Department of Pathology
and Laboratory Medicine

Akron Children's Hospital
One Perkins Square
Akron, OH 44308
Laboratory
Ph: (330) 543-8573
Fax: (330) 543-3659

LABORATORY TEST REQUISITION


PATIENT INFO
Patient Name:
Medical Record #:
BD:        /        /              Sex:    F    M

PHYSICIAN INFO
Physician Name :
Address:
Ph: (        )        -              Fax: (        )        -              
Additional Report to:
Ph: (        )        -              Fax: (        )        -              

TESTS REQUESTED
Test Name: ICD9 Code: (required)
1. Entamoeba histolytica, IgG   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Entamoeba histolytica, IgG
CPT Code: 86753

Specimen Type: Blood

Tube Type/Collection Container: Gold top SST (serum separator tube, no anticoagulant)

Collection Volume: 2.5 mL (minimum 0.5 mL)

Cause for rejection: Contaminated, heat inactivated or severely lipemic specimens.

Storage: Refrigerated

Availability: Sent to reference lab

Methodology: Enzyme-Linked Immunosorbent Assay (ELISA)

Special Instructions: Acute and convalescent specimens must be labeled as such; parallel testing is preferred and convalescent specimens must be received within 30 days from receipt of the acute specimens.

TAT: 3-7 days


Lab/Phone: 330-543-8418

Additional Info: Clinical information: Aid in the detection of amebic liver abscess. Test is not useful for intestinal infection. In case of extra-intestinal complications, a positive antibody can indicate amebiasis even though stool findings are negative. Seroconversion between acute and convalescent sera is considered strong evidence of recent infection. Reference Range: Negative: No significant level of detectable E. histoytica IgG Antibody: 8 U or less. Equivocal: (repeat testing in 10-14 days may be helpful) 9-11 U Positive: (current or past infection) 12 U or greater

Transport specimens to processing area of the laboratory in an appropriate container. Additional information is available from Ingrid Hershey, Laboratory Administrative Director, at 330-543-8721.

SHIP TO:
Department of Pathology and Laboratory Medicine
CCL
Akron Children's Hospital
One Perkins Square
Akron, OH 44308


Physician Signature: Date: