Hematology Case Study: Crystal of Death

Case History

A 56 year old female presented with symptoms of sepsis. During surgery, patient bleed profusely and received blood products. However, the patient expired.

Laboratory Findings

  • WBC: 18.8 x 109/L
  • Hemoglobin: 5.6 g/dL
  • Lactate: 8.3 mmol/L
  • AST: 1485
  • ALT: 1625

The blood smear was reviewed for these white blood cell inclusions:

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Image courtesy of Georgia McCauley, PhD, MT(AMT)
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Image courtesy of Georgia McCauley, PhD, MT(AMT)

Discussion

The image presented reveals to be the “blue green crystal of death”. Medical literature has documented an association between acute hepatic failure and coarse, bright-green neutrophilic inclusions. Upon identification of these unique inclusions patients have been reported to have poor outcomes and usually die within 24-72 hours (Haberichter KL, 2017). The exact nature of these inclusions has yet to be determined; it is postulated that they arise from lipofusion-like substance. Bright green inclusions in neutrophils have been reported as a sign of impending patient death (Hodgson, 2015).

Refractile bright-green irregular inclusions within neutrophils have been reported as a marker of impending patient death. In the three reported cases, death occurred within 2 d of recognition of the inclusions (Harris et al2009; Jazaerly & Gabali, 2014). Disease associations with green neutrophil inclusions included acute liver failure secondary to acetaminophin overdose, lactic acidosis with multisystem organ failure subsequent to trauma (Harris et al2009) and Escherichia coli-associated septic shock (Jazaerly & Gabali, 2014). Harris et al (2009) suggested that the inclusions were related to blood-borne bile products.

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Image 3 source: Source: Hodgson, 2015

These findings on the peripheral smear should be reported and considered a critical finding. Laboratory professionals and hematologists should acknowledge these inclusions; patients are noted to be seriously ill at the time of detection of neutrophil inclusions and have an ominous 24-72 hour survival period.

References

  1. Haberichter, K. L., & Crisan, D. (2017). Green Neutrophilic Inclusions and Acute Hepatic Failure: Clinical Significance and Brief Review of the Literature. Annals of Clinical & Laboratory Science47(1), 58-61.
  2. Harris, V.N., Malysz, J.& Smith, M.D. (2009) Green neutrophilic inclusions in liver disease. Journal of Clinical Pathology, 62, 853–854.
  3. Hodgson, T. O., Ruskova, A., Shugg, C. J., McCallum, V. J., & Morison, I. M. (2015). Green neutrophil and monocyte inclusions–time to acknowledge and report. British journal of haematology170(2), 229-235.
  4. Jazaerly, T.& Gabali, A.M. (2014) Green neutrophilic inclusions could be a sign of impending death! Blood, 123, 614.

 

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-Carlo Ledesma, MS, SH(ASCP)CM MT(ASCPi) MT(AMT) is the program director for the Medical Laboratory Technology and Phlebotomy at Rose State College in Midwest City, Oklahoma as well as a technical consultant for Royal Laboratory Services. Carlo has worked in several areas of the laboratory including microbiology and hematology before becoming a laboratory manager and program director.

Microbiology Case Study: A 75-Year-Old Man with Polymicrobial Bacteremia After Hemicolectomy

Case History

A 75-year-old male with a past medical history of hypertension, hyperlipidemia, and benign prostatic hyperplasia underwent an elective right hemicolectomy at an outside hospital after a cecal polypectomy demonstrated an intramucosal adenocarcinoma (in situ) arising in a background of a sessile serrated adenoma. On post-op day 6, he was transferred to our institution for management of an ST-elevation myocardial infarction that was treated with placement of a drug-eluting stent to the right coronary artery. After the cardiac catheterization, he complained of acute-onset abdominal pain and was tachypneic (49/min), hypotensive (72/48 mmHg), and febrile (39.4°C). He was emergently intubated, given vasopressors, and started on vancomycin and piperacillin/tazobactam empirically for septic shock. A chest X-ray showed atelectasis but no pulmonary consolidation. An abdominal X-ray did not show definitive evidence of pneumoperitoneum and abdominal CT showed some free fluid but no acute abdominal pathology. The WBC count was 3,640/cm3 with an absolute neutrophil count (2,880/cm3) within normal limits. The anaerobic bottle in one of two blood culture sets drawn on post-op day 7 became positive at 27 hours and Gram staining (Image 1) demonstrated gram negative bacilli. Subsequently, the bacilli detected in the anaerobic blood culture bottle were identified by MALDI-TOF as Clostridium clostridioforme, requiring a laboratory corrected report. On post-op day 8, two sets of repeat blood cultures were both positive with Clostridium tertium (Images 2 and 3) and Escherichia coli, consistent with bowel flora. Therapy for the patient’s polymicrobial bacteremia, thought to arise from an ileocolic anastomotic leak, was switched to piperacillin/tazobactam and Metronidazole. Blood cultures on post-op days 10 and 14 were negative. Meanwhile, the patient developed diarrhea, secondary to Clostridium difficile colitis, treated with oral vancomycin and oral thrush treated with micafungin. His hospital course was further complicated by formation of intra-abdominal abscesses, containing E. coli, C. tertium, and C. albicans, that required percutaneous drain placement.

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Image 1. Gram stain of Clostridium clostridioforme from a positive anaerobic blood culture bottle demonstrates thin gram negative bacilli with pointed ends arranged in pairs (100x, oil immersion).

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Image 2. Gram stain of Clostridium tertium from a positive anaerobic blood culture bottle demonstrates gram variable bacilli arranged in short chains (100x, oil immersion).

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Image 3. Clostridium tertium colonies are β-hemolytic on an anaerobic (Schaedler) blood agar plate and appear circular with slightly irregular margins, matte, and grey-white.

Discussion

The genus Clostridium contains approximately 200 species, of which approximately 32 have been associated with human pathologies (1). These organisms are normal members of the human gastrointestinal and cervical-vaginal microflora. Clostridia are also ubiquitously present in nature within soil. Thus, human infection may occur via endogenous or exogenous means. They are classified as gram positive rods and, as such, they do not grow on media that inhibit the growth of gram positive organisms (ie. MacConkey agar). However, upon gram staining, Clostridia may appear gram positive, gram variable, or gram negative. Due to the gram stain variability, inconsistent presence of spores, and atypical colony morphologies, laboratory identification of Clostridum species is problematic.

Clostridium clostridioforme was initially detected in the anaerobic blood culture bottle at 27 hours. Gram staining (Image 1) demonstrates gram negative long, thin bacilli with pointed ends, described as “elongated football shaped” that are arranged in pairs but may also lie singly or in short chains. Oval spores may not be seen but they can be central or subterminal. As obligate anaerobes, C. clostridioforme may be cultured on anaerobic blood agar plates where the gamma-hemolytic colonies appear small, convex to slightly peaked, translucent to opaque, and grey-white. They possess peritrichous flagella that confer motility. It is believed that C. clostridioforme may represent three different species that are frequently isolated anaerobically from blood cultures, particularly in association with mixed cultures, typical of colonic flora (2).

Subsequent blood cultures one day later were positive for both Escherichia coli (detected at 18 hours) and Clostridium tertium (detected at 21 hours). The anaerobic blood culture bottle gram stain (Image 2) demonstrates C. tertium staining as gram variable bacilli arranged in short chains. Terminal spores, only produced under anaerobic conditions, are not seen in Figure 2. C. tertium is one of the aerotolerant clostridia and was cultured on an anaerobic blood agar plate (Figure 3). Colonies appear circular with slightly irregular margins, low convex, matte, and grey-white. Hemolysis can be beta, alpha, or gamma. It was likely overgrown by the E. coli on the aerobic plates. This species is generally considered a weak human pathogen but it has been implicated as a cause of bacteremia in immunocompromised patients. In non-neutropenic patients, C. tertium bacteremia can occur in the setting of gastrointestinal mucosal injury due to gastrointestinal tract pathology or surgery (3).

References

  1. Tille PM. Bailey & Scott’s Diagnostic Microbiology, 13th ed. Elsevier Health Sciences; 2014. pp458-479.
  2. Finegold SM, Song Y, Liu C, et al. Clostridium clostridioforme: a mixture of three clinically important species. Eur J Clin Microbiol Infect Dis. 2005;24(5):319-24.
  3. Miller DL, Brazer S, Murdoch D, Reller LB, Corey GR. Significance of Clostridium tertium bacteremia in neutropenic and nonneutropenic patients: review of 32 cases. Clin Infect Dis. 2001;32(6):975-8.

 

-Adina Bodolan, MD is a 1st year anatomic and clinical pathology resident at the University of Vermont Medical Center.

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-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.

 

 

Logistics, Meetings, and Evacuations

Almost perfectly timed during my classroom-to-clinicals transition period from American University of the Caribbean School of Medicine (AUC), the 2017 ASCP Annual Meeting in Chicago was an excellent opportunity to get back to my lab roots. The Annual Meeting is always an excellent opportunity to expand lab-related knowledge, learn some new clinical skills, and easily network with colleagues. Professional societies like ours are highly dependent on the partnership and collaboration of our fellow scientists, sponsors, and clinicians. I have been fortunate enough to attend two of these meetings as an award recipient bookending my pre-clinical years in medical school. In 2015, I attended the ASCP Annual Meeting in Long Beach, California as a Regional Member of the Year. This year’s Annual Meeting was held in my hometown of Chicago, where I’m proud to say I attended as a 2017 ASCP Top 40 Under Forty honoree! But these meetings are more than just conferences with awards ceremonies—at every ASCP meeting I reconnected with old friends in workshops, shook hands with our great ASCP leadership, and collaborated with colleagues in roundtables or other sessions. There is a place for all of us in laboratory medicine. Our respective insights bring something valuable to the final outcomes of improved patient care. Nowhere is this more evident than the Annual Meeting.

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Image 1. ASCP Annual Meeting Chicago 2017, Top 40 Under Forty, and ASCP CEO Dr. Blair Holladay

Among the endless list of educational events and sessions, I especially enjoyed being a collaborator in round table discussions including “The Benefits of Data Integration in Clinical Decisions.” I truly enjoy these roundtables and wish I could have done more of them! Topics included effective feedback, utilization and evaluations, education, and global health initiatives—all of which I’m sure I’ve written about in one way or another this past year. Seeing some of the content in my online Lab Management University (LMU) modules applied in real-life situations was reaffirming. Attending sessions and meeting renowned experts from informatics to hematopathology was exciting. The keynote speakers were captivating. Dr. Birx’s discussion on PEPFAR and global health initiatives clearly piqued my interests, and Drs. Caliguiri and Pritchard’s lectures on analytics and resources spoke directly to my work in cancer research. And don’t forget: it’s all worth continuing education credit—can’t beat that.

I would just like to simply thank ASCP again for all the work that goes into these meetings. I know from experience that planning large events involves quite a bit of logistics. And in managing these events ASCP truly provides an excellent environment to collaborate and learn. What brought this appreciation for logistics to the forefront was a disaster that had unfolded in the week prior to the meeting. On the island of Sint Maarten, the location of my medical school and my home for two years, was absolutely decimated by hurricane Irma. The school managed to withstand for the most part intact and acted as a shelter for students, faculty, and family. While being sheltered from that storm, endless homes, apartments, and business were destroyed. Taking nothing but a suitcase or two to campus ended up the only possessions many people in the AUC community had left. The school and its administration did a spectacular job creating a stable, safe, and even comfortable environment for students and their families while evacuation efforts were organized. While AUC managed to get students off the island via military assistance and/or charter flights, evacuees were taken to the Chicago suburbs. Right after the ASCP Annual Meeting I began having conversations with contacts in the Chicago Department of Public Health and Emergency Preparedness to offer assistance. I provided contact data, relayed satellite telephone numbers to the right contact points, and provided relevant information regarding demographics, health, and needs. Both my wife (a trained nursing leader) and myself were happy to be involved with connecting critical points in this process. All the students and their families were accounted for and taken care of in the Chicago suburbs, and were later moved to the new school location relatively unscathed. Logistics from a distance can be difficult, especially when it’s behind-the-scenes. A lot of lab decisions are made that way, and ultimately we do our best for our patients.

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Image 2. Resort and villas halfway between my apartment and AUC campus on Sint Maarten before the hurricane.

 

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Image 3. Resort and villas halfway between my apartment and AUC campus on Sint Maarten after the hurricane.

The take home message: be flexible, be humble, and be helpful. If we want to improve patient outcomes, we need to work with evidence-based approaches matched with intelligent compassion. As laboratorians, we apply our scientific approach to critical life-saving algorithms. This was no exception. Lessons discussed at the Annual Meeting between networking colleagues and official sessions are accurate. Tap into your resources, keep an active and dynamic network, know what you can do and what you cannot, and always try to help. That’s what makes a good laboratorian, a good clinician, a good friend, and hopefully a good physician.

Thanks for reading! If you’re interested in donating to disaster relief for anyone affected by this year’s violent hurricane season in Sint Maarten, visit www.rotarysxm.org.

 

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Constantine E. Kanakis MSc, MLS (ASCP)CM graduated from Loyola University Chicago with a BS in Molecular Biology and Bioethics and then Rush University with an MS in Medical Laboratory Science. He is currently a medical student at the American University of the Caribbean and actively involved with local public health.

Hematopathology Case Study: A 56 Year Old Male with an Enlarged Lymph Node

Case History

A 56-year-old male with a past medical history significant for HIV currently on HAART presented to his primary care physician with an isolated enlarged left inguinal lymph node. In the context of his immunocompromised state, the patient was sent for a core needle biopsy of the lymph node to further elucidate the etiology of the isolated lymphadenopathy.

Diagnosis

luetiche20x
H&E, 20x
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H&E, 50x
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H&E, 100x
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Treponema immunoperoxidase

The core needle biopsy demonstrated multiple suppurative granulomata with a mixed inflammatory background including abundant plasma cells. The plasma cells are also found to surround small blood vessels. A Treponema immunostain was performed which highlighted the spirochetes. Overall, the diagnosis is that of luetic lymphadenitis.

Discussion

Syphilitic infections can cause isolated lymphadenopathy, especially in the inguinal lymph nodes. The morphologic features of luetic lymphadenitis include interfollicular plasmacytosis, capsular fibrosis, endarteritis, and occasionally sarcoid-like granulomata with rare cases demonstrating suppurative features. The differential diagnosis includes rheumatoid arthritis associated lymphadenopathy but a key histologic difference is that the capsular fibrosis of luetic lymphadenitis will have an infiltrate of lymphocytes and plasma cells while RA associated lymphadenopathy traditionally does not. Immunohistochemistry for Treponema organisms also serves to confirm the diagnosis. It is important to keep in mind the patient’s clinical history when interpreting the biopsy was as well as the differential for interfollicular plasmacytosis with capsular fibrosis.

 

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-Phillip Michaels, MD is a board certified anatomic and clinical pathologist who is a current hematopathology fellow at Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA. His research interests include molecular profiling of diffuse large B-cell lymphoma as well as pathology resident education, especially in hematopathology and molecular genetic pathology.

Microbiology Case Study: A 2 Week Old Female with Eye Discharge

Case History

A 2 week old African American female presented to the pediatric emergency department (ED) with erythema, swelling and copious mucopurulent discharge from the right eye. One week earlier, her Mom noted similar symptoms in the left eye which spontaneously resolved. Mom denied fever, irritability, lethargy, rash, and respiratory or urinary symptoms. The baby was born at term through a spontaneous vaginal delivery with no complications. Mom received regular prenatal care and all screening tests were negative. The baby received erythromycin eye ointment at birth prior to initial discharge. Complete blood count showed a slight leukocytosis (WBC 15.7 TH/cm2) and cerebral spinal fluid (CSF) values were unremarkable. A complete sepsis work up was performed with blood, CSF, eye swabs and urine sent for bacterial cultures. Given the high suspicion for a sexually transmitted infection, an eye swab was also collected for Neisseria gonorrhoeae and Chlamydia trachomatis polymerase chain reaction (PCR). Herpes simplex virus PCR from the CSF was also performed. The patient was started on IV ampicillin, cefotaxime and oral erythromycin in the ED.

Lab results

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Image 1. The eye swab showed growth of glistening, grey bacterial colonies on sheep blood and chocolate agars after 48 hours incubation at 35°C in 5% CO2.
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Image 2. Gram stain of the bacterial colonies showing uniform Gram negative diplococci.

The organism was positive for both catalase and oxidase and identified by matrix-assisted light desorption ionization- time of flight (MALDI-TOF) as Neisseria meningitidis. The health department also confirmed the identification. PCR of the eye swab was negative for Neisseria gonorrhoeae and Chlamydia trachomatis. Bacterial cultures from the blood, CSF and urine were all negative.

Discussion

Neisseria meningitidis is an encapsulated Gram negative diplococcus (Image 2) that is usually transmitted through large droplet secretions from the oropharynx from colonized individuals. It can cause invasive meningococcal disease, which can present as meningitis (high fever, stiff neck, and headache), acute sepsis or a combination of both. Waterhouse Friderichsen-syndrome can result in severe dissemination forms of the disease and is characterized by petechial hemorrhages, involvement of the adrenal glands, and disseminated intravascular coagulopathy (DIC). Rarely, N. meningitidis can cause acute bacterial conjunctivitis (1.5 % – 2.5% of cases). Local complications, including corneal ulcers or a more systemic disease, may occur as well.

N. meningitidis produces multiple virulence factors that help cause disease and evade human immune defense mechanisms. The polysaccharide capsule represents the major virulence factor and is also the basis of meningococcal serotyping. Twelve different capsular serotypes can be distinguished, with serotypes A, B, C, W, X, and Y accounting for most invasive disease worldwide. Other virulence factors include pili, which helps the bacteria attach to host surfaces, and IgA protease, an enzyme that cleaves IgA and allows the bacteria to escape the humoral portion of the immune system.

In the laboratory, N. meningitidis grows well on both blood and chocolate agars after 24 hours of incubation (Image 1) and it is positive for both catalase and oxidase. Traditionally, sugar fermentation was used to differentiate Neisseria species from one another. N. meningitidis ferments both glucose and maltose whereas N. gonorrhoeae is only capable of fermenting glucose. Currently, more rapid identification methods (MALDI-TOF, PCR and sequencing) are being increasingly used in most laboratories for a faster and more accurate identification of Neisseria species. The work up of suspected N. meningitidis isolates must be performed using BSL 2 standards, as aerosols created during mobilization from culture plates or performance of biochemical testing has been known to cause invasive disease in laboratory workers.

In general, N. meningitidis is susceptible to penicillin and cefotaxime, but susceptibility testing by disk or gradient diffusion is recommended. Both rifampin and ciprofloxacin can be used for chemoprophylaxis in close contacts of the patient and healthcare & laboratory workers. In addition, a number of meningococcal vaccines are available in the United States (US) and the Centers for Disease Control & Prevention (CDC) recommends vaccinating all adolescents and people at high risk for infection (college students, military recruits, those who had a splenectomy and patients with complement deficiencies). The most common vaccine is a quadrivalent polysaccharide-protein conjugate vaccine which covers serotypes A, C, W and Y. Recently in 2014, the Food and Drug Administration (FDA) approved Trumenba, a vaccine effective against serotype B, which a common serotype causing invasive disease in the US.

 

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-Akram Shalaby, MD, is a first year anatomical and clinical pathology resident at the University of Mississippi Medical Center.

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-Lisa Stempak, MD, is an Assistant Professor of Pathology at the University of Mississippi Medical Center in Jackson, MS. She is certified by the American Board of Pathology in Anatomic and Clinical Pathology as well as Medical Microbiology. She is the director of the Microbiology and Serology Laboratories. Her interests include infectious disease histology, process and quality improvement and resident education.

Team Dynamics

Teams are one of the most discussed work units. We throw “teamwork” and “team ethic” around during job interviews and performance reviews. When we apply for jobs, we highlight our teamwork capabilities on our resumes. Teams are indeed essential to productive work environments because they are the vital learning units in an organization. In other words, when teams learn, the entire organization learns.

But what constitutes a team exactly? Simply put, teams are a group of two or more people that have a shared goal. Not only that, they are committed to the team process and use team language (“we” instead of “I”) when discussing accomplishments and failures. Teams also focus on learning, whether that learning comes from outside information, success, or failure. Finally, teams possess a strong sense of commitment and accountability.

Teams that consistently perform above expectations are called high-performance teams. Everyone wants to be a part of a high-performance team, but how do they happen? These teams consistently have one trait in common: experiencing and working through conflict. Conflict is one of THE best things that can happen to a team, because when handled and resolved well, teams learn, grow, and function better as a unit.

Each person has different preferences for their role on a team. Everyone gravitates toward one these five team roles: Creator, Advancer, Refiner, Executor, and Flexer. The Creator focuses on generating ideas; the Advancer communicates the ideas; the Refiner challenges ideas; the Executor implements the ideas; and the Flexer assumes any of the other four roles based on the needs of the team. High-performing teams have members who are in their preferred role where they can excel and are sustained because those roles give them energy. It is our job as leaders to find jobs, tasks, and team roles where others can flourish. Without energized people, leaders will not be able to create high-performing teams or high-performing organizations.

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-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.


 

The team dynamics module gave me a great insight into my tendencies and an understanding on effectively getting the best out of teams.

When I received my assessment results, I learned I am an “advancer.” I tend to focus on execution and I pay attention to team interactions. One weakness of this profile, though, is how it potentially interacts with creators and refiners. If one is unaware of the valuable differences in prospective creators and refiners bring to the table, an advancer may get frustrated working with them in a team.

I came to realize I should be sure to include a refiner on the team, since having only executors or advancers could mean bypassing the analysis piece. I also gained new prospective on how I perceive creators. While in the past I may have discounted them as scattered or unrealistic, I learned this stems from the fact I like concrete ideas. Embracing innovation is essential to advancement and this is where creators excel.

The sections about communication and team roles were enlightening. How creators can easily get bored with discussions that are too concrete, and how executors are uninterested in theoretical discussions. On the flip side of things, creators need to partner with advancers, refiners and executors to bring about innovation. Advancers rely on refiners and refiners can benefit from the enthusiasm and networking of the advancers. I use these important concepts now in meetings and when I try to put teams together for a given project.

Although this may come with time, leadership and team member selection are paramount to foster the trust and respect and to facilitate free expression of ideas and sharing of information.

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-Laila Osama Abdel Wareth, MBBCh, FCAP, MRCPC, EMHCA is the Chief of Clinical Pathology for the Pathology & Laboratory Medicine Institute at the Cleveland Clinic Abu Dhabi in the United Arab Emirates.

 

 

Friday Poll: Variable K+ Results