2018 Spring SQLab NEWS 산모의매독선별검사지침과선천성매독 2p Q : HbA1C 수치가 2주사이에변동이있을때수치변화의원인 Q : TSH, Free T4, T3의결과해석시유의할점과추가적으로시행할검사 SQLab 소식선함 (SQLab) 바자회개최 2017년결산및 2018년 Kick off 워크샵개최진단검사의학전문의충원 ( 오덕자원장, 조애린원장 ) 대한임상검사정도관리협회주관춘계학술대회참석 8p 10p 12p
02 2018 Spring 산모의매독선별검사지침과선천성매독 매독은 Treponema pallidum (Fig. 1) 에의한세균성성매개감염 (bacterial STD) 으로, 성적인접촉 (sexual contact) 과정에서점막이나상처난피부병변을통하거나수혈등에의해감염되거나, 태반을통한태아감염 (congenital syphilis) 을일으킬수있다. 매독에감염된산모가조기에치료를받지않으면태아에게심각한문제를일으키게되는데, 2012년통계를참조하면세계적으로매독으로인한조기태아사망또는사산 143,000예, 신생아사망 62,000예, 조산 / 저체중아 44,000예및신생아감염 102,000예가발생하였다. 선천성매독은산모에대한효과적인조기선별검사및치료를통해예방할수있다. Figure 1. An electron photomicrograph of two spiral-shaped. Treponema pallidum bacteria ( 36,000). 진단검사및선별검사매독은환자의병력, 이학적검사, 검사실검사등을기초로진단하게되나매독에감염된환자라도증상이없거나경미한경우매독으로인식하지못할수있다. 그러므로감염된산모에의한태아감염을예방하려면매독에대한선별검사를통해산모의무증상감염을진단하고필요시치료해야한다. 매독을진단할수있는검사로는직접검출검사 ( 암시야현미경, 직접형광항체검사, 핵산증폭검사 ) 와혈청학적검사 ( 트레포네마검사, 비트레포네마검사 ) 및뇌척수액검사가있다.
www.sqlab.co.kr 03 < 혈청학적검사 > 매독에대한혈청학적검사로는비트레포네마와트레포네마검사가있는데, 두가지검사중하나에서양성이나오면매독을추정진단할수있고, 두검사모두양성이면확진할수있다. 뇌척수액은선천성매독과신경학적증상이있는경우 3기매독의진단에이용할수있다. 가장많이활용되는비트레포네마검사는 VDRL (Venereal Disease Research Laboratory) 와 RPR (Rapid Plasma Reagin) 검사로 (Fig. 2), 이검사는 Anti-lipid IgM 또는 IgG 항체여부를검출한다. 이항체는매독이외에급성열성바이러스감염이나만성자가면역질환이있는경우에도위양성으로검출이되기때문에진단에특이적이지않으며, 대부분의위양성은 1 : 4 미만의낮은역가를보이는특징이있다. 비트레포네마검사는잠복매독과 1기매독의병변이나타나고 4주까지음성을보일수있고 1기, 2기매독은전지대반응 (Prozone reaction) 때문에위음성으로나올수있다. 그러므로 1기매독이의심되는병변이있을경우, 매독을배제하기위하여, 2주, 4주후반복검사가필요하다. 경성하감 (Primary chancre) 이발생한뒤 3개월후비트레포네마검사가음성이면, 매독의진단을배제할수있다. 정량적비트레포네마검사는치료약물에대한반응을추적관찰하는데사용할수있다. 연속된두번의검사에서역가가 4배이상감소하면치료효과가있다고판단하며, 그렇지않을경우감염이지속되고있다고볼수있다. Figure 2. Rapid Plasmin Reagin test card showing 1. Non reactive, 2. Weakly reactive, and 3. Strongly reactive serum samples (wells 1 3) with their respective agglutination patterns 트레포네마검사에는 TPLA(Treponema Pallidum Latex Aggulutination), TPPA (Treponema Pallidum Particle Agglutination assay) 와 FTA-ABS(Fluorescent Treponemal Antibody Absorption) 가있다 (Fig. 3). 트레포네마검사는매독균특이항원에대한항체를검출하기때문에매독진단에매우특이적인검사이다. 트레포네마검사는비트레포네마검사에서양성으로나온환자에대한확진검사로사용되어왔으나치료를받았던환자의약 85% 에서치료가되었음에도불구하고지속적인양성을보인다. 인증기관
04 2018 Spring A B Figure 3. In vitro diagnostic modalities for venereal syphilis detection. A: Dark field microscopy technique ( 400) reveals the presence of motile spirochetes. B: Positive fluorescent treponemal antibody absorption (FTA-ABS) test for antibody response in patient with syphilis. 선천성매독산모가처음산전진찰을받을때혈청학적검사를통해매독이발견되면선천성매독을효과적으로예방할수있다. 감염위험이높거나, 매독유병율이높은지역에거주하는산모는임신 28주와분만시매독에대한추가검사를시행하여야한다. 신생아의혈청이나제대혈을이용한선별검사는신생아의선천성매독을예방하지못하기때문에권장되지않는다. 신생아에대한평가및치료 (<30 일 ) 산모의비트레포네마와트레포네마 IgG항체가태반을통해태아에게전달될수있기때문에, 신생아혈청검사에서양성반응이보였다해도이것만으로신생아가선천성매독에걸렸다고진단하기어렵다. 따라서, 1 ) 산모의매독감염 2 ) 산모치료의적절성 3 ) 임상, 검사및영상의학적으로신생아에게매독의근거가있는경우 4 ) 분만시산모와신생아의혈청학적검사의역가비교를통해선천성매독을진단하고치료를결정해야만한다. 비트레포네마검사와트레포네마검사에서양성반응을보인산모에게서태어난모든신생아는, 혈청을이용해정량적비트레포네마검사 (RPR 또는 VDRL) 를시행하여야한다. 트레포네마 (TP-PA, FTA-ABS, EIA, 또는 CIA) 검사는해석이어렵기때문에권장되지않는다. 혈청학적검사에서양성반응을보인산모에게서태어난신생아는, 혈청검사와별도로선천성매독의증상 ( 비면역성수종, 황달, 간비종대, 비염, 피부발진, 사지의가성마비 ) 여부를검사하여야하며, DFA-TP (Direct Fluorescent Antibody-T. Pallidum) 검사를할
www.sqlab.co.kr 05 수없는경우, 태반이나탯줄을특수염색하여조직학적검사를하거나, T. Pallidum PCR 검사를고려할수있다. 또한병변이나체액 (bullous rash and nasal discharge) 을이용해암시야현미경검사또는 PCR 검사를시행할수있다. Maternal reactive RPR and treponemal test* Appropriate treatment prior to or during pregnancy Treatment inadequate or not adequately documented in pregnancy (no treatment, nonpenicillin treatment or inadequate penicillin dose) At least 3 or 4 fold fall in maternal RPR titers Inadequate fall in maternal RPR titers Infant RPR non-reactive Infant RPR reactive and infant asymptomatic Infant RPR 4 fold higher than maternal or infant symptomatic Full evaluation for congenital syphilis including long bone and CSF 1. No further diagnostic evaluation or treatment required 2. Clinical and serological follow-up until 15 to 18months of age Patient asymptomatic CSF and long bones normal Signs or symptoms of congenital syphilis Treat for congenital syphilis Figure 4. Algorithm for the treatment and diagnosis of congenital syphilis. *Fluorescent Treponemal Antibody-Absorption or Micro hemagglutination Assay-Treponema pallidum. Consider to be serofast only if Venereal Disease Research Laboratory/ Rapid Plasma Reagin (RPR) is 1:4. CSF Cerebrospinal fluid 인증기관
06 2018 Spring Table 1. Summary of recommendations on syphilis screening and treatment strategies for pregnant women. Recommendations Screening for maternal syphilis Recommendation 1 The WHO STD guideline recommends screening all pregnant women for syphilis during the first antenatal care visit. Remarks : This recommendation applies to all settings, including settings with high or low prevalence of syphilis. Screening strategies* Recommendation 2 In settings with low coverage of syphilis screening and treatment for pregnant women, high loss to follow-up of pregnant women, or limited laboratory capacity, the WHO STD guideline suggests on-site tests(strategies A,B and C)rather than the standard off-site laboratory-based screening and treatment strategy. Recommendation 3 In settings with a low prevalence of syphilis (below 5%), the WHO STD guideline suggests a single on-site rapid syphilis test (RST) be used to screen pregnant women(strategy A) rather than a single on-site rapid plasma regain(rpr) test (Strategy B). Recommendation 4 In settings with a high prevalence of syphilis (5% or greater), the WHO STD guideline suggests an on-site rapid syphilis test (RST) and, if positive, provision of a first dose of treatment and a rapid plasma reagin (RPR) test, and then, if the RPR test is positive, provision of treatment according to duration of syphilis (Strategy C). The WHO STD guideline suggests this sequence of test and treatment rather than a single on-site RST (Strategy A) or a single on-site RPR (Strategy B). Remarks : These recommendations do not apply to countries that can provide appropriate/high-quality laboratory-based screening and treatment strategies. However, in some settings there may be challenges providing such strategies and/ or a sequence of tests. When resources do not permit the use of a sequence of tests, a single on-site rapid syphilis test (RST) (Strategy A) is suggested to ensure greater screening coverage despite the number of pregnant women who will be over-treated due to the high rate of false-positive results. Treatment is based on duration of syphilis, according to the WHO Guideline for the treatment of Treponema pallidum(syphilis). Strength of recommendation and quality of evidence Strong Recommendation Moderate-quality evidence Conditional Recommendations low-quality evidence Conditional Recommendations low-quality evidence Conditional Recommendations low-quality evidence * Note : Refer to section 5.3 of the main guideline text for the explanations and flow charts for the various screening and treatment strategies mentioned(strategies A-D). WHO guideline for the treatment of Treponema palladium(syphilis). Geneva : World Health Organization ; 2016(http://www.who.int/reproductivehealth/publications/rtis/syphilis-treatment-guideilnes/en/).
www.sqlab.co.kr 07 Table 2. Summary of existing recommendations on syphilis treatment for pregnant women. Recommendations Strength of recommendation and quality of evidence Early syphilis(primary, secondary and early latent syphilis of not more than two years duration) Recommendation 5 In pregnant women with early syphilis, the WHO STD guideline recommends benzathine penicillin G 2.4million units once intramuscularly over no treatment. Recommendation 6 In pregnant women with early syphilis, the WHO STD guideline suggests using benzathine penicillin G 2.4million units once intramuscularly over procaine penicillin 1.2million units intramuscularly once daily for 10 days When benzathine or procaine penicillin cannot be used (e.q. due to penicillin allergy where penicillin desensitization is not possible) or are not available (e. g. due to stockouts), the WHO STD guideline suggests using, with caution, erythromycin 500mg orally fout rimes daily for 14 days or ceftriaxone 1g intramuscularly once daily for 10-14days or azithromycin 2g once drally. Remarks : Although erythromycin and azithromycin treat the pregnant women, they do not cross the placental barrier completely and as a result the fetus in not treated. It is therefore necessary to treat the newborn infant soon after delivery (see Recommendations 9 and 10 in the WHO guidelines for the treatment of syphilis, which refer to congenital syphilis). Ceftriaxone is an expensive option and is injectable Doxycycline should not be used in pregnant women. Because syphilis during pregnancy can lead to severe adverse complications to the fetus or newborn, stock-outs of benzathine penicillin for use in antenatal care should be avoided. Late syphilis (infection of more than two years duration without evidence or treponemal infection) Recommendation 7 In pregnant women with late syphilis(more than two years duration) or unknown stage of syphilis, the WHO STD guideline recommends benzathine penicillin G 2.4 million units intramuscularly once weekly for three consecutive weeks over no treatment. Remarks: The interval between consecutive doses or benzathine penicillin should not exceed 14 days. Recommendation 8 In pregnant women with late syphilis, (more than two years duration) or unknown stage of syphilis, the WHO STD guideline suggests benzathinine penicillin G 2.4 million units intramuscularly once weekly for three consecutive weeks over procaine penicillin 1.2 million units intramuscularly once a day for 20 days When benzathine or procaine penicillin cannot be used (e.g. due to penicillin allergy where penicillin desensitization is not possible) or are not available (e.q. due to stock-outs), the WHO STD guideline suggests using, with caution, erythromycin 500mg orally four times daily for 30 days. Remarks : Although erythromycin treats the pregnant women, it does not cross the placental barrier completely and as a result the fetus in not treated. It is therefore necessary to the treat the newborn infant soon after delivery (see recommendation 9 and 10 in the WHO guidelines for the treatment of syphilis, which refer to congenital syphilis). Doxycycling should not be used in pregnant women. Because syphilis during pregnancy can lead to severe adverse complications to the fetus or newborn, stock-out of benzathine penicillin for use in antenatal care should be avoided. Strong Recommendation, Very low-quality evidence Conditional Recommendation, very Low-quality evidence Strong Recommendation Very-low quality Evidence Conditional Recommendation very low-quality evidence Source : WHO guidelines for the treatmenet of treponema pallidum(syphilis). Geneva : World Health Organization ; 2016(http://www.who.int/reproductivehealth/publications/rtis/syphilis-treatment-guidelines/en/)/ Note : In the source guideline, these recommendations were numbered 3, 4, 7, and 8.» 검사정보 검사정보 검사명 검사방법 검체 검사일 / 소요일 4410 Treponema pallidum PCR Swab 월-토 /1 0872 RPR( 정성 ) Immunochromatographic assay Serum 월-토 /1 0862 RPR( 정량 ) Turbidimetry Serum 월-토 /1 4427 RPR titer Card Serum 월-토 /1 3115 VDRL( 정량 ) Slide CSF 화, 금 /7 0905 FTA-ABS IgG IFA Serum 화, 금 /1 0917 FTA-ABS IgM IFA Serum 화, 금 /1 0863 TPLA( 정밀 ) Turbidimetry Serum 월-토 /1 참고문헌 1. WHO guideline on Syphilis screening and treatment for pregnant women. 2017. WHO. 2. Congenital syphilis : A guide to diagnosis and management. Amoled SA et al. 2000. Paediatrics & Child Health. 3. https://www.cdc.gov/std/tg2015/congenital.htm. 인증기관
08 2018 Spring Q A 당뇨병환자치료에따른추적검사중 HbA1c 결과치가 2주사이에 7.4%(NGSP) 에서 7.9% 로 0.5% 가증가되었습니다. 변화된수치에의미를둘수있는지요? 당화혈색소 (Glycosylated hemoglobin) 는적혈구내 Hemoglobin 분자에포도당이결합한것으로통상 HbA1c를의미하며, 공복혈당검사는공복상태에서만검사가 가능하고통증이나감염등다른요인들에의해영향을받는반면, HbA1c는아무때나검사가가능해당뇨환자의혈당관리확인에오랜기간이용되어온검사입니다. 적혈구의수명이 120일정도임을감안할때당화혈색소는대체로 2-3개월동안의장기적인혈당치를나타내게됩니다. 대부분의병원에서 HbA1c의결과보고방식은국제당화혈색소측정표준화컨센서스의권고에따라 NGSP (National Glycohemoglobin Standardization Program) 단위로보고하며, 참고범위는 4~6% 입니다. 당뇨와전당뇨 (prediabetes) 로나눠환자를관리할경우치료기준치참고범위는 4.1%~5.6% 이며, 5.5%~6.0% 사이로수치가나오면당뇨예방책을미리세워두는것이좋습니다. 결과치가 5.7%~6.4% 이면향후 5년안에당뇨병발생위험이높은전기당뇨병 (prediabetic range) 으로간주하여조치를취해야합니다. 당화혈색소가 6.5% 이상되면망막병증발생가능성도높아지므로이점을염두에두고주기적으로 follow up을하는것이좋습니다. 정밀한방법으로정확히검사했을경우 2주정도에 0.5% 정도당화혈색소가증가했다면, 적혈구 life cycle에변화를줄수있는다른요인이있는지전반적으로점검해본후, 당뇨이외에다른문제가없다고판단되면혈당조절을위한치료계획을재점검해야할것입니다. 통상 NGSP 단위의결과치가 1% 변할때마다평균약 30mg/dl의혈당변화를나타낸다고합니다. HbA1c 측정치에영향을주는요인 HbA1c 수치에가장큰영향을주는요인은적혈구수명입니다. 그러므로적혈구교체율에변화를줄수있는용혈성빈혈, 출혈, 수혈, 간질환등의이력이있는경우당화혈색소수치가낮아지게되며, 비장적출, 재생불량성빈혈, 철결핍성빈혈, 신장질환등이있으면수치는높아집니다. 또한아스피린이나비타민C 또는비타민E 같은약물도영향을줄수있습니다.
www.sqlab.co.kr 09 Table 1. Conditions causing inappropriately high or low HbA1c. Inappropriately Low HbA1c Inappropriately High HbA1c Variable Effect on HbA1c+ Hemolysis Certain Hemoglobinopathies Recent blood transfusion Acute blood loss Hypertriglyceridemia Drugs Chronic liver disease Iron deficiency Vitamin B12 deficiency Alcholism Uremia Hyperbilirubinemia Drugs Fetal hemoglobin Methemoglobin Certain Hemoglobinopathies Postulated Mechanism Falsely Low HbA1c Falsely High HbA1c Increased erythrocyte destruction altered hemoglobin altered glycation Interference with assays Dapsone Rivavirin Antiretrovirals Trimethoprimsulfamethoxazole Hydroxyurea Vitamin C Vitamin E Aspirin(Small doses) Aspirin(large doses) Chronic opiate use 당뇨환자를대상으로한 HbA1c 검사는통상 3-4 개월간격으로시행할경우보험으로인정되지만 ( 보건복지부고시제 2015-139 호 ), 혈당변화가심해진료상집중적인혈당조절이필요한경우에는, 2-3 개월간격으로시행한경우에도보험이인정됩니다.» 검사정보검사정보 검사명 검사방법 검체 검사일 / 소요일 0203 HbA1c HPLC WB 월-토 /1 0360 Glucose(S) Colorimetry Serum 월-토 /1 0388 Glucose(P) Colorimetry Plasma 월-토 /1 0443 Glucose(U) Colorimetry Random Urine 월-토 /1 1791 Vitamin C(Ascorbic acid) HPLC Plasma 월 /4 1778 Vitamin E(Tocopherol) HPLC Serum 목 /3 0492 Aspirin(Salicylic acid) Colorimetry Serum 월-토 /5 * WB : Whole Blood 참고문헌 1. American Diabetes Association, Diabetes care. 인증기관
10 2018 Spring Q TSH, Free T4, T3 의결과를해석할때유의할점과추가적으로 시행할검사는무엇인가요? A 1 TSH 증가, Free T4 가동시에증가한경우시상하부, 뇌하수체이상 ( 종양, 갑상샘호르몬내성증후군 ) 과비정상기능증후군의감별이필요합니다. 특히신생아는시상하부-뇌하수체-갑상선축이미성숙하여 TSH, Free T4 모두높을수있습니다. 또한조영제검사후나, 갑상샘기능이불안정한상태의검사결과는신중하게판단해야합니다. 갑상샘질환치료후 Free T4는 2-3주후정상화, TSH는 8주후에정상화가됨을감안하여결과를판정해야합니다. 2 TSH 감소, T3, Free T4 증가한경우갑상샘기능항진증 (Graves병) 을의심합니다. 그러나초기에는 T3만증가 (T3 toxicosis) 하고, TSH는감소, Free T4는정상을보이는경우도있습니다. 이때도움이되는검사는자가항체인 TSH-receptor Ab 가대부분환자에서양성을보이며 TPO Ab, Thyroglobulin Ab 검사는비특이적입니다. 추가적으로 Total Cholesterol 감소, ALP 증가 ( 골대사증가 ), 혈청칼슘증가, ALT/AST 증가 ( 간울혈 ) 를나타내기도합니다. 그외에경도의빈혈, 상대적림프구수증가, 드물게혈소판수감소도관찰되기도합니다. 3 TSH 증가, Free T4, T3 감소한경우갑상선기능저하증 ( 자가면역성갑상샘염, 하시모토갑상샘염 ) 을의심합니다. 자가면역항체인 Thyroglobulin Ab, Anti-microsomal Ab(TPO Ab) 가 90% 에서검출됩니다. 자가면역질환인제 1형당뇨, 악성빈혈, SLE, RA와동반여부가진단에도움이됩니다. 4 다양한 TSH, Free T4, T3 패턴을보이는경우갑상샘기능선별검사로 TSH 검사가가장예민하며, TSH가정상이면일단갑상샘기능은정상이라고판정할수있으나, 임신, 신생아, 스트레스, 질환등에민감한호르몬이므로정상치를벗어났다고해도반드시질환의존재로판정할수는없습니다. TSH가감소해도혈청 T3는저하증이어느정도진행될때까지정상수치를보일수도있습니다. 갑상샘선별검사에서 TSH 이상을보이면, Free T4, T3 검사를실시하고, 추가적으로필요한자가항체 TSH-receptor Ab, Anti microsome Ab, Thyroglobulin Ab 등을시행할수있을것입니다. 특히갑상샘기능저하증은다양한양상으로나타날수있습니다 (Tab. 1).
www.sqlab.co.kr 11 Table 1. 갑상샘기능저하증판독법 T4 Free T4 T3 TSH subclinical Normal Normal Normal Increased 1st mild decrease decrease Normal Increased moderate to severe decrease decrease decrease Increased 2nd, 3rd decrease decrease decrease/normal Increased» 검사정보 검사정보검사명검사방법검체검사일 / 소요일 0510 TSH CLIA Serum 월-토 /1 0655 TSH-receptor Ab(TBII) ECLIA Serum 월-토 /1 0509 T4 CLIA Serum 월-토 /1 0511 Free T4 CLIA Serum 월-토 /1 0508 T3 CLIA Serum 월-토 /1 0512 Free T3 CLIA Serum 월-토 /1 0151 Anti microsome Ab(TPO Ab) CLIA Serum 월-토 /1 0150 Thyroglobulin Ab CLIA Serum 월-토 /1 0356 Total Cholesterol Enzymatry Serum 월-토 /1 0458 Bone ALP CIA Serum 월, 수, 금 /3 0371 Calcium Arsenazo III Dye Serum 월-토 /1 0342 AST(SGOT) IFCC Serum 월-토 /1 0343 ALT(SGPT) IFCC Serum 월-토 /1 0310 Lymphocyte Flow cytometry WB* 월-토 /1 0221 platelet Electronic impedance WB* 월-토 /1 * WB : Whole Blood 참고문헌 1. 갑상선기능검사해석. 2015. SNUH Manual of medicine. Chapter 9. 3 rd Edition. 2. 진단검사의학. 2015. 5 판 인증기관
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