Laboratory tests in Rheumatology

1
Laboratory tests in Rheumatology

• In the name of God
• Salehi A. Iraj, M.D.

2
Clinical applications of Lab. Tests
Lab. tests

• Screening
• Diagnosis
• Severity, Activity
• Follow up
• Complications

Salehi I.
3
Clinical applications of Lab. Tests
Lab. tests

• Screening
• Diagnosis
• Severity, Activity
• Follow up
• Complications

Salehi I.
4
Clinical applications of Lab. Tests
Lab. tests

• Screening
• Diagnosis
• Severity, Activity
• Follow up
• Complications

Salehi I.
5
Clinical applications of Lab. Tests
Lab. tests

• Screening
• Diagnosis
• Severity, Activity
• Follow up
• Complications

Salehi I.
6
Clinical applications of Lab. Tests
Lab. tests

• Screening
• Diagnosis
• Severity, Activity
• Follow up
• Complications

Salehi I.
7
Clinical applications of Lab. Tests
Lab. tests

• Screening
• Diagnosis
• Severity, Activity
• Follow up
• Complications

Salehi I.
8
Almost all Hx Ph.E. is at first
Lab. tests

• Hx until 60 ? Dx
• Hx Ph.E. until 90 ? Dx
• Hx Ph.E. Lab. Data until 95 ? Dx

Salehi I.
9
Almost all Hx Ph.E. is at first
Lab. tests

• Hx until 60 ? Dx
• Hx Ph.E. until 90 ? Dx
• Hx Ph.E. Lab. Data until 95 ? Dx

Salehi I.
10
Almost all Hx Ph.E. is at first
Lab. tests

• Hx until 60 ? Dx
• Hx Ph.E. until 90 ? Dx
• Hx Ph.E. Lab. Data until 95 ? Dx

Salehi I.
11
Almost all Hx Ph.E. is at first
Lab. tests

• Hx until 60 ? Dx
• Hx Ph.E. until 90 ? Dx
• Hx Ph.E. Lab. Data until 95 ? Dx

Salehi I.
12
There is not any definite diagnostic test
Lab. tests

• Positive RF is not equal to Dx of RA
• Positive ANA is not equal to Dx of SLE
• Positive ANCA is not equal to Dx of WG
• Moreover anti-CCP for RA and anti-dsDNA or
  anti-Sm for SLE are not equal to Dx without
  compatible clinical findings

Salehi I.
13
There is not any definite diagnostic test
Lab. tests

• Positive RF is not equal to Dx of RA
• Positive ANA is not equal to Dx of SLE
• Positive ANCA is not equal to Dx of WG
• Moreover anti-CCP for RA and anti-dsDNA or
  anti-Sm for SLE are not equal to Dx without
  compatible clinical findings

Salehi I.
14
There is not any definite diagnostic test
Lab. tests

• Positive RF is not equal to Dx of RA
• Positive ANA is not equal to Dx of SLE
• Positive ANCA is not equal to Dx of WG
• Moreover anti-CCP for RA and anti-dsDNA or
  anti-Sm for SLE are not equal to Dx without
  compatible clinical findings

Salehi I.
15
There is not any definite diagnostic test
Lab. tests

• Positive RF is not equal to Dx of RA
• Positive ANA is not equal to Dx of SLE
• Positive ANCA is not equal to Dx of WG
• Moreover anti-CCP for RA and anti-dsDNA or
  anti-Sm for SLE are not equal to Dx without
  compatible clinical findings

Salehi I.
16
There is not any definite diagnostic test
Lab. tests

• Positive RF is not equal to Dx of RA
• Positive ANA is not equal to Dx of SLE
• Positive ANCA is not equal to Dx of WG
• Moreover anti-CCP for RA and anti-dsDNA or
  anti-Sm for SLE are not equal to Dx without
  compatible clinical findings

Salehi I.
17
We know that
Lab. tests

• A negative test never rule out the Dx
• A test may be positive or negative in a disease
• A test may be positive in different disease
• A test may be positive in normal population

Salehi I.
18
We know that
Lab. tests

• A negative test never rule out the Dx
• A test may be positive or negative in a disease
• A test may be positive in different disease
• A test may be positive in normal population

Salehi I.
19
We know that
Lab. tests

• A negative test never rule out the Dx
• A test may be positive or negative in a disease
• A test may be positive in different disease
• A test may be positive in normal population

Salehi I.
20
We know that
Lab. tests

• A negative test never rule out the Dx
• A test may be positive or negative in a disease
• A test may be positive in different disease
• A test may be positive in normal population

Salehi I.
21
We know that
Lab. tests

• A negative test never rule out the Dx
• A test may be positive or negative in a disease
• A test may be positive in different disease
• A test may be positive in normal population

Salehi I.
22
Attention please
Lab. tests

• With every new test we can not go away from old
  test
• We do not have Rheumatologic profile in
  laboratory tests
• Per case, after Hx and Ph.E. we must choose one
  or more compatible test and step by step,
  additional tests

Salehi I.
23
Attention please
Lab. tests

• With every new test we can not go away from old
  test
• We do not have Rheumatologic profile in
  laboratory tests
• Per case, after Hx and Ph.E. we must choose one
  or more compatible test and step by step,
  additional tests

Salehi I.
24
Attention please
Lab. tests

• With every new test we can not go away from old
  test
• We do not have Rheumatologic profile in
  laboratory tests
• Per case, after Hx and Ph.E. we must choose one
  or more compatible test and step by step,
  additional tests

Salehi I.
25
Attention please
Lab. tests

• With every new test we can not go away from old
  test
• We do not have Rheumatologic profile in
  laboratory tests
• Per case, after Hx and Ph.E. we must choose one
  or more compatible test and step by step,
  additional tests

Salehi I.
26
Attention please
Lab. tests

• We have many new tests that
• Very low sensitive
• Nonpractical
• Only for research
• Expensive
• There are many Laboratory centers that
• Nonstandard
• Nonreferral

Salehi I.
27
Attention please
Lab. tests

• We have many new tests that
• Very low sensitive
• Nonpractical
• Only for research
• Expensive
• There are many Laboratory centers that
• Nonstandard
• Nonreferral

Salehi I.
28
Attention please
Lab. tests

• We have many new tests that
• Very low sensitive
• Nonpractical
• Only for research
• Expensive
• There are many Laboratory centers that
• Nonstandard
• Nonreferral

Salehi I.
29
A wrong approach to patient
Lab. tests

• For an eighty y/o woman with hands and knees
  pain
• A physicin orders
• ESR, CRP
• RF, ANA,
• ASO,
• Wright, Widal
• Anti-CCP, Anti-dsDNA, Anti-Sm

Salehi I.
30
A wrong approach to patient
Lab. tests

• For an eighty y/o woman with hands and knees
  pain
• A physicin orders
• ESR, CRP
• RF, ANA,
• ASO,
• Wright, Widal
• Anti-CCP, Anti-dsDNA, Anti-Sm

Salehi I.
31
A wrong approach to patient
Lab. tests

• For an eighty y/o woman with hands and knees
  pain
• A physicin orders
• ESR, CRP
• RF, ANA,
• ASO,
• Wright, Widal
• Anti-CCP, Anti-dsDNA, Anti-Sm

Salehi I.
32
The principal Laboratory tests in Rheumatology
Lab. tests

• CBC, Diff., Plt.
• ESR, CRP
• BUN/Cr, U/A
• Ca/P, Alk. Ph.
• LFT SGOT, SGPT

Salehi I.
33
The principal Laboratory tests in Rheumatology
Lab. tests

• CBC, Diff., Plt.
• ESR, CRP
• BUN/Cr, U/A
• Ca/P, Alk. Ph.
• LFT SGOT, SGPT

Salehi I.
34
The principal Laboratory tests in Rheumatology
Lab. tests

• CBC, Diff., Plt.
• ESR, CRP
• BUN/Cr, U/A
• Ca/P, Alk. Ph.
• LFT SGOT, SGPT

Salehi I.
35
The principal Laboratory tests in Rheumatology
Lab. tests

• CBC, Diff., Plt.
• ESR, CRP
• BUN/Cr, U/A
• Ca/P, Alk. Ph.
• LFT SGOT, SGPT

Salehi I.
36
The principal Laboratory tests in Rheumatology
Lab. tests

• CBC, Diff., Plt.
• ESR, CRP
• BUN/Cr, U/A
• Ca/P, Alk. Ph.
• LFT SGOT, SGPT

Salehi I.
37
The principal Laboratory tests in Rheumatology
Lab. tests

• CBC, Diff., Plt.
• ESR, CRP
• BUN/Cr, U/A
• Ca/P, Alk. Ph.
• LFT SGOT, SGPT

Salehi I.
38
Rheumatoid Factor (RF)
Lab. tests

• Nonscreening for RA
• Nonspecific for RA
• Seen in many rheumatic and nonrheumatologic
  diseases
• Seen in normal population
• Young 5
• Elderly subjects until 25
• Positive RF nonequal to RA

Salehi I.
39
Rheumatoid Factor (RF)
Lab. tests

• Nonscreening for RA
• Nonspecific for RA
• Seen in many rheumatic and nonrheumatologic
  diseases
• Seen in normal population
• Young 5
• Elderly subjects until 25
• Positive RF nonequal to RA

Salehi I.
40
Rheumatoid Factor (RF)
Lab. tests

• Nonscreening for RA
• Nonspecific for RA
• Seen in many rheumatic and nonrheumatologic
  diseases
• Seen in normal population
• Young 5
• Elderly subjects until 25
• Positive RF nonequal to RA

Salehi I.
41
Rheumatoid Factor (RF)
Lab. tests

• Nonscreening for RA
• Nonspecific for RA
• Seen in many rheumatic and nonrheumatologic
  diseases
• Seen in normal population
• Young 5
• Elderly subjects until 25
• Positive RF nonequal to RA

Salehi I.
42
Rheumatoid Factor (RF)
Lab. tests

• Nonscreening for RA
• Nonspecific for RA
• Seen in many rheumatic and nonrheumatologic
  diseases
• Seen in normal population
• Young 5
• Elderly subjects until 25
• Positive RF nonequal to RA

Salehi I.
43
Rheumatoid Factor (RF)
Lab. tests

• Nonscreening for RA
• Nonspecific for RA
• Seen in many rheumatic and nonrheumatologic
  diseases
• Seen in normal population
• Young 5
• Elderly subjects until 25
• Positive RF nonequal to RA

Salehi I.
44
Rheumatoid Factor (RF)
Lab. tests

• Sensitivity in RA 26-90
• Negative RF No rule out RA
• Positive predictive value
• For RA 24
• For any Rheumatic disease 34

Salehi I.
45
Rheumatoid Factor (RF)
Lab. tests

• Sensitivity in RA 26-90
• Negative RF No rule out RA
• Positive predictive value
• For RA 24
• For any Rheumatic disease 34

Salehi I.
46
Rheumatoid Factor (RF)
Lab. tests

• Sensitivity in RA 26-90
• Negative RF No rule out RA
• Positive predictive value
• For RA 24
• For any Rheumatic disease 34

Salehi I.
47
Rheumatoid Factor (RF)
Lab. tests

• Sensitivity in RA 26-90
• Negative RF No rule out RA
• Positive predictive value
• For RA 24
• For any Rheumatic disease 34

Salehi I.
48
Rheumatoid Factor (RF)
Lab. tests

• Negative predictive value
• For RA until 89
• For any Rheumatic d. until 85
• In higher titer
• Positive predictive value increases
• RF titer gt 1/640
• Specificity for RA 99
• Sensitivity for RA 8
• It has prognostic value in RA

Salehi I.
49
Rheumatoid Factor (RF)
Lab. tests

• Negative predictive value
• For RA until 89
• For any Rheumatic d. until 85
• In higher titer
• Positive predictive value increases
• RF titer gt 1/640
• Specificity for RA 99
• Sensitivity for RA 8
• It has prognostic value in RA

Salehi I.
50
Rheumatoid Factor (RF)
Lab. tests

• Negative predictive value
• For RA until 89
• For any Rheumatic d. until 85
• In higher titer
• Positive predictive value increases
• RF titer gt 1/640
• Specificity for RA 99
• Sensitivity for RA 8
• It has prognostic value in RA

Salehi I.
51
Rheumatoid Factor (RF)
Lab. tests

• Negative predictive value
• For RA until 89
• For any Rheumatic d. until 85
• In higher titer
• Positive predictive value increases
• RF titer gt 1/640
• Specificity for RA 99
• Sensitivity for RA 8
• It has prognostic value in RA

Salehi I.
52
Rheumatoid Factor (RF)
Lab. tests

• We recommend RF testing in patients with
• Chronic polyarthralgia
• Arthritis
• Polyarthritis
• Oligoarthritis
• Chronic monoarthritis
• Prominent morning stiffness
• Sicca symptoms
• As prognostic value in RA

Salehi I.
53
Rheumatoid Factor (RF)
Lab. tests

• We recommend RF testing in patients with
• Chronic polyarthralgia
• Arthritis
• Polyarthritis
• Oligoarthritis
• Chronic monoarthritis
• Prominent morning stiffness
• Sicca symptoms
• As prognostic value in RA

Salehi I.
54
Rheumatoid Factor (RF)
Lab. tests

• We recommend RF testing in patients with
• Chronic polyarthralgia
• Arthritis
• Polyarthritis
• Oligoarthritis
• Chronic monoarthritis
• Prominent morning stiffness
• Sicca symptoms
• As prognostic value in RA

Salehi I.
55
Rheumatoid Factor (RF)
Lab. tests

• We recommend RF testing in patients with
• Chronic polyarthralgia
• Arthritis
• Polyarthritis
• Oligoarthritis
• Chronic monoarthritis
• Prominent morning stiffness
• Sicca symptoms
• As prognostic value in RA

Salehi I.
56
Rheumatoid Factor (RF)
Lab. tests

• We recommend RF testing in patients with
• Chronic polyarthralgia
• Arthritis
• Polyarthritis
• Oligoarthritis
• Chronic monoarthritis
• Prominent morning stiffness
• Sicca symptoms
• As prognostic value in RA

Salehi I.
57
Rheumatoid Factor (RF)
Lab. tests

• We recommend RF testing in patients with
• Chronic polyarthralgia
• Arthritis
• Polyarthritis
• Oligoarthritis
• Chronic monoarthritis
• Prominent morning stiffness
• Sicca symptoms
• As prognostic value in RA

Salehi I.
58
Rheumatoid Factor (RF)
Lab. tests

• We recommend RF testing in patients with
• Chronic polyarthralgia
• Arthritis
• Polyarthritis
• Oligoarthritis
• Chronic monoarthritis
• Prominent morning stiffness
• Sicca symptoms
• As prognostic value in RA

Salehi I.
59
Anti-Cyclic Citrullinated Peptide (anti-CCP)
Lab. tests

• In high titers more specific for RA
• Occurs in other disease in lower titer
• Active TB
• SLE
• Sjogrens syndrome
• PM/DM
• Scleroderma
• Prognostic value gt RF

Salehi I.
60
Anti-Cyclic Citrullinated Peptide (anti-CCP)
Lab. tests

• In high titers more specific for RA
• Occurs in other disease in lower titer
• Active TB
• SLE
• Sjogrens syndrome
• PM/DM
• Scleroderma
• Prognostic value gt RF

Salehi I.
61
Anti-Cyclic Citrullinated Peptide (anti-CCP)
Lab. tests

• In high titers more specific for RA
• Occurs in other disease in lower titer
• Active TB
• SLE
• Sjogrens syndrome
• PM/DM
• Scleroderma
• Prognostic value gt RF

Salehi I.
62
Anti-Cyclic Citrullinated Peptide (anti-CCP)
Lab. tests

• In high titers more specific for RA
• Occurs in other disease in lower titer
• Active TB
• SLE
• Sjogrens syndrome
• PM/DM
• Scleroderma
• Prognostic value gt RF

Salehi I.
63
Anti-CCP
Lab. tests

• Anti-CCP versus RF in RA
• Anti-CCP
• Sensitivity 56, Specificity 90
• IgM-RF
• Sensitivity 73, Specificity 82
• IgM-RF anti-CCP
• Sensitivity 48, Specificity 96

Salehi I.
64
Anti-CCP
Lab. tests

• Anti-CCP versus RF in RA
• Anti-CCP
• Sensitivity 56, Specificity 90
• IgM-RF
• Sensitivity 73, Specificity 82
• IgM-RF anti-CCP
• Sensitivity 48, Specificity 96

Salehi I.
65
Anti-CCP
Lab. tests

• Anti-CCP versus RF in RA
• Anti-CCP
• Sensitivity 56, Specificity 90
• IgM-RF
• Sensitivity 73, Specificity 82
• IgM-RF anti-CCP
• Sensitivity 48, Specificity 96

Salehi I.
66
Anti-CCP
Lab. tests

• Anti-CCP versus RF in RA
• Anti-CCP
• Sensitivity 56, Specificity 90
• IgM-RF
• Sensitivity 73, Specificity 82
• IgM-RF anti-CCP
• Sensitivity 48, Specificity 96

Salehi I.
67
Anti-CCP
Lab. tests

• In early undifferentiated arthritis
• High titer of (IgM-RF anti-CCP) RA
• Both RF and anti-CCP negative R/O RA
• Nonscreening test in normal population
• Anti-Mutated Citrullinated Vimentin (anti-MCV) in
  RA
• More sensitive than anti-CCP
• Equal specificity with anti-CCP
• Prognostic value more than anti-CCP

Salehi I.
68
Anti-CCP
Lab. tests

• In early undifferentiated arthritis
• High titer of (IgM-RF anti-CCP) RA
• Both RF and anti-CCP negative R/O RA
• Nonscreening test in normal population
• Anti-Mutated Citrullinated Vimentin (anti-MCV) in
  RA
• More sensitive than anti-CCP
• Equal specificity with anti-CCP
• Prognostic value more than anti-CCP

Salehi I.
69
Anti-CCP
Lab. tests

• In early undifferentiated arthritis
• High titer of (IgM-RF anti-CCP) RA
• Both RF and anti-CCP negative R/O RA
• Nonscreening test in normal population
• Anti-Mutated Citrullinated Vimentin (anti-MCV) in
  RA
• More sensitive than anti-CCP
• Equal specificity with anti-CCP
• Prognostic value more than anti-CCP

Salehi I.
70
Anti-CCP
Lab. tests

• In early undifferentiated arthritis
• High titer of (IgM-RF anti-CCP) RA
• Both RF and anti-CCP negative R/O RA
• Nonscreening test in normal population
• Anti-Mutated Citrullinated Vimentin (anti-MCV) in
  RA
• More sensitive than anti-CCP
• Equal specificity with anti-CCP
• Prognostic value more than anti-CCP

Salehi I.
71
Anti-Nuclear Antibody (ANA)
Lab. tests

• Nonspecific for SLE
• Seen in
• Systemic autoimmune disease
• Specific organ autoimmune disease
• Nonautoimmune disease
• Normal population
• Sensitivity
• SLE 93
• Scleroderma 85
• MCTD 93
• Sjogrens synd. 48

Salehi I.
72
Anti-Nuclear Antibody (ANA)
Lab. tests

• Nonspecific for SLE
• Seen in
• Systemic autoimmune disease
• Specific organ autoimmune disease
• Nonautoimmune disease
• Normal population
• Sensitivity
• SLE 93
• Scleroderma 85
• MCTD 93
• Sjogrens synd. 48

Salehi I.
73
Anti-Nuclear Antibody (ANA)
Lab. tests

• Nonspecific for SLE
• Seen in
• Systemic autoimmune disease
• Specific organ autoimmune disease
• Nonautoimmune disease
• Normal population
• Sensitivity
• SLE 93
• Scleroderma 85
• MCTD 93
• Sjogrens synd. 48

Salehi I.
74
Anti-Nuclear Antibody (ANA)
Lab. tests

• Nonspecific for SLE
• Seen in
• Systemic autoimmune disease
• Specific organ autoimmune disease
• Nonautoimmune disease
• Normal population
• Sensitivity
• SLE 93
• Scleroderma 85
• MCTD 93
• Sjogrens synd. 48

Salehi I.
75
ANA
Lab. tests

• Negative ANA no rule out SLE
• Positive ANA no equal to SLE
• Higher titer
• gt 1/160 probably autoimmune d.
• gt 1/640 only seen in autoimmune d.
• FANA pattern
• Homogeneous or diffuse
• Peripheral or rim
• Speckled
• Nucleolar
• Centromeric

Salehi I.
76
ANA
Lab. tests

• Negative ANA no rule out SLE
• Positive ANA no equal to SLE
• Higher titer
• gt 1/160 probably autoimmune d.
• gt 1/640 only seen in autoimmune d.
• FANA pattern
• Homogeneous or diffuse
• Peripheral or rim
• Speckled
• Nucleolar
• Centromeric

Salehi I.
77
ANA
Lab. tests

• Negative ANA no rule out SLE
• Positive ANA no equal to SLE
• Higher titer
• gt 1/160 probably autoimmune d.
• gt 1/640 only seen in autoimmune d.
• FANA pattern
• Homogeneous or diffuse
• Peripheral or rim
• Speckled
• Nucleolar
• Centromeric

Salehi I.
78
ANA
Lab. tests

• Negative ANA no rule out SLE
• Positive ANA no equal to SLE
• Higher titer
• gt 1/160 probably autoimmune d.
• gt 1/640 only seen in autoimmune d.
• FANA pattern
• Homogeneous or diffuse
• Peripheral or rim
• Speckled
• Nucleolar
• Centromeric

Salehi I.
79
ANA
Lab. tests

• Negative ANA no rule out SLE
• Positive ANA no equal to SLE
• Higher titer
• gt 1/160 probably autoimmune d.
• gt 1/640 only seen in autoimmune d.
• FANA pattern
• Homogeneous or diffuse
• Peripheral or rim
• Speckled
• Nucleolar
• Centromeric

Salehi I.
80
ANA
Lab. tests

• Nonscreening test in NL population
• Screening test in symptomatic Pt.
• If ANA is negative in patients suspicious to have
  autoimmune d. we recommend
• Anti-dsDNA, Anti-Sm
• Anti-RNP
• ACA, Anti-Scl-70
• Anti-Ro, Anti-La

Salehi I.
81
ANA
Lab. tests

• Nonscreening test in NL population
• Screening test in symptomatic Pt.
• If ANA is negative in patients suspicious to have
  autoimmune d. we recommend
• Anti-dsDNA, Anti-Sm
• Anti-RNP
• ACA, Anti-Scl-70
• Anti-Ro, Anti-La

Salehi I.
82
ANA
Lab. tests

• Nonscreening test in NL population
• Screening test in symptomatic Pt.
• If ANA is negative in patients suspicious to have
  autoimmune d. we recommend
• Anti-dsDNA, Anti-Sm
• Anti-RNP
• ACA, Anti-Scl-70
• Anti-Ro, Anti-La

Salehi I.
83
ANA
Lab. tests

• Nonscreening test in NL population
• Screening test in symptomatic Pt.
• If ANA is negative in patients suspicious to have
  autoimmune d. we recommend
• Anti-dsDNA, Anti-Sm
• Anti-RNP
• ACA, Anti-Scl-70
• Anti-Ro, Anti-La

Salehi I.
84
Anti-dsDNA
Lab. tests

• Specificity 97
• Sensitivity 70
• Correlate with SLE activity but not always
• Titer of anti-dsDNA
• High titer 100 specificity
• Low titer seen in others (lt 5)
• Peripheral or rim pattern
• Induced by Infliximab Etanercept

Salehi I.
85
Anti-dsDNA
Lab. tests

• Specificity 97
• Sensitivity 70
• Correlate with SLE activity but not always
• Titer of anti-dsDNA
• High titer 100 specificity
• Low titer seen in others (lt 5)
• Peripheral or rim pattern
• Induced by Infliximab Etanercept

Salehi I.
86
Anti-dsDNA
Lab. tests

• Specificity 97
• Sensitivity 70
• Correlate with SLE activity but not always
• Titer of anti-dsDNA
• High titer 100 specificity
• Low titer seen in others (lt 5)
• Peripheral or rim pattern
• Induced by Infliximab Etanercept

Salehi I.
87
Anti-dsDNA
Lab. tests

• Specificity 97
• Sensitivity 70
• Correlate with SLE activity but not always
• Titer of anti-dsDNA
• High titer 100 specificity
• Low titer seen in others (lt 5)
• Peripheral or rim pattern
• Induced by Infliximab Etanercept

Salehi I.
88
Anti-dsDNA
Lab. tests

• Specificity 97
• Sensitivity 70
• Correlate with SLE activity but not always
• Titer of anti-dsDNA
• High titer 100 specificity
• Low titer seen in others (lt 5)
• Peripheral or rim pattern
• Induced by Infliximab Etanercept

Salehi I.
89
Anti-dsDNA
Lab. tests

• Specificity 97
• Sensitivity 70
• Correlate with SLE activity but not always
• Titer of anti-dsDNA
• High titer 100 specificity
• Low titer seen in others (lt 5)
• Peripheral or rim pattern
• Induced by Infliximab Etanercept

Salehi I.
90
Anti-dsDNA
Lab. tests

• Specificity 97
• Sensitivity 70
• Correlate with SLE activity but not always
• Titer of anti-dsDNA
• High titer 100 specificity
• Low titer seen in others (lt 5)
• Peripheral or rim pattern
• Induced by Infliximab Etanercept

Salehi I.
91
Anti-Sm antibody
Lab. tests

• Specificity 100 for SLE
• Sensitivity 10-50
• No correlation with SLE activity
• We recommend anti-Sm in suspicious case of SLE
  with negative anti-dsDNA
• With less than 4 ACR criteria, if including
  anti-dsDNA or anti-Sm
• We have definite Dx of SLE

Salehi I.
92
Anti-Sm antibody
Lab. tests

• Specificity 100 for SLE
• Sensitivity 10-50
• No correlation with SLE activity
• We recommend anti-Sm in suspicious case of SLE
  with negative anti-dsDNA
• With less than 4 ACR criteria, if including
  anti-dsDNA or anti-Sm
• We have definite Dx of SLE

Salehi I.
93
Anti-Sm antibody
Lab. tests

• Specificity 100 for SLE
• Sensitivity 10-50
• No correlation with SLE activity
• We recommend anti-Sm in suspicious case of SLE
  with negative anti-dsDNA
• With less than 4 ACR criteria, if including
  anti-dsDNA or anti-Sm
• We have definite Dx of SLE

Salehi I.
94
Anti-Sm antibody
Lab. tests

• Specificity 100 for SLE
• Sensitivity 10-50
• No correlation with SLE activity
• We recommend anti-Sm in suspicious case of SLE
  with negative anti-dsDNA
• With less than 4 ACR criteria, if including
  anti-dsDNA or anti-Sm
• We have definite Dx of SLE

Salehi I.
95
Anti-Sm antibody
Lab. tests

• Specificity 100 for SLE
• Sensitivity 10-50
• No correlation with SLE activity
• We recommend anti-Sm in suspicious case of SLE
  with negative anti-dsDNA
• With less than 4 ACR criteria, if including
  anti-dsDNA or anti-Sm
• We have definite Dx of SLE

Salehi I.
96
Anti-Sm antibody
Lab. tests

• Specificity 100 for SLE
• Sensitivity 10-50
• No correlation with SLE activity
• We recommend anti-Sm in suspicious case of SLE
  with negative anti-dsDNA
• With less than 4 ACR criteria, if including
  anti-dsDNA or anti-Sm
• We have definite Dx of SLE

Salehi I.
97
Anti-Neutrophil Cytoplasmic Antibody (ANCA)
Lab. tests

• IF assay more sensitive
• C-ANCA
• P-ANCA
• Atypical (non-C, non-P) ANCA
• ELISA more specific
• PR3-ANCA
• MPO-ANCA
• C-ANCA usually PR3-ANCA
• P-ANCA usually MPO-ANCA

Salehi I.
98
Anti-Neutrophil Cytoplasmic Antibody (ANCA)
Lab. tests

• IF assay more sensitive
• C-ANCA
• P-ANCA
• Atypical (non-C, non-P) ANCA
• ELISA more specific
• PR3-ANCA
• MPO-ANCA
• C-ANCA usually PR3-ANCA
• P-ANCA usually MPO-ANCA

Salehi I.
99
Anti-Neutrophil Cytoplasmic Antibody (ANCA)
Lab. tests

• IF assay more sensitive
• C-ANCA
• P-ANCA
• Atypical (non-C, non-P) ANCA
• ELISA more specific
• PR3-ANCA
• MPO-ANCA
• C-ANCA usually PR3-ANCA
• P-ANCA usually MPO-ANCA

Salehi I.
100
Anti-Neutrophil Cytoplasmic Antibody (ANCA)
Lab. tests

• IF assay more sensitive
• C-ANCA
• P-ANCA
• Atypical (non-C, non-P) ANCA
• ELISA more specific
• PR3-ANCA
• MPO-ANCA
• C-ANCA usually PR3-ANCA
• P-ANCA usually MPO-ANCA

Salehi I.
101
Anti-Neutrophil Cytoplasmic Antibody (ANCA)
Lab. tests

• IF assay more sensitive
• C-ANCA
• P-ANCA
• Atypical (non-C, non-P) ANCA
• ELISA more specific
• PR3-ANCA
• MPO-ANCA
• C-ANCA usually PR3-ANCA
• P-ANCA usually MPO-ANCA

Salehi I.
102
ANCA
Lab. tests

• C-ANCA gt P-ANCA
• specificity for vasculitis
• Positive ANCA in WG
• 90 in active severe WG
• 60 in limited WG
• 80-90 PR3-ANCA
• Sensitivity
• WG 60-90
• MPA 70
• CSS 50
• Specificity 81-95

Salehi I.
103
ANCA
Lab. tests

• C-ANCA gt P-ANCA
• specificity for vasculitis
• Positive ANCA in WG
• 90 in active severe WG
• 60 in limited WG
• 80-90 PR3-ANCA
• Sensitivity
• WG 60-90
• MPA 70
• CSS 50
• Specificity 81-95

Salehi I.
104
ANCA
Lab. tests

• C-ANCA gt P-ANCA
• specificity for vasculitis
• Positive ANCA in WG
• 90 in active severe WG
• 60 in limited WG
• 80-90 PR3-ANCA
• Sensitivity
• WG 60-90
• MPA 70
• CSS 50
• Specificity 81-95

Salehi I.
105
ANCA
Lab. tests

• C-ANCA gt P-ANCA
• specificity for vasculitis
• Positive ANCA in WG
• 90 in active severe WG
• 60 in limited WG
• 80-90 PR3-ANCA
• Sensitivity
• WG 60-90
• MPA 70
• CSS 50
• Specificity 81-95

Salehi I.
106
ANCA
Lab. tests

• C-ANCA gt P-ANCA
• specificity for vasculitis
• Positive ANCA in WG
• 90 in active severe WG
• 60 in limited WG
• 80-90 PR3-ANCA
• Sensitivity
• WG 60-90
• MPA 70
• CSS 50
• Specificity 81-95

Salehi I.
107
ANCA
Lab. tests

• Positive predictive value of ANCA for ANCA
  associated vasculitis
• IF 45, ELISA 83, IF ELISA 88
• in acute or rapidly progressive GN 98
• in chronic sinusitis very low for WG
• in systemic disease (C-ANCA)
• 50 for ANCA associated vasculitis
• 28 for WG

Salehi I.
108
ANCA
Lab. tests

• Positive predictive value of ANCA for ANCA
  associated vasculitis
• IF 45, ELISA 83, IF ELISA 88
• in acute or rapidly progressive GN 98
• in chronic sinusitis very low for WG
• in systemic disease (C-ANCA)
• 50 for ANCA associated vasculitis
• 28 for WG

Salehi I.
109
ANCA
Lab. tests

• Positive predictive value of ANCA for ANCA
  associated vasculitis
• IF 45, ELISA 83, IF ELISA 88
• in acute or rapidly progressive GN 98
• in chronic sinusitis very low for WG
• in systemic disease (C-ANCA)
• 50 for ANCA associated vasculitis
• 28 for WG

Salehi I.
110
ANCA
Lab. tests

• Positive predictive value of ANCA for ANCA
  associated vasculitis
• IF 45, ELISA 83, IF ELISA 88
• in acute or rapidly progressive GN 98
• in chronic sinusitis very low for WG
• in systemic disease (C-ANCA)
• 50 for ANCA associated vasculitis
• 28 for WG

Salehi I.
111
ANCA
Lab. tests

• Positive predictive value of ANCA for ANCA
  associated vasculitis
• IF 45, ELISA 83, IF ELISA 88
• in acute or rapidly progressive GN 98
• in chronic sinusitis very low for WG
• in systemic disease (C-ANCA)
• 50 for ANCA associated vasculitis
• 28 for WG

Salehi I.
112
ANCA
Lab. tests

• Positive predictive value of ANCA for ANCA
  associated vasculitis
• IF 45, ELISA 83, IF ELISA 88
• in acute or rapidly progressive GN 98
• in chronic sinusitis very low for WG
• in systemic disease (C-ANCA)
• 50 for ANCA associated vasculitis
• 28 for WG

Salehi I.
113
ANCA
Lab. tests

• Negative predictive value
• With IF ELISA
• in acute or rapidly progressive GN
• for ANCA associated vasculitis
• Is 99
• Correlation with disease activity
• IF 57, ELISA 71
• FANA ? false positive P-ANCA

Salehi I.
114
ANCA
Lab. tests

• Negative predictive value
• With IF ELISA
• in acute or rapidly progressive GN
• for ANCA associated vasculitis
• Is 99
• Correlation with disease activity
• IF 57, ELISA 71
• FANA ? false positive P-ANCA

Salehi I.
115
ANCA
Lab. tests

• Negative predictive value
• With IF ELISA
• in acute or rapidly progressive GN
• for ANCA associated vasculitis
• Is 99
• Correlation with disease activity
• IF 57, ELISA 71
• FANA ? false positive P-ANCA

Salehi I.
116
ANCA
Lab. tests

• Negative predictive value
• With IF ELISA
• in acute or rapidly progressive GN
• for ANCA associated vasculitis
• Is 99
• Correlation with disease activity
• IF 57, ELISA 71
• FANA ? false positive P-ANCA

Salehi I.
117
Anti-Phospholipid (APL) Antibodies
Lab. tests

• Lupus Anticoagulant (LA)
• Anticardiolipin (aCL) antibodies
• Anti B2-Glycoprotein-I (B2-GP-I)
• Biologic False Positive test for syphilis
• VDRL, RPR
• Low sensitivity, Low specificity
• Nonscreening tests for APS
• Seen in SLE too

Salehi I.
118
Anti-Phospholipid (APL) Antibodies
Lab. tests

• Lupus Anticoagulant (LA)
• Anticardiolipin (aCL) antibodies
• Anti B2-Glycoprotein-I (B2-GP-I)
• Biologic False Positive test for syphilis
• VDRL, RPR
• Low sensitivity, Low specificity
• Nonscreening tests for APS
• Seen in SLE too

Salehi I.
119
Anti-Phospholipid (APL) Antibodies
Lab. tests

• Lupus Anticoagulant (LA)
• Anticardiolipin (aCL) antibodies
• Anti B2-Glycoprotein-I (B2-GP-I)
• Biologic False Positive test for syphilis
• VDRL, RPR
• Low sensitivity, Low specificity
• Nonscreening tests for APS
• Seen in SLE too

Salehi I.
120
Anti-Phospholipid (APL) Antibodies
Lab. tests

• Lupus Anticoagulant (LA)
• Anticardiolipin (aCL) antibodies
• Anti B2-Glycoprotein-I (B2-GP-I)
• Biologic False Positive test for syphilis
• VDRL, RPR
• Low sensitivity, Low specificity
• Nonscreening tests for APS
• Seen in SLE too

Salehi I.
121
Anti-Phospholipid (APL) Antibodies
Lab. tests

• Lupus Anticoagulant (LA)
• Anticardiolipin (aCL) antibodies
• Anti B2-Glycoprotein-I (B2-GP-I)
• Biologic False Positive test for syphilis
• VDRL, RPR
• Low sensitivity, Low specificity
• Nonscreening tests for APS
• Seen in SLE too

Salehi I.
122
APL Antibodies
Lab. tests

• When APS is suspected we recommend
• First step
• aCL and LA,
• if negative
• Second step
• Anti-B2-GP-I antibody
• Anti-Prothrombin
• Antiphosphatidyl inositol
• Only aCL and LA are diagnostic criteria

Salehi I.
123
APL Antibodies
Lab. tests

• When APS is suspected we recommend
• First step
• aCL and LA,
• if negative
• Second step
• Anti-B2-GP-I antibody
• Anti-Prothrombin
• Antiphosphatidyl inositol
• Only aCL and LA are diagnostic criteria

Salehi I.
124
APL Antibodies
Lab. tests

• When APS is suspected we recommend
• First step
• aCL and LA,
• if negative
• Second step
• Anti-B2-GP-I antibody
• Anti-Prothrombin
• Antiphosphatidyl inositol
• Only aCL and LA are diagnostic criteria

Salehi I.
125
APL Antibodies
Lab. tests

• When APS is suspected we recommend
• First step
• aCL and LA,
• if negative
• Second step
• Anti-B2-GP-I antibody
• Anti-Prothrombin
• Antiphosphatidyl inositol
• Only aCL and LA are diagnostic criteria

Salehi I.
126
Scleroderma related antibodies
Lab. tests

• Anti-topoisomerase-I (anti-Scl-70)
• More associated with Diffuse Scl.
• Sensitivity until 43
• Specificity until 98
• Anti-Centromere Antibody (ACA)
• Usually associated with Limited Scl.
• Sensitivity until 33
• Specificity until 95

Salehi I.
127
Scleroderma related antibodies
Lab. tests

• Anti-topoisomerase-I (anti-Scl-70)
• More associated with Diffuse Scl.
• Sensitivity until 43
• Specificity until 98
• Anti-Centromere Antibody (ACA)
• Usually associated with Limited Scl.
• Sensitivity until 33
• Specificity until 95

Salehi I.
128
Scleroderma related antibodies
Lab. tests

• Anti-topoisomerase-I (anti-Scl-70)
• More associated with Diffuse Scl.
• Sensitivity until 43
• Specificity until 98
• Anti-Centromere Antibody (ACA)
• Usually associated with Limited Scl.
• Sensitivity until 33
• Specificity until 95

Salehi I.
129
Scleroderma related antibodies
Lab. tests

• Anti RNA polymerase
• Anti-PM-Scl Overlap of PM Scl
• Anti-Fibrillin-1 Localized Scl.
• Anti-Nucleolus Organizer Region (NOR-90)
• Anti-Nucleolar RNA helicase (Gu) Scl. SLE

Salehi I.
130
Scleroderma related antibodies
Lab. tests

• Anti RNA polymerase
• Anti-PM-Scl Overlap of PM Scl
• Anti-Fibrillin-1 Localized Scl.
• Anti-Nucleolus Organizer Region (NOR-90)
• Anti-Nucleolar RNA helicase (Gu) Scl. SLE

Salehi I.
131
Scleroderma related antibodies
Lab. tests

• Anti RNA polymerase
• Anti-PM-Scl Overlap of PM Scl
• Anti-Fibrillin-1 Localized Scl.
• Anti-Nucleolus Organizer Region (NOR-90)
• Anti-Nucleolar RNA helicase (Gu) Scl. SLE

Salehi I.
132
Anti-Ro/SSA, Anti-La/SSB
Lab. tests

• Seen in
• Sjogrens syndrome
• SLE (SCLE), Neonatal lupus (CCHB)
• Others
• NL population 0.1-0.5
• Nonspecific
• Anti-Ro sensitivity
• Primary Sjogren 70-97
• SLE 10-60
• Anti-La sensitivity
• Primary Sjogren 70-95
• SLE 10-35

Salehi I.
133
Anti-Ro/SSA, Anti-La/SSB
Lab. tests

• Seen in
• Sjogrens syndrome
• SLE (SCLE), Neonatal lupus (CCHB)
• Others
• NL population 0.1-0.5
• Nonspecific
• Anti-Ro sensitivity
• Primary Sjogren 70-97
• SLE 10-60
• Anti-La sensitivity
• Primary Sjogren 70-95
• SLE 10-35

Salehi I.
134
Anti-Ro/SSA, Anti-La/SSB
Lab. tests

• Seen in
• Sjogrens syndrome
• SLE (SCLE), Neonatal lupus (CCHB)
• Others
• NL population 0.1-0.5
• Nonspecific
• Anti-Ro sensitivity
• Primary Sjogren 70-97
• SLE 10-60
• Anti-La sensitivity
• Primary Sjogren 70-95
• SLE 10-35

Salehi I.
135
Anti-Ro/SSA, Anti-La/SSB
Lab. tests

• Seen in
• Sjogrens syndrome
• SLE (SCLE), Neonatal lupus (CCHB)
• Others
• NL population 0.1-0.5
• Nonspecific
• Anti-Ro sensitivity
• Primary Sjogren 70-97
• SLE 10-60
• Anti-La sensitivity
• Primary Sjogren 70-95
• SLE 10-35

Salehi I.
136
Anti-Ro/SSA, Anti-La/SSB
Lab. tests

• Seen in
• Sjogrens syndrome
• SLE (SCLE), Neonatal lupus (CCHB)
• Others
• NL population 0.1-0.5
• Nonspecific
• Anti-Ro sensitivity
• Primary Sjogren 70-97
• SLE 10-60
• Anti-La sensitivity
• Primary Sjogren 70-95
• SLE 10-35

Salehi I.
137
Anti-Ro/SSA, Anti-La/SSB
Lab. tests

• Indication for ordering
• Women with SLE who have become pregnant
• Women with past Hx of CCHB or myocarditis in her
  neonate
• Photosensitive skin eruption
• ANA negative systemic CTD
• Xerostomia and Keratoconjunctivitis sicca
• Bilateral salivary and lacrimal gland enlargement

Salehi I.
138
Anti-Ro/SSA, Anti-La/SSB
Lab. tests

• Indication for ordering
• Women with SLE who have become pregnant
• Women with past Hx of CCHB or myocarditis in her
  neonate
• Photosensitive skin eruption
• ANA negative systemic CTD
• Xerostomia and Keratoconjunctivitis sicca
• Bilateral salivary and lacrimal gland enlargement

Salehi I.
139
Anti-Ro/SSA, Anti-La/SSB
Lab. tests

• Indication for ordering
• Women with SLE who have become pregnant
• Women with past Hx of CCHB or myocarditis in her
  neonate
• Photosensitive skin eruption
• ANA negative systemic CTD
• Xerostomia and Keratoconjunctivitis sicca
• Bilateral salivary and lacrimal gland enlargement

Salehi I.
140
Anti-Ro/SSA, Anti-La/SSB
Lab. tests

• Indication for ordering
• Women with SLE who have become pregnant
• Women with past Hx of CCHB or myocarditis in her
  neonate
• Photosensitive skin eruption
• ANA negative systemic CTD
• Xerostomia and Keratoconjunctivitis sicca
• Bilateral salivary and lacrimal gland enlargement

Salehi I.
141
Anti-Ro/SSA, Anti-La/SSB
Lab. tests

• Indication for ordering
• Women with SLE who have become pregnant
• Women with past Hx of CCHB or myocarditis in her
  neonate
• Photosensitive skin eruption
• ANA negative systemic CTD
• Xerostomia and Keratoconjunctivitis sicca
• Bilateral salivary and lacrimal gland enlargement

Salehi I.
142
Anti-Ro/SSA, Anti-La/SSB
Lab. tests

• Indication for ordering
• Women with SLE who have become pregnant
• Women with past Hx of CCHB or myocarditis in her
  neonate
• Photosensitive skin eruption
• ANA negative systemic CTD
• Xerostomia and Keratoconjunctivitis sicca
• Bilateral salivary and lacrimal gland enlargement

Salehi I.
143
Anti-Ro/SSA, Anti-La/SSB
Lab. tests

• Indication for ordering
• Women with SLE who have become pregnant
• Women with past Hx of CCHB or myocarditis in her
  neonate
• Photosensitive skin eruption
• ANA negative systemic CTD
• Xerostomia and Keratoconjunctivitis sicca
• Bilateral salivary and lacrimal gland enlargement

Salehi I.
144
Anti-Ro/SSA, Anti-La/SSB
Lab. tests

• Indication for ordering
• Women with SLE who have become pregnant
• Women with past Hx of CCHB or myocarditis in her
  neonate
• Photosensitive skin eruption
• ANA negative systemic CTD
• Xerostomia and Keratoconjunctivitis sicca
• Bilateral salivary and lacrimal gland enlargement

Salehi I.
145
Myositis Specific Autoantibody (MSA)
Lab. tests

• Anti-JO-1
• Most common MSA
• Anti-JO-1 syndrome
• Anti-SRP
• Almost exclusively in PM
• Severe uncontroled myositis
• Anti-Mi-2
• Acute DM with erythroderma

Salehi I.
146
Myositis Specific Autoantibody (MSA)
Lab. tests

• Anti-JO-1
• Most common MSA
• Anti-JO-1 syndrome
• Anti-SRP
• Almost exclusively in PM
• Severe uncontroled myositis
• Anti-Mi-2
• Acute DM with erythroderma

Salehi I.
147
Myositis Specific Autoantibody (MSA)
Lab. tests

• Anti-JO-1
• Most common MSA
• Anti-JO-1 syndrome
• Anti-SRP
• Almost exclusively in PM
• Severe uncontroled myositis
• Anti-Mi-2
• Acute DM with erythroderma

Salehi I.
148
Myositis Specific Autoantibody (MSA)
Lab. tests

• Anti-JO-1
• Most common MSA
• Anti-JO-1 syndrome
• Anti-SRP
• Almost exclusively in PM
• Severe uncontroled myositis
• Anti-Mi-2
• Acute DM with erythroderma

Salehi I.
149
MSA
Lab. tests

• Anti-CADM-140
• Amyopathic DM
• Anti-155/140
• DM Malignancy
• Anti-hPMS-1
• Anti-Ku
• Anti-155 KD Pr.

Salehi I.
150
MSA
Lab. tests

• Anti-CADM-140
• Amyopathic DM
• Anti-155/140
• DM Malignancy
• Anti-hPMS-1
• Anti-Ku
• Anti-155 KD Pr.

Salehi I.
151
MSA
Lab. tests

• Anti-CADM-140
• Amyopathic DM
• Anti-155/140
• DM Malignancy
• Anti-hPMS-1
• Anti-Ku
• Anti-155 KD Pr.

Salehi I.
152
Anti-RNP
Lab. tests

• High titer of Anti-U1 RNP
• More specific for MCTD
• Diagnostic criteria for MCTD
• Medium to Low titer
• SLE 3-69
• Low titer Others

Salehi I.
153
Anti-RNP
Lab. tests

• High titer of Anti-U1 RNP
• More specific for MCTD
• Diagnostic criteria for MCTD
• Medium to Low titer
• SLE 3-69
• Low titer Others

Salehi I.
154
Anti-RNP
Lab. tests

• High titer of Anti-U1 RNP
• More specific for MCTD
• Diagnostic criteria for MCTD
• Medium to Low titer
• SLE 3-69
• Low titer Others

Salehi I.
155
Anti-RNP
Lab. tests

• High titer of Anti-U1 RNP
• More specific for MCTD
• Diagnostic criteria for MCTD
• Medium to Low titer
• SLE 3-69
• Low titer Others

Salehi I.
156
Anti-Perinuclear Factor Antibody (APF),
Anti-Keratin Antibody (AKA)
Lab. tests

• The most specific antibodies for RA
• React with CCP in the filaggrin molecule
• Anti-CCP has replaced these tests
• More easier to perform than
• More standardize than

Salehi I.
157
Anti-Perinuclear Factor Antibody (APF),
Anti-Keratin Antibody (AKA)
Lab. tests

• The most specific antibodies for RA
• React with CCP in the filaggrin molecule
• Anti-CCP has replaced these tests
• More easier to perform than
• More standardize than

Salehi I.
158
Anti-Perinuclear Factor Antibody (APF),
Anti-Keratin Antibody (AKA)
Lab. tests

• The most specific antibodies for RA
• React with CCP in the filaggrin molecule
• Anti-CCP has replaced these tests
• More easie