Antinuclear Antibody Test Results Research Articles

Systemic lupus erythematosus in a 15-year-old female with multiple splenic nodules: A case report

BACKGROUND Systemic lupus erythematosus (SLE) is a chronic inflammatory disease primarily affecting young females. SLE can invade any organ, and various forms of splenic invasion have been reported. Manifestations include splenomegaly and splenic infarction, rupture, and calcification. The study encountered a rare case of splenic involvement, with nodules of various sizes without calcifications or ruptures. CASE SUMMARY A 15-year-old girl presented with arthralgia, weight loss, fever, increased levels of inflammatory markers, and positive antinuclear antibody test results. The patient was diagnosed with SLE. She was asymptomatic while taking steroids and hydroxychloroquine. Ten months after discharge, the patient developed a fever and abdominal pain. Lupus enteritis was suspected, and abdominopelvic computed tomography (AP-CT) was performed. There were no specific findings in the gastrointestinal tract, but multiple splenic nodules were observed. Infection or hemangioma was considered; however, no specific radiological findings were observed. A biopsy of the spleen was performed to determine the possibility of malignancy. The histological findings of the spleen included extensive periarteriolar necrosis with hematoxylin bodies and numerous karyorrhectic debris. Based on the biopsy results, the patient was diagnosed with an SLE flare-up and was maintained on high-dose steroids and immunosuppressants. CONCLUSION As disease activity increased, multiple nodules in the spleen that were previously unseen were observed using AP-CT and histologically confirmed. Spleen invasion by SLE can appear in multiple nodular forms and patterns. Therefore, physicians should consider these findings when differentiating these nodules from infections and malignancies.

Antinuclear antibody staining patterns by indirect immunofluorescence assay observed in patients from a tertiary health center in Latin America

IntroductionThis study aimed to describe the frequency of antinuclear antibody (ANA) staining patterns by indirect immunofluorescence assay observed in patients from a tertiary health center in Latin America. Methodology and methodsThis retrospective, descriptive, and observational study evaluated data from all patients undergoing antinuclear antibody indirect immunofluorescence assay from a single-tertiary center (University Hospital Fundación Valle del Lili, Cali-Colombia) in 2020. ResultsOne thousand and eight patients met the inclusion criteria. The median patient age was 47 (34–59.2) years, and most were female (769, 75.3%). A positive ANA immunofluorescence assay was observed in approximately two-thirds of patients (664, 65.8%). ANA test results were primarily used to exclude a suspected diagnosis in approximately half of the patients (466, 46.2%). Thirty-seven percent (250/664) of the cohort with ANA-positive titers had a systemic autoimmune rheumatic disease (SARD). The most prevalent SARDs included rheumatoid arthritis (RA) (55, 8.2%) followed by systemic lupus erythematosus (SLE) (37, 5.5%). The vast majority of ANA-positive patients had a reported speckled pattern (anti-cell [AC]-2,4,5; 269; 40.5%) followed by homogenous (AC-1; 266; 40%), nucleolar (AC-8,9,10; 46; 6.9%), and centromere (AC-3; 16; 2.4%). The most frequent patterns observed among SLE patients included homogenous (AC-1) patterns in 17 (45.9%) patients, speckled (AC-2,4,5) nuclear patterns in 11 (29.7%) patients, mixed patterns in 7 (18.9%) patients, and reticular/anti-mitochondrial antibody (AMA, AC-21) cytoplasmic patterns in 2 (5.4%) patients. ConclusionsThis study is the first to describe ANA patterns in a Colombian population. Speckled and homogenous patterns were predominant in patients with SARDs.

Alerjik Konjonktivit Hepatit B, C ve Antinükleer Antikor Arasındaki İlişki: Vaka-Kontrol Araştırması

Objective: The etiopathogenesis of allergy and autoimmune diseases involves genetic and environmental factors which might be common to both immunopathologies and infection also plays a significant role in the induction of allergy and autoimmunity. In this study, we aimed to evaluate the prevalence of hepatitis B, C, and antinuclear antibody (ANA) in patients with allergic conjunctivitis (AC). Material and Methods: A total of 128 patients with AC were enrolled and divided into 3 groups according to etiology: mite, pollen, and pollen/mite. Patients who complained of rhinoconjunctivitis underwent a skin-prick test. Hepatitis B surface antigen (HBsAg), anti-hepatitis C virus antibody (anti-HCV Ab), erythrocyte sedimentation rate (ESR), and ANA values of patients were evaluated. ANA screening was investigated with indirect immunofluorescence. p values <0.05 were accepted as statistically significant. Results: One hundred (78.1%) of the patients were women. Seventy-three (57%) patients were allergic to pollen, 33 (25.8%) to mites, and 22 (17.2%) to both pollen and mites. ANA test results were positive in 11 (8.6%) patients. HBsAg was detected in only (0.8%) 1 patient. Anti-HCV test was negative in all patients. The mean age of the patients was 37.45±10.46 years and mean ESR was 14.10±7.32 mm/h. Sex, ANA, and HBsAg distributions were statistically similar among the groups. No relationship was detected between AC and hepatitis B, C, or ANA positivity. Conclusion: AC was not significantly associated with hepatitis B, C, or ANA positivity. The prevalence of hepatitis B was lower among the AC patients than in the general population of Turkey, whereas the prevalence of hepatitis C was consistent at 0%. These results should be supported with larger numbers of patients with AC.

Comparison study of bead-based and line-blot multiplex ANA immunoassays in the diagnosis of systemic autoimmune rheumatic diseases

Detection of antinuclear antibodies (ANA) by immunofluorescence assay (IFA) is increasingly substituted by multiplex bead-based immunoassay (MBA) and line-blot immunoassay (LIA). This study is to compare the diagnostic performance of MBA and LIA ANA assays on clinically characterized patient samples. A total of 728 serum samples from 385 patients with systemic autoimmune rheumatic diseases (SARD), 204 patients with non-SARD diseases, and 139 apparently healthy subjects were tested with the BioPlex 2200 ANA Screen and EuroLine ANA Profile 3 as the representative MBA and LIA technologies and HEp-2 ANA IFA. Clinical data were collected independent of laboratory analysis and later related to the ANA test results. The clinical diagnostic performances were analyzed using Analyse-it software. The MBA demonstrated higher area under curve (AUC) compared to LIA (0.814 vs 0.761, p = 0.002) and HEp-2 IFA (0.814 vs 0.771, p = 0.008). The MBA and LIA ANA methods showed higher specificity (83.8% and 77.0% vs 67.6%, p < 0.001 and p = 0.005) but lower sensitivity (79.0% and 75.3% vs 86.5%, p < 0.001) compared to HEp-2 IFA. The MBA and LIA ANA revealed substantial to excellent agreements on specific antinuclear antibodies except anti-dsDNA, with the total agreement from 92.3 to 99.9% and Cohen's kappa from 0.71 to 0.98. The MBA demonstrated significantly higher sensitivity (58.1% vs 19.8%, p < 0.001) and comparable specificity (95.9% vs 97.5%, p = 0.221) on anti-dsDNA assay for the diagnosis of SLE compared to LIA. The MBA and LIA ANA assays have higher specificity but lower sensitivity compared to HEp-2 IFA. There are good agreements between MBA and LIA ANA for the specific antinuclear antibodies except for anti-dsDNA. The MBA ANA demonstrated better assay performance compared to LIA as the MBA possesses higher sensitivity and specificity in the diagnosis of SARD. Key Points • The multiplex bead-based immunoassay (MBA) ANA outperformed line-blot immunoassay (LIA) and traditional HEp-2 IFA. • There are good agreements between the MBA BioPlex 2200 ANA Screen and LIA EuroLine ANA Profile 3 for the most of specific antinuclear antibodies except anti-dsDNA. • Additional anti-dsDNA testing is suggested when EuroLine ANA Profile 3 is used for the aid of SLE diagnosis and management. • The positive predictive value of both multiplex ANA assays can be substantially increased without significantlyaffecting negative predictive value by using at least two specific antinuclear antibodies for reporting a positive ANAresult.

Anti-DFS70 Antibodies for Differentiating Systemic Autoimmune Rheumatic Disease in Patients with Positive ANA Tests: A Systematic Review and Meta-Analysis.

Anti-DFS70 antibodies have been proposed as a marker to exclude systemic autoimmune rheumatic disease (SARD). We conducted this systematic diagnostic test accuracy review and meta-analysis to determine the performance of anti-DFS70 antibodies in patients with a positive anti-nuclear antibody (ANA) test result to exclude SARD. We searched PubMed, Embase, Web of Science, Scopus and the Cochrane Library up to 22 February 2021, and included studies examining the diagnostic accuracy of anti-DFS70 antibodies in patients with a positive ANA test result. The results were pooled using a hierarchical bivariate model and plotted in summary receiver operating characteristic curves. R software and Stata Statistical Software were used for the statistical analysis. Eight studies with 4168 patients were included. The summary sensitivity was 0.19 (95% confidence interval: 0.12–0.28) and the specificity was 0.93 (95% confidence interval: 0.88–0.96). The area under the curve was 0.69 (95% confidence interval: 0.64–0.72). The meta-regression analysis showed that targeting only ANA-associated rheumatic disease was associated with higher specificity. In addition, the studies with a non-SARD prevalence of <80% and using a chemiluminescence assay were associated with higher specificity. Anti-DFS70 antibodies have high specificity for the exclusion of SARD among patients presenting with a positive ANA test, but the sensitivity is low.

Serum antinuclear antibodies associate with worse prognosis in AQP4-positive neuromyelitis optica spectrum disorder.

BackgroundStudies have demonstrated that antinuclear antibodies (ANAs) may be correlated with neuromyelitis optica spectrum disorder (NMOSD). However, the conflicting results of studies about the value of ANAs in AQP4 antibody‐positive NMOSD patients need to be further investigated.MaterialCase data were collected from 143 patients with AQP4 antibody‐positive NMOSD. Patients were divided into two groups based on the ANA test results. The analysis of clinical characteristics, laboratory tests, and MRI examination results were compared between two groups: the NMOSD patients with ANA (+) and with ANA (−).ResultsDisease duration of NMOSD is shorter in the ANA (+) patients with EDSS < 4 than in the ANA (−) patients (12.05 ± 16.73 versus 29.43 ± 41.03, p‐value = .013). The median time from disease onset to an EDSS score of 4.0 is significantly longer in the ANA (−) NMOSD patients than in the ANA (+) patients (48.2 months versus 24 months, p = .04). In addition, ANA (RR, 2.234; 95% CI, 1.078–4.629; p‐value = .031) can predict the severity of NMOSD.ConclusionsAntinuclear antibodies seem to be associated with more severe disease activity in NMOSD patients.

The Performances of the ACR 1997, SLICC 2012, and EULAR/ACR 2019 Classification Criteria in Pediatric Systemic Lupus Erythematosus.

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease. The American College of Rheumatology (ACR) 1997, Systemic Lupus International Collaborating Clinics (SLICC) 2012, and European League Against Rheumatism (EULAR)/ACR 2019 SLE classification criteria are formed based on data mainly from adult patients. We aimed to test the performances of the SLE classification criteria among pediatric patients with SLE. Pediatric patients with SLE (n = 262; 80.9% female) were included from 3 different centers in Turkey. As controls, 174 children (60.9% female) with other diseases who had ANA (antinuclear antibody) test results were included. The gold standard for SLE diagnosis was expert opinion. The sensitivities of the ACR 1997, SLICC 2012, and EULAR/ACR 2019 criteria were 68.7%, 95.4%, and 91.6%, respectively. The specificities of the ACR 1997, SLICC 2012, and EULAR/ACR 2019 criteria were 94.8%, 89.7%, and 88.5%, respectively. Eighteen patients with SLE met the SLICC 2012 but not the EULAR/ACR 2019 criteria. Among these, hematologic involvement was prominent (n = 13; 72.2%). Eight patients with SLE fulfilled the EULAR/ACR 2019 but not the SLICC 2012 criteria. Among these, joint involvement was prominent (n = 6; 75%). To our knowledge, this is the largest cohort study of pediatric SLE to test the performances of all 3 classification criteria. The SLICC 2012 criteria yielded the best sensitivity, whereas the ACR 1997 criteria had the best specificity. SLICC 2012 criteria performed better than EULAR/ACR 2019 criteria. Separation of different hematological manifestations in the SLICC 2012 criteria might have contributed to the higher performance of this criteria set.

Understanding and interpreting antinuclear antibody tests in systemic rheumatic diseases.

Antinuclear antibodies (ANAs) are valuable laboratory markers to screen for and support the diagnosis of various rheumatic diseases (known as ANA-associated rheumatic diseases). The importance of ANA testing has been reinforced by the inclusion of ANA positivity as an entry criterion in the 2019 systemic lupus erythematosus classification criteria. In addition, specific ANAs (such as antibodies to Sm, double-stranded DNA (dsDNA), SSA/Ro60, U1RNP, topoisomerase I, centromere protein B (CENPB), RNA polymerase III and Jo1) are included in classification criteria for other rheumatic diseases. A number of techniques are available for detecting antibodies to a selection of clinically relevant antigens (such as indirect immunofluorescence and solid phase assays). In this Review, we discuss the advantages and limitations of these techniques, as well as the clinical relevance of the differences between the techniques, to provide guidance in understanding and interpreting ANA test results. Such understanding not only necessitates insight into the sensitivity and specificity of each assay, but also into the importance of the disease context and antibody level. We also highlight the value of titre-specific information (such as likelihood ratios).

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

Anti-nuclear antibody (ANA) testing is frequently used as a diagnostic or screening test in patients with inflammatory or musculoskeletal symptoms. The value of repeat testing is unclear. We sought to evaluate the frequency, utility, and cost of repeat ANA testing. The main objective was to assess the positive predictive value of a repeat ANA test for the diagnosis of rheumatological conditions associated with ANA. In this retrospective cohort study, we analysed data from a single, multisite tertiary health network in Australia across a 7-year period. ANA and other autoimmune test results were obtained from the hospital pathology system with a positive ANA titre cutoff set at 1:160. Clinical information was sourced from clinical information systems on any patient who had a change in ANA result from negative to positive on repeat testing. The cost of repeated ANA testing was calculated using the Australian Government Medicare Benefits Schedule. From March 19, 2011, to July 23, 2018, a total of 36 715 ANA tests were done in 28 840 patients at a total cost of US$675 029 (2018 equivalent). 14 058 (38·3%) of these ANA tests were positive. 7875 (21·4%) of the ordered tests were repeats in 4887 (16·9%) of the patients, among whom 2683 (54·9%) had initially negative tests, and 2204 (45·1%) had initially positive tests. 511 (19·0%) of the 2683 patients with initially negative tests had a positive result on at least one repeat test, with a median time to first positive result of 1·74 years (IQR 0·54-3·60). A change from negative to positive ANA was associated with a new diagnosis in only five (1·1%) of the 451 patients with clinical information available and no previous diagnosis of an ANA-associated rheumatological condition, yielding a positive predictive value of 1·1% (95% CI 0·4-2·7). Repeat ANA testing after a negative result has low utility and results in high cost. Monash Health.

Antinuclear antibodies in infectious diseases

Introduction: Antinuclear antibody (ANA) tests are widely used for the diagnosis of autoimmune diseases, but ANAs are also commonly found in patients with various infections. This retrospective study aimed to investigate the relationship between infections and ANA status.Methods: Patients that visited the Department of Infectious Diseases at Inha University Hospital between January 2007 and July 2018 were investigated. We analysed their ANA test results and reviewed rheumatic and infectious diagnoses of patients with positive ANA findings.Results: Of the 9,320 patients during the study period, 1,111 underwent ANA testing and 110 tested positive. Seven of the 110 patients were previously diagnosed with ANA-positive disease, and 21 were diagnosed with autoimmune disease during the present study. Of the remaining 82 patients, 43 were confirmed with infectious disease. The most common pathogen was Mycobacterium tuberculosis (n = 10), followed by Treponema pallidum (n = 5), Orientia tsutsugamushi (n = 5), Escherichia coli (n = 5), Bartonella henselae (n = 3), and human immunodeficiency virus (n = 3). Of the 39 patients without a confirmed pathogen, 7 were seropositive for O. tsutsugamushi, B. henselae, or Rickettsia spp. Patients were observed at an average of 24 weeks in our hospital. One patient developed systemic lupus erythematosus after being diagnosed with Epstein–Barr virus-induced infectious mononucleosis, and another patient developed adult-onset Still’s disease after being diagnosed with scrub typhus.Conclusion: This study showed that various relationships exist between infections and rheumatic diseases. In particular, several patients with a positive ANA test result were found to have intracellular infections such as mycobacterial infections, syphilis, or scrub typhus.

A step towards standardization: A method for end-point titer determination by fluorescence index of an automated microscope. End-point titer determination by fluorescence index

ObjectivesIndirect Immunofluorescence (IIF) is widely considered the Gold Standard for Antinuclear Antibody (ANA) screening. However, the high inter-reader variability remains the major disadvantage associated with ANA testing and the main reason for the increasing demand of the computer-aided immunofluorescence microscope. Previous studies proposed the quantification of the fluorescence intensity as an alternative for the classical end-point titer evaluation. However, the different distribution of bright/dark light linked to the nature of the self-antigen and its location in the cells result in different mean fluorescence intensities. The aim of the present study was to correlate Fluorescence Index (F.I.) with end-point titers for each well-defined ANA pattern. MethodsRoutine serum samples were screened for ANA testing on HEp-2000 cells using Immuno Concepts Image Navigator System, and positive samples were serially diluted to assign the end-point titer. A comparison between F.I. and end-point titers related to 10 different staining patterns was made. ResultsAccording to our analysis, good technical performance of F.I. (97% sensitivity and 94% specificity) was found. A significant correlation between quantitative reading of F.I. and end-point titer groups was observed using Spearman's test and regression analysis. A conversion scale of F.I. in end-point titers for each recognized ANA-pattern was obtained. ConclusionsThe Image Navigator offers the opportunity to improve worldwide harmonization of ANA test results. In particular, digital F.I. allows quantifying ANA titers by using just one sample dilution. It could represent a valuable support for the routine laboratory and an effective tool to reduce inter- and intra-laboratory variability.

A Multiplex Autoantibody Panel for Early Detection of Autoimmune Disease Activity

Background: Detection of autoantibodies has played a consolidate role in diagnosis of systemic autoimmune disorders. A cascade autoantibody testing is usually performed by employing antinuclear antibodies (ANA) test as a first screening test and the other tests as second level determinations. Here, we present that supplementing extractable nuclear antigens (ENA) tests to the ANA test may capture more autoimmunity and provide critical medical information at an early stage. In this study, we evaluated the clinical significance of a multiplex ANA + ENA panel. Methods: A cohort of 110 subjects, identified as ANA negative but ENA positive, were followed up for two years. The detection of their ANA and anti-ENA autoantibodies was assessed with a multiplex ANA + ENA panel at Vibrant America Clinical Laboratory. Results: During two years of multi-visit follow-up, 23 out of 110 subjects (20.9%) were found to become ANA positive within an average of 385 (±144) days. Histone (50/110, 45.5%) and Chromatin (25/110, 22.7%) antibodies were the most frequently found antibodies at their first visits. The subjects who were positive for RNP (5/8, 62.5%) and SSA (Ro) (10/22, 45.5%) have the highest ratio of conversion to positive ANA. No significant correlation was observed between the conversion frequency and the number of anti-ENA antibodies being carried. Conclusion: This study, which followed up on the subjects who had disparate ANA and ENA test results, showed that anti-ENA antibodies may exist years earlier than ANA. Combining ENA tests with ANA screening may reduce false negatives and improve sensitivity.

Values of serum IgG4, IgG4/IgG ratio, and IgG4/IgG1 ratio in the diagnosis of Mikulicz′s disease

Objective To evaluate values of Serum IgG4, IgG4/IgG ratio, and IgG4/IgG1 ratio for distinguishing Mikulicz′s disease (MD) from primary Sjogren′s syndrome (pSS). Methods It retrospectively analyzed 186 patients subjected to serum IgG subclass testing to differentiate MD from primary Sjogren′s syndrome (pSS) at Peking University People′s Hospital from July 2012 to July 2016. This sample included 42 MD patients and 144 pSS patients. Serum IgG subclass concentrations were measured using Siemens reagents with nephelometry and BNⅡ instrument. In partial patients, serum antinuclear antibodies (ANA) were detected by indirect immunofluorescence assay, and serum anti-SSA antibodies and anti-SSB antibodies were detected by Western blot. Serum IgG subclass test results, ANA test results, serum anti-SSA antibody, and anti-SSB antibody test results were collected. The quantitative data were represented by median (quantile range). The Mann-Whitney U test was used to compare the medians between the two groups. Categorical variables were analyzed with a χ2 test and were shown as percentages. The ROC curve was constructed to identify the optimal cut-off values and the area under the curve (AUC) values of the serum IgG4, IgG4/IgG ratio, and IgG4/IgG1 ratio for distinguishing MD patients from pSS patients. Results The medians of serum IgG4, IgG4/IgG ratio and IgG4/IgG1 ratio in MD patients were 11 200 mg/L (17 330), 0.444 (0.314) and 1.318 (1.920), as compared with 329 mg/L (490) , 0.016 (0.025) and 0.023 (0.039) respectively in pSS patients (Z=-9.368, -9.560, and -9.571, respectively, P<0.001). For distinguishing MD from pSS, the optimal cut-off values of serum IgG4, IgG4/IgG ratio, and IgG4/IgG1 ratio were 1 870 mg/L, 0.111, and 0.206, respectively. The corresponding AUC values were 0.976, 0.985, and 0.986, respectively. Comparison of the ROC curves showed that there was no significant difference between AUC of serum IgG4/IgG ratio and IgG4/IgG1 ratio (Z=0.283, P=0.777). But AUC of serum IgG4/IgG ratio and IgG4/IgG1 ratio were significantly higher than AUC of serum IgG4 (Z=2.360 and 1.975, repectively, P=0.018 and 0.048, respectively). The positive rates of serum ANA in MD and pSS group were 10% and 85.8%, respectively (χ2=71.340, P<0.001). The positive rates of anti-SSA antibody and anti-SSB antibody in MD were 6.7% and 0%, respectively. Compared to 72.3% and 38.3% in pSS group, they were lower (χ2 =44.773 and 16.792, P<0.001). Conclusions Measurements of serum IgG4 concentration, IgG4/IgG ratio, and IgG4/IgG1 ratio were of important values in differentiating MD from pSS. Serum IgG4/IgG ratio or IgG4/IgG1 ratio was superior to serum IgG4.(Chin J Lab Med, 2017, 40: 805-809) Key words: Mikulicz′ disease; Sjogren′s syndrome; Immunoglobulin G; Odds ratio; Reference values

Antinuclear antibody prevalence in a general pediatric cohort from Mexico City: discordance between immunofluorescence and multiplex assays.

ObjectiveTo characterize antinuclear antibody (ANA) prevalence according to distinct assay methodologies in a pediatric cohort from Mexico City, and to further examine associations with age and sex.MethodsSerum ANA were measured by indirect immunofluorescence assay (IFA) and multiplex immunoassay in 114 children aged 9–17 years. IFA was considered positive at a cutoff titer of ≥1:80. Agreement between assay methods was assessed by kappa statistic. Sensitivity, specificity, and 95% confidence intervals (CIs) of the multiplex were computed with IFA as the reference standard.ResultsOf the 114 children (mean age 14.7 [standard deviation 2.1] years; 54 [47%] female), 18 of 114 (15.8%) were ANA positive by IFA, and 11 of 114 (9.6%) by 11-antigen multiplex assay. ANA prevalence was higher in females compared with males by both of the methods (ratios 1.6–1.9 to 1). Agreement between tests was classified as slight by kappa (κ=0.177 [95% CI −0.051, 0.406]). The multiplex immunoassay had sensitivity of 22.2% (95% CI 6.4, 47.6) and specificity of 92.7% (95% CI 85.6, 97.0), and failed to capture 3 of 4 (75%) of the high-titer (≥1:1280) IFA-positives.ConclusionUp to 15% of children in this general population cohort were ANA positive, with a higher rate of positivity among females according to both assay methods. Substantial discordance in ANA results was found between IFA and multiplex methods, even for high-titer IFA positives. These findings underscore the need to sufficiently account for assay characteristics when interpreting ANA test results, and support IFA as the more appropriate assay for studies of subclinical autoimmunity.

Laboratory Evaluation in Pediatric Autoimmune Diseases.

Pediatric autoimmune diseases are chronic lifelong disorders associated with potential disability and increased morbidity and mortality if not properly recognized and treated. On the basis of largely expert opinion in addition to observational studies, children with suspected autoimmune disease should undergo general laboratory and autoantibody screening. (1)(2)(4)(6)(7)(11) There can be many causes of positive antinuclear antibody test results, including, but not limited to, autoimmune disease. On the basis of expert opinion and observational studies, a thorough history and physical examination as well as laboratory evaluation is recommended (often in consultation with a pediatric rheumatologist) to elucidate the cause for a positive test result. (4) (6)(11)

Evaluation of Anti-Nuclear antibody test results in clinical practice

Objective: Aim of this study is to evaluate anti-nuclear antibody (ANA) test results obtained between 2009 and 2011. Methods: Of a totally 5068 cases tested for ANA by indirect immunofluorescence method (IIFA), randomly chosen 982 ANA-positive cases were reviewed in terms of gender, level and pattern of fluorescence, anti-dsDNA (anti-double stranded DNA) and anti-extractable nuclear antigen (ENA) profile. Anti-dsDNA levels and anti-ENA profiles were deter­mined by enzyme linked immune assay (ELISA) and immune-blotting (IB), respectively. Results: Sex distribution of ANA positive patients was determined as 756 (77%) females and 226 (23%) males. Fifty per cent of the cases were from rheumatology department, 20% from gastroenterology and 30% from other units. Fluo­rescence levels were considered borderline or weak positive in 62.6% of the samples. The most frequent patterns were homogeneous (23%), speckled (22%), homogeneous-speckled (15.5%) and nucleolar (13.5%). Anti-dsDNA were studied in 759 ANA positive patients and 66 (8.7%) samples were found positive, being 44 of them (68.8%) with homogeneous pattern and the rest with speckled, nucleolar, nuclear dots, centromeric or midbody patterns. Totally 131 (31.6%) of 414 samples studied for anti-ENA profile were found positive. The first four frequent profiles were SSA (34.4%), SSA-SSB (16.8%), Scl70 (16%) and Sm/RNP (9.2%). Conclusion: Our results are similar with the current related literature. It is known that autoantibodies can be detectable before clinical symptoms being apparent, especially in SLE. Therefore, borderline or weak fluorescence levels should also be reported and the patients having them should be followed-up carefully. J Microbiol Infect Dis 2015;5(2): 63-68 K ey words: Antinuclear antibody, indirect immune-fluorescence assay, extractable nuclear antigen antibodies

Frequency of antinuclear antibody positivity in patients with pattern hair loss.

Frequency of antinuclear antibody positivity in patients with pattern hair loss.

Clinical and Serological Features of Patients Referred through a Rheumatology Triage System because of Positive Antinuclear Antibodies

BackgroundThe referral of patients with positive anti-nuclear antibody (ANA) tests has been criticized as an inappropriate use of medical resources. The utility of a positive ANA test in a central triage (CT) system was studied by determining the autoantibody profiles and clinical diagnoses of patients referred to rheumatologists through a CT system because of a positive ANA test.MethodsPatients that met three criteria were included: (1) referred to Rheumatology CT over a three year interval; (2) reason for referral was a “positive ANA”; (3) were evaluated by a certified rheumatologist. The CT clinical database was used to obtain demographic and clinical information and a serological database was used to retrieve specific ANA and/or extractable nuclear antigen (ENA) test results. Clinical information was extracted from the consulting rheumatologist's report.Results15,357 patients were referred through the CT system; 643 (4.1%) of these because of a positive ANA and of these 263 (40.9%) were evaluated by a certified rheumatologist. In 63/263 (24%) of ANA positive patients, the specialist provided a diagnosis of an ANA associated rheumatic disease (AARD) while 69 (26.2%) had no evidence of any disease; 102 (38.8%) had other rheumatologic diagnoses and 29 (11%) had conditions that did not meet AARD classification criteria. Of ANA positive archived sera, 15.1% were anti-DFS70 positive and 91.2% of these did not have an AARD.ConclusionsThis is the first study to evaluate the serological and clinical features of patients referred through a CT system because of a positive ANA. The spectrum of autoantibody specificities was wide with anti-Ro52/TRIM21 being the most common autoantibody detected. Approximately 15% of referrals had only antibodies to DFS70, the vast majority of which did not have clinical evidence for an AARD. These findings provide insight into the utility of autoantibody testing in a CT system.

The Clinical Utility of a Positive Antinuclear Antibody Test Result

BackgroundThis retrospective study investigated the clinical utility of a positive antinuclear antibody (ANA) test performed outside of the rheumatology setting. Prior studies have investigated the frequency of ANA positivity within the general population. The purpose of this investigation was to evaluate the clinical utility of a positive ANA test result in a real-world setting by reviewing the final diagnoses of patients who were referred to a tertiary rheumatology clinic for evaluation of a positive ANA test result. MethodsWe reviewed the records of patients presenting to the authors between July 2007 and July 2009. Patients were included in the evaluation if they were referred for a positive ANA test result. All relevant descriptive and laboratory data were collated, as were the initial reasons for ordering ANA testing and the ultimate diagnoses reached. Positive predictive values for a “positive ANA test result” were calculated for all antinuclear antibody-associated rheumatic diseases and for lupus specifically. ResultsA total of 232 patients were referred for a positive ANA test result. The positive predictive value of a positive ANA test result in this cohort was 2.1% for lupus and 9.1% for any antinuclear antibody-associated rheumatic disease. No antinuclear antibody-associated rheumatic disease was identified in patients with an ANA<1:160. The most common reason for ordering ANA testing was widespread pain (54/232, 23.2%). ConclusionsIn this retrospective study, more than 90% of patients who were referred to a tertiary rheumatology clinic for a positive ANA test result had no evidence for an ANA-associated rheumatic disease. The poor predictive value of a positive ANA in this cohort was largely attributable to unnecessary testing in patients with low pretest probabilities for ANA-associated rheumatic disease.

A case of dermatomyositis accompanied by spontaneous intramuscular hemorrhage despite normal coagulability

A 60-year-old man presented with a 1-month history of high fever and an erythematous rash on the back and trunk. Gottron’s papules and mechanic’s hand lesions were also observed. Muscle weakness was not detected by manual muscle testing. Laboratory examination showed elevations of creatine kinase (807 IU/l; 64–279) and aldolase (10.9 U/l; 2.1–6.1). Coagulation test was normal. Antinuclear antibody test result was positive, with a speckled pattern, and titer 1:80. Anti-DNA, anti-Jo-1, and anti-U1-RNP antibodies were negative. High-resolution computed tomography (HRCT) did not detect any internal organ abnormalities. An electromyogram of the muscles was normal. A muscle biopsy showed sparse infiltration of lymphocytes between the muscle fibers. On the basis of these findings, dermatomyositis was diagnosed. Administration of oral prednisolone (60 mg/day) was started. On day 25, patient was in respiratory failure. HRCT detected consolidation and ground glass opacities. Therefore, an i.v. pulse of methylprednisolone (1,000 mg/ day for 3 days) was initiated. Unfractionated heparin (UFH) (10,000 IU) was also started to prevent venous thrombosis. After this treatment, the patient had 2 episodes of spontaneous intramuscular hemorrhage. The first episode occurred after 6 days of pulse methylprednisolone treatment. The patient complained of rapid-onset back pain. A CT revealed intramuscular hemorrhage in the left deltoid with hematoma spread into the intra fascia (Fig. 1a). Activated partial thromboplastin time [APTT (89.2 s; normal range, 24.8–35.0)] was prolonged, and UFH administration was stopped. However, 3 days after the first hemorrhage, a second episode occurred despite normal coagulability. The patient complained of sudden cervical pain and a 12-cm subcutaneous hematoma was revealed with no injury detected. A CT demonstrated another intramuscular hematoma in the trapezius muscle (Fig. 1b). The patient’s hemoglobin had fallen from 97 to 67 g/l; coagulation parameters were all within normal ranges. The autoantibodies related to coagulation disorder were not detected. The patient needed a transfusion (2 units of packed red blood cells). The patient subsequently experienced an exacerbated IP and died. Dermatomyositis accompanied by spontaneous intramuscular hemorrhage is neither a recognized complication of dermatomyositis nor a side effect of its treatment. There have been 6 other reported cases of dermatomyositis accompanied by spontaneous intramuscular hemorrhages [1–5] (Table 1). In case 5, the patient had also received i.v. UFH, but APTT was normal [5]. The patients in cases 2 and 3 had not received any anticoagulant therapy [2]. In our case (no. 7, Table 1), the patient was treated with i.v. UFH and methylprednisolone. Therefore, there is a possibility that the first intramuscular hemorrhage was caused by abnormal coagulability. However, the coagulability at the time of the second hemorrhage was completely normal. We believe that the cause of the intramuscular hemorrhages observed in dermatomyositis patients with normal coagulability may imply the presence of intrinsic risk factors for spontaneous intramuscular hemorrhage in patients with dermatomyositis. Kissel et al. [6] found immune complex in the wall of intramuscular venules and arterioles, indicating that complement is deposited, bound, and activated within the intramuscular microvasculature in patients with dermatomyositis. In dermatomyositis, there is focal capillary depletion and the capillary density is significantly reduced [7]. These capillary changes were not revealed in F. Hanawa (&) T. Inozume K. Harada N. Andou T. Kawamura N. Shibagaki S. Shimada Department of Dermatology, University of Yamanashi, Faculty of Medicine, 110 Shimokato, Chuo-shi, Yamanashi 409-3898, Japan e-mail: fumieh@yamanashi.ac.jp