Münchhausen Syndrome: A Case Report of an Unusual Cause of Vitamin K Antagonist Intoxication.

Psychiatric disorders must be considered in the differential diagnosis of patients presenting to the emergency department with unexplainable somatic symptoms. Physicians should be aware of Münchhausen syndrome as a possible diagnosis. A 46-year-old female patient presented at the emergency department with signs of coagulopathy. She denied taking any anticoagulant drugs as well as rat poison. Urine toxicology revealed the presence of vitamin K antagonists (VKAs). After an extensive workup, she was diagnosed with Münchhausen syndrome. Intentional intoxication with VKA is rare.

An unconscious man with profound drug-induced hypoglycaemia.

INTRODUCTION: Hypoglycaemia has been reported as an unusual complication of tramadol use and in a few cases of tramadol poisoning, but the exact mechanism is not known. CASE DESCRIPTION: An ambulance crew was dispatched to an unconscious 46-year old man. A glucometer point-of-care measurement revealed a profound hypoglycaemia (1.9 mmol/L). Treatment with intravenous glucose was started and the patient was transported to the hospital. The patient had several episodes of pulseless electrical activity requiring cardiopulmonary resuscitation in the ambulance and upon arrival in the hospital. Despite continuous glucose infusion the hypoglycaemia was difficult to correct during the next few hours and the patient developed hypokalaemia. Further investigation to identify the cause of hypoglycaemia revealed that insulin and C-peptide were inappropriately raised. A toxicological investigation revealed the presence of tramadol and its metabolites in lethal concentrations. Also acetaminophen, ibuprofen and lormetazepam were present. Ethanol screening was negative (< 0.1 g/L) and no sulfonylurea were detected. The patient developed multiple organ failure, but eventually recovered. WHAT HAPPENED: The hypoglycaemia was caused by inappropriate stimulation of insulin secretion in a patient intoxicated with tramadol. The sudden hypokalaemia was caused by a massive intracellular shift of potassium in response to the hyperinsulinemia, triggered by the intravenous administration of glucose. MAIN LESSON: To our knowledge, we are the first to document a significant rise in endogenous insulin production in a hypoglycaemic patient presenting with tramadol intoxication. Our observation suggests that hyperinsulinemia could be the cause of the hypoglycaemia associated with tramadol use.

Gliotoxin and bis(methylthio)gliotoxin are not reliable as biomarkers of invasive aspergillosis.

BACKGROUND: Invasive pulmonary aspergillosis (IPA) remains a life-threatening opportunistic infection, but can be difficult to diagnose. New biomarkers are therefore needed. Gliotoxin (GT), a secondary metabolite of Aspergillus fumigatus, and bis(methylthio)gliotoxin (bmGT), a degradation product of GT, have been proposed as potential biomarkers. However, these findings have yet to be confirmed. OBJECTIVES: To identify the diagnostic potential of GT and bmGT in serum and bronchoalveolar lavage fluid (BALf) in haematology patients compared to galactomannan (GM). MATERIALS AND METHODS: We prospectively collected culture supernatant, serum and BALf from patients with culture-positive IPA and measured GT and bmGT concentrations using ultra high-performance liquid chromatography-quadrupole time of flight mass spectrometry. Galactomannan was detected using a commercially available enzyme immunoassay. RESULTS: We included 18 patients with proven (n = 6) and probable (n = 12) IPA, all with positive cultures for Aspergillus fumigatus. BmGT was only detected in serum from one patient (5.6%), whereas GM was positive (optical density ≥ 0.5) in 11/18 patients (61.1%, P = 0.002). We could not find GT in any serum sample. In BALf, bmGT was detected in 8/18 patients (44.4%) and GT in 9/18 patients (50%), compared to GM (optical density ≥ 1.0) in all patients (100%). CONCLUSIONS: Gliotoxin and bis(methylthio)gliotoxin had a very poor performance for diagnosing IPA. As other biomarkers are more sensitive and easier to detect, we would not recommend serum or BALf GT/bmGT to be used in the diagnosis of IPA.

An abrupt rise of coagulation error messages on ACL TOP automated analysers.

INTRODUCTION: Blood coagulation tests (BCT) are very important for clinicians to diagnose bleeding or thrombotic disorders and to monitor anticoagulant therapy. CASE DESCRIPTION: On a Saturday morning, a laboratory technician noted an abrupt rise in the number of coagulation error messages on our ALC TOP analysers. Visual inspection revealed the presence of partially and/or fully clotted citrate tubes and prompted the clinical biologist to further investigate a potential preanalytical cause. CONSIDERED CAUSES: Partially or fully clotted blood in citrate tubes can have multiple causes including improper mixing of the tube, under- or overfilling or combining blood samples from different tubes into one citrate tube. WHAT HAPPENED: The affected citrate tubes originated mostly from the same clinical departments. Moreover, all the affected tubes shared the same lot number (1 of 7 in use at the time). Visual inspection of 7 unopened boxes of 100 citrate tubes of this lot number revealed one box with nine completely empty and two partially filled tubes and one box with two partially filled tubes. No under-filled tubes were found in the other 5 boxes. DISCUSSION: The blood to additive ratio is crucial for BCT. A sudden rise in clot errors should trigger a thorough investigation to identify the cause. MAIN LESSON: Laboratories should regularly monitor and evaluate the percentage of clotted samples as a quality indicator at scheduled time points. A problem with the volume of additive in citrate tubes should be considered as a possible cause.

Hemoglobin S monitoring on TOSOH G8 in hemoglobin A1c mode in case of urgent red blood cell exchange.

BACKGROUND: Pre- and post-transfusion hemoglobin S (HbS) levels are used to document the efficacy of red blood cell exchange (RCE) in patients with sickle cell disease (SCD). In case of urgent RCE a 24/7 short turn-around time (STAT) analysis, with the ability to identify and quantify HbS, is warranted. The use of TOSOH G8 (Tosoh Europe) is evaluated for this purpose, using the variant HbA1c mode. METHODS: Analytical performance of the HbS analysis on TOSOH G8 in variant HbA1c mode was evaluated, including assessment of imprecision and linearity for HbS. In addition, a comparison study between TOSOH G8 and Minicap Flex Piercing (FP) system CZE (Sebia) using 32 HbS samples (HbS range: 9%-93%) was carried out to evaluate analytical and clinical concordance. RESULTS: Total HbS imprecision was 1.77% and 0.31% for a sickle cell trait and a sickle cell anemia sample, respectively. An acceptable linearity (HbS range: 6%-88%) was observed (R2  > .99). Passing-Bablok regression analysis showed a significant proportional bias; however, a good analytical concordance (r > .95) was found. Our results suggested that TOSOH G8 underestimated HbS results compared with those of Minicap FP system (mean difference: -3.54%), especially in samples with a high HbS concentration. CONCLUSION: Hemoglobin S results obtained with TOSOH G8 in variant HbA1c mode are clinically acceptable to monitor urgent RCE. The observed underestimation will not alter clinical decision-making.

Evaluation of the V8 E-Class, a Novel Automated Capillary Isoelectric Focusing Instrument for Hemoglobinopathy Screening.

OBJECTIVES: We evaluated the performance of a novel capillary isoelectric focusing (CIEF) application for hemoglobinopathy screening on the recently introduced V8 E-Class platform. METHODS: Analytical performance of the V8 E-Class was evaluated and included assessment of hemoglobin A2 (HbA2) imprecision; linearity for HbA2, fetal hemoglobin (HbF), and sickle hemoglobin (HbS); and carryover for HbS. Furthermore, a method comparison with the Minicap Flex Piercing (Sebia, Lisses, France), the Variant Classic (Bio-Rad Laboratories, Hercules, CA), and the G8 (Tosoh Europe, Amsterdam, the Netherlands) was done to assess analytical and clinical concordance. RESULTS: Total HbA2 imprecision was 3.26% and 3.14% for normal and elevated HbA2 controls and 5.16% and 3.58% for a normal and a heterozygous HbS patient sample, respectively. HbA2, HbF, and HbS showed acceptable linearity, and no carryover was observed. The method comparison showed good analytical concordance (r > 0.95) except for a homozygous HbS subset (r = 0.532-0.704). A comparable phenomenon was seen for the clinical concordance with good agreement in samples without variants (weighted κ > 0.80) but poorer agreement in HbS samples (κ < 0.30). CONCLUSIONS: Good analytical performance was demonstrated for this novel CIEF application for hemoglobinopathy screening. Method comparison showed generally good correlation but highlights the need for standardization. Finally, software optimization could further add to its use for routine hemoglobinopathy screening.

A Mosaic Expression of a Hb J-Amiens (HBB: c.54G > T; p.Lys18Asn) and its Interference with Hb A1c Analysis.

We report the case of a 56-year-old Caucasian woman in whom hemoglobinopathy screening was triggered following an aberrant Hb A1c analysis. Preliminary diagnosis of the hemoglobin (Hb) variant was obtained through cation exchange high performance liquid chromatography (HPLC) and gel electrophoresis. DNA analysis confirmed the presence of Hb J-Amiens [ß17(A14)Lys→Asn; HBB: c.[54G > C or 54G > T)]. However, an unbalanced ratio between wild type and mutant signal after direct sequencing and a lower than expected percentage of this Hb variant led to the suggestion of a mosaic expression. Furthermore, different methods [capillary zone electrophoresis (CZE), cation exchange HPLC and boronate affinity] were tested to study the possible interference of this variant with Hb A1c measurements. These investigations showed a clinically relevant difference between the methods tested. Hb A1c analysis may lead to the discovery of new Hb variants or mosaicism for previously described Hb variants. This may have genetic consequences for the offspring of carriers and brings about the question of partner testing.

Possibilities and limitations of signal summing for an immunosuppressant LC-MS/MS method.

Liquid chromatography-tandem mass spectrometry (LC-MS/MS) is the method of choice for quantifying small molecules in research and clinical setting. Although there is a large toolkit to increase quantification levels for LC-MS/MS, these techniques are sometimes insufficient to attain the needed limits of quantification (LOQs) or the method becomes too impractical for routine use. We examined the possibilities and limitations of signal summing, an under-utilized, easy-to-apply practice to increase LOQs for an immunosuppressant LC-MS/MS method. The limits of signal summing for everolimus were tested by running samples of everolimus at three concentrations in triplicate programming, increasing amounts of identical transitions in a constant cycle time up to the maximum number the software permitted to sum. The increase in peak area and the signal-to-noise ratio were determined. The effect on imprecision of peak areas and response ratios was evaluated by injection of a low concentration of everolimus tenfold using respectively one and five identical transitions, retaining an identical ion counting time. We compared the imprecision, LOQ, and recovery for our routine everolimus method (using one transition for everolimus and one for d3-everolimus) and an adapted method summing three identical transitions for everolimus (and one for d3-everolimus). The increase in signal was close to the theoretically expected one with a larger experimental spread for everolimus once more than five transitions were used. There was no clear beneficial effect of summing on imprecision. The adapted everolimus method showed a lower LOQ, but comparable imprecision and recovery as the routine method. Quantification levels can be improved by signal summing. No clear effect on imprecision was observed.

Deproteination of whole blood for LC-MS/MS using paramagnetic micro-particles.

OBJECTIVES: Liquid chromatography tandem mass spectrometry has become increasingly popular in clinical laboratories over the last decade due to the inherent sensitivity and specificity of the technology. Nevertheless, full automation and hence application in routine laboratories is still hampered by laborious and difficult-to-automate sample pre-treatment protocols. Functionalized paramagnetic micro-particles could simplify sample pre-treatment and ease automation. We evaluated the applicability of a pre-commercial, straightforward paramagnetic micro-particle based kit for the lysis and deproteination of whole blood for the LC-MS/MS analysis of everolimus and compared the performance to our routine protein precipitation method. DESIGN AND METHODS: Samples were prepared for LC-MS/MS everolimus analysis on an Acquity UPLC chromatographic system coupled to a TQD mass spectrometer (both Waters Ltd.) using a pre-commercial MagSi-TDMprep kit and a routine protein precipitation respectively. Both pre-treatment methods were validated for imprecision, accuracy, linearity, limit of quantification, matrix effect, recovery and process efficiency. A method comparison (n=63) between both pre-treatment methods was performed. RESULTS: Imprecision and bias were within pre-defined criteria (15%) for both pre-treatment methods. Both methods were linear from 1.2 to 14.8µg/L with a limit of quantification of 0.6µg/L. Process efficiency was on average 65% for protein precipitation pre-treatment and was substantially higher for the MagSi-TDMprep method (85%). A Passing-Bablok regression showed no significant difference between the two pre-treatment methods. CONCLUSION: For everolimus in whole blood, the MagSi-TDMprep sample pre-treatment was applicable and comparable to protein precipitation for LC-MS/MS with the possible advantage of easier automation.

Ecstasy intoxication as an unusual cause of epileptic seizures in young children.

In light of the widespread use of ecstasy, it is surprising that only few cases of intoxicated young children have been reported. Patients almost invariably present with convulsions accompanied by sympathetic signs and symptoms such as hyperthermia. Two new cases of toddlers intoxicated with ecstasy are described. The first patient, a 19-month-old boy, presented with convulsions but no sympathetic signs. The pediatrician's suspicion was raised because of the absence of a postictal state. The second patient, a 20-month-old girl, had a more typical presentation with convulsions and hyperthermia. Her story illustrates the fact that immunoassays for toxicological screening can easily miss traces of additional illicit drugs present in the urine such as cocaine. The presence of other illicit drugs provides clues to the child's risky environment and should lead to further investigation. Finally, we review the available literature on ecstasy intoxication to summarize the key presenting manifestations.

Copper deficiency in patients with cystinosis with cysteamine toxicity.

OBJECTIVES: To assess whether copper deficiency plays a role in the recently described cysteamine toxicity in patients with cystinosis, and to examine whether polymorphisms in copper transporters, lysyl oxidase, and/or type I procollagen genes could be responsible for the occurrence of cysteamine toxicity in a small subset of patients with cystinosis. STUDY DESIGN: Thirty-six patients with cystinosis were included: 22 with Fanconi syndrome (including 7 with cysteamine toxicity), 12 after renal transplantation, 1 receiving hemodialysis, and 1 with ocular cystinosis. Serum copper and ceruloplasmin levels and urinary copper/creatinine ratio were measured. Genes ATP7A and CTR1 (encoding copper transporters), LOX (encoding lysyl oxidase), and COL1A1 and COL1A2 (encoding type I procollagen) were analyzed in patients with (n = 6) and without (n = 5) toxicity. Fibroblast (pro)collagen synthesis was compared in patients with (n = 3) and those without (n = 2) cysteamine toxicity. RESULTS: All 22 patients with Fanconi syndrome had increased urinary copper excretion. Serum copper and ceruloplasmin levels were decreased in 9 patients, including all 7 patients with cysteamine toxicity. No specific sequence variations were associated with toxicity. All fibroblasts exhibited normal (pro)collagen synthesis. CONCLUSION: Patients with cystinosis with cysteamine toxicity demonstrate copper deficiency. This can cause decreased activity of lysyl oxidase, the enzyme that generates the aldehydes required for collagen cross-linking. Thus, copper supplementation might prevent cysteamine toxicity.

Fast and simple LC-MS/MS method for quantifying plasma voriconazole.

BACKGROUND: An increasing number of publications point to the importance of voriconazole plasma monitoring. Our aim was to develop a fast and simple LC-MS/MS method for the quantification of plasma voriconazole. METHODS: 20 µL of plasma was extracted by adding a precipitation reagent containing the internal standard (d(3)-voriconazole). Analysis was performed on a Quattro Micro tandem mass spectrometer equipped with an Alliance HPLC 2795 separations module. MRM transitions were m/z 350.0→281.4 for voriconazole and m/z 353.0→284.4 for d(3)-voriconazole. Quantification was done by both linear calibration curves and multiplication of the response ratio by a predefined factor. RESULTS: A method using protein precipitation as only pretreatment with an analysis time of 2 min was developed. Within- and between-run precision, expressed as coefficient of variation, at 6 concentrations ranged from 2.8% to 11.7%. Accuracy, expressed as a percentage of the theoretically added concentration, ranged from 89.0% to 109.0%. Linearity was demonstrated from 0.06 mg/L (0.17 µM) to 20.0 mg/L (57.3 µM). CONCLUSIONS: The described method offers a simple and rapid analysis of voriconazole in human plasma for clinical routine. Quantification with a predefined factor permits omitting calibration to each run and thereby reduces workload, costs and turn-around time.

Apparent elevation of cyclosporine whole blood concentrations in a renal allograft recipient.

We describe a 77-year-old cyclosporine-treated renal allograft recipient in whom falsely elevated whole blood cyclosporine concentrations were encountered using the antibody conjugated magnetic immunoassay (ACMIA) for therapeutic drug monitoring.

Wilson's disease: long-term follow-up of a cohort of 24 patients treated with D-penicillamine.

BACKGROUND AND STUDY AIMS: Detailed data on long-term effectiveness of various drug therapies in Wilson's disease (WD) are lacking. Therefore, we retrospectively reviewed our patient cohort treated with D-penicillamine. PATIENTS AND METHODS: This study reports on the clinical presentation, the diagnostic evaluation, and the disease course in 24 WD patients treated long-term (15+/-12 years, between 1969 and 2009) with D-penicillamine. RESULTS: The overall survival in our cohort was 91.6%. Twenty-two of 24 patients had liver disease at presentation, 17 of 24 patients (71%) had cirrhosis, 11 of whom had complications of cirrhosis. Six of 11 of these patients showed hepatological improvement (five of six) or stabilization (one of six), three of 11 were transplanted, one of 11 died, one of 11 discontinued follow-up. In the six of 17 cirrhotic patients without complications, improvement (four of six) or stabilization (two of six) occurred. Of all other patients (seven of 24), five of seven showed improvement (three of five) or stabilization (two of five), hepatological deterioration occurred only in one patient due to poor therapy compliance and one of seven discontinued follow-up. Neuropsychiatric symptoms were present in 13 of 24 at presentation and resolved in one of 13, decreased in seven of 13, stabilized in four of 13 and worsened in one of 13 patients (due to poor compliance). In general, we observed a favorable hepatological and neurological evolution with D-penicillamine. CONCLUSION: Despite the presence of liver disease or neuropsychiatric symptoms at baseline in all but one of the patients, we report beneficial results on liver and neurological disease after very long-term treatment with D-penicillamine, thereby adding to its reputation as 'first-line' therapy in WD.

Evaluation of the suitability of sampling on Tenax TA and polydimethylsiloxane for the analysis of combustion gases.

Two sorbents commonly employed for air sampling were selected for the evaluation of their suitability for the analysis of combustion gases namely Tenax TA as adsorbent and polydimethylsiloxane (PDMS) as absorbent. Target compounds were selected among the gaseous combustion products of polyurethane foam and fire-retarded polystyrene. The combustion gases were generated by burning test materials in the flame of a Bunsen burner. Gaseous combustion products were sampled simultaneously with the two sorbents using a two-way adapter, thereby exposing each sorbent to the same combustion gas atmosphere. Special attention was given to the deterioration encountered in the Tenax TA performance upon repeated combustion gas exposure, limiting its use for sampling reactive atmospheres.

Ethylene glycol poisoning presenting with a falsely elevated lactate level.

Early diagnosis of ethylene glycol poisoning is crucial in order to prevent morbidity and mortality. However, diagnosis can sometimes be delayed because of the false elevation of lactate in some chemistry analyzers as a result of the interference of glycolate, a metabolite of ethylene glycol. We present a case of ethylene glycol poisoning presenting with a falsely elevated lactate level on a blood gas analyzer in the emergency department. Given the fact that nowadays there is a marked increase in use of point-of-care analyzers, one should be aware of possible false readings since they use different methods of measuring compared with clinical chemistry analyzers. On the other hand, measuring a "lactate gap" using two different technologies, only one of which is sensitive to glycolate, could be a clinically efficient way to make the diagnosis of advanced ethylene glycol poisoning in the emergency department or other critical care setting.