A
Simple
Time-saving
Interpretative
Report
M e t h o d
for
Generation
I. Lactate A c i d D e h y d r o g e n a s e Isozymes
WILLIAM R. DITO,
M.D.
Pontine General Hospital, Pontiac, Michigan 4S053
ABSTRACT
Dito, William R.: A simple time-saving method for interpretative report
generation. I. Lactate acid dehydrogenase isozymes. Am. J. Clin. Pathol. 59:
439-447, 1973. A simple binary code technic for interpretative report generation is presented. Positive responses to an individually weighted (by a power
of 2) sequence of questions designed to detect pattern aberrations of lactate
acid dehydrogenase isozymes are summated and provide a decimal equivalent
to the described pattern. Proper interpretative prose format ascribable to the
numerically identified pattern was recorded in a Magnetic Tape Selectric
Typewriter and utilized in a batch process mode. Pattern description is accomplished numerically by a medical technologist and the appropriate interpretation recalled and typed on a final report prior to evaluation by the
pathologist. Almost two thirds of 1,888 serum patterns were either normal
or fast fraction (heart type) increases. One third were midzone, slow, or combined fraction increases.
T H E WEALTH OF INFORMATION that can
be
derived from the generally nonspecific patterns of lactate acid dehydrogenase (LDH)
isozymes has been well documented *• -<8;
their greatest potential is realized when the
results are correlated with a patient's clinical history. Often, interpretative reports
are generated by the clinical pathologist
who, witli little or no clinical information,
is forced to consult a patient's physician or
the hospital chart. Either effort is time
consuming or may be impractical with increasing work load. In practice, a differential listing of generic organ disease or disease states associated with an isozyme pattern is sufficient for most clinicians to
apply the results directly to their patients. 3,4
It is the purpose of this study to show
how the binary code may be utilized to
formulate or numerically classify patterns
Received February 22, 1972; received revised
manuscript May 10, 1972; accepted for publication
May 31, 1972.
from which an interpretative differential
report can be generated on a simple numerical basis by comparatively untrained
personnel. Interpretative descriptions can
be cataloged on a Magnetic Tape Selectric
Typewriter (International Business Machines Corp.) or similar instrument, allowing easy recall and typing in a previously
designed format.
Conversion of Patterns to Decimal
Equivalent
The conversion of LDH patterns to a
simple decimal equivalent is based upon
a series of questions, sequentially devised,
each bearing a preassigned weight representing a power of 2 (Table 1).
Questions were designed to elucidate the
relationships between fractions and worded
specifically for ease of interpretation. Once
formulated and assigned sequentially, the
question bears a weight representing a
power of 2 and cannot be changed without
439
440
DITO
Table J. The List of Questions and Their
Assigned Weights (2n) used for LDH
Isozyme Pattern Classification
Assigned
Weight
1. Are bands visible?*
2. Is LDH1 greater than LDH2 in staining
intensity and/or width?
3. Is LDH2 greater than LDH3 in staining
intensity and/or width?
4. Are LDH4 and LDH5 visible?
5. Is LDH5 deeply stained and prominent?
6. Is LDH4 greater than LDH5 in staining
intensity and/or width?
7. Are all visible bands increased in staining
intensity and/or width?
8. Is LDH3 most prominent?
9. Are both LDH2 and LDH3 increased
and most prominent?
10. Is this cerebrospinal
fluid?*
512
256
128
64
32
16
8
4
2
1
A.J.C.P.—Vol. 59
wood P-101) utilizing a 0 for no and a 1
for yes responses to the listed questions.
The resultant decimal equivalent was then
handed to our secretary, who utilized a
precataloged Magnetic Tape Selectric
Typewriter to provide a typewritten report.
Over the past 10 months, this system was
converted to use by medical technologists.
The medical technologist now enters the
yes-no answer into the calculator, providing the secretary with the decimal equivalent of the pattern. The report is typed
and handed to the clinical pathologist for
review and signature. Of all patterns, 98%
are seen for the first time by the pathologist in a ready form for signature and
report delivery.
•Questions 1 and 10 are included for cerebrospinal fluid
specimens specifically.
Important Assumptions and
Apparent Errors
altering a resulting decimal equivalent.
Obviously, question design must be able to
elucidate normal as well as the wide variety of abnormal patterns.
In pattern classification, each question is
answered with a "yes" or "no," and its preassigned weight is summated only when
answered positively. Upon completing all
questions, the resultant summed decimal
value will uniquely represent a series of
yes-no answers. This integer value is then
documented as representing the described
pattern. At this time, one can formulate
the necessary prose which will supply the
clinician with a differential listing of potential organ involvement, physiologic conditions, etc., associated with it (Appendix).
This method of interpretative data generation assumes proper performance and
quality control regardless of laboratory
technic employed. It also assumes that the
user has answered the questions specifically
as stated and has summed their weights
accurately. These factors being accepted,
the resultant decimal equivalent is a
unique, consistent representation of the
isozyme pattern.
The major error occurs through careless
understanding of the question. Frequently,
a number previously unrecorded results;
this should force an immediate review of
answer entry. In addition, when using a
programmable calculator people are prone
to look ahead and answer a succeeding
question, rather than the one temporally
required.
It should be emphasized that a programmable calculator or other computer device
is not necessary for utilization of this concept. A pencil and paper will allow proper
summation of weighted positive responses.
Mode of Use
T h e weights of all positively answered
questions are summated and the decimal
equivalent is referenced in the Appendix.
These may be typed directly from the
table listing or cataloged on a device such
as a Magnetic Tape Selectric Typewriter.
Initially, all data were observed by the
author and entered into a simple programmable calculator program (Olivetti-Under-
New Pattern Recognition
T h e recognition of a new pattern of
LDH isozymes is easily accomplished. In
March 1973
441
LDH ISOZYMES BY BINARY CODE
essence, any summated number that has
not been previously coded constitutes a
pattern that its author has not describe:!
previously. Once this occurs, it is advisable
to recheck data entry and simple mathematics (if done manually) to be assured
that it is indeed a new observation. The
usual investigation should then follow and
result in the coding of this new fraction
relationship and its appropriate interpretation. In this way, on all subsequent occasions that this pattern appears, the interpretation offered will be identical and,
importantly, not forgotten.
Table 2, Distribution of 1,888 Serum Lactate
Acid Dehydrogenase Isozyme Patterns
Identified by a Binary Code
Classification Method
Type
Total Number % of Total
Normal
All
Fast*
Midzone
Slowf
Combined^
TOTAL
511
240
606
103
241
187
27.1
12.7
32.1
5.4
12.8
9.9
1,888
100.0
* Cardiac type (LDHI).
t Hepatic type (LDH5).
X Any combination of fast, slow, or midzone increases.
Discussion
We have employed this means of interpretative report generation for LDH isozymes for approximately 3 years. 3,4 The
last year of experience with pattern incidence is seen in Table 2.
Clinician acceptance in our community
hospital has been excellent. In fact, during
the first year of experience they were unaware that this means was being employed
and failed to recognize the repetitive dictations in the more frequently encountered
patterns. The principal code numbers utilized for reporting are summarized in
Table 3.
In our institution, all sera with total
LDH values in excess of the normal population mean plus 3 standard deviations are
analyzed by electrophoresis on cellulose
acetate.6 In addition, the test is done on
specific request. The values expressed in
Table 2 represent a summation of both
types of order entry. Total serum LDH
values were usually obtained from an SMA
12/60 (Technicon Corp., Ardsley, N. Y.).
In view of our automatic electrophoresis
effort, a wide expanse of patterns was obtained, including those from patients with
complicated and uncomplicated obstetrical
courses, trauma from a wide variety of
sources including surgery, and various metabolic, neoplastic, and other conditions.
Table 3. Principal Decimal Equivalents of
Common Pattern Codes Obtained by
this Binary Code Technic
Type
Pattern Code Numbers
Normal
All
Fast
Slow
Midzone,
combined, and
cerebrospinal fluid
640, 704
648, 712, 744
896, 960, 968
720, 736
Remainder
Prior to the advent of this technic, the
evaluation, dictation, proofreading, and
final signing of 20 interpretations was estimated at a total of 30 to 60 min. of the
clinical pathologist's time. At the present
time, the pathologist views only the final
report, scanning a densitometric tracing
and reading the basic pattern description
(first paragraph of report). The same 20
patterns now occupy no more than 1 to 2
min. of the pathologist's time. T o this effect, the pathologist's time is economically
utilized and repetitive dictation of comparatively identical reports is not necessary.
Clinical correlation has been excellent
since the inception of this method. This
is related to the differential causal description applied to each pattern and the ability
of the clinician to correlate the physiologic, pathologic, or diagnostic terms em-
442
DITO
ployed with the disease a patient is known
or suspected to have. It has frequently led
physicians to a proper generic organ diagnosis which was not considered originally.
In our opinion, a differential list of conditions or disease states associated with pattcrns of LDH isozymes is more important
to the clinician than a specific diagnosis.
This conceptual approach has increased
physician acceptance of computer-assisted
diagnostic efforts because of psychologic
implications.
Interestingly, of the recorded 1,888 patient tests evaluated by the interpretative
effort, essentially two thirds were varieties
of normal or fast fraction increase of the
heart source variety. The remaining third
of patterns included midzone, slow fraction,
or combined {i.e., fast plus slow, mid plus
slow, etc.) presentations. When one combines normal, fast, and slow fraction increases into one group, this totals 72% or
almost three fourths of the total effort.
Only 28% of our total population group
presented with midzone or combined fraction increases. Chemical means of differentiation of complex pattern presentations
seem inadequate in this regard.
The method of report generation described in this paper will provide for the
testing and development of a variety of interpretative criteria by a laboratory without immediate access to a computer. Importantly, the basis of application can be
simply adapted to that instrument when it
becomes available to a user. The basic development efforts leading toward the ultimate goal in automatic interpretative reporting can be documented and their
algorithms "debugged" prior to computer
installation.
Although the initial assignation of question weight is arbitrary, the resulting decimal equivalent represents a specific, unique
codification number which is automatically
computed for tabular reference. In addition, this numeric code can be easily converted to its binary equivalent (manually,
by programmable calculator or computer)
A.J.C.P.—Vol.
59
and the isozyme or other pattern easily regenerated. This offers the potential of
minimizing requirements for patient data
storage when only clinicopathologic patterns of presentation are required.
T h e primary difference between this
method of LDH isozyme interpretation
and that described by Pribor and colleagues 7 is the technic of number generation. In the latter instance, specific code
numbers of 4, 5, or 6 were assigned to
individual observations and the observations expressed in a series of these three
numerals for reference in a tabular dictionary containing a series of disease patterns. Matching patterns were collated by
manual methods or a computer for expression on a report. Both systems of interpretation offer similar advantages, including easy conversion to a total computer
report generation. In both efforts, at least
one aspect of codification is arbitrary, i.e.,
the numeric designation (or weight) of an
observation. We feel that automatic generation of a numeric code which has a
simple basis for automatic pattern recall
that can be handled by a single simple
computer subroutine (decimal number conversion to binary code) offers a greater
potential of application. In addition, a
single computer subroutine can be employed to compute all potential pattern
presentations easily 5 by defining a disease
according to its pattern of absolute definitions and variables.
References
1. Batsakis JG, Briere RO: Interpretative Enzymology. Springfield, 111., Charles C Thomas,
1967, pp 9-32, 79-120
2. Batsakis JG, Briere RO, Markel SF: Diagnostic
Enzymology. American Society of Clinical Pathologists, Commission on Continuing Education, Chicago, 111., 1970
3. Oito WR: Programmable calculator for quality
control in clinical chemistry. Mini-computers
in the Clinical Laboratory. Edited by EM
Knights Jr. Springfield, 111., Charles C Thomas,
1970, pp 9-29
4. Dito WR: The desk-lop computer in clinical
bacteriology. Commission on Continuing Education, Council on Special Topics Workshop,
American Society of Clinical Pathologists, September 17, 1970, Atlanta, Georgia
March 1973
LDH ISOZYMES BY BINARY CODE
5. Dito WR, Bulmash J, Campbell J, et al: A simple numerical coding and identification system
for clinical bacteriology. I. Enterobacteriaceae.
Commission on Continuing Education, Council
on Special Topics, American Society of Clinical
Pathologists (Chicago, Illinois), 1972
C. Preston JA, Russell OB, Batsakis JG: Rapid
electrophoretic separation of lactate dehydrogenase isoenzymes on cellulose acetate. Am J
Clin Pathol 43:256-260, 1965
7. Pribor HG, Kirkham WR, Fellows GE: Programmed processing and interpretation of lactic acid dehydrogenase isozyme electrophoretic
patterns for computer or for manual use. Am
J Clin Pathol 50:67-74, 1968
8. Wilkinson ]H: Isoenzymes. Second edition. Philadelphia, J. B. Lippincott Co., 1970, pp 134-203
APPENDIX
LDH Isozyme Interpretations
514. Fast fraction increase with LDH1 less than
LDH2 equal to LDH3 greater than LDH4
less than LDH5.
This pattern is suggestive of various organ
necroses including lung, lymph node, central
nervous system, pancreas, salivary gland, and
thymus gland. It has occasionally been described with some forms of renal necrosis.
516. Midzone increase, principally LDH3.
This pattern is seen in posttraumatic states,
postpartum thrombocytosis, or thromboplastin release into peripheral blood. It may also
be seen in isolated instances of splenic necrosis. It has also been identified in postallergic drug reaction.
524. Fast fraction increase with LDII1 less than
LDH2 less than LDH3.
This pattern is unusual in that all three fast
fractions arc increased with particular prominence of LDH3. This finding may be associated in posttraumatic cases in which thrombocytosis or some means of thromboplastin
release into peripheral blood is possible. The
increase of LDH1 and LDH2 may possibly
be related to absorption from a hematoma.
578. Fast fraction increase with LDH1 less than
LDH2 greater than LDH3 and without visible LDH4 or LDH5 bands. Both LDH2 and
LDH3 are accentuated and prominent.
The increased prominence of LDH2 and
LDH3 when compared to the staining level
of LDH1 suggests the possibility of organ necrosis to include lung, pancreas, salivary
gland, central nervous system, thymus gland,
and lymph nodes.
580. Midzone increase, principally LDH3 associated with visible LDH4 and LDH5 bands.
This pattern is seen in posttraumatic states,
postpartum thrombocytosis, or with thromboplastin release into peripheral blood. It may
443
also be seen in isolated instances of splenic
necrosis.
582. Midzone increase with LDH1 less than LDH2
less than LDH3 greater than LDH4 less than
LDH5. LDH2 and LDH3 are both increased
with LDH3 being most prominent. LDH4
and LDH5 bands are visible.
Midzone increases are associated with a variety of conditions including thrombocytosis or
any problem wherein thromboplastin or
thromboplastin-like substance is elaborated
into the peripheral blood as well as in some
forms of splenic necrosis. The prominence of
LDH2 in addition suggests lymph node, pancreas, salivary gland, brain, or thymic necrosis.
584. All fraction increase, principally midzone
with LDH1 less than LDH2 less than LDH3
greater than LDH4 greater than LDH5.
This pattern has been identified in posttraumatic situations associated with thrombocytosis or thromboplastin release into peripheral blood. It has also been identified
with some neoplasms.
586. All fraction increase with LDH I less than
LDH2 greater than LDH3 greater than LDH4
less than LDH5. LDH2 and LDH3 are most
prominent and generally all visible bands
are increased in staining intensity.
This pattern is compatible with multisystem
involvement such as that due to trauma, neoplasm, vasculitis, various collagen diseases,
etc. The principal prominence of LDH2 and
LDH3 suggests necrosis of organs such as
lymph nodes, lung, salivary gland, pancreas,
brain, and thymus gland.
594. Midzone increase with LDH1 less than LDH2
equal to LDH3 greater than LDH4 greater
than LDH5.
This pattern is compatible with multisystem
involvement most often seen with neoplasm
and in view of the increase o£ LDII2 and
LDH3 (equal) lymph node, lung, salivary
gland, brain, thymus gland, pancreas, etc.
may be considered as possible sources or involvement. The pattern has also been seen
occasionally in posttraumatic situations in
which platelets are increased in the peripheral blood or there is splenic necrosis.
596. Midzone increase, principally LDH3 with
LDH4 being greater in staining intensity than
LDH5.
This pattern is compatible with thrombocytosis, some form of thromboplastin release
into the peripheral blood such as that seen
during an obstetrical delivery, spleen necrosis
due to tumor or infection, and posttraumatic
state.
444
DITO
598. Midzone increase with LDHl greater than
LDH2 less than LDH3 greater than LDH4
greater than LDH5. LDH2 and LDH3 are
both increased and LDH3 is most prominent.
Midzone increases are most often associated
with thrombocytosis or some form of thromboplastin or thromboplastin-like substance release into peripheral blood or splenic necrosis. The finding of LDH4 greater than LDH5
has been associated with previously mentioned group of entities but, in addition, it
has also been seen with a variety of neoplasms.
600. All fraction increase with LDHl less than
LDH2 less than LDH3 associated with visible
LDH4 and LDH5 bands in which LDH4 is
greater than LDH5.
This pattern is compatible with multisystem
involvement most often seen with generalized
neoplasm. It may be seen on occasion with
trauma or with any condition in which
splenic necrosis, thrombocytosis, or thromboplastin release into peripheral blood is noted.
602. All fraction increase with LDHl less than
LDH2 less than LDH3 greater than LDH4
greater than LDH5 associated with a notable
prominence of LDH2 and LDH3.
An all fraction increase principally midzone
and notably in which LDH4 is greater than
LDH5 suggests neoplasm. It may also be
seen posttraumatically (or postpartum) or any
condition in which thromboplastin release
into peripheral blood is possible.
604. Midzone increase, principally LDH3 with associated increases of other fractions. (Of note,
LDH4 is greater than LDH5).
This pattern is consistent with postpartum
state. It may also be seen in any condition
associated with thrombocytosis or thromboplastin release into peripheral blood. The
finding of LDH4 being of increased intensity
over LDH5 has often been associated with
neoplasm.
608. Multiple fraction increase in which LDHl
appears normal yet less than LDH2 (mildly
increased). LDH3 is greater in staining intensity and width than LDH2 and is comparable to LDH5. LDH4 appears essentially
normal.
This is an unusual pattern wherein the slow
fraction (LDH5) suggests liver and/or muscle
necrosis. The increase of LDH2 and LDH3, if
alone, suggests lymph node, pancreas, salivary
gland, brain, and thymic necrosis. The association of LDH3 and LDH5 equality and
prominence is distinctly unusual. In overall
impression one would feel that it represents
some sort of multisystem necrosis.
A..J.C.P.—Vol. 59
612. Midzone increase with LDHl less than LDH2
less than LDH3 greater than LDH4 less than
LDH5. LDH5 is deeply stained and prominent.
Midzone increases associated with prominent
LDH5 bands are unusual. It can be explained by thrombocytosis or splenic necrosis
associated with muscle or liver necrosis. This
type pattern seems most likely as one to accompany trauma.
616. All fraction increase with LDHl less than
LDH2 less than LDH3 less than LDH4 less
than LDH5. LDH5 is deeply stained and
prominent.
This pattern is compatible with multisystem
involvement with particular attention paid to
the possibility of liver and/or muscle necrosis.
The all fraction increase may be associated
with generalized anoxia, shock, or trauma.
620. All fraction increase with LDH3 being most
prominent and LDH5 being deeply stained
and prominent.
This is an unusual pattern that is principally midzone and suggests some form of
thrombocytosis or thromboplastin release into
peripheral blood or even splenic necrosis.
The prominence of LDH5 may be related
to muscle or liver source. It could be seen
in congestive heart failure (liver) or in muscle trauma.
632. All fraction increase with LDHl less than
LDH2 less than LDH3 greater than LDH4
greater than LDH5.
This pattern is compatible with multisystem
involvement such as that due to shock or
trauma. It has been seen in variety of neoplasms.
640. Essentially normal electrophoretogram.
641. Essentially normal electrophoretogram.
642. Fast fraction increase with LDHl less than
LDH2 greater than LDH3 associated with obvious increased prominence of LDH2 and
LDH3.
This pattern is compatible with a variety of
tissue necrosis including lung, salivary gland,
central nervous system, pancreas, thymus
gland, and lymph node. It has been associated
with some neoplasms as well as with viral
diseases associated with lymph node or salivary gland diseases.
648. Accentuated normal electrophoretogram.
658. All fraction increase with prominent LDH5.
This pattern is unusual but suggests multisystem involvement with particular attention
to liver and/or muscle (LDH5) and miscellaneous other organs (LDHl through LDH4).
It may be due to a wide variety of disorders
including shock, anoxia, trauma, neoplasm,
March 1973
LDH ISOZYMES BY BINARY CODE
445
This pattern is associated with multisystem
acute liver necrosis with accompanying shock,
etc.
involvement by various necrotizing entities
704. Essentially normal electrophoretogram with
including carcinomatosis and sarcomatosis.
730. All fraction increase with LDHl less than
faintly visible slow fractions.
LDH2 greater than LDH3 greater than LDH4
70G. Fast fraction increase, principally LDH2 and
greater than LDH5. The most prominent isoLDH3.
zymes are LDH2 and LDH3.
The prominence of LDH2 and LDH3 assoThis pattern is compatible with trauma associated with visible yet essentially normal reciated with thrombocytosis or some form of
maining bands has been associated with many
thromboplastin release into peripheral blood.
conditions, including lung, central nervous
It is also compatible with neoplasm as manisystem, lymph node, thymus, pancreas, and
fested by the increase of LDH4 over LDH5.
salivary gland necroses. It may be associated
The prominence of LDH2 and LDH3 sugobviously with neoplasm involving any one or
gests lymph node, lung, pancreas, central
all of these organs. It may also be seen with
nervous system and/or salivary gland nevarious lymph node infectious diseases such
crosis or involvement by neoplasm of these
as infectious mononucleosis.
organs.
712. All fraction increase, with LDHl less than
736. Slow fraction increase, principally LDH5.
LDH2 less than LDH3 greater than LDH4
This pattern is that of acute liver or muscle
less than LDH5.
necrosis. It may be found in acute hepatitis,
This pattern is compatible with multisystem
liver necrosis associated with congestive heart
involvement as seen with shock, anoxia,
failure, muscle anoxia secondary to generaltrauma, and occasional neoplasms.
ized convulsions, muscle necrosis secondary to
714. All fraction increase, LDHl less than LDH2,
trauma, etc.
greater than LDH3 associated with visible
744. All fractions increase remaining in normal
LDH4 and LDH5 bands with LDH2 and
relationship to each other.
LDH3 being increased and most prominent.
This patern is compatible with multisystem
The finding of prominent LDH2 and LDH3
involvement as seen with shock, anoxia,
bands in association with an all fraction intrauma, and occasional neoplasms.
crease suggests lymph node, lung, central
746. All fraction increase with LDHl less than
nervous system, pancreatic, salivary gland, or
LDH2 greater than LDH3 greater than
thymic necrosis.
LDH4 less than LDH5. LDH2 and LDH3 are
720. Isozyme pattern shows LDHl less than LDH2
most prominent, and appear of greater ingreater than LDH3 greater than LDH4
tensity than could be ascribed to general all
greater than LDH5.
fraction increase.
It differs from an essentially normal pattern
This pattern is compatible with multisystem
by the increase of LDH4 over LDH5. This is
involvement including various organ necroses
associated frequently with platelet increases
(in view of prominence of LDH2 and LDH3)
in peripheral blood or some form of thromto include lung, lymph node, thymus gland,
boplastin release into the peripheral blood.
salivary gland, pancreas, and central nervous
It has also been identified with various neosystem. This pattern has been seen frequently
plasms. It is an unusual pattern and one
in neoplasms.
which is difficult to interpret.
754. Electrophoretic pattern shows LDHl less than
722. Midzone increase with LDHl less than LDH2
LDH2 greater than LDH3 greater than LDH4
greater than LDH3 greater than LDH4
greater than LDH5. LDH5 is deeply stained
greater than LDH5. LDH2 and LDH3 seem
and prominent. LDH2 and LDH3 are both
more prominent than usual.
increased but most prominent.
This pattern is compatible with multisystem
This is a distinctly unusual pattern. The
involvement and may include necrosis of mulprominence of LDH2 and LDH3 suggests
tiple organs such as lymph node, pancreas,
organ necroses such as lymph node, salivary
lung, thymus gland, central nervous system
gland, thymus gland, brain, and lung. The
and/or salivary gland. The finding of LDH4
increase of LDH4 over LDH5 suggests sevbeing greater than LDH5 suggests that we
eral possibilities including neoplasm and
are dealing with neoplasm, although one
when combined with the apparent increase
may also see this relationship when thromboof LDH3 may be a reflection of thrombocycytosis or some form of thromboplastin retosis or some form of thromboplastin release
lease into peripheral blood is noted.
into peripheral blood. The prominence of
728. All fractions increase, with LDHl less than
LDH5 suggests muscle or liver necrosis which
LDH2 greater than LDH3 greater than
may be either primary or secondary to a disLDH4 greater than LDH5.
446
DITO
case process. Congestive heart failure may
well be associated with this prominent LDH5
band. In essence this peculiar pattern is compatible with some form of multisystem involvement associated with various organ necrosis.
700. All fractions increase with LDHl less than
LDH2 equal to LDH3 greater than LDH4
greater than LDH5.
This pattern is consistent with multisystem
involvement (necrosis) and in view of the increase of LDH4 over LDH5 has been frequently associated with disseminated neoplasm. It may also be found in some varieties
of shock and generalized trauma.
708. Fast fraction increase with LDHl greater
than LDH2 less than LDII.'i.
This pattern is unusual in that it .suggests
either splenic necrosis, thrombocytosis, or
thromboplastin release into peripheral blood
accounting for the increase of LDH3. The
increase of LDHl may be seen with hemolysis
(in vivo or in vitro), absorption from a hematoma, renal, or myocardial necrosis.
770. The isozyme pattern shows LDHl greater
than LDH2 less than LDH3 without visible
LDH4 or LDH5 bands. The three fractions
visible are increased in staining intensity.
This pattern is unusual but with a history
of trauma could be explained on the basis of
absorption from a hematoma plus either
splenic necrosis or a posttraumatic thrombocytosis in peripheral blood. Without a history
of trauma this pattern is difficult to interpret.
832. Fast fraction increase with LDHl greater
than LDH2 less than LDH3 associated with
visible LDH4 and LDH5 bands.
This pattern is unusual in that it suggests
either splenic necrosis, thrombocytosis, or
thromboplastin release into peripheral blood
accounting for the increase in LDH3. The
increase of LDHl may be seen with hemolysis (in vivo or in vitro), absorption from a
hematoma, renal, or myocardial necrosis.
840. The isozyme pattern shows LDHl greater
than LDH2 less than LDH3 with all bands
increased in staining intensity.
The unusual relationship between LDH2 and
LDH3 wherein LDH3 is greater in staining
intensity is difficult to assess particularly in
view of the increase of LDHl over LDH2. In
the latter instance, it suggests hemolysis, myocardial necrosis, or even renal infarction. The
prominence of LDH3 suggests splenic necrosis and/or thromboplastin release into peripheral blood.
844. All fraction increase with LDHl greater
than LDH2 less than LDH3 greater than
AJ.C.P.— Vol. 59
LDH4 greater than LDH5. LDH2 and LDH.'i
are both increased and LDH3 is most prominent.
All fraction increases are most often associated with thrombocytosis or some form of
thromboplastin or thromboplastin-like substance release into peripheral blood, or
splenic necrosis. The finding of LDH4 greater
than LDH5 lias been associated with the previously mentioned group of entities but, in
addition, it has also been seen with a variety
of neoplasms.
852. Midzonc increase, principally LDH3.
This pattern is seen postpartum. It may also
be seen in any condition in which there is
associated splenic necrosis or thromboplastin
release into peripheral blood.
856. Elect rophoretic pattern shows 1.1)111 greater
than LDH2 less than LDII.'i associated with
visible LDH4 and LDH5 bands and notably
an increase of LDH4 over LDH5. In essence
all bands appear increased.
This pattern is somewhat unusual in the apparent equality of increase of LDHl and
LDH3. It would be expected that there is
some sort of multisystem involvement wherein
renal, myocardial necrosis, or hemolytic episodes are associated with splenic necrosis or
thrombocytosis (LDH3). The finding of LDH4
greater than LDH5 also makes one suspect
neoplasm.
860. All fractions increase with LDHl greater than
LDH2 less than LDH3 greater than LDH4
greater than LDH5, the most prominent band
being I.DH3.
This pattern, in view of the increase of LDHl
over LDH2 suggests hemolysis, renal infarct,
myocardial infarct (or myocarditis). The increase of LDH3 associated with an LDI14
greater than LDH5 suggests two added possibilities. These include some form of thromboplastin release into peripheral blood or neoplasm. Neoplasms associated with fast fractions have also been described.
872. Electrophoretic pattern shows LDHl greater
than LDH2, LDH2 less than LDH3, LDH4
less than LDH5 and less than LDH3. LDH5
is deeply stained and prominent although all
bands are visibly increased.
This pattern is somewhat unusual. It suggests
episodes of hemolysis and liver disease or
muscle disease and also could conceivably be
noted in patients with myocardial or renal
necrosis associated with some anoxia producing liver necrosis. It may also be identified
in neoplasms.
896. Fast fraction increase with LDHl greater
than LDH2 greater than LDH3.
March 1973
LDH ISOZYMES BY BINARY CODE
This pattern is that usually associated with
acute myocardial necrosis as seen with myocardial infarction or myocarditis. It has also
been identified with acute renal necrosis, in
vivo or in vitro hemolysis, muscular dystrophy, myxedema, and in association with some
neoplasms.
897. The isozyme pattern shows LDHl greater
than LDH2 greater than LDH3.
This pattern seen in cerebrospinal fluid has
been associated in the past with herniated
disk. It obviously may also be encountered
with hemolysis, related to either in vivo
bleeding or associated with a traumatic spinal
fluid tap.
905. Fast fraction increase with LDHl greater
than LDH2 greater than LDH3. This pattern
is compatible with that previously seen in
herniated disk. It may also be identified with
intracranial hemorrhage or hemolysis due to
a traumatic spinal fluid tap.
960. The isozyme pattern shows LDHl greater
than LDH2 greater than LDH3 with visible
LDH4 and LDH5 bands.
This pattern is consistent with acute myocardial necrosis (as seen with myocardial infarction), renal necrosis, in vivo or in vitro
hemolysis (including absorption from a hematoma), and in association with some neoplasms.
908. Electrophoretic pattern shows LDHl greater
than LDH2 greater than LDH3 associated
with visible essentially normal LDH4 and
LDH5 bands.
This pattern is suggestive of several possibilities including in vivo or in vitro hemolytic
episodes as well as acute myocardial necrosis
associated with a patient in congestive heart
failure. It has also been noted with a variety
of conditions including shock, trauma, and
some neoplasms.
976. Fast fraction increase with LDHl greater
than LDH2 greater than LDH3 greater than
LDH4 greater than LDH5.
This pattern is difficult to interpret but includes several possibilities. The finding of
LDII1 greater than LDH2 suggests we may
be dealing with myocardial necrosis, hemolysis (including absorption from a hematoma),
renal infarction, or even neoplasm. This observation in conjunction with an increase of
LDH4 over that of LDH5 may imply either
some increase in thromboplastin release into
peripheral blood as may accompany trauma
or healing attempts in organ necrosis or possibly an accompaniment to neoplasms.
447
977. Electrophoretic pattern shows LDHl greater
than LDH2 greater than LDH3 greater than
LDH4 greater than LDH5.
This is an unusual pattern for cerebrospinal
fluid, particularly when there is an obvious
increase in LDH4 over LDH5. The fast fraction increase is compatible with hemolysis
and has been seen in previous spinal fluid
examinations wherein the diagnosis of herniated disk was made. LDH4 increases arc seen
in peripheral blood where thromboplastin or
thromboplastin-like material from platelets is
elaborated. We do not know its significance
in cerebrospinal fluid.
984. All fractions increase showing LDHl greater
than LDH2 greater than LDH3 greater than
LDH4 greater than LDH5.
This pattern is one which may be associated
with a hemolytic episode in which spleen or
platelets show some form of necrosis. It may
also be seen in a variety of neoplasms particularly in view of the increase of LDH4
over LDH5 associated with the apparent
principal fast fraction increase.
985. Fast fraction increase with LDHl greater
than LDH2 greater than LDH3 with visible
LDH4 and LDH5 bands. All bands appear
increased and in addition LDH4 appears of
greater staining intensity than LDH5.
This pattern is unusual for cerebrospinal
fluid. If seen in a serum specimen, it suggests neoplasm in view of the increases in
fast fractions associated with LDH4 band increase over LDH5.
992. The isozyme pattern shows LDHl greater
than LDH3 greater than LDH4 less than
LDH5.
This pattern is consistent with several possibilities including acute myocardial necrosis
associated with liver necrosis frequently explained by acute myocardial infarction and
congestive heart failure. It may also be seen
in a hemolytic episode accompanying hepatitis or in a posttraumatic situation where
muscle and/or liver necrosis may be prominently associated with either hemolysis or
absorption of a hematoma.
1000. The isozyme pattern shows LDHl greater
than LDH3 associated with visible LDH4 anil
LDH5 bands. LDH5 appears prominent. All
bands are increased in staining intensity.
This pattern suggests acute myocardial necrosis associated with congestive heart failure.
It may also be seen in association with some
neoplasms, trauma wherein muscle is injured
and a hematoma is absorbed, renal necrosis
associated with congestive heart failure, etc.