ANA Workup

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ANA Workup

• October 31, 2003
• Tara Shaw, MD

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My Patient AH

• 74yo Eritrian woman with chronic joint pain that
  seems to be worsening.
• She complains of morning stiffness and pain in
  her hands that resolves slowly with rubbing and
  use.
• She also reports pain in both hips, her back and
  both knees.

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My patient, AH cont

• Past Medical Hx
• Chronic normocitic anemia.
• Osteoarthritis
• Trigger Finger

• Physical Exam
• Pt rises slowly from a chair and walks with a
  cane.
• MCP, PIP joints slightly full feeling.

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A Few Screening Labs

• RF negative
• Antinuclear Antibody positive
• 1640 titer
• Speckled Pattern
• Now What?

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Whats an ANA anyway?

• Serologic hallmarks of patients with systemic
  autoimmune disease.
• Also associated with organ-specific autoimmune
  diseases and a variety of infections.
• Used to establish a diagnosis, exclude such
  disorders, subclassify a patient, or monitor
  disease activity.

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How is an ANA assay done?

• HEp2 cells (Human epithelial cell tumor line)
  provide a standardized substrate with larger
  nuclei and nucleoli.
• HEp2 cells incubated with pts serum.
• Fluorochrome labeled anti-human gamma globulin
  added.
• Viewed with fluorescent microscope.
• Ab bound to nuclear Ag glow in a nuclear pattern.
• Pattern of fluorescence and the dilution at which
  it disappears (titer) are noted.

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What do those Nuclear Staining Patterns mean?

• Not as useful as previously thought largely
  replaced by specific Ab tests.
• Operator-dependent.
• Different serum dilutions can produce varying
  nuclear patterns.
• One nuclear pattern may obscure another.
• No single pattern denotes a single disease.

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Nuclear Staining Patterns Cont.

• Speckled pattern Ab to Sm, RNP, Ro/SSA, La/SSB,
  Scl-70, centromere, PCNA, others.
• Homogeneous or diffuse pattern Ab to the
  nucleosome DNA-histone comlex.
• Peripheral or rim pattern Ab to DNA and nuclear
  envelope antigens, especially lamins.

• Centromere pattern Ab to proteins present on
  active centromeres. Possible incipient CREST
  syndrome.
• Nucleolar pattern Ab to RNA polymerase I,
  fibrillarin, others. Likely early scleroderma.

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The ANA titer is still clinically relevant

• High titer (1640) strongly supports diagnosis
  of an autoimmune disorder.
• Low titer (polyarthralgias SLE unlikely but some will
  develop RA and a few will develop another
  connective tissue disease.

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So What Diseases is the ANA Sensitive for?

• Drug-induced lupus 100
• SLE 93
• Mixed connective tissue disease 93
• Scleroderma 85
• Pauciarticular juvenile chronic arthritis 71

• Polymyositis / dermatomyositis 61
• Sjogrens synd 48
• RA 41
• Rheumatoid vasculitis 33
• Discoid lupus 15

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ANA Sensitivities in Specific Organ Autoimmune
Diseases.

• Primary autoimmune cholangitis 100
• Autoimmune hepatitis 63-91
• Graves disease 50

• Hashimotos thyroiditis 46
• Primary pulmonary hypertension 40
• Primary biliary cirrhosis 10-40

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Other disorders associated with a positive ANA

• Chronic infectious diseases
• Mononucleosis
• Hepatitis C infection
• Subacute Bacterial Endocarditis
• Tuberculosis
• Some lymphoproliferative diseases

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Next Tests to Consider

• Anti-dsDNA (very specific for SLE)
• Anti-SM (very specific for SLE but only occurs in
  25 of pts)
• Anti-RNP (mixed connective tissue disease)
• Anti-centromere (limited scleroderma including
  CREST syndrome)
• Anti-Topoisomerase 1 or SCL-70 (diffuse
  scleroderma)
• Anti-Ro (Sjogrens syndrome)

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Sjogrens Syndrome

• Chronic immune-mediated inflammatory disorder.
• Characterized by lymphocytic infiltration of the
  exocrine glands, especially the lacrimal and
  salivary glands.
• Clinical features of keratoconjunctivitis sicca
  and xerostomia.

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Scleroderma (Systemic Sclerosis)

• Chronic, systemic disease targeting skin, lungs,
  heart, GI tract, kidneys and musculoskeletal
  system characterized by
• 1- tissue fibrosis, 2- small blood vessell
  vasculopathy, 3- specific autoimmune response
  associated with autoantibodies.
• Thickening of the skin most prominent clinical
  feature, hence hard skin.
• Two forms limited and diffuse cutaneous

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CREST Syndrome 3 of 5

• A form of limited Scleroderma
• Calcinosis
• Raynauds phenomenon
• Esophageal dysfunction
• Sclerodactyly
• Telangiectasia.
• Associated with anti-centromere Ab

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Mixed Connective Tissue Disease

• An overlap syndrome with features of Scleroderma,
  Polymyositis, lupus-like rashes, and
  rheumatoid-like polyarthritis.
• Specific Ab response to ribonuclear protein
  (anti-U1snRNP)
• May develop severe interstitial lung disease or
  isolated pulmonary hypertension

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Drug Induced Lupus

• Definite Association
• Chlopromazine
• Hydralazine
• Isoniazid
• Methyldopa
• Procainamide
• Quinidine

• Possible Association
• Beta-blockers, Captopril
• Carbamazepine, Cimetidine
• Ethosuximide, Levodopa
• Methimazole, Sulfonamides
• Nitrofurantoin, Lithium
• Penicilamine, Phenytoin
• Propothiouracil
• Sulfasalazine

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Systemic Lupus Erythematosus 4 or more

• 1.  Malar Rash
• 2.  Discoid rash Erythematous raised patches
  with adherent keratotic scaling and follicular
  plugging
• 3.  Photosensitivity
• 4.   Oral ulcers
• 5.   Non-erosive arthritis
• 6.   Serositis Pleuritis - convincing history
  of pleuritic chest pain or rub or evidence of
  pleural effusion OR Pericarditis.
• 7.   Renal disorder Persistent proteinuria
  0.5 g/day or 3 if quantification not performed
  OR Cellular casts.

• 8. Neurologic disorder Seizures OR psychosis
  in the absence of offending drugs or known
  metabolic derangements.
• 9.   Hematologic disorder Hemolytic anemia-with
  reticulocytosis OR Leukopenia Lymphopenia in absence of offending drugs
• 10.  Immunologic disorders Positive
  antiphospholipid antibody OR Anti-DNA OR Anti-SM
  OR false positive serologic test for syphilis
• 11.   Positive ANA, at any point in time, in the
  absence of drugs associated with  drug-induced
  lupus syndrome

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Rheumatoid Arthritis4 or more

• 1.   Morning Stiffness In/around joints, lasting
  1 hour before maximal improvement
• 2.  Soft tissue swelling of 3 or more joints. May
  include R/L PIP, MCP, wrist, elbow, knee, ankle,
  and MTP joints
• 3.  Arthritis of the hand joints 1 area swollen
  in the wrist, MCP, or PIP joint
• 4.  Symmetrical arthritis Bilateral PIP, MCP,
  MTP without absolute symmetry acceptable

• 5.  Rheumatoid nodules Subcutaneous nodules over
  bony prominences, extensor surfaces, or in
  juxta-articular regions
• 6.  Serum rheumatoid factor By any method in
  which result has been positive control subjects
• 7.   Radiographic changes PA hand/wrists x-ray
  with erosions or bony decalcification in or
  adjacent to involved joints
• 1-4 lasting 6wks or more.

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Rheumatoid Arthritis Cont.

• Pathologic hallmark synovial membrane
  proliferation and outgrowth associated with
  erosion of articular cartilage and subchondral
  bone.
• Morning stiffness related to the accumulation of
  edema fluid within inflamed tissues during sleep.
  Dissipates as edema and products of inflammation
  absorbed by lymphatics via motion.

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Rheumatoid Arthritis Cont.

• A negative RF with a positive ANA does not rule
  out RA.
• One report found that 7.5 of patients with RA
  were RF-neg and ANA-pos.

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But What About AH?

• Bilateral Hand Films
• Significan generalized osteopenia.
• Narrowing of the DIP joints.
• Mild narrowing of PIP joints.
• Lucency is noted in the left lunate which is
  nonspecific and may represent a geode.

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References

• 1 Measurement and Clinical Significance of
  Antinuclear Antibodies. Morris Reichlin, MD
  UpToDate.com.
• 2 Significance of a Positive ANA in Young
  Women With Symmetric Arthralgias. Morris
  Reichlin, MD UpToDate.com.
• 3 Arnett, Frank C. Rheumatoid Arthritis
  Chapter 286, Cecil Textbook of Medicine, 21st
  ed., 2000.
• 4 Ruddy Kelleys Textbook of Rheumatology, 6th
  ed., 2001.
• 5 Primer on Rheumatic Diseases Ed 11, Arthritis
  Foundation, 1997.
• 6 Housestaff Handbook 2001-2002, Department of
  Medicine, UCSF.