Clinical Conditions Associated With a High Antinuclear Antibody Titer in Individuals Without Autoimmune Disease.

The initial manifestations and final diagnosis of patients with high and low titers of antinuclear antibodies after 6 months of follow-up

We evaluated the reasons for requesting anti-nuclear antibody (ANA) analysis in clinical practice at a tertiary center and the performance of ANA in pediatric autoimmune diseases. Patients under 18years of age who underwent ANA testing for various symptoms between 2013 and 2017 were included. We retrieved data from medical records, including demographic and clinical characteristics, diagnoses, ANA results, titers, and staining patterns. The performance assessment tools were calculated according to the ANA titer for autoimmune diseases. Risk factors for autoimmune diseases in ANA-positive patients were evaluated using logistic regression analysis. Changes in ANA titer and seroconversion were evaluated using repeated ANA analyses. A total of 3812 patients underwent ANA. Medical records of 3320 patients were obtained. The rate of ANA positivity was 27.4%. ANA was requested most frequently because of musculoskeletal findings in 1355 patients (40.8%). Juvenile idiopathic arthritis (n = 174, 20.2%) was the most common diagnosis in ANA-positive patients, followed by systemic lupus erythematosus (n = 52, 6%). For autoimmune diseases, a titer of ≥ 1:100, a sensitivity of 40.1%, and a specificity of 77.1% were observed. At a titer ≥ 1:1000, the sensitivity and specificity were 24.1% and 89%, respectively. Homogeneous staining was an additional risk factor for autoimmune diseases in ANA-positive patients by multivariate logistic regression analysis (OR [95% CI]: 4.562 [3.076-6.766], p < 0.001). Conclusion: Our results revealed that the performance of the ANA test in diagnosing autoimmune diseases in pediatric clinical practice was poor. Therefore, clinical findings should be carefully evaluated before ANA testing is performed. What is Known: • ANA can be detected in systemic autoimmune rheumatic diseases. • The diagnostic role of ANA is controversial, especially in childhood. What is New: • One in four patients who requested the ANA test had an autoimmune disease. • Less than half of patients with an autoimmune disease had ANA positivity.

Background Minimising unnecessary tests is a global health economic priority with multiple initiatives in place to avoid inappropriate healthcare utilisation(1) and harm. Anti-nuclear antibody (ANA) testing is frequently performed as a diagnostic test for autoimmune conditions, such as systemic lupus erythematosus (SLE) or as a screening test in patients with inflammatory or musculoskeletal symptoms. The value of serial testing in the monitoring of such conditions is unclear and false positive tests can lead to unnecessary further investigation and increased patient anxiety(2) Objectives To evaluate the frequency of repeated ANA testing as a prelude to Electronic Medical Record (EMR) test alert design in an Australian healthcare network. The primary endpoint was calculation of the total cost associated with repeated testing and whether a longitudinal change in ANA resulted in any new ANA associated rheumatological diagnoses. Our secondary endpoint was the examination of baseline ANA testing behaviours. Methods We retrospectively analysed data from a multi-centre tertiary health network in Melbourne, Australia across a 7-year period (19 March 2011 to 23 July 2018). ANA and other autoimmune test results were obtained from the hospital pathology system with a positive ANA cut off set at 1:160. Clinical information was sourced from clinical information systems on patients who had a change in ANA result from negative to positive on repeat testing. The associated cost of repeated ANA testing was calculated based on the baseline cost to the public system. Results A total of 36,715 ANA tests (excluding 980 cancelled same-day requests) were performed in 28,840 patients. Of these, 14,058 (38.3%) were positive with females accounting for 9,265 (65.9%, p Conclusion Repeat ANA testing after a negative result had limited utility in the diagnosis of ANA associated rheumatological conditions with a positive predictive value of only 0.01, and resulted in high cost. New technology and clinical alert systems may help reduce unnecessary testing with potential significant direct cost savings when extrapolated across the Australian healthcare system.

Objective: To determine the rates of simultaneous antinuclear antibodies (ANA) screening and extractable nuclear antigen (ENA) testing that do not follow recommendations.Design, Setting, and Participants: Retrospective cohort study of adult patients (≥18 years) with a HEp-2 ANA or ENA ordered in the Marshfield Clinic Health System.Main Outcome(s) and Measure(s): Counts of patients having simultaneous ANA and ENA laboratory testing or ENA testing without ANA screening. Relevant ENA positivity in ANA negative patients. Secondary measures included relative timing of ANA and ENA ordering, potential cost savings of unnecessary testing, and provider ordering characteristics including specialty and provider type.Results: Of 58,627 cohort patients, 39,155 (66.8%) were women, and the mean (SD) age at first laboratory testing was 48.7 (19.0) years. The negative ANA with positive ENA rate was 2%. Further stratification identified only 23 diagnosed autoimmune connective tissue diseases (AI-CTDs) in this 2%, with a resulting negative ANA with relevant positive ENA rate of 0.37%. Simultaneous ANA and ENA testing occurred in 8.3% of patients, and an ENA only was ordered in 24.2% of patients. The simultaneous or non-sequential ordering of ANA and ENA testing resulted in significant health care costs of $2,293,251.80 over 20,112 unique patients.Conclusions and Relevance: A significant percentage of providers do not follow recommendations to sequentially order ANA and ENA testing on patients with suspected AI-CTDs. Significant saving in health care spending without failure to diagnose AI-CTDs can be achieved if ANA testing is performed first, followed by ENA testing when suspecting AI-CTDs in patients.

BackgroundLoss of self-tolerance and generation of numerous autoantibodies is a hallmark of systemic lupus erythematosus (SLE). Historically, testing for anti-nuclear antibodies (ANA) has been used as a screen for the...

Utility of repeated antinuclear antibody tests: a retrospective database study.

Background Testing for antinuclear antibodies (ANA) is useful for the diagnosis of autoimmune connective tissue diseases (CTD). Solid-phase assay such as the enzyme-linked immunosorbent (ELISA) assay has replaced the use of indirect immunofluorescence assay (IIF) for the detection of ANA. Patients and methods In this study, ELISA which is based on a qualitative screening of IgG class autoantibodies using commercially available kits from Orgetec Diagnostika GmbH was compared with IIF for the detection of ANA in patients with different connective tissue diseases. The study involved 73 patients with confirmed diagnosis (38 patients diagnosed as systemic lupus erythematosus (SLE), 27 patients with rheumatoid arthritis (RA), and eight patients with other connective tissue diseases: systemic sclerosis, mixed connective tissue diseases, and Sjogren’s syndrome). They were recruited from the outpatient clinic of the Rheumatology and Rehabilitation Department for follow-up and others were admitted patients of the Rheumatology Department at Assuit University Hospitals. Twenty-five apparently healthy participants served as the control group. Results ANA results by IIF: of the 73 patients, 39 (53.4%) had positive ANA results and 34 (46.6%) patients had negative ANA results. All healthy control group ANA results by IIF were negative (100%). ANA results by ELISA: from a total of 73 patients, 42 (57.5%) had positive ANA results, 27 (37%) patients had negative ANA results, and four (5.5%) patients had borderline ANA results. All control group ANA results by ELISA had negative ANA results. ELISA sensitivity was 86.8% compared with 84.2% by IIF in the SLE. In other CTD both tests had the same sensitivity (87.5%). The ELISA and IIF had the same high specificity (100%) in SLE and other CTD. Conclusion There is a comparable result between sensitivity, specificity, PPV, NPV, and accuracy of both ANA tests. So we can rely on the results of ELISA in our laboratories in Assuit University Hospitals as they can deal with large numbers of patients and it saves time. IIF is partly subjective, and therefore there is considerable variation in the interpretation of results between different observers, so we can avoid it. So ANA by ELISA tests can be used as a screening test and if we want to identify the ANA pattern we can use IIF on HEp-2 cells.

Systemic Lupus Erythematosus (SLE) is a complex chronic autoimmune disease that can affect multiple organ systems, with diverse clinical symptoms, disease course and prognosis. This study aims to evaluate the role of antinuclear antibody (ANA) tests and other immunologic tests in supporting the diagnosis of SLE, given the challenges in differentiating SLE from other autoimmune diseases. The method used was a literature review of relevant literature obtained through several databases, such as PubMed, Google Scholar, and ProQuest, which analyzed the accuracy and limitations of ANA tests and other immunological tests in supporting the diagnosis of SLE. The results show that the ANA test has high sensitivity but limited specificity, as positive ANA results can also be found in other autoimmune conditions or even in healthy individuals. Therefore, interpretation of ANA results should be done in the appropriate clinical context to optimize its diagnostic utility. In conclusion, ANA testing plays an important role in the evaluation of SLE and other ANA-related diseases, but should be combined with clinical evaluation and additional investigations to confirm or exclude the diagnosis.

Adult idiopathic thrombocytopenic purpura (ITP) is an acquired autoimmune disease that may be associated with other autoimmune disorders and a positive antinuclear antibody (ANA). This pilot study aimed to determine the clinical significance of a positive ANA test on the presentation and response to steroids. The medical records of 46 patients aged 15 years or older who were diagnosed with ITP at King Abdullah University Hospital from January, 2004 to December, 2006 were retrospectively analyzed. ANA results were available for 41 patients, and only 10 patients had a positive test. The study showed no association between the ANA and any of the patients' characteristics at presentation. This included the age, sex, presence of autoimmune diseases, a family history of autoimmune diseases, platelet count, hemoglobin level, and erythrocyte sedimentation rate (ESR). It is interesting to note that the mean platelet count after 2 weeks of steroids was 99,323 per cu/ml in patients with a negative ANA, and 32,800 per cu/ml in those with a positive ANA (P = 0.006). The difference in mean platelet count between positive and negative ANA-tested patients remained significant after adjusting for sex, age, and ESR (P = 0.001). Also, patients with a positive ANA were 6.25 times more likely of not achieving a complete response defined as a platelet count of 100,000 per cu/ml or more for a minimum of 3 months after discontinuation of therapy. In conclusion, the ANA test could be a useful screening test that predicts initial response to steroid therapy. Patients who test positive are expected to have lower response and should be monitored closely.

IntroductionThe term anti-nuclear antibody (ANA) is used to define a large group of autoantibodies which specifically bind to nuclear elements. Although healthy individuals may also have ANA positivity, the measurement of ANA is generally used in the diagnosis of autoimmune disorders. However, various studies have shown that ANA testing may be overused, especially in pediatrics clinics. Our aim was to investigate the reasons for antinuclear antibody (ANA) testing in the general pediatrics and pediatric rheumatology clinics of our hospital and to determine whether ANA testing was ordered appropriately by evaluating chief complaints and the ultimate diagnoses of these cases.MethodsThe medical records of pediatric patients in whom ANA testing was performed between January 2014 and June 2016 were retrospectively evaluated. Subjects were grouped according to the indication for ANA testing and ANA titers.ResultsANA tests were ordered in a total of 409 patients during the study period, with 113 positive ANA results. The ANA test was ordered mostly due to joint pain (50% of the study population). There was an increased likelihood of autoimmune rheumatic diseases (ARDs) with higher ANA titer. The positive predictive value of an ANA test was 16% for any connective tissue disease and 13% for lupus in the pediatric setting.Conclusionin the current study, more than one-fourth of the subjects were found to have ANA positivity, while only 15% were ultimately diagnosed with ARDs. Our findings underline the importance of an increased awareness of correct indications for ANA testing.

Background In the mid-2000s, a novel pattern in antinuclear antibody (ANA) testing was reported. Indirect immunofluorescence assays on HEp-2 cells, conducted with sera from patients with Hepatitis C virus (HCV) infection, revealed cytoplasmic structures in the form of rods and rings (RR). These structures typically displayed rod lengths of 3-10μm and ring diameters of 2-5μm. Inosine monophosphate dehydrogenase (IMPDH) was identified as the primary component of the RR structures. Research on the administration of interferon/ribavirin (IFN/RBV) showed that ribavirin, an IMPDH inhibitor, induced RR formation in over 95% of cells. Additionally, RR patterns were reported in patients receiving other IMPDH inhibitors such as mycophenolic acid and azathioprine. While cytidine triphosphate synthase 1 (CTPS1) was suggested to be associated with RR structures, there were no reported cases in patients. Interestingly, patients receiving methotrexate, which does not directly inhibit IMPDH but hinders GTP biosynthesis, also exhibited RR structures. To explore the clinical implications of specimens showing RR patterns, a study was conducted to investigate the actual clinical scenarios associated with these findings. Methods This is a retrospective study conducted at a single center, covering the period from January 2022 to December 2023, focusing on the results of ANA testing. The ANA tests were performed using HEp-2 cells (FLUORO HEPANA TEST, MBL, Nagoya, Japan) on slides manufactured with AP 16 IF Plus (das, Palombara Sabina, RM, Italy). ANA results were obtained through qualitative testing, ranging from 1+ to 4+, or quantitative testing based on dilutions ranging from 1:40 to 1:640, depending on clinical requirements. Results Out of the 7,648 ANA test results, the RR pattern was observed in 40 cases (0.5%). Among these, 2.5% had a history of HCV infection with IFN/RBV treatment, and an additional 2.5% had concurrent use of IMPDH inhibitors. There were no reported cases of medication history related to the synthetic pathway of nucleic acids, including CTPS1. Cases where RR patterns coexisted with autoimmune diseases accounted for 35%, infections for 25%, and other inflammatory conditions for 22.5%. RR patterns reported with an intensity of 3+ or at dilutions of 1:160 or higher constituted 27.5%. Among cases displaying strong fluorescence, 45% were associated with infections, 18% with autoimmune conditions, and another 18% with unexplained inflammatory causes. In the overall sample, elevated CRP or ESR was noted in 54.5% of cases with infections, autoimmune diseases, or other inflammatory conditions. Among samples with intense intensity, 55.5% showed elevated CRP or ESR when inflammatory conditions were present. Conclusions The majority of cases exhibiting the RR pattern showed no history of exposure to IMPDH inhibitors or drugs affecting the nucleic acid synthetic pathway. A high proportion of cases clinically diagnosed with inflammation showed a concurrent RR pattern, with only approximately half of them demonstrating elevated CRP or ESR levels. This study suggests the possibility of identifying inflammatory responses not captured by conventional acute inflammation markers through the RR pattern observed in ANA testing.

The antinuclear antibodies (ANA) test has been a cornerstone of the evaluation of connective tissue disease. The aim of this study was to investigate the diagnostic value of the ANA test in pleural or pericardial effusions of unknown causes. Over a 3-yr period, a total of 126 pleural fluid and 30 pericardial fluid samples were analysed. ANA tests were performed using a commercially available kit. The ANA kit used an indirect immunofluorescent antibody method with a human epithelial (HEP-2) cell line as substrate. Patients with high fluid ANA titre (>1:160) received a second aspiration 2 weeks after the initial aspiration if diagnosis was not confirmed. ANA results were positive in 39 pleural and 10 pericardial fluid samples. All but one of the effusions with positive ANA testing were exudative. Eleven pleural or pericardial effusions due to active systematic lupus erythematosus were identified and all had high ANA titres (1:160) with various staining patterns. Thirty-eight of 145 patients (26%) with effusions of nonlupus aetiologies had positive ANA testing in pleural or pericardial fluid. Thirteen of these 38 patients had high ANA titre. Malignant or paramalignant effusions constituted 11 of the 13 samples. In conclusion, although a negative antinuclear antibodies test makes a diagnosis of lupus serositis unlikely, high antinuclear antibodies titres in pleural or pericardial fluid are not diagnostic of lupus serositis even when as high as 1:5,120. An unexplained high antinuclear antibodies titre in pleural or pericardial effusion warrants search for malignancy.

Systemic lupus erythematosus (SLE) is a disorder that is heterogeneous and can be difficult to diagnose. One hallmark of the disease is the presence of antinuclear antibodies (ANAs), a feature that has been incorporated into multiple classification criteria over the years. In this study, we used a database of patients with cutaneous lupus erythematosus (CLE) to determine how many had a negative ANA and met criteria for SLE using the American College of Rheumatology (ACR) and/or Systemic Lupus International Collaborating Clinics (SLICC) criteria. We used a database of 301 biopsy-proven CLE patients that contained information including ANA status and the presence of features of SLE. The database was searched for patients who had a negative ANA result and whether or not they met SLE criteria using the ACR and/or SLICC criteria. Of the 301 patients with biopsy-proven CLE and a known ANA, 111 had a negative ANA test (36.9%) and 27 had an ANA test that fluctuated (33.3%). In all, 20 ANA-negative patients met SLE criteria (18.0%), and 12 patients with a fluctuating ANA test met SLE criteria (44.4%). Of all patients who had either a negative or fluctuating ANA result and who met criteria for SLE (n = 32), 27 patients had involvement of ≥1 organ system other than skin (84.4%), and 13 patients had involvement of ≥2 organ systems other than skin (40.6%). Our results show that an ANA is not always present in patients with systemic disease. This fact should be taken into consideration when devising SLE classification criteria to be used for clinical trials.

Idiopathic pulmonary fibrosis (IPF) is a diagnosis of exclusion, requiring that potential etiologies of interstitial lung disease be ruled out. Antinuclear antibody (ANA) testing is commonly performed in individuals with IPF, but the clinical significance of ANA positivity remains uncertain. A retrospective search identified 161 patients diagnosed with IPF between May 2010 and January 2021. Data on ANA titers at the time of diagnosis were available in all cases. Mean age of the patients was 66.4 ± 9.6 years; 70.8% were male. ANA titers were high (≥ 1:160) in 25.4% of the cohort. Baseline characteristics were comparable between those with high and low ANA titers. During follow-up (median 28 months), 93 patients (57%) died. On Cox proportional-hazards analysis with lung transplantation entered as a competing risk and adjusting for potential confounders (age, sex, and baseline forced vital capacity and diffusing lung capacity for carbon monoxide), ANA ≥ 1:160, as a dichotomized variable, was significantly associated with case-specific mortality (HR 2.25, 95% CI 1.14−4.42, P = 0.02) and older age (for each 10-year increment, HR 1.55, 95% CI 1.07−2.25, P = 0.02). High ANA titers appear to be associated with increased mortality in IPF. This finding emphasizes the potential prognostic value of ANA testing. Further studies are needed to validate these findings and explore their implications for patient management.

Cutaneous lupus erythematosus/lichen planus overlap syndrome