Collection And Submission Form Of Specimens For Viral Encephalitis Testing Page 3
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4NYS Lab Number:
Date Received
:
NEW YORK STATE DEPARTMENT OF HEALTH Viral Encephalitis/Meningitis Case Report Form
Suspect encephalitis/meningitis cases are reportable diseases.
Please fax a completed copy of this form to your Local County Health Department.
This form, including the full Viral Encephalitis/Meningitis History Form MUST be completed
and sent with clinical specimen(s).
Patient Information
Last Name_______________
First Name______________
Date of Birth__ /__ /__
Please complete this section if CSF is being submitted:
O
1. Does the patient have encephalitis (defined as temperature >100.4
F, and altered
mental status, and abnormal CSF)?
ڤYes → Go to question 2.
ڤNo → Stop here. CSF will be tested by ELISA
1
for WNV IgM antibodies.
2
CSF will not be tested by PCR for the viral encephalitis panel
.
3
(Please refer to commercial laboratories that can provide PCR testing
.)
2. Is the patient hospitalized?
ڤYes → Go to question 3.
1
ڤNo → Stop here. CSF will be tested by ELISA
for WNV IgM antibodies.
2
CSF will not be tested by PCR for the viral encephalitis panel
.
3
(Please refer to commercial laboratories that can provide PCR testing
.)
3. Is there at least 1.0 ml of CSF available for testing?
ڤYes → CSF will be tested by ELISA
1
for WNV IgM antibodies and by
2
PCR for the viral encephalitis panel
.
1
ڤNo →
There is not enough CSF to conduct both ELISA
and PCR testing.
Please indicate your preference for testing (check only one):
1
T est by ELISA
for WNV antibodies.
2
T est by PCR for the viral encephalitis panel
.
Please complete this section if SERUM is being submitted:
1. Please indicate if this is an acute or convalescent specimen:
→
ڤAcute
Serum will be tested for:
1
WNV IgM antibodies by ELISA
.
-
4
WNV polyvalent antibodies by MIA
.
-
5
Arboviral IgG antibodies by IFA
.
-
ڤConvalescent →Serum collected at least three weeks after the acute will be tested
for:
1
WNV IgM antibodies by ELISA
on paired sera.
-
4
WNV polyvalent antibodies by MIA
on paired sera.
-
5
Arboviral IgG antibodies by IFA
on paired sera, if acute was
-
reactive. (If acute specimen was negative, it will not be retested
with convalescent. If convalescent is reactive, the test will be
6
repeated on paired sera. Paired sera will be sent for PRNT
when at least one specimen is reactive).
See back of sheet for footnotes
Revised 7/7/05
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