Unraveling the unexpected: Interference in iron assay leads to diagnosis of multiple myeloma.

BACKGROUND: Iron studies are critical for diagnosing iron deficiency and hemochromatosis. We present a case exhibiting macrocytic anemia with perplexingly high plasma iron concentrations. METHODS AND RESULTS: The initial clinical presentation with significantly elevated iron results raised concerns for hemochromatosis. However, inconsistent results in dilution studies suggested the presence of an interfering substance. Inspection of the reaction curves from the instrument revealed very high background absorption in the 800 nm channel. This, coupled with the observation of an insoluble precipitate upon mixing the acid buffer reagent with the patient's serum, as well as the patient's high total protein and low albumin levels, suggested immunoglobulin overproduction. Serum protein electrophoresis confirmed a monoclonal gammopathy with a subsequent diagnosis of multiple myeloma. CONCLUSION: Excessive monoclonal immunoglobulins can precipitate in acidic buffers and interfere with spectrophotometric measurements in iron testing. Although challenging, investigating an interference and determining its cause can uncover underlying diseases that have yet to be diagnosed.

Characterization of bilirubin interference in three commonly used digoxin assays.

BACKGROUND: Due to the narrow therapeutic range of digoxin, determining serum/plasma digoxin concentrations is critical for assessing patients with congestive heart failure, atrial fibrillation, and certain types of arrhythmias. However, digoxin quantification by competitive immunoassays is susceptible to interferences that may alter the accuracy of its measurement in patient plasma. This study aimed to characterize the extent of bilirubin interference in three commonly used digoxin immunoassays. METHODS: Digoxin concentrations were compared using the Beckman Coulter® Unicel DxI 800, the Vitros® 4600, and the Roche Cobas® 8000 in neat or digoxin-spiked icteric and non-icetric plasma samples. A mixing study was performed to demonstrate how digoxin quantification is affected by bilirubin. An equation was derived that predicts the response of the DxI 800, given known bilirubin and digoxin concentrations. RESULTS: The DxI reported detectable concentrations of digoxin in high bilirubin samples with no added digoxin, while the Vitros® 4600 and Cobas® 8000 gave virtually undetectable results. Spiking digoxin into samples with elevated bilirubin concentrations resulted in a higher percent recovery for the DxI 800 when compared to the other two platforms. The mixing study also revealed an increase in the percent recovery in the DxI 800, while the Vitros® 4600 and Cobas® 8000 were comparable to the expected concentration of digoxin. CONCLUSIONS: The DxI 800 is most prone to interference by bilirubin, while the Vitros® 4600 and Cobas® 8000 are relatively unaffected. Icteric samples should be interpreted with caution if digoxin quantification is needed, especially on the DxI 800 assay.

Performance characteristics of the Beckman Coulter UniCel DxI 800 TSH (3rd IS) assay.

INTRODUCTION: Beckman Coulter recently reformulated their commercial TSH assay with primary calibration to the World Health Organization 3rd TSH international standard. An extensive evaluation of the performance characteristics for this assay was completed. METHODS: Intra-day and inter-day precision was evaluated using 3 concentrations of commercial quality control material. Linearity, reportable range, stability, sensitivity and susceptibility to common inferences were determined using pooled patient specimens. Inter-assay variability was assessed across 5 different platforms (n=47 patient specimens). RESULTS: Intra-day and inter-day CVs were <10% at all concentrations evaluated. The LOQ, LOD and LOB were 0.0047µIU/ml (10% CV), 0.0012µIU/ml and 0.0005µIU/ml, respectively. Variable bias was observed for the TSH3 assay when evaluated against the previous generation assay and other platforms, but overall TSH3 gave comparable results. CONCLUSIONS: The TSH3 assay for UniCel DxI 800, is precise, highly sensitive and comparable to the previous generation assay. The assay is acceptable for clinical testing.

Endogenous alkaline phosphatase interference in cardiac troponin I and other sensitive chemiluminescence immunoassays that use alkaline phosphatase activity for signal amplification.

BACKGROUND: False positive cardiac troponin results can lead to inappropriate diagnosis. Our laboratory workflow includes systematic quality practices to identify false positive cardiac troponin I (cTnI) results reported by the DxI AccuTnI+3 assay, which uses alkaline phosphatase (ALP) for signal amplification. Recently, a sample with elevated cTnI failed our quality standards and was found to have extremely elevated endogenous ALP activity. The objective of this study was to determine the true cTnI concentration and evaluate whether ALP was the source of interference. METHODS: The suspicious cTnI result was evaluated by repeat analyses, dilution, heterophile blocking treatment, alternative methodology (Vista), and heat treatment. Purified ALP was added to reference serum and we quantified DxI cTnI and human chorionic gonadotropin (hCG). Next, cTnI and/or hCG was measured in specimens with normal (N=20) or elevated (N=26) ALP using DxI and Vista assays. Finally, cTnI was quantified using a prototype, ALP-dependent high-sensitivity assay. RESULTS: The sentinel sample's DxI-cTnI results were imprecise on repeat, linear on dilution, unaffected by heterophile blocking antibodies, and correlated with ALP lability following heat treatment. The Vista-cTnI concentrations were ~7-fold lower. Addition of purified ALP to reference serum linearly increased the DxI-cTnI results. DxI-hCG results also appeared affected by ALP. Several independent patients' specimens with elevated ALP appeared to have falsely elevated DxI-cTnI and DxI-hCG. CONCLUSIONS: Elevated ALP can interfere with contemporary, ALP-dependent immunoassays, including DxI-cTnI and DxI-hCG. The validation of such methods should include evaluations for endogenous ALP interference. Specimens with ALP >1000U/L and elevated DxI-cTnI should be evaluated for ALP interference.