Blood Chemistry, Immunology & Serology - In alphabetical order

ACETOACETATE (KETONE BODIES, ACETONE) 

Normal = negative

Positive: diabetic ketoacidosis (DKA), starvation, emesis, stress, alcoholism, infantile organic acidemias, isopropanol ingestion

ACID PHOSPHATASE (PROSTATIC ACID PHOSPHATASE, PAP) - Not a useful screening test for cancer; most useful as a marker of response to therapy or in confirming metastatic disease. PSA is more sensitive in diagnosis of cancer. 

Normal: <3.0 ng/mL by radioimmunoassy (RIA), or <0.8 IU/L by enzymatic

Increased: Carcinoma of the prostate (usually outside of prostate), prostatic surgery or trauma (including prostatic massage), rarely in infiltrative bone disease (Gaucher's disease, myeloid leukemia), prostatitis, or benign prostatic hypertrophy (BPH)

ACTH, ADRENOCORTICOTROPIC HORMONE

Normal: 8 AM 20-140 pg/mL (SI: 20-140 ng/L)
Midnight, approximately 50% of AM value

Increased: Addison's disease (primary adrenal hypofunction), ectopic ACTH production (small [oat] cell lung carcinoma, pancreatic islet cell tumors, thymic tumors, renal cell carcinoma, bronchial carcinoid), Cushing's disease (pituitary adenoma), congenital adrenal hyperplasia (adrenogenital syndrome)

Decreased: Adrenal adenoma or carcinoma, nodular adrenal hyperplasia, pituitary insufficiency, corticosteroid use

ACTH STIMULATION TEST (CORTROSYN STIMULATION TEST) - Used to help diagnose adrenal insufficiency. Cortrosyn (an ACTH analogue) is given at a dose of 0.25 mg intramuscular (IM) or intravenous (IV) in adults or 0.125 mg in children <2 years. Collect blood at time 0, 30, and 60 min for cortisol and aldosterone. 

Normal Response: Three criteria are required: basal cortisol of at least 5 mg/dL, an incremental increase after cosyntropin (Cortrosyn) injection of at least 7 mg/dL, and a final serum cortisol of at least 16 mg/dL at 30 or 18 mg/dL at 60 min or cortisol increase of >10 mg/dL. Aldosterone increases >5 ng/dL over baseline.

Addison's Disease (Primary Adrenal Insufficiency): Neither cortisol nor aldosterone increase over baseline.

Secondary Adrenal Insufficiency: Caused by pituitary insufficiency or suppression by exogenous steroids, cortisol does not increase, but aldosterone does.

ALBUMIN

Normal:
Adult 3.5-5.0 g/dL (SI: 35-50 g/L)
Child 3.8-5.4 g/dL (SI: 38-54 g/L)

Decreased: Malnutrition, overhydration, nephrotic syndrome, cystic fibrosis (CF), multiple myeloma, Hodgkin's disease, leukemia, metastatic cancer, protein-losing enteropathies, chronic glomerulonephritis, alcoholic cirrhosis, inflammatory bowel disease, collagen-vascular diseases, hyperthyroidism

ALBUMIN/GLOBULIN RATIO (A/G RATIO) - A calculated value (Total protein minus albumin = globulins. Albumin divided by globulins = A/G ratio). Serum protein electrophoresis is a more informative test.

Normal: >1

Decreased: Cirrhosis, liver diseases, nephrotic syndrome, chronic glomerulonephritis, cachexia, burns, chronic infections and inflammatory states, myeloma

ALDOSTERONE - Discontinue antihypertensives and diuretics 2 wk prior to test. Upright samples should be drawn after 2 h. Primarily used to screen hypertensive patients for possible Conn's syndrome (adrenal adenoma producing excess aldosterone). Collection: Green or lavender top tube

Normal:
Serum: Supine 3-10 ng/dL (SI: 0.083-0.28 nmol/L) early AM, normal sodium intake [3 g sodium/d] Upright 5-30 ng/dL (SI: 0.138-0.83 nmol/L)
Urinary 2-16 mg/24 h (SI: 5.4-44.3 nmol/d)

Increased: Primary hyperaldosteronism, secondary hyperaldosteronism (congestive heart failure (CHF), sodium depletion, nephrotic syndrome, cirrhosis with ascites, others), upright posture

Decreased: Adrenal insufficiency, panhypopituitarism, supine posture

ALKALINE PHOSPHATASE - A fractionated alkaline phosphatase was formerly used to differentiate the origin of the enzyme in the bone from that in the liver. Replaced by the gamma-glutamyltransferase (GGT) and 5'-nucleotidase determinations. Collection: Tiger top tube; part of SMA-12

Normal: Adult 20-70 U/L, child 20-150 U/L

Increased: Increased calcium deposition in bone (hyperparathyroidism), Paget's disease, osteoblastic bone tumors (metastatic or osteogenic sarcoma), osteomalacia, rickets, pregnancy, childhood, healing fracture, liver disease such as biliary obstruction (masses, drug therapy), hyperthyroidism

Decreased: Malnutrition, excess vitamin D ingestion

ALPHA-FETOPROTEIN (AFP) 

Normal: <16 ng/mL (SI: <16 mL)
Third trimester of pregnancy maximum 550 ng/mL (SI: 550 mL)

Increased: Hepatoma (hepatocellular carcinoma), testicular tumor (embryonal carcinoma, malignant teratoma), neural tube defects (in mother's serum [spina bifida, anencephaly, myelomeningocele]), fetal death, multiple gestations, ataxia-telangiectasia, some cases of benign hepatic diseases (alcoholic cirrhosis, hepatitis, necrosis)

Decreased: Trisomy 21 (Down syndrome) in maternal serum

ALT -  ALANINE AMINOTRANSFERASE (ALAT) or SGPT

Normal: 0-35 U/L (SI: 0-0.58 mkat/L), higher in newborns 

Increased: Liver disease, liver metastasis, biliary obstruction, pancreatitis, liver congestion (ALT is more elevated than AST in viral hepatitis; AST elevated more than ALT in alcoholic hepatitis.)

AMMONIA

Normal: Adult 10-80 mg/dL (SI: 5-50 mmol/L) To convert mg/dL to mmol/L, multiply by 0.5872 

Increased: Liver failure, Reye's syndrome, inborn errors of metabolism, normal neonates (normalizes within 48 h of birth)

AMYLASE

Normal: 50-150 Somogyi units/dL (SI: 100-300 U/L) 

Increased: Acute pancreatitis, pancreatic duct obstruction (stones, stricture, tumor, sphincter spasm secondary to drugs), pancreatic pseudocyst or abscess, alcohol ingestion, mumps, parotiditis, renal disease, macroamylasemia, cholecystitis, peptic ulcers, intestinal obstruction, mesenteric thrombosis, after surgery

Decreased: Pancreatic destruction (pancreatitis, cystic fibrosis), liver damage (hepatitis, cirrhosis), normal newborns in the first year of life

ASO, ANTISTREPTOLYSIN O(ANTISTREPTOCOCCAL O) TITER (STREPTOZYME)

Normal: <200 IU/mL (Todd units) school-age children <100 IU/mL preschool and adults varies with lab 

Increased: Streptococcal infections (pharyngitis, scarlet fever, rheumatic fever, poststreptococcal glomerulonephritis), rheumatoid arthritis (RA), and other collagen diseases

AST (ASAT, ASPARTATE AMINOTRANSFERASE or SGOT) - Generally parallels changes in ALT in liver disease.

Normal: 8-20 U/L (SI: 0-0.58 mkat/L) 

Increased: acute myocardial infarction (AMI), liver disease, Reye's syndrome, muscle trauma and injection, pancreatitis, intestinal injury or surgery, factitious increase (erythromycin, opiates), burns, cardiac catheterization, brain damage, renal infarction

Decreased: Beriberi (vitamin B6 deficiency), severe diabetes with ketoacidosis, liver disease, chronic hemodialysis

AUTOANTIBODIES - Collection: Tiger top tube

Normal = negative

Antinuclear Antibody (ANA), fluorescent lupus erythematosus (FANA) - A useful screening test in patients with symptoms suggesting collagen-vascular disease, especially if titer is >1:160.

Positive: systemic lupus erythematosus (SLE), drug-induced lupus-like syndromes (procainamide, hydralazine, isoniazid, etc), scleroderma, mixed connective tissue disease (MCTD), RA, polymyositis, juvenile RA (5-20%). Low titers are also seen in non-collagen-vascular disease.

Specific Immunofluorescent ANA Patterns

Homogenous - Nonspecific, from antibodies to deoxyribonucleic protein (DNP) and native double-stranded deoxyribonucleic acid (DNA). Seen in SLE and a variety of other diseases. Antihistone is consistent with drug-induced lupus.

Speckled - Pattern seen in many connective tissue disorders. From antibodies to extractable nuclear antigen (ENA), including anti-RNP, anti-Sm, anti-PM-1, and anti-SS (Sjögren Syndrome). Anti-RNP is positive in MCTD and SLE. Anti-Sm is very sensitive for SLE. Anti-SS-A and anti-SS-B are seen in Sjögren's syndrome and subacute cutaneous lupus. The speckled pattern is also seen with scleroderma.

Peripheral Rim Pattern - From antibodies to native double-stranded DNA and DNP. Seen in SLE

Nucleolar Pattern - From antibodies to nucleolar ribonucleic acid (RNA). Positive in Sjögren's syndrome and scleroderma

Anticentromere: Scleroderma, Raynaud's disease, calcinosis cutis, Raynaud's disease, esophogeal dysmotility, syndactyly, telangiectasia (CREST) syndrome

Anti-DNA (Antidouble-stranded DNA):

SLE (but negative in drug-induced lupus), chronic active hepatitis, mononucleosis

Antimitochondrial: Primary biliary cirrhosis, autoimmune diseases such as SLE

Antineutrophil Cytoplasmic: Wegener's granulomatosis, polyarteritis nodosa, and other vasculitides

Anti-SCL 70: Scleroderma

Antismooth Muscle: Low titers are seen in a variety of illnesses; high titers (>1:100) are suggestive of chronic active hepatitis.

Sjögren Syndrome Antibody (SS-A): Sjögren syndrome, SLE, RA

Antimicrosomal: Hashimoto's thyroiditis

BASE EXCESS/DEFICIT: -2 to +2 

BICARBONATE (OR "TOTAL CO2"): 23-29 mmol/L [See CARBON DIOXIDE]

BILIRUBIN 

Normal:

Total, 0.3-1.0 mg/dL (SI: 3.4-17.1 mmol/L)
direct, <0.2 mg/dL (SI: <3.4 mmol/L)
indirect, <0.8 mg/dL (SI: <3.4 mmol/L)
To convert mg/dL to mmol/L, multiply by 17.10

Increased Total: Hepatic damage (hepatitis, toxins, cirrhosis), biliary obstruction (stone or tumor), hemolysis, fasting.

Increased Direct (Conjugated): Note: Determination of the direct bilirubin is usually unnecessary with total bilirubin levels <1.2 mg/dL (SI: 21 mmol/L) Biliary obstruction/cholestasis (gallstone, tumor, stricture), drug-induced cholestasis, Dubin-Johnson and Rotor's syndromes

Increased Indirect (Unconjugated): Note: This is calculated as total minus direct bilirubin. So-called hemolytic jaundice caused by any type of hemolytic anemia (transfusion reaction, sickle cell, etc), Gilbert's disease, physiologic jaundice of the newborn, Crigler-Najjar syndrome

Bilirubin, Neonatal ("Baby Bilirubin")

Normal levels dependent on prematurity and age in days "panic levels" usually >15-20 mg/dL (SI: >257-342 mmol/L in full-term infants) Collection: Capillary tube

Increased: Erythroblastosis fetalis, physiologic jaundice (may be due to breast-feeding), resorption of hematoma or hemorrhage, obstructive jaundice, others

BLOOD UREA NITROGEN (BUN) - Less useful measure of glomerular filtration rate (GFR) than creatinine because BUN is also related to protein metabolism

Normal:
Birth-1 year: 4-16 mg/dL (SI: 1.4-5.7 mmol/L)
1-40 years 5-20 mg/dL (SI: 1.8-7.1 mmol/L)]]
Gradual slight increase with age
To convert mg/dL to mmol/L, multiply by 0.3570 

Increased: Renal failure (including drug-induced from aminoglycosides, nonsteroidal antiinflammatory drug (NSAID)s), prerenal azotemia (decreased renal perfusion secondary to CHF, shock, volume depletion), postrenal (obstruction), gastrointestinal (GI) bleeding, stress, drugs (especially aminoglycosides)

Decreased: Starvation, liver failure (hepatitis, drugs), pregnancy, infancy, nephrotic syndrome, overhydration

BUN/CREATININE RATIO (BUN/CR) - Calculated based on serum levels

Normal: 6-20 [Mean 10]

Increased: Prerenal azotemia (renal hypoperfusion), GI bleeding, high-protein diet, ileal conduit, drugs (steroids, tetracycline)

Decreased: Malnutrition, pregnancy, low-protein diet, ketoacidosis, hemodialysis, syndrome of inappropriate antidiuretic hormone (SIADH), drugs (cimetidine)

C-PEPTIDE, INSULIN ("CONNECTING PEPTIDE") - Differentiates between exogenous and endogenous insulin production/administration. Liberated when proinsulin is split to insulin; levels suggest endogenous production of insulin

Fasting, <4.0 ng/mL (SI: <4.0 mg/L) Male >60 years, 1.5-5.0 ng/mL (SI: 1.5-5.0 mg/L) Female 1.4-5.5 ng/mL (SI: 1.4-5.5 mg/L) Collection: Tiger top tube

Decreased: Diabetes (decreased endogenous insulin), insulin administration (factitious or therapeutic), hypoglycemia

C-REACTIVE PROTEIN (CRP) - A nonspecific screen for infectious and inflammatory diseases, correlates well with erythrocyte sedimentation rate (ESR). In the first 24 h, however, ESR may be normal and CRP elevated.

Normal = none detected 

Increased: Bacterial infections, inflammatory conditions (acute rheumatic fever, acute RA, mitral insufficiency (MI), transplant rejection, embolus, inflammatory bowel disease), last half of pregnancy, oral contraceptives, some malignancies

CA 15-3 - Used to detect breast cancer recurrence in asymptomatic patients and monitor therapy. Levels related to stage of disease

Increased: Progressive breast cancer, benign breast disease and liver disease

Decreased: Response to therapy (25% change considered significant)

CA 19-9 - Primarily used to determine resectability of pancreatic cancers (ie, >1000U/mL 95% unresectable)

Normal: <37 U/ml (SI: <37 kU/L) 

Increased: GI cancers such as pancreas, stomach, liver, colorectal, hepatobiliary, some cases of lung and prostate, pancreatitis

CA-125 - Not a useful screening test for ovarian cancer when used alone; best used in conjunction with ultrasound and physical examination. Rising levels after resection predictive for recurrence

Normal: <35 U/mL (SI: <35 kU/L)

Increased: Ovarian, endometrial, and colon cancer; endometriosis; inflammatory bowel disease; pelvic inflammatory disease (PID); pregnancy; breast lesions; and benign abdominal masses (teratomas)

CALCITONIN (THYROCALCITONIN)

Normal: <19 pg/mL (SI: <19 ng/L)

Increased: Medullary carcinoma of the thyroid, C-cell hyperplasia (precursor of medullary carcinoma), small (oat) cell carcinoma of the lung, newborns, pregnancy, chronic renal insufficiency, Zollinger-Ellison syndrome, pernicious anemia.

CALCIUM, SERUM

Normal:
Infants to 1 month: 7-11.5 mg/dL (SI: 1.75-2.87 mmol/L)
1 month to 1 year: 8.6-11.2 mg/dL (SI: 2.15-2.79 mmol/L)
>1 year and adults: 8.2-10.2 mg/dL (SI: 2.05-2.54 mmol/L)
Ionized: 4.75-5.2 mg/dL (SI: 1.19-1.30 mmol/L)
To convert mg/dL to mmol/L, multiply by 0.2495

When interpreting a total calcium value, albumin must be known. If it is not within normal limits, a corrected calcium can be roughly calculated by the following formula. Values for ionized calcium need no special corrections.

Corrected total Ca = 0.8 (Normal albumin + Measured albumin) + Reported Ca

Increased: (Note: Levels >12 mg/dL [2.99 mmol/L] may lead to coma and death) Primary hyperparathyroidism, PTH-secreting tumors, vitamin D excess, metastatic bone tumors, osteoporosis, immobilization, milk-alkali syndrome, Paget's disease, idiopathic hypercalcemia of infants, infantile hypophosphatasia, thiazide diuretics, chronic renal failure, sarcoidosis, multiple myeloma

Decreased: (Note: Levels <7 mg/dL [ <1.75 mmol/L] may lead to tetany and death.) Hypoparathyroidism (surgical, idiopathic), pseudo-hypoparathyroidism, insufficient vitamin D, calcium and phosphorus ingestion (pregnancy, osteomalacia, rickets), hypomagnesemia, renal tubular acidosis, hypoalbuminemia (cachexia, nephrotic syndrome, CF), chronic renal failure (phosphate retention), acute pancreatitis, factitious decrease because of low protein and albumin

CAPTOPRIL TEST - See Aldosterone and renin (plasma renin) for normal values. Used in the evaluation of renovascular hypotension, the drug is an antigiotensin-converting enzyme (ACE) inhibitor that blocks angiotensin II. Captopril is administered (25 mg IV at 8AM). Aldosterone decreases 2 h later from baseline in normals or essential hypertension but does not suppress in patients with aldosteronism. 

For renovascular hypertension, the PRA increases >12 ng/mL/h and an absolute increase of 10 ng/mL/h plus a 400% increase in PRA if pretest level <3 ng/mL/h and >150% over baseline if the pretest PRA was >3 ng/mL/h. Test now also combined with nuclear renal scan to identify renal artery stenosis

CARBON DIOXIDE ("TOTAL CO2" OR BICARBONATE)

Adult 23-29 mmol/L, child 20-28 mmol/L (See Chapter 8 for pCO2 values).

Increased: Compensation for respiratory acidosis (emphysema) and metabolic alkalosis (severe vomiting, primary aldosteronism, volume contraction, Bartter's syndrome)

Decreased: Compensation for respiratory alkalosis, and metabolic acidosis (starvation, diabetic ketoacidosis, lactic acidosis, alcoholic ketoacidosis, toxins [methanol, ethylene glycol, paraldehyde], severe diarrhea, renal failure, drugs [salicylates, acetazolamide], dehydration, adrenal insufficiency)

CARBOXYHEMOGLOBIN (CARBON MONOXIDE)

Normal:
Nonsmoker: <2%;
Smoker: <9%; toxic >15%

Increased: Smokers, smoke inhalation, automobile exhaust inhalation, normal newborns

CARCINOEMBRYONIC ANTIGEN (CEA) - Not a screening test; useful for monitoring response to treatment and tumor recurrence of adenocarcinomas of the GI tract.

Normal:
Nonsmoker: <3.0 ng/mL (SI: <3.0 g/L)
Smoker: <5.0 ng/mL (SI: <5.0 g/L)

Increased: Carcinoma (colon, pancreas, lung, stomach), smokers, nonneoplastic liver disease, Crohn's disease, and ulcerative colitis

CATECHOLAMINES, FRACTIONATED SERUM - Values vary and depend on the lab and method of assay used. Normal levels shown here are based on a high-pressure liquidchromatography (HPLC) technique. Patient must be supine in a nonstimulating environment with IV access to obtain sample. 

Increased: Pheochromocytoma, neural CREST tumors (neuroblastoma), with extra-adrenal pheochromocytoma, norepinephrine may be markedly elevated compared with epinephrine.

CHLORIDE, SERUM

Normal: 97-107 mEq/L (SI: 97-107 mmol/L) 

Increased: Diarrhea, renal tubular acidosis, mineralocorticoid deficiency, hyperalimentation, medications (acetazolamide, ammonium chloride)

Decreased: Vomiting, diabetes mellitus with ketoacidosis, mineralocorticoid excess, renal disease with sodium loss

CHOLESTEROL

Total Normal - See Table 4-1; See also LIPID PROFILE/CHOLESTEROL SCREENING, and Figure 4-4. See also under "Lipoproteins" - Figure 4-4. To convert mg/dL to mmol/L, multiply by 0.02586 

Increased: Idiopathic hypercholesterolemia, biliary obstruction, nephrosis, hypothyroidism, pancreatic disease (diabetes), pregnancy, oral contraceptives, hyperlipoproteinemia (types IIb, III, V)

Decreased: Liver disease (hepatitis, etc), hyperthyroidism, malnutrition (cancer, starvation), chronic anemias, steroid therapy, lipoproteinemias, AMI

Normal Total Cholesterol Levels by Age

High-Density Lipoprotein Cholesterol (HDL), (HDL-C) - HDL-C has the best correlation with the development of coronary arery disease (CAD); decreased HDL-C in males leads to an increased risk. Levels <45 mg/dL associated with increased risk of CAD

Fasting 30-70 mg/dL (SI: 0.8-1.80 mmol/L) Female 30-90 mg/dL (SI: 0.80-2.35)

Increased: Estrogen (females), regular exercise, small ethanol intake, medications (nicotinic acid, gemfibrozil, others)

Decreased: Males, smoking, uremia, obesity, diabetes, liver disease, Tangier disease

Low-Density Lipoprotein Cholesterol (LDL), (LDL-C)

Normal: 50-190 mg/dL (SI: 1.30-4.90 mmol/L)

Increased: Excess dietary saturated fats, MI, hyperlipoproteinemia, biliary cirrhosis, endocrine disease (diabetes, hypothyroidism)

Decreased: Malabsorption, severe liver disease, abetalipoproteinemia

CLOSTRIDIUM DIFFICILE TOXIN ASSAY, FECAL - Majority of patients with pseudomembranous colitis have positive C. difficile assay. Often positive in antibiotic associated diarrhea and colitis. Can be seen in some normals and neonates

Normal negative

COLD AGGLUTININS - Most frequently used to screen for atypical pneumonias.

Normal: <1:32 Collection: Lavender or blue top tube

Increased: Atypical pneumonia (mycoplasmal pneumonia), other viral infections (especially mononucleosis, measles, mumps), cirrhosis, parasitic infections, Waldenström's macroglobulinemia, lymphomas and leukemias, multiple myeloma

COMPLEMENT - Complement describes a series of sequentially reacting serum proteins that participate in pathogenic processes and lead to inflammatory injury. 

• Complement C3 - Decreased levels suggest activation of the classical or alternative pathway, or both.

Normal: 85-155 mg/dL, (SI: 800-1500 ng/L)

Increased: RA (variable finding), rheumatic fever, various neoplasms (gastrointestinal, prostate, others), acute viral hepatitic, MI, pregnancy, amyloidosis

Decreased: SLE, glomerulonephritis (poststreptococcal and membranoproliferative), sepsis, subacute bacterial endocarditis (SBE), chronic active hepatitis, malnutrition, disseminated intravascular coagulation (DIC), gram-negative sepsis

• Complement C4

Normal: 20-50 mg/dL (SI: 200-500 ng/L)

Increased: RA (variable finding), neoplasia (gastrointestinal, lung, others)

Decreased: SLE, chronic active hepatitis, cirrhosis, glomerulonephritis, hereditary angioedema (test of choice).

Complement CH50 (Total) - Tests for complement deficiency in the classical pathway.

Normal: 33-61 mg/mL (SI: 330-610 ng/L)

Increased: Acute-phase reactants (tissue injury, infections, etc)

Decreased: Hereditary complement deficiencies

CORTISOL, SERUM

Normal: 8 AM, 5.0-23.0 mg/dL (SI: 138-365 nmol/L) 4 PM, 3.0-15.0 mg/dL (SI: 83-414 nmol/L) 

Increased: Adrenal adenoma, adrenal carcinoma, Cushing's disease, nonpituitary ACTH-producing tumor, steroid therapy, oral contraceptives

Decreased: Primary adrenal insufficiency (Addison's disease), congenital adrenal hyperplasia, Waterhouse-Friderichsen syndrome, ACTH deficiency

COUNTERIMMUNOELECTROPHORESIS (CIEP, counterimmunoelectrophoresis (CEP) - An immunologic technique that allows for rapid identification of infecting organisms from fluids, including serum, urine, cerebrospinal fluid, colony stimulating factor (CSF) and other body fluids. Organisms identified include Neisseria meningitidis, Streptococcus pneumoniae, Haemophilus influenzae, and group B Streptococcus.

Normal = negative

CREATINE PHOSPHOKINASE (KINASE) (cerebral palsy = CP / creatinine phosphokinase = CPK - Used in suspected MI or muscle diseases. Heart, skeletal muscle, and brain have high levels

Normal: 25-145 mU/mL (SI: 25-145 U/L) 

Increased: Muscle damage (AMI, myocarditis, muscular dystrophy, muscle trauma [including injections], after surgery), brain infarction, defibrillation, cardiac catheterization and surgery, rhabdomyolysis, polymyositis, hypothyroidism

CPK Isoenzymes:

• MB: Normal: <6%, heart origin
  Increased in AMI (begins in 2-12 h, peaks at 12-40 h, returns to normal in 24-72 h), pericarditis with myocarditis, rhabdomyolysis, crush injury, Duchenne's muscular dystrophy, polymyositis, malignant hyperthermia and cardiac surgery

• MM: Normal: 94-100%, skeletal muscle origin)
  Increased in crush injury, malignant hyperthermia, seizures, IM injections

• BB: Normal: 0%, brain origin)
  Increased in brain injury (cerebrovascular accident, costovertebral angle (CVA), trauma), metastatic neoplasms (prostate), malignant hyperthermia, colonic infarction

CREATININE, SERUM - A clinically useful estimate of GFR. As a rule of thumb, serum creatinine doubles with each 50% reduction in the GFR. Refer to Creatine clearance.

Normal:
Adult male <1.2 mg/dL (SI: 106 mmol/L)
Adult female <1.1 mg/dL (SI: 97 mmol/L)
Child 0.5-0.8 mg/dL (SI: 44-71 mmol/L)
To convert mg/dL to mol/L, multiply by 88.40

Increased: Renal failure (prerenal, renal, or postrenal obstruction or medication-induced [aminoglycosides, NSAIDs, others]), gigantism, acromegaly, ingestion of roasted meat, false-positive with DKA

Decreased: Pregnancy, decreased muscle mass, severe liver disease

CRYOGLOBULINS (CRYOCRIT) - These abnormal proteins precipitate out of serum at low temperatures. Cryocrit - a quantitative measure - is preferred over the qualitative method. Should be collected in nonanticoagulated tubes and transported at body temperature. Positive samples can be analyzed for immunoglobulin class, and light-chain type on request. Collection: Tiger top tube, process immediately

Normal: 0.4% (or negative if qualitative) ·

Monoclonal: Multiple myeloma, Waldenström's macroglobulinemia, lymphoma, chronic lymphocytic leukemia (CLL)

Mixed Polyclonal or Mixed Monoclonal: Infectious diseases (viral, bacterial, parasitic), such as SBE or malaria; SLE; RA; essential cryoglobulinemia; lymphoproliferative diseases; sarcoidosis; chronic liver disease (cirrhosis)

CYTOMEGALOVIRUS (CMV) ANTIBODIES - Used in neonates (CMV is the most common intrauterine infection), posttransfusion CMV infection, and organ donors and recipients. Most of adults will have detectable titers.

Normal: IgM <1:8, IgG <1:16 

Increased: Serial measurements 10-14 days apart with a 4× increase in titers or a single IgM >1:8 is suspicious for acute infection. Universally increased titers in acquired immunodeficiency syndrome (AIDS). IgM most useful in neonatal infections

  D to H

DEHYDROEPIANDROSTERONE (DHEA)

Normal:

Male 2.0-3.4 ng/mL (SI: 5.2-8.7 mmol/L) Female: Premenopausal: 0.8-3.4 ng/mL (SI: 2.1-8.8 mmol/L) Postmenopausal 0.1-0.6 ng/mL (SI: 0.3-1.6 mmol/L)

Increased: Anovulation, polycystic ovaries, adrenal hyperplasia, adrenal tumors

Decreased: Menopause

DEHYDROEPIANDROSTERONE SULFATE (DHEAS) 

Normal: Male 1.7-4.2 ng/mL (SI: 6-15 mmol/L) Female 2.0-5.2 ng/mL (SI: 7-18 mmol/L)

Increased: Hyperprolactinemia, adrenal hyperplasia, adrenal tumor, polycystic ovaries, lipoid ovarian tumors

Decreased: Menopause

DEXAMETHASONE SUPPRESSION TEST - Used in the differential diagnosis of Cushing's syndrome (elevated cortisol)

Overnight Test: In the "rapid" version of this test, a patient takes 1 mg of dexamethasone by mouth -per os- (PO) at 11 PM and a fasting 8 AM plasma cortisol is obtained. Normally the cortisol level should be <5.0 mg/dL [138 nmol/L]. A value that is >5 mg/dL [138 nmol/L] usually confirms the diagnosis of Cushing's syndrome; however, obesity, alcoholism, or depression may occasionally show the same result. In these patients, the best screening test is a 24-h urine for free cortisol.

Low-Dose Test: After collection of baseline serum cortisol and 24-h urine-free cortisol levels, dexamethasone 0.5 mg is administered PO every 6 h for eight doses. Serum and urine cortisol are repeated on the second day. Failure to suppress to a serum cortisol of <5.0 mg/dL [138 nmol/L] and a urine-free cortisol of <30 g/dL (82 nmol/L) confirms Cushing's syndrome.

High-Dose Test: After the low-dose test, dexamethasone, 2 mg PO every 6 h for eight doses will cause a fall in urinary-free cortisol to 50% of the baseline value in bilateral adrenal hyperplasia (Cushing's disease) but not in adrenal tumors or ectopic ACTH production.

ERYTHROPOIETIN (EPO) - EPO is a renal hormone that stimulates red blood cell (RBC) production. 

Normal: 5-36 mU/L (5-36 IU/L)

Increased: Pregnancy, secondary polycythemia (high altitude, chronic obstructive pulmonary disease (COPD), etc), tumors (renal cell carcinoma, cerebellar hemangioblastoma, hepatoma, others), polycystic kidney disease (PCKD), anemias with bone marrow unresponsiveness (aplastic anemia, iron deficiency, etc)

Decreased: Bilateral nephrectomy, anemia of chronic disease (ie, renal failure, nephrotic syndrome), primary polycythemia (Note: The determination of EPO levels before administration of recombinant EPO for renal failure is not usually necessary.)

ESTRADIOL, SERUM - Serial measurements useful in assessing fetal well-being especially in high-risk pregnancy. Also useful in evaluation of amenorrhea and gynecomastia in males. 

ESTROGEN/PROGESTERONE RECEPTORS - These are typically determined on fresh surgical (breast cancer) specimens. The presence of the receptors is associated with a longer disease-free interval, survival from breast cancer, and increased likelihood of responding to endocrine therapy. Fifty to seventy-five percent of breast cancers are estrogen-receptor-positive.

ETHANOL (BLOOD ALCOHOL)

Normal: 0 mg/dL (0 mmol/L) Collection: Tiger top tube; do not use alcohol to clean venipuncture site, use povidone-iodine

Physiologic changes can vary with degree of alcohol tolerance of an individual:

<50 mg/dL [ <10.85 mmol/L]: Limited muscular incoordination 50-100 [10.85-21.71]: Pronounced incoordination 100-150 [21.71-32.57]: Mood and personality changes; legally intoxicated in most states 150-400 [32.57-87]: Nausea, vomiting, marked ataxia, amnesia, dysarthria 400: Coma, respiratory insufficiency and death

FECAL FAT

Normal: 2-6 g/d on an 80-100 g/d fat diet 72-h collection time Sudan III stain, random <60 droplets fat/hpf

Increased: CF, pancreatic insufficiency, Crohn's disease, chronic pancreatitis, sprue

FERRITIN

Normal: Male 15-200 ng/mL (SI: 15-200 mg/L) Female 12-150 ng/mL (SI: 12-150 mg/L) 

Increased: Hemochromatosis, hemosiderosis, sideroblastic anemia

Decreased: Iron deficiency (earliest and most sensitive test before red cells show any morphologic change), severe liver disease

FOLIC ACID - Serum folate can fluctuate with diet. RBC levels are more indicative of tissue stores. Vitamin B12 deficiency can result in the RBC unable to take up folate in spite of normal serum folate levels.

Serum Folate = >2.0 ng/mL (SI: >5 nmol/L)

RBC = 125-600 ng/mL (283-1360 nmol/L) 

Increased: Folic acid administration

Decreased: Malnutrition/malabsorption (folic acid deficiency), massive cellular growth (cancer) or cell turnover, ongoing hemolysis, medications (trimethoprim, some anticonvulsants, oral contraceptives), vitamin B12 deficiency (low RBC levels), pregnancy

FOLLICLE-STIMULATING HORMONE (FSH) - Used in the workup of impotence, infertility in men, and amenorrhea in women. 

Normal: Males: <22 IU/L Females: nonmidcycle <20 IU/L midcycle surge <40 IU/L (Midcycle peak should be two times basal level) Postmenopausal 40-160 IU/L

Increased: (Hypergonadotropic >40 IU/L) postmenopausal, surgical castration, gonadal failure, gonadotropin-secreting pituitary adenoma

Decreased: (Hypogonadotropic <5 IU/L) prepubertal, hypothalamic and pituitary dysfunction, pregnancy

FTA-ABS, FLUORESCENT TREPONEMAL ANTIBODY ABSORBED - FTA - ABS may be negative in early primary syphilis and remain positive in spite of adequate treatment. 

Normal = nonreactive

Positive: Syphilis (test of choice to confirm diagnosis after a reactive Venereal Disease Research Laboratory (VDRL) test), other treponemal infections can cause false-positive (Lyme disease, leprosy, malaria)

FUNGAL SEROLOGIES - This is a screening technique for complement-fixed fungal antibodies, which usually detects antibodies to Histoplasma capsulatum, Blastomyces dermatitidis, Cryptococcus neoformans, Aspergillus species, Candida species and Coccidioides immitis. 

Negative <1:8

GASTRIN, SERUM - Make sure patient is not on H2 blockers or antacids. 

Normal: Fasting <100 pg/mL (SI: 47.7 pmol/L) Postprandial 95-140 pg/mL (SI: 45.3-66.7 pmol/L)

Increased: Zollinger-Ellison syndrome, medications (antacids, cimetidine, others) pyloric stenosis, pernicious anemia, atrophic gastritis, ulcerative colitis, renal insufficiency, and steroid and calcium administration

Decreased: Vagotomy and antrectomy

GGT (SERUM GAMMA-GLUTAMYL TRANSPEPTIDASE [SGGT]) - Generally parallels changes in serum alkaline phosphatase and 5'-nucleotidase in liver disease. Sensitive indicator of alcoholic liver disease. 

Male 9-50 U/L Female 8-40 U/L

Increased: Liver disease (hepatitis, cirrhosis, obstructive jaundice), pancreatitis.

GLUCOSE 

Normal: Fasting = 70-105 mg/dL (SI: 3.89-5.83 nmol/L) 2 h postprandial = <140 mg/dL (SI: <7.8 nmol/L) To convert mg/dL to nmol/L, multiply by 0.05551

American Diabetes Association Diagnostic Criterion for Diabetes: Normal fasting = <110 Impaired fasting = 110-126 Diabetes = n>126 or any random level >200 when associated with other symptoms. Confirm with repeat testing.

Increased: Diabetes mellitus, Cushing's syndrome, acromegaly, increased epinephrine (injection, pheochromocytoma, stress, burns, etc), acute pancreatitis, ACTH administration, spurious increase caused by drawing blood from a site above an IV line containing dextrose, elderly patients, pancreatic glucagonoma, drugs (glucocorticoids, some diuretics)

Decreased: Pancreatic disorders (pancreatitis, islet cell tumors), extrapancreatic tumors (carcinoma of the adrenals, stomach), hepatic disease (hepatitis, cirrhosis, tumors), endocrine disorders (early diabetes, hypothyroidism, hypopituitarism), functional disorders (after gastrectomy), pediatric problems (prematurity, infant of a diabetic mother, ketotic hypoglycemia, enzyme diseases), exogenous insulin, oral hypoglycemic agents, malnutrition, sepsis

GLUCOSE TOLERANCE TEST (GTT), ORAL (OGTT)

A fasting plasma glucose level >126 mg/dl (7.0 mmol/L) or a casual plasma glucose -200 mg/dL (11.1 mmol/L) meets the threshold for the diagnosis of diabetes, if confirmed on a subsequent day, and precludes the need for any glucose challenge. GTT is usually unnecessary to diagnose asymptomatic diabetes mellitus; it may be useful in gestational diabetes. The GTT is unreliable in the presence of severe infection, prolonged fasting, or after the injection of insulin. After an overnight fast, a fasting blood glucose is drawn, and the patient is given a 75-g oral glucose load (100 g for gestational diabetes screening, 1.75 mg/kg ideal body weight in children up to a dose of 75 g). Plasma glucose is then drawn at 30, 60, 120, and 180 min.

Interpretation of GTT:

Adult-Onset Diabetes: Any fasting blood sugar >126, or >200 at both 120 min and one other time interval measured

Gestational Diabetes: Any fasting blood sugar >126, 60 min >180, 120 min >155, 180 min >140

GLYCOHEMOGLOBIN (growth hormone -b- (GHB), GLYCATED HEMOGLOBIN, GLYCOHEMOGLOBIN, hepatitis B virus (HBA)1c, HBA1 HEMOGLOBIN A1c, GLYCOSYLATED HEMOGLOBIN) - Useful in long-term monitoring control of blood sugar in diabetics; reflects levels over preceding 3-4 months. Glycated serum protein (GSP) under study and may reflect serum glucose over the preceding 1-2 weeks. 

4.6-7.1% or new standard: Nondiabetic = <6 Near Normal = 6-7 Excellent glucose control = 7-8 Good control = 8-9 Fair control = 9-10 Poor control = >10

Increased: Diabetes mellitus (uncontrolled), lead intoxication

Decreased: Chronic renal failure, hemolytic anemia, pregnancy, chronic blood loss

HAPTOGLOBIN - Collection: Tiger top tube

Normal: 40-180 mg/dL (SI: 0.4-1.8 g/L)

Increased: Obstructive liver disease, any cause of increased ESR (inflammation, collagen-vascular diseases)

Decreased: Any type of hemolysis (transfusion reaction, etc), liver disease, anemia, oral contraceptives, children and infants

HELICOBACTER PYLORI ANTIBODY TITERS - Most patients with gastritis and ulcer disease (gastric or duodenal) have chronic H. pylori infection that should be treated. Positive in 35-50% asymptomatic patients (increases with age). Use in dyspepsia controversial. Four diagnostic methods are available to test for H. pylori, the organism associated with gastritis and ulcers. These include noninvasive (serology and a 13C breath test) and invasive (gastric mucosal biopsy and the Campylobacter-like organism test). The IgG subclass is found in all patient populations; occasionally only IgA antibodies can be detected. Serology is most useful in the evaluation of newly diagnosed H. pylori infection or in monitoring response to therapy. IgG levels decrease slowly after treatment, but can remain elevated after clearing infection.

Negative: IgG <0.17

Positive: Active or recent H. pylori infection, some asymptomatic carriers

HEPATITIS TESTING - Profile patterns of hepatitis A and B are shown in Figures 4-1 and 4-2, respectively. Recommended hepatitis panel tests based on clinical settings is shown in tables below

Hepatitis A diagnostic profile

(Courtesy of Abbott Laboratories, Chicago, Illinois)

Hepatitis B diagnostic profile. (Courtesy of Abbott Laboratories, North Chicago, Illinois)

Hepatitis Tests

Hepatitis A

Anti-hepatitis A virus (HAV) Ab: Total antibody to hepatitis A virus; confirms previous exposure to hepatitis A virus, elevated for life.

Anti-HAV IgM: IgM antibody to hepatitis A virus; indicative of recent infection with hepatitis A virus; declines typically 1-6 months after symptoms

Hepatitis B

HBsAg: Hepatitis B surface antigen. Earliest marker of HBV infection. Indicates either chronic or acute infection with hepatitis B virus. Used by blood banks to screen donors; vaccination does not affect this test

Anti-HBc-Total: IgG and IgM antibody to hepatitis B core antigen; confirms either previous exposure to hepatitis B virus (HBV) or ongoing infection. Used by blood banks to screen donors

Anti-HBc IgM: IgM antibody to hepatitis B core antigen. Early and best indicator of acute infection with hepatitis B

HBeAg: Hepatitis Be antigen; when present, indicates high degree of infectivity. Order only when evaluating for chronic HBV infection

HBV-DNA: Most sensitive and specific for early evaluation of hepatitis B and may be detected when all other markers are negative

Anti-HBe: Antibody to hepatitis Be antigen; associated with resolution of active inflammation

Anti-HBs: Antibody to hepatitis B surface antigen; when present, typically indicates immunity associated with clinical recovery from HBV infection or previous immunization with hepatitis B vaccine. Order only to assess effectiveness of vaccine and request titer levels

Anti-HDV: Total antibody to delta hepatitis; confirms previous exposure. Order only in patients with known acute or chronic HBV infection.

Anti-HDV IgM: IgM antibody to delta hepatitis; indicates recent infection. Order only in cases of known acute or chronic HBV infection

Hepatitis C

Anti-HCV: Antibody against hepatitis C. Indicative of active viral replication and infectivity. Used by blood banks to screen donors. Many false-positives

HCV-RNA: Nucleic acid probe detection of current HCV infection

HIGH-DENSITY LIPOPROTEIN CHOLESTEROL - See CHOLESTEROL.

HLA, HUMAN LEUKOCYTE ANTIGENS; HLA TYPING - This test identified a group of antigens on the cell surface that are the primary determinants of histocompatibility and useful in assessing transplantation compatibility. Some are associated with specific diseases but are not diagnostic of these diseases. 

HLA-B27: Ankylosing spondylitis, psoriatic arthritis, Reiter's syndrome, juvenile RA

HLA-DR4/HLA DR2: Chronic Lyme disease arthritis

HLA-DRw2: multiple sclerosis (MS)

HLA-B8: Addison's disease, juvenile-onset diabetes, Grave's disease, gluten-sensitive enteropathy

HOMOCYSTEINE, SERUM - Under investigation as a risk factor for CAD and atherosclerosis. Moderate, intermediate, and severe hyperhomocystinemia refer to concentrations between 16 and 30, between 31 and 100, and >100 mol/L, respectively. May be useful to screen high-risk patients and recommend strategies to obtain target of <10 (ie, dietary, lifestyle changes, vitamin supplementation)

Normal fasting 5 and 15 mol/L Fasting target <10 mol/L

Increased: Vitamin B12, B6 and folate deficiency, kidney and renal failure, medications (nicotinic acid, theophylline, methotrexate, L-dopa, anticonvulsants) advanced age, hypothyroidism, impaired kidney function, SLE, and certain medications

HUMAN CHORIONIC GONADOTROPIN, SERUM (HCG), (BETA SUBUNIT)

Normal = <3.0 mIU/mL 10 days after conception = >3 mIU/mL 30 days = 100-5000 mIU/mL 10 weeks = 50,000-140,000 mIU/mL >16 weeks = 10,000-50,000 mIU/mL Thereafter, levels slowly decline (SI units IU/L equivalent to mIU/mL) 

Increased: Pregnancy, some testicular tumors (nonseminomatous germ cell tumors, but not seminoma), trophoblastic disease (hydatidiform mole, choriocarcinoma levels usually >100,000 mIU/mL)

HUMAN IMMUNODEFICIENCY VIRUS (HIV) TESTING - See Figure 4-3 centers for disease control and prevention (CDC) guidelines. Any HIV-positive person over 13 years of age with a CD4+ T-cell level <200/mL or an HIV-positive patient with a series of CDC-defined indicator conditions (eg, pulmonary candidiasis, disseminated histoplasmosis, HIV wasting, Kaposi's sarcoma, tuberculosis (TB), various lymphomas, pneumocystis carinii pneumonia, phencyclidine (PCP), and others) is considered to have AIDS.

Diagnostic algorithm for HIV infection. (Courtesy of Burroughs-Wellcome, North Carolina)

HIV Antibody - Assay kits recognize both HIV-1 and HIV-2 antibodies. Used in the diagnosis of AIDS and to screen blood for use in transfusion. Antibodies appear in blood 1-4 mo after infection in most cases. 

Normal = negative

HIV Antibody, enzyme-linked immunosorbent assay (ELISA) - Initial screen to detect HIV antibody; a positive test is often repeated or confirmed by Western blot.

Normal = negative

Positive: AIDS, asymptomatic HIV infection

False-Positive: Flu vaccine within 3 months, hemophilia, rheumatoid factor, alcoholic hepatitis, dialysis patients

HIV Western Blot - The technique is used as the reference procedure for confirming the presence or absence of HIV antibody, usually after a positive

Normal = negative

HIV Antibody by ELISA Determination

Positive: AIDS, asymptomatic HIV infection (if indeterminate, repeat in 1 mo or perform polymerase chain reaction (PCR) for HIV-1 DNA or RNA)

False-Positive: Autoimmune or connective tissue diseases, hyperbilirubinemia, HLA antibodies, others

HIV DNA PCR - Performed on peripheral blood mononuclear cells. Preferred test to diagnose HIV infection in children <18 months of age

Normal = negative

HIV RNA PCR - Used to quantify plasma "viral load." Establishes the diagnosis before antibody production begins or when HIV antibody test is indeterminate. Obtained at baseline diagnosis, serves as an important parameter to initiate or modify HIV therapy (see the following details of viral load). Not recommended for routine testing of children <18 months

Normal = <400 copies/mL

HIV VIRAL LOAD - Single best predictor of progression to AIDS and death among HIV-infected individuals. Also used as a baseline and for initiation and modification of HIV therapy, but not for diagnosis. For example, antiretroviral therapy is uniformly initiated when the viral load is >20,000 copies/mL RNA or rubella titer, respiratory therapy, radiation therapy (RT) PCR.

Normal <50 copies/mL

HIV Antigen (P-24 antigen) - Detects early HIV infection before antibody conversion, used along with PCR testing

Normal = negative

I to Z

IMMUNOGLOBULINS, QUANTITATIVE - Levels are determined in the evaluation of immunodeficiency diseases, during replacement therapy, and to evaluate humoral immunity. 

IgG: 65-1500 mg/dL or 6.5-15 g/L IgM: 40-345 mg/dL or 0.4-3.45 mg/L IgA: 76-390 mg/dL or 0.76-3.90 g/L IgE: 0-380 IU/mL or KIU/L IgD: 0-8 mg/dL or 0-80 mg/L

Increased: Multiple myeloma (myeloma immunoglobulin increased, other immunoglobulins decreased); Waldenström's macroglobulinemia (IgM increased, others decreased); lymphoma; carcinoma; bacterial infection; liver disease; sarcoidosis; amyloidosis; myeloproliferative disorders

Decreased: Hereditary immunodeficiency, leukemia, lymphoma, nephrotic syndrome, protein-losing enteropathy, malnutrition

IRON 

Normal: Males 65-175 mg/dL (SI: 11.64-31.33 mmol/L) Females 50-170 mg/dL (SI: 8.95-30.43 mmol/L) To convert mg/dL to mmol/L, multiply by 0.1791

Increased: Hemochromatosis, hemosiderosis caused by excessive iron intake, excess destruction or decreased production of erythrocytes, liver necrosis

Decreased: Iron deficiency anemia, nephrosis (loss of iron-binding proteins), normochromic anemia of chronic diseases and infections

IRON-BINDING CAPACITY, TOTAL (TIBC) - The normal iron/TIBC ratio is 20-50%. Decreased ratio ( <10%) is almost diagnostic of iron deficiency anemia. Increased ratio is seen with hemochromatosis. 

250-450 mg/dL (SI: 44.75-80.55 mmol/L)

Increased: Acute and chronic blood loss, iron deficiency anemia, hepatitis, oral contraceptives

Decreased: Anemia of chronic diseases, cirrhosis, nephrosis/uremia, hemochromatosis, iron therapy overload, hemolytic anemia, aplastic anemia, thalassemia, megaloblastic anemia

LACTATE DEHYDROGENASE (LD, LDH) - Collection: Tiger top tube; carefully avoid hemolysis because this can increase LDH levels

Adults <230 U/L, ( <3.82 mkat/L) Higher levels in childhood

Increased: AMI, cardiac surgery, prosthetic valve, hepatitis, pernicious anemia, malignant tumors, pulmonary embolus, hemolysis (anemias or factitious), renal infarction, muscle injury. megaloblastic anemia, liver disease

LDH Isoenzymes (LDH 1 to LDH 5)

Normally, the ratio LDH 1/LDH 2 is <0.6-0.7. If the ratio becomes >1 (also termed "flipped"), suspect a recent MI (change in ratio can also be seen in pernicious or hemolytic anemia). With an AMI, the LDH will begin to rise at 12-48 h, peak at 3-6 days, and return to normal at 8-14 days. LDH 5 is >LDH 4 in liver diseases. (Largely replaced by troponin.)

LACTIC ACID (LACTATE) - Suspect lactic acidosis with elevated anion gap in the absence of other causes (renal failure, ethanol or methanol ingestion). 

4.5-19.8 mg/dL (SI: 0.5-2.2 mmol/L)

Increased: Lactic acidosis due to hypoxia, hemorrhage, shock, sepsis, cirrhosis, exercise, ethanol, DKA, regional ischemia (extremity, bowel) spurious (prolonged use of a tourniquet)

LAP SCORE (LEUKOCYTE ALKALINE PHOSPHATASE SCORE/STAIN) - Used to differentiate among various hematologic conditions. 

Normal: 50-150

Increased: Leukemoid reaction, acute inflammation, Hodgkin's disease, pregnancy, liver disease

Decreased: Chronic myelogenous leukemia, nephrotic syndrome

LUPUS ERYTHEMATOSUS (LE), PREPARATION

Normal = no cells seen

Positive: SLE, scleroderma, RA, drug-induced lupus (procainamide, others)

LEAD, BLOOD - Neurologic findings can be detected at 15 mg/dL in children and 30 mg/dL in adults; severe symptoms (lethargy, ataxia, coma) are present >60 mg/dL. 

Adult <40 mg/dL (1.93 mmol/L) Child <25 mg/dL (1.21 mmol/L)

Increased: Lead poisoning, occupational exposure

LEGIONELLA ANTIBODY - Obtain two sera, acute (within 2 wk of onset) and convalescent (at least 3 wk after onset of fever). A fourfold rise in titers or a single titer of 1:256 is diagnostic.

Normal: <1:32 titers

Increased: Legionella infection; false-positives with Bacteroides fragilis, Francisella tularensis, Mycoplasma pneumoniae.

LIPASE

Normal: 0-1.5 U/mL (SI: 10-150 U/L) by turbidimetric method 

Increased: Acute or chronic pancreatitis, pseudo-cyst, pancreatic duct obstruction (stone, stricture, tumor, drug-induced spasm), fat embolus syndrome, renal failure, dialysis (usually normal in mumps) gastric malignancy, intestinal perforation, diabetes (usually in DKA only)

LIPID PROFILE/LIPOPROTEIN PROFILE/LIPOPROTEIN ANALYSIS - See also CHOLESTEROL and TRIGLYCERIDES.

Usually includes cholesterol, HDL cholesterol, LDL cholesterol (calculated), triglycerides. Useful in the evaluation of CAD and allows classification of dyslipoproteinemias to direct treatment. Initial screening for cardiac risk includes total cholesterol and HDL as outlined in Figure 4-4. The main lipids in the blood are cholesterol and triglycerides. These lipids are carried by lipoproteins. Lipoproteins are further classified by density (least dense to most dense):

Chylomicrons (least dense, rise to surface of unspun serum) and are normally found only after a fatty meal is eaten (a "lipemic specimen" on a lab report usually refers to these chylomicrons).

• Very low density lipoprotein (VLDL) consist mainly of triglycerides.

• LDL in the fasting state; the LDL carry most cholesterol.

• HDL are the densest and consist of mostly apoproteins and cholesterol.

LOW-DENSITY LIPOPROTEIN-CHOLESTEROL (LDL, LDL-C) - See CHOLESTEROL.

LUTEINIZING HORMONE, SERUM (LH)

Normal: Male 7-24 IU/L Female 6-30 IU/L, midcycle peak increase two- to threefold over baseline, postmenopausal >35 IU/L 

Increased: (Hypergonadotropic >40 IU/L) postmenopausal, surgical or radiation castration, ovarian or testicular failure, polycystic ovaries

Decreased: (Hypogonadotropic <40 IU/L prepubertal) hypothalamic, and pituitary dysfunction, Kallmann's syndrome, luteininzing hormone releasing hormone (LHRH) analogue therapy

LYME DISEASE SEROLOGY - Most useful when comparing acute and convalescent serum levels for relative titers. Normal values differ among labs. IgM antibody becomes detectable 2-4 weeks after onset of rash; IgG rises in 4-6 weeks and peaks up to 6 mo after infection and may stay elevated for months to years.

Normal varies with assay, ELISA <1:8 Western blot nonreactive

Positive: Infection with Borrelia burgdorferi, syphilis, and other rickettsial diseases

Negative: After antibiotic therapy or during first few weeks of disease

MAGNESIUM 

Normal: 1.6-2.6 mg/dL (SI: 0.80-1.20 mmol/L)

Increased: Renal failure, hypothyroidism, magnesium-containing antacids, Addison's disease, diabetic coma, severe dehydration, lithium intoxication

Decreased: Malabsorption, steatorrhea, alcoholism and cirrhosis, hyperthyroidism, aldosteronism, diuretics, acute pancreatitis, hyperparathyroidism, hyperalimentation, nasogastric (NG) suctioning, chronic dialysis, renal tubular acidosis, drugs (cisplatin, amphotericin B, aminoglycosides), hungry bone syndrome, hypophosphatemia, intracellular shifts with respiratory or metabolic acidosis

METYRAPONE TEST 

MICROHEMAGGLUTINATION-TREPONEMA PALLIDUM (MHA-TP) - Confirmatory test for syphilis, similar to FTA-ABS. Once positive, remains so, therefore cannot be used to judge effect of treatment. False-positives with other treponemal infections (pinta, yaws, etc), mononucleosis, and SLE. 

Normal <1:160

B2-MICROGLOBULIN - A portion of the class I major histocompatibility complex (MHC) antigen. A useful marker to follow the progression of HIV infections

Normal: 0.1-0.26 mg/dL )1-2.6 mg/L) Collection: Tiger top tube

Increased: HIV infection, especially during periods of exacerbation, lymphoid malignancies, renal diseases (diabetic nephropathy, pyelonephritis, acute tubular necrosis (ATN), nephrotoxicity from medications), transplant rejection, inflammatory conditions

Decreased: Treatment of HIV with zidovudine (AZT)

MONOSPOT 

Normal = negative

Positive: Mononucleosis, rarely in leukemia, serum sickness, Burkitt's lymphoma, viral hepatitis, RA

MYOGLOBIN 

Normal: 30-90 ng/mL

Increased: Skeletal muscle injury (crush, injection, surgical procedures), delirium tremens, rhabdomyolysis (burns, seizures, sepsis, hypokalemia, others)

5'-NUCLEOTIDASE - Used in the workup of increased alkaline phosphatase and biliary obstruction

Normal: 2-15 U/L

Increased: Obstructive or cholestatic liver disease, liver metastasis, biliary cirrhosis

OLIGOCLONAL BANDING, CSF - This is performed simultaneously on CSF and serum samples when MS is clinically suspected. Agarose gel electrophoresis will reveal multiple bands in the IgG region not seen in the serum. Oligoclonal banding is present in up to 90% of patients with MS. Occasionally seen in other central nervous system (CNS) inflammatory conditions and CNS syphilis

Normal = negative Collection: Serum tiger top tube and simultaneous CSF sample collected in a plain tube by lumbar puncture (LP)

OSMOLALITY, SERUM - A rough estimation of osmolality is [2(Na) + BUN/2.8 + glucose/18]. Measured value is usually less than calculated value. If measured value is 15 mOsm/kg less than calculated, consider methanol, ethanol, or ethylene glycol ingestion. 

278-298 mOsm/kg (SI: 278-298 mmol/kg)

Increased: Hyperglycemia; ethanol, methanol, mannitol, or ethylene glycol ingestion; increased sodium because of water loss (diabetes, hypercalcemia, diuresis)

Decreased: Low serum sodium, diuretics, Addison's disease, SIADH (seen in bronchogenic carcinoma, hypothyroidism), iatrogenic causes (poor fluid balance)

OXYGEN - See Chapter 8, Table 8-1.

P-24 ANTIGEN (HIV CORE ANTIGEN) - Used to diagnose recent acute HIV infection; becomes positive earlier than HIV antibodies. Decreases "window" period. Can be positive as early as 2-4 weeks but becomes undetectable during antibody seroconversion (periods of latency). With progression of disease, P-24 usually becomes evident again. Used to screen blood donors. Collection: Tiger top tube See also Human Immunodeficiency Virus Testing

Normal = negative

PARATHYROID HORMONE (PTH) 

NOTE: Normal based on relationship to serum calcium, usually provided on the lab report Also, reference values vary depending on the laboratory and whether the N-terminal, C-terminal or midmolecule is measured.

PTH midmolecule: 0.29- -0.85 ng/mL (SI: 29-85 pmol/L) With calcium: 8.4-10.2 mg/dL (SI: 2.1-2.55 mmol/L)

Increased: Primary hyperparathyroidism, secondary hyperparathyroidism (hypocalcemic states, such as chronic renal failure, others)

Decreased: Hypercalcemia not due to hyperparathyroidism, hypoparathyroidism

PHOSPHORUS 

Normal: Adult 2.5-4.5 mg/dL (SI: 0.81-1.45 mmol/L) Child 4.0-6.0 mg/dL (SI: 1.29-1.95 mmol/L) To convert mg/dL to mmol/L, multiply by 0.3229

Increased: Hypoparathyroidism (surgical, pseudo-hypoparathyroidism), excess vitamin D, secondary hyperparathyroidism, renal failure, bone disease (healing fractures), Addison's disease, childhood, factitious increase (hemolysis of specimen)

Decreased: Hyperparathyroidism, alcoholism, diabetes, hyperalimentation, acidosis, alkalosis, gout, salicylate poisoning, IV steroid, glucose or insulin administration, hypokalemia, hypomagnesemia, diuretics, vitamin D deficiency, phosphate-binding antacids

POTASSIUM, SERUM 

Normal: 3.5-5 mEq/L (SI: 3.5-5 mmol/L)

Increased: Factitious increase (hemolysis of specimen, thrombocytosis), renal failure, Addison's disease, acidosis, spironolactone, triamterene, ACE inhibitors, dehydration, hemolysis, massive tissue damage, excess intake (oral or IV), potassium-containing medications, acidosis

Decreased: Diuretics, decreased intake, vomiting, nasogastric suctioning, villous adenoma, diarrhea, Zollinger-Ellison syndrome, chronic pyelonephritis, renal tubular acidosis, metabolic alkalosis (primary aldosteronism, Cushing's syndrome)

PREALBUMIN 

PROGESTERONE - Used to confirm ovulation and corpus luteum function. 

PROLACTIN - Used in the workup of infertility, impotence, hirsutism, amenorrhea and pituitary neoplasm. 

Normal:

Males 1-20 ng/mL (SI: 1-20 mg/L) Females 1-25 ng/mL (SI: 1-25 mg/L)

Increased: Pregnancy, nursing after pregnancy, prolactinoma, hypothalamic tumors, sarcoidosis or granulomatous disease of the hypothalamus, hypothyroidism, renal failure, Addison's disease, phenothiazines, haloperidol

PROSTATE-SPECIFIC ANTIGEN (PSA) - Most useful as a measure of response to therapy of prostate cancer; approved for screening for prostate cancer. Although any elevation increases suspicion of prostate cancer, levels >10.0 ng/dL are frequently associated with carcinoma. Age corrected levels gaining popularity (40-50 y 2.5 ng/dL; 50-60 y 3.5 ng/dL; 60-70 years 4.5 ng/dL; >70 years 6.5 ng/dL.)

Normal: <4 ng/dL by monoclonal - eg, Hybritech - assay

Increased: Prostate cancer, acute prostatitis, some cases of BPH, prostatic infarction, prostate surgery (biopsy, resection), vigorous prostatic massage (routine rectal exam does not elevate levels), rarely postejaculation

Decreased: Radical prostatectomy, response to therapy of prostatic carcinoma (radiation or hormonal therapy)

PSA Velocity - A rate of rise in PSA of 0.75 ng/mL or greater per year is suspicious for prostate cancer based on at least three separate assays 6 mo apart.

PSA Free and Total - Patients with prostate cancer tend to have lower free PSA levels in proportion to total PSA. Measurement of the free/total PSA can improve the specificity of PSA in the range of total PSA from 2.0-10.0 ng/mL. Some recommend prostate biopsy only if the free PSA percentage is low. Threshold for biopsy is controversial, ranging from a ratio of less than 15% to less than 25%, with a higher threshold having improved sensitivity and lower threshold having improved specificity.

PROTEIN ELECTROPHORESIS, SERUM AND URINE (SERUM PROTEIN ELECTROPHORESIS = SPEP) (URINE PROTEIN ELECTROPHORESIS = UPEP)

Qualitative analysis of the serum proteins is often used in the workup of hypoglobulinemia, macroglobulinemia, 1-antitrypsin deficiency, collagen disease, liver disease, myeloma, and occasionally in nutritional assessment. Serum electrophoresis yields five different bands (Figure 4-5 and Table 4-5. If a monoclonal gammopathy or a low globulin fraction is detected, quantitative immunoglobulins should be ordered.

Urine protein electrophoresis can be used to evaluate proteinuria and can detect Bence Jones protein (light chain) that is associated with myeloma, Waldenström's macroglobulinemia and Fanconi's syndrome.

Examples of (A) serum and (B) urine protein electrophoresis patterns. See also Table 4-5. (Courtesy of Dr. Steven Haist.)

*Access: Electrophoresis of Normal Serum Protein Components & Fractions

PROTEIN, SERUM 

Normal: 6.0-8.0 g/dL See also Serum Protein Electrophoresis.

Increased: Multiple myeloma, Waldenström's macroglobulinemia, benign monoclonal gammopathy, lymphoma, chronic inflammatory disease, sarcoidosis, viral illnesses

Decreased: Malnutrition, inflammatory bowel disease, Hodgkin's disease, leukemias, any cause of decreased albumin

RENIN - Useful in the diagnosis of hypertension associated with hypokalemia. Values highly dependent on salt intake and position. Stop diuretics, estrogens for 2-4 wk before testing.

Plasma (Plasma Renin Activity (PRA)

Adults, Normal sodium diet, upright 1-6 ng/mL/h (SI: 0.77-4.6 nmol/L/h) Renal vein renin: L & R should be equal)

Increased: Medications (ACE inhibitors, diuretics, oral contraceptives, estrogens), pregnancy, dehydration, renal artery stenosis, adrenal insufficiency, chronic hypokalemia, upright posture, salt-restricted diet, edematous conditions (CHF, nephrotic syndrome), secondary hyperaldosteronism

Decreased: Primary aldosteronism (renin will not increase with relative volume depletion, upright posture)

Renal Vein

Normal L & R should be equal

A ratio of >1.5 (affected/nonaffected) suggestive of renovascular hypertension

RETINOL-BINDING PROTEIN (RBP) 

Normal: Adults 3-6 mg/dL Children 1.5-3.0 mg/dL

Decreased: Malnutrition, vitamin A deficiency, intestinal malabsorption of fats, chronic liver disease

RHEUMATOID FACTOR (RA LATEX TEST) 

Normal: <15 IU by Microscan kit or <1:40

Increased: Collagen-vascular diseases (RA, SLE, scleroderma, polyarteritis nodosa, others), infections (TB, syphilis, viral hepatitis), chronic inflammation, SBE, some lung diseases, MI

ROCKY MOUNTAIN SPOTTED FEVER ANTIBODIES (RMSF) - The diagnosis of RMSF is made by acute and convalescent titers that demonstrate a 4× rise or a single convalescent titer >1:64 in the clinical setting of RMSF. Occasional false-positives in late pregnancy. 

Normal: <4(times) increase in paired acute and convalescent sera IgG <1:64 IgM <1:8

SEMEN ANALYSIS - Specimen must be collected after 48-72 h abstinence and analyzed within 1-2 h. Test may not be valid after a recent illness or high fever. Verify abnormal analysis by serial tests.

• Volume 2-5 mL 

• Sperm count >20-40 × 106/mL 

• Motility >60% 

• Forward migration Morphology >60% normal

Decreased: After vasectomy (should be 0 sperm after 3 mo), varicocele, primary testicular failure (ie, Klinefelter's syndrome), secondary testicular failure (chemotherapy, radiation, infections),varicocele, after recent illness, congenital obstruction of the vas, retrograde ejaculation, endocrine causes (hyperprolactinemia, low testosterone, others)

SGGT (SERUM GAMMA-GLUTAMYL TRANSPEPTIDASE) - See GGT.

SERUM GLUTAMIC-OXALOACETIC TRANSAMINASE (SGOT) - See AST.

SGPT SERUM, GLUTAMIC-PYRUVIC TRANSAMINASE - See ALT.

SODIUM, SERUM - In factitious hyponatremia due to hyperglycemia, for every 100 mmol/L blood glucose above normal, serum sodium decreases 1.6. For example, a blood glucose of 800 and a sodium of 129 would factitiously lower the sodium value by about 7 × 1.6, or 11.6. Corrected serum sodium would therefore be 129 + 11 = 140. 

136-145 mmol/L

Increased: Associated with low total body sodium (glycosuria, mannitol, or lactulose use urea, excess sweating), normal total body sodium (diabetes insipidus [central and nephrogenic], respiratory losses, and sweating), and increased total body sodium (administration of hypertonic sodium bicarbonate, Cushing's syndrome, hyperaldosteronism)

Decreased: Associated with excess total body sodium and water (nephrotic syndrome, CHF, cirrhosis, renal failure), excess body water (SIADH, hypothyroidism, adrenal insufficiency), decreased total body water and sodium (diuretic use, renal tubular acidosis, use of mannitol or urea, mineralocorticoid deficiency, vomiting, diarrhea, pancreatitis), and pseudo-hyponatremia (hyperlipidemia, hyperglycemia, and multiple myeloma)

STOOL FOR OCCULT BLOOD (HEMOCCULT TEST) - FOBT [Fecal Occult Blood Test]

Normal-Negative: Apply small amount of stool to test site on Hemoccult card and close. Open test panel on other side of card and apply 2-3 drops developer to the test and the positive control panels; read in 30 s. Blue color is positive. Detects >5 mg hemoglobin/g feces. Repeat three times for maximum yield. (A positive test more informative than a negative test)

Positive: Any GI tract ulcerated lesion (ulcer, carcinoma, polyp, diverticulosis, inflammatory bowel disease), hemorrhoids, telangiectasias, drugs that cause GI irritation (eg, NSAIDs) swallowed blood, ingestion of rare red meat, certain foods (horseradish, turnips) (vitamin C [>500 mg/d], antacids may result in false-negative test)

SWEAT CHLORIDE - Collection: 100-200 mg sweat on filter paper after electrical stimulation of sweating by pilocarpine iontophoresis on an extremity

Normal: 5-40 mEq/L (SI: 5-40 mmol/L)

Increased: CF (not valid on children <3 wk); Addison's disease, meconium ileus, and renal failure can occasionally raise levels.

T3 RESIN UPTAKE (RU); (THYROXINE-BINDING GLOBULIN RATIO) - This test is used in conjunction with a T4 to yield the Free T4 Index [FTI]), an estimate of the free T4.

Normal: 30-40%

Increased: Hyperthyroidism, medications (phenytoin [Dilantin], steroids, heparin, aspirin, others), nephrotic syndrome

Decreased: Hypothyroidism, medications (iodine, propylthiouracil, others), any cause of increased TBG, such as oral estrogen or pregnancy

TESTOSTERONE

Normal: Male free: 9-30 ng/dL, total 300-1200 ng/dL Female, seetable

Increased: Adrenogenital syndrome, ovarian stromal hyperthecosis, polycystic ovaries, menopause, ovarian tumors.

Decreased: Some cases of impotence, hypogonadism, hypopituitarism, Klinefelter's syndrome

THYROGLOBULIN - Useful for following patients with nonmedullary thyroid carcinomas. 

Normal: 1-20 ng/mL (mg/L)

Increased: Differentiated thyroid carcinomas (papillary, follicular), Graves' disease, nontoxic goiter

Decreased: Hypothyroidism, testosterone, steroids, phenytoin

THYROID-STIMULATING HORMONE (TSH) - Excellent screening test for hyperthyroidism as well as hypothyroidism. Differentiates between a low normal and a decreased TSH. 

Normal: 0.7-5.3 mU/mL

Increased: Hypothyroidism

Decreased: Hyperthyroidism. Less than 1% of hypothyroidism is from pituitary or hypothalamic disease resulting in a decreased TSH.

THYROXINE (T4 TOTAL) - Good screening test for hyperthyroidism. Measures both bound and free T4, therefore, can be affected by TBG levels. 

Normal: 5-12 mg/dL (SI: 65-155 nmol/L) Males: >60 years, 5-10 mg/dL (SI: 65-129 nmol) Females: 5.5-10.5 g/dL (SI: 71-135 nmol/L)

Increased: Hyperthyroidism, exogenous thyroid hormone, estrogens, pregnancy, severe illness, euthyroid sick syndrome

Decreased: Hypothyroidism, euthyroid sick syndrome, any cause of decreased TBG

THYROXINE-BINDING GLOBULIN (TBG) 

Normal: 21-52 mg/dL (270-669 nmol/L)

Increased: Hypothyroidism, pregnancy, oral contraceptives, estrogens, hepatic disease, acute porphyria

Decreased: Hyperthyroidism, androgens, anabolic steroids, prednisone, nephrotic syndrome, severe illness, surgical stress, phenytoin, hepatic disease

THYROXINE INDEX, FREE (FTI) - Practically speaking, the FTI is equivalent to the free thyroxine. Useful in patients with clinically suspected hyper- or hypothyroidism. Determined as follows:

Normal: 6.5-1.25

Increased: Hyperthyroidism, high-dose beta-blockers, psychiatric illnesses

Decreased: Hypothyroidism, phenytoin (Dilantin)

TORCH BATTERY (toxoplasma, rubella, cytomegalovirus, herpes virus {O = other [syphilis]}) 

Normal = negative

Serial determinations best (acute and convalescent titers).

Test is based on serologic evidence of exposure to toxoplasmosis, rubella, cytomegalovirus, and herpesviruses.

TRANSFERRIN - Used in the workup of anemias; transferrin levels can also be assessed by the total iron-binding capacity. 

Normal: 220-400 mg/dL (SI: 2.20-4.0 g/L)

Increased: Acute and chronic blood loss, iron deficiency, hemolysis, oral contraceptives, pregnancy, viral hepatitis

Decreased: Anemia of chronic disease, cirrhosis, nephrosis, hemochromatosis, malignancy

TRIGLYCERIDES - See also LIPID PROFILE.

Normal Recommended values: Males: 40-160 mg/dL (SI: 0.45-1.81 mmol/L) Females: 35-135 mg/dL (SI: 0.40-1.53 mmol/L) Can vary with age.

Increased: Nonfasting specimen, hyperlipoproteinemias (types I, IIb, III, IV, V), hypothyroidism, liver diseases, poorly controlled diabetes mellitus, alcoholism, pancreatitis, AMI, nephrotic syndrome, familial, medications (oral contraceptives, estrogens, beta-blockers, cholestyramine)

Decreased: Malnutrition, malabsorption, hyperthyroidism, Tangier disease, medications (nicotinic acid, clofibrate, gemfibrozil) congenital abetalipoproteinemia

TRIIODOTHYRONINE (T3 RIA) - Useful when hyperthyroidism is suspected, but T4 is normal; not useful in the diagnosis of hypothyroidism. 

Normal: 120-195 ng/dL (SI: 1.85-3.00 nmol/L)

Increased: Hyperthyroidism, T3 thyrotoxicosis, pregnancy, exogenous T4, any cause of increased TBG, such as oral estrogen or pregnancy

Decreased: Hypothyroidism and euthyroid sick state, any cause of decreased TBG

TROPONIN, CARDIAC-SPECIFIC - Used to diagnose AMI; increases rapidly 3-12 h, peak at 24 h and may stay elevated for several days (cTn1 5-7 days, cTnT up to 14 days). More cardiac-specific than CK-MB

Troponin 1 (cTn1) <0.35 ng/mL Troponin T cTnT <0.2 g/L

Positive: Myocardial damage, including MI, myocarditis (false-positive: renal failure)

URIC ACID (URATE) - Increased uric acid is associated with increased catabolism, nucleoprotein synthesis, or decreased renal clearing of uric acid (ie, thiazide diuretics or renal failure).

Normal: Males: 3.4-7 mg/dL (SI: 202-416 mmol/L) Females: 2.4-6 mg/dL (SI: 143-357 mmol/L) To convert mg/dL to mmol/L, multiply by 59.48 Collection: Tiger top tube

Increased: Gout, renal failure, destruction of massive amounts of nucleoproteins (leukemia, anemia, chemotherapy, toxemia of pregnancy), drugs (especially diuretics), lactic acidosis, hypothyroidism, PCKD, parathyroid diseases

Decreased: Uricosuric drugs (salicylates, probenecid, allopurinol), Wilson's disease, Fanconi's syndrome

VDRL TEST (Venereal Disease Research Laboratory) or RAPID PLASMA REAGIN (RPR) - Good screening for syphilis. Almost always positive in secondary syphilis but frequently becomes negative in late syphilis. Also, in some patients with HIV infection, the VDRL can be negative in primary and secondary syphilis. 

Normal = non reactive

Positive (Reactive): Syphilis, SLE, pregnancy and drug addiction. If reactive, confirm with FTA-ABS (false-positives with bacterial or viral illnesses).

VITAMIN B12 (EXTRINSIC FACTOR, CYANOCOBALAMIN)

Normal: >100-700 pg/mL (SI: 74-516 pmol/L) 

Increased: Excessive intake, myeloproliferative disorders

Decreased: Inadequate intake (especially strict vegetarians), malabsorption, hyperthyroidism, pregnancy

ZINC 

Normal: 60-130 mg/dL (SI: 9-20 mmol/L)

Increased: Atherosclerosis, CAD

Decreased: Inadequate dietary intake (parenteral nutrition, alcoholism); malabsorption; increased needs, such as pregnancy or wound healing; acrodermatitis enteropathica; dwarfism