title: A patient with pseudo-Addison's disease and falsely elevated thyroxine due to interference in serum cortisol and free thyroxine immunoassays by two different mechanisms.
abstract: Interference in immunoassays is a widely recognized problem, which could potentially lead to unnecessary investigations and treatment. We describe a case where interference in a cortisol immunoassay led to a falsely low serum cortisol concentration and interference in the free thyroxine assay led to falsely elevated serum thyroxine concentrations, in the same patient. A 42-year-old woman with documented hypothyroidism underwent a synacthen test for suspected adrenal insufficiency. Previous thyroid function tests had been discordant and difficult to interpret, with elevated thyroxine and non-suppressed thyroid-stimulating hormone. The synacthen test showed a subnormal cortisol response and she was commenced on cortisol replacement. Clinically, it was doubted whether she had true adrenal insufficiency and it was thought that the cortisol results might be artefactually low due to assay interference. Cortisol was measured by an alternative immunoassay, before and after incubation in an antibody blocking tube ('Scantibodies'), after heat treatment and also after treatment with Protein A. The results supported assay interference and cortisol 'replacement' was stopped. Thyroxine had been discontinued although thyroid function tests (TFTs) were significantly different between analytical platforms, also consistent with interference. Thyroxine replacement was restarted and once on a stable dose, the discrepancy in TFTs was also investigated by similar procedures as for cortisol. Good clinician-laboratory interface and laboratory work-up of patients with results that are discordant from the clinical findings can reduce unnecessary investigation and inappropriate treatment.
authors.affiliation: Canterbury Health Laboratories, Christchurch, New Zealand.
authors.forename: Mohamed
authors.initials: M
authors.lastname: Saleem
authors.forename: John G
authors.initials: JG
authors.lastname: Lewis
authors.forename: Christopher M
authors.initials: CM
authors.lastname: Florkowski
authors.forename: Guy P
authors.initials: GP
authors.lastname: Mulligan
authors.forename: Peter M
authors.initials: PM
authors.lastname: George
authors.forename: Pamela
authors.initials: P
authors.lastname: Hale
mesh_terms: D000224:Addison Disease / Q000175:diagnosis*; D000324:Adrenocorticotropic Hormone; D000328:Adult; D000910:Antibodies, Heterophile / Q000276:immunology; D005260:Female; D006801:Humans; D006854:Hydrocortisone / Q000097:blood*; D007037:Hypothyroidism / Q000175:diagnosis*; D007118:Immunoassay / Q000592:standards; D013205:Staphylococcal Protein A; D013960:Thyroid Function Tests / Q000592:standards*; D013974:Thyroxine / Q000097:blood* / Q000627:therapeutic use
chemical_list: D000910:Antibodies, Heterophile; D013205:Staphylococcal Protein A; D000324:Adrenocorticotropic Hormone; D013974:Thyroxine; D006854:Hydrocortisone