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. Aspergillus galactomannan Antigen   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Aspergillus galactomannan Antigen
CPT Code: 87305

Specimen Type: Serum

Tube Type/Collection Container: Red top (no anticoagulant) tube

Collection Volume: 4.0 mL(2.5 mL minimum)

Storage: Refrigerated

Availability: Sent to reference laboratory

Methodology: Enzyme Immunoassay (EIA)

Special Instructions: Send specimen in original container. Do not Aliquot. Two or more consecutive positive results should be obtained from separately drawn specimens before the patient is considered to have a positive Aspergillus antigen test. False positive results can be caused by: Piperacillin-tazobactam and a few other antibiotics; plasmalyte and other fluids containing sodium gluconate; Infection with Penicillium, Alternaria and Paecilomyces; Histoplasmosis, and possibly other endemic mycoses. The Platelia(r) Aspergillus EIA kit was evaluated for sensitivity (52.9% and 79.3%) and specificity (87.0% and 88.8%) in the multicenter US study that led to its FDA clearance of serum for pediatric and adult patients, respectively. The performance of this assay has not been evaluated with neonate samples. Antifungal therapy may reduce the assay's sensitivity.

TAT: 1-4 days


Lab/Phone: 330-543-8418

Additional Info: Reference range: Aspergillus galactomannan Ag: Range: <0.5 Index Days Performed: Mon-Fri

Transport specimens to processing area of the laboratory in an appropriate container. Additional information is available from Cindy Maurer at (330)543-8689.

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


Physician Signature: Date: