A Case & A Question

It’s been awhile since I’ve posted a case … so here you go:

A 53 year old female with a past medical history of hypertension, GERD (gastro-esophageal reflux disease), and depression presented to the emergency room with chest pains. Standard laboratory work-up including CBC, BMP, and troponin was ordered and all were completely normal. The EKG showed some very slight ST changes. Since her blood pressure was elevated at 180/95 and there were some slight ST changes on the EKG, she was admitted for observation. Her troponin was repeated at four hours and were still normal. However, shortly after her four hour troponin draw, she had a myocardial infarction. Luckily, she survived with minimal residual effects. However, I was requested to identify why the “lab messed up the troponin results”.

Now this request was from a resident that I had not previously worked with. The cardiology attending told him to contact me. I spoke with the patient’s nurse who drew the four hour troponin who assured me that she had drawn and labeled it at the patient’s bedside per protocol. By this point another troponin had been drawn and reported which was very minimally elevated, far lower than would be expected for a myocardial infarction. So now I knew this was not a solitary specimen issue, but rather some sort of test interference. I looked over the patient’s medication list and did not see anything that could remotely cause this kind of test interference. I then saw the patient’s husband in her room and had a conversation with him. I asked him if she took any kind of vitamins, supplements, or oils. He replied that she daily took several vitamins including a multivitamin, b-complex, “some hair and nails stuff”, and others. I asked him if someone could bring the bottles of everything she took to the hospital so we could look at them.

Once we had the bottles of the seven different supplements, it totaled over 12,000 mcg of biotin was being taken by this patient every day – and none of the supplements was reported to her physicians because, as the husband said “it’s not medicine”. High doses of biotin interferes with the facility’s troponin methodology as well as many other immunoassay tests. This resulted in this patient’s troponins being resulted as normal when they were likely quite elevated.

A conversation with the patient’s care team, including the resident who made the initial contact, incorporated a discussion of biotin interference with the troponin test results. I also made them aware of other tests that her high biotin intake would affect. Finally, education that this was not a laboratory error, but instead a lesson in taking accurate patient history including all vitamins and supplements being consumed by the patient as well as considering those when interpreting laboratory test results. While I didn’t get much of a response from the resident, the attending physician asked if I could make a continuing education for the medical staff regarding biotin interference. She stated that she had heard of it, but never really understood “what the fuss was all about”. Now she said she clearly understood and believed all her colleagues should know as well.

So what is my question?

I have had requests for different types of written products, and since I can’t write everything all at once, I wanted to ask you, my audience, what types of products you want me to write. So please do me a favor and answer this poll:

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One thought on “A Case & A Question

  1. Reminds me of an episode of “House” on TV. It emphasizes the importance of having DCLS in medicine. Most people think a test for something always “works” and never consider interferences. It also points out the necessity of asking questions that might seem “outside the norm”. I am going to update my supplements list and make sure my doctor has that list because “you never know”. Given the increasing use of supplements, essential oils and probiotics in common use, we would all be wise to do this. Great case Dr. Gunsolus!

    Like

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