Cefoperazone and sulbactam-related eosinophilic peritonitis: a case report and literature review.

Eosinophilic peritonitis (EP) is a well-described complication of peritoneal dialysis that occurs because of an overreaction to constituents that are related to the catheter or tubing, peritoneal dialysate, pathogenic infection, or intraperitoneal drug use. EP caused by antibiotic use is rare. We present the case of a patient with cefoperazone and sulbactam-related EP. A 59-year-old woman who was undergoing peritoneal dialysis presented with peritonitis with abdominal pain and turbid peritoneal dialysis. Empiric intraperitoneal cefazolin in combination with cefoperazone and sulbactam was started after peritoneal dialysis effluent cultures were performed. Her peritonitis achieved remission in 2 days with the help of cephalosporin, but she developed EP 1 week later, when her dialysate eosinophil count peaked at 49% of the total dialysate white blood cells (absolute count, 110/mm3). We excluded other possible causes and speculated that cefoperazone and sulbactam was the probable cause of EP. The patient continued treatment with cefoperazone and sulbactam for 14 days. EP resolved within 48 hours after stopping cefoperazone and sulbactam. Thus, EP can be caused by cefoperazone and sulbactam use. Physicians should be able to distinguish antibiotic-related EP from refractory peritonitis to avoid technique failure.

Efficiency of Leukocyte Differential Using Flow Cytometry with CytoDiff in Different Workflows.

BACKGROUND: To set up the review criteria for flow cytometry with CytoDiff (FCC) and evaluate the efficiency of different workflows using combinations of FCC with a hematology analyzer and microscopy. METHODS: Leucocyte differentials of the samples from 995 clinical specimens and 278 specimens from healthy donors were analyzed using a hematology analyzer, FCC, and microscopy. RESULTS: The correlations between the hematology analyzer, FCC, and microscopy were good for neutrophils, lymphocytes, and monocytes, but not in the case of basophils (r = 0.464, 0.358, 0.33) and eosinophils (r = 0.69, 0.67, 0.621). As a reference method of WBC differential using microscopy, the threshold of blasts for FCC was defined by a ROC curve at 1% (specificity 97.9%, sensitivity 97.5%, AUC 0.989). The optimal cutoff of immature granulocytes for FCC was 1% (specificity 85.8%, sensitivity 76.5%, AUC 0.866). The optimal cutoff of lymphocytes, neutrophils, and monocytes were 50%, 85% and 12%, respectively. According to the review criteria, the workflow of CBC after FCC and then microscopy had the highest sensitivity (97.07%), lower false negative rate (2.93%), and higher accuracy (80.3%) compared with others. CONCLUSIONS: Our study integrated FCC into a WBC differential workflow in a routine laboratory and, for the first time, demonstrates the efficiency of different workflows. It can be used for reference in the selection of different hematology workflows.

[Establishment and evaluation of a warfarin-dosing algorithm in Chinese Han population].

OBJECTIVE: To develop and evaluate a warfarin-dosing algorithm method which can be used to guide the adjustment of warfarin maintenance dose in Chinese Han population. METHODS: A total of 512 patients with steady warfarin taking were recruited from Beijing Hospital during May 2012 to December 2014. Indications for warfarin prescribing included prosthetic heart valve, atrial fibrillation and pulmonary embolism. Genomic DNAs were extracted from blood samples and used for the genetic polymorphism analysis of VKORC1 and CYP2C9 (include (*)3 and (*)13 alleles). Warfarin dose, demographic variabilities and amiodarone compliance were recorded during regular visit. These patients were randomly divided into groups using the method of random number table, 384 patients were randomly selected as derivation group, the remaining 128 cases as the validation group.Using data from derivation group, a warfarin-dosing algorithm was established based on the genetic information, demographic characteristics and concomitant compliance by a multiple linear regression analysis parameter. Then the accuracy of newly developed algorithm method was further evaluated by comparing the predicting dose with the actual dose in the validation group. RESULTS: The stable dose of warfarin was tightly associated with factors like age, height, weight, VKORC1 -1639G>A, CYP2C9(*)3, CYP2C9(*)13 and amiodarone usage. Newly developed algorithm method exhibited better prediction effect (R(2)=0.682, P<0.01) as compared with that of previously reported algorithm methods. The weights of VKORC1 and CYP2C9 for predicting of warfarin dosage were estimated to more than 50%. Using this method, 62.5% of patients in the validation group could be well recognized, in which the predicting dose of warfarin was within 20% of the actual dose, and only 7.81% patients showed underestimated prediction warfarin dose while 29.69% patients showed overestimated values. CONCLUSION: Newly developed algorithm method can be used for the guidance of warfarin maintenance dose adjustment in Chinese Han population.

[Clinical application of automated digital image analysis for morphology review of peripheral blood leukocyte].

OBJECTIVE: To explore the clinical application of automated digital image analysis in leukocyte morphology examination when review criteria of hematology analyzer are triggered. METHODS: The reference range of leukocyte differentiation by automated digital image analysis was established by analyzing 304 healthy blood samples from Peking University First Hospital. Six hundred and ninty-seven blood samples from Peking University First Hospital were randomly collected from November 2013 to April 2014, complete blood cells were counted on hematology analyzer, blood smears were made and stained at the same time. Blood smears were detected by automated digital image analyzer and the results were checked (reclassification) by a staff with abundant morphology experience. The same smear was examined manually by microscope. The results by manual microscopic differentiation were used as"golden standard", and diagnostic efficiency of abnormal specimens by automated digital image analysis was calculated, including sensitivity, specificity and accuracy. The difference of abnormal leukocytes detected by two different methods was analyzed in 30 samples of hematological and infectious diseases. RESULTS: Specificity of identifying abnormalities of white blood cells by automated digital image analysis was more than 90% except monocyte. Sensitivity of neutrophil toxic abnormities (including Döhle body, toxic granulate and vacuolization) was 100%; sensitivity of blast cells, immature granulates and atypical lymphocytes were 91.7%, 60% to 81.5% and 61.5%, respectively. Sensitivity of leukocyte differential count was 91.8% for neutrophils, 88.5% for lymphocytes, 69.1% for monocytes, 78.9% for eosinophils and 36.3 for basophils. The positive rate of recognizing abnormal cells (blast, immature granulocyte and atypical lymphocyte) by manual microscopic method was 46.7%, 53.3% and 10%, respectively. The positive rate of automated digital image analysis was 43.3%, 60% and 10%, respectively. There was no statistic significance between two methods (χ(2) = 0.067, 0.271, 0.000, all P>0.05). Automated digital image analysis could be used to morphology examination with abnormal leukocytes and optimize review criteria of hematology analyzer. CONCLUSION: Sensitivity and specificity of recognizing abnormal blood leukocytes by automated digital image analysis are satisfactory, which can be used as a tool of leukocyte morphology review when review criteria of hematology analyzer are triggered.

[Reference intervals and its verification for leukocyte differential count in peripheral blood by CytoDiff flow cytometry].

OBJECTIVE: To establish and verify the reference intervals for leukocyte differential count in peripheral blood by CytoDiff flow cytometry. METHODS: Leukocyte differentiation count was analyzed by using hematology analyzer, CytoDiff flow cytometry and morphology differential count in 278 healthy controls, 550 flagged and 102 unflagged samples. The reference intervals of leukocyte parameters were established and verified according to the healthy controls. Then the correlations of five leukocytes were analyzed among hematology analyzer, CytoDiff flow cytometry and morphology differential count. Lymphocyte subsets were analyzed and compared between healthy controls and patients with different diseases. The CytoDiff flow cytometric blast counts were explored to analyze the clinical diagnostic efficiency compared to morphology differential count as a reference method. RESULTS: CytoDiff flow cytometry can differentiate the leukocyte into 16 parameters, including percentage and absolute count, therefore 32 parameters in total. Among these parameters, 18 parameters had significant difference between male and female (P < 0. 05), and the others had no difference (P >0. 05). Except the CD16pos monocyte, there were no difference among ages in other parameters. The correlation between hematology analyzer, CytoDiff flow cytometry and morphology differential count were good for neutrophils, lymphocytes, monocytes, basophils and eosinophils in healthy controls and clinical samples. When the cutoff value of the ratio of T + NK and B lymphocyte was set at 1. 0 by ROC, the sensitivity was 90. 9% and specificity was 99. 8% for diagnosing the chronic lymphocyte leukemia (CLL). When the cutoff value of blast count by CytoDiff flow cytometry was set at 1%, the sensitivity was 100%, specificity was 96. 1% and accuracy was 96. 2% by morphology differential blast count for the reference method. CONCLUSIONS: Establish and verify the reference interval of leukocyte differential count in peripheral blood by CytoDiff flow cytometry in the adults of Beijing region. CytoDiff flow cytometry provide more parameters than hematology analyzer and morphology differential count, and therefore have excellent clinical diagnostic efficiency, especially for CLL and blasts from acute leukemia.

Characterization of a novel CYP2C9 mutation (1009C>A) detected in a warfarin-sensitive patient.

Warfarin is the most frequently prescribed anticoagulant for the long-term treatment in the clinic. Recent studies have shown that polymorphic alleles within the CYP2C9, VKORC1, and CYP4F2 genes are related to the warfarin dosage requirement. In this study, a novel non-synonymous mutation (1009C>A) in CYP2C9 was detected in a warfarin-hypersensitive patient, while the other two candidate genes were both found to be homozygous for the wild-type alleles. The newly identified point mutation results in an amino acid substitution at position 337 of the CYP2C9 protein (P337T) and has been designated as the novel allele CYP2C9*58. When expressed in insect cell microsomes, the relative intrinsic clearance values of the CYP2C9.58 variant for tolbutamide and losartan were quite similar to those of the typical defective variant CYP2C9.3, whereas the clearance value of CYP2C9.58 for diclofenac was slightly higher than that of another typical defective variant CYP2C9.2. These data suggested that when compared with wild-type CYP2C9.1, the enzymatic activity of the novel allelic variant has been greatly reduced by the 1009C>A mutation. If patients carrying this allele take drugs metabolized by CYP2C9, their metabolic rate might be slower than that of wild-type allele carriers and thus much more attention should be paid to their clinical care.

[Clinical evaluation of leukocyte differential count in peripheral blood by five-color flow cytometry].

OBJECTIVE: To explore the clinical application values of five-color flow cytometry for leukocyte differential count in peripheral blood. METHODS: Leukocyte differentiation in 265 peripheral blood samples collected at Peking University First Hospital from September 2010 to December 2010 was detected by standard microscopic cytology as a reference method. Meanwhile, Beckman-Coulter LH750 hematology analyzer and FC500 flow cytometer were performed. Then the correlations were analyzed between microscopic cytology, hematology analyzer and flow cytometry. Forty blood samples collected at Peking University First Hospital, Beijing Daopei Hospital and General Hospital of Beijing Military Command from August 2010 to November 2010 were analyzed by standard microscopic cytology, Beckman-Coulter LH750 hematology analyzer and NAVIOS flow cytometer. Then the correlations between microscopy, hematology analyzer and flow cytometry were explored to analyze the clinical diagnostic efficiency of flow cytometry. RESULTS: Correlation of leukocyte differential count between FC500 flow cytometer and standard microscopic cytology was significant (all P < 0.01) . And it was superior in the detection of lymphocytes, neutrophils and eosinophils (r = 0.955, 0.928, 0.876). Moreover, the correlation of leukocyte differential count between NAVIOS flow cytometer via manual gate and standard microscopic cytology was significant (r > 0.700, all P < 0.01) except for basophils. And it was superior in the detection of neutrophils, lymphocytes and blasts (r = 0.950, 0.915, 0.852). When 1% was set as the cut-off value of immature granulocytes on standard microscopic cytology, the sensitivity and specificity of flow cytometry was 87% and 76% respectively. When 0.5% was set as the cut-off value of blasts on standard microscopic cytology, the sensitivity and specificity of flow cytometry stood at 100% and 92% respectively. CONCLUSION: Five-color flow cytometry is well-correlated with standard microscopic cytology for leukocyte differential count in peripheral blood with different flow cytometers, and the sensitivity of detecting blasts and immature granulocytes is very excellent.

Assessment of a five-color flow cytometric assay for verifying automated white blood cell differentials.

BACKGROUND: White blood cell (WBC) counts and differentials performed using an automated cell counter typically require manual microscopic review. However, this last step is time consuming and requires experienced personnel. We evaluated the clinical efficiency of using flow cytometry (FCM) employing a six-antibody/five-color reagent for verifying automated WBC differentials. METHODS: A total of 56 apparently healthy samples were assessed using a five-color flow cytometer to verify the normal reference ranges of WBC differentials. WBC differentials of 622 samples were also determined using both a cell counter and FCM. These results were then confirmed using manual microscopic methods. RESULTS: The probabilities for all of the parameters of WBC differentials exceeded the corresponding normal reference ranges by no more than 7.5%. The resulting WBC differentials were well correlated between FCM and the cell counter (r > 0.88, P < 0.001), except in the case of basophils. Neutrophils, lymphocytes, and eosinophils were well correlated between FCM and standard microscopic cytology assessment (r > 0.80, P < 0.001). The sensitivities of FCM for identification of immature granulocytes and blast cells (72.03% and 22.22%, respectively) were higher than those of the cell counter method (44.92% and 11.11%, respectively). The specificities of FCM were all above 85%, substantially better than those of the cell counter method. CONCLUSION: These five-color FCM assays could be applied to accurately verify abnormal results of automated assessment of WBC differentials.

[Establishment and evaluation of review criteria for ADVIA 120/2120 and different series of hematology analyzers].

OBJECTIVE: To establish the suitable review criteria for ADVIA 120/2120 and those for different series of hematology analyzers. METHODS: A total of 2400 samples, including 6 blood neoplasms, were detected with ADVIA 120/2120 hematology analyzer, in which 1200 samples were detected by Sysmex XE-2100 and Beckman-Coulter LH750 hematology analyzers. In the meantime, blood smears were reviewed, and the results were analyzed statistically. The new review criteria were established by consulting and modifying the one as recommended by an international consensus group. Finally 300 samples were selected to validate the new review criteria. RESULTS: The results of 2400 samples detected by ADVIA 120/2120 hematology analyzer were analyzed statistically according to the international consensus review rules and blood smear positive criteria formulated by Chinese experts. The true positive rate was 22.1% (n = 530), false positive rate 28.1% (n = 675), true negative rate 44.3% (n = 1063), false negative rate 5.5% (n = 132), and the smear review rate 50.2% (n = 1205). The false negative rate was over the acceptable limit of 5%. The new review criteria were established by amending the blood smear positive criteria, i. e. increasing the percentage of band neutrophils, eosinophils, basophils and monocytes and adjusting the international consensus review rules. Then the results were re-analyzed. The true positive rate, false positive rate, true negative rate and false negative rate were 15.5% (n = 371), 18.7% (n = 449), 61.6% (n = 1479) and 4.2% (n = 101) respectively. The smear review rate was 34.2% (n = 821) and no specimen of blood neoplasms was missed. On that basis, the current review criteria for ADVIA 120/2120, XE-2100 and LH750 hematology analyzer were proposed by adding some specific parameters. The results of 1200 samples with three instruments were analyzed according to the current criteria. And the false negative rates were 4.3%, 4.6% and 4.6%, and false positive rate 14.7%, 17.5% and 12.7% respectively. And no specimen of blood neoplasm was missed. The false negative rates of three instruments were 3.8%, 4.3% and 4.0% in validation teses. CONCLUSION: The review criteria for three different series of hematology analyzers have been formulated for large general hospitals.