Author Archives: د.حسام أبو فرسخ

Introduction: This is a cell surface glycoprotein, strongly expressed in mesothelial cells, benign or malignant

:Clinical Use

-1

Confirming the diagnosis of Mesothelioma ( the only marker available as positive confirmation

-2 Identying atypical cells in the body fluid (e.g: pleural or peritoneal fluid) whether of mesothelial origin or

they are not

(very helpful in identifying metastatic carcinoma from atypical reactive mesothelial cells)

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

Please contact us for any further information

Microvillous inclusion disease (MID) : Familial Microvillous Atrophy is a cause of intractable diarrhea in infancy. The light microscopy picture is usually normal and that may account for many cases that may passed unnoticed. Its diagnosis is used to be troublesome in the past. Usually the patient may have more than one time biopsy due to the requirement of Electron Microscopy for definitive diagnosis. Now, with new development in molecular pathology, Immunostaining for CD 10 is replacing electron microscopy for its definite diagnosis. CD10 is an enkephalinase which plays a role in final stages of peptide hydrolysis at the membrane surface. With the use of Immunostaining for CD 10, the absorptive cells stains strongly for CD 10 involving more than � of the surface enterocytes cytoplasm. This is due to accumulation of enkephalinase in the surface enterocytes

Simple duodenal biopsy submitted in formalin (instead of gluteraldehyde) is a good specimen for the definite diagnosis. The staining in this disease is pathognomonic for this disorder. Electron microscopy used to be the goal standard for this diagnosis. Now, CD 10 Immunostaining is substituting electron microscopy

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

Colon carcinoma is known to have a familial tendency. 15% of patients with colorectal carcinoma have hereditary syndrome called: Hereditary Non-Polyposis Colorectal Caner (HNPCC). Patients that have colon carcinoma below the age of 50 years are likely to have this syndrome than older patients. The genetic alterations in this case includes mutations in Mismatch Repair Genes, the genes that are essential in correcting any �wrong� DNA synthesis during cell proliferation. The genetic hallmark of defective DNA Mismatch Repair is the presence of microsatellite instability (MSI-H). The most important of all these genes are MLH-1 and MSH-2 that compromise about 90% of all of these cases

           Molecular studies for these patient are essential and are performed in most of large centers in the world for several reasons

-1

Patients with Microstalite instability (MSI-H) have better prognosis

-2

Serrated adenoma may be an important precursor to colorectal carcinoma in these patients

-3

Conventional adjuvant chemotherapy is less beneficial than patient with usual type of colorectal carcinoma, and patients with MSI-H tumors could in fact be worsened by chemotherapy

-4

Patients with this syndrome could have more than one carcinoma, example endometrial adenocarcinoma in females affected with this syndrome

-5

Family members for patients expressing MSI-H should be examined for this gene and screened for colorectal carcinoma by endoscopy at an annul basis

The histopathology of Patients with this syndrome have carcinomas usually in the right side of the colon with poor differentiation, unusual histologic types (mucinous, medullar and signet ring cell histology), absence of dirty necrosis, expansile growth pattern, numerous tumor infiltrating lymphocytes and prominent peritumoral lymphoid nodules

In our effort to bring the best of clinical tests to medical practice in Jordan, we would like to announce that these tests are available now in Jordan in our lab only

Please contact us for any further inquiries

Dr. Hussam Abu-Farsakh

American Board of Anatomic & Clinical Pathology, and Cytopathology

Introduction: MRP is a surface glycoprotein that is expressed in the cell surface of many tumor cells and contributes to the tumor resistance, by moving chemotherapy (efflux) out of the cells

Clinical use: In acute leukemias, that are secondary (to Myelodysplasia or to Alkylating agents) or that occur in the elderly, the chance of expressing this gene is over 75%, while in de nevo cases occurs in 30% in younger patients

It is proved now beyond doubt that the expression of this gene is highly predictive of lower complete remission rate and more resistant disease. In addition, Cases with MRP have trilineage dysplasia

It is considered now a subentity based on the old FAB leukemia classification due to their poor response

Summary: Recognition of this subset of MRP positive cases is essentially important in acute leukemias that occur typically in older individual and in 30% of younger AML cases. Its recognition is important for treatment strategies and prognosis

We, in the First Medical Lab, have introduced this test that can be performed in bone marrow smears or in trephine biopsy. We are doing this in our effort to bring the best of laboratory medicine to clinical practice in Jordan

Please do not hesitate to contact us for further details

Dr. Hussam Abu-Farsakh

American boards of Anatomic, Clinical Pathology and Cytopathology

The advances made in muscle biopsy in Jordan, now, are becoming able to diagnose many of the muscle types of dystrophies with certainty

Introduction: the muscle membrane is peculiar among other cell membranes by having complex of proteins that are attached to the muscle membrane, that are very important for its integrity and action. The complex includes dystrophin and glycoprotein complex (DGC). This complex has several proteins. The defect in them leads to muscle dystrophies of various types, as indicated below

:The following diseases can be diagnosed or excluded with certainty in our lab

Duchenne and Becker�s muscular dystrophy: due to deficiency of dystrophin protein. Staining for dystorphin can be done in paraffin blocks

Limb girdle muscular dystrophy (LGMD) syndrome: divided into autosomal dominant form (Type 1); autosomal recessive form (type 2). we can diagnosis with certainty in our lab the following diseases of limb girdle syndrome

Type LGMD2b: due to deficiency of dysferlin. It is a common form and accounts up to 30% of the LGMD cases. This protein is important for the integrity of the muscle membrane and part of the Dystrophin-Glycoprotein Complex. The disease manifestation varies. The disease may present initially with gastrocnemius weakness and they will be unable to walk on their toes. Age of onset is between 10-late 30s. Wheelchair confinement occurs around 30 years after onset. Staining for dysferlin can be done on muscle tissue. The same mutation occurs in Mioshi distal myopathy

Type LGMD 2D: due to decrease or absence of Adhalin (alpha sacroglycan) in muscle membrane. This disease is common in the Arab countries. This mutation is 4 times as common as mutation in beta (2E) and gamma sacroglycan. (2C). Age of onset is between 2-15 years. Patients with early onset have rapid progression to wheelchair, while patient with later onset may have preserve ambulation. Staining for Adhalin can be done by immunohistochemical stain on frozen muscle tissue

Merosin Laminin Alpha 2 chain deficiency: this protein is part of Dystorphin-Glycoprotein complex. Autosomal recessive congenital muscular dystrophy due to decreased or deficiency of Merosin in the basement membrane. It is characterized by symmetrical proximal and distal weakness, with contractures. Serum CPK: moderately high. MRI of CNS: increased T2 signal in white mater. Staining for Merosin can be done by immunohistochemical stain on frozen muscle tissue

Emery-Drefuss muscular dystrophy : X linked form; due to deficiency in Emerin. It is localized in the nuclear membrane; characterized by slowly progressive contractures in elbow and neck (differential: Bethlem myopathy) , wasting of scapulohumeroperoneal muscles (differential: scapuloperoneal muscular dystrophy) and cardiomyopathy (with conduction heart block, presenting as syncope). CPK mildly elevated. Staining for Emerin can be done by on formalin fixed muscle tissue

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

Please call us for any further information

.Dr. Hussam Abu-Farsakh, M.D

American boards of Anatomic, clinical pathology & Cytopathology

Myocarditis can be a fatal disease and can be caused by several viruses and bacterial disease. Its exact diagnosis, in many instances, can help in the treatment

The Myocarditis profile contains a list of viruses and bacteria that can cause Myocarditis

:The list includes the followings

Mumps virus–

Adenovirus type 3–

(Influenza virus type A (H1N1–

(Influenza virus type A (H3N2–

Influenza virus type B–

Parainfluenza virus type 1–

Parainfluenza virus type 2–

Mycoplasma pneumonia–

CMV–

Coxsackie virus type B1–

Coxsackie virus type A16–

Echo virus type 7–

(Borrelia afzelii ( a cause of Lyme disease in Asia and Europe–

(Borrelia burgdorferi sensu stricto ( a cause of Lyme disease in US–

(Borrelia garinii   ( a cause of Lyme disease in Asia and Europe–

(Chlamydia pneumonia (can cause atherosclerosis and early myocardial infarction–

Material required: serum

Price/16 tests: 80 J.D

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

Nerve disease can be studies in details in our lab to detect meylin and axonal disoders

:We perform the following special stains and special tests

Holmes method for nerve cells and fibers-

Bielschowsky method for neurofibrils-

Luxol fast blue for myelin-

Electron microscpy for detail of nerve axons and myelins

:Material requied

A piece of affected nerve, piece submitted in formalin for the first 3 stains and a pice submitted in 2.5% gluteraldehyde for electron micrsopcy

Note: Elelctron microscpy examination of the nerve is an essential part of the diagnosis

Please call us for any further details

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

American Board 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

/Neuronal intestinal dysplasia (NID), described in 1971, is a poorly understood colonic motility disorder of neuronal structure in the bowel wall. NID is characterized by several histochemical and pathological findings such as

-1

Hyperplasia of submucous and myenteric plexus with formation of giant ganglia

-2

Isolated ganglion cells in the mucosal lamina propia and between muscle layers of muscularis mucosa

-3

Moderate elevation of acetylcholinesterase in the parasympathetic fibers of mucosal lamina propia and circular muscle

-4

Hypoplastic or aplastic myenteric plexus sympathetic innervation

The most characteristic alteration identified is acetylcholinesterase elevation of parasympathetic fibers, and the less reliable diagnostic feature, the giant ganglion cells. This disease entity has be divided   into two types ( A and B), with a common clinical feature in both: chronic constipation and megacolon . In type A the disease is confined to the colon causing a functional bowel obstruction with acute onset. Symptoms are present since birth and comprise: constipation, ulcerative colitis, painful straining, and bloody stools. Histologically there is aplasia or hypoplasia of myenteric sympathetic innervation and increase acetylcholinesterase activity in lamina propria, circular muscle and muscularis mucosa . Ganglion cells are present, excluding the diagnosis of Hirschsprung’s disease HD

Type B NID is more common. It is often associated with Hirschsprung’s disease and can constitute a cause of failure of clinical improvement after adequate resectional pull-through surgery. Other conditions associated with Type B NID are: Chronic intestinal pseudo-obstruction, anorectal malformations and MEN II syndrome patients. Histology is characterized by dysplastic parasympathetic submucous plexus with giant ganglion cells and hyperplasia, elevated acetylcholinesterase levels, and isolated ganglia in lamina propria . While an aggressive attitude given to patient with type A, a more conservative attitude is given to patient with Type B as most patients improve with age

In summary, NID is a motility disease affecting neonates and infants and requires special skills and stains for definite diagnosis

Note: Please submit the specimen in Saline and call us for arrangement to do Acetylcholinestearase staining

Please do not hesitate to contact us for further inquiries

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

Auto-immune hepatitis (AIH) has a clinical and histologic criteria with well established diagnostic scores. It has predilection for females. Liver enzymes show elevation of aminotransferease more than alkaline phosphatase. Increased serum gamma globulin, presence of smooth muscle antibody and LKM-1, (with usually negative anti-mitochondria antibodies) are usually part of diagnostic criteria. AIH patients have usually negative viral markers. It is associated with HLA DR3 and DR 4 or other autoimmune disease. Histologically. It usually shows interface hepatitis with predominant lymphoplasmacytic infiltrate with liver cell resetting with minimal bile duct changes. Auto-immune hepatitis (AIH) has at least 3 types. TYPE I, represents 80% of the cases, has predilection to adult females and known to be positive for Anti-smooth muscle antibodies (ASMA). Most of patients are asymptomatic, but 20% are cirrhotic at presentation. TYPE II, on the other hand, is known to affect young adults and children and represents 10-15% of AIH. It is known to be positive for anti-LKM-1 (antibody against renal proximal tubules and hepatocytes cytoplasm, a marker that is directed against cytochrome P450), and a new marker that is Liver Cytosole (LC-1) a marker that is directed against liver cytoplasmic component (formiminotransferase cycloadeaminase). Anti-LC-1 is detected in 50% of cases with LKM-1 positive sera. Serum immunoglobulins are moderately elevated with reduction of immunoglobulin A. It carries a high risk of progression to cirrhosis. TYPE III has lower prevalence rate than that of Type II, with similar course and outcome to Type I, with 90% of the cases are females. It is positive for Soluble Liver Antigens/ Liver-pancreas (SLA/LP) and directed against UGA repressor t-RNA associated protein. This marker may be the sole marker that is present in 10% of patient with AIH

Summary: Diagnosing AIH is not complete till you do all the serologic markers: Type I: ASMA. Type II: Anti-LKM-1 and LC-1. Type III: SLA/LP. In addition to requesting ANA, ANCA (positive in 60%-90% of sera in patients with AIH) and anti-mitochondria anti-bodies

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 test to clinical practice in Jordan

.Dr. Hussam Abu- Farsakh, M.D

American boards of Anatomic, Clinical Pathology and Cytopathology

Diagnosing T.B could be difficult sometimes and requires more tests. Relying on finding Acid Fast Bacilli is usually not reliable in many cases. PCR for T.B also has a limitation and can not be performed on the blood. FDA approved 2 new tests for T.B. The first one is �anda-tb�. This test is relying on finding antibodies against A60 antigen complex. This antigen is found in the cytosol of typical and atypical mycobacteria. It could be IgM or IgG. The advantage of this test that healthy non-infected individuals are negative for this test even if they have positive intradermal reaction test. It is positive only in patients with active T.B infections. It can be used in blood and in CSF specimen for diagnosing T.B meningitis. It can be used for diagnosing pulmonary and extrapulmonary tuberculosis. It can be used for diagnosing typical and atypical myocobacteria. It disappears when the patient is cured, and re-appears again on relapses. The disadvantage of the test is that is can be positive in Nocardia infected individuals (since Nocardia species have A60 antigen complex in their cystosol). However, clinical examination and histologic findings are different. Also the antibodies to A60 antigen complex can be negative or weak in 5% of patient who are anergic with suppressed immunity (like in HIV infected individual). Several studies have posted the specificity of this test to be from 80-98% and sensitivity from 60-100%. (Charpin et al, Cominero et al, Wang et al). To increased sensitivity and specificity of anda-tb test, it is strongly recommended to ask for both IgG and IgM antibodies against A60 antigen complex anda-tb test

The second test is �patho-tb� test. The idea of this test is detecting mycobacteria bacilli. The specimens used in this test are sputum, pleural fluid, bronchioalveolar lavage, CSF, FNA aspirated material, lymph node fresh material, gastric and intestinal wash. The specimen is first decontaminated by specific method in the lab then filtered into a specially designed filter. When the specimen with T.B passes through the filter which is coated by anti TB antibodies, the reaction change the filter color and indicate the presence of mycobacterium or atypical mycobacterium in the specimen. The patho-tb test is about 100 times more sensitive than finding ordinary acid fast bacilli in one field

In summary, it is strongly recommended that �anda-tb� test to be requested in the blood when no tissue is available. The �patho-tb� test is recommended when tissue or fluid material (BAL, CSF, sputum, gastric or intestinal wash, or FNA aspirate) is present. Both tests carry very high sensitivity and specificity for diagnosing active T.B infection

We, in the First Medical Lab, are committed to bring the best of laboratory test to clinical practice in Jordan. Please do not hesitate to contact me for any further information

Dr Hussam Abu-Farsakh

First Medical Lab Director