Molecular fluorescent approach to assessing intraerythrocytic hemoprotozoan Babesia canis infection in dogs

The development of recent flow cytometry-based protocols for the diagnosis of canine babesiosis, Babesia gibsoni in particular, has encouraged us to investigate its applicability to detect B. canis-infected erythrocytes as well as optimize the hydroethidine-flow cytometry methodology (HE-FC), using peripheral blood samples from naturally and experimentally infected dogs. Our data demonstrated that HE at 25 microg/ml provided the most outstanding fluorescence profile, able to discriminate between infected and uninfected dogs with no alterations in cell properties such as forward scatter and unspecific fluorescence. The results were expressed as the percentage of positive fluorescent erythrocytes (PPFE) for each individual sample, with 1.53% of PPFE as the cut-off determined between infected and uninfected animals. B. canis-infected erythrocytes during both acute and chronic experimental infection were identified through HE-FC, validating its use for diagnosis purposes in endemic areas for canine babesiosis. In a clinical trial, 22.8% out of 162 dogs showed to be positive to Babesia infection through this approach. Such prevalence was similar to that estimated for altered hematological profiles (HT) < or = 30% (29%), but highly distinct from the prevalence provided by direct blood smear (BS) examination (1.8%) or immunofluorescent assay (IFA) (60.5%). Furthermore, our findings indicate that positive PPFE data was associated with HT < or = 30%, emphasizing that, in clinical practice, the haematocrit should be used as a screening test followed by HE-FC, suitable to confirm hypotheses of canine babesiosis.     

Diagnosis of histoplasmosis by detection of the internal transcribed spacer region of fungal rRNA gene from a paraffin-embedded skin sample from a dog in Japan

The lesions of histoplasmosis in dogs in Japan differ from those in dogs in North America. Affected dogs in Japan have had multiple granulomatous or ulcerated foci in skin or gingiva and have not had pulmonary or gastrointestinal lesions. The present report introduces a polymerase chain reaction (PCR) diagnosis of canine histoplasmosis and the characteristic of disease in Japan. The surgically removed skin ulcerate samples from a 5-years-old female Shiba-inu native to Japan without traveling out of the country were evaluated. Tissue samples had many yeast-like organisms in the macrophages. DNA was extracted from paraffin-embedded tissue samples. A nested PCR technique was applied. The detected sequence of the internal transcribed spacer of ribosomal RNA gene had 99.7% in homology with Ajellomyces capsulatus (the teleomorph of Histoplasma capsulatum). Clinical manifestations, historical background of equine epizootic lymphangitis in Japan, and a human autochthonous case of histoplasmosis farciminosi indicated that this dog might have been infected with H. capsulatum var. farciminosum as a heteroecism.     

Detection of ehrlichial infection by PCR in dogs from Yamaguchi and Okinawa Prefectures, Japan

Species-specific nested polymerase chain reaction (PCR) was used to detect the presence of possible canine ehrlichial agents (Ehrlichia canis, E. chaffeensis, E. ewingii, E. equi and E. platys) and monocytic ehrlichial agents found in Japan (E. muris and a recently discovered Ehrlichia species detected from Ixodes ovatus) in blood samples from dogs in Yamaguchi and Okinawa Prefecture, Japan. Partial sequence of E. platys was detected from 1 of 67 dogs (1.5%) tested from Yamaguchi Prefecture and 24 out of 87 (27.6%) in the subtropical Okinawa Prefecture. Dogs in Okinawa and Miyako Islands had a higher positive rate (69.2 and 45.0%, respectively) than Ishigaki Island (11.1%). Another dog in Yamaguchi Prefecture had a positive PCR reaction to the Ehrlichia sp. detected from I. ovatus. No other Ehrlichia were found in these samples.     

Comparison of different tissue sampling for PCR-based diagnosis and follow-up of canine visceral leishmaniosis

In this study, different types of tissue sampling for PCR-based diagnosis and follow-up of canine visceral leishmaniosis were compared. Skin, whole blood and lymph node samples were collected from 95 naturally infected dogs living in South Italy, where the disease is endemic. Twenty-nine of these 95 dogs, treated with meglumine administered concurrently with allopurinol for 30 days, and then with allopurinol alone, were monitored during a period of 2 years. The DNA extracted from the clinical specimens was amplified by PCR using as target DNA a 116-bp fragment in the constant region of the kinetoplast DNA minicircle. PCR analysis was more sensitive than indirect immunofluorescence antibody test in detecting Leishmania infection in symptomatic dogs: 99% of lymph node samples resulted positive, whereas 94% of blood samples and 95% of skin samples gave a positive result. PCR analysis of samples from dogs followed up 2 years showed that: (1) all subjects resulted positive in at least one of the three types of samples; (2) all time the dogs had a relapse, PCR resulted positive in all three types of samples; (3) when dogs were apparently healthy, PCR analysis was positive on skin and lymph node samples, but not always on blood samples. Since lymph node sampling is invasive and sometimes difficult in healthy asymptomatic dogs, our results suggest that, independently from the presence or not of cutaneous lesions, skin biopsy represents a good substratum for PCR-based diagnosis and follow-up of canine visceral leishmaniosis.     

Babesia canis canis in dogs from Hungary: detection by PCR and sequencing

Canine babesiosis in Hungary has always been a severe and frequent disease, attributed to infection with Babesia canis transmitted by Dermacentor reticulatus. Identification of the disease agent has been based merely on size and morphology of the intraerythrocytic parasites and no evidence has been found concerning the subspecies (genotype) of B. canis. Therefore, a molecular survey on natural Babesia infection of dogs in Hungary using PCR and sequence analysis was attempted to clarify the subspecies (genotype) and to obtain information on the occurrence of B. canis. A total of 44 blood samples from dogs showing clinical signs of babesiosis were collected. A piroplasm-specific PCR amplifying the partial 18S rRNA gene yielded an approximately 450 bp PCR product in 39 (88.6%) samples. Thirteen positive samples originated from Budapest and 26 from 21 other locations. Five PCR products were chosen randomly for sequencing. The partial 18S rDNA sequences were submitted to GenBank (accession numbers AY611729; AY611730; AY611731; AY611732 and AY611733). The sequences showed 100% homology to one another or differed by one nucleotide. BLAST search against GenBank revealed the highest similarity (99.8 or 100%) with Babesia canis canis. The implication of these data, for the further study and diagnosis of canine babesiosis is discussed.     

Detection and molecular characterization of Babesia canis vogeli from naturally infected dogs and Rhipicephalus sanguineus ticks in Tunisia

Canine babesiosis, caused by intra-erythrocytic Babesia, is a tick-borne disease of worldwide importance. No information on canine babesiosis has been documented in Tunisia. Detection and analysis of Babesia species from naturally infected dogs and ticks recovered from dogs were attempted by reverse line blot hybridization and nucleotide sequence analysis based on 18S rRNA gene. Out of 180 blood samples collected from domestic dogs in 4 villages situated in different bioclimatic zones, 12 were positive for Babesia canis vogeli. In addition, a total of 160 Rhipicephalus sanguineus were analysed; only one male was infected by B. canis vogeli. This is the first report on the detection of DNA belonging to B. canis vogeli in domestic dogs and in R. sanguineus in Tunisia.     

Biochemical abnormalities observed in serum of dogs infected with large Babesia in Warsaw (Poland)

Biochemical abnormalities observed in canine babesiosis are related to the severity of the disease. The primary biochemical abnormalities found in affected dogs are: increase of the serum activity of transaminases and alkaline phosphatase, azotemia, and hypoglycemia. The purposes of this study were: 1) to estimate biochemical abnormalities in dogs infected with large Babesia in Warsaw and 2) to evaluate statistically changes observed during canine babesiosis in dogs from Warsaw. Samples of serum were collected from dogs naturally infected with large Babesia. Among 2023 positive samples, 202 were randomly selected. Alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), creatinine, blood urea nitrogen (BUN), total serum protein (TSP), albumin and blood glucose concentration were determined with a clinical chemistry analyser. Elevated activity of ALT, AST and ALP was detected accordingly in: 64.9, 92.6 and 31.7% of dogs. Elevated creatinine concentration and BUN were detected accordingly in 30.7 and 62.4% of dogs. Decrease of TSP, albumin, BUN, and hypoglycemia was detected accordingly in: 19.8, 32.7, 1.5 and 18.3% of dogs. The most common biochemical abnormalities found in affected dogs were: increase of activity of transaminases and ALP, elevated creatinine concentration, hypoalbuminemia and hypoglycemia. These abnormalities resulted from hepatopathy, renal failure and fasting.     

Comparison of the Immunofluorescence Assay with RT-PCR and Nested PCR in the Diagnosis of Canine Distemper

Two pairs of primers were prepared, both localized within the sequences of the nucleoprotein gene (NP) of canine distemper virus (CDV). A number of experiments were done to optimize the conditions of RT-PCR and nested PCR methods. The nucleic acids of the Onderstepoort, Rockborn, Snyder Hill and Lederle strains of CDV could be detected with these primers. However, they did not react with the sequences of the Edmonston strain of the measles virus. The detection limit for RT-PCR was 10 TCID50 and for nested PCR 0.1 TCID50 of CDV. The RT-PCR was able to demonstrate the nucleic acid of CDV in the blood of all seven puppies vaccinated with a modified live virus. Blood samples of 23 dogs clinically suspected of distemper were examined by RT-PCR combined with nested PCR, and the results were compared with the detection of the CDV antigen in the smears from the mucous membranes by the direct immunofluorescence (IF) test. Of the 23 dogs, 12 were positive in nested PCR, six in the IF assay, and only two in single RT-PCR. It is concluded that nested PCR seems to be the most sensitive method for ante-mortem diagnosis of canine distemper, especially in its subacute or chronic forms.     

Development of a polymerase chain reaction method for diagnosing Babesia gibsoni infection in dogs

A pair of oligonucleotide primers were designed according to the nucleotide sequence of the P18 gene of Babesia gibsoni (B. gibsoni), NRCPD strain, and were used to detect parasite DNA from blood samples of B. gibsoni-infected dogs by polymerase chain reaction (PCR). PCR was specific for B. gibsoni since no amplification was detected with DNA from B. Canis or normal dog leucocytes. PCR was sensitive enough to detect parasite DNA from 2.5 microl of blood samples with a parasitemia of 0.000002%. PCR detected parasite DNA from 2 to 222 days post-infection in sequential blood samples derived from a dog experimentally infected with B. gibsoni. The detection of B. gibsoni DNA by PCR was much earlier than the detection of antibodies to B. gibsoni in blood samples by the indirect fluorescent antibody test (IFAT) or that of the parasite itself in Giemsa-stained thin blood smear film examined by microscopy. In addition, 28 field samples collected from dogs in Kansai area, Japan, were tested for B. gibsoni infection. Nine samples were positive in blood smears, 9 samples were positive by IFAT and 11 samples were positive for B. gibsoni DNA by PCR. The nucleotide sequences of PCR products from all 11 samples found positive by PCR were completely identical to that of the P18 gene of the B. gibsoni, NRCPD strain. These results suggest that PCR provides a useful diagnostic tool for the detection of B. gibsoni infection in dogs.     

Canine babesiosis in Slovenia: molecular evidence of Babesia canis canis and Babesia canis vogeli

Canine babesiosis, caused by intraerythrocytic Babesia spp., is a tick-borne disease of worldwide importance. No information on canine babesiosis has been documented in Slovenia. Therefore, 238 dogs admitted to the Small animal clinic in Ljubljana from the years 2000 to 2002 were tested for the presence of babesial parasites in the blood. Based on clinical, microscopic and molecular investigations, 14 dogs (5.9%) were determined as being infected with babesiae. Clinical signs relating to acute haemolysis, fever, anorexia, depression and haematological abnormalities such as anaemia and thrombocytopenia were noticed in most of the 14 infected dogs. The morphology of the parasites was indicative of Babesia canis infection. Two subspecies were detected, namely B. canis canis (11 dogs, 4.6%) and B. canis vogeli (3 dogs, 1.3%) using PCR and subsequent sequence analysis of portions of nns rRNA gene. In addition, based on nucleotide sequence analysis, the 11 isolates of B. c. canis could be subdivided into three groups, whereas the three B. c. vogeli isolates were genetically identical. The results of this study demonstrate the presence of canine babesiosis due to B. c. canis and B. c. vogeli in Slovenia.     

Comparison of partial ribosomal DNA sequences of Babesia gibsoni occurring in Miyazaki prefecture, Japan.

Nucleotide sequences of ribosomal DNA (rDNA) of Babesia (B.) gibsoni occurring in Miyazaki, western Japan, were examined using blood samples obtained from seven dogs suffering from natural canine babesiosis. DNA isolated from these blood samples was subjected to the polymerase chain reaction (PCR). The nucleotide sequences of the PCR products were determined and compared with other rDNA sequences of B. gibsoni isolated from Asia, Europe and U.S.A. Although homology values between our isolates and those isolated from Europe and U.S.A. were both 84.0%, respectively, our isolates were identical to the Asian types. In conclusion, B. gibsoni occurring in Miyazaki was revealed to have the genotype Asia 1 or Asia 2 from a comparison of the partial rDNA sequences.     

Comparison of one-step RT-PCR and a nested PCR for the detection of canine distemper virus in clinical samples

OBJECTIVE: To develop a rapid and sensitive method for the detection of canine distemper virus (CDV) by nested PCR using clinical specimens. DESIGN: A nested PCR was developed, compared to a one-step RT-PCR and validated. PROCEDURE: Two sets of specific primers for a one-step RT-PCR and a nested PCR, targeting a 640 bp fragment and a 297 bp fragment, respectively, were selected from the highly conserved region of the nucleocapsid protein (NP) gene of CDV. The nested PCR and the one-step RT-PCR were used to amplify a part of the CDV NP gene of a CDV vaccinal strain and samples of urine, blood, nasal discharge and saliva from 29 dogs suspected of suffering CD. RESULTS: Both the one-step RT-PCR and the nested PCR reacted with the CDV vaccinal strain, but not with canine parvovirus. The expected 640 bp fragment of the NP gene was detected in 11/22 (50.0%) blood, 10/20 (50.0%) urine, 5/25 (20.0%) saliva and 6/27 (22.2%) nasal swab samples by one-step RT-PCR, whereas the nested PCR amplified an expected 297 bp fragment of the NP gene in 18/22 (81.8%) blood, 15/20 (75.0%) urine, 14/25 (56%) saliva and 19/27 (70.3%) nasal swab samples. CONCLUSION: The nested PCR detected CDV in blood, urine, nasal swab and saliva more frequently than did the one-step RT-PCR. Therefore, this assay should be a useful aid to antemortem diagnosis of CDV infections in dogs.     

Autochthonous cases of canine babesiosis in the canton Solothurn

Starting in November 2003 a series of five clinical cases of canine babesiosis was registered in the region of Oberg?sgen (canton Solothurn). All presented dogs showed increased body temperature, thrombocytopenia and hemoglobinuria, and none of the dogs had been abroad or visited endemic regions in the southern or western part of Switzerland so far. Babesia canis was detected in the blood smears of all five patients, but only three had detectable specific antibodies against this parasite. However, seroconversion was found in a second sample collected from the negative dogs at a later timepoint, confirming the diagnosis of canine babesiosis. The blood samples of two parasitized dogs were used for DNA-isolation and were tested with a Babesia-specific PCR, detecting the 18S rRNA-gene. Sequencing of the amplified products revealed a 100% identity with the sub-species B. canis canis. The ticks Rhipicephalus sanguineus and Dermacentor marginatus are potential vectors for B. canis. In the area where the infection with B. canis was suspected a total of 152 ticks was collected and characterized; one was a female R. sanguineus.Although babesia could not be detected in the latter tick and the final prooffor the complete life cycle is still lacking, it is very probable that B. canis has become autochthonous in the canton Solothurn.     

First isolation and molecular characterization of Ehrlichia canis in Costa Rica, Central America

The present study investigated Ehrlichia species in blood samples from dogs suspected of clinical ehrlichiosis, using molecular and isolation techniques in cell culture. From a total of 310 canine blood samples analyzed by 16S rRNA nested PCR, 148 (47.7%) were positive for Ehrlichia canis. DNA from Ehrlichia chaffeensis or Ehrlichia ewingii was not detected in any sample using species-specific primers in separated reactions. Leukocytes from five PCR-positive dogs were inoculated into DH82 cells; successful isolation of E. canis was obtained in four samples. Partial sequence of the dsb gene of eight canine blood samples (including the five samples for in vitro isolation) was obtained by PCR and their analyses through BLAST showed 100% of identity with the corresponding sequence of E. canis in GenBank. This study represents the first molecular diagnosis, isolation, and molecular characterization of E. canis in dogs from Costa Rica.     

Serum concentration of some acute phase proteins in naturally occurring canine babesiosis: a preliminary study

BACKGROUND: Serum concentrations of acute phase proteins can provide valuable diagnostic information in the detection, prognosis, or monitoring of disease. Information available on the acute phase response in naturally occurring canine babesiosis is limited. OBJECTIVE: The purpose of this investigation was to retrospectively evaluate serum concentrations of haptoglobin, C-reactive protein, and ceruloplasmin in dogs naturally infected with Babesia canis. METHODS: Haptoglobin, C-reactive protein, and ceruloplasmin concentrations were measured in serum samples from dogs with uncomplicated (n = 6) and complicated (n = 1) babesiosis and compared with 6 healthy dogs. RESULTS: Serum C-reactive protein and ceruloplasmin concentrations were significantly higher in dogs with babesiosis; however, serum haptoglobin concentration was significantly lower compared with control dogs (P <.01). CONCLUSIONS: Results of this study suggest that acute phase protein concentrations could be beneficial in the diagnosis and determination of the severity of babesiosis in dogs.     

Conflicting results of serological,PCR and microscopic methods clarify the various risk levels of canine babesiosis in Slovakia: A complex approach to Babesia canis diagnostics

We have performed a survey of Babesia canis prevalence within group of dogs living in Southern and Western Slovakia. Blood samples and sera from 217 dogs, including individuals suspected of having babesiosis, were examined by nested PCR-RFLP, light microscopy and indirect fluorescence antibody test (IFAT). The detection of B. canis DNA revealed the highest number of infected dogs in the region of Nové Zámky, with 23 B. canis-positive blood samples (35.4%, n = 65), followed by an area close to Komárno (both areas of Southern Slovakia), where 1 dog out of 52 collected (1.9%) had detectible B. canis DNA in the blood stream. The serological method revealed an opposing pattern, with only 3 dogs (4.8%, n = 63) sampled at Nové Zámky presenting IgG antibodies against B. canis, while in Komárno region such antibodies were detected in 15 dogs (28.8%, n = 52). This discrepancy may be because the majority of samples from Nové Zámky were dogs suspected of an acute phase of canine babesiosis, whereas dogs at Komárno were sampled during a vaccination campaign, and thus were without any clinical signs of the disease. The latter group contains evidently recovered carriers of IgG against B. canis. Hence, the combination of PCR-based and serological methods enabled us to discover both recently infected as well as recovered dogs, thus obtaining a more realistic view on the epidemiological situation. Remarkably, we did not find any positive samples in the vicinity of Stupava (district Malacky, Western Slovakia), either by PCR-RFLP, microscopy or IFAT (n = 100). Considering the numerous falsely diagnosed cases of canine babesiosis, we suggest that light microscopy as the simplest and most accessible diagnostic test. Southern Slovakia was confirmed as an area of high risk of canine babesiosis, whereas conclusions about B. canis spreading over Western Slovakia should be considered with wariness.     

Nested PCR for diagnosis of canine leishmaniosis in peripheral blood, lymph node and bone marrow aspirates

A nested polymerase chain reaction (PCR) assay was developed using primers selected from the genomic DNA of Leishmania infantum and applied to the diagnosis of leishmaniosis in peripheral blood in dogs. Blood of 39 dogs of different breeds, all sampled in Catalonia (Spain), were tested for leishmaniosis by enzyme linked immunosorbent assay (ELISA), western blotting (WB) and peripheral blood mononuclear cell (PBMC) culture and nested PCR. Twenty negative controls (healthy dogs less than 1-year-old that had not been exposed to a sandfly season) were also studied. Nineteen of the 39 dogs studied were positive by ELISA and/or WB, and 18 of these had a positive PBMC nested PCR. PBMC nested PCR was negative in all the remaining animals that were negative by serological examination, including the 20 negative controls. Parasitological examination and nested PCR of bone marrow and lymph node aspirate from the 19 dogs positive by serological examination, were also positive. These results indicate that PBMC nested PCR is a sensitive and specific tool to diagnose leishmaniosis in dogs. The use of PBMC has the advantage over bone marrow and lymph node aspirates in that it is a less invasive sample.     

Real-time PCR-based prevalence study, infection follow-up and molecular characterization of canine hemotropic mycoplasmas

Hemotropic mycoplasmas (hemoplasmas) have been reported in several mammalian species including dogs. Infections may lead to hemolytic anemia, but investigations in the dog had been hampered by the lack of adequate diagnostic methods. Only recently sensitive PCR-based assays were reported for the two canine hemoplasmas, Mycoplasma haemocanis and Candidatus Mycoplasma haematoparvum. By applying these assays, 15.4% of 460 dogs from the south of France tested hemoplasma positive. It was hypothesized that this high prevalence may be associated with the presence of Rhipicephalus sanguineus, a proposed vector for canine hemoplasmas. To address this hypothesis and expand the PCR-based knowledge on canine hemoplasmosis, we investigated dogs in a climatic zone that does not allow for the permanent establishment of R. sanguineus. Blood samples were collected throughout a year from 889 dogs in Switzerland: 1.2% of the dogs tested real-time PCR positive. The infection status was not significantly associated with anemia, age or gender. Phylogenetic analyses of Candidatus M. haematoparvum and M. haemocanis isolates revealed > or =99.8% identity to published sequences. All samples collected from three infected dogs throughout a follow-up period of < or =13 months tested PCR positive. Interestingly, the majority of the infected dogs either had been imported from or had visited regions where R. sanguineus is indigenous. Thus, canine hemoplasma prevalence was found to be low in a country with a climate incompatible with frequent occurrence of R. sanguineus. Nonetheless, veterinarians may expect hemoplasma infections in dogs with a travel history and/or after potential tick vector exposure.     

Failure of imidocarb dipropionate to clear experimentally induced Ehrlichia canis infection in dogs

The recommended treatment for canine ehrlichiosis is tetracycline or its analog doxycycline, although recent reports have documented ineffective clearing of Erchlichia canis after doxycycline administration. Imidocarb dipropionate is used as an alternative treatment to tetracycline or is used in conjunction with doxycycline. The effectiveness of imidocarb dipropionate in clearing Ehrlichia species from the blood and tissues of dogs with E. canis infection has not been thoroughly evaluated. Fifteen dogs were experimentally infected with E. canis. Ten dogs were treated with imidocarb dipropionate (6.6 mg/kg, IM, 2 injections given 2 weeks apart). Five infected control dogs were not treated. Blood samples from all 15 dogs were E. canis DNA positive by PCR assay by 3 weeks after inoculation (PI), and E. canis antibodies were detected by IFA assay by 1 week PI. Blood platelet counts in all dogs were below the reference interval by 4 weeks PI. E. canis DNA was detected in bone marrow and splenic aspirates by PCR assay 4 weeks PI but not before infection. Bone marrow aspirates were E. canis DNA positive by PCR assay in 14/15 dogs, and splenic aspirates were E. canis DNA positive by PCR assay in 13/15 dogs. Blood samples from all treated and control dogs remained positive for E. canis DNA by PCR assay, and platelet counts remained below preinoculation values 13 weeks PI (6 weeks after 2nd treatment). As administered in this study, imidocarb dipropionate did not clear experimental E. canis infection in dogs.     

Evaluation of a serum-based PCR assay for the diagnosis of canine monocytic ehrlichiosis

The aim of this study was to estimate the relative diagnostic sensitivity and specificity of a polymerase chain reaction (PCR) assay in the serum of dogs with naturally occurring non-myelosuppressive canine monocytic ehrlichiosis (CME), and to investigate the association between PCR positivity and immunofluorescence antibody (IFA) titres for Ehrlichia canis. Serum samples obtained from 38 dogs with non-myelosuppressive CME and 12 healthy dogs were analyzed retrospectively. Each serum sample was analyzed in triplicate using an E. canis-specific nested PCR assay targeting a 389 bp sequence of the 16S rRNA gene. E. canis DNA was amplified in 24 of 38 (63.1%) affected dogs; all samples from healthy dogs were negative. A high level of agreement was found among the PCR replicates (P < 0.0001). Median IFA titre of the 24 PCR-positive dogs was significantly lower than that of the PCR-negative infected dogs (P = 0.0029), indicating that E. canis DNA may circulate prior to the development of a high antibody titre. Serum-based PCR analysis is suggested for the early diagnosis of CME when whole blood samples are not available.