MUSCLE / NERVE BIOPSY REQUEST FORM
Neuromuscular Clinical Laboratory: Alan Pestronk, M.D., Director
Washington University School of Medicine – Neurology Department
Internet Home Page http://neuromuscular.wustl.edu

Referring institution

Patient name

Requesting physician

Sex           Age              Birth date
Send report to
NAME
ADDRESS
CITY, STATE, ZIP
PHONE & FAX #
Date biopsy performed
Date biopsy received
WU Lab accession #
Bill charges to


Labs other than Washington University: If we are billing patient, please provide insurance authorization number.

Clinical Diagnosis & History



Specimens & Site biopsied


Surgeon


INSTRUCTIONS
     Hand carried fresh tissue: Wrap in moist (saline) gauze; Do not immerse in saline or fixative
     Mailed tissue: NOTES - Laboratory only open Monday through Friday; Send by overnight mail for early next day delivery
                Method A. Freeze one piece of tissue in isopentane cooled with liquid nitrogen; Fix a 2nd piece, or
                Method B. Wrap biopsy specimens in moist (saline) gauze. Place in sealed plastic container. Send on cold packs. Do not freeze.

TESTS REQUESTED: Histochemical & Immunocytochemical stains are usually performed on frozen, unfixed tissue.
    Routine Histochemistry: Performed on all biopsies
        [ ] MUSCLE: H&E X 2, NADH, GT, ATPase X 3, VvG, Congo Red, Sudan Black, Alkaline & Acid Phosphatase, Esterase
                Periodic Acid Schiff, Cytochrome Oxidase, Succinic Dehydrogenase, Amylo-phosphorylase, AMPDA
        [ ] NERVE   Frozen sections: H&E, GT, Congo Red, Alkaline & Acid Phosphatase, VvG, Neurofilament   Plastic sections: Toluidine blue
                NEUROPATHOLOGY reports additional information covering the nerve biopsy in a separate report.

    Dystrophies (Immunocytochemistry (IHC) ± Western blot (WB)): [ ] Dystrophy-related protein panel
        [ ] Dystrophin (IHC); [ ] Dystrophin (WB); [ ] Sarcoglycans (α, β, δ, γ) (IHC); [ ] Sarcoglycans (WB); [ ] Caveolin (IHC & WB);
        [ ] Emerin (IHC & WB); [ ] Desmin (IHC); [ ] α-Dystroglycan (IHC); [ ] Laminin α2 & B (IHC); [ ] Collagen VI & IV (IHC);
        [ ] Dysferlin (IHC & WB); [ ] Calpain 3 (WB); [ ] VCP (IHC); [ ] LAMP-2; [ ] Phosphorylated tau (SMI-31); [ ] α-actinin
    Immune myopathy panel: [ ] MHC Class I; Capillary morphology (Ulex); C5b-9 (MAC); CD4; CD20; CD11b; Decorin
    Aggregate panel: [ ] Desmin; VCP; α-actinin; Caveolin; Ubiquitinated proteins (FK2); Phosphorylated tau (SMI-31)
    BIOCHEMISTRY Performed at Washington University Neuromuscular Lab   EXTRA SPECIMEN may be required (> 0.5 cm3, 100 mg)
        Mitochondrial oxidative enzymes [ ]: Activity (Complexes I, II, II + III, III, IV, Citrate synthase) + Coenzyme Q10; [ ] Complex I-V Western blot
        Glycogen pathways: [ ] Glycogen + Acid Maltase; [ ] Glycogen degradation (PFK, Phosphorylase, PGK, PGM, LDH, PBK); [ ] PFK stain


    Requirements for tissue to be forwarded from our Neuromuscular lab to other labs for further testing
        Extra specimen (minimum 0.5 cm3, 200 to 500 mg); Clinical information; Billing information & approval #; Patient release, signed;
        Completed requisition from testing lab; Minimum amount of tissue needed for testing; Shipping address, information & form

SHIPPING ADDRESSES
Frozen specimens Fresh tissue  -- HAND DELIVERY

SHIPPING/MAILING ADDRESS:
ALAN PESTRONK, M.D.
Washington University - Neurology, Box 8111
660 S. Euclid Ave.
St. Louis, MO 63110

STREET LOCATION:
NEUROMUSCULAR LABORATORY
Irene Walter Johnson Institute
509 S. Euclid, Room 404
St. Louis, MO 63110

Phone: 314-362-6981 (Office); 314-362-2406 (Lab); FAX: 314-362-3752 CAP# 19233-16 : CLIA ID# 26D0652044 : Medicare Provider # 26-8235
Turn around time: ~3 to 4 weeks pestronka@neuro.wustl.edu                 Revised 9/30/2009 GJP/AP