Pathology - PathCare

Pathology
Vol. 1 No. 2
I know but one freedom
and that is the freedom of the mind
- Antoine de Saint-Exupery
The mind is not a vessel to be filled,
but a fire to be ignited
That is what learning is.
- Plutarch
You suddenly understand something you've
understood all your life, but in a new way.
- Doris Lessing
You cannot teach a man anything;
you can only help him find it within himself
- Galileo Galilei
The
Academy
for Tr aining &
Development
11
Beyond the borders
Microangiopathic
haemolytic anaemia
3
14
Anaemia of chronic
disease
The coeliac iceberg
5
16
Clinical implications of
GFR estimation by
MDRD equation
Diagnosis of smear
negative pulmonary
and extrapulmonary
tuberculosis
7
17
Oral epithelial precursor
lesions
Learners benefit from
PathCare gift
9
18
The PathCare Academy
for Training and
Development
PathCare snippets
Education is the most powerful weapon
which you can use to change the world
- Nelson Mandela
June 2006
2
pathology forum
x
Editorial Team
Editor
Dr Dawie de Beer
Production
Dr Ross Millin
Elandi Bishop
Design and Layout
Adéle Borton, Hannes Vosloo,
Mark Calvert, Brent Davids
From the Editor
Private medical groups in South Africa have entered markets overseas in
recent times.
Life Healthcare (formerly Afrox Healthcare) has been involved for the past few
years in the Partnership Health Group (PHG) in Britain while Medi-Clinic and
Netcare, recently announced acquisitions in private hospital groups in the
United Arab Emirates and Britain respectively
These actions come as no surprise to us at PathCare. We have been involved
in expanding beyond our borders for more than a decade. This edition of the
PathCare Pathology Forum opens with an overview by the CEO of PathCare,
Bruce Dietrich, on these developments.
Recently PathCare announced the opening of the PathCare Academy of
Training and Development at N1 City, conceived to address the skills shortage
at certain levels in pathology in South Africa. This venture is headed by Eric
Spencer and his article on the Academy graces our middle pages.
The previous edition of the PathCare Pathology Forum carried an article by
chemical pathologist Esmé Hitchcock at the reference laboratory at N1 City
on formulas to estimate the glomerular filtration rate. In this edition she has
follows on with a discussion on the interpretation of GFR as calculated by die
MDRD-equation.
Other esteemed contributors are Vince Phillips, professor in oral pathology at
the dental faculty at the University of the Western Cape, Cor Aalbers chemical
pathologist and Alicia Els, haematologist, both at our reference laboratory,
Engela le Roux and Teresa Nel, haematologists at PathCare in Bloemfontein
and Kas Kasongo, pathologist at PathCare in Port Elizabeth.
Features
e-mail
[email protected]
Beyond the borders
2
Management
Anaemia of chronic disease
3
CEO
Dr Bruce Dietrich
Clinical implications of GFR estimation by MDRD equation
5
Oral epithelial precursor lesions
7
The PathCare Academy for Training and Development
9
Microangiopathic haemolytic anaemia
11
The coeliac iceberg
14
Diagnosis of smear negative pulmonary and extrapulmonary tuberculosis
16
Learners benefit from PathCare gift
17
PathCare snippets
18
Director Pathology Operations
Dr John Douglass
Director Operations Africa
Dr Nasser Mia
Director Special Operations
Dr Johan van Wyk
Chief Systems Officer
Dr Clive Prior
Chief Financial Officer
Ms Julie Buissinne
Human Resources Director
Vacant
A list of PathCare Pathologists is available
on our website at www.pathcare.co.za
Pathologist contact email
[email protected]
Published June 2006 by:
PathCare Business Centre • PathCare Park
Drs Dietrich, Voigt, Mia & Partners
Neels Bothma Street • N1 City • Goodwood • 7460
Private Bag X107 • N1 City • Goodwood • 7463
Tel : (021) 596 3400 • Fax : (021) 596 3726
S A N A S
ACCREDITED
LABORATORY
ISO / IEC
17025 / 15189
pathology forum
beyond the borders
During the early 1990's the partners in the practice of Dietrich, Street and
Partners (DSP) concluded that future changing circumstances in the country
could pose threats not only to private medical practice overall but specifically
also to private pathology. Based on the premise that threats should be viewed as
opportunities, DSP developed strategies to deal with these potential threats to
ensure a more secure future.
At that time private pathology in South Africa was fragmented and consisted of
practices of varying size, each operating independently, and characterised by a
limited bargaining power and an inability to fully maximise benefits from
economies of scale. As cost-effective practice of pathology is largely volume
driven, the management and partners of DSP saw value in consolidation
through associations and mergers with other practices in the region. This
approach eventually led to the formation of the PathCare Group of pathology
practices, currently one of the three large laboratory groups in private pathology
in South Africa.
The burgeoning Group also endeavoured early to expand beyond our national
borders. As a first step the Group merged with the private pathology practice of
Dr Jamie van Zyl in Windhoek, Namibia, in 1992. The practice in Windhoek has
since grown considerably and now performs the majority of private pathology
work in that country.
During the early 1990's the Group decided to open facilities in the United
Kingdom (UK). Rotation of South African staff through these gives them the
opportunity to gain wider experience and bring increased skills back to South
Africa.
With the collapse of the rand during the nineties, the Group experienced
additional pressure to broaden its base as almost all the reagents and
equipment were bought in dollars, pounds or yen. Expansion into the UK
enabled the Group to earn pounds which proved very helpful in financing
foreign purchases of reagents and equipment.
Automated Line
Cape Town
A recent development has been the drive in the UK towards privatisation of
certain sectors of the National Health Service. This gave impetus to the
formation of PathCare International Limited (PIL) which is a UK company fully
owned by PathCare in South Africa. PIL is involved in joint ventures with the New
Victoria Hospital in Kingston-on-Thames and Doublesure Diagnosis in Devon. It
also fully owns laboratories which provide laboratory services to the Partnership
Health Group Independent Sector Treatment Centres in Plymouth and
Barlborough Links.
The Group has expanded further into Africa in response to the Nepad initiative.
PathCare is a minor shareholder in laboratories in Kenya and Nigeria. These
laboratories are internationally accredited. A depot has been established in
Dubai. Overflow work from the Emirates Airline Clinic in Dubai as well as
specimens from other doctors, clinics and hospitals in the United Arab Emirates
and surrounding countries are collected there and flown to Cape Town for
processing. Similar working relationships have been established with
laboratories in Mauritius, Ethiopia and Ghana.
Burj Al Arab Hotel
Dubai
Nigeria
Processing this overflow work in Cape Town increases the volumes of specialized
tests in the laboratory. This allows PathCare to increase the number of South
Africans employed locally and to develop high-technology laboratories with
skilled staff and the opportunity to train South African citizens in these fields.
This also results in an inflow of revenue to South Africa.
It is clear that by a process of association and amalgamation PathCare has
formed a consolidated base from which to extend into the international arena
thereby not only bringing benefits to itself but also to South African pathology in
general.
2
Nigeria Laboratory
Dr Bruce Dietrich
pathology forum
anaemia of chronic disease
Causes of anaemia of chronic disease
The three main causes of ACD, infection, inflammation and neoplasia, are
responsible for about 75% of cases (see table).
Although the chronic diseases that cause ACD are mostly easily identified, this is
not always the case and therefore occult disease should be considered in all
cases of unexplained anaemia.
Characteristics of anaemia of chronic disease
•
•
•
•
Anaemia of chronic disease
(ACD) is the commonest
anaemia in hospitalised
patients and is the second
most common anaemia, after
iron deficiency anaemia,
outside the hospital. ACD
occurs in patients with acute
and chronic immune
activation and is therefore
often referred to as anaemia
of inflammation.
Moderate anaemia-normochromic normocytic to hypochromic microcytic
Hypoferraemia (decreased serum iron)
Raised tissue iron stores.
Decreased red cell production
Pathophysiology
The immune system is the driving force behind ACD, with cytokines (eg.
interleukin 1, interferon gamma and tumour necrosis factor) and cells of the
reticulo-endothelial system (RES) playing a central role.
A determining change in ACS is dysregulation of iron homeostasis, causing an
increased uptake and retention of iron in the cells of the RES. Iron is diverted out
of the circulation to the stores with a resultant decrease in iron available to the
erythroid precursors which in turn leads to ironrestricted erythropoiesis.
Hepcidin, released by the liver in response to inflammation, is an important
mediator of the process as it supresses iron absorption and iron release from
stores.
Figure 1
Erythrocytes in ACD
Figure 2
Iron (blue) in bone marrow particle
Other pathophysiological factors are:
•
•
•
a curtailed proliferation of erythroid precursors as a result of direct
inhibitory effects of cytokines;
insufficient erythropoietin (EPO) response for the degree of
anaemia; and
moderately decreased red cell survival resulting from increased
erythrophagocytosis.
Erythropoiesis can also be suppressed through infiltration of the bone marrow
by tumour cells or microorganisms.
Factors which may aggravate the anaemia include episodes of blood loss,
vitamin deficiencies (eg vitamin B12 and folate), hypersplenism, autoimmune
haemolytic anaemia, renal insufficiency and radio- and chemotherapy.
Dr Alicia Els
3
pathology forum
Chronic renal disease
Anaemia of chronic renal disease shares features with ACD, although the
decreased production of EPO as a result of renal insufficiency and the
antiproliferative effects of uraemic toxins contribute significantly to the
pathophysiology.
It is important to note that in patients with end stage renal disease, chronic
activation of the immune system can develop from contact activation by dialysis
membranes or as a result of repeated infections.
Laboratory evaluation of ACD
•
•
•
•
•
Serum iron and transferrin saturation is decreased (hypoferraemia).
Serum transferrin is decreased and serum ferritin is increased as part of
the acute phase response, or normal.
Soluble transferrin receptor levels are normal in pure ACD and may be
useful to recognise true iron deficiency in patients with ACD.
The bone marrow shows increased iron in macrophages but reduced
iron transfer to sideroblasts.
Determination of erythropoietin levels is only useful in patients with a
haemoglobin level less than 10g/L and interpretation should consider
the degree of anaemia.
Treatment of ACD
Treatment is indicated as the anaemia itself has adverse effects and also
because anaemia often indicates a poorer prognosis in a variety of conditions.
It is important to correct a moderate anaemia in patients older than 65 years, in
patients with additional risk factors (eg coronary vascular disease, lung disease
and chronic renal disease) and in patients receiving chemotherapy or dialysis.
Treatment of the underlying disorder, if possible, is most important. Alternatives
include red cell transfusion and recombinant EPO in selected patients.
CAUSES OF ACD
Infection
Neoplasia
Inflammatory
•
•
•
•
•
•
•
•
•
•
•
Viral infections, including HIV
Bacteria
Parasites
Fungi
Haematological malignancies
Solid tumours
RA, SLE and other connective tissue diseases
Vasculitis
Sarcoidosis
Inflammatory bowel disease
Chronic rejection after transplantation
Chronic renal disease
4
pathology forum
clinical implications of GFR estimation
by MDRD equation
Why do many normal individuals have decreased MDRD
calculated GFR values?
An important limitation of the GFR estimation equations is decreased accuracy
at higher levels of GFR. It has been shown that GFR estimates by MDRD
calculations are indeed more accurate in patients with chronic renal disease,
than in healthy subjects.
These findings are also reflected in our laboratory data. MDRD calculated GFR
results <60 ml/min show a closer correlation with creatinine clearance results,
than MDRD calculated GFR results >60 ml/min (see figure).
R 2 = 0.77
y = 0.5998x + 7.6519
The National Kidney
Foundation (US) and the UK
Chronic Kidney Disease
Guidelines Group have
recommended that all serum
creatinine concentrations
now be reported with an
estimated glomerular
filtration rate (GFR),
calculated by the abbreviated
MDRD equation * (MDRD
calculated GFR). This has
been implemented at
PathCare. An overview of the
GFR prediction equations was
presented in the previous
issue of the Pathology Forum.
In this article, we discuss
some practical implications
of the MDRD calculation.
90
80
70
MDRD
60
50
40
30
20
10
0
-10
0
20
40
MDRD <60
60
80
100
120
CrCl
y = 0.4853x + 34.509
R 2 = 0.43
180
160
MDRD
140
120
100
80
60
40
20
20
MDRD >60
Dr Esmé Hitchcock
5
70
120
CrCl
170
220
pathology forum
How should we interpret
decreased MDRD calculated GFR
results?
Reasons for the relatively inferior performance of the MDRD
equation in people with normal or near-normal renal function
are:
•
A GFR <60 ml/min suggests chronic
renal disease. A GFR >60 ml/min, with
markers of kidney damage, such as
proteinuria, also suggests chronic renal
disease. Individuals with a GFR 60-90
ml/min, with no markers of kidney
damage, but with risk factors for kidney
disease, such as hypertension, diabetes
mellitus, family history of renal disease
and autoimmune disease, should be
evaluated further.
Selection bias: The equation was developed in a population with
chronic renal disease (mean GFR 40 ml/min).
• The use of regression analysis, by its very nature of best fit to the observed
mean, decreases the accuracy of the estimate in populations with
different ranges of GFR. If applied to individuals with higher ranges of
GFR, the GFR will be underestimated.
• The relationship between serum creatinine and GFR may differ
fundamentally in populations with and without renal disease.
At the same serum creatinine level, age, and sex, GFR is on average 26%
higher in healthy persons than in patients with chronic renal disease. A
greater muscle mass and higher dietary protein intake in healthy persons
may account for this difference.
Can MDRD calculations be used in
acute renal failure?
No, the MDRD GFR estimate should not
be used during acute renal failure. Due
to a more complex association between
serum creatinine and rapidly changing
renal function, the GFR estimation
equations are not applicable during
acute renal failure.
Other possible
causes for unreliable MDRD calculated
GFR results were listed in the previous
issue of the PathCare Pathology Forum.
Conclusion
Figure 1
Interdigitating secondary processes
of podocytes on the outer surface of a
capillary in the renal glomerulus.
GFR estimation by the MDRD equation is
not accurate in the higher ranges of GFR.
It can, however, detect impaired renal
function much earlier than serum
creatinine alone and a MDRD calculated
GFR result between 60-90 ml/min should
be evaluated further in patients at risk for
chronic renal disease. The MDRD
equation currently provides the most
useful estimate of GFR in adults and is the
marker of choice for monitoring renal
function in chronic renal disease.
Figure 2
Diabetic nephropathy, thickening of
glomerular capillaries
Variability of serum creatinine levels in healthy persons could be mainly
attributed to muscle mass and dietary protein intake, A 50% higher
serum creatinine level is associated with an 18% lower GFR.
In chronic renal disease patients, a 50% higher serum creatinine level is
associated with a 41% lower GFR, possibly reflecting that here the GFR
may have the dominant effect on serum creatinine variability rather than
muscle mass and protein intake. It also reflects the increasing role of
tubular secretion of creatinine on serum creatinine levels as GFR
declines.
•
*
Calibration bias: The serum creatinine results from the MDRD study
laboratory may differ from those obtained in other laboratories. A
constant calibration bias between laboratories causes greater
inaccuracies in estimated GFR for persons with a normal serum
creatinine level, than for those with an elevated serum creatinine level.
In cases where the serum urea and
albumin values are also available, the
original MDRD equation is used.
Input by Dr. Julian Jacobs is gratefully
acknowledged.
If the MDRD calculated GFR results in the higher range are not
accurate, why do we report them?
The MDRD calculated GFR is nonetheless a more sensitive index of decreased
GFR than serum creatinine alone. It is well known that the GFR has reduced by
approximately 50% before the serum creatinine rises above the reference
range. Reporting serum creatinine alone, may therefore lead to delays in
diagnosis and treatment of chronic renal disease.
Sources:
1. Ann Intern Med. 2004;141:929-37
2. Ann Intern Med. 2003;139:137-47
6
pathology forum
oral epithelial precursor lesions
Precursor lesions are
defined as altered
epithelium with an
increased likelihood of
progression to squamous
carcinoma (SCC). The
altered epithelium shows
a variety of cytological
and architectural changes
that have traditionally
been grouped under the
term dysplasia¹. Atypia is
not considered
synonymous with
dysplasia and has been used in the
context of inflammatory and
regenerative changes particularly
referring to cytological features. Atypia
refers to cytological changes that may or
may not be pre-malignant. Dysplasia
refers to architectural disturbance
accompanied by cytological atypia. The
principal precursor lesions of the oral and
oropharyngeal region are white patches
(leukoplakia) (Fig 1) and red patches
(erythroplakia) (Fig 2) or mixed red and
white lesions (speckled leukoplakia Fig.
3).
Histopathology
Precursor lesions in the oral cavity can be thick or atrophic. By definition there is
no invasion of the lamina propria. The magnitude of the surface keratinisation
is of no importance and is often misleading.
Hyperplasia describes the increase in cell numbers that may occur in the
spinous layer or in the basal-parabasal cell layers (basal cell hyperplasia).
The architecture shows regular stratification without cellular atypia.
Dysplasia is architectural disturbance with cytological atypia. There is a
challenge in the recognition of the earliest manifestations of dysplasia and no
single combination of the features in Table 1 allow for consistent distinction
between hyperplasia and the earliest stages of dysplasia. Dysplasia is a
spectrum of cytological features and no rigid criteria exist to precisely delineate
this spectrum into specific categories. However, the features listed in Tables 1
and 2 can be applied to broadly distinguish mild, moderate and severe
dysplasia.
Mild dysplasia
Architectural disturbance is limited to the lower third of the epithelium and
accompanied by cytological atypia. (minimum criteria for dysplasia) There is
often a change in the keratin pattern in the area i.e. from para-keratin to orthokeratin (Fig.4 and 5).
Moderate dysplasia
The architectural disturbance in moderate dysplasia extends from the basal
layer up into the middel third of the epithelium, but on the degree of atypia may
be more severe.
Severe dysplasia
Architectural disturbance extending more than two thirds of the
epithelium with associated cytological atypia. The oral epithelium can
be atrophic and the severe atypical changes may be located in the
basal cell region (Fig. 7).
WHO CLASSIFICATION (2005)
SQUAMOUS INTRAEPITHELIAL NEOPLASIA (SIN)
Mild dysplasia
Basal/parabasal cell hyperplasia
SIN 1
Moderate dysplasia
Atypical hyperplasia (risky epithelium)
SIN 2
Carcinoma in-situ
Severe dysplasia / carcinoma in-situ
> two thirds of the epithelial thickness
shows atypical dysplasia
SIN 3
The theoretical concept is that malignant transformation has occurred
but invasion is not present. Pronounced cytological atypia is present
and extends the full thickness of the epithelium. Atypical mitotic
figures and abnormal superficial mitoses are commonly seen. The
Table 2. Classification scheme showing histological features
The majority of leukoplakias will not
show dysplasia and are as a result of
hyperplasia. The majority of leukoplakias
will not undergo malignant change and
may even regress if the aetiological agent
is removed. Red and mixed lesions
(speckled leukoplakia) show a high
frequency of dysplasia and are often of a
high grade.
Figure 1
Leukoplakia of the under
surface of the tongue with a
verrucous or wart-like
appearance.
Prof Vince Phillips
7
Figure 2
Erythroplakia of the right
pillar of the fauces
Figure 3
Speckled leukoplakia of
the cheek mucosa.
pathology forum
atrophic oral epithelium may show these signs limited to the
basal and parabasal layers and be covered by a layer of
keratin².
ARCHITECTURE
Abnormal variation in epithelial size
Loss of polarity of basal cells
Abnormal variation in nuclear shape
(nuclear pleomorphism)
Drop-shaped rete ridges
Abnormal variation in cell size
Increased number of mitotic figures
Abnormal variation in cell shape
(cellular pleomorphism)
Abnormally superficial mitoses
(mitoses above the basal cell layer)
Increased nuclear-cytoplasmic ratio
Premature keratinisation in single cells
(dyskeratosis)
Increased nuclear size
Keratin pearls within rete pegs
Atypical mitotic figures
Increased number and size of nucleoli
Hyperchromasia
Discussion
Squamous epithelium that is reactive, regenerative or
reparative in response to trauma, inflammation, irradiation or
ulceration may manifest architectural disturbance and a degree
of cytological atypia. Nutritional deficiencies of iron, folate and
vitamin B12 can simulate dysplasia. These lesions are not
considered precursor lesions and should be distinguished from
them.
Severe dysplasia is associated with a greater likelihood of
progression to malignancy. The dysplastic changes are as a
result of genetic changes within the epithelium. The mutations
are regarded to be a result of carcinogenic agents like tobacco
and alcohol usage as well as susceptible epithelial cells. There
are no genetic markers that reliably predict malignant
transformation.
Table 1. Criteria used for diagnosing dysplasia
The clinical appearance of the oral mucosa in precursor lesions can vary from a
thick white plaque to an erosive red area, but the clinical appearance only hints
at the changes that are present microscopically. Traditionally the dysplastic
lesions seen in the uterine cervix are graded according to the extent of the
atypical changes within the architecture of the epithelium. Thus a severely
dysplastic epithelium would show full thickness atypia. In the oral mucosa,
however, the clinical appearance often belies the atypical features seen
histologically. The surface retains a parakeratin or orthokeratin layer but the
basal cell and para-basal cell layers may show moderate to severe atypia (Figs.6
and 7) or even early infiltrating carcinoma.
The WHO² states that most leukoplakias are benign but that 4 - 8% of them will
become malignant. However, 30% of erythroplakias are either carcinoma insitu or infiltrating carcinoma at the first examination.
When the patient first presents with a white or red oral lesion, a biopsy of the
area is essential to establish the histological degree of dysplasia of the
epithelium. A patient with a mild or moderately dysplastic leukoplakia should be
encouraged to quit the carcinogenic habit and be followed up on a regular
basis. These patients should be examined at least once a year and if any change
Figure 4
Hyperkeratosis with basal
cell proliferation(hyperplasia)
and “drop-shaped” retepegs
Figure 5
Mild dysplasia. Cellular
pleomorphism of the basal cells
and prominent nucleoli.
CYTOLOGY
Irregular epithelial stratification
has occurred in the clinical appearance
i.e the lesions has become bigger or has
developed red areas, a biopsy should be
mandatory. Those patients with severe
dysplasia should be referred to an
oncologist.
Sources:
1. Gale N, Pilch BZ, Sidransky, Westra WH, Califano J.
(2005) Epithelial precursor lesions. Tumours of the
hypopharynx, larynx and trachea. Pathology &
Genetics. Head and Neck Tumours. WHO
Classification of Tumours. WHO Press. P140-3.
2.
Gale N, Pilch BZ, Sidransky, Westra WH, Califano J
Johnson N, MacDonald DG. (2005) Epithelial precursor
lesions. Tumours of the oral cavity and oropharynx.
Pathology & Genetics. Head and Neck Tumours. WHO
Classification of Tumours. WHO Press. P177-9.
Figure 6
Moderate dysplasia showing
pleomorphism of cells, mitotic
figures above the basal cell
layer, abnormal mitotic
figures and basal cells with
some nuclei showing more
than one prominent
nucleolus.
8
Figure 7
Severe dysplasia (squamous
intraepithelial neoplasia)
showing hyperchromatism and
atypical features. Abnormal
mitotic figures in the lower layers
of the epithelium, but a relatively
undisturbed surface layer.
The
Academy
for Tr aining &
Development
the PathCare Academy
for training and development
PathCare is pleased to introduce our newest division - the PathCare Academy
for Training and Development. The Academy opened its doors near our core reference
laboratory at N1 City in Cape Town on the 1st of February 2006.
The Academy was established by the
PathCare Chief Executive Officer, Dr
Bruce Dietrich, and his Executive
Committee. The new initiative is part of a
strategy to help address the South African
skills shortage in general and shortages
in the pathology sector, and in PathCare,
in particular.
The Academy is built upon three developmental pillars, namely: Development of
Technical Expertise, Quality Service, and
Business Capacity. The first major
programmes, which commenced
between February and April 2006, are
primarily focused on the technical field to
supply skilled professional and associate
professional technical staff for the future.
New and upgraded programmes in the
quality service and business capacity
fields commenced with the April 2006 to
March 2007 training year.
The Development of Technical
Expertise
Over the past six years PathCare has
been a leader in skills development in the
pathology sector. The first three
learnerships proposed for the sector were
spearheaded by PathCare through its
early involvement in the interim steering
committee and the first Board of the
Health and Welfare Sector Education and
Training Authority (HWSETA).
PathCare also spearheaded the establishment of Standards Generating Bodies
for new and / or updated qualifications to
be placed on the National Qualifications
Framework (NQF) of the South African
Qualifications Authority (SAQA).
PathCare has worked closely with the
Professional Board of Medical
Technology of the Health Professions
Council of South Africa (HPCSA) to
ensure that students receive quality
training and that they are able to be
registered with the Council in order to
practice.
Eric Spencer
The new programmes in the technical category include the following:
Learnerships for Phlebotomy Technicians
This new learnership provides learners from previously disadvantaged
backgrounds with an opportunity to acquire one of the newest nationally
recognised qualifications in South Africa. In keeping with international
trends, phlebotomy technicians develop specialised skills for the collection of
specimens in the pathology and blood transfusion sectors. The qualification
is designed to also strategically help relieve the shortage of qualified nursing
staff in the country. The new PathCare Academy commenced with South
Africa's first phlebotomy learners in a programme which is run with the
support and co-operation of the HWSETA, SAQA, HPCSA, Western Province
Blood Transfusion Services, and Cape
Peninsula University of Technology (CPUT).
Medical Laboratory Technicians
The training of medical laboratory technicians
is not yet in the form of a registered
learnership. Yet PathCare has dramatically
increased its number of student technicians
and is training them through the Academy and
in our accredited training laboratories in a
programme as similar to that of a learnership
as is possible at this time. Upon completion of
the programme, students write an exam set by
the professional board of the HPCSA and when successful are registered with
the Council. For the first time, PathCare has recruited additional numbers of
previously disadvantaged individuals from the general public (previously
only existing staff trained as technicians) to undergo this Academy
programme.
Bursaries for Medical Technology Students
Through co-operation with the CPUT, the Academy has also introduced new bursary schemes
for students of bio-medical technology. The first bursaries have been awarded for 2006.
These students will complete their experiential learning and internships in PathCare laboratories throughout South Africa and will provide a new pool of qualified medical technologists
from previously disadvantaged backgrounds for the organisation.
Bridging course from Medical Technician to Medical Technologist
The Academy is sponsoring a number of existing PathCare staff to attend part-time instruction
through the CPUT in order to again increase the number of qualified professionals in the
organisation.
Education is the most powerful weapon
In addition to the above
which you can use to change the world
programmes, various other
- Nelson Mandela
technical short courses are to be offered by the
Academy for existing staff in order to ensure that
the knowledge and skills of our technical and professional personnel are continuously
developed.
The Development of Service Quality and Business Capacity
Various new short courses and certificate programmes in the service quality and business
capacity categories will be introduced at the Academy in the 2006-2007 training year. These
programmes, like those in the pillar of technical expertise, run with the national SETA training
year. Our Workplace Skills Plans and Annual Training Reports have been fully approved by the
HWSETA every year since the inception of the Skills Development Act.
Through a combination of internal programmes and programmes outsourced to accredited
providers nationally, the Academy will help to ensure that PathCare's service delivery is
constantly enhanced through the continuous development of all of our staff. Courses to be
offered in the Academy prospectus for the year include programmes in customer care, quality
assurance, occupational health and safety, diversity awareness, coaching, industrial relations,
conflict management, human resources, financial skills, change management, various
computer skills, and general management skills, among others.
Particular emphasis is also being placed on the skills development of previously disadvantaged individuals in general, and the development of existing managers and new managers
for the future. Recently, a HWSETA supported initiative saw previously disadvantaged staff
members attend management development programmes through the University of
Stellenbosch Business School; further such programmes will be provided by and / or
outsourced by the Academy in the 2006-2007 training year.
By providing these learnerships, certificate and diploma programmes, bursaries, and short
courses through the three developmental pillars of of technical expertise, quality service, and
business capacity, the new PathCare Academy for Training and Development will contribute
towards the broader skills revolution in South Africa and will help ensure that PathCare offers
a continuously improving service to our valued supporters and patients. PathCare is proud of
this new initiative and we trust that it will grow from strength to strength.
pathology forum
microangiopathic haemolytic anaemia
Erythrocyte (or red cell) fragmentation
syndromes are characterised by the
presence of red cell fragments
(schistocytes) in the blood film. These are
usually accompanied by intravascular
haemolysis (fragmentation haemolysis).
There are many causes of fragmentation
haemolysis. Some common causes are
summarised in Table 1. This article will
concentrate on microangiopathic
haemolytic anaemia (MAHA).
CATEGORY
MODE OF HAEMOLYSIS
1. Microangiopathic haemolytic anaemia
2. Other physical trauma such as:
• Thermal injury (burns)
Physical damage to erythrocytes by
microthrombi
Thermal damage to cell membrane proteins
• Cardiac trauma (e.g. prosthetic valve)
Physical trauma to erythrocytes
• March haemoglobinuria (e.g. marathon
runners)
Excessive force on the erythrocytes as they pass
through the microcapillaries
Table 1: Causes of fragmentation haemolysis
Damage to the endothelial lining of the small vessels
Leucocytosis
may be
present
Platelet activation with the formation of fibrin strands and microthrombi
Thrombocytopenia due to
the consumption of
platelets
Fibrinolysis
Red cell fragmentation
Splenic sequestration
MAHA is a term that describes a
haemolytic process caused by
microcirculatory lesions. Damage to the
endothelial lining of the small vessels
results in deposits of fibrin within these
vessels. As erythrocytes (red blood cells)
are forced through the fibrin strands,
their cell membranes may be sliced open.
This leads to schistocytes (red cell
fragments) in the peripheral blood film
and is reported as fragmentation
haemolysis.
Dr Engela le Roux and Dr Teresa Nel
Intravascular haemolysis
Anaemia
Increase in the
number of
reticulocytes
Haemoglobinaemia
é in serum LDH and AST
é in serum unconjugated bilirubin
Haemoglobinuria
ê in serum haptoglobin ( this is seen with chronic haemolysis)
Figure 1 : Pathogenesis of microangiopathic haemolytic anaemia (MAHA)
11
pathology forum
1.
2.
3.
4.
5.
6.
It is important to identify the underlying
disease or condition responsible for the
MAHA and to start with effective
treatment and supportive care
immediately. The clinical symptoms, age
group and target organs affected and
laboratory tests may help to make the
correct diagnosis. See Table 2 for
diseases and conditions associated with
MAHA.
Disseminated Intravascular Coagulation (DIC)
Haemolytic Uraemic Syndrome (HUS)
Thrombotic Thrombocytopaenic Purpura (TTP)
Disseminated Carcinoma
Malignant Hypertension
HELLP Syndrome
Table 2: Diseases and conditions associated with MAHA.
Because of the similarity in clinical
manifestations there has been
considerable ongoing debate as to
whether TTP and HUS are simply different
clinical expressions of the same disease.
However, TTP occurs most often in young
adults and the variety of manifestations
present in TTP reflects damage to
multiple organs. The neurologic
symptoms of TTP are more prominent
and the condition carries a higher
mortality rate than HUS. There is an
increase in the prevalence of HIV
associated TTP and the central nervous
system (CNS) abnormalities are more
severe in HIV cases. The CNS
abnormalities of TTP include headaches,
confusion, seizures and coma. Drugs
associated with TTP include mitomycin,
ticlopidine, clopidogrel, cyclosporin and
quinine.
Fragmentation Haemolysis
Child
Pregnant woman
Male or pregnant female
without pre-eclampsia
DIC screen +
Acute renal failure
Pre - eclampsia
DIC
Consider HUS
DIC screen -
CNS symptoms ++
Consider HELLP
Clinical history:
Eg
Hypertension
Prosthetic valve
Carcinoma, etc.
Consider TTP
HELLP syndrome is a severe form of preeclampsia manifesting with hemolysis,
elevated liver enzymes and low platelets.
Figure 2: An approach to MAHA
Laboratory tests
Abnormalities in coagualation tests help
to distinguish between DIC and TTP/HUS.
Abnormal coagulation tests with DIC
include:
• Prolonged PT, PTT and thrombin time
• Increased fibrin degradation
products (FDP) and D-dimers
• Decreased fibrinogen levels
• Decreased antithrombin III levels
These abnormalities are absent in
TTP/HUS.
12
pathology forum
Summary:
• If faced with a patient with MAHA treat as TTP until proven otherwise.
• The clinical symptoms, age group affected, organs involved and laboratory
tests may assist in establishing the correct diagnosis.
• DIC coagulation screening helps to distinguish DIC from TTP/HUS
• The haematologist plays an important role in the diagnosis of MAHA through
the morphological evaluation of the peripheral blood smear and the
identification of fragmentation haemolysis.
• MAHA is a fragmentation haemolytic
process due to endothelial lining
damage of the small vessels
resulting in fibrin deposits within the
vessel.
• MAHA is a medical emergency and
early diagnosis, supportive care and
correct treatment will reduce the
mortality rate.
CATEGORY
ASSOCIATED CONDITION
AGE
CHARACTERISTICS
PATHOPHYSIOLOGY
TREATMENT
Microthrombi form with an
increased consumption of
platelets and coagulation
proteins. Patient develops
bleeding tendencies.
Treat the underlying cause.
Fresh Frozen Plasma
Cryoprecipitate
Blood products (red cell
concentrate and platelets
as is appropriate)
Heparin is controversial can be considered if liver
function is normal.
DIC
Infections
Complications of
pregnancy
Neoplasm (e.g. AML-M3)
Massive tissue injury
Vascular injury
Miscellaneous e.g. snake
bite
Any age
HUS (D+ or D-)
Classically D+
(with diarrhoea) or
occasionally D- ( without
diarrhoea)
> 90% of cases are due to
verocytotoxin-secreting
bacteria such as S.
dysenteriae or E. coli
0157:H7
<5 year (occasional reports MAHA
of adult cases)
Thrombocytopaenia
Acute renal failure
Mild CNS symptoms
DIC screen is negative
Previously healthy child
Toxin induces damage to
the colonic mucosa. This
allows for the toxin to enter
the circulation which leads
to endothelial damage
which is most prevalent in
the glomerular capillaries.
Peritoneal dialysis in the
anuric phase
Transfusions
Treat the hypertension
Treat the water and
electrolyte imbalances.
Fresh frozen plasma
exchange can also be
considered.
TTP
40% of cases are
associated with infection of
which HIV is a major
component.
10-25% of cases are
associated with pregnancy
or oral contraception.
Other causes include
drugs, systemic lupus
erythematosus, lymphoma,
carcinoma, etc.
20-50 years old
Females are affected more
than males
MAHA
Thrombocytopaenia
Renal dysfunction
Severe CNS symptoms
Fever
DIC screen is negative.
Lack of von Willebrand
factor cleaving protease
enzyme. This leads to
elevated levels of large von
Willebrand multimers.
Fresh Frozen plasma
Fresh Frozen plasma
exchange
IV steroids with or without
vincristine
Cryosupernatant (NOT
cryoprecipitate )
Anti-platelet agents
Splenectomy can be
considered for those
patients that develop the
chronic relapsing type of
TTP.
CONTRA - INDICATIONS:
Platelet transfusion as this
increases thrombi
formation.
HELLP syndrome
10% of pregnancies with
eclampsia develop HELLP
syndrome
Pregnant women
MAHA
Thrombocytopaenia
Elevated liver enzymes
Pre-eclampsia
The precipitating factor is
unknown.
Deliver the foetus. Steroid
therapy (lung maturation;
reduces cell destruction
and eliminates platelet
transfusion demands in the
mother).
Malignant hypertension
Underlying severe
hypertension
Mainly adults
MAHA
Thrombocytopaenia
Severe hypertension
Unknown
Possibly fibrinoid necrosis
of the arterioles
Lower blood pressure.
Disseminated cancer
Underlying carcinoma with
extensive metastases
(especially mucin secreting
tumours such as
adenocarcinoma)
Mainly adults
MAHA
Thrombocytopaenia
Underlying carcinoma
Endothelial damage
Chemotherapy and
supportive care.
Table 3 : Sumary of diseases and
conditions associated with MAHA
13
MAHA
Thrombocytopaenia
DIC screen is positive
pathology forum
the coeliac iceberg
Introduction
Coeliac disease (coeliac sprue) or gluten sensitive
enteropathy is characterized by an inflammatory
response in the mucosa of the small intestine after the
ingestion of wheat gluten, resulting in malabsorption.
Untill recently it was suspected that this is primarily a
disease of infants, but with more sensitive and specific
laboratory tests, the diagnosis is now being made more
frequently in adults. In fact it has been reported that up to
20% of new diagnoses are made in patients over the age of
60. Previously it was thought that the incidence is about
1:3000, but with recent emerging evidence it is estimated
to be 1:100 to 1:300, depending on the country.
Pathophysiology
The pathogenesis of coeliac disease (CD) is based on the presentation of gluten
in the small bowel in a genetically predisposed person, eliciting an
inappropriate T-cell response. There is a 10% prevalence of CD in first degree
relatives with CD.
malabsorption. Currently the most
common presenting feature in adults is
anaemia. Extra-intestinal symptoms
include osteoporosis, short stature,
dental enamel defects, arthritis and
arthralgias as well as neurological
symptoms like peripheral neuropathy,
cerebellar ataxia, epilepsy and migraine.
Over 95% of CD patients express the HLA-DQ2 and -DQ8 molecules. These
molecules bind the gliadin fraction of gluten, present it to the T-helper cells to
activate tissue transglutaminases, which in turn deaminate glutamine of the
gliadin peptide to glutamic acid. This elicits a stronger T-cell response. These
lymphocytes activate other lymphocytes with the release of cytokines and TNF-α
which result in villous atrophy.
The gold standard for the diagnosis of CD
remains a small bowel biopsy
demonstrating villous atrophy while the
patient is still consuming a gluten
containing diet (four slices of bread daily
for six weeks), followed by improvement
after institution of a gluten free diet
(GFD). When a patient is suspected of
suffering from CD, there is a range of
laboratory tests that can be performed: a
full blood count to establish anaemia or
abnormal red cell morphology, tests for
the diagnosis of diabetes and thyroid
disease as well as tests for diagnosing
malabsorption, like folate, ferritin,
calcium or alkaline phosphatase levels.
The enzyme, tissue transglutaminase, is one of the targets of the autoimmune
response in CD. It has been noted that autoimmune diseases occur more
commonly in patients with CD. These include diabetes mellitus and autoimmune
thyroiditis. Unexpected episodes of hypoglycaemia or diarrhoea should alert the
clinician to the possibility of CD.
Diagnosis
Classically the diagnosis of CD is made on infants between the ages of four
months and two years presenting with small bowel symptoms like vomiting,
diarrhoea, abdominal distension and impaired growth. Older children may
present with short stature, delayed puberty, anaemia and rickets. Atypical CD
may present with no features of malabsorption, but only with abdominal pain,
persistently elevated transaminase levels, recurrent aphthous stomatitis,
arthralgia and defects in dental enamel. Children may even present with
behavioural disturbances, irritability, depression and poor performance at
school.
Until recently the tests available for the
diagnosis of CD were the small bowel
biopsy and the IgA and IgG antigliadin
antibodies. The latter tests had moderate
sensitivity but far less specificity than the
more current IgA anti-endomysial
antibodies and the IgA
antitransglutaminase antibodies.
Older patients may have more atypical symptoms presenting them to various
specialities before the diagnosis is made. These may vary from being tired all the
time, to persistent anaemia or gynaecological problems like infertility, recurrent
miscarriages or orthopaedic problems like fractures. The absence of diarrhoea
does not exclude CD. Common signs and symptoms include abdominal pain,
frequency of bowel movement, weight loss, bone disease, chronic anaemia, or
severe anaemia during pregnancy, fatigue and biochemical evidence of
14
Dr Cor Aalbers
pathology forum
The latter two newer tests have proven to be far superior to the former two and
are now the tests of choice. From a diagnostic point of view they perform equally
well and as the IgA transglutaminase antibody test is easier to perform than the
IgA antiendomysial antibody test, the transglutaminase test is the test of choice.
The possibility of false positive results are rare, but should be suspected in IgA
myeloma and in liver cirrhosis, while false negative results are primarily seen in
IgA deficient individuals. It should also be noted that if the patient has been on a
GFD the test results will also become negative. This feature is used to monitor
the patient's compliance with his diet.
Treatment
The management of a patient with a confirmed CD, is a life time commitment to
label reading and a GFD. Therefore there is no place for a therapeutic trial as a
firm diagnosis has to be made first before this commitment can be expected of
the patient. Once the GFD has been instituted in a patient with confirmed CD,
70% of patients have symptomatic improvement within two weeks. Rebiopsy
results will only improve after about three months. If no improvement is noted
on a GFD, other causes should be considered like irritable bowel syndrome,
lactose intolerance, microscopic colitis or pancreatic insufficiency.
COMMON FEATURES
LESS COMMON
FEATURES
Adults
Iron deficiency
Diarrhoea
General
Short stature
Delayed puberty
Children
Diarrhoea
Failure to thrive
Abdominal distension
Gastrointestinal
Recurrent aphthous
stomatitis
Recurrent abdominal pain
Steatorrhea
Extraintestinal features
Folate deficiency anaemia
Osteopenia/osteoporosis
Dental enamel problems
Hypertransaminasaemia
Thrombocytosis
Arthralgia/arthropathy
Polyneuropathy
Ataxia
Epilepsy
Infertility
Recurrent abortions
Anxiety and depression
Follicular keratosis
Alopecia
ASSOCIATED
CONDITIONS
Definitive associations
Dermatitis herpetiformis
IgA deficiency
Type I DM
Autoimmune thyroiditis
Sjögren's syndrome
Microscopic colitis
Rheumatoid arthritis
Down's syndrome
IgA nephropathy
COMPLICATIONS
Refractory sprue
Enteropathy-associated
T-cell lymphoma
Ca of the oropharynx,
oesophagus and small
bowel
Ulcerative jejunoileitis
Collagenous sprue
Possible associations
Congenital heart
disease
Recurrent pericarditis
Sarcoidosis
Cystic fibrosis
Fibrosing alveolitis
Lung cavities
Pulmonary hemosiderosis
Inflammatory bowel
disease
Autoimmune hepatitis
Primary biliary cirrhosis
Addison's disease
SLE
Vasculitis
Polymyositis
Myasthenia gravis
Schizophrenia
Clinical presentations of coeliac disease
Sources
1. Farrell, RJ and Kelly, CP. Current concepts: Celiac Sprue.
N Engl J Med, 2002 Vol. 346, No 3; 180-188.
2. Hill, PG and McMillan, SA. Anti-tissue transglutaminase
antibodies and their role in the investigation of coeliac
disease. Ann Clin Biochem 2006; 43: 105-117
Photos of figures 2 & 3:
Dr Stephen Price
Figure 1
Normal villi in small intestine
Figure 2
Atrophic villi and lymphocytic
infiltrate in small intestine in
coeliac disease
Figure 3
CD3+ T-lymphocyte infiltrate in
mucosa and epithelium of small
intestine in coeliac disease
pathology forum
diagnosis of smear negative pulmonary
and extra pulmonary tuberculosis
The increase in smear-negative cases of tuberculosis (TB)
in HIV-infected individuals dramatically erodes the
predictive value of traditional methods of TB diagnosis
(microscopy and chest X-ray). Sputum smear positivity
rates in TB/HIV patients depend on the degree of immune
deficiency. As the CD4 count declines, the likelihood of
both extrapulmonary TB and smear-negative TB
increases.
Figure 1
Acid- and alcoholfast bacilli with Ziehl-Neelsen stain
Definition of Smear-Negative Pulmonary TB:
• At least two negative sputum specimens for TB, and
• radiographic abnormalities consistent with active TB, and
• decision by a clinician to treat with a full course of anti-TB chemotherapy,
or
• patients with a TB smear-negative sputum which is culture-positive for
Mycobacterium tuberculosis.
Indications for drug susceptibility
testing:
•
Smear positive at 2-3 months
•
Smear positive patients at the end
of treatment
•
Re-treatment cases
•
MDR contacts
WHO revised diagnostic algorithms:
The WHO recently revised their diagnostic algorithms for the diagnosis of TB
in ambulant and seriously ill patients. They can be viewed at
http://www.who.int/tb/smear_neg_tb_callforcomments/en/
Additional techniques that can reduce diagnostic delay in HIVinfected patients:
• Biopsy of peripheral lymph nodes
- fine needle aspirate: diagnostic yield of up to 75%
- core or excision biopsy: yield of up to 85%
• Induced sputum
• TB blood cultures and early morning urine for TB culture
• Bone marrow biopsy particularly in pancytopaenic patients
• Z-N stain and culture of gastric aspirations ( children)
When to request TB culture:
• Extra-pulmonary TB
• Smear-negative cases
• Suspected multiple drug resistance (MDR)
• Suspected mycobacteria other than tuberculosis (MOTT)
• Gastric aspirations (for PTB in children)
Sources:
1. WHO Shop TB Department Expert Consultation
Meeting ,Sept. 2005
2. Saranchuk P et al: The Diagnosis of Smear-negative TB in
HIV-infected patients. 2nd South African AIDS
Conference, Durban, Abstract 573,2005
16
Kas Kasongo
pathology forum
learners benefit from pathcare gift
Carl Sagan (1934-1996), the celebrated astronomer, author, critical thinker and
populariser of science once commented: “As a result of the rapid social and
technological changes over the last few centuries, the world is not working well.
The solution is to teach people to think, not only analitically, but creatively and
conceptually as well”.
Dr Ruth Rabinowitz, a medical doctor and scientist, has produced a teacher's
handbook, Working with Wonder, which echoes Sagan's sentiments, and in her
own words, '..develops critical thinking, creative individuals and a love of
learning. It also makes learning fun.' The book demonstrates '..how teachers can
make any subject matter interesting and relevant, part of a world perspective, a
springboard for communication and creativity..' according to Dr Rabinowitz.
The book has been warmly and enthusiastically received in educational circles.
Professor Kader Asmal, the then Minister of Education, states in his foreword:
'This is a book that strives to develop skills that learners need to collect, analyze,
organize and critically evaluate information.' The book has also been endorsed
by a variety of public and private educational institutions including the
departments of education in the Western Cape, North West Province and
Gauteng, the Jane Goodall Institute and the Endangered Wildlife Trust.
Unfortunately owing to the nature of the book, it cannot be purchased by
schools through the usual tendering process. While some private schools and
large business groups that have outreach programs have purchased the book,
most schools can only obtain the book through donation.
PathCare, as part of our Social Responsibility Programme, indentified 200
primary schools in the Western Cape with English and isiXhosa as medium of
instruction and donated a copy of the book to each of these schools.
17
pathology forum
pathcare snippets
The practice of Drs Voigt and Partners
with its main laboratory in
Bloemfontein and part of the PathCare
Group recently celebrated its 44th
anniversary.
Dr Willie van Rijswijk, head of Accreditation and Quality Assurance at
PathCare, recently attended the Clinical Pathology Accreditation Annual
Conference at the Royal Society of Medicine in London. He delivered a
lecture on automation in pathology with reference to the automated line at
the new PathCare Reference Laboratory at N1 City. His lecture was well
received and afterwards he was assailed with questions.
Dr George Röhm joined the
PathCare laboratory in Welkom as
clinical pathologist at the beginning of
April 2006. Dr Röhm was a partner at
PathCare for many years but decided
after his retirement recently that he
wanted to remain active and therefore
took the opportunity to join the
Welkom laboratory when the need
arose there for an additional
pathologist.
PathCare's peripheral laboratory at
Medpark, next to the N1 City Hospital,
has been moved to the nearby
Reference Laboratory and equipped as
a new urgent laboratory. All pathology
work for PathCare from N1 City
Hospital will be performed in this new
laboratory. A dedicated courier will
ensure that specimens are urgently
delivered to the new facility. Our
nursing service in the N1 City Hospital
and the services at the Medpark depot
remain the same.
Dr Tertius Gouws head of the Veterinary Laboratory at N1 City, Mr. Louis
Birch of our Occupational Health Department and staff of PathCare's Client
Service Departments in Bloemfontein, Bethlehem, Klerksdorp and Welkom
recently attended the Nampo Agricultural Week and Harvest Festival at
Bothaville. The extent of the show was enormous with more than 600
exhibitors and 70 000 visitors. PathCare's exhibit attracted much attention.
18
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