Author Archives: د.حسام أبو فرسخ

Cytomegalovirus infection (CMV) is fairly common in Immunocompromised patients. Typical CMV inclusions detect only 20% of the cases and can miss up to 80% of the cases

Now , we can perform CMV immunohistochemistry on any tissue suspected of CMV infections lung biopsy, Bronchial lavage, Esophageal biopsy, colonic biopsy, kidney biopsy, lymph node biopsy, blood buffy coat

Identifying CMV infection, with advent of new treatment has strong clinical implication

We, in the First Medical Laboratory, are determined to bring the best of laboratory medicine in clinical practice to Jordan

Please do not hesitate to contact me for further inquires

Dr. Hussam Abu-Farsakh

American boards of Anatomic, Clinical Pathology and Cytopathology

Circular: is a periodic circular that distributed to clinician informing them about new and important tests available at First Medical Laboratory. All information listed are supported by recent literature

Breast carcinoma, lung carcinoma and thyroid carcinoma are one of the most common sources of unknown primary. Now with new immunohistochemistry, we can be sure of lung carcinoma origin by doing TTF-1 and by breast carcinoma origin by doing Gross Fluid cystic protein on the tumor tissue. Both markers are, for practical purposes, specific and sensitive for lung and breast carcinoma respectively., even for poorly differentiated carcinoma

Good example of this is detecting carcinoma in cervical or in axillary lymph nodes where the differential usually lies between breast and lung carcinoma, even with negative mammogram and negative chest X ray

“Thyroid Transcription Factor” detect thyroid carcinomas in metastatic sites

           (Mesothelin” detect mesothelioma (where primary lung carcinoma is in the differential”

Detecting tumors of breast, lung, mesothelial or thyroid origin has different implications in therapy and prognosis

We, in the First Medical Laboratory, are determined to bring the best of laboratory medicine in clinical practice to Jordan

Please do not hesitate to contact me for further inquires

Dr. Hussam Abu-Farsakh

American boards of Anatomic, Clinical Pathology and Cytopathology

Circular: is a periodic circular that distributed to clinician informing them about new and important tests available at First Medical Laboratory. All information listed are supported by recent literature

Making a diagnosis of Type I DM is of paramount importance as early as possible to start on correct treatment. Some patients may not present with classical symptoms of ketoacidosis. In fact some may be adult with overweight with maintained residual b-cell function, leading to a misclassification as type 2 diabetes. Four autoantibody specificities have been shown to be relevant for the diagnosis:Autoantibodies against glutamic acid decarboxylase (anti-GAD) positive in 70�80% of children and adults with type 1 diabetes, Autoantibodies against tyrosine phophatase (anti-IA-2) present in 50�70% of children and in 30�50% of adults. Insulin autoantibodies (IAAs) are detectable in 50�70% of children and in 20�30% in adults. Cytoplasmic islet cell antibodies (ICAs) are positive in 80�90% of newly-diagnosed patients with DM type I

Combined screening for IAA and anti-GAD (age less than 10 years) or IA2-Ab and anti-GAD (age over 10 years) is the recommended first-line analysis. The detection of one autoantibody provides evidence of an ongoing autoimmune process. A special form of type 1 diabetes is the so-called latent autoimmune diabetes in adults (LADA). These patients typically develop diabetes after the age of 30 years and have a slowly progressing autoimmune process. Therefore, endogenous insulin secretory capacity is only slightly decreased at the manifestation of the disease. Due to clinical features, these patients are often misclassified as suffering from type 2 diabetes and are treated with oral hypoglycemic drugs. After several months or a few years, these patients develop absolute insulin deficiency and require insulin treatment. In young and middle-aged adults, the frequency of this form of diabetes is relatively high (approx. 20% of patients with type 2 diabetes in the age range 25�44 years). The detection of LADA should be made by primary screening for anti-GAD, ICA or Anti IA-2

It is recommended that any patient with suspected type I or type II diabetes, especially when clinical presentation is not typical to ask for the above antibodies

Please contact us for any further inquiries

We in the First Medical Lab are determined to bring the best of laboratory medicine to practice in Jordan

Dr. Hussam Abu-Farsakh, Am. Boards of Pathology

Muscle biopsy: Muscular dystrophies, myopathies , mitochondria disease , neurogenic: disorders and inflammatory myopathy

      Routine H&E–

      Trichome stainGomeriModified–

      PAS stain–

      Enzyme histochemical stains: ATPase at PH 4.2–

      Enzyme histochemical stains: ATPase at PH 4.6–

      Enzyme histochemical stains: ATPase at PH 9.4–

      (Enzyme histochemical stains: NADH(oxidative enzyme contents–

      Phosphorylase enzyme–

      Succinate Dehydrogenase–

Cytochrome oxidase–

  Dystrophin immunostaining for muscle dystrophy-

(performing the muscle biopsy)

Epstein Barr virus is a DNA virus that infects mostly young children and adolescence. But is does infect adults not infrequently. The virus enters the human body system through the oropharyngeal epithelial and lymphoid tissue. The virus enters the cell DNA and incorporate into the cell and may induce oncogenic changes in some of the cells later in life

:Antibodies response

Viral capsid antigen (VCA): IgM and IgG : first to rise in the incubation period and prodromal phase. IgM falls after 2^nd and 3^rd week. IgG: remains during life

EBV nuclear antigen antibody (EBNA): rises during the later portion of the convalescence (after 2 weeks) and detectable throughout life

Early antigen-Diffuse type: EA-D: rises with onset of clinical symptoms and decreased after 9-10 months. It is also increased during reactivation of the disease and is considered usually as a marker of reactivation of infection

:Summary of the results

IgG: VCA positive-

IgM: VCA positive

Indicates: Primary infection

IgG: VCA and EBNA positive-

IgM: Negative

Indicates Late phase of infection

IgG: VCA, EBNA and EA-D positive-

IgM: VCA positive

Indicates reactivated infection

IgG: VCA and EA-D positive-

IgM: Negative

Indicates reactivation of infection

This test is performed by Western Blot and is very sensitive for different viral antibodies and antigens

Please ask for full EBV virus profile to detect the status of the patient with EBV infections and that will include: VCA (IgG, IgM). EA-D, EBNA

Please do not hesitate to contact us for any further inquiries

We in the First Medical Lab are dedicated to bring the best of Laboratory medicine to clinical practice in Jordan

Dr. Hussam Abu-Farsakh

American Board of Anatomic & Clinical Pathology, and Cytopathology

Circular: is a periodic circular that distributed to clinician informing them about new and important tests available at First Medical Laboratory. All information listed are supported by recent literature

We would like announce that from now on, Electron Microscopy (EM) service is available in Jordan as one of the Laboratory services the First Medical Laboratory is dedicated to bring to Medical practice to Jordan

This has been done through special agreement between the First Medical Laboratory in Amman, Jordan and Texas Children Hospital in Houston, Texas

:Electron Microscopy has invaluable role in the following entities

Kidney biopsy-

(Muscle diseases (especially mitochondrial myopathies-

Some metabolic and congenital diseases i.e. Lysosomal storage disease-

 The cost of the test: 375 J.D; this includes providing fixative for E.M, sending the specimen through DHL to Houston, performing the E.M study, and providing reprint from the E.M, pathology reporting of the EM pictures

Turnout time : 2 weeks

We, in the First Medical Laboratory, are dedicated to bring the best of Laboratory medicine to Clinical practice to Jordan

.Dr. Hussam Abu- Farsakh, M.D

American board of Anatomic and Clinical Pathology

American board of Cytopathology

Purpose of the circular: we introduced EGFR test by immunohistochemistry. Summary of recent literature about the value of this test with its clinical applications is provided

Introduction: EGFR is a transmembrane protein receptor with tyrosinase kinase activity. Increased level of EGFR are linked with malignant transformation. Estimation of EGFR immunoreactivity by immunostaining detects EGF specific binding sites. Different Carcinomas showed significant staining in variable percentage. Examples of Carcinomas that express EGFR with variable percentage from 30-90%: Non-small cell lung carcinoma, breast carcinoma, endometrial carcinoma , cervical carcinoma and ovarian carcinoma

Clinical applications: Carcinomas that show positive staining for EGFR correlate with poor differentiation of the tumors. These tumors are usually undergoing an aggressive biological behavior and have unfavorable prognosis. There is a positive correlation between the EGF-R binding assay, immunohistochemistry and the relative amounts of mRNA by Northern blotting. Studies demonstrated a significance of EGFR status as an independent prognostic indicator in primary breast cancer with higher risk for relapse. With shorter period of relapse-free survival for EGFR positive patients compared to EGFR negative patients, particularly in node-positive patients. Epidermal growth factor receptor (EGFR) expression is also observed in 50%-70% of colorectal carcinomas and is associated with poor prognosis and poor response for pre-operative radiotherapy. The immunoreactivity of EGFR shows a concordance between the primary lesions and metastatic sites in majority of cases

Treatment of EGFR positive tumors is mainly by two mechanism: Monoclonal antibodies that interfere with receptor signaling (e.g: cetuximab) or by low molecular weight tyrosine kinase (TKI) that interfere with receptor signaling (e.g: gefitinib). This treatment have shown to be effective in many EGFR +ve tumors: for examples, in breast carcinoma that are ER negative/EGFR positive; gefitinib is active against ER negative and acquired tamoxifen �resistant ER positive breast cancers. For advanced stages of Non-small cell carcinoma of the lung: gefitinib shows improvement of lung carcinoma related symptoms (shortness of breath, cough, etc.) in 40% of the cases, with better overall survival in responding cases within EGFR positive cases group. Conclusion: EGFR immunostaining is important in many carcinomas, as tumors expressing this factor have aggressive course with early relapse and poor response to therapy. Treatment with anti-EGFR either alone or in combination of chemotherapy, have shown to be effective in many carcinomas

Dr. Hussam Abu-Farsakh, Lab Director

Introduction: EPO is a Glycoprotein growth factor that is primary stimulus to erythropoiesis, produced by the kidney, and acts directly on precursor cells in the bone marrow. Decreased oxygen delivery is the primary stimulus for EPO production that is the case usually in anemia and hypoxemia

:Clinical Use

-1

Very important in distinguishing Primary Polycythemia (Polycythemia Rubra Vera) from secondary Polycythemia causes. High level of EPO seen in cases of Secondary Polycythemia (as in chronic respiratory diseases), however, low levels of EPO is seen in primary Polycythemia Rubra Vera

-2

Decreased in patients with Chronic renal failure: Measurement of EPO blood level

is essential in deciding which patients with chronic renal disease worth to give Synthetic EPO. Synthetic EPO is very helpful in recovering these patients from the anemia

-3

EPO Raised in some malignancies and considered as a tumor marker: It is raised in Hepatocellular carcinoma in 23% of cases and in 5 % of Renal cell carcinoma

-4

Low EPO observed in patient with rheumatoid arthritis and contributed to the state of anemia in these cases

:Material needed

100 mL heparinized plasma sample specimen , preferably taken between 7:30 am and 12: 00 noon; patient not necessary to be fasting; hemolysis in specimen can have effect on the assay

We, in the First Medical Laboratory, are dedicated to bring the best of Laboratory medicine to Clinical practice to Jordan

.Dr. Hussam Abu- Farsakh, M.D

American Boards of Anatomic, Clinical Pathology

American Board of Cytopathology

Performing the complete profile of antibodies against nuclear antigens is very helpful is the diagnosis of different types of connective tissue diseases that are present. The full spectrum of

these antigens are as follows

nRNP, Sm, SS-A, SS-B, Scl-70, Jo-1, centromere, dsDNA, Histones, ribosomal P protein

Antibodies against these antigens can indicate specific disease pattern as shown below

Systemic lupus erythematosus: Anti-Double stranded DNA , Anti-Sm, anti-ribosomal P protein, anti-SS-A (RO), Anti-SS-B (La), Antihistone

(Sjogren’s syndrome: Anti-SS-A (Ro), Anti-SS-B(La

Mixed connective tissue disease: Anti-RNP

Scleroderma: Anti-Scl-70, Anti-PM-Scl, Anti-Ku

CREST: anticentromere

(Polymyositis: Anti-Jo1 (usually associated with interstitial lung fibrosis

Medication induced lupus: anti-histones

Material required: Serum

We, in the First Medical Laboratory, are dedicated to bring the best of laboratory medicine to clinical practice to Jordan

Dr. Hussam Abu-Farsakh

American Board of Anatomic & Clinical Pathology, and Cytopathology

Circular: is a periodic circular that distributed to clinician informing them about new and important tests available at First Medical Laboratory. All information listed are supported by recent literature

Introduction: MALT (mucosal associated lymphoid tissue) lymphoma originates from the gastric mucosa in patients mainly with H.Pylori infection. Patients usually present with epigastric pain, or non-specific dyspepsia

Histopathologic changes: patients have prominent germinal centers with proliferation of lymphoid cells of marginal zone area, scattered transformed blasts with plasma cell differentiation in maximal beneath the surface epithelium and follicular colonization of the germinal center. , and prominent lymphoid epithelial lesions

Immunophenotyping: is essential in the diagnosis of MALT lymphoma (as it could mimic other higher grade lymphomas). The malignant lymphoid cells are

-CD20+, IgM+, Bcl2 +, CD5, CD10-, Cyclin D1

Chromosomal translocation t (11; 18) is the most common event in MALT lymphoma. This translocation results in the formation of MALT protein which its main action is prevention of apoptosis (cell death) and progression of cells to lymphoma

Transformation of Gastric MALT lymphoma: to large cell type is not uncommon, the percentage of large cell has to be estimated in the histopathology report either, less than 5%, 5-20% or >20%. The prognosis is worse as the percentage of large cells increases

Treatment of MALT lymphoma: 75% of all patients respond to anti-H Pylori therapy which is considered the first line of therapy in cases with MALT lymphoma.. Absence of lymph node involvement is the best predictor for response. . The complete regression takes about 5 months Repeat biopsy is recommended in theses cases in 3 months intervals for the first year, and annually for the next 5 years

In cases where no response observed (usually these are the cases with deep penetration of the lymphoid tissue, with or without regional lymph nodes involvement), other modalities should be considered; Chemotherapy with Chlorambucil or cyclophosphomide; local radiotherapy, or gastrectomy. Survival ranges in these advance cases from 75%-95% in different studies depending on the stage of the disease

Prognostic factors in the MALT lymphoma: The depth of the lymphoid infiltration in the gastric wall; the percentage of the large cells, the involvement of the regional lymph nodes and the bone marrow involvement, observed in less than 15% of the cases

Summary Diagnosing MALT lymphoma using the best knowledge with immunophenotyping in the early cases, recording all Histopathologic Prognostic Factors and not missing them for chronic gastritis in one hand, or missing them with other higher grade lymphomas (on the other hand) are the best guard for effective therapy regimens

.Dr. Hussam Abu-Farsakh, M.D