NationalPathologyConference2021 latest

51

EP46
Severe Plasmodium knowlesi malaria infection mimics leptospirosis: A case report
Aishah, ND
Microbiology Unit, Department of Pathology, Hospital Sultanah Aminah, Johor Bahru

Introduction: Early detection of severe P.knowlesi malaria can be life-saving. However, the diagno-
sis of severe P. knowlesi malaria infection can be challenging due its non-specific presentation, simi-
lar to other endemic tropical diseases such as leptospirosis. Case Report: A 47 year old chinese
male presented with high grade fever for six days with right hypochondrium pain. He has recent
history of camping near a waterfall. Physical examination revealed jaundice, hypotension and right
hypochondrium tenderness. Laboratory investigation showed anemia, thrombocytopenia, acute kid-
ney injury and deranged liver enzymes. Rapid serological test for leptospirosis was positive. The
initial diagnosis was septic shock secondary to leptospirosis. Early antibiotic therapy with ceftriax-
one was commenced. He had worsening respiratory distress with multiorgan failure, requiring ICU
admission. An incidental finding of malaria on a full blood picture examination prompted further
test with blood film for malaria parasite (BFMP). Hyperparasitemia count of P.knowlesi was detect-
ed, confirmed by PCR. Microscopic agglutination test (MAT) for Leptospira was negative. Diagnosis
was revised to severe complicated P. knowlesi malaria. He was treated with intravenous artesunate
and doxycycline for one week. He responded well to treatment and discharged after 18 days of
hospitalization. Discussion: Cross reactivity can occur between Leptospira rapid serological test and
malaria.Result of a single positive rapid diagnostic test for leptospirosis should be interpreted with
caution. Clinicians should consider to investigate for severe malaria in the presence of similar
presentation, particularly with recent history of camping.
Keywords: Plasmodium knowlesi, severe malaria, multiorgan failure, leptospirosis

EP47
Rat bite fever without rat bite: A case report of Streptobacillus monoliformis bacteraemia
Rinusha Manogaran, Derrick Christie Sagayam, Siti Norsuhada Mua’ainue Deen, Tan Ruixin, Boon
Kah Ying
Microbiology Unit, Pathology Department, Hospital Pulau Pinang, Georgetown

Introduction: This is a case report of bacteraemia caused by Streptobacillus monoliformis. Bacterae-
mia caused by this organism is relatively rare and this is the first published case in Malaysia. Case
report: A 65-year-old man who is an ex-heroin chaser presented with unilateral knee pain and
swelling for a week without any history of fever. Arthrotomy and joint washout of the knee was
done and patient then developed right middle finger interphalangeal joint swelling and pain. Gram
-negative bacilli were isolated from his blood culture and were identified as Streptobacillus monoli-
formis using matrix assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF
MS). This patient denied any history of rat bite but he noticed rats around his housing area. He was
treated with two weeks duration of intravenous cloxacillin and was consequently discharged well.
Discussion: Rat bite fever is an uncommon zoonotic infection caused by Streptobacillus monoliformis
or Spirillum minus. It is usually under-diagnosed in view of the fastidious nature of the organism and
low rate of suspicion in patients who present with sudden onset of joint pain. Patients usually present
with symptoms such as fever, rashes, monoarthralgia and migratory polyarthralgia that is caused by
septic or reactive arthritis. Most patients recover well without long term complications if diagnosed
and treated early. In the case of our patient, it is proven that proper bacterial culture techniques
and advanced microbiological diagnostic technology played an important role in the identification
of the causative organism.
Keywords: Streptobacillus monoliformis. Bacteraemia. Rat bite. Arthritis.

52

EP48
Intestinal hookworm infection in a young immunocompetent patient
Nurul Amira Abu Hasan¹, Nur Diyanah Mohamed Fauzi¹, Choong K.Y1
¹Department of Pathology, Hospital Pakar Sultanah Fatimah, Muar, Johor, Malaysia

Introduction: Hookworm infection is common in endemic areas. It can be prevented by good sanita-
tion and personal hygiene practices. The manifestation is rarely seen in immunocompetent individu-
als unless in prolonged exposure to the parasite or heavy infection. Case report: In this case study,
we reported a case of hookworm infection in a young immunocompetent male patient, presented
with gastrointestinal symptoms after exposure to contaminated soil and cats at home. He suffered
generalised abdominal pain associated with foul-smelling loose stool for 10 days. He was initially
prescribed home with an oral antibiotic for five days, however, the condition did not improve. Sub-
sequently, he was referred to hospital and was admitted. During admission, the laboratory exami-
nation showed leukocytosis with eosinophilia, whilst hookworm ova was seen in stool ova and cyst
examination. The patient was treated with oral albendazole and covered for bacterial infection
with oral ciprofloxacin. He was discharged well with the medications with no subsequent follow-up.
Discussion: This case suggests the possibility that hookworm infection can occur in a healthy person
with prolonged exposure to the parasite and it can happen all over the places either in the remote
or urbanized regions.
Keywords: Parasite, Hookworm, Albendazole

EP49
A hospital-based study on the proportion of Campylobacter as a cause of diarrhoea among
patients in Hospital Pakar Sultanah Fatimah Muar Johor, Malaysia
K.Y. Choong1*, N. A. Abu Hasan1, and N. D. Mohamed Fauzi1
1 Department of Pathology, Hospital Pakar Sultanah Fatimah Muar - Johor, Malaysia

Campylobacter is one of the major etiologies of bacterial gastrointestinal infection and it has been
increasing in incidence reported worldwide. In Malaysia, very little information on the incidence of
Campylobacteriosis. The objectives of this study is to determine the proportion of Campylobacter
gastroenteritis and to compare the proportion of Campylobacter gastroenteritis with other common-
ly implicated enteric pathogens among in-patients in HPSF Muar, Johor. A total of 854 diarrhoiec
stool samples received from 1st January 2020 to 31st December 2020 were included in this cross-
sectional study but only 179 stool samples grew enteric pathogens. Data were extracted and col-
lected via HPSF Laboratory Information System. Salmonella non-typhi species were the commonest
stool bacteria pathogen isolated (10%) followed by Campylobacter species (4.5%), enteropatho-
genic Escherichia coli (3.8%), Aeromonas species (2.5%) and Vibrio parahemolyticus (0.35%). Out
of 38 stool samples that recovered Campylobacter, Campylobacter jejuni was identified in 36 stool
samples (94.7%) and the other 2 samples contained Campylobacter coli. 92.1% of the Campylo-
bacter was isolated from children below the age of 7. All of the Campylobacter isolates were re-
sistant to ciprofloxacin; 63.2% resistant to erythromycin and 94.7% resistant to doxycycline. In con-
clusion, Campylobacter was the second most common enteric bacterial pathogen in diarrhoiec stools
and can be the gastroenteritis aetiology in adult although it is more common to be recovered from
paediatric age group. This observation indicates that Campylobacter is one of the common bacteri-
al causes of diarrhea, thus this organism must be sought by diagnostic laboratories in their routine
examination of diarrhoeic stool.
Keywords: Antibiotic susceptibility, Campylobacter, Diarrhoea, Enteric bacterial pathogen

53

EP50
A review on cycle threshold (Ct)- value of real-time reverse transcriptase- polymerase chain
reaction (rRT-PCR) among COVID-19 cases in Terengganu
Wan Norliyana Wan Mahmud1, Fatimah Haslina Abdullah1, Norlela Othman1
1Department of Pathology, Hospital Sultanah Nur Zahirah, Terengganu

Introduction: The recommended method for detection of SARS-CoV-2 is by real-time reverse tran-
scriptase- Polymerase Chain Reaction (rRT-PCR) due to its specificity and adequate sensitivity for
diagnosing early infection. Viral load profile of SARS-CoV-2 during an infection state is varied be-
tween individual depending on disease development and sampling collection method and transpor-
tation. The aim of this study is to describe clinical characteristics and the viral load dynamic across
different time points throughout the hospital admission among Covid-19 patients in Terengganu.
Materials and Methods: A total of 80 hospitalized confirmed COVID-19 patients from Hospital
Sultanah Nur Zahirah, Terengganu were included. The clinical data and sequential results of SARS-
CoV-2 rRT-PCR were retrospectively analyzed. Results: Among 80 patients, 75% (60 patients)
were symptomatic, whilst 20 patients remain asymptomatic throughout admission. All symptomatic
patients (SPs) had mild symptoms, with cough and fever were the most common presentation (41.3%
and 38.8% respectively). There was a significant different in the development of fever compare to
other symptoms among symptomatic patients (SPs), (p < 0.05). Ct values detected on the day of
admission were similar for both APs and SPs (p = 0.388). Discussion and Conclusions: Consistent
with previous findings, majority of COVID-19 patients had mild symptoms with fever and cough
were the most common 1-3. This study demonstrated that SPs have a longer period of viral shedding
compared to APs (up to 7 weeks and 3 weeks respectively). Although no significant difference of Ct
value found between APs and SPs, isolation of asymptomatic patients was necessary to control the
spread of SARS-CoV-2 virus.
Keywords: coronavirus disease 2019, symptomatic infection, asymptomatic infection, Ct value

EP53
Isolation and conventional characteristics of non-pigmented strain Chromobacterium violaceum
from clinical sample : The side view from diagnostic laboratories
Amirul Ashraf Ismail1, Haziratul Hananie Usman1, Mohamad Safuan Mohamad Sharud-
din2, Muhammad Firdhaus Mohd Yazid3, Muhammad Suhaimi Abdul Nasir4
1Department of Pathology, Hospital Duchess of Kent, Sandakan,Malaysia, 2Department of Pathology,
Hospital Labuan, Labuan, Malaysia, 3Department of Pathology, Women's and Children's Hospital Likas,
Kota Kinabalu, Malaysia, 4Department of Pathology, Hospital Lahad Datu, Lahad Datu, Malaysia

Isolation non-pigmented of Chromobacterium violaceum bacteria from clinical samples is extremely
rare. Furthermore only 9-11% of Chromobacterium violeceum strains are non-pigmented. Non-
pigmented strains may have been isolated from clinical samples but high possibility to wrongly clas-
sified to other genera of Gram negative bacilli. Since, pigmentation cannot be considered an essen-
tial feature of the Chromobacterium genus, important for technologist to recognize the characteristic
of this organism. In this study, we isolated this organism from tracheal aspirate using conventional
methods. This organism showed Gram negative bacilli and Triple Sugar Iron (TSI) test showed yellow
slant/yellow butt indicates the fermentation of dextrose, lactose and sucrose. This organism had no
ability to produce indole by deamination of tryptophan and cannot use the amino acid ornithine as
a source of carbon and energy for growth. Motility, Methyl Red (MR) and citrate test show positive
results, means that this organism motile, had ability to produce and maintain stable acid end prod-
ucts from glucose fermentation and able to utilize citrate as a sole source of energy. Malonate neg-
ative demonstrated that this organism cannot utilize malonate as sole source of carbon and energy
for growth. On blood agar plate showed this organism beta hemolytic, white colonies and repug-
nant smells. After 48 incubation in 37 °C in ambient air the colonies looks dry and wrinkled. On type
3 macconkey agar the colonies non lactose fermenting. Identification had been confirmed by Analyt-
ical Profile Index (API), RapID NF PLUS System, BD BBL Crystal, VITEK 2 system and BD Phoenix
M50 instrument.
Keywords: Non-pigmented Chromobacterium violaceum, convetional methods, identification

54

EP54
Dengue infection and various serotypes identification in Sandakan
Logeswaran Muniandi
Hospital Queen Elizabeth II, Kota Kinabalu,Sabah

Dengue is mosquito-borne viral infection caused by dengue virus known as DENV. We aimed to
study the distributions of dengue case by age and gender together identifying positive dengue cas-
es in a relation FBC parameters. This is retrospective cross-sectional study based at Pathology De-
partment, HDOK,Sandakan. Patient’s details were collected form compiled database in microsoft
access. Blood investigation for dengue serology were performed via rapid serological tests. Other
data such as FBC parameters (Hb, HCT, PLT) and demographic profile (gender, age and race) were
traced from the mentioned database. Follow-up with dengue serotype testing for all cases with posi-
tive dengue serology were carried out at Virology Unit, MKA Kota Kinabalu, Sabah. Total sample
received were 3011 with 344(11.4%) positive and 2667(88.6%) negative. Majority of the samples
are by male gender group with 1589(52.8%). Age group 0-10 years with 1330(44.2%) were the
most detected dengue serology together with dengue serotypes 23 (63.9%). DENV-1 serotype is
the most common with 14 (38.9%). DENV-1 with FBC; Hb,g/dL(10.7-17.6), HCT,%(24.4-48.6) and
PLT, 103/µL(9-1556) may important markers in monitoring dengue patients. These findings could
help for better clinical management and reduce risk of mortality.
Keywords: full blood count, dengue virus, dengue serology, dengue serotype, hospital duchess of kent
Sandakan, makmal kesihatan awam

EP55
Clinical characteristics of Burkholderia cepacia bacteremia, their associated risk factors and anti-
biotic susceptibility pattern among hospitalised patients In Hospital Sultanah Aminah Johor
Bahru Malaysia
Aishah Nazir Deen¹, Ramliza Ramli², Siti Norlia Othman³
¹Microbiology Unit, Department of Pathology, Hospital Sultanah Aminah, Johor Bahru, ²Department of
Microbiology and Immunology, Faculty of Medicine, Universiti Kebangsaan Malaysia, ³ Department of
Microbiology and Immunology, Faculty of Medicine, Universiti Kebangsaan Malaysia

Introduction: This study is aimed to describe the clinical characteristics of Bcc bacteremia, their asso-
ciated risk factors and outcome among hospitalized adult patients in a tertiary hospital in Malaysia.
Materials And Methods: A retrospective case control study of 25 hospitalized adult patients with
Bcc bacteremia matched with 25 controls with Escherichia coli bacteremia from HSAJB was conducted
from June 2016 until May 2017. Result: Cases of Bcc bacteremia included 20 males and 5 females,
with median age of 53 years old (IQR: 42.5-66.0). Controls with E.coli bacteremia consist of 10
males and 15 females with median age of 54 years old (IQR: 46.5-66.0). Diabetes mellitus was
present in 32.0%. 88.0% of the cases had nosocomial infection. Median onset of bacteremia was 9
days from admission (IQR: 2.0-14.5). Presence of septic shock was significantly associated with Bcc
bacteremia (p=0.002). Male gender (p=0.004), ICU admission (p=0.001), presence of indwelling
catheters (p=0.001), presence of central venous catheter (p=0.001) and mechanical ventilation
(p=0.001) were significant factors. The overall case-mortality rate of 60.0% (p=0.001). Risk factors
associated with significant higher mortality were presence of shock on the day of blood culture
(p=0.001), inappropriate antibiotic therapy (p=0.001) and mechanical ventilation (p=0.023). Those
who were treated with ceftazidime had better survival rate (p=0.002). Discussion: Bcc bacteremia
is associated with high mortality, particularly among those with central venous catheters. Other risk
factors of Bcc bacteremia such as ICU admission, presence of indwelling catheters and mechanical
ventilation should also be considered by clinicians to initiate early appropriate antibiotic therapy.
Keywords: Burkholderia cepacia complex, bacteremia, nosocomial infection, central venous catheter,
mortality

55

EP56
Comparison of the BD Phoenix M50 Automated Microbiology System to agar diffusion method
for antimicrobial susceptibility testing using clinical isolates in a tertiary referral hospital
Ch’ng Wei Choong, Edna Eve Paul, Anishaa Kristy Arokianathan, Marilyne Pius, Boon Kah Ying, Tan
Ruixin
Microbiology Unit, Pathology Department, Hospital Pulau Pinang, Georgetown

Introduction: Agar diffusion method (ADM) is the commonest antimicrobial susceptibility test (AST)
used in clinical laboratories. It is relatively time consuming and labour intensive. This study aimed to
compare the performance of BD Phoenix M50 Automated Microbiology System against ADM in a
tertiary referral hospital. Materials and Methods: Ninety bacterial isolates from various clinical
specimens were tested by Phoenix system. The results obtained were compared with ADM to deter-
mine: I) ability to detect resistance patterns, II) percentage of category agreement (CA), minor dis-
crepancy (mD), major discrepancy (MD), very major discrepancy (VMD), III) time required for result
generation. Results: The Phoenix correctly identified all the multi-drug resistance patterns tested.
Generally, the percentage of CA was 92.7 % for Streptococci panel (SP), 96.7% for Gram Positive
panel (GPP) and 93.7% for Gram Negative panel (GNP). All the Phoenix AST results were con-
cordant with ADM results except for Gentamicin(high-level) and Ciprofloxacin from GPP; Imipenem,
Ciprofloxacin and Ampicillin-Sulbactam from GNP. Both GPP and GNP had met the acceptance
criteria for the discrepancy rates. SP had acceptable mD and MD rates but high VMD rate was
observed for Clindamycin and Erythromycin. The SP, GPP and GNP produced results within 12
hours, 15 hours and 14 hours respectively. Discussion: The Phoenix detected resistance patterns
accurately and produced faster results. The limitations of this study are the small sample size and
inhibition zone measurement was used for comparison. Overall, the Phoenix is an efficient AST sys-
tem which can expedite the antibiotic reporting that is useful in patient management and infection
control measures.
Keywords: Antimicrobial, Susceptibility, Clinical, Microbiology

EP57
A cross sectional study of viral load specimen cold chain temperature monitoring
Ch’ng Wei Choong, Fatin Natasha Amira Muliadi, Boon Kah Ying, Tan Ruixin, Ida Marhainis Isahak,
Hakimah Mahsin
Department of Pathology, Hospital Pulau Pinang, Georgetown

Introduction: Cold chain monitoring of viral load specimen is crucial for ensuring the quality of viral
load report and improving clinical outcome. This study aimed to assess the cold chain maintenance
of the specimen from randomly selected government health facilities and to develop appropriate
control measures. Materials and Methods: Hundred boxes containing viral load specimens were
examined to collect data of box volume, ice-packs volume used, number of ice-packs, quantity of
specimens, specimen temperature upon receipt and transportation duration. Specimen packaging
educational material was given out to the respective laboratories. Results: Up to 30 % of shipments
showed specimen temperature in the box exceeded upper specification limit (> 9 OC). Boxes in var-
ious sizes were received under conditions of insufficient ice-packs (< 3 units) and many specimen
tubes (> 20 tubes) per box. Other associated factors such as arrangement of Ice-packs and long
shipment duration (> 1 day) were also noted. A significant improvement in temperature mainte-
nance was observed after implementing corrective actions. Discussion: Failure of cold chain mainte-
nance was mainly due to lack of knowledge in cold chain management and absence of supervision
by personnel in-charge. Based on the data collected, two deductions were made to estimate num-
ber of ice-packs required and maximum quantity of specimens allowed in a box to retain tempera-
ture below 8 OC (transportation within 1 day). The data showed that at least 20% of the inner box
volume must be occupied by ice-packs. Overall, this study can be used as a guide in the future when
establishing standard protocols for molecularspecimen transportation.
Keywords: Cold Chain, Viral Load, Specimen Transportation

56

EP58
A retrospective study of the blood culture contamination rate in Hospital Melaka from 2018 to
2020.
Shalini Santhirasegar, Nur Humairah@Padmaloseni Thangerajah, Ummul Haninah
Hospital Melaka

Introduction: Blood culture is one of the first line tool being used to identify the causative organism
of bacteremia and for better antimicrobial treatment option. However, blood contamination is com-
monly seen in the hospital settings and it is indeed challenging for clinician to make a correct diag-
nosis of pathogenicity versus contamination. The most common organism identified are Staphylococ-
cus species, Corynebacterium species, Bacillus species and Propionibacterium acnes. According to the
American Society for microbiology (ASM) and the Clinical and Laboratory Standard Institute blood
contamination rate should be less than 3%. Objective: To establish blood culture contamination rate
and to determine the common organism associated with blood culture contamination. Methodology:
Descriptive study of retrospective data collection for blood culture contamination rate from January
2018 until December 2020. Result: Of the 102226 blood culture sample taken over the 36 months
period, 3120 (3.05%) were contaminants. The contamination rate are 3.78%, 3% and 2.78% re-
spectively for 2018, 2019 and 2020. The most common organism isolated is Staphylococcus species
which accounts for 85% in 2018, 82% in 2019 and 84% in 2020. Conclusion: This study revealed
blood culture contamination rate to be slightly above the bench mark with Staphylococcus species
being the most common organism identified. In an attempt to achieve contamination rate to less than
3%, it was proposed that continuous training in blood culture procedure using aseptic technique is
indicated. Hospital guideline including checklist of blood culture procedure should be incorporated
during orientation for house-officer.
Keywords: Blood culture, contamination, Staphylococcus species

EP59
Evaluation of new blood tube using Pneumatic Tube System (PTS) for sample transporting to
the Department of Pathology, Sultan Ismail Hospital
Zuraini Yacob, Khadijah Dawam, Nur Ajibah Osman, Ramdhan Wardhian Wardi Subandiono,
Amdan Malik, Zainal Abidin Husin, Rosmah Mahmood, Shah Rizal Md Hasan
Department of Pathology, Sultan Ismail Hospital, Johor Bahru

Introduction: The aim of this study is to identify the new blood tubes (TUD Brand) produced locally
that are safe to use in terms of leak-resistant during sample transportation using PTS at the Speci-
men Receiving Counter (SRC). The PTS showed fast and reliable carrier in sample transportation to
maintain stability for analysis. Materials and Methods: Testing of 256 blood tubes i.e.; lithium hep-
arin, glucose, EDTA and plain was conducted through 14 PTS stations in the wards. All testing were
conducted in duplicate and the average time of acceptance in the SRC was observed. Results: No
leaking was found on all blood tubes. This indicates that the new blood tubes are safe to use for
sample delivery via PTS with a current speed of 6-8 m / s and an air vacuum of 2.90076 psi or
200mBar. Discussion: New blood tubes can be suggested in the selection criteria of tubes in the
future. The bullet safety features during transportation need to be improved and enhanced such as
the use of a complete sponge on the inner side to prevent vibration that can cause leakage on the
sample tube.
Keywords: Pneumatic Tube System, Specimen Receiving Counter

57

EP61
Adenoid cystic carcinoma in uncommon sites
Kaveta BALASUBRAMANIAM1,Nurul Atiqah AHMAD ZAIDI1, Fong Wan LEE1
1Jabatan Patologi, Hospital Pulau Pinang

Introduction: Adenoid cystic carcinoma is a salivary gland-type tumour which commonly occurs in
parotid glands but can also rarely occur at other anatomical sites. Case Report: We report three
cases of adenoid cystic carcinoma that occur in uncommon sites i.e. breast, nasal cavity and lung. All
cases presented with common local symptoms. Their biopsies show similar typical morphological pat-
terns of adenoid cystic carcinoma. Discussion: Although occurs outside salivary glands, adenoid
cystic carcinoma has distinctive morphology that it should not be missed. It is important to recognize
its typical pattern before proceeding with immunohistochemistry to highlight its discrete components.

EP62
Diagnostic conundrum: A case of thalamic glioblastoma, initially treated as acute infarct
Nadiah Ahmad Sabri1,3, Leonard Leong Sang Xian2,3, Anani Aila Mat Zin1,3, Nur Asyilla Che Jalil1,3,
Abdul Rahman Izaini Ghani2,3, Nur Nazleen Said Mogutham2,3
1Department of Pathology, School of Medical Sciences, Universiti Sains Malaysia, Health Campus, Ku-
bang Kerian, Kelantan, Malaysia, 2Department of Neurosurgery, School of Medical Sciences, Universiti
Sains Malaysia, Health Campus, Kubang Kerian, Kelantan, Malaysia, 3Hospital Universiti Sains Malay-
sia, Kubang Kerian, Kelantan, Malaysia

Introduction: Glioblastoma (GBM) is a malignant primary brain tumour, with prevalence comprising
of almost half of all reported glioma cases. Under WHO classification, it is categorized as WHO
grade IV tumours. It is known to be an aggressive tumour with poor prognosis. However, current
multimodal treatment, which include surgery followed by adjuvant chemoradiotherapy, had im-
proved the overall survival rate. Case report: We presented a case of a 60-year-old lady who
was initially treated as acute bilateral thalamic infarct, but was later diagnosed as GBM. She ini-
tially presented with right-sided numbness for 5 months. Her first MRI brain showed ill-defined le-
sions at bilateral thalami that were not enhanced post contrast. She was treated as acute bilateral
thalamic infarct and was started on anticoagulant. However, she presented three months later with
worsening symptoms. Repeated MRI brain showed the bilateral thalamic lesions were increasing in
size with region in left thalamic lesion enhanced heterogeneously. She then underwent left burrhole
and image guided surgery biopsy of the left thalamic lesion. The histopathology examination (HPE)
of the lesion was reported as GBM. Discussion: Histologically, GBM is characterized by its high
cellularity, brisk mitotic activity, vascular proliferations and necrosis. HPE of this patient were con-
sistent with this high-grade lesion. Conclusion: Non specific symptoms may cause diagnosing GBM
challenging, hence causing delay in management. Correct diagnosis should be obtained with proper
analysis of the presenting complaints, together with radiological imaging and histopathological ex-
amination, in order to provide patient with prompt and proper treatment.
Keywords: glioblastoma

58

EP63
Lymphoepithelial carcinoma of the parotid gland: A rare malignant salivary gland neoplasm
Chew Bee See¹, Noor Idayu Ibrahim¹, Chia Earn Sun², Zahirrudin bin Zakaria², Noraida Khalid³
Department of Pathology, Hospital Pulau Pinang¹, Department of Otorhinolaryngology, Head and
Neck Surgery, Hospital Pulau Pinang², Department of Pathology, Hospital Sultan Aminah, Johor Baru³

Introduction: Lymphoepithelial carcinoma (LEC) of the salivary gland is a rare undifferentiated car-
cinoma accounting for less than 1% of all salivary gland neoplasm. It occurs predominantly in the
parotid gland with striking Epstein-Barr virus (EBV) endemic geographical areas and ethnic distribu-
tion, especially among the Arctic regions natives, south-eastern Chinese and Japanese. We report a
case of lymphoepithelial carcinoma in the parotid gland in a Chinese female patient. Case presen-
tation: A 67-year-old Chinese female presented with 2 years history of painless right parotid swell-
ing. Contrast enhanced computed tomography (CECT) of the neck showed a heterogeneously en-
hancing right parotid mass and bilateral enlarged cervical lymph nodes. Right total parotidectomy
and neck dissection was performed. Pathological findings: Histopathological examination of the
resected parotid gland showed a circumscribed tumour with greyish lobulated cut surface. Micro-
scopically the parotid gland is infiltrated by sheets and lobules of neoplastic cells with prominent
non-neoplastic lymphoid stroma. The tumour cells are positive for EBER- ISH, CK5/6, pan-
Cytokeratin and p63. There are multiple metastatic cervical lymph nodes. Nasopharynx biopsy
was negative for malignancy. Discussion & Conclusion: LEC is a rare malignant salivary neoplasm
and it shares overlapping histological and immunohistochemical features similar to nasopharyngeal
carcinoma, non-keratinizing undifferentiated type. Detailed clinical evaluation should be performed
and it is absolutely vital to exclude primary nasopharyngeal carcinoma. Nodal metastasis occurs in
as many as 40% of the patients and distant metastasis often involves the lung, liver, bone and brain
in 10-20% of patients. The 5 -year overall survival rate averages 70-80%.
Keywords: Lymphoepithelial carcinoma, salivary gland, parotid gland, EBER

EP64
Acquired cystic disease-renal cell carcinoma: A case report
Suhaila A1, Hanisah J1, Hamid G2, Syahril Anuar S2, Khatrulnada M S3
Department of Pathology, Hospital Tengku Ampuan Afzan, Department of Urology, Hospital Tengku
Ampuan Afzan, Department of Radiology, Hospital Sultan Haji Ahmad Shah

Introduction: Acquired cystic disease-associated renal cell carcinoma is the most common tumour
arising from kidneys of end-stage renal failure patients. They are hypothesized to arise from a
multistep mechanism, proposed as cyst atypical cysts adenoma carcinoma pathway. Case re-
port: A 41 year old gentleman, an end-stage renal failure patient on regular hemodialysis for 15
years, developed painless hematuria. CT-scan findings showed a right renal mass. Grossly, the right
kidney had multifocal tumours at the the mid- and inferior pole and was entirely replaced by nu-
merous cystic cavities and fat. Microscopically, the tumours comprised of papillary, tubulocystic and
cribriforming glands, lined by pleomorphic cells and scattered Calcium-oxalate crystals. Immuno-
histochemistry of AMACR+ and CK7-, confirms our diagnosis of Acquired cystic disease- associated
renal cell carcinoma. Discussion and conclusion: Acquired cystic disease-associated renal cell car-
cinoma is an indolent malignancy when detected early. A high index of suspicion would be benefi-
cial as patients could be listed for early intervention.

59

EP65
Monomorphic epitheliotropic intestinal T-cell lymphoma: A case report of a rare entity
Siti Shakinah Sobri1, Farhana Mohamad Mohaidin1, Khairul Shakir Ab Rahman1, Shafinaz
Shabudin2, Mohd Firdaus Ghazali1
¹Hospital Tuanku Fauziah, ²Hospital Raja Permaisuri Bainun

Introduction: Monomorphic Epitheliotropic Intestinal T Cell Lymphoma (MEITL), previously known as
Type-II Enteropathy-Associated T-cell lymphoma. It is often involves small bowel and lesser number
in colon. It is a rare disease with poor prognosis. This is a report on colonic MEITL complicated with
intestinal perforation. Case report: A 78-year-old Malay man presented with chronic diarrhea, loss
of weight and appetite in February 2020. Colonoscopy revealed multiple ulcers at left colon till
sigmoid and normal right-sided colon. Biopsies taken showed MEITL. Treatment was not commenced.
He presented again a year later with acute abdomen. Emergency right hemicolectomy was per-
formed showed multiple ulcers at caecum till transverse colon with patchy areas of indurated and
thickened mucosa. Microscopic examination demonstrated transmural infiltration by variable amount
of monomorphic neoplastic T-lymphocytes (CD3+,CD7+,CD8+) with epitheliotrophism in all areas
sampled and transmural necrosis in transverse colon. No nodal involvement seen. He passed away
postoperatively due to sepsis. Discussion:Primary gastrointestinal T-cell lymphomas are rare and
can be mistaken as other non-neoplastic condition such as infectious enterocolitis and inflammatory
bowel disease that may result in delayed appropriate treatment. MIETL is associated with poor
outcome and high mortality rate. In this case although without any proper treatment, patient able to
survive for a year. Clinical manifestations are nonspecific abdominal symptoms and often with
acute abdomen as results of intestinal obstruction or perforation. Often the treatment includes com-
bination of surgery, chemotherapy, and radiotherapy.
Keywords: T-cell lymphoma, MEITL, colonic lymphoma

EP66
A rare case of Warthin tumour-like mucoepidermoid carcinoma
Hidawati Munajat, Farveen Marican Abu Backer
Hospital Sultan Abdul Halim

Mucoepidermoid carcinoma (MEC) is the most common malignancy of the parotid glands. It has a
wide morphologic spectrum including epithelium with oncocytic or squamous metaplasia, cystic archi-
tectural pattern and dense lymphoid tissue which closely resembled Warthin tumour. These charac-
teristics make the diagnosis of rare morphologic variant of MEC such as Warthin tumour-like MEC
quite challenging, and could be easily missed. We herein report a case of 65-year-old male in
which all these featured prominently, mimicking a Warthin tumour, except for small foci of infiltra-
tive growth into the lymphoid tissue. After an uneventful superficial parotidectomy, the patient is
disease-free at 16 months follow-up. This case illustrates the need for diagnostic awareness of
Warthin tumour-like MEC which could be misdiagnosed as Warthin tumor.

60

EP67
Ear canal salivary gland choristoma in 1 year-old girl; a case report.
Farhana.MM1, Nik Adilah NO2,4, Noraida.K5 ,Sharifah Emilia.TS2,3
1Department of Pathology, Hospital Sultanah Bahiyah,, Alor setar, Kedah, Malaysia, 2Hospital Univer-
isiti Sains Malaysia, Kota Bharu, Kelantan, Malaysia, 3Department of Pathology, School of Medical
Sciences, Universiti Sains Malaysia, Kota Bharu, Kelantan, Malaysia, 4Department of Otorhinolaryngol-
ogy-Head &amp; Neck Surgery, School of Medical Sciences,Universiti Sains Malaysia Health Campus,
Kota Bharu, Kelantan, Malaysia, 5Department of Pathology, Hospital Sultanah Aminah, Johor Bahru,
Johor, Malaysia

Choristoma is a non-neoplastic proliferation of histologically normal tissue that forms at an abnormal
site. It is developmental abnormality and usually associated with abnormalities of adjacent struc-
tures. Here we report a case of ear canal salivary gland choristoma in one 1 year- old girl who was
born with right upper facial nerve palsy and right microtia grade III with ear canal stenosis. She
presented with persistent yellowish mucoid discharge from the right infraauricular area. Radiological
examination revealed a well -defined rounded soft tissue lesion within the external ear canal. The
patient underwent the right cortical mastoidectomy and removal of the lesion. Histologically re-
vealed a salivary gland choristoma. Ear canal salivary gland choristoma is an extremely rare condi-
tion. Radiologically it can be confused with other middle ear mass. Currently the only means to es-
tablish a diagnosis of the choristoma is by microscopic examination.
Keywords: Choristoma, Heterotopia, Middle Ear

EP68
Abnormal gel flotation in patient with hyperproteinemia
Saidah Madihah Binti Hashim1,2, Tuan Salwani Tuan Ismail1, Mahaya Che Mat2
1Department of Chemical Pathology, School of Medical Sciences, Universiti Sains Malaysia Health Cam-
pus, Kubang Kerian 16150, Kelantan, Malaysia, 2Department of Pathology, Hospital Raja Perempuan
Zainab II, 15586 Kota Bharu, Kelantan, Malaysia.

Serum separator tubes has advantage of barrier gel that facilitates rapid separation of serum. We
describe a case of an elderly lady with underlying diabetes and hypertension, presented to casual-
ty with unspecific symptoms of nausea and vomiting. Her blood specimen reached laboratory without
undue delay and centrifuged using standard procedure, however showed abnormal floating gel.
Similar finding observed after repeated analysis using new fresh sample in the gel tube. Fortunately,
post centrifugation in a plain tube without gel able to separate the serum and cells. And the results
reveals hyperproteinemia (114 g/L) predominantly globulin (88 g/L), urea 39.8 mmol/L, creatinine
1057 µmol/L, normocalcemia 2.18 mmol/L. Hemoglobin was 6.7 g/dL and full blood picture
showed rouleaux formation with 4% suspicious blast hence suspicious of myelodysplasia. The possi-
ble reason of abnormal floating gel in this case is high viscosity secondary to hyperproteinemia.
There was no clear cut off serum protein level that may affect the gel function to separate the cell
and serum. Other possibility of floating gel ie specific gravity, viscosity and density of gel material,
centrifugation speed, and sample contamination with contrast media or catheter locking solution also
need to be considered. Clinical laboratory must visually screen for improper separation post-
centrifugation and look for possible causes based on history and physical examination. The communi-
cation between lab personel with clinician very important to avoid delay in producing accurate re-
sults for better and prompt management of patient. Using plain tube without gel is an alternative to
solve the abnormal floating gel.
Keywords: gel flotation, hyperproteinemia, SST gel tube.

61

EP69
8 years old girl with milky serum: A case report
Nur Aisyah Shaiful Azman1*, Muhammad Saiful Azhar Sukaribin1, Zety Wizana Rusman1, Rahidatul
Fairuz Ibrahim1
1Chemical Pathology Unit, Department of Pathology, Hospital Pakar Sultanah Fatimah, Jalan Salleh,
84000 Muar, Johor, Malaysia.

8-year-old girl presented to hospital with two days history of rapid breathing. She appeared dehy-
drated with Kussmaul breathing. Initial laboratory investigations revealed glucometer of 27mmol/L,
severe metabolic acidosis and ketonuria. She had hyponatraemia with sodium of 130mmol/L and
hypokalaemia with potassium of 3.1mmol/L. Total cholesterol was 11.7mmol/L with markedly ele-
vated triglyceride of 16.1mmol/L. Her blood samples were persistently lipaemic and hemolysed
concurrent with persistent pseudohyponatraemia ranging from 125 to 135mmol/L. She was diag-
nosed as diabetic ketoacidosis (DKA) secondary to Type 1 Diabetes Mellitus (DM). DKA is a serious
acute complication and occurs approximately 30% of newly diagnosed type 1 DM patient. DKA is
defined by triad of hyperglycaemia (blood glucose >11mmol/L), ketonemia (>3mmol/L) or keto-
nuric (≥2+) and acidemia (venous pH<7.3 and/or bicarbonate <15mmol/L). Hypoinsulinemic condi-
tion in DM will increases lipolysis and decreased free fatty acid (FFA) clearance from the circulation
resulting excess of FFA to the liver. Decrease in utilization and excretions of FFA with the present of
nonfunctional lipoprotein lipase which results in hypertriglyceridemia. Pseudohyponatraemia in lipae-
mic sample is caused by displacement of serum water fraction by lipid as sodium is analyzed using
indirect ion-selective electrode (ISE) method. Severely lipaemic specimens are prone to hemolysis as
lipids may disrupt erythrocyte membranes during specimens processing and centrifugation. Clinician
should be vigilant of diabetic lipemia and pseudohyponatraemia in lipaemic sample. Sodium meas-
urement via direct ISE method yields accurate result and should be used.Lipid profile as reflex test-
ing should be monitored in children with DKA and lipaemic sample.
Keywords: Diabetic ketoacidosis, hyponatremia,hypertriglyceridemia.

EP71
Tricky interpretation in protein electrophoresis
Farah Hanan Aluwi1, Munirah Md Mansor1, Hanita Othman1, Dian Nasriana Nasuruddin1
1 Department of Pathology (Chemical Pathology), Faculty of Medicine, UKM

Introduction: Analytical interference is defined as the effect of a substance present in the sample
that alters the correct value of a result when being measured. Case presentation: We report a case
of a 63-year-old lady who presented with heart failure symptoms secondary to severe anaemia.
Laboratory investigations revealed a Hb level of 7.5 g/dL, platelet count of 128000/mm3 and total
protein concentration of 125 g/L. Serum protein electrophoresis (SPE) performed on Sebia Hydrasys
2 revealed a dense paraprotein band at gamma region with quantitation of 79.5 g/L. The immuno-
fixation electrophoresis (IFE) demonstrated distinct IgG lambda band and detectable monoclonal
bands of IgA, IgM, IgD and IgE with equal intensity at the same electrophoretic location. IgA, IgM
and IgG was measured via nephelometry with quantitation of 31.4 mg/dL, 6.35 mg/dL, and 10400
mg/dL respectively. Discussion: The disparity between the IFE result and the nephelometry quanti-
tation of immunoglobulins in this case was most likely attributable to artefact rather than triclonality.
The serum sample was further treated with Fluidil and Beta-mercaptoethanol (BME) however re-
vealed the same findings. It was speculated that Ig-anti Ig complexes are formed when an immuno-
globulin molecule has affinity to other antibody molecules most commonly the fragment of crystallize
region and immunoglobulin capable of recognizing human IgG class specifically known as RF. Con-
clusion: Interpretation of SPE/IFE is challenging as it is subjected by different type of interferences.
In some instances, interferences cannot be avoided, pathologist may comment on their presence and
communicate with clinicians of their potential effect on patient results.
Keywords: Serum protein electrophoresis, serum immunofixation electrophoresis, plasma cell myeloma,
paraprotein, interferences.

62

EP72
Pseudohyperkalemia in B – cell lymphoma
Azariah Adnan, Abdul Murad Mohd Nor
Department of Pathology, Hospital Tuanku Ja’afar, 70300 Seremban, Malaysia

Pre-analytical errors constitute a significant total laboratory errors of 68.2%.1 Pseudohyperkalemia
is one of the consequent in pre-analytical errors. It could be multifactorial in etiology which may
occur during sample collection, handling, transportation, or centrifugation. Patient’s disease state as
in thrombocytosis and leukocytosis are also responsible for the in-vitro pseudohyperkalemia. We
report here a case of pseudohyperkalemia in B- cell lymphoma. A 58 year old lady was diagnosed
with B cell lymphoma, had persistent hyperkalemia despite insulin chase and hemodialysis. Her ECG
was normal and other blood investigations were not in favor of tumor lysis syndrome or true hyper-
kalemia. Pseudohyperkalemia was then suspected in view of hyperleukocytosis. Whole blood potas-
sium using blood gas analyser was done to compare with plasma potassium. The whole blood po-
tassium was normal with latter was consistently elevated. The monitoring was then based on whole
blood potassium. There were no unnecessary treatments and repeated venipuncture subjected to the
patient since then. There are some learning points at the end of case discussion.
Keywords: plasma potassium, hyperkalemia, pseudohyperkalemia, lymphoma

EP73
Serial monitoring of branched-chain amino acids in Early diagnosis and treatment monitoring
of classical maple syrup urine disease (MSUD) in acute crisis: A case report
Nurul Aina K.1, Nurul Adibah R.1, Noreen J.1, Shamaala P.1, Farah2, Saraswathy A.1, Anasufiza H1.
¹Biochemistry Unit, Specialized Diagnostic Centre, Institute for Medical Research, National Institute of
Health, Jalan Pahang, 50588 Kuala Lumpur, Malaysia, ²Paediatric Department, Hospital Universiti
Sains Malaysia, Jalan Raja Perempuan Zainab II, Kubang Kerian, 16150 Kota Bharu, Kelantan

Introduction: Classical Maple Syrup Urine Disease (MSUD) is an autosomal recessive disorder
caused by defects in the branched-chain a-ketoacid dehydrogenase (BCKAD) complex. It results in
the accumulation of the neurotoxic branched-chain amino acids (BCAAs) leucine, valine, isoleucine,
alloisoleucine and branched-chain ketoacids (BCKA). Classical MSUD is the most severe form, caused
by very low residual enzyme activity. Early and accurate diagnosis enables appropriate treatment
and prevention from the neurological sequelae and early death. Case report: A 2 weeks old
boy,from a non-consanguineous parents presented with recurrent seizures, poor feeding, septicae-
mic-like and respiratory distress. Physical examination showed hypertonia and hyperreflexia. Rou-
tine examination showed only mild hyperammonemia and mild derangement of liver enzymes. Plas-
ma amino acid (PAA) analysis showed marked elevation of leucine, isoleucine, mild elevation of
valine with significant elevation of alloisoleucine, highly suggestive of Classical MSUD. Urine organic
acid showed elevated peaks of BCKAs. Serial PAA monitoring was performed during acute crisis, 2-
3x weekly upon treatment regime changes with BCAA-free amino acid mixtures. The BCAAs were
monitored closely. Significant reduction to normal baseline of the BCAAs and almost undetectable
alloisoleucine levels were achieved. Patient had improved clinically and discharged well with subse-
quent follow up at the metabolic clinic. Discussion: This case illustrates the importance of laboratory
support in the diagnosis and monitoring of MSUD patients in acute crisis. The determination of cor-
rect amino acid formulation was guided by the serial PAA monitoring of the BCAAs. Despite the
severe clinical presentation, patient had survived and has good prognosis for normal milestones.
Keywords: Maple Syrup Urine Disease (MSUD, plasma amino acids, branched-chain amino acids
(BCAAs), branched-chain ketoacids (BCKAs)

63

EP74
A practical improvement for cost-effectiveness troponin test after discontinuation of CK-MB in
tertiary teaching hospital
Mohd Zakwan Bin Md Muslim1,2, Aniza Mohammed Jelani1,2, Julia Omar1,2, Noorazliyana
Shafii1,2,Mohd Faiz Mohd Shukri2,3,Andey Rahman2,3 ,Ahmad Ezam Zainan1,2, Norkhuzairi Md Nor2,4,
Mohd Azirul Azim Mohamed Yusoff2,4 ,W Yus Haniff W Isa2,5,Wan Norlina Wan Azman1,2
1Department of Chemical Pathology, School of Medical Science, Health Campus, Universiti Sains Malay-
sia,16150 Kubang Kerian, Kelantan, 2Hospital Universiti Sains Malaysia, Health Campus, Universiti
Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia, 3Department of Emergency Medicine,
School of Medical Science, Health Campus, Universiti Sains Malaysia,16150 Kubang Kerian, Kelantan,
4The Center for Knowledge, Communication and Technology, Health Campus, Universiti Sains Malaysia,
16150 Kubang Kerian, Kelantan, Malaysia, 5Department of Internal Medicine, School of Medical Sci-
ence, Health Campus, Universiti Sains Malaysia,16150 Kubang Kerian, Kelantan.

Background: Cardiac troponin (cTn) has been recommended as an emerging cardiac marker to man-
age myocardial infarction. Thus, we decided to discontinue the creatine kinase–MB (CK-MB) activity
testing started May 2020, which caused a sudden increase in cTn request and led to a substantial
cost burden to our laboratory. Objective: This study aims to evaluate the cost-effectiveness strategies
of cTnT request post-discontinuation of CK-MB. Materials & Methods: This cross-sectional study involv-
ing Laboratory Information System (LIS) data from January 2019 to May 2021. The result is ana-
lysed using SPSS and Excel software. The calculation is based on cost per test. The strategies include;
(1) Regular discussion among physicians and laboratory consultants (2) Provide the Standard Operat-
ing Procedure without compromising patient care (3) Improvement in LIS for unnecessary request.
Results: Total request for cTnT in 2019 is 1057 with a mean(SD) test per month of 88(24). Discontinu-
ation of the CK-MB test in May 2020 caused an increment of 75% from the monthly mean in 2019. A
total cTnT request in 6 months during the intervention phase (June 2020- November 2020) was 2352
with a mean(SD) test per month of 392(46). From December 2020- May 2021, the total cTnT test
significantly reduce to 1077 with the mean(SD) test per month of 179(34) with p-value=0.001. Thus,
cost-effectiveness strategies was significant from intervention and post-intervention with the mean(SD)
of MYR15680(1827) to the mean(SD) of MYR7180(1345) per month, respectively with the p-
value=0.001. Conclusion: Several interventions illustrate the cost-effectiveness of cTn request after
the discontinuation of CK-MB.
Keywords: Troponin, CKMB, cost-saving

EP75
Clinical audit report on procalcitonin (PCT) test request in Hospital Sungai Buloh
Siti Azira Mohd Arif, Sharifah Khairul Atikah Syed Kamaruddin, Nor Adilah Abdul Rahman
Department of Pathology, Hospital Sungai Buloh

Introduction: Procalcitonin (PCT) has been used as bacterial infection/sepsis biomarker and also in
differentiating bacterial from viral pneumonia and chronic obstructive pulmonary disease (COPD).
This study aims to look at PCT test ordering frequency and to compare PCT with CRP results taken
simultaneously for duplicate PCT order within the same day. Materials and Methods: This was a ret-
rospective study in which 2465 cases were extracted from Laboratory Information System (LIS)
based on serum PCT test result done during period of 1st March 2020 until 31st January 2021. PCT
was tested using Atellica IM PCT Assay and data obtained was analysed and presented in tables
and figures. Results: From 1321 patients who had 2465 PCT testing done, 471 patients (36%) had
serial PCT testing for at least 2 testing done whereas 850 patients had only one PCT testing done.
108 patients (22.9%) had PCT testing time interval of 2 days whereas 22.3% of patients (105) had
next day repeat of PCT testing. About 13.1% of patients (61) had repeat PCT testing done within
the same day. From these, most of repeated PCT and CRP results within the same day did not differ
much except for few cases. Conclusions: PCT test should be requested in a clinically indicated pa-
tient with appropriate ordering frequency to make it cost-effective and available as a long term
test.
Keywords: Procalcitonin, C-reactive protein, bacterial infection

64

EP76
Comparison study between Abbott Architect i1000SR and Beckman Coulter Access2 for immu-
nochemistry tests
Normila Abdul Hadi, Norayuni Mohamed
Department of Pathology & Transfusion, Hospital Sultan Ismail Petra

Introduction: Replacement of equipment in the laboratory need to be evaluated for the suitability
to replace the current in-use equipment. We aimed to evaluate comparability of Architect i1000SR
and Beckman Coulter (BC) Access2 before change to BC Access2 platform for thyroid stimulating
hormone (TSH) test in our laboratory. Materials & Methods: Assay methodology for TSH is Chemilu-
minescence immunoassay in both analysers. The reference interval for TSH is 0.38-5.33 mIU/L. Com-
parison study was performed according to Malaysia Ministry of Health’s guideline. Forty patient
samples were measured by both analysers no more than 2 hours apart. Eight different samples
were analyzed each day for 5 days. Two graphs were plotted, data from the new analyser against
the current analyser and a difference plot. Correlation and regression analyses were conducted
using Excel program. Bias was calculated at lower and upper reference ranges using linear regres-
sion obtained. Calculated Total Error (TEcalculated) at upper and lower reference ranges were com-
pared to Total Allowable Error (TEa). Results: The correlation coefficient (r) was 0.989 indicating
adequate range of sample for the study. Regression equation was y=1.1998x – 0.0434. TEcalcu-
lated at both upper and lower reference ranges were less than TEa at the Desirable specification.
Discussion: Based on the result obtained, BC Access2 is acceptable for TSH assay and show no sig-
nificant different in patient results. As a conclusion, the study was successful and BC Access2 is suita-
ble to replace Abbott i1000SR for TSH assay in our laboratory.
Keywords: Comparison, Correlation, Architect, Access2, Immunochemistry, Chemiluminescence

EP77
Diagnosis of mucopolysaccharidoses in Institute for Medical Research (IMR) Malaysia: Five-
years’ experience (2016-2020)
Sofwatul Mukhtaroh N1, Hamizah I1, Norashareena MS2, Affandi O2, Julaina AJ2, and Anasufiza H1
1Biochemistry Unit, Specialised Diagnostic Centre, Institute for Medical Research, National Institutes of
Health, Jalan Pahang, 50588 Kuala Lumpur, 2Inborn Errors Metabolic and Genetics Unit, Nutrition,
Metabolic and Cardiovascular Research Centre, Institute for Medical Research, National Institutes of
Health, Bandar Setia Alam, 40710 Shah Alam, Selangor

Introduction: Mucopolysaccharidoses (MPS) are a group of inherited metabolic disorders due to
deficiency of different lysosomal enzymes involves in glycosaminoglycans (GAGs) degradation.
There are seven types of MPS namely MPS I, MPS II, MPS III with subtype IIIA-D, MPS IV with sub-
type IVA-B, MPS VI, MPS VII and MPS IX. The aim of this study is to review the distribution of dif-
ferent types of MPS in Malaysia. Methodology: Urine samples from of Malaysian patients suspect-
ed for MPS (n=1395) were received from hospitals all over Malaysia from January 2016 to De-
cember 2020 in this retrospective study. Screening for MPS was performed by GAGs quantitation
and high resolution electrophoresis (HRE). Whole blood samples from presumptive MPS patients
(n=125) were obtained and performed enzyme assay (EA) panel according to the band pattern of
HRE either α-L-iduronidase (IDA), iduronate-2-sulphatase (IDS), heparan N-sulphatase (SULPHA), α-N
-acetylglucosaminidase (AHEX), galactose 6-sulphate sulphatase (GALSO), β-galactosidase (BGAL),
arylsulphatase B (ASB) or β-glucuronidase (BGLUCU). Results & Discussion: Overall, 16.4% were
found presumptive positive during MPS screening (n=229). Confirmatory analysis using EA found
that 41/129 patients were diagnosed as MPS patient with 10 patients from MPS I and MPS II re-
spectively; MPS IIIA (n=1), MPS IIIB (n=3), MPS IVA (n=9), MPS VI (n=6) and 1 patient suggestive of
MPS VII and multiple sulphatase respectively. Conclusion: Most common MPS detected in Malaysia
within the 5 years period were MPS I and II. Diagnosis of patients suspected with MPS can be ob-
tained by urinary GAGs and EA in blood.
Keywords: Mucopolysaccharides, Mucopolysaccharidoses, glycosaminoglycans, enzyme assays

65

EP78
Distribution of alpha-1-antitrypsin phenotypes in Malaysia – 5 years experiences in Institute for
Medical Research (IMR)
Is’adah Khisma Ismail1, Nurul Izzati Hamzan1, Hema A/P Arunagiri1 & Noor Hafizah Hassan1
1Special Protein Unit, Specialised Diagnostic Centre, Institute for Medical Research, Kuala Lumpur, Ma-
laysia

Introduction: Alpha-1-antitrypsin (A1AT) protein is produced primarily in hepatocytes and released
into the blood circulation by the liver. Mutated A1AT can cause misfolding and impaired secretion,
lead to liver cirrhosis. A1AT phenotypes were determined by autosomal dominant alleles known as
the Pi (protease inhibitor) system. IMR serves as the only referred centre for A1AT Phenotyping.
Therefore, aim of this study is to focus on the distribution of A1AT phenotypes among Malaysi-
ans. Method: 207 samples collected from year 2016 till 2020 underwent isoelectrofocusing and
immunofixation method using Sebia Hydrasys 2 Scan analyser. Data collections were then classified
according to the types of phenotypes. Result: Out of 207 samples, 145 have Pi MM phenotypes
(70%), followed by Pi M; 30 samples (15%), Pi CM; 10 samples (5%), Pi MX; 9 samples (4%), Pi
IM; 4 samples (2%), Pi BM; 3 samples (1%) and Pi MP; 2 samples (1%). Only 1 sample received for
Pi MS, Pi MZ, Pi XX and Pi FM with 0.5% each. Malay contributes to the highest ethnic group with 91
cases for Pi MM and 49 cases for other phenotypes. Others Bumiputra ethnic group presented with
38 cases for Pi MM and 9 cases for other phenotypes while Chinese and Indian ethnic shows only
minimal cases. Male to female ratio was 7:5 and majority of the samples were from paediatric age
group (87%) where infants’ age group contributes the largest. Discussion: In Malaysia, Pi MM is the
most predominant A1AT phenotypes counts for 70% of the population and more often found in Ma-
lay male paediatric age group.
Keywords: Alpha-1-antitrypsin, A1AT Phenotypes

EP79
Evaluation of frozen aliquots of Bio-Rad Lyphochek Diabetes Controls Stability Using Bio-Rad D-
10 HbA1c analyser
Sharifah Khairul Atikah Syed Kamaruddin,,Rozita Abdullah, Nor Adilah Abdul Rahman, Adibah Na-
sir, Nadratul Hanim Mohd Drauff, Mohd Zakiuddin Sahlani, Suzana Ismail, Nur Amalina Berhan
Department of Pathology, Hospital Sungai Buloh

Introduction: To evaluate the stability of the aliquoted frozen (-20°C) Bio-Rad Lyphochek Diabetes
Quality Control (QC) if used beyond the recommended 7-day period, at two storage conditions; 2-
8°C and -20°C. Materials and Methods: We compare the stability of Bio-Rad Lyphochek Diabetes
Quality Control in two different QC conditions; open-vial QC material (Level 1 and Level 2) accord-
ing to 7-days recommended stability stored at 2-8°C, with aliquoted QC material (Level 1 and Lev-
el 2) stored at -20°C and beyond the 7-days recommended stability period at 2-8°C using Bio-Rad
D-10 analyser. Results: Intermediate imprecision was comparable across all QC conditions; manu-
facturer recommended extended and frozen aliquot (CV% of 1.54, 1.53, 1.65 for QC level 1 and
CV% of 1.37, 1.46 and 1.48 for QC level 2 respectively). Frozen aliquot still able to demonstrate
consistent stability throughout the study period of 93 days (n=63), for both QC levels when com-
pared to the QC reconstituted at manufacturer recommendation stored 2-8°C. The frozen aliquot CV
for both level 1 and level 2 was better than its peer group CV and allowable imprecision for HbA1c
of 2.5%, suggesting the performance was acceptable.In terms of bias, frozen aliquot and extended
days usage indicate higher bias (2.1% and 1.73% respectively) when compared to manufacturer
recommendation (0.39%) for level 1, that was not evident in level 2, but still acceptable when com-
paring to allowable bias of 2.1%. Conclusion: The findings support the use of Bio-Rad Lyphochek
Diabetes Control for a much longer period of time to save costs by reducing wastage.
Keywords: HbA1c, frozen aliquoted

66

EP80
Percentage of unreportable HBA1C results by VariantTM II Turbo in Serdang Hospital
Syazana Mohd Kuzi1, Siti Hajar Umar1, Shajaratul Dura Mat Ali1, Norlida Abdullah@Ghazali2
¹Chemical Pathology Unit, Department of Pathology, Serdang Hospital, ²IT Unit, Serdang Hospital.

Introduction: There has been a significant increase of unreportable HbA1c results since Serdang
Hospital changed to the VariantTM II Turbo for HbA1c analysis. This increment leads to dissatisfaction
by clinicians as well as wastage in laboratory resources. The objective of this study is to determine
the percentage of unreportable HbA1c and find the major factor that contributes to this problem.
Material And Methods: One-year (December 2019 until November 2020) data of 21998 patients’
HbA1c results were extracted from laboratory information system (LIS) and unreportable results
were analyzed. Samples were divided into two groups; internal and external samples, that repre-
sent samples of Serdang Hospital’s patients and samples that were sent from Kajang Hospital re-
spectively. Percentage of unreportable HbA1c result were determined. Results: From 21998 re-
quested tests of HbA1c, 400 samples were unreportable. The percentage of unreportable HbA1c
for internal and external samples were 1.72% and 2.26% respectively. The major cause of unre-
portable results is the presence of P3 peak >5% in patients with haemoglobin variant. This compris-
es of 361 (90.25%) cases of unreportable results. Discussion: Due to genetic factors, hemoglobin
variant is very common in Malaysia. It is very troublesome to monitor diabetic control in this group
of patients if the analyzer could not report the requested HbA1c. Thus, it is very crucial to select a
platform that is less susceptible to hemoglobin variant interference.
Keywords: Unreportable HbA1c, Variant II Turbo

EP81
Six sigma management in biochemistry tests in Core Laboratory, Hospital Kuala Lumpur
Nurul Atiqah, Azmi1., Marina Shah, Muhammad Zabri Tan1., Mohd Jokha, Yahya2., Sazaliah, Ishak1.,
Kumari, Somiah1., Normaizuwana, Mohamed Mokhtar1.
1Department of Pathology, Hospital Kuala Lumpur, Kuala Lumpur, 2Department of Pathology, Hospital
Sultanah Aminah, Johor Bharu

Introduction: Six sigma monitoring is adopted in the quality control monitoring strategy in Core
Laboratory, Hospital Kuala Lumpur on biochemistry tests. Objective: To evaluate the analytical per-
formance of biochemistry tests using sigma values and adopt in Quality Control (QC) design strate-
gy in the laboratory. Methods: The sigma values were determined from the Internal Quality Control
(IQC) data for 23 analytes tested in Core Laboratory, Hospital Kuala Lumpur. IQC data used was
from July 2020 to May 2021 analyzed on Cobas C8000. The sigma values were calculated from
Total Error Allowable (TEA), coefficient variation (CV) and bias. The standardized QC sigma charts
were plotted by dividing them to six categories ranging from Sigma 6 to Sigma 1 that correspond
to world class, excellent, good, marginal, poor to unacceptable respectively. Quality Goal Index
(QGI) monitoring is then being applied to understand the specific reason that contributed to the
performance. Results: Sigma more than 6 was observed for Triglycerides, Creatinine Kinase, Total
Bilirubin, Direct Bilirubin, ALT, Amylase, Urea and Phosphorus. Sigma value of 5 was reported for
Glucose, Uric Acid and AST. Sigma values of 4 was observed on HDL and Potassium. Sigma values
of 3 was obtained for Chloride, LDH, Albumin, Total Cholesterol, Total Protein and Creati-
nine. Magnesium, ALP and Sodium produced sigma value of less than 2. There are no test has sig-
ma value less than 1. Conclusions: The sigma values can assist the laboratory to monitor the analyt-
ical performance of the tests, plan the QC frequency and helps the laboratory to design improve-
ment activity.
Keywords: six sigma, quality goal index, quality control

67

EP82
Evaluation of Multichem S Plus ® for the measurement of twenty-four biochemistry analytes
Nurul Atiqah, Azmi1., Marina Shah, Muhammad Zabri Tan1., Sazaliah, Ishak1., Kumari, Somiah1.,
Normaizuwana, Mohamed Mokhtar1.
1Department of Pathology, Hospital Kuala Lumpur, Kuala Lumpur

Background: In the clinical laboratory setting, internal quality control (IQC) is one of the monitoring
indicators in quality management system to ensure the accuracy and confidence in the patient result
reporting. It is crucial that each laboratory ensure that the QC material of choice covers the neces-
sary analytical range and appropriately evaluated. Objective: The research was aimed to evalu-
ate Multichem S Plus® for the measurement of twenty-four (n=24) clinical chemistry analytes. Meth-
ods: Precision studies (within run and between run) were done according to Clinical and Laboratory
Standard Institute (CSLI) EP5-A2 using the Multichem S Plus® (Technopath Clinical Diagnostics, USA)
for 24 clinical chemistry analytes. Three levels of ready to use QC materials were analyzed in five
replicates (n=5) on Cobas 8000 (Roche Diagnostics, USA) for five (n=5) consecutive days. Evalua-
tion was also done on the material stability. The precision results were compared against the biolog-
ical variation from European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) as
well as Dr Carmen Ricos and colleague’s database. Results and discussion: All the precision result
for within-run and between-run were within the performance specification. The materials were sta-
ble more than the manufacturer claimed of 10 days. Multichem S Plus® QC material is ready to use
thus improves user’s convenience. Conclusions: The Multichem S Plus® QC materials on Cobas 8000
give acceptable analytical performance across all the test. However, more detailed study is neces-
sary to be conducted to cover all analytical aspects.
Keywords: Multichem S Plus® , quality control

EP83
Evaluation of thyroid stimulating hormone (TSH) functional sensitivity. The Beckman Coulter
DXi 600 Access TSH (3rd IS) assay experience.
Fatiha K1, Chua WC1, Rahidatul Fairuz I1
1Department of Pathology, Hospital Pakar Sultanah Fatimah, Muar, Johor

Introduction: Thyroid stimulating hormone (TSH) measurements are useful for detecting overt and
subclinical hyperthyroidism. For diagnosis of hyperthyroidism, the functional sensitivity (FS) is an im-
portant performance criteria. The diagnostic sensitivity of TSH measurement has been maximised by
sensitivity improvements. Current guideline recommend FS of 0.01 mIU/L for third generation per-
formance. The manufacturer’s claim for the functional sensitivity of TSH is ≤ 0.01 mIU/L at CV of
10% between-run. The aim of this study is to evaluate the TSH functional sensitivity as claimed by
the manufacturer as it is one of the quality requirement for method verification procedure to ensure
the method is fit for purpose for patients management. Material and methods: We evaluated TSH
FS using Beckman Coulter UniCel DxI 600 Access Immunoassay System with Access TSH (3rd IS)
method (Ref B63284). Three serum pools covering below and above the manufacturer’s functional
sensitivity claimed value were tested using 3 reagent lots and 3 instrument calibrations with 2 cali-
brator lots. Results: The functional sensitivity was obtained by extrapolating the imprecision profile
with a coefficient of variation of 10%. The TSH concentration obtained at CV of 10% is 0.0032
mIU/L and the CV obtained at TSH concentration of 0.01 mIU/L is 7%. Discussion: Results showed
excellent performance in FS consistent with manufacturer’s claim and third generation assay claim.
Clinical decisions can be facilitated for patients with subclinical hyperthyroidism, monitoring exoge-
nous thyroxine treatment, detecting TSH-secreting pituitary tumors and distinguishing the low TSH of
nonthyroidal illness from hyperthyroidism.
Keywords: TSH, functional sensitivity, Dxi platform, Beckman coulter, hyperthyroidism.

68

EP85
Parathyroid hormone assay in chronic kidney disease patients
Nur Shafini Che Rahim, Nor’ashikin Othman, Roziela Abu Bakar
Department of Pathology, Hospital Kuala Lumpur, Institute for Medical Research

Introduction: There are 3 generations of parathyroid hormone (PTH) assays. The third generation
PTH assay is thought to be more specific as it provides detection of only biologically active PTH
molecules. The first and second generation PTH assays may overestimate PTH values due to detec-
tion of additional inactive PTH fragments which are not biologically active. In Malaysia, third gener-
ation PTH assay began in Institute for Medical Research (IMR) and has been continuing for years
using immunoradiometric assay method which involve several manual procedures. Automated third
generation PTH assay is available and is more convenient for high workload, providing faster results
and does not involve radioactive reagent. We evaluated and compared the performances of both
third generation PTH assays before decision can be made nationwide to move to automated third
generation PTH. Material & Methods: This is a cross sectional study involving 221 archived chronic
kidney disease (CKD) samples. Samples were first analysed at IMR laboratory and then sent in
batches to Hospital Kuala Lumpur (HKL) for automated PTH analysis. Results: Precision, bias and line-
arity study for automated third generation PTH (1-84) assay were found to be acceptable. Auto-
mated second generation PTH assay yielded higher results compared to automated third generation
PTH assay (y=0.5584x + 1.4895, r2=0.967). Both PTH third generation assays showed acceptable
comparison data (y=0.921x + 23.753, r2= 0.967) with acceptable bias at medical decision limit
for CKD patients. Discussion: PTH is a short half life polypeptide hormone that rapidly metabolizes
to various inactive fragments. In CKD, these fragments are accumulated longer due to problem in
renal excretion which explains higher results obtained for second generation assay. Comparable
results are obtained for both third generation PTH assays at IMR and HKL for CKD samples.
Keywords: parathyroid hormone assay, chronic kidney disease

EP86
Reference interval of lysosomal acid lipase activity in human leucocytes: A preliminary study
Affandi Omar1*, Balqis Kamarudin1, Fatimah Diana Amin Nordin1, Sofwatul Mukhtaroh Nasohah2,
Suhaili Sallih2, Ahmad Kamal Abd Rahim2, Syarifah Nurhikmah Izzati Syed Nasarudin2, Noreen
Jazlina Ghazali2, Nur Ainaa Afhandi2 & Julaina Abdul Jalil1
1Inborn Errors of Metabolism & Genetics Unit, Nutrition, Metabolism & Cardiovascular Research Cen-
tre, Institute for Medical Research, National Institutes of Health Complex, Ministry of Health Malaysia,
No 1, Jalan Setia Murni U13/52, Bandar Setia Alam, 40170 Shah Alam, Selangor, Malaysia, 2Bio-
chemistry Unit, Specialised Diagnostic Centre, Institute for Medical Research, National Institutes of
Health Complex, Ministry of Health Malaysia, Jalan Pahang, 50588 Kuala Lumpur, Malaysia

Laboratory diagnostics of Wolman Disease (WD) and Cholesteryl Ester Storage Disease (CESD) are
based on the evaluation of lysosomal acid lipase (LAL) activity. LAL activity is highly expressed in
fibroblast, lymphocyte and monocytes. To date, the level of LAL activity in human leucocyte is not
reported making it difficult to diagnose the diseases. Therefore, we aimed to establish a reference
range for LAL activity for diagnosis of WD and CESD in Malaysia. Leucocytes were extracted from
whole blood of reference persons with no clinical symptoms of WD and CESD (n=20). LAL activity in
leucocytes was measured using 4-methylumbelliferyl palmitate (4MUP) as substrate. Reference
ranges was calculated using IBM SPSS software. Known case of WD patient (n=1) was used to vali-
date the established reference range. The mean age in the reference population including 3 males
and 17 females was 31.95 years (95% CI: 29.98-33.92). Distribution of LAL activity exhibited a
non-gaussian distribution. Median of LAL activity in the reference population was 478 nmol/hr/mg
protein (107-1437 nmol/hr/mg protein). The reference range of LAL activity was 108 – 1423
nmol/hr/mg protein (2.5-97.5 percentiles). There was no significant difference in LAL activity with
gender (p=0.765) and age group (p=0.266). The LAL activity in patient with WD was 65 nmol/hr/
mg protein which 86% less from the median reference population. We had successfully established
and validated a preliminary reference range of LAL activity in our laboratory for diagnosis of WD
and CESD. More subject numbers are needed to establish a population-based reference range.
Keywords: Lysosomal Acid Lipase, Wolman Disease, Cholesteryl Ester Storage Disease, Reference
Range, 4-Methylumbelliferyl Palmitate

69

EP87
A retrospective study of ornithine transcarbamylase (OTC) deficiency in Institute for Medical
Research: Clinical and biochemical profile
Nurul Adibah R1, Nurul Aina K1, Shaamala P1, Azzah Hana AY1 and Anasufiza Habib1
1Biochemistry Unit, Specialised Diagnostic Centre, Institute for Medical Research, Jalan Pahang, 50588
Kuala Lumpur, Malaysia

Introduction: Ornithine transcarbamylase (OTC) deficiency is an X-linked inborn errors of metabo-
lism (IEM) of urea cycle. It causes severe hyperammonemia leading to early death. This study aim to
describe the clinical and biochemical features of OTC deficiency patients. Materials and Methods:
We reviewed medical records of 13 patients diagnosed with OTC deficiency (2009 to 2021). Re-
sults: (69%) presented during neonatal period (8 male, 1 female) and (31%) presented at 4
months to 14 years old age (1 male, 3 female). Clinically, they presented with seizures, jaundice,
hyperreflexia, lethargy and poor sucking/ feeding. 6 patients had marked blood ammonia level
ranged 341-2360 umol/L (mean=1,439), 7 other patients had no documented ammonia. All pa-
tients had citrulline ranged 0-16 umol/L (mean=3), 54% had arginine ranged 7-36 umol/L
(mean=37) and 69% had glutamine ranged 1,249-4,023 umol/L (mean=1,870). All 13 patients
had marked urine orotic acid level ranged 31-4,068 umol/L (mean=661). Discussion: Majority of
OTC deficiency patients are male and presented during neonatal period (classical OTC deficiency).
Symptomatic female presented later in life from infancy to adulthood (partial OTC deficiency). Clin-
ical symptoms of OTC deficiency are non-specific and may overlap with other IEM and non-IEM
conditions. Blood ammonia measurement is crucial. As the N-acetylglutamate synthase (NAGS) and
carbamoyl phosphate synthetase 1 (CPS1) deficiency can have similar clinical and biochemical fea-
tures, urine orotic acid measurement is essential. OTC will always have orotic acid above the refer-
ence range, NAGS and CPS deficiency patients will have a normal or low level of orotic acid.
Keywords: OTC deficiency; urea cycle disorder; hyperammonaemia; amino acids; orotic acids

EP88
Inherited neurotransmitter disorder in Malaysia: A 6-year study
Julaina Abdul Jalil1, Norashareena Mohamed Shakrin1, Mohd Shahril Aszrin Zainudin2, Norzahidah
Khalid2, Zabedah Md Yunus2
1IEM & Genetics Unit, Nutrition, Metabolic & Cardiovascular Research Center (NMCRC), Institute for
Medical Research (IMR), National Institutes of Health (NIH), Malaysia, 2Biochemistry Unit, Specialised
Diagnostic Centre, Institute for Medical Research, Ministry of Health Malaysia, Jalan Pahang, 50588
Kuala Lumpur, Malaysia

Introduction: Inherited neurotransmitter disorders are a group of very rare neurometabolic diseases
characterized by primary defects of neurotransmitter metabolism involving its biosynthesis, break-
down and transport. This type of disorder results in neurological impairment occurring at any age
from new born to adulthood. We aimed to demonstrate cases of inherited neurotransmitter disor-
ders in Malaysia. Methods: We retrospectively evaluated data obtained from requests to Institute
for Medical Research (IMR) for analysis of neurotransmitter (n=1068) from hospitals all over Ma-
laysia starting January 2015 to December 2020. Briefly, all samples were subjected to measure-
ment of biogenic amines and pterins using Agilent high performance liquid chromatography (HPLC)
method with electrochemical detector (ECD) and fluorescence detection (FLD) respectively. The anal-
ysis time is 20 minutes for biogenic amines and 15 minutes for pterins. The chromatogram results
were integrated using ChemStation software. Results: We identified 2.5% patients with inherited
neurotransmitter disorder (n=27). The most patients were diagnosed as dihydropteridine reductase
(DHPR) deficiency (n=7) followed by tyrosine hydroxylase (TH) deficiency (n=5), 6-Pyruvoyl-
tetrahydropterin synthase (PTPS) deficiency and dopamine transporter defect syndrome (DTDS)
(n=4 respectively), aromatic l-amino acid decarboxylase (AADC) deficiency (n=3) and pterin-4a-
carbinolamine dehydratase (PCD) deficiency and guanosine triphosphate cyclohydrolase (GTPCH)
deficiency (n=2 respectively). Discussion: Overall, this study identified 2.5% or 25 in 1000 pa-
tients from the high-risk population for neurotransmitter disorder were diagnosed with this type of
disorder.
Keywords: neurotransmitter, neurological impairment, HPLC, biogenic amines, pterins

70

EP89
Detection of aminoacidopathies in high risk Malaysian patients: 6-year experience
of a national referral laboratory
Muhd Irfan Bukhari1, Azzah Hana AY1, Nur Khairunisa MA1, Nur Hani MA1, Saraswathy A1, Anasufi-
za H1
¹Specialised Diagnostic Centre, IMR, Kuala Lumpur, Malaysia.

Introduction: The use of tandem mass spectrometry (MS/MS) in expanded newborn screening
makes it possible to screen for a wide range of inborn errors of metabolism (IEM). Information on
the prevalence and incidence rate of IEM in Malaysia is scarce. Here, we would like to study the
spectrum of IEM specifically aminoacidopathies in symptomatic patients suspected of IEM. Methods:
Dried blood spots received from 2015 to 2020 for high risk screening were retrospectively re-
viewed. The diagnoses were further confirmed through clinical symptoms and other biochemical
studies. Results: Over the 6 years period, a total of 32,280 symptomatic patients were screened
nationwide. Among these, 66 (0.20%) patients were diagnosed with aminoacidopathies. 34
(51.5%) were males and 32 (48.5%) females and the median age was 1.37 months (range 2
days – 9.9 years). The most common aminoacidopathies was Citrin deficiency (37; 56.1%), followed
by urea cycle defects (13; 19.7%), MSUD (10; 15.2%), Tyrosinemia Type 1 (1; 1.5%), and PKU (3;
4.5%). Discussions: The detection rate of cumulative aminoacidopathies in this study (0.20%) was
lower than previous report by Thong MK et al (0.99%) in almost similar study group in Malaysia
from 1999-2005. where 13,400 patients were screened with most common aminoacidopathies was
urea cycle defects (54/113) followed by MSUD (44/133). The difference in overall detection rate
likely due to increase awareness among clinician about IEM and the availability of the diagnostic
services over the years as shown by the increased workloads of 2.5 times compared to 10 years
ago. Our result also in agreement with recent literatures that showed Citrin deficiency is highly
prevalence among Asian population. The spectrum of aminoacidopathies in Malaysia has changed.
Up to date data is important for national strategic planning on IEM management.
Keywords: Aminoacidopathies, inborn error of metabolism, newborn screening, tandem mass spectrom-
etry

EP90
1 year Hospital Sungai Buloh journey: Covid-19 biochemistry and hematology samples han-
dling
Sharifah Khairul Atikah Syed Kamaruddin1, Firdaus Mashuri1, Nor Khairina Mohamed Kamarudin1,
Nur Amalina Yusoff1, Nur Farahin Zainal Abidin1, Nurul Aishah Rehan1
1Department of Pathology, Hospital Sungai Buloh, Selangor, Malaysia

Introduction: Hospital Sungai Buloh as the main Infectious Disease referral centre has been chosen
as the COVID-19 center in Malaysia for screening, isolating & treating suspected or confirmed cas-
es. This poster portrays our one year experience on handling biochemistry and hematology COVID-
19 samples received throughout the pandemic with the hope of sharing some insight to further im-
prove our preparedness in the future. Materials and methods: We outlined our standard operating
procedures (SOPs) for the handling of biochemistry and hematology samples of COVID-19 patients.
This involved risk assessment, workflow and tests offered, recommendation of personal protective
equipment (PPE), decontamination and waste management processes. Results: We received numer-
ous hematology and biochemistry samples of COVID-19 monthly. Initially, there was a reducing
trend of COVID-19 samples received from January 2020 till May 2020. However, it started to
increase from June 2020 onwards. As this pandemic is still ongoing, it is crucial for all staffs espe-
cially laboratory personnel to adhere to the recommended guidelines while handling potentially
hazardous hematology and biochemistry samples. Our aim is to maximize the quality and minimize
transmission risks. Conclusion: Good laboratory practice, regular staff training and use of appro-
priate standard operating procedures detailing from pre-analytical, analytical and post-analytical
safety practices, can help minimize potential transmission risks.

71

EP91
Rate and the associated factors of sample rejection in the clinical laboratory of a secondary
healthcare facility; Hospital Tanah Merah
Nuradila Mohd Shukri 1, Nor Azah Farhah binti Ab Aziz 1
Wira Alfatah AA 2
1 Department of Pathology and Transfusion Medicine, Hospital Tanah Merah, Kelantan, 2 Kota Bharu
Health District Office

Introduction: Total testing process (TTP) in a clinical laboratory typically consists of pre-analytical,
analytical and post-analytical phases. The pre-analytical phase accounts for the most laboratory
errors at a rate of about 70%. This study aims to study the rate and its associated factors of sam-
ple rejection at our laboratory. Materials and Methods: Secondary data regarding sample rejec-
tions was extracted from Laboratory Information System between January 2020 to December
2020, and a descriptive analysis was employed to explore the sample rejection rate and causes for
rejection. Results: A total of 256,675 samples were received within the time frame with a rejection
rate of 1.38%, exceeding the national target of less than 1% set by MSQH Hospital Accreditation
Standards. The three leading causes of sample rejection were clotted samples (39.98%), followed
by sample haemolysis (32.19%) and insufficient sample (7.68%), corresponding to previous studies
at various centres. Discussion: Sample clot, hemolysis, and insufficiency are primarily caused by
errors during sample collection, according to many studies. Pre-analytical errors produce unreliable
and misleading laboratory results, which will negatively impact patient care. In addition, this condi-
tion burdens both clinicians and laboratory staffs. Therefore, efforts should be made to achieve
quality in both phlebotomy procedure and laboratory practice through continuous training and edu-
cation, increase use of technology, effective standard operating procedure and good communica-
tion.
Keywords: pre-analytical errors, rejection, haemolysis, clotted, insufficient, secondary hospital

ACKNOWLEDGEMENT

The organizing committee of the National Pathology Conference 2019 would like to
express our sincere appreciation to the following organizations and companies for
their kind assistance, generous support and contributions to this scientific event.

~ We apologise for any inadvertent omission ~

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