persons w
ith multiple
sclerosis. Low glucose in malignancy and multiple sclerosis results from increas
ed utilization.
Glucose is reduced in subarachnoid hemorrhage due to release of glycolytic enzym
es from RBCs. All
three conditions result in high CSF protein, but multiple sclerosis is associate
d with an
increased IgG index owing to local production of IgG. WBCs Lymphocytes Monoc
ytes
Eosinophils Neutrophils Neuroectodermal Cells 50/L 44% 55% 0% 0% 1% 300/L 75%
21% 3% 0% 1%
2,000/L 5% 15% 0% 80% 0% 2,500/L 40% 50% 0% 10% 0% CSF Values Peripheral Blood
Values RBCs
6,000/L 4.0 10 6
/
L
WBCs 150/L 5.0 10 3
/
L
A. 8 WBC/L B. 142 WBC/L C. 120 WBC/L D. 145 WBC/L Body uids/Calculate/CSF hem
atology/2
8. SITUATION: What is the most likely cause of the following CSF results? CSF gl
ucose 20 mg/dL;
CSF protein 200 mg/dL; CSF lactate 50 mg/dL (reference range 525 mg/dL) A. Viral
meningitis B.
Viral encephalitis C. Cryptococcal meningitis D. Acute bacterial meningitis Body

uids/Evaluate
laboratory data to recognize health and disease states/Cerebrospinal uid/2 9. Whi
ch of the
following conditions is most often associated with normal CSF glucose and protei
n? A. Multiple
sclerosis B. Malignancy C. Subarachnoid hemorrhage D. Viral meningitis Body uids/
Correlate
clinical and laboratory data/ Cerebrospinal uid/2 2828_Ch06_327-380 06/08/12 11
:23 AM Page
354 10. Te diagnosis of multiple sclerosis is often based upon which nding? A. Te
presence of
elevated protein and low glucose B. A decreased IgG index C. Te presence of olig
oclonal bands by
electrophoresis D. An increased level of CSF microlo ulin Body uids/Correl
te cl
inic
l
nd
l
or
tory d
t
/ Cere rospin
l uid/2 11. Which of the followin results is consis
tent with
fun
l meninitis? A. Norm
l CSF lucose B. Pleocytosis of mixed cellul
rity C.
Norm
l CSF
protein D. Hih CSF l
ct
te Body uids/Correl
te clinic
l
nd l
or
tory d
t
/ Cer
e rospin
l
uid/2 12. In wh
t suspected condition should
wet prep usin
w
rm slide e ex

mined? A.
Cryptococc
l meninitis B. Amoe ic meninoenceph
litis C. Myco
cterium tu ercul
osis infection D.
Neurosyphilis Body uids/Select course of
ction/Cere rospin
l uid/2 13. Which of t
he followin
CSF test results is most commonly incre
sed in p
tients with multiple sclerosis?
A. Glut
mine B.
L
ct
te C. IG index D. Ammoni
Body uids/Correl
te clinic
l
nd l
or
tory d
t
/
Cere rospin
l
uid/2 6.3 | Cere rospin
l, Serous,
nd Synovi
l Fluids 355 Answers to Questions
1013 10. C
The tot
l CSF protein is incre
sed in less th
n h
lf of persons with MS. The IG
index is
incre
sed in 80% or more of MS c
ses. While the IG index is sensitive, it is in
cre
sed in m
ny
other disorders. The presence of olioclon
l
ndin (two or more discrete
nds
in the 
mm

zone followin electrophoresis) is seen in 90% of persons with MS,
nd in few ot
her dise
ses.
While not entirely de nitive, it is the sinle most e ective l
or
tory test for the
di
nosis of
MS. When performin CSF electrophoresis, the serum p
ttern must e comp
red to t
he CSF p
ttern.
At le
st some of the olioclon
l
nds must not e found in the serum p
ttern fo
r the test to e
considered positive. Bet
-2 microlo ulins
re incre
sed in CSF in in
mm
tory dis
e
ses
(especi
lly m
lin
nt dise
ses). 11. B In fun
l meninitis, the lucose will e
low
nd the
tot
l protein elev
ted; however, unlike
cteri
l meninitis, the l
ct
te is usu

lly elow 35
m/dL. Fun
l meninitis usu
lly produces
pleocytosis of mixed cellul
rity con
sistin of
lymphocytes, PMNs, monocytes,
nd eosinophils. In some c
ses, lymphocytes predom
in
te; while in
others, PMNs comprise the m
jority of WBCs. 12. B Amoe
in CSF
ppe
r very simi
l
r to monocytes
in st
ined lms ut c
n e di erenti
ted y their ch
r
cteristic pseudopod mo ility

in
wet prep
on
prew
rmed slide. N
eleri
fowleri
nd Ac
nth
moe
spp.
re c
us
tive
en
ts of prim
ry

moe ic meninoenceph
litis. 13. C IG Index = (CSF IG serum IG) (CSF
l umin
serum

l umin) An IG
l umin index is the r
tio of CSF IG:serum IG divided y the CSF

l umin:serum

l umin. V
lues re
ter th
n 0.85 indic
te CSF IG production,
s seen in multip
le sclerosis; or
incre
sed CSF production com ined with incre
sed perme
ility,
s seen in CNS in
fections.
Multiple sclerosis is ch
r
cterized y the presence of olioclon
l
ndin in th
e CSF in more
th
n 90% of p
tients with
ctive dise
se. The tot
l protein
nd myelin
sic pro
tein
re often
incre
sed
nd the lucose is decre
sed. Reyes syndrome results in hep
tic f
ilure
, c
usin hih
CSF levels of
mmoni

nd lut
mine. CSF l
ct
te is usu
lly norm
l in p
tients w
ith multiple
sclerosis. 2828_Ch06_327-380 06/08/12 11:23 AM P
e 355 14. Which of the foll
owin is
n
in
ppropri
te procedure for performin routine CSF
n
lysis? A. A di erenti
l is d
one only if the
tot
l WBC count is re
ter th
n 10/L B. A di erenti
l should e done on
st
ined C
SF
concentr
te C. A minimum of 30 WBCs should e di erenti
ted D. A Wrihts-st
ined sl
ide should e
ex
mined r
ther th
n
ch
m er di erenti
l Body uids/Apply principles of st
nd
rd o
per
tin
procedures/Cere rospin
l uid/2 15. Which cell is present in the CSF in re
ter nu
m ers in
new orns th
n in older children or
dults? A. Eosinophils B. Lymphocytes C. Mono
cytes D.
Neutrophils Body uids/Correl
te clinic
l
nd l
or
tory d
t
/ Cere rospin
l uid/2
16.
Neutrophilic pleocytosis is usu
lly
ssoci
ted with
ll of the followin except:
A. Cere r
l
inf
rction B. M
lin
ncy C. Myelor
phy D. Neurosyphilis Body uids/Correl
te clin
ic
l
nd
l
or
tory d
t
/ Cere rospin
l uid/2 17. Which st
tement
out CSF protein is tru
e? A. An

norm
l serum protein electrophoretic p
ttern does not
ect the CSF p
ttern B. T
e upper
reference limit for CSF tot
l protein in new orns is one-h
lf
dult levels C. CS
F IG is
incre
sed in p
nenceph
litis, m
lin
ncy,
nd neurosyphilis D. Anti odies to Tre
ponem
p
llidum
dis
ppe
r
fter successful
nti iotic ther
py Body uids/Correl
te clinic
l
nd l

or
tory d
t
/
Cere rospin
l uid/2 18. Which of the followin st
tements re
rdin routine micro
ioloic
l
ex
min
tion of CSF is true? A. A Gr
m st
in is performed on the CSF prior to con
centr
tion B. Te
Gr
m st
in is positive in fewer th
n 40% of c
ses of
cute
cteri
l meninitis
C. Indi
ink
nd

cid f
st st
ins
re indic
ted if neutrophilic pleocytosis is present D. All CSF
specimens should
e cultured usin sheep lood

r, chocol
te

r,
nd supplemented roth Body u
ids/Apply
knowlede of st
nd
rd oper
tin procedures/Cere rospin
l uid/2 356 Ch
pter 6 | Ur

in
lysis
nd
Body Fluids Answers to Questions 1418 14. A A rel
tive (percent) incre
se in PMNs
m
y e
sini c
nt even when the WBC count does not exceed the upper limit of norm
l. For
this re
son,

WBC di erenti
l usin
concentr
ted CSF s
mple is
lw
ys performed on neon
tes
n
d when the WBC
count is > 5/L. Cytocentrifugation should be used to concentrate the cells follow
ed by staining
with Wrights stain. 15. C In newborns, the upper reference limit (URL) for WBCs i
s 30/L (URL
for adults is 5/L) with the majority of WBCs being monocytes or macrophages. In n
ormal neonates,
monocytes (including macrophages and histiocytes) account for about 75% of the W
BCs, lymphocytes
for about 20%, and PMNs for about 3%. In normal adults, lymphocytes account for
about 60% of the
WBCs, monocytes for about 35%, and PMNs for about 2%. 16. D Neutrophils may appe
ar in CSF from
many causes, making it necessary to correlate results of chemical assays with he
matologic
ndings. Low glucose and high protein occur in both malignancy and bacterial menin
gitis. Tumor
markers and lactate may be helpful in distinguishing malignancy from bacterial m
eningitis. In
neurosyphilis, there is usually an absolute lymphocytosis, increased total prote
in and IgG index.
17. C Although the bloodbrain barrier excludes most plasma proteins, abnormal ser
um proteins can
cause parallel CSF electrophoretic patterns. Therefore, an abnormal CSF pattern
indicates CNS
disease only if not duplicated by the serum pattern. Normal CSF total protein in
newborns may be
up to two times higher than adult levels. Antibodies to T. pallidum remain in CS
F after
treatment, but nontreponemal antibodies disappear. While the FTA-ABS test for sp
eci c antibodies
is more sensitive, the VDRL test is often performed concurrently. A positive res
ult for both
tests is diagnostic of active tertiary syphilis. 18. D A culture should be perfo
rmed on the
sediment of the third aliquot of the CSF after it is centrifuged. Blood and choc
olate agar and
anaerobic broth should always be used, and, if sterile, held a minimum of 3 days
. Blood cultures
should be done since septicemia occurs in about one-half of bacterial meningitis
cases. A Gram
stain is always performed using sediment of the CSF because it is positive in mo
re than 70% of
acute bacterial meningitis cases. India ink, acid-fast, and wet preparations may
be ordered if an
absolute monocytosis is present. 2828_Ch06_327-380 06/08/12 11:23 AM Page 356
19. Which
organism is the most frequent cause of bacterial meningitis in neonates? A. Neis
seria
meningitidis B. Group B Streptococcus C. Streptococcus pneumoniae D. Klebsiella
pneumoniae Body
uids/Correlate clinical and laboratory data/ Cerebrospinal uid/2 20. Following a h
ead injury,
which protein will identify the presence of CSF leakage through the nose? A. Tra

nsthyretin B.
Myelin basic protein C. Tau protein D. C-reactive protein Body uids/Select test/C
SF/2 21. Which
of the following statements regarding serous uids is true? A. Te normal volume of
pleural uid
is 3050 mL B. Mesothelial cells, PMNs, lymphocytes, and macrophages may be presen
t in normal
uids C. X-ray can detect a 10% increase in the volume of a serous uid D. Normal se
rous uids
are colorless Body uids/Correlate clinical and laboratory data/ Serous uid/2 22. T
e term
e usion refers to: A. A chest uid that is purulent B. A serous uid that is chylous C
. An
increased volume of serous uid D. An in ammatory process a ecting the appearance of a
serous
uid Body uids/Apply knowledge of fundamental biological characteristics/Pleural uid
/1 23.
Which of the following laboratory results is characteristic of a transudative uid
? A. SG = 1.018
B. Total protein = 3.2 g/dL C. LD uid/serum ratio = 0.25 D. Total protein uid/seru
m ratio =
0.65 Body uids/Evaluate laboratory data to recognize health and disease states/Ex
udates/2 6.3 |
Cerebrospinal, Serous, and Synovial Fluids 357 Answers to Questions 1923 19. B
Group B
Streptococcus and E. coli are the two most common isolates in neonates. Haemophi
lus in uenzae, S.
pneumoniae, and N. meningitidis are the most common isolates in children. S. pne
umoniae is the
most frequent isolate in the elderly. 20. C In cases of trauma, it may be necess
ary to
di erentiate rhinorrhea from CSF leakage, and this can be done by immuno xation elec
trophoresis
to identify tau protein found in CSF but not serum. Tau protein is an enzymatica
lly modi ed form
of transferrin that migrates in the slow beta zone just behind unmodi ed transferr
in.
Transthyretin or prealbumin is present in far greater concentration in CSF than
blood but may not
be seen if CSF is diluted with nasal uid. Myelin basic protein is a component of
nerve sheaths
and is present in CSF in about 60% of persons with MS. It is also found in perso
ns with other
demyelinating diseases, SLE, stroke and brain injury. C-reactive protein is elev
ated in the CSF
of approximately two-thirds of persons with bacterial meningitis. 21. B The sero
us uids include
pleural, pericardial, and peritoneal uid. They form from ultra ltration of plasma t
hrough serous
membranes. These are lined with specialized epithelium called mesothelium. They
comprise about 5%
of the cells in serous uid and may be di cult to di erentiate from malignant cells. P
leural uid
volume is normally less than 10 mL. The volume of pericardial uid is normally 1050
mL and
peritoneal uid 3050 mL. X-rays can detect an increase in serous uids of 300 mL or m
ore. Normal
serous uids are clear and range in color from straw to light yellow. 22. C E usions
are
classi ed as either transudates, exudates, or chylous. Transudates result from abn

ormal
hemodynamics (e.g., congestive heart failure, liver disease), and exudates and c
hylous uids from
local disease. A pleural uid that is purulent is called an empyemic uid. Such a uid
has a WBC
count of 10,000/L or greater. 23. C Transudative uids are distinguished from exuda
tive uids by
the physical appearance, cellularity, SG, total protein, LD, cholesterol, and bi
lirubin.
Exudative uids have a uid:serum LD ratio greater than 0.6 caused by release of the
enzyme from
in ammatory or malignant cells. Exudative uids have a total protein greater than 3.
0 g/dL, SG
greater than 1.015, uid:serum total protein ratio greater than 0.6, cholesterol g
reater than 60
mg/dL ( uid:serum ratio > 0.3) and uid:serum bilirubin ratio greater than 0.6. Exud
ates are
caused by infection, infarction, malignancy, rheumatoid diseases, and trauma. 28
28_Ch06_327-380
06/08/12 11:23 AM Page 357 24. Which observation is least useful in distinguis
hing a
hemorrhagic serous uid from a traumatic tap? A. Clearing of uid as it is aspirated
B. Presence
of xanthochromia C. Te formation of a clot D. Diminished RBC count in successive
aliquots Body
uids/Correlate laboratory data with physiological processes/Serous uids/2 25. Whic
h of the
following laboratory results on a serous uid is most likely to be caused by a tra
umatic tap? A.
An RBC count of 8,000/L B. A WBC count of 6,000/L C. A hematocrit of 35% D. A neut
rophil count
of 55% Body uids/Correlate laboratory data with physiological processes/Serous uid
/2 26. Which
of the following conditions is commonly associated with an exudative e usion? A. C
ongestive heart
failure B. Malignancy C. Nephrotic syndrome D. Cirrhosis Body uids/Correlate clin
ical and
laboratory data/ Transudate/2 27. Which of the following conditions is associate
d with a chylous
e usion? A. Necrosis B. Pulmonary infarction or infection C. Systemic lupus erythe
matosus or
rheumatoid arthritis D. Lymphatic obstruction Body uids/Correlate clinical and la
boratory data/
Exudates/2 28. Which of the following conditions is most often associated with a
pleural uid
glucose below 30 mg/dL? A. Diabetes mellitus B. Pancreatitis C. RA D. Bacterial
pneumonia Body
uids/Correlate clinical and laboratory data/ Pleural uid/2 358 Chapter 6 | Urinaly
sis and Body
Fluids Answers to Questions 2428 24. C Xanthochromia indicates either an exudativ
e process or
prior traumatic tap. Hemorrhagic pleural uids usually have RBC counts greater tha
n 100,000/L
and are usually caused by lung neoplasms. Clearing of uid or diminished RBC count
s in successive
tubes favors a diagnosis of a traumatic tap. A clot may form in a hemorrhagic uid
or following a
traumatic tap. However, a transudative uid will not clot. 25. A Normal uids have a
WBC count
less than 1,000/L, but counts between 1,000 and 2,500/L may be seen in both exudat

es or
transudates. All WBC types are present, but no type should account for more than
50% of the
leukocyte count. An RBC count below 10,000/L is usually caused by a traumatic tap
. A uid
hematocrit similar to blood is caused by a hemothorax. Pleural uids containing >
100,000/L RBCs
are associated most often with malignancies, but are also seen in trauma and pul
monary
infarction. 26. B Transudative uids are caused by circulatory problems, usually d
ecreased
oncotic pressure or increased hydrostatic pressure. In contrast, exudative e usion
s are caused by
in ammatory processes and cellular in ltration as seen in malignancy. In addition to
a RBC count
> 100,000/L, malignancies often involve the lung, colon, breast, or pancreas and
often produce
carcinoembryonic antigen. 27. D Malignancy, pulmonary infarction, SLE, and RA ar
e characterized
by in ammation with increases in protein, WBCs, and LD. Exudates can also be cause
d by
tuberculosis, pancreatitis, and lymphoma. Lymphatic obstruction is often associa
ted with lymphoma
and other malignancies that block the ow of lymph into the azygous vein. This cau
ses a chylous
e usion. Chylous e usions are also caused by traumatic injury to the thoracic duct.
Necrosis
causes a pseudochylous e usion. This resembles a chylous e usion in appearance but h
as a foul
odor. Chylous uids contain chylomicrons, stain positive for fat globules, show ly
mphocytosis,
and have a triglyceride concentration over twofold higher than plasma (or > 110
mg/dL).
Pseudochylous e usions are characterized by mixed cellularity and elevated cholest
erol. 28. C
Normal pleural uid has the same glucose concentration as plasma. Hyperglycemia is
the only
condition that is associated with a high pleural uid glucose. Low glucose levels
(<60 mg/dL) may
be seen in infection, malignancy, and rheumatic diseases. However, glucose level
s are lowest
(often below 30 mg/dL) and are a constant nding when rheumatoid disease a ects the
lungs.
Pancreatitis causes an exudative peritoneal and pleural e usion with an elevated p
eritoneal uid
amylase (without a low glucose). 2828_Ch06_327-380 06/08/12 11:23 AM Page 358
29. In which
condition is the pleural uid pH likely to be above 7.3? A. Bacterial pneumonia wi
th
parapneumonic exudate B. Rheumatoid pleuritis C. Esophageal rupture D. Pneumotho
rax Body
uids/Correlate clinical and laboratory data/ Pleural uid/2 30. Which of the follow
ing
hematology values best frames the upper reference limits for peritoneal uid? A. B
. C. D. Body
uids/Apply knowledge of fundamental biological characteristics/Serous uids/2 31. W
hich of the
following characteristics is higher for synovial uid than for the serous uids? A.
SG B. Glucose
C. Total protein D. Viscosity Body uids/Apply knowledge of fundamental biological

characteristics/Synovial uid/1 32. In which type of arthritis is the synovial WBC

count likely
to be greater than 50,000/L? A. Septic arthritis B. Osteoarthritis C. RA D. Hemor
rhagic
arthritis Body uids/Correlate clinical and laboratory data/ Synovial uid/2 33. Wha
t type of
cell is a ragocyte? A. Cartilage cell seen in in ammatory arthritis B. A PMN with in
clusions
formed by immune complexes C. A plasma cell seen in RA D. A macrophage containin
g large
inclusions Body uids/Apply knowledge of fundamental biological characteristics/Mo
rphology/1 6.3
| Cerebrospinal, Serous, and Synovial Fluids 359 Answers to Questions 2933 29.
D The pH of
pleural uid is approximately 7.64, and values below 7.30 are usually associated w
ith a poorer
prognosis and usually require drainage. Esophageal rupture produces the lowest p
H with values in
the range of 6.06.3. In addition, pleural uid pH is low in rheumatoid disease invo
lving the
lungs and pleura, some malignancies, and SLE. Low pH and glucose in pleural uid a
re seen in lung
abscess and exudative bacterial pneumonia (called parapneumonic e usion). Pneumoth
orax results
from air entering the pleural space and does not produce a low pH. 30. A Periton
eal uid normally
has a WBC count of less than 300/L. Neutrophils should account for no more than 2
5% of the WBCs.
A majority of PMNs indicates bacterial infection of the peritoneum. Lymphocytosi
s suggests
malignancy, tuberculosis, cirrhosis, and lymphatic leakage. Peritoneal uid amylas
e is elevated
in most cases of acute pancreatitis. Peritonitis is suspected when the uid LD is
greater than
40% of the serum level. In contrast, normal pleural uid has a WBC count usually b
elow 1,000/L.
Exudative uids usually have a WBC count above 10,000/L, but values tend to overlap
nonin ammatory uids. The PMNs should comprise 50% of the WBCs or less, and the RBC
count should
be less than 100,000/L. 31. D Synovial uid has approximately the same SG and gluco
se as plasma
and the serous uids but is far more viscous due to a high content of mucoprotein
(hyaluronate)
secreted by the synovium. Viscosity is estimated by pulling the uid from the tip
of a syringe or
pipet. Normal uid gives a string longer than 4 cm. Low viscosity indicates in ammat
ion. The
total protein of synovial uid is usually lower than serous uids, the upper referen
ce limit
being 2.0 g/dL. 32. A The WBC count is elevated in all types of arthritis, but i
s greatest
(50,000100,000/L) in septic arthritis. Neutrophils comprise less than 25% of WBCs
in normal and
nonin ammatory arthritis, but are above 50% in in ammatory and septic arthritis. Flu
ids are
diluted in saline because acetic acid causes a mucin clot to form. WBC counts sh
ould be performed
within 1 hour of collection because the WBC count will diminish over time. 33. B
Ragocytes are
PMNs containing dark granules composed of immunoglobulins, but they may be seen

in gout and
septic arthritis as well as RA. LE cells may be seen in uid from patients with SL
E. Reiters
cells, macrophages with ingested globular inclusions, are seen in Reiters syndrom
e and other
in ammatory diseases. Percentage WBC Count of PMNs RBC Count 300/L 25% 100,000/L
10,000/L
50% 500,000/L 50,000/L 50% 500,000/L 100,000/L 75% 1,000,000/L 2828_Ch06_327-380 06/
08/12
11:23 AM Page 359 34. Which of the following crystals is the cause of gout? A.
Uric acid or
monosodium urate B. Calcium pyrophosphate or apatite C. Calcium oxalate D. Chole
sterol Body
uids/Apply knowledge of fundamental biological characteristics/Synovial uid/1 35.
Which crystal
causes pseudogout? A. Oxalic acid B. Calcium pyrophosphate C. Calcium oxalate D. C
holesterol
Body uids/Apply knowledge of fundamental biological characteristics/Synovial uid/1
36. A
synovial uid sample is examined using a polarizing microscope with a red compensa
ting lter.
Crystals are seen that are yellow when the long axis of the crystal is parallel
to the slow
vibrating light. When the long axis of the crystal is perpendicular to the slow
vibrating light,
the crystals appear blue. What type of crystal is present? A. Calcium oxalate B.
Calcium
pyrophosphate C. Uric acid D. Cholesterol Body uids/Apply principles of special p
rocedures/
Synovial uid/2 37. In which condition is the synovial uid glucose most likely to b
e within
normal limits? A. Septic arthritis B. In ammatory arthritis C. Hemorrhagic arthrit
is D. Gout Body
uids/Correlate clinical and laboratory data/ Synovial uid/2 38. Which statement ab
out synovial
uid in RA is true? A. Synovial/serum IgG is usually 1:2 or higher B. Total hemoly
tic complement
is elevated C. Ninety percent of RA cases test positive for rheumatoid factor in
synovial uid D.
Demonstration of rheumatoid factor in joint uid is diagnostic for RA Body uids/Cor
relate
clinical and laboratory data/ Synovial uid/2 360 Chapter 6 | Urinalysis and Body
Fluids Answers
to Questions 3438 34. A Although all of the crystals mentioned can cause crystalinduced
arthritis, uric acid and sodium urate crystals cause gout and are seen in about
90% of gout
patients. 35. B Calcium pyrophosphate crystals occur as needles or small rhombic
plates and can
be confused with uric acid. They rotate plane polarized light but not as strongl
y as uric acid.
Synovial uid should never be collected in tubes containing powdered ethylenediami
netetraacetic
acid (EDTA) because it may form crystals that can be mistaken for in vivo crysta
ls. The
recommended anticoagulant is sodium heparin, although liquid EDTA may be used. 3
6. C Polarized
microscopy with a red compensating lter di erentiates uric acid and pseudogout crys
tals. When
the long axis of uric acid needles is parallel to the slow vibrating light, the

crystals appear
yellow. When the long axis is perpendicular to the slow vibrating light, the cry
stals appear
blue. Calcium pyrophosphate gives the reverse e ect. 37. C Synovial uid glucose is
normally less
than 10 mg/dL below the serum glucose, and should be collected after an 8-hour f
ast to ensure
that the uid and plasma are equilibrated. In septic arthritis, the glucose level
is often more
than 40 mg/dL below the serum level and about 2540 mg/dL lower in in ammatory arthr
itis, which
includes gout. Osteoarthritis and hemorrhagic arthritis are not usually associat
ed with low joint
uid glucose. 38. A Rheumatoid factor can be present in both serum and synovial uid
s from
patients with RA, SLE, and other in ammatory diseases. Rheumatoid factor is presen
t in synovial
uid of approximately 60% of patients with RA. Normally, IgG in synovial uid is abo
ut 10% of the
serum IgG level. CH 50 levels in serum and synovium are more di erential. Both are
increased in
Reiters syndrome but are often low in SLE; synovial CH 50 is decreased and serum
CH 50 is normal
(or increased) in RA. 2828_Ch06_327-380 06/08/12 11:23 AM Page 360 39. Which
of the following
organisms accounts for the majority of septic arthritis cases in young and middl
e-age adults? A.
H. in uenzae B. Neisseria gonorrhoeae C. Staphylococcus aureus D. Borrelia burgdor
feri Body
uids/Apply knowledge of fundamental biological characteristics/Synovial uid/2 40.
Which of the
following hematology values best frames the upper reference limits for synovial u
id? A. B. C. D.
Body uids/Apply knowledge of fundamental biological characteristics/Synovial uid/2
6.3 |
Cerebrospinal, Serous, and Synovial Fluids 361 Answers to Questions 3940 39. B
Synovial uid
is normally sterile, and all of the organisms listed may cause septic arthritis.
N. gonorrhoeae
is responsible for about 75% of septic arthritis cases occurring in young and mi
ddle-aged adults.
Staphylococcus spp. is responsible for the majority of cases involving the elder
ly, and is the
most frequently found isolate from infected joint replacements. Haemophilus spp.
, Staphylococcus
spp., and Streptococcus spp. are the most common causes of arthritis in young ch
ildren. 40. A The
WBC count of normal joint uid is 200/L or less. Values above 5,000/L cause the uid t
o be
purulent and occur in septic arthritis, RA, and gout. WBC counts greater than 50
,000 L indicate
septic arthritis. The majority of WBCs in normal uid are monocytes, which usually
account for
50%65%. Neutrophils and lymphocytes should account for no more than 25% each. An
increase in
RBCs occurs in cases of infectious and hemorrhagic arthritis or results from a t
raumatic tap.
Hemorrhagic uid will appear turbid, red to brown, and often clotted. In ammatory ar
thritis can
allow brinogen to enter the uid and thus clot. Fluid from a hemophiliac will not c

lot in spite
of its bloody appearance. Percentage WBC Count of PMNs RBC Count 200/L 25% 2,
000/L 5,000/L
50% 10,000/L 10,000/L 50% 50,000/L 20,000/L 5% 500,000/L 2828_Ch06_327-380 06/08/12
11:23
AM Page 361 362 6.4 Amniotic, Gastrointestinal, and Seminal Fluids 1. Which of
the following
statements about amniotic uid bilirubin measured by scanning spectrophotometry is
true? A. Te
410-nm peak is due to hemoglobin and the 450-nm peak is due to bilirubin B. Base
line correction
is not required if a scanning spectrophotometer is used C. Chloroform extraction
is necessary
only when meconium is present D. In normal amniotic uid, bilirubin increases with
gestational
age Body uids/Apply principles of special procedures/ Amniotic uid/2 2. Which test
best
correlates with the severity of HDN? A. Rh antibody titer of the mother B. Lecit
hin/sphingomyelin
(L/S) ratio C. Amniotic uid bilirubin D. Urinary estradiol Body uids/Correlate cli
nical and
laboratory data/ Amniotic uid/2 3. Which is the reference method for determining
fetal lung
maturity? A. Human placental lactogen B. L/S ratio C. Amniotic uid bilirubin D. U
rinary estriol
Body uids/Correlate laboratory data with physiological processes/L/S ratio/2 Answ
ers to
Questions 13 1. A Amniotic uid bilirubin re ects the extent of fetal RBC destruction
in cases
of hemolytic disease of the newborn (HDN). It is measured by scanning the uid fro
m 350 to 600
nm, then drawing a baseline using the points at 365 nm and 550 nm. The delta abs
orbance (A) of
hemoobin at 410 nm an biirubin at 450 nm are etermine by subtractin the a
bsorbance of the
baseine from the respective peaks. Sampes that are not rossy hemoyze can b
e correcte for
oxyhemoobin by subtractin 5% of the A at 410 nm from the A at 450 nm. When hemo
ysis is
severe or meconium is present, the biirubin must be extracte in choroform bef
ore measurin
absorbance. Biirubin normay ecreases with increasin estationa ae because
feta urine
contributes more to amniotic ui voume as the fetus matures. The biirubin conce
ntration must
be correate with estationa ae in orer to correcty evauate the severity o
f HDN. 2. C
Amniotic ui biirubin is the best inex of the severity of HDN an is measure b
y scannin or
ioe array spectrophotometry across the 550365 nm rane. When hemoobin prouce
s a positive
sope at 410 nm, the biirubin shou be extracte with choroform prior to scan
nin. Extraction
methos ive the best correation with RBC estruction. 3. B Respiratory istres
s synrome
eveops when surfactants are insu cient to prevent coapse of the infants aveoi
urin
expiration. Tests measurin pumonary phosphoipi surfactants are the most spec
i c an sensitive
inicators of respiratory istress synrome. An L/S ratio reater than 2:1 (in s

ome aboratories
2.5:1) is the most wiey accepte measure of feta un maturity. Most of the s
urfactants in the
amniotic ui are present in the form of amear boies. These can be counte usi
n an
eectronic ce counter at the settins for enumeratin pateets. 2828_Ch06_327
-380 06/08/12
11:23 AM Pae 362 4. Which of the foowin statements rearin the L/S ratio
is true? A. A
ratio of 2:1 or reater usuay inicates aequate pumonary surfactant to preve
nt respiratory
istress synrome (RDS) B. A ratio of 1.5:1 inicates feta un maturity in pre
nancies
associate with iabetes meitus C. Sphinomyein eves increase urin the th
ir trimester,
causin the L/S ratio to fa sihty urin the ast 2 weeks of estation D. A
phosphatiyycero (PG) spot inicates the presence of meconium in the amnioti
c ui Boy
uis/Correate cinica an aboratory ata/L/S ratio/2 5. Which of the foowin
conitions is
most ikey to cause a fasey ow L/S ratio? A. Te presence of PG in amniotic ui
 B. Freezin
the specimen for one month at 20C C. Centrifuation at 1,000  for 10 minutes D. M
aterna
iabetes meitus Boy uis/Appy knowee to reconize sources of error/Amnioti
c ui/3 6.
Which of the foowin statements accuratey escribes hCG eves in prenancy?
A. Leves of hCG
rise throuhout prenancy B. In ectopic prenancy, serum hCG oubin time is be
ow expecte
eves C. Moar prenancies are associate with ower eves than expecte for t
he time of
estation D. hCG returns to nonprenant eves within 2 ays foowin eivery,
stibirth, or
abortion Boy uis/Correate cinica an aboratory ata/ Chorionic onaotropin
/2 6.4 |
Amniotic, Gastrointestina, an Semina Fuis 363 Answers to Questions 46 4. A
Pumonary
surfactants are mainy isaturate ecithins prouce by type II ranuar pneumo
cytes. The L/S
ratio increases towar the en of the thir trimester ue to increase prouctio
n of ecithin.
The concentration of sphinomyein remains constant throuhout estation an ser
ves as an
interna reference. Meconium contains ess ecithin than amniotic ui an wi us
uay ecrease
the L/S ratio; however, meconium prouces a spot that can be misinterprete as 
ecithin, eain
to a fasey increase L/S ratio. Su cient PG to prouce a spot is seen ony when
the L/S ratio
is 2:1 or hiher. PG is not present in either boo or meconium an, therefore,
its presence
inicates feta un maturity. In iabetes, the feta uns may mature more sow
y than norma,
an infants may eveop RDS when the L/S ratio is 2:1 or sihty hiher. For th
is reason, an L/S
of 3:1 more cosey correates with feta un maturity when testin amniotic ui
from iabetic
mothers. As in a other cases, when the amniotic ui from a iabetic mother is p
ositive for PG,

feta un maturity is estabishe. 5. C Pumonary surfactants are arey prese

nt in the form of
amear boies an can be ost by centrifuin the amniotic ui at hih  force.
Centrifue
spee shou be the minimum require to spin own ces (450  for 10 minutes at
4C). Sampes
that cannot be measure immeiatey shou be refrierate or frozen. Sampes ar
e stabe for up
to 3 ays at 2C8C an for months when frozen at 20C or ower. Meconium an boo may
aso
introuce errors when measurin the L/S ratio. Boo has an L/S ratio of approxi
matey 2:1 an
wi fasey raise the L/S ratio when feta uns are immature an epress the L
/S ratio when
feta uns are mature. 6. B In norma prenancy, hCG eves rise exponentiay
foowin
impantation an peak at weeks 912, reachin in excess of 100,000 mIU/mL. Leves
fa after the
rst trimester to about 20,000 mIU/mL an then remain at about that eve throuh
term. The hCG
oubin time averaes 2.2 ays. In ectopic prenancy, the expecte increase bet
ween consecutive
ays is beow norma. Hyatiform moes are associate with reaty eevate eve
s of hCG. Serum
hCG can take up to 4 weeks to return to nonprenant (<25 mIU/mL) or baseine (<5
mIU/mL) eves
foowin eivery, stibirth, or abortion. 2828_Ch06_327-380 06/08/12 11:23
AM Pae 363 7.
Which of the foowin statements rearin prenancy testin is true? A. Su uni
ts of hum
n
chorionic on
dotropin (hCG), thyroid-stimul
tin hormone (TSH),
nd follicle-st
imul
tin hormone
(FSH)
re very simil
r B. Anti odies

inst the su unit of hCG cross-re
ct with
luteinizin
hormone (LH) C. A f
lse-positive result m
y occur in p
tients with heterophile

nti odies D.
Serum should not e used for pren
ncy tests ec
use proteins interfere Body uids
/Apply
principles of
sic l
or
tory procedures/Pren
ncy test/2 8. SITUATION: A pren

nt fem
le w
s
seen y her physici
n who suspected
mol
r pren
ncy. An hCG test w
s ordered

nd found to e
low. Te s
mple w
s diluted 10-fold
nd the
ss
y w
s repe
ted. Te result w
s fou
nd to e rossly
elev
ted. Wh
t est expl
ins this situ
tion? A. Te wron specimen w
s diluted B.
A pipetin error
w
s m
de in the rst
n
lysis C. Antien excess c
used
f
lsely low result in the
undiluted
s
mple D. An inhi itor of the
ntien
nti ody re
ction w
s present in the s
mple
Body
uids/Apply knowlede to reconize sources of error/hCG/3 9. Most c
ses of Down sy
ndrome
re the
result of: A. Nondisjunction of
n E chromosome (E trisomy) B. Nondisjunction of
chromosome 21 (G
trisomy) C. A 1421 chromosome tr
nsloc
tion D. Deletion of the lon
rm of chromo
some 21 Body
uids/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics/Cytoenetics/1 10.
Which
ss
y
result is often
pproxim
tely 25% elow the expected level in pren
ncies
ssoci

ted with Down

syndrome? A. Serum unconju
ted estriol B. L/S r
tio C. Amniotic uid iliru in D.

Urin
ry
chorionic on
dotropin Body uids/Correl
te l
or
tory d
t
with physioloic
l
processes/Estriol/2 364 Ch
pter 6 | Urin
lysis
nd Body Fluids Answers to Questi
ons 710 7. C The
su unit of hCG is very simil
r to the su unit of TSH
nd FSH
nd identic
l to LH
. Althouh
the su units of hCG
nd LH
re very simil
r,
nti odies c
n e m
de to the su un
it of hCG
th
t do not cross-re
ct with LH or other pituit
ry hormones. Most enzyme immuno

ss
y (EIA)
methods utilize two monoclon
l
nti odies

inst di erent sites of the hCG molecu
le. One

nti ody is speci c for the c
r oxy termin
l end of the ch
in,
nd the other re
ct
s with the
ch
in, resultin in
positive test only when int
ct hCG is present. Bec
use mon
oclon
l

nti odies
re derived from mouse hy ridom
s, r
re f
lse positives m
y occur in
p
tients who h
ve

ntimouse I
nti odies. Althouh the test c
n detect lower levels of hCG, 25 mI
U/mL is the
positive cuto point for pren
ncy. Serum is preferred over urine ec
use serum le
vels
re more
consistently
ove the cuto point th
n r
ndom urine in very e
rly pren
ncy. 8. C
Ass
ys of
int
ct hCG
re dou le
nti ody s
ndwich immuno
ss
ys. One
nti ody re
cts with t
he su unit
nd
the other with the su unit. In
ss
ys where oth
nti odies
re
dded toether,

process
c
lled the hook e ect is known to occur. In extreme
ntien excess, the hCG s
tur
te
s oth

nti odies, preventin s
ndwich form
tion. This results in
f
lsely low me
sure
ment of hCG. 9. B
Down syndrome c
n result from
1421 tr
nsloc
tion or isochromosome form
tion, u
t most c
ses

rise from nondisjunction of chromosome 21 durin meiosis. A qu
d m
rker screen
consistin of
m
tern
l serum AFP, hCG, dimeric inhi in A,
nd unconju
ted estriol is used to
screen for Down
syndrome durin the second trimester. If the test is positive,
mniocentesis is
performed,
nd 21
trisomy is investi
ted y chromosome k
ryotypin or FISH. 10. A Estriol is prod
uced y the
pl
cent

s well
s the fet
l
nd m
tern
l
dren
l l
nds
nd liver. Free estrio
l produced y the
pl
cent
is r
pidly conju
ted y the m
tern
l liver. M
tern
l serum unconju
te
d (free) estriol
is
lmost
ll derived from the fetus
nd is
direct re ection of current fet
l pl

cent
l
function. Serum unconju
ted estriol (uE 3 ) me
sured durin the second trimeste
r is used
lon
with serum AFP, hCG,
nd dimeric inhi in A
s p
rt of the qu
d m
rker screenin
test for Down
syndrome. AFP
nd uE 3
re decre
sed y
pproxim
tely 25%, inhi in A is incre
se
d y
f
ctor of

pproxim
tely 1.8,
nd hCG is incre
sed y
f
ctor of
pproxim
tely 2.5 in Down
syndrome
pren
ncies. When
ll four
ss
ys
re com ined with
djustments for m
tern
l
e
, est
tion
l

e, r
ce, m
tern
l weiht,
nd di
etes, the detection r
te is
pproxim
tely 708

0%
nd the
f
lse-positive r
te 7%. 2828_Ch06_327-380 06/08/12 11:23 AM P
e 364 11. Whic
h of the
followin st
tements
out AFP is correct? A. M
tern
l serum m
y e used to scre
en for open
neur
l tu e defects B. Levels
ove 4 n/mL
re considered positive C. Elev
ted
levels in

mniotic uid
re speci c for spin
i d
D. AFP levels incre
se in pren
ncies
ssoci

ted with
Down syndrome Body uids/Apply principles of speci
l procedures/ Alph
fetoprotein
/2 12.
First-trimester screenin for Down syndrome c
n e performed usin which m
rkers
? A. Alph

fetoprotein
nd unconju
ted estriol B. Free hCG
nd pren
ncy-
ssoci
ted pl
sm

protein A C.
Int
ct hCG
nd dimeric inhi in A D. Dimeric inhi in B
nd fetoprotein Body uids/A
pply
knowlede of speci
l procedures/ Trisomy screenin/1 13. When performin m
rker
screenin tests
for Down syndrome, why
re results expressed in multiples of the medi
n (MoM) r

ther th
n
concentr
tion? A. Concentr
tion is not norm
lly distri uted B. MoM norm
lizes fo
r est
tion
l
e
C. Some tests c
nnot e reported in m
ss units D. Me
n c
nnot e determined
ccu
r
tely for these

n
lytes Body uids/Apply knowlede of speci
l procedures/ Trisomy screenin/1 6.4
| Amniotic,
G
strointestin
l,
nd Semin
l Fluids 365 Answers to Questions 1113 11. A M
tern

l serum AFP
incre
ses ste
dily until 2 months prior to full term
s AFP p
sses from the fet

l urine into the

mniotic uid. Bec
use serum levels
re dependent upon est
tion
l
e, upper refe
rence limits
depend upon l
st menstru
l period d
tin. AFP is me
sured etween 14
nd 18 week
s est
tion,
nd
levels
re reported
s multiples of the medi
n in order to permit interl
or
tor
y comp
rison.
When serum levels
re hih, ultr
sound is used to determine fet
l
e
nd rule o
ut twins.
Incre
sed m
tern
l serum AFP levels (>2.5 MoM) m
y result from m
ny dise
ses in

ddition to open
neur
l tu e defects such
s spin
i d
. These include
nenceph
ly, ventr
l w
ll d
efects,
conenit
l hypothyroidism,
nd Turners syndrome. Decre
sed levels (<0.75 MoM) m
y
e seen in

pproxim
tely 25% of Down syndrome pren
ncies. 12. B M
tern
l serum AFP levels

re too low to
me
sure
ccur
tely durin the first trimester
nd int
ct hCG
nd estriol do not
discrimin
te well
etween 21 trisomy
nd norm
l pren
ncy efore the second trimester. First trime
ster screenin
for Down syndrome (
nd trisomy 18) c
n e performed etween weeks 10
nd 13 usin
 free hCG
(
lmost twofold hiher in Down syndrome)
nd pren
ncy-
ssoci
ted pl
sm
protein
A (PAPP-A) which
h
s
medi
n in Down syndrome less th
n h
lf of th
t seen in norm
l pren
ncy. T
hese two m
rkers
used toether with hih-resolution ultr
sound to determine nuch
l fold thickness
(swellin
t the

se of the neck) h
ve
sensitivity of 85%90%. Nuch
l fold thickness (NT) in Dow

n syndrome

ver
es 1.5 MoM comp
red to 1.0 MoM for norm
l pren
ncy. 13. B Reportin of sc
reenin m
rkers

s multiples of the medi
n h
s two
dv
nt
es. It elimin
tes interl
or
tory v
r
i
tion in
reference r
nes seen when concentr
tion units
re reported. L
or
tories usin
di erent methods
(
nti odies or c
li r
tors) m
y h
ve sini c
ntly di erent m
ss unit results for the
s
me s
mple,
necessit
tin di erent reference r
nes. The reference r
ne in concentr
tion unit
s is
lso
dependent upon the est
tion
l
e
t the time of s
mple collection; however, th
e
ver
e result
for norm
ls is
lw
ys 1.0 MoM, re
rdless of the est
tion
l
e of the cohort.
Use of MoM
o vi
tes the need to report speci c reference r
nes
sed on method or est
tion

l
e
nd m
kes
c
lcul
tion of risk less complic
ted. 2828_Ch06_327-380 06/08/12 11:23 AM P

e 365 14. Which
st
tement re
rdin the fet
l
ronectin test is true? A. A positive test is corre
l
ted with

low pro
ility of delivery within 14 d
ys B. Te test should not e performed e
fore week 24 or

fter the end of week 34 C. Te test is performed on
mniotic uid D. Te test is us
ed to identify

mniotic uid
fter rupture of the fet
l mem r
nes Body uids/Apply principles of sp
eci
l
l
or
tory procedures/Fet
l
ronectins/1 15. Wh
t is the term for sperm when the

nterior
portion of the he
dpiece is sm
ller th
n norm
l? A. Azoospermi
B. Microceph
ly
C. Acrosom
l
de ciency D. Necrozoospermi
Body uids/Apply knowlede of fund
ment
l ioloic
l
ch
r
cteristics/Semin
l uid/1 16. Wh
t is the most common c
use of m
le infertili
ty? A. Mumps B.
Klinefelters syndrome C. V
ricocele D. M
lin
ncy Body uids/Correl
te clinic
l
nd
l
or
tory
d
t
/ Semin
l uid/2 17. Which of the followin v
lues is the lower limit of norm

l for sperm
concentr
tion? A. 15 million per mL B. 40 million per mL C. 60 million per mL D.
100 million per
mL Body uids/Ev
lu
te l
or
tory d
t
to reconize he
lth
nd dise
se st
tes/Semi
n
l uid/2 366
Ch
pter 6 | Urin
lysis
nd Body Fluids Answers to Questions 1417 14. B The fet
l
ronectin test
is used m
inly to rule out the likelihood of preterm delivery in hih-risk pren

ncies or in
women with sins of preterm l
or. Fet
l
ronectin is

sement mem r
ne protein
produced y
the
mnion
nd chorion. It is present in cervic
l secretions in e
rly pren
ncy
ut dis
ppe
rs y

out week 20. When there is in
mm
tion to the mem r
nes precedin delivery, rone
ctin is
rele
sed
nd c
n e found in cervicov
in
l secretions. A positive test (>50 n/
mL) h
s

sensitivity of
out 60% in predictin preterm irth. However,
ne
tive test h

s
92% ne
tive
predictive v
lue for the likelihood of preterm delivery,
nd e ectively rules out
preterm
delivery within the next 2 weeks. Amniotic uid th
t h
s esc
ped from ruptured mem
r
nes is

identi ed y testin
v
in
l sw
for pH. V
in
l uid is norm
lly
cidic, with

pH etween
5.06.0. After rupture of the mem r
nes, the pH of the uid ch
nes to 6.57.5. This c
h
ne c
n
e detected usin Nitr
zine p
per or
sw
cont
inin Nitr
zine yellow. 15. C S
perm
tozo
h
ve

well-de ned he
dpiece consistin of the
crosome
nd nucleus. The
crosome compris
es the
nterior
portion of the he
d,
nd cont
ins nutrients
nd enzymes needed for penetr
tion o
f the ovum. A
thin l
ment, the neckpiece, connects the he
d
nd t
il. The t
il is divided into
the midpiece,
princip
l piece (m
inpiece),
nd endpiece. The midpiece is the thick
nterior en
d of

pproxim
tely 5 containing a 9 + 2 longitudinal arrangement of microtubules (two
central
microtubules surrounded by nine doublets so that a cross section appears like a
pinwheel). This
is called the axoneme and is surrounded by nine radial bers. The longest portion
of the tail
(4045 ) is the principal piece. It is thinner than the midpiece and lacks the oute
r radial
bers. The distal portion, called the endpiece, is approximately 5 . It contains th
e axoneme but
is unsheathed. 16. C Varicocele is the hardening of veins that drain the testes.
This causes
blood from the adrenal vein to ow into the spermatic vein. Adrenal corticosteroid
s retard the
development of spermatozoa. Mumps, Klinefelters syndrome, and malignancy cause te
sticular
failure which accounts for about 10% of infertility cases in men. 17. A The refe
rence range for
spermatozoa is 15150 10 6
/
mL. Concentrations below 15 10
6
/
mL are
considered abnormal. The sperm concentration is multiplied by the semina
l uid volume to
determine the sperm count. The lower limit of normal for the sperm count is 40 1
0 6 per
ejaculate. This often results from obstruction of the ejaculatory duct or testic
ular failure.
2828_Ch06_327-380 06/08/12 11:23 AM Page 366 18. Which morphological abnormal
ity of sperm is
most often associated with varicocele? A. Tapering of the head B. Cytoplasmic dr
oplet below the
neckpiece C. Lengthened neckpiece D. Acrosomal de ciency Body uids/Correlate clinic
al and
laboratory data/ Seminal uid/2 19. Which of the following stains is used to deter
mine sperm
viability? A. Eosin Y B. Hematoxylin C. Papanicolaou D. Methylene blue Body uids/
Apply
principles of special procedures/ Seminal uid/1 20. Which of the following semen
analysis
results is abnormal? A. Volume 1.0 mL B. Liquefaction 40 minutes at room tempera
ture C. pH 7.6 D.
Motility 50% progressive movement Body uids/Evaluate data to recognize abnormal r
esults/Seminal
uid/2 21. Which of the following sample collection and processing conditions will
lead to

inaccurate seminal uid analysis results? A. Sample stored at room temperature for
1 hour before
testing B. Sample collected following coitus C. Sample collected without an anti
coagulant D.
Sample collected without use of a condom Body uids/Apply knowledge to recognize s
ources of
error/Seminal uid/2 6.4 | Amniotic, Gastrointestinal, and Seminal Fluids 367 An
swers to
Questions 1821 18. A Acrosomal de ciency, nuclear abnormalities, and lengthened nec
kpiece are
the most common morphological abnormalities of spermatozoa. Tapering of the head
is a nuclear
abnormality. Sperm morphology should be evaluated by classifying 200 mature sper
m in duplicate by
strict criteria. There are several strict criteria in use. The normal sperm head
is approximately
4.05.0 m in length, 2.53.5 m in width, has a L:W ratio of 1.31.8, and an acrosomal ar
ea of
40%70%. Using strict criteria, there is a high likelihood of infertility when the
number of
normal forms is below 4%. 19. A Eosin Y is excluded by living sperm and is used
to determine the
percentage of living cells. Papanicolaou, Giemsas, and hematoxylin stains are use
d to evaluate
sperm morphology. The viability test should be performed whenever the results of
the motility
test are subnormal. 20. A The normal volume of seminal uid is 1.55.0 mL. A lower v
olume than
1.5 mL causes a low sperm count (sperm/mL volume) and can be caused by absence o
f the seminal
vesicles or prostate, ductal obstruction, or retrograde ejaculation of seminal ui
d into the
urinary bladder. The seminal uid should coagulate within 5 minutes after ejaculat
ion owing to
secretions of the seminal vesicles. Proteases such as PSA hydrolyze semenogelin
and bronectin,
causing liquefaction to occur within 1 hour at room temperature. The seminal uid
pH should be
between 7.2 and 8.0. Motility is evaluated by grading the movement of 2 replicat
es of 200 sperm
in 5 high-power elds. It is normal when 32% show progressive movement or when 40%
show
progressive and nonprogressive movement. 21. B A seminal fluid sample should no
t be collected
following coitus. The patient should abstain from ejaculation for at least 2 day
s but no more
than 7 days prior to submitting the sample. A condom should not be used because
it may contain
spermicides. The sample should be collected at the testing site in a sterile jar
with a wide
opening, and stored at room temperature. The specimen should be analyzed as soon
as possible. The
time between collection and delivery to the lab must be documented. Motility sho
uld be determined
as soon as the fluid has liquefied (maximum storage time is 1 hour). Anticoagula
nts are not used;
if the sample fails to liquefy, it can be treated with chymotrypsin before analy
sis.
2828_Ch06_327-380 06/08/12 11:23 AM Page 367 22. When performing a seminal uid
analysis, what

is the upper limit of normal for WBCs? A. 1 10 6

/
mL
B. 5 10 6
/
mL
C. 10 10 6
/
mL
D. 20 10 6
/
mL
Body uids/Evaluate laboratory data to recognize health and disease states
/Seminal uid/2 23.
Which carbohydrate measurement is clinically useful when performing a seminal uid
analysis? A.
Glucose B. Galactose C. Fructose D. Maltose Body uids/Apply knowledge of special
procedures/
Seminal uid/1 24. Which condition is most often associated with gastric ulcers? A
. Cancer of the
stomach B. H. pylori infection C. ZollingerEllison (ZE) syndrome D. Pernicious ane
mia Body
uids/Gastric/Correlate clinical and laboratory data/2 25. In which condition is t
he highest
level of serum gastrin usually seen? A. Atrophic gastritis B. Pernicious anemia
C. ZE syndrome
D. Cancer of the stomach Body uids/Correlate clinical and laboratory data/ Gastri
c function/2
368 Chapter 6 | Urinalysis and Body Fluids Answers to Questions 2225 22. A When e
valuating sperm
morphology, the number of immature spermatozoa and white blood cells (round cell
s) should also be
determined. The number of each is counted along with 200 mature sperm, then divi
ded by 2 to
determine their percentage. This is multiplied by the sperm concentration to giv
e the absolute
count per mL. An increased number of WBCs is an indicator of infection and is us
ually associated
with prostatitis. Round cells are also estimated by noting their number per high
-power eld. Each
round cell per eld counted with the 40 objective corresponds to one million per mL
. The upper
limit of normal for WBCs is 1 10 6
/
mL,
and for immature sperm 5 10 6
/
mL.
23. C Fructose is the primary nutrient in the seminal uid and is needed f
or motility. It is
supplied by the seminal vesicles, and is low when the vas deferens or seminal ve
sicles are
absent. The lower limit of normal is 150 mg/dL or13 mol per ejaculate. 24. B Pept
ic ulcer
disease may be caused by either gastric or duodenal ulcers, which are associated
with discomfort,
hyperacidity, and bleeding. Hyperacidity is most often caused by H. pylori infec
tion, which can
cause both gastric and duodenal ulcers. In the absence of a positive test for H.
pylori (e.g.,
endoscopic biopsy, breath test, ELISA, PCR) and no history of drug induced ulcer
s,
ZollingerEllison syndrome (gastrinoma) should be suspected, and can usually be id
enti ed by a
plasma gastrin assay. Cancer of the stomach is associated with increased gastric
uid volume but

not hyperacidity. Pernicious anemia is associated with gastric hypoacidity, and

not ulcers. 25. C
Gastrin is produced by specialized epithelium of the stomach and stimulates secr
etion of HCl by
parietal cells. Secretion is controlled by negative feedback causing levels to b
e high in
conditions associated with achlorhydria such as atrophic gastritis. ZollingerElli
son syndrome
results from a gastrin-secreting tumor, gastrinoma, usually originating in the p
ancreas. It is
characterized by very high levels of plasma gastrin and excessive gastric acidit
y. In duodenal
ulcers, increased gastric acidity occurs, but fasting plasma gastrin levels are
normal. However,
postprandial gastrin levels may be elevated in these patients because they do no
t respond to the
negative feedback signal caused by HCl release. In stomach cancer, gastric volum
e is increased
but acidity is not, and plasma gastrin levels are variable. 2828_Ch06_327-380 0
6/08/12 11:23 AM
Page 368 26. In determining free HCl, the gastric uid is titrated to pH ___. A.
6.5 B. 4.5 C.
3.5 D. 2.0 Body uids/Apply principles of special procedures/ Gastric pH/1 27. Whi
ch test can
identify persons with gastrin- secreting tumors who do not demonstrate a de nitive
ly increased
plasma gastrin concentration? A. Secretin stimulation B. Pentagastrin C.
Cholecystokininpancreozymin D. Trypsinogen Body uids/Select tests/Gastrointestinal
function/2
28. Which of the following tests would be normal in pancreatic insu ciency? A. Sec
retin
stimulation B. D-Xylose absorption C. Twenty-four-hour fecal fat D. C
rotene
s
orption Body
uids/Correl
te clinic
l
nd l
or
tory d
t
/ P
ncre
tic function/2 6.4 | Amniotic
,
G
strointestin
l,
nd Semin
l Fluids 369 Answers to Questions 2628 26. C G
stri
c
n
lysis is
performed r
rely ec
use endoscopic procedures usu
lly
re sufficient to di
nos
e hypo-
nd
hyper
cidity st
tes. In difficult c
ses,
n
lysis of 
stric fluid c
n e used t
o m
ke

definitive di
nosis. Free HCl in 
stric residue from
12-hour f
stin s
mple
o t
ined y
n
so
stric suction is me
sured y titr
tin with 0.1 N N
OH to
pH 3.5. Tot
l

cidity is
titr
ted to pH 7.0,
nd includes contri utions of other
cids, includin protein
s
nd s
lts of
chloride. B
s
l
cid output (BAO)
nd pe
k
cid output (PAO)
re determined usin
 timed
collection of 
stric s
mple
liquots efore
nd
fter stimul
tion of HCl rele
s
e y
pent

strin. In
chlorhydri
, the f
stin 
stric pH is often re
ter th
n 6.0,

nd this is
considered di
nostic. The BAO:PAO r
tio is norm
lly less th
n 0.2. P
tients wit
h 
stric ulcers
m
y
lso h
ve
r
tio less th
n 0.2 or etween 0.2
nd 0.4. In duoden
l ulcers,
the r
tio is
usu
lly etween 0.20.6. The r
tio is re
ter th
n 0.6 only in ZollinerEllison syn
drome. 27. A
Pl
sm

strin levels re
ter th
n 1,000 p/mL
re usu
lly di
nostic of Zollin

erEllison
syndrome. Sm
ller elev
tions c
n occur in other types of hyper
cidity, includin

stric ulcers,
in ren
l dise
se,
nd
fter v
otomy. ZollinerEllison syndrome c
n e differenti

ted from the
others y the secretin stimul
tion test. Secretin is
dministered IV,
nd timed
pl
sm
s
mples

re collected
nd me
sured for 
strin. In ZollinerEllison syndrome,
t le
st on
e specimen
should show
n incre
se of 200 p/mL
ove the
seline for 
strin. CCK-PZ is

hormone produced
y the sm
ll intestine th
t stimul
tes HCl production y the stom
ch, p
ncre
tic
rele
se of
ic
r on
te,
nd intestin
l motility. It m
y e me
sured to di
nose intestin
l
m
l
sorption, or
used
lon with tests of other 
stric reul
tory peptides to ev
lu
te dysfuncti
on. Trypsinoen
is
precursor of trypsin
nd is produced y the p
ncre
s. Urin
ry trypsinoen i
s incre
sed in

cute p
ncre
titis, while fec
l trypsin
nd chymotrypsin
re decre
sed in cystic
fi rosis due to
p
ncre
tic duct o struction. 28. B The xylose
sorption test di erenti
tes p
ncre

tic
insu ciency from m
l
sorption syndrome ( oth c
use de cient f
t
sorption). Xylose
is
sor ed
y the sm
ll intestine without the
id of p
ncre
tic enzymes. It is not met
oli
zed
nd is
excreted into urine. Low levels indic
te 
strointestin
l m
l
sorption. 2828_Ch
06_327-380
06/08/12 11:23 AM P
e 369 29. Which of the followin is commonly
ssoci
ted w
ith occult lood?
A. Colon c
ncer B. Atrophic 
stritis C. Pernicious
nemi
D. P
ncre
titis Body u
ids/Correl
te
clinic
l
nd l
or
tory d
t
/ Occult lood/2 30. Which test is most sensitive in
detectin
persons with chronic p
ncre
titis? A. Fec
l trypsin B. Fec
l chymotrypsin C. Fec

l el
stin-1 D.
Pl
sm
lip
se Body uids/Correl
te clinic
l
nd l
or
tory d
t
/ Fec
l enzymes/2 3
70 Ch
pter 6 |
Urin
lysis
nd Body Fluids Answers to Questions 2930 29. A Blood in feces is
ve
ry sensitive
indic
tor of 
strointestin
l leedin,
nd is
n excellent screenin test to de
tect
symptom
tic
ulcers
nd m
lin
ncy of the 
strointestin
l tr
ct. However, the test is nonspe
ci c
nd
cont
min
tion with v
in
l lood is
frequent source of error. 30. C Diestive
enzyme tests
re
used to identify inf
nts
nd children with p
ncre
tic insu ciency
s
consequence
of cystic
rosis,
nd
dults who h
ve chronic p
ncre
titis. Such tests include fec
l trypsi
n
nd
chymotrypsin, serum immunore
ctive trypsin, serum lip
se,
nd fec
l el
st
se-1.
Fec
l
chymotrypsin is somewh
t more sensitive in di
nosin p
ncre
tic insu ciency
nd c
hronic
p
ncre
titis th
n fec
l trypsin or serum immunore
ctive trypsin, ut the most se
nsitive
nd
speci c enzyme test is fec
l el
st
se-1, which is low in
out 90% of CF persons w
ith p
ncre
tic
insu ciency
nd > 75% of
dults with moder
te to severe chronic p
ncre
titis. Lip

se is neither
sensitive nor speci c for chronic p
ncre
titis. 2828_Ch06_327-380 06/08/12 11:23
AM P
e 370
371 6.5 Urin
lysis
nd Body Fluids Pro lem Solvin 1. Given the followin dry re

ent strip
urin
lysis results, select the most
ppropri
te course of
ction: pH = 8.0 Prote
in = 1+ Glucose
= Ne Blood = Ne Ketone = Ne Nitrite = Ne Biliru in = Ne A. Report the resul
ts,
ssumin

ccept
le qu
lity control B. Check pH with
pH meter efore reportin C. Perfo
rm

tur idimetric protein test
nd report inste
d of the dipstick protein D. Request

new specimen
Body uids/Ev
lu
te l
or
tory d
t
to reconize pro lems/Urin
lysis/3 2. Given th
e followin
urin
lysis results, select the most
ppropri
te course of
ction: pH = 8.0 Prote
in = Tr
ce
Glucose = Ne Ketone = Sm
ll Blood = Ne Nitrite = Ne Microscopic ndins: RBCs =
02/HPF WBCs =
2050/HPF B
cteri
= L
re Cryst
ls = Sm
ll, C
CO 3 A. C
ll for
new specimen ec

use urine w
s
cont
min
ted in vitro B. Recheck pH ec
use c
lcium c
r on
te (C
CO 3 ) does not
occur
t

lk
line pH C. No indic
tion of error is present; results indic
te
UTI D. Repo
rt
ll results
except
cteri
ec
use the nitrite test w
s ne
tive Body uids/Ev
lu
te l
or
to
ry d
t
to
reconize inconsistent results/Urin
lysis/3 Answers to Questions 13 1. C Hihly
uffered

lk
line urine m
y c
use
f
lse-positive dry re
ent strip protein test y titr

tin the
cid
uffer on the re
ent p
d. The tur idimetric test with SSA is not su ject to pos
itive
interference y hihly uffered
lk
line urine. 2. C A positive nitrite requires
infection with

nitr
te-reducin or
nism, diet
ry nitr
te,
nd incu
tion of urine in the l
dd
er. The test is
positive in
out 70% of UTI c
ses. Alk
line pH,
cteriuri
,
nd leukocytes poi
nt to UTI. 3. B
This discrep
ncy etween the lood re
ction
nd RBC count resulted from spinnin
less th
n 12 mL
of urine. When volume is elow 12 mL, the s
mple should e diluted with s
line t
o 12 mL efore
concentr
tin. Results
re multiplied y the dilution (12 mL/mL urine) to ive t
he correct r
ne.
3. SITUATION: A 6-mL pedi
tric urine s
mple is processed for routine urin
lysis
in the usu
l
m
nner. Te sediment is prep
red y centrifuin
ll of the urine rem
inin
fter
performin the
iochemic
l tests. Te followin results
re o t
ined: SG = 1.015 Protein = 2+ Bl
ood = L
re RBCs:
510/HPF WBCs: 510/HPF Select the most
ppropri
te course of
ction. A. Report thes
e results;
lood
nd protein correl
te with microscopic results B. Report iochemic
l resul
ts only; request

new s
mple for the microscopic ex
min
tion C. Request
new s
mple
nd report

s qu
ntity not
su cient (QNS) D. Recentrifue the supern
t
nt
nd repe
t the microscopic ex
min
t
ion Body
uids/Apply knowlede to reconize sources of error/Urin
lysis/3 2828_Ch06_327-380

06/08/12
11:23 AM P
e 371 4. Given the followin urin
lysis results, select the most
p
propri
te course
of
ction: pH = 6.5 Protein = Ne Glucose = Ne Ketone = Tr
ce Blood = Ne Bilir
u in = Ne
Microscopic ndins: Mucus = Sm
ll Ammonium ur
te = L
re A. Recheck urine pH B. R
eport these
results,
ssumin
ccept
le qu
lity control C. Repe
t the dry re
ent strip tes
ts to con rm the
ketone result D. Request
new s
mple
nd repe
t the urin
lysis Body uids/Ev
lu
t
e l
or
tory
d
t
to reconize pro lems/Urin
lysis/3 5. Given the followin urin
lysis result
s, select the
most
ppropri
te course of
ction: pH = 6.0 Protein = Ne Glucose = Ne Ketone =
Ne Blood = Ne
Biliru in = Ne Other ndins: Color: Am er Tr
nsp
rency: Microscopic: Cryst
ls C
le
r Biliru in
r
nules = Sm
ll A. Perform
t
let test for iliru in efore reportin B. Requ
est
new s
mple
C. Recheck the pH D. Perform
test for urin
ry uro ilinoen Body uids/Ev
lu
te l

or
tory d
t

to determine possi le inconsistent results/Urin
lysis/3 6. A iochemic
l pro le i
ves the
followin results: Cre
tinine = 1.4 m/dL BUN = 35 m/dL K = 5.5 mmol/L All othe
r results
re
norm
l
nd
ll tests
re in control. Urine from the p
tient h
s
n osmol
lity of
975 mOsm/k.
Select the most
ppropri
te course of
ction. A. Check for hemolysis B. Repe
t t
he BUN
nd report
only if norm
l C. Repe
t the serum cre
tinine
nd report only if elev
ted D. Rep
ort these results
Body uids/Ev
lu
te l
or
tory d
t
to reconize pro lems/Ren
l function/3 372 Ch

pter 6 |
Urin
lysis
nd Body Fluids Answers to Questions 47 4. A Ammonium ur
te cryst
ls o
ccur
t

lk
line pH only. The pH should e checked,
nd if elow 7.0, the cryst
ls shoul
d e reviewed in
order to identify correctly. The tr
ce ketone does not require con rm
tion, provid
ed th
t the
qu
lity control of the re
ent strips is
ccept
le. 5. A Biliru in cryst
ls c
n
not occur in
urine without iliru in. The t
let test is more sensitive th
n the dry re
ent
test
nd will
con rm the presence of iliru in. If ne
tive, the cryst
ls should e reviewed ef
ore reportin.
A norm
l cryst
ls occur only in
cid or neutr
l urine. 6. D P
tients with preren

l f
ilure
usu
lly h
ve
BUN:cre
tinine r
tio re
ter th
n 20:1. Reduced ren
l lood ow c
u
ses incre
sed
ure
re
sorption
nd hih urine osmol
lity. P
tients
re usu
lly hypertensive

nd show uid
retention
nd hyperk
lemi
. 7. A The urine lucose is determined y the lood l
ucose
t the time
the urine is formed. The postpr
ndi
l lucose (2 p.m.) level exceeded the ren
l
threshold,
resultin in tr
ce lycosuri
. Tests for reducin su
rs
re not used to con rm

positive urine
lucose test. 7. A 2 p.m. urin
lysis h
s
tr
ce lucose y the dry re
ent stri
p test. A f
stin
lood lucose dr
wn 8 hours e
rlier is 100 m/dL. No other results
re
norm
l.

Select the most

ppropri
te course of
ction. A. Repe
t the urine lucose
nd report if positive
B. Perform

test for reducin su
rs
nd report the result C. Perform
qu
ntit
tive urine 
lucose; report
s
tr
ce if re
ter th
n 100 m/dL D. Request
new urine specimen Body uids/Ev
lu
t
e l
or
tory
d
t
to determine possi le inconsistent results/Glucose/3 2828_Ch06_327-380 06/
08/12 11:23 AM
P
e 372 6.5 | Urin
lysis
nd Body Fluids Pro lem Solvin
373 Answers to Quest
ions 811 8. C
RBCs usu
lly rem
in int
ct
t
SG of 1.015. The
sence of RBCs, WBCs,
nd c
st
s points to
hemolo inuri
c
used y intr
v
scul
r hemolysis r
ther th
n lomerul
r injury.
A positive
protein re
ction will occur if su cient hemolo in is present. 9. D The pl
sm
fre
e hemolo in
will e incre
sed immedi
tely
fter
hemolytic tr
nsfusion re
ction,
nd the h

ptolo in will e
decre
sed. The hemolo in will e elimin
ted y the kidneys, ut the h
ptolo in
will rem
in low
or undetect
le for 23 d
ys. Norm
l urine uro ilinoen
nd serum unconju
ted il
iru in help in
rulin out extr
v
scul
r hemolysis. Pretr
nsfusion pot
ssium is needed to ev
lu

te the
contri ution of hemolysis to the posttr
nsfusion result. 10. B The com in
tion o
f lucose-
nd
ketone-positive urine points to
p
tient with insulin-dependent di
etes. A f
l
se-positive SSA
test is likely if tol ut
mide (Orin
se) h
s een
dministered. 11. A A nonhemoly
zed tr
ce m
y
h
ve een overlooked
nd the lood test should e repe
ted. A f
lse ne
tive (e.
., me
doses of
vit
min C) r
rely occurs. Ye
st cells often
ccomp
ny pyuri

nd lycosuri

nd

re e
sily
mist
ken for RBCs. 11. Urin
lysis results from
35-ye
r-old wom
n
re: SG = 1.0
15 pH = 7.5
Protein = Tr
ce Glucose = Sm
ll Ketone = Ne Blood = Ne Leukocytes = Moder
te
Microscopic
ndins: RBCs: 510/HPF WBCs: 2550/HPF Select the most
ppropri
te course of
ction.
A. Recheck
the lood re
ction; if ne
tive, look for uddin ye
st B. Repe
t the WBC count
C. Report
ll
results except lood D. Request
list of medic
tions Body uids/Ev
lu
te l
or
to
ry d
t
to
reconize sources of error/Urin
lysis/3 8. Followin
tr
nsfusion re
ction, uri
ne from
p
tient
ives positive tests for lood
nd protein. Te SG is 1.015. No RBCs or WBCs
re
seen in the
microscopic ex
min
tion. Tese results: A. Indic
te ren
l injury induced y tr
ns
fusion re
ction
B. Support the ndin of
n extr
v
scul
r tr
nsfusion re
ction C. Support the ndin
of
n
intr
v
scul
r tr
nsfusion re
ction D. Rule out
tr
nsfusion re
ction c
used y
RBC
incomp
ti ility Body uids/Correl
te clinic
l
nd l
or
tory d
t
/ Urin
lysis/3 9.
A urine s
mple
t
ken
fter
suspected tr
nsfusion re
ction h
s
positive test for lood, ut
int
ct RBCs
re
not seen on microscopic ex
min
tion. Which one test result would rule out
n int

r
v
scul
r
hemolytic tr
nsfusion re
ction? A. Ne
tive urine uro ilinoen B. Serum unconju

ted iliru in
elow 1.0 m/dL C. Serum pot
ssium elow 6.0 mmol/L D. Norm
l pl
sm
h
ptolo in
Body
uids/Select routine l
or
tory procedures to verify test results/Tr
nsfusion re
c
tion/3 10.
Given the followin urin
lysis results, select the most
ppropri
te course of
c
tion: pH = 5.0
Protein = Ne Glucose = 1,000 m/dL Blood = Ne Biliru in = Ne Ketone = Moder
t
e SSA protein =
1+ A. Report the SSA protein result inste
d of the dry re
ent strip result B. C

ll for
list of
medic
tions
dministered to the p
tient C. Perform
qu
ntit
tive urin
ry
l umi
n D. Perform

test for micro
l uminuri
Body uids/Ev
lu
te l
or
tory d
t
to determine possi l
e inconsistent
results/Urin
lysis/3 2828_Ch06_327-380 06/08/12 11:23 AM P
e 373 12. A routi
ne urin
lysis
ives the followin results: pH =6.5 Protein = Ne Blood = Ne Glucose= Tr
ce Ke
tone = Ne
Microscopic ndins: Blood c
sts: Mucus: Cryst
ls: 510/LFP Sm
ll L
re, Amorphous
Tese results

re most likely expl
ined y: A. F
lse-ne
tive lood re
ction B. F
lse-ne
tive
protein re
ction
C. Pseudoc
sts of ur
te mist
ken for true c
sts D. Mucus mist
ken for c
sts Body
uids/Ev
lu
te
l
or
tory d
t
to determine possi le inconsistent results/Urin
lysis/3 13. SITU
ATION: When
ex
minin
urin
ry sediment under 400 m
ni c
tion, the technoloist noted m
ny re
d lood cells
to h
ve cytopl
smic le s
nd
n irreul
r distri ution of the hemolo in. Tis p
henomenon is most
often c
used y: A. Intr
v
scul
r hemolytic
nemi
B. Glomerul
r dise
se C. Hypo
tonic or
lk
line
urine D. Severe dehydr
tion Body uids/Correl
te clinic
l
nd l
or
tory d
t
/ Hem

turi
/2 14.
SITUATION: A urine specimen is d
rk or
ne
nd turns rown
fter stor
e in the
refrier
tor
overniht. Te technoloist requests
new specimen. Te second specimen is riht
or
ne
nd is
tested immedi
tely. Which test result would di er etween the two specimens? A. Ke
tone B.
Leukocyte ester
se C. Uro ilinoen D. Nitrite Body uids/Apply knowlede to recon
ize sources of
error/Uro ilinoen/3 15. A p
tients r
ndom urine consistently cont
ins
tr
ce of
protein ut no
c
sts, cells, or other iochemic
l
norm
lity. Te rst voided mornin s
mple is c
onsistently
ne
tive for protein. Tese ndins c
n e expl
ined y: A. Norm
l diurn
l v
ri
tio
n in protein
loss B. E
rly lomerulonephritis C. Orthost
tic or postur
l
l uminuri
D. Micro

l uminuri
Body
uids/Ev
lu
te l
or
tory d
t
to determine possi le inconsistent results/Urin
lys
is/3 374
Ch
pter 6 | Urin
lysis
nd Body Fluids Answers to Questions 1215 12. C At pH 6.5,

morphous
cryst
ls
re most often ur
te. These form yellow- or reddish- rown refr
ctile de
posits sometimes
resem lin lood or r
nul
r c
sts. The num er of lood c
sts reported could not

h
ve occurred
with ne
tive protein
nd lood tests. 13. B When RBCs p
ss throuh the d
m
ed
endotheli
l w
ll
of the lomerulus, they ecome distorted,
nd such cells
re descri ed
s dysmor
phic in

ppe
r
nce. They
re ch
r
cterized y uneven distri ution of hemolo in, cytopl

smic le s
nd
n

symmetric
l mem r
ne distinct from cren
tion. The cytopl
sm m
y e extruded fro
m the cell
nd
m
y
re
te
t the mem r
ne ivin the cell
w
vy
ppe
r
nce. A predomin
nce
of dysmorphic
RBCs in the microscopic ex
m points to lomerul
r leedin
s opposed to hem
tur
i
from other
c
uses. Intr
v
scul
r hemolytic
nemi
c
uses hemolo inuri
r
ther th
n hem
tur
i
. RBCs lyse in
hypotonic
nd
lk
line urine. Severe dehydr
tion is not
c
use of hem
turi
. 14
. C Urin
ry
uro ilinoen is incre
sed in persons with extr
v
scul
r hemolysis or hep
tocellu
l
r liver
dise
se. A freshly voided specimen is needed to detect uro ilinoen ec
use it i
s r
pidly
photooxidized to uro ilin. This is
ccomp
nied y
color ch
ne from or
ne to
rown. Uro ilin
does not re
ct with 2,4 dimethyl
mino enz
ldehyde or 4-methoxy enzene di
zonium
tetr
uoro or
te,
which
re used to detect uro ilinoen. Consequently, the uro ilinoen test in th
e rst s
mple
will e norm
l, ut will e incre
sed in the second s
mple if tested immedi
tely

fter
collection. The est s
mple for detectin uro ilinoen is
2-hour timed urine s

mple collected
in the mid
fternoon, when uro ilinoen excretion is hihest. Ketones
nd nitrite
s do not
lter
the piment of the urine s
mple. Leukocytes c
use the urine to e tur id ut do
not c
use

norm
l color. These three tests
re st
le for 24 hours when urine is refrier

ted within 30
minutes of collection. 15. C Protein
nd other constituents of urine will often
e hihest in the
rst mornin void. A norm
l rst-voided s
mple m
kes lomerul
r dise
se hihly unlik
ely.
Orthost
tic
l uminuri
is
enin condition sometimes seen in
dolescents who

re t
ll
nd h
ve
ent posture th
t puts
ck pressure on the kidneys. The qu
ntity of
l umin exc
reted into the
urine is sm
ll. Di
nosis is m
de y demonstr
tin
positive test
fter the per
son is erect for
sever
l hours,
nd the
sence of proteinuri
when the person is recum ent. Micr
o
l uminuri
seen
in di
etic persons is usu
lly
ccomp
nied y
positive test for urin
ry lucos
e.
2828_Ch06_327-380 06/08/12 11:23 AM P
e 374 16. A urine s
mple with
pH of
8.0
nd
speci c
r
vity of 1.005 h
d
sm
ll positive lood re
ction, ut is ne
tive for protei
n
nd no RBCs
re
present in the microscopic ex
min
tion of urin
ry sediment. Wh
t est expl
ins t
hese ndins? A.
Hih pH
nd low SG c
used
f
lse-positive lood re
ction B. Te lood re
ction

nd protein
re
ction
re discrep
nt C. Hemolo in is present without int
ct RBCs due to hemo

lysis D. An error
w
s m
de in the microscopic ex
min
tion Body uids/Ev
lu
te l
or
tory d
t
to det
ermine possi le
inconsistent results/Urin
lysis/3 17. A urine s
mple h
s
ne
tive lood re
cti
on
nd 510 cells
per hih-power eld th
t resem le red lood cells. Wh
t is the est course of
cti
on? A. Mix

drop of sediment with 1 drop of WBC countin uid
nd reex
mine B. Report the resu
lts without
further testin C. Repe
t the lood test
nd if ne
tive report the results D. I
f the leukocyte
ester
se test is positive, report the cells
s WBCs Body uids/Apply knowlede to
reconize
sources of error/Microscopic/3 18. A toluidine lue ch
m er count on CSF ives t
he followin
v
lues: 6.5 | Urin
lysis
nd Body Fluids Pro lem Solvin
375 Answers to Questi
ons 1619 16. C
RBCs will lyse in
lk
line or dilute urine,
nd this s
mple displ
ys oth. The
lood test is
sensitive to
s little is 0.015 m/dL hemolo in,
nd the protein test is sini c

ntly less
sensitive. As
result,
tr
ce to sm
ll positive lood
nd ne
tive protein tes
t
re commonly
encountered. 17. A When 510 RBCs/HPFs
re seen, the lood test should show
nonh
emolyzed tr
ce.
Therefore, it is likely th
t the cells
re not RBCs. RBCs
re e
sily confused wi
th non uddin
ye
st
nd m
y
lso e mist
ken for WBCs. RBCs will lyse in dilute
cetic
cid u
t ye
st
nd WBCs
will not. If
ye
st infection is present, then the leukocyte ester
se test will
likely e
positive; therefore, the leukocyte ester
se test c
nnot e used to determine the
identity of the
cells. SternheimerM
l in st
in c
n e used to di erenti
te WBCs from RBCs
nd ye
st
. 18. D A
di erenti
l is performed usin CSF concentr
te on
ll neon
t
l s
mples
nd wheneve
r the WBC count
is
>
5L. A toluidine blue chamber count of PMNs is not
su ciently sensitive to detect neutrophilic pleocytosis. 19. A A traumatic
tap makes
classi cation of uids di cult on the basis of cell counts and protein. The values rep
orted for
protein, RBCs, and WBCs can occur in either an exudate or bloody transudate, but
the LD ratio is
signi cant. CSF Counts Peripheral Blood Counts WBCs 10 10 6
/
L WBCs 5 10
9
/L
RBCs 1,000 10 6
/
L RBCs 5 10
12
/L
After correcting the WBC count in CSF, the technologist should next: A.
Report the WBC count
as 9 10 6
/
L without
additional testing B. Report the WBC count and number of PMNs identi ed by
the chamber count
C. Perform a di erential on a direct smear of the CSF D. Concentrate CSF using a c

ytocentrifuge
and perform a di erential Body uids/Apply knowledge of standard operating
procedures/Cerebrospinal uid/3 19. A blood-tainted pleural uid is submitted for cu
lture. Which
test result would be most conclusive in classifying the uid as an exudate? A. B.
C. D. Body
uids/Correlate clinical and laboratory data/Pleural uid/3 Test Result LD uid/seru
m 0.65
Total protein 3.2 g/dL RBC count 10,000/L WBC count 1500/L 2828_Ch06_327-380 06/0
8/12 11:23
AM Page 375 20. A pleural uid submitted to the laboratory is milky in appearance
. Which test
would be most useful in di erentiating between a chylous and pseudochylous e usion?
A. Fluid to
serum triglyceride ratio B. Fluid WBC count C. Fluid total protein D. Fluid to s
erum LD ratio
Body uids/Select test/Pleural uid/2 21. A cerebrospinal fluid sample from an 8-yea
r-old child
with a fever of unknown origin was tested for glucose, total protein, lactate, a
nd IgG index. The
glucose was 180 mg/dL but all other results were within the reference range. The
CSF WBC count
was 9 10 6
/
L and the RBC
count was 10 10 6
/
L. The differential
showed 50% lymphocytes, 35% monocytes, 10% macrophages, 3% neutrophils,
and 2%
neuroectodermal cells. What is the most likely cause of these results? A. Asepti
c meningitis B.
Traumatic tap C. Subarachnoid hemorrhage D. Hyperglycemia Body uids/Apply knowled
ge to recognize
inconsistent results/CSF/2 22. A WBC count and di erential performed on ascites uid
gave a WBC
count of 20,000L with 90% macrophages. Te gross appearance of the uid was describe
d by the
technologist as thick and bloody. It was noted on the report that several clusters
of these
cells were observed and that the majority of the cells contained many vacuoles r
esembling
paper-punch holes. What do the observations above suggest? A. Malignant mesothel
ial cells were
counted as macrophages B. Adenocarcinoma from a metastatic site C. Lymphoma in ltr
ating the
peritoneal cavity D. Nodular sclerosing type Hodgkins disease Body uids/Apply know
ledge to
recognize inconsistent results/Serous uids/3 23. Given the following data for cre
atinine
clearance, select the most appropriate course of action. Volume = 2.8 L/day; sur
face area = 1.73
m 2 ; urine creatinine = 100 mg/dL; serum creatinine = 1.2 mg/dL A. Report a cre
atinine clearance
of 162 mL/min B. Repeat the urine creatinine; results point to a dilution error
C. Request a new
24-hour urine sample D. Request the patients age and sex Body uids/Evaluate labora
tory data to
recognize problems/Creatinine clearance/3 376 Chapter 6 | Urinalysis and Body Fl
uids Answers to
Questions 2023 20. A Chylous e usions are caused by extravasation of lymphatic uid i
nto the

pleural cavity. Pseudochylous e usions are caused by necrosis. Both uids often appe
ar white and
opalescent but both e usions can also be bloody, green, or yellow in addition to b
eing turbid.
However, chylous e usions are odorless and have a twofold higher triglyceride than
the plasma.
They also usually show a lymphocytosis. Pseudochylous e usions are foul smelling,
usually have a
mixed cellularity, and an elevated cholesterol. They may have an increased trigl
yceride but it is
usually below 50 mg/dL. Chylous e usions are most often caused by lymphoma or othe
r malignancy or
trauma, and like pseudochylous e usions may have an increased LD uid:serum ratio, t
otal protein,
and WBC count. 21. D CSF glucose is approximately 60% of the plasma glucose, but
may be somewhat
lower in a diabetic person. The reference range is approximately 4070 mg/dL. A CS
F glucose level
above 70 mg/dL is caused by a high plasma glucose that equilibrated with the CSF
. Therefore,
hyperglycorrhachia is caused by hyperglycemia. The WBC count in a child between
512 years is
010 10 6
/
L (010/L). The normal RBC count and
protein rule out subarachnoid hemorrhage and traumatic tap. Although ase
ptic meningitis
cannot be ruled out conclusively, it is unlikely given a normal WBC count and Ig
G index. 22. A
Bloody, exudative uids with a preponderance of a singular cell type are suggestiv
e of
malignancy. The cellularity in malignancy is variable but lymphocytosis occurs i
n about half of
cases. Mesothelial cells normally comprise less than 10% of the cells in serous u
id. They may be
resting cells, reactive, degenerated, or phagocytic in nonmalignant conditions.
In in ammatory
conditions, they are often increased and resemble macrophages. However, clusters
or balls of such
cells and paper-punch vacuoles throughout the cytoplasm and over the nucleus are
characteristics
of malignant mesothelial cells. Such cells secrete hyaluronic acid, making the ui
d highly
viscous. The gross appearance of this uid suggests malignancy. The description of
these cells
points to mesothelioma, and this specimen should be referred for cytological exa
mination in order
to con rm the diagnosis. 23. C A calculated clearance in excess of 140 mL/min is g
reater than the
upper physiological limit. The high volume per day suggests addition of H 2 O to
the sample. The
result should be considered invalid. 2828_Ch06_327-380 06/08/12 11:23 AM Page
376 24. An
elevated amylase is obtained on a stat serum collected at 8 p.m. An amylase perf
ormed at 8 a.m.
that morning was within normal limits. Te technologist also noted that a urine a
mylase was
measured at 6 p.m. Select the most appropriate course of action. A. Repeat the s
tat amylase;
report only if within normal limits B. Repeat both the a.m. and p.m. serum amyla
se and report

only if they agree C. Request a new specimen; do not report results of the stat
sample D. Review
the amylase result on the 6 p.m. urine sample; if elevated, report the stat amyl
ase Body
uids/Apply knowledge to recognize inconsistent results/Amylase/3 25. Results of a
fetal lung
maturity (FLM) study from a patient with diabetes mellitus are as follows: L/S r
atio = 2.0;
Phosphatidyl glycerol = Pos; Creatinine = 2.5 mg/dL Given these results, the tec
hnologist should:
A. Report the result and recommend repeating the L/S ratio in 24 hours B. Perfor
m scanning
spectrophotometry on the uid to determine if blood is present C. Repeat the L/S r
atio after 4
hours and report those results D. Report results as invalid Body uids/Correlate l
aboratory data
to verify test results/L/S ratio/3 26. A 24-hour urine sample from an adult subm
itted for
catecholamines gives a result of 140 g/day (upper reference limit 150 g/day). Te 2
4-hour urine
creatinine level is 0.6 g/day. Select the best course of action. A. Check the ur
ine pH to verify
that it is less than 2.0 B. Report the result in g catecholamines per mg creatini
ne C. Request a
new 24-hour urine sample D. Measure the VMA and report the catecholamine result
only if elevated
Body uids/Evaluate laboratory data to recognize problems/Catecholamines/3 6.5 | U
rinalysis and
Body Fluids Problem Solving 377 Answers to Questions 2427 24. D Serum amylase p
eaks 210 hours
after an episode of acute pancreatitis and this may have caused the elevated ser
um amylase at 8
p.m. Urinary amylase parallels serum amylase; therefore, a positive urine test a
t 6 p.m. makes
sample collection error unlikely. 25. A In patients with diabetes, lung maturity
may be delayed
and an L/S ratio of 2:1 may be associated with respiratory distress syndrome. A
positive PG spot
correlates with an L/S ratio of 2:1 or higher and rules out a falsely increased
result caused by
blood contamination. The best course of action is to wait an additional 24 hours
and perform
another L/S ratio on a fresh sample of amniotic uid because an L/S ratio of 3:1 w
ould indicate a
high probability of fetal lung maturity. 26. C Urine creatinine of less than 0.8
g/day indicates
incomplete sample collection. The patients daily catecholamine excretion would be
misinterpreted
from this result. 27. D Urinary xylose excretion is less reliable in children un
der the age of
10, and peak blood levels occur sooner than in adults. A 60-minute blood sample
should have been
used. A serum D-xylose level greater than 30 mg/dL at 1 hour is considered norma
l. Tests for
anti-tissue transglutaminase and other antibodies produced in celiac disease hav
e resulted in
diminished use of the D-xylose absorption test. 27. A 5-hour urinary D-xylose te
st on a
7-year-old boy who was given 0.5 g of D-xylose per pound is 15%. Te 2-hour timed
blood D-xylose

is 15 mg/dL (lower reference limit 30 mg/dL). Select the most appropriate action
. A. Request that
a c
rotene
sorption test e performed B. Repe
t the urin
ry result ec
use it
is orderline
C. Request
retest usin
25- dose of D-xylose D. Request
retest usin only

1-hour timed
lood s
mple Body uids/Apply principles of speci
l procedures/ D-Xylose
sorptio
n/3
2828_Ch06_327-380 06/08/12 11:23 AM P
e 377 28. A qu
ntit
tive serum hCG is
ordered on
m
le
p
tient. Te technoloist should: A. Perform the test
nd report the result B. Re
quest th
t the
order e c
ncelled C. Perform the test
nd report the result if ne
tive D. Perf
orm the test
nd
report the result only if re
ter th
n 25 IU/L Body uids/Apply knowlede of st
nd

rd oper
tin
procedures/Hum
n chorionic on
dotropin/3 29. SITUATION: A l
mell
r ody count (
LBC) w
s
performed on
n
mniotic uid s
mple th
t w
s slihtly pink in color within 1 hour
of specimen
collection. Te s
mple w
s stored
t 4C prior to
n
lysis. Te result w
s 25,000/L,
cl
ssi ed
s
intermedi
te risk of respir
tory distress syndrome. Te physici
n w
ited 24 hours

nd collected

new s
mple th
t w
s counted within 2 hours of collection on the s
me instrument.
Te LCB count of
the new s
mple w
s 14,000/ L
nd the p
tient w
s recl
ssi ed
s hih risk. Which st

tement est
expl
ins these results? A. Loss of l
mell
r odies occurred in the second s
mple
ec
use of
stor
e B. Blood c
used
f
lsely elev
ted result for the rst s
mple C. Te fet
l
st
tus ch
ned
in 24 hours owin to respir
tory illness D. Te di erence in counts is the result o
f d
y-to-d
y
physioloic
l
nd instrument v
ri
nce Body uids/Apply knowlede to identify sourc
es of
error/Specimen collectin
nd h
ndlin/3 30. When testin for drus of
use in
urine, which of
the followin test results indic
te dilution
nd would e c
use for rejectin th
e s
mple? A.
Temper
ture upon s
mple su mission 92F B. Speci c r
vity 1.002; Cre
tinine 15 m/d
L, C. pH 5.8;
temper
ture 94C D. Speci c r
vity 1.012, cre
tinine 25 m/dL Body uids/Apply knowle
de to
identify sources of error/Specimen collectin
nd h
ndlin/3 378 Ch
pter 6 | Uri
n
lysis
nd Body
Fluids Answers to Questions 2830 28. A hCG m
y e produced in men y tumors of tr
opho l
stic
oriin, such
s ter
tom

nd seminom
,
nd is
n import
nt m
rker for nontropho
l
stic tumors,
s
well. 29. B L
mell
r odies
re sm
ll p
rticles cont
inin pulmon
ry surf
ct
nts
th
t
re m
de y
Type II pneumocytes,
nd their num er in
mniotic fluid incre
ses
s the concent
r
tion of
phospholipids incre
ses. They
re
out the s
me size
s pl
telets
nd
re count
ed in the
pl
telet ch
nnel of cell counters. If the
mniotic fluid s
mple is cont
min
ted
with lood,
pl
telets will f
lsely r
ise the l
mell
r ody count. Amniotic fluid s
mples for
LBC
re st
le

for sever
l d
ys when stored
t 4C. However, cutoffs for fet
l lun m
turity need
to e
est
lished y e
ch l
or
tory since there
re sinific
nt differences in LBCs
etween different
counters. 30. B T
mperin with
s
mple su mitted for
use su st
nce testin c

n e either y
dilution or su stitution. Su st
nce A use
nd Ment
l He
lth Services Administr
t
ion (SAMHSA)
certified workpl
ce dru testin l
s
re required to test for oth,
nd reject
s
mples
sed on
SAMHSA cutoffs. A specimen is too dilute for testin if the cre
tinine is elow
20 m/dL
nd
specific r
vity elow 1.003. A s
mple is considered su stituted if the cre
tini
ne is elow 5.0
m/dL
nd the specific r
vity less th
n 1.002. V
lues
ove for pH
nd temper
t
ure
re within

ccept
le limits. 2828_Ch06_327-380 06/08/12 11:23 AM P
e 378 31. SITUATION
: A urine
specimen h
s
speci c r
vity of 1.025
nd is stronly positive for nitrite. All
other dry
re
ent strip test results
re norm
l,
nd the microscopic ex
m w
s unrem
rk
le
, showin no WBCs
or
cteri
. Te urine s
mple w
s su mitted
s p
rt of
preemployment physic
l e
x
m th
t
lso
includes dru testin. Which most likely c
used these results? A. A vir
l infect
ion of the kidney
B. A urin
ry tr
ct infection in
n immunosuppressed person C. An
dulter
ted uri
ne specimen D.
Error in re
din the nitrite p
d c
used y poor re ectometer c
li r
tion Body uids/
Apply
knowlede to identify sources of error/Dru testin/3 32. A CSF s
mple su mitted
for cell counts
h
s
visi le clot. Wh
t is the est course of
ction? A. Count RBCs
nd WBCs m

nu
lly
fter
dilutin the uid with norm
l s
line B. Te
se the cells out of the clot efore cou
ntin, then
dilute with WBC countin uid C. Request
new s
mple D. Perform
WBC count witho
ut correction
Body uids/Apply knowlede to identify the est course of
ction/CSF/3 33. Tot
l h
emolytic
complement
nd lucose
re ordered on
synovi
l uid s
mple th
t is too viscous t
o pipet. Wh
t
is the est course of
ction? A. Dilute the s
mple in s
line B. Add 1 m/mL hy
l
uronid
se to the
s
mple
nd incu
te
t room temper
ture for 30 minutes C. W
rm the s
mple to 65C
for 10 minutes
D. Request
new specimen Body uids/Apply knowlede to identify the est course o
f

ction/Synovi
l uid/3 34. A CSF CytoPrep sme
r shows m
ny smude cells
nd m
crop
h
es with torn
cell mem r
nes. Wh
t most likely c
used this pro lem? A. F
ilure to
dd
l umin
to the cytospin
cup B. F
ilure to collect the CSF in EDTA C. Centrifue speed too low D. Imprope
r
linment Body
uids/Apply knowlede to identify sources of error/Fluid cell counts/3 6.5 | Urin

lysis
nd Body
Fluids Pro lem Solvin
379 Answers to Questions 3134 31. C Urine v
lidity testi
n for drus of

use includes tests for nitrite, lut
thione, pyridinium dichrom
te,
nd peroxi
de in
ddition to

pH, speci c r
vity,
nd cre
tinine. These su st
nces
re known to c
use ne
tive
interference in
the EMIT immuno
ss
y. A vir
l infection of the kidney would e
ssoci
ted with h
ih num ers of
ren
l tu ul
r epitheli
l cells
nd leukocytes. An infection in
n immunosuppress
ed person would
still produce urin
ry WBCs. While l
or
tory error is possi le,
f
lse positive
c
used y
re ectometer error would e suspected if the test p
d were ne
tive when re
din i
t m
nu
lly. 32.
C CSF s
mples will not clot
s
result of
su
r
chnoid hemorrh
e. While the
s
mple is still
suit
le for micro ioloic
l
n
lysis, it will not ive reli
le cell counts or
iochemistry
results owin to extensive cont
min
tion with peripher
l lood. 33. B Joint uid t
oo viscous to
pipet
ccur
tely c
nnot e diluted
ccur
tely. Complement is he
t l
ile
nd tot

l hemolytic
complement is destroyed when the s
mple is he
ted to 56C for 5 minutes. Joint uid
is di cult to
collect
nd
new s
mple is likely to h
ve the s
me pro lem. 34. A Cellul
r dist
ortion c
used y
centrifu
tion is
common pro lem,
nd c
n e reduced y
ddin 22% ovine
l u
min or 10%
dextr
n to the cytospin cup
lon with the s
mple. CSF does not clot ec
use it
cont
ins no
rinoen,
nd the s
mple c
n e collected
nd counted without
ntico
ul
nt. 2828
_Ch06_327-380
06/08/12 11:23 AM P
e 379 35. An
utom
ted electronic lood cell counter w
s
used to count
RBCs
nd WBCs in
tur id pleur
l uid s
mple. Te WBC count w
s 5 10 10
/L
(50,000/L)
nd the RBC count w
s 5.5 10 10
/L
(55,000/ L). Wh
t is the sini c
nce of the RBC count? A. Te RBC count is n
ot sini c
nt
nd
should e reported
s 5,000/L B. Te RBC count should e reported
s determined y
the
n
lyzer
C. A m
nu
l RBC count should e performed D. A m
nu
l RBC
nd WBC count should
e performed
nd
reported inste
d Body uids/Apply knowlede to identify sources of error/Fluid cel
l counts/3 BI
BL I OGRAPHY 1. Brunzel NA. Fund
ment
ls of Urine
nd Body Fluid An
lysis. 2nd e
dition, 2004.
W.B. S
unders, Phil
delphi
. 2. Burtis CA, Ashwood ER,
nd Burns DE. Tietz Fund

ment
ls of
Clinic
l Chemistry. 6th edition, 2008. W.B. S
unders, Phil
delphi
. 3. K
pl
n LA

nd Pesce AJ.
Clinic
l Chemistry Teory An
lysis, Correl
tion. 5th edition, 2009. Mos y, St. Lo
uis. 4.
Kjelds er CR
nd Kniht JA. Body Fluids. 3rd edition, 1993. ASCP Press, Chic
o
. 380 Ch
pter 6 |
Urin
lysis
nd Body Fluids Answer to Question 35 35. A Electronic cell counters

re v
lid
ted for
ody fluid cell counts with specific minimum detection limits. For most counters
, this is 50200
WBC/L and 10,000 RBC/L. Since the RBCs are lysed in the WBC bath, the WBC count re
presents the
number of nucleated cells present. However, WBCs are not lysed in the RBC bath a
nd would be

counted as RBCs. In this case, the empyemic fluid would cause the RBCs count to
be erroneously
elevated, and this should be corrected before reporting by subtracting the WBC c
ount from the RBC
count. 5. McPherson RA and Pinccus MR. Henrys Clinical Diagnosis and Management b
y Laboratory
Methods. 22nd edition, 2011. W.B. Saunders, Philadelphia. 6. Mundt LA and Shanah
an K. Textbook of
Urinalysis and Body Flu- ids. 2nd edition, 2010. Lippincott Williams & Wilkins,
Philadel- phia.
7. Strasinger SK and DiLorenzo MS. Urinalysis and Body Fluids. 5th edition, 2008
. F.A. Davis,
Philadelphia. 2828_Ch06_327-380 06/08/12 11:23 AM Page 380 CHAPTER 7 7.1 Sp
ecimen
Collection, Media, and Methods 7.2 Enterobacteriaceae 7.3 Nonfermentative Ba
cilli 7.4
Miscellaneous and Fastidious Gram-Negative Rods 7.5 Gram-Positive and Gram-Neg
ative Cocci 7.6
Aerobic Gram-Positive Rods, Spirochetes, Mycoplasmas and Ureaplasmas, and Chlamy
dia 7.7
Anaerobic Bacteria 7.8 Mycobacteria 7.9 Mycology 7.10 Virology 7.11 Para
sitology 7.12
Microbiology and Parasitology Problem Solving 381 Microbiology 2828_Ch07_381-494
06/08/12 11:24
AM Page 381 2828_Ch07_381-494 06/08/12 11:24 AM Page 382 Answers to Question
s 15 1. B In
order to attain asepsis of the skin, 70% alcohol followed by 2% iodine is used f
or obtaining
blood cultures. 2. C The iodine should remain on the skin for 1 min because inst
ant antisepsis
does not occur when cleansing the skin for a blood culture. 3. A SPS is used in
most commercial
blood culture products because it functions as an anticoagulant and prevents pha
gocytosis and
complement activation. In addition, SPS neutralizes aminoglycoside antibiotics.
Addition of SPS
may inhibit some Neisseria and Peptostreptococcus, but this can be reversed with
1.2% gelatin. 4.
C C. diphtheriae must be recovered from the deep layers of the pseudomembrane
that forms in the
nasopharyngeal area. A exible calcium alginate nasopharyngeal swab is the best ch
oice for
collecting a specimen from the posterior nares and pharynx. 5. A Specimens for c
ulture of N.
gonorrhoeae are best if plated immediately or transported in a medium containing
activated
charcoal to absorb inhibitory substances that hinder their recovery. 1. Te asept
ic collection of
blood cultures requires that the skin be cleansed with: A. 2% iodine and then 70
% alcohol
solution B. 70% alcohol and then 2% iodine or an iodophor C. 70% alcohol and the
n 95% alcohol D.
95% alcohol only Microbiology/Apply knowledge of standard operating procedures/S
pecimen
collection/1 2. When cleansing the skin with alcohol and then iodine for the col
lection of a
blood culture, the iodine (or iodophor) should remain intact on the skin for at
least: A. 10 sec
B. 30 sec C. 60 sec D. 5 min Microbiology/Apply knowledge of standard operating
procedures/Specimen collection and handling/1 3. What is the purpose of adding 0

.025%0.050%
sodium polyanetholsulfonate (SPS) to nutrient broth media for the collection of
blood cultures?
A. It inhibits phagocytosis and complement B. It promotes formation of a blood c
lot C. It
enhances growth of anaerobes D. It functions as a preservative Microbiology/Appl
y knowledge of
standard operating procedures/Media/1 4. A exible calcium alginate nasopharyngeal
swab is the
collection device of choice for recovery of which organism from the nasopharynx?
A.
Staphylococcus aureus B. Streptococcus pneumoniae C. Corynebacterium diphtheriae
D. Bacteroides
fragilis Microbiology/Apply knowledge of standard operating procedure/Specimen c
ollection and
handling/1 7.1 Specimen Collection, Media, and Methods 383 5. Semisolid transpor
t media such as
Amies, Stuart, or CaryBlair are suitable for the transport of swabs for culture o
f most
pathogens except: A. Neisseria gonorrhoeae B. Enterobacteriaceae C. Campylobacte
r fetus D.
Streptococcus pneumoniae Microbiology/Select methods/Reagents/Media/Specimen col
lection and
handling/2 2828_Ch07_381-494 06/08/12 11:24 AM Page 383 6. Select the method
of choice for
recovery of anaerobic bacteria from a deep abscess. A. Cotton ber swab of the abs
cess area B.
Skin snip of the surface tissue C. Needle aspirate after surface decontamination
D. Swab of the
scalpel used for dbridement Microbiology/Apply knowledge of standard operating
procedures/Specimen collection and handling/2 7. Select the primary and di erentia
l media of
choice for recovery of most fecal pathogens. A. MacConkey, blood, birdseed, and
Campylobacter
(Campy) agars B. Hektoen, MacConkey, Campy, colistinnalidixic acid (CNA) agars C.
CNA and
Christensen urea agars and thioglycollate media D. Blood, Campy, MuellerHinton ag
ars, and
thioglycollate media Microbiology/Select methods/Reagents/Media/Stool culture/2
8. Select the
media of choice for recovery of Vibrio cholerae from a stool specimen. A. MacCon
key agar and
thioglycollate media B. Tiosulfatecitratebilesucrose (TCBS) agar and alkaline pepto
ne water
(APW) broth C. Blood agar and selenite-F (SEL) broth D. CNA agar Microbiology/Se
lect
methods/Reagents/Media/Stool culture/2 9. Colistinnalidixic acid agar (CNA) is us
ed primarily
for the recovery of: A. Neisseria species B. Enterobacteriaceae C. Pseudomonas a
eruginosa D.
Staphylococcus aureus Microbiology/Select methods/Reagents/Media/ Gram-positive
cocci/2 10. In
the United States, most blood agar plates are prepared with 5% or 10% red blood
cells (RBCs)
obtained from: A. Sheep B. Horses C. Humans D. Dogs Microbiology/Select methods/
Reagents/Media/
Culture/1 384 Chapter 7 | Microbiology Answers to Questions 610 6. C Anaerobic
specimens are
easily contaminated with organisms present on the skin or mucosal surfaces when
a swab is used.

Needle aspiration of an abscess following surface decontamination provides the l

east exposure to
ambient oxygen. 7. B Hektoen agar selectively isolates pathogenic coliforms, esp
ecially
Salmonella and Shigella. MacConkey agar di erentiates lactose fermenters from nonf
ermenters. CNA
agar contains antibiotics that prohibit growth of gram-negative coliforms but no
t gram-positive
cocci. Campy agar contains the antibiotics cephalothin, trimethoprim, vancomycin
, polymyxin B,
and amphotericin B to prevent growth of Enterobacteriaceae, Pseudomonas spp., an
d fungi. 8. B
TCBS agar is used to grow Vibrio cholerae, which appear as yellow colonies as a
result of the use
of both citrate and sucrose. APW is used as an enrichment broth and should be su
bcultured to TCBS
agar for further evaluation of Vibrio colonies. 9. D CNA agar inhibits the growt
h of
gram-negative bacteria and is used to isolate gram-positive cocci from specimens
. This medium is
especially useful for stool and wound cultures because these may contain large n
umbers of
gram-negative rods. 10. A Sheep RBCs are used in blood agar plates because they
are readily
available and less inhibitory than cells of other species. The type of hemolysis
is determined by
the source of RBCs. Sheep RBCs are chosen because of the characteristically clea
r hemolysis
produced by -hemolytic streptococci, St
phylococcus,
nd other p
thoens producin
 -hemolysins.
Sheep lood does not support the rowth of H
emophilus h
emolyticus, elimin
tin
the possi ility
of confusin it with -hemolytic streptococci in thro
t cultures. 2828_Ch07_381-49
4 06/08/12
11:24 AM P
e 384 11. All of the followin
re
ppropri
te when
ttemptin to i
sol
te N.
onorrhoe
e from
enit
l specimen except: A. Tr
nsport the enit
l sw
in ch

rco
l tr
nsport
medium B. Pl
te the specimen on modi ed T
yerM
rtin (MTM) medium C. Pl
te the speci
men on New
York City or M
rtinLewis

r D. Culture specimens in
m ient oxyen
t 37C Micro
ioloy/Select
methods/Re
ents/Medi
/ Culture/1 12. Chocol
te

r
nd modi ed T
yerM
rtin

r

re used for
the recovery of: A. H
emophilus spp.
nd Neisseri
spp., respectively B. H
emoph
ilus spp.
nd N.
onorrhoe
e, respectively C. Neisseri
spp.
nd Streptococcus spp., respectively
D. Streptococcus
spp.
nd St
phylococcus spp., respectively Micro ioloy/Select methods/Re
ents/
Medi
/Stool
culture/2 13. Cycloserinecefoxitin-fructose

r (CCFA) is used for the recovery
of: A. Yersini

enterocolitic
B. Yersini
intermedi
C. Clostridium perfrinens D. Clostridium
di cile
Micro ioloy/Select methods/Re
ents/Medi
/Stool culture/1 14. Deoxychol
te

r
(DCA) is useful
for the isol
tion of: A. Entero
cteri
ce
e B. Enterococcus spp. C. St
phylococc
us spp. D.
Neisseri
spp. Micro ioloy/Select methods/Re
ents/Medi
/Stool culture/1 15. Xy
lose lysine

deoxychol
te (XLD)

r is
hihly selective medium used for the recovery of wh
ich
cteri
? A.
St
phylococcus spp. from norm
l or
B. Yersini
spp. th
t do not row on Hektoen


r C.
Entero
cteri
ce
e from 
strointestin
l specimens D. Streptococcus spp. from st
ool cultures
Micro ioloy/Select methods/Re
ents/Medi
/Stool culture/1 7.1 | Specimen Collec
tion, Medi
,
nd
Methods 385 Answers to Questions 1115 11. D MTM, New York City,
nd M
rtinLewis


rs cont
in
lood f
ctors needed to support the rowth of N. onorrhoe
e
s well
s
nti iot
ics th
t prevent
rowth of norm
l enit
l flor
. Cultures must e incu
ted in 3%7% CO 2
t 35C. Cu
ltures should
e held
minimum of 48 hours efore ein considered ne
tive. 12. B Chocol
te


r provides X
f
ctor (hemin)
nd V f
ctor (NAD) required for the rowth of H
emophilus spp. Th

yerM
rtin
medium is
chocol
te

r cont
inin the
nti iotics th
t permit isol
tion of N
. onorrhoe
e in
specimens cont
inin l
re num ers of r
m-ne
tive
cteri
, includin commens

l Neisseri
spp.
13. D CCFA is used for recovery of C. di cile from stool cultures. Cycloserine
nd
cefoxitin
inhi it rowth of r
m-ne
tive coliforms in the stool specimen. C. di cile fermen
ts fructose,
formin
cid th
t, in the presence of neutr
l red, c
uses the colonies to ecome
yellow. 14. A
DCA inhi its r
m-positive or
nisms. N. onorrhoe
e
nd Neisseri
meninitidis

re too
f
stidious to row on DCA. Citr
te
nd deoxychol
te s
lts inhi it rowth of r
m
-positive

cteri
. The medi
cont
in l
ctose
nd neutr
l red,
llowin di erenti
tion of l

ctose
fermenters (pink colonies) from nonfermenters (colorless). 15. C XLD

r is sel
ective for
r
m-ne
tive coliforms ec
use of
hih concentr
tion (0.25%) of deoxychol
te,
which inhi its
r
m-positive
cteri
. In
ddition, XLD is di erenti
l for Shiell

nd S
lmonell

spp. The
medium cont
ins xylose, l
ctose,
nd sucrose, which
re fermented y most norm
l
intestin
l
coliforms producin yellow colonies. Shiell
does not ferment the su
rs
nd pr
oduces red (or
cle
r) colonies. S
lmonell
spp. ferment xylose; however, they
lso dec
r oxyl
t
e lysine in the
medium, c
usin production of
mmoni
. Therefore, S
lmonell
rst
ppe
r yellow u
t ecome red.
Some S
lmonell
produce hydroen sul de (H 2 S) from sodium thiosulf
te
nd theref
ore
ppe
r
s
red colonies with l
ck centers. 2828_Ch07_381-494 06/08/12 11:24 AM P
e 385
16. A sheep
lood

r pl
te is used
s
prim
ry isol
tion medium when
ll of the followin
or
nisms
re to
e recovered from
wound specimen except: A. -Hemolytic streptococci
nd co
ul

se-positive
st
phylococci B. H
emophilus in uenz
e
nd H
emophilus p
r
in uenz
e C. Proteus spp.

nd
Escherichi
coli D. Pseudomon
s spp.
nd Acineto
cter spp. Micro ioloy/Select
methods/Re
ents/Medi
/Wound culture/2 17. Prereduced
nd vit
min K 1 -supplemen

ted lood

r

pl
tes
re recommended isol
tion medi
for: A. Myco
cterium m
rinum
nd Myco
c
terium
vium
intr
cellul
re B. B
cteroides, Peptostreptococcus,
nd Clostridium spp. C. Prote
us spp. D.
Enterococcus spp. Micro ioloy/Select methods/Re
ents/Medi
/ An
ero es/2 18. Wh
ich procedure is

ppropri
te for culture of enit
l specimens in order to recover Chl
mydi
spp.?
A. Inocul
te
cycloheximide-tre
ted McCoy cells B. Pl
te onto lood
nd chocol
te

r C. Inoc
ul
te into
thiolycoll
te (THIO) roth D. Pl
te onto modi ed T
yerM
rtin

r within 24 hours
Micro ioloy/Select methods/Re
ents/Medi
/Virus culture/1 19. Specimens for vir
us culture should
e tr
nsported in medi
cont
inin: A. Anti iotics
nd 5% sheep lood B. S
line

nd 5% sheep
lood C. 22% ovine
l umin D. Anti iotics
nd nutrient Micro ioloy/Select
methods/Re
ents/Medi
/Virus culture/1 20. Cere rospin
l uid (CSF) should e cult
ured
immedi
tely, ut if del
yed the specimen should e: A. Refrier
ted
t 4C to 6C B.
Frozen
t
20C C. Stored
t room temper
ture for no loner th
n 24 hours D. Incu
ted
t 37C

nd cultured

s soon
s possi le Micro ioloy/Apply knowlede of st
nd
rd oper
tin procedure
s/Specimen
collection
nd tr
nsport/1 386 Ch
pter 7 | Micro ioloy Answers to Questions 1
620 16. B Both
r
m-positive cocci
nd r
m-ne
tive
cilli will row on lood

r pl
tes, u
t the medium is
used in conjunction with
selective medium such
s CNA

r for r
m-positive c
occi
nd
M
cConkey

r for r
m-ne
tive
cilli. H. in uenz
e requires X
nd V f
ctors,

nd H.
p
r
in uenz
e requires V f
ctor; the prim
ry isol
tion medium for H
emophilus is c
hocol
te

r.
17. B An
ero ic culture medi
c
n e prereduced efore steriliz
tion y oilin,
s
tur
tion with
oxyen-free 
s,
nd
ddition of cysteine or other thiol compounds. The n
l oxid

tion reduction
potenti
l (Eh) of the medium should e
pproxim
tely 150 mV to minimize the e ects
of exposure
of or
nisms to oxyen durin inocul
tion. 18. A Chl
mydi
e
re strict intr
cell
ul
r or
nisms

nd must e cultured usin livin cells. Direct sme
rs c
n
lso e m
de
t the t
ime of culture.
St
inin cells with iodine m
y reve
l the ch
r
cteristic reddish- rown inclusion
s sometimes seen
in Chl
mydi
infections. Fluorescein-conju
ted monoclon
l
nti odies m
y e use
d to identify the
or
nisms in infected cells. 19. D Medi
for tr
nsportin specimens for virus cu
lture include
H
nks
l
nced s
lt solution with ovine
l umin, Stu
rt tr
nsport medi
,
nd Le
i ovitzEmory
medi
. Medi
used for tr
nsportin specimens for vir
l culture
re simil
r to th
ose for
cteri

with the
ddition of
nutrient such
s fet
l c
lf serum or
l umin
nd
nti iot
ics. Specimens
should e refrier
ted
fter ein pl
ced in the tr
nsport medi
until the cultu
re medi
c
n e
inocul
ted. 20. D F
stidious or
nisms such
s Neisseri

nd H
emophilus frequen

tly isol
ted from

the CSF of p
tients with
cteri
l meninitis
re preserved y pl
cin the uid in
3%7% CO 2
t
35C37C (or
t room temper
ture for no loner th
n 30 min), if the specimen c
nnot
e cultured
immedi
tely. 2828_Ch07_381-494 06/08/12 11:24 AM P
e 386 21. Te most sensiti
ve method for the
detection of -l
ct
m
se in
cteri
is y the use of: A. Chromoenic ceph
lospori
n B. Penicillin
C. Oxid
se D. Chlor
mphenicol
cetyltr
nsfer
se Micro ioloy/Select methods/Re

ents/Medi
/
Sensitivity testin/2 22. Te re
kpoint of
n
ntimicro i
l dru refers to: A. T
e
mount needed
to c
use
cteriost
sis B. A minimum inhi itory concentr
tion (MIC) of 16 /mL or
re
ter C. A
MIC of 64 /mL or re
ter D. Te level of dru th
t is
chiev
le in serum Micro i
oloy/Apply
principle of theory
nd pr
ctice rel
ted to l
or
tory oper
tions/Sensitivity te
stin/2 23. Which
of the followin v
ri
les m
y ch
ne the results of
n MIC? A. Inoculum size B.
Incu
tion time
C. Growth r
te of the
cteri
D. All of these options Micro ioloy/Apply knowle
de to identify
sources of error/Sensitivity testin/2 24. Accordin to the Kir yB
uer st
nd
rd

ntimicro i
l
suscepti ility testin method, wh
t should e done when interpretin the zone si
ze of
motile,
sw
rmin or
nism such
s
Proteus species? A. Te sw
rmin
re
should e inor
ed B. Te results
of the disk di usion method
re inv
lid C. Te sw
rmin
re
should e me
sured
s
the rowth
ound
ry D. Te isol
te should e retested
fter dilutin to
0.05 McF
rl
nd st

nd
rd
Micro ioloy/Apply knowlede of st
nd
rd oper
tin procedures/Sensitivity testin
/2 25. Which
cl
ss of
nti iotics is used for the tre
tment of serious r
m-ne
tive infectio
ns
s well
s
infections with Myco
cterium tu erculosis? A. Ceph
losporins B. Penicillins C.
Tetr
cyclines D.
Aminolycosides Micro ioloy/Apply knowlede of fund
ment
l ioloic
l
ch
r
cteristics/Anti iotics/1 7.1 | Specimen Collection, Medi
,
nd Methods 38
7 Answers to
Questions 2125 21. A -L
ct
m
se production y
cteri
th
t
re resist
nt to penic
illin
nd
ceph
losporin is detected usin one of these drus
s
su str
te. Penicillin is
hydrolyzed y
-l
ct
m
se into
cidic products th
t c
n e detected
s
color ch
ne y
pH in
dic
tor. In the
iodometric method,
disk cont
inin
penicillinst
rch su str
te turns lue when

drop of
iodine is
dded. A loop of -l
ct
m
sepositive or
nisms
pplied to the center of t
he lue spot
will reduce the iodine to iodide, c
usin the
re
to cle
r. The most sensitive
method of
detection is
sed upon the
ility of the or
nism to hydrolyze the -l
ct
m rin
of

chromoenic ceph
losporin. 22. D The re
kpoint refers to
n
ntimicro i
l conce
ntr
tion in the
serum
ssoci
ted with optim
l ther
py usin the custom
ry dosin schedule. An or

nism is

suscepti le if the MIC is
t or elow the re
kpoint. 23. D In vitro testin of

drus is reli
le
if the method is st
nd
rdized. In
ddition to the rst three v
ri
les, the type o
f medi

nd the
st
ility of
nti iotics
ect the results of MIC testin
nd must e c
refully co
ntrolled. 24. A
A thin lm of rowth
ppe
rin in the zone
re
of inhi ition
round the suscepti
ility disk
should e inored when sw
rmin Proteus or other or
nisms
re encountered. Disc
ontinuous, poor
rowth or tiny colonies ne
r the end of the zone should
lso e inored. 25. D T
he
minolycoside

nti iotics
re
ctericid
l
ents th
t
ct y inhi itin protein synthesis. Th
ey show
low
incidence of
cteri
l resist
nce ut must e monitored c
refully ec
use
t hi
h doses they c
n
c
use ototoxicity
nd nephrotoxicity. The roup includes
mik
cin, ent
micin, t
o r
mycin,
k
n
mycin, streptomycin,
nd spectinomycin. These drus
re usu
lly
dministered
intr
venously or
intr
muscul
rly ec
use they
re poorly
sor ed from the 
strointestin
l tr
ct
.
2828_Ch07_381-494 06/08/12 11:24 AM P
e 387 26. Select the medium est suite
d for the
recovery of Yersini
enterocolitic
from
p
tient with 
stroenteritis. A. Hekt
oen

r B.
CefsulodinIr
s
nNovo iocin (CIN)

r C. Blood

r D. Eosinmethylene lue

r
Micro ioloy/Select methods/Re
ents/Medi
/ Gr
m-ne
tive
cilli/2 27. A suspec
ted c
se of
pl
ue requires which of the followin procedures in order to con rm Yersini
pest
is? A.
Collection of multiple sets of lood cultures B. Incu
tion of lood cultures
t
oth 28C
nd
35C C. Culture
spir
tes from u os to M
cConkey

r
t room temper
ture D. All
of these
options Micro ioloy/Apply knowlede of procedures/ Gr
m-ne
tive
cilli/2 28.
SITUATION:
A domin
l p
in, fever, vomitin,
nd n
use
prompted
n elderly m
le to seek med
ic
l
ttention. A
w
tery stool specimen producin no fec
l leukocytes or erythrocytes w
s cultured

nd rew

predomin
nce of r
m-ne
tive ferment
tive
cilli. The colonies were et
-hemol
ytic on lood


r
nd cre
m colored on M
cConkey

r. The colonies were oth oxid
se
nd c
t

l
se positive.
Wh
t is the most likely identific
tion? A. Aeromon
s hydrophili
B. Escherichi

coli C.
S
lmonell
spp. D. Shiell
spp. Micro ioloy/Ev
lu
te l
or
tory d
t
to m
ke
identi c
tions/Gr
m-ne
tive
cilli/3 29. SITUATION: Sever
l
ttendees of
medi
c
l conference
in the Gulf co
st
re
ec
me ill
fter frequentin
se
food rest
ur
nt. A pres
umptive
identi c
tion of Vi rio choler
w
s m
de
fter stool specimens from sever
l su jec
ts rew cle
r
colonies on M
cConkey

r
nd yellow colonies on TCBS

r. Which key tests wou
ld help elimin
te
Aeromon
s
nd Plesiomon
s spp.? A. M
nnitol ferment
tion, N
+ requirement B. Ox
id
se, motility
C. Oxid
se, nitr
te D. Hemolysis on lood

r, c
t
l
se Micro ioloy/Select
methods/Re
ents/Medi
/ Gr
m-ne
tive
cilli/3 388 Ch
pter 7 | Micro ioloy A

nswers to
Questions 2630 26. B CIN

r inhi its the rowth of m
ny other or
nisms from th
e f
mily
Entero
cteri
ce
e. Yersini
spp.
re
lso recovered from M
cConkey
nd S
lmonel
l
-Shiell



rs. 27. D Yersini
pestis is on the list of
ents of ioterrorism. Isol
tio
n
nd
identi c
tion should e performed in
f
cility with
Level II or hiher ios
fet
y r
tin. If
there is
hih risk of
erosolizin the specimen durin processin, procedures
should e
performed under Level III ios
fety conditions. Recovery of Y. pestis is hihest
if the specimen
is cultured within 2 hours of collection. 28. A The oxid
se positive test result
rules out the
mem ers of the Entero
cteri
ce
e f
mily. Colonies of Aeromon
s hydrophili

nd
Plesiomon
s spp.
miht e mist
ken for Vi rio spp. since
ll three row
s cle
r colonies on M
c
Conkey

r,
re
et
hemolytic on lood

r,
nd
re oxid
se positive. 29. A All three or
nism
s
re positive
for oxid
se production
nd
re motile. Plesiomon
s spp. do not row on TCBS

r
. Cle
r colonies
on M
cConkey

r
nd yellow colonies on TCBS

r indic
te Vi rio or Aeromon
s
spp. However,
only Vi rio spp. require N
+ (1% N
Cl) in the medium for rowth. Vi rio Aeromo
n
s Plesiomon
s
Oxid
se + + + N
+ + Ne Ne Requirement M
nnitol + + Ne ferment
tion Growth o
n + + Ne TCBS
30. C E. coli 0157:H7 ferments l
ctose,
nd therefore,
ppe
rs
s d
rk pink co
lonies on
M
cConkey

r. To di erenti
te E. coli 0157:H7 from norm
l fec
l or
, M
cConkey


r with
sor itol is used. E. coli 0157:H7 does not ferment sor itol,
nd usu
lly
re col
orless colonies.
30. SITUATION: A roup of element
ry students ec
me ill
fter e
tin undercooke
d round eef
prep
red in the school c
feteri
. Te suspected p
thoen, E. coli serotype 0157:H
7, is usu
lly
recovered usin which of the followin medi
? A. XLD

r B. M
cConkey

r C. M

cConkey

r
with sor itol D. Hektoen

r Micro ioloy/Select methods/Re
ents/Medi
/ Gr
m-n
e
tive
cilli/2
2828_Ch07_381-494 06/08/12 11:24 AM P
e 388 389 7.2 Entero
cteri
ce
e 1. Bi
ochemic
lly, the
Entero
cteri
ce
e
re r
m-ne
tive rods th
t: A. Ferment lucose, reduce nitr

te to nitrite,

nd
re oxid
se ne
tive B. Ferment lucose, produce indophenol oxid
se,
nd for
m 
s C. Ferment
l
ctose
nd reduce nitrite to nitroen 
s D. Ferment l
ctose
nd produce indoph
enol oxid
se
Micro ioloy/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics/Biochemic

l/Gr
m-ne
tive

cilli/1 2. Te ortho-nitrophenyl--
l
ctopyr
noside (ONPG) test is most useful w
hen
di erenti
tin: A. S
lmonell
spp. from Pseudomon
s spp. B. Shiell
spp. from som
e str
ins of
Escherichi
coli C. Kle siell
spp. from Entero
cter spp. D. Proteus vul
ris f
rom S
lmonell

spp. Micro ioloy/Apply principles of
sic l
or
tory procedures/Biochemic
l/2

3. Te
VoesProsk
uer (VP) test detects which end product of lucose ferment
tion? A. Ac
etoin B.
Nitrite C. Acetic
cid D. Hydroen sul de Micro ioloy/Apply principles of
sic l

or
tory
procedures/Biochemic
l/1 4. At which pH does the methyl red (MR) test ecome pos
itive? A. 7.0 B.
6.5 C. 6.0 D. 4.5 Micro ioloy/Apply principles of
sic l
or
tory procedures/B
iochemic
l/1
Answers to Questions 14 1. A The f
mily Entero
cteri
ce
e consists of more th
n
100 species
nd
represents the most commonly encountered isol
tes in clinic
l specimens. All Ent
ero
cteri
ce
e
ferment lucose
nd
re oxid
se ne
tive
nd nonsporul
tin. Most Entero
cteri

ce
e
re motile,
ut the ener
Shiell

nd Kle siell

re not. 2. B The ONPG test detects -
l
c
tosid
se

ctivity
nd is most useful in distinuishin l
te l
ctose fermenters from l
cto
se nonfermenters.
Some str
ins of E. coli
re slow l
ctose fermenters
nd m
y e confused with Shi
ell
spp., which
do not ferment l
ctose. E. coli
re ONPG positive while Shiell
spp.
re ONPG n
e
tive. 3. A
Acetoin or c
r inol,
n end product of lucose ferment
tion, is converted to di

cetyl
fter the

ddition of the VP re
ents (-n
phthol
nd 40% pot
ssium hydroxide [KOH]). Di
cet
yl is seen
s

red- to pink-colored complex. 4. D Both MR
nd VP tests detect
cid production f
rom the
ferment
tion of lucose. However,
positive MR test denotes
more complete c
t

olism of
lucose to hihly
cidic end products such
s form
te
nd
cet
te th
n occurs wi
th or
nisms th
t

re VP positive only (e.., Kle siell
pneumoni
e). 2828_Ch07_381-494 06/08/12
11:24 AM P
e
389 5. A positive Simmons citr
te test is seen
s
: A. Blue color in the medium

fter 24 hours
of incu
tion
t 35C B. Red color in the medium
fter 18 hours of incu
tion
t 3
5C C. Yellow
color in the medium
fter 24 hours of incu
tion
t 35C D. Green color in the med
ium
fter 18
hours of incu
tion
t 35C Micro ioloy/Apply principles of
sic l
or
tory
procedures/Biochemic
l/1 6. In the test for ure
se production,
mmoni
re
cts to
form which
product? A. Ammonium citr
te B. Ammonium c
r on
te C. Ammonium ox
l
te D. Ammoni
um nitr
te
Micro ioloy/Apply principles of
sic l
or
tory procedures/Biochemic
l/1 7. Wh
ich of the
followin re
ents is
dded to detect the production of indole? A. p-Dimethyl
mi
no enz
ldehyde B.
Bromcresol purple C. Methyl red D. Cytochrome oxid
se Micro ioloy/Apply princip
les of
sic
l
or
tory procedures/Biochemic
l/1 8. Dec
r oxyl
tion of the
mino
cids lysine
, ornithine,
nd

rinine results in the form
tion of: A. Ammoni
B. Ure
C. CO 2 D. Amines Micro
ioloy/Apply
principles of
sic l
or
tory procedures/Biochemic
l/1 9. Lysine iron

r (LIA
) showin

purple sl
nt
nd
l
ckened utt indic
tes: A. E. coli B. Citro
cter spp. C. S

lmonell
spp. D.

Proteus spp. Micro ioloy/Ev
lu
te l
or
tory d
t
to m
ke identi c
tions/Gr
m-ne

tive
cilli/2
10. Putrescine is
n
lk
line
mine product of which
cteri
l enzyme? A. Arini
ne dec
r oxyl
se
B. Phenyl
l
nine de
min
se C. Ornithine dec
r oxyl
se D. Lysine dec
r oxyl
se Mi
cro ioloy/Apply
principles of
sic l
or
tory procedures/Biochemic
l/1 390 Ch
pter 7 | Micro
ioloy Answers to
Questions 510 5. A The Simmons citr
te test determines if
n or
nism c
n utilize
citr
te
s the
sole source of c
r on. The medium turns lue, indic
tin the presence of
lk
lin
e products such

s c
r on
te. Tu es
re incu
ted
minimum of 24 hours
t 35C with
loose c
p
efore re
din.
6. B The test for ure
se production is
sed on the
ility of the colonies to h
ydrolyze ure
in
Stu
rt roth or Christensen

r to form CO 2
nd
mmoni
. These products form

mmonium
c
r on
te, resultin in
lk
liniz
tion. This turns the pH indic
tor (phenol red)
pink
t pH 8.0.
7. A The indole test detects the conversion of tryptoph
n (present in the medi
)
to indole y the
enzyme tryptoph
n
se. Indole is detected y the re
ction with the
ldehyde roup
of
p-dimethyl
mino enz
ldehyde (the
ctive re
ent in Kov
cs
nd Ehrlichs re
ents) i
n
cid,
formin
red complex. 8. D Speci c dec
r oxyl
ses split di
sic
mino
cids (lysi
ne,
rinine,

nd ornithine), formin
lk
line
mines. These products turn the pH indic
tors i
n the medium
(cresol red
nd romcresol purple) from yellow to purple. 9. C LIA is used
s
n

id for the
identi c
tion of S
lmonell
species. It cont
ins phenyl
l
nine, lysine, lucose, t
hiosulf
te,
ferric
mmonium citr
te,
nd romcresol purple. S
lmonell
produce H 2 S from th
iosulf
te. This
reduces ferric
mmonium citr
te, formin ferrous sulf
te
nd c
usin the utt to
l
cken.
S
lmonell

lso dec
r oxyl
te lysine to produce
lk
line
mines, ivin the sl
n
t its purple
color
nd di erenti
tin it from Citro
cter spp., which
re lysine dec
r oxyl
se
ne
tive. 10. C
Putrescine is the
mine product of the dec
r oxyl
tion of ornithine. 2828_Ch07_3
81-494 06/08/12
11:24 AM P
e 390 11. Which ener

re positive for phenyl
l
nine de
min
se? A.
Entero
cter,
Escherichi
,
nd S
lmonell
B. Mor
nell
, Providenci
,
nd Proteus C. Kle siell


nd
Entero
cter D. Proteus, Escherichi
,
nd Shiell
Micro ioloy/Ev
lu
te l
or
t
ory d
t
to m
ke
identi c
tions/Gr
m-ne
tive
cilli/2 12. Kliler iron

r (KIA) di ers from tripl
e-su
r iron


r (TSI) in the: A. R
tio of l
ctose to lucose B. A ility to detect H 2 S pro
duction C. Use of
sucrose in the medium D. Color re
ction denotin production of
cid Micro ioloy
/Apply principles
of
sic l
or
tory procedures/Methods/Re
ents/Medi
/Gr
m-ne
tive
cilli/2 13
. Te m
lon
te
test is most useful in di erenti
tin which mem ers of the Entero
cteri
ce
e? A.
Shiell
B.

Proteus C. S
lmonell
su roups 2, 3 (the former Arizon
) D. Serr
ti
Micro iolo

y/Ev
lu
te
l
or
tory d
t
to m
ke identi c
tions/Gr
m-ne
tive
cilli/2 14. Which ener
of
the
Entero
cteri
ce
e
re known to c
use di
rrhe

nd
re considered enteric p
tho
ens? A.
Entero
cter, Kle siell
, Providenci
,
nd Proteus B. Escherichi
, S
lmonell
, S
hiell
,
nd
Yersini
C. Pseudomon
s, Mor
xell
, Acineto
cter,
nd Aeromon
s D. Entero
cter
, Citro
cter,

nd Mor
nell
Micro ioloy/Apply knowlede of fund
ment
l ioloic
l
ch
r
cteristics/Gr
m-ne
tive
cilli/1 15. An isol
te of E. coli recovered from
the stool of

p
tient with severe loody di
rrhe
should e tested for which su
r efore send
in it to

reference l
or
tory for serotypin? A. Sor itol (ferment
tion) B. M
nnitol (oxi
d
tion) C.
R
nose (ferment
tion) D. Sucrose (ferment
tion) Micro ioloy/Ev
lu
te l
or
tory
d
t
to
reconize he
lth
nd dise
se st
tes/Gr
m-ne
tive
cilli/3 16. C
re must e t
k
en when
identifyin iochemic
l isol
tes of Shiell
ec
use seroloic
l cross re
ctions
occur with: A.
E. coli B. S
lmonell
spp. C. Pseudomon
s spp. D. Proteus spp. Micro ioloy/Appl
y knowlede of
fund
ment
l ioloic
l ch
r
cteristics/Gr
m-ne
tive
cilli/2 7.2 | Entero
cte
ri
ce
e 391
Answers to Questions 1116 11. B Phenyl
l
nine de
min
se oxid
tively de
min
tes ph
enyl
l
nine,
formin phenylpyruvic
cid. When
solution of ferric chloride is
dded, the iro
n re
cts with
phenylpyruvic
cid, formin
reen-colored complex. Phenyl
l
nine de
min
se is
found in the
ener
Mor
nell
, Providenci
,
nd Proteus
nd is
n excellent test to determin
e if
n or
nism
elons to this roup. R
rely, isol
tes of Entero
cter m
y e phenyl
l
nine de

min
se positive

s well. 12. C Both KIA
nd TSI cont
in 10-fold more l
ctose th
n lucose, pepto
ne,
nd phenol
red to detect
cid production (turns yellow)
nd sodium thiosulf
te
nd ferrous

mmonium sulf
te
to detect H 2 S production. However, TSI cont
ins sucrose
nd KIA does not. Or

nisms fermentin
either sucrose or l
ctose will turn the sl
nt of the

r tu e yellow. Therefore
, some or
nisms
(e.., m
ny species of Cedece
, Citro
cter, Edw
rdsiell
,
nd Serr
ti
) will pr
oduce
yellow
sl
nt on TSI ut
red sl
nt on KIA. 13. C The m
lon
te test determines whether

n or
nism c
n
utilize sodium m
lon
te
s the sole source of c
r on. M
lon
te is roken down, f
ormin
lk
line
met
olites th
t r
ise the pH of the roth
ove 7.6. This c
uses romthymol lu
e to turn from
reen to deep lue (Prussi
n lue). E. coli, Shiell
,
nd most S
lmonell

re m

lon
te ne
tive,
where
s Entero
cter
nd S
lmonell
(formerly Arizon
) su roups 2, 3
,
nd 3

re positive.
Proteus, Providenci
, Serr
ti
,
nd Yersini

re
lso m
lon
te ne
tive. 14. B
Escherichi
,
S
lmonell
, Shiell
,
nd Yersini

re responsi le for the m
jority of enteric d

i
rrhe
c
ses

ttri ut
le to the Entero
cteri
ce
e f
mily. 15. A An isol
te of E. coli recov
ered from
stool
culture in hemorrh
ic colitis c
n e de nitely identi ed only y serotypin. The is
ol
te is
identi ed
s E. coli y the usu
l iochemic
l re
ctions. The str
in of E. coli res
ponsi le for
hemorrh
ic colitis is O157:H7
nd is usu
lly ne
tive for sor itol ferment
tion
. Colonies of
this str
in of E. coli
ppe
r colorless on M
cConkey

r with sor itol
dded. 1
6. A Seroloic
l
con rm
tion of Shiell
isol
tes is
sed upon O
ntien typin. If
suspected Sh
iell
spp. is
seroloic
lly typed with polyv
lent ser
efore it h
s een correctly identi ed i
ochemic
lly,

f
lse-positive con rm
tion m
y occur with
n isol
te th
t is E. coli (i.e.,
n
ero
enic
non
s-producin, l
ctose-ne
tive or del
yed,
nd nonmotile str
ins). These str

ins were
formerly known
s the Alk
lescens-Disp
r serotype. 2828_Ch07_381-494 06/08/12
11:24 AM P
e
391 17. Which species of Shiell
is most commonly
ssoci
ted with di
rrhe
l dis
e
se in the
United St
tes? A. S. dysenteri
e B. S. exneri C. S. oydii D. S. sonnei Micro iol
oy/Apply
knowlede of fund
ment
l ioloic
l ch
r
cteristics/Gr
m-ne
tive
cilli/2 18.
Which of the
followin tests est di erenti
tes Shiell
species from E. coli? A. Hydroen sul de
, VP,
citr
te,
nd ure
se B. L
ctose, indole, ONPG,
nd motility C. Hydroen sul de, MR,
citr
te,
nd
ure
se D. G
s, citr
te,
nd VP Micro ioloy/Ev
lu
te l
or
tory d
t
to m
ke
identi c
tions/Gr
m-ne
tive
cilli/2 19. Which ener
of Entero
cteri
ce
e
re
usu
lly
nonmotile
t 36C? A. Shiell
, Kle siell
,
nd Yersini
B. Escherichi
, Edw
rdsie
ll
,
nd
Entero
cter C. Proteus, Providenci
,
nd S
lmonell
D. Serr
ti
, Mor
nell
,
n
d H
fni

Micro ioloy/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics/Gr
m-ne

tive
cilli/2
20. Fever,
domin
l cr
mpin, w
tery stools,
nd uid
nd electrolyte loss preced
ed y loody
stools 23 d
ys efore is ch
r
cteristic of shiellosis ut m
y
lso result from i
nfection with:
A. C
mpylo
cter spp. B. S
lmonell
spp. C. Proteus spp. D. Yersini
spp. Micro
ioloy/Apply
knowlede of fund
ment
l ioloic
l ch
r
cteristics/Gr
m-ne
tive
cilli/2 21.
Cold enrichment
of feces (incu
tion
t 4C) in phosph
te- u ered s
line prior to su culture onto en
teric medi

enh
nces the recovery of: A. Enterotoxienic E. coli B. S
lmonell
p
r
typhi C.
H
fni

lvei D.
Y. enterocolitic
Micro ioloy/Apply principles of speci
l procedures/ Gr
m-ne

tive
cilli/2
392 Ch
pter 7 | Micro ioloy Answers to Questions 1721 17. D The Shiell
spp.

re l
ctose
nonfermenters th
t for the most p
rt
re iochemic
lly inert
nd
re cl
ssified
into seroroups
A, B, C,
nd D
s
result of their iochemic
l simil
rity. S. sonnei is the spe
cies most often

isol
ted from di
rrhe
c
ses in the United St
tes. It is more
ctive iochemic
l
ly th
n the other
species owin to ornithine dec
r oxyl
se
nd -
l
ctosid
se
ctivity. These enzym
es, found in
most str
ins of S. sonnei, distinuish it from other Shiell
species. 18. B E
. coli, positive
for l
ctose, indole,
nd ONPG
re usu
lly motile. Shiell
species do not fermen
t l
ctose or
produce indole, l
ck -
l
ctosid
se,
nd
re nonmotile. 19. A Shiell
spp.
nd
Kle siell

spp.
re for the most p
rt nonmotile. Yersini
c
n e motile
t 22C ut is nonmot
ile
t 36C.
Other mem ers of the Entero
cteri
ce
e th
t h
ve een isol
ted from hum
n speci
mens
nd
re
usu
lly nonmotile include Leminorell
, R
hnell
,
nd T
tumell
. 20. A Shiell

spp.
nd
C
mpylo
cter spp.
re oth c
uses of di
rrhe
,
domin
l p
in, fever,
nd somet
imes vomitin.
Blood is present in the stools of p
tients infected with Shiell

s
result of
inv
sion
nd
penetr
tion of the owel. Youn children m
y
lso exhi it loody stools when inf
ected with
C
mpylo
cter. 21. D Cold enrichment is especi
lly useful when specimens cont
in
l
re num ers of
norm
l or
th
t
re sensitive to proloned exposure to ne
r-freezin temper
ture.
In
ddition to
Yersini
, the technique h
s een used to enh
nce recovery of Listeri
monocytoe
nes from
specimens cont
inin other
cteri
. 2828_Ch07_381-494 06/08/12 11:24 AM P
e
392 22. Which
roup of tests,
lon with coloni
l morpholoy on prim
ry medi
,
ids most in th
e r
pid
identi c
tion of the Entero
cteri
ce
e? A. MR
nd VP, ure
se,
nd lood

r pl
t
e B.
Phenyl
l
nine de
min
se, ure
se,
nd CDC

r pl
te C. B
citr
cin, -l
ct
m
se,
n
d M
cConkey


r pl
te D. Indole, oxid
se, M
cConkey,
nd lood

r pl
tes Micro ioloy/Sel
ect
methods/Re
ents/Medi
/ Gr
m-ne
tive
cilli/2 23. A routine, complete stool cu
lture procedure
should include medi
for the isol
tion of E. coli O157:H7
s well
s: A. S
lmone
ll
, Shiell
,
Yersini
, C
mpylo
cter,
nd St
phylococcus
ureus B. Vi rio choler
e, Brucell
,

nd Yersini

spp. C. S.
ureus, roup B streptococci,
nd roup D streptococci D. Clostridium
di cile,
Clostridium perfrinens,
nd Yersini
spp. Micro ioloy/Select methods/Re
ents/
Medi
/
Gr
m-ne
tive
cilli/2 24. Which roup of tests est identi es the Mor
nell

nd
Proteus
ener
? A. Motility, ure
se,
nd phenyl
l
nine de
min
se B. M
lon
te, lucose fe
rment
tion,
nd
deoxyri onucle
se (DN
se) C. Indole, oxid
se, MR,
nd VP D. Indole, citr
te,
nd
ure
se
Micro ioloy/Ev
lu
te l
or
tory d
t
to m
ke identi c
tions/Gr
m-ne
tive
cilli
/2 25. Which
roup of tests est di erenti
tes Entero
cter
eroenes from Edw
rdsiell
t
rd
?
A. Motility,
citr
te,
nd ure
se B. Hydroen sul de (H 2 S) production, sucrose ferment
tion, i
ndole,
nd VP

C. Lysine dec
r oxyl
se, ure
se,
nd
rinine dihydrol
se D. Motility, H 2 S pro

duction,
nd
DN
se Micro ioloy/Ev
lu
te l
or
tory d
t
to m
ke identi c
tions/Gr
m-ne
tive

cilli/2 26.
Entero
cter s
k
z
kii c
n est e di erenti
ted from Entero
cter clo
c
e y whic
h of the
followin ch
r
cteristics? A. Yellow piment
tion
nd ne
tive sor itol ferment

tion B. Pink
piment
tion
nd positive
rinine dihydrol
se C. Yellow piment
tion
nd positi
ve ure
se D. H 2
S production on TSI Micro ioloy/Ev
lu
te l
or
tory d
t
to m
ke identi c
tions/G
r
m-ne
tive

cilli/2 7.2 | Entero
cteri
ce
e 393 Answers to Questions 2226 22. D All Ente
ro
cteri
ce
e

re oxid
se ne
tive. Bec
use E. coli
nd Proteus spp. comprise
m
jority of th
e or
nisms
recovered from clinic
l specimens, they c
n e initi
lly identi ed throuh r
pid t
estin without

ddition
l overniht testin. E. coli displ
y
positive indole test,
nd the co
loni
l morpholoy
on M
cConkey

r is distinctive, showin
t, pink (l
ctose-positive) colonies wi
th
rin of
ile precipit
tion. Proteus spp. sw
rm on lood

r
nd
re indole ne
tive. 23
. A V. choler
e

nd C. di cile
re usu
lly not included in
routine stool culture. If Vi rio spp.

re suspected,

speci
l request should e included. Althouh M
cConkey

r will support the 
rowth of Vi rio
spp., norm
l enteric or
overrow
nd occlude these or
nisms. C. di cile culture r
equires
speci
l medi
(CCFA) th
t inhi it other
n
ero ic or

nd f
cult
tive
n
ero ic or


nd should
e requested speci c
lly if symptoms w
rr
nt. M
cConkey

r with sor itol will
l
low the E. coli
O157:H7 to e recovered. Yersini
spp. c
n e detected on
reul
r M
cConkey


r pl
te. 24. A
Mor
nell

nd Proteus spp.
re motile, produce ure
se,
nd de
min
te phenyl
l
n
ine. 25. B E.

eroenes E. t
rd
Test (% positive) (% positive) H 2 S 0 100 Sucrose >90 0
Indole <20 100 VP
100 0 Citr
te 95 0 26. A E. s
k
z
kii is c
lled
yellow-pimented E. clo
c
e

nd is est
di erenti
ted from E. clo
c
e y sor itol ferment
tion (95% positive for E. clo
c

e
nd 0% for E.
s
k
z
kii). In
ddition, E. clo
c
e is usu
lly positive for ure
se
nd m
lon
te
(65%
nd 75%,
respectively)
nd E. s
k
z
kii is usu
lly ne
tive (1%
nd < 20%, respectively).
Both species
re
usu
lly motile
nd
rinine dihydrol
se positive. 2828_Ch07_381-494 06/08/12 1
1:24 AM P
e 393
27. Mem ers of the enus Cedece

re est di erenti
ted from Serr
ti
spp. y whic
h test result?
A. Positive motility B. Positive ure
se C. Positive phenyl
l
nine de
min
se D. N
e
tive DN
se
Micro ioloy/Ev
lu
te l
or
tory d
t
to m
ke identi c
tions/Gr
m-ne
tive
cilli
/2 28. Which of
the followin or
nisms is often confused with the S
lmonell
species iochemic

lly
nd on pl
ted
medi
? A. E. coli B. Citro
cter freundii C. Entero
cter clo
c
e D. Shiell
dy
senteri
e

Micro ioloy/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics/Gr
m-ne

tive
cilli/2
29. A r
m-ne
tive rod is recovered from
c
theterized urine s
mple from
nur
sin home
p
tient. Te l
ctose-ne
tive isol
te tested positive for indole, ure
se, ornithi
ne dec
r oxyl
se,

nd phenyl
l
nine de
min
se
nd ne
tive for H 2 S. Te most pro
le identi c
tion
is: A.
Edw
rdsiell
spp. B. Mor
nell
spp. C. Ewinell
spp. D. Shiell
spp. Micro io
loy/Ev
lu
te
l
or
tory d
t
to m
ke identi c
tions/Gr
m-ne
tive
cilli/3 30. Which sinle te
st est
sep
r
tes Kle siell
oxytoc
from K. pneumoni
e? A. Ure
se B. Sucrose C. Citr
te
D. Indole
Micro ioloy/Ev
lu
te l
or
tory d
t
to m
ke identi c
tions/Gr
m-ne
tive
cilli
/2 31. Which of
the followin or
nisms, found in norm
l fec
l or
, m
y e mist
ken iochemic
lly
for the enus
Yersini
? A. Kle siell
spp. B. Proteus spp. C. E. coli D. Entero
cter spp. Mic
ro ioloy/Apply
knowlede of fund
ment
l ioloic
l ch
r
cteristics/Gr
m-ne
tive
cilli/2 394
Ch
pter 7 |
Micro ioloy Answers to Questions 2731 27. D DN
se is not produced y Cedece
spp
. ut is
produced (
lon with protein
ses) y Serr
ti
spp. Other key di erenti
l tests inc
lude lip
se
(positive for Cedece
, ne
tive for Serr
ti
)
nd el
tin hydrolysis (ne
tive f
or Cedece
,
positive for Serr
ti
). 28. B Biochemic
l differenti
tion is essenti
l ec
use C
itro
cter
isol
tes m
y ive
f
lse-positive
lutin
tion test with S
lmonell
roupin s
er
. C. freundii
str
ins, like S
lmonell
spp.,
re usu
lly H 2 S producers
nd m
y e confused w
ith S
lmonell

spp. unless the proper iochemic
l tests
re utilized. C. freundii
nd S
lmonell

spp.
re

donitol, indole,
nd m
lon
te ne
tive. However, C. freundii is KCN positive, w
here
s S
lmonell

spp.
re KCN ne
tive. 29. B Mor
nell

re iochemic
lly simil
r to Proteus s
pp., oth ein
l
ctose ne
tive, motile,
nd positive for phenyl
l
nine de
min
se
nd ure
se. H
owever,
Mor
nell
c
n e di erenti
ted from Proteus spp.
sed upon H 2 S, indole, ornith
ine
dec
r oxyl
se,
nd xylose ferment
tion. Ewinell
spp.
re usu
lly positive (70%
) for l
ctose
ferment
tion, where
s the other three ener

re l
ctose ne
tive. 30. D K. oxy
toc

nd K.
pneumoni
e
re
lmost identic
l iochemic
lly except for the
ility to produce
indole. Both
or
nisms
re usu
lly positive for ure
se, sucrose,
nd citr
te. However, K. oxy
toc
is indole
positive
nd K. pneumoni
e is indole ne
tive. 31. B Proteus spp.
re ure
se p
ositive
s
re

pproxim
tely 70% of Y. enterocolitic
isol
tes. Both or
nisms
re l
ctose ne

tive
nd motile.
However, Yersini
is motile
t 22C
nd not
t 35C (demonstr
ted usin motility med
i
).
2828_Ch07_381-494 06/08/12 11:24 AM P
e 394 32. Why miht it e necess
ry fo
r oth pink

(l
ctose-positive)
nd colorless (l
ctose-ne
tive) colonies from
n initi
l sto

ol culture on
M
cConkey

r to e su cultured
nd tested further for possi le p
thoens? A. M
ost Shiell

str
ins
re l
ctose positive B. Most S
lmonell
str
ins
re m
ltose ne
tive C.
Most Proteus spp.

re l
ctose ne
tive D. P
thoenic E. coli c
n e l
ctose positive or l
ctose ne

tive
Micro ioloy/Ev
lu
te l
or
tory d
t
to m
ke identi c
tions/Gr
m-ne
tive
cilli
/2 33. Which


r th
t is used for routine stool cultures is the medium of choice for the iso
l
tion of
Yersini
str
ins from stool specimens? A. S
lmonell
Shiell


r B. Hektoen ente
ric

r C.
M
cConkey

r D. CNA

r Micro ioloy/Select methods/Re
ents/Medi
/ Gr
m-ne

tive
cilli/2
34. Which or
nism is sometimes mist
ken for S
lmonell

nd will
lutin
te in
S
lmonell

polyv
lent
ntiserum? A. C. freundii str
ins B. Proteus mir
ilis str
ins C. S.
sonnei str
ins D.
E. coli Micro ioloy/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics/G
r
m-ne
tive

cilli/2 35. A loody stool cultured from
26-ye
r-old wom
n
fter 3 d
ys of s
evere di
rrhe

showed the followin results
t 48 hours
fter ein pl
ted on the followin med
i
: M
cConkey


r: little norm
l or
with m
ny nonl
ctose-fermentin colonies Hektoen enteric


r: m
ny
lue-reen colonies C
mpylo
cter lood

r
nd C. di cile

r: no rowth Cle
r
colonies (from
M
cConkey

r) tested ne
tive for oxid
se, indole, ure
se, motility,
nd H 2 S
Te most likely
identi c
tion is: A. Shiell
spp. B. S
lmonell
spp. C. Proteus spp. D. E. coli
Micro ioloy/Ev
lu
te l
or
tory d
t
to m
ke identi c
tions/Gr
m-ne
tive
cilli
/2 7.2 |
Entero
cteri
ce
e 395 Answers to Questions 3235 32. D Possi le p
thoenic str

ins of E. coli
should e picked from M
cConkey

r
nd su cultured onto M
cConkey

r with so
r itol. After
su culture, these str
ins c
n e serotyped or sent to
reference l
or
tory. Mo
st E. coli norm
l
or
ferment D-sor itol
nd
ppe
r pink to red on M
cConkeysor itol

r. The E. co
li str
in
O157:H7 c
uses the enteric dise
se hemorrh
ic colitis. It ferments D-sor itol s
lowly or not
t

ll
nd
ppe
rs
s colorless colonies on M
cConkeysor itol

r. 33. C
Cefsulodinir
s
nnovo iocin (CIN) medium is the est

r for the isol
tion of Yer
sini
str
ins
ec
use it inhi its rowth of other coliforms, ut it is not used routinely in c
linic
l
l
or
tories. Yersini
spp. row well on M
cConkey

r incu
ted
t 37C, ut the
colonies
re
much sm
ller th
n the other Entero
cteri
ce
e; therefore, 25C is the temper
ture
recommended
for isol
tion. Some serotypes of Yersini
m
y e inhi ited on more selective med
i
, such
s
S
lmonell
Shiell
or Hektoen. CNA

r inhi its the rowth of r
m-ne
tive
ct
eri
. 34. A
C. freundii
nd S
lmonell
spp.
re H 2 S positive
nd indole, VP,
nd phenyl
l

nine de
min
se

ne
tive. Biochemic
l ch
r
cteristics th
t help to di erenti
te C. freundii from S

lmonell

include l
ctose ferment
tion (50% of C. freundii
re l
ctose positive, where
s 1
00% of S
lmonell


re l
ctose ne
tive)
nd ure
se production (70% of Citro
cter
re positive
nd
re
ter th
n 99%
of S
lmonell

re ne
tive). 35. A Shiell
is the most likely or
nism ioche
mic
lly. E. coli

re usu
lly indole
nd motility positive,
nd Proteus
re motility
nd ure
se p
ositive. Most
S
lmonell

re H 2 S positive. Shiell

nd C
mpylo
cter c
use loody di
rrhe

ec
use they
inv
de the epitheli
l cells of the l
re owel; however, C
mpylo
cter spp. do n
ot row on
M
cConkey

r,
nd they
re oxid
se positive. 2828_Ch07_381-494 06/08/12 11:2
4 AM P
e 395
36. Which of the followin or
nisms
re ener
lly positive for -
l
ctosid
se? A
. S
lmonell

spp. B. Shiell
spp. C. Proteus spp. D. E. coli Micro ioloy/Ev
lu
te l
or
tor
y d
t
to m
ke
identi c
tions/Gr
m-ne
tive
cilli/2 37. In the K
u m
nnWhite schem
, the com ined

ntiens
used for seroloic
l identi c
tion of the S
lmonell
spp.
re: A. O
ntiens B. H

ntiens C. Vi

nd H
ntiens D. O, Vi,
nd H
ntiens Micro ioloy/Apply knowlede of fund
men
t
l ioloic
l
ch
r
cteristics/Gr
m-ne
tive
cilli/1 38. Te drus of choice for tre
tment of
infections with
Entero
cteri
ce
e
re: A. Aminolycosides, trimethoprimsulf
methox
zole, third-
ener
tion
ceph
losporins B. Ampicillin
nd n
lidixic
cid C. Streptomycin
nd isoni
zid D.
Chlor
mphenicol,

mpicillin,
nd colistin Micro ioloy/Apply knowlede of fund
ment
l ioloic
l
ch
r
cteristics/Gr
m-ne
tive
cilli/2 39. Te Shi
-like toxin (verotoxin) is p
roduced m
inly y
which Entero
cteri
ce
e? A. Kle siell
pneumoni
e B. E. coli C. S
lmonell
typh
imurium D.
Entero
cter clo
c
e Micro ioloy/Apply knowlede of fund
ment
l ioloic
l
ch
r
cteristics/Gr
m-ne
tive
cilli/2 40. Infections c
used y Yersini
pestis

re r
re in the
United St
tes. Tose c
ses th
t do occur
re most frequently loc
ted in which re
ion? A. New
Mexico, Arizon
,
nd C
liforni
B. Al
sk
, Oreon,
nd Ut
h C. North
nd South C

rolin

nd
Virini
D. Ohio, Michi
n,
nd Indi
n
Micro ioloy/Apply knowlede of fund
men
t
l ioloic
l
ch
r
cteristics/Gr
m-ne
tive
cilli/2 396 Ch
pter 7 | Micro ioloy Answers t
o Questions 3640
36. D Entero
cteri
ce
e
re rouped
ccordin to their
ility to ferment l
ct
ose,

-
l
ctoside. S
lmonell
, Shiell
, Proteus, Providenci
,
nd Mor
nell

re usu

lly l
ctose
nonfermenters. Othersincludin cert
in str
ins of E. coli, S. sonnei, H
fni

lve
i, Serr
ti

m
rcescens,
nd some Yersini

ppe
r to e l
ctose nonfermenters ec
use they l
ck
the perme
se
enzyme th
t
ctively tr
nsports l
ctose
cross the cell mem r
ne. However, true
l
ctose
nonfermenters do not possess -
l
ctosid
se. The test for -
l
ctosid
se uses the
su str
te

o-nitrophenyl--
l
ctopyr
noside. At
n
lk
line pH, -
l
ctosid
se hydrolyses the

su str
te,
formin o-nitrophenol, which turns the medium yellow. 37. D The K
ufm
nnWhite sch
em
roups the
s
lmonell
e on the
sis of the som
tic O (he
t-st
le)
ntiens
nd su divides
them into
serotypes
sed on their
ell
r H (he
t-l
ile)
ntiens. The Vi (or K)
ntien
is
c
psul
r
polys
cch
ride th
t m
y e removed y he
tin. There
re over 2,200 serotypes of
S
lmonell
. 38.
A The drus of choice for the Entero
cteri
ce
e v
ry,
nd sever
l ener
displ

y p
tterns of
resist
nce th
t
id in their identific
tion. K. pneumoni
e
nd Citro
cter diver
sus
re resist
nt
to
mpicillin
nd c
r enicillin; most Entero
cter spp.
nd H
fni

re resist
nt
to
mpicillin

nd ceph
lothin. Proteus, Mor
nell
,
nd Serr
ti

re resist
nt to colistin. Pr
ovidenci

nd
Serr
ti

re resist
nt to multiple drus. Sever
l ener

re resist
nt to chlor

mphenicol
nd
most
re resist
nt to penicillin. 39. B Str
ins of E. coli th
t produce one or
oth of the
Shi
-like toxins (SLT I
nd SLT II) c
n c
use loody di
rrhe
(hemorrh
ic coli
tis). In the
United St
tes, E. coli str
in O157:H7 is the serotype most often
ssoci
ted with
hemorrh
ic
colitis. 40. A Approxim
tely 15 c
ses of Y. pestis infection
re con rmed in the U
nited St
tes

nnu
lly. Most oriin
te in the Southwest. It is necess
ry to e
w
re of this r
eion
l
occurrence ec
use untre
ted c
ses
re
ssoci
ted with
mort
lity r
te of
ppro
xim
tely 60%. Y.
pestis is not f
stidious
nd rows well on lood

r. It is in
ctive iochemic

lly, which helps
to di erenti
te it from other Entero
cteri
ce
e. 2828_Ch07_381-494 06/08/12 11:
24 AM P
e 396
41. A le culture from
nursin home p
tient rew r
m-ne
tive rods on M
cConk
ey

r
s pink
to d
rk pink oxid
se-ne
tive colonies. Given the followin results, which is th
e most likely
or
nism? TSI = A/A Indole = Ne MR = Ne VP = + Citr
te = + H 2 S = Ne Ure
se
= + Motility =
Ne Anti iotic suscepti ility: resist
nt to c
r enicillin
nd
mpicillin A. Serr

ti
m
rcescens
B. Proteus vul
ris C. Entero
cter clo
c
e D. Kle siell
pneumoni
e Micro iolo
y/Ev
lu
te
l
or
tory d
t
to m
ke identi c
tions/Gr
m-ne
tive
cilli/3 42. Four lood cult
ures were t
ken
over
24-hour period from
20-ye
r-old wom
n with severe di
rrhe
. Te cultures
rew motile
(room temper
ture), r
m-ne
tive rods. A urine specimen o t
ined y c
theteriz

tion
lso showed
r
m-ne
tive rods, 100,000 col/mL. Given the followin results, which is the mo
st likely
or
nism? TSI = A/A 
s Indole = + VP = Ne MR = + H 2 S = Ne Citr
te = Ne Ure

se = Ne Lysine
dec
r oxyl
se = + Phenyl
l
nine de
min
se = Ne A. Proteus vul
ris B. S
lmonell

typhi C.
Yersini
enterocolitic
D. E. coli Micro ioloy/Ev
lu
te l
or
tory d
t
to m
ke
identi c
tions/Gr
m-ne
tive
cilli/3 43. A stool culture from
30-ye
r-old m
n

su erin from
loody mucoid di
rrhe

ve the followin results on di erenti
l enteric medi
: M

cConkey

r =
cle
r colonies; XLD

r = cle
r colonies; Hektoen

r = reen colonies; S
lmon
ell
Shiell



r = sm
ll, cle
r colonies Which tests
re most
ppropri
te for identi c
tion of
this enteric
p
thoen? A. TSI, motility, indole, ure
se, Shiell
typin with polyv
lent ser

B. TSI,
motility, indole, lysine, S
lmonell
typin with polyv
lent ser
C. TSI, indole,
MR, VP, citr
te
D. TSI, indole, MR,
nd ure
se Micro ioloy/Ev
lu
te l
or
tory d
t
to m
ke
identi c
tions/Gr
m-ne
tive
cilli/3 7.2 | Entero
cteri
ce
e 397 Answers to Q
uestions 4144
41. D K. pneumoni
e
nd E. clo
c
e displ
y simil
r IMViC (indole, MR, VP,
nd c
itr
te) re
ctions
(00++)
nd TSI results. However,
pproxim
tely 65% of E. clo
c
e str
ins
re ure

se positive
comp
red with 98% of those of K. pneumoni
e. Entero
cter spp.
re motile
nd Kl
e siell

re
nonmotile. The
nti iotic p
ttern of resist
nce to c
r enicillin
nd
mpicillin
is ch
r
cteristic
for Kle siell
. 42. D Typic
lly, the IMViC re
ctions for the or
nisms listed
r
e: E. coli (++00)
S. typhi (0+00) Y. enterocolitic
(V+00) P. vul
ris (++00) Note: Indole re
ctio
n is v
ri
le (V)
for Y. enterocolitic
. 43. A The most likely or
nism is
species of Shiell
.
Typic
lly,
S
lmonell
spp. produce H 2 S-positive colonies th
t displ
y l
ck centers on th
e di erenti
l
medi
(except on M
cConkey

r). The iochemic
l tests listed
re necess
ry to
di erenti
te
Shiell
from E. coli ec
use some E. coli str
ins cross-re
ct with Shiell
typ
in ser
.
Shiell
spp.
re one of the most common c
uses of
cteri
l di
rrhe
; roup D (
S. sonnei )
nd
roup B (S. exneri )
re the species most often isol
ted. 44. B S. m
rcescens h

s een
implic
ted in numerous nosocomi
l infections
nd is reconized
s
n import
nt p

thoen with
inv
sive properties. Gel
tin hydrolysis
nd DN
se
re positive for oth the Prot
eus spp.
nd
Serr
ti
, ut the ne
tive ure
se
nd phenyl
l
nine de
min
se
re di erenti
l. E.
clo
c
e does
not produce DN
se, el
tin
se, or lysine dec
r oxyl
se. 44. A le-wound culture
from

hospit
lized 70-ye
r-old di
etic m
n rew motile, l
ctose-ne
tive colonies on
M
cConkey

r.
Given the followin iochemic
l re
ctions
t 24 hours, wh
t is the most pro
le
or
nism? H 2 S
(TSI) = Ne Indole = Ne MR = Ne VP = + DN
se = + Citr
te = + Ure
se = Ne Phen
yl
l
nine
de
min
se = Ne Ornithine
nd lysine dec
r oxyl
se = + Arinine dec
r oxyl
se =
Ne Gel
tin
hydrolysis = + A. Proteus vul
ris B. Serr
ti
m
rcescens C. Proteus mir
ilis D
. Entero
cter
clo
c
e Micro ioloy/Ev
lu
te l
or
tory d
t
to m
ke identi c
tions/Gr
m-ne
tive

cilli/3
2828_Ch07_381-494 06/08/12 11:24 AM P
e 397 45. Tree lood cultures t
ken fr
om
30-ye
r-old

c
ncer p
tient receivin chemother
py
nd
dmitted with
urin
ry tr
ct infectio
n rew
l
ctose-ne
tive, motile, r
m-ne
tive rods prior to
nti iotic ther
py. Given
the followin
iochemic
l re
ctions, which is the most likely or
nism? H 2 S (TSI) = + Indole
= + MR = + VP =
Ne Citr
te = Ne Ure
se = + DN
se = + Phenyl
l
nine de
min
se = + Gel
tin hydro
lysis = +
Ornithine dec
r oxyl
se = Ne A. Proteus vul
ris B. Proteus mir
ilis C. Serr
t
i
m
rcescens D.
Kle siell
pneumoni
e Micro ioloy/Ev
lu
te l
or
tory d
t
to m
ke identi c
tions
/Gr
m-ne
tive

cilli/3 46. Tree consecutive stool cultures from
25-ye
r-old m
le p
tient pr
oduced sc
nt
norm
l fec
l or
on M
cConkey
nd Hektoen

rs. However, colonies on CIN

r
(cefsulodinir
s
nnovo iocin) displ
yed ulls-eye colonies
fter 48 hours incu
tion
. Te
p
tient h
d een su erin from enterocolitis with fever, di
rrhe
,
nd
domin
l p

in for 2 d
ys.
Wh
t is the most likely identi c
tion of this r
m-ne
tive rod? A. E. coli B. Pro
teus mir
ilis
C. Yersini
enterocolitic
D. Kle siell
pneumoni
e Micro ioloy/Ev
lu
te l
or

tory d
t
to m
ke
identi c
tions/Gr
m-ne
tive
cilli/3 47. A 6-ye
r-old fem
le p
tient w
s
dmitte
d to the
hospit
l followin 2 d
ys of severe di
rrhe
. Cultures from three consecutive st
ool s
mples
cont
ined lood
nd mucus. P
tient history reve
led
h
m urer lunch
t
f
stfood rest
ur
nt 3
d
ys e
rlier. Which p
thoen is most likely responsi le for the followin result
s? Growth on: XLD


r = yellow colonies HE

r = yellow colonies M
c

r = liht pink
nd d
rk
pink colonies M
c
with sor itol

r few d
rk pink
nd m
ny colorless colonies A. S
lmonell
spp.
B. Shiell

spp. C. E. coli O157:H7 D. Yersini
enterocolitic
Micro ioloy/Ev
lu
te l
or
t
ory d
t
to m
ke
identi c
tions/Gr
m-ne
tive
cilli/3 398 Ch
pter 7 | Micro ioloy Answers to Q
uestions 4547
45. A Althouh P. mir
ilis is more frequently recovered from p
tients with urin

ry tr
ct
infections, P. vul
ris is commonly recovered from immunosuppressed p
tients. P.
mir
ilis is
indole ne
tive
nd ornithine dec
r oxyl
se positive ut otherwise is very simil

r to P.
vul
ris. 46. C Most mem ers of the Entero
cteri
ce
e f
mily produce detect
le
rowth on
M
cConkey

r within 24 hours. Yersini
enterocolit
produces nonl
ctose-ferment
in colonies on
M
cConkey

r, s
lmon-colored colonies on Hektoen

r,
nd yellow or colorless
colonies on XLD


r. If Yersini
enterocolitic
is suspected, speci
lized

r (CIN) is employe
d. The typic
l
ulls-eye colonies, d
rk red with
tr
nslucent order, c
n e confused with Aer
omon
s spp. th
t

ppe
r simil
rly on CIN

r. To di erenti
te,
n oxid
se test must e performed,
since Yersini

spp.
re oxid
se ne
tive
nd Aeromon
s spp.
re oxid
se positive. 47. C In
mm
ti
on with
leedin of the mucos
of the l
re intestine (hemorrh
ic colitis) is
result

of
n
enterohemorrh
ic E. coli (EHEC) infection
ssoci
ted with cert
in serotypes, su
ch
s E. coli
O157:H7. The source of the E. coli infection is from inestion of undercooked r
ound eef
cont
min
ted with fec
l m
tter or drinkin r
w milk. 2828_Ch07_381-494 06/08/12
11:24 AM P
e
398 48. Followin
2-week c
mpin trip to the Southwest (US),
65-ye
r-old m
l
e p
tient w
s
hospit
lized with
hih fever
nd
n in
mm
tory swellin of the
xill

nd roin
lymph nodes.
Sever
l lood cultures were o t
ined, resultin in rowth of r
m-ne
tive rods
resem lin
closed s
fety pins. Te or
nism rew on M
cConkeys

r showin nonl
ctose-fermentin

colonies. Testin demonstr
ted
nonmotile rod th
t w
s iochemic
lly inert. Wh

t is the most
likely identi c
tion? A. Yersini
pestis B. Kle siell
pneumoni
e C. Proteus vul

ris D.
Mor
nell
mor
nii Micro ioloy/Ev
lu
te l
or
tory d
t
to m
ke identi c
tions/G
r
m-ne
tive

cilli/3 49. Te m
jority of clinic
l l
or
tories with
micro ioloy dep
rtmen
t should h
ve the
c
p
ility of serotypin which p
thoenic Entero
cteri
ce
e? A. Yersini
entero
colitic
,
Shiell
spp. B. E. coli O157:H7, S
lmonell
spp., Shiell
spp. C. Yersini
pes
tis, S
lmonell

spp. D. Edw
rdsiell
spp., S
lmonell
spp. Micro ioloy/Apply knowlede of st
nd

rd oper
tin
procedures/Identi c
tion/2 50. Direct spre
d of pneumonic pl
ue dise
se occurs y
which route?
A. Fec
lor
l route B. R
t ite C. Inestion of cont
min
ted tissue D. Inh
l
tion
of cont
min
ted

ir orne droplets Micro ioloy/Apply knowlede of epidemioloy of tr
nsmission/2
51. Which
isol
tes of the Entero
cteri
ce
e f
mily most commonly produce extended-spectru
m -l
ct
m
se
(ESBL)? A. E. coli
nd Kle siell
pneumoni
e B. Yersini
enterocolitic

nd Yers
ini
pestis C.
Mor
nell
mor
nii
nd Proteus vul
ris D. S
lmonell
typhi
nd Shiell
sonnei
Micro ioloy/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics/Anti ioti
c
suscepti ility/2 7.2 | Entero
cteri
ce
e 399 Answers to Questions 4851 48. A
Yersini

pestis is the c
use of u onic
nd pneumonic pl
ue. Bu onic pl
ue c
uses swell
in of the roin
lymph nodes ( u os), where
s pneumonic pl
ue involves the luns. The infection
c
used y u onic
pl
ue m
y result in fulmin
nt
cteremi
th
t is usu
lly f
t
l. The tr
nsmissio
n is from rodents
(r
ts, round squirrels, or pr
irie dos) to hum
ns y the ite of e
s (vectors)
or y inestion
of cont
min
ted
nim
l tissues. Pneumonic pl
ue is
cquired vi
the
ir orne ro
ute when there is
close cont
ct with other pneumonic pl
ue victims. 49. B Prelimin
ry seroloic
l
roupin of the
S
lmonell
spp.
nd Shiell
spp. should e performed, since reli
le commerci
l
polyv
lent

ntiser

re
v
il
le. Sor itol-ne
tive (M
cConkey

r with sor itol) colonie
s of E. coli

should e tested usin commerci
lly
v
il
le
ntiser
for som
tic O
ntien 157

nd
ell
r
H
ntien 7. However, Yersini
pestis isol
tes should e sent to
pu lic he
lth l

or
tory for
testin, since clinic
l l
or
tories ener
lly do not h
ve the typin ser

v
il

le. 50. D
Bu onic pl
ue involves
n in
mm
tory swellin of the lymph nodes of the
xill


nd roin,
where
s pneumonic pl
ue is
ssoci
ted with
n
ir orne route involvin the lun
s. Both
infections
re c
used y the s
me mem er of the Entero
cteri
ce
e f
mily, Yersi
ni
pestis. 51. A
Point mut
tions occur in most mem ers of the Entero
cteri
ce
e f
mily th
t resu
lt in production
of
-l
ct
m
se th
t hydrolyzes ro
d-spectrum
nti iotics such
s the ceph
lospo
rins
s well
s
penicillin
nd mono
ct
m
nti iotics. These
re known
s ESBL producers. The mo
st common ESBL
or
nisms
re Kle siell
pneumoni

nd E. coli. ESBL str
ins
re detected y dem
onstr
tin their
resist
nce to -l
ct
m
nti iotics. 2828_Ch07_381-494 06/08/12 11:24 AM P
e 39
9 400 7.3
Nonferment
tive B
cilli 1. Wh
t
re the most
ppropri
te screenin tests to pres
umptively
di erenti
te
nd identify the nonferment
tive r
m-ne
tive
cilli (NFB) from the
Entero
cteri
ce
e? A. C
t
l
se, dec
r oxyl
tion of
rinine, rowth on lood


r B. Motility,
ure
se, morpholoy on lood

r C. Oxid
se, TSI, nitr
te reduction, rowth on M

cConkey

r D.
Oxid
se, indole,
nd rowth on lood

r Micro ioloy/Ev
lu
te l
or
tory d
t

to m
ke
identi c
tions/NFB/2 2. Presumptive tests used for identi c
tion of the Pseudomon
s
spp.
re: A.
Oxid
se, oxid
tionferment
tion (OF) lucose (open), OF lucose (se
led), motility
, piment
production B. Growth on lood

r pl
te (BAP)
nd eosinmethylene lue (EMB)

r
s, lysine
dec
r oxyl
tion, c
t
l
se C. Growth on M
cConkey, EMB,
nd XLD

rs
nd motilit
y D. Growth on
m
nnitol s
lt

r
nd
ell
r st
in Micro ioloy/Ev
lu
te l
or
tory d
t
to m
k
e
identi c
tions/NFB/2 3. Which tests
re most
ppropri
te to di erenti
te etween Pse
udomon
s

eruinos

nd Pseudomon
s putid
? A. Oxid
se, motility, pyoverdin B. Oxid
se, m
otility, l
ctose
C. Oxid
se, ONPG, DN
se D. M
nnitol, nitr
te reduction, rowth
t 42C Micro iolo
y/Ev
lu
te
l
or
tory d
t
to m
ke identi c
tions/NFB/2 4. Which test roup est di erenti
tes
Acineto
cter

um
nnii from P.
eruinos
? A. Oxid
se, motility, NO 3 reduction B. M
cConkey
rowth, 37C
rowth, c
t
l
se C. Blood

r rowth, oxid
se, c
t
l
se D. Oxid
se, TSI, M
cCon
key rowth
Micro ioloy/Ev
lu
te l
or
tory d
t
to m
ke identi c
tions/NFB/2 Answers to Ques
tions 14 1. C
NFB will row on the sl
nt of TSI or KIA ut they do not
cidify the utt (luco
se ferment
tion),

s do the Entero
cteri
ce
e. NFB c
n e cytochrome oxid
se positive or ne
tive
, ut
ll the
Entero
cteri
ce
e
re oxid
se ne
tive. The Entero
cteri
ce
e row well on M
c

Conkey

r
nd

reduce nitr
te to nitrite, ut the NFB row poorly or not
t
ll
nd most do not
reduce nitr
te.
Ne
rly 70% of the NFB recovered from clinic
l specimens
re: Str
ins of Psuedom
on
s
eruinos

Acineto
cter
um
nnii Stenotrophomon
s m
ltophili
2. A The use of OF tu es he
lps to determine
the presumption of
nonferment
tive
cillus (lucose oxid
tion positive
nd l
ucose
ferment
tion ne
tive). The positive cytochrome oxid
se test
nd piment product
ion indic
te

possi le Pseudomon
s species. Sever
l NFB produce piments th
t
id in species i
denti c
tion: P.

eruinos
produces yellow pyoverdins ( uorescein)
nd/or pyocy
nin ( lue
qu
pi
ment). The
ch
r
cteristic r
pelike odor of
mino
cetophenone
s well
s rowth
t 42C
re c
h
r
cteristics
of P.
eruinos
. 3. D Both or
nisms
re oxid
se positive, motile,
nd produce
pyoverdin. Both

re ne
tive for ONPG
nd DN
se. The di erenti
tin tests
re: Test P.
eruinos

P. putid

M
nnitol + Ne Reduce NO 3 + Ne to NO 2 42C rowth + Ne 4. A Acineto
cter sp
p.
re
nonmotile rods th
t
ppe
r
s cocco
cill
ry forms from clinic
l specimens. All

re oxid
se
ne
tive
nd c
t
l
se positive. P.
eruinos
reduces NO 3 to NO 2 , while A.

um
nnii does not.
2828_Ch07_381-494 06/08/12 11:24 AM P
e 400 5. In
ddition to motility, whic
h test est
di erenti
tes Acineto
cter spp.
nd Alc
lienes spp.? A. TSI B. Oxid
se C. C
t
l

se D. Fl
ell
r
st
in Micro ioloy/Select methods/Re
ents/Medi
/NFB/ Identi c
tion/2 6. Te most n
oted di erences
etween P.
eruinos

nd Stenotrophomon
s m
ltophili

re: A. Oxid
se, c
t
l
se
,
nd TSI B.
Oxid
se, c
t
l
se,
nd ONPG C. Oxid
se, 42C rowth,
nd pol
r tuft of
ell
D. C

t
l
se, TSI,

nd piment Micro ioloy/Ev
lu
te l
or
tory d
t
to m
ke identi c
tions/NFB/2 7.
Which
Pseudomon
s is usu
lly
ssoci
ted with
lun infection rel
ted to cystic
rosis?
A. P.
uorescens B. P.
eruinos
C. P. putid
D. Burkholderi
pseudom
llei Micro ioloy
/Apply
knowlede of fund
ment
l ioloic
l ch
r
cteristics/NFB/2 8. A nonfermenter reco
vered from
n eye
wound is oxid
se positive, motile with pol
r monotrichous
ell
,
nd rows
t 42C
. Colonies

re dry, wrinkled or smooth, u to liht rown in color,
nd
re di cult to remove
from the


r. In which DNA homoloy roup should this or
nism e pl
ced? A. Pseudomon
s
stutzeri B.
Pseudomon
s uorescens C. Pseudomon
s
lc
lienes D. Pseudomon
s diminut
Micro io
loy/Apply
knowlede of fund
ment
l ioloic
l ch
r
cteristics/NFB/2 9. Which or
nism is

ssoci
ted with
immunode ciency syndromes
nd melioidosis (
l
nders-like dise
se in Southe
st As
i

nd northern
Austr
li
)? A. Pseudomon
s
eruinos
B. Pseudomon
s stutzeri C. Pseudomon
s put
id
D.
Burkholderi
pseudom
llei Micro ioloy/Apply knowlede of fund
ment
l ioloic
l

ch
r
cteristics/NFB/2 7.3 | Nonferment
tive B
cilli 401 Answers to Questions 59

5. B The two
ener
, Acineto
cter
nd Alc
lienes,
re very simil
r. Both use oxid
tion for
the met
olism of
c
r ohydr
te, with some str
ins ein nons
cch
rolytic. Both row well on M
cCon
key

r.
However, Acineto
cter is nonmotile
nd oxid
se ne
tive. Alc
lienes is motile
y peritrichous

ell

nd oxid
se positive. 6. C The two ener
, Pseudomon
s
nd Stenotrophomon

s,
re motile

nd row well on M
cConkey

r. However, P.
eruinos
is oxid
se positive
nd
rows
t 42C ut
is motile only y pol
r monotrichous
ell
. S. m
ltophili
is oxid
se ne
tive,
does not row

t 42C,
nd is motile y
pol
r tuft of
ell
. 7. B P.
eruinos
is often rec
overed from
the respir
tory secretions of cystic
rosis p
tients. If the p
tient is chronic
l
ly infected
with the mucoid str
in of P.
eruinos
, the iochemic
l identi c
tion is very di cu
lt. The
mucoid str
in results from production of l
re
mounts of
lin
te,
polys
cch

ride th
t
surrounds the cell. 8. A P. stutzeri produces dry, wrinkled colonies th
t
re
touh
nd
dhere
to the medi

s well
s smooth colonies. B. pseudom
llei produces simil
r colony
types ut is
distinuished y iochemic
l tests
nd suscepti ility to the polymyxins. The col
onies of P.
stutzeri
re u to liht rown ec
use of the rel
tively hih concentr
tion of cy
tochromes. 9. D
B. pseudom
llei produces wrinkled colonies resem lin P. stutzeri. Infections

re usu
lly

symptom
tic
nd c
n e di
nosed only y seroloic
l methods. The or
nism exis
ts in soil
nd
w
ter in
n
re
of l
titude 20 north
nd south of the equ
tor (m
inly in Th
il
n
d
nd Vietn
m).
Thous
nds of U.S. milit
ry personnel were infected with these
cteri
durin th
e 1960s
nd
1970s. The dise
se m
y re
ctiv
te m
ny ye
rs
fter exposure
nd h
s een c
lled
the Vietn
mese
time om . 2828_Ch07_381-494 06/08/12 11:24 AM P
e 401 10. Which iochemic
l
tests
re
needed to di erenti
te Burkholderi
cep
ci
from S. m
ltophili
? A. Piment on lo
od

r,
oxid
se, DN
se B. Piment on M
cConkey

r,
ell
r st
in, motility C. Glucose,
m
ltose, lysine
dec
r oxyl
se D. TSI, motility, oxid
se Micro ioloy/Ev
lu
te l
or
tory d
t
to
m
ke
identi c
tions/NFB/2 11. Te followin results were o t
ined from
pure culture of
r
m-ne
tive
rods recovered from the pulmon
ry secretions of
10-ye
r-old cystic rosis p
tie
nt with
pneumoni
: Oxid
se = + Motility = + Glucose OF (open) = + Gel
tin hydrolysis =
+ Piment = Red
Arinine dihydrol
se = + (non uorescent) Growth
t 42C = + Fl
ell
= + (pol
r, mon
otrichous)
Which is the most likely or
nism? A. Burkholderi
pseudom
llei B. Pseudomon
s s
tutzeri C.
Burkholderi
cep
ci
D. Pseudomon
s
eruinos
Micro ioloy/Ev
lu
te l
or
tory
d
t
to m
ke

identi c
tions/NFB/3 12. Alc
lienes f
ec
lis (formerly A. odor
ns) is distinuis

hed from
Bordetell
ronchiseptic
with which test? A. Ure
se (r
pid) B. Oxid
se C. Growt
h on M
cConkey


r D. Motility Micro ioloy/Ev
lu
te l
or
tory d
t
to m
ke identi c
tions/NFB/
2 13.
Chryseo
cterium spp.
re e
sily distinuished from Acineto
cter spp. y which
of the followin
two tests? A. Oxid
se, rowth on M
cConkey

r B. Oxid
se
nd OF (lucose) C. T
SI
nd ure

hydrolysis D. TSI
nd VP Micro ioloy/Ev
lu
te l
or
tory d
t
to m
ke identi c
ti
ons/NFB/2 402
Ch
pter 7 | Micro ioloy Answers to Questions 1013 10. A Both or
nisms produce y
ellowish
piment
nd h
ve pol
r tuft
ell
, ut the oxid
se
nd DN
se tests
re di erenti
l
. Test B.
cep
ci
S. m
ltophili
Piment on BAP Green-yellow L
vender-reen Oxid
se + Ne
DN
se Ne +
Motility + + Glucose OF + + (open) M
ltose OF + + (open) Lysine + + dec
r oxy
l
se 11. D The
oxid
se test
nd red piment (pyoru in),
s well
s rowth
t 42C, distinuish P.

eruinos

from the other pseudomon
ds listed, p
rticul
rly B. cep
ci
, which is
lso
ssoc
i
ted with cystic
rosis. 12. A Alc
lienes
nd Bordetell

re ener
elonin to the Alc
lien

ce
e f
mily.
The two or
nisms
re very simil
r iochemic
lly, ut B. ronchiseptic
is ure
s
e positive. Both
or
nisms
re oxid
se positive, row on M
cConkey

r,
nd
re motile y peritr
ichous
ell
.
B. ronchiseptic
rows well on M
cConkey

r ut other species of Bordetell


re f
stidious
r
m-ne
tive rods. 13. A Chryseo
cteriumspp.
nd Acineto
cter spp. often pr
oduce
yellow
piment on lood or chocol
te

r
nd
re nonmotile. Acineto
cter spp.
re oxi
d
se ne
tive,
row on M
cConkey

r,
nd
re cocco
cill
ry on the Gr
m st
in sme
r. In contr

st,
Chryseo
cteriumspp.
re oxid
se positive, do not row on M
cConkey

r,
nd
r
e typic
lly rod
sh
ped. Chryseo
cterium meninosepticumis hihly p
thoenic for prem
ture inf
n
ts.
2828_Ch07_381-494 06/08/12 11:24 AM P
e 402 14. A r
m-ne
tive cocco
cillu
s w
s recovered
on chocol
te

r from the CSF of
n immunosuppressed p
tient. The or
nism w
s
nonmotile
nd
positive for indophenol oxid
se ut f
iled to row on M
cConkey

r. The or
ni
sm w
s hihly
suscepti le to penicillin. The most pro
le identific
tion is: A. Acineto
cter
spp. B.
Pseudomon
s
eruinos
C. Pseudomon
s stutzeri D. Mor
xell
l
cun
t
Micro iolo
y/Ev
lu
te
l
or
tory d
t
to m
ke identi c
tions/NFB/2 15. Cetrimide

r is used
s
selec
tive isol
tion


r for which or
nism? A. Acineto
cter spp. B. Pseudomon
s
eruinos
C. Mor

xell
spp. D.
Stenotrophomon
s m
ltophili
Micro ioloy/Select methods/Re
ents/Medi
/NFB/ Ide
nti c
tion/2 16.
A specimen from
15-ye
r-old fem
le urn p
tient w
s cultured
fter d ridement,

nd the

followin results were o t
ined: Oxid
se = + Lysine dec
r oxyl
se = Ne C
t
l
se
= + Motility = +
Ornithine dec
r oxyl
se Glucose = + for oxid
tion = Ne (open tu e) Arinine di
hydrol
se = +
M
ltose = Ne for oxid
tion (open tu e) Penicillin = Resist
nt Aminolycosides =
Suscepti le
Colistin (Polymixin B) = Suscepti le Tese results indic
te which of the followin
 or
nisms? A.
Acineto
cter
um
nnii B. Mor
xell
l
cun
t
C. Pseudomon
s
eruinos
D. Acine
to
cter lwo i
Micro ioloy/Ev
lu
te l
or
tory d
t
to m
ke identi c
tions/NFB/3 17. A yellow pi
mentproducin
or
nism th
t is oxid
se positive, nonmotile,
nd does not row on M
cConkey


r is: A.
Acineto
cter
um
nnii B. Acineto
cter lwo i C. Burkholderi
cep
ci
D. Chryseo

cterium
meninosepticum Micro ioloy/Ev
lu
te l
or
tory d
t
to m
ke identi c
tions/NFB/2
7.3 |
Nonferment
tive B
cilli 403 Answers to Questions 1418 14. D Mor
xell
spp.
re
oxid
se
positive
nd nonmotile, which distinuishes them from Acineto
cter spp.
nd mos
t Pseudomon
s
spp. Mor
xell
spp.
re hihly sensitive to penicillin, ut Acineto
cter spp.

nd Pseudomon
s
spp.
re penicillin resist
nt. M. l
cun
t
is implic
ted in infections involvin
immunosuppressed
p
tients. 15. B Cetrimide (
cetyl trimethyl
mmonium romide)

r is used for t
he isol
tion
nd
identi c
tion of P.
eruinos
. With the exception of P. uorescens, the other pseud
omon
ds
re
inhi ited
lon with rel
ted nonferment
tive
cteri
. 16. C P.
eruinos
is

c
use of

sini c
nt num er of urn wound infections; these or
nisms c
n exist in distilled
w
ter
nd
underchlorin
ted w
ter. Acineto
cter spp.
re oxid
se ne
tive
nd Mor
xell
sp
p.
re hihly
suscepti le to penicillin, rulin them out
s possi le c
uses. 17. D All species
of Acineto
cter

re oxid
se ne
tive
nd row on M
cConkey

r. Chryseo
cteriumspp. produce ye
llow piment
(like Acineto
cter) ut
re oxid
se positive
nd do not row on M
cConkey

r.
B. cep
ci

lso
produces
yellow piment ut is motile. 18. A In the nitr
te test, nitrites for
med y
cteri
l
reduction of nitr
tes will di
zotize sulf
nilic
cid. The di
zonium compound com
plexes with
-n
phthyl
mine, formin
red product. Medi
cont
inin nitr
tes
re used for the
identi c
tion
of nonfermenters. When testin nonfermenters, it is wise to con rm
ne
tive re
c
tion usin zinc
dust. The di
zonium compound detects nitrite only,
nd the or
nism m
y h
ve red
uced the nitr
tes
to nitroen,
mmoni
, nitrous oxide, or hydroxyl
mine. Zinc ions reduce residu
l
nitr
tes in the
medi
to nitrites. A red color produced
fter
ddition of zinc indic
tes the pre
sence of residu
l
nitr
tes, con rmin
true ne
tive re
ction. If
red or pink color does not occu
r
fter
ddin
zinc, then the or
nism reduced the nitr
te to
product other th
n nitrite,
nd
the test is

considered positive. 18. Which re
ent(s) is (
re) used to develop the red color
indic
tive of

positive re
ction in the nitr
te reduction test? A. Sulf
nilic
cid
nd -n
phthyl

mine B.
Ehrlichs
nd Kov
cs re
ents C. o-Nitrophenyl--D-
l
ctopyr
noside D. Kov
cs re
ent
Micro ioloy/Apply knowlede of iochemic
l re
ctions/B
cteri
/1 2828_Ch07_381-4
94 06/08/12
11:25 AM P
e 403 19. A culture from
n intr
-
domin
l
scess produced or
ne
-t
n colonies on
lood

r th
t 
ve the followin results: Oxid
se = + Nitr
te reduction = + KI
A = Alk/Alk (H 2
S)+ Motility = + (sinle pol
r
ellum) DN
se = + Ornithine dec
r oxyl
se = + Gro
wth
t 42C =
Ne Te most likely identi c
tion is: A. Shew
nell
putref
ciens B. Acineto
cter s
pp. C.
Pseudomon
s
eruinos
D. Chryseo
cterium spp. Micro ioloy/Ev
lu
te l
or
tory
d
t
to m
ke
identi c
tions/NFB/3 20. Chryseo
cterium spp.
nd B. cep
ci

re e
sily di erenti

ted y which
test? A. Motility B. OF lucose C. Oxid
se D. Cetrimide

r Micro ioloy/Ev
lu

te l
or
tory
d
t
to m
ke identi c
tions/NFB/2 21. A 15-ye
r-old fem
le compl
ined of
severe
eye irrit
tion

fter removin her soft-cont
ct lenses. A sw
of the infected riht eye w
s o t

ined y
n
ophth
lmoloist, who ordered
culture
nd sensitivity test. Te culture w
s pl
t
ed on lood

r

nd M
cConkey

r. At 24 hours, rowth of
r
m-ne
tive rod th
t tested posit
ive for
cytochrome oxid
se w
s noted. Te MuellerHinton sensitivity pl
te showed
luishreen l
wn of
rowth th
t proved hihly resist
nt to most of the
nti iotics tested except
mi
k
cin,
to r
mycin,
nd cipro ox
cin. Wh
t is the most likely identi c
tion? A. Burkholderi

cep
ci
B.
Pseudomon
s
eruinos
C. Stenotrophomon
s m
ltophili
D. Acineto
cter
um
nni
i
Micro ioloy/Apply knowlede of l
or
tory d
t
to m
ke identi c
tions/GNNFB/3 22.
Which of the
listed Pseudomon
s spp. is
ssoci
ted with the followin virulence f
ctors: exot
oxin A,
endotoxins, proteolytic enzymes,
ntimicro i
l resist
nce,
nd production of
l
in
te? A. P.
uorescens B. P. putid
C. P. stutzeri D. P.
eruinos
Micro ioloy/Apply knowled
e of
virulence/ Identi c
tion/GNNFB/2 404 Ch
pter 7 | Micro ioloy Answers to Questio
ns 1923 19. A
S. putref
ciens produces
und
nt H 2 S on KIA or TSI. Shew
nell
e
re the only
nonfermenters
th
t produce H 2 S on these medi
. 20. A B. cep
ci
(93%)
re we
kly oxid
se p
ositive
nd
motile. Chryseo
cteriumspp.
re oxid
se positive ut
re nonmotile. 21. B P.

eruinos
is
n
opportunistic or
nism th
t is not p
rt of the hum
n norm
l or
. Cont
ct lens sol
ution
cont
min
tion, eye injury, or cont
ct lens eye tr
um

re f
ctors th
t contri ut
e to P.

eruinos
eye infections. The ch
r
cteristic lue-reen piment on MuellerHinton


r
(pyocy
nin piment) produced y P.
eruinos

nd the hih resist
nce to
nti io

tics
id in its

identi c
tion. 22. D P.
eruinos
is hihly resist
nt to m
ny
ntimicro i
l dru
s
s well
s
ein one of the most often cultured opportunistic or
nisms. This virulence f
c
tor
llows for
m
ny nosocomi
l infections such
s those of the urin
ry tr
ct, wounds ( urn p
ti
ents),

cteremi
, respir
tory tr
ct,
nd CNS. 23. A Burkholderi
m
llei is r
rely tr

nsmitted to
hum
ns. It is the c
us
tive
ent of l
nders in mules, donkeys,
nd horses. It
is not p
rt of
the hum
n skin or

nd the most likely tr
nsmission to hum
ns is throuh roken s
kin. 23. A
20-ye
r-old horse roomer exhi ited
l
nders-like infection. His history indic
t
ed he h
d
su ered sever
l open wounds on his h
nds 2 weeks efore the swellin of his lymph
nodes. A
r
m-ne
tive rod w
s recovered from
lood culture th
t rew well on lood
nd
M
cConkey

rs.
Most of the iochemic
l tests were ne
tive, includin the cytochrome oxid
se te
st. Wh
t is the
most likely identi c
tion? A. Burkholderi
m
llei B. Pseudomon
s
eruinos
C. Pse
udomon
s
stutzeri D. Burkholderi
pseudom
llei Micro ioloy/Apply epidemioloy for ID/GNN
FB/3
2828_Ch07_381-494 06/08/12 11:25 AM P
e 404 24. A Vietn
m W
r veter
n presen
ted with

l
nders-like infection (melioidosis). Sever
l lood cultures produced r
m-ne
ti
ve rods th
t
were positive for cytochrome oxid
se, oxidized lucose
nd xylose,
nd rew
t 4
2C. Wh
t is the
most likely or
nism? A. Stenotrophomon
s m
ltophili
B. Burkholderi
pseudom
ll
ei C. Pseudomon
s

eruinos
D. Acineto
cter spp. Micro ioloy/Apply knowlede for identi c
tion/ G
NNFB/2 25.
Cytochrome oxid
se-positive, nonferment
tive r
m-ne
tive
cilli were recovere
d from the stool
of
cystic rosis (CF) p
tient. Te isol
tes produced wet (mucoidy) colonies on
lood

r.
Which identi c
tion is most likely? A. Acineto
cter spp. B. Pseudomon
s
lc
lien
es C.
Pseudomon
s stutzeri D. Pseudomon
s
eruinos
Micro ioloy/Apply knowlede for
identi c
tion/
NFGNB/2 7.3 | Nonferment
tive B
cilli 405 Answers to Questions 2425 24. B Bur
kholderi

pseudom
llei infections often produce
scesses in or
ns (liver, spleen, luns)

s well
s on
the skin, in soft tissue,
nd in joints
nd ones. Vietn
m W
r veter
ns especi
l
ly m
y h
r or
these or
nisms, which
re limited to tropic
l
nd su tropic
l environments (Sou
the
st Asi

nd
Austr
li
). The or
nism m
y surf
ce ye
rs l
ter
fter survivin in
l
tent st

te within
ph
ocytes. The surf
ces of rice p
ddies in Northern Th
il
nd h
ve
hih prev
l
ence of this
or
nism. 25. D Infected CF p
tients usu
lly do not esc
pe P.
eruinos
infecti
ons completely.
P.
eruinos
produces
lin
te th
t
ccounts for the wet, mucoidy
ppe
r
nce of c
olonies. This
overproduction of
lin
te is thouht to c
use the inhi ition of ph
ocytosis. T

he result is
chronic infections in CF p
tients with the wet form of P.
eruinos
. 2828_Ch07_38
1-494
06/08/12 11:25 AM P
e 405 406 7.4 Miscell
neous
nd F
stidious Gr
m-Ne
tive
Rods 1. A visitor
to South Americ
who returned with di
rrhe
is suspected of ein infected with
V. choler
e.
Select the est medium for recovery
nd identi c
tion of this or
nism. A. M
cConk
ey

r B.
Blood

r C. TCBS

r D. XLD

r Micro ioloy/Select methods/Re
ents/Medi
/B

cteri
/
Identi c
tion/2 2. A curved r
m-ne
tive rod producin oxid
se-positive colonies
on lood

r
w
s recovered from
stool culture. Given the followin results, wh
t is the mos
t likely
identific
tion? Lysine dec
r oxyl
se = + Arinine dec
r oxyl
se = Ne Indole = +
KIA = Alk/Acid
VP = Ne L
ctose = Ne Ure
se =  Strin test = Ne TCBS

r = Green colonies A.
Vi rio choler
e
B. Vi rio p
r
h
emolyticus C. Shiell
spp. D. S
lmonell
spp. Micro ioloy/Ev
l
u
te l
or
tory
d
t
to m
ke identi c
tions/B
cteri
/3 3. A r
m-ne
tive S-sh
ped rod recovered f
rom selective
medi
for C
mpylo
cter species 
ve the followin results: C
t
l
se = + Oxid
se
= + Motility = +
Hippur
te hydrolysis = + Growth
t 42C = + N
lidixic
cid = Suscepti le Piment =
Ne Gr
pe odor
= Ne Ceph
lothin = Resist
nt Te most likely identi c
tion is: A. Pseudomon
s
eru
inos
B.
C
mpylo
cter jejuni C. C
mpylo
cter fetus D. Pseudomon
s putid
Micro ioloy/E
v
lu
te
l
or
tory d
t
to m
ke identi c
tions/B
cteri
/3 Answers to Questions 14 1. C The
rowth of
yellow or reen colonies on the selective TCBS

r (thiosulf
te citr
te ile s

lts sucrose) is
dependent on whether the or
nism ferments sucrose (producin yellow colonies).
Vi rio
lso row
well on 5% sheep lood, chocol
te,
nd M
cConkey

rs. Enrichment with
lk
line
peptone roth,
pH 8.4, helps in recoverin Vi rio spp. from stool specimens. 2. B V. p
r
h
em
olyticus
ppe
r

s reen colonies on TCBS

r, where
s V. choler
e
ppe
r
s yellow colonies on
TCBS. V.
choler
e is the only Vi rio species th
t c
uses
positive strin test. In the t
est,
loopful of

cteri
l colonies is suspended in sodium deoxychol
te, 0.5%, on
l
ss slide.
After 60 seconds,
the inocul
tin loop is lifted out of the suspension. V. choler
e forms
lon s
trin resem lin

strin of pe
rls. S
lmonell
spp.
nd Shiell
spp.
re oxid
se ne
tive. 3. B
The only
C
mpylo
cter spp. th
t hydrolyze hippur
te
re C. jejuni
nd su sp. doylei. How
ever, some
str
ins of P.
eruinos
row on

r selective for C
mpylo
cter
t 42C. C. fetu
s will not row

t 42C ut will row
t 25C
nd 37C. 4. A C
mpylo
cter spp.
re est recovered i
n

micro-
erophilic
tmosphere (reduced O 2 ). The use of
CO 2 incu
tor or c
ndl
e j
r is not
recommended ec
use the
mount of O 2
nd CO 2 do not permit
ny ut the most
e

rotoler
nt
C
mpylo
cter to survive. Cultures for C
mpylo
cter should e incu
ted for 4872
hours efore
reportin no rowth. 4. Which
tmospheric condition is needed to recover C
mpylo

cter spp. from
specimens inocul
ted onto
C
mpy-selective

r
t 35C37C
nd 42C? A. 5% O 2 , 10%
CO 2 ,

nd 85% N 2 B. 20% O 2 , 10% CO 2 ,
nd 70% N 2 C. 20% O 2 , 20% CO 2 ,
nd 60%
N 2 D. 20% O 2 ,
5% CO 2 ,
nd 75% N 2 Micro ioloy/Apply knowlede of fund
ment
l ioloic
l
ch
r
cteristics/B
cteri
/2 2828_Ch07_381-494 06/08/12 11:25 AM P
e 406 5. Wh
ich roup of
tests est di erenti
tes Helico
cter pylori from C. jejuni? A. C
t
l
se, oxid
se,

nd Gr
m st
in
B. C
t
l
se, oxid
se,
nd n
lidixic
cid sensitivity C. C
t
l
se, oxid
se,
nd c
eph
lothin
sensitivity D. Ure
se, nitr
te,
nd hippur
te hydrolysis Micro ioloy/Select
methods/Re
ents/Medi
/B
cteri
/ Identi c
tion/2 6. Which of the followin tests s
hould e done
rst in order to di erenti
te Aeromon
s spp. from the Entero
cteri
ce
e? A. Ure
se
B. OF lucose
C. Oxid
se D. C
t
l
se Micro ioloy/Select methods/Re
ents/Medi
/B
cteri
/ Iden
ti c
tion/2 7.
Which is the est r
pid test to di erenti
te Plesiomon
s shielloides from
Shie
ll
species on
selective enteric

r? A. Oxid
se B. Indole C. TSI D. Ure
se Micro ioloy/Selec
t
methods/Re
ents/Medi
/B
cteri
/ Identi c
tion/2 8. Which
re the est two tests t
o di erenti
te
A. hydrophili
from P. shielloides? A. Oxid
se
nd motility B. DN
se
nd VP C.
Indole
nd lysine
dec
r oxyl
se D. Growth on M
cConkey
nd lood

r Micro ioloy/Select
methods/Re
ents/Medi
/B
cteri
/ Identi c
tion/2 7.4 | Miscell
neous
nd F
stidiou
s Gr
m-Ne
tive
Rods 407 Answers to Questions 58 5. D Helico
cter pylori is found in specimen
s from 
stric
secretions
nd iopsies
nd h
s een implic
ted
s
c
use of 
stric ulcers. It
is found only in
the mucus-secretin epitheli
l cells of the stom
ch. Both H. pylori
nd C. jejun
i
re c
t
l
se

nd oxid
se positive. However, Helico
cter spp.
re ure
se positive, which di ere
nti
tes them
from C
mpylo
cter spp. Test H. pylori C. jejuni Nitr
te reduction Ne + Hippur

te hydrolysis Ne
+ Ure
se + Ne Ceph
lothin sensitivity Sensitive Resist
nt N
lidixic
cid sensit
ivity Resist
nt
Sensitive Test A. hydrophili
P. shielloides -Hemolysis + Ne on sheep lood


r DN
se + Ne
VP + Ne 6. C Aeromon
s hydrophili

nd other Aeromon
s spp. h
ve een implic

ted in
cute
di
rrhe
l dise
se
s well
s cellulitis
nd wound infections. Infections usu
lly
follow exposure
to cont
min
ted soil, w
ter, or food. Aeromon
s rowin on enteric medi

re di er
enti
ted from
the Entero
cteri
ce
e y demonstr
tin th
t colonies
re oxid
se positive. The
Aeromon
s
re
sometimes overlooked
s p
thoens ec
use most str
ins row on selective enteric


r
s l
ctose
fermenters. 7. A P. shielloides is
l
ctose nonfermenter th
t will resem le
Shiell
spp. on

M
cConkey

r. Both
re TSI Alk/Acid
nd ure
se ne
tive. Plesiomon
s produces
indole
nd
Shiell
usu
lly c
uses del
yed production of indole. However, Plesiomon
s is ox
id
se positive,
where
s Shiell
spp.
re oxid
se ne
tive. 8. B Both of these
cteri
c
use di

rrhe
, row well
on enteric

r,
nd m
y e confused with Entero
cteri
ce
e. Both or
nisms
re
positive for
oxid
se, motility, indole,
nd lysine dec
r oxyl
se. The followin re
ctions
re
di erenti
l:
2828_Ch07_381-494 06/08/12 11:25 AM P
e 407 9. Which enus (in which most sp
ecies
re oxid
se

nd c
t
l
se positive) of sm
ll r
m-ne
tive cocco
cilli is
ssoci
ted m
inly
with
nim
ls ut
m
y c
use endoc
rditis,
cteremi
,
s well
s wound
nd dent
l infections in hu
m
ns? A.
Actino
cillus B. Pseudomon
s C. C
mpylo
cter D. Vi rio Micro ioloy/Apply fund

ment
l
ioloic
l ch
r
cteristics/B
cteri
/2 10. Which of the followin tests m
y e us
ed to
di erenti
te C
rdio
cterium hominis from Actino
cillus spp.? A. Gr
m st
in B. In
dole C.
An
ero ic incu
tion D. Oxid
se Micro ioloy/Select methods/Re
ents/Medi
/B
cte
ri
/
Identi c
tion/2 11. A mixture of slender r
m-ne
tive rods
nd cocco
cilli with
rounded ends
w
s recovered from lood cultures followin
p
tients root c
n
l surery. Given
the followin
results
fter 48 hours, wh
t is the most likely or
nism? C
t
l
se = Ne Ornithi
ne dec
r oxyl
se
= + Ure
se = Ne Lysine dec
r oxyl
se = + Oxid
se = + X
nd V requirement = Ne
Indole = Ne
C
r ohydr
tes = Ne (no
cid produced) Growth on lood
nd chocol
te

r = + (w
ith pittin of


r) Growth on M
cConkey

r = Ne A. Eikenell
corrodens B. Actino
cillus sp
p. C.
C
rdio
cterium hominis D. Proteus spp. Micro ioloy/Ev
lu
te l
or
tory d
t
to
m
ke
identi c
tions/B
cteri
/3 12. Kinell
kin
e c
n est e di erenti
ted from Eikene
ll
corrodens
usin which medium? A. Sheep lood

r B. Chocol
te

r C. M
cConkey

r D. X
LD

r
Micro ioloy/Select methods/Re
ents/Medi
/B
cteri
/ Identi c
tion/2 408 Ch
pter
7 |
Micro ioloy Answers to Questions 912 9. A Actino
cillus spp. (formerly CDC r
oups HB-3
nd
HB-4) sh
re m
ny iochemic
l ch
r
cteristics of the H
emophilus spp. Infections
most often

ssoci
ted with this r
m-ne
tive cocco
cillus
re su
cute
cteri
l endoc
rd
itis
nd
periodont
l dise
se (its m
in h
it
t is the mouth). The most common hum
n isol

te is
Actino
cillus
ctinomycetemcomit
ns, which rows slowly on chocol
te

r. It i
s positive for
c
t
l
se, nitr
te reduction,
nd lucose ferment
tion. It does not row on M
cCo
nkey

r
nd is
ne
tive for oxid
se, ure
se, indole, X,
nd V requirements. 10. B C. hominis
is

r
m-ne
tive cocco
cillus iochemic
lly simil
r to Actino
cillus spp. Like Ac
tino
cillus, it

is
c
use of endoc
rditis. However, C
rdio
cteriumspp.
re positive for cytoch

rome oxid
se
nd
ne
tive for nitr
te reduction, while most Actino
cillus
re ne
tive for oxid

se
nd positive
for nitr
te reduction. C. hominis will row on lood

r
fter 4872 hours in 5%
CO 2
t 35C,
ut Actino
cillus requires chocol
te

r. 11. A E. corrodens is
p
rt of th
e norm
l or
of
the upper respir
tory tr
ct
nd the mouth. It is often seen
fter tr
um
to the
he
d
nd neck,
dent
l infections,
nd hum
n ite wounds. It requires lood for rowth. The or

nism c
uses

pittin of the

r where colonies
re loc
ted. The smell of le
ch m
y e
pp
r
ent when the
pl
tes
re uncovered for ex
min
tion. Actino
cillus spp.
nd C. hominis oth ut
ilize sever
l
c
r ohydr
tes,
nd Proteus spp.
re oxid
se ne
tive. 12. A Both Kinell
kin
e

nd E. corrodens

re r
m- ne
tive rods th
t
re oxid
se positive
nd c
t
l
se ne
tive. Both r
ow well on lood

nd chocol
te

rs
nd c
use pittin of the medi
,
nd neither rows on M
cConk
ey or XLD

r.
However, K. kin
e str
ins produce
n
rrow zone of -hemolysis on sheep lood


r simil
r to
th
t of roup B streptococci. 2828_Ch07_381-494 06/08/12 11:25 AM P
e 408 13
. Kinell

kin
e is usu
lly
ssoci
ted with which type of infection? A. Middle e
r B. Endo
c
rditis C.
Meninitis D. Uroenit
l Micro ioloy/Apply fund
ment
l ioloic
l ch
r
cteristi
cs/B
cteri
/1 14.
Cultures o t
ined from
do ite wound produced yellow, t
n,
nd slihtly pink
colonies on lood

nd chocol
te

r with
m
rin of nerlike projections
ppe
rin
s
lm
round
the colonies.
Given the followin results
t 24 hours, which is the most likely or
nism? Oxid

se = + C
t
l
se
= + Growth on M
cConkey

r = Ne Motility = Ne A. Actino
cillus spp. B. Eik
enell
spp. C.
C
pnocytoph

spp. D. Pseudomon
s spp. Micro ioloy/Ev
lu
te l
or
tory d
t
to
m
ke
identi c
tions/B
cteri
/3 15. Smooth r
y colonies showin no hemolysis
re recove
red from
n
infected c
t scr
tch on lood
nd chocol
te

r ut f
il to row on M
cConkey


r. Te or
nisms

re r
m-ne
tive pleomorphic rods th
t
re oth c
t
l
se
nd oxid
se positive

nd stronly
indole positive. Te most likely or
nism is: A. C
pnocytoph

spp. B. P
steurel
l
spp. C.
Proteus spp. D. Pseudomon
s spp. Micro ioloy/Ev
lu
te l
or
tory d
t
to m
ke
identi c
tions/B
cteri
/3 16. Which medi
should e used to recover Bordetell
per
tussis from

n
soph
ryne
l specimen? A. Chocol
te

r B. Blood

r C. M
cConkey

r D. Bo
rdetGenou

r
Micro ioloy/Select methods/Re
ents/Medi
/B
cteri
/ Identi c
tion/2 17. Which med
ium is
recommended for the recovery of Brucell
spp. from lood
nd one m
rrow specime
ns? A. Biph
sic
C
sten
d
ottles with Brucell
roth B. Blood culture ottles with Brucell
ro
th C.
BordetGenou

r pl
tes
nd THIO roth D. Blood culture ottles with THIO roth

Micro ioloy/Select methods/Re
ents/Medi
/B
cteri
/ Identi c
tion/2 7.4 | Miscell

neous
nd
F
stidious Gr
m-Ne
tive Rods 409 Answers to Questions 1317 13. B Kinell
sp
p.
re
r
m-ne
tive cocco
cilli or plump-lookin rods. They
re p
rt of the norm
l or

of the upper
respir
tory
nd uroenit
l tr
cts of hum
ns. Infection is seen prim
rily in p
ti
ents h
vin
underlyin he
rt dise
se, poor or
l hyiene, or i
troenic mucos
l ulcer
tions (
e.., r
di
tion
ther
py), in whom the or
nism is recovered from lood cultures. 14. C C
pnocy
toph


iniv
lis, C. sputien
,
nd C. ochr
ce

re p
rt of the norm
l oroph
ryne
l or

of hum
ns;
however, C. c
nimorsus
nd C. cynodemi (formerly CDC roups DF-2
nd DF-2-like

cteri
)
re

ssoci
ted with infections resultin from do ite wounds. 15. B P
steurell
m
ultocid
(P.
c
nis) is p
rt of the norm
l mouth or
of c
ts
nd dos
nd is frequently recover
ed from wounds
in icted y them. It produces l
re
mounts of indole
nd therefore
n odor resem
lin colonies
of E. coli. Pseudomon
s spp.
re
lso c
t
l
se
nd oxid
se positive ut c
n e
ruled out ec
use
they row on M
cConkey

r
nd do not produce indole. 16. D B. pertussis is
n
oxid
se-positive, nonmotile r
m-ne
tive cocco
cillus
nd
ppe
rs
s sm
ll, ro
und colonies
resem lin droplets of mercury. It is f
stidious
nd does not row on chocol
te
or M
cConkey


r. However, B. pertussis
d
pts to lood

r, rowin within 36 d
ys. This or

nism is the
c
use of whoopin couh, which c
n e prevented y immuniz
tion with diphtheri
,
tet
nus,
pertussis (DPT) v
ccine. The DPT v
ccine cont
ins diphtheri

nd tet
nus toxoids

nd killed
whole-cell B. pertussis. 17. A Althouh lood

r will support the rowth of Br
ucell
spp.,
C
sten
d
ottles
re the medium of choice. C
sten
d
ottles cont
in
sl
nt of
enriched

r
medium th
t is p
rti
lly su mered
nd surrounded y
n enriched roth medium. A
s the specimen is
injected into the ottles
nd mixed, the

r sl
nt is simult
neously co
ted wit
h the lood (or
one m
rrow). Brucell
is the c
use of undul
nt fever
nd is responsi le for m
n
y c
ses of fever
of unknown oriin. Brucell
spp.
re f
cult
tive intr
cellul
r or
nisms
nd ro
w very slowly,
usu
lly requirin 46 weeks for recovery. Brucell
melitensis is the most frquentl
y recovered
species. 2828_Ch07_381-494 06/08/12 11:25 AM P
e 409 18. In
ddition to CO 2
requirements
nd
iochemic
l ch
r
cteristics, Brucell
melitensis
nd Brucell

ortus
re di erent
i
ted y rowth
on medi
cont
inin which two dyes? A. B
sic fuchsin
nd thionin B. Methylene l
ue
nd cryst
l
violet C. C
r ol fuchsin
nd iodine D. S
fr
nin
nd methylene lue Micro ioloy/
Select
methods/Re
ents/Medi
/B
cteri
/ Identi c
tion/2 19. Which of the followin
mino

cids
re
required for rowth of Fr
ncisell
tul
rensis? A. Leucine
nd ornithine B. Arin

ine
nd lysine C.

Cysteine
nd cystine D. Histidine
nd tryptoph
n Micro ioloy/Apply fund
ment
l
ioloic
l
ch
r
cteristics/B
cteri
/1 20. Which medium is est for recovery of Leionell
p
neumophil
from
clinic
l specimens? A. Chocol
te

r B. BordetGenou

r C. New ye
st extr
ct


r D. Bu ered
ch
rco
lye
st extr
ct (CYE)

r Micro ioloy/Select methods/Re
ents/Medi
/B
cte
ri
/
Identi c
tion/1 21. H
emophilus in uenz
e c
uses ocul
r infections (pinkeye)
nd re
quires X
nd
V f
ctors in the prim
ry medium for rowth. Te su species H
emophilus in uenz
( i
oroup)

eyptius c
n further e identi ed
nd di erenti
ted y which two tests? A. Indole

nd xylose B.
Glucose
nd ure
se C. Oxid
se
nd c
t
l
se D. ALA test
nd oxid
se Micro ioloy/
Select
methods/Re
ents/Medi
/B
cteri
/ Identi c
tion/2 22. H
emophilus species th
t req
uire the V
f
ctor (NAD)
re e
sily recovered on which prim
ry

r pl
te? A. Blood

r m
d
e with sheep red
cells B. Blood

r m
de with horse red cells C. Chocol
te

r D. Xylose

r
Micro ioloy/Select methods/Re
ents/Medi
/B
cteri
/ Identi c
tion/2 410 Ch
pter
7 |
Micro ioloy Answers to Questions 1822 18. A B.
ortus c
n e di erenti
ted from
B.
melitensis y the followin re
ctions: CO 2 Require- B
sic Thionin H 2 S Ur
e
se ment
Fuchsin (20 m) B. melitensis Ne V Ne + + B.
ortus + + +/V + Ne 19. C F.
tul
rensis is

f
stidious r
m-ne
tive rod th
t is est recovered from lymph node
spir
tes
n
d tissue
iopsies. It is oxid
se ne
tive, nonmotile,
nd inert iochemic
lly. Cysteine
lood

r is the
medium of choice, ut F. tul
rensis will row on commerci
lly prep
red chocol
te


r ec
use it
cont
ins X f
ctor
nd is supplemented with
rowth enrichment (IsoVit
leX) th
t
cont
ins
cysteine. F. tul
rensis m
y not row well on M
cConkey

r. 20. D L. pneumophi
l
should e
recovered on u ered CYE

r. This

r is nonselective, ut c
n e m
de more sel
ective for
Leionell
spp. y
ddition of the
nti iotics cef
m
ndole, polymixin B,
nd
ni
somycin. Any
sm
ll, listenin, convex colonies on u ered CYE

r
fter 23 d
ys of incu
tion
th
t do not
row on L-cysteinede cient u ered CYE

r or routine nonselective medi
should e f
urther
tested y the direct uorescent
nti ody test (DFA) for con rm
tion of L. pneumophil

. 21. A H.
in uenz
e
nd su species H.
eyptius
re oth lucose, ure
se, oxid
se,
nd c
t
l

se positive.
H. in uenz
e ( iotype II) is positive for oth indole
nd xylose, where
s H.
eyp
tius is
ne
tive for oth tests. Biotype II encomp
sses 40%70% of H. in uenz
e str
ins reco
vered from
clinic
l specimens. H. in uenz
e su species
eyptius is responsi le for epidemics
of
conjunctivitis in children. 22. C The V f
ctor, NAD, must rst e rele
sed from RB
Cs efore it

c
n e
ssimil
ted y H
emophilus spp. Chocol
te

r is m
de y he
tin lood


r in order to
lyse RBCs. The rele
sed NAD is directly
v
il
le to those H
emophilus species r
equirin it.
Chocol
te

r
lso cont
ins the X f
ctor (hemin). All H
emophilus except H. duc
reyi
nd H.

phrophilus require V f
ctor, while X f
ctor is required y H. in uenz
e, H. h
emo
lyticus,
nd H.
ducreyi. 2828_Ch07_381-494 06/08/12 11:25 AM P
e 410 23. Which of the follow
in products is
responsi le for s
tellite rowth of H
emophilus spp.
round colonies of St
phylo
coccus
nd
Neisseri
spp. on sheep lood

r? A. NAD B. Hemin C. Indole D. Oxid
se Micro i
oloy/Apply
fund
ment
l ioloic
l ch
r
cteristics/B
cteri
/1 24. Which of the followin pl

tes should e
used in order to identify H
emophilus h
emolyticus
nd H
emophilus p
r
h
emolyti
cus? A. Sheep
lood

r
nd chocol
te

r B. Horse lood

r
nd MuellerHinton

r with X

nd V strips C.
Br
inhe
rt infusion

r with sheep red cells
dded D. Chocol
te

r
nd MuellerH
inton

r
with X f
ctor
dded Micro ioloy/Select methods/Re
ents/Medi
/B
cteri
/ Identi c

tion/2 7.4 |
Miscell
neous
nd F
stidious Gr
m-Ne
tive Rods 411 Answers to Questions 2324 2
3. A Colonies
rowin on sheep lood

r secretin NAD (V f
ctor) or producin -hemolysins (wh
ich lyse the
sheep RBCs rele
sin NAD)
llow pinpoint-size colonies of H
emophilus spp. to r
ow
round them.
Sheep lood

r
lone does not support the rowth of H
emophilus spp., which re
quire V f
ctor
ec
use of the presence of V f
ctorin
ctiv
tin enzymes th
t
re present in the


r. 24. B
Production of -hemolysis is used to distinuish these two species from other H
em
ophilus with
the s
me X
nd V requirements. Horse lood

r furnishes X f
ctor
nd, when sup
plemented with
ye
st extr
ct, supports the rowth of H
emophilus spp. Sheep lood

r is not u
sed ec
use it
cont
ins rowth inhi itors for some H
emophilus spp. The ch
rt on the next p
e
summ
rizes the
ch
r
cteristics of the H
emophilus spp. 2828_Ch07_381-494 06/08/12 11:25 AM P

e 411 25. Te
m
jority of H
emophilus in uenz
e infections
re c
used y which of the followin
c
psul
r
serotypes? A.
B. C. c D. d Micro ioloy/Correl
te clinic
l
nd l
or
tory d

t
/
B
cteri
/H
emophilus/2 26. Which H
emophilus species is ener
lly
ssoci
ted wit
h endoc
rditis?
A. H. in uenz
e B. H. ducreyi C. H.
phrophilus D. H. h
emolyticus Micro ioloy/Co
rrel
te
clinic
l
nd l
or
tory d
t
/B
cteri
/H
emophilus/2 27. Which H
emophilus specie
s is di cult to
isol
te
nd recover from enit
l ulcers
nd swollen lymph nodes? A. H.
phrophil
us B. H. ducreyi
C. H. h
emolyticus D. H. p
r
h
emolyticus Micro ioloy/Correl
te clinic
l
nd l

or
tory
d
t
/B
cteri
/H
emophilus/2 28. Which of the followin is
ch
r
cteristic of st
r
ins of

H
emophilus in uenz
e th
t
re resist
nt to
mpicillin? A. Production of -l
ct
m
se

enzymes B.
Hydrolysis of chlor
mphenicol C. Hydrolysis of ure
D. All of these options Micr
o ioloy/Apply
fund
ment
l ioloic
l ch
r
cteristics/B
cteri
/1 412 Ch
pter 7 | Micro ioloy
Answers to
Questions 2528 25. B The m
jority of H. in uenz
e infections occur in children unde
r 5 ye
rs old

nd
re c
used y c
psul
r serotype , one of six serotypes desin
ted
throuh
f. This str
in

ppe
rs to cont
in
virulence f
ctor th
t m
kes it resist
nt to ph
ocytosis
n
d intr
cellul
r
killin y neutrophils. Serotypin of H
emophilus is performed y mixin colonie
s with

lutin
tin
nti odies
v
il
le
s commerci
l
lutin
tion kits. 26. C H.

phrophilus does
not require either X or V f
ctor for rowth
nd is di erenti
ted from the other H

emophilus
species y its
ility to produce
cid from l
ctose
nd
positive -aminoevuini
c aci (ALA)
test. H. in uenzae an H. haemoyticus are incapabe of synthesizin protoporphyri
n from -ALA
an are neative for this test. 27. B H. ucreyi requires exoenous X factor a
n causes enita
esions referre to as soft chancres. The meium use for recovery is commercia c
hocoate aar
or onococcus base meium containin 1%2% hemoobin, 5% feta caf serum, an 1%
IsoVitaeX
enrichment. The pates must be incubate in a 3%5% CO 2 environment for 23 ays. M
ost specimens
are recovere from heterosexuas, an outbreaks in the Unite States are trace
to femae
prostitutes. 28. A Rouhy 20% of H. in uenzae strains prouce -l
ct
m
se, which hy
drolyses
nd
in
ctiv
tes the -l
ct
m rin of
mpicillin (
nd penicillin). H. H. H. H. H.
H. H.
influenz
e p
r
influenz
e h
emolyticus p
r
h
emolyticus
phrophilus
eyptius du
creyi X f
ctor +
Ne + Ne Ne + + V f
ctor + + + + Ne + Ne Hemolysis Ne Ne + + Ne Ne Ne 2
828_Ch07_381-494
06/08/12 11:25 AM P
e 412 29. A sm
ll, r
m-ne
tive cocco
cillus recovered
from the CSF of

2-ye
r-old child 
ve the followin results: Indole = + Glucose = + (
cid) X req
uirement = + V
requirement = + Ure
se = + L
ctose = Ne Sucrose = Ne Hemolysis = Ne Which is
the most likely
identi c
tion? A. H
emophilus p
r
in uenz
e B. H
emophilus in uenz
e C. H
emophilus du
creyi D.
H
emophilus
phrophilus Micro ioloy/Ev
lu
te l
or
tory d
t
to m
ke identi c
tio
ns/B
cteri
/3
30. Te -ALA test (for porphyrins) is a con rmatory proceure for which test use fo
r
ienti cation of Haemophius species? A. X factor requirement B. V factor requirem
ent C. Urease
prouction D. Inoe prouction Microbiooy/Appy knowee to reconize source
s of
error/Bacteria/Ienti cation/3 31. An eery woman who care for severa omestic
cats was
hospitaize with suspecte cat-scratch isease (CSD). Boo cutures appeare n
eative, but a

sma, sihty curve peomorphic ram-neative bacius rew on BHI aar (brai
n, heart infusion
aar with 5% horse or rabbit boo). What is the most ikey ienti cation? A. Bar
tonea spp. B.
Brucea spp. C. Kinea spp. D. Haemophius spp. Microbiooy/Evauate aborat
ory ata to make
ienti cations/Bacteria/3 32. A 5-year-o nonimmunize mae with a persistent cou
h, fever, an
uike symptoms was amitte to the hospita. Nasopharynea swabs were cuture o
n 15% boo,
chocoate, BoretGenjou, an ReanLowe (with 10% charcoa) aars. A meia rew a
ram-neative coccobacius. Carbohyrate an biochemica tests were neative. W
hat is the most
ikey ienti cation? A. Haemophius in uenza B. Boretea pertussis C. Haemophius
parain uenzae D. Boretea bronchiseptica Microbiooy/Evauate aboratory ata t
o make
ienti cations/Bacteria/3 7.4 | Misceaneous an Fastiious Gram-Neative Ros
413 Answers to
Questions 2932 29. B Athouh severa biotypes of H. parain uenzae prouce inoe a
n urease, H.
parain uenzae oes not require X factor for rowth. H. ucreyi requires X factor b
ut not V
factor. H. aphrophius oes not require either X factor or V factor for rowth.
30. A The X
factor requirement for rowth is the cause of many inaccuracies when ientifyin
Haemophius spp.
requirin this factor. Fase-neative resuts have been attribute to the presen
ce of sma
amounts of hemin in the basa meia, or X factor carryover from coonies transfe
rre from primary
meia containin boo. The -ALA test etermines the abiity of an oranism to sy
nthesize
protoporphyrin intermeiates in the biosynthetic pathway to hemin from the precu
rsor compoun
-aminoevuinic aci. Haemophius species that nee exoenous X factor to row ar
e unabe to
synthesize protoporphyrin from -ALA an are neative for the -ALA test. These inc
ue H.
in uenzae, H. haemoyticus, H. aeyptius, an H. ucreyi. 31. A Bartonea spp.
are i cut to
row on primary cuture meia. When CSD is suspecte from the patients history, b
oo cutures
shou be smeare an Gram staine. Bartonea spp. are biochemicay inert, mea
nin that they
are neative for oxiase, cataase, inoe, an urease tests. Therefore, commerc
ia ienti cation
systems, DNA ampi cation for various enes, an inirect immuno uorescence assays a
re use to
ientify these oranisms. 32. B B. pertussis, the cause of whoopin couh, is
hihy contaious
urin the 510 ay perio after acquisition. The incience of whoopin couh is 
reater in
nonimmunize iniviuas, an therefore, is hiher in chiren uner 1 year of a
e. B.
bronchiseptica is ony rarey foun in humans, but may cause respiratory isease
in animas.
Unike B. pertussis it is positive for nitrite, urease, an motiity. 2828_Ch07_
381-494 06/08/12
11:25 AM Pae 413 33. A 29-year-o mae who often hunte rabbits an spent a
ot of time in

the woos was amitte to the hospita with skin ucers on his upper extremities
. At 48 hours, a
sma coccobacius was recovere from the aerobic boo cuture botte ony. Te
oranism staine
poory with Gram stain, but i stain with acriine orane. Cutures taken from
the ucers i
not row on primary meia. What is the most ikey ienti cation? A. Pseuomonas a
eruinosa B.
Pseuomonas uorescens C. Chryseobacterium spp. D. Francisea tuarensis Microbio
oy/Evauate
aboratory ata to make ienti cations/Bacteria/3 34. A neonate was reamitte to
the hospita
with a ianosis of meninitis. Te CSF reveae ram-neative straiht ros. At
24 hours, the
oranism rew on 5% sheep boo an chocoate aars ispayin a yeow piment.
On MacConkey
aar, it appeare as a nonactose fermenter. Coonies were oxiase, DNase, an e
atinase
positive, an oxiize ucose an mannito. What is the most ikey ienti cation
? A.
Haemophius in uenza B. Chryseobacterium meninosepticum C. Stenotrophomonas mato
phiia D.
Acinetobacter baumannii Microbiooy/Evauate aboratory ata to make ienti catio
ns/Bacteria/3
35. A 46-year-o o waren was amitte to the hospita with severa puncture
bite wouns
encountere whie wranin with a stray o. Cuture at 48 hours prouce sma
yeow coonies
on 5% sheep boo an chocoate aars in 10% CO 2 , but no rowth on MacConkey a
ar. Gram stain
showe ram-neative curve, fusiform ros. Coonies were oxiase an cataase p
ositive. What is
the most ikey ienti cation? A. Capnocytophaa canimorsus B. Francisea tuaren
sis C.
Leionea pneumophia D. Pseuomonas aeruinosa Microbiooy/Evauate aborator
y ata to make
ienti cations/Bacteria/3 414 Chapter 7 | Microbiooy Answers to Questions 3336
33. D Persons
hanin sampes suspecte of containin F. tuarensis must wear oves an use
a biooica
safety cabinet (foow biosafety Leve II contros). For cutures, biosafety Lev
e III contros
must be foowe. Tuaremia is one of the most common aboratory-acquire infect
ions, an it is
recommene that specimens be sent to a reference aboratory for ienti cation an
serooica
testin. F. tuarensis requires cysteine an cystine to row. It may row on cho
coate aar
suppemente with IsoVitaex an aso on charcoa yeast extract aar use to iso
ate Leioneae.
34. B Chryseobacterium meninosepticumcan cause septicemia an meninitis in n
eonates an
immunocompromise auts. The abiity to encapsuate, prouce proteases, an sur
vive in
chorinate tap water are factors that contribute to hospita-acquire infection
s with this
bacterium. 35. A C. canimorsus are part of the ora ora of os. The oranisms
require at
east 5% CO 2 for rowth an row sowy on boo an chocoate aars. Coonies
can row in 48

hours if cuture in hih CO 2 on BHI aar with 5% sheep boo. 36. B Boo cut
ures rowin
sma ram-neative ros shou aert the microbiooist to the possibiity of i
nfection with one
of the ve HACEK oranisms. Athouh responsibe for ess than 5% of bacteria en
ocaritis
overa, reater than haf of enocaritis cases cause by ram-neative ros re
sut from one of
them. 36. Te HACEK roup of oranisms (Haemophius aphrophius, Actinobacius
actinomycetemcomitans, Cariobacterium hominis, Eikenea corroens, an Kine
a spp.) are a
known for which type of infection? A. Urinary tract B. Enocaritis C. Pharynit
is D. Tonsiitis
Microbiooy/Appy knowee of funamenta biooica characteristics/Fastiiou
s bacteria/2
2828_Ch07_381-494 06/08/12 11:25 AM Pae 414 37. A suspecte case of Leionna
ires isease was
note on the request form for a cuture an sensitivity orere on a sputum samp
e. Te patient
was a 70-year-o mae who presente with a positive serooica test for Leion
ea spp. What is
the most e cient way to con rm the infection usin the submitte sampe? A. Cuture
the sputum on
MacConkey aar B. Gram stain of the sputum C. Aci-fast stainin D. Direct immun
o uorescent
microscopy Microbiooy/Seect testin for ienti cation/Fastiious bacteria/2 7.4
|
Misceaneous an Fastiious Gram-Neative Ros 415 Answer to Question 37 37.
D Leionea
spp. stain poory if at a with Gram stain. Leionea pneumophiia is not aci
fast athouh L.
micaei, which accounts for a sma percentae of Leionea pneumonia infectio
ns, is aci-fast
positive. Specimens suspecte of containin Leionea spp. shou be hane in
a Cass II
biooica safety cabinet. Leionea spp. require buffere-charcoayeast extract
(BCYE) aar
for rowth an wi not row on MacConkey aar. Since cuture can take up to 10
ays, rapi
ianosis by irect immunofuorescence an DNA ampification are preferre. Dire
ct fuorescent
antiboy tests are not as sensitive as cuture or PCR, but are specific an can
be use to
rapiy confirm a positive serooica test, which may be positive in the absenc
e of isease.
2828_Ch07_381-494 06/08/12 11:25 AM Pae 415 416 7.5 Gram-Positive an Gram-N
eative Cocci 1.
Te test use most often to separate the Micrococcaceae famiy from the Streptoco
ccaceae famiy
is: A. Bacitracin B. Cataase C. Hemoysis pattern D. A of these options Micro
biooy/Seect
methos/Reaents/Meia/Bacteria/ Ienti cation/1 2. Micrococcus an Staphyococc
us species are
i erentiate by which test(s)? A. Fermentation of ucose (OF tube) B. Cataase t
est C. Gram
stain D. A of these options Microbiooy/Seect methos/Reaents/Meia/Bacteri
a/
Ienti cation/1 3. Lysostaphin is use to i erentiate Staphyococcus from which oth
er enus? A.
Streptococcus B. Stomatococcus C. Micrococcus D. Panococcus Microbiooy/Seect

methos/Reaents/Meia/Bacteria/ Ienti cation/2 Answers to Questions 13 1. B The c

ataase test
(utiizin a 3% hyroen peroxie [H 2 O 2
]
soution store in a brown botte uner
refrieration) is positive for the four enera beonin to the Micrococ
caceae famiy:
Panococcus, Micrococcus, Stomatococcus, an Staphyococcus. Members of the Stre
ptococcaceae
famiy are neative. Panococcus spp. are associate with marine ife an not hu
man infections.
Stomatococcus spp. are impicate in enocaritis foowin cariac catheterizat
ion; they are
weaky cataase positive an prouce white or transparent sticky coonies on aa
r, which hep to
i erentiate them from Staphyococcus. 2. A Both micrococci an staphyococci are
cataase-positive an ram-positive cocci. On irect smears, they both appear as
pairs, short
chains (resembin Streptococcus spp.), or custers. However, the micrococci fai
 to prouce aci
from ucose uner anaerobic conitions. The OF tube reactions are: Staphyococc
us Micrococcus
spp. spp. Open tube + + (oxiation) Cose tube + Ne (fermentation) 3. C Lyso
staphin is an
enopeptiase that ceaves the ycine-rich pentapeptie crossbries in the sta
phyococca ce
wa peptioycan. The susceptibiity of the staphyococci to ysostaphin is us
e to
i erentiate them from the micrococci. Staphyococci are susceptibe an show a 101
6 mm zone of
inhibition, whie micrococci are not inhibite. 2828_Ch07_381-494 06/08/12 11:
25 AM Pae 416
4. Which of the foowin tests is use routiney to ientify Staphyococcus aur
eus? A. Sie
coauase test B. Tube coauase test C. Latex autination D. A of these opt
ions
Microbiooy/Seect methos/Reaents/Meia/Bacteria/ Ienti cation/2 5. Which of t
he foowin
enzymes contribute to the viruence of S. aureus? A. Urease an ecithinase B. H
yauroniase an
-l
ct
m
se C. Lecithin
se
nd c
t
l
se D. Cytochrome oxid
se Micro ioloy/Apply k
nowlede of
fund
ment
l ioloic
l ch
r
cteristics/B
cteri
/1 6. Toxic shock syndrome is
tt
ri uted to
infection with: A. St
phylococcus epidermidis B. St
phylococcus hominis C. St
ph
ylococcus
ureus
D. St
phylococcus s
prophyticus Micro ioloy/Correl
te clinic
l
nd l
or
tory
d
t
/B
cteri
/St
phylococcus/2 7. Which St
phylococcus species, in
ddition to S
.
ureus,
lso
produces co
ul
se? A. S. intermedius B. S. s
prophyticus C. S. hominis D. All o
f these options
Micro ioloy/Correl
te clinic
l
nd l
or
tory d
t
/B
cteri
/St
phylococcus/2 8.
St
phylococcus
epidermidis (co
ul
se ne
tive) is recovered from which of the followin source
s? A. Prosthetic
he
rt v
lves B. Intr
venous c
theters C. Urin
ry tr
ct D. All of these options
Micro ioloy/Correl
te clinic
l
nd l
or
tory d
t
/B
cteri
/St
phylococcus/2 9.
Slime production
is
ssoci
ted with which St
phylococcus species? A. S.
ureus B. S. epidermidis
C. S. intermedius
D. S. s
prophyticus Micro ioloy/Apply knowlede of fund
ment
l ioloic
l

ch
r
cteristics/B
cteri
/1 7.5 | Gr
m-Positive
nd Gr
m-Ne
tive Cocci 417 Ans

wers to Questions
49 4. D The slide co
ul
se test usin r
it pl
sm
with ethylenedi
minetetr

ce
tic
cid (EDTA)
detects ound co
ul
se or clumpin f
ctor on the surf
ce of the cell w
ll, which
re
cts with
the rinoen in the pl
sm
. This test is not positive for
ll str
ins of S.
ureu
s,
nd

ne
tive result must e con rmed y the tu e method for detectin free co
ul
se or
extr
cellul
r co
ul
se. The tu e test is usu
lly positive within 4 hours
t 35C;
however,

ne
tive result must then e incu
ted
t room temper
ture for the rem
inder of
1824 hours. Some
str
ins produce co
ul
se slowly or produce rinolysin, which dissolves the clot

t 35C. L
tex

lutin
tion procedures utilize rinoen
nd IG-co
ted l
tex e
ds th
t detect
protein A on
the st
phylococc
l cell w
ll. 5. B In
ddition to co
ul
se, the virulence of S.

ureus is

ttri uted to hy
luronid
se, which d
m
es the intercellul
r m
trix (
sement me
m r
ne) of
tissues. -L
ct
m
seproducin str
ins
re
le to in
ctiv
te penicillin
nd
mpicil
lin, m
kin
the or
nism resist
nt to these
nti iotics. Lecithin
se is not produced y S.

ureus,
nd ure
se
is not
virulence f
ctor. 6. C S.
ureus is the or
nism most often recovered
from fem
le
p
tients. These str
ins produce toxic shock syndrome toxin 1 (TSST-1). Toxic sho
ck syndrome is

ttri uted to the use of cert
in hihly
sor ent t
mpons y menstru
tin fem
le
s. The toxin is

lso recovered from sites other th
n the enit
l
re

nd produces fever
nd lif
e-thre
tenin
systemic d
m
e
s well
s shock. 7. A S. intermedius infects m
mm
ls
nd cert

in irds ut not
usu
lly hum
ns. C
ses involvin hum
ns result from
nim
l ites
nd
re most oft
en seen in
persons who work closely with
nim
ls. 8. D S. epidermidis represents 50%80% of

ll
co
ul
se-ne
tive St
phylococcus spp. recovered from numerous clinic
l specimen
s. It is of
speci
l concern in nosocomi
l infections ec
use of its hih resist
nce to
nti
iotics. 9. B S.
epidermidis produces
n extr
cellul
r slime th
t enh
nces the
dhesion of these
or
nisms to
indwellin pl
stic c
theters. The slime production is considered
virulence f
c
tor
nd is

ssoci
ted with infections from prostheses. 2828_Ch07_381-494 06/08/12 11:25 A
M P
e 417 10.
Str
ins of St
phylococcus species resist
nt to the -l
ct
m
nti iotics y st
nd
r
dized disk
di usion
nd roth microdilution suscepti ility methods
re c
lled: A. Heteroresis
t
nt B.
B
cterioph
e roup 52A C. Cross resist
nt D. Pl
smid
ltered Micro ioloy/Apply
knowlede of
fund
ment
l ioloic
l ch
r
cteristics/B
cteri
/1 11. St
phylococcus s
prophyti
cus is est
di erenti
ted from St
phylococcus epidermidis y resist
nce to: A. 5  of lysost
ph
in B. 5  of
novo iocin C. 10 units of penicillin D. 0.04 unit of
citr
cin Micro ioloy/Cor

rel
te clinic
l

nd l
or
tory d
t
/ B
cteri
/St
phylococcus/2 12. Te followin results were o s
erved y usin

tu e co
ul
se test: Co
ul
se
t 4 hours = + Co
ul
se
t 18 hours = Ne DN
se
= + Novo iocin =
Sensitive (16-mm zone) Hemolysis on lood M
nnitol s
lt pl
te = +

r = (
cid
production)
Wh
t is the most pro
le identi c
tion? A. St
phylococcus s
prophyticus B. St
phy
lococcus
epidermidis C. St
phylococcus
ureus D. St
phylococcus hominis Micro ioloy/Ev
l
u
te l
or
tory
d
t
to m
ke identi c
tions/B
cteri
/3 13. St
phylococcus
ureus recovered from

wound culture

ve the followin
nti iotic sensitivity p
ttern y the st
nd
rdized Kir yB
uer
method (S =
sensitive; R = resist
nt): Penicillin = R Ampicillin = S Ceph
lothin = R Cefoxit
in = R V
ncomycin
= S Methicillin = R Which is the dru of choice for tre
tin this infection? A.
Penicillin B.
Ampicillin C. Ceph
lothin D. V
ncomycin Micro ioloy/Correl
te clinic
l
nd l
o
r
tory d
t
/
B
cteri
/St
phylococcus/2 418 Ch
pter 7 | Micro ioloy Answers to Questions 101
4 10. A
Methicillin-resist
nt S.
ureus (MRSA)
nd methicillin-resist
nt S. epidermidis
(MRSE)
re c
lled
heteroresist
nt. This refers to two su popul
tions in
culture, one th
t is sus
cepti le
nd the
other th
t is resist
nt to
nti iotic(s). The resist
nt popul
tion rows more sl
owly th
n the
suscepti le one
nd c
n e overlooked. Therefore, the more resist
nt su popul
ti
on should e
promoted rowthwise y usin
neutr
l pH (7.07.4), cooler incu
tion temper
ture
s (30C35C),
the
ddition of 2%4% N
Cl,
nd incu
tion up to 48 hours. 11. B S. s
prophyticu
s is co
ul
se
ne
tive
nd resist
nt to 5 g of novobiocin. Using the standardized KirbyBauer sen
sitivity
procedure, a 612 mm zone of growth inhibition is considered resistant. Susceptibl
e strains
measure 1627 mm (inhibition) zones. 12. C S. aureus can produce brinolysins that
dissolve the
clot formed by the coagulase enzyme. The tube method calls for an incubation of
4 hours at
35C37C and 1824 hours at room temperature. Both must be negative to interpret the re
sult as
coagulase negative. This organism is coagulase positive and, therefore, identi ed
as S. aureus.
13. D Vancomycin, along with rifampin, is used for strains of S. aureus that are
resistant to the
-l
ct
ms. MRSA str
ins pose pro lems when re
din the zone sizes for these str
in
s. Their
heteroresist
nce results in
lm of rowth consistin of very sm
ll colonies form
ed within the
de ned inhi ition zone surroundin the
nti iotic disk. Initi
lly, this
ppe
rs
s

mixed
culture or cont
min
nt. 14. A The production of
cetoin y S.
ureus from lucos
e or pyruv
te
di erenti
tes it from S. intermedius, which is
lso co
ul
se positive. This test
is
lso c
lled
the VP test. Acetoin production is detected y
ddition of 40% KOH
nd 1% -n
phth

ol to the VP
test roth
fter 48 hours of incu
tion. A distinct pink color within 10 minutes
denotes

positive test. 14. Which of the followin tests should e used to di erenti
te St

phylococcus

ureus from St
phylococcus intermedius? A. Acetoin B. C
t
l
se C. Slide co
ul
s
e test D. Ure
se
Micro ioloy/Select methods/Re
ents/Medi
/B
cteri
/ Identi c
tion/2 2828_Ch07_381
-494 06/08/12
11:25 AM P
e 418 15. A r
m-positive coccus recovered from
wound ulcer from

31-ye
r-old
di
etic p
tient showed p
le yellow, cre
my, -hemolytic colonies on lood

r. G
iven the
followin test results, wh
t is the most likely identi c
tion? C
t
l
se = + Glucos
e OF: positive
open tu e, ne
tive se
led tu e M
nnitol s
lt = Ne Slide co
ul
se = Ne A. St

phylococcus

ureus B. St
phylococcus epidermidis C. Micrococcus spp. D. Streptococcus spp.
Micro ioloy/Ev
lu
te l
or
tory d
t
to m
ke identi c
tions/B
cteri
/3 16. Urine
cultured from
the c
theter of
n 18-ye
r-old fem
le p
tient produced more th
n 100,000 col/mL
on
CNA pl
te.
Colonies were c
t
l
se positive, co
ul
se ne
tive y the l
tex
lutin
tion s
lide method
s
well
s the tu e co
ul
se test. Te est sinle test for identi c
tion is: A. L
ct
ose
ferment
tion B. Ure
se C. C
t
l
se D. Novo iocin suscepti ility Micro ioloy/Sel
ect
methods/Re
ents/Medi
/B
cteri
/ Identi c
tion/3 17. A St
phylococcus spp. recover
ed from
wound
(cellulitis) w
s ne
tive for the slide co
ul
se test (clumpin f
ctor)
nd ne

tive for
novo iocin resist
nce. Te next test(s) needed for identi c
tion is (
re): A. Tu e
co
ul
se test
B. -Hemolysis on lood

r C. M
nnitol s
lt

r pl
te D. All of these options
Micro ioloy/Select methods/Re
ents/Medi
/B
cteri
/ Identi c
tion/3 18. Fur
zolid
one (Furoxone)
suscepti ility is
test used to di erenti
te: A. St
phylococcus spp. from Microco
ccus spp. B.
Streptococcus spp. from St
phylococcus spp. C. St
phylococcus spp. from Pseudomo
n
s spp. D.
Streptococcus spp. from Micrococcus spp. Micro ioloy/Select methods/Re
ents/Me
di
/B
cteri
/
Identi c
tion/2 19. B
citr
cin resist
nce (0.04 unit) is used to di erenti
te: A. Mi
crococcus
spp. from St
phylococcus spp. B. St
phylococcus spp. from Neisseri
spp. C. Pl
n
ococcus spp. from
Micrococcus spp. D. St
phylococcus spp. from Streptococcus spp. Micro ioloy/Sel
ect
methods/Re
ents/Medi
/B
cteri
/ Identi c
tion/2 7.5 | Gr
m-Positive
nd Gr
m-Ne

tive Cocci
419 Answers to Questions 1520 15. C Micrococcus spp. utilize lucose oxid
tivel
y ut not under

n
ero ic conditions (se
led tu e). St
phylococcus spp. utilize lucose oxid
tiv
ely
nd

n
ero ic
lly. The c
t
l
se di erenti
tes the Micrococc
ce
e f
mily (positive) fro
m the
Streptococc
ce
e f
mily (ne
tive). 16. D S. epidermidis
nd S. s
prophyticus

re the two
possi ilities ec
use they
re oth c
t
l
se positive, co
ul
se ne
tive, ure
s

e positive,
nd
ferment l
ctose. Novo iocin suscepti ility is the test of choice for di erenti
tin
 these two
species. S. epidermidis is sensitive ut S. s
prophyticus is resist
nt to 5 g of
novobiocin. 17.
D S. aureus is novobiocin sensitive and cannot be ruled out by a negative clump
ing factor test.
Most S. aureus produce -hemolysis on sheep lood

r pl
tes
nd
re m
nnitol s
l
t positive
(produce
cid
nd
re not inhi ited y the hih s
lt concentr
tion). The tu e te
st should e
performed ec
use the slide test w
s ne
tive. 18. A St
phylococci
re suscepti
le to
fur
zolidone, ivin zones of inhi ition th
t
re 15 mm or re
ter. Micrococcus
spp.
re
resist
nt to fur
zolidone, ivin zones of 69 mm. The test is performed
s
disk
suscepti ility
procedure usin
lood

r pl
te. 19. A A
citr
cin disk (0.04 unit) is used
to identify roup
A -hemolytic streptococci, ut it will
lso di erenti
te c
t
l
se-positive or
nism
s. A zone of
10 mm or re
ter is considered suscepti le. The St
phylococcus species
re resis
t
nt
nd row up
to the disk, while Micrococcus species
re sensitive. 20. C The modi ed oxid
se te
st is used to
r
pidly identify c
t
l
se-positive r
m-positive cocci
s Micrococcus spp. (posi
tive) or
St
phylococcus spp. (ne
tive). Filter p
per disks th
t
re s
tur
ted with oxid

se re
ent
(tetr
methyl-p-phenylenedi
mine in dimethylsulfoxide)
re used. A colony of the
isol
te is ru ed
onto the p
per. Oxid
se-positive or
nisms produce
purple color within 30 sec.
20. Which of the
followin tests will r
pidly di erenti
te micrococci from st
phylococci? A. C
t
l

se B. Co
ul
se
C. Modi ed oxid
se D. Novo iocin suscepti ility Micro ioloy/Select
methods/Re
ents/Medi
/B
cteri
/ Identi c
tion/2 2828_Ch07_381-494 06/08/12 11:2
5 AM P
e 419
21. Streptococcus species exhi it which of the followin properties? A. Aero ic
, oxid
se
positive,
nd c
t
l
se positive B. F
cult
tive
n
ero e, oxid
se ne
tive, c
t
l

se ne
tive C.
F
cult
tive
n
ero e, -hemolytic, c
t
l
se positive D. M
y e -, -, or -hemolytic, c

t
l
se
positive Micro ioloy/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics/
Streptococci/1
22. Which roup of streptococci is
ssoci
ted with erythroenic toxin production
? A. Group A B.
Group B C. Group C D. Group G Micro ioloy/Apply knowlede of fund
ment
l iolo
ic
l
ch
r
cteristics/B
cteri
/1 23. A fourfold rise in titer of which
nti ody is the
est indic
tor
of
recent infection with roup A -hemolytic streptococci? A. Anti-streptolysin
O B.
Anti-streptolysin S C. Anti-A D. Anti-B Micro ioloy/Select methods/Re
ents/Med
i
/B
cteri
/
Identi c
tion/1 24. B
citr
cin A disks (0.04 unit)
re used for the presumptive id
enti c
tion of
which roup of -hemolytic streptococci? A. Group A B. Group B C. Group C D. Group
F

Micro ioloy/Select methods/Re
ents/Medi
/B
cteri
/ Identi c
tion/1 25.

Trimethoprimsulf
methox
zole (SXT) disks
re used
lon with
citr
cin disks to
di erenti
te
which streptococci? A. -Hemolytic streptococci B. -Hemolytic streptococci C. Strep
tococcus
pneumoni
e D. Enterococcus f
ec
lis Micro ioloy/Select methods/Re
ents/Medi
/B

cteri
/
Identi c
tion/1 420 Ch
pter 7 | Micro ioloy Answers to Questions 2125 21. B St
reptococcus
species
re f
cult
tive
n
ero es th
t row
ero ic
lly
s well,
nd
re oxid
se

nd c
t
l
se
ne
tive. In order to demonstr
te streptolysin O on lood

r, it is est to st

the

r to
cre
te
n
ero iosis ec
use streptolysin O is oxyen l
ile. 22. A Group A -hemol
ytic
streptococci
re the c
use of sc
rlet fever,
nd some str
ins produce toxins (py
roenic exotoxins
A, B,
nd C) th
t c
use
sc
rl
tiniform r
sh. 23. A The
ntistreptolysin O (ASO
) titer is used
to indic
te
recent infection with roup A -hemolytic streptococci. Streptolysin
O m
y
lso e
produced y some str
ins of roups C
nd G streptococci. 24. A The
citr
cin di
sk test is used
in conjunction with other confirm
tory tests for the -hemolytic streptococci. In

ddition to
roup A, roups C, F,
nd G
re
lso -hemolytic
nd ive
positive test for
ci
tr
cin (
zone
of inhi ition of
ny size). Therefore,
positive test does not confirm the pres
ence of roup A
-hemolytic streptococci. 25. B -Hemolytic streptococci
re the only streptococci t
h
t should e
tested. S. pneumoni
e, which is -hemolytic, is suscepti le to sm
ll concentr
tion
s of

citr
cin,
s
re other -hemolytic streptococci. SXT is inhi itory to most strep
tococci except
Streptococcus pyoenes
nd Streptococcus

l
cti
e. For this re
son, SXT is use
d in

commerci
lly
v
il
le streptococc
l selective

r (SSA)
s
prim
ry pl
tin


r for the
detection of roup A streptococci. 2828_Ch07_381-494 06/08/12 11:25 AM P
e 4
20 26.
-Hemolytic streptococci, not of roup A or B, usu
lly exhi it which of the follow
in re
ctions?
A. B. C. D. Micro ioloy/Correl
te clinic
l
nd l
or
tory d
t
/ B
cteri
/Strept
ococci/2 27. A
f
lse-positive CAMP test for the presumptive identi c
tion of roup B streptococci
m
y occur if
the pl
te is incu
ted in
(n): A. C
ndle j
r or CO 2 incu
tor B. Am ient
ir i
ncu
tor C. 35C
incu
tor D. 37C incu
tor Micro ioloy/Apply knowlede to identify sources of
error/Identi c
tion/Streptococci/3 28. Which test is used to di erenti
te the virid

ns
streptococci from the roup D streptococci
nd enterococci? A. B
citr
cin disk t
est B. CAMP test
C. Hippur
te hydrolysis test D. Bile esculin test Micro ioloy/Select
methods/Re
ents/Medi
/B
cteri
/ Identi c
tion/2 29. Te ile solu ility test c
use
s the lysis of:
A. Streptococcus ovis colonies on
lood

r pl
te B. Streptococcus pneumoni

e colonies on

lood

r pl
te C. Group A streptococci in roth culture D. Group B streptococc

i in roth
culture Micro ioloy/Apply knowlede to identify sources of error/Identi c
tion/St
reptococci/1
30. S. pneumoni
e
nd the virid
ns streptococci c
n e di erenti
ted y which tes
t? A. Optochin
disk test, 5 /mL or less B. B
citr
cin disk test, 0.04 unit C. CAMP test D. Bile
esculin test
Micro ioloy/Select methods/Re
ents/Medi
/B
cteri
/ Identi c
tion/2 7.5 | Gr
m-Po
sitive
nd
Gr
m-Ne
tive Cocci 421 Answers to Questions 2630 26. D Streptococci th
t
re n
ot roup A or B
m
y e either resist
nt or suscepti le to
citr
cin ut
re usu
lly suscepti le
to SXT. 27. A
The CAMP (hemolytic phenomenon rst descri ed y Christie, Atkins,
nd MunchPeterse
n in 1944)
test refers to
hemolytic inter
ction th
t is seen on
lood

r pl
te etwee
n the
-hemolysins produced y most str
ins of S.
ureus
nd
n extr
cellul
r protein pr
oduced y oth
hemolytic
nd nonhemolytic isol
tes of roup B streptococci. When performin
C
AMP test, the
pl
te must e pl
ced in
n
m ient
ir incu
tor
t 35C37C. Group A streptococci m

y e CAMP
positive if the pl
te is incu
ted in
c
ndle j
r, hih CO 2
tmosphere, or
n

ero ic
lly. 28. D
The ile esculin test differenti
tes those
cteri
th
t c
n hydrolyze esculin

nd
lso row in
the presence of 4% ile s
lts or 40% ile. The ile esculin sl
nt is inocul
ted
on the surf
ce

nd incu
ted for 2448 hours in
nonCO 2 incu
tor. Group D streptococci (entero
cocci
nd
nonenterococci)
re positive, c
usin l
ckenin of h
lf or more of the sl
nt wi
thin 48 hours.
Virid
ns streptococci
re ne
tive (do not row or hydrolyze esculin). 29. B The
ile solu ility
test c
n e performed directly y droppin 2% sodium deoxychol
te onto
few wel
l-isol
ted
colonies of S. pneumoni
e. The ile s
lts speed up the
utolysis o served in pne
umococc
l
cultures. The colonies lyse
nd dis
ppe
r when incu
ted
t 35C for 30 min, le
vi
n
p
rti
lly
hemolyzed
re
on the pl
te. The s
me phenomenon c
n e seen usin
roth cultu
re;
ddition of
10% deoxychol
te to roth cont
inin S. pneumoni
e results in visi le cle
rin o
f the suspension

fter incu
tion
t 35C for 3 hours. 30. A Optochin
t
concentr
tion of 5 g/mL o
r less
inhibits the growth of S. pneumoniae but not viridans streptococci. However, Opt
ochin at a
concentration in excess of 5 g/mL inhibits viridans streptococci as well. A zone
of inhibition
of 14 mm or more around the 6-mm disk is considered a presumptive identi cation of
S. pneumoniae.
A questionable zone size should be con rmed by performing a bile solubility test.
Trimethoprim
Bacitracin sulfamethoxazole Susceptible Resistant Resistant Resistant Resistan
t Susceptible
Susceptible or resistant Susceptible Hemolytic Trimethoprim Strep B
citr
cin
sulf
methox
zole Group A Suscepti le Resist
nt Group B Resist
nt Resist
nt Non-A
, Suscepti le

Suscepti le non-B or Resist
nt 2828_Ch07_381-494 06/08/12 11:25 AM P
e 421 3

1. Te s
lt
toler
nce test (6.5% s
lt roth) is used to presumptively identify: A. Streptoco
ccus pneumoni
e
B. Streptococcus ovis C. Streptococcus equinus D. Enterococcus f
ec
lis Micro i
oloy/Select
methods/Re
ents/Medi
/B
cteri
/ Identi c
tion/2 32. In
ddition to Enterococcus f

ec
lis, which
other streptococci will row in 6.5% s
lt roth? A. Group A streptococci B. Grou
p B streptococci
C. Streptococcus pneumoni
e D. Group D streptococci (nonenterococci) Micro iolo
y/Correl
te
clinic
l
nd l
or
tory d
t
/ B
cteri
/Streptococci/2 33. Te quellun test is us
ed to identify
which Streptococcus species? A. S. pyoenes B. S.

l
cti
e C. S. s
nuis D. S.
pneumoni
e
Micro ioloy/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics/Streptoco
cci/1 34. Te
L-pyrrolidonyl--n
pthyl
mide (PYR) hydrolysis test is
presumptive test for whic
h streptococci?
A. Group A
nd D (enterococcus) streptococci B. Group A
nd B -hemolytic streptoc
occi C.
Nonroup A or B -hemolytic streptococci D. Streptococcus pneumoni
e
nd roup D s
treptococci
(nonenterococcus) Micro ioloy/Apply knowlede of fund
ment
l ioloic
l
ch
r
cteristics/Streptococci/1 35. A pure culture of -hemolytic streptococci reco
vered from

le wound ulcer 
ve the followin re
ctions: CAMP test = Ne Hippur
te hydrolys
is = Ne Bile
esculin = Ne 6.5% s
lt = Ne PYR = Ne B
citr
cin = Resist
nt Optochin = Resist

nt SXT =
Sensitive Te most likely identi c
tion is: A. Group A streptococci B. Group B stre
ptococci C.
Enterococcus f
ec
lis D. Nonroup A, nonroup B, nonroup D streptococci Micro i
oloy/Ev
lu
te
l
or
tory d
t
to m
ke identi c
tions/B
cteri
/3 422 Ch
pter 7 | Micro ioloy A
nswers to
Questions 3136 31. D Enterococcus f
ec
lis will row in 6.5% s
lt
nd the nonent
erococci (S.
ovis
nd S. equinus) will not. This test distinuishes the enterococci roup fr
om S. ovis
nd
S. equinus (nonenterococci roup). Both roups row on ile esculin

r. 32. B
Approxim
tely 80%
of roup B streptococci
re c
p
le of rowin in 6.5% s
lt roth; however, they
do not hydrolyze
esculin or row in medi
cont
inin 4% ile s
lts. 33. D A precipitin re
ction s
een
microscopic
lly with methylene lue st
in (microprecipitin re
ction) occurs etw
een the
c
r ohydr
te of the c
psule of S. pneumoni
e
nd
ntic
psul
r
nti ody. The
nti
ody m
y e type
speci c or polyv
lent. Bindin of
nti odies to the
cteri
c
uses the c
psule to
swell,
identifyin the or
nisms
s S. pneumoni
e. 34. A The PYR hydrolysis test is hi
hly speci c for
roup A streptococci
nd roup D enterococci. The test detects the pyrrolidonyl

ryl
mid
se
enzyme, which hydrolyzes PYR. 35. D The -hemolytic streptococcinot of roups A, B,
or D
re
sensitive to SXT
nd m
y e either sensitive or resist
nt to
citr
cin. Groups

A
nd B
re oth

resist
nt to SXT. Group A
nd Enterococcus f
ec
lis
re PYR positive. Enterococc
us f
ec
lis is

lso positive for ile esculin
nd 6.5% s
lt roth. 36. C Group A streptococci

re sensitive to

citr
cin
nd ne
tive for ile esculin
nd 6.5% s
lt roth. Group B streptococ
ci will row in
6.5% s
lt roth ut
re ne
tive for ile esculin
nd PYR. The nonroup A, B, or
D streptococci
will not row in 6.5% s
lt roth
nd
re sensitive to SXT. Some roup D streptoc
occi will
hydrolyze hippur
te. Enterococcus f
ec
lis is positive for ile esculin, 6.5% s

lt roth,
nd
PYR. 36. -Hemolytic streptococci, more th
n 50,000 col/mL, were isol
ted from

urin
ry tr
ct
c
theter urine specimen. Given the followin re
ctions, wh
t is the most likely
identi c
tion?
CAMP test = Ne Hippur
te hydrolysis =  Bile solu ility = Ne 6.5% s
lt = + PYR =
+ Bile esculin
= + SXT = Resist
nt B
citr
cin = Resist
nt Optochin = Resist
nt A. Group A strep
tococci B. Group
B streptococci C. Enterococcus f
ec
lis D. Nonroup A, nonroup B, nonroup D st
reptococci
Micro ioloy/Ev
lu
te l
or
tory d
t
to m
ke identi c
tions/B
cteri
/3 2828_Ch07_
381-494
06/08/12 11:25 AM P
e 422 37. Nutrition
lly v
ri
nt streptococci (NVS) requir
e speci c thiol
compounds, cysteine, or the
ctive form of vit
min B 6 . Which of the followin
tests supplies
these requirements? A. CAMP test B. B
citr
cin suscepti ility test C. Bile solu
ility test D.
St
phylococc
l cross-stre
k test Micro ioloy/Apply knowlede of fund
ment
l io
loic
l
ch
r
cteristics/Streptococci/1 38. M
ny -hemolytic streptococci recovered from

wound were
found to e penicillin resist
nt. Given the followin results, wh
t is the most
likely
identi c
tion? Bile esculin = + PYR = + 6.5% s
lt = + Hippur
te Bile solu ility=
Ne hydrolysis
= + SXT = Resist
nt A. Enterococcus f
ec
lis B. Streptococcus pneumoni
e C. Stre
ptococcus ovis
D. Group B streptococci Micro ioloy/Ev
lu
te l
or
tory d
t
to m
ke identi c
tio
ns/B
cteri
/3
39. Which two tests est di erenti
te S. ovis (roup D, nonenterococcus) from Str
eptococcus
s
liv
rius? A. Bile esculin
nd 6.5% s
lt roth B. St
rch hydrolysis
nd
cid pr
oduction from
m
nnitol C. B
citr
cin
nd PYR D. Trimethoprimsulf
methox
zole suscepti ility
nd
PYR
Micro ioloy/Select methods/Re
ents/Medi
/B
cteri
/ Identi c
tion/2 40. Two lood
cultures on

new orn rew -hemolytic streptococci with the followin re
ctions: CAMP test = +
Hippur
te
hydrolysis = + Bile solu ility = Ne 6.5% s
lt = + B
citr
cin = Resist
nt Bile e
sculin = Ne PYR
= Ne Trimethoprimsulf
methox
zole = Resist
nt Which is the most likely identi c
ti
on? A. Group
A streptococci B. Group B streptococci C. Group D streptococci D. Nonroup A, no
nroup B,
nonroup D streptococci Micro ioloy/Ev
lu
te l
or
tory d
t
to m
ke identi c
tio

ns/B
cteri
/3
7.5 | Gr
m-Positive
nd Gr
m-Ne
tive Cocci 423 Answers to Questions 3741 37. D
The
st
phylococc
l stre
k,
cross the NVS inoculum, provides the nutrients needed. V
ery sm
ll
colonies of NVS c
n e seen rowin
dj
cent to the st
phylococc
l stre
k on the
lood

r pl
te
in
m
nner simil
r to the s
tellite phenomenon of H
emophilus spp.
round S.
u
reus. 38. A E.
f
ec
lis is resist
nt to penicillin
nd
mpicillin
s well
s some of the
mino
lycoside

nti iotics. Pneumococci, roup B streptococci,
nd S. ovis
re PYR ne
tive. 3
9. B S. ovis

nd S. s
liv
rius
re physioloic
lly
nd iochemic
lly simil
r. They
re oth P
YR
nd 6.5% s
lt
roth ne
tive
nd ile esculin positive, ut only S. ovis is positive for m
nn
itol
nd st
rch
re
ctions. See the followin ch
rt. B
ci- Bile 6.5% M
nni- tr
cin PYR Esc
ulin S
lt tol
St
rch S. ovis R Ne + Ne + + S. s
liv
rius R Ne + Ne Ne Ne 40. B Group B
streptococci (S.


l
cti
e)
re resist
nt to oth
citr
cin
nd SXT. Unlike roup A
nd roup D
streptococci,
the roup B streptococci
re ne
tive for PYR. With some exceptions, roup B str
eptococci will
row in 6.5% s
lt roth. 41. A Both N. onorrhoe
e
nd N. meninitidis row sele
ctively on MTM
owin to the
ddition of v
ncomycin
nd colistin, which inhi it r
m-positive
n
d r
m-ne
tive

cteri
, respectively. Trimethoprim is
dded to inhi it sw
rmin of Proteus spp
. ec
use

rect
l sw
m
y e used for culture. Nyst
tin
nd
mphotericin B
re used to pre
vent rowth of
ye
sts
nd molds from v
in
l specimens. 41. MTM medium is used prim
rily for th
e selective
recovery of which or
nism from enit
l specimens? A. Neisseri
onorrhoe
e B. N
eisseri

l
ct
mic
C. Neisseri
sicc
D. Neisseri

vescens Micro ioloy/Select
methods/Re
ents/Medi
/B
cteri
/ Identi c
tion/1 2828_Ch07_381-494 06/08/12 11:2
5 AM P
e 423
42. V
ri
tion in colony types seen with fresh isol
tes of Neisseri
onorrhoe
e

nd sometimes
with Neisseri
meninitidis
re the result of: A. Multiple nutrition
l requireme
nts B. Pili on
the cell surf
ce C. Use of
tr
nsp
rent medium D. All of these options Micro io
loy/Apply
knowlede of fund
ment
l ioloic
l ch
r
cteristics/Neisseri
/2 43. Gr
m-ne
tiv
e diplococci
recovered from
n MTM pl
te
nd ivin
positive oxid
se test c
n e presumptiv
ely identi ed
s:
A. Neisseri
onorrhoe
e B. Neisseri
meninitidis C. Neisseri
l
ct
mic
D. All
of these options
Micro ioloy/Ev
lu
te l
or
tory d
t
to m
ke identi c
tions/B
cteri
/2 44. Te Sup
eroxol test is
used
s
r
pid presumptive test for: A. Neisseri
onorrhoe
e B. Neisseri
meni
nitidis C.
Neisseri
l
ct
mic
D. Mor
xell
(Br
nh
mell
) c
t
rrh
lis Micro ioloy/Apply kn
owlede of
fund
ment
l ioloic
l ch
r
cteristics/Neisseri
/1 45. Nonp
thoenic Mor
xell
s
pp. c
p
le of

rowin on selective medi
for Neisseri
c
n e di erenti
ted from Neisseri
spp.
y which test?
A. C
t
l
se test B. 10-unit penicillin disk C. Oxid
se test D. Superoxol test Mi
cro ioloy/Select
methods/Re
ents/Medi
/B
cteri
/ Identi c
tion/2 46. A Gr
m st
in of
urethr
l di
sch
re from

m
n showin extr
cellul
r
nd intr
cellul
r r
m-ne
tive diplococci within sem
ented neutrophils
is
presumptive identi c
tion for: A. Neisseri
onorrhoe
e B. Neisseri
meninit
idis C.
Mor
xell
(Br
nh
mell
) c
t
rrh
lis D. Neisseri
l
ct
mic
Micro ioloy/Ev
lu
te
l
or
tory d
t

to m
ke identi c
tions/B
cteri
/3 47. Te -
l
ctosid
se test
ids in the identi c
tio
n of which
Neisseri
species? A. N. l
ct
mic
B. N. meninitidis C. N. onorrhoe
e D. N.
ve
scens
Micro ioloy/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics/Neisseri

/1 424 Ch
pter
7 | Micro ioloy Answers to Questions 4247 42. D Upon su culture from
prim
ry p
l
te, v
rious
sizes
nd
ppe
r
nces of onococci
re the result of multiple nutrition
l requir
ements, such
s

rininehypox
nthineur
cil (AHU)requirin str
ins. Colony size
nd color
tion (or l
iht
reflection)
re the
sis of Kellos scheme (types T1 throuh T5). Types T1
nd
T2 h
ve pili on
the surf
ce
nd T3, T4,
nd T5 do not. Tr
nsp
rent medi

re not used routinely,
ut op
que
nd
tr
nsp
rent coloni
l differences of the onococci c
n e seen when usin it. 43.
D All of the
listed Neisseri
spp. row on MTM
nd
re oxid
se positive. N. l
ct
mic
is
no
np
thoenic
component of norm
l thro
t flor
resem lin N. meninitidis ut it rows well on
selective MTM


r. Presumptive identific
tion of N. meninitidis or N. onorrhoe
e is st
ted
only if the
source of the specimen (i.e., uroenit
l or CSF) is iven. The identific
tion mu
st e confirmed
y further testin such
s c
r ohydr
te utiliz
tion tests, DNA tests, or r
pid l

tex slide

lutin
tion tests. 44. A N. onorrhoe
e colonies recovered from selective MT
M medi
ive
n
immedi
te positive re
ction ( u lin) when 30% H 2 O 2 is
dded. The c
t
l
se t
est uses 3% H 2 O
2 . This is
presumptive test for N. onorrhoe
e; N. meninitidis
nd N. l
ct
m
ic
ive
we
k
or del
yed u lin re
ction. M. c
t
rrh
lis is c
t
l
se positive, Superoxol ne

tive,
nd h
s

v
ri
le rowth p
ttern on MTM. 45. B Mor
xell
spp.
re oxid
se
nd c
t
l
se
positive,
s
re
the onococci. Neisseri
spp.
nd M. c
t
rrh
lis will keep their typic
l cocc
l
morpholoy
fter
overniht incu
tion on lood

r with
10-unit penicillin disk (CO 2 incu
ti
on). Other
Mor
xell
species form lon l
ments or lon spindle-sh
ped cells when rown ne
r

10-unit
penicillin disk. 46. A A Gr
m st
in of urethr
l disch
re (in men only) showin
typic
l
onococc
l cells in PMNs should e reported presumptive N. onorrhoe
e, con rm
tion
to follow.

With fem
le p
tients, the norm
l v
in
l or
cont
in r
m-ne
tive cocci
nd dipl
ococci
resem lin onococci
nd, therefore, no presumptive identi c
tion should e report
ed for N.
onorrhoe
e from the v
in
l Gr
m st
in sme
r. 47. A N. l
ct
mic
utilizes l
c
tose y producin
the enzyme -
l
ctosid
se. All other Neisseri
spp. th
t row on MTM medi

re l

ctose ne
tive.
2828_Ch07_381-494 06/08/12 11:25 AM P
e 424 48. Cystine tryptic diest (CTA)
medi
used for
identi c
tion of Neisseri
spp. should e inocul
ted
nd cultured in: A. A CO 2 in
cu
tor
t 35C
for 24 hours B. A CO 2 incu
tor
t 42C for up to 72 hours C. A nonCO 2 incu
tor

t 35C for up
to 72 hours D. An
n
ero ic incu
tor
t 35C for up to 72 hours Micro ioloy/Appl
y knowlede of

sic l
or
tory procedures/Gr
m-ne
tive cocci/1 49. Culture on MTM medi
of

v
in
l sw

produced sever
l colonies of r
m-ne
tive diplococci th
t were c
t
l
se
nd oxi
d
se positive
nd
Superoxol ne
tive. Given the followin c
r ohydr
te re
ctions, select the most
likely
identi c
tion. Glucose = + Sucrose = Ne L
ctose = + M
ltose = + Fructose = Ne A
. Neisseri

onorrhoe
e B. Neisseri
sicc
C. Neisseri

vescens D. Neisseri
l
ct
mic

Micro ioloy/Ev
lu
te l
or
tory d
t
to m
ke identi c
tions/B
cteri
/3 50. Sputum
from
p
tient
with pneumoni
produced m
ny colonies of r
m-ne
tive diplococci on
chocol
te
pl
te th
t were

lso present in fewer num ers on MTM
fter 48 hours. Given the followin results
, wh
t is the
most likely identi c
tion? C
t
l
se = + Oxid
se = + DN
se = + Tri utyrin hydrolysi
s = + Glucose =
Ne Sucrose = Ne L
ctose = Ne M
ltose = Ne Fructose = Ne A. Mor
xell
c
t
rr
h
lis B.
Neisseri

vescens C. Neisseri
sicc
D. Neisseri
elon
t
Micro ioloy/Apply kn
owlede of
fund
ment
l ioloic
l ch
r
cteristics/Gr
m-ne
tive cocci/1 51. Resist
nce to w
hich dru
c
teorizes
str
in of St
phylococcus
ureus
s methicillin-resist
nt St
phyloc
occus
ureus
(MRSA)? A. Ox
cillin B. Colistin C. Trimethoprimsulf
methox
zole D. Tetr
cycline
Micro ioloy/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics/Anti ioti
c
suscepti ility/1 7.5 | Gr
m-Positive
nd Gr
m-Ne
tive Cocci 425 Answers to Qu
estions 4852 48.
C CTA

r with 1% c
r ohydr
te
nd phenol red pH indic
tor
dded is used for th
e identific
tion
of Neisseri
species. CTA c
r ohydr
tes must e pl
ced in
n
m ient
ir incu
t
or ec
use
hih
CO 2 concentr
tion m
y reduce the pH, c
usin
f
lse-positive (
cid) result. Th
e utiliz
tion of
c
r ohydr
tes y some f
stidious onococc
l str
ins m
y t
ke up to 72 hours in o
rder to produce

color ch
ne in the pH indic
tor. 49. D N. l
ct
mic
is p
rt of the norm
l v
i
n
l
nd thro
t
flor

nd is the only Neisseri
species th
t rows on MTM th
t utilizes l
ctose.
Other
s
prophytic Neisseri
spp. m
y utilize l
ctose ut do not row on MTM medi
. 50.
A M.

c
t
rrh
lis is p
rt of the norm
l upper respir
tory or
ut is implic
ted in lowe

r respir
tory
infections, includin pneumoni
. It produces stunted rowth on MTM
nd is DN
se
positive,
ch
r
cteristics th
t di erenti
te it from the other s
prophytic Neisseri
species.
51. A
Ox
cillin is the dru used to screen st
phylococci for resist
nce to
nti iotics
h
vin the
-l
ct
m rin. Included in this roup
re penicillin, ceph
losporin, mono
ct
m,

nd c
r
penem.
MRSA defines str
ins of st
ph th
t
re resist
nt to
ll of these
nti iotic rou
ps. MRSA str
ins

re tre
ted with v
ncomycin or ox
zolidinone. 52. D The st
nd
rd Kir yB
uer metho
d used for disk
di usion suscepti ility testin recommended y CLSI is 20 mm. The test requires 202
4-hour
incu
tion
t 35C in 5%7% CO 2 . If the zone size is 19 mm,
n MIC should e perfo
rmed on
isol
tes from CSF or lood. 52. An ox
cillin-disk screen test is used to detect
Streptococcus
pneumoni
resist
nce to penicillin. Usin MuellerHinton

r with 5% sheep lood

nd
1 
ox
cillin disk, wh
t is the recommended inhi ition zone size for penicillin susc
epti ility? A. 5
mm B. 10 mm C. 15 mm D. 20 mm Micro ioloy/Apply knowlede of fund
ment
l ioloic

l
ch
r
cteristics/Anti iotic suscepti ility/2 2828_Ch07_381-494 06/08/12 11:25 A
M P
e 425 53.
Which one of the followin or
nisms is
known producer of -l
ct
m
seproducin st
r
ins,
nd
should e tested (screened) y
commerci
l -l
ct
m
se
ss
y prior to suscepti il
ity testin? A.
Streptococcus pneumoni
e B. Group B streptococci C. Enterococcus spp. D. Pl
noco
ccus spp.
Micro ioloy/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics/Anti ioti
c
suscepti ility/2 54. Which test is used for the determin
tion of induci le clind

mycin resist
nce
in st
phylococci
nd streptococci? A. E-test B. D-zone test C. A-test D. C
mp te
st
Micro ioloy/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics/Anti ioti
c
suscepti ility/2 426 Ch
pter 7 | Micro ioloy Answers to Questions 5354 53. C A
test for
-l
ct
m
se production should e performed on
ll isol
tes of St
phylococcus
nd E
nterococcus
s
well
s N. onorrhoe
e
nd H. influenz
e. Some or
nisms m
y
ppe
r to e penici
llin/
mpicillin
suscepti le y the convention
l Kir yB
uer disk diffusion method for -l
ct
m
se pr
oducers, ut
still produce sm
ll
mounts of -l
ct
m
se. An ex
mple is heteroresist
nt mecA-pos
itive S.
ureus
(the mecA ene confers penicillin resist
nce
nd is present in
ll MRSA str
ins)
. 54. B By usin

15-g erythromycin disk adjacent to a 2-g clindamycin disk in a disk di usion proce
dure, a
attening of the clindamycin zone occurs in inducible clindamycin resistance, caus
ing the zone to
look like the letter D. This is referred to as being D-zone positive. CLSI recom
mends that

inducible clindamycin resistant strains be reported as resistant with a comment

that clindamycin
may still be e ective in some patients. 2828_Ch07_381-494 06/08/12 11:25 AM Pag
e 426 427 7.6
Aerobic Gram-Positive Rods, Spirochetes, Mycoplasmas and Ureaplasmas, and Chlamy
dia 1. Large
gram-positive spore-forming rods growing on blood agar as large, raised, -hemolyt
ic colonies
th
t spre
d
nd
ppe
r
s frosted reen-r
y l
ss
re most likely: A. Pseudomon

s spp. B.
B
cillus spp. C. Coryne
cterium spp. D. Listeri
spp. Micro ioloy/Apply knowle
de of
fund
ment
l ioloic
l ch
r
cteristics/B
cteri
/2 2. B
cillus
nthr
cis
nd B

cillus cereus c
n
est e di erenti
ted y which tests? A. Motility
nd -hemolysis on
lood

r pl

te B.
Oxid
se
nd -hemolysis on
lood

r pl
te C. Lecithin
se
nd lucose D. Lecith
in
se
nd
c
t
l
se Micro ioloy/Select methods/Re
ents/Medi
/B
cteri
/ Identi c
tion/2 Answ
ers to
Questions 12 1. B The only spore former listed is the B
cillus spp., which row

s l
re,
spre
din colonies on lood

r pl
tes. Pseudomon
s spp.
re r
m-ne
tive rods
; Coryne
cterium
spp.
ppe
r
s sm
ll, very dry colonies on BAP; Listeri
spp.
ppe
r
s very sm

ll -hemolytic
colonies on BAP, resem lin Streptococcus species. 2. A Both species of B
cillus

re c
t
l
se
nd
lecithin
se positive
nd produce
cid from lucose. B. cereus is -hemolytic
nd m
otile, ut B.

nthr
cis is neither. See the followin ch
rt. Hemolysis Motility Oxid
se
C
t
l
se
Lecithin
se Glucose B. cereus + + Ne + + + B.
nthr
cis Ne Ne Ne + + + 282
8_Ch07_381-494
06/08/12 11:25 AM P
e 427 3. Which is the specimen of choice for proof of foo
d poisonin y
B
cillus cereus? A. Sputum B. Blood C. Stool D. Food Micro ioloy/Apply knowled
e of fund
ment
l
ioloic
l ch
r
cteristics/GPB/2 4. A suspected B
cillus
nthr
cis culture o t
i
ned from
wound
specimen produced colonies th
t h
d m
ny outrowths (Medus
-he
d
ppe
r
nce), u
t were not
-hemolytic on sheep lood

r. Which test should e performed next? A. Penicilli
n (10-unit)
suscepti ility test B. Lecithin
se test C. Glucose test D. Motility test Micro i
oloy/Select
course of
ction/GPB/3 5. Which of the followin tests should e performed for i
niti
l
di erenti
tion of Listeri
monocytoenes from roup B streptococci? A. Gr
m st
in,
motility
t
room temper
ture, c
t
l
se B. Gr
m st
in, CAMP test, H 2 S/TSI C. Oxid
se, CAMP
test, lucose D.
Oxid
se,
citr
cin Micro ioloy/Select methods/Re
ents/Medi
/ B
cteri
/2 6. Cu
lture of
ner
wound specimen from
me
t p
cker produced short r
m-positive
cilli on
loo
d

r pl
te with
no hemolysis. Given the followin test results
t 48 hours, wh
t is the most lik
ely
identi c
tion? C
t
l
se = Ne H 2 S/TSI = + Motility (wet prep) = Ne Motility (me
di
) = Ne

( ottle- rush rowth in st
culture) A. B
cillus cereus B. Listeri
monocytoen

es C.
Erysipelothrix rhusiop
thi
e D. B
cillus su tilis Micro ioloy/Ev
lu
te l
or
to
ry d
t
to m
ke
identi c
tions/B
cteri
/3 428 Ch
pter 7 | Micro ioloy Answers to Questions 36 3.
D The est
specimen is the suspected food itself. Stool cultures
re not useful ec
use B.
cereus is p
rt of
the norm
l fec
l or
. The suspected food c
n e the source of food poisonin y B
. cereus if
100,000 or re
ter or
nisms per r
m of infected food
re demonstr
ted. 4. A Th
e est
di erenti
tin test to perform on
suspected B.
nthr
cis culture is the 10-unit
penicillin disk
test. B.
nthr
cis is suscepti le ut other B
cillus spp.
re not. Or
nisms sus
pected to e B.

nthr
cis should e sent to
reference l
or
tory for n
l con rm
tion. All tests s
hould e
performed in
ioloic
l s
fety hood,
nd personnel should we
r protective clot
hin to reduce
risk from possi le production of
erosols. 5. A Streptococcus spp.
re c
t
l
s
e ne
tive
nd L.
monocytoenes is c
t
l
se positive. L. monocytoenes
ppe
rs on the Gr
m st
in s
me
r
s
r
m-positive short, thin, diphtheroid
l sh
pes, where
s streptococci usu
lly
p
pe
r
s short,
r
m-positive ch
ins. The re
ctions shown in the followin ch
rt di erenti
te L. m
onocytoenes
from the roup B streptococci. Bile C
t
l
se Motility CAMP H 2 S Esculin L. m
onocytoenes + +
+ Ne + Group B Ne Ne + Ne Ne streptococci 6. C E. rhusiop
thi
e is c
t
l

se ne
tive,
where
s the other three or
nisms
re c
t
l
se positive. E. rhusiop
thi
e is see
n prim
rily
s

skin infection on the ners of me
t
nd poultry workers. Colonies rowin on loo
d

r
re
sm
ll
nd tr
nsp
rent, m
y e either smooth or rouh,
nd
re often surrounded
y
reen tine.
E. rhusiop
thi
e is ch
r
cterized y H 2 S production in the utt of
TSI sl
nt
, which
di erenti
tes it from other c
t
l
se-ne
tive, r
m-positive rods. 2828_Ch07_381-4
94 06/08/12
11:25 AM P
e 428 7. A nonspore-formin, slender r
m-positive rod formin p
lis

des
nd ch
ins
w
s recovered from
v
in
l culture
nd rew well on tom
to juice

r. Te most
likely
identi c
tion is: A. L
cto
cillus spp. B. B
cillus spp. C. Neisseri
spp. D. Stre
ptococcus spp.
Micro ioloy/Ev
lu
te l
or
tory d
t
to m
ke identi c
tions/B
cteri
/2 8. A Coryn
e
cterium
species recovered from
thro
t culture is considered
p
thoen when it produce
s: A. A
pseudomem r
ne of the oroph
rynx B. An exotoxin C. Gr
y- l
ck colonies with
r
own h
lo on
Tinsd
les

r D. All of these options Micro ioloy/Apply knowlede of fund
ment

l ioloic
l
ch
r
cteristics/GPB/2 9. A presumptive di
nosis of G
rdnerell
v
in
lis c
n e
m
de usin which
of the followin ndins? A. Oxid
se
nd c
t
l
se tests B. Pleomorphic
cilli he

vily colonized

on v
in
l epithelium C. Hippur
te hydrolysis test D. All of these options Micro

ioloy/Select
methods/Re
ents/Medi
/ G
rdnerell
/2 10. A r
m-positive r
nchin l
mentous or

nism recovered
from
sputum specimen w
s found to e positive with
modi ed
cid-f
st st
in met
hod. Wh
t is
the most likely presumptive identi c
tion? A. B
cillus spp. B. Noc
rdi
spp. C. Co
ryne
cterium
spp. D. Listeri
spp. Micro ioloy/Ev
lu
te l
or
tory d
t
to m
ke identi c
tions
/B
cteri
/2 11.
Routine l
or
tory testin for Treponem
p
llidum involves: A. Culturin B. Sero
loic
l
n
lysis
C. Acid-f
st st
inin D. Gr
m st
inin Micro ioloy/Select methods/Re
ents/Medi

/ Spirochetes/1
7.6 | Aero ic Gr
m-Positive Rods, Spirochetes, Mycopl
sm
s
nd Ure
pl
sm
s,
nd
Chl
mydi
429
Answers to Questions 711 7. A L
cto
cillus spp. produce oth lon, slender rod
s or short
cocco
cilli th
t form ch
ins. L
cto
cillus spp.
re p
rt of the norm
l or
of t
he v
in
(
re
not considered
p
thoen)
nd
re sometimes confused with the streptococci. 8.
D
Coryne
cteriumspecies recovered from
thro
t culture
re usu
lly considered p

rt of the norm
l
thro
t or
. C. diphtheri
e is
n exception
nd should e suspected when one of th
e conditions
descri ed occurs. In this event, direct inocul
tion on Loe er serum medium or tell
urite medium

nd the followin iochemic
l tests should e performed to con rm the identi c
tion
of C.
diphtheri
e. Gel
tin hydrolysis = Ne C
t
l
se = + Motility = + Ure
se = + Acid
from lucose = +
C
r ohydr
te ferment
tion = + 9. D A Gr
m st
in sme
r from
v
in
l secretion s
howin m
ny
squ
mous epitheli
l cells lo
ded with pleomorphic r
m-v
ri
le (positive
nd ne

tive)
cilli
is considered presumptive for G. v
in
lis. Such cells
re c
lled clue cells. Ot
her import
nt
ndins
re: -Hemolysis on BAP = + C
t
l
se = Ne Oxid
se = Ne Hippur
te hydrolys
is = + 10. B
Noc
rdi
spp. should e suspected if colonies th
t
re p
rti
lly
cid f
st y t
he tr
dition
l
method
re positive with the modi ed
cid-f
st method usin Kinyoun st
in
nd 1% s
ulfuric
cid
s
the decolorizin
ent. The other or
nisms listed
re ne
tive for
cid-f
st st

in. 11. B
Seroloic
l tests of the p
tients serum for evidence of syphilis
re routinely pe
rformed, ut
culturin is not ec
use rese
rch
nim
ls must e used for inocul
tion of the su
spected
spirochete. T. p
llidum does not st
in y either the Gr
m or
cid-f
st technique
. D
rk eld
microscopy for direct visu
liz
tion or indirect immuno uorescence usin uorescein-c
onju
ted

ntihum
n lo ulin (the uorescent treponem
l
nti ody-
sorption test, FTA-ABS) m

y e used to
identify syphilis. Newer tests for speci c
nti odies to T. p
llidum
re
v
il
le
in
wide r
ne
of immuno
ss
y form
ts includin chemiluminescence
nd point-of-c
re immunochrom

tor
phy. T.

p
lliduminfection c
n e di
nosed y PCR. Bec
use the
cterium is f
stidious,

lood s
mples
should e collected in EDTA, CSF should e frozen
nd sent on dry ice,
nd s
mpl
es
n
lyzed
s
soon
s possi le. 2828_Ch07_381-494 06/08/12 11:25 AM P
e 429 12. Spirochete
s often detected
in the hem
toloy l
or
tory, even efore the physici
n suspects the infection,

re: A. Borreli

spp. B. Treponem
spp. C. C
mpylo
cter spp. D. Leptospir
spp. Micro ioloy/App
ly knowlede of
fund
ment
l ioloic
l ch
r
cteristics/Spirochetes/1 13. Which of the followin
or
nisms is the
c
use of Lyme dise
se? A. Treponem
p
llidum B. Neisseri
meninitidis C. B
esi

microti D.
Borreli
urdorferi Micro ioloy/Apply knowlede of fund
ment
l ioloic
l
ch
r
cteristics/Spirochetes/1 14. Te di
nostic method most commonly used for th
e identi c
tion
of Lyme dise
se is: A. Seroloy B. Culture C. Gr
m st
in D. Acid-f
st st
in Micr
o ioloy/Select
methods/Re
ents/Medi
/ Spirochetes/1 15. Prim
ry
typic
l pneumoni
is c
used
y: A.
Streptococcus pneumoni
e B. Mycopl
sm
pneumoni
e C. Kle siell
pneumoni
e D. My
co
cterium
tu erculosis Micro ioloy/Apply knowlede of fund
ment
l ioloic
l ch
r
cterist
ics/1 16. Which
or
nism typic
lly produces fried-e colonies on

r within 15 d
ys of culture fr
om

enit
l specimen? A. Mycopl
sm
hominis B. Borreli
urdorferi C. Leptospir
in
terro
ns D.
Treponem
p
llidum Micro ioloy/Apply knowlede of fund
ment
l ioloic
l ch
r
c
teristics/1 17.
Te m
n
nous chlorideure
test is used for the identi c
tion of which or
nism? A.
Mycopl
sm

pneumoni
e B. Ure
pl
sm
ure
lyticum C. B
cillus cereus D. Borreli
urdorferi
Micro ioloy/Select methods/Re
ents/Medi
/ Mycopl
sm
/1 430 Ch
pter 7 | Micro
ioloy Answers
to Questions 1217 12. A Borreli
spp.
re often seen on Wrihts-st
ined sme
rs o
f peripher
l
lood
s helic
l
cteri
with 310 loose coils. They
re r
m ne
tive ut st
in
well with
Giems
s st
in. 13. D Lyme dise
se m
y result in
cute
rthritis
nd meninitis
n
d is c
used y
B. urdorferi. This spirochete is c
rried y the deer tick elonin to the Ixo
des enus (I.
d
mmini in the E
stern
nd North-centr
l United St
tes
nd I. p
ci cus in the Nort
hwest United
St
tes). The life cycle of the tick involves sm
ll rodents such
s the white-foo
ted mouse
nd the
white-t
iled deer. 14. A Seroloic
l
n
lysis usin immuno uorescence or
n enzyme
immuno
ss
y is
the method of choice for di
nosis of Lyme dise
se. Titers of IM rem
in hih th
rouhout the
infection. B. urdorferi c
n e cultured directly from lesions,
nd d
rk eld micr
oscopy c
n e
used for detection of spirochetes in lood cultures
fter 23 weeks of incu
tion

t 34C37C.
15. B A common c
use of respir
tory tr
ct illness, M. pneumoni
e, ener
lly c
us
es
self-limited
infection (310 d
ys)
nd usu
lly does not require
nti iotic ther
py. M. pneumoni

e c
n e

cultured from the upper
nd lower respir
tory tr
cts onto speci
lly enriched (di
ph
sic) medi
,
ut is most frequently di
nosed y the ch
ne in
nti ody titer from
cute to c
onv
lescent serum
usin enzyme immuno
ss
y or other seroloic
l methods. 16. A Genit
l mycopl
sm
s
(M. hominis
nd
Ure
pl
sm
ure
lyticum)
re rown on specific

rs. M. hominis is rown on M

r
cont
inin

rinine
nd phenol red. Colonies of mycopl
sm

re 50300 m in diameter and displa
y a
fried-egg appearance with red holes. U. urealyticum is isolated from genital speci
mens on U
agar (containing urea and phenol red), then subcultured to A7/A8 agar. Colonies
of Ureaplasma are
small and golden brown on A7/A8 agar. 17. B U. urealyticumis the only human my
coplasma that
hydrolyzes urea. The manganous chlorideurea test utilizes manganous chloride (MnC
l 2 ) in the
presence of urea. Urease produced by the organism hydrolyzes the urea to ammonia
. This reacts
with MnCl 2 forming manganese oxide, which is insoluble and forms a dark brown p
recipitate around
the colonies. The reaction is observed under a dissecting microscope and is a ra
pid test for the
identi cation of U. urealyticum. 2828_Ch07_381-494 06/08/12 11:25 AM Page 430 1
8. A
gram-positive (gram-variable), beaded organism with delicate branching was recov
ered from the
sputum of a 20-year-old patient with leukemia. Te specimen produced orange, glab
rous, waxy
colonies on Middlebrooks agar that showed partial acid-fast staining with the mod
i ed Kinyoun
stain. What is the most likely identi cation? A. Rhodococcus spp. B. Actinomadura
spp. C.
Streptomyces spp. D. Nocardia spp. Microbiology/Evaluate laboratory data to make
identi cations/Bacteria/3 19. A direct smear from a nasopharyngeal swab stained wi
th Loe er
methylene blue stain showed various letter shapes and deep blue, metachromatic g
ranules. Te most
likely identi cation is: A. Corynebacterium spp. B. Nocardia spp. C. Listeria spp.
D. Gardnerella
spp. Microbiology/Evaluate laboratory data to make identi cations/Bacteria/3 20. W
hich of the
following is the best, rapid, noncultural test to perform when Gardnerella vagin
alis is suspected
in a patient with vaginosis? A. 10% KOH test B. 3% H 2 O 2 test C. 30% H 2 O 2 t
est D. All of
these options Microbiology/Select methods/Reagents/Media/ Gardnerella/2 21. Whic
h is the test of
choice for the con rmation of Chlamydia trachomatis infection in urine? A. Enzyme
immunoassay
antigen testing B. PCR molecular testing C. Culture using McCoy and Hela cells D
.
Microimmuno uorescence (MIF) test Microbiology/Select test/Identi cation/Chlamydia/2
22. Which
test is the most reliable for the detection of Mycoplasma pneumonia in serum and
for the
con rmation of diagnosis? A. EIA testing and direct antigen testing B. Cold agglut
inin testing
using Group O RBCs C. Culture on SP4 glucose broth with arginine D. Complement xa

tion
Microbiology/Select test/Identi cation/Mycoplasma/2 7.6 | Aerobic Gram-Positive Ro
ds,
Spirochetes, Mycoplasmas and Ureaplasmas, and Chlamydia 431 Answers to Questio
ns 1822 18. D
All of the listed organisms produce mycelium (aerial or substrate), causing them
to appear
branched when Gram stained, but only the Nocardia spp. are positive for modi ed ac
id-fast stain.
Nocardia is an opportunistic pathogen, and cultures typically have a musty basem
ent odor. 19. A
Corynebacteriumspp. are part of the normal upper respiratory tract ora. Organisms
display
typical pleomorphic shapes often resembling letters such as Y or L, and metachro
matic granules.
Identi cation of C. diphtheriae, however, requires selective culture media and bio
chemical
testing. 20. A The whi test is used for a presumptive diagnosis of an infection wit
h G.
vaginalis. A shlike odor is noted after the addition of 1 drop of 10% KOH to the
vaginal
washings. This odor results from the high concentration of amines found in women
with vaginosis
caused by G. vaginalis. 21. B EIA and MIF tests detect antibodies to Chlamydia t
rachomatis, but
may also detect antibodies that cross react with other organisms, and are perfor
med on serum.
Cell culture is time consuming and dependent on the quality of the specimen. PCR
is both
sensitive and speci c and may be performed on urine. 22. A The cold agglutinin tes
t is
nonspecific and time consuming, and therefore, outdated. Although M. pneumonia c
an be grown on
artificial media, many specimens fail to grow, and growth can take up to 3 weeks
. CF tests are
not as sensitive or specific as EIA tests. Direct antigen assay by immunofluores
cence is specific
but has a sensitivity at least two orders of magnitude below DNA amplification m
ethods. While PCR
is the most sensitive method, it may detect the presence of M. pneumonia in the
absence of
infection. EIA methods are sensitive, but some persons fail to produce antibodie
s especially in
extra respiratory infections, and antibody tests alone may detect past rather th
an current
infections. Adults may fail to produce an IgM response especially in recurrent i
nfections, so the
best confirmatory approach is a combination of EIA and direct antigen testing. 2
828_Ch07_381-494
06/08/12 11:25 AM Page 431 23. Identify the following bacterium and specimen p
airing that is
mismatched (specimen not appropriate for isolation). A. Chlamydia (Chlamydophila
) psittaci: fecal
swab B. Chlamydia trachomatis: rst voided urine C. Chlamydia trachomatis: endocer
vical swab D.
Chlamydia pneumonia: throat swab or sputum Microbiology/Apply knowledge of stand
ard operating
procedure/Specimen collection/Chlamydia/1 24. Which of the following organisms a
re transmitted to
animals and humans after a tick bite? A. Leptospira. B. Chlamydia and Mycoplasma

spp. C.
Neisseria sicca D. Ehrlichia and Anaplasma spp. Microbiology/Apply knowledge of
fundamental
biological characteristics/2 25. Following a hike in the woods, a young male not
ed a tick on his
ankle. He removed the tick, but 2 weeks later noticed a circular, bulls eye rash
at the site of
the bite. Which specimen(s) should be obtained to establish a diagnosis of Lyme
borreliosis? A.
Lymph node biopsy, skin scraping B. Blood, CSF, and skin biopsy C. Hair, ngernail
s D. Saliva,
sputum Microbiology/Apply knowledge of standard operating procedure/Specimen
collection/Borrelia/2 432 Chapter 7 | Microbiology Answers to Questions 2325 23
. A
Chlamydophila psittaci is the new taxonomic classi cation for Chlamydia psittaci.
This bacterium
is found naturally in psittacine birds and other avian species. Human infection,
psittacosis, is
a result of contact with pet birds, or from occupational contact in poultry farm
ing or
processing. Inhalation of the organisms from aerosols, fecal material, or feathe
r dust causes a
respiratory infection and the specimen of choice is a throat swab or sputum. 24.
D Ehrlichia and
Anaplasma spp. are intracellular bacteria and are the causative agents of human
monocytotropic
ehrlichiosis (HME) and human granulocytotropic anaplasmosis (HGA). The organisms
infect humans,
dogs, and cattle through the bite of an infected Ixodes tick which also transmit
s Borrelia spp.,
causing Lyme disease. Blood, CSF, and serum are used for serological testing or
PCR. A diagnosis
can be made by direct observation of the basophilic inclusions (morulae) in leuk
ocytes of
Giemsas or Wrights stained blood or bu y coat smears. This occurs in about 20% of HM
E in which
the organisms are present in the monocytes, and more frequently in HGA in which
they are found in
the granulocytes. 25. B In stages I and II of Lyme disease, EIA testing is perfo
rmed on serum for
antibodies. PCR testing and culture of Borrelia spp. are performed on a skin bio
psy. In stage
III, synovial uid, skin biopsy, and CSF are tested for Borrelia spp. by PCR. 2828
_Ch07_381-494
06/08/12 11:25 AM Page 432 433 7.7 Anaerobic Bacteria 1. Obligate anaerobes, f
acultative
anaerobes, and microaerophiles are terms referring to bacteria that require: A.
Increased
nitrogen B. Decreased CO 2 C. Increased O 2 D. Decreased O 2 Microbiology/Apply
principles of
fundamental biological characteristics/Anaerobes/1 2. Which of the following mos
t a ects the
oxidationreduction potential (Eh or redox potential) of media for anaerobic bacte
ria? A. O 2 B.
Nitrogen C. pH D. Glucose Microbiology/Apply principles of fundamental biologica
l
characteristics/Anaerobes/1 3. Which of the following is the medium of choice fo
r the selective
recovery of gram-negative anaerobes? A. Kanamycinvancomycin (KV) agar B. Phenylet
hyl alcohol

(PEA) agar C. Cycloserinecefoxitinfructose agar (CCFA) D. THIO broth Microbiology/

Select
methods/Reagents/Media/ Anaerobes/2 4. Anaerobic bacteria are routinely isolated
from all of the
following types of infections except: A. Lung abscesses B. Brain abscesses C. De
ntal infections
D. Urinary tract infections Microbiology/Apply principles of fundamental biologi
cal
characteristics/Anaerobes/1 Answers to Questions 14 1. D The anaerobic bacteria a
re subdivided
according to their requirement for O 2 . Obligate anaerobes are killed by exposu
re to atmospheric
O 2 for 10 min or longer. Facultative anaerobes grow under aerobic or anaerobic
conditions.
Microaerophilic organisms do not grow in an aerobic incubator on solid media and
only minimally
under anaerobic conditions. However, they will grow in minimal oxygen (5% O 2 ).
Superoxide
dismutase (SOD) is produced by many anaerobes, which catalyzes the conversion of
superoxide
radicals to less toxic H 2 O 2 and molecular O 2 . 2. C The Eh is most a ected by
pH and is
expressed at pH 7.0. In cultivating anaerobic bacteria, reducing agents such as
thioglycollate
and L-cysteine are added to anaerobic transport and culture media in order to ma
intain a low Eh.
Certain anaerobes do not grow in the media above a speci c critical Eh level. 3. A
KV allows the
growth of Bacteroides spp., Prevotella spp., and Fusobacteriumspp. and inhibits
most facultative
anaerobic gram-negative rods and gram-positive bacteria (both aerobic and anaero
bic). PEA
inhibits facultative gram-negative bacteria but will support gram-positive aerob
es and anaerobes
and gram-negative obligate anaerobes. CCFA is selective for C. di cile from stool,
while THIO
broth supports gram-positive and gram-negative aerobes and anaerobes. 4. D The i
ncidence of
anaerobic bacteria recovered from the urine is approximately 1% of isolates. The
other three
types of infection are associated with a 60%93% incidence of anaerobic recovery.
Urine is not
cultured routinely under anaerobic conditions unless obtained surgically (e.g.,
suprapubic
aspiration). 2828_Ch07_381-494 06/08/12 11:25 AM Page 433 5. Methods other th
an packaged
microsystems used to identify anaerobes include: A. Antimicrobial susceptibility
testing B.
Gasliquid chromatography (GLC) C. Special staining D. Enzyme immunoassay Microbio
logy/Select
methods/Reagents/Media/ Anaerobes/1 6. Which broth is used for the cultivation o
f anaerobic
bacteria in order to detect volatile fatty acids as an aid to identi cation? A. Pr
ereduced
peptoneyeast extractglucose (PYG) B. THIO broth C. Gram-negative (GN) broth D. Sel
enite (SEL)
broth Microbiology/Select methods/Reagents/Media/ Anaerobes/1 7. A gram-positive
spore-forming
bacillus growing on sheep-blood agar anaerobically produces a double zone of -hem
olysis
nd is

positive for lecithin
se. Wh
t is the presumptive identi c
tion? A. B
cteroides ur

eolyticus B.
B
cteroides fr
ilis C. Clostridium perfrinens D. Clostridium di cile Micro iolo
y/Ev
lu
te
l
or
tory d
t
to m
ke identi c
tions/B
cteri
/2 8. E yolk

r is used to dete
ct which enzyme
produced y Clostridium species? A. Lecithin
se B. -L
ct
m
se C. C
t
l
se D. Oxid

se
Micro ioloy/Apply principles of fund
ment
l ioloic
l ch
r
cteristics/An
ero e
s/1 9. Which of
the followin or
nisms will displ
y lip
se
ctivity on e yolk

r? A. Clostr
idium otulinum
B. Clostridium sporoenes C. Clostridium novyi (A) D. All of these options Micro
ioloy/Ev
lu
te
l
or
tory d
t
to m
ke identi c
tions/B
cteri
/2 434 Ch
pter 7 | Micro ioloy A
nswers to
Questions 59 5. B An
ero ic
cteri
c
n e identi ed y
n
lysis of met
olic prod
ucts usin

sliquid chrom
tor
phy. Results
re ev
lu
ted
lon with Gr
m st
inin ch
r
cte
ristics, spore
form
tion,
nd cellul
r morpholoy in order to m
ke the identi c
tion. 6. A Pepton
e ye
st
nd
chopped me
t with c
r ohydr
tes support the rowth of
n
ero ic
cteri
. The en
d products from
the met
olism of the peptone
nd c
r ohydr
tes
re vol
tile f
tty
cids th
t he
lp to identify
the
cteri
. After incu
tion, the roth is centrifued,
nd the supern
t
nt in
jected into


sliquid chrom
tor
ph. Pe
ks for
cetic, utyric, or formic
cid, for ex
mple,
c
n e
identi ed y comp
rison to the elution time of vol
tile or
nic
cid st
nd
rds. 7.
C C.
perfrinens produces
dou le zone of -hemolysis on lood

r, which m
kes ident
ific
tion
rel
tively e
sy. The inner zone of complete hemolysis is c
used y
-toxin and t
h
out
r zon

of incompl
t
h
molysis is caus
d by an -toxin (lecithin
se
ctivity). The B
cter
oides spp.
re
r
m-ne
tive
cilli,
nd C. difficile is lecithin
se ne
tive
nd does not pro
duce
dou le
zone of -hemolysis. 8. A E yolk

r (modi ed McCluns or neomycin e yolk

r)
is used to
determine the presence of lecithin
se
ctivity, which c
uses
n insolu le, op
qu
e, whitish
precipit
te within the

r. Lip
se
ctivity is indic
ted y
n iridescent sheen
or pe
rly l
yer
on the surf
ce of the

r. 9. D Lip
se is produced y some Clostridiumspp.
nd
is seen
s
n
iridescent pe
rly l
yer on the surf
ce of the colonies th
t extends onto the sur
f
ce of the e
yolk

r medium surroundin them. C. perfrinens, the most frequently isol
ted
Clostridiumspecies, is ne
tive for lip
se production. 2828_Ch07_381-494 06/08/
12 11:25 AM
P
e 434 10. Which spore type
nd loc
tion is found on Clostridium tet
ni? A. Ro
und, termin
l
spores B. Round, su termin
l spores C. Ovoid, su termin
l spores D. Ovoid, termi
n
l spores
Micro ioloy/Apply principles of fund
ment
l ioloic
l ch
r
cteristics/An
ero e
s/1 11.
Gr
m-positive
cilli recovered from two lood cultures from
60-ye
r-old di
e

tic p
tient 
ve

the followin results: Spores seen = Ne Hemolysis = + (dou le zone) Motility =
Ne Lecithin
se =
+ Vol
tile
cids y GLC (PYG) =
cetic
cid (A)
nd utyric
cid (B) Wh
t is the
most likely
identi c
tion? A. Clostridium tet
ni B. Clostridium perfrinens C. Clostridium nov
yi (B) D.
Clostridium sporoenes Micro ioloy/Ev
lu
te l
or
tory d
t
to m
ke identi c
tion
s/B
cteri
/3
12. Which mech
nism is responsi le for otulism in inf
nts c
used y Clostridium
otulinum? A.
Inestion of spores in food or liquid B. Inestion of preformed toxin in food C.
Virulence of the
or
nism D. Lip
se
ctivity of the or
nism Micro ioloy/Apply principles of fun
d
ment
l
ioloic
l ch
r
cteristics/An
ero es/2 13. Te cl
ssic form of food orne otulism
is ch
r
cterized
y the inestion of: A. Spores in food B. Preformed toxin in food C. Toxin H D.
All of these
options Micro ioloy/Apply principles of fund
ment
l ioloic
l ch
r
cteristics/
An
ero es/2 7.7 |
An
ero ic B
cteri

435 Answers to Questions 1013 10. A Spore
ppe
r
nce
nd loc

tion,
lon
with Gr
m st
in morpholoy,
ids in distinuishin the Clostridiumspp. Round, te
rmin
l spores
(drumstick spores)
re demonstr
ted when C. tet
ni is rown in chopped me
t with
lucose roth.
Reconition of spores is p
rticul
rly import
nt ec
use C. tet
ni sometimes
ppe

rs
s r
m
ne
tive. 11. B Spores
re ener
lly not demonstr
ted from clinic
l specimens co
nt
inin C.
perfrinens, which is the only species producin
dou le zone of hemolysis. The
re
ctions in the
ch
rt
ove distinuish the four species listed. 12. A Inf
nt otulism is the mo
st frequent form
occurrin in the United St
tes. Epidemioloic
l studies h
ve demonstr
ted th
t i
nf
nt otulism
results from the inestion of spores vi
re
stfeedin or exposure to honey. Pre
formed toxin h
s
not een detected in food or liquids t
ken y the inf
nts. C. otulinum multipli
es in the ut of
the inf
nt
nd produces the neurotoxin in situ. 13. B Food orne otulism in
dul
ts
nd children
is c
used y inestion of the preformed toxin ( otulinum toxins A, B, E,
nd F)
in food. The
neurotoxins of C. otulinum
re protopl
stic proteins m
de durin the rowin ph

se
nd rele
sed
durin lysis of the or
nisms. Con rm
tion of otulism is m
de y demonstr
tion of
the toxin in
serum, 
stric, or stool specimens. Spores Motility Lecithin
se Dou le-Zon
e Hemolysis GLC
Products C. tet
ni Termin
l* + Ne Ne A,B C. perfrinens Su termin
l Ne + + A,
B C. novyi (B)
Su termin
l + + Ne A,B,P C. sporoenes Su termin
l + Ne Ne A,B *Usu
lly l
cki
n Propionic

cid 2828_Ch07_381-494 06/08/12 11:25 AM P
e 435 14. Which test is performed
in order to
con rm
n infection with Clostridium otulinum? A. Toxin neutr
liz
tion B. Spore-f
ormin test C.
Lip
se test D. Gel
tin hydrolysis test Micro ioloy/Select methods/Re
ents/Medi


/ An
ero es/2
15. Which Clostridium spp. c
uses pseudomem r
nous colitis or
nti iotic-
ssoci

ted colitis? A.
C. r
mosum B. C. di cile C. C. perfrinens D. C. sporoenes Micro ioloy/Apply pri
nciples of
fund
ment
l ioloic
l ch
r
cteristics/An
ero es/2 16. Identi c
tion of Clostridiu
m tet
ni is

sed upon: A. Gr
m st
in of the wound site B. An
ero ic culture of the wound si
te C. Blood
culture results D. Clinic
l ndins Micro ioloy/Apply principles of fund
ment
l
ioloic
l
ch
r
cteristics/An
ero es/2 17. O li
te
n
ero ic r
m-ne
tive
cilli th
t do
not form spores
row well in 20% ile
nd
re resist
nt to penicillin 2-unit disks
re most like
ly: A.
Porphyromon
s spp. B. B
cteroides spp. C. Fuso
cterium spp. D. Prevotell
spp.
Micro ioloy/Ev
lu
te l
or
tory d
t
to m
ke identi c
tions/B
cteri
/2 18. Which
B
cteroides
spp. is noted for pittin of the

r
nd is sensitive to penicillin 2-unit disks?
A. B.
vul
tus B. B. ov
tus C. B. thet
iot
omicron D. B. ureolyticus Micro ioloy/Ev
l
u
te l
or
tory
d
t
to m
ke identi c
tions/B
cteri
/2 19. Which r
m-ne
tive
cilli produce l

ck piment
nd
rick red uorescence when exposed to
n ultr
violet liht source? A. Porphyromon

s spp.
nd
Prevotell
spp. B. Fuso
cterium spp.
nd Actinomyces spp. C. B
cteroides spp.

nd Fuso
cterium
spp. D. All of these options Micro ioloy/Ev
lu
te l
or
tory d
t
to m
ke
identi c
tions/B
cteri
/2 436 Ch
pter 7 | Micro ioloy Answers to Questions 1419
14. A C.
otulinum
nd C. sporoenes h
ve simil
r ch
r
cteristics iochemic
lly (see the f
ollowin ch
rt),

nd de nitive identi c
tion of C. otulinumis m
de y the toxin neutr
liz
tion test
for its
neurotoxins in serum or feces. Specimens should e kept
t 4C
nd sent to the CDC
for culture

nd toxin
ss
ys. GLC Spore Type Motility Lip
se Products C. otulinum Su
termin
l + + A,
(P)*, B, (IB) , IV C. sporog
n
s Subt
rminal + + A, (P), B, (IB), IV *Variabl
I
sobutyric
acid Isoval
ric acid 15. B C. di cil
is also implicat
d in hospital acuir
d di
arrh
a and
colitis. Clinical t
sting for C. di cil
includ
s cultur
and cytotoxin t
sting. B

caus
cultur

tak
s 3 days and will d
t
ct nontoxig
nic strains that do not caus
diarrh
al di
s
as
,
immunoassays using antibodi
s against
ith
r th
A toxin or both th
A and B tox
ins ar
most
fr
u
ntly
mploy
d. Assays d
t
cting both toxins ar
only slightly mor
s
nsiti
v
, sinc

inf
ctions producing only B toxin ar
infr
u
nt. Th
cytotoxin assay r
uir
s t
hat sp
cim
ns b

shipp
d to a r
f
r
nc
laboratory on dry ic
or k
pt at 4C6C if don
in-hous
. 16.
D Th

cultur
and Gram stain of th
punctur
wound sit
usually do
s not produc
any

vid
nc
of C.
t
tani. Th
diagnosis is usually bas
d upon clinical ndings, which ar
charact
ri
z
d by spastic
muscl
contractions, lockjaw, and backward arching of th
back caus
d by muscl

contraction. 17.
B Th
Bact
roid
s group grows w
ll in 20% bil
and is r
sistant to p
nicillin 2unit disks with
th

xc
ption of B. ur
olyticus. Most Pr
vot
lla ar
also r
sistant to p
nicilli
n 2-unit disks,
but most Fusobact
riumand Porphyromonas ar
s
nsitiv
. 18. D B. ur
olyticus is
th
only sp
ci
s
list
d that is susc
ptibl
to p
nicillin and produc
s ur
as
. Th
oth
r organism
s list
d ar

r
sistant to p
nicillin. 19. A Pigm
nting Porphyromonas spp. and Pr
vot
lla spp.
also show
h
molysis on sh

p blood agar. 2828_Ch07_381-494 06/08/12 11:25 AM Pag

436 2
0. T
following
charact
ristics of an obligat
ana
robic gram-n
gativ
bacilli b
st d
scrib
whi
ch of th
list
d
g
n
ra? Gram stain: long, sl
nd
r rods with point
d
nds Colonial app
aranc
: dr
y br
ad crumbs or
fri
d-
gg app
aranc
P
nicillin 2-unit disk t
st: Susc
ptibl
A. Bact
roid
s spp.
B.
Fusobact
rium spp. C. Pr
vot
lla spp. D. Porphyromonas spp. Microbiology/Evaluat

laboratory data
to mak
id
nti cations/Bact
ria/3 21. All of th
following g
n
ra ar
ana
robic co
cci that stain
gram positiv

xc
pt: A. P
ptococcus spp. B. P
ptostr
ptococcus spp. C. Str
ptoc
occus spp. D.
V
illon
lla spp. Microbiology/Apply principl
s of fundam
ntal biological
charact
ristics/Ana
rob
s/2 22. T
gram-positiv
nonspor
-forming ana
robic rods
most fr
u
ntly
r
cov
r
d from blood cultur
s as a contaminant ar
: A. Propionibact
rium acn
s B
. Clostridium
p
rfring
ns C. Staphylococcus int
rm
dius D. V
illon
lla parvula Microbiology/Ap
ply knowl
dg
of
fundam
ntal biological charact
ristics/Ana
rob
s/2 23. Which Clostridium sp
ci
s
is most oft
n
r
cov
r
d from a wound inf
ction with gas gangr
n
? A. C. sporog
n
s B. Clostrid
ium sord
llii C.
C. novyi D. C. p
rfring
ns Microbiology/Apply knowl
dg
of fundam
ntal biologica
l
charact
ristics/Ana
rob
s/1 24. Gram stain of a sm
ar tak
n from th
p
riodontal
pock
ts of a
30-y
ar-old man with poor d
ntal hygi
n
show
d sulfur granul
s containing grampositiv
rods
(short diphth
roids and som
unbranch
d lam
nts). Coloni
s on blood agar r
s
mbl

d molar t

th
in formation. T
most lik
ly organism is: A. Actinomyc
s isra
lii B. Propionibac
t
rium acn
s C.
Staphylococcus int
rm
dius D. P
ptostr
ptococcus ana
robius Microbiology/Evaluat

laboratory data
to mak
id
nti cations/Bact
ria/3 7.7 | Ana
robic Bact
ria 437 Answ
rs to Qu
sti
ons 2025 20. B
Fusobact
riumspp. ar
usually spindl
-shap
d, slim rods, wh
r
as th
oth
r g
n

ra ar
small
rods (variabl
l
ngth for Bact
roid
s spp. and tiny coccoid rods for Pr
vot
lla
and Porphyromonas
spp.). Fusobact
riumspp. and Porphyromonas spp. ar
susc
ptibl
to p
nicillin 2unit disks, whil

most Bact
roid
s spp. and Pr
vot
lla spp. ar
r
sistant. 21. D V
illon
lla spp.
ar

gram-n
gativ
cocci. All four g
n
ra ar
part of th
normal human ora and ar
th

ana
robic

cocci most fr
u
ntly isolat
d from blood cultur
s, absc
ss
s, wounds, and body u
ids. Th

Str
ptococcus spp. ar
facultativ
ana
rob
s, but only Str
ptococcus int
rm
dius
is classi
d as
an obligat
ana
rob
. 22. A P. acn
s is a nonspor
form
r and is d
scrib
d as
a
diphth
roid-shap
d rod. It is part of th
normal skin, nasopharynx, g
nitourinar
y, and
gastroint
stinal tract ora but is implicat
d as an occasional caus
of
ndocardit
is. 23. D
Wounds inf
ct
d with clostridia ar
charact
riz
d by invasion and liu
factiv
n

crosis of muscl

tissu
with gas formation. Th
most fr
u
nt isolat
is C. p
rfring
ns follow
d
by C. novyi and
C. s
pticum. 24. A A. isra
lii is part of th
normal ora of th
mouth and tonsi
ls but may
caus
upp
r or low
r r
spiratory tract inf
ctions. Th
sulfur granul
s ar
granu
lar microcoloni
s
with a purul
nt
xudat
. Lik
Nocardia, Actinomyc
s produc
s unbranch
d myc
lia
and is som
tim
s
(
rron
ously) consid
r
d a fungus. It has also b

n implicat
d in p
lvic inf
cti
on associat
d
with intraut
rin
contrac
ptiv
d
vic
s (IUDs). 25. C Th
ana
rob
s ar
not suit

d for th
broth
disk
lution or disk agar di usion t
sts b
caus
of th
ir slow rat
of growth. Kir
byBau
r m
thod
r
f
r
nc
charts ar
not d
sign
d to b
us
d as a r
f
r
nc
of susc
ptibility fo
r ana
rob
s. 25.
Antimicrobial susc
ptibility t
sting of ana
rob
s is don
by which of th
follow
ing m
thods? A.
Broth disk
lution B. Disk agar di usion C. Microtub
broth dilution D. -L
ct
m
se
testin
Micro ioloy/Apply knowlede of st
nd
rd oper
tin procedures/An
ero es/1 2828_C
h07_381-494
06/08/12 11:25 AM P
e 437 438 7.8 Myco
cteri
1. Te est specimen for recove
ry of the
myco
cteri
from
sputum s
mple is: A. First mornin specimen B. 10-hour eveni
n specimen C.
12-hour pooled specimen D. 24-hour pooled specimen Micro ioloy/Apply knowlede
of st
nd
rd
oper
tin procedures/Myco
cteri
/1 2. Wh
t concentr
tion of sodium hydroxide (N

OH) is used to
prep
re
workin decont
min
tion solution for the processin of not norm
lly st
erile specimens
for myco
cteri
? A. 1% N
OH B. 4% N
OH C. 8% N
OH D. 12% N
OH Micro ioloy/Appl
y knowlede of
st
nd
rd oper
tin procedures/Myco
cteri
/1 3. Which is the most
ppropri
te no
nselective medium
for recovery of myco
cteri
from
he
vily cont
min
ted specimen? A. LwensteinJen
sen

r B.
Middle rook 7H10

r C. Petr
n
nis

r D. Americ
n Tor
cic Society medium Micr
o ioloy/Select
method/Re
ents/Medi
/ Myco
cteri
/2 4. Myco
cteri
st
ined y the ZiehlNeelsen
or Kinyoun
methods with methylene lue counterst
in
re seen microscopic
lly
s: A. Briht
red rods

inst

lue
ckround B. Briht yellow rods

inst
yellow
ckround C. Or
ne-re
d rods

inst

l
ck
ckround D. Briht lue rods

inst
pink
ckround Micro ioloy/Appl
y knowlede of

fund
ment
l ioloic
l ch
r
cteristics/Myco
cteri
/1 Answers to Questions 14 1.

A Cont
min
tion
y funi
nd other
cteri
contri utes to lower yields of myco
cteri
in
24hour s
mple. The
rst mornin specimen collected y expector
tion or ne uliz
tion produces the hih
est
concentr
tion of myco
cteri
in sputum. 2. B A stron decont
min
tion solution
(6% N
OH or
re
ter) m
y kill or severely d
m
e the myco
cteri
. A 4% N
OH solution is mix
ed with
n equ
l
volume of N-
cetyl-L-cysteine (NALC),
diest
nt or mucolytic
ent, to yield

n
l workin
concentr
tion of 2% N
OH. The time of exposure of the specimen to the diestion/
decont
min
tion
solution must e monitored ec
use overtre
tment m
y result in fewer positive cu
ltures. 3. C All
four medi
cont
in m
l
chite reen
s
n inhi itory
ent of nonmyco
cteri
, u
t Petr
n
nis
medium cont
ins
hiher concentr
tion (0.052 /dL) th
n LwensteinJensen (0.025 /
dL),
Middle rook 7H10 (0.0025 /dL), or Americ
n Thor
cic Society medium (0.02 /dL).
The l
st is used
for norm
lly sterile specimens, such
s from CSF
nd one m
rrow. 4. A The c
r o
lfuchsin (fuchsin
with phenol) st
ins the myco
cteri
red
nd does not decolorize
fter the
cid
l
cohol is
dded.
The
ckround
nd
ny other
cteri
l elements will decolorize
nd
re counters
t
ined lue y
the methylene lue. A fluorescent st
inin procedure m
y e used
s
n
ltern
ti
ve to
cid-f
st
st
inin. Aur
mine fluorochrome produces riht yellow fluorescent myco
cteri


nd

ur
minerhod
mine c
uses
n or
ne-red (old) fluorescence

inst
d
rk
ckro
und. A
fluorescent microscope must e used, ut with this method the sme
r c
n e sc
nn
ed with
25
o jective inste
d of the 100 o jective, permittin more r
pid identific
tion of m
yco
cteri
.
2828_Ch07_381-494 06/08/12 11:25 AM P
e 438 5. Acid-f
st st
inin of
sme
r
prep
red from
diested sputum showed slender, slihtly curved, e
ded, red myco
cteri
l rods.
Growth on
Middle rook 7H10 sl
nts produced u -colored microcolonies with
serpentine p
tte
rn
fter 14
d
ys
t 37C. Ni
cin
nd nitr
te reduction tests were positive. Wh
t is the most p
ro
le
presumptive identi c
tion? A. Myco
cterium tu erculosis B. Myco
cterium ulcer
ns
C.
Myco
cterium k
ns
sii D. Myco
cterium
viumintr
cellul
re complex Micro ioloy/
Ev
lu
te
l
or
tory d
t
to m
ke identi c
tions/Myco
cteri
/3 6. Which or
nism,
ssoci
te
d with
tu erculosis in c
ttle, c
uses tu erculosis in hum
ns, especi
lly in reions whe
re d
iry f
rmin
is prev
lent? A. Myco
cterium
viumintr
cellul
re complex B. Myco
cterium k
ns

sii C.
Myco
cterium m
rinum D. Myco
cterium ovis Micro ioloy/Apply knowlede of fun
d
ment
l
ioloic
l ch
r
cteristics/Myco
cteri
/1 7. Which of the followin or
nisms
r
e used
s

controls for r
pid rowers
nd slow rowers? A. Myco
cterium fortuitum
nd Myco

cterium
tu erculosis B. Myco
cterium
vium-intr
cellul
re complex
nd Myco
cterium tu
erculosis C.
Myco
cterium chelonei
nd Myco
cterium fortuitum D. Myco
cterium k
ns
sii
nd
Myco
cterium
tu erculosis Micro ioloy/Apply knowlede of fund
ment
l ioloic
l
ch
r
cteristics/Myco
cteri
/2 8. Which of the followin Myco
cterium spp. prod
uce(s) pimented
colonies in the d
rk (is
scotochromoen)? A. M. szul
i B. M. k
ns
sii C. M. t
u erculosis D.
All of these options Micro ioloy/Apply knowlede of fund
ment
l ioloic
l
ch
r
cteristics/Myco
cteri
/2 9. All of the followin myco
cteri

re
ssoci
t
ed with skin
infections except: A. Myco
cterium m
rinum B. Myco
cterium h
emophilum C. Myco

cterium
ulcer
ns D. Myco
cterium k
ns
sii Micro ioloy/Apply knowlede of fund
ment
l
ioloic
l
ch
r
cteristics/Myco
cteri
/2 7.8 | Myco
cteri
439 Answers to Questions 59 5
. A M.
tu erculosis is positive for ni
cin
ccumul
tion, while the other three species

re ni
cin
ne
tive. M. ulcer
ns is
ssoci
ted with skin infections (in the tropics), does
not row
t 37C
(optim
l temper
ture is 33C),
nd is not recovered from sputum. A serpentine p
tt
ern of rowth
indic
tes production of cordin f
ctor,
virulence f
ctor for M. tu erculosis.
6. D M. ovis is

lso c
lled the ovine tu ercle
cillus. A nonvirulent str
in,
cillus C
lmett
eGurin (BCG),
is used
s
tu erculosis v
ccine throuhout the world. Infections with M. ovis
resem le
infections c
used y M. tu erculosis
nd
re seen in circumst
nces where there i
s close cont
ct
etween hum
ns
nd c
ttle. 7. A Growth r
tes of myco
cteri

re used
lon with
iochemic
l
tests
s
n
id to identific
tion. M. fortuitum rows within 35 d
ys
t 37C
nd is
used
s the
control for r
pid rowers. M. tu erculosis rows in 1225 d
ys
t 37C
nd is
cont
rol or
nism
for slow rowers. In
ddition to M. fortuitum, M. chelonei is
r
pid rower (35
d
ys
t
28C35C). In
ddition to M. tu erculosis, M.
vium
nd M. k
ns
sii
re slow rowers (
1021 d
ys

t 37C). 8. A M. tu erculosis does not produce piment
tion in the d
rk or
fte
r exposure to
liht (photochromoen). A common t
pw
ter scotochromoen is Myco
cterium ordon

e. The
p
thoenic scotochromoens
re Myco
cterium szul
i, Myco
cterium scroful
ceum
,
nd
Myco
cterium xenopi. M. k
ns
sii is
photochromoen producin
yellow piment
followin
exposure to liht
nd red -c
rotene cryst
ls
fter lon incu
tion periods. 9. D
M. k
ns
sii is

photochromoen th
t c
uses chronic pulmon
ry dise
se (cl
ssic tu erculosis). T
he other three
species c
use cut
neous or su cut
neous dise
se. It is import
nt to culture skin
lesions
t the

t 37C M.
correct temper
ture to f
cilit
te rowth. Optimum Growth temper
ture
m
rinum

30C32C Poor M. h
emophilum 28C32C Poor or no M. ulcer
ns 33C No 2828_Ch07_381-494

06/08/12 11:25 AM P
e 439 10. All of the followin Myco
cterium spp. produce
the enzyme
required to convert ni
cin to ni
cin ri onucleotide except: A. M. k
ns
sii B. M.
tu erculosis C.
M.
viumintr
cellul
re complex D. M. szul
i Micro ioloy/Apply knowlede of fund

ment
l
ioloic
l ch
r
cteristics/Myco
cteri
/2 11. Te c
t
l
se test for myco
cteri

di ers from th
t
used for other types of
cteri
y usin: A. 1% H 2 O 2
nd 10% Tween 80 B. 3%
H 2 O 2
nd
phosph
te u er, pH 6.8 C. 10% H 2 O 2
nd 0.85% s
line D. 30% H 2 O 2
nd 10% Twe
en 80
Micro ioloy/Select method/Re
ents/Medi
/ Myco
cteri
/2 12. Growth inhi ition
y
thiophene-2-c
r oxylic hydr
zide (T 2 H) is used to di erenti
te M. tu erculosis f
rom which other
Myco
cterium specie? A. M. ovis B. M.
viumintr
cellul
re complex C. M. k
ns
si
i D. M. m
rinum
Micro ioloy/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics/Myco
cte
ri
/2 13. Which
of the followin Myco
cterium spp. is est di erenti
ted y the r
pid hydrolysis
of Tween 80? A.
M. fortuitum B. M. chelon
e C. M. k
ns
sii D. M. ordon
e Micro ioloy/Apply kno
wlede of
fund
ment
l ioloic
l ch
r
cteristics/Myco
cteri
/2 14. Myco
cteri
isol
ted
from the hot
w
ter system of
hospit
l rew
t 42C. Colonies on LwensteinJensen medium were not
pimented

fter exposure to liht
nd were ne
tive for ni
cin
ccumul
tion
nd nitr
te re
duction. Te most
likely identi c
tion is: A. Myco
cterium xenopi B. Myco
cterium m
rinum C. Myco

cterium
ulcer
ns D. Myco
cterium h
emophilum Micro ioloy/Ev
lu
te l
or
tory d
t
to m

ke
identi c
tions/Myco
cteri
/3 440 Ch
pter 7 | Micro ioloy Answers to Questions
1014 10. B
Ni
cin production is common to
ll myco
cteri
. However, the ni
cin
ccumul
tes

s
w
tersolu le met
olite in the culture medium when the or
nism c
nnot form ni
cin ri
onucleotide. M.
tu erculosis, M. simi
e,
nd some str
ins of M. m
rinum, M. chelon
e,
nd M. ov
is l
ck the
enzyme
nd therefore
re c
lled ni
cin positive ec
use of the
ccumul
tion of n
i
cin detected in
the test medium. 11. D One milliliter of
n equ
l mixture of 30% H 2 O 2 (Supero
xol)
nd Tween 80
(
stron deterent) is
dded to
2-week-old su culture on LwensteinJensen medium

nd pl
ced
upriht for 5 minutes. C
t
l
se
ctivity is determined semiqu
ntit
tively y me

surin the heiht
of the column of u les produced
ove the culture surf
ce. 12. A M. ovis
n
d M. tu erculosis

re very simil
r iochemic
lly,
nd some str
ins of M. ovis
lso
ccumul
te ni

cin. The T 2 H
test di erenti
tes M. tu erculosis from M. ovis. M. tu erculosis is not inhi ited
y T 2 H. 13.
C The hydrolysis of Tween 80 is usu
lly positive when testin the clinic
lly ins
inific
nt
myco
cteri
. M. fortuitum, M. chelon
e,
nd M. ordon
e
re s
prophytic (
nd op

portunistic)
species, ut M. k
ns
sii is
p
thoen. M. k
ns
sii hydrolyses Tween 80 more r
p
idly th
n the
other species (within 36 hours). A positive re
ction is indic
ted y
ch
ne in
the color of
neutr
l red from yellow to pink. 14. A M. xenopi c
uses
pulmon
ry infection
resem lin M.
tu erculosis
nd is frequently isol
ted from p
tients with
n underlyin dise
se
such
s

lcoholism, AIDS, di
etes, or m
lin
ncy. It is often recovered from hot w
ter
t
ps
nd
cont
min
ted w
ter systems
nd is
possi le source of nosocomi
l infection. The
other three
species c
use skin infections
nd row on
rti ci
l medi

t
much lower temper
t
ure th
n M.
xenopi ( elow 32C). 2828_Ch07_381-494 06/08/12 11:25 AM P
e 440 15. A Myco
c
terium species
recovered from
p
tient with AIDS 
ve the followin results: Ni
cin = Ne T2H
= + Tween 80
hydrolysis = Ne Nitr
te reduction = Ne He
t-st
le c
t
l
se (68C) =  Nonphotochr
omoen Wh
t
is the most likely identi c
tion? A. M. ordon
e B. M. ovis C. M.
viumintr
cellul

re complex
D. M. k
ns
sii Micro ioloy/Ev
lu
te l
or
tory d
t
to m
ke identi c
tions/Myco

cteri
/3 16. Te
ure
se test is needed to di erenti
te Myco
cterium scroful
ceum from which of the
followin
myco
cteri
? A. M. ordon
e B. M. k
ns
sii C. M.
viumintr
cellul
re complex D.
M. ovis
Micro ioloy/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics/Myco
cte
ri
/2 17. A
l
or
tory provides the followin services for identi c
tion of myco
cteri
: Acid
-f
st st
inin
of clinic
l specimens Inocul
tion of cultures Shipment of positive cultures to

reference
l
or
tory for identi c
tion Accordin to the Americ
n Tor
cic Societys de nition for
levels of
service this l
or
tory is: A. Level I B. Level II C. Level III D. Level IV Micr
o ioloy/Apply
knowlede of l
or
tory oper
tions/Myco
cteri
/2 18. Accordin to the Collee o
f Americ
n
P
tholoists (CAP) uidelines, which services for myco
cteri
would e performe
d y
Level II
l
or
tory? A. No procedures performed B. Acid-f
st st
inin, inocul
tion,
nd r
eferr
l to

reference l
or
tory C. Isol
tion
nd identi c
tion of Myco
cterium tu erculosis;
prelimin
ry
identi c
tion of other species D. De nitive identi c
tion of
ll myco
cteri
Micro io
loy/Apply
knowlede of l
or
tory oper
tions/Myco
cteri
/2 7.8 | Myco
cteri

441 Answe
rs to Questions
1518 15. C With the exception of M. tu erculosis, M.
viumintr
cellul
re (MAI) com
plex is the
Myco
cterium species most often isol
ted from AIDS p
tients. It is iochemic
ll
y inert, which is

distinuishin f
ctor for identific
tion. MAI complex is hihly resist
nt to t
he
nti iotics
used to tre
t tu erculosis, includin multidru ther
py. Tre
tment with streptom
ycin, rif
mpin,
ethion
mide, eth
m utol with cycloserine, or k
n
mycin h
s shown little success.

16. A Both
p
thoenic
nd s
prophytic myco
cteri
m
y produce ure
se,
nd ure
se productio
n is used to
di erenti
te sever
l myco
cteri
species. Biochemic
lly, M. scroful
ceumis identi
c
l to M.
ordon
e, except for the ure
se re
ction for which M. scroful
ceumis positive
n
d M. ordon
e is
ne
tive. Ure
se re
ctions for the other p
thoenic myco
cteri

re: M. tu ercu
losis = + M.
k
ns
sii = + M. ovis = + M.
viumintr
cellul
re complex = Ne 17. A The Americ
n
Thor
cic
Society reconizes three levels of l
or
tory services for myco
cteri
testin.
Level I
l
or
tories
re those th
t row myco
cteri

nd perform
cid-f
st st
ins ut d
o not identify M.
tu erculosis (they m
y or m
y not perform dru suscepti ility tests on M. tu erc
ulosis). Level II
l
or
tories perform
ll of the functions of Level I l
or
tories
nd
lso ident
ify M.
tu erculosis. Level III l
or
tories identify
ll myco
cteri
species from clin
ic
l specimens

nd perform dru suscepti ility tests on
ll species. 18. B The CAP lists four o
ptions for
l
or
tories to follow in order to correl
te the services provided with uidelin
es for inspection

nd
ccredit
tion. A l
or
torys perform
nce on CAP proficiency tests is ev
lu
te
d y
interl
or
tory comp
rison with l
or
tories within these levels of perform
nce.
2828_Ch07_381-494 06/08/12 11:25 AM P
e 441 19. Culture of
skin (h
nd) wou
nd from
m
n
er
of
tropic
l sh store rew on LwensteinJensen

r sl
nts
t 30C in 10 d
ys ut did
not row
on the s
me medi

t 37C in 20 d
ys. Given the followin results, wh
t is the mos
t likely
identi c
tion? Photochromoen = + Ni
cin = Ne Ure
se = + He
t-st
le c
t
l
se (68C
) = Ne
Nitr
te reduction = Ne Tween 80 hydrolysis = + A. Myco
cterium m
rinum B. Myc
o
cterium
k
ns
sii C. Myco
cterium
vium-intr
cellul
re complex D. Myco
cterium tu ercul
osis
Micro ioloy/Ev
lu
te l
or
tory d
t
to m
ke identi c
tions/Myco
cteri
/3 20. Wh
ich
nonp
thoenic Myco
cterium specie is isol
ted most often from clinic
l specimen
s
nd is c
lled
the t
pw
ter
cillus? A. M. k
ns
sii B. M.
viumintr
cellul
re complex C. M. lepr

e D. M.
ordon
e Micro ioloy/Apply knowlede of l
or
tory oper
tions/Myco
cteri
/2 21
. Which of the
followin drus
re rst-line
nti iotics used to tre
t cl
ssic tu erculosis for w
hich
suscepti ility testin is performed y the disk di usion method on Middle rook 7H1
0 or 7H11

r
pl
tes? A. Ampicillin, penicillin, streptomycin,
nd c
r enicillin B. Ampicillin
, penicillin,
nd
methicillin C. V
ncomycin, methicillin,
nd c
r enicillin D. Isonicotinic
cid h
ydr
zide (INH),
rif
mpin, eth
m utol,
nd pyr
zin
mide Micro ioloy/Apply principles of speci
l
procedures/
Myco
cteri
/2 22. How lon should Myco
cterium tu erculosispositive cultures e
kept y the

l
or
tory
fter identific
tion
nd
nti iotic suscepti ility testin h
ve een
performed? A. 12
months B. 24 months C. 56 months D. 612 months Micro ioloy/Apply knowlede of st
n
d
rd
oper
tin procedures/Myco
cteri
/2 442 Ch
pter 7 | Micro ioloy Answers to Qu
estions 1923 19.
A M. m
rinumis typic
lly recovered from cut
neous wounds resultin from infect
ion when the skin
is tr
um
tized
nd comes into cont
ct with in
dequ
tely chlorin
ted fresh w
ter
or s
lt w
ter,
such
s in swimmin pools or sh
qu
riums. The other three species
re slow rowe
rs
t 37C. M.
tu erculosis
nd M.
viumintr
cellul
re complex
re nonphotochromoens. M.
viumin
tr
cellul
re
complex is ure
se ne
tive, M. tu erculosis is positive for ni
cin
nd nitr
te,

nd M. k
ns
sii
is positive for nitr
te
nd c
t
l
se. 20. D M. ordon
e is
nonp
thoen, scoto
chromoen,
nd
r
pid rower (7 d
ys
t 37C). R
rely, it is implic
ted in opportunistic infection
s in p
tients
with shunts, prosthetic he
rt v
lues, or hep
toperitone
l dise
se. The other thr
ee species
re
p
thoenic myco
cteri
. 21. D The rst-line
nti iotics, except for eth
m utol,

re

ctericid
l. Second-line
nti iotics used to tre
t rst-line dru-resist
nt tu er
culosis include
streptomycin, pyr
zin
mide, cycloserine, ethion
mide, k
n
mycin,
mik
cin, viomy
cin,
nd
c
preomycin. 22. D St
nd
rd ther
py usin INH
nd rif
mpin for cl
ssic, uncompli
c
ted pulmon
ry
tu erculosis is 9 months. The p
tient m
y not respond to ther
py, even when the
or
nism is
suscepti le to the
nti iotics in vitro; therefore, cultures must e kept for up
to 1 ye
r in
order to f
cilit
te testin of
ddition
l
nti iotics should the infection ecom
e refr
ctory to
ther
py. 23. A Acid-f
st sme
rs
re st
nd
rdized y the Americ
n Thor
cic Societ
y for reportin
the num er of AFB seen. The followin criteri
should e used to uniformly repor
t results: 12
AFB per sme
r: Report num er seen
nd request
nother s
mple 39 AFB per sme
r: Re
port
s r
re
(1+) 10 or more per sme
r: Report
s few (2+) 19 or more per oil immersion eld: Re
port
s
numerous (3+) 23. Accordin to the reportin st
nd
rds of the Americ
n Tor
cic S
ociety, one or
more
cid-f
st
cilli (AFB) per oil immersion eld (1,000)
re reported
s: A. Num
erous or 3+
B. Few or 2+ C. R
re or 1+ D. Indetermin
te;
new specimen should e requested
Micro ioloy/Apply knowlede of st
nd
rd oper
tin procedures/Myco
cteri
/1 282
8_Ch07_381-494
06/08/12 11:25 AM P
e 442 24. Which of the followin Myco
cterium spp. would
e most likely
to row on
M
cConkey

r pl
te? A. M. chelon
efortuitum complex B. M. ulcer
ns
C. M. m
rinum
D. M.
viumintr
cellul
re complex Micro ioloy/Apply knowlede of fund
ment
l io
loic
l
ch
r
cteristics/Myco
cteri
/1 25. R
pid methods for identifyin cl
ssic infecti
on with M.
tu erculosis include: A. G
sliquid chrom
tor
phy B. Nucleic
cid pro es C. Acid-

f
st sme
rs D.
All of these options Micro ioloy/Apply principles of speci
l procedures/Myco
c
teri
/2 26.
Individu
ls showin
positive puri ed protein deriv
tive (PPD) skin test for M. t
u erculosis
re
usu
lly: A. Infective B. Symptom
tic of pulmon
ry dise
se C. L
tently infected D
. F
lsely
positive Micro ioloy/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics/
Myco
cteri
/2
27. Which of the followin Myco
cterium species is di
nosed y me
ns other th

n culture? A. M.
lepr
e B. M. ovis C. M. c
netti D. M.
vium Micro ioloy/Apply knowlede of fun
d
ment
l
ioloic
l ch
r
cteristics/Myco
cteri
/2 28. Which M.
vium complex (MAC) or
n
ism is the most
frequently isol
ted myco
cterium from AIDS p
tients? A. M.
vium B. M. intr
cel
lul
re C. M.
scroful
ceum D. M. ovis Micro ioloy/Apply knowlede of fund
ment
l ioloic
l
ch
r
cteristics/Myco
cteri
/2 29. Which myco
cterium of the M. tu erculosis co
mplex f
ils to
row in culture
nd h
s
ch
r
cteristic croiss
nt-like morpholoy in st
ined sme

rs? A. M.

fric
num B. M. microti C. M. ovis D. M. lepr
e Micro ioloy/Ev
lu
te l
or
tor
y d
t
to m
ke
identi c
tions/Myco
cteri
/3 7.8 | Myco
cteri
443 Answers to Questions 2429 24
. A
Myco
cteri
rowin on M
cConkey

r
re usu
lly nonp
thoens. M. chelon
e
nd
M. fortuitum
re
oth nonp
thoenic r
pid rowers th
t will row on M
cConkey

r (with no cryst

l violet) within
5 d
ys. MAI complex is v
ri
le on M
cConkey

r ut t
kes much loner to row.
M. m
rinum
nd M.
ulcer
ns do not row on M
cConkey

r. 25. D M. tu erculosis is
slow rower
with
proloned
culture time of 1225 d
ys
nd requires 36 weeks for de nitive identi c
tion
nd
nti i
otic
suscepti ility testin. The
cid-f
st sme
r rem
ins the num er one r
pid test fo
r the detection
of myco
cteri
l infection. A positive sme
r h
s
predictive v
lue of 96% when

ll l
or
tory

nd clinic
l ndins
re considered. GLC is used to ev
lu
te cell w
ll lipid p
tte
rns for
identi c
tion. DNA pro es
re
v
il
le for r
pid identi c
tion of M. tu erculosis,
M. ovis, M.

viumintr
cellul
re complex,
nd M. ordon
e. A commonly used PCR method for myco

cteri
l
detection involves
mpli c
tion of
species-speci c reion of DNA with
l
eled (
iotinyl
ted)
olionucleotide primer. The PCR product is detected y den
tur
tion
nd hy ridiz

tion to

c
pture pro e. After w
shin to remove un ound DNA, strep
vidin conju
ted to
n
enzyme is
dded.
After w
shin to remove un ound conju
te, su str
te is
dded. The presence of p
roduct indic
tes

positive result. 26. C A positive PPD test indic
tes
person who is l
tently
infected with M.
tu erculosis. Such persons
re
symptom
tic
nd not infectious, ut h
ve
10% r
isk of developin
tu erculosis durin their lifetime. 27. A M. lepr
e
nd M. microti
re di erent
from
ll other

myco
cteri
ec
use they c
nnot e cultured in vitro. Biopsies from nodules
nd
pl
ques of skin
th
t show numerous AFB
re presumptively di
nosed
s positive for M. lepr
e. Co
n rm
tory
identi c
tion is m
de y nucleic
cid testin (NAT) usin PCR. 28. A More th
n 90%
of MAC
or
nisms th
t
re isol
ted from AIDS p
tients
re M.
vium. These
re distinui
shed from M.
intr
ceullu
re y NATs. 29. B M. microti is found in uine
pis, r
its, c
t
s,
nd other
w
rm- looded
nim
ls. It is
c
use of tu erculosis in immunocompromised hum
ns,
ut is
lso
known to c
use tu erculosis in immunocompetent persons
s well. M. microti c
nno
t e cultured in
vitro, ut c
n e distinuished from M. lepr
e y its distinctive croiss
nt-like m
orpholoy.
Di
nosis is confirmed y NAT. 2828_Ch07_381-494 06/08/12 11:25 AM P
e 443 3
0. Which two
myco
cteri
commonly isol
ted from su cut
neous skin h
ve
n optim
l rowth tem
per
ture of 30C?
A. M. h
emophilum
nd M. ulcer
ns B. M. k
ns
sii
nd M. xenopi C. M. ordon
e
n
d M.
vium D. M.
simi
e
nd M.
vium Micro ioloy/Ev
lu
te l
or
tory d
t
to m
ke identi c
tions/M
yco
cteri
/2
31. Which myco
cterium is
ssoci
ted with Crohns dise
se? A. M. m
rinum B. M. p

r
tu erculosis
C. M.
vium D. M. ordon
e Micro ioloy/Apply knowlede of fund
ment
l ioloic

l
ch
r
cteristics/Myco
cteri
/2 32. Which temper
ture r
ne is ide
l for the reco
very of M.
m
rinum? A. 24C26C B. 30C32C C. 42C44C D. 44C48C Micro ioloy/Apply principles of
speci
l procedures/ Myco
cteri
/2 444 Ch
pter 7 | Micro ioloy Answers to Que
stions 3032 30.
A M. h
emophilum, M. ulcer
ns,
nd M. m
rinumrow optim
lly
t 27C30C. M. xenopi
rows
optim
lly
t 42C45C,
nd is frequently isol
ted from hot w
ter systems
nd stor
e
t
nks. All
other myco
cterium
re cultured
t 35C37C. 31. B M. p
r
tu erculosis is known to
c
use
n
ulcer
tive intestin
l dise
se with chronic di
rrhe
in c
ttle known
s Johnes dis
e
se. While M.
p
r
tu erculosis h
s een isol
ted from the intestines of hum
ns with Crohns dise

se, the
or
nism h
s not yet een proven to c
use ileitis in hum
ns. 32. B M. m
rinumi
s usu
lly
recovered from skin lesions th
t h
ve een in cont
ct with underchlorin
ted fres
hw
ter,
s
ltw
ter, or tropic
l sh
qu
riums. 2828_Ch07_381-494 06/08/12 11:25 AM P
e
444 445 7.9
Mycoloy 1. All of the followin
re ex
mples of
ppropri
te specimens for the r
ecovery of funi
except: A. Tissue iopsy B. CSF C. Aspir
te of exud
te D. Sw
Micro ioloy/Appl
y knowlede to
identify sources of error/Mycoloy/1 2. For which clinic
l specimens is the KOH
direct mount
technique for ex
min
tion of fun
l elements used? A. Skin B. CSF C. Blood D. Bo
ne m
rrow
Micro ioloy/Apply principles of
sic l
or
tory procedures/Mycoloy/1 3. Te In
di
ink st
in is
used
s
presumptive test for the presence of which or
nism? A. Asperillus ni

er in lood B.
Cryptococcus neoform
ns in CSF C. Histopl
sm
c
psul
tum in CSF D. C
ndid

l ic

ns in lood or
ody uids Micro ioloy/Correl
te clinic
l
nd l
or
tory d
t
/ Mycoloy/2 4. Cut

neous dise
se
involvin skin, h
ir,
nd n
ils usu
lly indic
tes
n infection with
: A. Dimorp
hic funus B.
Derm
tophyte C. Zyomycetes D. C
ndid
species Micro ioloy/Correl
te clinic
l

nd l
or
tory
d
t
/ Mycoloy/2 Answers to Questions 14 1. D Specimens for fun
l culture must
e kept in

moist, sterile environment. Sw
s th
t
re dried out or su mitted with insu cient
m
teri
l on
them should e rejected. Gener
lly, sw
s
re in
dequ
te for the recovery of fun
i ec
use they

re e
sily cont
min
ted y surroundin skin or
. 2. A A solution of 10% KOH is us
ed for
cont
min
ted specimens such
s skin, n
il scr
pins, h
ir,
nd sputum to cle
r

w
y
ckround
de ris th
t m
y resem le fun
l elements. Norm
lly sterile specimens (CSF, lood
,
nd one
m
rrow) do not require KOH for cle
rin. 3. B Meninitis c
used y C. neoform
ns
is di
nosed
throuh culture, iochemic
l re
ctions,
nd r
pid
lutin
tion tests for crypto
cocc
l
ntien.
The Indi
ink test is not di
nostic for cryptococc
l meninitis ec
use positiv
e st
inin
results
re demonstr
ted in less th
n 50% of confirmed c
ses. A positive Indi
i
nk test shows
ye
st cells in CSF with
surroundin cle
r
re
(the c
psule) ec
use the c
psu
le of C.
neoform
ns is not penetr
ted y ink p
rticles. 4. B Superfici
l derm
tophytes r

rely inv
de the
deeper tissues
nd
re the c
use of most cut
neous fun
l infections. Fun
l inf
ections of the
skin
re most often c
used y Microsporum spp., Trichophyton spp.,
nd Epidermop
hyton spp.,

lthouh C
ndid
spp.
re sometimes implic
ted
s the c
use of n
il infections.
2828_Ch07_381-494
06/08/12 11:25 AM P
e 445 5. Wh
t is the rst step to e performed in the iden
ti c
tion of
n
unknown ye
st isol
te? A. Gr
m st
in sme
r B. Indi
ink st
in C. C
t
l
se test D
. Germ tu e test
Micro ioloy/Select methods/Re
ents/Medi
/ Mycoloy/2 6. An isol
te produced

constriction th
t
w
s interpreted
s
positive erm tu e, ut C
ndid

l ic
ns w
s ruled out when
con rm
tory
tests were performed. Which of the followin funi is the most likely identi c
tio
n? A. C
ndid

tropic
lis B. Cryptococcus neoform
ns C. C
ndid
l
r
t
D. Rhodotorul
ru r
M
icro ioloy/Apply
knowlede of fund
ment
l ioloic
l ch
r
cteristics/Mycoloy/2 7. Cornme
l

r
with Tween 80 is
used to identify which ch
r
cteristic of
n unknown ye
st isol
te? A. Hyph
e (tr
ue
nd pseudo) B.
Bl
stoconidi

nd
rthroconidi
C. Chl
mydospores D. All of these options Micro
ioloy/Apply
knowlede of
sic l
or
tory procedures/Mycoloy/1 8. Bl
stoconidi

re the e
innin of which
structures? A. Arthroconidi
B. Germ tu es C. Pseudohyph
e D. True hyph
e Micro

ioloy/Apply
knowlede of fund
ment
l ioloic
l ch
r
cteristics/Mycoloy/1 9. An isol
te fro
m CSF rowin on
cornme
l

r produces the followin structures: Bl
stoconidi
= + Pseudohyph
e
= Ne
Chl
mydospores = Ne Arthroconidi
= Ne Which tests should e performed next? A.
Birdseed

r

nd ure
se B. Germ tu e
nd lucose C. Indi
ink
nd erm tu e D. All of these o
ptions
Micro ioloy/Select methods/Re
ents/Medi
/ Mycoloy/2 446 Ch
pter 7 | Micro i
oloy Answers to
Questions 510 5. D The true erm tu e ( l
mentous extension from
ye
st cell) is

pproxim
tely
one-h
lf the width
nd three to four times the lenth of the cell with no true h
yph
e
constriction
t the point of oriin. C.
l ic
ns produce erm tu es (95%),
nd

positive test is
considered
presumptive identi c
tion. 6. A C. tropic
lis forms pseudohyph
e th

t resem le
true erm tu es y producin
constriction
t the point of oriin of the ye
st
cell. Germ tu es
represent true hyph
e without constriction,
nd therefore the test should h
ve
een repe
ted

lon with c
r ohydr
te tests efore m
kin
presumptive identi c
tion. The other
three species
of ye
st listed do not form hyph
e. 7. D Cornme
l

r with Tween 80 (polysor
t
e) reduces the
surf
ce tension
nd
llows for enh
nced form
tion of hyph
e, l
stospores,
nd c
hl
mydospores. 8.
C Pseudohyph
e
re the result of
pinchin-off process, l
stoconidi
tion, with
the rowth of
fil
ments with constrictions. Germ tu es
re the einnin of true hyph
e (no co
nstrictions).
Arthrospores
re the result of
re
kin-off process of true sept
te hyph
e res
ultin in squ
re
conidi
. 9. A A ye
st isol
ted from the CSF producin l
stospores is most likel
y to e C.
neoform
ns, which is positive for ure
se
nd produces rown colonies on irdseed


r. 10. A Most
isol
tes of C. neoform
ns produce phenol oxid
se when rown on Guizoti

yssini
c
medium
( irdseed medium), producin rown to l
ck pimented colonies. C. neoform
ns is
the only
Cryptococcus species th
t oxidizes o-diphenol to mel
nin, which is responsi le f
or the color. 10.
Which of the followin ye
st enzymes is detected usin irdseed (nier seed)


r? A. Phenol
oxid
se B. C
t
l
se C. Ure
se D. Nitr
te reduct
se Micro ioloy/Apply knowlede
of fund
ment
l
ioloic
l ch
r
cteristics/Mycoloy/2 2828_Ch07_381-494 06/08/12 11:25 AM P

e 446 11. Which
of the followin ye
sts is ch
r
cteristic
lly positive for erm tu e production?
A. C
ndid

tropic
lis B. C
ndid
kefyr (pseudotropic
lis) C. Cryptococcus neoform
ns D. C
n
did

l ic
ns
Micro ioloy/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics/Mycoloy/
1 12.
Arthroconidi
production is used to di erenti
te which two ye
st isol
tes? A. C
nd
id

l ic
ns

nd C
ndid
du liniensis B. Trichosporon cut
neum
nd Cryptococcus neoform
ns C.

C
ndid

l ic
ns

nd C
ndid
tropic
lis D. S
cch
romyces cerevisi
e
nd C
ndid
l
r
t
Micro io
loy/Apply
knowlede of fund
ment
l ioloic
l ch
r
cteristics/Mycoloy/2 13. Te ure
se tes
t, nier seed


r test,
nd the erm tu e test
re
ll used for the presumptive identi c
tion o
f: A.
Rhodotorul
ru r
B. Cryptococcus neoform
ns C. Trichosporon cut
neum D. C
ndid


l ic
ns
Micro ioloy/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics/Mycoloy/
2 14. Which of
the followin ye
sts produces only l
stoconidi
on cornme
l Tween 80

r? A. C

ndid
spp. B.
Trichosporon spp. C. Geotrichum spp. D. Cryptococcus spp. Micro ioloy/Apply kno
wlede of
fund
ment
l ioloic
l ch
r
cteristics/Mycoloy/2 7.9 | Mycoloy 447 Answers t
o Questions 1114
11. D C.
l ic
ns
nd C
ndid
du liniensis,
v
ri
nt of C.
l ic
ns,
re the o
nly ye
sts th
t
produce erm tu es within 13 hours of incu
tion
t 37C. C. tropic
lis produces ps
eudohyph
e

fter incu
tion for 3 hours, which m
y e mist
ken for erm tu es. A c
reful ev

lu
tion of the
tu e oriin for constriction is required to
void
f
lse-positive interpret
tio
n. 12. B T.
cut
neum
nd C. neoform
ns
re oth ure
se positive, ut T. pullul
ns produces

rthroconidi

nd
C. neoform
ns does not. In
ddition to Trichosporon spp.,
rthroconidi

re prod
uced y
Geotrichum spp. 13. B Germ tu ene
tive isol
tes producin d
rk rown to l
ck co
lonies on nier
seed

r
nd
positive ure
se test
re presumptive of C. neoform
ns. A positiv
e erm tu e test
is
presumptive identific
tion for C.
l ic
ns
s well
s for C. du liniensis.
See the ch
rt

ove. 14. D Cryptococcus spp. do not form either pseudohyph
e or
rthroconidi

. C
ndid
spp.
produce l
stoconidi
or pseudohyph
e. Trichosporon spp. produce pseudohyph
e,
l
stoconidi
,
nd

rthroconidi
. See the ch
rt elow. C. neoform
ns R. ru r
T. cut
neum C.

l ic
ns Ure
se +
+ + Ne Germ tu e Ne Ne Ne + Brown
nd l
ck colonies on nier seed

r + Ne
 Ne Ne
Bl
stoconidi

Pseudohyph
e Arthroconidi
Cryptococcus spp. + Ne Ne C
ndid

spp. + + Ne
Trichosporon spp. + + + Geotrichum spp. Ne + + 2828_Ch07_381-494 06/08/12 11:
25 AM P
e 447
15. Ascospores
re formed y which ye
st isol
te? A. S
cch
romyces cerevisi
e B.
C
ndid

l ic
ns
C. Cryptococcus neoform
ns D. All of these options Micro ioloy/Apply knowlede
of fund
ment
l
ioloic
l ch
r
cteristics/Mycoloy/2 16. A erm tu ene
tive, pink ye
st isol
te
w
s recovered
from the respir
tory secretions
nd urine of
p
tient with AIDS. Given the foll
owin results,
wh
t is the most likely identi c
tion? CORNMEAL TWEEN 80 AGAR Bl
stoconidi
= + Ps
eudohyph
e =
Ne Arthroconidi
= Ne Ure
se = + A. C
ndid

l ic
ns B. Rhodotorul
spp. C. Cry
ptococcus spp. D.
Trichosporon spp. Micro ioloy/Ev
lu
te l
or
tory d
t
to m
ke identi c
tions/Myc

oloy/3 17.
Chl
mydospore production is demonstr
ted y which C
ndid
species? A. C. l
r
t

B. C. krusei C.
C.
l ic
ns D. C. tropic
lis Micro ioloy/Apply knowlede of fund
ment
l ioloi
c
l
ch
r
cteristics/Mycoloy/1 18. C
r ohydr
te
ssimil
tion tests
re used for the
identi c
tion of
ye
st isol
tes y inocul
tin medi
: A. Free of c
r ohydr
tes B. Free of nier s
eed C. Cont
inin
c
r ohydr
tes D. Cont
inin ye
st extr
ct Micro ioloy/Apply principles of
sic
l
or
tory
procedures/Mycoloy/1 19. Ye
st recovered from the urine of
c
theterized p
tie
nt receivin
chemother
py for c
ncer 
ve the followin results: CORNMEAL TWEEN 80 AGAR Germ
tu e = +
Bl
stoconidi
= + Pseudohyph
e = + Arthroconidi
= Chl
mydospores Ne = + Wh
t f
urther testin is
necess
ry? A. C
r ohydr
te
ssimil
tion
nd ure
se B. Ure
se
nd nier seed C. N
itr
te reduct
se

nd c
r ohydr
te ferment
tion D. No further testin is needed for identi c
tion
Micro ioloy/Select course of
ction/Mycoloy/3 448 Ch
pter 7 | Micro ioloy A
nswers to
Questions 1519 15. A Sexu
l spore production is
ch
r
cteristic of the Ascomycot
in
, which
produce
n
scus (s
clike structure)
fter the union of two nuclei. The resultin
 spore is termed

n
scospore. S. cerevisi
e produces
scospores when rown on
scospore

r for
10 d
ys
t 25C.
16. B Rhodotorul
spp. produce pink- to cor
l-colored colonies on S
our
uds


r
nd cornme
l


r. It is usu
lly considered
cont
min
nt ut is
n opportunistic p
thoen,

nd must e
identi ed when found in specimens from immunosuppressed p
tients. 17. C Cornme
l T
ween 80

r
supports the rowth of C.
l ic
ns
nd the form
tion of its distinctive thick-w

lled, usu
lly
sinle, termin
l chl
mydospores. C. du liniensis
lso produces chl
mydospores (i
n p
irs,
triplets,
nd clusters). 18. A The ye
st isol
te is inocul
ted directly into the
molten

r
se
free of c
r ohydr
tes or is poured
s
suspension onto
ye
st nitroen

r

se pl
te.
C
r ohydr
te disks
re then
dded to the surf
ce of the

r,
nd the pl
tes
re
incu
ted for
2448 hours
t 30C. Growth
round the disk indic
tes the
ility of the ye
st to ut
ilize the
c
r ohydr
te(s)
s
sole source of c
r on. 19. D This isol
te is C.
l ic
ns, w
hich
lso
produces some true hyph
e
lon with pseudohyph
e. A positive erm tu e is
pre
sumptive
identi c
tion
lon with the production of l
stoconidi
, termin
l chl
mydospores,

nd
pseudohyph
e. 2828_Ch07_381-494 06/08/12 11:25 AM P
e 448 20. A lood

r p
l
te inocul
ted
with sputum from
p
tient with di
etes mellitus rew very few
cteri
l flor


nd

predomin
nce of ye
st. Given the followin results, wh
t is the most likely iden
tific
tion of the
ye
st isol
te? CORNMEAL TWEEN 80 AGAR Germ tu e = Ne Pseudohyph
e = + Arthrocon
idi
= Ne

Bl
stoconidi
= + (
rr
ned
lon pseudohyph
e) Chl
mydospores = Ne A. C
ndid

tropic
lis B.
C
ndid
kefyr (pseudotropic
lis) C. Trichosporon cut
neum D. Geotrichum c
ndidum
Micro ioloy/Ev
lu
te l
or
tory d
t
to m
ke identi c
tions/Mycoloy/3 21. Dimorp
hic molds
re
found in infected tissue in which form? A. Mold ph
se B. Ye
st ph
se C. Enc
psul

ted D. L
tent
Micro ioloy/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics/Mycoloy/
1 22. Te myceli
l
form of which dimorphic mold produces thick-w
lled, rect
nul
r, or
rrel-sh
pe
d
ltern
te

rthroconidi
? A. Coccidioides immitis B. Sporothrix schenckii C. Histopl
sm
c

psul
tum D.
Bl
stomyces derm
titidis Micro ioloy/Apply knowlede of fund
ment
l ioloic
l
ch
r
cteristics/Mycoloy/2 23. Te ye
st form of which dimorphic funus
ppe
rs

s ov
l or
elon
ted ci
r sh
pes? A. Coccidioides immitis B. Sporothrix schenckii C. Histo
pl
sm
c
psul
tum
D. Bl
stomyces derm
titidis Micro ioloy/Apply knowlede of fund
ment
l ioloic

l
ch
r
cteristics/Mycoloy/2 24. Te myceli
l form of Histopl
sm
c
psul
tum seen o
n

r resem les:
A. Sepedonium spp. B. Penicillium spp. C. Sporothrix spp. D. Coccidioides spp. M
icro ioloy/Apply
knowlede of fund
ment
l ioloic
l ch
r
cteristics/Mycoloy/2 7.9 | Mycoloy
449 Answers to
Questions 2025 20. A C. tropic
lis
nd C. kefyr (pseudotropic
lis) di er in their

rr
nement
of l
stoconidi

lon the pseudohyph
e. C. kefyr (pseudotropic
lis) forms elon

ted
l
stoconidi

rr
ned in p
r
llel clusters th
t simul
te los in
stre
m. Tric
hosporon spp.
nd
Geotrichumspp. form
rthroconidi
. 21. B Dimorphic molds
re in the ye
st form i
n infected
tissues ec
use they
re in the ye
st form
t 37C. Specimens
re cultured
nd inc
u
ted
t oth
room temper
ture
nd 35C37C. To prove th
t
mold rowin
t room temper
ture (or 3
0C) is

dimorphic funus, conversion to the ye
st form must e demonstr
ted vi
su cultu
re
nd incu
tion

t 37C. 22. A The mold form of C. immitis shows
rrel-sh
ped
rthroconidi
sep
r

ted y empty
cells (host cells) th
t c
use
n uneven st
inin effect when they
re ex
mined
under

microscope. S. schenckii, H. c
psul
tum,
nd B. derm
titidis produce conidi
th

t
re round or
ov
l in sh
pe in the mold ph
se. 23. B S. schenckii is usu
lly
cquired y hum

ns throuh
thorns or splinters ec
use it is commonly found on livin or de
d veet
tion. I
t is c
lled rose

rdeners dise
se ec
use 
rdeners, orists,
nd f
rmers
re most often infected. S
. schenckii
is often recovered from exud
tes of unopened su cut
neous nodules or open dr
ini
n lesions. 24. A
Sepedoniumspp.
re s
prophytic molds th
t do not h
ve
ye
st ph
se
nd produc
e l
re spheric
l
tu ercul
te m
croconidi
like H. c
psul
tum. Histopl
smosis is
chronic r
nulo
m
tous infection
prim
rily found in the luns th
t inv
des the reticuloendotheli
l system. Infect
ion occurs vi

spores rele
sed from dec
yin ird or chicken droppins th
t
re inh
led when di
stur ed. 25. A
P. r
siliensis ye
st forms
re sometimes seen
s
m
riners wheel ec
use multiple
uddin
cells completely surround the periphery of the p
rent cell. 25. Te ye
st form of
which dimorphic
mold shows
l
re p
rent ye
st cell surrounded y sm
ller uddin ye
st cells?
A.
P
r
coccidioides r
siliensis B. Sporothrix schenckii C. Coccidioides immitis D.
Histopl
sm

c
psul
tum Micro ioloy/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristic
s/Mycoloy/2
2828_Ch07_381-494 06/08/12 11:25 AM P
e 449 26. Which roup of molds c
n e
ruled out when
sept
te hyph
e
re o served in
culture? A. Dem
ti
ceous B. Zyomycetes C. Derm

tophytes D.
Dimorphic molds Micro ioloy/Apply knowlede of fund
ment
l ioloic
l ch
r
cter
istics/Mycoloy/1
27. Tine
versicolor is
skin infection c
used y: A. M
l
ssezi
furfur B. Tric
hophyton ru rum
C. Trichophyton schoenleinii D. Microsporum ypseum Micro ioloy/Apply knowlede
of fund
ment
l
ioloic
l ch
r
cteristics/Mycoloy/1 28. Which of the followin structures is i
nv
ded y the
enus Trichophyton? A. H
ir B. N
ils C. Skin D. All of these options Micro iolo
y/Apply knowlede
of fund
ment
l ioloic
l ch
r
cteristics/Mycoloy/1 29. An or
nism cultured fr
om the skin
produces colonies displ
yin
cherry-red color on S
our
ud dextrose

r
fter
34 weeks
nd
te
rdrop-sh
ped microconidi

lon the sides of the hyph
e. Te most likely ident
i c
tion is: A.
Trichophyton ru rum B. Trichophyton tonsur
ns C. Trichophyton schoenleinii D. Tr
ichophyton
viol
ceum Micro ioloy/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics
/Mycoloy/1 30.
Which Microsporum species c
uses
n epidemic form of tine
c
pitis in children?
A. Microsporum
c
nis B. Microsporum
udouinii C. Microsporum ypseum D. All of these options
Micro ioloy/Correl
te clinic
l
nd l
or
tory d
t
/ Mycoloy/2 450 Ch
pter 7
| Micro ioloy
Answers to Questions 2630 26. B Zyomycetes commonly recovered from clinic
l spec
imens
re
Rhizopus spp.
nd Mucor spp. Both displ
y
sept
te hyph
e, while the other roup
s
ove displ
y
sept
te hyph
e. Zyomycetes usu
lly not encountered in clinic
l specimens
re
l
so
sept
te
nd
include A sidi
spp., Rhizomucor spp., Cunninh
mell
spp.,
nd Synceph
l
strums
pp. 27. A M.
furfur h
s
worldwide distri ution
nd c
uses
super ci
l, rownish, dry, sc
ly
p
tch on the
skin of liht-skinned persons
nd lihter p
tches on persons with d
rk skin. M.
furfur is not
cultured ec
use di
nosis c
n e m
de from microscopic ex
min
tion of the skin
sc
les. Skin
scr
pins prep
red in KOH show ov
l or ottle-sh
ped cells th
t exhi it monopol

r uddin in the
presence of
cell w
ll
nd
lso produce sm
ll hyph
e. 28. D Trichophyton spp.,
Microsporumspp.,

nd Epidermophyton spp.
re the or
nisms c
usin hum
n derm
tomycoses or cut
ne

ous infections.
Trichophyton spp. infect h
ir
nd n
ils
s well
s skin. Infections with mem ers
of the enus
Microsporum
re con ned to the h
ir
nd skin, while infections c
used y the enus
Epidermophyton

re seen only on the skin
nd n
ils. 29. A Mem ers of the enus Microsporumprodu
ce clu -sh
ped
microconidi

nd
re usu
lly pimented white, u , yellow, or rown. Epidermophyto
n does not
displ
y microconidi

nd produces yellow-reen or yellow-t
n colonies. T. ru rum
c
n e
di erenti
ted from the other mem ers of the enus y its distinctive cherry-red co
lor.
Trichophyton ment
rophytes m
y
lso produce
red piment, ut it is usu
lly ro
se colored or
or
ne, or deep red. T. tonsur
ns produces white-t
n to yellow suedelike colonie
s. T.
schoenleinii produces white to cre
m-colored colonies,
nd T. viol
ceum produces
port wine to
deep violet colonies. 30. B M.
udouinii
nd T. tonsur
ns m
y oth c
use epide
mic tine
c
pitis
in children. M.
udouinii c
uses
chronic infection tr
nsmitted directly vi
in
fected h
irs on
c
ps, h
ts, com s, upholstery,
nd h
ir clippers. Infected h
ir sh
fts uoresce ye
llow-reen
under
Woods l
mp. M.
udouinii does not usu
lly sporul
te in culture
nd forms

typic
l
veet
tive forms such
s
ntler
nd r
cquet hyph
e
nd termin
l chl
mydospores.
In contr
st, M.
c
nis produces spindle-sh
ped, thick-w
lled multicelled m
croconidi
,
nd M. yp
seumproduces
ellipsoid
l, multicellul
r m
croconidi
. 2828_Ch07_381-494 06/08/12 11:25 AM
P
e 450 31.
Microscopic ex
min
tion of
funus cultured from
p
tient with
thletes foot sh
owed l
re,
smooth-w
lled, clu -sh
ped m
croconidi

ppe
rin sinly or in clusters of two t
o three from the
tips of short conidiophores. Te colonies did not produce microconidi
. Wh
t is t
he most likely
identi c
tion? A. Trichophyton spp. B. Altern
ri
spp. C. Epidermophyton spp. D. M
icrosporum spp.
Micro ioloy/Ev
lu
te l
or
tory d
t
to m
ke identi c
tions/Mycoloy/2 32. Which
Trichophyton
species c
uses the f
vus type of tine
c
pitis seen in the Sc
ndin
vi
n countrie
s
nd in the
App
l
chi
n reion of the United St
tes? A. T. verrucosum B. T. viol
ceum C. T.
tonsur
ns D. T.
schoenleinii Micro ioloy/Correl
te clinic
l
nd l
or
tory d
t
/Mycoloy/2 33.
Te H
ir B
itin
Test is used to di erenti
te which two species of Trichophyton th
t produce red co
lonies on
S
our
ud

r pl
tes? A. T. ment
rophytes
nd T. ru rum B. T. tonsur
ns
nd T.
schoenleinii C.
T. tonsur
ns
nd T. viol
ceum D. T. verrucosum
nd T. ru rum Micro ioloy/Correl

te clinic
l
nd
l
or
tory d
t
/ Mycoloy/2 34. A mold th
t produces colonies with
d
rk rown,
reen- l
ck, or
l
ck
ppe
r
nce of oth the surf
ce
nd reverse side is cl
ssi ed
s
: A. Dem
ti

ceous mold B.
Derm
tophyte C. Hy
line mold D. Dimorphic funus Micro ioloy/Apply knowlede of

fund
ment
l
ioloic
l ch
r
cteristics/Mycoloy/1 35. A r
pidly rowin hy
line mold e
n

s
white colony
ut soon developed
l
ck pepper e ect on the

r surf
ce. Te older colony produce
d
l
ck
m
tte, m
kin it resem le
dem
ti
ceous mold. Wh
t is the most likely identi c
ti
on? A.
Penicillium not
tum B. Asperillus nier C. P
ecilomyces spp. D. Scopul
riopsis
spp.
Micro ioloy/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics/Mycoloy/
1 7.9 | Mycoloy
451 Answers to Questions 3136 31. C Epidermophyton spp. do not produce microco
nidi
; this
di erenti
tes them from Trichophyton spp.
nd Microsporumspp. Altern
ri
is not

derm
tophyte.
Epidermophyton occosumis the most frequently isol
ted mem er of the enus
nd inf
ects the skin
ut not the h
ir. 32. D T. schoenleinii is identi ed microscopic
lly y its ch
r

cteristic

ntler-sh
ped hyph
e
nd chl
mydospores in the
sence of conidi
. 33. A T. me
nt
rophytes m
y
produce
deep red piment seen throuh the reverse side of the

r pl
te th
t
resem les the
cherry-red piment produced y T. ru rum. However, T. ment
rophytes c
n e di ere
nti
ted y its

ility to inv
de the h
ir sh
ft. T. ru rumrows on the surf
ce of the h
ir ut
does not
penetr
te the sh
ft. 34. A The dem
ti
ceous molds
re e
sily reconized
nd con rm
ed y o servin
d
rk yellow or rown sept
te hyph
e upon microscopic ex
min
tion. 35. B A. ni
er is the only
species listed producin l
ck conidi
, which c
uses
pepper e ect
s the colony r
ows. The
reverse side of the

r pl
te rem
ins u or cre
m colored, which di erenti
tes it
from the
dem
ti
ceous (d
rk) molds. 36. A Phi
lophor
, Exophi
l
,
nd W
niell

ll pro
duce phi
lides,
ut the l
st two ener
form elon
ted, tu elike phi
lides without
coll
rette,

s opposed to
the
sk-sh
ped phi
lides of Phi
lophor
, which cont
in clusters of conidi

t the
tips. 36.
Which dem
ti
ceous mold forms
sk-sh
ped phi
lides, e
ch with

sk-sh
ped coll
re
tte? A.
Phi
lophor
spp. B. Exophi
l
spp. C. W
niell
spp. D. All of these options Mic
ro ioloy/Apply
knowlede of fund
ment
l ioloic
l ch
r
cteristics/Mycoloy/1 2828_Ch07_381-494
06/08/12 11:25
AM P
e 451 37. Which Asperillus species, recovered from sputum or ronchi
l m
ucus, is the most
common c
use of pulmon
ry
sperillosis? A. A. nier B. A.
vus C. A. fumi
tus D
. All of these
options Micro ioloy/Correl
te clinic
l
nd l
or
tory d
t
/ Mycoloy/2 38. A hy

line mold
recovered from
p
tient with AIDS produced rose-colored colonies with l
vender
centers on
S
our
ud dextrose

r. Microscopic ex
min
tion showed multisept
te m
croconidi


ppe
rin
s
sickles or c
noes. Wh
t is the most likely identi c
tion? A. Fus
rium spp. B. W
n
iell
spp. C.
Exophi
l
spp. D. Phi
lophor
spp. Micro ioloy/Ev
lu
te l
or
tory d
t
to m
ke

identi c
tions/Mycoloy/3 39. M
teri
l from
funus-
ll infection produced colon
ies with

reen surf
ce on S
our
ud

r in 5 d
ys
t 30C. Microscopic ex
min
tion showed
clu -sh
ped
vesicles with sporul
tion only from the top h
lf of the vesicle. Tis hy
line mol
d is most
pro
ly which Asperillus spp.? A. A. nier B. A. fumi
tus C. A.
vus D. A. ter
reus
Micro ioloy/Ev
lu
te l
or
tory d
t
to m
ke identi c
tions/Mycoloy/3 40. A r
pi
dly rowin
nonsept
te mold produced colonies with
r
y surf
ce resem lin cotton c
ndy th

t covered the
entire pl
te. Microscopic ex
min
tion reve
led spor
niophores
risin etween,
not opposite, the
rhizoids
nd producin pe
r-sh
ped spor
ni
. Wh
t is the most likely identi c
tio
n? A. A sidi

spp. B. Penicillium spp. C. Rhizopus spp. D. Asperillus spp. Micro ioloy/Ev
lu

te l
or
tory
d
t
to m
ke identi c
tions/Mycoloy/3 452 Ch
pter 7 | Micro ioloy Answers to Q
uestions 3741
37. C A. fumi
tus is most often
ssoci
ted with compost piles
nd is found in
the soil of
potted pl
nts. A. nier is the c
use of c
vit
ry funus
ll lesions of the lun
s
nd n
s
l
p
ss
es. 38. A Fus
riumspp.
re usu
lly
cont
min
nt ut
re sometimes seen

s
c
use of
mycotic eye, n
il, or skin infection in de ilit
ted p
tients. Fus
riumspp. is

hy
line (liht)
mold
nd rows on S
our
ud

r pl
tes
t 30C within 4 d
ys. The other three or

nisms
re
mem ers of the Dem
ti
ce
e f
mily (d
rk molds). 39. B A. fumi
tus is the most
common c
use of

sperillosis. It is ch
r
cterized y sporul
tion only from the upper h
lf or tw
o-thirds of the
vesicle. Colonies of A. nier
re white with l
ck pepper rowth
nd produce phi

lides over the
entire vesicle, formin the cl
ssic r
di
te he
d. A.
vus colonies
re yellow to ye
llow-reen

nd produce phi
lides th
t cover the entire vesicle
nd point out in
ll directi
ons. A. terreus
produces rown colonies
nd phi
lides th
t
lso cover the entire vesicle. 40. A
A sidi
spp.

re simil
r to Rhizopus spp. except for the loc
tion of rhizoids (rootlike hyph

e). The rhizoids
of Rhizopus spp.
re loc
ted
t the point where the stolons
nd spor
niophores
meet, where
s
those of A sidi
spp.
rise
t
point on the stolon etween the rhizoids. Penic
illiumspp.
nd
Asperillus spp. do not form rhizoids. 41. B Immunocompromised p
tients
re
t r
isk for inv
sion
of Cryptococcus neoform
ns. The polys
cch
ride c
psule of C. neoform
ns is not r
econized y
ph
ocytes, which
llow p
tients with imp
ired cell-medi
ted immunity to ecome
re
dily infected
with C. neoform
ns. 41. An Indi
ink test w
s performed on CSF from
n HIV-infec
ted m
le p
tient.
M
ny enc
psul
ted ye
st cells were seen in the centrifued s
mple. Further testi
n reve
led

positive ure
se test
nd rowth of rown colonies on nier-seed

r. Te di
nos
is of meninitis

w
s c
used y which ye
st? A. C
ndid

l ic
ns B. Cryptococcus neoform
ns C. Cry

ptococcus
l
urentii D. C
ndid
tropic
lis Micro ioloy/Apply knowlede for identi c
tion/ My
coloy/3
2828_Ch07_381-494 06/08/12 11:25 AM P
e 452 42. A one m
rrow s
mple o t
ine
d from
n
immunocompromised p
tient reve
led sm
ll intr
cellul
r cells usin
Wrihts st
i
n prep
r
tion.
Growth on S
our
uddextrose

r pl
tes of
mold ph
se
t 25C
nd
ye
st ph
se

t 37C
desin
tes the or
nism
s dimorphic. Te mold ph
se produced thick, spheric
l tu
ercul
ted
m
croconidi
. Wh
t is the most likely identi c
tion? A. Histopl
sm
c
psul
tum B.
Sepedonium spp.
C. Sporothrix schenckii D. Coccidioides immitis Micro ioloy/Apply knowlede for
identi c
tion/
Mycoloy/3 43. A lun iopsy o t
ined from
n immunocompromised p
tient showed m

ny cup-sh
ped
cysts (r
y to l
ck) in
fo
my exud
te (reen
ckround) usin Gomori methen

mine silver (GMS)
st
in. Te or
nism c
nnot e cultured ec
use it does not row on routine cultur
e medi
for
molds. Te p
tient w
s di
nosed with pneumoni
th
t resisted
nti iotic tre
tmen
t. Te most likely
identi c
tion is? A. Pneumocystis jirovecci (c
rinii) B. Histopl
sm
c
psul
tum C.
Sporothrix
schenckii D. Scopul
riopsis spp. Micro ioloy/Apply knowlede for identi c
tion/ M
ycoloy/3 44.
Upon direct ex
min
tion of
sputum specimen, sever
l spherules were noted th
t
cont
ined
endospores. Growth on S
our
uddextrose

r showed
eri
l myceli
l elements. Te
sept
te hyph
e
produced
rrel-sh
ped
rthroconidi
. Wh
t is the most likely identi c
tion? A. Pe
nicillium
m
rne ei B. Scopul
riopsis spp. C. Cryptococcus neoform
ns D. Coccidioides immitis
Micro ioloy/Ev
lu
te l
or
tory d
t
to m
ke identi c
tions/Mycoloy/3 7.9 | Myco
loy 453
Answers to Questions 4244 42. A Therm
lly dimorphic Histopl
sm
c
psul
tum produc
e microconidi


nd hyph
l fr
ments
t 37C (ye
st ph
se), where
s
t 25C (mold ph
se) the or
nis
m displ
ys
l
re, thick-w
lled, round m
croconidi
with kno y or kno like projections. The
ye
st form is

le to survive within circul
tin monocytes or tissue m
croph
es th
t c
n e d
emonstr
ted with
Giems
s or Wrihts st
in. 43. A Pneumocystis jirovecii (c
rinii), most recently
cl
ssi ed
s

funus ut formerly
s
p
r
site, is est recovered y roncho
lveol
r l
v
e
or induced
sputum in immunocompromised p
tients. Open lun iopsy s
mple w
s the specimen o
f choice efore
the AIDS epidemic. Gomori methen
mine silver st
in is used to identify the or
n
ism; it st
ins
the cyst form ut not the trophozoites. 44. D Coccidioides immitis endospores

re often confused
with ye
st cells ut they do not ud. C. immitis is endemic in the southwestern
United St
tes.
Since the
rthroconidi

re hihly infectious,
n open pl
te should not e used,

nd
slide
culture test should not e performed. R
ther, tu ed medi
is used for testin,

nd
ll work
should e performed in
ioloic
l s
fety c
inet. 2828_Ch07_381-494 06/08/12
11:25 AM P
e
453 45. A one m
rrow specimen w
s o t
ined from
n immunocompromised p
tient wh
o tested positive
for HIV. Te or
nism rew r
pidly
t 3 d
ys showin
mold form (
t 25C), displ
y
in
conidiophores with four to ve termin
l metul
e with e
ch h
vin four to six phi
l
ides. Te
conidi

t the end of the phi
lides were ov
l
nd in short ch
ins. Tey
ppe
r
s

f
n or room
when viewin under 10
nd 40. At 37C, the ye
st form rew more slowly, showin coni
di
th
t
formed hyph
l elements re
kin
t the sept
to produce ov
l
rthroconidi
. Tis
thermo- dimorphic
mold is most likely: A. P
ecilomyces spp. B. Penicillium m
rne ei C. Rhizomucor sp
p. D.
Asperillus fumi
tus Micro ioloy/Ev
lu
te l
or
tory d
t
to m
ke identi c
tions
/Mycoloy/3 46.
Wh
t is the specimen of choice for the initi
l di
nosis of Pneumocystis jirovec
ii (c
rinii) in

n immunocompromised p
tient, such
s someone with AIDS? A. Induced sputum B. Op
en-thor
x lun
iopsy C. CSF D. Urine Micro ioloy/Specimen collection/Mycoloy/2 47. A tr
nspl

nt p
tient is
suspected of h
vin inv
sive
sperillosis on the
sis of clinic
l
nd r
diolo
ic
l ndins.
Which specimen is est for the initi
l identi c
tion of
sperillosis y solu le

ntien testin?
A. Blood culture B. Lun iopsy C. Serum or urine D. Sputum Micro ioloy/Specime
n
collection/Mycoloy/2 48. Wh
t is the most common c
use of mucormycosis infectio
n in hum
ns? A.
Penicillium spp. B. C
ndid

l ic
ns C. Scopul
riopsis spp. D. Rhizopus spp.
Micro ioloy/Identi c
tion/Mycoloy/2 454 Ch
pter 7 | Micro ioloy Answers to Qu
estions 4548
45. B Other Penicilliumspp.
re di erenti
ted from P. m
rne ei (therm
lly dimorphic)
throuh
conversion from the mold to ye
st ph
se. P. m
rne ei
re seen
s ye
st
t 35C37C on 5
% sheep
lood

r or in BHI roth. Other Penicilliumspp. do not displ
y
ye
st ph
se.
P. m
rne ei
re
recovered from lood, skin, lymph nodes, one m
rrow,
nd intern
l or
ns of imm
unocompromised
p
tients. 46. A Open lun iopsy is not recommended for persons with AIDS ec
us
e of the
incre
sed risk of de
th, infection,
nd complic
tions
ssoci
ted with this suri
c
l procedure.
Persons with AIDS
nd Pneumocystis jirovecii (c
rinii) pneumoni
(PCP) c
n e di

nosed y chest
x-r
y, speci
l st
ins,
nd PCR. Non-AIDS p
tients h
ve
much lower yield,
nd t
herefore,
roncho
lveol
r l
v
e, tr
che
l
spir
tion, endoscopic lun iopsy,
nd open lu
n iopsy
re
more often indic
ted. 47. C To determine
n e
rly di
nosis, the detection of so
lu le
ntiens of
Asperillus spp. y methods such
s ELISA, l
tex
lutin
tion,
nd immuno lotti
n usin serum or
other ody uids is used frequently. Blood
nd sputum cultures
re frequently ne

tive,
nd

tissue iopsy is
ssoci
ted with
sini c
ntly hiher risk of complic
tions. 48.
D V
scul
r
inv
sion followed y throm osis, tissue inf
rction,
nd necrosis
re the most co
mmon clinic
l
m
nifest
tions of cut
neous infections c
used y Rhizopus spp. Infections occur
m
inly in
p
tients who
re
lre
dy ein tre
ted for other conditions includin lymphom
,
leukemi
,
neutropeni
, ren
l f
ilure,
nd di
etic keto
cidosis. 2828_Ch07_381-494 06/08/
12 11:25 AM
P
e 454 49. A therm
lly dimorphic funus shows
l
mentous mold form with tu erc
ul
te
m
croconidi

t room temper
ture,
nd
ye
st form
ove 35C. Which or
nism est
ts this
description? A. Histopl
sm
c
psul
tum B. P
r
coccidioides r
siliensis C. C
ndi
d

l ic
ns D.
Coccidioides immitis Micro ioloy/Identi c
tion/Mycoloy/2 50. SITUATION: After

v
c
tion to the
Southwestern United St
tes,
midwesterner compl
ined of ulike symptoms with feve
r, chills,
nonproductive couh,
nd chest p
in. Microscopic ex
m of sputum, cle
red with KO
H, reve
led
l
re, thick-w
lled spherules cont
inin endospores. Upon culture, the mold ph
s
e showed sept
te
hyph
e
nd
ltern
tin
rrel-sh
ped
rthroconidi
. Which or
nism is most likel
y the c
use of
this pneumoni
? A. Coccidioides immitis B. Histopl
sm
c
psul
tum C. P
r
coccidi
oides
r
siliensis D. Penicillium m
rne ei Micro ioloy/Identi c
tion/Mycoloy/2 7.9 | Myc
oloy 455
Answers to Questions 4950 49. A The ye
st ph
se of H. c
psul
tumdevelops
s sm
ll
ov
l uddin
cells seen in m
croph
es. The ye
st ph
se of P
r
coccidioides r
siliensis deve
lops l
re cells
th
t ud cre
tin
structure resem lin
m
riners wheel,
nd Coccidioides immit
is produces
very l
re spherules. At 25C, P. r
siliensis produces sm
ll sinle conidi
,
nd
C. immitis
produces
rthroconidi
. C
ndid
spp.
re not dimorphic. H. c
psul
tumis found in
soil cont
inin
excrement of irds
nd
ts. It is endemic in the Ohio
nd Mississippi river v
l
leys,
nd the
most common systemic mycosis in North Americ
. 50. A Coccidioides immitis is

soil funus
nd
is endemic to the Southwestern United St
tes. Infection results from inh
lin th
e
rthroconidi
,
which form endospore-formin spherules
nd le
ds to infection within 13 weeks.
Nonimmunocompromised people usu
lly do not require tre
tment,
nd
re immune to
reinfection.
However, immunode cient persons m
y develop symptom
tic pulmon
ry
nd multi-or
n
infections.
2828_Ch07_381-494 06/08/12 11:25 AM P
e 455 456 7.10 Viroloy 1. Cl
ssi c
tion
of viruses is
m
de y: A. Complement x
tion seroloy B. Electron microscopy C. Nucleic
cid com
position D.
Cellul
r inclusion odies Micro ioloy/Apply knowlede of fund
ment
l ioloic
l
ch
r
cteristics/Viruses/1 2. Which virus is the most common etioloic
l
ent of
vir
l
respir
tory dise
ses in inf
nts
nd children? A. Respir
tory syncyti
l virus (RS
V) B. Me
sles

virus C. Coxs
ckie A virus D. Coxs
ckie B virus Micro ioloy/Apply knowlede of

fund
ment
l
ioloic
l ch
r
cteristics/Viruses/1 3. Te most common vir
l syndrome of peric
r
ditis,
myoc
rditis,
nd pleurodyni
(p
in upon re
thin) is c
used y: A. Herpes simpl
ex virus B.
Respir
tory syncyti
l virus C. EpsteinB
rr virus D. Coxs
ckie B virus Micro iolo
y/Apply
knowlede of fund
ment
l ioloic
l ch
r
cteristics/Viruses/1 4. Which of the fo
llowin viruses
is implic
ted
lon with EpsteinB
rr virus
s
c
use of infectious mononucleosis
? A.
Cytome
lovirus (CMV) B. Coxs
ckie A virus C. Coxs
ckie B virus D. Hep
titis B v
irus
Micro ioloy/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics/Viruses/1
5. Te most
common c
uses of vir
l pneumoni
in
dults
re: A. In uenz

nd
denovirus B. Hep

titis A
nd B
viruses C. Coxs
ckie A
nd B viruses D. Herpes simplex
nd CMV Micro ioloy/Appl
y knowlede of
fund
ment
l ioloic
l ch
r
cteristics/Viruses/1 Answers to Questions 15 1. C Tru
e viruses h
ve
nucleic
cid th
t is either RNA or DNA,
nd this serves
s the
sis for initi
l
cl
ssi c
tion.
Mem ers of these cl
sses
re further divided into roups th
t c
use hum
n dise
s
e
sed upon the
mode of tr
nsmission, tissues inv
ded, dise
ses produced,
nd
ntienic ch
r
cte
ristics. 2. A RSV
is the c
use of croup, ronchitis, ronchiolitis,
nd interstiti
l pneumoni
. Ch
ildren under 1
ye
r old who
re hospit
lized
re the most suscepti le roup. 3. D Coxs
ckie A v
irus, Coxs
ckie B
virus,
nd the echoviruses
re most commonly implic
ted in myoc
rditis
nd other
syndromes,
includin
cute cere ell
r
t
xi

nd hep
titis. Like poliovirus, infections
re
more common in
the summer
nd f
ll
nd 
in entry throuh the 
strointestin
l tr
ct. 4. A CMV
infection in

previously he
lthy individu
l c
uses
self-limited mononucleosis syndrome. CMV
is
n
opportunistic p
thoen th
t m
y produce lifelon infections
nd c
n c
use
v
ri
ety of dise
ses,
includin conenit
l
nd neon
t
l infection, hep
titis, pneumoni
,
nd dissemin

ted infection in
immunocompromised p
tients. 5. A In uenz

nd
denoviruses
re the m
in c
uses of
respir
tory
infections, includin the common cold, tr
cheo ronchitis,
nd pneumoni
. Adenovi
ruses
lso c
use
conjunctivitis, ker
titis, cystitis,
nd 
stroenteritis. 2828_Ch07_381-494 06/
08/12 11:25 AM
P
e 456 6. Which virus elonin to the Reovirid
e roup c
uses 
stroenteritis
in inf
nts
nd
youn children ut
n
symptom
tic infection in
dults? A. Coxs
ckie B virus B.
Rot
virus C.
Respir
tory syncyti
l virus D. Rh
dovirus Micro ioloy/Apply knowlede of fund

ment
l ioloic
l
ch
r
cteristics/Viruses/1 7. A very sm
ll, sinle-str
nded DNA virus th
t c
uses

fe rile
illness with
r
sh
nd is c
lled the fth childhood dise
se
fter ru eol
, ru ell

, v
ricell
,


nd roseol
is: A. Rot
virus B. Adenovirus type 40 C. Coxs
ckie A virus D. P
rvo

virus B19
Micro ioloy/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics/Viruses/1
8. Hep
titis B
virus c
n e tr
nsmitted y: A. Acupuncture B. T
ttoos C. Sexu
l cont
ct D. All
of these options
Micro ioloy/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics/Viruses/1
9. Which virus
h
s een implic
ted in
dult 
stroenteritis resultin from inestion of cont
mi
n
ted food
(especi
lly shell sh)
nd w
ter? A. Norw
lk-like viruses B. Rot
virus C. Hep
titis
C virus D.
Coron
virus Micro ioloy/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristi
cs/Viruses/1 10.
Which virus is
ssoci
ted with venere
l
nd respir
tory tr
ct w
rts
nd produces
lesions of skin

nd mucous mem r
nes? A. Polyom
virus B. Poxvirus C. Adenovirus D. P
pillom
viru
s
Micro ioloy/Apply knowlede of fund
ment
l ioloic
l ch
r
cteristics/Viruses/1
11. A clinic
l
test used for the detection
nd identi c
tion of vir
l infections other th
n cultu
re is: A.
Hem
lutin
tion B. Hem
dsorption C. Vir
l
ntien detection D. All of these opt
ions
Micro ioloy/Apply principles of
sic l
or
tory procedures/Viruses/1 7.10 | Vi
roloy 457
Answers to Questions 611 6. B Rot
viruses h
ve een implic
ted in oth nosocomi
l
infections
nd
epidemic 
stroenteritis. Children 324 months old
re most commonly
ffected. Di

rrhe
eins

fter
n incu
tion period of 3 d
ys, l
sts for 210 d
ys,
nd is
ssoci
ted with
vomitin
nd
dehydr
tion. In immunosuppressed children, rot
virus c
uses
chronic infection.
7. D P
rvovirus
c
uses
fever
nd ch
r
cteristic sl
pped cheek r
sh in youn children. Adults
re
usu
lly
immune, ut immunocompromised persons m
y exhi it
n
rthritis or
nemi
(the vi
rus infects
imm
ture RBCs in the one m
rrow). 8. D Althouh the most common mode of tr
nsmi
ssion of
hep
titis B is vi
needle puncture, it m
y
lso e tr
nsmitted y other p
renter

l me
ns,
includin sexu
l tr
nsmission
nd cont
ct with cont
min
ted lood throuh roken
skin or mucous
mem r
nes. 9. A Norw
lk-like viruses
re sm
ll RNA viruses th
t h
ve een implic

ted in epidemics
of community 
stroenteritis
s well
s spor
dic infections. Unlike rot
viruses,
which c
use

stroenteritis in inf
nts
nd youn children, Norw
lk-like viruses produce infe
ctions in
ll
e
roups. 10. D The hum
n p
pillom
viruses (HPVs) c
use enit
l w
rts. Sever
l str

ins, includin
HPV-6, HPV-11, HPV-16,
nd HPV-18,
re
ssoci
ted with cervic
l
nd v
in
l neop
l
si
. Bec
use
the virus c
nnot e cultured in vitro, di
nosis is usu
lly m
de usin DNA pro e
s. A di
nostic
ch
r
cteristic of infected cells is koilocytosis,
perinucle
r cle
rin in the
squ
mous
epithelium
ccomp
nied y nucle
r
typi
. 11. D In
ddition to seroloic
l tests
for
nti odies



inst the virus
nd DNA pro es th
t identify vir
l DNA or RNA, the methods
o
ve
id in the
r
pid di
nosis of sever
l viruses. V
rious species of
nim
l RBCs
re used for
identific
tion of
viruses th
t cont
in receptors th
t
lutin
te the RBCs. Some influenz
A
nd p

r
influenz

viruses m
y e detected only y hem
lutin
tion or hem
dsorption. Testin for v
ir
l
ntien in
culture is used for detection of RSV, CMV,
nd v
ricell
zoster. 2828_Ch07_381-4
94 06/08/12
11:25 AM P
e 457 12. Which technique is used for the con rm
tion of infection wi
th hum
n
immunode ciency virus (HIV-1)? A. Western lot (immuno lot)
ss
y B. Enzyme-linked
immunosor ent

ss
y (ELISA) C. Complement x
tion D. p24 Antien testin Micro ioloy/Select
methods/Re
ents/Medi
/Viruses/2 13. A 13-ye
r-old oy w
s
dmitted to the hospi
t
l with

di
nosis of vir
l enceph
litis. History reve
led th
t the oy h
r ored wild r
c
coons from ne
r y
woods. Wh
t is the est method to determine if the oy h
s contr
cted r
ies? A.
Remove the
r
instems from
ll of the r
ccoons
nd ex
mine for cytop
thic e ects B. Request i
mmuno uorescent
test for
nti ody on the s
liv
from
ll of the r
ccoons C. Request immuno uoresce
nt test for

ntien in cut
neous nerves o t
ined y nuch
l iopsy of the p
tient D. Isol
te
the virus from
the s
liv
of oth the
nim
ls
nd the p
tient Micro ioloy/Select
methods/Re
ents/Medi
/Viruses/3 14. A 65-ye
r-old wom
n w
s
dmitted to the hos
pit
l with
cute
respir
tory distress, fever, my
li
,
nd he
d
che. In uenz
A or B w
s suspected

fter rulin
out
cteri
l pneumoni
. Which of the followin methods could e used to con rm in u
enz

infection? A. In uenz
virus culture in M
dinD
r y c
nine kidney B. Hem
lutin
tio
n-inhi ition
test for
nti odies in the p
tients serum C. Direct ex
min
tion of n
s
l epitheli
um for virus
usin uorescent
nti ody st
in D. All of these options Micro ioloy/Select
methods/Re
ents/Medi
/Viruses/3 458 Ch
pter 7 | Micro ioloy Answers to Quest
ions 1214 12. A
The Western lot
ss
y is most often used to con rm
positive seroloic
l test of

nti odies to
HIV. A s
mple is con rmed positive if
nti odies
re demonstr
ted

inst two of t
he three m
jor
reions (env, pol,
nd 
). However, ec
use the Western lot detects
nti odie
s it m
y miss
people in the window ph
se of infection, is not con rm
tory for neon
t
l infection
s due to the
presence of m
tern
l
nti odies,
nd h
s
lon turn
round time resultin in los
s of cont
ct with
the p
tient. For these re
sons, the CDC is ev
lu
tin
new
ppro
ch usin
sim
ult
neous test
for
nti odies to oth HIV-1
nd HIV-2
nd p24
ntien to screen for infection.
Positives would
e tested y sep
r
te immuno
ss
ys to identify whether the infection is HIV-1 or
HIV-2. S
mples
testin ne
tive for oth of these would e tested y
nucleic
cid
mpli c
tion
method such
s
PCR for vir
l RNA. 13. C Usin direct immuno uorescence, r
ies
ntien c
n e det

ected in the
cut
neous nerves surroundin the h
ir follicles of the posterior reion of the n
eck (nuch
l
iopsy)
nd in epitheli
l cells o t
ined y
corne
l impression. Anti odies to
r
ies c
n e
detected in the serum
nd CSF of infected persons within 810 d
ys of illness; how
ever, infection
usu
lly occurs sever
l months efore the onset of symptoms. Isol
tion of virus f
rom the s
liv
of
the p
tient m
y e
ccomplished y mouse inocul
tion or y inocul
tion of suscep
ti le cell
culture lines with su sequent detection y immuno uorescent
nti odies. 14. D In uen
z
virus
types A, B,
nd C m
y e rown
nd isol
ted in em ryon
ted hen es or cell cult
ures usin
M
dinD
r y c
nine kidney (MDCK), rhesus monkey, or cynomolus monkey kidney cells
. Cell culture
usin MDCK cells is the most r
pid technique, permittin identi c
tion within 13 d

ys. The
hem
lutin
tion inhi ition test c
n e used to titer
nti ody to in uenz
virus

nd to
distinuish virus su types, if speci c
ntiserum is
v
il
le. Direct uorescent
nd
enzyme
immuno
ss
ys usin monoclon
l
nti odies to nucleoprotein
ntiens in infected n

s
l epithelium

re used for r
pid di
nosis of oth in uenz
A
nd in uenz
B infections. 2828_Ch07
_381-494
06/08/12 11:25 AM P
e 458 15. Te most r
pid de nitive di
nosis of
enit
l he
rpes simplex
(HSV-2) infection in
20-ye
r-old m
n is m
de y which method? A. Direct immuno u
orescence test
for vir
l
ntien in vesicle uid B. Titer of serum
nd semin
l uid for
nti odies
to herpes
simplex C. Detection of
ntiherpes simplex in semin
l uid D. Cell culture of vesi
cle uid
Micro ioloy/Select methods/Re
ents/Medi
/Viruses/2 16. A 20-ye
r-old fem
le co
llee student
compl
ined of
sore thro
t
nd extreme f
tiue. Te physici
n noted lymph
denop

thy
nd ordered

r
pid test for infectious mononucleosis
nti odies th
t w
s ne
tive. B
cteri
l
cultures were
ne
tive,
s were seroloic
l tests for in uenz
A
nd B, HIV-1, CMV, hep
titis B,

nd

ntistreptolysin O. Wh
t would e the next line of vir
l testin to est
lish

di
nosis? A.
Herpes simplex B. Ru ell
C. EpsteinB
rr D. West Nile Micro ioloy/Select testin
for
identi c
tion/Viroloy/3 17. A 60-ye
r-old m
le 
rdener from New York St
te w
s h
ospit
lized
with ulike symptoms
nd eventu
lly di
nosed with enceph
litis. While workin in
his 
rden, he
noticed sever
l de
d irds
round his ird feeder. Te reion w
s known to e he

vily infested
with mosquitoes. Wh
t is the most likely c
use of his illness? A. West Nile viru
s B. EpsteinB
rr
virus C. P
rvovirus D. H
nt
virus Micro ioloy/Select di
nosis/Viroloy/2 18. A
30-ye
r-old m
le
p
tient who w
s
contr
ctor
nd uildin inspector in the southwestern United S
t
tes compl
ined
of difficulty re
thin
nd w
s
dmitted to the hospit
l with severe respir
tory

dise
se. The
physici
n noted
hih fever
nd couh. Two d
ys efore, the p
tient h
d inspect
ed
n old
w
rehouse,

ndoned
nd infested with rodents. The p
tient w
s iven intr
venou
s
nti iotics,
ut 2 d
ys into ther
py the pneumoni
worsened
nd he developed pulmon
ry edem
.
Which or
nism
should e suspected of c
usin his illness? A. H
nt
virus B. Rot
virus C. West N
ile virus D.
Norw
lk-like virus Micro ioloy/Select di
nosis/Viroloy/2 7.10 | Viroloy 45
9 Answers to
Questions 1518 15. A Direct immuno uorescence testin of vesicle (lesion) uid for vi
rus usin
uorescein-conju
ted
nti odies is the most r
pid method for di
nosis of enit
l
herpes
infection. Immuno uorescence
nd immunoperoxid
se methods
re
lso used to distin
uish HSV-1
nd
HSV-2. PCR
nd re
l-time PCR
re more sensitive r
pid methods for detection
nd
identi c
tion.
Vir
l cell culture is
lso very sensitive
nd m
y yield
positive result within
24 hours when
uid cont
ins
hih concentr
tion of virus. Vero cells or prim
ry hum
n em ryonic
cells
re
inocul
ted with vesicle uid
nd ex
mined for cytop
thic e ects (CPE), the most comm
on of which

re l
re
lloon cells
nd multinucle
ted i
nt cells. 16. C EpsteinB
rr virus ser
oloic
l
testin for IM-VCA (vir
l c
psid
ntien) durin the
cute ph
se would e indic

ted ec
use
testin for infectious mononucleosis
nti odies m
y or m
y not e positive. P
ti
ents who present
with
n infectious mononucleosis-like syndrome should e tested for oth EBV
nd
CMV. Both
viruses c
use the s
me symptoms durin the
cute ph
se of the illness. 17. A Wes
t Nile virus
c
uses neuroloic
l dise
ses with meninitis
nd enceph
litis
t the top of the
list. The
nim
l
reservoirs
re irds, with hum
ns ein
ccident
l hosts. Tr
nsmission of West N
ile virus is from
mosquito to ird. The prim
ry site of infection for Norw
lk
nd rot
virus is the

strointestin
l

re

nd for h
nt
virus the pulmon
ry sector. 18. A H
nt
virus is tr
nsmitted y

rodent host,
the deer mouse,
nd is endemic in the southwestern United St
tes. The n
me of th
e h
nt
virus
responsi le for out re
ks in this reion is the Sin Nom re virus. Bre
thin in e
xcrement from the
mouse is the most common route of infection,
nd the lun is the site of initi
l
infection.
Di
nosis is usu
lly m
de usin
n IM ELISA
ss
y. 2828_Ch07_381-494 06/08/12
11:25 AM P
e
459 19. A 3-ye
r-old fem
le w
s
dmitted to the hospit
l followin
2-d
y visit
with rel
tives
over the Christm
s holid
ys. Vomitin
nd di
rrhe
left the child severely dehyd
r
ted. No other
mem ers of the f
mily were
ected. All
cteri
l cultures proved ne
tive. A stoo
l s
mple should
e tested for which virus? A. CMV B. EBV C. Hep
titis D D. Rot
virus Micro iolo
y/Select testin
for identi c
tion/Viroloy/2 20. A 25-ye
r-old m
le p
tient w
s di
nosed with HIV

-1 y enzyme
immuno
ss
y, testin positive twice,
nd the di
nosis w
s confirmed y Western
lot testin.
Which l
or
tory test should e performed prior to initi
tin
ntivir
l ther
py?
A. Qu
ntit
tive
pl
sm
virus concentr
tion (vir
l lo
d testin) B. Qu
ntit
tion of CD4 lymphocyt
es C.
Phenotype/enotype resist
nce testin D. All of these options Micro ioloy/Selec
t
tests/Viroloy/3 21. A 6-month-old m
le inf
nt w
s hospit
lized with
respir
to
ry infection. He
w
s di
nosed with
pne

nd ronchiolitis. Further testin reve
led conenit
l
he
rt dise
se.
B
cteri
l cultures were ne
tive for Streptococcus pneumoni
e
nd H
emophilus in u
enz
e. Wh
t
further testin should e done? A. Respir
tory syncyti
l virus (RSV) B. Rot
viru
s C. Norw
lk
virus D. HIV Micro ioloy/Select testin for identi c
tion/Viruses/2 22. A youn m

le hunter
encountered
fox in his p
th durin
w
lk in the woods. Te fox w
s st
erin
ut
ppe
red
nonthre
tenin. Te m
n tried to
void cont
ct ut w
s
tt
cked
nd itten on the
le. Te ite
roke the skin ut w
s not deep. Wildlife o ci
ls were un
le to loc
te the fox fo
r testin. Wh
t
procedure should t
ke pl
ce next for the hunter? A. Spin
l t
p with CSF testin
for r
ies virus
B. Administr
tion of hyperimmune
ntir
ies lo ulin
nd r
ies v
ccine C. Biops
y of the wound
site D. Tro
t culture
nd lood culture Micro ioloy/Ev
lu
te inform
tion for te
stin
nd
identi c
tion/Viroloy/2 460 Ch
pter 7 | Micro ioloy Answers to Questions 1922 1
9. D
Rot
virus is one of the most common c
uses of 
stroenteritis in inf
nts
nd you
n children (6
months to 2 ye
rs old). Vomitin
nd di
rrhe

re
lso common symptoms of Norw
l
k virus
infections, ut the prev
lence of rot
virus durin the winter months
nd the l
c
k of illness in
other f
mily mem ers m
ke rot
virus
more likely c
use. Commerci
l
v
il
ility
of immuno
ss
ys
for rot
virus m
kes its di
nosis e
sier to est
lish
nd rule out th
n infectio
n with
Norw
lk-like viruses. 20. D The decision to initi
te
ntivir
l ther
py is
sed
upon the presence
or
sence of symptoms, CD4 lymphocyte count,
nd the vir
l lo
d. For ex
mple, t
re
tment is
usu
lly withheld from p
tients with CD4 counts > 350/L and viral load < 55,000/mL
and is
instituted in asymptomatic patients if the CD4 count is < 200/L regardless of vir
al load.
Treatment failure within the rst year with three-drug regimens is 35%45%, and drug
resistance
testing (genotype and/or phenotype testing) is recommended to identify drug-resi
stant strains
prior to initiating treatment. 21. A Respiratory syncytial virus (RSV) is spread
by large
particle droplets such as dust and is one of the most common causes of hospitali
zation for
respiratory illness of infants less than 1 year old. RSV causes bronchiolitis, p

neumonia, and
croup in infants and upper respiratory illness in children. It has also been fou
nd to cause
nosocomial infection in nursing homes. Diagnosis is made by EIA, uorescent antibo
dy (FA)
staining, and cell culture. 22. B Rabies virus can be detected by FA staining an
d PCR testing.
The virus replicates at the site of the bite and penetrates the surrounding tiss
ue, nding its
way to the central nervous system. Since the source cannot be tested, the best c
ourse of action
is to initiate postexposure prophylaxis with antirabies globulin and to immunize
the patient with
rabies vaccine. 2828_Ch07_381-494 06/08/12 11:25 AM Page 460 23. A 40-year-ol
d female
experienced a respiratory infection after returning home from a visit to her hom
eland of China. A
rapid onset of pneumonia in the lower respiratory area prompted the physician to
place her in
isolation. She was diagnosed presumptively with severe acute respiratory syndrom
e (SARS) and
placed on a respirator. What type of testing should be done next to diagnose thi
s disease? A.
Molecular technique and cell culture B. Latex agglutination test C. Blood cultur
e D. Complement
xation Microbiology/Select tests for identi cation/Virology/2 24. A pregnant 25-yea
r-old female
with genital lesions delivered a premature newborn with complications. Te baby t
ested negative
for bacterial infection (cultures of blood and urine). Antigen testing of the ba
bys urine proved
negative for group B streptococci and Streptococcus pneumoniae. Te mother tested
negative for
bacterial sexually transmitted diseases and for group B streptococci. Te baby wa
s treated with
acyclovir and failed to survive. What was the most likely cause of death? A. CMV
B. Human
immunode ciency virus C. Respiratory syncytial virus D. Herpes simplex virus Micro
biology/Select
diagnosis/Viruses/2 25. A young father of two small children complained of a ras
h on the torso of
his body. Te children had been diagnosed with chickenpox and con ned to their home
. Te father had
experienced chickenpox as a child and knew he did not have the same rash as his
children. What is
the most likely cause of the fathers rash? A. Herpes simplex 1 virus B. Varicella
-zoster virus
C. Herpes simplex 2 virus D. EpsteinBarr virus Microbiology/Select diagnosis/Viru
ses/2 26. Te
organs of a 65-year-old male were donated soon after a fatal auto accident. Tree
recipients of
his corneas and kidneys died within weeks after receiving his organs. Which of t
he following
viruses most likely caused the death of these recipients? A. HIV B. Rabies C. No
rwalk-like D.
Rotavirus Microbiology/Select diagnosis/Viruses/2 7.10 | Virology 461 Answers
to Questions
2326 23. A SARS virus was discovered in China in 2003. The virus belongs to the c
ommon cold
group of coronaviruses, and is easily transmitted to health care workers having

close contact
with infected patients. It is the cause of a severe lower respiratory infection
that can be
fatal. Laboratory con rmation may be done by PCR testing that is available commerc
ially, cell
culture, EIA, or IFA. Typically, PCR is used on two di erent specimen types or the
same specimen
type submitted at least 2 days apart. If both tests are positive, the infection
is con rmed. 24.
D Herpes simplex virus type 2 infections produce genital lesions. Infants born p
rematurely with
disseminated infection of HSV type 2 from HSV-positive mothers have a mortality
rate of 50%60%.
Testing of pregnant women for antibody and Cesarean section delivery can prevent
most neonatal
HSV infections because the virus enters the fetus during the delivery process. 2
5. B
Varicella-zoster virus is the cause of an infection with chickenpox. As an adult
, the father is
experiencing shingles, a reactivation of the virus. The virus lies dormant in th
e sensory (dorsal
root) ganglia of the spinal nerves, and its reactivation produces a nonweeping b
listerlike rash
on an inflamed skin base that follows the path of the underlying nerves. 26. B T
ransmission of
rabies (rhabdovirus) occurs primarily from the bite of a rabid animal, but in 20
% of human rabies
cases there is no known exposure to rabid animals. Donor tissues are not routine
ly tested for
rabies. Diagnosis is performed by uorescent antibody staining of the infected tis
sues, and
electron microscopy that shows the presence of bullet-shaped virus particles. 28
28_Ch07_381-494
06/08/12 11:25 AM Page 461 27. While on a 7-day cruise to Vancouver and Alaska
, a number of
passengers reported to the ships medical sta complaining of vomiting and diarrhea.
Which is the
most likely virus to have infected these mainly adult passengers? A. Rotavirus B
. Parain uenza C.
Respiratory syncytial D. Norwalk or Norwalk-like viruses Microbiology/Select dia
gnosis/Viruses/2
28. SITUATION: A patient tested positive for HIV-1 infection using a reverse
transcriptase-polymerase chain reaction (RT-PCR) method. However, 1 week later a
second blood
sample was collected and sent to a reference lab that performed a con rmatory test
by Western
blot. Te Western blot test was negative. What best explains these results? A. Te
samples for
RT-PCR and Western blot were not from the same patient B. RT-PCR is more sensiti
ve for early
detection C. Te RT-PCR result was falsely positive D. Te RT-PCR test detected HI
V-2 and the
Western blot is speci c for HIV-1 Microbiology/Apply knowledge to identify sources
of error/HIV
testing/3 29. SITUATION: A pregnant women was seen by her obstetrician with sign
s of ulike
illness during her second trimester. NAT tests were ordered for Toxoplasma gondi
i, rubella,
cytomegalovirus, and herpes simplex 1 and 2. All test results were negative. How
ever, after

delivery, the newborn exhibited signs of an infection and failed to survive. Whi
ch virus causes a
90% transplacental infection rate when found in the mother? A. Hepatitis A B. He
patitis B C.
Hepatitis D D. Hepatitis G Microbiology/Select diagnosis/Viruses/2 30. An immuno
compromised
patient was admitted to the hospital with a diagnosis of hemorrhagic cystitis. W
hich combination
of virus and specimen would be most appropriate to diagnose a viral cause of thi
s disorder? A. BK
virusurine B. Human papilloma virusskin C. Hepatitis B virusserum D. EpsteinBarr vir
usserum
Microbiology/Select identi cation/Viruses/2 462 Chapter 7 | Microbiology Answers
to Questions
2730 27. D Adult gastroenteritis caused by Norwalk and Norwalk-like viruses follo
ws a 12 day
incubation. Diagnosis is usually made on the basis of clinical criteria and conf
irmed by enzyme
immunoassay, RT-PCR, or immune electron microscopy. Hepatitis E virus, also of t
he Caliciviridae
family, also causes gastroenteritis 12 days following exposure, but is not endemi
c in the United
States and other developed countries. 28. B Western blot is a test for antibodie
s to HIV, and
sufficient antibodies are not usually present in the first 34 weeks of infection
to cause a
positive test. In some persons, antibodies do not appear until 3 months after in
itial HIV
infection. RT-PCR detects viral RNA, and reduces the window phase of infection t
o approximately 1
week. Real-time PCR tests for HIV-1 have 100% specificity at a cutoff of 2040 cop
ies RNA/mL. PCR
is the preferred test for neonates because it avoids detection of maternal antib
ody, and is
replacing Western blot as the confirmatory test of choice. 29. B Tests for toxop
lasmosis, German
measles, CMV, and HSV comprise a panel of infectious agents known at a TORCH pan
el. The TORCH
panel consists of serological tests for antibodies to these organisms, and has l
argely been
replaced by more sensitive NAT tests when infection is suspected. The O in TORCH s
tands for
other and other viruses that cause transplacental infection such as HBV and HIV sh
ould be
considered. 30. A The BK virus, a polyoma virus, is transmitted by direct contac
t with infected
respiratory secretions. It has tropism for the urinary system, and often causes
a latent,
asymptomatic infection in the kidney. However, in immunocompromised patients, th
e virus is often
implicated in renal and bladder infections. Kidney failure caused by BK virus is
a signi cant
concern in bone marrow and renal transplant recipients. 2828_Ch07_381-494 06/08
/12 11:25 AM
Page 462 463 7.11 Parasitology 1. Te incorrect match between organism and the ap
propriate
diagnostic procedure is: A. Onchocerca volvulusexamination of skin snips B.
Cryptosporidiummodi ed acid-fast stain C. Echinococcus granulosusroutine ova and par
asite
examination D. Schistosoma haematobiumexamination of urine sediment Microbiology/

Apply knowledge
of diagnostic techniques/Parasitology/2 2. In a patient with diarrhea, occasiona
lly Entamoeba
histolytica/E. dispar (four nucleated cysts, no chromatoidal bars) are identi ed a
s being
present; however, these cells, which are misdiagnosed as protozoa, are really: A
. Macrophages B.
Polymorphonuclear leukocytes C. Epithelial cells D. Eosinophils Microbiology/App
ly knowledge of
the morphology of artifacts/Parasitology/3 3. CharcotLeyden crystals in stool may
be associated
with an immune response and are thought to be formed from the breakdown products
of: A.
Neutrophils B. Eosinophils C. Monocytes D. Lymphocytes Microbiology/Apply knowle
dge of the
morphology of artifacts/Parasitology/1 4. Parasitic organisms that are most ofte
n transmitted
sexually include: A. Entamoeba gingivalis B. Dientamoeba fragilis C. Trichomonas
vaginalis D.
Diphyllobothrium latum Microbiology/Apply knowledge of life cycles and
epidemiology/Parasitology/1 Answers to Questions 14 1. C The appropriate procedur
e for the
diagnosis of E. granulosus (hydatid disease) would involve the microscopic exami
nation of hydatid
fluid aspirated from a cyst. Immature scolices and/or hooklets would be found in
the centrifuged
fluid sediment and could be identified under the microscope. 2. B As polymorphon
uclear leukocyte
(PMN) nuclei in stool begin to fragment and appear to be four nuclei, they will
resemble E.
histolytica/E. dispar cysts. However, E. histolytica/E. dispar cysts are rarely
seen in cases of
diarrhea. The species name E. histolytica is reserved for the true pathogen, whe
reas E. dispar is
used for the nonpathogenic species. Unfortunately, morphologically they look ide
ntical. The only
time E. histolytica could be identified morphologically would be from trophozoit
es containing
ingested red blood cells (RBCs). Nonpathogenic E. dispar would not contain inges
ted RBCs. The
correct way to report these organisms is Entamoeba histolytica/E. dispar (no tro
phozoites
containing ingested RBCs) or Entamoeba histolytica (trophozoites seen that conta
in ingested
RBCs). Physicians may treat based on patient symptoms. 3. B When eosinophils dis
integrate, the
granules reform into CharcotLeyden crystals. 4. C T. vaginalis has been well do
cumented to be
a sexually transmitted agellate. 2828_Ch07_381-494 06/08/12 11:25 AM Page 463
5. Te incorrect
match between the organism and one method of acquiring the infection is: A. Tryp
anosoma brucei
rhodesiensebite of sand eas B. Giardia lambliaingestion of water contaminated with
cysts C.
Hookwormskin penetration of larvae from soil D. Toxoplasma gondiiingestion of raw
or rare meats
Microbiology/Apply knowledge of fundamental life cycles/Parasitology/1 6. Upon e
xamination of
stool material for Cystoisospora belli, one would expect to see: A. Cysts contai
ning sporozoites

B. Precysts containing chromatoidal bars C. Oocysts that are modi ed acid-fast var
iable D.
Sporozoites that are hematoxylin positive Microbiology/Apply knowledge of life c
ycles and
organism morphology/Parasitology/1 7. Which specimen is the least likely to prov
ide recovery of
Trichomonas vaginalis? A. Urine B. Urethral discharge C. Vaginal discharge D. Fe
ces
Microbiology/Apply knowledge of pathogenesis and diagnostic procedures/Parasitol
ogy/2 8. Which of
the following is the best technique to identify Dientamoeba fragilis in stool? A
. Formalin
concentrate B. Trichrome-stained smear C. Modi ed acid-faststained smear D. Giemsas
stain
Microbiology/Apply knowledge of diagnostic procedures/Parasitology/2 9. One of t
he following
protozoan organisms has been implicated in waterborne and foodborne outbreaks wi
thin the United
States. Te suspect organism is: A. Pentatrichomonas hominis B. Dientamoeba fragi
lis C. Giardia
lamblia D. Balantidium coli Microbiology/Apply knowledge of life cycles and
epidemiology/Parasitology/1 464 Chapter 7 | Microbiology Answers to Questions
510 5. A East
and West African trypanosomiasis (T. b. rhodesiense and T. b. gambiense) are cau
sed when
infective forms are introduced into the human body through the bite of the tsets
e y, not sand
eas. 6. C C. belli oocysts in various stages of maturity would be seen in the c
oncentration
sediment or possibly the direct, wet preparation; these oocysts would stain posi
tive with modi ed
acid-fast stains. 7. D T. vaginalis is site speci c. The organisms are found in t
he urogenital
tract; thus, the intestinal tract is not the normal site for these organisms. 8.
B Because there
is no known cyst form, the best technique to recover and identify D. fragilis tr
ophozoites would
be the trichrome-stained smear. 9. C For a number of years, G. lamblia has been
implicated in
both waterborne and foodborne outbreaks from the ingestion of infective cysts wi
thin contaminated
water and food. 10. C E. gingivalis is known to be an inhabitant of the mouth
and is
characterized by morphology that resembles Entamoeba histolytica/E. dispar. Howe
ver, E.
gingivalis tends to ingest PMNs, whereas Entamoeba histolytica/E. dispar do not.
10. A Gram stain
from a gum lesion showed what appeared to be amoebae. A trichrome smear showed a
moebae with a
single nucleus and partially digested PMNs. Te correct identi cation is: A. Tricho
monas tenax B.
Entamoeba histolytica/E. dispar C. Entamoeba gingivalis D. Entamoeba polecki Mic
robiology/Apply
knowledge of organism morphology and body site/Parasitology/3 2828_Ch07_381-494
06/08/12 11:25
AM Page 464 11. An Entamoeba histolytica trophozoite has the following characte
ristics: A.
Central karyosome in the nucleus, ingested RBCs, and clear pseudopodia B. Ingest
ed RBCs, clear
pseudopodia, and uneven chromatin on the nuclear membrane C. Ingested RBCs, clea

r pseudopodia,
and large glycogen vacuoles in cytoplasm D. Large, blotlike karyosome, ingested
white blood cells
(WBCs), and granular pseudopods Microbiology/Apply knowledge of organism
morphology/Parasitology/2 12. A 12-year-old girl is brought to the emergency dep
artment with
meningitis and a history of swimming in a warm-water spring. Motile amoebae that
measure 10 in
size are seen in the CSF and are most likely: A. Iodamoeba btschlii trophozoites
B. Endolimax
nana trophozoites C. Dientamoeba fragilis trophozoites D. Naegleria fowleri trop
hozoites
Microbiology/Apply knowledge of life cycle and epidemiology/Parasitology/3 13. C
haracteristics of
the rhabditiform (noninfective) larvae of Strongyloides stercoralis include a: A
. Short buccal
capsule and large genital primordium B. Long buccal capsule and pointed tail C.
Short buccal
capsule and small genital primordium D. Small genital primordium and notch in ta
il
Microbiology/Apply knowledge of organism morphology and life cycle/Parasitology/
2 14. Visceral
larva migrans is associated with which of the following organisms? A. Toxocaraser
ology B.
Onchocercaskin snips C. Dracunculusskin biopsy D. AngiostrongylusCSF examination
Microbiology/Apply knowledge of life cycle and diagnostic procedures/Parasitolog
y/2 15. The
following organisms are linked with specific, relevant information. The incorrec
t combination is:
A. Strongyloides stercoralisinternal autoinfection B. Echinococcus granulosushydat
id
examination C. Toxoplasmaserology D. Balantidium colicommon within the United Stat
es
Microbiology/Apply knowledge of life cycle and epidemiology/Parasitology/2 7.11
| Parasitology
465 Answers to Questions 1116 11. A The trophozoite of E. histolytica has evenly
arranged
chromatin on the nuclear membrane; a central, compact karyosome in the nucleus;
clear
pseudopodia; and ingested RBCs in the cytoplasm. 12. D N. fowleri are free-livi
ng soil and water
amoebae that cause primary amoebic meningoencephalitis, or PAM. The number of ca
ses reported is
few; however, the infection is very acute and almost always fatal. 13. A The rha
bditiform larvae
of S. stercoralis are characterized by the short buccal capsule (mouth) and larg
e genital
primordium, whereas hookworm larvae have a long buccal capsule and very small ge
nital primordium.
14. A Toxocara spp. are the cause of visceral larva migrans and occur when hum
ans accidentally
ingest the infective eggs of the dog or cat ascarid. The larvae migrate through
the deep tissues,
including the eye. The test of choice is the serology. 15. D B. coli is a cilia
te that can cause
watery diarrhea in humans and is associated with pigs; however, it is not common
ly found within
the United States. It is the largest of the intestinal protozoa and can be found
in pro ciency
testing specimens. Therefore, although it is not common, laboratories must still

be able to
identify these organisms. 16. B S. haematobiumblood ukes reside in the veins ov
er the bladder.
When the eggs are passed from the body, they are often found in urine; egg viabi
lity can also be
determined in unpreserved urine. 16. Examination of 24-hour unpreserved urine sp
ecimen is
sometimes helpful in the recovery of: A. Trichomonas vaginalis trophozoites B. S
chistosoma
haematobium eggs C. Enterobius vermicularis eggs D. Strongyloides stercoralis la
rvae
Microbiology/Apply knowledge of life cycle and diagnostic methods/Parasitology/1
2828_Ch07_381-494 06/08/12 11:25 AM Page 465 17. Te examination of sputum may
be necessary to
diagnose infection with: A. Paragonimus westermani B. Trichinella spiralis C. Wu
chereria
bancrofti D. Fasciola hepatica Microbiology/Apply knowledge of life cycle and di
agnostic
methods/Parasitology/1 18. Two helminth eggs that may resemble one another are:
A.
Diphyllobothrium latum and Paragonimus westermani B. Opisthorchis sinensis and F
asciolopsis buski
C. Taenia saginata and Hymenolepis nana D. Ascaris lumbricoides and Trichostrong
ylus
Microbiology/Apply knowledge of organism morphology/Parasitology/2 19. Eating po
orly cooked pork
can lead to an infection with: A. Taenia solium and Trichinella spiralis B. Taen
ia saginata and
Hymenolepis nana C. Trichuris trichiura and Hymenolepis diminuta D. Diphylloboth
rium latum and
Ascaris lumbricoides Microbiology/Apply knowledge of organism life cycle/Parasit
ology/1 20. An
operculated cestode egg that can be recovered from human feces is: A. Clonorchis
sinensis B.
Diphyllobothrium latum C. Paragonimus westermani D. Dipylidium caninum Microbiol
ogy/Apply
knowledge of organism morphology/Parasitology/1 21. Te adult tapeworm of Echinoc
occus granulosus
is found in the intestine of: A. Dogs B. Sheep C. Humans D. Cattle Microbiology/
Apply knowledge
of life cycle/ Parasitology/1 22. In infections with Taenia solium, humans can s
erve as the: A.
De nitive host B. Intermediate host C. Either the de nitive or the intermediate host
D. None of
these options Microbiology/Apply knowledge of life cycle/ Parasitology/2 466 C
hapter 7 |
Microbiology Answers to Questions 1723 17. A P. westermani adult worms are foun
d in the lung,
and eggs may be coughed up in the sputum. Consequently, both sputum and stool (i
f the sputum
containing the eggs is swallowed) are the recommended specimens for examination
for the eggs. 18.
A Both D. latumand P. westermani eggs are operculated and approximately the same
size. The
morphology is similar, although D. latumhas a knob at the abopercular end and P.
westermani has a
thickened abopercular end and shoulders into which the operculum ts. 19. A Both T
. solium(pork
tapeworm) and T. spiralis can be acquired from the ingestion of raw or poorly co
oked pork. 20. B

D. latumis the only operculated cestode egg that is found in humans; the infect
ion is acquired
from the ingestion of raw freshwater sh. 21. A Although the hydatid cysts are fou
nd in sheep or
in humans (accidental intermediate host), the adult tapeworms of E. granulosus a
re found in the
intestine of the dog. 22. C If humans ingest T. soliumcysticerci in uncooked or
rare pork, the
adult tapeworm will mature within the intestine (human will serve as de nitive hos
t); if eggs
from the adult tapeworm are ingested, then the cysticerci will develop in human
tissues
(accidental intermediate host), causing cysticercosis. 23. D The ingestion of ra
w freshwater sh
containing the encysted larvae of D. latumwill result in the development of an a
dult tapeworm
within the human intestine. 23. Humans acquire infections with Diphyllobothrium
latum adult worms
by: A. Ingestion of freshwater crabs B. Skin penetration of cercariae C. Ingesti
on of water
chestnuts D. Ingestion of raw freshwater sh Microbiology/Apply knowledge of life
cycle/
Parasitology/1 2828_Ch07_381-494 06/08/12 11:25 AM Page 466 24. Humans can se
rve as both the
intermediate and de nitive host in infections caused by: A. Enterobius vermiculari
s B.
Hymenolepis nana C. Schistosoma japonicum D. Ascaris lumbricoides Microbiology/A
pply knowledge of
life cycle/ Parasitology/1 25. Babesia has been implicated in disease from both
splenectomized
and nonsplenectomized patients. Morphologically, the parasites resemble: A. Plas
modium falciparum
rings B. Leishmania donovani amastigotes C. Trypanosoma cruzi trypomastigotes D.
Microsporidial
spores Microbiology/Apply knowledge of parasite morphology/ Parasitology/2 26. O
rganisms (and
infections) that under normal conditions cannot be transmitted in the laboratory
are: A.
Cryptosporidiumcryptosporidiosis B. Taenia soliumcysticercosis C. Ascaris
lumbricoidesascariasis D. Enterobius vermicularispinworm infections Microbiology/A
pply
knowledge of life cycles/ Parasitology/2 27. Toxoplasma gondii is characterized
by: A. Possible
congenital infection and ingestion of oocysts B. Cosmopolitan distribution and p
ossible
di culties with interpretation of serological results C. Neither A nor B D. Both A
and B
Microbiology/Apply knowledge of all areas of parasite biology, diagnostic
procedures/Parasitology/3 28. Oocysts of Cryptosporidium spp. can be detected in
stool specimens
using: A. Modi ed ZiehlNeelsen acid-fast stain B. Gram stain C. Methenamine silver
stain D.
Trichrome stain Microbiology/Apply knowledge of diagnostic procedures, staining
characteristics/Parasitology/1 29. Which micro lariae are usually not found circul
ating in the
peripheral blood? A. Brugia malayi B. Wuchereria bancrofti C. Onchocerca volvulu
s D. Loa loa
Microbiology/Apply knowledge of diagnostic procedures, staining characteristics/
Parasitology/1
7.11 | Parasitology 467 Answers to Questions 2430 24. B In infections with H. n

ana, humans
serve as both intermediate and de nitive hosts. When ingested, the oncosphere pene
trates the
intestinal mucosa, develops into the mature cysticercoid (human is intermediate
host), and
returns to the gut, where the adult tapeworm matures (human is de nitive host). 25
. A Babesia
is an intracellular parasite that closely resembles the ring forms (early tropho
zoites) of P.
falciparum. Often in babesiosis, there are more rings per cell and the ring form
is the only
stage seen. 26. C A. lumbricoides eggs require a period of development in the
soil before they
are infective for humans. The other organisms listed can be transmitted within t
he laboratory or
in the hospital setting. 27. D Infection with T. gondii is acquired through the
ingestion of rare
or raw meats, infective oocysts from cat feces, or as a congenital transmission.
The organism has
a cosmopolitan distribution and although serological testing is generally the te
st of choice, the
results may be very di cult to interpret in certain situations (e.g., congenital i
nfection and
immunocompromised patients). 28. A The oocysts of Cryptosporidium spp. can be fo
und and identi ed
using microscopic examination of fecal smears stained with modi ed acid-fast stain
s. They appear
as purple-red-pink round objects, measuring approximately 46 . Often, the four spo
rozoites and
residual body can be seen within the oocyst wall. 29. C The micro lariae of O. vol
vulus are
normally found in the uid right under the outer layer of skin. Therefore, the ski
n snip is the
proper specimen to examine. 30. B The pathogenic sequelae of malarial infections
with P.
falciparumare the most severe of the ve species of human malaria. They can includ
e massive
hemolysis, blackwater fever, and multiple organ involvement, including the centr
al nervous system
(cerebral malaria). 30. Massive hemolysis, blackwater fever, and central nervous
system
involvement are most common with: A. Plasmodium vivax B. Plasmodium falciparum C
. Plasmodium
ovale D. Plasmodium malariae Microbiology/Apply knowledge of disease pathogenesi
s/ Parasitology/2
2828_Ch07_381-494 06/08/12 11:25 AM Page 467 31. Organisms that should be con
sidered in a
nursery school outbreak of diarrhea include: A. Endolimax nana, Giardia lamblia,
and Entamoeba
coli B. Giardia lamblia, Dientamoeba fragilis, and Cryptosporidium spp. C. Crypt
osporidium spp.,
Trichomonas vaginalis, and Entamoeba coli D. Pentatrichomonas hominis, Dientamoe
ba fragilis, and
Endolimax nana Microbiology/Apply knowledge of epidemiology/ Parasitology/2 32.
Te incorrect
match between disease and symptoms is: A. Paragonimiasishemoptysis B. Cryptospori
diosiswatery
diarrhea C. Toxoplasmosis in compromised hostcentral nervous system symptoms D.
Enterobiasisdysentery Microbiology/Apply knowledge of life cycles/ Parasitology/2
33. Te

formalinether (ethyl acetate) concentration procedure for feces is used to demons

trate: A.
Motility of helminth larvae B. Protozoan cysts and helminth eggs C. Formation of
amoebic
pseudopods D. Trophozoites Microbiology/Apply knowledge of diagnostic procedures
/Parasitology/2
34. Cysts of Iodamoeba btschlii typically have: A. Chromatoidal bars with rounded
ends B. A
heavily vacuolated cytoplasm C. A large glycogen vacuole D. Many ingested bacter
ia and yeast
cells Microbiology/Apply knowledge of morphology/ Parasitology/1 35. Te miracidi
al hatching test
helps to demonstrate the viability of eggs of: A. Taenia species B. Schistosoma
species C.
Hookworm species D. Opisthorchis species Microbiology/Apply knowledge of diagnos
tic
procedures/Parasitology/1 36. Organisms that should be considered in a waterborn
e outbreak of
diarrheal disease include: A. Giardia lamblia and Cryptosporidium spp. B. Endoli
max nana and
Entamoeba histolytica C. Blastocystis hominis and Trichomonas vaginalis D. Toxop
lasma gondii and
Schistosoma mansoni Microbiology/Apply knowledge of epidemiology/ Parasitology/2
468 Chapter 7
| Microbiology Answers to Questions 3137 31. B G. lamblia, D. fragilis, and
Cryptosporidiumhave been implicated in nursery school outbreaks. Among the many
protozoa and
coccidia found in the human, these three organisms have become the most likely p
arasites in this
type of setting. 32. D Infections with E. vermicularis (the pinworm) may cause a
nal itching,
sleeplessness, and possibly some vaginal irritation or discharge; however, dysen
tery (bloody
diarrhea) has not been associated with this infection. 33. B The ova and parasit
e examination
contains three components: the direct wet lm (demonstrates protozoan trophozoite
motility), the
formalinethyl acetate concentration (demonstrates protozoan cysts, coccidian oocy
sts, and
helminth eggs), and the trichrome or iron hematoxylinstained smear (con rms protozo
an cysts and
trophozoites). 34. C The cyst of I. btschlii is characterized by a large glycogen
vacuole that
is seen on the wet smear (stains brown with iodine) and on the permanent stained
smear (vacuole
will appear clear). Occasionally, the vacuole will be so large that the organism
will collapse on
itself. 35. B The determination of egg viability is important in schistosomiasis
; therefore, the
miracidial hatching test is helpful in demonstrating the egg viability of Schist
osoma species.
Once the eggs are hatched, the living miracidium larvae will be visible in the w
ater. 36. A Both
G. lamblia and Cryptosporidiumhave been implicated in waterborne outbreaks or di
arrheal disease.
These infections would result from the ingestion of G. lamblia cysts and/or Cryp
tosporidium
oocysts. 37. B Rapid fecal immunoassays have become more widely used for the dia
gnosis of
infections with G. lamblia and Cryptosporidium. For these two organisms, the fec

al immunoassays
are more sensitive than the routine O&P examination. 37. Fecal immunoassays have
become more
commonly used to diagnose infections with: A. Endolimax nana and Blastocystis ho
minis B. Giardia
lamblia and Cryptosporidium spp. C. Ascaris lumbricoides and Trichuris trichiura
D. Strongyloides
stercoralis and Trichomonas vaginalis Microbiology/Apply knowledge of pathogenes
is and diagnostic
procedures/Parasitology/3 2828_Ch07_381-494 06/08/12 11:25 AM Page 468 38. Pr
imary infections
with the microsporidia may originate in: A. Te lung B. Te nervous system C. Te g
astrointestinal
tract D. Mucocutaneous lesions Microbiology/Apply knowledge of life cycles/ Para
sitology/2 39.
Eye infections with Acanthamoeba spp. have most commonly been traced to: A. Use
of soft contact
lenses B. Use of hard contact lenses C. Use of contaminated lens care solutions
D. Failure to
remove lenses while swimming Microbiology/Apply knowledge of epidemiology/ Paras
itology/2 40.
Select the most sensitive recovery method for Acanthamoeba spp. from lens care s
olutions or
corneal biopsies. A. Te trichrome staining method B. Te use of monoclonal reagen
ts for the
detection of antibody C. Te use of non-nutrient agar cultures seeded with Escher
ichia coli D. Te
Giemsas stain method Microbiology/Apply knowledge of diagnostic procedures/Parasi
tology/2 41. Te
microsporidia are protozoans (now classi ed with the fungi) that have been implica
ted in human
disease primarily in: A. Immunocompromised patients B. Pediatric patients under
the age of 5
years C. Adult patients with congenital immunode ciencies D. Patients who have bee
n traveling in
the tropics Microbiology/Apply knowledge of pathogenesis and epidemiology/Parasi
tology/2 42. When
staining Cystoisospora belli oocysts with modi ed acid-fast stains, the important
di erence
between these methods and the acid-fast stains used for acid-fast bacilli (AFB)
is: A. Te
staining time is much longer with regular AFB acid-fast stains B. Te decolorizer
is weaker than
acid alcohol used for AFB decolorizing C. A counterstain must be used for the mo
di ed methods D.
Te stain is more concentrated when staining for AFB Microbiology/Apply knowledge
of diagnostic
procedures/Parasitology/2 7.11 | Parasitology 469 Answers to Questions 3843 38.
C With the
possible exception of direct inoculation infection in the eye, the microsporidia
are thought to
initially infect the gastrointestinal (GI) tract through ingestion of the infect
ive spores;
infections in other body sites are thought to disseminate from the GI tract. 39.
C The majority
of eye infections with Acanthamoeba spp. have resulted from the use of contamina
ted eye care
solutions, primarily the use of homemade saline. It is recommended that all solu
tions be
discarded at the expiration date. Continued use may increase the risk of environ

mental
contamination of the uids. 40. C Currently, the most sensitive method for the rec
overy of
Acanthamoeba spp. from clinical specimens is the non-nutrient agar culture seede
d with E. coli.
The amoebae feed on the bacteria; both trophozoites and cysts can be recovered f
rom the agar
surface. 41. A Although the microsporidia have been known as pathogens in many g
roups of animals,
their involvement in humans has primarily been in immunocompromised patients, es
pecially those
with AIDS. Microsporidia can be found in di erent tissues, and currently there are
approximately
10 genera implicated in human disease. 42. B The decolorizer in modi ed acid-fast
stains
(Kinyouns cold method, modi ed hot method) is usually 1% sulfuric acid rather than
the stronger
acid alcohol used in the routine AFB stains. 43. D T. trichiura (whipworm) may
cause diarrhea
and occasionally dysentery in very heavy infections; however, the worms are con ne
d to the
intestine, and myalgias are not seen in this helminth infection. 43. Te incorrec
t match between
symptoms and disease is: A. Dysenteryamebiasis B. Malabsorption syndromegiardiasis
C. Cardiac
involvementchronic Chagas disease D. Myalgiastrichuriasis Microbiology/Apply knowl
edge of life
cycle and pathogenesis/Parasitology/2 2828_Ch07_381-494 06/08/12 11:25 AM Pag
e 469 44. Te
incorrect match between organism and characteristic is: A. Chilomastix mesniliShe
pherds crook
and lemon shape B. Plasmodium malariaeband troph C. Hymenolepis nanastriated shell D
.
Wuchereria bancroftisheathed micro lariae Microbiology/Apply knowledge of morpholog
y/
Parasitology/2 45. Te incorrect match between method and method objective is: A.
Direct wet
examinationdetection of organism motility B. Knotts concentrationthe recovery of op
erculated
helminth eggs C. Baermanns concentrationthe recovery of Strongyloides D. Permanent
stained
fecal smearcon rmation of protozoa Microbiology/Apply knowledge of diagnostic
procedures/Parasitology/2 46. Te incorrect match between organism and characteri
stic is: A.
Dientamoeba fragilistetrad karyosome in the nucleus B. Toxoplasma gondiidiagnostic
serology C.
Echinococcus granulosusdaughter cysts D. Schistosoma mansoniegg with terminal spin
e
Microbiology/Apply knowledge of morphology/ Parasitology/2 47. Tere are few proc
edures considered
STAT in parasitology. Te most obvious situation would be: A. Ova and parasite ex
amination for
giardiasis B. Baermanns concentration for strongyloidiasis C. Blood lms for malari
a D. Culture
of amoebic keratitis Microbiology/Apply knowledge of pathogenesis and diagnostic
procedures/Parasitology/3 48. An immunosuppressed man has several episodes of pn
eumonia,
intestinal pain, sepsis with gram-negative rods, and a history of military servi
ce in Southeast
Asia 20 years earlier. Te most likely cause is infection with: A. Trypanosoma cr

uzi B.
Strongyloides stercoralis C. Naegleria fowleri D. Paragonimus westermani Microbi
ology/Apply
knowledge of pathogenesis and life cycles/Parasitology/3 470 Chapter 7 | Micro
biology Answers
to Questions 4449 44. C H. nana has a thin eggshell containing a six-hooked emb
ryo
(oncosphere) and polar laments that lie between the eggshell and the embryo. The
striated
eggshell is generally associated with Taenia spp. eggs. 45. B The Knott concentr
ation is designed
to allow the recovery of micro lariae from a blood specimen. Dilute formalin (2%)
is used; blood
is introduced into the formalin, the red cells lyse, and the sediment can be exa
mined as a wet
preparation or permanent stained smear (Giemsas or hematoxylin-based stain) for t
he presence of
micro lariae. 46. D The egg of S. mansoni is characterized by a large lateral spin
e; S.
haematobiumhas the characteristic terminal spine. 47. C The request for blood lms
for malaria
should always be considered a stat request. Any laboratory providing these servi
ces should be
available 24 hours a day, 7 days a week. In cases of P. falciparummalaria, any d
elay in
diagnosing the infection could be fatal for the patient. 48. B A latent infectio
n with S.
stercoralis acquired years before may cause severe symptoms in the immunosuppres
sed patient
(autoinfective capability of life cycle and migratory route of the larvae through
the body).
49. D In a pediatric patient, the most appropriate diagnostic test for recovery
of Enterobius
vermicularis eggs is a series of Scotch tape preparations. 49. In a pediatric pa
tient, the
recommended clinical specimen for recovery of Enterobius vermicularis is the: A.
Stool specimen
B. Sigmoidoscopy scrapings C. Duodenal aspirates D. Series of Scotch tape prepar
ations
Microbiology/Apply knowledge of pathogenesis and life cycle/Parasitology/2 2828_
Ch07_381-494
06/08/12 11:25 AM Page 470 50. Which parasite causes eosinophilic meningoencep
halitis, a form
of larva migrans causing fever, headache, sti neck, and increased cells in the sp
inal uid? A.
Necator americanus B. Angiostrongylus cantonensis C. Ancylostoma braziliense D.
Strongyloides
stercoralis Microbiology/Apply knowledge of pathogenesis and life cycle/Parasito
logy/2 51.
Cultures of parasites are di erent from bacterial cultures; no quality control is n
eeded. Tis
statement is: A. True, if two tubes of media are set up for each patient B. True
, if the media
are checked every 24 hours C. False, unless two di erent types of media are used D
. False, and
organism and media controls need to be set up Microbiology/Apply knowledge of di
agnostic
procedures/Parasitology/2 52. Protozoan cysts were seen in a concentration sedim
ent and
tentatively identi ed as Entamoeba coli. However, the organisms were barely visibl

e on the
permanent stained smear because: A. Te organisms were actually not present in th
e concentrate
sediment B. Tere were too few cysts to allow identi cation on the stained smear C.
E. coli cysts
were present but poorly xed D. Te concentrate and permanent stained smear were no
t from the same
patient Microbiology/Apply knowledge of xatives and diagnostic procedures/Parasit
ology/3 53.
When humans have hydatid disease, the causative agent and host classi cation are:
A. Echinococcus
granulosusaccidental intermediate host B. Echinococcus granulosusde nitive host C. T
aenia
soliumaccidental intermediate host D. Taenia soliumde nitive host Microbiology/Apply
knowledge
of life cycles/ Parasitology/3 54. A 45-year-old hunter developed fever, myalgia
, and periorbital
edema. He has a history of bear meat consumption. Te most likely causative agent
is: A.
Toxoplasma gondii B. Taenia solium C. Hymenolepis nana D. Trichinella spiralis M
icrobiology/Apply
knowledge of pathogenesis and life cycles/Parasitology/3 7.11 | Parasitology 4
71 Answers to
Questions 5055 50. B Eosinophilic meningoencephalitis is a form of larva migrans
and is caused
by A. cantonensis, the rat lungworm. This Paci c area infection is associated with
CSF symptoms
and sometimes eye involvement. 51. D Duplicate cultures should be set up, and sp
eci c American
Type Culture Collection (ATCC) strains should be cultured along with the patient
specimens to
con rm that the culture system is operating properly. This approach is somewhat di e
rent from
that used in diagnostic bacteriology and mycology. 52. C As E. coli cysts mature
, the cyst wall
becomes more impenetrable to xatives. Consequently, the cysts may be visible in t
he concentrate
sediment but appear very distorted or pale on the permanent stained smear. 53. A
The cause of
hydatid disease is E. granulosus, and the human is classi ed as the accidental int
ermediate host.
Infection occurs when humans accidentally ingest the eggs of E. granulosus and t
he hydatid cysts
develop in the liver, lung, and other organs of the human instead of sheep (norm
al cycle). 54. D
Bear meat is another excellent source of T. spiralis. In this case, the patient
had evidently
consumed poorly cooked bear meat, thus ingesting the encysted larvae of T. spira
lis. 55. B The
accidental ingestion of T. soliumeggs can result in the disease called cysticerc
osis. The
cysticerci will develop in a number of di erent tissues, including the brain, and
the human is
the accidental intermediate host. 55. In a condition resulting from the accident
al ingestion of
eggs, the human becomes the intermediate rather than the de nitive host. Te correc
t answer is: A.
Trichinosis B. Cysticercosis C. Ascariasis D. Strongyloidiasis Microbiology/Appl
y knowledge of
pathogenesis and life cycles/Parasitology/3 2828_Ch07_381-494 06/08/12 11:25 A

M Page 471 56. A

transplant patient on immunosuppressive drugs developed increasing diarrhea. Te
most likely
combination of disease and diagnostic procedure is: A. Trichinosis and trichrome
stain B.
Microsporidiosis and modi ed trichrome stain C. Toxoplasmosis and Gram stain D. Pa
ragonimiasis
and wet preparation Microbiology/Apply knowledge of pathogenesis and diagnostic
procedures/Parasitology/3 57. After returning from a 2-year stay in India, a pat
ient has
eosinophilia, an enlarged left spermatic cord, and bilateral inguinal lymphadeno
pathy. Te most
likely clinical specimen and organism match is: A. Tin blood lmsLeishmania B.
Urineconcentration for Trichomonas vaginalis C. Tin blood lmsBabesia D. Tick blood
lmsmicro lariae Microbiology/Apply knowledge of pathogenesis and diagnostic
procedures/Parasitology/3 58. Patients with severe diarrhea should use enteric pr
ecautions to
prevent nosocomial infections with: A. Giardia lamblia B. Ascaris lumbricoides C
. Cryptosporidium
spp. D. Cystoisospora belli Microbiology/Apply knowledge of pathogenesis and lif
e
cycles/Parasitology/3 59. A 60-year-old Brazilian patient with cardiac irregular
ities and
congestive heart failure suddenly dies. Examination of the myocardium revealed n
umerous
amastigotes, an indication that the cause of death was most likely: A. Leishmani
asis with
Leishmania donovani B. Leishmaniasis with Leishmania braziliense C. Trypanosomia
sis with
Trypanosoma gambiense D. Trypanosomiasis with Trypanosoma cruzi Microbiology/App
ly knowledge of
pathogenesis and life cycles/Parasitology/3 60. When malaria smears are requeste
d, what patient
information should be obtained? A. Diet, age, sex B. Age, antimalarial medicatio
n, sex C. Travel
history, antimalarial medication, date of return to United States D. Fever patte
rns, travel
history, diet Microbiology/Apply knowledge of pathogenesis and life cycle, and
epidemiology/Parasitology/3 472 Chapter 7 | Microbiology Answers to Questions
5661 56. B The
fact that the patient has received a transplant, is on immunosuppressive drugs,
and has
continuing diarrhea suggests microsporidiosis; the appropriate diagnostic test w
ould be modi ed
trichrome staining of fecal material. 57. D Based on the history, the most relev
ant procedure to
perform is the preparation and examination of thick blood lms for the recovery an
d identi cation
of micro lariae. The symptoms suggest early lariasis. 58. C Cryptosporidium oocys
ts (unlike
those of C. belli) are immediately infective when passed in stool, and nosocomia
l infections have
been well documented with this coccidian. 59. D T. cruzi, the cause of Chagas d
isease, has two
forms within the human: the trypomastigote in the blood and the amastigote in th
e striated muscle
(usually cardiac muscle and intestinal tract muscle). 60. C Travel history (area
s of drug
resistance), the date of return to the United States (primary versus relapse cas
e), and history

of antimalarial medication and illness (severe illness, few organisms on smear)

are very
important questions to ask. Without this information, a malaria diagnosis can be
missed or
delayed with severe patient consequences. 61. A Cryptosporidiumoocysts have be
en transmitted
through contaminated municipal water supplies. Such outbreaks have been well doc
umented. 61. In
an outbreak of diarrheal disease traced to a municipal water supply, the most li
kely causative
agent is: A. Cryptosporidium spp. B. Cystoisospora belli C. Entamoeba histolytic
a D. Dientamoeba
fragilis Microbiology/Apply knowledge of life cycles and epidemiology/Parasitolo
gy/2
2828_Ch07_381-494 06/08/12 11:25 AM Page 472 62. Within the United States, sp
oradic
mini-outbreaks of diarrheal disease have been associated with the ingestion of s
trawberries,
raspberries, fresh basil, mesclun (baby lettuce leaves), and snow peas. Te most
likely causative
agent is: A. Dientamoeba fragilis B. Cyclospora cayetanensis C. Schistosoma mans
oni D.
Cystoisospora belli Microbiology/Apply knowledge of life cycles and epidemiology
/Parasitology/2
63. Which of the following statements is true regarding onchocerciasis? A. Te ad
ult worm is
present in the blood B. Te micro lariae are in the blood during the late evening h
ours C. Te
diagnostic test of choice is the skin snip D. Te parasite resides in the deep ly
mphatics
Microbiology/Apply knowledge of life cycles and diagnostic procedures/Parasitolo
gy/2 64. Te most
prevalent helminth to infect humans is: A. Enterobius vermicularis, the pinworm
B. Ascaris
lumbricoides, the large intestinal roundworm C. Taenia saginata, the beef tapewo
rm D. Schistosoma
mansoni, one of the blood ukes Microbiology/Apply knowledge of life cycles and
epidemiology/Parasitology/1 65. A helminth egg is described as having terminal p
olar plugs. Te
most likely helminth is: A. Hookworm B. Trichuris trichiura C. Fasciola hepatica
D.
Diphyllobothrium latum Microbiology/Apply knowledge of organism morphology/Paras
itology/1 66.
Ingestion of which of the following eggs will result in infection? A. Strongyloi
des stercoralis
B. Schistosoma japonicum C. Toxocara canis D. Opisthorchis sinensis Microbiology
/Apply knowledge
of life cycles/ Parasitology/2 7.11 | Parasitology 473 Answers to Questions 626
7 62. B The
coccidian C. cayetanensis has been linked to mini-outbreaks of diarrheal disease
. Epidemiological
evidence strongly implicates various berries, basil, mesclun, and snow peas as l
ikely causes.
These outbreaks are very sporadic and tend to occur primarily in March through M
ay. 63. C The
adult O. volvulus reside in subcutaneous nodules, and the micro lariae are found i
n the uids
right under the outer layers of skin; thus, the appropriate diagnostic test is t
he microscopic
examination of skin snips for the presence of micro lariae. 64. A The pinworm, E.

vermicularis,
is the most common parasitic helminth infection throughout the world, and the eg
gs are infective
within just a few hours. Some have said, You either had the infection as a child,
have it now,
or will have it again when you have children. 65. B The eggs of T. trichiura (the
whipworm) have
been described as being barrel shaped with a thick shell and two polar plugs. 66
. C The eggs of
T. canis are infectious for humans and cause visceral larva migrans. These ascar
id eggs of the
dog can infect humans; the eggs hatch and the larvae wander through the deep tis
sues,
occasionally the eye. In this case, the human becomes the accidental intermediat
e host. 67. A
Both P. vivax and P. ovale infect young red cells, have true stippling (Sch ners dot
s), contain
malarial pigment, and have a true relapse stage in the life cycle. 67. Plasmodi
um vivax and
Plasmodium ovale are similar because they: A. Exhibit Sch ners dots and have a true
relapse in
the life cycle B. Have no malarial pigment and multiple rings C. Commonly have a
ppliqu forms in
the red cells D. Have true stippling, do not have a relapse stage, and infect ol
d red cells
Microbiology/Apply knowledge of life cycles and morphology/Parasitology/2 2828_C
h07_381-494
06/08/12 11:25 AM Page 473 68. Te term internal autoinfection can be associate
d with the
following parasites: A. Cryptosporidium spp. and Giardia lamblia B. Cystoisospor
a belli and
Strongyloides stercoralis C. Cryptosporidium spp. and Strongyloides stercoralis
D. Giardia
lamblia and Cystoisospora belli Microbiology/Apply knowledge of life cycles/ Par
asitology/2 69.
Microsporidia have been identi ed as causing severe diarrhea, disseminated disease
in other body
sites, and ocular infections. Routes of infection have been identi ed as: A. Inges
tion B.
Inhalation C. Direct contamination from the environment D. Ingestion, inhalation
, and direct
contamination Microbiology/Apply knowledge of life cycles/ Parasitology/2 70. An
immunocompromised patient continues to have diarrhea after repeated ova and para
sites (O&P)
examinations (sedimentation concentration, trichrome permanent stained smear) we
re reported as
negative; organisms that might be responsible for the diarrhea include: A. Crypt
osporidium spp.,
Giardia lamblia, and Cystoisospora belli B. Giardia lamblia, microsporidia, and
Endolimax nana C.
Taenia solium and Endolimax nana D. Cryptosporidium spp. and microsporidia Micro
biology/Apply
knowledge of life cycles and diagnostic procedures/Parasitology/3 71. Con rmation
of an infection
with microsporidia can be achieved by seeing: A. Te oocyst wall B. Sporozoites w
ithin the spore
C. Evidence of the polar tubule D. Organisms stained with modi ed acid-fast stains
Microbiology/Apply knowledge of life cycles and diagnostic procedures/Parasitolo
gy/3 72. Early
ring stages of the fth human malaria, Plasmodium knowlesi, resemble those of: A.

Plasmodium
malariae B. Plasmodium ovale C. Plasmodium falciparum D. Plasmodium vivax Microb
iology/Apply
knowledge of organism morphology/ Parasitology/3 474 Chapter 7 | Microbiology
Answers to
Questions 6874 68. C Both Cryptosporidiumand S. stercoralis have an internal auto
infection
capability in their life cycles. This means that the cycle and infection can con
tinue even after
the patient has left the endemic area. In the case of Cryptosporidium, the cycle
continues in
patients who are immunocompromised and unable to self-cure. 69. D Infectious rou
tes for
microsporidial infections have been con rmed as ingestion and inhalation of the sp
ores; direct
transfer of infectious spores from environmental surfaces to the eyes has also b
een reported. 70.
D Routine O&P examinations usually do not allow the detection of Cryptosporidium
spp. oocysts and
microsporidial spores; special stains are required. Modi ed acid-fast stains for c
occidia and
modi ed trichrome stains for the microsporidial spores are recommended. 71. C Con rm
ation of an
infection with microsporidial spores can be achieved by seeing evidence of the p
olar tubule
within the spores (horizontal or diagonal line across/within the spore). 72. C T
he early ring
stages of Plasmodium knowlesi resemble those of P. falciparum. 73. D Cryptospor
idiumspp. oocysts
are immediately infectious when passed in the stool, regardless of the stool con
sistency
(formedliquid). 74. A The older developmental stages of Plasmodium knowlesi (trop
hs, schizonts)
resemble those seen in infections with P. malariae (band forms, rosette schizont
s). 73. Parasite
stages that are immediately infective for humans on passage from the gastrointes
tinal tract
include: A. Schistosoma spp. eggs B. Toxoplasma gondii bradyzoites C. Giardia la
mblia
trophozoites D. Cryptosporidium spp. oocysts Microbiology/Apply knowledge of lif
e cycles and
organism morphology/Parasitology/3 74. Older developing stages (trophs, schizont
s) of the fth
human malaria, Plasmodium knowlesi, resemble those of: A. Plasmodium malariae B.
Plasmodium ovale
C. Plasmodium falciparum D. Plasmodium vivax Microbiology/Apply knowledge of org
anism morphology/
Parasitology/3 2828_Ch07_381-494 06/08/12 11:25 AM Page 474 75. Auto uorescence
requires no
stain and is recommended for the identi cation of: A. Entamoeba histolytica cysts
B. Toxoplasma
gondii tachyzoites C. Dientamoeba fragilis trophozoites D. Cyclospora cayetanens
is oocysts
Microbiology/Apply knowledge of organism morphology and diagnostic procedures/Pa
rasitology/3 76.
Key characteristics of infection with Plasmodium knowlesi include: A. Rapid eryt
hrocytic cycle
(24 hr), will infect all ages of RBCs, and can cause serious disease B. Erythroc
ytic cycle
limited to young RBCs and causes a relatively benign disease C. Te possibility o

f a true relapse
from the liver, infection in older RBCs, and causes serious disease D. Extended
life cycle (72
hr), will infect all ages of RBCs, and disease is similar to that caused by P. o
vale
Microbiology/Apply knowledge of organism life cycle and pathogenesis/Parasitolog
y/3 77.
Microsporidial infections can be con rmed using: A. Light microscopy and modi ed tri
chrome stains
B. Phase contrast microscopy and routine trichrome stains C. Electron microscopy
and modi ed
acid-fast stains D. Fluorescence microscopy and hematoxylin stains Microbiology/
Apply knowledge
of organism morphology and diagnostic procedures/Parasitology/3 78. Although the
pathogenicity of
Blastocystis hominis remains controversial, newer information suggests that: A.
Most organisms
are misdiagnosed as artifacts B. Numerous strains/species are included in the na
me, some of which
are pathogenic and some are nonpathogenic C. Te immune status of the host is sol
ely responsible
for symptomatic infections D. Te number of organisms present determines pathogen
icity
Microbiology/Apply knowledge of organism life cycle and pathogenesis/Parasitolog
y/3 7.11 |
Parasitology 475 Answers to Questions 7579 75. D Auto uorescence requires no stai
n and is
often recommended for con rmation of Cyclospora cayetanensis oocysts. 76. A Key ch
aracteristics
of an infection with Plasmodium knowlesi include a rapid life cycle (24 hr), the
potential to
infect all ages of RBCs, and the possibility of serious symptoms similar to thos
e seen with P.
falciparum infections. There is no relapse from the liver with this species. 77.
A An infection
with microsporidia can be con rmed using modi ed trichrome stains (10X the normal dy
e content
found in routine trichrome stains) and light microscopy. The internal polar tubu
le will be
visible within some of the spores; this will serve as con rmation of the infection
. 78. B The
name Blastocystis hominis contains approximately 10 di erent strains/species that
are
morphologically identical; some are pathogenic and some are nonpathogenic. Becau
se we cannot
separate these organisms by morphology, this probably explains why some patients
are symptomatic
and some remain asymptomatic with this infection. 79. D There are many changes t
hat occur if
blood is held longer than 12 hours prior to thick and thin blood lm preparation. T
hese include
changes in parasite morphology, loss of parasites, poor staining, poor adherence
of the blood to
the slide, and the parasites beginning that portion of the life cycle that norma
lly occurs within
the vector. These changes are merely one reason that the ordering, specimen coll
ection,
processing, examination, and reporting for thick/thin blood lms are considered ST
AT procedures.
79. Potential problems using EDTA anticoagulant and holding the blood too long p

rior to
preparation of thick and thin blood lms include: A. Changes in parasite morpholog
y, loss of
organisms within several hours, and poor staining B. Loss of Sch ners dots, poor adh
erence of
the blood to the glass slide, and parasites beginning the vector cycle within th
e tube of blood
C. Neither A nor B D. All of these options Microbiology/Apply knowledge of speci
men collection
and processing, organism morphology, and diagnostic procedures/Parasitology/3 28
28_Ch07_381-494
06/08/12 11:25 AM Page 475 80. Which of the following is a key characteristic
of the thick
blood lm? A. Te ability to see the parasite within the RBCs B. Te ability to iden
tify the
parasites to the species level C. Te examination of less blood than the thin blo
od lm D. Te
necessity to lake the RBCs during or prior to staining Microbiology/Apply knowle
dge of specimen
processing and diagnostic procedures/Organism morphology/ Parasitology/3 476 C
hapter 7 |
Microbiology Answer to Question 80 80. D With the thick blood lm, there is more b
lood per slide
than on the thin lm, resulting in greater sensitivity. It is di cult to identify th
e parasite to
the species level from the thick blood lm. The RBCs are laked while drying or durin
g staining,
making it impossible to observe the parasites within the RBCs. 2828_Ch07_381-494
06/08/12 11:25
AM Page 476 477 7.12 Microbiology and Parasitology Problem Solving 1. An emerge
ncy department
physician ordered a culture and sensitivity test on a catheterized urine specime
n obtained from a
24-year-old female patient. A colony count was done and gave the following resul
ts after 24
hours: Blood agar plate = >100,000 col/mL of gram-positive cocci resembling stap
hylococci
MacConkey agar = No growth CNA plate = Inhibited growth Hemolysis = Neg Catalase
= Positive
Novobiocin = Resistant Tis isolate is: A. Staphylococcus saprophyticus B. Microc
occus luteus C.
Staphylococcus aureus D. Streptococcus pyogenes Microbiology/Select methods/Reag
ents/Media/
Culture/3 2. An outbreak of Staphylococcus aureus in the nursery department prom
pted the
Infection Control Committee to proceed with an environmental screening procedure
. Te best
screening media to use for this purpose would be: A. CNA agar B. THIO broth C. M
annitol salt agar
D. PEA agar Microbiology/Select methods/Reagents/Media/ Culture/3 3. A listless
12-month-old boy
with a fever of 103F was taken to the emergency department. He had been diagnosed
with an ear
infection 3 days earlier. A spinal tap was performed, but only one tube of CSF w
as obtained from
the lumbar puncture. Te single tube of CSF should be submitted rst to which depar
tment? A.
Chemistry B. Microbiology C. Hematology D. Cytology/Histology Microbiology/Selec
t
methods/Reagents/Media/ Culture/3 Answers to Questions 14 1. A CNA inhibits most

strains of S.
saprophyticus. Therefore, blood agar should be used when culturing catheterized
urine samples
from young female patients. Most S. saprophyticus isolates are obtained from fem
ale patients
2030 years old. 2. C The high concentration of NaCl (7.5%) in mannitol salt agar
allows for the
recovery of S. aureus from heavily contaminated specimens while inhibiting other
organisms. Also,
S. aureus ferments mannitol, thus allowing for easy detection of yellow-haloed c
olonies of S.
aureus on red mannitol salt agar. 3. B Generally, tube 2 or 3 is submitted to th
e microbiology
laboratory for culture and Gram stain smear. To ensure recovery of any pathogens
and correct
diagnosis without other bacterial contamination, immediate centrifugation and in
oculation to the
appropriate media as well as a Gram stain smear should be performed prior to del
ivery of the
specimen to the chemistry department for testing. 4. D In general, a 24-hour uri
ne is unsuitable
for culture; a rst morning specimen is best for the recovery of mycobacteria in t
he urine. 4. A
65-year-old female outpatient was requested by her physician to submit a 24-hour
urine specimen
for protein and creatinine tests. He also requested testing for mycobacteria in
the urine. Should
the microbiology laboratory accept this 24-hour specimen for culture? A. Yes, if
the specimen is
kept on ice B. Yes, if the specimen is for aerobic culture only C. No, the speci
men must be kept
at room temperature D. No, the specimen is unsuitable for the recovery of mycoba
cteria
Microbiology/Select methods/Reagents/Media/ Culture/3 2828_Ch07_381-494 06/08/1
2 11:25 AM Page
477 5. A lymph node biopsy obtained from a 30-year-old male patient was submitte
d to the
microbiology laboratory for a culture and AFB smear for mycobacteria. Te specime
n was xed in
formalin. Tis specimen should be: A. Accepted for AFB smear and cultured B. Reje
cted C. Held at
room temperature for 24 hours and then cultured D. Cultured for anaerobes only
Microbiology/Select methods/Reagents/Media/ Culture/3 6. A 49-year-old man who t
raveled to Mexico
City returned with a bad case of dysentery. His symptoms were fever; abdominal c
ramping; and
bloody, mucoidal, frequent stools. In addition to this, many WBCs were seen on t
he Gram stain
smear. Stool culture gave the following results: Gram stain: Gram-negative rods
Lactose = +
Indole = + Lysine decarboxylase = Neg Urease = Neg Motility = Neg What is the mo
st likely
organism? A. Salmonella spp. B. Proteus mirabilis C. Escherichia coli D. Enteroi
nvasive E. coli
(EIEC) Microbiology/Evaluate laboratory data to make identi cation/Gram-negative b
acilli/3 7. An
80-year-old male patient was admitted to the hospital with a fever of 102F. A spu
tum culture
revealed many gram-negative rods on MacConkey agar and blood agar. Te patient wa
s diagnosed with

pneumonia. Te following biochemical results were obtained from the culture: H 2

S = Neg Lactose =
+ Urease = + Citrate = + Indole = + VP = + Motility = Neg Resistance to ampicill
in and
carbenicillin What is the most likely identi cation? A. Klebsiella oxytoca B. Prot
eus mirabilis
C. Escherichia coli D. Klebsiella pneumoniae Microbiology/Evaluate laboratory da
ta to make
identi cation/Gram-negative bacilli/3 478 Chapter 7 | Microbiology Answers to Qu
estions 58 5.
B Specimens submitted for culture and recovery of any bacteria should be submitt
ed without
xatives. 6. D EIEC, or enteroinvasive E. coli, produces dysentery similar to that
of Shigella,
with invasion and destruction of the intestinal mucosal epithelium. Leukocytes a
re seen on the
Gram stain smear. Adults who are travelers to foreign countries, especially Mexi
co, are at
greatest risk. 7. A K. oxytoca is similar to K. pneumoniae except that the ind
ole test is
positive for K. oxytoca. 8. B Y. enterocolitica has been associated with fatal
bacteremia and
septic shock from contaminated blood transfusion products. The motility at room
temperature is a
clue to this identi cation. 8. An immunocompromised 58-year-old female chemotherap
y patient
received 2 units of packed RBCs. Te patient died 3 days later, and the report fr
om the autopsy
revealed that her death was due to septic shock. Te blood bags were cultured, an
d the following
results were noted: GROWTH OF AEROBIC GRAM NEGATIVE RODS ON BOTH MACCONKEY AND BLO
OD AGARS
Lactose = Neg Sucrose = + Citrate = Neg Indole = Neg VP = Neg H 2 S = Neg Urease
= + Motility
22C = + Motility 37C = Neg What is the most likely identi cation? A. Escherichia col
i B.
Yersinia enterocolitica C. Enterobacter cloacae D. Citrobacter freundii Microbio
logy/Evaluate
laboratory data to make identi cation/Gram-negative bacilli/3 2828_Ch07_381-494 0
6/08/12 11:25
AM Page 478 9. A pediatric patient with severe bloody diarrhea who had been cam
ping with his
parents was admitted to the hospital with complications of hemolytic uremic synd
rome (HUS).
Several stool specimens were cultured with the following results noted: Gram sta
in smear = Many
gram-negative rods with no WBCs seen Blood agar = Normal ora MacConkey agar = No
rmal ora
MacConkey agar with sorbitol = Many clear colonies (sorbitol negative) Hektoen a
gar = Normal
Campy agar = No growth ora What is the most likely identi cation? A. Yersinia spp.
B. E. coli
O157:H7 C. Salmonella spp. D. Shigella spp. Microbiology/Evaluation laboratory d
ata to make
identi cation/Gram-negative bacilli/3 10. A 14-year-old emergency department patie
nt had been to
the doctors o ce 2 days previously with abdominal pain, diarrhea, and a low-grade f
ever. He was
diagnosed with pseudoappendicular syndrome. Cultures from the stool containing b
lood and WBCs

showed the following results: AEROBIC GRAM NEGATIVE RODS ON MACCONKEY AGAR CLEAR CO
LONIES Campy
agar = No growth Lactose = Neg Sucrose = + Citrate = Neg Indole = Neg VP = Neg H
2 S = Neg
Motility 37C = Motility 22C = + Hektoen agar = NF Neg What is the most likely ide
nti cation?
A. Yersinia enterocolitica B. Salmonella spp. C. Shigella spp. D. Escherichia co
li
Microbiology/Evaluate laboratory data to make identi cation/Gram-negative nonferme
nter/3 7.12 |
Microbiology and Parasitology Problem Solving 479 Answers to Questions 911 9. B
E. coli
O157:H7 is usually the most common isolate from bloody stools of the enterohemor
rhagic E. coli
(EHEC) group, which results from undercooked beef. These strains are waterborne
and foodborne,
and the infections from E. coli O157:H7 are greatest during the summer months in
temperate
climates. 10. A Y. enterocolitica is responsible for diseases in younger perso
ns. Blood and
leukocytes can be present in stools. Patients (usually teens) exhibiting appendi
citis-like
symptoms with lactose-negative colonies growing on MacConkey agar (small colonie
s at 24 hours,
but larger colonies at 48 hours if incubated at room temperature) should be test
ed for the growth
of Y. enterocolitica. 11. A S. maltophilia is the third most frequently isolat
ed
nonfermentative gram-negative rod in the clinical laboratory. Cystic brosis patie
nts are at
greater risk for infections because of previous antimicrobial treatment and recu
rrent pneumonia
and because some strains may be colonizers. 11. A sputum culture from a 13-yearold cystic
brosis patient grew a predominance of short, gram-negative rods that tested oxida
se negative. On
MacConkey, chocolate, and blood agar plates, the organism appeared to have a lav
ender-green
pigment. Further testing showed: Motility = + DNase = + Glucose = + (oxidative)
Maltose = +
(oxidative) Lysine decarboxylase = + Esculin hydrolysis = + What is the most lik
ely
identi cation? A. Stenotrophomonas maltophilia B. Acinetobacter baumannii C. Pseud
omonas
aeruginosa D. Burkholderia (P.) cepacia Microbiology/Evaluate laboratory data to
make
identi cation/Gram-negative nonfermenter/3 2828_Ch07_381-494 06/08/12 11:25 AM
Page 479 12. A
patient with a human bite wound on the right forearm arrived at the clinic for t
reatment. Te
wound was in icted 36 hours earlier, and a culture was taken by the physician on d
uty. After 48
hours, the culture results were: Gram-stain smear = Gram-negative straight, slen
der rods
Chocolate agar plate = Pitting of the agar by small, yellow, opaque colonies Oxida
se = +
Motility = Neg Catalase = Neg Glucose = + Growth in increased CO 2 = + Growth at
42C = Neg What
is the most likely identi cation of this facultative anaerobe? A. Pseudomonas aeru
ginosa B.

Acinetobacter baumannii C. Kingella kingae D. Eikenella corrodens Microbiology/E

valuate
laboratory data to make identi cation/Unusual gram-negative bacteria/3 13. A dog b
ite wound to
the thumb of a 20-year-old male patient became infected. Te culture grew a gramnegative, slender
rod, which was a facultative anaerobe. Te following results were noted: Oxidase
= + Motility =
Neg Catalase = + Capnophilic = + Gliding on the agar was noted. What is the most l
ikely
identi cation? A. Pseudomonas aeruginosa B. Capnocytophaga canimorsus C. Acinetoba
cter baumannii
D. Proteus mirabilis Microbiology/Evaluate laboratory data to make identi cation/U
nusual
gram-negative bacteria/3 14. A patient exhibits fever, chills, abdominal cramps,
diarrhea,
vomiting, and bloody stools 10 to 12 hours after eating. Which organisms will mo
st likely grow
from this patients stool culture? A. Salmonella or Yersinia spp. B. E. coli O157:
H7 or Shigella
spp. C. Staphylococcus aureus or Clostridium perfringens D. Salmonella or Staphy
lococcus spp.
Microbiology/Identi cation gram-negative bacteria/3 480 Chapter 7 | Microbiology
Answers to
Questions 1216 12. D E. corrodens is part of the normal ora of the human mouth an
d typically
pits the agar. This organism is capnophilic (needing increased CO 2 ). 13. B C.
canimorsus is
associated with septicemia or meningitis following dog bites. All Capnocytophaga
strains are
capnophilic, facultative anaerobic, gram-negative slender or lamentous rods with
tapered ends.
14. B Both E. coli O157:H7 and Shigella spp. are invasive and cause bloody stool
s. 15. A S.
aureus is an opportunistic human pathogen. A wound or ulcer infected with S. aur
eus that is left
untreated is especially detrimental to a diabetic patient. 16. C MRSA isolates a
re usually tested
for susceptibility or resistance to vancomycin, a glycopeptide. 15. When testing
for coagulase
properties, staphylococci isolates from a 67-year-old male diabetic patient show
ed a positive
tube test (free coagulase). Te organism should be identi ed as: A. Staphylococcus
aureus B.
Staphylococcus haemolyticus C. Staphylococcus saprophyticus D. Micrococcus luteu
s
Microbiology/Identi cation gram-positive cocci/2 16. An isolate of Staphylococcus
aureus was
cultured from an ulcer obtained from the leg of a diabetic 79-year-old female pa
tient. Te
organism showed resistance to methicillin. Additionally, this isolate should be
tested for
resistance or susceptibility to: A. Erythromycin B. Gentamicin C. Vancomycin D.
Kanamycin
Microbiology/Select antibiotic/Identi cation/3 2828_Ch07_381-494 06/08/12 11:25
AM Page 480
17. An isolate recovered from a vaginal culture obtained from a 25-year-old fema
le patient who is
8 months pregnant is shown to be a gram-positive cocci, catalase negative, and -h
emolytic on

lood

r. Which tests
re needed for further identi c
tion? A. Optochin, ile so
lu ility, PYR
B. B
citr
cin, CAMP, PYR C. Methicillin, PYR, treh
lose D. Co
ul
se, lucose, P
YR
Micro ioloy/Ev
lu
te d
t
to m
ke identi c
tion/ Gr
m-positive cocci/3 18. Which
or
nism is the
most often recovered r
m- positive cocci (c
t
l
se ne
tive) from
series of
lood cultures
o t
ined from individu
ls with endoc
rditis? A. Streptococcus

l
cti
e B. Clos
tridium
perfrinens C. Enterococcus f
ec
lis D. Pediococcus spp. Micro ioloy/Ev
lu
te d

t
to m
ke
identi c
tion/ Gr
m-positive cocci/3 19. A presumptive di
nosis of onorrhe
c
n
e m
de from
n
exud
te from
20-ye
r-old emerency dep
rtment p
tient if which of the followin
 criteri

re
present? A. Sme
r of urethr
l exud
te (m
le only) shows typic
l r
m-ne
tive, i
ntr
cellul
r
diplococci; rowth of oxid
se-positive, r
m-ne
tive diplococci on selective


r (modi ed
T
yerM
rtin) B. Sme
r from v
in
l
re
shows r
m-ne
tive diplococci; rowth of
typic
l
colonies on lood

r C. Sme
r from rectum shows typic
l r
m-ne
tive diplococ
ci; no rowth on
chocol
te

r D. Growth of r
m-ne
tive cocci on M
cConkey

r
nd lood

r
Micro ioloy/Select/Re
ents/Medi
/Gr
m-ne
tive cocci identi c
tion/3 20. Clue cel
ls
re seen
on
sme
r of v
in
l disch
re o t
ined from
n 18-ye
r-old fem
le emerency de
p
rtment p
tient.
Tis ndin,
lon with
shy odor (
mine)
fter the
ddition of 10% KOH, suests

cteri
l
v
inosis c
used y which or
nism? A. St
phylococcus epidermidis B. Streptococc
us

l
cti
e C.
G
rdnerell
v
in
lis D. E. coli Micro ioloy/Ev
lu
te l
or
tory d
t
for
identi c
tion/Gr
m-v
ri
le cocco
cilli/3 7.12 | Micro ioloy
nd P
r
sitoloy Pr
o lem Solvin
481 Answers to Questions 1721 17. B Group B streptococci (S.

l
cti
e)
re impo
rt
nt p
thoens

nd c
n c
use serious neon
t
l infections. Women who
re found to e he
vily col
onized v
in
lly
with S.

l
cti
e pose
thre
t to the new orn, especi
lly within the rst few d

ys
fter
delivery. The infection
cquired y the inf
nt is
ssoci
ted with pneumoni
. 18.
C Enterococcus
(Streptococcus) f
ec
lis is the c
use of up to 20% of the
cteri
l endoc
rditis
c
ses
nd is the
most commonly encountered species in this condition. 19. A N. onorrhoe
e c
n
e presumptively
identi ed from
m
le p
tient only from the Gr
m st
in
nd rowth on selective


r. In fem
le
p
tients, the norm
l or
from
urethr
l sw
m
y
ppe
r to e N. onorrhoe
e (r

m-ne
tive
diplococci) ut m
y e p
rt of the norm
l or
, such
s Veillonell
spp. (
n
ero i
c r
m-ne
tive
cocci resem lin N. onorrhoe
e). 20. C G. v
in
lis,
r
m-ne
tive or r
mv
ri
le
pleomorphic cocco
cillus, c
uses
cteri
l v
inosis, ut is
lso present
s p

rt of the norm
l
v
in
l or
of women of reproductive
e with
norm
l v
in
l ex
min
tion. Clue c
ells
re

v
in
l epitheli
l cells with r
m-ne
tive or r
m-v
ri
le cocco
cilli
tt
ch

ed to them. 21. A
L. monocytoenes is c
t
l
se positive
nd displ
ys
tum lin motility
t room t
emper
ture.
Streptococcus spp.
re c
t
l
se ne
tive
nd nonmotile. 21. A 1-month-old inf
nt
underwent

spin
l t
p to rule out
cteri
l meninitis. The CSF w
s cloudy,
nd the sme
r s
howed m
ny pus
cells
nd short r
m-positive rods. After 18 hours, m
ny colonies
ppe
red on l
ood

r th
t
resem led Streptococcus spp. or L. monocytoenes. Which of the followin prelimi
n
ry tests should
e performed on the colonies to est differenti
te L. monocytoenes from Strepto
coccus spp.? A.
H
nin-drop motility (25C)
nd c
t
l
se B. PYR
nd
citr
cin C. Oxid
se
nd lu
cose D.
Co
ul
se
nd c
t
l
se Micro ioloy/Select methods/Re
ents/Medi
/ Culture/3 282
8_Ch07_381-494
06/08/12 11:25 AM P
e 481 22. Acid-f
st positive
cilli were recovered from
the sputum of

79-ye
r-old m
n who h
d een tre
ted for pneumoni
. Which of the followin test
re
ctions
fter 3
weeks of incu
tion on LwensteinJensen

r
re consistent with Myco
cterium tu e
rculosis? A.
Ni
cin = + Nitr
te Photochromoenic reduction = + = Ne B. Ni
cin= Ne Optochin
= + C
t
l
se = +
C. PYR = + Ure
se = + B
citr
cin = + D. Ampicillin = Penicillin = Resist
nt R
esist
nt
Micro ioloy/Ev
lu
te l
or
tory d
t
to m
ke identi c
tion/Acid-f
st
cilli/3 23
. Which
iochemic
l tests should e performed in order to identify colorless colonies r
owin on
M
cConkey

r (sw
rmin colonies on lood

r) from
c
theterized urine speci
men? A. Indole,
phenyl
l
nine de
min
se,
nd ure
se B. Glucose, oxid
se,
nd l
ctose utiliz
tion
C. Phenyl
l
nine
de
min
se
nd ile solu ility D. H 2 S
nd c
t
l
se Micro ioloy/Ev
lu
te l
or

tory d
t
to m
ke
identi c
tion/Gr
m-ne
tive
cilli/3 24. A r
m-ne
tive nonfermenter w
s isol
te
d from

culture t
ken from
urn p
tient. Which of the followin is the est choice of
tests to
di erenti
te Pseudomon
s
eruinos
from Acineto
cter spp.? A. Growth on M
cConke
y

r,
c
t
l
se, rowth
t 37C B. Oxid
se, motility, rowth
t 42C C. Growth on lood


r, oxid
se,
rowth
t 35C D. Strin test
nd co
ul
se test Micro ioloy/Select methods/Re
e
nt/Medi
/
Identi c
tion nonferment
tive r
m ne
tives/3 25. A H
emophilus spp., recovered f
rom
thro
t
culture o t
ined from
59-ye
r-old m
le p
tient underoin chemother
py, requir
ed hemin (X
f
ctor)
nd NAD (V f
ctor) for rowth. This species
lso hemolyzed horse erythro
cytes on lood


r. Wh
t is the most likely species? A. H. ducreyi B. H. p
r
h
emolyticus C. H
. h
emolyticus D.
H.
eyptius Micro ioloy/Ev
lu
te l
or
tory d
t
to m
ke identi c
tion/Gr
m-ne

tive
cocco
cilli/3 482 Ch
pter 7 | Micro ioloy Answers to Questions 2226 22. A M
. tu erculosis

is ni
cin positive
nd nonphotochromoenic. This or
nism t
kes up to 3 weeks to

row on
selective

r. 23. A A sw
rmer on lood

r would most likely e
Proteus spp
. A l
ctose
nonfermenter
nd sw
rmer th
t is often isol
ted from urin
ry tr
ct infections is
P. mir
ilis.
24. B P.
eruinos
h
s
distinctive r
pe odor. The est choice of tests is:
25. C H.
h
emolyticus requires oth X
nd V f
ctors for rowth
nd lyses horse erythrocyt
es. 26. A C.
perfrinens is
n
n
ero ic r
m-positive rod th
t is often isol
ted from the ti
ssue of p
tients
with 
s 
nrene (myonecrosis). Spore production is not usu
lly seen with this
or
nism, which
m
y
lso st
in r
m ne
tive. 42 C Growth Oxid
se Motility P.
eruinos
+ +
+ Acineto
cter
spp. +/Ne Ne Ne 26. L
re r
m-positive
cilli ( oxc
r sh
ped) were recovere
d from
lood
culture t
ken from
70-ye
r-old fem
le di
etic p
tient. Te followin results w
ere recorded:
Aero ic rowth = Ne An
ero ic rowth = + Spores = Ne Motility = Ne Lecithin
s
e = + Hemolysis =
(dou le zone) GLC (vol
tile
cids) =
cetic
cid
nd utyric
cid Wh
t is the mo
st likely
identi c
tion? A. Clostridium perfrinens B. Fuso
cterium spp. C. B
cteroides spp
. D.
Clostridium sporoenes Micro ioloy/Ev
lu
te l
or
tory d
t
to m
ke identi c
tion
/An
ero ic
r
m-positive
cilli/3 2828_Ch07_381-494 06/08/12 11:25 AM P
e 482 27. An
e
ro ic
r
m-ne
tive rods were recovered from the lood of
p
tient
fter 
ll l
dder
surery. Te

cteri
rew well on

r cont
inin 20% ile, ut were resist
nt to k
n
mycin

nd v
ncomycin.
Wh
t is the most likely identi c
tion? A. Clostridium perfrinens B. B
cteroides f
r
ilis roup
C. Prevotell
spp. D. Porphyromon
s spp. Micro ioloy/Ev
lu
te l
or
tory d
t
t
o m
ke
identi c
tion/An
ero ic r
m-ne
tive
cilli/3 28. In Bre
kpoint Antimicro i
l Dr
u Testin,
interpret
tion of suscepti le (S), intermedi
te (I),
nd resist
nt (R) refers to
testin

nti iotics y usin: A. Te
mount needed to c
use
cteriost
sis B. Only the sp
eci c
concentr
tions necess
ry to report S, I, or R C. An MIC of 64 /mL D. A dilution
of dru th
t is
one tu e less th
n the toxic level Micro ioloy/Select methods/Re
ents/Medi
/ A
nti iotic
testin/2 29. A CSF s
mple o t
ined from
2-week old inf
nt with suspected
ct
eri
l meninitis
rew r
m-ne
tive rods on lood
nd chocol
te

rs. Te followin results were
noted: M
cConkey


r = No rowth ONPG = + Glucose (open) OF = + Ure
se = Ne Glucose (closed) OF
= Ne C
t
l
se =
+ Indole = + Oxid
se = + Motility = Ne Piment = Yellow 42 C rowth = Ne Wh
t i
s the correct
identi c
tion? A. Pseudomon
s
eruinos
B. Chryseo
cterium meninosepticum C. Ac
ineto
cter

um
nnii D. E. coli Micro ioloy/Ev
lu
te l
or
tory d
t
for identi c
tion/Gr
mne
tive rods/3

7.12 | Micro ioloy
nd P
r
sitoloy Pro lem Solvin

483 Answers to Questions
2730 27. B B.
fr
ilis is the most often isol
ted r
m-ne
tive
n
ero ic
cillus. It is resi
st
nt to m
ny

nti iotics. A ood screenin

r is
20% ile pl
te th
t does not support the
rowth of
Prevotell
spp. or Porphyromon
s spp. 28. B Bre
kpoint suscepti ility testin is
done y
selectin only two
ppropri
te dru concentr
tions for testin. If the results s
how rowth
t
oth concentr
tions, then resist
nce is indic
ted; rowth only
t the lower conc
entr
tion
sini es
n intermedi
te result; no rowth
t either concentr
tion is interpreted

s suscepti le.
29. B C. meninosepticumis
well-known c
use of neon
t
l meninitis. It will
row well on
chocol
te

r, producin yellow pimented colonies. 30. A L. pneumophil
is t
he c
use of
pneumoni

nd c
n occur
s p
rt of
n epidemic spor
dic
lly or nosocomi
lly, or
m
y e community

cquired. The
ppe
r
nce of mottled, cut-l
ss colonies on u ered CYE

r under
low power
nd
the use of
direct immuno uorescence technique on sputum s
mples determine the pr
esence of L.
pneumophil
. The most common environment
l sites for recovery
re shower he
ds,
f
ucets, w
ter
t
nks,
nd
ir-conditionin systems. 30. Durin the summer re
k, sever
l middle
-
ed element
ry
school te
chers from the s
me school district
ttended
3-d
y semin
r in Chic

o. Upon returnin
home, three fem
le te
chers from the roup were hospit
lized with pneumoni
, ulik
e symptoms,
nd

nonproductive couh. Routine testin of sputum s
mples reve
led norm
l or
. Fur
ther testin
usin u ered CYE

r with L-cysteine
nd -ketolut
r
te in 5% CO 2 produced rowt
h of op
que
colonies th
t st
ined f
intly, showin thin r
m-ne
tive rods. Wh
t is the most
likely
identi c
tion? A. Leionell
pneumophil
B. H
emophilus in uenz
e C. Eikenell
corro
dens D.
Streptococcus pneumoni
e Micro ioloy/Ev
lu
te l
or
tory d
t
for identi c
tion/G
r
m-ne
tive
rods/3 2828_Ch07_381-494 06/08/12 11:25 AM P
e 483 31. A v
ncomycin-resist
n
t r
m-positive
cocco
cillus resem lin the Streptococcus virid
ns roup w
s isol
ted from the
lood of

42-ye
r-old fem
le p
tient underoin
one m
rrow tr
nspl
nt. The PYR
nd leuc
ine

minopeptid
se (LAP) tests were ne
tive. The followin results were noted: C
t

l
se = Ne CAMP =
Ne Esculin hydrolysis = Ne G
s from lucose = + Hippur
te hydrolysis = Ne 6.5
% s
lt roth =
Ne Wh
t is the correct identi c
tion? A. Leuconostoc spp. B. Enterococcus spp. C.
St
phylococcus
spp. D. Micrococcus spp. Micro ioloy/Ev
lu
te l
or
tory d
t
to m
ke identi c
ti
on/Aero ic
r
m-positive cocco
cilli/3 32. A c
t
l
se-ne
tive, r
m-positive coccus resem
lin
st
phylococci (clusters on the Gr
m- st
ined sme
r) w
s recovered from three di er
ent lood

cultures o t
ined from
60-ye
r-old p
tient di
nosed with endoc
rditis. Te fol

lowin test
results were noted: PYR = Ne LAP = Ne (V) Esculin hydrolysis = Ne 6.5% S
lt
roth = Ne
V
ncomycin = Sensitive CAMP test = Ne Wh
t is the correct identi c
tion? A. Leuco
nostoc spp. B.
Gemell
spp. C. Enterococcus spp. D. Micrococcus spp. Micro ioloy/Ev
lu
te l
o
r
tory d
t
for
identi c
tion/Gr
m-positive cocci/3 33. An immunocompromised p
tient with prior
n
ti iotic
tre
tment rew
ero ic r
m-positive cocci from sever
l clinic
l specimens th
t
were cultured. Te
or
nism w
s v
ncomycin resist
nt
nd c
t
l
se ne
tive. Addition
l testin prov
ed ne
tive for
enterococci. Wh
t other roups of or
nisms miht e responsi le? A. Leuconostoc
spp.
nd
Pediococcus spp. B. Streptococcus pyoenes
nd Streptococcus

l
cti
e C. Micro
coccus spp.
nd
Gemell
spp. D. Clostridium spp.
nd Streptococcus ovis Micro ioloy/Ev
lu
te l

or
tory d
t

for identi c
tion/Gr
m-positive cocci/3 484 Ch
pter 7 | Micro ioloy Answers to
Questions 3134
31. A Leuconostoc spp.
re v
ncomycin-resist
nt opportunistic p
thoens
nd fo
llow inv
sive
procedures. They
re often recovered from positive neon
t
l lood cultures resul
tin from
coloniz
tion durin delivery. 32. B Gemell
spp.
re often recovered from p
ti
ents with
endoc
rditis
nd meninitis. On the Gr
m st
in, they resem le st
phylococci morp
holoic
lly ut

re c
t
l
se ne
tive. 33. A Leuconostoc spp.
nd Pediococcus spp.
re v
ncomy
cin-resist
nt,
c
t
l
se-ne
tive, r
m-positive
ero ic or
nisms recovered from immunosuppress
ed p
tients. 34.
D S.
ureus is
usu
l c
use of skin infections
nd
common c
use of celluliti
s, impetio,
postsuric
l wounds,
nd sc
lded skin syndrome in inf
nts. 34. A c
t
l
se-positi
ve, r
m-positive
coccus (clusters on Gr
m st
in sme
r) rew p
le yellow, cre
my colonies on 5% sh
eep lood

r.
Te specimen w
s recovered from pustules on the f
ce of
5-ye
r-old irl with im
petio. Te
followin test re
ctions indic
te which or
nism? Glucose = + (Ferment
tion) Ox
id
se = Ne PYR =
Ne B
citr
cin = Sensitive Lysost
phin = Sensitive A. Micrococcus spp. B. Strept
ococcus spp. C.
Enterococcus spp. D. St
phylococcus spp. Micro ioloy/Ev
lu
te l
or
tory d
t
f
or
identi c
tion/Gr
m-positive cocci/3 2828_Ch07_381-494 06/08/12 11:25 AM P
e 48
4 35. A wound
(skin lesion) specimen o t
ined from
new orn rew predomin
ntly -hemolytic colo
nies of
r
m-positive cocci on 5% sheep lood

r. Te new orn inf
nt w
s covered with s
m
ll skin
eruptions th
t 
ve the
ppe
r
nce of
sc
ldin of the skin. Te r
m-positive coc
ci proved to
e c
t
l
se positive. Which tests should follow for the
ppropri
te identi c
tion?
A. Optochin,
ile solu ility, PYR B. Co
ul
se, lucose ferment
tion, DN
se C. B
citr
cin, PY
R, 6.5% s
lt

roth D. CAMP, ile-esculin, 6.5% s
lt roth Micro ioloy/Ev
lu
te l
or
tory d

t
to m
ke
identi c
tion/Select tests/Gr
m-positive cocci/3 36. A 20-ye
r-old fem
le p
tient
entered the
emerency clinic compl
inin of
domin
l p
in, fever,
nd
urnin sens
tion d
urin urin
tion.
An
ove-norm
l WBC count
lon with pus cells
nd
cteri
in the urine specime
n prompted the
emerency physici
n to order
urine culture. Te colony count reported for this
p
tient reve
led
>
100,000 col/mL of
nonhemolytic, c
t
l
sene
tive, r
m-positive or
nism on 5% sheep lood

r. Te followin te
st results indic
te
which or
nism? PYR = + Bile Esculin = + 6.5% S
lt roth = + rowth B
citr
cin =
Ne Optochin =
Ne A. Enterococcus f
ec
lis B. Streptococcus pyoenes C. Streptococcus

l
cti

e D.
Streptococcus ovis Micro ioloy/Ev
lu
te l
or
tory d
t
to m
ke identi c
tion/Gr

m-positive
cocci/3 37. A sputum specimen from
n 89-ye
r-old m
le p
tient with suspected

cteri
l pneumoni

rew
predomin
nce of r
m-positive cocci displ
yin
lph
-hemolysis on 5% shee
p lood

r. Te
colonies
ppe
red donut sh
ped
nd mucoidy
nd tested ne
tive for c
t
l
se. Te
most
ppropri
te
tests for
n
l identi c
tion
re: A. Co
ul
se, lucose ferment
tion, lysost
phin
B.
Penicillin,
citr
cin, CAMP C. Optochin, ile solu ility, PYR D. Bile esculin,
hippur
te
hydrolysis Micro ioloy/Ev
lu
te l
or
tory d
t
to m
ke identi c
tion/Gr
m-positi
ve cocci/3 7.12
| Micro ioloy
nd P
r
sitoloy Pro lem Solvin
485 Answers to Questions 3538 3
5. B S.

ureus is the c
use of sc
lded skin syndrome in new orn inf
nts. The production of

potent
exotoxin (exfoli
tin) c
uses the epidermis to slouh o , le
vin the new orns skin
with
red,
r
w texture or
urned, sc
lded look. 36. A E. f
ec
lis ives
positive re
c
tion to the PYR
test
nd is often implic
ted in urin
ry tr
ct infections (UTIs). It is p
rt of t
he norm
l or
of
the fem
le enitourin
ry tr
ct
nd the hum
n 
strointestin
l tr
ct. On 5% sheep
lood

r, E.
f
ec
lis colonies m
y
ppe
r
s nonhemolytic, -hemolytic, or -hemolytic colonies,
dependin on
the str
in. 37. C S. pneumoni
e colonies
ppe
r
s -hemolytic donut sh
ped coloni
es on 5%
sheep lood

r. The mucoid colonies m
y
ppe
r wet or w
tery due to the c
psule su
rroundin
the or
nism. The Gr
m-st
ined sme
r reve
ls l
ncet-sh
ped r
m-positive cocci i
n p
irs
surrounded y
cle
r
re
(the c
psule). To di erenti
te the virid
ns streptococc
i from S.
pneumoni
e, the most
ppropri
te test is the Optochin disk test. S. pneumoni
e o
n lood

r
re
suscepti le to Optochin ut virid
ns streptococci
re resist
nt. 38. B H. pylo
ri is not e
sily
cultured for rowth
nd identi c
tion. Tissue s
mples should e tr
nsported in
pp
ropri
te medi


nd tested immedi
tely. Other me
ns of successful identi c
tion
re r
pid ure
se t

est on iopsy
m
teri
l; ure
re
th test;
nd seroloic
l tests for the detection of
nti odie
s to H. pylori y
ELISA
nd IFA procedures. 38. A tissue iopsy specimen of the stom
ch w
s o t
in
ed from

38-ye
r-old m
le p
tient di
nosed with 
stric ulcers. The specimen w
s tr
nspo
rted immedi
tely

nd processed for culture
nd histoloy. At 5 d
ys, the culture produced colonie
s of
r
m-ne
tive (curved)
cilli on chocol
te
nd Brucell


r with 5% sheep loo
d. The cultures
were held
t 35C37C in
micro
erophilic
tmosphere. The colonies tested positive f
or ure
se.
The most likely identific
tion is: A. E. coli B. Helico
cter pylori C. Enteroco
ccus f
ec
lis D.
Streptococcus ovis Micro ioloy/Ev
lu
te d
t
for identi c
tion/ Gr
m-ne
tive cu
rved rods/3
2828_Ch07_381-494 06/08/12 11:25 AM P
e 485 39. A c
t
l
se-positive, r
m-po
sitive short rod
w
s recovered from the lood of
pren
t
l p
tient. Te or
nism
ppe
red on 5% s
heep lood
s
white colonies surrounded y
sm
ll zone of et
-hemolysis. Te followin tests
were performed,
indic
tin the p
tient w
s infected with which or
nism? Motility = + (tum lin
on wet prep) room
temper
ture Motility = + (um rell
-sh
pe on semisolid

r) room temper
ture Glu
cose = +
(ferment
tion) Esculin = + VoesProsk
uer = + A. Listeri
monocytoenes B. Strept
ococcus


l
cti
e C. Streptococcus pyoenes D. L
cto
cillus spp. Micro ioloy/Ev
lu
te
d
t
for
identi c
tion/ Gr
m-positive short rods/3 40. An emerency dep
rtment physici
n su
spected
Coryne
cterium diphtheri
e when ex
minin the sore thro
t of
n exch
ne studen
t from South
Americ
. Wh
t is the
ppropri
te medi
for the culture of the n
soph
ryne
l sw

o t
ined from
the p
tient? A. Chocol
te

r B. T
yerM
rtin

r C. Tinsd
le medium D. M
cConke
y

r
Micro ioloy/Ev
lu
te d
t
for identi c
tion/ Gr
m-positive rods/2 41. A 25-ye
r-o
ld pren
nt
p
tient compl
ined of v
in
l irrit
tion. Cultures t
ken for STDs proved ne
tiv
e. A Gr
m-st
ined
v
in
l sme
r reve
led m
ny epitheli
l cells with r
m-v
ri
le short rods (cocc
o
cilli)
coverin the m
rins. Wh
t is the most likely c
use of the v
inosis? A. Group B
streptococci
spp. B. G
rdnerell
v
in
lis C. St
phylococcus
ureus D. St
phylococcus s
proph
yticus
Micro ioloy/Ev
lu
te d
t
for identi c
tion/ Gr
m-v
ri
le rods/3 486 Ch
pter 7
| Micro ioloy
Answers to Questions 3941 39. A L. monocytoenes colonies recovered from lood

nd CSF displ
y

n
rrow zone of -hemolysis on 5% sheep lood

r, which often mimics roup B -he
molytic
streptococci. A c
t
l
se test
nd
Gr
m st
in will di erenti
te the two or
nisms
. L.
monocytoenes
re c
t
l
se positive
nd
re motile (tum lin motility
t room te
mper
ture)
s
well
s rod sh
ped inste
d of cocci sh
ped. 40. C C. diphtheri
e, unlike other

Coryne
cteriumspp.,
re not p
rt of the norm
l or
of the hum
n n
soph
rynx. Exp
osure throuh
direct cont
ct (respir
tory or cut
neous lesions) is the most likely mode of tr

nsmission.
Underdeveloped countries
re the prime pl
ces for exposure to C. diphtheri
e. Th
e di
nosis is
m
de more r
pidly when the ex
minin physici
n
lerts the l
or
tory th
t diphth
eri
is
suspected, so th
t Tinsd
le

r or other medi
cont
inin tellurite s
lts c
n
e used for
culture. Coryne
cteriumwill row on lood
nd chocol
te

rs, ut Tinsd
le


r is the
preferred culture medium ec
use the pot
ssium tellurite in the

r c
uses C. d
iphtheri
e to
produce rown colonies surrounded y
rown h
lo. The h
lo e ect is seen with C.
diphtheri
e, C.
ulcer
ns,
nd C. pseudotu erculosis ut not with other Coryne
cteriumor with ot
her pimented
colonies rowin on Tinsd
le

r such
s Streptococcus or St
phylococcus spp. 4
1. B G.
v
in
lis is p
rt of the norm
l or
(
norect
l) of
dults
nd children. Clue cell
s (v
in
l
epitheli
l cells with r
m-v
ri
le cocco
cilli on the cell m
rins)
re seen i
n v
in
l
w
shins
nd the or
nism rows slowly on chocol
te

r, 5% sheep lood

r,

nd V-

r.
2828_Ch07_381-494 06/08/12 11:25 AM P
e 486 42. A 50-ye
r-old m
le tr
nspl
n
t p
tient w
s
experiencin neuroloic
l di culties
fter
pulmon
ry infection. A spin
l t
p rev
e
led
cloudy
CSF with
Gr
m-st
ined sme
r reve
lin r
m-positive lon- e
ded
cilli. An
c
id-f
st sme
r
showed l
mentous p
rti
lly
cid-f
st
cilli. Wh
t is the most likely identi c
tion
of the
or
nism? A. Noc
rdi

steroides B. Myco
cterium
vium C. Myco
cterium ovis D
. Leionell
spp.
Micro ioloy/Ev
lu
te d
t
for identi c
tion/ Gr
m-positive
cilli/3 43. A 22-ye

r-old pren
nt
wom
n (third trimester) entered the emerency dep
rtment compl
inin of di
rrhe

, fever,
nd
other ulike symptoms. Blood cultures were ordered
lon with
urine culture. Aft
er 24 hours,
the urine culture w
s ne
tive, ut the lood cultures reve
led
r
m-positive
short rod th
t
rew
ero ic
lly on lood

r. Te colonies were sm
ll
nd smooth, resem lin

Streptococcus
spp. with
sm
ll n
rrow zone of -hemolysis. Te followin test results indic
te w
hich or
nism?
Motility = + (Wet mount = C
t
l
se = + Tum lin) Glucose = + (Acid) Esculin hyd
rolysis = + A.
Listeri
monocytoenes B. Streptococcus pneumoni
e C. Streptococcus

l
cti
e D
. Coryne
cterium
spp. Micro ioloy/Ev
lu
te l
or
tory d
t
for identi c
tion/Gr
m-positive rod/3 7
.12 |
Micro ioloy
nd P
r
sitoloy Pro lem Solvin
487 Answers to Questions 4244 42.
A N.

steroides is
r
m-positive, e
ded, lon
cillus
nd is p
rti
lly
cid f
st.
It is
n
intr
cellul
r p
thoen th
t rows in hum
n cells. Immunocompromised p
tients
re
suscepti le to

infections, especi
lly pulmon
ry, which then dissemin
te to other or
ns, often

provin f
t
l.
43. A E
rly detection in pren
nt women is very import
nt when de
lin with L. m
onocytoenes. If
it is not detected
nd tre
ted, infection of the fetus, resultin in still irth,

ortion, or
prem
ture irth m
y result. Detection c
n
lso e m
de postp
rtum y culturin t
he CSF, lood,

mniotic uid,
nd respir
tory secretions of the neon
te. 44. D The overrowth of
C. di cile in
the owel is the c
use of
ntimicro i
l-
ssoci
ted colitis. Culturin for C. di ci
le is the le
st
speci c ut the most sensitive method to detect possi le dise
se rel
ted to C. di ci
le. A
ch
r
cteristic horse-st
le odor is noted on CCFA rowin C. di cile. 44. An
ero ic
r
m-positive, spore-formin
cilli were recovered from the feces of
chemothe
r
py p
tient with
severe di
rrhe
. Te p
tient h
d underone
nti iotic ther
py 1 week prior. Te fe
c
l culture
produced rowth only on the CCFA pl
te. No
ero ic rowth of norm
l or
w
s seen

fter 48 hours.
Te followin results were noted: K
n
mycin = Sensitive V
ncomycin = Sensitive Co
listin =
Resist
nt Lecithin
se = Ne Lip
se = Ne Nitr
te = Ne Indole = Ne Ure
se = Ne
C
t
l
se = Ne
Spores = + CCFA

r = Growth of yellow, round-l
ss colonies th
t uoresce ch
rtre
use
(yellow-reen) Wh
t is the correct identi c
tion? A. Clostridium perfrinens B. Cl
ostridium
tet
ni C. Clostridium sordellii D. Clostridium di cile Micro ioloy/Ev
lu
te l
or

tory d
t
for
identi c
tion/An
ero ic r
m-positive rods/3 2828_Ch07_381-494 06/08/12 11:25 AM
P
e 487 45.
An
ero ic r
m-positive diphtheroids (nonspore formers) were cultured from two s
ep
r
te lood
culture ottles (
t 5 d
ys) o t
ined from
25-ye
r-old p
tient
dmitted to the
hospit
l with
dehydr
tion, di
rrhe
,
nd other ulike symptoms. Four other lood culture ottles
did not row

ny or
nisms
t 7 d
ys
nd were disc
rded. Te followin results were o t
ined f
rom the recovered

n
ero e: Indole = + Nitr
te = + C
t
l
se = + K
n
mycin = Sensitive V
ncomycin =
Sensitive
Colistin = Resist
nt M
jor
cid from PYG roth y GLC = Propionic
cid Wh
t is t
he correct
identi c
tion? A. Eu
cterium lentum B. Propioni
cterium
cnes C. Actinomyces spp
. D.
Peptostreptococcus spp. Micro ioloy/Ev
lu
te l
or
tory d
t
for identi c
tion/An

ero ic
r
m-positive rods/3 46. An
ero ic r
m-positive
cilli with su termin
l spores
were recovered
from sever
l lood cultures o t
ined from
p
tient di
nosed with
m
lin
ncy
of the colon. Te
followin results were recorded: Indole = Ne Ure
se = Ne Lip
se = Ne C
t
l
se
= Ne
Lecithin
se = Ne Growth on lood

r = Sw
rmin colonies Wh
t is the correct i
denti c
tion? A.
Clostridium septicum B. Clostridium perfrinens C. Clostridium sordellii D. Prop
ioni
cterium

cnes Micro ioloy/Ev
lu
te l
or
tory d
t
for identi c
tion/An
ero ic r
m-posit

ive rods/3 47.

An
ero ic r
m-ne
tive
cilli were recovered from uid o t
ined from dr
in
e of

postsuric
l

domin
l wound. Te followin test results were recorded: K
n
mycin = Resist
nt
V
ncomycin =
Resist
nt Colistin = Resist
nt Growth on 20% ile pl
te = + Piment = Ne Indole
= V (Ne)
Nitr
te = Ne Ure
se = Ne Lip
se = Ne Wh
t is the correct identi c
tion? A. Prev
otell
spp. B.
B
cteroides fr
ilis roup C. Porphyromon
s spp. D. Clostridium spp. Micro iolo
y/Ev
lu
te
l
or
tory d
t
for identi c
tion/An
ero ic r
m-ne
tive rods/3 488 Ch
pter 7 |
Micro ioloy
Answers to Questions 4548 45. B P.
cnes is
diphtheroid (pleomorphic rod) th

t m
y
ppe
r to
r
nch on the Gr
m-st
ined sme
r. It is one of the most common or
nisms isol
te
d from lood
cultures
nd is often
cont
min
nt. A und
nt propionic
cid is produced y GLC.
46. A C.
septicumis often recovered from p
tients with m
lin
ncies or other dise
ses of
the colon,
especi
lly the cecum. The followin ch
rt de nes the sw
rmin Clostridiumspp. 47.
B The B.
fr
ilis roup is
domin
nt p
rt of the indienous or
of the l
re owel
nd is
recovered most
commonly from postoper
tive
domin
l uids. The B. fr
ilis roup is more resist

nt to

nti iotics
nd is not pimented. Prevotell

nd Porphyromon
s spp.
re pimente
d. 48. A A
slender r
m-ne
tive rod with pointed ends th
t does not row on 20% ile

r
rules out B.
fr
ilis roup
nd indic
tes F. nucle
tum. Indole Ure
se Spores C. septicum
Ne Ne
Su termin
l C. tet
ni /+ Ne Termin
l C. sordellii + + Su termin
l 48. An
ero ic,
nonpimented,
r
m-ne
tive rods were recovered from
n
n
ero ic lood

r pl
te
fter 48 ho
urs of
incu
tion. Te Gr
m-st
ined sme
r showed thin
cilli with pointed ends. Te colo
nies on lood


r h
d the
ppe
r
nce of dry, irreul
r, white re
dcrum -like morpholoy with
reenin of the


r. Te followin re
ctions were noted: K
n
mycin = Sensitive V
ncomycin = Resi
st
nt Colistin =
Sensitive Nitr
te = Ne Indole = + C
t
l
se = Ne Lip
se = Ne Ure
se = Ne Gro
wth on 20% ile


r = Ne Wh
t is the correct identi c
tion? A. Fuso
cterium nucle
tum B. B
cter
oides fr
ilis
C. Clostridium perfrinens D. Peptostreptococcus spp. Micro ioloy/Ev
lu
te l
o
r
tory d
t
for
identi c
tion/An
ero ic r
m-ne
tive rods/3 2828_Ch07_381-494 06/08/12 11:25 AM
P
e 488 49.
A 2-month-old inf
nt in ood he
lth w
s scheduled for
checkup
t the pedi
tric
i
ns o ce. After

rrivin for the
ppointment, the mother noted white p
tches on the
ys tonue

nd in his
mouth. Te
y const
ntly used
p
ci er. Wh
t is the most likely or
nism c
usin
the white
p
tches? A. Cryptococcus neoform
ns B. C
ndid

l ic
ns C. Asperillus fumi
tus
D. None of these
options Micro ioloy/Ev
lu
te l
or
tory d
t
to m
ke identi c
tion/Mycoloy/3 50.

A 69-ye
r-old
m
le p
tient who w
s
ci
rette smoker visited the doctors o ce compl
inin of
c
ouh
nd
conestion of the luns. Routine cultures of e
rly mornin sputum (3) for
cteri


s well
s
for AFB reve
led no p
thoens. A fun
l culture w
s
lso ordered th
t rew the f
ollowin on
S
our
ud dextrose

r
fter 3 d
ys: Hyph
e = Sept
te with dichotomous r
nchin
 Spores =
Produced y conidi
l he
ds with numerous conidi
Colonies = Velvety or powdery,
white
t rst,
then turnin d
rk reenish to r
y (reverse = white to t
n) Vesicle = Holdin ph
i
lides usu
lly
on upper two-thirds only Wh
t is the most likely identi c
tion? A. Asperillus ni
er B. A sidi

spp. C. Mucor spp. D. Asperillus fumi
tus Micro ioloy/Ev
lu
te l
or
tory d
t

to m
ke
identi c
tion/Mycoloy/3 7.12 | Micro ioloy
nd P
r
sitoloy Pro lem Solvin
48
9 Answers to
Questions 4950 49. B C.
l ic
ns is the common c
use of or
l thrush involvin t
he
mucocut
neous mem r
nes of the mouth. C.
l ic
ns is p
rt of the norm
l or
of th
e skin, mucous
mem r
nes,
nd 
strointestin
l tr
ct. 50. D A. fumi
tus is the c
use of
sper
illosis
nd
involves the or
nism colonizin the mucous plus in the lun. This is c
lled
l
leric

sperillosis
nd is ch
r
cterized y
hih titer of IE
nti ody to Asperillu
s. Inv
sive

sperillosis seen in neutropenic p
tients exhi its sinusitis,
nd is dissemin
t
ed throuhout the
ody. 2828_Ch07_381-494 06/08/12 11:25 AM P
e 489 51. A youn m
le p
tient w
ith
funus of
the feet visited the podi
trist for relief from the itchin. A culture w
s sent
to the
micro ioloy l
or
tory th
t rew
fter 8 d
ys on S
our
ud dextrose

r. Colon
ies were powdery
pink with concentric
nd r
di
l folds, with the reverse side showin rownish-t

n to red in
color. Other o serv
tions were: Hyph
e = Sept
te Ure
se = + M
croconidi
= Ci
r
sh
ped, thin
w
lled with 16 cells Microconidi
= Round
nd clustered on r
nched conidiophores
Red piment on
cornme
l (1% dextrose) = Ne In vitro h
ir perfor
tion = + Te most likely identi c

tion is: A.
Trichophyton ment
rophytes B. Trichophyton ru rum C. C
ndid

l ic
ns D. Asper
illus nier
Micro ioloy/Ev
lu
te l
or
tory d
t
to m
ke identi c
tion/Mycoloy/3 52. A 79-ye

r-old fem
le
nursin home p
tient w
s
dmitted to the hospit
l with
fever
nd centr
l nervo
us system
dysfunction. Routine lood work
nd lood cultures were ordered. After 48 hours,
the lood
cultures reve
led
uddin ye
st. Te followin tests performed from S
our
ud d
extrose

r
(
fter 3 d
ys of rowth) showed: Germ tu e = Ne rowth Birdseed

r = Brown Ur
e
se = +
Pseudohyph
e = Ne Bl
stospores =+ Chl
mydospores = Ne Arthrospores = Ne Assim
il
tion

r = +
(dextrose, sucrose, m
ltose) Wh
t is the most likely identi c
tion? A. C
ndid

l

ic
ns B.
Cryptococcus l
urentii C. Cryptococcus neoform
ns D. C
ndid
tropic
lis Micro io
loy/Ev
lu
te
l
or
tory d
t
for identi c
tion/Mycoloy/3 490 Ch
pter 7 | Micro ioloy Answer
s to Questions
5153 51. A T. ment
rophytes,
common c
use of
thletes foot, is sometimes conf
used with T.
ru rum, the most common derm
tophyte to infect hum
ns. The di erenti
l tests
re s
hown in the
followin ch
rt. 52. C C. neoform
ns produces rown colonies on irdseed

r,
is ure
se
positive,
nd produces only l
stospores. Immunosuppressed p
tients
re vulner

le to this
or
nism. 53. A CMV infection in youn
dults c
uses
self-limited mononucleosi
s syndrome. CMV
infections
re common
nd usu
lly self-limited, except in neon
tes
nd immunosup
pressed p
tients,
in whom they m
y c
use
life-thre
tenin situ
tion. In vitro H
ir Red Piment
Perfor
tion on
Cornme
l Ure
se Test A
r T. ment
rophytes + + Ne T. ru rum Ne Ne + or
W 53. A
dehydr
ted 25-ye
r-old m
le p
tient w
s
dmitted to the hospit
l with symptoms s
imil
r to those
of chronic f
tiue syndrome. Seroloic
l testin proved ne
tive for recent stre
ptococc
l
infection, EpsteinB
rr virus,
nd hep
titis. Which of the followin vir
l serolo
ic
l tests
should help with
possi le di
nosis? A. CMV B. Echovirus C. Respir
tory syncyt
i
l virus D.
Me
sles virus Micro ioloy/Select tests for identi c
tion/Viroloy/3 2828_Ch07_381
-494 06/08/12
11:25 AM P
e 490 54. A nursin student workin in the emerency dep
rtment
cc
ident
lly stuck
herself with
needle
fter removin it from
n intr
venous set t
ken from
sus
pected dru user.
Te est course of
ction,
fter reportin the incident to her supervisor, is to:
A. Test the
student for HIV virus if ulike symptoms develop in 24 weeks B. Immedi
tely test th
e p
tient
nd
the student for HIV usin
n EIA or ELISA test C. Perform
Western lot
ss
y o
n the students
serum D. Dr
w lood from the student only
nd freeze it for further testin Micr
o ioloy/Ev
lu
te
testin for virus exposure/ Viroloy/3 55. A 30-ye
r-old fem
le p
tient compl
in
ed of v
in
l
irrit
tion
nd symptoms (fever, dysuri
,
nd inuin
l lymph
denop
thy)
ssoci
te
d with sexu
lly
tr
nsmitted dise
se (STD). Ex
min
tion showed extensive lesions in the enit
l

re
. Chl
mydi

spp. testin, Neisseri
onorrhoe
e,
nd G
rdnerell
v
in
lis cultures were ne

tive. R
pid
pl
sm
re
in (RPR) testin w
s
lso ne
tive. Wh
t is the next line of testin?
A. D
rk eld
ex
min
tion B. Herpes simplex testin C. Trichomon
s spp. testin D. Group B str
eptococc
l
testin Micro ioloy/Select tests for identi c
tion/Viroloy/3 56. A p
tient is e
in seen in the
emerency dep
rtment for
low-r
de fever, he
d
che,
nd ener
l m
l
ise
fter
returnin from
Afric
on
photor
phic s
f
ri. Te physici
n h
s requested lood for m
l
ri
; t

he l
or
tory
would like to h
ve p
tient inform
tion re
rdin: A. Speci c tr
vel history
nd o
dy temper
ture
every 4 hours B. Liver function tests
nd prophyl
ctic medic
tion history C. Tr

nsfusion history

nd ody temper
ture every 4 hours D. Prophyl
ctic medic
tion history
nd speci c
tr
vel history
Micro ioloy/Apply knowlede of life cycles, di
nostic techniques,
nd clinic
l
present
tion/P
r
sitoloy/3 7.12 | Micro ioloy
nd P
r
sitoloy Pro lem Solvin
491 Answers to
Questions 5457 54. B With the permission of the p
tient (st
te l
w m
y require hi
m or her to
sin
consent form)
nd counselin of the student nurse, the
ppropri
te course
of
ction is to
test the p
tient for HIV usin
screenin test (EIA or ELISA). The student shou
ld
lso e

seline tested. If the test result is positive for the p
tient, the student is

dministered the

ppropri
te
ntivir
l dru(s) immedi
tely or within 2 hours of the incident. Con r
m
tory testin
is done on
ny positive HIV tests. 55. B Herpes enit
lis is
n infection c
used
y HSV-2.
Symptom
tic prim
ry herpes y HSV-2 is responsi le for
out 85% of herpes infec
tions. HSV-1
(c
usin the other 15%) does not involve recurrin infections of herpes
nd c
us
es fever
listers. HSV-2 c
uses 99% of recurrent enit
l herpes. 56. D If the p
tient h
s
m
l
ri

nd h
s
een t
kin prophyl
xis (often spor
dic
lly), the num er of p
r
sites on the lo
od sme
r will e
reduced
nd ex
min
tion of routine thick
nd thin lood lms should e more exh
us
tive. Also
speci c eor
phic tr
vel history m
y help to determine whether chloroquine-resist

nt Pl
smodium
f
lcip
rumm
y e
f
ctor. 57. C One of the newer coccidi
n p
r
sites, C. c
yet

nensis, h
s een
implic
ted in c
ses of hum
n di
rrhe
. The recommended st
ins
re modi ed
cid-f
s
t st
ins,
nd
the or
nisms
re quite v
ri
le in their st
inin ch
r
cteristics. The oocysts

re imm
ture when
p
ssed (no intern
l morpholoy)
nd they me
sure
out 810 m. 57. Examination of a
modi ed
acid-fast stained fecal smear reveals round structures measuring approximately 81
0 m, some of
which are stained and some of which are not. Tey do not appear to show any inter
nal morphology.
Te patient is symptomatic with diarrhea, and the cause may be: A. Blastocystis h
ominis B.
Polymorphonuclear leukocytes C. Cyclospora cayetanensis D. Large yeast cells Mic
robiology/Apply
knowledge of the morphology of artifacts, organism life cycles, and diagnostic
methods/Parasitology/3 2828_Ch07_381-494 06/08/12 11:25 AM Page 491 58. A pat
ient has been
diagnosed as having amebiasis but continues to be asymptomatic. Te physician has
asked for an
explanation and recommendations regarding follow-up. Suggestions should include:
A. Consideration
of Entamoeba histolytica versus Entamoeba dispar B. A request for an additional
three stools for
culture C. Initiating therapy, regardless of the patients asymptomatic status D.

Performance of
barium x-ray studies Microbiology/Apply knowledge of the morphology of organisms
and
pathogenesis/Parasitology/3 59. Although a patient is strongly suspected of havi
ng giardiasis and
is still symptomatic, three routine stool examinations (O&P exam) have been perf
ormed correctly
and reported as negative. Biopsy con rmed the patient had giardiasis. Reasons for
these ndings
may include: A. Te patient was coinfected with several bacterial species B. Giar
dia lamblia tends
to adhere to the mucosal surface and more than three stool examinations may be r
equired to
confirm a suspected infection C. Te organisms present did not stain with trichro
me stain and
therefore the morphology is very atypical D. Special diagnostic procedures such
as the Knott
concentration and nutrient-free agar cultures should have been used Microbiology
/Apply knowledge
of life cycles, organism morphology, pathogenesis, and diagnostic procedures/Par
asitology/3 60. A
transplant patient is currently receiving steroids. The patient is now complaini
ng of abdominal
pain and has symptoms of pneumonia and positive blood cultures with gram-negativ
e rods. The
individual has been living in the United States for 20 years but grew up in Cent
ral America. The
most likely parasite causing these symptoms is: A. Trypanosoma brucei rhodesiens
e B. Giardia
lamblia C. Strongyloides stercoralis D. Schistosoma japonicum Microbiology/Apply
knowledge of
fundamental life cycles, pathogenesis, and immunosuppressives/ Parasitology/3 49
2 Chapter 7 |
Microbiology Answers to Questions 5860 58. A It is now well established that E. h
istolytica is
being used to designate the pathogenic species, whereas E. dispar is now being u
sed to designate
the nonpathogenic species. However, unless trophozoites containing ingested red
blood cells (E.
histolytica) are seen, the two organisms cannot be differentiated on the basis o
f morphology.
Based on this information, there are now two separate species, only one of which
(E. histolytica)
is pathogenic. Because this patient is asymptomatic, the organisms seen in the f
ecal smears are
probably E. dispar (nonpathogen); the laboratory report should have said Entamoeb
a histolytica/
E. disparunable to differentiate on the basis of morphology unless trophozoites a
re seen to
contain ingested RBCs (E. histolytica). 59. B It is well known that G. lamblia tr
ophozoites
adhere to the intestinal mucosal surface by means of the sucking disk. Although
a patient may
have giardiasis and be symptomatic, confirmation of the infection from stool exa
minations may
require more than the routine three stools or may require the examination of duo
denal contents.
If fecal immunoassays are used, two different stool specimens should be tested b
efore indicating
the patient is negative. 60. C Although infection with S. stercoralis may have b

een acquired in
Central America many years before, the patient may have remained asymptomatic wh
ile the infection
was maintained at a low level in the body via the autoinfective portion of the l
ife cycle. As the
patient became more immunosuppressed (steroids), the life cycle began to reactiv
ate with
penetration of the larvae through the intestinal wall (abdominal pain) and larva
l migration
through the lungs (pneumonia), and the patient may have presented with evidence
of sepsis (often
with gram-negative bacteria carried with the larvae as they penetrate the intest
inal wall).
Patients who become immunosuppressed may see the life cycle of Strongyloides rea
ctivated with
serious illness resulting; this can occur many years after the initial infection
and after the
patient has left the endemic area. 2828_Ch07_381-494 06/08/12 11:25 AM Page 4
92 BI BL I
OGRAPHY 1. Forbes BA, Sahm DF, and Weissfeld AS. Bailey and Scotts Diagnostic Mic
robiology. 11th
edition, 2007. Mosby, St. Louis. 2. Garcia LS. Diagnostic Medical Parasitology.
5th edition,
2007. ASM Press, Washington, DC. 3. Koneman EW, Allen SD, Janda WM, Winn W, Proc
op G,
Schreckenberger P, and Wood G. Color Atlas and Textbook of Diagnostic Microbiolo
gy. 6th edition,
2005. Lippincott Williams & Wilkins, Philadelphia. 7.12 | Microbiology and Paras
itology Problem
Solving 493 4. Larone DH. Medically Important Fungi: A Guide to Identi cation. 5
th edition,
2011. ASM Press, Washington, DC. 5. Mahon CR, Lehman DC, and Manuselis G. Textbo
ok of Diagnostic
Microbiology. 4th edition, 2010. WB Saunders, Philadelphia. 6. Versalovic J, Car
roll KC, Guido F,
Jorgensen JH, Landry ML, Warnock DW. Manual of Clinical Microbiology. 10th editi
on, 2011. ASM
Press, Washington, DC. 2828_Ch07_381-494 06/08/12 11:25 AM Page 493 2828_Ch07
_381-494
06/08/12 11:25 AM Page 494 CHAPTER 8 8.1 Molecular Methods 8.2 Molecular Diagn
ostics 495
Molecular Diagnostics 2828_Ch08_495-522 06/08/12 11:26 AM Page 495 2828_Ch08_
495-522 06/08/12
11:26 AM Page 496 Answers to Questions 12 1. C The melting temperature of DNA
refers to the
temperature required to separate the molecule into single strands. The T m is th
e temperature
required to convert half of the DNA from dsDNA to ssDNA. This is done by breakin
g the hydrogen
bonds between base pairs. A-T base pairs have two hydrogen bonds, while C-G base
pairs have
three. Therefore, molecules with a high proportion of C-G base pairs are more re
sistant to heat
denaturation or melting. 2. D Restriction endonucleases are enzymes that cut d
ouble-stranded
DNA into fragments and are important tools used in molecular diagnostics. Each r
estriction enzyme
recognizes a speci c oligonucleotide sequence, and the size and number of fragment
s it produces
when DNA is digested depend upon the number of times that sequence is repeated i

n the DNA
molecule. Restriction endonucleases recognize palindromic sequences (i.e., the b
ase sequence of
complementary strands reads the same from opposite directions). The sequence A-A
-G-C-T-T
T-T-C-G-A-A is the recognition site for HindIII, a restriction endonuclease isol
ated from
Haemophilus in uenzae. If a disease gene produces a base pair substitution at the
restriction
site, the enzyme will not recognize it and not cut the DNA. This results in a lo
nger fragment
that can be recognized by electrophoresis. This process was initially used to id
entify the
hemoglobin S gene using the restriction enzyme MstII. The point mutation changes
an A to a T
within the restriction site, causing loss of the normal-sized fragment. 1. Which
double-stranded
DNA molecule has the highest melting temperature? A. An oligonucleotide with a r
epeating sequence
of A-A-A at the 5 end B. A molecule of 5,000 base pairs with a high number of A-T
base pairs C.
An oligonucleotide with a large number of repeating C-G-C codons D. A DNA polyme
r of 100,000 base
pairs Molecular/Apply knowledge of fundamental biological characteristics/DNA/2
2. Which base
pair sequence is most likely to serve as a binding site for a restriction endonu
clease? A.
A-T-T-C-A T-A-A-G-T B. C-T-A-C-T-G G-A-T-G-A-C C. C-A-C G-T-G D. A-A-G-C-T-T T-T
-C-G-A-A
Molecular/Apply knowledge of fundamental biological characteristics/DNA/2 8.1 Mo
lecular Methods
497 2828_Ch08_495-522 06/08/12 11:26 AM Page 497 3. Cloning a human gene into
a bacterium in
order to make a large molecular probe requires which vector? A. Plasmid B. Bacte
rial microsome C.
30S bacterial ribosome D. Single-stranded DNA Molecular/Apply principles of spec
ial procedures/
DNA/1 4. What process can be used to make a DNA probe produce a uorescent or chem
iluminescent
signal? A. Enzymatic attachment of acridinium esters to terminal ends of the pro
be B.
Substitution of biotinylated or uorescent nucleotides into the probe C. Splicing
the gene for
-
l
ctosid
se into the pro e D. He
t den
tur
tion of the pro e followed y
cid
tre
tment
Molecul
r/Apply principles of speci
l procedures/ DNA/1 5. Wh
t term descri es t
he products
produced when DNA is diested y restriction endonucle
ses? A. Mos
icisms B. Chi
mer
s C.
Amplicons D. Restriction fr
ment lenth polymorphisms Molecul
r/Apply principle
s of
sic
l
or
tory procedures/DNA/1 498 Ch
pter 8 | Molecul
r Di
nostics Answers to Que
stions 35 3. A
A pl
smid is
piece of circul
r dou le-str
nded DNA loc
ted in the cytopl
sm of


cterium.
Althouh not
tt
ched to
chromosome, the pl
smid is replic
ted like chromosom

l DNA. The
pl
smid is cut with the restriction endonucle
se th
t is used to isol
te the DNA
fr
ment
cont
inin the ene of interest. The fr
ment
nne
ls to the sticky ends of the

pl
smid DNA,
nd

the cut is rep
ired y DNA li
se. The recom in
nt pl
smid is
dded to
culture
of
cteri
th
t
is disrupted to promote the upt
ke of pl
smid DNA. Commerci
lly
v
il
le pl
smi
ds h
ve promoter

nd reporter enes such
s l
c
nd l
cZ th
t produce -
l
ctosid
se. These c
n e
used to
identify colonies with successful recom in
nts. They
lso c
rry
nti iotic resis
t
nce enes th
t

llow the recom in
nts to e puri ed. Culture of the recom in
nt
cteri
results
in l
re

mounts of the ene, which c
n e h
rvested usin the restriction enzyme, den
tu
red,
nd l
eled
to m
ke the pro e. 4. B Fluorescent or enzyme l
els c
n e
tt
ched to pro es
y nick
tr
nsl
tion. A DN
se is used to cut the pro e
t
few phosphodiester link
es.
PolI rep
irs the
nicks y removin nucleotides from the 3 end
nd repl
cin them with l
eled nucl
eotides
t the
5 end of the nick. Altern
tively,
primer cont
inin
l
eled nucleotide c
n e
used to m
ke
copies of the pro e y DNA
mpli c
tion (PCR). A common l
el used for pro es cons
ists of iotin
conju
ted to the 5 end of the pro e. After hy ridiz
tion, strept
vidin conju

ted to
n enzyme
such
s
lk
line phosph
t
se is
dded. Strept
vidin stronly inds to iotin, fo
rmin
n
enzyme-l
eled complex with the DNA. After w
shin to remove un ound strept
vidi
n,

colorimetric, uorescent, or chemiluminescent su str
te is
dded. 5. D Mos
icism
occurs when
cells within the s
me individu
l cont
in di erent num ers of chromosomes
nd resul
ts from
nondisjunction durin e
rly em ryonic development. Chimer
s
re molecules cre
te
d when
tr
nsloc
tion occurs etween enes (exons) on di erent chromosomes. Amplicons
re
ex
ct copies of

DNA templ
te produced y DNA
mpli c
tion techniques such
s the polymer
se ch
i
n re
ction
(PCR). When
restriction enzyme cuts two di erent DNA molecules, the size of some
fr
ments will
di er ec
use the num er
nd position of restriction sites di er. Such fr
ments
re
c
lled RFLPs
for restriction fr
ment lenth polymorphisms (RFLPs). An
lysis of RFLPs c
n e
used to test for
dise
se enes, study enetic link
e,
nd est
lish identity. It is used usu
lly
when PCR is
impr
ctic
l, such
s when cont
min
tion occurs repe
tedly or when the enes to
e
n
lyzed
comprise
lenth of DNA too lon for e cient
mpli c
tion. 2828_Ch08_495-522 06/08
/12 11:26 AM
P
e 498 6. Te followin ure shows
DNA size st
nd
rd (l
dder) m
de y restric
tion enzyme
diestion (PstI) of l
m d
ph
e DNA th
t h
s een sep
r
ted y

rose el elec
trophoresis.
Which DNA
nd h
s the hihest molecul
r weiht? 8.1 | Molecul
r Methods 499 A
nswers to
Questions 68 6. A E
ch phosphoric
cid su unit within
phosphodiester ond to

dj
cent
deoxyri ose molecules h
s
sinle ne
tive ch
re
t
n
lk
line pH. Since the

ch
re is
distri uted evenly, sm
ller fr
ments move more r
pidly throuh the el. When su
spended in
n

lk
line u er (pH 8) such
s tris- or
te-EDTA (TBE) or tris-
cet
te-EDTA (TAE), t
he DNA
fr
ments mir
te tow
rd the
node
t
r
te th
t is inversely proportion
l to t
he lo 10 of
molecul
r size. If the dist
nce tr
veled is plotted

inst the lo of molecul
r
weiht, the plot
will e
str
iht line with
ne
tive slope ec
use the l
rer the molecule, t
he more slowly it
moves throuh the pores of the el. The plot c
n e c
li r
ted with
DNA size l

dder,
nd the
molecul
r weiht of DNA fr
ments c
n e determined from the c
li r
tion curve.
7. D When
ethidium romide inserts etween the
se p
irs of dou le-str
nded DNA, the dye
ecomes
uorescent, rele
sin 480 nm liht when stimul
ted y lon w
velenth ultr
violet
liht. Ethidium
romide st
inin h
s
sensitivity of
pproxim
tely 10 n/mL (1.5 n per
nd) D
NA. It is
frequently
dded to molten

rose or c
pill
ry electrophoresis u er
t
concent
r
tion of 0.5
g/mL in order to visualize and quantify DNA. Its binding to single-stranded DNA a
nd RNA is not
as e cient as that of more sensitive dyes such as SYBR gold, picoGreen, and YOYO-1
. 8. A
Southern blot hybridization is a method commonly used to detect disease genes in
both PCR
products and RFLP testing. The DNA fragments are electrophoresed, and the DNA ba
nds are
transferred by suction to a nylon or nitrocellulose membrane. The bands are immo
bilized and
denatured on the membrane, and a solution containing the labeled probe is added.
Hybridization is
the binding of the complementary base sequence of the probe to the target sequen
ce. This process
is highly dependent upon temperature, ionic strength, and the presence of reagen
ts in the
hybridization solution that in uence stringency (the degree of exactness of base p
airing). A
Northern blot test follows the same process, except that the sample is RNA. In a
Western blot
test, the sample is a mixture of proteins, and the probes used are (labeled) ant
ibodies to the
proteins of interest. A dot blot is a hybridization method in which samples of D
NA are placed
directly on the nitrocellulose membrane as a circular spot (or bar in the case o
f a slot blot),
followed by the hybridization process. A. 1 B. 2 C. 3 D. 4 Molecular/Apply princ
iples of basic
laboratory procedures/DNA electrophoresis/2 7. What reagent is most commonly use
d to stain DNA
separated by electrophoresis? A. Silver nitrate B. Nicotinamide adenine dinucleo
tide C. Cationic
dye D. Ethidium bromide Molecular/Apply principles of basic laboratory procedure
s/DNA
electrophoresis/2 8. Which technique is used to detect DNA containing a speci c ba
se sequence by
applying a labeled probe to DNA bands immobilized onto nitrocellulose paper foll

owing
electrophoresis? A. Southern blot B. Northern blot C. Dot blot D. Western blot M
olecular/Apply
principles of basic laboratory procedures/DNA blotting/2 2828_Ch08_495-522 06/0
8/12 11:26 AM
Page 499 9. Which of the following types of mutation causes the premature termin
ation of protein
synthesis? A. Missense B. Nonsense C. Insertion D. Frame shift Molecular/Apply k
nowledge of
fundamental biological characteristics/DNA/1 10. In humans, which component of a
gene is
translated into a protein? A. Intron B. Exon C. Promoter D. TATA box Molecular/A
pply knowledge of
fundamental biological characteristics/DNA/1 11. Which statement best describes
a DNA
polymorphism? A. A point mutation arising in a gene B. Any change in DNA that is
associated with
abnormal function C. A change in the base sequence of DNA that is translated int
o an abnormal
protein D. A variation in DNA that occurs with a frequency of at least 1% Molecu
lar/Apply
knowledge of fundamental biological characteristics/DNA/1 500 Chapter 8 | Molecu
lar Diagnostics
Answers to Questions 911 9. B A nonsense mutation occurs when a nucleotide subs
titution within
a codon changes the code from that for an amino acid to a stop sequence. For exa
mple, a change
from TTC to GTC changes the mRNA transcript from AAG to UAG. AAG codes for lysin
e and UAG is a
stop codon; therefore, instead of lysine being added to the protein during trans
lation, protein
synthesis is terminated. In the reverse situation, the point mutation changes a
termination codon
into one for an amino acid and a longer protein is produced. A missense mutation
occurs when a
base substitution alters the codon so that a di erent amino acid is inserted durin
g translation.
A frame shift mutation occurs when there is a deletion or insertion of more or l
ess than three
bases. This changes the triplet order, altering the amino acid sequence of the p
rotein. 10. B
Exons are the components of genes that determine the amino acid sequence of the
protein
synthesized. Exons are separated by noncoding regions called introns that are tr
anscribed and
later removed from mRNA before translation. Promoters are sequences located near
the gene at the
5 end and facilitate binding of proteins that increase transcription. A TATA box
is an
oligonucleotide sequence often found in the promoter region. The AT base pairs h
ave two hydrogen
bonds that separate more easily than CG bonds, thus creating a point where the d
ouble helix is
easier to open. 11. D The human genome contains approximately 3 billion base p
airs and
approximately 25,000 genes. Post-transcription modi cation of mRNA enables product
ion of about
100,000 proteins. However, approximately 99.9% of the DNA is homologous. The rem
aining 0.1% is
variable and accounts for individual di erences. A polymorphism is an individual d

i erence in DNA
sequence or length that occurs in at least 1% of the population. Polymorphisms a
rise from
mutation and are transmitted to o spring. They are subject to selection pressures
that cause
genes to drift in the population. Over 350,000 such di erences are present in the
human genome,
but very few are associated with human disease. 2828_Ch08_495-522 06/08/12 11:
26 AM Page 500
12. Which of the following is the most common type of polymorphism? A. Single nu
cleotide
polymorphism (SNP) B. Variable number tandem repeat (VNTR) C. Short tandem repea
t (STR) D. Short
repetitive interspersed element (SINES) Molecular/Apply knowledge of fundamental
biological
characteristics/DNA/1 13. Which of the following mechanisms facilitates DNA sepa
ration by
capillary electrophoresis? A. Molecular sieving B. Partitioning C. Adsorption D.
De ection
Molecular/Apply principles of special procedures/ Electrophoresis/1 8.1 | Molecu
lar Methods 501
Answers to Questions 1213 12. A Approximately 80% of polymorphisms result from
single
nucleotide substitutions and are called single nucleotide polymorphisms. Some SN
Ps are silent,
whereas others cause a change in the codon within the gene. VNTRs, STRs, and SIN
ES refer to
polymorphisms involving di erences in the length of as opposed to the sequence of
bases. These
are speci c base sequences that occur throughout the genome that are repeated at a
particular
locus. The number of times the sequence repeats is an inherited trait. For examp
le, the sequence
AATG is a repeat that occurs within the tyrosine hydroxylase gene on chromosome
11. The sequence
can repeat 3 to 14 times, resulting in 12 di erent alleles. Someone who inherits a
llele 6 (AATG
repeats six times) will have a DNA molecule that is four base pairs longer than
someone who
inherits allele 5 (AATG repeats ve times). This locus, called TH01, is used in fo
rensic and
parentage testing to establish identity. 13. A Capillary electrophoresis (CE)
is a method
commonly used to separate DNA fragments. Unlike conventional electrophoresis, a
stationary
support such as agarose is not used. Instead, a small-bore open tubular column i
s immersed in
bu er solution at its ends and subjected to an electric eld. Molecules such as prot
eins and DNA
are injected by application of either pressure or high voltage (electrokinetic t
ransfer). The
negative nature of the glass capillary attracts cations that are pulled to the c
athode when the
voltage is applied. This creates an electro-osmotic force (EOF) that draws water
and other
molecules toward the cathode. An ultraviolet light detector or laser-induced uore
scence detector
is located near the cathode and detects the molecules as they migrate. At an alk
aline pH, DNA and
protein molecules are negatively charged but are pulled toward the cathode by EO

F at a rate
inversely proportional to their size. CE columns can be coated with a gel such a
s acrylamide or a
polymer that neutralizes the EOF, so that the DNA molecules are drawn toward the
anode at a rate
inversely related to the molecular size. DNA molecules such as PCR products of 1
00 to 1,000 base
pairs can be detected with a band resolution as high as 12 base pairs and a sensi
tivity of
approximately 1 ng/mL DNA. Such high resolution is possible because very high vo
ltage can be
used, since the heat produced is lost through the capillary wall. 2828_Ch08_495522 06/08/12
11:26 AM Page 501 14. Te polymerase chain reaction (PCR) involves three process
es. Select the
order in which these occur. A. ExtensionAnnealingDenaturation B.
AnnealingDenaturationExtension C. DenaturationAnnealingExtension D.
DenaturationExtensionAnnealing Molecular/Apply principles of special procedures/PC
R/1 15. In
the PCR cycle, how is denaturation accomplished? A. Heat B. Alkali treatment C.
Addition of
sulfonylurea D. Formamide Molecular/Apply principles of special procedures/PCR/1
16. What is the
composition of the primer used in PCR? A. A cocktail of enzymes and nucleotide t
riphosphates that
bind to the target B. An oligonucleotide complementary to bases at the 3 end of t
he target C. A
small piece of dsDNA that attaches to the template D. A probe made of mRNA that
binds downstream
from the target Molecular/Apply principles of special procedures/PCR/1 17. Te ma
ster mix solution
used for PCR contains which of the following reagents? A. Deoxyribonucleotide tr
iphosphates B.
Deoxyribonucleotide monophosphates C. Deoxyribonucleosides D. Ribonucleotide mon
ophosphates
Molecular/Apply principles of special procedures/PCR/1 18. What is the unique ch
aracteristic of
the DNA polymerase, Taq DNA polymerase, used in PCR? A. It can be enzyme labeled
B. It is more
e cient than eukaryotic polymerases C. It is heat stable D. It works with DNA of a
ny species
Molecular/Apply principles of special procedures/PCR/1 502 Chapter 8 | Molecular
Diagnostics
Answers to Questions 1418 14. C The PCR process results in identical copies of
a piece of
double-stranded DNA. The process involves three steps that are repeated to doubl
e the number of
copies produced with each cycle. The rst step is denaturation to separate the com
plementary
strands. Annealing occurs when a primer binds upstream to the segment of interes
t on each strand,
called the template. Extension involves the enzymatic addition of nucleotides to
the primer to
complete the new strand. 15. A In PCR, the separation of dsDNA occurs by heati
ng the sample to
a temperature between 90C and 94C. This breaks the double bonds between the base p
airs and is
reversible by lowering the temperature. Alkali, high salt, and formamide also de
nature dsDNA, but
they are not used in PCR because they would have to be removed and added with ev

ery cycle. 16.

B PCR primers are small oligonucleotides, usually 12 to 36 bases, complementary
to the base
sequence at the 3 end of the target DNA. Two primers are used, one to the sense s
trand of DNA
(the strand containing the gene) and the other to its complement (the antisense
strand). Primers
for PCR are made only for the 3 end of each target sequence because the DNA polym
erase that
extends the primer does so only by addition of bases in the 5 3 direction. 17. A
Master mix
solutions must contain all of the reagents needed to generate new dsDNA. This in
cludes DNA
polymerase, the enzyme needed to replicate the target sequence, primers to initi
ate replication,
magnesium (a polymerase cofactor), bu ers to maintain pH, and deoxyribonucleotide
triphosphates
that are the substrates for DNA polymerase (adenosine triphosphate, guanosine tr
iphosphate,
thymidine triphosphate, and cytosine triphosphate). 18. C Because heat is used
to denature
dsDNA with every cycle of PCR, the polymerase used must be heat stable. Taq poly
merase is
obtained from Thermus aquaticus, a bacterium that lives in the hot springs of Ye
llowstone
National Park. It retains its activity even after repeated heating at 95C. The op
timal
temperature for extension by Taq is 72C. A typical PCR cycle involves heating to
94C for
denaturation, cooling to 64C for annealing, and heating to 72C for extension. 2828
_Ch08_495-522
06/08/12 11:26 AM Page 502 19. In PCR methods, how can several targets be cop
ied
simultaneously and detected? A. By following the increase in absorbance at 260 n
m during melting
B. By labeling multiple primers with speci c uors C. By substitution of hybridizati
on probes for
primers D. By analysis of adenosine tail signatures Molecular/Apply principles o
f special
procedures/PCR/1 20. Which formula predicts the number of PCR products that can
be produced? A. 2
n where n is the number of cycles B. N 4 where N is the number of cycles C. p 2
+ 2pq + q 2 = 1
where p and q are the number of primers D. N 2
/
2 where N is the number of cycles
Molecular/Apply principles of special procedures/PCR/2 21. How can PCR b
e applied to the
detection of human immunode ciency and other RNA viruses? A. Te virus must be inse
rted into human
DNA by viral integrase prior to PCR B. Substitute deoxyuridine triphosphate in p
lace of
deoxythymidine triphosphate in the master mix C. Add a heat-stable reverse trans
criptase enzyme
to the master mix D. Substitute ribonucleotide triphosphates for deoxyribonucleo
tide
triphosphates in the master mix Molecular/Apply principles of special procedures
/PCR/2 22. Which
statement best describes the method of branched DNA signal ampli cation? A. Te DNA
template is
ampli ed directly using patented enzymes B. Multiple primers are used to create br

anches of the
template DNA, permitting multiple extension sites C. Te target DNA is denatured
and hybridized to
RNA, and the hybrid molecules are ampli ed by both DNA and RNA polymerases D. Te t
arget DNA is
bound by multiple probes, and those are ampli ed instead of the target DNA Molecul
ar/Apply
principles of special procedures/DNA ampli cation/1 8.1 | Molecular Methods 503
Answers to
Questions 1922 19. B In PCR, several target sequences can be tested for simulta
neously using
multiple primers (multiplex PCR). Several methods exist for detection and quanti
tation of
possible PCR products. The traditional method is Southern blotting, in which uore
scent- labeled
probes to each template hybridize with their respective product after PCR. Alter
natively, the
primers can be labeled with di erent uorescent dyes. These can be detected after PC
R by
capillary electrophoresis using laser-induced uorescence. 20. A PCR has the pot
ential to
double the quantity of PCR products with every cycle. Therefore 2 n predicts the
number of PCR
products that can be produced from n cycles. For example, if 30 cycles are progr
ammed, then 2 30
predicts slightly over 1 billion PCR products. The formula p 2 + 2pq + q 2 = 1 d
escribes the
distribution of a two-allele gene in a population. 21. C Reverse transcriptase
PCR (RT-PCR) is
used to detect RNA viruses and to amplify RNA transcription products by converti
ng the template
to DNA. The master mix contains the same components needed for PCR with the addi
tion of a
heat-stable reverse transcriptase (enzyme that transcribes RNA to DNA, such as r
Tth DNA
polymerase), manganese (a cofactor for this enzyme), and an mRNA primer. In addi
tion to testing
for infectious diseases (HIV, hepatitis C, and hepatitis E), RT-PCR is used to i
dentify
translocations in leukemia where the crossover regions are too large for e cient P
CR. 22. D In
branched DNA (bDNA) signal ampli cation, the target DNA is denatured and added to
a well
containing immobilized probes. One end of each probe hybridizes with the target
DNA, capturing
it, and the other contains multiple branches that hybridize with alkaline phosph
atase-labeled
probes. After washing to remove the unbound labeled probes, dioxetane is added,
and
chemiluminescence is measured. A thermocycler is not used and the target DNA is
not ampli ed. PCR
is a licensed technology, and other methods of nucleic acid ampli cation have sinc
e been
developed including nucleic acid sequence-based ampli cation (NASBA), transcriptio
n-mediated
ampli cation (TMA), hybrid capture, and rolling circle ampli cation (RCA). 2828_Ch08
_495-522
06/08/12 11:26 AM Page 503 23. A PCR reaction is performed, and the negative c
ontrol
demonstrates the presence of a detectable number of PCR products (amplicons) by

capillary
electrophoresis. What is the most likely cause? A. False-positive post-PCR hybri
dization reaction
due to low stringency B. Dimerization of PCR primers C. Contamination of control
sample with a
trace amount of template DNA D. Background signal from gel uorescence or inadequa
te removal of
unbound probe Molecular/Evaluate sources of error/PCR/3 24. How can a false-nega
tive PCR test
caused by the presence of an inhibitor of the reaction in a patients sample be de
tected? A.
Using a positive control B. Using an internal control C. Performing each test in
duplicate D.
Performing serial dilutions of the sample Molecular/Evaluate sources of error/PC
R/3 25. All of
the following are requirements for reducing contamination in DNA ampli cation meth
ods except: A.
Use of aerosol barrier pipette tips when transferring samples or reaction produc
ts B. Preparation
of reagents in a dead air box or biological cabinet C. A separate area for perfo
rming
preampli cation, postampli cation, and detection steps D. Pretreatment of samples wi
th
high-intensity ultraviolet light Molecular/Apply knowledge to identify sources o
f error/PCR/2 504
Chapter 8 | Molecular Diagnostics Answers to Questions 2325 23. C PCR and other
methods of DNA
ampli cation have a great potential for error caused by contamination of sample or
reagents with
template DNA. This can derive from other samples, positive controls, or amplicon
s from preceding
samples, but the most common source of contamination is by amplicons. Each run m
ust contain a
negative (as well as positive) control. The negative control contains all PCR re
agents except the
template DNA and should produce no detectable amplicons. However, PCR reactions
that detect
product by enzymatic, uorescent, or chemiluminescent methods instead of gel or ca
pillary
electrophoresis will generate a signal for the negative control. This signal sho
uld be comparable
to that for a substrate blank. Signals above a predetermined cuto point will inva
lidate the
test. 24. B Some samples may contain inhibitors of the PCR reaction. For examp
le, a sample in
which DNA was extracted using a cation chelator to prevent DNA degradation may b
e contaminated
with residual chelating reagent. Since DNA polymerase requires Mg +2 , this will
inhibit amplicon
production. An internal control can identify this problem. The sample is mixed w
ith the internal
control, a DNA molecule with the same primer binding region. The internal contro
l should always
be ampli ed, but the product can be distinguished from the target amplicons. Failu
re of a sample
to demonstrate the internal control product in an assay where positive and negat
ive control
reactions are valid indicates the presence of an inhibitor in the sample. 25.
D The laboratory
area where manual DNA amplification methods are performed should be organized so

that work flow

moves from preamplification to amplification and detection. In addition to stand
ard precautions,
cotton-plugged tips are used to prevent aerosol contamination of samples. As few
as 10 copies of
the template introduced by accident are likely to cause a false-positive reactio
n. Ultraviolet
light causes cross-linking of thymine bases in dsDNA, which prevents replication
. This has been
used as a post-PCR method of reducing contamination. 2828_Ch08_495-522 06/08/12
11:26 AM Page
504 26. Which method has been used successfully to reduce contamination in the p
reampli cation
stage of PCR? A. Substitution of deoxyuridine triphosphate for deoxythymidine tr
iphosphate in the
master mix B. Use of low-molecular-size primers C. Use of a denaturation tempera
ture above 95C
D. Pretreatment of samples with antisense RNA Molecular/Apply knowledge to ident
ify sources of
error/PCR/2 27. How are PCR methods adapted to yield quantitative data? A. By co
mparing PCR
product to an internal standard B. By applying a conversion factor to the PCR si
gnal that
converts it to copies per milliliter C. By determining the mass of PCR product u
sing ultraviolet
spectrophotometry D. By making serial dilutions of the sample Molecular/Apply kn
owledge of
special procedures/ PCR/2 28. A PCR analysis of a vaginal sample for Chlamydia t
rachomatis gives
a negative result (optical density of biotinylated reaction product below the cu
to point). Te
internal control result is also below the cuto . Positive and negative controls pr
oduced
acceptable results. What action should be taken? A. Te test should be reported a
s negative B. Te
sample should be diluted and the test repeated C. Te result should not be report
ed and the sample
should be repeated D. A preliminary result of negative should be reported but sh
ould be con rmed
by further testing using a di erent method of analysis Molecular/Apply knowledge t
o identify
sources of error/PCR/3 8.1 | Molecular Methods 505 Answers to Questions 2628 26
. A One
method of preventing PCR products from previous assays from contaminating a samp
le or test in
progress is to substitute the RNA base uracil for thymine in the PCR products. T
aq polymerase
will insert deoxyuridine phosphate instead of deoxythymidine phosphate during th
e primer
extension phase of each cycle. The enzyme uracil N-glycosylase is added to the m
aster mix along
with deoxyuridine triphosphate, which replaces deoxythymidine triphosphate. Prio
r to the rst
denaturation, the enzyme hydrolyzes the bond between uracil and deoxyribose. Whe
n the sample is
heated to separate the strands, the enzyme becomes denatured and any contaminati
ng PCR products
fragment into small oligonucleotides that cannot be replicated. 27. A Quantita
tive PCR can be
used to measure viral load and gene expression. However, the PCR process is asso

ciated with a
high run-to-run variance that can be reduced by simultaneously measuring the PCR
products of an
internal standard of known concentration (molecules per PCR). For example, in co
mpetitive PCR, a
DNA template having the same primer binding region but that is shorter than the
native DNA is
added to each sample. The signal used to determine concentration is derived from
the ratio of the
native DNA product to the competitive template product. This value is compared t
o the signal
generated by adding a known amount of DNA from a reference gene (internal standa
rd) and is
reported as copies per milliliter or copies per molecule of reference gene. Some
quantitative PCR
methods use external standards. However, an advantage of the internal standard m
ethod is that the
calibrator is subject to the same in uences as the target DNA by being mixed with
DNA from the
patients sample. 28. C The internal control in PCR is an oligonucleotide sequen
ce di erent
from that of the target but that binds the same primers. Its product is detected
using a di erent
probe than is used for the target sequence. If the internal control is not ampli e
d, this
indicates an invalid test. Causes include the presence of a PCR inhibitor, denat
uration of the
polymerase, hybridization failure, or error in the detection system (e.g., impro
per pH preventing
enzyme-conjugated streptavidin from acting on the substrate). The assay of this
sample must be
repeated. 2828_Ch08_495-522 06/08/12 11:26 AM Page 505 29. In real-time PCR a
nalysis, the
absolute concentration of PCR product is determined by plotting which two values
? A. Fluorescent
intensity versus melting temperature B. Te threshold cycle versus concentration
C. Te well factor
versus threshold cycle D. Te melting temperature versus concentration Molecular/
Apply principles
of special procedures/PCR/2 30. In real-time PCR, quantitation can be done witho
ut standards of
known copy number. Relative quantitation (estimated concentration) is possible b
ecause: A. Each
cycle generates a twofold increase in product B. Each cycle threshold represents
a 10-fold
increase in product C. Te uorescence of two samples can be compared directly D. C
oncentration is
proportional to uorescence at the endpoint of the PCR reaction Molecular/Apply pr
inciples of
special procedures/PCR/3 31. Which real-time PCR parameter can be used to detect
the presence of
a contaminant? A. Treshold cycle B. Baseline C. Melting temperature D. Relative u
orescent
intensity Molecular/Apply principles of special procedures/PCR/2 506 Chapter 8 |
Molecular
Diagnostics Answers to Questions 2931 29. B The threshold cycle (Ct) is the poi
nt of maximum
curvature in the signal plot of uorescence versus PCR cycle. It is the number of
cycles needed
before PCR product is detected. The Ct is determined for each DNA standard and i

s plotted against
the log of the concentration. This gives a straight line with a negative slope b
ecause the Ct is
inversely related to the concentration of the PCR product. A standard curve is a
lso required for
a reference gene. The reference gene is one that will display the same ampli catio
n from sample
to sample. The signal for the target is divided by the reference signal to corre
ct the
measurement for error caused by variable rates of target ampli cation. This occurs
because the
samples contain variable amounts of DNA to start with. 30. A Concentration is
exponentially
related to uorescence at the start of the PCR reaction, but beyond the early expo
nential phase,
the relationship does not hold. The cycle threshold is in the exponential phase
of ampli cation,
which is why the Ct is used for quanti cation. Since in theory, each cycle doubles
the amount of
PCR product, two samples that di er in Ct by four cycles di er in PCR product by 16fold. However
this assumes 100% e ciency in the PCR reaction and does not take into account di ere
nces in the
amount of starting material. A commonly used formula to estimate PCR product is
the CT metho.
The sampe PCR prouct is normaize by subtractin the PCR prouct of a referen
ce ene (such as
actin). In aition, a contro ce is aso measure an its prouct is subtract
e from the test
sampe after subtractin the sina for the same reference ene. Reative concen
tration = 2 -CT
, where the CT = Ct sampe minus Ct contro. 31. C In rea-time PCR, the metin
temperature (Tm) correspons to the temperature at which haf of the DNA prouct
separates into
sine strans. When the neative rst erivative (-F/T) is potte aainst temperat
ure, the
metin peak for the PCR prouct is prouce. When more than a sine metin pe
ak occurs, there
is more than a sine PCR prouct. Thus, metin temperature anaysis can ienti
fy situations
where an unexpecte prouct or a contaminant may be present. 2828_Ch08_495-522
06/08/12 11:26
AM Pae 506 32. In rea-time PCR, what vaue is neee in orer to etermine th
e thresho? A.
Backroun sina B. Metin temperature C. Maximum uorescence D. Tresho cyce
Moecuar/Appy
principes of specia proceures/PCR/2 33. In rea-time PCR, which of the foow
in methos is
not base on usin a probe? A. TaqMan B. Moecuar beacon C. Scorpion D. SYBR r
een
Moecuar/Appy principes of specia proceures/PCR/2 34. Which statement accur
atey escribes
the process of uorescent in situ hybriization (FISH)? A. Hybriization is perfor
me on DNA
extracte from ces B. Hybriization is performe irecty on intact chromosome
s C.
Hybriization probes are attache to histones associate with the chromosomes D.
Hybriization
occurs by attachment to the probe ony at the centromere Moecuar/Appy princip
es of specia

proceures/ FISH/1 8.1 | Moecuar Methos 507 Answers to Questions 3234 32.
A In rea-time
PCR, the uorescence of the reporter probe is proportiona to the concentration of
PCR proucts.
For quantitation of PCR proucts, a we factor an backroun uorescence must be
etermine.
We factor vaues are anaoous to cuvette banks. They are use to correct the
measurements
from each we so that the same concentration of uorescent ye ives the same si
na intensity
rearess of the we. The thresho is the owest sina that inicates the pr
esence of
prouct. It can be cacuate manuay from a rea-time ampi cation curve by nin
the averae
stanar eviation of the uorescent sina (RFU) from cyces 210. This is mutipi
e by 10 to
ive the thresho vaue in RFUs. 33. D The rst three methos are probe-base P
CR, whie SYBR
reen is not. SYBR reen is an intercaatin ye that uoresces when boun to sDN
A. Therefore,
it can be use to quantify any PCR prouct, but wi aso uoresce with primer im
ers that may
form in the PCR master mix. This can cause resuts to be fasey eevate. FRET
(Frster or
uorescence resonance enery transfer) probes work by transfer of enery from one
moecue to
another. One exampe of FRET uses a uorescent moecue an a quencher moecue, w
hichwhen not
boun to the tempateinteract, resutin in no uorescence. Binin of the primer t
o the taret
causes separation of the two moecues, resutin in excitation of the uorescent
ye by the
iht source. 34. B FISH is use to etect abnormaities of chromosomes in ce
s an tissues by
faciitatin the irect attachment of a uorescent-abee oionuceotie probe o
r probes to the
chromosome. Hybriization of the oionuceotie probe requires treatment of the
ces with
proteinase K an other aents such as nonionic eterent to increase permeabiit
y.
Prehybriization may be require to ecrease backroun uorescence. Denaturation
requires
controe temperatures at or near the metin point an the aition of a hybri
ization
soution. This usuay contains formamie, soium chorie an soium citrate, a
n EDTA to weaken
the hyroen bons of the sDNA taret. Hybriization of the uorescent-abee pr
obe(s) to the
chromosoma DNA aso requires controe temperature incubation. After incubatin
 with the ces,
any unattache probe is remove by washin, an the ces are examine with a uor
escent
microscope containin the appropriate ters to transmit the excite iht from th
e speci c
probe(s). 2828_Ch08_495-522 06/08/12 11:26 AM Pae 507 35. Which type of spec
imen wou be
unsuitabe for FISH anaysis? A. Para n-embee tissue B. Ces with chromosomes
in metaphase C.
Ces with chromosomes in interphase D. A ce suspension containin materna an
 feta boo

Moecuar/Appy knowee to reconize sources of error/FISH/2 36. FISH can ist

inuish each of
the foowin chromosoma abnormaities except: A. Aneupoiy B. Transocation C
. Deetion D.
Trinuceotie repeats Moecuar/Appy principes of specia proceures/ FISH/1 3
7. In microarray
an macroarray anaysis, which moecues are abee? A. Te immobiize DNA moe
cues B. Te
sampe DNA C. Both taret an sampe moecues D. Te substrate matrix Moecuar/
Appy principes
of specia proceures/DNA arrays/1 508 Chapter 8 | Moecuar Dianostics Answers
to Questions
3537 35. D FISH can be use with amost any type of ce preparation, incuin
frozen
sections, formain fixe tissues, embee tissues, an ce suspensions such as
those erive
from amniotic fui or chorionic vius sampin provie they are pure. Ces i
n suspension can
be roppe onto ass sies or concentrate usin a cytocentrifue before proce
ssin. However, a
mixture of ces from ifferent iniviuas is inappropriate because the probe c
annot istinuish
between sources such as feta an materna ces. 36. D FISH can etect conit
ions that are
associate with structura chromosoma abnormaities an an abnorma number of c
hromosomes
(aneupoiy). A screenin test for aneupoiy empoys probes abee with iffer
ent fuorescent
yes that simutaneousy etect trisomy 21, 18, an 13 an the X an Y chromosom
es. Deetions
cause the absence of a fuorescent sina when expecte, an microeetions such
as those that
occur on the short arm of chromosome 5 in cri u chat synrome can be etecte b
y FISH.
Transocations cause two ifferent FISH probes to bin to the same chromosome. S
uch probes are
use to ientify IH ene transocations such as t(11:14) in mutipe myeoma th
at are of
pronostic vaue. However, trinuceotie repeats, repetitive sequences of the sa
me three base
pairs, are not etecte by FISH. This is associate with fraie X synrome, myo
tonic ystrophy,
Huntintons isease, an other enetic iseases. PCR or Southern bottin are use
 for etection
of these repeats, epenin upon their number. 37. B An array is an oranize
arranement of
known moecues (either DNA or proteins for proteomic array anaysis). DNA array
s are use
primariy for stuyin ene expression an sine nuceotie poymorphisms. Comm
erciay prepare
arrays use short synthetic oionuceoties (1236 bases) of sine-strane DNA i
mmobiize onto
a substrate, usuay a ass or a siicon chip. These are usuay cae the tar
ets, an a
sine array can contain hunres to many thousans of tarets. The sampe DNA i
s usuay erive
by RT-PCR of test ces. This prouces sine-strane compementary DNA (cDNA)
representative of
active enes within the ces. These are abee with one or two uorescent yes a
n therefore

are usuay cae probes. However, some commercia systems refer to the immobi
ize (array) DNA
as the probe an the abee DNA as the taret. 2828_Ch08_495-522 06/08/12 11:
26 AM Pae 508
38. How can a of the mRNA within a sampe be ampi e to prepare microarray prob
es? A. A
speci c primer for each mRNA must be synthesize B. A primer is mae to the poyA
tai of mRNA C.
Nonspeci c attachment of T7 poymerase occurs when the ces are treate with ete
rent D. Ranom
primer sets are use uner ow strinency conitions Moecuar/Appy principes
of specia
proceures/DNA arrays/1 39. What is the i erence between a microarray an a macro
array DNA
assay? A. Te number of tarets is arer on a macroarray B. Te moecuar size of
each taret is
arer on a macroarray C. Te amount of each taret is arer on a macroarray D.
Te substrate use
for a macroarray is i erent from a microarray Moecuar/Appy principes of speci
a
proceures/DNA arrays/2 40. Protein microarray anaysis requires the use of whic
h of the
foowin techniques to enerate protein pro e ata? A. Eectrophoresis B. Mass s
pectroscopy C.
Tin-ayer chromatoraphy D. Gas chromatoraphy Moecuar/Appy principes of spe
cia
proceures/DNA arrays/1 8.1 | Moecuar Methos 509 Answers to Questions 3840 3
8. B When
messener RNA is transcribe, the enzyme poyA poymerase as 50 to 250 aenine
bases to the 3
en of the moecue. This poyA tai protects the mRNA from enzymatic eraatio
n an promotes
its binin to the ribosome. Since amost a eukaryotic mRNA has a poyA tai,
oio T primers
are use to initiate reverse transcription, makin cDNA copies of the mRNA, an
oio A primers
are use to initiate ampi cation of the cDNA prouct. 39. C The i erence between
a micro- an
a macroarray assay is that the amount of DNA printe onto the substrate is arer
in a
macroarray assay, necessitatin a arer spot. A microarray uses ess than 200 L
of DNA and
allows a larger number of targets to be applied. Commercially available microarr
ays are available
that contain over 250,000 oligonucleotide spots. Short oligonucleotide targets c
an be synthesized
on the substrate or applied by photolithography, inkjet spraying, or manually wi
th print plates
and tips that can be purchased. 40. B Protein microarray analysis uses immobil
ized bait to
isolate proteins from serum, body fluids, or cell lysates. The array may contain
antibodies,
antigens, receptor molecules, or protein binding ligands (e.g., drugs). The prot
eins can be
identified by fluorescent- or enzyme-labeled probes and can be analyzed by mass
spectroscopy to
produce a fingerprint of the proteins isolated on the array. This can be compare
d to a learning
set, a combination of proteins that is associated with a specific disease such a
s ovarian cancer.

If the pattern falls within specified parameters determined by the learning set,
then cancer is
identified. Analysis is based upon determining the time required for each protei
n to move through
a mass filter. Two related instrument principles are used, matrix-assisted laser
desorption
ionizationtime of flight mass spectrometry (MALDI-TOF), and surface enhanced lase
r desorption
ionizationtime of flight mass spectrometry (SELDI-TOF). Both use a laser to ioniz
e the proteins
and a mass filter to separate them based upon their mass/charge ratio. Since pro
tein expression
of cancer cells is altered before morphology changes, the analysis of protein pa
tterns of serum
and suspected cells provides an opportunity for diagnosis at an early stage of p
rogression or at
a premalignant state. 2828_Ch08_495-522 06/08/12 11:26 AM Page 509 510 8.2 Mo
lecular
Diagnostics 1. Which method is most useful for con rmation that a culture isolate
is Group B
streptococcus? A. Southern blotting B. Polymerase chain reaction C. Direct hybri
dization D. Probe
capture assay Molecular/Apply principles of special procedures/DNA hybridization
/1 2. In situ
hybridization (ISH) tests for human papilloma virus (HPV) using cervical smears
di er from
immunochemical staining of tissue in which regard? A. ISH has lower analytical s
ensitivity B. ISH
has lower analytical speci city C. ISH di erentiates subtypes more easily D. ISH di er
entiates
cervical neoplasia from genital warts Molecular/Apply principles of special proc
edures/ISH/2
Answers to Questions 12 1. C In direct hybridization, a specific labeled probe
reacts directly
with the sample. Since a colony or pure broth culture of a primary isolate repre
sents the progeny
of a single bacterium, there is no need for the use of Southern blotting. The qu
antity of DNA
available for testing is sufficient, so that amplification methods such as PCR o
r probe capture
hybridization are unnecessary. The colony or broth isolate is lysed, and a hybri
dization solution
is used to promote denaturation. The sample is heated above the melting temperat
ure, and a DNA
probe is added that hybridizes with bacterial DNA or ribosomal RNA. The probe is
conjugated to a
chemiluminescent label. A reagent is added to neutralize the unbound probe, and
H 2 O 2 and NaOH
are added to cause chemiluminescence. The signal is read in a luminometer and co
mpared to a
cutoff value. Such tests take approximately 1 hour to perform and most are 99%100
% sensitive and
specific. 2. C In situ hybridization using probes that anneal with specific su
btypes of HPV are
able to distinguish the subtype of virus most commonly responsible for sexually
transmitted warts
and associated with neoplasia. Positive reactions can be detected by light micro
scopy using
probes conjugated to biotin. After the hybridization reaction, the slides are wa
shed to remove

the unbound probe, and streptavidin conjugated to horseradish peroxidase is adde

d. Addition of
hydrogen peroxide and aminoethylcarbazole results in the formation of a reddishbrown
precipitate. Sensitivity is approximately 88% and specificity 99%, which is high
er than for
histochemical immunoperoxidase staining. HPV is present in normal-appearing cell
s as well as
those demonstrating intraepithelial neoplastic lesions. However, persons testing
positive for HPV
types associated with cervical cancer such as type 16 are at higher risk for the
disease.
2828_Ch08_495-522 06/08/12 11:26 AM Page 510 3. Which method is most sensitiv
e for detection
of viral meningitis? A. Viral culture B. CSF WBC count C. Speci c antibody testing
of CSF for
viral antigens D. Real-time RT-PCR Molecular/Apply principles of special laborat
ory
procedures/Virus testing/2 4. What gene must be ampli ed in PCR to di erentiate
methicillin-resistant Staphylococcus aureus from methicillin-resistant coagulase
-negative
Staphylococcus? A. orfX B. mecA C. VanA D. iles-2 Molecular/Apply knowledge of f
undamental
biological characteristics/MRSA/2 5. Which statement best describes real-time PC
R testing for
Mycobacterium tuberculosis? A. Te test is positive only in cases of smear-positi
ve and
culture-positive infections B. Te test has a sensitivity of > 99% on all specime
n types when
compared to culture C. Te test can detect 85%90% of smear-negative, culture-posit
ive infections
D. Te test sensitivity is near 100% but speci city is approximately 80% Molecular/
Apply
principles of special laboratory procedures/Tuberculosis testing/2 6. How can ce
ll proliferation
be explained by the BCR/ABL gene rearrangement that occurs in the 9:22 transloca
tion that causes
the Ph 1 chromosome of CML? A. It causes underexpression of p53 B. A hybrid prot
ein is made that
up-regulates the cell cycle C. Translocation induces a point mutation in the ABL
oncogene D. ABL
activates p23 Molecular/Apply knowledge of fundamental biological characteristic
s/CML/2 8.2 |
Molecular Diagnostics 511 Answers to Questions 36 3. D Enterovirus is the mos
t common cause
of viral meningitis, accounting for more than 85% of cases. Viral culture is pos
itive in 50%70%,
while the sensitivity of real-time PCR is above 95%. Enterovirus strains show si
gni cant homology
at the 5 end, making it possible to detect several di erent enterovirus serotypes u
sing a single
primer pair. The PCR reaction is not inhibited by antiviral therapy and can be d
one in hours
versus days for viral culture. 4. A The mecA gene codes for resistance to meth
icillin in S.
aureus and coagulase-negative Staphylococcus. In order to di erentiate mecA-positi
ve S. aureus
from coagulase-negative Staphylococcus such as Staphylococcus epidermidis that a
re often present
together in clinical specimens, the orfX gene speci c for S. aureus is also ampli ed

by multiplex
PCR. A molecular beacon binds to the amplicon, causing uorescence in real-time PC
R, indicating
the presence of both mecA and orfX products. The VanA gene codes for vancomycin
resistance but is
not found in S. aureus. The iles-2 gene codes for resistance to mupirocin in S.
aureus. 5. C
PCR detection is dependent on having at least a minimal number of organisms pres
ent in the
specimen, and sensitivity is 90% or lower when the specimen is AFB smear negativ
e but culture
positive. Specificity of PCR is approximately 98%. 6. B Cancers are caused by
genetic damage to
cells that disrupt the cell cycle. Cell proliferation can be induced by under-ex
pression of genes
with tumor suppressor properties (e.g., p53) or overexpression of oncogenes (e.g
., p21) that
increases cell signaling, transcription, and mitosis. In CML, translocation of t
he ABL oncogene
from chromosome 9 to the 3 end of the BCR (breakpoint cluster region or area wher
e recombination
occurs) of chromosome 22 results in production of a hybrid BCR/ABL mRNA. This pr
oduces a chimeric
protein with increased tyrosine kinase activity, causing the cell to enter G1. F
ISH can be used
to identify cells with the BCR/ABL translocation. DNA probes speci c for ABL and B
CR are labeled
with two di erent uorescent dyes. In normal cells, each dye produces two colored sp
ots (e.g.,
red and green) on chromosome pairs 9 and 22. If a BCR/ABL translocation is prese
nt, the probes
bind next to each other, producing a spot of a di erent color (e.g., yellow). 2828
_Ch08_495-522
06/08/12 11:26 AM Page 511 7. Which statement accurately describes the clinica
l utility of
translocation testing in leukemia? A. Relapse is predicted by any new translocat
ion occurring
after treatment B. Speci c translocations associated with a type of leukemia will
occur in all
cases C. Translocation products for each leukemia subtype are always the same D.
Translocation is
a sensitive way to identify surviving leukemic cells following treatment Molecul
ar/Correlate
clinical and laboratory data/ Translocation/2 8. Which is the most sensitive met
hod of minimal
residual disease testing in chronic myelogenous leukemia? A. Karyotyping analysi
s B. FISH C. Flow
cytometry D. RT-PCR Molecular/Apply principles of special laboratory procedures/
CML/2 9. How can
cell proliferation be explained by the BCL 2 translocation t(14;18) that occurs
in up to 90% of
persons with follicular B-cell lymphoma? A. p53 is underexpressed B. A hybrid pr
otein is made
that up-regulates the cell cycle C. Transcription of the BCL 2 oncogene is incre
ased by the
translocation D. Te BCL 2 gene joins with the p21 gene, making it inactive Molec
ular/Apply
knowledge of fundamental biological characteristics/Translocation/2 512 Chapter
8 | Molecular
Diagnostics Answers to Questions 79 7. D Some translocations occurring after tr

eatment are
predictive of relapse. For example, a second translocation in a person with Phil
adelphia
chromosome-positive CML occurs in the majority of persons preceding blast crisis
. However, other
translocations, such as the 15:22 translocation associated with M3 AML are seen
during remission
and are not associated with relapse. Some translocations occur with 100% or near
100% frequency,
such as 9:22 in CML and 15:17 in M3 AML. However, others occur only in some a ecte
d persons.
Translocations associated with a type of leukemia are not identical in all cases
. For example,
the 9:22 translocation associated with CML can give rise to transcripts of di eren
t length.
RT-PCR can detect as few as 1 per 10 5 cells containing the translocation, makin
g translocations
useful markers for detecting cells that have escaped destruction following treat
ment. 8. D
RT-PCR measures the mRNA transcript of BCR/ABL using primers to the p210 and p23
0 transcripts.
The procedure can be done using real-time PCR with a sensitivity of 1:100,000 ce
lls far more
sensitive than karyotyping and FISH that have sensitivities of around 1:100 and
1:1,000 cells,
respectively. Flow cytometry can detect 1 malignant cell per 10,000 nonmalignant
cells, but a
panel of antibodies is required that can di erentiate malignant from normal cells.
RT-PCR can
also be used to evaluate the response to treatment. A 3-log decrease in copy num
ber indicates
e ective treatment. 9. C In follicular B-cell lymphoma, relocation of the BCL on
cogene next to
the gene for the immunoglobulin heavy chain (IgH) occurs. The BCL oncogene produ
ct is a protein
that inhibits apoptosis. When the cell transcribes the IgH gene, it produces the
BCL 2 protein as
well, which protects the cell from apoptosis. This translocation occurs in all c
ases of
follicular B-cell lymphoma and can be identi ed using FISH with uorescent-labeled D
NA probes to
IgH and BCL 2 genes. 2828_Ch08_495-522 06/08/12 11:26 AM Page 512 10. Which m
echanism is
responsible for retinoblastoma? A. Mutation of a tumor suppressor gene B. Mutati
on of a tyrosine
kinase gene C. Activation of an oncogene D. Deletion of a gene encoding a GTPase
activator
Molecular/Apply knowledge of fundamental biological characteristics/Malignancy/2
11. Which
oncogene is involved in the etiology of Burkitts lymphoma? A. ABL B. Myc C. Ras D
. HER/neu
Molecular/Apply knowledge of fundamental biological characteristics/Malignancy/2
12. Te majority
of cases of Duchennes muscular dystrophy are caused by which type of genetic dama
ge? A. Point
mutation B. Insertion C. Deletion D. Trinucleotide repeats Molecular/Apply knowl
edge of
fundamental biological characteristics/Muscular dystrophy/2 13. How are cases of
Duchennes
muscular dystrophy not detected by PCR usually con rmed? A. DNA sequencing B. Link

age analysis C.
Macroarray analysis D. Dystrophin protein staining Molecular/Apply knowledge of
special
procedures/ Muscular dystrophy/2 8.2 | Molecular Diagnostics 513 Answers to Qu
estions 1013 10.
A A mutation or deletion of a tumor suppressor gene such as p53, p14, or RB1 (
the
retinoblastoma gene) causes loss of a protein that inhibits mitosis and is assoc
iated with an
increased risk of malignancy. Mutations of p53 occur frequently in several cance
rs, including
lung, breast, liver, and colon cancer. RB1 mutations are associated primarily wi
th
retinoblastoma, a tumor of the retina occurring in young children. Although they
may be
inherited, mutations usually arise in somatic cells. Mutations that produce more
active proteins
with tyrosine kinase activity such as HER-2/neu are oncogenic because they stimu
late the signal
transduction pathway for mitosis. Likewise, a deletion of a GTPase activator is
also oncogenic,
since it permits higher levels of intracellular GTP, which is involved in the sa
me pathway. 11.
B Burkitts lymphoma is associated with a translocation involving the long arm of
chromosome (8
on which the c-myc gene is located) with one of three immunoglobulin genes. The
translocation
most often involves the IgH gene on chromosome 14. The result is a hybrid mRNA t
hat produces the
c-myc protein whenever the immunoglobulin gene is transcribed. The c-myc protein
is an activator
of genes involved in mitosis. 12. C The dystrophin gene is approximately 2.5 m
illion bases and
has extensive sites at which both large and small deletions, insertions, and poi
nt mutations can
occur. Approximately 60% of cases are caused by deletions that can be detected b
y the absence of
one or more PCR products produced by the normal gene. The remaining 40% can be c
aused by
microdeletions, point mutations, or insertions that are not usually detected by
available primer
sets. 13. B The majority of gene deletions associated with Duchennes muscular d
ystrophy is
detected by PCR using multiple primers (multiplex PCR). The others are usually d
etected by
indirect gene analysis. An alternative to testing for these mutations is linkage
analysis. This
process follows other genetic markers located near the disease gene so that cros
sing over is
improbable. Linkage analysis for an X-linked disease or an autosomal recessive d
isease such as
cystic brosis requires DNA from at least one a ected family member. However, linkag
e analysis
for an autosomal dominant disease such as Huntingtons disease requires DNA from a
t least two
family members. Next generation gene sequencing (several technologies that are a
lternatives to
Sanger sequencing) have been used to identify deletions of the dystrophin gene t
hat cannot be
detected by PCR. 2828_Ch08_495-522 06/08/12 11:26 AM Page 513 14. Inheritance

of BRCA1 or
BRCA2 mutations increases the risk of breast and ovarian cancer by which mechani
sm? A. Oncogene
production B. Transcription signaling by the mutant protein C. De cient tumor supp
ressor function
D. Chimeric protein production Molecular/Apply knowledge of fundamental biologic
al
characteristics/BRCA/2 15. Polymorphisms of the cytochrome p450 genes are import
ant in
identifying which condition? A. Poor drug metabolism B. Risk for primary biliary
cirrhosis C.
Progression of hepatitis C to hepatic cirrhosis D. Parentage in cases where HLA
results are
inconclusive Molecular/Correlate clinical and laboratory data/ Genomics/2 16. Ap
proximately how
may mutations have been identi ed in the gene coding for the cystic brosis trans me
mbrane
conductor regulator protein (CFTR)? A. 10 B. 100 C. 1,000 D. 10,000 Molecular/Ap
ply knowledge of
fundamental biological characteristics/CF/2 514 Chapter 8 | Molecular Diagnostic
s Answers to
Questions 1416 14. C BRCA1 and BRCA2 are mutations of genes that produce tumo
r suppressor
proteins. These down-regulate cell signaling events that lead to cell division.
The mutations are
inherited as autosomal dominant traits and are associated with > 85% lifetime ri
sk at age 70 of
developing breast cancer if one is found in a person with a positive family hist
ory. 15. A
Pharmacogenetics (sometimes called pharmacogenomics) is the study of the role in
heritance plays
in the metabolism of drugs. Individual di erences in drug metabolism can be attrib
uted in part to
polymorphisms in the genes coding for enzymes comprising the cytochrome p450 sys
tem. Of the more
than 100 CYP genes, seven are principally involved in drug metabolism. Of these,
CYP2D6, CYP2C9,
CYP2C19, and CYP2A6 are polymorphic genes that account for metabolism of approxi
mately 40% of
drugs. Phenotypical expression varies with the locus involved. For the CYP2C19 l
ocus that
metabolizes several dozen drugsincluding some tricyclic antidepressants, antiepil
eptics, and
acid re ux inhibitorspersons who inherit one copy of the wild-type gene metabolize
normally,
whereas homozygotes or double heterozygotes for any of the seven polymorphisms m
etabolize poorly.
For CYP2D6which metabolizes tricyclic antidepressants, antipsychotics, antihypert
ensives, and
several other drugsheterozygotes with one wild-type gene have intermediate and th
ose with no
wild-type gene have poor drug metabolism. Persons with poor metabolic e ciency are
at a greater
risk of drug toxicity. On the other hand, their response to some antibiotics may
be more
positive. 16. C The CFTR protein regulates the movement of chloride across the
cell membrane,
and a defect in this protein results in cystic fibrosis (CF). The CFTR gene is l
ocated on the
long arm of chromosome 7 and consists of 27 exons spread over 230,000 bases. The

most common
mutation is a deletion of three base pairs that code for phenylalanine at positi
on 508 of the
protein, F508. This mutation accounts for 70% of CF enes in Whites. It causes a
severe form of
CF invovin pancreatic insufficiency. No sine test can etect a possibe CF
carriers an a
core pane consistin of 25 probes is recommene for initia screenin. The cor
e pane is use
to screen for carriers of the CF ene an can etect more than 85% of CF mutatio
ns. Since two
mutations are require to prouce CF, the core pane can etect approximatey 80
% of CF.
2828_Ch08_495-522 06/08/12 11:26 AM Pae 514 17. Which statement about CF is
accurate? A. A
sweat chorie test is abnorma in a forms of CF B. Immunoreactive trypsin is
e cient in a
persons with CF C. Some CF mutations can cause mae infertiity with no other sy
mptoms D. Te CF
enotype aways preicts the severity of the isease Moecuar/Correate cinica
 an aboratory
ata/CF/3 18. Which of the foowin aees has the hihest frequency in the e
nera popuation?
A. F508 (cystic brosis) B. Factor V-Leien (hereitary thrombophiia) C. Prothromb
in G20210A
(hereitary thrombophiia) D. Methyene tetrahyrofoate reuctase mutation C677
T homocysteinemia
Moecuar/Correate cinica an aboratory ata/ Mutations/2 8.2 | Moecuar Di
anostics 515
Answers to Questions 1718 17. C Serum immunoreactive trypsin is the recommene
screenin test
for CF, but pancreatic insu ciency is not foun in about 15% of CF cases. An abnor
ma resut is
con rme by sweat chorie testin. Some infants may be too youn for accurate swe
at testin, an
some mi forms of CF may ive ineterminate resuts. DNA testin can be use in
these cases. The
CF enotype is not preictive of phenotype in most cases (an exception bein F508
, which is
amost aways associate with pancreatic isease). CF mutations are responsibe
for about 75% of
conenita biatera absence of the vas eferens. A ecte persons have at east on
e abnorma CF
ene. Other than infertiity, they are asymptomatic an may or may not have a sw
eat chorie
eve above 65 mmo/L. 18. D Methyene tetrahyrofoate reuctase (MTHFR) muta
tion is a point
mutation in which thymiine repaces cytosine at nuceotie 677 in the ene. Thi
s resuts in a
coon that substitutes vaine for aanine an resuts in an enzyme that is more
heat sensitive.
The enzyme converts 5,10 methyenetetrahyrofoate to 5-methytetrahyrofoate (
foate). The
methy roup from the atter is transferre to homocysteine, formin methionine.
In homozyotes
(TT) with ess than optima ietary foate intake, e ciency of the enzyme reuces
the
avaiabiity of 5-methytetrahyrofoate, causin the serum homocysteine to be i
ncrease. Such
persons have an approximatey threefo increase risk of coronary artery iseas

e. In the enera
popuation, the C677T aee of MTHFR has a frequency of 30%. A of the aees
iste are of
su cienty hih frequency to warrant screenin of at-risk popuations. The prothro
mbin G20210A
aee has a frequency of approximatey 2%, factor V-Leien 5%, an F508 approxim
atey 3% (in
Whites). Both factor V-Leien an the prothrombin G20210A mutation resut in pro
teins that
increase the risk of thrombosis. The point mutation in factor V-Leien resuts i
n a protein that
is resistant to inactivation by protein C. The base substitution in G20210A (ua
nine to aenine
at position 20210) resuts in increase transcription of the ene an overprouc
tion of
prothrombin. 2828_Ch08_495-522 06/08/12 11:26 AM Pae 515 19. HLA typin can
be one by which
moecuar metho? A. PCR anaysis usin 96 we microtrays with aee or roups
speci c primers
in each B. Restriction frament enth poymorphism testin C. Direct hybriizat
ion with WBCs on
a periphera boo m D. Fuorescent in situ hybriization reactions with periphe
ra boo
ymphocytes Moecuar/Appy knowee of specia proceures/ HLA/2 20. Which sta
tement best
escribes the reationship between HLA DNA typin an serooica hapotypes? A.
One or two bans
are seen for each ocus correatin to reactivity with a speci c antien or roup
of antiens B.
HLA aees cannot be reate to HLA antiens because antisera speci city is unre
ate to enetic
poymorphism C. A sine antiboy speci city aways correspons to a sine aee
D. Not a HLA
enes prouce antiens reconize by antiboies Moecuar/Appy knowee of spe
cia proceures/
HLA/2 21. Hihest-resoution HLA typin is neee for which of the foowin tra
nspants? A.
Heart B. Liver C. Kiney D. Bone marrow Moecuar/Correate cinica an aborat
ory ata/HLA/2
22. Which metho of DNA anaysis is use most often to etect the hemoobin S 
ene? A. FISH B.
PCR foowe by RFLP C. Cytoenetic anaysis of chromosome 11 D. Labee probe p
aintin of
chromosome 11 Moecuar/Appy knowee of specia proceures/ HLA/2 516 Chapter
8 | Moecuar
Dianostics Answers to Questions 1922 19. A The DNA is extracte from periphera
 boo
eukocytes, ae to the master mix, an an aiquot is transferre to each we
of a 96-we
pate. Each we contains a primer to a speci c base sequence of one aee or a
ee roup. Ge
eectrophoresis is performe after PCR to ientify those wes that contain amp
i e proucts.
Each we aso contains a primer to a secon nuceotie sequence, such as a rei
on of the rowth
hormone ene that serves as a PCR interna contro. Bans are staine with ethi
ium bromie an
can be visuaize by irect observation with a near utravioet iht source. 20
. A Antiboies
to HLA antiens reconize eterminants that may be share by severa poymorphis

ms. However, it
is possibe to correate primer speci cities to ene proucts that react with comm
ercia HLA
typin seras. For exampe, DR103 correates with the primer reconizin DRB1*010
3. On the other
han, aees DRB3*010101-10, DRB3*0101-14, an DRB3*030101-03 wi a react wi
th antisera to
DR52. 21. D Soi oran transpants require meium resoution of aees beon
in to HLA cass
I an cass II enes. Bone marrow transpants require hih-resoution typin. Th
is invoves
ientifyin which aeic roups are present by meium-resoution testin, then
sequencin of the
PCR proucts to etermine the exact aees present. 22. B The -lo in ene is
loc
ted ne
r
the end of the short
rm on chromosome 11
nd consists of three exons
nd two in
trons
constitutin 1,600
se p
irs. The su stitution of v
line for lut
mic
cid
t p
osition 6 of the
protein is the result of
sinle-point mut
tion
t position 6(A3) in exon 1, in
which GAG is
repl
ced y GTG. In hemolo in C, the s
me codon is mut
ted ut the su stitution
involves the
precedin
se
t the 5 end (GAG is ch
ned to AAG). The hemolo in S mut
tion
l
ters the
restriction site for MstII, preventin the enzyme from cuttin the DNA. This c
u
ses production of

fr
ment th
t is 200
se p
irs loner th
n seen for the norm
l -ene. Most com
monly, PCR is
used to
mplify
portion of the exon cont
inin the S mut
tion,
nd MstII is us
ed to diest the
PCR product. Heterozyotes produce one norm
l
nd one loner
nd, where
s homoz
yotes produce

sinle
nd th
t is 200
se p
irs loner th
n the norm
l
mplicon. Altern
tivel
y, PCR is
performed followed y Southern lottin, usin speci c olionucleotide pro es for
hemolo in A

nd S. 2828_Ch08_495-522 06/08/12 11:26 AM P
e 516 23. Which of the followin
 enetic
dise
ses is c
used y
n exp
nded trinucleotide repe
t? A. Pr
derWilli syndrome B
. Anelm
ns
syndrome C. Fr
ile X syndrome D. Willi
ms syndrome Molecul
r/Correl
te clinic
l

nd l
or
tory
d
t
/ Lenth polymorphism/2 24. Which is the most common method used for p
rent

e testin in the
United St
tes? A. Short t
ndem repe
t
n
lysis B. Nucle
r DNA sequencin C. HLA
DNA typin D.
Mitochondri
l DNA sequencin Molecul
r/Apply knowlede of speci
l procedures/ P

ternity testin/2
8.2 | Molecul
r Di
nostics 517 Answers to Questions 2324 23. C Pr
derWilli
n
d Anelm
ns
syndromes
re most often c
used y microdeletion,
nd Willi
ms syndrome is c
used
y

microdeletion in the ene codin for el
stin. Fr
ile X syndrome, Huntintons dis
e
se,
nd
myotonic dystrophy
re ex
mples of dise
ses c
used y
n exp
nsion of trinucleot
ide repe
ts.
Fr
ile X is so n
med ec
use when cells from
n
ffected individu
l
re culture
d in
fol
te-deficient medium, the lon
rm of the X chromosome
ppe
rs to h
ve
re

k c
used y
deficient st
inin. The Xq27 reion cont
ins
CGG t
ndem sequence th
t c
n repe

t up to 50 times
in norm
l individu
ls. In fr
ile X syndrome, the repe
t is extended
nd its len
th determines
whether the
ffected persons will show ment
l ret
rd
tion. Repe
ts of 50 to 230
times
re

ssoci
ted with
c
rrier (premut
tion) st
te. Durin meiosis in fem
les, the CG
G repe
t c
n
undero further exp
nsion. The pro
ility of this exp
nsion incre
ses with e
ch
ener
tion. As
the size of the repe
t incre
ses, so does the ch
nce th
t it will c
use methyl
t
ion of the
promoter for the FMR1 ene. The ene is needed for norm
l r
in function
nd its
underexpression
results in ment
l ret
rd
tion. Fem
les in whom the premut
tion exp
nds in size t
o
full mut
tion
tr
nsmit the syndrome to
ll of their m
le
nd h
lf of their fem
le offsprin. 2
4. A DNA
testin is the prim
ry method of determinin p
rent
e ec
use it is 100%
ccur

te in exclusion

nd > 99.9 %
ccur
te for inclusion of p
rent
e. DNA testin is
t le
st 10-fol
d more conclusive
th
n the com in
tion of HLA, lood roup,
nd protein m
rkers,
nd DNA s
mples c

n e tested
pren
t
lly, neon
t
lly,
nd postmortem. Testin is performed on nucle
r DNA ec

use mitochondri
l
DNA is inherited exclusively from the mother. R
ther th
n testin for
se seque
nce v
ri
tions
within enes, DNA is tested for lenth polymorphisms. These
re short
se seque
nces within the
introns th
t repe
t. The num er of times the sequence repe
ts is inherited
s

tr
it. Short
t
ndem repe
ts (STRs)
re olionucleotide sequences of four or ve
se p
irs. Usu

lly, 12 STR
loci
re
mpli ed y PCR usin speci c olionucleotide primers l
eled with uorescent
dyes. The
products
re detected y c
pill
ry electrophoresis. The size of the fr
ments
n
d their
uorescence determine which
lleles
re present. 2828_Ch08_495-522 06/08/12 11:2
6 AM P
e 517
25. In order to prove exclusion in DNA p
ternity testin, why must two enes e
identi ed th
t
must come from the ioloic
l f
ther
nd did not? A. A sinle exclusion c
n resu
lt from
l
or
tory error B. A sinle exclusion c
n result from erm line mut
tion within
one locus ein
tested C. Te ioloic
l f
ther m
y e
lood rel
tive to the
lleed f
ther D.
Te ioloic
l
mother m
y e di erent th
n the purported mother Molecul
r/Apply knowlede of spec
i
l procedures/
P
ternity testin/3 26. Heredit
ry hemochrom
tosis is the result of which type o
f mut
tion? A.
Nonsense mut
tion B. Microdeletion C. Tr
nsloc
tion D. Sinle nucleotide su stit
ution
Molecul
r/Correl
te clinic
l
nd l
or
tory d
t
/Point mut
tions/2 27. p21 is

GTP indin
protein produced y which oncoene? A. RET B. R
s C. HER-2/neu D. N-Myc Molecul

r/Apply knowlede
of fund
ment
l ioloic
l ch
r
cteristics/p21/2 28. Which of the followin th
l

ssemi
s c
n e
detected y PCR followed y lottin with
sinle speci c olionucleotide pro e?
A. -T
l
ssemi

B. Hemolo in S/-th
l
ssemi
C. -T
l
ssemi
D. Hemolo in S/-th
l
ssemi
Molecul
r/
Apply
knowlede of speci
l procedures/ T
l
ssemi
/2 29. Which method is used to determ
ine if the
hemolo in C ene is present in fet
l cells? A. Chromosome p
intin B. FISH C. R
estriction enzyme

n
lysis D. PCR followed y lottin with
speci c olionucleotide pro e Molecul

r/Apply
knowlede of speci
l procedures/ Hemolo in C/3 518 Ch
pter 8 | Molecul
r Di
no
stics Answers to
Questions 2529 25. B Two exclusions
re needed r
ther th
n one to e 100% cert

in of
nonp
ternity ec
use of the r
re possi ility of
mut
tion h
vin occurred in on
e of the loci
ein tested. Loci used for DNA testin
re su ciently polymorphic th
t the mothers
s
mple is
not necess
ry to determine p
ternity. Exclusion is
sed on the premise th
t the
ioloic
l
f
ther must h
ve
t le
st one
llele in common with the child
t e
ch locus. 26.
D Heredit
ry
hemochrom
tosis is
n
utosom
l recessive dise
se with
frequency
s hih
s 0.
5% in the White
popul
tion. The mut
tion occurs in the HFE ene on chromosome 6
nd involves
s
inle
se th
t
results in tyrosine su stitutin for cysteine in the HFE protein. The HFE protei
n down-reul
tes
iron
sorption. The mut
nt protein usu
lly incre
ses iron
sorption y
t le
s
t 100%.
Homozyous HFE mut
tion (C28Y)
ccounts for
pproxim
tely 80% of heredit
ry hemo
chrom
tosis. The
rem
inin c
ses
re c
used y
sinle-point mut
tion
t position 63 on the prot
ein (H63D), which
produces
milder incre
se in iron
sorption. Genotype is determined y PCR usi
n speci c
olionucleotide pro es to identify the products. 27. B All of the enes
re on
coenes. RAS is

roup of three enes th
t produce GTP- indin proteins, which
ctiv
te tr
nscrip
tion y
up-reul
tin the sin
l tr
nsduction p
thw
y of the cell. RAS is implic
ted in
lun, re
st,
colon,
nd other c
rcinom
s. It is me
sured y RT-PCR, which qu
nti es the
mount
of mRNA present
in the m
lin
nt cells. 28. A -Th
l
ssemi
c
rriers h
ve
full or p
rti
l dele
tion of one or
two of their four lo in enes. Genotypin c
n determine whether two deletions

re cis or tr
ns

nd is performed y PCR usin primers th
t
re speci c for the four most common de
letions.
-Th
l
ssemi
m
y e c
used y sinle
se su stitutions, deletions, or mut
tions
in the
nkin
reions of the -ene. Over 200 di erent mut
tions h
ve een descri ed,
nd 20
re r
el
tively
common. Micro
rr
y
n
lysis is required to detect these. 29. D The
se su sti
tution of
hemolo in C does not
ect the MstII restriction site
nd is not visi le y FISH
or other tests
th
t detect d
m
e to l
rer
re
s of the chromosome. PCR is used to
mplify the

ene reion
involved,
nd the product is tested y Southern lottin usin
l
el-speci c oli
onucleotide
pro e. 2828_Ch08_495-522 06/08/12 11:26 AM P
e 518 30. In ow cytometry, the t
erm 
tin
refers to: A. Selection of
su popul
tion of cells to count B. Determinin the u
orescent
emission spectrum of cells of interest C. Interference c
used y indin of more
th
n
sinle

nti ody D. Selectin the
ppropri
te countin
perture Molecul
r di
nostics/Ap
ply principles of
speci
l procedures/Flow cytometry/1 31. Which of the followin p
r
meters
re us
ed to 
te cells
processed y the ow cytometer? A. Font surf
ce uorescence versus incident l
ser in
tensity B.
Forw
rd liht sc
tter versus side sc
tter C. Te r
tio of liht emitted
t two di e
rent
w
velenths D. Imped
nce
mplitude versus
ckround conduct
nce Molecul
r di
n
ostics/Apply
principles of speci
l procedures/Flow cytometry/1 32. In ener
l, which st
temen
t est
ch
r
cterizes the rel
tionship etween white lood cells
nd liht sc
tterin in
ow cytometry?
A. Forw
rd sc
tter is rel
ted to cell size
nd side sc
tter to r
nul
rity B. Fo
rw
rd sc
tter is
rel
ted to nucle
r density
nd side sc
tter to size C. Forw
rd sc
tter is invers
ely rel
ted to
size
nd side sc
tter is directly rel
ted to size D. Forw
rd sc
tter is rel
ted
to sh
pe
nd side
sc
tter to size Molecul
r di
nostics/Apply principles of speci
l procedures/Flo
w cytometry/2 33.
Fluorescent dyes most commonly conju
ted to
nti odies used in ow cytometry
re:
A. Fluorescein
isothiocy
n
te
nd Tex
s red B. C
lco uor white
nd Tex
s red C. Phycoerythrin
nd
uorescein
isothiocy
n
te D. Acridine or
ne
nd rhod
mine Molecul
r di
nostics/Apply prin
ciples of speci
l
procedures/Flow cytometry/1 8.2 | Molecul
r Di
nostics 519 Answers to Questio
ns 3033 30. A
In ow cytometry, cells c
n e divided into su popul
tions
sed upon their lihtsc
tterin
properties. Cells to e interro
ted y the l
ser(s)
re selected y identifyin
the
re
in
which they
ppe
r on
sc
tterplot. 31. B The 
ted popul
tion is selected y
ev
lu
tin the
sc
tterplot of forw
rd liht sc
tterin (x
xis)
nd riht
nul
r or side sc
tt
er (y
xis).
Cells f
llin within the speci ed limits
re counted. For ex
mple, monocytes c
n
e di erenti
ted
from neutrophils ec
use the former h
ve re
ter forw
rd sc
tter
nd less side s
c
tter. 32. A
Forw
rd sc
tter of liht from
l
ser directed throuh the
perture of the cytom
eter is directly
rel
ted to cell size. Riht
nul
r sc
tter (side sc
tter) is dependent upon the
num er of
r
nules inside the cytopl
sm. For ex
mple, sm
ll lymphocytes th
t
re
r
nul
r
h
ve the lowest
forw
rd
nd side sc
tter
nd
re e
sily identi ed
s the cluster of cells closest
to the ottom

nd left of the sc
tterplot. 33. C In ow cytometry, cells
re mixed with
p
ne

l of speci c

nti odies th
t ind to surf
ce
ntiens th
t ch
r
cterize their line
e
nd m
t
ur
tion st
te.
The
nti odies
re conju
ted to uorescent dyes th
t
re excited y the l
ser. If
liht of the
ch
r
cteristic w
velenth emitted y the uorescent l
el is detected, then the ce
ll ound the
l
eled
nti ody
nd is positive for the respective
ntien. The two most freque
ntly used dyes

re uorescein isothiocy
n
te (FITC)
nd phycoerythrin (PE). Since they emit reen

nd red liht,
respectively, they c
n e di erenti
ted in the s
me s
mple,
llowin two
nti odie
s to e tested
simult
neously. Usin more dyes such
s PE-Tex
s Red
llows for the simult
neous
me
surement of
more m
rkers. For ex
mple, di erent uorescent dyes c
n e
tt
ched to l
tex e
ds i
n di erent
proportions so th
t up to 100 com in
tions c
n e discrimin
ted y the optics. T
his
llows 100
di erent m
rkers to e me
sured in the s
me s
mple simult
neously. Flow cytometry
is used to
me
sure speci c pl
sm
proteins
nd
nti odies usin uorescent
nti odyco
ted e
ds.
2828_Ch08_495-522 06/08/12 11:26 AM P
e 519 34. A cell popul
tion is positiv
e for surf
ce
m
rkers CD45, CD3, CD4,
nd Tdt. Which type of leukocytes
re these? A. Lymphocy
tes B.
Gr
nulocytes C. Monocytes D. E
rly myeloid precursors Molecul
r di
nostics/Appl
y principles of
speci
l procedures/Flow cytometry/3 35. A FISH test is performed on
slide of p
eripher
l lood
leukocytes. Te test uses
du
l fusion pro e, consistin of
Spectrum Green l

eled pro e to the
BCR 22 q11.2 locus,
nd
Spectrum Or
ne l
eled pro e to ABL 9q34. Wh
t dise
s
e is this test
for? A. Chronic myeloenous leukemi
B. Multiple myelom
C. Bl
dder c
ncer D. Ty
roid c
ncer
Molecul
r/Apply principles of speci
l l
or
tory procedures/FISH/2 36. A tissue
s
mple for DNA

n
lysis y PCR w
s processed for DNA y simple lysis
nd protein
se K diestion
. The lys
te w
s
diluted 1:100
nd its
sor
nce me
sured in
n ultr
violet spectrophotometer
t
260 nm
nd 280
nm. The
sor
nce r
tio 260:280 w
s 1.2. Wh
t does this indic
te? A. Te DNA con
centr
tion is too
hih for PCR B. Te DNA concentr
tion is too low for PCR C. Te s
mple cont
ins to
o much protein D.
Te s
mple is optim
l for PCR Molecul
r/Ev
lu
te l
or
tory d
t
to reconize sou
rces of error/3
520 Ch
pter 8 | Molecul
r Di
nostics Answers to Questions 3436 34. A CD45 is

p
nleukocyte
m
rker
nd re
cts with
ll white lood cells
nd precursors. CD3, CD4,
nd Tdt

re m
rkers for T
lymphocytes. Typic
lly,
p
nel of 12 or more
nti odies is used to ch
r
cterize
the line
e
nd
m
turity of
cell popul
tion. The
revi
tion CD st
nds for cluster of di erenti

tion.
Monoclon
l
nti odies with the s
me CD num er reconize the s
me m
rker,
lthou
h the speci c
moiety they re
ct with m
y e di erent. 35. A Althouh
ll of these c
ncers invo
lve chromosom
l

ploidy or ene re
rr
nement th
t c
n e detected y FISH, the BCR/ABL tr
nsloc

tion is found in
>
95% of CML
nd 25% of AML p
tients
nd in
r
re c
ses of chronic neutrophilic leukemi
. There is
rel
tionship et
ween the type of
leukemi

nd the portion of the BCR locus involved in the tr
nsloc
tion. In CML,
the m
jor (M
BCR) portion of the ene is involved, ivin rise to
210 d
lton chimeric prote
in. In ALL, the
minor (m BCR) portion is involved, ivin rise to
190 d
lton chimeric protein.
In CNL,
n
extended reion eyond the M reion, c
lled the BCR region, is involved, giving
rise to a 230
dalton chimeric protein. Also, variants in BCR/ABL exist, giving rise to differe
nt FISH patterns.
Some variants are associated with essential thrombocythemia that occurs at disea
se onset in a
small percentage of CML patients. 36. C The mass and purity of DNA a ect the e cie
ncy of DNA
ampli cation. A common way to determine the amount of DNA recovered from a sample
is to measure
its absorbance at 260 nm, where the nitrogenous bases have an absorbance maximum
. Based on the
molar absorptivity of DNA at 260 nm, an absorbance of 1.0 equates to 50 ng/L; thu
s, multiplying
the absorbance by 50 and the dilution factor estimates the DNA concentration in
ng/L. However,
proteins also absorb at 260 nm, and if present in su cient amounts will cause over
estimation of
DNA and inhibit ampli cation. An absorbance maximum for protein is 280 nm owing to
the phenolic
rings of tyrosine and tryptophan. The absorbance ratio of 260:280 is a measure o
f protein
contamination. If the ratio is below 1.7, then too much protein is present, and
further
puri cation is needed. 2828_Ch08_495-522 06/08/12 11:26 AM Page 520 37. Which m
ethod of
analysis is considered the most reliable means of detecting mutations of BRCA, p
53, BRAF, and
other genes linked to cancer? A. FISH B. Immunohistochemistry C. Sequencing D. S
TR analysis
Molecular/Select method/Gene mutation testing/3 38. An assay based on the princi
ple of proteomics
may be used for which of the following? A. Screening for colorectal cancer B. Sc
reening for lung
cancer C. Identifying malignant ovarian masses D. Identifying malignant breast t
umors
Molecular/Apply principles of special laboratory procedures/Proteomics/2 39. Wha
t method is used
to identify maternal cell contamination in amniocentesis and chorionic villus sa
mples (CVS)? A.
STR analysis B. FISH C. Microarray analysis D. MicroRNA (MiRNA) analysis Molecul
ar/Apply
principles of special laboratory procedures/Genetic testing/2 8.2 | Molecular Di
agnostics 521
Answers to Questions 3739 37. C Genes such as BRCA1 and BRCA2 are large and tho
usands of point
mutations have been identi ed, making it impossible to perform an assay using DNA
probes. When
many mutations of a gene are possible, the most widely used detection method is

sequencing. Next
generation sequencing has made clinical applications a ordable. The process involv
es creating a
library of templates, copying them by PCR, separating the copied strands, and de
termining their
base order by PCR using a reversible dye termination reaction. When a uorescent-l
abeled
nucleotide is added a laser determines its emission and the base is identi ed. The
blocking group
and uorescent dye are removed and the process repeated for the next base added. 3
8. C
Proteomics is the study of the proteome. Analogous to the genome, the proteome i
s the totality of
proteins present within a cell or organism. Proteomic studies are aimed mainly a
t identifying
protein signatures for various cancers. Serum is analyzed by time-of- ight mass sp
ectroscopy and
thousands of proteins are matched to identify those that can discriminate betwee
n cancerous and
normal cells. A commercially available test based on proteomics is available for
di erentiating
malignant from benign ovarian tumors. The test detects the presence of ve protein
s in serum
linked to ovarian cancer, and uses multivariate statistical analysis to derive a
number from 110
indicating the risk of cancer. It has a high sensitivity and negative predictive
value. 39. A
Maternal cell contamination can result in misinterpretation when performing gene
tic testing
directly on uncultured CVS or amniotic uid cells. FISH can identify maternal cell
contamination
if the fetus is male but not female. STR analysis using 5 loci can detect matern
al cell
contamination as little as 1%. A level of maternal contamination below 1% does n
ot guarantee
accuracy, but misinterpretation due to maternal contamination is unlikely. Negat
ive genetic tests
can be reported, but positive results should be con rmed using cultured cells. Mat
ernal
contamination is more common from CVS than amniotic uid samples. MiRNAs are small
RNA molecules
that bind to mRNA and block their translation. There are about 500 miRNAs in hum
an cells and
their expression has been used to identify the tissue of tumor origin. 2828_Ch08
_495-522
06/08/12 11:26 AM Page 521 40. What is the clinical signi cance of K-ras testing
? A. K-Ras
mutations make tumor cells more susceptible to chemotherapy B. K-Ras is a tumor
suppressor gene
and mutations are associated with increased lifetime risk of malignancy C. K-Ras
mutations result
in treatment resistance to growth factor receptor inhibitors D. K-Ras is used to
identify the
tissue of origin Molecular/Correlate clinical and laboratory data/Oncogene testi
ng/2 BI BL I
OGRAPHY 1. Buckingham L. Molecular Diagnostics, Fundamentals, Methods, & Clinica
l Applications.
2nd edition, 2012. F. A Davis, Philadelphia. 2. Burtis CA, Ashwood ER, and Burns
DE. Tietz
Textbook of Clinical Chemistry and Molecular Diagnostics. 4th edition, 2006. Els

evier Saunders,
St. Louis. 3. Kaplan LA and Pesce AJ. Clinical Chemistry Teory Analysis, Correla
tion. 5th
edition, 2009. Mosby, St. Louis. 522 Chapter 8 | Molecular Diagnostics Answer to
Question 40 40.
C K-Ras is a proto-oncogene that makes a GTP binding protein. When the protei
n is bound to
GTP, it initiates a cascade of phosphorylation reactions leading to transcriptio
n. K-Ras is
activated when an epidermal growth factor binds to the epidermal growth factor r
eceptor (EGFR).
EGFR is overexpressed in several cancers including colorectal, lung, and pancrea
tic cancer. These
can be treated with EGFR inhibitors, but treatment resistance occurs if the cell
s have a K-Ras
mutation because K-Ras is downstream of EGFR in the signaling pathway. 4. Lodish
H et al.
Molecular Cell Biology. 6th edition, 2007. W. H. Freeman, New York. 5. McPherson
RA and Pinccus
MR. Henrys Clinical Diagnosis and Management by Laboratory Methods. 22nd edition,
2011.
Saunders, Philadelphia. 6. Patrinos G and Ansorge W. Molecular Diagnostics. 2nd
edition, 2009.
Elsevier Academic Press, Burlington, MA. 2828_Ch08_495-522 06/08/12 11:26 AM
Page 522 CHAPTER
9 523 Education and Management 1. A comparison of methods for the determination
of alkaline
phosphatase is categorized in which domain of educational objectives? A. A ective
B. Psychomotor
C. Cognitive D. Behavioral Education and management/Apply knowledge of education
al methodology/1
2. Attitude, judgment, and interest refer to which domain of educational objecti
ves? A. Cognitive
B. A ective C. Psychomotor D. Competency Education and management/Apply knowledge
of educational
methodology/1 3. Criterion-referenced examinations are used in order to determin
e the: A.
Competency of a student according to a predetermined standard B. Validity of a t
est C. Status of
one student compared to the whole group D. Accuracy of a test Education and mana
gement/Apply
knowledge of educational testing/1 Answers to Questions 13 1. C The cognitive d
omain of
educational objectives deals with application, analysis, synthesis, and evaluati
on of information
or knowledge learned to be utilized in problem solving. 2. B The a ective domain
of educational
objectives includes those that emphasize values, attitudes, and interests that a
ttach a worth to
an activity, situation, or phenomenon. 3. A A criterion-referenced test is use
d to determine
the mastery of predetermined competencies, while a norm-referenced test evaluate
s students by
comparison to the group. Criterion-referenced examinations use questions of know
n di culty and
can be calibrated against established criteria in order to evaluate the examinees
performance.
2828_Ch09_523-536 06/08/12 11:27 AM Page 523 4. An instructor curved a blood ba
nk exam given
to medical laboratory science students. Te highest grade was an 85% and the lowe

st grade was a
60%. What type of test is this? A. Subjective B. Objective C. Norm referenced D.
Criterion
referenced Education and management/Apply knowledge of educational testing/2 5.
A stated
competency requirement for a medical laboratory science student is to perform ca
libration, plot
data, and evaluate the acceptability of controls. Tis competency requirement enc
ompasses which
educational objective? A. Cognitive B. Psychomotor C. A ective D. All of these opt
ions Education
and management/Apply knowledge of educational methodology/3 6. A chemistry test
result from a
chemotherapy patient was within normal limits on Tuesday. Te same test was repor
ted as abnormal
on Monday ( agged high and approaching a critical value). Te technologist performing
the test
noted a delta-check error and remembered that both controls ran much higher on M
onday although
they were within acceptable limits. Te technologists decision to follow-up this d
iscrepancy
before reporting the results is an example of which domain of behavioral objecti
ves? A. Cognitive
B. A ective C. Psychomotor D. Organizational Education and management/Apply knowle
dge of
educational methodology/3 7. In general, academic evaluation of students depends
on the ability
of the instructor to create a test that re ects the stated objectives of the cours
e material as
well as making the test: A. Reliable and valid B. Normally distributed and pract
ical C. Fair and
short D. Written and oral Education and management/Apply knowledge of educationa
l testing/1 524
Chapter 9 | Education and Management Answers to Questions 48 4. C This type of
test compares
the students to each other rather than grading the students on a set of standard
s or criterion
that must be met. 5. D The student will perform the actual calibration (psycho
motor skills),
utilize the cognitive domain of analysis to plot the standards, construct a best
-fit calibration
line, and determine the concentration of the controls. The affective domain desc
ribes the
students ability to value the results as acceptable or to repeat the calibration,
if an error is
apparent. 6. B The technologist chose to investigate the situation in order to
resolve a
discrepancy. The responding, valuing, and characterization refer to the a ective d
omain in
dealing with the problem presented here. In doing so, a rule-based process is fo
llowed that
includes evaluation of the specimen, instrument performance, potential sources o
f interference
(such as the e ects of drugs), and physiological variation before determining whet
her to report
the result, repeat the test, or call for a new specimen. 7. A A test should be
based on stated,
measurable objectives and contain ve attributes: reliability, validity, objectivi
ty, fairness,
and practicality. 8. C When a demonstration of a complex instrument is necessa

ry, a small group

of students should be assembled around the instrument to permit clear visibility
. A diagram with
the major functioning parts should be provided, along with an assignment of a wr
itten summary or
questions about the function, principle, testing done, and reagents needed. 8. W
hen dealing with
the instruction of complex instrumentation, a demonstration by the instructor is
necessary and
should include the following: A. Detailed diagrams of the electrical system B. A
blueprint of the
optical system C. A step-by-step narrative with comparisons to a manual method D
. A quiz as soon
as the demonstration is complete Education and management/Apply knowledge of edu
cational
methodology/1 2828_Ch09_523-536 06/08/12 11:27 AM Page 524 9. One method of l
earning is by
giving a small group of students a topic to discuss or a problem to solve rather
than a formal
lecture by the instructor. Each participant is given a portion of the topic to d
iscuss or solve.
Tis method of learning is popular and used easily with which of the following ap
proaches? A. Case
study B. Manual demonstration C. Implementing new equipment D. Histogram evaluat
ion Education and
management/Apply knowledge of educational methodology/2 10. An instructor of med
ical laboratory
science was given the task of expanding the curriculum for the senior (baccalaur
eate degree)
medical laboratory science students. Which of the following subjects should be i
ncluded in the
curriculum? A. Cytologycytogenetics B. Histologyspecial stains C. Computer (labora
tory
information systems [LIS]) D. Economicsbudget analysis Education and management/E
ducation/Apply
knowledge of entry level skills/1 11. McGregors XY theory advocates managing emplo
yees by
stressing: A. Equal pay for equal work B. A pyramid of attainable goals for sati
sfaction at work
C. Respect for the worker and acknowledgment of his/her ability to perform a tas
k D. Collective
bargaining Education and management/Apply knowledge of management theory/1 12. M
aslows theory of
management is based upon: A. Te premise that all workers are unmotivated B. A py
ramid of goals
for the satisfaction of employee needs C. Use of detractors and perks to keep em
ployees happy D.
Te professional development of the employee Education and management/Apply knowl
edge of
management theory/1 Chapter 9 | Education and Management 525 Answers to Questi
ons 913 9. A
The case study approach allows a student to engage in problem solving and to uti
lize the input of
all members of the group. This allows for interaction and use of higher cognitiv
e levels in order
to determine the cause of the patients illness and various laboratory test result
s. 10. C The
ever-changing role of the medical laboratory scientist in a clinical laboratory
prompts the
curriculum committee to re-evaluate the courses required by the students on a ye

arly basis. The

heart of the laboratory, the LIS, is one of the rst important areas to which stud
ents are
introduced when entering the professional clinical training portion of their deg
ree. 11. C
McGregors theory deals with participatory management in which the employee is con
sidered a
valuable asset. 12. B Maslows theory of managing people deals with six levels.
As the basic
needs of an employee are met, the next highest need is substituted. The needs, i
n ascending
order, are physiological, safety, security, social, esteem, and self-actualizati
on. Unsatis ed
needs are considered motivators. 13. A According to Frederick Herzberg, achiev
ement,
opportunity for advancement, recognition, challenging work, responsibility, and
a chance for
advancement and personal growth are motivators and should be included as part of
a job design.
13. Herzbergs theory relies on motivators that are part of the job design in orde
r to instill
job satisfaction. Tese same motivators can become dissatis ers if they are lacking
in a job.
Herzbergs motivators are: A. Opportunity for achievement and advancement B. Perfo
rmance
evaluations every 24 months C. Continuing education sessions requiring superviso
ry approval D.
Punitive actions taken when improvement diminishes Education and management/Appl
y knowledge of
management theory/1 2828_Ch09_523-536 06/08/12 11:27 AM Page 525 14. Manageme
nt by objective
(MBO) is least e ective for managing employees in which situation? A. Employees mu
st be creative
in their work B. Te laboratory is converting to a new computer system C. Te labo
ratory is
undergoing a renovation D. Employees jointly agree to institutional goals Educat
ion and
management/Apply knowledge of management theory/2 15. Te four essential function
s of a manager
are: A. Sta ng, decision making, cost analysis, evaluating B. Directing, leading,
forecasting,
implementing C. Planning, organizing, directing, controlling D. Innovating, desi
gning,
coordinating, problem solving Education and management/Apply knowledge of manage
ment theory/1 16.
Which of the following questions is allowable during a pre-employment interview?
A. How many
times have you been pregnant? B. Have you been convicted of any felonies? C. Doe
s your husband
belong to any religious societies? D. Are you planning to use the hospital day c
are center?
Education and management/Labor law/3 17. Direct laboratory costs for tests inclu
de which of the
following? A. Equipment maintenance B. Insurance C. Depreciation D. Overtime pay
Education and
management/Laboratory economics/1 18. Which of the following accounts for the la
rgest portion of
the direct cost of a laboratory test? A. Reagents B. General supplies C. Technol
ogist labor D.
Instrument depreciation Education and management/Laboratory economics/1 19. Usin

g the
surcharge/cost-plus method for determining test charges, determine the charge fo
r an ova and
parasite examination on fecal specimens, given the following information: Collec
tion, handling,
clerical, and so forth = $2.00 Reference lab charge to lab = $20.00 Lab markup = 1
00% A. $22.00
B. $32.00 C. $42.00 D. $122.00 Education and management/Laboratory economics/2 5
26 Chapter 9 |
Education and Management Answers to Questions 1419 14. A MBO stresses teamwork
and shared
goals and objectives but sti es creativity. 15. C While managing may involve all
of the
functions listed, the four core processes for all managers are planning, organiz
ing, directing,
and controlling. Planning includes formulating of goals and objectives, organizi
ng the tasks, and
establishing schedules. Organizing includes establishing e ective communication, r
elationships,
job descriptions, and training. Directing involves oversight of the various step
s and stages of
the plan, including coordination and leadership. Controlling involves evaluating
resource
utilization and outcomes, managing costs, and modifying the process to improve q
uality. 16. B
Title VII of the Civil Rights Act of 1964 states that questions are permissible
during interviews
if they are related to legitimate occupational quali cations. Inquiries concerning
convictions
for drug use or theft are legitimate questions when hiring a laboratory night su
pervisor or other
individuals who will utilize controlled substances. 17. D All costs that are s
peci cally linked
to a test (e.g., personnel, overtime, chemicals, supplies) are direct costs. 18.
C Labor
accounts for 60%70% of the direct cost per test in most laboratories. The cost of
labor,
reagents, and supplies are direct costs, but instrument depreciation is not. 19.
C The markup
factor is used to establish part of the cost of a test in order to obtain the de
sired pro t
margin. Tests sent to reference laboratories or done in-house have the added cos
t that is
referred to as the surcharge/cost-plus method of determining test charges. 2828_
Ch09_523-536
06/08/12 11:27 AM Page 526 20. In deciding whether to adopt a new test on the
laboratorys
automated chemistry analyzer, which parameters are needed to determine the numbe
r of tests that
must be performed to break even? A. Test turnaround time B. Cost of labor per ho
ur C. Number of
other tests performed per month D. Total xed laboratory costs Education and
management/Laboratory economics/2 21. Which statement best represents the relati
onship between
test volume and revenue or costs for batch-run tests? A. As volume increases, th
e xed cost per
test also increases B. As volume increases, the revenue also increases C. Revenu
e is
approximately equal for both high- and low-volume tests D. 90% of the revenue is
generated by 5%

of the tests o ered Education and management/Laboratory economics/2 22. A hospital

submits a bill
for $200.00 to the patients insurance company for the cost of outpatient laborato
ry tests. Te
laboratory services rendered by the hospital are paid according to an agreed fee
schedule. Te
speci c laboratory procedures are billed according to which system of coding? A.
Diagnosis-related group (DRG) B. Current procedural terminology (CPT) C. Medicar
e D. Medicaid
Education and management/Laboratory economics/1 23. A hospital has a contract wi
th a major
medical insurer that reimburses the laboratory at a rate of $1.00 per insured li
fe per year. Tis
type of reimbursement is called: A. A prospective payment system B. A preferred
provider discount
C. Capitation D. Diagnosis-related group Education and management/Laboratory eco
nomics/2 24.
According to federal and state regulations, a hospitals capital budget should inc
lude which of
the following before projects that cost $150,000 can be submitted for approval?
A. A time table
of completion B. A cost analysis C. Salaries and wages for new employees D. A ce
rti cate of need
Education and management/Laboratory economics/1 Chapter 9 | Education and Manage
ment 527
Answers to Questions 2024 20. D The formula for calculating the break-even poin
t in test
volume is: No. of tests = total xed costs (average reimbursement variable cost pe
r test).
The total xed costs are the expenses that are not expected to change as the workl
oad increases
(e.g., cost of the instrument). The variable cost per test includes any costs th
at increase as
the workload increases (e.g., cost of reagents). The average reimbursement repre
sents the
expected revenue generated per billable test result. 21. B As volume increases
, costs should
decrease and revenues should increase. The large xed costs such as instrumentatio
n, labor, and
management do not change with the size of the batch. As volume increases, reagen
t and consumable
costs per test often become lower thus reducing the variable cost per test. In m
ost laboratories,
about 80% of the revenue is generated by the laboratory tests that comprise the
top 20% of the
test volume. 22. B The CPT code refers to Current Procedural Terminology. Code
s are assigned to
all medical procedures, which are grouped according to common disease characteri
stics. The
insurance company or payer (e.g., Medicare) usually has agreed to a reimbursemen
t amount per test
or procedure. The American Medical Association publishes Current Procedural Term
inology, or CPT,
which is updated yearly. 23. C Capitation plans provide the laboratory with a x
ed (known)
revenue based upon a negotiated per-capita fee for the members of the group. In
order to pro t,
the laboratory must manage its resources to provide covered laboratory tests to
the group at a
cost that does not equal or exceed its reimbursement. A prospective payment syst

em is used by
Medicare and Medicaid programs for outpatient reimbursements and is based upon p
rojecting the
cost of a laboratory test in a speci c region. For inpatients, the fees for labora
tory tests are
incorporated into the reimbursement covering the speci c diagnosis-related group r
ather than the
type or number of laboratory procedures performed. 24. D A certi cate of need (C
ON) is an
authorization to proceed with a needed project, such as a new obstetrics departm
ent or new wing
to the laboratory. There are speci c federal guidelines (most states also require
them) to follow
and the limit is set at $150,000. This is done to control duplication of service
s as well as
oversupply of hospital beds. 2828_Ch09_523-536 06/08/12 11:27 AM Page 527 25.
A rural hospital
laboratory employs 8.25 FTEs (full-time equivalents). In order to budget for nex
t years salaries
for these employees, the laboratory manager needs to submit which gures for the l
aboratorys
projected annual budget? A. Total (paid) hours B. Productive (worked) hours C. T
otal hours of
full-time employees D. Total hours of part-time employees Education and manageme
nt/Laboratory
economics/1 26. A chemistry pro le that includes electrolytes, glucose, blood urea
nitrogen
(BUN), and creatinine is ordered on an 80-year-old woman with symptoms of vomiti
ng and dizziness.
How should the laboratory submit the charge for these tests for reimbursement by
Medicare? A.
Submit as one test B. Submit each test separately C. Submit Medicare-approved te
sts only D.
Submit as four individual tests Education and management/Laboratory regulation a
nd law/2 27.
According to the Clinical Laboratory Improvement Act of 1988 (CLIA 88), control o
f laboratory
test reliability is accomplished by all of the following requirements except: A.
Documentation of
quality control results and corrective actions B. Participation in pro ciency test
ing for all
nonwaivered tests C. Professional certi cation of all testing personnel D. Demonst
ration that all
quantitative tests meet manufacturers performance speci cations Education and
management/Laboratory regulation and law/2 28. CLIA 88 speci es that the minimum re
quirements
for pro ciency testing (PT) of analytes for which PT is required (excluding cytolo
gy) are: A. One
challenge per analyte and one testing event per year B. Ten challenges per analy
te and ve
testing events per year C. Five challenges per analyte and at least three testin
g events per year
D. Twelve challenges per analyte and one testing event per month Education and
management/Laboratory regulation and law/1 528 Chapter 9 | Education and Managem
ent Answers to
Questions 2528 25. A The total (paid) hours are the total number of hours for w
hich employees
are paid. This includes vacation time, sick time, and the actual time spent work
ing in the
laboratory. On the other hand, productive (worked) hours refers only to the actu

al hours worked,
including overtime. A budget must include the total (paid) hours in order to giv
e a clear picture
of what is needed for the next year of wages and salaries. 26. A A chemistry p
ro le that
includes electrolytes, glucose, BUN, and creatinine is considered a billable pro
cedure and has a
single CPT code (currently this panel is called the Basic Metabolic Panel and is
coded as CPT
80049). Splitting a pro le into many individual tests for billing purposes may be
prohibited by
law. For example, a complete blood count (CBC) cannot be split into ve parts with
each component
being charged separately. 27. C CLIA 88 requires all clinical laboratories to b
e certi ed, but
the requirements di er for each of the three certi cation levelswaivered, moderate, o
r high
complexity. For example, quality control must be practiced by all laboratories,
but standards for
testing personnel di er for all three levels and do not specify certi cation, only e
ducational
levels. 28. C Analytes for which pro ciency testing is required are identi ed in s
ection 493
subpart I of the CLIA rules. A minimum number of ve challenges for each analyte a
nd at least
three testing events per year are required. The testing events are evenly spaced
throughout the
year. Unsatisfactory performance for the same analyte for two out of two events
or two out of the
three most recent events constitutes unsuccessful participation and may result i
n punitive
action. 2828_Ch09_523-536 06/08/12 11:27 AM Page 528 29. According to CLIA 88,
satisfactory
performance for ABO, Rh, and compatibility tests requires a score of: A. 100% B.
90% C. 80% D.
75% Education and management/Laboratory regulation and law/1 30. In order to com
ply with CLIA
88, calibration materials must: A. Be purchased by an authorized agency such as t
he College of
Pathology B. Have concentration values that cover the laboratorys reportable rang
e C. Be
traceable to the National Calibration Board D. Be identical in concentration to
those sold by the
reagent manufacturer Education and management/Laboratory regulation and law/1 31
. According to
CLIA 88, calibration materials should be appropriate for the methodology and be:
A. Of bovine
origin B. Tree times the normal range for the speci c analyte C. Traceable to a re
ference method
and reference material of known value D. Twice the laboratorys reference range fo
r the analyte
Education and management/Laboratory regulation and law/1 32. Under CLIA 88, testi
ng personnel
with an associate degree and appropriate training in the clinical laboratory are
authorized to
perform: A. Waived tests only B. Tests that are qualitative or waived and some
moderate-complexity tests C. Waived and moderate-complexity tests D. Waived, mod
erate-complexity,
and high- complexity tests Education and management/Laboratory regulation and la
w/1 33. Sexual

harassment is a form of discrimination and therefore is prohibited by the: A. Oc

cupational Safety
and Health Administration (OSHA) B. Civil Rights Act of 1964 (Title VII) C. Righ
t to Privacy Act
of 1974 D. Department of Health and Human Services Education and management/Labo
r law/1 Chapter 9
| Education and Management 529 Answers to Questions 2934 29. A Unsatisfactory
performance
occurs when any challenge for ABO, Rh, or compatibility testing is in error. For
all other tests,
a score below 80% is defined as unsatisfactory performance. Unsatisfactory perfo
rmance for the
same analyte for two out of two events or two out of the three most recent event
s constitutes
unsuccessful participation. 30. B According to CLIA 88, the minimum requirement
for
calibration is every 6 months or more frequently if speci ed by the manufacturer.
The calibrators
must cover the reportable range of the method. A minimum of two levels of calibr
ant must be used
(more if speci ed by the manufacturer). 31. C Calibrators must have an assigned
concentration
determined by assay using a reference method. The reference method should be cal
ibrated using
standards that are traceable to National Bureau of Standards material or accepta
ble primary
standards. 32. D Testing personnel with an associate degree and approved labor
atory training
may perform high-complexity tests as well as waived and moderate-complexity test
s. However, the
laboratory must be certi ed at all three levels. 33. B The Civil Rights Act of 1
964 prohibits
by federal law discrimination in employment because of race, color, religion, or
gender. The law
established the Equal Employment Opportunity Commission (EEOC) to hear complaint
s of
discrimination by employees and initiate legal action as appropriate. 34. B Ac
cording to the
OSHA Bloodborne Pathogens Rule of 1992, gloves and lab coats are to be removed a
fter disinfection
of the work area. 34. Which order of events should be followed at the conclusion
of a laboratory
workers shift in order to prevent the spread of bloodborne pathogens? A. Remove g
loves,
disinfect area, wash hands, remove lab coat B. Disinfect area, remove gloves, re
move lab coat,
wash hands C. Disinfect area, remove gloves, wash hands, remove lab coat D. Remo
ve gloves, wash
hands, remove lab coat, disinfect area Education and management/Laboratory safet
y and standard
precautions/2 2828_Ch09_523-536 06/08/12 11:27 AM Page 529 35. Records of a p
atients
laboratory test results may not be released without his or her consent to anyone
outside the
clinical laboratory except to the: A. American Red Cross B. Department of Health
and Human
Services C. Insurance carrier D. Physician who ordered the tests Education and
management/Laboratory regulation and law/2 36. Unethical behavior by a laborator
y supervisor that
results in a compromise of employee safety should be: A. Reported to a higher au

thority B.
Directly confronted C. Reported to the EEOC D. All of these options Education an
d
management/Apply principles of laboratory management/Personnel/2 37. Te most com
mon de ciency
cited during an onsite laboratory inspection by the College of American Patholog
ists (CAP) and
the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is: A.
Improper
documentation B. Insu cient work space area C. Improper reagent storage D. Imprope
r instrument
calibration frequency Education and management/Laboratory regulation and certi cat
ion/2 38. Which
of the following circumstances is considered a form of sexual harassment? A. Unw
elcome sexual
advances by a supervisor B. Requests for favors of a sexual nature from a fellow
laboratory
employee C. Physical conduct of a sexual nature from an employee working in anot
her department D.
All of these options Education and management/Labor law/2 39. Te material safety
data sheets
(MSDSs) for hazardous chemicals address which of the following conditions? A. Ph
ysical
characteristics of the chemical B. Safe handling and storage of the chemical C.
Speci c health
hazards associated with the chemical D. All of these options Education and manag
ement/Laboratory
regulation and safety/1 530 Chapter 9 | Education and Management Answers to Ques
tions 3540 35.
D The Privacy Act of 1974 prohibits the release of medical records without the p
atients consent
except to the patients attending physician, attorney, or next of kin if deceased
unless
solicited by a valid subpoena. 36. D Direct confrontation is in order, followe
d by reporting
the behavior to a higher authority at the clinical site. Major violations that a
re a threat to
the safety of employees, patients, and the facility in general should be reporte
d to the EEOC or
OSHA, if the violations are not corrected in a timely fashion, and if all avenue
s of action have
been exhausted. 37. A Improper documentation accounts for the majority of labo
ratory
de ciencies, while outdated or inadequate procedure manuals is the second most fre
quently cited
de ciency. 38. D Sexual harassment is a form of discrimination and it is prohibi
ted by the
Civil Rights Act of 1964 (Title VII). The suggestion that a sexual favor must be
performed to
avoid punitive action or receive a favorable performance evaluation constitutes
sexual
harassment. Additionally, offensive language and behavior with sexual connotatio
ns are forms of
sexual harassment. 39. D The MSDS documents describe the chemical and physical
characteristics,
safe handling and storage, and potential health hazards of reagents used in the
laboratory. These
documents must be located in an easily accessible place so that all employees ha
ve access to
them. They should be reviewed at least once per year during safety inservice tra

ining. 40. A
The information used for the employees performance review should re ect the job des
cription used
at the time of hire. An employee should receive a written job description that s
tates the
responsibilities and activities of the position. Job performance criteria and th
e rating system
used should be clearly stated and available to the employee. 40. A new employees
performance is
to be evaluated at the end of his or her probationary period, and must relate to
: A. Te persons
job description B. Verbal instructions given C. Wage and salary policies D. Recr
uitment practices
Education and management/Apply principles of laboratory management/Personnel/1 2
828_Ch09_523-536
06/08/12 11:27 AM Page 530 41. Which regulatory agency mandates the following
requirements for
protection of employees of clinical laboratories? Provide personal protective eq
uipment (PPE)
Require hepatitis B vaccinations at no cost Require speci c biohazard materials la
beling
Provide training and updating yearly of safety standards A. Food and Drug Admini
stration (FDA) B.
Occupational Safety and Health Administration (OSHA) C. American Association of
Blood Banks
(AABB) D. American Society of Clinical Pathologists (ASCP) Education and managem
ent/Apply
knowledge of lab regulations/1 42. Te Clinical Laboratory Improvement Act of 198
8 (CLIA 88) was
enacted to regulate the following: A. All clinical laboratories in the United St
ates B.
Independent labs not regulated by OSHA C. Environmental Protection Agency labora
tories D.
Industrial laboratories Education and management/Apply knowledge of lab regulati
ons/1 43. Records
of a patients laboratory test results may be released without the prior consent o
f the patient
to all of the following except: A. An insurance carrier B. Physician on call C.
Nursing sta D.
An employer Education and management/Apply knowledge of lab regulations/2 44. Te
following is
(are) successful indicator(s) of Quality Assurance (QA) and Quality Improvement
(QI) programs in
a clinical laboratory: A. A log of incident report and solutions attained B. Emerg
ency
department and STAT turnaround times C. Positive patient identi cation wristbands fo
r blood
bank operations D. All of these options Education and management/Apply knowledge
of quality
performance/2 45. Continuous Quality Improvement (CQI) is a team e ort approach fo
r clinical
laboratories to: A. Identify potential problems and correct them B. Set lab nanci
al benchmarks
for the year C. Make up new CPT codes D. Improve overall wages for lab employees
Education and
management/Quality improvement/2 Chapter 9 | Education and Management 531 Answ
ers to Questions
4145 41. B The U.S. Department of Labor, through OSHA, mandates a workplace tha
t is safe and
healthy. Other agencies that inspect clinical laboratories (CLIA 88, CAP, JCAHO,

etc.) also
require safety guidelines for the health care workers in the clinical laboratory
. 42. A The
regulations for clinical laboratories (CLIA 88) were nally published in 1992 in th
e Federal
Register (USDHHS, 1992). The federal mandate was designed to regulate a speci c st
andard for each
laboratory test as well as categorize the laboratories according to the level of
testing and the
lab personnel. 43. D HIPAA (Health Insurance Portability and Accountability Ac
t, 1996) provides
increased access to health care by making it easier for providers to send medica
l information to
insurance companies electronically. The law requires health care providers to sa
feguard the
con dentiality of patient medical information and to provide patients with a compl
iance statement
that de nes who is entitled to receive their health information. The physician ord
ering the tests
as well as health care workers directly involved with the patient are allowed to
see laboratory
results. Laboratory results may also be released to the patients insurance provid
er, and to
medical review o cers, and public health o cials. They may also be released to the p
atients
family provided the patient is noti ed of this policy beforehand, and is given the
right to
object. 44. D These policies, along with laboratory performances on pro ciency s
urveys, are a
part of QA, QI, and TQI (total quality improvement), which are now included in t
he JCAHO
accreditation process. 45. A The CQI team identi es problems by collecting data,
analyzing it,
and developing methods of correcting problems. By identifying potential problems
and correcting
existing problems, a high competency is achieved and potential law suits are avo
ided.
2828_Ch09_523-536 06/08/12 11:27 AM Page 531 46. Which of the following is no
t an appropriate
guideline for phlebotomists to follow in order to prevent a malpractice lawsuit?
A. Use one form
of patient ID, such as a last name B. Keep patient con dentiality at all times C.
Use aseptic
venipuncture technique at all times D. Label specimens only after the blood has
been drawn
Education and management/Malpractice law/2 47. According to CLIA 88, testing pers
onnel
performing high-complexity laboratory tests must have at least a: A. Bachelor of
Arts degree B.
Bachelor of Science degree in medical laboratory science (MLS) C. Associate degr
ee in medical
laboratory science (MLT) D. High school diploma Education and management/Regulat
ion lab/2 48.
During an interview, an employer may request the following from a prospective ne
w employee: A.
Marital status B. Age of children C. Arrest record for driving under the in uence
of alcohol D.
Professional certi cation Education and management/Labor law/2 49. A new laborator
y information
system (LIS) will be evaluated by the laboratory sta . Which of the following poin

ts should be
considered in the evaluation? A. Cost of updating software B. Interface ability
with existing
laboratory instruments C. Tracking of uncrossmatched blood units in Blood Bank D
. All of these
options Education and management/Laboratory economics/3 50. Point-of-care testin
g (POCT) refers
to: A. All testing done to the patient to save time B. All lab testing done in t
he central lab C.
Any clinical lab testing done at the patients bedside D. Satellite lab testing Ed
ucation and
management/Laboratory economics/2 51. Six sigma is a method used in industry and b
usiness as
well as the clinical laboratory in order to: A. Allow for improved performance B
. Prevent and
remove defects in production C. Improve customer satisfaction D. All of these op
tions Education
and management/Apply knowledge of quality assurance/1 532 Chapter 9 | Education
and Management
Answers to Questions 4651 46. A Outpatient identi cation through two means (name
and date of
birth) are standard procedures to avoid drawing the wrong patient. Other malprac
tice prevention
measures include treating people equally; securing informed consent before testi
ng; and listening
to patients concerns. 47. C CLIA 88 requires personnel performing high-complexit
y tests to
have earned at least an associate degree in medical laboratory science, or attai
ned a level of
college education and clinical laboratory training equivalent to an associate de
gree in medical
laboratory science. 48. D All of the questions are in violation of Title VII o
f the Civil
Rights Act of 1964, except the request for certi cation. The certi cation is usually
a
requirement for job performance and is listed in the job description. 49. D Ea
ch laboratory
will have speci c needs to determine the appropriate LIS. However, storage capacit
y, reliability,
security, upgrade costs, instrument interface availability, inventory management
, and quality
control functions are common parameters that must be considered. 50. C Point-o
f-care testing
saves time and is invaluable for patient care. When a device is used at the beds
ide of a patient
to produce a laboratory result, it is considered a point-of-care instrument. Man
y such devices
are often waived by CLIA, thus allowing them to be used by personnel without lab
oratory training.
However, the institution must have a CLIA license to perform the testing, and ap
propriate quality
control procedures must be followed. Some devices used for point-of-care testing
utilize
equivalent quality control, usually electronic simulation of the measurement tha
t takes place
with disposable unit-dose reagent packs. 51. D Six sigma management is a metho
d for measuring
the e ciency of a process such as mass production, and it is applied in the clinic
al laboratory
to reduce the frequency of test errors. The process consists of ve steps: de ne, me

asure,
analyze, improve, and control. The term six sigma denotes a process so precise tha
t six times
the standard deviation still results in a useful product (laboratory test result
that is within
acceptable limits for total allowable error). 2828_Ch09_523-536 06/08/12 11:27
AM Page 532 52.
Te Material Safety Data Sheets (MSDS) for hazardous materials must be reviewed b
y personnel per
Occupational Safety and Health Administration (OSHA) regulations: A. Weekly B. M
onthly C. Every 6
months D. Yearly Education and management/Laboratory regulations/1 53. SITUATION
: A medical
laboratory science student in training accidentally splashed a few drops of an e
xtraction reagent
from an enzyme immunoassay kit for group A Streptococcus into her right eye, and
felt an
immediate burning sensation. What should she do rst? A. Locate the MSDS sheet for
the EIA test
kit B. Go directly to the emergency department for treatment C. Go to the eye-wa
sh station and
rinse the eye thoroughly with water D. Report directly to her immediate supervis
or Education and
management/Laboratory operations/ Safety/1 54. A laboratory information system (
LIS) uses an
algorithm based on the delta check process to identify erroneous results. Tis pr
ocess is a part
of which LIS function? A. Quality control management B. Real-time instrument int
erfacing C.
Autoveri cation of test results D. Electronic crossmatching Education and manageme
nt/LIS/1 55.
According to CLIA 88, when performing and documenting linearity, the following sa
mples are
required: A. A single calibrator and a zero set point B. One normal and one abno
rmal level C.
Tree levels of known concentration and a zero level D. A high and low control ma
terial Education
and management/Laboratory operations/ Test validation/1 56. Which of the followi
ng would not be
appropriate for point-of-care testing? A. Cardiac markers B. Tyroid stimulating
hormone C.
Parathyroid hormone (PTH) D. Blood gases Education and management/Test utilizati
on/2 Chapter 9 |
Education and Management 533 Answers to Questions 5256 52. D OSHA requires sa
fety training
and the review of safety documents, including MSDS, on a yearly basis. The labor
atory must
maintain an MSDS inventory for all hazardous materials it uses. The inventory mu
st be readily
available to all employees who may come into contact with them. 53. C OSHA reg
ulations require
new employees and students be informed of all occupational hazards at the labora
tory, that the
laboratory testing personnel be provided with personal protective equipment, and
receive training
in procedures to be followed when exposed to hazardous materials. When a chemica
l compound comes
into contact with the skin or eyes, the rst course of action is to dilute the che
mical by
ooding it with a large volume of water. This process will be documented in the la

boratorys
chemical hygiene plan. 54. C Laboratory information systems perform many basic
functions such
as test ordering and worklist generation through real-time interfaces with labor
atory
instruments, quality control and assurance management, inventory control, and pr
oduction of
patient reports. In addition, they are capable of immediate decision making base
d on validated
algorithms. This process, called autoveri cation, is used to determine whether a t
est result is
reported, or whether another action is required. 55. C CLIA 88 guidelines requi
re linearity
testing by clinical laboratories on all nonwaived tests at least one time before
the test is
performed on patient samples. The linearity test veri es the manufacturers reportab
le range. In
simplest terms, this consists of a reagent blank, and three samples of known con
centration that
span the reportable range. A low, normal, and high control and reagent blank are
adequate for
this purpose. 56. B Point-of-care testing (POCT) refers to all tests performed
outside of the
laboratory environment. This includes bedside testing, emergency department test
ing, home and
nursing home testing, and tests performed in surgical and intensive care units.
POCT is done when
the care of the patient is improved by obtaining the result immediately. Cardiac
markers
performed in the emergency department allow for thromboembolitic and other inter
ventions to take
place more rapidly. Blood gas analysis at the beside permits immediate oxygen an
d ventilation
adjustments to be made and administration of drugs to counteract acidbase imbalan
ces. PTH assays
done in surgery allow the surgeon to determine if a PTH-secreting mass has been
successfully
removed. 2828_Ch09_523-536 06/08/12 11:27 AM Page 533 57. SITUATION: A shipme
nt from a
laboratory supply company arrived over the weekend. Te shipment consisted of gla
ss slides, latex
gloves, and plastic test tubesall nonperishable items. It was left on the outside
loading dock
overnight. Are these supplies useable for patient care/testing? A. Yes, with no
further quality
assurance testing required B. Yes, but only after quality analysis is performed
to ensure they
were not a ected adversely C. No, the latex gloves might be contaminated, but the
slides and test
tubes may be used D. No, all supplies left outside for 24 hours unattended must
be discarded
Education and management/Laboratory operations/3 58. SITUATION: An immunology su
pervisor ordered
several antinuclear antibody and in uenza A kits. Te outside packaging of both kit
s was marked to
store at 2 C8 C. Te kits were shipped with dry ice, but were unpacked at 7:00 p.m
. and left
in the mailroom at room temperature until 7:00 a.m. the next morning. What shoul
d be done with
the kits? A. Tey can be placed into inventory B. Tey must be tested using qualit

y controls before
use and used only if QC performance is acceptable C. Te kits should not be used
for clinical
testing D. Te disposition of the kits depends on the manufacturers documentation
for stability
and the labs lot-to-lot analysis Education and management/Laboratory operations/
Quality
assurance/3 59. SITUATION: Your immediate supervisor requests that you back date
and complete the
QC log for RPR test controls that were supposed to have been performed the previ
ous day. You did
not work that day, and suspect that the technologist who did work that day faile
d to enter the QC
results. Such an ethical dilemma falls under which behavioral domain? A. Cogniti
ve B. Psychomotor
C. A ective D. None of these options Education and management/Apply knowledge of e
ducational
methodology/2 534 Chapter 9 | Education and Management Answers to Questions 5760
57. B
Laboratories must have written policies for determining whether laboratory reage
nts and supplies
may be used. Nonperishable items should be inspected for contamination, damage,
and manufacturing
defects. Because items left in an uncontrolled environment may be exposed to adv
erse conditions
such as extreme temperatures, they should be inspected and tested to ensure that
their
performance is una ected. 58. D All laboratory kits and reagents must be stored
according to
the manufacturers instructions. The manufacturer should be consulted to determine
if storage
time and temperature limits have been established for the kits. If these have no
t been exceeded,
and the lot-to-lot analysis con rms that they are una ected, then the kits may be us
ed. 59. C
Ethical behavior in the laboratory falls under the a ective domain of behavioral o
bjectives. The
technologist should never enter results for a test that he or she did not perfor
m. Such false
documentation could lead to dismissal of the employee, and loss of licensure for
the laboratory.
60. A ISO refers to the International Organization for Standardization. ISO 90
00 is a set of
three standardsISO 9000, 9001, and 9004 (ISO 9003 is no longer used)for quality ma
nagement that
can be applied to any business or organization such as a clinical laboratory. Wh
en an
organization demonstrates compliance with ISO 9000 standards, it is said to be c
ertified. ISO
certification tells an organizations customers that it adheres to quality improve
ment standards
and guidelines that improve performance and ensure the highest quality possible.
60. What
documents are needed to meet the ISO-9000 standards for laboratory certi cation? A
. Quality
manual, document control, internal audits, corrective and preventive actions B.
Work performance
evaluation, maintenance, budgeting C. Inventory, quality control, customer satis
faction D. Risk
prevention, quality control, personnel Education and management/Laboratory regul

ations/2
2828_Ch09_523-536 06/08/12 11:27 AM Page 534 61. In the eld of clinical labora
tory testing
and in vitro diagnostic test systems, ISO/TC 212 is the document used for standa
rdization and
guidance in all of the following areas except: A. Quality management and quality
assurance B.
Scheduling, yearly evaluations, and workloads C. Pre- and postanalytical procedu
res D. Laboratory
safety and reference systems Education and management/Laboratory regulations/2 6
2. SITUATION: In
the course of isolation, B. anthracis is recovered that may be implicated in an
act of
bioterrorism. Such an organism would fall under which Centers for Disease Contro
l category of
biological agent? A. Category A B. Category B C. Category C D. None of these opt
ions Education
and management/Laboratory operations/ Safety/2 63. SITUATION: A patient refuses
to have his blood
drawn for a routine laboratory test request made by his physician. What is the m
ost appropriate
course of action? A. Perform the venipuncture against the patients will B. Do not
attempt the
venipuncture and le an incident report with the laboratory manager C. Request tha
t the patient
be sedated, then collect the sample D. Request assistance from the legal departm
ent Education and
management/Laboratory operations/2 64. Which of the following accurately describ
es the steps
involved in a LEAN process? A. Lower cost, e cient ow, added value, net result B. C
ustomer
value, value stream map, ow, pull, improved outcome C. Satisfaction, cost savings
, turnaround
time D. E ciency study, modeling, construct, step-by-step process Education and
management/Laboratory operations/2 65. SITUATION: A lab wishes to evaluate its s
pecimen
processing operations to improve test turnaround time for cardiac markers using
a LEAN process.
To accomplish this, the lab manager measures the time it takes for specimens to
be collected and
transported to the lab, entered into the LIS and instrument data link, centrifug
ed, and placed on
the automated track. Tis process is called: A. Establishing pull B. Creating a ow
diagram C.
Mapping the value stream D. Process analysis Education and management/Laboratory
operations/2
Chapter 9 | Education and Management 535 Answers to Questions 6165 61. B TC 2
12 is an ISO
standard written for clinical laboratory testing and manufacturing of in vitro d
iagnostic
products. The standards deal with the analytical test process, pre- and postanal
ytical processes,
laboratory safety, and quality assurance including personnel quali cations and acc
reditation. The
standards committee for ISO TC 212 in the United States works under the auspices
of the American
National Standards Institute (ANSI), and they have designated the Clinical Labor
atory Standards
Institute (CLSI) to oversee the standards committee. 62. A The CDC groups biol
ogical agents

that may be used to carry out terrorist threats into one of three categories: A,
B, or C.
Category A agents are those that would cause the most harm because of their high
ly infectious
nature, mode of transmission, and high mortality. This group includes Bacillus a
nthracis,
Clostridium botulinum, Francisella tularensis, Yersinia pestis, smallpox virus,
and viruses that
cause hemorrhagic fever such as Ebola and Marburg viruses. Category B includes b
acteria and
viruses that pose a lesser threat such as the organisms that produce ricin, gang
rene, and Q
fever. Category C includes emergent infectious agents such as hantavirus. 63.
B Patients have
the right to refuse treatment, even if they signed a document upon admission giv
ing consent for
treatment. In this situation, the supervisor should be noti ed, the incident docum
ented, and the
physician noti ed. The issue of informed consent is a legal one, and the laborator
y personnel
should act in accordance with the laws governing their jurisdiction. For example
, some courts
will not admit results of blood tests into evidence, if the subject had not been
formally
arrested and the sample was collected against the subjects will. 64. B LEAN is
a method used
to improve customer satisfaction. It is used often in clinical laboratories to i
mprove a process
such as test turnaround time. LEAN is not an acronym; it refers to streamlining
a process so that
there is no waste. The ve steps in the LEAN method are: value, value stream map, o
w, pull, and
improvement. 65. C A value stream map is a diagram of all steps involved in a
process. The map
is used to identify areas of waste where e ciency can be improved. Flow is the re ne
ment of the
value stream, eliminating waste and improving e ciency. Pull is the process of mer
ging the steps
into the next part of the process so that it works seamlessly and problems can b
e easily
identi ed and corrected. 2828_Ch09_523-536 06/08/12 11:27 AM Page 535 BI BL I O
GRAPHY 1.
Harmening DM. Laboratory Management, Principles, and Processes. 2nd edition, 200
7. D.H.
Publishing and Consulting, Inc., St. Petersburg, FL. 2. McGregor D. Te Human Sid
e of Enterprise.
1985. McGraw-Hill, New York. 3. Pozgar GD, Santucci NM, and Pinella JW. Legal an
d Ethical Issues
for Health Professionals. 2nd edition, 2005. Jones and Bartlett, Boston. 4. Regu
lations
Implementing the Clinical Laboratory Improvement Amendments of 1988 (42 CFR Part
405). Federal
Register. February 28, 1992:57(40). 536 Chapter 9 | Education and Management 5.
Varnadoe LA.
Medical Laboratory Management and Supervision. 2nd edition, 2008. PriorityEd, Fo
rt Pierce, FL. 6.
Wallace MA and Klosinski DD. Clinical Laboratory Science Education and Managemen
t. 1998. W. B.
Saunders, Philadelphia. 7. Westgard JO. Six Sigma Quality Design and Control. 20
01. Westgard QC.,

Inc., Madison, WI. 2828_Ch09_523-536 06/08/12 11:27 AM Page 536 CHAPTER 10 53

7
Photomicrographs and Color Plate Examination Refer to the photomicrographs and c
olor plates that
follow p. 544 Answers to Questions 12 1. A Using FITC-conjugated antihuman seru
m, di use
apple-green uorescence seen over the entire nucleus characterizes the homogenous
pattern. At a
signi cant titer, this pattern occurs in a variety of systemic autoimmune diseases
including
systemic lupus erythematosus, rheumatoid arthritis, systemic sclerosis, and Sjgre
ns syndrome.
The antibodies are directed against nucleoprotein; although they are mainly nonp
athological, they
are useful markers for active disease. 2. C A monoclonal gammopathy causes a b
and showing
restricted electrophoretic mobility usually located in the or the reion. The

nd represents
the
ccumul
tion of identic
l immunolo ulin molecules or fr
ments secreted y

m
lin
nt or
enin clone of pl
sm
cells. Con rm
tion of the
nd
s immunolo ulin is require
d ec
use other
homoenous proteins (such
s rinoen or c
rcinoem ryonic
ntien) c
n occur in t
he s
me
reions. 1. Pl
te 1 is
photomicror
ph of
n
ntinucle
r
nti ody test usin h
um
n ro l
sts,
uorescein isothiocy
n
te (FITC)conju
ted
ntihum
n serum,
nd tr
nsmitted uorescen
ce
microscopy. Which p
ttern of immuno uorescence is demonstr
ted in this 400 eld? A. H
omoenous
B. Peripher
l C. Nucleol
r D. Speckled Immunoloy/Identify microscopic morpholo
y/
Immuno uorescence/2 2. Pl
te 2 shows the electrophoresis of serum proteins on
hi
h-resolution


rose el
t pH 8.6. S
mple 1 (in l
ne 1) is
norm
l serum control. Which s
m
ple c
n e
presumptively cl
ssi ed
s
monoclon
l 
mmop
thy? A. S
mple 2 B. S
mple 4 C. S
m
ple 6 D. S
mple
8 Chemistry/Ev
lu
te clinic
l
nd l
or
tory d
t
/ Protein electrophoresis/3 282
8_Ch10_537-550
06/08/12 11:28 AM P
e 537 3. Pl
te 3 shows
densitometric sc
n of
control
serum for protein
electrophoresis. Te percent
es of e
ch fr
ction
re shown elow the sc
n. Given
these results,
wh
t is the most
ppropri
te initi
l corrective
ction? A. Repe
t the electropho
resis run usin
fresh control serum B. Report the results, provided th
t the previous run w
s in
control C. Move
the fourth fr
ction m
rk to the riht
nd redr
w the sc
n D. C
lcul
te the conce
ntr
tion of e
ch
fr
ction in r
ms per deciliter Chemistry/Identify sources of error/Densitometry
/3 4. Pl
te 4
shows the electrophoresis of serum proteins on
hih-resolution

rose el
t
pH 8.6. Which

nd represents the lipoprotein? A. A B. B C. C D. D Chemistry/Ev
lu
te clinic
l

nd l
or
tory
d
t
/ Protein electrophoresis/2 5. Pl
te 5 is
densitometric sc
n of
serum pr
otein
electrophoresis s
mple. Te rel
tive
nd
solute concentr
tion of e
ch fr
ction

nd reference

limits
re shown elow the sc
n. Wh
t is the correct cl
ssi c
tion of this densito
metric p
ttern?
A. Polyclon
l 
mmop
thy
ssoci
ted with chronic in
mm
tion B. Nephrotic syndrome
C. Acute
in
mm
tion D. Hep
tic cirrhosis Chemistry/Ev
lu
te clinic
l
nd l
or
tory d
t
/
Protein
electrophoresis/3 6. Pl
te 6 shows
n

rose el on which immuno x
tion electroph
oresis (IFE)
w
s performed
t pH 8.6. Te el cont
ins the s
me serum s
mple
s num er 6 shown
in Pl
te 2. Wh
t
is the he
vy
nd liht ch
in type of the monoclon
l protein present in this s
mp
le? A. IA B.
IgG C. IgG D. IM Chemistry/Evauate cinica an aboratory ata/ Immuno xation
eectrophoresis/3 538 Chapter 10 | Photomicroraphs an Coor Pate Examination
Answers to
Questions 36 3. C The fraction marker between the 2 -
nd -fr
ctions is m
rked i
mproperly.
Hih-resolution els produce individu
l pe
ks for h
ptolo in
nd 2 - m
crolo u
lin, which
p
rti
lly splits the 2 -
nd into two su fr
ctions. In
ddition, the -
nd m
y c
ont
in three
su fr
ctions correspondin to -lipoprotein, tr
nsferrin,
nd complement. In this
sc
n, the
v
lley etween the 2 -su fr
ctions w
s selected incorrectly
s the ound
ry etw
een the 2
nd -fr
ctions. This fr
ction m
rker should e pl
ced
t the next v
lley to the r
iht
nd the
sc
n redr
wn to determine the
re
under the 2 -
nd -fr
ctions correctly. 4. C
Usin hih
current, lipoprotein c
n e sep
r
ted from tr
nsferrin
nd complement (C3). Lipo
protein
mir
tes
nod
l to the tr
nsferrin (
nd l
eled D),
nd
ppe
rs
s
thin w
vy

nd. C3 mir
tes
c
thod
l to the tr
nsferrin
nd. The
nd l
eled A is -1
ntitrypsin
nd the

nd l
eled B
cont
ins -2 m
crolo ulin
nd h
ptolo in. The -2 m
crolo ulin is usu
lly
nod
l
to the
h
ptolo in. 5. C This p
ttern is ch
r
cterized y sini c
nt rel
tive incre
ses
in the 1
nd 2 -fr
ctions
nd
decre
se in serum
l umin concentr
tion. This p
ttern is
most often
c
used y incre
sed production of
cute ph
se re
ct
nts such
s 1 -
ntitrypsin

nd h
ptolo in
th
t
re
ssoci
ted with
cute in
mm
tion. This p
ttern is seen in myoc
rdi
l inf

rction
nd
other forms of
cute tissue injury, the e
rly st
e of
cute infection,
nd pre
n
ncy. 6. B IFE
is performed y pl
cin the p
tients s
mple in
ll six l
nes
nd sep
r
tin the p
roteins y
electrophoresis. Followin electrophoresis, the proteins in l
ne 1
re precipit

ted
nd xed y
overl
yin sulfos
licylic
cid onto the el. Monospeci c
ntiserum

inst e
ch he

vy or liht
ch
in is
pplied to the el over the l
nes
s l
eled
nd incu
ted to precipit

te the
immunolo ulins cont
inin the correspondin ch
in. The el is w
shed to remove
unprecipit
ted
proteins, then st
ined to visu
lize the precipit
ted
nds. This IFE el shows

n insolu le
immunoprecipit
te restricted to
sinle
nd in l
nes 2
nd 5. The proteins in

l
ne 2 re
cted
with
nti- (
nti-IG),
nd the proteins in l
ne 5 re
cted with
nti-. Lane 5 also
conains a
fain resriced band anodal o he IgG band. This band is no presen in lane 2
(does no
conain chains) an represents free ligh chains. 2828_Ch10_537-550 06/08/12 1
1:28 AM Page
538 7. Plae 7 shows he elecrophoresis of hemoglobin (Hgb) samples performed o
n agarose gel, pH
8.8. Te conrol sample is locaed in lanes 2 and 10 and conains Hgb A, S, and C
. Which sample(s)
are from neonaes? A. Samples 1 and 5 B. Sample 3 C. Sample 7 D. Samples 8 and 9
Chemisry/Evaluae clinical and laboraory daa/ Hemoglobin elecrophoresis/2 8.
Plae 8 shows
he elecrophoresis of Hgb samples on acid agar gel, pH 6.0. Te sample order is
he same as for
plae 7 wih he A, S, C conrol hemolysae in lanes 2 and 10. Based upon he el
ecrophoreic
mobiliy of sample 7 as seen in boh plae 7 and plae 8, wha is he paiens Hg
b phenoype? A.
SS B. AS C. AD D. AG Chemisry/Evaluae clinical and laboraory daa/ Hemoglobin
elecrophoresis/3 9. Plae 9 is a phoomicrograph of a fungal slide culure sai
ned wih
lacophenol coon blue, 400. Which of he following fungi is presen? A. Microsp
orum gypseum B.
Microsporum canis C. Aspergillus niger D. Aspergillus fumigaus Microbiology/Ide
nify microscopic
morphology/Fungi/2 10. Plae 10 is a phoomicrograph of a fungal slide culure s
ained wih
lacophenol coon blue, 400. Which of he following fungi is presen? A. M. gyps
eum B. M. canis
C. Trichophyon schoenleinii D. Epidermophyon occosum Microbiology/Idenify micr
oscopic
morphology/Fungi/2 Chaper 10 | Phoomicrographs and Color Plae Examinaion 5
39 Answers o
Quesions 710 7. A Neonaes and infans up o 6 monhs old have Hgb F levels be
ween 8% and
40%. The Hgb F level falls o below 2% in children over 2 years old. Hgb F is mo
re acidic han
Hgb S, and less acidic han Hgb A. Therefore, a an alaline pH, Hgb F has a gre
aer ne negaive
charge han Hgb S bu a lesser ne negaive charge han Hgb A, and migraes bew
een Hgb A and Hgb
S. 8. A Sample 7 demonsraes one major band on plae 7 in he Hgb S posiion.
Because Hgb A is
no presen, here is no normal -ene,
nd the p
tient c
n e cl
ssi ed
s
homozy
ote for H
S, D, or G which mir
te to the s
me position on

rose el
t
pH etween 8.4

nd 9.2. H S
c
n e di erenti
ted from H s D
nd G y performin electrophoresis on

r el

t pH 6.06.2.
On

r
t
cid pH, H C mir
tes furthest tow
rd the
node. H S mir
tes tow

rd the
node,
ut not
s f
r
s H C. H F mir
tes furthest tow
rd the c
thode, while H s
A, D, G,
nd E
mir
te to the s
me position, slihtly c
thod
l to the point of
pplic
tion. On
pl
te 8, s
mple 7
shows
sinle l
re
nd th
t mir
ted tow
rd the
node
t the s
me position
s
the S
nd in
the control s
mple. 9. D A. fumi
tus produces hy
line, sept
te hyph
e,
nd d

ome-sh
ped
vesicles, the upper one-h
lf to two-thirds of which
re covered with
row of ph
i
lides producin
lon ch
ins of conidi
. A. nier produces spheric
l vesicles th
t
re completely
covered with
phi
lides. The phi
lides produce jet- l
ck conidi
th
t o scure the vesicle surf

ce, formin

r
di
ted he
d. M. ypseum
nd M. c
nis produce sept
te m
croconidi
, not vesicles
with phi
lides.
10. A M. ypseum produces enormous num ers of symmetric, rouh m
croconidi
.
These h
ve thin
w
lls with not more th
n six comp
rtments
nd h
ve rounded ends. M. c
nis produc
es spindle-sh
ped
m
croconidi
with usu
lly more th
n six comp
rtments
nd pointed ends. E. flocco
sum forms
m
croconidi
ut not microconidi
. The m
croconidi

re smooth
nd clu sh
ped w
ith rounded ends.
E
ch cont
ins 26 cells
nd
re found sinly or in clusters. T. schoenleinii does
not produce
m
croconidi
or microconidi

nd is identified y its hyph
e-formin ch
r
cteris
tics. T.
schoenleinii forms
ntler-like r
nchin hyph
e c
lled f
vic ch
ndeliers. 2828_C
h10_537-550
06/08/12 11:28 AM P
e 539 11. Pl
te 11 is
photomicror
ph of
fun
l slide
culture st
ined
with l
ctophenol cotton lue, 400. Te morpholoy is most consistent with which fu
nus? A.
Asperillus spp. B. Penicillium spp. C. Scedosporium D. Fus
rium Micro ioloy/Id
entify
microscopic morpholoy/ Mycoloy/2 12. Pl
te 12 is
roncho
lveol
r l
v
e s
mp
le concentr
ted
y cytocentrifu
tion
nd st
ined with Wrihts st
in, 1,000. Te s
mple w
s o t
ine
d from

p
tient with AIDS who resides in the midwestern United St
tes. Which infectious

ent is present?
A. Pneumocystis jiroveci (c
rinii) B. Myco
cterium
viumintr
cellul
re C. Histop
l
sm

c
psul
tum D. Cryptococcus neoform
ns Micro ioloy/Identify microscopic morpholo
y/ Mycoloy/2
13. Pl
te 13 is
fec
l specimen seen under 400 usin riht eld microscopy. Te pl

te shows the
ovum of which p
r
site? A. Nec
tor
meric
nus B. Trichuris trichiur
C. Asc
ris
lum ricoides D.
Entero ius vermicul
ris Micro ioloy/Identify microscopic morpholoy/ P
r
sites/
2 14. Pl
te 14 is

fec
l specimen unst
ined seen under 400 usin riht eld microscopy. Te pl
te sho
ws the ovum
of which p
r
site? A. N.
meric
nus B. T. trichiur
C. A. lum ricoides D. E. ver
micul
ris
Micro ioloy/Identify microscopic morpholoy/ P
r
sites/2 15. Pl
te 15 is
n iod
ine-st
ined fec
l
specimen seen under 400 usin riht eld microscopy. Te pl
te shows the ovum of whi
ch p
r
site?
A. Pinworm B. Tre
dworm C. Hookworm D. Whipworm Micro ioloy/Identify microscopi
c morpholoy/
P
r
sites/2 540 Ch
pter 10 | Photomicror
phs
nd Color Pl
te Ex
min
tion Answer
s to Questions
1115 11. A This pl
te shows
funus with thin, sept
te, r
nchin hyph
e. A co
nidiophore is
present in the center th
t cont
ins
dou le row of phi
lides producin round co

nidi
.
Fus
riumspp. produces c
noe-sh
ped m
croconidi
. These
re m
de y phi
lides
tt

ched to the
hyph
e in the
sence of conidiophores. Penicilliumspp. produce conidi
from
s
inle row of
phi
lides th
t resem les
rush or the skeleton of
h
nd. Scedosporiumspp. pro
duce
nnellides
on short conidiophores with ov
l conidi
th
t
re t
pered
t one end. 12. C Th
is pl
te shows

und
nt Histopl
sm
c
psul
tum (ye
st ph
se) within the cytopl
sm of oth the m

croph
e
nd
histiocyte. All of the or
nisms listed m
y c
use pulmon
ry pneumoni
in immunod
e cient p
tients.
Sm
ll ov
l ye
st cells, 25 in diameter, are seen. 13. B The ova of T. trichiura
are brown
and shaped like a football with mucus plugs at both ends. Ova have a thick wall
and measure about
50 long by 20 wide. Enterobius ova are approximately the same size but have a cl
ear (hyaline)
shell, flat on one side with a visible larva within. Necator eggs are larger (ap
proximately 6575
long by 40 wide) and have a clear shell. 14. C Ascaris ova are large and ova
l, usually
measuring 5075 long by 3550 wide. They are often bile stained and may have a thick
shell
with a coarse covering (corticated). This egg demonstrates a contracted embryo,
leaving space
between the shell and the embryo at the opposing poles. This indicates that the
egg is
fertilized. 15. C Hookworm ova are approximately 6075 in length and 3540 in widt
h. They
have a thin outer shell usually containing an unembryonated or partly embryonate
d egg within. The
ova of Necator and Ancylostoma cannot be di erentiated from one another. Threadwor
m
(Strongyloides) produces similar ova, but these hatch in the intestine, releasin
g the rhabditoid
larvae that are found in the feces. Pinworm (Enterobius) ova are approximately t
he same size but
are more elongated and at on one side. Whipworm (Trichuris) ova are smaller and t
hick walled
with mucus plugs at both ends. 2828_Ch10_537-550 06/08/12 11:28 AM Page 540 1
6. Plate 16 is an
unstained fecal specimen seen under 400 using bright eld microscopy. Te plate shows
the ovum of
which parasite? A. Clonorchis sinensis B. Fasciola hepatica C. Paragonimus weste
rmani D.
Fasciolopsis buski Microbiology/Identify microscopic morphology/ Parasites/2 17.
Plate 17 is an
unstained fecal specimen seen under 400 using bright eld microscopy. Te plate shows
the ovum of
which parasite? A. Fasciola hepatica B. Paragonimus westermani C. Metagonimus yo
kogawai D.
Opisthorchis viverrini Microbiology/Identify microscopic morphology/ Parasites/2
18. Plate 18 is
a peripheral blood lm stained with Giemsas stain, 1,000. What condition is suspecte
d from this
eld? A. Macrocytic anemia B. Agranulocytosis C. Relapsing fever D. Lead poisoning
Microbiology/Identify microscopic morphology/ Spirochete/2 19. Plate 19 shows an
organism

isolated from an eye wash of a patient with a cornea infection who had been wear
ing contact
lenses for the past 2 years. What is the name of the causative agent? A. Naegler
ia spp. B.
Acanthamoeba spp. C. Entamoeba histolytica D. Trichomonas vaginalis Microbiology
/Identify
microscopic morphology/ Parasites/2 20. Plate 20 is a Wrights-stained peripheral
blood lm,
1,000. Which malarial stage is present in the RBC in the center of the plate? A.
Ring
trophozoite of Plasmodium vivax B. Mature trophozoite of Plasmodium malariae C.
Macrogametocyte
stage of Plasmodium falciparum D. Mature gametocyte stage of Plasmodium ovale
Microbiology/Identify microscopic morphology/ Parasites/3 Chapter 10 | Photomicr
ographs and Color
Plate Examination 541 Answers to Questions 1620 16. A C. sinensis produces
small,
bile-stained ova approximately 2535 in length and 1020 in width. Ova have a collar
(shoulder) on both sides of the operculum and a knob at the end opposite the ope
rculum. Fasciola,
Paragonimus, and Fasciolopsis all produce large, yellow-brown operculated ova. 1
7. B P.
westermani produces large, operculated ova measuring approximately 80100 in lengt
h and 5070
in width. They are yellow-brown and nonembryonated. Metagonimus and Opisthorchis
ova are small
ova resembling Clonorchis. Fasciola produces ova that are also yellow-brown, ope
rculated, and
unembryonated. The ova are larger than Paragonimus and lack the small shoulders
adjacent to the
operculum of Paragonimus ova. 18. C This eld shows long helical bacteria betwee
n red blood
cells (RBCs) of normal size and color. These spirochetes are sometimes seen in t
he blood of
patients su ering from the febrile septic phase of infection with Borrelia or Lept
ospira spp. The
former are more commonly encountered in di erential exams, especially in patients
infected with
Borrelia recurrentis and other species that cause relapsing fever. Borrelia burg
dorferi, the
causative agent of Lyme disease, is rarely seen in Wrights-stained blood lms and i
s usually
diagnosed by enzyme-linked immunosorbent assay (ELISA) and other serological met
hods. 19. B
This is a large trophozoite with spiculated cytoplasm characteristic of Acantham
oeba. Eye
infections caused by this organism have been documented in contact lens wearers
who do not
properly disinfect lenses. Acanthamoeba spp. are large trophozoites measuring 255
0 . They may
also cause primary amoebic meningoencephalitis, although they are isolated less
often than
Naegleria in the cerebrospinal fluid (CSF) of patients with this disease. 20.
A The infected
RBC demonstrates enlarged amoeba-like cytoplasm and Schffners dots, which are char
acteristic of
P. vivax and ovale. The parasite is at the ring-form trophozoite stage. 2828_Ch1
0_537-550
06/08/12 11:28 AM Page 541 21. Plate 21 is a modi ed acid-fast stain with malach
ite green

counterstain of a stool specimen, 1,000 magni cation. Te oocysts seen in this eld ar
e
approximately 5 in diameter. Which organism is present? A. Isospora belli B. Cry
ptosporidium
parvum C. Cyclospora spp. D. Sarcocystis spp. Microbiology/Identify microscopic
morphology/
Parasites/2 22. Plate 22 is a Gram-stained CSF concentrated by centrifugation, 1
,000. Which
organism is present? A. Neisseria meningitidis B. Staphylococcus aureus C. Strep
tococcus
pneumonia D. Listeria monocytogenes Microbiology/Identify microscopic morphology
/CSF/2 23. Plate
23 is a urinary sediment viewed under 400 magni cation using a bright eld microscope.
What is
the object located in the center of the eld? A. Schistosoma haematobium ovum B. O
val fat body C.
Glitter cell D. Fecal contaminant Body uids/Identify microscopic morphology/Urine
sediment/2 24.
Plate 24 is a urinary sediment viewed under 400 magni cation using a bright eld micro
scope.
Which crystals are seen? A. Uric acid B. Calcium oxalate C. Ammonium magnesium p
hosphate D.
Hippuric acid Body uids/Identify microscopic morphology/Urine sediment/2 25. Plat
e 25 is a
urinary sediment viewed under 400 magni cation using a bright eld microscope. Which c
rystals are
seen? A. Uric acid B. Calcium oxalate C. Ammonium magnesium phosphate D. Hippuri
c acid Body
uids/Identify microscopic morphology/Urine sediment/2 542 Chapter 10 | Photomicro
graphs and
Color Plate Examination Answers to Questions 2125 21. B All of the organisms li
sted are
coccidian parasites that cause diarrhea, especially in immunode cient patients suc
h as those with
AIDS. Cryptosporidium produces the smallest oocysts (half the size of Cyclospora
, which is the
next smallest) and is visible in stools using either the acid-fast or immuno uores
cent staining
techniques. The oocysts are round, about 5 in diameter, and deep pink. 22. C T
his eld shows
abundant gram-positive diplococci with the lancet shape that is characteristic o
f S. pneumoniae.
Group B Streptococcus is a common cause of bacterial meningitis in infants. List
eria may cause
bacterial meningitis in infants and elderly patients, while S. pneumonia is most
often
encountered in middle-aged adults and older patients. Staphylococcus, Streptococ
cus, and Listeria
spp. are gram positive while Neisseria is gram negative. Listeria is a small coc
cobacillus or
rod. Staphylococcus is rarely isolated from CSF and appears as small grapelike c
occi. 23. B
Oval fat bodies are degenerated renal tubular epithelia that contain a high conc
entration of
neutral fat, largely reabsorbed cholesterol droplets. These appear highly refrac
tile under
bright eld microscopy, and the fat globules produce a Maltese cross e ect under a po
larizing
microscope. Oval fat bodies occur in conditions associated with increased urinar
y lipoprotein

excretion such as the nephrotic syndrome. 24. A Uric acid crystals are yellow
to reddish-brown
in color and occur in acid or neutral urine. Common forms include whetstones and
rhombic plates
(as seen here), as well as thin needles and rosettes. Calcium oxalate crystals a
re usually
colorless octahedrons. Ammonium magnesium phosphate crystals are long, colorless
six-sided
prisms, and hippuric acid crystals are colorless long, at, hexagonal plates. 25.
C Ammonium
magnesium phosphate crystals (triple phosphate) occur in alkaline or neutral uri
ne. They are
long, colorless hexagonal prisms that often resemble a co n lid. They may also occur
in a
feathery form that resembles a fern leaf. Triple phosphate crystals may form cal
culi in the renal
pelvis appearing on an x-ray as an outline of the calyces and referred to as stag
-horn calculi.
2828_Ch10_537-550 06/08/12 11:28 AM Page 542 26. Plate 26 is a urinary sedime
nt viewed under
400 magni cation using a bright eld microscope. Which type of cast is present? A. Hya
line cast
B. Broad cast C. Waxy cast D. Coarse granular cast Body uids/Identify microscopic
morphology/Urine sediment/2 27. Plate 27 shows a urinary sediment viewed under 4
00 magni cation
using bright eld microscopy. Tis colorless crystal is presumptively identi ed as: A.
Calcium
phosphate B. Acetaminophen C. Cystine D. Hippuric acid Body uids/Identify microsc
opic
morphology/Urine sediment/2 28. Plate 28 is a Wrights-stained cytocentrifuge prep
aration of
pleural uid, 1,000. What is the correct classi cation of the largest mononuclear cel
l located
in the center of the plate? A. Histiocyte B. Macrophage C. Lymphoblast D. Mesoth
elial cell Body
uids/Identify microscopic morphology/Pleural uid/2 29. Plate 29 is a Wrights-staine
d smear of
pleural uid prepared by cytocentrifugation. Te largest cell in this eld (see arrow
) is
identi ed as a: A. Signet ring macrophage B. Reactive mesothelial cell C. Foam cel
l D. Metastatic
cell from the breast Body uids/Identify microscopic morphology/Pleural uid/2 30. P
late 30 is
from a Wrights-stained peripheral blood lm, 1,000. Which of the following best desc
ribes the
cells in this plate? A. Normal morphology B. Macrocytic red blood cells C. Hyper
segmented
neutrophil present D. Reduced platelets Hematology/Identify microscopic morpholo
gy/RBCs/2 Chapter
10 | Photomicrographs and Color Plate Examination 543 Answers to Questions 2630
26. D Coarse
granular casts often form from degeneration of cellular casts. The nding of more
than a rare
granular cast is signi cant and helps to identify the kidney as the source of urin
ary protein and
cells. Coarse and ne granular casts have the same signi cance as cellular casts and
point to
glomerular damage. 27. C Cystine crystals form in acid urine and appear as col
orless uniform
six-sided hexagonal plates in urinary sediment. Calcium phosphate crystals form

in neutral to
alkaline urine and appear as thin amorphous crystals resembling a sheet of ice o
r as at needles
that form a rosette. Acetaminophen crystals are cylinder shaped with round edges
. Hippuric acid
crystals form long six-sided prisms in acid urine. Cystine crystals must be di ere
ntiated from
uric acid on the basis of solubility, polarized microscopy, or biochemical testi
ng. Cystine
crystals are less anisotropic than uric acid. Cystine crystals are soluble in di
lute hydrochloric
acid (HCl), but uric acid is insoluble. Cystine causes a positive cyanidenitropru
sside test and
uric acid does not. 28. D Mesothelial cells are specialized epithelium that li
ne the serous
membranes, and they may be seen in small numbers in normal pleural, pericardial,
and ascites
uids. They are often seen in increased numbers when there is an in ammatory injury
involving the
serous membranes. They are large mononuclear or binucleate cells with an open ch
romatin pattern
and abundant agranular cytoplasm. Mesothelial cells may transform into phagocyti
c cells and
undergo morphological changes that cause them to resemble malignant cells. 29.
A Macrophages
are frequently seen in serous uids. They are present in increased numbers in exud
ative
conditions. Signet ring forms result from compression of the nucleus against the
cell wall,
usually caused by large vacuoles that form after phagocytosis of erythrocytes or
fat. 30. A The
size, shape, and central pallor of the red cells in this plate are normal. The m
orphology of the
neutrophil is typical in appearance. Platelets of normal size and shape are pres
ent. On average,
there should be less than three platelets per oil immersion (1,000) eld when throm
bocytopenia
is present. 2828_Ch10_537-550 06/08/12 11:28 AM Page 543 31. Plate 31 is a Wr
ights-stained
peripheral blood lm, 1,000. What is the most appropriate classi cation of the red ce
ll
morphology seen in this eld? A. Microcytic, hypochromic B. Microcytic, normochrom
ic C.
Normocytic, normochromic D. Macrocytic, normochromic Hematology/Identify microsc
opic
morphology/RBCs/3 32. Plate 32 is a Wrights-stained peripheral blood lm, 1,000. Wha
t is the
most appropriate classi cation of the white blood cells (WBCs) present in this eld?
A. Reactive
(atypical) lymphocytes B. Large lymphoblasts exhibiting L2 morphology C. Te M4 s
ubtype of acute
granulocytic leukemia D. Monocytes Hematology/Identify microscopic morphology/WB
Cs/3 33. Plate 33
is from a Wrights-stained peripheral blood lm, 400. Which of the following tests ma
y be
performed to enable an accurate diagnosis? A. Leukocyte alkaline phosphatase (LA
P) stain B.
Myeloid marker study by ow cytometry C. Myeloperoxidase stain D. Periodic acidSchi
(PAS) stain
Hematology/Identify microscopic morphology/WBCs/3 34. Plate 34 is from a Wrights-

stained
peripheral blood lm, 400. Te cells seen are diagnostic of which condition? A. Intr
avascular
hemolytic anemia B. Sickle cell disease C. Myelo brosis D. Erythroleukemia Hematol
ogy/Identify
microscopic morphology/RBCs/3 35. Plate 35 is from a Wrights-stained peripheral b
lood lm,
1,000. Which description of the RBC morphology and platelets is correct? A. Micro
cytic,
hypochromic with marked poikilocytosis and increased platelets B. Macrocytic, hy
pochromic with
marked anisocytosis and normal platelets C. Normocytic, normochromic with mild p
oikilocytosis and
increased platelets D. Microcytic, hypochromic, with mild anisocytosis and norma
l platelets
Hematology/Identify microscopic morphology/RBCs/2 544 Chapter 10 | Photomicrogra
phs and Color
Plate Examination Answers to Questions 3135 31. D Many of the RBCs in this eld a
re larger
than the nucleus of the small lymphocyte indicating that they are macrocytic. Se
veral of the RBCs
are elliptical in shape and are classi ed as ovalocytes. The region of central pal
lor of most of
the cells is normal. Macrocytic anemia (anemia with an increased mean cell volum
e [MCV]) is
commonly seen in patients with chronic liver disease, vitamin B 12 or folate de ci
ency,
hypothyroidism, and alcoholism. 32. A These cells are lymphocytes characterist
ic of those found
in viral infections such as infectious mononucleosis. In these conditions, the W
BC count is
increased (usually 1525 10 3
/
L), and
lymphocytes account for the majority of the WBCs. Reactive lymphocytes a
re larger than
normal. The cytoplasm is increased in volume and may be vacuolated, and the edge
s of the cell are
often scalloped and basophilic. The nuclear chromatin pattern is open and reticu
lar. 33. A This
plate shows marked granulocytosis demonstrating cells at all stages of maturity
and marked
thrombocytosis. These characteristics suggest chronic myelogenous leukemia (CML)
, but they also
occur in the leukemoid response, which is a severe granulocytosis in response to
infection,
inflammation, tissue damage, or malignancy. The LAP test is performed to disting
uish the two
conditions. In CML, the LAP score is markedly reduced, usually 10 or below. In t
he leukemoid
response (and leukoerythroblastosis) the LAP score is elevated (reference range
20100). In
addition to the LAP stain, cytogenetic evaluation is another important diagnosti
c marker for CML.
Ninety-five percent of patients with CML display the Philadelphia (Ph 1 ) chromo
some in their
granulocytes. 34. B This plate displays polychromasia, abundant target cells (
leptocytes), and
well-defined sickle cells (drepanocytes) characteristic of sickle cell disease.
Sickle cells are
elongated with pointed ends, and the Hgb is concentrated in the center of the ce

ll. They may also

be encountered in a few other hemoglobinopathies, such as Hgb SC disease, but ar
e rarely seen in
patients with sickle cell trait. 35. A These RBCs demonstrate extreme central
pallor
characteristic of cells that are microcytic and hypochromic. Target cells, ovalo
cytes, burr
cells, and cell fragments are present. On average, when more than 20 platelets a
re seen per oil
immersion eld, the platelet count is elevated. 2828_Ch10_537-550 06/08/12 11:28
AM Page 544
36. Plate 36 is a Wrights-stained peripheral blood lm, 1,000. Te RBCs in this plate
are
characteristic of: A. Hemolytic anemia B. Myelo brosis C. Hgb C disease D. Siderob
lastic anemia
Hematology/Identify microscopic morphology/RBCs/ 3 37. Plate 37 is a Wrights-stai
ned peripheral
blood lm, 1,000. Te cells seen in this plate are associated with: A. Lead poisonin
g B. Aplastic
anemia C. Iron de ciency anemia D. Intravascular hemolysis Hematology/Identify mic
roscopic
morphology/RBCs/3 38. Plate 38 is from a Wrights-stained peripheral blood lm, 400.
Which of
the following conditions is consistent with this RBC morphology? A. Erythroleuke
mia B.
T
l
ssemi
m
jor C. Fol
te de ciency
nemi
D. Autoimmune hemolytic
nemi
Hem
tol
oy/Identify
microscopic morpholoy/RBCs/3 39. Pl
te 39 is from
Wrihts-st
ined sme
r of per
ipher
l lood,
1,000 from
p
tient with
WBC count of 35 10 9
/
L. The p
tient is
60 ye
rs old with firm, enl
red lymph nodes
nd hep
tosplenome
ly. The
se s
me cells
comprise 50% of the one m
rrow WBCs
nd
re positive for PAS
nd ne
tive for m
yeloperoxid
se

nd nonspecific ester
se. Wh
t is the most likely di
nosis? A. EpsteinB
rr virus
infection B.
Infectious mononucleosis C. Chronic lymphocytic leukemi
D. W
ldenstrms m
crolo u
linemi

Hem
toloy/Ev
lu
te clinic
l
nd l
or
tory d
t
/ Leukemi
/3 Ch
pter 10 | Photom
icror
phs
nd
Color Pl
te Ex
min
tion 545 Answers to Questions 3639 36. B The peripher
l l
ood in
myelofi rosis is leukoerythro l
stic
nd is ch
r
cterized y te
rdrop cells (d
c
rocytes),
ov
locytes, nucle
ted RBCs,
sophilic stipplin, poikilocytosis, leukocytosis,

nd (often)
microme
k
ryocytes. H C dise
se produces normocytic or slihtly microcytic
n
emi
with m
ny
t
ret cells. Sidero l
stic
nemi
produces oth microcytic, hypochromic RBCs,

nd normocytic
RBCs in the lood (dimorphic RBC morpholoy). Hemolytic
nemi
s
re usu
lly norm
ocytic,
normochromic, or m
crocytic with polychrom
si
, ut morpholoy v
ries with the c

use of
hemolysis. 37. A Sever
l RBCs in this pl
te show co
rse
sophilic stipplin.
B
sophilic
stipplin results from unst
le RNA within the cell
nd is
ssoci
ted with defec
ts in H
synthesis. This is most often
ssoci
ted with le
d poisonin, hemolo inop
thies

, myelo rosis,

nd me
lo l
stic
nemi
s. 38. B This pl
te shows severe microcytic, hypochrom
ic RBCs with
numerous t
ret cells
nd m
rked
nisocytosis. A polychrom
tophilic normo l
st i
s present. In

ddition, th
l
ssemi
is
lso
ssoci
ted with poikilocytes, HowellJolly odies, o
v
locytes,
nd
siderocytes. Fol
te de ciency produces
m
crocytic
nemi
,
nd
utoimmune hemolyt
ic
nemi
is
usu
lly normocytic, normochromic. The peripher
l lood in erythroleukemi
cont
i
ns m
ny nucle
ted
RBC precursors demonstr
tin iz
rre sh
pes. 39. C The WBCs in this pl
te (wit
h the exception
of one r
nulocyte)
re sm
ll lymphocytes. Chronic lymphocytic leukemi
is r
re
in p
tients under
the
e of 30. The peripher
l lood demonstr
tes
predomin
nce of sm
ll lymphoc
ytes, usu
lly
20200 10 9