Abstract
The antinuclear antibody test (ANA) is a much overused test in pediatrics. The ANA does have a role in serologic testing but it should be a very limited one. It is often ordered as a screening test for rheumatic illnesses in a primary care setting. However, since it has low specificity and sensitivity for most rheumatic and musculoskeletal illnesses in children, it should not be ordered as a screening test for non-specific complaints such as musculoskeletal pain. It should only be used as a diagnostic test for children with probable Systemic Lupus Erythematosus (SLE) or Mixed Connective Tissue Disease, (MCTD) and other possible overlap-like illnesses. Such children should have developed definite signs and symptoms of a disease before the ANA is ordered. This review presents data supporting these conclusions and a review of the ANA literature in adults and children.By limiting ANA testing, primary care providers can avoid needless venipuncture pain, unnecessary referrals, extra medical expenses, and most importantly, significant parental anxieties. It is best not to do the ANA test in most children but if it ordered and is positive in a low titer (<1:640), the results can be ignored if the child is otherwise well and does not have other features of a systemic illness.
Highlights
Since the introduction of the indirect immunofluorescence (IF) test for antinuclear antibodies (ANA) by Friou in 1957 [1], ordering an ANA appears to have become a reflexive response to the question “could this patient have a rheumatic disease?” What is the evidence that ordering such tests is of any value, and what should be done with a positive test?
The question why the ANA test is so frequently positive in populations without an autoimmune disease remains a fascinating one. It suggests that the breaking of immunological tolerance is really quite common, but that this tolerance breakdown only rarely leads to disease
It is possible that antinuclear antibodies have some useful function that is not yet fully understood
Summary
Since the introduction of the indirect immunofluorescence (IF) test for antinuclear antibodies (ANA) by Friou in 1957 [1], ordering an ANA appears to have become a reflexive response to the question “could this patient have a rheumatic disease?” What is the evidence that ordering such tests is of any value, and what should be done with a positive test?. In another study from a pediatric rheumatology clinic, only 55% of all of the children with a positive ANA test had an inflammatory rheumatic disease. It wasn’t the elevated ANA titer that distinguished the children with JRA from those with other musculoskeletal problems, but the history (e.g., morning stiffness) and the physical exam (e.g., presence of rash, swollen joints) All these studies demonstrate that a positive ANA test is found frequently in a pediatric hospital population, and even in high titer has only a poor ability to determine whether a child has an inflammatory rheumatic disease. We would suggest that a positive ANA test can safely be ignored unless there are other suggestive clinical signs, and simple laboratory tests (such as a raised ESR or cytopenias) that point towards a diagnosis of lupus or similar connective tissue disease, if the ANA titer is less than 1:640. The cost of inappropriate referrals, extra venipuncture, unnecessary expense, and increased parental and child anxiety is a considerable problem that pediatric rheumatologists see every day
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