Although the combination of apple-green and golden-yellow hues might look lovely in a new spring ensemble, 色中色 clinical lab scientist Rena Kuramoto suspected something was amiss when these colors appeared on slides viewed under her microscope last fall at 色中色 Health System鈥檚 Specialty Testing Center.
Kuramoto鈥檚 instincts were on the mark. She and fellow clinical lab scientist
Jackie Csicsery were the key people in an investigation by the clinical virology
laboratory that led to a national recall of a product, used in clinical laboratories across the United States, which could have resulted in false positive results for the influenza B virus in respiratory specimens.
鈥淭his affected a huge number of laboratories,鈥 said Lynda Braun, supervising
clinical lab scientist. 鈥淗ad it not been detected by our lab, this defective product could have led to serious consequences for patients.鈥
Kuramoto鈥檚 and Csicsery鈥檚 analysis, investigative work and judgment reflect the complexity and importance of the clinical laboratory at 色中色 Health System and other health care institutions. The contributions of these laboratories are celebrated during National Medical Laboratory Professionals Week (this year鈥檚 week was April 19 to 25).
The events that led to the recall of the product, called Simulfluor, began with Kuramoto鈥檚 examination of a patient鈥檚 respiratory specimen. On one slide, Kuramoto was looking for the presence of influenza A and B, while on the second, she was on the lookout for the respiratory synctial virus, or RSV. The specimens on both slides had been treated with Simulfluor, which contains antibodies
to the viruses.
The first slide had cells glowing golden yellow, indicating the presence of influenza B, while the second slide had cells glowing apple green, signifying RSV, a respiratory virus that infects the lungs and breathing passage. The problem?
As Braun explained, 鈥淲e had samples showing positive tests for two viruses. That could happen, but it鈥檚 rare, and usually occurs during the normal flu season
between November and March. And this was in the early fall.鈥
Suspicious of the dual positive results, Kuramoto sent the samples to the Sacramento County Department of Public Health laboratory for further testing. The county鈥檚 tests showed a positive test for RSV only, confirming that Kuramoto鈥檚 skepticism was warranted.
Then, last November, Csicsery saw the same, dual-positive results in specimens from two separate patients on consecutive days, Friday and Saturday.
When she did, Braun recalled, Csicsery said, 鈥淚 don鈥檛 believe this. We need to follow up.鈥
Braun said, 鈥淭his was highly unusual. We hardly ever see that.鈥
On the following Monday, Braun called the Simulfluor manufacturer to notify it of her staff鈥檚 suspicions that something was amiss with the company鈥檚 product. The manufacturer replied that it would investigate and, on Friday, announced that it would recall the faulty product.
The replacement product arrived in a week and a half. During that period, the laboratory staff backed up influenza B results with a viral culture and an algorithm for testing and reporting, implemented by Christopher Polage, medical director of the Microbiology Laboratory. This process prevented reporting erroneous results.
鈥淭he excellent detective work and perseverance by our staff was tremendously important not only for our patients, but patients across the country,鈥 Braun said.
Darrell O鈥橲ullivan, chief administrative officer of the Department of Pathology and Laboratory Medicine, said, 鈥淲e are very proud of the complex, important work our laboratory professionals perform every day.鈥
David Ong is a senior public information representative for the 色中色 Health System.
Media Resources
Dave Jones, Dateline, 530-752-6556, dljones@ucdavis.edu