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Routine Laboratory Examination

for Infectious Diseases

Umi S. Intansari
Clinical pathology Department

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The Role of Lab Exam

Screening

Diagnosis :

Routine Lab tests

Confirmatory Lab tests

Prognosis

Monitoring

Disease activity

Therapy responses

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Laboratory examination for Infection
• - Hematology
1. Routine : • - Urinalysis : physic, microscopic, enzymatic
• - Faeces

• Sero-immunology
2. • Microbiologic examination
Confirmatory: • Molecular diagnostic

• CRP
3. Others Lab • PCT
exam • Biomarkers

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 Routine examination
HEMATOLOGY :
Blood cell count → complete blood cont (CBC)

Hemoglobin concentration (Hb)

White Blood Cell Count (WBC)

Platelet count

Differential cell count

Red blood cell count & Hematocrit

Erythrocyte Sedimentation Rate (ESR)

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 Routine examination - hematology

Blood cell count

 Hemoglobin concentration
• Normal range :
• At birth : 15 – 20 g/dl
• At 2 months : 9 – 14 g/dl
• 10 years of age : 12 – 15 g/dl
• Female adult : 12 - 16 g/dl
• Male adult : 13 – 18 g/dl

• < Normal range : Anemia

• Anemia occur in several infection diseases as
follows: - bacterial infection
- virus infection
- parasite infection
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Anemia in bacterial infection

Extracellular microorganism

Clostridial Septicemia Bartonellosis

Invade to RBCs Adhere to the exterior surface

of the RBC

Destruction of RBCs

Lysis ANEMIA

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Hemolytic anemia in parasites infection
Infected cell

Immune complexes ruptures

Lysis ANEMIA

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 Anemia of Chronic Disease

ACD is associated with an underlying disease
(usually inflammation, infection, or malignancy),
but is without apparent cause (not due to a lack
of the nutrients iron, vitamin B 12, or folic acid)

Anemia of chronic disease (ACD) is difficult to

define as its etiology and pathogenesis is not
clear.

ACD is the most common anemia in hospitalized
patients.

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Anemia of Chronic Disease
Pathophysiology:

Erythropoesis suppression

Chronic inflammatory process → secretion of TNF
& IL-1 ↑

Lack of iron for Hb synthesis

Lactoferrin release from granules of neutrophils

Lactoferrin competes with transferrin for iron

Decreased RBC survival

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 Routine examination - hematology

LEUKOCYTE COUNT (WBC)

Measure number of total leucocytes

Method: manually & automatically
Principle : dilution of blood with acid solution in
order to lyses erythrocytes

Reference range :
adult = 4000 -11.000 cells/µL
child = 45000-17.000 cells/µL
newborn= 6000-30.000 cells/µL

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 Kinetics of Leucocyte
Storage pool

Circulating pool
Input
Output
from
to tissue
marrow

Marginal pool

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 WBC

Pathology
Leukocytosis Leukopenia
WBC > 11.0 (x 109/L) WBC < 4.0 (x 109/L)

Bacterial infection Virus infection

Leukemia Typhoid fever
Uremia Rheumatoid arthritis
Cirrhosis of the liver
Physiologic: SLE
Pregnancy Radiation, drugs
Strenuous exercise
Emotional stress, anxiety

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 Routine examination - hematology

White Blood Cell Differential

 To determine the relative number of each

type of WBC present in the blood.

 Blood smear :
- relative number
- leukocyte immaturity
- morphologic abnormality

 Abnormality: Quantitative
Qualitative

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Classification of Leucocytes
Granulocyte Non-granulocyte
Netrofil, Monosit
Eosinofil, Limfosit
Basofil
Polimorfonuclear Mononuclear
Netrofil, Monosit
Eosinofil, Limfosit
Basofil
Phagocyte Immunocyte
Netrofil Limfosit
Monosit

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 All white blood cells originate from the bone marrow

Growth and differentiation factors (cytokines) produced by and present on bone

marrow stromal cells determine the type of white blood cell that will emerge, as well
as their relative numbers.
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Blood cells derived from bone marrow cells

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Blood cells migrate through blood and lymph nodes or home to tissues

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 Cells in blood circulation

Very few in blood

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Resting lymphocytes are round cells with a large nucleus

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Differential cell count
Refference range:

Polymorphonuclear
neutrophils : 50 – 70 %
 Bands : 0–5 %

 Lymphocytes : 18 – 42 %
 Monocytes : 1 – 10 %
 Eosinophils : 1–4 %
 Basophils : 0–2 %

• Course of d’s : shift to the left (acute), shift to the right (chronic)
• Cause : bacterial, viral and parasites infection
neutrophilia (bacterial infection), lymphocytosis
(viral infection, tuberculosis) 22
 Quantitative abnormality

NEUTROPHILIA
 3 major cause : infection,
inflammation, malignancy

 Severity of neutrophilia in
infection depend on:
- virulency of organism,
- age : child >
- patient immunity:
immunocompromised host

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 Quantitative abnormality
Causes of neutrophilia
1. Bacterial Infection
2. Toxic agent
3. Metabolic: uremia, eclampsy, metabolic
acidosis
4. Drugs & chemicals: mercury, digitalis, steroid
5. Physic & emotional stimuli
6. Tissue damage & necrosis: myocardial infarct,
wound, neoplastic diseases
7. Hemorrhage: especially intra serous cavity
(peritoneal, pleural, joint space, subdural)
8. Hematological diseases: leukemia.

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 Qualitative Abnormality

Shift to the left or right:

mieloblas promielosit mielosit metamielosit batang segmen

Shift to the left : Shift to the right:

• increase immatur cells • increase of segment
• most frequent: stab, • hypersegmentation
• metamielosit, mielosit, promielosit • chronic infection
• acute infection (bacterial)
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 Quanti+Qualitative abnormality
Leukemoid reaction
mielocytic/netrophyilic

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Bain, 2002. Blood Cells, A Practical Guide,3rd ed, Blackwell Publ, UK
 Qualitative abnormality

White blood cell (blood smear)

vacuolisation

vacuolisation

Toxic granulation

Leucocytosis : netrophilia absolute with toxic granulation & vacuolisation

Bacterial infection
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Vacuolisation & toxic granulation

Toxic Granulation

vakuolisation

Bacterial infection
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 Qualitative abnormality

Toxic Granulation

Stimulated by organism or antigen

Color of granule: dark blue-blackish

Profound toxic granulation ⇒ worse prognosis

Vacuolisation of cytoplasm
⇒ phagocytosis process

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Neutropenia
Netropenia lekopenia
Agranulositosis: severe netropenia

Causes of netropenia:

Viral infection

Certain Bacteria: Tifoid/ paratifoid

Severe infection

Immune reaction: autoimmune/ drug induced

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EOSINOPHILIA :

1. Parasite investation
- correlate with killed parasites
- eosinophyl attracted to parasite will be killed
by degranulation process

2. Allergy/ hypersensitivity

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EOSINOPHILIA :

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Lymphocytosis

Absolute lymphocytosis Viral infection

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 Qualitative abnormality

Variant / atypical/ virocyte/ reactive

lymphocyte ⇒ response to infection

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• Lymphocytosis with variant lymph:
- Mononukleosis infecsiosa (var lymph > 40%),
acute hepatitis, citomegalovirus (CMV)
- measles, pneumonia viral, rubela ⇒ relatif
- Non viral : Tuberculosis, syphilis, malaria,
typhus, diphteria, toxoplasmosis
Lymphocitosis without var lymph:
asimptomatic viral inf., diarrhea, resp. inf

Lymphopenia; HIV, SLE, intensive chemotherapy

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 Virus Infection
MONONUKLEOSIS
INFEKSIOSA (MI)

cause: virus Epstein-
Barr (EBV)

Lekositosis with
limphocytosis, dan
atypical lymphocyte

“Kissing-cell”

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Dengue virus infection

Reactive Lymphocyte
Blue cytoplasm-
Lymphocyte

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Monocyte

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MONOCYTOSIS

 Some bacterial inf.,:

- Active Tuberculosis :
- Sub acute bacterial endocarditis
- Syphilis
 Myeloproliferatif
 Recovery

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 Routine examination - hematology

Erythrocyte Sedimentation rate

(ESR)

ESR is the rate in millimeters at
which the RBCs fall in 1 hour

Monitoring the course of an existing

inflammatory disease

Normal range: 0-20 mm/hrs F

0-15 mm/hrs M

Elevated : bacterial infection

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Normal sedimentation Increase Sedimentation
iinfection
iPolisitemia : AE
iDekompensasi imyocardial infarct
jantung iRheumatic fever
iSickle sel anemia, iMalignancy with necrosis
sferositosis
iNeonatus iActive tuberculosis ,
tissue destruction
iSurgery Trauma, shock
iHiperglobulinemia
iPregnancy

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 C-REACTIVE PROTEIN (CRP)

 an acute phase reactant

 In general parallel ESR but not influenced by
erythrocyte
 More sensitive than ESR
 Increase & decrease faster :
- early indicator of acute infection
- monitor course of disease

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CRP increase in :

Infection:

Lower in viral compared to bacterial infection

Useful to monitor disease activity

Inflammatory disorders:

Earlier,more intense increase than ESR

Dissaperance of CRP precedes the return to normal
of ESR

Tissue injury or necrosis

AMI : appears within 24-48 hrs

Malignant disease, Following surgery, burns

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Urinalysis

1. Physical examination

Specific Gravity
Color

Foam Volume

Clarity Odor

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 2. Chemical 3. Microscopic
examination examination of
urine sediment

 Specific gravity
 pH  White blood
 Blood
 Leukocyte esterase cells
 Nitrit  Red Blood Cells
 Protein  Epithelial cells
 Glucose Crystal
 Ketones  Bacteria
 Bilirubin & Urobilinogen

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Faecal analysis
 Macroscopic examination
• Color
• The normal brown color of feces reluts from bile
pigments
• Orange-brown: intestinal anaerobic bacteriuria
• Pale or clay-colored stools = alcholic stools: posthepatic
obstructions
• Consistency and foam
• Normal formed masses
• ranges: loose & watery (diarrhea) – hard (constipation)
masses
• Mucus
• Normal: -
• Mucus+: villous adenoma, colitis, intestinal tuberculosis,
ulcerativa diverticulitis, bacillary dysentery, neoplasma,
rectal inflammation
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Faecal analysis

 Microscopic examination
• Cyst, trophozoite, egg of parasites, worm
• Fecal leukocytes
• intestinal tuberculosis, ulcerativa colitis, ulcerativa
diverticulitis, bacillary dysentery, abscesses or fistulas
• Leukocytes negative: amebic colitis, viral gastroenteritis

Fecal fat
> 6 gr/d (steatorrhea) – maldigestion or malabsorption

 Chemical examination
• Fecal blood:
• Bleeding anywhere in the GI

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 SERO-IMMUNOLOGY TESTS

Principal: antigen-antibody reaction

1. Antigen Identification
ex: HBsAg
2. Antibody measurement
ex: Anti HBs

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Detection, Measurement &
Characterization of Antibody/Antigen
1. Affinity chromatography
2. Precipitin reaction
3. Agglutination
4. Anti immunoglobulin Ab (Coomb’s test)
5. RIA, ELISA, Fluorescence IA
6. Immunohistochemistry
7. Immunoblotting

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 MICROBIOLOGIC EXAMINATION

Microorganism identification
1. Direct staining:
fungi, Gram +/-, bacteria, etc
2. culture of bacteria & fungi
Sensitivity test for antibiotics
3. Polymerase chain reaction:
to detect DNA/ RNA of microorg.

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