Medical Laboratory Journal

External Quality Assurance Scheme as a tool for evaluating laboratory performance in a tertiary care hospital

Charushila Kadam

Background: Quality control (QC) is a crucial tool in the clinical laboratory for error identification and correction. While the Internal Quality Control (IQC) ensures daily precision and accuracy, the External Quality Assurance Scheme (EQAS) ensures long-term accuracy by providing external verification. The objective of this study was to evaluate our laboratory’s performance in the EQAS program services and assess the impact of corrective actions implemented, where necessary, to enhance EQAS performance.
Methods: This retrospective observational study was undertaken in a tertiary care hospital. The biochemistry department of the laboratory participated in the monthly clinical chemistry EQA program administered by CMC Vellore EQAS. Nineteen parameters were assessed using a structured approach to analyze deviating EQAS results. Monthly performance was analyzed in terms of the Standard Deviation Index (SDI) and variance index score (VIS) from October 2019 to September 2021.
Results: Among the nineteen parameters assessed in the EQAS program, most showed ‘excellent’ performance between October 2019 and September 2021 based on mean SDI. Some improvement was observed in the SDI values between the two cycles after implementing a structured approach to root cause analysis, indicating an enhanced level of performance in the EQAS program. The VIS analysis revealed that 89.47% of parameters in the October 2019 to September 2020 period and 94.73% in the October 2020 to September 2021 period achieved scores classified as ‘very good’ performance.
Conclusion: Adopting a structured approach to analyze deviating EQAS results enables the evaluation of laboratory performance and offers opportunities for improvement. Consequently, EQAS plays a significant role as a cornerstone in the accreditation process.

Molecular evaluation of Leishmania species in negative ulcer smears from patients suspected of having cutaneous leishmaniasis referred to the health Center of Aq Qala city during 2019-2020

Hamed Kalani

Background: Cutaneous leishmaniasis (CL) is a prevalent infectious zoonotic disease between humans and animals. Golestan Province is one of the important centers of CL in Iran. The current method for detecting Leishmania parasites in patients is Giemsa-stained direct smear from skin ulcers; however, PCR is a strongly recommended method for epidemiological studies. This study aimed to investigate Leishmania species in negative ulcer smears from patients suspected of having CL referred to Aq Qala Health Center using the multiplex nested PCR method.
Methods: This study was performed on 72 negative ulcer smears from patients suspected of having CL referred to Aq Qala Health Center, Golestan Province, northeastern Iran, from August 2019 to April 2020, using the multiplex nested PCR method to detect Leishmania major and Leishmania tropica species.
Results: Out of 72 samples, 4 (5.55%) samples were positive by multiplex nested PCR. Moreover, all positive samples are related to Leishmania major species.
Conclusion: The multiplex nested PCR method is strongly recommended for detecting Leishmania species in negative ulcer smears from patients suspected of having CL.

Hairy cell leukemia: A case report of unusual presentation without splenomegaly

Iffat Jamal

Hairy cell leukemia (HCL) is characterized by pancytopenia and is usually associated with massive splenomegaly; however, the same may not be true in clinical settings. Here, we report a case of HCL without the classical clinical feature of splenomegaly. Absence of splenomegaly doesn’t exclude the diagnosis of HCL. A careful study of morphological findings on bone marrow aspirate and biopsy, followed by appropriate ancillary tests, aids in correct diagnosis. A high index of suspicion is essential for diagnosing and appropriately managing such cases. A strong suspicion on morphology in such cases is a prerequisite for reaching a correct diagnosis, even in the absence of usual clinical presentation.

Investigating the roles of cytokines and chemokines in pregnancy-related toxemia

Adedeji Okikiade

Background: Hypertensive disorders, particularly preeclampsia (PE), complicate 2–8% of pregnancies and significantly contribute to maternal and perinatal mortality. PE disproportionately affects low-resource regions, accounting for 26% of maternal deaths in Latin America and 9% in Africa and Asia. Risk factors include extreme maternal age, chronic hypertension, obesity, diabetes, and racial disparities (Higher incidence in Black and Hispanic populations). The exact cause remains unclear, but angiogenic imbalance and immune dysregulation play key roles. This review focuses on the role of cytokines and chemokines in developing preeclampsia (PE).
Methods: A narrative review was conducted to examine studies on the immunological and vascular mechanisms of preeclampsia, with a focus on recent systematic reviews and high-impact research.
Results: The results highlighted a critical imbalance between pro-inflammatory (IL-6, TNF-α) and anti-inflammatory (IL-4, IL-10) cytokines in PE pathogenesis. Notably, reduced second-trimester IL-10 levels served as an early predictive biomarker. Endothelin-mediated vasoconstriction and Th1/Th2 immune imbalance further exacerbated endothelial dysfunction, a central feature of PE. While human and animal studies support these findings, precise mechanistic pathways remain elusive.
Conclusion: Cytokine and endothelin can serve as promising biomarkers and therapeutic targets for PE. Early IL-10 detection may improve risk prediction, but no causal links have been confirmed yet. Gaining a better understanding of these mediators could improve clinical strategies and help minimize complications. Future longitudinal research should focus on biomarkers and explore anti-inflammatory treatments for PE prevention.

Impact of COVID-19 pandemic on tuberculosis

Rajesh Karyakarte

Background: Tuberculosis (TB) is a disease of the respiratory system that spreads when a patient coughs, sneezes, or spits. COVID-19, another respiratory disease, created havoc in 2020 and 2021. During this pandemic, the whole healthcare system was diverted into COVID-19 patient care. It is important to determine what the status of TB was during the COVID-19 period. This study was mainly undertaken to detect the occurrence of Mycobacterium tuberculosis (M. tuberculosis) and rifampicin resistance before, during, and after COVID-19 restrictions were fully released.
Methods: Pulmonary and extrapulmonary samples from 1^stJanuary 2018 till 31^st December 2022 were included in the present retrospective study. The period was divided as- 2018, 2019 - Before COVID-19 2020, 2021 -COVID-19 period with restrictions (Such as use of masks, social distancing, avoiding gatherings) 2022 -COVID-19 period without restrictions. All samples received in TB section were subjected to Cartridge-Based Nucleic Acid Amplification Test (CBNAAT). The samples were processed according to the manufacturer’s guidelines.
Results: There was no significant difference in samples received per year from 2018 to 2022. The positivity of M. tuberculosis decreased from 22.52% in the pre-COVID-19 period to 15.70% in the COVID-19 period with restrictions and increased again in 2022 (16.80%). Rifampicin resistance decreased from 10.40% to 6.89% in the COVID-19 period with restrictions. A decrease in positivity was not observed in extrapulmonary TB cases.
Conclusion: In the present study, total samples for TB received over five years were relatively the same. Restrictions imposed during the COVID-19 period could decrease TB and rifampicin resistance. Thus, imposing restrictions on TB-suspected and positive patients regularly can help prevent the spread of the disease.

Investigating the relationship between serum zinc levels and red blood cell indices in anemic patients referred to the laboratories in Gorgan, Iran

Hamidreza Joshaghani

Background: Bivalent minerals function as crucial cofactors that participate in a multitude of metabolic pathways within the organism. Specifically, zinc (Zn) assumes catalytic, structural, and regulatory roles in numerous biological processes. A severe deficiency in Zn can lead to disruptions in nucleic acid and protein synthesis, impaired cellular proliferation, increased apoptosis, and heightened lipid peroxidation of cellular membranes, a phenomenon associated with a reduced lifespan of red blood cells (RBCs). The objective of this study was to investigate the correlations between Zn status and various erythrocyte indices in a cohort of anemic patients, in comparison to a control group.
Methods: A cohort of 563 participants was enrolled in this investigation. Serum Zn concentration was quantified using a BT-3500 autoanalyzer, while hematological indices were determined via a Sysmex KX21N cell counter. Following confirmation of data normality, Spearman's rank correlation coefficient was employed to analyze the relationship between serum Zn levels and RBC indices.
Results: The mean serum Zn concentration was 102.8 ± 17.6 mg/dL. Serum Zn levels exhibited a weak correlation with RBC and hemoglobin (Hb) concentrations in healthy women, as well as a weak correlation with mean corpuscular hemoglobin concentration (MCHC) in anemic men (p < 0.05). Furthermore, the results indicated significantly higher serum Zn levels, RBC, Hb, hematocrite (HCT), and MCHC in men (p < 0.01), while mean corpuscular volume (MCV) was significantly higher in women (p < 0.01). Notably, in individuals with serum Zn levels < 30 mg/dL, MCHC (p < 0.01) and RBC (p < 0.05) were elevated, whereas Hb (p < 0.05), HCT, MCV, and MCH (p < 0.01) were higher than 30.
Conclusion: Considering the potential impact of varying Zn concentrations on erythrocyte indices, including Hb and MCHC, in both healthy and anemic individuals, careful regulation of its dosage is warranted.

Detection of β-lactamase genes and characterization of class 1 integrons in multidrug-resistant Pseudomonas aeruginosa strains in Guilan, Iran

Leila Asadpour

Background: Infections caused by extended-spectrum β-lactamase (ESBL)-producing Pseudomonas aeruginosa (P. aeruginosa) are a serious concern in hospitals around the world. Many β-lactamase genes are carried by integrons. This study was conducted to investigate the frequency of β-lactamase genes and characterize class 1 integrons in multidrug-resistant P. aeruginosa strains in Guilan, northern Iran.
Methods: A total of 110 P. aeruginosa isolates were collected from different hospitals in 2021 and identified using standard microbiological methods. The isolates were studied for their antibacterial susceptibility and ESBL-producing ability by disk diffusion. All ESBL-producing isolates were investigated for the presence of β-lactamase resistance and integron genes by polymerase chain reaction (PCR). Gene cassette screening was done based on sequence analysis of class 1 integrons.
Results: Based on antibiotic susceptibility testing, 40 isolates (37.4%) were ESBL producers. The frequency of β-lactamase genes, including VIM, SIM, IMP, SPM, and OXA2, was 10.3%, 1.9%, 20.6%, 14%, and 4%, respectively. GIM and OXA 10 genes were not found in any of the strains. Furthermore, the int1 gene was identified among 37 isolates (34.6%). The sequencing results of int1 showed 12 different types of gene cassettes among 13 strains. In this assay, blaOXA-2 was the only bla gene identified in int1.
Conclusion: The integrons carrying multidrug resistance genes are highly prevalent in P. aeruginosa isolates, and ESBL genes were also observed in these strains. Therefore, constant monitoring of drug resistance, especially ESBL producers, is critical to disease management in clinical settings.

Enterobius vermicularis as a cause of acute appendicitis in a child with acute lymphocytic leukemia: A case report

Majid Khanmohammadi

Background: Enterobius vermicularis is the most important intestinal parasite in children worldwide. When this parasite migrates unexpectedly, the larvae move out of the intestine and enter organs such as the appendix, and can cause health risks.
Case presentation: An 8-year-old boy was admitted to the oncology clinic of Tabriz Children’s Hospital, complaining of fever of 39-40°C with abdominal pain, cramps, loss of appetite, weakness, and fatigue, associated with cervical lymphadenopathy, hepatomegaly, axillary mass, abdominal upper thigh, maculopapular rashes, and tiny petechiae on the chest and abdomen.
Results: On CT examination of the chest, moderate mediastinal and mesenteric lymphadenopathy was noted. The patient was hospitalized with a definitive diagnosis of acute lymphoblastic leukemia. On the seventh day of hospitalization, the patient developed additive colic pain (Contraction and cramping) around the umbilicus and concomitantly developed pain downward and rightward into the abdomen. Based on the clinical findings, the patient was thought to have acute appendicitis. Pathological examinations showed that E. vermicularis was the cause of the appendicitis.
Conclusion: The results of this study indicate that this parasite may be associated with inflammation of the appendix in patients with acute lymphoblastic leukemia. A screening program is still required in patients with immunodeficiency or those taking immunosuppressive drugs.

Prevalence of carbapenem resistance genes in Enterobacteriaceae, Pseudomonas aeruginosa, and Acinetobacter baumannii from meat samples

Laleh Hoveida

Background: Infections caused by bacteria transmitted from food, including carbapenem-resistant Enterobacteriaceae, Pseudomonas aeruginosa (P. aeruginosa), and Acinetobacter baumannii (A. baumannii), are spreading, and this has caused concerns in treatment. This study investigated the frequency of carbapenem resistance genes in Enterobacteriaceae, P. aeruginosa, and A. baumannii, isolated from raw chicken meat.
Methods: In this cross-sectional study, 100 samples of raw chicken meat were collected from Isfahan. Bacterial contamination was evaluated and confirmed using biomedical tests. Antibiotic sensitivity tests were performed using disc diffusion for Enterobacteriaceae, P. aeruginosa, and Acinetobacter baumannii isolates. The frequency of carbapenem resistance genes (OXA-181, OXA-48, VIM, NDM, IMP, and KPC) was determined through polymerase chain reaction (PCR) analysis.
Results: Out of 100 samples, 70 were positive for bacterial infection, of which 30 were infected with Escherichia coli (E. coli), 14 samples with Klebsiella pneumoniae (K. pneumoniae), 9 samples with Salmonella typhimurium (S. typhimurium), 11 samples with P. aeruginosa, and 6 samples with A. baumannii. The highest levels of antibiotic resistance were estimated to be tetracycline, cotrimoxazole, gentamicin, trimethoprim, and streptomycin, and the lowest levels were azithromycin and rifampin. Among genes encoding resistance to carbapenem, NDM and OXA-48 genes were the most commonly expressed, with a frequency of 60% and 28.24%, respectively.
Conclusion: This study found significant bacterial contamination, especially for Enterobacteriaceae, with notable antibiotic resistance to tetracycline. Carbapenem resistance genes NDM and OXA-48 were prevalent, indicating the urgency of addressing antibiotic resistance.

Resistance investigation of uropathogenic Escherichia coli strains isolated from urinary tract infections in the north of Iran

Tooba Shafighi

Background: Urinary tract infections (UTIs) caused by uropathogenic Escherichia coli (UPEC) represent a significant global health concern. Virulence factors (VFs) expressed by UPEC strains play a crucial role in promoting bacterial pathogenicity within the urinary tract. Effective treatment of these infections is frequently complicated by the high prevalence of antimicrobial resistance exhibited by Escherichia coli. The objective of this study was to investigate the VFs and antibiotic susceptibility profiles of UPEC strains isolated in the northern region of Iran.
Methods: One hundred and five urine specimens were collected from female patients diagnosed with UTIs in Rasht, located in the north of Iran. These samples underwent culturing on both Eosin Methylene Blue (EMB) agar and MacConkey agar. Following a 24-hour incubation period at 37°C, pure bacterial isolates were identified through Gram staining and a battery of standard biochemical assays. The prevalence of six VF genes - papC, sfa/foc, fimH, afa, ibeA, and neuC - within UPEC strains was determined utilizing polymerase chain reaction (PCR) and subsequently confirmed via direct sequencing. Antibiotic susceptibility testing (AST) was conducted using the disk diffusion method, adhering to the guidelines established by the Clinical and Laboratory Standards Institute (CLSI M02).
Results: The study identified 65.71% of the isolates as Escherichia coli. Among the virulence genes examined, fimH exhibited the highest prevalence (100%), while afa was the least frequent (1.44%). Antibiotic resistance analysis revealed the highest rate against Cefazolin (66.66%) and the lowest against Gentamicin (24.63%). Notably, the prevalence of multi-drug resistance (MDR) was determined to be 73.91%.
Conclusion: This study underscored the significance of localized surveillance of UPEC isolates. This emphasis stems from the pathogen's considerable capacity for genetic mutation, coupled with the influence of environmental variables and individual patient characteristics. Understanding these dynamic factors at a local level is crucial for formulating the most effective strategies to combat UTIs.