2019 Call for Abstracts

The Abstract Submission site is open for ASCP 2019. Last year, ASCP had a record number of submissions and we aim to bring in even more this year. ASCP’s selection process is known as highly competitive, and as a result, presenters receive close attention from big-name faculty and industry contacts. Some have even gained immediate funding opportunities to expand their research.

Abstracts can be submitted until 11:59pm CST on March 20th. Submit your abstract HERE.

Call for Abstracts 2019

The Not So Legendary Chimera

In the Iliad, Homer described the chimera as “a thing of immortal make, not human, lion-fronted and snake behind, a goat in the middle, and snorting out the breath of the terrible flame of bright fire (1).” This mythical creature has a lion’s head, a goat’s middle and the tail of a serpent, and the siting of a chimera was considered to be an omen for disaster! Thankfully, not so much in blood bank. Though ABO discrepancies can be a challenge, even most chimeras can easily be resolved with a few additional steps and a patient history.

Figure 1. The mythical chimera.

To review, an ABO discrepancy occurs when unexpected reactions occur in the forward or reverse grouping, or the forward typing does not match the reverse typing. Some weak subgroups of A (notably A3) are known for giving mixed field reactions. Weak activity with anti-A, anti-B or anti-D can also in result mixed field reactions in leukemia patients. In these examples, the mixed field reactions are due to the weakened expression of the corresponding antigens.

Chimerism is the presence of 2 cell populations in a single individual. There are scenarios where ABO discrepancies causing mixed field reactions indicate an apparent chimera. A group A positive patient who received several units of O negative blood will have mixed field reactions due to the presence of two blood types in their peripheral blood. This would be a temporary situation. A patient who received a bone marrow or stem cell transplant from a non-group identical donor will have 2 populations of red blood cells until the new type is established. We refer to these as artificial chimera cases, as the second blood type is not naturally occurring, but present due to the introduction of a different blood type via transfusion or transplantation.

Table 1. Group A pos patient who received several units of group O neg red cells

Like the mythical beast, a chimera in biology describes an organism that has cells from two or more zygotes. When chimerism exhibits only in the blood, the phenomenon can be termed an artificial chimerism, as described above, as dispermic chimerism or as twin chimerism. Dispermic chimerism occurs in other animal species but is a rarity in humans. It occurs when 2 eggs are fertilized by 2 sperm and these products are fused into one body. In this case, the chimerism is not limited to blood, but may also result in hermaphroditism, or two different skin colors or eye colors.

Twin chimerism occurs when, in utero, one twin transfuses blood cells, including stem cells,  to the other. Sine the fetal immune system is immature, the host does not see these transfused blood cells as foreign antigens.  The stem cells can proliferate and this results in the production of cells from both the donor and the host for the rest of the individual’s life. Two non-compatible blood groups can co-exist in one individual! This phenomenon is usually discovered by coincidence during a routine type and screen. This patient could be found to have mixed field or weak reactions on ABO typing, or could have missing reactions in the back type, all with no history of transfusion, transplantation and no disorder that could explain the findings. What is a tech to do? An important step in resolving all ABO discrepancies is to review patient history.

In 1953 a human chimera was reported in the British Medical Journal. A woman was found to have blood containing two different blood types. Apparently this resulted from her twin brother’s cells living in her body (2). More recently, in 2014, a case described in Blood Transfusion describes a 70 year old female who was found to have mixed field reactions with ABO and RhD typing during routine testing before surgery. She had no history of transfusion or transplantation, and a history of seven pregnancies. Repeat testing by other methods and with different reagents gave the same results. On further questioning, the patient affirmed that she had been born a twin, but her twin brother had died as an infant. Since chimerism was suspected, molecular typing and flow cytometry were performed. The presence of male DNA was found by PCR testing and flow cytometry confirmed two distinct populations of red blood cells (3).

Twin chimeras with mixed blood types of 50%/50% or 75%/25% are easily picked up in ABO typing as mixed field reactions. A twin chimera with 95% group O blood and 5% group A may show a front type of a group O and a back type that lacks anti-A . Because there is immune tolerance to A cells from the twin, the expected naturally occurring anti-A is not present. On the other hand, a twin chimera who is primarily group A with 5% O cells would not be recognized as a chimera in routine ABO typing.

Table 2. Group O chimera with 5% minor cell population A cells
Table 3. Group A chimera with 5% O cells

How common is blood group chimerism?  A 1996 study found that such blood group chimerism is not rare. Though we do not often encounter this in blood bank, their study of 600 twin pairs and 24 triplet pairs showed that this occurs more often than was originally thought, with a higher incidence in triplets than in twins. Because it does not cause any symptoms or medical issues, many such chimeras go undetected. In addition, the study found that many of these chimeras had very minor second populations, making them undetectable in serological testing. In blood bank, we generally test for ABO/RH  and do not test for other antigens in routine testing. The study used 849 marker antigens. They also used a very sensitive fluorescent technique which they developed for detecting these very subtle minor populations. This study showed that while chimeras are not rare, they are something that, with present testing methods, we will not encounter too often (4).

Dual cell populations induced by chimeras have been the subject of many studies. Historically, most chimeras were naturally occurring. With newer medical interventions and therapies, we may see more situations that lead to mixed cell populations. Transfusion, stem cell transplants, kidney transplantation, IVF and artificial insemination can all lead to temporary and sometimes permanent chimeras. These can present challenges in the blood bank laboratory in interpreting results and for patient management. A question of chimera presentation can usually be solved by putting on our detective hats and investigating patient history. Further testing can be done with flow cytometry and molecular methods, if needed. Modern medicine may have given us more blood bank challenges but modern technology has equipped us with newer methods to solve them. A chimera is no longer a sign of impending trouble!


  1. Homer, Iliad.  In Richmond Lattimore’s Translation.
  2. Bowley, C. C.; Ann M. Hutchison; Joan S. Thompson; Ruth Sanger (July 11, 1953). “A human blood-group chimera” (PDF). British Medical Journal: 8
  3. Sharpe, C.; Lane, D.; Cote J.; Hosseini-Maaf, B.; Goldman, M; Olsson, M.; Hull, A. (2014 Oct ). “Mixed Field reactions in ABO and Rh typing chimerism likely resulting from twin hematopoiesis”, Blood Transfusion:12(4): 608-610
  4. Van Dijk, B. A.; Boomsma, D. I.; De Man, A. J. (1996). “Blood group chimerism in human multiple births is not rare”. American Journal of Medical Genetics. 61(3): 264–8 

-Becky Socha, MS, MLS(ASCP)CM BB CM graduated from Merrimack College in N. Andover, Massachusetts with a BS in Medical Technology and completed her MS in Clinical Laboratory Sciences at the University of Massachusetts, Lowell. She has worked as a Medical Technologist for over 30 years. She’s worked in all areas of the clinical laboratory, but has a special interest in Hematology and Blood Banking. When she’s not busy being a mad scientist, she can be found outside riding her bicycle.

History of Generations: Baby Boomers

One of most well-known names of generations, besides perhaps Millennials, are the Baby Boomers. The Baby Boomers generation is currently the largest generation. Of all the generations, they cover the largest span of time (those born from 1946 to 1964). In large parts of the world, there was a big surge in births after the Second World War. That war had a significant influence on their values, perceptions, attitude, and approach to work.

One of the major aspects that make Baby Boomers stand out from previous generations is that this was really the first generation in which women started to work outside the home in large numbers, at least in the Western Hemisphere. This has a major influence on the home and work environment. In the United States, the children of Baby Boomers often had a latchkey around their neck so that they could go home after school without their parents being there.

Baby Boomers played a large role in shaping today’s society; they used music as a political tool, they increased focus environmental conservation, they were involved with the civil rights and women’s rights movements, and they are politically informed and outspoken. It is also the first generation in which both divorce and homosexuality became accepted. Overall, this generation is known for optimism, adaptability, having a strong work ethic, and being team-oriented.

Even though technology did not become part of daily life until Generation X, Baby Boomers witnessed enormous technological milestones, such as the first orbit around earth, landing a man on the moon, and the creation of the first nuclear power plant. All these events set the stage for later advances, and Baby Boomers are typically interested in learning how to use technology, although it does not come as natural to them as future generations. They also have tend to work longer and retire later in age, mainly because they link their self-worth to their job. In other words, their work ethic becomes their “worth ethic.” Knowing this when working with them is important, as they appreciate recognition in forms of awards, title changes, and public acknowledgement for their contributions.

Because this generation spans such a long time (and because some Boomers had children later in life due to second and third marriages), Baby Boomers are parents to both Generation X and Generation Y.  There is a lot to learn from this generation, so next time you work with one ask for some of their insights and understanding. This generation makes great mentors, especially because they are likely to have children of mentee age.



-Lotte Mulder earned her Master’s of Education from the Harvard Graduate School of Education in 2013, where she focused on Leadership and Group Development. She’s currently working toward a PhD in Organizational Leadership. At ASCP, Lotte designs and facilitates the ASCP Leadership Institute, an online leadership certificate program. She has also built ASCP’s first patient ambassador program, called Patient Champions, which leverages patient stories as they relate to the value of the lab.



Here is an interesting fact: there are two sub-sets of Baby Boomers. The first ones are the “Save-The-World Revolutionaries” of the ’60s and ’70s. The second set of Boomers are the career climbers, the yuppies, of the ’70s/’80s. The most profound characteristic of a Baby Boomer is their work ethic. They identify with their job, profession, or their career. So much so, that this generation has remained in the workforce beyond the age of 70.

In a lot of ways, I’m the typical Baby Boomer woman. I married the first time just before I was 20 years old. Divorced in my early 30’s and moved forward in my career because that’s what the “Boomer Women” did. They worked inside and outside of the home.

As a laboratory professional that left the bench many decades ago, and now working in the field of Organizational Leadership and Development, I am approaching the age of 70. I’m starting to realize my retirement day is closer than I’d like.    Like others of my generation, this concerns me because I am defined by my career! The thought of not working left me searching for my identity so much that I started seeing a therapist last year. I was, and am fortunate to work for an incredible organization that doesn’t judge one by their age. They look at the skills and competencies one brings to the table. I’m consciously working on succession planning so that my institutional knowledge remains with the organization and its people. It also helps to have two gifted professionals who wanted to learn from me and grow. Then it takes a manager like mine who supports me through this often painful process. I am blessed with that kind of support. Sometimes the work ethic equals “worth ethic” in the body, mind, and spirit of a Baby Boomer, which is something to keep in mind when working with this generation.




-Catherine Stakenas, MA, is the Senior Director of Organizational Leadership and Development and Performance Management at ASCP. She is certified in the use and interpretation of 28 self-assessment instruments and has designed and taught masters and doctoral level students.  

Microbiology Case Study: A 45 Year Old Woman with Breast Abscess

Case History

Our patient is a 45-year-old female who presents to the Emergency department with breast pain. She was diagnosed with granulomatous mastitis 3 months prior. She was treated with 3 weeks of steroids, but they were stopped when the mass was unchanged and the patient was experiencing increasing breast tenderness. Since then she and has undergone several procedures to drain her right breast abscess, the most recent being five days prior. The woman has been treated with sequential courses of sulfamethoxazole–trimethoprim and metronidazole without improvement. On this visit, the abscess was again drained and sent to the microbiology laboratory for culture. The Gram stain showed no bacteria and 3+ polymorphonuclear cells. After 48 hours incubation there was scant growth on the blood agar plate and no growth on the chocolate, MacConkey or CNA plates. The colonies growing on the blood plate were tiny, white, and lipophilic (Image 1).

Image 1. Small, white, lipophilic colonies growing on blood agar plate at 48 h incubation.  There was no growth of this organism on chocolate or MacConkey agars this time point.


The organism was identified as Corynebacterium kroppenstedtii.

Colonies on the blood agar plate were identified as Corynebacterium kroppenstedtii using MALDI-TOF mass spectrometry for identification. C. kroppenstedtii is catalase positive, non-motile and a facultative anaerobe. It grows better on 5% sheep blood agar than chocolate agar, as is the case for many Corynebacterium spp. Corynebacterium come in two varieties, lipophilic such as Corynebacterium jeikeium, and luxuriantly growing, such as Corynebacterium straitum. C. kroppenstedtii is part of the former lipophilic group, forming small colonies after extended incubation.  Lipids such as Tween-80 can added to the media to improve growth of lipophilic Corynebacterium such as C. kroppenstedtii, but clinically this is not routinely performed. When viewed on a gram stain, the bacteria are rod-shaped gram positive diptheroids with typical coryneform morphology. Both MALDI-TOF and 16S rRNA sequencing can accurately identify C. kroppenstedtii to the species level.

C. kroppenstedtii is a relatively newly recognized species within the Corynebacterium genus. It was first described in a case series of young Polynesian women with histological evidence of lobar mastitis, from which C. kroppenstedtii was identified from >40% of the patients’ abscesses. Since that time, isolation of C. kroppenstedtii has been clinically associated with breast abscesses and granulomatis mastitis. C. kroppenstedtii is a highly lipophilic bacterium. Its cell wall lacks many mycolic acids, which may explain its propensity to grow in lipid-rich sites such as mammary glands. C. kroppenstedtii typically affects women of reproductive age and can be difficult to diagnose due to the slow growing nature of the lipophilic organism and the relatively few organisms present in abscess specimens.

Prior to identification by MALDI-TOF MS and 16s rRNA sequencing this patient’s culture would have been reported as rare or 1+ “dipthroid,” “coryneform,” or “Corynebacterium spp.” Without knowing the clinical significance of this organism, the culture results could easily be dismissed as contaminating skin flora.

It is very difficult to treat C. kroppenstedtii in abscesses, with the most effective treatment requiring both surgical drainage of the abscess and long term antibiotic use. It is fairly difficult to get antibiotics to the site of infection, so antibiotics that test as susceptible in the laboratory may not eradicate the pathogen. Our patient’s isolate of C. kroppenstedtii was susceptible to ciprofloxacin, clindamycin, doxycycline, and intermediate to penicillin. She remains on ciprofloxacin therapy, but has ongoing right breast tenderness. She had another surgical drainage of her breast abscess a week after this case, and the culture also grew 1+ C. kroppenstedtii with 3+ PMN seen on Gram stain, so her infection has not yet been resolved.

  1. Tauch, Andreas, et al. “A Microbiological and Clinical Review on Corynebacterium Kroppenstedtii.” International Journal of Infectious Diseases, vol. 48, 2016, pp. 33–39., doi:10.1016/j.ijid.2016.04.023. ScienceDirect.
  2. Johnson, Matthew G., et al. “The brief case: recurrent granulomatous mastitis due to Corynebacterium kroppenstedtii.” Journal of clinical microbiology 54.8 (2016): 1938-1941.
  3. Paviour, Sue, et al. “Corynebacterium species isolated from patients with mastitis.” Clinical Infectious Diseases 35.11 (2002): 1434-1440.



-Carolyn Wiest, MT(ASCP) graduated from Michigan State University with a BS in molecular genetics and is a medical technologist at NorthShore University HealthSystem.  Her interests are in microbiology and molecular diagnostics. 

-Erin McElvania, PhD, D(ABMM), is the Director of Clinical Microbiology NorthShore University Health System in Evanston, Illinois.

The Syncytial Variant: A High-Risk Subgroup Amongst the Traditionally Well-Behaved Classic Nodular Sclerosis Hodgkin Lymphomas

Lymphoid neoplasias are traditionally categorized as Hodgkin Lymphomas or Non-Hodgkin Lymphomas. Hodgkin Lymphomas are typically characterized by both expansive reactive lymphocytes and a paucity of the interspersed, malignant Reed-Sternberg (RS) Cell. These RS cells are large neoplastic B-Cell variants with ‘owl-eye’ nucleoli within multilobed nuclei. The background reactive lymphocytes are non-neoplastic cells drawn by secreted RS cytokines (IL-5, IL-6, IL-13, TNF, and GM-CSF), which often result in presenting B symptoms (fevers, chills, and night sweats). Histiocytes, granulocytes, and plasma cells are also commonly identified. Confirmatory immunohistochemistry staining for RS cells involves CD30 positivity, CD15 positivity, and negativity for CD20 and LCA (CD45) staining. The two major types of Hodgkin Lymphoma are recognized as Nodular Lymphocyte Predominant Hodgkin Lymphoma (NLPHL) and Classic Hodgkin Lymphoma (CHL). In NLPHL, B-Cell immunophenotype is generally preserved and is histologically recognized by a nodular predominance of small lymphocytes and RS cell variants, called lymphocyte predominant (LP) or popcorn cells (formerly called L&H cells for lymphocytic and/or histiocytic RS cell variants), which exhibit muted, lobed nuclei and smaller nucleoli. The Classic Hodgkin Lymphomas are categorized histologically as Nodular Sclerosis CHL (NSCHL), Lymphocyte Rich CHL (LRCHL), Mixed Cellularity CHL (MCCHL), and Lymphocyte Depleted CHL (LDCHL).

Nodular Sclerosis Classic Hodgkin Lymphoma (NSCHL) comprises over 70% of all CHL and is characterized by broad, fibroblast-poor collagen banding surrounding at least one nodule and by RS cells with lacunar morphology. The RS cells tend to have a larger amount of cytoplasm than those in other types of classic Hodgkin lymphoma. When fixed in formalin, this excess cytoplasm causes their membranes to retract so that the cells seem to be sitting in lacunae. Typically, EBV association is uncommon, CD30 is almost always expressed, CD15 is expressed in 75-85% of cases, and PAX5 is weakly positive. Most cases do not express T-Cell antigens (CD4, CD3, CD8), but when they do (~5% of cases), they can be difficult to distinguish from ALK-negative Anaplastic Large Cell Lymphomas (PAX5 positivity can help to rule out ALCL). True T-cell marker expression on RS cells has been seen (usually weak) and is associated with a poorer prognosis.

Two histologic variants of NSCHL have been proposed: a fibrocystic variant (FV) and a syncytial variant (SV). The FV contains abundant fibroblasts and histiocytes in the setting of difficultly identified RS cells. The SV describes the finding of RS cells in prominent, sheet-like aggregates forming cohesive lacunar nests in the center of nodules (Figure 1). The SV represents 5-16% of all cases of NSCHL (Ben-Yehuda-Salz et al. 1990), though some suspect it may be as high as 25% (Sethi, T., et al. 2017).

Advancements in chemoradiation therapies have improved the long-term survival of patients of with CHL. Today, more than 85% of patients with early stage CHL will be cured of the disease (Ansell, S., et al. 2014). The 5-year overall survival for early stage CHL is 95% and for advanced disease is 82%. Overall, the prognosis of NSCHL is better than that of other types of CHL.

Initial studies examining the prognostic significance of grading of NSCHL based on cytological and tumor microenvironment features showed an association of higher grade (based on the British National Lymphoma Investigation (BNLI) criteria (Bennett et al. 1981; MacLennan et al. 1989)) with a poorer prognosis (MacLennan et al. 1989; Wijlhuizen et al. 1989; Ferry et al. 1993). However, since the advent of combination chemotherapy and the relatively good prognosis of NSCHL today, the significance of such grading or further classification has been called into question. Importantly, grading based on proposed histological features has declined in the last two decades because such advances in therapy can actually obscure the differences seen in less-effectively treated patients. As such, grading is not currently deemed necessary for routine clinical purposes.

Despite the broadly recognized clinical favorability of NSCHL, slowly accumulating evidence of poor clinical outcomes associated with the syncytial NSCHL histological variant is only now beginning to declare itself with strong evidence. While BNLI grading may no longer be a useful clinical tool, variant typing may instead prove effective as both a prognostic and alternative treatment indicator.

Small case studies have reported aggressive disease in SV NSCHL since the first histologic case was described. Clinical behavior has included presenting with a considerable mediastinal mass, significant B symptoms, and advanced stage at diagnosis. Despite these case reports, it was not until recently that systematic analysis of progression free survival and complete therapy response among morphology and immunophenotype SV confirmed cases in patients with similar treatment regimens (combination doxorubicin, bleomycin, vinblastine, and dacarbazine, or ABVD) was conducted (Sethi, T., et al. 2017).

Sethi, T., et al evaluated 167 patients with NSCHL: 43 patients with SV were compared with 124 patients with typical NSCHL on patient characteristics, disease variables, treatment administered, and outcome at Vanderbilt University Medical Center between 1995 and 2014. The rate of complete treatment response was lower in the SV variant as compared with typical NSCHL with standard induction therapy, 74% versus 87% (p= 0.05). Patients with SV had a shorter progression free survival and experienced disease relapse. The median progression free survival for the entire cohort was 174.7 months. The median progression free survival in the SV group was 17.02 months which was significantly shorter compared with that of the typical NS group, which was not reached (p < 0.0001).

The BNLI criteria for the grading of NSCHL (Grades I-II) are based on the amount of sclerosis, the degree of nodular cellularity, and the number of atypical neoplastic cells. Most SV cases are grade II because of the number of atypical cells present. However, most grade II cases are not syncytial variants. Therefore, BNLI grade alone is not an accurate depiction of the clinicopathologic features of this disease. In the same way, it may also not be the best determinant of disease prognosis, therapeutic indication, or investigative classification.

Patients with Syncytial Variant Nodular Sclerosis Classic Hodgkin Lymphoma experience a lower than expected rate of complete therapeutic response with shorter progression-free than non-SV NSCHL treated with standard therapy. Syncytial Variant NSCHL should therefore be recognized as a high-risk subgroup within the otherwise traditionally docile NSCHL classification. It is time the SV finally be considered a true histopathologic variant in future trials involving novel agents to assess treatment response. While a majority of patients with SV NSCHL can likely be successfully salvaged with high-dose therapy and autologous stem cell transplantation, studies of novel agents such as conjugated antibodies or immunotherapeutic agents should be considered in these patients to improve complete response rates and to avoid the need for toxic salvage therapies.


  1. Sethi T., et al. Differences in outcome of patients with syncytial variant Hodgkin lymphoma compared with typical nodular sclerosis Hodgkin lymphoma. (2017) Ther. Adv. Hematol. 8(1):13-20.
  2. Granot, N., et al. Syncytial variant of nodular sclerosing Hodgkin lymphoma in children: A prognostic factor? (2018) J. Ped. Hem. & Onc. 35;1:33-36.
  3. Ansell, S. (2014) Hodgkin lymphoma: 2014 update on diagnosis, risk stratification, and management. Am J Hematol 89: 771–779.
  4. Bennett, M., Maclennan, K., Easterling, M., Vaughan Hudson, B., Jelliffe, A. and Vaughan Hudson, G. (1983) The prognostic significance of cellular subtypes in nodular sclerosing Hodgkin’s disease: an analysis of 271 non-laparotomised cases (BNLI report no. 22). Clin Radiol 34: 497–501.
  5. Ben-Yehuda-Salz, D., Ben-Yehuda, A., Polliack, A., Ron, N. and Okon, E. (1990) Syncytial variant of nodular sclerosing Hodgkin’s disease. A new clinicopathologic entity. Cancer 65: 1167–1172.
  6. Ferry, J., Linggood, R., Convery, K., Efird, J., Eliseo, R. and Harris, N. (1993) Hodgkin disease, nodular sclerosis type. Implications of histologic subclassification. Cancer 71: 457–463.
  7. Maclennan, K., Bennett, M., Tu, A., Hudson, B., Easterling, M., Hudson, G. et al. (1989) Relationship of histopathologic features to survival and relapse in nodular sclerosing Hodgkin’s disease. A study of 1659 patients. Cancer 64: 1686–1693.
  8. Wijlhuizen, T., Vrints, L., Jairam, R., Breed, W., Wijnen, J., Bosch, L. et al. (1989) Grades of nodular sclerosis (NSI-NSII) in Hodgkin’s disease. Are they of independent prognostic value? Cancer 63: 1150–1153.
  9. Strickler, J., Michie, S., Warnke, R. and Dorfman, R. (1986) The “syncytial variant” of nodular sclerosing Hodgkin’s disease. Am J Surg Pathol 10: 470–477.
  10. Van Spronsen, D., Vrints, L., Hofstra, G., Crommelin, M., Coebergh, J. and Breed, W. (1997) Disappearance of prognostic significance of histopathological grading of nodular sclerosing Hodgkin’s disease for unselected patients, 1972–92. Br J Haematol 96: 322–327.
  11. Hess, J., Bodis, S., Pinkus, G., Silver, B. and Mauch, P. (1994) Histopathologic grading of nodular sclerosis Hodgkin’s disease. Lack of prognostic significance in 254 surgically staged patients. Cancer 74: 708–714.
  12. Darabi, K., Tester, W., Daskal, I. and Cohn, J. (2015) Syncytial variant of nodular sclerosing Hodgkin’s disease. Blood 104: 4533–4533.

Austin Headshot

-Austin McHenry is an M3 at Loyola University Stritch School of Medicine in Maywood, IL. Austin is past-president of the pathology intrest group SCOPE (Students Curious about Outrageous Pathology Experiences) and is a recent recipient of ASCP’s Academic Excellence and Achievement in Pathology Award. Follow Austin on Twitter @AustinMcHenry


-Kamran M. Mirza, MD PhD is an Assistant Professor of Pathology and Medical Director of Molecular Pathology at Loyola University Medical Center. He was a top 5 honoree in ASCP’s Forty Under 40 2017. Follow Dr. Mirza on twitter @kmirza.

Microbiology Case Study: A 51 Year Old Male with Swelling in His Finger

Case History

A 51-year-old man was hospitalized for swelling of his left middle finger. He was in a normal state of health until 6 months prior, when he sustained an injury to his left third finger from a catfish while fishing in Florida in brackish water. The patient claimed he had caught a catfish and was stabbed by one of the spines of the fish in the middle portion of his finger. It became infected and he was prescribed a couple different courses of antibiotics, the details of which are not entirely clear. About one week leading up to his hospitalization, the finger became more swollen, and he had prominent lymphangitic streaking up the left arm as high as the upper bicep, with pain. He did not have any fevers, chills, or night sweats. Initial blood cultures taken were negative. He was admitted for three days on vancomycin/cipro, with resolution of the lymphangitic streaking but ongoing prominence of the swollen left third finger. MRI showed prominent tenosynovitis of the left 3rd finger tendon sheath, though the second, fourth, and fifth digits were also involved. Surgical debridement was recommended at the time but he preferred to pursue medical management. He was started on cipro/doxy/clarithro empirically at the time.

The infection was refractory to medical management. About 3 weeks later, his left third finger “burst open” with a draining sinus tract and purulent discharge (Image 1). He still denied any systemic symptoms such as fever, chills, night sweats. He was seen by infectious disease and orthopedic surgery and subsequently consented to radical tenosynovectomy for suspected mycobacterial chronic tenosynovitis.

Image 1. Infected third finger.

Tissue biopsy was sent for surgical pathology and culture. Histopathologically, the lesion showed chronic lymphohistiocytic and granulomatous inflammation; no microorganisms were identified on special stains. However, AFB culture was positive in the LJ slant and speciation was confirmed (Image 2).

Figure 2. Bright yellow colonies after light exposure on LJ slant media.


Mycobacterium marinum was identified at a reference laboratory. Although infection with M. marinum is uncommon, the epidemiology of M. marinum disease is distinctive from other non-tuberculous mycobacterial species. The natural habitat of M. marinum is aquatic, and can be found in both fresh and salt water, including marine organisms, swimming pools, and fish tanks. The annual incidence is estimated at 0.27 cases per 100,000 adult patients.1 The infection is typically limited to the skin, mostly involving limbs, with rare spread to deeper structures reported.

M. marinum causes cutaneous disease as a consequence of exposure to water, usually in the context of a minor abrasion, laceration, puncture wound, or bite wound. Skin infections can occur from putting one’s hand into a contaminated fish tank, resulting in the condition called fish tank granuloma.

Histopathology often demonstrates suppurative granulomatous inflammation. In the microbiology laboratory, M. marinum is a photochromogen, meaning it produces pigment when cultured and exposed to light. Culture growth is optimal at 32°C over 7-14 days. Therefore, cooler extremities, particularly hands, are affected more often than central areas. Providers should be aware that M. marinum may cause a positive tuberculin skin test.2

M. marinum is a slow growing organism that is readily detected by acid fast smear and culture techniques. Confirmation of the presence or absence of mycobacteria in clinical specimens has traditionally required culture. However, traditional methods of identifying mycobacterial isolates to the species level are slow, based upon growth characteristics on solid media and subsequent biochemical tests, requiring additional weeks for subcultures. Newer techniques include MALDI-TOF MS, 16S ribosomal DNA sequencing, PCR-restriction length polymorphism analysis (PRA), and high-performance liquid chromatography (HPLC).

M. marinum infection responds slowly to appropriate antibiotic therapy. Infected patients may require treatment for 2 weeks or up to 18 months. M. marinum infection sequelae include persistent ulceration, draining sinuses, or septic arthritis.


      1. Akram SM, Bhimji SS. Mycobacterium Marinum. 2017. StatPearls.
      2. Lewis et al. Fish tank exposure and cutaneous infections due to Mycobacterium marinum: tuberculin skin testing, treatment, and prevention. CID. 2003;37(3):390-7.


-Thomas Rogers, DO is a 4th year anatomic and clinical pathology resident at the University of Vermont Medical Center.


-Christi Wojewoda, MD, is the Director of Clinical Microbiology at the University of Vermont Medical Center and an Associate Professor at the University of Vermont.

Essential Diagnostics List

A propos of Lab Week 2018, the WHO announced the development of an Essential Diagnostic List (EDL). The first Strategic Advisory Group of Experts on In Vitro Diagnostics (SAGE IVD) met in Geneva in April. The role of the SAGE-IVD is to act as an advisory body to matters of global policy and strategies related to in vitro diagnostics (IVDs) – to guide the development of the EDL.

The EDL is, as it sounds, a catalog of IVDs that are essential for diagnosis, treatment, and management of diseases. An EDL was called for in 2016 by Dr. Tim Amukele, a clinical pathologist at Johns Hopkins and President of the non-profit organization Pathologists Oveseas, and Dr. Lee Schroeder, a clinical pathologist at University of Michigan Ann Arbor (N Engl J Med 2016; 374:2511-4). Amukele and Schroeder suggested the EDL to complement the WHO’s Essential Medicines List (EML). They suggested 19 categories of IVDs that are essential for 10 of the medicines appearing on the EML. As it stands, the initial EDL focuses on 4 disease areas: HIV, TB, Malaria, and Hepatitis B & C. The following categories are provided for each disease area: analyte, intended use, level of facility that should have the IVD, assay format, specimen type, and links to WHO guidelines and any WHO prequalified or endorsed products.

For example, in the disease area “Malaria”, the analyte P. falciparum has the intended use of diagnosis of P. falciparum. The rapid diagnostic assay format is recommended for all level facilities. The specimen type is capillary whole blood, and the corresponding WHO guideline is “Good practices for selecting and procuring rapid diagnostic tests for malaria, 2011”.

The EDL will provide countries a way to focus attention on which tests are most appropriate, which can have a huge impact on the cost-effectiveness of the health care system, and also improve the quality of the laboratory results. Cost-effectiveness can be achieved by 1) focusing on evidence-based IVDs appropriate for a specific disease burden and 2) facilitating proper utilization of medicines and other clinical supplies necessary for treatment/management. In my experience, many laboratories in resource-limited areas are developed seemingly on a whim; testing might reflect a pet project of an absentee lab director, or donated equipment. Focusing on more appropriate testing, as Dr. Amukele told Clinical Laboratory News, give a lab more bang for their buck. Dr. Schroeder indicated that “lab testing develop ad hoc is more prone to quality issues”. The hope is that providing more direction for development of lab testing will encourage greater quality control programs. One way I can see that playing out is, if more labs in a specific area adopt the same testing, a shared sample program for cost-effective proficiency testing might be developed.

The WHO hopes that countries will use the EDL to develop country-specific EDLs, based on the disease burden specific to the country. National EMLs have been successful. Personally, I am very excited about the EDL! The WHO efforts to control HIV, Malaria, and TB have highlighted the need for laboratory diagnostics. I think it’s about time that labs got a chance to show their worth! The EDL is an important step in bringing the lab out of the basement and onto the global health stage.


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Sarah Riley, PhD, DABCC, is an Assistant Professor of Pediatrics and Pathology and Immunology at Washington University in St. Louis School of Medicine. She is passionate about bringing the lab out of the basement and into the forefront of global health.