Alkaline phosphatase is an enzyme present in all tissues of the human body. Several isoforms of this enzyme have been described with different catalytic nature, stability and antigenic structure. Rises in the activity of alkaline phosphatase are recognised in various states including bone diseases, liver disease, pregnancy, hyperthyroidism and malignant processes. The Regan isoenzyme, a rare variant of placental alkaline phosphatase, has been identified circulating in association with various tumours. The reported case describes a rising Regan isoform of alkaline phosphatase concentrations that led to a new diagnosis of occult renal cell carcinoma and persistently elevated activity postoperatively signposting persistent or recurrent disease. KeywordsIsoenzymes, amylase, cancer Accepted: 8th February 2014 Case report A 71-year-old woman was referred from primary care with a history of persistently elevated alkaline phosphatase (AP) for 11 months prior to referral, with normal results for serum bilirubin, transaminases and g-glutamyl transpeptidase. Laboratory records had shown previous AP results to be within reference limits. Medical and surgical history included chronic obstructive pulmonary disease (COPD), primary hypothyroidism, dyslipidaemia, obesity, hysterectomy and a history of recurrent drop-attacks likely secondary to partial complex seizures which responded well to carbamazepine treatment. The list of daily medications included thyroxine, atorvastatin, carbamazepine, vitamin D, folic acid, paracetamol, as well as regular inhalers (tiotropium, salbutamol and a combined budesonide/formoterol preparation). There was a family history of colon cancer.The myeloma screen was negative. Plasma carbamazepine concentration was stable and within the therapeutic interval since 2009. Hypovitaminosis D (25 hydroxyvitamin D concentration ¼ 21 nmol/L) was corrected with oral cholecalciferol supplementation, but a few months later despite being vitamin D replete (62 nmol/L), AP concentrations remained elevated and continued to rise further. Serum C-terminal collagen
Diagnostic Enzymology covers commonly requested biochemistry tests, with explanations about their functions, methods of measurement and clinical use. The authors' aim is to provide a resource for those supervising and training within Chemical Pathology and to aid in the interpretation of changes in enzyme values. I was interested that the term 'diagnostic' was included within the title and hoped that this indicated a clinical grounding to this relatively compact book. This is the second edition of the title, initially published 28 years ago, and it has been updated to reflect standardization of methods along with additional coverage of naturetic peptides. It consists of 10 chapters covering the commoner enzymes such as the aminotransferases (ALT and AST), creatinine kinase, lactate dehydrogenase and some of those less frequently seen in the clinical laboratory such as butylcholinesterase and aldolase. Naturetic peptides are also included even if not traditionally recognized as enzymes. The inclusion of some enzymes is slightly puzzling from a British perspective (e.g. the chapter on aldolase) whereas the more commonly measured enzyme amylase is omitted. This may reflect the intended international readership.Each chapter follows a similar format including three to six short clinical cases involving abnormalities of the enzyme in different scenarios. The cases include not only biochemistry data but also pertinent findings from other pathology disciplines and radiological investigations. Cases are followed by a discussion giving a clear explanatory background and relevance of the biochemical abnormality to the case in question.The editors have produced a clear structure for each chapter, with subdivision into sections providing information on reference intervals, analytical methods, interferences and practicalities of measurement. The subsections are concise and often supplemented by tables and illustrative diagrams augmented by informative and appropriate text.Within the chapters, the function and diagnostic value of the enzymes are explained. The depth of coverage is illustrated by some more unusual measurements such as the quantification of gamma-glutamyl transferase in urine. It also provides information where the tests may have become obsolete, such as measurement of CK-MB being surpassed following the advent of the troponins. The authors also touch on some fundamentals of diagnostic testing in general, including the importance of Bayes' theorem and how pre-test probability is intrinsically linked to the interpretation of test results.Every chapter concludes with a number of questions about the analyte which follow a 'true or false' format. The answers are not included within the book, which may be a disadvantage for those reading this on the move, but they are accessible from the internet on a specified webpage. Unfortunately, the published URL lacks the 'pdf' suffix required to locate the webpage.This would be a good revision aid for those working towards the Part One FRCPath Examination. Although larger tex...
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