The Cancer & Blood Diseases Institute Clinical Laboratories at Cincinnati Children's perform a variety of tests for patients of all ages. Doctors need not be affiliated with Cincinnati Children's to order tests.
You can search for a test either by disorder or alphabetically.
Autoimmune lymphoproliferative syndrome (ALPS) is a primary immunodeficiency disorder (PID), characterized by defective lymphocyte homeostasis. Its main clinical manifestations are lymphoproliferation, causing lymphadenopathy, [hepato] splenomegaly and hypersplenism, autoimmunity (autoimmune cytopenias and other autoimmune disorders) and a highly increased, life-long risk of lymphoma.
From a laboratory standpoint, there is defective Fas-mediated apoptosis, the immunophenotypic presence of T cells that lack CD4 or CD8 expression, so called ab-double negative T cells (ab-DNTC), other lymphocyte-specific immunophenotypic changes, hyperimmunoglobulinemia and the presence of auto-antibodies.
This flow cytometric assay, using a combination of conjugated monoclonal antibodies, is intended to screen for the presence of ALPS. Together with clinical and laboratory data of the patient, the ALPS panel will help in making a preliminary determination whether the patient has ALPS.
This flow cytometry assay is intended to be used as a screening test. Screening tests are neither 100 percent sensitive nor specific, and a normal result should not preclude molecular sequencing if a patient’s clinical presentation suggests that the probability of a diagnosis is high.
IL-18 has been included in secondary diagnostic criteria for ALPS. IL-18, also known as Interferon-gamma Inducing Factor (IGIF), has been implicated as a mediator of septic shock and tissue injury in response to inflammation. IL-1b converting enzyme (caspase-1) cleaves pro-IL-18 to produce the bioactive peptide that is readily released from cells such as dendritic cells, activated macrophages, and intestinal epithelial cells. In combination with IL-12, IL-18 has been shown to act on T helper (Th1) cells to induce their production of IFN-g. IL-18 enhancement of Th1 cytokine (IL-2, GM-CSF and IFN-g) production, FAS ligand expression, and IL-2R alpha chain expression has also been reported in Th1 cells.
Peripheral blood mononuclear cells are activated with Concanavalin A and then expanded in culture. Expanded T cells are then treated with agonistic anti-Fas antibody, APO-1-3, and Protein A in the presence of IL-2 to evaluate Fas-mediated lymphocyte apoptosis. After treatment, cells are stained with propidium iodide and analyzed by flow cytometry.
By appointment, cell sorting for double negative T cells (DNTCs) can be performed so that testing for somatic FAS mutations can be done in the Molecular Genetics Lab. (Call 513-636-4685 to schedule and write in on requisition.)
Soluble Fas-Ligand (sFasL) is included in the secondary diagnostic criteria for ALPS. It is also known as CD178 or CD95L and is a member of the tumor-necrosis factor superfamily with a primary role in the induction of apoptosis in cells expressing its receptor Fas (Apo-1/CD95). The Fas/FasL system plays a role in modulating immune responses by inducing cell apoptosis to maintain homeostasis, self-tolerance of lymphocytes and immune privilege. This is a solid-phase ELISA assay that measures Fas Ligand in serum or plasma
In chronic granulomatous disease (CGD), microbial killing is defective due to a mutation in one of four known components of the NADPH oxidase system. This prevents the generation of an oxidative burst and results in an inability to generate toxic oxygen radicals, which seriously compromises the patient’s ability to kill phagocytosed microorganisms.
A flow cytometric whole blood assay determines the ability of polymorphonuclear (PMNs) cells to produce an oxidative burst. This is accomplished by indirectly measuring the increase in fluorescence generated by the oxidation of a laser sensitive dye, dihydrorhodamine (DHR) 123.
DHR is an uncharged and nonfluorescent reduction product of the mitochondrion-selective dye rhodamine 123. When incubated with PMNs, DHR diffuses into the cells and localizes in the mitochondria. When the cells are stimulated with phorbol-12-myristate-13 acetate (PMA), the DHR is oxidized to the highly fluorescent rhodamine 123. The level of fluorescence is proportional to the amount of dye oxidized. CGD patients’ PMNs remain nonfluorescent while the PMNs obtained from female carriers with the X-linked form of GCD have two populations of cells; one fluorescent (normal), and one nonfluorescent (abnormal active X chromosome).
Lymphocytes are a subpopulation of white blood cells, bone marrow-derived cells that can be differentiated into subsets of T cells, B cells and natural killer cells by expression of distinguishing cell surface molecules. T cells can be further differentiated into CD4 and CD8 cells, which each have unique roles in the immune response. Defects in one or more lymphocyte lineages can indicate the presence of an immune deficiency. This assay uses flow cytometry to detect the following lymphocyte subsets: T cells (CD3, CD4 and CD8); B cells (CD19); and NK cells (CD16 and CD56).
This flow cytometric B-cell panel, using a combination of conjugated monoclonal antibodies, is intended to provide a global overview of B-cell development and differentiation. Using specific combinations of surface markers, its goal is to detect defects in the normal sequence of maturation and differentiation through the absence of certain subpopulations, and / or the presence of unusual populations (e.g., transitional B cells), not normally found in peripheral blood. In addition, aberrant B-cell function may be detected by alterations in the normal distribution of B-cell populations, including plasma-blasts. In conjunction with other laboratory data, as well as clinical information, this assay can assist in providing a more detailed picture of the B-cell compartment and its context with the overall immune system.
This procedure is a flow cytometric assay that uses whole blood to screen for abnormalities in the expression of CD40-Ligand, CD40-Ig FP (Fusion Protein) and ICOS (inducible co-stimulator) on the surface of in vitro activated CD4+ T cells. It has also been observed that both gene and surface expression of CD40L by activated T cells is depressed in a subgroup of common variable immunodeficiency while the lack of ICOS upregulation on activated T cells would suggest the possibility of a genetic defect in the ICOS gene, underlying CVID.
This flow cytometry assay is intended to be used as a screening test. Screening tests are neither 100 percent sensitive nor specific, and a normal result should not preclude molecular sequencing if a patient’s clinical presentation suggests that the probability of a diagnosis is high.
Hemoglobin A1c is used to monitor glycemic control for diabetic patients or patients at risk for diabetes. The method used is capillary zone electrophoresis.
The red blood cell pit count can be used as a screening test for splenic phagocytic function. A normally functioning spleen should remove damaged or aging RBCs from circulation, and a correlation has been shown between an increase in the number of “pitted” RBCs and decreasing spleen function. A pit count of ≥3.5 percent has been associated with decreased or absent uptake on radionuclide spleen scans in individuals with sickle cell disease [Pearson HA, et al. Pediatrics. 1985;76(3):392-397, 1985]. More recent data indicate that normal spleen function is predicted by a pit count of ≤1.2 percent, and absent function is predicted by a pit count ≥4.5 percent in individuals with sickle cell disease [Rogers ZR, et al. Blood. 2011;117(9):2614-2617]. Limited data are available to guide the interpretation of pit counts in other causes of hyposplenism [de Porto, AP. Eur J Clin Microbiol Infect Dis. 2010;29(12):1465-73]. The method used is microscopy using differential interference contrast (DIC, Nomarski) optics.
Heinz bodies are small round erythrocyte inclusions thought to consist of denatured precipitated hemoglobin. Heinz bodies are not normally present in erythrocytes and are prominent in hemolytic anemia produced by agents that have been toxic to the erythrocytes or after removal of the spleen. The test method employed is microscopy with a methyl violet stain.
This test may be useful for the diagnosis or therapeutic monitoring patients with sickle cell disease, polycythemia / erythrocytosis, and other diseases associated with abnormal whole blood viscosity.
The instrument is a cone-and-plate viscometer, which is appropriate for measuring viscosity in non-Newtonian fluids, like blood. Values for viscosity will be reported at a single shear rate of 187.5 s-1, which is consistent with blood flow in conduit arteries. Viscosity is also measured at other shear rates, and these results can be provided upon request. The result will be reported in centipoise (cP) units with reference to a normal range
Hemoglobin electrophoresis is used for the screening and/or confirmation of hemoglobin variants and/or thalassemias. The methods used include capillary zone electrophoresis for the initial screen followed by confirmatory testing with acid hemoglobin electrophoresis and isoelectric focusing. The final report will include the hemoglobin pattern with interpretation, hemoglobin variant identification and quantitation of significant hemoglobin components.
Hemoglobin S and F levels can be ordered independently for the purposes of therapeutic monitoring of sickle cell patients receiving transfusion or hydroxyurea therapy, respectively. Method used is capillary zone electrophoresis, and quantitative hemoglobin fraction levels will be reported.
The oxygen dissociation (p50) assay is used to aid in the diagnosis of hemoglobin variants that cause abnormal hemoglobin oxygen affinity. The method employs dual wavelength spectrophotometry to measure oxygen saturation of hemoglobin and a Clark electrode to assess oxygen partial pressure in millimeters of mercury. The p50 value is determined as the partial pressure of oxygen where hemoglobin is 50 percent oxygenated.
CXCL9, also known as monokine induced by gamma interferon (MIG), is a member of the CXC chemokine subfamily. CXC chemokines are known to recruit activated lymphocytes and hinder angiogenesis via CXCR3. CXCR3 is a transmembrane protein expressed on activated Th1 lymphocytes. It has been observed in monocytes, endothelial cells, eosinophils, malignant B cells, melanoma cells, CD34+ hematopoietic progenitors and neurons. Expression of CXCL9 is induced by the Th1 cytokine, IFN-gamma. This is dramatically enhanced by the addition of TNF-alpha. CXCL9 production has been proven to be a sensitive measure of antigen-specific IFN-gamma production. CXCL9 has been implicated in pathologies characterized by the accumulation of activated Th1 lymphocytes. These include acute allograft rejection, glomerulonephritis, autoimmunity, rheumatoid arthritis, atherosclerosis, psoriasis and allergic contact dermatitis.
Natural killer (NK) cells are a subset of cytotoxic lymphocytes that have the ability to induce cell death in tumor cells or in virally infected cells.
NK cells play a crucial role in the homeostasis of the immune system. They are typically characterized by the expression of CD16 and CD56 on their cell surface. This assay makes use of the fact that NK cells will lyse the human erythroleukemia cell line, K562, in vitro. K562 cells are loaded with radioactive chromium and incubated with various ratios of a mononuclear cell preparation. Lysis of the K562 targets by NK cells contained in the cell preparation is measured by the amount of chromium released into the supernatant.
A soluble form of IL-2R appears in serum and plasma, concomitant with its increased expression on cells. Increased levels of the soluble IL-2R in biological fluids correlate with activation of T and / or B cells.
Results of a number of studies suggest a correlation of levels of IL-2R in serum with disease activity in autoimmune and infectious disorders as well as in transplantation rejection. Markedly increased IL-2sR levels have been associated with hematologic malignancies. Levels of IL-2R correlate with tumor burden and response to therapy in numerous malignancies. IL-2R levels can be used to predict the long-term prognosis in non-Hodgkin’s lymphoma patients and to assess the status of patients with HIV and acquired immunodeficiency.
We use a solid-phase, two-site chemiluminescent immunometric assay, and results are reported in units/ml (U/ml).
Perforin is a 70kD protein with cytolytic functions. It is expressed in the cytoplasmic granules of cytotoxic T lymphocytes (CTLs) and natural killer (NK) cells. Cytolytic cells release the contents of their granules, including perforin in response to recognition of their target cell.
In the presence of calcium, perforin forms transmembrane pores in the membrane of the target cell, facilitating cell death. Mutations in the perforin gene have been associated with primary hemophagocytic lymphohistiocytosis (HLH). The absence or otherwise atypical staining pattern of cytoplasmic perforin therefore can indicate a disease state. In this assay, peripheral blood is stained with both surface and intracellular monoclonal antibodies and analyzed using four-color flow cytometry.
Granzyme B is a serine protease which is involved in apoptotic cell death. Granzyme B, along with other enzymes, is contained in cytoplasmic lytic granules and is released primarily by cytotoxic T lymphocytes and natural killer cells. When Granzyme B is released from cytotoxic cells, it enters the target cell through the non-classical receptor-mediated entry pathway. Intracellularly it is enabled by perforin to convert to cytosolic Granzyme B, which then activates executioner caspase causing cell death. If perforin is not present, there is a break in the apoptosis pathway and cell death does not occur. Levels of Granzyme B, when compared with perforin levels, can be indicative of differing clinical states.
This flow cytometry assay is intended to be used as a screening test. Screening tests are neither 100 percent sensitive nor specific, and a normal result should not preclude molecular sequencing if a patient’s clinical presentation suggests that the probability of a diagnosis is high.
Additional information regarding the accuracy of this flow cytometry screening assay is available.[1]
Also known as LAMP-1 (lysosome-associated membrane protein – 1), CD107a is normally expressed on the membranes of lysosomes (lytic granules) found in the cytoplasm of cytotoxic cells. These lysosomes contain perforin and granzymes and, when the cell is presented with a target cell, are mobilized to move to the surface of the effector cell, fuse with the target cell membrane and release their contents.
The perforin inserts into the plasma membrane of the target cells forming pores that allow destruction of the target cell both by osmotic lysis and by allowing entry of apoptosis-inducing granzymes. The CD107a is then transiently expressed on the effector cell surface during this degranulation process. The other cells that express CD107a are degranulated platelets, PHA-activated T cells, TNF-a activated endothelium and FMLP-activated neutrophils.
MUNC 13-4 is involved in vesicle priming and has been described as a positive regulator of secretory lysosome exocytosis. It has been observed that mutations in the gene regulating MUNC 13-4 results in defective cytolytic granule exocytosis, despite polarization of the lytic granules and docking with the plasma membrane. Our studies indicate that lack of CD107a after presentation with a target cell results in statistically significant differences in patients with MUNC 13-4 mutations as compared to other patients with HLH and no MUNC 13-4 mutations.
In this assay, mononuclear cells from peripheral blood are stimulated with K562, target cells, which induces degranulation. Tagged anti-CD107a is present with the cells during the stimulation period. After a six-hour incubation, the cells are surface stained with markers to allow the analysis of just NK cells. If the NK cells have been degranulated, the CD107a will be expressed on the effector surface and will be detected by flow cytometry.
The hemoglobin-haptoglobin scavenger receptor (CD163 / HbSR) is a monocyte / macrophage-restricted transmembrane protein of the scavenger receptor cysteine-rich family. Antigen expression is related to monocyte / macrophage differentiation, with weak expression on peripheral blood monocytes and abundant expression on the majority of tissue macrophages.
Monocytes and macrophages play a central role in host response to infection. They synthesize and secrete a variety of inflammatory mediators. It has become increasingly clear that the pro-inflammatory process is balanced by associated anti-inflammatory mechanisms that result in monocyte deactivation, characterized by a decrease in HLA-DR expression and the release of anti-inflammatory cytokines such as IL-10.
It has been shown that the extracellular portion of CD163 is shed from the cell surface in the form of soluble CD163 when the cells are appropriately stimulated. Serum levels of sCD163 have been shown to be associated with levels of CRP. It has also been shown that sCD163 acts as a cytokine with modulatory effects on other cells. sCD163 may be a valuable marker in diseases with macrophage / monocyte involvement, particularly in infectious, inflammatory and myeloproliferative diseases. This assay uses a non-competitive sandwich ELISA technique to measure soluble CD163 in plasma.
Neopterin biosynthesis is closely associated with cellular immune system activation. Increased levels of neopterin have been measured in patients with viral infections, suggesting that the increased concentrations may originate from the patient’s immune response against the virally infected cells. Antigenic stimulation of human peripheral blood mononuclear cells has been shown to lead to neopterin release in culture medium and human macrophages produce neopterin in vitro when stimulated with interferon gamma. Therefore, determining neopterin levels in human body fluids offers a beneficial and innovative tool in monitoring diseases associated with cell-mediated immunity activation.
Principle of the assay: The assay is a solid-phase competitive ELISA. The intensity of color that develops is inversely proportional to the amount of antigen in the sample. Final concentration is determined directly using the standard curve.
SLAM-associated protein (SAP) is a small lymphocyte-specific signaling molecule that is defective or absent in patients with X-linked lymphoproliferative disease (XLP). Mutations in the SAP gene (SH2D1A) have been described in a majority of patients with the clinical syndrome of XLP. XLP is a primary immunodeficiency, which is characterized by an extreme susceptibility to EBV and should always be considered in males with EBV-associated HLH. Half of XLP patients can have a fatal outcome with EBV infection because of explosive activation and proliferation of lymphocytes in many organs, which leads to fulminant hepatitis and bone marrow failure with hemophagocytosis. This assay is a rapid flow cytometry screening test for the presence of the SAP protein.
This flow cytometry assay is intended to be used as a screening test. Screening tests are neither 100 percent sensitive nor specific, and a normal result should not preclude molecular sequencing if a patient’s clinical presentation suggests that the probability of a diagnosis is high. Additional information regarding the accuracy of this flow cytometry screening assay is available.[1]
1. Gifford, CE; Weingartner, E; Villanueva, J; Johnson, J; Zhang, K; Filipovich AH; Bleesing, J; Marsh, RA. Clinical flow cytometric screening of SAP and XIAP expression accurately identifies patients with SH2D1A and XIAP/BIRC4 mutations. Cytometry B Clin Cytom. v. 86 p. 263-271.
Deficiency of X-linked inhibitor of apoptosis (XIAP), caused by mutations in the BIRC4 gene, is the second most common cause of X-linked lymphoproliferative syndrome (XLP). The most common cause is deficiency of SLAM-associated protein (SAP) caused by mutations in the SH2D1a gene. XLP due to BIRC4 mutation is associated with the development of HLH and other lymphoproliferative disorders, sometimes in association with EBV.
XIAP is an intracellular protein expressed in many tissues. To rapidly screen patients for this disorder, patient and normal sample lymphocytes are fixed, permeabilized and stained with a mouse monoclonal antibody against XIAP, followed by secondary PE-conjugated anti-mouse antibody staining. Following intracellular staining, residual PE conjugated anti-mouse antibody is blocked, followed by lymphocyte surface marker staining. Samples are analyzed by five-color flow cytometry, and XIAP expression is measured in the CD4+ and CD8+ T cells, NK cells and B cells.
This flow cytometry assay is intended to be used as a screening test. Screening tests are neither 100 percent sensitive nor specific, and a normal result should not preclude molecular sequencing if a patient’s clinical presentation suggests that the probability of a diagnosis is high.
Evaluation of degranulation via measurement of CD107a following various stimuli can be used as a diagnostic screening test for the causes of familial hemophagocytic lymphohistiocytosis due to mutations in Munc 13-4, STX11 and STXBP2. A large prospective study revealed that over 95 percent of patients with these forms of HLH can be detected via screening CD107a assays utilizing measurement of CD107a on resting NK cells following exposure to the K562 cell line (Bryceson et al, 2012). We have since adopted this method as our CD107a Mobilization (NK Cell Degranulation assay) and have confirmed it to be useful (unpublished data). However, assays are not always able to be interpreted and reported, due to the fact that patient samples sometimes have too few NK cells.
Because degranulation can also be measured in T cells, we have developed a CD107a degranulation assay utilizing T cells. In this assay, mononuclear cells from peripheral blood samples are exposed to P815 cells coated with anti-CD3 (the P815 cell line is a murine mastocytoma which readily binds the Fc portions of the anti-CD3 antibody), which stimulates degranulation. PE-conjugated anti-CD107a is present with the cells during the stimulation period. After the two-hour incubation at 37°C, the cells are surface stained with markers to allow the analysis of T cells. If the T cells have degranulated, the CD107a will be expressed on the effector cell surface and will be detected by flow cytometry.
Hyperimmunoglobulin E syndrome (HIES) is a rare immune deficiency typically characterized by dermatitis, recurrent infections, abnormalities of bone and connective tissue and elevated serum IgE.1
The most common genetic mutations reported in HIES patients are in either STAT3 or DOCK8, which result in interference with the differentiation pathway of Th17 cells, causing low or non-existent cell numbers.
Th17 is the name of interleukin (IL)-17 producing CD4+ T cells that are a subpopulation of T helper lymphocytes involved in immune responses to fungal and extracellular bacterial pathogens.
In our assay, IL-17 cytokine production is stimulated by activating whole blood in the presence of Brefeldin-A to block release of intracellular cytokines, trapping cytokines produced during activation inside the cell. The activated cells are stained with surface monoclonal antibodies for phenotyping, fixed, permeabilized and stained with antibody against IL-17. The cells are then analyzed by flow cytometry to detect the peripheral blood levels of Th17 cells in order to screen patients for Hyper IgE syndrome. This test is only run on day-old samples. Please collect Monday-Thursday.
This flow cytometric B-cell panel, using a combination of conjugated monoclonal antibodies, is intended to provide a global overview of B-cell development and differentiation. Using specific combinations of surface markers, its goal is to detect defects in the normal sequence of maturation and differentiation through the absence of certain subpopulations, and / or the presence of unusual populations (e.g., transitional B cells), not normally found in peripheral blood. In addition, aberrant B-cell function may be detected by alterations in the normal distribution of B-cell populations, including plasma-blasts. In conjunction with other laboratory data, as well as clinical information, this assay can assist in providing a more detailed picture of the B-cell compartment and its context with the overall immune system.
This procedure is a flow cytometric assay that uses whole blood to screen for abnormalities in the expression of CD40-Ligand, CD40-Ig FP (Fusion Protein) and ICOS (inducible co-stimulator) on the surface of in vitro activated CD4+ T cells. It has also been observed that both gene and surface expression of CD40L by activated T cells is depressed in a subgroup of common variable immunodeficiency while the lack of ICOS upregulation on activated T cells would suggest the possibility of a genetic defect in the ICOS gene, underlying CVID.
This flow cytometry assay is intended to be used as a screening test. Screening tests are neither 100 percent sensitive nor specific, and a normal result should not preclude molecular sequencing if a patient’s clinical presentation suggests that the probability of a diagnosis is high.
Also known as FORKHEAD BOX P3, SCURFIN and JM2, FoxP3 is a 49-55 kDa protein and a member of the forkhead or winged helix family of transcription factors. It is constitutively expressed in regulatory T cells (Treg), a subset of CD4+ T cells that are responsible for suppressing a variety of physiological and pathological immune responses, primarily through the elimination of self-reactive lymphocytes.
Treg cells can be identified by their high expression of CD25, the IL-2 receptor alpha chain. Defects of Treg cells are thought to play a role in autoimmune and inflammatory diseases. Mutations of the FoxP3 gene have been described in patients with immune dysregulation, polyendocrinopathy, enteropathy, X-linked syndrome (IPEX). This assay uses flow cytometry to determine the proportion and intensity of intracellular FoxP3 protein expression in the subset of CD4+ T cells that are CD25 bright and CD127 negative. The PCH101 antibody reacts with the amino terminus of human foxp3 protein.
This flow cytometry assay is intended to be used as a screening test. Screening tests are neither 100 percent sensitive nor specific, and a normal result should not preclude molecular sequencing if a patient’s clinical presentation suggests that the probability of a diagnosis is high.
The adhesion marker assay is intended to screen for leukocyte adhesion deficiency type 1 (LAD-1). Recruitment of neutrophils from the bloodstream to extravascular sites of inflammation is a critical event in host defense against bacterial infection and in the repair of tissue damage.
In response to extravascular stimuli such as bacterial-derived chemoattractants, or endogenous lipid and peptide mediators generated at sites of infection or tissue damage, leukocytes are first observed to “roll” along the vessel wall adjacent to the site of inflammation. Some of the rolling cells subsequently adhere firmly or “stick,” then diapedese between endothelial cells and migrate through the subendothelial matrix to the site of inflammation. CD11b / CD18 and its endothelial cell ligands including intracellular adhesion molecule-1 (ICAM-1, CD54) are necessary for firm neutrophil adherence and transendothelial migration. Leukocyte adhesion deficiency syndrome type 1 (LAD-1) results from a congenital deficiency of the leukocyte beta-2 integrin receptor complex CD11 / CD18 on the cell surface.
This flow cytometry assay is intended to be used as a screening test. Screening tests are neither 100 percent sensitive nor specific, and a normal result should not preclude molecular sequencing if a patient’s clinical presentation suggests that the probability of a diagnosis is high.
Flow cytometric analysis easily permits testing for the GPI-anchor expression by immunophenotyping erythrocytes and WBCs with anti-CD59 (termed: membrane attack complex inhibitory factor, [MACIF], membrane inhibitor of reactive lysis [MIRL] and prolactin) and FLAER, an inactive variant of aerolysin.
Paroxysmal nocturnal hemoglobinuria (PNH) is an acquired clonal disorder arising by somatic mutation in the pluripotent hematopoietic stem cell. A close relationship between PNH and aplastic anemia and other myelodysplastic disorders has been reported. PNH is characterized by the deficiency, absolute or partial, of all proteins anchored to membrane by the glycosylphosphatidylinositol (GPI) anchor. At least 15 of these proteins have been shown to be lacking on the abnormal blood cells of these patients.
The most prominent clinical feature in PNH is intravascular hemolysis due to increased susceptibility of red blood cells to complement-mediated lysis. This defect in PNH is caused by the lack of GPI-anchored proteins on the red cell surface, a consequence of a block in the biosynthesis of the GPI molecule where N-acetylglucosamine is transferred to the phosphoinositol molecule. Not only is this defect seen in erythrocytes, but is also shared by WBCs and platelets of affected individuals.
Pulmonary alveolar proteinosis (PAP) is not a specific disease, but rather a syndrome characterized by the accumulation of surfactant in pulmonary alveoli that impairs respiratory gas exchange. This can lead to respiratory insufficiency, and in severe cases, respiratory failure. Primary PAP and other disorders of surfactant production (DSP) are caused by various, but identifiable, genetic mutations.
Autoimmune pulmonary alveolar proteinosis (autoimmune PAP) is a rare disease characterized by alveolar surfactant accumulation, respiratory failure, and an increased risk of opportunistic infections. The disease is associated with GM-CSF autoantibodies that neutralize GM-CSF bioactivity and mediate pathogenesis by blocking signaling to alveolar macrophages and neutrophils. Alveolar macrophages require GM-CSF for terminal differentiation and constitutive regulation of functions including surfactant clearance. Without pulmonary GM-CSF signaling, immature alveolar macrophages have impaired pulmonary surfactant clearance, which results in slowly progressive surfactant accumulation and the insidious onset of clinical manifestations. Disruption of GM-CSF signaling by recessive mutations in CSF2RA or CSF2RB, which encode the GM-CSF receptor α and β chains, respectively, causes a hereditary form of PAP that is clinically, physiologically, and histologically indistinguishable from autoimmune PAP. PAP can also occur in a heterogeneous group of other diseases either as a consequence of an underlying clinical condition presumably affecting alveolar macrophage function (secondary PAP) or due to mutations in genes (e.g., SFTPB, SFTPC, ABCA3, TTF1) involved surfactant production (congenital PAP, and PAP associated with interstitial lung disease). Clinically, the diagnosis of PAP is made by the presence of a compatible history, typical radiologic findings, and lung biopsy or bronchoalveolar lavage cytology findings. However, while these methods can determine if PAP is present, none are capable of identifying the underlying PAP-causing disease responsible. The strong association of a high serum GM-CSF autoantibody (GMAb) level with autoimmune PAP, development of an ELISA to measure GMAbs and demonstration that GMAbs actually drive the pathogenesis of autoimmune PAP, support what is now widespread use of serum GMAb measurement for the clinical research diagnosis of autoimmune PAP. The potential clinical use of the GMAb ELSA is further supported by the identification of critical threshold of serum GMAb that is associated with an increased risk of autoimmune PAP.
Pulmonary alveolar proteinosis (PAP) is characterized by alveolar macrophage dysfunction, impairing pulmonary surfactant clearance in the alveolar space, possibly leading to respiratory failure. PAP has been further categorized to three main forms: hereditary, secondary, and autoimmune PAP. Hereditary PAP is associated with mutations in the GM-CSF receptor, affecting receptor binding and signaling. Secondary PAP is associated with a variety of hematological malignancies, where macrophage dysfunction occurs as a result of decreased numbers and/or function. Autoimmune PAP is associated with a disruption in clearance due to the presence of an autoantibody to GM-CSF. Autoimmune PAP comprises the largest majority of diagnosed cases, about 90 percent. STAT5 is an important protein within the GM-CSF signal transduction pathway. STAT5 is activated upon phosphorylation of its tyrosine. Hereditary and autoimmune PAP patients will exhibit decreased phosphorylation of STAT5 due to the mutations in GM-CSF receptor or the presence of autoantibodies to the cytokine, respectively.
Osmotic gradient ektacytometry measures RBC deformability under a defined stress as a function of suspending medium osmolality. Ektacytometry is used to evaluate for inherited RBC membrane disorders, such as hereditary spherocytosis (HS), hereditary elliptocytosis (HE) and its severe form known as hereditary pyropoikilocytosis (HPP), hereditary ovalocytosis (SAO), and hereditary stomatocytosis (HSt), which are commonly responsible for hemolytic anemia. The report contains an ektacytometry profile (patient versus a normal control), the Omin, EImax and Ohyp values and an interpretation.
G6PD deficiency is an X-linked recessive genetic condition that predisposes an individual to hemolysis (spontaneous destruction of red blood cells) in response to a number of triggers, such as certain foods, illness, or medication. It is particularly common in people of Mediterranean and African origin. The EDL offers G6PD screen and quantitation assays that can be used to detect congenital G6PD deficiency for hemolytic anemia investigation or to reduce drug-induced hemolytic anemia events. The methods detect the activity of the G6PD enzyme in RBCs using either dye reduction (G6PD Screen) or kinetic (G6PD quantitation) methods.
Following stimulation of whole blood with IL-2, phosphorylation of STAT5 is measured in CD4 T cells using monoclonal antibodies and flow cytometry.
The amount of phosphorylation of STAT5 through the IL-2 pathway is age dependent in healthy individuals, with younger children having less pSTAT5 than older children and adults. Phosphorylation is a mechanism of cell signaling involved in many functional pathways including: differentiation, activation, proliferation and apoptosis. Detection of the phosphorylation of STAT5 Tyrosine is important in evaluating the IL-2 signal transduction pathway. Patients having decreased phosphorylation of STAT5 may have pathways that are non-functional or compromised. Patients with severe combined immune deficiency (SCID) attributed to either JAK3 deficiency or defects of the common gamma chain shared by many cytokine receptors, namely IL-2, will have decreased phosphorylation of STAT5.
The complex cascade of events that comprise the cellular portion of the immune response include the proliferation of lymphocytes in response to upstream events (activation, Ca++ flux, etc.).
This assay tests the capacity of lymphocytes to proliferate in response to exposure to mitosis-inducing agents (mitogens). Specifically, peripheral blood mononuclear cells are exposed to phytohemagglutinin (PHA), concanavalin A (ConA), and pokeweed mitogen (PWM), and cultured for several days. An excess of radio-labeled thymidine is made available to the cells during the later part of the culture period. As the stimulated cells enter the S phase of the cell cycle, they synthesize DNA, incorporating the radio-labeled thymidine which is then quantitated using a microplate scintillation counter. Results are expressed as counts per minute (cpm).
Lymphocytes are a subpopulation of white blood cells, bone marrow-derived cells that can be differentiated into subsets of T cells, B cells and natural killer cells by expression of distinguishing cell surface molecules. T cells can be further differentiated into CD4 and CD8 cells which each have unique roles in the immune response. Defects in one or more lymphocyte lineages can indicate the presence of an immune deficiency. This assay uses flow cytometry to detect the following lymphocyte subsets: T cells (CD3, CD4 and CD8); B cells (CD19); and NK cells (CD16 and CD56).
Bare lymphocyte syndrome (BLS) is a rare immunodeficiency disorder caused by or associated with the failure of expression of cell surface antigens encoded for by the major histocompatibility complex (MHC).
It is now apparent that this syndrome is heterogeneous with regards to defective cell surface antigen expression. In some patients with this disorder, there is defective expression of only class l MHC antigens encoded for by the HLA-A, B and C genetic loci, while in other patients class ll MHC antigens (HLA-Dr, DQ and DP) are not expressed. Patients who fail to express both class l and class ll MHC antigens have also been identified. Clinically, this syndrome is manifested as a combined immunodeficiency presenting early in life, and affected individuals are susceptible to a number of severe and/or opportunistic infections by a wide variety of pathogens. MHC class I and class II epitope expression on peripheral blood lymphocytes and monocytes are performed by multiparameter flow cytometry.
Children with severe combined immunodeficiency (SCID) are prone to repeated and persistent infections that can be very serious or life-threatening. Infants with SCID typically experience pneumonia, chronic diarrhea and widespread skin rashes. If not treated in a way that restores immune function, children with SCID usually live only a year or two.
ZAP-70-related SCID is one of several forms of severe combined immunodeficiency, a group of disorders with several genetic causes. ZAP-70 is an intracellular tyrosine kinase that is recruited in the CD3 T-cell receptor (TCR) complex and is required for T-cell activation following TCR engagement. ZAP-70 deficiency is a rare autosomal recessive form of SCID characterized by a lack of CD8+ T cells and presence of circulating CD4+ T cells. Most individuals with ZAP-70-related SCID are diagnosed in the first six months of life. ZAP-70 SCID is a rare disorder where only about 15 affected individuals have been identified.
A permeabilization reagent renders intracellular antigens accessible and allows cytoplasmic and nuclear immunophenotyping of leukocytes. It creates apertures in the membrane without affecting the gross morphology of the cell and therefore preserves its flow cytometric light scattering characteristics. This permeabilization reagent allows one to perform simultaneous surface and intracellular antigen staining. A “Fix and Perm Cell Permeabilization Kit” standardizes the procedure that consists of first fixing cells with reagent A, and second, permeabilizing the leukocytes and lysing red cells using reagent B.
Naïve T lymphocytes are mature resting T cells that have not yet encountered antigen. Memory T cells are long-lived antigen-specific T cells that have the capacity to quickly differentiate to an end stage effector cells upon re-exposure to antigen. Naïve and memory cells are present in both the CD4 and the CD8 subsets of T cells. Two isoforms of the CD45 molecule, CD45RA and CD45RO, are expressed on the surface of naïve and memory cells, respectively. Using four-color flow cytometry, monoclonal antibodies against these antigens are used to quantitate the relative proportions of each subset in the peripheral blood.
The Wiskott-Aldrich syndrome (WAS) is an X-linked recessive disorder characterized by the triad of thrombocytopenia, eczema and immune deficiency. The gene responsible for WAS is located on the short arm of the X chromosome at Xp11.22. WAS is caused by mutations in an intracellular protein, WASP, that is involved in signal transduction and regulation of actin cytoskeleton rearrangement
Detection of WASP is possible by permeabilizing peripheral blood lymphocytes, monocytes and neutrophils and staining intracellularly with mouse anti-human WASP antibody then analyzing on a flow cytometer. The absence or otherwise atypical staining pattern of intracellular WASP therefore can indicate the disease, carrier state or mixed chimerism after BMT.
This flow cytometry assay is intended to be used as a screening test. Screening tests are neither 100 percent sensitive nor specific, and a normal result should not preclude molecular sequencing if a patient’s clinical presentation suggests that the probability of a diagnosis is high.
(Includes quantification of WASP in specific lymphocyte subsets) – Success of engraftment after BMT can be evaluated by performing multicolor flow cytometric analysis using monoclonal antibodies to cell surface antigens to characterize the hematopoietic cell populations of interest before the intracellular staining for WASP.
This flow cytometric B-cell panel, using a combination of conjugated monoclonal antibodies, is intended to provide a global overview of B-cell development and differentiation.
Using specific combinations of surface markers, its goal is to detect defects in the normal sequence of maturation and differentiation through the absence of certain subpopulations, and / or the presence of unusual populations (e.g., transitional B cells), not normally found in peripheral blood.
In addition, aberrant B-cell function may be detected by alterations in the normal distribution of B-cell populations, including plasma-blasts. In conjunction with other laboratory data, as well as clinical information, this assay can assist in providing a more detailed picture of the B-cell compartment and its context with the overall immune system.
SLAM-associated protein (SAP) is a small lymphocyte-specific signaling molecule that is defective or absent in patients with X-linked lymphoproliferative disease (XLP).
Mutations in the SAP gene (SH2D1A) have been described in a majority of patients with the clinical syndrome of XLP. XLP is a primary immunodeficiency, which is characterized by an extreme susceptibility to EBV and should always be considered in males with EBV-associated HLH. Half of XLP patients can have a fatal outcome with EBV infection because of explosive activation and proliferation of lymphocytes in many organs, which leads to fulminant hepatitis and bone marrow failure with hemophagocytosis. This assay is a rapid flow cytometry screening test for the presence of the SAP protein.
This flow cytometry assay is intended to be used as a screening test. Screening tests are neither 100 percent sensitive nor specific, and a normal result should not preclude molecular sequencing if a patient’s clinical presentation suggests that the probability of a diagnosis is high. Additional information regarding the accuracy of this flow cytometry screening assay is available.[1]
1. Gifford, CE; Weingartner, E; Villanueva, J; Johnson, J; Zhang, K; Filipovich AH; Bleesing, J; Marsh, RA. Clinical flow cytometric screening of SAP and XIAP expression accurately identifies patients with SH2D1A and XIAP/BIRC4 mutations. Cytometry B Clin Cytom. v. 86 p. 263-271.
Deficiency of X-linked inhibitor of apoptosis (XIAP), caused by mutations in the BIRC4 gene, is the second most common cause of X-linked lymphoproliferative syndrome (XLP). The most common cause is deficiency of SLAM-associated protein (SAP) caused by mutations in the SH2D1a gene. XLP due to BIRC4 mutation is associated with the development of HLH and other lymphoproliferative disorders, sometimes in association with EBV.
XIAP is an intracellular protein expressed in many tissues. To rapidly screen patients for this disorder, patient and normal sample lymphocytes are fixed, permeabilized and stained with a mouse monoclonal antibody against XIAP, followed by secondary PE-conjugated anti-mouse antibody staining. Following intracellular staining, residual PE conjugated anti-mouse antibody is blocked, followed by lymphocyte surface marker staining. Samples are analyzed by five-color flow cytometry, and XIAP expression is measured in the CD4+ and CD8+ T cells, NK cells and B cells.
This flow cytometry assay is intended to be used as a screening test. Screening tests are neither 100 percent sensitive nor specific, and a normal result should not preclude molecular sequencing if a patient’s clinical presentation suggests that the probability of a diagnosis is high.
Type 1, “classical” or “invariant” natural killer T cells (iNKT) are a T-cell subset which express a semi-invariant T-cell receptor (TCR) that recognizes CD1d.
This invariant TCR consists of TCR-V-alpha-24-J-alpha-18 and TCR-V-beta-11, and can be identified on the basis of this unique TCR. The only known disorder characterized by absence of iNKT cells is X-linked lymphoproliferative disease, caused by SAP deficiency. Four-color flow cytometry, using monoclonal antibodies against TCR-V-alpha-24 and TCR-V-beta-11 antigens, is used to quantitate the proportion of iNKT cells present in the peripheral blood relative to peripheral blood CD3+ T cells.
Alemtuzumab (brand name Campath or Lemtrada) is a lymphocyte-depleting monoclonal antibody (anti-CD52) used in reduced-intensity conditioning regimens for allogeneic hematopoietic cell transplant (HCT). CD52 is expressed on the surface of mature lymphocytes, and also monocytes and eosinophils. In this assay, alemtuzumab levels in peripheral blood plasma are determined by binding of alemtuzumab to normal donor peripheral blood mononuclear cells followed by fluorogenic secondary antibody labeling and analysis by flow cytometry. A standard curve is set up with each run, median fluorescent intensity is imported into curve-fit software and alemtuzumab concentration of patient samples is interpolated. High and low controls are included in each run. Levels from individual patients need to be interpreted in the in the context of various specific clinical treatment goals. The reportable range of alemtuzumab for this assay is 0.04 - 5.0 mcg/mL. The reportable range should not be considered a reference range.
Other antibody therapies may interfere with the assay and either prevent the test from being reported, or give false positive results. The test cannot be performed for patients who have recently received ATG. There is a possibility that basiliximab could cause false positive results, so the test should not be performed in patients receiving basiliximab therapy. The following agents were evaluated and do not interfere with the assay or prevent testing: infliximab, rituximab, tocilizumab, eculizumab, and IVIG.
This flow cytometric assay, using a combination of conjugated monoclonal antibodies, is intended to screen for the presence of ALPS. Together with clinical and laboratory data of the patient, the ALPS panel will help in making a preliminary determination whether the patient has ALPS.
This flow cytometry assay is intended to be used as a screening test. Screening tests are neither 100 percent sensitive nor specific, and a normal result should not preclude molecular sequencing if a patient’s clinical presentation suggests that the probability of a diagnosis is high.
Peripheral blood lymphocytes that have previously been exposed in vivo to antigens become sensitized. If they are subsequently exposed in vitro to those same antigens, they will be triggered to initiate an immune response that culminates in proliferation.
This assay uses the antigens Candida Albicans and tetanus toxoid to stimulate a purified mononuclear cell preparation and test for the ability of the cells to respond by proliferating. An excess of radio-labeled thymidine is made available to the cells during the later part of the culture period. Cells undergoing DNA synthesis will incorporate the thymidine, which can then be measured using a microplate scintillation counter.
Peripheral blood mononuclear cells are activated with Concanavalin A and then expanded in culture. Expanded T cells are then treated with agonistic anti-Fas antibody, APO-1-3, and Protein A in the presence of IL-2 to evaluate Fas-mediated lymphocyte apoptosis. After treatment, cells are stained with propidium iodide and analyzed by flow cytometry.
B-cell activating factor (BAFF), also known as B Lys, TALL-1, and THANK, is a TNF superfamily member (TNFSF13B) known for its role in the survival and maturation of B cells. The BAFF gene encodes a putative 285 amino acid type II transmembrane protein. A 152 amino acid form can also be shed from the membrane by proteolytic cleavage, and this soluble form is detectable in human serum.
BAFF is produced by several cell types and tissues including monocytes, macrophages, neutrophils, dendritic cells, T lymphocytes, spleen, lymph node and bone marrow. Its expression in resting monocytes is upregulated by IFN-α, IFN-β, LPS and IL-10. It is thought to exist as a homotrimer, but it may also exist as a heteromer in association with related TNFSF member APRIL.
BAFF is a ligand for at least three TNF receptor superfamily (TNFRSF) members: B-cell maturation antigen (BCMA / TNFRSF17), transmembrane activator and calcium-modulator and cyclophilin ligand interactor (TACI / TNFRSF13B), and BAFF receptor (BAFF R / BR3 / TNFRSF13C). TACI and BAFF R are receptors for both BAFF and APRIL; however BAFF R selectively binds BAFF. All three receptors are primarily expressed by B cells. BAFF appears to be necessary for the proper transition from T1 to T2 phases of the B-cell maturation pathway.
Mechanisms underlying BAFF effects on B-cell survival may include the upregulation or downregulation of anti- or pro-apoptotic members of the Bcl-2 family, respectively. Consistent with a role in human autoimmune disorders, BAFF is elevated in the serum of patients with SLE and Sjogren’s syndrome. It is also produced locally in the joints of patients with inflammatory arthritis and serum levels correlate with antibody titers in arthritis and Sjogren’s syndrome.
The Quantikine Human BAFF Immunoassay is a solid-phase ELISA designed to measure human BAFF levels in plasma and can be used to determine relative mass values for naturally occurring human BAFF. The assay employs the quantitative sandwich enzyme immunoassay technique.
This flow cytometric B-cell panel, using a combination of conjugated monoclonal antibodies, is intended to provide a global overview of B-cell development and differentiation. Using specific combinations of surface markers, its goal is to detect defects in the normal sequence of maturation and differentiation through the absence of certain subpopulations, and / or the presence of unusual populations (e.g., transitional B cells), not normally found in peripheral blood.
In addition, aberrant B-cell function may be detected by alterations in the normal distribution of B-cell populations, including plasma-blasts. In conjunction with other laboratory data, as well as clinical information, this assay can assist in providing a more detailed picture of the B-cell compartment and its context with the overall immune system.
Activation of the classical, alternative or lectin complement pathways results in the formation of a C3 convertase multimolecular enzyme capable of cleaving C3 to C3a and C3b. C3a has been shown to increase vascular permeability, to be spasmogenic and chemotactic, and to induce the release of pharmacologically active mediators from a number of cell types. See more information about TMA testing.
Activation of the classical, alternative, or lectin complement pathways results in the formation of a C5 convertase multimolecular enzyme capable of cleaving C5 to C5a and C5b. C5a has a host of biologic functions including mast cell degranulation, chemotaxis, leukosequestration, as well as cellular activation via binding to the C5a receptor. See more information about TMA testing.
Also known as LAMP-1 (lysosome-associated membrane protein-1), CD107a is normally expressed on the membranes of lysosomes (lytic granules) found in the cytoplasm of cytotoxic cells. These lysosomes contain perforin and granzymes and, when the cell is presented with a target cell, are mobilized to move to the surface of the effector cell, fuse with the target cell membrane and release their contents. The perforin inserts into the plasma membrane of the target cells forming pores that allow destruction of the target cell both by osmotic lysis and by allowing entry of apoptosis-inducing granzymes. The CD107a is then transiently expressed on the effector cell surface during this degranulation process. The other cells that express CD107a are degranulated platelets, PHA-activated T cells, TNF-a activated endothelium and FMLP-activated neutrophils.
MUNC 13-4 is involved in vesicle priming and has been described as a positive regulator of secretory lysosome exocytosis. It has been observed that mutations in the gene regulating MUNC 13-4 results in defective cytolytic granule exocytosis, despite polarization of the lytic granules and docking with the plasma membrane. Our studies indicate that lack of CD107a after presentation with a target cell results in statistically significant differences in patients with MUNC 13-4 mutations as compared to other patients with HLH and no MUNC 13-4 mutations.
In this assay, mononuclear cells from peripheral blood are stimulated with K562, target cells, which induces degranulation. Tagged anti-CD107a is present with the cells during the stimulation period. After a six-hour incubation, the cells are surface stained with markers to allow the analysis of just NK cells. If the NK cells have been degranulated, the CD107a will be expressed on the effector surface and will be detected by flow cytometry.
This procedure is a flow cytometric assay that uses whole blood to screen for abnormalities in the expression of CD40-Ligand, CD40-Ig FP (Fusion Protein) and ICOS (inducible co-stimulator) on the surface of in vitro activated CD4+ T cells. It has also been observed that both gene and surface expression of CD40L by activated T cells is depressed in a subgroup of common variable immunodeficiency while the lack of ICOS upregulation on activated T cells would suggest the possibility of a genetic defect in the ICOS gene, underlying CVID.
This flow cytometry assay is intended to be used as a screening test. Screening tests are neither 100 percent sensitive nor specific, and a normal result should not preclude molecular sequencing if a patient’s clinical presentation suggests that the probability of a diagnosis is high.
Naïve T lymphocytes are mature resting T cells that have not yet encountered antigen. Memory T cells are long-lived antigen-specific T cells that have the capacity to quickly differentiate to an end stage effector cells upon re-exposure to antigen. Naïve and memory cells are present in both the CD4 and the CD8 subsets of T cells.
Two isoforms of the CD45 molecule, CD45RA and CD45RO, are expressed on the surface of naïve and memory cells, respectively. Using four-color flow cytometry, monoclonal antibodies against these antigens are used to quantitate the relative proportions of each subset in the peripheral blood.
The use of therapeutic monoclonal antibodies for the treatment of cancer has become a promising approach. Alemtuzumab (anti-CD52) targets the CD52 antigen present on the surface of most normal human monocytes, lymphocytes, as well as some malignant T cells and B cell lymphomas.
Once the monoclonal antibody binds with the CD52 antigen, it initiates antibody-dependent cellular toxicity and complement binding, which leads to apoptosis and activation of normal T-cell cytotoxicity against the malignant cells.
CD52 expression can be found in the vast majority of low-grade B-cell lymphoproliferative disorders such as follicular lymphoma, lymphoplasmacytic lymphoma, hairy cell leukemia and mucosa-associated lymphoid tissue lymphomas and may prove useful in treatment. Alemtuzumab therapy has also been used to prevent graft versus host disease following allogeneic bone marrow transplantation by inducing lymphopenia.
CD55 is included in the panel to monitor the development of paroxysmal nocturnal hemoglobinuria (PNH)-like symptoms in a small group of patients receiving Alemtuzumab with complications of hemolysis and thrombosis. Both CD52 and CD55 are antibodies against the glycosylphosphatidylinositol (GPI) anchor on the cell membrane.
If a small clone of T cells are negative for CD52 and CD55, they will not be targeted by the drug and will survive and multiply after treatment. This development of GPI deficient T cells has been noted in patients with chronic lymphocytic leukemia, patients following allogeneic stem cell transplants, and patients with aplastic anemia.
Neutrophil CD64 expression is rapidly increased both in vitro and in vivo within hours by mediators of inflammation such as interferon-gamma and G-CSF. The same change is observed in response to documented infection or tissue injury, thus indicating the measurement of neutrophil CD64 expression correlates with the presence of such conditions in humans.
The expression of CD64 on neutrophils is analyzed by labelling peripheral blood with CD64; CD163, a monocyte marker; and CD45, a pan-leukocyte marker, and analyzing the cells by flow cytometry. The combination of CD45 and CD163 increases the specificity of the leukocyte subpopulations and allows for elimination of any unlysed red blood cells or debris from the analysis.
Lymphocytes are CD64-negative, while monocytes are CD64 positive. These populations can be used as internal positive (monocytes) and negative (lymphocytes) controls for the analysis of increased CD64 levels on neutrophils.
Cytotoxic T lymphocytes (CTL) are a subset of lymphocytes that have the ability to lyse target cells bearing specific antigens. To assess the functionality of CTLs, target cells previously primed to contain radioactive chromium within the cell membrane are incubated with patient or control lymphocytes.
Lysis of the target cells by the CTLs is measured by the amount of chromium released into the supernatant.
CXCL9, also known as monokine induced by gamma interferon (MIG), is a member of the CXC chemokine subfamily. CXC chemokines are known to recruit activated lymphocytes and hinder angiogenesis via CXCR3. CXCR3 is a transmembrane protein expressed on activated Th1 lymphocytes. It has been observed in monocytes, endothelial cells, eosinophils, malignant B cells, melanoma cells, CD34+ hematopoietic progenitors and neurons. Expression of CXCL9 is induced by the Th1 cytokine, IFN-gamma. This is dramatically enhanced by the addition of TNF-alpha. CXCL9 production has been proven to be a sensitive measure of antigen-specific IFN-gamma production. CXCL9 has been implicated in pathologies characterized by the accumulation of activated Th1 lymphocytes. These include acute allograft rejection, glomerulonephritis, autoimmunity, rheumatoid arthritis, atherosclerosis, psoriasis and allergic contact dermatitis.
Various diseases show disturbances in the proportion of circulating Th1 and Th2 CD4 cells, and in overall cytokine production by T cells. By observing intracellular IFN-g, the Th1 CD4 cells can be enumerated and by looking at IL-4, the Th2 CD4 cells can be quantitated. If overproduction of cytokines is suspected, IFN-g, IL4 and TNF-a can be analyzed in CD4, CD8, NKT and NK cells.
Cytokine production is stimulated by incubating whole blood or mononuclear cells with Phorbol 12-Myristate 13 Acetate and Ionomycin. Activation is carried out in the presence of Brefeldin A, which inhibits intracellular transport, causing all cytokines produced during the activation to be retained inside the cell.
The activated cells are stained with surface monoclonal antibodies for phenotyping, then fixed, permeabilized and stained with antibodies to the cytokines IFN-g, TNF-a and IL4. The cells are then analyzed by flow cytometry.
This assay uses spectrally encoded antibody-conjugated beads to measure the following cytokines: IL-1b, IL-2, IL-4, IL-5, IL-6, IL-8, IL-10, IFN-g, TNF-a, and GM-CSF.
Cytokines are small secreted proteins that mediate and regulate immunity, inflammation and hematopoiesis. Cytokines are produced de novo in response to an immune stimulus. They generally (although not always) act over short distances and short time spans and at very low concentrations. They act by binding to specific membrane receptors, which then signal the cell via second messengers, often tyrosine kinases, to alter its behavior. Responses to cytokines include increasing or decreasing expression of membrane proteins (including cytokine receptors), proliferation and secretion of effector molecules.
It is common for different cell types to secrete the same cytokine or for a single cytokine to act on several different cell types (pleiotropy). Cytokines are redundant in their activity, meaning similar functions can be stimulated by different cytokines.
Cytokines are often produced in a cascade, as one cytokine stimulates its target cells to make additional cytokines. Cytokines can also act synergistically (two or more cytokines acting together) or antagonistically (cytokines causing opposing activities). Cytokines’ short half-life, low plasma concentrations, pleiotropy and redundancy all complicate their isolation and characterization.
By appointment, cell sorting for double negative T cells (DNTCs) can be performed so that testing for somatic FAS mutations can be done in the Molecular Genetics Lab. (Call 513-636-2731 to schedule and write in on requisition.)
The Epstein-Barr virus is a human herpes virus associated with two malignancies – African Burkitt’s lymphoma and nasopharyngeal carcinoma. Infection of primary human B cells by EBV in vitro immortalizes them; infected cells enter the cell cycle and proliferate indefinitely.
EBV is the only known agent capable of this human B-cell immortalization and is an invaluable research tool in that it allows for the establishment of permanent lymphoblastoid cell lines. Once the cells have proliferated sufficiently, they are cryogenically preserved. The frozen cell line will then be shipped back at the ordering physician’s discretion.
Osmotic gradient ektacytometry measures RBC deformability under a defined stress as a function of suspending medium osmolality. Ektacytometry is used to evaluate for inherited RBC membrane disorders, such as hereditary spherocytosis (HS), hereditary elliptocytosis (HE) and its severe form known as hereditary pyropoikilocytosis (HPP), hereditary ovalocytosis (SAO) and hereditary stomatocytosis (HSt), which are commonly responsible for hemolytic anemia. The report contains an ektacytometry profile (patient versus a normal control), the Omin, EImax and Ohyp values and an interpretation.
This multiparametric flow cytometric assays measures the amount and distribution of hemoglobin (Hb) F in red blood cells in combination with the evaluation of immature reticulocytes. This is accomplished in a 3-color assay using antibodies to RBCs, Hemoglobin F and immature reticulocytes (CD71). We quantify F-cells in three main populations: % of all RBCs (CD71+ and CD71-); mature erythrocytes (CD71-); and immature reticulocytes (CD71+). The results are reported as percent of red blood cells (RBCs) unless otherwise specified.
Also known as FORKHEAD BOX P3, SCURFIN and JM2, Foxp3 is a 49-55 kDa protein and a member of the forkhead or winged helix family of transcription factors. It is constitutively expressed in regulatory T cells (Treg), a subset of CD4+ T cells that are responsible for suppressing a variety of physiological and pathological immune responses, primarily through the elimination of self-reactive lymphocytes. Treg cells can be identified by their high expression of CD25, the IL-2 receptor alpha chain. Defects of Treg cells are thought to play a role in autoimmune and inflammatory diseases.
Mutations of the Foxp3 gene have been described in patients with immune dysregulation, polyendocrinopathy, enteropathy, X-linked syndrome (IPEX). This assay uses flow cytometry to determine the proportion and intensity of intracellular Foxp3 protein expression in the subset of CD4+ T cells that are CD25 bright and CD127 negative. The PCH101 antibody reacts with the amino terminus of human Foxp3 protein.
This flow cytometry assay is intended to be used as a screening test. Screening tests are neither 100 percent sensitive nor specific, and a normal result should not preclude molecular sequencing if a patient’s clinical presentation suggests that the probability of a diagnosis is high.
G6PD deficiency is an X-linked recessive genetic condition that predisposes an individual to hemolysis (spontaneous destruction of red blood cells) in response to a number of triggers, such as certain foods, illness or medication. It is particularly common in people of Mediterranean and African origin. The EDL offers G6PD screen and quantitation assays that can be used to detect congenital G6PD deficiency for hemolytic anemia investigation or to reduce drug-induced hemolytic anemia events. The methods detect the activity of the G6PD enzyme in RBCs using either dye reduction (G6PD screen) or kinetic (G6PD quantitation) methods.
Autoimmune pulmonary alveolar proteinosis (autoimmune PAP) is a rare disease characterized by alveolar surfactant accumulation, respiratory failure, and an increased risk of opportunistic infections. The disease is associated with GM-CSF autoantibodies that neutralize GM-CSF bioactivity and mediate pathogenesis by blocking signaling to alveolar macrophages and neutrophils. Alveolar macrophages require GM-CSF for terminal differentiation and constitutive regulation of functions including surfactant clearance. Without pulmonary GM-CSF signaling, immature alveolar macrophages have impaired pulmonary surfactant clearance, which results in slowly progressive surfactant accumulation and the insidious onset of clinical manifestations. Disruption of GM-CSF signaling by recessive mutations in CSF2RA or CSF2RB, which encode the GM-CSF receptor α and β chains, respectively, causes a hereditary form of PAP that is clinically, physiologically, and histologically indistinguishable from autoimmune PAP. PAP can also occur in a heterogeneous group of other diseases either as a consequence of an underlying clinical condition presumably affecting alveolar macrophage function (secondary PAP) or due to mutations in genes (e.g., SFTPB, SFTPC, ABCA3, TTF1) involved surfactant production (congenital PAP, and PAP associated with interstitial lung disease). Clinically, the diagnosis of PAP is made by the presence of a compatible history, typical radiologic findings, and lung biopsy or bronchoalveolar lavage cytology findings. However, while these methods can determine if PAP is present, none are capable of identifying the underlying PAP-causing disease responsible. The strong association of a high serum GM-CSF autoantibody (GMAb) level with autoimmune PAP, development of an ELISA to measure GMAbs and demonstration that GMAbs actually drive the pathogenesis of autoimmune PAP, support what is now widespread use of serum GMAb measurement for the clinical research diagnosis of autoimmune PAP. The potential clinical use of the GMAb ELSA is further supported by the identification of critical threshold of serum GMAb that is associated with an increased risk of autoimmune PAP.
Pulmonary alveolar proteinosis (PAP) is characterized by alveolar macrophage dysfunction, impairing pulmonary surfactant clearance in the alveolar space, possibly leading to respiratory failure. PAP has been further categorized to three main forms: hereditary, secondary, and autoimmune PAP. Hereditary PAP is associated with mutations in the GM-CSF receptor, affecting receptor binding and signaling. Secondary PAP is associated with a variety of hematological malignancies, where macrophage dysfunction occurs as a result of decreased numbers and/or function. Autoimmune PAP is associated with a disruption in clearance due to the presence of an autoantibody to GM-CSF. Autoimmune PAP comprises the largest majority of diagnosed cases, about 90 percent. STAT5 is an important protein within the GM-CSF signal transduction pathway. STAT5 is activated upon phosphorylation of its tyrosine. Hereditary and autoimmune PAP patients will exhibit decreased phosphorylation of STAT5 due to the mutations in GM-CSF receptor or the presence of autoantibodies to the cytokine, respectively.
Heinz bodies are small round erythrocyte inclusions thought to consist of denatured precipitated hemoglobin. Heinz bodies are not normally present in erythrocytes and are prominent in hemolytic anemia produced by agents that have been toxic to the erythrocytes or after removal of the spleen. The test method employed is microscopy with a methyl violet stain.
Hemoglobin A1c is used to monitor glycemic control for diabetic patients or patients at risk for diabetes. The method used is capillary zone electrophoresis.
Hemoglobin electrophoresis is used for the screening and/or confirmation of hemoglobin variants and/or thalassemias. The methods used include capillary zone electrophoresis for the initial screen followed by confirmatory testing with acid hemoglobin electrophoresis and isoelectric focusing. The final report will include the hemoglobin pattern with interpretation, hemoglobin variant identification and quantitation of significant hemoglobin components.
Hemoglobin F level can be ordered independently for the purposes of therapeutic monitoring of sickle cell patients receiving transfusion or hydroxyurea therapy, respectively. Method used is capillary zone electrophoresis, and quantitative hemoglobin fraction levels will be reported.
The oxygen dissociation (p50) assay is used to aid in the diagnosis of hemoglobin variants that cause abnormal hemoglobin oxygen affinity. The method employs dual wavelength spectrophotometry to measure oxygen saturation of hemoglobin and a Clark electrode to assess oxygen partial pressure in millimeters of mercury. The p50 value is determined as the partial pressure of oxygen where hemoglobin is 50 percent oxygenated.
Hemoglobin S level can be ordered independently for the purposes of therapeutic monitoring of sickle cell patients receiving transfusion or hydroxyurea therapy, respectively. Method used is capillary zone electrophoresis, and quantitative hemoglobin fraction levels will be reported.
Our multiparameter flow cytometry-based clinical testing assays aids in the diagnosis and management of oncologic and hematologic malignancies and other disorders in pediatric and adult patients. It can also be used to monitor therapy in patients with established diagnoses of hematopoietic neoplasms. We offer standard panels for many specimen types and leukemias, myelodysplasias, lymphomas and other myeloproliferative neoplasms. We are also able to customize a panel based on your specific patient and sample needs. Abnormal cells can be distinguished from normal hematopoietic progenitors on the basis of immunophenotyping by flow cytometric analysis. Monoclonal antibodies conjugated with fluorescent dyes combine with antigen sites on leukocytes, analyzed by flow cytometry, and subsequently evaluated with histograms to identify the fluorescently tagged cell populations.
Type 1, “classical” or “invariant” natural killer T cells (iNKT) are a T-cell subset which express a semi-invariant T-cell receptor (TCR) that recognizes CD1d. This invariant TCR consists of TCR-V-alpha-24-J-alpha-18 and TCR-V-beta-11, and can be identified on the basis of this unique TCR.
The only known disorder characterized by absence of iNKT cells is X-linked lymphoproliferative disease, caused by SAP deficiency. Four-color flow cytometry, using monoclonal antibodies against TCR-V-alpha-24 and TCR-V-beta-11 antigens, is used to quantitate the proportion of iNKT cells present in the peripheral blood relative to peripheral blood CD3+ T cells.
IL-18 has been included in secondary diagnostic criteria for ALPS. IL-18, also known as Interferon-gamma Inducing Factor (IGIF), has been implicated as a mediator of septic shock and tissue injury in response to inflammation. IL-1b converting enzyme (caspase-1) cleaves pro-IL-18 to produce the bioactive peptide that is readily released from cells such as dendritic cells, activated macrophages, and intestinal epithelial cells. In combination with IL-12, IL-18 has been shown to act on T helper (Th1) cells to induce their production of IFN-g. IL-18 enhancement of Th1 cytokine (IL-2, GM-CSF and IFN-g) production, FAS ligand expression, and IL-2R alpha chain expression has also been reported in Th1 cells.
Flow cytometric measures of lymphocyte activation has clinical application in the following areas: evaluation of cellular immune response, assessment of the activity of autoimmune disease processes, and monitoring of pre- and post-transplant for early signs of graft rejection, to name a few.
Detection of activated T cells is perceived as providing a more precise indication of the dynamics of immune function than could be obtained simply from counting absolute or relative numbers of different lymphocyte types in the blood. Quiescent lymphocytes, i.e., not motivated by an antigenic stimulus, express little if any surface appearance of the activation antigens (CD69, CD25, CD154, CD134, CD95, CD71, HLA-DR) and only upon stimulation will these antigens upregulate or over-express on the surface of lymphocytes.
Lymphocytes are a subpopulation of white blood cells, bone marrow-derived cells that can be differentiated into subsets of T cells, B cells and natural killer cells by expression of distinguishing cell surface molecules. T cells can be further differentiated into CD4 and CD8 cells, which each have unique roles in the immune response. Defects in one or more lymphocyte lineages can indicate the presence of an immune deficiency.
This assay uses BD Trucount antibodies and software to detect the following lymphocyte subsets: T cells (CD3, CD4 and CD8); B cells (CD19); and NK cells (CD16 and CD56).
Bare lymphocyte syndrome (BLS) is a rare immunodeficiency disorder caused by or associated with the failure of expression of cell surface antigens encoded for by the major histocompatibility complex (MHC).
It is now apparent that this syndrome is heterogeneous with regards to defective cell surface antigen expression. In some patients with this disorder, there is defective expression of only class l MHC antigens encoded for by the HLA-A, B and C genetic loci, while in other patients class ll MHC antigens (HLA-Dr, DQ and DP) are not expressed. Patients who fail to express both class l and class ll MHC antigens have also been identified.
Clinically, this syndrome is manifested as a combined immunodeficiency presenting early in life, and affected individuals are susceptible to a number of severe and/or opportunistic infections by a wide variety of pathogens. MHC class I and class II epitope expression on peripheral blood lymphocytes and monocytes are performed by multiparameter flow cytometry.
The complex cascade of events that comprise the cellular portion of the immune response include the proliferation of lymphocytes in response to upstream events (activation, Ca++ flux, etc.).
This assay tests the capacity of lymphocytes to proliferate in response to exposure to mitosis-inducing agents (mitogens). Specifically, peripheral blood mononuclear cells are exposed to phytohemagglutinin (PHA), concanavalin A (ConA), and pokeweed mitogen (PWM), and cultured for several days. An excess of radio-labeled thymidine is made available to the cells during the later part of the culture period.
As the stimulated cells enter the S phase of the cell cycle, they synthesize DNA, incorporating the radio-labeled thymidine which is then quantitated using a microplate scintillation counter. Results are expressed as counts per minute (cpm).
Neopterin biosynthesis is closely associated with cellular immune system activation. Increased levels of neopterin have been measured in patients with viral infections, suggesting that the increased concentrations may originate from the patient’s immune response against the virally infected cells.
Antigenic stimulation of human peripheral blood mononuclear cells has been shown to lead to neopterin release in culture medium and human macrophages produce neopterin in vitro when stimulated with interferon gamma. Therefore, determining neopterin levels in human body fluids offers a beneficial and innovative tool in monitoring diseases associated with cell-mediated immunity activation.
Principle of the assay: The assay is a solid-phase competitive ELISA. The intensity of color that develops is inversely proportional to the amount of antigen in the sample. Final concentration is determined directly using the standard curve.
The adhesion marker assay is intended to screen for leukocyte adhesion deficiency type 1 (LAD-1). Recruitment of neutrophils from the bloodstream to extravascular sites of inflammation is a critical event in host defense against bacterial infection and in the repair of tissue damage.
In response to extravascular stimuli such as bacterial-derived chemoattractants, or endogenous lipid and peptide mediators generated at sites of infection or tissue damage, leukocytes are first observed to “roll” along the vessel wall adjacent to the site of inflammation. Some of the rolling cells subsequently adhere firmly or “stick,” then diapedese between endothelial cells and migrate through the subendothelial matrix to the site of inflammation. CD11b / CD18 and its endothelial cell ligands including intracellular adhesion molecule-1 (ICAM-1, CD54) are necessary for firm neutrophil adherence and transendothelial migration.
Leukocyte adhesion deficiency syndrome type 1 (LAD-1) results from a congenital deficiency of the leukocyte b2 integrin receptor complex CD11 / CD18 on the cell surface.
This flow cytometry assay is intended to be used as a screening test. Screening tests are neither 100 percent sensitive nor specific, and a normal result should not preclude molecular sequencing if a patient’s clinical presentation suggests that the probability of a diagnosis is high.
A flow cytometric whole blood assay determines the ability of polymorphonuclear (PMNs) cells to produce an oxidative burst. This is accomplished by indirectly measuring the increase in fluorescence generated by the oxidation (by O2-) of a laser sensitive dye, dihydrorhodamine (DHR) 123. DHR is an uncharged and nonfluorescent reduction product of the mitochondrion-selective dye rhodamine 123. When incubated with PMNs, DHR diffuses into the cells and localizes in the mitochondria.
When the cells are stimulated with phorbol-12-myristate-13 acetate (PMA), the DHR is oxidized to the highly fluorescent rhodamine 123. The level of fluorescence is proportional to the amount of dye oxidized. CGD patients’ PMNs remain nonfluorescent while the PMNs obtained from female carriers with the X-linked form of GCD have two populations of cells; one fluorescent (normal), and one nonfluorescent (abnormal active X chromosome).
Natural killer (NK) cells are a subset of cytotoxic lymphocytes that have the ability to induce cell death in tumor cells or in virally infected cells. NK cells play a crucial role in the homeostasis of the immune system. They are typically characterized by the expression of CD16 and CD56 on their cell surface.
This assay makes use of the fact that NK cells will lyse the human erythroleukemia cell line, K562, in vitro. K562 cells are loaded with radioactive chromium and incubated with various ratios of a mononuclear cell preparation. Lysis of the K562 targets by NK cells contained in the cell preparation is measured by the amount of chromium released into the supernatant.
Perforin is a 70kD protein with cytolytic functions. It is expressed in the cytoplasmic granules of cytotoxic T lymphocytes (CTLs) and natural killer (NK) cells. Cytolytic cells release the contents of their granules, including perforin in response to recognition of their target cell. In the presence of calcium, perforin forms transmembrane pores in the membrane of the target cell, facilitating cell death.
Mutations in the perforin gene have been associated with primary hemophagocytic lymphohistiocytosis (HLH). The absence or otherwise atypical staining pattern of cytoplasmic perforin therefore can indicate a disease state. In this assay, peripheral blood is stained with both surface and intracellular monoclonal antibodies and analyzed using four-color flow cytometry.
Granzyme B is a serine protease which is involved in apoptotic cell death. Granzyme B, along with other enzymes, is contained in cytoplasmic lytic granules and is released primarily by cytotoxic T lymphocytes and natural killer cells. When Granzyme B is released from cytotoxic cells, it enters the target cell through the non-classical receptor-mediated entry pathway. Intracellularly it is enabled by perforin to convert to cytosolic Granzyme B, which then activates executioner caspase causing cell death.
If perforin is not present, there is a break in the apoptosis pathway and cell death does not occur. Levels of Granzyme B, when compared with perforin levels, can be indicative of differing clinical states.
This flow cytometry assay is intended to be used as a screening test. Screening tests are neither 100 percent sensitive nor specific, and a normal result should not preclude molecular sequencing if a patient’s clinical presentation suggests that the probability of a diagnosis is high.
Additional information regarding the accuracy of this flow cytometry screening assay is available.[1]
Flow cytometric analysis easily permits testing for the GPI-anchor expression by immunophenotyping erythrocytes and WBCs with anti-CD59 (termed: membrane attack complex inhibitory factor, [MACIF], membrane inhibitor of reactive lysis [MIRL] and prolactin) and FLAER, an inactive variant of aerolysin.
Paroxysmal nocturnal hemoglobinuria (PNH) is an acquired clonal disorder arising by somatic mutation in the pluripotent hematopoietic stem cell. A close relationship between PNH and aplastic anemia and other myelodysplastic disorders has been reported.
PNH is characterized by the deficiency, absolute or partial, of all proteins anchored to membrane by the glycosylphosphatidylinositol (GPI) anchor. At least 15 of these proteins have been shown to be lacking on the abnormal blood cells of these patients. The most prominent clinical feature in PNH is intravascular hemolysis due to increased susceptibility of red blood cells to complement-mediated lysis.
This defect in PNH is caused by the lack of GPI-anchored proteins on the red cell surface, a consequence of a block in the biosynthesis of the GPI molecule where N-acetylglucosamine is transferred to the phosphoinositol molecule. Not only is this defect seen in erythrocytes, but is also shared by WBCs and platelets of affected individuals.
Following stimulation of whole blood with IL-2, phosphorylation of STAT5 is measured in CD4 T cells using monoclonal antibodies and flow cytometry. The amount of phosphorylation of STAT5 through the IL-2 pathway is age dependent in healthy individuals, with younger children having less pSTAT5 than older children and adults.
Phosphorylation is a mechanism of cell signaling involved in many functional pathways including: differentiation, activation, proliferation and apoptosis. Detection of the phosphorylation of STAT5 Tyrosine is important in evaluating the IL-2 signal transduction pathway. Patients having decreased phosphorylation of STAT5 may have pathways that are non-functional or compromised.
Patients with severe combined immune deficiency (SCID) attributed to either JAK3 deficiency or defects of the common gamma chain shared by many cytokine receptors, namely IL-2, will have decreased phosphorylation of STAT5.
The red blood cell pit count can be used as a screening test for splenic phagocytic function. A normally functioning spleen should remove damaged or aging RBCs the cell from circulation and a correlation has been shown between an increase in the number of “pitted” RBCs and decreasing spleen function. A pit count of ≥3.5 percent has been associated with decreased or absent uptake on radionuclide spleen scans in individuals with sickle cell disease [Pearson HA, et al. Pediatrics. 1985;76(3):392-397, 1985]. More recent data indicate that normal spleen function is predicted by a pit count of ≤1.2 percent, and absent function is predicted by a pit count ≥4.5 percent in individuals with sickle cell disease [Rogers ZR, et al. Blood. 2011;117(9):2614-2617]. Limited data are available to guide the interpretation of pit counts in other causes of hyposplenism [de Porto, AP. Eur J Clin Microbiol Infect Dis. 2010;29(12):1465-73]. The method used is microscopy using differential interference contrast (DIC, Nomarski) optics.
The calcium-binding proteins S100A8 (alias: MRP8), S100A9 (alias: MRP14) and S100A12 (aliases: Calgranulin C, EN-RAGE) are typically secreted during activation of neutrophils and monocytes. S100A8/A9 form a complex (alias: calprotectin) that can serve as an endogenous TLR agonist and trigger TLR4 signaling pathways (Vogl et al 2007) leading to production of proinflammatory cytokines including IL1-beta. S100A12 can also activate human monocytes via Toll-like receptor 4 (Foell et al 2007, Kessel et al 2013).
High levels of S100A8/A9 and S100A12 are characteristic of active systemic juvenile idiopathic arthritis (sJIA) and may distinguish sJIA from other febrile illnesses, including systemic infection, various forms of leukemia and Kawasaki disease (Wittkowski et al 2008, Frosch et al 2009). S100A8/9 serum concentrations correlate closely in response to drug treatment and disease activity and therefore might be an additional measurement for monitoring anti-inflammatory treatment of individual patients with sJIA. During clinically inactive disease, S100A8/9 serum concentrations are reported to be one of the first predictive biomarkers indicating subclinical disease activity (Holzinger et al 2012), and low S100A8/A9 levels indicate that it is relatively unlikely that subclinical disease activity is present at the time the test is performed (Foell et al 2010). Highly elevated S100 proteins are also a feature that may be shared with other auto-inflammatory syndromes such as familial Mediterranean fever (FMF) and cryopyrin-associated periodic syndromes CAPS (Wittkowski et all 2011), and may be elevated in other diseases.
See our clinical lab index page for additional information and references.
The calcium-binding proteins S100A8 (alias: MRP8), S100A9 (alias: MRP14) and S100A12 (aliases: Calgranulin C, EN-RAGE) are typically secreted during activation of neutrophils and monocytes. S100A8/A9 form a complex (alias: calprotectin) that can serve as an endogenous TLR agonist and trigger TLR4 signaling pathways (Vogl et al 2007) leading to production of proinflammatory cytokines including IL1-beta. S100A12 can also activate human monocytes via Toll-like receptor 4 (Foell et al 2007, Kessel et al 2013).
High levels of S100A8/A9 and S100A12 are characteristic of active systemic juvenile idiopathic arthritis (sJIA) and may distinguish sJIA from other febrile illnesses, including systemic infection, various forms of leukemia and Kawasaki disease (Wittkowski et al 2008, Frosch et al 2009). S100A8/9 serum concentrations correlate closely in response to drug treatment and disease activity and therefore might be an additional measurement for monitoring anti-inflammatory treatment of individual patients with sJIA. During clinically inactive disease, S100A8/9 serum concentrations are reported to be one of the first predictive biomarkers indicating subclinical disease activity (Holzinger et al 2012), and low S100A8/A9 levels indicate that it is relatively unlikely that subclinical disease activity is present at the time the test is performed (Foell et al 2010). Highly elevated S100 proteins are also a feature that may be shared with other auto-inflammatory syndromes such as familial Mediterranean fever (FMF) and cryopyrin-associated periodic syndromes CAPS (Wittkowski et all 2011), and may be elevated in other diseases.
See our clinical lab index page for additional information and references.
SLAM-associated protein (SAP) is a small lymphocyte-specific signaling molecule that is defective or absent in patients with X-linked lymphoproliferative disease (XLP). Mutations in the SAP gene (SH2D1A) have been described in a majority of patients with the clinical syndrome of XLP.
XLP is a primary immunodeficiency, which is characterized by an extreme susceptibility to EBV and should always be considered in males with EBV-associated HLH. Half of XLP patients can have a fatal outcome with EBV infection because of explosive activation and proliferation of lymphocytes in many organs, which leads to fulminant hepatitis and bone marrow failure with hemophagocytosis. This assay is a rapid flow cytometry screening test for the presence of the SAP protein.
This flow cytometry assay is intended to be used as a screening test. Screening tests are neither 100 percent sensitive nor specific, and a normal result should not preclude molecular sequencing if a patient’s clinical presentation suggests that the probability of a diagnosis is high. Additional information regarding the accuracy of this flow cytometry screening assay is available.[1]
1. Gifford, CE; Weingartner, E; Villanueva, J; Johnson, J; Zhang, K; Filipovich AH; Bleesing, J; Marsh, RA. Clinical flow cytometric screening of SAP and XIAP expression accurately identifies patients with SH2D1A and XIAP/BIRC4 mutations. Cytometry B Clin Cytom. v. 86 p. 263-271.
The SC5b-9 enzyme immunoassay (EIA) measures the amount of the SC5b-9 complex present in human plasma. The Terminal Complement Complex (TCC, SC5b-9) is generated by the assembly of C5 through C9 as a consequence of activation of the complement system by either the classical, lectin or alternative pathway. The membrane attack complex (MAC), a form of TCC, is a stable complex that mediates the irreversible target cell membrane damage associated with complement activation. Complexes formed in the absence of a target membrane bind to naturally occurring regulatory serum proteins, e.g. the S protein forming non-cytolytic complexes in plasma. The SC5b-9 EIA test quantitates SC5b-9 in plasma.
The drug eculizumab, a terminal complement inhibitor, has been shown to inhibit hemolysis in patients with paroxysmal nocturnal hemoglobinuria (PNH) and to inhibit complement-mediated thrombotic microangiopathy in patients with atypical HUS (aHUS). Eculizumab is a humanized monoclonal antibody that binds to the complement protein C5 with high affinity, thereby inhibiting its cleavage to C5a and C5b and preventing the generation of the cytolytic terminal complement complex, C5b-9. Elevated plasma levels of SC5b-9 may be an indicator of an insufficient level of eculizumab to maintain blocking the formation of the terminal attack complex. See more information about TMA testing.
The hemoglobin-haptoglobin scavenger receptor (CD163 / HbSR) is a monocyte / macrophage-restricted transmembrane protein of the scavenger receptor cysteine-rich family. Antigen expression is related to monocyte / macrophage differentiation, with weak expression on peripheral blood monocytes and abundant expression on the majority of tissue macrophages.
Monocytes and macrophages play a central role in host response to infection. They synthesize and secrete a variety of inflammatory mediators. It has become increasingly clear that the pro-inflammatory process is balanced by associated anti-inflammatory mechanisms that result in monocyte deactivation, characterized by a decrease in HLA-DR expression and the release of anti-inflammatory cytokines such as IL-10.
It has been shown that the extracellular portion of CD163 is shed from the cell surface in the form of soluble CD163 when the cells are appropriately stimulated. Serum levels of sCD163 have been shown to be associated with levels of CRP. It has also been shown that sCD163 acts as a cytokine with modulatory effects on other cells. sCD163 may be a valuable marker in diseases with macrophage / monocyte involvement, particularly in infectious, inflammatory and myeloproliferative diseases. This assay uses a non-competitive sandwich ELISA technique to measure soluble CD163 in plasma.
Soluble Fas-Ligand (sFasL) is included in the secondary diagnostic criteria for ALPS. It is also known as CD178 or CD95L and is a member of the tumor-necrosis factor superfamily with a primary role in the induction of apoptosis in cells expressing its receptor Fas (Apo-1/CD95). The Fas/FasL system plays a role in modulating immune responses by inducing cell apoptosis to maintain homeostasis, self-tolerance of lymphocytes and immune privilege. This is a solid-phase ELISA assay that measures Fas Ligand in serum or plasma.
A soluble form of IL-2R appears in serum and plasma, concomitant with its increased expression on cells. Increased levels of the soluble IL-2R in biological fluids correlate with activation of T and / or B cells.
Results of a number of studies suggest a correlation of levels of IL-2R in serum with disease activity in autoimmune and infectious disorders as well as in transplantation rejection. Markedly increased IL-2sR levels have been associated with hematologic malignancies. Levels of IL-2R correlate with tumor burden and response to therapy in numerous malignancies. IL-2R levels can be used to predict the long-term prognosis in non-Hodgkin’s lymphoma patients and to assess the status of patients with HIV and acquired immunodeficiency.
We use a solid-phase, two-site chemiluminescent immunometric assay, and results are reported in units/ml (U/ml).
Evaluation of degranulation via measurement of CD107a following various stimuli can be used as a diagnostic screening test for the causes of familial hemophagocytic lymphohistiocytosis due to mutations in Munc 13-4, STX11 and STXBP2. A large prospective study revealed that over 95 percent of patients with these forms of HLH can be detected via screening CD107a assays utilizing measurement of CD107a on resting NK cells following exposure to the K562 cell line (Bryceson et al, 2012). We have since adopted this method as our CD107a Mobilization (NK Cell Degranulation assay) and have confirmed it to be useful (unpublished data). However, assays are not always able to be interpreted and reported, due to the fact that patient samples sometimes have too few NK cells.
Because degranulation can also be measured in T cells, we have developed a CD107a degranulation assay utilizing T cells. In this assay, mononuclear cells from peripheral blood samples are exposed to P815 cells coated with anti-CD3 (the P815 cell line is a murine mastocytoma which readily binds the Fc portions of the anti-CD3 antibody), which stimulates degranulation. PE-conjugated anti-CD107a is present with the cells during the stimulation period. After the two-hour incubation at 37°C, the cells are surface stained with markers to allow the analysis of T cells. If the T cells have degranulated, the CD107a will be expressed on the effector cell surface and will be detected by flow cytometry.
The T-cell receptor (TCR) is a molecule on the surface of T lymphocytes and is the primary receptor responsible for recognizing MHC-bound antigens on antigen presenting cells.
It is a heterodimer typically comprised of an alpha chain and a beta chain (>90 percent of T cells), but occasionally comprised of a gamma chain and a delta chain (<10 percent of T cells). TCR gamma / delta cells arise early in development and although their role in the immune response is not fully understood, they may play a regulatory role in bacterial infections. Increased circulating TCR gamma / delta cells may indicate certain disease states.
This test uses monoclonal antibodies against alpha-beta and gamma-delta antigens and flow cytometry to quantitate the relative proportions of each subset in the peripheral blood.
TCR is a molecular complex that comprises two units. A recognition unit composed of either ab or gd heterodimers, located on the cell surface, and a transducing unit, the CD3 complex, common to ab and gd heterodimers, that triggers the T cell when the recognition unit is engaged with the antigen.
There are four TCR gene loci (a, b, g and d). Each locus is composed of several V (variable) segments, a short D (diversity) segment (b and d only), a short J (joining) segment and one or two C (constant) region exons. During T-cell ontogeny, a T cell “chooses” at random one V, D, (if any), J and C segment. The D and J regions are short but very diverse due to an additional process that adds or deletes nucleotides at random, when the V, D and J segments are linked together.
The consequence of this process is that a given T cell displays a single and unique combination on its cell surface. There are in fact 65 Vb segments in the b locus that are grouped into 25 subfamilies (22 functional families).
This test is designed to quantitate 24 antigens of the TCR Vb repertoire of human T lymphocytes in eight test tubes using a flow cytometric procedure (immunostain, lyse, wash and fix).
The assay is achieved by combining three TCR Vb specific antibodies in a single test but with only two colors. One TCR Vb antibody is conjugated to FITC, another to PE, and the third to both FITC and PE. In this way, the third Vb stained population shows up in quadrant 2 in an FL1vs FL2 histogram. Results will distinguish polyclonal from oligoclonal or monoclonal T cell proliferation.
Th17 is the name of interleukin (IL)-17 producing CD4+ T cells that are a subpopulation of T helper lymphocytes involved in immune responses to fungal and extracellular bacterial pathogens.
In our assay, IL-17 cytokine production is stimulated by activating whole blood in the presence of Brefeldin-A to block release of intracellular cytokines, trapping cytokines produced during activation inside the cell. The activated cells are stained with surface monoclonal antibodies for phenotyping, fixed, permeabilized and stained with antibody against IL-17. The cells are then analyzed by flow cytometry to detect the peripheral blood levels of Th17 cells in order to screen patients for Hyper IgE syndrome. This test is only run on day-old samples. Please collect Monday-Thursday.
This test may be useful for the diagnosis or therapeutic monitoring patients with sickle cell disease, polycythemia/erythrocytosis, and other diseases associated with abnormal whole blood viscosity.
The instrument is a cone-and-plate viscometer, which is appropriate for measuring viscosity in non-Newtonian fluids, like blood. Values for viscosity will be reported at a single shear rate of 187.5 s-1, which is consistent with blood flow in conduit arteries. Viscosity is also measured at other shear rates, and these results can be provided upon request. The result will be reported in centipoise (cP) units with reference to a normal range
(Includes quantification of WASP in specific lymphocyte subsets) − Success of engraftment after BMT can be evaluated by performing multicolor flow cytometric analysis using monoclonal antibodies to cell surface antigens to characterize the hematopoietic cell populations of interest before the intracellular staining for WASP.
Detection of WASP is possible by permeabilizing peripheral blood lymphocytes, monocytes and neutrophils and staining intracellularly with mouse anti-human WASP antibody then analyzing on a flow cytometer. The absence or otherwise atypical staining pattern of intracellular WASP therefore can indicate the disease, carrier state or mixed chimerism after BMT.
This flow cytometry assay is intended to be used as a screening test. Screening tests are neither 100 percent sensitive nor specific, and a normal result should not preclude molecular sequencing if a patient’s clinical presentation suggests that the probability of a diagnosis is high.
Deficiency of X-linked inhibitor of apoptosis (XIAP), caused by mutations in the BIRC4 gene, is the second most common cause of X-linked lymphoproliferative syndrome (XLP). The most common cause is deficiency of SLAM-associated protein (SAP) caused by mutations in the SH2D1a gene. XLP due to BIRC4 mutation is associated with the development of HLH and other lymphoproliferative disorders, sometimes in association with EBV.
XIAP is an intracellular protein expressed in many tissues. To rapidly screen patients for this disorder, patient and normal sample lymphocytes are fixed, permeabilized and stained with a mouse monoclonal antibody against XIAP, followed by secondary PE-conjugated anti-mouse antibody staining.
Following intracellular staining, residual PE conjugated anti-mouse antibody is blocked, followed by lymphocyte surface marker staining. Samples are analyzed by five-color flow cytometry, and XIAP expression is measured in the CD4+ and CD8+ T cells, NK cells and B cells.
This flow cytometry assay is intended to be used as a screening test. Screening tests are neither 100 percent sensitive nor specific, and a normal result should not preclude molecular sequencing if a patient’s clinical presentation suggests that the probability of a diagnosis is high.
Children with severe combined immunodeficiency (SCID) are prone to repeated and persistent infections that can be very serious or life-threatening. Infants with SCID typically experience pneumonia, chronic diarrhea and widespread skin rashes. If not treated in a way that restores immune function, children with SCID usually live only a year or two.
ZAP-70-related SCID is one of several forms of severe combined immunodeficiency, a group of disorders with several genetic causes. ZAP-70 is an intracellular tyrosine kinase that is recruited in the CD3 T-cell receptor (TCR) complex and is required for T-cell activation following TCR engagement. ZAP-70 deficiency is a rare autosomal recessive form of SCID characterized by a lack of CD8+ T cells and presence of circulating CD4+ T cells. Most individuals with ZAP-70-related SCID are diagnosed in the first six months of life. ZAP-70 SCID is a rare disorder where only about 15 affected individuals have been identified.
A permeabilization reagent renders intracellular antigens accessible and allows cytoplasmic and nuclear immunophenotyping of leukocytes. It creates apertures in the membrane without affecting the gross morphology of the cell and therefore preserves its flow cytometric light scattering characteristics.
This permeabilization reagent allows one to perform simultaneous surface and intracellular antigen staining. A “Fix and Perm Cell Permeabilization Kit” standardizes the procedure that consists of first fixing cells with reagent A, and second, permeabilizing the leukocytes and lysing red cells using reagent B.
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